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Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study

Ponce de Leon-Ballesteros, Guillermo; Pouwels, Sjaak; Romero-Velez, Gustavo; Aminian, Ali; Angrisani, Luigi; Bhandari, Mohit; Brown, Wendy; Copaescu, Catalin; De Luca, Maurizio; Fobi, Mathias; Ghanem, Omar M.; Hasenberg, Till; Herrera, Miguel F.; Herrera-Kok, Johnn H.; Himpens, Jacques; Kow, Lilian; Kroh, Matthew; Kurian, Marina; Musella, Mario; Narwaria, Mahendra; Noel, Patrick; Pantoja, Juan P.; Ponce, Jaime; Prager, Gerhard; Ramos, Almino; Ribeiro, Rui; Ruiz-Ucar, Elena; Salminen, Paulina; Shikora, Scott; Small, Peter; Stier, Christine; Taha, Safwan; Taskin, Eren Halit; Torres, Antonio; Vaz, Carlos; Vilallonga, Ramon; Verboonen, Sergio; Zerrweck, Carlos; Zundel, Natan; Parmar, Chetan
Background: Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. Methods: A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts"™ votes was achieved. Results: A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations. Conclusion: This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population. Graphical Abstract: [Figure not available: see fulltext.]
ISSN: 0960-8923
CID: 5629712

Routine extended (30 days) chemoprophylaxis for patients undergoing laparoscopic sleeve gastrectomy may reduce Portomesenteric vein thrombosis rates

Cuva, Dylan; Somoza, Eduardo; Alade, Moyosore; Saunders, John K.; Park, Julia; Lipman, Jeffrey; Einersen, Peter; Chui, Patricia; Parikh, Manish
Background: Venous thromboembolism (VTE), including Portomesenteric vein thrombosis (PMVT), is a major complication of sleeve gastrectomy (SG). We changed our practice in July 2021 to routinely discharge all SG patients postoperatively with extended chemoprophylaxis for 30 days. Objectives: Evaluate the efficacy and safety of routine extended chemoprophylaxis compared to 2 prior timeframes using selective extended chemoprophylaxis. Setting: University Hospital. Methods: Between 2012"“2018, SG patients were discharged on extended chemoprophylaxis for patients deemed "high-risk" for VTE, including patients with body mass index (BMI) >50, and previous VTE. Between 2018"“2021, extended chemoprophylaxis was broadened to include patients with positive preoperative thrombophilia panels (including Factor VIII). After 2021, all SG were routinely discharged on extended chemoprophylaxis. The typical regimen was 30 days Lovenox BID (40-mg twice daily for BMI> 40, 60-mg twice daily for BMI >60). Outcomes evaluated were rate of VTE/PMVT and postoperative bleed, including delayed bleed. Results: A total of 8864 patients underwent SG. Average age and BMI were 37.5 years and 43.0 kg/m2, respectively. The overall incidence of PMVT was 33/8864 (.37%). Converting from selective extended chemoprophylaxis (Group 1) to routine extended chemoprophylaxis (Group 3) decreased the rate of PMVT from .55% to .21% (P = .13). There was a significantly higher overall bleeding rate (.85%), including delayed bleeds (.34%) in the routine extended chemoprophylaxis patients (P < .05). These bleeds were mainly managed nonoperatively. Conclusions: Routine extended (30 day) chemoprophylaxis for all SG may reduce PMVT rate but lead to a higher bleeding rate post-operatively. The vast majority of the increased bleeds are delayed and can be managed non-operatively.
ISSN: 1550-7289
CID: 5629922

Anti-Obesity Pharmacotherapy to Facilitate Living Kidney Donation

Orandi, Babak J; Lofton, Holly; Montgomery, Robert A; Segev, Dorry L
Obesity is a chronic, relapsing disease that increases the risks of living kidney donation; at the same time, transplant centers have liberalized body mass index constraints for donors. With the increasing number of anti-obesity medications available, the treatment of obesity with anti-obesity medications may increase the pool of potential donors and enhance donor safety. Anti-obesity medications are intended for long-term use given the chronic nature of obesity. Cessation of treatment can be expected to lead to weight regain and increases the risk of comorbidity rebound/development. In addition, anti-obesity medications are meant to be used in conjunction with-rather than in replacement of-diet and physical activity optimization. Anti-obesity medication management includes selecting medications that may ameliorate any co-existing medical conditions, avoiding those that are contraindicated in such conditions, and being sensitive to any out-of-pocket expenses that may be incurred by the potential donor. A number of questions remain regarding who will and should shoulder the costs of long-term obesity treatment for donors. In addition, future studies are needed to quantify the degree of weight loss and duration of weight loss maintenance needed to normalize the risk of adverse kidney outcomes relative to comparable non-donors and lower weight donors.
PMID: 38072121
ISSN: 1600-6143
CID: 5589452

Measuring Outcomes in the Treatment of Obesity

Jenkins, Megan; Kurian, Marina; Moore, Rachel
PMID: 38055228
ISSN: 2168-6262
CID: 5595752

The robotic approach for vascular and endovascular procedures: a narrative review

Huber, Michael A.; Robbins, Justin M.; Sebastian, Stacy M.; Vu, Alexander Hien; Ferzli, George; Schutzer, Richard; Hingorani, Anil
Background and Objective: The use of robot technology has greatly expanded the field of general surgery. While robot technology has become almost standard for many general surgeons, there is an increasing interest in how this same technology may be utilized within more specialized fields. We sought to explore the advances and current uses of robot technology within the field of vascular surgery. We evaluated this topic broadly in the context of both the open and endovascular approach. Methods: A comprehensive literature search was employed using the following search strategy on PubMed: ("Robotic Surgical Procedures"[Mesh]) AND ("Vascular Surgical Procedures"[Mesh]). A total of 381 articles were identified. No filters were applied. All articles were then screened manually for applicability. Articles relating to cardiothoracic and neurosurgery were excluded (n=366), as the authors were most interested in performing this literature review from the focus of the vascular surgeon, and procedures involving the heart and brain are outside his or her scope of practice. The remaining (n=15) articles were then utilized to provide a synopsis of the advances made in robotic-assisted procedures within the field of vascular surgery. Key Content and Findings: Robot technology is currently being utilized by vascular surgeons to assist in both open and endovascular procedures. Some typical open procedures wherein the robot has shown to be most effective are in complex aortic reconstruction, first rib resection, venous thrombectomy and venous reconstruction following oncologic resection. In addition to open procedures, there is also evidence that robot technology may offer some benefits in purely endovascular ones, such as in inferior vena cava (IVC) filter retrieval and in standard angiograms. Conclusions: This work highlights that robot technology is greatly expanding the field of vascular surgery. In addition to offering a less invasive approach for both major and minor procedures, robot technology has also led to significant increases in team members"™ safety by decreasing radiation exposure. This review will hopefully act as a catalyst to further expand the use of robot technology in vascular procedures, and by effect increase the value that the vascular surgeon brings to the health care system.
ISSN: 2518-6973
CID: 5614882

Do all roads lead to Rome? A retrospective analysis on surgical technique in sleeve gastrectomy

Vu, Alexander Hien; Chiang, Jessica; Qian, Yunzhi; Tursunova, Nilufar; Nha, Jaein; Ferzli, George
BACKGROUND:New York University Langone Health has three accredited bariatric centers, with 10 different bariatric surgeons. This retrospective analysis compares surgeon techniques in laparoscopic or robotic sleeve gastrectomy (SG) to identify associations with perioperative morbidity and mortality. METHODS:All adults who underwent SG between 2017 and 2021 at NYU Langone Health were evaluated via EMR and MBSAQIP 30-day data. We also surveyed all 10 bariatric surgeons and compared their techniques and total adverse outcomes. Bleeding, SSI, mortality, readmission, and reoperation were specifically sub-analyzed via logistic regression. RESULTS:86 (2.77%) out of 3,104 patients who underwent SG encountered an adverse event. Lower adverse outcomes were observed with a laparoscopic approach, 40-Fr bougie, buttressing, not oversewing the staple line, using hemostatic agents, stapling 3-cm from pylorus, and no routine UGI series. Lower bleeding rates were observed in a laparoscopic approach, 40-Fr bougie, buttressing, not oversewing the staple line, using hemostatic agents, stapling 3-cm from pylorus, no routine UGI series, and not proceeding with SG if hiatal hernia is present. Lower SSI rates were observed with ViSiGi™ bougie, no hemostatic agents, and routine EGD. Lower readmission rates were observed with 40-Fr bougie, buttressing, not oversewing, and stapling 3-cm from pylorus. Hemostatic agents had higher reoperation rates. It was not feasible to test for mortality given the low incidence. CONCLUSION:Certain surgical techniques in SG among our bariatric surgeons had a significant effect on the rates of adverse outcomes, bleeding, readmission, reoperation, and SSI. Our findings warrant further investigation into these techniques via multivariate regression or prospective design. LIMITATIONS:This study was limited by its retrospective and univariate design. We did not account for interaction. The sample size was small, and follow-up of 30 days was relatively short. We did not include patient characteristics in the model or control for surgeon skill.
PMID: 37488445
ISSN: 1432-2218
CID: 5604932

Surgeon experience with insurance barriers to offering gastric bypass as an evidence-based operation for pathologic GERD

Ibele, Anna R; Nau, Peter N; Galvani, Carlos; Roth, J Scott; Goldberg, Ross F; Kurian, Marina S; Khaitan, Leena; Gould, Jon; Pandya, Yagnik K; ,
INTRODUCTION:Obesity is an increasingly prevalent public health problem often associated with poorly controlled gastroesophageal reflux disease. Fundoplication has been shown to have limited long-term efficacy in patients with morbid obesity and does not address additional weight-related co-morbidities. Roux-en-Y gastric bypass (RYGB) is the gold standard operation for durable resolution of GERD in patients with obesity, and is also used as a salvage operation for GERD after prior foregut surgery. Surgeons report access to RYGB as surgical treatment for GERD is often limited by RYGB-specific benefit exclusions embedded within insurance policies, but the magnitude and scope of this problem is unknown. METHODS:A 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD was developed and piloted by a SAGES Foregut Taskforce working group. This survey was then administered to surgeon members of the SAGES Foregut Taskforce and to surgeons participating in the SAGES Bariatrics and/or Foregut Facebook groups. RESULTS:respectively as cutoff for the RYGB. 89% viewed RYGB as the procedure of choice for GERD after bariatric surgery. 69% reported using RYGB to address recurrent reflux secondary to failed fundoplication. 74% of responders experienced trouble with insurance coverage at least half the time RYGB was offered for GERD, and 8% reported they were never able to get approval for RYGB for GERD indications in their patient populations. CONCLUSION:For many patients, GERD and obesity are related diseases that are best addressed with RYGB. However, insurance coverage for RYGB for GERD is often limited by policies which run contrary to evidence-based medicine. Advocacy is critical to improve access to appropriate surgical care for GERD in patients with obesity.
PMID: 37491660
ISSN: 1432-2218
CID: 5604952

Do all roads lead to Rome?: A retrospective analysis on surgical technique in Roux-en-Y gastric bypass

Vu, Alexander Hien; Chiang, Jessica; Qian, Yunzhi; Tursunova, Nilufar; Nha, Jaein; Ferzli, George
BACKGROUND:New York University Langone Health has three accredited bariatric centers, with altogether ten different bariatric surgeons. This retrospective analysis compares individual surgeon techniques in laparoscopic or robotic Roux-en-Y gastric bypass (RYGB) to identify potential associations with perioperative morbidity and mortality. METHODS:All adult patients who underwent RYGB between 2017 and 2021 at NYU Langone Health campuses were evaluated via electronic medical records and MBSAQIP 30-day follow-up data. We surveyed all ten practicing bariatric surgeons to analyze the relationship between their techniques and total adverse outcomes. Bleeding, SSI, mortality, readmission, and reoperation were specifically sub-analyzed via logistic regression. RESULTS:54 (7.59%) out of 711 patients who underwent laparoscopic or robotic RYGB encountered an adverse outcome. Lower adverse outcomes were observed with laparoscopic approach, creating the JJ anastomosis first, flat positioning, division of the mesentery, Covidien™ laparoscopic staplers, gold staples, unidirectional JJ anastomosis, hand-sewn common enterotomy, 100-cm Roux limb, 50-cm biliopancreatic limb, and routine EGD. Lower bleeding rates were observed with flat positioning, gold staples, hand-sewn common enterotomy, 50-cm biliopancreatic limb, and routine EGD. Lower readmission rates were observed in laparoscopic, flat positioning, Covidien™ staplers, unidirectional JJ anastomosis, and hand-sewn common enterotomy. Gold staples had lower reoperation rates. Otherwise, there was no statistically significant difference in SSI. CONCLUSION/CONCLUSIONS:Certain surgical techniques in RYGB within our bariatric surgery group had significant effects on the rates of total adverse outcomes, bleeding, readmission, and reoperation. Our findings warrant further investigation into the aforementioned techniques via multivariate regression models or prospective study design. LIMITATIONS/CONCLUSIONS:This study was limited by the inherent nature of its retrospective and univariate statistical design. We did not account for the interaction between techniques. The sample size of surgeons was small, and follow-up of 30 days was relatively short. We did not include patient characteristics in the model or control for surgeon skill.
PMID: 37415013
ISSN: 1432-2218
CID: 5539382

One Anastomosis Gastric Bypass for Revisional Bariatric Surgery: Assessment of Short-Term Safety

Pivo, Sarah; Jenkins, Megan; Fielding, Christine Ren; Kim, Mirhee; Schwack, Bradley
PURPOSE/OBJECTIVE:With the continued increase in bariatric procedures being performed in the USA, a growing percentage are revisions for weight regain after sleeve gastrectomy (SG) and gastric banding (LAGB). Standard practice in the USA involves conversion to Roux-en-Y gastric bypass (RYGB). Internationally, one anastomosis gastric bypass (OAGB) has become a popular and effective alternative. Without the jejuno-jejunal anastomosis, OAGB has reduced potential related long-term complications. The purpose of this study is to compare the short-term safety of revision to OAGB versus RYGB. MATERIALS AND METHODS/METHODS:Patients who underwent conversion to OAGB from LAGB or SG for weight regain from January 2019 to October 2021 were compared to BMI, sex, and age-matched patients who underwent conversion to RYGB. RESULTS:In our study, 82 patients were included, 41 in each cohort (41 OAGB vs. 41 RYGB). The majority in both groups underwent conversion from SG (71% vs. 78%). Operative time, estimated blood loss, and length of stay were comparable. There was no difference in 30-day complications (9.8% vs. 12.2%, p = .99) or reoperation (4.9% vs. 4.9%, p = .99). Mean weight loss at 1 month was also comparable (7.91 lbs vs 6.36 lbs). CONCLUSIONS:Patients undergoing conversion to OAGB for weight regain had similar operative times, post-operative complication rates, and 1-month weight loss compared to those who underwent RYGB. While more research is needed, this early data suggests that OAGB and RYGB provide comparable outcomes when used as conversion procedures for to failed weight loss. Therefore, OAGB may present a safe alternative to RYGB.
PMID: 37191735
ISSN: 1708-0428
CID: 5503522

Factor structure and measurement invariance of the English- versus Spanish-language Eating Disorder Examination Questionnaire: Brief Form (S-EDE-Q-BF) in Hispanic/Latino/a/x persons seeking bariatric surgery

Marek, Ryan J; Ivezaj, Valentina; Parikh, Manish S; Jayade, Maansi; Davila-Shiau, Elissa; Grilo, Carlos M
BACKGROUND:Assessment of eating disorder psychopathology during preoperative psychological evaluations could be facilitated with psychometrically valid measures. One of the most commonly used measures, the Eating Disorder Examination Questionnaire (EDE-Q), is lengthy and has been found to have psychometric limitations. Research has identified a shorter version that has received reliable support across diverse samples but requires further validation for use with patients being evaluated for bariatric surgery. OBJECTIVES/OBJECTIVE:To cross-validate the factor structure of the EDE-Q: Brief Form (EDE-Q-BF, standalone, nonnested version) with patients being evaluated for bariatric surgery across English- and Spanish-language versions and establish measurement invariance for gender and language. SETTING/METHODS:Northeastern hospital in the United States. METHODS:Participants (n = 618) undergoing evaluations prior to bariatric surgery who identified as Hispanic/Latino/a/x and consented to participate in this research study (which did not influence eligibility for bariatric surgery) completed self-reports. Of the 618 participants, 92 were male and 526 were female, 318 preferred English and were administered English versions of the measures, and 300 preferred Spanish and were administered Spanish versions of the measures. RESULTS:[11] = 18.47; P = .071; root mean square error of approximation [RMSEA] = .033; comparative fit index [CFI] > .99; standardized root mean squared residual [SRMR] = .02). Scaler invariance was met for both gender and language. Correlations with external criteria further supported its validity. CONCLUSION/CONCLUSIONS:The EDE-Q-BF can easily be administered as part of a preoperative psychological assessment battery to screen for eating disorder psychopathology and is valid for Hispanic/Latino/a/x men and women who speak either English or Spanish.
PMID: 36639321
ISSN: 1878-7533
CID: 5410562