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Prevalence and Risk Factors for Bariatric Surgery Readmissions: Findings From 130,007 Admissions in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.
Berger, ER, Huffman, KM, Fraker, T, Petrick, AT, Brethauer, SA, Hall, BL, Ko, CY, Morton, JM
Annals of surgery. 2018;(1):122-131
Abstract
OBJECTIVE To evaluate readmissions following laparoscopic adjustable gastric banding (LAGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB). BACKGROUND Few studies have evaluated national readmission rates for primary bariatric surgery with national, bariatric-specific data. METHODS Patients undergoing primary LAGB, LSG, or LRYGB from January 1, 2014 to December 31, 2014, at 698 centers were identified based upon Current Procedural Terminology codes. The primary outcome was 30-day readmission from date of initial operation. RESULTS A total of 130,007 patients who underwent primary bariatric surgery were identified: 7378 LAGB (5.7%), 80,646 LSG (62.0%), and 41,983 LRYGB (32.3%). A total of 5663 (4.4%) patients were readmitted within 30 days for all causes. Patients undergoing LAGB had the lowest related readmission rate of 1.4%, followed by LSG (2.8%), and LRYGB (4.9%). Of patients who had a complication, 17.9% (n = 785) were readmitted, whereas those without readmission had a complication 1.9% of the time (P < 0.001). The most common cause of a related readmission was nausea, vomiting, fluid, electrolyte, and nutritional depletion (35.4%), followed by abdominal pain (13.5%), anastomotic leak (6.4%), and bleeding (5.8%), accounting for more than 61% of readmissions. When compared with LAGB, LSG, and LRYGB had significantly higher rates of readmission (LSG: odds ratio 1.89; 95% confidence interval 1.52-2.33; LRYGB odds ratio 3.06; 95% confidence interval 2.46-3.81). CONCLUSIONS National bariatric readmissions after primary procedures were closely associated with complications, varied based on the type of procedure, and were most commonly due to nausea, vomiting, electrolyte, and nutritional depletion.
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Multicentre randomized clinical trial of the effect of chewing gum after abdominal surgery.
de Leede, EM, van Leersum, NJ, Kroon, HM, van Weel, V, van der Sijp, JRM, Bonsing, BA, ,
The British journal of surgery. 2018;(7):820-828
Abstract
BACKGROUND Postoperative ileus is a common complication of abdominal surgery, leading to patient discomfort, morbidity and prolonged postoperative length of hospital stay (LOS). Previous studies suggested that chewing gum stimulates bowel function after abdominal surgery, but were underpowered to evaluate its effect on LOS and did not include enhanced recovery after surgery (ERAS)-based perioperative care. This study evaluated whether chewing gum after elective abdominal surgery reduces LOS and time to bowel recovery in the setting of ERAS-based perioperative care. METHODS A multicentre RCT was performed of patients over 18 years of age undergoing abdominal surgery in 12 hospitals. Standard postoperative care (control group) was compared with chewing gum three times a day for 30 min in addition to standard postoperative care. Randomization was computer-generated; allocation was concealed. The primary outcome was postoperative LOS. Secondary outcomes were time to bowel recovery and 30-day complications. RESULTS Between 2011 to 2015, 1000 patients were assigned to chewing gum and 1000 to the control arm. Median LOS did not differ: 7 days in both arms (P = 0·364). Neither was any difference found in time to flatus (24 h in control group versus 23 h with chewing gum; P = 0·873) or time to defaecation (60 versus 52 h respectively; P = 0·562). The rate of 30-day complications was not significantly different either. CONCLUSION The addition of chewing gum to an ERAS postoperative care pathway after elective abdominal surgery does not reduce the LOS, time to bowel recovery or the rate of postoperative complications. Registration number: NTR2594 (Netherlands Trial Register).
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Inadequate protein intake after laparoscopic sleeve gastrectomy surgery is associated with a greater fat free mass loss.
Sherf Dagan, S, Tovim, TB, Keidar, A, Raziel, A, Shibolet, O, Zelber-Sagi, S
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2017;(1):101-109
Abstract
BACKGROUND Low postoperative protein intake may represent a modifiable risk factor that leads to fat free mass (FFM) loss postlaparoscopic sleeve gastrectomy (LSG), but data concerning this phenomenon is scarce. OBJECTIVES To evaluate the association between daily protein intake and relative FFM loss at 6 (M6) and 12 (M12) months after LSG surgery. SETTINGS Private hospital and university hospital. METHODS A prospective cohort study with 12 months follow-up of 77 patients who underwent LSG surgery. Anthropometrics including body composition analysis measured by multifrequency bioelectrical impedance analysis, 3-day food diaries, food intolerance, and habitual physical activity were evaluated at baseline and at M3, M6, and M12. RESULTS Repeated body composition measurements and food diary were available for 77 patients (45 women) at M6 and for 68 patients at M12. Mean age was 42.7±9.4 years and mean preoperative body mass index was 42.2±4.8 kg/m2. A protein intake of≥60 g/d was achieved in 13.3%, 32.5% and 39.7% of the study participants at M3, M6 and M12, respectively. FFM significantly decreased at M6 and stabilized at M12. Protein intake of≥60 g/d was associated with a significantly lower relative FFM loss at M6 among women (8.9±6.5% versus 12.4±4.1%; P = .039) and this trend was also reported among men (9.5±5.5% versus 13.4±6.0%; P = .068). A logistic regression for the prediction of FFM loss of≥10% at M6, indicated that protein intake≥60 g/d is a strong protective factor (odds ratio = 0.29, 95% confidence interval .09-.96, P = .043). CONCLUSION Our study supports the currently recommended protein intake goal of≥60 g/d as an efficient strategy for better preservation of FFM post-LSG.
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Bile acid profiles over 5 years after gastric bypass and duodenal switch: results from a randomized clinical trial.
Risstad, H, Kristinsson, JA, Fagerland, MW, le Roux, CW, Birkeland, KI, Gulseth, HL, Thorsby, PM, Vincent, RP, Engström, M, Olbers, T, et al
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2017;(9):1544-1553
Abstract
BACKGROUND Bile acids have been proposed as key mediators of the metabolic effects after bariatric surgery. Currently no reports on bile acid profiles after duodenal switch exist, and long-term data after gastric bypass are lacking. OBJECTIVE To investigate bile acid profiles up to 5 years after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch and to explore the relationship among bile acids and weight loss, lipid profile, and glucose metabolism. SETTINGS Two Scandinavian University Hospitals. METHODS We present data from a randomized clinical trial of 60 patients with body mass index 50-60 kg/m2 operated with gastric bypass or duodenal switch. Repeated measurements of total and individual bile acids from fasting serum during 5 years after surgery were performed. RESULTS Mean concentrations of total bile acids increased from 2.3 µmol/L (95% confidence interval [CI], -.1 to 4.7) at baseline to 5.9 µmol/L (3.5-8.3) 5 years after gastric bypass and from 1.0 µmol/L (95% CI, -1.4 to 3.5) to 9.5 µmol/L (95% CI, 7.1-11.9) after duodenal switch; mean between-group difference was -4.8 µmol/L (95% CI, -9.3 to -.3), P = .036. Mean concentrations of primary bile acids increased more after duodenal switch, whereas secondary bile acids increased proportionally across the groups. Higher levels of total bile acids at 5 years were associated with lower body mass index, greater weight loss, and lower total cholesterol. CONCLUSIONS Total bile acid concentrations increased substantially over 5 years after both gastric bypass and duodenal switch, with greater increases in total and primary bile acids after duodenal switch. (Surg Obes Relat Dis 2017;0:000-000.) © 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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Laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass lead to equal changes in body composition and energy metabolism 17 months postoperatively: a prospective randomized trial.
Schneider, J, Peterli, R, Gass, M, Slawik, M, Peters, T, Wölnerhanssen, BK
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2016;(3):563-570
Abstract
BACKGROUND Weight loss is the sum of fat and lean mass loss. The aim of this study was to examine whether there are differences between 2 surgical procedures, laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), in terms of their effect on body composition and energy metabolism. In addition, the predictive value of preoperative body composition and energy metabolism on postoperative outcome was evaluated. SETTING All procedures were performed by the same surgeon (RP) at the St. Claraspital Basel in Switzerland. Calorimetry and DEXA were carried out at the same institution (Interdisciplinary Center of Nutritional and Metabolic Diseases, St. Claraspital Basel). METHODS Forty-two morbidly obese, mainly female (85%), nondiabetic and diabetic (50%) patients (body mass index [BMI]: 43.9 kg/m(2)±1.3) before and 17±5.6 months after LSG (n = 23) and LRYGB (n = 19) were examined. Body composition was analyzed by dual-energy X-ray absorptiometry (DEXA) and resting energy expenditure (REE); fat and carbohydrate oxidation was determined by indirect calorimetry. RESULTS Follow-up was 100%. Excessive BMI loss (EBMIL) was 64.4% in the LSG group and 76.4% in the LRYGB group (P<.046). In both groups total fat and muscle mass decreased significantly compared with baseline (P<.001) and the percentage of muscle mass per kilogram of weight increased postoperatively (results not significant). REE decreased (P<.001) and REE per kilogram of weight increased significantly (P<.003) compared with baseline. Carbohydrate oxidation remained stable in both groups, and fat oxidation decreased significantly (P<.001) compared with baseline. In diabetic patients compared with nondiabetic patients there were no statistically significant differences in REE, substrate oxidation, or reduction in truncal fat. Postoperatively, lean mass was higher in diabetic patients (P = .037). Preoperative indirect calorimetry and DEXA results were of no predictive value for outcome. CONCLUSION Changes in REE and body composition were equal after both procedures in a bariatric population mainly consisting of women. No predictors for amount of weight loss could be found.
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Randomized controlled trial comparing laparoscopic greater curvature plication versus laparoscopic sleeve gastrectomy.
Grubnik, VV, Ospanov, OB, Namaeva, KA, Medvedev, OV, Kresyun, MS
Surgical endoscopy. 2016;(6):2186-91
Abstract
BACKGROUND Laparoscopic greater curvature plication (LGCP) is a new restrictive bariatric procedure, which has a similar restrictive mechanism like laparoscopic sleeve gastrectomy (LSG) without potential risk of leak. Aim of the study was to compare 2-year outcomes of LSG and LGCP. METHODS Multicenter prospective randomized trial was started in 2010. A total of 54 patients with morbid obesity were allocated either to LGCP group (n = 25) or LSG group (n = 27). Main exclusion criteria were: ASA > III, age > 75 and BMI > 65 kg/m(2). There were 40 women and 12 men, and the mean age was 42.6 ± 6.8 years (range 35-62). Data on the operation time, complications, hospital stay, body mass index loss, percentage of excess weight loss (%EWL), loss of appetite and improvement in comorbidities were collected during the follow-up examinations. RESULTS All procedures were completed laparoscopically. The mean operative time was 92.0 ± 15 min for LSG and 73 ± 19 min for LGCP (p > 0.05). The mean hospital stay was 4.0 ± 1.9 days in the LSG group and 3.8 ± 1.7 days in LGCP group (p > 0.05). One year after surgery, the mean %EWL was 59.5 ± 15.4 % in LSG group and 45.8 ± 17 % in LGCP group (p > 0.05). After 2 years, mean %EWL was 78.9 ± 20 % in the LSG group and 42.4 ± 18 % in the LGCP group (p < 0.01). After 3 years, mean %EWL was 72.8 ± 22 in the LSG group and only 20.5 ± 23.9 in the LGCP group (p < 0.01). Loss of feeling of hunger after 2 years was 25 % in LGCP group and 76.9 % in the LSG group (p < 0.05). The comorbidities including diabetes, sleep apnea and hypertension were markedly improved in the both groups after surgery. CONCLUSION The short-term outcomes demonstrated equal effectiveness of the both procedures, but 2-year follow-up showed that LGCP is worse than LSG as a restrictive procedure for weight loss.
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Preoperative factors and 3-year weight change in the Longitudinal Assessment of Bariatric Surgery (LABS) consortium.
Courcoulas, AP, Christian, NJ, O'Rourke, RW, Dakin, G, Patchen Dellinger, E, Flum, DR, Melissa Kalarchian, PD, Mitchell, JE, Patterson, E, Pomp, A, et al
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2015;(5):1109-18
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Abstract
BACKGROUND Limited data guide the prediction of weight loss success or failure after bariatric surgery according to presurgery factors. There is significant variation in weight change after bariatric surgery and much interest in identifying preoperative factors that may contribute to these differences. This report evaluates the associations of a comprehensive set of baseline factors and 3-year weight change. SETTING Ten hospitals in 6 geographically diverse clinical centers in the United States. METHODS Adults undergoing a first bariatric surgical procedure as part of clinical care by participating surgeons were recruited between 2006 and 2009. Participants completed research assessments utilizing standardized and detailed data collection on over 100 preoperative and operative parameters for individuals undergoing Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB). Weight was measured 3 years after surgery. Percent weight change for RYGB or LAGB from baseline to 3 years was analyzed as both a continuous and dichotomous outcome with cut points at 25% for RYGB and 10% for LAGB. Multivariable linear and logistic regression models were used to identify independent baseline predictors of the continuous and categorical outcomes, respectively. RESULTS The median weight loss 3 years after surgery for RYGB (n = 1513) participants was 31.5% (IQR: 24.6%-38.4%; range, 59.2% loss to .9% gain) of baseline weight and 16.0% (IQR: 8.1%-23.1%; range, 56.1% loss to 12.5% gain) for LAGB (n = 509) participants. The median age was 46 years for RYGB and 48 years for LAGB; 80% of RYGB participants and 75% of LAGB participants were female; and the median baseline body mass index (BMI) was 46 kg/m(2) for RYGB and 44 kg/m(2) for LAGB. For RYGB, black participants lost 2.7% less weight compared with whites and participants with diabetes at baseline had 3.7% less weight loss at year 3 than those without diabetes at baseline. There were small but statistically significant differences in weight change for RYGB in those with abnormal kidney function and current or recent smoking. For LAGB participants, those with a large band circumference had 75% greater odds of experiencing less than 10% weight loss after adjusting for BMI and sex. CONCLUSIONS Few baseline variables were associated with 3-year weight change and the effects were small. These results indicate that baseline variables have limited predictive value for an individual's chance of a successful weight loss outcome after bariatric surgery. TRIAL REGISTRATION NCT00465829, ClinicalTrials.gov.
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[Treatment of diffuse peritonitis in children].
Zavyalkin, VA, Barskaya, MA, Varlamov, AV, Bykov, DV, Kuzmin, AI, Borodin, RV, Rodionov, VG, Frolova, YV
Khirurgiia. 2015;(7):65-68
Abstract
THE PURPOSE OF THE STUDY Improving the treatment of advanced peritonitis via use in therapy antihypoxant Reamberin and hepatoprotector Remaxol, nutritional support, sanitation laparoscopic abdominal cavity. SUBJECTS A total of 232 children aged 1 to 15 years with generalized purulent peritonitis treated at the children's surgical departments of Samara from 2001 to 2014. A study group comprised 148 patients who used the optimized pathogenetic therapy. In the study group was allocated two groups: 64 patients in the pathogenetic therapy that used antihypoxant reamberin, and 84 children in the treatment of which reamberin and hepatoprotector remaxol. All the children of the main group received nutritional support (trophic feedings), used in the surgical treatment of abdominal laparoscopic sanitation. Comprehensive survey includes the study of the dynamics of the level of white blood cells, leukocyte index on Kalf-Caliph, erythrocyte sedimentation rate, temperature, total albumin concentration, transaminase levels. RESULTS Comparison of the studied parameters in the study and control groups, showed a more rapid decrease in the symptoms and signs of intoxication (leukocytosis, LII, body temperature), relief of enteric disease, recovery of protein-synthetic function of the liver, a decrease of cytolytic and mesenchymal-inflammatory syndrome in the study group, especially in the subgroup in which therapy was included remaxol. CONCLUSIONS Optimization of treatment involving the application of the combined drugs--antihypoxant reamberin, hepatoprotector remaxol, nutritional support and implementation of laparoscopic abdominal sanitation led to improved results of therapy common purulent peritonitis in children.
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Laparoscopic versus open adhesiolysis for small bowel obstruction - a multicenter, prospective, randomized, controlled trial.
Sallinen, V, Wikström, H, Victorzon, M, Salminen, P, Koivukangas, V, Haukijärvi, E, Enholm, B, Leppäniemi, A, Mentula, P
BMC surgery. 2014;:77
Abstract
BACKGROUND Laparoscopic adhesiolysis is emerging as an alternative for open surgery in adhesive small bowel obstruction. Retrospective studies suggest that laparoscopic approach shortens hospital stay and reduces complications in these patients. However, no prospective, randomized, controlled trials comparing laparoscopy to open surgery have been published. METHODS/DESIGN This is a multicenter, prospective, open label, randomized, controlled trial comparing laparoscopic adhesiolysis to open surgery in patients with computed-tomography diagnosed adhesive small bowel obstruction that is not resolving with conservative management. The primary study endpoint is the length of postoperative hospital stay in days.Sample size was estimated based on preliminary retrospective cohort, which suggested that 102 patients would provide 80% power to detect a difference of 2.5 days in the length of postoperative hospital stay with significance level of 0.05. Secondary endpoints include passage of stool, commencement of enteral nutrition, 30-day mortality, complications, postoperative pain, and the length of sick leave. Tertiary endpoints consist of the rate of ventral hernia and the recurrence of small bowel obstruction during long-term follow-up. Long-term follow-up by letter or telephone interview will take place at 1, 5, and 10 years. DISCUSSION To the best of our knowledge, this trial is the first one aiming to provide level Ib evidence to assess the use of laparoscopy in the treatment of adhesive small bowel obstruction. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01867528. Date of registration May 26th 2013.
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Patient factors associated with undergoing laparoscopic adjustable gastric banding vs Roux-en-Y gastric bypass for weight loss.
Apovian, CM, Huskey, KW, Chiodi, S, Hess, DT, Schneider, BE, Blackburn, GL, Jones, DB, Wee, CC
Journal of the American College of Surgeons. 2013;(6):1118-25
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Abstract
BACKGROUND Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are 2 commonly performed bariatric procedures in the US with different profiles for risk and effectiveness. Little is known about factors that might lead patients to proceed with one procedure over the other. STUDY DESIGN We recruited and interviewed patients seeking bariatric surgery from 2 academic centers in Boston (response rate 70%). We conducted multivariable analyses to identify patient perceptions and clinical and behavioral characteristics that correlated with undergoing gastric banding (n = 239) vs gastric bypass (n = 297). RESULTS After adjustment for socio-demographic and clinical factors, we found that older patients (odds ratio [OR] 1.03; 95% CI 1.00 to 1.05) and those with higher quality of life scores and higher levels of uncontrolled eating were more likely to undergo gastric banding as opposed to gastric bypass. In contrast, patients with type 2 diabetes (OR 0.46; 95% CI 0.28 to 0.77), those who desired greater weight loss, and those who were willing to assume higher mortality risk to achieve their ideal weight were less likely to proceed with gastric banding. After initial adjustment, male sex and lower body mass index were associated with a likelihood of undergoing gastric banding; however, these factors were no longer significant after adjustment for other significant correlates such as patients' perceived ideal weight, predilection to assume risk to lose weight, and eating behavior. CONCLUSIONS Patients' diabetes status, quality of life, eating behavior, ideal weight loss, and willingness to assume mortality risk to lose weight were associated with whether patients proceeded with gastric banding as opposed to gastric bypass. Other clinical factors were less important.