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Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity.
Aminian, A, Fathalizadeh, A, Tu, C, Butsch, WS, Pantalone, KM, Griebeler, ML, Kashyap, SR, Rosenthal, RJ, Burguera, B, Nissen, SE
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2021;17(1):208-214
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A growing body of evidence indicates that patients with obesity are disproportionately affected with a severe form of SARS-CoV-2 infection and may experience resultant higher mortality. The aim of this study was to determine the association of prior metabolic surgery with severity of SARSCoV-2 infection in patients with severe obesity. This study is a retrospective, matched-cohort analysis of a prospective, observational, institutional review board–approved clinical registry of all patients tested for SARS-CoV-2 infection. The study population included a total of 363 patients, including 33 individuals who had metabolic surgery and 330 matched patients who tested positive. Results indicate that a history of metabolic surgery is associated with lower severity of SARSCoV-2 infection in patients with severe obesity, as manifested by lower risks of hospital and ICU admission. Authors conclude that prior metabolic surgery with subsequent weight loss and improvement of metabolic abnormalities could potentially reduce morbidity from SARS-CoV-2 infection.
Abstract
BACKGROUND Obesity is a risk factor for poor clinical outcomes in patients with coronavirus disease 2019 (COVID-19). OBJECTIVES To investigate the relationship between prior metabolic surgery and the severity of COVID-19 in patients with severe obesity. SETTING Cleveland Clinic Health System in the United States. METHODS Among 4365 patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 8, 2020 and July 22, 2020 in the Cleveland Clinic Health System, 33 patients were identified who had a prior history of metabolic surgery. The surgical patients were propensity matched 1:10 to nonsurgical patients to assemble a cohort of control patients (n = 330) with a body mass index (BMI) ≥ 40 kg/m2 at the time of SARS-CoV-2 testing. The primary endpoint was the rate of hospital admission. The exploratory endpoints included admission to the intensive care unit (ICU), need for mechanical ventilation and dialysis during index hospitalization, and mortality. After propensity score matching, outcomes were compared in univariate and multivariate regression models. RESULTS The average BMI of the surgical group was 49.1 ± 8.8 kg/m2 before metabolic surgery and was down to 37.2 ± 7.1 at the time of SARS-CoV-2 testing, compared with the control group's BMI of 46.7 ± 6.4 kg/m2. In the univariate analysis, 6 (18.2%) patients in the metabolic surgery group and 139 (42.1%) patients in the control group were admitted to the hospital (P = .013). In the multivariate analysis, a prior history of metabolic surgery was associated with a lower hospital admission rate compared with control patients with obesity (odds ratio, 0.31; 95% confidence interval, 0.11-0.88; P = .028). While none of the 4 exploratory outcomes occurred in the metabolic surgery group, 43 (13.0%) patients in the control group required ICU admission (P = .021), 22 (6.7%) required mechanical ventilation, 5 (1.5%) required dialysis, and 8 (2.4%) patients died. CONCLUSION Prior metabolic surgery with subsequent weight loss and improvement of metabolic abnormalities was associated with lower rates of hospital and ICU admission in patients with obesity who became infected with SARS-CoV-2. Confirmation of these findings will require larger studies.
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Medical and surgical management of gastroparesis: a systematic review.
Fonseca Mora, MC, Milla Matute, CA, Alemán, R, Castillo, M, Giambartolomei, G, Schneider, A, Szomstein, S, Lo Menzo, E, Rosenthal, RJ
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2021;(4):799-814
Abstract
BACKGROUND Gastroparesis (GPS) is a rare disease with multiple etiologies that results in delayed gastric emptying. Diagnosis of GPS can be challenging due to its rather complex clinical presentation. Pharmacologic refractory cases require surgical interventions, all of which have yet to be standardized and characterized. OBJECTIVES We present a review of the literature and provide an update of current therapies for patients with GPS. SETTING Department of General Surgery, Academic Hospital, United States. METHODS We conducted a comprehensive search in PubMed, Google Scholar, and Embase of English-written articles published in the last 38 years, with an advance title search of "gastroparesis management." Other keywords included: "surgical management" and "refractory gastroparesis." Further references were obtained through cross-reference. RESULTS A total of 12,250 articles were selected after eliminating duplicates. Following thorough screening of selection criteria, 68 full-text articles were included for review. CONCLUSION GPS is a challenging disease to manage. Nutritional support must remain the primary approach, followed by either medical or surgical treatment modalities if necessary. In patients with refractory gastroparesis, adjunctive therapies have been proposed as promising long-term options.
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Anemia, iron and vitamin B12 deficiencies after sleeve gastrectomy compared to Roux-en-Y gastric bypass: a meta-analysis.
Kwon, Y, Kim, HJ, Lo Menzo, E, Park, S, Szomstein, S, Rosenthal, RJ
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2014;(4):589-97
Abstract
BACKGROUND The effective treatment of postoperative anemia and nutritional deficiencies is critical for the successful management of bariatric patients. However, the evidence for nutritional risk or support of bariatric patients remains scarce. The aims of this study were to assess current evidence of the association between 2 methods of bariatric surgery, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), and postoperative anemia and nutritional deficiencies. METHODS MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for English-language studies using a list of keywords. Reference lists from relevant review articles were also searched. In the authors' meta-analysis, they included studies with a duration of>12 months, those comparing SG with RYGB, and those with available outcome data for postoperative anemia and iron and vitamin B12 deficiencies. Of 36 potentially relevant studies, 9 met the inclusion criteria. Data were combined by means of a fixed-effects model or random-effects model. RESULTS Compared with the SG group, the odds ratio for postoperative vitamin B12 deficiency in the RYGB group was 3.55 (95% confidence interval, 1.26-10.01; P<.001). In the subgroup analysis, studies in which prophylactic iron or vitamin B12 was administered lost significance in the odds ratio for postoperative vitamin B12 deficiency. CONCLUSION The authors' findings suggest that SG is more beneficial than RYGB with regard to postoperative vitamin B12 deficiency risk, whereas the 2 methods are comparable with regard to the risk of postoperative anemia and iron deficiency. Postoperative prophylactic iron and B12 supplementation, in addition to general multivitamin and mineral supplementation, is recommended based on the comparable deficiency risk of the 2 methods as indicated by subgroup analysis.
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The foregut theory as a possible mechanism of action for the remission of type 2 diabetes in low body mass index patients undergoing subtotal gastrectomy for gastric cancer.
Kwon, Y, Abdemur, A, Lo Menzo, E, Park, S, Szomstein, S, Rosenthal, RJ
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2014;(2):235-42
Abstract
BACKGROUND The question of whether pure metabolic surgery could be used in nonobese patients with type 2 diabetes has been considered. The objective of this study was to assess the comparative effects of the Billroth I (BI) and Billroth II (BII) reconstruction methods on remission of type 2 diabetes in nonobese patients undergoing subtotal gastrectomy for cancer. METHODS The charts of 404 patients who underwent radical subtotal gastrectomy for cancer between January 2008 and December 2010 were retrospectively reviewed. From these patients, 49 with type 2 diabetes were included in this study. Diabetes remission rates, the percentage change in fasting plasma glucose levels, glycated hemoglobin levels, body mass index, and fasting total cholesterol levels at 2 years were observed. Outcomes were compared using propensity scores and inverse probability-weighting adjustment that reduced treatment-selection bias. Covariate-adjusted logistic regression models were assessed. RESULTS The 2-year diabetes remission rate for the 23 patients who underwent BI reconstruction was 39.1%, compared with 50.0% for the 26 patients who underwent BII reconstruction. At 2 years, the BII group showed lower glycated hemoglobin levels (BI, 6.4%; BII, 6.1%; P = .003) and had greater percent reductions in their average glycated hemoglobin levels from baseline (BI,-11.6%; BII,-14.5%; P = .043). BII reconstruction was significantly associated with an increased diabetes remission rate (odds ratio, 3.22; 95% confidence interval, 1.05-9.83) in covariate-adjusted logistic regression analysis. CONCLUSIONS These propensity score-adjusted analyses of patients who had undergone subtotal gastrectomy indicated that BII reconstruction was associated with increased diabetes remission compared with BI reconstruction during the 2-year follow-up period. This study suggests the possibility of employing the surgical duodenal switch for the treatment of nonobese type 2 diabetes patients.
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Open-label, sham-controlled trial of an endoscopic duodenojejunal bypass liner for preoperative weight loss in bariatric surgery candidates.
Gersin, KS, Rothstein, RI, Rosenthal, RJ, Stefanidis, D, Deal, SE, Kuwada, TS, Laycock, W, Adrales, G, Vassiliou, M, Szomstein, S, et al
Gastrointestinal endoscopy. 2010;(6):976-82
Abstract
BACKGROUND The duodenojejunal bypass liner (DJBL) (EndoBarrier Gastrointestinal Liner) is an endoscopically placed and removable intestinal liner that creates a duodenojejunal bypass resulting in weight loss and improvement in type 2 diabetes mellitus. OBJECTIVE Weight loss before bariatric surgery to decrease perioperative complications. DESIGN Prospective, randomized, sham-controlled trial. SETTING Multicenter, tertiary care, teaching hospitals. PATIENTS Twenty-one obese subjects in the DJBL arm and 26 obese subjects in the sham arm composed the intent-to-treat population. INTERVENTIONS The subjects in the sham arm underwent an EGD and mock implantation. Both groups received identical nutritional counseling. MAIN OUTCOME MEASUREMENTS The primary endpoint was the difference in the percentage of excess weight loss (EWL) at week 12 between the 2 groups. Secondary endpoints were the percentage of subjects achieving 10% EWL, total weight change, and device safety. RESULTS Thirteen DJBL arm subjects and 24 sham arm subjects completed the 12-week study. EWL was 11.9% +/- 1.4% and 2.7% +/- 2.0% for the DJBL and sham arms, respectively (P < .05). In the DJBL arm, 62% achieved 10% or more EWL compared with 17% of the subjects in the sham arm (P < .05). Total weight change in the DJBL arm was -8.2 +/- 1.3 kg compared with -2.1 +/- 1.1 kg in the sham arm (P < .05). Eight DJBL subjects terminated early because of GI bleeding (n = 3), abdominal pain (n = 2), nausea and vomiting (n = 2), and an unrelated preexisting illness (n = 1). None had further clinical symptoms after DJBL explantation. LIMITATIONS Study personnel were not blinded. There was a lack of data on caloric intake. CONCLUSIONS The DJBL achieved endoscopic duodenal exclusion and promoted significant weight loss beyond a minimal sham effect in candidates for bariatric surgery. ( CLINICAL TRIAL REGISTRATION NUMBER NPT00469391.).
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Malnutrition in morbidly obese patients: fact or fiction?
Kaidar-Person, O, Rosenthal, RJ
Minerva chirurgica. 2009;(3):297-302
Abstract
Reports of nutritional deficiencies after Bariatric surgery have lead investigators to inquire about the preoperative nutritional status of morbidly obese patients. Interestingly, numerous reports demonstrated a pattern of low levels of various micronutrients among overweight and obese patients, even in comparison with normal weight population. In this article we reviewed the literature for micronutrient deficiencies in obese patients prior to weight reduction surgery.
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Gastric emptying is not affected by sleeve gastrectomy--scintigraphic evaluation of gastric emptying after sleeve gastrectomy without removal of the gastric antrum.
Bernstine, H, Tzioni-Yehoshua, R, Groshar, D, Beglaibter, N, Shikora, S, Rosenthal, RJ, Rubin, M
Obesity surgery. 2009;(3):293-8
Abstract
BACKGROUND The aim of this study is to clarify whether laparoscopic sleeve gastrectomy (LSG) to treat morbid obesity causes changes in gastric emptying. METHODS Gastric emptying scintigraphy was performed before and 3 months after LSG, in 21 consecutive morbidly obese patients. After an overnight fast, subjects consumed a standard semi-solid meal, to which 0.5 mCi Tc99-labeled sulfur colloid had been added. The meal was consumed within 10 min. Scintigraphic imaging was performed with a gamma camera immediately after the completion of the meal as well as after 30, 60, 120, 180, and 240 min. Quantitative and qualitative analysis was performed by drawing a region of interest (ROI) enclosing the stomach on the anterior and the posterior images. Time 0 was considered the time of meal completion (all the ingested activity) and was defined as 100% retention. The same ROI was used on all consecutive images of the same projection for the same patient. The geometric mean of the anterior and the posterior counts for each time point is calculated and corrected for Tc(99m) decay. Gastric emptying curves were constructed. T 1/2 is the time interval between completion of the meal and the point at which half of the meal (by radioactivity counts) has left the stomach. Retention is expressed as the percent remaining in the stomach at each time point (half, 1, 2, 3, 4 h). RESULTS The mean T 1/2 raw data was 62.39+/-19.83 and 56.79+/-18.72 min (p=0.36, t=-0.92, NS) before and 3 months after LSG, respectively. The T 1/2 linear was 103.64+/-9.82 and 106.92+/-14.55, (p=0.43, t=-0.43, NS), and the linear fit slope 0.48+/-0.04 and 0.47+/-0.05 (p=0.48, t=0.7, NS). CONCLUSIONS LSG with antrum preservation as performed in this series has no effect on gastric emptying.
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Nutritional deficiencies in morbidly obese patients: a new form of malnutrition? Part A: vitamins.
Kaidar-Person, O, Person, B, Szomstein, S, Rosenthal, RJ
Obesity surgery. 2008;(7):870-6
Abstract
It is a common belief that clinical vitamin or mineral deficiencies are rare in Western countries because of the low cost and unlimited diversity of food supply. However, many people consume food that is either unhealthy or of poor nutritional value that lacks proteins, vitamins, minerals, and fiber. In this, article we reviewed the literature and highlighted the vitamin deficiencies in obese patients before bariatric surgery. Deficiency of dietary minerals is described in the accompanying manuscript. The prevalence of vitamin deficiencies in the morbidly obese population prior to bariatric surgery is higher and more significant than previously believed.
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The new concept of bariatric surgery in China--reevaluation of surgical indications and criteria of therapeutic effect of laparoscopy for treatment of obesity.
Li, X, Zheng, C, Rosenthal, RJ
Obesity surgery. 2008;(9):1180-2
Abstract
The etiology of morbid obesity is multifactorial and is related to inheritance, physiology, metabolism, sociocultural, behavioral, and psychological factors. In China, the incidence of obesity is increasing with the improvement of the standard of living each year. The USA is known as the nation that has a high prevalence of overweight and obese individuals, as indicated from the Nutrition and Health Status report. Obesity in China is a growing phenomenon that cannot be ignored. In this paper, we review the relatively new concept of bariatric surgery in China.
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Nutritional deficiencies in morbidly obese patients: a new form of malnutrition? Part B: minerals.
Kaidar-Person, O, Person, B, Szomstein, S, Rosenthal, RJ
Obesity surgery. 2008;(8):1028-34
Abstract
Even though in the Western world there is almost no limitation to a wide variety of food supply, nutritional deficiencies can be found in both normal-weight population and in the obese population. In this review, we examine the prevalence and manifestations of various mineral deficiencies in obese patients.