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Background: Metabolic surgery has beneficial metabolic effects, including remission of type 2 diabetes. We hypothesized that duodenojejunal bypass (DJB) surgery can protect against development of type 1 diabetes (T1D) by enhancing regulation of cellular and molecular pathways that control glucose homeostasis., Methods: BBDP/Wor rats, which are prone to develop spontaneous autoimmune T1D, underwent loop DJB (n = 15) or sham (n = 15) surgery at a median age of 41 days, before development of diabetes. At T1D diagnosis, a subcutaneous insulin pellet was implanted, oral glucose tolerance test was performed 21 days later, and tissues were collected 25 days after onset of T1D. Pancreas and liver tissues were assessed by histology and RT-qPCR. Fecal microbiota composition was analyzed by 16S V4 sequencing., Results: Postoperatively, DJB rats weighed less than sham rats (287.8 vs 329.9 g, P = 0.04). In both groups, 14 of 15 rats developed T1D, at similar age of onset (87 days in DJB vs 81 days in sham, P = 0.17). There was no difference in oral glucose tolerance, fasting and stimulated plasma insulin and c-peptide levels, and immunohistochemical analysis of insulin-positive cells in the pancreas. DJB rats needed 1.3 ± 0.4 insulin implants vs 1.9 ± 0.5 in sham rats (P = 0.002). Fasting and glucose stimulated glucagon-like peptide 1 (GLP-1) secretion was elevated after DJB surgery. DJB rats had reduced markers of metabolic stress in liver. After DJB, the fecal microbiome changed significantly, including increases in Akkermansia and Ruminococcus, while the changes were minimal in sham rats., Conclusion: DJB does not protect against autoimmune T1D in BBDP/Wor rats, but reduces the need for exogenous insulin and facilitates other metabolic benefits including weight loss, increased GLP-1 secretion, reduced hepatic stress, and altered gut microbiome.

Background: Non-alcoholic fatty liver disease (NAFLD)/steatohepatitis (NASH) is the hepatic manifestation of metabolic syndrome. Our aim was to study the long-term effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on NAFLD/NASH., Methods: Between 2008 and 2015, 3813 patients had an intraoperative liver biopsy performed at the time of primary RYGB and SG at a single academic center. Utilizing strict inclusion criteria, 487 patients with biopsy-proven NAFLD who had abnormal alanine aminotransferase (ALT) or aspartate aminotransferase (AST) values (≥ 40 IU/L) at baseline were identified. Matching of SG to RYGB patients (1:4) was performed via logistic regression and propensity scores adjusting for clinical and liver histological characteristics. Changes in liver function tests (LFTs) at least 1 year after surgery were compared to baseline values and between the surgical groups., Results: A total of 310 (weighted) patients (SG n = 62, and RYGB n = 248) with a median follow-up time of 4 years (range, 1-10) were included in the analysis. The distribution of covariates was well-balanced after propensity matching. In 84% of patients, LFT values normalized after bariatric surgery at the last follow-up time. The proportions of patients having normalized LFT values did not differ significantly between the SG and RYGB groups (82% vs. 84%, p = 0.66). The AST decreased from (SG: 49.1 ± 21.5 vs. RYGB: 49.3 ± 22.0, p = 0.93) at baseline to (SG: 28.0 ± 16.5 vs. RYGB: 26.5 ± 15.5, p = 0.33) at the last follow-up. Similarly, a significant reduction in ALT values from (SG: 61.7 ± 30.0 vs. RYGB 59.4 ± 24.9, p = 0.75) at baseline to (SG: 27.2 ± 21.5 vs. RYGB: 26.1 ± 19.2, p = 0.52) at the last follow-up was observed., Conclusions: In patients with biopsy-proven NAFLD/NASH, abnormal LFTs are normalized in most SG and RYGB patients by the end of the first postoperative year and remain normal until the last follow-up. This study also suggests that both bariatric procedures are similarly effective in improving liver function.

Introduction: Bariatric and metabolic surgery significantly improves type 2 diabetes mellitus (T2DM). However, a small percentage of patients after bariatric surgery either have persistent hyperglycemia or relapse of their T2DM. These patients are usually medically managed. The aim of this study was to evaluate the effect of revisional surgery on the glycemic status of patients with T2DM who either failed to remit or relapsed after an initial remission following bariatric surgery., Methods: Metabolic parameters and clinical outcomes of 81 patients with persistent or relapsed T2DM after revisional bariatric surgery at an academic center between 2008 and 2017 were studied., Results: The most common types of revisional surgery were pouch and/or stoma revision of Roux-en-Y gastric bypass (RYGB) (n = 22, 27.2%), conversion of vertical banded gastroplasty (VBG) to RYGB (n = 20, 24.7%), conversion of adjustable gastric banding (AGB) to RYGB (n = 14, 17.3%), and conversion of sleeve gastrectomy (SG) to RYGB (n = 13, 16%). Revision of pouch/stoma after RYGB yielded improvement of T2DM in 50% of patients and remission in 22.7%. Conversion to RYGB yielded improvement of T2DM in 55%, 35.7%, and 30.8% of patients who previously had VBG, AGB, or SG, respectively. Furthermore, conversion of VBG, AGB, and SG to RYGB was associated with diabetes remission rates of 35%, 35.7%, and 23.1%, respectively., Conclusion: Findings of this study, which is the largest series to date, indicate that revisional surgery in patients with persistent or relapsed T2DM after bariatric surgery can significantly improve glucose control and use of diabetes medications. Further clinical and mechanistic studies are needed to better demonstrate the role of revisional bariatric surgery in patients with residual T2DM.

Background: Perioperative pulmonary complications are frequent in patients with interstitial lung diseases (ILD). Limited literature exists regarding the safety of bariatric procedures in patients with ILD. This study aims to assess the safety, feasibility, and outcomes of patients with ILD who underwent bariatric surgery at our institution., Methods: After IRB approval, all patients with preoperative diagnosis of ILD who had bariatric surgery at an academic center between 2004 and 2014 were retrospectively reviewed., Results: A total of 25 patients with ILD underwent bariatric surgery: Roux-en-Y gastric bypass (n = 17, 68%), sleeve gastrectomy (n = 7, 28%), and adjustable gastric banding (n = 1, 4%). Twenty-one patients (84%) were females. The median age and preoperative body mass index (BMI) were 53 (IQR 42-58) years and 39 (IQR 37-44) kg/m 2 , respectively. The median operative time and length of stay was 137 (IQR 110-187) min and 3 (IQR 2-5) days, respectively. The 30-day complications were reported in four patients (16%) but there was no pulmonary complication or unplanned admission to the intensive care unit. At 1-year follow-up (85%), the median BMI and excess weight loss were 30 (IQR 25-36) kg/m 2 and 67% (IQR 45-100), respectively. Compared to preoperative values, there was significant improvement in the pulmonary function test (PFT) variables at 1 year with respect to forced vital capacity (62% vs 74%; n = 13, p = 0.003), and diffusing capacity of the lungs for carbon monoxide (53% vs 66%; n = 10, p = 0.003). Six out of the seven potential lung transplant candidates became eligible for transplantation after weight loss, and one of them had successful lung transplant at 88 months after bariatric surgery., Conclusion: In our experience, bariatric patients with ILD achieved significant weight loss and improvement in PFT. Bariatric surgery in these higher risk ILD patients appears relatively safe with acceptable perioperative morbidity and improved candidacy for lung transplantation.

Background: Bariatric surgery has been shown to improve and resolve diabetes. However, limited literature about its impact on end-organ complications of diabetes is available. The aim of this study was to examine the long-term effect of bariatric surgery on albuminuria., Methods: We studied 101 patients with pre-operative diabetes and albuminuria [defined as urine albumin:creatinine ratio (uACR) > 30 mg/g] who underwent bariatric surgery at an academic center from 2005 to 2014., Results: Fifty-seven patients (56%) were female with a mean age of 53 (± 11) years. The mean pre-operative BMI and glycated hemoglobin (HbA1c) were 43.1 (± 7.6) kg/m 2 and 8.4 (± 1.8)%, respectively. The median pre-operative uACR was 80.0 (45.0-231.0) mg/g. Bariatric procedures included Roux-en-Y gastric bypass (n = 75, 74%) and sleeve gastrectomy (n = 26, 26%). The mean follow-up period was 61 (± 29) months. At last follow-up, the mean BMI was 33.8 (± 8.3) kg/m 2 . The overall glycemic control improved after bariatric surgery. At last follow-up, 73% had good glycemic control (HbA1c < 7%) and 27% met diabetes remission criteria. The mean HbA1c at last follow-up was 6.7 (± 1.0)% and the median uACR was 30 (IQR 7-94) mg/g. Albuminuria improved in 77% and resolved in 51% of patients at long-term., Conclusions: Bariatric surgery has a significantly positive impact on albuminuria in patients with obesity and type 2 diabetes. Our data showed almost an 80% improvement in albuminuria at the short- and long-term period after bariatric surgery.

Background: During the 2004 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), a panel of experts convened to provide updated information on best practices in bariatric surgery. The rapid evolution of endoluminal technologies, surgical indications, and training in bariatric surgery since 2004 has led to new questions and concerns about optimal treatment algorithms, patient selection, and the preparation of our current and future bariatric workforce., Methods: An expert panel was convened at the SAGES 2017 annual meeting to provide a summative update on current practice patterns, techniques, and training in bariatric surgery in order to review and establish best practices. This was a joint effort by SAGES, International Society for the Perioperative Care of the Obese Patient, and the American Society for Metabolic and Bariatric Surgery., Results: On March 23, 2017, seven expert faculty convened to address current areas of controversy in bariatric surgery and provide updated guidelines and practice recommendations. Areas addressed included the expanded indications for use of metabolic surgery in the treatment of diabetes, the safety and efficacy of new and investigational endoluminal procedures, updates on new guidelines for the management of airway and sleep apnea in the obese patient, the development of clinical pathways to reduce variation in the management of the bariatric patient, and new guidelines for training, credentialing, and bariatric program accreditation. The following article is a summary of this panel., Conclusion: Bariatric surgery is a field that continues to evolve. A timely, systematic approach, such as described here, that coalesces data and establishes best practices on the current body of available evidence is imperative for optimal patient care and to inform provider, insurer, and policy decisions.

Background: Currently there is no consensus on management of ventral hernias encountered during bariatric surgery (BS). This study aims to evaluate the incidence and outcomes of concomitant ventral hernia repair (VHR) during BS at our institution., Methods: Patients who had concomitant VHR during BS from 2004 to 2015 were identified. Data collected included baseline demographics, comorbidities, perioperative parameters, surgical approach and postoperative outcomes., Results: A total of 159 patients underwent concomitant VHR during the study period at the time of BS. One hundred and one (64 %) patients were female; median age was 53 years (IQR 45.0-60.3) and median BMI was 48.2 kg/m 2 (IQR 41.6-54.1). Comorbidities included: hypertension (n = 124, 78 %), type 2 diabetes (n = 103, 65 %), hyperlipidemia (n = 100, 63 %), obstructive sleep apnea (n = 98, 62 %) and reflux disease (n = 54, 34 %). Out of 159 patients, 41 patients (26 %) had a prior VHR. Out of 103 patients, 69 patients (67 %) had a previous abdominal surgery. Of the concomitant VHR, 144 (91 %) were completed laparoscopically, 12 (7 %) patients were converted to open surgery and 3 (2 %) patients underwent primary open procedures. Technique included primary suture closure in 115 (72 %) and mesh repair in 44. Early postoperative complications (<30 days) were reported in 16 (10 %) patients, with superficial wound infection (n = 9), bowel obstruction (n = 2), marginal ulcer (n = 2), DVT (n = 1) and pneumonia (n = 1). Hernia recurrence was reported in 3 patients (2 %) in the early post-op period and in 40 patients (25 %) as a late (>30 days) complication. Surgery for recurrent hernia was performed in 31/42 patients during follow-up. At 12-month follow-up, median BMI and % excess weight loss were 34.2 kg/m 2 (IQR 29.5-40.9) and 59.6 % (IQR 44.9-74.8 %), respectively., Conclusion: Ventral hernia is a common finding in patients undergoing BS. Both primary suture repair and mesh repair result in acceptable results, both in terms of recurrence and perioperative complications.

Introduction: The laparoscopic approach to inguinal hernia repair (IHR) has proven beneficial in reducing postoperative pain and facilitating earlier return to normal activity. Except for indications such as recurrent or bilateral inguinal hernias, there remains a paucity of data that specifically identities patient populations that would benefit most from the laparoscopic approach to IHR. Nevertheless, previous experience has shown that obese patients have increased wound morbidity following open surgical procedures. The aim of this study was to investigate the effect of a laparoscopic versus open surgical approach to IHR on early postoperative morbidity and mortality in the obese population using the National Surgical Quality Improvement Program (NSQIP) database., Methods: All IHRs were identified within the NSQIP database from 2005 to 2013. Obesity was defined as a body mass index ≥30 kg/m 2 . A propensity score matching technique between the laparoscopic and open approaches was used. Association of obesity with postoperative outcomes was investigated using an adjusted and unadjusted model based on clinically important preoperative variables identified by the propensity scoring system., Results: A total of 7346 patients met inclusion criteria; 5573 patients underwent laparoscopic IHR, while 1773 patients underwent open IHR. On univariate analysis, obese patients who underwent laparoscopic IHR were less likely to experience a deep surgical site infection, wound dehiscence, or return to the operating room compared with those who underwent an open IHR. In both the adjusted and unadjusted propensity score models, there was no difference in outcomes between those who underwent laparoscopic versus open IHR., Conclusions: The laparoscopic approach to IHR in obese patients has similar outcomes as an open approach with regard to 30-day wound events. Preoperative risk stratification of obese patients is important to determining the appropriate surgical approach to IHR. Further studies are needed to investigate the long-term effects of the open and laparoscopic approaches to IHR in the obese population.

Background: Due to the steady increase in patients on chronic dialysis, more of these patients are undergoing elective operations. The literature on safety and postoperative outcomes in dialysis-dependent patients following elective bariatric surgery is scant. We compared the 30-day major morbidity and mortality rates in dialysis-dependent (DD) and non-dependent (ND) patients after primary bariatric surgery., Methods: From American College of Surgeons National Surgical Quality Improvement Program, we identified patients, who underwent primary bariatric surgery between 2005 and 2013. Thirty-day postoperative outcomes were compared between DD and ND patients. Logistic regression was used to determine the prognostic impact of dependence on chronic dialysis on the 30-day postoperative outcomes., Results: Two hundred and thirty-four DD and 113,677 ND patients were analyzed. DD patients had a higher baseline risk profile compared to ND patients. Thirty-day mortality rates for DD and ND patients were 0.43 and 0.11 %, respectively (P = 0.134). DD patients had a higher 30-day major morbidity compared to ND patients (5.98 vs. 2.31 %; P < 0.001, respectively). Despite a crude OR of 2.70 (95 % CI 1.57-4.63) after adjusting for confounding, dependence on dialysis was not found to be an independent predictor of major morbidity., Conclusions: Primary bariatric surgery is safe in patients dependent on dialysis with an acceptable 30-day postoperative morbidity and mortality. Even though dependence on dialysis does not independently increase the risk of 30-day adverse outcomes following primary bariatric surgery, the comorbid conditions in this patient population render them at risk. The higher prevalence of major morbidities in this group is mainly due to the impact from older age, male sex, higher BMI, cardiac comorbidities, and hypertension.

Background: Readmission rate is an indicator of quality in surgical practice. We aimed to determine the predictors of unplanned early readmissions following stapling bariatric surgeries., Methods: From the American College of Surgeons National Surgical Quality Improvement Program database, we identified morbidly obese patients, who underwent either laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) in 2012 and 2013. Demographic, comorbidities, operative and postoperative parameters of the readmitted (within 30 days) and non-readmitted patients were evaluated using a multivariate logistic regression analysis., Results: A total of 35,655 patients (17,101 LSG and 18,554 LRYGB) were analyzed. Of those, 1758 patients (4.9 %) were readmitted within 30 days of surgery. Multivariate analysis showed the following significant predictors for readmission: Non-Hispanic black ethnicity (OR: 1.56, 95 % CI:1.34-1.81), Hispanic ethnicity (OR: 1.29, 95 % CI:1.05-1.58), totally or partially dependent functional status (OR: 1.94, 95 % CI:1.06-3.55), higher preoperative creatinine (OR: 1.13, 95 % CI:1.04-1.22), lower serum albumin (OR: 0.78, 95 % CI:0.68-0.90), diabetes mellitus on insulin (OR: 1.28, 95 % CI:1.09-1.51), steroid or immunosuppressant use for a chronic condition (OR: 1.61, 95 % CI:1.11-2.33), history of cardiac disease with intervention (OR: 2.05, 95 % CI:1.10-3.83), bleeding disorders (OR: 1.71, 95 % CI:1.15-2.54), LRYGB versus LSG (OR: 1.63, 95 % CI:1.44-1.85), longer operative time (OR: 1.13, 95 % CI:1.07-1.20), concurrent splenectomy (OR: 4.10, 95 % CI:1.05-16.01), and occurrence of any postoperative complication during index admission (OR: 2.61, 95 % CI:1.99-3.42)., Conclusions: Ethnicity, baseline functional status, comorbidities, type and duration of surgical procedure, and postoperative complications occurred in the index admission can predict risk of early readmission following LRYGB and LSG.

Introduction: The risk of venous thromboembolic (VTE) events is increased in patients undergoing bariatric surgery. Population studies examining VTE rates after bariatric surgery often lack details and uniformity regarding the prophylactic regimens used. The aim of this study was to determine the incidence of VTE in patients undergoing laparoscopic bariatric surgery., Methods: Database searches from Cleveland Clinic bariatric surgery programs in Cleveland, OH, and Weston, FL, were conducted from January 2005 to January 2013. Mechanical and chemical prophylaxes were provided for all patients as per protocol. Data on age, gender, body mass index (BMI), interval between procedure and VTE, inpatient versus outpatient status, anticoagulation prophylaxis, type of surgery and mortality were collected., Results: A total of 4,293 patients underwent primary or revisional bariatric surgery during this 8-year time period. VTE events were identified in 57 patients (1.3 %). Pulmonary embolism (PE) was identified in 39 patients (0.9 %), and 15 of these patients had negative duplex studies of the lower extremities. Deep venous thrombosis only was identified in 18 patients (0.4 %). VTE rates for gastric bypass (n = 2,945), sleeve gastrectomy (n = 709), gastric banding (n = 467) and revisional procedures (n = 171) were 1.1, 2.9, 0.2 and 6.4 %, respectively. Eight patients had VTE diagnosed during their inpatient stay. The mean time to VTE diagnosis after surgery was 24 days. Seventeen patients who developed VTE had been prescribed extended prophylaxis for 2-4 weeks after discharge. There was only one VTE-related mortality from PE reported in this cohort (0.02 %). Univariate and multivariate analyses revealed age, BMI, open and revisional surgery as predictive of VTE (p < 0.05)., Conclusion: The risk of VTE among morbidly obese patients undergoing bariatric surgery is persistent despite use of laparoscopy and aggressive prophylactic anticoagulation policy. Patients with advanced age, higher BMI and those undergoing open or revisional surgery are at higher risk of postoperative VTE.

Complications of laparoscopic adjustable gastric banding (LAGB) include band slippage, material infection, and band erosion. Band erosion can lead to chronic infection, obstruction, delayed perforation, and ineffectiveness; therefore, removal is indicated. A myriad of approaches exist for band removal and many authors have described novel techniques. A minimally invasive approach, including laparoscopic or endoscopic assistance, is favored given the reduction of postoperative complications compared with laparotomy. We present a novel approach to band retrieval following partial erosion involving a complete endoscopic/transgastric technique. Perioperative management and a review of the literature also are described.

Background: Obesity is associated with a chronic low-grade inflammatory state, insulin resistance, and endothelial dysfunction, all of which contribute to increased risk of cardiovascular disease. We hypothesized that gastric bypass would produce rapid improvements in endothelial function, reduce inflammation, and lead to a decrease in cardiovascular risk., Methods: We performed a prospective study of morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB). Clinical data, biochemical markers of inflammation, and parameters indicative of cardiovascular risk were collected preoperatively and at 3 and 6 months postoperatively. Metabolic and inflammatory mediators that were quantified included C-reactive protein, fibrinogen, PAI-1, IL-6, IL-10, IL-1Ra, adiponectin, leptin, triglycerides, total cholesterol, HDL, LDL, glucose, insulin, and HbA1c. Brachial artery reactivity testing (BART) was performed to assess peripheral arterial endothelial function, and Framingham cardiovascular risk score (FRS) was calculated on all study participants pre- and postoperatively., Results: Fifteen patients (11 female) were enrolled (age = 49.2 ± 10.4 years; BMI = 48.1 ± 5.3 kg/m(2)). Six months post RYGB, mean BMI decreased to 35.4 ± 4.5, corresponding to 51.7% excess weight loss (P < 0.001). Mean waist circumference decreased significantly from 132 cm at baseline to 110 cm at 3 months (P = 0.003) and 107 cm at 6 months (P < 0.001). Six months after RYGB, weight loss led to significant improvements in clinical parameters indicative of cardiovascular disease or risk, including brachial artery diameter, endothelial independent vasodilation, and FRS. Favorable improvements in the proinflammatory markers CRP (P = 0.01) and leptin (P = 0.005), the anti-inflammatory mediator adiponectin (P = 0.002), and insulin sensitivity (HOMA-IR, P = 0.007) were evident at 3 months. At 6 months, improvements in CRP, leptin, and fasting insulin were maintained and fibrinogen levels also decreased (P = 0.047). Adiponectin continued to increase at 6 months (P = 0.004)., Conclusion: Gastric bypass is associated with early reversal of endothelial dysfunction, a more favorable inflammatory milieu, and, most importantly, a reduction in cardiovascular risk.