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Bariatric surgery complications carry a high rate of morbidity and mortality. This review highlights the pearls and pitfalls of bariatric surgery complications, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. Bariatric surgeries include restrictive procedures (e.g., adjustable gastric banding, endoscopic gastric balloon insertion, and sleeve gastrectomy) and mixed restrictive and malabsorptive procedures (e.g., roux-en-y gastric bypass and duodenal switch-biliopancreatic diversion). Several complications may occur, which may be associated with severe morbidity and mortality. These complications include anastomotic/staple line leaks, small bowel obstruction and internal hernia, marginal ulceration, biliary disease, and device-specific issues. History concerning the type of surgery, when and where it was performed, prior complications, changes in weight, and systemic symptoms is essential. Many signs and symptoms are subtle, but fever, tachycardia, and persistent vomiting are concerning for a severe complication. If there is concern for a complication, emergent consultation with the bariatric surgeon is recommended (preferably the patient's surgeon). Imaging studies can assist in the evaluation, including computed tomography with oral and intravenous contrast. Resuscitation in the ED and early intervention by a bariatric surgeon provide the best opportunity to reduce morbidity and mortality for patients with intra-abdominal pathology. Understanding bariatric surgery complications can assist emergency clinicians in diagnosing and managing this potentially deadly disease. [ABSTRACT FROM AUTHOR]

• High rates of childhood obesity have led to increased use of pediatric metabolic and bariatric surgery. • Pediatric metabolic and bariatric surgery results in durable improvements related illnesses. • Significant knowledge gaps remain following approval of GLP-1 agonists for the treatment of childhood obesity (≥12 years of age). • Guidance for GLP-1 use prior to or following pediatric metabolic and bariatric surgery are needed. • Comparative studies (GLP agonists versus pediatric metabolic and bariatric surgery) are needed. [ABSTRACT FROM AUTHOR]

Metabolic/bariatric surgery (MBS) is the most effective treatment for obesity, yet many factors influence successful individual weight loss. Among those are a variety of health behaviors that are assessed in the process of presurgical psychological evaluations, including eating pathology and sleep disturbance (both of which are relatively common among surgical candidates). This study aims to examine the relationship between sleep, binge eating, and night eating behaviors among individuals seeking MBS. Medical center and private psychological practice in Mississippi. Patients (N = 311) seeking presurgical psychological evaluations for bariatric surgery completed self-report measures. Of these, 83.0% were females and 70.7% of those with ethnicity data identified as White. Average body mass index (BMI) in the sample was 46.5 (standard deviation [SD] = 8.02). Correlations between variables were calculated and examination of the indirect effect of sleep disturbance on night eating as mediated by binge eating was conducted. Sleep disturbance, binge eating, and night eating were significantly associated (b =.22–.45). Mediation analysis yielded a significant indirect effect, indicating that binge eating propensity explains the relationship between impaired sleep and night eating symptoms (b =.09, standard error [SE] =.03, confidence interval [CI]:.04–.18). The observed relationship between sleep disturbance, night eating, and binge eating among bariatric candidates provides implications for future research and treatment approaches. Specifically, additional attention to sleep disturbance in the presurgical assessment process and consideration of sleep hygiene as a potential target for intervention may facilitate improvements in overall health, adjustment, and sustained weight loss. [ABSTRACT FROM AUTHOR]

Breast hypertrophy may cause significant suffering, such as back- and breast pain, painful shoulder groves, and eczemas. Furthermore, women with breast hypertrophy may have lower quality of life than women without breast hypertrophy. Although 50% of the women undergoing breast reduction in the US have body mass index (BMI) >30 kg/m2, the current standard of normality is based on studies focusing on women <40 years of age and BMIs <25 kg/m2. This study aimed to present reference values for breast measurements for women with obesity and to investigate the relationship between BMI loss and each breast measurement. One hundred and six women underwent laparoscopic Roux-en-Y gastric bypass in Gothenburg, Sweden. The participants' breast anthropometrics were measured before and after bariatric surgery and their perception of the skin on their breasts was measured using the Sahlgrenska Excess Skin Questionnaire. Breast volume, sternal notch to nipple (SNN) distance, and ptosis increased significantly with increasing BMI. For instance, women with BMIs between 30–34.9 kg/m2 have a mean breast volume of approximately 770 ml, those with BMIs of 40–44.9 kg/m2 have approximately 1150 ml, and those with BMIs above 50 kg/m2 have approximately 1400 ml. Furthermore, the percent change in the respective breast measurements relative to percent BMI change can be predicted, for instance, with a 20% reduction in BMI, the breast volume, SNN-distance, and ptosis decrease by 25%, 4%, and 20% respectively. This article presents the first standard of normality for breast anthropometrics in women with obesity and a model for predicting the change in breast anthropometrics relative to BMI. This is a longitudinal observation study, registered https://fou.nu/is/gsb/ansokan/49651 , No: VGFOUGSB-49651. Trial registry name: "Överskottshud efter överviktskirurgi – dess utveckling samt behov och effekt av plastikkirurgi" ("Excess skin after bariatric surgery – its development and the need and effect of plastic surgery"). [ABSTRACT FROM AUTHOR]

Psychological testing is used in some preoperative psychological evaluations of patients seeking metabolic and bariatric surgery. The Minnesota Multiphasic Personality Inventory-3 (MMPI-3) contains new norms, updated item content, and new scales such as Eating Concerns and Impulsivity, which are relevant to the assessment of patients seeking metabolic and bariatric surgery. The goal of this investigation was to establish convergent and discriminant properties of the MMPI-3 scales with relevant clinical interview and medical record data from electronic medical records. Academic medical center in the Midwest. A sample of 790 consecutive patients who completed a preoperative psychological evaluation and took the MMPI-3 were included. Data from medical records and the assessment report were coded by a trained research assistant. MMPI-3 scale scores demonstrated good convergent and discriminant validity. For instance, the Emotional/Internalizing Dysfunction scales correlated with depression and anxiety disorder, suicide history, sexual abuse history, psychotropic medication use, and eating behaviors. Behavioral/Externalizing Dysfunction scales correlated with alcohol, nicotine, and substance use and eating behaviors such as loss-of-control overeating. The Eating Concerns scale demonstrated the highest correlational patterns with various eating behaviors such as loss-of-control overeating, binge eating, and stress eating. MMPI-3 scale scores perform as well as their Minnesota Multiphasic Personality Inventory-2 Restructured Form counterparts. Newer scales, such as Eating Concerns and Impulsivity, perform particularly well in the assessment of various eating behaviors. [ABSTRACT FROM AUTHOR]

Laparoscopic sleeve gastrectomy (LSG) is the most common Bariatric procedure in the United States; however, the frequency of conversion to Roux-en-Y gastric bypass (RYGB) is unknown. The primary aim was to determine the conversion rate over time from LSG to RYGB. The secondary objectives were to evaluate factors associated with conversion and postconversion weight loss outcomes. Single Academic Institution, Center of Bariatric Excellence. A retrospective analysis of all LSG from 2011 to 2020 was done. Kaplan-Meier analysis was utilized to estimate the conversion rate over time after LSG. Cox regression was utilized to identify predictors of future conversion. Of 875 LSGs, 46 were converted to RYGB from 2011 to 2020. Median follow-up was 2.6 years, and 7-year follow-up rate was 59.9%. The 1-year conversion rate was 1.4%, increasing to 3.8%, 9.0%, and 12.6% at 3, 5, and 7 years respectively. Female gender (hazard ratio [HR] = 4.2, P =.05) and age <55 (HR = 3.5, P =.04) were associated with greater chance of conversion. Preoperative asthma (HR = 1.7, P =.14) and gastroesophageal reflux disease (GERD) (HR = 1.5, P =.18) trended toward higher conversion but were not significant. Of those with body mass index (BMI) >35 at time of conversion, the mean total body weight loss (TBWL) was 13.0% at the time of conversion. This subgroup had additional 13.6% of TBWL 1-year after conversion. Conversion of LSG to RYGB increased with time to 12.6% conversion rate at 7-years. Patients with GERD prior to LSG had a nonsignificant trend toward conversion, while younger patients and females had significantly higher rates of conversion. There may be additional weight loss benefit for patients converted to RYGB. • Seven years after LSG, over 12% of patients have refractory GERD necessitating conversion to RYGB. • Younger patients (<55 years old) and females had significantly higher rates of conversion for refractory GERD. • Patients undergoing LSG conversion to RYGB for refractory GERD benefit from additional weight loss at 1 year. [ABSTRACT FROM AUTHOR]

Metabolic and bariatric surgery (MBS) leads to beneficial and sustained outcomes. However, many patients evidence weight recurrence and psychosocial functioning may be associated with weight recurrence. The Minnesota Multiphasic Personality Inventory – 3 (MMPI-3) is validated for use in presurgical MBS evaluations and likely has clinical utility in understanding weight recurrence and other aspects of postoperative functioning. The objective of the current investigation is to understand how postoperative psychosocial functioning relates to weight recurrence and other behaviors and constructs 6 years after MBS. Cleveland Clinic Bariatric and Metabolic Institute. A sample of 163 participants consented to take a battery of self-report measures related to psychological functioning, eating behaviors, adherence, alcohol misuse, and quality of life along with their postoperative weight. MMPI-3 scale scores were prorated from the Minnesota Multiphasic Personality Inventory – 2 – Restructured Form (MMPI-2-RF) or scored from the Minnesota Multiphasic Personality Inventory – 2 – Restructured Form – Expanded (MMPI-2-RF-EX). Weight recurrence was quite variable in this sample. Postoperative MMPI-3 scales related to emotional/internalizing dysfunction were modestly associated with higher weight recurrence. Postoperative MMPI-3 scale scores also demonstrated associations with other postoperative outcomes including measures of eating behaviors, adherence, alcohol misuse, and quality of life. Postoperative psychosocial functioning as assessed by the MMPI-3 was associated with weight recurrence and a number of other problematic psychological outcomes beyond weight recurrence. • A new version of a widely-used psychological test, the Minnesota Multiphasic Personality Inventory – 3 (MMPI-3) contains new norms, updated item content, and new scales relevant to the prediction of outcomes of patients seeking metabolic and bariatric surgery (MBS). • Higher scale scores on the MMPI-3 were associated with weight recurrence 6-years after surgery. • Poorer eating behaviors, adherence, alcohol misuse, and quality of life were also associated with higher postoperative MMPI-3 scale scores. [ABSTRACT FROM AUTHOR]

Current evidence recommends dietary counselling with a registered dietitian (RD) for successful weight loss after metabolic bariatric surgery; however, there are limited data on the effect of RD follow-ups on micronutrient deficiencies. This study evaluated the effects of the number of postoperative RD visits on nutritional outcomes, including weight loss and micronutrient deficiencies. The aim of this study was to evaluate the effects of the number of postoperative registered dietitian visits on nutritional outcomes, including weight loss and micronutrient deficiencies after metabolic and bariatric surgery. Cleveland Clinic Abu Dhabi, United Arab Emirates This retrospective study included patients who underwent bariatric surgery between September 2015 and June 2020. Demographics, weight loss, micronutrients, and the number of postoperative RD visits were evaluated. Baseline and 12-month postsurgery outcomes were compared based on the number of RD follow-ups. A total of 174 primary and 46 revisions were included. Patients were 73.6% female, with a mean age of 40 years. The initial mean body mass index was 42.8 kg/m2. Number of RD visits were as follows: 0–1 (39 patients), 2 (59 patients), 3 (55 patients), and 4 or more (67 patients). Baseline (pre-operative) micronutrient values were within normal range. In comparison with the reference group (REF = 0–1 post-op RD visits), patients with 3 RD visits had 7% higher total body weight loss (P <.001) and maintained micronutrients within the normal range at 12 months postoperative. Mean differences in postoperative values were statistically significant (P <.05) for weight, vitamin B12, and vitamin D but not for hemoglobin, ferritin, calcium, folate, vitamin B1, copper, and zinc. Our study suggests that three or more RD visits during the first 12 months after bariatric surgery are associated with improved outcomes, including significant percent total body weight loss and lower rates of micronutrient deficiencies. [ABSTRACT FROM AUTHOR]

Marginal ulceration (MU) is a significant cause of morbidity after Roux-en-Y gastric bypass (RYGB). Proton pump inhibitors (PPIs) are the primary treatment. Prior limited data suggest that open-capsule PPIs (OC-PPIs) improve MU healing compared with intact-capsule PPIs (IC-PPIs), necessitating further validation. We aimed to compare healing times of MU after RYGB when treated with OC-PPIs versus IC-PPIs. Tertiary academic center, United States. We retrospectively analyzed patients with prior RYGB diagnosed with MU from 2012 to 2022. Patients requiring mechanical closure without documented healing and without clear PPI prescriptions were excluded. The primary outcome was time to ulcer healing. Log-rank testing and Kaplan–Meier survival curve analyses were performed to compare MU healing times when treated with OC-PPIs versus IC-PPIs. Subgroup analyses further characterized ulcer healing times based on type and dosage of PPI used. A total of 108 patients were included for final analysis (38 received OC-PPIs and 70 received IC-PPIs). Treatment with OC-PPIs significantly decreased MU healing time compared with IC-PPIs (146.18 versus 226.14 d; p =.018). However, when stratified by PPI potency, the positive effect of opening the capsule lost significance. In this study, OC-PPIs significantly improved MU healing times compared with IC-PPIs in RYGB patients, consistent with prior data. However, on subgroup analysis comparing therapy with similar PPI potency, the MU healing time did not differ with respect to administration method. These results highlight the need for a prospective randomized trial to compare the true effect of administration method. [ABSTRACT FROM AUTHOR]

Metabolic and bariatric surgery is effective for sustained weight loss, but binge eating disorder (BED) can be associated with poorer outcomes and lead to weight regain. A common measure used to screen for BED is the Binge Eating Scale (BES). A BES cut-off score of ≥17 previously identified patients who have a high likelihood of meeting criteria for BED. The Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition (DSM-5), lowered the threshold for meeting criteria for BED, and the psychometrics of the BES need to be reevaluated. The objective of the current investigation is to evaluate whether alternative cut-scores on the BES result in better classification of BED based on the DSM-5 revision of the the BED diagnostic criteria. Academic medical hospital in the Midwestern United States. Patients (n =1133) seeking metabolic and bariatric surgery were randomly split into 2 samples for validation and replication. The validation sample consisted of 561 patients (30.1% men, 35% non-White). The replication sample consisted of 572 patients who were demographically similar to the first random split sample (e.g., 25.3% men, 34.4% non-White). Of these patients, 13.5% met DSM-5 criteria for BED in the validation sample and 13.8% met criteria for BED in the replication sample. Lowering the interpretative cut-off to ≥15 on the BES yielded sensitivity values of >.72, specificity values of >.67, and an accurate classification of BED in >.70 of patients across both samples. These classification values were as good as or better than the standard cut-off score of ≥17 in both samples. The BES is appropriate to screen for BED in patients who are seeking bariatric surgery. A 2-point decrease in the BES score for clinical interpretation is appropriate—lowering it from 17 to 15 given DSM-5 updates to diagnostic criteria. [ABSTRACT FROM AUTHOR]

Obesity can be termed a chronic disease defined by excessive adiposity presenting a risk to health, with wide-ranging complications and reduced life expectancy. The rising prevalence of obesity in childhood poses a significant public health challenge, in the UK and globally. Obesity is a complex disease with sequelae in every system in the body. These include type 2 diabetes, hypertension, obstructive sleep apnoea, dyslipidaemia, non-alcoholic fatty liver disease, increased risk of malignancy, orthopaedic conditions, and mental health problems. Obesity should be screened for and managed pro-actively in children and young people to improve long-term outcomes. This article provides an overview of managing excess weight gain in childhood considering aetiology, assessment, lifestyle, pharmacological and surgical interventions, and potential complications. [ABSTRACT FROM AUTHOR]

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. 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. Northeastern hospital in the United States. 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. The 3-factor structure ("Restraint," "Weight/Shape Concerns," and "Body Dissatisfaction") of the EDE-Q-BF fit the data well (χ 2 [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. 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. [ABSTRACT FROM AUTHOR]

Introduction: This study aims to identify risk factors associated with 30-day major complications, readmission, and delayed discharge for patients undergoing robotic bariatric surgery. Methods: From the metabolic and bariatric surgery and accreditation quality improvement program (2015–2018) datasets, adult patients who underwent elective robotic bariatric operations were included. Predictors for 30-day major complications, readmission, and delayed discharge (hospital stay ≥ 3 days) were identified using univariable and multivariable analyses. Results: Major complications in patients undergoing robotic bariatric surgery were associated with both pre-operative and intraoperative factors including pre-existing cardiac morbidity (OR = 1.41, CI = [1.09–1.82]), gastroesophageal reflux disease [GERD] (OR = 1.23, CI = [1.11–1.38]), pulmonary embolism (OR = 1.51, CI = [1.02–2.22]), prior bariatric surgery (OR = 1.66, CI = [1.43–1.94]), increased operating time (OR = 1.003, CI = [1.002–1.004]), gastric bypass or duodenal switch (OR = 1.58, CI = [1.40–1.79]), and intraoperative drain placement (OR = 1.28, CI = [1.11–1.47]). With regard to 30-day readmission, non-white race (OR = 1.25, CI = [1.14–1.39]), preoperative hyperlipidemia (OR = 1.16, CI = [1.14–1.38]), DVT (OR = 1.48, CI = [1.10–1.99]), therapeutic anticoagulation (OR = 1.48, CI = [1.16–1.89]), limited ambulation (OR = 1.33, CI = [1.01–1.74]), and dialysis (OR = 2.14, CI = [1.13–4.09]) were significantly associated factors. Age ≥ 65 (OR = 1.18, CI = [1.04–1.34]), female gender (OR = 1.21, CI = [1.10–1.32]), hypertension (OR = 1.08, CI = [1.01–1.15]), renal insufficiency (OR = 2.32, CI = [1.69–3.17]), COPD (OR = 1.49, CI = [1.23–1.82]), sleep apnea (OR = 1.10, CI = [1.03–1.18]), oxygen dependence (OR = 1.47, CI = [1.10–2.0]), steroid use (OR = 1.26, CI = [1.02–1.55]), IVC filter (OR = 1.52, CI = [1.15–2.0]), and BMI ≥ 40 (OR = 1.12, CI = [1.04–1.21]) were risk factors associated with delayed discharge. Conclusion: When selecting patients for bariatric surgery, surgeons early in their learning curve for utilizing robotics should avoid individuals with pre-existing cardiac or renal morbidities, venous thromboembolism, and limited functional status. Patients who have had previous bariatric surgery or require technically demanding operations are at higher risk for complications. An evidence-based approach in selecting bariatric candidates may potentially minimize the overall costs associated with adopting the technology. [ABSTRACT FROM AUTHOR]

Creating a metric in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) to assess Black-versus-White disparities is critical if we are to ensure equitable care for all. To investigate Black-versus-White disparities while replicating MBSAQIP methodology with regard to covariates and modeling so that the results can serve as the foundation to create a benchmarked site-level Disparities Metric for MBSAQIP. United States and Canada. Across the 2015–2019 MBSAQIP cohorts, 543,976 adults underwent primary or revision sleeve gastrectomy or Roux-en-Y gastric bypass and were reported as either White or Black. Using a set of covariates derived from published MBSAQIP performance models, we performed multivariable logistic modeling with 10-fold cross-validation for the 11 outcomes evaluated in MBSAQIP Semiannual Reports, plus venous thromboembolism (VTE) and death. We analyzed primary and revision cases separately. After risk adjustment, Black patients experienced higher odds of all-occurrence morbidity (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.19–1.25; P <.001), serious events (OR, 1.08; 95% CI, 1.04–1.13; P <.001), all-cause intervention (OR, 1.31; 95% CI, 1.24–1.37; P <.001), related intervention (OR, 1.29; 95% CI, 1.22–1.37; P <.001), all-cause readmission (OR, 1.37; 95% CI, 1.33–1.41; P <.001), related readmission (OR, 1.41; 95% CI, 1.36–1.46; P <.001), venous thromboembolism (OR, 1.49; 95% CI, 1.34–1.65; P <.001), and death (OR, 1.59; 95% CI, 1.34–1.89; P <.001) after primary procedures. Black patients experienced lower odds of morbidity (OR,.94; 95% CI,.91–.98; P =.004) and surgical-site infection (OR,.72; 95% CI,.66–.78; P <.001). Black patients experienced a higher risk for serious complications and required more readmissions, reoperations, and postoperative interventions. This study supports the creation of a site-level Disparities Metric for the MBSAQIP and provides the framework to do so. [ABSTRACT FROM AUTHOR]

• Admission considerations for people with obesity include costs of care. • Nursing Assistants are coached to provide safe care to residents with obesity. • Residents with obesity have challenges transitioning back to the community. The prevalence of nursing home (NH) residents with obesity is rising. Perspectives of NH Directors of Nursing (DONs) who oversee care trajectories for residents with obesity is lacking. This study aimed to describe the experiences of NH DONs regarding care and safety for NH residents with obesity. An adapted version of Donabedian's structure-process-outcome model guided this qualitative descriptive study. Semi-structured interviews were conducted with 15 DONs. Data were analyzed using directed content analysis, and findings are presented under the model's constructs. We learned that admission decisions for NH referrals of patients with obesity are complex due to reimbursement issues, available space and resources, and resident characteristics. DONs described the need to coach and mentor Certified Nursing Assistants to provide safe quality care and that more staff education is needed. We identified novel findings regarding the challenges of short-term residents' experience transitioning out of care due to limited resources. [ABSTRACT FROM AUTHOR]

Bariatric surgery has demonstrated sustained improvements in quality. Malpractice closed claims have been offered as a means of assessing quality. Few studies have investigated malpractice closed claims and opportunities for improvement in bariatric surgery. To examine the prevalence and causes of malpractice claims with examination of prospects for quality improvement. University hospital, United States; private practice. Four national malpractice insurers participated in the closed-claims registry. Data regarding patients, staff, procedures, and hospital status were gathered from closed-claims files. Following data collection, a clinical summary of each closed claim was collected and later assessed by an expert panel on the basis of the following: contributing diagnosis and treatment events; whether complications were potentially preventable by the surgeon; the role of language, fatigue, distraction, workload, or teaching hospital/trainee supervision; communication concerns; and final care determination. A total of 175 closed claims were collected from index bariatric surgeries within the period from 2006–2014. Of these, 75.9% of surgeons were board certified and 43.3% of the hospitals were accredited for bariatric surgery. Most clinical complications after bariatric surgery that led to malpractice lawsuits were mortality (35.1%) and leaks (17.5%). While they were not the common cause for malpractice suits, bleeding (5.3%), retained foreign body (5.3%), and vascular injury (4.4%) occurred at higher rates than national averages. Prevalence of malpractice claims regarding bariatric surgery is low. Failure to diagnose, delay in treatment, postoperative care, and communication domain responses indicate future opportunities for improvement. [ABSTRACT FROM AUTHOR]

The article presents the discussion on outlining common postoperative complications after bariatric surgery. Topics include patients undergoing effective preoxygenation before induction of anaesthesia with tracheal intubation and artificial ventilation; and obesity challenging to treat and involving lifestyle, psychological factors, medical management, and surgery.

Two large nationwide databases collect data on common operations in the United States. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) collects bariatric data, whereas the National Quality Improvement Program (NSQIP) gathers details on a broader range of general surgical cases. Evaluate the differences in rates of complications between both databases regarding Roux-en-Y gastric bypass and sleeve gastrectomy. National databases, United States. We evaluated the MBSAQIP and NSQIP from 2017 to 2019 using the procedure codes 43644 and 43775. Fifteen common complications were evaluated. Propensity-matched analyses (PMAs) were done to control for differences across databases. Significantly different variables after a PMA were included in multivariable models. The data were examined for differences between the 2 databases before and after the PMA, with and without adjustment for operation type. There were 483,361 cases reported in the MBSAQIP and 57,598 in the NSQIP. PMA matched 57,479 cases for each database. Seven complications were different, with higher rates reported in the NSQIP than in the MBSAQIP: myocardial infarction, sepsis, organ/space surgical site infections, deep vein thrombosis, urinary tract infections, pulmonary embolism, ventilator dependence >48 hours, and pneumonia. When adjusting for the procedure performed, sleeve gastrectomy in the NSQIP had higher rates of organ/space surgical site infections, deep vein thrombosis, sepsis, and death. Roux-en-Y gastric bypass in the NSQIP had higher rates of organ/space surgical site infections, ventilator dependence >48 hours, urinary tract infections, myocardial infarction, deep vein thrombosis, and sepsis. When compared with the MBSAQIP, the NSQIP reports higher rates of bariatric complications. Further studies are needed to confirm the reasons behind this. [ABSTRACT FROM AUTHOR]

Background: Evidence is lacking regarding the efficacy of Optiflow transnasal humidified rapid-insufflation ventilator exchange (THRIVE™) in obese patients. We compared the impact of this technique at 70 L min-1 with 4 L min-1 oxygen via nasal prongs on safe apnoea times of paralysed obese patients.Methods: We randomised adults with a BMI >35 kg m-2 undergoing elective bariatric surgery. While apnoeic and paralysed, Group T received 70 L min-1 oxygen via Optiflow THRIVE™. Group N received nasal prong oxygen at 4 L min-1. The primary outcome was time to SpO2 ≤95% while apnoeic, with a 360 s cut-off. This was analysed by applying a time-to-event analysis.Results: Forty-two patients were included. The median (inter-quartile range) BMI was 44.8 kg m-2 (40.0-50.0) in Group T and 42.0 kg m-2 (39.3-45.1) in Group N. Median (inter-quartile range) time to SpO2 ≤95% in Group T was 356 (165 to ≥360) s and in Group N, 210 (160-270) s. Using a survival analysis framework, median time-to-event in Group T was 356 s (95% confidence interval 165 s-upper limit not defined) and 210 s (95% confidence interval 160-242 s) (P=0.049) in Group N.Conclusions: Compared with oxygen delivered via nasal prongs at 4 L min-1, oxygen delivery via Optiflow THRIVE™ at a flow rate of 70 L min-1 can prolong safe apnoea time, however, the results are statistically inconclusive. Optiflow THRIVE™ did decrease the rate of reduction in Pao2 during apnoea.Clinical Trial Registration: ANZCTR 12618000445279. [ABSTRACT FROM AUTHOR]

Initial radiologic appearance rather than management strategy predicts the outcome s of sleeve gastrectomy leaks. Multiple modalities have been advocated for the treatment of sleeve gastrectomy leak, and there remains no consensus on the best treatment paradigm. For more than 10 years, we have variably attempted luminal occlusive therapies and repeated endoscopic debridement as treatment options. By evaluating the outcomes from these approaches, we aimed to determine whether the first management strategy is superior to the second in terms of outcomes. Patients were analyzed by group (luminal occlusive therapy versus repeated endoscopic debridement). Leaks were then stratified by radiologic appearance on computed tomography, defined as phlegmon, collection, contrast medium leak, or fistula. The primary outcome was length of stay (LOS). Secondary outcomes were comprehensive complication index and the need for resection. There were 54 patients, with 22 in the luminal occlusion group and 32 in the repeated debridement group. There was no difference in LOS (59.8 ± 41.6 versus 46.5 ± 51.2 days, P =.179) and no difference in the requirement for resection (4 versus 3 resections, p =.425). Subset analysis suggested that patients who underwent operative versus conservative management (P =.006) had a longer LOS. Excluding management strategy, radiologic appearance on admission significantly predicted LOS (P =.0053). Patients presenting with fistula (84 ± 25.4 days) and contrast medium leak (64.1 ± 40 days) had a significantly longer LOS than those diagnosed with phlegmon (13.5 ± 5.5 days). Radiologic appearance was predictive of complication severity (P <.0001) and salvage resection (P =.008). There was no significant difference in outcomes between patients treated with intraluminal occlusion or repeated debridement. Initial radiologic appearance was predictive of LOS and complication severity. This highlights the need for routine use of a validated classification system in studies reporting outcomes and treatment of sleeve leaks. • The radiological appearance of leak on admission appeared to be associated with patient morbidity and outcome after leak • Sleeve gastrectomy leak continues to represent a morbid complication resulting prolonged inpatient stays and multiple interventions • Transition from luminal occlusive to a multiple modality strategy did not result in significantly improved outcomes [ABSTRACT FROM AUTHOR]

Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric operation performed. However, it is not without its drawbacks and patients may develop gastroesophageal reflux (GERD) after LSG. There are limited data available to guide treatment choice for patients suffering these sequelae. This study was undertaken to evaluate the success of conversion to Roux-en-Y gastric bypass (RYGB) in treating GERD symptoms after LSG. Single bariatric center, United States. Analysis of a prospectively maintained clinical database was performed. Outcomes studied included heartburn-related quality of life score (GERD-HRQL), anti-secretory usage, and body mass index (BMI). A total of 54 patients met inclusion criteria during the review period. Of these, 41 patients (76%) underwent conversion for indication including GERD. Mean BMI at conversion was 33.8 ± 5.61 and was found to be significantly reduced at 12 months after conversion (n = 26; 63%; P <.001) and at long-term follow-up (n = 37; 90%) (P ≤.001; mean follow-up period: 33.3 mo). Mean GERD-HRQL at time of conversion was 31.5 ± 11.4. Conversion to RYGB produced a significant reduction of HRQL at 6 months after conversion (n = 30; 73%) (mean: 5.6, P <.001) and long-term follow-up (n = 38; 93%) (mean: 7.3, P <.001. mean follow-up period: 15.1 mo). Prior to conversion, 32 patients (78%) required antisecretory therapy for GERD and after conversion, 12 of these patients (38%) required antisecretory therapy (P <.001). These 12 patients were found to exhibit a significantly (P =.005) smaller decrease in GERD-HRQL after revision compared with their peers who were liberated from antisecretory therapy. Preoperative symptoms were compared between these 2 groups. Delayed onset of GERD symptoms after LSG (>3 mo) was found to be a significant risk factor for continued antisecretory dependence after conversion to RYGB. Conversion of LSG to RYGB quantitatively reduces GERD symptoms, and results in a modest but significant amount of weight loss. While there was a significant improvement in HRQL after revision, a subgroup of patients continued to be antisecretory-dependent and showed a limited improvement in HRQL. This limited response was predicted by a gradual onset of GERD symptoms prior to revision. An interval of 3 months or greater between LSG and onset of symptoms was found to be a significant risk factor for limited response to conversion. • Conversion of LSG to RYGB resulted in a significant reduction in GERD-HRQL • Conversion of LSG to RYGB resulted in a significant reduction in BMI • The rate of antisecretory dependence was reduced after conversion of LSG to RYGB • Delayed onset of symptoms after LSG predicts limited improvement of symptoms after conversion [ABSTRACT FROM AUTHOR]

• After weight-loss surgery, patients no longer sought care for their spinal diagnosis • Lumbar herniation had higher resolution than cervical herniation by 90 days. • Cervical degeneration and stenosis resolved at higher rates than lumbar pathologies. The effects of bariatric surgery on diminishing spinal diagnoses have yet to be elucidated in the literature. The purpose of this study was to assess the rate in which various spinal diagnoses diminish after bariatric surgery. This was a retrospective analysis of the NYSID years 2004–2013. Patient linkage codes allow identification of multiple and return inpatient stays within the time-frame analyzed (720 days). Time from bariatric surgery until the patient's respective spinal diagnosis was no longer present was considered a loss of previous spinal diagnosis (LOD). Included: 4,351 bariatric surgery pts with a pre-op spinal diagnosis. Cumulative LOD rates at 90-day, 180-day, 360-day, and 720-day f/u were as follows: lumbar stenosis (48%,67.6%,79%,91%), lumbar herniation (61%,77%,86%,93%), lumbar spondylosis (47%,65%,80%,93%), lumbar spondylolisthesis (37%,58%,70%,87%), lumbar degeneration (37%,56%,72%,86%). By cervical region: cervical stenosis (48%,70%,84%,94%), cervical herniation (39%,58%,74%,87%), cervical spondylosis (46%, 70%,83%, 94%), cervical degeneration (44%,64%,78%,89%). Lumbar herniation pts saw significantly higher 90d-LOD than cervical herniation pts (p < 0.001). Cervical vs lumbar degeneration LOD rates did not differ @90d (p = 0.058), but did @180d (p = 0.034). Cervical and lumbar stenosis LOD was similar @90d & 180d, but cervical showed greater LOD by 1Y (p = 0.036). In conclusion, over 50% of bariatric patients diagnosed with a cervical or lumbar pathology before weight-loss surgery no longer sought inpatient care for their respective spinal diagnosis by 180 days post-op. Lumbar herniation had significantly higher LOD than cervical herniation by 90d, whereas cervical degeneration and stenosis resolved at higher rates than corresponding lumbar pathologies by 180d and 1Y f/u, respectively. [ABSTRACT FROM AUTHOR]

Reoperation is often required after bariatric procedures. Single-anastomosis gastric bypass (SAGB) is increasingly utilized as a primary bariatric procedure. Few series document SAGB as a revisional bariatric procedure. To describe our short-term experience with revisional SAGB, focusing on weight loss and reflux symptom outcomes. Three hospitals in Australia with both private and public (government funded) patients. We reviewed all revisional SAGB cases from 2012 to 2019 at. Complications were considered significant if they were Clavien-Dindo grade 3a or higher. A phone survey was conducted to assess weight loss outcomes, patient satisfaction, reflux symptoms, and other complications. We identified 254 patients who had a revisional bariatric procedure to SAGB (21 previous sleeve gastrectomies and 233 previous adjustable bands), with a mean follow-up of 22 ± 15.6 months (range, 1–55 mo). The mean percentage of excess weight loss was 77% (183 patients, 72%), and the number of patients with follow-ups at 1 and 4 years was 184 (73%) and 35 patients (14%). Within 30 days, there were 29 patients (11%) who required reinterventions (21 endoscopies, 1 interventional radiology procedure, and 7 reoperations) with no deaths. Beyond 30 days, 27 patients (11%) required rerevision to Roux-en-Y gastric bypass for reflux symptoms and 10 (4%) required a laparotomy or laparoscopy for another reason (e.g., bowel obstruction). At a median follow-up of 36.6 months, 87 patients (34%) completed a phone survey, 45 (52%) of whom were taking proton pump inhibitors and 66 patients (76%) of whom were satisfied with their experience. In our series, revision to SAGB was safe, with low short-term morbidity and favorable weight loss outcomes. However, beyond 1 year, a large proportion of patients experienced severe reflux symptoms and required rerevision. • Many patients require revisional surgery following bariatric procedures. Indications and choice of procedure are controversial • We present the largest series to date of revision to single-anastomosis gastric bypass • Weight loss outcomes were excellent and morbidity was low, especially for revision surgery • Unfortunately, a high rate of intractable reflux was observed, leading to a high rate of re-revision [ABSTRACT FROM AUTHOR]

Obesity is a disease that has achieved the level that can be considered an epidemic. According to the National Center for Health Statistics data, the prevalence of obesity has increased from 30.5% in 1999–2000 to 42.4% in 2017–2018. During the same period, severe obesity has increased from 4.7% to 9.2%. With the growing prevalence of obesity, related conditions such as coronary artery disease, diabetes, and strokes have also become more prevalent. In the past few years, the need for bariatric surgeries such as laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic adjustable gastric banding has increased considerably. With an increasing number of bariatric surgeries, multiple postoperative complications have become common. In this review, we have attempted to describe normal postsurgical anatomical findings after bariatric surgeries and pictorial review of a few common postoperative complications. • The knowledge of the post-surgical anatomy, imaging and complications of these bariatric surgeries is essential. • Most commonly performed bariatric surgery is laparoscopic sleeve gastrectomy. • Most common complication after sleeve gastrectomy is gastric pouch dilatation. • Most dreaded complication after sleeve gastrectomy is perforation with postoperative leak. • Most common complication after gastric bypass surgery is gastroesophageal reflux disease. [ABSTRACT FROM AUTHOR]

Sleeve gastrectomy continues to be the most commonly performed bariatric operation worldwide. Development or worsening of pre-existing GERD has been recognized as a significant issue postoperatively. There is a paucity of information concerning the most appropriate preoperative workup and the technical and anatomical factors that may or may not contribute to the occurrence of reflux symptoms. Contemporary data quality is deficient given the predominantly retrospective nature, limited follow-up time, and heterogeneous outcome measures across studies. This has produced mixed results regarding the postoperative incidence and severity of GERD. Ultimately, better-constructed investigations are needed in order to offer evidence-based recommendations that may guide preoperative workup and improved patient selection criteria. [ABSTRACT FROM AUTHOR]

Introduction: Visceral adipose tissue has been linked with cardiovascular events. Visceral adiposity index (VAI) is a routinely applicable tool for evaluation of visceral adipose dysfunction and linked to 10 year-cardiovascular risk. No previous studies have evaluated the changes over time of the VAI in patients who underwent different types of bariatric surgery.Materials and Methods: We reviewed data of 42 patients who underwent laparoscopic sleeve gastrectomy (LSG) and 61 patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB). VAI, lipid profile, and several anthropometric variables were measured before and after 5 years following surgery.Results: During the studied time period, the BMI was similar between LSG and LRYGB patients (34.1 vs 31.6; p = 0.191), but the percentage of total weight loss (%TWL) for LRYGB was significantly higher than LSG (31.3% vs 23.0%; p < 0.001). LRYGB patients had a significant improvement of all lipid parameters evaluated over time, while LSG patients experienced only a reduction in triglycerides (TG) levels and an increase in HDL cholesterol (HDL-C). VAI values were similar in the two groups at baseline as well at the last follow-up point (5-year VAI, LSG: 0.93, RYGB: 0.93; p = 0.951). At multivariate regression analysis, 5-year-%TWL was the only independent predictor of a greater amount of VAI reduction over time.Conclusion: Bariatric surgery, independent of the type of surgical procedure, decreases the cardiovascular disease (CVD) risks due to weight loss and improvement of lipid parameters. VAI could be a useful tool to better identify eligible patients for bariatric surgery and to determine the success of surgery. [ABSTRACT FROM AUTHOR]

Background and Aims: To investigate the effect of obesity and bariatric-induced weight loss on circulating levels of proprotein convertase subtilisin/kexin 9 (PCSK9) in severely obese patients.Methods and Results: In this non-randomized interventional study, we enrolled 36 severely obese patients (BMI 43.7 ± 5.6 kg/m2), of which 20 underwent bariatric surgery, and 12 nonobese healthy controls. An oral glucose tolerance test (75-g OGTT) was performed in 31 of these obese patients at baseline (T0) and in 14 patients at 6 months after bariatric surgery (T6) to assess plasma glucose, insulin and PCSK9 levels. Plasma PCSK9 levels were also measured in 18 of these obese patients at T0 during a 2-h hyperinsulinemic-euglycemic clamp (HEC). At T0, PCSK9 levels were higher in obese patients than in controls (274.6 ± 76.7 ng/mL vs. 201.4 ± 53.3 ng/mL) and dropped after bariatric surgery (T6; 205.5 ± 51.7 ng/mL) along with BMI (from 44.1 ± 5.9 kg/m2 to 33.1 ± 5.6 kg/m2). At T6, there was also a decrease in plasma glucose (T0 vs. T6: 6.0 ± 1.8 vs. 5.0 ± 0.5 mmol/L) and insulin (15.7 ± 8.3 vs. 5.4 ± 2.1 mU/L) levels. At T0, plasma PCSK9 levels decreased during OGTT in obese patients, reaching a nadir of 262.0 ± 61.4 ng/mL at 120 min with a hyperinsulinemic peak of 75.1 ± 40.0 mU/L, at 60 min. Similarly, at T0 insulin infusion during 2-h HEC acutely reduced plasma PCSK9 levels in obese patients. The aforementioned OGTT-induced changes in plasma PCSK9 levels were not observed neither in nonobese healthy controls nor in obese patients after bariatric-surgery weight loss.Conclusions: These results suggest a pivotal role of adipose tissue and insulin resistance on PCSK9 homeostasis in severely obese patients. [ABSTRACT FROM AUTHOR]

The article focuses on the study of the Anaesthesia for the obese patient. Topics discussed include describe the limitations of BMI when classifying obesity; understand the impact of obesity and related health conditions upon the provision of anaesthesia; identify the high-risk obese patient; and plan safe and individualised perioperative care determined by comorbidities and the extent of surgery.

The long-term outcomes of primary single-anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) have never been reported in the literature. The study aimed to evaluate the long-term outcomes after primary laparoscopic SADI-S (LSADI-S). Single, private institute, United States. Data from 750 patients who underwent a primary LSADI-S from June 2013 through November 2019 by 3 surgeons were retrospectively analyzed. Seven hundred fifty patients were included in the study. The mean age and preoperative body mass index were 49.3 ± 13.1 years and 50 ± 12.6 kg/m2, respectively. Follow-up was available on 109 patients (61%) at 5 years and on 87 patients (53%) at 6 years. Six patients did not have any follow-up. The average operative time and length of stay were 67.6 ± 27.4 minutes and 1.5 ±.8 days, respectively. The intraoperative, short-term, and long-term complication rates were 0%, 7.8%, 11.7%, respectively. The 30-day emergency room visit, readmission, and reoperation rates were.4%, 1.1%, and 1.1%, respectively. In total, there were 15 (2%) grade IIIb long-term complications unique to LSADI-S. Complete remission of type 2 diabetes was seen in 77% of the diabetic population. At 5 and 6 years, the mean change in body mass index was 17.5 ± 6.9 and 17.6 ± 6.4 kg/m2, respectively. The mortality rate was.5%. LSADI-S is effective in this retrospective review in achieving good initial weight loss and weight maintenance. Although our data show acceptable nutritional complications, questions still remain because of the retrospective nature of the study. [ABSTRACT FROM AUTHOR]

Evidence supports that providing preoperative education using an audiovisual format is an effective method to reduce anxiety in the surgical patient. The purpose of this quality improvement project was to evaluate the effect of viewing a video tour of the perioperative division had on patient-perceived preoperative anxiety. A quasi-experimental design using a pre-post survey method of two individual groups. Sixty bariatric surgery patients completed a visual analog scale for anxiety (VAS-A), consisting of 10 items, on arrival and at the end of their preassessment appointment. Thirty patients in the comparison group received preoperative education with the current process of written and verbal instructions. Thirty patients in the intervention group received education with written and verbal instructions as well as inclusion of an informational video tour of the perioperative division. A paired sample t test was used to compare VAS-A results of the comparison and intervention groups. Data supported that bariatric patients who received only verbal and written instructions preoperatively had a statistically significant reduction in anxiety levels in five of 10 items on the VAS-A. Bariatric patients who received education with verbal and written instructions, as well as inclusion of the informational video tour, had a statistically significant reduction in self-perceived anxiety in 9 of 10 items on the VAS-A. Data supported that the addition of an audiovisual component in the form of an informational tour of the perioperative division is an effective method to reduce perceived preoperative anxiety in patients having bariatric surgery. [ABSTRACT FROM AUTHOR]

Obesity in the United States is increasingly prevalent in adolescents. Metabolic and bariatric surgery is offered at select sites to adolescents (<18 yr). Controversy exists regarding the safety of performing metabolic and bariatric surgery in adolescents. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program registry was employed to compare outcomes of adolescents with adults (18–40 yr) undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Academic Teaching Institution. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant User Files were reviewed for patients undergoing SG or RYGB (2015–2018). Patients were stratified by age and outcomes for adolescents versus adults compared. A bivariate analysis was performed on propensity-matched data. After exclusion criteria were applied, 227,671 patients <40 years remained, of whom 1005 were adolescents. For those undergoing RYGB (13.8% adolescents, 25.3% adults), demographic characteristics were similar. Adolescent SG patients were more likely to be male and Hispanic, but less likely to be smokers or have preoperative co-morbidities. There were no differences in infection rates, mortality, major complications, reoperation, readmission, or other interventions for RYGB and SG groups. For both adult SG and adolescent SG, patients' operative times were less than adult and adolescent RYGB, respectively. However, operative times were shorter for adolescent RYGB versus adult RYGB patients, yet longer for adolescent SG patients versus adult SG patients. Metabolic and bariatric surgery is as safe for adolescents undergoing an SG or RYGB as adults. Currently, SG is more commonly performed in adolescents than RYGB, and adolescent SG patients have similar outcomes and shorter operating room times compared with adolescent RYGB patients. [ABSTRACT FROM AUTHOR]

The DiaRem score has proven to be a reliable predictor tool for diabetes remission in Roux-en-Y gastric bypass (RYGB), as well as laparoscopic adjustable gastric band (LAGB) and laparoscopic sleeve gastrectomy (LSG). To our knowledge there are no studies that analyze DiaRem in patients undergoing biliopancreatic diversion with duodenal switch (BPD/DS). To test the validity of the DiaRem score as a predictor of type 2 diabetes remission at 1 year post surgery in patients who underwent LABG, LSG, RYGB, and BPD/DS, as well as to develop and test a novel model that uses DiaRem to predict type 2 diabetes remission by procedure type (LABG, LSG, RYGB, and BPD/DS). University Medical Center, United States. A retrospective review of institutional records identified patients who underwent primary bariatric procedures (LAGB, LSG, RYGB, and BPD/DS) between January 1, 2000 to April 10, 2017, had a diagnosis of diabetes and had complete preoperative and 1-year postoperative follow-up information. A univariable logistic regression model was fit to assess the association between DiaRem score and diabetes remission. A multivariable logistic regression model was created, including procedure type and other preoperative characteristics. The area under the receiver operating curve (AUROC) was calculated to analyze the performance of both models for the entire cohort as well as a BPD/DS only subgroup. A total study cohort of 602 was obtained. The majority of patients underwent RYGB (456; 75.7%), followed by LSG (84; 14.0%), BPD/DS (35; 5.8%), and LAGB (27; 4.5%). The multivariable regression model with RYGB as the reference procedure, showed that BPD/DS results in higher odds of type 2 diabetes remission at 1 year post surgery (adjusted odds ratio [OR] 3.29, 95% confidence interval [CI] 1.27, 8.51), while LSG (adjusted OR.52, 95%CI.29,.93) and LAGB resulted in lower odds (adjusted OR.23, 95% CI.09,.60). The univariable DiaRem model and the novel model were determined to be moderately strong in classifying diabetes remission in the entire cohort (AUROC:.79, 95% CI:.75,.83 and.82, 95% CI:.79,.85, respectively) as well as in the BPD/DS sub-group (AUROC:.85, 95% CI:.70,.99 and.84, 95% CI.69,.99, respectively). Our study shows that the DiaRem score is a reliable tool to predict diabetes remission, amongst a wide variety of different procedures as well as specifically those receiving BPD/DS. Our novel model, which takes into account procedure type, not only shows that BPD/DS patients have the highest odds of diabetes remission than other procedures, but also that this model performs significantly better at predicting diabetes remission than DiaRem alone. [ABSTRACT FROM AUTHOR]

Opioid analgesics are often prescribed to manage pain after bariatric surgery, which may develop into chronic prescription opioid use (CPOU) in opioid-naïve patients. Bariatric surgery may affect opioid use in those with or without presurgical CPOU. To compare CPOU persistence and incidence in a large multisite cohort of veterans undergoing bariatric surgery (open Roux-en-Y gastric bypass, laparoscopic RYGB, or laparoscopic sleeve gastrectomy) and matched nonsurgical controls. Veterans Administration hospitals. In a retrospective cohort study, we matched 1117 surgical patients with baseline CPOU to 9531 nonsurgical controls, and 2822 surgical patients without CPOU at baseline to 26,392 nonsurgical controls using sequential stratification. CPOU persistence in veterans with baseline CPOU was estimated using generalized estimating equations by procedure type. CPOU incidence in veterans without baseline CPOU was estimated in Cox regression models by procedure type because postoperative pain, complications, and absorption may differ by procedure. In veterans with baseline CPOU, postsurgical CPOU declined over time for each surgical procedure; these trends did not differ between surgical patients and nonsurgical controls. In veterans without baseline CPOU, compared with nonsurgical controls, bariatric patients had higher CPOU incidence within 5 years after open Roux-en-Y gastric bypass (hazard ratio = 1.19; 95% confidence interval: 1.06–1.34) or laparoscopic open Roux-en-Y gastric bypass (hazard ratio = 1.22, 95% confidence interval: 1.06–1.41). Veterans undergoing laparoscopic sleeve gastrectomy had higher CPOU incidence 1 to 5 years after surgery (hazard ratio = 1.28; 95% confidence interval: 1.05–1.56) than nonsurgical controls. Bariatric surgery was associated with greater risk of CPOU incidence in patients without baseline CPOU but was not associated with greater CPOU persistence. [ABSTRACT FROM AUTHOR]

Bariatric surgery is the most effective long-term treatment for obesity. Opioid-sparing anesthesia and multimodal analgesia such as lidocaine infusion have been recommended in these patients to reduce opioid-related complications. However, evidence supporting its use for bariatric surgery population is limited. To investigate whether intraoperative lidocaine infusion is associated with decreasing opioid consumption in laparoscopic bariatric surgery. A university hospital, California, USA. In this retrospective cohort study, outcomes among consecutive obese patients undergoing laparoscopic bariatric surgery between January 2016 to December 2018 were evaluated to determine the impact of adjunctive intraoperative lidocaine infusion on 24-hour postoperative opioid consumption. Secondary outcomes, including opioid consumption during hospitalization, length of stay, and postoperative complications were determined. Post hoc analyses were performed exploring possible dose effects and drug-drug interactions. Univariable and multivariable analyses were performed to identify factors associated with opioid consumption. Among 345 patients, 54 (15.7%) received intraoperative lidocaine infusion (L+) whereas 291 (84.3%) did not receive intraoperative lidocaine infusion (L−). Both L+ and L− groups shared similar demographic characteristics. The 24-hour postoperative opioid consumption was 17.6% lower in L+ (95% confidence interval −28.4 to −5.2, P =.007), but nonsignificantly lower in the multivariate model (12.8%, 95% confidence interval −24.4 to.5, P =.06). Opioid consumption during hospitalization, length of stay, and other clinically significant outcomes did not differ. However, subgroup analysis restricted to opioid-naïve patients indicated significantly reduced opioid consumption in the L+ group. Post hoc analysis suggested interaction between lidocaine and ketamine in decreasing 24-hour postoperative opioid consumption. Intraoperative lidocaine infusion was not significantly associated with decreasing 24-hour postoperative opioid consumption in obese patients undergoing laparoscopic bariatric surgery. [ABSTRACT FROM AUTHOR]

Conversions and revisions after bariatric procedures are inevitable and associated with longer operative time and higher complication rates. Because robot-assisted procedures allow better dissection, robotic conversions and revisions may be more beneficial to the patients than laparoscopic ones. This study aimed to compare the feasibility and safety of robot-assisted conversions and revisions to laparoscopic procedures. Academic Hospital, United States. A retrospective chart review was performed on 94 consecutive patients who underwent a bariatric conversion or revision (revision of gastrojejunostomy, conversions of vertical sleeve gastrectomy to Roux-en-Y gastric bypass, adjustable gastric banding to sleeve gastrectomy, Roux-en-Y gastric bypass to sleeve gastrectomy, adjustable gastric banding to Roux-en-Y gastric bypass, Roux-en-Y gastric bypass to duodenal switch, and adjustable gastric banding to duodenal switch) between January 1, 2017, and February 28, 2019. Of these, 30 underwent a robot-assisted conversion or revision. Patients who underwent a robot-assisted approach were more likely to be older (45.4-versus 38.8-yr old) and lighter (44.6 versus 50.3 kg/m2) than patients who underwent a laparoscopic approach. The mean operative time was longer in the robot-assisted group (155.5 min) than in the laparoscopic group (113.3 min). No difference was observed between the 2 groups in the mean length of hospital stay, 30-day readmission rate, or 30-day reoperation rate. Results were similar when the baseline difference in age and body mass index were accounted for. Robot-assisted conversions and revisions were as feasible and safe as laparoscopic procedures. However, operative time was longer in robot-assisted conversions. [ABSTRACT FROM AUTHOR]

The isolated stricture after the sleeve gastrectomy is one of the possible surgical complications. Previous algorithms have been proposed to address the workup and treatment of sleeve gastrectomy stricture. However, current literature lacks standardization and systematic reviews on this topic. This study aimed to review all currently available publications and to create evidence-based recommendations. We searched Medline (PubMed), EMBASE, and Central Cochrane from inception to June 10, 2019. Inclusion criteria were studies reporting treatment of sleeve gastrectomy stricture with no associated leaks. The primary outcome was the reported clinical resolution rate. The final analysis included 32 articles. The pooled reported clinical resolution rate for the primary treatment was 68% (11/16), 82% (296/361), and 75% (34/45) for noninvasive medical therapy, endoscopic, and surgical treatments, respectively (not significant). Among the endoscopic modalities, the pneumatic dilation has the highest clinical success rate. Most rescue surgeries described in the literature were successful. Conclusively, the initial treatment should entail noninvasive medical management followed by the endoscopic approach, if needed. Pneumatic balloon dilation should be the preferred approach, if technically feasible. Revisional surgery should be reserved for endoscopic failure. [ABSTRACT FROM AUTHOR]

Metabolic and bariatric surgery (MBS) is a safe and effective treatment choice for severe obesity. Yet only approximately 50% of those referred to MBS complete the procedure. Studies show that racial minority groups are less likely than non-Hispanic whites to complete MBS despite having higher rates of severe obesity and co-morbidities. To conduct a qualitative study to determine facilitators and challenges to racially diverse patients completing MBS based on the 4 socioecological model domains (intrapersonal, interpersonal, organization/clinical interaction, and societal/environmental). One university-based surgery practice serving a racially diverse patient population. Focus groups and in-depth interviews were conducted (Spring 2019) among patients (n = 24, 70% female, 50% non-Hispanic black, 4% Hispanic) who completed MBS over the past year. Social support members were also included (n = 7). Grand tour questions were organized by the 4 socioecological model domains and within the context of MBS completion. Data were audio-recorded, transcribed, and coded. A thematic analysis combining a deductive and inductive approach was conducted. Codes were analyzed using Dedoose to identify themes/subthemes. Ten themes and 15 subthemes were identified. Key intra- and interpersonal facilitators to MBS completion included social support systems, primary care physician support of MBS, co-morbidity resolution, discrimination experiences, and mobility improvements. Key community and environment themes associated with post-MBS sustained weight loss included community support groups and access to healthy foods and exercise facilities. No themes or subthemes varied by race. Educating primary care physicians and social support networks about the benefits of MBS could improve utilization rates. MBS patients have a desire to have their communities provide resources to support their postoperative success. [ABSTRACT FROM AUTHOR]

Obesity is a risk factor for pregnancy-induced hypertension, preeclampsia, gestational diabetes, and large gestational age pregnancy. Bariatric surgery is widely accepted to treat obesity but associated with small for gestational age fetuses. To report maternal and fetal outcomes after bariatric surgery in morbidly obese Asian females. University Hospital, Singapore. We maintain a prospective cohort of patients who underwent bariatric surgery in our institution. Maternal and fetal outcomes are compared with a control group of 31 pregnancies matched for age, parity, presurgery weight, and year of delivery. Twenty-four pregnancies occurred in 16 patients in our postoperative cohort. Morbidly obese women in the control group were more likely to develop gestational diabetes (19.3% versus 5.0%, P =.150) and pregnancy-induced hypertension/preeclampsia (32.2% versus 0%, P =.003) compared with the postoperative group. Of fetuses, 37.5% in the bariatric group had low birth weight compared with only 9.4% fetuses in the control group (P =.016). Preoperative body mass index, short interval between conception and surgery, and poor weight gain during pregnancy did not predict for small for gestational age fetuses. Subsequent weights were available for 37.5% of the children in the surgical cohort and none of these children exhibited growth retardation. Bariatric surgery lowers the risk of maternal co-morbidities and large gestational age fetus during pregnancy. Asians are at high risk of small for gestational age pregnancies after bariatric surgery and should undergo close monitoring for fetal growth throughout their pregnancy. [ABSTRACT FROM AUTHOR]

Prolonged sitting time has been associated with numerous deleterious effects on humans. The degree to which sitting time influences weight loss outcomes of obesity treatments is poorly understood. The objective was to characterize and describe the amount of time spent sitting in an adolescent bariatric surgical and nonoperative cohort and evaluate its relationship with long-term change in body mass index (BMI). Tertiary care hospital, United States. From 2011 to 2014, a 1-time study visit was conducted to collect long-term outcomes of Roux-en-Y gastric bypass (RYGB; n = 58) and nonoperative (n = 30) management of adolescents with severe obesity. The International Physical Activity Questionnaire was used to assess sitting time. Linear regression was used to evaluate the association between sitting time and percent BMI change from baseline. A total of 88 patients participated in the long-term follow-up visit at an average of 8 years from baseline. Percent BMI loss for participants who underwent RYGB (mean age at follow-up 25 yr) and for nonoperative (mean age at follow-up 23 yr) participants was −29% and +8%, respectively. The surgical group reported a median sitting time of 5.1 hr/d, while the nonoperative group reported a median sitting time of 7.0 hr/d (P =.11). Increasing sitting time was significantly associated with decreased percent BMI loss (P <.01). RYGB was associated with long-term weight loss. Those participants with and without prior RYGB self-reported similar amounts of time spent sitting each day. Irrespective of whether participants had previously undergone surgery, lower levels of sitting time were found to be associated with greater BMI loss many years later. [ABSTRACT FROM AUTHOR]

Postoperative pain has many adverse effects and, if not properly controlled, it may lead to a wide range of complications. Opioids, as frequently used drugs for pain control, have some serious respiratory and gastrointestinal complications, especially in obese patients. In this study, we planned to evaluate the effect of intraperitoneal bupivacaine lavage on postoperative pain in laparoscopic bariatric surgeries. The study was conducted in Firoozgar Hospital (affiliated to Iran University of Medical Sciences), Tehran, Iran. In this clinical trial, 106 patients scheduled for laparoscopic bariatric surgery, randomly assigned to receive either intraperitoneal lavage with 50 mL of.2% bupivacaine or the same volume of normal saline during the operation. One-gram intravenous paracetamol was infused for all patients at the end of surgery, and all patients received intravenous paracetamol infusion for 1 day after surgery. Pain level, assessed by visual analog scale, was recorded at 1, 4, 8, and 24 hours after surgery. Total additive analgesics administered during the first day after surgery was also recorded. The pain score during the first 24 hours after surgery decreased significantly in both groups, but comparing the groups showed that pain level at 1, 4, 8, and 24 hours after surgery in the bupivacaine group was significantly lower than the normal saline group (P <.05). Also, opioid consumption during 24 hours was significantly lower in the bupivacaine group (P <.001). Intraperitoneal lavage with bupivacaine is an effective approach to control postoperative pain in obese patients undergoing laparoscopic bariatric surgery. [ABSTRACT FROM AUTHOR]

To date, there have been no large-scale enhanced recovery projects in bariatric surgery in the United States. The aim of this project was to implement an enhanced recovery protocol for selected Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program centers and determine its impact on length of stay, bleeding, readmissions, and reoperation rates. University and private practice programs, United States. Participating sites were identified based on historical extended length of stay (ELOS, ≥4 d). A 6-month run-up period was used to allow implementation of the protocol. Primary bariatric procedures were included in the analysis, which compared ELOS from historic data (2016) with outcomes during the Employing Enhanced Recovery Goals in Bariatric Surgery (ENERGY) project. Relationships between adherence to the 26 process measures and ELOS were analyzed. Specific adverse 30-day outcomes were monitored. Thirty-six centers participated in the project. The final analytic sample consisted of 18,048 cases total over a 24-month period, including 8946 from the 2016 calendar year and 9102 from the ENERGY period. The overall rates of ELOS for pre- and postintervention were 8.1% and 4.5%, respectively, without increasing readmission rates, reoperation rates, or overall morbidity. Bleeding rates increased from.8% preintervention to 1.1% during ENERGY (adjusted P =.06). There was a significant association between increased adherence score and decreased odds of ELOS (P <.01). Implementation of a large-scale enhanced recovery project is feasible and results in decreased ELOS without increasing overall adverse events or readmissions. Increased adherence to the protocol was closely associated with decreased ELOS. The ENERGY protocol or similar enhanced recovery pathways should be implemented on a larger scale to further improve the care and outcomes of bariatric surgery patients. • 36 centers participated in the ENERGY project which was designed to decrease extended LOS by implementing an enhanced recovery protocol in bariatric surgery patients. • The final analytical sample consisted of 18,048 cases total over a 24-month period: 8,946 from calendar year 2016 and 9,102 from the ENERGY LIVE period (June 2017-July 2018). • The overall rates of extended LOS for pre- and post-intervention were 8.1% and 4.5%, respectively. • Readmission, reoperation, and 30 day morbidity rates did not increase. Bleeding rates increased from 0.8 to 1.1% when compared to the year prior to the study. • Implementation of enhanced recovery requires multiple stakeholder involvement and culture change to be successful. The ENERGY project demonstrated feasibility of employing an enhanced recovery protocol on a national scale. [ABSTRACT FROM AUTHOR]

For the management of obesity in childhood and adolescence, nonoperative approaches have limited efficacy, including community-based and behavioral interventions and pharmacotherapy approved for use in adults. Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy are efficacious in reducing weight, body mass index, and comorbidities in adolescents. Understanding the phenotype associated with obesity provides an opportunity to individualize patients' treatments directed at the brain–gut axis. These phenotypes include rapid gastric emptying, increased fasting gastric volume, reduced postprandial incretins, and central mechanisms that impact appetite and satiation including hedonic eating and affective disorders. Further studies are required in adolescents. Identifying phenotypes could enhance the efficacy of behavioral, dietary, and pharmacotherapeutic interventions alone or in combination in children and adolescents. Bariatric surgery represents the most efficacious weight loss treatment for obesity, with targets including reduced gastric capacity and fasting ghrelin and increased postprandial incretin levels. Behavioral and dietetic treatment is the mainstay of long-term management alone or in combination with other treatments. There are essentially no approved pharmacological treatments for obesity in the pediatric age group. Various phenotypes that modify appetite and satiation are identified in obesity. Identifying such phenotypes provides opportunities for individualizing treatment by targeting the putative mechanisms that increase appetite or reduce satiation in pediatric obesity. [ABSTRACT FROM AUTHOR]

Metabolic and bariatric surgery in adolescents with severe obesity has been demonstrated to be safe and have long-term treatment efficacy. However, less than 0.1% of adolescents meeting criteria undergo surgery. A prospective pilot study of adolescents who underwent laparoscopic gastric plication (LGP) was conducted to evaluate safety and effects on anthropometrics and weight-related medical and psychological comorbidities. Four adolescents enrolled and underwent LGP; two withdrew 90 days postoperatively and two were followed through 36 months. Preprocedure body mass index was 41.7–53.7 kg/m2 with decreases in % change of BMI of 17.5% and 39.7% at 36 months after surgery. Patients reported early satiety, good hunger control, and limited nausea at all time points. There were no major complications. Mild gastroesophageal reflux and abdominal pain occurred; both resolved without surgical intervention. Minor improvements in psychological comorbidities were also reported. LGP can be safely performed in adolescents with severe obesity and achieves modest weight loss. Although limited by its small sample size, this study provides preliminary support for LGP as an appropriate surgical option for adolescents. A larger, multidisciplinary study is planned. Prospective case series review. Level IV evidence: case series without comparison. [ABSTRACT FROM AUTHOR]

We reported that 30% of individuals with medically complicated obesity have bowel symptoms, suggesting irritable bowel syndrome, but this prevalence of bowel symptoms is not related to body mass index or diabetes mellitus. Hypovitaminosis D is common in individuals with obesity and type 2 diabetes mellitus and is associated with depressive symptoms. Because antidepressants improve global symptoms in individuals with bowel symptoms, we hypothesize that the high prevalence of bowel symptoms in medically complicated obesity is associated with hypovitaminosis D. This is a single-institution, retrospective cohort study performed in a large, urban community teaching hospital. Over 2 years, individuals considering bariatric surgery completed a Manning symptom questionnaire to quantify bowel symptoms. Serum 25-hydroxy vitamin D was ordered, and the results were recorded for all individuals. Among 271 subjects, 229 subjects (80% women, 20% men; 67% black, 31% white; age range: 23-73 years; body mass index range: 35-91 kg/m2) completed 25-hydroxy vitamin D testing. Sixty-seven subjects (29%) have 3 to 6 Manning bowel symptoms, suggesting irritable bowel syndrome; 84 (37%) have type 2 diabetes; and 180 (79%) had vitamin D insufficiency. There are significant negative associations between Manning bowel symptoms and vitamin D concentrations in subjects with obesity (P =.01) and with type 2 diabetes mellitus and obesity (P =.007). The results support our hypothesis that the high prevalence of bowel symptoms in people with medically complicated obesity is associated with hypovitaminosis D. A prospective study is required to evaluate vitamin D supplementation and relief of bowel symptoms in people with medically complicated obesity. [ABSTRACT FROM AUTHOR]

• LSG is a reasonable alternative to RYGB in patients with intestinal non-rotation. • Concurrent appendectomy may not be necessary in the era of modern imaging. An incidental finding of intestinal nonrotation at the time of bariatric surgery poses the following 2 dilemmas: (1) which operation to perform, and (2) whether an appendectomy should be performed concurrently. To review the experience of 2 Bariatric Centers of Excellence with laparoscopic sleeve gastrectomy (LSG) in patients with intestinal nonrotation, and to perform a systematic review of the literature on this topic. Two Bariatric Centers of Excellence as designated by the Ontario Bariatric Network. A chart review of all LSG cases performed in patients with intestinal nonrotation at 2 centers was performed. A systematic review on performing bariatric surgery in patients with intestinal nonrotation/malrotation was conducted using EMBASE and MEDLINE databases. Four patients (.4% of all cases) underwent LSG in the setting of intestinal nonrotation. Two patients underwent a concurrent appendectomy. Three patients developed postoperative gastrointestinal reflux disease and 1 patient required conversion to a laparoscopic Roux-en-Y gastric bypass. A total of 12 retrospective studies with 23 patients were included in the systematic review. Nineteen patients underwent Roux-en-Y gastric bypass, 3 patients underwent a duodenal switch, and 1 patient underwent LSG. Nine patients (41%) underwent a concurrent appendectomy. Reasons cited for not performing an appendectomy include not completely understanding the anatomic defect, being surprised by the discovery of nonrotation, no consent for the procedure, and suboptimal trocar placement for an appendectomy. LSG is a reasonable alternative to laparoscopic Roux-en-Y gastric bypass in patients with intestinal nonrotation. A concurrent appendectomy may not be necessary in the era of modern cross-sectional imaging for diagnosing acute appendicitis. [ABSTRACT FROM AUTHOR]

• COVID-19 pandemic has negative impact on bariatric surgery. National lockdowns influenced availability of elective surgeries. • Surprisingly, the mean operational BMI of patients operated on after resumption of elective surgery was significantly lower. • Reassumption of bariatric surgery after national lockdown is safe and does not affect postoperative course and complications rates. As a result of the COVID-19 pandemic, the health care systems around the world have been overburdened resulting in significant reduction of planned surgical procedures such as bariatric surgeries. The primary aim of this study is to assess the influence of the COVID-19 national lockdown in Poland on the short-term outcomes and intraoperative course of bariatric patients in a high volume IFSO certified bariatric center. This is a retrospective analysis of 158 bariatric surgery patients, who underwent bariatric procedures either prior to or after the first national lockdown in Poland. The patients were categorized as pre-lockdown group and the post-lockdown group, each comprising of 79 patients. The post-lockdown group had significantly lower operative weight (105.76 vs 114.25, p = 0.012) and BMI (36.99 vs 39.93, p = 0.005) compared to pre-lockdown group. The primary length of stay was significantly longer in the post-lockdown group (3.04 vs 2.44, p = 0.001). The post-lockdown group had significantly lower mean CCI score (1.90 vs 6.67, p = 0.046) and less short-term readmissions post-discharge (0 vs 8.86, p = 0.007) than pre-lockdown group. The post-lockdown group was found to have lower body weight and BMI on the day of the operation than those operated prior to the lockdown. These findings are conflicting to previous research assessing weight changes during lockdowns. Since the qualification criteria and order of operations were similar and pre-defined for both groups, possible explanations for these findings are higher patient motivation due to COVID-19 fears and longer preparation period due to elective surgery postponement. We encourage bariatric centers globally to assess the effect of national lockdowns on the patient profiles as well as the psychological and behavioral impact on the bariatric cohort. [ABSTRACT FROM AUTHOR]

Highlights • This is the first single blinded randomised controlled trial comparing wound healing in patients undergoing laparoscopic gastric bypass after taking pre-operative very low calorie diet for 4 weeks. • Primary outcome was collagen type I and III gene expression and sample size calculations suggested at least 9 patients in each group were required. • A significant reduction in mature collagen I gene expression was seen 7 days after surgery in patients taking the diet. • No clinical evidence of poorer wound healing like anastomotic leak or wound infection was seen. • Among the secondary outcomes, the liver was found to have shrunk by 23% in patients undergoing the diet but difference in peri-operative outcomes like operating time, operative difficulty or complications was seen. Abstract Background In bariatric surgery, preoperative very low-calorie diets (VLCD) may better meet the technical demands of surgery by shrinking the liver. However, diets may affect tissue healing and influence bowel anastomosis in an as-yet-undefined manner. Objective This randomized controlled trial aimed to examine the effect on collagen deposition in wounds in patients on a 4-week VLCD before laparoscopic gastric bypass. Setting University hospital. Methods The trial was undertaken in patients undergoing laparoscopic Roux-en-Y gastric bypass, with a control group (n = 10) on normal diet and an intervention group (n = 10) on VLCD (800 kcal) for 4 weeks. The primary outcome measured was expression of collagen I and III in skin wounds, with biopsies taken before and after the diet and 7 days postoperatively as a surrogate of anastomotic healing. Secondary outcome measures included liver volume and fibrosis score, body composition, operating time, blood loss, hospital stay, and complications. Results Patients in both groups were similar in age, sex, body mass index (53.4 versus 52.8 kg/m2), co-morbidities, liver volume, and body composition. Expression of mature collagen type I was significantly decreased in diet patients compared with controls after 4 weeks of diet and 7 days after surgery. This was significant decrease in liver volume (23% versus 2%, P =.03) but no difference in operating times (129 versus 139 min, P =.16), blood loss, length of stay, or incidence of complications. Conclusions Preoperative diets shrink liver volume and decrease expression of mature collagen in wounds after surgery. Whether the latter has a detrimental effect on clinical outcomes requires further evaluation. [ABSTRACT FROM AUTHOR]

Highlights • Intra-gastric balloons represent an endoscopic therapy aimed at achieving weight loss by mechanical induction of satiety. • Our study evaluated the efficacy and safety of intra-gastric balloon therapy at one large city academic bariatric center over a sixteen-year period for super-obese patients. • Intra-gastric balloons can offer effective weight loss in selected super-obese patients within a dedicated bariatric centre offering multidisciplinary support. • Balloon insertion alone offers only short-term weight loss, however when combined with definite bariatric surgical approaches durable weight loss outcomes can be achieved. Abstract Background Intragastric balloons represent an endoscopic therapy aimed at achieving weight loss by mechanical induction of satiety. Their exact role within the bariatric armamentarium remains uncertain. Objective Our study aimed to evaluate the use of intragastric balloon therapy alone and before definitive bariatric surgery over a 16-year period. Setting A large city academic bariatric center for super-obese patients. Methods Between January 2000 and February 2016, 207 patients underwent ORBERA intragastric balloon placement at esophagogastroduodenoscopy. Four surgeons performed the procedures, and data were entered prospectively into a dedicated bariatric database. Patients' weight loss data were measured through body mass index (BMI) and excess weight loss and recorded at each clinic review for up to 5 years (60 mo). Treatment arms included intragastric balloon alone with lifestyle therapy or intragastric balloon and definitive bariatric surgery: gastric banding, sleeve gastrectomy, or Roux-en-Y gastric bypass. An additional treatment arm of analysis included the overall results from intragastric balloon followed by stapled procedure. Results One hundred twenty-nine female and 78 male patients had a mean age of 44.5 (±11.3) years and a mean BMI of 57.3 (±9.7) kg/m2. Fifty-eight percent of patients suffered from type 2 diabetes. Time from initial or first balloon insertion to definitive surgical therapy ranged between 9 and 13 months. Seventy-six patients had intragastric balloon alone, and 131 had intragastric balloon followed by definitive procedure. At 60 months postoperatively the intragastric balloon alone with lifestyle changes demonstrated an excess weight loss of 9.04% and BMI drop of 3.8; intragastric balloon with gastric banding demonstrated an excess weight loss of 32.9% and BMI drop of 8.9. Intragastric balloon and definitive stapled procedure demonstrated a BMI drop of 17.6 and an excess weight loss of 52.8%. Overall, there were 3 deaths (1.4%), 2 within 10 days due to acute gastric perforation secondary to vomiting and 1 cardiac arrest at 4 weeks postoperatively. Conclusion Intragastric balloons can offer effective weight loss in selected super-obese patients within a dedicated bariatric center offering multidisciplinary support. Balloon insertion alone offers only short-term weight loss; however, when combined with definitive bariatric surgical approaches, durable weight loss outcomes can be achieved. A strategy of early and continual vigilance for side effects and a low threshold for removal should be implemented. Surgeon and unit experience with intragastric balloons can contribute to "kick starting" successful weight loss as a bridge to definitive therapy in an established bariatric surgical pathway. [ABSTRACT FROM AUTHOR]

Purpose To explore gastric bypass patients' perceptions of their postoperative recovery over 1 month. Design A standardized questionnaire, the postoperative recovery profile, was used. Methods Postoperative recovery profile is a multi-item questionnaire for self-assessment of general postoperative recovery. Participants were patients who had undergone gastric bypass surgery (n = 39). The changes in recovery between 1 day and 1 month postsurgery were evaluated by a statistical method developed specifically for analyzing changes in paired ordered data over time. Findings Most of the symptoms and/or functions were significantly improved on a group level. The most marked improvement was to pain and sleeping difficulties followed by mobilization. In terms of the psychological items, the proportion of patients who indicated no problems was high at both endpoints. The items that deviated from the improvement pattern were appetite changes and gastrointestinal function which demonstrated a relatively high proportion of deterioration, and the individual variability was prominent. Conclusions There is a need for interventions to improve recovery on a group as well as an individual level. [ABSTRACT FROM AUTHOR]

Highlights • body image is an important indicator of patient's well-being • desire for body contouring surgery is related to a negative body image and depressive symptoms • higher weight loss is related in less depressive symptoms, via positive body image • body image should be considered a key outcome in post-bariatric patients. Abstract Background Overhanging skin in postbariatric patients leads to a negative body image. In patients with obesity, negative body image is related to more depressive symptoms and a higher weight. This relationship might also be important in postbariatric patients, because improvement of body image via body contouring surgery (BCS) could lead to better weight loss results. Objectives To evaluate the relationship between body image, depressive symptoms, and weight loss in a postbariatric population, focusing on desire for BCS. Setting Outpatient clinic. Methods One thousand twenty-four primary bariatric surgery patients were contacted, and 590 patients agreed to participate and filled in online questionnaires regarding body image (Body Shape Questionnaire and Multidimensional Body-Self Relations Questionnaire-Appearance Scales) and depression (Beck Depression Inventory-II). Differences between patients who had BCS, patients who desired BCS, and patients who did not desire BCS were studied. The mediating role of body image in the association between percentage total weight loss and depressive symptoms was assessed via a 2-mediator model. Results There was a desire for BCS in 368 patients (62.4%); these patients had significantly lower scores on appearance evaluation and body image satisfaction scales and showed more depressive symptoms. Patients without a desire (n = 157, 26.6%) had lowest rates of depressive symptoms and a more positive body image. Sixty-five patients (11.0%) had undergone BCS. In the patients who desired BCS, percentage total weight loss was negatively affected by depressive symptoms via appearance evaluation and body-area satisfaction. Conclusions There are striking differences regarding body image satisfaction and depressive symptoms when comparing postbariatric patients and without desire for BCS. Body image satisfaction is associated with less depressive symptoms in all postbariatric patients. In patients who desired BCS, body image is one of the mediators of the relationship between percentage total weight loss and depressive symptoms. Therefore, body image should be taken seriously and be part of outcome assessment in postbariatric patients. [ABSTRACT FROM AUTHOR]