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Background: We previously demonstrated how kidney injury in patients with morbid obesity can be reversed by bariatric surgery (BaS)., Objective(s): Based on previous experience, we hypothesize patients' potentially reversible kidney injury might be secondary to reduction in renal blood flow (RBF), which improves following BaS., Setting: Academic Hospital., Methods: We conducted a retrospective analysis of patients who underwent BaS at our institution from 2002 to 2019. We identified patients with chronic kidney disease (CKD) using the estimated glomerular filtration rate (eGFR) from the CKD Epidemiology Collaboration Study (CKD-EPI) classification system. We used the BUN/Creatinine (Cr) ratio pre- and postoperatively to determine a prerenal (decreased RBF) versus intrinsic component as the responsible cause of CKD in this patient population. Decreased RBF was defined as BUN/Cr > 20 preoperatively., Results: Our analysis included n = 2924 patients, of which 11% (n = 325) presented decreased RBF. From our original sample, only n = 228 patients had the complete data necessary to assess both eGFR and RBF (BUN/Cr). Patients with baseline CKD stage 2 demonstrated preoperative BUN/Cr 20.85 ± 10.23 decreasing to 14.99 ± 9.10 at 12-month follow-up (P < .01). Patients with baseline CKD stage 3 presented with preoperative BUN/Cr 23.88 ± 8.75; after 12-month follow-up, BUN/Cr ratio decreased to 16.38 ± 9.27 (P < .01). Patients with CKD stage 4 and ESRD (eGFR < 30) did not demonstrate a difference for pre- and postoperative BUN/Cr 21.71 ± 9.28 and 19.21 ± 14.58, respectively., Conclusion(s): According to our findings, patients with CKD stages 1-3 present improvement of their kidney function after BaS. This amelioration could be secondary to improvement of the RBF, an unstudied reversible mechanism of kidney injury in the bariatric population., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Morbid obesity is strongly associated with hypertension., Objective: The objective of this study is to compare the risk of developing hypertension before and after bariatric surgery., Setting: U.S. university hospital., Methods: We retrospectively reviewed all patients who underwent bariatric surgery from 2010 to 2015 at our institution. Nonhypertensive white individuals without diabetes at baseline were included in our study. The Framingham Hypertension Risk Score was used to predict the near-term incidence of the disease. This calculator predicts 1-, 2-, and 4-year incidence of hypertension., Results: A total of 475 patients met the criteria for the hypertension risk score calculation. Females composed 72% (n = 342) of our population with a mean age of 42.6 ± 11.6 years. Laparoscopic sleeve gastrectomy was the most prevalent procedure at 81.89% (n = 389). At 12- month follow-up, the 1-year absolute risk reduction (ARR) and the relative risk reduction (RRR) were 6.2% and 69.2% (P < .01), respectively. The 2-year ARR was 11.9%, with an RRR of 67.9% (P < .01). The 4-year risk was also calculated at 12-month follow-up, resulting in an ARR of 20.1%, and RRR of 63.7% (P < .01). Furthermore, stratifying by type of procedure, the results were comparable between sleeve gastrectomy and Roux-en-Y gastric bypass. Regarding blood pressure values at 12-month follow-up, the systolic blood pressure was reduced 11.4 mm Hg (P < .01) and the diastolic blood pressure was reduced 4.4 mm Hg (P = .07). The percentage of estimated body mass index loss at 12-month follow-up was 71.7%., Conclusions: Sleeve gastrectomy and Roux-en-Y gastric bypass significantly diminish the risk of developing hypertension in morbidly obese patients. Prospective studies are needed to better comprehend these findings., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Paradoxically, advances in anti-retroviral therapy that has increased survival for patients with human immunodeficiency virus (HIV) have resulted in greater numbers of HIV+ patients developing other chronic diseases, including obesity. Little comparative literature exists detailing perioperative or metabolic outcomes of bariatric surgery in the HIV+ population compared to HIV negative (HIV-) controls., Methods: This is a retrospective case-control study with both HIV+ (case) and HIV- control patients. Individuals undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between January 1, 2006 and December 31, 2015 were included. HIV+ status was defined as any individual with documented history of HIV., Results: Eleven HIV+ patients underwent RYGB or SG during the study period. After matching (1:5 HIV+: HIV-) both cohorts had similar mean age (42 years), gender distribution (63% female), and preoperative BMI (48 kg/m2), as well as comorbidities. There were no differences in postoperative length of stay, or all cause 30-day morbidity. There were 63.7% HIV+ and 76.4% with 1-year follow-up available. Both percent excess weight loss (56% HIV+ vs. 60% HIV-) and BMI (32 HIV+ vs. 34 kg/m2 HIV-) were similar in both groups. There were minimal changes to CD4 count or HIV viral load in the patients during the follow-up period., Conclusion: Bariatric surgery is safe and feasible in HIV-infected population well controlled on anti-retroviral medication. The short-term surgical and metabolic outcomes are similar to HIV- controls with minimal effect on the CD4 count and viral load in HIV+ cohort for long-term follow-up.

Background: There is vast evidence that supports the importance of obesity in the pathogenesis and progression of cardiovascular disease. Rapid weight loss induced by laparoscopic Roux-en-Y gastric bypass (RYGB) and adjustable gastric banding (LAGB) has proven beneficial. The aim of this study is to evaluate laparoscopic sleeve gastrectomy (LSG) as an alternative treatment modality and its impact on the Framingham-BMI 10-year risk score., Methods: We retrospectively reviewed all patients that underwent bariatric surgery at our institution between 2010 and 2014. Patients who met the criteria for calculating the Framingham BMI 10-year risk score were included. Data collected included baseline demographics, perioperative parameters such as tobacco use, diagnosis of diabetes, treatment for hypertension, BMI and postoperative outcomes at 3 and 12 months., Results: From our 1129 bariatric patients, 358 (31.7%) met criteria for the Framingham BMI 10-year risk score calculation. LSG was the most prevalent surgery 61.45% (N = 220) followed by LRYGB 22.06% (N = 79). Females composed 69% (N = 248) of our population. The average age for females was 52.3 ± 10.8 years and for males 54.07 ± 11.2 years. The initial Framingham 10-year score risk was significantly higher in males compared with females (36.16% ± 22.3 vs. 16.97% ± 15.6 (p < 0.001)). After 12-month follow-up, the absolute risk reduction in males was 11.58% (p < 0.001) and 6.17% in females (p < 0.001). The preoperative heart age was high in females and males (69.23 ± 15.72 years and 73.55 ± 13.55 years, respectively (p = 0.012)), and after 12 months it was reduced 7.19 years in females (p < 0.001) and 7.04 years in males (p < 0.001). The percentage of estimated BMI loss at 1 year was 64.43% in females and 60.69% in males., Conclusion: Sleeve gastrectomy has demonstrated to be an effective method of treatment for obesity. Our results suggest that rapid weight loss after LSG has a positive impact in the reduction of the 10-year cardiovascular disease risk. Further prospective studies may be needed to better assess these findings.

Background: Our objective was to investigate the predictive preoperative factors and surgical components for type 2 diabetes mellitus (T2D) improvement in patients with body mass index (BMI) <35 kg/m(2)., Methods: All patients undergoing curative surgical resection for gastric cancer involving Billroth I gastroduodenal anastomosis, Billroth II gastrojejunal anastomosis (B-I, B-II), or Roux-en-Y total gastrectomy (RYTG), from 2008-2011, were retrospectively reviewed. Of these, 90 patients with T2D were analyzed. The study population was divided into the "improved" and "not improved" groups. The preoperative and postoperative data were assessed using multiple logistic regression analysis. To assess the necessary surgical elements, the gastrointestinal reconstruction methods were categorized according to the presence of the fundus and gastrointestinal bypass., Results: Fifty-four patients (60%) experienced improvements in their T2D 2 years after surgery. Lower preoperative glycated hemoglobin (A1C) (odds ratio [OR]: .502; 95% confidence interval [CI]: .313-.804; P = .004), not using multiple oral antidiabetic medications (OR: .341; 95% CI: .120-.969; P = .043), and high BMI before surgery (OR: 1.294; 95% CI: 1.074-1.559; P = .007) were identified as independent predictors of T2D improvements. RYTG was more effective at improving T2D than B-I (OR: .160; 95% CI: .032-.794; P = .025). Statistical analysis according to the surgical elements showed that the bypass procedure was associated with T2D improvements (OR: 3.023; 95% CI: .989-9·240; P = .052)., Conclusion: Gastrointestinal bypass significantly contributes to T2D improvements in patients with BMI <35 kg/m(2). Low A1C, high BMI, and not using multiple antidiabetic medications were important predictors of T2D improvement., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

The prevalence and severity of obesity in children and adolescents has been increasing in recent years at an unprecedented rate. Morbidly obese children will almost certainly develop severe comorbidities as they progress to adulthood, and bariatric surgery may provide the only alternative for achieving a healthy weight. The aim of this study was to assess the long-term outcomes and safety of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) as new treatment modalities for morbidly obese adolescents. We conducted a retrospective review of a prospectively collected database of all adolescent patients who underwent LSG and RYGB under IRB protocol at the Bariatric and Metabolic Institute in Cleveland Clinic Florida between 2002 and 2011. Patients were also contacted by phone, adhering to HIPAA regulations, and were asked to answer a survey. Eighteen adolescents had a bariatric procedure performed at this institution. The mean age was 17.5 years, the average weight was 293.1 lbs, and the average BMI was 47.2 kg/m2. The mean follow-up period consisted of 55.2 months. The postoperative weight at 55 months follow-up was 188.4 lbs and average BMI was 30.1 kg/m2. Fifteen of the patients were available for follow-up. Thirteen out of 16 (81%) comorbidities in patients available for follow-up were in remission following rapid weight loss. The long-term follow-up and perioperative morbidity shown in this study suggest that LSG and LRYGB appear to be safe and effective operations in morbidly obese adolescents.

Background: Laparoscopic sleeve gastrectomy is a relatively new treatment modality implemented in the surgical management for morbid obesity. It has been well documented that obesity is not only associated with an increased risk of malignancies but is also consistent with a higher incidence of surgical complications related to its definitive management. In spite of the weight loss experienced by patients with malignancy due to a catabolic state, bariatric surgery might be considered as a step procedure allowing for a more efficient and suitable surgical approach to treat early stage malignancies, thereby decreasing the procedure-related morbidity and mortality. This study aims to examine the effectiveness of laparoscopic sleeve gastrectomy as a primary weight loss procedure in patients with untreated malignancy facilitating a definitive oncologic surgical approach., Methods: After institutional review board approval and following Health Insurance Portability and Accountability Act guidelines, we conducted a retrospective review of a prospectively collected database. From September 2006 to March 2009, we analyzed all morbidly obese patients with early stage malignancy that underwent laparoscopic sleeve gastrectomy at the Bariatric and Metabolic Institute as a weight loss surgery prior to a second oncologic procedure. The variables examined were excess body weight, percent excess weight loss, comorbidities, malignancy type, preoperative body mass index (BMI), postoperative BMI, morbidity, and mortality. Mean follow-up time was 3 months until an oncologic procedure was performed., Results: Our series included four morbidly obese patients. There were three males and one female, with a mean age of 53.75 years (range 27-67 years) and a mean BMI of 48.25 kg/m(2) (range 42-55 kg/m(2)). Mean excess weight in our patient population 176 lbs. Mean weight loss at 3 months after laparoscopic sleeve gastrectomy was 59.35 lbs (range 28-79 lbs). Comorbidities included diabetes mellitus, hypertension, obstructive sleep apnea, chronic obstructive pulmonary disease, Crohn's disease, coronary artery disease, and previous history of DVT. One patient was diagnosed with a small bowel carcinoid, two patients with renal hypernephroma, and one patient with prostate cancer. After an average time of 3 months, patients underwent a definitive procedure in accordance to their type of malignancy. There were neither postoperative complications nor mortality., Conclusions: Laparoscopic sleeve gastrectomy is a safe and reasonable approach to effectively reduce weight in order to allow morbidly obese patients with early stage malignancies to undergo a second oncologic procedure.

Background: Laparoscopic sleeve gastrectomy is a viable option that is becoming common in the management of morbid obesity. The aim of this study was to examine the effectiveness and safety of laparoscopic sleeve gastrectomy as a primary step for rapid weight loss in patients who required a second non-bariatric procedure., Methods: After Internal Review Board approval and with adherence to HIPAA guidelines, we conducted a retrospective review of a prospectively collected database of all patients who underwent laparoscopic sleeve gastrectomy as a primary procedure for a second non-bariatric operation from November 2004 to September 2008 at the Bariatric and Metabolic Institute at Cleveland Clinic Florida. The data was reviewed for age, gender, percentage of excess weight loss (%EWL), preoperative and postoperative body mass index (BMI), morbidity, and mortality. Mean follow-up time was 7 months (range, 2 weeks-12 months)., Results: Laparoscopic sleeve gastrectomy was performed in 18 patients who needed a second non-bariatric procedure such as knee replacement surgery, recurrent incisional hernia repair, laminectomy of the lumbar spine, kidney transplant, anterior cervical discectomy, and nephrectomy. Mean preoperative weight and BMI were 124.9 kg (range, 95.5-172.3 kg) and 44.87 kg/m2 (range, 33.36-58.87 kg/m2), respectively. Mean postoperative weight and BMI were 99.2 kg (range, 68.2-132.2 kg) and 35.79 kg/m2 (range, 23.46-48.97 kg/m2), respectively. There were no conversions to an open procedure in this series. There was no morbidity or mortality in this series., Conclusions: In this small group, laparoscopic sleeve gastrectomy appears to be an effective and safe first surgical approach for rapid weight loss in high-risk patients that require a second non-bariatric procedure.

Background: The duodenojejunal bypass liner (DJBL) (EndoBarrier Gastrointestinal Liner) is an endoscopically placed and removable intestinal liner that creates a duodenojejunal bypass resulting in weight loss and improvement in type 2 diabetes mellitus., Objective: Weight loss before bariatric surgery to decrease perioperative complications., Design: Prospective, randomized, sham-controlled trial., Setting: Multicenter, tertiary care, teaching hospitals., Patients: Twenty-one obese subjects in the DJBL arm and 26 obese subjects in the sham arm composed the intent-to-treat population., Interventions: The subjects in the sham arm underwent an EGD and mock implantation. Both groups received identical nutritional counseling., Main Outcome Measurements: The primary endpoint was the difference in the percentage of excess weight loss (EWL) at week 12 between the 2 groups. Secondary endpoints were the percentage of subjects achieving 10% EWL, total weight change, and device safety., Results: Thirteen DJBL arm subjects and 24 sham arm subjects completed the 12-week study. EWL was 11.9% +/- 1.4% and 2.7% +/- 2.0% for the DJBL and sham arms, respectively (P < .05). In the DJBL arm, 62% achieved 10% or more EWL compared with 17% of the subjects in the sham arm (P < .05). Total weight change in the DJBL arm was -8.2 +/- 1.3 kg compared with -2.1 +/- 1.1 kg in the sham arm (P < .05). Eight DJBL subjects terminated early because of GI bleeding (n = 3), abdominal pain (n = 2), nausea and vomiting (n = 2), and an unrelated preexisting illness (n = 1). None had further clinical symptoms after DJBL explantation., Limitations: Study personnel were not blinded. There was a lack of data on caloric intake., Conclusions: The DJBL achieved endoscopic duodenal exclusion and promoted significant weight loss beyond a minimal sham effect in candidates for bariatric surgery. (, Clinical Trial Registration Number: NPT00469391.)., (2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Risk factors for gallstone formation in the general population have been well studied while those after weight reduction surgery are unknown. The aim of this study was to identify the risk factors for the development of symptomatic gallstones after bariatric surgery., Method: Retrospective review was performed for patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), adjustable gastric banding (LAGB) or sleeve gastrectomy (LSG) between 2004 and 2006. Statistical evaluation was performed using a univariate and multivariate analysis. Risk factors, including age, gender, preoperative body mass index (BMI), BMI > 45 kg/m(2), diabetes mellitus, hyperlipidemia, types of operation, and weight loss >25% of original weight, were analyzed for their association with postoperative symptomatic gallstones formation., Results: 670 laparoscopic RYGBP, 47 LAGB, and 79 LSG were performed in our institute. Preoperative gallbladder disease, as indicated by presence of gallstones or sludge on preoperative transabdominal ultrasound, or previous cholecystectomy, were found in 25.3, 14.9, and 30.4% of patients who subsequently had RYGBP, LAGB, and LSG, respectively. A total of 586 patients were included for analysis. Mean follow-up was 25.9 (range 12-42) months. Overall rate of symptomatic gallstone formation was 7.8% and mean time for its development was 10.2 (range 2-37) months. Incidence of symptomatic gallstones with complications as initial presentation was found in 1.9% of the patients. Logistic regression analysis showed that only postoperative weight loss of more than 25% of original weight was associated with symptomatic gallstones formation [B = 1.482, SE = 0.533, odds ratio 4.44, 95% confidence interval (CI) 1.549-12.498, p = 0.005]., Conclusions: Traditional risk factors for gallstone formation in the general population are not predictive of symptomatic gallstone formation after bariatric surgery. Weight loss of more than 25% of original weight was the only postoperative factor that can help selecting patients for postoperative ultrasound surveillance and subsequent cholecystectomy once gallstones were identified.

Many diseases in the obese population have been found to improve after weight loss. A 56-year-old female with a long history of myasthenia gravis (MG) and morbid obesity is reported. Preoperatively, she presented with a BMI of 46.5 kg/m2, and was on three medications and IV immunoglobulin every 5 weeks. After the surgical procedure, she improved and required less medication. Because MG and morbid obesity require careful perioperative management in order to avoid complications, a multidisciplinary approach is recommended.

Background Laparoscopic adjustable gastric banding ( LAGB) has a high incidence of long-term complications and failures. The best procedure to handle these failures and the optimal number of stages in such cases is still controversial. The aim of this retrospective study was to compare the results of conversions of LAGB to either laparoscopic sleeve gastrectomy ( LSG) or laparoscopic Roux-en- Y gastric bypass ( LRYGB) in failed LAGB using a single-stage approach. Methods All patients who underwent conversion from LAGB to either LRYGB or LSG between January 2005 and March 2012 were included in the study. Early and late complications were reviewed. The percentage excess weight loss (% EWL) between the two groups was compared at 3, 6, 12 and 24 months of follow-up. Results Fifty-nine patients, 11 men and 48 women, were included in the study. The most frequent indication was insufficient weight loss or weight regain (non-responders group), in 44 patients (75 per cent); 15 patients had a revision for complicated LAGB. The early complication rate in the non-responders group was 7 per cent (3 of 44 patients), compared with 13 per cent (2 of 15) in the complicated LAGB group. Mean(s.d.) % EWL in the non-responders group was 55(22) per cent in patients converted to LRYGB and 28(25) in those converted to LSG ( P = 0·001). Conclusion LRYGB and LSG are both safe and feasible options for failed or complicated LAGB. In the non-responders group, % EWL was superior for conversion to LRYGB. The surgical morbidity rate was highest in patients having revision for band complications. [ABSTRACT FROM AUTHOR]

Morbid obesity is associated with a high prevalence of cholecystopathy, and there is an increased risk of cholelithiasis during rapid weight loss following gastric bypass. In the era of open gastric bypass prophylactic cholecystectomy was advocated. However, routine cholecystectomy at laparoscopic gastric bypass is controversial. We performed a retrospective review of a prospectively maintained database of morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) from February 2000 to August 2006. All had routine preoperative biliary ultrasonography. Concomitant cholecystectomy at LRYGB was planned in patients with proven cholelithiasis and/or gallbladder polyp ≥1 cm diameter. 1711 LRYGBs were performed. Forty-two patients (2.5%) had a previous cholecystectomy and were excluded from further analysis. Two hundred and five patients (12%) had gallbladder pathology: cholelithiasis in 190 (93%), sludge in 14 (6.8%), and a 2 cm polyp in 1 (0.5%). One hundred and twenty-three patients with cholelithiasis (65%) had a concomitant cholecystectomy at LRYGB, while 68 (35.7%) did not. Of these, 123 (99%) were completed laparoscopically. Concomitant cholecystectomy added a mean operative time of 18 min (range 15–23 min). One patient developed an accessory biliary radicle leak requiring diagnostic laparoscopic transgastric endoscopic retrograde cholangiopancreatography (LTG-ERCP). Of the 68 patients with cholelithiasis who did not undergo cholecystectomy 12 (17.6%) required subsequent cholecystectomy. A further 4 patients with preoperative gallbladder sludge required cholecystectomy. All procedures were completed laparoscopically. One patient required laparoscopic choledochotomy and common bile duct exploration (CBDE) with stone retrieval. Eighty-eight patients (6%) with absence of preoperative gallbladder pathology developed symptomatic cholelithiasis after LRYGB; 69 (78.4%) underwent laparoscopic cholecystectomy; 3 presented with gallstone pancreatitis and 2 with obstructive jaundice, requiring laparoscopic transcystic CBDE in 4 and LTG-ERCP in one. In our experience, concomitant cholecystectomy at LRYGB for ultrasonography-confirmed gallbladder pathology is feasible and safe. It reduces the potential for future gallbladder-related morbidity, and the need for further surgery. [ABSTRACT FROM AUTHOR]

Background: Single-stage laparoscopic sleeve gastrectomy (LSG) may represent an additional surgical option for morbid obesity.Methods: We performed a retrospective review of a prospectively maintained database of LSG performed from November 2004 to April 2007 as a one-stage primary restrictive procedure.Results: One hundred forty-eight LSGs were performed as primary procedures for weight loss. The mean patient age was 42 years (range, 13-79), mean body mass index of 43.4 kg/m(2) (range, 35-75), mean operative time of 60 min (range, 58-190), and mean blood loss of 60 ml (range, 0-300). One hundred forty-seven procedures (99.3%) were completed laparoscopically, with a mean hospital stay of 2.7 days (range, 2-25). A 2.7% major complication rate was observed with four events in three patients and no deaths. Four patients required readmission; mild dehydration in two, choledocholithiasis in one, and a gastric sleeve stricture in one.Conclusion: Laparoscopic SG is a safe one-stage restrictive technique as a primary procedure for weight loss in the morbidly obese with an acceptable operative time, intraoperative blood loss, and perioperative complication rate. [ABSTRACT FROM AUTHOR]