Bariatric Surgery Outcomes in Appalachia Influenced by Surgery Type, Diabetes, and Depression

Background Most effective treatment for morbid obesity and its comorbidities is bariatric surgery. However, research is limited on weight loss and associated outcomes among patients in Appalachia. The objective of this study was to examine demographic and comorbidity influence on surgical outcomes of this population including age, sex, race, state of residence, education, marital status, body mass index (BMI kg/m2), excess body weight (EBW), percent excess weight loss (%EWL), blood pressure, diagnosed depression, diagnosed type 2 diabetes (T2D), Beck Depression Inventory-II (BDI-II), and laboratory values (i.e., hemoglobin A1c). Methods A retrospective electronic medical record (EMR) data extraction was performed on N = 582 patients receiving bariatric surgery (laparoscopic Roux-en-Y gastric bypass [RYGB] and laparoscopic sleeve gastrectomy [SG]) between 10/2013 and 2/2017. Results Patient population was 92.5% Caucasian, 79.3% female, 62.8% married, 45 ± 11.1 years, 75.8% received RYGB, and 24.2% received SG. Average %EWL from baseline to 1-year follow-up was 68.5 ± 18.4% (n = 224). In final descriptive models, surgery type, diagnosed T2D, HbA1c, and depressive symptoms were significant covariates associated with lower %EWL. Conclusions Findings suggest patients completing surgery within an Appalachian region have successful surgical outcomes at 1-year post-surgery, as indicated by significant reductions of \u3e 50% EWL, regardless of other covariates. Results suggest that bariatric programs should consider paying special consideration to patients with T2D or depressive symptoms to improve outcomes. Results have potential to inform future prospective studies and aid in guiding specific interventions tailored to address needs of this unique population

Emergency Laparoscopic Repair of an Iatrogenic Gastric Perforation in a Hiatal Hernia following a Failed Endoscopic Closure

Iatrogenic gastrointestinal perforation is a rare, life-threatening complication of endoscopic procedures, which requires either endoscopic or surgical repair. We report the account of an 82-year-old woman with an iatrogenic gastric perforation of a hiatal hernia secondary to an endoscopic retrograde cholangiopancreatography (ERCP) procedure. Despite immediate recognition of the complication and endoscopic closure with through-the-scope (TTS) clips, the patient developed mediastinitis, peritonitis, and sepsis. She subsequently underwent an emergency laparoscopic hiatal hernia dissection and repair of the perforation with mediastinal and peritoneal washout. Given the patient’s age and the degree of insult, subdiaphragmatic anchoring with abdominal drain placement was performed, and the hiatus was left open for additional drainage. The use of a side-viewing duodenoscope with the presence of a large hiatal hernia contributed to the risk of gastric perforation. We conclude that performing endoscopic procedures in patients with a known hiatal hernia should be carefully undertaken. If a perforation in such patients occurs, laparoscopic repair of such complications is feasible as demonstrated in this case video

Psychological Diagnoses and Weight Loss among Appalachian Bariatric Surgery Patients

Background. The relationship between presurgical psychopathology and weight loss following bariatric surgery is complex; previous research has yielded mixed results. The current study investigates the relationship among presurgical mental health diagnoses, symptom severity, and weight loss outcomes in an Appalachian population, where obesity-related comorbidities are prominent. Methods. A retrospective chart review was performed on bariatric surgery patients in an accredited Appalachian centered academic hospital in northern West Virginia between 2013 and 2015 (n = 347). Data extraction included basic demographics, anthropometrics (percent excess weight loss (%EWL)) at six-month, one-year, and two-year postoperative visits, and two validated psychological questionnaires (Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory (BAI)) from patient’s presurgical psychological evaluation. Results. Average patient population was 92.5% Caucasian, 81.5% female, 45 ± 11.5 years old, and 84.1% who underwent laparoscopic Roux-en-Y gastric bypass surgery with the remaining having laparoscopic sleeve gastrectomy. At baseline, no differences were detected in weight, excess body weight, or body mass index between surgery types. Average baseline BDI-II score was 10.1 ± 8.68 (range 0–41) and BAI score was 6.1 ± 6.7 (range 0–36), and this was not significantly different by surgery at baseline. Both baseline psychological scores were in the “minimal” severity range. BDI-II was positively related to BMI of patients at baseline (p=0.01). Both BDI-II and BAI were not significantly related to %EWL across follow-up. Conclusion. Other than baseline weight, BDI-II and BAI scores were not related to %EWL outcomes in patients receiving bariatric surgery in the Appalachian region. Future work should examine mixed methods approaches to capture prospective and longitudinal data to more thoroughly delve into mental health aspects of our Appalachian patients and improve efforts to recapture postoperative patients who may have been lost to follow-up

Laparoscopic Removal of Angelchik Prosthesis Followed by Interval Sleeve Gastrectomy

Introduction. The Angelchik prosthesis (AP) is a historic antireflux device which consists of a C-shaped silicone ring placed around the gastroesophageal junction (GEJ) and secured by Dacron tape. We present a rare experience with an AP and its impact on bariatric surgical outcomes. Case. Our patient is a 66-year-old woman who had an open antireflux procedure with an AP in 1987. She presented to a bariatric clinic for consideration of bariatric surgery for the treatment of morbid obesity and associated comorbidities. She also reported significant problems with reflux and dysphagia. After an appropriate work-up, an AP was identified at her GEJ. She was taken to the operating room for laparoscopic removal with planned interval laparoscopic sleeve gastrectomy. Intraoperatively, the AP was identified around the GEJ; after extensive adhesiolysis, the prosthesis was removed. Postoperatively, in order to determine if the AP had caused any lasting esophageal motility problems, the patient underwent a high-resolution esophageal manometry which demonstrated normal esophageal motility. Interval laparoscopic sleeve gastrectomy was performed safely 9 weeks later. Conclusion. Although rarely used, it is still possible to encounter an Angelchik prosthesis in practice. General and bariatric surgeons need to be aware of this rare device and understand how to manage its related complications

First-line antiretroviral therapy with a protease inhibitor versus non-nucleoside reverse transcriptase inhibitor and switch at higher versus low viral load in HIV-infected children: An open-label, randomised phase 2/3 trial

Background: Children with HIV will be on antiretroviral therapy (ART) longer than adults, and therefore the durability of first-line ART and timing of switch to second-line are key questions. We assess the long-term outcome of protease inhibitor and non-nucleoside reverse transcriptase inhibitor (NNRTI) first-line ART and viral load switch criteria in children. Methods: In a randomised open-label factorial trial, we compared effectiveness of two nucleoside reverse transcriptase inhibitors (NRTIs) plus a protease inhibitor versus two NRTIs plus an NNRTI and of switch to second-line ART at a viral load of 1000 copies per mL versus 30 000 copies per mL in previously untreated children infected with HIV from Europe and North and South America. Random assignment was by computer-generated sequentially numbered lists stratified by age, region, and by exposure to perinatal ART. Primary outcome was change in viral load between baseline and 4 years. Analysis was by intention to treat, which we defined as all patients that started treatment. This study is registered with ISRCTN, number ISRCTN73318385. Findings: Between Sept 25, 2002, and Sept 7, 2005, 266 children (median age 6\ub75 years; IQR 2\ub78-12\ub79) were randomly assigned treatment regimens: 66 to receive protease inhibitor and switch to second-line at 1000 copies per mL (PI-low), 65 protease inhibitor and switch at 30 000 copies per mL (PI-higher), 68 NNRTI and switch at 1000 copies per mL (NNRTI-low), and 67 NNRTI and switch at 30 000 copies per mL (NNRTI-higher). Median follow-up was 5\ub70 years (IQR 4\ub72-6\ub70) and 188 (71%) children were on first-line ART at trial end. At 4 years, mean reductions in viral load were -3\ub716 log10copies per mL for protease inhibitors versus -3\ub731 log10copies per mL for NNRTIs (difference -0\ub715 log10copies per mL, 95% CI -0\ub741 to 0\ub711; p=0\ub726), and -3\ub726 log10copies per mL for switching at the low versus -3\ub720 log10copies per mL for switching at the higher threshold (difference 0\ub706 log10copies per mL, 95% CI -0\ub720 to 0\ub732; p=0\ub756). Protease inhibitor resistance was uncommon and there was no increase in NRTI resistance in the PI-higher compared with the PI-low group. NNRTI resistance was selected early, and about 10% more children accumulated NRTI mutations in the NNRTI-higher than the NNRTI-low group. Nine children had new CDC stage-C events and 60 had grade 3/4 adverse events; both were balanced across randomised groups. Interpretation: Good long-term outcomes were achieved with all treatments strategies. Delayed switching of protease-inhibitor-based ART might be reasonable where future drug options are limited, because the risk of selecting for NRTI and protease-inhibitor resistance is low. Funding: Paediatric European Network for Treatment of AIDS (PENTA) and Pediatric AIDS Clinical Trials Group (PACTG/IMPAACT). \ua9 2011 Elsevier Ltd