A case report of an adjustable gastric band erosion and migration into the jejunum resulting in biliary obstruction

Introduction: Laparoscopic adjustable gastric band is a bariatric operation which has lost popularity due to its high rate of reoperation and complications such as band erosion. Erosion may be partial or complete with intragastric migration of the band. Once in the stomach lumen, the band has the potential to migrate into the small bowel. Presentation of case: A 43-year-old male with history of morbid obesity and laparoscopic adjustable gastric band placement presented with abdominal pain secondary to biliary obstruction. Endoscopic retrograde cholangiopancreatography revealed eroded gastric band tubing into the lumen of the stomach and duodenum with resultant distortion of the ampulla. Upon surgical exploration, the band was found to have migrated into the jejunum and was removed through an enterotomy. The patient did well and was discharged home on postoperative day 8. Discussion: Once completely eroded into the gastric lumen, a gastric band can migrate into the small bowel with the distance traveled being limited by the length of the connecting tube. The stretched tubing can result in distortion of the ampulla leading to biliary obstruction. Band erosion should be managed with band removal which can be completed using endoscopic, laparoscopic, or open approach. Conclusion: Band migration should be suspected in patients with a history of gastric band placement presenting with bowel or biliary obstruction. Its management depends on the location of the band as well as the expertise of the surgical team

Outcomes of Roux-En-Y Gastric Bypass and Sleeve Gastrectomy in the Super-Obese and Super-Super-Obese: An Analysis of the Metabloic and Bariatric Surgery Accreditation and Quality Improvement Program Database

Background: With the increase in the prevalence of obesity and the need for bariatric surgery, there continues to be contradictory evidence for the perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients. The purpose of this is study is to investigate 30-day morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Methods: All patients undergoing LSG and LRYGB between the years 2015 and 2017 in the MBSAQIP database were identified. Patients were divided into three groups based on body mass index (BMI): obese (BMI 35 – 50 kg/m2), SO (BMI 50 – 60 kg/m2), and SSO (BMI ≥ 60 kg/m2). Primary outcomes included the occurrence of any complication or mortality. Secondary outcomes included readmission, reoperation, renal events, cardiac events, respiratory events, unplanned intensive care admission, surgical site infections, venous thromboembolic events, transfusion, and reintervention. These were compared between the BMI groups using Pearson X2 test or Fischer’s exact test. Multivariate logistic regression was then used to adjust for demographics, co-morbidities, and operative variables and adjusted odds ratio (AOR) was reported for each outcome. Results: A total of 356,621 patients met inclusion criteria: 71.6% LSG and 28.4% LRYGB. SSO and SO groups was associated with marginally longer operative times and conversion to open. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for the SO group (AOR = 1.20 for LSG; AOR = 1.08 for LRYGB) and SSO group (AOR = 1.44 for LSG; AOR = 1.31 for LRYGB). Mortality rate was also significantly higher for the SO group (AOR = 1.65 for LSG; AOR = 1.85 for LRYGB) and SSO group (AOR = 3.30 for LSG; AOR = 3.32 for LRYGB). Conclusion: SO and SSO patients are at increased risk of 30-day morbidity and mortality compared to patients with BMI ≤ 50 kg/m2. Despite this statistically significant increase, the risks remain low and acceptable especially that bariatric surgery is the only reliable treatment option for obesity.https://scholarlycommons.henryford.com/merf2019clinres/1054/thumbnail.jp

Association of obesity with illness severity in hospitalized patients with COVID-19: A retrospective cohort study

BACKGROUND: Although recent studies have shown an association between obesity and adverse coronavirus disease 2019 (COVID-19) patient outcomes, there is a paucity in large studies focusing on hospitalized patients. We aimed to analyze outcomes associated with obesity in a large cohort of hospitalized COVID-19 patients. METHODS: We performed a retrospective study at a tertiary care health system of adult patients with COVID-19 who were admitted between March 1 and April 30, 2020. Patients were stratified by body mass index (BMI) into obese (BMI ≥ 30 kg/m 2) and non-obese (BMI \u3c 30 kg/m 2) cohorts. Primary outcomes were mortality, intensive care unit (ICU) admission, intubation, and 30-day readmission. RESULTS: A total of 1983 patients were included of whom 1031 (51.9%) had obesity and 952 (48.9%) did not have obesity. Patients with obesity were younger (P \u3c 0.001), more likely to be female (P \u3c 0.001) and African American (P \u3c 0.001) compared to patients without obesity. Multivariable logistic models adjusting for differences in age, sex, race, medical comorbidities, and treatment modalities revealed no difference in 60-day mortality and 30-day readmission between obese and non-obese groups. In these models, patients with obesity had increased odds of ICU admission (adjusted OR, 1.37; 95% CI, 1.07-1.76; P = 0.012) and intubation (adjusted OR, 1.37; 95% CI, 1.04-1.80; P = 0.026). CONCLUSIONS: Obesity in patients with COVID-19 is independently associated with increased risk for ICU admission and intubation. Recognizing that obesity impacts morbidity in this manner is crucial for appropriate management of COVID-19 patients

Risks and benefits of prophylactic inferior vena cava filters in patients undergoing bariatric surgery

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/97509/1/jhm2013.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/97509/2/jhm2013-sup-0001-suppinfo.pd

Predictors of postoperative emergency department visits after laparoscopic bariatric surgery

BACKGROUND: Postoperative emergency department (ED) visits are a quality metric for bariatric surgical programs. Predictive factors of ED visits that do not result in readmission are not clear. OBJECTIVES: We aimed to identify predictors of ED visits in patients without readmission after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). SETTING: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. METHODS: The MBSAQIP database was queried for patients who underwent LSG and LRYGB from 2015 through 2017. Patients were grouped by those who presented to the ED (ED group) and those who did not. ED visits analyzed included only those that did not result in readmission. Multivariable forward selection logistic regression was used to report adjusted odds ratios (AORs) with 95% CIs for ED visits. RESULTS: Of 276,073 patients, 257,985 (93.4%) were in the group who did not present to the ED, and 18,088 (6.6%) were in the ED group. Most underwent LSG (71.9%) versus LRYGB (28.1%). Multivariable forward logistic regression identified outpatient treatment for dehydration (AOR, 22.26; 95% CI, 21.30-23.27; P \u3c .001) as the most predictive factor of an ED visit, followed by urinary tract infection (AOR, 7.25; 95% CI, 6.22-8.46; P \u3c .001), wound disruption (AOR, 4.63; 95% CI, 3.09-6.96; P \u3c .001), and surgical site infection (AOR, 3.80; 95% CI, 3.38-4.28; P \u3c .001). CONCLUSIONS: Postoperative complications were the strongest predictors of ED visits after laparoscopic bariatric surgery. Quality improvement initiatives should target these variables to decrease postoperative ED visits

Dehydration risk factors and impact after bariatric surgery: an analysis using a national database

BACKGROUND: Dehydration is a common complication after bariatric surgery and often quoted as the reason for emergency department (ED) visits and readmission. OBJECTIVE: We sought to investigate risk factors for dehydration after bariatric surgery and evaluate its impact on ED visits and readmission. SETTING: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. METHODS: We used the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database to identify patients who underwent laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2016 through 2017. The primary outcome was need for outpatient treatment of dehydration within 30 days postsurgery. Secondary outcomes were association between need for outpatient dehydration therapy and 30-day readmission or ED evaluation not resulting in admission. RESULTS: Of 256,817 patients, 73% underwent laparoscopic sleeve gastrectomy and 27% LRYGB. Of 9592 patients who required dehydration treatment, they were more often younger than age 40, female, black, had a ≥3-day length of stay during their index admission, and experienced a postoperative complication. More patients receiving LRYGB than laparoscopic sleeve gastrectomy required treatment for dehydration. On multivariable analysis, independent-risk factors for postoperative dehydration treatment included LRYGB, length of stay ≥3 days, gastroesophageal reflux disease, hypertension, previous deep vein thrombosis, chronic steroid/immunosuppression, and a postoperative complication. Patients who developed dehydration requiring treatment compared with those that did not had adjusted odds ratio of 3.7 (95% confidence interval: 3.44-3.96; P \u3c .001) and 22 (95% confidence interval: 21.05-23.06; P \u3c .001) of readmission and ED visit. CONCLUSION: Dehydration is a strong risk factor for postoperative ED visits and readmission. Closer surveillance and proactive measures for those at higher risk may prevent the development of postoperative dehydration

Perioperative Outcomes of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Patients with Diabetes Mellitus: an Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database

BACKGROUND: The safety and efficacy of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) to treat obesity and associated comorbidities, including diabetes mellitus, is well established. As diabetes may add risk to the perioperative period, we sought to characterize perioperative outcomes of these surgical procedures in diabetic patients. METHODS: Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we identified patients who underwent LSG and LRYGB between 2015 and 2017, grouping by non-diabetics (NDM), non-insulin-dependent diabetics (NIDDM), and insulin-dependent diabetics (IDDM). Primary outcomes included serious adverse events, 30-day readmission, 30-day reoperation, and 30-day mortality. Univariate and multivariable analyses were used to evaluate the outcome in each diabetic cohort. RESULTS: Multivariable analysis of patients who underwent LSG (with NDM patients as reference) showed higher 30-day mortality (NIDDM AOR = 1.52, p = 0.043; IDDM AOR = 1.91, p = 0.007) and risk of serious adverse events (NIDDM AOR = 1.15, p \u3c 0.001; IDDM AOR = 1.58, p \u3c 0.001) in the diabetic versus NDM groups. Multivariable analysis of patients who underwent LRYGB (with NDM patients as reference) showed higher risk of serious adverse events (NIDDM AOR = 1.09, p = 0.014; IDDM AOR = 1.43, p \u3c 0.001) in the diabetic versus NDM groups. CONCLUSIONS: Diabetics who underwent LSG and LRYGB had higher rates of several perioperative complications compared with non-diabetics. IDDM had a stronger association with several perioperative complications compared with NIDDM. This increase in morbidity and mortality is modest and should be weighed against the real benefits of bariatric surgery in patient with obesity and diabetes mellitus

Perioperative outcomes of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in super-obese and super-super-obese patients: a national database analysis

BACKGROUND: Evidence remains contradictory for perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients undergoing bariatric surgery. OBJECTIVE: To identify national 30-day morbidity and mortality of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients. SETTING: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. METHODS: All LSG and LRYGB patients from 2015 through 2017 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were grouped based on body mass index (BMI) as follows: morbidly obese (MO; BMI 35.0-49.9 kg/m(2)), SO (BMI 50.0-59.9 kg/m(2)), and SSO (BMI \u3e/=60.0 kg/m(2)). Complications and mortality within 30 days were compared between BMI groups using Pearson X(2) or Fischer\u27s exact tests. Multivariate logistic regression was used to adjust for demographic characteristics and co-morbidities, and adjusted odds ratio (AOR) was reported for each outcome. RESULTS: Of 356,621 patients, 71.6% had LSG and 28.4% LRYGB. A total of 272,195 patients were in the MO group, 65,565 in the SO group, and 18,861 in the SSO group. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for SO (AOR = 1.20, 95% confidence interval [CI] 1.13-1.28 for LSG; AOR = 1.08, 95% CI 1.01-1.15 for LRYGB) and SSO (AOR = 1.44, 95% CI 1.31-1.58 for LSG; AOR = 1.31, 95% CI 1.19-1.45 for LRYGB) compared with the MO group. Mortality was also significantly higher for SO (AOR = 1.65, 95% CI 1.10-2.48 for LSG; AOR = 1.85, 95% CI 1.23-2.80 for LRYGB) and SSO (AOR = 3.30, 95% CI 1.98-5.48 for LSG; AOR = 3.32, 95% CI 1.93-5.73 for LRYGB) compared with the MO group. CONCLUSIONS: SO and SSO patients are at increased risk of 30-day morbidity and mortality compared with MO patients. Despite this elevated perioperative risk, the overall risk of these procedures remains low and acceptable especially as bariatric surgery is the durable treatment option for obesity

Risk Factors for Surgical Site Infections after Laparoscopic Bariatric surgery: An Analysis of the MBSAQIP Database

Background: Surgical site infection (SSI) is a preventable postoperative complication. There is a paucity of literature on risk factors for SSI after bariatric surgery. The aim of this study was to evaluate risk factors for SSI after laparoscopic bariatric surgery using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Methods: Patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) between 2015 and 2017 were identified from the MBSAQIP database. Descriptive analysis was used to evaluate associations between SSI and perioperative complications. Multivariate logistic regression analysis was used to identify predictors of SSI. Results: A total of 266,791 LSG and 104,442 LRYGB cases were identified with 2494 (0.67%) total cases of SSI (1595 cases of superficial SSI; 211 cases of deep/incisional SSI; 715 cases of organ-space SSI). SSI was associated with an increased risk of complications (32.5% vs. 3.08%; p\u3c0.01) and mortality (0.52% vs. 0.07%; p\u3c0.01). LRYGB was associated with higher risk of SSI compared to LSG (AOR 2.52; 95% CI 2.31-2.76; p\u3c0.01). The most predictive risk factors for SSI were body mass index ≥ 60 kg/m2 (AOR 1.71; 95% CI 1.33-2.21; p\u3c0.01) and steroid use (AOR 1.61; 95% CI 1.27-2.03; p\u3c0.01). Additional risk factors for SSI are listed in Table 1. Conclusions: Despite low incidence, SSI after laparoscopic bariatric surgery is associated with perioperative morbidity and mortality. Modifiable risk factors such as diabetes mellitus, smoking, and steroid use may provide an opportunity to decrease SSI risk. [Figure presented

Perioperative Outcomes of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Type 2 Diabetics: A MBSAQIP Analysis

Introduction: The safety and efficacy of laparoscopic sleeve gastrectomy (LSG) and roux-en-Y gastric bypass (RYGB) for the treatment of obesity and associated comorbidities, including type 2 diabetes mellitus (T2DM), is well established. However, these comorbidities may add risk to the perioperative period. We sought to characterize perioperative outcomes of these surgical procedures in type 2 diabetics using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, and further analyze diabetic patients based on their insulin dependence.Methods: All patients undergoing LSG and LRYGB between the years 2015 and 2017 in the MBSAQIP database were identified. Patients were divided into three groups: non-diabetics (NDM), non-insulin dependent type 2 diabetics (NIDDM), and insulin dependent type 2 diabetics (IDDM). Primary outcomes included serious adverse events, 30-day readmission, 30-day reoperation, and 30-day mortality. Secondary outcomes included length of stay, renal events, cardiac events, respiratory complications, surgical site infections, septic events, urinary tract infections, venous thromboembolism, perioperative transfusions, and reinterventions. These were compared between the groups using Pearson chi square test or Fisher’s exact test as appropriate. Multivariate logistic regression was then used to adjust for demographics, co-morbidities, and operative variables, with adjusted odds ratio (AOR) reported for each outcome. This was done with the NDM group as reference for the diabetic groups, and then with the NIDDM group as reference for the IDDM group. Significance was established at p\u3c0.05. All analysis was performed using IBM SPSS version 25.Results: Multivariable analysis of patients who underwent LSG with, NDM patients as reference, showed higher 30-day mortality (NIDDM AOR=1.52, p=0.043; IDDM AOR=1.91, p=0.007) and risk of serious adverse events (NIDDM AOR=1.15, p\u3c0.001; IDDM AOR=1.58, p\u3c0.001) in the diabetic versus NDM groups. The IDDM group was associated with higher 30-day readmission (AOR=1.69, p\u3c0.001) and reoperation (AOR=1.40, p\u3c0.001) risk as well. IDDM patients had higher risk of all secondary outcomes with the exception of venous thromboembolism events. When the IDDM group was compared to the NIDDM group directly, the IDDM group was at higher risk of serious adverse events (AOR=1.38, p\u3c0.001), 30-day readmission (AOR=1.68, p\u3c0.001), and 30-day reoperation (AOR=1.25, p=0.013), while also at higher risk of all secondary outcomes except septic events and venous thromboembolism events.Multivariable analysis of patients who underwent RYGB, with NDM patients, as reference showed higher risk of serious adverse events (NIDDM AOR=1.09, p=0.014; IDDM AOR=1.43, p\u3c0.001) in the diabetic versus NDM groups. The IDDM group was associated with higher risk of 30-day readmission (AOR=1.26, p\u3c0.001) and lower risk of reoperation (AOR=0.88, p=0.070). Both diabetic groups had higher risk of surgical site infection, while IDDM patients had higher risk of all other secondary outcomes with the exception of septic and venous thromboembolism events and reintervention. When the IDDM group was compared to the NIDDM group directly, the IDDM group was at higher risk of serious adverse events (AOR=1.32, p\u3c0.001) and 30-day readmission (AOR=1.30, p\u3c0.001), while also at higher risk of secondary outcomes except respiratory complications, septic events, venous thromboembolism events, and perioperative transfusions. Conclusions: Type 2 diabetes had significant associations with several perioperative complications in patients who underwent LSG and RYGB. IDDM had even stronger associations with perioperative complications than NIDDM. A preoperative emphasis on optimizing diabetes mellitus control may be of benefit in preventing perioperative complications.https://scholarlycommons.henryford.com/merf2019clinres/1030/thumbnail.jp