- Email: [email protected]
Description of Revisional Bariatric Surgery Operations Performed in a Diverse Population of Patients from a Large Integrated Health Care System
S70
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
A5027
A5028
CHARACTERISTICS OF ADOLESCENTS WITH A POOR MENTAL HEALTH OUTCOME AFTER BARIATRIC SURGERY Kajsa Jarvholm, PsyD; Jan Karlsson, Dr; Markku Peltonen, PhD; Claude Marcus, MD, PhD; Torsten Olbers, MD, PhD; Per Johnsson, PhD; Jovanna Dahlgren, MD, PhD; Carl-Erik Flodmark, MD PhD; Eva Gronowitz, RN, PhD; Lund University, Lund, Sweden
THROMBOPHYLAXIS IN PATIENTS UNDERGOING BARIATRIC SURGERY Maureen Quigley, MS, APRN; Monic Roengvoraphoj, MD; Gina Adrales, MD, MPH; Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
Background: Even if a majority of adolescents experience an overall improvement in mental health following bariatric surgery, some do not. About 1 in 5 report substantial depressive symptoms two years after surgery. This study explores differences between adolescents with a poor mental health (PMH) two years after bariatric surgery and adolescents with an average or good mental health (A/GMH). Methods: Subjects were 82 Swedish adolescents with severe obesity from the Adolescent Morbid Obesity Surgery (AMOS)-study cohort, undergoing gastric bypass surgery. Mean age was 16.8 years (⫾ 1.19; range 13-18), mean BMI was 45.4 (⫾ 6.05; range 35.1-68.5) at inclusion and 67% were girls. Generic mental health variables (anxiety, depression, anger, disruptive behavior, and self-concept) as well as obesity-related problems were assessed by self-report questionnaires at baseline, 1 year and 2 years after gastric bypass. Standardized cut-offs on two different variables, depression and obesity-related problems, were used to classify adolescents as either PMH or A/GMH two years after surgery. Mixed-model was used to analyze differences in outcomes between the groups. Results: In total, 16 (20%) of 82 adolescents were classified as having a PMH two years after surgery. There were more girls (n¼14) than boys (n¼2) in this group and the inequality in gender distribution had a trend towards significance (p¼0.053). No significant age difference was found (p¼0.30). Anxiety and depression differed significantly (P¼0.004 and P¼0.028) between the groups at baseline, as adolescents with a PMH after two years had more symptoms of anxiety and depression already before surgery. One year after surgery more differences were observed as adolescents with a PMH in addition to reporting more symptoms of anxiety (P¼o0.0001) and depression (P¼0.003) also reported more anger (P¼0.005) and obesity-related problems (P¼0.006) than adolescents with a A/GMH. Still no differences in self-concept (P¼0.345) or disruptive behavior (P¼0.296) were seen. Two years after surgery, all measured aspects of mental health were worse in adolescents with PMH (all Pso0.0001). BMI did not differ between groups at baseline nor at any follow-up (P¼0.228, year 2). Conclusions: A substantial number of adolescents, 20%, report PMH two years after undergoing gastric bypass which is much higher than expected from previous studies in adults. This indicates that there is an unmet need for psychological and psychiatric interventions in adolescents undergoing bariatric surgery. Pre-op identification appears difficult, but higher scores for anxiety and depression before surgery indicate need for increased support and close follow up. At the one year follow-up differences between the groups are prominent, except for self-concept and disruptive behavior, and targeted interventions should be offered to adolescents with more mental health problems already one year after surgery. Weight loss did, however, not differ between the groups demonstrating PMH and A/GMH.
Background: Patients undergoing bariatric surgery are at increased risk for developing symptomatic venous thromboembolism (VTE). The incidence of symptomatic VTE ranges from 0%6%. Although the overall incidence of clinical VTE is lower than that seen with other general and orthopedic surgical procedures, pulmonary embolism is an independent predictor of death after gastric bypass surgery. The optimal strategy for perioperative thrombophylaxis in bariatric surgery has yet to be elucidated. The current available published literatures vary on the optimal type, dose and length of pharmacologic thrombophylaxis and the benefit of prophylactic IVC filter. Prior 2010 our institution used unfractionated heparin 5,000 units prior to induction of anesthesia, then twice daily during hospital stay. In 2010 our institution has proposed a guideline for perioperative thrombophylaxis for bariatric surgery based on risk stratification. Patients will be considered to be at high risk if they have one or more of the following: previous VTE or BMI 4/¼ 60 kg/m2 Or two or more of the following: Age 4 50, BMI 4/¼ 50 kg/m2, male sex, recent history of smoking, obstructive sleep apnea, venous insufficiency, varicose veins, oral contraceptive or post-menopausal hormone use within 30 days The proposed guideline recommends pharmacologic thrombophylaxis using enoxaparin 40 mg SC at induction of anesthesia and then twice daily throughout hospitalization. High risk patients will continue enoxaparin injections after discharge for a total of 10-14 days postoperatively. Prophylactic IVC filter is not recommended. Methods: We propose a retrospective study to evaluate the incidence of VTE rates and bleeding complications in all bariatric surgery patients at Dartmouth Hitchcock Medical Center (DHMC) from 1/2013-12/2014 after initiation of the current proposed guideline for perioperative thrombophylaxis. Results: Of 254 patients undergoing bariatric surgery at DHMC, none of them (0%) developed VTE and 6 patients (2.6%) developed postoperative bleeding complications within 30 days post-operatively. As compared with the other MBSAQIP sites, our site has a lower incidence of VTE (0% vs 0.1%), but higher incidence of postoperative bleeding (0.5% vs 2.4%) within 3 months after surgery. Conclusions: Our proposed guideline for perioperative thrombophylaxis for bariatric surgery based on risk stratification appears to be effective to minimize the risk of VTE, but may need to be modified in patients with high bleeding risk.
A5029
DESCRIPTION OF REVISIONAL BARIATRIC SURGERY OPERATIONS PERFORMED IN A DIVERSE POPULATION OF PATIENTS FROM A LARGE INTEGRATED HEALTH CARE SYSTEM Karen Coleman, PhD1; Robert Casillas, MD2; Katie Chapmon, MS, RD2; Philip Chin, MD2; Peter Fedorka, MD2; Jorge Zelada Getty, MD2; Fadi Hendee, MD2;
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
Benjamin Kim, MD2; Mary Jane Mancuso, NP2; Edward Mun, MD2; Laura Sirikuldvadhana, MPH2; Scott Um, MD2; Robert Zane, MD2; Jialuo Liu, MS2; 1Kaiser Permanente Southern California, Pasadena, CA, USA; 2Kaiser Permanente Southern California, Los Angeles, CA, USA Purpose: This study was designed to describe the characteristics and weight outcomes for revisional bariatric surgery that converted one bariatric operation to another from a large integrated healthcare system. Methods: Participants were 349 patients who had a revisional bariatric surgery between 1/1/2004 and 3/31/13. Revisions for these analyses were defined as an initial bariatric operation converted to a second bariatric operation. This was distinct from revisions that were done to remove or revise laparoscopic adjustable gastric bands or to address complications with other initial operations such as laparoscopic sleeve gastrectomy or Rouxen-Y gastric bypass without conversion to another operation. Electronic medical records were abstracted before and after surgery to include patient demographics, body weight, and body mass index (BMI) at the time of surgery. Percent excess weight loss was calculated using weight on the day of surgery and a BMI of 25 kg/m2 for ideal weight. The demographics and percent excess weight loss were compared between the three main revisional surgeries in the sample using t-tests for continuous variables and chi squared for categorical variables. These three revisional surgeries were: laparoscopic adjustable gastric band removal converted to sleeve gastrectomy, laparoscopic adjustable gastric band removal converted to Roux-en-Y gastric bypass, and sleeve gastrectomy converted to bypass. In addition to these statistical analyses, cases were chart reviewed to determine the reasons for conversion to another procedure. Results: Of the 349 patients in the sample, 65% (n ¼ 228) had their bands converted to sleeve gastrectomy, 22% (n ¼ 78) had their bands converted to bypass, and 12% (n ¼43) had their sleeve gastrectomy converted to bypass. Each group had similar postoperative follow-up (39.5 þ 42.3 months overall) and had similar racial/ethnic backgrounds (45% non-Hispanic white, 29% Hispanic, 22% non-Hispanic black, and 4% other/missing/mixed overall), gender (89% women overall), and age (44.6 þ 11.4 years overall). Patients who had their band removed and converted to bypass were heavier at the time of surgery (BMI 39.9 þ 8.6 kg/ m2) than patients who had their band converted to sleeve gastrectomy (BMI 36.6 þ 6.5 kg/m2; p ¼ .002). Patients whose bands were converted to bypass also lost more weight than the band patients who converted to sleeve gastrectomy (46% vs. 34% excess weight loss; p ¼ .004). Patients who had their sleeve gastrectomy converted to bypass had similar weight at the time of surgery to the band to sleeve gastrectomy patients (BMI 37.1 þ 7.2 kg/m2) but had higher excess weight loss (51% vs. 34%; p ¼ .004). The sleeve to bypass patients had similar weight loss (51%) as the band to bypass patients (46%). When the reasons for conversions were chart reviewed we found that 43% of the cases where sleeve gastrectomy was converted to bypass were done due to insufficient weight loss, 43% were due to severe reflux and/or hiatal hernia, and 14% were from complications associated with the sleeve gastrectomy operation. Conversions of bands to either sleeve gastrectomy or bypass were done 73% of the time for insufficient weight loss, 7% due to severe reflux, and 20% because of complications with the band device.
S71
Conclusions: In this large study of revisional bariatric procedures where one bariatric operation was converted to another bariatric operation we found that the majority of these revisions were done for insufficient weight loss. Once patients were revised to another operation, they demonstrated significant excess weight loss varying from 34% to 51% excess weight loss over three years of follow-up. A large proportion of the sleeve gastrectomy revisions to Roux-en-Y gastric bypass were due to severe reflux and/or hiatal hernias (43%). A5030
EARLY SURGES IN FASTING PLASMA BILE ACIDS AFTER ROUX-EN-Y GASTRIC BYPASS ARE DUE TO INSULIN-SENSITIZING, BACTERIALLY-DERIVED SECONDARY BILE ACIDS Vance Albaugh, MD, PhD1; Steven Cai, Medical Student2; Travis Cyphert, PhD1; Robyn Tamboli, PhD1; Charles Flynn, PhD1; Naji Abumrad, MD1; 1Vanderbilt University, Nashville, TN, USA; 2Rosalind Franklin University, North Chicago, IL, USA Increasing evidence demonstrates that Roux-en-Y gastric bypass (RYGB) is associated with elevated plasma bile acids compared to preoperative levels, though the physiologic significance of these changes is unknown. Recent data suggests that different bile acids have different physiologic effects. Thus, identifying the specific bile acid changes following RYGB may provide mechanistic insight to their contributions to the acute or chronic effects of RYGB. We hypothesized that changes in specific bile acids over time may be significantly associated with other hormonal or physiologic changes that might help explain the metabolic improvements following RYGB. Using a prospective RYGB patient cohort, we used mass spectroscopy to measure 17 individual bile acid species preoperatively and at 1, 6, 12, and 24 months postoperatively. Anthropometric, hormonal, and hyperinsulinemic-euglycemic clamp data were also examined to identify physiologic parameters that were associated with changes in bile acids. Linear mixed effects modeling was used to analyze the longitudinal data and identify associated factors that changed significantly with bile acid changes. Consistent with previous reports, fasting total bile acids increased following RYGB. However, the increases were bimodal with two observed peaks at 1 and 24 months. The one-month increases were secondary to surges in ursodeoxycholic acid (UDCA) and its glycine-conjugate, which are bacterially-derived bile acids with putative insulinsensitizing effects. These increases were associated with significant improvement in hepatic insulin sensitivity. Later increases up to 24 month were due to gradual rises in primary unconjugated bile acids as well as deoxycholic (DCA) acid and its glycine conjugate. These later increases, however, were not significantly associated with any anthropometric or hormonal measures, and were not associated with significant additional improvements in insulin sensitivity. Overall finding suggest that bacterially-derived bile acids, particularly ursodeoxycholic acid, may mediate the early improvements in hepatic insulin sensitivity at one month after RYGB. However, the physiologic effects associated with the gradual increases in unconjugated bile acids in combination with DCA over time are independent of glucose metabolism (F32DK103474, R01DK105847).
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
A5027
A5028
CHARACTERISTICS OF ADOLESCENTS WITH A POOR MENTAL HEALTH OUTCOME AFTER BARIATRIC SURGERY Kajsa Jarvholm, PsyD; Jan Karlsson, Dr; Markku Peltonen, PhD; Claude Marcus, MD, PhD; Torsten Olbers, MD, PhD; Per Johnsson, PhD; Jovanna Dahlgren, MD, PhD; Carl-Erik Flodmark, MD PhD; Eva Gronowitz, RN, PhD; Lund University, Lund, Sweden
THROMBOPHYLAXIS IN PATIENTS UNDERGOING BARIATRIC SURGERY Maureen Quigley, MS, APRN; Monic Roengvoraphoj, MD; Gina Adrales, MD, MPH; Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
Background: Even if a majority of adolescents experience an overall improvement in mental health following bariatric surgery, some do not. About 1 in 5 report substantial depressive symptoms two years after surgery. This study explores differences between adolescents with a poor mental health (PMH) two years after bariatric surgery and adolescents with an average or good mental health (A/GMH). Methods: Subjects were 82 Swedish adolescents with severe obesity from the Adolescent Morbid Obesity Surgery (AMOS)-study cohort, undergoing gastric bypass surgery. Mean age was 16.8 years (⫾ 1.19; range 13-18), mean BMI was 45.4 (⫾ 6.05; range 35.1-68.5) at inclusion and 67% were girls. Generic mental health variables (anxiety, depression, anger, disruptive behavior, and self-concept) as well as obesity-related problems were assessed by self-report questionnaires at baseline, 1 year and 2 years after gastric bypass. Standardized cut-offs on two different variables, depression and obesity-related problems, were used to classify adolescents as either PMH or A/GMH two years after surgery. Mixed-model was used to analyze differences in outcomes between the groups. Results: In total, 16 (20%) of 82 adolescents were classified as having a PMH two years after surgery. There were more girls (n¼14) than boys (n¼2) in this group and the inequality in gender distribution had a trend towards significance (p¼0.053). No significant age difference was found (p¼0.30). Anxiety and depression differed significantly (P¼0.004 and P¼0.028) between the groups at baseline, as adolescents with a PMH after two years had more symptoms of anxiety and depression already before surgery. One year after surgery more differences were observed as adolescents with a PMH in addition to reporting more symptoms of anxiety (P¼o0.0001) and depression (P¼0.003) also reported more anger (P¼0.005) and obesity-related problems (P¼0.006) than adolescents with a A/GMH. Still no differences in self-concept (P¼0.345) or disruptive behavior (P¼0.296) were seen. Two years after surgery, all measured aspects of mental health were worse in adolescents with PMH (all Pso0.0001). BMI did not differ between groups at baseline nor at any follow-up (P¼0.228, year 2). Conclusions: A substantial number of adolescents, 20%, report PMH two years after undergoing gastric bypass which is much higher than expected from previous studies in adults. This indicates that there is an unmet need for psychological and psychiatric interventions in adolescents undergoing bariatric surgery. Pre-op identification appears difficult, but higher scores for anxiety and depression before surgery indicate need for increased support and close follow up. At the one year follow-up differences between the groups are prominent, except for self-concept and disruptive behavior, and targeted interventions should be offered to adolescents with more mental health problems already one year after surgery. Weight loss did, however, not differ between the groups demonstrating PMH and A/GMH.
Background: Patients undergoing bariatric surgery are at increased risk for developing symptomatic venous thromboembolism (VTE). The incidence of symptomatic VTE ranges from 0%6%. Although the overall incidence of clinical VTE is lower than that seen with other general and orthopedic surgical procedures, pulmonary embolism is an independent predictor of death after gastric bypass surgery. The optimal strategy for perioperative thrombophylaxis in bariatric surgery has yet to be elucidated. The current available published literatures vary on the optimal type, dose and length of pharmacologic thrombophylaxis and the benefit of prophylactic IVC filter. Prior 2010 our institution used unfractionated heparin 5,000 units prior to induction of anesthesia, then twice daily during hospital stay. In 2010 our institution has proposed a guideline for perioperative thrombophylaxis for bariatric surgery based on risk stratification. Patients will be considered to be at high risk if they have one or more of the following: previous VTE or BMI 4/¼ 60 kg/m2 Or two or more of the following: Age 4 50, BMI 4/¼ 50 kg/m2, male sex, recent history of smoking, obstructive sleep apnea, venous insufficiency, varicose veins, oral contraceptive or post-menopausal hormone use within 30 days The proposed guideline recommends pharmacologic thrombophylaxis using enoxaparin 40 mg SC at induction of anesthesia and then twice daily throughout hospitalization. High risk patients will continue enoxaparin injections after discharge for a total of 10-14 days postoperatively. Prophylactic IVC filter is not recommended. Methods: We propose a retrospective study to evaluate the incidence of VTE rates and bleeding complications in all bariatric surgery patients at Dartmouth Hitchcock Medical Center (DHMC) from 1/2013-12/2014 after initiation of the current proposed guideline for perioperative thrombophylaxis. Results: Of 254 patients undergoing bariatric surgery at DHMC, none of them (0%) developed VTE and 6 patients (2.6%) developed postoperative bleeding complications within 30 days post-operatively. As compared with the other MBSAQIP sites, our site has a lower incidence of VTE (0% vs 0.1%), but higher incidence of postoperative bleeding (0.5% vs 2.4%) within 3 months after surgery. Conclusions: Our proposed guideline for perioperative thrombophylaxis for bariatric surgery based on risk stratification appears to be effective to minimize the risk of VTE, but may need to be modified in patients with high bleeding risk.
A5029
DESCRIPTION OF REVISIONAL BARIATRIC SURGERY OPERATIONS PERFORMED IN A DIVERSE POPULATION OF PATIENTS FROM A LARGE INTEGRATED HEALTH CARE SYSTEM Karen Coleman, PhD1; Robert Casillas, MD2; Katie Chapmon, MS, RD2; Philip Chin, MD2; Peter Fedorka, MD2; Jorge Zelada Getty, MD2; Fadi Hendee, MD2;
Poster Presentations / Surgery for Obesity and Related Diseases 11 (2015) S56–S211
Benjamin Kim, MD2; Mary Jane Mancuso, NP2; Edward Mun, MD2; Laura Sirikuldvadhana, MPH2; Scott Um, MD2; Robert Zane, MD2; Jialuo Liu, MS2; 1Kaiser Permanente Southern California, Pasadena, CA, USA; 2Kaiser Permanente Southern California, Los Angeles, CA, USA Purpose: This study was designed to describe the characteristics and weight outcomes for revisional bariatric surgery that converted one bariatric operation to another from a large integrated healthcare system. Methods: Participants were 349 patients who had a revisional bariatric surgery between 1/1/2004 and 3/31/13. Revisions for these analyses were defined as an initial bariatric operation converted to a second bariatric operation. This was distinct from revisions that were done to remove or revise laparoscopic adjustable gastric bands or to address complications with other initial operations such as laparoscopic sleeve gastrectomy or Rouxen-Y gastric bypass without conversion to another operation. Electronic medical records were abstracted before and after surgery to include patient demographics, body weight, and body mass index (BMI) at the time of surgery. Percent excess weight loss was calculated using weight on the day of surgery and a BMI of 25 kg/m2 for ideal weight. The demographics and percent excess weight loss were compared between the three main revisional surgeries in the sample using t-tests for continuous variables and chi squared for categorical variables. These three revisional surgeries were: laparoscopic adjustable gastric band removal converted to sleeve gastrectomy, laparoscopic adjustable gastric band removal converted to Roux-en-Y gastric bypass, and sleeve gastrectomy converted to bypass. In addition to these statistical analyses, cases were chart reviewed to determine the reasons for conversion to another procedure. Results: Of the 349 patients in the sample, 65% (n ¼ 228) had their bands converted to sleeve gastrectomy, 22% (n ¼ 78) had their bands converted to bypass, and 12% (n ¼43) had their sleeve gastrectomy converted to bypass. Each group had similar postoperative follow-up (39.5 þ 42.3 months overall) and had similar racial/ethnic backgrounds (45% non-Hispanic white, 29% Hispanic, 22% non-Hispanic black, and 4% other/missing/mixed overall), gender (89% women overall), and age (44.6 þ 11.4 years overall). Patients who had their band removed and converted to bypass were heavier at the time of surgery (BMI 39.9 þ 8.6 kg/ m2) than patients who had their band converted to sleeve gastrectomy (BMI 36.6 þ 6.5 kg/m2; p ¼ .002). Patients whose bands were converted to bypass also lost more weight than the band patients who converted to sleeve gastrectomy (46% vs. 34% excess weight loss; p ¼ .004). Patients who had their sleeve gastrectomy converted to bypass had similar weight at the time of surgery to the band to sleeve gastrectomy patients (BMI 37.1 þ 7.2 kg/m2) but had higher excess weight loss (51% vs. 34%; p ¼ .004). The sleeve to bypass patients had similar weight loss (51%) as the band to bypass patients (46%). When the reasons for conversions were chart reviewed we found that 43% of the cases where sleeve gastrectomy was converted to bypass were done due to insufficient weight loss, 43% were due to severe reflux and/or hiatal hernia, and 14% were from complications associated with the sleeve gastrectomy operation. Conversions of bands to either sleeve gastrectomy or bypass were done 73% of the time for insufficient weight loss, 7% due to severe reflux, and 20% because of complications with the band device.
S71
Conclusions: In this large study of revisional bariatric procedures where one bariatric operation was converted to another bariatric operation we found that the majority of these revisions were done for insufficient weight loss. Once patients were revised to another operation, they demonstrated significant excess weight loss varying from 34% to 51% excess weight loss over three years of follow-up. A large proportion of the sleeve gastrectomy revisions to Roux-en-Y gastric bypass were due to severe reflux and/or hiatal hernias (43%). A5030
EARLY SURGES IN FASTING PLASMA BILE ACIDS AFTER ROUX-EN-Y GASTRIC BYPASS ARE DUE TO INSULIN-SENSITIZING, BACTERIALLY-DERIVED SECONDARY BILE ACIDS Vance Albaugh, MD, PhD1; Steven Cai, Medical Student2; Travis Cyphert, PhD1; Robyn Tamboli, PhD1; Charles Flynn, PhD1; Naji Abumrad, MD1; 1Vanderbilt University, Nashville, TN, USA; 2Rosalind Franklin University, North Chicago, IL, USA Increasing evidence demonstrates that Roux-en-Y gastric bypass (RYGB) is associated with elevated plasma bile acids compared to preoperative levels, though the physiologic significance of these changes is unknown. Recent data suggests that different bile acids have different physiologic effects. Thus, identifying the specific bile acid changes following RYGB may provide mechanistic insight to their contributions to the acute or chronic effects of RYGB. We hypothesized that changes in specific bile acids over time may be significantly associated with other hormonal or physiologic changes that might help explain the metabolic improvements following RYGB. Using a prospective RYGB patient cohort, we used mass spectroscopy to measure 17 individual bile acid species preoperatively and at 1, 6, 12, and 24 months postoperatively. Anthropometric, hormonal, and hyperinsulinemic-euglycemic clamp data were also examined to identify physiologic parameters that were associated with changes in bile acids. Linear mixed effects modeling was used to analyze the longitudinal data and identify associated factors that changed significantly with bile acid changes. Consistent with previous reports, fasting total bile acids increased following RYGB. However, the increases were bimodal with two observed peaks at 1 and 24 months. The one-month increases were secondary to surges in ursodeoxycholic acid (UDCA) and its glycine-conjugate, which are bacterially-derived bile acids with putative insulinsensitizing effects. These increases were associated with significant improvement in hepatic insulin sensitivity. Later increases up to 24 month were due to gradual rises in primary unconjugated bile acids as well as deoxycholic (DCA) acid and its glycine conjugate. These later increases, however, were not significantly associated with any anthropometric or hormonal measures, and were not associated with significant additional improvements in insulin sensitivity. Overall finding suggest that bacterially-derived bile acids, particularly ursodeoxycholic acid, may mediate the early improvements in hepatic insulin sensitivity at one month after RYGB. However, the physiologic effects associated with the gradual increases in unconjugated bile acids in combination with DCA over time are independent of glucose metabolism (F32DK103474, R01DK105847).