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GASTRIC BYPASS LITERATURE REVIEW 2009-10

GASTRIC BYPASS LITERATURE REVIEW 2009-10. Bruce Schirmer, M.D. Treatment of vitamin D depletion after Roux-en-Y gastric bypass: a randomized prospective clinical trial A.M. Carlin, D. S. Rao, K.M. Yager, et al. (Henry Ford Hospital, Detroit) SOARD 2009 5:444-9. VITAMIN D DEFICIENCY.

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GASTRIC BYPASS LITERATURE REVIEW 2009-10

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  1. GASTRIC BYPASSLITERATURE REVIEW2009-10 Bruce Schirmer, M.D.

  2. Treatment of vitamin D depletion after Roux-en-Y gastric bypass: a randomized prospective clinical trial A.M. Carlin, D. S. Rao, K.M. Yager, et al. (Henry Ford Hospital, Detroit) SOARD 2009 5:444-9

  3. VITAMIN D DEFICIENCY PRCT (n=60) RYGB patients Preop assessment of vitamin D depletion (25 OH D < 20 ng/mL) Controls: 800 IU vit D + 1500 mg calcium daily Treatment: Add 50,000 IU vitD/week

  4. VITAMIN D DEFICIENCY 1 yr postop: remeasure: Ca, PTH, 25OHD, alk phos, urinary N-telopeptide, and bone min. dens. Found higher 25OH vit D levels, higher resolution of HTN in rx Criticism: Data not tight

  5. TREATMENT GROUP

  6. CONTROL GROUP

  7. Patterns of readmission and reoperation within 90 days after Roux-en-Y gastric bypass T.A. Kellogg, T. Swan, D.A. Leslie, H. Buchwald, S. Ikramuddin (Univ. of Minnesota) SOARD 2009; 5:416-24

  8. GASTRIC BYPASS READMISSIONS • 1222 gastric bypass patients • 3 year period • 173 had 252 ED visits (79), readmissions (164), or reoperations (35) • 58% to primary, 42% to local hospital

  9. GASTRIC BYPASS READMISSIONS • Readmitted/operated patients had a greater BMI than no return group (50 vs. 48, p=.001) • Open RYGB had higher incidence (37/134) than laparoscopic RYGB (136/915, p=.002) • 1 visit: 120, 2: 34, 3: 12, 4: 7

  10. ENCOUNTER RELATED TO RYGB • Readmissions 126/164 77% • ED visits 48/79 61% • Reoperations 25/35 71% • Same day surgery 5/9 56%

  11. TIMING OF EVENTS

  12. CAUSE OF ENCOUNTERS

  13. Improved bariatric surgery outcomes for Medicare beneficiaries after implementation of Medicare National Coverage Determination N. Nguyen, S. Hohmann, J. Slone, et al (UC Irvine) Arch Surg 2010; 145:72-8

  14. OUTCOMES AFTER NCD • Study compared 3196 bariatric procedures done 18 mos before and 3068 18 mos after NCD from UHC database • First six months after NCD volume of Medicare cases was down 29% but returned to baseline in one year and increased after two years

  15. OUTCOMES AFTER NCD • More bands done (twice as many) and RYGB proportion increased from 60 to 77% • LOS decreased (3.5 vs. 3.1 days) and complication rates decreased (12.2 vs. 10.0%) while mortality remained stable (.28 vs. .20%)

  16. Identifying high-quality bariatric surgery centers: hospital volume or risk-adjusted outcomes? J.B. Dimick, N.H. Osborne, L. Nicholas, & J.D. Birkmeyer (Univ. of Michigan) JACS 2009; 209:702-6

  17. VOLUME VS. OUTCOMES • New York State Inpatient database for 2003-4 • 105 hospitals, 32,381 patients • Morbidity from dx & procedure codes • Calculated risk-adjusted morbidity

  18. VOLUME VS. OUTCOMES • Ascertained proportion of hospital-level variation explained by both outcome and volume • Compared outcome vs. volume at predicting future performance

  19. VOLUME VS. OUTCOMES • Risk-adjusted morbidity (RAM) explained 83% of future hospital-level variation in morbidity vs. only 21% with volume alone • “Best” vs. “worst” quartile hospitals predicted fourfold difference in future performance versus twofold based on hospital volume

  20. Standardization of the fully stapled laparoscopic Roux-en-Y gastric bypass for obesity reduces early immediate postoperative morbidity and mortality: a single center study on 2606 patients B. Dillermans, N. Sakran, S. Van Cauwenberge, et al (Bruges) Obesity Surg 2009; 19:1355-64

  21. LARGE SINGLE CENTER BELGIAN STUDY • Fully-stapled Lap RYGB • 4 year period, 2606 patients • Mean BMI 41.4 • Mean LOS 3.35 days • Mean OR time 63 minutes • One death (0.04%)

  22. LARGE SINGLE CENTER BELGIAN STUDY • Total postop complications in 5.8% • GI bleeding in 3.42% • SBO in 0.35% • Leak in 0.19% • Other complications 1.8%

  23. Quality of life after bariatric surgery: A population-based cohort study J.A. Batsis, F. Lopez-Jiminez, M.L. Collazo-Claveil, et al (Mayo Clinic, Rochester) Am J Medicine 2009; 122: issue 11 (online)

  24. SURVEY METHODS • RYGB patients assessed by baseline and follow-up Linear Analogue Self-Assessment Questionnaire, LASA) • Follow-up quality of life (Short Form-12) and activity (Goldman’s Specific Activity Scale) • 268 & 273 mailed with 55% of operative and 32% of non-operative returned

  25. RESULTS • Mean follow-up was 4.0 & 3.8 yrs • Change in LASA was + 3.1+0.4 (p<.001) • Adjusted SF-12 = 12 points higher for operative pts (p<.001) • Operative patients with symptomatic improvement (p<.001) and self-reported exercise tolerance improvement (p=.01) versus non-operative patients

  26. RESULTS • Predictors of high follow-up LASA were rx for depression, % wt lost, resolution of dyslipidemia and CV disease • Predictors of follow-up for SF-12 were % wt loss, resolution of diabetes, cardiovascular disease, and rx for depression

  27. CLINICAL SIGNIFICANCE • Quality of life improved after RYGB • Better follow-up QOL related to degree of wt loss • Self-reported functional status markedly better in surgical pts • Multidisciplinary wt loss program affords better outcomes

  28. Perioperative safety in the Longitudinal Assessment of Bariatric Surgery The Longitudinal Assessment of Bariatric Surgery Consortium NEJM 2009; 361:445-54

  29. METHODS • 10 sites in LABS • 2005-2007 • 30 day major adverse outcomes • Death, VTE, percut., endo or operative intervention, failure to be discharged

  30. RESULTS • 4776 patients • Age 44.5 yrs, 21% male, BMI 46.5 • RYGB in 3412 (87.2% laparosc.) • LAGB in 1198 • 30 day mortality 0.3% • 4.3% patients had one major adverse outcome

  31. RESULTS • Increased risk seen for: • Hx DVT/PE, OSA, and impaired functional status • Extreme BMI associate with increased risk but age, sex, race, ethnic group were not

  32. Improvement in glucose metabolism after bariatric surgery: Comparison of laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy R. Peterli, B. Wolnerhanssen, T. Peters, et al. (Basel, Switzerland) Ann Surg 2009; 250:234-41

  33. METHODS • Prospective randomized trial • 13 RYGB vs. 14 LSG patients • Fasting and meal-stimulated insulin, glucose, and GLP-1 levels • Before and 1 wk & 3 mos postop • Test meal followed by blood samples

  34. RESULTS • Excess BMI loss equivalent after RYGB (43.3%) and LSG (39.4%) at 3 months • Both operations produced increased postprandial levels of plasma insulin and GLP-1 (p<.01)

  35. RESULTS • Comparable levels of insulin and GLP-1 at 3 months • RYGB patients had early and augmented insulin response at 1 week postop • Authors conclude that data do NOT support the idea that proximal small intestine mediates the improvement in glucose homeostasis

  36. Probiotics improve outcomes after Roux-en-Y gastric bypass surgery: A prospective randomized trial G.A. Woodard, B. Encarnacion, RJ Downey, J.M. Morton (Stanford Univ) JOGS 2009; 13:1198-1204

  37. METHODS • 44 RYGB patients randomized to probiotic (Lactobacillus daily postop) vs. control • Measured H2 levels, GIQoL, serologies, and wt loss postop and at 3 & 6 mos

  38. RESULTS • Lower bacterial overgrowth in probiotic group at 6 mos • Wt loss for probiotic significantly better at 3 mos (47.7% vs. 38.6%) but not 6 mos (67.2% vs. 60.8%) • Probiotic group had higher B12 levels • Both groups had better GIQoL

  39. Effect of stoma size on weight loss after laparoscopic gastric bypas surgery: results of a blinded randomized controlled trial D.R. Cottam, B. Fisher, et al (Salt Lake City) Obes Surgery 2009; 19:13-7

  40. METHODS • 200 RYGB patients randomized into two groups of 100 • 21 vs. 25 mm stapler to do GJ • %EWL and clinical comorbidities measured postop • Logistic regression to determine effect of stapler size • 2 year follow-up

  41. RESULTS • Follow-up for groups: 68% & 66% • Stapler size did not predict weight loss • Did predict need for dilatations • Only predictor of wt loss was male gender and high initial wt • Both groups > 80% EWL

  42. Five-year outcome with gastric bypass: Roux limb length makes a difference JJ Gleysteen (UAB) SOARD 2009; 5:242-9

  43. METHODS • Weight loss at 5 yrs compared for 3 sequential groups of pts after RYGB • Comparisons for pts with BMI > or < 50 (SO vs. MO) • 344 patients followed 49% 5 yrs

  44. BMI LOSS

  45. CONCLUSIONS • Roux limb lengths improve weight loss early and late in SO but not in MO patients • Recidivism was not affected by Roux limb length

  46. Revisional operations for marginal ulcer after Roux-en-Y gastric bypass RA Patel, RE Brolin, A Gandhi (Princeton, NJ) SOARD 2009; 5:317-22

  47. FINDINGS • 2282 patients who underwent RYGB reviewed for marginal ulcer • 122 (5.3%) developed marginal ulcers • 32% required revision surgery • Of these, 72% had gastrogastric fistulas

  48. FINDINGS • Recurrent ulcers after surgery in 7.7% (all smokers) • Revision rate less after lap than open (0.6% vs. 2.1%, p<.0025) • 87% of revisions pts remained asymptomatic

  49. QUICK SHOT: REVIEW ARTICLE Endocrine and metabolic response to gastric bypass J. Saliba, J. Wattanacheril, N.N. Abumrad (UT Memphis) Curr Opin Clin Nutr Metab Care 2009; 12:515-21

  50. FINDINGS • Reviewed literature on hormonal changes after RYGB • Strongest effects seen in GLP-1, GIP, and ghrelin • Less so in PYY and PP • Conclude GLP-1 not whole story

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