Obesity Week 2017

 

NATIONAL HARBOR, MD. – Gastric bypass and sleeve gastrectomy procedures for weight loss should not be denied to patients older than 60 years, despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.

Although the analysis was drawn from one of the largest datasets to evaluate the safety of bariatric surgery in the elderly, it is not the first to conclude that morbidity and mortality rates are acceptably low, according to Dr. Zeni. This may explain why the proportion of bariatric procedures performed in patients 60 years of age or older has been increasing. In figures provided by Dr. Zeni, that proportion rose from 2.7% during 1999-2005 to 10.1% during 2009-2013.

There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.

Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.

Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”

Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.

Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.

However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.

The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.

Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.

Dr. Zeni reports no relevant financial relationships.

 

NATIONAL HARBOR, MD. – Gastric bypass and sleeve gastrectomy procedures for weight loss should not be denied to patients older than 60 years, despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.

Although the analysis was drawn from one of the largest datasets to evaluate the safety of bariatric surgery in the elderly, it is not the first to conclude that morbidity and mortality rates are acceptably low, according to Dr. Zeni. This may explain why the proportion of bariatric procedures performed in patients 60 years of age or older has been increasing. In figures provided by Dr. Zeni, that proportion rose from 2.7% during 1999-2005 to 10.1% during 2009-2013.

There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.

Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.

Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”

Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.

Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.

However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.

The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.

Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.

Dr. Zeni reports no relevant financial relationships.

 

NATIONAL HARBOR, MD. – Gastric bypass and sleeve gastrectomy procedures for weight loss should not be denied to patients older than 60 years, despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.

Although the analysis was drawn from one of the largest datasets to evaluate the safety of bariatric surgery in the elderly, it is not the first to conclude that morbidity and mortality rates are acceptably low, according to Dr. Zeni. This may explain why the proportion of bariatric procedures performed in patients 60 years of age or older has been increasing. In figures provided by Dr. Zeni, that proportion rose from 2.7% during 1999-2005 to 10.1% during 2009-2013.

There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.

Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.

Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”

Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.

Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.

However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.

The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.

Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.

Dr. Zeni reports no relevant financial relationships.

 

NATIONAL HARBOR, MD. – Gastric bypass and sleeve gastrectomy procedures for weight loss should not be denied to patients older than 60 years, despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.

Although the analysis was drawn from one of the largest datasets to evaluate the safety of bariatric surgery in the elderly, it is not the first to conclude that morbidity and mortality rates are acceptably low, according to Dr. Zeni. This may explain why the proportion of bariatric procedures performed in patients 60 years of age or older has been increasing. In figures provided by Dr. Zeni, that proportion rose from 2.7% during 1999-2005 to 10.1% during 2009-2013.

There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.

Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.

Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”

Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.

Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.

However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.

The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.

Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.

Dr. Zeni reports no relevant financial relationships.

 

 

NATIONAL HARBOR, MD. – Gastric bypass and sleeve gastrectomy procedures for weight loss should not be denied to patients older than 60 years, despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.

Although the analysis was drawn from one of the largest datasets to evaluate the safety of bariatric surgery in the elderly, it is not the first to conclude that morbidity and mortality rates are acceptably low, according to Dr. Zeni. This may explain why the proportion of bariatric procedures performed in patients 60 years of age or older has been increasing. In figures provided by Dr. Zeni, that proportion rose from 2.7% during 1999-2005 to 10.1% during 2009-2013.

There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.

Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.

Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”

Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.

Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.

However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.

The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.

Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.

Dr. Zeni reports no relevant financial relationships.

 

 

NATIONAL HARBOR, MD. – Gastric bypass and sleeve gastrectomy procedures for weight loss should not be denied to patients older than 60 years, despite a slight increase in unadjusted mortality rates, according to an analysis of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).

Based on data that was collected in 2015 and submitted to MBSAQIP, “bariatric surgery is safe in the elderly, even in those 70 years old and older,” reported Tallal Zeni, MD, director of the Michigan Bariatric Institute in Livonia.

Although the analysis was drawn from one of the largest datasets to evaluate the safety of bariatric surgery in the elderly, it is not the first to conclude that morbidity and mortality rates are acceptably low, according to Dr. Zeni. This may explain why the proportion of bariatric procedures performed in patients 60 years of age or older has been increasing. In figures provided by Dr. Zeni, that proportion rose from 2.7% during 1999-2005 to 10.1% during 2009-2013.

There were 16,568 patients older than age 60 years entered into the MBSAQIP database in 2015. When those were compared with the 117,443 younger patients, the unadjusted rates of morbidity (6.5% vs. 6.0%) and mortality (0.3% vs. 0.1%) were higher for the older patients, but “they are close,” according to Dr. Zeni. Both rates reached significance by the conventional definition (P < .05), but he suggested that they are lower in this study than those in prior studies of MBSAQIP datasets and that they are acceptable relative to the anticipated health benefits.

Above the age of 60 years, no correlation could be made between increasing age and increasing risk of morbidity, mortality, or rate of reoperations, according to Dr. Zeni.

Why should bariatric surgery be considered in older patients? He cited data from a study that showed the life expectancy in a 70-year-old without functional limitations is 13 years. As a result, he added, “it behooves us to provide them with the best quality of life we can.”

Relative to prior MBSAQIP evaluations of bariatric surgery in the elderly, the proportion of patients undergoing sleeve gastrectomy relative to gastric bypass has been increasing, Dr. Zeni reported. In the analysis, approximately two-thirds of the bariatric procedures were performed with sleeve gastrectomy, which is higher relative to what previous MBSAQIP analyses have shown.

Based on rates of morbidity for those two surgical approaches in the analysis, that trend makes sense. While the higher 30-day mortality for gastric bypass, compared with sleeve gastrectomy, was not significant (0.38% vs. 0.26%; P = .221), all-cause morbidity was almost two times greater for those undergoing gastric bypass than it was for those undergoing sleeve gastrectomy (10.61% vs. 5.81%; P < .001), Dr. Zeni reported.

However, some of that difference may be explained by baseline disparities between the two groups. In the gastric bypass group, there were higher rates of preoperative diabetes (54% vs. 40%; P < .001), sleep apnea (57% vs. 50%; P < .001) and hyperlipidemia (59% vs. 54%; P < .001). Also, gastric bypass patients were more likely to have a history of a previous bariatric procedure (11% vs. 8.5%; P < .001) and to be in the American Society of Anesthesiologists Physical Status score of 3 (84% vs. 80%; P < .001), according to Dr. Zeni.

The specific complications more common in the gastric bypass group than the sleeve gastrectomy group included anastomotic leak (0.56% vs. 0.3%; P = .017), surgical site infection (1.74% vs. 0.61%; P < .001), pneumonia (0.87% vs. 0.32%; P < .001), and bleeding (1.14% vs. 0.5%; P = .024). Although the average operating time was 40 minutes longer in the bypass group, there were no significant differences in thromboembolic complications.

Overall, despite a modest increase in the risk of complications for bariatric surgery in elderly patients, that risk can be considered acceptable in relation to the potential health benefits, according to Dr. Zeni. He suggested that the data might encourage further growth in the rates of bariatric procedures among patients older than 60 years.

Dr. Zeni reports no relevant financial relationships.

 

 

NATIONAL HARBOR, MD. – Laparoscopic sleeve gastrectomy has been associated with low mortality, but the mortality is even lower when it includes overnight observation, according to a national database evaluation.

Among patients discharged on the same day, 30-day mortality was 0.1%, but it fell to 0.02% among patients discharged the following day, according to Colette Inaba, MD, a surgery resident at the University of California, Irvine.*

In absolute risk, this translated into an increased odds ratio for mortality of 5.7 (P = .032) for same-day discharge. After adjustment for numerous potential confounders including operating time and number of postoperative swallow studies, the OR for mortality fell to 4.7, but the statistical strength for the greater risk increased (P less than .01).

“Surgeons who are considering same-day discharge in sleeve gastrectomy patients should have a low threshold to admit these patients for overnight observation given our findings,” Dr. Inaba reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.

Same-day discharge has been associated with an increased mortality risk in previously published descriptive institutional reviews, but this is the first study to evaluate this question through analysis of a national database, according to Dr. Inaba. It was based on 37,301 laparoscopic sleeve gastrectomy cases performed in 2015 and submitted to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. All participants in this database are accredited bariatric centers.

There were baseline differences between same-day and next-day discharges, but many of these differences conferred the next-day group with higher risk. In particular, the next-day group had significantly higher rates of hypertension, diabetes mellitus, hypercholesterolemia, chronic obstructive pulmonary disease, and sleep apnea. On average, the procedure time was 13 minutes longer in the next-day versus the same-day discharge groups.

In addition to mortality, 30-day morbidity and need for revisions were compared between the two groups, but there were no significant differences between groups in the rates of these outcomes.

Overall, the baseline demographics of the patients in same-day and next-day groups were comparable, according to Dr. Inaba. She described the population as predominantly female and white with an average body mass index of 45 kg/m². In this analysis, only primary procedures (excluding redos and revisions) were included.

Relative to the next-day discharge cases, a significantly higher percentage of same-day discharge procedures were performed with a surgical tech or another provider rather than a designated first-assist surgeon, according to Dr. Inaba. For next-day cases, a higher percentage was performed with the participation of fellows or surgical residents. There were fewer swallow studies performed before discharge in the same-day discharge group.

Very similar results were generated by a study evaluating same-day discharge after laparoscopic Roux-en-Y gastric bypass, according to John M. Morton, MD, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University. Dr. Morton, first author of the study and moderator of the session in which Dr. Inaba presented the LSG data, reported that same-day discharge in that study was also associated with a trend for an increased risk of serious complications (Ann Surg. 2014;259:286-92).

“Same-day discharge is often reimbursed at a lower rate, so there is less pay and patients are at greater risk of harm,” Dr. Morton said.

The reasons that same-day discharge is associated with higher mortality cannot be derived from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, but, Dr. Inaba said, “Our thought is it is a function of failure to rescue patients from respiratory complications.” She acknowledged that this is a speculative assessment not supported by data, but she suggested that history of sleep apnea might be a particular indication to consider next-day discharge.

Dr. Inaba reports no financial relationships relevant to this topic.

Correction, 12/4/17: An earlier version of this article misstated the 30-day mortality among patients discharged the next day.

 

NATIONAL HARBOR, MD. – Laparoscopic sleeve gastrectomy has been associated with low mortality, but the mortality is even lower when it includes overnight observation, according to a national database evaluation.

Among patients discharged on the same day, 30-day mortality was 0.1%, but it fell to 0.02% among patients discharged the following day, according to Colette Inaba, MD, a surgery resident at the University of California, Irvine.*

In absolute risk, this translated into an increased odds ratio for mortality of 5.7 (P = .032) for same-day discharge. After adjustment for numerous potential confounders including operating time and number of postoperative swallow studies, the OR for mortality fell to 4.7, but the statistical strength for the greater risk increased (P less than .01).

“Surgeons who are considering same-day discharge in sleeve gastrectomy patients should have a low threshold to admit these patients for overnight observation given our findings,” Dr. Inaba reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.

Same-day discharge has been associated with an increased mortality risk in previously published descriptive institutional reviews, but this is the first study to evaluate this question through analysis of a national database, according to Dr. Inaba. It was based on 37,301 laparoscopic sleeve gastrectomy cases performed in 2015 and submitted to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. All participants in this database are accredited bariatric centers.

There were baseline differences between same-day and next-day discharges, but many of these differences conferred the next-day group with higher risk. In particular, the next-day group had significantly higher rates of hypertension, diabetes mellitus, hypercholesterolemia, chronic obstructive pulmonary disease, and sleep apnea. On average, the procedure time was 13 minutes longer in the next-day versus the same-day discharge groups.

In addition to mortality, 30-day morbidity and need for revisions were compared between the two groups, but there were no significant differences between groups in the rates of these outcomes.

Overall, the baseline demographics of the patients in same-day and next-day groups were comparable, according to Dr. Inaba. She described the population as predominantly female and white with an average body mass index of 45 kg/m². In this analysis, only primary procedures (excluding redos and revisions) were included.

Relative to the next-day discharge cases, a significantly higher percentage of same-day discharge procedures were performed with a surgical tech or another provider rather than a designated first-assist surgeon, according to Dr. Inaba. For next-day cases, a higher percentage was performed with the participation of fellows or surgical residents. There were fewer swallow studies performed before discharge in the same-day discharge group.

Very similar results were generated by a study evaluating same-day discharge after laparoscopic Roux-en-Y gastric bypass, according to John M. Morton, MD, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University. Dr. Morton, first author of the study and moderator of the session in which Dr. Inaba presented the LSG data, reported that same-day discharge in that study was also associated with a trend for an increased risk of serious complications (Ann Surg. 2014;259:286-92).

“Same-day discharge is often reimbursed at a lower rate, so there is less pay and patients are at greater risk of harm,” Dr. Morton said.

The reasons that same-day discharge is associated with higher mortality cannot be derived from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, but, Dr. Inaba said, “Our thought is it is a function of failure to rescue patients from respiratory complications.” She acknowledged that this is a speculative assessment not supported by data, but she suggested that history of sleep apnea might be a particular indication to consider next-day discharge.

Dr. Inaba reports no financial relationships relevant to this topic.

Correction, 12/4/17: An earlier version of this article misstated the 30-day mortality among patients discharged the next day.

 

NATIONAL HARBOR, MD. – Laparoscopic sleeve gastrectomy has been associated with low mortality, but the mortality is even lower when it includes overnight observation, according to a national database evaluation.

Among patients discharged on the same day, 30-day mortality was 0.1%, but it fell to 0.02% among patients discharged the following day, according to Colette Inaba, MD, a surgery resident at the University of California, Irvine.*

In absolute risk, this translated into an increased odds ratio for mortality of 5.7 (P = .032) for same-day discharge. After adjustment for numerous potential confounders including operating time and number of postoperative swallow studies, the OR for mortality fell to 4.7, but the statistical strength for the greater risk increased (P less than .01).

“Surgeons who are considering same-day discharge in sleeve gastrectomy patients should have a low threshold to admit these patients for overnight observation given our findings,” Dr. Inaba reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.

Same-day discharge has been associated with an increased mortality risk in previously published descriptive institutional reviews, but this is the first study to evaluate this question through analysis of a national database, according to Dr. Inaba. It was based on 37,301 laparoscopic sleeve gastrectomy cases performed in 2015 and submitted to the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. All participants in this database are accredited bariatric centers.

There were baseline differences between same-day and next-day discharges, but many of these differences conferred the next-day group with higher risk. In particular, the next-day group had significantly higher rates of hypertension, diabetes mellitus, hypercholesterolemia, chronic obstructive pulmonary disease, and sleep apnea. On average, the procedure time was 13 minutes longer in the next-day versus the same-day discharge groups.

In addition to mortality, 30-day morbidity and need for revisions were compared between the two groups, but there were no significant differences between groups in the rates of these outcomes.

Overall, the baseline demographics of the patients in same-day and next-day groups were comparable, according to Dr. Inaba. She described the population as predominantly female and white with an average body mass index of 45 kg/m². In this analysis, only primary procedures (excluding redos and revisions) were included.

Relative to the next-day discharge cases, a significantly higher percentage of same-day discharge procedures were performed with a surgical tech or another provider rather than a designated first-assist surgeon, according to Dr. Inaba. For next-day cases, a higher percentage was performed with the participation of fellows or surgical residents. There were fewer swallow studies performed before discharge in the same-day discharge group.

Very similar results were generated by a study evaluating same-day discharge after laparoscopic Roux-en-Y gastric bypass, according to John M. Morton, MD, chief of bariatric and minimally invasive surgery, Stanford (Calif.) University. Dr. Morton, first author of the study and moderator of the session in which Dr. Inaba presented the LSG data, reported that same-day discharge in that study was also associated with a trend for an increased risk of serious complications (Ann Surg. 2014;259:286-92).

“Same-day discharge is often reimbursed at a lower rate, so there is less pay and patients are at greater risk of harm,” Dr. Morton said.

The reasons that same-day discharge is associated with higher mortality cannot be derived from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, but, Dr. Inaba said, “Our thought is it is a function of failure to rescue patients from respiratory complications.” She acknowledged that this is a speculative assessment not supported by data, but she suggested that history of sleep apnea might be a particular indication to consider next-day discharge.

Dr. Inaba reports no financial relationships relevant to this topic.

Correction, 12/4/17: An earlier version of this article misstated the 30-day mortality among patients discharged the next day.

 

NATIONAL HARBOR, MD. – In an evaluation of 633 emergency department visits following bariatric surgery in Michigan over a 1-year period, the vast majority were for complaints amenable to a phone call consultation or treatment in a lower-acuity setting, but few patients would have been satisfied with this type of management, according to an evaluation based on patient interviews presented at Obesity Week 2017.

“Unfortunately, 91% of the patients said that there was nothing the surgical team could have done that would have helped avoid the ED visit,” reported Haley Stevens, quality improvement coordinator at the Michigan Bariatric Surgery Collaborative, University of Michigan, Ann Arbor.

Unnecessary ED visits in the immediate postoperative period following bariatric surgery are common and a source of increased costs, according to a variety of evidence cited by Ms. Stevens. The purpose of this study was to document patient circumstances and rationale for an ED visit with the ultimate goal of considering new strategies to provide alternatives to care.

The 633 ED visits followed 7,617 bariatric surgeries for a rate of 8.3%. According to Ms. Stevens, this is consistent with the rates of 5%-11% reported previously. Based on clinically abstracted data and patient interviews conducted by trained nurses in a sample of patients involved in these ED visits, it was estimated that 62% were made without any attempt to first contact the surgical team, she reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.

In the interviews, a variety of reasons were offered for not first contacting the surgical team, according to Ms. Stevens. Most commonly, patients reported that a sense of urgency drove them to the ED. In 18% of cases, the complaint occurred after office hours, leading the patient to believe that the ED was the only option. Another 16% of patients reported that calling the surgeon simply did not occur to them.

“When interviewed, many patients considered the visit necessary and unavoidable even after learning subsequently that the symptoms were not serious,” Ms. Stevens reported.

The primary reasons for the ED visit were nausea, vomiting, or abdominal pain, which accounted for 50% of the visits. The next most common reasons were chest pain (8%) and concerns regarding the incision (7%). Only 30% of the ED visits ultimately resulted in a hospital admission, but 60% of the visits resulted in administration of intravenous fluids. Thirty-eight percent of ED visits resulted in oral or intravenous therapy for pain.

Based on the interviews, most patients reported that they visited the ED because they wanted an immediate evaluation of their symptoms, according to Ms. Stevens. She said that the goal in most cases was simply obtaining reassurance. While better patient education about symptoms and recovery might have circumvented patient concerns about nonurgent complaints, Ms. Stevens also suggested that visits to a lower-acuity center, such as an urgent care facility, might provide a lower-cost alternative for reassurance or simple treatments.

As this study represents the first in a series to guide a quality improvement initiative, Ms. Stevens acknowledged that the best solution to reducing unnecessary ED visits is unclear, but she did suggest that multiple strategies might be needed. Based on this and previously published studies evaluating this issue “there is no silver bullet” for reducing ED visits, Ms. Stevens said.

In an animated discussion that followed presentation of these results, others recounting efforts to reduce ED visits following bariatric surgery emphasized the importance of follow-up phone calls or home visits within 2 or 3 days of surgery. According to several of those who commented, these steps allow early identification of problems while providing the type of reassurance that can prevent unnecessary ED visits.

The average cost of an ED visit following bariatric surgery is approximately $1,300, according to Ms. Stevens. For this and other reasons, strategies to reduce ED visits are needed, but Ms. Stevens cautioned that the solutions might not be simple. Based on data from this study, the key may be providing patients with a clear route to the reassurance they need to avoid seeking care for nonurgent issues.

Ms. Stevens reports no financial relationships relevant to this topic.

 

NATIONAL HARBOR, MD. – In an evaluation of 633 emergency department visits following bariatric surgery in Michigan over a 1-year period, the vast majority were for complaints amenable to a phone call consultation or treatment in a lower-acuity setting, but few patients would have been satisfied with this type of management, according to an evaluation based on patient interviews presented at Obesity Week 2017.

“Unfortunately, 91% of the patients said that there was nothing the surgical team could have done that would have helped avoid the ED visit,” reported Haley Stevens, quality improvement coordinator at the Michigan Bariatric Surgery Collaborative, University of Michigan, Ann Arbor.

Unnecessary ED visits in the immediate postoperative period following bariatric surgery are common and a source of increased costs, according to a variety of evidence cited by Ms. Stevens. The purpose of this study was to document patient circumstances and rationale for an ED visit with the ultimate goal of considering new strategies to provide alternatives to care.

The 633 ED visits followed 7,617 bariatric surgeries for a rate of 8.3%. According to Ms. Stevens, this is consistent with the rates of 5%-11% reported previously. Based on clinically abstracted data and patient interviews conducted by trained nurses in a sample of patients involved in these ED visits, it was estimated that 62% were made without any attempt to first contact the surgical team, she reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.

In the interviews, a variety of reasons were offered for not first contacting the surgical team, according to Ms. Stevens. Most commonly, patients reported that a sense of urgency drove them to the ED. In 18% of cases, the complaint occurred after office hours, leading the patient to believe that the ED was the only option. Another 16% of patients reported that calling the surgeon simply did not occur to them.

“When interviewed, many patients considered the visit necessary and unavoidable even after learning subsequently that the symptoms were not serious,” Ms. Stevens reported.

The primary reasons for the ED visit were nausea, vomiting, or abdominal pain, which accounted for 50% of the visits. The next most common reasons were chest pain (8%) and concerns regarding the incision (7%). Only 30% of the ED visits ultimately resulted in a hospital admission, but 60% of the visits resulted in administration of intravenous fluids. Thirty-eight percent of ED visits resulted in oral or intravenous therapy for pain.

Based on the interviews, most patients reported that they visited the ED because they wanted an immediate evaluation of their symptoms, according to Ms. Stevens. She said that the goal in most cases was simply obtaining reassurance. While better patient education about symptoms and recovery might have circumvented patient concerns about nonurgent complaints, Ms. Stevens also suggested that visits to a lower-acuity center, such as an urgent care facility, might provide a lower-cost alternative for reassurance or simple treatments.

As this study represents the first in a series to guide a quality improvement initiative, Ms. Stevens acknowledged that the best solution to reducing unnecessary ED visits is unclear, but she did suggest that multiple strategies might be needed. Based on this and previously published studies evaluating this issue “there is no silver bullet” for reducing ED visits, Ms. Stevens said.

In an animated discussion that followed presentation of these results, others recounting efforts to reduce ED visits following bariatric surgery emphasized the importance of follow-up phone calls or home visits within 2 or 3 days of surgery. According to several of those who commented, these steps allow early identification of problems while providing the type of reassurance that can prevent unnecessary ED visits.

The average cost of an ED visit following bariatric surgery is approximately $1,300, according to Ms. Stevens. For this and other reasons, strategies to reduce ED visits are needed, but Ms. Stevens cautioned that the solutions might not be simple. Based on data from this study, the key may be providing patients with a clear route to the reassurance they need to avoid seeking care for nonurgent issues.

Ms. Stevens reports no financial relationships relevant to this topic.

 

NATIONAL HARBOR, MD. – In an evaluation of 633 emergency department visits following bariatric surgery in Michigan over a 1-year period, the vast majority were for complaints amenable to a phone call consultation or treatment in a lower-acuity setting, but few patients would have been satisfied with this type of management, according to an evaluation based on patient interviews presented at Obesity Week 2017.

“Unfortunately, 91% of the patients said that there was nothing the surgical team could have done that would have helped avoid the ED visit,” reported Haley Stevens, quality improvement coordinator at the Michigan Bariatric Surgery Collaborative, University of Michigan, Ann Arbor.

Unnecessary ED visits in the immediate postoperative period following bariatric surgery are common and a source of increased costs, according to a variety of evidence cited by Ms. Stevens. The purpose of this study was to document patient circumstances and rationale for an ED visit with the ultimate goal of considering new strategies to provide alternatives to care.

The 633 ED visits followed 7,617 bariatric surgeries for a rate of 8.3%. According to Ms. Stevens, this is consistent with the rates of 5%-11% reported previously. Based on clinically abstracted data and patient interviews conducted by trained nurses in a sample of patients involved in these ED visits, it was estimated that 62% were made without any attempt to first contact the surgical team, she reported at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.

In the interviews, a variety of reasons were offered for not first contacting the surgical team, according to Ms. Stevens. Most commonly, patients reported that a sense of urgency drove them to the ED. In 18% of cases, the complaint occurred after office hours, leading the patient to believe that the ED was the only option. Another 16% of patients reported that calling the surgeon simply did not occur to them.

“When interviewed, many patients considered the visit necessary and unavoidable even after learning subsequently that the symptoms were not serious,” Ms. Stevens reported.

The primary reasons for the ED visit were nausea, vomiting, or abdominal pain, which accounted for 50% of the visits. The next most common reasons were chest pain (8%) and concerns regarding the incision (7%). Only 30% of the ED visits ultimately resulted in a hospital admission, but 60% of the visits resulted in administration of intravenous fluids. Thirty-eight percent of ED visits resulted in oral or intravenous therapy for pain.

Based on the interviews, most patients reported that they visited the ED because they wanted an immediate evaluation of their symptoms, according to Ms. Stevens. She said that the goal in most cases was simply obtaining reassurance. While better patient education about symptoms and recovery might have circumvented patient concerns about nonurgent complaints, Ms. Stevens also suggested that visits to a lower-acuity center, such as an urgent care facility, might provide a lower-cost alternative for reassurance or simple treatments.

As this study represents the first in a series to guide a quality improvement initiative, Ms. Stevens acknowledged that the best solution to reducing unnecessary ED visits is unclear, but she did suggest that multiple strategies might be needed. Based on this and previously published studies evaluating this issue “there is no silver bullet” for reducing ED visits, Ms. Stevens said.

In an animated discussion that followed presentation of these results, others recounting efforts to reduce ED visits following bariatric surgery emphasized the importance of follow-up phone calls or home visits within 2 or 3 days of surgery. According to several of those who commented, these steps allow early identification of problems while providing the type of reassurance that can prevent unnecessary ED visits.

The average cost of an ED visit following bariatric surgery is approximately $1,300, according to Ms. Stevens. For this and other reasons, strategies to reduce ED visits are needed, but Ms. Stevens cautioned that the solutions might not be simple. Based on data from this study, the key may be providing patients with a clear route to the reassurance they need to avoid seeking care for nonurgent issues.

Ms. Stevens reports no financial relationships relevant to this topic.

 

NATIONAL HARBOR, MD. – Psychological screening prior to bariatric surgery is not effective for identifying who will do poorly after the procedure, but it can identify patients who are at risk for less weight loss and likely to benefit from additional support, according to one of the largest studies designed to evaluate the predictive accuracy of this screening. The results were presented at Obesity Week 2017.

“Psychological evaluations should not be used to exclude patients, because we do not appear to be very good at predicting who does well,” said Nina E. Boulard, PhD, a psychologist who currently performs preoperative psychological screening of bariatric surgery candidates at Eastern Maine Medical Center, Bangor. Rather, “our evaluations identify those who need to be followed more closely so we can intervene early when patients struggle,” she said at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.

Even though psychological screening is common prior to bariatric surgery, Dr. Boulard said the value of this screening for predicting postsurgical outcomes has not been well documented. The goal of this study was to evaluate outcomes in bariatric surgery patients relative to presurgical psychological screening. Patients treated between 2009 and 2013 with at least 2 years of follow-up were included.

The two primary outcomes of interest were the ability to predict postsurgical mental health issues and the ability to predict difficulty in complying with behavioral changes. Percent excess weight loss (EWL) was also monitored. For mental health screening, the protocol included clinical interviews augmented with standardized testing, such as the Minnesota Multiphasic Personality Inventory-2-Restuctured Form (MMPI-2-RF). Patients were placed into five risk categories: low, low-moderate, moderate, moderate-high, and high.

For compliance, the patient evaluation was based primarily on interviews capturing self-reports of adherence to presurgical dietary and other lifestyle recommendations. Patients were also asked about eating behaviors, such as binge eating, and history of sexual abuse and attention-deficit/hyperactivity disorder and other neurodevelopmental issues.

The psychological screening report is provided to the surgeon, who ultimately decides whether patients go on to surgery. In this analysis, relatively few high-risk patients were included because these patients, such as those with active psychosis, uncontrolled binge eating, or severe depression, were excluded from surgery and therefore did not generate postsurgical follow-up data.

As has been reported by others, Dr. Boulard reported that no single standardized test or clinical variable was an effective predictor of “who will and will not struggle” psychologically after surgery. However, after adjusting for age, gender, presurgery weight, diabetes history, and surgery type, several variables were associated with reduced proportion EWL. These included anxiety (P = .02), ADHD (P = .01), and prior hospitalization of a psychological indication (P less than .05). History of sexual abuse was predictive of reduced percentage EWL 1 year but not 2 years after surgery.

“So, what this tells us is the clinical interpretation of the big picture might be important,” Dr. Boulard commented.

The presurgical psychological screening was not predictive of compliance, a result that Dr. Boulard labeled as “surprising.” She speculated that because weight loss in the first 2 years after bariatric surgery is relatively uniform, longer follow-up, such as 5 years, might be needed to capture the impact of patients predicted to have poor compliance.

Importantly, percent EWL remained high even among patients with risk factors associated with mental health challenges after surgery, according to Dr. Boulard. She stressed that even those with less weight loss “did not do poorly.” Rather, the relative differences in postsurgical weight loss for those who were predicted to struggle versus those who were not was “a matter of degrees.”

While Dr. Boulard acknowledged a prospective study using a standardized psychological screening protocol would be appropriate to validate the findings of this study, the study results have already changed practice at her institution.

“We are following the at-risk patients more closely, so we can intervene quickly if there are issues after surgery,” Dr. Boulard explained. The question raised by this study is, “can we bring them [patients at higher risk] to a higher level of response so they are just as successful” as those without risk factors identified in psychological screening.

Dr. Boulard reports no financial relationships relevant to this topic.

 

NATIONAL HARBOR, MD. – Psychological screening prior to bariatric surgery is not effective for identifying who will do poorly after the procedure, but it can identify patients who are at risk for less weight loss and likely to benefit from additional support, according to one of the largest studies designed to evaluate the predictive accuracy of this screening. The results were presented at Obesity Week 2017.

“Psychological evaluations should not be used to exclude patients, because we do not appear to be very good at predicting who does well,” said Nina E. Boulard, PhD, a psychologist who currently performs preoperative psychological screening of bariatric surgery candidates at Eastern Maine Medical Center, Bangor. Rather, “our evaluations identify those who need to be followed more closely so we can intervene early when patients struggle,” she said at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.

Even though psychological screening is common prior to bariatric surgery, Dr. Boulard said the value of this screening for predicting postsurgical outcomes has not been well documented. The goal of this study was to evaluate outcomes in bariatric surgery patients relative to presurgical psychological screening. Patients treated between 2009 and 2013 with at least 2 years of follow-up were included.

The two primary outcomes of interest were the ability to predict postsurgical mental health issues and the ability to predict difficulty in complying with behavioral changes. Percent excess weight loss (EWL) was also monitored. For mental health screening, the protocol included clinical interviews augmented with standardized testing, such as the Minnesota Multiphasic Personality Inventory-2-Restuctured Form (MMPI-2-RF). Patients were placed into five risk categories: low, low-moderate, moderate, moderate-high, and high.

For compliance, the patient evaluation was based primarily on interviews capturing self-reports of adherence to presurgical dietary and other lifestyle recommendations. Patients were also asked about eating behaviors, such as binge eating, and history of sexual abuse and attention-deficit/hyperactivity disorder and other neurodevelopmental issues.

The psychological screening report is provided to the surgeon, who ultimately decides whether patients go on to surgery. In this analysis, relatively few high-risk patients were included because these patients, such as those with active psychosis, uncontrolled binge eating, or severe depression, were excluded from surgery and therefore did not generate postsurgical follow-up data.

As has been reported by others, Dr. Boulard reported that no single standardized test or clinical variable was an effective predictor of “who will and will not struggle” psychologically after surgery. However, after adjusting for age, gender, presurgery weight, diabetes history, and surgery type, several variables were associated with reduced proportion EWL. These included anxiety (P = .02), ADHD (P = .01), and prior hospitalization of a psychological indication (P less than .05). History of sexual abuse was predictive of reduced percentage EWL 1 year but not 2 years after surgery.

“So, what this tells us is the clinical interpretation of the big picture might be important,” Dr. Boulard commented.

The presurgical psychological screening was not predictive of compliance, a result that Dr. Boulard labeled as “surprising.” She speculated that because weight loss in the first 2 years after bariatric surgery is relatively uniform, longer follow-up, such as 5 years, might be needed to capture the impact of patients predicted to have poor compliance.

Importantly, percent EWL remained high even among patients with risk factors associated with mental health challenges after surgery, according to Dr. Boulard. She stressed that even those with less weight loss “did not do poorly.” Rather, the relative differences in postsurgical weight loss for those who were predicted to struggle versus those who were not was “a matter of degrees.”

While Dr. Boulard acknowledged a prospective study using a standardized psychological screening protocol would be appropriate to validate the findings of this study, the study results have already changed practice at her institution.

“We are following the at-risk patients more closely, so we can intervene quickly if there are issues after surgery,” Dr. Boulard explained. The question raised by this study is, “can we bring them [patients at higher risk] to a higher level of response so they are just as successful” as those without risk factors identified in psychological screening.

Dr. Boulard reports no financial relationships relevant to this topic.

 

NATIONAL HARBOR, MD. – Psychological screening prior to bariatric surgery is not effective for identifying who will do poorly after the procedure, but it can identify patients who are at risk for less weight loss and likely to benefit from additional support, according to one of the largest studies designed to evaluate the predictive accuracy of this screening. The results were presented at Obesity Week 2017.

“Psychological evaluations should not be used to exclude patients, because we do not appear to be very good at predicting who does well,” said Nina E. Boulard, PhD, a psychologist who currently performs preoperative psychological screening of bariatric surgery candidates at Eastern Maine Medical Center, Bangor. Rather, “our evaluations identify those who need to be followed more closely so we can intervene early when patients struggle,” she said at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.

Even though psychological screening is common prior to bariatric surgery, Dr. Boulard said the value of this screening for predicting postsurgical outcomes has not been well documented. The goal of this study was to evaluate outcomes in bariatric surgery patients relative to presurgical psychological screening. Patients treated between 2009 and 2013 with at least 2 years of follow-up were included.

The two primary outcomes of interest were the ability to predict postsurgical mental health issues and the ability to predict difficulty in complying with behavioral changes. Percent excess weight loss (EWL) was also monitored. For mental health screening, the protocol included clinical interviews augmented with standardized testing, such as the Minnesota Multiphasic Personality Inventory-2-Restuctured Form (MMPI-2-RF). Patients were placed into five risk categories: low, low-moderate, moderate, moderate-high, and high.

For compliance, the patient evaluation was based primarily on interviews capturing self-reports of adherence to presurgical dietary and other lifestyle recommendations. Patients were also asked about eating behaviors, such as binge eating, and history of sexual abuse and attention-deficit/hyperactivity disorder and other neurodevelopmental issues.

The psychological screening report is provided to the surgeon, who ultimately decides whether patients go on to surgery. In this analysis, relatively few high-risk patients were included because these patients, such as those with active psychosis, uncontrolled binge eating, or severe depression, were excluded from surgery and therefore did not generate postsurgical follow-up data.

As has been reported by others, Dr. Boulard reported that no single standardized test or clinical variable was an effective predictor of “who will and will not struggle” psychologically after surgery. However, after adjusting for age, gender, presurgery weight, diabetes history, and surgery type, several variables were associated with reduced proportion EWL. These included anxiety (P = .02), ADHD (P = .01), and prior hospitalization of a psychological indication (P less than .05). History of sexual abuse was predictive of reduced percentage EWL 1 year but not 2 years after surgery.

“So, what this tells us is the clinical interpretation of the big picture might be important,” Dr. Boulard commented.

The presurgical psychological screening was not predictive of compliance, a result that Dr. Boulard labeled as “surprising.” She speculated that because weight loss in the first 2 years after bariatric surgery is relatively uniform, longer follow-up, such as 5 years, might be needed to capture the impact of patients predicted to have poor compliance.

Importantly, percent EWL remained high even among patients with risk factors associated with mental health challenges after surgery, according to Dr. Boulard. She stressed that even those with less weight loss “did not do poorly.” Rather, the relative differences in postsurgical weight loss for those who were predicted to struggle versus those who were not was “a matter of degrees.”

While Dr. Boulard acknowledged a prospective study using a standardized psychological screening protocol would be appropriate to validate the findings of this study, the study results have already changed practice at her institution.

“We are following the at-risk patients more closely, so we can intervene quickly if there are issues after surgery,” Dr. Boulard explained. The question raised by this study is, “can we bring them [patients at higher risk] to a higher level of response so they are just as successful” as those without risk factors identified in psychological screening.

Dr. Boulard reports no financial relationships relevant to this topic.

 

NATIONAL HARBOR, MD. – When combined with bariatric surgery, adjunctive therapies for obesity should be individualized for specific drivers of weight gain, which can differ among obesity phenotypes, according to an expert view presented at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society .

“Surgery is the most effective therapy we have, but it is only one of multiple treatments that should be considered in a treatment paradigm,” suggested Robert F. Kushner, MD, a professor of endocrinology and specialist in obesity at the Northwestern University, Chicago.

Ted Bosworth

The remarks were part of a symposium in which Dr. Kushner was asked how surgeons should bridge the gap with nonsurgeon physicians working to improve outcomes in patients with obesity. Perhaps the most important point stressed by Dr. Kushner is that surgeons need to consider the obesity phenotype to understand what – in addition to surgery – will improve long-term outcomes.

“It is very useful to take a narrative approach to understand the patients in front of us and to understand who they are and how they got to where they are now,” Dr. Kushner explained. Dr. Kushner often asks patients to graph weight history over time. This can connect social, biological, and psychological events with significant weight gains, and these connections can generate insight into the underlying obesity phenotype.

“It is a like a fingerprint. Everyone has his or her own story to tell,” Dr. Kushner explained. A clinical picture of patients’ phenotypes can be developed from observing large jumps in weight connected to such factors as a stressful life event, a period of sustained inactivity, or a pregnancy. Over a weight history, several events may be identified that provide insight into each patient’s “unique weight journey.”

This understanding provides the basis for a systematic approach to combining strategies that may include lifestyle changes, surgery, and pharmacologic management, all tailored for the specific triggers and needs of the patient. Dr. Kushner advised that, even for those who are candidates for surgery, bariatric procedures are just one component of the treatment and must be integrated in a team approach with other modalities.

This approach may include pharmacologic therapy both before and after surgery; Dr. Kushner noted that the availability of drug options has expanded in recent years with approval of such therapies as lorcaserin and liraglutide. According to Dr. Kushner, drug therapy can be used for preoperative weight loss and may be useful for preventing postoperative weight gain in certain patients.

“There are no randomized trials demonstrating efficacy for prevention of postoperative weight gain, but there is supportive evidence from a retrospective study,” said Dr. Kushner, referring to a recently published two-center evaluation (Surg Obes Relat Dis. 2017;13:491-500).

In that study, 258 patients underwent Roux-en-Y gastric bypass, and 61 patients underwent sleeve gastrectomy. Those who received adjunctive drug support, particularly in the RYGB group, had greater sustained weight loss than those who did not, leading to the conclusion that postoperative pharmacotherapy “is a useful adjunct.” The advantage for drug therapy was observed even though patients did not receive the most recently approved and potentially more effective drugs, according to Dr. Kushner. However, he cautioned that information about the optimal timing of treatment after surgery remains “limited.”

The variability in weight loss and weight regain after bariatric procedures is one reason to consider bariatric surgery as only one component in a continuum of care, according to Dr. Kushner. He emphasized that obesity is a chronic condition that requires ongoing and perhaps indefinite treatment. While surgeons may already work with a team that manages preoperative and postoperative lifestyle changes to improve immediate surgical outcomes, Dr. Kushner believes that surgeons and physicians should work more collaboratively toward long-term management plans. By also appreciating obesity phenotypes and the specific mix of treatments that are most likely to help individual patients achieve durable weight loss, surgeons and physicians working together are likely to improve outcomes beyond those that could be expected from either working alone.

Dr. Kushner reports he has financial relationships with Novo Nordisk, Retrofit, Takeda Pharmaceuticals, and Vivus.

 

NATIONAL HARBOR, MD. – When combined with bariatric surgery, adjunctive therapies for obesity should be individualized for specific drivers of weight gain, which can differ among obesity phenotypes, according to an expert view presented at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society .

“Surgery is the most effective therapy we have, but it is only one of multiple treatments that should be considered in a treatment paradigm,” suggested Robert F. Kushner, MD, a professor of endocrinology and specialist in obesity at the Northwestern University, Chicago.

Ted Bosworth

The remarks were part of a symposium in which Dr. Kushner was asked how surgeons should bridge the gap with nonsurgeon physicians working to improve outcomes in patients with obesity. Perhaps the most important point stressed by Dr. Kushner is that surgeons need to consider the obesity phenotype to understand what – in addition to surgery – will improve long-term outcomes.

“It is very useful to take a narrative approach to understand the patients in front of us and to understand who they are and how they got to where they are now,” Dr. Kushner explained. Dr. Kushner often asks patients to graph weight history over time. This can connect social, biological, and psychological events with significant weight gains, and these connections can generate insight into the underlying obesity phenotype.

“It is a like a fingerprint. Everyone has his or her own story to tell,” Dr. Kushner explained. A clinical picture of patients’ phenotypes can be developed from observing large jumps in weight connected to such factors as a stressful life event, a period of sustained inactivity, or a pregnancy. Over a weight history, several events may be identified that provide insight into each patient’s “unique weight journey.”

This understanding provides the basis for a systematic approach to combining strategies that may include lifestyle changes, surgery, and pharmacologic management, all tailored for the specific triggers and needs of the patient. Dr. Kushner advised that, even for those who are candidates for surgery, bariatric procedures are just one component of the treatment and must be integrated in a team approach with other modalities.

This approach may include pharmacologic therapy both before and after surgery; Dr. Kushner noted that the availability of drug options has expanded in recent years with approval of such therapies as lorcaserin and liraglutide. According to Dr. Kushner, drug therapy can be used for preoperative weight loss and may be useful for preventing postoperative weight gain in certain patients.

“There are no randomized trials demonstrating efficacy for prevention of postoperative weight gain, but there is supportive evidence from a retrospective study,” said Dr. Kushner, referring to a recently published two-center evaluation (Surg Obes Relat Dis. 2017;13:491-500).

In that study, 258 patients underwent Roux-en-Y gastric bypass, and 61 patients underwent sleeve gastrectomy. Those who received adjunctive drug support, particularly in the RYGB group, had greater sustained weight loss than those who did not, leading to the conclusion that postoperative pharmacotherapy “is a useful adjunct.” The advantage for drug therapy was observed even though patients did not receive the most recently approved and potentially more effective drugs, according to Dr. Kushner. However, he cautioned that information about the optimal timing of treatment after surgery remains “limited.”

The variability in weight loss and weight regain after bariatric procedures is one reason to consider bariatric surgery as only one component in a continuum of care, according to Dr. Kushner. He emphasized that obesity is a chronic condition that requires ongoing and perhaps indefinite treatment. While surgeons may already work with a team that manages preoperative and postoperative lifestyle changes to improve immediate surgical outcomes, Dr. Kushner believes that surgeons and physicians should work more collaboratively toward long-term management plans. By also appreciating obesity phenotypes and the specific mix of treatments that are most likely to help individual patients achieve durable weight loss, surgeons and physicians working together are likely to improve outcomes beyond those that could be expected from either working alone.

Dr. Kushner reports he has financial relationships with Novo Nordisk, Retrofit, Takeda Pharmaceuticals, and Vivus.

 

NATIONAL HARBOR, MD. – When combined with bariatric surgery, adjunctive therapies for obesity should be individualized for specific drivers of weight gain, which can differ among obesity phenotypes, according to an expert view presented at an annual meeting presented by the American Society for Metabolic and Bariatric Surgery and The Obesity Society .

“Surgery is the most effective therapy we have, but it is only one of multiple treatments that should be considered in a treatment paradigm,” suggested Robert F. Kushner, MD, a professor of endocrinology and specialist in obesity at the Northwestern University, Chicago.

Ted Bosworth

The remarks were part of a symposium in which Dr. Kushner was asked how surgeons should bridge the gap with nonsurgeon physicians working to improve outcomes in patients with obesity. Perhaps the most important point stressed by Dr. Kushner is that surgeons need to consider the obesity phenotype to understand what – in addition to surgery – will improve long-term outcomes.

“It is very useful to take a narrative approach to understand the patients in front of us and to understand who they are and how they got to where they are now,” Dr. Kushner explained. Dr. Kushner often asks patients to graph weight history over time. This can connect social, biological, and psychological events with significant weight gains, and these connections can generate insight into the underlying obesity phenotype.

“It is a like a fingerprint. Everyone has his or her own story to tell,” Dr. Kushner explained. A clinical picture of patients’ phenotypes can be developed from observing large jumps in weight connected to such factors as a stressful life event, a period of sustained inactivity, or a pregnancy. Over a weight history, several events may be identified that provide insight into each patient’s “unique weight journey.”

This understanding provides the basis for a systematic approach to combining strategies that may include lifestyle changes, surgery, and pharmacologic management, all tailored for the specific triggers and needs of the patient. Dr. Kushner advised that, even for those who are candidates for surgery, bariatric procedures are just one component of the treatment and must be integrated in a team approach with other modalities.

This approach may include pharmacologic therapy both before and after surgery; Dr. Kushner noted that the availability of drug options has expanded in recent years with approval of such therapies as lorcaserin and liraglutide. According to Dr. Kushner, drug therapy can be used for preoperative weight loss and may be useful for preventing postoperative weight gain in certain patients.

“There are no randomized trials demonstrating efficacy for prevention of postoperative weight gain, but there is supportive evidence from a retrospective study,” said Dr. Kushner, referring to a recently published two-center evaluation (Surg Obes Relat Dis. 2017;13:491-500).

In that study, 258 patients underwent Roux-en-Y gastric bypass, and 61 patients underwent sleeve gastrectomy. Those who received adjunctive drug support, particularly in the RYGB group, had greater sustained weight loss than those who did not, leading to the conclusion that postoperative pharmacotherapy “is a useful adjunct.” The advantage for drug therapy was observed even though patients did not receive the most recently approved and potentially more effective drugs, according to Dr. Kushner. However, he cautioned that information about the optimal timing of treatment after surgery remains “limited.”

The variability in weight loss and weight regain after bariatric procedures is one reason to consider bariatric surgery as only one component in a continuum of care, according to Dr. Kushner. He emphasized that obesity is a chronic condition that requires ongoing and perhaps indefinite treatment. While surgeons may already work with a team that manages preoperative and postoperative lifestyle changes to improve immediate surgical outcomes, Dr. Kushner believes that surgeons and physicians should work more collaboratively toward long-term management plans. By also appreciating obesity phenotypes and the specific mix of treatments that are most likely to help individual patients achieve durable weight loss, surgeons and physicians working together are likely to improve outcomes beyond those that could be expected from either working alone.

Dr. Kushner reports he has financial relationships with Novo Nordisk, Retrofit, Takeda Pharmaceuticals, and Vivus.

 

NATIONAL HARBOR, MD. – A standard definition of bariatric surgery failure based on weight regain is needed to assess long-term outcomes in place of the seemingly arbitrary thresholds now in use, according to discussion generated by long-term outcome studies presented at Obesity Week 2017.

Ted Bosworth/Frontline Medical News

In one of two studies evaluating weight recidivism in long-term follow-up after bariatric surgery, failure rates at 10 years ranged from 25% to more than 70% according to the definition used, reported to Michael C. Morell, MD, a bariatric surgeon at the Gundersen Medical Foundation, Encinitas, CA.

In another study, presented by Colin Martyn, MD, a general surgery resident at Texas Tech University Health Sciences Center, El Paso, the bariatric surgery failure rate at 11 years was characterized as an “alarming” 33.9%. In this study, bariatric surgery was considered a failure if the patient did not maintain excess weight loss (EWL) of 50% or greater.

The problem with this definition, like many others, is that “it fails to recognize that there could be significant health benefits and improvements in quality of life with less weight loss,” according to Philip Schauer, MD, director of the Cleveland Clinic Bariatric and Metabolic Institute. As the invited discussant for the data presented by Dr. Martyn, Dr. Schauer acknowledged that 50% EWL has been used by others as the dividing line between success and failure, but he called it “obsolete.”

This definition was one of several applied to weight recidivism in the study presented by Dr. Morell. Others included weight regain of more than 25% EWL over the postoperative nadir, an increase in body mass index to more than 35 kg/m² after achieving a lower BMI, and a postsurgical BMI increase of more than 5 mg/m². Not surprisingly, weight recidivism “varied widely with regard to the definitions used,” Dr. Morell reported.

Dr. Morell’s study involved evaluation of 1,766 patients with at least 1 year of follow-up after bariatric procedure. Most (1,490 patients) underwent laparoscopic Roux-en-y gastric bypass. After 2 years of follow-up, 93% achieved at least the 50% EWL threshold of treatment success, but Dr. Morell reported that the proportion above this or any threshold progressively diminished over time. For a definition of treatment success, Dr. Morell favors maintenance of at least 20% total weight loss as a threshold of long-term clinical success, a threshold met by 75% of patients at 5 years, in his analysis.

Ted Bosworth/Frontline Medical News

In the meta-analysis presented by Dr. Martyn, nine published studies with at least 7 years of follow-up were included. These involved a cumulative 345 patients followed for at least 7 years with diminishing numbers followed up to 11 years. Using the at least 50% EWL as the definition of treatment success, the overall failure rate was 27.8% at 7 years but climbed to 33.9% at 11 years.

As has been shown in these studies and reported previously, the regaining of weight over time after bariatric surgery is common and progressive, but both studies ignited controversy about what measure is meaningful for declaring that bariatric surgery has failed over the long term. None of the current thresholds for failure are based on evidence that clinical benefit has been lost. Rather, it appears that these are simply accepted conventions.

“It bothers me to hear the word failure in these presentations, because I think the paradigm is changing from success and failure to that of treating chronic disease,” said Stacy Brethauer, MD, a staff surgeon in the Cleveland Clinic Digestive Disease Institute. Dr. Brethauer, the moderator of the session at Obesity Week where both long-term follow-up papers were presented, agreed that the at least 50% EWL benchmark is “flawed.” He suggested that more clinically meaningful methods of evaluating long-term outcome are needed for both clinical and research purposes.

The discussant of Dr. Morell’s paper, Samer G. Mattar, MD, a bariatric surgeon at the Swedish Medical Center, Seattle, also called for metrics based on clinical benefit rather than on weight alone.

“I would caution against this overall emphasis that we seem to place on weight gain and weight loss as a benchmark and predominant objective for what we do,” he said. “Our nonsurgeon colleagues have repeatedly demonstrated clinical benefits from total body weight loss of 10% or even 5%. So let’s not beat up ourselves over trying to maintain a greater than 50% EWL in all our patients.”

 

AGA created the Obesity Practice Guide to help gastroenterologists integrate and operationalize obesity management in their practice for financial success. Learn more at www.gastro.org/obesity.

 

NATIONAL HARBOR, MD. – A standard definition of bariatric surgery failure based on weight regain is needed to assess long-term outcomes in place of the seemingly arbitrary thresholds now in use, according to discussion generated by long-term outcome studies presented at Obesity Week 2017.

Ted Bosworth/Frontline Medical News

In one of two studies evaluating weight recidivism in long-term follow-up after bariatric surgery, failure rates at 10 years ranged from 25% to more than 70% according to the definition used, reported to Michael C. Morell, MD, a bariatric surgeon at the Gundersen Medical Foundation, Encinitas, CA.

In another study, presented by Colin Martyn, MD, a general surgery resident at Texas Tech University Health Sciences Center, El Paso, the bariatric surgery failure rate at 11 years was characterized as an “alarming” 33.9%. In this study, bariatric surgery was considered a failure if the patient did not maintain excess weight loss (EWL) of 50% or greater.

The problem with this definition, like many others, is that “it fails to recognize that there could be significant health benefits and improvements in quality of life with less weight loss,” according to Philip Schauer, MD, director of the Cleveland Clinic Bariatric and Metabolic Institute. As the invited discussant for the data presented by Dr. Martyn, Dr. Schauer acknowledged that 50% EWL has been used by others as the dividing line between success and failure, but he called it “obsolete.”

This definition was one of several applied to weight recidivism in the study presented by Dr. Morell. Others included weight regain of more than 25% EWL over the postoperative nadir, an increase in body mass index to more than 35 kg/m² after achieving a lower BMI, and a postsurgical BMI increase of more than 5 mg/m². Not surprisingly, weight recidivism “varied widely with regard to the definitions used,” Dr. Morell reported.

Dr. Morell’s study involved evaluation of 1,766 patients with at least 1 year of follow-up after bariatric procedure. Most (1,490 patients) underwent laparoscopic Roux-en-y gastric bypass. After 2 years of follow-up, 93% achieved at least the 50% EWL threshold of treatment success, but Dr. Morell reported that the proportion above this or any threshold progressively diminished over time. For a definition of treatment success, Dr. Morell favors maintenance of at least 20% total weight loss as a threshold of long-term clinical success, a threshold met by 75% of patients at 5 years, in his analysis.

Ted Bosworth/Frontline Medical News

In the meta-analysis presented by Dr. Martyn, nine published studies with at least 7 years of follow-up were included. These involved a cumulative 345 patients followed for at least 7 years with diminishing numbers followed up to 11 years. Using the at least 50% EWL as the definition of treatment success, the overall failure rate was 27.8% at 7 years but climbed to 33.9% at 11 years.

As has been shown in these studies and reported previously, the regaining of weight over time after bariatric surgery is common and progressive, but both studies ignited controversy about what measure is meaningful for declaring that bariatric surgery has failed over the long term. None of the current thresholds for failure are based on evidence that clinical benefit has been lost. Rather, it appears that these are simply accepted conventions.

“It bothers me to hear the word failure in these presentations, because I think the paradigm is changing from success and failure to that of treating chronic disease,” said Stacy Brethauer, MD, a staff surgeon in the Cleveland Clinic Digestive Disease Institute. Dr. Brethauer, the moderator of the session at Obesity Week where both long-term follow-up papers were presented, agreed that the at least 50% EWL benchmark is “flawed.” He suggested that more clinically meaningful methods of evaluating long-term outcome are needed for both clinical and research purposes.

The discussant of Dr. Morell’s paper, Samer G. Mattar, MD, a bariatric surgeon at the Swedish Medical Center, Seattle, also called for metrics based on clinical benefit rather than on weight alone.

“I would caution against this overall emphasis that we seem to place on weight gain and weight loss as a benchmark and predominant objective for what we do,” he said. “Our nonsurgeon colleagues have repeatedly demonstrated clinical benefits from total body weight loss of 10% or even 5%. So let’s not beat up ourselves over trying to maintain a greater than 50% EWL in all our patients.”

 

AGA created the Obesity Practice Guide to help gastroenterologists integrate and operationalize obesity management in their practice for financial success. Learn more at www.gastro.org/obesity.

 

NATIONAL HARBOR, MD. – A standard definition of bariatric surgery failure based on weight regain is needed to assess long-term outcomes in place of the seemingly arbitrary thresholds now in use, according to discussion generated by long-term outcome studies presented at Obesity Week 2017.

Ted Bosworth/Frontline Medical News

In one of two studies evaluating weight recidivism in long-term follow-up after bariatric surgery, failure rates at 10 years ranged from 25% to more than 70% according to the definition used, reported to Michael C. Morell, MD, a bariatric surgeon at the Gundersen Medical Foundation, Encinitas, CA.

In another study, presented by Colin Martyn, MD, a general surgery resident at Texas Tech University Health Sciences Center, El Paso, the bariatric surgery failure rate at 11 years was characterized as an “alarming” 33.9%. In this study, bariatric surgery was considered a failure if the patient did not maintain excess weight loss (EWL) of 50% or greater.

The problem with this definition, like many others, is that “it fails to recognize that there could be significant health benefits and improvements in quality of life with less weight loss,” according to Philip Schauer, MD, director of the Cleveland Clinic Bariatric and Metabolic Institute. As the invited discussant for the data presented by Dr. Martyn, Dr. Schauer acknowledged that 50% EWL has been used by others as the dividing line between success and failure, but he called it “obsolete.”

This definition was one of several applied to weight recidivism in the study presented by Dr. Morell. Others included weight regain of more than 25% EWL over the postoperative nadir, an increase in body mass index to more than 35 kg/m² after achieving a lower BMI, and a postsurgical BMI increase of more than 5 mg/m². Not surprisingly, weight recidivism “varied widely with regard to the definitions used,” Dr. Morell reported.

Dr. Morell’s study involved evaluation of 1,766 patients with at least 1 year of follow-up after bariatric procedure. Most (1,490 patients) underwent laparoscopic Roux-en-y gastric bypass. After 2 years of follow-up, 93% achieved at least the 50% EWL threshold of treatment success, but Dr. Morell reported that the proportion above this or any threshold progressively diminished over time. For a definition of treatment success, Dr. Morell favors maintenance of at least 20% total weight loss as a threshold of long-term clinical success, a threshold met by 75% of patients at 5 years, in his analysis.

Ted Bosworth/Frontline Medical News

In the meta-analysis presented by Dr. Martyn, nine published studies with at least 7 years of follow-up were included. These involved a cumulative 345 patients followed for at least 7 years with diminishing numbers followed up to 11 years. Using the at least 50% EWL as the definition of treatment success, the overall failure rate was 27.8% at 7 years but climbed to 33.9% at 11 years.

As has been shown in these studies and reported previously, the regaining of weight over time after bariatric surgery is common and progressive, but both studies ignited controversy about what measure is meaningful for declaring that bariatric surgery has failed over the long term. None of the current thresholds for failure are based on evidence that clinical benefit has been lost. Rather, it appears that these are simply accepted conventions.

“It bothers me to hear the word failure in these presentations, because I think the paradigm is changing from success and failure to that of treating chronic disease,” said Stacy Brethauer, MD, a staff surgeon in the Cleveland Clinic Digestive Disease Institute. Dr. Brethauer, the moderator of the session at Obesity Week where both long-term follow-up papers were presented, agreed that the at least 50% EWL benchmark is “flawed.” He suggested that more clinically meaningful methods of evaluating long-term outcome are needed for both clinical and research purposes.

The discussant of Dr. Morell’s paper, Samer G. Mattar, MD, a bariatric surgeon at the Swedish Medical Center, Seattle, also called for metrics based on clinical benefit rather than on weight alone.

“I would caution against this overall emphasis that we seem to place on weight gain and weight loss as a benchmark and predominant objective for what we do,” he said. “Our nonsurgeon colleagues have repeatedly demonstrated clinical benefits from total body weight loss of 10% or even 5%. So let’s not beat up ourselves over trying to maintain a greater than 50% EWL in all our patients.”

 

AGA created the Obesity Practice Guide to help gastroenterologists integrate and operationalize obesity management in their practice for financial success. Learn more at www.gastro.org/obesity.

 

NATIONAL HARBOR, MD – Hospital discharge after bariatric surgery can be significantly and meaningful accelerated by using multimodality pain control techniques that do not include patient-controlled analgesia (PCA), according to data from a two-hospital study presented at Obesity Week 2017.

“It was our impression that PCA was delaying milestones of recovery, so we prospectively evaluated this hypothesis. The result was a meaningful reduction in the length of stay without any meaningful adverse consequences,” reported Aline Van, RN, a weight loss surgery nurse navigator at Doctors Hospital, Manteca, Calif.

Ted Bosworth/Frontline Medical News

There is some irony in these results, because “we had moved to PCA as a strategy to reduce opioid use,” explained Patrick Coates, MD, who is director of metabolic bariatric surgery at Central California Bariatric Surgery, Modesto, Calif., and a coauthor. According to Dr. Coates, who performs bariatric surgery at both of the hospitals that participated in this study, “these data demonstrate that opioids can be largely avoided during recovery without any real disadvantages.”

The study was conducted because of concern that nausea and vomiting related to PCA was a common cause of discharge delay at both Doctors Hospital in Manteca (DHM) and the affiliated Doctors Medical Center (DMC) in Modesto. Led by Maria Marple, PA-C, the two-part prospective study consisted of an initial six-month evaluation of average length of stay (LOS) and a formal evaluation of the causes of delayed discharge. In the second phase, the same analyses were performed over a six-month period when PCA was halted.

At 1.83 days in one center and 1.84 days in the other, the average LOS was nearly identical during the initial six-month baseline evaluation. In the 75 patients evaluated in this period at DHC, inadequate fluid intake due to nausea and vomiting was involved in 61.7% of the cases in which discharge was delayed. At DMC, where 46 patients were evaluated in the baseline period, 47.6% of delays were due to inadequate fluid intake attributed to nausea and vomiting. In both cases, this was the most common reason for delay.

In the study period after PCA was discontinued, inadequate fluid intake remained the major cause of delayed discharges, but there were fewer discharge delays overall due to less nausea and vomiting. The average length of stay among the 104 patients treated in the study period at DHM fell to 1.64 days, while the average LOS fell to 1.66 days in the 83 patients treated at DMC. This was largely driven by a reduction in the proportion of patients with >2 days LOS, which fell from 52% to 41% at DHC (P = .04) and from 45% to 32% at DMC (P = .008).

The surgical procedures at both centers (all performed laparoscopically) included sleeve gastrectomy, gastric bypass, and duodenal switch. Although a multimodality approach is employed for postoperative pain control at both institutions, the protocols differ modestly. At DHC, acetaminophen by mouth is the primary postoperative analgesic with hydromorphone permitted if needed. At DMC, intravenous acetaminophen is used in the first 24 hours in all patients with acetaminophen/hydrocodone offered if needed.

Since the trial was completed and results analyzed, PCA has been discontinued completely at both institutions. In follow-up to date there has been a slight additional reduction in average LOS at both institutions, reaching 1.5 days at DHC and 1.61 days at DMC.

“The four to five hour average reduction in LOS following discontinuation of PCA is significant because it frees up beds at our hospital, which is run at capacity,” Ms. Van said. “When considered cumulatively, the average reduction in LOS is very meaningful.”

Although the benefits are generally attributed to reduced nausea and vomiting, which has implications for a better patient experience, Ms. Van also believes patients are having faster cognitive and physical recovery since PCA was eliminated, producing faster time to ambulation and discharge readiness.

“There really have been no negatives,” Dr. Coates confirmed. “In our experience, eliminating PCA has been better for the patients and has important implications for costs.”

Ms. Van and Dr. Coates reported no financial relationships relevant to this topic.
 

 

NATIONAL HARBOR, MD – Hospital discharge after bariatric surgery can be significantly and meaningful accelerated by using multimodality pain control techniques that do not include patient-controlled analgesia (PCA), according to data from a two-hospital study presented at Obesity Week 2017.

“It was our impression that PCA was delaying milestones of recovery, so we prospectively evaluated this hypothesis. The result was a meaningful reduction in the length of stay without any meaningful adverse consequences,” reported Aline Van, RN, a weight loss surgery nurse navigator at Doctors Hospital, Manteca, Calif.

Ted Bosworth/Frontline Medical News

There is some irony in these results, because “we had moved to PCA as a strategy to reduce opioid use,” explained Patrick Coates, MD, who is director of metabolic bariatric surgery at Central California Bariatric Surgery, Modesto, Calif., and a coauthor. According to Dr. Coates, who performs bariatric surgery at both of the hospitals that participated in this study, “these data demonstrate that opioids can be largely avoided during recovery without any real disadvantages.”

The study was conducted because of concern that nausea and vomiting related to PCA was a common cause of discharge delay at both Doctors Hospital in Manteca (DHM) and the affiliated Doctors Medical Center (DMC) in Modesto. Led by Maria Marple, PA-C, the two-part prospective study consisted of an initial six-month evaluation of average length of stay (LOS) and a formal evaluation of the causes of delayed discharge. In the second phase, the same analyses were performed over a six-month period when PCA was halted.

At 1.83 days in one center and 1.84 days in the other, the average LOS was nearly identical during the initial six-month baseline evaluation. In the 75 patients evaluated in this period at DHC, inadequate fluid intake due to nausea and vomiting was involved in 61.7% of the cases in which discharge was delayed. At DMC, where 46 patients were evaluated in the baseline period, 47.6% of delays were due to inadequate fluid intake attributed to nausea and vomiting. In both cases, this was the most common reason for delay.

In the study period after PCA was discontinued, inadequate fluid intake remained the major cause of delayed discharges, but there were fewer discharge delays overall due to less nausea and vomiting. The average length of stay among the 104 patients treated in the study period at DHM fell to 1.64 days, while the average LOS fell to 1.66 days in the 83 patients treated at DMC. This was largely driven by a reduction in the proportion of patients with >2 days LOS, which fell from 52% to 41% at DHC (P = .04) and from 45% to 32% at DMC (P = .008).

The surgical procedures at both centers (all performed laparoscopically) included sleeve gastrectomy, gastric bypass, and duodenal switch. Although a multimodality approach is employed for postoperative pain control at both institutions, the protocols differ modestly. At DHC, acetaminophen by mouth is the primary postoperative analgesic with hydromorphone permitted if needed. At DMC, intravenous acetaminophen is used in the first 24 hours in all patients with acetaminophen/hydrocodone offered if needed.

Since the trial was completed and results analyzed, PCA has been discontinued completely at both institutions. In follow-up to date there has been a slight additional reduction in average LOS at both institutions, reaching 1.5 days at DHC and 1.61 days at DMC.

“The four to five hour average reduction in LOS following discontinuation of PCA is significant because it frees up beds at our hospital, which is run at capacity,” Ms. Van said. “When considered cumulatively, the average reduction in LOS is very meaningful.”

Although the benefits are generally attributed to reduced nausea and vomiting, which has implications for a better patient experience, Ms. Van also believes patients are having faster cognitive and physical recovery since PCA was eliminated, producing faster time to ambulation and discharge readiness.

“There really have been no negatives,” Dr. Coates confirmed. “In our experience, eliminating PCA has been better for the patients and has important implications for costs.”

Ms. Van and Dr. Coates reported no financial relationships relevant to this topic.
 

 

NATIONAL HARBOR, MD – Hospital discharge after bariatric surgery can be significantly and meaningful accelerated by using multimodality pain control techniques that do not include patient-controlled analgesia (PCA), according to data from a two-hospital study presented at Obesity Week 2017.

“It was our impression that PCA was delaying milestones of recovery, so we prospectively evaluated this hypothesis. The result was a meaningful reduction in the length of stay without any meaningful adverse consequences,” reported Aline Van, RN, a weight loss surgery nurse navigator at Doctors Hospital, Manteca, Calif.

Ted Bosworth/Frontline Medical News

There is some irony in these results, because “we had moved to PCA as a strategy to reduce opioid use,” explained Patrick Coates, MD, who is director of metabolic bariatric surgery at Central California Bariatric Surgery, Modesto, Calif., and a coauthor. According to Dr. Coates, who performs bariatric surgery at both of the hospitals that participated in this study, “these data demonstrate that opioids can be largely avoided during recovery without any real disadvantages.”

The study was conducted because of concern that nausea and vomiting related to PCA was a common cause of discharge delay at both Doctors Hospital in Manteca (DHM) and the affiliated Doctors Medical Center (DMC) in Modesto. Led by Maria Marple, PA-C, the two-part prospective study consisted of an initial six-month evaluation of average length of stay (LOS) and a formal evaluation of the causes of delayed discharge. In the second phase, the same analyses were performed over a six-month period when PCA was halted.

At 1.83 days in one center and 1.84 days in the other, the average LOS was nearly identical during the initial six-month baseline evaluation. In the 75 patients evaluated in this period at DHC, inadequate fluid intake due to nausea and vomiting was involved in 61.7% of the cases in which discharge was delayed. At DMC, where 46 patients were evaluated in the baseline period, 47.6% of delays were due to inadequate fluid intake attributed to nausea and vomiting. In both cases, this was the most common reason for delay.

In the study period after PCA was discontinued, inadequate fluid intake remained the major cause of delayed discharges, but there were fewer discharge delays overall due to less nausea and vomiting. The average length of stay among the 104 patients treated in the study period at DHM fell to 1.64 days, while the average LOS fell to 1.66 days in the 83 patients treated at DMC. This was largely driven by a reduction in the proportion of patients with >2 days LOS, which fell from 52% to 41% at DHC (P = .04) and from 45% to 32% at DMC (P = .008).

The surgical procedures at both centers (all performed laparoscopically) included sleeve gastrectomy, gastric bypass, and duodenal switch. Although a multimodality approach is employed for postoperative pain control at both institutions, the protocols differ modestly. At DHC, acetaminophen by mouth is the primary postoperative analgesic with hydromorphone permitted if needed. At DMC, intravenous acetaminophen is used in the first 24 hours in all patients with acetaminophen/hydrocodone offered if needed.

Since the trial was completed and results analyzed, PCA has been discontinued completely at both institutions. In follow-up to date there has been a slight additional reduction in average LOS at both institutions, reaching 1.5 days at DHC and 1.61 days at DMC.

“The four to five hour average reduction in LOS following discontinuation of PCA is significant because it frees up beds at our hospital, which is run at capacity,” Ms. Van said. “When considered cumulatively, the average reduction in LOS is very meaningful.”

Although the benefits are generally attributed to reduced nausea and vomiting, which has implications for a better patient experience, Ms. Van also believes patients are having faster cognitive and physical recovery since PCA was eliminated, producing faster time to ambulation and discharge readiness.

“There really have been no negatives,” Dr. Coates confirmed. “In our experience, eliminating PCA has been better for the patients and has important implications for costs.”

Ms. Van and Dr. Coates reported no financial relationships relevant to this topic.
 

 

NATIONAL HARBOR, MD – Many third-party payers require candidates for bariatric surgery to complete weight loss programs in order to qualify for reimbursement, but two new studies presented at Obesity Week 2017 have found no identifiable justification for the delay in treatment.

“When comparing those who did or did not participate in a weight management program, there was no significant benefit in regard to surgery complications, patient rate of followup, or percent excess weight loss at 12 months,” reported Andrew Schneider, MD, who is completing his residency in general surgery in the Greenville Health Systems, Greenville, South Carolina.

The analysis presented by Dr. Schneider was drawn from prospectively maintained data in the Greenville Health System. From 354 patients in this pool of data, a cohort of 266 required to participate in an insurance-mandated, medically supervised weight management program were compared to a second cohort of 88 patients who were not.

No significant differences were observed in a long list of procedural and outcome variables including operating time, length of hospital stay, and excess weight loss (EWL) at 3, 6, and 12 months, according to Dr. Schneider, who emphasized that no differences even approached significance.

A second study, evaluating the effect of presurgical weight management programs from a different perspective, drew the same conclusion. In this study, the goal was to correlate the number of preoperative weight loss sessions with change in multiple outcomes including EWL, according Genna Hymowitz, PhD, a psychologist at the Stony Brook Medicine Bariatric and Metabolic Weight Loss Center, Stony Brook, New York.

No correlation was observed between number of presurgical weight management program visits and any outcome evaluated in followup out to 12 months, according to Dr. Hymowitz. There was one exception.

“The number of visits attended and weight loss 3 weeks after surgery was a negative correlation, suggesting that the number of sessions attended was associated with lower excess weight loss,” Dr. Hymowitz reported.

Insurance company requirements for presurgical weight management programs vary widely, but the American Society for Metabolic and Bariatric Surgery (ASMBS) concluded in a position statement issued in 2011 that they are unsupported by controlled evidence. According to this statement, which referenced several clinical studies, “there is no evidence of any kind that insurance mandated preoperative weight loss…has any clear impact on postoperative outcomes or weight loss.”

In the ASBMS statement, the objection is directed at specific requirements for medically supervised weight loss program. These can demand six or more months of participation before reimbursement for surgery will be granted. In the ASBMS statement, mandated treatment required by insurance companies is distinguished from Medicare policy. Medicare reimbursement requires patients to fail medical treatment prior to bariatric surgery but providers are allowed to define failure. In contrast, specified periods of medical management required by insurance companies can have the effect of delaying treatment with proven efficacy in appropriate candidates.

Asked to speculate why insurance companies mandate supervised weight loss program for bariatric surgery eligibility, Dr. Schneider suggested that it might be considered a method to evaluate patient motivation and compliance. However, he also acknowledged that the requirement is likely to provide a barrier for some individuals thereby reducing surgical costs for the third-party payers.

While there are now several studies, including those cited in the ASBMS position statement, arguing that these mandates should be eliminated, longer followup is needed, according to Maher El Chaar, MD, Co-Medical Director, Bariatric surgery, St. Luke’s University Hospital, Allentown, Pennsylvania. One of the moderators for the Obesity Week session in which the two latest studies were presented, Dr. El Chaar said that insurance company representatives with whom he has spoken insist that longer-term studies are needed.

“When I point out that there is no data supporting mandated weight management programs, they tell me that there is very little data beyond 12 months,” Dr. El Chaar explained. He suggested data beyond 12 months could be helpful in the effort to get these requirements waived.

Dr. Schneider and Dr. Hymowitz reported no relevant financial relationships.


 

 

NATIONAL HARBOR, MD – Many third-party payers require candidates for bariatric surgery to complete weight loss programs in order to qualify for reimbursement, but two new studies presented at Obesity Week 2017 have found no identifiable justification for the delay in treatment.

“When comparing those who did or did not participate in a weight management program, there was no significant benefit in regard to surgery complications, patient rate of followup, or percent excess weight loss at 12 months,” reported Andrew Schneider, MD, who is completing his residency in general surgery in the Greenville Health Systems, Greenville, South Carolina.

The analysis presented by Dr. Schneider was drawn from prospectively maintained data in the Greenville Health System. From 354 patients in this pool of data, a cohort of 266 required to participate in an insurance-mandated, medically supervised weight management program were compared to a second cohort of 88 patients who were not.

No significant differences were observed in a long list of procedural and outcome variables including operating time, length of hospital stay, and excess weight loss (EWL) at 3, 6, and 12 months, according to Dr. Schneider, who emphasized that no differences even approached significance.

A second study, evaluating the effect of presurgical weight management programs from a different perspective, drew the same conclusion. In this study, the goal was to correlate the number of preoperative weight loss sessions with change in multiple outcomes including EWL, according Genna Hymowitz, PhD, a psychologist at the Stony Brook Medicine Bariatric and Metabolic Weight Loss Center, Stony Brook, New York.

No correlation was observed between number of presurgical weight management program visits and any outcome evaluated in followup out to 12 months, according to Dr. Hymowitz. There was one exception.

“The number of visits attended and weight loss 3 weeks after surgery was a negative correlation, suggesting that the number of sessions attended was associated with lower excess weight loss,” Dr. Hymowitz reported.

Insurance company requirements for presurgical weight management programs vary widely, but the American Society for Metabolic and Bariatric Surgery (ASMBS) concluded in a position statement issued in 2011 that they are unsupported by controlled evidence. According to this statement, which referenced several clinical studies, “there is no evidence of any kind that insurance mandated preoperative weight loss…has any clear impact on postoperative outcomes or weight loss.”

In the ASBMS statement, the objection is directed at specific requirements for medically supervised weight loss program. These can demand six or more months of participation before reimbursement for surgery will be granted. In the ASBMS statement, mandated treatment required by insurance companies is distinguished from Medicare policy. Medicare reimbursement requires patients to fail medical treatment prior to bariatric surgery but providers are allowed to define failure. In contrast, specified periods of medical management required by insurance companies can have the effect of delaying treatment with proven efficacy in appropriate candidates.

Asked to speculate why insurance companies mandate supervised weight loss program for bariatric surgery eligibility, Dr. Schneider suggested that it might be considered a method to evaluate patient motivation and compliance. However, he also acknowledged that the requirement is likely to provide a barrier for some individuals thereby reducing surgical costs for the third-party payers.

While there are now several studies, including those cited in the ASBMS position statement, arguing that these mandates should be eliminated, longer followup is needed, according to Maher El Chaar, MD, Co-Medical Director, Bariatric surgery, St. Luke’s University Hospital, Allentown, Pennsylvania. One of the moderators for the Obesity Week session in which the two latest studies were presented, Dr. El Chaar said that insurance company representatives with whom he has spoken insist that longer-term studies are needed.

“When I point out that there is no data supporting mandated weight management programs, they tell me that there is very little data beyond 12 months,” Dr. El Chaar explained. He suggested data beyond 12 months could be helpful in the effort to get these requirements waived.

Dr. Schneider and Dr. Hymowitz reported no relevant financial relationships.


 

 

NATIONAL HARBOR, MD – Many third-party payers require candidates for bariatric surgery to complete weight loss programs in order to qualify for reimbursement, but two new studies presented at Obesity Week 2017 have found no identifiable justification for the delay in treatment.

“When comparing those who did or did not participate in a weight management program, there was no significant benefit in regard to surgery complications, patient rate of followup, or percent excess weight loss at 12 months,” reported Andrew Schneider, MD, who is completing his residency in general surgery in the Greenville Health Systems, Greenville, South Carolina.

The analysis presented by Dr. Schneider was drawn from prospectively maintained data in the Greenville Health System. From 354 patients in this pool of data, a cohort of 266 required to participate in an insurance-mandated, medically supervised weight management program were compared to a second cohort of 88 patients who were not.

No significant differences were observed in a long list of procedural and outcome variables including operating time, length of hospital stay, and excess weight loss (EWL) at 3, 6, and 12 months, according to Dr. Schneider, who emphasized that no differences even approached significance.

A second study, evaluating the effect of presurgical weight management programs from a different perspective, drew the same conclusion. In this study, the goal was to correlate the number of preoperative weight loss sessions with change in multiple outcomes including EWL, according Genna Hymowitz, PhD, a psychologist at the Stony Brook Medicine Bariatric and Metabolic Weight Loss Center, Stony Brook, New York.

No correlation was observed between number of presurgical weight management program visits and any outcome evaluated in followup out to 12 months, according to Dr. Hymowitz. There was one exception.

“The number of visits attended and weight loss 3 weeks after surgery was a negative correlation, suggesting that the number of sessions attended was associated with lower excess weight loss,” Dr. Hymowitz reported.

Insurance company requirements for presurgical weight management programs vary widely, but the American Society for Metabolic and Bariatric Surgery (ASMBS) concluded in a position statement issued in 2011 that they are unsupported by controlled evidence. According to this statement, which referenced several clinical studies, “there is no evidence of any kind that insurance mandated preoperative weight loss…has any clear impact on postoperative outcomes or weight loss.”

In the ASBMS statement, the objection is directed at specific requirements for medically supervised weight loss program. These can demand six or more months of participation before reimbursement for surgery will be granted. In the ASBMS statement, mandated treatment required by insurance companies is distinguished from Medicare policy. Medicare reimbursement requires patients to fail medical treatment prior to bariatric surgery but providers are allowed to define failure. In contrast, specified periods of medical management required by insurance companies can have the effect of delaying treatment with proven efficacy in appropriate candidates.

Asked to speculate why insurance companies mandate supervised weight loss program for bariatric surgery eligibility, Dr. Schneider suggested that it might be considered a method to evaluate patient motivation and compliance. However, he also acknowledged that the requirement is likely to provide a barrier for some individuals thereby reducing surgical costs for the third-party payers.

While there are now several studies, including those cited in the ASBMS position statement, arguing that these mandates should be eliminated, longer followup is needed, according to Maher El Chaar, MD, Co-Medical Director, Bariatric surgery, St. Luke’s University Hospital, Allentown, Pennsylvania. One of the moderators for the Obesity Week session in which the two latest studies were presented, Dr. El Chaar said that insurance company representatives with whom he has spoken insist that longer-term studies are needed.

“When I point out that there is no data supporting mandated weight management programs, they tell me that there is very little data beyond 12 months,” Dr. El Chaar explained. He suggested data beyond 12 months could be helpful in the effort to get these requirements waived.

Dr. Schneider and Dr. Hymowitz reported no relevant financial relationships.


 

 

NATIONAL HARBOR, MD – Forty-four percent of insulin-dependent patients with type 2 diabetes mellitus (DM2) were at their glycemic target without insulin a median of seven years after surgery. The data from the largest study to evaluate long-term outcomes in this population were presented at Obesity Week 2017.

“These data confirm that the impressive metabolic effects of bariatric surgery in patients with type 2 diabetes are sustained beyond five years,” reported Ali Aminian, MD, a surgeon who specializes in bariatric procedures at the Cleveland Clinic, Cleveland, Ohio. He said that long-term efficacy has not been well characterized previously.

Bariatric surgery patients treated at the Cleveland Clinic were included in this analysis if they had DM2, were taking insulin at the time of their procedure, and had been followed for at least five years. The median follow-up was 7 years with a range out to 12 years. Of the 252 patients included, 194 underwent roux-en-y gastric bypass (RYGB) and 58 underwent sleeve gastrectomy.

Reaching the glycemic target, defined as less than 7% HbA_1c, without insulin was only one of the primary endpoints. The other was diabetes remission, which was defined as H_bA_1c less than 6.5%, fasting blood glucose less than 126 mg/dL, and being off all diabetes medications. This was observed in 15% of the patients after a median of 7 years followup.

Contrasting short-term results, defined as outcomes one to two years after bariatric surgery with the long-term followup, Dr. Aminian was able to show that declines were relatively modest over time. For example, 51% were at the glycemic target off insulin at the short-term mark, which translates into an absolute decline of only 7% relative to the 44% observed at the long-term followup assessment.

Similarly, 70% had achieved the American Diabetes Association (ADA) goal of less than 7% within the first two years of surgery, while 59% remained at this goal at the most recent followup. The proportion taking insulin at the short-term mark was 36% rising only to 40% long-term.

When data were stratified by procedure, results favored RYGB over sleeve gastrectomy. For example, 47% of the RYGB patients versus 33% of the sleeve gastrectomy patients were able to reach the ADA goal without insulin at the end of the study. The proportions in diabetes remission were 17% and 10%, respectively. RYGB was also associated with greater improvement in BMI (median -12 vs. - 8 kg/m2) and reduced late weight gain (median 20% vs. 31%).

However, Dr. Aminian, who did not provide statistical calculations for these differences, cautioned that higher risk patients might have been preferentially selected for sleeve gastrectomy. He noted that difference in median HbA_1c levels was significantly lower in the RYGB group two years after surgery (P less than .001) but the numerical advantage had lost significance at the last followup (P = .32).

In an evaluation of predictors for glycemic control, a shorter duration of diabetes (less than 10 years) and good glycemic control prior to surgery were both predictors of achieving the primary outcomes on the basis of a multivariate analysis, according to Dr. Aminian. Younger age was a marginal predictor, but Dr. Aminian said that neither type of procedure nor presurgical BMI predicted outcomes from the multivariate analysis.

Relative to baseline, there were significant improvements in median LDL (P = .001). In addition, HDL, triglyceride levels, systolic, and diastolic blood pressure measurements were all significantly improved, both short-term and long-term after bariatric surgery (all P values less than .001), according to Dr. Aminian. When expressed as ADA goals, 82% of participants had blood pressure less than 140/90 mm Hg 7 years after surgery relative to 44% at baseline (P less than .001). The proportion with LDL less 100 mg/dL approached, but did not reach clinical significance (61% vs. 70%; P=0.06).

“When you consider all three parameters [ADA targets for glycemic control, blood pressure control, and lipid control], only 3% of patients met all three targets at baseline but 32% [P< less than .001] were at these targets at long-term followup,” Dr. Aminian reported.

Dr. Aminian reported having no relevant financial relationships.

As the invited discussant on these data, Raul Rosenthal, MD, Director, Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida, reiterated that time with diabetes prior to bariatric surgery may be an important predictor of postsurgical control of metabolic parameters.

“I published a paper about 10 years ago on outcomes in patients with diabetes, and in our experience 5 years was the limit. If you have a history of 5 years or less with diabetes, the chance of going into remission were 80%, and if it was more than 5 years, the likelihood dropped dramatically,” Dr. Rosenthal noted. He indicated duration of diabetes deserves further evaluation for its potential relevance to the optimal timing of bariatric surgery.
 

 

NATIONAL HARBOR, MD – Forty-four percent of insulin-dependent patients with type 2 diabetes mellitus (DM2) were at their glycemic target without insulin a median of seven years after surgery. The data from the largest study to evaluate long-term outcomes in this population were presented at Obesity Week 2017.

“These data confirm that the impressive metabolic effects of bariatric surgery in patients with type 2 diabetes are sustained beyond five years,” reported Ali Aminian, MD, a surgeon who specializes in bariatric procedures at the Cleveland Clinic, Cleveland, Ohio. He said that long-term efficacy has not been well characterized previously.

Bariatric surgery patients treated at the Cleveland Clinic were included in this analysis if they had DM2, were taking insulin at the time of their procedure, and had been followed for at least five years. The median follow-up was 7 years with a range out to 12 years. Of the 252 patients included, 194 underwent roux-en-y gastric bypass (RYGB) and 58 underwent sleeve gastrectomy.

Reaching the glycemic target, defined as less than 7% HbA_1c, without insulin was only one of the primary endpoints. The other was diabetes remission, which was defined as H_bA_1c less than 6.5%, fasting blood glucose less than 126 mg/dL, and being off all diabetes medications. This was observed in 15% of the patients after a median of 7 years followup.

Contrasting short-term results, defined as outcomes one to two years after bariatric surgery with the long-term followup, Dr. Aminian was able to show that declines were relatively modest over time. For example, 51% were at the glycemic target off insulin at the short-term mark, which translates into an absolute decline of only 7% relative to the 44% observed at the long-term followup assessment.

Similarly, 70% had achieved the American Diabetes Association (ADA) goal of less than 7% within the first two years of surgery, while 59% remained at this goal at the most recent followup. The proportion taking insulin at the short-term mark was 36% rising only to 40% long-term.

When data were stratified by procedure, results favored RYGB over sleeve gastrectomy. For example, 47% of the RYGB patients versus 33% of the sleeve gastrectomy patients were able to reach the ADA goal without insulin at the end of the study. The proportions in diabetes remission were 17% and 10%, respectively. RYGB was also associated with greater improvement in BMI (median -12 vs. - 8 kg/m2) and reduced late weight gain (median 20% vs. 31%).

However, Dr. Aminian, who did not provide statistical calculations for these differences, cautioned that higher risk patients might have been preferentially selected for sleeve gastrectomy. He noted that difference in median HbA_1c levels was significantly lower in the RYGB group two years after surgery (P less than .001) but the numerical advantage had lost significance at the last followup (P = .32).

In an evaluation of predictors for glycemic control, a shorter duration of diabetes (less than 10 years) and good glycemic control prior to surgery were both predictors of achieving the primary outcomes on the basis of a multivariate analysis, according to Dr. Aminian. Younger age was a marginal predictor, but Dr. Aminian said that neither type of procedure nor presurgical BMI predicted outcomes from the multivariate analysis.

Relative to baseline, there were significant improvements in median LDL (P = .001). In addition, HDL, triglyceride levels, systolic, and diastolic blood pressure measurements were all significantly improved, both short-term and long-term after bariatric surgery (all P values less than .001), according to Dr. Aminian. When expressed as ADA goals, 82% of participants had blood pressure less than 140/90 mm Hg 7 years after surgery relative to 44% at baseline (P less than .001). The proportion with LDL less 100 mg/dL approached, but did not reach clinical significance (61% vs. 70%; P=0.06).

“When you consider all three parameters [ADA targets for glycemic control, blood pressure control, and lipid control], only 3% of patients met all three targets at baseline but 32% [P< less than .001] were at these targets at long-term followup,” Dr. Aminian reported.

Dr. Aminian reported having no relevant financial relationships.

As the invited discussant on these data, Raul Rosenthal, MD, Director, Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida, reiterated that time with diabetes prior to bariatric surgery may be an important predictor of postsurgical control of metabolic parameters.

“I published a paper about 10 years ago on outcomes in patients with diabetes, and in our experience 5 years was the limit. If you have a history of 5 years or less with diabetes, the chance of going into remission were 80%, and if it was more than 5 years, the likelihood dropped dramatically,” Dr. Rosenthal noted. He indicated duration of diabetes deserves further evaluation for its potential relevance to the optimal timing of bariatric surgery.
 

 

NATIONAL HARBOR, MD – Forty-four percent of insulin-dependent patients with type 2 diabetes mellitus (DM2) were at their glycemic target without insulin a median of seven years after surgery. The data from the largest study to evaluate long-term outcomes in this population were presented at Obesity Week 2017.

“These data confirm that the impressive metabolic effects of bariatric surgery in patients with type 2 diabetes are sustained beyond five years,” reported Ali Aminian, MD, a surgeon who specializes in bariatric procedures at the Cleveland Clinic, Cleveland, Ohio. He said that long-term efficacy has not been well characterized previously.

Bariatric surgery patients treated at the Cleveland Clinic were included in this analysis if they had DM2, were taking insulin at the time of their procedure, and had been followed for at least five years. The median follow-up was 7 years with a range out to 12 years. Of the 252 patients included, 194 underwent roux-en-y gastric bypass (RYGB) and 58 underwent sleeve gastrectomy.

Reaching the glycemic target, defined as less than 7% HbA_1c, without insulin was only one of the primary endpoints. The other was diabetes remission, which was defined as H_bA_1c less than 6.5%, fasting blood glucose less than 126 mg/dL, and being off all diabetes medications. This was observed in 15% of the patients after a median of 7 years followup.

Contrasting short-term results, defined as outcomes one to two years after bariatric surgery with the long-term followup, Dr. Aminian was able to show that declines were relatively modest over time. For example, 51% were at the glycemic target off insulin at the short-term mark, which translates into an absolute decline of only 7% relative to the 44% observed at the long-term followup assessment.

Similarly, 70% had achieved the American Diabetes Association (ADA) goal of less than 7% within the first two years of surgery, while 59% remained at this goal at the most recent followup. The proportion taking insulin at the short-term mark was 36% rising only to 40% long-term.

When data were stratified by procedure, results favored RYGB over sleeve gastrectomy. For example, 47% of the RYGB patients versus 33% of the sleeve gastrectomy patients were able to reach the ADA goal without insulin at the end of the study. The proportions in diabetes remission were 17% and 10%, respectively. RYGB was also associated with greater improvement in BMI (median -12 vs. - 8 kg/m2) and reduced late weight gain (median 20% vs. 31%).

However, Dr. Aminian, who did not provide statistical calculations for these differences, cautioned that higher risk patients might have been preferentially selected for sleeve gastrectomy. He noted that difference in median HbA_1c levels was significantly lower in the RYGB group two years after surgery (P less than .001) but the numerical advantage had lost significance at the last followup (P = .32).

In an evaluation of predictors for glycemic control, a shorter duration of diabetes (less than 10 years) and good glycemic control prior to surgery were both predictors of achieving the primary outcomes on the basis of a multivariate analysis, according to Dr. Aminian. Younger age was a marginal predictor, but Dr. Aminian said that neither type of procedure nor presurgical BMI predicted outcomes from the multivariate analysis.

Relative to baseline, there were significant improvements in median LDL (P = .001). In addition, HDL, triglyceride levels, systolic, and diastolic blood pressure measurements were all significantly improved, both short-term and long-term after bariatric surgery (all P values less than .001), according to Dr. Aminian. When expressed as ADA goals, 82% of participants had blood pressure less than 140/90 mm Hg 7 years after surgery relative to 44% at baseline (P less than .001). The proportion with LDL less 100 mg/dL approached, but did not reach clinical significance (61% vs. 70%; P=0.06).

“When you consider all three parameters [ADA targets for glycemic control, blood pressure control, and lipid control], only 3% of patients met all three targets at baseline but 32% [P< less than .001] were at these targets at long-term followup,” Dr. Aminian reported.

Dr. Aminian reported having no relevant financial relationships.

As the invited discussant on these data, Raul Rosenthal, MD, Director, Bariatric and Metabolic Institute, Cleveland Clinic Florida, Weston, Florida, reiterated that time with diabetes prior to bariatric surgery may be an important predictor of postsurgical control of metabolic parameters.

“I published a paper about 10 years ago on outcomes in patients with diabetes, and in our experience 5 years was the limit. If you have a history of 5 years or less with diabetes, the chance of going into remission were 80%, and if it was more than 5 years, the likelihood dropped dramatically,” Dr. Rosenthal noted. He indicated duration of diabetes deserves further evaluation for its potential relevance to the optimal timing of bariatric surgery.