ASMBS 2021 Annual Meeting Invited Papers

Long-Term Outcomes of Duodenal Switch (DS) Versus Single Anastomosis Duodeno-Ileostomy with Sleeve Gastrectomy (SADI-S): A Matched Cohort Study

Amit Surve South Salt Lake City UT1, Daniel Cottam Salt Lake City UT2, LeGrand Belnap Salt Lake City UT1, Christina Richards Salt Lake City UT1, Walter Medlin Salt Lake City UT1 

Bariatric Medicine Institute1 Bariatric Medical Institute2 

Background: There are no comparative studies on the long-term outcomes after the traditional duodenal switch (DS) and single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S).

Aim: Compare the long-term outcomes (> five years). 

Setting: Single private institute, USA.

Methods: Data from 815 patients who underwent primary traditional DS or SADI-S were used for a retrospective matched cohort. Data were obtained by matching every DS patient to a SADI-S patient of the same age, sex, and BMI. Besides, only patients that were out five years, and had at least one >five-year follow-up were included. 

Results: The matched cohort included 30 DS and 30 SADI-S patients. At five years, a 100% follow-up was available in each group. The SADI-S patients had significantly lower blood loss, shorter length of stay and operative time. The short-term complication rates were statistically similar; however, the long-term complication rates were significantly fewer with SADI-S. The long-term Clavien-Dindo grade IIIb complications were significantly fewer with SADI-S. Weight loss was significantly better with the DS at six years. However, there was no statistically significant difference in the ending BMIs. The median highest %EWL trend, nadir BMI trend, and the last available follow-up %EWL trend with both procedures were similar. The long-term resolution rates of OSA, T2D, GERD, and HTN, and nutritional outcomes were statistically similar. The long-term failure rates were comparable.

Conclusions: The SADI-S procedure offers comparable comorbidity resolution rates and nutritional outcomes; however, the DS seems to offer somewhat better weight loss at the cost of patient complications. 

Factors affecting relapse of type 2 diabetes after bariatric surgery in Sweden 2007– 2015: A registry-based cohort study.

Anders Jans Örebro 1, Ingmar Näslund Orebro 2, Johan Ottosson Lindesberg 2, Eva Szabo Örebro 2, Erik Näslund Stockholn 3, Erik Stenberg Örebro 2 Faculty of Medicine and Health, Örebro University, Örebro1 Örebro University2 Karolinska Institutet3 

Background: Although a large proportion of patients with T2D experience initial remission some patients later suffer from relapse. 

Objectives: To identify possible risk factors for T2D recurrence in patients who initially experienced remission. 

Setting: Nationwide, registry-based 

Methods: We conducted a nationwide registry-based retrospective cohort study including all adult patients with T2D and BMI ≥35 kg/m2 who received primary bariatric surgery with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in Sweden between 2007 and 2015. Patients who achieved complete diabetes remission 2 years after surgery was identified and analyzed. Main outcome was postoperative relapse of T2D, defined as reintroduction of diabetes medication. 

Results: Complete T2D remission was achieved in 2090 patients 2 years after surgery. Mean age was 46.6 ± 10.10 years, mean BMI was 42.7 ± 5.83 kg/m2, proportion of women was 64.6% and mean HbA1c was 54.8 ± 16.0 mmol/mol at the time of surgery. This group was studied with a median follow-up time of 5.9 years after surgery with a cumulative T2D relapse incidence 20.1%. Duration of diabetes (hazard ratio [HR] 1.09 95%CI 1.05-1.14,p<0.001), preoperative HbA1c level (HR 1.01 95%CI 1.00- 1.02,p=0.013), and preoperative insulin treatment (HR 2.67, 95%CI 1.84- 3.90,p<0.001) were associated with higher rates for relapse, while postoperative weight-loss (HR 0.93, 95%CI 0.91-0.96, p<0.001), and male sex (HR 0.65, 95%CI 0.46-0.91,p=0.012) were associated with lower rates. 

Conclusions: Longer duration of T2D, higher preoperative HbA1c level, less postoperative weight- loss, female sex and insulin treatment prior to surgery are risk factors for T2D relapse after initial remission. 

Bariatric Surgery Targeting Opioid Prescribing (BSTOP); Interim Analysis of the 3rd MBSAQIP National Quality Improvement Project

Anthony Petrick Danville PA1, April Smith Omaha NE2, Jon Gould Milwaukee WI3, Dominick Gadaleta Great Neck NY4, Teresa Fraker Chicago IL5, Kimberly Evans- Labok Chicago IL5, Leandra Knapp Naperville IL5, John Morton New Haven CT6, Stacy Brethauer Cleveland OH7 

Geisinger Medical Center1 Creighton University2 Medical College ofWisconsin3 North Shore University Hospital4 American College of Surgeons5 Yale University Health System6 Ohio State University Medical Center7 

Background: Opioids caused 70% of the 71,000 drug-overdose deaths in the US in 2019, a problem magnified by the COVID pandemic. About 6% of opioid-naïve general surgery patients and 14% of bariatric patients become chronic opioid users after surgery. The purpose of this MBSAQIP quality improvement project was to provide centers with a toolkit to reduce opioid use after bariatric surgery. 

Methods: The project proposal was approved in May 2019 by ACS. All accredited MBSAQIP centers were invited to participate. The timeline included 3 phases for data collection in 17 custom fields; Baseline, Pilot, and Implementation scheduled to close March 2021. Implementation phase data has been audited through September 2020. 

Results: Initially, 324 centers agreed to participate; 310 centers are actively collecting data totaling 37,891 cases. Preoperative opioid use was reported in 7.14%(n=2708) which disqualified patients from analysis. 80% of centers completed >75% of data fields. 8/9 binary measures improved from the baseline audit. Compared to baseline, morphine milliequivalent use (MME) decreased for all phases of care: inpatient 68.2 to 44.2 MME, prescribed at discharge 129.5 to 111.9 MME, used post- discharge 60.3 to 49.3 MME. 1194 patients returned unused opioids for safe disposal (7.3%). 

Conclusions: Despite COVID, participation rates in BSTOP have remained high with significant improvements in 8/9 binary fields including increased non-opioid analgesic and TAP block use. Decreases were observed in opioid prescribing as well as MME use in all phases of care. Excessive discharge opioid prescribing remains a key target for improvement prior to project conclusion. 

Is there a Role for Bariatric Surgery in Patients with severe obesity in Type 1 Diabetes Mellitus?

Brian Dessify Danville PA1, Gabriel Mekel Danville PA1, Craig Wood Danville PA1, Robin Tanner Danville PA1, Dylan Carmichael Danville PA1, Christopher 

Still Danville PA1, Jon Gabrielsen Danville PA1, David Parker Danville PA1, Anthony Petrick Danville PA1, Mustapha Daouadi Dnville PA1Geisinger Medical Center1 

Background: The prevalence of obesity in type I diabetes mellitus has been increasing over the past decades. Multiple studies have demonstrated suboptimal outcomes with dietary control and medical management for obesity and diabetes mellitus type I. This study's objective was to evaluate insulin and diabetic medication requirements in patients with type I diabetes mellitus two years after bariatric surgery. 

Methods: This was a retrospective chart review study from 2002-2019 at Geisinger health system. Of 4549 total bariatric surgeries, 38 bariatric surgery patients were confirmed to have type I diabetes mellitus. Type I diabetes mellitus was confirmed by chart review and/or presence of c-peptide <5 ng/mL. 

Results: The patient cohort had a mean age of 41 years, with 87% being female. The mean BMI was 43.0, with a mean HbA1c of 8.4% before surgery. During follow-up the insulin requirements improved from 114 units preoperatively to 60 units at 1 year postoperatively (SD= 54.5, p= 0.0018) and 60 units at 2-years postoperatively (SD= 60.3, p= 0.0033). Though not significant, the number of patients on more than one diabetic medication decreased from 66% preoperatively to 53% 1-year postoperatively (p=0.343) and 52% at 2-years (p=0.149). 

Discussion: This study demonstrated significant improvement in the insulin and the total number of diabetic medication requirements after bariatric surgery, suggesting that bariatric surgery may be a viable treatment within patients that have type I diabetes mellitus. 

Are insurance mandates requiring medically refractory hypertension despite concurrent use of more than one anti-hypertensive agents for patients with a BMI between 35 and 39.9 kg/m2 medically justified for eligibility for bariatric surgery? 

Yannis Raftopoulos Holyoke MA Holyoke Medical Center 

Introduction: Several insurance policies require the presence of hypertension, defined as blood pressure > 140 mmHg systolic (SBP), or 90 mmHg diastolic (DBP), despite concurrent use of >1 anti-hypertensive agents for patients with a BMI <40 kg/m2 to qualify for bariatric surgery (BS). No peer reviewed literature to support or refute such requirements exists. 

Methods: A total of 461 patients who underwent BS were included. Systolic (SBP) and diastolic (DBP) blood pressure BP (in mmHg) was assessed by an automated manometer at each office visit until 3 years postoperatively and recorded in a prospectively maintained database. 

Results: Thirty-three (7.15%) patients with BMI <40 Kg/m2, treated by 1, 2 or three anti- hypertensive medications and BP below 140/90, would have been denied BS under such policies. Number of anti-hypertensive medications had no impact on SBP/DBP control preoperatively. Patients being treated preoperatively with < 3 anti- hypertensive medications had a significantly higher % hypertension resolution at 1 (one-med: 66.2%, two-med: 50.9% vs. three-med: 12.5%, p<.0001), 2 (one-med: 63.9%, two-med: 52.8% vs. three-med: 15.4%, p=.0068) and 3 (one-med: 76.9%, two-med: 52.9% vs. three-med: 20%, p=.005) years postoperatively. Multivariate regression demonstrated a significant linear correlation between the number of preoperative anti-hypertensive medications and 1-year postoperative SBP, adjusting for BMI and age (p<.0001). 

Conclusions: The earlier BS intervention takes place, related to the preoperative severity of hypertension, the more likely it will resolve postoperatively. Restricting access to BS because a patient has hypertension on <3 anti-hypertensive medications is not supported by our data and is harmful. 

An Analysis of Readmission Trends by Urgency and Race/Ethnicity in the MBSAQIP Registry, 2015-2018

Sean O'Neill Columbus OH1, Bradley Needleman Columbus OH1, vimalnarula Columbus OH1, Stacy Brethauer Cleveland OH1, Sabrena Noria Columbus OH1 Ohio State University Wexner Medical Center1 

INTRODUCTION: Readmission after bariatric surgery is a quality improvement target, but no MBSAQIP analyses have studied the significance of readmission urgency, particularly for low- risk patients. Therefore, we identified straightforward patients and ascertained readmission trends by degree of urgency, over time and by race/ethnicity. 

METHODS: Patients with only typical weight-related comorbidities (e.g., hypertension, obstructive sleep apnea, diabetes, gastroesophageal reflux) who underwent primary sleeve gastrectomy (SG) or Roux-en-Y-gastric-bypass (RYGB) between 2015-2018, with an uneventful postoperative course, were identified. Readmissions were classified as “Urgent” (e.g., leak, obstruction, bleeding) or “Nonurgent” (e.g., dehydration, nonspecific abdominal pain). Chi-squared or T-test analyses were used for bivariate significance testing. Multivariate logistic regression models were constructed to assess independent predictors of readmission. 

RESULTS: Our sample(N=404,377) of straightforward cases comprised 53% of the MBSAQIP registry(Female:81%; SG:75%; Non-Hispanic-White:62%, Black/African- American:17%, Hispanic: 14%). Overall readmission rate was 2.85%(n=11,512) and decreased from 2015-2018(3.20% to 2.68%;p<0.0001). Nonurgent readmission rate was 1.30%(n=5,253) and decreased from 2015-2018(1.44% to 1.17%,p<0.0001). Black(OR 1.47,p<0.0001) and Hispanic(OR 1.15,p<0.0001) race/ethnicity were independent predictors of readmission. Readmissions overall became progressively less likely in 2016(OR 0.93,p=0.006), 2017(OR 0.87, p<0.0001), and 2018(OR 0.86, p<0.0001). Black (OR 1.80,P<0.0001) and Hispanic(OR 1.18,p<0.0001) race/ethnicity predicted non-urgent readmission. Non-urgent readmissions became less likely in 2017(OR 0.87,p<0.0001) and 2018(OR 0.83,p<0.0001), but urgent readmissions did not trend similarly. 

CONCLUSIONS: Readmission rates for straightforward primary bariatric patients from 2015 to 2018 reveal an improvement in readmission rates, but racial disparities persist. Improvements appear to be driven by reductions in non-urgent readmissions. 

Bariatric Surgery decreases the number of future hospital admissions for Diastolic Heart Failure in severely-obese subjects. Retrospective analysis of the US National Inpatient Sample (NIS) database 

David Romero Funes Weston FL1, Cristina Botero Fonnegra Weston FL1, David Gutierrez Blanco Weston FL1, Liang Hong weston FL1, Emanuele Lo Menzo Weston FL1, Samuel Szomstein North Miami Beach FL1, Raul Rosenthal Weston FL2 Cleveland Clinic Florida1 Cleveland Clinic of FL2 

BACKGROUND: The effectiveness of bariatric surgery on reducing the prevalence and severity of obesity-related comorbidities has been well established. Diastolic heart failure (DHF) is an increasingly common condition associated with considerable morbidity and mortality, yet recalcitrant to treatment. Our objectives were to assess whether bariatric surgery (BaS) is associated with a decreased incidence of DHF, and further assess its impact upon DHF-incidence among patients with hypertension (HTN) and coronary artery disease (CAD). 

METHODS: The US National Inpatient Sample (NIS) database was queried for obesity, BaS, DHF, HTN, CAD for the years 2010—2015. Univariate and multivariable analysis were performed to assess the impact of BaS on the incidence of hospital admissions for DHF, adjusting for demographics, comorbidities, and other risk factors associated with cardiovascular disease (CVD). 

RESULTS: A total of 296,041 BaS-cases and 2,004,804 obese control-cases wereidentified. Relative to controls, all baseline CVD risk factors were less common among BaS-cases. Nonetheless, even after adjusting for all CVD risk factors, controls exhibited marked increases in the odds of DHF overall (OR=2.80; 95% CI=2.52— 3.10), and strongly-significant increases of 180%(OR=2.80; 95% CI: 2.52—3.10), 422%(OR=5.22; CI: 4.41—6.17), and 167%(OR=2.67; 95% CI: 1.88—3.80) amongst patients with and without HTN and patients with CAD, respectively. 

CONCLUSIONS: In this retrospective, case-control study of a large, representative national sample of severely-obese patients, BaS was found to be associated with significantly-reduced subsequent hospitalizations for DHF when adjusted for baseline CVD risk factors. It also reduced DHF incidence in high-risk patients with HTN and CAD. 

Effect of Pre-Operative HbA1c on Bariatric Surgery Outcomes 

Eileen Bui Loma Linda CA1, Gener J Aviles-Rodriguez Ensenada 2, AndrewAjoku Loma Linda CA1, Ebtesam Attia Redland CA1, Ruth Ramon Hacienda Heights CA1, Tori Severs Loma Linda CA1, Temitope Idowu Colton CA1, Juan Quispe Espíritu Loma Linda CA1, Panicha Kittipha Loma Linda CA1, Aarthy Kannappan Loma Linda CA1, Marcos Michelotti Loma Linda CA1, Jeffrey Quigley Loma Linda CA1, Daniel Srikureja Loma Linda CA1, Esther Wu Loma Linda CA1, Keith Scharf Loma Linda CA1Loma Linda University Health1 Universidad Autónoma de Baja California2 

INTRODUCTION: Obesity is a strong independent risk factor for numerous comorbidities including diabetes type II. Elevated hemoglobin A1c is a predictor in postoperative outcomes. We sought to investigate the impact of preoperative levels of HbA1c on the efficacy and outcomes of bariatric surgery. 

METHODS: A retrospective study was conducted in our hospital from 2012 to 2019, identifying patients that underwent a sleeve gastrectomy or Roux-en-Y bypass, and then separated into controlled (HbA1c ≤6), elevated (HbA1c <6 to ≤ 8.5) and super- elevated (HbA1c >8.5) groups. Analysis using R was performed to find significant differences up to 1 year post-op. 

RESULTS: 557 patients were identified: 348 in the controlled group (mean HbA1c 5.5), 175 in the elevated group (HbA1c 6.7), and 34 in the super-elevated group (HbA1c 9.2). By 1 year, all groups achieved a mean HbA1c of <7. The controlled group achieved more significant improvements in blood pressure and triglyceride levels, while the super-elevated group showed less significant improvements in HDL. 30-day complication rates were similar amongst all groups, including readmission, reoperation, and surgical site infection. Only the elevated group demonstrated higher rates of urinary retention (p<0.05). Length of stay was significantly different (p<0.001) but clinically similar (2 vs. 2.5 vs 2.4 days). 

CONCLUSION: Patients with higher pre-operative HbA1c levels experience a similar benefit from bariatric surgery without higher complication rates as those with controlled levels. 

Effect of Bariatric Surgery on Ischemic Stroke Risk 

Michael Williams Chicago IL1, Marc Sarran Chicago IL1, Seungjun Kim Chicago IL1, Syed Khalid 1, Adan Becerra Chicago IL1, Alfonso Torquati Chicago IL1, Philip Omotosho Chicago IL1 Rush1 

INTRODUCTION: Bariatric surgery has demonstrated improvements in cardiovascular health. The effect on ischemic stroke risk remains unclear. The goal of this study was to compare the risk of stroke among bariatric surgery patients versus controls. 

METHODS: Using Mariner, a national all-payer claims database, we identified patients with BMI > 40, or BMI > 35 with qualifying comorbidities who underwent sleeve gastrectomy or gastric bypass from 2010 to 2019. Similar patients who did not have bariatric surgery were used as controls. Coarsened exact matching in 1:1 fashion was performed, with logistic regression analysis to determine the effect of bariatric surgery on stroke risk at 1, 3, and 5 years. 

RESULTS: 96094 surgery patients and 1533725 controls were identified. Before matching, the stroke risk for surgery vs control was 0.05% vs 0.26% at 1 year, 0.13% vs 0.43% at 3 years, and 0.21% vs 0.59% at 5 years (p<0.01). After matching, the 1- year stroke risk among 95565 surgery patients and 95565 controls was 0.05% vs 0.15% (OR 0.36, 95% CI 0.26-0.49). The 3-year stroke risk after surgery (n=81050) vs controls (n=81050) was 0.12% vs 0.28% (OR 0.44, 95% CI 0.35-0.55). The 5-year stroke risk of surgery (n=58241) vs controls (n=58241) controls was 0.21% vs 0.41% (OR 0.51, 95% CI 0.41-0.64). 

CONCLUSION: Bariatric surgery is associated with decreased stroke risk at 1,3, and 5 years, with the greatest effect seen in the 1st year. To our knowledge, this is the largest sample size in a study of ischemic cerebrovascular disease in bariatric surgery. 

Effect of bariatric surgery on major cardiovascular events: a population level studyPhilippe Bouchard Montreal, Quebec 1, Safiya Masrouri 1, Sebastian Demyttenaere Westmount 1, Olivier Court Montreal 1, Amin Andalib Montreal 1 McGill University1 

Background: Obesity and metabolic syndrome are associated with an increased rate in major adverse cardiovascular events (MACE). Bariatric surgery is the most effective treatment for obesity and related conditions including metabolic syndrome.

Methods: In a population-based cohort study, we compared all morbidly obese patients with metabolic syndrome (diabetes and/or hypertension) who underwent bariatric surgery in Quebec, Canada during 2007 and 2012 with obese controls matched on age, sex, geography and comorbidity burden (Charlson comorbidity index). The incidence of MACE (myocardial infarct, stroke, all-cause mortality) and all-cause mortality at 5 years were compared between both groups. Cox proportional hazard regression was also used to compare the effect of surgery and other variables with respect to outcomes.

Results: 3,627 surgical patients met inclusion criteria and were matched to 5,420 obese controls. Baseline demographics were comparable between groups, but diabetes was more prevalent among the surgery group. There was a significant difference in MACE at 5 years between the surgical group and obese controls (17% vs 22% respectively; p<0.01). A significant difference in all-cause mortality was also present between both groups (2.2% vs 3.9% respectively; p<0.01). Bariatric surgery was independently associated with decreased all-cause mortality (HR 0.78 [0.68-0.89]) after adjusting for age, sex and comorbidities.

Conclusion: Bariatric surgery is associated with a decrease in MACE and all-cause mortality in obese patients with metabolic syndrome long term after surgery.