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Endoscopic weight loss surgery cuts costs, side effects
Obese patients who underwent endoscopic sleeve gastroplasty had significantly fewer complications and shorter hospital stays than did those who had laparoscopic sleeve gastrectomy or laparoscopic band placement, according to results from a study of 278 adults. The data were presented at the annual Digestive Disease Week®.
Overall, 1% of patients who underwent endoscopic sleeve gastroplasty (ESG) experienced adverse events, compared with 8% of those who underwent laparoscopic sleeve gastrectomy (LSG) and 9% of those who underwent laparoscopic band placement (LAGB).
ESG, which reduces gastric volume by use of an endoscopic suturing system of full-thickness sutures through the greater curvature of the stomach, is becoming a popular weight-loss procedure for patients with a body mass index greater than 30 kg/m2 who are poor candidates for laparoscopic surgery or who would prefer a less invasive procedure, according to Reem Z. Sharaiha, MD, of Cornell University, New York.
Dr. Sharaiha and her colleagues randomized 91 patients to ESG, 120 to LSG, and 67 to LAGB. Patient demographic characteristics, including age, gender, and diabetes, were similar among the three groups. However, patients in the LSG group had a higher average BMI than did the LAGB and ESG groups (47.3 kg/m2, 45.7 kg/m2, and 38.8 kg/m2, respectively). In addition, the incidence of hypertension, and hyperlipidemia was significantly higher in each of the surgical groups compared to the ESG group (P less than .01).
The average postprocedure hospital stay was 0.13 days for ESG patients compared with 3.09 days for LSG patients and 1.68 days for LAGB patients. ESG also had the lowest cost of the three procedures, averaging $12,000 for the procedure compared to $22,000 for LSG and $15,000 for LAGB.
After 1 year, patients in the LSG group had the greatest percentage of total body weight loss (29.3%), followed by ESG patients (17.6%), and LAGB patients (14.5%). Rates of leaks, pulmonary embolism events, and 90-day readmission were not significantly different among the groups.
The study results do not imply that ESG will replace either LAGB or LSG for weight loss, Dr. Sharaiha noted, but the results suggest that ESG is a viable option for some patients.
Dr. Sharaiha had no relevant financial conflicts to disclose.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
Obese patients who underwent endoscopic sleeve gastroplasty had significantly fewer complications and shorter hospital stays than did those who had laparoscopic sleeve gastrectomy or laparoscopic band placement, according to results from a study of 278 adults. The data were presented at the annual Digestive Disease Week®.
Overall, 1% of patients who underwent endoscopic sleeve gastroplasty (ESG) experienced adverse events, compared with 8% of those who underwent laparoscopic sleeve gastrectomy (LSG) and 9% of those who underwent laparoscopic band placement (LAGB).
ESG, which reduces gastric volume by use of an endoscopic suturing system of full-thickness sutures through the greater curvature of the stomach, is becoming a popular weight-loss procedure for patients with a body mass index greater than 30 kg/m2 who are poor candidates for laparoscopic surgery or who would prefer a less invasive procedure, according to Reem Z. Sharaiha, MD, of Cornell University, New York.
Dr. Sharaiha and her colleagues randomized 91 patients to ESG, 120 to LSG, and 67 to LAGB. Patient demographic characteristics, including age, gender, and diabetes, were similar among the three groups. However, patients in the LSG group had a higher average BMI than did the LAGB and ESG groups (47.3 kg/m2, 45.7 kg/m2, and 38.8 kg/m2, respectively). In addition, the incidence of hypertension, and hyperlipidemia was significantly higher in each of the surgical groups compared to the ESG group (P less than .01).
The average postprocedure hospital stay was 0.13 days for ESG patients compared with 3.09 days for LSG patients and 1.68 days for LAGB patients. ESG also had the lowest cost of the three procedures, averaging $12,000 for the procedure compared to $22,000 for LSG and $15,000 for LAGB.
After 1 year, patients in the LSG group had the greatest percentage of total body weight loss (29.3%), followed by ESG patients (17.6%), and LAGB patients (14.5%). Rates of leaks, pulmonary embolism events, and 90-day readmission were not significantly different among the groups.
The study results do not imply that ESG will replace either LAGB or LSG for weight loss, Dr. Sharaiha noted, but the results suggest that ESG is a viable option for some patients.
Dr. Sharaiha had no relevant financial conflicts to disclose.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
Obese patients who underwent endoscopic sleeve gastroplasty had significantly fewer complications and shorter hospital stays than did those who had laparoscopic sleeve gastrectomy or laparoscopic band placement, according to results from a study of 278 adults. The data were presented at the annual Digestive Disease Week®.
Overall, 1% of patients who underwent endoscopic sleeve gastroplasty (ESG) experienced adverse events, compared with 8% of those who underwent laparoscopic sleeve gastrectomy (LSG) and 9% of those who underwent laparoscopic band placement (LAGB).
ESG, which reduces gastric volume by use of an endoscopic suturing system of full-thickness sutures through the greater curvature of the stomach, is becoming a popular weight-loss procedure for patients with a body mass index greater than 30 kg/m2 who are poor candidates for laparoscopic surgery or who would prefer a less invasive procedure, according to Reem Z. Sharaiha, MD, of Cornell University, New York.
Dr. Sharaiha and her colleagues randomized 91 patients to ESG, 120 to LSG, and 67 to LAGB. Patient demographic characteristics, including age, gender, and diabetes, were similar among the three groups. However, patients in the LSG group had a higher average BMI than did the LAGB and ESG groups (47.3 kg/m2, 45.7 kg/m2, and 38.8 kg/m2, respectively). In addition, the incidence of hypertension, and hyperlipidemia was significantly higher in each of the surgical groups compared to the ESG group (P less than .01).
The average postprocedure hospital stay was 0.13 days for ESG patients compared with 3.09 days for LSG patients and 1.68 days for LAGB patients. ESG also had the lowest cost of the three procedures, averaging $12,000 for the procedure compared to $22,000 for LSG and $15,000 for LAGB.
After 1 year, patients in the LSG group had the greatest percentage of total body weight loss (29.3%), followed by ESG patients (17.6%), and LAGB patients (14.5%). Rates of leaks, pulmonary embolism events, and 90-day readmission were not significantly different among the groups.
The study results do not imply that ESG will replace either LAGB or LSG for weight loss, Dr. Sharaiha noted, but the results suggest that ESG is a viable option for some patients.
Dr. Sharaiha had no relevant financial conflicts to disclose.
Digestive Disease Week® is jointly sponsored by the American Association for the Study of Liver Diseases (AASLD), the American Gastroenterological Association (AGA) Institute, the American Society for Gastrointestinal Endoscopy (ASGE), and the Society for Surgery of the Alimentary Tract (SSAT).
FROM DDW
Key clinical point: Endoscopic sleeve gastroplasty is a viable option for patients seeking weight loss but wishing to avoid major surgery.
Major finding: After 1 year, 1% of patients who underwent endoscopic sleeve gastroplasty experienced adverse events, compared with 8% of laparoscopic sleeve gastrectomy patients, and 9% of laparoscopic band placement patients.
Data source: A randomized trial of 278 obese adults who underwent one of three weight loss procedures.
Disclosures: Dr. Sharaiha had no relevant financial conflicts to disclose.
Series supports viability of ambulatory laparoscopic sleeve gastrectomy
HOUSTON – An ambulatory approach to laparoscopic sleeve gastrectomy is a safe and viable option to improve patient satisfaction and soften the economic blow of these procedures on patients, based on a large series at one surgery center in Cincinnati.
“With proper patient selection, utilization of enhanced recovery pathways with an overall low readmission rate and the complication profile point to the feasibility of laparoscopic sleeve gastrectomy [LSG] as a safe outpatient procedure,” said Sepehr Lalezari, MD, now a surgical fellow at Johns Hopkins University, Baltimore.
About 105,000 LSG operations were performed in the United States in 2015, representing 54% of all bariatric operations, according to the American Society for Metabolic and Bariatric Surgery.
Patient selection and strict adherence to protocols are keys to success for ambulatory LSG, Dr. Lalezari said. Suitable patients were found to be ambulatory, between ages 18 and 65 years; had a body mass index (BMI) less than 55 kg/m2 for males and less than 60 kg/m2 for females; weighed less than 500 lb; had an American Society of Anesthesiologists’ classification score less than 4; and had no significant cardiopulmonary impairment, had no history of renal failure or organ transplant, and were not on a transplant wait list.
In this series, 71% of patients (579) were female, and the average BMI was 43. The total complication rate was 2.3% (19); 17 of these patients required hospital admission.
Postoperative complications included gastric leaks (seven, 0.9%); intra-abdominal abscess requiring percutaneous drainage (four, 0.5%); dehydration, nausea, and/or vomiting (four, 0.5%); and one of each of the following: acute cholecystitis, postoperative bleeding, surgical site infection (SSI), and portal vein thrombosis/pulmonary embolism.
The two complications managed on an outpatient basis were the SSI and one intra-abdominal abscess, Dr. Lalezari said.
“The only readmissions in our series that could have been possibly prevented with an overnight stay in the hospital were the four cases of nausea, vomiting, and/or dehydration,” he said. “These only accounted for 0.5% of the total cases performed.”
The readmission rates for ambulatory LSG in this series compared favorably with large trials that did not distinguish between ambulatory and inpatient LSG procedures, Dr. Lalezari noted. A 2016 analysis of 35,655 patients in the American College of Surgeons National Surgical Quality Improvement Program database reported a readmission rate of 3.7% for LSG (Surg Endosc. 2016 Jun;30[6]:2342-50).
A larger study of 130,000 patients who had bariatric surgery reported an LSG readmission rate of 2.8% (Ann Surg. 2016 Nov 15. doi: 10.1097/SLA.0000000000002079). The most common cause for readmissions these trials reported were nausea, vomiting, and/or dehydration.
Bariatric surgeons have embraced enhanced recovery pathways and fast-track surgery, with good results, Dr. Lalezari said, citing work by Zhamak Khorgami, MD, and colleagues at the Cleveland Clinic (Surg Obes Relat Dis. 2017 Feb;13[2]:273-80).
“Looking at fast-track surgery, they found that patients discharged on postoperative day 1 vs. day 2 or 3 did not change outcomes”; those discharged later than postoperative day 1 trended toward a higher readmission rate of 2.8% vs. 3.6%, Dr. Lalezari said.
The enhanced recovery/fast track protocol Dr. Lalezari and his coauthors used involves placing intravenous lines and infusing 1 L crystalloid before starting the procedure, and administration of famotidine and metoclopramide prior to anesthesia. The protocol utilizes sequential compression devices and avoids Foley catheters and intra-abdominal drains. Patients receive dexamethasone and ondansetron during the operation. The protocol emphasizes early ambulation and resumption of oral intake.
The operation uses a 36-French bougie starting about 5 cm from the pylorus, and all staple lines are reinforced with buttress material. At the end of the surgery, all incisions are infiltrated with 30 cc of 0.5% bupivacaine with epinephrine.
Patients are ambulating about 90 minutes after surgery and are monitored for 3-4 hours. They receive a total volume of 3-4 L crystalloids. When they’re tolerating clear liquids, voiding spontaneously, and walking independently, and their pain is well controlled (pain score less than 5/10) and vital signs are within normal limits, they’re discharged.
Postoperative follow-up involves a call at 48 hours and in-clinic follow-up at weeks 1 and 4. Additional follow-up is scheduled at 3-month intervals for 1 year, then at 6 months for up to 2 years, and then yearly afterward.
“With proper patient selection and utilization of enhanced recovery pathways, the low overall readmission rate (2.1%) and complication profile (2.3%) in our series point to the feasibility of laparoscopic sleeve gastrectomy as a safe outpatient procedure,” Dr. Lalezari said.
He reported having no relevant financial disclosures.
HOUSTON – An ambulatory approach to laparoscopic sleeve gastrectomy is a safe and viable option to improve patient satisfaction and soften the economic blow of these procedures on patients, based on a large series at one surgery center in Cincinnati.
“With proper patient selection, utilization of enhanced recovery pathways with an overall low readmission rate and the complication profile point to the feasibility of laparoscopic sleeve gastrectomy [LSG] as a safe outpatient procedure,” said Sepehr Lalezari, MD, now a surgical fellow at Johns Hopkins University, Baltimore.
About 105,000 LSG operations were performed in the United States in 2015, representing 54% of all bariatric operations, according to the American Society for Metabolic and Bariatric Surgery.
Patient selection and strict adherence to protocols are keys to success for ambulatory LSG, Dr. Lalezari said. Suitable patients were found to be ambulatory, between ages 18 and 65 years; had a body mass index (BMI) less than 55 kg/m2 for males and less than 60 kg/m2 for females; weighed less than 500 lb; had an American Society of Anesthesiologists’ classification score less than 4; and had no significant cardiopulmonary impairment, had no history of renal failure or organ transplant, and were not on a transplant wait list.
In this series, 71% of patients (579) were female, and the average BMI was 43. The total complication rate was 2.3% (19); 17 of these patients required hospital admission.
Postoperative complications included gastric leaks (seven, 0.9%); intra-abdominal abscess requiring percutaneous drainage (four, 0.5%); dehydration, nausea, and/or vomiting (four, 0.5%); and one of each of the following: acute cholecystitis, postoperative bleeding, surgical site infection (SSI), and portal vein thrombosis/pulmonary embolism.
The two complications managed on an outpatient basis were the SSI and one intra-abdominal abscess, Dr. Lalezari said.
“The only readmissions in our series that could have been possibly prevented with an overnight stay in the hospital were the four cases of nausea, vomiting, and/or dehydration,” he said. “These only accounted for 0.5% of the total cases performed.”
The readmission rates for ambulatory LSG in this series compared favorably with large trials that did not distinguish between ambulatory and inpatient LSG procedures, Dr. Lalezari noted. A 2016 analysis of 35,655 patients in the American College of Surgeons National Surgical Quality Improvement Program database reported a readmission rate of 3.7% for LSG (Surg Endosc. 2016 Jun;30[6]:2342-50).
A larger study of 130,000 patients who had bariatric surgery reported an LSG readmission rate of 2.8% (Ann Surg. 2016 Nov 15. doi: 10.1097/SLA.0000000000002079). The most common cause for readmissions these trials reported were nausea, vomiting, and/or dehydration.
Bariatric surgeons have embraced enhanced recovery pathways and fast-track surgery, with good results, Dr. Lalezari said, citing work by Zhamak Khorgami, MD, and colleagues at the Cleveland Clinic (Surg Obes Relat Dis. 2017 Feb;13[2]:273-80).
“Looking at fast-track surgery, they found that patients discharged on postoperative day 1 vs. day 2 or 3 did not change outcomes”; those discharged later than postoperative day 1 trended toward a higher readmission rate of 2.8% vs. 3.6%, Dr. Lalezari said.
The enhanced recovery/fast track protocol Dr. Lalezari and his coauthors used involves placing intravenous lines and infusing 1 L crystalloid before starting the procedure, and administration of famotidine and metoclopramide prior to anesthesia. The protocol utilizes sequential compression devices and avoids Foley catheters and intra-abdominal drains. Patients receive dexamethasone and ondansetron during the operation. The protocol emphasizes early ambulation and resumption of oral intake.
The operation uses a 36-French bougie starting about 5 cm from the pylorus, and all staple lines are reinforced with buttress material. At the end of the surgery, all incisions are infiltrated with 30 cc of 0.5% bupivacaine with epinephrine.
Patients are ambulating about 90 minutes after surgery and are monitored for 3-4 hours. They receive a total volume of 3-4 L crystalloids. When they’re tolerating clear liquids, voiding spontaneously, and walking independently, and their pain is well controlled (pain score less than 5/10) and vital signs are within normal limits, they’re discharged.
Postoperative follow-up involves a call at 48 hours and in-clinic follow-up at weeks 1 and 4. Additional follow-up is scheduled at 3-month intervals for 1 year, then at 6 months for up to 2 years, and then yearly afterward.
“With proper patient selection and utilization of enhanced recovery pathways, the low overall readmission rate (2.1%) and complication profile (2.3%) in our series point to the feasibility of laparoscopic sleeve gastrectomy as a safe outpatient procedure,” Dr. Lalezari said.
He reported having no relevant financial disclosures.
HOUSTON – An ambulatory approach to laparoscopic sleeve gastrectomy is a safe and viable option to improve patient satisfaction and soften the economic blow of these procedures on patients, based on a large series at one surgery center in Cincinnati.
“With proper patient selection, utilization of enhanced recovery pathways with an overall low readmission rate and the complication profile point to the feasibility of laparoscopic sleeve gastrectomy [LSG] as a safe outpatient procedure,” said Sepehr Lalezari, MD, now a surgical fellow at Johns Hopkins University, Baltimore.
About 105,000 LSG operations were performed in the United States in 2015, representing 54% of all bariatric operations, according to the American Society for Metabolic and Bariatric Surgery.
Patient selection and strict adherence to protocols are keys to success for ambulatory LSG, Dr. Lalezari said. Suitable patients were found to be ambulatory, between ages 18 and 65 years; had a body mass index (BMI) less than 55 kg/m2 for males and less than 60 kg/m2 for females; weighed less than 500 lb; had an American Society of Anesthesiologists’ classification score less than 4; and had no significant cardiopulmonary impairment, had no history of renal failure or organ transplant, and were not on a transplant wait list.
In this series, 71% of patients (579) were female, and the average BMI was 43. The total complication rate was 2.3% (19); 17 of these patients required hospital admission.
Postoperative complications included gastric leaks (seven, 0.9%); intra-abdominal abscess requiring percutaneous drainage (four, 0.5%); dehydration, nausea, and/or vomiting (four, 0.5%); and one of each of the following: acute cholecystitis, postoperative bleeding, surgical site infection (SSI), and portal vein thrombosis/pulmonary embolism.
The two complications managed on an outpatient basis were the SSI and one intra-abdominal abscess, Dr. Lalezari said.
“The only readmissions in our series that could have been possibly prevented with an overnight stay in the hospital were the four cases of nausea, vomiting, and/or dehydration,” he said. “These only accounted for 0.5% of the total cases performed.”
The readmission rates for ambulatory LSG in this series compared favorably with large trials that did not distinguish between ambulatory and inpatient LSG procedures, Dr. Lalezari noted. A 2016 analysis of 35,655 patients in the American College of Surgeons National Surgical Quality Improvement Program database reported a readmission rate of 3.7% for LSG (Surg Endosc. 2016 Jun;30[6]:2342-50).
A larger study of 130,000 patients who had bariatric surgery reported an LSG readmission rate of 2.8% (Ann Surg. 2016 Nov 15. doi: 10.1097/SLA.0000000000002079). The most common cause for readmissions these trials reported were nausea, vomiting, and/or dehydration.
Bariatric surgeons have embraced enhanced recovery pathways and fast-track surgery, with good results, Dr. Lalezari said, citing work by Zhamak Khorgami, MD, and colleagues at the Cleveland Clinic (Surg Obes Relat Dis. 2017 Feb;13[2]:273-80).
“Looking at fast-track surgery, they found that patients discharged on postoperative day 1 vs. day 2 or 3 did not change outcomes”; those discharged later than postoperative day 1 trended toward a higher readmission rate of 2.8% vs. 3.6%, Dr. Lalezari said.
The enhanced recovery/fast track protocol Dr. Lalezari and his coauthors used involves placing intravenous lines and infusing 1 L crystalloid before starting the procedure, and administration of famotidine and metoclopramide prior to anesthesia. The protocol utilizes sequential compression devices and avoids Foley catheters and intra-abdominal drains. Patients receive dexamethasone and ondansetron during the operation. The protocol emphasizes early ambulation and resumption of oral intake.
The operation uses a 36-French bougie starting about 5 cm from the pylorus, and all staple lines are reinforced with buttress material. At the end of the surgery, all incisions are infiltrated with 30 cc of 0.5% bupivacaine with epinephrine.
Patients are ambulating about 90 minutes after surgery and are monitored for 3-4 hours. They receive a total volume of 3-4 L crystalloids. When they’re tolerating clear liquids, voiding spontaneously, and walking independently, and their pain is well controlled (pain score less than 5/10) and vital signs are within normal limits, they’re discharged.
Postoperative follow-up involves a call at 48 hours and in-clinic follow-up at weeks 1 and 4. Additional follow-up is scheduled at 3-month intervals for 1 year, then at 6 months for up to 2 years, and then yearly afterward.
“With proper patient selection and utilization of enhanced recovery pathways, the low overall readmission rate (2.1%) and complication profile (2.3%) in our series point to the feasibility of laparoscopic sleeve gastrectomy as a safe outpatient procedure,” Dr. Lalezari said.
He reported having no relevant financial disclosures.
AT SAGES 2017
Key clinical point: Laparoscopic sleeve gastrectomy is a safe outpatient procedure – with strict adherence to enhanced recovery pathways and fast-track protocols.
Major finding: This series reported an overall readmission rate of 2.1% and a complication rate of 2.3% in patients who had outpatient LSG.
Data source: A retrospective review of 821 patients who had ambulatory LSG by a single surgeon from 2011 to 2015.
Disclosures: Dr. Lalezari reported having no relevant financial disclosures.
Study underscores antipsoriatic effect of gastric bypass surgery
Gastric bypass surgery was associated with more than a 50% drop in baseline rates of psoriasis, and with about a 70% decrease in the incidence of psoriatic arthritis, investigators reported.
In contrast, gastric banding did not appear to affect baselines rates of either of these autoimmune conditions, Alexander Egeberg, MD, of Herlev and Gentofte Hospital, Hellerup, Denmark, and associates reported in JAMA Surgery. “Although speculative, these findings may be the result of post-operative differences in weight loss and nutrient uptake, as well as differences in the postsurgical secretion of a number of gut hormones, including [glucagon-like peptide-1],” they wrote.
Psoriasis strongly correlates with obesity, and weight loss appears to mitigate psoriatic symptoms, the investigators noted. Previously, small studies and case series indicated that bariatric surgery might induce remission of psoriasis. To further investigate this possibility, Dr. Egeberg and his associates conducted a longitudinal cohort study of all 12,364 patients who underwent gastric bypass surgery and all 1,071 patients who underwent gastric banding in Denmark between 1997 and 2012 (JAMA Surg. 2017;152:344-349). No patient had psoriasis symptoms at the start of the study. A total of 272 (2%) gastric bypass patients developed psoriasis before their surgery, while only 0.5% did so afterward. In contrast, gastric banding was not tied to a significant change in the incidence of psoriasis – the preoperative rate was 0.5%, and the postoperative rate was 0.4%. Similarly, respective rates of psoriatic arthritis were 0.5% and 0.1% before and after gastric bypass, but were 0.3% and 0.6% before and after gastric banding. Additionally, respective rates of severe psoriasis were 0.8% and 0% before and after gastric bypass, but were about 0.2% and 0.5% before and after gastric banding.
After adjusting for age, sex, alcohol abuse, socioeconomic status, smoking, and diabetes status, gastric bypass was associated with about a 48% drop in the incidence of any type of psoriasis (P = .004), with about a 56% drop in the rate of severe psoriasis (P = .02), and with about a 71% drop in the rate of psoriatic arthritis (P = .01). In contrast, neither crude nor adjusted models linked gastric banding to a decrease in the incidence of psoriasis, severe psoriasis, or psoriatic arthritis, the researchers said.
Gastric banding is “a purely restrictive procedure,” while gastric bypass – especially Roux-en-Y bypass – diverts nutrients to the distal small intestine, where enteroendocrine cells secrete GLP-1, the researchers wrote.
“These postoperative hormonal changes may, in addition to the weight loss, be important for the antipsoriatic effect of gastric bypass,” they added. “Both gastric bypass and gastric banding have been shown to lead to sustained weight loss, suggesting that the observed differences in our study might be caused by factors other than weight loss.”
An unrestricted research grant from the Novo Nordisk Foundation funded the work. Dr. Egeberg disclosed ties to Pfizer and Eli Lilly. One coinvestigator disclosed ties to these and several other pharmaceutical companies.
Gastric bypass surgery was associated with more than a 50% drop in baseline rates of psoriasis, and with about a 70% decrease in the incidence of psoriatic arthritis, investigators reported.
In contrast, gastric banding did not appear to affect baselines rates of either of these autoimmune conditions, Alexander Egeberg, MD, of Herlev and Gentofte Hospital, Hellerup, Denmark, and associates reported in JAMA Surgery. “Although speculative, these findings may be the result of post-operative differences in weight loss and nutrient uptake, as well as differences in the postsurgical secretion of a number of gut hormones, including [glucagon-like peptide-1],” they wrote.
Psoriasis strongly correlates with obesity, and weight loss appears to mitigate psoriatic symptoms, the investigators noted. Previously, small studies and case series indicated that bariatric surgery might induce remission of psoriasis. To further investigate this possibility, Dr. Egeberg and his associates conducted a longitudinal cohort study of all 12,364 patients who underwent gastric bypass surgery and all 1,071 patients who underwent gastric banding in Denmark between 1997 and 2012 (JAMA Surg. 2017;152:344-349). No patient had psoriasis symptoms at the start of the study. A total of 272 (2%) gastric bypass patients developed psoriasis before their surgery, while only 0.5% did so afterward. In contrast, gastric banding was not tied to a significant change in the incidence of psoriasis – the preoperative rate was 0.5%, and the postoperative rate was 0.4%. Similarly, respective rates of psoriatic arthritis were 0.5% and 0.1% before and after gastric bypass, but were 0.3% and 0.6% before and after gastric banding. Additionally, respective rates of severe psoriasis were 0.8% and 0% before and after gastric bypass, but were about 0.2% and 0.5% before and after gastric banding.
After adjusting for age, sex, alcohol abuse, socioeconomic status, smoking, and diabetes status, gastric bypass was associated with about a 48% drop in the incidence of any type of psoriasis (P = .004), with about a 56% drop in the rate of severe psoriasis (P = .02), and with about a 71% drop in the rate of psoriatic arthritis (P = .01). In contrast, neither crude nor adjusted models linked gastric banding to a decrease in the incidence of psoriasis, severe psoriasis, or psoriatic arthritis, the researchers said.
Gastric banding is “a purely restrictive procedure,” while gastric bypass – especially Roux-en-Y bypass – diverts nutrients to the distal small intestine, where enteroendocrine cells secrete GLP-1, the researchers wrote.
“These postoperative hormonal changes may, in addition to the weight loss, be important for the antipsoriatic effect of gastric bypass,” they added. “Both gastric bypass and gastric banding have been shown to lead to sustained weight loss, suggesting that the observed differences in our study might be caused by factors other than weight loss.”
An unrestricted research grant from the Novo Nordisk Foundation funded the work. Dr. Egeberg disclosed ties to Pfizer and Eli Lilly. One coinvestigator disclosed ties to these and several other pharmaceutical companies.
Gastric bypass surgery was associated with more than a 50% drop in baseline rates of psoriasis, and with about a 70% decrease in the incidence of psoriatic arthritis, investigators reported.
In contrast, gastric banding did not appear to affect baselines rates of either of these autoimmune conditions, Alexander Egeberg, MD, of Herlev and Gentofte Hospital, Hellerup, Denmark, and associates reported in JAMA Surgery. “Although speculative, these findings may be the result of post-operative differences in weight loss and nutrient uptake, as well as differences in the postsurgical secretion of a number of gut hormones, including [glucagon-like peptide-1],” they wrote.
Psoriasis strongly correlates with obesity, and weight loss appears to mitigate psoriatic symptoms, the investigators noted. Previously, small studies and case series indicated that bariatric surgery might induce remission of psoriasis. To further investigate this possibility, Dr. Egeberg and his associates conducted a longitudinal cohort study of all 12,364 patients who underwent gastric bypass surgery and all 1,071 patients who underwent gastric banding in Denmark between 1997 and 2012 (JAMA Surg. 2017;152:344-349). No patient had psoriasis symptoms at the start of the study. A total of 272 (2%) gastric bypass patients developed psoriasis before their surgery, while only 0.5% did so afterward. In contrast, gastric banding was not tied to a significant change in the incidence of psoriasis – the preoperative rate was 0.5%, and the postoperative rate was 0.4%. Similarly, respective rates of psoriatic arthritis were 0.5% and 0.1% before and after gastric bypass, but were 0.3% and 0.6% before and after gastric banding. Additionally, respective rates of severe psoriasis were 0.8% and 0% before and after gastric bypass, but were about 0.2% and 0.5% before and after gastric banding.
After adjusting for age, sex, alcohol abuse, socioeconomic status, smoking, and diabetes status, gastric bypass was associated with about a 48% drop in the incidence of any type of psoriasis (P = .004), with about a 56% drop in the rate of severe psoriasis (P = .02), and with about a 71% drop in the rate of psoriatic arthritis (P = .01). In contrast, neither crude nor adjusted models linked gastric banding to a decrease in the incidence of psoriasis, severe psoriasis, or psoriatic arthritis, the researchers said.
Gastric banding is “a purely restrictive procedure,” while gastric bypass – especially Roux-en-Y bypass – diverts nutrients to the distal small intestine, where enteroendocrine cells secrete GLP-1, the researchers wrote.
“These postoperative hormonal changes may, in addition to the weight loss, be important for the antipsoriatic effect of gastric bypass,” they added. “Both gastric bypass and gastric banding have been shown to lead to sustained weight loss, suggesting that the observed differences in our study might be caused by factors other than weight loss.”
An unrestricted research grant from the Novo Nordisk Foundation funded the work. Dr. Egeberg disclosed ties to Pfizer and Eli Lilly. One coinvestigator disclosed ties to these and several other pharmaceutical companies.
Key clinical point: Gastric bypass, but not gastric banding, was associated with significant drops in rates of psoriasis and psoriatic arthritis.
Major finding: In an adjusted model, gastric bypass was associated with about a 48% drop in the incidence of any type of psoriasis, with a 56% drop in the rate of severe psoriasis, and with a 71% drop in the rate of psoriatic arthritis.
Data source: A population-based cohort study of 12,364 gastric bypass patients and 1,071 gastric banding patients.
Disclosures: An unrestricted research grant from the Novo Nordisk Foundation funded the work. Dr. Egeberg disclosed ties to Pfizer and Eli Lilly. One coinvestigator disclosed ties to these and several other pharmaceutical companies. The other coinvestigators reported having no ties to industry.
Liver disease likely to become increasing indication for bariatric surgery
PHILADELPHIA – There is a long list of benefits from bariatric surgery in the morbidly obese, but prevention of end-stage liver disease and the need for a first or second liver transplant is likely to grow as an indication, according to an overview of weight loss surgery at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.
“Bariatric surgery is associated with significant improvement not just in diabetes, dyslipidemia, hypertension, and other complications of metabolic disorders but for me more interestingly, it is effective for treating fatty liver disease where you can see a 90% improvement in steatosis,” reported Subhashini Ayloo, MD, chief of minimally invasive robotic hepato-pancreato-biliary surgery and liver transplantation at New Jersey Medical School, Newark.
Trained in both bariatric surgery and liver transplant, Dr. Ayloo predicts that these fields will become increasingly connected because of the obesity epidemic and the related rise in nonalcoholic fatty liver disease (NAFLD). Dr. Ayloo reported that bariatric surgery is already being used in her center to avoid a second liver transplant in obese patients who are unable to lose sufficient weight to prevent progressive NAFLD after a first transplant.
The emphasis Dr. Ayloo placed on the role of bariatric surgery in preventing progression of NAFLD to nonalcoholic steatohepatitis and the inflammatory process that leads to fibrosis, cirrhosis, and liver decompensation, was drawn from her interest in these two fields. However, she did not ignore the potential of protection from obesity control for other diseases.
“Obesity adversely affects every organ in the body,” Dr. Ayloo pointed out. As a result of weight loss achieved with bariatric surgery, there is now a large body of evidence supporting broad benefits, not just those related to fat deposited in hepatocytes.
“We have a couple of decades of experience that has been published [with bariatric surgery], and this has shown that it maintains weight loss long term, it improves all the obesity-associated comorbidities, and it is cost effective,” Dr. Ayloo said. Now with long-term follow-up, “all of the studies are showing that bariatric surgery improves survival.”
Although most of the survival data have been generated by retrospective cohort studies, Dr. Ayloo cited nine sets of data showing odds ratios associating bariatric surgery with up to a 90% reduction in death over periods of up to 10 years of follow-up. In a summary slide presented by Dr. Ayloo, the estimated mortality benefit over 5 years was listed as 85%. The same summary slide listed large improvements in relevant measures of morbidity for more than 10 organ systems, such as improvement or resolution of dyslipidemia and hypertension in the circulatory system, improvement or resolution of asthma and other diseases affecting the respiratory system, and resolution or improvement of gastroesophageal reflux disease and other diseases affecting the gastrointestinal system.
Specific to the liver, these benefits included a nearly 40% reduction in liver inflammation and 20% reduction in fibrosis. According to Dr. Ayloo, who noted that NAFLD is expected to overtake hepatitis C virus as the No. 1 cause of liver transplant within the next 5 years, these data are important for drawing attention to bariatric surgery as a strategy to control liver disease. She suggested that there is a need to create a tighter link between efforts to treat morbid obesity and advanced liver disease.
“There is an established literature showing that if somebody is morbidly obese, the rate of liver transplant is lower than when compared to patients with normal weight,” Dr. Ayloo said. “There is a call out in the transplant community that we need to address this and we cannot just be throwing this under the table.”
Because of the strong relationship between obesity and NAFLD, a systematic approach is needed to consider liver disease in obese patients and obesity in patients with liver disease, she said. The close relationship is relevant when planning interventions for either. Liver disease should be assessed prior to bariatric surgery regardless of the indication and then monitored closely as part of postoperative care, she said.
Dr. Ayloo identified weight control as an essential part of posttransplant care to prevent hepatic fat deposition that threatens transplant-free survival.
Global Academy and this news organization are owned by the same company. Dr. Ayloo reports no relevant financial relationships.
PHILADELPHIA – There is a long list of benefits from bariatric surgery in the morbidly obese, but prevention of end-stage liver disease and the need for a first or second liver transplant is likely to grow as an indication, according to an overview of weight loss surgery at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.
“Bariatric surgery is associated with significant improvement not just in diabetes, dyslipidemia, hypertension, and other complications of metabolic disorders but for me more interestingly, it is effective for treating fatty liver disease where you can see a 90% improvement in steatosis,” reported Subhashini Ayloo, MD, chief of minimally invasive robotic hepato-pancreato-biliary surgery and liver transplantation at New Jersey Medical School, Newark.
Trained in both bariatric surgery and liver transplant, Dr. Ayloo predicts that these fields will become increasingly connected because of the obesity epidemic and the related rise in nonalcoholic fatty liver disease (NAFLD). Dr. Ayloo reported that bariatric surgery is already being used in her center to avoid a second liver transplant in obese patients who are unable to lose sufficient weight to prevent progressive NAFLD after a first transplant.
The emphasis Dr. Ayloo placed on the role of bariatric surgery in preventing progression of NAFLD to nonalcoholic steatohepatitis and the inflammatory process that leads to fibrosis, cirrhosis, and liver decompensation, was drawn from her interest in these two fields. However, she did not ignore the potential of protection from obesity control for other diseases.
“Obesity adversely affects every organ in the body,” Dr. Ayloo pointed out. As a result of weight loss achieved with bariatric surgery, there is now a large body of evidence supporting broad benefits, not just those related to fat deposited in hepatocytes.
“We have a couple of decades of experience that has been published [with bariatric surgery], and this has shown that it maintains weight loss long term, it improves all the obesity-associated comorbidities, and it is cost effective,” Dr. Ayloo said. Now with long-term follow-up, “all of the studies are showing that bariatric surgery improves survival.”
Although most of the survival data have been generated by retrospective cohort studies, Dr. Ayloo cited nine sets of data showing odds ratios associating bariatric surgery with up to a 90% reduction in death over periods of up to 10 years of follow-up. In a summary slide presented by Dr. Ayloo, the estimated mortality benefit over 5 years was listed as 85%. The same summary slide listed large improvements in relevant measures of morbidity for more than 10 organ systems, such as improvement or resolution of dyslipidemia and hypertension in the circulatory system, improvement or resolution of asthma and other diseases affecting the respiratory system, and resolution or improvement of gastroesophageal reflux disease and other diseases affecting the gastrointestinal system.
Specific to the liver, these benefits included a nearly 40% reduction in liver inflammation and 20% reduction in fibrosis. According to Dr. Ayloo, who noted that NAFLD is expected to overtake hepatitis C virus as the No. 1 cause of liver transplant within the next 5 years, these data are important for drawing attention to bariatric surgery as a strategy to control liver disease. She suggested that there is a need to create a tighter link between efforts to treat morbid obesity and advanced liver disease.
“There is an established literature showing that if somebody is morbidly obese, the rate of liver transplant is lower than when compared to patients with normal weight,” Dr. Ayloo said. “There is a call out in the transplant community that we need to address this and we cannot just be throwing this under the table.”
Because of the strong relationship between obesity and NAFLD, a systematic approach is needed to consider liver disease in obese patients and obesity in patients with liver disease, she said. The close relationship is relevant when planning interventions for either. Liver disease should be assessed prior to bariatric surgery regardless of the indication and then monitored closely as part of postoperative care, she said.
Dr. Ayloo identified weight control as an essential part of posttransplant care to prevent hepatic fat deposition that threatens transplant-free survival.
Global Academy and this news organization are owned by the same company. Dr. Ayloo reports no relevant financial relationships.
PHILADELPHIA – There is a long list of benefits from bariatric surgery in the morbidly obese, but prevention of end-stage liver disease and the need for a first or second liver transplant is likely to grow as an indication, according to an overview of weight loss surgery at Digestive Diseases: New Advances, held by Rutgers, the State University of New Jersey, and Global Academy for Medical Education.
“Bariatric surgery is associated with significant improvement not just in diabetes, dyslipidemia, hypertension, and other complications of metabolic disorders but for me more interestingly, it is effective for treating fatty liver disease where you can see a 90% improvement in steatosis,” reported Subhashini Ayloo, MD, chief of minimally invasive robotic hepato-pancreato-biliary surgery and liver transplantation at New Jersey Medical School, Newark.
Trained in both bariatric surgery and liver transplant, Dr. Ayloo predicts that these fields will become increasingly connected because of the obesity epidemic and the related rise in nonalcoholic fatty liver disease (NAFLD). Dr. Ayloo reported that bariatric surgery is already being used in her center to avoid a second liver transplant in obese patients who are unable to lose sufficient weight to prevent progressive NAFLD after a first transplant.
The emphasis Dr. Ayloo placed on the role of bariatric surgery in preventing progression of NAFLD to nonalcoholic steatohepatitis and the inflammatory process that leads to fibrosis, cirrhosis, and liver decompensation, was drawn from her interest in these two fields. However, she did not ignore the potential of protection from obesity control for other diseases.
“Obesity adversely affects every organ in the body,” Dr. Ayloo pointed out. As a result of weight loss achieved with bariatric surgery, there is now a large body of evidence supporting broad benefits, not just those related to fat deposited in hepatocytes.
“We have a couple of decades of experience that has been published [with bariatric surgery], and this has shown that it maintains weight loss long term, it improves all the obesity-associated comorbidities, and it is cost effective,” Dr. Ayloo said. Now with long-term follow-up, “all of the studies are showing that bariatric surgery improves survival.”
Although most of the survival data have been generated by retrospective cohort studies, Dr. Ayloo cited nine sets of data showing odds ratios associating bariatric surgery with up to a 90% reduction in death over periods of up to 10 years of follow-up. In a summary slide presented by Dr. Ayloo, the estimated mortality benefit over 5 years was listed as 85%. The same summary slide listed large improvements in relevant measures of morbidity for more than 10 organ systems, such as improvement or resolution of dyslipidemia and hypertension in the circulatory system, improvement or resolution of asthma and other diseases affecting the respiratory system, and resolution or improvement of gastroesophageal reflux disease and other diseases affecting the gastrointestinal system.
Specific to the liver, these benefits included a nearly 40% reduction in liver inflammation and 20% reduction in fibrosis. According to Dr. Ayloo, who noted that NAFLD is expected to overtake hepatitis C virus as the No. 1 cause of liver transplant within the next 5 years, these data are important for drawing attention to bariatric surgery as a strategy to control liver disease. She suggested that there is a need to create a tighter link between efforts to treat morbid obesity and advanced liver disease.
“There is an established literature showing that if somebody is morbidly obese, the rate of liver transplant is lower than when compared to patients with normal weight,” Dr. Ayloo said. “There is a call out in the transplant community that we need to address this and we cannot just be throwing this under the table.”
Because of the strong relationship between obesity and NAFLD, a systematic approach is needed to consider liver disease in obese patients and obesity in patients with liver disease, she said. The close relationship is relevant when planning interventions for either. Liver disease should be assessed prior to bariatric surgery regardless of the indication and then monitored closely as part of postoperative care, she said.
Dr. Ayloo identified weight control as an essential part of posttransplant care to prevent hepatic fat deposition that threatens transplant-free survival.
Global Academy and this news organization are owned by the same company. Dr. Ayloo reports no relevant financial relationships.
Open-capsule PPIs linked to faster ulcer healing after Roux-en-Y
The use of proton pump inhibitors in opened instead of closed capsules was associated with a nearly fourfold shorter median healing time among patients who developed marginal ulcers after Roux-en-Y gastric bypass, in a single-center retrospective cohort study.
In contrast, the specific class of proton pump inhibitor (PPI) did not affect healing times, wrote Allison R. Schulman, MD, and her associates at Brigham and Women’s Hospital, Boston. The report is in the April issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2016.10.015). “Given these results and the high prevalence of marginal ulceration in this patient population, further study in a randomized controlled setting is warranted, and use of open-capsule PPIs should be considered as a low-risk, low-cost alternative,” they added.
Roux-en-Y gastric bypass is one of the most common types of gastric bypass surgeries in the world, and up to 16% of patients develop postsurgical ulcers at the gastrojejunal anastomosis, the investigators noted. Acidity is a prime suspect in these “marginal ulcerations” because bypassing the acid-buffering duodenum exposes the jejunum to acid from the stomach, they added. High-dose PPIs are the main treatment, but there is no consensus on the formulation or dose of therapy. Because Roux-en-Y creates a small gastric pouch and hastens small-bowel transit, closed capsules designed to break down in the stomach “even may make their way to the colon before breakdown occurs,” they wrote.
They reviewed medical charts from patients who developed marginal ulcerations after undergoing Roux-en-Y gastric bypass at their hospital from 2000 through 2015. A total of 115 patients received open-capsule PPIs and 49 received intact capsules. All were followed until their ulcers healed.
For the open-capsule group, median time to healing was 91 days, compared with 342 days for the closed-capsule group (P less than .001). Importantly, capsule type was the only independent predictor of healing time (hazard ratio, 6.0; 95% confidence interval, 3.7 to 9.8; P less than .001) in a Cox regression model that included other known correlates of ulcer healing, including age, smoking status, the use of nonsteroidal anti-inflammatory drugs, Helicobacter pylori infection, the length of the gastric pouch, and the presence of fistulae or foreign bodies such as sutures or staples.
The use of sucralfate also did not affect time to ulcer healing, reflecting “many previous studies showing a lack of definitive benefit to this medication,” the researchers said. The findings have “tremendous implications” for health care utilization, they added. Indeed, patients who received open-capsule PPIs needed significantly fewer endoscopic procedures (median, 1.2 versus 1.8; P = .02) and used fewer health care resources overall ($7,206 versus $11,009; P = .05) compared with those prescribed intact PPI capsules.
This study was limited to patients who developed ulcer symptoms and underwent repeated surveillance endoscopies after surgery, the researchers noted. Selection bias is always a concern with retrospective studies, but insurers always covered both types of therapy and the choice of capsule type was entirely up to providers, all of whom consistently prescribed either open- or closed-capsule PPI therapy, they added.
The investigators did not acknowledge external funding sources. Dr. Schulman and four coinvestigators reported having no competing interests. One coinvestigator disclosed ties to Olympus, Boston Scientific, and Covidien.
Proton pump inhibitors (PPIs) are frequently employed to treat marginal ulcers after Roux-en-Y gastric bypass (RYGB). In a retrospective study, Schulman et al. compared intact vs. “open” PPI capsules. 
They state that “this may be overcome by use of a soluble form of PPI,” but don’t state what is meant by “soluble PPI” or how the open-capsule PPI was delivered. Among the PPIs they reported using to compare intact vs. open capsules was Protonix [pantoprazole] which is not produced as a capsule, and soluble Prevacid [lansoprazole], which is an orally disintegrating tablet that should provide characteristics similar to an “open capsule.”
PPI capsules provide PPI in enteric-coated granules, which are designed to protect the PPI from acid degradation in the stomach of individuals with intact gastrointestinal tracts and allow more of the PPI dose to reach the small intestine where it is absorbed. If capsules really fail to release their enteric-coated granules until very distally in RYGB patients, bypassing this step to allow earlier release of PPI makes intuitive sense; formulations such as suspensions and rapidly disintegrating tablets that deliver enteric-coated granules without capsules are currently available.
However, if this is an issue, administering a suspension of uncoated PPI with bicarbonate potentially might be the most attractive option, given more rapid absorption than PPI delivered as enteric-coated granules.
Loren Laine, MD, AGAF, professor of medicine, digestive diseases, Yale University, New Haven, Conn. He has no conflicts of interest.
Proton pump inhibitors (PPIs) are frequently employed to treat marginal ulcers after Roux-en-Y gastric bypass (RYGB). In a retrospective study, Schulman et al. compared intact vs. “open” PPI capsules.
They state that “this may be overcome by use of a soluble form of PPI,” but don’t state what is meant by “soluble PPI” or how the open-capsule PPI was delivered. Among the PPIs they reported using to compare intact vs. open capsules was Protonix [pantoprazole] which is not produced as a capsule, and soluble Prevacid [lansoprazole], which is an orally disintegrating tablet that should provide characteristics similar to an “open capsule.”
PPI capsules provide PPI in enteric-coated granules, which are designed to protect the PPI from acid degradation in the stomach of individuals with intact gastrointestinal tracts and allow more of the PPI dose to reach the small intestine where it is absorbed. If capsules really fail to release their enteric-coated granules until very distally in RYGB patients, bypassing this step to allow earlier release of PPI makes intuitive sense; formulations such as suspensions and rapidly disintegrating tablets that deliver enteric-coated granules without capsules are currently available.
However, if this is an issue, administering a suspension of uncoated PPI with bicarbonate potentially might be the most attractive option, given more rapid absorption than PPI delivered as enteric-coated granules.
Loren Laine, MD, AGAF, professor of medicine, digestive diseases, Yale University, New Haven, Conn. He has no conflicts of interest.
Proton pump inhibitors (PPIs) are frequently employed to treat marginal ulcers after Roux-en-Y gastric bypass (RYGB). In a retrospective study, Schulman et al. compared intact vs. “open” PPI capsules.
They state that “this may be overcome by use of a soluble form of PPI,” but don’t state what is meant by “soluble PPI” or how the open-capsule PPI was delivered. Among the PPIs they reported using to compare intact vs. open capsules was Protonix [pantoprazole] which is not produced as a capsule, and soluble Prevacid [lansoprazole], which is an orally disintegrating tablet that should provide characteristics similar to an “open capsule.”
PPI capsules provide PPI in enteric-coated granules, which are designed to protect the PPI from acid degradation in the stomach of individuals with intact gastrointestinal tracts and allow more of the PPI dose to reach the small intestine where it is absorbed. If capsules really fail to release their enteric-coated granules until very distally in RYGB patients, bypassing this step to allow earlier release of PPI makes intuitive sense; formulations such as suspensions and rapidly disintegrating tablets that deliver enteric-coated granules without capsules are currently available.
However, if this is an issue, administering a suspension of uncoated PPI with bicarbonate potentially might be the most attractive option, given more rapid absorption than PPI delivered as enteric-coated granules.
Loren Laine, MD, AGAF, professor of medicine, digestive diseases, Yale University, New Haven, Conn. He has no conflicts of interest.
The use of proton pump inhibitors in opened instead of closed capsules was associated with a nearly fourfold shorter median healing time among patients who developed marginal ulcers after Roux-en-Y gastric bypass, in a single-center retrospective cohort study.
In contrast, the specific class of proton pump inhibitor (PPI) did not affect healing times, wrote Allison R. Schulman, MD, and her associates at Brigham and Women’s Hospital, Boston. The report is in the April issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2016.10.015). “Given these results and the high prevalence of marginal ulceration in this patient population, further study in a randomized controlled setting is warranted, and use of open-capsule PPIs should be considered as a low-risk, low-cost alternative,” they added.
Roux-en-Y gastric bypass is one of the most common types of gastric bypass surgeries in the world, and up to 16% of patients develop postsurgical ulcers at the gastrojejunal anastomosis, the investigators noted. Acidity is a prime suspect in these “marginal ulcerations” because bypassing the acid-buffering duodenum exposes the jejunum to acid from the stomach, they added. High-dose PPIs are the main treatment, but there is no consensus on the formulation or dose of therapy. Because Roux-en-Y creates a small gastric pouch and hastens small-bowel transit, closed capsules designed to break down in the stomach “even may make their way to the colon before breakdown occurs,” they wrote.
They reviewed medical charts from patients who developed marginal ulcerations after undergoing Roux-en-Y gastric bypass at their hospital from 2000 through 2015. A total of 115 patients received open-capsule PPIs and 49 received intact capsules. All were followed until their ulcers healed.
For the open-capsule group, median time to healing was 91 days, compared with 342 days for the closed-capsule group (P less than .001). Importantly, capsule type was the only independent predictor of healing time (hazard ratio, 6.0; 95% confidence interval, 3.7 to 9.8; P less than .001) in a Cox regression model that included other known correlates of ulcer healing, including age, smoking status, the use of nonsteroidal anti-inflammatory drugs, Helicobacter pylori infection, the length of the gastric pouch, and the presence of fistulae or foreign bodies such as sutures or staples.
The use of sucralfate also did not affect time to ulcer healing, reflecting “many previous studies showing a lack of definitive benefit to this medication,” the researchers said. The findings have “tremendous implications” for health care utilization, they added. Indeed, patients who received open-capsule PPIs needed significantly fewer endoscopic procedures (median, 1.2 versus 1.8; P = .02) and used fewer health care resources overall ($7,206 versus $11,009; P = .05) compared with those prescribed intact PPI capsules.
This study was limited to patients who developed ulcer symptoms and underwent repeated surveillance endoscopies after surgery, the researchers noted. Selection bias is always a concern with retrospective studies, but insurers always covered both types of therapy and the choice of capsule type was entirely up to providers, all of whom consistently prescribed either open- or closed-capsule PPI therapy, they added.
The investigators did not acknowledge external funding sources. Dr. Schulman and four coinvestigators reported having no competing interests. One coinvestigator disclosed ties to Olympus, Boston Scientific, and Covidien.
The use of proton pump inhibitors in opened instead of closed capsules was associated with a nearly fourfold shorter median healing time among patients who developed marginal ulcers after Roux-en-Y gastric bypass, in a single-center retrospective cohort study.
In contrast, the specific class of proton pump inhibitor (PPI) did not affect healing times, wrote Allison R. Schulman, MD, and her associates at Brigham and Women’s Hospital, Boston. The report is in the April issue of Clinical Gastroenterology and Hepatology (doi: 10.1016/j.cgh.2016.10.015). “Given these results and the high prevalence of marginal ulceration in this patient population, further study in a randomized controlled setting is warranted, and use of open-capsule PPIs should be considered as a low-risk, low-cost alternative,” they added.
Roux-en-Y gastric bypass is one of the most common types of gastric bypass surgeries in the world, and up to 16% of patients develop postsurgical ulcers at the gastrojejunal anastomosis, the investigators noted. Acidity is a prime suspect in these “marginal ulcerations” because bypassing the acid-buffering duodenum exposes the jejunum to acid from the stomach, they added. High-dose PPIs are the main treatment, but there is no consensus on the formulation or dose of therapy. Because Roux-en-Y creates a small gastric pouch and hastens small-bowel transit, closed capsules designed to break down in the stomach “even may make their way to the colon before breakdown occurs,” they wrote.
They reviewed medical charts from patients who developed marginal ulcerations after undergoing Roux-en-Y gastric bypass at their hospital from 2000 through 2015. A total of 115 patients received open-capsule PPIs and 49 received intact capsules. All were followed until their ulcers healed.
For the open-capsule group, median time to healing was 91 days, compared with 342 days for the closed-capsule group (P less than .001). Importantly, capsule type was the only independent predictor of healing time (hazard ratio, 6.0; 95% confidence interval, 3.7 to 9.8; P less than .001) in a Cox regression model that included other known correlates of ulcer healing, including age, smoking status, the use of nonsteroidal anti-inflammatory drugs, Helicobacter pylori infection, the length of the gastric pouch, and the presence of fistulae or foreign bodies such as sutures or staples.
The use of sucralfate also did not affect time to ulcer healing, reflecting “many previous studies showing a lack of definitive benefit to this medication,” the researchers said. The findings have “tremendous implications” for health care utilization, they added. Indeed, patients who received open-capsule PPIs needed significantly fewer endoscopic procedures (median, 1.2 versus 1.8; P = .02) and used fewer health care resources overall ($7,206 versus $11,009; P = .05) compared with those prescribed intact PPI capsules.
This study was limited to patients who developed ulcer symptoms and underwent repeated surveillance endoscopies after surgery, the researchers noted. Selection bias is always a concern with retrospective studies, but insurers always covered both types of therapy and the choice of capsule type was entirely up to providers, all of whom consistently prescribed either open- or closed-capsule PPI therapy, they added.
The investigators did not acknowledge external funding sources. Dr. Schulman and four coinvestigators reported having no competing interests. One coinvestigator disclosed ties to Olympus, Boston Scientific, and Covidien.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: The use of proton pump inhibitors in opened instead of closed capsules was associated with a nearly fourfold shorter median healing time among patients who developed ulcers at the gastrojejunal anastomosis after Roux-en-Y gastric bypass.
Major finding: The median time to ulcer healing was 91.0 versus 342.0 days for the open- and closed-capsule groups, respectively (P less than .001).
Data source: A single-center retrospective study of 162 patients.
Disclosures: The investigators did not acknowledge external funding sources. Dr. Schulman and four coinvestigators reported having no competing interests. One coinvestigator disclosed ties to Olympus, Boston Scientific, and Covidien.
AGA Clinical Practice Update: Best practice advice on EBT use released
The AGA Institute has released a series of new best practice statements that gastroenterologists should use when considering a patient for endoscopic bariatric treatments or surgeries (EBTs).
“There is a need for less-invasive weight loss therapies that are more effective and durable than lifestyle interventions alone, less invasive and risky than bariatric surgery, and easily performed at a lower expense than that of surgery, thereby allowing improved access and application to a larger segment of the population with moderate obesity,” wrote the authors of the expert review, led by Barham K. Abu Dayyeh, MD of the Mayo Clinic in Rochester, Minn. The report is in the March issue of Gastroenterology (doi: 10.1053/j.gastro.2017.01.035). “[EBTs] potentially meet these criteria and may provide an effective treatment approach to obesity in selected patients.”
The best practice statements come from a review of relevant studies in the Ovid, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus databases, among others, that were published between Jan. 1, 2000, and Sept. 30, 2016.
EBTs should be used on patients who have already been unable to lose weight despite lifestyle interventions and more traditional weight loss methods. However, patients that undergo EBTs should also be placed on a weight loss regimen that includes diet, exercise, and lifestyle changes. 
In addition to being used for weight loss, they can also be used to transition a patient to traditional bariatric surgery, or to lower a patient’s weight so that they can undergo a different procedure unrelated to bariatric surgery. Anyone being considered for EBT, or a weight loss regimen involving EBT, should be thoroughly evaluated for comorbidities, behavior, or medical concerns that could lead to adverse effects.
Any patients who are placed on EBT regimens should be followed up regularly by their clinicians, to monitor their progress in terms of weight loss and the development of any adverse effects. Should any adverse outcomes arise, alternative therapies should be implemented as soon as possible. Clinicians are advised to know the ins and outs of risks, contraindications, and potential complications related to EBTs before ever implementing them in their practice, let alone recommending them to a patient.
Finally, it’s imperative that health care institutions with EBT programs make sure there are training protocols clinicians must stringently follow before being allowed to perform EBT procedures.
“Moving ahead, it will be important to better incorporate training in obesity management principles into the GI fellowship curriculum to have a more significant impact,” the authors wrote, adding that it’s important to study the “tandem and sequential use of a combination of EBTs and obesity pharmacotherapies in addition to a comprehensive life-style intervention program.”
Dr. Abu Dayyeh disclosed relationships with Apollo Endosurgery, Metamodix, Aspire Bariatric, and GI Dynamics. Other coauthors also disclosed potential conflicting interests.
The AGA Institute has released a series of new best practice statements that gastroenterologists should use when considering a patient for endoscopic bariatric treatments or surgeries (EBTs).
“There is a need for less-invasive weight loss therapies that are more effective and durable than lifestyle interventions alone, less invasive and risky than bariatric surgery, and easily performed at a lower expense than that of surgery, thereby allowing improved access and application to a larger segment of the population with moderate obesity,” wrote the authors of the expert review, led by Barham K. Abu Dayyeh, MD of the Mayo Clinic in Rochester, Minn. The report is in the March issue of Gastroenterology (doi: 10.1053/j.gastro.2017.01.035). “[EBTs] potentially meet these criteria and may provide an effective treatment approach to obesity in selected patients.”
The best practice statements come from a review of relevant studies in the Ovid, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus databases, among others, that were published between Jan. 1, 2000, and Sept. 30, 2016.
EBTs should be used on patients who have already been unable to lose weight despite lifestyle interventions and more traditional weight loss methods. However, patients that undergo EBTs should also be placed on a weight loss regimen that includes diet, exercise, and lifestyle changes.
In addition to being used for weight loss, they can also be used to transition a patient to traditional bariatric surgery, or to lower a patient’s weight so that they can undergo a different procedure unrelated to bariatric surgery. Anyone being considered for EBT, or a weight loss regimen involving EBT, should be thoroughly evaluated for comorbidities, behavior, or medical concerns that could lead to adverse effects.
Any patients who are placed on EBT regimens should be followed up regularly by their clinicians, to monitor their progress in terms of weight loss and the development of any adverse effects. Should any adverse outcomes arise, alternative therapies should be implemented as soon as possible. Clinicians are advised to know the ins and outs of risks, contraindications, and potential complications related to EBTs before ever implementing them in their practice, let alone recommending them to a patient.
Finally, it’s imperative that health care institutions with EBT programs make sure there are training protocols clinicians must stringently follow before being allowed to perform EBT procedures.
“Moving ahead, it will be important to better incorporate training in obesity management principles into the GI fellowship curriculum to have a more significant impact,” the authors wrote, adding that it’s important to study the “tandem and sequential use of a combination of EBTs and obesity pharmacotherapies in addition to a comprehensive life-style intervention program.”
Dr. Abu Dayyeh disclosed relationships with Apollo Endosurgery, Metamodix, Aspire Bariatric, and GI Dynamics. Other coauthors also disclosed potential conflicting interests.
The AGA Institute has released a series of new best practice statements that gastroenterologists should use when considering a patient for endoscopic bariatric treatments or surgeries (EBTs).
“There is a need for less-invasive weight loss therapies that are more effective and durable than lifestyle interventions alone, less invasive and risky than bariatric surgery, and easily performed at a lower expense than that of surgery, thereby allowing improved access and application to a larger segment of the population with moderate obesity,” wrote the authors of the expert review, led by Barham K. Abu Dayyeh, MD of the Mayo Clinic in Rochester, Minn. The report is in the March issue of Gastroenterology (doi: 10.1053/j.gastro.2017.01.035). “[EBTs] potentially meet these criteria and may provide an effective treatment approach to obesity in selected patients.”
The best practice statements come from a review of relevant studies in the Ovid, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus databases, among others, that were published between Jan. 1, 2000, and Sept. 30, 2016.
EBTs should be used on patients who have already been unable to lose weight despite lifestyle interventions and more traditional weight loss methods. However, patients that undergo EBTs should also be placed on a weight loss regimen that includes diet, exercise, and lifestyle changes.
In addition to being used for weight loss, they can also be used to transition a patient to traditional bariatric surgery, or to lower a patient’s weight so that they can undergo a different procedure unrelated to bariatric surgery. Anyone being considered for EBT, or a weight loss regimen involving EBT, should be thoroughly evaluated for comorbidities, behavior, or medical concerns that could lead to adverse effects.
Any patients who are placed on EBT regimens should be followed up regularly by their clinicians, to monitor their progress in terms of weight loss and the development of any adverse effects. Should any adverse outcomes arise, alternative therapies should be implemented as soon as possible. Clinicians are advised to know the ins and outs of risks, contraindications, and potential complications related to EBTs before ever implementing them in their practice, let alone recommending them to a patient.
Finally, it’s imperative that health care institutions with EBT programs make sure there are training protocols clinicians must stringently follow before being allowed to perform EBT procedures.
“Moving ahead, it will be important to better incorporate training in obesity management principles into the GI fellowship curriculum to have a more significant impact,” the authors wrote, adding that it’s important to study the “tandem and sequential use of a combination of EBTs and obesity pharmacotherapies in addition to a comprehensive life-style intervention program.”
Dr. Abu Dayyeh disclosed relationships with Apollo Endosurgery, Metamodix, Aspire Bariatric, and GI Dynamics. Other coauthors also disclosed potential conflicting interests.
FROM GASTROENTEROLOGY
FDA confirms complications from intragastric balloons
Complications from overinflation and acute pancreatitis can create problems for obesity patients treated with intragastric balloons, according to a statement from the Food and Drug Administration. In a letter to health care providers published on February 9, 2017, the FDA warned of the two specific issues that have been the subject of multiple adverse event reports.
“We recommend that you closely monitor patients with these devices for these adverse events, and to submit reports to help us better understand any complications from the use of these obesity treatment devices,” the letter said.
Most of the overinflation reports involved the Orbera Intragastric Balloon System (Apollo Endosurgery) that uses a single balloon, although some reports involved the ReShape Integrated Dual Balloon System (ReShape Medical) that uses two balloons. Neither product mentions overinflation risk in its labeling. “At this moment there is not enough information to determine what is causing the balloon to overinflate,” according to the FDA letter.
A separate set of adverse event reports noted the development of acute pancreatitis caused when the balloons compressed other gastrointestinal structures. Both the Orbera and ReShape products were associated with pancreatitis, although neither lists pancreatitis as a potential complication on their labels. Pancreatitis was reported as early as 3 days after implantation, and symptoms included severe back and abdominal pain.
The FDA letter recommends that health care providers consider overinflation and pancreatitis in their differential diagnoses of obesity patients with intragastric balloons who present with the symptoms described, and to report any type of serious adverse events associated with intragastric balloons to the FDA through the MedWatch program. For more information about reporting adverse events to the FDA, visit the MedWatch site.
Complications from overinflation and acute pancreatitis can create problems for obesity patients treated with intragastric balloons, according to a statement from the Food and Drug Administration. In a letter to health care providers published on February 9, 2017, the FDA warned of the two specific issues that have been the subject of multiple adverse event reports.
“We recommend that you closely monitor patients with these devices for these adverse events, and to submit reports to help us better understand any complications from the use of these obesity treatment devices,” the letter said.
Most of the overinflation reports involved the Orbera Intragastric Balloon System (Apollo Endosurgery) that uses a single balloon, although some reports involved the ReShape Integrated Dual Balloon System (ReShape Medical) that uses two balloons. Neither product mentions overinflation risk in its labeling. “At this moment there is not enough information to determine what is causing the balloon to overinflate,” according to the FDA letter.
A separate set of adverse event reports noted the development of acute pancreatitis caused when the balloons compressed other gastrointestinal structures. Both the Orbera and ReShape products were associated with pancreatitis, although neither lists pancreatitis as a potential complication on their labels. Pancreatitis was reported as early as 3 days after implantation, and symptoms included severe back and abdominal pain.
The FDA letter recommends that health care providers consider overinflation and pancreatitis in their differential diagnoses of obesity patients with intragastric balloons who present with the symptoms described, and to report any type of serious adverse events associated with intragastric balloons to the FDA through the MedWatch program. For more information about reporting adverse events to the FDA, visit the MedWatch site.
Complications from overinflation and acute pancreatitis can create problems for obesity patients treated with intragastric balloons, according to a statement from the Food and Drug Administration. In a letter to health care providers published on February 9, 2017, the FDA warned of the two specific issues that have been the subject of multiple adverse event reports.
“We recommend that you closely monitor patients with these devices for these adverse events, and to submit reports to help us better understand any complications from the use of these obesity treatment devices,” the letter said.
Most of the overinflation reports involved the Orbera Intragastric Balloon System (Apollo Endosurgery) that uses a single balloon, although some reports involved the ReShape Integrated Dual Balloon System (ReShape Medical) that uses two balloons. Neither product mentions overinflation risk in its labeling. “At this moment there is not enough information to determine what is causing the balloon to overinflate,” according to the FDA letter.
A separate set of adverse event reports noted the development of acute pancreatitis caused when the balloons compressed other gastrointestinal structures. Both the Orbera and ReShape products were associated with pancreatitis, although neither lists pancreatitis as a potential complication on their labels. Pancreatitis was reported as early as 3 days after implantation, and symptoms included severe back and abdominal pain.
The FDA letter recommends that health care providers consider overinflation and pancreatitis in their differential diagnoses of obesity patients with intragastric balloons who present with the symptoms described, and to report any type of serious adverse events associated with intragastric balloons to the FDA through the MedWatch program. For more information about reporting adverse events to the FDA, visit the MedWatch site.
Study finds Roux-en-Y safe, effective for older patients
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
[email protected]
On Twitter @Alz_Gal
LAS VEGAS – Older obese patients shouldn’t be excluded from undergoing a Roux-en-Y gastric bypass based on concern for their long-term survival.
A 30-year review has determined that patients 60 years and older who had the surgery lost most of their excess body weight, and lived just as long as an age- and weight- matched cohort.
“We found a major weight loss benefit and no long-term differences in survival,” Taryn Hassinger, MD, said at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress. “Our data support the use of this surgery in the elderly to achieve safe and effective weight loss.”
These subjects were matched for age and baseline weight to a group of 425 who did not have any bariatric surgery. Survival data in the univariate analysis came from Social Security death records.
The groups were similar at baseline, with a mean age of 62 and a mean body mass index of 47 kg/m2. About half of each group had obstructive sleep apnea. Other comorbidities were osteoarthritis (63%), chronic obstructive pulmonary disease (24%), type 2 diabetes (58%), gastroesophageal reflux (52%), congestive heart failure (8%), and hypertension (78%). About a quarter of each group smoked.
Patients were followed for up to 6 years. At the end of follow-up, those who had the surgery had lost a mean of 84% of their excess body weight. There was hardly any weight loss evident in the control group – a mean reduction of 4.6%. At the end of the follow-up period, 90% of surgical patients and 93% of the control patients were still alive.
The study provides reassuring data in an area that has not been well explored, Dr. Hassinger added. The only extant studies have compared older and younger cohorts. Peter Muscarella, MD, who moderated the session, agreed.
“This is very interesting, and good to know as we continue to expand the use of Roux-en-Y into different populations,” said Dr. Muscarella, a surgeon at Montefiore Medical Center, New York. “We have already expanded it into the pediatric population and now we are looking at its use in older individuals. But one question is, are there epidemiologic data on obesity in elderly patients? In my own practice, I just don’t see a lot of obese elderly patients. Is this really a problem in our country?”
A 2012 paper published by the National Center for Health Statistics addressed this issue. Data from the National Health and Nutrition Examination Survey, 2007-2010, found that nearly one-third of U.S. adults aged 65 years and older were obese. Other key findings:
• Obesity prevalence was higher among those aged 65-74, compared with those aged 75 and over in both men and women.
• The prevalence of obesity in women aged 65-74 was higher than in women aged 75 and over in all racial and ethnic groups except non-Hispanic black women, where approximately one in two were obese among both age groups.
• Between 1999-2002 and 2007-2010, the prevalence of obesity among older men increased.
As the proportion of older adults increases in the U.S. population, surgeons are likely to see older patients who are candidates for bariatric surgery, Dr. Hassinger said.
“We believe that surgery may be an option for people who are in the 60-70 year range,” she said. “We do operate on those patients not infrequently.”
The investigator had no disclosures.
[email protected]
On Twitter @Alz_Gal
AT THE ACADEMIC SURGICAL CONGRESS
Key clinical point: Older patients can safely lose weight after Roux-en-Y gastric bypass without excess mortality risk.
Major finding: At the end of follow-up, patients had lost a mean of 84% of their excess body weight, compared with 4.6% loss in controls. Survival was similar (90% of surgical patients and 93% of controls).
Data source: The retrospective study comprised 107 patients and 425 controls.
Disclosures: The investigator had no disclosures.
Updated guidelines offer insight into pediatric obesity
Among other things, the guidelines offer new insight into the role of genetics in childhood obesity, provide more extensive guidance regarding bariatric surgery in adolescents, and suggest that measurements of insulin concentrations aren’t useful barometers.
The guidelines also point to research gaps in several areas and call for more studies.
Why issue new guidelines now? “Eight years have passed since the last publication. We did a very thorough job, but there’s been an incredible amount of interest in child obesity, and more information is available,” lead author Dennis M. Styne, MD, professor of pediatrics and the Yocha Dehe endowed chair in pediatric endocrinology at the University of California at Davis, said in an interview. Indeed, recent years have produced hundreds of studies into pediatric obesity, he noted.
The 49-page guidelines are cosponsored by the European Society of Endocrinology and the Pediatric Endocrine Society (J Clin Endocrinol Metab. 2017 March;102[3]:1-49).
Pediatric obesity is of special interest to endocrinologists, Dr. Styne said. “While there’s interest from many specialists now, we are at the forefront of evaluation and treatment of complications like polycystic ovary syndrome, metabolic syndrome, dyslipidemia, and type 2 diabetes.”
The guidelines provide recommendations about a wide variety of obesity-related topics including screening, diagnosis, and treatment. The Endocrine Society commissioned two systematic reviews to support the guidelines: One examined longer randomized controlled trials into medication, surgery, lifestyle, and community-based intervention treatments. The other examined how changing body mass index levels corresponded to cardiometabolic changes.
Several updated areas in the guidelines should be of special interest to endocrinologists: guidance regarding the genetic causes of pediatric obesity, the use of weight-loss medication and surgery, and the roles of insulin tests and breast-feeding, according to Dr. Styne.
In regard to genetics, the guidelines note that research suggests 7% of patients with extreme pediatric obesity “may have rare chromosomal abnormalities and/or highly penetrant genetic mutations that drive their obesity. This percentage is likely to increase with newer methods for genetic testing.”
Dr. Styne calls this finding “remarkable.” As he put it, “we didn’t appreciate that so much in the past.”
The guidelines suggest genetic testing for patients who become obese before the age of 5 years, have a family history of extreme obesity, or show clinical signs of genetic obesity syndromes, especially extreme hyperphagia.
As for the most extreme treatments for the most obese children, the guidelines recommend against weight-loss medication outside of clinical trials and note that “increasing evidence” supports bariatric surgery in teens who haven’t been able to lose enough pounds through lifestyle modification. However, “the use of surgery requires experienced teams with resources for long-term follow-up.”
The guidelines also recommend against measuring serum insulin concentrations as part of pediatric screening for obesity. “A lot of people like to get insulin levels and think it tells them about the future of the child,” Dr. Styne said. “But it doesn’t work very well.”
In another area that reflects new information, the guidelines note that breast-feeding hasn’t been definitively shown to be effective in reducing childhood obesity. “The literature is contradictory,” Dr. Styne said, although he noted that breast-feeding still has many other benefits.
The guidelines point to research gaps in several areas, including the prevention and treatment of pediatric obesity. There’s also “uncharted territory” regarding how to “effectively transition to adult care, with continued necessary monitoring, support, and intervention.”
In regard to the best treatment programs, “we didn’t come up with an answer regarding overall effectiveness,” Dr. Styne said. “School- and community-based programs have promise, but I can’t give you the percentage of success.”
As for the overall picture of pediatric obesity in the United States, “we’re in a better situation than we were 8 years ago,” he said. “Everyone is talking about the problem, and when you talk to families, they’re more aware of it.”
Still, he said, the prevalence of obesity in kids is high, estimated at 17% of those aged 2-19 years in 2014. “That’s not a good place to be,” he said. “We still have to work harder.”
The Endocrine Society funded the guidelines. Dr. Styne reports ownership interests in Teva, Bristol Myers and Organovo. Other authors report various disclosures.
Among other things, the guidelines offer new insight into the role of genetics in childhood obesity, provide more extensive guidance regarding bariatric surgery in adolescents, and suggest that measurements of insulin concentrations aren’t useful barometers.
The guidelines also point to research gaps in several areas and call for more studies.
Why issue new guidelines now? “Eight years have passed since the last publication. We did a very thorough job, but there’s been an incredible amount of interest in child obesity, and more information is available,” lead author Dennis M. Styne, MD, professor of pediatrics and the Yocha Dehe endowed chair in pediatric endocrinology at the University of California at Davis, said in an interview. Indeed, recent years have produced hundreds of studies into pediatric obesity, he noted.
The 49-page guidelines are cosponsored by the European Society of Endocrinology and the Pediatric Endocrine Society (J Clin Endocrinol Metab. 2017 March;102[3]:1-49).
Pediatric obesity is of special interest to endocrinologists, Dr. Styne said. “While there’s interest from many specialists now, we are at the forefront of evaluation and treatment of complications like polycystic ovary syndrome, metabolic syndrome, dyslipidemia, and type 2 diabetes.”
The guidelines provide recommendations about a wide variety of obesity-related topics including screening, diagnosis, and treatment. The Endocrine Society commissioned two systematic reviews to support the guidelines: One examined longer randomized controlled trials into medication, surgery, lifestyle, and community-based intervention treatments. The other examined how changing body mass index levels corresponded to cardiometabolic changes.
Several updated areas in the guidelines should be of special interest to endocrinologists: guidance regarding the genetic causes of pediatric obesity, the use of weight-loss medication and surgery, and the roles of insulin tests and breast-feeding, according to Dr. Styne.
In regard to genetics, the guidelines note that research suggests 7% of patients with extreme pediatric obesity “may have rare chromosomal abnormalities and/or highly penetrant genetic mutations that drive their obesity. This percentage is likely to increase with newer methods for genetic testing.”
Dr. Styne calls this finding “remarkable.” As he put it, “we didn’t appreciate that so much in the past.”
The guidelines suggest genetic testing for patients who become obese before the age of 5 years, have a family history of extreme obesity, or show clinical signs of genetic obesity syndromes, especially extreme hyperphagia.
As for the most extreme treatments for the most obese children, the guidelines recommend against weight-loss medication outside of clinical trials and note that “increasing evidence” supports bariatric surgery in teens who haven’t been able to lose enough pounds through lifestyle modification. However, “the use of surgery requires experienced teams with resources for long-term follow-up.”
The guidelines also recommend against measuring serum insulin concentrations as part of pediatric screening for obesity. “A lot of people like to get insulin levels and think it tells them about the future of the child,” Dr. Styne said. “But it doesn’t work very well.”
In another area that reflects new information, the guidelines note that breast-feeding hasn’t been definitively shown to be effective in reducing childhood obesity. “The literature is contradictory,” Dr. Styne said, although he noted that breast-feeding still has many other benefits.
The guidelines point to research gaps in several areas, including the prevention and treatment of pediatric obesity. There’s also “uncharted territory” regarding how to “effectively transition to adult care, with continued necessary monitoring, support, and intervention.”
In regard to the best treatment programs, “we didn’t come up with an answer regarding overall effectiveness,” Dr. Styne said. “School- and community-based programs have promise, but I can’t give you the percentage of success.”
As for the overall picture of pediatric obesity in the United States, “we’re in a better situation than we were 8 years ago,” he said. “Everyone is talking about the problem, and when you talk to families, they’re more aware of it.”
Still, he said, the prevalence of obesity in kids is high, estimated at 17% of those aged 2-19 years in 2014. “That’s not a good place to be,” he said. “We still have to work harder.”
The Endocrine Society funded the guidelines. Dr. Styne reports ownership interests in Teva, Bristol Myers and Organovo. Other authors report various disclosures.
Among other things, the guidelines offer new insight into the role of genetics in childhood obesity, provide more extensive guidance regarding bariatric surgery in adolescents, and suggest that measurements of insulin concentrations aren’t useful barometers.
The guidelines also point to research gaps in several areas and call for more studies.
Why issue new guidelines now? “Eight years have passed since the last publication. We did a very thorough job, but there’s been an incredible amount of interest in child obesity, and more information is available,” lead author Dennis M. Styne, MD, professor of pediatrics and the Yocha Dehe endowed chair in pediatric endocrinology at the University of California at Davis, said in an interview. Indeed, recent years have produced hundreds of studies into pediatric obesity, he noted.
The 49-page guidelines are cosponsored by the European Society of Endocrinology and the Pediatric Endocrine Society (J Clin Endocrinol Metab. 2017 March;102[3]:1-49).
Pediatric obesity is of special interest to endocrinologists, Dr. Styne said. “While there’s interest from many specialists now, we are at the forefront of evaluation and treatment of complications like polycystic ovary syndrome, metabolic syndrome, dyslipidemia, and type 2 diabetes.”
The guidelines provide recommendations about a wide variety of obesity-related topics including screening, diagnosis, and treatment. The Endocrine Society commissioned two systematic reviews to support the guidelines: One examined longer randomized controlled trials into medication, surgery, lifestyle, and community-based intervention treatments. The other examined how changing body mass index levels corresponded to cardiometabolic changes.
Several updated areas in the guidelines should be of special interest to endocrinologists: guidance regarding the genetic causes of pediatric obesity, the use of weight-loss medication and surgery, and the roles of insulin tests and breast-feeding, according to Dr. Styne.
In regard to genetics, the guidelines note that research suggests 7% of patients with extreme pediatric obesity “may have rare chromosomal abnormalities and/or highly penetrant genetic mutations that drive their obesity. This percentage is likely to increase with newer methods for genetic testing.”
Dr. Styne calls this finding “remarkable.” As he put it, “we didn’t appreciate that so much in the past.”
The guidelines suggest genetic testing for patients who become obese before the age of 5 years, have a family history of extreme obesity, or show clinical signs of genetic obesity syndromes, especially extreme hyperphagia.
As for the most extreme treatments for the most obese children, the guidelines recommend against weight-loss medication outside of clinical trials and note that “increasing evidence” supports bariatric surgery in teens who haven’t been able to lose enough pounds through lifestyle modification. However, “the use of surgery requires experienced teams with resources for long-term follow-up.”
The guidelines also recommend against measuring serum insulin concentrations as part of pediatric screening for obesity. “A lot of people like to get insulin levels and think it tells them about the future of the child,” Dr. Styne said. “But it doesn’t work very well.”
In another area that reflects new information, the guidelines note that breast-feeding hasn’t been definitively shown to be effective in reducing childhood obesity. “The literature is contradictory,” Dr. Styne said, although he noted that breast-feeding still has many other benefits.
The guidelines point to research gaps in several areas, including the prevention and treatment of pediatric obesity. There’s also “uncharted territory” regarding how to “effectively transition to adult care, with continued necessary monitoring, support, and intervention.”
In regard to the best treatment programs, “we didn’t come up with an answer regarding overall effectiveness,” Dr. Styne said. “School- and community-based programs have promise, but I can’t give you the percentage of success.”
As for the overall picture of pediatric obesity in the United States, “we’re in a better situation than we were 8 years ago,” he said. “Everyone is talking about the problem, and when you talk to families, they’re more aware of it.”
Still, he said, the prevalence of obesity in kids is high, estimated at 17% of those aged 2-19 years in 2014. “That’s not a good place to be,” he said. “We still have to work harder.”
The Endocrine Society funded the guidelines. Dr. Styne reports ownership interests in Teva, Bristol Myers and Organovo. Other authors report various disclosures.
Postop incentive spirometry had minimal impact on hypoxemia in bariatric surgery patients
The effect of incentive spirometry (IS) on postoperative hypoxemia in bariatric surgery patients was found to be insignificant, according to a randomized cohort study published in JAMA Surgery.
“At present, postoperative IS is considered the standard of care and is incorporated into standardized bariatric surgery recovery protocols,” wrote the authors of the study, led by Haddon Pantel, MD, of the Lahey Hospital and Medical Center in Burlington, Mass. “However, despite the ubiquitous use of IS in the postoperative period, data on its efficacy are conflicting, and high-quality evidence is lacking.” (JAMA Surg. doi:10.1001/jamasurg.2016.4981)
A total of 224 patients were evenly randomized into one of two cohorts; one cohort received no postoperative IS and acted as the control, while the other received postoperative IS. Patients from each of these cohorts were followed up at 6, 12, and 24 hours to measure SaO2 levels as a sign of hypoxemia, which was defined as a level of under 92%.
No significant differences were observed between the two cohorts at any of the three follow-up periods in terms of SaO2 levels. At 6 hours, hypoxemia incidence rates were 11.9% in the control group and 10.4% in the IS group (P = .72). At the 12-hour follow-up, the control group registered a 5.4% incidence rate, compared with 8.2% for those receiving postoperative IS (P = .40). And finally, at 24-hour follow-up, the control group had a 3.7% rate of hypoxemia, while those in the IS cohort had a 4.6% rate (P = .73). In addition, there were no significant differences observed in the average SaO2 levels between the two cohorts (P = .99, P = .40, and P = .69 at 6, 12, and 24 hours, respectively) nor was there a significantly higher rate of pulmonary complications in one cohort versus the other (P = .24).
The authors concluded, “With health care moving toward a more evidence-based, economically driven, and environmentally sustainable field, this study adds evidence to the concept that IS should not be universally used in all patients undergoing surgery and does not appear to be necessary in elective bariatric surgical procedures.”
The study was funded by Lahey Hospital and Medical Center’s department of general surgery; the authors reported no relevant financial disclosures.
The effect of incentive spirometry (IS) on postoperative hypoxemia in bariatric surgery patients was found to be insignificant, according to a randomized cohort study published in JAMA Surgery.
“At present, postoperative IS is considered the standard of care and is incorporated into standardized bariatric surgery recovery protocols,” wrote the authors of the study, led by Haddon Pantel, MD, of the Lahey Hospital and Medical Center in Burlington, Mass. “However, despite the ubiquitous use of IS in the postoperative period, data on its efficacy are conflicting, and high-quality evidence is lacking.” (JAMA Surg. doi:10.1001/jamasurg.2016.4981)
A total of 224 patients were evenly randomized into one of two cohorts; one cohort received no postoperative IS and acted as the control, while the other received postoperative IS. Patients from each of these cohorts were followed up at 6, 12, and 24 hours to measure SaO2 levels as a sign of hypoxemia, which was defined as a level of under 92%.
No significant differences were observed between the two cohorts at any of the three follow-up periods in terms of SaO2 levels. At 6 hours, hypoxemia incidence rates were 11.9% in the control group and 10.4% in the IS group (P = .72). At the 12-hour follow-up, the control group registered a 5.4% incidence rate, compared with 8.2% for those receiving postoperative IS (P = .40). And finally, at 24-hour follow-up, the control group had a 3.7% rate of hypoxemia, while those in the IS cohort had a 4.6% rate (P = .73). In addition, there were no significant differences observed in the average SaO2 levels between the two cohorts (P = .99, P = .40, and P = .69 at 6, 12, and 24 hours, respectively) nor was there a significantly higher rate of pulmonary complications in one cohort versus the other (P = .24).
The authors concluded, “With health care moving toward a more evidence-based, economically driven, and environmentally sustainable field, this study adds evidence to the concept that IS should not be universally used in all patients undergoing surgery and does not appear to be necessary in elective bariatric surgical procedures.”
The study was funded by Lahey Hospital and Medical Center’s department of general surgery; the authors reported no relevant financial disclosures.
The effect of incentive spirometry (IS) on postoperative hypoxemia in bariatric surgery patients was found to be insignificant, according to a randomized cohort study published in JAMA Surgery.
“At present, postoperative IS is considered the standard of care and is incorporated into standardized bariatric surgery recovery protocols,” wrote the authors of the study, led by Haddon Pantel, MD, of the Lahey Hospital and Medical Center in Burlington, Mass. “However, despite the ubiquitous use of IS in the postoperative period, data on its efficacy are conflicting, and high-quality evidence is lacking.” (JAMA Surg. doi:10.1001/jamasurg.2016.4981)
A total of 224 patients were evenly randomized into one of two cohorts; one cohort received no postoperative IS and acted as the control, while the other received postoperative IS. Patients from each of these cohorts were followed up at 6, 12, and 24 hours to measure SaO2 levels as a sign of hypoxemia, which was defined as a level of under 92%.
No significant differences were observed between the two cohorts at any of the three follow-up periods in terms of SaO2 levels. At 6 hours, hypoxemia incidence rates were 11.9% in the control group and 10.4% in the IS group (P = .72). At the 12-hour follow-up, the control group registered a 5.4% incidence rate, compared with 8.2% for those receiving postoperative IS (P = .40). And finally, at 24-hour follow-up, the control group had a 3.7% rate of hypoxemia, while those in the IS cohort had a 4.6% rate (P = .73). In addition, there were no significant differences observed in the average SaO2 levels between the two cohorts (P = .99, P = .40, and P = .69 at 6, 12, and 24 hours, respectively) nor was there a significantly higher rate of pulmonary complications in one cohort versus the other (P = .24).
The authors concluded, “With health care moving toward a more evidence-based, economically driven, and environmentally sustainable field, this study adds evidence to the concept that IS should not be universally used in all patients undergoing surgery and does not appear to be necessary in elective bariatric surgical procedures.”
The study was funded by Lahey Hospital and Medical Center’s department of general surgery; the authors reported no relevant financial disclosures.
FROM JAMA SURGERY
Key clinical point:
Major finding: No significant difference in hypoxemia frequency was found between postoperative IS and control cohorts at 6, 12, and 24-hour follow-ups (P = .72, .40, and .73, respectively).
Data source: A randomized, noninferiority cohort study of 224 bariatric surgery patients during May 2015 through June 2016.
Disclosures: Study funded by Lahey Hospital and Medical Center; authors reported no relevant financial disclosures.