General Surgery

LOS ANGELES – Revisional surgery after failed adjustable gastric banding (AGB) is associated with an increased risk of adverse events and resource utilization, according to Dr. Steven Poplawski, medical director for Barix Clinics in Ypsilanti, Mich.

His conclusion is based on safety outcomes at 30 days for 55,237 patients who underwent primary bariatric surgery and 1,417 patients who underwent AGB revision between June 2006 and July 2015 in the Michigan Bariatric Surgery Collaborative. Patients were excluded from the retrospective evaluation if they had urgent/emergent procedures or more than one previous bariatric operation.

The primary bariatric surgery was Roux-en-Y gastric bypass (RYGB) in 43%, sleeve gastrectomy in 37%, AGB in 19%, and biliopancreatic diversion with duodenal switch (BPD/DS) in 1%.

The patients turned to AGB revision for the same reasons that have prompted its dramatic decline in utilization: weight loss failure (38%), band complications (33%), or both (29%). AGB revisional procedures were sleeve gastrectomy in 54%, RYGB in 35%, AGB in 9%, and BPD/DS in 2%.

Patients undergoing band-to-RYGB conversions had significantly more serious complications, compared with primary RYGB procedures (10.2% vs. 4.4%; P less than .0001), reoperations (5.1% vs. 2.3%; P = .0001), and hospital readmissions (10% vs. 7.3%; P = .0064), and a nonsignificant trend toward more leaks (1.3% vs. 0.7%; P = .13), Dr. Poplawski reported.

Patients undergoing band-to-sleeve conversions had significantly more serious complications when compared with primary sleeve gastrectomy (5% vs. 1.8%; P less than .0001), reoperations (3.3% vs. 1%; P less than .0001), and leaks (1.5% vs. 0.5%; P = .0001), and a nonsignificant trend toward more readmissions (7.7% vs. 4.6%; P = .0685).

Outcomes were not reported for the smaller number of patients undergoing AGB-to-AGB or AGB-to-BPD/DS conversions.

A secondary analysis was performed examining a one-stage versus a two-stage procedure in 525 patients undergoing revisional surgery for weight loss failure only. The only safety outcome to show a significant difference at 30 days was hospital readmissions in the RYGB-conversion group, favoring the one-stage over the two-stage procedure (7.1% vs. 11.5%; P = .0164).

“Clearly, the benefit of a one-stage procedure versus a two-stage procedure is unclear in the way it was studied here,” Dr. Poplawski said at Obesity Week 2015, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

“You can read in some reports that [surgeons] do all [of these procedures as] two-stage because they think it’s safer, but I don’t know that there’s much support for that here. I think it’s reasonable to get most of them done in one stage because there’s also two hospitalizations, two periods of convalescence, and when we talk about the complications of the two-stage operation we aren’t even including the costs to remove the initial band, which are not insignificant,” he noted.

Dr. Raul Rosenthal of the Cleveland Clinic in Weston, Fla., who comoderated the session, said the takeaway message is that “reoperative surgery pays a price. No matter how you look at it, one stage, two stages, with bands or sleeve, you’re going to get in trouble.”

[email protected]

LOS ANGELES – Revisional surgery after failed adjustable gastric banding (AGB) is associated with an increased risk of adverse events and resource utilization, according to Dr. Steven Poplawski, medical director for Barix Clinics in Ypsilanti, Mich.

His conclusion is based on safety outcomes at 30 days for 55,237 patients who underwent primary bariatric surgery and 1,417 patients who underwent AGB revision between June 2006 and July 2015 in the Michigan Bariatric Surgery Collaborative. Patients were excluded from the retrospective evaluation if they had urgent/emergent procedures or more than one previous bariatric operation.

The primary bariatric surgery was Roux-en-Y gastric bypass (RYGB) in 43%, sleeve gastrectomy in 37%, AGB in 19%, and biliopancreatic diversion with duodenal switch (BPD/DS) in 1%.

The patients turned to AGB revision for the same reasons that have prompted its dramatic decline in utilization: weight loss failure (38%), band complications (33%), or both (29%). AGB revisional procedures were sleeve gastrectomy in 54%, RYGB in 35%, AGB in 9%, and BPD/DS in 2%.

Patients undergoing band-to-RYGB conversions had significantly more serious complications, compared with primary RYGB procedures (10.2% vs. 4.4%; P less than .0001), reoperations (5.1% vs. 2.3%; P = .0001), and hospital readmissions (10% vs. 7.3%; P = .0064), and a nonsignificant trend toward more leaks (1.3% vs. 0.7%; P = .13), Dr. Poplawski reported.

Patients undergoing band-to-sleeve conversions had significantly more serious complications when compared with primary sleeve gastrectomy (5% vs. 1.8%; P less than .0001), reoperations (3.3% vs. 1%; P less than .0001), and leaks (1.5% vs. 0.5%; P = .0001), and a nonsignificant trend toward more readmissions (7.7% vs. 4.6%; P = .0685).

Outcomes were not reported for the smaller number of patients undergoing AGB-to-AGB or AGB-to-BPD/DS conversions.

A secondary analysis was performed examining a one-stage versus a two-stage procedure in 525 patients undergoing revisional surgery for weight loss failure only. The only safety outcome to show a significant difference at 30 days was hospital readmissions in the RYGB-conversion group, favoring the one-stage over the two-stage procedure (7.1% vs. 11.5%; P = .0164).

“Clearly, the benefit of a one-stage procedure versus a two-stage procedure is unclear in the way it was studied here,” Dr. Poplawski said at Obesity Week 2015, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

“You can read in some reports that [surgeons] do all [of these procedures as] two-stage because they think it’s safer, but I don’t know that there’s much support for that here. I think it’s reasonable to get most of them done in one stage because there’s also two hospitalizations, two periods of convalescence, and when we talk about the complications of the two-stage operation we aren’t even including the costs to remove the initial band, which are not insignificant,” he noted.

Dr. Raul Rosenthal of the Cleveland Clinic in Weston, Fla., who comoderated the session, said the takeaway message is that “reoperative surgery pays a price. No matter how you look at it, one stage, two stages, with bands or sleeve, you’re going to get in trouble.”

[email protected]

LOS ANGELES – Revisional surgery after failed adjustable gastric banding (AGB) is associated with an increased risk of adverse events and resource utilization, according to Dr. Steven Poplawski, medical director for Barix Clinics in Ypsilanti, Mich.

His conclusion is based on safety outcomes at 30 days for 55,237 patients who underwent primary bariatric surgery and 1,417 patients who underwent AGB revision between June 2006 and July 2015 in the Michigan Bariatric Surgery Collaborative. Patients were excluded from the retrospective evaluation if they had urgent/emergent procedures or more than one previous bariatric operation.

The primary bariatric surgery was Roux-en-Y gastric bypass (RYGB) in 43%, sleeve gastrectomy in 37%, AGB in 19%, and biliopancreatic diversion with duodenal switch (BPD/DS) in 1%.

The patients turned to AGB revision for the same reasons that have prompted its dramatic decline in utilization: weight loss failure (38%), band complications (33%), or both (29%). AGB revisional procedures were sleeve gastrectomy in 54%, RYGB in 35%, AGB in 9%, and BPD/DS in 2%.

Patients undergoing band-to-RYGB conversions had significantly more serious complications, compared with primary RYGB procedures (10.2% vs. 4.4%; P less than .0001), reoperations (5.1% vs. 2.3%; P = .0001), and hospital readmissions (10% vs. 7.3%; P = .0064), and a nonsignificant trend toward more leaks (1.3% vs. 0.7%; P = .13), Dr. Poplawski reported.

Patients undergoing band-to-sleeve conversions had significantly more serious complications when compared with primary sleeve gastrectomy (5% vs. 1.8%; P less than .0001), reoperations (3.3% vs. 1%; P less than .0001), and leaks (1.5% vs. 0.5%; P = .0001), and a nonsignificant trend toward more readmissions (7.7% vs. 4.6%; P = .0685).

Outcomes were not reported for the smaller number of patients undergoing AGB-to-AGB or AGB-to-BPD/DS conversions.

A secondary analysis was performed examining a one-stage versus a two-stage procedure in 525 patients undergoing revisional surgery for weight loss failure only. The only safety outcome to show a significant difference at 30 days was hospital readmissions in the RYGB-conversion group, favoring the one-stage over the two-stage procedure (7.1% vs. 11.5%; P = .0164).

“Clearly, the benefit of a one-stage procedure versus a two-stage procedure is unclear in the way it was studied here,” Dr. Poplawski said at Obesity Week 2015, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

“You can read in some reports that [surgeons] do all [of these procedures as] two-stage because they think it’s safer, but I don’t know that there’s much support for that here. I think it’s reasonable to get most of them done in one stage because there’s also two hospitalizations, two periods of convalescence, and when we talk about the complications of the two-stage operation we aren’t even including the costs to remove the initial band, which are not insignificant,” he noted.

Dr. Raul Rosenthal of the Cleveland Clinic in Weston, Fla., who comoderated the session, said the takeaway message is that “reoperative surgery pays a price. No matter how you look at it, one stage, two stages, with bands or sleeve, you’re going to get in trouble.”

[email protected]

CHICAGO – Infected ventral hernia mesh is most likely to be salvaged if it’s made from lightweight polypropylene, according to data from a series of 161 mesh infection cases at Carolinas Medical Center in Charlotte, N.C.

Investigators there were able to salvage 33% of lightweight polypropylene and 8% of polytetrafluoroethylene mesh patients, but salvage failed in patients with composite, polyester, or heavyweight polypropylene meshes. The overall salvage rate was less than 10%.

WikiMedia Commons/Zhangzhugang/Creative Commons

“We sometimes think that we’ve salvaged the mesh, but if we follow these patients long enough” – follow-up was an average of 37 months in the series – “the majority of them will need to be excised,” said investigator Dr. Vedra Augenstein of the department of surgery at the medical center.

Wound complications are common in ventral hernia repairs, and mesh infections, said Dr. Augenstein, are among “the most dreaded.” The North Carolina findings help define the small pool of patients in whom salvage might work.

The average body mass index in the series was 36 kg/m², and patients had an average of 2.6 previous ventral hernia repairs. The majority had a polypropylene mesh. Most of the cases were referred to the medical center from elsewhere, so mesh excision came an average of 10 months after the diagnosis of infection.

Almost a third of patients had their infections diagnosed a year or more after mesh implant, which goes against the common notion that mesh patients are out of the woods after a year. “It took a very long time for some of these infections to present. This was a big surprise for us,” Dr. Augenstein said.

The team tried to salvage all of their patients, using antibiotics in 90%, vacuum-assisted closure and/or debridement in 57%, and percutaneous drainage in 17%.

No patient presented with an obvious fistula, but the investigators found fistulas during surgery in about 16% of patients. Meanwhile, salvage failed in every patient who continued to smoke despite being diagnosed with a mesh infection.

The team assembled their findings into an informal algorithm for considering mesh salvage.

“Think about what you need to ask yourself. First, does the patient have a fistula or do you suspect one” from, for instance, gut bacteria in the wound or oral contrast above the mesh on CT? If so, “they are going to need an operation,” Dr. Augenstein said.

Smoking is the next stop point; salvage is likely to fail in smokers.

Mesh type is the third consideration; lightweight polypropylene is a good sign. “If they have heavyweight polypropylene, composite, or polyester mesh, they were not salvageable in our series,” she said.

For patients still in the running, Methicillin-resistant Staphylococcus aureus (MRSA) is the next concern. If it’s in the wound, mesh is going to be harder to salvage, said Dr. Augenstein. Most of the infections in the series were caused by Staphylococcus, with MRSA present in 45% of patients.

Infection recurrence is common even when salvage seems to work, so “we need to follow these patients for a very, very long time,” Dr. Augenstein said.

Along with clinical exams, the North Carolina team follows C-reactive protein and erythrocyte sedimentation rate. “If the abdomen gets red or if, for example, the C-reactive protein goes up, we’ll do a CT scan or ultrasound to make sure they are not brewing an infection,” she said.

Dr. Augenstein has received research and educational grants from Gore, Ethicon, Novadaq, Bard, and LifeCell.

[email protected]

CHICAGO – Infected ventral hernia mesh is most likely to be salvaged if it’s made from lightweight polypropylene, according to data from a series of 161 mesh infection cases at Carolinas Medical Center in Charlotte, N.C.

Investigators there were able to salvage 33% of lightweight polypropylene and 8% of polytetrafluoroethylene mesh patients, but salvage failed in patients with composite, polyester, or heavyweight polypropylene meshes. The overall salvage rate was less than 10%.

WikiMedia Commons/Zhangzhugang/Creative Commons

“We sometimes think that we’ve salvaged the mesh, but if we follow these patients long enough” – follow-up was an average of 37 months in the series – “the majority of them will need to be excised,” said investigator Dr. Vedra Augenstein of the department of surgery at the medical center.

Wound complications are common in ventral hernia repairs, and mesh infections, said Dr. Augenstein, are among “the most dreaded.” The North Carolina findings help define the small pool of patients in whom salvage might work.

The average body mass index in the series was 36 kg/m², and patients had an average of 2.6 previous ventral hernia repairs. The majority had a polypropylene mesh. Most of the cases were referred to the medical center from elsewhere, so mesh excision came an average of 10 months after the diagnosis of infection.

Almost a third of patients had their infections diagnosed a year or more after mesh implant, which goes against the common notion that mesh patients are out of the woods after a year. “It took a very long time for some of these infections to present. This was a big surprise for us,” Dr. Augenstein said.

The team tried to salvage all of their patients, using antibiotics in 90%, vacuum-assisted closure and/or debridement in 57%, and percutaneous drainage in 17%.

No patient presented with an obvious fistula, but the investigators found fistulas during surgery in about 16% of patients. Meanwhile, salvage failed in every patient who continued to smoke despite being diagnosed with a mesh infection.

The team assembled their findings into an informal algorithm for considering mesh salvage.

“Think about what you need to ask yourself. First, does the patient have a fistula or do you suspect one” from, for instance, gut bacteria in the wound or oral contrast above the mesh on CT? If so, “they are going to need an operation,” Dr. Augenstein said.

Smoking is the next stop point; salvage is likely to fail in smokers.

Mesh type is the third consideration; lightweight polypropylene is a good sign. “If they have heavyweight polypropylene, composite, or polyester mesh, they were not salvageable in our series,” she said.

For patients still in the running, Methicillin-resistant Staphylococcus aureus (MRSA) is the next concern. If it’s in the wound, mesh is going to be harder to salvage, said Dr. Augenstein. Most of the infections in the series were caused by Staphylococcus, with MRSA present in 45% of patients.

Infection recurrence is common even when salvage seems to work, so “we need to follow these patients for a very, very long time,” Dr. Augenstein said.

Along with clinical exams, the North Carolina team follows C-reactive protein and erythrocyte sedimentation rate. “If the abdomen gets red or if, for example, the C-reactive protein goes up, we’ll do a CT scan or ultrasound to make sure they are not brewing an infection,” she said.

Dr. Augenstein has received research and educational grants from Gore, Ethicon, Novadaq, Bard, and LifeCell.

[email protected]

CHICAGO – Infected ventral hernia mesh is most likely to be salvaged if it’s made from lightweight polypropylene, according to data from a series of 161 mesh infection cases at Carolinas Medical Center in Charlotte, N.C.

Investigators there were able to salvage 33% of lightweight polypropylene and 8% of polytetrafluoroethylene mesh patients, but salvage failed in patients with composite, polyester, or heavyweight polypropylene meshes. The overall salvage rate was less than 10%.

WikiMedia Commons/Zhangzhugang/Creative Commons

“We sometimes think that we’ve salvaged the mesh, but if we follow these patients long enough” – follow-up was an average of 37 months in the series – “the majority of them will need to be excised,” said investigator Dr. Vedra Augenstein of the department of surgery at the medical center.

Wound complications are common in ventral hernia repairs, and mesh infections, said Dr. Augenstein, are among “the most dreaded.” The North Carolina findings help define the small pool of patients in whom salvage might work.

The average body mass index in the series was 36 kg/m², and patients had an average of 2.6 previous ventral hernia repairs. The majority had a polypropylene mesh. Most of the cases were referred to the medical center from elsewhere, so mesh excision came an average of 10 months after the diagnosis of infection.

Almost a third of patients had their infections diagnosed a year or more after mesh implant, which goes against the common notion that mesh patients are out of the woods after a year. “It took a very long time for some of these infections to present. This was a big surprise for us,” Dr. Augenstein said.

The team tried to salvage all of their patients, using antibiotics in 90%, vacuum-assisted closure and/or debridement in 57%, and percutaneous drainage in 17%.

No patient presented with an obvious fistula, but the investigators found fistulas during surgery in about 16% of patients. Meanwhile, salvage failed in every patient who continued to smoke despite being diagnosed with a mesh infection.

The team assembled their findings into an informal algorithm for considering mesh salvage.

“Think about what you need to ask yourself. First, does the patient have a fistula or do you suspect one” from, for instance, gut bacteria in the wound or oral contrast above the mesh on CT? If so, “they are going to need an operation,” Dr. Augenstein said.

Smoking is the next stop point; salvage is likely to fail in smokers.

Mesh type is the third consideration; lightweight polypropylene is a good sign. “If they have heavyweight polypropylene, composite, or polyester mesh, they were not salvageable in our series,” she said.

For patients still in the running, Methicillin-resistant Staphylococcus aureus (MRSA) is the next concern. If it’s in the wound, mesh is going to be harder to salvage, said Dr. Augenstein. Most of the infections in the series were caused by Staphylococcus, with MRSA present in 45% of patients.

Infection recurrence is common even when salvage seems to work, so “we need to follow these patients for a very, very long time,” Dr. Augenstein said.

Along with clinical exams, the North Carolina team follows C-reactive protein and erythrocyte sedimentation rate. “If the abdomen gets red or if, for example, the C-reactive protein goes up, we’ll do a CT scan or ultrasound to make sure they are not brewing an infection,” she said.

Dr. Augenstein has received research and educational grants from Gore, Ethicon, Novadaq, Bard, and LifeCell.

[email protected]

LOS ANGELES – A nationwide analysis shows modest early morbidity and low mortality following bariatric surgery in patients with type 2 diabetes who are not morbidly obese.

At 30 days’ follow-up among 1,003 patients, the composite complication rate, defined as the presence of any of 16 adverse events, was 4.2%; the reoperation rate was 1.6%; and two patients (0.2%) died.

Patrice Wendling/Frontline Medical News

“A 2-hour surgical procedure requiring a 2-day hospital stay that is associated with low morbidity and mortality can lead to remission of a chronic, progressive, and disabling disease,” lead author Dr. Ali Aminian of the Cleveland Clinic said at Obesity Week 2015.

“Based on these findings, bariatric surgery can be considered a relatively safe option for managing type 2 diabetes in patients with mild obesity.”

The analysis included adults with a body mass index of at least 25 kg/m², but less than 35 kg/m² (mean, 33 kg/m²).

These data are important because most patients with type 2 diabetes fall into this BMI category, he said.

Most of the patients were women (74.3%), 40% were using insulin, 78% had hypertension, and 9% had cardiac disease, according to the analysis, drawn from the American College of Surgery National Surgical Quality Improvement Program 2005-2013 database.

Roux-en-Y bypass was performed in 574 patients, adjustable gastric banding in 227, sleeve gastrectomy in 189, and duodenal switch in 13.

The most common adverse events overall were blood transfusion and reoperation (both 1.6%), a hospital stay longer than 7 days (0.6%), and organ space surgical-site infection (0.5%).

Composite morbidity and mortality was highest in the Roux-en-Y bypass group, compared with the adjustable banding and sleeve groups (5% vs. 3.1% vs. 3.2%, respectively), Dr. Aminian said at the meeting, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

Only 3 of 46 patients with a BMI of less than 30 kg/m² had an adverse event.

Available randomized controlled trials can’t clearly resolve the safety concerns of bariatric surgery in the subgroup of patients with type 2 diabetes who are overweight and mildly obese because such small trials are unlikely to reveal uncommon but clinically serious complications, Dr. Aminian said. In addition, many of the trials have screened out low-BMI and high-risk patients.

Those in attendance at the presentation, however, weren’t entirely convinced the current analysis could allay all safety concerns.

Session comoderator Dr. Daniel Cottam, a bariatric surgeon in group practice in Salt Lake City, said, “I like the summary; however, the use of the word ‘safe’ can be taken to mean a lot of things. It’s one of those squishy words.”

Though the authors have shown that bariatric surgery can be performed in diabetics with a low BMI, in order to say it is safe, the comparison needs to be drawn to the all-cause mortality for these patients in the general population and with other surgical procedures.

“That would be useful in the manuscript because as we approach our patients, we want to be able to say, ‘Listen, if you live with diabetes and a BMI of 25-35 for 5 years, this is your all-cause mortality, and surgery is going to save your life, not hurt it,’ ” Dr. Cottam said.

Along the same lines, Dr. Harvey Sugerman emeritus professor of surgery at Virginia Commonwealth University in Richmond, commented, “Like the old days of routinely operating on any patient with diabetes and gallstones, the data were that just having one death in a young person and the quality-of-life-years lost, it would take you thousands of gallbladders to make up for that one death.”

Dr. Sugarmen also asked for details on the deaths including where they occurred, in whom, and whether the centers were inexperienced.

Dr. Aminian could not recall at the time, but in an interview with this news organization said one death was in a 61-year-old with a history of cardiac disease and chronic kidney failure secondary to insulin-dependent diabetes who developed postop bleeding after gastric bypass. The second was in a 59-year-old patient, again on insulin, who was discharged without problems after gastric bypass, but died within 30 days after surgery.

Although most serious complications occur in this period, the main limitation of the study is that the dataset does not capture adverse events beyond 30 days after surgery, which can lead to underestimation of real risk, Dr. Aminian told the crowd.

“Further large clinical studies on long-term safety and efficacy outcomes of bariatric surgery in patients with type 2 diabetes and low BMI are warranted,” he said.

[email protected]

LOS ANGELES – A nationwide analysis shows modest early morbidity and low mortality following bariatric surgery in patients with type 2 diabetes who are not morbidly obese.

At 30 days’ follow-up among 1,003 patients, the composite complication rate, defined as the presence of any of 16 adverse events, was 4.2%; the reoperation rate was 1.6%; and two patients (0.2%) died.

Patrice Wendling/Frontline Medical News

“A 2-hour surgical procedure requiring a 2-day hospital stay that is associated with low morbidity and mortality can lead to remission of a chronic, progressive, and disabling disease,” lead author Dr. Ali Aminian of the Cleveland Clinic said at Obesity Week 2015.

“Based on these findings, bariatric surgery can be considered a relatively safe option for managing type 2 diabetes in patients with mild obesity.”

The analysis included adults with a body mass index of at least 25 kg/m², but less than 35 kg/m² (mean, 33 kg/m²).

These data are important because most patients with type 2 diabetes fall into this BMI category, he said.

Most of the patients were women (74.3%), 40% were using insulin, 78% had hypertension, and 9% had cardiac disease, according to the analysis, drawn from the American College of Surgery National Surgical Quality Improvement Program 2005-2013 database.

Roux-en-Y bypass was performed in 574 patients, adjustable gastric banding in 227, sleeve gastrectomy in 189, and duodenal switch in 13.

The most common adverse events overall were blood transfusion and reoperation (both 1.6%), a hospital stay longer than 7 days (0.6%), and organ space surgical-site infection (0.5%).

Composite morbidity and mortality was highest in the Roux-en-Y bypass group, compared with the adjustable banding and sleeve groups (5% vs. 3.1% vs. 3.2%, respectively), Dr. Aminian said at the meeting, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

Only 3 of 46 patients with a BMI of less than 30 kg/m² had an adverse event.

Available randomized controlled trials can’t clearly resolve the safety concerns of bariatric surgery in the subgroup of patients with type 2 diabetes who are overweight and mildly obese because such small trials are unlikely to reveal uncommon but clinically serious complications, Dr. Aminian said. In addition, many of the trials have screened out low-BMI and high-risk patients.

Those in attendance at the presentation, however, weren’t entirely convinced the current analysis could allay all safety concerns.

Session comoderator Dr. Daniel Cottam, a bariatric surgeon in group practice in Salt Lake City, said, “I like the summary; however, the use of the word ‘safe’ can be taken to mean a lot of things. It’s one of those squishy words.”

Though the authors have shown that bariatric surgery can be performed in diabetics with a low BMI, in order to say it is safe, the comparison needs to be drawn to the all-cause mortality for these patients in the general population and with other surgical procedures.

“That would be useful in the manuscript because as we approach our patients, we want to be able to say, ‘Listen, if you live with diabetes and a BMI of 25-35 for 5 years, this is your all-cause mortality, and surgery is going to save your life, not hurt it,’ ” Dr. Cottam said.

Along the same lines, Dr. Harvey Sugerman emeritus professor of surgery at Virginia Commonwealth University in Richmond, commented, “Like the old days of routinely operating on any patient with diabetes and gallstones, the data were that just having one death in a young person and the quality-of-life-years lost, it would take you thousands of gallbladders to make up for that one death.”

Dr. Sugarmen also asked for details on the deaths including where they occurred, in whom, and whether the centers were inexperienced.

Dr. Aminian could not recall at the time, but in an interview with this news organization said one death was in a 61-year-old with a history of cardiac disease and chronic kidney failure secondary to insulin-dependent diabetes who developed postop bleeding after gastric bypass. The second was in a 59-year-old patient, again on insulin, who was discharged without problems after gastric bypass, but died within 30 days after surgery.

Although most serious complications occur in this period, the main limitation of the study is that the dataset does not capture adverse events beyond 30 days after surgery, which can lead to underestimation of real risk, Dr. Aminian told the crowd.

“Further large clinical studies on long-term safety and efficacy outcomes of bariatric surgery in patients with type 2 diabetes and low BMI are warranted,” he said.

[email protected]

LOS ANGELES – A nationwide analysis shows modest early morbidity and low mortality following bariatric surgery in patients with type 2 diabetes who are not morbidly obese.

At 30 days’ follow-up among 1,003 patients, the composite complication rate, defined as the presence of any of 16 adverse events, was 4.2%; the reoperation rate was 1.6%; and two patients (0.2%) died.

Patrice Wendling/Frontline Medical News

“A 2-hour surgical procedure requiring a 2-day hospital stay that is associated with low morbidity and mortality can lead to remission of a chronic, progressive, and disabling disease,” lead author Dr. Ali Aminian of the Cleveland Clinic said at Obesity Week 2015.

“Based on these findings, bariatric surgery can be considered a relatively safe option for managing type 2 diabetes in patients with mild obesity.”

The analysis included adults with a body mass index of at least 25 kg/m², but less than 35 kg/m² (mean, 33 kg/m²).

These data are important because most patients with type 2 diabetes fall into this BMI category, he said.

Most of the patients were women (74.3%), 40% were using insulin, 78% had hypertension, and 9% had cardiac disease, according to the analysis, drawn from the American College of Surgery National Surgical Quality Improvement Program 2005-2013 database.

Roux-en-Y bypass was performed in 574 patients, adjustable gastric banding in 227, sleeve gastrectomy in 189, and duodenal switch in 13.

The most common adverse events overall were blood transfusion and reoperation (both 1.6%), a hospital stay longer than 7 days (0.6%), and organ space surgical-site infection (0.5%).

Composite morbidity and mortality was highest in the Roux-en-Y bypass group, compared with the adjustable banding and sleeve groups (5% vs. 3.1% vs. 3.2%, respectively), Dr. Aminian said at the meeting, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

Only 3 of 46 patients with a BMI of less than 30 kg/m² had an adverse event.

Available randomized controlled trials can’t clearly resolve the safety concerns of bariatric surgery in the subgroup of patients with type 2 diabetes who are overweight and mildly obese because such small trials are unlikely to reveal uncommon but clinically serious complications, Dr. Aminian said. In addition, many of the trials have screened out low-BMI and high-risk patients.

Those in attendance at the presentation, however, weren’t entirely convinced the current analysis could allay all safety concerns.

Session comoderator Dr. Daniel Cottam, a bariatric surgeon in group practice in Salt Lake City, said, “I like the summary; however, the use of the word ‘safe’ can be taken to mean a lot of things. It’s one of those squishy words.”

Though the authors have shown that bariatric surgery can be performed in diabetics with a low BMI, in order to say it is safe, the comparison needs to be drawn to the all-cause mortality for these patients in the general population and with other surgical procedures.

“That would be useful in the manuscript because as we approach our patients, we want to be able to say, ‘Listen, if you live with diabetes and a BMI of 25-35 for 5 years, this is your all-cause mortality, and surgery is going to save your life, not hurt it,’ ” Dr. Cottam said.

Along the same lines, Dr. Harvey Sugerman emeritus professor of surgery at Virginia Commonwealth University in Richmond, commented, “Like the old days of routinely operating on any patient with diabetes and gallstones, the data were that just having one death in a young person and the quality-of-life-years lost, it would take you thousands of gallbladders to make up for that one death.”

Dr. Sugarmen also asked for details on the deaths including where they occurred, in whom, and whether the centers were inexperienced.

Dr. Aminian could not recall at the time, but in an interview with this news organization said one death was in a 61-year-old with a history of cardiac disease and chronic kidney failure secondary to insulin-dependent diabetes who developed postop bleeding after gastric bypass. The second was in a 59-year-old patient, again on insulin, who was discharged without problems after gastric bypass, but died within 30 days after surgery.

Although most serious complications occur in this period, the main limitation of the study is that the dataset does not capture adverse events beyond 30 days after surgery, which can lead to underestimation of real risk, Dr. Aminian told the crowd.

“Further large clinical studies on long-term safety and efficacy outcomes of bariatric surgery in patients with type 2 diabetes and low BMI are warranted,” he said.

[email protected]

SAN FRANCISCO – It might be time to add psoriasis to the list of comorbidities bariatric surgery is likely to help.

New York University investigators have found a marked improvement in psoriasis and psoriatic arthritis following bariatric surgery, especially with severe disease. The more weight people lose, the better they do.

In an interview at the annual meeting of the American College of Rheumatology, investigator Dr. Soumya Reddy, codirector of NYU’s Psoriatic Arthritis Center in Manhattan, explained how the findings can be used in the clinic and their potential impact on bariatric surgery authorization.

[email protected]

SAN FRANCISCO – It might be time to add psoriasis to the list of comorbidities bariatric surgery is likely to help.

New York University investigators have found a marked improvement in psoriasis and psoriatic arthritis following bariatric surgery, especially with severe disease. The more weight people lose, the better they do.

In an interview at the annual meeting of the American College of Rheumatology, investigator Dr. Soumya Reddy, codirector of NYU’s Psoriatic Arthritis Center in Manhattan, explained how the findings can be used in the clinic and their potential impact on bariatric surgery authorization.

[email protected]

SAN FRANCISCO – It might be time to add psoriasis to the list of comorbidities bariatric surgery is likely to help.

New York University investigators have found a marked improvement in psoriasis and psoriatic arthritis following bariatric surgery, especially with severe disease. The more weight people lose, the better they do.

In an interview at the annual meeting of the American College of Rheumatology, investigator Dr. Soumya Reddy, codirector of NYU’s Psoriatic Arthritis Center in Manhattan, explained how the findings can be used in the clinic and their potential impact on bariatric surgery authorization.

[email protected]

CHICAGO – Weight loss and comorbidity reduction from Roux-en-Y gastric bypass remain durable at 10 years, according to a reviewof 651 patients at the University of Virginia in Charlottesville.

Investigators checked up on their patients after a decade because “the long-term durability of this operation remains ill-defined in the American population.” Their study, likely the largest American series with 10-year follow-up, helps “to more clearly define long-term outcomes that may be achieved following performance of Roux-en-Y gastric bypass and establish a benchmark for future clinical investigation,” they said.

M. Alex Otto/Frontline Medical News

The study included 335 open and 316 laparoscopic Roux-en-Y gastric bypass (RYGB) patients. Although gastric bypass is preformed laparoscopically at the university now, the team felt comfortable including open cases in the analysis because patients and outcomes were similar in both groups. The mean preoperative body mass index, for instance, was about 53 kg/m² and the mean operative time about 230 minutes. Postoperative incisional hernia and anastomotic stenosis were more likely with open surgery.

As in other studies, weight loss peaked at 24 months, with patients shedding a mean of 74% of their excess weight. Although that had fallen to a mean of 52% at 10 years, “they still kept off half of their excess weight, which is outstanding,” investigator and general surgery resident Dr. Hunter Mehaffey said at the annual clinical congress of the American College of Surgeons.

Surgery also led to persistent reductions in obesity-related comorbidities. Before RYGB, for instance, 38% of patients had gastroesophageal reflux disease, versus 29% after 10 years. Similarly, the prevalence of degenerative joint disease fell from 61% to 32%, diabetes from 41% to 18%, obstructive sleep apnea from 36% to 16%, hypertension from 59% to 47%, pulmonary problems from 28% to 13%, and psychiatric issues from 39% to 29%. About a quarter of patients had cardiac comorbidities before RYGB, versus 16% at 10 years after surgery. The data came from chart reviews and patient interviews, and the findings were statistically significant.

Overall, patients seemed glad to have had the operation, reporting an average satisfaction score of 8.7 out of 10 points, he said, adding, “I would expect these findings to be generalizable to other institutions. This is a good, durable operation.”

Given the scope of the comorbidity reductions, “the savings in health care costs” from RYGB “are likely underestimated,” Dr. Mehaffey said.

There was another lesson from the study, as well. It took a while to track down patients for 10-year follow-up because they were no longer seeing their surgeons. “If we are not going to see these patients much after 2 years, we really have to make sure that their primary care physician knows” how to recognize and manage possible complications, such as nutritional deficiency or hypoglycemia, he said.

Dr. Mehaffey had no disclosures, and there was no outside funding for the work.

[email protected]

CHICAGO – Weight loss and comorbidity reduction from Roux-en-Y gastric bypass remain durable at 10 years, according to a reviewof 651 patients at the University of Virginia in Charlottesville.

Investigators checked up on their patients after a decade because “the long-term durability of this operation remains ill-defined in the American population.” Their study, likely the largest American series with 10-year follow-up, helps “to more clearly define long-term outcomes that may be achieved following performance of Roux-en-Y gastric bypass and establish a benchmark for future clinical investigation,” they said.

M. Alex Otto/Frontline Medical News

The study included 335 open and 316 laparoscopic Roux-en-Y gastric bypass (RYGB) patients. Although gastric bypass is preformed laparoscopically at the university now, the team felt comfortable including open cases in the analysis because patients and outcomes were similar in both groups. The mean preoperative body mass index, for instance, was about 53 kg/m² and the mean operative time about 230 minutes. Postoperative incisional hernia and anastomotic stenosis were more likely with open surgery.

As in other studies, weight loss peaked at 24 months, with patients shedding a mean of 74% of their excess weight. Although that had fallen to a mean of 52% at 10 years, “they still kept off half of their excess weight, which is outstanding,” investigator and general surgery resident Dr. Hunter Mehaffey said at the annual clinical congress of the American College of Surgeons.

Surgery also led to persistent reductions in obesity-related comorbidities. Before RYGB, for instance, 38% of patients had gastroesophageal reflux disease, versus 29% after 10 years. Similarly, the prevalence of degenerative joint disease fell from 61% to 32%, diabetes from 41% to 18%, obstructive sleep apnea from 36% to 16%, hypertension from 59% to 47%, pulmonary problems from 28% to 13%, and psychiatric issues from 39% to 29%. About a quarter of patients had cardiac comorbidities before RYGB, versus 16% at 10 years after surgery. The data came from chart reviews and patient interviews, and the findings were statistically significant.

Overall, patients seemed glad to have had the operation, reporting an average satisfaction score of 8.7 out of 10 points, he said, adding, “I would expect these findings to be generalizable to other institutions. This is a good, durable operation.”

Given the scope of the comorbidity reductions, “the savings in health care costs” from RYGB “are likely underestimated,” Dr. Mehaffey said.

There was another lesson from the study, as well. It took a while to track down patients for 10-year follow-up because they were no longer seeing their surgeons. “If we are not going to see these patients much after 2 years, we really have to make sure that their primary care physician knows” how to recognize and manage possible complications, such as nutritional deficiency or hypoglycemia, he said.

Dr. Mehaffey had no disclosures, and there was no outside funding for the work.

[email protected]

CHICAGO – Weight loss and comorbidity reduction from Roux-en-Y gastric bypass remain durable at 10 years, according to a reviewof 651 patients at the University of Virginia in Charlottesville.

Investigators checked up on their patients after a decade because “the long-term durability of this operation remains ill-defined in the American population.” Their study, likely the largest American series with 10-year follow-up, helps “to more clearly define long-term outcomes that may be achieved following performance of Roux-en-Y gastric bypass and establish a benchmark for future clinical investigation,” they said.

M. Alex Otto/Frontline Medical News

The study included 335 open and 316 laparoscopic Roux-en-Y gastric bypass (RYGB) patients. Although gastric bypass is preformed laparoscopically at the university now, the team felt comfortable including open cases in the analysis because patients and outcomes were similar in both groups. The mean preoperative body mass index, for instance, was about 53 kg/m² and the mean operative time about 230 minutes. Postoperative incisional hernia and anastomotic stenosis were more likely with open surgery.

As in other studies, weight loss peaked at 24 months, with patients shedding a mean of 74% of their excess weight. Although that had fallen to a mean of 52% at 10 years, “they still kept off half of their excess weight, which is outstanding,” investigator and general surgery resident Dr. Hunter Mehaffey said at the annual clinical congress of the American College of Surgeons.

Surgery also led to persistent reductions in obesity-related comorbidities. Before RYGB, for instance, 38% of patients had gastroesophageal reflux disease, versus 29% after 10 years. Similarly, the prevalence of degenerative joint disease fell from 61% to 32%, diabetes from 41% to 18%, obstructive sleep apnea from 36% to 16%, hypertension from 59% to 47%, pulmonary problems from 28% to 13%, and psychiatric issues from 39% to 29%. About a quarter of patients had cardiac comorbidities before RYGB, versus 16% at 10 years after surgery. The data came from chart reviews and patient interviews, and the findings were statistically significant.

Overall, patients seemed glad to have had the operation, reporting an average satisfaction score of 8.7 out of 10 points, he said, adding, “I would expect these findings to be generalizable to other institutions. This is a good, durable operation.”

Given the scope of the comorbidity reductions, “the savings in health care costs” from RYGB “are likely underestimated,” Dr. Mehaffey said.

There was another lesson from the study, as well. It took a while to track down patients for 10-year follow-up because they were no longer seeing their surgeons. “If we are not going to see these patients much after 2 years, we really have to make sure that their primary care physician knows” how to recognize and manage possible complications, such as nutritional deficiency or hypoglycemia, he said.

Dr. Mehaffey had no disclosures, and there was no outside funding for the work.

[email protected]

SAN DIEGO – Nearly one-third of pain-related emergency room visits or hospital readmissions following same-day surgery were attributable to inadequate pain management in the peridischarge period, a large single-center analysis demonstrated.

“Pain management in the perioperative period is largely an anesthesiologist responsibility, but maybe it would be helpful if it was a little bit more multispecialty, if we had more communication,” study author Dr. Martha O. Herbst said in an interview at the annual meeting of the American Society of Anesthesiologists.

“There were some patients who came back for pain because they didn’t even receive prescriptions from their surgeon. Maybe a little better communication between the anesthesiologist and the surgeon on how to optimize specific patients and prevent those readmissions for pain would help,” she said.

Inspired by a similar study published in 2002 (J Clin Anesth. 2002;14[5]:349-53), Dr. Herbst, a fourth-year anesthesiology resident at Beaumont Hospital in Royal Oak, Mich., and her associates retrospectively evaluated the number of readmissions or revisits that occurred among 28,647 patients who underwent same-day surgery in the Beaumont Health system in 2012. A total of 1,559 revisits occurred during the study period. Of these, 621 (39.8%) were revisits related to the surgical procedure and 145 (9.3% overall and 23.3% of readmissions) were due to pain.

The researchers then stratified patients into one of six categories for readmission. These included all-cause pain (16%); surgical-related issues such as wound opening or reinfection (21%); medical issues such as exacerbation of chronic obstructive pulmonary disease (43%); bleeding complications such as hematuria, hemodialysis, and surgical site bleeding (6%); adverse medical reactions (2%); and other (12%).

Of the 145 patients who were readmitted for pain from the same-day surgery, 71% were deemed to have no pre-existing risk for readmission while 29% had at least one risk factor for readmission. These included opioid monotherapy during the procedure (11%), history of chronic pain (9%), no pain medication given during the procedure (4%), inadequate doses of analgesics used (3%), and discharge without a prescription for an analgesic (2%).

“There were people who got tiny doses of pain medications after a huge, painful procedure, so that was surprising,” Dr. Herbst said. “Maybe they weren’t optimally managed at the time of surgery.”

The findings, she concluded, underscore the need for a team-based approach to pain management in the same-day surgery population, with discharge planning focused on patient education, expectation management, multimodal analgesia optimization, and pain risk assessment.

The researchers reported having no financial disclosures.

[email protected]

SAN DIEGO – Nearly one-third of pain-related emergency room visits or hospital readmissions following same-day surgery were attributable to inadequate pain management in the peridischarge period, a large single-center analysis demonstrated.

“Pain management in the perioperative period is largely an anesthesiologist responsibility, but maybe it would be helpful if it was a little bit more multispecialty, if we had more communication,” study author Dr. Martha O. Herbst said in an interview at the annual meeting of the American Society of Anesthesiologists.

“There were some patients who came back for pain because they didn’t even receive prescriptions from their surgeon. Maybe a little better communication between the anesthesiologist and the surgeon on how to optimize specific patients and prevent those readmissions for pain would help,” she said.

Inspired by a similar study published in 2002 (J Clin Anesth. 2002;14[5]:349-53), Dr. Herbst, a fourth-year anesthesiology resident at Beaumont Hospital in Royal Oak, Mich., and her associates retrospectively evaluated the number of readmissions or revisits that occurred among 28,647 patients who underwent same-day surgery in the Beaumont Health system in 2012. A total of 1,559 revisits occurred during the study period. Of these, 621 (39.8%) were revisits related to the surgical procedure and 145 (9.3% overall and 23.3% of readmissions) were due to pain.

The researchers then stratified patients into one of six categories for readmission. These included all-cause pain (16%); surgical-related issues such as wound opening or reinfection (21%); medical issues such as exacerbation of chronic obstructive pulmonary disease (43%); bleeding complications such as hematuria, hemodialysis, and surgical site bleeding (6%); adverse medical reactions (2%); and other (12%).

Of the 145 patients who were readmitted for pain from the same-day surgery, 71% were deemed to have no pre-existing risk for readmission while 29% had at least one risk factor for readmission. These included opioid monotherapy during the procedure (11%), history of chronic pain (9%), no pain medication given during the procedure (4%), inadequate doses of analgesics used (3%), and discharge without a prescription for an analgesic (2%).

“There were people who got tiny doses of pain medications after a huge, painful procedure, so that was surprising,” Dr. Herbst said. “Maybe they weren’t optimally managed at the time of surgery.”

The findings, she concluded, underscore the need for a team-based approach to pain management in the same-day surgery population, with discharge planning focused on patient education, expectation management, multimodal analgesia optimization, and pain risk assessment.

The researchers reported having no financial disclosures.

[email protected]

SAN DIEGO – Nearly one-third of pain-related emergency room visits or hospital readmissions following same-day surgery were attributable to inadequate pain management in the peridischarge period, a large single-center analysis demonstrated.

“Pain management in the perioperative period is largely an anesthesiologist responsibility, but maybe it would be helpful if it was a little bit more multispecialty, if we had more communication,” study author Dr. Martha O. Herbst said in an interview at the annual meeting of the American Society of Anesthesiologists.

“There were some patients who came back for pain because they didn’t even receive prescriptions from their surgeon. Maybe a little better communication between the anesthesiologist and the surgeon on how to optimize specific patients and prevent those readmissions for pain would help,” she said.

Inspired by a similar study published in 2002 (J Clin Anesth. 2002;14[5]:349-53), Dr. Herbst, a fourth-year anesthesiology resident at Beaumont Hospital in Royal Oak, Mich., and her associates retrospectively evaluated the number of readmissions or revisits that occurred among 28,647 patients who underwent same-day surgery in the Beaumont Health system in 2012. A total of 1,559 revisits occurred during the study period. Of these, 621 (39.8%) were revisits related to the surgical procedure and 145 (9.3% overall and 23.3% of readmissions) were due to pain.

The researchers then stratified patients into one of six categories for readmission. These included all-cause pain (16%); surgical-related issues such as wound opening or reinfection (21%); medical issues such as exacerbation of chronic obstructive pulmonary disease (43%); bleeding complications such as hematuria, hemodialysis, and surgical site bleeding (6%); adverse medical reactions (2%); and other (12%).

Of the 145 patients who were readmitted for pain from the same-day surgery, 71% were deemed to have no pre-existing risk for readmission while 29% had at least one risk factor for readmission. These included opioid monotherapy during the procedure (11%), history of chronic pain (9%), no pain medication given during the procedure (4%), inadequate doses of analgesics used (3%), and discharge without a prescription for an analgesic (2%).

“There were people who got tiny doses of pain medications after a huge, painful procedure, so that was surprising,” Dr. Herbst said. “Maybe they weren’t optimally managed at the time of surgery.”

The findings, she concluded, underscore the need for a team-based approach to pain management in the same-day surgery population, with discharge planning focused on patient education, expectation management, multimodal analgesia optimization, and pain risk assessment.

The researchers reported having no financial disclosures.

[email protected]

LOS ANGELES – In the 3 years following bariatric surgery, 50%-70% of adults will experience clinically meaningful easing of bodily pain and improved physical function, a collaborative study shows.

Further, 75% of patients with severe knee and hip pain or disability had lessening of symptoms indicative of osteoarthritis, Wendy C. King, Ph.D., of the University of Pittsburgh Graduate School of Public Health, reported at Obesity Week 2015.

The study also sheds new light on several factors associated with easing of the debilitating joint pain and physical limitations that are common among patients undergoing bariatric surgery.

Previous studies have reported lessening of symptoms after surgery but had small sample sizes, short-term follow-up of 1 year or less, or used obsolete surgical procedures, she said.

The investigators followed 2,221 patients participating in the prospective, observational Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study who underwent weight-loss surgery at any of ten U.S. hospitals. Most (70%) had Roux-en-Y bypass, 25% laparoscopic adjustable gastric banding, and 5% other procedures. Their median age was 47 years, median body mass index 46 kg/m², and 79% were female. Follow-up assessment with several validated measures was available in 1,724 (72%) of patients at 3 years.

Short Form Health Survey (SF-36) scores at years 1, 2, and 3 of follow-up were 57.6, 53.5, and 48.6 for bodily pain and 76.5, 74.2, and 70.2 for physical function, Dr. King said.

Knee pain scores on the Western Ontario and McMaster Universities Arthritis Index (WOMAC) were 75.1 at 1 year, 71.6 at year 2, and 71.3 at year 3.

In Poisson mixed models, younger age, higher household income, and fewer depressive symptoms before surgery were among the factors independently related to a higher likelihood of easing of pain and improvements in function, she said. In addition, greater weight loss and lessening of depressive symptoms after surgery predicted easing of pain and improved physical function.

Opioid use and mobility deficits after bariatric surgery, however, proved more thorny outcomes to alter, Dr. King acknowledged.

Less than half of the 353 patients who reported opioid pain medication use at baseline discontinued opioids at years 1, 2, and 3 of follow-up (42.2%, 40.2%, 45.7%).

Only younger age and higher household income at baseline predicted discontinuation, she said. When the SF-36 pain score was added to the model to account for perceived pain, only having less presurgical pain and a more significant postsurgical lessening of pain were related to postsurgical cessation of opioid use.

“It’s possible that the improvement in depressive symptoms and improvement in pain and function are bidirectional,” Dr. King said. “So if you have improvement in pain and function, you may have improvement in depressive symptoms. But I think it’s noteworthy that presurgery depressive symptoms predicted lower likelihood of improvement in pain, suggesting that depressive symptoms may contribute to pain perception in this population.”

Mobility deficits, defined as the inability to complete a timed 400-m walk in 7 minutes, were present in 836 patients (44%) at entry, with deficit remission rates holding steady at each year of follow-up (55.6%, 55.8%, 56.5%).

After controlling for factors related to pain and function (age, income, depressive symptoms, weight loss), baseline pain and easing of pain were related to improvement in function. Thus, effective pain management may also improve physical function in this population, Dr. King suggested.

“These findings may help clinicians identify patients likely to require additional intervention to address pain and physical limitations that may otherwise limit or reduce their quality of life and pose significant barriers to their ability to adopt an active lifestyle,” she said at the meeting, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “There was some decline in the original improvement between year 1 and year 3, so I think it will be really important for us to get the 7-year data out there to see if that trend continues.”

[email protected]

LOS ANGELES – In the 3 years following bariatric surgery, 50%-70% of adults will experience clinically meaningful easing of bodily pain and improved physical function, a collaborative study shows.

Further, 75% of patients with severe knee and hip pain or disability had lessening of symptoms indicative of osteoarthritis, Wendy C. King, Ph.D., of the University of Pittsburgh Graduate School of Public Health, reported at Obesity Week 2015.

The study also sheds new light on several factors associated with easing of the debilitating joint pain and physical limitations that are common among patients undergoing bariatric surgery.

Previous studies have reported lessening of symptoms after surgery but had small sample sizes, short-term follow-up of 1 year or less, or used obsolete surgical procedures, she said.

The investigators followed 2,221 patients participating in the prospective, observational Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study who underwent weight-loss surgery at any of ten U.S. hospitals. Most (70%) had Roux-en-Y bypass, 25% laparoscopic adjustable gastric banding, and 5% other procedures. Their median age was 47 years, median body mass index 46 kg/m², and 79% were female. Follow-up assessment with several validated measures was available in 1,724 (72%) of patients at 3 years.

Short Form Health Survey (SF-36) scores at years 1, 2, and 3 of follow-up were 57.6, 53.5, and 48.6 for bodily pain and 76.5, 74.2, and 70.2 for physical function, Dr. King said.

Knee pain scores on the Western Ontario and McMaster Universities Arthritis Index (WOMAC) were 75.1 at 1 year, 71.6 at year 2, and 71.3 at year 3.

In Poisson mixed models, younger age, higher household income, and fewer depressive symptoms before surgery were among the factors independently related to a higher likelihood of easing of pain and improvements in function, she said. In addition, greater weight loss and lessening of depressive symptoms after surgery predicted easing of pain and improved physical function.

Opioid use and mobility deficits after bariatric surgery, however, proved more thorny outcomes to alter, Dr. King acknowledged.

Less than half of the 353 patients who reported opioid pain medication use at baseline discontinued opioids at years 1, 2, and 3 of follow-up (42.2%, 40.2%, 45.7%).

Only younger age and higher household income at baseline predicted discontinuation, she said. When the SF-36 pain score was added to the model to account for perceived pain, only having less presurgical pain and a more significant postsurgical lessening of pain were related to postsurgical cessation of opioid use.

“It’s possible that the improvement in depressive symptoms and improvement in pain and function are bidirectional,” Dr. King said. “So if you have improvement in pain and function, you may have improvement in depressive symptoms. But I think it’s noteworthy that presurgery depressive symptoms predicted lower likelihood of improvement in pain, suggesting that depressive symptoms may contribute to pain perception in this population.”

Mobility deficits, defined as the inability to complete a timed 400-m walk in 7 minutes, were present in 836 patients (44%) at entry, with deficit remission rates holding steady at each year of follow-up (55.6%, 55.8%, 56.5%).

After controlling for factors related to pain and function (age, income, depressive symptoms, weight loss), baseline pain and easing of pain were related to improvement in function. Thus, effective pain management may also improve physical function in this population, Dr. King suggested.

“These findings may help clinicians identify patients likely to require additional intervention to address pain and physical limitations that may otherwise limit or reduce their quality of life and pose significant barriers to their ability to adopt an active lifestyle,” she said at the meeting, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “There was some decline in the original improvement between year 1 and year 3, so I think it will be really important for us to get the 7-year data out there to see if that trend continues.”

[email protected]

LOS ANGELES – In the 3 years following bariatric surgery, 50%-70% of adults will experience clinically meaningful easing of bodily pain and improved physical function, a collaborative study shows.

Further, 75% of patients with severe knee and hip pain or disability had lessening of symptoms indicative of osteoarthritis, Wendy C. King, Ph.D., of the University of Pittsburgh Graduate School of Public Health, reported at Obesity Week 2015.

The study also sheds new light on several factors associated with easing of the debilitating joint pain and physical limitations that are common among patients undergoing bariatric surgery.

Previous studies have reported lessening of symptoms after surgery but had small sample sizes, short-term follow-up of 1 year or less, or used obsolete surgical procedures, she said.

The investigators followed 2,221 patients participating in the prospective, observational Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study who underwent weight-loss surgery at any of ten U.S. hospitals. Most (70%) had Roux-en-Y bypass, 25% laparoscopic adjustable gastric banding, and 5% other procedures. Their median age was 47 years, median body mass index 46 kg/m², and 79% were female. Follow-up assessment with several validated measures was available in 1,724 (72%) of patients at 3 years.

Short Form Health Survey (SF-36) scores at years 1, 2, and 3 of follow-up were 57.6, 53.5, and 48.6 for bodily pain and 76.5, 74.2, and 70.2 for physical function, Dr. King said.

Knee pain scores on the Western Ontario and McMaster Universities Arthritis Index (WOMAC) were 75.1 at 1 year, 71.6 at year 2, and 71.3 at year 3.

In Poisson mixed models, younger age, higher household income, and fewer depressive symptoms before surgery were among the factors independently related to a higher likelihood of easing of pain and improvements in function, she said. In addition, greater weight loss and lessening of depressive symptoms after surgery predicted easing of pain and improved physical function.

Opioid use and mobility deficits after bariatric surgery, however, proved more thorny outcomes to alter, Dr. King acknowledged.

Less than half of the 353 patients who reported opioid pain medication use at baseline discontinued opioids at years 1, 2, and 3 of follow-up (42.2%, 40.2%, 45.7%).

Only younger age and higher household income at baseline predicted discontinuation, she said. When the SF-36 pain score was added to the model to account for perceived pain, only having less presurgical pain and a more significant postsurgical lessening of pain were related to postsurgical cessation of opioid use.

“It’s possible that the improvement in depressive symptoms and improvement in pain and function are bidirectional,” Dr. King said. “So if you have improvement in pain and function, you may have improvement in depressive symptoms. But I think it’s noteworthy that presurgery depressive symptoms predicted lower likelihood of improvement in pain, suggesting that depressive symptoms may contribute to pain perception in this population.”

Mobility deficits, defined as the inability to complete a timed 400-m walk in 7 minutes, were present in 836 patients (44%) at entry, with deficit remission rates holding steady at each year of follow-up (55.6%, 55.8%, 56.5%).

After controlling for factors related to pain and function (age, income, depressive symptoms, weight loss), baseline pain and easing of pain were related to improvement in function. Thus, effective pain management may also improve physical function in this population, Dr. King suggested.

“These findings may help clinicians identify patients likely to require additional intervention to address pain and physical limitations that may otherwise limit or reduce their quality of life and pose significant barriers to their ability to adopt an active lifestyle,” she said at the meeting, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “There was some decline in the original improvement between year 1 and year 3, so I think it will be really important for us to get the 7-year data out there to see if that trend continues.”

[email protected]

LOS ANGELES – An increasing number of adolescents are undergoing gastric band removal after 2 years post operation, a prospective, longitudinal study shows.

“At 2 years most bands are still in place, with 96% of patients having them. After this point, however, multiple bands are removed each year, demonstrating that 2 years perhaps is only the tip of the iceberg,” Dr. Christine Schad said at Obesity Week.

Indeed, the number of adolescents with bands in place reduced to 87%, 76%, and 53% at years 3, 4, and 5 of follow-up. After 5 years, patients continued to undergo band removal.

Like their adult counterparts, adolescents underwent band removal secondary to weight loss failure, reflux esophagitis, and refractory gastric prolapse, Dr. Schad of Morgan Stanley Children’s Hospital, New York-Presbyterian Columbia University Medical Center, New York, said.

Weight loss seemed to plateau over time among the 79 evaluable adolescents, with less than 39% of patients able to lose more than 50% of their excess body weight over the 5-year study.

“Although gastric banding can be performed safely, 2 years seems inadequate to evaluate efficacy,” she said.

The use of adjustable gastric banding rose rapidly after Food and Drug Administration approval in 2001, thanks to low perioperative morbidity, reversibility, and good early results.

Gastric banding has fallen sharply, however, with recent adult studies showing a high incidence of weight loss failure, weight regain, and device-related complications.

Previous studies have reported on the safety of laparoscopic adjustable gastric banding in adolescents; however, these studies are limited to 3-year follow-up at most, Dr. Schad said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

The investigators enrolled 137 morbidly obese adolescents, aged 14-18 years, who underwent laparoscopic adjustable gastric banding from 2006 to 2011. The current analysis included patients with at least 5 years follow-up and patients who had band removal at any point or who did not survive to study end. There were two deaths. The remaining patients had not reached the 5-year follow-up mark or still had their bands in place.

The 79 evaluable patients had a preoperative weight of 138 kg, body mass index of 49.3 kg/m², and excess body weight of 47.2%. At the time of surgery, their average age was 16.9 years, 71% were female, 43% Hispanic, 36.7% white, and 16.5% black.

Even though gastric banding is declining, the results are important because there has been little information about adolescents, and in some parts of the country, gastric banding may be the only available option, session comoderator Dr. Robert Carpenter of Scott & White Healthcare in Temple, Tex., said in an interview.

“The other issue is that there are a lot of pediatricians that only want their patients to have nonstapled, nondivided operations,” he said. “If that’s the case, and we now know that perhaps for adolescents there is a 30%, 40%, 50% conversion and/or failure rate, then we are putting these kids at an extreme risk.”

Oftentimes, these adolescents also won’t have an opportunity for another operation.

“Many insurance companies that they’ll transition to away from their parents will actually have a complete exclusion for bariatric surgery or they have a onetime, lifetime operative opportunity,” Dr. Carpenter said. “So, if that’s been burned, it’s burned.”

[email protected]

LOS ANGELES – An increasing number of adolescents are undergoing gastric band removal after 2 years post operation, a prospective, longitudinal study shows.

“At 2 years most bands are still in place, with 96% of patients having them. After this point, however, multiple bands are removed each year, demonstrating that 2 years perhaps is only the tip of the iceberg,” Dr. Christine Schad said at Obesity Week.

Indeed, the number of adolescents with bands in place reduced to 87%, 76%, and 53% at years 3, 4, and 5 of follow-up. After 5 years, patients continued to undergo band removal.

Like their adult counterparts, adolescents underwent band removal secondary to weight loss failure, reflux esophagitis, and refractory gastric prolapse, Dr. Schad of Morgan Stanley Children’s Hospital, New York-Presbyterian Columbia University Medical Center, New York, said.

Weight loss seemed to plateau over time among the 79 evaluable adolescents, with less than 39% of patients able to lose more than 50% of their excess body weight over the 5-year study.

“Although gastric banding can be performed safely, 2 years seems inadequate to evaluate efficacy,” she said.

The use of adjustable gastric banding rose rapidly after Food and Drug Administration approval in 2001, thanks to low perioperative morbidity, reversibility, and good early results.

Gastric banding has fallen sharply, however, with recent adult studies showing a high incidence of weight loss failure, weight regain, and device-related complications.

Previous studies have reported on the safety of laparoscopic adjustable gastric banding in adolescents; however, these studies are limited to 3-year follow-up at most, Dr. Schad said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

The investigators enrolled 137 morbidly obese adolescents, aged 14-18 years, who underwent laparoscopic adjustable gastric banding from 2006 to 2011. The current analysis included patients with at least 5 years follow-up and patients who had band removal at any point or who did not survive to study end. There were two deaths. The remaining patients had not reached the 5-year follow-up mark or still had their bands in place.

The 79 evaluable patients had a preoperative weight of 138 kg, body mass index of 49.3 kg/m², and excess body weight of 47.2%. At the time of surgery, their average age was 16.9 years, 71% were female, 43% Hispanic, 36.7% white, and 16.5% black.

Even though gastric banding is declining, the results are important because there has been little information about adolescents, and in some parts of the country, gastric banding may be the only available option, session comoderator Dr. Robert Carpenter of Scott & White Healthcare in Temple, Tex., said in an interview.

“The other issue is that there are a lot of pediatricians that only want their patients to have nonstapled, nondivided operations,” he said. “If that’s the case, and we now know that perhaps for adolescents there is a 30%, 40%, 50% conversion and/or failure rate, then we are putting these kids at an extreme risk.”

Oftentimes, these adolescents also won’t have an opportunity for another operation.

“Many insurance companies that they’ll transition to away from their parents will actually have a complete exclusion for bariatric surgery or they have a onetime, lifetime operative opportunity,” Dr. Carpenter said. “So, if that’s been burned, it’s burned.”

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LOS ANGELES – An increasing number of adolescents are undergoing gastric band removal after 2 years post operation, a prospective, longitudinal study shows.

“At 2 years most bands are still in place, with 96% of patients having them. After this point, however, multiple bands are removed each year, demonstrating that 2 years perhaps is only the tip of the iceberg,” Dr. Christine Schad said at Obesity Week.

Indeed, the number of adolescents with bands in place reduced to 87%, 76%, and 53% at years 3, 4, and 5 of follow-up. After 5 years, patients continued to undergo band removal.

Like their adult counterparts, adolescents underwent band removal secondary to weight loss failure, reflux esophagitis, and refractory gastric prolapse, Dr. Schad of Morgan Stanley Children’s Hospital, New York-Presbyterian Columbia University Medical Center, New York, said.

Weight loss seemed to plateau over time among the 79 evaluable adolescents, with less than 39% of patients able to lose more than 50% of their excess body weight over the 5-year study.

“Although gastric banding can be performed safely, 2 years seems inadequate to evaluate efficacy,” she said.

The use of adjustable gastric banding rose rapidly after Food and Drug Administration approval in 2001, thanks to low perioperative morbidity, reversibility, and good early results.

Gastric banding has fallen sharply, however, with recent adult studies showing a high incidence of weight loss failure, weight regain, and device-related complications.

Previous studies have reported on the safety of laparoscopic adjustable gastric banding in adolescents; however, these studies are limited to 3-year follow-up at most, Dr. Schad said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

The investigators enrolled 137 morbidly obese adolescents, aged 14-18 years, who underwent laparoscopic adjustable gastric banding from 2006 to 2011. The current analysis included patients with at least 5 years follow-up and patients who had band removal at any point or who did not survive to study end. There were two deaths. The remaining patients had not reached the 5-year follow-up mark or still had their bands in place.

The 79 evaluable patients had a preoperative weight of 138 kg, body mass index of 49.3 kg/m², and excess body weight of 47.2%. At the time of surgery, their average age was 16.9 years, 71% were female, 43% Hispanic, 36.7% white, and 16.5% black.

Even though gastric banding is declining, the results are important because there has been little information about adolescents, and in some parts of the country, gastric banding may be the only available option, session comoderator Dr. Robert Carpenter of Scott & White Healthcare in Temple, Tex., said in an interview.

“The other issue is that there are a lot of pediatricians that only want their patients to have nonstapled, nondivided operations,” he said. “If that’s the case, and we now know that perhaps for adolescents there is a 30%, 40%, 50% conversion and/or failure rate, then we are putting these kids at an extreme risk.”

Oftentimes, these adolescents also won’t have an opportunity for another operation.

“Many insurance companies that they’ll transition to away from their parents will actually have a complete exclusion for bariatric surgery or they have a onetime, lifetime operative opportunity,” Dr. Carpenter said. “So, if that’s been burned, it’s burned.”

[email protected]