Ghanem, Omar M.

Introduction: Patients undergoing bariatric surgery with body mass index (BMI) >50 kg/m2 are at a higher risk of surgical morbidity when compared with less obese patients, however, there is limited data correlating surgical risk and efficacy with increasing BMI in patients with severe obesity. We hypothesize that regardless of the degree above 50 kg/m2 their BMI, patients with severe obesity respond similarly to bariatric surgery. Materials and Methods: We performed a retrospective analysis of patients with BMI >50 kg/m2 who underwent biliopancreatic diversion with duodenal switch, Roux-en-Y gastric bypass, or sleeve gastrectomy at a single institution. Outcomes were compared in patients with a BMI between 50 and 60 kg/m2 to patients with a BMI >60 kg/m2 and included percent total weight loss as well as early and late complications. Statistical analyses were performed using logistic regression, univariate, and multivariate models. Results: There were 571 patients with BMI >50 kg/m2 who underwent bariatric surgery at our center, 170 (29.8%) had a BMI >60 kg/m2. Percent total weight loss was statistically significant between the BMI 50 and 60 kg/m2 and BMI >60 kg/m2 groups at 24 months (P=0.047) but not at 60 months (P=0.54). No significant difference was found in the incidence of early complications in a univariate (P=0.46) or a multivariate (P=0.06) analysis. The BMI >60 subgroup was associated with a higher rate of late complications in univariate analysis (heart rate=2.37; 1.03-5.47, P=0.04), but not in multivariate analysis (P=0.78). Conclusions: Efficacy and complication rates of bariatric surgeries are similar in patients with BMI 50 to 60 kg/m2 and >60 kg/m2, providing evidence supporting similar management of patients despite specific subgroups.

Background: Bariatric surgery is the most effective treatment for weight loss and obesity-related comorbidity resolution. However, bariatric surgery is not readily offered in specific populations due to the lack of data assessing its feasibility. This study intends to evaluate bariatric surgery in patients with an existing ostomy. Methods: We conducted a retrospective case series to assess the safety of Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) in patients with an end ileostomy or colostomy. Patient demographics, including obesity-related comorbidities, overall health status (American Society of Anesthesiologists score), and short-term complications (up to 30 days postoperatively), were analyzed. Results: Six patients were included. The mean age was 58 years, and the mean preoperative body mass index was 41.6. Three patients had a colostomy, and three had an ileostomy. The mean time of ostomy before surgery was 11 years. Two ostomies were due to trauma, two due to inflammatory bowel disease, one due to cancer, and one due to scleroderma. Mean postoperative follow-up was 23 months. No patient had increased ostomy output or infusion center visit. One patient had an ED visit, one had a short-term complication, and one had SG conversion to RYGB. Conclusions: Bariatric surgery is technically feasible in selected patients with ileostomy/colostomy with a reasonable short-term safety profile.

While the safety of video follow-up in bariatric surgery is established, patients’ perception of telemedicine visits remained unknown. A randomized clinical trial evaluating patients’ perception of video postoperative follow-up (F/U) visits was conducted in the pre COVID-19 era. 24 patients were randomized in the preoperative clinic to receive either in-person or video F/U, and then surveyed about their experience and preference. The majority reported that if they had to do it over, they would prefer a video visit. Among those who received video visits, 11/12 reported that the lack of physical contact was acceptable. 82% of the video group expressed that their visit was better or as good as an in-person visit, while 9% were not sure, and 9% reported that video was worse. This finding suggests that postoperative video follow-up visits are acceptable among bariatric surgery patients and should be offered as an alternative to traditional visits.

Background: Nondepolarizing neuromuscular blockade is reversed with neostigmine/glycopyrrolate or sugammadex. Anticholinergic glycopyrrolate decreases bladder detrusor muscle contractility, potentially leading to postoperative urinary retention (POUR). POUR commonly complicates inguinal herniorrhaphy. In this study we assess association between reversal technique and POUR. Methods: Records of adult patients undergoing unilateral inguinal herniorrhaphy with neuromuscular blockade from January 2013 to September 2020 were reviewed for POUR (unplanned postoperative insertion of urinary catheter). A propensity-adjusted analysis was performed to assess POUR in neostigmine/glycopyrrolate versus sugammadex using inverse probability of treatment weighting (IPTW) to adjust for potential confounding. Results: We identified 181 patients who underwent herniorrhaphy with amnio-steroidal neuromuscular blockers, 75 (41.4%) who received sugammadex and 106 (58.6%) neostigmine/glycopyrrolate. Compared with sugammadex, neostigmine/glycopyrrolate group had longer surgical course [unweighted standardized difference (USTD)=0.38, P=0.004], received more intraoperative opioids (USTD=0.704, P<0.001), more often performed via laparoscopic approach (USTD=0.407, P=0.012), and less often with periprocedural urinary catheter insertion (USTD=0.452, P=0.003). POUR was observed in 2 (3%) of patients in the sugammadex group, and 16 (15%) in neostigmine/glycopyrrolate [unadjusted odds ratio (OR)=0.15; 95% confidence interval (CI): 0.03-0.69; P=0.015, and IPTW OR=0.13; 95% CI: 0.03-0.64; P=0.012]. Results remained similar with further analysis adjusted for opioid administration in the postanesthesia care unit (adjusted IPTW OR=0.18; 95% CI: 0.04-0.88; P=0.034). Of the POUR patients, 9 required unplanned overnight admission and 4 emergency room visit. Conclusion: These results suggest that neuromuscular blockade reversal with sugammadex is associated with lower rates of POUR following unilateral inguinal herniorrhaphy. Our results need to be reconfirmed in a randomized prospective study.