Welcome to our weekly round-up of the latest bariatric and obesity-related papers published in the medical literature. As ever, we have looked far and wide to give you an overview of papers including a paper by the SAGES Foregut Taskforce on insurance coverage for RYGB for GERD, erector spinae plane block improves postoperative quality of recovery, prior bariatric surgery independently associated with decreased mortality in patients hospitalised for COVID-19, concomitant cholecystectomy during sleeve gastrectomy and gastric bypass should be avoided and a study assessing percentage alterable weight loss (%AWL), and more (please note, log-in maybe required to access the full paper).
Surgeon experience with insurance barriers to offering gastric bypass as an evidence-based operation for pathologic GERD
The SAGES Foregut Taskforce has reported for many patients, gastroesophageal reflux disease (GERD) and obesity are related diseases that are best addressed with Roux-en-Y gastric bypass (RYGB) however, insurance coverage for RYGB for GERD is often limited by policies which run contrary to evidence-based medicine.
Writing in Surgical Endoscopy, they noted that surgeons report access to RYGB as surgical treatment for GERD is often limited by RYGB-specific benefit exclusions embedded within insurance policies, but the magnitude and scope of this problem is unknown. The Taskforce carried out a 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD.
In total, 187 surgeons completed the survey and 89% reported using the RYGB as an anti-reflux procedure. 44% and 26% used a BMI of 35 kg/m2 and 30 kg/m2 respectively as cutoff for the RYGB. A further 69% reported using RYGB to address recurrent reflux secondary to failed fundoplication however, 74% of responders experienced trouble with insurance coverage at least half the time RYGB was offered for GERD, and 8% reported they were never able to get approval for RYGB for GERD indications in their patient populations.
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Efficacy of the Erector Spinae Plane Block for Quality of Recovery in Bariatric Surgery: a Randomized Controlled Trial
Researchers from Karamanoğlu Mehmetbey University, Karaman, Turkey, have reported erector spinae plane block (ESPB) improved postoperative quality of recovery, reduced numerical rating scale (NRS) scores and total analgesic consumption in patients with obesity undergoing bariatric surgery.
Writing in Obesity Surgery, 80 patients were randomised either bilateral ESPB (group E) each side or no block (group C). The primary aim was to evaluate the effects of ESPB on the quality of recovery 24h postoperatively in bariatric surgery by using 40-item Quality of Recovery-40 (QoR-40) questionnaire.
Postoperative mean QoR-40 scores were found to be higher in group E (175.02±11.25) than in group C (167.78±18.59) at the postoperative 24th hour (p<0.05). Pain scores at rest and during movement were higher in group C than in group E. At the postoperative 24th hour, NRS mean SD scores at rest for group C and group E were 3.25±1.32 and 2.40±0.96, respectively. NRS mean SD scores during movement for groups C and E were 3.88±1.49 and 3.12±1.30, respectively. The total amount of tramadol consumed in the first 24 h in group C and group E were mean SD: 86.40±69.60 and 40.00±46.96, respectively; p<0.05.
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Prior Bariatric Surgery and Risk of Poor In-Hospital Outcomes in COVID-19: Findings from a National Inpatient Sample
Prior bariatric surgery was independently associated with decreased mortality and better in-hospital outcomes in patients hospitalised for COVID-19, according to researchers from Boston University Chobanian & Avedisian School of Medicine, Boston, MA.
Published in SOARD, they hypothesised that prior bariatric surgery may be associated with a reduced risk of severe COVID-19 and they retrospectively analysed 2020 Healthcare Cost and Utilization Project National Inpatient Sample. All patients diagnosed with COVID-19 were examined, and stratified by history of bariatric surgery. They performed 1:1 propensity score-matching and compared patients with COVID-19 with and without prior bariatric surgery.
The outcomes showed that in-hospital mortality rate was significantly lower in patients with prior bariatric surgery (6.2% vs. 8.7%, p=0.001). Furthermore, sepsis, acute kidney injury, and mechanical ventilation rates were significantly lower in patients with COVID-19 and prior bariatric surgery, resulting in a reduced need for intensive treatment (12.1% vs. 14.9%, p=0.005).
In addition, total hospitalisation costs were lower and length of hospital stay was shorter in patients with prior bariatric surgery, demonstrating statistical significance. Old age, male sex, BMI >50, and comorbidities were significantly associated with in-hospital mortality in patients with COVID-19 and prior bariatric surgery.
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Risk-Benefit Balance of Simultaneous Gastric Bypass or Sleeve Gastrectomy and Concomitant Cholecystectomy - A Comprehensive Nationwide Cohort of 289,627 Patients
Concomitant cholecystectomy (CC) during sleeve gastrectomy (SG) and gastric bypass (GBP) should be avoided, according to a study led by researchers from Lille University Hospital, Lille, France.
Published in the Annals of Surgery, they assessed the relevance of concomitant laparoscopic metabolic bariatric surgery (MBS) and cholecystectomy. This nationwide retrospective cohort research was conducted in two parts using information from a national administrative database (PMSI). The 90-day morbidity of MBS with or without CC was first compared in a matched trial (propensity score). Then they observed medium-term biliary complication following MBS when no CC had been performed during MBS up to nine years after MBS.
Between 2013 and 2020, a total of 289,627 patients had a SG (70%) or GBP (30%), with the principal indications of CC were symptomatic cholelithiasis (79.5%) or acute cholecystitis (3.6%). Prophylactic CC occurred only in 15.5% of the cases. In the matched group analysis, they included 9,323 patients in each arm. The complication rate at Day 90 after surgery was greater in the CC arm (p<0.001], independently of the reason of the CC. At 18 months, there was a 0.1% risk of symptomatic gallstone migration and a 0.08% risk of biliary pancreatitis.
At nine years, 20.5±0.52% of patients underwent an interval cholecystectomy (IC) and the likelihood of IC decreased from 5.4% per year to 1.7% per year after the first 18 months the whole cohort, risk at 18 months of symptomatic gallstone migration was 0.1%, of pancreatitis 0.08%, and of angiocholitis 0.1%.
In case of asymptomatic gallstones after MBS, prophylactic cholecystectomy should not be recommended, they added.
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Study on weight loss outcomes after bariatric surgery to determine a metric least influenced by preoperative BMI
Percentage excess weight loss (%EWL) is least influenced by initial BMI during short-term follow-up after LSG and LRYGB, according to researchers from Changi General Hospital, Singapore.
Writing in the International Journal of Obesity, they noted that %EWL and percentage total weight loss (%TWL) are not ideal for comparing outcomes on populations of varied initial BMI. Their study sought to validate a recently introduced metric - percentage alterable weight loss (%AWL), after LSG and RYGB.
The study included 1,020 LSG and 322 LRYGB patients, with initial mean BMI of 43.5±7.5 and 41.9±8.3 kg/m2, respectively. They reported that %EWL significantly favours lower BMI subgroups for both procedures, whilst %TWL is ideal for comparing weight loss during the first six months but it then favours higher BMI subgroups beyond six months.
Interestingly, they reported that %AWL with reference BMI of 13 kg/m2 seems the best metric for medium-term comparison of weight loss for LRYGB and an intermediary metric based on BMI 8 kg/m2 provides the best fit for medium-term comparison for LSG.
They concluded that in the medium-term comparison, %AWL is best suited for RYGB while an intermediary metric is found to provide the best fit for LSG.
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