Dr. Callery

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  1. Dear JoeG, Inadequate weight loss 10 months after sleeve gastrectomy is extremely frustrating. The sleeve may be too large to be effective, you may be eating more than you realize, or both. An upper GI series with food is an effective way to evaluate sleeve size. If it really is too large, then going back and recutting the sleeve is a reasonable option. Any type of revision surgery is riskier than initial surgery because of scar tissue. The staple line leak rate is increased several fold over primary surgery. I did a search of the medical literature on PubMed, and couldn't find any medical articles describing the success or complication rates of resleeving. Another option would be to convert the sleeve to a gastric bypass. This might be easier technically and perhaps safer depending on the shape of the upper part of the sleeve and the amount of scar tissue present. It could be a fall back option if your surgeon finds too much scar tissue at the time of the resleeve procedure. Also it might be better if you have significant diabetes. Again, there is little data in the medical literature to inform these decisions. So in summary, resleeving can be a good option. You may achieve much better long term success. You just want to be absolutely sure that your dietary choices aren't the real issue. Patients who are snacking, comfort feeding, and eating a high carb diets frequently continue to do so after revision. For success: good surgery and good choices. Dr. Callery
  2. Dear North Star, As you know a bougie is a flexible tube that is place in the stomach by the anesthesiologist. The surgeon uses the bougie to guide the stomach transection (cut/stapling). Bougie sizes are expressed in French (Fr.) units. Divide the Fr. by 3 to get mm. So 42 Fr. is the same as 13 mm. If the sleeve is too tight, people can't eat thicker foods. If the stomach is too large, there is less restriction. There may also be an increased risk of staple line leak if the stomach is too narrow. Here's were it gets tricky. Many surgeons use the bougie as a guide, but don't cut exactly on the bougie. To do so would leave the stomach too narrow near the top of the stomach and near the bend in the stomach (angula incisura). So surgeons often cut wide of the bouie as needed. There is no absolute agreement on bougie size, and there is little objective research that can be used to inform a surgeon's choice. To make matters even trickier, there is a lot of variation from stomach to stomach. Some are thicker or thinner and some are more or less elastic. These differences can make getting an exact diameter of the sleeve difficult. In addition the stomach isn't flat. It bends toward the back near the top. So getting a nice clean staple line going around a bend while not getting too close to the esophagus is a challenge. Bougie size choices range from 36 to 50. The "consensus" among surgeons who have done large numbers of cases is that about 40 Fr. best. However, as we all know consensus is a good starting point. There is no substitute for carefully done research. "The great tragedy of science - the slaying of beautiful hypothesis by and ugly fact." - Thomas Huxley. Bariatric surgeries including the sleeve are "tools" to help with weight loss. The sleeve works partially by restriction, partially by changes in internal hormone signalling, and to a great extent by patient behavior. As you know behavior is a matter of choice. But choice is a tricky issue. Our choices are a matter of immediate will power, but are influenced by environment, social factors, and genetics. The sleeve is definitely more restrictive early on, and like the bypass, becomes looser as time passes. Hormonal effects of surgery may be more profound early one and less so later. Finally, people are often more highly motivated at first, and lose resolve with time. So as you can see there are a lot of trade-offs. Larger diameter sleeves may be safer, but may not give quite as much resistance to eating. Sleeve diameter is probably not related to hormonal effect. Sleeve diameter doesn't affect a patient's social setting, genetics, or activity level. Before surgery each patient should have a discussion with her/his surgeon about technical aspects of the surgery and expectations for weight loss and relief of medical problems. From a practical standpoint, after surgery, each person should make the best of the situation. If you are not losing weight as quickly as you expect,discuss it with your surgeon. Are your expectations realistic given your preop weight and medical condition? How many calories are you taking in each day. It's easy to over eat after any operation by nibbling or snacking. What is the quality of the food that you are eating? Are you getting in as much physical activity as possible? Are you getting a good night's sleep? Who are your hanging out with, and what are their eating habits? Are you taking medications that tend to make you hungrier? Can you do anything to reduce your stress level? In summary, bougie size matters, but it's only one of many things that matter. Patients can see a real improvement in their health and weight regardless of which size bougie the surgeon uses. Choose healthy, be active, and have a Happy New Year, Dr. Callery Surg Endosc. 2015 Jul 21. [Epub ahead of print]Laparoscopic sleeve gastrectomy with 27 versus 39 Fr bougie calibration: a randomized controlled trial.Cal P1, Deluca L, Jakob T, Fernández E.BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a widely used primary bariatric surgery. As this is a restrictive procedure, calibrating bougie size is assumed to impact on both morbidity and weight loss. However, no prospective studies have confirmed this hypothesis. The objective of this trial was to compare LSG outcomes using different calibrating bougie diameters. MATERIALS AND METHODS:A randomized controlled trial: 126 patients undergoing LSG were randomized to either a 27-Fr (group A) or a 39-Fr (group calibrating bougie. Inclusion criteria were BMI 40-50 kg/m2, aged 20-70 and absence of prior gastric surgery. All surgeries were performed by the same surgeon. Sample size was calculated to detect a six-point difference in percentage of excess weight loss (%EWL) at 1 year after surgery, considering an α error = 0.05 and a β error = 0.2. The volume of resected stomach, morbidity and weight loss at 6 months and at 1 year after surgery were analyzed. RESULTS:Groups (group A n = 62, group B n = 64) were similar in BMI (44.3 vs. 43.5), aged (41.9 vs. 42.2) and female percentage (87.1 vs. 84.3 %). A 1-year follow-up was achieved in 90.1 and 87.1 %, respectively. Two major complications occurred, one leak in each group (1.6 %). The volume of resected stomach was similar (426 vs. 402 ml, P = 0.71), as well as 6 months %EWL (66.3 vs. 66.6 %; P = 0.91) and 1 year %EWL (75.6 vs. 71.3 %, P = 0.21). A 1-year %EWL higher than 50 was achieved in 96.5 % of patients in group A versus 85.2 % in group B (P = 0.11). CONCLUSIONS:The use of different bougie diameters had no impact on the volume of resected stomach, morbidity or short-term weight loss after LSG, although a trend was seen toward better weight loss with the smaller bougie. A longer-lasting follow-up will be necessary to further assess differences. ______________________________________________________________________________________________________________________________________________ Obes Surg. 2014 Jul;24(7):1090-3. doi: 10.1007/s11695-014-1199-9.Laparoscopic sleeve gastrectomy using 42-French versus 32-French bougie: the first-year outcome.Spivak H1, Rubin M, Sadot E, Pollak E, Feygin A, Goitein D.BACKGROUND:The optimal size of bougie in laparoscopic sleeve gastrectomy (LSG) remains controversial. The aim of this study was to evaluate the first-year outcome of LSG using two different sizes of bougies. METHODS:This study used a single institute retrospective case-control study of two groups of patients. Group A (N = 66) underwent LSG using 42-Fr and group B (N = 54) using 32-Fr bougies. A medication score was applied to assess the change in comorbid conditions. RESULTS:Groups A and B's age (39.5 ± 12 vs. 43.6 ± 12.3 years), weight (119 ± 17 vs. 120 ± 20), and BMI (42.8 ± 3.8 vs. 43.6 ± 6.9 kg/m(2)), respectively, were comparable (p = NS). Comorbid conditions were type 2 diabetes (T2DM) in 19 (29%) vs. 23 (43%) patients, hypertension in 22 (33%) vs. 18 (33%) patients, and gastroesophageal reflux (GERD) in 28 (42%) vs. 10 (19%) patients, respectively. At 1 year, group A vs. B BMI was (29.4 ± 5 vs. 30 ± 5 kg/m(2)) and excess weight loss was 67 vs. 65%, respectively (p = NS). Postoperatively, T2DM (79 vs. 83%), hypertension (82 vs. 61%), and GERD (82 vs. 60%) (p = NS), respectively, in groups A vs. B did not require previous medications anymore. Complications were comparable. CONCLUSIONS:Our data suggest that using a 42-Fr or 32-Fr bougie does not influence LSG first-year weight loss or resolution of comorbid conditions. Long-term data is needed to conclude this issue. _________________________________________________________________________________________________________________________ Int J Surg. 2014;12(5):504-8. doi: 10.1016/j.ijsu.2014.02.008. Epub 2014 Feb 18.Long term predictors of success after laparoscopic sleeve gastrectomy.Abd Ellatif ME1, Abdallah E2, Askar W2, Thabet W2, Aboushady M3, Abbas AE2, El Hadidi A2, Elezaby AF4, Salama AF4, Dawoud IE2, Moatamed A2, Wahby M5.BACKGROUND:To evaluate early, mid and long term efficacy of laparoscopic sleeve gastrectomy as a definitive management of morbid obesity and to study factors that may predict its success. MATERIALS AND METHODS:A retrospective study was conducted by reviewing the database of patients who underwent LSG as a definitive bariatric procedure, from April 2005 to March 2013. Univariate and multivariate analysis were performed. RESULTS:1395 patients were included in this study. Mean age was 33 years and women:men ratio was 74:26. The mean preoperative BMI was 46 kg/m(2). Operative time was 113 ± 29 min. Reinforcement of staple line was done only in 447 (32%) cases. 11 (0.79%) cases developed postoperative leak, with total number of complications 72 (5.1%) and 0% mortality. Percentage of excess weight loss (%EWL) was 42%, 53%, 61%, 73%, 67%, 61%, 59% and 57% at 6 months, 1-7 years. Remission of diabetes (DM), hypertension (HTN) and hyperlipidaemia (HLP) occurred 69%, 54% and 43% respectively. 56 (4%) patients underwent revision surgery, for insufficient weight loss (n = 37) and severe reflux symptoms (n = 19). Mean follow up was 76 ± 19 (range: 6-103) months. Smaller bougie size and leaving smaller antrum were associated with significant %EWL. Bougie ≤36F remained significant in multivariate analysis. CONCLUSION:This study supports safety, effectiveness and durability of LSG as a sole definitive bariatric procedure. Smaller bougie size and shorter distance from pylorus were associated with significant %EWL. Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved. __________________________________________________________________________________________________________________ Obes Surg. 2013 Oct;23(10):1685-91. doi: 10.1007/s11695-013-1047-3.The effects of bougie caliber on leaks and excess weight loss following laparoscopic sleeve gastrectomy. Is there an ideal bougie size?Yuval JB1, Mintz Y, Cohen MJ, Rivkind AI, Elazary R.Laparoscopic sleeve gastrectomy (LSG) has become a common surgical procedure, yet there is no consensus on what bougie size is best for LSG. We reviewed the literature and assessed the relationship between the size of bougie used and the incidence of leak as well as weight loss parameters. We wanted to determine if there is an ideal bougie size for LSG. A search of the medical literature was undertaken. We limited the search to articles published in the last 5 years written in English and investigating humans. We analyzed 32 publications comprising 4,999 patients. We determined the frequency of staple line leaks as well as weight loss parameters in relation to bougie size. This study was exempt from our institutional review board. The use of bougies of 40 French (F) and larger was associated with a leak rate of 0.92% as opposed to 2.67% for smaller bougies (p < 0.05). Weight loss in percent of extra weight loss (%EWL) was 69.2% when a bougie of 40 F and larger was used, as opposed to 60.7% of EWL when smaller bougies were used (p = 0.29). LSG is becoming an important and common procedure. Larger sizing bougies are associated with a significant decrease in incidence of leak with no change in weight loss. Further studies are needed before an unequivocal decision on the optimal bougie size is made. A recommendation to use the smallest bougie possible should be avoided because the risks may outweigh the benefits. __________________________________________________________________________________________________________________ Surg Endosc. 2012 Jun;26(6):1509-15. doi: 10.1007/s00464-011-2085-3. Epub 2011 Dec 17.Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients.Aurora AR1, Khaitan L, Saber AA.INTRODUCTION:Sleeve gastrectomy has become a popular stand-alone bariatric procedure with comparable weight loss and resolution of comorbidities to that of laparoscopic gastric bypass. The simplicity of the procedure and the decreased long-term risk profile make this surgery more appealing. Nonetheless, the ever present risk of a staple-line leak is still of great concern and needs further investigation. METHODS:An electronic literature search of MEDLINE database plus manual reference checks of articles published on laparoscopic sleeve gastrectomy for morbid obesity and its complications was completed. Keywords used in the search were "sleeve gastrectomy" OR "gastric sleeve" AND "leak." We analyzed 29 publications, including 4,888 patients. We analyzed the frequency of leak after sleeve gastrectomy and its associated risks of causation. RESULTS:The risk of leak after sleeve gastrectomy in all comers was 2.4%. This risk was 2.9% in the super-obese [body mass index (BMI) > 50 kg/m(2)] and 2.2% for BMI < 50 kg/m(2). Staple height and use of buttressing material did not affect leak rate. The use of a size 40-Fr or greater bougie was associated with a leak rate of 0.6% compared with those who used smaller sizes whose leak rate was 2.8%. Leaks were found at the proximal third of the stomach in 89% of cases. Most leaks were diagnosed after discharge. Endoscopic management is a viable option for leaks and was documented in 11% of cases as successful. CONCLUSIONS:Sleeve gastrectomy has become an important surgical option for the treatment of the ever growing morbidly obese population. The risk of leak is low at 2.4%. Attention to detail specifically at the esophagogastric junction cannot be stressed enough. Careful patient selection (BMI < 50 kg/m(2)) and adopting the use of a 40-Fr or larger bougie may decrease the risk of leak. Vigilant follow-up during the first 30 days is critical to avoid catastrophe, because most leaks will happen after patient discharge. ___________________________________________________________________________________________________________________ Surg Obes Relat Dis. 2008 Jul-Aug;4(4):528-33. doi: 10.1016/j.soard.2008.03.245. Laparoscopic sleeve gastrectomy: does bougie size affect mean %EWL? Short-term outcomes. Parikh M1, Gagner M, Heacock L, Strain G, Dakin G, Pomp A.BACKGROUND:Laparoscopic sleeve gastrectomy (LSG) has been increasingly offered to high-risk bariatric patients as the first-stage procedure before gastric bypass or biliopancreatic diversion or as the primary weight loss procedure. The bougie size has varied by surgeon during LSG. The aim of this study was to determine whether short-term weight loss correlates with the bougie size used during creation of the sleeve. METHODS:We retrospectively reviewed the data from all patients who had undergone LSG at our institution between 2003 and 2006. Revision LSG for failed bariatric procedures was excluded. The data analyzed included preoperative age, body mass index (BMI), bougie size, and percentage of excess weight loss (%EWL). RESULTS:A total of 135 patients underwent LSG during the 4-year period. Most of these patients (79%) underwent LSG as part of a 2-stage operation (either gastric bypass or duodenal switch within a mean of 11 months). The mean preoperative age and BMI was 43.5 years and 60.1 kg/m(2), respectively. The mean BMI and %EWL at 6 months was 47.1 kg/m(2) and 37.9%, respectively. The mean BMI and %EWL at 12 months was 44.3 kg/m(2) and 47.3%, respectively. When stratifying the %EWL by bougie size (40F versus 60F), we did not find a significant difference at 6 months (38.8% versus 40.6%, P = NS) or 12 months (51.9% versus 45.4%, P = NS). CONCLUSION:LSG results in significant weight loss in the short term. When stratifying outcomes by bougie size, our results suggested that a bougie size of 40F compared with 60F does not result in significantly greater weight loss in the short term. However, longer follow-up of the primary LSG group is required to determine whether a difference becomes evident over time.
  3. Dear Cocoa, Good to hear from you and to know that you are doing well after all of these years. It's always a good idea to carry a wallet card that states your medical conditions, medications, medication allergies, and previous surgeries. I'd place it with your insurance card so that in the event of a real emergency, the hospital folks will be sure to see it. NG tubes are riskiest for GBP patients. The tube can potentially perforate the stub of small bowel near the gastrojejunostomy. Misplacement or perforation can be avoided if the NG tube is placed under x-ray guidance (flouroscopy). Sleeve and lap band patients are much less vulnerable, but there is still increased risk in certain circumstances. If the cause of the vomiting is a lap band slip, the tissue that has slipped up through the stomach can become thinned out and weakened under certain circumstances. The tube could go right through it. Likewise, if a sleeve were twisted or "corkscrewed", the tube could be pushed through the wall of the stomach. So if you have to go to the ER because of repetitive vomiting, discuss your stomach surgery with the ER doctor. I would be sure to speak with the physician about this, not just the nurse or assistant. Let him or her know about your concern about stomach perforation. Suggest that either he or she pass the tube or have the radiologist do it under flouroscopy. Hope this is non-issue! Happy New Year, Dr. Callery
  4. Yes. A gastric feeding tube can be inserted into the lower (excluded) portion of the stomach. The tube is usually inserted using laparoscopic technique on an out patient or overnight stay basis. The tube can be used for feeding or it can be used to decompress the stomach. The tube may be used for feeding within a day in most cases.
  5. Dear KN, There has been quite a bit written about the effect of gastric bypass on pregnancy. Sleeve is much newer, and medical reports are just starting to come in. As a general rule, pregnancy after weight loss surgery is safe both for mom and baby. Maternal complications decrease as the mother loses weight. There has been a higher risk of need for cesarean section in some studies of women who've had gastric bypass. There are very few fetal complications reported. There are some reports that suggest that there may be an increased incidence in babies who have a low birthweight. There are also reports of vitamin deficiencies. Most surgeons recommend that patients weight a year or 18 months before pregnancy, but some research suggests that this may not be necessary. Get good prenatal care from a reputable obstetrician. Ask her or him if you need to visit a "high risk" clinic. Your OB will make that decision based on his or her comfort level and experience with managing pregnancies after weight loss surgery. Managing the pregnancy during the acute weight loss phase, the first year, is trickier than later when mom's weight is stable. Be sure to take adequate protein and prenatal vitamins. Folate is especially important to avoid neural tube defects. Your vitamin levels should be checked before and during the pregnancy. Best of luck with very wonderful part of life. Dr. Callery Adv Nutr. 2015 Jul 15;6(4):420-9. doi: 10.3945/an.114.008086. Print 2015 Jul.Maternal micronutrient deficiencies and related adverse neonatal outcomes after bariatric surgery: a systematic review.Jans G1, Matthys C2, Bogaerts A3, Lannoo M4, Verhaeghe J5, Van der Schueren B2, Devlieger R6.Pregnant and postpartum women with a history of bariatric surgery are at risk of micronutrient deficiencies as a result of the combination of physiologic changes related to pregnancy and iatrogenic postoperative alterations in the absorption and metabolism of crucial nutrients. This systematic review investigates micronutrient deficiencies and related adverse clinical outcomes in pregnant and postpartum women after bariatric surgery. A systematic approach involving critical appraisal was conducted independently by 2 researchers to examine deficiencies of phylloquinone, folate, iron, calcium, zinc, magnesium, iodide, copper, and vitamins A, D, and B-12 in pregnant and postpartum women after bariatric surgery, together with subsequent outcomes in the neonates. The search identified 29 relevant cases and 8 cohort studies. The quality of reporting among the case reports was weak according to the criteria based on the CARE (CAse REporting) guidelines as was that for the cohort studies based on the criteria from the Cohort Study Quality Assessment list of the Dutch Cochrane Center. The most common adverse neonatal outcomes related to maternal micronutrient deficiencies include visual complications (vitamin A), intracranial hemorrhage (phylloquinone), neurological and developmental impairment (vitamin B-12), and neural tube defects (folate). On the basis of the systematically collected information, we conclude that the evidence on micronutrient deficiencies in pregnant and postpartum women after bariatric surgery and subsequent adverse neonatal outcomes remains weak and inconclusive. _______________________________________________________________________________________________________________________________ Obes Surg. 2013 Jun;23(6):756-9. doi: 10.1007/s11695-012-0858-y.Pregnancy outcomes after laparoscopic sleeve gastrectomy in morbidly obese Korean patients.Han SM1, Kim WW, Moon R, Rosenthal RJ.Laparoscopic sleeve gastrectomy (LSG) is an effective procedure for treating morbid obesity, and the majority of female patients who received LSG were at childbearing age. Female patients, who successfully lost weight following LSG and became pregnant, need to be evaluated carefully. Information was gathered, through prospectively maintained database and phone interview, on women who underwent LSG from May 2003 to July 2011. A total of 136 women underwent LSG in this period. There were 13 (9.6 %) pregnancies in 12 patients after LSG. The age before surgery was 28.3 ± 4.0. The mean weight and body mass index (BMI) before LSG were 95.3 ± 9.4 kg and 35.1 ± 3.5 kg/m(2), respectively. The average time from LSG to the first live birth was 32.0 ± 19.1 months. Mean BMI decreased significantly after LSG, from 35.1 ± 3.5 to 24.9 ± 2.3 kg/m(2) at conception. The mean percentage of excess body mass index loss was 85.8 ± 16.7 % at conception and 42.7 ± 25.1 % at delivery. Gained weight during pregnancy was 15.1 ± 5.2 kg. The mean gestational age and birth weight were 39.0 ± 1.6 weeks and 3,229.0 ± 505.9 g. In two cases (15.4 %), cesarean section was performed. No cases of pregnancy-induced hypertension and diabetes developed. Major congenital anomalies and neonatal deaths were not recorded. Larger study with longer follow-up is needed to evaluate the effect of LSG in pregnancies. However, these findings show that LSG seems to be a safe option for morbidly obese women in their reproductive period._______________________________________________________________________________________________________________________________ Int J Gynaecol Obstet. 2015 Aug;130(2):127-31. doi: 10.1016/j.ijgo.2015.03.022. Epub 2015 Apr 24.Pregnancy outcomes after laparoscopic sleeve gastrectomy among obese patients.Ducarme G1, Chesnoy V2, Lemarié P3, Koumaré S4, Krawczykowski D4.OBJECTIVE:To analyze pregnancy outcomes after laparoscopic sleeve gastrectomy (LSG) according to body mass index (BMI) at conception and the interval between LSG and pregnancy.METHODS:In a retrospective study, data were obtained for all women who became pregnant after LSG at a center in France between December 2001 and December 2011. Frequencies of perinatal events according to BMI at conception and the interval between LSG and pregnancy were compared.RESULTS:A total of 63 pregnancies occurring in 54 patients were included, among which 52 (83%) occurred after the first postoperative year and 26 (41%) in women who remained obese. Compared with women who were no longer obese at conception, women who were still obese delivered neonates of significantly lower gestational age at birth (P=0.02) and birth weight (P=0.001). Odds of preterm delivery were also increased (odds ratio 4.37, 95% confidence interval 1.17-16.27; P=0.03). Maternal and neonatal outcomes according to the interval between LSG and pregnancy did not differ significantly.CONCLUSION:Women who remain obese following LSG are at increased risk of adverse outcomes, including low gestational age at birth, low birth weight, and preterm delivery, and should be regarded as a risk group._______________________________________________________________________________________________________________________________ Surg Obes Relat Dis. 2014 Nov-Dec;10(6):1166-73. doi: 10.1016/j.soard.2014.02.011. Epub 2014 Feb 24.Pregnancy outcomes and nutritional indices after 3 types of bariatric surgery performed at a single institution.Mead NC1, Sakkatos P2, Sakellaropoulos GC3, Adonakis GL4, Alexandrides TK5, Kalfarentzos F6.BACKGROUND: Nutritional status during pregnancy and the effects of nutritional deficiencies on pregnancy outcomes after bariatric surgery is an important issue that warrants further study. The objective of this study was to investigate pregnancy outcomes and nutritional indices after restrictive and malabsorptive procedures.METHODS: We investigated pregnancy outcomes of 113 women who gave birth to 150 children after biliopancreatic diversion (BPD), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) between June 1994 and December 2011. Biochemical indices and pregnancy outcomes were compared among the different types of surgery and to overall 20-year hospital data, as well as to 56 presurgery pregnancies in 36 women of the same group.RESULTS: Anemia was observed in 24.2% and 15.6% of pregnancies after BPD and RYGB, respectively. Vitamin B12 levels decreased postoperatively in all groups, with no further decrease during pregnancy; however, low levels were observed not only after BPD (11.7%) and RYGB (15.6%), but also after SG (13.3%). Folic acid levels increased. Serum albumin levels decreased in all groups during pregnancy, but hypoproteinemia was seen only after BPD. Neonates after BPD had significantly lower average birth weight without a higher frequency of low birth weight defined as<2500 g. A comparison of neonatal data between babies born before surgery and siblings born after surgery (AS) showed that AS newborns had lower average birth weight with no significant differences in body length or head circumference and no cases of macrosomia.CONCLUSION: Our study showed reasonably good pregnancy outcomes in this sample population after all types of bariatric surgery provided nutritional supplement guidelines are followed. Closer monitoring is required in pregnancies after malabsorptive procedures especially regarding protein nutrition._______________________________________________________________________________________________________________________________ Obes Surg. 2015 Mar;25(3):436-42. doi: 10.1007/s11695-014-1387-7.Maternal and perinatal outcomes after bariatric surgery: a Spanish multicenter study.González I1, Rubio MA, Cordido F, Bretón I, Morales MJ, Vilarrasa N, Monereo S, Lecube A, Caixàs A, Vinagre I, Goday A, García-Luna PP.BACKGROUND: Bariatric surgery (BS) has become more frequent among women of child-bearing age. Data regarding the underlying maternal and perinatal risks are scarce. The objective of this nationwide study is to evaluate maternal and perinatal outcomes after BS.METHODS: We performed a retrospective observational study of 168 pregnancies in 112 women who underwent BS in 10 tertiary hospitals in Spain over a 15-year period. Maternal and perinatal outcomes, including gestational diabetes mellitus (GDM), pregnancy-associated hypertensive disorders (PAHD), pre-term birth cesarean deliveries, small and large for gestational age births (SGA, LGA), still births, and neonatal deaths, were evaluated. Results were further compared according to the type of BS performed: restrictive techniques (vertical-banded gastroplasty, sleeve gastrectomy, and gastric banding), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion (BPD).RESULTS: GDM occurred in five (3 %) pregnancies and there were no cases of PAHD. Women whose pregnancies occurred before 1 year after BS had a higher pre-gestational body mass index (BMI) than those who got pregnant 1 year after BS (34.6 ± 7.7 vs 30.4 ± 5.3 kg/m(2), p = 0.007). In pregnancies occurring during the first year after BS, a higher rate of stillbirths was observed compared to pregnancies occurring after this period of time (35.5 vs 16.8 %, p = 0.03). Women who underwent BPD delivered a higher rate of SGA babies than women with RYGB or restrictive procedures (34.8, 12.7, and 8.3 %, respectively).CONCLUSIONS: Pregnancy should be scheduled at least 1 year after BS. Malabsorptive procedures are associated to a higher rate of SGA births._______________________________________________________________________________________________________________________________ Obes Surg. 2013 Aug;23(8):1281-5. doi: 10.1007/s11695-013-0903-5.Timing of pregnancy after gastric bypass-a national register-based cohort study.Kjær MM1, Nilas L.Author informationCurrent recommendations suggest postponing pregnancy by at least 1 year after gastric bypass. During the first postoperative year, women are in a catabolic phase with a rapid weight loss which may increase the risk of adverse pregnancy and neonatal outcomes. This study tested the hypothesis that the risk of adverse pregnancy and neonatal outcomes is increased in women who conceive during the first year after gastric bypass surgery.METHODS: This is a national register-based cohort study covering all Danish deliveries during 2004-2010 in women with prior Roux-en-Y gastric bypass surgery. Only the first postoperative birth was included. The risk of adverse pregnancy and neonatal outcomes was compared between women who conceived within the first postoperative year and women who conceived later. Data were extracted from the Danish National Patient Registry and The Danish Medical Birth Register.RESULTS: Of 286 women who had a singleton delivery after Roux-en-Y gastric bypass surgery, 158 women conceived within the first year and 128 later. There was no statistically significant difference (p > 0.05) between the two groups regarding neonatal birth weight, gestational age, risk of preeclampsia, gestational diabetes mellitus, labor induction, cesarean section, postpartum hemorrhage (>500 ml), preterm birth (before 37 weeks), small for gestational age, large for gestational age, or Apgar score (5 min ) below 7, or in the need of neonatal intensive care.CONCLUSIONS: This study showed no evidence to support a recommendation to delay pregnancy until after the first postoperative year. At present, the optimal time for pregnancy after gastric bypass is unknown.
  6. Dear HJ, It's not unusual for patients to have a bite too much early on after sleeve or bypass surgery. If the sleeve or pouch streches there will be some pain. The pain usually resolves fairly quickly, but may last a day. Consider staying on clear liquids for a day or two. Monitor yourself for persistent vomiting, rising heart rate, elevated temperature, or any new pain in the shoulders, chest, or abdomen. If you notice new symptoms, call your surgeon. Your surgeon will advise you on how quickly to advance your diet. Surgeons have different general preferences. And surgeons will give specific advice to patients based on the patient's surgery and medical condition. We tend to keep our patients on clear liquids for 2 or 3 days, nutritious liquids for a couple of weeks, and then puree/very soft foods until six weeks. After six weeks our patients introduce solid foods like fresh vegetables and soft cooked meats. So you may be advancing to fresh vegetables before your sleeve is ready. My biggest concern as a surgeon is for patients one or two weeks post op who move from liquids to solids too quickly. The staple line still is in the healing process and may not tolerate food impaction and vomiting. A word to the wise. Many patients want to experiment with thicker foods during the first couple of weeks after surgery. Call it old habits, a need to experiment, the thrill of getting away with it, or what ever. Just don't! Think of this analogy. You are on a hike in the winter. You're in a hurry to meet some friends at a trail junction. You come across a dozen lake. Now, you can either take the train around the lake, or take the "short cut" across the lake. What are the chances that you will break through the ice and either have a nasty chill or freeze and drown? Go around the lake, don't be a fool. Same thing with your new sleeve or GBP pouch. It may take a while and be boring, but stick with the liquids until your surgeon says it's ok to move to thicker foods. Do not take the chance of eating solids, vomiting, and possibly rupturing your staple line. A staple line leak means a trip to the OR or radiology suite and weeks or months of recovery. You could develop blood clots. Your could die. So, enjoy the hike. Take your time. Be safe. Happy New Year!
  7. Dear MOK, Ferritin is an iron storage molecule. Interpretation of serum ferritin is fairly complicated. Ferritin is elevated with iron excess, but also goes up under a variety of other conditions. Some of these conditions include acute inflammation, liver disease, and significant malnutrition. I'd discuss your ferritin level with your PCP since so many factors need to be taken into account. The following is quoted from Mariana Koperdanova, British Medical Journal, 2015;351:h3692 "Elevated ferritin levels are usually due to causes such as acute or chronic inflammation, chronic alcohol consumption, liver disease, renal failure, metabolic syndrome, or malignancy rather than iron overload Exclude these causes clinically or with initial tests such as full blood count, liver and renal function, and inflammatory markers (C reactive protein or erythrocyte sedimentation rate) A normal serum transferrin saturation (ideally fasting) usually excludes iron overload (where it is raised) and suggests a reactive cause for raised ferritin Unexplained serum ferritin values >1000 μg/L warrant referral for further investigation Consider HFE mutation screen for hereditary haemochromatosis in individuals with elevated ferritin and a raised transferrin saturation >45%" Here's the summary of a medical journal article that you might find interesting: Nutr Hosp. 2014 Oct 16;31(2):666-71. doi: 10.3305/nh.2015.31.2.7629.Ferritin in hypertensive and diabetic women before and after bariatric surgery.Marin FA1, Rasera Junior I2, Leite CV3, Oliveira MR4. In addition to its important role as marker of iron stores, serum ferritin is a marker of systemic inflammation, and obesity has been associated with chronic inflammation. OBJECTIVE: To verify, six months after surgery, the effect of bariatric surgery on the serum ferritin of women who were hypertensive, diabetic, or comorbidity free before surgery. SAMPLE AND METHODS: This retrospective study included 200 women aged 20 to 45 years, with a body mass index (BMI) equal to or greater than 35 kg/m2, submitted to Roux-en-Y gastric bypass (RYGB). Seventy of these women were hypertensive, forty had type 2 diabetes (T2D), and ninety were comorbidity free (CF). They were assessed before and six months after surgery. Anthropometric, laboratory (serum ferritin and hemoglobin), and comorbidity- related data were collected from their medical records. RESULTS: Before surgery, women with comorbidities were older, the hypertensives had higher BMI, and the diabetics had higher serum ferritin levels than the CF women. The study comorbidities had resolved in 68% of the hypertensive women and 86% of the diabetic women six months after RYGB. Also at this time, the serum ferritin of hypertensive women decreased from 110.1±86.3 to 88.7±80.5 ng/dL and of diabetic women, from 164.8±133.4 to 101.2±97.7 ng/dL (p0.05). CONCLUSION: High ferritin in premenopausal obese women was associated with the main obesity-related comorbidities, and these comorbidities determined the reduction of serum ferritin after bariatric surgery.
  8. Dear Jerrod24, A gallbladder ultrasound sounds like a good idea. Patients who have undergone gastric bypass have a 30% chance of developing gallstones. The risk of developing gallstones can be reduced to about 2% if a patient takes ursodiol (Actigall) 300mg twice daily for 6 months after surgery. Gallstones can cause upper abdominal pain, upper back pain, right shoulder pain, nausea, and vomiting. However, diarrhea is not a usual symptom of gallstones. If gallstones are causing the problem, the gallbladder can be removed safely, laparoscopically by most general surgeons. There is no need to travel to see your gastric bypass surgeon unless you have faith in him and he is willing to do your surgery. For more information see: Mayo Clinic article. Dr. Callery
  9. Dear Pilotswife, Bloody mucus in the stool is an important problem, and you should discuss it with your physician. There are many causes of bloody mucus some of which include colitis, infection, malignancy, and benign polyps. It is unlikely to be related to your gastric bypass. You may need a colonoscopy for diagnosis. Dr. Callery
  10. Dear Jordan, A nasogastric tube (NG tube) is a tube that is passed through the nose, down the esophagus, and into the stomach. A nasojejunal tube is longer. It passes through the nose, through the stomach, and into the jejunum (after gastric bypass). There are two reasons to pass such tubes: decompression and feeding. The first reason is to take pressure off of the stomach and intestines by removing fluid or air. This might be needed if there were an obstruction blocking the intestine further down. The second reason is for feeding. A feeding tube can deliver nutrition and medication into the stomach or Roux limb if a patient can't take food by mouth or if there is a narrowing in the connection between the stomach and jejunum (gastrojejunostomy). Medications can be administered through a feeding tube or NG tube if they can be prepared as a liquid or thin mixture. Pills that are simply crushed and mixed with water can be a problem if they clog the tube. An NG tube used to decompress the intestine is a fairly heavy duty tube. It is reasonably stiff and must be inserted carefully by a knowledgable nurse or physician. There is some risk that the tube can catch in the jejunum near the gastrojejunostomy and can even perforate the jejunum. In some cases the patient's physician may ask the radiologist to pass the NG tube under x-ray guidance. That way the radiologist can be sure it goes to the correct location and does not cause damage. An NG tube used for decompression can be left in place for a few days or week or two, but eventually causes quite a bit of irritation to the nose. A feeding tube has a fairly narrow diameter and is very flexible. It is usually passed through the nose, through the stomach, and into the jejunum by a radiologist using fluoroscopy (active x-ray guidance). Sometimes it is even necessary to ask a gastroenterologist to use endoscopy to guide the tube though a tight gastrojejunostomy. A feeding tube is usually well tolerated and can be left in place for weeks or longer. Other types of tubes include gastrostomy tubes and jejunostomy tubes. These can be inserted via surgery or endoscopy through the skin and directly into the stomach or jejunum. Gastrostomy tubes can be used to decompress the stomach or for feeding. Jejunostomy tubes are used for feeding. Both types of tubes are usually well tolerated and can be left in place for prolonged periods of time. Dr. Callery
  11. Dear Lori, It is extremely important that your bipolar symptoms be well controlled. If aripiprazole (Abilify) works well, you should plan to continue to take it after your sleeve gastrectomy. You and your psychiatrist may need to change the dose depending on how well it is absorbed and how your weight loss changes your response to the drug. It is annoying that Abilify seems to make you gain weight, but hopefully that will not be too big a factor after your surgery. Even if the surgery is not quite as effective with Abilify on board, you still will be much better off overall at a lower weight. I've attached an interesting review article that ranks the various newer psychological medications by their tendency to cause weight gain. Fortunately, aripiprazole is relatively low on the list. It causes a lot less weight gain than many other medications. Dr. Callery Expert Opin Drug Saf. 2015 Jan;14(1):73-96. doi: 10.1517/14740338.2015.974549. Epub 2014 Nov 15. Weight gain and antipsychotics: a drug safety review. Musil R1, Obermeier M, Russ P, Hamerle M. Abstract INTRODUCTION: Second-generation antipsychotics (SGAs) are widely used in several psychiatric disease entities and exert to a different extent a risk for antipsychotic-induced weight gain (AIWG). As AIWG is associated with an increase in metabolic syndrome or cardiovascular events, knowledge of these risks is crucial for further monitoring and the initiation of counteractive measures. AREAS COVERED: We searched PubMed and Web of Sciences for randomized-controlled trials and naturalistic observational studies published between 2010 and 2014 with sample sizes exceeding 100, including all marketed SGAs apart from zotepine, and providing data on weight increase. We also summarized relevant systematic reviews and meta-analyses of head-to-head comparisons. EXPERT OPINION: Recently published data still support the hierarchical ranking of SGAs already proposed in previous reviews ranking clozapine and olanzapine as having the highest risk, followed by amisulpride, asenapine, iloperidone, paliperidone, quetiapine, risperidone and sertindole in the middle, and aripiprazole, lurasidone and ziprasidone with the lowest risk. Number needed to harm varied considerably in our meta-analysis. Younger patients and patients with a lower baseline body mass index are most vulnerable. The greatest amount of weight gain occurs within the first weeks of treatment. AIWG occurs in all diagnostic groups and is also common in treatment with first-generation antipsychotics; therefore, awareness of this adverse event is essential for anyone prescribing antipsychotics.
  12. Dear Jb, As a general rule, age is only a relative factor. Most surgeons think more of "physiological" age than chronological age. In other words, one's general health and ability to tolerate the surgery is the key, and age is just one of many factors to take into consideration. There may be higher complication rates in the elderly, but not to the extent that surgery should not be considered. We have done Lap-Bands, sleeve gastrectomies, and gastric bypasses in patients in their 70's with good results. These patients have all passed careful medical evaluation including cardiac and pulmonary testing. I've included the summaries of three journal articles on the subject. Dr. Callery Obes Surg. 2014 Oct;24(10):1662-9. doi: 10.1007/s11695-014-1247-5. Gastric bypass for obesity in the elderly: is it as appropriate as for young and middle-aged populations? Robert M1, Pasquer A, Espalieu P, Laville M, Gouillat C, Disse E. Abstract BACKGROUND: Obesity prevalence increases in elderly population. Bariatric surgery has been underused in patients over 60 because of fears of complications and lower weight loss. We postulated worse outcomes in the elderly in comparison to young and middle-aged population 1 year after gastric bypass. METHODS: We retrospectively analyzed gastric bypass outcomes in young (<40 years), middle-aged (40 to 55 years), and elderly (>60 years) patients between 2007 and 2013. Each subject over 60 (n = 24) was matched with one subject of both the other groups according to gender, preoperative body mass index (BMI), surgical procedure, and history of previous bariatric surgery (n = 72). RESULTS: Older subjects demonstrated higher prevalence of preoperative metabolic comorbidities (70 vs 30 % in the <40-year-old group, p < 0.0001). Mean duration of the surgical procedure, mean length of stay, and early and late complication rates were similar between age groups. A trend towards fewer early complications and less-severe complications in the younger groups was noted. One-year weight loss results were similar between young, middle-aged, and elderly patients (percentage of excess BMI loss (EBL%), 74.4 ± 3.5; 78.9 ± 4.5, and 73.7 ± 4.5 respectively, p = 0.69). Age was not predictive of weight loss failure 1 year after surgery. Remission and improvement rates of comorbidities were similar between age groups 6 months after surgery. CONCLUSIONS: Our study confirms weight loss efficacy of gastric bypass in the elderly with acceptable risks. Further studies evaluating the benefit-risk balance of bariatric surgery in the elderly population will be required so as to confirm the relevance of increasing age limit. _______________________________________________________________________________________________________________ Obes Surg. 2015 Mar;25(3):406-12. doi: 10.1007/s11695-014-1462-0. Advanced Age as an Independent Predictor of Perioperative Risk after Laparoscopic Sleeve Gastrectomy (LSG). Qin C1, Luo B, Aggarwal A, De Oliveira G, Kim JY. Abstract BACKGROUND: While the safety of many bariatric procedures has been previously studied in older patients, we examine the effect of advancing ageon medical/surgical complications in laparoscopic sleeve gastrectomy, a relatively unstudied procedure but that is trending upwards in use. METHODS: Patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (RYGB) were extracted from the National Surgical Quality Improvement Program 2005-2012 database. Pre- and postoperative variables were analyzed using chi-square and student t test as appropriate to determine the comparative safety of LSG to RYGB in the elderly. Multivariate regression modeling was used to evaluate whether age is associated with adverse 30-day events following LSG. RESULTS: Of the patients that met the inclusion criteria, 56,664 (84 %) patients underwent RYGB and 10,835 (16 %) underwent LSG. In the LSG cohort, incidence of overall complications, medical complications, and death significantly increased with increasing age (p < 0.05). No statistically significant differences in rates of 30-day complications, return to the OR, and mortality exist between RYGB and LSG cohorts in patients older than 65 years. The age group of over 65 years independently predicted increased risk for overall and medical complications (OR, 1.748; OR, 2.027). Notably, age was not significantly associated with surgical complications in LSG. CONCLUSION: In this large, multi-institutional study, advanced age was significantly associated with overall and medical complications but not surgical complications in LSG. Our findings suggest that the risk conferred by advancing age in LSG is predominantly for medical morbidity and advocate for improved perioperative management of medical complications. LSG may be the preferable option to RYGB for elderly patients as neither procedure is riskier with regards to 30-day morbidity while LSG has been shown to be safer with regards to long-term reoperation and readmission risk. ________________________________________________________________________________________________________________ J Am Assoc Nurse Pract. 2015 Mar 4. doi: 10.1002/2327-6924.12235. [Epub ahead of print] A review of the safety and efficacy of bariatric surgery in adults over the age of 60: 2002-2013. Caceres BA1, Moskowitz D, O'Connell T. Abstract PURPOSE: The purpose of this review is to compare outcomes of bariatric surgery in adults over 60 to younger patients. This analysis is important to determine if nurse practitioners (NPs) and other providers should recommend bariatric surgery to obese older adults. DATA SOURCES: This review included 15 studies published between 2002 and 2013. CONCLUSIONS: Although older adults seem to experience less weight loss, bariatric surgery has potential benefits for these patients. Significant improvements in hypertension, diabetes, and, to a lesser extent, dyslipidemia are noted. Mortality and surgical complications in older adults are low, while differences in length of hospital stay are inconclusive. IMPLICATIONS FOR PRACTICE: The risks of bariatric surgery in older adults need to be carefully evaluated based on individual medical condition. Overall the evidence suggests that bariatric surgery can be safely performed in older adults but more research is needed to determine which older adult patients are the best candidates for bariatric surgery. As bariatric surgery among older adults increases, interdisciplinary teams will continue to serve an important role in the management of bariatric surgery patients. NPs must be aware of trends in this emerging population of bariatric surgery patients.
  13. Dear Bikewash, Revision surgery is always more challenging and carries a higher complication rate than primary surgery. I can only imagine how much scar tissue was present after so many failed fundoplication surgeries. I can't comment about the specifics on your case, but if you are working with a qualified bariatric or general surgeon and gastroenterologist, I'd rely on their advice and encouragement. As a rule, there is very little choice this soon after revision surgery but to continue conservative management with endoscopic dilation as needed. Trying to reoperate now may be fraught with danger. If you need nutritional support, a G-tube could be inserted into the bypassed portion of the stomach. If you remain nutritionally crippled, at some point your surgeons may consider going back. It might be possible to reverse your gastric bypass, or they might advise removing the remainder of the gastric pouch and bringing the roux limb up to the esophagus. Either would be difficult and potentially dangerous surgery, but would restore your ability to eat. If the bypass were reversed, you might well have renewed reflux problems, and you would probably regain weight. Patients who have total removal of the stomach maintain weight loss to a greater or lesser extent. If the roux limb is long enough, they usually don't have problems with bile reflux. They can do quite well. Best of luck to you with this most challenging problem. Dr. Callery
  14. Dear DeeDee, As I read your post, you have two problems. The first is abdominal pain of unclear origin, and the second is a systems problem: you can't find a physician to treat you because you are a "gastric bypass patient". I can't give you personal medical advice. I do think you are doing the right thing. Your are being persistent and conscientious by going back to the ER because you are not improving. Any good general surgeon and any good gastroenterologist should be able to help you. There is very little difference between a gastric bypass and a partial gastrectomy other than the bypassed portion of the stomach is left in place with gastric bypass. Having said that, there are some surgeons and some gastroenterologists that duck the care they should provide. (Never assume malice until you rule out ignorance ... or laziness.) If a surgeon or gastroenterologist feels insecure about how to proceed, he or she can always call a bariatric surgeon and ask for advice. If you go to your local hospital, and if you need acute care that isn't available locally, you should be transferred to a center that can provide the care. It would be prudent for you to call your insurance company at the time to inform them. If you are an outpatient and can't find local care, call your insurance company and ask them how to proceed. They have the responsibility to see that there is an adequate network of qualified physicians to care for their insured. If you are having trouble getting the care you need at your local hospital, you can contact the chief of the medical staff, the medical director of the hospital, or the chief administrator of the hospital. If your insurance company is not helpful, you can contact your state's insurance commissioner or department of managed care. Your situation finding a qualified and caring doctor is not unique. The federal government is forcing rapid change on the healthcare system in the name of cost containment. As we go from a fee for service model where at times too many services were provided, we are moving to a rationing system where good care will be less accessible and less timely. I encourage you to stick up for yourself and insist on proper care. Dr. Callery
  15. You've asked a pretty straightforward question, so I've posted and answer and some links that will help you get more information. But I'm concerned, because from the sound of your question, I'd guess that you are trying to figure out how best to beat the test. So I've also included some summaries on smoking risks and surgery. I hope you understand that smoking confers increased risk of wound infections and may contribute to other complications as well. It's in your best interest to quit as soon as possible and consider allowing a couple of months to go by before having surgery. A couple of months allows the inflammation in your lungs to quiet so that there are less secretions. A cotinine blood, urine, or saliva test will usually be negative after 4 days, but may be positive for up to a week. Second hand smoke will also be reflected in a cotinine level. The denser the exposure, the higher the level, and the longer it will be detectable. Wikipedia discussion: http://en.wikipedia.org/wiki/Cotinine In depth paper Nicotine Cemistry, Metabolism, Kinetics, and Biomarkers: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953858/ Background summaries that you may find helpful: Ann Surg. 2012 Jun;255(6):1069-79. doi: 10.1097/SLA.0b013e31824f632d. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Sørensen LT1. Author information Abstract OBJECTIVE: The aim was to clarify how smoking and nicotine affects wound healing processes and to establish if smoking cessation and nicotine replacement therapy reverse the mechanisms involved. BACKGROUND: Smoking is a recognized risk factor for healing complications after surgery, but the pathophysiological mechanisms remain largely unknown. METHODS: Pathophysiological studies addressing smoking and wound healing were identified through electronic databases (PubMed, EMBASE) and by hand-search of articles' bibliography. Of the 1460 citations identified, 325 articles were retained following title and abstract reviews. In total, 177 articles were included and systematically reviewed. RESULTS: Smoking decreases tissue oxygenation and aerobe metabolism temporarily. The inflammatory healing response is attenuated by a reduced inflammatory cell chemotactic responsiveness, migratory function, and oxidative bactericidal mechanisms. In addition, the release of proteolytic enzymes and inhibitors is imbalanced. The proliferative response is impaired by a reduced fibroblast migration and proliferation in addition to a downregulated collagen synthesis and deposition. Smoking cessation restores tissue oxygenation and metabolism rapidly. Inflammatory cell response is reversed in part within 4 weeks, whereas the proliferative response remains impaired. Nicotine does not affect tissue microenvironment, but appears to impair inflammation and stimulate proliferation. CONCLUSIONS: Smoking has a transient effect on the tissue microenvironment and a prolonged effect on inflammatory and reparative cell functions leading to delayed healing and complications. Smoking cessation restores the tissue microenvironment rapidly and the inflammatory cellular functions within 4 weeks, but the proliferative response remain impaired. Nicotine and nicotine replacement drugs seem to attenuate inflammation and enhance proliferation but the effect appears to be marginal. ____________________________________________________________________ Can J Anaesth. 2012 Mar;59(3):268-79. doi: 10.1007/s12630-011-9652-x. Epub 2011 Dec 21. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Wong J1, Lam DP, Abrishami A, Chan MT, Chung F. Author information Abstract PURPOSE: The literature was reviewed to determine the risks or benefits of short-term (less than four weeks) smoking cessation on postoperative complications and to derive the minimum duration of preoperative abstinence from smoking required to reduce such complications in adult surgical patients. SOURCE: We searched MEDLINE, EMBASE, Cochrane, and other relevant databases for cohort studies and randomized controlled trials that reported postoperative complications (i.e., respiratory, cardiovascular, wound-healing) and mortality in patients who quit smoking within six months of surgery. Using a random effects model, meta-analyses were conducted to compare the relative risks of complications in ex-smokers with varying intervals of smoking cessation vs the risks in current smokers. PRINCIPAL FINDINGS: We included 25 studies. Compared with current smokers, the risk of respiratory complications was similar in smokers who quit less than two or two to four weeks before surgery (risk ratio [RR] 1.20; 95% confidence interval [CI] 0.96 to 1.50 vs RR 1.14; CI 0.90 to 1.45, respectively). Smokers who quit more than four and more than eight weeks before surgery had lower risks of respiratory complications than current smokers (RR 0.77; 95% CI 0.61 to 0.96 and RR 0.53; 95% CI 0.37 to 0.76, respectively). For wound-healing complications, the risk was less in smokers who quit more than three to four weeks before surgery than in current smokers (RR 0.69; 95% CI 0.56 to 0.84). Few studies reported cardiovascular complications and there were few deaths. CONCLUSION: At least four weeks of abstinence from smoking reduces respiratory complications, and abstinence of at least three to four weeks reduces wound-healing complications. Short-term (less than four weeks) smoking cessation does not appear to increase or reduce the risk of postoperative respiratory complications. ___________________________________________________________________ Arch Intern Med. 2011 Jun 13;171(11):983-9. doi: 10.1001/archinternmed.2011.97. Epub 2011 Mar 14. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Myers K1, Hajek P, Hinds C, McRobbie H. Author information Abstract OBJECTIVE: To examine existing smoking studies that compare surgical patients who have recently quit smoking with those who continue to smoke to provide an evidence-based recommendation for front-line staff. Concerns have been expressed that stopping smoking within 8 weeks before surgery may be detrimental to postoperative outcomes. This has generated considerable uncertainty even in health care systems that consider smoking cessation advice in the hospital setting an important priority. Smokers who stop smoking shortly before surgery (recent quitters) have been reported to have worse surgical outcomes than early quitters, but this may indicate only that recent quitting is less beneficial than early quitting, not that it is risky. DESIGN: Systematic review with meta-analysis. DATA SOURCES: British Nursing Index (BNI), The Cochrane Library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Medline, PsycINFO to May 2010, and reference lists of included studies. STUDY SELECTION: Studies were included that allow a comparison of postoperative complications in patients undergoing any type of surgery who stopped smoking within 8 weeks prior to surgery and those who continued to smoke. DATA EXTRACTION: Two reviewers independently screened potential studies and assessed their methodologic quality. Data were entered into 3 separate meta-analyses that considered all available studies, studies with a low risk of bias that validated self-reported abstinence (to assess possible benefits), and studies of pulmonary complications only (to assess possible risks). Results were combined by using a random-effects model, and heterogeneity was evaluated by using the I(2) statistic. RESULTS: Nine studies met the inclusion criteria. One found a beneficial effect of recent quitting compared with continuing smoking, and none identified any detrimental effects. In meta-analyses, quitting smoking within 8 weeks before surgery was not associated with an increase or decrease in overall postoperative complications for all available studies (relative risk [RR], 0.78; 95% confidence interval [CI], 0.57-1.07), for a group of 3 studies with high-quality scores (RR, 0.57; 95% CI, 0.16-2.01), or for a group of 4 studies that specifically evaluated pulmonary complications (RR, 1.18; 95% CI, 0.95-1.46). CONCLUSIONS: Existing data indicate that the concern that stopping smoking only a few weeks prior to surgery might worsen clinical outcomes is unfounded. Further larger studies would be useful to arrive at a more robust conclusion. Patients should be advised to stop smoking as early as possible, but there is no evidence to suggest that health professionals should not be advising smokers to quit at any time prior to surgery. _________________________________________________________________ JAMA Surg. 2013 Aug;148(8):755-62. doi: 10.1001/jamasurg.2013.2360. Smoking and the risk of mortality and vascular and respiratory events in patients undergoing major surgery. Musallam KM1, Rosendaal FR, Zaatari G, Soweid A, Hoballah JJ, Sfeir PM, Zeineldine S, Tamim HM, Richards T, Spahn DR, Lotta LA, Peyvandi F, Jamali FR. Author information Abstract IMPORTANCE: The effects of smoking on postoperative outcomes in patients undergoing major surgery are not fully established. The association between smoking and adverse postoperative outcomes has been confirmed. Whether the associations are dose dependent or restricted to patients with smoking-related disease remains to be determined. OBJECTIVE: To evaluate the association between current and past smoking on the risk of postoperative mortality and vascular and respiratory events in patients undergoing major surgery. DESIGN: Cohort study using the American College of Surgeons National Surgical Quality Improvement Program database. We obtained data on smoking history, perioperative risk factors, and 30-day postoperative outcomes. We assessed the effects of current and past smoking (>1 year prior) on postoperative outcomes after adjustment for potential confounders and effect mediators (eg, cardiovascular disease, chronic obstructive pulmonary disease, and cancer). We also determined whether the effects are dose dependent through analysis of pack-year quintiles. SETTING AND PARTICIPANTS: A total of 607,558 adult patients undergoing major surgery in non-Veterans Affairs hospitals across the United States, Canada, Lebanon, and the United Arab Emirates during 2008 and 2009. MAIN OUTCOMES AND MEASURES: The primary outcome measure was 30-day postoperative mortality; secondary outcome measures included arterial events (myocardial infarction or cerebrovascular accident), venous events (deep vein thrombosis or pulmonary embolism), and respiratory events (pneumonia, unplanned intubation, or ventilator requirement >48 hours). RESULTS: The sample included 125,192 current (20.6%) and 78,763 past (13.0%) smokers. Increased odds of postoperative mortality were noted in current smokers only (odds ratio, 1.17 [95% CI, 1.10-1.24]). When we compared current and past smokers, the adjusted odds ratios were higher in the former for arterial events (1.65 [95% CI, 1.51-1.81] vs 1.20 [1.09-1.31], respectively) and respiratory events (1.45 [1.40-1.51] vs 1.13 [1.08-1.18], respectively). No effects on venous events were observed. The effects of smoking mediated through smoking-related disease were minimal. The increased adjusted odds of mortality in current smokers were evident from a smoking history of less than 10 pack-years, whereas the effects of smoking on arterial and respiratory events were incremental with increased pack-years. CONCLUSIONS AND RELEVANCE: Smoking cessation at least 1 year before major surgery abolishes the increased risk of postoperative mortality and decreases the risk of arterial and respiratory events evident in current smokers. These findings should be carried forward to evaluate the value and cost-effectiveness of intervention in this setting. Our study should increase awareness of the detrimental effects of smoking-and the benefits of its cessation-on morbidity and mortality in the surgical setting.