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INTRODUCTION: There has been a recent increased interest in the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ketorolac for post-operative pain management to minimize opioid use and decrease hospital length of stay (LOS). Although NSAID use has been controversial following bariatric surgery due to anecdotal concerns for increased gastric bleeding, the impact of ketorolac as an adjunct to opioids needs further investigation on LOS and post-operative complications like bleeding. OBJECTIVE: This study aims to evaluate the impact of post-operative ketorolac use on opioid consumption, LOS, and bleeding risk after bariatric surgery. METHODS: We retrospectively analyzed a prospectively maintained database of all bariatric surgery patients who either underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass surgery (RYGB) at a tertiary center between 2011 and 2015. Patients were stratified into 2 groups based on post-operative pain control regimen as follows: (1) ketorolac and opioids and (2) opioids alone. RESULTS: A total of 1555 patients were identified who underwent either SG (n = 1255) or RYGB (n = 300). The overall LOS was 1.81 ± .059 days for ketorolac-opioid patients vs. 2.09 ± .065 days for opioid-only patients (P < 0.001). Furthermore, the risk of post-operative bleeding was similar between the two groups (P = 0.097). CONCLUSION: Patients who received ketorolac as an adjunct to opioids had a significantly shorter LOS compared to opioid-only patients. Additionally, ketorolac use was not associated with increased risk of post-operative bleeding complications. Therefore, if not contraindicated, ketorolac should be considered routinely for post-operative pain control among bariatric surgery patients.

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BACKGROUND: Type 2 diabetes (T2D), obstructive sleep apnea (OSA), hypertension (HTN), and hyperlipidemia (HLD) are common co-morbidities that are strongly associated with obesity. OBJECTIVE: The purpose of this study was to compare the rate of obesity-related co-morbidity remission and percent total body weight loss of super-obese patients with a body mass index (BMI) ≥50 kg/m2 with bariatric patients who have a BMI of 30 to 49.9 kg/m2. SETTING: Academic hospital, United States. METHODS: A retrospective analysis of outcomes of a prospectively maintained database was done on obese patients with a diagnosis of ≥1 co-morbidity (T2D, OSA, HTN, or HLD) who at the time of initial visit had undergone either a sleeve gastrectomy or a Roux-en-Y gastric bypass at our hospital between 2011 and 2015. The patients were stratified based on their preoperative BMI class, BMI of 30 to 49.9 kg/m2 versus BMI ≥50 kg/m2. RESULTS: Of the 930 patients, 732 underwent sleeve gastrectomy and 198 underwent Roux-en-Y gastric bypass. The 6-month follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m2 (n = 759) versus super-obese patients (n = 171) were 46.0% and 36.7% (P = .348) for T2D; 75.0% and 73.2% (P = .772) for OSA; 35.0% and 22.0% (P = .142) for HTN; and 37.0% and 21.0% (P = .081) for HLD, respectively. The 1-year follow-up co-morbidity remission rates for patients with a BMI of 30 to 49.9 kg/m2 versus super-obese patients were 54.2% and 45.5% (P = .460) for T2D; 87.0% and 89.7% (P = .649) for OSA; 37.4% and 23.9% (P = .081) for HTN; and 43.2% and 34.6% (P = .422) for HLD, respectively. Furthermore, there was no difference in the mean percent total weight loss for patients with a preoperative BMI of 30 to 49.9 kg/m2 versus the super-obese at the 6-month (21.4%, 20.9%, P = .612) and 1-year (28.0%, 30.7%, P = .107) follow-ups. CONCLUSION: In our study, preoperative BMI did not have an impact on postoperative co-morbidity remission rates or percent total body weight loss. Future studies should investigate the effect of other factors, such as disease severity and duration.

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BACKGROUND: Obesity not only increases the chances of developing diabetes-one of the top causes of death in the United States-but it also results in further medical complications. OBJECTIVE: To compare the 6-month and 1-year postoperative remission rates of type 2 diabetic (T2D) patients after bariatric surgery based on preoperative glycosylated hemoglobin (A1C) stratification and pharmacologic therapy: insulin-dependent diabetic (IDD) versus noninsulin-dependent diabetic (NIDD). SETTING: Academic hospital, United States. METHODS: We retrospectively analyzed a prospectively maintained database of 186 obese patients with a diagnosis T2D who had undergone either a sleeve gastrectomy or a Roux-en-Y gastric bypass surgery at our hospital. RESULTS: At 6 months (n = 180), patients who were stratified by preoperative A1C levels (<6.5; ≥6.5 to<8; ≥8) had 70.5%, 51.7%, and 30.0% remission rates (P<.001) and at 1 year (n = 118) patients had 72.0%, 54.0%, and 42.8% remission rates (P = .053), respectively. When patients were substratified by preoperative pharmacologic therapy, IDD and NIDD patients had different remission rates within the same A1C level. At 6-months follow-up within A1C ≥6.5 to<8 (IDD versus NIDD), the remission rate was 23.5% versus 64.1% (odds ratio [OR]: .173, confidence interval [CI]: .0471, .6308, P = .0079), and within A1C ≥8 the remission was 24.0% versus 37.5% (OR: .5263, CI: .2115, 1.3096, P = .1676), respectively. At 1-year follow-up within A1C ≥6.5 to<8, the remission rate was 30.0% versus 62.9% (OR: .2521, CI: .0529, 1.2019, P = .0838), and within A1C ≥8 the remission was 31.4% versus 61.9% (OR: .2821, CI: .0908, .8762, P = .0286), respectively. Furthermore, when IDD patients were compared between A1C ≥6.5 to<8 and A1C ≥8 the remission rates were nearly identical, and for NIDD patients A1C was not significantly associated with remission regardless of the level, except at 6 months. CONCLUSION: While a difference was observed between overall A1C levels-the lower the A1C level, the higher the remission rate-IDD patients had lower remission rates than NIDD patients irrespective of A1C levels; further, IDD patients performed similarly across A1C levels.

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BACKGROUND: Obstructive sleep apnea (OSA) is a serious obesity-associated disorder that causes significant short- and long-term medical consequences. OBJECTIVE: The objective of this study is to compare the 6-month and 1-year postoperative symptomatic OSA remission rates of patients undergoing bariatric surgery based on their preoperative body mass index (BMI) stratification, type of bariatric operation-sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB)-and OSA severity. METHODS: We retrospectively analyzed 297 obese patients with a diagnosis of OSA who had undergone either SG or RYGB between 2011 and 2015. RESULTS: The overall 6-month symptomatic OSA remission rate for patients (n = 255) was 74.5%. At 6 months, patients with a preoperative BMI of 30-34.9 kg/m2 (class I), 35-39.9 kg/m2 (class II), and 40+ kg/m2 (class III) had 100, 70.0, and 75.0% (p = 0.2164) remission rates, respectively. The 6-month remission rates for SG and RYGB were 75.3 and 70.8% (p = 0.5165), respectively. The overall 1-year symptomatic OSA remission rate for patients (n = 162) was 87.1%. At 1 year, class I, II, and III patients had 100, 85.7, and 87.5% (p = 0.5740) remission rates, respectively. The 1-year remission rates for SG and RYGB were 89.2 and 81.2% (p = 0.2189), respectively. A sub-analysis (n = 69) based on preoperative OSA severity levels did not affect the remission outcome at either the 6-month (p = 0.3670) or 1-year (p = 0.3004) follow-up. CONCLUSION: Most obese patients experience symptomatic remission of their OSA after bariatric surgery, regardless of their preoperative BMI, choice of operation, or OSA severity.

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OBJECTIVE: To evaluate effects of bariatric surgery on pelvic floor mediated quality of life in morbidly obese women. STUDY DESIGN: Prospective cohort study of 44 women undergoing bariatric surgery. RESULTS: Thirty-six women gave data at baseline and at mean follow-up of 3.15 years following bariatric surgery. Although urinary impact questionnaire scores improved (-34.92, P = .0020), colorectal-anal impact questionnaire and pelvic organ prolapse impact questionnaire scores did not improve despite significant weight loss. Baseline female sexual function index scores were low (17.70 ± 8.38) and did not improve with weight loss (16.91 ± 9.75, P = .5832). Pelvic organ prolapse/urinary incontinence sexual questionnaire scores did improve (35.78 ± 6.06 preoperatively vs 38.22 ± 6.03 postoperatively, P = .0193). CONCLUSION: Bariatric surgery is associated with significant improvement in the impact of urinary incontinence on quality of life. Sexual function was poor, and improved only on the pelvic organ prolapse/urinary incontinence sexual questionnaire that evaluated urinary incontinence.

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Type 2 diabetes mellitus affects more than 170 million people worldwide. Because this disease is strongly linked to obesity, the term "diabesity" has been coined to describe the confluence of the 2 disease processes. Bariatric surgery has been performed for many years to achieve sustained weight loss in the morbidly obese population. As a secondary effect, a remarkable improvement in glycemic control is commonly achieved postoperatively. This has led to substantial interest in the use of bariatric procedures to treat type 2 diabetes mellitus. Surgical procedures in common use include the adjustable gastric band, the Roux-en-Y gastric bypass, the biliopancreatic diversion with duodenal switch, and the sleeve gastrectomy. Additionally, several investigational procedures including the ileal interposition and duodenal-jejunal bypass have been proposed as primary interventions for type 2 diabetes mellitus. These operations achieve their metabolic effects through a combination of volume restriction, intestinal bypass, and hormonal changes. As more data become available on the positive effect of bariatric procedures on type 2 diabetes mellitus, the use of such operations may grow. Bariatric surgery may ultimately become a major tool in the long-term treatment of type 2 diabetes mellitus. This manuscript presents an extensive review of the literature supporting these concepts.

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BACKGROUND: Gastrojejunal anastomotic stricture is the most commonly occurring short-term complication after Roux-en-Y gastric bypass. Endoscopic balloon dilation is the first-line treatment for stricture. However, an optimal dilation protocol has not been identified. This study aimed to document routine management of stricture after laparoscopic gastric bypass and its impact on postoperative weight loss. METHODS: Charts of patients who underwent gastric bypass from 2000 to 2006 were reviewed using a standardized abstraction form. Patients with stricture were matched with control subjects based on age +/-5 years, gender, and preoperative body mass index (BMI +/- 5). Patients with at least 6 months of follow-up assessment were included in the study. RESULTS: Of the 113 patients included in the study, 20% were male, 26% black, 19% Hispanic, and 51% white. Their mean age was 42 +/- 10 years (range, 22-66 years). The mean preoperative BMI was 47.0 +/- 5.4 kg/m(2) for the case group and 46.6 +/- 5.5 kg/m(2) for the control group (p = 0.3). After adjustment for patient characteristics, using a larger balloon was associated with reduced odds of stricture recurrence (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.12-0.85; p = 0.02). All the patients were without signs or symptoms of stricture at the last follow-up visit (20 +/- 17 months). Weight loss was similar between the two groups. The percentage of estimated weight loss (%EWL) at 12 months postoperatively was 66% for the study participants and 67% for the control subjects (p = 0.5). Baseline alcohol use and higher preoperative BMI were associated with a higher BMI 6 months postoperatively (p = 0.004 and p < 0.001, respectively). CONCLUSIONS: Initial dilation with a larger balloon is safe and may prevent stricture recurrence. Further study of modifiable risk factors for reduced weight loss after surgery, such as alcohol use, may improve patient outcomes.

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