Johns Hopkins Center for Bariatric Surgery

Baltimore, MD, United States

Johns Hopkins Center for Bariatric Surgery

Baltimore, MD, United States

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Steele K.E.,Johns Hopkins University | Steele K.E.,Johns Hopkins Center for Bariatric Surgery | Canner J.,Johns Hopkins University | Prokopowicz G.,Johns Hopkins University | And 7 more authors.
Surgery for Obesity and Related Diseases | Year: 2015

Background Prophylaxis for venous thromboembolism is routinely performed for all patients undergoing bariatric surgery. However, there is disagreement regarding the optimal dosing and duration of anticoagulant therapy. Furthermore, there is little data regarding the incidence of asymptomatic deep venous thrombosis (DVT) in this population. Our objective was to conduct a pilot randomized double blind study to evaluate the pharmacodynamic parameters of 2 different anticoagulation medications (enoxaparin and fondaparinux) administered to patients undergoing bariatric surgery. Methods From July 2010 to August 2013, 198 consecutive bariatric surgery patients from an academic institution were randomized in a double blinded manner to receive either 40mg enoxaparin twice daily or 5mg fondaparinux sodium once daily. Antifactor Xa activity was measured on all patients in both study arms, 3 hours after the first dose (on the day of the operation), immediately before the second dose (postoperative day one), and 3 hours after the second dose. At the routine 2 week postoperative visit, patients underwent magnetic resonance venography (MRV) to detect DVT. The primary outcome was attainment of therapeutic antifactor Xa levels. The secondary outcome was DVT, as detected by MRV. Safety outcomes were perioperative bleeding, perioperative complications, and death. Results Of 198 patients randomized, 177 underwent MRV and 137 had interpretable antifactor Xa levels. Nearly half of the patients (47.4%) did not attain target prophylactic antifactor Xa levels. Adequate antifactor Xa levels were more common with fondaparinux (74.2%) than with enoxaparin (32.4%). Antifactor Xa levels were also associated with preoperative D-dimer level. 4 of the 175 patients who underwent MRV developed DVT, 2 in each arm of the study. No major adverse events occurred in either arm. Conclusion Fondaparinux was much more likely to produce target prophylactic antifactor Xa levels than enoxaparin. Both regimens appear to be equally effective at reducing the risk of DVT. Further prospective studies are needed to determine the optimal DVT prophylaxis regimen in the bariatric surgical population. © 2015 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery.

Caufield-Noll C.P.,Johns Hopkins Harrison Medical Library | Schweitzer M.A.,Johns Hopkins Center for Bariatric Surgery | Magnuson T.H.,Johns Hopkins Center for Bariatric Surgery | Steele K.E.,Johns Hopkins Center for Bariatric Surgery
Surgery for Obesity and Related Diseases | Year: 2016

Background Bariatric surgery is the most effective long-term weight loss method. The most common procedures are Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG). Bariatric patients are at high risk of Vitamin D deficiency (VDD) and insufficiency (VDI), which are associated with skeletal and nonskeletal ailments. There is no consensus regarding the optimal treatment for VDD/VDI in bariatric patients. Objectives To critically examine the literature on Vitamin D status (serum 25[OH]D concentrations) pre- and postbariatric surgery as well as supplementation regimens currently used. Methods We searched PubMed, Embase, and Cochrane from inception to May 2015 for articles relating to Vitamin D, RYGB, and VSG. Of 208 citations retrieved, 30 were included. Results Preoperative VDD (<20 ng/mL) ranged from 13% to 90%, while VDI (<30 ng/mL) was found in up to 98%. Prevalence remained similar postoperatively and was highest after RYGB. Most studies found dosages<800 IU daily insufficient postbariatric surgery. Other studies examined the effectiveness of dosages between 1000 and 5000 IU daily, reaching similar conclusions. Several studies suggested using 50,000 IU weekly plus a daily dose. No studies reported optimization. Conclusions It is widely accepted that serum 25(OH)D concentrations above 30 ng/mL are optimal; however, current postbariatric Vitamin D supplementation fails to raise 25(OH)D above that level universally. This review highlights both the great need and the lack of consensus on the optimal supplementation regimen (dosage and frequency) for pre- and postbariatric patients. Future studies should investigate multiple regimens and attempt to identify methods for personalizing these regimens if found necessary. © 2016 American Society for Bariatric Surgery.

Shade J.,Johns Hopkins Center for Bariatric Surgery | Shade J.,Johns Hopkins University | Abraham A.,Johns Hopkins Center for Bariatric Surgery | Abraham A.,Johns Hopkins University | And 12 more authors.
JAMA Surgery | Year: 2015

IMPORTANCE From February 21, 2006, through September 24, 2013, the Centers for Medicare & Medicaid Services (CMS) required, via the National Coverage Determination manual, that bariatric surgery be performed only in hospitals that had been designated as a Center of Excellence (COE). The effect of this certification requirement on access to bariatric surgery has been reported only anecdotally. OBJECTIVE To investigate whether the COE certification requirement proved to be a barrier to patients' access to bariatric surgical procedures. DESIGN, SETTING, AND PARTICIPANTS Using the National Inpatient Sample,we retrospectively identified patients who underwent bariatric surgery from January 1, 2006, through December 31, 2011. EXPOSURE Bariatric surgery. MAIN OUTCOMES AND MEASURES Logistic regression and χ2 testswere used to examine differences in patients' sociodemographic characteristics over time. RESULTS A total of 134 227 bariatric surgical patients were identified. The proportion of the population who were older than 64 years increased from 2.9% in 2006 to 7.0% in 2011 (P < .001) and there was a decrease in the proportion of patients who were 49 years and younger (P < .001). The percentage of female patients who underwent bariatric surgery decreased from 80.4%to 78.1% (P < .001) and the percentage of patients who were classified as black, Hispanic, or Asian or Pacific Islander increased from 12.3%to 15.1% (P < .001), 9.7%to 12.5%(P < .001), and 0.3%to 0.4%(P < .001), respectively. The proportion of patients with Medicare increased from 8.5%to 16.3%(P < .001) and those with Medicaid from 6.6%to 11.8%(P < .001). The percentage of patients with private insurance declined from 72.4%to 63.3%(P < .001). The proportion of patients in the lowest income quartile increased from 20.7%to 22.9% (P < .001) while those in the highest income quartile decreased from 25.8% to 23.9%(P < .001). CONCLUSIONS AND RELEVANCE The COE certification requirement by CMS did not appear to limit access to bariatric surgery. Future studies should determine whether CMS's recent (2013) change in policy (ie, removing the mandatory COE certification for bariatric surgical insurance coverage) might sacrifice patient safety without addressing the real cause of limited access to health care. Copyright 2015 American Medical Association. All rights reserved.

Wolf R.M.,Johns Hopkins University | Steele K.E.,Johns Hopkins Center for Bariatric Surgery | Peterson L.A.,Johns Hopkins Center for Bariatric Surgery | Magnuson T.H.,Johns Hopkins Center for Bariatric Surgery | And 2 more authors.
PLoS ONE | Year: 2015

Purpose C1q/TNF-related protein-3 (CTRP3) is a novel adipokine that lowers blood glucose levels, reduces liver triglyceride synthesis, and is protective against hepatic steatosis in dietinduced obese mouse models. We hypothesized that higher circulating serum levels of CTRP3 would be associated with a lean body mass index (BMI) and a more favorable metabolic profile in humans. The aim of this study was to investigate CTRP3 levels in lean individuals compared to obese individuals. Methods This was a cross-sectional study of obese (n=44) and lean control patients (n=60). Fasting metabolic parameters were measured in all patients and serum CTRP3 levels were measured by ELISA. Results BMI of the lean group was 21.9 ± 0.2 kg/m2 and obese group was 45.2 ± 1.1 kg/m2. We found significantly lower circulating levels of CTRP3 in obese individuals (405 ± 8.3 vs. 436 ± 6.7ng/mL, p=0.004) compared to the lean group. Serum CTRP3 levels were inversely correlated with BMI (p=0.001), and triglycerides (p<0.001), and significantly associated with gender (p<0.01), ethnicity (p=0.05), HDL-cholesterol (p<0.01), and adiponectin (p<0.01). We found BMI (p<0.01), gender (p<0.01), and ethnicity (p<0.05) to be significant predictors of CTRP3 levels when controlling for age in multiple regression analysis. Conclusions CTRP3 is a beneficial adipokine whose circulating levels are significantly lower in obese individuals. Obesity causes dysregulation in adipokine production, including the down-regulation of CTRP3. Lower CTRP3 levels may contribute to the pathophysiology of metabolic disorders associated with obesity. Optimizing CTRP3 levels through novel therapies may improve obesity and its comorbidities. © 2015 Wolf et al.

Steele K.E.,Johns Hopkins University | Steele K.E.,Johns Hopkins Center for Bariatric Surgery | Prokopowicz G.P.,Johns Hopkins University | Schweitzer M.A.,Johns Hopkins University | And 6 more authors.
Obesity Surgery | Year: 2010

Background: While bariatric surgery has proved highly successful at producing sustained weight loss, variability in treatment response persists. A better understanding of the pathophysiology of appetite and obesity may improve patient selection and management. Research into feeding behavior and satiety has focused on the role of dopamine in reward-based behaviors. Specifically, positron-emission computed tomography (PET) has demonstrated reduced brain dopamine receptor availability in obese subjects compared to controls. This may be due to a primary deficiency in dopamine receptors or to secondary dopamine receptor downregulation. We performed a preliminary study to investigate dopamine D2 receptor activity in obese subjects before and after laparoscopic Roux-en Y gastric bypass (LGBP). Methods: Five female subjects, ages 20 to 38 years old with a mean body mass index of 45, underwent PET with [C-11] raclopride injection. Five regions of interest were studied: ventral striatum, anterior and posterior putamen, and anterior and posterior caudate nucleus. Repeat PET was performed at 6 weeks following LGBP. D2 receptor binding was compared within subjects pre- and post-surgery. Baseline D2 binding was also compared to historical nonobese controls. Results: D2 receptor availability increased 6 weeks after gastric bypass surgery. The increase in receptor availability appeared roughly proportional to the amount of weight lost. No significant difference in D2 binding was seen between the obese subjects and historical nonobese controls. Conclusions: Brain available dopamine D2 binding appears to increase following GBP. This preliminary finding needs to be replicated in a larger population but suggests that diminished D2 binding in the obese may be due to D2 receptor downregulation. Changes in available dopamine receptor binding may play an important role in centrally mediated appetite suppression and resultant weight loss after LGBP. © 2009 Springer Science + Business Media, LLC.

Semins M.J.,James Buchanan Brady Urological Institute | Asplin J.R.,Litholink Corporation | Steele K.,Johns Hopkins Center for Bariatric Surgery | Assimos D.G.,Wake forest University | And 5 more authors.
Urology | Year: 2010

OBJECTIVES: Malabsorptive bariatric procedures such as Roux-en-Y gastric bypass (RYGB) place patients at risk for developing kidney stones. Stone risk factors after purely restrictive procedures such as gastric banding and sleeve gastrectomy are not well characterized. Therefore, we performed a study to examine urinary risk factors of patients who underwent restrictive gastric surgery for bariatric indications. METHODS: A total of 18 patients were enrolled in the study; 14 underwent gastric banding and 4 underwent sleeve gastrectomy. All subjects collected 24-hour urine specimens; at least 6 months had elapsed between surgery and urine collection. Standard stone risk parameters were assessed, and comparisons were made with a group of normal adult nonstone-formers, routine stone-formers, and RYGB bariatric surgery subjects. RESULTS: Urinary oxalate excretion of the restrictive cohort was significantly less than the RYGB cohort (35.4 vs. 60.7 mg/d; P <.001) and not significantly different from that of the normal subjects (32.9 mg/d; P = .798) and routine stone-formers (37.2 mg/d; P = .997). There were no other significant differences in urinary parameters. CONCLUSIONS: Restrictive bariatric surgery does not appear to be associated with an increased risk for kidney stone disease. In particular, urinary oxalate levels were significantly less than those of RYGB subjects and not significantly different from routine stone-formers and nonstone-forming controls. © 2010 Elsevier Inc.

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