Expanded indications for bariatric surgery: should patients on chronic steroids be offered bariatric procedures?

Abstract

Background Patients who take chronic corticosteroids are increasingly referred for bariatric surgery. Little is known about their clinical outcomes. Objective Determine whether chronic steroid use is associated with increased morbidity and mortality after stapled bariatric procedures. Setting American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Methods We reviewed all patients who underwent laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (RYGB) and were reported to the ACS-NSQIP from 2011 to 2013. Patients were grouped based on type of surgery and history of chronic steroid use. Primary outcome measures were mortality and serious morbidity in the first 30 days. Regression analyses were used to determine predictors of outcome. Results Of 23,798 patients who underwent LSG and 38,184 who underwent RYGB, 385 (1.6%) and 430 (1.1%), respectively, were on chronic steroids. Patients on chronic steroids had a 3.4 times increased likelihood of dying within 30 days (95% CI 1.4–8.1, p=0.007), and two-fold increased odds of serious complications (95% CI 1.2–2.3, p=0.008), regardless of surgery type. In multivariate regression, steroid usage remained an independent predictor of mortality and serious complications. Conclusions In a large, nationally-representative patient database, steroid use independently predicted mortality and serious postoperative complications after stapled bariatric procedures. Surgeons should be cautious about offering stapled bariatric procedures to patients on chronic steroids.

Outcomes of Sleeve Gastrectomy in Obese Liver Transplant Candidates

“…First, we hypothesized that sustained weight loss after SG may reduce the risk for further hepatic decompensation and potentially even negate the need for LT altogether in some candidates. Second, in those candidates who proceed to LT, SG prior to LT versus concurrent with LT may lessen the risk of staple‐line complications, which could be precipitated by high‐dose steroid exposure after LT . Additionally, we postulated that rapid weight loss in the posttransplant period resulting from a combined SG and LT procedure could make immunosuppressive management more challenging.…”

“…First, we hypothesized that sustained weight loss after SG may reduce the risk for further hepatic decompensation and potentially even negate the need for LT alto-gether in some candidates. Second, in those candidates who proceed to LT, SG prior to LT versus concurrent with LT may lessen the risk of staple-line complications, which could be precipitated by high-dose steroid exposure after LT. (25) Additionally, we postulated that rapid weight loss in the posttransplant period resulting from a combined SG and LT procedure could make immunosuppressive management more challenging. Finally, as compared with simultaneous SG and LT, patients who undergo pre-LT SG may have lower risk of intolerance to oral intake immediately after LT, which is especially important given that the optimization of nutritional intake is an integral component of immediate post-LT care.…”

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures – 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

“…Various preoperative psychological instruments have also been used to predict postoperative outcomes . The use of chronic steroids is associated with mortality and serious postoperative complications after stapled bariatric procedures, with no difference between patients undergoing RYGB and patients undergoing SG .…”

Does Gastric Surgery (Such as Bariatric Surgery) Impact the Risk of Intestinal Inflammation?

“…Furthermore, without any available evidence, Moum and Jahnsen [41] mention the potential risk of exacerbating intestinal inflammation and the increased risk of small-intestine neoplasia following RYGBP. As chronic steroid use is associated with increased morbidity and mortality after BS [42], operating on IBD patients with immunosuppressive treatment should be preceded by meticulous risk stratification.…”