Show Notes

Jeff: Welcome back to EMplify the podcast corollary to EB Medicine’s Emergency Medicine Practice. I’m Jeff Nusbaum and I’m back with Nachi Gupta for the 30th episode of EMplify and the first Post-Ponte Vedra Episode of 2019. I hope everybody enjoyed a fantastic conference. This month, we are sticking in the abdomen for another round of evidence-based medicine, focusing on Emergency Department Management of Patients With Complications of Bariatric Surgery.

Nachi: As the obesity epidemic continues to worsen in America, bariatric procedures are becoming more and more common, and this population is one that you will need to be comfortable seeing.

Jeff: Thankfully, this month’s author, Dr. Ogunniyi, associate residency director at Harbor-UCLA, is here to help with this month’s evidence-based article.

Nachi: And don’t forget Dr. Li of NYU and Dr. Luber of McGovern Medical School, who both played a roll by peer reviewing this article. So let’s dive in, starting with some background. Starting off with some real basics, obesity is defined as a BMI of greater than 30.

Jeff: Oh man, already starting with the personal assaults, I see how this is gonna go…

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Nachi: Nah! Just some definitions, nothing personal!

Jeff: Whatever, back to the article… Obesity is associated with an increased risk of hypertension, hyperlipidemia, and diabetes. Rising levels of obesity and associated co-morbidities also lead to an increase in bariatric procedures, and thereby ED visits!

Nachi: One study found a 30-day ED utilization rate of 11% for those undergoing bariatric surgery with an admission rate of 5%. Another study found a 1-year post Roux-en-y ED visit rate of 31% and yet another found that 25% of these patients will require admission within 2 years of surgery.

Jeff: Well that’s kind worrisome.

Nachi: It sure is, but maybe even more worrisome is the rising prevalence of obesity. While it was < 15% in 1990, by 2016 it reached 40%. That’s almost half of the population. Additionally, back in 2010, it was estimated that 6.6% of the US population had a BMI> 40 – approximately 15.5 million adults!!

Jeff: Admittedly, the US numbers look awful, and honestly are awful, but this is a global problem. From the 80’s to 2008, the worldwide prevalence of obesity nearly doubled!

Nachi: Luckily, bariatric surgical procedures were invented and honed to the point that they have really shown measurable achievements in sustained weight loss. Along with treating obesity, these procedures have also resulted in an improvement in associated comorbidities like hypertension, diabetes, NAFLD, and dyslipidemia.

Jeff: A 2014 study even showed an up to 80% reduction in the likelihood of developing DM2 postoperatively at the 7-year mark.

Nachi: Taken all together, the rising rates of obesity and the rising success and availability of bariatric procedures has led to an increased number of bariatric procedures, with 228,000 performed in the US in 2017.

Jeff: And while it’s not exactly core EM, we’re going to briefly discuss indications for bariatric surgery, as this is something we don’t often review even in academic training programs.

Nachi: According to joint guidelines from the American Society for Metabolic and Bariatric Surgery, the American Association of Clinical Endocrinologists, and The Obesity Society, there are three groups that meet indications for bariatric surgery. The first is patients with a BMI greater than or equal to 40 without coexisting medical problems. The second is patients with a BMI greater than or equal to 35 with at least one obesity related comorbidity such as hypertension, hyperlipidemia, or obstructive sleep apnea. And finally, the third is patient with a BMI of 30-35 with DM or metabolic syndrome though current evidence is limited for this group.

Jeff: Based on the obesity numbers, we just cited – it seems like a TON of people should be eligible for these procedures.