Sleeve Gastrectomy for Weight Loss

Early changes of microRNAs in blood one month after bariatric surgery

BACKGROUND

Changes in microRNAs (miRNAs) are relevant to bariatric surgery and its comorbidities. The characteristics of changes in miRNAs of the early postoperative period following both bariatric procedures, sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), as well as the factors that related to the effectiveness of early weight loss remain unclear.

METHODS

We recruited 18 patients who performed SG and 15 patients who performed RYGB. Their preoperative and 1-month postoperative clinical data and fasting serum samples were collected, and the latter were analyzed by RNA-sequencing. Differential expression analysis of miRNAs was performed by the R-tool. Functional classification annotation and pathway enrichment analysis of targeted genes were analyzed by KOBAS software. The change profiles of miRNAs for both surgeries and their correlation with clinical characteristics and weight loss effectiveness were further analyzed.

RESULTS

A total of 85 differentially expressed miRNAs were identified before and after SG, while a total of 76 were found before and after RYGB. The target genes of these miRNAs were similar in the Gene Ontology enrichment analysis in SG and RYGB, and the enrichment analysis in the Kyoto Encyclopedia of Genes and Genomes was mainly related to metabolic pathways. Hsa-miR-493-5p, hsa-miR-184, and hsa-miR-3199 exhibited similar changes in SG and RYGB, and the former two were correlated with clinical characteristics. Hsa-miR-6729-5p, hsa-miR-4659b-5p, and hsa-miR-2277-5p were correlated with the weight loss effectiveness of SG, while hsa-miR-4662a-5p was correlated with the weight loss effectiveness of RYGB.

CONCLUSIONS

Short-term metabolic improvement and weight loss occurring after SG and RYGB surgery might be related to changes in miRNAs, which act on multiple biological pathways by regulating genes. In addition, some clinical characteristics and miRNAs were related to the effectiveness of early weight loss after SG and RYGB surgery.

CLINICAL TRIAL REGISTRATION

ChiCTR2200058333.

Comparison of the postoperative outcome with and without intraoperative leak testing for sleeve gastrectomy: a systematic review and meta-analysis of 469 588 cases

OBJECTIVE

Postoperative staple line leakage (SLL) after sleeve gastrectomy (SG) is a rare but serious complication. Many surgeons routinely test anastomosis with an intraoperative leak test (IOLT) as part of the SG procedure. This meta-analysis aims to determine whether an IOLT plays a role in reducing the rate of postoperative staple line related complications in patients who underwent SG.

METHODS

The authors searched the PubMed, Web of science, the Cochrane Library, and Clinical Trials.gov databases for clinical studies assessing the application of IOLT in SG. The primary endpoint was the development of postoperative SLL. Secondary endpoints included the postoperative bleeding, 30 days mortality rates, and 30 days readmission rates.

RESULTS

Six studies totaling 469 588 patients met the inclusion criteria. Our review found that the SLL rate was 0.38% (1221/ 324 264) in the IOLT group and 0.31% (453/ 145 324) in the no intraoperative leak test (NIOLT) group. Postoperative SLL decreased in the NIOLT group compared with the IOLT group (OR=1.27; 95% CI: 1.14-1.42, P =0.000). Postoperative bleeding was fewer in the IOLT group than that in the NIOLT group (OR 0.79; 95% CI: 0.72-0.87, P =0.000). There was no significant difference between the IOLT group and the NIOLT group regarding 30 days mortality rates and 30 days readmission rates ( P >0.05).

CONCLUSION

IOLT was correlated with an increase in SLL when included as a part of the SG procedure. However, IOLT was associated with a lower rate of postoperative bleeding. Thus, IOLT should be considered in SG in the situation of suspected postoperative bleeding.

Pharmacotherapy for obesity: moving towards efficacy improvement

Obesity is a chronic, recurring, progressive disease and a major public health problem associated with several other diseases that lead to disability, morbidity, and mortality. The prevalence of obesity has increased at pandemic levels, along with increasing weight-related comorbidities and deaths worldwide. Lifestyle interventions alone provide clinically significant long-term weight loss in only a small proportion of individuals, and bariatric surgery is not suitable or desirable for all patients. Historically, anti-obesity medications achieved a mean efficacy with weight loss between 5 and 10%, which significantly impacted several comorbidities and risk factors, but the average efficacy of these medications remained lower than that expected by both patients and health care professionals and eventually curbed long-term use. Moreover, there is no direct evidence on the impact of anti-obesity medications on cardiovascular outcomes. Semaglutide is a newer anti-obesity medication that changes the overall landscape, as phase 3 studies show a mean weight loss near the 15% threshold and significant proportions of patients with a weight loss of greater than 20%. In this review, we focus on the currently available anti-obesity medications, discuss the results of semaglutide, and present perspectives on the future of obesity treatment after semaglutide.

Adverse perinatal outcomes after Roux-en-Y Gastric Bypass vs. Sleeve Gastrectomy: a systematic review

BACKGROUND

Pregnancies occurring after bariatric surgery are associated with various perinatal complications. However, there may be differences in the type of perinatal complications occurring after different methods of bariatric surgery. The aim of the current study was to compare adverse perinatal outcomes in pregnant women following Roux-en-Y Gastric Bypass (RYGB) vs. Sleeve Gastrectomy (SG).

METHODS

A systematic database search was performed in PubMed, Embase, Scopus and CINAHL. Observational studies comparing perinatal outcomes post-bariatric (RYGB and SG) surgery to pregnancies without prior surgery were selected. Outcomes of interest were: maternal body mass index (BMI) at the time of conception, mode of delivery, time from surgery to conception, birth weight, gestational age and intrauterine fetal death. Article selection, risk of bias assessment and data extraction, were performed by two authors. The study protocol was published in its revised form in PROSPERO, registration number: CRD42021234480.

RESULTS

A total of 3201 records were extracted. After duplicates were removed, 3143 records were screened for inclusion. Six studies fitted the selection criteria, of which four studies were RYGB and two SG (1100 post-RYGB vs. 209 post-SG). For the included studies, higher incidence of both SGA (22.9%, 11.9%, 14.2%) and LGA (4.2%, 4.8%, 1.7%) in SG compared to Roux-en-Y (SGA: 8.8%, 7.7%, 11.5%, 8.3% and LGA: 3.4%, 0.7%) were observed. SG had a shorter surgery to conception interval as compared to RYGB. Risk of bias assessment was moderate to serious for the studies included in the review, with bias in selection of participants being the major reason.

CONCLUSION

Our systematic review demonstrated no major differences in BMI, mode of delivery, birthweight, gestational age, or rates of intrauterine death between women having undergone RYGB vs. SG. The rate of SGA and LGA births were higher in the SG group, but this group also had a shorter surgery to conception interval. Future studies are indicated to counsel women of reproductive age on the most appropriate type of bariatric surgery that is associated with the best perinatal outcomes.

Prevalence of Gastroesophageal Reflux Symptoms Post Sleeve Gastrectomy in Al-Qassim Region

BACKGROUND AND AIMS

After sleeve gastrectomy, heartburn sensation and regurgitation are frequent postoperative consequences. This study aimed to determine the prevalence and severity of heartburn sensation and regurgitation symptoms among patients who underwent sleeve gastrectomy, as well as the relationship between demographic variables and the presence and severity of these symptoms.

METHODOLOGY

This cross-sectional study included 290 patients who underwent sleeve gastrectomy in the Al-Qassim region, Saudi Arabia. Patients were asked to complete a questionnaire that assessed the presence and severity of heartburn and regurgitation symptoms. Demographic data, including age, gender, smoking status, and the date of bariatric surgery, were also collected.

RESULTS

The results showed that heartburn and regurgitation were common symptoms among patients who underwent sleeve gastrectomy, with 78% and 73.9% of patients reporting these symptoms, respectively. 11.5% of patients who experienced severe symptoms of regurgitation, and 6.4% of patients with severe heartburn reported serious symptoms that affected their lives by causing an inability to perform daily activities. Age and the date of bariatric surgery were significant factors associated with heartburn and regurgitation symptoms. Patients aged 25-35 years reported the highest prevalence of heartburn symptoms, and the more recent surgery; dated less than one year ago had the highest prevalence of heartburn symptoms.

CONCLUSION

Patients who have sleeve gastrectomy frequently experience heartburn and regurgitation, which can have a substantial influence on their quality of life. Routine evaluation and treatment of heartburn and regurgitation symptoms should be an integral component of postoperative care. Younger patients and those who undergo surgery in the early postoperative period may be at a greater risk for developing heartburn and regurgitation symptoms, necessitating more active measures to treat these symptoms.

The impact of microbially modified metabolites associated with obesity and bariatric surgery on antitumor immunity

Obesity is strongly associated with the occurrence and development of many types of cancers. Patients with obesity and cancer present with features of a disordered gut microbiota and metabolism, which may inhibit the physiological immune response to tumors and possibly damage immune cells in the tumor microenvironment. In recent years, bariatric surgery has become increasingly common and is recognized as an effective strategy for long-term weight loss; furthermore, bariatric surgery can induce favorable changes in the gut microbiota. Some studies have found that microbial metabolites, such as short-chain fatty acids (SCFAs), inosine bile acids and spermidine, play an important role in anticancer immunity. In this review, we describe the changes in microbial metabolites initiated by bariatric surgery and discuss the effects of these metabolites on anticancer immunity. This review attempts to clarify the relationship between alterations in microbial metabolites due to bariatric surgery and the effectiveness of cancer treatment. Furthermore, this review seeks to provide strategies for the development of microbial metabolites mimicking the benefits of bariatric surgery with the aim of improving therapeutic outcomes in cancer patients who have not received bariatric surgery.

Pharmacological interventions for preventing venous thromboembolism in people undergoing bariatric surgery

BACKGROUND

Venous thromboembolism (VTE), which comprises deep vein thrombosis (DVT) and pulmonary embolism (PE), is the leading cause of preventable death in hospitalised people and the third most common cause of mortality in surgical patients. People undergoing bariatric surgery have the additional risk factor of being overweight. Although VTE prophylaxis in surgical patients is well established, the best way to prevent VTE in those undergoing bariatric surgery is less clear.

OBJECTIVES

To evaluate the benefits and harms of pharmacological interventions (alone or in combination) on venous thromboembolism and other health outcomes in people undergoing bariatric surgery compared to the same pharmacological intervention administered at a different dose or frequency, the same pharmacological intervention or started at a different time point, another pharmacological intervention, no intervention or placebo.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 1 November 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in males and females of any age undergoing bariatric surgery comparing pharmacological interventions for VTE (alone or in combination) with the same pharmacological intervention administered at a different dose or frequency, the same pharmacological intervention started at a different time point, a different pharmacological intervention, no treatment or placebo.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. VTE and 2. major bleeding. Our secondary outcomes were 1. all-cause mortality, 2. VTE-related mortality, 3. PE, 4. DVT, 5. adverse effects and 6. quality of life. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We included seven RCTs with 1045 participants. Data for meta-analysis were available from all participants. Four RCTs (597 participants) compared higher-dose heparin to standard-dose heparin: one of these studies (139 participants) used unfractionated heparin (UFH) and the other three (458 participants) used low-molecular-weight heparin (LMWH). One study compared heparin versus pentasaccharide (198 participants), and one study compared starting heparin before versus after bariatric surgery (100 participants). One study (150 participants) compared combined mechanical and pharmacological (enoxaparin) prophylaxis versus mechanical prophylaxis alone. The duration of the interventions ranged from seven to 15 days, and follow-up ranged from 10 to 180 days. Higher-dose heparin versus standard-dose heparin Compared to standard-dose heparin, higher-dose heparin may result in little or no difference in the risk of VTE (RR 0.55, 95% CI 0.05 to 5.99; 4 studies, 597 participants) or major bleeding (RR 1.19, 95% CI 0.48 to 2.96; I2 = 8%; 4 studies, 597 participants; low-certainty) in people undergoing bariatric surgery. The evidence on all-cause mortality, VTE-related mortality, PE, DVT and adverse events (thrombocytopenia) is uncertain (effect not estimable or very low-certainty evidence). Heparin versus pentasaccharide Heparin compared to a pentasaccharide after bariatric surgery may result in little or no difference in the risk of VTE (RR 0.83, 95% CI 0.19 to 3.61; 1 study, 175 participants) or DVT (RR 0.83, 95% CI 0.19 to 3.61; 1 study, 175 participants). The evidence on major bleeding, PE and mortality is uncertain (effect not estimable or very low-certainty evidence). Heparin started before versus after the surgical procedure Starting prophylaxis with heparin 12 hours before surgery versus after surgery may result in little or no difference in the risk of VTE (RR 0.11, 95% CI 0.01 to 2.01; 1 study, 100 participants) or DVT (RR 0.11, 95% CI 0.01 to 2.01; 1 study, 100 participants). The evidence on major bleeding, all-cause mortality and VTE-related mortality is uncertain (effect not estimable or very low-certainty evidence). We were unable to assess the effect of this intervention on PE or adverse effects, as the study did not measure these outcomes. Combined mechanical and pharmacological prophylaxis versus mechanical prophylaxis alone Combining mechanical and pharmacological prophylaxis (started 12 hours before surgery) may reduce VTE events in people undergoing bariatric surgery compared to mechanical prophylaxis alone (RR 0.05, 95% CI 0.00 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 9; 1 study, 150 participants; low-certainty). We were unable to assess the effect of this intervention on major bleeding or morality (effect not estimable), or on PE or adverse events (not measured). No studies measured quality of life.

AUTHORS' CONCLUSIONS

Higher-dose heparin may make little or no difference to venous thromboembolism or major bleeding in people undergoing bariatric surgery when compared to standard-dose heparin. Heparin may make little or no difference to venous thromboembolism in people undergoing bariatric surgery when compared to pentasaccharide. There are inadequate data to draw conclusions about the effects of heparin compared to pentasaccharide on major bleeding. Starting prophylaxis with heparin 12 hours before bariatric surgery may make little or no difference to venous thromboembolism in people undergoing bariatric surgery when compared to starting heparin after bariatric surgery. There are inadequate data to draw conclusions about the effects of heparin started before versus after surgery on major bleeding. Combining mechanical and pharmacological prophylaxis (started 12 hours before surgery) may reduce VTE events in people undergoing bariatric surgery when compared to mechanical prophylaxis alone. No data are available relating to major bleeding. The certainty of the evidence is limited by small sample sizes, few or no events, and risk of bias concerns. Future trials must be sufficiently large to enable analysis of relevant clinical outcomes, and should standardise the time of treatment and follow-up. They should also address the effect of direct oral anticoagulants and antiplatelets, preferably grouping them according to the type of intervention.

GASTRIC TWIST AFTER SLEEVE GASTRECTOMY: A PROPOSAL FOR ENDOSCOPIC CLASSIFICATION

ABSTRACT - BACKGROUND: The twisting of the gastric tube is one of the main causes of persistent reflux and food intolerance after sleeve gastrectomy (SG). To date, there is no classification for gastric twist after SG. OBJECTIVE: This study aimed to propose an endoscopic classification for this condition and outline the clinical profile of these patients with sleeve gastrectomy. METHODS: Patients in the postoperative period of SG presenting endoscopic findings of gastric twist were included. All patients underwent an esophagogastroduodenoscopy 12 months after SG. The classification proposed consists of three degrees: degree I: mild rotation of the staple line without relevant shrinkage of the gastric lumen; degree II: moderate rotation of the staple line, leading to a focal area of fixed narrowing that requires additional maneuvers for its transposition; and degree III: severe rotation of the staple line leading to stenosis, with increased difficulty for transposition or complete blockage. RESULTS: Out of 2,723 patients who underwent SG, 45 (1.6%) presented gastric twist. Most patients were female (85%), with mean age of 39±10.4 years. In all, 41 (91.1%) presented degree I, 3 (6.7%) presented degree II, and 1 (2.2%) had degree III. Most patients were asymptomatic (n=26). Vomiting was the most prevalent symptom (15.5%). Statistically significant correlation of twisting degrees was not observed for both the presence of symptoms and the degrees of esophagitis. CONCLUSION: Gastric twist after SG is rare, with generally mild and asymptomatic presentation. The endoscopic classification was not statistically related to clinical presentation but set the ground for further analysis.

Current status of gastroesophageal reflux disease after sleeve gastrectomy: Still a long way to go

Obesity is a public health concern that is becoming increasingly more serious around the world. Bariatric surgery has become more prevalent due to the obesity epidemic worldwide. Sleeve gastrectomy (SG) is one of the most popular procedures which is safe and efficient. Despite all its favorable features, however, there is an increasing evidence from the literature that the long-term incidence of gastroesophageal reflux disease (GERD) is likely to represent the Achilles' heel of this procedure. Management of severe reflux after SG usually requires revisional surgery. The relationship between SG and GERD needs to be better ascertained in order to prevent related complications, such as esophageal adenocarcinoma. This review attempts to elucidate the effect of SG on GERD and the postoperative management of reflux disease according to recent literature in the hope of drawing the attention of clinicians to postoperative gastroesophageal reflux and guiding the optimal management strategy associated with this "troublesome complication".

Long-Term Changes in Weight in Patients With Severe and Complicated Obesity After Completion of a Milk-Based Meal Replacement Programme

Introduction: Even with very significant short term weight loss with intensive dietary restriction, subsequent weight regain remains a challenge for most patients. We sought to assess long-term weight change in patients with obesity following completion of a 24-week milk-based meal replacement programme. Methods: We conducted a retrospective cohort study of bariatric patients who completed our milk-based meal replacement programme. This programme started with an 8-week weight loss phase, followed by weight stabilization (8 weeks) and weight maintenance (8 weeks) phases, after which patients were followed up in the bariatric outpatient clinics. A paired sample t-test was used to compare mean differences in weight at the start and the end of the programme and at follow-up. Linear regression was used to identify predictors of weight regain. Results: In total, 78 patients had long term follow-up data at a mean of 34.4 ± 19.8 months after the start of the milk diet and were included in this analysis. Mean body mass index at baseline was 50.5 ± 7.6 kg m^-2, 41 (52.6%) were female and the mean age was 51.6 ± 12.0 (range 18.0-71.5) years. Weight decreased from144 ± 26 kg at the start of the milk diet to 121.2 ± 24 kg at completion (P < 0.001), with a non-significant trend upwards in the 1st and 2nd years of follow-up to 129.0 ± 27.7 (P = 0.07 compared to nadir) and 123.4 ± 29.0kg (P = 0.17), respectively. Although regains in the 3rd and 4th follow-up years were substantial to 131.0 ± 22.3 (P < 0.001), and 139.8 ± 35.4 kg (P < 0.001), there was still a moderate net weight loss of 4.7 [9.5, 0.21] and 7.0 [13.9, 0.26] kg (both P = 0.04) between the start and the 3rd and 4th follow-up years, respectively. The amount of weight regain was inversely associated with weight loss at completion of the programme, age, and directly associated with the duration of follow up in months (β = 1.2 [0.46, 1.9] P = 0.002). Conclusion: In patients with severe obesity who completed a milk-based meal replacement programme and lost a large amount of weight, over 4 years of follow-up there was very substantial weight regain. Greater initial weight loss and older age were associated with less subsequent weight regain.

Gastric emptying scintigraphy results may influence the selection of the type of bariatric surgery: A cohort study

Bariatric surgery (BAS) may result in adverse outcomes that include appearance of gastrointestinal (GI) symptoms and/or failure to reach the weight reduction goal. This retrospective study tested the hypothesis that pre-operative gastric emptying (GE) abnormality is responsible for adverse post-surgical outcomes.Pre-operative GE was performed using the standard solid-meal GE scintigraphy (GES) in 111 consecutive patients (105 females and 6 males, mean age 46.2 years, range 20-70 years) who were evaluated for BAS. All underwent BAS - 93 had laparoscopic sleeve gastrectomy (LSG) and 18 had Roux-en-Y (ReY) gastric bypass. All had short-term (3-6 months) and long-term (up to 54 months) follow-up with review of symptoms, physical, and laboratory examinations. Chi-square analysis was performed. P-value < .05 was considered significant.Of the 111 patients, 83 had normal and 28 had abnormal pre-op GES. Sixty-eight were asymptomatic and 43 were symptomatic prior to surgery. Following surgery, 81 patients were asymptomatic and 30 were symptomatic at long-term follow-up. There was no significant difference between pre-op GE results and post-surgical adverse clinical outcome (p = ns). However, GES results seem to have guided the selection of surgical procedure significantly (P = .008).Pre-operative GE study was not a strong predictor of clinical outcome in BAS. Although, it influenced the type of surgery, as when the GES was abnormal, the patient was more likely to undergo ReY and when GES was normal, they favored LSG. Interestingly, many of our symptomatic patients at 6 months post-op were asymptomatic after long-term follow-up.