Limited Bariatric Surgery-induced Weight Loss in Subjects With Type 2 Diabetes: Predictor Variables in Adipose Tissue

CONTEXT

The impact of type 2 diabetes mellitus (T2D) at baseline on limited weight loss (WL) after bariatric surgery (BS) remains controversial, and the potential underlying mechanisms incompletely understood.

OBJECTIVE

We aimed at gaining further insight on this relationship and identifying novel associations between adipose tissue (AT) parameters and short-term WL outcomes in subjects with or without T2D undergoing BS.

METHODS

Mid-term WL trajectories after BS have been evaluated in a cohort of 1659 subjects (cohort 1) with (n = 543) and without T2D (n = 1116). Paired subcutaneous and visceral AT samples were obtained from a cohort of 48 pairs of subjects with and without T2D matched for age, sex, BMI, and type of BS (cohort 2). Differences in AT parameters between groups were evaluated and potential associations with WL response explored.

RESULTS

T2D was independently associated with a 5% lesser mid-term WL in cohort 1, while HbA1c, insulin treatment, and number of T2D medications prior to BS were only related to short-term WL outcomes. In cohort 2, a number of differentially expressed genes in AT were identified between groups, while fat cell size and fibrosis were comparable. Subcutaneous ATG7 expression was found as an independent predictor of limited WL 1 year after surgery (β: -12.21 ± 4.41, P = .008) and its addition to a clinical model significantly improved the amount of WL variability explained (R2 = 0.131 vs R2 = 0.248, F change P = .009).

CONCLUSION

Our results highlight the importance of T2D as determinant of limited WL following BS and suggest that dysregulated macroautophagy in subcutaneous AT may contribute to this association.

Evidence-Based Classification for Post-bariatric Weight Regain from a Benchmark Registry Cohort of 18,403 Patients and Comparison with Current Criteria

INTRODUCTION

There is a need for a standardized, evidence-based classification of post-bariatric weight-regain, to investigate and compare revision procedures and to advice and treat patients in an evidence-based way.

METHODS

We used standard deviations (SD) of the highest (1-2 years) and latest (> 2 years) percentage total weight loss (%TWL) results after primary bariatric surgery from the Dutch Audit for Treatment of Obesity (DATO) bariatric registry as benchmarks for (above) average (≥ - 1SD), poor (- 1SD to - 2SD) and insufficient (< - 2SD) weight loss. Weight regain maintaining (above) average weight loss was called grade 1, weight regain towards poor weight loss grade 2, towards insufficient weight loss grade 3, with subgrades 2a/3a for below average weight loss from the start, and 2b/3b for weight regain from (above) average to below average weight loss. Patient characteristics and diabetes improvement/impairment were compared. Sensitivity and specificity of 14 existing weight regain criteria were calculated.

RESULTS

We analyzed 93,465 results from 38,830 patients (77.1% gastric bypass, 22.5% sleeve gastrectomy). The - 1SD thresholds for early and late weight loss approximated 25%TWL and 20%TWL, the - 2SD threshold for late weight loss 10%TWL. Weight regain could be analyzed for 18,403 patients (2.5-5.2 years follow-up). They regained mean 6.7 kg (5.4%TWL), with 66.8% grade 1 weight regain, 7.2% grade 2a, 7.4% grade 2b, 2.1% grade 3a, and 0.6% grade 3b. There were significant differences in comorbidities, gender, age, weight regain, diabetes impairment, and diabetes improvement across grades. Weight regain criteria from literature were extremely divers. None had high sensitivity.

CONCLUSION

The DATO classification for post-bariatric weight regain combines the extent of weight regain with evidence-based endpoints of weight loss. It differentiated weight regain maintaining (above) average weight loss, two intermediate grades, gradual weight regain with below average weight loss from the start (primary non-response) and steep weight regain towards insufficient weight loss (secondary non-response). The classification is superior to existing criteria and well supported by evidence.

Long-term Safety and Efficacy of Closure of Mesenteric Defects in Laparoscopic Gastric Bypass Surgery: A Randomized Clinical Trial

Importance

Short-term and midterm data suggest that mesenteric defects closure during laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery reduces the risk of internal herniation with small bowel obstruction (SBO) but may increase risk of kinking of the jejunojejunostomy in the early postoperative period. However, to our knowledge, there are no clinical trials reporting long-term results from this intervention in terms of risk for SBO or opioid use.

Objective

To evaluate long-term safety and efficacy outcomes of closure of mesenteric defects during LRYGB.

Design, Setting, and Participants

This randomized clinical trial with a 2-arm, parallel, open-label design included patients with severe obesity scheduled for LRYGB bariatric surgery at 12 centers in Sweden from May 1, 2010, through November 14, 2011, with 10 years of follow-up after the intervention.

Interventions

During the operation, patients were randomly assigned 1:1 to closure of mesenteric defects beneath the jejunojejunostomy and at the Petersen space using nonabsorbable running sutures during LRYGB or to nonclosure.

Main Outcome and Measures

The primary outcome was reoperation for SBO. New incident, chronic opioid use was a secondary end point as a measure of harm.

Results

A total of 2507 patients (mean [SD] age, 41.7 [10.7] years; 1863 female [74.3%]) were randomly assigned to closure of mesenteric defects (n = 1259) or nonclosure (n = 1248). After censoring for death and emigration, 1193 patients in the closure group (94.8%) and 1198 in the nonclosure group (96.0%) were followed up until the study closed. Over a median follow-up of 10 years (IQR, 10.0-10.0 years), a reoperation for SBO from day 31 to 10 years after surgery was performed in 185 patients with nonclosure (10-year cumulative incidence, 14.9%; 95% CI, 13.0%-16.9%) and in 98 patients with closure (10-year cumulative incidence, 7.8%; 95% CI, 6.4%-9.4%) (subhazard ratio [SHR], 0.42; 95% CI, 0.32-0.55). New incident chronic opioid use was seen among 175 of 863 opioid-naive patients with nonclosure (10-year cumulative incidence, 20.4%; 95% CI, 17.7%-23.0%) and 166 of 895 opioid-naive patients with closure (10-year cumulative incidence, 18.7%; 95% CI, 16.2%-21.3%) (SHR, 0.90; 95% CI, 0.73-1.11).

Conclusions and Relevance

This randomized clinical trial found long-term reduced risk of SBO after mesenteric defects closure in LRYGB. The findings suggest that routine use of this procedure during LRYGB should be considered.

Trial Registration

ClinicalTrials.gov Identifier: NCT01137201.

Association Between Bariatric Surgery and Alcohol Use-Related Hospitalization and All-Cause Mortality in a Veterans Affairs Cohort

Importance

Bariatric surgery procedures, in particular Roux-en-Y gastric bypass (RYGB), have been associated with subsequent alcohol-related complications. However, previous studies lack data to account for changes in body mass index (BMI) or alcohol use over time, which are key potential confounders.

Objective

To evaluate the association between RYGB, sleeve gastrectomy, or gastric banding on subsequent alcohol use disorder (AUD)-related hospitalization and all-cause mortality as compared with referral to a weight management program alone.

Design, Setting, and Participants

This cohort study included 127 Veterans Health Administration health centers in the US. Patients who underwent RYGB, sleeve gastrectomy, or gastric banding or who were referred to MOVE!, a weight management program, and had a BMI (calculated as weight in kilograms divided by height in meters squared) of 30 or greater between January 1, 2008, and December 31, 2021, were included in the study.

Exposures

RYGB, sleeve gastrectomy, or gastric banding or referral to the MOVE! program.

Main Outcomes and Measures

The primary outcome was time to AUD-related hospitalization from the time of bariatric surgery or MOVE! referral. The secondary outcome was time to all-cause mortality. Separate propensity scores were created for each pairwise comparison (RYGB vs MOVE! program, RYGB vs sleeve gastrectomy, sleeve gastrectomy vs MOVE!). Sequential Cox regression approaches were used for each pairwise comparison to estimate the relative hazard of the primary outcome in unadjusted, inverse probability treatment weighting (IPTW)-adjusted (generated from the pairwise logistic regression models), and IPTW-adjusted approaches with additional adjustment for time-updating BMI and categorical Alcohol Use Disorders Identification Test-Concise scores.

Results

A total of 1854 patients received RYGB (median [IQR] age, 53 [45-60] years; 1294 men [69.8%]), 4211 received sleeve gastrectomy (median [IQR] age, 52 [44-59] years; 2817 men [66.9%]), 265 received gastric banding (median [IQR] age, 55 [46-61] years; 199 men [75.1%]), and 1364 were referred to MOVE! (median [IQR] age, 59 [49-66] years; 1175 men [86.1%]). In IPTW Cox regression analyses accounting for time-updating alcohol use and BMI, RYGB was associated with an increased hazard of AUD-related hospitalization vs MOVE! (hazard ratio [HR], 1.70; 95% CI, 1.20-2.41; P = .003) and vs sleeve gastrectomy (HR, 1.98; 95% CI, 1.55-2.53; P < .001). There was no significant difference between sleeve gastrectomy and MOVE! (HR, 0.76; 95% CI, 0.56-1.03; P = .08). While RYGB was associated with a reduced mortality risk vs MOVE! (HR, 0.63; 95% CI, 0.49-0.81; P < .001), this association was mitigated by increasing alcohol use over time.

Conclusions and Relevance

This cohort study found that RYGB was associated with an increased risk of AUD-related hospitalizations vs both sleeve gastrectomy and the MOVE! program. The mortality benefit associated with RYGB was diminished by increased alcohol use, highlighting the importance of careful patient selection and alcohol-related counseling for patients undergoing this procedure.

Association between neighborhood food environments and bariatric surgery outcomes

BACKGROUND

Individual characteristics associated with weight loss after bariatric surgery are well established, but the neighborhood characteristics that influence outcomes are unknown.

OBJECTIVES

The objective of this study was to determine if neighborhood characteristics, including social determinants and lifestyle characteristics, were associated with weight loss after bariatric surgery.

SETTING

Single university healthcare system, United States.

METHODS

In this retrospective cohort study, all patients who underwent primary bariatric surgery from 2008 to 2017 and had at least 1 year of follow-up data were included. Patient-level demographics and neighborhood-level social determinants (area deprivation index, urbanicity, and walkability) and lifestyle factors (organic food use, fresh fruit/vegetable consumption, diet to maintain weight, soda consumption, and exercise) were analyzed. Median regression with percent total body weight (%TBW) loss as the outcome was applied to examine factors associated with weight loss after surgery.

RESULTS

Of the 647 patients who met inclusion criteria, the average follow-up period was 3.1 years, and the mean %TBW loss at the follow-up was 22%. In adjusted median regression analyses, Roux-en-Y gastric bypass was associated with greater %TBW loss (11.22%, 95% confidence interval [8.96, 13.48]) compared to sleeve, while longer follow-up time (-2.42% TBW loss per year, 95% confidence interval [-4.63, -0.20]) and a preoperative diagnosis of diabetes (-1.00% TBW loss, 95% confidence interval [-1.55, -0.44]) were associated with less. None of the 8 neighborhood level characteristics was associated with weight loss.

CONCLUSIONS

Patient characteristics rather than neighborhood-level social determinants and lifestyle factors were associated with weight loss after bariatric surgery in our cohort of bariatric surgery patients. Patients from socioeconomically deprived neighborhoods can achieve excellent weight loss after bariatric surgery.

Long-term weight loss and metabolic benefit from Roux-en-Y gastric bypass in patients with superobesity

BACKGROUND

Although Roux-en-Y gastric bypass (RYGB) is widely performed worldwide, its efficacy in patients with a body mass index (BMI) greater than 50 kg/m2 remains controversial. The aim of the present paper was to assess long-term (10 years or more) weight loss and metabolic results of RYGB in patients with superobesity (SO; BMI > 50 kg/m2), compared with patients with morbid obesity (MO; BMI 35-50 kg/m2).

METHODS

This study involved retrospective analysis of a prospectively followed cohort of adult patients operated on for a primary RYGB between 1999 and 2008. Long-term weight loss and metabolic parameters were compared between SO and MO patients, with a sex-specific subgroup analysis in SO patients. Multiple logistic regression assessed independent predictors of poor long-term weight loss.

RESULTS

Among the 957 included patients, 193 (20.2 per cent) were SO (mean BMI 55.3 kg/m2versus 43.3 kg/m2 in MO). Upon 10-year follow-up, which was complete in 86.3 per cent of patients, BMI remained higher in SO patients (mean 39.1 kg/m2versus 30.8 kg/m2, P < 0.001) although total bodyweight loss (per cent TBWL) was similar (28.3 per cent versus 28.8 per cent, P = 0.644). Male SO patients had a trend to higher 10-year per cent TBWL, while initial BMI greater than 50 kg/m2 and low 5-year per cent TBWL were independent predictors of long-term TBWL less than 20 per cent. Diabetes remission was observed in 39 per cent SO and 40.9 per cent MO patients (P = 0.335) at 10 years, and all patients had a significant lipid profile improvement.

CONCLUSION

Substantial improvement in co-morbidities was observed in all patients 10 years after RYGB. Total weight loss was similar in SO and MO patients, leaving SO patients with higher BMI. Suboptimal TBWL 5 years after surgery in SO, especially female patients, may warrant prompt reassessment to improve long-term outcomes.

Subcutaneous Stromal Cells and Visceral Adipocyte Size Are Determinants of Metabolic Flexibility in Obesity and in Response to Weight Loss Surgery

Adipose tissue (AT) expansion either through hypertrophy or hyperplasia is determinant in the link between obesity and metabolic alteration. The present study aims to profile the unhealthy subcutaneous and visceral AT (SAT, VAT) expansion in obesity and in the outcomes of bariatric surgery (BS). The repartition of adipocytes according to diameter and the numbers of progenitor subtypes and immune cells of SAT and VAT from 161 obese patients were determined by cell imaging and flow cytometry, respectively. Associations with insulin resistance (IR) prior to BS as well as with the loss of excessive weight (EWL) and IR at 1 and 3 years post-BS were studied; prior to BS, SAT and VAT, unhealthy expansions are characterized by the accumulation of adipogenic progenitors and CD4+ T lymphocytes and by adipocyte hypertrophy and elevated macrophage numbers, respectively. Such SAT stromal profile and VAT adipocyte hypertrophy are associated with adverse BS outcomes. Finally, myofibrogenic progenitors are a common determinant of weight and IR trajectories post-BS; the study suggests that adipogenesis in SAT and adipocyte hypertrophy in VAT are common determinants of metabolic alterations with obesity and of the weight loss and metabolic response to bariatric surgery. The data open up new avenues to better understand and predict individual outcomes in response to changes in energy balance.

Biliopancreatic Diversion (BPD), Long Common Limb Revisional Biliopancreatic Diversion (BPD + LCL-R), Roux-en-Y Gastric Bypass [RYGB] and Sleeve Gastrectomy (SG) mediate differential quantitative changes in body weight and qualitative modifications in body composition: a 5-year study

AIMS

Bariatric surgeries induce profound weight loss (decrease in body mass index, BMI), through a decrease in fat mass (FM) and to a much lesser degree of fat-free mass (FFM). Some reports indicate that the weight which is lost after gastric bypass (RYGB) and sleeve gastrectomy (SG) is at least partially regained 2 years after surgery. Here we compare changes in BMI and body composition induced by four bariatric procedures in a 5 years follow-up study.

METHODS

We analyzed retrospectively modifications in BMI, FM and FFM obtained through Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), biliopancreatic diversion (BPD) and a long common limb revisional biliopancreatic diversion (reduction of the gastric pouch and long common limb; BPD + LCL-R). Patients were evaluated at baseline and yearly for 5 years. Of the whole cohort of 565 patients, a subset of 180 patients had all yearly evaluations, while the remaining had incomplete evaluations. Setting University Hospital.

RESULTS

In a total of 180 patients evaluated yearly for 5 years, decrease in BMI and FM up to 2 years was more rapid with RYGB and SG than BPD and BPD + LCL-R; with RYGB and SG both BMI and FM slightly increased in the years 3-5. At 5 years, the differences were not significant. When analysing the differences between 2 and 5 years, BPD + LCL-R showed a somewhat greater effect on BMI and FM than RYGB, BPD and SG. Superimposable results were obtained when the whole cohort of 565 patients with incomplete evaluation was considered.

CONCLUSIONS

All surgeries were highly effective in reducing BMI and fat mass at around 2 years; with RYGB and SG both BMI and FM slightly increased in the years 3-5, while BPD and BPD + LCL-R showed a slight further decreases in the same time interval.

Impact of Preoperative Weight Loss on Postoperative Weight Loss Revealed from a Large Nationwide Quality Registry

PURPOSE

Weight loss before bariatric surgery is not mandatory, but questions remain as to whether preoperative weight loss has an impact on weight loss after surgery. Most studies have small sample sizes. The objective was to evaluate the relationship between preoperative and successful postoperative weight loss defined as ≥25% total weight loss (TWL) at 1 and 2 years after primary bariatric surgery with regard to the obesity-related comorbidities.

MATERIALS AND METHODS

Data were extracted from a large nationwide quality registry of patients who underwent a sleeve gastrectomy (SG) or gastric bypass (GBP) between January 2015 and January 2018. Patients with completed screening and preoperative and postoperative data were included. A multivariate logistic regression analysis was performed for each technique and follow-up years separately.

RESULTS

In total, 8751 were included in the analysis. Patients with preoperative weight loss were more likely to achieve ≥25% postoperative TWL in both procedures. Patients with higher preoperative weight loss of 5-10% had an increased likelihood for achieving 25% TWL compared to 0-5%, OR 1.79 (CI (1.42-2.25), p < 0.001) vs 1.25 (CI (1.08-1.46), p < 0.004) for the GBP group for year 2 postoperative. This was the same for the SG group at year 2, OR 1.30 (CI (1.03-1.64), p < 0.029) vs 1.14 (CI (0.94-1.38), p < 0.198).

CONCLUSION

Patients with preoperative weight loss were more likely to achieve ≥25% postoperative TWL at 1 and 2 years after surgery in both procedures; moreover, the extent of preoperative weight loss contributes to the significance and odds of this success.

Impact of smoking on weight loss outcomes after bariatric surgery: a literature review

BACKGROUND

The association between smoking and surgical complications after bariatric surgery has been well-established. However, given that this patient population is inherently weight-concerned, understanding the effects of tobacco use on postoperative weight loss is essential to guiding clinicians in counseling patients. We aimed to summarize the current literature examining the effects of preoperative and postoperative smoking, as well as changes in smoking status, on bariatric surgery weight loss outcomes.

METHODS

Ovid MEDLINE, PubMed, and SCOPUS databases were queried to identify relevant published studies.

RESULTS

Overall, 20 studies were included. Preoperative and postoperative smoking rates varied widely across studies, as did requirements for smoking cessation prior to bariatric surgery. Reported preoperative smoking prevalence ranged from 1 to 62%, and postoperative smoking prevalence ranged from 6 to 43%. The majority of studies which examined preoperative and/or postoperative smoking habits found no association between smoking habits and postoperative weight loss outcomes. A minority of studies found relatively small differences in postoperative weight loss between smokers and nonsmokers; these often became nonsignificant with longer follow-up. No studies found significant associations between changes in smoking status and weight loss outcomes.

CONCLUSION

While smoking has been associated with weight loss in the general population, most current evidence demonstrates that smoking habits are not associated with weight loss outcomes after bariatric surgery. However, due to the heterogeneity in study design and analysis, no definitive conclusions can be made, and more robust studies are needed to investigate any relationship between smoking and long-term weight loss outcomes. Given the established increased risk of surgical complications and mortality in smokers, smoking cessation should be encouraged.

Smoking in bariatric surgery: a systematic review

BACKGROUND

The prevalence of smoking among patients undergoing bariatric surgery has been reported to be as high as 40%. The effect of smoking in the perioperative period has been extensively studied for various surgical procedures, but limited data are available for bariatric surgery. The objective of this study is to review the existing literature to assess: (1) the impact of smoking on postoperative morbidity and mortality after bariatric surgery, (2) the relationship between smoking and weight loss after bariatric surgery, and (3) the efficacy of smoking cessation in the perioperative period among bariatric surgery patients.

METHODS

A comprehensive search of electronic databases including MEDLINE, EMBASE and the Cochrane Library from 1946 to February 2020 was performed to identify relevant articles. Following an initial screen of 940 titles and abstracts, 540 full articles were reviewed.

RESULTS

Forty-eight studies met criteria for analysis: five structured interviews, three longitudinal studies, thirty-two retrospective studies and eight prospective studies. Smoking within 1 year prior to bariatric surgery was found to be an independent risk factor for increased 30-day mortality and major postoperative complications, particularly wound and pulmonary complications. Smoking was significantly associated with long-term complications including marginal ulceration and bone fracture. Smoking has little to no effect on weight loss following bariatric surgery, with studies reporting at most a 3% increased percentage excess weight loss. Rates of smoking recidivism are high with studies reporting that up to 17% of patients continue to smoke postoperatively.

CONCLUSIONS

Although current best practice guidelines recommend only a minimum of 6 weeks of abstinence from smoking prior to bariatric surgery, the findings of this review suggest that smoking within 1 year prior to bariatric surgery is associated with significant postoperative morbidity. More investigation is needed on strategies to improve smoking cessation compliance among bariatric surgery patients in the perioperative period.

What Is Weight Loss After Bariatric Surgery Expressed in Percentage Total Weight Loss (%TWL)? A Systematic Review

Percentage total weight loss (%TWL) might be better than percentage excess weight loss to express weight loss in bariatric surgery. In this systematic review, performed according to the PRISMA statement, results of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB) are assessed in %TWL. A total of 13,426 studies were screened and 49 included, reporting data of 24,760 patients. The results show that, despite limiting data, LRYGB is favorable over LSG in terms of weight loss in short-term follow-up. Although recent guidelines recommend to use %TWL when reporting outcome in bariatric surgery, this study shows that there is still insufficient quality data in %TWL, especially on LSG. The use of %TWL as the primary outcome measure in bariatric surgery should be encouraged.

Unequal rates of postoperative complications in relatively healthy bariatric surgical patients of white and black race

BACKGROUND

Racial disparities in postsurgical complications are often presumed to be due to a higher preoperative co-morbidity burden among patients of black race, although being relatively healthy is not a prerequisite for a complication-free postoperative course.

OBJECTIVES

To examine the association of race with short-term postbariatric surgery complications in seemingly healthy patients.

SETTINGS

Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database (2015-2018).

METHODS

We studied a relatively healthy (American Society of Anesthesiologists physical status 1 or 2), propensity score-matched cohort of adult non-Hispanic black and non-Hispanic white bariatric surgery patients. We compared the risk-adjusted incidences of postoperative complications, serious adverse events, and measures of postoperative resource utilization across racial groups.

RESULTS

We identified 44,090 matched pairs of relatively healthy black and white bariatric surgery patients. Patients of black race were 72% more likely than those of white race to develop 1 or more postoperative complications (.7% versus .4%, respectively; odds ratio [OR], 1.72; 95% confidence interval [CI], 1.32-2.24; P < .01). Measures of postbariatric resource utilization were significantly higher in patients of black race than those of white race, including unplanned reoperations (1.3% versus 1.0%, respectively; OR, 1.28; 95% CI, 1.07-1.52; P = .01), unplanned readmissions (4.5% versus 3.0%, respectively; OR, 1.53; 95% CI, 1.38-1.69; P < .01), unplanned interventions (1.6% versus 1.2%, respectively; OR, 1.36; 95% CI, 1.16-1.60; P < .01), and extended hospital lengths of stay (51.2% versus 42.7%, respectively; OR, 1.41; 95% CI, 1.36-1.46; P < .01).

CONCLUSION

Even among relatively healthy patients, race appears to be an important determinant of postbariatric surgery complications and resource utilization. Research and interventions aimed at narrowing the racial disparities in bariatric surgery outcomes may need to broaden the focus beyond the racial variation in the preoperative co-morbidity burden.

A Genetic Risk Score for the Estimation of Weight Loss After Bariatric Surgery

BACKGROUND

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most frequent bariatric surgery procedures worldwide. In this prospective study, we examined the association of a genetic risk score (GRS) with loss of excess weight after bariatric surgery.

METHODS

A total of forty-seven morbidly obese Greek patients who underwent SG (81%) or RYGB were recruited, followed up for 2 years and genotyped. Weight loss after surgery was reported as the percentage of excess weight that was lost (%EWL) at 12 and 24 months after surgery. A GRS was constructed based on previously BMI- and WHR-related single nucleotide polymorphisms (SNPs) that were found significantly correlated with weight loss after bariatric surgery in our population. The level of post-surgery %EWL after 12 and 24 months was estimated through two multiple linear regression models that considered the effects of relevant genetic risk variants.

RESULTS

The first proposed model suggested that the predictor variables of GRS, age, and BMI had a significant effect on %EWL12m. GRS was significantly associated with %EWL12m, indicating a 4.618% decrease of %EWL12m per score unit. The second model indicated a positive correlation between %EWL24m and %EWL12m, suggesting that while post-surgery weight loss increased during the first 12 months, an increase was expected in the next 12 months as well. GRS was also significantly associated with %EWL24m, indicating approximately 3% decrease of %EWL24m per score unit.

CONCLUSION

GRS can be used in the future together with other preoperative parameters in order to predict the outcome of bariatric surgery.

The Relationship Between Preoperative Kidney Function and Weight Loss After Bariatric Surgery in Patients with Estimated Glomerular Filtration Rate ≥ 30 mL/min: Tehran Obesity Treatment Study

INTRODUCTION

Severe obesity can lead to progressive kidney injury and chronic kidney disease (CKD). The current study aimed at determining whether preoperative kidney function level in patients with estimated glomerular filtration rate (eGFR) ≥30 mL/min affects weight loss after bariatric surgery.

METHODS

A total of 1958 bariatric patients underwent laparoscopic sleeve gastrectomy and gastric bypass from March 2013 to March 2017. The patients were categorized according to preoperative eGFR (30-59, 60-89, 90-124, and ≥ 125 mL/min). Changes in body mass index (BMI), percentage of total weight loss (TWL%), and percentage of excess weight loss (EWL%) were compared across the eGFR categories. Moreover, multivariable logistic regression analysis was used to evaluate the relationship between eGFR and insufficient weight loss (defined as not achieving 50% EWL at 12 months after surgery).

RESULTS

Preoperative eGFR was positively associated with unadjusted ΔBMI (P trend < 0.001), TWL% (P trend < 0.001), and EWL% (P trend = 0.007) after 12 months of surgery. However, these associations were no longer significant after multivariable adjustment. Further, univariate analysis demonstrated a positive relationship between preoperative eGFR and insufficient weight loss (odds ratio [OR] 1.38; 95% confidence interval [CI] 1.11-1.71; P = 0.004). By contrast, preoperative eGFR was not a predictor of insufficient weight loss in multivariable logistic regression analysis (OR 0.98; 95% CI 0.46-1.24; P = 0.886).

CONCLUSION

Although patients with lower preoperative eGFR experience less weight loss after bariatric surgery, preoperative kidney function does not appear to have an independent impact on postoperative weight loss in patients with eGFR ≥ 30 mL/min.

Banding the Pouch with a Non-adjustable Ring as Revisional Procedure in Patients with Insufficient Results After Roux-en-Y Gastric Bypass: Short-term Outcomes of a Multicenter Cohort Study

BACKGROUND

After laparoscopic Roux-en-Y gastric bypass (RYGB), approximately 10-35% of patients with morbid obesity regain weight after an initial good result or fail to achieve a sufficient amount of weight loss. Patients in which conservative measures are not successful may potentially benefit from revisional surgery.

OBJECTIVE

To evaluate the effect of a non-adjustable ring placed around the gastric pouch in patients with insufficient weight loss or weight regain after RYGB.

SETTING

Four specialized bariatric hospitals in The Netherlands, Germany, and Switzerland.

METHODS

From 2011 to 2017, 79 patients underwent revisional surgery using a non-adjustable silicone ring because of insufficient results after RYGB. Data on weight loss and complications up to 2 years after revisional surgery was collected and analyzed retrospectively.

RESULTS

A follow-up percentage of 86% after 1 year and 61% after 2 years was achieved. In 75% of patients, further weight regain was prevented. Percentage total body weight loss improved by 7 to 26% 1 year after revisional surgery and remained stable during 2 years of follow-up. The additional weight loss effect of placing a non-adjustable ring was more pronounced in patients with an initial good result after primary RYGB. Eighteen (23%) rings were removed, most often due to dysphagia.

CONCLUSION

Especially for patients who experience weight regain after initial good weight loss, placing a non-adjustable silicone ring around the gastric pouch results in modest improvements in weight loss. To prevent the risk of ring removal due to dysphagia, surgeons should take notice not to place the ring too tight around the gastric pouch during revisional surgery.

Intersection of smoking, e-cigarette use, obesity, and metabolic and bariatric surgery: a systematic review of the current state of evidence

BACKGROUND

Millions of Americans qualify for metabolic and bariatric surgery (MBS) based on the proportion of the population with severe obesity. Simultaneously, the use of electronic nicotine/non-nicotine delivery systems (ENDS) has become epidemic.

OBJECTIVE

We conducted a timely systematic review to examine the impact of tobacco and ENDS use on post-operative health outcomes among MBS patients.

METHODS

PRISMA guidelines were used as the search framework. Keyword combinations of either "smoking," "tobacco," "e-cigarette," "vaping," or "ENDS" and "bariatric surgery," "RYGB," or "sleeve gastrectomy" were used as search terms in PUBMED, Science Direct, and EMBASE. Studies published in English between January 1990 and June 2020 were screened.

RESULTS

From the 3251 articles found, a total of 48 articles were included in the review. No articles described a relationship between ENDS and post-operative health outcomes in MBS patients. Seven studies reported smokers had greater post-MBS weight loss, six studies suggested no relationship between smoking and post-MBS weight loss, and one study reported smoking cessation pre-MBS was related to post-MBS weight gain. Perioperative use of tobacco is positively associated with several post-surgery complications and mortality in MBS patients.

CONCLUSIONS

Combustible tobacco use among MBS patients is significantly related to higher mortality risk and complication rates, but not weight loss. No data currently is available on the impact of ENDS use in these patients. With ENDS use at epidemic levels, it is imperative to determine any potential health effects among patients with severe obesity, and who complete MBS.

Long-term BAROS scores and independent obesity-related co-morbidity predictors of failure after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Long-term (>5 yr) studies assessing outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB) using the Bariatric Analysis and Reporting Outcome System (BAROS) are limited. Evidence of predictors of failure long-term after LRYGB is also lacking.

OBJECTIVES

To compare BAROS scores at 5 and 10 years post LRYGB and to establish whether individual obesity-related co-morbidities are associated with suboptimal outcomes at these time points.

SETTING

Single bariatric unit.

METHODS

BAROS scores were analyzed in patients who were 5 years (group A) and 10 years (group B) post LRYGB. Obesity-related co-morbidities as predictors of failure of surgery (defined by % excess weight loss [%EWL] <50% or BAROS total score ≤1) were examined. Intergroup comparative analysis of outcomes and logistic regression modeling to determine predictors of weight loss failure were conducted.

RESULTS

A total of 88 patients were 5 years post LRYGB (group A), and 91 patients were 10 years post LRYGB (group B). A total of 52.3% (46/88) in group A and 54.9% (50/91) in group B had failure of weight loss defined by %EWL <50%. There were no significant differences in percentage of total weight loss, %EWL, or BAROS scores between the 2 groups (21.8% versus 22.0%, P = .897; 48.5% versus 47.1%, P = .993; and 3.7 versus 3.3, P = .332, respectively). No individual obesity-related co-morbidity at time of surgery was associated with suboptimal outcomes (%EWL <50% or BAROS total score ≤1) at 5 years or 10 years after LRYGB.

CONCLUSIONS

Long-term outcomes assessed by the BAROS score appear sustainable between 5 and 10 years after LRYGB surgery, and weight loss achieved at 5 years is maintained at 10 years. Preoperative presence of specific obesity-related co-morbidities was not associated with failure of surgery long-term.

Self-Reported Smoking Compared to Serum Cotinine in Bariatric Surgery Patients: Smoking Is Underreported Before the Operation

BACKGROUND

Smoking has been associated with postoperative complications and mortality in bariatric surgery. The evidence for smoking is based on self-report and medical charts, which can lead to misclassification and miscalculation of the associations. Determination of cotinine can objectively define nicotine exposure. We determined the accuracy of self-reported smoking compared to cotinine measurement in three phases of the bariatric surgery trajectory.

METHODS

Patients in the phase of screening (screening), on the day of surgery (surgery), and more than 18 months after surgery (follow-up) were consecutively selected. Self-reported smoking was registered and serum cotinine was measured. We evaluated the accuracy of self-reported smoking compared to cotinine, and the level of agreement between self-report and cotinine for each phase.

RESULTS

In total, 715 patients were included. In the screening, surgery, and follow-up group, 25.6%, 18.0%, and 15.5%, respectively, was smoking based on cotinine. The sensitivity of self-reported smoking was 72.5%, 31.0%, and 93.5% in the screening, surgery, and follow-up group, respectively (p < 0.001). The specificity of self-report was > 95% in all groups (p < 0.02). The level of agreement between self-report and cotinine was 0.778, 0.414, and 0.855 for the screening, surgery, and follow-up group, respectively.

CONCLUSIONS

Underreporting of smoking occurs before bariatric surgery, mainly on the day of surgery. Future studies on effects of smoking and smoking cessation in bariatric surgery should include methods taking into account the issue of underreporting.

The association between socioeconomic factors and weight loss 5 years after gastric bypass surgery

INTRODUCTION

Patients with low socioeconomic status have been reported to have poorer outcome than those with a high socioeconomic status after several types of surgery. The influence of socioeconomic factors on weight loss after bariatric surgery remains unclear. The aim of the present study was to evaluate the association between socioeconomic factors and postoperative weight loss.

MATERIALS AND METHODS

This was a retrospective, nationwide cohort study with 5-year follow-up data for 13,275 patients operated with primary gastric bypass in Sweden between January 2007 and December 2012 (n = 13,275), linking data from the Scandinavian Obesity Surgery Registry, Statistics Sweden, the Swedish National Patient Register, and the Swedish Prescribed Drugs Register. The assessed socioeconomic variables were education, profession, disposable income, place of residence, marital status, financial aid and heritage. The main outcome was weight loss 5 years after surgery, measured as total weight loss (TWL). Linear regression models, adjusted for age, preoperative body mass index (BMI), sex and comorbid diseases were constructed.

RESULTS

The mean TWL 5 years after surgery was 28.3 ± 9.86%. In the adjusted model, first-generation immigrants (%TWL, B -2.4 [95% CI -2.9 to -1.9], p < 0.0001) lost significantly less weight than the mean, while residents in medium-sized (B 0.8 [95% CI 0.4-1.2], p = 0.0001) or small towns (B 0.8 [95% CI 0.4-1.2], p < 0.0001) lost significantly more weight.

CONCLUSIONS

All socioeconomic groups experienced improvements in weight after bariatric surgery. However, as first-generation immigrants and patients residing in larger towns (>200,000 inhabitants) tend to have inferior weight loss compared to other groups, increased support in the pre- and postoperative setting for these two groups could be of value. The remaining socioeconomic factors appear to have a weaker association with postoperative weight loss.

Ten-year remission rates in insulin-treated type 2 diabetes after biliopancreatic diversion with duodenal switch

BACKGROUND

Biliopancreatic diversion with duodenal switch (BPD-DS) confers the highest rate of type 2 diabetes (T2D) remission compared with other bariatric procedures. Previous studies suggest that type of antidiabetic therapy used before surgery and duration of disease influence postsurgical glycemic outcomes. Short-term, progressive improvement in insulin sensitivity and beta-cell function after metabolic surgery in patients with noninsulin-treated T2D has been demonstrated. Whether patients with more advanced disease can achieve sustained remission remains unclear.

OBJECTIVE

The aim of this study was to assess long-term glycemic outcomes in insulin-treated patients with T2D after BPD-DS and identify predictors of sustained diabetes remission or relapse.

SETTING

University-affiliated tertiary care center.

METHODS

Data from 141 patients with insulin-treated T2D who underwent BPD-DS between 1994 and 2006 with 10 years of follow-up data were collected from a prospective electronic database.

RESULTS

Follow-up was available in 132 patients (91%). At 10 years after metabolic surgery, 90 patients (68.1%) had a complete remission of diabetes, 3 (2.3%) had a partial remission, 21 (15.9%) had an improvement, and 3 (2.3%) were unchanged in their diabetes status. Fourteen patients died during the 10-year follow-up period. Relapse after an initial period of remission occurred in 15 (11.4%) patients. Insulin discontinuation was achieved in 97%. Duration of diabetes was an independent predictor of nonremission at 10 years.

CONCLUSIONS

The BPD-DS maintains remission at 10 years postoperatively in patients with more advanced diabetes. Long-term benefits of the BPD-DS on weight loss and glycemic control should be considered when offering metabolic surgery to patients with insulin-treated T2D.

Bariatric surgery-induced weight loss in patients with and without type 2 diabetes mellitus

Surgical treatment of obesity leads to weight loss and metabolic improvement, but it is unclear if the response differs between patients with and without type 2 diabetes. Retrospective cohort study comparing weight loss and metabolic outcomes between patients with and without type 2 diabetes, matched for body mass index (BMI), gender and age, 12 months after Roux-en-Y gastric bypass. Forty-eight patients with type 2 diabetes (D) and 48 without type 2 diabetes (ND) were evaluated, 87.5% female, mean age 42.2 ± 0.9 years. The mean baseline weight and BMI of the D and ND groups were, respectively, 120.3 ± 21.6 vs 123.7 ± 20.8 kg (P = .45) and 47.2 ± 7.5 vs 47.2 ± 6.9 kg/m² (P = .70). After 12 months, there was no significant difference in weight (40.4 ± 16.9 vs 44.1 ± 12.2 kg, P = .28) and BMI (15.8 ± 6.5 vs 16.9 ± 4.5 kg/m² , P = .26) variation between groups. The parameters that presented significant variation were (D vs ND): fasting blood glucose (41.6 ± 43.0 vs 12.7 ± 17.2 mg/dL, P < .01), HbA1c (1.8 ± 1.6 vs 0.6 ± 0.7%; P < .01), triglycerides (91.1 ± 100.4 vs 54.2 ± 43.8 mg/dL; P = .04), low-density lipoprotein (27.2 ± 41.5 vs 37.5 ± 24.2 mg/dL; P < .01) and gamma glutamyl transferase (46.5 ± 55.3 vs 17.7 ± 11.9 UI/L; P = .04). Weight loss 12 months after a gastric bypass was similar in patients with and without type 2 diabetes, the greater metabolic benefits appearing in patients with type 2 diabetes as they had more pronounced changes at baseline.

Bariatric endoscopy procedure type or follow-up: What predicted success at 1 year in 962 obese patients?

Background and study aims  It is uncertain if the difference in weight loss outcomes between different endoscopic bariatric therapies (EBTs) is technique-related or multidisciplinary team (MDT) follow-up-related. We hypothesized that at 1 year, the weight loss is determined more by adherence to MDT follow-up than by procedure type. We aimed to compare 1 year weight loss outcomes of four different EBTs at a single center with a standardized MDT follow-up. Patients and methods  We prospectively collected and retrospectively analyzed outcomes in 962 patients (female-691, 71.2 %; mean age, 44.8 ± 10.6 years, mean BMI, 37.8 ± 5.9 Kg/m ² ) treated with Intragastric balloons (IGBs) or endoscopic gastroplasty (EG) at HM Sanchinarro University Hospital between March 2012 to January 2017. The procedures were performed by the same endoscopist and followed up by the same MDT. We compared the percentage total body weight loss (%TWBL) at 1 year. We performed linear and logistic regression to identify predictive factors for weight loss and follow-up adherence at 1 year. Results  Four hundred and eighty-one IGBs (Orbera-80.9 %; ReShape Duo-19.1 %), and 481 EG (Apollo ESG-51.3 %; Primary obesity surgery endoluminal-POSE-48.6 %) were performed. Only 480 patients (IGB- 45 %; EG- 55 %) completed 1 year follow-up. Among them, Apollo ESG achieved significantly higher TBWL (19.5 ± 13 %, P  = 0.035), %TBWL (17.4 ± 10.2 %, P  = 0.025), and ≥ 20 % TBWL (36.7 %, P  = 0.032). However, in linear regression after adjusting for variables, only higher initial BMI (B = 0.31, P  < 0.001) and higher percentage follow-up attendance (B = 0.24, P  < 0.001) significantly predicted %TBWL at 1 year in the completion group but not the procedure type (B = 0.02, P  = 0.72). In logistic regression, we observed female sex ( P  = 0.01), high initial BMI ( P  < 0.001), endoscopic gastroplasty ( P  = 0.04), and high 1-month %TBWL ( P  < 0.001) significantly predicted follow-up completion at 1 year. Conclusions  Weight loss at 1 year is dependent on MDT follow-up rather than procedure type. Endoscopic gastroplasty promoted follow-up adherence more than IGBs.

Sensitivity and Specificity of 50% Excess Weight Loss (50%EWL) and Twelve Other Bariatric Criteria for Weight Loss Success

BACKGROUND

Criteria for bariatric weight loss success are numerous. Most of them are arbitrary. None of them is evidence-based. Our objective was to determine their sensitivity and specificity.

METHODS

Thirteen common bariatric weight loss criteria were compared to a benchmark reflecting the gold standard in bariatric surgery. We used an elaborate baseline BMI-independent weight loss percentile chart, based on retrospective data after laparoscopic Roux-en-Y gastric bypass (LRYGB), performed between 2007 and 2017. Percentile curves p31.6 (patients' expectation), p25 (interquartile range), p15.9 (1 standard deviation (SD) below median), and p10.9 (surgeons' goal) were used as possible cutoff for success to determine true or false positive and negative results beyond 1 year.

RESULTS

We operated 4497 primary LRYGB patients, with mean follow-up 22 (± 1 SD 19; range 0-109) months, 3031 patients with last result ≥ 1 year, 518 ≥ 5 years. For all four cutoff percentile curves for success, specificities were low (2-72%) for criteria < 35 body mass index (BMI), ≥ 25percentage excess BMI loss (%EBMIL), ≥ 50%EBMIL, ≥ 15 percentage total weight loss (%TWL), ≥ 20%TWL, ≥ 25 percentage excess weight loss (%EWL), and high (83-96%) for < 30 BMI. No criterion had > 80% specificity and sensitivity for a cutoff above p15.9. For p15.9, they were both > 80% for criteria ≥ 10 BMI reduction and ≥ 50%EWL, both > 90% for ≥ 25%TWL and ≥ 35 percentage alterable weight loss (%AWL). All criteria had high sensitivities for all cutoff percentile curves (87-100%), except < 30 BMI (65-78%).

CONCLUSIONS

For the first time, common bariatric criteria for weight loss success were systematically validated. Most criteria recognized success very well (high sensitivities), but ≥ 15%TWL, ≥ 20%TWL, < 35BMI, ≥ 25%EWL, ≥ 25%EBMIL, and ≥ 50%EBMIL left too many poor responders unnoticed (low specificities). Bariatric weight loss success is best assessed by comparing results to percentile curve 1 SD below median (p15.9) in a bariatric baseline BMI-independent weight loss percentile chart. Criteria ≥ 35%AWL and ≥ 25%TWL came close to that curve, both with > 90% sensitivity and specificity. Among others, criterion ≥ 50%EBMIL did not.

Pros and cons of Roux en-Y gastric bypass surgery in obese patients with type 2 diabetes

INTRODUCTION

The worldwide prevalence of obesity and type 2 diabetes (T2D) constitutes an epidemic that is a threat to public health. Bariatric surgery, including Roux en-Y gastric bypass (RYGB), is currently the most effective treatment to induce long-term weight loss and remission of co-morbid conditions. Surgery, however, comes with an added risk of complications, highlighting the need to understand the comparative effectiveness and risks of surgical versus conventional approaches to the treatment of obesity and T2D.

AREAS COVERED

Positive and negative outcomes of RYGB surgery in patients with T2D are assessed, with a primary focus on RYGB surgery versus standard non-surgical treatment of obese patients with T2D in randomized clinical trials or high-quality observational cohorts. Searches were conducted in the PubMed database up to 11 April 2019 for relevant studies.

EXPERT OPINION

High-level evidence reveals that RYGB ameliorates the clinical manifestations of T2D to a significantly higher degree than medical therapy. Postoperative incidence of beneficial effects and complications, however, differ across subgroups of patients with different preoperative characteristics. Key knowledge gaps, particularly on long-term complications, microvascular- and macrovascular events, and mortality should be addressed, so treatment with RYGB can be applied in an individualized approach to maximize benefits and minimize complications.

Postoperative continuation of antidepressant therapy is associated with reduced short-term weight loss following Roux-en-Y gastric bypass surgery

PURPOSE

Bariatric surgery candidates are frequently treated with antidepressants. Several of these drugs have been associated with weight gain and could potentially interfere with weight loss after bariatric surgery. This cohort study aimed to investigate the short-term effects of antidepressants on weight loss during the first 24 months after a Roux-en-Y gastric bypass.

METHODS

Patients with a fully documented antidepressant treatment status for at least 12 months were retrospectively included. Weight loss was expressed as the percentage excess BMI loss (%EBMIL) or percentage total weight loss (%TWL). A mixed linear effects model was used to determine the impact of continued and discontinued treatment with antidepressants on weight loss.

RESULTS

A total of 751 patients were included in this study. At 24 months, patients had lost 77.38 ± 30.10 %EBMIL (30.63 ± 13.12 %TWL). In patients treated with antidepressants (n = 125), the %EBMIL and %TWL was reduced with - 2.81% (p = 0.025) and - 1.36% (p = 0.002) respectively, and with - 5.52 %EBMIL (p < 0.001; - 1.05 %TWL, p = 0.012) after multivariate adjustment. Serotonin-norepinephrine reuptake inhibitors (- 12.47 %EBMIL, p < 0.001) and tricyclic antidepressants (- 11.01 %EBMIL, p = 0.042) were predominantly responsible for worse outcomes. Beyond 24 months, at 36 months (- 4.83%, p < 0.001) and 48 months (- 3.54%, p = 0.006), the %EBMIL was still reduced. No significant effects of antidepressants on metabolic outcomes after surgery were observed.

CONCLUSIONS

Treatment with antidepressants was associated with reduced weight loss after gastric bypass surgery, but only if treatment was continued for at least 1 year postoperatively. Mainly tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors were responsible for this reduction in weight loss.

Endoscopic management of weight regain following Roux-en-Y gastric bypass

INTRODUCTION

With the cumulative increase in the number of patients undergoing bariatric surgery, postoperative weight regain has become a considerable challenge. Mechanisms for weight regain are not fully understood and the process is likely multifactorial in many cases. Endoluminal revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective and less invasive management strategy for this population.

AREAS COVERED

We critically review data from case series, retrospective and prospective studies, and meta-analyses pertaining to weight regain after gastric bypass. A variety of endoscopic revision approaches are reviewed, including technique details, procedural safety and efficacy, and post-procedure care.

EXPERT COMMENTARY

Given the proliferation of endoluminal therapies with evidence showing safety and efficacy in the treatment of weight regain, it is likely that endoscopic revision will be the gold standard to treat weight regain in patients with gastric bypass.

Polygenic risk score for predicting weight loss after bariatric surgery

BACKGROUND

The extent of weight loss among patients undergoing bariatric surgery is highly variable. Herein, we tested the contribution of genetic background to such interindividual variability after biliopancreatic diversion with duodenal switch.

METHODS

Percentage of excess body weight loss (%EBWL) was monitored in 865 patients over a period of 48 months after bariatric surgery, and two polygenic risk scores were constructed with 186 and 11 (PRS186 and PRS11) single nucleotide polymorphisms previously associated with body mass index (BMI).

RESULTS

The accuracy of the %EBWL logistic prediction model - including initial BMI, age, sex, and surgery modality, and assessed as the area under the receiver operating characteristics (ROC) curve adjusted for optimism (AUCadj = 0.867) - significantly increased after the inclusion of PRS186 (ΔAUCadj = 0.021; 95% CI of the difference [95% CIdiff] = 0.005-0.038) but not PRS11 (ΔAUCadj= 0.008; 95% CIdiff= -0.003-0.019). The overall fit of the longitudinal linear mixed model for %EBWL showed a significant increase after addition of PRS186 (-2 log-likelihood = 12.3; P = 0.002) and PRS11 (-2 log-likelihood = 9.9; P = 0.007). A significant interaction with postsurgery time was found for PRS186 (β = -0.003; P = 0.008) and PRS11 (β = -0.008; P = 0.03). The inclusion of PRS186 and PRS11 in the model improved the cost-effectiveness of bariatric surgery by reducing the percentage of false negatives from 20.4% to 10.9% and 10.2%, respectively.

CONCLUSION

These results revealed that genetic background has a significant impact on weight loss after biliopancreatic diversion with duodenal switch. Likewise, the improvement in weight loss prediction after addition of polygenic risk scores is cost-effective, suggesting that genetic testing could potentially be used in the presurgical assessment of patients with severe obesity.

FUNDING

Heart and Stroke Foundation of Canada (G-17-0016627) and Canada Research Chair in Genomics Applied to Nutrition and Metabolic Health (no. 950-231-580).

Surgical treatment of obesity

Obesity prevalence continues to increase worldwide, as do the numerous chronic diseases associated with obesity, including diabetes, non-alcoholic fatty liver disease, dyslipidemia, and hypertension. The prevalence of bariatric surgery also continues to increase and remains the most effective and sustainable treatment for obesity. Over the last several years, numerous prospective and longitudinal studies have demonstrated the benefits of bariatric surgery on weight loss, mortality, and other chronic diseases. Even though the mechanisms underlying many of these beneficial effects remain poorly understood, surgical management of obesity continues to increase given its unmatched efficacy. In this commentary, we discuss recent clinical advancements as well as several areas needed for future research, including indications for bariatric and metabolic surgery, determination of responders and non-responders, metabolic surgery in non-obese individuals, and the evolving role of bariatric surgery in adolescents.

The Accumulating Data to Optimally Predict Obesity Treatment (ADOPT) Core Measures Project: Rationale and Approach

BACKGROUND

Individual variability in response to multiple modalities of obesity treatment is well documented, yet our understanding of why some individuals respond while others do not is limited. The etiology of this variability is multifactorial; however, at present, we lack a comprehensive evidence base to identify which factors or combination of factors influence treatment response.

OBJECTIVES

This paper provides an overview and rationale of the Accumulating Data to Optimally Predict obesity Treatment (ADOPT) Core Measures Project, which aims to advance the understanding of individual variability in response to adult obesity treatment. This project provides an integrated model for how factors in the behavioral, biological, environmental, and psychosocial domains may influence obesity treatment responses and identify a core set of measures to be used consistently across adult weight-loss trials. This paper provides the foundation for four companion papers that describe the core measures in detail.

SIGNIFICANCE

The accumulation of data on factors across the four ADOPT domains can inform the design and delivery of effective, tailored obesity treatments. ADOPT provides a framework for how obesity researchers can collectively generate this evidence base and is a first step in an ongoing process that can be refined as the science advances.

Weight Loss and Timing of J Tube Removal in Biliopancreatic Diversion with Duodenal Switch Patients Who Report Physical or Sexual Abuse

BACKGROUND

Bariatric surgery patients who report physical or sexual abuse form a sizeable cohort that stands out due to psychological comorbidity. Their possible vulnerability to suboptimal weight loss remains of interest. Their risk for malnutrition due to inadequate oral intake following surgery is underexplored.

OBJECTIVES

Study aims were to determine the effect of self-reported physical or sexual abuse in patients undergoing open biliopancreatic diversion with duodenal switch (BPD/DS) on (a) 3-year weight loss trajectories and (b) timing of feeding jejunostomy tube (J tube) removal. Delayed J tube removal served as an indicator for inadequate oral intake.

METHODS

In this retrospective cohort study, the sample (N = 189) consisted of all patients who underwent primary BPD/DS by the same surgeon during 2009 and 2010 at a Midwestern health system. All patients had a J tube placed during surgery. Longitudinal mixed models were used for testing differences in weight loss trajectories by abuse status.

RESULTS

There were no significant differences in weight loss trajectories by abuse status. The abused group had the J tube in place a mean of 61.9 days (SD = 39.5) compared to 44.8 days (SD = 32.8) for the not abused group, a significant difference.

CONCLUSIONS

Our use of the best available statistical methods lends validity to previous findings that suggest physical or sexual abuse does not affect weight loss after bariatric surgery. Increased likelihood of persistent inadequate oral intake in the abused group suggests the need for early multidisciplinary interventions that include mental health and nutrition experts.

Clinical significance of failure to lose weight 10 years after roux-en-y gastric bypass

BACKGROUND

Although Roux-en-Y gastric bypass (RYGB) induces short-term weight loss and co-morbidity amelioration, long-term data suggest that a subset of patients return to their preoperative body mass index (BMI).

OBJECTIVES

To identify the clinical implications of 10-year weight loss failure after RYGB.

SETTING

An academic teaching hospital.

METHODS

Adults undergoing RYGB (1985-2004) were included in this study (n = 1087). Absolute weight loss failure was defined as ≤0% reduction in excess BMI 10 years after surgery. Univariate analyses compared co-morbidity rates and resolution by weight loss classification. Multivariable regression modeling analyzed preoperative predictors of 10-year percent reduction in excess BMI and weight loss failure.

RESULTS

Complete follow-up was available for 617 (57%) patients with a 10-year median percent reduction in excess BMI of 57.1%; 10.2% of patients had weight loss failure. Prevalence of all co-morbidities decreased, even in patients with weight loss failure (all P<.05). Compared with patients with successful weight loss, patients with weight loss failure had similar rates of resolution of pre-existing co-morbidities, except for reduced resolution of apnea and cardiac co-morbidities (both P<.05). Risk factors for weight loss failure included lower BMI, nongovernmental insurance, longer travel time to hospital, and year of surgery. Nongovernmental insurance (odds ratio 2.03, P = .036) conferred the highest adjusted odds of weight loss failure.

CONCLUSIONS

The vast majority of patients experience dramatic health improvement 10 years after RYGB, even though some patients fail to maintain their weight loss. Renewed focus should be placed on prevention and treatment of chronic disease, with further investigation of weight loss independent mechanisms of health improvement.

Qualifying for bariatric surgery: is preoperative weight loss a reliable predictor of postoperative weight loss?

BACKGROUND

Over the last 20 years, bariatric surgery has emerged as a highly effective weight loss intervention that can also improve co-morbid medical conditions. However, some payors have required preoperative supervised diets and weight loss.

OBJECTIVE

To determine if preoperative weight loss is the best predictor of postoperative weight loss.

SETTING

Academic county hospital, United States.

METHODS

A retrospective chart review of 218 patients. Patients who received psychological evaluation and bariatric surgery were followed up at 1 year. All preoperative patients were encouraged to lose weight; however, no specified amount of weight loss was required. Preoperative weight loss and postoperative weight loss in body mass index (BMI), percent excess weight loss, and percent total weight loss were measured. Bariatric outcome predictor variables evaluated included age, race, and sex; BMI change; measures of depression and anxiety; number of unhealthy eating types; and co-morbid medical conditions. A linear regression model and stepwise regression analyses were used to estimate contributions of independent variables to the 1-year weight loss.

RESULTS

All patients had a mean 28% reduction in BMI (63.3% excess weight loss and 29.1% total weight loss) at 1 year postoperatively. As a single independent variable, preoperative weight loss was a significant predictor of 1-year change in postoperative BMI (P = .006). However, when age, race, and sex were added to the regression equation, the predictive value of preoperative weight loss became nonsignificant (P = .543).

CONCLUSION

The present findings indicate that preoperative weight loss should not be considered in isolation when clearance for bariatric surgery is being evaluated.