Comparative effectiveness of Roux-en-Y gastric bypass and sleeve gastrectomy in super obese patients

Long-Term Safety and Efficacy Profile of Bariatric Surgery in Patients Classified with ASA IV Status

INTRODUCTION

Metabolic and bariatric surgery (MBS) is a safe and effective treatment option to reduce weight and manage obesity-related medical conditions in patients with obesity. However, due to limited data, there is uncertainty regarding the short-, mid-, and long-term safety and efficacy profile of MBS in patients with a preoperative ASA IV status.

METHODS

A single-center retrospective cohort study was performed on patients with ASA IV status who underwent sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or biliopancreatic diversion with duodenal switch (BPD-DS) between 2008 and 2020. Data collected included operative details; postoperative complications at 30 days, 90 days, and beyond 90 days; BMI changes; and resolution of obesity-related comorbidities at 0, 6, 12, 24, 48, and 60 months postoperatively.

RESULTS

Among 131 ASA class IV patients, 43 patients underwent SG (32.8%), 66 patients underwent RYGB (50.4%), and 22 patients underwent BPD-DS (16.8%). The greatest %TWL occurred in the BPD-DS cohort (39.5%) at 24 months post-op followed by the RYGB (32.5%) and SG (20.7%) cohorts (p < 0.001). The overall major 30-day complication rate was 8.4% (n = 11/131), while the overall major 90-day complication rate within the cohort was 6.9% (n = 9/131). The overall major late (> 90 days) complication rate was found to be 14.5% (n = 19/131).

CONCLUSIONS

Our study demonstrated that MBS is relatively safe and effective in ASA IV patients in the short-, mid-, and long-term. Accordingly, careful procedure selection is required in this patient population. Further long-term studies are needed to support our findings.

Impact of Leptin-Melanocortin Pathway Genetic Variants on Weight Loss Outcomes After Endoscopic Transoral Outlet Reduction

PURPOSE

Variants in the leptin-melanocortin pathway (LMP) are associated with severe obesity. We evaluated weight loss of patients with or without heterozygous LMP variants, with weight recurrence after Roux-en-Y gastric bypass, who underwent endoscopic transoral outlet reduction (TORe).

MATERIALS AND METHODS

We retrospectively reviewed patients genotyped for an LMP who had undergone TORe, classified as "carriers" or "non-carriers" of genetic variants.

RESULTS

We included 54 patients (22 carriers, 32 non-carriers). We identified 34 genetic variants in 21 different genes in 22 patients. Total body weight loss (%TBWL) after TORe was significantly different at 9 and 12 months (12 months: 0.68 ± 7.5% vs. 9.6 ± 8.2%, p < 0.01). This difference in weight loss was present even when analyzed in subgroups of patients who had undergone tubular TORe technique, and TORe plus APC. At 3, 6, and 12 months, the percentage of carriers achieving ≥ 5% and ≥ 10% TBWL was lower than non-carriers.

CONCLUSIONS

Patients with LMP variant who underwent RYGB had decreased weight loss 1 year after undergoing TORe.

Long-Term Safety and Efficacy of Bariatric Surgery in Septuagenarians

BACKGROUND

Metabolic and bariatric surgery (MBS) has been shown to be safe and effective in the elderly population. Unfortunately, utilization of MBS in patients aged 70 years or older remains low, as MBS was just recently endorsed by the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity (IFSO) for septuagenarians.

MATERIALS AND METHODS

We performed a single-center retrospective cohort study of 103 patients aged ≥ 70 years who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from January 2008 until March 2023. The data analyzed included patient demographics, post-operative complications, resolution of obesity-related comorbidities, and weight loss.

RESULTS

A total of 103 patients (71% female; age 72.1 ± 2.5 years; BMI 43.7 ± 6.8 kg/m2) were included. Sixty-two patients (60.2%) underwent RYGB while the remaining 41 underwent SG (39.8%), with a mean follow-up of 4.7 ± 3.7 years. There was no MBS-related mortality. All-cause mortality rates were 7.3% for the SG group after a mean period of 4.5 ± 3.9 years compared to 8.1% for the RYGB cohort after 7.7 ± 3.5 years (p = 0.601). RYGB was reported to have a higher rate of early and late complications when compared to LSG (p = 0.083 and p = 0.274). T2DM (p = 0.011) and OSA (p = 0.019) resolved significantly after RYGB.

CONCLUSION

Our study demonstrates that bariatric surgery is safe and effective in patients aged 70 years and older. Bariatric surgery should not be denied to this group of patients based on chronological age alone. Further studies are required to support these findings.

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.

Effects of Heterozygous Variants in the Leptin-Melanocortin Pathway on Transoral Outlet Reduction After Roux-en-Y Gastric Bypass: A Case-Control Study and Review of Literature

BACKGROUND

Transoral outlet reduction (TORe) is a safe and effective technique for management of weight regain (WR) after Roux-en-Y Gastric Bypass (RYGB). Carriers of a heterozygous variant in the leptin melanocortin pathway (LMP) have been shown to be at high risk for WR in the mid- and long-term after RYGB. Our case series includes four patients with heterozygous LMP variants and presents novel data on their weight loss after TORe.

METHODS

We performed a retrospective study of the Mayo Clinic Biobank and identified adult participants who had been genotyped and found to have or do not have a heterozygous variant in the LMP ("carriers" vs "non-carriers", respectively) and had undergone a TORe procedure. TBWL% at 1, 3, 6, 9, and 12 months ± 15 days were calculated based on baseline weight at TORe procedure.

RESULTS

A total of 14 patients were included in the analysis: four patients (mean age 51.0 [5.2] years, 100% females, body mass index [BMI] 40.5 [8.7] kg/m²) with LMP variant and 10 non-carriers (age 55.4 [15.3] years, 90% females, BMI 37.3 [7.7] kg/m²). There were no baseline differences between carriers and non-carriers at time of TORe procedure. After TORE, carriers lost less weight when compared to non-carriers at 3, 6, 9, and 12 months. The difference at 12 months was statistically significant (1.6 vs 12.3%; p = 0.03).

CONCLUSIONS

Patients with a LMP variant and that underwent RYGB showed decreased weight loss after undergoing TORe. Further and larger studies are needed to comprehend the effect of TORe on patients with LMP variants.

Current status of metabolic surgery in patients with type I diabetes mellitus and obesity: a nationwide multicenter study

PURPOSE

While obesity is prevalent among patients with type I diabetes mellitus (T1DM), the effects of metabolic surgery on patients with T1DM have not been adequately investigated. The study aims to investigate the perioperative outcomes and the improvement of comorbidity 1 year following metabolic surgery amongst this patient population.

METHODS

In this study, we evaluated the effects of sleeve gastrectomy (SG) and Roux-Y gastric bypass (RYGB) on patients with T1DM and insulin resistance.

RESULTS

One hundred forty-nine patients (SG n = 91 and RYGB n = 58) with obesity, T1DM, and insulin resistance were analyzed. There was no significant difference in BMI reduction and %EWL 1 year after surgery between the two groups. In the SG group, BMI reduction was 6.5 kg/m2 versus 5.9 kg/m2 in the RYGB group (p=0.406). The %EWL was 68.2 ± 25.2 in the RYGB group and 64.3 ± 21.5 in SG (p=0.332). There was also no significant difference in weight loss between the two groups (14.9 ± 5.4 kg in SG vs. 14.2 ± 7 kg in RYGB; p=0.548). In all patients, insulin requirements decreased after surgery, and in 22% of patients, insulin requirements were equivalent to those of normal-weight individuals. There was a significantly higher rate of remission of reflux in RYGB patients than in SG patients (94·44% vs 29·41; p<0.001).

CONCLUSION

Patients with obesity and T1DM may benefit from metabolic surgery. Both methods produce satisfactory results in this group of patients regarding daily insulin requirements and treatment of obesity-related diseases. However, the decision of which procedure should be carried out still depends on the patient's general condition and the surgeon's technical ability.

Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy effects on obesity comorbidities: A systematic review and meta-analysis

Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures. There is an increasing awareness about a comorbidity-based indication for bariatric surgery regardless of weight (metabolic surgery). The best operation to mitigate obesity-associated comorbidities is a matter of controversy. This review is aimed at comparing LRYGB and LSG for the treatment of diabetes, hypertension, dyslipidemias, obstructive sleep apnea (OSA), and gastroesophageal reflux (GERD). We searched PubMed, MEDLINE, SCOPUS, Web of Science, and Cochrane library for articles comparing these two commonly used bariatric approaches. We identified 2,457 studies, 1,468 of which stood after the removal of duplications; from them, 81 full texts were screened and only 16 studies were included in the final meta-analysis. LRYGB was equal weight to LSG for diabetes (P-value = 0.10, odd ratio, 1.24, 95% CI, 0.96-1.61, I 2 for heterogeneity = 30%, P-value for heterogeneity, 0.14), and OSA (P-value = 0.38, odd ratio, 0.79, 95% CI, 0.47-1.33, I 2 for heterogeneity = 0.0%, P-value for heterogeneity, 0.98). However, LRYGB was superior to LSG regarding hypertension (P-value = 0.009, odd ratio, 1.55, 95% CI, 1.20-2.0, I 2 for heterogeneity = 0.0%, P-value for heterogeneity, 0.59), dyslipidemia (odd ratio, 2.18, 95% CI, 1.15-4.16, P-value for overall effect, 0.02), and GERD (P-value = 0.003, odd ratio, 3.16, 95% CI, 1.48-6.76). LRYGB was superior to LSG for gastroesophageal reflux, hypertension, and dyslipidemia remission. While the two procedures were equal regarding diabetes and obstructive sleep, further reviews comparing LSG, and one anastomosis gastric bypass are recommended.

Early postoperative weight loss predicts nadir weight and weight regain after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass

BACKGROUND

Weight regain (WR) post bariatric surgery affects almost 20% of patients. It has been theorized that a complex interplay between physiologic adaptations and epigenetic mechanisms promotes WR in obesity, however, reliable predictors have not been identified. Our study examines the relationship between early postoperative weight loss (WL), nadir weight (NW), and WR following laparoscopic Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (LSG).

METHODS

A retrospective review of prospectively collected data was conducted for LRYGB or LSG patients from 2012 to 2016. Demographics, preoperative BMI, procedure type, and postoperative weight at 6, 12, 24, 36, and 48 months were recorded. WR was defined as > 20% increase from NW. Univariate and multivariate linear and logistic regression models were used to determine the association between early postoperative WL with NW and WR at 4 years.

RESULTS

Thousand twenty-six adults were included (76.8% female, mean age 44.9 ± 11.9 years, preoperative BMI 46.1 ± 8); 74.6% had LRYGB and 25.3% had LSG. Multivariable linear regression models showed that greater WL was associated with lower NW at 6 months (Coef - 2.16; 95% CI - 2.51, - 1.81), 1 year (Coef - 2.33; 95% CI - 2.58, - 2.08), 2 years (Coef - 2.04; 95% CI - 2.25, - 1.83), 3 years (Coef - 1.95; 95% CI - 2.14, - 1.76), and 4 years (Coef - 1.89; 95% CI - 2.10, - 1.68), p ≤ 0.001. WR was independently associated with increased WL between 6 months and 1 year (Coef 1.59; 95% CI 1.05,2.14; p ≤ 0.001) and at 1 year (Coef 1.24; 95% CI 0.84,1.63;p ≤ 0.001) postoperatively. The multivariable logistic regression model showed significantly increased risk of WR at 4 years for patients with greater WL at 6 months (OR 1.20, 95% CI 1.08,1.33; p = 0.001) and 1 year (OR 1.14; 95% CI 1.06,1.23; p ≤ 0.001).

CONCLUSION

Our findings demonstrate that higher WL at 6 and 12 months post bariatric surgery may be risk factors for WR at 4 years. Surgeons may need to follow patients with high early weight loss more closely and provide additional treatment options to maximize their long-term success.

A Single-Center Experience: What is the Effect of Sleeve Gastrectomy in Patients With a BMI ≥ 50 kg/m²?

BACKGROUND

Our research aimed to see how sleeve gastrectomy (SG) affects weight loss and comorbidities in patients with a body mass index (BMI) ≥ 50 kg/m².

MATERIALS AND METHODS

Prospectively kept data of patients with a BMI ≥50 kg/m² who underwent SG between February 2016 and February 2020 were evaluated.

RESULTS

A total of 138 patients with a BMI ≥ 50 kg/m² were operated on. The average BMI was 56.36±7.661, the average age was 37.41±12.33. Forty-eight patients underwent concomitant cholecystectomy and/or hiatal hernia repair (HHR). The percentage of excess weight loss (EWL%) of patients at the 3rd, 6th, 12th, 18th, and 24th months were 36%, 54%, 67%, 72%, and 74%, respectively. Mean BMI values of the 0th, 3rd, 6th, 12th, 18th, and 24th months were 56, 45, 39, 35, 33, and 33, respectively. 0th, 3rd, 6th, 12th, 18th, and 24th months were significantly different for EWL%, total weight loss (TWL%), and BMI variables (p<0.001), but EWL% (p=0.527), TWL% (p=0.396) and BMI (p=0,657) were not found significantly different between the 18th and 24th months. When EWL% ≥ 50 was accepted, the success rate was 93% (n=93) and 92% (n=50) at the 18th and 24th months, respectively. While there was 82% remission in type 2 diabetes mellitus (DM) and 90% in hypertension (HT), the remission rate in patients with obstructive sleep apnea syndrome (OSAS) and gastroesophageal reflux disease (GERD) undergoing HHR was 100%.

CONCLUSIONS

In patients with a BMI ≥ 50 kg/m², SG seems to be an effective and safe therapy option as the first line for weight loss and treatment of comorbid diseases. Further long-term studies are needed to confirm these results.

Volume-outcome relationships for Roux-en-Y gastric bypass patients in the sleeve gastrectomy era

BACKGROUND

Sleeve gastrectomy is now the most common bariatric operation performed. With lower volumes of Roux-en-Y gastric bypass (RYGB), it is unclear whether decreasing surgeon experience has led to worsening outcomes for this procedure.

METHODS

We used State Inpatient Databases from Florida, Iowa, New York, and Washington. Bariatric surgeons were designated as those who performed ten or more bariatric procedures yearly. Patients who had RYGB were included in our analysis. Using multi-level logistic regression, we examined whether surgeon average yearly RYGB volume was associated with RYGB patient 30-day complications, reoperations, and readmissions and 1-year revisions and readmissions.

RESULTS

From 2013 to 2017 there were 27,714 patients who underwent laparoscopic RYGB by 311 surgeons. Median surgeon volume was 77 RYGBs per year. The distribution was 10 bypasses yearly at the 5th percentile, 16 bypasses at the 10th percentile, 38 bypasses at the 25th percentile, and 133 bypasses at the 75th percentile. Multi-level regression revealed that patients of surgeons with lower RYGB volumes had small but statistically significant increased risks of 30-day complications and 1-year readmissions. At 30 days, risk for any complication was 6.71%, 6.43%, and 5.55% at 10, 38, and 133 bypasses per year, respectively (p = 0.01). Risk for readmission at 1 year was 13.90%, 13.67%, and 12.90% at 10, 38, and 133 bypasses per year, respectively (p = 0.099). Of note, volume associations with complications and reoperations due to hemorrhage and leak were not statistically significant. There was also no significant association with revisions.

CONCLUSION

This is the first study to examine the association of surgeon RYGB volume with patient outcomes as the national experience with RYGB diminishes. Overall, surgeon RYGB volume does not appear to have a large effect on patient outcomes. Thus, patients can safely pursue RYGB in this early phase of the sleeve gastrectomy era.

Outcome of Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass for Patients with Super Obesity (Body Mass Index > 50 kg/m2)

PURPOSE

With increasing BMI, the complexity of treating patients with obesity rises. The focus of this study is to investigate the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on perioperative morbidity and remission of comorbidities at 3 years in patients with a BMI > 50 kg/m².

MATERIALS AND METHODS

A retrospective multicenter analysis of a prospectively maintained database was performed to enroll patients with a 3-year follow-up after SG or RYGB between 2005 and 2019 and a BMI of > 50 kg/m² preoperatively. Patients' BMI and comorbidity status were recorded preoperatively.

RESULTS

We analyzed data from 2939 patients who had at least a preoperative BMI > 50 kg/m². A total of 1278 patients underwent RYGB surgery, and 1661 underwent SG. The distribution of sex, BMI, hypertension, reflux, and sleep apnea was significant between the two groups. Three years after surgery, the percent excess weight loss (%EWL) was 62.21% in RYGB and 55.87% in SG (p < 0.001). The change in hypertension (p < 0.001) and reflux (p < 0.001) was significantly in favor of RYGB. The change in diabetes mellitus was not significant between the two groups (p > 5%). There was a minimal difference in sleep apnea in favor of SG (p < 0.001). Mortality and overall complication rates were not significant in either group.

CONCLUSION

Both procedures positively affected comorbidities, BMI, and %EWL in patients with super obesity 3 years after surgery. In some categories, RYGB was better than SG. Nevertheless, the decision between the two methods remains a matter of the surgeon's experience and the patient's general condition.

Roux-en-Y Gastric Bypass Vs Sleeve Gastrectomy in Super Obesity: a Systematic Review and Meta-Analysis

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are safe procedures that may present sub-optimal results in superobesity (SO). A meta-analysis was performed aiming to summarize the available evidence on weight loss (primary outcome) and comorbidities resolution of LRYGB and LSG in patients with SO (BMI ≥ 50 kg/m2). From the 16 included studies, 7 integrated the meta-analysis. LRYGB showed a significantly higher weight loss at 6 to 12-months, but not after 24 months and a higher dyslipidemia resolution at 12 months. When compared with LSG, LRYGB achieved better weight loss after 6 and 12 months and higher dyslipidemia resolution after 1 year. There were no significant differences for resolution of the other co-morbidities studied.

Ten year comparative analysis of sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch in patients with BMI ≥ 50 kg/m2

INTRODUCTION

Bariatric surgery is the most effective modality to stably reduce weight and related comorbidities in patients suffering from class II and III obesity. Data comparing long-term safety and efficacy of the three most effective bariatric operations are limited in patients with BMI ≥ 50 kg/m², which complicate shared surgeon-patient decision making regarding optimal procedure selection.

METHODS

A retrospective analysis was performed on all patients with BMI ≥ 50 kg/m² who underwent biliopancreatic diversion with duodenal switch (BPD/DS), Roux-en-Y gastric bypass (RYGB), or sleeve gastrectomy (SG) at our institution between 2009 and 2019. Data collected from patients' electronic medical records included operative details as well as BMI and presence and resolution of obesity-related comorbidities at 0, 6, 12, 24, 48, and 60 months post-operatively.

RESULTS

Among 537 patients with BMI ≥ 50 kg/m² who had a primary bariatric procedure, 93 patients underwent BPD/DS (17.3%), 341 patients underwent RYGB (63.5%), and 103 patients underwent SG (19.2%). BMI decreased by 23.7 kg/m² in BPD/DS, 14.7 kg/m² in RYGB, and 13.6 kg/m² in SG cohorts at 60 months post-operatively (p < 0.0001). The greatest %TWL occurred in BPD/DS cohort (38.4%) followed by the RYGB (26.3%) and SG (23.6%) cohorts (p < 0.0001). The thirty-day complication rate was 12.9% for BPD/DS, 4.7% for RYGB, and 8.7% for SG (p = 0.015).

CONCLUSIONS

Our study demonstrated that the BPD/DS is the most effective operation at long-term reduction of BMI and achieved highest %TWL while SG and RYGB had similar results at 60 months post-op. BPD/DS is associated with increased early and late surgical complications compared to RYGB and SG.

Gut Microbiota Metabolism of Bile Acids Could Contribute to the Bariatric Surgery Improvements in Extreme Obesity

Bariatric surgery is the only procedure to obtain and maintain weight loss in the long term, although the mechanisms driving these benefits are not completely understood. In the last years, gut microbiota has emerged as one of the drivers through its metabolites, especially secondary bile acids. In the current study, we have compared the gut microbiota and the bile acid pool, as well as anthropometric and biochemical parameters, of patient with morbid obesity who underwent bariatric surgery by two different techniques, namely Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Gut microbiota populations differed after the respective procedures, particularly with respect to the Enterobacteriaceae family. Both techniques resulted in changes in the bile acids pool, but RYGB was the procedure which suffered the greatest changes, with a reduction in most of their levels. Blautia and Veillonella were the two genera that more relationships showed with secondary bile acids, indicating a possible role in their formation and inhibition, respectively. Correlations with the anthropometric and biochemical variables showed that secondary bile acids could have a role in the amelioration of the glucose and HDL-cholesterol levels. Thus, we have observed a possible relationship between the interaction of the bile acids pool metabolized by the gut microbiota in the metabolic improvements obtained by bariatric surgery in the frame of morbid obesity, deserving further investigation in greater cohorts to decipher the role of each bile acid in the homeostasis of the host for their possible use in the development of microbiota-based therapeutics, such as new drugs, postbiotics or probiotics.

Long-term Emergency Department Visits and Readmissions After Laparoscopic Roux-en-Y Gastric Bypass: a Systematic Review

PURPOSE

There is considerable evidence on short-term outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB), but data on long-term outcome is scarce, especially on postoperative emergency department (ED) visits and readmissions. We aim to systematically review evidence on the incidence, indications, and risk factors of ED visits and readmissions beyond 30 days after LRYGB.

MATERIALS AND METHODS

A systematic search in PubMed, Scopus, Embase.com , Cochrane Library, and PsycINFO was performed. All studies reporting ED visits and readmissions > 30 days after LRYGB, with ≥ 50 patients, were included. PRISMA statement was used and the Newcastle-Ottawa Scale for quality assessment.

RESULTS

Twenty articles were included. Six studies reported on ED visits (n = 2818) and 19 on readmissions (n = 276,543). The rate of patients with an ED visit within 90 days after surgery ranged from 3.9 to 32.6%. ED visits at 1, 2, and 3 years occurred in 25.6%, 30.0%, and 31.1% of patients. Readmissions within 90 days and at 1-year follow-up ranged from 4.1 to 20.5% and 4.75 to 16.6%, respectively. Readmission was 29% at 2 years and 23.9% at 4.2 years of follow-up. The most common reason for ED visits and readmissions was abdominal pain.

CONCLUSION

Emergency department visits and readmissions have been reported in up to almost one in three patients on the long-term after LRYGB. Both are mainly indicated for abdominal pain. The report on indications and risk factors is very concise. A better understanding of ED visits and readmissions after LRYGB is warranted to improve long-term care, in particular for patients with abdominal pains.

Gender as a Deterministic Factor in Procedure Selection and Outcomes in Bariatric Surgery

Background and Objectives:

With obesity rates rising in the United States, bariatric surgery has become a well-established and effective treatment for morbid obesity and its comorbid conditions. Laparoscopic Roux-en-Y gastric bypass and laparoscopic Sleeve Gastrectomy are two of the more common bariatric procedures. This study analyzes whether gender differences play a role in procedure selection and outcomes following either procedure.

Methods:

Using the American College of Surgeons National Surgical Quality Improvement Program database for years 2015 to 2017, we assessed demographics, postoperative complications, and readmission rates. Chi-square analysis, student t-test, and propensity analyses were performed appropriately.

Results:

Data review found that men presenting for bariatric surgery had a higher incidence of comorbidities and higher body mass index than women. More men than women underwent Sleeve Gastrectomy (68.5% vs 63.0%, P <0.0001), while more women than men underwent Laparoscopic Roux-en-Y gastric bypass (37.0% vs 31.5%, P < 0.0001). In the Laparoscopic Roux-en-Y group, men experienced more postoperative complications, including cardiac arrest (0.2% vs 0.1%, P = 0.02) and unplanned intubation (0.4% vs 0.2%, P = 0.02). In the Sleeve Gastrectomy group, men experienced more postoperative complications, including myocardial infarction (0.2% vs 0.1%, P = 0.006). In both groups, women experienced higher rates of unplanned readmissions (3.5% vs 2.8%, P = 0.0012).

Conclusions:

This study found that men are more likely to undergo Sleeve Gastrectomy than Laparoscopic Roux-en-Y gastric bypass, despite higher complication rates for both. Women have higher rates of unplanned readmission rates regardless of procedure, despite lower postoperative morbidity.

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.

RYGB Is More Effective than VSG at Protecting Mice from Prolonged High-Fat Diet Exposure: An Occasion to Roll Up Our Sleeves?

PURPOSE

Understanding the effects of Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) on adipose tissue physiology is important for the treatment of obesity-related metabolic disorders. By using robust mouse models of bariatric surgery that closely resemble those performed in humans, we can compare the effects of RYGB and VSG on adipose physiology in the absence of post-operative confounds such as diet and lifestyle changes.

MATERIALS AND METHODS

RYGB and VSG were compared using a diet-induced mouse model of obesity. High-fat diet (HFD) was administered post-operatively and changes to white and brown adipose tissue were evaluated, along with alterations to weight, glucose homeostasis, dyslipidemia, and insulin sensitivity.

RESULTS

After prolonged exposure to high-fat diet post-operatively, RYGB was effective in achieving sustained weight loss, while VSG unexpectedly accelerated weight gain rates. The resolution of obesity-related comorbidities such as glucose and insulin intolerance, dyslipidemia, and insulin sensitivity was improved after RYGB, but not for VSG. In RYGB, there were improvements to the function and health of white adipose tissue, enhanced brown adipose metabolism, and the browning of subcutaneous white adipose tissue, with no comparable changes seen for these factors after VSG. Some markers of systemic inflammation improved after both RYGB and VSG.

CONCLUSION

There are significantly different effects between RYGB and VSG when HFD is administered post-operatively and robust mouse models of bariatric surgery are used. RYGB resulted in lasting physiological and metabolic changes but VSG showed little difference from that of its sham-operated, DIO counterpart.

Comparison of 2-Year Results of Roux-en-Y Gastric Bypass and Transit Bipartition with Sleeve Gastrectomy for Superobesity

PURPOSE

Although Roux-en-Y gastric bypass is a powerful procedure, achieving and maintaining significant weight loss remains challenging in superobese populations. Transit bipartition with sleeve gastrectomy is derived from biliopancreatic diversion with duodenal switch and might improve weight loss control.

MATERIALS AND METHODS

Two series of 71 primary laparoscopic Roux-en-Y gastric bypass (RYGB) and transit bipartition (TB) with a body mass index ≥ 50 kg/m² were retrospectively compared after 2 years. Postoperative course, side effects, nutritional status, and weight outcomes were reviewed. Weight was expressed as BMI, percentage of excess BMI lost (%EBMIL), and percentage of total weight lost (%TWL).

RESULTS

The 2 groups were comparable for age and BMI of 51.9 ± 1.8 for RYGB and 51.6 ± 5 for TB. TB was longer to perform (92 vs 74 min, p ≤ 0.001) with a 30-day complication rate of 4.2% and 5.6%, but there was 1 death after RYGB. Weight loss was greater after TB compared with RYGB with %EBMIL of 85.3 ± 15.8% vs 73.9 ± 17.2% (p = 0.0002). One TB patient suffered from protein malnutrition but none after RYGB. After TB, 7% of the patients experienced > 3 stools a day and 1 patient required revision, while 3 patients had diarrhea after RYGB. Late reoperations were required for 7 and 1 patients after RYGB and TB. Comorbidity improvement was similar.

CONCLUSION

In a superobese population, TB appeared relatively safer compared with RYGB. It achieved a better weight loss at 2 years with a trend for more digestive side effects.

Clinical Outcomes, Trends in Weight, and Weight Loss Strategies in Patients With Obesity After Durable Ventricular Assist Device Implantation

PURPOSE OF REVIEW

To discuss clinical outcomes, changes in weight, and weight loss strategies of patients with obesity post left ventricular assist device (LVAD) implantation.

RECENT FINDINGS

Despite increased complications in patients with obesity after LVAD implantation, survival is comparable to patients without obesity. A minority of patients with obesity lose significant weight and become eligible for heart transplantation after LVAD implantation. In fact, a great majority of such patients gain weight post-implantation. Obesity by itself should not be considered prohibitive for LVAD therapy but, rather, should be incorporated into the overall risk assessment for LVAD implantation. Concerted strategies should be developed to promote sustainable weight loss in patients with obesity and LVAD to improve quality of life, eligibility, and outcomes after heart transplantation. Investigation of the long-term impact of weight loss on patients with obesity with LVAD is warranted.

Factors influencing the choice between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass

BACKGROUND

While laparoscopic sleeve gastrectomy (LSG) continues to be the most commonly performed bariatric operation, several variables influence surgeons' practice patterns and patients' decision-making in the type of bariatric procedure to perform. The aim of this study was to evaluate patient factors that influence the decision between laparoscopic Roux-en-Y gastric bypass (LRYGB) versus LSG.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried for patients undergoing LSG and LRYGB between 2015 and 2017. Univariate analysis and multivariate logistic regression were used to evaluate factors associated with performing LRYGB compared to LSG.

RESULTS

A total of 252,117 (72.3%) LSG and 96,677 (27.7%) LRYGB cases were identified. Patients undergoing LSG were younger (44.3 ± 12.0 vs 45.2 ± 11.8 years; p < 0.01) and had a lower body mass index (BMI; 45.1 ± 7.8 vs 46.2 ± 8.1 kg/m²; p < 0.01). Most of the patients were females (79.4%), white (73.0%), with an American Society of Anesthesiology (ASA) class ≤ 3 (96.4%). The factors associated with undergoing LRYGB compared to LSG were diabetes mellitus, gastroesophageal reflux disease, BMI ≥ 50 kg/m², ASA class > 3, obstructive sleep apnea, hypertension, and hyperlipidemia. However, patients with kidney disease, black race, chronic steroid use, age ≥ 60 years, recent smoking history, chronic obstructive pulmonary disease, and coronary artery disease were more likely to undergo LSG.

CONCLUSIONS

The decision to perform LRYGB is primarily driven by obesity-associated comorbidities and higher BMI, whereas LSG is more likely to be performed in higher risk patients.

The long-term benefits of bariatric surgery in elderly and super-obese populations

PURPOSE

to assess the long-term benefits of bariatric surgery in super-obese (body mass index [BMI] ≥ 50) and in elderly obese (age > 60 years) populations.

METHODS

one hundred and twenty one patients who underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy in a university hospital were retrospectively subdivided into the following groups: BMI < 50 vs ≥ 50 and age < 60 vs ≥ 60 years. Weight loss, body composition and comorbidity outcomes were registered after one and six months and one, two, three and five years with 100%, 93%, 89%, 80%, 75% and 60% successful follow-up.

RESULTS

the percentage of excess BMI loss (%EBMIL) was comparable between BMI groups and age groups and the difference in the long-term follow up was not statistically significant (p > 0.05). Complication rates, comorbidity resolution, reduction in body fat and increase in fat-free mass were comparable between BMI groups and age groups. Gastric bypass resulted in a greater weight loss compared to sleeve gastrectomy. The % EBMIL was 65.2% vs 46.7% (p = 0.002), 65.8% vs 44.9% (p = 0.004), 64.4% vs 30.5% (p = 0.001), 55.6% vs 17.6% (p = 0.016) at one, two, three and five years postoperative, respectively. Similarly, in the super-obese group, weight loss was more pronounced after gastric bypass versus sleeve gastrectomy.

CONCLUSIONS

bariatric surgery in super-obese and elderly populations is an effective and safe weight loss measure with a good comorbidity resolution in the long-term. Gastric bypass is superior to sleeve gastrectomy in terms of long-term weight loss and comorbidity resolution in all the groups investigated.

Comparing the 5-Year Diabetes Outcomes of Sleeve Gastrectomy and Gastric Bypass: The National Patient-Centered Clinical Research Network (PCORNet) Bariatric Study

IMPORTANCE

Bariatric surgery can lead to substantial improvements in type 2 diabetes (T2DM), but outcomes vary across procedures and populations. It is unclear which bariatric procedure has the most benefits for patients with T2DM.

OBJECTIVE

To evaluate associations of bariatric surgery with T2DM outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted in 34 US health system sites in the National Patient-Centered Clinical Research Network Bariatric Study. Adult patients with T2DM who had bariatric surgery between January 1, 2005, and September 30, 2015, were included. Data analysis was conducted from April 2017 to August 2019.

INTERVENTIONS

Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG).

MAIN OUTCOME AND MEASURES

Type 2 diabetes remission, T2DM relapse, percentage of total weight lost, and change in glycosylated hemoglobin (hemoglobin A1c).

RESULTS

A total of 9710 patients were included (median [interquartile range] follow-up time, 2.7 [2.9] years; 7051 female patients [72.6%]; mean [SD] age, 49.8 [10.5] years; mean [SD] BMI, 49.0 [8.4]; 6040 white patients [72.2%]). Weight loss was significantly greater with RYGB than SG at 1 year (mean difference, 6.3 [95% CI, 5.8-6.7] percentage points) and 5 years (mean difference, 8.1 [95% CI, 6.6-9.6] percentage points). The T2DM remission rate was approximately 10% higher in patients who had RYGB (hazard ratio, 1.10 [95% CI, 1.04-1.16]) than those who had SG. Estimated adjusted cumulative T2DM remission rates for patients who had RYGB and SG were 59.2% (95% CI, 57.7%-60.7%) and 55.9% (95% CI, 53.9%-57.9%), respectively, at 1 year and 86.1% (95% CI, 84.7%-87.3%) and 83.5% (95% CI, 81.6%-85.1%) at 5 years postsurgery. Among 6141 patients who experienced T2DM remission, the subsequent T2DM relapse rate was lower for those who had RYGB than those who had SG (hazard ratio, 0.75 [95% CI, 0.67-0.84]). Estimated relapse rates for those who had RYGB and SG were 8.4% (95% CI, 7.4%-9.3%) and 11.0% (95% CI, 9.6%-12.4%) at 1 year and 33.1% (95% CI, 29.6%-36.5%) and 41.6% (95% CI, 36.8%-46.1%) at 5 years after surgery. At 5 years, compared with baseline, hemoglobin A1c was reduced 0.45 (95% CI, 0.27-0.63) percentage points more for patients who had RYGB vs patients who had SG.

CONCLUSIONS AND RELEVANCE

In this large multicenter study, patients who had RYGB had greater weight loss, a slightly higher T2DM remission rate, less T2DM relapse, and better long-term glycemic control compared with those who had SG. These findings can help inform patient-centered surgical decision-making.

Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy for Super Super Obese and Super Obese: Systematic Review and Meta-analysis of Weight Results, Comorbidity Resolution

BACKGROUND

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) used for super obesity (SO) and super super obesity (SSO) remain controversial. The meta-analysis was to summarize the evidence.

METHODS

We searched in MEDLINE and PubMed for studies concerning RYGB and SG for SO or SSO and pooled complication, percentage excess weight loss (%EWL), and resolution of comorbidities.

RESULTS

Twelve studies were identified. RYGB achieved higher %EWL at 12 months, but no significant difference at 24 months. Resolution of diabetes mellitus and dyslipidemia reached a statistical significance; however, there was no significant difference in hypertension.

CONCLUSIONS

RYGB was superior in %EWL for SSO and SO at 12 months. However, regarding at 24 months, RYGB was equal to SG, which is from a meta-analysis and cannot be seen as a definitive conclusion.

The genus Sutterella is a potential contributor to glucose metabolism improvement after Roux-en-Y gastric bypass surgery in T2D

BACKGROUND

Alterations in gut microbiota have been associated with improvements in blood glucose due to bariatric surgery.

OBJECTIVES

Our aim is to identify specific gut microbiota that contribute to the remission of T2D after RYGB and SG.

METHODS

Rats fed a high-fat diet (HFD) were administered a low dose of streptozotocin as T2D models; next, their caecum content was collected 8 weeks after RYGB and SG. We also used case-control of gut microbial profiles of T2D patients and healthy people by collecting the mucosal-luminal interface from the ascending colon. Samples were profiled by 16S rRNA gene sequencing.

RESULTS

RYGB and SG reduced weight and improved glucose and insulin tolerance. Principal coordinate analysis showed that SG and, especially, RYGB cause changes in the composition of gut microbiota. We found that family Alcaligenaceae (genus Sutterella) was significantly decreased in the ascending colon of patients with T2D and increased after RYGB surgery in the caecum of T2D rats as shown by a linear discriminant analysis effect size (LEfSe) analysis, with no significant changes after SG. This result might benefit the improvement of glycometabolism.

CONCLUSIONS

RYGB can significantly reduce weight, improve glycometabolism and change the composition of the gut microbiota. Sutterella may have beneficial effects on glycometabolism in T2D patients after RYGB.

Laparoscopic Roux en Y gastric bypass in the super obese

Bariatric surgery in super obese patients presents technical, metabolic and risk related challenges. Moreover, there is concern that weight loss and health outcomes of surgery, including gastric bypass, may be lesser than in non super obese (morbidly obese) patients. This may drive clinicians toward more aggressive forms of surgery at the risk of greater morbidity. This review examines outcomes pertaining to laparoscopic Roux en Y gastric bypass (LRYGB) in the super obese and determines the role of such surgery in the current day. Whilst a minor increase in morbidity and mortality risk exists, weight loss outcomes when measured as percentage total body weight loss are equivalent to non super obese patients. Final BMI is not an appropriate indicator of benefit in such patients and may lead to escalation surgery inappropriately. Surgeons employing the use of LRYGB in the super obese should have adequate training and expertise in the technique and operating upon super obese patients should be avoided during the learning curve phase to minimise morbidity risk.

Comparative Effectiveness of Different Bariatric Procedures in Super Morbid Obesity

BACKGROUND

Super obesity (BMI ≥ 50 kg/m²) is associated with significant morbidity and mortality. The best procedure to treat super obesity is not completely established. Our aim was to compare the effectiveness of bariatric procedures (adjustable gastric band [AGB], Roux-en-Y gastric bypass [RYGB], sleeve gastrectomy [SG]) in super obesity.

METHODS

Retrospective observational study of super obese patients who underwent bariatric surgery. Data was assessed preoperatively and in the 1st and 2nd years of follow-up.

RESULTS

We evaluated 213 individuals, 77.9% female, age of 43.38 ± 11.49 years, and preoperative BMI of 54.53 ± 4.54 kg/m²; 19 submitted to AGB, 127 to RYGB, and 67 to SG. In the pre-surgical assessment, there were no significant differences in age, anthropometric parameters, blood pressure, glycemic profile, and lipid profile between the three surgical groups. The percentage of excess weight loss (%EWL) in the 1st year was 67.58% in RYGB, 58.74% in SG, and 38.71% in AGB (p < 0.001), and the percentage of total weight loss (%TWL) was 36.29%, 31.59%, and 21.07%, respectively (p < 0.001). Two years after surgery (n = 147; follow-up rate of 69%), the %EWL and %TWL were significantly higher in the RYGB group (p < 0.001). RYGB had a higher success rate (%EWL ≥ 50% and %TWL ≥ 20%) in both years of follow-up (p < 0.001). In multiple linear regression, after adjusting for other covariates, RYGB was the only strong predictive factor of %EWL and %TWL (p < 0.001).

CONCLUSION

RYGB proved to be more effective in super obesity. The beneficial effects in weight loss were evident both 1 and 2 years after the procedure, regardless of pre-surgical anthropometric characteristics.

Risk of Operative and Nonoperative Interventions Up to 4 Years After Roux-en-Y Gastric Bypass vs Vertical Sleeve Gastrectomy in a Nationwide US Commercial Insurance Claims Database

IMPORTANCE

There are few nationwide studies comparing the risk of reintervention after contemporary bariatric procedures.

OBJECTIVE

To compare the risk of intervention after Roux-en-Y gastric bypass (RYGB) vs vertical sleeve gastrectomy (VSG).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a nationwide US commercial insurance claims database. Adults aged 18 to 64 years who underwent a first RYGB or VSG procedure between January 1, 2010, and June 30, 2017, were matched on US region, year of surgery, most recent presurgery body mass index (BMI) category (based on diagnosis codes), and baseline type 2 diabetes. The prematch pool included 4496 patients undergoing RYGB and 8627 patients undergoing VSG, and the final weighted matched sample included 4476 patients undergoing RYGB and 8551 patients undergoing VSG.

EXPOSURES

Bariatric surgery procedure type (RYGB vs VSG).

MAIN OUTCOMES AND MEASURES

The primary outcome was any abdominal operative intervention after the index procedure. Secondary outcomes included the following subtypes of operative intervention: biliary procedures, abdominal wall hernia repair, bariatric conversion or revision, and other abdominal operations. Nonoperative outcomes included endoscopy and enteral access. Time to first event was compared using multivariable Cox proportional hazards regression modeling.

RESULTS

Among 13 027 patients, the mean (SD) age was 44.4 (10.3) years, and 74.1% were female; 13.7% had a preoperative BMI between 30 and 39.9, 45.8% had a preoperative BMI between 40 and 49.9, and 24.2% had a preoperative BMI of at least 50. Patients were followed up for up to 4 years after surgery (median, 1.6 years; interquartile range, 0.7-3.2 years), with 41.9% having at least 2 years of follow-up and 16.3% having at least 4 years of follow-up. Patients undergoing VSG were less likely to have any subsequent operative intervention than matched patients undergoing RYGB (adjusted hazard ratio [aHR], 0.80; 95% CI, 0.72-0.89) and similarly were less likely to undergo biliary procedures (aHR, 0.77; 95% CI, 0.67-0.90), abdominal wall hernia repair (aHR, 0.60; 95% CI, 0.47-0.75), other abdominal operations (aHR, 0.71; 95% CI, 0.61-0.82), and endoscopy (aHR, 0.54; 95% CI, 0.49-0.59) or have enteral access placed (aHR, 0.58; 95% CI, 0.39-0.86). Patients undergoing VSG were more likely to undergo bariatric conversion or revision (aHR, 1.83; 95% CI, 1.19-2.80).

CONCLUSIONS AND RELEVANCE

In this nationwide study, patients undergoing VSG appeared to be less likely than matched patients undergoing RYGB to experience subsequent abdominal operative interventions, except for bariatric conversion or revision procedures. Patients considering bariatric surgery should be aware of the increased risk of subsequent procedures associated with RYGB vs VSG as part of shared decision-making around procedure choice.

Preoperative liking and wanting for sweet beverages as predictors of body weight loss after Roux-en-Y gastric bypass and sleeve gastrectomy

Background/objectives:

Patients who receive Roux-en-Y gastric bypass (RYGB) lose more weight than those who receive vertical sleeve gastrectomy (VSG). RYGB and VSG alter hedonic responses to sweet flavor, but whether baseline differences in hedonic responses modulate weight loss after RYGB or VSG remains untested.

Participants/methods:

Male and female candidates (n=66) for RYGB or VSG were recruited and tested for their subjective liking and wanting ratings of sucrose solutions and flavored beverages sweetened with aspartame. Participants were classified by unsupervised hierarchical clustering for their liking and wanting ratings of sucrose and aspartame. Participant liking ratings were also used in a supervised classification using pre-established categories of liking ratings (liker, disliker, and inverted u-shape). Effects of categories obtained from unsupervised or supervised classification on body weight loss and their interaction with surgery type were analyzed separately at 3 and 12 months after surgery using linear models corrected for sex and age.

Results:

RYGB participants lost more body weight compared to VSG participants at 3 and 12 months after surgery (P < 0.001 for both time points). Unsupervised clustering analysis identified clusters corresponding to high and low wanting or liking ratings for sucrose or aspartame. RYGB participants in high-wanting clusters based on sucrose, but not aspartame, lost more weight than VSG at both 3 (P = 0.01) and 12 months (P = 0.03), yielding a significant cluster by surgery interaction. Categories based on supervised classification using liking ratings for sucrose or aspartame showed no significant effects on body weight loss between RYGB and VSG participants.

Conclusions:

Classification of patients into high/low wanting ratings for sucrose before surgery can predict differential body weight loss after RYGB or VSG in adults and could be used to advise on surgery type.

Perioperative outcomes of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy in super-obese and super-super-obese patients: a national database analysis

BACKGROUND

Evidence remains contradictory for perioperative outcomes of super-obese (SO) and super-super-obese (SSO) patients undergoing bariatric surgery.

OBJECTIVE

To identify national 30-day morbidity and mortality of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in SO and SSO patients.

SETTING

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

METHODS

All LSG and LRYGB patients from 2015 through 2017 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were grouped based on body mass index (BMI) as follows: morbidly obese (MO; BMI 35.0-49.9 kg/m²), SO (BMI 50.0-59.9 kg/m²), and SSO (BMI ≥60.0 kg/m²). Complications and mortality within 30 days were compared between BMI groups using Pearson X² or Fischer's exact tests. Multivariate logistic regression was used to adjust for demographic characteristics and co-morbidities, and adjusted odds ratio (AOR) was reported for each outcome.

RESULTS

Of 356,621 patients, 71.6% had LSG and 28.4% LRYGB. A total of 272,195 patients were in the MO group, 65,565 in the SO group, and 18,861 in the SSO group. Higher BMI was associated with increased overall morbidity and mortality. The overall complication rate was significantly higher for SO (AOR = 1.20, 95% confidence interval [CI] 1.13-1.28 for LSG; AOR = 1.08, 95% CI 1.01-1.15 for LRYGB) and SSO (AOR = 1.44, 95% CI 1.31-1.58 for LSG; AOR = 1.31, 95% CI 1.19-1.45 for LRYGB) compared with the MO group. Mortality was also significantly higher for SO (AOR = 1.65, 95% CI 1.10-2.48 for LSG; AOR = 1.85, 95% CI 1.23-2.80 for LRYGB) and SSO (AOR = 3.30, 95% CI 1.98-5.48 for LSG; AOR = 3.32, 95% CI 1.93-5.73 for LRYGB) compared with the MO group.

CONCLUSIONS

SO and SSO patients are at increased risk of 30-day morbidity and mortality compared with MO patients. Despite this elevated perioperative risk, the overall risk of these procedures remains low and acceptable especially as bariatric surgery is the durable treatment option for obesity.

Long-term outcomes of laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass for morbid obesity: Results from a meta-analysis of randomized controlled trials

BACKGROUND

Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass (LRYGB) are 2 widely used procedures performed in bariatric surgery. However, their long-term weight loss effects have not been well compared.

OBJECTIVES

To evaluate the long-term outcome of 2 procedures for treating morbid obesity.

SETTING

The gastrointestinal surgery center, Eastern Hospital, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital.

METHODS

Three electronic databases, PubMed, CNKI, and EMBASE, were searched ending in September 2018. Eligible studies were prospective randomized controlled trials.

RESULTS

Of 15 randomized controlled trials studies, 1381 cases were included, 697 were randomly divided into the laparoscopic sleeve gastrectomy group and 684 to the LRYGB group. A statistically significant percent excess weight loss reduction in weighted mean difference was observed in LRYGB group at 5 years (weighted mean difference = -8.9, 95% confidence interval [CI] = -13.08 to -4.73, P < .0001), and at 3 years (weighted mean difference = -11.96, 95% CI = -17.62 to -6.30, P < .0001). However, there was not any statistically difference between the 2 procedures in <3 years. The total complication of the LSC group were less than that of the LRYGB groups (odds ratio = .52, 95%CI = .35-.76, P = .0007). This meta-analysis showed that the LRYGB procedure could reduce gastrointestinal reflux disease (odds ratio = .26, 95%CI = .11-.61, P = .002); however, no statistically significant differences were found in type 2 diabetes, hypertension, dyslipidemia, and sleep apnea.

CONCLUSIONS

This meta-analysis showed that significantly greater in percent excess weight loss after 5 years of LRYGB treatment; however, it seems to have a higher incidence of total complications.

Long-Term Weight Loss and Metabolic Syndrome Remission after Bariatric Surgery: The Effect of Sex, Age, Metabolic Parameters and Surgical Technique - A 4-Year Follow-Up Study

INTRODUCTION

Bariatric surgery is an effective treatment for morbid obesity and its metabolic related comorbidities. However, the literature reports inconsistent results regarding weight loss (WL) and the resolution of comorbidities associated with obesity.

OBJECTIVE

We aim to evaluate long-term differences in WL between different surgical techniques and the impact of each surgical technique on metabolic parameters (type 2 diabetes mellitus [T2DM], dyslipidemia,hypertension, and metabolic syndrome). We also aim to evaluate the effect of baseline clinical characteristics in WL and in the evolution of metabolic syndrome (MetS) components. Our hypothesis is that different types of surgery have different effects on WL and the prevalence of comorbidities over time.

METHODS

We retrospectively evaluated WL and metabolic parameter remission (T2DM, dyslipidemia, hypertension, and MetS) during 4 years in 1,837 morbidly obese patients (females, 85%; age, 42.5 ± 10.6 years; BMI, 44.0 ± 5.8) who underwent bariatric surgery (Roux-en-Y gastric bypass [RYGB], laparoscopic sleeve gastrectomy [LSG], and laparoscopic adjustable gastric band [LAGB]).

RESULTS

The mean percentage of WL for RYGB, LSG, and LAGB was, respectively, 32.9 ± 8.7, 29.8 ± 9.8, and 16.2 ± 9.6 at 12 months and 30.6 ± 9.1, 22.7 ± 10.0, and 15.8 ± 10.8 at 48 months (p < 0.001), even after adjustment for baseline weight, BMI, age, and sex (p < 0.001). Women had more WL during the first 36 months (p = 0.013 and 0.007 at 12 and 36 months, respectively) and older patients had less WL compared to younger ones (p <0.001), except at 48 months. Patients with T2DM had less WL than those without diabetes after adjustment (sex, age, and surgical technique) during the same period. Patients with hypertension had less WL at 12 months (p = 0.009) and MetS at 24 months (p = 0.020) compared to those without these comorbidities. There was no significant difference regarding the presence of dyslipidemia in WL. The RYGB group showed better results for MetS resolution.

CONCLUSION

During the 4-year follow-up, RYGB was the surgical procedure that caused the highest WL and MetS resolution.

Effect of alcohol ingestion on plasma glucose kinetics after Roux-en-Y gastric bypass surgery

BACKGROUND

Roux-en-Y gastric bypass surgery (RYGB) increases the rate of alcohol absorption so that peak blood alcohol concentration is 2-fold higher after surgery compared with concentrations reached after consuming the same amount presurgery. Because high doses of alcohol can lead to hypoglycemia, patients may be at increased risk of developing hypoglycemia after alcohol ingestion.

OBJECTIVES

We conducted 2 studies to test the hypothesis that the consumption of approximately 2 standard drinks of alcohol would decrease glycemia more after RYGB than before surgery.

SETTING

Single-center prospective randomized trial.

METHODS

We evaluated plasma glucose concentrations and glucose kinetics (assessed by infusing a stable isotopically labelled glucose tracer) after ingestion of a nonalcoholic drink (placebo) or an alcoholic drink in the following groups: (1) 5 women before RYGB (body mass index = 43 ± 5 kg/m²) and 10 ± 2 months after RYGB (body mass index = 31 ± 7 kg/m²; study 1), and (2) 8 women who had undergone RYGB surgery 2.2 ± 1.2 years earlier (body mass index = 30 ± 5 kg/m²; study 2) RESULTS: Compared with the placebo drink, alcohol ingestion decreased plasma glucose both before and after surgery, but the reduction was greater before (glucose nadir placebo = -.4 ± 1.0 mg/dL versus alcohol = -9.6 ± 1.5 mg/dL) than after (glucose nadir placebo = -1.0 ± 1.6 mg/dL versus alcohol = -5.5 ± 2.6 mg/dL; P < .001) surgery. This difference was primarily due to an alcohol-induced early increase followed by a subsequent decrease in the rate of glucose appearance into systemic circulation.

CONCLUSION

RYGB does not increase the risk of hypoglycemia after consumption of a moderate dose of alcohol.

Outcomes of Roux-en-Y gastric bypass versus sleeve gastrectomy in super-super-obese patients (BMI ≥60 kg/m2): 6-year follow-up at a single university

BACKGROUND

Among the population of morbidly obese people, super-super-obese (SSO) individuals (body mass index >60 kg/m²) present a treatment challenge for bariatric surgeons.

OBJECTIVES

To compare the long-term outcomes between laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) and to evaluate the efficacy of SG as a stand-alone bariatric procedure for SSO patients.

SETTING

University hospital, Paris, France.

METHODS

We retrospectively reviewed the data outcomes of 210 SSO patients who underwent SG or RYGB between January 2000 and December 2011. The 6-year follow-up data were analyzed and compared.

RESULTS

Follow-up data at 6 years were collected for 57.1% and 52.1% of patients in the SG group and RYGB groups, respectively. Both procedures were effective at promoting weight loss. Most weight loss was achieved at 24 months with both procedures. The average percent excess weight loss and change in body mass index of SG versus RYGB showed no significant differences at the 4-year follow-up. Except for sleep apnea, RYGB showed slightly better resolution of the evaluated co-morbidities. The composite endpoint of major short-term adverse events (<30 d) occurred in 11.7% of patients with RYGB and 6.4% of those with SG (P = .02). Postoperative complications were seen in 26% of RYGB patients and 16.1% of SG patients.

CONCLUSIONS

SG as a primary procedure for SSO patients remains effective even though RYGB achieves better midterm outcomes. SG can be proposed as the primary-option p+rocedure. Further investigations are needed to identify the ideal procedure for patients with symptoms of gastroesophageal reflux disease.

RYGB Produces more Sustained Body Weight Loss and Improvement of Glycemic Control Compared with VSG in the Diet-Induced Obese Mouse Model

BACKGROUND

Weight regain and type-2 diabetes relapse has been reported in a significant proportion of vertical sleeve gastrectomy (VSG) patients in some studies, but definitive conclusions regarding the long-term comparative effectiveness of VSG and Roux-en-Y gastric bypass (RYGB) surgery are lacking both in humans and rodent models. This study's objective was to compare the effects of murine models of VSG and RYGB surgery on body weight, body composition, food intake, energy expenditure, and glycemic control.

METHODS

VSG, RYGB, and sham surgery was performed in high-fat diet-induced obese mice, and the effects on body weight and glycemic control were observed for a period of 12 weeks.

RESULTS

After the initial weight loss, VSG mice regained significant amounts of body weight and fat mass that were only marginally lower than in sham-operated mice. In contrast, RYGB produced sustained loss of body weight and fat mass up to 12 weeks and drastically improved fasting insulin and HOMA-IR compared with sham-operated mice. Using weight-matched control groups, we also found that the adaptive hypometabolic response to weight loss was blunted by both VSG and RYGB, and that despite large weight/fat regain, fasting insulin and HOMA-IR were markedly improved, but not reversed, in VSG mice.

CONCLUSIONS

VSG is less effective to lastingly suppress body weight and improve glycemic control compared with RYGB in mice. Given similar observations in many human studies, the run towards replacing RYGB with VSG is premature and should await carefully controlled randomized long-term trials with VSG and RYGB.

Weight Management in Patients with Type 1 Diabetes and Obesity

PURPOSE OF REVIEW

Patients with type 1 diabetes (T1D) are typically viewed as lean individuals. However, recent reports showed that their obesity rate surpassed that of the general population. Patients with T1D who show clinical signs of type 2 diabetes such as obesity and insulin resistance are considered to have "double diabetes." This review explains the mechanisms of weight gain in patients with T1D and how to manage it.

RECENT FINDINGS

Weight management in T1D can be successfully achieved in real-world clinical practice. Nutrition therapy includes reducing energy intake and providing a structured nutrition plan that is lower in carbohydrates and glycemic index and higher in fiber and lean protein. The exercise plan should include combination stretching as well as aerobic and resistance exercises to maintain muscle mass. Dynamic adjustment of insulin doses is necessary during weight management. Addition of anti-obesity medications may be considered. If medical weight reduction is not achieved, bariatric surgery may also be considered.

Sleeve Gastrectomy Efficacy on Metabolic and Cardiovascular Dysfunction With a Focus on the Role of Comorbidities

We evaluated the effects of sleeve gastrectomy (SG) on metabolic/cardiovascular parameters according to weight loss, visceral fat area (VFA), and homeostasis model assessment (HOMA)-insulin resistance index; we also assessed the influence of SG on comorbidities (diabetes/hypertension). At baseline and 10 to 12 months after SG, we assessed anthropometric and biochemical parameters, bioimpedentiometry, ultrasonographic VFA, liver steatosis, flow-mediated dilation, and echocardiography in 110 patients with obesity. We found that 23 (21%) patients had diabetes. Diabetic patients who normalized their glycated hemoglobin A_1C (HbA_1C) level experienced greater total weight loss (TWL), and the probability of normalizing HbA_1C levels directly correlated with TWL. Diabetic patients experienced a greater improvement in systolic blood pressure, VFA, and high-density lipoprotein cholesterol than nondiabetics, while patients with hypertension experienced a greater improvement in VFA, triglycerides, HOMA, and HbA_1C than nonhypertensive patients. The most important determinant of glucose control in diabetic patients was weight loss. Patients with diabetes and hypertension experienced a greater improvement in vascular and metabolic status after SG.

Pathophysiology and Potential Non-Pharmacologic Treatments of Obesity or Kidney Disease Associated Refractory Hypertension

PURPOSE OF REVIEW

The review assesses the role of non-pharmacologic therapy for obesity and chronic kidney disease (CKD) associated refractory hypertension (rf HTN).

RECENT FINDINGS

Hypertensive patients with markedly heightened sympathetic nervous system (SNS) activity are prone to develop refractory hypertension (rfHTN). Patients with obesity and chronic kidney disease (CKD)-associated HTN have particularly heightened SNS activity and are at high risk of rfHTN. The role of bariatric surgery is increasingly recognized in treatment of obesity. Current evidence advocates for a greater role of bariatric surgery in the management of obesity-associated HTN. In contrast, renal denervation does not appear have a role in the management of obesity or CKD-associated HTN. The role of baroreflex activation as adjunctive anti-hypertensive therapy remains to be defined.