Change in Predicted 10-Year Cardiovascular Risk Following Laparoscopic Roux-en-Y Gastric Bypass Surgery

An Assessment of the Effect of Bariatric Surgery on Cardiovascular Disease Risk in the Chinese Population Using Multiple Cardiovascular Risk Models

BACKGROUND

Many studies have reported that bariatric surgery may reduce postoperative cardiovascular risk in patient with obesity, but few have addressed this risk in the Chinese population.

OBJECTIVE

To assess the impact of bariatric surgery on cardiovascular disease (CVD) risk in the Chinese population using the World Health Organization (WHO) risk model, the Global risk model, and the Framingham Risk Score.

METHODS

We retrospectively analyzed data collected on patient with obesity who underwent bariatric surgery at our institution between March 2009 and January 2021. Their demographic characteristics, anthropometric variables, and glucolipid metabolic parameters were assessed preoperatively and at their 1-year postoperative follow-up. Subgroup analysis compared body mass index (BMI) < 35 kg/m² and BMI ≥ 35 kg/m², as well as gender. We used the 3 models to calculate their CVD risk.

RESULTS

We evaluated 61 patients, of whom 26 (42.62%) had undergone sleeve gastrectomy (SG) surgery and 35 (57.38%) Roux-en-Y gastric bypass (RYGB) surgery. Of the patients with BMI ≥ 35 kg/m², 66.67% underwent SG, while 72.97% with BMI < 35 kg/m² underwent RYGB. HDL levels were significantly higher at 12 months postoperatively relative to baseline. When the models were applied to calculate CVD risk in Chinese patients with obesity, the 1-year CVD risk after surgery were reduced lot compared with the preoperative period.

CONCLUSION

Patient with obesity had significantly lower CVD risks after bariatric surgery. This study also demonstrates that the models are reliable clinical tools for assessing the impact of bariatric surgery on CVD risk in the Chinese population.

Reducing the 10-year risk of ischemic cardiovascular disease to receive early cardiovascular benefits from bariatric surgery for obesity in China

Background

Cardiovascular risk due to obesity can be improved greatly by bariatric surgery. However, there is no research involving appropriate model for evaluating cardiovascular disease risk reduction in bariatric surgery for obesity in China. We selected the ischemic cardiovascular disease (ICVD) risk score that accurately predict cardiovascular risk in Chinese adults to evaluate the 10-year risk of ICVD and estimated early cardiovascular benefits of bariatric surgery in obese Chinese patients through its reduction.

Methods

From 2017 to 2019 we followed up 107 patients 6 months after surgery and measured the ICVD 10-year risk and other cardiovascular factors before and after surgery.

Results

There were significant reductions in the ICVD total score (p < 0.001) and ICVD 10-year risk (%) (p < 0.001) 6 months post-operation compared with baseline. Furthermore, we found significant reductions in body mass index (BMI), body adiposity index (BAI), low-density lipoprotein (LDL), small dense-low-density lipoprotein (sd-LDL) and triglycerides (TG) 6 months after surgery compared with pre-operation (all p < 0.05). The decrease in ICVD total score was correlated with excess BMI loss (%EBMIL), reduced BAI, reduced LDL, reduced sd-LDL and reduced TG respectively (all p < 0.05) at 6 months post-operation. Moreover, there were significant reductions in the ICVD total score in the male subgroup [3 (3, 5) vs. 2.5 (2, 4), p < 0.001] and female subgroup [3 (2, 4) vs. 2 (1, 3), p < 0.001] 6 months post-operation compared with baseline. At last there were also significant reductions in the ICVD total score in the diabetic subgroup [5 (4, 6) vs. 4 (3, 5), p < 0.001] and non-diabetic subgroup [2 (2,3) vs. 2 (1, 2), p < 0.001] 6 months post-operation compared with baseline.

Conclusions

Bariatric surgery could provide early cardiovascular benefits for patients with obesity in China by reducing the 10-year risk of ICVD. Both men and women with obesity achieved cardiovascular benefits according to bariatric surgery, so did diabetic and non-diabetic patients.

Comparative Effectiveness of Gastric Bypass and Vertical Sleeve Gastrectomy for Hypertension Remission and Relapse: The ENGAGE CVD Study

Weight loss is an effective strategy for the management of hypertension, and bariatric surgery is the most effective weight loss and maintenance strategy for obesity. The importance of bariatric surgery in the long-term management of hypertension and which operation is most effective is less clear. We compared the effectiveness of vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) for remission and relapse of hypertension after surgery in the ENGAGE CVD cohort study (Effectiveness of Gastric Bypass Versus Gastric Sleeve for Cardiovascular Disease). Operations were done by 23 surgeons across 9 surgical practices. Hypertension remission and relapse were assessed in each year of follow-up beginning 30 days and up to 5 years postsurgery. We used a local instrumental variable approach to account for selection bias in the choice of VSG or RYGB. The study population included 4964 patients with hypertension at the time of surgery (n=3186 VSG and n=1778 RYGB). At 1 year, 27% of patients with RYGB and 28% of patients with VSG achieved remission. After 5 years, without accounting for relapse, 42% of RYGB and 43% of VSG patients had experienced hypertension remission. After accounting for relapse, only 17% of RYGB and 18% of VSG patients remained in remission 5 years after surgery. There were no statistically significant differences between VSG and RYGB for hypertension remission, relapse, or mean systolic and diastolic blood pressure at any time during follow-up.

Can surgical weight loss reduce the risk of developing coronary heart disease?

BACKGROUND

Coronary heart disease (CHD) accounts for one third of all deaths in people older than 35 years in the United States.

OBJECTIVES

The aim of this study is to determine the impact of bariatric surgery, especially laparoscopic sleeve gastrectomy, on the risk of developing CHD.

SETTING

Academic, University affiliated hospital.

METHODS

We retrospectively reviewed all patients who underwent bariatric surgery from 2010-2016. All patients between 30 and 74 years of age without a previous history of CHD were included in our study. The risk score for predicting the incidence of CHD was measured preoperatively and at 12 months of follow-up.

RESULTS

Of the 1330 patients studied, 225 patients (16.9%) had all the required variables to calculate the CHD risk score. The mean age of our population was 51.4 ± 11.3 years, mostly female (67%, n = 152) and white (58.7%, n = 132). At the preoperative setting, our patient population had a systolic blood pressure in the prehypertensive ranges, with 40% (n = 90) having type 2 diabetes and 60% (n = 134) having arterial hypertension. The preoperative CHD preoperative risk was 8.9 ± 7.7% or 8-fold higher than the ideal risk. After 12 months of follow-up, the CHD absolute risk reduction was 2.7%, and the relative risk reduction was 42.0% for female patients and 5.4% and 38.8%, respectively, for male patients. All the metabolic factors used to calculate the risk of developing CHD had a significant improvement after 12 months.

CONCLUSIONS

Surgical weight loss reduces the risk of developing CHD. Further studies should assess these findings in a long-term follow-up.

Cardiovascular risk reduction following metabolic and bariatric surgery

Cardiovascular disease (CVD) is the world’s leading cause of mortality and obesity is a well-recognized risk factor of CVD. Early detection and management of CVD is critical to reduce CVD risk. Especially in patients suffering from obesity with obesity-related CVD risk factors such as hypertension (HTN), dyslipidemia, and diabetes mellitus (DM). A substantial and sustained decrease in body weight after metabolic and bariatric surgery is associated with a significant reduction of cardiovascular risk factors. This article reviews CVD risk models, mechanisms of CVD risk associated with obesity, and overall CVD risk reduction between different metabolic and bariatric procedures.

Association Between Bariatric Surgery and Macrovascular Disease Outcomes in Patients With Type 2 Diabetes and Severe Obesity

IMPORTANCE

Macrovascular disease is a leading cause of morbidity and mortality for patients with type 2 diabetes, and medical management, including lifestyle changes, may not be successful at lowering risk.

OBJECTIVE

To investigate the relationship between bariatric surgery and incident macrovascular (coronary artery disease and cerebrovascular diseases) events in patients with severe obesity and type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective, matched cohort study, patients with severe obesity (body mass index ≥35) aged 19 to 79 years with diabetes who underwent bariatric surgery from 2005 to 2011 in 4 integrated health systems in the United States (n = 5301) were matched to 14 934 control patients on site, age, sex, body mass index, hemoglobin A1c, insulin use, observed diabetes duration, and prior health care utilization, with follow-up through September 2015.

EXPOSURES

Bariatric procedures (76% Roux-en-Y gastric bypass, 17% sleeve gastrectomy, and 7% adjustable gastric banding) were compared with usual care for diabetes.

MAIN OUTCOMES AND MEASURES

Multivariable-adjusted Cox regression analysis investigated time to incident macrovascular disease (defined as first occurrence of coronary artery disease [acute myocardial infarction, unstable angina, percutaneous coronary intervention, or coronary artery bypass grafting] or cerebrovascular events [ischemic stroke, hemorrhagic stroke, carotid stenting, or carotid endarterectomy]). Secondary outcomes included coronary artery disease and cerebrovascular outcomes separately.

RESULTS

Among a combined 20 235 surgical and nonsurgical patients, the mean (SD) age was 50 (10) years; 76% of the surgical and 75% of the nonsurgical patients were female; and the baseline mean (SD) body mass index was 44.7 (6.9) and 43.8 (6.7) in the surgical and nonsurgical groups, respectively. At the end of the study period, there were 106 macrovascular events in surgical patients (including 37 cerebrovascular and 78 coronary artery events over a median of 4.7 years; interquartile range, 3.2-6.2 years) and 596 events in the matched control patients (including 227 cerebrovascular and 398 coronary artery events over a median of 4.6 years; interquartile range, 3.1-6.1 years). Bariatric surgery was associated with a lower composite incidence of macrovascular events at 5 years (2.1% in the surgical group vs 4.3% in the nonsurgical group; hazard ratio, 0.60 [95% CI, 0.42-0.86]), as well as a lower incidence of coronary artery disease (1.6% in the surgical group vs 2.8% in the nonsurgical group; hazard ratio, 0.64 [95% CI, 0.42-0.99]). The incidence of cerebrovascular disease was not significantly different between groups at 5 years (0.7% in the surgical group vs 1.7% in the nonsurgical group; hazard ratio, 0.69 [95% CI, 0.38-1.25]).

CONCLUSIONS AND RELEVANCE

In this observational study of patients with type 2 diabetes and severe obesity who underwent surgery, compared with those who did not undergo surgery, bariatric surgery was associated with a lower risk of macrovascular outcomes. The findings require confirmation in randomized clinical trials. Health care professionals should engage patients with severe obesity and type 2 diabetes in a shared decision making conversation about the potential role of bariatric surgery in the prevention of macrovascular events.

Laparoscopic Sleeve Gastrectomy for Morbid Obesity at a Veterans Affairs Medical Center

BACKGROUND

Class III obesity is a global health emergency associated with an increase in the incidence of many other diseases such as type 2 diabetes mellitus, hypertension, hyperlipidemia, cancer, obstructive sleep apnea, nonalcoholic fatty liver disease, osteoarthritis, infertility, and mental health disorders. Minimal work has been published regarding the efficacy of laparoscopic sleeve gastrectomy (LSG) in the veteran population to surgically manage morbid obesity.

DESIGN

Retrospective analysis of LSG performed at a Veterans Affairs Medical Center (VAMC) between 2010 and 2017. Veterans were followed from their enrollment in the bariatric program until twelve months following LSG. The primary outcome of interest was excess and total weight loss with resolution of associated comorbidities.

RESULTS

Excess weight loss at nine and 12 months was 43.5% and 40.7% and total weight loss was 20.1% and 19.0%, respectively. LSG performed at a VAMC resulted in 86.9% improvement in type 2 diabetes mellitus and a 66.1% improvement in hypertension and 74.3% improvement in hyperlipidemia. Approximately 10.0% of diabetics obtained partial and 9.0% obtained complete resolution of their disease. Similarly, 22.0% of Veterans obtained partial and 13.0% obtained complete resolution from hypertension. Complete resolution from hyperlipidemia was achieved in 8.8% of Veterans. There were no postoperative complications or staple line leaks.

CONCLUSION

LSG is a safe and effective tool for morbid obesity with clinical and serological improvements for individuals who are unable to lose weight with medical management alone.

Bariatric Surgery for Adolescents with Type 2 Diabetes: an Emerging Therapeutic Strategy

PURPOSE OF REVIEW

Type 2 diabetes (T2D) is a growing public health problem in youth, but conventional treatments are often insufficient to treat this disease and its comorbidities. We review evidence supporting an emerging role for bariatric surgery as a treatment for adolescent T2D.

RECENT FINDINGS

Paralleling what has been seen in adult patients, bariatric surgery dramatically improves glycemic control in patients with T2D. In fact, remission of T2D has been observed in as many as 95-100% of adolescents with diabetes after bariatric surgery, particularly vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) surgery. This striking outcome may be due to both weight-dependent- and weight-independent factors, and recent studies suggest that T2D-related comorbidities may also improve after surgery. Bariatric surgery including RYGB and VSG is a powerful therapeutic option for obese adolescents with T2D. Benefits must be weighed against risk for postoperative complications such as nutritional deficiencies, but earlier surgical intervention might lead to more complete metabolic remission in obese patients with T2D.

Gastric Bypass Surgery Produces a Durable Reduction in Cardiovascular Disease Risk Factors and Reduces the Long-Term Risks of Congestive Heart Failure

Background

Obesity and its association with reduced life expectancy are well established, with cardiovascular disease as one of the major causes of fatality. Metabolic surgery is a powerful intervention for severe obesity, resulting in improvement in comorbid diseases and in cardiovascular risk factors. This study investigates the relationship between metabolic surgery and long‐term cardiovascular events.

Methods and Results

A cohort of Roux‐en‐Y gastric bypass surgery (RYGB) patients was tightly matched by age, body mass index, sex, Framingham Risk Score, smoking history, use of antihypertension medication, diabetes mellitus status, and calendar year with a concurrent cohort of nonoperated control patients. The primary study end points of major cardiovascular events (myocardial infarction, stroke, and congestive heart failure) were evaluated using Cox regression. Secondary end points of longitudinal cardiovascular risk factors were evaluated using repeated‐measures regression. The RYGB and matched controls (N=1724 in each cohort) were followed for up to 12 years after surgery (overall median of 6.3 years). Kaplan–Meier analysis revealed a statistically significant reduction in incident major composite cardiovascular events (P=0.017) and congestive heart failure (0.0077) for the RYGB cohort. Adjusted Cox regression models confirmed the reductions in severe composite cardiovascular events in the RYGB cohort (hazard ratio=0.58, 95% CI=0.42–0.82). Improvements of cardiovascular risk factors (eg, 10‐year cardiovascular risk score, total cholesterol, high‐density lipoprotein, systolic blood pressure, and diabetes mellitus) were observed within the RYGB cohort after surgery.

Conclusions

Gastric bypass is associated with a reduced risk of major cardiovascular events and the development of congestive heart failure.

No more broken hearts: weight loss after bariatric surgery returns patients' postoperative risk to baseline following coronary surgery

BACKGROUND

The obesity epidemic is associated with a rise in coronary surgeries because obesity is a risk factor for coronary artery disease. Bariatric surgery is linked to improvement in cardiovascular co-morbidities and left ventricular function. No studies have investigated survival advantage in postoperative bariatric patients after coronary surgery.

OBJECTIVES

To determine if there is a benefit after coronary surgery in patients who have previously undergone bariatric surgery.

SETTING

National Inpatient Sample.

METHODS

We performed a retrospective, cross-sectional analysis of the National Inpatient Sample database from 2003 to 2010. We selected bariatric surgical patients who later underwent coronary surgery (n = 257). A comparison of postoperative complications and mortality after coronary surgery were compared with controls (n = 1442) using χ² tests, linear regression analysis, and multivariate logistical regression models.

RESULTS

A subset population was identified as having undergone coronary surgery (n = 1699); of this population, 257 patients had previously undergone bariatric surgery. They were compared with 1442 controls. The majority was male (67.2%), white (82.6%), and treated in an urban environment (96.8%). Patients with bariatric surgery assumed the risk of postoperative complications after coronary surgery that was associated with their new body mass index (BMI) (BMI<25 kg/m²: odds ratio (OR) 1.01, 95% CI .76-1.34, P = .94; BMI 25 to<35 kg/m²: OR .20, 95% CI .02-².16, P = .19; BMI≥35 kg/m²: OR>999.9, 95% CI .18 to>999.9, P = .07). Length of stay was significantly longer in postbariatric patients (BMI<25, OR 1.62, 95% CI 1.14-2.30, P = .007).

CONCLUSIONS

Postoperative bariatric patients have a return to baseline risk of morbidity and mortality after coronary surgery.

Decreased Cardiovascular Risk after Roux-en-Y Gastric Bypass Surgery in Chinese Diabetic Patients with Obesity

BACKGROUND

The influence of bariatric surgery on cardiovascular risks in Chinese diabetic patients remains unclear. Here, we aimed to explore the impact of Roux-en-Y gastric bypass surgery (RYGB) on cardiovascular risks in Chinese diabetic patients with obesity.

METHODS

Twenty Chinese patients with T2DM and obesity undergoing RYGB surgery were included in this study. Cardiovascular risk factors were measured before and 18 months after surgery. A 10-year cardiovascular risk was calculated by the UKPDS risk engine. Linear regression analysis was performed on CHD risk, stroke risk, and baseline metabolic parameters.

RESULTS

The complete remission rate of diabetes was 90% after RYGB surgery, with significant improvements in blood pressure, BMI, glucose, and lipid metabolism (P < 0.05). The 10-year cardiovascular risk of coronary heart disease reduced from 13.05% to 3.81% (P = 0.001) and the 10-year risk of stroke reduced from 19.66% to 14.22% (P = 0.002). In subgroup analysis, Chinese diabetic patients who were women, <45 years old, with BMI < 35 kg/m², and DM duration > 5 years, using noninsulin therapy presented more obvious improvements in the 10-year cardiovascular risk after RYGB surgery. WHR, age, LDL-C, and HbA1c were the most important factors influencing CHD or stroke risk after RYGB surgery (P < 0.01).

CONCLUSION

RYGB surgery is an effective treatment to reduce cardiovascular risk in Chinese diabetic patients with obesity.

Clinical Update: Cardiovascular Disease in Diabetes Mellitus: Atherosclerotic Cardiovascular Disease and Heart Failure in Type 2 Diabetes Mellitus - Mechanisms, Management, and Clinical Considerations

Cardiovascular disease remains the principal cause of death and disability among patients with diabetes mellitus. Diabetes mellitus exacerbates mechanisms underlying atherosclerosis and heart failure. Unfortunately, these mechanisms are not adequately modulated by therapeutic strategies focusing solely on optimal glycemic control with currently available drugs or approaches. In the setting of multifactorial risk reduction with statins and other lipid-lowering agents, antihypertensive therapies, and antihyperglycemic treatment strategies, cardiovascular complication rates are falling, yet remain higher for patients with diabetes mellitus than for those without. This review considers the mechanisms, history, controversies, new pharmacological agents, and recent evidence for current guidelines for cardiovascular management in the patient with diabetes mellitus to support evidence-based care in the patient with diabetes mellitus and heart disease outside of the acute care setting.

Clinical Outcomes of Metabolic Surgery: Microvascular and Macrovascular Complications

Understanding of the long-term clinical outcomes associated with bariatric surgery has recently been advanced. Research related to the sequelae of diabetes-in particular, long-term microvascular and macrovascular complications-in patients who undergo weight-loss surgery is imperative to this pursuit. While numerous randomized control trials have assessed glucose control with bariatric surgery compared with intensive medical therapy, bariatric surgery outcome data relating to microvascular and macrovascular complications have been limited to observational studies and nonrandomized clinical trials. As a result, whether bariatric surgery is associated with a long-term reduction in microvascular and macrovascular complications when compared with current intensive glycemic control therapy cannot be determined because the evidence is insufficient. However, the consistent salutary effects of bariatric surgery on diabetes remission and glycemic improvement support the opportunity (and need) to conduct high-quality studies of bariatric surgery versus intensive glucose control. This review provides relevant background information related to the treatment of diabetes, hyperglycemia, and long-term complications; reports clinical findings (to date) with bariatric surgery; and identifies ongoing research focusing on long-term vascular outcomes associated with bariatric surgery.

Bariatric surgery outcomes: a single-center study in the United Arab Emirates

BACKGROUND

Bariatric surgery has become an attractive treatment for severe obesity over the last decade, due to its impacts on weight loss and remission of type 2 diabetes and metabolic syndrome. In the United Arab Emirates, a country where the rate of obesity is dramatically increasing bariatric surgery has gained popularity in recent years; however, published data on its outcomes in the Emirati population are lacking.

METHODS

We retrospectively reviewed the medical records of 95 patients who underwent bariatric surgery (ie, laparoscopic Roux-en-Y gastric bypass [RYGB] or laparoscopic sleeve gastrectomy) at the Rashid Center for Diabetes and Research in Ajman, United Arab Emirates. Weight outcomes and metabolic marker data were abstracted at baseline and at 3, 6, and 12 months postoperatively.

RESULTS

Laparoscopic RYGB was the main procedure performed by our bariatric unit. All variables demonstrated postoperative improvement. An average excess weight loss of 68% was observed at 12 months. Fat mass was the body component that decreased the most, with an average reduction of 46%. Additionally, lipid profiles were significantly different (P<0.01) at 12 months, with triglyceride levels improving by 27% and low-density lipoprotein levels improving by 21%. Similarly, glycated hemoglobin (HbA1c) levels decreased significantly (P<0.001) in patients with type 2 diabetes, with an average reduction of 73%.

CONCLUSION

Our results show that a substantial short-term reduction in weight and significant improvements in metabolic markers followed bariatric surgery in severely obese Emirati patients. Our results are consistent with the outcomes of other internationally published studies. Additional studies are warranted to determine whether the favorable impacts of bariatric surgery can be sustained over the long term.

Gastrointestinal intervention ameliorates high blood pressure through antagonizing overdrive of the sympathetic nerve in hypertensive patients and rats

Background

We investigated the hypothesis that the favorable effects of gastrointestinal (GI) intervention on hypertension (HTN) and cardiovascular (CV) disturbances are mediated by antagonizing overdrive of the sympathetic nervous system (SNS).

Methods and Results

Hypertensive patients with metabolic disturbances underwent laparoscopic Roux‐en‐Y gastric bypass surgery, and spontaneously hypertensive rats (SHRs) underwent RYGB or sham surgery. Blood pressure (BP), heart rate (HR), endothelium‐dependent flow‐mediated dilation, and anthropometric as well as laboratory parameters were measured at baseline and during follow‐up. Changes of BP and HR in response to cold stress, renal sympathetic nervous activity (RSNA), vasoconstriction induced by electrical field stimulation, microinjection of nucleus of the solitary tract (NTS), and CV function and structure were examined in SHRs with or without surgery. Compared with baseline, BP and HR were significantly reduced in both hypertensive patients with type 2 diabetes and rats. Impaired endothelial‐dependent vasodilatation and metabolic disturbances in hypertensive patients were also ameliorated after surgery. CV disturbances were reversed by surgery in SHRs. Under acute cold exposure, the variations in BP and HR were smaller in surgically treated SHRs, compared to sham SHRs. RSNA and vasoconstriction induced by perivascular nerve stimulation as well as NTS‐mediated changes of BP were decreased in surgically treated SHRs, compared to sham SHR. Weight loss did not affect BP and RSNA in sham SHRs.

Conclusions

GI intervention ameliorates HTN in both hypertensive patients and rats by inhibiting overdrive of the SNS. Therefore, targeting gastrointestine could be a novel strategy to treat HTN with metabolic disturbances.

Reduction in Framingham risk of cardiovascular disease in obese patients undergoing laparoscopic adjustable gastric banding

Background

Obesity is a major risk factor for cardiovascular disease (CVD), with weight loss offering improvement in CVD risk factors.

Aims

To examine whether weight loss in laparoscopic adjustable gastric band (LAGB)-treated obese patients is associated with meaningful reductions in estimated 10- and 30- year Framingham CVD risk 12–15 months post-LAGB.

Methods

Obese adult patients [body mass index (BMI) ≥30 kg/m²] treated with LAGB were identified in a large US healthcare database. Patients without CVD at baseline and with measures of BMI, systolic blood pressure, diabetes, and smoking status at baseline and follow-up were eligible. Non-LAGB patients were propensity score matched to LAGB patients on baseline BMI, age, and gender. Estimated 10- and 30-year risk of developing CVD using office-based data, including BMI, was calculated at baseline and 12–15 months follow-up.

Results

Mean BMI in LAGB patients (n = 647, average age 45.66 years, 81.1% female) decreased from 42.7 to 33.4 kg/m² (P < 0.0001), with 35.4% no longer obese; 10- and 30-year estimated CVD risk decreased from 10.8 to 7.6% (P < 0.0001) and 44.34 to 32.30% (P < 0.0001), respectively, 12–15 months post-LAGB. Improvements were significantly greater than in non-LAGB patients (N = 4,295) (P < 0.0001). In the subset with lipid data (n = 74), improvements in total (−20.6 mg/dL; P < 0.05) and high-density lipoprotein (+10.6 mg/dL, P < 0.0001) cholesterol 1 year post-LAGB were also observed.

Conclusions

Data from a US healthcare database show that individuals undergoing LAGB have significant weight loss and reductions in estimated 10- to 30-year CVD risk within 1 year post-LAGB.

Bariatric surgery for adolescents

Obesity is no longer just an adult disease. An increasing number of youth are overweight, defined as body mass index (BMI) at or greater than the 95th percentile for age (1). Between 2009 and 2010, 16.9% of children aged 2–19 yr were classified as overweight based on BMI (2), as compared with only 5% of children affected by obesity in 1976–1980 (3). This is a problem of enormous proportion from a public health standpoint, as without intervention these children will grow up to become overweight and obese adults. For an obese child, the risk of becoming an obese adult may be as high as 77%, compared with 7%for a child of healthy weight (4). Morbid obesity is a major risk factor for later complications such as cardiovascular disease, type 2 diabetes, obstructive sleep apnea (OSA), polycystic ovary syndrome (PCOS), and degenerative joint disease (4–10). Obesity is also an expensive problem: the US government spends $147 billion yearly on obesity-related healthcare costs (11). Thus, there is an urgent need to target obesity in the pediatric population, before the expensive and life-threatening consequences of obesity manifest. Unfortunately, the effectiveness of medical treatments for obesity is limited. Behaviorally based dietary and physical activity interventions offer little benefit for pediatric obesity, while pharmacologic therapy is also limited and carries low success rates and recidivism (12–14) (Table 1).

A multisite study of long-term remission and relapse of type 2 diabetes mellitus following gastric bypass

BACKGROUND

Gastric bypass has profound effects on glycemic control in adults with type 2 diabetes mellitus. The goal of this study was to examine the long-term rates and clinical predictors of diabetes remission and relapse among patients undergoing gastric bypass.

METHODS

We conducted a retrospective cohort study of adults with uncontrolled or medication-controlled type 2 diabetes who underwent gastric bypass from 1995 to 2008 in three integrated health care delivery systems in the USA. Remission and relapse events were defined by diabetes medication use and clinical laboratory measures of glycemic control. We identified 4,434 adults with uncontrolled or medication-controlled type 2 diabetes who had gastric bypass.

RESULTS

Overall, 68.2 % (95 % confidence interval [CI], 66 and 70 %) experienced an initial complete diabetes remission within 5 years after surgery. Among these, 35.1 % (95 % CI, 32 and 38 %) redeveloped diabetes within 5 years. The median duration of remission was 8.3 years. Significant predictors of complete remission and relapse were poor preoperative glycemic control, insulin use, and longer diabetes duration. Weight trajectories after surgery were significantly different for never remitters, relapsers, and durable remitters (p = 0.03).

CONCLUSIONS

Gastric bypass surgery is associated with durable remission of type 2 diabetes in many but not all severely obese diabetic adults, and about one third experience a relapse within 5 years of initial remission. More research is needed to understand the mechanisms of diabetes relapse, the optimal timing of surgery in effecting a durable remission, and the relationship between remission duration and incident microvascular and macrovascular events.

Advances in the surgical treatment of morbid obesity

Due to the rapidly expanding prevalence of obesity, bariatric surgery is becoming an increasingly popular treatment option. Bariatric surgeries including Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) produce long-term weight loss and metabolic improvement, reducing mortality. This review discusses the important benefits and risks of RYGB and VSG, highlighting hypothesized mechanisms for these effects. We present data suggesting that VSG, albeit a newer procedure, may be as effective as RYGB with fewer adverse effects including less surgical risk, reduced nutritional deficiency, and less incidence of dumping syndrome. This may position VSG as an increasingly important procedure, particularly for the treatment of pediatric obesity.

Preliminary outcomes of laparoscopic sleeve gastrectomy in a Veterans Affairs medical center

BACKGROUND

Preliminary results of a new bariatric surgery program in a VA Medical Center using laparoscopic sleeve gastrectomy (LSG).

METHODS

Prospective review of the first 50 patients who underwent LSG. Percentage change in body mass index (BMI), comorbidities, serum glucose, glycosylated hemoglobin (HbA1c), lipid profiles, and medications were recorded.

RESULTS

Mean age was 52 years. Average BMI was 46 kg/m(2). There were no mortalities or staple line leaks. The percentage excess BMI loss was 47% and 54% at 6 and 12 months, respectively. After 6 months, fasting glucose level decreased from 127 to 93 mg/dL, and mean glycosylated hemoglobin decreased from 6.8% to 5.7%. At 1-year follow-up evaluation, serum cholesterol decreased from 182 to 168 mg/dL, mean triglycerides from 179 to 93 mg/dL, low-density lipoprotein from 110 to 94 mg/dL, and high-density lipoprotein increased from 42 to 50 mg/dL.

CONCLUSIONS

Laparoscopic sleeve gastrectomy is safe and effective for morbidly obese VA patients and resulted in significant discontinuation of medication for hypertension, diabetes and hyperlipidemia.

Effect of bariatric surgery on cardiovascular risk profile

Obesity is associated with increased risk for cardiovascular (CV) disease (CVD) and CV mortality. Bariatric surgery has been shown to resolve or improve CVD risk factors, to varying degrees. The objective of this systematic review was to determine the impact of bariatric surgery on CV risk factors and mortality. A systematic review of the published research was performed to evaluate evidence regarding CV outcomes in morbidly obese bariatric patients. Two major databases (PubMed and the Cochrane Library) were searched. The review included all original reports reporting outcomes after bariatric surgery, published in English, from January 1950 to July 2010. In total, 637 studies were identified from the initial screen. After applying inclusion and exclusion criteria, 52 studies involving 16,867 patients were included (mean age 42 years, 78% women). The baseline prevalence of hypertension, diabetes, and dyslipidemia was 49%, 28%, and 46%, respectively. Mean follow-up was 34 months (range 3 to 155), and the average excess weight loss was 52% (range 16% to 87%). Most studies reported significant decreases postoperatively in the prevalence of CV risk factors, including hypertension, diabetes, and dyslipidemia. Mean systolic pressure reduced from to 139 to 124 mm Hg and diastolic pressure from 87 to 77 mm Hg. C-reactive protein decreased, endothelial function improved, and a 40% relative risk reduction for 10-year coronary heart disease risk was observed, as determined by the Framingham risk score. In conclusion, this review highlights the benefits of bariatric surgery in reducing or eliminating risk factors for CVD. It provides further evidence to support surgical treatment of obesity to achieve CVD risk reduction.

Laparoscopic sleeve gastrectomy and laparoscopic gastric bypass are equally effective for reduction of cardiovascular risk in severely obese patients at one year of follow-up

BACKGROUND

Very few studies have compared laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) outcomes or analyzed improvement in cardiovascular risk (CVR) after bariatric surgery. None of the studies considered the Mediterranean population. Our primary objective was to compare the 10-year estimated CVR reduction achieved by LRYGB and LSG in Spanish subjects with severe obesity. The secondary objectives were to compare the techniques in terms of weight loss and co-morbidity improvement. The study was performed at a university hospital in Barcelona, Spain.

METHODS

A 12-month prospective cohort study of 140 consecutive patients (95 LRYGB and 45 LSG) compared the 2 surgical intervention groups to study the percentage of excess weight loss, resolution and improvement/resolution of co-morbidities, and effect on CVR using both the Framingham risk score (FRS) and the Registre Gironí del Cor (REGICOR) model.

RESULTS

At 12 months, the overall CVR decreased from 6.6% to 3.4% using the FRS and from 3.7% to 1.9% using the REGICOR score. Neither model found a difference between the 2 surgical intervention groups in decreased postoperative CVR risk, with a FRS of 3.4% ± 2.2% for LRYGB versus 3.3% ± 2.1% for LSG (P = .872) and a REGICOR score of 1.9% ± 1.5% versus 1.8% ± 1.6%, respectively (P = .813). No differences were observed in the percentage of excess weight loss or the resolution of type 2 diabetes mellitus and hypertension. The hypercholesterolemia improvement/resolution rate was lower in the LSG group than in the LRYGB group.

CONCLUSION

Bariatric surgery reduces the estimated CVR by one half at 1 year after surgery. Except for the less-improved cholesterol metabolism, LSG, a restrictive technique, proved to be equally as effective at 1 year of follow-up as LRYGB.

Effects of weight loss, induced by gastric bypass surgery, on HDL remodeling in obese women

Plasma lipoproteins and glucose homeostasis were evaluated after marked weight loss before and over 12 months following Roux-en-Y gastric-bypass (RYGBP) surgery in 19 morbidly obese women. Standard lipids, remnant-lipoprotein cholesterol (RLP-C); HDL-triglyceride (TG); apolipoproteins (apo) A-I, A-II, E, and A-I-containing HDL subpopulations; lecithin-cholesterol acyltransferase (LCAT) and cholesteryl ester transfer protein (CETP) mass and activity; plasma glucose and insulin levels were measured before and at 1, 3, 6, and 12 months after GBP surgery. Baseline concentrations of TG, RLP-C, glucose, and insulin were significantly higher in obese than in normal-weight, age-matched women, whereas HDL cholesterol (HDL-C), apoA-I, apoA-II, alpha-1 and alpha-2 levels were significantly lower. Over 1 year, significant decreases of body mass index, glucose, insulin, TG, RLP-C, HDL-TG, and prebeta-1 levels were observed with significant increases of HDL-C and alpha-1 levels (all P < 0.05). Changes of fat mass were correlated with those of LDL cholesterol (P = 0.018) and LCAT mass (P = 0.011), but not with CETP mass (P = 0.265). Changes of fasting plasma glucose concentrations were inversely correlated with those of CETP mass (P = 0.005) and alpha-1 level (P = 0.004). Changes of fasting plasma insulin concentrations were positively correlated with those of LCAT mass (P = 0.043) and inversely with changes of alpha-1 (P = 0.03) and alpha-2 (P = 0.05) concentrations. These results demonstrate beneficial changes in HDL remodeling following substantial weight loss induced by RYGBP surgery and that these changes are associated with improvement of glucose homeostasis in these patients.

One year improvements in cardiovascular risk factors: a comparative trial of laparoscopic Roux-en-Y gastric bypass vs. adjustable gastric banding

BACKGROUND

Coronary artery disease (CAD) is the leading cause of death in the industrialized world with obesity as a leading preventable risk factor. Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) have been shown to improve certain biochemical cardiovascular risk factors (BCRFs) at 1 year post-op, however no study has directly compared the 12-month BCRF improvements of RYGB vs. LAGB.

METHODS

At a single academic institution (2004-2009), we measured BCRF in 838 consecutive bariatric patients (765 RYGB, 73 LAGB) pre-operatively and at 12 months post-operatively. BCRF included total cholesterol (TC), low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides (Trig), Trig/HDL ratio, lipoprotein(a) (Lp(a)), homocysteine (HmC), high sensitivity C-reactive protein (hs-CRP), fasting insulin (FI), and hemoglobin A1C (Hgb A1C). Pre-op and 12-month post-op values were compared by a paired t test of equal variance.

RESULTS

At 12 months post-op, RYGB patients had lost 77% of their excess weight and had significant improvements in TC, LDL, HDL, Trig, Trig/HDL, HmC, hs-CRP, FI, and Hgb A1C. LAGB patients lost 47.6% of their excess weight and had significant improvements in Trig, Trig/HDL, HmC, hs-CRP, and Hgb A1C. Having RYGB instead of LAGB was predictive of significantly greater improvements in TC at 12 months post-operatively.

CONCLUSIONS

In this study, both RYGB and LAGB demonstrated significant weight loss and improvements in BCRF at 12 months post-op. RYGB produced significant improvements in a greater number of BCRFs and in some instances the 12-month post-op BCRF values were significantly lower risk in RYGB vs. LAGB patients.

Nonalcoholic fatty liver disease and cardiovascular risk

Nonalcoholic fatty liver disease (NAFLD) is a very common cause of chronic liver disease in the United States. A large proportion of patients with NAFLD have coexisting metabolic syndrome, a major risk factor for cardiovascular disease. A strong association between NAFLD and cardiovascular disease has been long suspected, and recent studies have confirmed that cardiovascular disease is the single most important cause of mortality in this patient population. NAFLD may pose cardiovascular risk beyond the risk conferred by traditional factors such as dyslipidemia, diabetes, and smoking. Health care providers managing patients with NAFLD should recognize this increased cardiovascular risk and should undertake early, aggressive risk factor modification.