Roux-En-Y Gastric Bypass Vs. Sleeve Gastrectomy: Balancing the Risks of Surgery with the Benefits of Weight Loss

Challenges of Revisional Metabolic and Bariatric Surgery: A Comprehensive Guide to Unraveling the Complexities and Solutions of Revisional Bariatric Procedures

Revisional metabolic and bariatric surgery (RMBS) presents unique challenges in addressing weight loss failure or complications arising from initial bariatric procedures. This review aims to explore the complexities and solutions associated with revisional bariatric procedures comprehensively, offering insights into the evolving terrain of metabolic and bariatric surgery. A literature review is conducted to identify pertinent studies and expert opinions regarding RMBS. Methodological approaches, patient selection criteria, surgical techniques, preoperative assessments, and postoperative management strategies are synthesized to provide a comprehensive overview of current practices and advancements in the field, including institutional protocols. This review synthesizes key findings regarding the challenges encountered in RMBS, including the underlying causes of primary procedure failure, anatomical complexities, technical considerations, and assessments of surgical outcomes. Additionally, patient outcomes, complication rates, and long-term success are presented, along with institutional approaches to patient assessment and procedure selection. This review provides valuable insights for clinicians grappling with the complexities of RMBS. A comprehensive understanding of patient selection, surgical techniques, preoperative management, and postoperative care is crucial for enhancing outcomes and ensuring patient satisfaction in the field of metabolic bariatric surgery.

Influence of Bariatric Surgery on Gut Microbiota Composition and Its Implication on Brain and Peripheral Targets

Obesity remains a significant global health challenge, with bariatric surgery remaining as one of the most effective treatments for severe obesity and its related comorbidities. This review highlights the multifaceted impact of bariatric surgery beyond mere physical restriction or nutrient malabsorption, underscoring the importance of the gut microbiome and neurohormonal signals in mediating the profound effects on weight loss and behavior modification. The various bariatric surgery procedures, such as Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), act through distinct mechanisms to alter the gut microbiome, subsequently impacting metabolic health, energy balance, and food reward behaviors. Emerging evidence has shown that bariatric surgery induces profound changes in the composition of the gut microbiome, notably altering the Firmicutes/Bacteroidetes ratio and enhancing populations of beneficial bacteria such as Akkermansia. These microbiota shifts have far-reaching effects beyond gut health, influencing dopamine-mediated reward pathways in the brain and modulating the secretion and action of key gut hormones including ghrelin, leptin, GLP-1, PYY, and CCK. The resultant changes in dopamine signaling and hormone levels contribute to reduced hedonic eating, enhanced satiety, and improved metabolic outcomes. Further, post-bariatric surgical effects on satiation targets are in part mediated by metabolic byproducts of gut microbiota like short-chain fatty acids (SCFAs) and bile acids, which play a pivotal role in modulating metabolism and energy expenditure and reducing obesity-associated inflammation, as well as influencing food reward pathways, potentially contributing to the regulation of body weight and reduction in hedonic eating behaviors. Overall, a better understanding of these mechanisms opens the door to developing non-surgical interventions that replicate the beneficial effects of bariatric surgery on the gut microbiome, dopamine signaling, and gut hormone regulation, offering new avenues for obesity treatment.

Comparative evaluation of early diabetic outcomes in southeast asian patients with type 2 diabetes mellitus undergoing Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (LSG)

Obesity and type 2 diabetes mellitus (T2DM) is an alarming problem globally and a growing epidemic. Metabolic surgery has been shown to be successful in treating both obesity and T2DM, usually after other treatments have failed. This study aims to compare Roux-Y gastric bypass and sleeve gastrectomy in determining early diabetic outcomes in obese Malaysian patients with T2DM following surgery. A total of 172 obese patients with T2DM who were assigned to either laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were analysed up to a year post-procedure. The patients' T2DM severity were stratified using the Individualized Metabolic Surgery (IMS) score into mild, moderate and severe. Remission rates of diabetes were compared between surgical techniques and within diabetic severity categories. T2DM remission for patients who underwent either surgical technique for mild, moderate or severe disease was 92.9%, 56.2% and 14.7% respectively. Both surgical techniques improved T2DM control for patients in the study. Comparing baseline with results 1 year postoperatively, median HbA1c reduced from 7.40% (IQR 2.60) to 5.80% (IQR 0.80) (p < 0.001), mean total antidiabetic medications use reduced from 1.48 (SD 0.99) to 0.60 (SD 0.86) [p < 0.001], insulin usage reduced from 27.9 to 10.5% (p < 0.001), and T2DM control improved from 27.9 to 82% (p < 0.001). The patients had a median excess BMI loss of 69.4% (IQR 34%) and 53.2% (IQR 36.0%) for RYGB and SG respectively (p = 0.016). At one year following surgery, there is no difference between LRYGB and LSG in terms of diabetic remission. LSG is not inferior to LRYGB in terms of early diabetic outcomes. Milder T2DM shows a better response. LSG is a simpler procedure with a lower risk profile and should be considered as an early treatment option for obese patients with T2DM.

Impact of Nonalcoholic Fatty Liver Disease (NAFLD) on Weight Loss After Bariatric Surgery

OBJECTIVE

Obesity and associated comorbidities, such as NAFLD, impose a major healthcare burden worldwide. Bariatric surgery remains the most successful approach for sustained weight loss and the resolution of obesity-related complications. However, the impact of preexisting NAFLD on weight loss after bariatric surgery has not been previously studied. The goal of this study is to assess the impact of preexisting NAFLD on weight loss outcomes up to 5 years after weight loss surgery.

RESEARCH DESIGN AND METHODS

Data from the Michigan Bariatric Surgery Cohort (MI-BASiC) was extracted to examine the effect of baseline NAFLD on weight loss outcomes. The cohort included a total of 714 patients older than 18 years of age undergoing gastric bypass (GB; 380 patients) or sleeve gastrectomy (SG; 334 patients) at the University of Michigan between January 2008 and November 2013. Repeated measure analysis was used to determine if preexisting NAFLD was a predictor of weight loss outcomes up to 5 years post-surgery.

RESULTS

We identified 221 patients with an established clinical diagnosis of NAFLD at baseline. Multivariable repeated measure analysis with adjustment for covariates shows that patients with preexisting NAFLD had a significantly lower percentage of total and excess weight loss compared to patients without preexisting NAFLD. Furthermore, our data show that baseline dyslipidemia is an indicator of the persistence of NAFLD after bariatric surgery.

CONCLUSIONS

Our data show that patients' body weight loss in response to bariatric surgery is impacted by factors such as preexisting NAFLD. Additionally, we show that NAFLD may persist or recur in a subset of patients after surgery, and thus careful continued follow-up is recommended.

Sleeve gastrectomy facilitates weight loss and permits cardiac transplantation in patients with severe obesity and a left ventricular assist device (LVAD)

INTRODUCTION

Patients suffering from advanced heart failure may undergo left ventricular assist device (LVAD) placement as a bridge to cardiac transplantation. However, those with a BMI above 35 kg/m2 are generally not considered eligible for transplant due to their elevated cardiac risk. We review our experience with bariatric surgery in this high-risk population to assess its safety and efficacy in reducing BMI to permit cardiac transplantation.

METHODS

We retrospectively reviewed all patients on durable LVAD support who underwent sleeve gastrectomy (SG) at Mount Sinai Hospital between August 2018 and December 2022. Electronic medical records were reviewed to analyze patient demographics, surgical details, and outcomes regarding weight loss and heart transplantation.

RESULTS

We identified twelve LVAD patients who underwent SG. Three were performed laparoscopically and 9 via robotic approach. Four patients (33.3%) underwent an orthotopic heart transplant (OHTx). Half of these patients were female. For patients who underwent OHTx, mean age at LVAD placement was 41.0 (R30.6-52.2), at SG was 43.9 (R32.7-55.0) and at OHTx was 45.3 years (R33.3-56.8). Mean BMI increased from 38.8 at LVAD placement to 42.5 prior to SG. Mean time from SG to OHTx was 17.9 months (R6-7-27.5) during which BMI decreased to mean 32.8 at the time of OHTx. At most recent follow-up, mean BMI was 31.9. All patients were anticoagulated prior to surgery; one required return to the operating room on post-operative day 1 after SG for bleeding and one was re-admitted on post-operative day 7 for hematochezia treated conservatively.

CONCLUSION

SG is a safe and effective operation in patients with severe obesity and heart failure requiring an LVAD. 66.7% of our cohort achieved target BMI < 35 and 33.3% underwent heart transplantation. Longer term follow-up is needed to clarify full bridge-to-transplant rate and long-term survival outcomes.

Milestones in the journey towards addressing obesity; Past trials and triumphs, recent breakthroughs, and an exciting future in the era of emerging effective medical therapies and integration of effective medical therapies with metabolic surgery

The 21st century is characterized by an increasing incidence and prevalence of obesity and the burden of its associated comorbidities, especially cardiometabolic diseases, which are reaching pandemic proportions. In the late '90s, the "black box" of adipose tissue and energy homeostasis was opened with the discovery of leptin, transforming the adipose tissue from an "inert fat-storage organ" to the largest human endocrine organ and creating the basis on which more intensified research efforts to elucidate the pathogenesis of obesity and develop novel treatments were based upon. Even though leptin was eventually not proven to be the "standalone magic bullet" for the treatment of common/polygenic obesity, it has been successful in the treatment of monogenic obesity syndromes. Additionally, it shifted the paradigm of treating obesity from a condition due to "lack of willpower" to a disease due to distinct underlying biological mechanisms for which specific pharmacotherapies would be needed in addition to lifestyle modification. Subsequently, the melanocortin pathway proved to be an equally valuable pathway for the pharmacotherapy of obesity. Melanocortin receptor agonists have recently been approved for treating certain types of syndromic obesity. Other molecules- such as incretins, implicated in energy and glucose homeostasis- are secreted by the gastrointestinal tract. Glucagon-like peptide 1 (GLP-1) is the most prominent one, with GLP-1 analogs approved for common/polygenic obesity. Unimolecular combinations with other incretins, e.g., GLP-1 with gastric inhibitory polypeptide and/or glucagon, are expected to be approved soon as more effective pharmacotherapies for obesity and its comorbidities. Unimolecular combinations with other compounds and small molecules activating the receptors of these molecules are currently under investigation as promising future pharmacotherapies. Moreover, metabolic and bariatric surgery has also demonstrated impressive results, especially in the case of morbid obesity. Consequently, this broadening therapeutic armamentarium calls for a well-thought-after and well-coordinated multidisciplinary approach, for instance, through cardiometabolic expertise centers, that would ideally address effectively and cost-effectively obesity and its comorbidities, providing tangible benefits to large segments of the population.

A 5-year propensity-matched analysis of perioperative outcomes in patients with chronic kidney disease undergoing bariatric surgery

BACKGROUND

Bariatric surgery can improve renal function in patients with comorbid chronic kidney disease (CKD) and obesity. Additionally, bariatric surgery can enhance outcomes following renal transplantation. The safety of bariatric surgery in patients with CKD has been debated in the literature. This study evaluates the frequency of perioperative complications associated with CKD.

METHODS

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was queried from 2015-2019. Patients were included if they had a vertical sleeve gastrectomy (VSG) or Roux-en-Y gastric bypass (RYGB) and were stratified based on CKD status. An unmatched and propensity-matched analysis was performed comparing 30-day perioperative outcomes between the groups.

RESULTS

A total of 717,809 patients included in this study, 5817(0.8%) had CKD, of whom 2266(0.3%) were on dialysis. 74.3% of patients with CKD underwent VSG with 25.7% underwent RYGB. Comparing RYGB to VSG, patients who underwent RYGB had a higher rate of deep organ space infection (0.7%vs.0.1%,p = 0.021) and re-intervention (5.0% vs. 2.2%,p < 0.001). Within the VSG cohort, a matched analysis was performed for those with CKD and without CKD. The CKD cohort had higher risk of complications such as bleeding (2.1%vs. 0.9%,p < 0.001), readmission (9.3%vs.4.9%,p < 0.001), reoperation (2.7%vs.1.3%,p < 0.001), and need for reintervention (2.2%vs.1.3%,p < 0.001). Notably, patients with CKD also had a higher mortality (0.6%vs.0.2%,p = 0.003). No difference was seen between patients with renal insufficiency and patients on dialysis.

CONCLUSION

VSG has been the operation of choice in patients with CKD. Our results showed it is the safer option for patients with CKD compared to RYGB. Although this patient population does have an increased risk of adverse perioperative events, dialysis didn't affect the outcome. Bariatric surgeons who operate on patients with CKD should be well informed and remain vigilant given the increased perioperative risk. The risk is still considerably low, and the potential benefit on renal function and improvement in candidacy for renal transplant outweigh the risk. They should be considered as surgical candidates.

Finding balance: understanding the energetics of time-restricted feeding in mice

Over the course of mammalian evolution, the ability to store energy likely conferred a survival advantage when food became scarce. A long-term increase in energy storage results from an imbalance between energy intake and energy expenditure, two tightly regulated parameters that generally balance out to maintain a fairly stable body weight. Understanding the molecular determinants of this feat likely holds the key to new therapeutic development to manage obesity and associated metabolic dysfunctions. Time-restricted feeding (TRF), a dietary intervention that limits feeding to the active phase, can prevent and treat obesity and metabolic dysfunction in rodents fed a high-fat diet, likely by exerting effects on energetic balance. Even when body weight is lower in mice on active-phase TRF, food intake is generally isocaloric as compared with ad libitum fed controls. This discrepancy between body weight and energy intake led to the hypothesis that energy expenditure is increased during TRF. However, at present, there is no consensus in the literature as to how TRF affects energy expenditure and energy balance as a whole, and the mechanisms behind metabolic adaptation under TRF are unknown. This review examines our current understanding of energy balance on TRF in rodents and provides a framework for future studies to evaluate the energetics of TRF and its molecular determinants.

Hiatal reconstruction is safe and effective for control of reflux after laparoscopic sleeve gastrectomy

Background

Gastroesophageal reflux is a known complication following laparoscopic sleeve gastrectomy (LSG) as anatomical changes predispose to reduced lower esophageal sphincter pressure and development of hiatus hernia. The mainstay of surgical management has been Roux-en-Y gastric bypass (RYGB) which is not without risk. Hiatus hernia repair (HHR) with surgical reattachment of the oesophagus to the crura, recreating the phreno-esophageal ligament is a simple procedure specifically targeting a number of anatomical changes responsible for reflux in this population.

Methods

We conducted a single centre retrospective analysis of adult patients with post-sleeve reflux refractory to medical treatment, managed with either HHR, RYGB or One-anastomosis Duodenal switch (OADS). PPI use and symptoms of reflux were assessed at early and mid-term time points via validated questionnaires.

Results

99 patients were included, of these the surgical procedure was HHR alone in 58, RYGB in 29 and OADS in 12. At early follow-up control of reflux symptoms was achieved in 72.4% after HHR, 82.1% after RYGB and 100% after OADS with no significant difference between groups (p = 0.09). At mid-term followup (median 10 months IQR 7–21) there was no significant difference in the presence of symptomatic reflux as determined by post-op Visick score nor a difference in PPI use. The GerdQ score was significantly lower after OADS as compared to HHR and RYGB (4.6 ± 2.3 vs 7.7 ± 2.2 vs 8.7 ± 3.5, p = 0.006).

Conclusion

HHR with reconstruction of the phreno-esophageal ligament is a safe and effective procedure for patients with reflux after LSG, that avoids more complex operations such as RYGB and OADS and their associated long-term sequelae.

How safe is adolescent bariatric surgery? An analysis of short-term outcomes

BACKGROUND

The prevalence of childhood obesity in the U.S. has tripled over the last three decades. However, fewer than 1% of children with severe obesity undergo surgical weight loss interventions each year.

MATERIALS AND METHODS

All patients age 10 to 19 years old who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2015 through 2018 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were included in this retrospective cohort analysis. The primary outcomes were mortality and overall complications. Procedural trends, readmission and reoperation rates were also examined using a multivariate regression model.

RESULTS

Patients had a mean BMI of 47.3 kg/m² and 80.0% were either 18 or 19 years old (n = 4,051). There were two reported deaths. Reoperation within 30 days occurred in 1.1% of patients, readmission in 3.5%, and complications in 1.2%. Among all readmissions, primary reasons included nausea/vomiting or nutritional depletion (41.3%) and abdominal pain (16.3%). RYGB was associated with higher odds for readmission (p = 0.006) and complications (p = 0.005). Higher BMI and younger age were not associated with an increased likelihood to experience poorer outcomes. The proportion of patients undergoing SG increased yearly over RYGB from 73.9% in 2015 to 84.3% in 2018.

CONCLUSIONS

Bariatric surgery appears to be low risk for adolescents and SG has become the operation of choice. More research on early consideration of surgical therapy in adolescents with severe obesity is needed given the safety profile.

LEVEL OF EVIDENCE

III.

Bariatric Surgery With Roux-En-Y Gastric Bypass or Sleeve Gastrectomy for Treatment of Obesity and Comorbidities: Current Evidence and Practice

Background: With the growing prevalence of obesity in the global population, alternative measures for weight loss and treatment of comorbidities must be considered due to the increasing difficulty of conservative management alone. Here we discuss the benefits of bariatric surgery on weight loss as well comorbidities that are present in a majority of obese patients. 

Methods: In this review, we discuss the current practice and evidence of bariatric surgery as it pertains to weight loss and the beneficial effect on comorbidities commonly present in obesity.

Results: Our review found that bariatric surgery with either the roux-en-y gastric bypass or laparoscopic sleeve gastrectomy can result in weight loss of up to 80% of excess weight. We also found that bariatric surgery has a profound effect on multiple comorbidities such as type 2 diabetes mellitus, hypertension, and hyperlipidemia through remission of the disease.

Conclusion: Bariatric surgery serves as an efficacious alternative for treatment of obesity and comorbidities.

Kidney Transplantation in Patients After Bariatric Surgery: High-Volume Bariatric and Transplant Center Experience

BACKGROUND

Kidney transplantation (KTx) is the best type of treatment for patients with end-stage renal disease (ESRD). Unfortunately, obesity may be a contraindication for transplantation. Our study aimed to evaluate the results of KTx in patients who had bariatric surgery (BS) prior to transplantation.

METHODS

A single center, with experience in bariatric and transplant surgery, presents a retrospective study of 13 patients who received a kidney transplant after a gastric bypass (GB) operation between 2012 and 2019.

RESULTS

Thirteen patients, who were potential candidates for KTx, were previously qualified for BS because of a body mass index (BMI) > 35 kg/m². Additionally, all patients had arterial hypertension, 60% of patients had diabetes, and 30% of patients had coronary artery disease. Patients were activated on the waiting list when their BMI was < 35 kg/m². KTx was performed between 5 and 29 months after BS. One patient needed reoperation due to a urinary leak and another patient needed reoperation because of a high-pressure lymphocele. We diagnosed 2 delayed graft functions (DGFs) and 1 acute rejection. One patient died for reasons independent of surgery. The KTx observation period ranged from 3 to 8 years. Currently, 11 patients has stable renal function: creatinine concentration is 0.8-1.8 mg/dL and BMI is between 23 and 35 kg/m².

CONCLUSIONS

Despite the small group of patients, we can assume that kidney transplantation can be safely performed in patients with end-stage renal disease (ESRD) who have previously undergone gastric bypass (GB) as a graft bridging procedure. In some cases, BS may be the only chance of getting an organ.

Medication Use for Obesity-Related Comorbidities After Sleeve Gastrectomy or Gastric Bypass

IMPORTANCE

Sleeve gastrectomy and gastric bypass are the most common bariatric surgical procedures in the world; however, their long-term medication discontinuation and comorbidity resolution remain unclear.

OBJECTIVE

To compare the incidence of medication discontinuation and restart of diabetes, hypertension, and hyperlipidemia medications up to 5 years after sleeve gastrectomy or gastric bypass.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness research study of adult Medicare beneficiaries who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between January 1, 2012, to December 31, 2018, and had a claim for diabetes, hypertension, or hyperlipidemia medication in the 6 months before surgery with a corresponding diagnosis used instrumental-variable survival analysis to estimate the cumulative incidence of medication discontinuation and restart. Data analyses were performed from February to June 2021.

EXPOSURES

Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

MAIN OUTCOMES AND MEASURES

The primary outcome was discontinuation of diabetes, hypertension, and hyperlipidemia medication for any reason. Among patients who discontinued medication, the adjusted cumulative incidence of restarting medication was calculated up to 5 years after discontinuation.

RESULTS

Of the 95 405 patients included, 71 348 (74.8%) were women and the mean (SD) age was 56.6 (11.8) years. Gastric bypass compared with sleeve gastrectomy was associated with a slightly higher 5-year cumulative incidence of medication discontinuation among 30 588 patients with diabetes medication use and diagnosis at the time of surgery (74.7% [95% CI, 74.6%-74.9%] vs 72.0% [95% CI, 71.8%-72.2%]), 52 081 patients with antihypertensive medication use and diagnosis at the time of surgery (53.3% [95% CI, 53.2%-53.4%] vs 49.4% [95% CI, 49.3%-49.5%]), and 35 055 patients with lipid-lowering medication use and diagnosis at the time of surgery (64.6% [95% CI, 64.5%-64.8%] vs 61.2% [95% CI, 61.1%-61.3%]). Among the subset of patients who discontinued medication, gastric bypass was also associated with a slightly lower incidence of medication restart up to 5 years after discontinuation. Specifically, the 5-year cumulative incidence of medication restart was lower after gastric bypass compared with sleeve gastrectomy among 19 599 patients who discontinued their diabetes medication after surgery (30.4% [95% CI, 30.2%-30.5%] vs 35.6% [95% CI, 35.4%-35.9%]), 21 611 patients who discontinued their antihypertensive medication after surgery (67.2% [95% CI, 66.9%-67.4%] vs 70.6% [95% CI, 70.3%-70.9%]), and 18 546 patients who discontinued their lipid-lowering medication after surgery (46.2% [95% CI, 46.2%-46.3%] vs 52.5% [95% CI, 52.2%-52.7%]).

CONCLUSIONS AND RELEVANCE

Findings of this study suggest that, compared with sleeve gastrectomy, gastric bypass was associated with a slightly higher incidence of medication discontinuation and a slightly lower incidence of medication restart among patients who discontinued medication. Long-term trials are needed to explain the mechanisms and factors associated with differences in medication discontinuation and comorbidity resolution after bariatric surgery.

Effect of presurgical aerobic exercise on cardiometabolic health 30 days after bariatric surgery

We evaluated the effect of preoperative standard medical care (SC) vs. unsupervised aerobic exercise combined with SC (EX + SC) on cardiometabolic health and quality of life (QoL) 30 days after bariatric surgery. Bariatric patients (n = 14, age: 42.3 ± 2.5 years, body mass index: 45.1 ± 2.5 kg/m2 ) were match-paired to presurgical SC (n = 7) or EX + SC (n = 7; walking 30 min/day, 5 day/week, 65-85% HRpeak ) for 30 days. Body composition, peak cardiorespiratory fitness (VO2 peak), QoL, inflammation (adiponectin, leptin, cytokeratin-18), and a 120 min mixed meal tolerance test was performed to assess aortic waveforms (augmentation index, AIx@75), insulin sensitivity, and glucose total area under the curve (tAUC) at the time of surgery (post-intervention) and 30 days post-surgery. EX + SC had significantly higher high molecular weight (HMW) adiponectin (p = 0.01) and ratio of HMW to total adiponectin (p = 0.04) than SC at 30 days post-surgery, although they significantly (p = 0.006; ES = 1.86) decreased total time spent in moderate to vigorous physical activity (MVPA). SC had a significantly greater increase in VO2 peak (p = 0.02; ES = 1.54) and decrease in 120 min AIx@75 (p = 0.02; ES = 1.78) than EX + SC during the post-surgical period. The increase in MVPA was associated with a reduction in cytokeratin-18 (r = -0.67, p = 0.02). Increased VO2 peak was associated with increased activity/mobility QoL domain (r = 0.52, p = 0.05) and decreased 120 min AIx@75 (r = -0.61, p = 0.03) from surgery to post-surgery. Preoperative EX + SC did not maintain more favorable cardiometabolic health 30 days post-operation in this pilot study. However, changes in MVPA appear important for QoL and should be considered in future work.

Bariatric surgery induces morphological changes in the extensor digitorum longus muscle in the offspring of obese rats

INTRODUCTION

The effects of the maternal nutritional environment on the growth and metabolism of the offspring, and its impacts on health in adult life are defined as metabolic programming. Thus, the objective of this study was to evaluate the effects of Roux-en-Y gastric bypass (RYGB) on the morphology of muscle fiber and neuromuscular junction (NMJ) of the offspring of rats submitted to RYGB.

METHODS

Three-week-old Wistar rats were separated into two groups: 1) CAF SHAM which received a cafeteria diet and was submitted to a sham operation and 2) CAF RYGB, which received a cafeteria diet and was submitted to RYGB. The first generation (F1) offspring (male) was named according to the treatment of mothers as CAF SHAM-F1 and CAF RYGB-F1 and received a standard diet after weaning. At 17 weeks, the animals were euthanized, and the extensor digitorum longus muscle (EDL) was collected and processed in light microscopy and transmission electron microscopy for morphological and morphometric analysis.

RESULTS

The CAF RYGB-F1 group showed a reduction in the weight of the EDL muscle and also a reduction in the area of type I, IIa and IIb fibers and a nucleus/fiber ratio. This same group also showed an increase in the capillary density and myofibrillar disorganization and in the Z-line, as well as a reduction in the area of the NMJs.

CONCLUSION

The RYGB surgery in mothers produced morphological changes in the skeletal striated muscles of the offspring.

Characterizing Timing of Postoperative Complications Following Elective Roux-en-Y gastric Bypass and Sleeve Gastrectomy

Purpose

With the growing prevalence of bariatric procedures performed worldwide, it is important to understand the timing of postoperative complications following bariatric surgery and the differences which may exist between procedures.

Methods

This retrospective study was conducted using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry from 2017 to 2018. All patients with primary elective Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures were included. The primary outcome was to characterize the timing of postoperative complications for RYGB and SG.

Results

A total of 316,314 patients were identified with 237,066 (74.9%) in the SG cohort and 79,248 (25.1%) in the RYGB cohort. Early complications included myocardial infarction (4.7 ± 6.4 days), cardiac arrest (6.4 ± 8.5 days), pneumonia (6.9 ± 6.9 days), progressive renal insufficiency (8.1 ± 8.1 days), and acute renal failure (8.2 ± 7.6 days). Late complications included Clostridioides difficile infection (11.3 ± 7.8 days), organ space infections (11.7 ± 7.9 days), deep incisional infections (12.4 ± 6.6 days), superficial incisional infections (13.2 ± 6.9 days), and urinary tract infections (14.0 ± 8.4 days). SG patients were more likely to be diagnosed later than RYGB patients with regard to superficial incisional infections (14.0 ± 7.4 days vs 12.5 ± 6.3 days; p = 0.002), organ space infections (12.6 ± 7.8 days vs 10.8 ± 7.9 days; p = 0.001), acute renal failure (9.3 ± 8.1 days vs 6.8 ± 6.8 days; p = 0.03), and pulmonary embolism (13.7 ± 7.5 days vs 11.3 ± 8.0 days; p = 0.003). No significant difference in timing was observed for any other complication by procedures.

Conclusion

We demonstrate that significant differences in timing exist between complications and that these differences also vary by surgical procedure.

Graphical abstract

Centile Charts for Monitoring of Weight Loss Trajectories After Bariatric Surgery in Asian Patients

BACKGROUND

Following bariatric surgery, accurate charting of weight loss and regain is crucial. Various preoperative factors affect postoperative weight loss, including age, sex, ethnicity, and surgical type. These are not considered by current weight loss metrics, limiting comparison of weight loss outcomes between patients or centers and across time.

METHODS

Patients (n=1022) who underwent sleeve gastrectomy (n=809) and gastric bypass (n=213) from 2008 to 2020 in a single center were reviewed. Weight loss outcomes (% total weight loss) were measured for 60 months postoperatively. Longitudinal centile lines were plotted using the post-estimation predictions of quantile regression models, adjusted for type of procedure, sex, ethnicity, and baseline BMI.

RESULTS

Median regression showed that %TWL was 1.0% greater among males than females (β = +1.1, 95% CI: +0.6 to +1.7, P = <0.0001). Participants who underwent SG had less %TWL compared to GB (β = -1.3, 95% CI: -1.9 to -0.8, P < 0.0001). There was a trend towards less %TWL among the Indian and Malay participants compared to Chinese. Age and diabetes were not significant predictors. Reference centile charts were produced for the overall cohort, as well as specific charts adjusted for type of bariatric procedure, sex, ethnicity, and baseline BMI.

CONCLUSION

Centile charts provide a clinically relevant method for monitoring of weight trajectories postoperatively and aid in realistic and personalised goal setting, and the early identification of "poor responders". This is the first study to present post-bariatric surgery centile charts for an Asian cohort.

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.

Orosensory Perception of Fat/Sweet Stimuli and Appetite-Regulating Peptides before and after Sleeve Gastrectomy or Gastric Bypass in Adult Women with Obesity

The aim of this study was to explore the impact of bariatric surgery on fat and sweet taste perceptions and to determine the possible correlations with gut appetite-regulating peptides and subjective food sensations. Women suffering from severe obesity (BMI > 35 kg/m2) were studied 2 weeks before and 6 months after a vertical sleeve gastrectomy (VSG, n = 32) or a Roux-en-Y gastric bypass (RYGB, n = 12). Linoleic acid (LA) and sucrose perception thresholds were determined using the three-alternative forced-choice procedure, gut hormones were assayed before and after a test meal and subjective changes in oral food sensations were self-reported using a standardized questionnaire. Despite a global positive effect of both surgeries on the reported gustatory sensations, a change in the taste sensitivity was only found after RYGB for LA. However, the fat and sweet taste perceptions were not homogenous between patients who underwent the same surgery procedure, suggesting the existence of two subgroups: patients with and without taste improvement. These gustatory changes were not correlated to the surgery-mediated modifications of the main gut appetite-regulating hormones. Collectively these data highlight the complexity of relationships between bariatric surgery and taste sensitivity and suggest that VSG and RYGB might impact the fatty taste perception differently.

Primary laparoscopic sleeve gastrectomy versus gastric bypass: a propensity-matched comparison of 30-day outcomes

BACKGROUND

Bariatric surgery is the most effective treatment for obesity. There is uncertainty regarding rates of adverse outcomes between the most common methods: laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG).

OBJECTIVES

To compare rates of readmission, reoperation, intervention, unplanned intensive care unit (ICU) admission, all-cause and procedure-related mortality, and postoperative complications at 30 days between LRYGB and LSG.

SETTING

Retrospective, observational, multicenter registry.

METHODS

We identified 611,619 patients from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data registry between January 1, 2015, and December 31, 2018 (447,326 [73.1%] LSG; 164,293 [26.9%] LRYGB).

RESULTS

Adverse events were more common after LRYGB (readmission: 3% with LSG versus 5.9% with LRYGB [P < .001; odds ratio {OR}, LSG/LRYGB = .489]; intervention: .9% with LSG versus 2.4% with LRYGB [P < .001; OR, LSG/LRYGB = .357]; reoperation: .8% with LSG versus 2.3% with LRYGB [P < .001; OR, LSG/LRYGB = .363]; unplanned ICU admission: .52% with LSG versus 1.1% with LRYGB [P < .001; OR, LSG/LRYGB = .454]; all-cause mortality: .07% with LSG versus .15% with LRYGB [P < .001; OR, LSG/LRYGB = .489]; procedure-related mortality: .04% with LSG versus .08% with LRYGB [P < .001; OR, LSG/LRYGB = .446]; Clavien-Dindo I: .20% with LSG versus .63% with LRYGB [P < .001; OR, LSG/LRYGB = .317]; Clavien-Dindo II: .70% with LSG versus 1.3% with LRYGB [P < .001; OR, LSG/LRYGB = .527]; Clavien-Dindo III: 3.3% with LSG versus 6.6% with LRYGB [P < .001; OR, LSG/LRYGB = .481]; Clavien-Dindo IV: .36% with LSG versus .76% with LRYGB [P < .001; OR, LSG/LRYGB = .466]; and Clavien-Dindo V: .07% with LSG versus .15% with LRYGB [P < .001; OR, LSG/LRYGB = .488]). Surgery type was among the strongest independent predictors of adverse events, and LRYGB conferred higher adjusted odds of all adverse outcomes (all-cause mortality: OR, LRYGB/LSG = 1.791 [P < .001]; procedure-related mortality: OR, LRYGB/LSG = 1.979 [P < .001]; readmission: OR, LRYGB/LSG = 1.921 [P < .001]; unplanned ICU admission: OR, LRYGB/LSG = 1.870 [P < .001]; intervention: OR, LRYGB/LSG = 2.662 [P < .001]; reoperation: OR, LRYGB/LSG = 2.646 [P < .001]; and Clavien-Dindo grade: OR, LRYGB/LSG = 2.007 [P < .001]).

CONCLUSION

The rates of 30-day adverse outcomes are lower after LSG compared with after LRYGB. LRYGB independently conferred increased odds of adverse outcomes compared with LSG, and surgery type was among the strongest predictors of adverse outcomes.

Regression of severe heart failure after combined left ventricular assist device placement and sleeve gastrectomy

Patients who suffer morbid obesity and heart failure (HF) present unique challenges. Two cases are described where concomitant use of laparoscopic sleeve gastrectomy (LSG) and left ventricular assist device (LVAD) placement enabled myocardial recovery and weight loss resulting in explantation. A 29‐year‐old male patient with a body mass index (BMI) of 59 kg/m² and severe HF with a left ventricular ejection fraction (LVEF) of 20–25% underwent concomitant LSG and LVAD placement. Sixteen months after surgery, his BMI was reduced to 34 kg/m² and his LVEF improved to 50–55%. A second 41‐year‐old male patient with a BMI of 44.8 kg/m² with severe HF underwent the same procedures. Twenty‐four months later, his BMI was 31.1 kg/m² and his LVEF was 50–55%. In both cases, the LVAD was successfully explanted and patients remain asymptomatic. HF teams should consult and collaborate with bariatric experts to determine if LSG may improve the outcomes of their HF patients.

Bariatric surgery outcomes in Medicare beneficiaries

Background

The Medicare population is increasing while the prevalence of obesity remains high. Bariatric surgery is the most efficacious treatment of obesity and its comorbidities. The objective of this investigation was to assess trends in utilization, readmission, mortality, and cost of bariatric surgery in the Medicare population.

Methods

Utilizing the Medicare Provider Analysis and Review database, patients with clinically severe obesity undergoing laparoscopic Roux‐en‐Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB) from 2011–2015 were identified. Trends in procedure selection, readmissions, mortality, and cost were examined. A multivariable logistic regression analysis to evaluate factors associated with readmission and mortality was performed.

Results

Of the 73,718 patients identified, 53,949 (73%) of patients were enrolled in Medicare due to disability, 19,191 (26%) due to age, and 578 (<1%) due to end stage renal disease (ESRD). Utilization of SG increased (1% in 2011 to 61% in 2015), while utilization of RYGB (68% to 32%) and LAGB (31% to 1%) decreased. Length of stay (LOS) was highest after RYGB (2.54 days), and lowest after LAGB (1.32 days). LOS decreased from 2.23 days in 2011 to 2.12 days in 2015. Thirty‐day readmissions were 8.24% for the disabled, 5.5% for the elderly, 12.8% with ESRD. Odds of readmission increased with black race, higher body mass index (BMI), and RYGB. Readmission decreased from 8% in 2011 to 7% in 2015. Thirty‐day mortality was 0.22% in the disabled, and 0.28% in the elderly. Odds of 30‐day mortality increased among men, those with higher BMI, some comorbidities, and those who underwent RYGB. Cost of SG decreased while cost of RYGB increased.

Conclusions

Among the Medicare population, an increase in SG while a decrease in RYGB and LAGB utilization was noted from 2011–2015. Readmissions and cost have decreased, while mortality has remained low.

Role of imaging in assessment and detection of complications after bariatric surgery

Background

Bariatric surgery is performed to control morbid obesity secondary to failed medical approaches. Practical knowledge of post-surgical anatomy allows accurate interpretation of imaging findings related to normal post-surgical anatomy and common post-surgical complications.

The purpose of this study was to highlight the role of imaging in the assessment and detection of complications after bariatric surgery.

Results

This prospective study included 49 patients who had bariatric surgery. Sleeve gastrectomy was the most common bariatric surgery. The leak was the commonest complication (12%). The sensitivity of upper GI series for diagnosis of post-operative complication after bariatric surgery was 70% and specificity 94% while the sensitivity of CT study was 95% and specificity 95%.

Conclusion

CT has a golden role in the diagnosis of post-operative complications. Both post-contrast CT and upper GI series should be used in diagnosing complications following bariatric surgery. US is useful for diagnosis of a superficial problem.

The Effectiveness and Feasibility of Laparoscopic Re-sleeve Gastrectomy

BACKGROUND

Weight regain following laparoscopic sleeve gastrectomy (LSG) may be due to dilation of the gastric reservoir. Laparoscopic re-sleeve gastrectomy (LrSG) is among the revisional surgery options.

OBJECTIVES

We aimed to investigate the effectiveness of LrSG for weight loss after a 12- and 24-month follow-up period.

SETTING

Bariatric surgery center in Baku/Azerbaijan.

METHOD

From June 2016 to June 2019, a total of 34 LSG patients with weight regain, underwent LrSG. We prospectively followed outcomes data were BMI changes, excessive weight loss, changes in laboratory values, and the presence of complications.

RESULTS

The mean age at revision surgery was 36 ± 7.09 (range, 22-51) years, and the mean body mass index (BMI) before LrSG was 40 ± 5.2 kg/m2. The mean time between the primary and revision surgery was 50 ± 7.8 months. The main reasons for the revisions were weight regain and inadequate weight loss. The mean BMI value decrease at the 12th and 24th months were 27.7 ± 2 and 24.3 ± 1.02, which were statistically significant (p < 0.05). Analyses of hemoglobin A1C (A1C) values showed that the differences at the baseline, 12th and 24th months were statistically significant (95% 1.96 to 3.39, p < 0.001 and 95% CI 0.34 to 2.08, p = 0.005, respectively).

CONCLUSIONS

In patients with weight regain or inadequate weight loss after LSG, LrSG may be a feasible and safe revisional procedure in a selected group of patients. Larger studies that compare other revisional surgery options (LRYGB, OAGB, duodenal switch, single anastomosis duodeno-ileal bypass) with LrSG are required.

Outcomes of Sleeve Gastrectomy at a Veterans Affairs Medical Center

Introduction: Bariatric surgery is the most effective treatment for obesity while improving comorbid conditions and decreasing mortality rates. The purpose of this analysis was to identify the predictive factors associated with the short-term outcomes of laparoscopic sleeve gastrectomy (LSG) at a single Veterans Affairs Medical Center (VAMC). Methods: This is a retrospective analysis of LSG performed at a VAMC from 2013 to 2019. Veterans were followed for 12 months postoperatively. The primary outcomes of interest were excess weight loss (EWL) and total weight loss (TWL) at 3, 6, 9, and 12 months along with resolution of comorbidities. Independent predictors included: demographics, pre- and postoperative findings, geographic distance from VAMC, and per-capita salary of the veteran's residence. Results: A total of 128 patients, including 50 males, completed 12 months' follow-up after LSG. There were no mortalities, transfusions, or conversions to open surgery. The mean length of stay was 2.3 days. At 3, 6, 9, and 12 months, EWL was 27.2%, 33.7%, 35.9%, and 36.6%, respectively; TWL was 12.3%, 15.3%, 16.3%, and 16.7%, respectively. Postoperative hemoglobin A1c and oral hyperglycemic medication usage significantly decreased. High-density lipoprotein levels significantly increased. At 6 months' follow-up, preoperative body mass index (BMI; odds ratio [OR] = 0.7 [95% confidence interval, CI 0.6-0.9]) and age (OR = 0.9 [95% CI 0.8-1.0]) were significant predictors of 50% EWL and EWL broadly (P = .002). Conclusion: Similar to the private sector, LSG is a safe and effective tool for morbid obesity with clinical and serological improvements. For Veterans, increasing BMI and age may portend less weight loss but does not affect resolution of some comorbidities.

Disordered eating and weight loss after bariatric surgery

PURPOSES

Aberrant eating patterns are frequently observed in bariatric patients. Since bariatric operations produce alterations in food transit and in appetite/satiety balance, postoperative eating behavior changes are not surprising.

METHODS

88 consecutive obese patients undergoing Roux-en-Y gastric bypass (RYGBP, 50 cases) and Sleeve Gastrectomy (SG, 38 cases) were retrospectively evaluated. Beside anthropometric data measurement, eating behavior was assessed by direct interview prior to the operation and at the first and second postoperative years: patients were considered as eating disordered (ED) when referred habitual occurrence of binge eating and nibbling/grazing. Weight loss was assessed by percent of BMI loss (% Δ BMI). Together with standard follow-up, patients received additional behavioral/dietetic support upon request.

RESULTS

Postoperative ED patients showed lower % Δ BMI than the not ED ones at one (30.7% ± 8,5 vs. 26.8% ± 10, p < 0.02) and two (32% ± 10.3 vs. 27.4% ± 12.9, p < 0.05) years after operation, the follow-up rate being 82% and 76%, respectively, without differences between RYGBP and SG group. After RYGBP, an improvement of eating behavior was observed (ED patients from 75 to 28% at 1 year and to 27% at 2 years), while no changes were observed after SG. In SG patients, the number of additional behavioral/dietetic support sessions throughout the follow-up was positively associated with % Δ BMI.

DISCUSSION

The postoperative normalization of eating pattern has a role in weight loss after bariatric surgery. Behavioral/dietetic support is indicated in all SG patient, while after RYGBP is useful only when weight loss is unsatisfactory.

LEVEL OF EVIDENCE

III: retrospective cohort study.

Sleeve Gastrectomy Surgery Improves Glucose Metabolism by Downregulating the Intestinal Expression of Sodium-Glucose Cotransporter-3

AIMS

Sleeve gastrectomy (SG) has been proven effective in the treatment of obesity and type 2 diabetes. We hypothesized that SGLT3 may play an important role in the mechanism of glucose control and weight loss after SG.

MATERIALS AND METHODS

Daily body weight and food intake were measured in SG and sham-operated mice. Glucose tolerance test, SGLT3 agonist (αMG), and SGLT1 inhibitor (phlorizin) perfusion experiments were used to detect changes in intestinal SGLT3 and SGLT1 activity following SG. Expression of SGLT3a and SGLT1 was assessed at 2 weeks, 1 month after surgery by quantitative PCR and fluorescence immunoassay. Hematoxylin and eosin staining was used to detect morphological changes in the villi. SGLT3 and SGLT1 expression was measured after stimulation of human intestinal epithelial cells (HIEC).

RESULTS

Both the body weight and daily food intake of the SG-treated mice decreased within 30 days after surgery. Oral glucose absorption was significantly reduced at 30 days. The intestinal stimulation proved that SG can improve glucose metabolism, which can be reversed by αMG and enhanced by phlorizin. Villus height and surface area of the intestine in SG mice decreased after surgery. mRNA expression of SGLT3a and SGLT1 decreased at 2 weeks and 1 month after SG, immunofluorescence also confirmed these changes. HIEC stimulation confirmed that αMG could increase the expression of SGLT3 and SGLT1, but the expression of SGLT1 was down regulated when phlorizin was added to the medium.

CONCLUSION

The results suggest that reducing SGLT3 expression might contribute to lowering blood glucose and controlling body weight after SG.

Gastric Bypass Versus Sleeve Gastrectomy: Patient Selection and Short-term Outcome of 47,101 Primary Operations From the Swedish, Norwegian, and Dutch National Quality Registries

OBJECTIVE

The aim of this study was to compare the use and short-term outcome of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in Sweden, Norway, and the Netherlands.

BACKGROUND

Although bariatric surgery is performed in high volumes worldwide, no consensus exists regarding the choice of bariatric procedure for specific groups of patients.

METHODS

Data from 3 national registries for bariatric surgery were used. Patient selection, perioperative data (severe complications, mortality, and rate of readmissions within 30 days), and 1-year results (follow-up rate and weight loss) were studied.

RESULTS

A total of 47,101 primary operations were registered, 33,029 (70.1%) RYGB and 14,072 (29.9%) SG. Patients receiving RYGB met international guidelines for having bariatric surgery more often than those receiving SG (91.9% vs 83,0%, P < 0.001). The 2 procedures did not differ in the rate of severe complications (2.6% vs 2.4%, P = 0.382), nor 30-day mortality (0.04% vs 0.03%, P = 0.821). Readmission rates were higher after RYGB (4.3% vs 3.4%, P < 0.001).One-year post surgery, less RYGB-patients were lost-to follow-up (12.1% vs 16.5%, P < 0.001) and RYGB resulted in a higher rate of patients with total weight loss of more than 20% (95.8% vs 84.6%, P < 0.001). While the weight-loss after RYGB was similar between hospitals, there was a great variation in weight loss after SG.

CONCLUSION

This study reflects the pragmatic use and short-term outcome of RYGB and SG in 3 countries in North-Western Europe. Both procedures were safe, with RYGB having higher weight loss and follow-up rates at the cost of a slightly higher 30-day readmission rate.

Surgical resident training program to perform laparoscopic bariatric procedures: Are safety and postoperative outcomes compromised?

INTRODUCTION

Laparoscopic bariatric procedures such as laparoscopic Roux-en-Y gastric bypass (LRYGB) are technically demanding and require a long learning curve. Little is known about whether surgical resident (SR) training programs to perform these procedures are safe and feasible. This study aims to evaluate the results of our SR training program to perform LRYGB.

METHODS

We designed a retrospective study including patients with LRYGB between January 2014 and December 2018, comparing SR results to experienced bariatric surgeons (EBS). In our country, SR have a five-year surgical formative period, and in the fourth year they are trained for 6 months in our bariatric surgery unit, from January to June. In the beginning, they perform different steps of this procedure, to finally complete an LRYGB. We collected demographic data, comorbidities, intraoperative outcomes, and postoperative complications and outcomes after a one-year follow-up.

RESULTS

Two hundred and eight patients were eligible for inclusion: 67 in group I (SR), and 141 in group II (EBS). Both groups were comparable. There was no statistically significant difference in operating time (166.45min in group I vs. 156.69min in group II; P=0.156). Conversion to open surgery, hospital stay, postoperative complications, and short-term outcomes had no significant differences between the two groups. There was no mortality registered during this period.

CONCLUSION

Implementation of LRYGB stepwise learning as part of an SR training program is safe, and results are comparable to EBS, without loss of efficiency. Therefore, it is feasible to train SR in bariatric surgery under EBS supervision.

Short-Term Results Suggest That Sleeved Stomach without Resection Is as Effective as Sleeve Gastrectomy in Improving Glucose Control in Type 2 Diabetes Mellitus Sprague-Dawley Rat Model

Background

Although sleeve gastrectomy results in good weight loss and metabolic improvements, it is an irreversible procedure. Therefore, we attempted to assess the possibility of creating a sleeved stomach without resection. Material and Methods. A total of 22 male Sprague-Dawley rats with type 2 diabetes were randomly assigned into 3 different groups: (1) sleeve gastroplasty with gastric remnant-jejunal anastomosis (SGP, n = 8); (2) sleeve gastrectomy (SG, n = 8); and (3) SHAM (n = 6). Body weight, food intake, fasting blood glucose (FBG), hormonal analysis, and oral glucose tolerance test (OGTT) were performed and measured preoperatively and postoperatively.

Results

During the postoperative period, SGP and SG showed significantly lower food intake and body weight when compared with the preoperative levels, respectively (p value < 0.05). Postoperatively, SGP and SG showed improvements in FBG and glucose tolerance levels compared to their respective preoperative levels (p < 0.05). FBG and glucose tolerance levels did not differ between SGP and SG postoperatively. SG resulted in a reduction in fasting ghrelin levels when compared with the preoperative level (p < 0.05). Fasting insulin levels did not differ preoperatively and postoperatively among all groups. Postoperatively, fasting GLP-1 levels were higher in SGP and SG when compared with the preoperative levels, but no statistical significance was observed. Compared preoperatively, the SGP and SG procedures resulted in a decline in HOMA-IR at postoperative 6th week (p < 0.05).

Conclusion

Our animal experiment suggested that at least in the short term, sleeved stomach without resection resulted in similar weight loss and improved glucose control effects compared to sleeve gastrectomy.

Bariatric surgery in posttransplantat patients: does diabetes influence outcomes?

BACKGROUND

Type 2 diabetes (T2D) is frequently present in Metabolic and Bariatric Surgery (MBS) patients and is associated with increased morbidity and mortality. Organ transplantation patients also suffer from severe obesity and are now increasingly undergoing MBS.

OBJECTIVE

To determine the association of T2D and perioperative outcomes after MBS in previous solid organ transplantation patients SETTING: University Hospital, United States.

METHODS

Patients with a history of solid organ transplantation undergoing sleeve gastrectomy and Roux-en-Y gastric bypass were identified from the 2017 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database. Patients were then stratified by a history of T2D. Propensity-score matching was performed between the 2 cohorts. Outcomes were compared by Mann-Whitney U, Χ², and multivariable logistic regression analysis for overall and morbidity related to MBS.

RESULTS

Before matching 338 patients with a prior history of solid organ transplantation were identified including 132 (39%) with and 206 (61%) without diabetes. There were no significant differences in outcomes between the 2 cohorts at baseline, but these patients were significantly different at baseline. After matching, 85 patients with and without T2D were identified. Overall and morbidity related to MBS were similar (P > .5). Furthermore, multivariable logistic regression revealed T2D to not have an increased risk for overall (odds ratio .95, P = .09) or morbidity related to MBS (odds ratio .92, P = .87).

CONCLUSION

MBS in T2D patients with previous solid organ transplantation is overall safe with low rates of morbidity and mortality. Diabetes was not an independent predictor of adverse outcomes in this cohort of patients. Larger cohort studies are needed.

Sexually Dimorphic Effects of Dietary Methionine Restriction are Dependent on Age when the Diet is Introduced

OBJECTIVE

Restricting dietary methionine to 0.17% in male mice increases energy expenditure, reduces fat deposition, and improves metabolic health. The goal of this work was to compare each of these responses in postweaning male and female mice and in physically mature male and female mice.

METHODS

Methionine-restricted (MR) diets were fed to age-matched cohorts of male and female mice for 8 to 10 weeks beginning at 8 weeks of age or beginning at 4 months of age. The physiological and transcriptional responses to MR were compared in the respective cohorts.

RESULTS

Dietary MR produced sexually dimorphic changes in body composition in young growing animals, with males preserving lean at the expense of fat and females preserving fat at the expense of lean. The effects of MR on energy balance were comparable between sexes when the diet was initiated after attainment of physical maturity (4 months), and metabolic and endocrine responses were also comparable between males and females after 8 weeks on the MR diet.

CONCLUSIONS

The sexually dimorphic effects of MR are limited to nutrient partitioning between lean and fat tissue deposition in young, growing mice. Introduction of the diet after physical maturity produced comparable effects on growth and metabolic responses in male and female mice.

Delayed Sleeve Gastrectomy Following Liver Transplantation: A 5-Year Experience

Obesity has become an epidemic in the United States over the past decade, and recent studies have shown this trend in the liver transplantation (LT) population. These patients may be candidates for laparoscopic sleeve gastrectomy (LSG) to promote significant and sustained weight loss to prevent recurrence of nonalcoholic steatohepatitis. However, safety remains a concern, and efficacy in this setting is uncertain. A single-institution database from 2014 to 2018 was queried for patients undergoing LSG following LT. The selection criteria for surgery were consistent with National Institutes of Health guidelines, and patients were at least 6 months after LT. A total of 15 patients (median age, 59.0 years; Caucasian, 86.7%; and female, 60%) underwent LSG following LT. Median time from LT to LSG was 2.2 years with a median follow-up period of 2.6 years. The median hospital length of stay (LOS) was 2 days after LSG. Mortality and rate of liver allograft rejection was 0, and there was 1 postoperative complication (a surgical site infection). Following LSG, body mass index (BMI) decreased from 42.7 to 35.9 kg/m² (P < 0.01), and in 12 patients with at least 1 year of follow-up, the total body weight loss was 20.6%. Following LSG in patients with diabetes, the median daily insulin requirements decreased from 98 (49-118) to 0 (0-29) units/day (P = 0.02), and 60% discontinued insulin. Post-LT patients had a similar decrease in BMI and reduction in comorbidities at 1 year compared with a matched non-LT patient cohort. In the largest patient series to date, we show that LSG following LT is safe, effective, and does not increase the incidence of liver allograft rejection. Larger longer-term studies are needed to confirm underlying metabolic changes following LSG.

Metabolic Parameters, Weight Loss, and Comorbidities 4 Years After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

BACKGROUND

Sleeve gastrectomy (LSG) is now the predominant bariatric surgery performed, yet there is limited long-term data comparing important outcomes between LSG and Roux-en-Y gastric bypass (RYGB). This study compares weight loss and impact on comorbidities of the two procedures.

METHODS

We retrospectively evaluated weight, blood pressure, hemoglobin A1c, cholesterol, and medication use for hypertension, diabetes, and hyperlipidemia at 1-4 years post-operatively in 380 patients who underwent RYGB and 334 patients who underwent LSG at the University of Michigan from January 2008 to November 2013. Follow-up rates from 714 patients initially were 657 (92%), 556 (78%), 507 (71%), and 498 (70%) at 1-4 years post-operatively.

RESULTS

Baseline characteristics were similar except for higher weight and BMI in LSG. There was greater weight loss with RYGB vs. LSG at all points. Hemoglobin A1c and total cholesterol improved more in RYGB vs. LSG at 4 years. There was greater remission of hypertension and discontinuation of all medications for hypertension and diabetes with RYGB at 4 years.

CONCLUSIONS

Weight loss, reduction in medications for hypertension and diabetes, improvements in markers of diabetes and hyperlipidemia, and remission rates of hypertension were superior with RYGB vs. LSG 4 years post-operatively. Choice of bariatric procedures should be tailored to surgical risk, comorbidities, and weight loss goals.

Gut microbiota adaptation after weight loss by Roux-en-Y gastric bypass or sleeve gastrectomy bariatric surgeries

BACKGROUND

Gut microbiota could be involved in the metabolic improvement after surgery.

OBJECTIVE

The aim of the present study was to evaluate the short-term evolution of the gut microbiome after different bariatric surgery procedures and their functionality and relate it with obesity resolution.

SETTING

University hospital, Spain.

METHODS

We studied 28 patients with severe obesity; 14 underwent a Roux-en-Y gastric bypass (RYGB) and 14 underwent laparoscopic sleeve gastrectomy (SG). All patients were examined before and 3 months after the correspondent bariatric surgery. Gut microbiome profile was assessed by the sequencing of amplicons from the 16S rDNA gene by next-generation sequencing.

RESULTS

Gut microbiota profiles significantly differed between surgical procedures. RYGB suffered the largest changes in the microbiota population. SG and RYGB differed in their profiles with higher levels of Akkermansia, Eubacterium, Haemophilus, and Blautia for SG, while Veillonella, Slackia, Granucatiella, and Acidaminococcus occurred with greater levels in RYGB. RYGB microbiota changes were reflected also at the level of functionality, especially in pathways related to environmental adaptation. A biomarker discovery analysis revealed the genus Blautia as characteristic in SG, while Veillonella was of RYGB.

CONCLUSION

Our study shows a shift of the gut microbiome after a bariatric surgery in a procedure-related manner. Gut microbiome changes are related to the adaptation to the changing gut environment and could be related to the pH fluctuations.

Effects of the Postoepartive Dietetic/Behavioral Counseling on the Weight Loss After Bariatric Surgery

OBJECTIVE

Weight outcomes after bariatric surgery are due to an adequate adjustment of eating behavior to the new gastrointestinal conditions created by operation. The efficacy of dietary/behavior counseling for promoting weight loss and maintenance in a growing number of bariatric patients was investigated.

MATERIAL AND METHODS

One hundred seventy-six non-diabetic obese patients undergoing Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG) were investigated. The first group (CO, 88 subjects, 16 male) attended a standard surgical follow-up, while in the second (DIET, 88 subjects, 15 male) the surgeon was supported by a dietitian, and patients received behavioral-dietary sessions on individual request. Data prior to the operation and at 2 years were considered, the weight outcome being regarded as successful when postoperative body mass index (BMI) value was lower than 30 kg/m².

RESULTS

Weight results were better (p < 0.01) in the RYGBP than in the SG patients. In comparison to CO, in the DIET group a greater adherence to the bariatric program was observed (76% vs. 41%, < 0.01), while body weight data and prevalence of successful cases at 2 years (87 ± 23 vs. 83 ± 16 kg and 27% vs.33%, respectively) were similar.

CONCLUSIONS

After RYSG and SG, postoperative dietetic/behavioral sessions delivered on patient's request does not influence weight results. The dietetic intervention promotes the adherence to bariatric program and prevents postoperative follow-up loss. In a dietitian/behavioral strategy after RYGBP and SG, a cognitive reinforcement of the compliance to bariatric program and a strengthening of the motivation to changes could promote better weight results.

The impact of the affordable care act (ACA) Medicaid Expansion on access to minimally invasive surgical care

INTRODUCTION

This study aims to evaluate the effect of the ACA Medicaid expansion on the utilization of minimally invasive (MIS) approaches to common general surgical procedures.

METHODS

We queried five Healthcare Cost and Utilization Project State Inpatient Databases to evaluate rates of utilization and costs of MIS and open approaches pre and post Medicaid expansion.

RESULTS

117,241 patients met the inclusion criteria. Following the enactment of the ACA, use of both laparoscopic gastric bypass (IRR 1.08; 95% CI: [1.02, 1.15]) and Nissen fundoplication (IRR 1.17; 95% CI [1.09, 1.26]) increased in Medicaid patients treated in expansion states than in those treated in non-expansion states. Simultaneously, the costs reported for self-pay patients increased in expansion states more than in non-expansion states (+$1669; 95% CI [$655, $2682]).

CONCLUSIONS

Medicaid expansion was associated with increased rates of utilization of MIS approaches to several surgical procedures and a shifting of costs toward patients who were self-insured.

Longitudinal Impacts of Gastric Bypass Surgery on Pharmacodynamics and Pharmacokinetics of Statins

PURPOSE

Undergoing Roux-en-Y gastric bypass (RYGB) is expected to affect orally administered drug absorption. Statins are commonly prescribed to patients with obesity for the prevention of atherosclerotic cardiovascular diseases by lowering cholesterol. This is the first longitudinal prospective study on impacts of RYGB on weight loss, pharmacodynamics, and pharmacokinetics of atorvastatin, rosuvastatin, and simvastatin, and their active metabolites, up to 1-year post-surgery.

METHODS

Forty-six patients were recruited, five patients on atorvastatin, twelve on rosuvastatin, nine on simvastatin, and twenty on no statin. The concentrations of atorvastatin, rosuvastatin, and simvastatin with their active metabolites were monitored.

RESULTS

Mean plasma concentrations of atorvastatin and metabolites and rosuvastatin normalized by the unit dose [(nM)/(mg/kg)] decreased by 3- to 6-month post-surgery. Conversely, simvastatin and its metabolite concentrations increased up to 6-month post-surgery, then declined to preoperative levels by 1-year post-surgery. The metabolisms of atorvastatin to hydroxyl-metabolites and simvastatin to simvastatin acid were decreased after RYGB. The weight loss and PD outcomes were comparable between statin and non-statin groups suggesting the key impacts were from RYGB. The discontinuation or reduction of dose of atorvastatin or rosuvastatin post-RYGB exhibited rebounds of LDL levels in some subjects, but the rebound was not apparent with patients on simvastatin pre-surgery.

CONCLUSION

Discontinuations of statin dosing post-RYGB require LDL monitoring and reducing the dose to half seems to have better results. Patients on statin treatment post-RYGB should be followed-up closely based on our pharmacokinetic findings, to ensure therapeutic effects of the treatment with minimal adverse effects.

Outcomes of Sleeve Gastrectomy in Obese Liver Transplant Candidates

Morbid obesity (body mass index [BMI] ≥40 kg/m² ) is a relative contraindication to liver transplantation (LT) at many transplant centers. The safety and efficacy of pre-LT bariatric surgery in morbidly obese LT candidates is unknown. Herein, we describe a cohort study of morbidly obese LT candidates who failed to achieve adequate weight loss through a medically supervised weight loss program and subsequently underwent sleeve gastrectomy (SG) at our institution. In total, 32 LT candidates with a median Model for End-Stage Liver Disease (MELD) score of 12 (interquartile range [IQR], 10-13) underwent SG. All LT candidates had a history of hepatic decompensation, but complications of liver disease were required to be well controlled at the time of SG. Median pre-SG BMI was 45.0 kg/m² (IQR, 42.1-49.0 kg/m² ). There were no perioperative deaths or liver-related morbidity. One patient experienced major perioperative morbidity secondary to a gastric leak, which was managed nonoperatively. Median weight loss at 6 and 12 months after SG was 22.0 kg (IQR, 18.9-26.8 kg) and 31.0 kg (IQR, 23.6-50.3 kg), respectively, corresponding to a percentage of excess body weight lost of 33.4% and 52.4%. Within 6 months after SG, 28 (88%) candidates were deemed eligible for LT. Our center's experience highlights the potential option of SG in morbidly obese LT candidates with advanced liver disease who might otherwise be excluded from pursuing LT.

Evidence summaries and recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome: assessment and treatment of infertility

STUDY QUESTION

What is the recommended assessment and management of infertile women with polycystic ovary syndrome (PCOS), based on the best available evidence, clinical expertize and consumer preference?

SUMMARY ANSWER

International evidence-based guidelines, including 44 recommendations and practice points, addressed prioritized questions to promote consistent, evidence-based care and improve the experience and health outcomes of infertile women with PCOS.

WHAT IS KNOWN ALREADY

Previous guidelines on PCOS lacked rigorous evidence-based processes, failed to engage consumer and multidisciplinary perspectives or were outdated. The assessment and management of infertile women with PCOS are inconsistent. The needs of women with PCOS are not being adequately met and evidence practice gaps persist.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Governance included a six continent international advisory and a project board, a multidisciplinary international guideline development group (GDG), consumer and translation committees. Extensive health professional and consumer engagement informed the guideline scope and priorities. The engaged international society-nominated panel included endocrinology, gynaecology, reproductive endocrinology, obstetrics, public health and other experts, alongside consumers, project management, evidence synthesis and translation experts. Thirty-seven societies and organizations covering 71 countries engaged in the process. Extensive online communication and two face-to-face meetings over 15 months addressed 19 prioritized clinical questions involving nine evidence-based reviews and 10 narrative reviews. Evidence-based recommendations (EBRs) were formulated prior to consensus voting within the guideline panel.

STUDY DESIGN, SIZE, DURATION

International evidence-based guideline development engaged professional societies and consumer organizations with multidisciplinary experts and women with PCOS directly involved at all stages. A (AGREE) II-compliant processes were followed, with extensive evidence synthesis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was applied across evidence quality, desirable and undesirable consequences, feasibility, acceptability, cost, implementation and ultimately recommendation strength. The guideline was peer-reviewed by special interest groups across our partner and collaborating societies and consumer organizations, was independently assessed against AGREE II criteria and underwent methodological review. This guideline was approved by all members of the GDG and has been approved by the NHMRC.

MAIN RESULTS AND THE ROLE OF CHANCE

The quality of evidence (QOE) for the EBRs in the assessment and management of infertility in PCOS included very low (n = 1), low (n = 9) and moderate (n = 4) quality with no EBRs based on high-quality evidence. The guideline provides 14 EBRs, 10 clinical consensus recommendations (CCRs) and 20 clinical practice points on the assessment and management of infertility in PCOS. Key changes in this guideline include emphasizing evidence-based fertility therapy, including cheaper and safer fertility management.

LIMITATIONS, REASONS FOR CAUTION

Overall evidence is generally of low to moderate quality, requiring significantly greater research in this neglected, yet common condition. Regional health systems vary and a process for adaptation of this guideline is provided.

WIDER IMPLICATIONS OF THE FINDINGS

The international guideline for the assessment and management of infertility in PCOS provides clinicians with clear advice on best practice based on the best available evidence, expert multidisciplinary input and consumer preferences. Research recommendations have been generated and a comprehensive multifaceted dissemination and translation program supports the guideline with an integrated evaluation program.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was primarily funded by the Australian National Health and Medical Research Council of Australia (NHMRC) supported by a partnership with ESHRE and the American Society for Reproductive Medicine (ASRM). GDG members did not receive payment. Travel expenses were covered by the sponsoring organizations. Disclosures of conflicts of interest were declared at the outset and updated throughout the guideline process, aligned with NHMRC guideline processes. Dr Costello has declared shares in Virtus Health and past sponsorship from Merck Serono for conference presentations. Prof. Norman has declared a minor shareholder interest in the IVF unit Fertility SA, travel support from Merck and grants from Ferring. Prof. Norman also has scientific advisory board duties for Ferring. The remaining authors have no conflicts of interest to declare.

This article was not externally peer-reviewed by Human Reproduction Open.

Influence of Patient Choice on Outcome of Bariatric Surgery

BACKGROUND

The "perfect" bariatric procedure remains the topic of debate. The aim of this study is to compare the safety and outcome of laparoscopic Roux-en-Y gastric bypass (LRYGB) to those of laparoscopic sleeve gastrectomy (LSG) and adjustable gastric band (AGB) in a single centre, amongst those patients who made their own choice of which procedure they prefer.

METHODS

After the multi-disciplinary team's assessment, the patients could make their own choice of procedures (self-selected, SS), unless medical/surgical conditions limited this (medically restricted, MR). All consecutive primary bariatric procedures were involved and reviewed between June 2010 and September 2014. The primary outcomes included 30-day complication and readmission rates, excess weight loss (%EWL) and co-morbidity resolution at 24 months postoperatively.

RESULTS

A total of 303 patients were included and 271 of them made their own choice (SS 90%). One hundred eighty-three chose LRYGB (60.4%), and 57 underwent LSG (SS 45 and MR 12; overall 18.8%), with the initial BMI of 50.7 and 52.5 kg/m², respectively. Sixty-two patients (SS 43, MR 19, overall 20%) underwent AGB, with a BMI of 52.1 kg/m². Thirty-day complication rates for LRYGB and LSG were 10.2 and 2.9% (p < 0.05), and the readmission rates were 4.7 and 2.9%, respectively. %EWL for LRYGB was significantly higher than that of other procedures at 24 months (67.8 vs SS-sleeve 43.9%, MR-sleeve 47%, SS-band 33.8% and MR-band 36%; FU rate 94%). Diabetes remission was achieved in 31/50 patients in the LRYGB group (62%) and 2/9 patients (22%) in the LSG group.

CONCLUSIONS

Self-selected bariatric procedures yield excellent weight loss and metabolic outcome. Providing an information-dense environment augments the choice of the right operation and could improve patients' compliance with weight loss surgery programmes.