The Impact of Preoperative BMI (Obesity Class I, II, and III) on the 12-Month Evolution of Patients Undergoing Laparoscopic Gastric Bypass

Who gains the most quality-of-life benefits from metabolic and bariatric surgery: findings from the prospective REBORN cohort study

BACKGROUND

Prioritizing patients for metabolic and bariatric surgery (MBS) based on their potential postoperative benefits is essential.

OBJECTIVES

To examine changes in quality of life (QoL) during the initial postoperative year among patients with diverse eligibility statuses and determine which group experiences greater benefits.

SETTING

Center intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de- Montréal (CIUSSS-NIM), Canada.

METHODS

We categorized patients into 3 groups based on obesity class and the presence of comorbidities: Group 1 (obesity class II without comorbidities, n = 28); Group 2 (obesity class II with comorbidities, n = 36); and Group 3 (obesity class III, n = 460). QoL (Short-Form QoL questionnaire [SF-12]) and anthropometrics were measured at 6 months before, and 6 and 12 months after surgery.

RESULTS

Repeated measures mixed models revealed a significant main effect of time (P < .001) and an interaction between time and group for the physical component of QoL (P = .007). These indicated consistent improvements across time in all groups, with the greatest benefits seen in Group 3 relative to Group 1. There were no interactions between time and group for the mental components of QoL (P = .402). There were significant interaction effects for weight and BMI (P's < .001), with Group 3 losing more weight than Groups 1 or 2.

CONCLUSIONS

All groups that underwent MBS had improvements in the physical aspects of QoL and weight over time, even those who have traditionally not be considered eligible for MBS (i.e., Group 1). This provides a starting point to explore the importance of not excluding patients due to their weight and comorbidity status and setting comprehensive eligibility criteria encompassing all patients who might benefit from MBS, beyond just weight loss.

The Battle of Endoscopic Bariatric Therapies for Obesity: Endoscopic Sleeve Gastroplasty Versus Endoscopically Inserted Intragastric Balloon-A Pairwise Meta-Analysis of Comparative Studies and a Call for Randomized Controlled Trials

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) represents the latest primary endoscopic intervention for managing obesity. Both ESG and intragastric balloons (IGBs) have demonstrated effectiveness and safety for weight loss. However, there is a paucity of high-quality evidence supporting the superiority of one over the other, and no pairwise meta-analysis of comparative studies has been published to date. Our aim was to conduct a pairwise meta-analysis of comparative studies directly comparing ESG and IGB.

METHODS

We systematically conducted a literature search on PubMed and Google Scholar following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our search used specific search terms. The Risk of Bias in Non-Randomized Studies of Interventions (ROBINS-I) Tool was used to evaluate the quality of the included studies. Data were analyzed using Review Manager (RevMan) 5.4.1 software with a random-effects model. The statistical method used was the Mantel-Haenszel method. For dichotomous data, the effect size was represented using odds ratio (OR), while mean difference (MD) was utilized as the effect size for continuous data.

RESULTS

After screening 967 records, a total of 9 studies met the inclusion criteria for this meta-analysis (5302 patients). The quality assessment categorized 5 studies as having a moderate risk of bias, while 3 studies were classified as having a low risk of bias. Sufficient information was not available for one study to ascertain its overall quality. A statistically significant increase in total weight loss percentage (TWL%) at 1 and 6 months was observed with ESG compared with IGB. In addition, a statistically insignificant decrease in the incidence of adverse events and readmissions was observed with ESG. Furthermore, a statistically significant decrease in the incidence of reintervention was observed with ESG.

CONCLUSIONS

While this study suggests a higher TWL% associated with ESG compared with IGB, drawing definitive conclusions is challenging due to limitations identified during a comprehensive quality assessment of the available literature. We advocate for randomized controlled trials (RCTs) directly comparing the newer IGB (with a 12-mo placement duration) with ESG. However, this study consistently reveals higher rates of early reintervention (re-endoscopy) within the IGB group, primarily necessitated by the removal or adjustment of the IGB due to intolerance. Given the additional intervention required at 6 or 12 months to remove the temporarily placed IGB, this trend may imply that IGB is less economically viable than ESG. Cost-effectiveness analyses comparing ESG and IGB are warranted to provide valuable scientific insights.

Assessing the predictive value of the suppressed 1 mg overnight dexamethasone suppression test in success of bariatric surgery

Bariatric surgery has been proven to be a successful intervention for managing obesity. There are numerous studies in the literature aiming to predict the factors influencing the success of bariatric surgery. Our study aims to determine whether preoperative 1 mg overnight dexamethasone suppression test (1 mg-DST) serum cortisol levels can serve as predictors of the effectiveness of bariatric surgery in severe obese patients without Cushing syndrome. A total of 98 patients who underwent bariatric surgery were included in the study. The preoperative 1 mg-DST levels, insulin levels, thyroid function tests, and lipid profiles of the patients were recorded. The patients' preoperative, postoperative 3rd, and 6th month weights were recorded and the percent total weight loss (%TWL) is calculated. Patients were categorized into 2 groups based on their TWL at 6 months. The 1 mg-DST results were significantly lower in the high-TWL-6 group (0.93 ± 0.37 μg/dL) compared to the low-TWL-6 group (1.09 ± 0.36 μg/dL, P = .040). Similarly, Homeostatic Model Assessment for Insulin Resistance values were lower in the high-TWL-6 group (5.63 ± 2.21) compared to the low-TWL-6 group (6.63 ± 2.55, P = .047). The optimal cutoff value found for 1 mg-DST level was 0.97 µg/dL, providing 50% sensitivity and 70% specificity. This study is the first to examine the predictive role of suppressed 1 mg-DST levels on postoperative weight loss in nondiabetic patients. The most prominent result of this study was that we observed a negative correlation between 1 mg-DST levels and %TWL.

National usage of bariatric surgery for class I obesity: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program

BACKGROUND

National and international consensus statements, as well as the National Institutes of Health (NIH), support the use of bariatric surgery for the treatment of class I obesity. Despite this, most payors within the United States limit reimbursement to the outdated 1991 NIH guidelines or a similar adaptation.

OBJECTIVES

This study aimed to determine the safety of bariatric surgery in patients with lower BMI compared with standard patients, as well as determine U.S. utilization of bariatric surgery in class I obesity in 2015-2019.

SETTING

A retrospective analysis was performed of the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.

METHODS

Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass patients were divided into body mass index cohorts: class I obesity (<35 kg/m2) and severe obesity (≥35 kg/m2). Differences in preoperative patient selection and postoperative outcomes were established, and frequency trends were delineated.

RESULTS

Analysis included 760,192 surgeries with 8129 (1%) for patients with class I obesity. The patients with class I obesity were older, more commonly female, and with lower American Society of Anesthesiologists (ASA) class, but with higher rates of type 2 diabetes, hyperlipidemia, and gastroesophageal reflux disease (P < .05). Variation was found for operative time, length of stay, 30-day readmission, and composite morbidity. Minimal annual variation was found for bariatric surgeries performed for patients with class I obesity.

CONCLUSIONS

The short-term safety of bariatric surgery in patients with class I obesity was corroborated by this study. Despite consensus statements and robust support, rates of bariatric surgery in patients with class I obesity have failed to increase and remain limited to 1%. This demonstrates the impact of the outdated 1991 NIH guidelines regarding access to care for these potentially life-saving surgeries.

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

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

Long versus short biliopancreatic limb in Roux-en-Y gastric bypass: short-term results of a randomized clinical trial

BACKGROUND

The Roux-en-Y gastric bypass continues to be one of the most performed bariatric surgeries because of its adequate balance of outcomes, complications, and durability. Recently, the role of the biliopancreatic limb on weight loss and co-morbidity control has gained attention because it seems to have a positive impact based on limb length.

OBJECTIVE

To compare results at 12 months of a "standard" (group 1) versus a long (group 2) biliopancreatic limb bypass. Biliopancreatic limbs were 50 cm and 200 cm, and alimentary limbs were 150 cm and 50 cm, respectively.

SETTING

Academic Referal Center; Mexico City; Public Seeting.

METHODS

Randomized study with patients undergoing both types of surgeries at a single academic center from 2016 to 2018. The analysis included weight loss, co-morbidity control (diabetes and hypertension), biochemical panel, operative outcomes, and complications.

RESULTS

Two-hundred ten patients were included (105 in each group). Almost all data were homogenous at baseline. Female sex comprised 86.1% of cases, with a mean body mass index of 43.5 kg/m². Excess weight loss (77.6 ± 15.7% versus 83.6 ± 16.7%; P = .011) and total weight loss (33.5 ± 6.4% versus 37.1 ± 7.1%; P < .001) was higher in group 2; better HbA1C levels were also observed. Co-morbidity outcomes, operative data, and complications were similar between groups.

CONCLUSION

The Roux-en-Y gastric bypass with 200 cm of biliopancreatic limb length induces more weight loss at 12 months than a 50 cm limb length. Better HbA1C levels were also observed, but similar effects on co-morbidities and complications were noted.

Type 2 Diabetes Mellitus Remission Models Following Laparoscopic Gastric Bypass: a 4-Model Analysis in a Latino Population

BACKGROUND

Bariatric surgery is indicated for major weight loss and for the control of associated comorbidities, particularly type 2 diabetes. Remission prediction scores have been proposed for this end, such as: DiaRem, Ad-DiaRem, ABCD, and DiaBetter. Nevertheless, they have not been evaluated all together in a specific population.

METHODS

Retrospective study with Mexican patients submitted to gastric bypass with at least 12 months follow-up. All patients had BMI > 30 kg/m² and type 2 diabetes. The primary objective was to evaluate the remission prediction performance of scores. A baseline analysis (anthropometric, biochemical, and metabolic) and remission rates were obtained. Remission scores and cut-off values were assigned based on original descriptions. A ROC analysis was performed for sensibility and specificity.

RESULTS

A total of 95 patients were included. Mean age 44 years, 85.6% female with mean BMI of 44.1 kg/m², and mean HbA1C of 7.2%. At 12 months, complete remission was obtained in 76.8%. ROC curves were plotted showing that DiaRem had 75.3% sensitivity and 68.2% specificity (AUC 0.723 p = 0.001), Ad-DiaRem had 84.9% and 50% (AUC 0.702 p = 0.002), ABCD had 57.5% and 77.3% (AUC 0.0.690 p = 0.002), and DiaBetter had 72.6% and 77.3% (AUC 0.748 p < 0.001).

CONCLUSION

In Mexican patients with obesity and type 2 Diabetes, submitted to gastric bypass, remission prediction could be assessed with any current model showing satisfactory sensibility and specificity. Among such models, DiaBetter obtained the best statistical performance in our population. Type 2 diabetes remission rate at 1 year is similar to any other race or ethnicity.

Bariatric/Metabolic Surgery in Type 1 and Type 2 Diabetes Mellitus

The prevalence of type 2 diabetes mellitus (T2DM) and obesity shows a gradual increase nowadays. Despite the introduction of multiagent treatment modalities, many patients with T2DM still do not have good results. Bariatric/metabolic surgery performed in obese patients to attain weight loss has been shown to improve T2DM. Type 1 diabetes mellitus is another type of diabetes that also shows an increase in prevalence. The aim of the present study was to evaluate the literature about the bariatric/metabolic surgical procedures performed in patients with type 1 and type 2 diabetes.