Mechanisms of long-term weight regain in patients undergoing sleeve gastrectomy

Intensive pre-operative information course (IPIC) and pre-operative weight loss results in long-term sustained weight loss following bariatric surgery: 11 years results from a tertiary referral centre

INTRODUCTION

Outcomes of long-term (5-10-year) weight loss have not been investigated thoroughly and the role of pre-operative weight loss on long-term weight loss, among other factors, are unknown. Our regional bariatric service introduced a 12 week intensive pre-operative information course (IPIC) to optimise pre-operative weight loss and provide education prior to bariatric surgery. The present study determines the effect of pre-operative weight loss and an intense pre-operative information course (IPIC), on long-term weight outcomes and sustained weight loss post-bariatric surgery.

METHODS

Data were collected prospectively from a bariatric center (2008-2022). Excess weight loss (EWL) ≥ 50% and ≥ 70% were considered outcome measures. Survival analysis and logistic regression identified variables associated with overall and sustained EWL ≥ 50% and ≥ 70%.

RESULTS

Three hundred thirty-nine patients (median age, 49 years; median follow-up, 7 years [0.5-11 years]; median EWL%, 49.6%.) were evaluated, including 158 gastric sleeve and 161 gastric bypass. During follow-up 273 patients (80.5%) and 196 patients (53.1%) achieved EWL ≥ 50% and ≥ 70%, respectively. In multivariate survival analyses, pre-operative weight loss through IPIC, both < 10.5% and > 10.5% EWL, were positively associated with EWL ≥ 50% (HR 2.23, p < 0.001) and EWL ≥ 70% (HR 3.24, p < 0.001), respectively. After a median of 6.5 years after achieving EWL50% or EWL70%, 56.8% (154/271) had sustained EWL50% and 50.6% (85/168) sustained EWL70%. Higher pre-operative weight loss through IPIC increased the likelihood of sustained EWL ≥ 50% (OR, 2.36; p = 0.013) and EWL ≥ 70% (OR, 2.03; p = 0.011) at the end of follow-up.

CONCLUSIONS

IPIC and higher pre-operative weight loss improve weight loss post-bariatric surgery and reduce the likelihood of weight regain during long-term follow-up.

Weight Regain after Metabolic Surgery: Beyond the Surgical Failure

Patients undergoing metabolic surgery have factors ranging from anatomo-surgical, endocrine metabolic, eating patterns and physical activity, mental health and psychological factors. Some of the latter can explain the possible pathophysiological neuroendocrine, metabolic, and adaptive mechanisms that cause the high prevalence of weight regain in postbariatric patients. Even metabolic surgery has proven to be effective in reducing excess weight in patients with obesity; some of them regain weight after this intervention. In this vein, several studies have been conducted to search factors and mechanisms involved in weight regain, to stablish strategies to manage this complication by combining metabolic surgery with either lifestyle changes, behavioral therapies, pharmacotherapy, endoscopic interventions, or finally, surgical revision. The aim of this revision is to describe certain aspects and mechanisms behind weight regain after metabolic surgery, along with preventive and therapeutic strategies for this complication.

Prevalence and predictors of weight recurrence following bariatric surgery: A longitudinal prospective cohort study from Tehran Obesity Treatment Study (TOTS)

BACKGROUND

Considering the lack of a standardized definition for weight recurrence (WR), the prevalence and predictors of WR remain inconsistent.

METHODS

The prospective study was conducted on 1939 individuals who underwent bariatric surgery;66.8% underwent sleeve gastrectomy (SG), 33.2%, underwent gastric bypass (GB)[of them 87% one-anastomosis gastric bypass (OAGB), and 13% Rue and Y gastric bypass (RYGB)]. During a follow-up of 72 months, the prevalence of WR ranged from 13.5% to 35.5% according to five different definitions. The generalized estimated equation method was used to assess weight changes, excess weight loss (EWL%), and body composition (fat mass (FM), fat-free mass (FFM)and FFM loss/weight loss% (FFML/WL%)) by a bioelectrical impedance analyzer. Stepwise logistic regression models were applied to determine the independent predictors of WR.

RESULTS

Among 1939 participants followed up for 72 months, WR definitions were applied to 650 patients (75.4% females) with an average BMI of 44.3 ± 5.4 kg/m2,491 (75.5%) and 159 (24.5%) of whom underwent SG and GB, respectively. WR group had relatively higher weights and FM and lower EWL%. A WR turning point was observed at 24 months post-surgery (Ptime before & after 24 months<0.001). The most significant risk factors for WR included SG (in all WR definitions), a younger age (in four out of five definitions), and a higher baseline BMI (in three out of five definitions).

CONCLUSION

The prevalence and predictors of WR varied greatly depending on the definition applied. The prominent risk factors of WR included SG, younger age, and a higher baseline BMI.

Towards precision medicine in bariatric surgery prescription

Obesity is a complex, multifactorial and chronic disease. Bariatric surgery is a safe and effective treatment intervention for obesity and obesity-related diseases. However, weight loss after surgery can be highly heterogeneous and is not entirely predictable, particularly in the long-term after intervention. In this review, we present and discuss the available data on patient-related and procedure-related factors that were previously appointed as putative predictors of bariatric surgery outcomes. In addition, we present a critical appraisal of the available evidence on which factors could be taken into account when recommending and deciding which bariatric procedure to perform. Several patient-related features were identified as having a potential impact on weight loss after bariatric surgery, including age, gender, anthropometrics, obesity co-morbidities, eating behavior, genetic background, circulating biomarkers (microRNAs, metabolites and hormones), psychological and socioeconomic factors. However, none of these factors are sufficiently robust to be used as predictive factors. Overall, there is no doubt that before we long for precision medicine, there is the unmet need for a better understanding of the socio-biological drivers of weight gain, weight loss failure and weight-regain after bariatric interventions. Machine learning models targeting preoperative factors and effectiveness measurements of specific bariatric surgery interventions, would enable a more precise identification of the causal links between determinants of weight gain and weight loss. Artificial intelligence algorithms to be used in clinical practice to predict the response to bariatric surgery interventions could then be created, which would ultimately allow to move forward into precision medicine in bariatric surgery prescription.

Prediction of 5-Year Weight Loss and Weight Regain According to Early Weight Loss after Sleeve Gastrectomy

BACKGROUND

Patients with morbid obesity exhibit sustained weight loss after sleeve gastrectomy (SG), but some individuals exhibit subsequent weight regain in the following years. Early weight loss was proven as a predictor of short- and mid-term weight loss and regain. However, the long-term effects of early weight loss have yet to be fully investigated. This study investigated the predictive effects of early weight loss on long-term weight loss and regain after SG.

METHODS

Data of patients who underwent SG from November 2011 to July 2016 and followed through July 2021 were collected retrospectively. Weight regain was defined by weight increase more than 25% of their lost weight at the first postoperative year. Linear regression analysis and Cox proportional hazards analysis were performed to evaluate the correlations among early weight loss, weight loss, and weight regain.

RESULTS

Data of 408 patients were included. The percentages of total weight loss (%TWL) at postoperative months 1, 3, 12, and 60 were 10.6%, 18.1%, 29.3%, and 26.6%, respectively. The %TWL at months 1 and 3 were significantly correlated with %TWL after 5 years (P < .01). The weight regain rate was 29.8% at 5 years. The %TWL at months 1 and 3 significantly influenced weight regain (hazard ratio: 0.87 and 0.89, P = .017 and .008).

CONCLUSION

Early weight loss may be used to predict weight loss and regain 5 years after SG. Patients with poor early weight loss are recommended to receive early interventions to achieve long-term weight loss and prevent weight regain.

Bariatric endoscopy: from managing complications to primary metabolic procedures

Obesity is a worldwide epidemic and is the second leading cause of preventable death. The approach to treating obesity involves a multidisciplinary approach including lifestyle interventions, pharmacological therapies, and bariatric surgery. Endoscopic interventions are emerging as important tools in the treatment of obesity with primary and revisional bariatric endoscopic therapies. These include intragastric balloons, aspiration therapy, suturing and plication, duodenal-jejunal bypass liners, endoscopic duodenal mucosal resurfacing, and incisionless magnetic anastomosis systems. Endoscopic interventions have also demonstrated efficacy in treating complications of bariatric surgery. Approaches include stenting, endoscopic internal drainage, and endoscopic vacuum-assisted closure. This review aimed to discuss the current endoscopic procedures used as primary and revisional bariatric therapy including those used for managing bariatric surgical complications.

Association Between Energy and Macronutrient Intakes and Weight Change After Bariatric Surgery: a Systematic Review and Meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to summarize the evidence on the associations of energy and macronutrient intakes (carbohydrates, fats, and proteins) with weight loss in adults after sleeve gastrectomy or gastric bypass and to determine whether these dietary characteristics of patients with suboptimal weight loss (SWL) or weight regain differ from those without these experiences.

METHODS

PubMed, Scopus, and Web of Science were searched until December 2021. Twenty-three observational studies were included.

RESULTS

Studies on the association of postoperative energy and macronutrients and weight loss used diverse approaches. Pooled results showed that patients with SWL consumed more energy than those with acceptable weight loss. Weight regainers consumed more energy and carbohydrates and less protein than non-regainers.

CONCLUSIONS

Higher energy consumption is related to SWL and weight regain after surgery. Associations between macronutrients and weight outcome following bariatric surgery warrant further investigation.

A nomogram model based on the combination of the systemic immune-inflammation index and prognostic nutritional index predicts weight regain after laparoscopic sleeve gastrectomy

BACKGROUND

The high rate of weight regain after laparoscopic sleeve gastrectomy is a great challenge. The systemic immune-inflammation index (SII; calculated by neutrophils, lymphocytes, and platelets) and prognostic nutritional index (PNI; calculated by albumin and lymphocytes) are widely used as prognostic factors in various diseases.

OBJECTIVES

The objective of this study was to investigate independent the independent risk factors associated with weight regain in patients after laparoscopic sleeve gastrectomy.

SETTING

A single-center retrospective study.

METHODS

Weight regain was defined as the percentage of increase in body weight ≥10% in comparison with the nadir weight postoperatively. Eligible patients admitted to the bariatric center of our hospital were consecutively enrolled and grouped according to the occurrence of weight regain within 5 postoperative years. Univariate and multivariate logistic regression analyses were performed to assess potential risk factors. A nomogram model containing the risk factors was then constructed and evaluated by R.

RESULTS

A total of 217 patients were enrolled, and 87 (40.1%) patients experienced weight regain. Univariate and logistic regression analyses indicated that depression (odds ratio [OR]: 2.51, 95% confidence interval [CI]: 1.20-5.22, P = .015), psychological counseling (OR: 2.27, 95% CI: 1.20-4.33, P = .017), preoperative C-reactive protein (OR: 2.20, 95% CI: 1.18-4.13, P = .012), and combination of SII-PNI scores (OR: .45, 95% CI: .31-.67, P < .001) were 4 independent risk factors for postoperative weight regain in laparoscopic sleeve gastrectomy patients. The area under the curve of the constructed nomogram model for predicting weight regain was .706.

CONCLUSIONS

This study concluded that the combination of the SII-PNI was an independent risk factor for weight regain and that the nomogram model based on the combination of the SII-PNI had a good predictive value.

Definition, Mechanisms and Predictors of Weight Loss Failure After Bariatric Surgery

It has been proven that surgery is more effective than non-surgical treatment in obese patients. However, this approach has several disadvantages, especially long-term weight loss. Weight loss failures can be broadly classified into two categories; insufficient weight loss (poor responder) and weight regain. However, a unified definition has not been established yet for each category, and there is no clear standard for the post-surgery time point to be used to assess weight loss failure. In addition, analyzing factors that contribute to weight loss failure will lead to strategies for reducing it. Therefore, many researchers have been interested in this subject and have published conflicting results. This review presents a definition for and describes the mechanisms and predictors of weight loss failure after bariatric surgery.

Weight Loss and Eating Pattern 7 Years After Sleeve Gastrectomy: Experience of a Bariatric Center of Excellence

PURPOSE

Report the analysis from a single center series of consecutive primary sleeve gastrectomy (SG) on the factors affecting weight loss at long term.

MATERIALS AND METHODS

Patients submitted to primary SG with a follow-up of 7 years were screened. Weight loss was evaluated with %excess weight loss (%EWL) and %excess BMI loss (%BMIL). Weight regain (WR) was defined as in increase of 25% of the obtained %EWL and insufficient weight loss (IWL) as loss < 50% EWL. Eating behaviors were evaluated with 7 days record (7dR). All the variables potentially affecting the weight loss were cross-matched for correlation. The study population was divided in three groups: group A (WR), group B (IWL), and group C (sustained weight loss) for comparative analysis.

RESULTS

A total of 86 patients (21 M/65 F) with a preoperative BMI of 47.08 ± 6.15 kg/m² were evaluated. Cumulative 7 years weight loss was as follows: 61.66 ± 22.69% EWL and 32 ± 9% EBMIL. A total of 4.6% had an IWL while 27.9% a WR. The analysis showed a significant difference among the daily calories and fats consuming, number of meals, physical activity, grazing/sweet eating habits, and adherence to follow-up (p < 0.05) between groups A and C. Cox hazard demonstrated a significant risk (p < 0.05) to WR in case of adherence to follow-up shorter than 48 months, high daily calories, and fats intake (hazard ratio (HR) range 5-9). Eight patients (9.3%) had a surgical revision.

CONCLUSION

Our data demonstrated that long-term results (7 years) of SG are strongly related to eating habits and patient's behaviors.

Health Status, Eating, and Lifestyle Habits in the Long Term Following Sleeve Gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) is an established bariatric procedure. However, long-term data on eating and lifestyle behaviors and their effect on weight outcomes are scarce. Therefore, this study aimed to examine these long-term behaviors and their associations to weight outcomes following SG.

METHODS

A long-term follow-up study (>5 years post-surgery) of 266 adult patients admitted to a primary SG surgery during 2008-2012 and who participated in a pre-surgery study was conducted. Data on pre-surgery demographics, anthropometrics, and medical status were obtained from the patients' medical records. Data on long-term health status, anthropometrics, lifestyle and eating habits, eating pathologies, follow-up regime, and satisfaction from the surgery were collected by an interview phone calls according to a structured questionnaire.

RESULTS

Data of 169 patients were available before and 7.8±1.0 years post-SG. Their baseline mean age was 41.8±11.3 years, and 71.6% of them were females. The mean post-surgery excess weight loss (EWL) was 53.2±31.2%, and 54.2% had EWL of ≥50%. Eating 3-6 meals per day, not having the urge to eat after dinner, separating liquids from solids, avoiding carbonated beverages, and performing physical activity were related to better weight-loss outcomes (P≤0.026). However, frequent need for eating sweets, binge eating, and feeling guilty or sad after eating were related to worse weight-loss outcomes (P≤0.010). Furthermore, only a minority reported taking a multivitamin and participating in follow-up meetings after more than 1 year since the surgery (≤21.3%).

CONCLUSIONS

In the long term following SG, approximately half achieved EWL of ≥50%, and physical activity, certain eating patterns, and eating pathologies were related to weight outcomes.

Intrathoracic Migration of Gastric Sleeve Affects Weight Loss as well as GERD-an Analysis of Remnant Gastric Morphology for 100 Patients at One Year After Laparoscopic Sleeve Gastrectomy

PURPOSE

Laparoscopic sleeve gastrectomy (SG) is now frequently performed as a definitive bariatric procedure. The aim of the study was to evaluate the detailed morphology of remnant stomachs after SG with respect to volume and sleeve migration.

MATERIALS AND METHODS

We performed a review of prospectively collected data on patients that completed a 12-month postop examination, which included CT volumetry of the sleeve, and a questionnaire that addressed postop food tolerance. CT volumetry study included total sleeve volume (TSV), tube volume (TV), antral volume (AV), tube/antral volume ratio (TAVR), and the presence of intrathoracic sleeve migration (ITSM).

RESULTS

One hundred patients were included in this study. Mean %TWL (total weight loss) at 12 months postop was 31.1% (14.3~55.5), and mean TSV, TV, AV, and TAVR were 188.3 ± 67.3 ml, 81.3 ± 38.5 ml. 107.0 ± 45.1 ml, and 0.846 ± 0.514 respectively. TSV was not correlated significantly with %TWL at 12 months postop (r=-0.140, p=0.164). Thirty patients (30/100, 30%) showed ITSM. Patients with ITSM had a significantly lower mean GER score (5.9 ± 2.3 vs. 7.5±1.9, p=0.001), and a higher proportion showed suboptimal weight loss (43.3% vs. 15.7%, p=0.003).

CONCLUSIONS

Mean TSV was not found to be significantly correlated with %TWL at 12 months postop. The presence of ITSM indicated more frequent GER symptoms and a higher probability of suboptimal weight loss.

Patterns of Change in Device-Based Physical Activity and Sedentary Time Following Bariatric Surgery: a Longitudinal Observational Study

PURPOSE

The aim of this study is to investigate changes in physical activity (PA) and sedentary time (ST) over 12 months following bariatric surgery.

METHODS

Pre-surgery and at 3, 6, 9, and 12 months post-surgery, wearable devices were used to measure PA at different intensities, grouped according to energy expenditure and daily step count, and ST. Measures were also collected of weight and self-efficacy for exercise. Pre- and 12 months post-surgery, measures were collected of body composition and cardiovascular fitness.

RESULTS

Thirty adults scheduled for bariatric surgery were recruited (20 females, 44.1 [range, 22.0 to 65.0] years, body mass index 39.6 [range, 30.9 to 50.9] kg/m²). When compared to pre-surgery measures, over the 12 months post-surgery, there were no changes in the percentage of waking hours (mean [95% CI]) spent in ST (- 2% [- 6 to 3]), light intensity PA (1% [- 3 to 5]), and moderate-to-vigorous intensity PA (1% [- 1 to 3]). At all time points, participants spent most (> 70%) of their waking hours accumulating ST, with little time spent in light intensity PA (~ 21%) and almost no time in moderate-to-vigorous intensity PA (~ 5%). Step count and cardiovascular fitness were also unchanged. There were significant changes in weight, self-efficacy for exercise, and body composition.

CONCLUSIONS

Although bariatric surgery resulted in substantial weight loss and improved self-efficacy for exercise, it was insufficient to effect change in PA, ST or cardiovascular fitness. Complementing surgical intervention with behavioral interventions may optimize change in PA and ST.

Factors associated with weight regain post-bariatric surgery: a systematic review

INTRODUCTION

To systematically review the literature to assess the incidence and risk factors of weight regain (WR) after bariatric surgery. Bariatric surgery is the most effective intervention for sustained weight loss of morbidly obese patients, but WR remains a concern.

MATERIALS AND METHODS

A PRISMA compliant systematic literature review was performed using the PubMed database, Embase and the Cochrane Library in July of 2019. Studies that reported ≥ 10% WR after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) were included. The Newcastle-Ottawa scale (NOS) was used for assessing study quality.

RESULTS

Out of 2915 retrieved abstracts, 272 full papers were reviewed, and 32 studies included (25 of high and 7 of fair quality) reporting weight outcomes on 7391 RYGB and 5872 SG patients. 17.6% (95% CI 16.9-18.3) had a WR ≥ 10%. Risk factors related with WR fell into 5 categories, namely anatomical, genetic, dietary, psychiatric, and temporal. Specifically, gastrojejunal stoma diameter, gastric volume following sleeve, anxiety, time after surgery, sweet consumption, emotional eating, portion size, food urges, binge eating, loss of control/disinhibition when eating, and genetics have been positively associated with WR while postprandial GLP-1, eagerness to change physical activity habits, self-esteem, social support, fruit and zinc consumption, HDL, quality of life have been negatively associated.

CONCLUSION

At least 1 in 6 patients after bariatric surgery had ≥ 10% WR. This review identified several factors related to WR that can be used to counsel patients preoperatively and direct postoperative strategies that minimize WR risk.

Conversion of laparoscopic sleeve gastrectomy after weight loss failure into laparoscopic one anastomosis gastric bypass: short-term safety and efficacy and effect of indications on outcome

BACKGROUND

Revisional surgery after failed laparoscopic sleeve gastrectomy (LSG) is growing and laparoscopic one anastomosis gastric bypass (LOAGB) has been proposed as a revisional procedure due to its combined restrictive and malabsorptive effects. The aim is to study short-term complications and weight loss (WL) results of the revisional LOAGB after LSG for the two-weight loss failure (WLF) types [insufficient weight loss (IWL) and weight regain (WR)] and to assess the possible effects of these two types of failure and gastric tube anatomy on the final outcome.

METHODS

The data of 28 patients who completed 1-year follow-up for their revisional LOAGB after their failed LSG were assessed and statistically correlated to leakage and one year WL results.

RESULTS

Operative time was 96 ± 17.4 min. Leakage occurred in 2 patients (7.1%); the small number of leak patients does not allow statistical analysis for leakage. Percentage of excess weight loss (%EWL) at one year was 79.0 ± 14.4%; percentage of total weight loss (%TWL) was 31.7 ± 6.4%. %EWL was 84.2 ± 13.1 with IWL and 73.0 ± 13.9 with WR (P = 0.036). %TWL was 35.0 ± 5.2 with IWL and 27.8 ± 5.5 with WR (P = 0.001). %TWL at persistent fundus, diffusely dilated, and nondilated stomach were 38.98 ± 4.57, 31.3 ± 5.33, and 28.54 ± 5.91, respectively (P = 0.006).

CONCLUSION

LOAGB is a highly effective and safe procedure as a revision after LSG with WLF. Patients with IWL and patients with persistent fundus lost more weight than those with WR and those with diffuse stomach dilation or nondilation, respectively.

Revisional Surgeries of Laparoscopic Sleeve Gastrectomy

Bariatric surgery has become increasingly common due to the worldwide obesity epidemic. A shift from open to laparoscopic surgery, specifically, laparoscopic sleeve gastrectomy (LSG), has occurred in the last two decades because of the low morbidity and mortality rates of LSG. Although LSG is a promising treatment option for patients with morbid obesity due to restrictive and endocrine mechanisms, it requires modifications for a subset of patients because of weight regain and tough complications, such as gastroesophageal reflux, strictures, gastric leak, and persistent metabolic syndrome., Revision surgeries have become more and more indispensable in bariatric surgery, accounting for 7.4% in 2016. Mainstream revisional bariatric surgeries after LSG include Roux-en-Y gastric bypass, repeated sleeve gastrectomy, biliopancreatic diversion, duodenal switch, duodenal-jejunal bypass, one-anastomosis gastric bypass, single anastomosis duodeno-ileal bypass (SAID) and transit bipartition. This review mainly describes the revisional surgeries of LSG, including the indication, choice of surgical method, and subsequent effect.

Morphologic Study of Gastric Sleeves by CT Volumetry at One Year after Laparoscopic Sleeve Gastrectomy

PURPOSE

Laparoscopic sleeve gastrectomy (SG) is now frequently performed as a definitive bariatric procedure. The aim of the study was to evaluate the detailed morphology of remnant stomachs after SG with respect to volume and sleeve migration.

MATERIALS AND METHODS

We performed a retrospective review of prospectively collected data on patients that completed a 12-month postop examination, which included CT volumetry of sleeve, and a questionnaire that addressed postop food tolerance. CT volumetry study included total sleeve volume (TSV), tube volume (TV), antral volume (AV), tube/antral volume ratio (TAVR), and the presence of intrathoracic sleeve migration (ITSM).

RESULTS

Fifty-five patients were included in this retrospective study. Mean %TWL (% total weight loss) at 12 months postop was 32.8% (14.3-55.5), and mean TSV, TV, AV, and TAVR were 166.6±63.3 ml, 68.9±35.4 ml, 97.7±42.9 ml, and 0.8±0.6 respectively. TSV was not correlated significantly with %TWL at 12 months postop (r=-0.069, P=0.619). Fourteen patients (14/55, 25.5%) showed ITSM by CT. Patients with ITSM had a significantly lower mean GER score (5.1±2.0 vs. 7.3±2.0, P=0.001), a lower total food tolerance score (21.6±3.8 vs. 24.4±4.6, P=0.048), and a higher proportion showed suboptimal weight loss (35.7% vs. 9.8%, P=0.023).

CONCLUSION

Mean TSV was not found to be significantly correlated with %TWL at 12 months postop. Patients with suboptimal weight loss had higher mean TAVR, and the presence of ITSM indicated more frequent GER symptoms, lower food tolerance, and a higher probability of suboptimal weight loss.

Associations between Physical Activity and Changes in Weight Across 7 Years following ROUX-en-Y Gastric Bypass Surgery: A Multicenter Prospective Cohort Study

OBJECTIVE

To examine associations of objectively-measured physical activity (PA) with changes in weight after Roux-en-Y gastric bypass (RYGB) over 7 years.

BACKGROUND

The contribution of free-living PA to surgery-induced weight loss and subsequent weight regain is not well understood.

METHODS

Participants of a multi-center prospective cohort study of bariatric surgery were followed annually ≥7 years. Of 807 participants who underwent RYGB and were given an activity monitor, 649 (80%) had sufficient data for this report (78% female; median age 47 years; median body mass index 46 kg/m). Mean daily steps, hours/day in sedentary behavior (SB) and minutes/week in moderate-to-vigorous physical activity (MVPA) were determined at each assessment. Mixed models tested associations between PA measures and weight outcomes, controlling for sociodemographics, health status and eating behaviors.

RESULTS

Across follow-up, mean pre- to post-surgery changes in PA were small, and mean post-surgery PA level was below PA recommendations for health (e.g., 101 MVPA min/week 7 years post-surgery versus the ≥150 MVPA min/week recommendation). There was a dose-response association between more steps, less SB and more MVPA with greater weight loss. Steps and SB, but not MVPA, were also associated with weight regain. For example, participants in the highest versus lowest steps quartile lost 2.9% (95%CI, 1.8-4.1) more of their pre-surgery weight and regained 5.4% (95%CI, 2.4-8.3) less of their maximum weight lost across follow-up.

CONCLUSION

Despite only small increases in objectively-measured PA level after RYGB, PA level was independently associated with weight outcomes of bariatric surgery throughout 7 years of follow-up.

REPRINTS

Reprints will not be available from the authors.

Effects of bariatric surgery in Chinese with obesity and type 2 diabetes mellitus: A 3-year follow-up

The incidence of obesity and type 2 diabetes mellitus is growing, and bariatric surgery was applied as a new therapy in the past few decades. However, bariatric surgery started rather late in China, and the number of surgeries and the follow-up data is limited.We assessed body weight, glucose, lipid levels, and blood pressure at baseline and 6-month, 1-year, 3-year in patients who underwent bariatric surgery. Vitamins and trace elements were investigated at 3-year after surgery. The quality of life was assessed at 3-year and compared with the control group.In total 20 patients were recruited in the study, and all the 20 patients underwent surgery and completed all follow-ups. Results showed that the body weight, body mass index, glycated hemoglobin (HbA1C), glucose, and insulin level were decreased, and islet function improved significantly in 6-month and 1-year (P < .001), and the changes were more obvious in the first 6 months. However, all the indexes rebound significantly at the 3-year (P < .05), but still better than baseline (P < .05). Weight regain was 50% after 3 years, and the mean weight regain rate was 31.45%. Besides, blood pressure and lipid levels decreased significantly compared with baseline (P < .001). At the 3-year follow-up, we found that 100% of the patients showed vitamin D deficiency, 50% calcium deficiency, 20% vitamin B12 deficiency, 20% iron deficiency, and 15% suffered from anemia. Compared with the control group, the quality of life was better in patients who underwent surgery, especially in the physical health (P < .05).The current study showed that the body weight, glucose and islet function improved significantly after bariatric surgery, and the indexes changed mainly in the first 6 months, but there seemed to be a rebound after 3 years. Furthermore, the surgery may improve the blood pressure, lipid profile, and the quality of life. However, some patients may suffer anemia, calcium deficiency, iron deficiency, vitamin D, and vitamin B12 deficiency after 3 years.

Five-Year Weight Loss Outcomes in Laparoscopic Vertical Sleeve Gastrectomy (LVSG) Versus Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) Procedures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Laparoscopic vertical sleeve gastrectomy (LVSG) has overtaken the laparoscopic Roux-en-Y gastric bypass (LRYGB) as the most frequently performed bariatric surgical procedure. To date little has been reported on the long-term outcomes of the LVSG procedure comparative to the traditionally favoured LRYGB. We undertook a systematic review and meta-analysis to review the 5-year outcomes of comparing LVSG and LRYGB. We undertook a systematic review and meta-analysis to compare 5-year weight loss outcomes of randomized controlled trials comparing LVSG to LRYGB.

MATERIALS AND METHODS

Searches of electronic databases (PubMed, Embase, CINAHL, Cochrane) were undertaken for randomized controlled trials describing weight loss outcomes in adults at 5 years postoperatively. Where sufficient data was available to undertake meta-analysis, the Hartung-Knapp-Sidik-Jonkman estimation method for random effects model was utilized. The review was registered with PROSPERO and reported following in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Five studies met the inclusion criteria totaling 1028 patients (LVSG=520, LRYGB=508). Moderate but comparable levels of bias were observed within studies. Statistically significant body mass index loss ranged from -11.37 kg/m (range: -6.3 to -15.7 kg/m) in the LVSG group and -12.6 kg/m (range: -9.5 to -15.4 kg/m) for LRYGB at 5 years (P<0.001). Systematic review suggested that LRYGB produced a greater weight loss expressed as percent excess weight and percent excess body mass index loss than LVSG: this was not corroborated in the meta-analysis.

CONCLUSIONS

Five year weight loss outcomes suggest both LRYGB and LVSG are effective in achieving significant weight loss at 5 years postoperatively, however, differences in reporting parameters limit the ability to reliably compare the outcomes using statistical methods. Furthermore, results may be impacted by large dropout rates and per protocol analysis of the 2 largest included studies. Further long-term studies are required to contradict or validate the results of this meta-analysis.

Weight regain after bariatric surgery: a systematic literature review and comparison across studies using a large reference sample

Published estimates of weight regain (WR) after bariatric surgery vary greatly. Understanding the sources of variability in the literature and clarifying the magnitude of WR after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are critical for informing expectations and planning interventions. A literature search through January 2019 yielded 15 English-language studies that reported WR in at least 30 participants, not selected based on weight loss or WR, at least 3 years after primary RYGB (n = 11) or SG (n = 5). Median follow-up was 5.0 (range, 3.2-10.0) years. Median sample size was 62 (range, 33-464). Samples represented a median of 54.3% (range, 10.7%-100%) of eligible participants. Nadir weight was determined by serial research assessments (n = 1), medical records (n = 7), participant recall (n = 4), or an undisclosed method (n = 4). Three continuous and 8 binary WR measures (the latter, based on various thresholds for clinically meaningful WR) were reported. To enable comparison across studies, the percentage difference in WR in each study versus a reference sample (n = 1433 RYGB), matched on time since surgery and WR measure, was calculated. Median WR in the reference sample increased from 8.2 (25th-75th percentile: 0-19.5) to 23.8 (25th-75th percentile: 9.0-33.9) percent of maximum weight lost, 3 to 6 years post RYGB surgery. Studies of RYGB versus SG, with larger versus smaller samples, with higher versus lower participation rates, that determined nadir weight via participant recall versus medical records, and reported continuous versus binary WR measures tended to have WR values closer to the reference sample and each other. Variation in WR estimates was explained by heterogeneity in WR measures, timing of assessment, surgical procedure, and study design characteristics. The best estimate of WR after RYGB likely comes from the large reference sample. WR after SG versus RYGB appears higher. However, additional high-quality studies with uniform reporting of WR by surgical procedure are needed.

Perception of Hunger/Satiety and Nutrient Intake in Women Who Regain Weight in the Postoperative Period After Bariatric Surgery

OBJECTIVE

To investigate the perception of hunger and satiety and its association with nutrient intake in women who regain weight in the postoperative period after bariatric surgery.

METHODS

Cross-sectional study of adult women divided into three groups: weight regain (n = 20), stable weight (n = 20) (both at least 24 months after Roux-en-Y gastric bypass surgery), and non-operated obesity (n = 20). A visual analogue scale measured hunger/satiety perception while fasting, immediately after finishing a test meal, and 180 min after finishing the test meal. The incremental area above or under the curve was calculated. Food intake was analyzed by 3 days of food recall and adjusted for intraindividual variation. To make between-group comparisons, Mann-Whitney, ANOVA, Kruskal-Wallis, and independent-samples T tests and Pearson's correlation were used.

RESULTS

There were no between-group differences in incremental areas of hunger/satiety, but protein intake was significantly lower among patients who regained weight compared with those who had stable body weight (0.99 ± 0.23 g/kg body weight vs. 1.17 ± 0.21 g/kg body weight, p = 0.047). In the group that regained weight, satiety was correlated positively with usual dietary protein density (r = 0.541; p = 0.017) and negatively with usual carbohydrate intake (r = - 0.663; p = 0.002).

CONCLUSION

Women who regained weight presented similar perceptions of hunger/satiety to those of patients without weight regain and with non-operated obesity. In patients who regained weight postoperatively, satiety perception was correlated positively with usual dietary protein density and inversely with usual carbohydrate intake.

Effects of a High-Intensity Exercise Program on Weight Regain and Cardio-metabolic Profile after 3 Years of Bariatric Surgery: A Randomized Trial

Weight regain is one of the most common problems in the long-term after bariatric surgery. It is unknown if high-intensity exercise programs applied in late phases of post-surgical follow-up could counteract this trend. After a 3-year follow-up, 21 patients underwent sleeve gastrectomy were randomized into an exercise group (EG, n = 11), that performed a 5-month supervised exercise program, and a control group (CG, n = 10), that followed the usual care. Body composition, cardiorespiratory fitness, glycaemia and blood cholesterol were evaluated before and after the intervention. Finally, the EG repeated the evaluations 2 months after the end of the exercise program. Both groups reached their maximum weight loss at the first year after surgery and showed significant weight regain by the end of the follow-up. After the exercise program, the EG showed reductions in fat mass (-2.5 ± 2.6  kg, P < 0.05), glycaemia (-13.4 ± 8.7  mg·dL-1, P < 0.01) and blood cholesterol (-24.6 ± 29.1  mg·dL-1, P < 0.05), whereas the CG during the same period showed increases in weight (1.5 ± 1.3  kg, P < 0.05) and fat mass (1.8 ± 0.9, P < 0.01). Two months after the end of the program, EG had increases in weight (1.1 ± 1.2  kg, P < 0.05), fat mass (2.6 ± 2.2  kg, P < 0.01), glycaemia (8.2 ± 11.6  mg·dL-1, P < 0.05) and blood cholesterol (20.0 ± 22.1  mg·dL-1, P < 0.05), when compared with the values after the exercise program. Therefore, in the medium-term after sleeve gastrectomy exercise may contribute to prevent weight regain and to reduce fat mass, glycaemia, and blood cholesterol.

Impact of Weight Regain on the Evolution of Non-alcoholic Fatty Liver Disease After Roux-en-Y Gastric Bypass: a 3-Year Follow-up

BACKGROUND

The influence of post-surgical weight regain on the course of non-alcoholic fatty liver disease (NAFLD) is unclear.

OBJECTIVE

To evaluate the influence of weight regain on the NAFLD assessed by means of a non-invasive score after Roux-en-gastric bypass (RYGB) over a 3-year period.

METHODS

This is a prospective observational cohort study which evaluated individuals who underwent RYGB. Comparisons were made between the periods immediately before surgery and 12, 24, and 36 months following surgery. Liver disease was estimated by means of the NAFLD fibrosis score. Individuals were classified into three categories according to weight regain status: (1) no weight regain, (2) expected weight regain (regain less or equal than 20% of the maximal weight lost), (3) obesity recidivism (regain above 20% of the maximal weight lost).

RESULTS

Of 90 patients analyzed after 3 years of surgery, 35.6% presented obesity recidivism and 28.8% of the expected regain; 35.6% presented no regain. There was no difference in baseline fibrosis score between groups; at 3 years, the score observed in the relapse group was significantly higher than that observed in the other two groups (p = 0.015). The percent variation of the fibrosis score was significantly higher in the recidivism group (+ 11.8 ± 77.2%) than in the expected regain (- 45.6 ± 64.5%) and no regain (- 37.8 ± 63.2%) groups (p = 0.013).

CONCLUSION

Long-term significant post-RYGB weight regain is associated with a significantly attenuated improvement of NAFLD evaluated by means of liver fibrosis score.

Modifiable factors associated with weight regain after bariatric surgery: a scoping review

Background: Although bariatric surgery is the most effective treatment for severe obesity, weight regain may still occur. While non-modifiable factors associated with weight regain have been explored, modifiable factors responsible for weight regain are understudied. This scoping review aimed to identify modifiable behaviors associated with weight regain after bariatric surgery. Methods: A systematic search was conducted in Medline, Google Scholar, Cochrane, National Collaborating Centre for Methods and Tools (NCCMT) and Practice-based Evidence in Nutrition (PEN) which included articles published between January 1990 and February 2 2017, for studies examining "weight regain" after bariatric surgery. A total of 293 citations were retrieved. Eligible articles must have examined modifiable factors and addressed weight regain, or a long-term post-operative phase in which weight regain may occur. After removing duplicates, 22 studies were included for thematic analysis. Results: Key modifiable factors associated with weight regain were identified and categorized under the following themes: poor dietary adherence (e.g. excessive calorie, carbohydrate, and alcohol intake), maladaptive eating behaviors (e.g. grazing, binging), lack of on-going follow-up with the bariatric team and insufficient physical activity. Conclusions:  Health professionals and self-monitoring tools for patients who have undergone bariatric surgery may benefit from these findings to direct their education and interventions to target behavior change.

Modifiable factors associated with weight regain after bariatric surgery: a scoping review

Background: Although bariatric surgery is the most effective treatment for severe obesity, weight regain may still occur. While non-modifiable factors associated with weight regain have been explored, modifiable factors responsible for weight regain are understudied. This scoping review aimed to identify modifiable behaviors associated with weight regain after bariatric surgery. Methods: A systematic search was conducted in Medline, Google Scholar, Cochrane, National Collaborating Centre for Methods and Tools (NCCMT) and Practice-based Evidence in Nutrition (PEN) which included articles published between January 1990 and February 2 2017, for studies examining "weight regain" after bariatric surgery. A total of 293 citations were retrieved. Eligible articles must have examined modifiable factors and addressed weight regain, or a long-term post-operative phase in which weight regain may occur. After removing duplicates, 22 studies were included for thematic analysis. Results: Key modifiable factors associated with weight regain were identified and categorized under the following themes: poor dietary adherence (e.g. excessive calorie, carbohydrate, and alcohol intake), maladaptive eating behaviors (e.g. grazing, binging), lack of on-going follow-up with the bariatric team and insufficient physical activity. Conclusions:  Health professionals and self-monitoring tools for patients who have undergone bariatric surgery may benefit from these findings to direct their education and interventions to target behavior change.

Predictors of weight regain after sleeve gastrectomy: an integrative review

BACKGROUND

Sleeve gastrectomy (SG) is one of the most effective treatments for severe obesity, but weight regain after surgery is a challenging issue. The mechanism of postoperative weight relapse is barely understood because of the lack of long-term data.

OBJECTIVES

To review and synthesize current evidence related to factors that contribute to weight regain after SG.

METHODS

Whittemore and Knafl's integrative method guided the research. The databases PubMed, EMBASE, and CINAHL, as well as 2 selected journals, were searched through October 2018 to gather English-language journal articles on the potential predictors of post-SG weight regain among adult populations. Only articles with sample size ≥10 were included. A narrative synthesis was used to analyze the 17 studies included in the review.

RESULTS

In recent years there has been an upward trend in the published reports of SG on longer-term outcomes. After a review of 6863 records, 17 eligible studies were identified, reporting various definitions of weight regain and 3 main categories of predictors: surgical/anatomic factors, hormonal/metabolic imbalance, and behavioral/mood factors. The 17 studies used quantitative (n = 16) and qualitative methods (n = 1).

CONCLUSION

There is a dearth of available literature addressing predictors of weight regain after SG, and the inconsistency in the definition of regain limited the comparability between studies. Besides the surgical/anatomic factors that have been reported as significant predictors, other modifiable factors such as behavioral and psychosocial determinants need to be further investigated.

Analysis of the Association between Eating Behaviors and Weight Loss after Laparoscopic Sleeve Gastrectomy

SETTING

In a private medical center, 300 patients who underwent a laparoscopic sleeve gastrectomy (LSG) were classified into 4 groups according to their eating behaviors (EB) preoperatively. During a 3-year postoperative follow-up, dietary changes in relation to weight loss were studied.

OBJECTIVES

To explore the influence of abnormal EB on the outcome of sleeve gastrectomy.

BACKGROUND

Patients with morbid obesity often suffer from abnormal EB. After LSG, the outcome depends largely on improvement of the feeding behaviors acquired.

METHODS

This prospective study includes 300 patients who underwent LSG from 2013 to 2014, divided into the following 4 groups: binge eaters, snack eaters, sweet eaters, and volume eaters.

RESULTS

The average age was 41.65 years, the ratio of male to females was 1 to 2. The average baseline body mass index (BMI) was 42.02. After 3 years, no significant change was found in the number of binge eaters (p = 0.396), but there was an 8.9% increase in snack eaters (p < 0.001), a 12.9% increase in sweet eaters (p < 0.001), and 17.2% increase in healthy eating habits (p < 0.001). Sixty-five (24.8%) patients did not experience changes in their eating patterns. However, after surgery, 24.6% of the patients continued with the same EB and 125 (49.5%) patients changed from one EB to another unhealthy EB. Weight loss, measure as ΔBMI, was similar in each group after 3 years, with a mean BMI of 29.8. When eating habits were related to different features such as gender, sports practice, type of work, smoking, marital status, comorbidities, no influence on the operative results were found.

CONCLUSION

LSG promotes the reduction of overeaters; however, it promotes a switch between other unhealthy EB. The significant increase in snack eaters and sweet eaters is outstanding, although it did not affect weight loss in the midterm follow-up. Worsening of eating habits after LSG is a common fact.

Functional Foods and Lifestyle Approaches for Diabetes Prevention and Management

Functional foods contain biologically active ingredients associated with physiological health benefits for preventing and managing chronic diseases, such as type 2 diabetes mellitus (T2DM). A regular consumption of functional foods may be associated with enhanced anti-oxidant, anti-inflammatory, insulin sensitivity, and anti-cholesterol functions, which are considered integral to prevent and manage T2DM. Components of the Mediterranean diet (MD)-such as fruits, vegetables, oily fish, olive oil, and tree nuts-serve as a model for functional foods based on their natural contents of nutraceuticals, including polyphenols, terpenoids, flavonoids, alkaloids, sterols, pigments, and unsaturated fatty acids. Polyphenols within MD and polyphenol-rich herbs-such as coffee, green tea, black tea, and yerba maté-have shown clinically-meaningful benefits on metabolic and microvascular activities, cholesterol and fasting glucose lowering, and anti-inflammation and anti-oxidation in high-risk and T2DM patients. However, combining exercise with functional food consumption can trigger and augment several metabolic and cardiovascular protective benefits, but it is under-investigated in people with T2DM and bariatric surgery patients. Detecting functional food benefits can now rely on an "omics" biological profiling of individuals' molecular, genetics, transcriptomics, proteomics, and metabolomics, but is under-investigated in multi-component interventions. A personalized approach for preventing and managing T2DM should consider biological and behavioral models, and embed nutrition education as part of lifestyle diabetes prevention studies. Functional foods may provide additional benefits in such an approach.

Banding the Sleeve Improves Weight Loss in Midterm Follow-up

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) can achieve excellent weight loss, yet sleeve dilatation with concomitant weight regain proves to be a relevant issue. Hence, additional restriction might improve results after LSG.

METHODS

In a retrospective matched-pair analysis, 42 patients who underwent banded LSG (BLSG) using a MiniMizer® ring between January 2012 and October 2014 were analysed regarding weight loss, complications and comorbidity. Median follow-up was 3 years. Forty-two patients who had undergone conventional LSG were selected as matched pairs.

RESULTS

Mean preoperative BMI was 54.93 ± 7.42 kg/m² for BLSG and 53.46 ± 6.69 kg/m² for LSG (Mann-Whitney P = 0.540). Total weight loss (%TWL) was significantly greater in the BLSG group 3 years after surgery (BLSG 38.22% ± 7.26; n = 26 vs. LSG 32.69 ± 9.47; n = 26; P = 0.0154). Ring placement had no relevant impact on new-onset reflux (Fisher's exact test P = 1.0) but a tendency towards reflux improvement when reflux pre-existed (odds ratio 1.96). The major side effect of ring implantation was regurgitation with over 44% of patients presenting with regurgitation >1 per week (Fisher's exact test P = 0.0019, odds ratio 18.07).

CONCLUSION

BLSG is a safe procedure showing similar comorbidity to conventional LSG. However, BLSG leads to a higher rate of postoperative regurgitation. Weight loss is significantly improved 3 years after surgery. Hence, additional ring implantation might be an option for increased restriction in LSG surgery.

Bariatric surgery and long-term nutritional issues

Bariatric surgery is recognized as a highly effective therapy for obesity since it accomplishes sustained weight loss, reduction of obesity-related comorbidities and mortality, and improvement of quality of life. Overall, bariatric surgery is associated with a 42% reduction of the cardiovascular risk and 30% reduction of all-cause mortality. This review focuses on some nutritional consequences that can occur in bariatric patients that could potentially hinder the clinical benefits of this therapeutic option. All bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract; this alteration makes these patients more susceptible to developing nutritional complications, namely, deficiencies of macro- and micro-nutrients, which could lead to disabling diseases such as anemia, osteoporosis, protein malnutrition. Of note is the evidence that most obese patients present a number of nutritional deficits already prior to surgery, the most important being vitamin D and iron deficiencies. This finding prompts the need for a complete nutritional assessment and, eventually, an adequate correction of pre-existing deficits before surgery. Another critical issue that follows bariatric surgery is post-operative weight regain, which is commonly associated with the relapse of obesity-related co-morbidities. Nu-tritional complications associated with bariatric surgery can be prevented by life-long nutritional monitoring with the administration of multi-vitamins and mineral supplements according to the patient's needs.

Self-Regulation of Weight After Sleeve Gastrectomy

Bariatric surgery is recognized as the most effective method for achieving relevant weight loss in subjects with severe obesity. However, there is insufficient knowledge about weight self-regulation and quality of motivation in these patients. The main goal of this study was to characterize the association between the percentage of excess weight loss (%EWL) and the motivation to manage weight, at least 1 year after sleeve gastrectomy (SG). This is an observational longitudinal retrospective study. All patients corresponding to predefined inclusion criteria who underwent SG from January 2008 to July 2010 at a main general hospital were invited. A version of the Treatment Self-Regulation Questionnaire (TSRQ) was used to assess patients' quality of motivation: TSRQ concerning continuing the weight self-management program. Clinical data were collected from patients' records. Overall, 81 patients participated (16 men and 65 women, 25-64 years old). The average body mass index was significantly reduced from 45.3 ± 7.0 kg/m² preoperatively to 32.7 ± 6.9 kg/m² postoperatively. Autonomous self-regulation was higher than externally controlled self-regulation, regarding motives to keep managing weight after SG. Postoperatively, %EWL correlated negatively with external self-regulation. SG was found to be associated with the quality of motivation for losing weight. External motivations were associated with worse results. These findings support the importance of multiprofessional teams in the assessment and treatment of patients, aiming for the promotion of weight self-regulation after bariatric surgery.

Long-term weight loss in laparoscopic sleeve gastrectomy

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) has become an option as a bariatric surgical technique. There is a lack of long-term results of this procedure in the literature. The aim of this study is to present weight loss results of LSG for up to 7 years of follow-up.

METHODS

A retrospective series of patients who underwent LSG between 2008 and 2011 was examined. The primary endpoint was weight loss: percentage of excess weight loss (%EWL), percentage of total weight loss (%TWL), and body mass index (BMI) were reported. Failure was defined as %EWL<50%. Multivariate analysis for weight loss was performed. The complications rate was reported.

RESULTS

A total of 148 patients met the inclusion criteria; 76.3% were female. Mean preoperative BMI was 36 ± 4 kg/m². Mean operative time was 89.3 ± 3.2 minutes. Follow-up at 5, 6, and 7 years was 77.7%, 83.3%, and 82.2%, respectively. Mean %EWL and %TWL at 1, 3, 5, and 7 years was 93.2%, 80.7%, 70.6%, and 51.7%, and 27.2%, 23.3%, 20.4%, and 16.3%, respectively. The failure rate was 30.4% at the fifth year and 51.4% at the seventh year. High preoperative BMI was related to worse %EWL (P<0.001) but not to %TWL. Preoperative BMI<35 kg/m² was associated with better %EWL but not with %TWL (P = 0.003). Four leaks (2.7%) and no mortalities were reported.

CONCLUSIONS

LSG is an acceptable surgical technique for weight loss, but in this series, up to one third of the patients fail at the fifth year and half fail in the seventh year. %EWL is better in patients with BMI<35 kg/m², but this difference disappears when we express outcomes with %TWL.

Does Bariatric Surgery Improve Obesity Associated Comorbid Conditions

Obesity is a constantly growing health problem which reduces quality of life and life expectancy. Bariatric surgery for obesity is taken into account when all other conservative treatment modalities have failed. Comparison of the multidisciplinary programs with bariatric surgery regarding to weight loss showed that substantial and durable weight reduction have been achieved only with bariatric surgical treatments. However, the benefits of weight loss following bariatric procedures are still debated regarding the pro-inflammatory and metabolic profile of obesity.

Prognostic factors of weight loss after sleeve gastrectomy: Multi centre study in Spain and Portugal

INTRODUCTION

Sleeve gastrectomy (SG) has become a technique in its own right although a selective or global indication remains controversial. The weight loss data at 5 years are heterogeneous. The aim of the study is to identify possible prognostic factors of insufficient weight loss after SG.

METHODS

A SG retrospective multicenter study of more than one year follow-up was performed. Failure is considered if EWL>50%. Univariate and multivariate study of Cox regression were performed to identify prognostic factors of failure of weight loss at 1, 2 and 3 years of follow up.

RESULTS

A total of 1,565 patients treated in 29 hospitals are included. PSP per year: 70.58±24.7; 3 years 69.39±29.2; 5 years 68.46±23.1. Patients with EWL<50 (considered failure): 17.1% in the first year, 20.1% at 3 years, 20.8% at 5 years. Variables with influence on the weight loss failure in univariate analysis were: BMI>50kg/m², age>50years, DM2, hypertension, OSA, heart disease, multiple comorbidities, distance to pylorus> 4cm, bougie>40F, treatment with antiplatelet agents. The reinforcement of the suture improved results. In multivariate study DM2 and BMI are independent factors of failure.

CONCLUSION

The SG associates a satisfactory weight loss in 79% of patients in the first 5 years; however, some variables such as BMI>50, age>50, the presence of several comorbidities, more than 5cm section of the pylorus or bougie>40F can increase the risk of weight loss failure.

Early post-operative psychosocial and weight predictors of later outcome in bariatric surgery: a systematic literature review

This is the first systematic review to synthesize the evidence concerning early post-operative variables predictive of later weight and psychosocial outcomes in bariatric surgery. Eight electronic databases for empirical studies were searched (1954 to 2016). Most of the 39 included studies reported solely on weight outcomes; eating and psychosocial outcomes were less common. A better early weight loss trajectory was the most consistent predictor of more successful medium-term weight outcome (≤24 months); however, its relationship to longer term weight loss maintenance is less certain. Early eating adaptation may be associated with later weight loss, but further research is needed. Evidence is lacking for associations between early adherence or early psychosocial variables and later outcome. In particular, the relationship between early post-operative depression and later weight remains unclear. Little research has considered early prediction of later eating or psychosocial outcomes. Consideration of mediating or moderating relationships is lacking. The body of evidence is limited, and synthesis is hampered by heterogeneity in the type and time at which predictors and outcomes are measured and quality of statistical reporting. Further research on prospective prediction of bariatric surgery outcome is needed to guide early post-operative intervention for those at greatest risk of poor outcomes.

Overview on nutritional issues in bariatric surgery

PURPOSE OF REVIEW

In the context of the worldwide obesity epidemic, bariatric surgery is the only therapy associated with a sustainable weight loss and to midterm prevention of obesity-related complications. However, nutritional and behavioral multidisciplinary medical preparation, as well as long-term postoperative nutritional follow-up, is strongly advised to avoid postoperative surgical, nutritional, or psychiatric complications.

RECENT FINDINGS

Due to a long history of restrictive diets and large body weight fluctuations, preoperative nutritional assessment and correction of vitamin and trace elements deficiencies are mandatory. A rapid and massive weight loss induces the loss of muscle mass and fat-free mass that could lead to malnutrition and osteoporosis. Dietetic counseling is advised to prevent postoperative food intolerance syndrome, malnutrition, and weight regain. Protein intake should be at least 60 g/day. Planned and structured physical exercise should be systematically promoted to maintain muscle mass and bone health.

SUMMARY

Bariatric surgery is mostly successful if patients are well prepared and monitored. The perfect patients' selection remains difficult in the absence of well defined predictive criteria of success. Future research is needed to define optimal perioperative nutritional management and its influence on long-term outcome, including quality of life and healthcare-related costs.

How do patients' clinical phenotype and the physiological mechanisms of the operations impact the choice of bariatric procedure?

Bariatric surgery is currently the most effective option for the treatment of morbid obesity and its associated comorbidities. Recent clinical and experimental findings have challenged the role of mechanical restriction and caloric malabsorption as the main mechanisms for weight loss and health benefits. Instead, other mechanisms including increased levels of satiety gut hormones, altered gut microbiota, changes in bile acid metabolism, and/or energy expenditure have been proposed as explanations for benefits of bariatric surgery. Beside the standard proximal Roux-en-Y gastric bypass and the biliopancreatic diversion with or without duodenal switch, where parts of the small intestine are excluded from contact with nutrients, resectional techniques like the sleeve gastrectomy (SG) have recently been added to the armory of bariatric surgeons. The variation of weight loss and glycemic control is vast between but also within different bariatric operations. We surveyed members of the Swiss Society for the Study of Morbid Obesity and Metabolic Disorders to assess the extent to which the phenotype of patients influences the choice of bariatric procedure. Swiss bariatric surgeons preferred Roux-en-Y gastric bypass and SG for patients with type 2 diabetes mellitus and patients with a body mass index >50 kg/m², which is consistent with the literature. An SG was preferred in patients with a high anesthetic risk or previous laparotomy. The surgeons’ own experience was a major determinant as there is little evidence in the literature for this approach. Although trends will come and go, evidence-based medicine requires a rigorous examination of the proof to inform clinical practice.