Effects of bariatric surgery on glycemic and lipid metabolism, surgical complication and quality of life in adolescents with obesity: a systematic review and meta-analysis

BMI and sex disparity in uric acid level improvement in patients with obesity and diabetes following laparoscopic sleeve gastrectomy

BACKGROUND

The potential improvement in uric acid (UA) levels following laparoscopic sleeve gastrectomy (LSG) in patients with obesity and type II diabetes mellitus (T2DM) has not been systematically studied. Our aim was to investigate the influencing factors of UA level improvement following LSG and its correlation with glucose metabolism and lipid metabolism.

METHODS

A total of 392 patients with obesity and T2DM were prospectively recruited from 1 November 2022 to 31 December 2023. All patients underwent LSG surgery and were followed at 1, 2, 3, 6, 12 months after surgery. The presurgical and postsurgical levels of body-mass index(BMI), UA and indicators of glucose metabolism and lipid metabolism were recorded.

RESULTS

Distinct UA improvement was observed between males and females and among different BMI groups following LSG. Female patients exhibited more sustained and greater recovery of UA level up to 12 months than male patients in all BMI groups, although male patients showed a sharper UA level decrease in the first two months. Furthermore, patients with BMI ≥ 37.5 appeared to have significantly greater UA level decrease than other patients up to 12 months. UA level improvement showed significant correlation with BMI improvement in all three BMI groups in females while only in BMI 28-32.5 group in males. For glucose metabolism, a significant linear correlation between UA level changes and fasting blood glucose (FBG), fasting blood insulin (FBI), glycosylated hemoglobin A1c (HbA1c) and C-peptide (CP) was found in patients with presurgical elevated UA level group, and in female patients for FBI and CP. For lipid metabolism, a significant linear correlation was only observed between UA level changes and HDL in female and those with high presurgical UA levels.

CONCLUSIONS

Sex and presurgical BMI appeared to influence the UA improvement following LSG. Females and those with presurgical elevated UA levels exhibited the most significant UA level alleviation. UA level changes also correlated with glucose metabolism and lipid metabolism.

Outcomes of bariatric surgery in Adolescents: A meta-analysis comparing three surgical techniques

Metabolic and bariatric surgery (MBS) is used for managing obesity. Herein, we conducted the first meta-analysis directly comparing the three most performed MBS procedures among adolescents. Fourteen studies, comprising 13,994 patients, and comparing outcomes between at least two of laparoscopic gastric bypass (RYGB), laparoscopic sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (AGB) in adolescents (age ≤21 years), were included. On subgroup analyses, SG (MD: -15.95 ​kg; -13.76 ​%) and RYGB (MD: -23.86 ​kg; -11.36 ​%) demonstrated a significantly greater absolute change in weight and percentage change in BMI than AGB, respectively. RYGB demonstrated a significantly greater absolute (MD: -1.68 ​kg/m) and percentage change in BMI (MD: -3.01 ​%) than SG. However, it was associated with a greater risk of post-operative complications than both SG (RR: 2.09) and AGB (RR: 3.51). Our meta-analysis shows that while RYGB is the most effective bariatric procedure for weight loss in adolescents, SG is much safer.

Neurobiological and Microbiota Alterations After Bariatric Surgery: Implications for Hunger, Appetite, Taste, and Long-Term Metabolic Health

Bariatric surgery (BS) is an effective intervention for obesity, inducing significant neurobiological and gut microbiota changes that influence hunger, appetite, taste perception, and long-term metabolic health. This narrative review examines these alterations by analyzing recent findings from clinical and preclinical studies, including neuroimaging, microbiome sequencing, and hormonal assessments. BS modulates appetite-regulating hormones, reducing ghrelin while increasing glucagon-like peptide-1 (GLP-1) and peptide tyrosine-tyrosine (PYY), leading to enhanced satiety and decreased caloric intake. Neuroimaging studies reveal structural and functional changes in brain regions involved in reward processing and cognitive control, contributing to reduced cravings and altered food choices. Additionally, BS reshapes the gut microbiota, increasing beneficial species such as Akkermansia muciniphila, which influence metabolic pathways through short-chain fatty acid production and bile acid metabolism. These findings highlight the complex interplay between the gut and the brain in post-surgical metabolic regulation. Understanding these mechanisms is essential for optimizing post-operative care, including nutritional strategies and behavioral interventions. Future research should explore how these changes impact long-term outcomes, guiding the development of targeted therapies to enhance the recovery and quality of life for BS patients.

Effects of sleeve gastrectomy on populations with obesity and obstructive sleep apnea: a meta-analysis

BACKGROUND

Obstructive sleep apnea (OSA) is highly prevalent in patients with morbid obesity, prompting interest in bariatric surgery as a potential management strategy. Sleeve gastrectomy (SG), being the primary bariatric surgical option, offers simplicity, reduced postoperative complications, and favorable outcomes for obesity and its associated conditions.

OBJECTIVES

This study aims to assess the efficacy of SG in treating populations with obesity and OSA.

SETTING

University-affiliated hospital, China.

METHODS

We conducted a comprehensive literature search across PubMed, Embase, Cochrane Library, and Web of Science databases to identify pertinent studies published up to March 28, 2024. Our review encompassed studies that assessed the effectiveness of SG on primary outcomes, including the apnea-hypopnea index (AHI), as well as secondary outcomes such as forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), nonrapid eye movement sleep stage 3 (NREM 3), rapid eye movement sleep (REM), sleep efficiency (SE), arousal index, Epworth sleepiness scale (ESS), oxygen desaturation index (ODI), apnea index (AI), meanSpO2, body mass index (BMI), weight, neck circumference (NC), waist circumference (WC), waist-to-hip ratio (WHR), subcutaneous fat area (SFA), visceral fat area (VFA), systolic blood pressure(SBP)/diastolic blood pressure(DBP), and measurements related to glucolipid metabolism. A total of 12 eligible studies underwent a systematic screening process and were subsequently subjected to meta-analysis using either randomized effects model or fixed-effect models.

RESULTS

Significant reductions in AHI, BMI, weight, SFA, and VFA were observed following SG. Correspondingly, enhancements in FVC, meanSpO2, NREM 3%, REM%, and SE, were noted after SG. Additionally, the populations with obesity and OSA exhibited decreases in arousal index, ODI, AI, ESS, NC, WC, WHR, and DBP post-SG. Moreover, reductions in HOMA-IR and glycosylated hemoglobin were also observed after SG.

CONCLUSION

SG demonstrates favorable outcomes in the populations with obesity and OSA.

Optimizing Nutritional Management Before and After Bariatric Surgery: A Comprehensive Guide for Sustained Weight Loss and Metabolic Health

Obesity is associated with multiple comorbidities that contribute to increased mortality among affected individuals. There are multiple treatments for this condition, including nutritional interventions, pharmacological therapies, and surgical procedures. Within these, bariatric surgery is an effective treatment option that requires a multidisciplinary approach, both before and after surgery. Nutritional management prior to surgery aims to achieve metabolic control and reduce comorbidities associated with the procedure. Postoperative nutritional management focuses on preventing complications, ensuring adequate nourishment, and providing necessary supplementation for optimal recovery and long-term success. This narrative review examines all these critical aspects of nutritional management in bariatric surgery, including preoperative nutrition, postoperative nutrition and physical activity recommendation, different nutritional aspects according to the type of bariatric surgery, and future directions for investigation.

Effectiveness of surgical interventions for managing obesity in children and adolescents: A systematic review and meta-analysis framed using minimal important difference estimates based on GRADE guidance to inform a clinical practice guideline

OBJECTIVE

To summarize the literature on bariatric surgery for managing pediatric obesity, including intervention effects to improve patient-reported outcome measures (PROMs), cardiometabolic risk factors, anthropometry, and assess adverse events (AEs).

METHODS

Eligible studies were published between January 2012 and January 2022 and included randomized controlled trials (RCTs) and observational (controlled and uncontrolled) studies before and after surgery with a mean age <18 years old. Outcomes and subgroups were selected a priori by stakeholders; estimates of effect for outcomes were presented relative to minimal important differences (MIDs) and GRADE certainty of evidence. We examined data on PROMs, cardiometabolic risk factors, anthropometry, and AEs. Subgroup analyses examined outcomes by follow-up duration and surgical technique, when possible.

RESULTS

Overall, 63 publications (43 original studies) met our inclusion criteria (n = 6128 participants; 66% female). Studies reported six different surgical techniques that were evaluated using uncontrolled single arm observational (n = 49), controlled observational (n = 13), and RCT (n = 1) designs. Most studies included short-term follow-up (<18 months) only. PROMs were measured in 12 (28%) studies. Surgery led to large improvements in health-related quality of life compared to baseline and control groups, and moderate to very large improvements in cardiometabolic risk factors compared to baseline. Large to very large improvements in BMIz were noted compared to baseline across all follow-up periods. There was limited evidence of AEs with most reporting mild or non-specific AEs; serious AEs were uncommon.

CONCLUSION

Bariatric surgery demonstrated primarily moderate to very large improvements across diverse outcomes with limited evidence of AEs, albeit with low to moderate certainty of evidence.

Metabolic bariatric surgery, alcohol misuse and liver cirrhosis: a narrative review

Bariatric surgery and liver cirrhosis have considerable overlap. Bariatric procedures intend to reduce metabolic dysfunction-associated steatotic liver disease (MASLD); however, these procedures are thought to increase the propensity for alcohol misuse. This may predispose the bariatric surgical patient to a new form of liver insult in the postoperative period. This review explores the complex relationship between obesity and alcohol misuse in the context of the bariatric surgical patient. There is evidence to support the safety of bariatric procedures in compensated cirrhotic patients, with an improvement of liver function and architecture. However, data suggest that after a two-year period, these patients exhibit an increased propensity for alcohol misuse postoperatively, particularly after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) procedures. A paucity of evidence exists with respect to alcohol-induced liver dysfunction, or MASLD and increased alcohol intake (MetALD) in the post-bariatric surgery patient. This review aims to provide an overview of the current evidence and offer recommendations for further robust studies.

Effect of Obesity on Surgical Outcomes and Complication Rates in Pediatric Patients: A Comprehensive Systematic Review and Meta-Analysis

Obesity is one of the primary public health problems faced by children. The increased incidence of obesity in the pediatric population poses significant challenges during and after surgical procedures. This systematic review and meta-analysis aimed to understand to what extent obesity is to surgical complications in pediatric patients. A systematic database search of PubMed, Web of Science, Scopus, and Science Direct was performed in June 2023. According to the inclusion and exclusion criteria, two evaluators independently conducted literature screening, data extraction, and quality evaluation of the retrieved literature. The Newcastle-Ottawa Scale score was used for quality evaluation, and a meta-analysis was performed using Review Manager software 5.4.1. A total of 1,170 relevant articles were initially identified, and 20 articles were finally included for data extraction and meta-analysis. The results of the meta-analysis showed that compared with normal-weight individuals, obese pediatric patients had a higher risk of developing surgical site infection (SSI) (relative risk (RR) = 1.63; 95% confidence interval (CI) = 1.33-2.00), wound dehiscence (RR = 2.01; 95% CI = 1.24-3.23), and underwent procedures that were 11.32 minutes longer (95% CI = 5.36-17.29). There were no differences in bleeding requiring transfusion, deep venous thromboembolism, postoperative abscess rate, and length of stay. Obese pediatric patients have a higher risk of SSI and dehiscence, along with a longer operative time. The established risks in obese adults undergoing surgery suggest a similar risk for obese pediatric patients. The findings of this study hold significant implications for clinical practice, suggesting the potential for additional measures to prevent surgical complications in children.

Methodology and Results of a Joint IFSO-WGO Delphi Survey of 94 Intercontinental, Interdisciplinary Experts in Obesity Management

BACKGROUND

Obesity affects 1.5 billion people worldwide, yet few are treated effectively and considerable variability exists in its management. In 2020, a joint International Federation of Surgery for Obesity and Metabolic Diseases (IFSO) and World Gastroenterology Organization (WGO) advisory committee initiated the drafting of consensus guidelines on obesity management, to be based on detailed literature reviews and the results of an extensive multi-disciplinary survey of intercontinental experts. This paper reports on the latter. The objective of this study is to identify areas of consensus and non-consensus among intercontinental, inter-disciplinary experts in obesity management.

METHODS

Guided by an international consensus-survey expert, a three-round online Delphi survey was conducted in the summer of 2021 of international obesity-management experts spanning the fields of medicine, bariatric endoscopy and surgery, psychology, and nutrition. Issues like epidemiology and risk factors, patient selection for metabolic and bariatric surgery (ASMBS-Clinical-Issues-Committee, Surg Obes Relat Dis : Off J Am Soc Bariatric Surg. 8:e27-32, 1), psychological issues, patient preparation for MBS, bariatric endoscopy, and outcomes and follow-up were addressed.

RESULTS

Ninety-four experts from six continents voted on 180 statements, with consensus reached on 158, including consensus agreement with 96 and disagreement with 24 statements (38 had other response options besides agree/disagree). Among unanimous opinions were the need for all medical societies to work together to address obesity, for regular regional and national obesity surveillance, for multi-disciplinary management, to recognize the increasing impact of childhood and adolescent obesity, to accept some weight regain as normal after MBS, and for life-long follow-up of MBS patients.

CONCLUSIONS

Obesity is a major health issue that requires aggressive surveillance and thoughtful multidisciplinary management.

Bariatric surgery improves postprandial VLDL kinetics and restores insulin-mediated regulation of hepatic VLDL production

Dyslipidemia in obesity results from excessive production and impaired clearance of triglyceride-rich (TG-rich) lipoproteins, which are particularly pronounced in the postprandial state. Here, we investigated the impact of Roux-en-Y gastric bypass (RYGB) surgery on postprandial VLDL1 and VLDL2 apoB and TG kinetics and their relationship with insulin-responsiveness indices. Morbidly obese patients without diabetes who were scheduled for RYGB surgery (n = 24) underwent a lipoprotein kinetics study during a mixed-meal test and a hyperinsulinemic-euglycemic clamp study before the surgery and 1 year later. A physiologically based computational model was developed to investigate the impact of RYGB surgery and plasma insulin on postprandial VLDL kinetics. After the surgery, VLDL1 apoB and TG production rates were significantly decreased, whereas VLDL2 apoB and TG production rates remained unchanged. The TG catabolic rate was increased in both VLDL1 and VLDL2 fractions, but only the VLDL2 apoB catabolic rate tended to increase. Furthermore, postsurgery VLDL1 apoB and TG production rates, but not those of VLDL2, were positively correlated with insulin resistance. Insulin-mediated stimulation of peripheral lipoprotein lipolysis was also improved after the surgery. In summary, RYGB resulted in reduced hepatic VLDL1 production that correlated with reduced insulin resistance, elevated VLDL2 clearance, and improved insulin sensitivity in lipoprotein lipolysis pathways.

The treatment of obesity in children and adolescents: consensus position statement of the Italian society of pediatric endocrinology and diabetology, Italian Society of Pediatrics and Italian Society of Pediatric Surgery

This Position Statement updates the different components of the therapy of obesity (lifestyle intervention, drugs, and surgery) in children and adolescents, previously reported in the consensus position statement on pediatric obesity of the Italian Society of Pediatric Endocrinology and Diabetology and the Italian Society of Pediatrics. Lifestyle intervention is the first step of treatment. In children older than 12 years, pharmacotherapy is the second step, and bariatric surgery is the third one, in selected cases. Novelties are available in the field of the medical treatment of obesity. In particular, new drugs demonstrated their efficacy and safety and have been approved in adolescents. Moreover, several randomized control trials with other drugs are in process and it is likely that some of them will become available in the future. The increase of the portfolio of treatment options for obesity in children and adolescents is promising for a more effective treatment of this disorder.

Long-Term Results of Bariatric Surgery in Adolescents with at Least 5 Years of Follow-up: a Systematic Review and Meta-Analysis

OBJECTS

The purpose of this study was to investigate the long-term outcomes of bariatric surgery in adolescents with obesity by including studies with a follow-up of at least 5 years.

METHODS

PubMed, EMBASE, and CENTRAL were systematically searched. Studies that met the criteria were included in the analysis.

RESULT

We identified 29 cohort studies with a total population of 4970. Preoperative age ranged from 12 to 21 years; body mass index (BMI) ranged from 38.9 to 58.5 kg/m². Females were the predominant gender (60.3%). After at least 5-year of follow-up, the pooled BMI decline was 13.09 kg/m² (95%CI 11.75-14.43), with sleeve gastrectomy (SG) was 15.27 kg/m², Roux-en-Y gastric bypass (RYGB) was 12.86 kg/m², and adjustable gastric banding (AGB) was 7.64 kg/m². The combined remission rates of type 2 diabetes mellitus (T2DM), dyslipidemia, hypertension (HTN), obstructive sleep apnea (OSA), and asthma were 90.0%, 76.6%, 80.7%, 80.8%, and 92.5%, (95%CI 83.2-95.6, 62.0-88.9, 71.5-88.8, 36.4-100, and 48.5-100), respectively. Postoperative complications were underreported. Combined with the current study, we found a low level of postoperative complications. Iron and vitamin B12 deficiencies were the main nutritional deficiency complications identified so far.

CONCLUSION

For adolescents with severe obesity, bariatric surgery (especially RYGB and SG) is the independent and effective treatment option. After at least 5 years of follow-up, bariatric surgery in adolescents showed a desirable reduction in BMI and significant remission of T2DM, dyslipidemia, and HTN. Surgical and nutrition-related complications still need to be further explored by more long-term studies.

Laparoscopic sleeve gastrectomy for obesity treatment in adolescents and young adults: a systematic review and meta-analysis

BACKGROUND

The incidence of obesity has been increasing in younger population, posing a significant impact on adolescents' life and health care system worldwide.

METHODS

We critically analyzed the existing literature on the use of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity. We performed an in-depth evaluation of 37 studies and analyzed the effect of LSG in 2300 patients, aged ≤ 22 years.

RESULTS

Mean body mass index (BMI) loss after LSG was 17.81 kg/m2. Gastroesophageal reflux was the most common complication. Most of the patients showed remission of comorbidities including hypertension, diabetes, and obstructive sleep apnea after LSG.

CONCLUSIONS

These findings suggest that surgical intervention is highly beneficial for reducing BMI in appropriately selected adolescents and young adults suffering from obesity and comorbidities such as life-threatening obstructive sleep apnea.

Metabolic and hormonal changes after laparoscopic sleeve gastrectomy in pediatric population: An observational study

Introduction

Despite the growing popularity of laparoscopic sleeve gastrectomy (SG) for managing severe obesity in children, adolescents, and adults, there is a paucity of studies reporting the effects of SG on metabolic and hormonal outcomes in pediatric populations.

Methodology

In this single-centre, retrospective study, we assessed nutritional biomarkers (hemoglobin, ferritin, iron profile, Vitamin B12, Vitamin D, and calcium), glucose homeostasis indicators (C-peptide, HbA1C, and random blood glucose), blood lipids (triglycerides and cholesterol components), hormones involved in the hypothalamic-pituitary-adrenal axis (cortisol and adrenocorticotropic hormone), and thyroid hormones (T3, T4, thyroid-stimulating hormone, and parathyroid hormone) preoperatively and 12-month after SG in children aged 5-15 years.

Results

This study included 64 adolescents (mean age = 11.2 ± 2.3 years) who underwent laparoscopic SG. Significant reduction in circulatory C-peptide (-62.1%; p = 0.005), HbA1C (-10.9%; p = 0.001), random blood glucose (-15.4%; p = 0.036), and triglycerides (-39.4%; p = 0.003) were observed postoperatively at 12 months compared to baseline. Although we did not observe any changes in cortisol levels, adrenocorticotropic hormone levels declined significantly by -40.9% postoperatively (p = 0.033). However, cholesterol components, thyroid hormones, and nutritional biomarkers remained unchanged from baseline.

Conclusions

Consistent with prior literature, our study demonstrates improvement or resolution of diabetes and hypertriglyceridemia in the year following SG. However, given that blood cholesterol components, nutritional biomarkers, and thyroid profiles remained unchanged warrants long-term monitoring of nutritional, metabolic, and endocrine factors in adolescents undergoing laparoscopic SG. To the best of our knowledge, this is the first study reporting the effects of SG on thyroid and hypothalamic-pituitary-adrenal axis hormones in pediatric populations.

Risk of sarcopenia after bariatric surgery in patients with type 2 diabetes mellitus

Introduction. Despite the great popularity of Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy in the treatment of morbid obesity, the problem of the development and progression of sarcopenia in patients with type 2 diabetes mellitus in the postoperative period remains insufficiently studied.

Aim. To study the prevalence and dynamics of sarcopenia in patients with type 2 diabetes mellitus after Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy in the long term.

Materials and methods. Our prospective study included 257 bariatric patients (170 Roux-en-Y gastric bypass and 87 laparoscopic sleeve gastrectomy) with type 2 diabetes mellitus. All patients underwent a standard set of preoperative examination with obligatory determination of the skeletal muscle mass index using the bioelectrical impedance analysis. After 6, 12, 18 and 24 months, control examinations were carried out.

Results. At the preoperative stage, 28 patients (16.5%) with signs of moderate sarcopenia were identified in the Roux-en-Y gastric bypass group and 15 patients (17.2%) in the laparoscopic sleeve gastrectomy group. According to the bioelectrical impedance analysis, 24 months after the operation, 37 patients (25.9%) with signs of moderate sarcopenia and 2 patients (1.4%) with severe sarcopenia were identified in the first group. 24 months after surgery in the second group there was no statistical difference in the number of patients with signs of sarcopenia in comparison with the preoperative period.

Conclusion. The frequency of development and progression of signs of sarcopenia after Roux-en-Y gastric bypass is statistically higher than after laparoscopic sleeve gastrectomy. In this regard, in our opinion, when choosing a method of surgical treatment of morbid obesity with concomitant type 2 diabetes mellitus, a detailed assessment of the state of protein metabolism by the bioelectrical impedance analysis is necessary.

Surgery for the treatment of obesity in children and adolescents

BACKGROUND

Child and adolescent overweight and obesity have increased globally and are associated with significant short- and long-term health consequences.

OBJECTIVES

To assess the effects of surgery for treating obesity in childhood and adolescence.

SEARCH METHODS

For this update, we searched Cochrane Central Register of Controlled Trials, MEDLINE, Latin American and Caribbean Health Science Information database (LILACS), World Health Organization International Clinical Trials Registry Platform (ICTRP)and ClinicalTrials.gov on 20 August 2021 (date of the last search for all databases). We did not apply language restrictions. We checked references of identified studies and systematic reviews.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of surgical interventions for treating obesity in children and adolescents (age < 18 years) with a minimum of six months of follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or which included participants with a secondary or syndromic cause of obesity, or who were pregnant.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently extracted data and assessed the risk of bias using the Cochrane Risk of Bias 2.0 tool. Where necessary, we contacted authors for additional information.

MAIN RESULTS

With this update, we did not find any new RCTs. Therefore, this updated review still includes a single RCT (a total of 50 participants, 25 in both the intervention and comparator groups). The intervention focused on laparoscopic adjustable gastric banding surgery, which was compared to a control group receiving a multi-component lifestyle programme. The participating population consisted of Australian adolescents (a higher proportion of girls than boys) aged 14 to 18 years, with a mean age of 16.5 and 16.6 years in the gastric banding and lifestyle groups, respectively. The trial was conducted in a private hospital, receiving funding from the gastric banding manufacturer. For most of the outcomes, we identified a high risk of bias, mainly due to bias due to missing outcome data. Laparoscopic gastric banding surgery may reduce BMI by a mean difference (MD) of -11.40 kg/m2 (95% CI -13.22 to -9.58) and weight by -31.60 kg (95% CI -36.66 to -26.54) compared to a multi-component lifestyle programme at two years follow-up. The evidence is very uncertain due to serious imprecision and a high risk of bias. Adverse events were reported in 12/25 (48%) participants in the intervention group compared to 11/25 (44%) in the control group. A total of 28% of the adolescents undergoing gastric banding required revisional surgery. The evidence is very uncertain due to serious imprecision and a high risk of bias. At two years of follow-up, laparoscopic gastric banding surgery may increase health-related quality of life in the physical functioning scores by an MD of 16.30 (95% CI 4.90 to 27.70) and change in health scores by an MD of 0.82 (95% CI 0.18 to 1.46) compared to the lifestyle group. The evidence is very uncertain due to serious imprecision and a high risk of bias. No data were reported for all-cause mortality, behaviour change, participants' views of the intervention and socioeconomic effects. Finally, we have identified three ongoing RCTs that are evaluating the efficacy and safety of metabolic and bariatric surgery in children and adolescents.

AUTHORS' CONCLUSIONS

Laparoscopic gastric banding led to greater body weight loss compared to a multi-component lifestyle program in one small study with 50 participants. These results have very limited application, primarily due to more recent recommendations derived from observation studies to avoid the use of banding in youth due to long-term reoperation rates. This systematic review update still highlights the lack of RCTs in this field. The authors are concerned that there may be ethical barriers to RTCs in this field, despite the lack of other effective therapies for severe obesity in children and adolescents and the significant morbidity and premature mortality caused by childhood obesity. Nevertheless, future studies, whether pre-registered and planned non-randomised or pragmatic randomised trials, should assess the impact of the surgical procedure and post-operative care to minimise adverse events, including the need for post-operative adjustments and revisional surgery. Long-term follow-up is also critical to comprehensively assess the impact of surgery as participants enter adulthood.

Disparity Between United States Adolescent Class II and III Obesity Trends and Bariatric Surgery Utilization, 2015-2018

OBJECTIVES

Class II (120% > body mass index [BMI] < 140% of the 95th percentile for age and sex) and Class III (BMI >140% of the 95th percentile for age and sex) obesity are the fastest growing subcategories of obesity in the United States pediatric population. Metabolic and bariatric surgery (MBS) is a safe and effective treatment option for with class II/III obesity. The primary objectives of this analysis were to determine the (1) current US MBS utilization rates in those with class II/III obesity and (2) utilization rates and 30-day postoperative outcomes.

BACKGROUND

The 2015 to 2018 National Health and Nutrition Examination Survey cross-sectional data (N = 19,225) generated US with class II/III obesity prevalence estimates. The 2015 to 2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) longitudinal (30 days) cohort data were used to compare adolescent and adult (N = 748,622) postoperative outcomes and to calculate utilization rates.

METHODS

The 2015 to 2018 youth and adult MBS utilization rates were calculated using MBSAQIP data (numerator) and National Health and Nutrition Examination Survey data (denominator). Two-sample tests of proportions were performed to compare the MBS utilization rates by age, ethnicity, and sex and expressed per 1000.

RESULTS

Mean age of the analytical MBSAQIP sample was 17.9 (1.15) years in youth (n = 3846) and 45.1 (11.5) in adults (N = 744,776), majority female (77.4%, 80.7%, respectively) and non-Hispanic White (68.5%, 59.4%, respectively). The overall 2015 to 2018 MBS utilization rate for youth was 1.81 per 1000 and 5.56 per 1000 for adults ( P < 0.001). Adult patients had slightly higher percentage (4.2%) of hospital readmissions compared to youth (3.4%, P = 0.01) but there were no other post-MBS complication differences. From 2015 to 2018 the US prevalence of youth with class II/III obesity increased in Hispanics and non-Hispanic Blacks (P trend < 0.001), but among youth who did complete MBS non-Hispanic Whites had higher rates of utilization (45.8%) compared to Hispanics (22.7%) and non-Hispanic blacks 14.2% (P = 0.006).

CONCLUSIONS

MBS is an underutilized obesity treatment tool for both youth and adults, and among ethnic minority groups in particular.

Bariatric Surgery in Adolescents with Obesity: Long-Term Perspectives and Potential Alternatives

BACKGROUND

Severe obesity among adolescent shows a worrisome trend in regard to its increasing prevalence and poses a great challenge for treatment. Conservative measures have modest effects on weight loss, usually fail in achieving a sustainable weight loss and resolution of comorbidities. This has led to greater utilization of bariatric surgery (BS) that offers a fast reduction in body mass index with little perioperative complications. Despite the increasing utilization of BS, data are still insufficient, regarding their long-term outcome in adolescents. We review short- and long-term effects of BS and their implications on bone health and nutritional deficiencies in adolescents. In addition, we discuss possible pharmaceutical alternatives.

SUMMARY

BS results in a substantial weight loss of roughly 37% in the first-year post-operation and is superior to conservative measures in resolution of metabolic comorbidities. BS significantly improves health-related quality of life. Longer follow-up (F/U) shows weight regain in 50% of patients. Furthermore, reduced bone mass and nutritional deficiencies were reported in up to 90% of patients. Most recently, alternative to BS became more relevant with approval of GLP-1 analogues use in adolescents. GLP-1 analogues are potent enough to induce moderate clinically meaningful weight loss and improvement of metabolic component.

KEY MESSAGES

We conclude that obese adolescents without major obesity-related complications may benefit from pharmacological interventions with lifestyle modification. We advise considering BS as treatment approach in adolescents with severe obesity and major obesity-related complications with proper preoperative preparation and postoperative F/U in excellence centers.

Reversal and Remission of T2DM - An Update for Practitioners

Over the past 50 years, many countries around the world have faced an unchecked pandemic of obesity and type 2 diabetes (T2DM). As best practice treatment of T2DM has done very little to check its growth, the pandemic of diabesity now threatens to make health-care systems economically more difficult for governments and individuals to manage within their budgets. The conventional view has been that T2DM is irreversible and progressive. However, in 2016, the World Health Organization (WHO) global report on diabetes added for the first time a section on diabetes reversal and acknowledged that it could be achieved through a number of therapeutic approaches. Many studies indicate that diabetes reversal, and possibly even long-term remission, is achievable, belying the conventional view. However, T2DM reversal is not yet a standardized area of practice and some questions remain about long-term outcomes. Diabetes reversal through diet is not articulated or discussed as a first-line target (or even goal) of treatment by any internationally recognized guidelines, which are mostly silent on the topic beyond encouraging lifestyle interventions in general. This review paper examines all the sustainable, practical, and scalable approaches to T2DM reversal, highlighting the evidence base, and serves as an interim update for practitioners looking to fill the practical knowledge gap on this topic in conventional diabetes guidelines.

Short-Term Changes in Mental, Physical, and Social Factors After Metabolic Bariatric Surgery in Adolescents: A Nationwide Prospective Cohort Study

Background

Metabolic bariatric surgery (MBS) is an effective treatment for adolescents with severe obesity. However, changes in mental, physical, and social factors, as well as their association with the extent of excess weight loss (%EWL) after MBS, remain controversial.

Methods

We followed 97 adolescents (64% females, aged 17 ± 0.9 years, BMI 46.1 ± 5.9 kg/m2) before and 9 months following MBS in a multi-center, prospective cohort study. Changes in mental, physical, and social factors were assessed by self-reported questionnaires, and associations with %EWL were evaluated after adjustment for potential confounders.

Results

The body mass index (BMI) decreased by 30%, and all physical parameters significantly improved (p ≤ 0.001). Energy level increased by 24%, mood level by 14%, and mental health by 9.5% (p ≤ 0.002). Social parameters were also improved, with a significant decrease in social rejection (p = 0.02), and an increase in participation in after-school social activities (p = 0.008). Mental health improvement was associated with baseline social rejection (r = 0.514, p < 0.001). The improvement in all factors was not related to the extent of %EWL.

Conclusion

Metabolic bariatric surgery MBS in adolescents led to a meaningful decrease in BMI and to an improvement in short-term physical, mental, and social factors that were not related to %EWL. Patients experiencing social rejection may improve their mental health following BS.

An Unusual Long-Term Complication of Bariatric Surgery

Roux-en-Y gastric bypass (RNYGB) has become the standard of care in treating obesity, a global health concern with associated comorbidities contributing to rising health care costs [1]. The positive outcomes of RNYGB have been well documented along with adverse effects such as nutrient deficiencies, hernia, postprandial dumping syndrome, chronic kidney disease and hypoglycemia. A lesser-known long term complication of RNYGB is liver failure. Here, we present a case where RNYGB performed 10 years prior contributed to acute liver failure.

Anemia After Sleeve Gastrectomy and One-Anastomosis Gastric Bypass: An Investigation Based on the Tehran Obesity Treatment Study (TOTS)

BACKGROUND

Bariatric surgery has been associated with iron, folate, and vitamin B12 deficiencies, which can lead to anemia. This study compares the incidence of anemia between sleeve gastrectomy (SG) and one-anastomosis gastric bypass (OAGB).

METHODS

Patients from a prospectively collected database of patients with morbid obesity undergoing a primary bariatric procedure from April 2013 to September 2018 were included. Statistical analysis was performed using the general estimation equation. Patients were followed for 6, 12, 24, and 36 months post-surgery.

RESULTS

The present study included 2618 patients, of whom 72.3% underwent SG and 27.6% underwent OAGB. The majority of the study population were women (75.7%), and the mean age of the participants was 39.5 ± 11.7 years. At the end of the follow-up, the excess weight loss percentage was 66.15 in the SG group and 75.41 in the OAGB group (P <  0.05). The incidence of anemia at 12-, 24-, and 36-month was 16.2, 19.7, and 24.3% in the SG group and 28.4, 37.6, and 56.5% in the OAGB group, showing significantly higher incidence in the OAGB than the SG group ([Formula: see text] < 0.001). However, there was no significant difference between the SG and OAGB groups regarding the incidence of iron and vitamin B12 deficiency.

CONCLUSIONS

The patients undergoing bariatric surgery, especially OAGB, should be closely monitored post-surgery regarding the incidence of anemia, and supplementation in developing countries could be continued even after the first year.

Cirugía bariátrica en pediatría, ¿qué impacto tiene? Revisión de la literatura

Introducción. La obesidad en la población pediátrica ha ido aumentando de manera progresiva y el manejo médico de la obesidad mórbida en esta población se ha mostrado insuficiente. El objetivo de este artículo fue describir el estado actual de la literatura científica publicada hasta abril 15 de 2021 sobre el impacto de la cirugía bariátrica en la población pediátrica. Métodos. Se realizó una revisión de la literatura que evaluó dos bases de datos, donde se incluyeron revisiones sistemáticas, reportes de casos, series de casos y ensayos clínicos, publicados desde el 1 de enero de 2010 hasta el 15 de abril de 2021, en español, inglés y francés. Resultados. Se incluyeron 56 documentos y 18 estudios clínicos, en los que se encontró que la cirugía bariátrica (bypass gástrico por Y de Roux, gastrectomía en manga, plicatura gástrica y banda gástrica) alcanzó una pérdida de peso significativa en el primer año, con un adecuado sostenimiento de dicha pérdida al quinto año, además de una resolución completa de las comorbilidades metabólicas y cardiovasculares en la mayoría de los pacientes. Conclusión. La cirugía bariátrica se presenta como una alternativa eficaz en el manejo de la obesidad mórbida y sus complicaciones en el paciente pediátrico

Sleeve gastrectomy suppresses hepatic de novo cholesterogenesis and improves hepatic cholesterol accumulation in obese rats with type 2 diabetes mellitus

OBJECTIVES

Cholesterol metabolic disturbance increases the risk of various acquired diseases and affects public health. An apparent correlation between hypercholesterolemia and type 2 diabetes mellitus (T2DM) was confirmed recently. Bariatric surgery can induce durable and sufficient loss of body weight and T2DM remission. A previous study illustrated a cholesterol-lowering effect of sleeve gastrectomy (SG), but the intrinsic mechanism is still elusive. The present study aimed to investigate the effects of SG on hypercholesterolemia and hepatic cholesterol accumulation in a T2DM rat model.

METHODS

Obese rats with T2DM were randomly subjected to sham operation, sham operation combined with food restriction, or SG. Body weight, food intake, blood glucose, body composition, and cholesterol level were measured at the indicated time points. Subsequently, hepatic cholesterol content and both protein and transcriptional levels of sterol regulatory element-binding protein 2, 3-hydroxy-3-methylglutaryl-coenzyme A reductase, and low-density lipoprotein receptor were measured at 2 and 4 wk postoperatively.

RESULTS

SG rapidly reduced blood glucose independent of loss of body weight and food restriction. Rats that underwent SG exhibited lower total cholesterol and free cholesterol in both serum and liver. The cholesterol-lowering effect was independent of loss of body weight and food restriction at just 2 wk postoperatively. Protein and mRNA expression of sterol regulatory element-binding protein 2, 3-hydroxy-3-methylglutaryl-coenzyme A reductase, and low-density lipoprotein receptor were inhibited at 2 wk postoperatively and recovered by 4 wk after SG.

CONCLUSION

SG alleviated hypercholesterolemia and hepatic cholesterol accumulation partially by inhibiting hepatic de novo cholesterogenesis.

The adolescent with obesity: what perspectives for treatment?

The dramatic increase in overweight and obesity among children and adolescents has become a major public health problem. Obesity in children and young adults is associated with an increased prevalence of cardiometabolic risk factors. Obesity during adolescence represents a strong predictor of obesity and higher mortality in adulthood. Due to the serious implications of obesity in adolescents, effective treatments are urgently needed. Lifestyle interventions represent the recommended therapy. Nevertheless, real world data show that the majority of adolescents do not achieve weight loss in the long term, and are reluctant to participate in lifestyle interventions. Pharmacological treatment is recommended if a formal lifestyle modification program fails to limit weight gain or to improve comorbidities. However, until 2020 the European Medicines Agency (EMA) had not approved any pharmacotherapeutic agents for obesity in pediatric patients. On April 2021, EMA has authorized the use of Liraglutide, a glucagon-like peptide (GLP)-1 analog, for the treatment of obesity in adolescents (12–17 years). The efficacy and safety of Liraglutide were demonstrated in a randomized, double-blind trial, enrolling 251 adolescents. After 56 weeks, a reduction in BMI of at least 5% was observed in 43.3% of participants in the liraglutide group vs. 18.7% in the placebo group, and a reduction in BMI of at least 10% was observed in 26.1 and 8.1%, respectively. Gastrointestinal events were the events most frequently reported with liraglutide. Bariatric surgery represents another effective treatment for adolescents with severe obesity, with sustained benefits on weight loss and cardiometabolic risk factors. However, long-term safety and effectiveness data in adolescents are still scarce. Risks of bariatric surgery include the need for additional abdominal surgical procedures and specific micronutrient deficiencies. Hopefully, new pharmacological treatments in addition to lifestyle interventions will offer more chances of success.

Durability of Cardiometabolic Outcomes Among Adolescents After Sleeve Gastrectomy: First Study with 9-Year Follow-up

BACKGROUND

Long-term durability of weight loss and comorbidity resolution beyond 7 years after laparoscopic sleeve gastrectomy (LSG) among adolescents is completely lacking.

METHODS

Retrospective review of adolescents aged ≤ 18 years who underwent primary LSG at our institution between 2011 and 2015 (N = 146). We assessed anthropometric and cardiometabolic outcomes at 1, 3, 5, 7, and 9 years.

RESULTS

Follow-up rates were 57.53%, 82.87%, 85.24%, 83.92%, and 83.33% at the five time points. The preoperative mean body mass index (BMI) (45.60 ± 6.50 kg/m2) decreased at year 1 (30.04 ± 4.96 kg/m2, P=0.001) and was maintained up to 9 years (30.20 ± 3.92 kg/m2, P = 0.001). Remission rates were triglycerides, 100% (11/11) at 5 years, and 100% (1/1) at 9 years; high density lipoprotein, 89.4% (17/19) at 5 years, and 100% (3/3) at 7 years; low density lipoprotein, 71.4% (11/14) and 100% (3/3) at 5 and 7 years; total cholesterol, 70% (7/10) at 5 years, and 100% (2/2) at 9 years; uric acid, 100% (3/3) at 5 years. Remission of liver enzymes was 84.6-100% (22/26-2/2) at 5-9 years. Prediabetes remission was 87.5% (14/16 and 7/8) at 5 and 7 years and 100% (3/3) at year 9. Type 2 diabetes complete remission was 50% (3/6, 1/2) at years 5 and 7, with all cases resolved at 9 years. The only case of hypertension completely resolved.

CONCLUSIONS

LSG achieved substantial weight loss and remission of cardiometabolic risk factors that were sustained on the long term. This is the first study among adolescents to assess such outcomes beyond 7 years.

Metabolic Surgery and Cancer Risk: An Opportunity for Mechanistic Research

Simple Summary

Metabolic (bariatric) surgery (MBS) provides the greatest maximum and sustained weight loss among individuals who are morbidly obese. It is more effective than lifestyle interventions in improving or eliminating type 2 diabetes mellitus (T2DM) and in decreasing cardiovascular (CV) risk. Preclinical studies have been conducted to investigate the mechanisms by which MBS leads to the benefits in T2DM and CV risk. In this review, we describe the emerging evidence that MBS may also impact cancer risk and mortality, and whom may benefit most. We describe the long term involvement and commitment of the National Institutes of Health in obesity research in general and MBS in particular. We outline the need for additional research to understand the mechanism(s) by which MBS may influence cancer, since these mechanism(s) are currently unknown.

Abstract

Metabolic (bariatric) surgery (MBS) is recommended for individuals with a BMI > 40 kg/m² or those with a BMI 35–40 kg/m² who have one or more obesity related comorbidities. MBS leads to greater initial and sustained weight loss than nonsurgical weight loss approaches. MBS provides dramatic improvement in metabolic function, associated with a reduction in type 2 diabetes mellitus and cardiovascular risk. While the number of MBS procedures performed in the U.S. and worldwide continues to increase, they are still only performed on one percent of the affected population. MBS also appears to reduce the risk of certain obesity related cancers, although which cancers are favorably impacted vary by study, who benefits most is uncertain, and the mechanism(s) driving this risk reduction are mostly speculative. The goal of this manuscript is to highlight (1) emerging evidence that MBS influences cancer risk, and that the potential benefit appears to vary based on cancer, gender, surgical procedure, and likely other variables; (2) the role of the NIH in MBS research in T2DM and CV risk for many years, and more recently in cancer; and (3) the opportunity for research to understand the mechanism(s) by which MBS influences cancer. There is evidence that women benefit more from MBS than men, that MBS may actually increase the risk of colorectal cancer in both women and men, and there is speculation that the benefit in cancer risk reduction may vary according to which MBS procedure an individual undergoes. Herein, we review what is currently known, the historical role of government, especially the National Institutes of Health (NIH), in driving this research, and provide suggestions that we believe could lead to a better understanding of whether and how MBS impacts cancer risk, which cancers are impacted either favorably or unfavorably, the role of the NIH and other research agencies, and key questions to address that will help us to move the science forward.

Clinical management and treatment of obesity in China

China has one of the largest populations with obesity in the world, and obesity has become a major challenge for the country's health-care system. Current guidelines for obesity management are not adequately supported by evidence from clinical studies in Chinese populations. Effective lifestyle interventions suitable for Chinese populations are scarce, insufficient weight-loss medications have been approved by regulatory bodies, and there is low acceptance of non-lifestyle interventions (ie, medications and surgery) among both health-care providers and the general public. Large, well designed, and well implemented clinical trials are needed to strengthen the evidence base for the clinical management of obesity in China. Obesity management can be improved through use of a tiered system involving health management centres, integrated lifestyle interventions and medical treatments, strengthened obesity education and training, and use of advanced electronic health technologies. Resource mobilisation, support from major stakeholders for people with overweight or obesity, and education and changes to social norms among the wider public are also needed. National health policies should prioritise both obesity prevention and improvement of the treatment and management of obesity.

Vascular endothelial growth factor B exerts lipid-lowering effect by activating AMPK via VEGFR1

As an ambiguous member of vascular endothelial growth factor family, VEGF-B has long been poorly understood in its function. Recent researches showed VEGF-B isoforms exerted their metabolic effect through indirectly activating the VEGF-A/VEGFR2 pathway. Here, we report the lipid-lowing effect of VEGF-B via VEGFR1. We investigated the effect of VEGF-B on lipid metabolism in vivo and in vitro approaches. Treatment of mice with VEGF-B recombinant protein repressed HFD-induced body weight gain. This treatment also alleviated obesity associated hyperlipidemia and fatty liver disease. In the muscle and liver of VEGF-B-treated HFD mice were observed increased protein expression of carnitine palmitoyltransferase-1 (CPT-1) and the phosphorylation of ACC and AMP-activated protein kinase (AMPK). This effect was confirmed in HepG2 cells incubated with VEFG-B in which the increased AMPK activation and CPT-1 expression occurs due to activation of Calcium/calmodulin-dependent Protein Kinase β (CaMKKβ) by VEFG-B. VEGF-B increased expression of key genes responsible for lipid oxidation while reducing those for fatty acid synthesis in vivo and in vitro. In addition, the selective inhibitor of VEGFR1 blocked the lipid clearance effect of VEGF-B in HepG2. Our study unraveled unknown role of VEGF-B/VEGFR1 signaling in regulating lipid metabolism. Furthermore, our findings indicate that VEGF-B may have beneficial effects for the treatment of dyslipidemia.

Decrease of dipeptidyl peptidase 4 activity is associated with weight loss after bariatric surgery

Purpose

Dipeptidyl peptidase 4 (DPP4) is expressed and secreted by adipocytes. DPP4 induces insulin resistance independently of its effect on glucagon-like peptide 1, thus it is conceivable that DPP4 directly contributes to metabolic dysfunction in patients with morbid obesity. The aim of this study was to investigate the impact of weight loss induced by bariatric surgery on DPP4 activity, and whether these changes are associated with improvements in markers of metabolic dysfunction and fatty liver disease.

Materials and Methods

We included 68 non-diabetic patients who underwent bariatric surgery. Serum DPP4 activity was measured using a fluorogenic substrate before and after surgery.

Results

Results: After a median follow-up period of 12 (IQR 11-17) months, median serum DPP4 activity decreased from 230 (IQR: 194-273) to 193 (164-252) pmol/min (p=0.012). The decrease in DPP4 activity was significantly correlated with decreases in BMI, improved cholesterol levels, reduced hepatic injury markers as well as improved post-prandial insulin sensitivity. After multivariable adjustment, ΔDPP4 activity remained significantly associated with Δcholesterol (beta=0.341, p=0.025), ΔLDL cholesterol (beta=0.350, p=0.019), Δgamma-glutamyltransferase (beta=0.323, p=0.040) and ΔMatsuda index (beta=-0.386, p=0.045).

Conclusion

We demonstrated that weight loss induced by bariatric surgery results in decreased circulating DPP4 activity beyond the initial phase of weight loss. The associations between decreased DPP4 activity and improved cholesterol levels as well as hepatic injury markers point towards pleiotropic effects of DPP4 beyond glucose metabolism which warrant further investigation.

Effect of sleeve gastrectomy on lipid parameters and cardiometabolic risk in young women

OBJECTIVE

to analyze the effect of vertical gastrectomy on lipid profile and cardiometabolic risk in young women, preoperatively and 6 months after the operation.

METHODS

retrospective study, encompassing medical record reviews of women's charts, preoperatively and in six months after the operation. Data collection was performed in the second half of 2015, using a review protocol with questions on the clinical-laboratory profile, anthropometric and laboratory classification of dyslipidemias. Descriptive and inferential analysis were used to treat the variables, using measures of variance, association and linear regression.

RESULTS

we analyzed medical records of 114 women undergoing vertical gastrectomy, with a mean age of 33.82±10.92, and with complete high school education. There was a significant reduction of anthropometric data, as well as serum lipid values, six months after the surgical procedure. The coefficients of determination and the results of linear regression, showed that the reduction in serum triglyceride values and increase in high-density lipoprotein have a direct impact on the reduction of the cardiometabolic risk. Regarding the laboratory classification of dyslipidemias, it was observed that the majority presented a significant reduction at the six-month follow-up. Mixed hyperlipidemia showed no significant reduction. The categorized cardiometabolic risk showed a significant reduction in women at risk before vertical gastrectomy.

CONCLUSION

at the six-month follow-up, vertical gastrectomy was effective in reducing the serum lipid profile and the cardiometabolic risk of young women when compared to the preoperative data. There was also a different improvement in the laboratory classification of dyslipidemias at the six-month follow-up after the surgical procedure.

Optimizing Bariatric Surgery outcomes: the impact of preoperative elevated hemoglobin A1c levels on composite perioperative outcome measures

Introduction

The use of bariatric surgery in the management of obesity and its related morbidity has significantly increased in the US over the past decade. There is a lack of data on the impact of optimal preoperative glycemic control on the morbidity and mortality following bariatric surgery. The aim of this study was to analyze the impact of hemoglobin (Hb) A1c > 7 on outcomes among patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG).

Methods

Data were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (2017) and limited to patients undergoing an elective laparoscopic RYGB or SG. Multivariable logistic regression was conducted to adjust for other preoperative variables.

Results

A total number of 31,060 (69.3%) patients underwent SG, while 13,754 (30.7%) received RYGB. Patients who were older, male, non-Hispanic, smokers, and those with a higher American Society of Anesthesiologist Classification (ASA) score were more likely to have elevated HbA1c levels. Compared to individuals with normal HbA1c levels, patients with elevated levels had no significant difference in mortality (p = 0.902) but did have a difference in composite morbidity and mortality (p < 0.001). On multivariable analysis, elevated HbA1c, older age, increasing body mass index (BMI), elevated creatinine, longer operations, African American race, receiving RYGB, and having a trainee as surgical assistant were found to increase the odds of having an adverse outcome. No significant difference was found within smoking status, sex, ASA Classification, robotic vs laparoscopic, or if a second attending surgeon was assisting.

Conclusions

HbA1c levels and presence of trainees in the OR are modifiable preoperative risk factors for adverse events following bariatric surgery. Improving preoperative glycemic control may be an effective and achievable quality improvement measure.

Metabolic and cardiovascular outcomes of bariatric surgery

PURPOSE OF REVIEW

Bariatric surgery is an effective therapy for morbid obesity that also improves weight-related metabolic parameters and reduces morbidity and mortality. The purpose of this review is to consolidate our current understanding of metabolic, macrovascular and microvascular benefits of bariatric surgery and to provide an update.

RECENT FINDINGS

Early resolution of insulin resistance and type 2 diabetes mellitus (T2DM) varies by type of bariatric surgery and appears to be mediated by changes in secretion of gut hormones, metabolism of bile acids, expression of glucose transporters and the gut microbiome. Dyslipidaemia, atherosclerosis, microvascular complications of obesity and diabetes, systemic and tissue-level inflammation show evidence of regression and hypertension improves significantly after bariatric surgery.

SUMMARY

Bariatric surgery leads to improvements in obesity-related metabolic comorbidities such as dyslipidaemia, HDL functionality, hypertension, T2DM, insulin resistance and inflammation. It slows the atherosclerotic process and reduces cardiovascular and all-cause mortality. Recent data have demonstrated regression of the microvascular complications of obesity and diabetes including the regeneration of small nerve fibres. The magnitude of change in short-term metabolic effects depends on the surgical procedure whilst longer term effects are related to the amount of sustained excess weight loss.

Glucose-Lipid Metabolism in Obesity with Elevated Prolactin Levels and Alteration of Prolactin Levels After Laparoscopic Sleeve Gastrectomy

PURPOSE

We investigated the differences in metabolism between obesity with or without increased prolactin (PRL) and the change in PRL after laparoscopic sleeve gastrectomy (LSG).

METHODS

Patients were divided into two groups: obesity with normal PRL (NP, n = 123) and high PRL (HP, n = 108). Glucose-lipid metabolism and inflammation were measured. A total of 115 patients with obesity (NP, n = 64; HP, n = 51) underwent LSG were recruited, and PRL was measured at 12 months after LSG.

RESULTS

(1) Blood glucose (BG), total cholesterol (TCH), LDL, triglyceride, and TNF-α were lower in the HP than in the NP group in the cross-sectional study (all P < 0.05). (2) PRL was negatively associated with neck circumference, waist-to-hip ratio, systolic blood pressure, heart rate, basal metabolism rate (BMR), ALP, TCH, and LDL in all subjects. PRL levels were positively associated with weight, HC, and BMR in males but were negatively associated with ALT, AST, ALP, BG 30 min, BG 60 min, FFA, and TCH in females (all P < 0.05). (3) Regression analysis showed that PRL negatively correlated with ALP and LDL-C in the whole baseline (β = - 0.051, P = 0.002; β = - 1.372, P = 0.033). PRL was a negative factor for ALP in females and a positive factor for BMR2 in males (β = - 0.099, P = 0.041; β = 0.005, P = 0.006). (4) PRL decreased in the HP group and increased in the NP group at 12 months post-operation (all P < 0.05). Increased PRL was associated with a change in TCH in the NP group (P < 0.05).

CONCLUSION

Increased PRL resulted in improved glucose-lipid metabolism and chronic low-grade inflammation. LSG led to increased PRL in NP and decreased PRL in HP. Improved lipid was associated with increased PRL in NP after surgery.

CLINICAL TRIAL REGISTRATION NUMBER

ChiCTR-OCS-12002381.

Chylous Ascites Post Laparoscopic Sleeve Gastrectomy: Video Case Report of a Rare Complication

We report a 38-year-old morbidly obese female patient, who presented 10 days post sleeve gastrectomy with chylous ascites. A lymphangiogram showed free leakage from a small tributary of the cisterna chyli. Conservative measures failed to control the leak. The patient was taken for surgery. Laparoscopic exploration with intralipid injection through an orogastric tube revealed the leaking area near the hiatal surface posterior to the stomach and it was ligated with non-absorbable sutures and wrapped with a thrombin patch. The patient was discharged home in a good condition. Patient was followed up in the clinic after 2 weeks, 6 weeks, and 3 months with no complaint.

Partnering Support Interventions with Bariatric Surgery to Maximize Health Outcomes in Adolescents with Severe Obesity

OBJECTIVE

Rates of adolescents with severe obesity continue to rise worldwide, with concurrent increases in metabolic and bariatric surgery (MBS) uptake. The gap between support (lifestyle, pharmacotherapy) interventions and MBS as treatment options for adolescents has been understudied. This review, couched in a socio-ecological framework, investigates how support interventions for adolescents with severe obesity could be combined or sequenced with MBS to optimize health outcomes.

METHODS

A comprehensive search revealed 36 published articles between 1995 and 2019 that included the combination of support interventions and MBS among adolescents.

RESULTS

There were no studies that specifically reported outcomes or effect sizes for the combination of lifestyle intervention with MBS. Previous studies have reported individual results for either lifestyle intervention or MBS but not for their compound effect.

CONCLUSIONS

As rates of adolescents with severe obesity are on the rise globally, future research should focus on how partnering support interventions with MBS can amplify positive short- and long-term health outcomes and within a socio-ecological framework. Understanding the sequence of these approaches will be of particular importance. High-risk and vulnerable populations such as ethnic minorities who have suffered a disproportionate burden of the obesity epidemic must be included in rigorously tested future trials of combination interventions to maximize health outcomes worldwide.

Pharmacological and surgical treatment of nonreproductive outcomes in polycystic ovary syndrome: An overview of systematic reviews

BACKGROUND

Polycystic ovary syndrome (PCOS) affects up to 13% women and is associated with significant complications. The quality of evidence supporting the recommendations on treatment of nonreproductive outcomes in PCOS is unknown.

OBJECTIVE

To summarize and appraise the methodological quality of systematic reviews and meta-analyses evaluating pharmacological and surgical treatments for nonreproductive outcomes in PCOS.

METHODS

A literature search from MEDLINE, EMBASE, CINAHL PLUS and PROSPERO was performed from inception until 15th of September 2017. Article selection, data extraction and quality appraisal of included reviews were performed in duplicate. A narrative synthesis of the findings was conducted.

RESULTS

This overview included 31 reviews. The quality was low for 7 (23%), moderate for sixteen (52%) and high for 8 reviews (26%). Two reviews assessed psychological outcomes. Metformin improved anthropometric (7 of 10 reviews), metabolic (4 of 14 reviews) and endocrine outcomes (3 of twelve reviews). Thiazolidinediones improved metabolic (2 of 5 reviews) and endocrine outcomes (one of 5 reviews) but worsened weight gain (5 of 5 reviews). Combined oral contraceptive pill (COCP) improved clinical hyperandrogenism (2 of 2 reviews). Statins improved lipid profile (3 of 3 reviews) and testosterone level (2 of 3 reviews). There was no conclusive evidence from included systematic reviews regarding the use of other interventions.

CONCLUSIONS

There is reliable evidence regarding the use of metformin for anthropometric outcomes and COCPs for hyperandrogenism in women with PCOS but not for other interventions. There is significant gap in knowledge regarding the management of psychological outcomes in women with PCOS which needs further evaluation.

Long-term outcomes of metabolic and bariatric surgery in adolescents with severe obesity with a follow-up of at least 5 years: A systematic review

The practice of metabolic and bariatric surgery for adolescents with severe obesity has been increasing, and evidence of the outcomes in the long term remains unclear. The aim of this study was to review and analyze the outcomes of this therapy in adolescents with a follow-up ≥5 years. MEDLINE, EMBASE, and Cochrane databases were systematically searched. Inclusion criteria were 10- to < 20-year-old adolescents, 5 years minimum of follow-up, and a retention rate ≥70% at 5 years of follow-up. Adiposity indicators outcomes, co-morbidity remission, and complications were analyzed. A total of 10 studies met the inclusion criteria. Surgeries performed included gastric bypass, gastric band, and sleeve gastrectomy. The age of the participants ranged from 13 to 17 years. The longest follow-up after intervention was 156 months. Mean body mass index at baseline and follow-up was 47 and 32.4 kg/m 2 , respectively. Most of the studies reported weight regain within 1 to 12 years of follow-up. Remission rate of co-morbidities was 75% for dyslipidemia, 78% for musculoskeletal problems, 85% for hypertension, and 85% for type 2 diabetes. Not all studies stated that they were looking for all complications. Iron deficiency and anemia were high, ranging from 30% to 70% and 16% to 50%, respectively. The review indicates that there is low to moderate evidence that metabolic and bariatric surgery in adolescents with severe obesity after 5 years of follow-up results in substantial reduction in body mass index, and very low to low evidence in the resolution of related co-morbidities. Although long-term complications were inadequately reported or nonreported, a high prevalence of iron deficiency and anemia was found. Because maternal anemia might be implicated in deleterious effects for offspring, monitoring female patients for anemia after metabolic and bariatric surgery is strongly recommended. Further high-quality studies with long-term follow-up are warranted to assess related co-morbidities and long-term complications.

Bioelectrical Impedance Analysis Results for Estimating Body Composition Are Associated with Glucose Metabolism Following Laparoscopic Sleeve Gastrectomy in Obese Japanese Patients

We investigated the association between body composition and changes in glucose metabolism following laparoscopic sleeve gastrectomy (LSG) in obese Japanese patients. Thirty-two Class III obese patients were assessed before LSG and 3, 6, and 12 months postoperatively. Variables including fat mass (FM), % body fat (%FM), total and skeletal muscle mass (MM), the ratio of lower extremity MM to body weight (BW) (L/W), and the ratio of upper extremity MM to BW (U/W) were measured while using bioelectrical impedance analysis (BIA). LSG significantly decreased BW, FM, and %FM in all time periods observed after surgery with concomitant improvements in metabolic markers. MM was decreased at three months but maintained from 3⁻12 months post-surgery. Importantly, %MM, U/W, and the L/W ratio increased after LSG. Furthermore, change in FM was positively correlated with change in BW 12 months after LSG, whereas changes in %MM were negatively correlated with fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c). Finally, multivariable stepwise regression analyses showed that changes in % total MM was an independent determinant of FPG and change in % skeletal MM was a significant independent determinant of HbA1c in Class III obese Japanese patients after LSG.

Roux-en-Y gastric bypass surgery in youth with severe obesity: 1-year longitudinal changes in spexin

BACKGROUND

Spexin is a novel peptide predominantly produced in human white adipose tissue and has recently been implicated as a potential signal in the regulation of body weight, energy homeostasis, and satiety. The effect of bariatric surgery on spexin is unknown.

OBJECTIVES

To study the effect of Roux-en-Y gastric bypass (RYGB) surgery on endogenous spexin concentration and various risk factors of type 2 diabetes and cardiovascular disease in youth with severe obesity.

SETTING

University hospital, United States METHODS: Spexin, body mass index (BMI), insulin, glucose, total and high molecular weight adiponectin, leptin, and high sensitivity C- reactive protein were measured longitudinally (baseline, 6 mo, and 12 mo) after RYGB surgery in girls with severe obesity (n = 12; age = 16.7 ± 1.5 years; BMI = 51.6 ± 2.9 kg/m²).

RESULTS

Serum spexin concentration increased (P = .01) at 6 months after surgery and stabilized afterward. Spexin level correlated negatively with homeostatic model assessment insulin resistance, HOMA-IR (Spearman correlation r = -.796, P < .001) and positively with high molecular weight adiponectin (Spearman correlation r = .691, P = .011). The change in spexin concentration, from baseline to 6 months after surgery, was inversely correlated with the corresponding change in BMI (Spearman correlation r = -.573, P = .051). Furthermore, the 6-month changes in spexin and HOMA-IR were inversely correlated (slope [standard error, SE] = -.0084 (.0019), P = .001)], even after adjusting for the change in BMI.

CONCLUSIONS

The enhancement of circulating spexin concentration in response to RYGB and correlations with beneficial postoperative changes in various adipokines in youth are novel findings that require further validation.