Low overall mortality during 10 years of bariatric surgery: nationwide study on 63,469 procedures from the Scandinavian Obesity Registry

Therapeutic Options for Recurrence of Weight and Obesity Related Complications After Metabolic and Bariatric Surgery: An IFSO Position Statement

Obesity is a chronic disease that may require multiple interventions and escalation of therapy throughout the years. Until recently, no universal definition existed for recurrent weight gain and insufficient weight loss. Standardization of reporting is key so outcomes can be compared and data can be pooled. The recent IFSO consensus provided standard terminology and definitions that will likely resolve this in the future, and publishers will need to enforce for authors to use these definitions. This current IFSO position statement provides guidance for the management of recurrent weight gain after bariatric surgery.

Results from the Scandinavian Obesity Surgery Registry: A narrative review

In 2007, the Scandinavian Obesity Surgery Registry (SOReg) was started by the profession to monitor the results of bariatric surgery and to provide a high-quality database for research. In the end of August 2023, SOReg contains 88,379 patients (body mass index [BMI] 41.7 kg/m2 , 41.2 years, 77.1% females, gastric bypass 76.8%). In this narrative review, we demonstrate that preoperative weight loss is of value and that the laparoscopic double omega-loop technique is highly suitable for gastric bypass. Closing the mesenteric openings is, however, important. Swedish bariatric surgery has low mortality, and our results are comparative to those of other countries. Significant long-term improvements are found in common obesity-related diseases such as diabetes, hypertension, and sleep apnea. Furthermore, the risk for cardiac failure and major adverse cardiovascular events is significantly reduced. Pregnancy-related outcomes are also improved. Gastric bypass results in significant improvements in quality of life and seems to be cost saving. We have revealed that low socioeconomic status is associated with reduced chance of undergoing bariatric surgery and inferior outcomes. Of note, we have performed several randomized clinical trials within the registry database. In conclusion, high-quality national registry databases, such as SOReg, are important for maintaining high-quality care and present a platform for extensive research.

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.

General Practitioner's Knowledge about Bariatric Surgery Is Associated with Referral Practice to Bariatric Surgery Centers

(1) Background: Patients seeking treatment for obesity and related diseases often contact general practitioners (GPs) first. The aim of this study was to evaluate GPs’ knowledge about weight loss surgery (WLS) and potential stereotypes towards obese patients. (2) Methods: For this prospective cohort study, 204 GPs in the region of the bariatric surgery center at the University Hospital Aachen were included. The participants filled out a questionnaire comprising general treatment of obese patients, stigmatization towards obese patients (1–5 points) as well as knowledge regarding WLS (1–5 points). (3) Results: The mean age of the GPs was 54 years; 41% were female. Mean score for self-reported knowledge was 3.6 points out of 5. For stigma-related items, the mean score was 3.3 points out of 5. A total of 60% of the participants recognized bariatric surgery as being useful. Knowledge about bariatric surgery significantly correlated with the number of referrals to bariatric surgery centers (p < 0.001). No significant correlation was found between stigma and referral to surgery (p = 0.057). (4) Conclusions: The more GPs subjectively know about bariatric surgery, the more often they refer patients to bariatric surgery specialists—regardless of potentially present stereotypes. Therefore, GPs should be well informed about indications and opportunities of WLS.

Perioperative mortality in bariatric surgery: meta-analysis

BACKGROUND

Bariatric surgery is an established treatment for severe obesity; however, fewer than 1 per cent of eligible patients undergo surgery. The perceived risk of surgery may contribute to the low uptake. The aim of this study was to determine perioperative mortality associated with bariatric surgery, comparing different operation types and data sources.

METHODS

A literature search of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials was conducted to identify studies published between 1 January 2014 and 31 July 2020. Inclusion criteria were studies of at least 1000 patients reporting short-term mortality after bariatric surgery. Data were collected on RCTs. Meta-analysis was performed to establish overall mortality rates across different study types. The primary outcome measure was perioperative mortality. Different operation types were compared, along with study type, in subgroup analyses. The study was registered at PROSPERO (2019: CRD 42019131632).

RESULTS

Some 4356 articles were identified and 58 met the inclusion criteria. Data were available on over 3.6 million patients. There were 4707 deaths. Pooled analysis showed an overall mortality rate of 0.08 (95 per cent c.i. 0.06 to 0.10; 95 per cent prediction interval 0 to 0.21) per cent. In subgroup analysis, there was no statistically significant difference between overall, 30-day, 90-day or in-hospital mortality (P = 0.29). There was no significant difference in reported mortality for RCTs, large studies, national databases or registries (P = 0.60). The pooled mortality rates by procedure type in ascending order were: 0.03 per cent for gastric band, 0.05 per cent for sleeve gastrectomy, 0.09 per cent for one-anastomosis gastric bypass, 0.09 per cent for Roux-en-Y gastric bypass, and 0.41 per cent for duodenal switch (P < 0.001 between operations).

CONCLUSION

Bariatric surgery is safe, with low reported perioperative mortality rates.

The Role of Relaparoscopy in the Management of Early Bariatric Surgery Complications and 30-Day Outcome: a Tertiary Centre Experience

The laparoscopic approach for dealing with bariatric complications has become the gold standard of modern practice. The aim of this study is to assess the role of relaparoscopy as a diagnostic and therapeutic approach towards managing complications and improving 30-day outcome.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database was conducted in a tertiary bariatric unit. Data were collected on all bariatric surgical procedures performed between March 2013 and March 2019. Any patient who was returned to theatre for a suspected serious complication was identified and their outcome studied.

RESULTS

Over the 5-year study period, the total number of operations performed was 1660 (981 laparoscopic gastric bypass (LRYGB), 612 laparoscopic sleeve gastrectomy (LSG) and 67 revisional bariatric operations). Early postoperative complications (in hospital or within 30 days of surgery) that lead to reoperation were recorded in 33 patients (1.9%). These complications occurred after LRYGB in 26 patients (2.65%) and LSG in 7 patients (1.14%), respectively. Anastomotic leaks occurred in 1.1% of LRYGB, whilst 0.6% of patients have jejuno-jejunostomy obstruction. Obstruction at the gastro-jejunostomy anastomosis occurred in one patient. Following LSG, one mortality was recorded following bleeding from the staple line (0.06%) and five patients (0.3%) had leaks from the staple line. Thirty-one reoperations were performed laparoscopically, and two were converted to the open approach, whilst 2 operations were planned as open from the outset.

CONCLUSION

Relaparoscopy is an effective and safe approach to the management of clinically or radiologically suspected early complications after bariatric surgery. Graphical abstract.

Complications in Bariatric Surgery

Bariatric surgery represents the most valid option to treat the chronic disease of morbid obesity and all its related comorbid conditions with the purpose to increase life expectancy. Despite multiple recommendations of the different scientific societies, bariatric surgery remains worldwide largely underused. Considering only a 16% rate of obesity disease, with the largest number of bariatric surgeries performed in Europe of 50k procedures a year, France should need more than 200 years to surgically approach all morbid obese patients. Similarly, in the United States, obesity is a chronic condition that affects more than 1 in 3 adults, with a mean number of 250k bariatric procedures a year, hence they would need 437 years to manage this population. Definitely, the bariatric surgery is very poorly used and there are several factors to explain it. Inadequate access to medical care and insufficient information provided by the general practitioner are frequently encountered in our practice. But the main limitation for the bariatric treatment remains the patients' "fear" of a surgical complication.

Preoperative cardiac screening using NT-proBNP in obese patients 50 years and older undergoing bariatric surgery: a study of 310 consecutive patients

Background

Obesity is associated with cardiovascular (CV) risk factors and diseases. Because bariatric surgery is increasingly performed in relatively elderly patients, a risk for pre- and postoperative CV complications exists.

Objectives

We aimed to assess the value of plasma N-terminal-probrain natriuretic peptide (NT-proBNP) as a CV screening tool.

Setting

High-volume bariatric center.

Methods

Between June 2019 and January 2020, all consecutive bariatric patients 50 years and older underwent preoperative NT-proBNP assessment in this cohort study to screen for CV disease. Patients with elevated NT-proBNP (≥125 pg/mL) were referred for further cardiac evaluation, including electrocardiography and echocardiography.

Results

We included 310 consecutive patients (median age, 56 years; 79% female; body mass index = 43±6.5 kg/m²). A history of CV disease was present in 21% of patients, mainly atrial fibrillation (7%) and coronary artery disease (10%). A total of 72 patients (23%) had elevated NT-proBNP levels, and 67 of them underwent further cardiac workup. Of these 67 patients, electrocardiography (ECG) showed atrial fibrillation in 7 patients (10%). On echocardiography, 3 patients had left ventricular ejection fraction (LVEF) <40%, 9 patients had LVEF 40%–49%, and 13 patients had LVEF ≥50% with structural and/or functional remodeling. In 2 patients, elevated NT-proBNP prompted workup leading to a diagnosis of coronary artery disease and consequent percutaneous coronary intervention in 1 patient.

Conclusions

Elevated NT-proBNP levels are present in 23% of patients 50 years and older undergoing bariatric surgery. In 37% of them, there was echocardiographic evidence for structural and/or functional remodeling. Further studies are needed to assess if these preliminary results warrant routine application of NT-proBNP to identify patients at risk for CV complications after bariatric surgery.

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This study assessed NT-proBNP as a cardiac screening tool in bariatric patients.

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Elevated NT-proBNP levels were present in 23% of patients ≥50 years.

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In 37% of them (n=25), echocardiography showed LV dysfunction or heart failure.

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NT-proBNP is a non-invasive tool that can detect new CV diseases in bariatric patients

Insulin resistance in bariatric surgery

PURPOSE OF REVIEW

To give an updated review on the underlying mechanisms and clinical effects of improved glucose control after bariatric surgery.

RECENT FINDINGS

The basic principles of the mechanism for the metabolic effects of bariatric surgery can be categorized into calorie restriction, deviation of nutrients, and reduced amounts of adipose tissue. Recent findings suggest the importance of early changes following deviation of nutrients to more distal parts of the small bowel resulting in altered release of gastrointestinal hormones, altered gut microbiota, and weight-reduction. In the long-term, loss of adipose tissue results in reduced inflammation and improved insulin sensitivity. From a clinical perspective these changes are associated with remission of diabetes in patients with morbid obesity and type 2 diabetes, prevention of diabetes in patients with insulin resistance without overt type 2 diabetes and prevention of both microvascular and macrovascular complications for all patients with morbid obesity.

SUMMARY

At present, bariatric surgery remains the most effective treatment option to improve glucose control and long-term complications associated with hyperglycemia in patients with obesity.Although the mechanisms behind these metabolic effects remain only partially understood, further knowledge on these complex mechanisms may help identifying durable treatment options for morbid obesity and important metabolic comorbidities.