Clinical update: bariatric surgery

Key genes involved in nonalcoholic steatohepatitis improvement after bariatric surgery

Background

Nonalcoholic steatohepatitis (NASH) is the advanced stage of nonalcoholic fatty liver disease (NAFLD), one of the most prevalent chronic liver diseases. The effectiveness of bariatric surgery in treating NASH and preventing or even reversing liver fibrosis has been demonstrated in numerous clinical studies, but the underlying mechanisms and crucial variables remain unknown.

Methods

Using the GSE135251 dataset, we examined the gene expression levels of NASH and healthy livers. Then, the differentially expressed genes (DEGs) of patients with NASH, at baseline and one year after bariatric surgery, were identified in GSE83452. We overlapped the hub genes performed by protein-protein interaction (PPI) networks and DEGs with different expression trends in both datasets to obtain key genes. Genomic enrichment analysis (GSEA) and genomic variation analysis (GSVA) were performed to search for signaling pathways of key genes. Meanwhile, key molecules that regulate the key genes are found through the construction of the ceRNA network. NASH mice were induced by a high-fat diet (HFD) and underwent sleeve gastrectomy (SG). We then cross-linked the DEGs in clinical and animal samples using quantitative polymerase chain reaction (qPCR) and validated the key genes.

Results

Seven key genes (FASN, SCD, CD68, HMGCS1, SQLE, CXCL10, IGF1) with different expression trends in GSE135251 and GSE83452 were obtained with the top 30 hub genes selected by PPI. The expression of seven key genes in mice after SG was validated by qPCR. Combined with the qPCR results from NASH mice, the four genes FASN, SCD, HMGCS1, and CXCL10 are consistent with the biological analysis. The GSEA results showed that the 'cholesterol homeostasis' pathway was enriched in the FASN, SCD, HMGCS1, and SQLE high-expression groups. The high-expression groups of CD68 and CXCL10 were extremely enriched in inflammation-related pathways. The construction of the ceRNA network obtained microRNAs and ceRNAs that can regulate seven key genes expression.

Conclusion

In summary, this study contributes to our understanding of the mechanisms by which bariatric surgery improves NASH, and to the development of potential biomarkers for the treatment of NASH.

Update on Metabolic Bariatric Surgery for Morbidly Obese Adolescents

Despite worldwide public attention and intense medical efforts, the prevalence of severe morbid obesity in children and adolescents is still rising. Similar to adults, excess adipose tissue triggers multiple immunological and metabolic pathways leading to serious co-morbidities such as impaired glucose tolerance or even type 2 diabetes (T2D), dyslipidemia, arterial hypertension, non-alcoholic fatty liver disease, and hyperuricemia. The management of severe childhood obesity requires a life-long multidisciplinary approach with a combination of lifestyle changes, nutrition, and medications. Standardized life-style intervention programs remain the first-line treatment for morbid obese children and adolescents, but unfortunately reveal limited long-term success. In such cases, metabolic bariatric surgery (MBS) has evolved from being a controversial issue to being included in distinct recommendations. According to the American Society for Metabolic and Bariatric Surgery (ASMBS) Pediatric Committee, indications for bariatric surgery in adolescence must follow very strict criteria. Adolescents with class II obesity (BMI > 120% of the 95th percentile) and a diagnosed co-morbidity or with class III obesity (BMI ≥ 140% of the 95th percentile) should be considered for MBS. These interventions represent high-risk operations, and adolescents should be treated in specialized, multidisciplinary high-volume obesity centers with long-term follow-up programs. The Roux-en-Y gastric bypass (RYGB) remains the gold standard of all malabsorptive procedures. Laparoscopic sleeve gastrectomy (LSG), which the authors pioneered as a stand-alone procedure in morbidly obese adolescents in 2008, has become the most commonly performed operation in morbidly obese adolescents at present. Recent literature proves that MBS is safe and effective in morbidly obese adolescents. Mid-term data have revealed significant improvement or even resolution of major co-morbidities. Thus, MBS for the treatment of morbidly obese adolescents has evolved from being a controversial issue to being included in distinct recommendations by several medical societies as a therapeutic strategy to reduce severe co-morbidities potentially causing end-organ damage in adulthood.

Association between Obesity, Surgical Route, and Perioperative Outcomes in Patients with Uterine Cancer

Objective

To study temporal trends of hysterectomy routes performed for uterine cancer and their associations with body mass index (BMI) and perioperative morbidity.

Methods

A retrospective review of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) 2005-2013 databases was conducted. All patients who were 18 years old and older with a diagnosis of uterine cancer and underwent hysterectomy were identified using ICD-9-CM and CPT codes. Surgical route was classified into four groups: total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), laparoscopic assisted vaginal hysterectomy (LAVH), and total laparoscopic hysterectomy (TLH) including both conventional and robotically assisted. Patients were then stratified according to BMI.

Results

7199 records were included in the study. TLH was the most commonly performed route of hysterectomy regardless of BMI, with proportions of 50.9%, 48.9%, 50.4%, and 51.2% in ideal, overweight, obese, and morbidly obese patients, respectively. The median operative time for TAH was 2.2 hours compared to 2.7 hours for TLH (p < 0.01). The median length of stay for TAH was 3 days compared to 1 day for TLH (p < 0.01). The percentage of patients with an adverse outcome (composite indicator including transfusion, deep venous thrombosis, and infection) was 17.1 versus 3.7 for TAH and TLH, respectively (p < 0.01).

Conclusion

During the last decade, TLH has been increasingly performed in women with uterine cancer. The increased adoption of TLH was seen in all BMI subgroups.

Psychological and Personality Predictors of Weight Loss and Comorbid Metabolic Changes After Bariatric Surgery

Bariatric surgery (BS) has proven to be the most effective treatment for weight loss and for improving comorbidities in severe obesity. A comprehensive psychological assessment prior to surgery is proposed to prepare patients for a successful post-surgical outcome. Therefore, the main aim of the present study was to assess psychological and personality predictors of BS outcome. The sample comprised 139 severely obese patients who underwent BS. Assessment measures included the Eating Disorders Inventory-2, the Symptom Checklist-Revised and the Temperament and Character Inventory-Revised. Our results show that favourable BS outcome, after 2 years follow up, was associated with younger age, less depression, moderate anxiety symptoms and high cooperativeness levels. Likewise, metabolic improvements were found to be linked to younger age and certain psychopathological factors. In conclusion, our findings suggest that age, baseline body mass index, psychopathological indexes and personality traits predict successful BS outcome.

Effects of Theodore Millon's Teaching, Mentorship, Theory, and Scientific Contributions on Health Psychology and Behavioral Medicine Research and Practice

This article summarizes the impact of Theodore Millon's work on the disciplines of health psychology and behavioral medicine over the past 5 decades spanning from the late 1960s to present. The article is written from my perspectives as a graduate student mentored by Millon on through my faculty career as a collaborator in test construction and empirical validation research. Several of the most recent entries in this summary reflect projects that were ongoing at the time of his passing, revealing the innovation and visionary spirit that he demonstrated up until the end of his life. Considering that this summary is restricted to Millon's contributions to the disciplines of health psychology and behavioral medicine, this work comprises only a small portion of his larger contribution to the field of psychology and the areas of personality theory and psychological assessment more broadly.

Total weight loss associated with increased physical activity after bariatric surgery may increase the need for total joint arthroplasty

BACKGROUND

Retrospectively, our institution noticed an increased number of patients undergoing total joint arthroplasty (TJA) after bariatric surgery. Considering that bariatric surgery is a proven modality to reduce osteoarthritic pain, we sought to identify a reason some patients may later require TJA. The objective of this study was to investigate the hypothesis that rapid or increased weight loss after bariatric surgery may be a risk factor for TJA.

METHODS

Weight loss parameters were retrospectively assessed in 15 bariatric surgery patients who subsequently received a primary TJA and compared with matched bariatric controls.

RESULTS

Patients who required a TJA lost 27.9% more of their body mass index (BMI) compared with controls (P = .049). Furthermore, patients who underwent TJA 25-48 months postbariatric surgery lost 78.2% more of their BMI compared with controls (P<.001). Total knee arthroplasty patients lost 43.9% more of their BMI compared with controls (P = .02), and the difference in BMI change for total hip arthroplasty patients was not significant versus controls.

CONCLUSION

These results contradict the tenant that weight loss is universally protective against arthritis and merit larger prospective investigations.

Reporting results after bariatric surgery: reproducibility of predicted body mass index

BACKGROUND

There is a controversy about the best way to report results after bariatric surgery. Several indices have been proposed over the years such as percentage of total weight loss (%TWL), percentage of excess weight loss (%EWL), and percentage of excess body mass index loss (%EBMIL). More recently, it has been suggested to individualize the body mass index (BMI) goal to be achieved by the patients (predicted BMI-PBMI). The objective was to assess the reproducibility of this PBMI in our service.

METHODS

In this retrospective study, we assessed the %TWL, %EWL, %EBMIL (with expected BMI of 25 kg/m2), and %EBMIL (with PBMI) over 4 years of observation in two groups of patients: BMI <50 kg/m2 and BMI ≥50 kg/m2.

RESULTS

The medical records of 403 patients were studied. From 18 to 42 months after surgery, %TWL was higher in the superobese group, whereas %EWL was similar for the two groups. %EBMIL was higher in less obese patients up to 24 months and similar thereafter. In contrast, %EBMIL with PBMI was greater in the superobese group, although it never reached the 100% goal.

CONCLUSIONS

We conclude that %EBMIL results according to PBMI were not reproducible in our institution. There is a need to elaborate a new easy-to-obtain and reproducible index.

[Bariatric surgery and associated complications: radiological imaging]

Obesity is an increasing problem faced by the healthcare system. In managing obesity, bariatric surgery is becoming more important with evidence showing a reduction in long-term morbidity and mortality. There are special challenges faced by the radiology department in providing an imaging service for this population of patients, from technical requirements through to the interpretation of post-surgical images. This article provides an overview of the most frequently performed procedures, normal postoperative imaging findings and the appearance of common complications.

From longitudinal gastric resection to sleeve gastrectomy--revival of a previously established surgical procedure

INTRODUCTION

Sleeve gastrectomy is becoming increasingly popular within bariatric surgery. Initially introduced as a component of complex interventions and later as part of a two-stage operation in high-risk patients, the procedure is now more common as one-stage operation and subject of avid scientific discussion. However, the concept of longitudinal gastric resection is not new. The procedure was already established in ulcer surgery but soon faded into insignificance. This article aims to trace the historical development of resection of the greater curvature with particular reference to its origin in ulcer and bariatric surgery. The contribution of ulcer surgery to modern sleeve gastrectomy is highlighted. Furthermore, the current value of sleeve gastrectomy within the spectrum of bariatric surgical procedures will be discussed. Relevant medical literature from PubMed to April 2010 was reviewed.

DISCUSSION

Besides bariatric surgery modern sleeve gastrectomy has one more so far largely neglected origin: segmental and later longitudinal gastric resection used in ulcer surgery. Experience and achievements from ulcer surgery simplified and facilitated development of sleeve gastrectomy which is not the desired universal procedure for bariatric surgery but certainly an attractive treatment option. It should be performed in a more standardized manner and with due regard to future long-term results.

Imaging in bariatric surgery: service set-up, post-operative anatomy and complications

Obesity is an increasingly prevalent and costly problem faced by the healthcare system. The role of bariatric surgery in managing obesity has also increased with evidence showing a reduction in long-term morbidity and mortality. There are unique challenges faced by the radiology department in providing an imaging service for this population of patients, from technical and staffing requirements through to the interpretation of challenging post-surgical images. We describe these challenges and provide an overview of the most frequently performed procedures, normal post-operative imaging findings and the appearance of common complications.

[Influence of previous psychiatric disorders on postoperative course in patients undergoing bariatric surgery]

INTRODUCTION

Presurgical evaluation of patients undergoing bariatric surgery includes, among others, a psychological/psychiatric evaluation. Psychiatric disorders that did not contraindicate surgery may persist and influence on weight loss and postoperative clinical course, hindering the success of the procedure. The aim of our study was to analyze the postoperative evolution of our series of patients with and without psychiatric symptoms before surgery.

PATIENTS AND METHODS

Retrospective analysis of 109 patients undergoing bariatric surgery with duodenal switch from 2003 to 2008 (follow up > 6 months). We studied weight changes, immediate and delayed complications of surgery and nutritional deficiencies in post-surgical follow-up in patients with previous psychiatric disorders (group 1, n = 17) compared with patients without psychiatric disorders (group 2, n = 92).

RESULTS

Patients in group 1 showed a greater tendency for weight gain. They regained a 9.4% of the initial excess weight lost between 18 months after surgery and 36 months after surgery, while patients in group 2 regained only 0.2% in the same period (p < 0.05). There was no difference in immediate surgical complications (5/17 vs 25/92 patients). The mean incidence of late surgical complications was 0.71 per patient in group 1 and 0.22 complications per patient in group 2 (p = 0.02). 52.9% of patients in group 1 had at least one late complication compared to 19.6% of patients in group 2 (p = 0.003). The three most common complications in patients with previous psychiatric disorders were chronic diarrhea, vomits and malnutrition. The presence of nutritional deficiencies were common in both groups, mainly soluble vitamins, iron and zinc. During postoperative follow-up, we found 3.1 +/- 1.6 nutritional deficiencies per patient in group 1 and 2.5 +/- 1.7 in group 2 (p = 0.04). More than three nutritional deficiencies were found in 8 patients in group 1 (52.9%) compared to 23 patients in group 2 (25%) (p = 0.03).

CONCLUSIONS

The presence of previous psychiatric disorders may be a predictor of a less positive outcome in morbidly obese patients who undergo bariatric surgery.

Laparoscopic adjustable gastric band in an obese unrelated living donor prior to kidney transplantation: a case report

INTRODUCTION

Obese living donors who undergo donor nephrectomy have higher rates of intra-operative and post-operative complications. Many centres exclude obese donors from living donor transplant programs. Diet, exercise and medication are often ineffective weight loss interventions for donors, hence bariatric surgery should be considered.

CASE PRESENTATION

We report the case of a 53-year-old Caucasian woman who underwent laparoscopically adjustable gastric banding. The procedure enabled her to lose sufficient weight to gain eligibility for kidney donation. After losing weight, she had an uncomplicated laparoscopic donor nephrectomy surgery, and the recipient underwent successful kidney transplantation.

CONCLUSION

Laparoscopically adjustable gastric banding should be considered for obese potential living kidney donors whenever transplantation units restrict access to donor nephrectomy based on the increased surgical risk for donors.

Mapping utility scores from a disease-specific quality-of-life measure in bariatric surgery patients

OBJECTIVES

To develop algorithms for a conversion of disease-specific quality-of-life into health state values for morbidly obese patients before or after bariatric surgery.

METHODS

A total of 893 patients were enrolled in a prospective cross-sectional multicenter study. In addition to demographic and clinical data, health-related quality-of-life (HRQoL) data were collected using the disease-specific Moorehead-Ardelt II questionnaire (MA-II) and two generic questionnaires, the EuroQoL-5D (EQ-5D) and the Short Form-6D (SF-6D). Multiple regression models were constructed to predict EQ-5D- and SF-6D-based utility values from MA-II scores and additional demographic variables.

RESULTS

The mean body mass index was 39.4, and 591 patients (66%) had already undergone surgery. The average EQ-5D and SF-6D scores were 0.830 and 0.699. The MA-IIwas correlated to both utility measures (Spearman's r = 0.677 and 0.741). Goodness-of-fit was highest (R(2) = 0.55 in the validation sample) for the following item-based transformation algorithm: utility (MA-II-based) = 0.4293 + (0.0336 x MA1) + (0.0071 x MA2) + (0.0053 x MA3) + (0.0107 x MA4) + (0.0001 x MA5). This EQ-5D-based mapping algorithm outperformed a similar SF-6D-based algorithm in terms of mean absolute percentage error (P = 0.045).

CONCLUSIONS

Because the mapping algorithm estimated utilities with only minor errors, it appears to be a valid method for calculating health state values in cost-utility analyses. The algorithm will help to define the role of bariatric surgery in morbid obesity.

A critical review of the cannabinoid receptor as a drug target for obesity management

The discovery of cannabinoids, with the well-known stimulatory effect of Cannabis sativa on appetite, has offered a new drug target for obesity treatment. Cannabinoids act on two different receptors: CB1 receptors which are sited in the brain and many peripheral tissues, and CB2 receptors which are primarily found in immune system cells. Cannabinoid receptor antagonists act centrally by blocking CB1 receptors, thereby reducing food intake. Moreover, they probably also act peripherally by increasing thermogenesis and therefore energy expenditure, as has been suggested by animal experiments. Despite these promising mechanisms of action, recent clinical studies examining the effect of the two CB1 receptor antagonists rimonabant and taranabant showed that the attained weight loss did not exceed that attained with other currently approved anti-obesity medications. Moreover, potentially severe psychiatric adverse effects limit their clinical use. As several new CB1 receptor antagonists are presently undergoing development, it remains to be elucidated to what extent they differ in terms of efficacy and safety. This review primarily discusses how close cannabinoid receptor antagonists are to the ideal anti-obesity drug, with respect to their mechanisms of action, clinical effectiveness and safety.

Factors associated with weight loss after gastric bypass

BACKGROUND

Gastric bypass (GBP) is the most common operation performed in the United States for morbid obesity. However, weight loss is poor in 10% to 15% of patients. We sought to determine the independent factors associated with poor weight loss after GBP.

DESIGN

Prospective cohort study. We examined demographic, operative, and follow-up data by means of multivariate analysis. Variables investigated were age, sex, race, marital and insurance status, initial weight and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared), comorbidities (diabetes mellitus, hypertension, joint disease, sleep apnea, hyperlipidemia, and psychiatric disease), laparoscopic vs open surgery, gastric pouch area, gastrojejunostomy technique, and alimentary limb length.

SETTING

University tertiary referral center.

PATIENTS

All patients at our institution who underwent GBP from January 1, 2003, through July 30, 2006.

MAIN OUTCOME MEASURES

Weight loss at 12 months defined as poor (< or =40% excess weight loss) or good (>40% excess weight loss).

RESULTS

Follow-up data at 12 months were available for 310 of the 361 patients (85.9%) undergoing GBP during the study period. Mean preoperative BMI was 52 (range, 36-108). Mean BMI and excess weight loss at follow-up were 34 (range, 17-74) and 60% (range, 8%-117%), respectively. Thirty-eight patients (12.3%) had poor weight loss. Of the 4 variables associated with poor weight loss in the univariate analysis (greater initial weight, diabetes, open approach, and larger pouch size), only diabetes (odds ratio, 3.09; 95% confidence interval, 1.35-7.09 [P = .007]) and larger pouch size (odds ratio, 2.77;95% confidence interval, 1.81-4.22 [P <.001]) remained after the multivariate analysis.

CONCLUSIONS

Gastric bypass results in substantial weight loss in most patients. Diabetes and larger pouch size are independently associated with poor weight loss after GBP.

Successful multi-intervention treatment of severe obesity: a 7-year prospective study with 96% follow-up

BACKGROUND

No long-term, high participation study of the outcome of bariatric surgery has examined how a multi-intervention approach to the treatment of severe obesity can achieve and sustain weight loss after an initial bariatric procedure.

METHODS

We employed a multi-intervention treatment that combines adjustable gastric banding with intensive follow-up to support patient life-style change and use of an algorithm allowing reoperation-to bypass, if necessary-in the event of complications. Four hundred four severely obese patients with an average BMI = 42.6 at the outset had initial AGB surgery and were followed with a high rate of face-to-face consultations for 7 years. Seventy-five percent of the patients retained a gastric band throughout the study. Weight loss, complications, and comorbidities were studied, and quality of life was assessed using Bariatric Analysis and Reporting Outcome System (BAROS).

RESULTS

Three hundred eighty-eight (96%) patients completed the 7-year follow-up. Average BMI reduction at 5 years was 28% and remained stable through year 7, at which the mean excess weight loss was 61%. The preoperative prevalence of metabolic syndrome, 59.7%, decreased to 13.3% at 7 years and was abolished for patients with more than 40% loss of initial BMI. Similar changes were seen for all components of metabolic syndrome. More than 60% of patients had a "good" or higher BAROS score; 10.1% were considered failures. Patients converted to gastric bypass, and those retaining gastric bands throughout the study had very similar outcomes.

CONCLUSIONS

Long-term, multi-intervention treatment of severe obesity can achieve and preserve weight loss and thus improved quality of life and sustained reduction or disappearance of all components of metabolic syndrome, for a high proportion of severely obese patients with preoperative BMI between 35 and 55.

Laparoscopic gastric banding surgery performed in obese dialysis patients prior to kidney transplantation

Obese patients with end-stage renal disease who receive a kidney transplant experience greater rates of posttransplantation diabetes, delayed graft function, and local wound complications. Many centers exclude obese patients from transplantation programs. Diet, exercise, and medication in general are not reliable weight loss options for patients with end-stage renal disease; hence, bariatric surgery should be considered. We report 3 patients who underwent laparoscopically adjustable gastric banding, which enabled sufficient weight loss to gain eligibility for kidney transplantation. All these patients subsequently underwent successful uncomplicated kidney transplantations.