Bariatric surgery: a review of procedures and outcomes

Pregnant women's experiences of nutrition care after previous bariatric surgery

PROBLEM

The rate of pregnancy following bariatric surgery is rising globally and is associated with health benefits but also increased risk of micronutrient deficiency, preterm birth and small for gestational age offspring. Bariatric surgery may limit women's ability to meet the nutrient demands of pregnancy, necessitating individualised nutrition therapy. However, little is known about women's experiences of, and preferences for nutrition-related care during pregnancy after bariatric surgery.

AIM

To describe women's experiences of pregnancy after bariatric surgery, focussing on nutrition-related care.

METHODS

This qualitative study interviewed women across Australia with a history of any bariatric surgery. Semi-structured telephone interviews were conducted after 36-weeks gestation and before childbirth. Data were analysed using reflexive thematic analysis.

FINDINGS

Thirteen women aged 26-37 participated. Three themes were generated: navigating healthcare, the personal toll of pregnancy after bariatric surgery, and women's agency. Despite a strong desire for specialised nutrition care, women encountered several barriers to accessing this. When care was available, it often did not meet women's needs due to healthcare professionals' limited understanding of the nutrition challenges faced in pregnancies following bariatric surgery. This compelled women to seek information outside their maternity care team and advocate for themselves during care.

DISCUSSION

These findings highlight the need to address barriers to accessing nutrition care for pregnant women following bariatric surgery. Improved understanding of pregnancy and post-operative symptoms may enable enhanced woman-centred care.

CONCLUSION

Greater awareness of bariatric surgery among all maternity care professionals is needed to improve opportunities for informed, shared decision-making with pregnant women.

Prescribing preoperative weight loss prior to major non-bariatric surgery for patients with elevated weight: a national provider survey (PREPARE provider survey)

Background

The surgical patient with obesity presents several challenges in intraoperative and postoperative care. We designed this cross-sectional survey to assess surgeon willingness to prescribe preoperative very low energy diets (VLEDs) and practice patterns in prescribing preoperative weight loss interventions for patients with obesity undergoing non-bariatric abdominal surgery.

Methods and findings

We conducted a cross-sectional survey of practicing surgeons in Canada who perform major non-bariatric abdominal surgery, reported in accordance with the Consensus-Based Checklist for Reporting of Survey Studies and utilizing non-probability convenience sampling. The primary outcome was willingness to prescribe preoperative VLED to obese patients undergoing major non-bariatric abdominal surgery for both benign and malignant indications. We created a multivariable proportional odds model to identify factors associated with willingness to prescribe VLEDs. A total of 78 participants completed and returned the survey (response rate 10.9%; mean age 43.54 ± 8.13 years; 48.72% female). Most surgeons (79.5%) felt that obesity significantly impacted the technical difficulty of their operations. We identified a disconnect between those surgeons who were willing prescribe VLEDs vs. those who actually prescribed them (78.2% vs. 30.8%, respectively). Approximately half of the surgeons reported being unfamiliar with VLEDs. Regression analysis identified practicing in academic institutions was associated with increased willingness to prescribe [odds ratio (OR) 3.71, 95% confidence intervals (CI) 1.01-13.7, p < 0.01].

Conclusion

Although the majority of surgeons feel that obesity adversely impacts perioperative care, only one-third routinely discuss preoperative VLEDs with their patients. Opportunities to increase awareness and evaluate the impact of VLEDs on patient outcomes remain high.

Measuring Dietary Intake of Pregnant Women Post-Bariatric Surgery: Do Women Meet Recommendations?

Background: Bariatric surgery is increasingly offered to women of childbearing age and significantly reduces food intake and nutrient absorption. During pregnancy, associated risks, including micronutrient deficiency, are accentuated. This study describes maternal dietary intake and adherence to dietary recommendations in pregnant women with a history of bariatric surgery. Methods: Women aged 18-45 with singleton pregnancies post-bariatric surgery were recruited at <23 weeks of gestation and followed until birth. Dietary intake was measured using three non-consecutive 24 h recalls at enrolment and at 28 and 36 weeks using the standardized tool ASA24-Australia. Micronutrient supplementation dose and adherence was reported using the Brief Medication Adherence Questionnaire. Mean macronutrient intake was calculated from all diet recalls. Micronutrient intake was determined from diet recalls and from supplementation. Intake was compared to the recommended daily intakes for pregnancy. Results: Sixty-three women participated in the study. The participants met 65 ± 17.3% (mean ± SD) of estimated energy requirements, 53(23)% (median(IQR)) of fiber requirements, and exceeded fat and saturated fat recommendations. Dietary intake levels of iron, folate, zinc, calcium, and vitamin A were below recommended levels. Gastric bypass recipients consumed significantly less folate (p = 0.008), vitamin A (p = 0.035), and vitamin E (p = 0.027) than women post-gastric sleeve or gastric band. Multivitamins were used by 80% (n = 55) of participants at study enrolment, which increased their mean intake of all micronutrients to meet recommendations. Conclusions: Women who conceive post-bariatric surgery may require targeted support to meet the recommended nutrient intake. Micronutrient supplementation enables women to meet nutrient recommendations for pregnancy and is particularly important for gastric bypass recipients.

Integrated Insights into Metabolic and Bariatric Surgery: Improving Life Quality and Reducing Mortality in Obesity

Metabolic and bariatric surgery (MBS) is an effective intervention for patients with severe obesity and metabolic comorbidities, particularly when non-surgical weight loss methods prove insufficient. MBS has shown significant potential for improving quality of life and metabolic health outcomes in individuals with obesity, yet it carries inherent risks. Although these procedures offer a multifaceted approach to obesity treatment and its clinical advantages are well-documented, the limited understanding of its long-term outcomes and the role of multidisciplinary care pose challenges. With an emphasis on quality-of-life enhancements and the handling of postoperative difficulties, the present narrative review seeks to compile the most recent findings on MBS while emphasizing the value of an integrated approach to maximize patient outcomes. Effective MBS and patients' management require a collaborative team approach, involving surgeons, dietitians, psychologists, pharmacists, and other healthcare providers to address not only physiological but also psychosocial patient needs. Comparative studies demonstrate the efficacy of various MBS methods, including Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy that may considerably decrease morbidity and mortality in individuals with obesity. Future studies should target long-term patient treatment, and decision making should be aided by knowledge of obesity, comorbidity recurrence rates, and permanence of benefits.

Impact of glucagon-Like peptide-1 agonists in optimizing abdominal wall Reconstruction patients

PURPOSE

Pre-optimization of obese patients prior to abdominal wall reconstruction (AWR) is essential in mitigating their increased preoperative risks. Traditionally diet, exercising, bariatric surgery are the tools typically prescribed for weight loss. The advent of glucagon-like peptide-1 agonists (GLP-1A) which stimulate insulin secretion and inhibit gastric emptying have improved the weight loss armamentarium. However, there is a limited amount of literature on GLP-1A effectiveness and postoperative outcomes in AWR patients. This study compares the efficacy of GLP-1A to Bariatric Surgery (BAS) in perioperative AWR patient.

METHODS

A prospectively maintained database was retrospectively reviewed to identify all patients undergoing AWR at our institution between January 2021 and March 2024. We included patients who required GLP-1A or BAS for weight optimization prior to AWR. We excluded patients on GLP1-A or history BAS not performed for AWR preoptimization. Basic demographics such as age, sex, race, weight and BMI at initial clinic visit and at surgery were compared. Primary endpoints included time to surgery, time to bowel recovery and length of stay (LOS). Time to surgery was defined as the number of months between the initial clinic visit and AWR. Time to bowel recovery was defined as the number of days it took for the first postoperative bowel function. Secondary endpoints included standard 30-days postoperative variables. Nominal variables were analyzed using a Fisher exact test and continuous variables were analyzed with Student's T test.

RESULTS

35 patients were included in this study (GLP-1A: 17, BAS: 18). The GLP-1A cohort had a lesser BMI at the initial clinic visit (40.8 vs 43.4, p = 0.188). GLP-1A cohort made it to the operating room faster (9.1 months vs 13.5 months, p = 0.06) from the first clinic visit; and (7.9 months vs 9.7 months, p = 0.4) from initiation of weight loss intervention. Albeit losing less weight (14.9 kg vs 27.1 kg, p = 0.008) with a lesser reduction in the BMI (4.69 vs 9.23, p = 0.004). The GLP-1A cohort showed a non-significant elevated LOS (5.2 days vs 3.6 days, p = 0.25) and an increased ileus rate (17.6% vs 0%, p = 0.1). However, there were no differences noted in time to bowel recovery (2.9 days vs 3.1 days, p = 0.76).

CONCLUSION

GLP-1A is effective in optimizing patients needing weight loss before AWR. They shorten the timeline to AWR intervention and have comparable peri-operative outcomes to BAS patients.

Intragastric botulinum toxin injection: a promising alternative for obesity treatment?

Introduction

Over the past 50 years, the rise in obesity has prompted a search for new treatments. Intragastric injections of botulinum toxin A (BT-A), a safer alternative to surgery, show promise in reducing weight and caloric intake by inducing early satiety. This study examines their efficacy for weight loss.

Material and methods

From 2021 to 2023, we conducted a retrospective analysis of patients who underwent intragastric BT-A injections in a general surgery endoscopy unit. The inclusion criteria were being aged 18-65 and having a body mass index (BMI) over 25 kg/m2. Patients with specific medical conditions or incomplete records were excluded. We monitored patient weight and BMI values before the procedure and at monthly intervals, with further assessments conducted in the sixth month, including appetite and patient satisfaction.

Results

Our study on 67 patients, predominantly female (82.1%), aged 35.5 ±9.0 years with a mean BMI of 33.5 ±3.3 kg/m², examined BT-A injections' effectiveness. 58.2% received injections in both gastric antrum and fundus regions, showing greater weight loss (mean: 10.7 ±7.0 kg) than those treated in the antrum alone. Side effects occurred in 16.4%, with various symptoms. High dietary compliance (80.6%) correlated with weight loss, especially among those reporting intense satiety. Patient satisfaction positively correlated with weight loss, highlighting treatment efficacy and patient response to dual-region injections.

Conclusions

Our study suggested that intragastric BT-A injections in the antrum and fundus are effective and safe for satiety and weight loss, with few side effects. Individual responses vary, and diet adherence is crucial. More studies are needed to assess the treatment's efficacy in obesity.

Insights into the clinical impact of complete blood cell inflammatory markers on body composition variations and fatty liver grading in Iranian adults undergoing bariatric surgery: a retrospective longitudinal study

Background

In bariatric surgery, inflammatory biomarkers predict outcomes. Limited research on complete blood cell (CBC) markers stresses the need for correlation study. This research explores links between CBC inflammatory markers, body changes, and fatty liver grades in Iranian bariatric patients.

Materials and methods

This retrospective longitudinal study examined 237 bariatric surgery patients who satisfied the inclusion criteria and were deemed eligible for participation. These criteria encompassed patients who had undergone sleeve or mini-bypass surgery and were aged between 18 and 65 years. The study gathered demographic data, pre and post-surgery changes in CBC inflammatory biomarkers [neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR), mean platelet volume (MPV), MPV-to-platelet count ratio (MPV/PC), and red cell distribution width (RDW)] and fatty liver grades. Additionally, it recorded pre and post-surgery changes in body composition, such as weight, muscle mass (MM), fat mass (FM), and fat-free mass (FFM).

Results

The pre-surgery RDW marker significantly associated with FM changes, highlighting its predictive nature. While no significant association was found between changes in patients' fatty liver grade and baseline marker values, it's worth noting that individuals with higher MM at 3 months achieved a fatty liver grade of zero. Also, at 6 months, higher FFM and MM were also associated with reaching a fatty liver grade of zero.

Conclusions

While the retrospective design of this study limits its findings to existing clinical data, future prospective research should collect additional samples, extend the observation time, and examine the long-term predictive value of these markers.

Vagus Nerve and Gut-Brain Communication

The vagus nerve, as an important component of the gut-brain axis, plays a crucial role in the communication between the gut and brain. It influences food intake, fat metabolism, and emotion by regulating the gut-brain axis, which is closely associated with the development of gastrointestinal, psychiatric, and metabolism-related disorders. In recent years, significant progress has been made in understanding the vagus-mediated regulatory pathway, highlighting its profound implications in the development of many diseases. Here, we summarize the latest advancements in vagus-mediated gut-brain pathways and the novel interventions targeting the vagus nerve. This will provide valuable insights for future research on treatment of obesity and gastrointestinal and depressive disorders based on vagus nerve stimulation.

The Weight of Bariatric Surgery: Wernicke-Korsakoff Syndrome after Vertical Sleeve Gastrectomy-A Case Series

In this case series, the simultaneous occurrence of Wernicke's encephalopathy (WE) and dry beriberi was reported in three patients who underwent vertical sleeve gastrectomy (VSG) between May 2021 and May 2023. All patients were obese women who underwent vertical sleeve gastrectomy (VSG) without immediate postoperative complications, but two weeks later, hyperemesis and subsequent encephalopathy with ocular movement abnormalities and weakness were observed over the following thirty days. Patients were referred to neurology, where due to the high suspicion of WE, thiamine replacement therapy was initiated; meanwhile, diagnostic neuroimaging and blood tests were conducted. Neurological and psychiatric evaluations and neuroconduction studies were performed to assess the clinical evolution and present sequelae. One year after diagnosis, all patients exhibited affective and behavioral sequelae, anterograde memory impairment, and executive functioning deficits. Two patients met the criteria for Korsakoff syndrome. Additionally, peripheral nervous system sequelae were observed, with all patients presenting with sensorimotor polyneuropathy. In conclusion, Wernicke's encephalopathy requires a high diagnostic suspicion for timely intervention and prevention of irreversible sequelae, which can be devastating. Therefore, raising awareness among medical professionals regarding the significance of this disease is essential.

Overview of the Last 71 Years of Metabolic and Bariatric Surgery: Content Analysis and Meta-analysis to Investigate the Topic and Scientific Evolution

Obesity is a worldwide epidemic, and bariatric surgery has become increasingly popular due to its effectiveness in treating it. Therefore, understanding this area is of paramount importance. This article aims to provide an understanding of the development of the topic related to procedures, content, data, and status. To achieve this objective, a literature review and a bibliometric analysis were conducted. The methods provided insight into the current state and relevant topics over time. In conclusion, the article provided the identification of the transformation of the research field, initially focused only on physical aspects, to a more complex approach, which also incorporates psychological and social aspects and the correlation between obesity, bariatric surgery, and quality of life.

Impact of Bariatric Surgery on Circulating Metabolites and Cognitive Performance

INTRODUCTION

Bariatric surgery is an effective intervention to reduce obesity and improve associated comorbidities. However, its effects on cognitive function are still the subject of debate. Given that the bioavailability of circulating metabolites can influence brain metabolism and cognitive performance, we aimed to assess the effects of bariatric surgery on plasma metabolic profiles and cognitive performance.

METHODS

We recruited 26 women undergoing gastric bypass surgery. We conducted anthropometric assessments and collected plasma samples for metabolomic analysis. A set of 4 cognitive tests were used to evaluate cognitive performance. Participants were reevaluated 1 year post-surgery.

RESULTS

After surgery, attention capacity and executive function were improved, while immediate memory had deteriorated. Regarding metabolic profile, reduction of beta-tocopherol and increase of serine, glutamic acid, butanoic acid, and glycolic acid were observed. To better understand the relationship between cognitive function and metabolites, a cluster analysis was conducted to identify more homogeneous subgroups based on the cognitive performance. We identified cluster 1, which did not show changes in cognitive performance after surgery, and cluster 2, which showed improved attention and executive function, but reduced performance in the immediate memory test. Thus, cluster 2 was more homogeneous group that replicated the results of non-clustered subjects. Analysis of the metabolic profile of cluster 2 confirmed serine, glutamic acid, and glycolic acid as potential metabolites associated with cognitive performance.

CONCLUSIONS

Metabolites identified in this study have potential for biomarkers and alternative therapeutic target to prevent obesity-related cognitive decline.

KEY POINTS

• Attention capacity and executive function were improved 12 months post bariatric surgery. • Immediate memory was worsened 12 months post bariatric surgery. • Serine, glutamic acid, and glycolic acid are potential metabolites linked to the alteration of cognitive performance.

Metabolic surgery in improving arterial health in obese individuals

PURPOSE

Arterial stiffness has gained recognition as a stand-alone risk factor for cardiovascular disease (CVD). Obesity is intricately linked to elevated arterial stiffness, the development of left ventricular (LV) hypertrophy, and the emergence of diastolic dysfunction, all of which collectively contribute substantially to an unfavorable prognosis. Weight loss has become a standard recommendation for all patients with CVD concurrent with morbid obesity; however, randomized evidence to support this recommendation was limited earlier. The latest scientific studies revealed dynamic changes in aortic stiffness after substantial weight loss by bariatric surgery, also known as metabolic surgery, in patients with obesity. There is also a favorable evolution in LV hypertrophy and a significant impact on arterial hypertension and other promising cardiovascular outcomes in obese people after bariatric surgery.

METHODS/RESULTS

We aimed to examine the cardiovascular effects of various metabolic surgeries in morbidly obese individuals, especially their role in improving arterial health, the potential impact on surrogate markers of atherosclerotic vascular disease, and consequently reducing the likelihood of cardiovascular events.

CONCLUSION

In conclusion, metabolic surgery is associated with a significant decrease in the occurrence of major adverse cardiovascular events (MACE) and all-cause mortality among obese individuals, alongside remarkable enhancement of arterial health. These findings underscore the critical importance of implementing strategies to combat obesity and reduce adiposity within the general population.

Role of gastric bypass surgery in control of blood sugar in obese uncontrolled type 2 diabetic patients

BACKGROUND AND GOAL

The pandemic of the twenty-first century is diabetes. Both type 2 diabetes mellitus and obesity pose severe problems for public health. Despite significant improvements in diagnosing and managing both conditions, diabetes mellitus remains poorly controlled, and diabetic complications are more common than ever. Internists have discovered over the past 20 years that obese people with type 2 diabetes who have gastric bypass surgery to shed weight have improved glycemic control. Thus, interventional diabetology has a growing significance in patients' ability to reverse type 2 diabetes mellitus. We want to evaluate the impact of gastric bypass on blood sugar regulation and look for potential causes.

PATIENTS AND METHODS

Between 2018 and 2020, a prospective interventional study was carried out. Ninety patients in total were enrolled in the trial. The two patient groups (A and B) contained 45 obese T2DM patients with a body mass index (BMI) of over 35 kg/m2. Group B received its antidiabetic medications, either oral hypoglycemic or insulin, while Group A underwent gastric bypass surgery. Each patient underwent a comprehensive history review and clinical assessment. Both groups had their HA1c and blood sugar levels measured; group A had their insulin, GLP-1, and HOMA-IR (Homeostasis Model Assessment for Insulin Resistance) levels calculated at time O and one year later.

RESULTS

The demographic differences between the two study groups were negligible. After a one-year follow-up, group A had significantly lower anthropometric measurement data for BMI and waist circumference (cm), lipid profile data for triglycerides, total cholesterol, and LDL levels, and systolic and diastolic blood pressure. Fasting plasma glucose and HbA1c, two metrics of glucose metabolism, significantly decreased in group A. Regarding indicators of glucose metabolism, there was a drop in fasting insulin level and HOMA-IR and an increase in GLP1 level in the gastric bypass group.

CONCLUSION

As a result of improving all indicators, gastric bypass is an effective treatment for patients with uncontrolled T2DM. Future research that is confirmed is needed.

Recent advances in bariatric surgery: a narrative review of weight loss procedures

Bariatric surgery has emerged as a highly effective option for individuals with obesity, offering significant and sustainable weight loss outcomes. This surgical approach involves various procedures that alter the anatomy of the gastrointestinal tract, leading to reduced food intake and nutrient absorption. Established procedures such as sleeve gastrectomy, gastric bypass, adjustable gastric banding, and biliopancreatic diversion with duodenal switch have proven track records. In contrast, emerging options like intragastric balloons, AspireAssist devices, and endoscopic sleeve gastroplasty show promise but require further investigation. Numerous studies have highlighted the remarkable benefits of bariatric surgery, not only in weight loss but also in the resolution of obesity-related comorbidities and significant improvements in quality of life. However, successful outcomes rely on a multidisciplinary approach, encompassing preoperative evaluation, patient selection, comprehensive postoperative care, nutritional support, and psychological counseling. Regular follow-up and adherence to postsurgical recommendations are crucial for sustained weight loss and positive long-term results. As bariatric surgery continues to evolve, tailored procedures based on individual needs and ongoing research hold the potential for even more refined and effective approaches. Through this ongoing advancement, bariatric surgery is poised to offer improved patient outcomes, transforming lives for those grappling with the challenges of obesity.

Desire for Body Contouring Surgery after Bariatric Surgery: A Nationwide Cross-sectional Study in Saudi Arabia

Background

The obesity pandemic in Saudi Arabia has led to a high demand for bariatric surgery (BS). Post-BS patients experience rapid and massive weight loss, with most patients experiencing redundant skin, leading to a desire for body contouring surgery (BCS).

Methods

A cross-sectional study was conducted from September 2022 to May 2023 among patients who underwent BS in Saudi Arabia, using an online self-administered questionnaire. The questionnaire comprised sociodemographic data, weight, and BS-related questions, and the post-BS appearance questionnaire assessed the desire for BCS, excess skin satisfaction, and overall appearance.

Results

A total of 410 of the patients electively enrolled. The mean perceived satisfaction of post-BS patients with the body's excess skin was rated as 4.28 ± 1.69 out of 7 points. The overall desire for BCS among the post-BS population was equal to a collective mean desire of 2.10 ± 0.92 out of 4 points. The desired body sites for BCS were focused on the abdomen/waist, followed by the lower back, then upper arms, buttocks, and thighs. Only 25.1% of the patients fulfilled their desires and recently underwent BCS.

Conclusions

The study highlights the importance of incorporating plastic and reconstructive surgery as an integral part of the multidisciplinary approach to morbidly obese patients after BS and the need for national guidelines on the referral pathway for post-BS BCS.

Scientific and Public Interest in Bariatric Surgery for Obesity: The Italian Scenario

Background: Obesity is an escalating concern in our society. Bariatric surgery appears to be the only feasible alternative for severe obesity. This study aims to conduct an integrative analysis of the Italian context concerning bariatric surgery, with a specific focus on the surgical procedures of sleeve gastrectomy, mini-gastric bypass, and gastric bypass. Methods: The analysis is based on bibliometric data extracted from the Scopus database to find Italian publications in this field from 2012 to 2022. Along with scientific interest, it is essential to assess the level of public interest in these topics. Google Trends is the most extensively utilized free tool for the analysis of online behavior. Using Google Trends data, we analyzed the amount of internet volume searches (Relative Search Volume = RSV) for the Italian terms “sleeve gastrectomy”, “mini-gastric bypass” and “gastric bypass”, both temporally (from 2012 to 2022 years) and geographically. Furthermore, to illustrate the Italian landscape, we compared Google Trends data with data from the Italian registry “Società Italiana di Chirurgia dell’Obesità e delle malattie metaboliche” (SICOB), which includes information about bariatric surgery procedures performed in the country. Results: Over the past decade, there has been a significant increase in the scientific literature on sleeve gastrectomy, mini-gastric bypass, and gastric bypass surgeries in Italy. Google Trends data has shown an increase in online public interest in these surgical procedures, from 2012 to 2022. The examination of the Google Trends information combined with the SICOB data demonstrated a remarkable association between the two data sets. Conclusions: Bariatric surgery has increased quickly in Italy in terms of scientific research and surgical interventions. The analysis of Google Trends data in conjunction with data from SICOB has revealed an interesting correlation between the two datasets therefore, Google Trends can be useful for estimating the demand for bariatric surgical procedures.

A Systematic Review Investigating Maternal Nutrition During Pregnancy After Bariatric Surgery

The aim of this review was to report on maternal diet, micronutrient supplementation, and gestational weight gain (GWG) during pregnancy following bariatric surgery and explore the impact on maternal micronutrient deficiency, offspring growth, and perinatal outcomes. A search in PubMed, CINAHL, EMBASE, and ProQuest in July 2022 returned 23 eligible studies (n = 30-20, 213). Diet was reported in two studies, supplementation in six and GWG in 19 studies. Although many women did not achieve healthy GWG, no consistent link with adverse outcomes was reported. Studies were grades II and III on the National Health and Medical Research Council evidence hierarchy and received a neutral or negative score on the Academy of Nutrition and Dietetics Quality Criteria Checklist, suggesting that methodological limitations impact the reliability of reported findings.

Oxadiazolopyridine Derivatives as Efficacious Mitochondrial Uncouplers in the Prevention of Diet-Induced Obesity

Small-molecule mitochondrial uncouplers are gaining recognition as potential therapeutics for metabolic diseases such as obesity, diabetes, and nonalcoholic steatohepatitis (NASH). Specifically, heterocycles derived from BAM15, a potent and mitochondria-selective uncoupler, have yielded promising preclinical candidates that are efficacious in animal models of obesity and NASH. In this study, we report the structure-activity relationship studies of 6-amino-[1,2,5]oxadiazolo[3,4-b]pyridin-5-ol derivatives. Using oxygen consumption rate as a readout of mitochondrial uncoupling, we established 5-hydroxyoxadiazolopyridines as mild uncouplers. In particular, SHM115, which contains a pentafluoro aniline, had an EC50 value of 17 μM and exhibited 75% oral bioavailability. SHM115 treatment increased the energy expenditure and lowered the body fat mass in two diet-induced obesity mouse models, including an obesity prevention model and an obesity reversal model. Taken together, our findings demonstrate the therapeutic potential of mild mitochondrial uncouplers for the prevention of diet-induced obesity.

GLP-1/GIP analogues: potential impact in the landscape of obesity pharmacotherapy

INTRODUCTION

: Obesity is recognised as a major healthcare challenge. Following years of slow progress in discovery of safe, effective therapies for weight management, recent approval of the glucagon-like peptide 1 receptor (GLP-1R) mimetics, liraglutide and semaglutide, for obesity has generated considerable excitement. It is anticipated these agents will pave the way for application of tirzepatide, a highly effective glucose-dependent insulinotropic polypeptide receptor (GIPR), GLP-1R co-agonist recently approved for management of type 2 diabetes mellitus.

AREAS COVERED

: Following promising weight loss in obese individuals in Phase III clinical trials, liraglutide and semaglutide were approved for weight management without diabetes. Tirzepatide has attained Fast Track designation for obesity management by the US Food and Drug Association. This narrative review summarises experimental, preclinical and clinical data for these agents and related GLP-1R/GIPR co-agonists, prioritising clinical research published within the last 10 years where possible.

EXPERT OPINION

: GLP-1R mimetics are often discontinued within 24-months, owing to gastrointestinal side-effects, meaning long-term application of these agents in obesity is questioned. Combined GIPR/GLP-1R agonism appears to induce fewer side-effects, indicating GLP-1R/GIPR co-agonists may be more suitable for enduring obesity management. After years of debate, this GIPR-biased GLP-1R/GIPR co-agonist highlights the therapeutic promise of including GIPR modulation for diabetes and obesity therapy.

Bariatric surgery in the management of childhood and adolescence obesity

BACKGROUND

Nowadays, childhood obesity is literally a global pandemic health problem. According to current data, pediatric obesity is strongly associated with adult excess weight status as well as the development of certain co morbidities, already present in childhood, including cardiovascular disorders (dyslipidemia, hypertension), endocrine/metabolic (Type 2 diabetes, fatty liver disease, metabolic syndrome), respiratory, gastrointestinal, and musculoskeletal problems. Additionally, children with obesity frequently experience psychosocial issues, such as mood disorders, anxiety, prejudice and low self-esteem.

METHODS AND RESULTS

The aim of this article was to evaluate whether or not bariatric surgery is an effective and safe treatment option for childhood obesity. This paper is based on a literature search in Pub Med for articles referring to the medical co morbidities and the results of different types of bariatric surgery for the treatment of childhood obesity (up to 18 years) until December 2021. The following keywords were used as MESH terms: childhood obesity, adolescence obesity, co morbidities and bariatric surgery. The bibliographic references of the studies found in these databases were also reviewed.

CONCLUSION

Although some researchers demonstrate that surgical interventions in adolescents might be a reliable intervention to lose weight in a maintainable way and reverse many of the co morbidities associated with severe obesity, their safety and long-term efficacy are still not clarified. Thus, large long-term prospective studies, with detailed recording of complications and co morbidity resolution are obviously needed in order to determine the role of surgical treatment in childhood obesity.

The impact of bariatric surgery on macronutrient malabsorption depends on the type of procedure

Introduction

Bariatric surgery, currently the most effective treatment for morbidly obese patients, may induce macronutrient malabsorption depending on the type of procedure. Macronutrient malabsorption affects the supply of substrates to the colon, subsequent microbial fermentation and possibly colonic health.

Methods

Using isotope technology, we quantified the extent of macronutrient and bile acid malabsorption and its impact on colonic protein fermentation in patients after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) and in controls. Participants consumed a single test meal (day 0) that contained intrinsically labeled (¹³C, ¹⁵N, and ²H) egg protein for quantification of protein digestion, malabsorption and fermentation, respectively, together with a transit marker and a marker for bile acid malabsorption. They collected breath samples up to 6 h and all urine and stool for 48 and 72 h, respectively. Food intake was registered from day -3 to day 2.

Results

Malabsorption of fat, protein and carbohydrates differed between groups (p = 0.040; p = 0.046; and p = 0.003, respectively) and was slightly higher in RYGB but not in SG patients compared to controls. Protein fermentation was increased in both RYGB and SG patients compared to controls (p = 0.001) and was negatively correlated to ²H-recovery as a marker of transit (ρ = -0.47, p = 0.013).

Conclusion

The limited macronutrient malabsorption likely does not affect the nutritional status of the patient. However, the higher protein fermentation may affect colonic health and warrants further investigation.

Impacts of sleeve gastrectomy on gastroesophageal reflux disease in severely obese Korean patients

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has established popularity as a bariatric and metabolic surgery. However, the incidence of gastroesophageal reflux disease (GERD) following LSG is controversial. This study aims to describe the prevalence of de novo GERD after LSG.

METHODS

A retrospective chart review was performed for 130 patients who underwent a routine endoscopic surveillance before and after LSG between January 2013 and October 2018. The diagnosis of GERD was determined by presence of symptoms, history of PPI treatment, and endoscopic findings. The esophagogastroduodenoscopy (EGD) was performed annually after LSG and/or when the patients complained of severe reflux symptoms.

RESULTS

The prevalence of GERD before surgery was 18.5%. At 1 year after LSG, GERD was present in 70 (53.8%) of the 130 patients. GERD consisted of 55 patients with newly developed GERD, and 15 with preexisting GERD. 9 (37.5%) out of pre-existing GERD patients were free of symptoms and abnormal finding at EGD following LSG. During the LSG, 66 (50.8%) patients with hiatal hernia underwent re-approximation of the diaphragmatic crura. There was no significant relationship between hiatal hernia repair and postoperative GERD (p = 0.39). Number of patients taking PPI medication before and after LSG were 34 (26.2%) and 49 (37.7%). Out of 56 (43.1%) patients with endoscopic lesions, LA grade A was 31 (23.9%), B = 15 (11.5%), C = 4 (3.1%), and D = 6 (4.6%).

CONCLUSION

In this study, 42.3% (n = 55) of total patients developed newly developed GERD, and 7.7% (n = 10) had LA grade C or D esophagitis.

Exocrine pancreatic insufficiency after bariatric surgery

BACKGROUND

Exocrine pancreatic insufficiency (EPI) is a known complication of upper gastrointestinal surgery and has recently been associated with bariatric surgery. Our objectives were to determine the incidence of EPI in patients who underwent bariatric surgery and to identify the type of bariatric procedure most associated with EPI.

METHODS

This retrospective cohort analysis included patients age ≥18 years who underwent bariatric surgery at Mayo Clinic between 2010 and 2020. Patients with a history of other gastrointestinal or hepatobiliary resection, revision of bariatric surgery, EPI prior to surgery, and surgery greater than >10 years earlier were excluded from the study. Characteristics were compared between two groups based on type of bariatric surgery including Roux-en-Y gastric bypass (RYGB) or gastric sleeve (GS). Characteristics were also analyzed between patients with RYGB who developed post-operative steatorrhea and those who did not.

RESULTS

Of 150 patients, 126 underwent RYGB while 24 patients had GS. Thirty-one (20.6%) patients developed post-operative steatorrhea and 14 (9.3%) were diagnosed with EPI. Mean pancreatic elastase level was 287 ± 156 mcg/g and fecal fat level 31 ± 22 g/d. There was a significantly higher proportion of post-operative steatorrhea in patients who underwent RYGB compared to gastric sleeve surgery (p = 0.029).

CONCLUSION

The incidence of EPI after bariatric surgery in our cohort was 9.3%. Overall, patients who underwent RYGB had higher rates of EPI (10.3%) than those who had GS (4.2%). Clinicians should be aware of EPI as a cause for steatorrhea in patients who underwent bariatric surgery and consider treatment with enzyme replacement therapy.

Metabolic effects of truncal vagotomy when combined with bariatric-metabolic surgery

Bariatric-metabolic surgery (BMS) in patients with obesity frequently leads to remission of concurrent type 2 diabetes mellitus (T2DM), even before body weight loss takes place. This is probably based on the correction of a dysmetabolic cycle in the gastrointestinal physiology of T2DM that includes increased vagus-dependent exocrine pancreatic secretion (EPS) and, hence, amplified digestion and nutrient absorption. The resultant chronic exposure of tissues to high plasma levels of glucose, fatty acids and amino acids causes tissue resistance to the actions of insulin and, at a later stage, β-cell dysfunction and reduction of insulin release. We hypothesize that the addition of a surgical truncal vagotomy (TV) may improve and solidify the beneficial results of BMS on T2DM by stably decreasing EPS, - hence reducing the digestion and absorption of nutrients -, and increasing incretin secretion as a result of increased delivery of unabsorbed nutrients to the distal intestine. This hypothesis is supported by surgical data from gastrointestinal malignancies and peptic ulcer operations that include TV, as well as by vagal blockade studies. We suggest that TV may result in a stable reduction of EPS, and that its combination with the appropriate type of BΜS, may enhance and sustain the salutary effects of the latter on T2DM.

Volumetric Pouch Study After Laparoscopic Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is considerably utilized as a bariatric method for treating morbid obesity through the reduction of stomach volume. The present study attempted to assess the volumetric changes of the gastric reservoir 1 year after LSG using multi-slice spiral computed tomography (MSCT) as well as to verify their association with weight loss. The current study is a prospective study of 40 consecutive morbid obese patients managed with laparoscopic sleeve gastrectomy. All patients were referred to abdominal MSCT besides volumetric measurement of the gastric pouch 1 month and 12 months postoperatively after the LSG. There were statistically substantial differences throughout the whole period of follow-up (p value ≤ 0.05) regarding the ratio of excess weight loss, weight loss, and decreased BMI, in addition to the ratio of excess body mass index loss (% EBMIL) after LSG. Substantial elevation of the overall volume of the gastric reservoir (82.9 SD11 and 171.6 SD23.6 ml at 1 and 12 months, respectively) was observed. However, the current findings did not demonstrate any significant association (r = 0.131, p = 0.491) between excess weight loss percentage and the increase in gastric reservoir volume 1 year postoperatively. Sleeve dilatation is a common finding following sleeve gastrectomy (SG) even after conducting a narrow gastric pouch, yet dilatation was not correlated with insufficient weight loss after 1 year postoperatively. Trial registration number: NCT04880902.

Oral Potassium Malabsorption Following Bariatric Surgery

Bariatric surgery is one of the most effective long-term solutions for treating obesity due to its sustained weight loss and reduction of obesity-related comorbidities. However, nutritional deficiencies are common due to the alteration of the anatomy and physiology of the gastrointestinal tract. These include the malabsorption of macronutrients, vitamins, minerals, trace elements, and drugs. In this report, we present the case of a female patient who underwent Roux-en-Y gastric bypass surgery and subsequently developed exclusive potassium malabsorption refractory to oral replenishment. 

T and B Cell Composition and Cytokine Producing Capacity Before and After Bariatric Surgery

Morbid obesity is associated with a chronic state of low-grade inflammation, which may lead to accelerated differentiation of T and B cells. These differentiated immune cells are strongly cytotoxic and have an increased pro-inflammatory cytokine producing capacity. Furthermore, the anti-inflammatory function of the T and B cells decreases. The aim of this study was to evaluate the effect of morbid obesity on the subset profile and cytokine producing capacity of T and B cells. Subsequently, we assessed whether bariatric surgery affected the subset profile and cytokine producing capacity of these cells. We determined the proportion of T and B cell subsets and their cytokine producing capacity in peripheral blood collected from 23 morbidly obese patients before and three months after bariatric surgery using flow-cytometry. We compared this with the results of 25 lean controls. Both CD4+ and CD8+ T cells showed a more differentiated subset profile in morbidly obese patients as compared to lean controls, which was not recovered three months after bariatric surgery. The B cell composition of morbidly obese patients after bariatric surgery adjusted towards the profile of lean controls. However, the IL-2 and IFN-γ producing capacity of CD8+ T cells and the IL-2, IFN-γ, TNF-α and IL-10 producing capacity of B cells was not restored three months after bariatric surgery. In conclusion, the data suggest that the immune system has the capacity to recover from the detrimental effects of morbid obesity within three months after bariatric surgery in terms of cell composition; however, this was not seen in terms of cytokine producing capacity. The full restoration of the immune system after bariatric surgery may thus take longer.

The Neuro-Endo-Microbio-Ome Study: A Pilot Study of Neurobiological Alterations Pre- Versus Post-Bariatric Surgery

BACKGROUND

Plausible phenotype mechanisms following bariatric surgery include changes in neural and gastrointestinal physiology. This pilot study aims to investigate individual and combined neurologic, gut microbiome, and plasma hormone changes pre- versus post-vertical sleeve gastrectomy (VSG), Roux-en-Y gastric bypass (RYGB), and medical weight loss (MWL). We hypothesized post-weight loss phenotype would be associated with changes in central reward system brain connectivity, differences in postprandial gut hormone responses, and increased gut microbiome diversity.

METHODS

Subjects included participants undergoing VSG, n = 7; RYGB, n = 9; and MWL, n = 6. Ghrelin, glucagon-like peptide-1, peptide-YY, gut microbiome, and resting state functional magnetic resonance imaging (rsfMRI; using fractional amplitude of low-frequency fluctuations [fALFF]) were measured pre- and post-intervention in fasting and fed states. We explored phenotype characterization using clustering on gut hormone, microbiome, and rsfMRI datasets and a combined analysis.

RESULTS

We observed more widespread fALFF differences post-bariatric surgery versus post-MWL. Decreased post-prandial fALFF was seen in food reward regions post-RYGB. The highest number of microbial taxa that increased post-intervention occurred in the RYGB group, followed by VSG and MWL. The combined hormone, microbiome, and MRI dataset most accurately clustered samples into pre- versus post-VSG phenotypes followed by RYGB subjects.

CONCLUSION

The data suggest surgical weight loss (VSG and RYGB) has a bigger impact on brain and gut function versus MWL and leads to lesser post-prandial activation of food-related neural circuits. VSG subjects had the greatest phenotype differences in interactions of microbiome, rsfMRI, and gut hormone features, followed by RYGB and MWL. These results will inform future prospective research studying gut-brain changes post-bariatric surgery.

Changes in Cognition Functions and Depression Severity After Bariatric Surgery: A 3-Month Follow-up Study

Background: Changes in cognitive profile, such as memory and other functions in patients with morbid obesity after bariatric surgery have been reported in the literature with inconsistent results. Objectives: This study aimed to evaluate cognitive changes, executive function and depression severity before and after bariatric surgery in patients with morbid obesity. Methods: In this prospective cohort study, 70 patients with morbid obesity (40 patients undergoing bariatric surgery and 30 patients in the waiting list) referred to the Rasool Akram Medical Complex, obesity clinic, Tehran, Iran, in 2016 entered the study. The two groups were assessed using the Wechsler Memory Scale (WMS) (consists of 7 subscales and assesses memory), the Wisconsin Cart Sorting test (WCST) (includes 64 cards and assesses cognitive skills), the Hamilton Depression Scale (HAM-D) (for measuring depression) and bariatric analysis and reporting outcome system (BAROS) questionnaire (scale to report of the therapeutic results of bariatric surgery and including the three criteria of the weight loss percentage, the change in health state, and the quality of life) at the beginning of the study and three months after the surgery. Moreover, the Bariatric Analysis and reporting outcome system (BAROS) questionnaire was filled three months after surgery. Results: The average changes in WMS score (P = 0.043), working memory (P = 0.002), HAM-A (P = 0.032), weight, and BMI (P = 0.0001) in the surgery group were significantly higher than the control group. There was a significant positive correlation between change in the number of preservative errors in WCST within the surgery group with BAROS score (P = 0.004). Moreover, there was a significant correlation between changes in the score of WMS and those in BMI in the surgery group. Conclusions: Bariatric surgery is associated with improvements in some cognitive functions and worsening of depressive scores in patients with morbid obesity.

Dietary supplements and bariatric surgery

Bariatric surgery or weight loss surgery has been in practice for achieving significant weight loss in patients who have failed to achieve weight loss after pharmacological interventions. The rising cases of obesity are a triggering factor for more bariatric surgeries worldwide. Interestingly, sustained weight loss achieved post-bariatric surgery offers metabolic advantages, and patients show improved glucose and lipid metabolisms. Bariatric surgery is directly linked to higher incidences of vitamin, mineral, and trace element deficiencies, thus making patients susceptible to anemia, osteoporosis, and cardiomyopathy. Reduced nutrient absorption capacity, dietary changes, dietary restriction, and altered gastrointestinal tract morphology are some reasons for nutritional deficiency observed in post-bariatric surgery procedures. Micro-and-macronutrient deficiency observed in patients during the postoperative phase requires continuous monitoring of nutritional parameters. Therefore, adequate multivitamin and mineral supplements become essential to prevent/overcome micronutrient deficiencies. Bariatric surgery also raises the risk of small for gestational age (SGA) babies. Hence, a 12 - 24 months gap is recommended between bariatric surgery and pregnancy to achieve desired weight loss targets. The topic of this review is the impact of bariatric surgery procedures on vitamin and mineral absorption and the role of dietary supplements in maintaining a healthy nutritional balance during the postoperative phase.

Taste-Driven Responsiveness to Fat and Sweet Stimuli in Mouse Models of Bariatric Surgery

A preferential consumption of healthier foods, low in fat and sugar, is often reported after bariatric surgery, suggesting a switch of taste-guided food choices. To further explore this hypothesis in well-standardized conditions, analysis of licking behavior in response to oily and sweet solutions has been realized in rats that have undergone a Roux-en-Y bypass (RYGB). Unfortunately, these studies have produced conflicting data mainly due to methodological differences. Paradoxically, whereas the vertical sleeve gastrectomy (VSG) becomes the most commonly performed bariatric surgery worldwide and is easier to perform and standardize in small animals, its putative impacts on the orosensory perception of energy-dense nutrients remains unknown. Using brief-access licking tests in VSG or RYGB mice, we found that (i) VSG induces a significant reduction in the fat mass in diet-induced obese (DIO) mice, (ii) VSG partially corrects the licking responses to lipid and sucrose stimuli which are degraded in sham-operated DIO mice, (iii) VSG improves the willingness to lick oily and sucrose solutions in DIO mice and (iv) RYGB leads to close outcomes. Altogether, these data strongly suggest that VSG, as RYGB, can counteract the deleterious effect of obesity on the orosensory perception of energy-dense nutrients in mice.

Surgical Treatment of Obesity. Special Mention to Roux-en-Y Gastric Bypass and Vertical Gastrectomy

INTRODUCTION

The prevalence of obesity has increased exponentially in recent decades, being one of the diseases that most affects global health. It is a chronic disease associated with multiple comorbidities, which lead to a decrease in life expectancy and quality of life. It requires a multidisciplinary approach by a specialized medical team. Obesity can be treated with conservative or with surgical treatments that will depend on the characteristics of the patient.

OBJECTIVE/METHODOLOGY

The referenced surgery can be performed using different surgical techniques that are analyzed in the present work through an exhaustive narrative bibliographic review in the PubMed and Cochrane databases, as well as in UpToDate.

RESULTS

Currently, those most used are restrictive techniques, specifically vertical gastrectomy and mixed techniques, with gastric bypass being the "gold standard".

CONCLUSIONS

In order to choose one technique or another, the characteristics of each patient and the experience of the surgical team must be taken into account.

Progress in understanding of influence of bariatric surgery on reflux esophagitis

In today's society, as the number of obese people increases year by year, the incidence of gastroesophageal reflux disease (GERD) continues to rise. Although bariatric surgery has brought good news to these patients who are unable to lose weight on their own, it is still unclear whether it is effective in relieving GERD, or even inducing or aggravating GERD. In this article, we will review and provide evidence of the effect of bariatric surgery on GERD.

Late complications of biliopancreatic diversion in an older patient: a case report

BACKGROUND

In the mid-seventies, biliopancreatic diversion became popular as weight-loss surgery procedure. This bariatric procedure combines distal gastric resection and intestinal malabsorption, leading to greater weight loss and improvement of co-morbidities than other bariatric procedures. Nowadays, biliopancreatic diversion has become obsolete due to the high risk of nutritional complications. However, current patients with biliopancreatic diversions are aging. Consequently, geriatricians and general practitioners will encounter them more often and will be faced with the consequences of late complications.

CASE PRESENTATION

A 74-year old female presented with weakness, recurrent falls, confusion, episodes of irresponsiveness, anorexia and weight loss. Her medical history included osteoporosis, herpes encephalitis 8 years prior and a biliopancreatic diversion (Scopinaro surgery) at age 52. Cerebral imaging showed herpes sequelae without major atrophy. Delirium was diagnosed with underlying nutritional deficiencies. Biochemical screening indicated vitamin A deficiency, vitamin E deficiency, zinc deficiency and severe hypoalbuminemia. While thiamin level and fasting blood glucose were normal. However, postprandial hyperinsulinemic hypoglycemia was observed with concomitant signs of confusion and blurred consciousness. After initiating parenteral nutrition with additional micronutrient supplementation, a marked improvement was observed in cognitive and physical functioning.

CONCLUSIONS

Long-term effects of biliopancreatic diversion remain relatively underreported in older patients. However, the anatomical and physiological changes of the gastrointestinal tract can contribute to the development of metabolic and nutritional complications that may culminate in cognitive impairment, functional decline and delirium. Therefore, it is warranted to evaluate the presence of metabolic disturbances and nutritional complications in older patients after biliopancreatic diversion.

Reduction of Major Adverse Cardiovascular Events (MACE) after Bariatric Surgery in Patients with Obesity and Cardiovascular Diseases: A Systematic Review and Meta-Analysis

Cardiovascular diseases (CVDs) are the leading cause of death worldwide and obesity is a major risk factor that increases the morbidity and mortality of CVDs. Lifestyle modifications (e.g., diet control, physical exercise and behavioral changes) have been the first-line managements of obesity for decades. Nonetheless, when such interventions fail, pharmacotherapies and bariatric surgery are considered. Interestingly, a sudden weight loss (e.g., due to bariatric surgery) could also increase mortality. Thus, it remains unclear whether the bariatric surgery-associated weight reduction in patients with obesity and CVDs is beneficial for the reduction of Major Adverse Cardiovascular Events (MACE). Here, we performed a systematic literature search and meta-analysis of published studies comparing MACE in patients with obesity and CVDs who underwent bariatric surgery with control patients (no surgery). Eleven studies, with a total of 1,772,305 patients, which consisted of 74,042 patients who underwent any form of bariatric surgery and 1,698,263 patients with no surgery, were included in the systematic review. Next, the studies' data, including odds ratio (OR) and adjusted hazard ratio (aHR), were pooled and analyzed in a meta-analysis using a random effect model. The meta-analysis of ten studies showed that the bariatric surgery group had significantly lower odds of MACE as compared to no surgery (OR = 0.49; 95% CI 0.40-0.60; p < 0.00001; I² = 93%) and the adjustment to confounding variables in nine studies revealed consistent results (aHR = 0.57; 95% CI 0.49-0.66; p < 0.00001; I² = 73%), suggesting the benefit of bariatric surgery in reducing the occurrence of MACE in patients with obesity and CVDs (PROSPERO ID: CRD42021274343).

Acute Pancreatitis as a Complication of Intragastric Balloon

The intragastric balloon is a common minimally invasive procedure used prior to bariatric surgery for weight reduction. There are complications of this balloon with varying degrees of severity ranging from mild to severe life-threatening complications. Acute pancreatitis due to direct compression or catheter migration of the balloon should be considered in these patients. In the literature, there is little evidence that intragastric balloons could cause acute pancreatitis. We present two cases in which they had a history of IGB insertion complicated by acute pancreatitis. The diagnosis of acute pancreatitis due to the intragastric balloon was made after excluding other possible causes of acute pancreatitis. Both patients were hospitalized and managed conservatively.

A Review of Current Trends with Type 2 Diabetes Epidemiology, Aetiology, Pathogenesis, Treatments and Future Perspectives

Type 2 diabetes (T2D), which has currently become a global pandemic, is a metabolic disease largely characterised by impaired insulin secretion and action. Significant progress has been made in understanding T2D aetiology and pathogenesis, which is discussed in this review. Extrapancreatic pathology is also summarised, which demonstrates the highly multifactorial nature of T2D. Glucagon-like peptide (GLP)-1 is an incretin hormone responsible for augmenting insulin secretion from pancreatic beta-cells during the postprandial period. Given that native GLP-1 has a very short half-life, GLP-1 mimetics with a much longer half-life have been developed, which are currently an effective treatment option for T2D by enhancing insulin secretion in patients. Interestingly, there is continual emerging evidence that these therapies alleviate some of the post-diagnosis complications of T2D. Additionally, these therapies have been shown to induce weight loss in patients, suggesting they could be an alternative to bariatric surgery, a procedure associated with numerous complications. Current GLP-1-based therapies all act as orthosteric agonists for the GLP-1 receptor (GLP-1R). Interestingly, it has emerged that GLP-1R also has allosteric binding sites and agonists have been developed for these sites to test their therapeutic potential. Recent studies have also demonstrated the potential of bi- and tri-agonists, which target multiple hormonal receptors including GLP-1R, to more effectively treat T2D. Improved understanding of T2D aetiology/pathogenesis, coupled with the further elucidation of both GLP-1 activity/targets and GLP-1R mechanisms of activation via different agonists, will likely provide better insight into the therapeutic potential of GLP-1-based therapies to treat T2D.

Evaluation of Dietary Assessment Tools Used in Bariatric Population

Severe obesity is associated with major health issues and bariatric surgery is still the only treatment to offer significant and durable weight loss. Assessment of dietary intakes is an important component of the bariatric surgery process. Objective: To document the dietary assessment tools that have been used with patients targeted for bariatric surgery and patients who had bariatric surgery and explore the extent to which these tools have been validated. Methods: A literature search was conducted to identify studies that used a dietary assessment tool with patients targeted for bariatric surgery or who had bariatric surgery. Results: 108 studies were included. Among all studies included, 27 used a dietary assessment tool that had been validated either as part of the study per se (n = 11) or in a previous study (n = 16). Every tool validated per se in the cited studies was validated among a bariatric population, while none of the tools validated in previous studies were validated in this population. Conclusion: Few studies in bariatric populations used a dietary assessment tool that had been validated in this population. Additional studies are needed to develop valid and robust dietary assessment tools to improve the quality of nutritional studies among bariatric patients.

Micronutrient screening, monitoring, and supplementation in pregnancy after bariatric surgery

We present the case of a woman with a history of biliopancreatic diversion and duodenal switch procedure who developed severe malnourishment requiring total parenteral nutrition during three pregnancies. The widespread use of bariatric surgery, particularly among those of reproductive age, has led to an increase in the number of women who become pregnant following bariatric surgery. There is a paucity of evidence to guide nutritional recommendations for women during pregnancy post bariatric surgery. We review this literature and summarize key published evidence and provide comprehensive recommendations concerning the common challenges in the management of nutrition status during pregnancy. The focus is on the impact of malabsorptive bariatric surgeries on pregnancy outcomes, nutrient deficiencies, recommendations for micro- and macronutrient monitoring and supplementation, and altered glucose metabolism and implications for diabetes screening. Optimizing pregnancy outcomes for individuals following bariatric surgery requires multidisciplinary team management including obstetrical providers, obstetric medicine specialists, and dietitians.

Different limb lengths in gastric bypass surgery: study protocol for a Swiss multicenter randomized controlled trial (SLIM)

Background

Obesity and type 2 diabetes mellitus are reaching epidemic proportions. In morbidly obese patients, bariatric operations lead to sustained weight loss and relief of comorbidities in the majority of patients. Laparoscopic Roux-Y-gastric bypass (RYGB) is one of the most frequently performed operations, but it is still unknown why some patients respond better than others. Therefore, a number of variations of this operation have been introduced. Recent evidence suggests that a longer bypassed biliopancreatic limb (BPL) has the potential to be more effective compared to the standard RYGB with a shorter BPL length. This article describes the design and protocol of a randomized controlled trial comparing the outcome of a RYGB operation with a long versus short BPL.

Methods/design

The trial is designed as a multicenter, randomized, patient- and observer-blinded trial. The relevant ethics committee has approved the trial protocol. To demonstrate that long BPL RYGB is superior compared to short BPL RYGB in terms of weight loss and resolution of T2DM, the study is conducted as a superiority trial. Postoperative percent total weight loss and nutritional deficiency rate are the primary endpoints, whereas morbidity, mortality, remission of obesity-related comorbidities and quality of life are secondary endpoints. Eight hundred patients, between 18 and 65 years and with a body mass index (BMI) from 35 to 60 kg/m² who meet the regulatory rules for bariatric surgery in Switzerland, will be randomized. The endpoints and baseline measurements will be assessed pre-, intra-, and postoperatively.

Discussion

With its high number of patients and a 5-year follow-up, this study will answer questions about effectiveness and safety of long BPL RYGB and provide level I evidence for improvement of the standard RYGB. These findings might therefore potentially influence global bariatric surgery guidelines.

Trial registration

ClinicalTrials.gov NCT04219787. Registered on 7 January 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05313-6.

Midterm Outcome of Laparoscopic Sleeve Gastrectomy in Asians: a Systematic Review and Meta-analysis

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric surgery. Studies have suggested that LSG can provide effective and sustainable weight loss although most of them were conducted in Western populations. Our aim was to characterize the midterm outcome of LSG in Asians with obesity.

METHODS

MEDLINE and EMBASE were searched through August 2019 for studies that reported % total body weight loss (TBWL) and/or % excess weight loss (EWL) at 3 and/or 5 years among adult Asians with obesity who underwent LSG. Data on complications and surgical revision rate were also extracted. The pooled effect size and 95% confidence interval (CI) were calculated using a random effects model.

RESULTS

A total of 19 studies involving 6235 patients were included. The pooled mean %EWLs were 72.6% (95% CI 67.2-78.0, I² = 97%); 67.1% (95% CI 61.7-72.6, I² = 95%); and 59.1% (95% CI 48.8-69.4, I² = 94%) at 1, 3, and 5 years, respectively. The pooled mean %TBWLs were 32.1%, 29.0%, and 25.5% at 1, 3, and 5 years, respectively. The pooled rates of revision due to gastroesophageal reflux disease and weight regain were 1.9% and 2.5%, respectively.

CONCLUSIONS

Our meta-analysis suggests that LSG is an effective procedure for weight reduction that offers durable response for up to 5 years among Asians with obesity. The longer-term data is needed.

Is there an indication left for gastric band? A single center experience on 178 patients with a follow-up of 10 years

BACKGROUND

Laparoscopic Adjustable Gastric Banding (LAGB) has been widely performed in the past at our university bariatric center. Aim of this study was to retrospectively assess long term outcomes of LAGB at our university hospital, with special regard to non-response (EWL < 25%) and rate of band removal.

METHODS

Retrospective search of prospectively maintained database of our university bariatric center was carried out to find all consecutive patients that had undergone LAGB at our department with a minimum follow-up of 10 years. Collected data were sex, age, body mass index (BMI), obesity related diseases remission, complications and weight loss.

RESULTS

After 10 years, patients with the band (n = 144) in place had a BMI of 35.2 ± 7.5 kg/m2, while %EWL and % TWL were 40.8 ± 52.4 and 18.9 ± 20.7. Seventy-four (41.6%) achieved a success (%EWL > 50), while 38 (21.3%) were non-responders (%EWL < 25), 32 (18%) had an insufficient weight loss (25 < %EWL < 50) and 34 (19.1%) underwent band removal. Among these, 6 (3.4%) were removed for complications and 28 (15.7%) for insufficient weight loss. Weight regain occurred in 38 out of 144 (26.4%) subjects with the band in place at 10 years. Only one case of early vomiting with readmission for medical treatment was recorded. Slippage, erosion/migration and port/tube complications occurred in 4 (2.2%), 2(1.1%) and 9(5%) cases respectively.

CONCLUSION

LAGB is a safe and moderately effective bariatric procedure but it showed disappointing rates of removal, non-response and remission from comorbidities. However, LAGB could still be proposed for selected/motivated patients.

Mitochondrial uncoupler SHC517 reverses obesity in mice without affecting food intake

AIMS

Mitochondrial uncouplers decrease caloric efficiency and have potential therapeutic benefits for the treatment of obesity and related metabolic disorders. Herein we investigate the metabolic and physiologic effects of a recently identified small molecule mitochondrial uncoupler named SHC517 in a mouse model of diet-induced obesity.

METHODS

SHC517 was administered as an admixture in food. The effect of SHC517 on in vivo energy expenditure and respiratory quotient was determined by indirect calorimetry. A dose-finding obesity prevention study was performed by starting SHC517 treatment concomitant with high fat diet for a period of 12 days. An obesity reversal study was performed by feeding mice western diet for 4 weeks prior to SHC517 treatment for 7 weeks. Biochemical assays were used to determine changes in glucose, insulin, triglycerides, and cholesterol. SHC517 concentrations were determined by mass spectrometry.

RESULTS

SHC517 increased lipid oxidation without affecting body temperature. SHC517 prevented diet-induced obesity when administered at 0.05% and 0.1% w/w in high fat diet and reversed established obesity when tested at the 0.05% dose. In the obesity reversal model, SHC517 restored adiposity to levels similar to chow-fed control mice without affecting food intake or lean body mass. SHC517 improved glucose tolerance and fasting glucose levels when administered in both the obesity prevention and obesity reversal modes.

CONCLUSIONS

SHC517 is a mitochondrial uncoupler with potent anti-obesity and insulin sensitizing effects in mice. SHC517 reversed obesity without altering food intake or compromising lean mass, effects that are highly sought-after in anti-obesity therapeutics.