Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: 5-year outcomes of merged data from two randomized clinical trials (SLEEVEPASS and SM-BOSS)

Bridging the gap in obesity research: A consensus statement from the European Society for Clinical Investigation

BACKGROUND

Most forms of obesity are associated with chronic diseases that remain a global public health challenge.

AIMS

Despite significant advancements in understanding its pathophysiology, effective management of obesity is hindered by the persistence of knowledge gaps in epidemiology, phenotypic heterogeneity and policy implementation.

MATERIALS AND METHODS

This consensus statement by the European Society for Clinical Investigation identifies eight critical areas requiring urgent attention. Key gaps include insufficient long-term data on obesity trends, the inadequacy of body mass index (BMI) as a sole diagnostic measure, and insufficient recognition of phenotypic diversity in obesity-related cardiometabolic risks. Moreover, the socio-economic drivers of obesity and its transition across phenotypes remain poorly understood.

RESULTS

The syndemic nature of obesity, exacerbated by globalization and environmental changes, necessitates a holistic approach integrating global frameworks and community-level interventions. This statement advocates for leveraging emerging technologies, such as artificial intelligence, to refine predictive models and address phenotypic variability. It underscores the importance of collaborative efforts among scientists, policymakers, and stakeholders to create tailored interventions and enduring policies.

DISCUSSION

The consensus highlights the need for harmonizing anthropometric and biochemical markers, fostering inclusive public health narratives and combating stigma associated with obesity. By addressing these gaps, this initiative aims to advance research, improve prevention strategies and optimize care delivery for people living with obesity.

CONCLUSION

This collaborative effort marks a decisive step towards mitigating the obesity epidemic and its profound impact on global health systems. Ultimately, obesity should be considered as being largely the consequence of a socio-economic model not compatible with optimal human health.

Major Adverse Cardiac Events After Gastric Bypass vs Sleeve Gastrectomy

Importance

Metabolic bariatric surgery is the most effective and durable treatment for weight loss and improvement of cardiovascular diseases. With sleeve gastrectomy now surpassing gastric bypass as the most common procedure worldwide, comparing these procedures' associations with major adverse cardiac events (MACE) is needed.

Objective

To compare the risk of MACE among individuals undergoing gastric bypass or sleeve gastrectomy.

Design, Setting, and Participants

This population-based, inverse probability-weighted cohort study was conducted using administrative claims data from Switzerland among adults undergoing gastric bypass or sleeve gastrectomy for obesity treatment between January 2012 and December 2022. Inpatient individuals with a primary or secondary discharge procedure code for gastric bypass or sleeve gastrectomy were eligible for inclusion. Data were analyzed from April 2024 to September 2025.

Exposure

Gastric bypass vs sleeve gastrectomy.

Main Outcomes and Measures

A weighted cohort was analyzed to study the primary outcome of 4-point MACE, including acute myocardial infarction, ischemic stroke, hospitalizations for heart failure, and all-cause mortality. Secondary outcomes were the individual components of MACE, surgical reinterventions, and associated complications.

Results

Of 39 067 patients, 30 270 patients (77.5%) underwent gastric bypass and 8798 patients (22.5%) underwent sleeve gastrectomy. Median (IQR) patient age was 42 (35-50) years, and 28 560 patients (73.1%) were women. A total of 23 708 patients (60.7%) had a body mass index (calculated as weight in kilograms divided by height in meters squared) of 40 or higher. After weighting, over a median (IQR) follow-up of 5.1 years (2.6-7.6), the primary outcome occurred in 577 patients in the gastric bypass group (1.9%) and 264 patients in the sleeve gastrectomy group (3.0%), with incidence rates of 3.96 and 5.10 per 1000 patient-years, respectively (hazard ratio [HR], 0.75; 95% CI, 0.64-0.88). This difference was primarily driven by lower rates of acute myocardial infarction (HR, 0.63; 95% CI, 0.46-0.86). No differences were observed in ischemic stroke, hospitalization for heart failure, and all-cause mortality. Both short- and long-term secondary outcomes favored gastric bypass over sleeve gastrectomy, except for higher rates of revision surgery and immediate postoperative complications.

Conclusions and relevance

In this inverse probability-weighted cohort study, for patients undergoing metabolic bariatric surgery, gastric bypass was associated with lower rates of MACE than sleeve gastrectomy over a follow-up period of up to 11 years. Known postoperative complications were confirmed for both gastric bypass and sleeve gastrectomy.

Long-term changes in lipid indices following Roux-en-Y gastric bypass: a meta-analysis

INTRODUCTION

Bariatric surgery yields clinically significant long-term weight loss accompanied by marked improvements in numerous weight-related comorbidities including type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, and fatty liver disease.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the effect of (RYGB) surgery on lipid profile.

DATA SOURCE

We searched PubMed, Scopus, Web of Science and Scholar from inception to May 20th, 2024.

STUDIES SELECTION

Clinical studies that reported lipid profile data with a follow-up of at least 5 years after RYGB were eligible.

DATA EXTRACTION

Two independent reviewers extracted data and assessed the risk of bias.

RESULTS

Of the 4922 articles identified from our database search, 38 studies that measured lipid profile following RYGB were identified and selected for the analysis. Compared to pre-surgery, at post-surgery follow-up of ≥ 5 years, RYGB was associated with significant reductions in mean total cholesterol (TC) (WMD: - 17.95 mg/dl, 95% CI: - 22.68, - 13.22, 95% PI: - 46.18, 10.27 p < 0.001; I2:92.3), LDL-cholesterol (WMD: - 18.55 mg/dl, 95% CI: -21.85, -15.25, 95% PI: - 39.01, 1.92 p < 0.001; I2:91.8), and triglycerides (WMD: - 60.76 mg/dl, 95% CI: - 66.29, - 55.22, 95% PI: - 91.24, - 30.27 p < 0.001; I2:83.7), and increase in HDL-cholesterol (WMD: 13.75 mg/dl, 95% CI: 12.38, 15.13, 95% PI: 5.32, 22.19 p < 0.001; I2:91.4).

CONCLUSION

RYBG is associated with clinically significant large improvements in serum lipids at a post-operative follow-up of 5 years or more.

Effect of gastric bypass versus sleeve gastrectomy on the remission of type 2 diabetes, weight loss, and cardiovascular risk factors at 5 years (Oseberg): secondary outcomes of a single-centre, triple-blind, randomised controlled trial

BACKGROUND

For individuals with obesity and type 2 diabetes, weight loss improves insulin sensitivity and β-cell function and can induce remission of diabetes. However, the long-term comparative effectiveness of standard gastric bypass and sleeve gastrectomy on remission of type 2 diabetes remains unclear. We aimed to compare the effects of gastric bypass and sleeve gastrectomy on type 2 diabetes remission, weight loss, and cardiovascular risk factors 5 years after surgery.

METHODS

We present a secondary analysis of a two-armed, single-centre, triple-blind, randomised controlled trial conducted at a public tertiary obesity centre in Norway. Adults (ie, age ≥18 years) with type 2 diabetes and obesity were randomly assigned (1:1) by a computerised random number generator to laparoscopic gastric bypass or sleeve gastrectomy, with balanced block sizes of ten. Study personnel, participants, and the primary-outcome assessor were all masked to the allocation until 1 year after surgery, after which further follow-up was open label. Changes in key secondary outcomes, including type 2 diabetes remission, weight loss, and cardiovascular risk factors, were assessed 5 years after surgery. The trial procedure estimand assessed treatment effects in all randomised participants, with data collected after conversional surgery removed from analyses. The trial was registered with ClinicalTrials.gov (NCT01778738) and was completed in December, 2022.

FINDINGS

Between Oct 15, 2012, and Sept 1, 2017, 319 patients were assessed for eligibility, resulting in 109 participants who were randomly assigned to gastric bypass (n=54) or sleeve gastrectomy (n=55). The baseline mean age was 47·7 years (SD 9·6), mean BMI 42·3 kg/m2 (SD 5·3), 72 (66%) were women, and 37 (34%) were men. 93 (85%) participants completed 5-year follow-up (47 [85%] in the sleeve gastrectomy group and 46 [85%] in the gastric bypass group). The proportions with remission of type 2 diabetes were higher after gastric bypass than after sleeve gastrectomy (HbA1c ≤6·0% 23 [50%] of 46 vs nine [20%] of 44, risk difference 29·5% [95% CI 10·8 to 48·3]; HbA1c <6·5% 29 [63%] vs 13 [30%], risk difference 33·5% [14·1 to 52·9]). Gastric bypass provided greater loss in bodyweight (mean 22·2% [95% CI 20·3 to 24·1] vs 17·2% [15·3 to 19·1], treatment difference 5·0% [2·4 to 7·7]) and lower LDL-cholesterol (treatment difference -0·5 mmol/L [-0·8 to -0·1]). The prevalence of erosive oesophagitis and Barrett's oesophagus was similar between groups, whereas pathological acid reflux occurred more frequently after sleeve gastrectomy (risk difference 51·1% [28·0 to 74·2]). More participants had symptomatic postprandial hypoglycaemia after gastric bypass than after sleeve gastrectomy (15 [28%] vs one [2%]).

INTERPRETATION

Gastric bypass was superior to sleeve gastrectomy regarding long-term remission of type 2 diabetes, weight loss, and LDL cholesterol concentrations, at the expense of a higher frequency of symptomatic postprandial hypoglycaemia. These findings could inform clinical practice and future guidelines regarding the preferred surgical procedure in patients with type 2 diabetes.

FUNDING

Vestfold Hospital Trust.

TRANSLATION

For the Norwegian translation of the abstract see Supplementary Materials section.

Comparative survival of sleeve gastrectomy versus Roux-en-Y gastric bypass in adults with obesity: a systematic review and meta-analysis

BACKGROUND

The difference in survival between sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) remains controversial.

OBJECTIVE

To investigate the comparative survival difference between SG and RYGB in adults with morbid obesity.

SETTING

A meta-analysis.

METHODS

MEDLINE, EMBASE, and Cochrane Library Central Register of Controlled Trial were searched through June 30th, 2023 to identify studies comparing SG and RYGB. To minimize confounding, only adjusted outcomes were used from observational studies. The primary outcome was all-cause mortality during follow-up. Secondary outcomes were revision, reoperation, reintervention, hospitalization, endoscopic procedure, and emergency department visit.

RESULTS

Twenty-two studies (10 randomized controlled trials [RCTs] and 12 observational studies) met the inclusion criteria. Three RCTs and seven observational studies with 333,713 patients (SG, n = 172,909; RYGB, n = 160,804) were analyzed for all-cause mortality, with a weighted median follow-up of 34.4 months. SG was associated with decreased risks of all-cause mortality during follow-up (hazard ratio [HR]: .85; 95% confidence interval [CI]: .79 to .92), reoperation (HR: .69; 95% CI: .59 to .80), reintervention (HR: .74; 95% CI: .66 to .81), hospitalization (HR: .86; 95% CI: .77 to .97), and endoscopic procedure (HR: .55; 95% CI: 0.40-.76), whereas SG was associated with a higher risk of revision (HR: 2.18, 95% CI: 1.52 to 3.14). Meta-regression suggested consistent survival advantages of SG regardless of the proportion of patients with diabetes or follow-up duration.

CONCLUSION

In adults with morbid obesity undergoing bariatric surgery, SG was associated with a decreased risk of all-cause mortality during follow-up compared with RYGB. A large-scale randomized trial with long-term follow-up is still necessary for validation.

Postoperative outcomes following revision or conversion surgery after primary sleeve gastrectomy: an analysis of the MBSAQIP database

BACKGROUND

A significant proportion of patients that undergo primary sleeve gastrectomy (SG) require revision or conversion metabolic and bariatric surgery (MBS). Despite various procedures performed in practice, comparative analyses of short-term outcomes remain limited.

OBJECTIVES

We conducted a retrospective comparative analysis of postoperative outcomes of revision or conversion MBS following primary SG.

SETTING

The 2020-2022 MBSAQIP database.

METHODS

We included patients who underwent any one of the following: revision SG (Re-SG), Roux-en-Y gastric bypass (SG-RYGB), biliopancreatic diversion/duodenal switch (SG-BPD/DS), single anastomosis duodenoileal bypass (SG-SADI), or one anastomosis gastric bypass (SG-OAGB). Our primary outcome was 30-day major complications, defined as Clavien-Dindo Grade≥ II.

RESULTS

Among 33,348 revision/conversion MBS, SG-RYGB was the most common (n = 27,393, 82.1%). Compared to SG-RYGB, the odds of 30-day major complications were lower in Re-SG (odds ratio [OR] .75, 95%- confidence interval [CI] .61-.90) and SG-SADI (OR .75, 95%-CI .57 - .97). However, both Re-SG and SG-SADI were associated with higher odds of anastomotic or staple line leak (OR 2.74; 95%-CI 1.78-4.12 and OR 2.44; 95%-CI 1.35-4.17, respectively). In addition, both Re-SG (mean difference 1.66 days, 95%-CI .44 - 2.88) and SG-SADI (MD 3.0 days, 95%-CI 1.31- 4.70) resulted in longer hospital stays upon readmission.

CONCLUSIONS

In our analysis, Re-SG and SG-SADI had lower odds of 30-day major complications compared to SG-RYGB, but had significantly higher odds of anastomotic or staple line leak and had longer hospital stays on readmission. Given its limited indications and significant potential morbidity, Re-SG should not be routinely offered as a revisional procedure for primary SG.

Long-Term Outcomes of Laparoscopic Roux-en-Y Gastric Bypass vs Laparoscopic Sleeve Gastrectomy for Obesity: The SM-BOSS Randomized Clinical Trial

Importance

Reports on long-term outcomes from randomized clinical trials comparing laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are scarce.

Objective

To compare long-term weight and metabolic outcomes, reoperation rates, and quality of life for patients undergoing SG vs RYGB at 10 years and beyond.

Design, Setting, and Participants

The SM-BOSS (Swiss Multicenter Bypass or Sleeve Study) randomized clinical trial was conducted from January 2007 to November 2011 at 4 bariatric centers in Switzerland. (The last follow-up was obtained in July 2023.) A total of 3971 patients with severe obesity were assessed, and 217 patients were enrolled and randomized to undergo SG or RYGB.

Interventions

Laparoscopic SG or RYGB.

Main Outcomes and Measures

The primary outcome of the SM-BOSS trial was the percentage excess body mass index loss (%EBMIL) at 5 years. The present study reports on the long-term weight and metabolic outcomes at 10 years and beyond, including changes in weight and obesity-related diseases, reoperation rates, and quality of life.

Results

Of 217 patients randomized to undergo SG or RYGB, mean (SD) age was 42.5 (11.1) years, mean (SD) baseline BMI was 43.9 (5.3), and 156 patients (71.9%) were female. Of 217 patients, 110 patients were randomized to RYGB and 107 to SG. Complete 10-year follow-up is available for 65.4% of patients. In the intention-to-treat population, mean (SD) %EBMIL was 60.6% (25.9) after SG and 65.2% (26.0) after RYGB (P = .29). Patients who underwent SG had significantly higher conversion rates because of insufficient weight reduction or reflux compared to RYGB (29.9% vs 5.5%; P < .001). Patients undergoing RYGB had significantly higher mean (SD) %EBMIL compared to SG after 10 years in the per-protocol (PP) population (65.9% [26.3] vs 56.1% [25.2]; P = .048). However, mean (SD) percentage total weight loss was not significantly different between groups (RYGB: 27.7% [10.8]; SG: 25.5% [15.1]; P = .37). SG patients had significantly more de novo gastroesophageal reflux (GERD) compared with RYGB (P = .02).

Conclusions and Relevance

In the SM-BOSS randomized clinical trial, RYGB led to significantly higher %EBMIL in the PP population compared with SG beyond 10 years of follow-up, with better results for GERD. Patients undergoing SG experienced a significantly higher number of conversions to different anatomy compared with RYGB.

Trial Registration

ClinicalTrials.gov Identifier NCT00356213.

Long-term glycemic control after sleeve gastrectomy and biliopancreatic diversion with duodenal switch in patients with type 2 diabetes mellitus

BACKGROUND AND OBJECTIVES

Long-term studies exploring factors associated with glycemic control of type 2 diabetes mellitus (T2DM) after bariatric surgery are being requested. This prospective cohort study aimed to evaluate potential predictors of long-term glycemic control 5 years after surgery.

METHODS

Patients were operated between 2002 and 2014. Data were collected prospectively in a database after obtaining written informed consent from the patients. Surgical methods were sleeve gastrectomy (SG) or biliopancreatic diversion with duodenal switch (BPDDS). Possible predictors of postoperative long-term glycemic control (HbA1c) were investigated using multiple path regression analysis, which handles missing data.

RESULTS

A total of 181 patients were included consecutively, 87 after SG and 94 after BPDDS. The follow-up rate was 124/181 (69%), 57 (66%) after SG and 67 (71%) after BPDDS. We found that 39/57 (68%) of the patients who underwent SG and 54/67 (81%) of the patients who underwent BPDDS had remission of T2DM at 5 years. Lower preoperative HbA1c (P < 0.010), higher preoperative C-peptide (P = 0.004), greater percent total weight loss (P < 0.005), and the BPDDS procedure (P < 0.001) were associated with better postoperative long-term glycemic control (explained variance = 39.4%).

CONCLUSIONS

Both procedures, especially BPDDS, were effective in achieving long-term glycemic control. Lower preoperative HbA1c, higher C-peptide levels, greater weight loss, and the BPDDS procedure were key predictors of better long-term glycemic control.

Koala Sleeve: innovative technique for enhanced GERD control without sacrificing weight loss

BACKGROUND

Sleeve gastrectomy (SG) is the most frequently performed bariatric surgery worldwide, offering effective weight loss and improvement in metabolic conditions. However, one of its major complications is the exacerbation or development of gastroesophageal reflux disease (GERD), affecting over 30% of patients. While Roux-en-Y gastric bypass (RYGB) is often the preferred alternative for patients with pre-existing GERD, it may not be suitable for all patients due to contraindications or patient preference.

OBJECTIVE

This study introduces a novel modification to SG, combining it with horizontal gastroplasty to address GERD symptoms without compromising weight loss outcomes.

METHODS

The procedure involves a standard SG with complete fundus resection, followed by the creation of a horizontal valve at the gastroesophageal (GE) junction using three horizontal mattress sutures. Seven patients with preoperative GERD were selected for this technique. Post-operative outcomes were assessed, including weight loss and GERD symptom resolution.

RESULTS

The mean operative time was 76 min, with no procedure-related complications. Three months postoperatively, the average percentage of excess weight loss (%EWL) was 68%. Importantly, none of the patients reported GERD symptoms, indicating effective reflux control.

CONCLUSION

Sleeve gastrectomy with horizontal gastroplasty appears to be a promising, simple, and safe option for patients with GERD undergoing SG. This technique may offer a viable alternative to RYGB for managing GERD in bariatric patients. Further studies are needed to validate these initial findings and assess long-term outcomes.

Weight loss outcomes and associated factors after metabolic bariatric surgery: Analysis of routine clinical data in Scotland

BACKGROUND

Bariatric surgery is a cornerstone intervention for individuals with severe obesity, offering substantial and sustainable weight loss.

METHODS

This retrospective cohort study included 186 patients with obesity and Type2 diabetes who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 2009 and 2020 ​at University Hospital Ayr. Optimal clinical response weight loss was defined as excess weight loss (%EWL) ≥50 ​% or total weight loss (%TWL) ≥20 ​%.

RESULTS

At 2-years post-surgery, 43.6 ​% achieved ≥50 %EWL, and 44.1 ​% achieved ≥20%TWL, with 31.8 ​% maintaining this at 5-years. Depending on the definition used, between 11.2 ​% and 45.9 ​% of patients experienced recurrent weight gain. BMI had significant positive association with %TWL but negative with %EWL (p ​< ​0.05). RYGB had significantly higher %TWL compared to SG (p ​< ​0.05).

CONCLUSION

Most patients experienced weight loss which was maintained over time, however recurrent weight gain was noted. Pre-surgery BMI was significantly associated with weight changes.

Ring Augmentation of the Roux-en-Y Gastric Bypass: A Propensity Score Matched Analysis of 5-Year Follow-Up Results

BACKGROUND

The ring-augmented Roux-en-Y gastric bypass (raRYGB) has been reported to result in higher long-term weight loss compared to regular Roux-en-Y gastric bypass (RYGB). However, the type of ring used varied within studies, leading to heterogeneity in reported results. Therefore, this study compares the 5-year results of RYGB with and without ring augmentation using a specific prefabricated gastric ring.

METHODS

All consecutive patients from a single center who received primary raRYGB between June 1, 2016, and May 31, 2018, with complete 5-year follow-up data were included and compared to a propensity score matched cohort receiving RYGB in the same period from the Dutch Audit for Treatment of Obesity. To ensure fair effect estimation of placing a ring, only RYGB procedures with alimentary and biliopancreatic limb lengths similar to those of the raRYGB were considered eligible. The primary outcome was percentage total weight loss (%TWL). Secondary outcomes included recurrent weight gain (RWG), obesity complication improvement, and complications.

RESULTS

In total, 592 matched patients were analyzed. raRYGB was associated with higher %TWL at 5 years (31.5% versus 28.0%, β = 3.59, 95% CI [2.09-5.09], p < 0.01) and lower odds on RWG (odds ratio = 0.56, 95% CI [0.38-0.83], p < 0.01). Improvement of obesity complications and short-term complication rates were comparable in both groups. After 5 years, 13 patients (4%) had experienced ring-related complications needing reoperation.

CONCLUSIONS

At 5 years, raRYGB was associated with higher %TWL and lower odds on RWG. The occurrence of ring-related complications was limited.

How preoperative upper gastrointestinal investigations affect the management of bariatric patients: results of a cohort study of 897 patients

INTRODUCTION

Preoperative diagnostic protocols vary worldwide, some prioritizing safety while others question routine procedures. Building on prior research, this study explores the impact of diverse preoperative findings on bariatric management and procedure selection.

METHODS

In a retrospective analysis of prospective data of over 1000 bariatric surgery patients from January 2017 to December 2022 undergoing primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (LSG) were analyzed. Preoperative assessment included upper endoscopy, upper GI series, and esophageal manometry. Sonography data were excluded. The primary endpoint examined the influence of preoperative exams on procedure selection, the secondary endpoint evaluated their therapeutic impact.

RESULTS

897 patients (741 RYGB, 156 SG) were included. All underwent upper endoscopy, revealing common findings such as type C gastritis and reflux esophagitis. Upper endoscopy prompted a therapeutic consequence in 216 patients (24.3%), resulting in a number needed to screen (NNS) of 4.1. Upper GI series and manometry were more frequently performed before LSG. Upper GI series detected hiatal hernias and motility disorders but did not result in any change of procedures. Esophageal manometry found pathologies in 37 (25.3%) patients rising to 41.5% if symptoms were present. Overall, 16 (1.8%) patients experienced a change in the planned procedure, with 14 changes prompted by preoperative findings and two by technical difficulties.

CONCLUSION

We advise routine upper endoscopies for all patients undergoing LRYGB or LSG, while reserving upper GI series only for selected cases. Manometry should be exclusively performed on symptomatic patients undergoing LSG, ensuring a balanced and individualized preoperative assessment.

Bariatric surgery for treatment of morbid obesity in adults

Morbid obesity requires active intervention, with treatment options including lifestyle modification, pharmacotherapy, and surgery. As the prevalence of obesity continues to rise in Korea, it is crucial for specialists and general practitioners to have a comprehensive understanding of obesity and its management. Bariatric surgery is the most effective treatment modality for obesity, leading to significant weight loss and metabolic benefits. It involves surgical alterations of normal anatomical structures to improve overall health. Therefore, selecting the appropriate procedure based on the individual characteristics of patients is crucial. This review highlights the two most commonly performed bariatric procedures worldwide, including in Korea: sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Furthermore, it provides a comprehensive overview of the surgical techniques involved in SG and RYGB, addresses potential complications, and presents findings from key studies on the weight loss and metabolic outcomes of these surgeries. Additionally, to support clinical application, the review provides outcome data for these procedures based on studies conducted in Korean populations. In addition to SG and RYGB, this review briefly introduces other surgical and endoscopic options, as well as pharmacological treatments that are currently available or may become viable options in the near future.

Preoperative nonalcoholic steatohepatitis and resolution of metabolic comorbidities after bariatric surgery

BACKGROUND

Most patients undergoing bariatric surgery demonstrate elements of the metabolic syndrome (MetS) and can therefore be diagnosed with metabolically unhealthy obesity (MUO). Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) as hepatic manifestations of the MetS occur in many patients with obesity, but their leverage on postoperative improvement to Metabolic Health (MH), defined as absence of any metabolic comorbidity, remains unclear.

OBJECTIVES

The aim of this study was to assess the influence of liver health status, operative procedure, and sex on postoperative switch from a MUO to an MH phenotype. Secondary objective was weight loss to MH.

SETTING

University Hospital, Germany.

METHODS

Patients who underwent either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at our obesity surgery center were included in this retrospective study. Liver biopsy was taken and evaluated for presence of NAFLD/NASH. For diagnosis of MH, blood pressure and laboratory values referring to the MetS were assessed preoperatively and at 3, 6, 12, and 24 months' postoperatively.

RESULTS

One hundred thirty-three patients (73% female) with a mean body mass index of 52.0 kg/m2 and mean age of 43 years were included in this study. A total of 55.6% underwent RYGB and 44.4% underwent SG. NAFLD was found in 51.1% of patients and NASH in 33.8%. All patients were diagnosed MUO at baseline. Postoperatively, 38.3% patients (n = 51) switched to a MH condition. Mean time to MH was 321 days and mean excess body mass index loss to MH was 63.8%. There were no differences regarding liver health status, operative procedure, or sex.

CONCLUSIONS

Bariatric surgery can resolve MUO independent of liver health status, operative procedure, and sex. However, patients should be closely monitored to ensure sustainable long-term outcomes following the switch to the MH condition.

Eight Year Follow-Up After Gastric Bypass and Sleeve Gastrectomy in a Brazilian Cohort: Weight Trajectory and Health Outcomes

INTRODUCTION

Despite Sleeve Gastrectomy (SG) being the most commonly performed bariatric surgery today, studies with over 5 years of follow-up show that patients undergoing SG have inferior weight loss compared to those undergoing Roux-en-Y gastric bypass (RYGB). The aim of this study was to examine differences in weight loss and the prevalence of weight regain between SG and RYGB up to 8 years after surgery.

METHODS

Retrospective study including adult patients undergoing SG or RYGB between 2015 and 2018 at a tertiary center in Brazil. We evaluate the weight trajectory and pre- and postoperative behavior of type 2 diabetes (T2D), hypertension, and dyslipidemia. Differences betwen variables were tested using Student t-test, Mann-Whitney U, Pearson's chi-square or Fisher's exact test as appropriate. The level of significance adopted was p < 0,005.

RESULTS

Among 591 patients (40 ± 10 years; baseline body mass index 41.7 [IQR 39.1-45]; 83% women), 327 underwent RYGB (55%) and 264 SG (45%). Preoperatively, 14% had T2D, 40% hypertension, and 53% dyslipidemia. The mean total percentage of weight loss was higher in the RYGB group after 8 years: 32% compared to 19% after SG (difference 13%, p < 0.004). At 8 years, weight regain was also lower in RYGB (23%) compared to SG (39%) (p < 0.001). At 5 years postoperatively, the remission rates for T2D, hypertension, and dyslipidemia were 63%, 42%, and 51%, respectively, among the patients who remained in follow-up.

CONCLUSIONS

Patients undergoing RYGB showed greater weight loss and less weight regain 8 years after bariatric surgery compared to those undergoing SG.

Effectiveness of conversional metabolic and bariatric surgery on dyslipidemia and the cost of lipid-lowering medications over 4 years: a French nationwide study

BACKGROUND

The need for conversional metabolic and bariatric surgery (CMBS) is still growing. No large-scale prospective cohort studies have assessed changes in lipid-lowering treatment (LLT) after CMBS.

OBJECTIVES

This study assesses and compares the effectiveness of the 4 main CMBS sequences after sleeve gastrectomy (SG) and adjustable gastric banding (AGB) on reimbursement and cost of LLT.

SETTING

France.

METHODS

This nationwide observational population-based cohort study analyzed data from the French National Health Insurance database. It included all patients who had undergone primary SG and AGB in France between January 1, 2012, and December 31, 2014, and followed until December 31, 2020. The study assessed LLT reimbursement evolution and costs across 4 different CMBS sequences.

RESULTS

During follow-up, 6396 patients underwent the 4 CMBS sequences: SG-RYGB (Roux-en-Y gastric bypass) (n = 2400), AGB-SG (n = 2277), AGB-RYGB (n = 1173), and SG-SG (n = 546), with a rate of LLT reimbursement of 9.8%, 3.6%, 6.6%, and 7.9%, respectively, in the year before CMBS. The rates of discontinuation of treatment at 2 and 4 years were 41.9%, 35.4%, 45.6%, 20.5% and 45.6%, 31.3%, 64.3%, 31.6%, respectively. At 4 years, the median [interquartile range] annual costs (euros) per patient were significantly lower (P < .01) than the costs in the year before CMBS for each sequence: 86.8 [57.3; 136.1] versus 38.0 [.0; 64.6], 79.1 [50.5; 120.1] versus 50.4 [15.6; 64.1], 89.0 [66.5; 139.6] versus .0 [.0; 58.8], and 89.8 [66.1; 121.4] versus 63.1 [.0; 93.4].

CONCLUSIONS

Our study underlines the effectiveness of CMBS in significantly reducing the need and associated costs of LLT for patients with dyslipidemia over a 4-year period.

Role of sleeve gastrectomy in improving metabolic syndrome: an overview

Metabolic syndrome (MetS) presents a global health challenge characterized by cardiometabolic risk factors like central obesity, elevated blood pressure, dyslipidemia, and high fasting glucose levels. Despite lifestyle interventions and medications, the increasing prevalence of MetS calls for effective treatments. Sleeve gastrectomy (SG) has emerged as a promising intervention. This review examines the role of SG in improving MetS outcomes, drawing from a PubMed/Medline literature search. It highlights SG's multifaceted metabolic effects, including hormonal changes and improved insulin sensitivity, contributing to improved metabolic outcomes. Additionally, SG leads to significant weight loss and effectively addresses comorbidities like hypertension, dyslipidemia, and type 2 diabetes mellitus (T2DM), with low rates of early morbidity and mortality. However, long-term studies indicate that Roux-en-Y gastric bypass (RYGB) provides more sustained weight loss and superior resolution of metabolic comorbidities, whereas SG is associated with fewer early complications and a lower risk of nutritional deficiencies. In conclusion, SG offers a valuable option for managing MetS, providing significant weight loss and comorbidity improvement. Nevertheless, potential long-term complications, such as gastroesophageal reflux disease (GERD) and suboptimal weight response, emphasize careful patient selection and monitoring.

Evaluating the impact and costs of conversional or revisional metabolic bariatric surgery on obstructive sleep apnea: Insights from a French nationwide cohort

BACKGROUND

This study assesses the effectiveness of 5 main conversional or revisional metabolic bariatric surgery sequences after sleeve gastrectomy, adjustable gastric banding and gastric bypass on reimbursement and cost of continuous positive airway pressure therapy, the first line treatment for obstructive sleep apnea, in France.

METHODS

This nationwide observational population-based cohort study analyzed data from the French National Health Insurance database. It included all patients who had undergone primary metabolic bariatric surgery in France between January 1, 2012, and December 31, 2014, and followed until December 31, 2020. The study assessed continuous positive airway pressure therapy reimbursement discontinuation and costs of reimbursed continuous positive airway pressure therapy across 5 different conversional or revisional metabolic bariatric surgery sequences.

RESULTS

During follow-up, 6,396 patients underwent the following sequences: sleeve gastrectomy-gastric bypass (n = 2,400), adjustable gastric banding-sleeve gastrectomy (n = 2,277), adjustable gastric banding-gastric bypass (n = 1,173), sleeve gastrectomy-sleeve gastrectomy (n = 546), and gastric bypass-others (n =332), with a rate of obstructive sleep apnea of 15.2%, 12.4%, 15.5% 12.8%, and 9.9% in the year before conversional or revisional metabolic bariatric surgery. The rates of patients who had a discontinuation of continuous positive airway pressure were at 2 and 4 years: 41.1%, 41.9%, 46.4%, 29.3%, and 33.3%; 62.3%, 57.0%, 78.2%; 57.5%, and 44.4%, respectively. At 4 years, the mean annual costs (euros) of obstructive sleep apnea treatment per patient were significantly lower (P < .01) than the costs in the year before conversional or revisional metabolic bariatric surgery for each sequence: 526.9 ± 414.4 vs 257.4 ± 349.7; 368.0 ± 247.5 vs 230.9 ± 288.4; 433.7 ± 326.0 vs 116.8 ± 238.3; 540.7 ± 275.3 vs 248.0 ± 308.4 and 501.2 ± 254.0 vs 281.1 ± 287.0, respectively.

CONCLUSIONS

Our study underscore the effectiveness of conversional or revisional metabolic bariatric surgery in significantly reducing the need and associated costs of continuous positive airway pressure therapy for patients with obstructive sleep apnea postprimary metabolic bariatric surgery over a 4-year period.

Fat Mass Index Predicts the Effect of Weight Loss and Quality of Life Early After Laparoscopic Sleeve Gastrectomy

BACKGROUND

Fat mass index (FMI) is a body composition indicator that reflects body fat content. Laparoscopic sleeve gastrectomy (LSG) is widely performed in patients with obesity.

OBJECTIVE

This study aimed to evaluate the value of the FMI in predicting weight loss effect and quality of life early after LSG.

MATERIAL AND METHODS

From January 2014 to July 2022, the clinical data and computed tomography (CT) images of patients who underwent LSG at a tertiary referral teaching hospital were analyzed. Body composition indicators were calculated using the SliceOmatic software. Achieving initial body mass index within 6 months postoperatively was defined as early eligible weight loss (EEWL). The relationship between body composition and EEWL was analyzed.

RESULTS

A total of 243 patients were included. Receiver operating characteristic (ROC) curve analysis showed that the predictive value of the FMI for EEWL in patients after LSG was higher than that of other indicators (all P < 0.05; area under the curve = 0.813). The best FMI cut-off point was 13.662. Accordingly, the patients were divided into the high-FMI group and low-FMI group. The %EWL and BMI of patients in the low-FMI group at 1, 3, 6, 9, 12, and 24 months after surgery were better than those in the high-FMI group (all P < 0.001). Patients in the low-FMI group had higher BAROS (Bariatric Analysis and Reporting Outcome System) scores than those in the high-FMI group (P < 0.001).

CONCLUSION

Compared with other body composition indicators, FMI can effectively predict the early effect of weight loss and quality of life after LSG.

Associations between Type of Bariatric Surgery and Obstructive Sleep Apnoea, Employment Outcomes, and Body Image Satisfaction: A Systematic Review and Meta-Analysis

INTRODUCTION

Bariatric surgery has been shown to provide significant patient benefits in terms of weight loss and mitigation of obesity-linked comorbidities, as well as providing improvements in occupational productivity and patient quality of life. However, the choice of which bariatric surgery procedure provides the most patient benefit in each of these cases is still in question. In this review, we provide a systematic review, with the objective of evaluating associations between different bariatric surgery procedures and mitigation of obesity-linked comorbidities, improvement in occupational productivity, and patient quality of life, concentrating on three areas: obstructive sleep apnoea (OSA), employment prospects, and body image.

METHODS

The CINAHL, PubMed, Web of Science, and CENTRAL databases were searched for eligible studies. Summary risk ratio (RR) and 95% confidence intervals were estimated using random-effects models. Thirty-three studies were included in this review, including 29 cohort studies and 4 randomised clinical trials (RCTs).

RESULTS

Pooled analysis of the observational studies showed significantly lower OSA remission in sleeve gastrectomy (SG) compared to Roux-en-Y gastric bypass (RYGB) across both short-term (1-2 years) and longer term (3+ years) follow-up periods (RR = 0.91, 95% CI = 0.84-0.99, p = 0.02; and RR = 0.88, 95% CI = 0.65-0.99, p = 0.03, respectively). In contrast, a meta-analysis of the RCT studies found no difference in OSA remission between SG and RYGB (RR = 1.01, 95% CI = 0.81-1.25, p = 0.93). An analysis of four studies showed significantly higher OSA remission for SG versus adjustable gastric banding (RR = 1.83, 95% CI = 1.57-2.14, p < 0.001). No significant difference was observed regarding improvement in employment status between SG and RYGB (RR = 0.77, 95% CI = 0.32-1.87, p = 0.57). A narrative synthesis of studies on body image reported no significant differences between body image scores and surgery types.

CONCLUSION

This review found significantly lower OSA remission in SG as compared to RYGB across different follow-up periods, while no significant statistical difference was observed in RCT studies. Further studies are recommended to assess the effectiveness of the various bariatric surgeries in relation to improving employment status and body image, where primary studies are lacking.

Changes in use and hospital outcomes of bariatric surgery in Spain (2016-2022): analysis of the role of type 2 diabetes using propensity score matching

INTRODUCTION

The objectives of this study were to examine temporal trends in the incidence of bariatric surgery (Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG)) in patients with and without type 2 diabetes mellitus (T2DM). Outcomes of hospitalization and the impact of T2DM on these outcomes were also analyzed.

RESEARCH DESIGN AND METHODS

We performed an observational study with the Spanish national hospital discharge database. Obese patients with and without T2DM who underwent RYGB and SG between 2016 and 2022 were identified. Propensity score matching (PSM) and logistic regression were used to compare patients with and without T2DM and to evaluate the effect of T2DM and other variables on outcomes of surgery. A variable "severity" was created to cover patients who died in hospital or were admitted to the intensive care unit (ICU).

RESULTS

A total of 32,176 bariatric surgery interventions were performed (28.86% with T2DM). 31.57% of RYGBs and 25.53% of SG patients had T2DM. The incidence of RYGB and SG increased significantly between 2016 and 2022 (p<0.001), with a higher incidence in those with T2DM than in those without (incidence rate ratio 4.07 (95% CI 3.95 to 4.20) for RYGB and 3.02 (95% CI 2.92 to 3.14) for SG). In patients who underwent SG, admission to the ICU and severity were significantly more frequent in patients with T2DM than in those without (both p<0.001). In the multivariate analysis, having T2DM was associated with more frequent severity in those who received SG (OR 1.23; 95% CI 1.07 to 1.42).

CONCLUSIONS

Between 2016 and 2022, bariatric surgery procedures performed in Spain increased in patients with and without T2DM. More interventions were performed on patients with T2DM than on patients without T2DM. RYGB was the most common procedure in patients with T2DM. The presence of T2DM was associated with more severity after SG.

Optimizing Hospital Performance Evaluation in Total Weight Loss Outcomes After Bariatric Surgery: A Retrospective Analysis to Guide Further Improvement in Dutch Hospitals

INTRODUCTION

Bariatric surgery aims for optimal patient outcomes, often evaluated through the percentage total weight loss (%TWL). Quality registries employ funnel plots for outcome comparisons between hospitals. However, funnel plots are traditionally used for dichotomous outcomes, requiring %TWL to be dichotomized, potentially limiting feedback quality. This study evaluates whether a funnel plot around the median %TWL has better discriminatory performance than binary funnel plots for achieving at least 20% and 25% TWL.

METHODS

All hospitals performing bariatric surgery were included from the Dutch Audit for Treatment of Obesity. A funnel plot around the median was constructed using 5-year %TWL data. Hospitals positioned above the 95% control limit were colored green and those below red. The same hospitals were plotted in the binary funnel plots for 20% and 25% TWL and colored according to their performance in the funnel plot around the median. We explored the hospital's procedural mix in relation to %TWL performance as possible explanatory factors.

RESULTS

The median-based funnel plot identified four underperforming and four outperforming hospitals, while only one underperforming and no outperforming hospitals were found with the binary funnel plot for 20% TWL. The 25% TWL binary funnel plot identified two underperforming and three outperforming hospitals. The proportion of sleeve gastrectomies performed per hospital may explain part of these results as it was negatively associated with median %TWL (β =  - 0.09, 95% confidence interval [- 0.13 to - 0.04]).

CONCLUSION

The funnel plot around the median discriminated better between hospitals with significantly worse and better performance than funnel plots for dichotomized %TWL outcomes.

Update on comparison of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass: a systematic review and meta-analysis of weight loss, comorbidities, and quality of life at 5 years

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) are the two most commonly performed bariatric surgeries for the treatment of obesity. This meta-analysis was performed with the aim of summarizing the available evidence on weight loss, remission of comorbidities, and quality of life in LRYGB and LSG, complementing the current literature.

METHODS

We searched PubMed, EMBASE and the Cochrane Library from January 2012 to June 2023 for randomized controlled trials and non-randomized interventional studies. We finally selected 18 eligible studies.

RESULTS

LRYGB resulted in greater weight loss compared with LSG at 5 years [WMD= -7.65 kg/m², 95% confidence interval (CI) -11.54 to -3.76, P = 0.0001], but there exists high heterogeneity with I²=84%. Resolution rate of type 2 diabetes mellitus (T2D) (OR = 0.60, 95%Cl 0.41-0.87, p = 0.007) and dyslipidemia (OR = 0.44, 95%Cl 0.23-0.84, p = 0.01) was higher in the LRYGB group than that in the LSG group at 5 years. There was no difference between LRYGB and LSG for remission of hypertension, and obstructive sleep apnea. No differences were observed in the QoL after LRYGB or LSG. Morbidity was lower in the LSG group (WMD = -0.07, 95% CI: -0.13, -0.02, P = 0.01) than in the LRYGB group. No statistically significant difference was found in mortality between the two procedures.

CONCLUSION

At 5 years after surgery, LRYGB resulted in greater weight loss and achieved better remission rate of T2D and dyslipidemia than LSG. However, LSG has a lower morbidity rate than that of LRYGB.

Two-Year Results of Sleeve Gastrectomy Combined with Posterior Fundoplication for Obesity Patients with Gastroesophageal Reflux Disease

INTRODUCTION

Currently, gastroesophageal reflux disease (GERD) is the main side effect after sleeve gastrectomy (SG), causing discomfort and potential long-term risks. Surgical techniques combining fundoplication with SG are being evaluated to limit postoperative GERD.

METHODS

This single-center retrospective study evaluated patients who underwent SG with posterior fundoplication in the context of GERD between 2018 and 2021, with postoperative follow-up up to 24 months. The results were compared to a control group (ratio 1 to 4) who had SG without fundoplication. Observed total weight loss (TWL) was compared to predicted TWL using the Sophia multinational study's machine learning-based calculator.

RESULTS

The series included 22 patients (mean body mass index 44.4 kg/m2) with GERD conditions: GERD symptoms (n = 15), hiatal hernia (n = 6), esophagitis (n = 7), and Barrett's esophagus (n = 5). Two patients required reoperation, including one for valve perforation. At 2 years, GERD was present in three patients (13.6%), including two who regularly took proton pump inhibitors. Compared to the control group (n=88), the frequency of GERD persisting at 2 years was significantly reduced in the SG with fundoplication group (p=0.05). The TWL at 12 and 24 months was 27.7% and 26.1%, respectively, with no significant difference compared to the weight predicted by the model, nor compared to the control group.

CONCLUSION

The combination of posterior fundoplication with SG can be proposed in patients with GERD who have a contraindication to Roux-en-Y gastric bypass. Specific morbidity may exist at the beginning of the experience.

Comparison between total weight loss and other metrics after bariatric surgery using a multilevel mixed-effects linear regression model

BACKGROUND

Several tools are used to assess postoperative weight loss after bariatric surgery, including the percentage of excess body weight loss (%EWL), percentage of total weight loss (%TWL), and percentage of excess body mass index (BMI) loss (%EBMIL). A repeated series of measurements should be considered to assess weight loss as accurately as possible. This study aimed to test weight loss metrics.

METHODS

Data were obtained from a prospective database of patients with obesity who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between 2016 and 2017 in a French tertiary referral bariatric center. A multilevel mixed-effects linear regression model with repeated measures was used to analyze repeated weight measurements over time.

RESULTS

A total of 435 patients underwent LRYGB (n = 266) or LSG (n = 169). At 2 years, the average %EWL, %EBMIL, and %TWL were 56.8%, 61.3%, and 26.6%, respectively. Patients who underwent LSG experienced lower weight loss (β: - 4233 in %TWL model, β: - 6437 in %EWL model, and β: - 6989 in %EBMIL model) than those who underwent LRYGB. In multivariate mixed analysis, preoperative BMI was not significantly associated with %TWL at 2 years (β, - 0.09 [- 0.22-0.03] p = 0.1). Preoperative BMI was negatively associated with both %EWL (β, - 1.61 [- 1.84-- 1.38] p < 0.0001) and %EBMIL (β, - 1.91 [- 2.16-- 1.66] p < 0.0001).

CONCLUSION

This is the first study to assess %TWL use for postoperative weight measurement, using a multilevel mixed-effects linear regression model %TWL is the measure of choice to assess weight loss following bariatric surgery.

Cost-Effectiveness of Sleeve Gastrectomy and Gastric Bypass as Revisional Surgery on Antidiabetic Reimbursement: A Nationwide Cohort Study

Objective

This study compared the effectiveness of 4 main revisional bariatric surgery (RBS) sequences after sleeve gastrectomy (SG) and adjustable gastric banding (AGB), on the reimbursement of antidiabetic treatments in France.

Background

Few large-scale prospective cohort studies have assessed the changes in antidiabetic treatments after RBS.

Method

This nationwide observational population-based cohort study analyzed data from the French National Health Insurance Database. All patients who underwent primary SG and AGB in France between January 2012 and December 2014 were included and followed up until December 31, 2020. The changes in categories and costs of reimbursed antidiabetic treatments across different RBS sequences were assessed (presented as follows: bariatric surgery (BS)-RBS).

Results

Among the 107,088 patients who underwent BS, 6396 underwent RBS, 2400 SG-GBP (SG converted to gastric bypass [GBP] during follow-up), 2277 AGB-SG, 1173 AGB-GBP, and 546 SG-SG. Pre-RBS insulin was used in 10 (2.9%), 4 (0.9%), 8 (2.4%), and 10 (2.6%) patients, respectively. Two years after RBS, the treatment discontinuation or decrease (the change of treatment to a lighter one category rates [eg, insulin to bi/tritherapy]) was 47%, 47%, 49%, and 34%, respectively. Four years after RBS, the median annual cost per patient compared with baseline was lower (P < 0.01) for all sequences, except SG-SG (P = 0.24). The most notable effect concerned AGB-GBP (median of more than 220 euros to 0).

Conclusions

This study demonstrated the positive impact of RBS over a 4-year follow-up period on antidiabetic treatments reimbursement, through the reduction or discontinuation of treatments and a significant decrease in costs per patient.

Analysis of quality of life in patients with clinically severe obesity and type 2 diabetes mellitus after laparoscopic sleeve gastrectomy - a 12-month prospective observational study

<b>Introduction:</b> Due to a short history of laparoscopic sleeve gastrectomy (LSG) as an independent bariatric procedure, we stilllack studies providing analysis of the quality of life (QoL) in patients with type 2 diabetes mellitus (DM2).<b>Aim:</b> We aimed to assess the influence of LSG on QoL in obese patients with DM2.<b>Material and Methods:</b> Prospective, observational study included patients with: morbid obesity, body mass index (BMI) ≥ 35 kg/m and ≤ 50 kg/m², DM2 shorter than 10 years, qualified for LSG. Bariatric Analysis and Reporting Outcome System (BAROS) that included the Moorehead-Ardelt Quality of Life Questionnaire II (MA-QoLQII) score, and the SF-36 Health Survey (SF-36) questionnaire were used for repetitive assessment of QoL before LSG and after one and 12 months following surgery. Selected clinical and biochemical parameters were also repeatedly measured.<b>Results:</b> Thirty-three patients were included in the study (23 females). Patients' mean age was 45 10 years. BAROS significantly increased before LSG, one month, and one year after surgery (0.63 1.12, 2.94 1.90, and 4.97 2.08, respectively). The MA-QoLQII score significantly rose with an increase of excess body mass index loss (EBMIL) (P = 0.002) and remission of DM2 (P = 0.049), while inversely correlated with Homeostatic Model Assessment for Insulin Resistance index (HOMA-IR) (P = 0.003). Degenerative joint disease (P = 0.025) and average time of low glucose concentration in continuous glucose monitoring (CGM) (P = 0.005) had an inverse correlation with SF-36 Physical Component Summaries (PCS), standardized for cardiovascular comorbidity, EBMIL and HOMA-IR (P = 0.839; P = 0.086; P = 0.571, respectively). EBMIL (P = 0.003), remission of DM2 (P < 0.001) had a positive correlation with Mental Component Summaries (MCS), while HOMA-IR (P < 0.001) and count of low glucose concentration events (P = 0.022) had an inverse correlation with MCS, while standardized for average glucose concentration in CGM after 12 months (P = 0.586).<b>Discussion:</b> Significant improvement in QoL was observed in patients with DM2 after LSG. Remission of DM2, higher EBMIL, lower HOMA-IR, fewer and shorter low glucose concentration events in CGM after 12 months were factors that increased selected QoL scores.

Obesity

Obesity is a common condition and a major cause of morbidity and mortality. Fortunately, weight loss treatment can reduce obesity-related complications. This review summarizes the evidence-based strategies physicians can employ to identify, prevent, and treat obesity, including best practices to diagnose and counsel patients, to assess and address the burden of weight-related disease including weight stigma, to address secondary causes of weight gain, and to help patients set individualized and realistic weight loss goals and an effective treatment plan. Effective treatments include lifestyle modification and adjunctive therapies such as antiobesity medications and metabolic and bariatric surgery.

Standardized Assessment of Metabolic Bariatric Surgery Outcomes: Secondary Analysis of 2 Randomized Clinical Trials

Importance

A standardized definition and reporting of metabolic bariatric surgery (MBS) outcomes is not available for actual clinical practice and science.

Objective

To assess the feasibility of using a clinically relevant and feasible MBS outcome score (Swiss-Finnish Bariatric Metabolic Outcome Score [SF-BARI Score]).

Design, Setting, and Participants

This assessment of a bariatric surgery outcome score is based on the secondary analysis of merged 5-year individual patient data (N = 457) of 2 large randomized clinical trials (Swiss SM-BOSS [Swiss Multicenter Bypass or Sleeve Study], conducted from January 2007 to November 2011, and Finnish SLEEVEPASS [Laparoscopic Gastric Bypass Vs Sleeve Gastrectomy to Treat Morbid Obesity], conducted from March 2008 until June 2010) that compared laparoscopic sleeve gastrectomy with laparoscopic Roux-en-Y gastric bypass in the treatment of severe obesity. This secondary analysis was performed from January 2022 to January 2023.

Main Outcomes and Measures

The main outcome was the feasibility of the SF-BARI Score and the SF-BARI Score QOL (quality of life) as tools to assess MBS outcomes. The score includes percentage of total weight loss (%TWL), 4 obesity-related comorbidities (type 2 diabetes, hypertension, dyslipidemia, and obstructive sleep apnea), complications, and QOL, if available.

Results

Among the 457 included patients, 323 (70.7%) were female and 134 (29.3%) were male, and the mean (SD) age was 45.6 (10.7) years. Outcomes for the SF-BARI Score were available for 435 patients (95.2%) at 1 year and 398 patients (87.1%) at 5 years and for SF-BARI Score QOL in 289 (63.2%) patients at 1 year and 318 patients (69.6%) at 5 years. The SF-BARI Score was correlated with both the SF-BARI Score QOL (r = 0.96; 95% CI, 0.95-0.96; P < .001) and %TWL (r = 0.86; 95% CI, 0.84-0.89; P < .001) and with the Bariatric Analysis and Reporting Outcome System (r = 0.59; 95% CI, 0.51-0.65; P < .001). Score outcomes were categorized as excellent, very good, good, fair, and suboptimal response. There was a statistically significant difference in scores at 1 vs 5 years (4.0; 95% CI, 1.4-6.6; P = .003), and the gastric bypass group had a higher score compared with the sleeve gastrectomy group (7.4; 95% CI, 3.4-11.5; P < .001).

Conclusions and Relevance

These findings indicate that this metabolic bariatric surgery outcome score is a simple, relevant, and feasible composite tool to define and measure MBS outcomes, enabling standardized reporting.

Trial Registration

ClinicalTrials.gov Identifiers: NCT00356213 (SM-BOSS) and NCT00793143 (SLEEVEPASS).

Characterization changes and research waste in randomized controlled trials of global bariatric surgery over the past 20 years: cross-sectional study

BACKGROUND

The results of several large randomized controlled trials (RCTs) have changed the clinical practice of bariatric surgery. However, the characteristics of global RCTs of bariatric surgery have not been reported internationally and whether there was research waste in these RCTs is unknown.

METHODS

Search ClinicalTrials.gov for bariatric surgery RCTs registered between January 2000 and December 2022 with the keywords 'Roux-en-Y gastric-bypass' and 'Sleeve Gastrectomy'. The above analysis was conducted in January 2023.

RESULTS

A total of 326 RCTs were included in this study. The number of RCTs registered for sleeve gastrectomy and gastric bypass surgery increased year by year globally. Europe has always accounted for the largest proportion, Asia has gradually increased, and North America has decreased. A total of 171 RCTs were included in the analysis of waste, of which 74 (43.8%) were published. Of the 74 published RCTs, 37 (37/74, 50.0%) were judged to be adequately reported and 36 (36/74, 48.6%) were judged to have avoidable design defects. In the end, 143 RCTs (143/171, 83.6%) had at least one research waste. Body weight change as the primary endpoint (OR: 0.266, 95% CI: 0.103-0.687, P =0.006) and enrolment greater than 100 (OR: 0.349, 95% CI: 0.146-0.832, P =0.018) were independent protective factors for research waste.

CONCLUSIONS

This study for the first time describes the characteristic changes of the mainstream RCT of bariatric surgery globally in the last 20 years and identifies a high research waste burden and predictive factor in this area, which provides reference evidence for carrying out bariatric surgery RCTs more rationally.

Banded Versus Non-banded Sleeve Gastrectomy: 5-Year Results of a 3-Year Randomized Controlled Trial

PURPOSE

Banded sleeve gastrectomy (BSG) has been shown to enable better weight loss than non-banded sleeve gastrectomy (SG) in retrospective analyses. These findings were supported by two randomized controlled trials (RCT). However, to date, mid-term prospective data is not available.

MATERIALS AND METHODS

We invited all 94 patients of an RCT comparing banded to non-banded sleeve gastrectomy at 3 years (DRKS00007729) for a 5-year follow-up visit. Eighty-two patients (BSG n = 42; SG n = 40) came for evaluation. Outcome measures were identical with the RCT to allow longitudinal comparison. Data analysis was descriptive and focused on biometric data, development of comorbidities, mid-term complications, quality of life, and type of body contouring surgery (BCS).

RESULTS

The per-protocol analysis revealed a treatment difference of 9% (CI - 1.5 to 19.6) excess weight loss (EWL). Total weight loss (TWL) was 27.4% (CI 23.5-31.3) after SG and 31.6% (CI 27.3-35.5) after BSG. Twenty percent of patients after SG and 11.9% following BSG had been converted to a gastric bypass. Type 2 diabetes went into remission in most patients (SG 66.7% vs. BSG 63.6%). Antihypertensive medication was stopped or reduced in 81.3% after SG and 80% after BSG. Reflux symptoms were similar in both groups (symptoms [Formula: see text] 1/ week: SG 28.2% vs. BSG 26.8%). Frequency of postprandial regurgitation was higher after BSG (SG 23% vs. BSG 59%). Forty percent of patients had undergone BCS at time of follow-up.

CONCLUSION

Five-year weight loss after BSG was 9% EWL and 4.2% TWL higher compared to SG. The main added morbidity following BSG was postprandial regurgitation.

Comparing Safety and Efficacy Outcomes of Gastric Bypass and Sleeve Gastrectomy in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

Sleeve Gastrectomy (SG) could be done by the removal of a big portion of the stomach, leading to reduced amounts of food taken as a result of the smaller stomach size. In contrast, Roux-en-Y Gastric Bypass (RYGB) can be done by creating a small stomach pouch and rerouting a part of the small intestine, employing combined mechanisms of restriction and malabsorption to limit food intake and modify nutrient absorption. Our aim is to identify the most effective and safest surgical intervention for individuals with both Type 2 Diabetes Mellitus (T2DM) and obesity, considering both short and long-term outcomes. We will assess participants undergoing either SG or RYGB to determine the optimal surgical approach. We made a thorough search of PubMed, Cochrane Library, Scopus, and Web of Science databases up to November 2023. Our focus was on randomized controlled trials (RCTs) comparing the safety and efficacy of RYGB and SG in T2DM regarding any extractable data. We excluded studies of other designs, such as cohorts, case reports, case series, reviews, in vitro studies, postmortem analyses, and conference abstracts. Utilizing Review Manager 5.4, we performed a meta-analysis, combining risk ratios (RR) with a 95% confidence interval (CI) conducted for binary outcomes, while mean with SD and 95% CI are pooled for the continuous ones. The total number of participants in our study is 4,148 patients. Our analysis indicates superior outcomes in the group undergoing RYGB surgery compared to the SG group (RR = 0.76, 95% (CI) (0.66 to 0.88), P = 0.0002). The pooled data exhibited homogeneity (P = 0.51, I2 = 0%) after employing the leave-one-out method. For the 1-3 year period, six studies involving 332 patients with T2DM yielded non-significant results (RR = 0.83, 95% CI (0.66 to 1.06), P = 0.14) with homogeneity (P = 0.24, I2 = 28%). Conversely, the 5-10 year period, with six studies comprising 728 DM patients, demonstrated significant results (RR = 0.69, 95% CI (0.56 to 0.85), P = 0.14) and homogeneity (P = 0.84, I2 = 0%). In terms of total body weight loss, our findings indicate significantly higher weight loss with RYGB (mean difference (MD) = -6.13, 95% CI (-8.65 to -3.6), P > 0.00001). However, pooled data exhibited considerable heterogeneity (P > 0.00001, I2 = 93%). Subgroup analyses for the 1-3 year period (five studies, 364 DM patients) and 5-10 year period (six studies, 985 DM patients) also revealed significant differences favoring RYGB, with heterogeneity observed in both periods (1-3 years: P > 0.00001, I2 = 95%; 5-10 years: P = 0.001, I2 = 75%). RYGB demonstrated significant long-term improvement in diabetes remission and superior total body weight loss compared to SG. While no notable differences were observed in other efficacy outcomes, safety parameters require further investigation. no significant distinctions were found in any of the safety outcomes: hypertension (HTN), high-density lipoprotein (HDL), hyperlipidemia, fasting blood glucose, vomiting, low-density lipoprotein (LDL), and total cholesterol. Further research is essential to comprehensively assess safety outcomes for both surgical approaches.

Clinical Perspectives, Eligibility, and Success Criteria for Bariatric/Metabolic Surgery

Obesity is a worldwide chronic, complex, and progressive disease that poses a challenge for physicians to pursue optimal therapeutic decision making. This chapter focuses on the definition of obesity, based on excessive fat accumulation, and thus underscores the importance of body composition, and the clinical tools used to diagnose it in the context of excess weight, metabolic alteration, and obesity-associated comorbidity development. Additionally, it addresses the indications for surgery that are currently applicable and the description of the different types of patients who could benefit the most from the surgical management of excessive body fat and its associated metabolic derangements and quality of life improvement. Furthermore, it also highlights plausible underlying mechanisms of action for the beneficial effects following bariatric/metabolic surgery.

Long term outcomes of metabolic/bariatric surgery in adults

The prevalence of obesity continues to rise around the world, driving up the need for effective and durable treatments. The field of metabolic/bariatric surgery has grown rapidly in the past 25 years, with observational studies and randomized controlled trials investigating a broad range of long term outcomes. Metabolic/bariatric surgery results in durable and significant weight loss and improvements in comorbid conditions, including type 2 diabetes. Observational studies show that metabolic/bariatric surgery is associated with a lower incidence of cardiovascular events, cancer, and death. Weight regain is a risk in a fraction of patients, and an association exists between metabolic/bariatric surgery and an increased risk of developing substance and alcohol use disorders, suicidal ideation/attempts, and accidental death. Patients need lifelong follow-up to help to reduce the risk of these complications and other nutritional deficiencies. Different surgical procedures have important differences in risks and benefits, and a clear need exists for more long term research about less invasive and emerging procedures. Recent guidelines for the treatment of obesity and metabolic conditions have been updated to reflect this growth in knowledge, with an expansion of eligibility criteria, particularly people with type 2 diabetes and a body mass index between 30.0 and 34.9.

The Efficacy and Safety of Laparoscopic Single-Anastomosis Duodeno-ileostomy with Sleeve Gastrectomy (SADI-S) in Mid- and Long-Term Follow-Up: a Systematic Review

This systematic review of 10 studies aimed to investigate the mid- and long-term results of duodeno-ileostomy with sleeve gastrectomy (SADI-S) according to the PRISMA guideline. Related articles, which reported outcomes of laparoscopic SADI-S with follow-up ≥ 3 years, were selected and analyzed. The percentage of excess weight loss (EWL) was 70.9-88.7%, and 80.4% at 6, and 10 years, respectively. The more common late complications were malabsorption (6.3%) and gastroesophageal reflux disease (GERD) (3.6%). The remission rates of hypertension, diabetes, GERD, obstructive sleep apnea, and dyslipidemia were 62.9%, 81.3%, 53.2%, 60.9%, and 69.7%, respectively. In conclusion, SADI-S is a safe and effective surgical technique with durable weight loss and a high rate of comorbidity resolution in mid and long term.

Outcomes and Adverse Events After Bariatric Surgery: An Updated Systematic Review and Meta-analysis, 2013-2023

Purpose

Bariatric surgery is an increasingly common treatment for obesity and related comorbidities. This meta-analysis aimed to compare the outcomes of bariatric surgery and medical treatment (MT).

Materials and Methods

A systematic search of articles published from January 2013 to May 2023 identified 20 studies. The treatment arms included Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), gastric banding, and MT. The assessed outcomes included body weight loss, diabetes mellitus (DM) remission, changes in dyslipidemia and hypertension markers, and adverse events.

Results

Bariatric surgery resulted in significantly better short- and long-term weight loss than MT, with RYGB and SG showing the most substantial reduction. The DM remission rates were notably higher in the surgery group, with marked improvements in hemoglobin A1c and fasting glucose levels. Improvements in dyslipidemia were inconclusive, whereas hypertension showed modest improvements, particularly with RYGB. Complication rates varied, with RYGB reporting higher rates of early complications, and SG reporting increased rates of late complications. The perioperative reoperation rates were low across all surgical treatments. Specific adverse events, such as intestinal obstruction and anastomosis site problems, were more common in the RYGB group, whereas reflux symptoms were more common in the SG group.

Conclusion

Bariatric surgery, especially RYGB and SG, provided superior weight loss and DM remission outcomes compared to MT, although with varied complication profiles. These findings underscore the need for careful patient selection and postoperative management in bariatric surgery. Future studies should aim to refine these processes to improve patient outcomes.

Prescription drug usage as measure of comorbidity resolution after bariatric surgery: a population-based cohort study

BACKGROUND

Obesity is a chronic and progressive disease associated with significant morbidity, mortality, and health-care costs. Bariatric surgery is the most effective intervention for sustainable weight loss and resolution of obesity-related comorbidities. Studies examining comorbidity resolution largely rely on individual self-reported outcomes and electronic record reviews. We present a population-based study looking at prescription medication utilization before and after bariatric surgery as a measure of comorbidity resolution.

METHODS

All patients enrolled in the Center for Metabolic and Bariatric Surgery who underwent either gastric bypass or sleeve gastrectomy between 2013 and 2019 in Manitoba were included. Demographic information, follow up, and outpatient prescription dispensation data were obtained from the Manitoba Population Research Data Repository housed at the Manitoba Centre for Health Policy for 5 years pre- and post-surgery.

RESULTS

A total of 1184 patients were included. Antidepressants and selective serotonin reuptake inhibitors were the most commonly prescribed classes, and along with thyroid medication, utilization remained stable after bariatric surgery. Proton pump inhibitors and opioid class drugs increased at 1 year after surgery then returned to baseline. Glucose and lipid-lowering medications, including statins, biguanides, sulfonylureas, and insulin, were decreased. Antihypertensives, including ACE inhibitors, calcium channel blockers, angiotensin receptors blockers, thiazides, and beta blockers, similarly decreased.

CONCLUSION

This is the first Canadian study employing a provincial-wide prescription database to measure long-term comorbidity resolution after bariatric surgery. The use of administrative data eliminates potential biases and inaccuracies in follow up and self-reported outcomes. Consistent with the literature, prescriptions for the treatment of metabolic syndrome all decreased and were sustained at long-term follow up. Further studies are needed to delineate the effects of altered pharmaceutical utilization on patient quality of life and health-care expenditures.

Medium-Term Weight Loss and Remission of Comorbidities Following Endoscopic Sleeve Gastroplasty: a Systematic Review and Meta-analysis

This systematic review and meta-analysis aimed to determine the short- and medium-term weight loss outcomes and comorbidity resolution following endoscopic sleeve gastroplasty. Our search identified 35 relevant studies containing data from 7525 patients. Overall, pooled short-term (12 months) total weight loss (TWL) was 16.2% (95% CI 13.1-19.4%) in 23 studies (n = 5659). Pooled medium-term TWL was 15.4% (95% CI 13.7-17.2%) in 10 studies (n = 4040). Diabetes resolution was 55.4% (95% CI 46-64%), hypertension resolution was 62.8% (95% CI 43-82%), dyslipidaemia resolution was 56.3% (95% CI 49-63%), and obstructive sleep apnoea resolution was 51.7% (95% CI 16.2-87.3%) in four studies (n = 480). This pooled analysis demonstrates that ESG can induce durable weight loss and resolution of obesity-associated comorbidities in patients with moderate obesity.

Milestones in the journey towards addressing obesity; Past trials and triumphs, recent breakthroughs, and an exciting future in the era of emerging effective medical therapies and integration of effective medical therapies with metabolic surgery

The 21st century is characterized by an increasing incidence and prevalence of obesity and the burden of its associated comorbidities, especially cardiometabolic diseases, which are reaching pandemic proportions. In the late '90s, the "black box" of adipose tissue and energy homeostasis was opened with the discovery of leptin, transforming the adipose tissue from an "inert fat-storage organ" to the largest human endocrine organ and creating the basis on which more intensified research efforts to elucidate the pathogenesis of obesity and develop novel treatments were based upon. Even though leptin was eventually not proven to be the "standalone magic bullet" for the treatment of common/polygenic obesity, it has been successful in the treatment of monogenic obesity syndromes. Additionally, it shifted the paradigm of treating obesity from a condition due to "lack of willpower" to a disease due to distinct underlying biological mechanisms for which specific pharmacotherapies would be needed in addition to lifestyle modification. Subsequently, the melanocortin pathway proved to be an equally valuable pathway for the pharmacotherapy of obesity. Melanocortin receptor agonists have recently been approved for treating certain types of syndromic obesity. Other molecules- such as incretins, implicated in energy and glucose homeostasis- are secreted by the gastrointestinal tract. Glucagon-like peptide 1 (GLP-1) is the most prominent one, with GLP-1 analogs approved for common/polygenic obesity. Unimolecular combinations with other incretins, e.g., GLP-1 with gastric inhibitory polypeptide and/or glucagon, are expected to be approved soon as more effective pharmacotherapies for obesity and its comorbidities. Unimolecular combinations with other compounds and small molecules activating the receptors of these molecules are currently under investigation as promising future pharmacotherapies. Moreover, metabolic and bariatric surgery has also demonstrated impressive results, especially in the case of morbid obesity. Consequently, this broadening therapeutic armamentarium calls for a well-thought-after and well-coordinated multidisciplinary approach, for instance, through cardiometabolic expertise centers, that would ideally address effectively and cost-effectively obesity and its comorbidities, providing tangible benefits to large segments of the population.

Baseline Psychosocial, Environmental, Health, and Behavioral Correlates of 1- and 3-Year Weight Loss After Bariatric Surgery

PURPOSE

Weight loss surgery is an effective, long-term treatment for severe obesity but individual response to surgery varies widely. The purpose of this study was to test a comprehensive theoretical model of factors that may be correlated with the greatest surgical weight loss at 1-3 years following surgery. Such a model would help determine what predictive factors to measure when patients are preparing for surgery that may ensure the best weight outcomes.

MATERIALS AND METHODS

The Bariatric Experience Long Term (BELONG) study collected self-reported and medical record-based baseline information as correlates of 1- and 3-year % total weight loss (TWL) in n = 1341 patients. Multiple linear regression was used to determine the associations between 120 baseline variables and %TWL.

RESULTS

Participants were 43.4 ± 11.3 years old, Hispanic or Black (52%; n = 699), women (86%; n = 1149), and partnered (72%; n = 965) and had annual incomes of ≥ $51,000 (60%; n = 803). A total of 1006 (75%) had 3-year follow-up weight. Regression models accounted for 10.1% of the variance in %TWL at 1-year and 13.6% at 3 years. Only bariatric operation accounted for a clinically meaningful difference (~ 5%) in %TWL at 1-year. At 3 years after surgery, only bariatric operation, Black race, and BMI ≥ 50 kg/m2 were associated with clinically meaningful differences in %TWL.

CONCLUSIONS

Our findings combined with many others support a move away from extensive screening and selection of patients at the time of surgery to a focus on improving access to this treatment.

Long-term impact of gastropexy on use of acid-reducing medication, second operations for gastroesophageal reflux and subjective reflux symptoms after sleeve gastrectomy

We investigated whether adding gastropexy to sleeve gastrectomy (SG) reduced gastroesophageal reflux disease (GERD) in patients operated for severe obesity, assessed mainly by use of anti-reflux medication (ARM) and second operations due to GERD worsening. In a prospective non-randomized study, patients undergoing SG at two Norwegian hospitals were included from 2011 to 2015 and followed for 7 years. GERD was defined by regular use of ARM, and epigastric pain and heartburn were measured by the Rome II questionnaire. Gastropexy was done by suturing the gastrocolic ligament to the staple line. Patients undergoing SG only, mainly before gastropexia was introduced in 2013, were compared to those with additional gastropexy from 2013 onwards. Of 376 included patients (75% females, mean age 42.6 years and BMI 42.9 kg/m2 ), 350 (93%) and 232 (62%) were available for evaluation after 1 and 7 years, respectively. Baseline characteristics in the no-gastropexy (n = 235) and gastropexy groups (n = 141) were similar. In patients without ARM use before surgery, the use increased and in those that used ARM at baseline, the proportion decreased, with no difference in the no-gastropexy and gastropexy groups. With a combined endpoint of ARM use and/or second operation for GERD, there was no difference during follow-up between the two groups. With time, adding gastropexy did not reduce symptoms of GERD significantly. In this population, adding gastropexy to SG did not reduce use of ARM and/or second operation for uncontrolled GERD, epigastric pain or heartburn during the first 7 postoperative years.