Laparoscopic Sleeve Gastrectomy Versus Laparoscopic Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis of Weight Loss, Comorbidities, and Biochemical Outcomes From Randomized Controlled Trials

Effect of Gastric Bypass vs Sleeve Gastrectomy on Remission of Type 2 Diabetes Mellitus Among Patients with Severe Obesity: A Meta-Analysis

BACKGROUND

Obesity and type 2 diabetes mellitus (T2DM) are global health crises, with bariatric surgery emerging as a key intervention. However, the comparative efficacy of Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (SG) in achieving diabetes remission remains debated.

METHODS

This PRISMA-compliant meta-analysis included three randomized controlled trials (RCTs, n = 613 patients) comparing RYGB and SG in adults with severe obesity (BMI ≥30 kg/m²) and T2DM.

PRIMARY OUTCOME

diabetes remission (HbA1c 6.0%). Risk of bias was assessed via Cochrane RoB-2 tool; statistical analysis used fixed-effect models (I²=0%).

RESULTS

RYGB demonstrated superior diabetes remission rates vs. SG (OR 2.77, 95% CI 1.83-4.20, p0.001), with no heterogeneity. Subgroup analyses confirmed consistency across studies. Mean follow-up was ≤5 years; baseline demographics were comparable (mean age 46.2 years, 53.4% male).

CONCLUSION

RYGB significantly outperforms SG in achieving T2DM remission, likely due to its combined restrictivemalabsorptive mechanisms and metabolic hormonal effects. These findings support RYGB as the preferred surgical option for obese patients with T2DM, though long-term studies are needed to assess durability.

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.

Does living in a food desert impact weight loss after bariatric surgery?

BACKGROUND

Lower access to fresh foods and lower income level are associated with greater obesity rates.

OBJECTIVES

We aim to study if weight loss 1 year after bariatric surgery is associated with living in areas defined as food deserts, that is, low access to foods and lower income.

SETTING

Virginia Commonwealth University Hospital System, Richmond, VA; Academic Center.

METHODS

Review of consecutive patients who underwent primary bariatric surgery in a single institution. Patients were studied in groups based the USDA Economic Research Service classification: low access (>1 mile grocery urban setting or >10 miles rural setting), low income (poverty rate ≥20%, or family income <80% of state), food desert (low income and low access), and food secure (neither low income nor low access).

RESULTS

A total of 396 patients had surgery, 89% female, 51% Black. Among those patients, 133 (34%) had LRYGB and 263 (66%) LSG. Twenty-nine percent, 26%, 22%, and 23% were defined as low access, low income, food desert, or food secure, respectively. Factors independently associated with inferior excess BMI loss at 1 year were LSG, Black race, being single, and obstructive sleep apnea.

CONCLUSIONS

Living in a food desert was not associated with inferior weight loss after bariatric surgery. It suggests that patients can overcome these barriers to attain appropriate weight loss 1 year after surgery.

Reduced Risk of Cardiovascular Diseases After Bariatric Surgery Based on the New Predicting Risk of Cardiovascular Disease EVENTs Equations

BACKGROUND

We applied the novel Predicting Risk of Cardiovascular Disease EVENTs equations to evaluate cardiovascular-kidney-metabolic (CKM) health and estimated cardiovascular disease (CVD) risk after bariatric surgery.

METHODS

Among 7804 patients (aged 20-79 years) undergoing bariatric surgery at Vanderbilt University Medical Center during 1999 to 2022, CVD risk factors from before surgery to 2 years after surgery were extracted from electronic health records. The 10- and 30-year risks of total CVD, atherosclerotic CVD, coronary heart disease, stroke, and heart failure (HF) were estimated for patients without CVD history at each time point (n=124-2910), using the social deprivation index-enhanced Predicting Risk of Cardiovascular Disease EVENTs equations. Paired t tests or McNemar tests were used to compare pre- with postsurgery CKM health and CVD risk. Two-sample t tests were used to compare CVD risk reduction between patient subgroups.

RESULTS

CKM health was significantly improved after surgery with lower systolic blood pressure, non-high-density lipoprotein cholesterol, and diabetes prevalence, and higher high-density lipoprotein and estimated glomerular filtration rate. The 10-year risks of total CVD and its subtypes decreased by 21.7% to 56.3% at 1 year after surgery and by 14.6% to 46.5% at 2 years after surgery, with the largest reduction observed for HF. Younger age, White race, >30% weight loss, and diabetes history were associated with greater HF risk reductions. Similar results were found for the 30-year CVD risk estimates.

CONCLUSIONS

Bariatric surgery significantly improves CKM health and reduces estimated CVD risk, particularly HF, by 47% to 56% within 1 to 2 years after surgery. HF risk reduction may vary by patient's demographics, weight loss, and disease history, which warrants further research.

Which Procedure Yields Better Outcomes: Sleeve Gastrectomy, Roux-en-Y Gastric Bypass or Mini Gastric Bypass? Seven Years Outcome Analysis

Background and Objectives: Bariatric surgery is the most effective method for achieving sustainable weight loss, improving quality of life, and resolving obesity-related comorbidities over the long term. However, data from long-term studies remain scarce and contradictory. Materials and Methods: This study is a retrospective analysis of prospectively collected data over a 7-year follow-up period involving 211 patients diagnosed with morbid obesity who underwent sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), or mini gastric bypass (MGB) at Samsun University Training and Research Hospital, Department of General Surgery, between 1 January 2014 and 1 January 2018. Changes in weight, remission of associated comorbidities, postoperative complications, re-admission rates, and revision requirements were compared among the patients. Results: Of the 211 patients, 20.4% were male, and 79.6% were female. During the study period, 61.1% of patients underwent SG, 29.4% underwent MGB, and 9.5% underwent RYGB. There was no statistically significant difference among the three surgical techniques in terms of weight change parameters, comorbidity remission, postoperative complications, and readmission rates. However, revision rates were significantly higher among patients who underwent SG (p < 0.05). Conclusions: SG, MGB, and RYGB techniques are comparable and reliable methods in terms of long-term weight loss, surgical outcomes, and complications. After a 7-year follow-up period, all three techniques were found to be similar in terms of HT, T2DM, and GERD remission; however, SG was observed to have a higher revision requirement compared to the other surgical techniques.

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.

Long-Term Cancer Outcomes Following Bariatric Surgery: A Comparative Analysis of Surgical Procedures

Background/Objectives: Metabolic and bariatric surgery (MBS) is known to reduce cancer risk. However, the association between specific bariatric procedures and cancer incidence is not well-studied. This study examined the association between four different MBS procedures and cancer incidence. Methods: Bariatric surgery registry data were linked with statewide cancer registry data from 1979 to 2018. The study included 27,092 adult subjects (aged ≥ 18 years old at surgery) who underwent MBS (BMI ≥ 30 kg/m2 at surgery) from 1979 to 2017. Cancer records were linked to MBS patient records, resulting in 1547 cancer cases. Cox proportional hazards regression was used to examine the association between MBS procedure types and cancer incidence. Results: Of all patients, 75% underwent Roux-en-Y gastric bypass (RYGB), 9% adjustable gastric banding (AGB), 10% sleeve gastrectomy (SG), and 6% duodenal switch (BPD-DS). The overall cancer incidence during the follow-up period was 6.4% for RYGB, 4.6% for AGB, 1.6% for SG, and 5.9% for BPD-DS. The mean follow-up duration from surgery to cancer incidence or censoring was 167 months (standard deviation = 121 months). Compared to RYGB, patients who underwent AGB (Hazard Ratio [HR] = 1.26, p = 0.03) and BPD-DS (HR = 1.91, p < 0.01) had a significantly higher hazard of developing cancer, while SG (HR = 1.17, p = 0.33) showed no significant difference. Conclusions: These findings suggest that AGB and BPD-DS may be associated with higher cancer risks compared to RYGB. Additional large population studies are needed to better understand the long-term cancer risks and mechanisms associated with different MBS types.

Comparing the effects of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy on weight loss and comorbidity resolution: A systematic review and meta-analysis

Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y gastric bypass (LRYGB) are the most common bariatric modalities. There is ongoing debate on the two modalities' long-term effects on weight loss and comorbidity resolution.PubMed, EMbase, and Cochrane Central Register of Controlled Trials for randomized controlled trials (RCTs) comparing LRYGB versus LSG were searched by March 2024. Quality assessment was conducted by Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines, following the procedures outlined in the Cochrane Collaborations tool (RoB 2.0 Assessment Form).In total, 13 datasets were included from 10 RCTs that involved 1106 individuals. Both the percentage of excess weight loss (%EWL) and percentage of total weight loss (%TWL) were greater in LRYGB compared to LSG at 3 years (MD: 13.04, 95%CI: 6.95-19.13; P < 0.0001) and 1 year (MD: 5.97, 95%CI: 5.23-6.71; P < 0.00001), respectively. When comparing LRYGB to LSG, the remission percentage for type 2 diabetes mellitus was greater at one (RR: 0.15, 95%CI: 0.03-0.27; P = 0.02) and 3 years (RR: 0.17, 95 % CI: 0.07-0.28; P = 0.001). Moreover, early (RR: 1.72, 95%CI: 1.19-2.46; P = 0.003) and late (RR: 1.40, 95%CI: 1.15-1.71; P = 0.001) adverse events were more common with LRYGB. Regarding remission from obstructive sleep apnea syndrome, dyslipidemia, and hypertension, no significant changes were seen. LRYGB and LSG are both viable bariatric surgery options for resolving long-term comorbidities. While the rate of adverse events is greater with LRYGB than LSG, the former may provide more long-term sustainable weight reduction.Additional research of a higher quality is necessary.

Long-term (11 Years) Results of Laparoscopic Gastric Bypass: Changes in Weight, Blood Levels of Sugar and Lipids, and Late Adverse Effects : Laparoscopic Gastric Bypass Results

PURPOSE

Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) remains the most effective procedure to treat severe obesity with proven short- and intermediate-term benefits. The main goal is to describe the effects on weight and biochemical laboratory tests after long-term follow-up (11 years).

MATERIALS AND METHODS

A prospective cohort of adults with obesity treated with LRYGB between 2004 and 2010 in one center were studied. Patients with prior bariatric or upper digestive tract surgery, hiatal hernia >4 cm, alcoholism, or decompensated conditions were excluded. The study enrolled 123 patients, with a mean follow-up of 133±29 months and a 14% loss of participants.

RESULTS

The percentage of Total Weight Loss (%TWL) at one, five, and eleven years was 30.3±8.4%, 29.1±6.9%, and 23.4±7%, respectively. Of the patients, 61.3% (65/106) maintained a %TWL≥20 after eleven years. Recurrent Weight Gain (RWG) at five and eleven years was 2.6±11.4% and 11 ±11.5%, respectively. At the end of the follow-up, 31.1% (33/106) of patients had RWG≥15%. Hypercholesterolemia and hypertriglyceridemia improved in 85.7% (54/63) and 90.2% (7/61) of the cohort, respectively. Remission of diabetes occurred in 80% of this subgroup. Gallstones developed in 28% of patients, and bowel obstruction due to internal hernia occurred in 9.4%. Anemia due to iron deficiency appeared in 25 patients.

CONCLUSION

After surgery, there is a significant and durable loss of weight, with a tendency for late Recurrent Weight Gain. Furthermore, the improvement in biochemical parameters is sustained over time, but surgery's adverse effects may appear later.

Assessment of guidelines for bariatric and metabolic surgery: a systematic review and evaluation using appraisal of guidelines for research and evaluation II (AGREE II)

BACKGROUND

In recent years, multiple guidelines on bariatric and metabolic surgery were published, however, their quality remains unknown, leaving providers with uncertainty when using them to make perioperative decisions. This study aims to evaluate the quality of existing guidelines for perioperative bariatric surgery care.

METHODS

A comprehensive search of MEDLINE and EMBASE were conducted from January 2010 to October 2022 for bariatric clinical practice guidelines. Guideline evaluation was carried out using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework.

RESULTS

The initial search yielded 1483 citations, of which, 26 were included in final analysis. The overall median domain scores for guidelines were: (1) scope and purpose: 87.5% (IQR: 57-94%), (2) stakeholder involvement: 49% (IQR: 40-64%), (3) rigor of development: 42.5% (IQR: 22-68%), (4) clarity of presentation: 85% (IQR: 81-90%), (5) applicability: 6% (IQR: 3-16%), (6) editorial independence: 50% (IQR: 48-67%), (7) overall impressions: 48% (IQR: 33-67%). Only six guidelines achieved an overall score >70%.

CONCLUSIONS

Bariatric surgery guidelines effectively outlined their aim and presented recommendations. However, many did not adequately seek patient input, state search criteria, use evidence rating tools, and consider resource implications. Future guidelines should reference the AGREE II framework in study design.

Reduced Risk of Cardiovascular Diseases after Bariatric Surgery Based on the New PREVENT Equations

Background

We applied the novel Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) equations to evaluate cardiovascular-kidney-metabolic (CKM) health and estimated CVD risk, including heart failure (HF), after bariatric surgery.

Methods

Among 7804 patients (20-79 years) undergoing bariatric surgery at Vanderbilt University Medical Center during 1999-2022, CVD risk factors at pre-surgery, 1-year, and 2-year post-surgery were extracted from electronic health records. The 10- and 30-year risks of total CVD, atherosclerotic CVD (ASCVD), coronary heart disease (CHD), stroke, and HF were estimated for patients without a history of CVD or its subtypes at each time point, using the social deprivation index-enhanced PREVENT equations. Paired t-tests or McNemar tests were used to compare pre- with post-surgery CKM health and CVD risk. Two-sample t-tests were used to compare CVD risk reduction between patient subgroups defined by age, sex, race, operation type, weight loss, and history of diabetes, hypertension, and dyslipidemia.

Results

CKM health was significantly improved after surgery with lower systolic blood pressure, non-high-density-lipoprotein cholesterol (non-HDL), and diabetes prevalence, but higher HDL and estimated glomerular filtration rate (eGFR). The 10-year total CVD risk decreased from 6.51% at pre-surgery to 4.81% and 5.08% at 1- and 2-year post-surgery (relative reduction: 25.9% and 16.8%), respectively. Significant risk reductions were seen for all CVD subtypes (i.e., ASCVD, CHD, stroke, and HF), with the largest reduction for HF (relative reduction: 55.7% and 44.8% at 1- and 2-year post-surgery, respectively). Younger age, White race, >30% weight loss, diabetes history, and no dyslipidemia history were associated with greater HF risk reductions. Similar results were found for the 30-year risk estimates.

Conclusions

Bariatric surgery significantly improves CKM health and reduces estimated CVD risk, particularly HF, by 45-56% within 1-2 years post-surgery. HF risk reduction may vary by patient's demographics, weight loss, and disease history, which warrants further research.

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.

Long-term outcomes of laparoscopic sleeve gastrectomy in Denmark from 2010 to 2016: a nationwide cohort study

BACKGROUND

Bariatric surgery is the most effective treatment of morbid obesity and obesity-related conditions. Laparoscopic sleeve gastrectomy (LSG) has become increasingly popular in Denmark and worldwide.

OBJECTIVE

To evaluate long-term outcomes including postoperative complications after LSG.

SETTING

University Hospitals, Denmark.

METHODS

This was a nationwide multicenter cohort study including all patients who underwent LSG during 2010 to 2016 in Denmark. Data were collected from the Danish Obesity Surgery Registry and medical records. Representatives from all public bariatric centers in Denmark registered information on demography, indication, preoperative tests, operative information, weight loss, status of co-morbidities, and early and late complications.

RESULTS

In total, 541 patients were included in the study. Median follow-up was 6 years, and 536 patients (99%) were available at the end of follow-up. The patients achieved a persistent weight loss. Quality of life significantly improved after both 12 and 24 months. Overall, 3% of the patients had a major complication ≤30 days after the procedure and 3% underwent reoperation. One in 5 patients (22%) had an early minor complication. In the long term, 3% of the patients had a major complication and 24% of the patients had ≥1 minor complication. The most common surgery-related healthcare contacts addressed gastroesophageal reflux, weight recurrence, and stenosis symptoms.

CONCLUSIONS

Patients after LSG achieved sufficient weight loss and improved quality of life. The procedure was safe with low risk of early and late major complications. However, there was a high frequency of early and late minor complications in 22% and 24% of the patients, respectively.

Long-term weight loss of distal gastric bypass is moderately superior compared to proximal gastric bypass in patients with a BMI of 37-44 Kg/m2

PURPOSE

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the standard procedures in metabolic surgery. Different limb lengths have been proposed in the past to maximize weight loss (WL) and reduce metabolic complications. Distal gastric bypass surgery with a very short common channel (CC) (up to 100 cm) has been often criticized due to frequent side effects such as malnutrition, bone weakening and short-bowel syndrome. We introduced a modified version of a distal LRYGB with a 50-70 cm long biliopancreatic limb (BPL) and an intermediate short CC (120-150 cm). Our primary goal was to compare the long-term WL between distal and proximal LRYGB in two cohorts of patients. Secondary outcomes were weight regain (WR), insufficient weight loss (IWL), postoperative complications and metabolic changes 5 years after surgery.

METHODS

In this retrospective study we collected data from 160 patients operated between 2014 and 2015, with a BMI of 37-44 Kg/m2. 101 patients underwent a distal and 59 patients a proximal LRYGB in two bariatric centers. WL was calculated as percent of excess of BMI loss (%EBMIL), loss of body mass index (Delta-BMI), percent of excess weight loss (%EWL) and percent of total weight loss (%TWL). Data were collected 3, 6, 9, 12, 24, 48 and 60 months after surgery.

RESULTS

The distal LRYGB resulted in significantly better 5-year-WL compared to the proximal bypass in terms of %EBMIL (median at 5 years: 83% vs. 65%, p = 0.001), %TWL (median at 5 years: 32% vs. 26%, p = 0.017) and %EWL (median at 5 years: 65% vs. 51%, p = 0.029), with equal major complications and metabolic alterations. In addition, WR was significantly lower in patients with distal bypass (18% vs. 35%, p = 0.032).

CONCLUSIONS

Distal LYRGB with a 120-150 long CC results in better WL and WL-maintenance compared to proximal LRYGB without major side effects after five years.

Randomized controlled trials comparing gastric bypass, gastric band, and sleeve gastrectomy: A systematic review examining validity and applicability to wider clinical practice

Consideration of how applicable the results of surgical trials are to clinical practice is important to inform decision-making. Randomized controlled trials comparing at least two surgical interventions (of gastric bypass, gastric band, and sleeve gastrectomy) for severe and complex obesity were examined using the PRagmatic Explanatory Continuum Indicator Summary-2 tool, to consider how applicable the trial results are to clinical practice, and the Risk of Bias 2 tool, to examine validity. MEDLINE, Embase, and CENTRAL databases were searched for studies published between November 2013 and June 2021, and 15 were identified. Using the PRagmatic Explanatory Continuum Indicator Summary-2 tool, three were classified as pragmatic, with good applicability to clinical practice. Ten had more explanatory domains but did include some pragmatic characteristics, and two were predominantly explanatory. This was due to some trial design features that would not be considered applicable to the wider clinical setting, including being single-centered, having prescribed intervention delivery methods, and intensive follow-up regimens. Only two trials had low risk of bias, of which one was considered pragmatic. Three had high risk of bias. Overall, few trials in bariatric surgery are pragmatic with low risk of bias. Well-designed pragmatic trials are needed to inform practice and reduce research waste.

Safety and Efficacy of LSG Versus LRYGB on Patients with Obesity: a Systematic Review and Meta-analysis from RCTs

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the two most frequently performed techniques in treating obesity and its related comorbidities. We aimed to compare the clinical efficacy and safety of LSG with LRYGB in terms of short- and mid-term outcomes of weight loss, obesity-related comorbidities, and post-operative complications via a meta-analysis of RCTs.

METHODS

Clinical comparative RCTs on LSG and LRYGB were searched through PubMed, MEDLINE, and Web of Science databases from inception to August 2022. Pooled outcomes from the selected studies were discussed by the random-effect meta-analysis method. Quality assessment and risk of bias for selected RCTs were implemented, and all the statistical analyses were performed.

RESULTS

Twenty studies, including 1270 patients, were enrolled. Meta-analysis results indicated the great superior efficacy of LRYGB to LSG in BMI loss at 6 (MD -1.35 kg/m2, 95% CI: -2.07 to -0.62, p = 0.0003), 12 months (MD -1.09 kg/m2, 95% CI: -1.86 to -0.33, p = 0.005), and 36 months (MD -1.47 kg/m2, 95% CI: -2.77 to -0.16, p = 0.03) as well as %EWL gaining at 36 months. Significantly higher remission rates of T2DM and dyslipidemia were achieved by LRYGB at 12 months. Besides, better improvements for T2DM-related and lipid biochemical parameters were found favoring LRYGB. However, LSG resulted in a lower post-operative complication rate and shorter operating time.

CONCLUSIONS

Present meta-analysis results suggested that LRYGB was superior to LSG concerning short- and mid-term weight loss, short-term T2DM remission efficacy, and related biochemical parameters. LSG is favored for obviously fewer complications and shorter operating time.

Magnetic anchoring device assisted-laparoscopic sleeve gastrectomy versus conventional laparoscopic sleeve gastrectomy: A retrospective cohort study

Background

Bariatric surgeries, including the sleeve gastrectomy, have been recognized as the most effectively treatment strategy for severe obesity. Magnetic devices have been successfully used in bariatric surgeries. Here, we intended to evaluate the safety and efficiency of magnetic anchoring device assisted-laparoscopic sleeve gastrectomy (MLSG), and to make a comparison of the short-term results between conventional laparoscopic sleeve gastrectomy (CLSG) and MLSG.

Methods

The retrospective cohort study was carried out by analyzing and summarizing the data from a database of routinely collected data. The cohort included the patients who underwent either CLSG (n = 120) or MLSG (n = 115) at a single center between January 2018 and December 2020 with a two-year follow-up. The effects of these two surgeries on the weight loss, resolution of comorbidities and quality of life (QOL) were analyzed.

Results

The two groups were similar in gender, age, body mass index, abdominal girth, as well as the type and proportion of comorbidities. And the cases in MLSG group had a markedly shorter time of operation (MLSG, 72.59 min vs. CLSG, 76.67 min; P = 0.003). Length of stay in hospital was significantly shorter in the MLSG group than that in the CLSG group (MLSG, 5.59 days vs. CLSG, 5.96 days; P = 0.016). Neither fatal event nor conversion to open surgery happened among all cases. There were no differences in terms of the postoperative complications between the two groups. Magnetic device-related mild hepatic lacerations occurred and were handled by hemostatic treatments in 3 cases. The QOL of patients in MLSG was better at 6-month after surgery, but there was no significant difference between the two groups at 1-year or 2-year after surgery.

Conclusion

Both MLSG and CLSG prove safe and effective, and the patients underwent MLSG have a shorter length of stay in hospital, and a better QOL during 6 months after surgery.

Cardiometabolic Improvements After Metabolic Surgery and Related Presurgery Factors

Context

Metabolic surgery remains the most effective and durable treatment for severe obesity and related metabolic diseases.

Objective

We examined cardiometabolic improvements after metabolic surgery and associated presurgery demographic and clinical factors in a large multiracial cohort.

Methods

Included were 7804 patients (20-79 years) undergoing first-time metabolic surgery at Vanderbilt University Medical Center from 1999 to 2022. Pre- and 1-year postsurgery cardiometabolic profiles were extracted from medical records, including body mass index (BMI), blood pressure, blood lipids, glucose, and hemoglobin A1c. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk was estimated per American College of Cardiology/American Heart Association equations. Pre- to postsurgery cardiometabolic profiles were compared by paired t-test, and associated factors were identified by multivariable linear and logistic regression.

Results

Among 7804 patients, most were women and White, while 1618 were men and 1271 were Black; median age and BMI were 45 years [interquartile range (IQR): 37-53] and 46.4 kg/m2 (IQR: 42.1-52.4). At 1-year postsurgery, patients showed significant decreases in systolic blood pressure (10.5 [95% confidence interval: 10.1, 10.9] mmHg), total cholesterol (13.5 [10.3, 16.7] mg/dL), glucose (13.6 [12.9, 14.4] mg/dL), hemoglobin A1c (1.13% [1.06, 1.20]), and 10-year ASCVD risk (absolute reduction: 1.58% [1.22, 1.94]; relative reduction: 34.4% [29.4, 39.3]); all P < .0001. Older, male, or Black patients showed less reduction in 10-year ASCVD risk and lower odds of diabetes/hypertension/dyslipidemia remission than younger, female, or White patients. Patients with a history of diabetes, hypertension, dyslipidemia, or cardiovascular disease showed less cardiometabolic improvements than those without. Results were similar with or without further adjusting for weight loss and largely sustained at 2-year postsurgery.

Conclusion

Metabolic surgery results in significant cardiometabolic improvements, particularly among younger, female, or White patients and those without comorbidities.

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.

Obesity and Skeletal Fragility

Skeletal fracture has recently emerged as a complication of obesity. Given the normal or better than normal bone mineral density (BMD), the skeletal fragility of these patients appears to be a problem of bone quality rather than quantity. Type 2 diabetes mellitus (T2DM), the incidence of which increases with increasing body mass index, is also associated with an increased risk for fractures despite a normal or high BMD. With the additional bone pathology from diabetes itself, patients with both obesity and T2DM could have a worse skeletal profile. Clinically, however, there are no available methods for identifying those who are at higher risk for fractures or preventing fractures in this subgroup of patients. Weight loss, which is the cornerstone in the management of obesity (with or without T2DM), is also associated with an increased risk of bone loss. This review of the literature will focus on the skeletal manifestations associated with obesity, its interrelationship with the bone defects associated with T2DM, and the available approach to the bone health of patients suffering from obesity.

Comparative evaluation of early diabetic outcomes in southeast asian patients with type 2 diabetes mellitus undergoing Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (LSG)

Obesity and type 2 diabetes mellitus (T2DM) is an alarming problem globally and a growing epidemic. Metabolic surgery has been shown to be successful in treating both obesity and T2DM, usually after other treatments have failed. This study aims to compare Roux-Y gastric bypass and sleeve gastrectomy in determining early diabetic outcomes in obese Malaysian patients with T2DM following surgery. A total of 172 obese patients with T2DM who were assigned to either laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were analysed up to a year post-procedure. The patients' T2DM severity were stratified using the Individualized Metabolic Surgery (IMS) score into mild, moderate and severe. Remission rates of diabetes were compared between surgical techniques and within diabetic severity categories. T2DM remission for patients who underwent either surgical technique for mild, moderate or severe disease was 92.9%, 56.2% and 14.7% respectively. Both surgical techniques improved T2DM control for patients in the study. Comparing baseline with results 1 year postoperatively, median HbA1c reduced from 7.40% (IQR 2.60) to 5.80% (IQR 0.80) (p < 0.001), mean total antidiabetic medications use reduced from 1.48 (SD 0.99) to 0.60 (SD 0.86) [p < 0.001], insulin usage reduced from 27.9 to 10.5% (p < 0.001), and T2DM control improved from 27.9 to 82% (p < 0.001). The patients had a median excess BMI loss of 69.4% (IQR 34%) and 53.2% (IQR 36.0%) for RYGB and SG respectively (p = 0.016). At one year following surgery, there is no difference between LRYGB and LSG in terms of diabetic remission. LSG is not inferior to LRYGB in terms of early diabetic outcomes. Milder T2DM shows a better response. LSG is a simpler procedure with a lower risk profile and should be considered as an early treatment option for obese patients with T2DM.

Effect of Bariatric Surgery on Gut Microbiota: A Scientometric Analysis

Objective

To perform a bibliometric analysis of the scientific production related to intestinal microbiota and bariatric surgery between January 2016 and December 2022.

Materials and Methods

A bibliographic search was performed in the Scopus database to identify published papers. Free and controlled terms (MeSH and Emtree) were used. The information collected was analyzed with SciVal.

Results

A total of 518 published papers were included in the analysis. Carel Le Roux was the author with the highest scientific production; however, Edi Prifti had the highest impact. French National Institute of Health and Medical Research (Institut national de la santé et de la recherche médicale) was the institution with the highest number of published articles. Six of the 10 institutions with the highest production were in France, yet the United States had the highest volume of scientific production in this research topic. Most papers were published in first quartile journals. Articles with international collaboration had the highest impact. There is a sustained increase in the number of publications since 2019.

Conclusions

The study found that the vast majority of research on gut microbiota changes following bariatric surgery are conducted in the United States and European countries. In addition, the sustained increase in production coupled with the articles being published in high-quality journals and having good citation impact are indictors of the current interest in this research field.

Additional preparation program for bariatric surgery: Two-year results of a large cohort study

BACKGROUND

Multidisciplinary screening of bariatric surgery candidates is recommended, and some centers provide an additional preparation program (APP) to optimize patients preoperatively.

OBJECTIVE

To compare patients with APP to standard care 2 years after primary bariatric surgery regarding postoperative weight loss and resolution of obesity-related comorbidities.

METHODS

A retrospective cohort study was conducted for patients undergoing primary Roux-en-Y gastric bypass and sleeve gastrectomy between September 2017 and March 2019. The first 12 months patients received an APP, after September 2018, the APP was no longer part of the weight loss trajectory. A multivariable linear regression model was built.

RESULTS

Of the 384 patients receiving an APP advice, 50 were lost to follow up. In total, 192 (57%) received the APP and 142 (43%) received standard care. Percentage total weight loss after 2 years was significantly different, 28.8% for the APP group versus 32% for the standard group (p = 0.001). Postoperative weight loss after 2 years was increased in patients who had a gastric bypass, a higher baseline body mass index, and female gender in multivariable analysis. An APP was predictive for decreased postoperative weight. Diabetes mellitus was in remission significantly more often in the preparation group (84.1% of the cases) compared with the standard group (61.9%, p = 0.028).

CONCLUSION

A weight loss trajectory is at least as effective without additional preparation in terms of 2 years postoperative %TWL for primary gastric bypass and sleeve procedures. For comorbidities, diabetes mellitus was in remission more often in the APP group.

Abdominal Pain After Roux-en-Y Gastric Bypass: A Review

Importance

Roux-en-Y gastric bypass (RYGB) remains one of the most commonly performed operations for morbid obesity and is associated with significant long-term weight loss and comorbidity remission. However, health care utilization rates following RYGB are high and abdominal pain is reported as the most common presenting symptom for those seeking care.

Observations

Given the limitations of physical examination in patients with obesity, correct diagnosis of abdominal pain following RYGB depends on a careful history and appropriate use of radiologic, laboratory and endoscopic studies, as well as a clear understanding of post-RYGB anatomy. The most common etiologies of abdominal pain after RYGB are internal hernia, marginal ulcer, biliary disease (eg, cholelithiasis and choledocholithiasis), and jejunojejunal anastomotic issues. Early identification of the etiology of the pain is essential, as some causes, such as internal hernia or perforated gastrojejunal ulcer, may require urgent or emergent intervention to avoid significant morbidity. While laboratory findings and imaging may prove useful, they remain imperfect, and clinical judgment should always be used to determine if surgical exploration is warranted.

Conclusions and Relevance

The etiologies of abdominal pain after RYGB range from the relatively benign to potentially life-threatening. This Review highlights the importance of understanding key anatomical and technical aspects of RYGB to guide appropriate workup, diagnosis, and treatment.

Laparoscopic sleeve gastrectomy followed by laparoscopic adrenalectomy for patients with obesity and primary aldosteronism: Report of two patients

INTRODUCTION AND IMPORTANCE

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension. Surgical treatment of unilateral PA usually resolves excessive aldosterone secretion. Obesity is an independent factor for postoperative persistent hypertension for patients with unilateral PA. Laparoscopic sleeve gastrectomy has become popular due to its efficacy in resolving obesity. A specific strategy might to be needed for patients with unilateral PA and obesity.

CASE PRESENTATION

Two males with PA and obesity (Body Mass Index: BMIs of 35.9 and 39.0, respectively) were referred for evaluation. Both patients had hypertension caused by PA and obesity. We performed laparoscopic sleeve gastrectomy (LSG) prior to adrenalectomy to avoid persistent postoperative hypertension and perioperative obesity related comorbidities. LSG could lead to decreasing of BMIs to 27.7 and 32.1. Comorbidities associated with obesity were also resolved in both patients. Laparoscopic adrenalectomy was then safely performed in these two patients with PA.

CLINICAL DISCUSSIONS

Patients with PA developing resistant hypertension were estimated to be 20 % of those who underwent adrenalectomy. Decreased BMI can be an independent preoperative determinant for successful outcome after adrenalectomy regarding hypertension. We need to review with special care the preoperative BMI and the nature of hypertension before performing surgery on patients with unilateral PA.

CONCLUSIONS

A successful strategy was used to treat two obese patients with unilateral PA who underwent laparoscopic adrenalectomy after LSG to minimize complications associated with obesity-related comorbidities.

A Population-Based Cohort Study on Efficacy and Safety of Bariatric Surgery in Young Adults Versus Adults

PURPOSE

Bariatric surgery is the most effective treatment for severe obesity in adults and has shown promising results in young adults. Lack of insight regarding efficacy and safety outcomes might result in delayed bariatric surgery utilization in young adults. Therefore, this study aimed to assess the efficacy and safety of bariatric surgery in young adults compared to adults.

METHODS

This is a nationwide population-based cohort study utilizing data from the Dutch Audit Treatment of Obesity (DATO). Young adults (aged 18-25 years) and adults (aged 35-55 years) who underwent primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were included. Primary outcome was percentage total weight loss (%TWL) until five years postoperatively.

RESULTS

A total of 2,822 (10.3%) young adults and 24,497 (89.7%) adults were included. The follow-up rates of the young adults were lower up to five years postoperatively (46.2% versus 56.7% three years postoperatively; p < 0.001). Young adults who underwent RYGB showed superior %TWL compared to adults until four years postoperatively (33.0 ± 9.4 versus 31.2 ± 8.7 three years after surgery; p < 0.001). Young adults who underwent SG showed superior %TWL until five years postoperatively (29.9 ± 10.9 versus 26.2 ± 9.7 three years after surgery; p < 0.001). Postoperative complications ≤ 30 days were more prevalent among adults, 5.3% versus 3.5% (p < 0.001). No differences were found in the long term complications. Young adults revealed more improvement of hypertension (93.6% versus 78.9%), dyslipidemia (84.7% versus 69.2%) and musculoskeletal pain (84.6% versus 72.3%).

CONCLUSION

Bariatric surgery appears to be at least as safe and effective in young adults as in adults. Based on these findings the reluctance towards bariatric surgery in the younger age group seems unfounded.

Bariatric surgery in patients with obesity and end-stage renal disease

BACKGROUND

Bariatric surgery has been suggested as a treatment for obesity and end-stage renal disease (ESRD). Although the number of bariatric surgeries in patients with ESRD is increasing, its safety and effectiveness in these patients are still controversial and the surgical method of choice in these patients is under debate.

OBJECTIVES

To compare the outcomes of bariatric surgery between patients with and without ESRD and to assess different methods of bariatric surgery in patients with ESRD.

SETTING

Meta-analysis.

METHODS

A comprehensive search was conducted in Web of Science and Medline (via Pubmed) until May 2022. Tow meta-analyses were performed: A) to compare bariatric surgery outcomes among patients with and without ESRD, and B) to compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) in patients with ESRD. Using a random-effect model, odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were computed for surgical and weight loss outcomes.

RESULTS

Of 5895 articles, 6 studies were included in meta-analysis A and 8 studies in meta-analysis B. The risk of bias was moderate to serious among studies. Major postoperative complications (OR = 2.82; 95% CI = 1.66-4.77; P = .0001), reoperation (OR = 2.66; 95% CI = 1.99-3.56; P < .00001), readmission (OR = 2.37; 95% CI = 1.55-3.64; P < .0001), and in-hospital/90-d mortality (OR = 4.03; 95% CI = 1.80-9.03; P = .0007) were higher in patients with ESRD. Patients with ESRD also had a longer hospital stay (MD = 1.23; 95% CI = .32-2.14; P = .008). Bleeding, leakage, and total weight loss were comparable among groups. SG showed a 10% lower rate of overall complications and significantly shorter hospital stay than RYGB did. The quality of evidence was very low for the outcomes CONCLUSIONS: Bariatric surgery in patients with ESRD seems to have higher rates of major complications and perioperative mortality than in patients without ESRD, but a comparable rate of overall complications. SG has fewer postoperative complications and could be the method of choice in these patients. These findings should be interpreted cautiously in light of the moderate to high risk of bias in most included studies.

Rate of Cardiovascular Events and Safety Outcomes Seven Years Following Gastric Bypass Versus Sleeve Gastrectomy

Objective

The study aimed to assess major adverse cardiovascular events (MACEs), complications requiring revision surgery, and bariatric conversion surgery 7 years after gastric bypass (GB) and sleeve gastrectomy (SG) using real-world data.

Background

GB and SG both result in weight loss and improved cardiometabolic health. Whether the long-term rate of MACE differs between the 2 bariatric procedures is unclear.

Methods

In this population-based retrospective cohort study, we used inhospital National Health Registry data from January 2012 to December 2018. Patients undergoing GB were 1:1 propensity score-matched with patients who had SG. The primary outcome was the incidence of MACE, defined as acute myocardial infarction, ischemic stroke, cardiac arrest, or hospitalization for heart failure. Secondary outcomes encompassed individual MACE components, postoperative complications, and the need for bariatric conversion surgery.

Results

Among 5240 propensity score-matched pairs, the incidence rate per 1000 person-years of MACE was 2.8 among patients undergoing GB and 3.2 among those undergoing SG (hazard ratio [HR], 0.92; 95% confidence interval [CI], 0.62-1.37). Single components of MACE were not different between both groups. Patients after GB had a higher risk of long-term postoperative complications requiring a revision surgery compared with those after SG (HR, 3.53 [95% CI, 2.78-4.49]). Bariatric conversion surgery was less frequently performed among patients undergoing GB compared with patients undergoing SG (HR, 0.09 [95% CI, 0.06-0.13]).

Conclusions

In this study, the performance of GB versus SG was associated with a similar risk of MACE. While postoperative complications were more frequent among patients undergoing GB, patients following SG had a higher probability of bariatric conversion surgery.

Very Low-Calorie Ketogenic Diet (VLCKD) as Pre-Operative First-Line Dietary Therapy in Patients with Obesity Who Are Candidates for Bariatric Surgery

Bariatric surgery is currently the most effective method for achieving long-term weight loss and reducing the risk of comorbidities and mortality in individuals with severe obesity. The pre-operative diet is an important factor in determining patients' suitability for surgery, as well as their post-operative outcomes and success in achieving weight loss. Therefore, the nutritional management of bariatric patients requires specialized expertise. Very low-calorie diets and intragastric balloon placement have already been studied and shown to be effective in promoting pre-operative weight loss. In addition, the very low-calorie ketogenic diet has a well-established role in the treatment of obesity and type 2 diabetes mellitus, but its potential role as a pre-operative dietary treatment prior to bariatric surgery has received less attention. Thus, this article will provide a brief overview of the current evidence on the very low-calorie ketogenic diet as a pre-operative dietary treatment in patients with obesity who are candidates for bariatric surgery.

Is prior bariatric surgery associated with poor COVID-19 outcomes? A systematic review and meta-analysis of case-control studies

Background

Obesity is an independent risk factor for severe coronavirus disease 2019 (COVID-19), but there is little evidence on whether prior bariatric surgery benefits the outcomes of patients with COVID-19. We aimed to summarize this relationship by conducting a systematic review and meta-analysis of current case-control studies.

Methods

We searched several electronic databases for case-control studies conducted between January 2020 and March 2022. We compared the rates of mortality, mechanical ventilation, intensive care unit (ICU) admission, dialysis, hospitalization, and length of hospital stay between COVID-19 patients with and without a history of bariatric surgery.

Results

We included six studies with 137 903 patients; 5270 (3.8%) had prior bariatric surgery, while 132 633 (96.2%) did not. COVID-19 patients with a history of bariatric surgery had significantly lower mortality (odds ratio (OR) = 0.42; 95% confidence interval (CI) = 0.23-0.74), ICU admission (OR = 0.48; 95% CI = 0.36-0.65), and mechanical ventilation rates than those with a history of non-bariatric surgery (OR = 0.51; 95% CI = 0.35-0.75).

Conclusions

Prior bariatric surgery was associated with a reduced risk of mortality and reduced severity of COVID-19 in patients with obesity compared to those with no prior bariatric surgery. Further large-sample prospective studies are needed to support these results.

Registration

CRD42022323745.

Fragility of statistically significant outcomes in randomized trials comparing bariatric surgeries

BACKGROUND

Randomized controlled trials (RCTs) are regarded as high-level evidence, but the strength of their P values can be difficult to ascertain. The Fragility Index (FI) is a novel metric that evaluates the frailty of trial findings. It is defined as the minimum number of patients required to change from a non-event to event for the findings to lose statistical significance. This study aims to characterize the robustness of bariatric surgery RCTs by examining their FIs.

METHODS

A search was conducted in MEDLINE, EMBASE, and CENTRAL from January 2000 to February 2022 for RCTs comparing two bariatric surgeries with statistically significant dichotomous outcomes. Bivariate correlation was conducted to identify associations between FI and trial characteristics.

RESULTS

A total of 35 RCTs were included with a median sample size of 80 patients (Interquartile range [IQR] 58-109). The median FI was 2 (IQR 0-5), indicating that altering the status of two patients in one treatment arm would overturn the statistical significance of results. Subgroup analyses of RCTs evaluating diabetes-related outcomes produced a FI of 4 (IQR 2-6.5), while RCTs comparing Roux-en-Y gastric bypass and sleeve gastrectomy had an FI of 2 (IQR 0.5-5). Increasing FI was found to be correlated with decreasing P value, increasing sample size, increasing number of events, and increasing journal impact factor.

CONCLUSION

Bariatric surgery RCTs are fragile, with only a few patients required to change from non-events to events to reverse the statistical significance of most trials. Future research should examine the use of FI in trial design.

Contemporary medical, device, and surgical therapies for obesity in adults

The goal of obesity management is to improve health. Sustained weight loss of more than 10% overall bodyweight improves many of the complications associated with obesity (eg, prevention and control of type 2 diabetes, hypertension, fatty liver disease, and obstructive sleep apnoea), as well as quality of life. Maintenance of weight loss is the major challenge of obesity management. Like all chronic diseases, managing obesity requires a long-term, multimodal approach, taking into account each individual's treatment goals, and the benefit and risk of different therapies. In conjunction with lifestyle interventions, anti-obesity medications and bariatric surgery improve the maintenance of weight loss and associated health gains. Most available anti-obesity medications act on central appetite pathways to reduce hunger and food reward. In the past 5 years, therapeutic advances have seen the development of targeted treatments for monogenic obesities and a new generation of anti-obesity medications. These highly effective anti-obesity medications are associated with weight losses of more than 10% of overall bodyweight in more than two-thirds of clinical trial participants. Long-term data on safety, efficacy, and cardiovascular outcomes are awaited. Long-term studies have shown that bariatric surgical procedures typically lead to a durable weight loss of 25% and rapid, sustained improvements in complications of obesity, although they have not yet been compared with new-generation highly effective anti-obesity medications. Further work is required to determine optimal patient-specific treatment strategies, including combinations of lifestyle interventions, anti-obesity medications, endoscopic and bariatric surgical procedures, and to ensure equitable access to effective treatments.

Determinant factors of bone health after long-term of Roux-en-Y gastric bypass surgery: A cross-sectional study

OBJECTIVES

The aim of this study was to evaluate bone health and the potential influencing factors of bone metabolism disorders in adults ≥5 y after Roux-en-Y gastric bypass (RYGB) surgery.

METHODS

In this cross-sectional study, patients who were ≥5 y post-RYGB were invited. Bone health considered as bone mineral content (BMC) and bone mineral density (BMD) in this study was assessed by dual x-ray absorptiometry. We also assessed 25-hydroxy-vitamin D concentrations, individual ultraviolet B radiation levels, serum ionized calcium, alkaline phosphatase, parathyroid, anthropometric, and body composition.

RESULTS

The study evaluated 104 adults (90% women; 49.6 ± 9.1 y old; postoperative period 8.7 ± 2.2 y). Lumbar and femoral BMC and BMD were positively correlated to body mass index (BMI), appendicular lean mass (ALM), and negatively to %excess of weight loss (EWL). Femoral BMD was negatively correlated to age, and both femoral BMD and BMC were positively correlated to weekly exposed body part score. Sex, age, BMI, ALM, and weekly exposed body part score explained 35% and 54% of the total variance of femoral BMD and BMC, respectively.

CONCLUSIONS

The present findings suggested that older age, lower BMI, higher %EWL, lower ALM, and lower weekly body part exposure score are important determinants in lowering BMD and BMC parameters in long-term post-bariatric surgery individuals, rather than serum 25-hydroxy-vitamin D and parathyroid.

Obesity and Cardiovascular Risk: Systematic Intervention Is the Key for Prevention

Obesity is a serious public health issue and associated with an increased risk of cardiovascular disease events and mortality. The risk of cardiovascular complications is directly related to excess body fat mass and ectopic fat deposition, but also other obesity-related complications such as pre-type 2 diabetes, obstructive sleep apnoea, and non-alcoholic fatty liver diseases. Body mass index and waist circumference are used to classify a patient as overweight or obese and to stratify cardiovascular risk. Physical activity and diet, despite being key points in preventing adverse events and reducing cardiovascular risk, are not always successful strategies. Pharmacological treatments for weight reduction are promising strategies, but are restricted by possible safety issues and cost. Nonetheless, these treatments are associated with improvements in cardiovascular risk factors, and studies are ongoing to better evaluate cardiovascular outcomes. Bariatric surgery is effective in reducing the incidence of death and cardiovascular events such as myocardial infarction and stroke. Cardiac rehabilitation programs in obese patients improve cardiovascular disease risk factors, quality of life, and exercise capacity. The aim of this review was to critically analyze the current role and future aspects of lifestyle changes, medical and surgical treatments, and cardiac rehabilitation in obese patients, to reduce cardiovascular disease risk and mortality, and to highlight the need for a multidisciplinary approach to improving cardiovascular outcomes.

Sleeve Gastrectomy Improves Hepatic Glucose Metabolism by Downregulating FBXO2 and Activating the PI3K-AKT Pathway

Type 2 diabetes mellitus (T2DM), a chronic metabolic disease, is a public health concern that seriously endangers human health. Sleeve gastrectomy (SG) can relieve T2DM by improving glucose homeostasis and enhancing insulin sensitivity. However, its specific underlying mechanism remains elusive. SG and sham surgery were performed on mice fed a high-fat diet (HFD) for 16 weeks. Lipid metabolism was evaluated via histology and serum lipid analysis. Glucose metabolism was evaluated using the oral glucose tolerance test (OGTT) and insulin tolerance test (ITT). Compared with the sham group, the SG group displayed a reduction in liver lipid accumulation and glucose intolerance, and western blot analysis revealed that the AMPK and PI3K-AKT pathways were activated. Furthermore, transcription and translation levels of FBXO2 were reduced after SG. After liver-specific overexpression of FBXO2, the improvement in glucose metabolism observed following SG was blunted; however, the remission of fatty liver was not influenced by the over expression of FBXO2. Our study explores the mechanism of SG in relieving T2DM, indicating that FBXO2 is a noninvasive therapeutic target that warrants further investigation.

Reliability of Non-invasive Liver Fibrosis Assessment Tools Versus Biopsy in Pre- and Post-bariatric Surgery Patients with Non-alcoholic Fatty Liver Disease

PURPOSE

Liver biopsy (LBx) remains the gold standard to assess fibrosis in non-alcoholic fatty liver disease (NAFLD). Biochemical markers are also useful, but their reliability is not clear in patients with morbid obesity. We assessed the performance of six non-invasive fibrosis assessment tools before and after bariatric surgery (BSx) using LBx.

MATERIALS AND METHODS

This is a cross-sectional and prospective cohort study. LBx was performed at the time of BSx and 12-month post-operatively and assessed using the Brunt system. Clinical and biochemical measurements were collected at the same time points and six non-invasive fibrosis assessment tools were calculated.

RESULTS

One hundred seventy patients had BSx; 79.4% female; age was 46.6 ± 9.8 years, and BMI was 48.6 ± 7.5 kg/m². From liver histology, 88% had F0-F2 and 11.2% F3-F4. At BSx, aspartate aminotransferase to platelet ratio index (APRI) and FIB-4 had better accuracy (0.86 and 0.88) with specificity of 96.6% and 94.0% and negative predictive values (NPV) of 88.9% and 93.7%. However, sensitivity (6.7% and 40.0%) and positive predictive values (PPV) (20.0% and 46.2%) were low. Twelve months post-surgery (n = 54), 88.9% of patients had F0-F2 and 11.1% had F3-F4. Fibrosis-4 index (FIB-4) and NAFLD fibrosis score (NFS) had the best accuracy (0.79 and 0.77) with specificity of 83.7% and 86.9% and NPV of 92.3% and 86.9%. However, sensitivity (25% and 0%) and PPV (12.5% and 0%) were low.

CONCLUSION

Overall, FIB-4, APRI, and NFS showed similar performances with higher accuracy, specificity, and NPV. Sensitivity and PPV were low. These tests are more useful at excluding advanced fibrosis.

Low-Grade Hepatic Steatosis Is Associated with Long-term Remission of Type 2 Diabetes Independent of Type of Bariatric-Metabolic Surgery

BACKGROUND

Bariatric-metabolic surgery (BS) decreases the grade of steatosis, hepatic inflammation, and fibrosis in patients with severe obesity and non-alcoholic fatty liver disease (NAFLD). Mechanisms include substantial weight loss, but also simultaneous effects on glucose homeostasis. Therefore, we aimed to investigate the association between NAFLD and remission of type 2 diabetes (T2D) up to 8 years following different types of BS.

METHODS

In a retrospective cohort study including 107 patients with obesity and T2D at baseline, the association between biopsy-proven NAFLD defined as steatosis in > 5% of hepatocytes at the time of surgery and T2D remission up to 8 years following different surgical procedures was investigated. Univariate regression analysis was used to examine the association between NAFLD and remission of T2D.

RESULTS

Long-term remission of T2D was present in 56% of patients (n = 60). The presence of low-grade liver steatosis (grade 1) was associated with remission of T2D. Patients with a liver steatosis score ≥ 2 showed higher HbA1c levels at baseline. There were no significant differences in preoperative presence of lobular inflammation, hepatocyte ballooning, or fibrosis between patients who achieved T2D remission compared with those with no remission. Type of surgery did not affect remission of T2D.

CONCLUSION

Our results suggest that the presence of low-grade liver steatosis is associated with remission of T2D following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Therefore, BS should be considered at an early NAFLD stage in patients with T2D.

Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy effects on obesity comorbidities: A systematic review and meta-analysis

Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly used bariatric procedures. There is an increasing awareness about a comorbidity-based indication for bariatric surgery regardless of weight (metabolic surgery). The best operation to mitigate obesity-associated comorbidities is a matter of controversy. This review is aimed at comparing LRYGB and LSG for the treatment of diabetes, hypertension, dyslipidemias, obstructive sleep apnea (OSA), and gastroesophageal reflux (GERD). We searched PubMed, MEDLINE, SCOPUS, Web of Science, and Cochrane library for articles comparing these two commonly used bariatric approaches. We identified 2,457 studies, 1,468 of which stood after the removal of duplications; from them, 81 full texts were screened and only 16 studies were included in the final meta-analysis. LRYGB was equal weight to LSG for diabetes (P-value = 0.10, odd ratio, 1.24, 95% CI, 0.96-1.61, I 2 for heterogeneity = 30%, P-value for heterogeneity, 0.14), and OSA (P-value = 0.38, odd ratio, 0.79, 95% CI, 0.47-1.33, I 2 for heterogeneity = 0.0%, P-value for heterogeneity, 0.98). However, LRYGB was superior to LSG regarding hypertension (P-value = 0.009, odd ratio, 1.55, 95% CI, 1.20-2.0, I 2 for heterogeneity = 0.0%, P-value for heterogeneity, 0.59), dyslipidemia (odd ratio, 2.18, 95% CI, 1.15-4.16, P-value for overall effect, 0.02), and GERD (P-value = 0.003, odd ratio, 3.16, 95% CI, 1.48-6.76). LRYGB was superior to LSG for gastroesophageal reflux, hypertension, and dyslipidemia remission. While the two procedures were equal regarding diabetes and obstructive sleep, further reviews comparing LSG, and one anastomosis gastric bypass are recommended.

Combined non-alcoholic fatty liver disease and type 2 diabetes in severely obese patients-medium term effects of sleeve gastrectomy versus Roux-en-Y-gastric bypass on disease markers

Background

We aimed to evaluate the medium-term efficacy of sleeve gastrectomy (SG) vs. Roux-en-Y gastric bypass (RYGB) on remission of non-alcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes mellitus (T2DM).

Methods

We identified severely obese patients [body mass index (BMI) >35 kg/m2] with NAFLD (as defined by the Longitudinal Assessment of Bariatric Surgery Study) and T2DM (as defined by the American Association of Clinical Endocrinologists and the American College of Endocrinology) who underwent SG or RYGB in a single university surgical centre. The cohorts were match-paired and data were analysed after at least 3 years of follow up. The key outcomes measured were: (I) the improvement of liver function tests and NAFLD markers; (II) glycemic control and insulin resistance.

Results

Ninety-six patients were investigated; 44 (45.8%) were women. The mean pre-operative BMI was 45.2 kg/m2 in the SG and 42.0 kg/m2 in the RYGB group. SG and RYGB both significantly reduced serum liver enzyme concentrations. NAFLD markers resolved 2 years after SG in all patients. In contrast, only 78% and 80% of patients achieved remission of NAFLD 2 and 3 years after RYBG respectively. Both procedures resulted in comparable rates of remission of T2DM.

Conclusions

Bariatric surgery with SG may be preferable to RYGB for obese patients with NAFLD and T2DM based on the rates of remission of markers of these co-morbidities. However, our results need to be confirmed in prospective trials. Understanding the metabolic effects of specific bariatric surgical procedures may facilitate the development of a personalised approach to weight-loss surgery.

Validation of the Individual Metabolic Surgery Score for Bariatric Procedure Selection in the Merged Data of Two Randomized Clinical Trials (SLEEVEPASS and SM-BOSS)

BACKGROUND

LSG and LRYGB are globally the most common bariatric procedures. IMS score categorizes T2D severity (mild, moderate, and severe) based on 4 independent preoperative predictors of long-term remission as follows: T2D duration, number of diabetes medications, insulin use, and glycemic control. IMS score has not been validated in a randomized patient cohort.

OBJECTIVES

To assess the feasibility of individualized metabolic surgery (IMS) score in facilitating procedure selection between laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) for patients with severe obesity and type 2 diabetes (T2D).

SETTING

Merged individual patient-level 5-year data of 2 large randomized clinical trials (SLEEVEPASS and SM-BOSS [Swiss Multicenter Bypass or Sleeve Study]).

METHODS

IMS score was calculated for study patients and its performance was analyzed.

RESULTS

One hundred thirty-nine out of 155 patients with T2D had available preoperative data to calculate IMS score as follows: mild stage (n = 41/139), moderate stage (n = 77/139), severe stage (n = 21/139). At 5 years, 135 (87.1%, 67 LSG/68 LRYGB) were available for follow-up and 121 patients had both pre- and postoperative data. Diabetes remission rates according to preoperative IMS score were as follows: mild stage 87.5% (n = 14/16) after LSG and 85.7% (n = 18/21) after LRYGB (P = .999), moderate stage 42.9% (n = 15/35) and 45.2% (n = 14/31) (P = .999), and severe stage 18.2% (n = 2/11) and 0% (n = 0/7) (P = .497), respectively. The T2D remission rate varied significantly between the stages as follows: mild versus moderate odds ratio (OR) 8.3 (95% CI, 2.8-24.0; P < .001), mild versus severe OR 52.2 (95% CI 9.0-302.3; P < .001), and moderate versus severe OR 6.3 (95% CI, 1.3-29.8; P = .020).

CONCLUSIONS

In our study, remission rates of T2D were not statistically different after LSG and LRYGB among all patients and among patients with mild, moderate, and severe diabetes stratified by the IMS score. However, the study may be underpowered to detect differences due to small number of patients in each subgroup. IMS score seemed to be useful in predicting long-term T2D remission after bariatric surgery.

Distal gastric bypass revision for weight recurrence or nonresponse to primary procedure: initial experience and outcomes in an academic practice

BACKGROUND

Considerable weight recurrence (WR) after Roux-en-Y gastric bypass (RYGB) may occur in nearly 20% of patients. While several nonoperative, endoscopic, and surgical interventions exist for this population, the optimal approach is unknown. This study reports our initial experience with distal bypass revision (DGB) and provides a comparison with patients after primary RYGB.

METHODS

Single-institution, retrospective review was conducted for patients who underwent DGB from 2018 to 2020. A Roux and common channel of 150 cm each were constructed (total alimentary limb 300 cm). A group of primary RYGB patients with similar demographics were selected as controls. Demographics, comorbidity resolution, surgical technique, complications, excess weight loss (EWL), total weight loss (TWL), BMI, and weight change data were compared. Patient postoperative weight loss (WL) was also compared after their primary and DGB operations.

RESULTS

Sixteen DGB patients, all female, were compared with 29 controls. DGB was performed on average 12.3 years after primary RYGB. In the DGB group, mean BMI was 53.7 before primary RYGB, 31.9 at nadir, and 44.1 prior to DGB. Post-DGB, mean BMI was 40.5, 37.4, 34.8, and 34.4, at 3-, 6-, 12-, and 24-months, respectively. Five patients (31.3%) experienced complications and were readmitted within 30 days, with two of them (12.5%) requiring reintervention and one (6.3%) undergoing reoperation. Mean EWL and TWL up to 2 years after DGB were lower than that after the patient's original RYGB (52.3 ± 18.6 vs. 67.2 ± 33.2; p = 0.126 and 19.6 ± 13.3 vs. 29.6 ± 11.8; p = 0.027, respectively).

CONCLUSIONS

DGB resulted in excellent WL up to 2 years after surgery but was associated with considerable postoperative complication rates. The magnitude of TWL was lower compared with the primary operation. Only a few patients experienced nutritional complications. Results of this study can help counsel patients pursuing DGB for WR or nonresponse to primary RYGB. The comparative effectiveness of this approach to other available options remains to be determined.

Remission and Relapse of Dyslipidemia After Vertical Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass in a Racially and Ethnically Diverse Population

IMPORTANCE

The comparative effectiveness of the most common operations in the long-term management of dyslipidemia is not clear.

OBJECTIVE

To compare 4-year outcomes associated with vertical sleeve gastrectomy (VSG) vs Roux-en-Y gastric bypass (RYGB) for remission and relapse of dyslipidemia.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective comparative effectiveness study was conducted from January 1, 2009, to December 31, 2016, with follow-up until December 31, 2018. Participants included patients with dyslipidemia at the time of surgery who underwent VSG (4142 patients) or RYGB (2853 patients). Patients were part of a large integrated health care system in Southern California. Analysis was conducted from January 1, 2018, to December 31, 2021.

EXPOSURES

RYGB and VSG.

MAIN OUTCOMES AND MEASURES

Dyslipidemia remission and relapse were assessed in each year of follow-up for as long as 4 years after surgery.

RESULTS

A total of 8265 patients were included, with a mean (SD) age of 46 (11) years; 6591 (79.8%) were women, 3545 (42.9%) were Hispanic, 1468 (17.8%) were non-Hispanic Black, 2985 (36.1%) were non-Hispanic White, 267 (3.2%) were of other non-Hispanic race, and the mean (SD) body mass index (calculated as weight in kilograms divided by height in meters squared) was 44 (7) at the time of surgery. Dyslipidemia outcomes at 4 years were ascertained for 2168 patients (75.9%) undergoing RYGB and 3999 (73.9%) undergoing VSG. Remission was significantly higher for those who underwent RYGB (824 [38.0%]) compared with VSG (1120 [28.0%]) (difference in the probability of remission, 0.10; 95% CI, 0.01-0.19), with no differences in relapse (455 [21.0%] vs 960 [24.0%]). Without accounting for relapse, remission of dyslipidemia after 4 years was 58.9% (1279) for those who underwent RYGB and 51.9% (2079) for those who underwent VSG. Four-year differences between operations were most pronounced for patients 65 years or older (0.39; 95% CI, 0.27-0.51), those with cardiovascular disease (0.43; 95% CI, 0.24-0.62), or non-Hispanic Black patients (0.13; 95% CI, 0.01-0.25) and White patients (0.13; 95% CI, 0.03-0.22).

CONCLUSIONS AND RELEVANCE

In this large, racially and ethnically diverse cohort of patients who underwent bariatric and metabolic surgery in clinical practices, RYGB was associated with higher rates of dyslipidemia remission after 4 years compared with VSG. However, almost one-quarter of all patients experienced relapse, suggesting that patients should be monitored closely throughout their postoperative course to maximize the benefits of these operations for treatment of dyslipidemia.

Effect of Banded Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy on Diabetes Remission at 5 Years Among Patients With Obesity and Type 2 Diabetes: A Blinded Randomized Clinical Trial

OBJECTIVE

To determine whether silastic ring laparoscopic Roux-en-Y gastric bypass (SR-LRYGB) or laparoscopic sleeve gastrectomy (LSG) produces superior diabetes remission at 5 years.

RESEARCH DESIGN AND METHODS

In a single-center, double-blind trial, 114 adults with type 2 diabetes and BMI 35-65 kg/m2 were randomly assigned to SR-LRYGB or LSG (1:1; stratified by age-group, BMI group, ethnicity, diabetes duration, and insulin therapy) using a web-based service. Diabetes and other metabolic medications were adjusted according to a prespecified protocol. The primary outcome was diabetes remission assessed at 5 years, defined by HbA1c <6% (42 mmol/mol) without glucose-lowering medications. Secondary outcomes included changes in weight, cardiometabolic risk factors, quality of life, and adverse events.

RESULTS

Diabetes remission after SR-LRYGB versus LSG occurred in 25 (47%) of 53 vs. 18 (33%) of 55 patients (adjusted odds ratios 4.5 [95% CI 1.6, 15.5; P = 0.009] and 4.2 [1.3, 13.4; P = 0.015] in the intention-to-treat analysis). Percent body weight loss was greater after SR-LRYGB than after LSG (absolute difference 10.7%; 95% CI 7.3, 14.0; P < 0.001). Improvements in cardiometabolic risk factors were similar, but HDL cholesterol increased more after SR-LRYGB. Early and late complications were similar in both groups. General health and physical functioning improved after both types of surgery, with greater improvement in physical functioning after SR-LRYGB. People of Māori or Pacific ethnicity (26%) had lower incidence of diabetes remission than those of New Zealand European or other ethnicities (2 of 25 vs. 41 of 83; P < 0.001).

CONCLUSIONS

SR-LRYGB provided superior diabetes remission and weight loss compared with LSG at 5 years, with similar low risks of complications.

Are Geographical Health Accessibility and Socioeconomic Deprivation Associated with Outcomes Following Bariatric Surgery? A Retrospective Study in a High-Volume Referral Bariatric Surgical Center

PURPOSE

Few studies have evaluated the association between non-clinical determinants (socioeconomic status and geographic accessibility to healthcare) and the outcomes of bariatric surgery, with conflicting results. This study aimed to evaluate this association.

METHODS

The medical records of 1599 consecutive patients who underwent either laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between June 2005 and December 2017 were retrieved. All relevant data, including patient characteristics, biometric values before and after surgery, related medical problems, surgical history, medications, and habitus, for each patient were prospectively collected in a database. Logistic regressions were used to assess the influence of non-clinical determinants on surgical indications and complications. Multilevel linear or logistic regression was used to evaluate the influence of non-clinical determinants on long-term %TWL and the probability to achieve adequate weight loss (defined as a %TWL > 20% at 12 months).

RESULTS

Analysis of the 1599 medical records revealed that most geographically isolated patients were more likely to have undergone laparoscopic Roux-en-Y gastric bypass (odds ratio: 0.97; 95% confidence interval: 0.94 to 0.99; P = 0.018) and had a greater likelihood of adequate weight loss (β: 0.03; 95% CI: 0.01 to 0.05; P = 0.021). Conversely, socioeconomic status (measured by the European Deprivation Index) did not affect outcomes following bariatric surgery.

CONCLUSION

Geographical health isolation is associated with a higher probability to achieve adequate weight loss after 1 year of follow-up, while neither health isolation nor socioeconomic deprivation is associated with post-operative mortality and morbidity. This results suggests that bariatric surgery is a safe and effective tool for weight loss despite socioeconomic deprivation.

Roux-en-Y gastric bypass, sleeve gastrectomy, or one-anastomosis gastric bypass? A systematic review and meta-analysis of randomized-controlled trials

OBJECTIVE

This study aimed to determine which bariatric procedure allows patients to obtain the best weight-loss outcomes and a remission of type 2 diabetes.

METHODS

Databases were searched for randomized-controlled trials comparing Roux-en-Y gastric bypass (RYGB) with sleeve gastrectomy (SG) or one-anastomosis gastric bypass (OAGB). The mean difference (MD) or the relative risk was determined.

RESULTS

Twenty-five randomized-controlled trials were analyzed. Excess weight loss (EWL, percentage) was greater for RYGB patients at 3 years (MD: 11.93, p < 0.00001) and 5 years (MD: 13.11, p = 0.0004). Higher excess BMI loss (percentage) was found in RYGB at 1 year (MD: 11.66, p = 0.01). Total weight loss (percentage) was greater for RYGB patients after 3 months (MD: 2.41, p = 0.02), 6 months (MD: 3.83, p < 0.00001), 1 year (MD: 6.35, p < 0.00001), and 5 years (MD: 3.90, p = 0.005). No difference in terms of remission of type 2 diabetes was seen between RYGB and SG. EWL was significantly more important after OAGB than after RYGB after 1 year (MD: -10.82, p = 0.003).

CONCLUSIONS

RYGB is more efficient than SG in the midterm. OAGB offers greater EWL than RYGB after 1 year, but further evidence is needed to confirm this result.

Obesity Surgery

BACKGROUND

In 2017, the prevalence of obesity (BMI ≥= 30 kg/m2) in Germany was approximately 16%. Obesity increases an individual's risk of developing type 2 diabetes (T2DM) and arterial hypertension; it also increases overall mortality. Consequently, effective treatment is a necessity. Approximately 20 000 bariatric operations are performed in Germany each year.

METHODS

This review is based on pertinent publications retrieved by a selective search in the PubMed and Cochrane databases and on current German clinical practice guidelines.

RESULTS

The types of obesity surgery most commonly performed in Germany, Roux-en-Y gastric bypass and sleeve gastrectomy, lead to an excess weight loss of 27-69% ≥= 10 years after the procedure. In obese patients with T2DM, the diabetes remission rate ≥= 10 years after these procedures ranges from 25% to 62%. Adjusted regression analyses of data from large registries have shown that the incidence of malignancies is 33% lower in persons who have undergone obesity surgery compared to control subjects with obesity (unadjusted incidence 5.6 versus 9.0 cases per 1000 person-years). The operation can cause vitamin deficiency, surgical complications, gastroesophageal reflux, and dumping syndrome. Therefore, lifelong follow-up is necessary.

CONCLUSION

In view of an increasing number of patients undergoing bariatric surgery, it will probably not be feasible in the future for lifelong follow-up to be provided exclusively in specialized centers.

Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy in Young Adults: a Dutch Registry Study

BACKGROUND

The most commonly performed bariatric procedures worldwide are Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), yet outcomes following these procedures in young adults are limited. Therefore, the objective of this study was to compare weight loss outcomes between RYGB and SG in young adults.

METHODS

This is a nationwide retrospective cohort study of young adults, aged 18-25 years, who underwent RYGB or SG between 2015 and 2019, with data from the Dutch Audit Treatment of Obesity (DATO). The primary outcome was weight loss expressed as percentage total weight loss (%TWL) in a period of 3 years after surgery. Secondary outcomes were the incidence of complications (< 30 days) and progression of obesity-related comorbidities.

RESULTS

In total, 2313 patients were included, 1246 in the RYGB group and 1067 in the SG group. Percentage TWL was significantly higher in the RYGB group compared to the SG group at 1, 2, and 3 years after surgery (respectively 2.4%, 2.9%, and 3.3% higher, p < 0.001). RYGB was associated with an on-average 2.75 higher %TWL compared to SG in females (p < 0.001), although this was not seen in males (β = 0.63, p = 0.514). No differences were found in the incidence of complications, nor the progression of obesity-related comorbidities except for gastroesophageal reflux disease (GERD). There was more improvement or resolution of GERD in the RYGB group (95.2% vs. 56.3%, p < 0.001).

CONCLUSION

Similar numbers of RYGB and SG were performed in young adults, whereas RYGB was associated with greater weight loss in the short- and midterm, particularly in females.