Outcomes of Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding

Quality evaluation of metabolic and bariatric surgical guidelines

OBJECTIVE

To evaluate the quality of surgical guidelines on bariatric/metabolic surgery.

METHODS

Four independent reviewers used the AGREE II (The Appraisal of Guidelines for Research and Evaluation II) tool to assess the methodological quality of the included guidelines and conducted a comparative analysis of the main recommendations for surgical methods of these guidelines.

RESULTS

Nine surgical guidelines were included in this study. Five articles with AGREE II scores over 60% are worthy of clinical recommendation. The field of rigor of development was relatively low, with an average score of 50.82%. Among 15 key recommendations and the corresponding best evidence in the guidelines, only 4 key recommendations were grade A recommendations.

CONCLUSIONS

The quality of metabolic and bariatric guidelines is uneven, and there is much room for improvement.

Preoperative Physical Activity Level and Exercise Prescription in Adults With Obesity: The Effect on Post-Bariatric Surgery Outcomes

This systematic review summarizes current evidence on the relation between preoperative physical activity (PA) levels with bariatric surgery (BS) outcomes and on the beneficial role of preoperative exercise/PA program among BS candidates. This systematic review suggests that candidate patients accumulating the preoperative PA level improved several BS outcomes. These improvements were reported mainly for anthropometric and cardiometabolic parameters and physical function. Observed improvements manifested during a distinct period of time in response to a wide variety of exercise programs. Evidence on the preoperative PA level as well as on preoperative exercise implementation on BS outcomes is advocated despite the small number of participants and lack of control. Thus, further studies are required to explore the most effective and suitable form of exercise prescription prior to BS while considering physical and psychological limitations of obese patients.

Pre-operative aerobic exercise on metabolic health and surgical outcomes in patients receiving bariatric surgery: A pilot trial

Objective

Examine if adding aerobic exercise to standard medical care (EX+SC) prior to bariatric surgery improves metabolic health in relation to surgical outcomes.

Methods

Fourteen bariatric patients (age: 42.3±2.5y, BMI: 45.1±2.5 kg/m²) met inclusion criteria and were match-paired to pre-operative SC (n = 7) or EX+SC (n = 7; walking 30min/d, 5d/wk, 65–85% HR_peak) for 30d. A 120min mixed meal tolerance test was performed pre- and post-intervention (~2d prior to surgery) to assess insulin sensitivity (Matsuda Index) and metabolic flexibility (indirect calorimetry). Aerobic fitness (VO₂peak), body composition (BodPod), and adipokines (adiponectin, leptin) were also measured. Omental adipose tissue was collected during surgery to quantify gene expression of adiponectin and leptin, and operating time and length of hospital stay were recorded. ANOVA and Cohen’s d effect size (ES) was used to test group differences.

Results

SC tended to increase percent body fat (P = 0.06) after the intervention compared to EX+SC. Although SC and EX+SC tended to raise insulin sensitivity (P = 0.11), EX+SC enhanced metabolic flexibility (P = 0.01, ES = 1.55), reduced total adiponectin (P = 0.01, ES = 1.54) with no change in HMW adiponectin and decreased the length of hospital stay (P = 0.05) compared to SC. Albeit not statistically significant, EX+SC increased VO₂peak 2.9% compared to a 5.9% decrease with SC (P = 0.24, ES = 0.91). This increased fitness correlated to shorter operating time (r = -0.57, P = 0.03) and length of stay (r = -0.58, P = 0.03). Less omental total adiponectin (r = 0.52, P = 0.09) and leptin (r = 0.58, P = 0.05) expression correlated with shorter operating time, and low leptin expression was linked to shorter length of stay (r = 0.70, P = 0.01), and low leptin expression was linked to shorter length of stay (r = 0.70, P = 0.01).

Conclusion

Adding pre-operative aerobic exercise to standard care may improve surgical outcomes through a fitness and adipose tissue derived mechanism.

Bariatric Surgery Resistance: Using Preoperative Lifestyle Medicine and/or Pharmacology for Metabolic Responsiveness

Bariatric surgery is an effective and durable treatment for individuals with obesity and its associated comorbidities. However, not all patients meet weight loss and/or cardiometabolic goals following bariatric surgery, suggesting that some people are bariatric surgery resistant. The reason for this resistance is unclear, but potential factors, such as adiposity-derived inflammation, insulin resistance, hyperglycemia, and aerobic fitness prior to surgery, have been related to blunted surgery responsiveness. Exercise, diet, and/or pharmacology are effective at reducing inflammation and improving insulin action as well as physical function. Herein, we present data that supports the novel hypothesis that intervening prior to surgery can enhance disease resolution in people who are resistant to bariatric surgery.

A Novel Auxiliary Device for Preventing Band Slippage After Laparoscopic Adjustable Gastric Banding: Infra-Band Fixation Using S-Loop

BACKGROUND

Band slippage is known to be a troublesome complication of laparoscopic adjustable gastric banding (LAGB), often requiring surgical intervention. To prevent band slippage, a new auxiliary device "S-loop" was developed.

METHODS

From July 2010 to January 2014, a total of 814 LAGBs were performed by a single surgeon. The patients were divided into two groups based on the application of S-loop: conventional LAGB group (n = 378) and S-loop group (n = 436). The operative outcomes were compared between the two groups.

RESULTS

The mean operative time and the length of hospital stay were significantly longer in the conventional LAGB group than in the S-loop group (64.3 minutes versus 57.1 minutes; P < .001 and 5.0 hours versus 3.6 hours; P < .001, respectively). The complications occurred in 7.1% of the conventional LAGB group and 1.6% in the S-loop group (P < .001). Slippage was the most common complication: 13 cases were observed in the conventional LAGB group, whereas no slippage was observed in the S-loop group.

CONCLUSION

Infra-band fixation using S-loop is a simple and effective method for preventing band slippage compared with the conventional LAGB.

Tratamiento médico-quirúrgico de la obesidad en el SAHOS

La obesidad es uno de los factores de riesgo más importantes en los trastornos respiratorios relacionados con el sueño. Más de 70% de los pacientes con síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) presenta algún grado de obesidad. La pérdida de peso, ya sea médica o quirúrgica, debe ser un objetivo primordial en el manejo del SAHOS al mejorar el índice de apnea-hipopnea (IAH) en un alto porcentaje, el cual se debe estimular en todos los pacientes. Siempre se debe iniciar con cambios en el estilo de vida a través de intervenciones con múltiples componentes que incluyen hábitos alimentarios, actividad física y soporte psicológico. Si después de 3 a 6 meses de tratamiento no se han alcanzado las metas de peso establecidas, se pueden formular medicamentos contra la obesidad o cirugía bariátrica. El riesgo actual de someterse a una cirugía bariátrica es bajo y los beneficios son evidentes.

The Effect of Bariatric Surgery Type on Lipid Profile: An Age, Sex, Body Mass Index and Excess Weight Loss Matched Study

BACKGROUND

Bariatric surgery improves lipid profile. A still unanswered question is whether this improvement is merely weight-dependent or also results from factors inherent to specificities of the bariatric procedure. We aimed to study lipid profile 1 year after bariatric surgery and compare its changes between the different procedures in patients matched for initial weight and weight loss.

METHODS

We retrospectively analysed patients submitted to Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB) or sleeve gastrectomy (SG) between 2010 and 2013. Patients were matched for age (±5 years), sex, pre-surgery body mass index (BMI) (±2 Kg/m(2)) and excess weight loss (EWL) (±5%). Baseline and 1-year lipid profile, its variation and percentage of variation was compared between surgeries.

RESULTS

We analysed 229 patients: 72 pairs RYGB-AGB, 47 pairs RYGB-SG and 33 pairs AGB-SG. The median age was 41 (35-52) years and 11.8% were male. Pre-operative BMI was 44.0 ± 4.6 and 32.1 ± 4.4 Kg/m(2) at 1 year. EWL at 1 year was 64.2 ± 18.9%. There were no differences in baseline lipid profile between patients submitted to different types of bariatric surgery. At 1 year, high-density lipoprotein cholesterol (HDL) and triglycerides (TG) improved similarly with all surgeries. Total cholesterol (TC) and low-density lipoprotein cholesterol (LDL) at 1 year decreased significantly more in patients submitted to RYGB than in weight-matched patients undergoing AGB or SG.

CONCLUSIONS

RYGB is the only bariatric surgery that reduces TC and LDL in age-, sex-, BMI- and EWL-matched patients. All three procedures improved TG and HDL similarly when the confounding effect of weight loss is eliminated.

Obesity in Women: The Clinical Impact on Gastrointestinal and Reproductive Health and Disease Management

Approximately 36% of adult women in the United States are obese. Although obesity affects women similarly to men in terms of prevalence, there seem to be gender-specific differences in the pathophysiology, clinical manifestations, and treatment of obesity. Obesity is linked to comorbid diseases involving multiple organ systems, including the gastrointestinal tract, like gastroesophageal reflux disease, fatty liver disease, and gallstones. This article focuses on obesity in women, specifically the impact of obesity on gastrointestinal diseases and reproductive health, as well as the treatment of obesity in women.

Effects of Fat and Protein Preloads on Pouch Emptying, Intestinal Transit, Glycaemia, Gut Hormones, Glucose Absorption, Blood Pressure and Gastrointestinal Symptoms After Roux-en-Y Gastric Bypass

BACKGROUND

The aim was to determine the effects of fat and protein preloads on pouch emptying (PE), caecal arrival time (CAT), glucose absorption, blood glucose (BSL), gut hormones, haemodynamics and gastrointestinal (GI) symptoms in subjects who had undergone Roux-en-Y gastric bypass (RYGB) >12 months previously.

METHODS

Ten RYGB subjects were studied on three occasions, in randomised order, receiving 200-ml preloads of either water, fat (30 ml olive oil) or whey protein (55 g), 30 min before a mixed meal. PE, CAT, BSL, plasma 3-O-methyl-D-glucopyranose (3-OMG), insulin, glucose-dependent insulinotropic polypeptide (GIP), glucagon-like peptide 1 (GLP-1) and glucagon, blood pressure (BP), heart rate (HR) and GI symptoms were assessed over 270 min.

RESULTS

Although fat and protein preloads did not alter PE of either solids or liquids, the CAT of solids, but not liquids, was longer than that after the water preload (fat 68 ± 5 min and protein 71 ± 6 min vs. water 46 ± 5 min; P = 0.02). BSL elevated promptly after the meal on all days (P < 0.001), but after protein, the magnitude and integrated increases in the first 75 min were less than fat and water preloads (area under the curve (AUC(0-75 min)), 18.7 ± 18.2 vs. 107.2 ± 30.4 and 76.1 ± 19.3 mmol/L/min; P < 0.05). Compared to water preload, the protein and fat preloads were associated with greater increases in plasma insulin, GLP-1 and glucagon concentrations, a reduction in BP, and greater increases in HR, fullness, bloating and nausea. Plasma 3-OMG levels were lower after the protein than after the water and fat preloads (P < 0.001).

CONCLUSIONS

Given its effects to attenuate post-prandial glycaemia, reduce intestinal glucose absorption and potentiate the "incretin response", without inducing more adverse post-prandial GI symptom, protein preload may prove clinically useful in RYGB patients and warrant further evaluation, particularly in those with type 2 diabetes (T2DM) and/or dumping syndrome.

Cross-sectional imaging, with surgical correlation, of patients presenting with complications after remote bariatric surgery without bowel obstruction

Both restrictive and malabsorptive types of bariatric surgery may be associated with short- and long-term complications. The lack of small bowel obstruction is not necessarily indicative of a normal study, as a variety of non-obstructed complications exist. These include stenosis at the gastrojejunostomy, leaks, abscesses, hemorrhage, internal hernias, and gastric band erosions. Radiologists should be familiar with these complications for early diagnosis and intervention before symptoms become life threatening. An understanding of the intraoperative appearances of these complications may improve imaging descriptions and add value to radiological consults for surgeons. This review provides surgical correlations to the imaging features of post-bariatric complications without obstruction of the bowel.

Effects of Posture and Meal Volume on Gastric Emptying, Intestinal Transit, Oral Glucose Tolerance, Blood Pressure and Gastrointestinal Symptoms After Roux-en-Y Gastric Bypass

BACKGROUND

The purpose of this study is to determine the effects of posture and drink volume on gastric/pouch emptying (G/PE), intestinal transit, hormones, absorption, glycaemia, blood pressure and gastrointestinal (GI) symptoms after gastric bypass (Roux-en-Y gastric bypass (RYGB)).

METHODS

Ten RYGB subjects were studied on four occasions in randomized order (sitting vs. supine posture; 50 vs. 150 ml of labelled water mixed with 3 g 3-O-methyl-D-glucose (3-OMG) and 50 g glucose). G/PE, caecal arrival time (CAT), blood glucose, plasma insulin, glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), peptide YY (PYY), 3-OMG, blood pressure, heart rate and GI symptoms were assessed over 240 min. Controls were ten volunteers with no medical condition or previous abdominal surgery, who were studied with the 150-ml drink in the sitting position.

RESULTS

Compared to controls, PE (P < 0.001) and CAT (P < 0.001) were substantially more rapid in RYGB subjects. In RYGB, PE was more rapid in the sitting position (2.5 ± 0.7 vs. 16.6 ± 5.3 min, P = 0.02) and tends to be faster after 150 ml than the 50-ml drinks (9.5 ± 2.9 vs. 14.0 ± 3.5 min, P = 0.16). The sitting position and larger volume drinks were associated with greater releases of insulin, GLP-1 and PYY, as well as more hypotension (P < 0.01), tachycardia (P < 0.01) and postprandial symptoms (P < 0.001).

CONCLUSIONS

Pouch emptying, blood pressure and GI symptoms after RYGB are dependent on both posture and meal volume.

Factors Associated With Long-Term Weight Loss Following Bariatric Surgery Using 2 Methods for Repeated Measures Analysis

We used electronic health record data from 162 patients enrolled in the NUgene Project (2002-2013) to determine demographic factors associated with long-term (from 1 to up to 9.5 (mean = 5.6) years) weight loss following Roux-en-Y gastric bypass surgery. Ninety-nine (61.1%) patients self-reported white, and 63 (38.9%) self-reported black, mixed, or missing race. The average percent weight loss was -33.4% (standard deviation, 9.3) at 1 year after surgery and -30.7% (standard deviation, 12.5) at the last follow-up point. We used linear mixed and semiparametric trajectory models to test the association of surgical and demographic factors (height, surgery age, surgery weight, surgery body mass index, marital status, sex, educational level, site, International Classification of Diseases code, Current Procedural Terminology code, Hispanic ethnicity, and self-reported race) with long-term percent weight loss and pattern of weight loss. We found that black, mixed, and missing races (combined) in comparison with white race were associated with a decreased percent weight loss of -4.31% (95% confidence interval: -7.30, -1.32) and were less likely to have higher and sustained percent weight loss (P = 0.04). We also found that less obese patients were less likely to have higher and sustained percent weight loss (P = 0.01). These findings may be helpful to patients in setting expectations after weight loss surgery.

Gastric Band Slippage: The Impact of a Change in Education and Band Filling

BACKGROUND

Gastric band slippage is a significant challenge in gastric band surgery and can result in poor weight loss, pain and dysphagia, often requiring re-operation. The Royal Berkshire Hospital is one of 49 UK centres performing bariatric surgery. We audited our band slippage rates.

METHODS

All patients undergoing gastric banding from February 2007 to December 2013 were included (follow-up until December 2014). Slip rate was calculated and compared to an audit standard (3.9 %). The impact of two interventions altering the method of band filling and post-operative dietary advice was studied.

RESULTS

Initial slippage rates were high (17 %). Rates decreased following the interventions: 8.5 % by July 2012 (p = 0.05); 2.7 % by December 2014 (p = 0.2).

CONCLUSIONS

Two simple, low-risk interventions have reduced complication rates in a high-risk population.

Change in consumption patterns for treatment-seeking patients with alcohol use disorder post-bariatric surgery

OBJECTIVE

The aim of this study is to describe the clinical phenotype of alcohol use disorder (AUD) treatment-seeking patients with Roux-en-Y Gastric Bypass Surgery (RYGB) history; and to compare it to AUD obese non-RYGB controls.

METHODS

Retrospective study of electronic medical records for all patients 30-60years treated at the Mayo Clinic Addiction Treatment Program, between June, 2004 and July, 2012. Comparisons were performed with consumption patterns pre-RYGB and at time of treatment; excluding patients with AUD treatments pre-RYGB.

RESULTS

Forty-one out of 823 patients had a RYGB history (4.9%); 122 controls were selected. Compared to controls, the RYGB group had significantly more females [n=29 (70.7%) vs. n=35 (28.7%) p<0.0001]; and met AUD criteria at a significantly earlier age (19.1±0.4 vs. 25.0±1years old, p=0.002). On average, RYGB patients reported resuming alcohol consumption 1.4±0.2years post-surgery, meeting criteria for AUD at 3.1±0.5years and seeking treatment at 5.4±0.3years postoperatively. Pre-surgical drinks per day were significantly fewer compared to post-surgical consumption [2.5±0.4 vs. 8.1±1.3, p=0.009]. Prior to admission, RYGB patients reported fewer drinking days per week vs. controls (4.7±0.3 vs. 5.5±1.8days, p=0.02). Neither RYGB, gender, age nor BMI was associated with differential drinking patterns.

CONCLUSION

The results of this study suggest that some patients develop progressive AUD several years following RYGB. This observation has important clinical implications, calling for AUD-preventive measures following RYGB. Further large-scale longitudinal studies are needed to clarify the association between RYGB and AUD onset.

Laparoscopic revolution in bariatric surgery

The history of bariatric surgery is investigational. Dedicated surgeons have continuously sought for an ideal procedure to relieve morbidly obese patients from their burden of comorbid conditions, reduced life expectancy and low quality of life. The ideal procedure must have low complication risk, both in short- and long term, as well as minimal impact on daily life. The revolution of laparoscopic techniques in bariatric surgery is described in this summary. Advances in minimal invasive techniques have contributed to reduced operative time, length of stay, and complications. The development in bariatric surgery has been exceptional, resulting in a dramatic increase of the number of procedures performed world wide during the last decades. Although, a complex bariatric procedure can be performed with operative mortality no greater than cholecystectomy, specific procedure-related complications and other drawbacks must be taken into account. The evolution of laparoscopy will be the legacy of the 21^st century and at present, day-care surgery and further reduction of the operative trauma is in focus. The impressive effects on comorbid conditions have prompted the adoption of minimal invasive bariatric procedures into the field of metabolic surgery.

Upregulation of intestinal glucose transporters after Roux-en-Y gastric bypass to prevent carbohydrate malabsorption

OBJECTIVE

To determine the effect of Roux-en-Y gastric bypass (RYGB) on the expression of intestinal sweet taste receptors (STRs), glucose transporters (GTs), glucose absorption, and glycemia.

METHODS

Intestinal biopsies were collected for mRNA expression of STR (T1R2) and GTs (SGLT-1 and GLUT2) from 11 non-diabetic RYGB, 13 non-diabetic obese, and 11 healthy subjects, at baseline and following a 30 min small intestinal (SI) glucose infusion (30 g/150 ml water with 3 g 3-O-methyl-d-glucopyranose (3-OMG)). Blood glucose, plasma 3-OMG, and insulin were measured for 270 min.

RESULTS

In RYGB patients, expression of both GTs was ∼2-fold higher at baseline and after glucose infusion than those of morbidly obese or healthy subjects (P < 0.001). STR expressions were comparable amongst the groups. Peak plasma 3-OMG in both RYGB (r = 0.69, P = 0.01) and obese (r = 0.72, P = 0.005) correlated with baseline expression of SGLT-1, as was the case with peak blood glucose in RYGB subjects (r = 0.69, P = 0.02).

CONCLUSIONS

The upregulated intestinal GTs in RYGB patients are associated with increased glucose absorption when glucose is delivered at a physiological rate, suggesting a molecular adaptation to prevent carbohydrate malabsorption from rapid intestinal transit after RYGB.

Rapid gastric and intestinal transit is a major determinant of changes in blood glucose, intestinal hormones, glucose absorption and postprandial symptoms after gastric bypass

OBJECTIVE

To evaluate the effect of modulating pouch emptying (PE) and SI transit of glucose after Roux-en-Y gastric bypass (RYGB) on blood glucose, incretin hormones, glucose absorption and gastrointestinal (GI) symptoms.

METHODS

Ten RYGB patients were studied twice in random order, receiving either a 150 ml glucose drink (200 kcal) or the same solution infused into the proximal Roux-limb at 4 kcal/min. Data were compared with 10 healthy volunteers who received a 4 kcal/min duodenal infusion. PE, cecal arrival time (CAT), blood glucose, plasma 3-O-methylglucose (3-OMG), insulin, glucose-dependent insulinotropic polypeptide (GIP), and glucagon-like peptide-1 (GLP-1), and GI symptoms were measured.

RESULTS

In RYGB subjects, the glucose drink emptied very rapidly (PE t50 = 3 ± 1 min) and intestinal glucose infusion was associated with higher blood glucose and plasma 3-OMG, but lower plasma GLP-1, GIP, insulin, and GI symptoms than oral glucose (all P < 0.001), and comparable to volunteers. In RYGB subjects, CAT correlated inversely with peak GLP-1 (r = -0.73, P = 0.01), and plasma 3-OMG correlated tightly blood glucose (r = 0.94, P < 0.0001).

CONCLUSIONS

After RYGB, reducing intestinal glucose delivery to 4 kcal/min is associated with higher blood glucose, greater glucose absorption, lower incretin responses, and less GI symptoms, supporting rapid transit contribution to the exaggerated incretin responses and "dumping symptoms".

Long-term results after laparoscopic adjustable gastric banding: a mean fourteen year follow-up study

BACKGROUND

For over a decade, the laparoscopic adjustable gastric band (LAGB) was 1 of the most performed bariatric procedures in Europe. This study is a retrospective analysis with prospectively collected data of the experience in 1 specialized Dutch center with the adjustable gastric band over 14 years.

METHODS

Between 1995 and 2003, 201 patients underwent an LAGB for morbid obesity in our hospital. Data on preoperative clinical characteristic, postoperative outcome and weight loss patterns, and co-morbidities for up to 18 years are presented and evaluated using the Bariatric Analysis and Reporting Outcome System (BAROS).

RESULTS

Average follow-up was 13.6 (± 2.0) years (163 mo) and 99% of patients with complete follow-up. Two thirds of patients reached an excess weight loss (EWL)>50% at some point after LAGB placement. However, due to insufficient weight loss or complications in 53% of patients, the LAGB had to be removed or converted to a Roux-en-Y gastric bypass. Additionally, half of the remaining patients had disappointing results according to the BAROS score. In total, less than one quarter (22%) of patients had a functioning band with a good result after the follow-up period. Although initially the number of patients experiencing co-morbidities was reduced, most of them returned and a large number of patients developed new co-morbidities. Complications, other than weight regain, were numerous as 47% of patients experienced at least 1. In total, 204 reoperations were performed in 137 (68%) patients. Furthermore, patients who were lost to follow-up did almost twice as bad in terms of EWL compared to patients who had regular follow-up.

CONCLUSION

Morbid obesity is a chronic disease that can be resolved with bariatric surgery. One of the treatment options is the LAGB, which in the short term shows good results in terms of EWL and co-morbidity reduction. In the long term, however, EWL and co-morbidity reduction are disappointing, and the LAGB does not seem to live up to expectations. Besides the decrease in EWL over time, the number of reoperations required is alarming. In total, less than a quarter of patients still had a functioning band after a mean 14 years of follow-up.