Weight loss, cardiovascular risk factors, and quality of life after gastric bypass and duodenal switch: a randomized trial

Comparative multicenter analysis of sleeve gastrectomy, gastric bypass, and duodenal switch in patients with BMI ≥70kg/m2: a 2-year follow-up

Patients undergoing metabolic and bariatric surgery (MBS) with body mass index (BMI) ≥ 70 kg/m2 are considered a high-risk group. There is limited literature to guide surgeons on the perioperative safety as well as the different procedural outcomes of MBS in this cohort. Our aim is to compare the safety profiles, early- and medium-term outcomes of sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and duodenal switch (DS) in patients with BMI ≥ 70 kg/m2. A total of 156 patients with BMI ≥ 70kg/m2 underwent MBS (SG = 40, RYGB = 40, and DS = 76). Mean baseline BMI was 75.5 kg/m2. Total weight loss (%TWL) at 24 months was highest in the DS group compared to RYGB (40.6% versus 33.8%, P value = .03) and SG (40.6% versus 28.5%, P value = .006). There was no significant difference in %TWL between RYGB and SG (33.8% versus 28.5%, P value = .20). The 30-day complication rates were similar [SG (7.5%), RYGB (10%), and DS (9.2%) (P value = 1.0)]. There was one reported leak (DS). The 30-day mortality was zero. MBS is safe and effective in patients with BMI ≥ 70 kg/m2. All procedures had comparable safety profiles and complication rates. While DS achieved the highest %TWL at 24 months, similar comorbidity resolution rates among the procedures attenuate its clinical significance.

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.

A prospective single-center study evaluating the efficacy of the stomach, intestinal, and pylorus-sparing procedure

BACKGROUND

The stomach, intestinal, and pylorus-sparing (SIPS) procedure is a single-anastomosis duodeno-intestinal bypass used in obesity management.

OBJECTIVE

Weight and metabolic outcomes in patients with severe obesity who underwent the SIPS procedure were evaluated in a community hospital-based study.

SETTING

Community hospital.

METHODS

This single-site prospective study of patients who underwent the SIPS procedure evaluated outcomes at 12 and 24 months. Mean changes in total weight loss and body mass index (BMI) and resolution of gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), hypertension, type 2 diabetes (T2D), and hyperlipidemia were evaluated.

RESULTS

At baseline, 185 patients were enrolled; mean weight and BMI were 144.0 kg and 52.2 kg/m², respectively. Data for 88 (47.6%) and 29 (15.7%) patients who completed follow-up at 12 and 24 months, respectively, were available. At 12 months, mean total weight loss was 35.6% (weight reduction of 51.3 kg) and BMI reduction of 17.8 points were achieved and were maintained for the 29 patients who completed 24-month follow-up. No leaks or infections occurred. Complications occurred in 8 patients (.4%) and were not serious. Resolution of GERD, OSA, hypertension, T2D, and hyperlipidemia achieved in 87.1%, 59.2%, 32.7%, 93.1%, and 87.6% of patients, respectively, at 12 months was maintained at 24 months. Nutritional deficiency was absent.

CONCLUSIONS

Patients who underwent the SIPS procedure had meaningful reductions in weight and BMI, and many had resolution of metabolic co-morbidities; procedural complication rates were low. Our results support that the SIPS procedure is a safe and effective primary treatment for clinically severe obesity in a community-based hospital setting.

Depressive symptoms before and after abdominoplasty among post-bariatric patients - a cohort study

The majority of post-bariatric patients suffer from excess skin after weight loss, impairing physical, psychosocial and mental health. The abdomen is the most common location for excess skin, and abdominoplasty is the most commonly required reconstructive procedure. Abdominoplasty removes excess abdominal skin and attenuates related symptoms, but knowledge regarding mental health-related effects is scarce. Here, we aimed to evaluate the symptoms and severity of depression before and after abdominoplasty in post-bariatric patients and to analyse the relationships between depressive symptoms, quality of life (QoL) and experience of excess skin. We enrolled 110 former obese patients undergoing abdominoplasty. Three questionnaires evaluating the symptoms of depression (Beck Depression Inventory (BDI-II)), experience of excess skin (Sahlgrenska Excess Skin Questionnaire (SESQ)) and QoL (36-item Short-Form Health Survey (SF-36)) were completed preoperatively and 1 year postoperatively. After abdominoplasty, symptoms of depression (BDI sum score) significantly decreased (5.8 vs. 3.0, p = .037). Scores on three BDI questions improved (p < .05), and the SESQ score normalised (p < .001), while the SF-36 score was unaffected. The BDI sum score was moderately correlated with the SF-36 mental composite score (preoperatively, r_s = -0.69; postoperatively, r_s = -0.66) and fairly correlated with the SF-36 physical composite score (r_s = 0.32, r_s = 0.26). The correlation between the BDI sum and SESQ scores was poor preoperatively (r_s = -0.106) and fair postoperatively (r_s = 0.232). The results indicate that abdominoplasty may reduce symptoms of depression in post-bariatric patients. However, the procedure did not affect SF-36 scores. Further studies are required to validate these results.

Predictors for weight loss after Roux-en-Y gastric bypass: the trend and associated factors for weight loss

BACKGROUND

Historically, Roux-en-Y gastric bypass (RYGB) has been considered the gold standard of bariatric surgery (BS). This procedure acts as a mixed restrictive and malabsorptive operation.

METHODS

 This retrospective cohort study included 410 morbidly obese patients (BMI > 40 kg/m2 or BMI > 35 kg/m2 along with at least one major comorbidity) who underwent primary laparoscopic RYGB surgery from 2009 to 2015 by a single surgery team. The patients were 18 years and older with at least 12 months of follow-up. Total weight loss (%TWL) and comorbidity resolution were compared in short-term (12 months) and mid-term (12-60 months) follow-ups. The primary and secondary outcomes were evaluating the effect of Roux-en-Y on weight loss and control of comorbidities, respectively.

RESULTS

 The mean ± SD age, weight, and BMI at surgery were 40.1 ± 10.58 years, 123.32 ± 19.88 kg, and 45.78 ± 5.54 kg/m2, respectively, and 329 (80%) were female, and 62 (15%) had T2DM. %TWL was significantly higher in T2DM patients 9 months postoperatively and after that. Patients with lower BMI (< 50 kg/m2) at surgery and non-diabetic patients had a significantly lower %TWL over a short- and long-term follow-up (P < 0.001).

CONCLUSIONS

BS remains the most efficacious and durable weight loss treatment. However, a proportion of patients will experience insufficient weight loss following BS.

Comparison of the Outcomes of Single Anastomosis Duodeno-Ileostomy with Sleeve Gastrectomy (SADI-S), Single Anastomosis Sleeve Ileal (SASI) Bypass with Sleeve Gastrectomy, and Sleeve Gastrectomy Using a Rodent Model with Diabetes

OBJECTIVE

Single anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S) is a powerful form of bariatric surgery; however, it has a high risk of malnutrition. Single anastomosis sleeve ileal (SASI) bypass with sleeve gastrectomy may be used as an alternative procedure to avoid malnutrition associated with SADI-S; however, no comparison between the two procedures has been performed.

METHODS

Sprague-Dawley rats with diabetes (n = 32) were divided into four groups: SADI-S (n = 8), SASI (n = 8), SG (n = 8), and SHAM (n = 8). Body weight, food intake, and fasting blood glucose were measured, and the oral glucose tolerance test (OGTT) and insulin tolerance test (ITT) were performed before and after surgery. Blood samples were collected before and after the surgery to assess the levels of glucagon-like peptide-1 (GLP-1), hemoglobin, albumin, vitamin B12, calcium, and iron.

RESULTS

The SADI-S and SASI groups showed significantly greater weight loss and better glucose control than the SG group postoperatively. The SADI-S and SASI groups showed similar improvements in glucose control throughout the study. The SADI-S and SASI groups had significantly higher GLP-1 levels than the SG group at 6 months. The SADI-S and SASI groups presented with various degrees of deficiencies, with the SADI-S group showing a higher risk for hypoalbuminemia and iron deficiency than the SASI group.

CONCLUSIONS

The SASI procedure may be a better alternative as it has excellent bariatric and metabolic results with lower risk for hypoalbuminemia and can be easily converted into either SADI-S or SG procedures. Nevertheless, further clinical results are needed.

Ten year comparative analysis of sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch in patients with BMI ≥ 50 kg/m2

INTRODUCTION

Bariatric surgery is the most effective modality to stably reduce weight and related comorbidities in patients suffering from class II and III obesity. Data comparing long-term safety and efficacy of the three most effective bariatric operations are limited in patients with BMI ≥ 50 kg/m², which complicate shared surgeon-patient decision making regarding optimal procedure selection.

METHODS

A retrospective analysis was performed on all patients with BMI ≥ 50 kg/m² who underwent biliopancreatic diversion with duodenal switch (BPD/DS), Roux-en-Y gastric bypass (RYGB), or sleeve gastrectomy (SG) at our institution between 2009 and 2019. Data collected from patients' electronic medical records included operative details as well as BMI and presence and resolution of obesity-related comorbidities at 0, 6, 12, 24, 48, and 60 months post-operatively.

RESULTS

Among 537 patients with BMI ≥ 50 kg/m² who had a primary bariatric procedure, 93 patients underwent BPD/DS (17.3%), 341 patients underwent RYGB (63.5%), and 103 patients underwent SG (19.2%). BMI decreased by 23.7 kg/m² in BPD/DS, 14.7 kg/m² in RYGB, and 13.6 kg/m² in SG cohorts at 60 months post-operatively (p < 0.0001). The greatest %TWL occurred in BPD/DS cohort (38.4%) followed by the RYGB (26.3%) and SG (23.6%) cohorts (p < 0.0001). The thirty-day complication rate was 12.9% for BPD/DS, 4.7% for RYGB, and 8.7% for SG (p = 0.015).

CONCLUSIONS

Our study demonstrated that the BPD/DS is the most effective operation at long-term reduction of BMI and achieved highest %TWL while SG and RYGB had similar results at 60 months post-op. BPD/DS is associated with increased early and late surgical complications compared to RYGB and SG.

Efficacy and effects of bariatric surgery in the treatment of obesity: Network meta-analysis of randomized controlled trials

AIMS

Bariatric surgery (BS) is recommended for subjects with a Body Mass Index (BMI) over of 40 kg/m² or with a BMI between 35 and 40 kg/m² with obesity-related comorbidities. Aim of the study was to compare different types of BS with medical therapy (MT) for the treatment of obesity.

DATA SYNTHESIS

We conducted a network-meta-analysis (NMA) including randomized clinical trials comparing different BS techniques versus MT in people with obesity, with a duration ≥24 weeks (PROSPERO, #CRD42020160359). Primary endpoint was BMI. Indirect comparisons of different types of surgery were performed by NMA. Types of BS included: laparoscopic adjustable gastric banding (LAGB), Roux-en-Y gastric bypass, sleeve gastrectomy (SG), bilio-pancreatic diversion (BPD); greater curvature plication (GCP); one-anastomosis gastric bypass (OAGB); Laparoscopic Vertical Banded Gastroplasty (LVBG) and duodenal switch (DS). 43 trials were retrieved in this metanalysis. BS was associated with a significant reduction in BMI, systolic blood pressure, triglyceride and fasting glucose, and with a significant increase of HDL cholesterol when compared to MT. In direct comparisons, RYGB was more effective than LAGB, LVBG, and GCP, but less effective than DS, whereas LAGB was less effective than LVBG and SG. In the NMA, DS and BPD appeared to be more effective than other procedures.

CONCLUSIONS

BS produces a greater weight loss than MT in morbidly obese patients, inducing a greater improvement of obesity-associated metabolic parameters. Available data are insufficient to assess the effect of BS on mortality. Different surgical procedures are heterogeneous for efficacy and safety.

Obesity Primer for the Practicing Gastroenterologist

With worsening of the obesity pandemic, gastroenterologists will see more patients with this chronic disease. Given the association between obesity and several gastrointestinal conditions and the interplay between obesity pathophysiology and gut hormones, gastroenterologists can play an important role in the management of this disease. Furthermore, because more patients undergo bariatric surgery, an understanding of postsurgical anatomy and medical and endoscopic management of bariatric surgical complications is essential. This article provides clinical tools for the assessment and management of obesity for the general gastroenterologist. Tables containing high-yield practical information are also provided for quick reference.

The Importance of Intestinal Length in Triglyceride Metabolism and in Predicting the Outcomes of Comorbidities in Laparoscopic Roux-en-Y Gastric Bypass-a Narrative Review

In this narrative review, we will appraise if modification of the length of bypassed small intestine based on measured total small intestinal length could optimize the outcomes of the laparoscopic Roux-en-Y gastric bypass (LRYGB). We provide a summary of carefully selected studies to serve as examples and to draw tentative conclusions of the effects of LRYGB on remission of comorbidities. As the heterogeneity of the included studies varied in terms of outcomes, type of study, length of the bypassed small intestine, and the follow-up, a common endpoint could not be defined for this narrative article. To achieve efficient metabolic outcomes, it is important to carefully choose the small intestine length excluded from the food passage suited best to each individual patient.

The effects of bariatric surgery on dyslipidemia and insulin resistance in overweight patients with or without type 2 diabetes: a systematic review and network meta-analysis

Obesity has become an epidemic in several regions globally; it may lead to cardiovascular diseases, diabetes, and dyslipidemia. Despite many therapies, all bariatric procedures fail in some patients. There is a lack of literature comparing treatment effects on specific metabolic indexes. PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for relevant articles. GeMTC and R software were used to perform a network meta-analysis, draw forest plots, investigate the possibility of statistical heterogeneity, generate I² statistics, rank probabilities, and evaluate relative effects of surgical procedures. All analyses were based on a Bayesian consistency model. We included 35 randomized controlled trials, comprising 2198 individuals and 13 interventions. For patients with high insulin resistance, single-anastomosis (mini-) gastric bypass (SAGB) and sleeve gastrectomy (SG) may be effective options, with mean differences (95% confidence intervals [CIs]) of -4.45 (-9.04 to -.34) and -4.23 (-6.74 to -2.22), respectively, compared with control groups. For patients with severe dyslipidemia, in addition to SAGB and SG, duodenal switch (DS) may be an effective surgery, with mean differences (95% CIs) of -.97 (-1.39 to -.55), -1.98 (-3.76 to -.19), .53 (.04 to 1.04), and -.94 (-1.66 to -.16) compared with control groups in terms of triglycerides, total cholesterol, high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) concentrations, respectively. In adult overweight patients with or without diabetes, SAGB and SG are most effective at ameliorating insulin resistance. SAGB, Roux-en-Y gastric bypass + omentectomy, and DS are useful for reducing triglycerides, total cholesterol, and LDL-C. SG + omentectomy elevates HDL-C concentrations best. Adjustable gastric band and biliopancreatic diversion may not control insulin resistance or dyslipidemia well.

Effects of bariatric surgery on lipid-lipoprotein profile

Most patients with severe obesity will present some lipid-lipoprotein abnormalities. The atherogenic dyslipidemia associated with severe obesity is characterized by elevated fasting and postprandial triglyceride levels, low high-density lipoprotein cholesterol concentrations, and increased proportion of small and dense low-density lipoproteins. Bariatric surgery has been proven safe and successful in terms of long-term weight loss and improvement in obesity co-existing metabolic conditions including lipid-lipoprotein abnormalities. Nevertheless, bariatric surgery procedures are not all equivalent. We conducted a comprehensive critical analysis of the literature related to severe obesity, bariatric surgery and lipid-lipoprotein metabolism/profile. In this review, we described the metabolic impacts of different bariatric surgery procedures on the lipid-lipoprotein profile, and the mechanisms linking bariatric surgery and dyslipidemia remission based on recent epidemiological, clinical and preclinical studies. Further mechanistic studies are essential to assess the potential of bariatric/metabolic surgery in the management of lipid-lipoprotein abnormalities associated with severe obesity. Understanding the beneficial effects of various bariatric surgery procedures on the lipid-lipoprotein metabolism and profile may result in a wider acceptance of this strategy as a long-term metabolic treatment of lipid-lipoprotein abnormalities in severe obesity and help clinician to develop an individualized and optimal approach in the management of dyslipidemia associated with severe obesity. BRIEF SUMMARY: Abnormal lipid-lipoprotein profile is frequent in patients with severe obesity. Significant improvements in lipid-lipoprotein profile following bariatric surgery occur early in the postoperative period, prior to weight loss, and persists throughout the follow-up. The mechanisms that facilitate the remission of dyslipidemia after bariatric surgery, may involve positive effects on adipose tissue distribution/function, insulin sensitivity, liver fat content/function and lipid-lipoprotein metabolism.

Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.

Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists

OBJECTIVE

The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists.

METHODS

Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts.

RESULTS

New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest).

CONCLUSIONS

Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Lurasidone Malabsorption Following Bariatric Surgery: A Case Report

A significant segment of the United States adult population is obese. Bariatric surgery is one approach to weight loss when nonsurgical efforts have failed. In individuals with a body mass index ≥50, gastric reduction with duodenal switch is more effective than gastric bypass. More than half of bariatric surgery candidates report a history of mental illness and more than one third were taking at least one psychotropic medication at the time of surgery. Thus, the impact of surgery on absorption of psychiatric medications should be considered. Lurasidone, a second-generation antipsychotic used to treat schizophrenia and bipolar disorder, is recommended to be taken with food of at least 350 calories. We describe the case of a patient with incomplete response to lurasidone therapy in the year following a duodenal switch procedure. This case raises concern about the effect that the duodenal switch procedure may have on lurasidone absorption.

Vitamin D deficiency in relation to general and abdominal obesity among high educated adults

PURPOSE

To assess the association of vitamin D deficiency with general and abdominal obesity among high educated Iranian adults.

METHODS

Current cross-sectional study was done on 500 Iranian professors aged 35 years or more. Complete data on general and abdominal obesity as well as serum 25(OH)D concentrations were available for 352 persons. Obesity was considered as body mass index ≥ 30, and abdominal obesity as waist circumference ≥ 80 cm for women and ≥ 94 cm for men. Furthermore, vitamin D deficiency was defined as serum 25(OH)D < 30 ng/ml.

RESULTS

Mean age of study population was 53.03 ± 7.15 years. Compared with those in the first quartile of serum 25(OH)D, participants in the fourth quartile were less likely to be generally obese (OR 0.46, 65% CI 0.22-0.99). Such finding was also seen even after taking potential confounders into account. Furthermore, we found an inverse association between serum 25(OH)D and abdominal obesity in fully adjusted model (OR 0.44, 95% CI 0.22-0.86). In addition, a significant positive association was found between vitamin D deficiency and obesity; such that after controlling for potential confounders, participants with vitamin D deficiency had 2.16 and 2.04 times greater odds for having general (OR 2.16, 95% CI 1.05-4.45) and abdominal obesity (OR 2.04, 95% CI 1.16-3.60), respectively, than those with normal levels of vitamin D.

CONCLUSION

Serum 25(OH)D concentrations were inversely associated with general and abdominal obesity. In addition, vitamin D deficiency was positively associated with both general and abdominal obesity.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Patient-Reported Outcome Measures 2 Years After Standard and Distal Gastric Bypass-a Double-Blind Randomized Controlled Trial

BACKGROUND

The preferred surgical procedure for treating morbid obesity is debated. Patient-reported outcome measures (PROMs) are relevant for evaluation of the optimal bariatric procedure.

METHODS

A total of 113 patients with BMI from 50 to 60 were randomly assigned to standard (n = 57) or distal (n = 56) Roux-en-Y gastric bypass (RYGB). Validated PROMS questionnaires were completed at baseline and 2 years after surgery. Data were analyzed using mixed models for repeated measures and the results are expressed as estimated means and mean changes.

RESULTS

Obesity-related quality of life improved significantly after both procedures, without significant between-group differences (- 0.4 (95% CI = - 8.4, 7.2) points, p = 0.88, ES = 0.06). Both groups had significant reductions in the number of weight-related symptoms and symptom distress score, with a mean group difference (95% CI) of 1.4 (- 0.3, 3.3) symptoms and 5.0 (2.9. 12.8) symptom distress score points. There were no between-group differences for uncontrolled eating (22.0 (17.2-26.7) vs. 28.9 (23.3-34.5) points), cognitive restraint (57.4 (52.0-62.7) vs. 62.1 (57.9-66.2) points), and emotional eating (26.8 (20.5-33.1) vs. 32.6 (25.5-39.7) points). The prevalence of anxiety was 33% after standard and 25% after distal RYGB (p = 0.53), and for depression 12 and 9%, respectively (p = 0.76).

CONCLUSIONS

There were no statistically significant differences between standard and distal RYGB 2 years post surgery regarding weight loss, obesity-related quality of life, weight-related symptoms, anxiety, depression, or eating behavior.

TRIAL REGISTRATION

Clinical Trials.gov number NCT00821197.

Small Intestinal Length Associates with Serum Triglycerides Before and After LRYGB

BACKGROUND AND AIMS

Different bariatric procedures have been associated with variable weight loss and decrease in serum levels of lipids and lipoproteins. This variation could be partly related to the length of the small intestinal bypass. We evaluated the association of the small intestinal length with the non-alcoholic fatty liver disease (NAFLD) at baseline and with lipid metabolism before and after laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

Seventy consecutive morbidly obese patients were recruited to this prospective study. A standard 60-cm biliopancreatic limb (BPL) and 120-cm alimentary limb (AL) was performed, and thereafter, the common channel (CC) length was measured during elective LRYGB. Histological analysis of liver biopsy to diagnose NAFLD was performed. The mRNA expression of genes participating in the cholesterol and fatty acid metabolism in the liver was analyzed.

RESULTS

Female sex (p = 0.006), serum triglycerides (TG, p = 0.016), serum alanine aminotransferase (ALT, p = 0.007), and liver steatosis (p = 0.001) associated with the small intestinal length (BPL + AL + CC) at baseline. Association remained significant between levels of serum TG and CC length (p = 0.048) at 1-year follow-up. Liver mRNA expression of genes regulating cholesterol synthesis and bile metabolism did not associate with the baseline small intestinal length.

CONCLUSIONS

Our findings support the suggestions that small intestinal length regulates TG metabolism before and after LRYGB. Therefore, modification of the length of bypassed small intestine based on measured total small intestinal length could optimize the outcomes of the elective LRYGB.

MRI assessment of changes in adipose tissue parameters after bariatric surgery

Bariatric surgery and other therapeutic options for obese patients are often evaluated by the loss of weight, reduction of comorbidities or improved quality of life. However, little is currently known about potential therapy-related changes in the adipose tissue of obese patients. The aim of this study was therefore to quantify fat fraction (FF) and T1 relaxation time by magnetic resonance imaging (MRI) after Roux-en-Y gastric bypass surgery and compare the resulting values with the preoperative ones. Corresponding MRI data were available from 23 patients (16 females and 7 males) that had undergone MRI before (M0) and one month after (M1) bariatric surgery. Patients were 22–59 years old (mean age 44.3 years) and their BMI ranged from 35.7–54.6 kg/m² (mean BMI 44.6 kg/m²) at M0. Total visceral AT volumes (V_VAT-T, in L) were measured by semi-automatic segmentation of axial MRI images acquired between diaphragm and femoral heads. MRI FF and T1 relaxation times were measured in well-defined regions of visceral (VAT) and subcutaneous (SAT) adipose tissue using two custom-made analysis tools. Average BMI values were 45.4 kg/m² at time point M0 and 42.4 kg/m² at M1. Corresponding V_VAT-T values were 5.94 L and 5.33 L. Intraindividual differences in both BMI and V_VAT-T were highly significant (p<0.001). Average relaxation times T1_VAT were 303.7 ms at M0 and 316.9 ms at M1 (p<0.001). Corresponding T1_SAT times were 283.2 ms and 280.7 ms (p = 0.137). Similarly, FF_VAT differences (M0: 85.7%, M1: 83.4%) were significant (p <0.01) whereas FF_SAT differences (M0: 86.1, M1: 85.9%) were not significant (p = 0.517). In conclusion, bariatric surgery is apparently not only related to a significant reduction in common parameters of adipose tissue distribution, here BMI and total visceral fat volume, but also significant changes in T1 relaxation time and fat fraction of visceral adipose tissue. Such quantitative MRI measures may potentially serve as independent biomarkers for longitudinal and cross-sectional measurements in obese patients.

Repercussões da cirurgia bariátrica na qualidade de vida, no perfil bioquímico e na pressão arterial de pacientes com obesidade mórbida

RESUMO A indicação da cirurgia bariátrica (CB) para perda de peso e redução de comorbidades associadas à obesidade é crescente. O objetivo do presente estudo foi analisar as repercussões da CB na qualidade de vida (QV), no perfil bioquímico e na pressão arterial (PA) de indivíduos obesos mórbidos em três momentos distintos: um mês antes, três meses depois e seis meses após a CB. Participaram da pesquisa 42 indivíduos com obesidade mórbida do programa de CB de um hospital da cidade de Juiz de Fora - MG, os quais foram aleatoriamente divididos em grupo intervenção (GI, n=21) e grupo controle (GC, n=21). O GI sofreu intervenção cirúrgica e o GC foi orientado a manter os afazeres diários usuais durante todo período do estudo, além de receberem acompanhamento nutricional. Foram avaliados a QV, o perfil bioquímico e a PA através do instrumento SF-36, do exame laboratorial de sangue obtido no prontuário dos pacientes e do esfigmomanômetro e estetoscópio, respectivamente. Os resultados demonstraram redução nas variáveis bioquímicas High-density lipoproteins (HDL), Low-density lipoproteins (LDL), Very Low-Density Lipoprotein (VLDL), colesterol, triglicerídeos, hemoglobina glicada, glicose, pressão arterial sistólica e pressão arterial diastólica no GI, após 6 meses de cirurgia. Houve melhora significativa nas variáveis relacionadas à QV, exceto nos aspectos emocionais. Conclui-se que a CB pode repercutir positivamente na maioria dos domínios da QV, na melhora do perfil bioquímico e na PA de pacientes obesos mórbidos após 3 e 6 meses de CB.

Long-Term Results After Sleeve Gastrectomy for Gastroesophageal Reflux Disease: a Single-Center French Study

BACKGROUND

Many studies have analyzed the impact of sleeve gastrectomy (SG) on weight loss and/or the evolution of obesity-related comorbid conditions, but few have reported the long-term outcomes after surgery. The objective of this study was to investigate the outcomes after SG on weight loss, obesity-related comorbid conditions, quality of life (QoL), and GERD symptoms (GERDS) beyond 5 years.

METHODS

A prospective database was retrospectively searched for the following factors: gender, age, anthropometrics, presence of comorbid conditions, QoL (BAROS questionnaire), and presence of GERDS. The data were analyzed before and at 1 and 6 years after surgery.

RESULTS

Of the 64 patients included, 32.8% were lost to follow-up (76% during the first postoperative year). A complete follow-up of >5 years was obtained for 41 patients. Before surgery, mean excess BMI was 22 ± 7 kg/m², and 26.8% of patients had GERDS. Percent excess BMI loss was 55 ± 30% at 1 year and 48 ± 27% at 6 years. Preoperative BMI and absence of type 2 diabetes (T2D) before surgery were the only independent variables for long-term failure. Six years after SG, remission from metabolic comorbidities was as follows: 50% for T2D, 28% for blood hypertension, 58% for dyslipidemia, and 33% for sleep-apnea syndrome. Thirty percent of patients with preoperative GERD had resolution of symptoms at 6 years whereas 9 patients (32%) had de novo GERD. QoL was improved for 62% of patients at 6 years.

CONCLUSION

The benefits of SG on weight loss, resolution of comorbidities, and QoL were maintained in the long term for most patients.

Three-Year Outcomes of Revisional Laparoscopic Gastric Bypass after Failed Laparoscopic Sleeve Gastrectomy: a Case-Matched Analysis

BACKGROUND

While previous studies suggest laparoscopic Roux-en-Y gastric bypass (LRYGB) as a reasonable treatment approach to address weight loss failure after laparoscopic sleeve gastrectomy (LSG), data focusing on long-term outcomes are still lacking. The purpose of this study was to evaluate weight and comorbidity outcomes comparing revisional LRYGB (rLRYGB) with primary LRYGB (pLRYGB).

METHODS

Retrospective single-centre case-matched analysis was conducted at a bariatric tertiary referral centre. Between January 2009 and July 2013, 239 patients were entered into a prospective database, and 32 patients undergoing rLRYGB (cases) were matched with 32 patients undergoing pLRYGB (controls) for sex, age and BMI. The end point was data at 3 years of follow-up. Thirty-one patients (12.9%) were lost to follow-up during the study period.

RESULTS

There were no significant differences in patient demographics or median BMI (kg/m²) for pLRYGB or rLRYGB (42.8 ± 12.1 vs. 42.3 ± 11.5, respectively; p = 0.748). Coexisting comorbidities were rated similarly in both groups. At 3 years, the percentage of excess weight loss (74.4 ± 23.3 vs 52.0 ± 26, respectively; p = 0.007) was higher for pLRYGB than rLRYGB, while similar improvements of coexisting comorbidities could be observed.

CONCLUSION

rLRYGB is a feasible and practical surgical approach that allows effective weight loss at 3 years of follow-up and alleviates refractory reflux symptoms. Although weight loss is lower compared to pLRYGB, resolution or improvement of coexisting comorbidities appears similar. Therefore, rLRYGB seems to be a reliable procedure to address failure after LSG.

Thin bones: Vitamin D and calcium handling after bariatric surgery

Bariatric surgery has proven to be a valuable treatment option for morbid obesity. However, these procedures can lead to impaired intestinal absorption of calcium and vitamin D, thereby challenging calcium homeostasis and possibly contributing to bone loss leading to an increased fracture risk. Besides calcium and vitamin D malabsorption, hormonal changes occurring after surgery can also be the source of observed bone loss. In this review, first, a case report will be discussed, highlighting the relevance of this topic. Afterwards, changes in bone density and fracture risk, after the two most performed types of bariatric surgery, Sleeve Gastrectomy (SG) and Roux-en-Y Gastric Bypass (RYGB) will be discussed. In addition, we discuss the putative underlying mechanisms leading to bone changes based on both preclinical and clinical observations. Nonetheless, it is clear further research is needed to further elucidate the exact mechanisms of bone loss following bariatric surgery and subsequently identify potential treatment options for bone preservation.

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Bariatric surgery induces bone loss and leads to increased fracture risk.

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Bone resorption increases after both SG and, more strongly, after RYGB.

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Malabsorption and adipose tissue-related hormones likely contribute to bone loss.

Disturbed Vitamin A Metabolism in Non-Alcoholic Fatty Liver Disease (NAFLD)

Vitamin A is required for important physiological processes, including embryogenesis, vision, cell proliferation and differentiation, immune regulation, and glucose and lipid metabolism. Many of vitamin A’s functions are executed through retinoic acids that activate transcriptional networks controlled by retinoic acid receptors (RARs) and retinoid X receptors (RXRs).The liver plays a central role in vitamin A metabolism: (1) it produces bile supporting efficient intestinal absorption of fat-soluble nutrients like vitamin A; (2) it produces retinol binding protein 4 (RBP4) that distributes vitamin A, as retinol, to peripheral tissues; and (3) it harbors the largest body supply of vitamin A, mostly as retinyl esters, in hepatic stellate cells (HSCs). In times of inadequate dietary intake, the liver maintains stable circulating retinol levels of approximately 2 μmol/L, sufficient to provide the body with this vitamin for months. Liver diseases, in particular those leading to fibrosis and cirrhosis, are associated with impaired vitamin A homeostasis and may lead to vitamin A deficiency. Liver injury triggers HSCs to transdifferentiate to myofibroblasts that produce excessive amounts of extracellular matrix, leading to fibrosis. HSCs lose the retinyl ester stores in this process, ultimately leading to vitamin A deficiency. Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of metabolic syndrome and is a spectrum of conditions ranging from benign hepatic steatosis to non-alcoholic steatohepatitis (NASH); it may progress to cirrhosis and liver cancer. NASH is projected to be the main cause of liver failure in the near future. Retinoic acids are key regulators of glucose and lipid metabolism in the liver and adipose tissue, but it is unknown whether impaired vitamin A homeostasis contributes to or suppresses the development of NAFLD. A genetic variant of patatin-like phospholipase domain-containing 3 (PNPLA3-I148M) is the most prominent heritable factor associated with NAFLD. Interestingly, PNPLA3 harbors retinyl ester hydrolase activity and PNPLA3-I148M is associated with low serum retinol level, but enhanced retinyl esters in the liver of NAFLD patients. Low circulating retinol in NAFLD may therefore not reflect true “vitamin A deficiency”, but rather disturbed vitamin A metabolism. Here, we summarize current knowledge about vitamin A metabolism in NAFLD and its putative role in the progression of liver disease, as well as the therapeutic potential of vitamin A metabolites.

[Quality indicators for metabolic and bariatric surgery in Germany : Evidence-based development of an indicator panel for the quality of results, indications and structure]

An expert committee was appointed by the German Society for General and Visceral Surgery to develop a panel of appropriate quality indicators to collate the quality of results, indications and structure in metabolic and bariatric surgery. This entailed assimilating the available evidence (systematic literature search), results from the national registry of the society (StuDoQ|MBE) and specific socioeconomic aspects (e. g. severely limited access to metabolic and bariatric surgery in Germany). These quality parameters were to be incorporated into the national guidelines and the rules of procedure for certification in the future. The committee concluded that mortality, MTL30 and severe complications needing intervention (Clavien-Dindo ≥ 3b) are suitable indicators to measure surgical outcome quality due to their relevance, scientific soundness and practicability. As a systematic follow-up is mandatory after bariatric surgery, a minimum follow-up quota is now required using reported quality of life data as an indicator of process quality. As intestinal bypass procedures have been shown to be superior in the treatment of type 2 diabetes, these procedures should be offered to eligible patients and also be performed. The proposed threshold values based on the results of the available literature and StuDoQ registry are to be considered as preliminary and need to be validated and adjusted if necessary in the future. The StuDoQ|MBE is considered a valuable tool to gather this information and also represents the appropriate infrastructure for the collation of relevant risk adjustors.

Short- and long-term mortality after bariatric surgery: A systematic review and meta-analysis

AIMS

The objective of this study was to investigate short- (≤ 30 days) and long-term (≥ 2 years) all-cause mortality after bariatric surgery among adult patients with obesity.

MATERIALS AND METHODS

For short-term mortality, eligible studies comprised randomized controlled trials (RCTs) reporting perioperative mortality. For long-term mortality, eligible studies comprised RCTs and observational studies comparing mortality between obese patients after bariatric surgery and non-operated controls. Random-effects models using a Bayesian or frequentist approach were used to pool effect estimates of short- and long-term mortality, respectively.

RESULTS

Short-term all-cause mortality based on 38 RCTs involving 4030 patients was 0.18% (95% CI, 0.04%-0.38%) and was higher for open surgeries (0.31%; 95% CI, 0.03%-0.97%) and similar in mixed surgeries (0.17%; 95% CI, 0.03%-0.43%) and restrictive surgeries (0.17%; 95% CI, 0.03%-0.45%). For long-term mortality, 12 observational studies involving 27 258 operated patients and 97 154 non-operated obese controls were included. Of these, 8 studies were eligible for the meta-analysis, which showed a reduction of 41% in all-cause mortality (hazard ratio, 0.59; 95% CI, 0.52-0.67; P < .001). Additionally, operated patients were 0.42 times as likely (95% CI, 0.25-0.72, P < .001) and 0.47 times as likely (95% CI, 0.36-0.63, P < .001) as non-operated obese controls to die from cardiovascular diseases and cancer, respectively.

CONCLUSIONS

Bariatric surgery is associated with low short-term mortality and may be associated with long-term reductions in all-cause, cardiovascular and cancer-related mortality.

Systematic review and retrospective validation of prediction models for weight loss after bariatric surgery

BACKGROUND

Patients often have less than realistic expectations of the weight loss they are likely to achieve after bariatric surgery. It would be useful to have a well-validated prediction tool that could give patients a realistic estimate of their expected weight loss.

OBJECTIVES

To perform a systematic review of the literature to identify existing prediction models and attempt to validate these models.

SETTING

University hospital, United Kingdom.

METHODS

A systematic review was performed. All English language studies were included if they used data to create a prediction model for postoperative weight loss after bariatric surgery. These models were then tested on patients undergoing bariatric surgery between January 1, 2013 and December 31, 2014 within our unit.

RESULTS

An initial literature search produced 446 results, of which only 4 were included in the final review. Our study population included 317 patients. Mean preoperative body mass index was 46.1 ± 7.1. For 257 (81.1%) patients, 12-month follow-up was available, and mean body mass index and percentage excess weight loss at 12 months was 33.0 ± 6.7 and 66.1% ± 23.7%, respectively. All 4 of the prediction models significantly overestimated the amount of weight loss achieved by patients. The best performing prediction model in our series produced a correlation coefficient (R²) of .61 and an area under the curve of .71 on receiver operating curve analysis.

CONCLUSIONS

All prediction models overestimated weight loss after bariatric surgery in our cohort. There is a need to develop better procedures and patient-specific models for better patient counselling.

Medium-Term Results of Combined Laparoscopic Sleeve Gastrectomy and Modified Jejuno-Ileal Bypass in Bariatric Surgery

BACKGROUND

The ideal bariatric operation achieves 70-100 % maintained excess weight loss, is simple with low operative risks, and maintains absorption of trace elements. Our aim was to find a bariatric procedure that achieves the above while avoiding drawbacks of current options.

METHODS

A standard sleeve gastrectomy was combined with a modified jejuno-ileal bypass dividing the small bowel 75 cm distal to the duodeno-jejunal flexure, anastomosing it to the ileum 75 cm proximal to the ileocaecal valve. Operative and follow-up data were collected prospectively between December 2004 and January 2013.

RESULTS

One hundred sixty-eight procedures were analysed (110 female, 58 male). Mean patient age was 43 years (IQR 37-47), and median preoperative body mass index (kg/m(2)) was 52 (IQR 49-59). All operations were completed laparoscopically. Excess weight loss was 78 % (IQR 70-83 %, 12 months, n = 168), 79 % (IQR 70-85 %, 24 months), maintained at most recent follow-up with 77 % (IQR 68-84 %, n = 168), and for 8 year follow-up alone 75 % (IQR 66-84 %, n = 18). There was no operative mortality and 5.4 % morbidity. A 6.5 % of patients experienced transient vomiting. No symptoms of dumping or bacterial overgrowth were observed. All had normal liver enzymes. Hypocalcaemia (20.8 %) and zinc deficiency (25.6 %) resolved with oral supplementation. Type 2 diabetes mellitus resolved in 80.3 % and improved in the remainder of patients, hypertension resolved in 92.3 % and improved in the rest.

CONCLUSIONS

Whilst currently an investigative procedure, and within the studies limitations combined sleeve gastrectomy with modified jejuno-ileal bypass is safe and effective, and evades many problems associated with current bariatric operations whilst offering maintained excess weight loss.

A systematic review and narrative synthesis of interventions for uncomplicated obesity: weight loss, well-being and impact on eating disorders

OBJECTIVE

Most weight loss research focuses on weight as the primary outcome, often to the exclusion of other physiological or psychological measures. This study aims to provide a holistic evaluation of the effects from weight loss interventions for individuals with obesity by examining the physiological, psychological and eating disorders outcomes from these interventions.

METHODS

Databases Medline, PsycInfo and Cochrane Library (2011-2016) were searched for randomised controlled trials and systematic reviews of obesity treatments (dietary, exercise, behavioural, psychological, pharmacological or surgical). Data extracted included study features, risk of bias, study outcomes, and an assessment of treatment impacts on physical, psychological or eating disorder outcomes.

RESULTS

From 3628 novel records, 134 studies met all inclusion criteria and were evaluated in this review. Lifestyle interventions had the strongest evidence base as a first-line approach, with escalation to pharmacotherapy and bariatric surgery in more severe or complicated cases. Quality of life was the most common psychological outcome measure, and improved in all cases where it was assessed, across all intervention types. Behavioural, psychological and lifestyle interventions for weight loss led to improvements in cognitive restraint, control over eating and binge eating, while bariatric surgery led to improvements in eating behaviour and body image that were not sustained over the long-term.

DISCUSSION

Numerous treatment strategies have been trialled to assist people to lose weight and many of these are effective over the short-term. Quality of life, and to a lesser degree depression, anxiety and psychosocial function, often improve alongside weight loss. Weight loss is also associated with improvements in eating disorder psychopathology and related measures, although overall, eating disorder outcomes are rarely assessed. Further research and between-sector collaboration is required to address the significant overlap in risk factors, diagnoses and treatment outcomes between obesity and eating disorders.

Serum levels of vitamin A, visual function and ocular surface after bariatric surgery

BACKGROUND

- Bariatric surgery is the most effective treatment for severe obesity, but the surgery increases the risk of developing nutritional deficiencies, such as vitamin A deficiency. In human metabolism, vitamin A plays a role in vision.

OBJECTIVE

- To evaluate serum vitamin A, visual function and ocular surface of patients undergoing bariatric surgery.

METHODS

- A cross-sectional and analytical study was conduced with 28 patients undergoing bariatric surgery for at least 6 months. Ophthalmologic evaluation was done through color vision test, contrast sensitivity test, ocular surface tests and confocal microscopy, as well as vitamin A serum measurement.

RESULTS

- Vertical sleeve gastrectomy was performed in seven (25.0%) patients and Roux -en-Y gastric by-pass in 21 (75.0%). Mean serum vitamin A level was 1.7±0.5 µmoL/L. Most patients (60.7%) had symptoms of dry eye. Five (17.9%) patients had contrast sensitivity impairment and 18 (64.3%) color vision changes. In the group of patients undergoing Roux -en-Y gastric by-pass , mean vitamin A levels were 1.8±0.6 µmoL/L, whereas they were 1.7±0.5 µmoL/L in patients submitted to the restrictive technique vertical sleeve gastrectomy . The analysis of the influence of serum levels of vitamin A in the visual function and ocular surface was performed by Pearson correlation test and there was no significant correlation between any of the variables and vitamin A.

CONCLUSION

- There was no influence of the bariatric surgery technique used on serum vitamin A levels, on the visual function or on the ocular surface. Moreover, there was no correlation between serum levels of vitamin A and the visual function or the ocular surface changes.

Rapid Evidence Review of Bariatric Surgery in Super Obesity (BMI ≥ 50 kg/m2)

BACKGROUND

Despite accumulating evidence of the important health benefits of bariatric surgery in morbidly obese patients in general, bariatric surgery outcomes are less clear in higher-risk, high-priority populations of patients with BMI ≥ 50 kg/m². To help the Department of Veterans Affairs (VA) Health Services Research & Development Service (HSR&D) develop a research agenda, we conducted a rapid evidence review to better understand bariatric surgery outcomes in adults with BMI ≥ 50 kg/m².

METHODS

We searched MEDLINE^®, the Cochrane Database of Systematic Reviews, the Cochrane Central Registry of Controlled Trials, and ClinicalTrials.gov through June 2016. We included trials and observational studies. We used pre-specified criteria to select studies, abstract data, and rate internal validity and strength of the evidence (PROSPERO registration number CRD42015025348). All decisions were completed by one reviewer and checked by another.

RESULTS

Among 1892 citations, we included 23 studies in this rapid review. Compared with usual care, one large retrospective VA study provided limited evidence that bariatric surgery can lead to increased mortality in the first year, but decreased mortality long-term among super obese veterans. Studies that compared different bariatric surgical approaches suggested some differences in weight loss and complications. Laparoscopic gastric bypass generally resulted in greater short-term proportion of excess weight loss than did other procedures. Duodenal switch led to greater long-term weight loss than did gastric bypass, but with more complications.

CONCLUSIONS

The published literature that separates the super obese is insufficient for determining the precise balance of benefits and harms of bariatric surgery in this high-risk subgroup. Future studies should evaluate a more complete set of key outcomes with longer follow-up in larger samples of more broadly representative adults.

Weight loss and carotid intima-media thickness-a meta-analysis

OBJECTIVE

Obesity is a risk factor for clinical cardiovascular disease, putatively via increased burden of atherosclerosis. It remains contentious as to whether weight loss in people with obesity is accompanied by a reduction in intima-media thickness, a noninvasive marker of subclinical atherosclerosis, consistent with a lowering of risk of cardiovascular events.

METHODS

A systematic literature search was performed to identify all surgical and nonsurgical weight loss interventions that reported intima-media thickness. A meta-analysis was undertaken to obtain pooled estimates for change in intima-media thickness.

RESULTS

From the 3,197 articles screened, 9 studies were included in the meta-analysis, with a total of 393 participants who lost an average of 16 kg (95% CI 9.4-22.5) of body weight over an average follow-up of 20 months. The pooled mean change in carotid intima-media thickness was -0.03 mm (95% CI -0.05 to -0.01), which was similar between surgical and nonsurgical interventions.

CONCLUSIONS

In people with obesity, weight loss was associated with a reduction in carotid intima-media thickness, consistent with a lowering in risk of cardiovascular events.

Early dumping syndrome is not a complication but a desirable feature of Roux-en-Y gastric bypass surgery

Early dumping syndrome after gastric bypass surgery due to rapid delivery of hyperosmolar nutrients into the bowel causing intense symptoms is often described as a complication. Twelve patients, mean age 47 years, were interviewed approximately 9 years post-operation. The interviews were audiotaped and transcribed verbatim, followed by an inductive content analysis to reveal patients' experience of the dumping syndrome. The core category 'Dumping syndrome is a positive consequence of Roux-en-Y gastric bypass surgery and a tool to control food intake' was identified based on the following four sub-categories: (i) 'The multidimensional emergence and effects of dumping syndrome', (ii) 'Dumping syndrome as something positive although unpleasant', (iii) 'Developing coping mechanisms and ingenious strategies' and (iv) 'My own fault if I expose myself to dumping syndrome'. From the patients' perspective, dumping syndrome gives control over food intake; although the symptoms were unpleasant, patients considered dumping syndrome as a positive protection against over-consumption. Hence, healthcare professionals should not present dumping syndrome as a complication but rather as an aid to control eating behaviour and excessive food intake.

The future of the Roux-en-Y gastric bypass

Archaic surgical procedures such as the jejunoileal bypass, vertical banded gastroplasty and duodenal switch have contributed to the current best practice of Roux-en-Y gastric bypass (RYGB) procedure for the treatment of obesity and its consequences. Despite this, RYGB has been blighted with late occurring adverse events such as severe malnutrition, marginal ulcer and reactive hypoglycemia. Despite this, RYGB has given us an opportunity to examine the effect of surgery on gut hormones and the impact on metabolic syndrome which in turn has allowed us to carry out a lower impact but equally, if not more effective, procedure - the vertical sleeve gastrectomy (VSG). We examine the benefits of sleeve gastrectomy from the less challenging technical aspect to the effect on obesity and its metabolic syndrome long-term and have concluded that sleeve gastrectomy is possibly the next current best practice.

From bariatric to metabolic surgery: Looking for a “disease modifier” surgery for type 2 diabetes

In this review the recent evolution of the comprehension of clinical and metabolic consequences of bariatric surgery is depicted. At the beginning bariatric surgery aim was a significant and durable weight loss. Later on, it became evident that bariatric surgery was associated with metabolic changes, activated by unknown pathways, partially or totally independent of weight loss. Paradigm of this “metabolic” surgery is its effects on type 2 diabetes mellitus (T2DM). In morbid obese subjects it was observed a dramatic metabolic response leading to decrease blood glucose, till diabetes remission, before the achievement of clinically significant weight loss, opening the avenue to search for putative anti-diabetic “intestinal” factors. Both proximal duodenal (still unknown) and distal (GLP1) signals have been suggested as hormonal effectors of surgery on blood glucose decrease. Despite these findings T2DM remission was never considered a primary indication for bariatric surgery but only a secondary one. Recently T2DM remission in obese subjects with body mass index (BMI) greater than 35 has become a primary aim for surgery. This change supports the idea that “metabolic surgery” definition could more appropriate than bariatric, allowing to explore the possibility that metabolic surgery could represent a “disease modifier” for T2DM. Therefore, several patients have undergone surgery with a primary aim of a definitive cure of T2DM and today this surgery can be proposed as an alternative therapy. How much surgery can be considered truly metabolic is still unknown. To be truly “metabolic” it should be demonstrated that surgery could cause T2DM remission not only in subjects with BMI > 35 but also with BMI < 35 or even < 30. Available evidence on this topic is discussed in this mini-review.

SAFETY AND EFFECTIVENESS OF SINGLE ANASTOMOSIS DUODENAL SWITCH PROCEDURE: PRELIMINARY RESULT FROM A SINGLE INSTITUTION

Background

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) was introduced into bariatric surgery by Sanchez-Pernaute et al. as an advancement of the biliopancreatic diversion with duodenal switch.

Aim

To evaluate the SADI-S procedure with regard to weight loss, comorbidity resolution, and complication rate in the super obese population.

Methods

A retrospective chart review was performed on initial 72 patients who underwent laparoscopic or robot-assisted laparoscopic SADI-S between December 17th, 2013 and July 29th, 2015.

Results

A total of 48 female and 21 male patients were included with a mean age of 42.4±10.0 years (range, 22-67). The mean body mass index (BMI) at the time of procedure was 58.4±8.3 kg/m2 (range, 42.3-91.8). Mean length of hospital stay was 4.3±2.6 days (range, 3-24). Thirty-day readmission rate was 4.3% (n=3), due to tachycardia (n=1), deep venous thrombosis (n=1), and viral gastroenteritis (n=1). Thirty-day reoperation rate was 5.8% (n=4) for perforation of the small bowel (n=1), leakage (n=1), duodenal stump leakage (n=1), and diagnostic laparoscopy (n=1). Percentage of excess weight loss (%EWL) was 28.5±8.8 % (range, 13.3-45.0) at three months (n=28), 41.7±11.1 % (range, 19.6-69.6) at six months (n=50), and 61.6±12.0 % (range, 40.1-91.2) at 12 months (n=23) after the procedure. A total of 18 patients (26.1%) presented with type II diabetes mellitus at the time of surgery. Of these patients, 9 (50.0%) had their diabetes resolved, and six (33.3%) had it improved by 6-12 months after SADI-S.

Conclusions

SADI-S is a feasible operation with a promising weight loss and diabetes resolution in the super-obese population.

Great Health Benefits But No Change in Employment or Psychopharmaceutical Drug Use 2 Years After Roux-en-Y Gastric Bypass

BACKGROUND

The aim was to examine health benefits and lifestyle factors after Roux-en-Y gastric bypass (RYGB).

METHODS

Patients (n = 165) were investigated 2 years after RYGB in relation to psychopharmaceutical drugs, employment status, type 2 diabetes mellitus (T2DM), hypertension, metabolic syndrome (MetS), body weight, physical activity (PA), and energy intake.

RESULTS

Excess weight loss (EWL) was 71.4 ± 20.6 %. Prevalence of T2DM, hypertension, and MetS was reduced (P < 0.001 for all). There were no changes in the use of psychopharmaceutical drugs (20.6 vs. 18.8 %, P = 0.549) or in the proportion of unemployed participants (37.7 vs. 33.3 %, P = 0.189) from pre- to post-surgery. Eighty-three percent achieved EWL ≥ 50 %. These subjects had a lower pre-surgery BMI. We found no differences in the prevalence of hypertension, T2DM, and MetS pre-surgery, but the prevalence was lower after surgery compared with subjects with EWL < 50 %.

CONCLUSION

RYGB induced remission of T2DM, hypertension, and MetS 2 years after surgery. The benefit was greatest in the group with EWL ≥ 50 %. Despite excellent weight loss, there was no change in the use of psychopharmaceutical drugs or proportion of unemployed participants.

Malabsorption as a Therapeutic Approach in Bariatric Surgery

Background

The increasing prevalence of obese patients will lead to a more frequent use of bariatric procedures in the future. Compared to conservative medical therapy, bariatric procedures achieve greater weight loss and superior control of comorbidities, resulting in improved overall mortality.

Methods

A search for current literature regarding mechanisms, indications, and outcomes of bariatric surgery was performed.

Results

In order to care for patients after bariatric surgery properly, it is important to understand its mechanisms of action and effects on gastrointestinal physiology. Recent investigations indicate that the beneficial effects of bariatric procedures are much more complex than simply limiting food intake or an associated malabsorption. Changes in gastrointestinal hormone secretion, energy expenditure, intestinal bacterial colonization, bile acid metabolism, and epigenetic modifications resulting in altered gene expression are likely responsible for the majority of the beneficial effects of bariatric surgery. Malabsorptive bariatric procedures divert the flow of bile and pancreatic enzymes from food and therefore limit the digestion and absorption of nutrients, resulting in reduced calorie intake and subsequent weight loss. Essential micronutrients such as vitamins and trace elements are also absorbed to a lesser extent, potentially leading to severe side effects.

Conclusion

To prevent malnutrition, dietary supplementation and regular control of micronutrient levels are mandatory for patients undergoing malabsorptive bariatric procedures, in whom the fat-soluble vitamins A and D are commonly deficient.

The link between obesity and vitamin D in bariatric patients with omega-loop gastric bypass surgery - a vitamin D supplementation trial to compare the efficacy of postoperative cholecalciferol loading (LOAD): study protocol for a randomized controlled trial

Background

Beyond its classical role in calcium homoeostasis and bone metabolism, vitamin D deficiency has been found to be associated with several diseases, including diabetes, non-alcoholic fatty liver disease, and even obesity itself. Importantly, there are limited data on therapeutic strategies for vitamin D deficiency in bariatric patients, and the procedure-specific guidelines may not be sufficient. To improve long-term outcomes, nutritional screening and appropriate supplementation to prevent nutrient deficiencies are urgently needed. Therefore, the aim of this study is to examine effects and safety of a forced dosing regimen of vitamin D versus conventional dose supplementation on vitamin D levels and other parameters in bariatric patients.

Methods/Design

The study includes loading plus repeat dosing compared with repeated administration of vitamin D without a loading dose, according to guidelines, in a prospective, double-blind, randomized controlled trial. Up to a triple oral loading dose is given on day 1, then 2 and 4 weeks after surgery (100,000 IU dose each time), followed by an oral maintenance dose (3420 IU/day). The control group (n = 25) will receive placebo, followed by administration of a standard dose (3420 IU/day). We hypothesize that a significant increase in vitamin D levels will occur in patients in the treatment group (n = 25) by 24 weeks after surgery. Further measurements are aimed at evaluating changes in inflammation, bone turnover, insulin resistance, blood pressure, liver, mental health, and gut microbiota of patients undergoing omega-loop gastric bypass surgery. Furthermore, possible associations between concentrations of vitamin D, the involved enzymes, or vitamin D receptor in adipose and/or liver tissues will be determined.

Discussion

To our knowledge, this trial is the first of its kind with this type of vitamin D supplementation in bariatric patients. Its major strength is the design and implementation of evaluation of influencing factors such as liver function, bone health, inflammation, insulin resistance, blood pressure, symptoms of depression, or microbiota. This alternative vitamin D dosing regimen has the potential to be a safe, fast, evidence-based treatment of vitamin D deficiency in bariatric patients. Owing to the increasing number of bariatric patients, it is also of interest to elucidate the link between obesity and vitamin D.

Trial registration

ClinicalTrials.gov identifier: NCT02092376. Registered on 17 March 2014.