Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss in Patients With Morbid Obesity: The SM-BOSS Randomized Clinical Trial

Alterations of Gastric Emptying Features Following Laparoscopic Sleeve Gastrectomy in Chinese Patients with Obesity: a Self-Controlled Observational Study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become an increasingly popular metabolic surgical procedure. Alteration in motor gastric function is a fundamental feature following LSG but still remains controversial.

PURPOSE

To determine the gastric emptying time 3 month after LSG, correlations between gastric emptying time and body weight, weight loss, and glycemia levels, alongside determining predictive factors of weight loss at the 3-month follow-up.

MATERIALS AND METHODS

Twenty-one patients were recruited in this study. Gastric emptying time was measured using a standard solid-phase gastric emptying scan at both baseline and 3 months after LSG. Paired sample t tests and a general linear model with repeated measures were applied to investigate the alterations in major parameters after surgery. Univariate analyses were performed to evaluate the factors predicting weight loss at the 3-month follow-up.

RESULTS

Compared with baseline levels, gastric emptying time, body weight, and HbA_1c levels decreased significantly at 3 months after LSG (P < 0.001). Significant positive correlations were detected between HbA_1c levels and gastric emptying time at baseline (P = 0.03). Significant positive correlations were detected between HbA_1c levels at baseline and change in gastric emptying time (P = 0.03). Univariate logistic regression revealed a lower baseline BMI level to be independently associated with %EWL (P < 0.001).

CONCLUSIONS

The rate of gastric emptying increased following LSG. Patients with a higher risk of type 2 diabetes at baseline had longer gastric emptying times prior to treatment and significantly shortened emptying times following surgery.

Sleeve Gastrectomy: You Might Lose your Liver!

Sleeve gastrectomy (SG) is currently the most popular bariatric procedure. Portomesenteric venous thrombosis (PVT) is a feared and increasingly reported complication. Herein, we describe the history of a patient who developed a post-operative PVT after SG, aggravated with refractory ascites, and finally required orthotopic liver transplantation (LT). Acquired thrombophilia-anti-cardiolipin syndrome was present. As SG expands worldwide, this first case of LT for PVT following SG may warrant a systematic screening for prothrombotic condition and information on the possible consequences of PVT prior to bariatric surgery.

Laparoscopic Sleeve Gastrectomy Carries a Lower Perioperative Mortality Including Sudden Cardiac Death over Roux-en-Y Gastric Bypass in Patients with a Prior Cardiac History: An MBSAQIP Analysis

BACKGROUND

Although bariatric surgery has proven beneficial for those with cardiovascular disease (CVD), the overall and procedure-specific risk associated with bariatric surgery in this patient population remains unknown.

DESIGN

Patients who underwent primary laparoscopic, laparoscopic-assisted, or robotic-assisted Roux-En-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at a MBSAQIP-accredited center were included (n = 494,611). Exposures include history of MI, PCI, or cardiac surgery who underwent RYGB or SG. Outcome measures were 30-day mortality, perioperative cardiac arrest, and rehospitalization.

RESULTS

Of 494,611 patients enrolled in MBSAQIP, 15,923 had a history of MI, PCI, or cardiac surgery (prior cardiac history). Patient history of MI, PCI, and cardiac surgery was associated with significantly increased adjusted risk of perioperative cardiac arrest requiring CPR (OR: 2.31, 2.12, 2.42, respectively) and adjusted 30-day mortality (OR: 1.72, 1.50, 1.68, respectively). Prior cardiac history was associated with increased adjusted 30-day readmission rate (MI - OR, 1.42; PCI - OR, 1.45; and cardiac surgery - OR, 1.68). Further, 30-day postoperative readmission, postoperative cardiac arrest, and death were lower for patients undergoing SG compared to RYGB (OR: 0.48, 0.49, and 0.54 respectively).

CONCLUSION AND RELEVANCE

Prior cardiac history was associated with significant greater risk of perioperative cardiac arrest and 30-day mortality among patients undergoing bariatric surgery. SG was associated with less adverse events than RYGB among this population. While there is a clear benefit to weight loss in patients with CVD, it is important to consider whether cardiac patients considering bariatric surgery may require additional preoperative optimization, perioperative interventions, and postoperative monitoring.

WEIGHT LOSS COMPARISON AFTER SLEEVE AND ROUX-EN-Y GASTRIC BYPASS: SYSTEMATIC REVIEW

INTRODUCTION

Bariatric surgery is currently the gold standard treatment for obesity. The two most accomplished surgeries are the Roux-en-Y gastric bypass and the sleeve gastrectomy, and controversies exist in which is better.

OBJECTIVE

To compare the two techniques in relation to weight loss with at least five years of follow-up.

METHODS

Search in Medline, PubMed, Embase, SciElo, Lilacs, Cochrane databases from 2001 (beginning of vertical gastrectomy) until 2018, using the following headings: "sleeve" or "sleeve gastrectomy" combined with "gastric bypass" or "Roux-en-Y gastric bypass", "weight loss" and "clinical trial". Criteria for inclusion of articles were patients aged between 18 and 65 years; clinical trial; comparison between the two techniques; minimum five-year follow-up; outcome with weight loss assessment.

RESULTS

The initial search identified 1940 articles, of which 185 publications were identified as clinical trials. One hundred and forty-one were excluded, 67 because they did not compare the two techniques, 57 not addressed weight loss and 17 were repeated articles. Thirty-four studies were retrieved for a more detailed analysis; 36 studies were excluded due to a follow-up of less than five years, and another compared the mini-gastric bypass. In total, seven studies were included in the systematic review, but there was no significant difference in three of them.

CONCLUSION

The gastric bypass had a greater weight loss than the vertical gastrectomy in all the evaluated studies.

Bariatric Surgery in the Treatment of Type 2 Diabetes

PURPOSE OF REVIEW

We seek to characterize the impact of bariatric surgery on diabetes mellitus by recalling its history, examining the clinical data, exploring the putative mechanisms of action, and anticipating its future.

RECENT FINDINGS

Results of clinical trials reveal that bariatric surgery induces remission of diabetes in 33-90% of individuals at 1-year post-treatment versus 0-39% of medically managed. Remission rates decrease over time but remain higher in surgically treated individuals. Investigations have revealed numerous actions of surgery including effects on intestinal physiology, neuronal signaling, incretin hormone secretion, bile acid metabolism, and microbiome changes. Bariatric surgery improves control of diabetes through both weight-dependent and weight-independent actions. These various mechanisms help explain the difference between individuals treated surgically vs. medically. They also explain differing effects of various bariatric surgery procedure types. Understanding how surgery affects diabetes will help optimize utilization of the therapy for both disease prevention and treatment.

Risk of Operative and Nonoperative Interventions Up to 4 Years After Roux-en-Y Gastric Bypass vs Vertical Sleeve Gastrectomy in a Nationwide US Commercial Insurance Claims Database

IMPORTANCE

There are few nationwide studies comparing the risk of reintervention after contemporary bariatric procedures.

OBJECTIVE

To compare the risk of intervention after Roux-en-Y gastric bypass (RYGB) vs vertical sleeve gastrectomy (VSG).

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a nationwide US commercial insurance claims database. Adults aged 18 to 64 years who underwent a first RYGB or VSG procedure between January 1, 2010, and June 30, 2017, were matched on US region, year of surgery, most recent presurgery body mass index (BMI) category (based on diagnosis codes), and baseline type 2 diabetes. The prematch pool included 4496 patients undergoing RYGB and 8627 patients undergoing VSG, and the final weighted matched sample included 4476 patients undergoing RYGB and 8551 patients undergoing VSG.

EXPOSURES

Bariatric surgery procedure type (RYGB vs VSG).

MAIN OUTCOMES AND MEASURES

The primary outcome was any abdominal operative intervention after the index procedure. Secondary outcomes included the following subtypes of operative intervention: biliary procedures, abdominal wall hernia repair, bariatric conversion or revision, and other abdominal operations. Nonoperative outcomes included endoscopy and enteral access. Time to first event was compared using multivariable Cox proportional hazards regression modeling.

RESULTS

Among 13 027 patients, the mean (SD) age was 44.4 (10.3) years, and 74.1% were female; 13.7% had a preoperative BMI between 30 and 39.9, 45.8% had a preoperative BMI between 40 and 49.9, and 24.2% had a preoperative BMI of at least 50. Patients were followed up for up to 4 years after surgery (median, 1.6 years; interquartile range, 0.7-3.2 years), with 41.9% having at least 2 years of follow-up and 16.3% having at least 4 years of follow-up. Patients undergoing VSG were less likely to have any subsequent operative intervention than matched patients undergoing RYGB (adjusted hazard ratio [aHR], 0.80; 95% CI, 0.72-0.89) and similarly were less likely to undergo biliary procedures (aHR, 0.77; 95% CI, 0.67-0.90), abdominal wall hernia repair (aHR, 0.60; 95% CI, 0.47-0.75), other abdominal operations (aHR, 0.71; 95% CI, 0.61-0.82), and endoscopy (aHR, 0.54; 95% CI, 0.49-0.59) or have enteral access placed (aHR, 0.58; 95% CI, 0.39-0.86). Patients undergoing VSG were more likely to undergo bariatric conversion or revision (aHR, 1.83; 95% CI, 1.19-2.80).

CONCLUSIONS AND RELEVANCE

In this nationwide study, patients undergoing VSG appeared to be less likely than matched patients undergoing RYGB to experience subsequent abdominal operative interventions, except for bariatric conversion or revision procedures. Patients considering bariatric surgery should be aware of the increased risk of subsequent procedures associated with RYGB vs VSG as part of shared decision-making around procedure choice.

Gastric bypass versus sleeve gastrectomy in patients with type 2 diabetes (Oseberg): a single-centre, triple-blind, randomised controlled trial

BACKGROUND

For patients with obesity and type 2 diabetes, weight loss improves insulin sensitivity and β-cell function, and can induce remission of diabetes. The comparative efficacy of various bariatric procedures for the remission of type 2 diabetes has not been fully elucidated. We aimed to compare the effects of the two most common bariatric procedures, gastric bypass and sleeve gastrectomy, on remission of diabetes and β-cell function.

METHODS

We conducted a single-centre, triple-blind, randomised trial at Vestfold Hospital Trust (Tønsberg, Norway), in which patients (aged ≥18 years) with type 2 diabetes and obesity were randomly assigned (1:1) to receive gastric bypass or sleeve gastrectomy (the Oseberg study). Randomisation was performed with a computerised random number generator and a block size of 10. Treatment allocation was masked from participants, study personnel, and outcome assessors and was concealed with sealed opaque envelopes. Surgeons used identical skin incisions during both surgeries and were not involved in patient follow-up. The primary clinical outcome was the proportion of participants with complete remission of type 2 diabetes (HbA_1c of ≤6·0% [42 mmol/mol] without the use of glucose-lowering medication) at 1 year after surgery. The primary physiological outcome was disposition index (a measure of β-cell function) at 1 year after surgery, as assessed by an intravenous glucose tolerance test. Primary outcomes were analysed in the intention-to-treat and per-protocol populations. This trial is ongoing and closed to recruitment, and is registered with ClinicalTrials.gov, NCT01778738.

FINDINGS

Between Oct 15, 2012, and Sept 1, 2017, 1305 patients who were preparing for bariatric surgery were screened, of whom 319 consecutive patients with type 2 diabetes were assessed for eligibility. 109 patients were enrolled and randomly assigned to gastric bypass (n=54) or sleeve gastrectomy (n=55). 107 (98%) of 109 patients completed 1-year follow-up, with one patient in each group withdrawing after surgery (per-protocol population). In the intention-to-treat population, diabetes remission rates were higher in the gastric bypass group than in the sleeve gastrectomy group (risk difference 27% [95% CI 10 to 44]; relative risk [RR] 1·57 [1·14 to 2·16], p=0·0054); results were similar in the per-protocol population (risk difference 27% [95% CI 10 to 45]; RR 1·57 [1·14 to 2·15], p=0·0036). In the intention-to-treat population, disposition index increased in both groups (between-group difference 55 [-111 to 220], p=0·52); results were similar in the per-protocol population (between-group difference 21 [-214 to 256], p=0.86). In the gastric bypass group, ten of 54 participants had early complications and 17 of 53 had late side-effects. In the sleeve gastrectomy group, eight of 55 participants had early complications and 22 of 54 had late side-effects. No deaths occurred in either group.

INTERPRETATION

Gastric bypass was found to be superior to sleeve gastrectomy for remission of type 2 diabetes at 1 year after surgery, and the two procedures had a similar beneficial effect on β-cell function. The use of gastric bypass as the preferred bariatric procedure for patients with obesity and type 2 diabetes could improve diabetes care and reduce related societal costs.

FUNDING

Morbid Obesity Centre, Vestfold Hospital Trust.

An Approach to Obesity Management for Gastroenterologists and Hepatologists

PURPOSE OF REVIEW

Obesity is associated with multiple gastrointestinal and liver diseases such as gastroesophageal reflux disease, Barrett's esophagus, esophageal adenocarcinoma, cholelithiasis, colon polyps, and fatty liver disease. To effectively manage obesity, it is imperative to understand current and emerging therapies and procedures.

FINDINGS

Obesity is becoming increasingly prevalent and is associated with a growing monetary health care burden. Cardiac disease, cerebrovascular disease, and diabetes are among the leading causes of preventable and premature death of Americans related to obesity. In addition to behavioral modification (diet and exercise) and bariatric surgery, multiple pharmacotherapies and endoscopic procedures are newly approved and available for the management of obesity. This paper reviews the current literature on the treatments available for the management of obesity including behavior modification, pharmacotherapy, endoscopic weight loss procedures (endobariatrics), and bariatric surgery.

Comparative analysis for the effect of Roux-en-Y gastric bypass vs sleeve gastrectomy in patients with morbid obesity: Evidence from 11 randomized clinical trials (meta-analysis)

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most common procedures performed during bariatric surgery and both of them have been demonstrated having significant efficacy for morbid obesity. However, the comparative analysis of the effect of them has not been well studied. Thus, this comparative analysis was conducted to determine whether LRYGB and LSG are equivalent for mid- and long-term weight loss, resolution of comorbidities and adverse events (AEs).

METHODS

We searched the Cochrane Library, PubMed, Embase and Web of Science databases up to January 1, 2019 for studies that investigated LRYGB and LSG with respect to weight loss outcomes, resolution of comorbidities and AEs. Standardised mean differences (SMDs) and risk ratios (RR) with 95% confidence intervals (CIs) were calculated to compare the outcomes of the groups. Two reviewers assessed the quality of the trials and extracted the data independently. All statistical analyses were performed using the standard statistical procedures in Review Manager 5.2.

RESULTS

We included 11 studies (N = 1,328 participants) in this meta-analysis. Our results showed no significant difference in excess weight loss between LRYGB and LSG, with a pooled SMD of -0.16 (95% CI: -0.52-0.19; P = 0.36). Further, the pooled results showed no significant difference in midterm and long-term weight loss between the comparative groups. Similarly, no significant difference was found in T2DM resolution. The pooled results indicate that patients receiving LSG experienced fewer postoperative complications and reoperation rate, with pooled RRs of 1.66 (95% CI: 1.33-2.07; P < 0.00001) and 1.73 (95% CI: 1.14-2.62; P = 0.01). LRYGB may be superior to LSG in dyslipidemia, hypertension and gastroesophageal reflux disease (GERD) remission.

CONCLUSIONS

The present meta-analysis indicated that both LRYGB and LSG are equivalent for excess weight loss and T2DM resolution. However, patients receiving LSG experienced fewer postoperative complications and reoperation rate than those who underwent LRYGB. LRYGB may be superior in dyslipidemia, hypertension and gastroesophageal reflux disease (GERD) remission.

The Role of Bariatric Surgery on Diabetes and Diabetic Care Compliance

PURPOSE OF REVIEW

Bariatric surgery is a durable and long-term solution to treat both obesity and its associated comorbidities, specifically type 2 diabetes mellitus (T2DM). Many studies have demonstrated the benefits of bariatric surgery on T2DM, but weight recidivism along with recurrence of comorbidities can be seen following these procedures. Patient compliance post-bariatric surgery is linked to weight loss outcomes and comorbidity improvement/resolution. The role of compliance with respect to T2DM medication in bariatric patients specifically has not recently been examined. This article seeks to review the role of bariatric surgery on short- and long-term resolution of T2DM, recurrence, and compliance with T2DM medication following bariatric surgery.

RECENT FINDINGS

Seven randomized control trials have examined metabolic surgery versus medical therapy in glycemic control in patients meeting criteria for severe obesity. Six out of seven studies demonstrate a significant advantage in the surgical arms with regards to glycemic control, as well as secondary endpoints such as weight loss, serum lipid levels, blood pressure, renal function, and other parameters. While patient compliance with lifestyle modifications post-bariatric surgery is linked to weight loss outcomes, there are no studies to date that directly evaluate the role of lifestyle modifications and T2DM medication adherence in the management of T2DM post-bariatric surgery. Bariatric surgery is an effective treatment option to achieve long-term weight loss and resolution of obesity-related medical comorbidities, specifically T2DM. Patient compliance to lifestyle modifications post-bariatric surgery is linked to weight loss outcomes and comorbidity resolution. The role of diabetic care compliance in bariatric patient outcomes, however, is poorly understood. Further studies are needed to elucidate the predictors and associated risk factors for non-compliance in this patient population.

Surgical management of gastroesophageal reflux disease in the obese patient

BACKGROUND

Gastroesophageal reflux disease (GERD) affects two thirds of the American population. Obesity is also a disease that affects two thirds of the population. The pathophysiology of reflux disease is reasonably understood, however, the degree to which obesity affects this disease remains poorly defined. Therefore the approach to GERD in the obese patient requires special attention and its own algorithm.

METHODS

A literature search was conducted to consolidate the current available literature on GERD and its management in the obese. In addition, the authors reviewed the literature and present expert opinion on controversial topics.

RESULTS

It is well established that GERD is increased in obesity and the pathophysiology is reviewed. Management options for GERD are discussed, with a focus on the obese population. Management strategies including fundoplication and gastric bypass are discussed. In addition, bariatric surgery in the setting of GERD is also reviewed.

CONCLUSIONS

Currently this is an extremely controversial topic and this white paper presents a strong review of the literature to help guide the management of this challenging disease in this population. Expert recommendations are given throughout the paper based upon the current available data.

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.

Metabolic Parameters, Weight Loss, and Comorbidities 4 Years After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

BACKGROUND

Sleeve gastrectomy (LSG) is now the predominant bariatric surgery performed, yet there is limited long-term data comparing important outcomes between LSG and Roux-en-Y gastric bypass (RYGB). This study compares weight loss and impact on comorbidities of the two procedures.

METHODS

We retrospectively evaluated weight, blood pressure, hemoglobin A1c, cholesterol, and medication use for hypertension, diabetes, and hyperlipidemia at 1-4 years post-operatively in 380 patients who underwent RYGB and 334 patients who underwent LSG at the University of Michigan from January 2008 to November 2013. Follow-up rates from 714 patients initially were 657 (92%), 556 (78%), 507 (71%), and 498 (70%) at 1-4 years post-operatively.

RESULTS

Baseline characteristics were similar except for higher weight and BMI in LSG. There was greater weight loss with RYGB vs. LSG at all points. Hemoglobin A1c and total cholesterol improved more in RYGB vs. LSG at 4 years. There was greater remission of hypertension and discontinuation of all medications for hypertension and diabetes with RYGB at 4 years.

CONCLUSIONS

Weight loss, reduction in medications for hypertension and diabetes, improvements in markers of diabetes and hyperlipidemia, and remission rates of hypertension were superior with RYGB vs. LSG 4 years post-operatively. Choice of bariatric procedures should be tailored to surgical risk, comorbidities, and weight loss goals.

Gastric emptying scintigraphy results may influence the selection of the type of bariatric surgery: A cohort study

Bariatric surgery (BAS) may result in adverse outcomes that include appearance of gastrointestinal (GI) symptoms and/or failure to reach the weight reduction goal. This retrospective study tested the hypothesis that pre-operative gastric emptying (GE) abnormality is responsible for adverse post-surgical outcomes.Pre-operative GE was performed using the standard solid-meal GE scintigraphy (GES) in 111 consecutive patients (105 females and 6 males, mean age 46.2 years, range 20-70 years) who were evaluated for BAS. All underwent BAS - 93 had laparoscopic sleeve gastrectomy (LSG) and 18 had Roux-en-Y (ReY) gastric bypass. All had short-term (3-6 months) and long-term (up to 54 months) follow-up with review of symptoms, physical, and laboratory examinations. Chi-square analysis was performed. P-value < .05 was considered significant.Of the 111 patients, 83 had normal and 28 had abnormal pre-op GES. Sixty-eight were asymptomatic and 43 were symptomatic prior to surgery. Following surgery, 81 patients were asymptomatic and 30 were symptomatic at long-term follow-up. There was no significant difference between pre-op GE results and post-surgical adverse clinical outcome (p = ns). However, GES results seem to have guided the selection of surgical procedure significantly (P = .008).Pre-operative GE study was not a strong predictor of clinical outcome in BAS. Although, it influenced the type of surgery, as when the GES was abnormal, the patient was more likely to undergo ReY and when GES was normal, they favored LSG. Interestingly, many of our symptomatic patients at 6 months post-op were asymptomatic after long-term follow-up.

Type 2 diabetes remission 1 year after an intensive lifestyle intervention: A secondary analysis of a randomized clinical trial

AIM

To investigate whether an intensive lifestyle intervention induces partial or complete type 2 diabetes (T2D) remission.

MATERIALS AND METHODS

In a secondary analysis of a randomized, assessor-blinded, single-centre trial, people with non-insulin-dependent T2D (duration <10 years), were randomly assigned (2:1, stratified by sex, from April 2015 to August 2016) to a lifestyle intervention group (n = 64) or a standard care group (n = 34). The primary outcome was partial or complete T2D remission, defined as non-diabetic glycaemia with no glucose-lowering medication at the outcome assessments at both 12 and 24 months from baseline. All participants received standard care, with standardized, blinded, target-driven medical therapy during the initial 12 months. The lifestyle intervention included 5- to 6-weekly aerobic and combined aerobic and strength training sessions (30-60 minutes) and individual dietary plans aiming for body mass index ≤25 kg/m² . No intervention was provided during the 12-month follow-up period.

RESULTS

Of the 98 randomized participants, 93 completed follow-up (mean [SD] age 54.6 [8.9] years; 46 women [43%], mean [SD] baseline glycated haemoglobin 49.3 [9.3] mmol/mol). At follow-up, 23% of participants (n = 14) in the intervention and 7% (n = 2) in the standard care group met the criteria for any T2D remission (odds ratio [OR] 4.4, 95% confidence interval [CI] 0.8-21.4]; P = 0.08). Assuming participants lost to follow-up (n = 5) had relapsed, the OR for T2D remission was 4.4 (95% CI 1.0-19.8; P = 0.048).

CONCLUSIONS

The statistically nonsignificant threefold increased remission rate of T2D in the lifestyle intervention group calls for further large-scale studies to understand how to implement sustainable lifestyle interventions among people with T2D.

The Effects of Bariatric Surgery on Islet Function, Insulin Secretion, and Glucose Control

Although bariatric surgery was developed primarily to treat morbid obesity, evidence from the earliest clinical observations to the most recent clinical trials consistently demonstrates that these procedures have substantial effects on glucose metabolism. A large base of research indicates that bariatric surgeries such as Roux-en-Y gastric bypass (RYGB), vertical sleeve gastrectomy (VSG), and biliopancreatic diversion (BPD) improve diabetes in most patients, with effects frequently evident prior to substantial weight reduction. There is now unequivocal evidence from randomized controlled trials that the efficacy of surgery is superior to intensive life-style/medical management. Despite advances in the clinical understanding and application of bariatric surgery, there remains only limited knowledge of the mechanisms by which these procedures confer such large changes to metabolic physiology. The improvement of insulin sensitivity that occurs with weight loss (e.g., the result of diet, illness, physical training) also accompanies bariatric surgery. However, there is evidence to support specific effects of surgery on insulin clearance, hepatic glucose production, and islet function. Understanding the mechanisms by which surgery affects these parameters of glucose regulation has the potential to identify new targets for therapeutic discovery. Studies to distinguish among bariatric surgeries on key parameters of glucose metabolism are limited but would be of considerable value to assist clinicians in selecting specific procedures and investigators in delineating the resulting physiology. This review is based on literature related to factors governing glucose metabolism and insulin secretion after the commonly used RYGB and VSG, and the less frequently used BPD and adjustable gastric banding.

Prevalence of gastroesophageal reflux and risk factors for erosive esophagitis in obese patients considered for bariatric surgery

BACKGROUND

Gastroesophageal reflux disease (GERD) is common in obese individuals. Prospective studies investigating validated GERD questionnaires and clinical parameters at identifying erosive esophagitis (EE) in this population are limited.

OBJECTIVE

To prospectively evaluate the prevalence of GERD in obese patients considered for bariatric surgery and identify risk and predictive factors for EE.

METHODS

Eligible patients completed two validated questionnaires: GERDQ and Nocturnal Symptom Severity Impact (N-GSSIQ) before routine esophagogastroduodenoscopy.

RESULTS

242 consecutive patients were enrolled (130 females; mean age 37.8 ± 11.8 years; mean BMI 40.4 ± 5.3 kg/m²). The overall prevalence of gastroesophageal reflux (GERDQ ≥ 8, EE and/or PPI use) was 62.4%. EE was identified in 82 patients (33.9%) including 13/62 (21.0%) receiving PPIs at baseline. Multivariate logistic regression identified GERDQ ≥ 8 (OR = 6.3, 95%CI 3.0-13.1), hiatal hernia (OR = 4.2, 95%CI 1.6-10.7), abnormal Hill grade (OR = 2.7, 95%CI 1.4-5.4), and tobacco use (OR = 2.5, 95%CI 1.2-4.9) as independent risk factors for EE. A pre-endoscopic composite assessment including GERDQ ≥ 8 and presence of severe nocturnal reflux symptoms had 90% specificity and 20.7% sensitivity in identifying EE (NPV 68.9% and PPV 51.5%).

CONCLUSION

GERD is highly prevalent in obese patients. Anthropometric data and GERD questionnaires have limited accuracy at predicting erosive disease. Pre-operative endoscopic assessment in this population appears warranted.

Impact of Fecal Microbiota Transplantation on Obesity and Metabolic Syndrome-A Systematic Review

Fecal microbiota transplantation (FMT) is a gut microbial-modulation strategy that has been investigated for the treatment of a variety of human diseases, including obesity-associated metabolic disorders. This study appraises current literature and provides an overview of the effectiveness and limitations of FMT as a potential therapeutic strategy for obesity and metabolic syndrome (MS). Five electronic databases and two gray literature sources were searched up to 10 December 2018. All interventional and observational studies that contained information on the relevant population (adult patients with obesity and MS), intervention (receiving allogeneic FMT) and outcomes (metabolic parameters) were eligible. From 1096 unique citations, three randomized placebo-controlled studies (76 patients with obesity and MS, body mass index = 34.8 ± 4.1 kg/m², fasting plasma glucose = 5.8 ± 0.7 mmol/L) were included for review. Studies reported mixed results with regards to improvement in metabolic parameters. Two studies reported improved peripheral insulin sensitivity (rate of glucose disappearance, RD) at 6 weeks in patients receiving donor FMT versus patients receiving the placebo control. In addition, one study observed lower HbA1c levels in FMT patients at 6 weeks. No differences in fasting plasma glucose, hepatic insulin sensitivity, body mass index (BMI), or cholesterol markers were observed between two groups across all included studies. While promising, the influence of FMT on long-term clinical endpoints needs to be further explored. Future studies are also required to better understand the mechanisms through which changes in gut microbial ecology and engraftment of microbiota affect metabolic outcomes for patients with obesity and MS. In addition, further research is needed to better define the optimal fecal microbial preparation, dosing, and method of delivery.

Gastroesophageal reflux disease, obesity and laparoscopic sleeve gastrectomy: The burning questions

Obesity is a global health epidemic with considerable economic burden. Surgical solutions have become increasingly popular following technical advances leading to sustained efficacy and reduced risk. Sleeve gastrectomy accounts for almost half of all bariatric surgeries worldwide but concerns regarding its relationship with gastroesophageal reflux disease (GERD) has been a topic of debate. GERD, including erosive esophagitis, is highly prevalent in the obese population. The role of pre-operative endoscopy in bariatric surgery has been controversial. Two schools of thought exist on the matter, one that believes routine upper endoscopy before bariatric surgery is not warranted in the absence of symptoms and another that believes that symptoms are poor predictors of underlying esophageal pathology. This debate is particularly important considering the evidence for the association of laparoscopic sleeve gastrectomy (LSG) with de novo and/or worsening GERD compared to the less popular Roux-en-Y gastric bypass procedure. In this paper, we try to address 3 burning questions regarding the inter-relationship of obesity, GERD, and LSG: (1) What is the prevalence of GERD and erosive esophagitis in obese patients considered for bariatric surgery? (2) Is it necessary to perform an upper endoscopy in obese patients considered for bariatric surgery? And (3) What are the long-term effects of sleeve gastrectomy on GERD and should LSG be done in patients with pre-existing GERD?

Incremental Cost-Effectiveness of Aspiration Therapy vs Bariatric Surgery and No Treatment for Morbid Obesity

INTRODUCTION

Despite its recent approval by the US Food and Drug Administration and Health Canada, aspiration therapy-one of the latest weight loss treatments-remains controversial. Critics have expressed concerns that the therapy could lead to bulimia and other binge eating disorders. Meanwhile, proponents argue that the therapy is less invasive, reversible, and cheaper than bariatric surgery. Cost-effectiveness of this therapy, however, is not yet established.

METHODS

We developed a Markov model to estimate the incremental cost-effectiveness of aspiration therapy relative to 2 most common bariatric surgery procedures (gastric bypass and sleeve gastrectomy) and no treatment over a lifetime horizon. Costs were estimated from the health system's perspective using US data. Effectiveness was measured in terms of quality-adjusted life-years (QALYs).

RESULTS

Despite being a cheaper procedure than bariatric surgery, aspiration therapy costs more than bariatric surgery in the long term because of its high maintenance costs (i.e., periodic replacement of device parts). It also yields lower QALYs than bariatric surgery because of its smaller weight loss effects. Thus, the therapy is dominated by bariatric surgery. In particular, compared with gastric bypass, it costs US$5,318 more and yields 1.31 fewer QALYs. However, aspiration therapy is cost-effective relative to no treatment with an incremental cost-effectiveness ratio of US$17,532 per QALY gained.

DISCUSSION

Given its high lifetime costs and its modest weight loss effects, aspiration therapy is not cost-effective relative to bariatric surgery. However, it is a cost-effective treatment option for patients who lack access to bariatric surgery.

BEST: Bypass equipoise sleeve trial; rationale and design of a randomized, registry-based, multicenter trial comparing Roux-en-Y gastric bypass with sleeve gastrectomy

BACKGROUND

Laparoscopic gastric bypass (LGBP) is a well-documented surgical intervention for severe obesity. Recently, laparoscopic sleeve gastrectomy (LSG) has gained increased popularity. Short-term follow-up in limited-sized randomized trials comparing LGBP and LSG show no major differences in weight-loss, adverse events, or effect on comorbidities; however, there is a lack of sufficiently powered, pragmatic, randomized controlled trials comparing the mid- and long-term results of the two methods.

METHOD

BEST is a randomized, registry-based, multicenter trial comparing LGBP and LSG. The trial has two primary outcomes; rates of substantial complications (SC) and total body weight loss. We hypothesize that patients treated with LSG will experience 35% fewer substantial complications during the 5-year follow-up compared to patients treated with LGBP, and that the efficacy of LSG will remain within a non-inferiority margin of 5% in terms of weight loss. Our sample size calculation, using data from the Scandinavian Obesity Surgery Registry (SOReg), shows a power of 80% for SC and > 95% for weight loss at p < .025 with a total of 2100 included patients. The design of the trial will also enable comparisons within several relevant patient subgroups.

CONCLUSIONS

As a large-sized, pragmatic, randomized trial, BEST will provide robust data comparing LGBP with LSG by generating long-term results on weight loss and SC's, as well as secondary outcomes and comparisons within patient subgroups. The use of a well-established registry for registration of all data facilitates a large multicenter trial, and combines the strengths of registry studies with those of a randomized trial. Clinical Trials registry: NCT02767505.

Bariatric surgery for prospective living kidney donors with obesity?

The obesity epidemic has gripped the transplant community. With nearly 40% of adults in the United States being obese (BMI ≥30 kg/m² ) and 20% being morbidly obese (BMI ≥35 kg/m² ), the implications for both donors and recipients of solid organs continue to grow.¹ Nowhere is this more impactful than the candidacy of living kidney donors (LKDs). As increasing numbers of obese adults present for LKD consideration and evidence of inferior outcomes among obese LKDs grows, transplant surgeons will become progressively challenged by how to manage these patients in the clinic. Therefore, we offer this Personal Viewpoint to the transplant surgery community in order to review the current impact of obesity on living kidney donation, highlight what weight-loss interventions have already been attempted, and discuss the role that referral for weight-loss interventions including bariatric surgery might have going forward.

Is sleeve gastrectomy overcriticized? A single-center Indian experience with 5-year follow-up results

BACKGROUND

Bariatric surgery has seen a sharp rise in numbers worldwide in the last decade. Being a popular procedure, sleeve gastrectomy (SG) has been widely studied over the years for its efficacy, potential for weight regain, metabolic impact, and de novo gastroesophageal reflux disease (GERD).

OBJECTIVES

To evaluate clinical outcomes of laparoscopic SG after 5 years of follow-up in terms of weight loss, co-morbidity resolution, and GERD.

SETTING

The study was performed in a center of excellence in bariatric surgery in India.

METHODS

All patients who underwent laparoscopic SG from January 2012 to April 2013 were included in the study. Their demographic, preoperative, and postoperative data were prospectively maintained in Microsoft Excel and analyzed statistically.

RESULTS

Two hundred eighteen patients underwent SG in 2012-2013. Patients had a preoperative body mass index of 45.8 ± 9.5 kg/m² (mean ± standard deviation) and excess weight of 54.1 ± 25.6 kg. Percent excess weight loss was 87.6% ± 28.9% at 1 year, 77.2% ± 29.3% at 3 years, and 69.1% ± 27.8% at 5 years. Percent total weight loss at 1 year was 35.5% ± 7.6%, 31.4% ± 9.1% at 3 years, and 29.2% ± 9.8% at 5 years. At 5 years, 11 of 25 (44%) showed complete diabetic remission and 5 of 25 (20%) showed partial remission. De novo GERD was seen in 24 of 153 (15.7%) patients.

CONCLUSION

Our study reflects good outcomes after SG in terms of weight loss and diabetes resolution at 5-year follow-up, though GERD remains a matter of concern.

The effect of bougie size and distance from the pylorus on dehydration after laparoscopic sleeve gastrectomy: an analysis of the ACS-MBSAQIP database

BACKGROUND

Dehydration is the most common cause of readmission after laparoscopic sleeve gastrectomy (SG). Bougie size and distance from the pylorus, both of which have been associated with rates of dehydration postoperatively, varies by surgeon and across institutions.

OBJECTIVES

To determine if there is an association between bougie size or distance from the pylorus on the rate of dehydration after laparoscopic SG.

SETTING

American College of Surgeons Metabolic and Bariatric Surgery Accreditation Quality Improvement Program database.

METHODS

All patients undergoing first-time, elective laparoscopic SG from 2015-2016 were identified. The association of bougie size and distance from the pylorus on the rate of dehydration within the first 30 days postoperatively was investigated.

RESULTS

The inclusion criteria were met by 170,751 patients. The most commonly used bougie size was 36 Fr and the most common distance from the pylorus at which the gastric sleeve was started was 5 cm. Patients were divided into 4 groups based on bougie size and distance from the pylorus (Group 1: bougie size <36 Fr, pylorus distance <4 cm; Group 2: bougie size ≥36 Fr, pylorus distance <4 cm; Group 3: bougie size ≥36 Fr, pylorus distance ≥4 cm; and Group 4: bougie size <36 Fr, pylorus distance ≥4 cm). Patients in Group 4 were significantly less likely than any other group to experience dehydration-related complications.

CONCLUSION

Both distance from the pylorus and bougie size are significantly associated with dehydration-related complications after SG. Consideration should be made for standardizing these technical aspects of SG to help reduce the rate of postoperative dehydration and hospital readmission.

Effectiveness of laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy for morbid obesity in achieving weight loss outcomes

OBJECTIVE

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are commonly performed weight loss procedures worldwide. Unfortunately, few studies have compared percentage total weight loss (%TWL) following these procedures. This research compared short-term, mid-term and long-term %TWL by LRYGB and LSG.

METHODS

Selected databases were searched for original articles that compared %TWL by LSG and LRYGB. Review manager 5.3 was used for data analysis. Effect summary was presented by forest plot.

RESULTS

A significantly better %TWL in 5 years was shown by LRYGB than LSG; pooled mean difference (MD) 1.87 (95% CI 0.27-3.48, z statistics = 2.28, p < 0.05). Subgroup analysis showed better %TWL by LRYGB than LSG at 24 months pooled MD 6.47 (95% CI 1.22-11.72, z statistics = 2.42, p < 0.05), however, better %TWL by LSG was noted after 36 months (pooled MD -0.23; 95% CI -0.39-0.06, z statistics = 2.65, p < 0.05). Finally, significantly better %TWL was noted for LRYGB at 60 months.

CONCLUSION

This study shows %TWL of 70.4% by LRYGB and 59.8% following LSG in at least half of patients from selected cohort. A significantly greater %TWL by LRYGB in short and long term, while higher %TWL by LSG in mid-term is reported.

Laparoscopic sleeve gastrectomy is an independent predictor of poor follow-up and reaching ≤ 40% excess body weight loss at 1, 2, and 3 years after bariatric surgery

INTRODUCTION

Contrary to published literature, our institutional data demonstrated reduced weight loss following laparoscopic sleeve gastrectomy (LSG) compared to gastric bypass (LRYGB). The purpose of this study was to determine if known predictors of poor weight loss accounted for this discrepancy at a large volume center.

METHODS

All patients undergoing primary LSG (n = 322) and LRYGB (n = 249), from 2014 to 2016, at a single institution were retrospectively reviewed. Baseline medical, socioeconomic, and follow-up data (6, 12, 24, and 36 months) were obtained. The first aim characterized differences in LSG and LRYGB. The second objective determined predictors of experiencing the lowest or highest quartile of excess body weight loss [(EBWL), (%EBWL-25th, %EBWL-75th)] at 12, 24, and 36 months. Thirdly, predictors of poor weight loss within sleeve gastrectomy were characterized.

RESULTS

In comparison to patients undergoing LRYGB, LSG patients demonstrated lower baseline BMI (47.9 ± 8.2 vs. 51.5 ± 10.1, p < 0.0005), lower incidences of obesity-related comorbidities (p < 0.05), were more likely to have higher education (p = 0.02), and were associated with no-shows up to 2 years post-operatively. LSG remained a strong independent predictor of %EBWL-25th at 12 months (OR = 5.2, p < 0.005), 24 months (OR = 5.3, p < 0.005), and 36 months (OR = 7.3, p = 0.006), after adjusting for comorbidities, education, and no-shows. Predictors of poor weight loss after LSG included hypertension, African American race, major depression, no-shows at 6 and 12 months. Within patients associated with these characteristics, the relative risk of experiencing poor weight loss was significantly higher following LSG compared to LRYGB at 12 months (60% vs. 25.0%, p < 0.05), 24 months (43% vs. 18%, p < 0.05), and 36 months (70% vs. 21%, p < 0.05).

CONCLUSIONS

LSG remained an independent predictor of poor weight loss at all post-operative time points. Furthermore, the risk of experiencing poor weight loss was significantly higher following LSG compared to LRYGB for patients with high-risk characteristics.

Hospital utilization 4 years after bariatric surgery: sleeve gastrectomy versus Roux-en-Y gastric bypass

BACKGROUND

While sleeve gastrectomy (SG) has lower perioperative risk compared with Roux-en-Y gastric bypass (RYGB), long-term data about their differential impact on overall health are unclear. Hospital use after bariatric surgery is an important parameter for improving peri- and postoperative care.

OBJECTIVE

This present study was aimed to compare SG and RYGB in terms of their effect on long-term hospital-based healthcare utilization.

SETTING

Multicenter, statewide database.

METHODS

A retrospective cohort study of adult patients who underwent SG and RYGB between 2009 and 2011, with follow-up until 2015 and 2-year presurgery information. Propensity score-matched SG and RYGB groups were created using preoperative demographic characteristics, co-morbidities, and presurgery hospital use, measured by cumulative length of stay (LOS) and frequency of emergency department visits. Postsurgery yearly LOS, incidence of hospital visits, and the reason for the visit were compared. Primary outcomes included postoperative hospital visits during years 1 to 4 after bariatric surgery and cumulative LOS. Secondary outcomes included specific reasons for hospital use.

RESULTS

There were 3540 SG and 13,587 RYGB patients, whose mean (95% confidence interval [CI]) LOS was 1.3 (1.3-1.4), .9 (.8-1), 1 (.9-1.1), and 1.2 (1-1.3) days at years 1 through 4, respectively. Postoperative yearly LOS was similar between the 2 propensity-matched groups. The risk of hospitalizations (odd ratio .73, 95% CI .64-.84, P < .0001) and emergency department visits (odds ratio .84, 95% CI .75-.95, P = .005) was significantly lower for SG, during the first postoperative year. The reverse was seen at the fourth postoperative year, with higher risk of emergency department use after SG (odds ratio 1.16, 95% CI 1.01-1.33, P = .035).

CONCLUSION

Postoperative 4-year hospital utilization remains low for both SG and RYGB. The previously established lower early perioperative risk of SG was not appreciated for longer-term hospital use compared with RYGB.

The pros and cons of gastric bypass surgery - The role of the Roux-limb

The prevalence of overweight and obesity has exploded in the post-industrial era. Life style interventions like dieting and exercise can induce a marked weight loss, but the main problem for most patients is to maintain the reduced body weight over time. Gastric bypass surgery is a commonly performed and very effective method for achieving a pronounced and sustained weight loss including metabolic improvements in obese patients. Despite the therapeutic successfulness there are known side-effects like chronic postprandial nausea and pain that in some patients become intractable. The pathophysiology is complex and partly unexplored. The physician or surgeon handling a patient with "post-bariatric symptoms" must be aware of the risk for symptom aggravations due to iatrogenic opioid-associated intestinal dysmotility. The present paper gives a brief overview of obesity surgery and its associated postsurgical conditions with a focus on the unexplored role of the Roux-limb following gastric bypass surgery.

The impact of the affordable care act (ACA) Medicaid Expansion on access to minimally invasive surgical care

INTRODUCTION

This study aims to evaluate the effect of the ACA Medicaid expansion on the utilization of minimally invasive (MIS) approaches to common general surgical procedures.

METHODS

We queried five Healthcare Cost and Utilization Project State Inpatient Databases to evaluate rates of utilization and costs of MIS and open approaches pre and post Medicaid expansion.

RESULTS

117,241 patients met the inclusion criteria. Following the enactment of the ACA, use of both laparoscopic gastric bypass (IRR 1.08; 95% CI: [1.02, 1.15]) and Nissen fundoplication (IRR 1.17; 95% CI [1.09, 1.26]) increased in Medicaid patients treated in expansion states than in those treated in non-expansion states. Simultaneously, the costs reported for self-pay patients increased in expansion states more than in non-expansion states (+$1669; 95% CI [$655, $2682]).

CONCLUSIONS

Medicaid expansion was associated with increased rates of utilization of MIS approaches to several surgical procedures and a shifting of costs toward patients who were self-insured.

Metabolic effects and safety of Roux-en-Y gastric bypass surgery vs. conventional medication in obese Chinese patients with type 2 diabetes

AIM

To assess metabolic effects and safety of Roux-en-Y gastric bypass (RYGB) versus conventional medication (CM) in obese Chinese patients with type 2 diabetes (T2DM).

METHODS

This retrospective cohort study included 40 patients who underwent RYGB (mean age 44.1 years, body mass index [BMI] 33.3 kg/m² ) and 36 patients administered CM (mean age 49.4 years, BMI 32.1 kg/m² ). The primary endpoint was achievement of the triple endpoint (haemoglobin A1C [HbA1c] < 7.0%, low-density lipoprotein cholesterol < 2.6 mmol/L, and systolic blood pressure < 130 mmHg). Changes in weight, BMI, medication usage, complications, and adverse events were assessed.

RESULTS

After 1-year follow-up, 35% of RYGB patients and 8% of CM patients achieved the triple endpoint (P = 0.005). More patients in the RYGB group achieved complete (48% vs 3%, P < 0.001) and partial (23% vs 0%, P = 0.007) remission of diabetes, and complete remission of hypertension (58% vs 24%, P = 0.019). Patients in the RYGB group had greater weight loss and decrease in BMI, waist circumference, fasting and postprandial of blood glucose and insulin levels, HbA1c, blood pressure, triglycerides, and increased high-density cholesterol (P < 0.001- < 0.05). A lower proportion of the RYGB group received antidiabetics, antihypertensives, or antilipemic treatments, and had non-alcoholic fatty liver disease (NAFLD) than the CM group during follow-up. More patients had nutrient deficiency-related diseases in the RYGB group over 1-year follow-up.

CONCLUSIONS

For obese Chinese patients with T2DM, RYGB resulted in better metabolic control, greater weight loss, and lower medication usage and NAFLD, but more frequently resulted in diseases related to nutrient deficiency.

Adipose Tissue Protein Glycoxidation is Associated with Weight-Loss Potential

OBJECTIVE

This study aimed to characterize the differences in protein oxidation biomarkers in adipose tissue (AT) as an indicator of AT metabolism and bariatric surgery weight-loss success.

METHODS

A human model, in which sixty-five individuals with obesity underwent bariatric surgery, and a diet-induced obesity animal model, in which animals were treated for 2 months with normocaloric diets, were analyzed to determine the associations between AT protein oxidation and body weight loss. Protein oxidative biomarkers were determined by gas chromatography/mass spectrometry in AT from human volunteers before the surgery, as well as 2 months after a diet treatment in the animal model.

RESULTS

The levels of carboxyethyl-lysine (CEL) and 2-succinocystein (2SC) in both visceral and subcutaneous AT before the surgery directly correlated with greater weight loss in both human and animal models. 2SC levels in subcutaneous AT greater than 4.7 × 10⁶  μmol/mol lysine (95% CI: 3.4 × 10⁶ to 6.0 × 10⁶ ) may predict greater weight loss after bariatric surgery (receiver operating characteristic curve area = 0.8222; P = 0.0047). Additionally, it was observed that individuals with diabetes presented lower levels of CEL and 2SC in subcutaneous AT (P = 0.0266 and P = 0.0316, respectively) compared with individuals without diabetes.

CONCLUSIONS

CEL and 2SC in AT are useful biomarkers of AT metabolism and predict the individual's ability to reduce body weight after bariatric surgery.

Effects of Weight Loss on Echocardiographic Parameters 1 Year after Sleeve Gastrectomy

Background: Bariatric surgery is efficiently associated with the long-term resolution of obesity and its related morbidities. Not only can this surgical modality improve the metabolic profile, diastolic and systolic cardiac functions, and the clinical symptoms of heart failure or cardiomyopathy, but it can also reduce the atherosclerosis risk, ventricular mass, and pericardial fat thickness. The aim of the present study was to evaluate the effects of weight loss on echocardiographic parameters 1 year after sleeve gastrectomy. Methods: This quasi-experimental study, conducted in Modarres Hospital, Tehran, Iran, from September 2016 to September 2017, recruited 101 patients. Those with morbid obesity (body mass index ≥40 kg/m²) had undergone surgery 1 year before the study commencement. All the patients underwent sleeve gastrectomy. The data of echocardiographic indices before and 1 year after surgery were recorded and analyzed. Results: The mean age of the participants was 37.11±9.81 years. The majority of the study participants were female (n=77, 76.2%). During the first postoperative year, the mean weight loss was 43.82±14.53 kg. The mean systolic blood pressure was 137.96±19.60 mmHg and 123.37±9.60 mmHg before sleeve gastrectomy and 1 year afterward, respectively (P<0.001). The mean left ventricular size was 48.22±4.04 mm and 44.97±5.70 mm before sleeve gastrectomy and 1 year postoperatively, correspondingly (P<0.001). The mean pulmonary artery pressure was 28.88±5.25 mmHg and 24.10±4.78 mmHg before sleeve gastrectomy and 1 year after surgery, respectively (P<0.001). The mean left atrial size was 35.72±3.32 mm and 33.12±3.52 mm before sleeve gastrectomy and 1 year thereafter, correspondingly (P<0.001). Conclusion: Weight loss resulting from sleeve gastrectomy may improve systolic blood pressure, left atrial and left ventricular size, and pulmonary artery pressure.

Obesity Disease Pandemic on Joint Disease and Longevity

Epidemiologic trends and recent literature reports indicate that the combination of bariatric surgery as a first step followed by orthopedic interventions as a second stage is beneficial for our patients. Bariatric interventions have proven to be safe and efficacious, offering a bridge to patients affected by severe obesity and osteoarthritis to undergoing a successful and long-lasting joint arthroplasty. In addition, the combination of joint arthroplasty after bariatric interventions will help patients resume their normal activities while introducing lifestyle changes that will, in turn, enable them to maintain weight loss.

Clinician's Guide to the Updated ABCs of Cardiovascular Disease Prevention: A Review Part 2

Efforts to better control risk factors for cardiovascular disease and prevent the development of subsequent cardiovascular events are crucial to maintaining healthy populations. In today's busy practice environment and with the overwhelming pace of new research findings, ensuring appropriate emphasis and implementation of evidence-based preventive cardiovascular care can be challenging. The ABCDEF approach to cardiovascular disease prevention is intended to improve dissemination of contemporary best practices and ease the implementation of comprehensive preventive strategies for clinicians. This review serves as a succinct yet authoritative overview for interested internists as well as for cardiologists not otherwise focused on cardiovascular disease prevention. The goal of this 2-part series is to compile a state-of-the-art list of elements central to primary and secondary prevention of cardiovascular disease, using an ABCDEF checklist. In Part 2, we review new recommendations about lipid-modifying strategies, contemporary best practice for tobacco cessation, new evidence related to cardiovascular risk reduction in diabetes using novel therapies, ways to implement a heart-healthy diet, modern interventions to improve physical exercise, and how best to prevent the onset of heart failure.

Internal hernias in pregnant females with Roux-en-Y gastric bypass: a systematic review

Improved fertility following a Roux-en-Y gastric bypass (RYGB) can lead to pregnancy and increase the risk of internal herniation. A developing fetus and symptoms of pregnancy can mask the diagnosis and delay intervention, leading to deleterious maternal and fetal consequences. The aim of this systematic review is to summarize the literature regarding internal hernias during pregnancy, their management, and patient outcomes. A comprehensive literature search was undertaken on PubMed and Google Scholar to identify cases of internal hernias presenting during pregnancy after RYGB. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for eligibility and inclusion of articles. Twenty-seven articles, with a total of 59 patients, regarding internal herniation during pregnancy after RYGB were identified. Epigastric pain and nausea and vomiting was the most common presentation. Regardless of orientation of the Roux limb and despite previous closure of mesenteric defects, internal herniation can still occur. A triad of epigastric pain, pregnancy, and a history of RYGB should be a red flag for clinicians to consider internal hernias as a top differential diagnosis. Prompt bariatric consultation and rapid intervention will improve maternal and fetal outcomes.

Single-centre, triple-blinded, randomised, 1-year, parallel-group, superiority study to compare the effects of Roux-en-Y gastric bypass and sleeve gastrectomy on remission of type 2 diabetes and β-cell function in subjects with morbid obesity: a protocol for the Obesity surgery in Tønsberg (Oseberg) study

INTRODUCTION

Bariatric surgery is increasingly recognised as an effective treatment option for subjects with type 2 diabetes and obesity; however, there is no conclusive evidence on the superiority of Roux-en-Y gastric bypass or sleeve gastrectomy. The Oseberg study was designed to compare the effects of gastric bypass and sleeve gastrectomy on remission of type 2 diabetes and β-cell function.

METHODS AND ANALYSIS

Single-centre, randomised, triple-blinded, two-armed superiority trial carried out at the Morbid Obesity Centre at Vestfold Hospital Trust in Norway. Eligible patients with type 2 diabetes and obesity were randomly allocated in a 1:1 ratio to either gastric bypass or sleeve gastrectomy. The primary outcome measures are (1) the proportion of participants with complete remission of type 2 diabetes (HbA1c≤6.0% in the absence of blood glucose-lowering pharmacologic therapy) and (2) β-cell function expressed by the disposition index (calculated using the frequently sampled intravenous glucose tolerance test with minimal model analysis) 1 year after surgery.

ETHICS AND DISSEMINATION

The protocol of the current study was reviewed and approved by the regional ethics committee on 12 September 2012 (ref: 2012/1427/REK sør-øst B). The results will be disseminated to academic and health professional audiences and the public via publications in international peer-reviewed journals and conferences. Participants will receive a summary of the main findings.

TRIAL REGISTRATION NUMBER

NCT01778738;Pre-results.

Change in gastrointestinal symptoms over the first 5 years after bariatric surgery in a multicenter cohort of adolescents

BACKGROUND

Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) are effective for weight loss in adolescents with severe obesity. However, little is known about adverse gastrointestinal symptoms (GIS) following these operations in adolescents. The objective was to examine GIS over 5 years after surgery and differences by surgery type.

METHODS

We prospectively studied 228 adolescents (161 RYGB, 67 VSG) undergoing bariatric surgery. Gastrointestinal symptoms were assessed before surgery, at 6-months, and yearly to 5 years after surgery. Symptom severity was dichotomized for analysis. Analysis of post-surgery symptoms involved linear models adjusting for baseline symptoms, BMI, early post-operative complication, sex, and race.

RESULTS

Participants at surgery were 17 ± 1.6 years with preoperative BMI 53 ± 9.4 kg/m². From 6 months to 5 years, gastroesophageal reflux symptoms (GERS), nausea, bloating, and diarrhea increased. Crude prevalence rates of GERS increased from 4% (1% RYGB, 11% VSG) at 6-months post-surgery to 14% (10% RYGB, 26% VSG) at 5-years. In adjusted analyses, the VSG group experienced 4-fold (4.85 95% CI 2.63, 8.91, p < 0.0001) greater odds of GERS compared to RYGB.

CONCLUSIONS

Adolescents who underwent VSG experienced greater risk of GERS compared to those undergoing RYGB. Adolescents undergoing VSG should be counseled preoperatively about GERS and objectively monitored postoperatively for gastroesophageal reflux when indicated.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT00474318, https://clinicaltrials.gov/ct2/show/NCT00474318?term=Teen-LABS&rank=1.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

Level II.

Long-term effect of bariatric surgery versus conventional therapy in obese Korean patients: a multicenter retrospective cohort study

Purpose

Long-term results following bariatric surgery compared to conventional treatments has never been reported in morbidly obese Korean patients. This study aimed to evaluate the long-term efficacy of bariatric surgery in morbidly obese Korean patients compared to conventional medical treatments.

Methods

In this multicenter retrospective cohort study, we reviewed 137 obese subjects between January 2008 and February 2011 with a body mass index (BMI) > 30 kg/m² who had more than 5 years of follow-up clinical data after bariatric surgery (surgery group, n = 49) or conventional treatment (conventional treatment group, n = 88). Anthropometric data and the status of comorbidities were compared between the 2 groups.

Results

The median follow-up period was 72.1 months (range 19.3–109.7 months). At the last follow-up, the surgery group showed a greater amount of total weight loss than the conventional treatment group (24.9% vs. 2.8%, P < 0.001). The prevalence of diabetes and hypertension significantly decreased in the surgery group, while the conventional treatment group showed a marked increase in these comorbidities. In the surgery group, Roux-en-Y gastric bypass and sleeve gastrectomy achieved comparable long-term weight loss (26.5% vs. 22.4%, respectively; P = 0.087).

Conclusion

In the long-term, bariatric surgery achieved and maintained significantly greater weight reduction, as well as a decrease in obesity-related comorbidities, than did conventional medical therapy in morbidly obese Korean patients.