Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years

Bariatric revisional surgery for gastrogastric fistula following Roux-en-Y gastric bypass positively impacts weight loss

BACKGROUND

Gastrogastric fistula (GGF) is a rare complication from Roux-en-Y gastric bypass (RYGB). It is a known risk factor associated with weight recidivism and an indication for Bariatric Revisional Surgery (BRS).

OBJECTIVES

The primary outcome of this study is to evaluate perioperative outcomes and the long-term total body weight loss (TBWL) outcomes following revision.

SETTING

Single Academic Institution, Center of Bariatric Excellence.

METHODS

We selected patients who had primary bariatric surgery and BRS from 2003 to 2020, followed by BRS for GGF. Patients' demographics, perioperative outcomes, and TBWL were analyzed.

RESULTS

One hundred five patients underwent BRS for GGF. Mean body mass index (BMI) at index operation and revision was 51.6 ± 10.1, and 42.4 ± 11.2 respectively. Ninety percent of patients had open primary RYGB, and 69% had open revisional surgery. The median length of stay after BRS was 3 days. The 30-day reintervention rate was 19%. The 30-day readmission rate was 34%. Of the 77 patients included for weight loss analysis, the mean %TBWL after primary RYGB was 34% ± 14. The total mean %TBWL at the time of revision was 18.8%, translating into a weight regain of 13.6% ± 9.5. The total mean %TBWL after revision was 37.6% ± 11.4, translating into TBWL of 18.8% ± 9.4 after revision when compared to TBWL at revision time.

CONCLUSIONS

Our results demonstrate that revision for GGF can be safely performed, however is associated with higher morbidity than primary bariatric surgery. Revision for GGF results in significant long-term weight loss.

Long-term weight loss and metabolic benefit from Roux-en-Y gastric bypass in patients with superobesity

BACKGROUND

Although Roux-en-Y gastric bypass (RYGB) is widely performed worldwide, its efficacy in patients with a body mass index (BMI) greater than 50 kg/m2 remains controversial. The aim of the present paper was to assess long-term (10 years or more) weight loss and metabolic results of RYGB in patients with superobesity (SO; BMI > 50 kg/m2), compared with patients with morbid obesity (MO; BMI 35-50 kg/m2).

METHODS

This study involved retrospective analysis of a prospectively followed cohort of adult patients operated on for a primary RYGB between 1999 and 2008. Long-term weight loss and metabolic parameters were compared between SO and MO patients, with a sex-specific subgroup analysis in SO patients. Multiple logistic regression assessed independent predictors of poor long-term weight loss.

RESULTS

Among the 957 included patients, 193 (20.2 per cent) were SO (mean BMI 55.3 kg/m2versus 43.3 kg/m2 in MO). Upon 10-year follow-up, which was complete in 86.3 per cent of patients, BMI remained higher in SO patients (mean 39.1 kg/m2versus 30.8 kg/m2, P < 0.001) although total bodyweight loss (per cent TBWL) was similar (28.3 per cent versus 28.8 per cent, P = 0.644). Male SO patients had a trend to higher 10-year per cent TBWL, while initial BMI greater than 50 kg/m2 and low 5-year per cent TBWL were independent predictors of long-term TBWL less than 20 per cent. Diabetes remission was observed in 39 per cent SO and 40.9 per cent MO patients (P = 0.335) at 10 years, and all patients had a significant lipid profile improvement.

CONCLUSION

Substantial improvement in co-morbidities was observed in all patients 10 years after RYGB. Total weight loss was similar in SO and MO patients, leaving SO patients with higher BMI. Suboptimal TBWL 5 years after surgery in SO, especially female patients, may warrant prompt reassessment to improve long-term outcomes.

Weight Recidivism and Dumping Syndrome after Roux-En-Y Gastric Bypass: Exploring the Therapeutic Role of Transoral Outlet Reduction

Obesity is a chronic, relapsing disease representing a global epidemic. To date, bariatric surgery is the most effective treatment for morbid obesity in the long-term. Roux-en-Y gastric bypass (RYGB) is one of the most performed bariatric interventions, with excellent long-term outcomes. However, about one-third of patients may experience weight regain over time, as well as dumping syndrome. Both these conditions are challenging to manage and require a multidisciplinary and personalized approach. The dilation of the gastro-jejunal anastomosis is a recognized etiological factor for both weight regain and dumping syndrome. Dietary modifications, behavioral interventions, and medications represent the first therapeutic step. Revisional surgery is the traditional approach when non-invasive treatments fail. However, re-interventions may be technically difficult and are associated with increased morbidity and mortality. Transoral outlet reduction (TORe) is an endoscopic procedure aimed at reducing the size of the anastomosis and is proposed as a minimally invasive treatment of weight regain and/or dumping syndrome refractory to conservative therapies. This review is aimed at providing a narrative overview of the role of TORe as part of the multidisciplinary therapeutic toolkit nowadays available to approach weight regain and dumping syndrome after RYGB.

Efficacy of liraglutide 3.0 mg treatment on weight loss in patients with weight regain after bariatric surgery

PURPOSE

Bariatric surgery, as Roux-en-Y gastric bypass (RYGB), laparoscopic gastric banding (LGB), and laparoscopic sleeve gastrectomy (LSG), is considered the gold standard treatment to achieve long-term weight loss in severe obesity. In patients who fail to maintain the achieved weight, pharmacological treatment may be required. Here, we reported our real-life experience on the efficacy of liraglutide therapy in 62 patients who regained weight after bariatric surgery.

METHODS

We retrospectively evaluated 62 (60 F-2 M; mean age: 43.6 ± 9.9 years) patients received liraglutide for weight loss after bariatric surgery (17 RYGB, 22 LGB, and 23 LSG). Body mass index (BMI) before and after surgery was, respectively, of 45.4 ± 5.5 kg/m² and 29.5 ± 4.9 kg/m². Patients were followed up from 2016 until 2021. Liraglutide was administered after weight regain once-daily subcutaneously at starting dose of 0.6 mg and with weekly increases up to 3.0 mg. Treatments were administered when a weight regain of 10-15% occurred after reaching a minimum weight loss from bariatric surgery or if weight loss after bariatric surgery was unsatisfactory.

RESULTS

After a mean of 70.7 ± 43.7 months from any bariatric surgery, all patients started liraglutide therapy. At this time, mean BMI was 34.2 ± 4.8 kg/m² (mean increased BMI: 4.7 ± 2.8 kg/m²). After a mean of 10.5 ± 4.4 months from the beginning of liraglutide, 9 patients achieved normal weight (BMI 24.1 ± 0.9 kg/m²), and 28 were overweight (BMI 26.9 ± 1.6 kg/m²). Twenty patients achieved grade I (BMI 32.1 ± 1.5 kg/m²), 5 grade II (BMI 37.3 ± 2.0 kg/m²) obesity, and none had grade III obesity (mean BMI change: - 5.1 ± 2.5 kg/m²). The treatment was well tolerated, and no serious adverse events were recorded.

CONCLUSION

These data confirm the efficacy and safety of liraglutide in patients who experienced weight regain after bariatric surgery. Considering the long-term follow-up, patients should be followed up regularly and the pharmacological treatment should be adapted to the weight fluctuations observed during the clinical history.

LEVEL OF EVIDENCE

V. Opinions of authorities, based on descriptive studies, narrative reviews, clinical experience, or reports of expert committees.

Single Anastomosis Jejuno-ileal (SAJI): a New Model of Malabsorptive Revisional Procedure for Insufficient Weight Loss or Weight Regain After Roux-en-Y Gastric Bypass

BACKGROUND

In case of insufficient weight loss or weight regain or relapse of weight-related comorbidities after Roux-en-Y gastric bypass (RYGB), other procedures such as reduction of a large gastric pouch and stoma, lengthening of the Roux limb, conversion to sleeve gastrectomy and/or bilio-pancreatic diversion with duodenal switch have been advocated. Single anastomosis jejuno-ileal (SAJI) is a new revisional simple operation performed after RYGB failure which adds malabsorption to the previous gastric bypass.

METHODS

SAJI includes a single jejuno-ileal anastomosis specifically joining the ileum 250-300 cm proximal to the ileo-caecal valve and the jejunum 30 cm below the gastro-jejunal anastomosis on the Roux limb of the previous RYGB. Thirty-one patients underwent SAJI for insufficient weight loss and/or weight regain after RYGB. The percent total weight loss (%TWL) after RYGB and before SAJI was 21.8 ± 7.8. All SAJI operations were performed laparoscopically. The SAJI mean operating time was 145 min.

RESULTS

Regarding weight loss after SAJI, %TWL is 27.2 ± 7.4, 31.2 ± 6.4, 33.7 ± 5.9 and 32.9 ± 5.2 at 12, 24, 36 and 48 months, respectively. Our series recorded a low rate of peri-operative and medium-term complications with a low grade of severity (Clavien-Dindo classification grade). One patient required reoperation 36 days after SAJI for epigastrium incarcerated incisional hernia at the previous RYGB laparotomy site. Mortality was 0. Comorbidity reduction/resolution after SAJI is 83.2% for type 2 diabetes mellitus, 42.8% for arterial hypertension, 72.8% for dyslipidemia and 45.3% for OSA.

CONCLUSIONS

Treatment of failed RYGB is challenging. SAJI is a less complicated, purely low invasive malabsorptive operation that should reach satisfactory %TWL and comorbidity reduction/resolution.

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.

A Single-Center Experience: What is the Effect of Sleeve Gastrectomy in Patients With a BMI ≥ 50 kg/m²?

BACKGROUND

Our research aimed to see how sleeve gastrectomy (SG) affects weight loss and comorbidities in patients with a body mass index (BMI) ≥ 50 kg/m².

MATERIALS AND METHODS

Prospectively kept data of patients with a BMI ≥50 kg/m² who underwent SG between February 2016 and February 2020 were evaluated.

RESULTS

A total of 138 patients with a BMI ≥ 50 kg/m² were operated on. The average BMI was 56.36±7.661, the average age was 37.41±12.33. Forty-eight patients underwent concomitant cholecystectomy and/or hiatal hernia repair (HHR). The percentage of excess weight loss (EWL%) of patients at the 3rd, 6th, 12th, 18th, and 24th months were 36%, 54%, 67%, 72%, and 74%, respectively. Mean BMI values of the 0th, 3rd, 6th, 12th, 18th, and 24th months were 56, 45, 39, 35, 33, and 33, respectively. 0th, 3rd, 6th, 12th, 18th, and 24th months were significantly different for EWL%, total weight loss (TWL%), and BMI variables (p<0.001), but EWL% (p=0.527), TWL% (p=0.396) and BMI (p=0,657) were not found significantly different between the 18th and 24th months. When EWL% ≥ 50 was accepted, the success rate was 93% (n=93) and 92% (n=50) at the 18th and 24th months, respectively. While there was 82% remission in type 2 diabetes mellitus (DM) and 90% in hypertension (HT), the remission rate in patients with obstructive sleep apnea syndrome (OSAS) and gastroesophageal reflux disease (GERD) undergoing HHR was 100%.

CONCLUSIONS

In patients with a BMI ≥ 50 kg/m², SG seems to be an effective and safe therapy option as the first line for weight loss and treatment of comorbid diseases. Further long-term studies are needed to confirm these results.

Metabolomic signatures after bariatric surgery - a systematic review

Metabolomics emerged as an important tool to gain insights on how the body responds to therapeutic interventions. Bariatric surgery is the most effective treatment for severe obesity and obesity-related co-morbidities. Our aim was to conduct a systematic review of the available data on metabolomics profiles that characterize patients submitted to different bariatric surgery procedures, which could be useful to predict clinical outcomes including weight loss and type 2 diabetes remission. For that, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - PRISMA guidelines were followed. Data from forty-seven original study reports addressing metabolomics profiles induced by bariatric surgery that met eligibility criteria were compiled and summarized. Amino acids, lipids, energy-related and gut microbiota-related were the metabolite classes most influenced by bariatric surgery. Among these, higher pre-operative levels of specific lipids including phospholipids, long-chain fatty acids and bile acids were associated with post-operative T2D remission. As conclusion, metabolite profiling could become a useful tool to predict long term response to different bariatric surgery procedures, allowing more personalized interventions and improved healthcare resources allocation.

Appetite Changes in Weight Regain and Weight Maintenance After Roux-en-Y Gastric Bypass

PURPOSE

Roux-en-Y gastric bypass (RYGB) surgery produces significant weight loss. However, a number of patients experience weight regain years after surgery. Factors driving weight regain after surgical interventions are currently being explored. Our objective was to investigate appetite-related measures associated with weight regain after RYGB surgery.

MATERIALS AND METHODS

Using a cross-sectional design, 29 participants (49.6 ± 9.1 years of age; current BMI 32.4 ± 4.7 kg/m², 43.6 ± 8.9 months post-RYGB) were stratified into tertiles according to weight regain per month after nadir (weight maintenance (WM), n = 9; low weight regain (LWR), n = 10; and high weight regain (HWR), n = 10). The average weight regain was, by design, significantly different between the groups (WM = 2.2 ± 2.5 kg; LWR = 10.0 ± 3.4 kg; HWR = 14.9 ± 6.3 kg regained, p < 0.05). Appetite (visual analog scales), olfactory performance ("sniffin sticks"), eating behaviors (Three Factor Eating Questionnaire), food reward (Leeds Food Preference Questionnaire), and appetite-related hormones (ghrelin, PYY, GLP-1 and leptin) were measured fasting and in response to a standardized test meal.

RESULTS

Dietary restraint was significantly higher than clinical cutoffs in WM and LWR (p < 0.05). As expected, significant time effects were noted for ghrelin, PYY, and GLP-1, but there were no group differences.

CONCLUSION

The results suggest that appetite-related outcomes are similar across individuals who have maintained weight loss and experienced regain following RYGB.

Is Sleeve Gastrectomy as Effective in Older Patients as in Younger Patients? A Comparative Analysis of Weight Loss, Related Comorbidities, and Medication Requirements

Background

Bariatric surgery in the older population has been the subject of ongoing debate but several studies have recently demonstrated its short-term advantages in this age group. It is not yet clear, however, whether these benefits are long-lasting.

Methods

We retrospectively analyzed patients with morbid obesity who underwent laparoscopy sleeve gastrectomy (LSG). These patients were divided into two groups: those above 60 years of age (older group) and those of 60 years or under (younger group). Variables evaluated included demographics and anthropometrics data, comorbidities, and daily medication requirements.

Results

Two hundred fifty-two patients underwent LSG, 57 in the older group and 195 in the younger group. Outcomes related to weight loss in the older subjects were modest compared to those in the younger population (older group %EWL 41.6 vs younger group %EWL 51.1, p < 0.05, older group %TWL 24.9% vs younger group %TWL 25.2%, p < 0.05). During follow-up, both older and younger patients showed an improvement in all the comorbidities: hypertension (older 82.5% vs 38.1%, younger 52.6% vs 29.2%, p < 0.05), type 2 diabetes mellitus (older 38.6% vs 27.3%, 34.9% vs 23.9%, p < 0.05), hyperlipidemia (older 75.4% vs 42.9%, younger 35.9% vs 21.1%, p < 0.05), and OSAHS (older 57.9% vs 30%, younger 40.4% vs 7.1%, p < 0.05). The average number of daily medications used to manage comorbidities decreased in both groups.

Conclusion

LSG in older patients is effective in terms of weight loss, improvement of comorbidities, and lower daily medication requirements up to 5 years of follow-up.

Graphical abstract

Standard Biliopancreatic Limb (50 cm) Roux-en-Y Gastric Bypass Versus Long Biliopancreatic Limb (100 cm) Roux-en-Y Gastric Bypass in Patients with Body Mass Index 40-50 kg/m2: a Randomized Prospective Study

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is a widely performed procedure worldwide especially with the presence of associated medical conditions. Patients with body mass index (BMI) 40-50 kg/m² are at more risk of weight regain and relapse of comorbidities. There is a controversy on the optimum alimentary (AL) and biliopancreatic (BPL) limb lengths to be used in RYGB to achieve weight loss and remission of comorbidities without causing nutritional deficiencies in those patients.

STUDY DESIGN

hundred-and-fifty patients with BMI between 40 and 50 kg/m² were divided equally into 2 groups undergoing standard RYGB (S-RYGB) with AL:150 cm and BPL: 50 cm and long biliopancreatic RYGB (L-RYGB) with AL: 100 cm and BPL: 100 cm. BMI, % of total weight loss (%TWL), effect on diabetes (DM), hypertension (HTN), dyslipidemia, and nutritional statuses were recorded at 1, 2, and 3 years.

RESULTS

Only 64/75 patients in S-RYGB and 57/75 patients in L-RYGB completed the study. L-RYGB had faster weight loss, higher %TWL, and less BMI than S-RYGB with the maintenance of achieved weight. L-RYGB had better control of DM and dyslipidemia than S-RYGB. There were no significant differences in nutritional status between S-RYGB and L-RYGB rather than lower levels of calcium and Hb and higher levels of PTH in L-RYGB yet they remain within the normal range.

CONCLUSION

The application of L-RYGB helps in achieving faster weight loss for a longer period with better remission of associated comorbidities as DM, HTN, and dyslipidemia in patients with BMI 40-50 kg/m² but with effects on the nutritional status.

Comparison of safety and efficacy of intragastric botulinum toxin-A versus gastric balloon

BACKGROUND

A prospective case-matched study was conducted to compare the safety and efficacy of endoscopic intragastric botulinum toxin-A (EIBT) versus endoscopically planned gastric balloon (EPGB), as a treatment for obesity.

METHODS

A total of 176 patients (matched for age and sex) were equally divided to undergo EIBT (n = 88) or EPGB (n = 88). Patients who received EIBT were restricted to a body mass index (BMI) of 25 to 35 kg/m², whereas a BMI >25 kg/m² was allowed in the EPGB group. The main measured outcomes were weight loss, procedure duration, complications, early satiety, and quality of life (QoL).

RESULTS

The patients were followed up for a mean of 6 months. The mean weight loss was greater in the EPGB group than in the EIBT group (15.6 kg vs. 9.3 kg, P < 0.001). However, the percentage excess weight loss and the satiety score were greater in the EIBT group (59.1% vs. 42.2%, P < 0.001; and 3.5 vs. 2.3, P < 0.001) respectively. The procedure duration was shorter for EIBT patients (10 min vs. 15 min, P < 0.001). The postoperative complication rate recorded in the EPGB group was significantly higher (30% vs. 9%, P = 0.001). Adverse symptoms lasted longer in EPGB (5.2 days vs. 0.7 days, P < 0.001). Both groups enjoyed similar improvements in QoL.

CONCLUSION

EIBT is a safe and effective treatment for mild obesity. Although the weight loss was greater in the EPGB group, the percentage excess weight loss, procedure duration, postoperative complications, and symptom duration were significantly better in the EIBT group. QoL improvement was comparable between the two groups.

Therapeutic endoscopy for the treatment of post-bariatric surgery complications

Obesity rates continue to climb worldwide. Obesity often contributes to other comorbidities such as type 2 diabetes, hypertension, heart disease and is a known risk factor for many malignancies. Bariatric surgeries are by far the most invasive treatment options available but are often the most effective and can result in profound, durable weight loss with improvement in or resolution of weight associated comorbidities. Currently performed bariatric surgeries include Roux-en-Y gastric bypass, sleeve gastrectomy, and laparoscopic gastric banding. These surgeries are associated with significant weight loss, but also with significant rates of major complications. The complexity of these patients and surgical anatomies makes management of these complications by a multidisciplinary team critical for optimal outcomes. Minimally invasive treatments for complications are typically preferred because of the high risk associated with repeat operations. Endoscopy plays a large role in both the diagnosis and the management of complications. Endoscopy can provide therapeutic interventions for many bariatric surgical complications including anastomotic strictures, anastomotic leaks, choledocholithiasis, sleeve stenosis, weight regain, and eroded bands. Endoscopists should be familiar with the various surgical anatomies as well as the various therapeutic options available. This review article serves to delineate the current role of endoscopy in the management of complications after bariatric surgery.

The Effect of Pre-operative Exercise Intervention on Patient Outcomes Following Bariatric Surgery: a Systematic Review and Meta-analysis

This systematic review aimed to assess the effect of a pre-operative exercise intervention on short- and long-term health and clinical outcomes for adult patients undergoing bariatric surgery (BS). We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), SPORTDiscus and reference lists of relevant papers, through March 2021. Five randomised controlled trials were included (n = 199 patients). Modest increases in cardiorespiratory fitness (VO2max) were found at both pre-operative (0.73 mL kg-1 min-1, P ≤ 0.001) and maximum follow-up time points (0.98 mL kg-1 min-1, P ≤ 0.04). There was no significant effect of an exercise intervention on percentage total weight loss (%TWL). Pre-operative exercise can induce significant short- and long-term improvements in fitness in individuals with obesity. There is insufficient evidence to determine whether pre-operative training impacts other post-operative clinical outcomes.

Endoscopic therapy of weight regain after bariatric surgery

Weight regain following primary bariatric surgery occurs in a significant proportion of patients and is attributed to epidemiological, anatomical and metabolic factors. Surgical revision of these patients has significant risks and limited benefits. Endoscopic revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective, safe, less invasive and even reproducible treatment. We herein discuss the indication, selection and feasibility of different endoscopic techniques that could be used in the management of weight regain following primary bariatric surgery. Future research could optimize a personalized approach not only in the endoscopic management but also in combination with other therapeutic modalities for weight regain after bariatric surgery.

Do Emotion Dysregulation, Alexithymia and Personality Dimensions Explain the Association Between Attention-Deficit/Hyperactivity Disorder and Binge Eating Among Bariatric Surgery Candidates?

Background: Addictive-like eating and attention-deficit/hyperactivity disorder (ADHD) are both common among persons seeking treatment for severe obesity. Given that ADHD and addictive-like eating, especially binge eating (BE) and food addiction (FA), are both strongly associated with personality dimensions and emotion dysregulation, it is possible emotional and personality characteristics contribute to the link between addictive-like eating behaviors and ADHD in people with severe obesity. This study aimed to investigate the psychological factors associated with BE and FA in bariatric surgery candidates, and to explore the mediational role of emotional factors (emotion dysregulation and alexithymia) and personality dimensions in the association between ADHD and BE.

Method: Two hundred and eighty-two (n = 282) bariatric surgery candidates were recruited during the systematic preoperative psychiatric assessment (University Hospital of Tours, France). We assessed significant BE (Binge Eating Scale), probable adult ADHD (Wender Utah Render Scale and Adult ADHD Self-Report Scale), FA (Yale Food Addiction Scale 2.0, YFAS 2.0), emotion dysregulation (Difficulties in Emotion Regulation Scale-16), alexithymia (Toronto Alexithymia Scale-20) and personality dimensions (Big Five Inventory). Mediation analyses were performed using the PROCESS macro for IBM SPSS Statistics 22.

Results: Prevalence of probable adult ADHD, significant BE and FA were 8.2, 19.1, and 26.6%, respectively. Participants who screened positive for addictive-like eating showed higher prevalence of probable adult ADHD, as well as higher scores on adult and childhood ADHD symptoms. They also reported lower conscientiousness, but higher emotion dysregulation, higher alexithymia, and higher neuroticism. Only BE (as opposed to FA) was also associated with lower scores on agreeableness and openness. Analysis of the association between adult ADHD and BE suggests that emotion dysregulation, conscientiousness, agreeableness, and neuroticism are total mediators and alexithymia a partial mediator.

Conclusion: Our findings suggest a significant association between ADHD and addictive-like eating among bariatric surgery candidates, and also suggest a significant role of emotion dysregulation and personality dimensions in this association. For individuals with ADHD and obesity, eating may be a way to cope with negative emotions, potentially increasing the risk for addictive-like eating behavior.

Revisional Adjustable Gastric Band in Roux-en-Y Gastric Bypass-Is It Worth It?

PURPOSE

A subset of patients undergoing Roux-en-Y gastric bypass (RYGB) presents with either insufficient weight loss or weight regain. Data on the revisional restrictive options including laparoscopic adjustable gastric band (LAGB) is scarce. This study analyzes the mid-term efficacy and safety of LAGB as a revisional procedure after RYGB.

METHODS

Data of all patients with revisional LAGB after primary RYGB between January 2011 and May 2019 were retrospectively reviewed. Outcomes included assessment of weight changes, resolution of comorbidities, and early and late complications during the study period.

RESULTS

Twenty patients were included. The median Body Mass Index (BMI) before revisional LAGB was 34.8 (interquartile range [IQR] 31.9-38.1) kg/m2. After a median follow-up of 33.5 (IQR 19.5-76.5) months, the median BMI was 28.7 (IQR 26.1-32.2) kg/m2. The median additional Excess Weight Loss (EWL) was 37.6% (IQR 23-44.4), leading to a median total EWL of 79.5% (IQR 54.4-94.6). BMI and EWL post-LAGB improved significantly compared to BMI and EWL pre-LAGB (p<0.001 and p<0.001, respectively). Obstructive sleep apnea syndrome resolved 6 months after LAGB in one patient. Three band deflations occurred during the follow-up. Six patients underwent band removal after a median time of 19 (IQR 15.8-26) months. Overall, thirteen patients underwent a reoperation. There was no loss of follow-up until 5 years. After that, two patients were lost to follow-up.

CONCLUSION

LAGB may be a salvage option after failed RYGB. However, the high rate of revisions after secondary LAGB needs to be taken into consideration.

Standard versus distal Roux-en-Y gastric bypass in patients with BMI 50-60 kg/m2: 5-year outcomes of a double-blind, randomized clinical trial

Background

The optimal surgical weight loss procedure for patients with a BMI of 50 kg/m² or more is uncertain. This study compared distal Roux-en-Y gastric bypass (RYGB) with standard RYGB.

Methods

In this double-blind RCT, patients aged 18–60 years with a BMI of 50–60 kg/m² were allocated randomly to receive standard (150 cm alimentary, 50 cm biliopancreatic limb) or distal (150 cm common channel, 50 cm biliopancreatic limb) RYGB. The primary outcome (change in BMI at 2 years) has been reported previously. Secondary outcomes 5 years after surgery, such as weight loss, health-related quality of life, and nutritional outcomes are reported.

Results

Between May 2011 and April 2013, 123 patients were randomized, 113 received an intervention, and 92 attended 5-year follow-up. Mean age was 40 (95 per cent c.i. 38 to 41) years and 73 patients (65 per cent) were women; 57 underwent standard RYGB and 56 distal RYGB. BMI was reduced by 15.1 (95 per cent c.i. 13.9 to 16.2) kg/m² after standard and 15.7 (14.5 to 16.9) kg/m² after distal RYGB; the between-group difference was −0.64 (−2.3 to 1.0) kg/m² (P = 0.447). Total cholesterol, low-density lipoprotein cholesterol, and haemoglobin A1c levels declined more after distal than after standard RYGB. High-density lipoprotein cholesterol levels increased more after standard RYGB. Vitamin A and vitamin D levels were lower after distal RYGB. Changes in bone mineral density, resting metabolic rate, and total energy intake were comparable.

Conclusion

Distal RYGB did not enable greater weight loss than standard RYGB. Differences in other outcomes favouring distal RYGB may not justify routine use of this procedure in patients with a BMI of 50–60 kg/m². Registration number: NCT00821197 (http://www.clinicaltrials.gov).

Presented in part as abstract to the IFSO (International Federation for the Surgery of Obesity and Metabolic disorders) conference, Madrid, Spain, August 2019.

Long-Term Weight Outcomes after Bariatric Surgery: A Single Center Saudi Arabian Cohort Experience

BACKGROUND

Obesity is considered a global chronic disease requiring weight management through lifestyle modification, pharmacotherapy, or weight loss surgery. The dramatic increase in patients with severe obesity in Saudi Arabia is paralleled with those undergoing bariatric surgery. Although known to be beneficial in the short term, the long-term impacts of surgery within this group and the sustainability of weight loss after surgery remains unclear.

OBJECTIVES

We aimed to assess the long-term weight outcomes after bariatric surgery.

SETTING

The study was conducted at King Khalid University Hospital (KKUH), King Saud University Medical City (KSUMC) in Riyadh, Saudi Arabia.

METHODS

An observational prospective cohort study on adult patients with severe obesity undergoing bariatric surgery (sleeve gastrectomy (SG) or Roux-en Y gastric bypass (RYGB)) during the period between 2009 and 2015 was conducted. Weight loss patterns were evaluated pre- and post-surgery through clinical and anthropometric assessments. Absolute weight loss was determined, and outcome variables: percent excess weight loss (%EWL), percent total weight loss (%TWL), and percent weight regain (%WR), were calculated. Statistical analysis using univariate and multivariate general linear modelling was carried out.

RESULTS

A total of 91 (46 males and 45 females) patients were included in the study, with the majority belonging to the SG group. Significant weight reductions were observed at 1 and 3 years of follow-up (p < 0.001) from baseline. The %EWL and %TWL were at their maximum at 3 years (72.4% and 75.8%) and were comparable between the SG and RYGB. Decrements in %EWL and %TWL and increases in %WR were seen from 3 years onwards from bariatric surgery until the study period ended. The yearly follow-up attrition rate was 20.8% at 1 year post-surgery, 26.4% at year 2, 31.8% at year 3, 47.3% at year 4, 62.6% at year 5, and 79.1% at end of study period (at year 6).

CONCLUSION

The major challenge to the successful outcome of bariatric surgery is in maintaining weight loss in the long-term and minimizing weight regain. Factors such as the type of surgery and gender need to be considered before and after surgery, with an emphasis on the need for long-term follow-up to enssure the optimal benefits from this intervention.

Impact of Bariatric Surgery on the Healthy Eating Index, Binge Eating Behavior and Food Craving in a Middle Eastern Population: A Lebanese Experience

Even though bariatric surgeries (BS) are on the rise in Lebanon and the Middle East, the changes in diet quality, binge eating, and food cravings in this region are poorly studied peri-operatively. This cross-sectional study aimed to assess binge eating behaviors, food craving and the Healthy Eating Index (HEI) in Lebanese patients who underwent BS in a duration that exceeds 6 months. Evaluation included a dietary assessment of usual diet preoperatively and postoperatively. It included the collection of information on sociodemographic, anthropometric and surgical variables, as well as the administration of dietary recalls and questionnaires to calculate the HEI score, the Binge Eating Scale (BES) and the Food Craving Inventory (FCI). Participants (n = 60) were mostly females (85%) who had undergone sleeve gastrectomy (90%), with a mean duration since BS of 2.4 ± 1.8 years. Despite improvements in their HEI scores, 97% of the participants remained in the worst category. The frequency of participants in the severe BES category dropped markedly postoperatively from 78% to 5% (p < 0.01). Food craving followed a similar trend, with scores dropping from 50 ± 36 pre-surgery to 30 ± 25 post surgery (p < 0.01). Weight regain, prevalent among 40% of participants, was predicted by BES. Despite the improvement in BES and FCI, HEI improvement remained shy. Future interventions should validate findings in other countries and assess means for optimizing HEI scores among BS patients in the Middle East region.

Metabolic profiles, energy expenditures, and body compositions of the weight regain versus sustained weight loss patients who underwent Roux-en-Y gastric bypass

BACKGROUND

Weight regain (WR) has been an emerging problem after Roux-en Y gastric bypass (RYGB) and little is known about the mechanisms of WR after RYGB.

OBJECTIVE

To evaluate the mechanisms of WR after RYGB through the postprandial gut hormones response, particularly glucagon-like peptide-1 (GLP-1), which regulates appetite control, energy expenditure, body composition, physical activities, dietary intake, and psychological factors.

SETTING

Duke University Medical Center, Durham, North Carolina.

METHODS

A cross sectional study of 34 patients who underwent RYGB at least 2 years and achieved ≥50% of excess weight loss at 1year was conducted. The subjects were categorized into WR group or sustained weight loss group, based upon whether their WR was ≥15% of postoperative lowest weight.

RESULTS

The WR group had less augmented postprandial GLP-1 response but exaggerated hyperinsulinemia. Postprandial peptide YY, ghrelin, and glucose were not different between group. Patients who regained weight required less weight-adjusted energy expenditure and had more percentage body fat and less percentage lean mass. The caloric intake and diet composition were comparable between groups; however, the WR group had higher depression scores, binge eating scales, and hunger rating and spent significantly less time on vigorous exercise.

CONCLUSIONS

The mechanisms of WR in patients who were initially successful after RYGB are complex and involved not only the role of postprandial gut hormone response but are also related to energy expenditure adaptation and body composition changes. Moreover, food preference and physical activity may play roles in weight control after bariatric surgery. Further prospective controlled trial is needed to explore the mechanisms of WR.

Are eHealth interventions for adults who are scheduled for or have undergone bariatric surgery as effective as usual care? A systematic review

This systematic review aimed to evaluate the effect of eHealth-delivered interventions for adults who undergo bariatric surgery on postoperative weight loss, weight loss maintenance, eating psychopathology, quality of life, depression screening, and self-efficacy. Six electronic databases were searched, with 14 studies (across 17 reports) included, involving 1633 participants. With substantial heterogeneity, qualitative descriptions have been provided. Interventions were delivered via an online program or internet modules (n = 2), telephone (n = 2), text messages (n = 2), videoconferencing (n = 3), mobile application (n = 1), and audiovisual media (n = 1). Three studies included a combination, including internet modules and telephone (n = 1), wireless fidelity scales, emails, and telephone (n = 1), and a combination of online treatment, weekly emails, and access to a private Facebook group (n = 1). All the eHealth interventions, except for one, implemented behavior change techniques, including self-monitoring, problem solving, social support, goal setting, and shaping knowledge. Both eHealth intervention and control groups lost weight across the included studies, and eHealth was found to be as effective as or more effective than the control for weight loss. Two studies measured weight loss maintenance; both eHealth and control groups regained weight in the longer term. The interventions showed significant improvement on assessment measures for eating psychopathology. In conclusion, when bariatric surgery patients have limited or no access to healthcare teams or require additional support, eHealth may be a suitable option. Future studies implementing eHealth interventions would benefit from reporting intervention components as per the behavior change techniques taxonomy and further consideration of delivering eHealth in a stepped care approach would be beneficial.

MD, Eckel-Passow J, Acosta A. Precision Medicine for Obesity

Obesity is a multifactorial disease with a variable and underwhelming weight loss response to current treatment approaches. Precision medicine proposes a new paradigm to improve disease classification based on the premise of human heterogeneity, with the ultimate goal of maximizing treatment effectiveness, tolerability, and safety. Recent advances in high-throughput biochemical assays have contributed to the partial characterization of obesity's pathophysiology, as well as to the understanding of the role that intrinsic and environmental factors, and their interaction, play in its development and progression. These data have led to the development of biological markers that either are being or will be incorporated into strategies to develop personalized lines of treatment for obesity. There are currently many ongoing initiatives aimed at this; however, much needs to be resolved before precision obesity medicine becomes common practice. This review aims to provide a perspective on the currently available data of high-throughput technologies to treat obesity.

One-year outcome of laparoscopic sleeve gastrectomy in morbidly obese adolescents

Background

Adolescent obesity is an important health issue. Non-surgical weight management programs, even the most aggressive, have shown modest weight reduction results. Laparoscopic sleeve gastrectomy (LSG) is gaining reliability as a low surgical risk bariatric procedure with proper efficiency for this age group. The aim of this study was to present our initial experience with LSG in morbidly obese adolescents and to report short-term clinical and metabolic outcome.

Results

Mean age was 16.43 years, and mean preoperative weight and body mass index (BMI) were 132.68 kg and 48.90 respectively. Mean excess weight loss (EWL) was 54.11 kg 1 year after LSG, corresponding to 74 EWL% as well as mean BMI loss (BML) of 19.89. LSG improved fatty infiltration of the liver in 75% of cases and other comorbidities in 100% of patients.

Conclusions

LSG proved to be a safe procedure with significant short-term clinical and metabolic success for adolescent obesity.

Laparoscopic Adjustable Gastric Banding with the Adhesix® Bioring® for Weight Regain or Insufficient Weight Loss After a Roux-en-Y Gastric Bypass: Midterm Data from the Pronto Registry

PURPOSE

Although Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures, insufficient weight loss is described to be as high as 20-35%. To treat weight regain/inadequate weight loss, laparoscopic adjustable gastric banding (LAGB) could be a feasible revisional strategy.

MATERIALS AND METHODS

We report on a prospective study which included 35 patients who presented inadequate weight loss or significant weight regain after primary RYGB (percentage excess weight loss [%EWL] at revision < 50%). All patients underwent revisional LAGB with the placement of an Adhesix® Bioring® adjustable gastric band (Cousin Biotech, Wervicq-Sud, France). Patients' weight loss, complications, frequency of revisions and quality of life were evaluated.

RESULTS

Follow-up data at 24 months are available for 80% of the included patients. The mean BMI before RYGB was 43.6 ± 5.4 kg/m² and before revisional LAGB was 38.8 ± 4.3kg/m². The %EWL before revisional surgery was 23.3 ± 24.8%. The average time between both procedures was 6.7 (mean) ± 3.6 (SD) years. Twenty-four months after revisional LAGB, the average BMI calculated from the weight at RYGB dropped to 32.0 ± 4.5 kg/m², with an additional %EWL of 49.9 ± 30.3% resulting in a total %EWL of 60.7 ± 28%. The reoperation rate for complications related to LAGB was 21.2%. No band erosions occurred, but two bands needed to be removed during the study.

CONCLUSION

Revisional LAGB may be considered a valid salvage procedure in patients with weight regain or inadequate weight loss after RYGB, though band- and port-related complications remain a notable concern.

Surgical Prevention of Weight Regain and Type 2 Diabetes Recurrence in 3 Different Bariatric Operations and Their Differential Long-Term Outcome: An 8-Year Prospective Observational Study

Introduction

Comparative data on long-term outcomes of mechanistically different bariatric operations are scarce.

Methods

In this prospective, observational study, consecutive patients with severe obesity were studied using a predefined reoperation algorithm to determine long-term health outcomes after bariatric surgery (BS): adjustable gastric banding (AGB), Roux-en-Y gastric bypass (RYGB), or biliopancreatic diversion (BPD). All patients were assessed for mortality, postoperative weight loss, rate of reoperation, comorbidities, and quality of life (QoL) 8 years after surgery.

Results

Between 1996 and 2008, 2364 Swiss patients, with a mean body mass index of 43 ± 7 kg/m2 (mean ± SD) underwent AGB (n = 1404), RYGB (n = 790), or BPD (n = 170). Two thousand two hundred twenty-eight (94%) were followed for 8 years after BS. Eight-year mortality of the whole study group was 34.3 per 104 person-years. Percent excessive weight loss at 8 years was 56.7 ± 1.4% (95% confidence interval) in AGB, 62.5 ± 2.4% in RYGB and 64.8+-3.0% in BPD. The rate of major reoperation was highest in AGB and significantly lower in RYGB and BPD (63.4 vs 54.3 vs 47.2 per 103 person-years, P < 0.001). Remission of comorbidities was observed across all 3 groups, with key improvement (P < 0.01) in esophagitis in the RYGB group, and type 2 diabetes (T2D) (>60%) in procedures involving duodenal exclusion. Total improvement in QoL was similar between the 3 types of operations but was strongly correlated with weight loss preservation (P < 0.001).

Conclusions

BS, at the expense of a high reoperation rate but low procedural mortality, considerably improves the QoL and results in sustained remission of comorbidities, especially T2D using a predefined reoperation algorithm developed to prevent weight regain and operation-specific complications.

The Effect of Standard Versus Longer Intestinal Bypass on GLP-1 Regulation and Glucose Metabolism in Patients With Type 2 Diabetes Undergoing Roux-en-Y Gastric Bypass: The Long-Limb Study

OBJECTIVE

Roux-en-Y gastric bypass (RYGB) characteristically enhances postprandial levels of glucagon-like peptide 1 (GLP-1), a mechanism that contributes to its profound glucose-lowering effects. This enhancement is thought to be triggered by bypass of food to the distal small intestine with higher densities of neuroendocrine L-cells. We hypothesized that if this is the predominant mechanism behind the enhanced secretion of GLP-1, a longer intestinal bypass would potentiate the postprandial peak in GLP-1, translating into higher insulin secretion and, thus, additional improvements in glucose tolerance. To investigate this, we conducted a mechanistic study comparing two variants of RYGB that differ in the length of intestinal bypass.

RESEARCH DESIGN AND METHODS

A total of 53 patients with type 2 diabetes (T2D) and obesity were randomized to either standard limb RYGB (50-cm biliopancreatic limb) or long limb RYGB (150-cm biliopancreatic limb). They underwent measurements of GLP-1 and insulin secretion following a mixed meal and insulin sensitivity using euglycemic hyperinsulinemic clamps at baseline and 2 weeks and at 20% weight loss after surgery.

RESULTS

Both groups exhibited enhancement in postprandial GLP-1 secretion and improvements in glycemia compared with baseline. There were no significant differences in postprandial peak concentrations of GLP-1, time to peak, insulin secretion, and insulin sensitivity.

CONCLUSIONS

The findings of this study demonstrate that lengthening of the intestinal bypass in RYGB does not affect GLP-1 secretion. Thus, the characteristic enhancement of GLP-1 response after RYGB might not depend on delivery of nutrients to more distal intestinal segments.

Endoscopic Sleeve Gastroplasty (ESG) for High-Risk Patients, High Body Mass Index (> 50 kg/m2) Patients, and Contraindication to Abdominal Surgery

BACKGROUND

For high-risk classified patients, patients with superobesity and in cases of contraindication to abdominal surgery, traditional bariatric surgery might lead to potential morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a novel and effective bariatric therapy for morbidly obese patients. Our research group initially evaluated the safety, feasibility, and efficacy of ESG for high-risk, high body mass index (BMI) patients, and patients contraindicated to abdominal surgeries.

METHODS

Eligible patients characterized as high-risk for bariatric surgery due to high-BMI, severe comorbidities, or impenetrable abdomen were prospectively documented. ESG was performed by using Overstich® (Apollo Endosurgery, Austin, TX, USA). Primary outcomes included technical success, post-procedure adverse events and mortality, and the change of weight and BMI.

RESULTS

ESG was successfully performed for all patients (N = 24, mean age was 55.6 (± 9.2) years old, 75% male). Baseline weight and BMI were 157.9 (± 49.1) kg and 49.9 (± 14.4) kg/m². According to Edmonton Obesity Staging System (EOSS), 8 (33.3%), 14 (58.3%), and 2 (8.3%) patients were respectively classified as EOSS 2, 3, and 4. Mean operation time was 114.7 (± 26.0) min, without intraoperative complication. Weight loss, BMI reduction, %total weight loss (%TWL), and %excess weight loss (%EWL) were 17.5 (± 14.6) kg, 5.6 (± 4.6) kg/m², 12.2% (± 8.9%), and 29.1% (± 17.9%) at post-ESG 12-month, respectively. One (4.2%) moderate post-procedure adverse event (gastric mucosal bleeding) was observed.

CONCLUSIONS

ESG can be used as a safe, feasible, and effective option for the therapy of patients with superobesity, high-risk patients, and patients contraindicated to abdominal surgery. Graphical Abstract.

Comparison of 2-Year Results of Roux-en-Y Gastric Bypass and Transit Bipartition with Sleeve Gastrectomy for Superobesity

PURPOSE

Although Roux-en-Y gastric bypass is a powerful procedure, achieving and maintaining significant weight loss remains challenging in superobese populations. Transit bipartition with sleeve gastrectomy is derived from biliopancreatic diversion with duodenal switch and might improve weight loss control.

MATERIALS AND METHODS

Two series of 71 primary laparoscopic Roux-en-Y gastric bypass (RYGB) and transit bipartition (TB) with a body mass index ≥ 50 kg/m² were retrospectively compared after 2 years. Postoperative course, side effects, nutritional status, and weight outcomes were reviewed. Weight was expressed as BMI, percentage of excess BMI lost (%EBMIL), and percentage of total weight lost (%TWL).

RESULTS

The 2 groups were comparable for age and BMI of 51.9 ± 1.8 for RYGB and 51.6 ± 5 for TB. TB was longer to perform (92 vs 74 min, p ≤ 0.001) with a 30-day complication rate of 4.2% and 5.6%, but there was 1 death after RYGB. Weight loss was greater after TB compared with RYGB with %EBMIL of 85.3 ± 15.8% vs 73.9 ± 17.2% (p = 0.0002). One TB patient suffered from protein malnutrition but none after RYGB. After TB, 7% of the patients experienced > 3 stools a day and 1 patient required revision, while 3 patients had diarrhea after RYGB. Late reoperations were required for 7 and 1 patients after RYGB and TB. Comorbidity improvement was similar.

CONCLUSION

In a superobese population, TB appeared relatively safer compared with RYGB. It achieved a better weight loss at 2 years with a trend for more digestive side effects.

One Anastomosis Gastric Bypass Performed with a 150-cm Biliopancreatic Limb Delivers Weight Loss Outcomes Similar to Those with a 200-cm Biliopancreatic Limb at 18 -24 Months

BACKGROUND

It has been suggested that shortening the biliopancreatic limb (BPL) length with one anastomosis gastric bypass (OAGB) to 150 cm would reduce the revision rates for malnutrition. But, it remains unclear if this would not compromise the efficacy of this procedure.

METHODS

We examined our prospectively maintained database to compare the outcomes of patients who had their OAGB performed with a 150-cm BPL with those performed with a 200-cm BPL.

RESULTS

Medium-term weight loss data at 18-24 months was available for 343/398 (86.1% follow-up) patients. Of these, 225 had undergone OAGB-200 and 118 had undergone OAGB-150. The mean preoperative weight and body mass index were 141.6 ± 32.8 kg and 49.76 ± 8.6 kg/m², respectively, in the OAGB-200 group compared with 133.7 ± 24.5 kg and 47.83 ± 7.2 kg/m², respectively, in the OAGB-150 group. There was no significant difference in albumin and haemoglobin levels in the two groups at 18-month follow-up. The mean excess weight loss was 75.0% ± 20.1 in the OAGB-200 group and 74.0% ± 22.0 in the OAGB-150 group (p = 0.6714). A total of 89.7% (n = 202) patients achieved an excess weight loss (EWL) of ≥ 50.0% in the OAGB-200 group compared with 85.5% (n = 103) in the OAGB-150 group (p value = 0.4754). The mean total weight loss was 36.1% ± 9.2 in the OAGB-200 group compared with 34.0% ± 9.8 in the OAGB-150 group (p value = 0.0598).

CONCLUSIONS

OAGB performed with a BPL of 150 cm delivers weight loss outcomes similar to that seen with a BPL of 200 cm.

Efficacy and Drawbacks of Single-Anastomosis Duodeno-Ileal Bypass After Sleeve Gastrectomy in a Tertiary Referral Bariatric Center

Background

The need for revisional procedures after sleeve gastrectomy (SG) for insufficient weight loss or weight regain, gastroesophageal reflux, or other complications is reported to be 18–36% in studies with 10-year follow-up. Single-anastomosis duodeno-ileal bypass (SADI) may be performed as a revisional procedure after SG. This study aims to evaluate the short- and mid-term outcomes of SADI after SG in a referral center for bariatric surgery.

Materials and Methods

Data of patients who underwent SADI between March 2015 and March 2020 were collected prospectively and analyzed retrospectively. Follow-up comprised clinical and biochemical assessment at 1, 3, 6, 12, 18, and 24 months postoperatively, and once a year thereafter.

Results

Overall, 106 patients underwent SADI after a previous SG. The timeframe between SG and SADI was 50 ± 31.3 months. Postoperative mortality was observed in two cases (1.8%) and morbidity in 15.1% of patients. At 24 months, %total weight loss was 37.6 ± 12.3 and %excess weight loss 76.9 ± 25.2 (64 patients). Three patients were treated for malnutrition during follow-up, two with medical treatment and one with SADI reversal.

Conclusion

SADI after SG provides effective weight loss results in the short-term, even if in the present series the postoperative complication rate was non-negligible. Further trials are needed to establish the more advantageous revisional bariatric procedure after failed SG.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05323-y.

Behavioral weight management interventions in metabolic and bariatric surgery: A systematic review and meta-analysis investigating optimal delivery timing

Metabolic and bariatric surgery (MBS) yields unprecedented clinical outcomes, though variability is high in weight change and health benefits. Behavioral weight management (BWM) interventions may optimize MBS outcomes. However, there is a lack of an evidence base to inform their use in practice, particularly regarding optimal delivery timing. This paper evaluated the efficacy of BWM conducted pre- versus post- versus pre- and post-MBS. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and included pre- and/or post-operative BWM interventions in adults reporting anthropometric and/or body composition data. Thirty-six studies (2,919 participants) were included. Post-operative BWM yielded greater decreases in weight (standardized mean difference [SMD] = -0.41; 95% confidence interval [CI]: -0.766 to -0.049, p < 0.05; I² = 93.5%) and body mass index (SMD = -0.60; 95% CI: -0.913 to -0.289, p < 0.001; I² = 87.8%) relative to comparators. There was no effect of BWM delivered pre- or joint pre- and post-operatively. The risk of selection and performance bias was generally high. Delivering BWM after MBS appears to confer the most benefits on weight, though there was high variability in study characteristics and risk of bias across trials. This provides insight into the type of support that should be considered post-operatively.

Long-term results of laparoscopic Roux-en-Y gastric bypass for morbid obesity: 105 patients with minimum follow-up of 15 years

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the second most frequently performed bariatric procedure worldwide; however, long-term results are not frequently reported.

OBJECTIVES

To evaluate the outcomes of LRYGB on weight loss and co-morbidities in a single center 15 years after the operation.

SETTING

Tertiary-care referral hospital.

METHODS

From February 2000 to December 2003, 105 patients (86 women; mean age 39.9 ± 17.4; mean body mass index [BMI] 47.2 ± 6.4 kg/m²; 78 with BMI < 50 kg/m² and 27 with BMI ≥ 50 kg/m²) underwent LRYGB. Retrospective analyses of a prospectively maintained database were carried out to evaluate weight loss; resolution of co-morbidities, including type 2 diabetes mellitus (T2D), hypertension (HTN), and dyslipidemia; complications; and nutritional status.

RESULTS

The follow-up rate at 15 years was 87.6%. Mean excess weight loss was 58.6 ± 27%, with 74.1% of patients achieving a total weight loss ≥ 20%. According to the Biron et al. criteria, an inadequate outcome was found in 11/21 (52.4%) of patients with an initial BMI ≥ 50 kg/m² versus 21/64 (32.8%) of patients with a preoperative BMI < 50 kg/m² (P = .001). Both groups experienced gradual weight regain (WR); specifically, 34.1% of patients regained more than 15% of their lowest postoperative weight. The rates of reoperations due to early and late surgical complications were 3.8% and 9.5%, respectively. T2D was resolved in 50% of patients, HTN in 61.1%, and dyslipidemia in 58.3%. Iron deficiency anemia (53%) was the most common postoperative nutritional finding.

CONCLUSION

LRYGB provides satisfactory weight loss and resolution of co-morbidities up to 15 years. WR was a common finding. A significant proportion of patients with a preoperative BMI ≥ 50 kg/m² did not achieve a favorable weight loss outcome. Indications to perform LRYGB in this group of patients should be definitively reconsidered.

Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy in Terms of Efficacy and Safety: a Comparative Study During 11-Year Experience

PURPOSE

This cohort study was designed to compare the efficacy and safety of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) for the management of morbid obesity during the 11-year experience.

MATERIALS AND METHODS

This study was conducted between July 2006 and August 2019. Annually we recorded data about the weight, body mass index (BMI), percentage of excess weight loss (%EWL), percentage of weight loss (%WL), weight regain, and postoperative complications into a prospectively collected database.

RESULTS

A total of 1146 patients (LRYGB=396 and LSG=750) aged >18 years old were included in the study. Over the first 7 years after surgery, the weight loss rate was significantly higher in the LRYGB-treated group than the LSG-treated group, and weight regain was significantly lower in the LRYGB-treated group in comparison with the LSG-treated group. Our results revealed that statistically, but not clinically, the efficacy of LRYGB and LSG is equivalent in terms of %WL, %EWL, and weight regain within 8 years and more. Besides, there were no significant differences in surgery-related mortality and severe complications between the two procedures.

CONCLUSION

Our study's results indicated that the clinical efficacy of LRYGB in the management of obesity is better than LSG during the 11-year experience. But the differences in weight loss and weight regain were not statistically relevant at 8 years and more after the surgery. Also, a comparison of severe complications did not indicate significant differences between the two groups.

Factors associated with weight regain post-bariatric surgery: a systematic review

INTRODUCTION

To systematically review the literature to assess the incidence and risk factors of weight regain (WR) after bariatric surgery. Bariatric surgery is the most effective intervention for sustained weight loss of morbidly obese patients, but WR remains a concern.

MATERIALS AND METHODS

A PRISMA compliant systematic literature review was performed using the PubMed database, Embase and the Cochrane Library in July of 2019. Studies that reported ≥ 10% WR after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) were included. The Newcastle-Ottawa scale (NOS) was used for assessing study quality.

RESULTS

Out of 2915 retrieved abstracts, 272 full papers were reviewed, and 32 studies included (25 of high and 7 of fair quality) reporting weight outcomes on 7391 RYGB and 5872 SG patients. 17.6% (95% CI 16.9-18.3) had a WR ≥ 10%. Risk factors related with WR fell into 5 categories, namely anatomical, genetic, dietary, psychiatric, and temporal. Specifically, gastrojejunal stoma diameter, gastric volume following sleeve, anxiety, time after surgery, sweet consumption, emotional eating, portion size, food urges, binge eating, loss of control/disinhibition when eating, and genetics have been positively associated with WR while postprandial GLP-1, eagerness to change physical activity habits, self-esteem, social support, fruit and zinc consumption, HDL, quality of life have been negatively associated.

CONCLUSION

At least 1 in 6 patients after bariatric surgery had ≥ 10% WR. This review identified several factors related to WR that can be used to counsel patients preoperatively and direct postoperative strategies that minimize WR risk.

Oral Recombinant Methioninase Prevents Nonalcoholic Fatty Liver Disease in Mice on a High Fat Diet

BACKGROUND/AIM

We have recently shown that oral recombinant methionase (o-rMETase) prevents obesity and diabetes onset in mice on a high-fat (HF) diet. The present study aimed to determine if o-rMETase can inhibit the onset of nonalcoholic fatty liver disease (NAFLD) onset in mice on a high-fat diet.

MATERIALS AND METHODS

Male C57BL/6J mice in the control group were fed a normal-fat diet (NFD) (+6.5% fat), and other mice were fed a high-fat (HF) diet (+34.3% fat). Then, the mice on the HF diet were divided into two dietary groups: i) HF+phosphate buffered saline (PBS) group, and ii) HF+o-rMETase group.

RESULT

The fatty change score in the livers of mice treated with HF+PBS increased to an average of 2.6 during the experimental period of 8 weeks. In contrast, the fatty change in the livers of mice on the HF+o-rMETase group had an average score of 0.92 (p=0.04, HF+PBS vs HF+o-rMETase).

CONCLUSION

o-rMETase inhibited the onset of NAFLD as well as prevented obesity and the onset of diabetes on a high-fat diet, offering a possibility of a new paradigm to prevent liver cirrhosis or liver cancer via NAFLD.

Oral Recombinant Methioninase Inhibits Diabetes Onset in Mice on a High-fat Diet

BACKGROUND/AIM

We have recently shown that oral recombinant methionase (o-rMETase) prevents obesity in mice on a high-fat (HF) diet. The present study aimed to determine if o-rMETase can inhibit the onset of diabetes in mice on a HF diet.

MATERIALS AND METHODS

The mice on a HF diet were divided into two groups: 1) HF+phosphate buffered saline (PBS) group; 2) HF+o-rMETase group.

RESULTS

The blood glucose level in the HF+PBS group increased to average of 201 mg/dl during the experimental period of 8 weeks. In contrast, the blood glucose level in the HF+o-rMETase group maintained an average of 126 mg/dl (p<0.01, HF+PBS vs. HF+o-rMETase). The glucose tolerance test showed a significant increase in tolerance in the HF+o-rMETase group at 120 min after glucose injection compared to the HF+PBS group (p=0.04). Visceral adipose tissue was significantly less in the HF+o-rMETase group than the HF+PBS group (p=0.05). There was no difference in insulin levels, cholesterol or triglycerides between the HF+PBS and HF+o-rMETase groups.

CONCLUSION

o-rMETase inhibited the onset of diabetes as well as prevented obesity on a high-fat diet, offering a possibility of a new and easy-to-use alternative to severe dieting or insulin injections.

Bariatric Surgery-How Much Malabsorption Do We Need?-A Review of Various Limb Lengths in Different Gastric Bypass Procedures

The number of obese individuals worldwide continues to increase every year, thus, the number of bariatric/metabolic operations performed is on a constant rise as well. Beside exclusively restrictive procedures, most of the bariatric operations have a more or less malabsorptive component. Several different bypass procedures exist alongside each other today and each type of bypass is performed using a distinct technique. Furthermore, the length of the bypassed intestine may differ as well. One might add that the operations are performed differently in different parts of the world and have been changing and evolving over time. This review evaluates the most frequently performed bariatric bypass procedures (and their variations) worldwide: Roux-en-Y Gastric Bypass, One-Anastomosis Gastric Bypass, Single-Anastomosis Duodeno-Ileal Bypass + Sleeve Gastrectomy, Biliopancreatic Diversion + Duodenal Switch and operations due to weight regain. The evaluation of the procedures and different limb lengths focusses on weight loss, remission of comorbidities and the risk of malnutrition and deficiencies. This narrative review does not aim at synthesizing quantitative data. Rather, it provides a summary of carefully selected, high-quality studies to serve as examples and to draw tentative conclusions on the effects of the bypass procedures mentioned above. In conclusion, it is important to carefully choose the procedure and small bowel length excluded from the food passage suited best to each individual patient. A balance has to be achieved between sufficient weight loss and remission of comorbidities, as well as a low risk of deficiencies and malnutrition. In any case, at least 300 cm of small bowel should always remain in the food stream to prevent the development of deficiencies and malnutrition.

Early Weight Loss after Laparoscopic Sleeve Gastrectomy Predicts Sustained Weight Maintenance Among Chinese Individuals with a BMI < 35 kg/m2

OBJECTIVES

This study assessed the efficacy and safety of laparoscopic sleeve gastrectomy (LSG) in Chinese individuals with a body mass index (BMI) under 35 kg/m² and to explore the association between early weight loss and sustained weight maintenance.

METHODS

Patients whose BMI < 35 kg/m² were recruited. Changes in BMI, total weight loss (%TWL), and excess weight loss (%EWL) were evaluated, with successful weight loss being a %EWL of > 50% and a %TWL of > 25%. Binary logistic regression was employed to assess relationships between %EWL and %TWL and to calculate a joint predictor. The association between early weight loss and sustained weight maintenance was assessed as a function of %EWL, %TWL, and this joint predictor, with receiver operating characteristic (ROC) curves being used for optimal cutoff threshold identification.

RESULTS

In total, 143 individuals with average preoperative weight and BMI values of 88 (82, 95) kg and 31.99 (29.41, 33.15) kg/m², respectively, were enrolled in present study. At 5 years, 48.00% of patients achieved successful weight loss. Both 3-month %EWL and %TWL were significantly related to sustained weight loss at 5 years (P < 0.05). ROC curves were used to identify %TWL of 19.54% at 3 months as the most reliable predictor of weight loss at a 5-year follow-up (sensitivity: 61.11%, specificity: 76.92%).

CONCLUSION

LSG had long-term safety and efficacy, and %TWL at 3 months can predict sustained 5-year weight loss in Chinese individuals with BMI < 35 kg/m².

Gestational weight gain and postpartum weight retention after bariatric surgery: data from a prospective cohort study

BACKGROUND

It is unknown whether international guidelines on gestational weight gain can be used in pregnancies after bariatric surgery.

OBJECTIVES

To investigate gestational weight gain, intrauterine growth, and postpartum weight retention in postbariatric women.

SETTING

8 Belgian hospitals.

METHODS

Prospective data from 127 postbariatric pregnancies from September 2014 through October 2018. Patients were grouped according to achievement of 2009 Institute of Medicine (IOM) guidelines.

RESULTS

In 127 patients with a mean age of 30.2 years (standard deviation [SD], 4.7), the mean gestational weight gain was 12.5 kg (SD, 6.7). Of these patients, 24% (30 of 127) showed insufficient weight gain, 20% (26 of 127) showed adequate weight gain, and 56% (71 of 127) showed excessive weight gain. Of 127 patients, 27 (21%) had small-for-gestational-age infants. This peaked in the group with insufficient weight gain (47%; 95% confidence interval [CI], 29%-65%; P < .001). The prevalence of large-for-gestational-age infants was comparable between groups, although highest in the group with excessive weight gain (0% in those with insufficient weight gain, 4% in those with adequate weight gain, and 8% in those with excessive weight gain). Preterm births were recorded more in patients with insufficient weight gain (23%; 95% CI, 8%-38%; P = .048). The mean amounts of postpartum weight retained were 4.0 kg (SD, 7.4) at 6 weeks and 3.0 kg (SD, 9.1) at 6 months. Weight retention at 6 weeks (7.1 kg; 95% CI, 5.5-8.7; P < .001) and 6 months (8.3 kg; 95% CI, 4.5-12.2; P < .001) was highest in women gaining excessive weight.

CONCLUSION

Achievement of IOM guidelines is low in postbariatric pregnancies. Insufficient weight gain increases the risk for small-for-gestational-age babies. Excessive weight gain increases weight retention after delivery and could precipitate weight regain. After bariatric surgery, women should be encouraged to achieve IOM recommendations.

Telemedicine intervention on physical activity recovery after bariatric surgery: the MyGoodTrip randomized controlled trial (Preprint)

BACKGROUND

Despite bariatric surgery showing significant weight loss trajectories for many patients, a substantial proportion regain weight after the first year following surgery. The addition of telemedicine to standard care could support patients with engaging in a more active lifestyle and thus improve clinical outcomes.

OBJECTIVE

Our aim was to evaluate a telemedicine intervention program dedicated to the promotion of physical activity including digital devices, teleconsultation, and telemonitoring the first 6 months following bariatric surgery.

METHODS

This study employed a mixed methods design based on an open-label randomized controlled trial. Patients were included during the first week after bariatric surgery; then, they were randomized into 2 intervention groups: The TelePhys group received a monthly telemedicine consultation focusing on physical activity coaching, while the TeleDiet group received a monthly telemedicine consultation involving diet coaching. Data were collected using a watch pedometer and body weight scale, both of which were connected wirelessly. The primary outcome was the difference between the 2 groups in the mean numbers of steps at the first and sixth postoperative months. Weight change was also evaluated, and focus groups and interviews were conducted to enrich the results and capture perceptions of the telemedicine provided.

RESULTS

Among the 90 patients (mean age 40.6, SD 10.4 years; 73/90, 81% women; 62/90, 69% gastric bypass), 70 completed the study until the sixth month (n=38 TelePhys; n=32 TeleDiet), and 18 participants agreed to be interviewed (n=8 Telephys; n=10 TeleDiet). An increase in the mean number of steps between the first and sixth months was found in both groups, but this change was significant only in the TeleDiet group (P=.01). No difference was found when comparing both intervention groups. Interviewed participants reported having appreciated the teleconsultations, as the individualized tailored counseling helped them to make better choices about behaviors that could increase their likelihood of a daily life in better health. Weight loss followed by social factors (such as social support) were identified as the main facilitators to physical activity. Family responsibilities, professional constraints as well as poor urban policies promoting physical activity, and lack of accessibility to sport infrastructure were their major barriers to postoperative lifestyle adherence.

CONCLUSIONS

Our study did not show any difference in mobility recovery after bariatric surgery related to a telemedicine intervention dedicated to physical activity. The early postoperative timing for our intervention may explain the null findings. eHealth interventions aiming to change behaviors and carried out by clinicians require support from structured public health policies that tackle patients' obesogenic environment in order to be efficient in their struggle against sedentary lifestyle-related pathologies. Further research will need to focus on long-term interventions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02716480, https://clinicaltrials.gov/ct2/show/NCT02716480.

A Matched Cohort Comparison of Long-term Outcomes of Roux-en-Y Gastric Bypass (RYGB) Versus Single-Anastomosis Duodeno-ileostomy with Sleeve Gastrectomy (SADI-S)

BACKGROUND

The long-term effectiveness of Roux-en-Y gastric bypass (RYGB) and single-anastomosis duodeno-ileostomy with sleeve gastrectomy (SADI-S) is unknown.

PURPOSE

Compare the long-term outcomes.

SETTING

Single private institute, USA.

MATERIALS AND METHODS

Data from 1254 patients who underwent primary RYGB or SADI-S were used for a retrospective matched cohort. Data were obtained by matching every RYGB patient to a SADI-S patient of the same sex, body mass index (BMI), and weight. Only patients out 5 years and had at least one > 5-year follow-up visit were included.

RESULTS

The matched cohort included 61 RYGB and 61 SADI-S patients. There was no statistical, demographic difference between the two groups. At 5 years, a 100% follow-up was available in each group. The intraoperative outcomes were significantly better with SADI-S. The 30-day readmission, reoperation, emergency department (ED) visits, and complication rates were statistically similar between the two groups. The long-term complication rates, Clavien-Dindo grade IIIb complications, and number of patients with more than one complication were significantly lower with SADI-S. Weight loss was significantly greater in the SADI-S group at 5 years. The long-term weight-loss failure rate was significantly higher in the RYGB group. The SADI-S procedure was associated with fewer reintervention through 6 years (14.7% patients vs. 39.3% patients, p = 0.001). Conversion or reversal of the procedure was required only in the RYGB group. There also was no significant difference in nutritional outcomes between the two procedures.

CONCLUSIONS

This study showed that problems, including long-term complications, reinterventions, weight-loss failure, and conversion, were more often associated with RYGB than with SADI-S. The SADI-S may be considered one of the viable alternatives to RYGB.