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Vilallonga R, Pereira-Cunill JL, Morales-Conde S, Alarcón I, Breton I, Domínguez-Adame E, Ferrer JV, Ruiz-de-Gordejuela AG, Goday A, Lecube A, García-Almenta EM, Rubio MÁ, Tinahones FJ, García-Luna PP. A Spanish Society joint SECO and SEEDO approach to the Post-operative management of the patients undergoing surgery for obesity. Obes Surg 2020; 29:3842-3853. [PMID: 31342249 DOI: 10.1007/s11695-019-04043-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Bariatric surgery is the method of choice for the management or treatment of obesity. Bariatric surgery brings about several physiological changes in the body and is associated with set of complications. The aim of this study is to provide guidelines on post bariatric surgery management based on consensus by the Spanish society for Obesity Surgery (Sociedad Española de Cirugía de la Obesidad) (SECO) and the Spanish Society for the Study of Obesity (Sociedad Española para el Estudio de la Obesidad) (SEEDO). METHOD The boards proposed seven experts from each society. The experts provided the evidence and a grade of recommendation on the selected topics based on systematic reviews/meta-analysis. A list of clinical practical recommendations levels of evidence and grades of these recommendations was derived from the consensus statements from the members of these societies. RESULTS Seventeen topics related to post-operative management were reviewed after bariatric surgery. The experts came with 47 recommendations and statements. The mean number of persons voting at each statement was 54 (range 36-76). CONCLUSION In this consensus, we have designed a set of guidelines to be followed while managing patients after bariatric surgery. Expertise and knowledge of the clinicians are required to convey suitable considerations to the post-bariatric patients. There should also be extensive follow-up plans for the bariatric surgery patients.
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Affiliation(s)
- R Vilallonga
- Endocrine, metabolic and bariatric Unit, General Surgery Department, Hospital Vall d'Hebron, Center of Excellence for the EAC-BC, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - J L Pereira-Cunill
- Clinical Nutritión Unit, Endocrinology and Nutrition Service, University Hospital "Virgen del Rocío", Seville, Spain
| | - S Morales-Conde
- Unit of Innovation in Minimally Invasive Surgery, Department of Surgery, University Hospital "Virgen del Rocío", Hospital Quironsalud Sagrado Corazón, University of Sevilla, Sevilla, Spain
| | - I Alarcón
- Unit of Innovation in Minimally Invasive Surgery, Department of Surgery, University Hospital "Virgen del Rocío", Hospital Quironsalud Sagrado Corazón, University of Sevilla, Sevilla, Spain
| | - I Breton
- Unidad de Nutrición Clínica y Dietética del Servicio de Endocrinología y Nutrición del Hospital Gregorio Marañón, Madrid, Spain
| | - E Domínguez-Adame
- UGC Cirugía General y Aparato Digestivo, Hospital Universitario Virgen Macarena, Universidad de Sevilla, Sevilla, Spain
| | | | - A Garcia Ruiz-de-Gordejuela
- Endocrine, metabolic and bariatric Unit, General Surgery Department, Hospital Vall d'Hebron, Center of Excellence for the EAC-BC, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Goday
- Servicio de Endocrinología, Hospital del Mar de Barcelona, Departament de Medicina, CIBERobn, ISCIII, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Lecube
- Servicio deEndocrinología y Nutrición, Hospital Universitari Arnau de Vilanova de Lleida, Institut de Recerca Biomèdica de Lleida (IRBLleida), Universitat de Lleida (UdL), Avda. Rovira Roure, 80 25198, Lleida, Spain
| | - E Martín García-Almenta
- Unidad Cirugía Esófago-Gástrica, Metabólica y Bariátrica, Hospital Clínico San Carlos, Madrid, Spain
| | - M Á Rubio
- Servicio de Endocrinología y Nutrición, Hospital Clínico San Carlos, Idissc, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - F J Tinahones
- Service of Endocrinology and Nutrition, Hospital Clínico Universitario Virgen de Victoria de Malaga, Málaga, Spain
| | - P P García-Luna
- Unidad de Nutrición Clínica y de la Unidad de Obesidad Mórbida (Unidad de Gestión de Endocrinología y Nutrición, UGEN), Hospital Universitario Virgen del Rocío, Seville, Spain
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102
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Tornese S, Aiolfi A, Bonitta G, Rausa E, Guerrazzi G, Bruni PG, Micheletto G, Bona D. Remnant Gastric Cancer After Roux-en-Y Gastric Bypass: Narrative Review of the Literature. Obes Surg 2020; 29:2609-2613. [PMID: 31001760 DOI: 10.1007/s11695-019-03892-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed procedures for surgical weight loss. It has been shown that overweight may be associated with an increased risk of gastric cancer. However, the risk of remnant gastric cancer after RYGB has not been defined yet and the development of neoplasm in the excluded stomach remains a matter of concern. METHODS PubMed, EMBASE, and Web of Science databases were consulted. Articles that described the diagnosis and management of remnant gastric cancer after RYGB were considered. RESULTS Seventeen patients were included. The age of the patient population ranged from 38 to 71 years. The most commonly reported symptoms were abdominal pain, nausea/vomiting, and anemia. Abdominal computed tomography was used for diagnosis in the majority of patients. The neoplasm was located in the antrum/pre-pyloric region in 70% of cases and adenocarcinoma was the most common tumor histology (80%). An advanced tumor stage (III-IV) was diagnosed in almost 70% of patients and 40% were considered unresectable. Gastrectomy with lymphadenectomy was performed in 9 cases (53%). Post-operative morbidity was 12%. The follow-up ranged from 3 to 26 months and the overall disease-related mortality rate was 33.3%. CONCLUSION The development of remnant gastric cancer after RYGB is rare. Surgeons should be aware of this potential event and the new onset of epigastric pain, nausea, and anemia should raise clinical suspicion. Further epidemiologic studies are warranted to deeply investigate the post-RYGB-related risk of remnant gastric cancer development in high-risk populations.
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Affiliation(s)
- Stefania Tornese
- Department of Biomedical Science for Health, Division of General Surgery Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Alberto Aiolfi
- Department of Biomedical Science for Health, Division of General Surgery Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy.
| | - Gianluca Bonitta
- Department of Biomedical Science for Health, Division of General Surgery Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Emanuele Rausa
- Department of Biomedical Science for Health, Division of General Surgery Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Guglielmo Guerrazzi
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Piero Giovanni Bruni
- Department of Biomedical Science for Health, Division of General Surgery Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Giancarlo Micheletto
- Department of Pathophysiology and Transplantation, INCO and Department of General Surgery, Istituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
| | - Davide Bona
- Department of Biomedical Science for Health, Division of General Surgery Istitituto Clinico Sant'Ambrogio, University of Milan, Milan, Italy
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103
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Effect of Bariatric Surgery on Serum Inflammatory Factors of Obese Patients: a Systematic Review and Meta-Analysis. Obes Surg 2020; 29:2631-2647. [PMID: 31093862 DOI: 10.1007/s11695-019-03926-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Obesity is one of the main causes of inflammation. Previous studies have reported inconclusive results regarding the effect of bariatric surgery on inflammatory markers. This systematic review and meta-analysis is aimed at describing the effect of bariatric surgery on C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α). PubMed/Medline and Scopus were systematically searched for all eligible studies from inception to June 2018. Results are expressed as weighted mean difference (MD) with 95% confidence intervals (CI) using a random effects model. Overall, 116 studies which evaluated serum CRP, IL-6, and TNF-α after bariatric surgery were included. Pooled effect size showed significant reduction in serum CRP (- 5.30 mg/l, 95% CI - 5.46, - 5.15, P < 0.001), IL-6 (- 0.58 pg/ml, 95% CI - 0.64, - 0.53, P < 0.001), and TNF-α (- 0.20 pg/ml, 95% CI - 0.39, - 0.02, P = 0.031) with significant heterogeneity across studies (> 95% for all factors). Bariatric surgery significantly lowered inflammatory factors; however, baseline BMI, follow-up duration and type of surgery could impact the extent of observed effects.
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104
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Parackal A, Tarride JE, Xie F, Blackhouse G, Hoogenes J, Hylton D, Hanna W, Adili A, Matsumoto ED, Shayegan B. Economic evaluation of robot-assisted radical prostatectomy compared to open radical prostatectomy for prostate cancer treatment in Ontario, Canada. Can Urol Assoc J 2020; 14:E350-E357. [PMID: 32379598 DOI: 10.5489/cuaj.6376] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Recent health technology assessments (HTAs) of robot-assisted radical prostatectomy (RARP) in Ontario and Alberta, Canada, resulted in opposite recommendations, calling into question whether benefits of RARP offset the upfront investment. Therefore, the study objectives were to conduct a cost-utility analysis from a Canadian public payer perspective to determine the cost-effectiveness of RARP. METHODS Using a 10-year time horizon, a five-state Markov model was developed to compare RARP to open radical prostatectomy (ORP). Clinical parameters were derived from Canadian observational studies and a recently published systematic review. Costs, resource utilization, and utility values from recent Canadian sources were used to populate the model. Results were presented in terms of increment costs per quality-adjusted life years (QALYs) gained. A probabilistic analysis was conducted, and uncertainty was represented using cost-effectiveness acceptability curves (CEACs). One-way sensitivity analyses were also conducted. Future costs and QALYs were discounted at 1.5%. RESULTS Total cost of RARP and ORP were $47 033 and $45 332, respectively. Total estimated QALYs were 7.2047 and 7.1385 for RARP and ORP, respectively. The estimated incremental cost-utility ratio (ICUR) was $25 704 in the base-case analysis. At a willingness-to-pay threshold of $50 000 and $100 000 per QALY gained, the probability of RARP being cost-effective was 0.65 and 0.85, respectively. The model was most sensitive to the time horizon. CONCLUSIONS The results of this analysis suggest that RARP is likely to be cost-effective in this Canadian patient population. The results are consistent with Alberta's HTA recommendation and other economic evaluations, but challenges Ontario's reimbursement decision.
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Affiliation(s)
- Anna Parackal
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Jean-Eric Tarride
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada.,McMaster Chair in Health Technology Management, McMaster University, Hamilton, ON, Canada
| | - Feng Xie
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada.,Centre for Health Economics and Policy Analysis (CHEPA), McMaster University, Hamilton, ON, Canada
| | - Gord Blackhouse
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada.,Programs for Assessment of Technology in Health (PATH), The Research Institute of St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Jen Hoogenes
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Danielle Hylton
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Wael Hanna
- Department of Health Research Methods, Evidence & Impact (HEI), McMaster University, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Anthony Adili
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Bobby Shayegan
- Department of Surgery, McMaster University, Hamilton, ON, Canada
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105
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Preis MA, Zellerhoff M, Brockmeyer T. Approach bias modification training to increase physical activity: A pilot randomized controlled trial in healthy volunteers. J Health Psychol 2020; 26:2470-2486. [DOI: 10.1177/1359105320913936] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Regular physical activity is associated with better physical and mental health outcomes as well as higher quality of life. This pilot randomized controlled trial examined whether approach bias modification, an economical and easily accessible computerized cognitive training, could increase objectively and subjectively measured physical activity in individuals aiming for more physical activity. Forty healthy volunteers of normal weight were randomly allocated to six sessions of approach bias modification or no treatment. The approach bias modification adopted an implicit learning paradigm that trained participants to show approach behavior in response to visual cues of physical activity. Approach bias modification did not increase objectively and subjectively measured physical activity.
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106
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de La Harpe R, Rüeger S, Kutalik Z, Ballabeni P, Suter M, Vionnet N, Laferrère B, Pralong F. Weight Loss Directly Influences Intermediate-Term Remission of Diabetes Mellitus After Bariatric Surgery: A Retrospective Case-Control Study. Obes Surg 2020; 30:1332-1338. [PMID: 31754925 PMCID: PMC10015445 DOI: 10.1007/s11695-019-04283-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE Roux en Y gastric bypass surgery (RYGB) is an effective therapy for patients with severe obesity. It induces both significant weight loss and rapid improvements of metabolic complications. This study was undertaken to better define the direct role of weight loss in the metabolic improvements. METHODS A retrospective, case-control study of a cohort of 649 patients with obesity who underwent RYGB, comparing higher and lower responders at 2 years after surgery (n = 100 pairs). Pairs of patients were matched for age, gender, and initial BMI. The rates of remission of diabetes, hypertension, dyslipidemia, and hyperuricemia were compared using a mixed effects logistic regression analysis. RESULTS Diabetes before surgery was present in 12/100 lower responders and 17/100 higher responders. Remission at 2 years was observed in 4/12 (33%) of lower responders, compared to 15/17 (88%) of higher responders. Thus, the odds of diabetes remission was significantly smaller in lower responders (OR = 0.067, 95% CI 0.01-0.447). A mixed model regression analysis of all the parameters for each patient showed that the odds of achieving remission of any comorbidity was significantly lower in lower responders (OR = 0.62, 95% CI = 0.39-0.97). CONCLUSION We could demonstrate that weight loss is a significant determinant of the remission of diabetes 2 years after RYGB. These data underline the importance of weight loss in the benefits of this procedure.
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Affiliation(s)
- R de La Harpe
- Service of Internal Medicine, Morges, Switzerland. .,Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland.
| | - S Rüeger
- School of Life Sciences, EPFL, Lausanne, Switzerland.,Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Z Kutalik
- Swiss Institute of Bioinformatics, Lausanne, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne (UNIL), Lausanne, Switzerland
| | - P Ballabeni
- Swiss Institute of Bioinformatics, Lausanne, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne (UNIL), Lausanne, Switzerland.,Clinical Research Center (CRC), Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - M Suter
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland.,Department of Visceral Surgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Department of Surgery, Riviera-Chablais Hospital, Aigle-Monthey, Switzerland
| | - N Vionnet
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - B Laferrère
- New York Obesity Nutrition Research Center, Divison of Endocrinology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, United States
| | - F Pralong
- Center for Endocrinology, Diabetology and Obesity, La Tour Private Hospital, Meyrin, Switzerland
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107
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Yuce TK, Khorfan R, Soper NJ, Hungness ES, Nagle AP, Teitelbaum EN, Bilimoria KY, Odell DD. Post-Operative Complications and Readmissions Associated with Smoking Following Bariatric Surgery. J Gastrointest Surg 2020; 24:525-530. [PMID: 31848871 PMCID: PMC7485607 DOI: 10.1007/s11605-019-04488-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 11/23/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The link between smoking and poor postoperative outcomes is well established. Despite this, current smokers are still offered bariatric surgery. We describe the risk of postoperative 30-day complications and readmission following laparoscopic sleeve gastrectomy and laparoscopic Roux-En-Y gastric bypass in smokers. METHODS The National Surgical Quality Improvement Program database was queried to identify patients who underwent laparoscopic sleeve gastrectomy and Roux-En-Y gastric bypass from 2012 to 2017. Patient outcomes were compared based on smoking status. Primary outcomes included 30-day readmission and death or serious morbidity. Secondary outcomes included wound and respiratory complications. Multivariable logistic regression was used to determine the association between smoking status and measured outcomes. RESULTS Of the 133,417 patients who underwent bariatric surgery, 12,424 (9.3%) were smokers. Smokers more frequently experienced readmission (4.9% v 4.1%, p < 0.001), death or serious morbidity (3.8% v 3.4%, p = 0.019), wound complications (2% v 1.4%, p < 0.001), and respiratory complications (0.8% v 0.5%, p < 0.001). The likelihood of death or serious morbidity (OR 1.13, 95% CI 1.01-1.26), readmission (OR 1.21, 95% CI 1.10-1.33), wound (OR 1.44, 95% CI 1.24-1.68), and respiratory complications (OR 1.69, 95% CI 1.34-2.14) were greater in smokers. The adjusted ORs remained significant on subgroup analysis of laparoscopic sleeve gastrectomy and Roux-En-Y gastric bypass patients, with the exception of death or serious morbidity in laparoscopic Roux-En-Y gastric bypass (OR 1.04, 95% CI 0.89-1.24). CONCLUSIONS Smokers undergoing bariatric surgery experience significantly worse 30-day outcomes when compared with non-smokers. There should be a continued emphasis on perioperative smoking cessation for patients being evaluated for bariatric surgery.
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Affiliation(s)
- Tarik K Yuce
- Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA
| | - Rhami Khorfan
- Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA
| | - Nathaniel J Soper
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA
| | - Eric S Hungness
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA
| | - Alexander P Nagle
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA
| | - Ezra N Teitelbaum
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA
| | - Karl Y Bilimoria
- Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA
| | - David D Odell
- Surgical Outcomes and Quality Improvement Center (SOQIC), Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA.
- Department of Surgery, Feinberg School of Medicine, Northwestern University, 633 N St Clair St, 20th Floor, Chicago, IL, 60611, USA.
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108
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Alcohol Use Thresholds for Identifying Alcohol-related Problems Before and Following Roux-en-Y Gastric Bypass. Ann Surg 2020; 269:1001-1009. [PMID: 31082893 DOI: 10.1097/sla.0000000000003078] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The aim of this study was to determine the sensitivity and specificity of potential thresholds of alcohol use for identifying alcohol-related problems in women post-Roux-en-Y gastric bypass (RYGB). BACKGROUND Despite evidence that RYGB alters alcohol pharmacokinetics and is associated with an increased risk for alcohol-related problems, the level of alcohol use that should prompt further screening for alcohol-related problems following RYGB is unclear. METHODS The Longitudinal Assessment of Bariatric Surgery-2 is a prospective cohort study. Before surgery and annually for ≤7 years following surgery, participants completed the 10-item Alcohol Use Disorder Identification Test (AUDIT), which assesses past-year frequency and quantity of alcohol, frequency of consuming ≥6 drinks, and alcohol-related problems (ie, symptoms of alcohol dependence and/or alcohol-related harm). The AUDIT-Consumption (AUDIT-C) score was determined from the first 3 AUDIT items. RESULTS Post-RYGB, 835 women reported current drinking at 1 or more annual assessment(s). Compared with higher frequency thresholds, drinking ≥2 times/month had the highest combined sensitivity (85.3%) and specificity (61.4%) for identifying alcohol-related problems. Compared with higher quantity thresholds, drinking ≥3 drinks/drinking day had the highest combined sensitivity (64.2%) and specificity (87.2%). An AUDIT-C score ≥3, versus other thresholds, had the highest combined sensitivity (76.4%) and specificity (81.6%). CONCLUSION The sensitivity and specificity of these thresholds indicate assessment of alcohol consumption alone may be inadequate for identifying women at risk for alcohol-related problems post-RYGB. Additional screening tools for alcohol-related problems, which assess symptoms of alcohol-related problems, should be conducted in this population.
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Orthostatic Renal Transplant Compression Following Weight Gain Leading to Acute Kidney Injury. Transplant Proc 2020; 52:153-156. [PMID: 31924406 DOI: 10.1016/j.transproceed.2019.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/02/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND We present a first case of orthostatic renal graft compression and acute kidney injury following weight gain. CASE REPORT A 61-year-old male with a second cadaveric transplant presented with acute kidney injury - creatinine rise from 80 to 210 μmol/L (0.90 to 2.38 mg/dL). His medical history included diabetes, hypertension, ischemic heart disease, and obesity despite bariatric surgery. Renal biopsy was consistent with acute tubular necrosis. Serial renovascular duplex studies showed absence of diastolic flow and reduced renal perfusion despite a patent renal transplant artery and vein. Raising the fatty apron cephalad normalized renal blood flow with resistive indices throughout the kidney. Subsequent laparascopy ruled out adhesional obstruction and carbon dioxide angiogram confirmed normal transplant vessels, anastomotic sites, and intrarenal branches. He was treated with bedrest and an abdominal support belt with improvement of creatinine to 100 to 110 μmol/L (1.1-1.2 mg/dL). CONCLUSIONS Transplant physicians and surgeons need to be aware of positional renal graft compression from an enlarged bulky omentum and fatty apron. Diagnosis requires positional sonography.
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110
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Ramya MV, Manangi M, Hegde B, Shivashankar S, Anandan P, Venkatappa S. Obesity and surgical intervention: How acquainted are we? FORMOSAN JOURNAL OF SURGERY 2020. [DOI: 10.4103/fjs.fjs_29_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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111
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Lewis KH, Arterburn DE, Callaway K, Zhang F, Argetsinger S, Wallace J, Fernandez A, Ross-Degnan D, Wharam JF. 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. JAMA Netw Open 2019; 2:e1917603. [PMID: 31851344 PMCID: PMC6991222 DOI: 10.1001/jamanetworkopen.2019.17603] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
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.
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Affiliation(s)
- Kristina H. Lewis
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David E. Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Katherine Callaway
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Fang Zhang
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Stephanie Argetsinger
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Jamie Wallace
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - Adolfo Fernandez
- Department of General Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Dennis Ross-Degnan
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
| | - James F. Wharam
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Pilgrim Healthcare Institute, Harvard Medical School, Boston, Massachusetts
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112
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Bademci R, Vilallonga R, Piero A, Renato R, Yuhamy C, Posadas Ramirez LA. Is the Primary Obesity Surgery Endolumenal as Effective and Reliable as the Surgical Procedures? Bariatr Surg Pract Patient Care 2019. [DOI: 10.1089/bari.2019.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Refik Bademci
- Quirobes, Integral Obesity Care, Barcelona, Spain
- SCIAS, Hospital de Barcelona, Barcelona, Spain
| | - Ramon Vilallonga
- Quirobes, Integral Obesity Care, Barcelona, Spain
- SCIAS, Hospital de Barcelona, Barcelona, Spain
- ELSAN, Clinique St-Michel, Toulon, France
| | - Alberti Piero
- Quirobes, Integral Obesity Care, Barcelona, Spain
- SCIAS, Hospital de Barcelona, Barcelona, Spain
| | - Roriz Renato
- Quirobes, Integral Obesity Care, Barcelona, Spain
- SCIAS, Hospital de Barcelona, Barcelona, Spain
| | - Curbero Yuhamy
- Quirobes, Integral Obesity Care, Barcelona, Spain
- SCIAS, Hospital de Barcelona, Barcelona, Spain
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113
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Doumouras AG, Albacete S, Mann A, Gmora S, Anvari M, Hong D. A Longitudinal Analysis of Wait Times for Bariatric Surgery in a Publicly Funded, Regionalized Bariatric Care System. Obes Surg 2019; 30:961-968. [DOI: 10.1007/s11695-019-04259-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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114
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Morris MC, Jung AD, Kim Y, Lee TC, Kaiser TE, Thompson JR, Bari K, Shah SA, Cohen RM, Schauer DP, Smith EP, Diwan TS. Delayed Sleeve Gastrectomy Following Liver Transplantation: A 5-Year Experience. Liver Transpl 2019; 25:1673-1681. [PMID: 31518478 DOI: 10.1002/lt.25637] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/02/2019] [Indexed: 12/31/2022]
Abstract
Obesity has become an epidemic in the United States over the past decade, and recent studies have shown this trend in the liver transplantation (LT) population. These patients may be candidates for laparoscopic sleeve gastrectomy (LSG) to promote significant and sustained weight loss to prevent recurrence of nonalcoholic steatohepatitis. However, safety remains a concern, and efficacy in this setting is uncertain. A single-institution database from 2014 to 2018 was queried for patients undergoing LSG following LT. The selection criteria for surgery were consistent with National Institutes of Health guidelines, and patients were at least 6 months after LT. A total of 15 patients (median age, 59.0 years; Caucasian, 86.7%; and female, 60%) underwent LSG following LT. Median time from LT to LSG was 2.2 years with a median follow-up period of 2.6 years. The median hospital length of stay (LOS) was 2 days after LSG. Mortality and rate of liver allograft rejection was 0, and there was 1 postoperative complication (a surgical site infection). Following LSG, body mass index (BMI) decreased from 42.7 to 35.9 kg/m2 (P < 0.01), and in 12 patients with at least 1 year of follow-up, the total body weight loss was 20.6%. Following LSG in patients with diabetes, the median daily insulin requirements decreased from 98 (49-118) to 0 (0-29) units/day (P = 0.02), and 60% discontinued insulin. Post-LT patients had a similar decrease in BMI and reduction in comorbidities at 1 year compared with a matched non-LT patient cohort. In the largest patient series to date, we show that LSG following LT is safe, effective, and does not increase the incidence of liver allograft rejection. Larger longer-term studies are needed to confirm underlying metabolic changes following LSG.
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Affiliation(s)
- Mackenzie C Morris
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Andrew D Jung
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Young Kim
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Tiffany C Lee
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Tiffany E Kaiser
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Jonathan R Thompson
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Khurram Bari
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
| | - Robert M Cohen
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Daniel P Schauer
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Eric P Smith
- Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH.,Department of Internal Medicine, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Tayyab S Diwan
- Department of Surgery, Section of Transplantation, University of Cincinnati School of Medicine, Cincinnati, OH.,Cincinnati Collaborative for Obesity Research, University of Cincinnati, Cincinnati, OH
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115
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Kokkinos A, Tsilingiris D, le Roux CW, Rubino F, Mantzoros CS. Will medications that mimic gut hormones or target their receptors eventually replace bariatric surgery? Metabolism 2019; 100:153960. [PMID: 31412266 DOI: 10.1016/j.metabol.2019.153960] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/31/2019] [Accepted: 08/05/2019] [Indexed: 02/07/2023]
Abstract
Bariatric surgery is currently the most effective therapeutic modality through which sustained beneficial effects on weight loss and metabolic improvement are achieved. During recent years, indications for bariatric surgery have been expanded to include cases of poorly controlled type 2 (T2DM) diabetes mellitus in lesser extremes of body weight. A spectrum of the beneficial effects of surgery is attributed to robust changes of postprandial gut peptide responses that are observed post operatively. Consolidated knowledge regarding gut peptide physiology as well as emerging new evidence shedding light on the mode of action of previously overlooked gut hormones provide appealing potential obesity and T2DM therapeutic perspectives. The accumulation of evidence from the effect of exogenous administration of native gut peptides alone or in combinations to humans as well as the development of mimetic agents exerting agonistic effects on combinations of gut hormone receptors pave the way for future integrated gut peptide-based treatments, which may mimic the effects of bariatric surgery.
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Affiliation(s)
- Alexander Kokkinos
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece.
| | - Dimitrios Tsilingiris
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Carel W le Roux
- Diabetes Complications Research Centre, University College Dublin, Dublin, Ireland
| | - Francesco Rubino
- Department of Metabolic and Bariatric Surgery, Diabetes and Nutritional Science Division, King's College Hospital, London, United Kingdom
| | - Christos S Mantzoros
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, USA
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116
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Salminen P. Standardized Uniform Reporting and Indications for Bariatric and Metabolic Surgery: How Can We Reach This Goal? JAMA Surg 2019; 153:1077-1078. [PMID: 30326029 DOI: 10.1001/jamasurg.2018.4452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Paulina Salminen
- Division of Digestive Surgery and Urology, Department of Digestive Surgery, Turku University Hospital, Turku, Finland.,Department of Surgery, University of Turku, Turku, Finland
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117
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van Rijn S, Betzel B, de Jonge C, van Dijk DPJ, Janssen IM, Berends FJ, Bouvy ND, Greve JWM. The Effect of 6 and 12 months Duodenal-Jejunal Bypass Liner Treatment on Obesity and Type 2 Diabetes: a Crossover Cohort Study. Obes Surg 2019; 28:1255-1262. [PMID: 29110244 PMCID: PMC5968053 DOI: 10.1007/s11695-017-2997-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The aim of this research was to study the duodenal-jejunal bypass liner (DJBL) treatment for obesity and type 2 diabetes mellitus (T2DM) in patients after dietary treatment in a cross-over design. BACKGROUND DJBL treatment has been proven effective for treatment of obesity and T2DM. However, data on safety and efficacy of a 12-month DJBL treatment is limited. METHODS In 2014, our research group reported on a multicenter randomized clinical trial. Patients were randomized to DJBL or dietary treatment (control group). Twenty-eight patients crossed over after their dietary treatment and received up to 12 months of DJBL treatment. Patient visits were conducted at baseline, during DJBL treatment (1 week, 1-6, 9, 12 months) and 6 months after removal of the liner. Patients underwent a standard physical examination, blood sampling, assessment of adverse events, nutritional and diabetes counseling, and a standardized meal tolerance test. RESULTS Of the 28 patients included in this study, 24 patients completed 6 months of treatment. Eighteen patients were extended to 12 months of DJBL treatment; 13 patients completed this treatment period. After 6 months of DJBL treatment, a significant increase in excess weight loss (EWL) and decrease in weight, BMI, HbA1c, fasting glucose, cholesterol, HDL and LDL improved significantly. After 12 months of DJBL treatment, these parameters stabilized. CONCLUSIONS The DJBL is an effective, minimally invasive treatment option. Even after successful treatment with dietary restrictions, the DJBL is still capable of significantly reducing weight and improving cardiovascular and type 2 diabetes mellitus parameters in obese patients.
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Affiliation(s)
- Selwyn van Rijn
- Department of General Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bark Betzel
- Department of General Surgery, Rijnstate Medical Center, Arnhem, The Netherlands
| | - Charlotte de Jonge
- Department of General Surgery, Zuyderland Medical Center, Heerlen-Sittard, The Netherlands
| | - David P J van Dijk
- Department of General Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ignace M Janssen
- Department of General Surgery, Rijnstate Medical Center, Arnhem, The Netherlands
| | - Frits J Berends
- Department of General Surgery, Rijnstate Medical Center, Arnhem, The Netherlands
| | - Nicole D Bouvy
- Department of General Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Willem M Greve
- Department of General Surgery, Zuyderland Medical Center, Heerlen-Sittard, The Netherlands. .,, Henri Dunantstraat 5, 6419 PC, Heerlen, The Netherlands.
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118
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Ten-year Outcomes of a Prospective Randomized Trial of Laparoscopic Gastric Bypass Versus Laparoscopic Gastric Banding. Ann Surg 2019; 268:106-113. [PMID: 28692476 DOI: 10.1097/sla.0000000000002348] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The primary endpoints of this study were long-term weight loss, morbidity, and changes in comorbidities and quality of life. BACKGROUND Bariatric surgery is an effective option for the treatment of severe obesity and its related comorbidities. However, few studies have reported on the long-term outcome (>5 yrs) of bariatric surgery. METHODS Between 2002 and 2007, 250 patients with a body mass index (BMI) of 35 to 60 kg/m were randomly assigned to undergo laparoscopic gastric bypass or laparoscopic gastric banding. After exclusions, 111 patients underwent gastric bypass and 86 patients underwent gastric banding. Factors predictive of improved weight loss were analyzed using multiple logistic regressions. RESULTS At baseline, the mean age was 43 ± 10 years and the mean BMI was 46.5 ± 5.6 kg/m. At 10-year follow-up, the mean total body weight loss for the entire cohort was -37.5 ± 19.4 kg, -42.4 ± 19.6 kg for gastric bypass versus -27.4 ± 14.5 kg for gastric banding. Late reoperation was significantly higher after gastric banding compared with the gastric bypass group (31.4% vs. 8.1%, respectively, P < 0.01). For the entire cohort, improvement or remission of diabetes occurred in 68%; 61% for hypertension; and 57% for dyslipidemia. The long-term mortality for the entire cohort was 1.0% at a mean follow-up of 9.5 ± 0.4 years. Factors predictive of improved weight loss included the type of operation (ie, gastric bypass), female sex, and the absence of diabetes at baseline. At long-term follow-up, quality of life continues to be improved from baseline for both the groups. CONCLUSIONS Bariatric surgery is an effective treatment for severe obesity with durable 10-year weight loss and improvement in comorbidities and quality of life. Compared with gastric banding, gastric bypass was associated with better long-term weight loss, lower rate of late reoperation, and improved remission of comorbidities.
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119
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Caslin HL, Hasty AH. Extrinsic and Intrinsic Immunometabolism Converge: Perspectives on Future Research and Therapeutic Development for Obesity. Curr Obes Rep 2019; 8:210-219. [PMID: 30919312 PMCID: PMC6661206 DOI: 10.1007/s13679-019-00344-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Research over the past decade has shown that immunologic and metabolic pathways are intricately linked. This burgeoning field of immunometabolism includes intrinsic and extrinsic pathways and is known to be associated with obesity-accelerated metabolic disease. Intrinsic immunometabolism includes the study of fuel utilization and bioenergetic pathways that influence immune cell function. Extrinsic immunometabolism includes the study of immune cells and products that influence systemic metabolism. RECENT FINDINGS Th2 immunity, macrophage iron handling, adaptive immune memory, and epigenetic regulation of immunity, which all require intrinsic metabolic changes, play a role in systemic metabolism and metabolic function, linking the two arms of immunometabolism. Together, this suggests that targeting intrinsic immunometabolism can directly affect immune function and ultimately systemic metabolism. We highlight important questions for future basic research that will help improve translational research and provide therapeutic targets to help establish new treatments for obesity and associated metabolic disorders.
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Affiliation(s)
- Heather L Caslin
- Molecular Physiology and Biophysics, Vanderbilt University, 813 Light Hall, 23rd Ave. South and Pierce, Nashville, TN, 37232, USA
| | - Alyssa H Hasty
- Molecular Physiology and Biophysics, Vanderbilt University, 813 Light Hall, 23rd Ave. South and Pierce, Nashville, TN, 37232, USA.
- VA Tennessee Valley Healthcare System, Nashville, TN, USA.
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120
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Smith ME, Bacal D, Bonham AJ, Varban OA, Carlin AM, Ghaferi AA, Finks JF. Perioperative and 1-year outcomes of bariatric surgery in septuagenarians: implications for patient selection. Surg Obes Relat Dis 2019; 15:1805-1811. [PMID: 31530451 DOI: 10.1016/j.soard.2019.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/12/2019] [Accepted: 08/03/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Although bariatric surgery is an effective treatment for obesity, utilization of bariatric procedures in older adults remains low. Previous work reported higher morbidity in older patients undergoing bariatric surgery. However, the generalizability of these data to contemporary septuagenarians is unclear. OBJECTIVES We sought to evaluate differences in 30-day outcomes, 1-year weight loss, and co-morbidity remission after bariatric surgery among 3 age groups as follows: <45 years, 45-69 years, and ≥70 years. SETTING Statewide quality improvement collaborative. METHODS Using a large quality improvement collaborative, we identified patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between 2006 and 2018. We used multivariable logistic regression models to evaluate the association between age cohorts and 30-day outcomes, 1-year weight loss, and co-morbidity remission. RESULTS We identified 641 septuagenarians who underwent SG (68.5%) or RYGB (31.5%). Compared with 45-69 year olds, septuagenarians had higher rates of hemorrhage (5.1% versus 3.1%; P = .045) after RYGB and higher rates of leak/perforation (.9% versus .3%; P = .044) after SG. Compared with younger patients, septuagenarians lost less of their excess weight, losing 64.8% after RYGB and 53.8% after SG. Remission rates for diabetes and obstructive sleep were similar for patients aged ≥70 years and 45-69 years. CONCLUSIONS Bariatric surgery in septuagenarians results in substantial weight loss and co-morbidity remission with an acceptable safety profile. Surgeons with self-imposed age limits should consider broadening their selection criteria to include patients ≥70 years old.
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Affiliation(s)
- Margaret E Smith
- Department of General Surgery, University of Michigan, Ann Arbor, Michigan.
| | - Daniel Bacal
- Department of Surgery, Beaumont Hospital Dearborn, Dearborn, Michigan
| | - Aaron J Bonham
- Department of General Surgery, University of Michigan, Ann Arbor, Michigan
| | - Oliver A Varban
- Department of General Surgery, University of Michigan, Ann Arbor, Michigan
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, Michigan
| | - Amir A Ghaferi
- Department of General Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jonathan F Finks
- Department of General Surgery, University of Michigan, Ann Arbor, Michigan
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121
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The effect of surrogate procedure volume on bariatric surgery outcomes: do common laparoscopic general surgery procedures matter? Surg Endosc 2019; 34:1278-1284. [PMID: 31222634 DOI: 10.1007/s00464-019-06897-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/04/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND A growing body of evidence shows that experience and acquired skills from surrogate surgical procedures may be transferrable to a specific index operation. It is unclear whether this applies to bariatric surgery. This study aims to determine whether there is a surrogate volume effect of common laparoscopic general surgery procedures on all-cause bariatric surgical morbidity. METHODS This was a population-based study of all patients aged ≥ 18 who received a bariatric procedure in Ontario from 2008 to 2015. The main outcome of interest was all-cause morbidity during the index admission. All-cause morbidity included any documented complication which extended length of stay by 24 h or required reoperation. Bariatric cases included laparoscopic Roux-en-Y gastric bypass, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. Non-bariatric cases included three common laparoscopic general surgery procedures. RESULTS 13,836 bariatric procedures were performed by 29 surgeons at nine centers of excellence. A reduction in all-cause morbidity was seen when bariatric surgeons exceeded 75 cases annually (OR 0.82, 95% CI 0.69-0.98, P = 0.023), with further reduction in increasing bariatric volume. However, the volume of non-bariatric surgeries did not significantly affect bariatric all-cause morbidity rates amongst bariatric surgeons, even when exceeding 100 cases (OR 0.84, 95% CI 0.61-1.12, P = 0.222). CONCLUSIONS The present study suggests that experience and skills acquired in performing non-bariatric laparoscopic general surgery does not appear to affect all-cause morbidity in bariatric surgery. Therefore, only a surgeon's bariatric procedure volume should considered be a quality marker for outcomes after bariatric surgery.
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122
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Acevedo E, Mazzei M, Zhao H, Lu X, Soans R, Edwards MA. Outcomes in conventional laparoscopic versus robotic-assisted primary bariatric surgery: a retrospective, case-controlled study of the MBSAQIP database. Surg Endosc 2019; 34:1353-1365. [PMID: 31209608 PMCID: PMC7222911 DOI: 10.1007/s00464-019-06915-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 06/12/2019] [Indexed: 12/16/2022]
Abstract
Introduction Robotic-assisted bariatric surgery is increasingly performed. There remains controversy about the overall benefit of robotic-assisted (RBS) compared to conventional laparoscopic (LBS) bariatric surgery. In this study, we used a large national risk-stratified bariatric clinical database to compare outcomes between robotic and laparoscopic gastric bypass (RNYGB) and sleeve gastrectomy (SG). Methods A retrospective analysis of the 2015 and 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use Data File (PUF) was performed. Primary robotic and laparoscopic RYNGB and SG were analyzed. Descriptive analysis was performed of the unmatched cohorts, followed by 1:3 case-controlled matching. Cases and controls were matched by patient demographics and pre-operative comorbidities, and peri-operative outcomes compared. Results 77,991 Roux-en-Y gastric bypass (RnYGB) (7.5% robotic-assisted) and 189,503 SG (6.8% robotic-assisted) cases were identified. Operative length was significantly higher in both the robotic-assisted RnYGB and SG cohorts (p < 0.0001). Outcomes were similar between the robotic-assisted and laparoscopic RnYGB cohorts, except a lower mortality rate (p = 0.05), transfusion requirement (p = 0.005), aggregate bleeding (p = 0.04), and surgical site infections (SSI) (p = 0.006) in the robotic-assisted cohort. Outcomes were also similar between robotic-assisted and laparoscopic SG, except for a longer length of stay (p < 0.0001) and higher rates of conversion (p < 0.0001), 30-day intervention (p = 0.01), operative drain present (p < 0.0001), sepsis (p = 0.01), and organ space SSI (p = 0.0002) in the robotic cohort. Bleeding was lower in the robotic SG cohort and mortality was similar. Conclusion Both robotic-assisted and laparoscopic RnYGB and SG are overall very safe. Robotic-assisted gastric bypass is associated with a lower mortality and morbidity; however, a clear benefit for robotic-assisted SG compared to laparoscopic SG was not seen. Given the longer operative and hospital duration, robotic SG is not cost-effective. Electronic supplementary material The online version of this article (10.1007/s00464-019-06915-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edwin Acevedo
- Department of Surgery, Division of Bariatric and Minimally Invasive Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Michael Mazzei
- Department of Surgery, Division of Bariatric and Minimally Invasive Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Huaqing Zhao
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Xiaoning Lu
- Department of Clinical Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Rohit Soans
- Department of Surgery, Division of Bariatric and Minimally Invasive Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Michael A Edwards
- Department of General Surgery, Mayo Clinic, 4500 San Pablo Rd. S, Jacksonville, FL, 32224, USA.
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The hidden cost of an extensive preoperative work-up: predictors of attrition after referral for bariatric surgery in a universal healthcare system. Surg Endosc 2019; 34:988-995. [DOI: 10.1007/s00464-019-06894-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 06/04/2019] [Indexed: 01/27/2023]
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124
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Psychometric Characteristics of the Revised Illness Perception Questionnaire (IPQ-R) in People Undergoing Weight Loss Surgery. J Clin Psychol Med Settings 2019; 27:79-88. [PMID: 31069587 DOI: 10.1007/s10880-019-09624-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The Illness Perception Questionnaire-Revised (IPQ-R) has been used extensively across many health conditions to measure patient illness and treatment perceptions. The constructs have an association with treatment adaptation and adherence which, in turn, are considered core factors involved in bariatric surgery outcome. This study examines the factorial validity and internal reliability of a modified (IPQ-R) in bariatric surgery candidates. After wording modifications, participants (N = 310) completed the IPQ-R as part of standard pre-surgery assessments. After removal of two items, confirmatory factor analysis (CFA) supported the original 7-factor solution of the Beliefs scale, with good to marginal subscale internal consistency. Exploratory factor analysis (EFA), with two items removed only partially supported the original 5-factor Causal Attributions scale. Internal consistency was unacceptably low for two subscales. Further research is needed to generate new items which better fit the IPQ-R to this population before research can explore the relevance of illness perceptions.
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125
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Kaouk L, Hsu AT, Tanuseputro P, Jessri M. Modifiable factors associated with weight regain after bariatric surgery: a scoping review. F1000Res 2019; 8:615. [PMID: 32983412 PMCID: PMC7492783 DOI: 10.12688/f1000research.18787.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2019] [Indexed: 08/26/2023] Open
Abstract
Background: Although bariatric surgery is the most effective treatment for severe obesity, weight regain may still occur. While non-modifiable factors associated with weight regain have been explored, modifiable factors responsible for weight regain are understudied. This scoping review aimed to identify modifiable behaviors associated with weight regain after bariatric surgery. Methods: A systematic search was conducted in Medline, Google Scholar, Cochrane, National Collaborating Centre for Methods and Tools (NCCMT) and Practice-based Evidence in Nutrition (PEN) which included articles published between January 1990 and February 2 2017, for studies examining "weight regain" after bariatric surgery. A total of 293 citations were retrieved. Eligible articles must have examined modifiable factors and addressed weight regain, or a long-term post-operative phase in which weight regain may occur. After removing duplicates, 22 studies were included for thematic analysis. Results: Key modifiable factors associated with weight regain were identified and categorized under the following themes: poor dietary adherence (e.g. excessive calorie, carbohydrate, and alcohol intake), maladaptive eating behaviors (e.g. grazing, binging), lack of on-going follow-up with the bariatric team and insufficient physical activity. Conclusions: Health professionals and self-monitoring tools for patients who have undergone bariatric surgery may benefit from these findings to direct their education and interventions to target behavior change.
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Affiliation(s)
- Lisa Kaouk
- McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC H4A 3J1, Canada
| | - Amy T. Hsu
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahsa Jessri
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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126
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Kaouk L, Hsu AT, Tanuseputro P, Jessri M. Modifiable factors associated with weight regain after bariatric surgery: a scoping review. F1000Res 2019; 8:615. [PMID: 32983412 PMCID: PMC7492783 DOI: 10.12688/f1000research.18787.2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 01/22/2023] Open
Abstract
Background: Although bariatric surgery is the most effective treatment for severe obesity, weight regain may still occur. While non-modifiable factors associated with weight regain have been explored, modifiable factors responsible for weight regain are understudied. This scoping review aimed to identify modifiable behaviors associated with weight regain after bariatric surgery. Methods: A systematic search was conducted in Medline, Google Scholar, Cochrane, National Collaborating Centre for Methods and Tools (NCCMT) and Practice-based Evidence in Nutrition (PEN) which included articles published between January 1990 and February 2 2017, for studies examining "weight regain" after bariatric surgery. A total of 293 citations were retrieved. Eligible articles must have examined modifiable factors and addressed weight regain, or a long-term post-operative phase in which weight regain may occur. After removing duplicates, 22 studies were included for thematic analysis. Results: Key modifiable factors associated with weight regain were identified and categorized under the following themes: poor dietary adherence (e.g. excessive calorie, carbohydrate, and alcohol intake), maladaptive eating behaviors (e.g. grazing, binging), lack of on-going follow-up with the bariatric team and insufficient physical activity. Conclusions: Health professionals and self-monitoring tools for patients who have undergone bariatric surgery may benefit from these findings to direct their education and interventions to target behavior change.
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Affiliation(s)
- Lisa Kaouk
- McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC H4A 3J1, Canada
| | - Amy T. Hsu
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahsa Jessri
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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Simonson DC, Vernon A, Foster K, Halperin F, Patti ME, Goldfine AB. Adjustable gastric band surgery or medical management in patients with type 2 diabetes and obesity: three-year results of a randomized trial. Surg Obes Relat Dis 2019; 15:2052-2059. [PMID: 31931977 DOI: 10.1016/j.soard.2019.03.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few randomized trials have compared surgical versus lifestyle and pharmacologic approaches for type 2 diabetes (T2D) patients with mild to moderate obesity. OBJECTIVES This study examined resolution of hyperglycemia (A1C <6.5% and fasting glucose <126 mg/dL) 3 years after randomization to either a laparoscopic adjustable gastric band (LAGB) or 1-year diabetes and weight management (DWM) program. SETTING University medical center, United States. METHODS Forty T2D patients (mean ± SD: age, 51.3 ±10.0 yr; weight 109.5 ± 15.0 kg; body mass index [BMI] 36.5 ± 3.7 kg/m2; HBA1C 8.2% ± 1.2%) were randomized to LAGB (n = 18) or DWM (n = 22). RESULTS At 3 years, 13% of 16 patients in LAGB and 5% of 17 patients in DWM achieved resolution of hyperglycemia (P = .601), with a modestly greater reduction in antidiabetic medications in the surgical group (P = .054). Reductions from baseline in A1C were sustained at 3 years in LAGB (-.82% [95% CI: -1.62 to -.01], P = .046) compared with DWM (+.23% [95% CI: -.57 to 1.03], P = .567). The surgical group had greater weight loss (-12.0 kg [95% CI: -15.9 to -8.1] versus -4.8 [95% CI: -8.6 to -.9], P = .010). HDL-cholesterol increased more after surgery (P = .003), but changes in triglycerides, LDL-cholesterol, and blood pressure did not differ between treatments. Diabetes- and obesity-specific quality of life improved comparably with both therapies. CONCLUSIONS Achievement of American Diabetes Association targets for glucose, lipids, and blood pressure was similar with both treatment strategies. LAGB leads to greater sustained weight loss and higher HDL cholesterol compared with a DWM program. These findings may help guide patients with T2D and obesity when exploring options for diabetes and weight management.
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Affiliation(s)
- Donald C Simonson
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Ashley Vernon
- Center for Metabolic and Bariatric Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kathleen Foster
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Florencia Halperin
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
| | - Allison B Goldfine
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, Massachusetts
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El Kary N, Chahine E, Moryoussef F, Vitte RL, Chouillard MA, Gumbs A, Chouillard E. Esophageal Stricture Due to a Self-Expandable Metal Stent (SEMS) Placement for Post Sleeve Gastrectomy Leak: a Case Report. Obes Surg 2019; 29:1943-1945. [PMID: 30900151 DOI: 10.1007/s11695-019-03835-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Nader El Kary
- Department of General and Digestive Surgery, Bariatric Surgery Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
- Service de Chirurgie Générale et Digestive, Centre Hospitalier de Poissy-Saint Germain, 10 rue du Champ Gaillard, 78300, Poissy, France
| | - Elias Chahine
- Department of General and Digestive Surgery, Bariatric Surgery Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France.
- Service de Chirurgie Générale et Digestive, Centre Hospitalier de Poissy-Saint Germain, 10 rue du Champ Gaillard, 78300, Poissy, France.
| | - Frédérick Moryoussef
- Department of Gatsroenterology and Liver Disease, Interventional Endoscopy Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
| | - René-Louis Vitte
- Department of Gatsroenterology and Liver Disease, Interventional Endoscopy Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
| | - Marc-Anthony Chouillard
- Department of General and Digestive Surgery, Bariatric Surgery Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
| | - Andrew Gumbs
- Department of General and Digestive Surgery, Bariatric Surgery Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
| | - Elie Chouillard
- Department of General and Digestive Surgery, Bariatric Surgery Unit, Poissy Saint Germain Medical Center, 10 rue du Champ Gaillard, Poissy, 78300, France
- Service de Chirurgie Générale et Digestive, Centre Hospitalier de Poissy-Saint Germain, 10 rue du Champ Gaillard, 78300, Poissy, France
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Elshaer M, Hamaoui K, Rezai P, Ahmed K, Mothojakan N, Al-Taan O. Secondary Bariatric Procedures in a High-Volume Centre: Prevalence, Indications and Outcomes. Obes Surg 2019; 29:2255-2262. [DOI: 10.1007/s11695-019-03838-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
The role of internists in evaluating obesity is to assess the burden of weight-related disease, mitigate secondary causes of weight gain (medications, sleep deprivation), and solicit patient motivation for weight loss. Internists should assess these factors and emphasize the importance of weight loss for the individual patient. All patients wishing to lose weight should be encouraged to monitor their diet and physical activity and should be referred to high-intensity behavioral programs. Some patients with obesity may also benefit from pharmacotherapy or bariatric surgery.
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Affiliation(s)
- Adam Gilden Tsai
- From Kaiser Permanente, Metabolic-Surgical Weight Management, Denver, Colorado. (A.G.T.)
| | - Daniel H Bessesen
- From University of Colorado School of Medicine, Aurora, Colorado. (D.H.B.)
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131
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Perakakis N, Kokkinos A, Peradze N, Tentolouris N, Ghaly W, Tsilingiris D, Alexandrou A, Mantzoros CS. Follistatins in glucose regulation in healthy and obese individuals. Diabetes Obes Metab 2019; 21:683-690. [PMID: 30393997 PMCID: PMC6368471 DOI: 10.1111/dom.13572] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/18/2018] [Accepted: 10/31/2018] [Indexed: 01/02/2023]
Abstract
AIMS It has been suggested recently that follistatin (FST) and its homologous protein, follistatin-like 3 (FSTL3), may be a therapeutic target in the treatment of type 2 diabetes because of their glucose-regulatory effects in rodents. MATERIALS AND METHODS We investigated this hypothesis in humans by studying the physiology of a possible glycaemia-follistatin feedback loop, that is, whether glucose, but not lipid intake (oral or intravenous), can regulate circulating FST and FSTL3 in healthy humans (n = 32), whether the levels of follistatins change in response to various types of bariatric operation in morbidly obese individuals, with or without type 2 diabetes (n = 41), and whether such changes are associated prospectively with improvement of glucose homeostasis/insulin sensitivity. RESULTS In healthy individuals, circulating FST decreases after intravenous or oral glucose intake compared to controls, indicating the presence of a negative feedback mechanism. In morbid obesity, insulin resistance, glycaemia, circulating FST and FSTL3 are all reduced (by 22%-33%) after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy. Importantly, the changes in circulating FST 3 months after bariatric surgery are associated prospectively with the changes in glucose, insulin, HOMA-IR and HbA1c observed 6 months postoperatively in individuals with and without type 2 diabetes. CONCLUSIONS Our findings provide evidence of an important role of FST in glucose homeostasis in healthy individuals as well as in severely obese individuals with insulin resistance and type 2 diabetes. Our data extend recent results from animal studies to humans and support the need for further evaluation of FST inactivation strategies for targeting hyperglycaemia and insulin resistance.
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Affiliation(s)
- Nikolaos Perakakis
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Alexander Kokkinos
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Natia Peradze
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Nicholas Tentolouris
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Wael Ghaly
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
- Department of Physiology, Fayoum University, Fayoum, Egypt
| | - Dimitrios Tsilingiris
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Andreas Alexandrou
- First Department of Surgery, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Christos S. Mantzoros
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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132
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Preventive effect of bariatric surgery on type 2 diabetes onset in morbidly obese inpatients: a national French survey between 2008 and 2016 on 328,509 morbidly obese patients. Surg Obes Relat Dis 2019; 15:478-487. [DOI: 10.1016/j.soard.2018.12.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/23/2018] [Accepted: 12/28/2018] [Indexed: 12/31/2022]
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133
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Haneuse S, VanderWeele TJ, Arterburn D. Using the E-Value to Assess the Potential Effect of Unmeasured Confounding in Observational Studies. JAMA 2019; 321:602-603. [PMID: 30676631 DOI: 10.1001/jama.2018.21554] [Citation(s) in RCA: 544] [Impact Index Per Article: 108.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Sebastien Haneuse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Tyler J VanderWeele
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
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134
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Gordon KH, King WC, White GE, Belle SH, Courcoulas AP, Ebel FE, Engel SG, Flum DR, Hinojosa MW, Pomp A, Pories WJ, Spaniolas D, Wolfe BM, Yanovski SZ, Mitchell JE. A longitudinal examination of suicide-related thoughts and behaviors among bariatric surgery patients. Surg Obes Relat Dis 2018; 15:269-278. [PMID: 31010651 DOI: 10.1016/j.soard.2018.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 11/19/2018] [Accepted: 12/02/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Past research suggests self-harm/suicidality are more common among adults who have undergone bariatric surgery than the general population. OBJECTIVES To compare prevalence of self-harm/suicidal ideation over time and identify presurgery risk factors for postsurgery self-harm/suicidal ideation. SETTING The Longitudinal Assessment of Bariatric Surgery-2 is a cohort study with presurgery and annual postsurgery assessments conducted at 10 U.S. hospitals. METHODS Adults with severe obesity undergoing bariatric surgery between March 2006 and April 2009 (n = 2458). Five-year follow-up is reported. Self-reported history of suicidality assessed retrospectively via the Suicide Behavior Questionnaire-Revised (SBQ-R) and self-reported self-harm/suicidal ideation assessed prospectively via the Beck Depression Inventory-Version 1 (BDI-1). RESULTS The SBQ-R was completed by 1540 participants; 2217 completed the BDI-1 pre- and postsurgery. Over 75% of participants were female, with a median age of 46 years and body mass index of 45.9 kg/m2. Approximately one fourth of participants (395/1534) reported a presurgery history of suicidal thoughts or behavior (SBQ-R). The prevalence of self-harm/suicidal ideation (BDI-1) was 5.3% (95% confidence interval [CI], 3.7-6.8) presurgery and 3.8% (95% CI, 2.5-5.1) at year 1 postsurgery (P = .06). Prevalence increased over time postsurgery to 6.6% (95% CI, 4.6-8.6) at year 5 (P = .001) but was not significantly different than presurgery (P = .12). CONCLUSIONS A large cohort of adults with severe obesity who underwent bariatric surgery had a prevalence of self-harm/suicidal ideation that may have decreased in the first postoperative year but increased over time to presurgery levels, suggesting screening for self-harm/suicidality is warranted throughout long-term postoperative care. Several risk factors were identified that may help with enhanced monitoring.
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Affiliation(s)
- Kathryn H Gordon
- Neuropsychiatric Research Institute, Fargo, North Dakota; Department of Psychology, North Dakota State University, Fargo, North Dakota.
| | - Wendy C King
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Gretchen E White
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Steven H Belle
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Anita P Courcoulas
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Scott G Engel
- Neuropsychiatric Research Institute, Fargo, North Dakota
| | - Dave R Flum
- Department of Surgery, University of Washington, Seattle, Washington
| | | | | | - Walter J Pories
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Dino Spaniolas
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Bruce M Wolfe
- Department of Surgery, Oregon Health Sciences University, Portland, Oregon
| | - Susan Z Yanovski
- Office of Obesity Research, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland
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135
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Lascaris B, Pouwels S, Houthuizen P, Dekker LR, Nienhuijs SW, Bouwman RA, Buise MP. Cardiac structure and function before and after bariatric surgery: a clinical overview. Clin Obes 2018; 8:434-443. [PMID: 30208261 DOI: 10.1111/cob.12278] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 05/23/2018] [Accepted: 07/13/2018] [Indexed: 12/19/2022]
Abstract
Obesity, defined as a body mass index of ≥30 kg/m2 , is the most common chronic metabolic disease worldwide and its prevalence has been strongly increasing. Obesity has deleterious effects on cardiac function. The purpose of this review is to evaluate the effects of obesity and excessive weight loss due to bariatric surgery on cardiac function, structural changes and haemodynamic responses of both the left and right ventricle.
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Affiliation(s)
- B Lascaris
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - S Pouwels
- Department of Epidemiology, CAPHRI Research School, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - P Houthuizen
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - L R Dekker
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - S W Nienhuijs
- Department of Surgery, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - R A Bouwman
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - M P Buise
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Catharina Hospital, Eindhoven, The Netherlands
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136
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Racial Differences in the Predictors of Interest in Bariatric Surgery in the Rural, Southeastern USA. J Racial Ethn Health Disparities 2018; 6:481-486. [DOI: 10.1007/s40615-018-00546-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/11/2018] [Accepted: 11/13/2018] [Indexed: 01/06/2023]
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137
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Takemoto E, Wolfe BM, Nagel CL, Boone-Heinonen J. Reduction in Comorbid Conditions Over 5 Years Following Bariatric Surgery in Medicaid and Commercially Insured Patients. Obesity (Silver Spring) 2018; 26:1807-1814. [PMID: 30358155 PMCID: PMC6817972 DOI: 10.1002/oby.22312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/21/2018] [Accepted: 08/21/2018] [Indexed: 01/30/2023]
Abstract
OBJECTIVE This study sought to determine changes in the prevalence of comorbid disease following bariatric surgery in Medicaid patients compared with commercially insured patients. METHODS Data were obtained from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery at one of six geographically diverse centers in the United States. A total of 1,201 patients who underwent Roux-en-Y gastric bypass with 5 years of follow-up were identified. Poisson mixed models were used to estimate relative risks (RRs) and compare changes in common comorbidities between insurance groups within 0-1 and 1-5 years post surgery. Propensity scores were used to achieve balance in the baseline comorbidity burden between Medicaid and commercial patients. RESULTS In the first year, risk of all six comorbidities decreased substantially over time in both groups, ranging from a 32% to a 69% decrease from baseline. After 1 year post surgery, the risk of disease was stable in both groups (RRs ranged from 1.0 to 1.1). After propensity score weighting, the RRs in the first year were more similar in magnitude, while the RRs in the 1- to 5-year period were unchanged. CONCLUSIONS These results suggest that Medicaid patients experience a medium-term reduction in comorbid disease after bariatric surgery.
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Affiliation(s)
- Erin Takemoto
- Oregon Health & Science University—Portland State University School of Public Health 3181 SW Sam Jackson Park Rd., Mail Code CB669 Portland, OR 97239-3098
| | - Bruce M. Wolfe
- Oregon Health & Science University School of Medicine Department of Surgery, Portland, OR
| | - Corey L. Nagel
- University of Arkansas for Medical Sciences School of Nursing Little Rock, AR
| | - Janne Boone-Heinonen
- Oregon Health & Science University—Portland State University School of Public Health 3181 SW Sam Jackson Park Rd., Mail Code CB669 Portland, OR 97239-3098
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138
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Lent MR, Hu Y, Benotti PN, Petrick AT, Wood GC, Still CD, Kirchner HL. Demographic, clinical, and behavioral determinants of 7-year weight change trajectories in Roux-en-Y gastric bypass patients. Surg Obes Relat Dis 2018; 14:1680-1685. [DOI: 10.1016/j.soard.2018.07.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/22/2018] [Indexed: 12/28/2022]
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139
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Smith ME, Lee JS, Bonham A, Varban OA, Finks JF, Carlin AM, Ghaferi AA. Effect of new persistent opioid use on physiologic and psychologic outcomes following bariatric surgery. Surg Endosc 2018; 33:2649-2656. [PMID: 30353238 DOI: 10.1007/s00464-018-6542-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 10/15/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION New persistent opioid use following surgery is a common iatrogenic complication, developing in roughly 6% of patients after elective surgery. Despite increased awareness of misuse and associated morbidity, opioids remain the cornerstone of pain management in bariatric surgery. The potential impact of new persistent opioid use on long-term postoperative outcomes is unknown. We sought to determine the relationship between new persistent opioid use and 1-year postoperative outcomes for patients undergoing bariatric surgery. METHODS Using data from the MBSC registry, we identified patients undergoing primary bariatric surgery between 2006 and 2016. Using previously validated patient-reported survey methodology, we evaluated patient opioid use preoperatively and at 1 year following surgery. New persistent use was defined as a previously opioid-naïve patient who self-reported opioid use 1 year after surgery. We used multivariable logistic regression models to evaluate the association between new persistent opioid use, risk-adjusted weight loss, and psychologic outcomes (psychological wellbeing, body image, and depression). RESULTS 27,799 patients underwent primary bariatric surgery between 2006 and 2016. Among opioid-naïve patients, the rate of new persistent opioid use was 6.3%. At 1-year after surgery, patients with new persistent opioid user lost significantly less excess body weight compared to those without new persistent use (57.6% vs. 60.3%; p < 0.0001). Patients with new persistent opioid use had significantly worse psychological wellbeing (35.0 vs. 33.1; p < 0.0001), body image (19.9 vs. 18.0; p < 0.0001), and depression scores (2.4 vs. 5.0; p < 0.0001). New persistent opioid users also reported less overall satisfaction with their bariatric surgery (75.1% vs. 85.7%; p < 0.0001). CONCLUSIONS New persistent opioid use is common following bariatric surgery and associated with significantly worse physiologic and psychologic outcomes. More effective screening and postoperative surveillance tools are needed to identify these patients, who likely require more aggressive counseling and treatment to maximize the benefits of bariatric surgery.
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Affiliation(s)
- Margaret E Smith
- Department of General Surgery, University of Michigan, Ann Arbor, MI, USA. .,University of Michigan Health System, 1500 E. Medical Center Drive, TC 2110, Ann Arbor, MI, 48109-5346, USA.
| | - Jay S Lee
- Department of General Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Aaron Bonham
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
| | - Oliver A Varban
- Department of General Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Jonathan F Finks
- Department of General Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Arthur M Carlin
- Department of Surgery, Henry Ford Health System, Detroit, MI, USA
| | - Amir A Ghaferi
- Department of General Surgery, University of Michigan, Ann Arbor, MI, USA
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Fisher DP, Johnson E, Haneuse S, Arterburn D, Coleman KJ, O’Connor PJ, O’Brien R, Bogart A, Theis MK, Anau J, Schroeder EB, Sidney S. Association Between Bariatric Surgery and Macrovascular Disease Outcomes in Patients With Type 2 Diabetes and Severe Obesity. JAMA 2018; 320:1570-1582. [PMID: 30326126 PMCID: PMC6233803 DOI: 10.1001/jama.2018.14619] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE Macrovascular disease is a leading cause of morbidity and mortality for patients with type 2 diabetes, and medical management, including lifestyle changes, may not be successful at lowering risk. OBJECTIVE To investigate the relationship between bariatric surgery and incident macrovascular (coronary artery disease and cerebrovascular diseases) events in patients with severe obesity and type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS In this retrospective, matched cohort study, patients with severe obesity (body mass index ≥35) aged 19 to 79 years with diabetes who underwent bariatric surgery from 2005 to 2011 in 4 integrated health systems in the United States (n = 5301) were matched to 14 934 control patients on site, age, sex, body mass index, hemoglobin A1c, insulin use, observed diabetes duration, and prior health care utilization, with follow-up through September 2015. EXPOSURES Bariatric procedures (76% Roux-en-Y gastric bypass, 17% sleeve gastrectomy, and 7% adjustable gastric banding) were compared with usual care for diabetes. MAIN OUTCOMES AND MEASURES Multivariable-adjusted Cox regression analysis investigated time to incident macrovascular disease (defined as first occurrence of coronary artery disease [acute myocardial infarction, unstable angina, percutaneous coronary intervention, or coronary artery bypass grafting] or cerebrovascular events [ischemic stroke, hemorrhagic stroke, carotid stenting, or carotid endarterectomy]). Secondary outcomes included coronary artery disease and cerebrovascular outcomes separately. RESULTS Among a combined 20 235 surgical and nonsurgical patients, the mean (SD) age was 50 (10) years; 76% of the surgical and 75% of the nonsurgical patients were female; and the baseline mean (SD) body mass index was 44.7 (6.9) and 43.8 (6.7) in the surgical and nonsurgical groups, respectively. At the end of the study period, there were 106 macrovascular events in surgical patients (including 37 cerebrovascular and 78 coronary artery events over a median of 4.7 years; interquartile range, 3.2-6.2 years) and 596 events in the matched control patients (including 227 cerebrovascular and 398 coronary artery events over a median of 4.6 years; interquartile range, 3.1-6.1 years). Bariatric surgery was associated with a lower composite incidence of macrovascular events at 5 years (2.1% in the surgical group vs 4.3% in the nonsurgical group; hazard ratio, 0.60 [95% CI, 0.42-0.86]), as well as a lower incidence of coronary artery disease (1.6% in the surgical group vs 2.8% in the nonsurgical group; hazard ratio, 0.64 [95% CI, 0.42-0.99]). The incidence of cerebrovascular disease was not significantly different between groups at 5 years (0.7% in the surgical group vs 1.7% in the nonsurgical group; hazard ratio, 0.69 [95% CI, 0.38-1.25]). CONCLUSIONS AND RELEVANCE In this observational study of patients with type 2 diabetes and severe obesity who underwent surgery, compared with those who did not undergo surgery, bariatric surgery was associated with a lower risk of macrovascular outcomes. The findings require confirmation in randomized clinical trials. Health care professionals should engage patients with severe obesity and type 2 diabetes in a shared decision making conversation about the potential role of bariatric surgery in the prevention of macrovascular events.
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Affiliation(s)
- David P. Fisher
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland
| | - Eric Johnson
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - David Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Karen J. Coleman
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Rebecca O’Brien
- The Permanente Medical Group, Kaiser Permanente Northern California, Oakland
| | | | - Mary Kay Theis
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Jane Anau
- Kaiser Permanente Washington Health Research Institute, Seattle
| | | | - Stephen Sidney
- Division of Research, Kaiser Permanente Northern California, Oakland
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141
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Stephansson O, Johansson K, Söderling J, Näslund I, Neovius M. Delivery outcomes in term births after bariatric surgery: Population-based matched cohort study. PLoS Med 2018; 15:e1002656. [PMID: 30256796 PMCID: PMC6157842 DOI: 10.1371/journal.pmed.1002656] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 08/20/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Obesity increases the risk of adverse delivery outcomes. Whether weight loss induced by bariatric surgery influences these risks remains to be determined. The objective was to investigate the risk of adverse delivery outcomes among post-surgery women compared with women without bariatric surgery history but with similar characteristics. METHODS AND FINDINGS We identified 801,443 singleton live-born term births (≥37 gestational weeks) in the Swedish Medical Birth Register between 1 January 2006 and 31 December 2013, of which 1,929 were in women with a history of bariatric surgery and a pre-surgery weight available from the Scandinavian Obesity Surgery Registry. For each post-surgery delivery, up to 5 control deliveries were matched by maternal pre-surgery BMI (early-pregnancy BMI used for controls), age, parity, smoking, education, height, country of birth, and delivery year (N post-surgery deliveries:matched controls = 1,431:4,476). The main outcome measures were mode of delivery, induction of labor, post-term pregnancy (≥42 + 0 gestational weeks), epidural analgesia, fetal distress, labor dystocia, peripartum infection, obstetric anal sphincter injury (perineal tear grade III-IV), and postpartum hemorrhage. Among the women with a history of bariatric surgery, the mean pre-surgery BMI was 42.6 kg/m2, the median surgery-to-conception interval was 1.4 years, and the mean BMI loss between surgery and early pregnancy was 13.5 kg/m2 (38 kg). Compared to matched control women, post-surgery women were less likely to have cesarean delivery (18.2% versus 25.0%, risk ratio [RR] 0.70, 95% CI 0.60-0.80), especially emergency cesarean (6.8% versus 15.1%, RR 0.40, 95% CI 0.31-0.51). Post-surgery women also had lower risks of instrumental delivery (5.0% versus 6.5%, RR 0.73, 95% CI 0.53-0.98), induction of labor (23.4% versus 34.0%, RR 0.68, 95% CI 0.59-0.78), post-term pregnancy (4.2% versus 10.3%, RR 0.40, 95% CI 0.30-0.53), obstetric anal sphincter injury (1.5% versus 2.9%, RR 0.46, 95% CI 0.25-0.81), and postpartum hemorrhage (4.6% versus 8.0%, RR 0.58, 95% CI 0.44-0.76). Since this study was not randomized, a limitation is the possibility of selection bias, despite our efforts using careful matching. CONCLUSIONS Bariatric-surgery-induced weight loss was associated with lower risks for adverse delivery outcomes in term births.
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Affiliation(s)
- Olof Stephansson
- Department of Medicine, Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics and Gynaecology, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Kari Johansson
- Department of Medicine, Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
- * E-mail:
| | - Jonas Söderling
- Department of Medicine, Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
| | - Ingmar Näslund
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Martin Neovius
- Department of Medicine, Solna, Clinical Epidemiology Unit, Karolinska Institutet, Stockholm, Sweden
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Yolsuriyanwong K, Thanavachirasin K, Sasso K, Zuro L, Bartfield J, Marcotte E, Chand B. Effectiveness, Compliance, and Acceptability of Preoperative Weight Loss with a Liquid Very Low-Calorie Diet Before Bariatric Surgery in Real Practice. Obes Surg 2018; 29:54-60. [DOI: 10.1007/s11695-018-3444-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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143
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Johnson LP, Asigbee FM, Crowell R, Negrini A. Pre-surgical, surgical and post-surgical experiences of weight loss surgery patients: a closer look at social determinants of health. Clin Obes 2018; 8:265-274. [PMID: 29766655 PMCID: PMC6039235 DOI: 10.1111/cob.12251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/25/2018] [Accepted: 01/30/2018] [Indexed: 01/05/2023]
Abstract
Using a novel qualitative approach, Photovoice, researchers assessed social, psychological, physical and economic barriers encountered by patients of weight loss surgery. Applying the Photovoice approach and Williams' theory of narrative reconstruction for qualitative interviewing, the research team set out to investigate the bariatric patient experience from pre-surgery to hospitalization to post-surgery. Fifteen participants were given digital cameras and asked to take photographs that represented their weight loss journeys. Photographs and qualitative interviews were used to theorize the role played by comorbidities, social determinants of health, provider communication experiences and understanding of insurance coverage in patient outcomes. Several themes emerged from the interviews and photographs including themes centred around: (i) racial/ethnic standards of beauty; (ii) gender expectations; (iii) comorbidities, depression/disordered eating and obesity discrimination and (iv) financial hardship impacting adherence. Photographs also illuminated the impact of hospital and state-wide policies on patient lives. Results suggest that Photovoice may be a useful adjunct to standard-of-care to help patients identify barriers, and to identify shortcomings in health services. Additional screening tools for gender- and income-related barriers (and concomitant referrals to support services) provide an opportunity to improve patient care and reduce post-operative readmissions.
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Affiliation(s)
- L P Johnson
- Master of Public Health Program, Creighton University, Omaha, NE, USA
| | - F M Asigbee
- Department of Nutritional Sciences, University of Texas at Austin, Austin, TX, USA
| | - R Crowell
- Department of Medical Education, Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | - A Negrini
- Department of Medical Education, Saint Francis Hospital and Medical Center, Hartford, CT, USA
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144
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Decreased Chromosomal Damage in Lymphocytes of Obese Patients After Bariatric Surgery. Sci Rep 2018; 8:11195. [PMID: 30046046 PMCID: PMC6060147 DOI: 10.1038/s41598-018-29581-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 07/16/2018] [Indexed: 01/10/2023] Open
Abstract
The number of bariatric surgeries being performed worldwide has markedly risen. While the improvement in obesity-associated comorbidities after bariatric surgery is well-established, very little is known about its impact on cancer risk. The peripheral lymphocyte micronucleus test is a widely used method for the monitoring of chromosomal damage levels in vivo, and micronucleus frequency positively correlates with cancer risk. Therefore, the aim of this study was to compare the micronucleus frequency before and after bariatric surgery in obese subjects. Peripheral blood mononuclear cells were collected from 45 obese subjects before and at two time-points after bariatric surgery (6 and 12 months) to assess spontaneous micronucleus frequency. Consistent with the increased cancer risk previously shown, bariatric surgery-induced weight loss led to a significant reduction in lymphocyte micronucleus frequency after 12 months. Interestingly, comorbidities such as type 2 diabetes mellitus and metabolic syndrome further seemed to have an impact on the lymphocyte micronucleus frequency. Our findings may indicate a successful reduction of cancer risk in patients following weight loss caused by bariatric surgery.
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145
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Jans G, Devlieger R, De Preter V, Ameye L, Roelens K, Lannoo M, Van der Schueren B, Verhaeghe J, Matthys C. Bariatric Surgery Does Not Appear to Affect Women's Breast-Milk Composition. J Nutr 2018; 148:1096-1102. [PMID: 29901782 DOI: 10.1093/jn/nxy085] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 04/03/2018] [Indexed: 01/01/2023] Open
Abstract
Background The breast-milk composition in the first 6 wk postpartum of women who have undergone bariatric surgery (BS) is unknown. Objective The aim of this study was to examine 1) the breast-milk macronutrient and vitamin A composition in women who had and who had not undergone BS and 2) the impact of maternal diet on the breast-milk composition. We hypothesized that the milk of women who had undergone BS would be less energy dense and have a lower vitamin A concentration than that of other women. Methods A multicenter prospective substudy was conducted at 2 university hospitals. Breast-milk samples were collected from 24 normal-weight [NW; mean ± SD body mass index (BMI; kg/m2): 21.5 ± 1.7; mean ± SD age: 29 ± 6 y], 39 overweight (OW; BMI: 26.9 ± 1.5; aged 29 ± 5 y), and 12 obese women (BMI: 35.0 ± 5.7; aged 29 ± 5 y) as well as from 11 women who had undergone BS (BMI: 28.0 ± 4.4; aged 30 ± 4 y) from day 3 until week 6 of lactation. Milk energy and macronutrients (Human Milk Analyzer; Miris) and vitamin A concentrations (iCheck Fluoro; BioAnalyt) were determined at the end of each week. Maternal diet (food-frequency questionnaire) and physical activity (Kaiser Physical Activity Survey) were measured during the third trimester of pregnancy and on day 3 or 4 and during week 6 of lactation. Statistical analyses include 1-factor ANOVA, Spearman and Pearson correlations, and multiple linear regression. Results In all women, a weekly increase in milk energy, total fat, and total carbohydrates was seen, whereas a weekly decrease in proteins and vitamin A was found during the first 2 wk of lactation, followed by a stable concentration of all nutrients. At week 4, milk protein concentrations were higher in women who had undergone BS (14 g/L) compared with NW (8 g/L; P = 0.005) and OW (9 g/L; P = 0.019) women. At week 5, milk carbohydrate concentrations were higher in women who had undergone BS (74 g/L) compared with NW women (68 g/L; P = 0.042). Conclusions Breast milk of women who have undergone BS appears to be adequate in energy, macronutrients, and vitamin A during the first 6 wk of lactation. This supports the conclusion that breast feeding should not be discouraged in this group of women. This trial was registered at http://www.clinicaltrials.gov as NCT02515214.
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Affiliation(s)
- Goele Jans
- Departments of Development and Regeneration, KU Leuven, Leuven, Belgium.,Faculty of Health and Social Work, Research Unit Healthy Living, UC Leuven-Limburg, Leuven, Belgium
| | - Roland Devlieger
- Departments of Development and Regeneration, KU Leuven, Leuven, Belgium.,Departments of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Vicky De Preter
- Faculty of Health and Social Work, Research Unit Healthy Living, UC Leuven-Limburg, Leuven, Belgium
| | - Lieveke Ameye
- Departments of Development and Regeneration, KU Leuven, Leuven, Belgium.,Faculty of Health and Social Work, Research Unit Healthy Living, UC Leuven-Limburg, Leuven, Belgium
| | - Kristien Roelens
- Department of Obstetrics and Gynecology, Ghent University Hospital, Ghent, Belgium
| | - Matthias Lannoo
- Departments of Development and Regeneration and Chronic Diseases, Metabolism, and Aging, KU Leuven, Leuven, Belgium.,Departments of Obstetrics and Gynecology Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Bart Van der Schueren
- Departments of Development and Regeneration and Chronic Diseases, Metabolism, and Aging, KU Leuven, Leuven, Belgium.,Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Verhaeghe
- Departments of Development and Regeneration, KU Leuven, Leuven, Belgium.,Departments of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
| | - Christophe Matthys
- Departments of Development and Regeneration and Chronic Diseases, Metabolism, and Aging, KU Leuven, Leuven, Belgium.,Endocrinology, University Hospitals Leuven, Leuven, Belgium
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146
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Vanholder R, Van Laecke S, Glorieux G, Verbeke F, Castillo-Rodriguez E, Ortiz A. Deleting Death and Dialysis: Conservative Care of Cardio-Vascular Risk and Kidney Function Loss in Chronic Kidney Disease (CKD). Toxins (Basel) 2018; 10:E237. [PMID: 29895722 PMCID: PMC6024824 DOI: 10.3390/toxins10060237] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 05/11/2018] [Indexed: 02/07/2023] Open
Abstract
The uremic syndrome, which is the clinical expression of chronic kidney disease (CKD), is a complex amalgam of accelerated aging and organ dysfunctions, whereby cardio-vascular disease plays a capital role. In this narrative review, we offer a summary of the current conservative (medical) treatment options for cardio-vascular and overall morbidity and mortality risk in CKD. Since the progression of CKD is also associated with a higher cardio-vascular risk, we summarize the interventions that may prevent the progression of CKD as well. We pay attention to established therapies, as well as to novel promising options. Approaches that have been considered are not limited to pharmacological approaches but take into account lifestyle measures and diet as well. We took as many randomized controlled hard endpoint outcome trials as possible into account, although observational studies and post hoc analyses were included where appropriate. We also considered health economic aspects. Based on this information, we constructed comprehensive tables summarizing the available therapeutic options and the number and kind of studies (controlled or not, contradictory outcomes or not) with regard to each approach. Our review underscores the scarcity of well-designed large controlled trials in CKD. Nevertheless, based on the controlled and observational data, a therapeutic algorithm can be developed for this complex and multifactorial condition. It is likely that interventions should be aimed at targeting several modifiable factors simultaneously.
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Affiliation(s)
- Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Steven Van Laecke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Francis Verbeke
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | | | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, 28040 Madrid, Spain.
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147
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Takemoto E, Wolfe BM, Nagel CL, Pories W, Flum DR, Pomp A, Mitchell J, Boone-Heinonen J. Insurance status differences in weight loss and regain over 5 years following bariatric surgery. Int J Obes (Lond) 2018; 42:1211-1220. [PMID: 29892045 DOI: 10.1038/s41366-018-0131-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 04/14/2018] [Accepted: 05/09/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND The effectiveness of bariatric surgery among Medicaid beneficiaries, a population with a disproportionately high burden of obesity, remains unclear. We sought to determine if weight loss and regain following bariatric surgery differed in Medicaid patients compared to commercial insurance. SUBJECTS/METHODS Data from the Longitudinal Assessment of Bariatric Surgery, a ten-site observational cohort of adults undergoing bariatric surgery (2006-2009) were examined for patients who underwent Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Band (LAGB), or Sleeve Gastrectomy (SG). Using piecewise spline linear mixed-effect models, weight change over 5 years was modeled as a function of insurance type (Medicaid, N = 190; commercially insured, N = 1448), time, procedure type, and sociodemographic characteristics; additionally, interactions between all time, insurance, and procedure type indicators allowed time- and procedure-specific associations with insurance type. For each time-spline, mean (kg) difference in weight change in commercially insured versus Medicaid patients was calculated. RESULTS Medicaid patients had higher mean weight at baseline (138.3 kg vs. 131.2 kg). From 0 to 1 year post-operatively, Medicaid patients lost similar amounts of weight to commercial patients following all procedure types (mean weight Δ difference [95% CI]: RYGB: -0.9 [-3.2, 1.4]; LAGB: -1.5 [-6.7, 3.8]; SG: 5.1 [-4.0, 14.2]). From 1 to 3 years post-operatively Medicaid and commercial patients continued to experience minimal weight loss or began to slowly regain weight (mean weight Δ difference [95% CI]: RYGB: 0.9 [0.0, 2.0]; LAGB: -2.1 [-4.2, 0.1]; SG: 0.7 [-3.0, 4.3]). From 3 to 5 years post-operatively, the rate of regain tended to be faster among commercial patients compared to Medicaid patients (mean weight Δ difference [95% CI]: RYGB: 1.1 [0.1, 2.0]; LAGB: 1.5 [-0.5, 3.5]; SG: 1.0 [-2.5, 4.5]). CONCLUSIONS Although Medicaid patients had a higher baseline weight, they achieved similar amounts of weight loss and tended to regain weight at a slower rate than commercial patients.
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Affiliation(s)
- Erin Takemoto
- Oregon Health & Science University-Portland State University School of Public Health, 3181 SW Sam Jackson Park Rd., Mail Code CB669, Portland, OR, 97239-3098, USA.
| | - Bruce M Wolfe
- Oregon Health & Science University School of Medicine Department of Surgery, Portland, OR, USA
| | - Corey L Nagel
- Oregon Health & Science University-Portland State University School of Public Health, 3181 SW Sam Jackson Park Rd., Mail Code CB669, Portland, OR, 97239-3098, USA
| | - Walter Pories
- East Carolina University School of Medicine Department of Surgery, Greenville, NC, USA
| | - David R Flum
- University of Washington Department of Surgery, Seattle, WA, USA
| | - Alfons Pomp
- Weill Cornell Medical College Department of Surgery, New York, NY, USA
| | | | - Janne Boone-Heinonen
- Oregon Health & Science University-Portland State University School of Public Health, 3181 SW Sam Jackson Park Rd., Mail Code CB669, Portland, OR, 97239-3098, USA
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Abstract
Obesity prevalence continues to increase worldwide, as do the numerous chronic diseases associated with obesity, including diabetes, non-alcoholic fatty liver disease, dyslipidemia, and hypertension. The prevalence of bariatric surgery also continues to increase and remains the most effective and sustainable treatment for obesity. Over the last several years, numerous prospective and longitudinal studies have demonstrated the benefits of bariatric surgery on weight loss, mortality, and other chronic diseases. Even though the mechanisms underlying many of these beneficial effects remain poorly understood, surgical management of obesity continues to increase given its unmatched efficacy. In this commentary, we discuss recent clinical advancements as well as several areas needed for future research, including indications for bariatric and metabolic surgery, determination of responders and non-responders, metabolic surgery in non-obese individuals, and the evolving role of bariatric surgery in adolescents.
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Affiliation(s)
- Vance L Albaugh
- Department of Surgery, MCN CC-2308, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Naji N Abumrad
- Department of Surgery, MCN CC-2308, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Neves JS, Souteiro P, Oliveira SC, Pedro J, Magalhães D, Guerreiro V, Costa MM, Bettencourt-Silva R, Santos AC, Queirós J, Varela A, Freitas P, Carvalho D. Preoperative thyroid function and weight loss after bariatric surgery. Int J Obes (Lond) 2018; 43:432-436. [PMID: 29769703 DOI: 10.1038/s41366-018-0071-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 02/24/2018] [Indexed: 01/02/2023]
Abstract
Thyroid function has an important role on body weight regulation. However, the impact of thyroid function on weight loss after bariatric surgery is still largely unknown. We evaluated the association between preoperative thyroid function and the excess weight loss 1 year after surgery, in 641 patients with morbid obesity who underwent bariatric surgery. Patients with a history of thyroid disease, treatment with thyroid hormone or antithyroid drugs and those with preoperative evaluation consistent with overt hypothyroidism or hyperthyroidism were excluded. The preoperative levels of TSH and FT4 were not associated with weight loss after bariatric surgery. The variation of FT3 within the reference range was also not associated with weight loss. In contrast, the subgroup with FT3 above the reference range (12.3% of patients) had a significantly higher excess weight loss than patients with normal FT3. This difference remained significant after adjustment for age, sex, BMI, type of surgery, TSH and FT4. In conclusion, we observed an association between high FT3 and a greater weight loss after bariatric surgery, highlighting a group of patients with an increased benefit from this intervention. Our results also suggest a novel hypothesis: the pharmacological modulation of thyroid function may be a potential therapeutic target in patients undergoing bariatric surgery.
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Affiliation(s)
- João Sérgio Neves
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal. .,Department of Surgery and Physiology, Cardiovascular Research Center, Faculty of Medicine of the University of Porto, Porto, Portugal.
| | - Pedro Souteiro
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal.,Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Sofia Castro Oliveira
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal.,Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Jorge Pedro
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal
| | - Daniela Magalhães
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal.,Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Vanessa Guerreiro
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal
| | - Maria Manuel Costa
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal.,Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Rita Bettencourt-Silva
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal.,Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Ana Cristina Santos
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal.,EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
| | - Joana Queirós
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal.,Multidisciplinary Group for Surgical Management of Obesity, Centro Hospitalar São João, Porto, Portugal
| | - Ana Varela
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal.,Faculty of Medicine of the University of Porto, Porto, Portugal.,Multidisciplinary Group for Surgical Management of Obesity, Centro Hospitalar São João, Porto, Portugal
| | - Paula Freitas
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal.,Faculty of Medicine of the University of Porto, Porto, Portugal.,Multidisciplinary Group for Surgical Management of Obesity, Centro Hospitalar São João, Porto, Portugal.,Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
| | - Davide Carvalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar São João, Porto, Portugal.,Faculty of Medicine of the University of Porto, Porto, Portugal.,Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal
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150
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Frohman HA, Rychahou PG, Li J, Gan T, Evers BM. Development of murine bariatric surgery models: lessons learned. J Surg Res 2018; 229:302-310. [PMID: 29937006 DOI: 10.1016/j.jss.2018.04.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/27/2018] [Accepted: 04/12/2018] [Indexed: 01/07/2023]
Abstract
Roux-en-Y gastric bypass (RYGB) improves comorbidities such as diabetes and hypertension and lowers the risk of obesity-related cancers. To better understand the physiologic and genetic influences of bariatric surgery, a reliable murine model is needed that can be extended to genetically engineered mice. Given the complexity of these procedures, few researchers have successfully implemented these techniques beyond larger rodent models. The purpose of our study was to develop a technically feasible and reproducible murine model for RYGB and sleeve gastrectomy (SG). Mice were converted to liquid diet perioperatively without fasting and housed in groups on raised wire platforms. SG involved significant reduction of stomach volume followed by multilayer repair of the gastrotomy. RYGB procedure consisted of side-to-side, functional end-to-side bowel anastomoses and exclusion of the stomach medial to the gastroesophageal junction. Sham surgeries consisted of enterotomies and gastrotomy followed by primary repair without resection or rerouting. Survival after incorporation of the aforementioned techniques was 100% in the SG group and 41% in the RYGB group at 1 mo after surgery. Only 26% of RYGB mortality was attributed to leak, obstruction, or stricture; the majority of postoperative mortality was due to stress, dumping, or malnutrition. Much of the survival challenge for this surgical model was related to perioperative husbandry, which is to be expected given their small stature and poor response to stress. Utilization of the perioperative and surgical techniques described will increase survival and feasibility of these technically challenging procedures, allowing for a better understanding of mechanisms to explain the beneficial effects of bariatric surgery.
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Affiliation(s)
- Heather A Frohman
- Department of Surgery, University of Kentucky, Lexington, Kentucky; Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Piotr G Rychahou
- Department of Surgery, University of Kentucky, Lexington, Kentucky; Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Jing Li
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - Tong Gan
- Department of Surgery, University of Kentucky, Lexington, Kentucky; Markey Cancer Center, University of Kentucky, Lexington, Kentucky
| | - B Mark Evers
- Department of Surgery, University of Kentucky, Lexington, Kentucky; Markey Cancer Center, University of Kentucky, Lexington, Kentucky.
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