Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery

Visual Analysis of Biomarkers Reveals Differences in Lipid Profiles and Liver Enzymes before and after Gastric Sleeve and Bypass

INTRODUCTION

Bariatric surgery results in both intentional and unintentional metabolic changes. In a high-volume bariatric center, extensive laboratory panels are used to monitor these changes pre- and postoperatively. Consecutive measurements of relevant biochemical markers allow exploration of the health state of bariatric patients and comparison of different patient groups.

OBJECTIVE

The objective of this study is to compare biomarker distributions over time between 2 common bariatric procedures, i.e., sleeve gastrectomy (SG) and gastric bypass (RYGB), using visual analytics.

METHODS

Both pre- and postsurgical (6, 12, and 24 months) data of all patients who underwent primary bariatric surgery were collected retrospectively. The distribution and evolution of different biochemical markers were compared before and after surgery using asymmetric beanplots in order to evaluate the effect of primary SG and RYGB. A beanplot is an alternative to the boxplot that allows an easy and thorough visual comparison of univariate data.

RESULTS

In total, 1,237 patients (659 SG and 578 RYGB) were included. The sleeve and bypass groups were comparable in terms of age and the prevalence of comorbidities. The mean presurgical BMI and the percentage of males were higher in the sleeve group. The effect of surgery on lowering of glycated hemoglobin was similar for both surgery types. After RYGB surgery, the decrease in the cholesterol concentration was larger than after SG. The enzymatic activity of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphate in sleeve patients was higher presurgically but lower postsurgically compared to bypass values.

CONCLUSIONS

Beanplots allow intuitive visualization of population distributions. Analysis of this large population-based data set using beanplots suggests comparable efficacies of both types of surgery in reducing diabetes. RYGB surgery reduced dyslipidemia more effectively than SG. The trend toward a larger decrease in liver enzyme activities following SG is a subject for further investigation.

Clinical and hemodynamic outcome of morbidly obese patients with severe chronic venous insufficiency with and without bariatric surgery

OBJECTIVE

Obesity is associated with several medical problems, including chronic venous insufficiency resistant to usual conservative measures. Venous intervention in patients with a body mass index (BMI) >30 kg/m² is associated with a higher anesthetic risk and recurrence rate. The aim of the present study was to compare the severity of venous insufficiency in terms of the clinical findings and hemodynamics between morbidly obese patients who had and had not undergone bariatric surgery (BS).

METHODS

A total of 123 patients with morbid obesity and severe venous manifestations were included in the present study. The patients were divided into two groups. Group A included 72 patients who had undergone BS, and group B included 51 patients who had not undergone BS. Assessments were performed using both disease-specific and physician-generated tools and duplex ultrasonography.

RESULTS

Of the 123 patients, 66% were men. The mean patient age was 44 ± 8.2 years. All the patients were followed up for 1 year. The mean BMI for group A had decreased from 50.1 ± 5.6 kg/m² to 32.9 ± 4.2 kg/m² (P = .0001). However, the mean BMI for group B had increased from 49.2 ± 6.1 kg/m² to 50 ± 5.7 kg/m² (P = .16). For the patients with a history of venous ulcer, the Charing Cross Venous Ulceration Questionnaire score for group A had decreased 77.5 to 36.8 (P = .0001) compared with a decrease in group B from 77.34 to 75.36 (P = .13). In group A, the median Venous Disability Score had improved from 2 to 0 and the median Venous Clinical Severity Score from 8.6 to 2.1 compared with nonsignificant changes in group B. The number of patients with venous claudication had decreased from 8 to 2 (P = .036) in group A compared with no changes in group B. For group A, the mean 36-item short-form heath survey score had increased from 48 ± 6.8 to 81 ± 4.4 (P = .001) compared with an increase from 52 ± 8.8 to 59 ± 1.2 (P = .52) in group B. The mean common femoral vein diameter had decreased significantly in group A (7.3 ± 1.3 mm) compared with that in group B (8.93 ± 1.08; P = .0001). The peak venous velocity showed higher values for the patients who had undergone BS (group A, 14.9 ± 2.5 cm/s; group B, 10.75 ± 2.05 cm/s; P = .0001). Higher mean velocities and a lower diameter resulted in a higher wall shear stress in group A compared with that in group B (2.2 ± 1.1 dyn/cm² vs 1.16 ± 0.52 dyn/cm²; P = .0001).

CONCLUSIONS

The patients who had lost weight after BS experienced noticeable improvements in chronic venous insufficiency compared with the patients who had not lost weight, including an increased rate of ulcer healing, a decreased incidence of venous claudication, and improved quality of life.

The role of health insurance characteristics in utilization of bariatric surgery

BACKGROUND

Bariatric surgery is underutilized in the United States.

OBJECTIVE

To examine temporal changes in patient characteristics and insurer type mix among adult bariatric surgery patients in southeastern Pennsylvania and to investigate the associations between payor type, insurance plan type, cost-sharing arrangements (among traditional Medicare beneficiaries), and bariatric surgery utilization.

SETTING

Pennsylvania Health Care Cost Containment Council's databases in southeastern Pennsylvania during 2014-2018.

METHODS

All adult patients who underwent the most common types of bariatric surgery and a 1:1 matched sample of surgery patients and those who were eligible for surgery but did not undergo surgery were identified. Contingency tables, Pearson χ² tests, and logistic regression were used for statistical analysis.

RESULTS

Over the 5 years, there was an increase in the proportion of Black individuals (37.1% in 2014 versus 43.0% in 2018), Hispanics (5.4% versus 8.0%), and Medicaid beneficiaries (19.2% in 2014 versus 28.5% in 2018) who underwent surgery. The odds of undergoing bariatric surgery based on payor type only between Medicare beneficiaries were statistically different (22% smaller odds) compared with privately insured individuals. There were significantly different odds of undergoing surgery based on insurance plan type within Medicare and private insurance payor categories. Individuals with traditional Medicare plans with no supplementary insurance and those with dual eligibility had smaller odds of undergoing surgery (42% and 32%, respectively) compared with those with private secondary insurance.

CONCLUSIONS

Insurance plan design may be as important in determining the utilization of bariatric surgery as the general payor type after controlling for confounding socio-demographic factors.

Reaching LDL-C Targets in Patients with Moderate, High, and Very High Risk for Cardiovascular Disease After Bariatric Surgery According to Different Guidelines

BACKGROUND

Cardiovascular disease (CVD) is highly prevalent in obese patients and is the leading cause of death. High levels of plasma low-density lipoprotein cholesterol (LDL-C) are associated with higher coronary artery disease (CAD) risk. The aim of the study was to assess the impact of the Roux-en-Y gastric bypass on the achievement of the currently proposed cardiovascular prevention goals after 1 year.

PATIENTS AND METHODS

We performed a retrospective analysis from a prospectively built database of patients who underwent a primary Roux-en-Y gastric bypass (RYGB) from 2004 to 2018. Patients with intermediate, high, or very high risk for CVD according to the 2018 AHA/ACC or the 2019 ESC/EAS guidelines were selected. An analysis of clinical and biochemical variables in 1 year was performed. Logistic multivariate regressions were made to assess the impact of preoperative and weight loss parameters in the achievement of LDL-C goals.

RESULTS

From 1039 patients, 70 met the selection criteria and were included in the analysis of the 2018 AHA/ACC guidelines, and 75 in the 2019 ESC/EAS guidelines. Mean decrease in LDL-C levels was 21.1 ± 40.2 mg/dL 1 year after surgery, and 29/34 patients were off medications. The percentage of patients achieving LDL-C goals according to the 2018 AHA/ACC guidelines was 27.1%, whereas according to the 2019 ESC/EAS guidelines, the percentages was 9.3%. The %TWL was associated with achieving LDL-C goals according to the 2018 AHA/ACC at 1 year.

CONCLUSIONS

RYGB induces a significant weight loss and an improvement in LDL-C levels 1 year after surgery. The number of patients that reached the goals varies according to the guidelines used and ranged from 9.3 to 27.1%.

A review of the psychosocial aspects of clinically severe obesity and bariatric surgery

For the past 2 decades, clinically severe obesity (operationalized as a body mass index ≥40 kg/m2) has increased at a more pronounced rate that less severe obesity. As a result, the surgical treatment of obesity (bariatric surgery) has become a more widely accepted, yet still underutilized, treatment for persons with severe obesity and significant weight-related health problems. Psychologists play a central role on the multidisciplinary team involved in the preoperative assessment and postoperative management of patients. They also have played a central role in clinical research which has enhanced understanding of the psychosocial and behavioral factors that contribute to the development of severe obesity as well as how those factors and others contribute to postoperative outcomes. This article, written specifically for psychologists and other mental health professionals who currently work with these patients or are considering the opportunity to do so in the future, reviews these contributions over the past 20 years. The article highlights how this work has become a fundamental part of international clinical care guidelines, which primarily focus on preoperative psychosocial screening. The article also outlines avenues for future research in the field, with a specific focus on the need for additional behavioral and psychosocial interventions to promote lifelong success after bariatric surgery. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Laparoscopic sleeve gastrectomy alters 1H-NMR-measured lipoprotein and glycoprotein profile in patients with severe obesity and nonalcoholic fatty liver disease

Patients with morbid obesity frequently present non-alcoholic fatty liver (NAFL) and non-alcoholic steatohepatitis (NASH) associated with pro-atherogenic alterations. Laparoscopic sleeve gastrectomy (LSG) is an effective treatment for weight reduction, and for the remission of hepatic alterations. Using ¹H-nuclear magnetic resonance (¹H-NMR), we investigated the effects of LSG on lipoprotein and glycoprotein profile in patients with morbid obesity and liver disease. We included 154 patients with morbid obesity (49 non-NASH, 54 uncertain NASH, 51 definite NASH). A blood sample was obtained before surgery and, in patients with definite NASH, one year after surgery. Patients with NASH had increased concentrations of medium and small VLDL particles, VLDL and IDL cholesterol concentrations, IDL, LDL, and HDL triglyceride concentrations, and elevated glycoprotein levels. These changes were more marked in patients with type 2 diabetes mellitus. LSG produced significant decreases in the concentration of VLDL particles, VLDL cholesterol and triglycerides, an increase in the concentration LDL particles and LDL cholesterol concentrations, and a decrease in protein glycation. We conclude that patients with obesity and NASH had significant alterations in circulating levels of lipoproteins and glycoproteins that were associated with the severity of the disease. Most of these changes were reversed post-LSG.

Physical Activity Level, Sedentary Time, and Weight Regain After Bariatric Surgery in Patients Without Regular Medical Follow-up: a Cross-Sectional Study

PURPOSE

The impact of regular exercises or physical activity (PA) on weight of bariatric patients need to be elucidated. We investigated PA levels, sedentary time (ST), and weight regain on these patients who were without regular medical follow-up before recruitment. Moreover, we investigated correlation and concordance between self-reported and objective measures in moderate-to-vigorous PA (MVPA) and ST.

MATERIALS AND METHODS

We invited 132 patients previously subjected to a bariatric procedure to a medical appointment in our unit and proposed them to be volunteers. Ninety patients, aged 42 ± 8 years and BMI 32.9 ± 6.6 kg/m², entered the study and were allocated into groups according to time since surgery < or ≥5 years (G5- or G5+, respectively). They were further assigned into low or high rates of weight regain (RWR; cutoff 20%). PA and ST were measured by International PA Questionnaire (IPAQ) and ActiGraph GT3X+ accelerometer.

RESULTS

In G5- group, PA and ST were similar between low and high RWR. In G5+ group, MVPA time, number of steps/day, percent of patients somewhat active, and 30-60 min/day of MVPA were statistically higher in those with low RWR. Of note, measures of MVPA < 30 min/day occurred more frequently in those with high RWR. MVPA and ST self-reported vs. objective measures were correlated (P < 0.001). Nevertheless, there was no concordance between these measures (P > 0.05).

CONCLUSIONS

Low level of PA and longer ST occurred more frequently in those with high RWR and longer time since surgery. Although well-correlated, any concordance between IPAQ and accelerometer measures was noted.

Assessment of depressive symptoms, self-esteem, and eating psychopathology after laparoscopic sleeve gastrectomy: 1-year follow-up and comparison with healthy controls

PURPOSE

The aim of this study was to assess depressive symptoms, self-esteem, and eating psychopathology in bariatric surgery patients at the preoperative period (t0) and at the 6-month (t1) and 12-month (t2) follow-ups after laparoscopic sleeve gastrectomy (LSG). A second aim was to investigate associations between these variables and weight loss.

METHOD

The study participants were 48 bariatric surgery candidates and 50 non-obese controls. Both groups underwent assessment with the Sociodemographic Data Form, Hamilton Depression Rating Scale (HDRS), Eating Disorder Examination Questionnaire (EDE-Q), and Rosenberg Self-esteem Scale (RSES). These assessments were repeated for the patient group at t1 and t2.

RESULTS

The HDRS, RSES, and EDE-Q scores were higher in the patients before LSG (t0) than in the control group. A significant progressive improvement was identified in the patient HDRS and RSES scores as well as EDE-Q weight and shape subscale scores at t1 and t2. However, the patient EDE-Q total and dietary restraint scores improved at t1 then stabilized. The patient EDE-Q eating concern subscale improved at t1, but then worsened. The patient HDRS scores at t2 were similar to the control group, but the EDE-Q and RSES scores were still higher than the control scores at t2. Regression analyses revealed no association between the preoperative scores and percent changes in postoperative scores for any scale and patient weight loss at t2.

CONCLUSION

Depressive symptoms, self-esteem, and eating psychopathology showed an improving trend in patients after LSG. However, some aspects of eating psychopathology worsened despite an initial improvement.

LEVEL OF EVIDENCE

III, prospective cohort and case-control study.

Prevalence of Upper Gastrointestinal Pathology in Patients with Obesity on Preoperative Endoscopy

Background and Objectives:

The preoperative work up for bariatric surgery is variable and not all centers perform a preoperative upper gastrointestinal endoscopy. A study was undertaken to determine the frequency of clinically significant gross endoscopic and pathological diagnoses in a large sample of patients with obesity undergoing work-up for bariatric surgery.

Methods:

Routine endoscopy was performed on all preoperative bariatric patients. A retrospective chart review of 1000 consecutive patients was performed. Patients were divided into three groups: Group A (no endoscopic findings), Group B (clinically insignificant findings), Group C (clinically significant findings).

Results:

Patients had a mean body mass index (BMI) of 49 kg/m2 and 79% were female. In this sample one finding was found on preoperative EGD in 95.2% of patients, 33.9% had at least two diagnoses, and 29.9% had three or more diagnoses. Group A (no findings) consisted of 4.8% of patient, 52.5% in Group B (clinically insignificant findings), and 42.7% were in Group C (clinically significant findings). Clinically significant findings included hiatal hernia 23.5%, esophagitis 9.5%, H. pylori 7.1%, gastric erosions 5.7%, duodenitis 3.7%, Barrett's esophagus 3.1%, and Schatzki ring 1.2%. There was no significant correlation between preoperative BMI and any endoscopic findings (all p-value 0.05). Patients in Group C were statistically older than Groups A and B.

Conclusion:

Upper gastrointestinal pathology is highly common in patients with obesity. There is a significant rate of clinically significant endoscopy findings and all bariatric surgery patients should undergo preoperative endoscopy.

Missing something? A scoping review of venous thromboembolic events and their associations with bariatric surgery. Refining the evidence base

Background

Venous thromboembolic events (VTE) post-bariatric surgery (BS) lead to morbidity and mortality.

Methods

This scoping review assessed whether reported VTE post-BS could be under/over-estimated; suggested a possible number of VTE post-BS; appraised whether VTE are likely to decrease/increase; examined BS as risk/protective factor for VTE; and mapped the gaps, proposing potential solutions.

Results

VTE appears under-estimated due to: identification/coding of BS and VTE; reporting of exposure (BS); and reporting of outcomes (VTE). The review proposes a hypothetical calculation of VTE post-BS. VTE are unlikely to decrease soon. BS represents risk and protection for VTE. Better appreciation of VTE-BS relationships requires longer-term strategies.

Conclusion

VTE are underestimated. Actions are required for understanding the VTE-BS relationships to in order to crease VTE by better-informed prevention strategy/ies.

Early changes in immune cell metabolism and function are a hallmark of sleeve gastrectomy: a prospective human study

OBJECTIVE

To characterize longitudinal changes in blood biomarkers, leukocyte composition, and gene expression following laparoscopic sleeve gastrectomy (LSG).

BACKGROUND

LSG is an effective treatment for obesity, leading to sustainable weight loss and improvements in obesity-related co-morbidities and inflammatory profiles. However, the effects of LSG on immune function and metabolism remain uncertain.

METHODS

Prospective data was collected from 23 enrolled human subjects from a single institution. Parameters of weight, co-morbidities, and trends in blood biomarkers and leukocyte subsets were observed from pre-operative baseline to one year in three-month follow-up intervals. RNA-sequencing was performed on pairs of whole blood samples from the first six subjects of the study (baseline and three months post-surgery) to identify genome-wide gene expression changes associated with undergoing LSG.

RESULTS

LSG led to a significant decrease in mean total body weight loss (18.1%) at three months and among diabetic subjects a reduction in HbA1c. Improvements in clinical inflammatory and hormonal biomarkers were demonstrated as early as three months after LSG. A reduction in neutrophil-lymphocyte ratio was observed, driven by a reduction in absolute neutrophil counts. Gene set enrichment analyses of differential whole blood gene expression demonstrated that after three months, LSG induced transcriptomic changes not only in inflammatory cytokine pathways but also in several key metabolic pathways related to energy metabolism.

CONCLUSIONS

LSG induces significant changes in the composition and metabolism of immune cells as early as three months post-operatively. Further evaluation is required of bariatric surgery's effects on immunometabolism and consequences for host defense and metabolic disease.

British Obesity and Metabolic Surgery Society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery-2020 update

Bariatric surgery is recognized as the most clinically and cost-effective treatment for people with severe and complex obesity. Many people presenting for surgery have pre-existing low vitamin and mineral concentrations. The incidence of these may increase after bariatric surgery as all procedures potentially cause clinically significant micronutrient deficiencies. Therefore, preparation for surgery and long-term nutritional monitoring and follow-up are essential components of bariatric surgical care. These guidelines update the 2014 British Obesity and Metabolic Surgery Society nutritional guidelines. Since the 2014 guidelines, the working group has been expanded to include healthcare professionals working in specialist and non-specialist care as well as patient representatives. In addition, in these updated guidelines, the current evidence has been systematically reviewed for adults and adolescents undergoing the following procedures: adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch. Using methods based on Scottish Intercollegiate Guidelines Network methodology, the levels of evidence and recommendations have been graded. These guidelines are comprehensive, encompassing preoperative and postoperative biochemical monitoring, vitamin and mineral supplementation and correction of nutrition deficiencies before, and following bariatric surgery, and make recommendations for safe clinical practice in the U.K. setting.

An exercise-based educational and motivational intervention after surgery can improve behaviors, physical fitness and quality of life in bariatric patients

Introduction

Unhealthy lifestyles may hinder bariatric surgery outcomes. This non-randomized controlled study aimed to evaluate the effects of an integrated post-operative exercise-based educational and motivational program in improving behaviors, quality of life, anthropometric features, cardiorespiratory and physical fitness in bariatric patients respect to the only surgical intervention.

Methods

A group of adult sedentary bariatric patients chose to attend a 12-month exercise program integrated with diet education and motivational support, or to receive usual care. Dietary habits, binge eating disorder, physical activity, obesity-related quality of life, Body Mass Index, waist and hip circumference, VO₂max, strength and flexibility were assessed at the start and at the end of the study in both groups.

Results

On a total of 82 patients enrolled, follow-up measures were obtained from 28 (85.7% females, mean age 38.2±8.7) and 42 (71.4% females, mean age 40.2±9.5) patients included in the intervention and control group, respectively. All the behavioral and physical outcomes improved significantly in the participants to the intervention, while the control group showed lesser changes, especially regarding quality of life and physical fitness.

Conclusions

Notwithstanding the self-selection, these results suggest that a timely postoperative behavioral multidisciplinary program for bariatric patients may be effective in establishing healthy behaviors which can lead to better surgery outcomes.

Google Trends as a resource for bariatric education: what do patients want to know?

BACKGROUND

Bariatric surgery (BaS) is the safest, most effective, and most durable therapy for obesity but is performed in less than 1% of the affected United States (US) population. It is challenging to determine from traditional surveys if this phenomenon is the result of poor access to care or lack of interest among Internet users.

OBJECTIVES

The aim of this study was to use Google Trends (GT) as a tool to analyze the US general population interest in BaS.

SETTING

Academic Hospital, United States.

METHODS

GT was used to access data searched for the term bariatric surgery. The gathered information included data from 2008 through 2018 in English within the US. Search frequency, time intervals, locations, frequent topics of interest, and related searches were analyzed. GT reports search frequency on means, and a value of 100 represented peak popularity.

RESULTS

The number of Google searches related to the term bariatric surgery has gradually increased over time, from a mean of 67% in 2008 to a 94% interest in 2017. Regarding interest by subregion in 2017, the state of Michigan lead the frequency of searches, followed by Indiana, Delaware, West Virginia, and Tennessee. Top searched terms by frequency were the following: patient eligibility for BaS, what is BaS, what are the complications of BaS, financial costs of BaS, and what insurance companies cover BaS. It appears that traditional Web sites only address a few.

CONCLUSIONS

GT complements the understanding of interest in BaS. Using these trends can improve an Internet user's education, and tailor specific official Web sites for the public's general interest.

Bariatric surgery affects obesity-related protein requirements

CONTEXT

Following bariatric surgery, protein deficiency intakes are reported in morbidly obese patients, whereas post-bariatric protein requirements are not specifically defined with validated method in this population.

OBJECTIVE

To assess average protein requirement (APR) in obese subjects, before, 3 months and 12 months after bariatric surgery using the validated method of nitrogen balance.

DESIGN AND SETTING

Prospective longitudinal study conducted in 21 morbidly obese patients (BMI 43.9 ± 1.4 kg/m²) before (M0), 3 months (M3) and 12 months (M12) after sleeve gastrectomy or Roux-en-Y gastric by-pass. An additional larger cross-sectional study was performed to validate APR before surgery in non-operated matched obese patients (n = 106). APR was evaluated at M0, M3, M12 by measuring 3 days dietary intakes together with losses of nitrogen in urine and stools.

MAIN OUTCOME MEASURE

APR was defined as the mean value of protein intake required to achieve balance nitrogen equilibrium.

RESULTS

Before surgery, APR in morbidly obese patients was 0.76 [95%CI, 0.66-0.92] g/kg Body Weight (BW)/d in the experimental group, and 0.74 [0.70-0.80] g/kg BW/d in the validation group. APR was 0.62 [0.51-0.75] g/kg/d at M3 and 0.87 [0.75-0.98] g/kg/d at M12, with no difference between surgical procedures. Spontaneous protein intakes were respectively 0.80 ± 0.05, 0.43 ± 0.03 and 0.71 ± 0.04 g/kg BW/d respectively at M0, M3 and M12.

CONCLUSION

This study demonstrates a temporal change in protein requirement after bariatric surgery whatever the type of surgery. Spontaneous protein intakes following bariatric surgery does not cover protein requirements for most patients, suggesting that specific dietary protein recommandations have to be adapted in obese patients with bariatric surgery.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT01249326.

The Relevance of Thiamine Evaluation in a Practical Setting

Thiamine is a crucial cofactor involved in the maintenance of carbohydrate metabolism and participates in multiple cellular metabolic processes. Although thiamine can be obtained from various food sources, some common food groups are deficient in thiamine, and it can be denatured by high temperature and pH. Additionally, different drugs can alter thiamine metabolism. In addition, the half-life of thiamine in the body is between 1 and 3 weeks. All these factors could provide an explanation for the relatively short period needed to develop thiamine deficiency and observe the consequent clinical symptoms. Thiamine deficiency could lead to neurological and cardiological problems. These clinical conditions could be severe or even fatal. Marginal deficiency too may promote weaker symptoms that might be overlooked. Patients undergoing upper gastrointestinal or pancreatic surgery could have or develop thiamine deficiency for many different reasons. To achieve the best outcome for these patients, we strongly recommend the execution of both an adequate preoperative nutritional assessment, which includes thiamine evaluation, and a close nutritional follow up to avoid a nutrient deficit in the postoperative period.

Relationships Between Vitamin D Status and PTH over 5 Years After Roux-en-Y Gastric Bypass: a Longitudinal Cohort Study

PURPOSE

Secondary hyperparathyroidism (SHPT) after obesity surgery may affect bone health. Optimal vitamin D levels have not been established to prevent SHPT postoperatively. We investigated whether SHPT differed across threshold levels of serum 25-hydroxyvitamin D (S-25(OH)D) from 6 months up to 5 years after Roux-en-Y gastric bypass (RYGB).

MATERIALS AND METHODS

We included 554 patients at follow-up 5 years postoperatively. Blood samples were analysed for S-25(OH)D, ionized calcium (iCa) and parathyroid hormone (PTH) during follow-up.

RESULTS

PTH and prevalence of SHPT increased from 6 months to 5 years postoperatively, while S-25(OH)D and iCa decreased (all P < 0.001). PTH and SHPT development are related with S-25(OH)D, and PTH differed between all subgroups of S-25(OH)D. SHPT occurred less frequently across all subgroups of S-25(OH)D ≥ 50 nmol/l during follow-up: odds ratio (OR) 0.44 (95% CI 0.36-0.54) in patients with S-25(OH)D ≥ 50 nmol/l, OR 0.38 (0.30-0.49) with S-25(OH)D ≥ 75 nmol/l and OR 0.19 (0.12-0.31) with S-25(OH) D ≥ 100 nmol/l, all compared with S-25(OH)D < 50 nmol/l. At 5 years, 208/554 patients (38%) had SHPT; SHPT was found in 94/188 patients (50%) with S-25(OH)D < 50 nmol/l, in 69/222 (31%) with S-25(OH)D 50-74 nmol/l, in 40/117 (34%) with S-25(OH)D 75-99 nmol/l and in 5/27 (19%) with S-25(OH)D ≥ 100 nmol/l. An interaction existed between S-25(OH)D and iCa. Bone alkaline phosphatase remained increased with SHPT.

CONCLUSIONS

A significant relationship existed between S-25(OH)D and development of PTH and SHPT. The prevalence of SHPT was lower with threshold levels 25(OH)D ≥ 50 nmol/l and ≥ 75 nmol/l over the 5 years, and lowest with S-25(OH)D ≥ 100 nmol/l.

Perioperative screening, management, and surveillance of Barrett's esophagus in bariatric surgical patients

Obesity is a strong risk factor for Barrett's esophagus (BE), the only proven precursor lesion to esophageal adenocarcinoma (EAC). Bariatric surgery is currently the only reliable treatment that achieves long-term sustained weight loss; however, it can markedly affect the development of de novo BE, and the progression or regression of existing BE. Bariatric procedures may also have implications on future surgical management of any consequent EAC. In this review, we examine the current evidence and published guidelines for BE in bariatric surgery. Current screening practices before bariatric surgery vary substantially, with conflicting recommendations from bariatric societies. If diagnosed, the presence of BE may alter the type of bariatric procedure. A selective screening approach prevents unnecessary endoscopy; however, there is poor symptom correlation with disease. Studies suggest that sleeve gastrectomy predisposes patients to gastroesophageal reflux and de novo BE. Conversely, Roux-en-Y gastric bypass is associated with decreased reflux and potential improvement or resolution of BE. There are currently no guidelines addressing the surveillance for BE following bariatric surgery. BE is an important consideration in the management of bariatric surgical patients. Evidence-based recommendations are required to guide procedure selection and postoperative surveillance.

Benefits of multidisciplinary team management of obese patients with intragastric balloon placement: an analysis of 159 cases at a single center

BACKGROUND

Intragastric balloon placement is an ideal weight loss method for those unfit or unwilling to undergo surgery. It is not known if multidisciplinary team management helps these patients the way it does with those who enroll in bariatric surgery programs.

OBJECTIVES

The primary objective was to assess the efficacy of intragastric balloon on weight loss after a 6-month follow-up and the secondary objective was to assess the impact of multidisciplinary team intervention (psychological consultation, nutritional follow-up, and regular physical activity) on weight loss in the study patients.

SETTING

Referral military tertiary care center, Mexico.

METHODS

Retrospective study of 159 patients treated with intragastric balloon between June 2011 and December 2016 in a single institution with aims of assessing its efficacy and the impact of regular exercise, supervised diet, and psychological consultation during the intervention.

RESULTS

One hundred fifty-nine patients were enrolled. There were no drop-offs nor patients lost to follow-up. The mean initial weight was 92.6 ± 12.6 kg with a decrease to a mean of 80.7 ± 12.4 kg at 6 months with a mean reduction of 11.9 kg (P < .0001). The initial mean body mass index (BMI) of the population was 33.8 ± 2.8 kg/m², which decreased to a mean of 29.5 ± 3.3 kg/m² of BMI. The mean BMI units lost was 4.3 kg/m² (P < .0001). A 50.8 ± 33.8% excess weight loss was observed (P < .0001), and a mean 12.6 ± 7.6% of total weight loss was found (P < .0001). Significant interventions on BMI at 6 months were psychological consultation associated with a mean BMI reduction of 6.0 ± 3.0 kg/m² versus a mean BMI reduction of 4.1 ± 1.9 kg/m² of those who did not (P < .0001) and physical activity with a mean BMI reduction of 4.8 ± 2.3 kg/m² for those who did exercise versus a mean BMI reduction of 4.1 ± 2.0 kg/m² for those who did not (P = .041).

CONCLUSIONS

Intragastric balloon managed patients get additional benefit on weight loss with psychological follow-up and exercise during the intervention. Given the retrospective nature of the study, further studies are needed to definitive conclusions.

Evaluating a potential role for community pharmacists in post-bariatric patient nutritional support

Physiological changes to the body from bariatric surgery necessitate lifelong vitamin and mineral supplementation to prevent potential nutritional deficiencies. Presently, there is no consensus on appropriate long-term follow-up in community settings for people who have undergone bariatric surgery. Current UK guidelines recommend annual monitoring of nutritional status, but little else. Semi-structured interviews were carried out with members of a high volume bariatric surgical unit and community pharmacists working in a variety of settings and locations. Data were collected between June and August 2018 and analysed using a thematic analytic framework. Twenty-five participants were recruited. Bariatric staff (n = 9) reported negligible interaction with community pharmacists but felt establishing communication and developing a potential pathway to collaborate, would provide additional support and potentially improved levels of patient compliance. Community pharmacists (n = 16) reported poor knowledge of bariatric surgery, indicating they were unable to routinely identify people who had bariatric surgery, but understood issues with absorption of vitamins. There is evident potential to involve community pharmacists in post-bariatric patient care pathways. Pharmacists possess knowledge of absorption and metabolism of supplements which could be used to actively support people who have had bariatric surgery in their changed physiological status. Education ought to focus on the functional impact of bariatric surgical procedures and interventions and the consequent nutritional recommendations required. Communication between bariatric units and community pharmacies is needed to construct a clear and formalized infrastructure of support, with remuneration for pharmacy specialist expertise agreed to ensure both financial viability and sustainability.

Fracture Risk After Roux-en-Y Gastric Bypass vs Adjustable Gastric Banding Among Medicare Beneficiaries

Importance

Roux-en-Y gastric bypass (RYGB) is associated with significant bone loss and may increase fracture risk, whereas substantial bone loss and increased fracture risk have not been reported after adjustable gastric banding (AGB). Previous studies have had little representation of patients aged 65 years or older, and it is currently unknown how age modifies fracture risk.

Objective

To compare fracture risk after RYGB and AGB procedures in a large, nationally representative cohort enriched for older adults.

Design, Setting, and Participants

This population-based retrospective cohort analysis used Medicare claims data from January 1, 2006, to December 31, 2014, from 42 345 severely obese adults, of whom 29 624 received RYGB and 12 721 received AGB. Data analysis was performed from April 2017 to November 2018.

Main Outcomes and Measures

The primary outcome was incident nonvertebral (ie, wrist, humerus, pelvis, and hip) fractures after RYGB and AGB surgery defined using a combination of International Classification of Diseases, Ninth Edition and Current Procedural Terminology 4 codes.

Results

Of 42 345 participants, 33 254 (78.5%) were women. With a mean (SD) age of 51 (12) years, recipients of RYGB were younger than AGB recipients (55 [12] years). Both groups had similar comorbidities, medication use, and health care utilization in the 365 days before surgery. Over a mean (SD) follow-up of 3.5 (2.1) years, 658 nonvertebral fractures were documented. The fracture incidence rate was 6.6 (95% CI, 6.0-7.2) after RYGB and 4.6 (95% CI, 3.9-5.3) after AGB, which translated to a hazard ratio (HR) of 1.73 (95% CI, 1.45-2.08) after multivariable adjustment. Site-specific analyses demonstrated an increased fracture risk at the hip (HR, 2.81; 95% CI, 1.82-4.49), wrist (HR, 1.70; 95% CI, 1.33-2.14), and pelvis (HR, 1.48; 95% CI, 1.08-2.07) among RYGB recipients. No significant interactions of fracture risk with age, sex, diabetes status, or race were found. In particular, adults 65 years and older showed similar patterns of fracture risk to younger adults. Sensitivity analyses using propensity score matching showed similar results (nonvertebral fracture: HR 1.75; 95% CI, 1.22-2.52).

Conclusions and Relevance

This study of a large, US population-based cohort including a substantial population of older adults found a 73% increased risk of nonvertebral fracture after RYGB compared with AGB, including increased risk of hip, wrist, and pelvis fractures. Fracture risk was consistently increased among RYGB patients vs AGB across different subgroups, and to a similar degree among older and younger adults. Increased fracture risk appears to be an important unintended consequence of RYGB.

Recommendations Based on Evidence by the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the Pre- and Postoperative Management of Patients Undergoing Obesity Surgery

In order to develop evidence-based recommendations and expert consensus for nutrition management of patients undergoing bariatric surgery and postoperative follow-up, we conducted a systematic literature search using PRISMA methodology plus critical appraisal following the SIGN and AGREE-II procedures. The results were discussed among all members of the GARIN group, and all members answered a Likert scale questionnaire to assess the degree of support for every recommendation. Patients undergoing bariatric surgery should be screened preoperatively for some micronutrient deficiencies and treated accordingly. A VLCD (Very Low-Calorie Diet) should be used for 4-8 weeks prior to surgery. Postoperatively, a liquid diet should be maintained for a month, followed by a semi-solid diet also for one month. Protein requirements (1-1.5 g/kg) should be estimated using adjusted weight. Systematic use of specific multivitamin supplements is encouraged. Calcium citrate and vitamin D supplements should be used at higher doses than are currently recommended. The use of proton-pump inhibitors should be individualised, and vitamin B12 and iron should be supplemented in case of deficit. All patients, especially pregnant women, teenagers, and elderly patients require a multidisciplinary approach and specialised follow-up. These recommendations and suggestions regarding nutrition management when undergoing bariatric surgery and postoperative follow-up have direct clinical applicability.

The Effect of Laparoscopic Sleeve Gastrectomy on Nonalcoholic Fatty Liver Disease

Obesity is associated with nonalcoholic fatty liver disease which is one of the most common causes of chronic liver disease. FibroScan is a noninvasive tool for liver stiffness measurement and controlled attenuation parameter to evaluate liver steatosis and fibrosis. We aimed to demonstrate the effect of laparoscopic sleeve gastrectomy on liver steatosis and fibrosis. Of the 120 consecutive patients screened, 72 were enrolled in this study. FibroScan M probe and XL probe were used for the evaluation of liver steatosis and fibrosis. Fifty-two patients (72.2%) were female individuals and 20 (27.8%) were male individuals; the mean age was 37.9±10.4 years. Percentage of excess weight loss was significant at the third and sixth months: 57.2±18.3 (P<0.05) and 81.4±24.6 (P<0.05), respectively. Mean preoperative controlled attenuation parameter and liver stiffness measurement values were 309.2±68.7 dB/m and 7.5±5.0 kPa, respectively, and significantly declined to 217.4±56.4 dB/m and 5.6±2.5 kPa, respectively, at sixth postoperative month (P<0.001 and <0.01, respectively). These results suggest that laparoscopic sleeve gastrectomy is associated with significant improvement in liver steatosis and fibrosis. Bariatric surgery has a beneficial effect on nonalcoholic fatty liver disease in morbidly obese patients.

Weight Loss Prior to Bariatric Surgery and 30-Day Mortality, Readmission, Reoperation, and Intervention: an MBSAQIP Analysis of 349,016 Cases

INTRODUCTION

Despite preoperative weight loss being a common prerequisite to metabolic and bariatric surgery, its relationship to 30-day postoperative outcomes is unclear. The aim of this study was to assess whether preoperative weight loss is associated with 30-day postoperative quality outcomes in adults undergoing metabolic and bariatric surgery.

METHODS

Retrospective cohort study assessing adults who underwent Roux-en-Y gastric bypass or sleeve gastrectomy in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use File, years 2015-2017. The relationship between preoperative weight loss and 30-day readmission, reoperation, mortality, intervention, and morbidity was assessed using multivariable logistic regression.

RESULTS

Preoperative weight loss, body mass index loss, and percent weight loss were not associated with 30-day postoperative overall readmission, reoperation, mortality, or intervention (p > 0.01). Preoperative percent weight loss was associated with increased incidence of superficial surgical site infections (OR = 1.023, 95% CI 1.009-1.036; p = 0.001) and urinary tract infections (OR = 1.044, 95% CI 1.030-1.059; p < 0.001).

CONCLUSION

Weight loss prior to metabolic and bariatric surgery may not be necessary or safe for all patients. Unsafe weight loss prior to surgery may compromise nutrition status and lead to increased infection rates.

The impact of pregnancy on postoperative outcomes among obese women who underwent bariatric surgery: A systematic review and meta-analysis

OBJECTIVES

Women who had a history of bariatric surgery are increasingly becoming pregnant. There is growing evidence showing that increased risk of postoperative complications may be associated with the gestation after bariatric surgery.The objective of this systematic review was to evaluate the potential impact of pregnancy on weight loss and postoperative complications in obese women after bariatric surgery.

STUDY DESIGN

PubMed, Embase, Medline and Cochrane Central Register of Controlled Trails were searched from inception through October 2018. Selection criteria included observational or randomized trial examining weight loss and medical complications in pregnant compared to non-pregnant women after bariatric surgery. Two reviewers extracted information and performed quality appraisal of eligible articles. Meta-analysis was performed to ascertain the certainty of the evidence when possible.

RESULTS

Seven observational cohort studies with a total of 27,369 obese women were included in the final analysis. The mean difference (95 % confidence interval) in percent excess weight loss between pregnant and non-pregnant subjects was -9.5 (-19.9, 0.9). The odds ratio (95 % confidence interval) for postoperative complications in pregnant relative to non-pregnant subjects was 0.85 (0.33, 2.18).

CONCLUSIONS

Pregnancy may have little or no effect on weight loss or postoperative complications in women who have undergone bariatric surgery.

Family Meal Practices and Weight Talk Between Adult Weight Management and Weight Loss Surgery Patients and Their Children

OBJECTIVE

To identify predictors associated with specific family meal practices and weight talk among patients participating in weight management programs (WMPs) and weight loss surgery (WLS) and their children.

DESIGN

Cross-sectional survey.

SETTING

Two US weight management centers.

PARTICIPANTS

259 patients (aged ≥ 18 years) in either WMP (n = 101) or WLS (n = 158) and residing with a child (aged 2-18 years) MAIN OUTCOME MEASURE(S): Dependent variables: family meal practices (Project EAT) and weight talk (investigator-created). Covariates: family communication (Family Communication Scale), family discouragement for making eating habit change (Social Support for Eating Habits Survey), child age, sex, and perceived weight status, and WMP or WLS participation.

ANALYSIS

Binomial and ordinal regression models determined the odds of engaging in specific family meal practices and weight talk, including covariates.

RESULTS

Patients had increased odds of engaging in family dinners if they reported lower family discouragement (P = .003) and had younger children (P < .001), and increased odds of engaging in family breakfast if they had higher family communication (P = .002) and younger children (P = .020). Patients had increased odds of talking about their child's weight if their child was perceived to have an overweight/obese weight status (P < .001). Patients with older children had increased odds of talking about their weight with their child (P = .021).

CONCLUSIONS AND IMPLICATIONS

Additional research assessing the family meal practices and weight talk in the families of adults pursuing weight loss could yield important evidence that could lead to improved patient outcomes, and safely promote healthy behaviors and prevention of obesity in children.

A Spanish Society joint SECO and SEEDO approach to the Post-operative management of the patients undergoing surgery for obesity

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.

Clinical factors correlated with vitamin D deficiency in patients with obesity scheduled for bariatric surgery: A single center experience

We aim to assess the prevalence of vitamin D deficiency (VDD) in patients scheduled for bariatric surgery (BS), and to identify factors that might be associated with VDD. We conducted a cross-sectional observational study involving all consecutive patients scheduled for BS from 2017 to 2019. The exclusion criteria were missing data for vitamin D levels, intake of vitamin D supplements in the 3 months prior to serum vitamin D determination, and renal insufficiency. A total of 206 patients (mean age and body mass index [BMI] of 34.9 ± 10.7 years, and 44.3 ± 6.99 kg/m², respectively) met the inclusion criteria and were enrolled for data analysis. VDD (<19.9 ng/mL), severe VDD (<10 ng/mL), and vitamin D insufficiency (20-29.9 ng/mL) were present in 68.8 %, 12.5 %, and 31.2 % of patients, respectively. A significant inverse correlation was found between vitamin D levels and initial BMI, parathyroid hormone, and homeostatic model assessment of insulin resistance (r = -0.280, p < 0.05; r = -0.407, p = 0.038; r = -0.445, p = 0.005), respectively. VDD was significantly more prevalent in patients with higher BMI [-0.413 ± 0.12, CI95 % (-0.659; -0.167), p = 0.006], whereas no significant association between hypertension [-1.005 ± 1.65, CI95 % (-4.338; 2.326), p = 0.001], and diabetes type 2 (T2D) [-0.44 ± 2.20, CI95 % (-4.876; 3.986), p = 0.841] was found. We observed significant association between female sex and levels of vitamin D [6.69 ± 2.31, CI95 % (2.06; 11.33), p = 0.006]. The present study shows that in patients scheduled for BS, VDD deficiency is common and was associated with higher BMI, and female sex.

Nutritional Deficiencies, Bariatric Surgery, and Serum Homocysteine Level: Review of Current Literature

Obesity is currently one of the biggest global health problems. In the case of severe obesity, bariatric surgeries are considered to be the most important method of treatment. The 2 most commonly performed bariatric surgery procedures include Roux-en-Y gastric bypass and sleeve gastrectomy. However, these methods are not free from complications, and the most common ones (moderately long or long term) are micronutrient deficiencies. The deficiency of vitamins B6, B12, and folic acid as cofactors of the folate cycle contributes to the development of hyperhomocysteinemia. It seems that apart from nutritional factors, there are other aspects that have a significant influence on the concentration of homocysteine in blood, such as the type of conducted bariatric surgery, the post-surgical concentration of betaine and creatinine, and the clearance of methionine (i.e., the mutations of the gene that encodes the MTHFR reductase as well as other genes associated with the process of methylation, e.g., methionine synthase). Their presence might be one of the causes of the increased concentration of homocysteine after surgery despite the fact that patients take vitamin-mineral supplementation.

Anemia Before and After Roux-en-Y Gastric Bypass: Prevalence and Evolution on Long-Term Follow-up

PURPOSE

Anemia due to iron deficiency or inflammatory state is often associated with obesity. Bariatric surgery is responsible for increasing iron deficiency, but weight loss decreases the inflammatory state associated with obesity. The objective of our study was to investigate the prevalence and causes of anemia before and after bariatric surgery for severe obesity in a 5-year follow-up.

MATERIALS AND METHODS

Retrospective study, with electronic record analysis of obese patients, submitted to Roux-en-Y gastric bypass. Laboratory data were collected before and up to 60 months after surgery. Diagnosis and classification of anemia were done according to hemoglobin levels, serum ferritin, and transferrin saturation.

RESULTS

Preoperatively, 8.8% of patients had anemia (93.2%, mild), and 43.8% of the patients had anemia due to chronic disease. After 24 months, there was a progressive increase of iron-deficiency anemia (72.4%) and decrease in anemia due to chronic disease (15.5%) and mixed (12.1%), with maintenance of this profile during long-term follow-up.

CONCLUSION

Anemia is very frequent in severely obese patients and must be investigated both before and after bariatric surgery. The cause of anemia must be determined in order to use the best treatment available. We observed a reduction in the prevalence of chronic disease anemia during long-term follow-up probably due to the improvement in the systemic inflammatory state.

A 5-Year Follow-up in Children and Adolescents Undergoing One-Anastomosis Gastric Bypass (OAGB) at a European IFSO Excellence Center (EAC-BS)

BACKGROUND

The children and adolescent population with obesity has increased worldwide, both in developing areas and in developed countries. Consequently, the prevalence of morbid obesity among this population has also increased, leading to an exponential growth of bariatric approaches in this population. Many surgeons fear eventual nutritional sequelae after malabsorptive approaches and prefer restrictive or mixed procedures.

METHODS

A retrospective review of all the morbidly obese patients between 13 and 19 years, undergoing a one-anastomosis gastric bypass (OAGB) as bariatric procedure between 2004 and 2012, was performed.

RESULTS

A total of 39 patients were included, 8 males (20.5%) and 31 females (79.5%), with a mean age of 17.8 ± 2 years (range 13-19 years). Mean preoperative weight was 114.3 ± 20.4 kg and mean BMI 42.2 ± 5.9 kg/m². Preoperative comorbidities include only type 2 diabetes mellitus (T2DM) in 7.9% of the patients, hypertension in 10.3%, and dyslipidemia in 23.1%. Five years after surgery, mean BMI was 25.9 ± 5.3 kg/m² and total weight loss 32.1 ± 15.7%. Remission rate of T2DM, hypertension and dyslipidemia was 100%. All the patients received multivitamin and vitamin D supplementation. Anemia secondary to iron deficiency occurred in one female, requiring intravenous iron supplementation during 1 year and later on oral supplementation.

CONCLUSIONS

OAGB is a valid alternative for long-term weight loss and remission of comorbidities in childhood and adolescence. No cases of malnutrition or growth disorders were observed.

Impact of Biliopancreatic Limb Length (70 cm vs 120 cm), with Constant 150 cm Alimentary Limb, on Long-Term Weight Loss, Remission of Comorbidities and Supplementation Needs After Roux-En-Y Gastric Bypass: a Prospective Randomized Clinical Trial

BACKGROUND

The best alimentary and biliopancreatic limb (BPL) lengths in the Roux-en-Y gastric bypass (RYGB) still remain unclear. The aim of this study was to compare the effect of a BPL of 70 vs 120 cm, with a constant AL of 150 cm on long-term weight loss, remission of comorbidities, and supplementation needs after RYGB.

PATIENTS AND METHODS

A prospective randomized study of morbidly obese patients undergoing RYGB was performed. Patients were randomized into two groups: those patients undergoing RYGB with a BPL of 70 cm (BPL 70 cm) and those ones undergoing RYGB with a BPL of 120 cm (BPL 120 cm). BMI, excess BMI loss (EBMIL), remission of comorbidities and specific vitamin and mineral supplementation needs at 1, 2, and 5 years were analyzed.

RESULTS

Two hundred fifty-three patients were included in each group. There were no significant differences in BMI, EBMIL and the remission of diabetes mellitus, hypertension, and dyslipidemia between groups at 1, 2, and 5 years after surgery. Patients from group BPL 120 cm required greater specific supplementation of vitamin B12, folic acid, and vitamin A during all the follow-up.

CONCLUSION

A RYGB with 120 cm BPL does not achieve greater weight loss or remission of comorbidities than a RYGB with 70 cm BPL but is associated with greater deficiencies of vitamin B12, vitamin A, and folic acid.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT03607305. https://clinicaltrials.gov/.

Commentary on disordered eating symptoms and bariatric/metabolic surgery

OBJECTIVE

This article presents an argument for the rethinking of concerns around bariatric/metabolic surgery in people with disordered eating.

CONCLUSION

Practice has usually been cautious but disordered eating and eating disorders should not be a contraindication other than exceptional cases. Further research directions are suggested.

Mental Health in Bariatric Surgery: Selection, Access, and Outcomes

Severe obesity has many psychiatric consequences that can be influenced by bariatric surgery. The goal of this article is to review these challenges, including the mental health status of patients with severe obesity, the evaluation of surgical candidates, and the early and late effects of the operations, and to offer some recommendations to manage these challenges. The failure of the insurance-mandated preoperative psychosocial evaluation is also discussed.

Physical Exercise following bariatric surgery in women with Morbid obesity: Study protocol clinical trial (SPIRIT compliant)

BACKGROUND

Severe and morbid obesity are increasing globally, particularly in women. As BMI increases, the likelihood of anovulation is higher. The primary aim of the EMOVAR clinical trial is to examine, over the short (16 weeks) and medium (12 months) term, the effects of a supervised physical exercise program (focused primarily on aerobic and resistance training) on ovarian function in women with severe/morbid obesity who have undergone bariatric surgery. Secondary objectives are to examine the effects of the intervention on chronic inflammation, insulin resistance, arterial stiffness, physical fitness, and health-related quality of life.

METHODS

This is a randomized controlled trial in which ∼40 female bariatric surgery patients, aged between 18 and 45 years old, will be included. Participants assigned to the experimental group will perform a total of 48 sessions of supervised concurrent (strength and aerobic) training (3 sessions/week, 60 min/session) spread over 16 weeks. Patients assigned to the control group will receive lifestyle recommendations. Outcomes will be assessed at baseline, week 16 (i.e., after the exercise intervention) and 12 months after surgery. The primary outcome is ovarian function using the Sex-Hormone Binding Globuline, measured in serum. Secondary outcomes are serum levels of anti-mullerian hormone, TSH, T4, FSH, LH, estradiol, prolactine, and free androgen index, as well as oocyte count, the diameters of both ovaries, endometrial thickness, and uterine arterial pulsatility index (obtained from a transvaginal ultrasound), the duration of menstrual bleeding and menstrual cycle duration (obtained by personal interview) and hirsutism (Ferriman Gallwey Scale). Other secondary outcomes include serum markers of chronic inflammation and insulin resistance (i.e., C-reactive protein, interleukin 6, tumor necrosis factor-alpha, leptin, glomerular sedimentation rate, glucose, insulin and the HOMA-IR), arterial stiffness, systolic, diastolic and mean blood pressure, body composition, and total weight loss. Physical fitness (including cardiorespiratory fitness, muscular strength, and flexibility), health-related quality of life (SF-36 v2) and sexual function (Female Sexual Function Index) will also be measured.

DISCUSSION

This study will provide, for the first time, relevant information on the effects of exercise training on ovarian function and underlying mechanisms in severe/morbid obese women following bariatric surgery.

TRIAL REGISTRATION NUMBER

ISRCTN registry (ISRCTN27697878).

Physiologic Mechanisms of Type II Diabetes Mellitus Remission Following Bariatric Surgery: a Meta-analysis and Clinical Implications

INTRODUCTION

As obesity prevalence grows in the USA, metabolic syndrome is becoming increasingly more common. Current theories propose that insulin resistance is responsible for the hypertension, dyslipidemia, type II diabetes mellitus (T2DM), and low HDL that comprise metabolic syndrome. Bariatric surgery is one potential treatment, and its effects include permanently altering the patient's physiology and glucose regulation. Consequently, patients with T2DM who undergo bariatric surgery often experience tighter glucose control or remission of their T2DM altogether. This meta-analysis aims to explore the physiologic mechanisms underlying T2DM remission following bariatric surgery, which demonstrates effects that could lead to expansion of the NIH criteria for bariatric surgery candidates.

METHODS

A comprehensive search was conducted in PubMed and Scopus. Two independent reviewers conducted title, abstract, and full text review of papers that met inclusion criteria. Papers that measured hormone levels before and after bariatric surgery were included in the meta-analysis. Weighted means and standard deviations were calculated for preoperative and postoperative GLP-1, GIP, ghrelin, and glucagon.

RESULTS

Total postprandial GLP-1 increased following bariatric surgery, which correlated with improvements in measures of glycemic control. Fasting GLP-1, fasting GIP, total postprandial GIP, total fasting ghrelin, and fasting glucagon all decreased, but all changes in hormones evaluated failed to reach statistical significance. Studies also demonstrated changes in hepatic and peripancreatic fat, inflammatory markers, miRNA, and gut microbiota following bariatric surgery.

CONCLUSION

While this meta-analysis sheds light on possible mechanisms, further studies are necessary to determine the dominant mechanism underlying remission of T2DM following bariatric surgery.

Patients' experiences of life after bariatric surgery and follow-up care: a qualitative study

OBJECTIVES

Bariatric surgery is the most clinically effective treatment for people with severe and complex obesity, however, the psychosocial outcomes are less clear. Follow-up care after bariatric surgery is known to be important, but limited guidance exists on what this should entail, particularly related to psychological and social well-being. Patients' perspectives are valuable to inform the design of follow-up care. This study investigated patients' experiences of life after bariatric surgery including important aspects of follow-up care, in the long term.

DESIGN

A qualitative study using semistructured individual interviews. A constant comparative approach was used to code data and identify themes and overarching concepts.

SETTING

Bariatric surgery units of two publicly funded hospitals in the South of England.

PARTICIPANTS

Seventeen adults (10 women) who underwent a primary operation for obesity (mean time since surgery 3.11 years, range 4 months to 9 years), including Roux-en-Y gastric bypass, adjustable gastric band and sleeve gastrectomy, agreed to participate in the interviews.

RESULTS

Experiences of adapting to life following surgery were characterised by the concepts of 'normality' and 'ambivalence', while experiences of 'abandonment' and 'isolation' dominated participants' experiences of follow-up care. Patients highlighted the need for more flexible, longer-term follow-up care that addresses social and psychological difficulties postsurgery and integrates peer support.

CONCLUSIONS

This research highlights unmet patient need for more accessible and holistic follow-up care that addresses the long-term multidimensional impact of bariatric surgery. Future research should investigate effective and acceptable follow-up care packages for patients undergoing bariatric surgery.

Preoperative considerations for the pediatric patient undergoing metabolic and bariatric surgery

To ensure successful outcomes in pediatric patients with severe obesity who undergo metabolic and bariatric surgery (MBS), a number of pre-operative patient management options should be considered. This manuscript will review the indications and contraindications of MBS and special considerations for youth who might benefit from MBS. The treatment team conducts a thorough pre-operative evaluation, assessing risks and benefits of surgical intervention, and prepares patients and families to be successful with MBS by providing education about the surgical intervention and lifestyle changes that will be necessary. This article reviews the pre-operative considerations for adolescents with severe obesity who are being considered for MBS, based upon recent clinical practice guidelines.

Family Influences on Patients' Decisions to Undergo Bariatric Surgery

Bariatric surgery is the treatment of choice for many obese patients. Although bariatric surgery has recognized benefits, some patients wait several years before deciding to proceed and many patients rely on family member advice and support during the decision-making process. Using a secondary qualitative analysis of transcribed interviews, we examined family member influences on the patient's decision to undergo bariatric surgery. We identified four main themes: role modeling, quality of life with children, family and marital factors, and acquaintances' success with bariatric surgery. Participants indicated that being active with children and demonstrating healthier lifestyles was important, and that adult family members' perceptions of the surgery affect the decision. Because family member influences are evident in the decision-making process, perioperative nurses should be aware of the family's influence and include family members and significant others in the patient's decision-making process for bariatric surgery.