Bariatric Surgery versus Intensive Medical Therapy for Diabetes - 5-Year Outcomes

Diabetes Outcomes More than a Decade Following Sustained Weight Loss After Laparoscopic Adjustable Gastric Band Surgery

BACKGROUND

Long-term outcome data are needed to define the role of bariatric surgery in type 2 diabetes (T2D). To address this, we collated diabetes outcomes more than a decade after laparoscopic adjustable gastric band (LAGB) surgery.

METHOD

Clinical and biochemical measures from 113 obese T2D patients who underwent LAGB surgery in 2003 and 2004 were analyzed. Diabetes remission was defined as HbA1c < 6.2% (44 mmol/mol) and fasting glucose < 7.0 mmol/L.

RESULTS

Seventy-nine patients had weight data at 10 years and attained a median [Q1, Q3] weight loss of 16 [10, 21] percent. Sixty patients attended a follow-up assessment. Their baseline HbA1c of 7.8 [7.1, 9.3] percentage units (62 [54, 78] mmol/mol) had decreased to 6.6 [6.1, 8.4] (49 [43, 68] mmol/mol) despite no significant change in glucose-lowering therapy. Eleven patients (18%) were in diabetes remission and another 18 had HbA1c ≤ 6.5%. Significant improvements in physical measures of quality of life, blood pressure, and lipid profile were also observed but there was no change in the proportion of patients with albuminuria and a significant decline in estimated glomerular filtration rate. Twelve patients in the follow-up cohort (20%) required anti-reflux medication after surgery and 26 (43%) underwent gastric band revision surgery.

CONCLUSION

Weight loss for over 10 years after LAGB surgery delivers clinically meaningful improvements in HbA1c, blood pressure, lipids, and quality of life at the cost of a high rate of revision surgery and increased use of anti-reflux medication. These findings support the use of bariatric surgery as a long-term treatment for weight loss and wellbeing in patients with T2D.

STUDY REGISTRATION

Registered with the Australian Clinical trials registry as ACTRN12615000089538.

Bariatric surgery among patients with heart failure: a systematic review and meta-analysis

Background

Bariatric surgery reduces cardiovascular risk in obese patients. Heart failure (HF) is associated with an increased perioperative risk following bariatric surgery. This systematic review aimed to assemble the evidence on bariatric surgery in patients with known HF and the potential effect of bariatric surgery on incident HF in obese patients without prevalent HF.

Methods

We performed a comprehensive literature search up to 30 September 2017 and included studies comparing bariatric surgery to non-surgical treatment in patients with known presurgical HF. To assess whether bariatric surgery has any effect on incident HF, we also assembled studies looking at new-onset HF among patients without HF prior to surgery.

Results

We found five observational studies (0 randomised trials) comparing bariatric surgery with non-surgical treatment in patients with a diagnosis of HF prior to surgery. A review of the available studies (n=676 patients) suggested reduced admission rates for HF exacerbation and increased left ventricular ejection fraction after bariatric surgery. No meta-analysis was possible due to the heterogeneous nature of these studies. Seven studies (one randomised trial) reported data on new-onset HF in obese patients without HF prior to bariatric surgery (n=111 127 patients). When comparing surgical to non-surgical treatment groups, the pooled univariable and multivariable HRs for incident HF were 0.28 (95% CI 0.13 to 0.55) and 0.44 (95% CI 0.36 to 0.55), respectively.

Conclusion

In this systematic review, no randomised trial assessed the benefits and risks of bariatric surgery in obese patients with concomitant HF. Available studies do, however, show that surgery might prevent incident HF.

Comparative Effectiveness and Safety of Bariatric Procedures for Weight Loss: A PCORnet Cohort Study

BACKGROUND

There has been a dramatic shift in use of bariatric procedures, but little is known about their long-term comparative effectiveness.

OBJECTIVE

To compare weight loss and safety among bariatric procedures.

DESIGN

Retrospective observational cohort study, January 2005 to September 2015. (ClinicalTrials.gov: NCT02741674).

SETTING

41 health systems in the National Patient-Centered Clinical Research Network.

PARTICIPANTS

65 093 patients aged 20 to 79 years with body mass index (BMI) of 35 kg/m2 or greater who had bariatric procedures.

INTERVENTION

32 208 Roux-en-Y gastric bypass (RYGB), 29 693 sleeve gastrectomy (SG), and 3192 adjustable gastric banding (AGB) procedures.

MEASUREMENTS

Estimated percent total weight loss (TWL) at 1, 3, and 5 years; 30-day rates of major adverse events.

RESULTS

Total numbers of eligible patients with weight measures at 1, 3, and 5 years were 44 978 (84%), 20 783 (68%), and 7159 (69%), respectively. Thirty-day rates of major adverse events were 5.0% for RYGB, 2.6% for SG, and 2.9% for AGB. One-year mean TWLs were 31.2% (95% CI, 31.1% to 31.3%) for RYGB, 25.2% (CI, 25.1% to 25.4%) for SG, and 13.7% (CI, 13.3% to 14.0%) for AGB. At 1 year, RYGB patients lost 5.9 (CI, 5.8 to 6.1) percentage points more weight than SG patients and 17.7 (CI, 17.3 to 18.1) percentage points more than AGB patients, and SG patients lost 12.0 (CI, 11.6 to 12.5) percentage points more than AGB patients. Five-year mean TWLs were 25.5% (CI, 25.1% to 25.9%) for RYGB, 18.8% (CI, 18.0% to 19.6%) for SG, and 11.7% (CI, 10.2% to 13.1%) for AGB. Patients with diabetes, those with BMI less than 50 kg/m2, those aged 65 years or older, African American patients, and Hispanic patients lost less weight than patients without those characteristics.

LIMITATION

Potential unobserved confounding due to nonrandomized design; electronic health record databases had missing outcome data.

CONCLUSION

Adults lost more weight with RYGB than with SG or AGB at 1, 3, and 5 years; however, RYGB had the highest 30-day rate of major adverse events. Small subgroup differences in weight loss outcomes were observed.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.

Comorbidities as an Indication for Metabolic Surgery

Metabolic diseases, comprising type 2 diabetes mellitus (T2DM), dyslipidemia, and non-alcoholic steatohepatitis (NASH), are rapidly increasing worldwide. Conservative medical therapy, including the newly available drugs, has only limited effects and does neither influence survival or the development of micro- or macrovascular complications, nor the progression of NASH to liver cirrhosis, nor the development of hepatocellular carcinomas in the NASH liver. In contrast, metabolic surgery is very effective independent of the preoperative body mass index (BMI) in reducing overall and cardiovascular mortality in patients with T2DM. Furthermore, metabolic surgery significantly reduces the development of micro- and macrovascular complications while being the most effective therapy in order to achieve remission of T2DM and to reach the targeted glycemic control. Importantly, even existing diabetic complications such as nephropathy as well as the features of NASH can be reversed by metabolic surgery. Here, we propose indications for metabolic surgery due to T2DM and NASH based on a simple but objective, disease-specific staging system. We outline the use of the Edmonton Obesity Staging System (EOSS) as a clinical staging system independent of the BMI that will identify patients who will benefit the most from metabolic surgery.

Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication, and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.

Network meta-analysis of the relative efficacy of bariatric surgeries for diabetes remission

BACKGROUND

Bariatric surgery leads to a higher remission rate for type 2 diabetes mellitus than non-surgical treatment. However, it remains unsolved which surgical procedure is the most efficacious. This network meta-analysis aimed to rank surgical procedures in terms of diabetes remission.

METHODS AND FINDINGS

We electronically searched for randomized controlled trials in which at least one surgical treatment was included among multiple arms and the diabetes remission rate was included in study outcomes. A random-effects network meta-analysis was performed within a frequentist framework. The hierarchy of treatments was expressed as the surface under the cumulative ranking curve value. Results of the analysis of 25 eligible randomized controlled trials that covered non-surgical treatments and eight surgical procedures (biliopancreatic diversion [BPD], BPD with duodenal switch, Roux-en Y gastric bypass, mini gastric bypass [mini-GBP], laparoscopic adjustable gastric banding, laparoscopic sleeve gastrectomy, greater curvature plication and duodenal-jejunal bypass) showed that BPD and mini-GBP had the highest surface under the cumulative ranking curve values among the eight surgical treatments.

CONCLUSION

Current network meta-analysis indicated that BPD or mini-GBP achieved higher diabetes remission rates than the other procedures. However, the result needs to be interpreted with caution considering that these procedures were in the minority of bariatric surgeries.

Comparative Outcomes of Bariatric Surgery in Patients With and Without Human Immunodeficiency Virus

BACKGROUND

Paradoxically, advances in anti-retroviral therapy that has increased survival for patients with human immunodeficiency virus (HIV) have resulted in greater numbers of HIV+ patients developing other chronic diseases, including obesity. Little comparative literature exists detailing perioperative or metabolic outcomes of bariatric surgery in the HIV+ population compared to HIV negative (HIV-) controls.

METHODS

This is a retrospective case-control study with both HIV+ (case) and HIV- control patients. Individuals undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between January 1, 2006 and December 31, 2015 were included. HIV+ status was defined as any individual with documented history of HIV.

RESULTS

Eleven HIV+ patients underwent RYGB or SG during the study period. After matching (1:5 HIV+: HIV-) both cohorts had similar mean age (42 years), gender distribution (63% female), and preoperative BMI (48 kg/m2), as well as comorbidities. There were no differences in postoperative length of stay, or all cause 30-day morbidity. There were 63.7% HIV+ and 76.4% with 1-year follow-up available. Both percent excess weight loss (56% HIV+ vs. 60% HIV-) and BMI (32 HIV+ vs. 34 kg/m2 HIV-) were similar in both groups. There were minimal changes to CD4 count or HIV viral load in the patients during the follow-up period.

CONCLUSION

Bariatric surgery is safe and feasible in HIV-infected population well controlled on anti-retroviral medication. The short-term surgical and metabolic outcomes are similar to HIV- controls with minimal effect on the CD4 count and viral load in HIV+ cohort for long-term follow-up.

Ten Years After Bariatric Surgery: Bad Quality of Life Promotes the Need of Psychological Interventions

Background: This study aims to evaluate long-term quality of life (QoL) and primary clinical outcomes, 10 years after biliointestinal bypass (BIB) surgery. It was expected that, although BIB might show encouraging primary outcomes, long term QoL could be significantly impaired. Methods: Ninety patients were contacted for a phone interview [age 41.0 ± 10.6 (mean ± SD) years, age-range 31-65 years]. QoL (by SF-36) and the clinical situation (by ad hoc questionnaire) were collected. Data were analyzed with SPSS 22. SF-36 scores were compared with Italian normative data from general and healthy population. We also compared primary clinical outcomes and SF-36 scores between patients who reported high and low levels of satisfaction with BIB. Results: Considering SF-36 results, patients showed significant impairments in QoL compared to general and healthy populations. Sixty-five percent would repeat the BIB. All patients showed at least one chronic adverse event. It occurred a significant decrease in pre-post co-occurrence rates of diabetes (χ2 = 18.41; p < 0.001) and hypertension (χ2 = 50.27; p < 0.001). Large and significant weight loss indexes (i.e., percent excess weight loss (%EWL); body mass index) were observed between pre-post intervention. Conclusion: BIB showed promising primary clinical outcomes (i.e., hypertension, diabetes, and weight loss). However, subjects reported a significant impairment in all SF-36 domains. Ad hoc psychological interventions should be implemented to ameliorate the quality of life of these patients.

Reoperative surgery for nonresponders and complicated sleeve gastrectomy operations in patients with severe obesity. An international expert panel consensus statement to define best practice guidelines

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) has rapidly become the most commonly performed bariatric procedure in the United States as well as other countries, with approximately 120,000 procedures being performed annually in the United States. Reoperative interventions after SG have become more prevalent in the past few years since the initial development of SG as a primary operation. Given the expected rapid growth of these reinterventions, an expert consensus conference was held with some of the most experienced bariatric surgeons in the world to better understand, discuss, and provide consensus on the reasons, indications, contraindications, and surgical options for nonresponders and complicated SG operations.

OBJECTIVES

Provide consensus-based best practice guidelines regarding the performance of reinterventions after failed or complicated SG in patients with obesity, using expert opinion by organizing a consensus meeting of experts and evaluating the current literature.

SETTING

The meeting was held in Boca Raton, Florida on February 18, 2017.

METHODS

The panel of 32 expert bariatric surgeons representing 12 countries and major regions of the world and all 6 populated continents identified 54 questions for consensus. Questions encompassed patient selection, indications, contraindications, surgical technique, prevention and management of weight regain, and short- and long-term complications after SG. Responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement). The current available literature was extensively reviewed for each topic in question and proposed to the panel.

RESULTS

Full consensus was obtained for the essential aspects of indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 35 of 54 key questions. Highlights include consensus recommendations regarding technique in reoperation, management of GERD and Barrett's esophagus after SG, and surgical options for poor initial weight loss. No consensus was reached on topics, such as management of chronic proximal fistula after SG.

CONCLUSIONS

This first international expert meeting provides 35 statements and recommendations for a clinical consensus guideline regarding standardization of indications, contraindications, surgical options, and surgical techniques when reoperating on patients who underwent a failed or complicated SG. To our knowledge, the present consensus report represents the first document that defines best practice guidelines for the performance of reinterventions after failed or complicated SG.

Impact of Ileal Transposition Surgical Intervention on Antioxidant Status Measured in Liver Tissue of Obese Zucker Rats (Crl:ZUC-Leprfa)

Background

The main factor characteristic for low-grade systemic inflammation typical for obesity is oxidative stress (OS). Reactive oxygen species (ROS) production is higher and more increased in time in the obese patients than in lean subjects.

Aims

To assess the effect of ileal transposition (IT) and sham types of bariatric procedures on the antioxidative systems in the liver tissue of Zucker rats (Crl:ZUC Lepr^fa).

Method

21 animals were divided into the experimental groups: control group (n = 7), sham group (n = 7), and IT group (n = 7). Sham and IT animals underwent selected surgery. The concentration of total antioxidant capacity (TAC), total antioxidant status (TOS), and activity of glutathione reductase (glutathione-disulfide reductase, GR, GSR), catalase (CAT), glutathione peroxidase (GPx), glutathione S-transferase (GST), and total superoxide dismutase activity (SOD) were assessed in liver tissue 3 months after surgery.

Results

IT procedure significantly increased TAC when compared to sham and the control group. Animals after IT showed higher levels of TOS when compared to sham procedure. The total amount of TOS was similar in IT and control groups. GPx activity was increased in the groups submitted to the sham and IT surgery in relation to control. GR and CAT activities were significantly higher after IT in comparison to control and sham procedures. Total SOD and MnSOD were significantly higher in sham-operated animals in comparison to IT intervention and control groups.

Conclusions

IT procedure had a positive impact on the diminishing of oxidative stress measured by TAC and TOS markers. The dynamic, adaptive, and protective mechanisms of enzymatic antioxidant systems were observed after the IT but not sham procedure. Nevertheless, 3 months after surgery, the midterm effect of bariatric surgery was observed, which might not fully balance the antioxidative response.

High Incidence of Secondary Hyperparathyroidism in Bariatric Patients: Comparing Different Procedures

BACKGROUND

Bariatric surgery is an effective therapy for morbid obesity but may reduce calcium absorption and significantly decrease the bone mineral density. This study examined the prevalence of secondary hyperparathyroidism (SHPT) in obese subjects during follow-up after different bariatric surgeries. We investigated predictors of SHPT.

METHODS

We enrolled 1470 obese subjects undergoing bariatric/metabolic surgery with at least 1-year follow-up, including 322 patients undergoing Roux-en-Y gastric bypass (RYGB), 695 undergoing single anastomosis (mini-) gastric bypass (SAGB), 93 undergoing laparoscopic adjustable gastric banding (LAGB), and 360 undergoing sleeve gastrectomy (SG). Five years of data were available for 215 patients. Patients were instructed to supplement their diet according to the guideline. Calcium, parathyroid hormone (PTH), and vitamin D levels were measured before surgery and at 1 and 5 years after surgery. SHPT was defined as PTH > 69 pg/mL.

RESULTS

The overall prevalence of SHPT was high, 21.0% before surgery and was not different between patients with different bariatric procedures. Pre-operative PTH correlated with age, BMI, and vitamin D levels. Multi-variate analysis confirmed that vitamin D level was the only independent predictor of SHPT before surgery. The prevalence of SHPT increased to 35.4% at 1 year after surgery and 63.3% at 5 years after surgery. SAGB had the highest prevalence of SHPT (50.6%) followed by RYGB (33.2%), LAGB (25.8%), and SG (17.8%) at 1 year after surgery. At 5 years after surgery, SAGB still had the highest prevalence of SHPT (73.6%), followed by RYGB (56.6%), LAGB (38.5%), and SG (41.7%). Serum PTH at 1 year after surgery correlated with decreased BMI and weight loss. Multi-variate analysis confirmed that age, sex, calcium level, and bypass procedure were independent predictor of SHPT after surgery.

CONCLUSIONS

The prevalence of SHPT is high in morbidly obese patients before bariatric surgery which is related to vitamin D deficiency. The prevalence of SHPT increased continually along with the time after bariatric surgery, especially in patients receiving SAGB, followed by RYGB. The supplementation of vitamin D and calcium have to be higher in bypass procedure, especially in malabsorptive procedure.

Effect of Surgical Weight Loss on Plantar Fasciitis and Health-Care Use

BACKGROUND:

Plantar fasciitis (PF) is one of the most common causes of heel pain. Obesity is recognized as a major factor in PF development, possibly due to increased mechanical loading of the foot due to excess weight. The benefit of bariatric surgery is documented for other comorbidities but not for PF.

METHODS:

A retrospective medical record review was performed for patients with PF identified from a prospectively maintained database of the Cleveland Clinic Bariatric and Metabolic Institute. Age, sex, surgery, excess weight loss, body mass index (BMI), and health-care use related to PF treatment were abstracted. Comparative analyses were stratified by surgery type.

RESULTS:

Two hundred twenty-eight of 10,305 patients (2.2%) had a documented diagnosis of PF, of whom 163 underwent bariatric surgery and were included in the analysis. Eighty-five percent of patients were women, mean ± SD age was 52.2 ± 9.9 years, and mean ± SD preintervention BMI was 45 ± 7.7. Postoperatively, mean ± SD BMI and excess weight loss were 34.8 ± 7.8 and 51.0% ± 20.4%, respectively. One hundred forty-six patients (90%) achieved resolution of PF and related symptoms. The mean ± SD number of treatment modalities used for PF per patient preoperatively was 1.9 ± 1.0 ( P = .25). After surgery, the mean ± SD number of treatment modalities used per patient was reduced to 0.3 ± 0.1 ( P = .01).

CONCLUSIONS:

We present new evidence suggesting that reductions in BMI after bariatric surgery may be associated with decreasing the number of visits for PF and may contribute to symptomatic improvement.

Nutrition Care in Bariatric Surgery: An Academy Evidence Analysis Center Systematic Review

Obesity continues to be a major public health crisis, both nationally and globally. Metabolic and bariatric surgery has been proven to be a safe and effective treatment for this multifactorial chronic disease. However, inconsistent and varied results in bariatric nutrition literature have prevented the implementation of standardized guidelines. The purpose of this Evidence Analysis Library systematic review is to provide an evidence-based summary of nutrition-related practices in bariatric surgery. The systematic review methodology of the Academy of Nutrition and Dietetics was applied. A total of 27 research studies were included, analyzed, and assessed for risk of bias by trained evidence analysts. The literature included in the systematic review was published from 2003 to 2015. Evaluation of the literature resulted in the development of five graded conclusion statements. Limited research demonstrates that registered dietitian nutritionists play a role in improving weight loss outcomes after bariatric surgery; further research is needed to understand the role of registered dietitian nutritionists in changing behaviors after bariatric surgery. Bariatric surgery results in significant reductions in resting metabolic rate and postoperative energy intake. There is no significant relationship between macronutrient distribution and postoperative weight loss. The graded conclusion statements provide registered dietitian nutritionists who practice in the field of bariatric nutrition with more insight and evidence that can guide and support their recommendations.

Preventive Nephrology: The Role of Obesity in Different Stages of Chronic Kidney Disease

BACKGROUND

Obesity is increasing worldwide and has become a nontraditional risk factor in chronic kidney disease (CKD).

SUMMARY

Obesity-related nephropathy may aggravate renal complications of the metabolic syndrome and progress to advanced CKD stages, while obesity in early stages of CKD is clearly related to the development of kidney disease. A high body mass index (BMI) in advanced CKD stages and dialysis is an advantage for survival (so called "obesity paradox"). A high lean body to fat mass index indicates a beneficial state of body composition. In contrast, loss of muscle mass with increasing fat mass causes "sarcopenia obesity," which is related to unfavorable outcomes in renal replacement therapy. Obesity (BMI > 30-35) in renal transplant recipients is associated with a higher risk of complications such as delayed graft function, increased rates of rejection, and graft loss. While conservative management of morbid obesity is failing in most cases, bariatric surgery seems to be an option in some cases to improve renal complications in the early stage of CKD or in transplant candidates.

KEY MESSAGE

In conclusion, obesity is increasingly prevalent among CKD patients. Adequate management with respect to the specific role of obesity in different stages of CKD should be integrated in routine renal care.

Exercise and Bariatric Surgery: An Effective Therapeutic Strategy

Exercise is a clinically effective adjunct therapy with the potential to promote long-term weight loss maintenance for bariatric surgery patients.

The long-term efficacy of bariatric surgery is not entirely clear, and weight regain and diabetes relapse are problems for some patients. Exercise is a feasible and clinically effective adjunct therapy for bariatric surgery patients. We hypothesize that exercise is also a critical factor for long-term weight loss maintenance and lasting remission of type 2 diabetes.

30-day outcomes of robot-assisted versus conventional laparoscopic sleeve gastrectomy: First analysis based on MBSAQIP

BACKGROUND

Sleeve gastrectomy (SG) is the most popular bariatric procedure in the United States. Although standardized, variation exists in how the staple line is managed. Robotic approaches to SG (RSG) are increasing, though benefits compared with the conventional laparoscopic approach (LSG) remain controversial.

OBJECTIVE

Evaluate the safety of RSG versus LSG using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry, controlling for variation in staple-line management.

SETTING

University health network, United States.

METHODS

SG cases from January 1 to December 31, 2016, in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program data registry were included. Demographic characteristics and 30-day outcomes were analyzed with separate Mann-Whitney rank sums tests, χ² tests, or Fisher's exact tests, with P < .05 denoting statistical significance. Multivariate regression analysis was performed to control for method of staple-line treatment.

RESULTS

Of the 107,726 patients who underwent SG, 7385 were RSG. Treatment of the staple line was associated with a significantly lower rate of bleeding, with odds ratios of .69 and .58 for staple-line reinforcement alone and staple-line reinforcement plus oversewing, respectively. Multivariate analysis revealed RSG had a higher rate of organ space infection than LSG (odds ratio 2.07). Otherwise, RSG did not significantly differ from LSG save for a longer median operative time (89 versus 63 min, respectively, P < .0001).

CONCLUSIONS

RSG is a growing alternative to the conventional laparoscopic approach. According to the 2016 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, the RSG carries a higher risk of organ space infection. The reasons behind this finding require further study.

Bariatric surgery in patients with interstitial lung disease

BACKGROUND

Perioperative pulmonary complications are frequent in patients with interstitial lung diseases (ILD). Limited literature exists regarding the safety of bariatric procedures in patients with ILD. This study aims to assess the safety, feasibility, and outcomes of patients with ILD who underwent bariatric surgery at our institution.

METHODS

After IRB approval, all patients with preoperative diagnosis of ILD who had bariatric surgery at an academic center between 2004 and 2014 were retrospectively reviewed.

RESULTS

A total of 25 patients with ILD underwent bariatric surgery: Roux-en-Y gastric bypass (n = 17, 68%), sleeve gastrectomy (n = 7, 28%), and adjustable gastric banding (n = 1, 4%). Twenty-one patients (84%) were females. The median age and preoperative body mass index (BMI) were 53 (IQR 42-58) years and 39 (IQR 37-44) kg/m², respectively. The median operative time and length of stay was 137 (IQR 110-187) min and 3 (IQR 2-5) days, respectively. The 30-day complications were reported in four patients (16%) but there was no pulmonary complication or unplanned admission to the intensive care unit. At 1-year follow-up (85%), the median BMI and excess weight loss were 30 (IQR 25-36) kg/m² and 67% (IQR 45-100), respectively. Compared to preoperative values, there was significant improvement in the pulmonary function test (PFT) variables at 1 year with respect to forced vital capacity (62% vs 74%; n = 13, p = 0.003), and diffusing capacity of the lungs for carbon monoxide (53% vs 66%; n = 10, p = 0.003). Six out of the seven potential lung transplant candidates became eligible for transplantation after weight loss, and one of them had successful lung transplant at 88 months after bariatric surgery.

CONCLUSION

In our experience, bariatric patients with ILD achieved significant weight loss and improvement in PFT. Bariatric surgery in these higher risk ILD patients appears relatively safe with acceptable perioperative morbidity and improved candidacy for lung transplantation.

Attenuation of diet-induced hypothalamic inflammation following bariatric surgery in female mice

Background

Exposure of rodents to chronic high-fat diet (HFD) results in upregulation of inflammatory markers and proliferation of microglia within the mediobasal hypothalamus. Such hypothalamic inflammation is associated with metabolic dysfunction, central leptin resistance, and maintenance of obesity. Bariatric surgeries result in long-term stable weight loss and improved metabolic function. However, the effects of such surgical procedures on HFD-induced hypothalamic inflammation are unknown. We sought to characterize the effects of two bariatric surgical procedures, Roux-en-Y gastric bypass (RYGB) and biliary diversion (BD-IL), in female mice with particular emphasis on HFD-induced hypothalamic inflammation and microgliosis.

Methods

RYGB and BD-IL were performed on diet-induced obese (DIO) mice. Quantitative RT-PCR and fluorescent microscopy were used to evaluate hypothalamic inflammatory gene expression and microgliosis. Results were compared to lean (CD), DIO sham-surgerized mice (DIO-SHAM), and dietary weight loss (DIO-Rev) controls.

Results

In female mice, RYGB and BD-IL result in normalization of hypothalamic inflammatory gene expression and microgliosis within 8 weeks of surgery, despite ongoing exposure to HFD. Paralleling these results, the hypothalamic expression levels of the orexigenic neuropeptide Agrp and the anorexic response of surgical mice to exogenous leptin were comparable to lean controls (CD). In contrast, results from DIO-Rev mice were comparable to DIO-SHAM mice, despite transition back to standard rodent show and normalization of weight.

Conclusion

Bariatric surgery attenuates HFD-induced hypothalamic inflammation and microgliosis and restores leptin sensitivity, despite ongoing exposure to HFD.

Multicentre cohort study of antihypertensive and lipid-lowering therapy cessation after bariatric surgery

Background

Few studies have assessed changes in antihypertensive and lipid-lowering therapy after bariatric surgery. The aim of this study was to assess the 6-year rates of continuation, discontinuation or initiation of antihypertensive and lipid-lowering therapy after bariatric surgery compared with those in a matched control group of obese patients.

Methods

This nationwide observational population-based cohort study used data extracted from the French national health insurance database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009 were matched with control patients. Mixed-effect logistic regression models were used to analyse factors that influenced discontinuation or initiation of treatment over a 6-year interval.

Results

In 2009, 8199 patients underwent primary gastric bypass (55·2 per cent) or sleeve gastrectomy (44·8 per cent). After 6 years, the proportion of patients receiving antihypertensive and lipid-lowering therapy had decreased more in the bariatric group than in the control group (antihypertensives: –40·7 versus –11·7 per cent respectively; lipid-lowering therapy: –53·6 versus –20·2 per cent; both P &lt; 0·001). Gastric bypass was the main predictive factor for discontinuation of therapy for hypertension (odds ratio (OR) 9·07, 95 per cent c.i. 7·72 to 10·65) and hyperlipidaemia (OR 11·91, 9·65 to 14·71). The proportion of patients not receiving treatment at baseline who were subsequently started on medication was lower after bariatric surgery than in controls for hypertension (5·6 versus 15·8 per cent respectively; P &lt; 0·001) and hyperlipidaemia (2·2 versus 9·1 per cent; P &lt; 0·001). Gastric bypass was the main protective factor for antihypertensives (OR 0·22, 0·18 to 0·26) and lipid-lowering medication (OR 0·12, 0·09 to 0·15).

Conclusion

Bariatric surgery is associated with a good discontinuation of antihypertensive and lipid-lowering therapy, with gastric bypass being more effective than sleeve gastrectomy.

Obesity and type 2 diabetes: Also linked in therapeutic options

The prevalence of obesity has increased worldwide over the past decades. Obesity is associated with multiple comorbidities, such as type 2 diabetes, that generates a great impact on health and economy. Weight loss in these patients leads to glycemic control so it is a target to achieve. Lifestyle changes are not effective enough and recently other treatments have been developed such as bariatric/metabolic surgery, as well as drugs for type 2 diabetes and antiobesity drugs. The aim of this review is to compare the results in weight reduction and glycemic control of the different kinds of drugs with bariatric / metabolic surgery's results in type 2 diabetes.

Laparoscopic sleeve gastrectomy versus Roux-en-Y gastric bypass in cardiovascular risk reduction: A match control study

BACKGROUND

There is a paucity of studies comparing risk reduction of the atherosclerotic cardiovascular disease (ASCVD) and Framingham-body mass index (BMI) Coronary Heart risk score after a laparoscopic Roux-en-Y gastric bypass (RYGB), and few studies have assessed the efficacy of laparoscopic sleeve gastrectomy (SG) in reducing cardiovascular risk.

OBJECTIVE

Our goal in this study was to compare the impact of SG and RYGB on cardiovascular risk reduction.

SETTING

U.S. university hospital.

METHODS

We retrospectively reviewed the records of all SG or RYGB cases at our institution between 2010 and 2015. Patients who met the criteria for calculating the ASCVD 10-year and Framingham-BMI score were included in the study. Propensity score matching was used to match SG and RYGB on demographic characteristics and co-morbidities.

RESULTS

Of the 1330 bariatric patients reviewed in the study period, 219 (19.3%) patients met the criteria for risk score calculation. SG was the most prevalent surgery in 72.6% (N = 159) of cases compared with RYGB in 27.4% (N = 60) of cases. At 12-month follow-up, ASCVD 10-year score had an absolute risk reduction of 3.9 ± 6.5% in SG patients and 2.9 ± 5.8% in RYGB patients (P = .3). Framingham-BMI score absolute risk reduction was 11.0 ± 12.0% in SG and 9.0 ± 11.0% in RYGB patients (P = .4), and the decrease in estimated heart age was 12.1 ± 15.6 years in SG versus 9.2 ± 9.6 years in RYGB (P = .1). The percentage of estimated BMI loss at 1 year was 68.1 ± 23.3% in SG versus 74.2 ± 24.8% in RYGB (P = .1).

CONCLUSION

Our results suggest that SG and RYGB are equally effective in improving cardiovascular risk and decreasing the estimated vascular/heart age at 12-month follow-up.

Long-term Relapse of Type 2 Diabetes After Roux-en-Y Gastric Bypass: Prediction and Clinical Relevance

OBJECTIVE

Roux-en-Y gastric bypass (RYGB) induces type 2 diabetes remission (DR) in 60% of patients at 1 year, yet long-term relapse occurs in half of these patients. Scoring methods to predict DR outcomes 1 year after surgery that include only baseline parameters cannot accurately predict 5-year DR (5y-DR). We aimed to develop a new score to better predict 5y-DR.

RESEARCH DESIGN AND METHODS

We retrospectively included 175 RYGB patients with type 2 diabetes with 5-year follow-up. Using machine learning algorithms, we developed a scoring method, 5-year Advanced-Diabetes Remission (5y-Ad-DiaRem), predicting longer-term DR postsurgery by integrating medical history, bioclinical data, and antidiabetic treatments. The scoring method was based on odds ratios and variables significantly different between groups. This score was further validated in three independent RYGB cohorts from three European countries.

RESULTS

Compared with 5y-DR patients, patients who had relapsed after 5 years exhibited more severe type 2 diabetes at baseline, lost significantly less weight during the 1st year after RYGB, and regained more weight afterward. The 5y-Ad-DiaRem includes baseline (diabetes duration, number of antidiabetic treatments, and HbA_1c) and 1-year follow-up parameters (glycemia, number of antidiabetic treatments, remission status, 1st-year weight loss). The 5y-Ad-DiaRem was accurate (area under the receiver operating characteristic curve [AUROC], 90%; accuracy, 85%) at predicting 5y-DR, performed better than the Diabetes Remission score (DiaRem) and the Advanced-DiaRem (AUROC, 81% and 84%; accuracy, 79% and 78%, respectively), and correctly reclassified 13 of 39 patients misclassified with the DiaRem. The 5y-Ad-DiaRem robustness was confirmed in the independent cohorts.

CONCLUSIONS

The 5y-Ad-DiaRem accurately predicts 5y-DR and appears relevant to identify patients at risk for relapse. Using this score could help personalize patient care after the 1st year post-RYGB to maximize weight loss, limit weight regains, and prevent relapse.

An update on research examining the implications of stigma for access to and utilization of bariatric surgery

PURPOSE OF REVIEW

To summarize recent literature examining the relationship between stigma and utilization of surgical treatments for obesity.

RECENT FINDINGS

The stigma of obesity and stigma associated with surgical treatments for obesity can affect both healthcare providers' recommendations of these options and patients' likelihood of considering and choosing these treatments. Presurgical requirements of healthcare and insurance organizations and a lack of postsurgical support reflect the stigmatizing attitudes that bariatric/metabolic surgery is an 'easy fix' and 'last resort' for patients too undisciplined to lose weight in other ways.

SUMMARY

Here we review the literature published in the last year that addresses the implications of stigma for the utilization and outcomes of surgical treatments for obesity.

Gut adaptation after metabolic surgery and its influences on the brain, liver and cancer

Metabolic surgery is the best treatment for long-term weight loss maintenance and comorbidity control. Metabolic operations were originally intended to change anatomy to alter behaviour, but we now understand that the anatomical changes can modulate physiology to change behaviour. They are no longer considered only mechanically restrictive and/or malabsorptive procedures; rather, they are considered metabolic procedures involving complex physiological changes, whereby gut adaptation influences signalling pathways in several other organs, including the liver and the brain, regulating hunger, satiation, satiety, body weight, glucose metabolism and immune functions. The integrative physiology of gut adaptation after these operations consists of a complex mechanistic web of communication between gut hormones, bile acids, gut microbiota, the brain and both enteric and central nervous systems. The understanding of nutrient sensing via enteroendocrine cells, the enteric nervous system, hypothalamic peptides and adipose tissue and of the role of inflammation has advanced our knowledge of this integrative physiology. In this Review, we focus on the adaptation of gut physiology to the anatomical alterations from Roux-en-Y gastric bypass and vertical sleeve gastrectomy and the influence of these procedures on food intake, weight loss, nonalcoholic fatty liver disease (NAFLD) and cancer. We also aim to demonstrate the underlying mechanisms that could explain how metabolic surgery could be used as a therapeutic option in NAFLD and certain obesity-related cancers.

Publication patterns and the impact of self-citation among minimally invasive surgery fellowships

INTRODUCTION

The h-index is a widely utilized academic metric that measures both productivity and citation impact. The purpose of this study is to define the impact of self-citation among minimally invasive surgery (MIS) fellowship program directors.

METHODS

Through the Fellowship Council's website, all program directors and associate program directors from the 148 MIS fellowship programs were identified. Using the Scopus database, we calculated the number of publications, citations, self-citations, and h-index for each surgeon.

RESULTS

A total of 274 surgeons were identified. The mean number±SD of publications, citations, and h-index for the cohort were 60.5 ± 77.2, 1765 ± 4024, and 16.0 ± 15.0, respectively. The self-citation rate for the entire cohort was 3.23%. Excluding self-citations reduces the mean number of citations to 1708 ± 3887 and h-index to 15.8 ± 14.6. The h-index remained unchanged for 77% (210/274) of surgeons. Only 5% (15/274) of surgeons had a change in h-index of greater than one integer and no surgeon had a change greater than three integers.

CONCLUSION

Self-citation is infrequent and has a minimal impact on the academic profile of program directors of MIS fellowships.

Small Bowel Endoscopic Bariatric Therapies

Endoscopic bariatric therapies that emulate some of the principles of bariatric surgery have been developed as a less invasive option for the treatment of obesity and related comorbidities. Small bowel endoscopic bariatric therapies include bypass sleeves, incisionless anastomosis systems, and duodenal mucosal resurfacing. Clinical experience with small bowel devices suggests that endoscopic bariatric procedures can be safely implemented and that these devices are effective for both weight loss and metabolic improvement. Although the mechanisms behind these effects should be further elucidated, endoscopic bariatric therapies may be more effective and safer adjunctive interventions than lifestyle modifications and pharmacological regimens for patients with obesity or obesity-related comorbidities.

Metabolic Surgery as a Treatment Option for Type 2 Diabetes Mellitus: Surgical View

PURPOSE OF REVIEW

Type 2 diabetes mellitus (T2DM) is increasing in prevalence and associated with numerous metabolic complications leading to increased mortality and costs. Metabolic surgery, or surgery to treat T2DM and obesity, is effective at achieving remission from T2DM. This review discusses the most commonly used surgical options including the adjustable gastric band, the Roux-en-Y gastric bypass, the sleeve gastrectomy, and the biliopancreatic diversion with duodenal switch and their ability to treat and prevent T2DM.

RECENT FINDINGS

There is an increasing body of literature that justifies the inclusion of metabolic surgery into the treatment algorithm for patients with obesity and T2DM. Metabolic procedures should be performed at centers that offer comprehensive treatment of metabolic disorders and have expertise in gastrointestinal surgery. The incremental improvement in the quality and safety of metabolic surgery has significantly reduced the risk of serious post-operative complications. Metabolic surgery is a safe and effective treatment option for obese patients with T2DM.

Healthy Weight and Obesity Prevention: JACC Health Promotion Series

Overweight and obesity have reached epidemic levels in the United States and worldwide, and this has contributed to substantial cardiovascular and other health risks. However, controversy exists concerning the causes of obesity and effective modalities for its prevention and treatment. There is also controversy related to the concept of metabolically healthy obesity phenotype, the "obesity paradox," and on the importance of fitness to protect individuals who are overweight or obese from cardiovascular diseases. In this state-of-the-art review, the authors focus on "healthy weight" with the emphasis on the pathophysiologic effects of weight gain on the cardiovascular system; mechanistic/triggering factors; and the role of preventive actions through personal, education/environment, and societal/authoritative factors, as well as factors to provide guidance for caregivers of health promotion. Additionally, the authors briefly review metabolically healthy obesity, the obesity paradox, and issues beyond lifestyle consideration for weight loss with medications and bariatric surgery.

Ileal interposition coupled with duodenal diverted sleeve gastrectomy versus standard medical treatment in type 2 diabetes mellitus obese patients: long-term results of a case-control study

BACKGROUND

Randomized controlled trials have demonstrated that bariatric surgery is effective in obtaining remission of type 2 diabetes mellitus (T2DM) in obese patients, yet no data exist in the literature from prospective studies with ileal interposition with duodenal diversion sleeve gastrectomy (II-DD-SG). The aim of this case-control study is to investigate if II-DD-SG is superior to medical treatment in T2DM obese patients.

METHODS

Thirty obese patients (BMI > 30) affected by T2DM were recruited for surgery (II-DD-SG) between 2008 and 2011 and were matched with an equal control group which received standard medical treatment. Anthropometric measures, glucose metabolism, cardiovascular risk factors were determined baseline and during follow-up. The primary end point was T2DM remission; reduction of body weight, BMI, and cardiovascular risk factors were secondary end-points.

RESULTS

Shortly after II-DD-SG, normalization of glucose plasma levels and glycated hemoglobin was observed followed by a significant decrease in body weight and BMI. At one-year follow-up, insulin resistance strongly declined as did insulin plasma levels. Complete remission was observed in 26 patients (86%); 2 (6.6%) had partial remission, and two (6.6%) were still diabetic. After 5 years, 17 of 25 patients on follow-up (68%) showed complete remission of T2DM and 56% had remission of cardiovascular risk factors. Only two patients receiving medical treatment showed complete remission of T2DM (p < 0.0001 versus II-DD-SG). No significant changes of anthropometric parameters and lipid metabolism were recorded.

CONCLUSIONS

II-DD-SG is an effective surgical procedure, able to induce complete and prolonged remission of T2DM in obese patients as opposed to medical treatment.

Laparoscopic Roux-en-Y gastric bypass is as safe as laparoscopic sleeve gastrectomy. Results of a comparative cohort study

Background

A meta-analysis and six randomized controlled trials show higher 30-day complication rates with laparoscopic Roux-en-Y gastric bypass (LRYGB) than with laparoscopic sleeve gastrectomy (LSG).

Aim

To identify any difference in 30-day outcomes of patients treated with LRYGB or LSG when a standardized technique and identical post-operative protocol was followed with all procedures being conducted either by or under the supervision of a single consultant surgeon who had significant experience in bariatric surgery prior to commencing independent practice.

Methods

A prospectively collected database of all patients under primary LRYGB or LSG, between March 2010 and February 2017, was analyzed. Data on demographics, length-of-stay (LOS), conversion to open, 30-day complications and mortality were reviewed.

Results

Over a seven-year period, 485 patients (LRYGB-279 and LSG-206) were included. There were no significant demographic differences and no difference in the pre-operative risk scoring [American Society of Anesthesiologists (ASA) and obesity surgery mortality risk score (OSMRS)] between the groups. There was no significant difference between the groups in terms of LOS (p = 0.275), complications (p = 0.920), re-admissions (p = 0.593) or re-operations (p = 0.366) within 30-days. There were no conversions to open or in-patient mortality in either group.

Conclusions

Unlike previous studies, we found no difference in early complication rates between LRYGB and LSG in a comparable cohort when performed by a surgeon with sufficient experience in bariatric surgery.

•

Low complication rates with both procedures.

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Most complications were minor (Clavien-Dindo ≤ IIIa).

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LRYGB is as safe as SG in the early post-operative period when performed by a surgeon with adequate experience.

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Bariatric fellowships play an important role in ensuring optimal outcomes.

Metabolic surgery ameliorates cardiovascular risk in obese diabetic patients: Influence of different surgical procedures

BACKGROUND

In recent years, bariatric surgery was found to have therapeutic potential for the treatment of type 2 diabetes (T2D) in severely obese patients (body mass index [BMI] ≥35 kg/m²) and to reduce cardiovascular disease (CVD) risk and mortality. However, the benefit of CVD risk reduction after metabolic surgery in nonseverely obese T2D patients (BMI <35 kg/m²) remained to be proven.

OBJECTIVE

To evaluate the CVD risk after metabolic surgery in T2D patients using The UK Prospective Diabetes Study score.

SETTING

Tertiary referral general hospital, Taiwan, Republic of China.

METHODS

Outcomes of 392 patients (235 women and 147 men) who had undergone sleeve gastrectomy (87) or gastric bypass (305) for treatment of T2D with 1-year follow-up were assessed. Data were prospectively collected for study, and cerebral and coronary heart disease risk was calculated by using The UK Prospective Diabetes Study risk engine. Outcomes of patients who had undergone different surgical procedures were assessed.

RESULTS

One year after surgery, weight and glycemic control with complete and partial remission of T2D were significant in most of the patients. The 10-year coronary heart disease risk and fatal coronary heart disease risk were also reduced from 8.8% to 4.6% and from 4.6% to 2.1%, respectively (both P < .001). Similar CVD risk reduction was seen in both patients with BMI ≥35 and BMI <35. Multivariable analysis confirmed that surgical procedure of sleeve gastrectomy was a negative independent predictor of CVD risk reduction after metabolic surgery.

CONCLUSION

The present study confirms the efficacy of metabolic surgery for the T2D treatment and reduction of CVD risk up to 50% 1 year after surgery. Gastric bypass surgery has more power on CVD risk reduction than sleeve gastrectomy.

Weight-Independent Mechanisms of Glucose Control After Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass results in large and sustained weight loss and resolution of type 2 diabetes in 60% of cases at 1-2 years. In addition to calorie restriction and weight loss, various gastro-intestinal mediated mechanisms, independent of weight loss, also contribute to glucose control. The anatomical re-arrangement of the small intestine after gastric bypass results in accelerated nutrient transit, enhances the release of post-prandial gut hormones incretins and of insulin, alters the metabolism and the entero-hepatic cycle of bile acids, modifies intestinal glucose uptake and metabolism, and alters the composition and function of the microbiome. The amelioration of beta cell function after gastric bypass in individuals with type 2 diabetes requires enteric stimulation. However, beta cell function in response to intravenous glucose stimulus remains severely impaired, even in individuals in full clinical diabetes remission. The permanent impairment of the beta cell may explain diabetes relapse years after surgery.

Predictors of glycemic control after sleeve gastrectomy versus Roux-en-Y gastric bypass: A meta-analysis, meta-regression, and systematic review

Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most commonly performed bariatric procedures globally. However, it remains controversial which procedure provides better glycemic control. To identify predictors of glycemic control after SG versus RYGB, a systematic search of PubMed, EMBASE, and the Cochrane Library was conducted up to January 2017 for comparative studies with both SG and RYGB arms for the treatment of type 2 diabetes (T2D). A meta-analysis and systematic review was performed to evaluate glycemic control after SG versus RYGB with both short- and long-term follow-up. A meta-regression was performed to evaluate impacts of clinical indicators on glycemic control after SG versus RYGB. A total of 17 comparative studies involving 1160 patients were included. SG and RYGB achieved similar diabetic remission rates with both short- and long-term follow-up. However, SG provided lower endpoint glycosylated hemoglobin (A1C) after 1-year follow-up (mean deviation = .17, 95% confidence interval .03-.31, P = .02). When adjusted by baseline A1C, SG and RYGB provided similar percent delta A1C with 1-, 2-, 3-, and 5-year follow-up. The baseline body mass index, duration of T2D, preoperative fasting plasma glucose, and preoperative A1C had predictive value for glycemic control after SG, but only duration of T2D and preoperative A1C were correlated with that after RYGB. These findings showed that the choice of procedure between SG and RYGB predicts no better glycemic control. However, more factors should be considered when SG is recommended to a given patient with diabetes.