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

Impact of Mental Health Background and Nutrition Intake on Medium-Term Weight Loss in Japanese Patients Undergoing Laparoscopic Sleeve Gastrectomy

OBJECTIVES

Bariatric surgery is the most effective weight loss therapy, and recently laparoscopic sleeve gastrectomy (LSG) is gaining popularity worldwide. On the other hand, patients undergoing bariatric surgery have a high prevalence of mental disorders. A Japanese nationwide survey reported high prevalence of mental disorders in patients with low percent total weight loss (%TWL) and also in those with high %TWL. The aim of this study was to investigate the relationship of 1-year %TWL with background mental health status, 3-year outcomes, and nutrition intake in Japanese patients after LSG.

METHODS

This study was a single-center retrospective database analysis. A total of 89 Japanese patients who underwent LSG and were followed for 3 years were enrolled (mean age 41.9 years, baseline body mass index 44.9, baseline glycosylated hemoglobin, HbA1c, 7.0%). The patients were divided into 3 groups according to 1-year %TWL as follows: ≤19.9% (insufficient group), 20.0-34.9% (average group) and ≥35.0% (excessive group). Psychosocial and nutritional status as well as physical data were collected from all patients.

RESULTS

The prevalence of mental disorders was 51.7%, and 1-year %TWL was 28.1% in all patients. No significant differences were observed in the changes in body weight and HbA1c between patients with and those without mental disorders. The prevalence of mental disorders was particularly high in the insufficient and excessive groups. In the insufficient group, mood disorders and mental retardation/developmental disorders were frequent, and snacking and eating out habits were often observed. In the excessive group, the frequencies of mood disorders and binge eating were high, and a decrease in skeletal muscle mass due to low protein intake was observed. Furthermore, weight regain was shown 12 months after LSG in both groups. In the average group, there were fewer problems in weight loss outcomes, mental health, nutrition intake and body composition.

CONCLUSIONS

Psychosocial and nutritional problems were often found not only in patients with insufficient weight loss, but also in those with seemingly "excellent" weight reduction. To improve long-term weight loss outcome and future health, a multidisciplinary approach focusing on mental health and nutrition is essential for patients undergoing bariatric surgery.

Minimally Invasive Sleeve Gastrectomy as a Surgical Treatment for Nonalcoholic Fatty Liver Disease in Liver Transplant Recipients

BACKGROUND

Obesity is a major public health burden that affects the transplant community because of its key role in fatty liver disease and transplantation outcomes.

OBJECTIVES

To evaluate the role of sleeve gastrectomy in treating recurrent and de novo nonalcoholic fatty liver disease (NAFLD) in liver transplant recipients.

SETTING

A university hospital.

METHODS

We describe 2 obese liver transplant recipients with recurrent and de novo NAFLD who underwent minimally invasive metabolic and bariatric surgery.

RESULTS

The surgery was performed successfully, with much of the operative time consumed by enterolysis. There were no intraoperative or postoperative complications. At last follow-up appointment (16 months postoperatively), there was a mean reduction in weight (31.98 kg), body mass index (10.2 kg/m²), glycosylated hemoglobin (1.05%), alanine aminotransferase (38 IU/L), steatosis score (0.34), and fibrosis score (0.05). The mean decrease in 6-month postoperative hepatic fat quantification was 6%.

CONCLUSIONS

These cases show that metabolic and bariatric surgery in obese, posttransplant recipients with recurrent and de novo nonalcoholic steatohepatitis lead to improved steatosis and reduced obesity and obesity-associated comorbidities.

Interplay between the Adaptive Immune System and Insulin Resistance in Weight Loss Induced by Bariatric Surgery

Low-grade chronic inflammation plays a pivotal role among other pathophysiological mechanisms involved in obesity. Innate and adaptive immune cells undergo systemic proinflammatory polarization that gives rise to an increased secretion of proinflammatory cytokines, which in turn leads to insulin resistance. Bariatric surgery is currently the most effective treatment for obesity, as it brings on significant weight loss, glucose metabolism improvement, and a decrease in systemic inflammation biomarkers. After bariatric surgery, several changes have been reported to occur in adaptive immunity, including reduction in CD4+ and CD8+ T cell counts, a decrease in the Th1/Th2 ratio, an increase in B regulatory cells, and reduction in proinflammatory cytokine secretion. Overall, there seems to be a major shift in several lymphocyte populations from a proinflammatory to an anti-inflammatory phenotype. Furthermore, increased antioxidant activity and reduced lipid and DNA oxidation products have been reported after bariatric surgery in circulating mononuclear cells. This paper highlights the shift in the adaptive immune system in response to weight loss and improved insulin sensitivity, as well as the interplay between immunological and metabolic adaptations as a result of bariatric surgery. Finally, based on data from research, we propose several mechanisms such as changes in adaptive immune cell phenotypes and their by-products, recruitment in adipose tissue, reduced oxidative stress, and modification in metabolic substrate availability as drivers to reduce low-grade chronic inflammation after bariatric surgery in severe obesity.

Using the preoperative psychological evaluation to determine psychosocial risk factors for CPAP nonadherence among bariatric surgery candidates

BACKGROUND

Obstructive sleep apnea (OSA) is prevalent among bariatric surgery candidates and is associated with numerous adverse health conditions, both pre- and postoperatively. Continuous positive airway pressure therapy (CPAP) is the first-line treatment for OSA, but it requires significant behavioral changes. As such, CPAP adherence is a significant problem in OSA treatment. Information from the preoperative psychological evaluation may be used to identify psychosocial risk factors associated with CPAP nonadherence and inform the implementation of more specific and appropriate interventions.

OBJECTIVES

Examine the utility of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) behavioral/externalizing dysfunction scale scores to determine personality and psychopathology associations with, and risk for, CPAP nonadherence.

SETTING

Academic medical center.

METHODS

Patients who underwent a preoperative psychological evaluation and were diagnosed with OSA (n = 358) were divided into 2 groups: CPAP adherent (n = 271) and CPAP nonadherent (n = 87). Independent samples t tests were computed to examine differences in average MMPI-2-RF scale scores between these groups. Relative risk ratios were computed using multiple MMPI-2-RF substantive scale score cut-offs to determine which MMPI-2-RF scales were associated with increased risk of CPAP nonadherence.

RESULTS

Higher scores on scales measuring behavioral/externalizing dysfunction and family problems were associated with and indicative of risk for CPAP nonadherence.

CONCLUSIONS

CPAP nonadherence is related to and may be affected by generally higher levels of behavioral/externalizing dysfunction. Using a broadband measure of personality and psychopathology, like the MMPI-2-RF, during the preoperative evaluation can provide important information about co-morbid symptoms that may interfere with CPAP adherence. Considering this information during preoperative treatment planning could increase the likelihood of preoperative CPAP adherence and reduce the likelihood of adverse postoperative outcomes.

Very-low-calorie ketogenic diet (VLCKD) in the management of metabolic diseases: systematic review and consensus statement from the Italian Society of Endocrinology (SIE)

BACKGROUND

Weight loss is a milestone in the prevention of chronic diseases associated with high morbility and mortality in industrialized countries. Very-low calorie ketogenic diets (VLCKDs) are increasingly used in clinical practice for weight loss and management of obesity-related comorbidities. Despite evidence on the clinical benefits of VLCKDs is rapidly emerging, some concern still exists about their potential risks and their use in the long-term, due to paucity of clinical studies. Notably, there is an important lack of guidelines on this topic, and the use and implementation of VLCKDs occurs vastly in the absence of clear evidence-based indications.

PURPOSE

We describe here the biochemistry, benefits and risks of VLCKDs, and provide recommendations on the correct use of this therapeutic approach for weight loss and management of metabolic diseases at different stages of life.

Systematic review of management of gallbladder disease in patients undergoing minimally invasive bariatric surgery

The introduction and subsequent widespread adaptation of minimally invasive approaches for bariatric surgery have not only changed the outcomes of bariatric surgery but also called into question the management of co-morbid surgical conditions, in particular gallbladder disease. The American Society for Metabolic and Bariatric Surgery Foregut Committee performed a systematic review of the published literature from 1995-2018 on management of gallbladder disease in patients undergoing bariatric surgery. The papers reviewed generated the following results. (1) Routine prophylactic cholecystectomy at the time of bariatric surgery is not recommended. (2) In symptomatic patients who are undergoing bariatric surgery, concomitant cholecystectomy is acceptable and safe. (3) Ursodeoxycholic acid may be considered for gallstone formation prophylaxis during the period of rapid weight loss. (4) Routine preoperative screening and postoperative surveillance ultrasound is not recommended in asymptomatic patients. In the era of minimally invasive surgery, the management of gallbladder disease in patients undergoing bariatric surgery continues to evolve.

Increase in Physical Activity After Bariatric Surgery Demonstrates Improvement in Weight Loss and Cardiorespiratory Fitness

Background

Low cardiorespiratory fitness is strongly associated with cardiovascular diseases and mortality. Although increased physical activity can improve cardiorespiratory fitness, this relationship has not been examined in a large bariatric population undergoing perioperative care focusing on long-term lifestyle change.

Objectives

To evaluate changes in physical activity, weight loss, and cardiorespiratory fitness up to 24 months after bariatric surgery, and to evaluate the relationships of change in physical activity with weight loss and change in cardiorespiratory fitness.

Materials and Methods

Four thousand seven hundred eighty-five patients who underwent primary Roux-en-Y gastric bypass or sleeve gastrectomy between January 2012 and December 2014 were included. Physical activity was assessed by the Baecke questionnaire (work, leisure, and sport activity) and cardiorespiratory fitness, defined as VO₂max relative to fat-free mass (VO₂max/FFM), was assessed by the Åstrand test.

Results

Twenty-four months postoperative, significant improvements were seen in sport and leisure activity assessments (n = 3548, P < 0.001), weight loss (n = 3695, P < 0.001), and VO₂max/FFM (n = 1852, P < 0.001). Furthermore, regression analysis showed that change in leisure activity was positively associated with weight loss (n = 3535, ß = 1.352, P < 0.001) and change in sport activity was positively associated with change in VO₂max/FFM (n = 1743, ß = 1.730, P < 0.001).

Conclusion

Bariatric surgery complemented by a comprehensive bariatric care program can lead to improvement in physical activity, as well as weight loss and improvement in cardiorespiratory fitness. The positive associations of change in leisure activity with weight loss and change in sport activity with cardiorespiratory fitness suggest that bariatric care programs can enhance postoperative outcomes by improving the patient’s physical activity.

The feasibility of a behavioral group intervention after weight-loss surgery: A randomized pilot trial

Background

Formal psychosocial support programs after weight-loss surgery are limited in scope and availability.

Objective

This randomized pilot study evaluated the feasibility of a postoperative behavioral intervention program.

Materials and methods

Postoperative weight-loss surgery patients (N = 50) were recruited from February 2017–July 2017 and randomized to a four-month behavioral program or usual care wait-list. Outcomes evaluated in addition to feasibility included health-related quality of life (Short Form -36), psychosocial functioning and adherence. Secondary outcomes included within-group changes for each outcome.

Results

Out of eight possible sessions, intervention participants attended a mean of 4.2 sessions. Intervention group participants experienced greater improvements in the social functioning domain of health-related quality of life compared to usual care. Self-reported dietary adherence in the intervention group remained stable, while usual care group dietary adherence declined. Within the intervention group, participants also reported gains in the physical function, pain and general health aspects of quality life from baseline to post-treatment. No differences in weight, mood or other eating behaviors (e.g., loss of control, emotional eating) were evident between groups.

Conclusion

Though participation in a postoperative behavioral intervention varied, the program helped participants to maintain aspects of quality of life and self-reported adherence to dietary recommendations.

Trial registration

ClinicalTrials.gov NCT03092479

The Effect of the Bariatric Surgery Type on the Levothyroxine Dose of Morbidly Obese Hypothyroid Patients

BACKGROUND

Doubts exist about the effect of different bariatric surgery (BS) types on levothyroxine (Lt4) absorption. We compared Lt4 doses and their variation (ΔLt4) in patients with hypothyroidism that underwent malabsorptive (MS) or restrictive (RS) surgery and studied predictors of Lt4 dose change.

METHODS

Retrospective study of morbidly obese hypothyroid patients submitted to BS. We compared RS ("sleeve" gastrectomy or adjustable gastric banding) with MS (Roux-en-Y gastric bypass) patients. We built a multivariable logistic regression and a linear regression model to study predictors of Lt4 dose changes and ΔLt4, respectively.

RESULTS

Fifty-seven patients: 35 MS and 22 RS. Mean age 47 years; 7% men. Patients submitted to MS had lower BMI at 1 year than those submitted to RS. Lt4 dose remained unchanged in 61.4%, increased in 12.3%, and decreased in 26.3% of patients. Initial and 1-year Lt4 dose were not different between surgical groups. Relative Lt4 dose, but not absolute (p = 0.07), increased at 1 year (p < 0.001). Neither BS nor BMI variation were predictors of Lt4 dose variation. BMI variation was associated with relative Lt4 dose change independently of initial BMI and BS type: β (95%CI) - 0.03 (- 0.05; 0.00); p = 0.03.

CONCLUSIONS

There were no differences in Lt4 dose and its variation between restrictive and malabsorptive techniques 1 year after surgery. Malabsorptive procedures may not affect Lt4 absorption differently from restrictive ones. Bariatric surgery type was not predictive of Lt4 dose changes. BMI variation is associated with relative Lt4 dose (dose per weight) variation and its association was independent of bariatric surgery type.

The Efficacy of Energy-Restricted Diets in Achieving Preoperative Weight Loss for Bariatric Patients: a Systematic Review

In bariatric practice, a preoperative weight loss of at least 5% is recommended. However, the hypocaloric diets prescribed vary and no consensus exists. This study examined the efficacy of preoperative diets in achieving 5% weight loss. From a systematic literature search, eight randomised controlled trials (n = 862) were identified. Half of the trials used a "very-low-calorie diet" whilst the rest employed a "low-calorie diet". Only five diets achieved ≥ 5% weight loss over varying durations and energy intakes. By inference, compliance with a 700-1050 kcal (2929-4393 kJ) diet, consisting of moderate carbohydrate, high protein and low/moderate fat, for 3 weeks is likely to achieve 5% weight loss. A low-carbohydrate diet (< 20 g/day) may achieve this target within a shorter duration. Additional research is required to validate these conclusions.

Is weight regain after bariatric surgery associated with psychiatric comorbidity? A systematic review and meta-analysis

Bariatric surgery has been recognized as the gold standard treatment for severe obesity. Although postbariatric surgery patients usually achieve and maintain substantial weight loss, a group of individuals may exhibit weight regain. Several factors are proposed to weight regain, including psychiatric comorbidity. The objective of the study is to conduct a systematic review and meta-analysis of studies investigating the relationship between psychiatric comorbidity and weight regain. A systematic review through PubMed, Web of Science, Cochrane Library, Scopus, and PsycINFO was performed, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). After a stepwise selection, 13 articles were included in the qualitative analysis and 5 were included for a meta-analysis. Women was majority in most of the studies (87.6%), and a bypass procedure was the bariatric intervention most evaluated (66.8%), followed by gastric banding (32.1%) and sleeve (1.1%). Higher rates of postbariatric surgery eating psychopathology were reported in patients with weight regain. However, the association between general psychopathology and weight regain was not consistent across the studies. In the meta-analysis, the odds of eating psychopathology in the weight regain group was higher compared with the nonweight regain group (OR = 2.2, 95% CI 1.54-3.15). Postbariatric surgery eating psychopathology seems to play an important role in weight regain.

Long-term adverse events after sleeve gastrectomy or gastric bypass: a 7-year nationwide, observational, population-based, cohort study

BACKGROUND

Concerns are rising about the late adverse events following gastric bypass and sleeve gastrectomy. We aimed to assess, over a 7-year period, the late adverse events after gastric bypass and sleeve gastrectomy compared with matched control groups.

METHODS

In this nationwide, observational, population-based, cohort study, we used data extracted from the French National Health Insurance (Système National des Données de Santé) database. All patients undergoing gastric bypass or sleeve gastrectomy in France in 2009, except those who had undergone bariatric surgery in the previous 4 years before inclusion, were matched with control patients with obesity in terms of age, sex, BMI category, baseline antidiabetic therapy, and baseline insulin therapy. Exclusion criteria for the control group included cancer, pregnancy, chronic infectious disease, serious acute or chronic disease in 2008-09, or previous (2005-09) or forthcoming (2010-11) bariatric surgery. The incidence rate was calculated for each type of adverse event leading to inpatient hospital admission over a 7-year period; incidence rate ratios (with 95% CIs) were computed to compare the rate of complications among the bariatric surgery and control groups. Risks of complications during follow-up were compared using Cox proportional-hazards regression analyses. Data were analysed according to the intention-to-treat methodology.

FINDINGS

From Jan 1, 2009, to Dec 31, 2009, 8966 patients who underwent bariatric surgery (7359 [82%] women; mean age 40·4 years [SD 11·3]) and 8966 matched controls (7359 [82%] women; mean age 40·9 years [11·4]) were included in analyses 4955 (55%) off 8966 patients in the bariatric surgery group had a primary gastric bypass and 4011 (45%) patients had sleeve gastrectomy. With a mean follow-up of 6·8 years (SD 0·2), mortality was lower in the gastric bypass group than in its control group (hazard ratio 0·64 [95% CI 0·52-0·78]; p<0·0001) and in the sleeve gastrectomy group than in its control group (0·38 [0·29-0·50]; p<0·0001). The gastric bypass and sleeve gastrectomy groups had higher risk than did their control groups for invasive gastrointestinal surgery or endoscopy (incidence rate ratio 2·4 [95% CI 2·1-2·7], p<0·0001, for gastric bypass vs control and 1·5 [1·3-1·7], p<0·0001, for sleeve gastrectomy vs control); for gastrointestinal disorders not leading to invasive procedures (1·9 [1·7-2·1]), p<0·0001, for gastric bypass vs control and 1·2 [1·1-1·4], p<0·0001, for sleeve gastrectomy vs control); and for nutritional disorders (4·9 [3·8-6·4], p<0·0001, for gastric bypass vs control and 1·8 [1·3-2·5], p<0·0001, for sleeve gastrectomy vs control). For psychiatric disorders, there was no significant association (1·1 [0·9-1·4], p=0·190, for gastric bypass vs control and 1·1 [0·8-1·3], p=0·645, for sleeve gastrectomy vs control), except for gastric bypass and alcohol dependence (1·8 [1·1-2·8], p=0·0124).

INTERPRETATION

Despite lower 7-year mortality, patients undergoing gastric bypass or sleeve gastrectomy had higher risk of hospital admission at least once for late adverse events, except for psychiatric disorders, than did control patients, with a higher risk observed after gastric bypass than with sleeve gastrectomy.

FUNDING

None.

Associations Between Romantic Relationship Factors and Body Mass Index Among Weight Loss Surgery Patients

The current study utilized a sample of 183 patients, in romantic relationships, who were either pre- or post-weight loss surgery (WLS), to assess (a) associations between romantic relationship factors and pre- and post-surgery body mass index (BMI), (b) the positive and negative influences of obesity in romantic relationships, and (c) the influence of romantic relationship factors on BMI and the reciprocal. Correlations, confirmatory factor analysis, and multiple linear regression were conducted. Patients endorsed greater negative influence of obesity in their romantic relationships compared to positive influences, and their romantic relationship quality was predicted by several variables, including BMI, in pre- and post-surgery patient groups.

Prevalence of Micronutrient Deficiencies Prior to Bariatric Surgery: Tehran Obesity Treatment Study (TOTS)

BACKGROUND

Micronutrient deficiencies are major concerns after bariatric surgery, although these conditions often go undiagnosed pre-surgery.

OBJECTIVE

To assess pre-surgery micronutrient status of an Iranian population of morbidly obese candidates of bariatric surgery in a cross-sectional study.

METHODS

A cross-sectional analysis of 2008 candidates for bariatric surgery, aged 15-65 years, with either body mass index (BMI) ≥ 40 kg/m² or 30 < BMI < 35 kg/m² with a medical comorbidity was conducted. In order to determine the micronutrient status of participants, blood samples were collected to assess serum concentrations of vitamins (B12 and D), minerals (copper, calcium, phosphate, and zinc), and iron profiles (total iron binding capacity, iron concentration, ferritin, and iron saturation), according to standard protocol.

RESULTS

The mean age and BMI of patients (79.3% female) were 37.8 years and 44.8 kg/m², respectively. Deficiencies were found for 25(OH) D (53.6%), vitamin B12 (34.4%), serum iron (10.2%), and low levels of hemoglobin (16.6%). The prevalence of other deficiencies were all below 10%. Body mass index had a negative correlation with iron, calcium, vitamin B12, and 25(OH) D and was positively correlated with copper.

CONCLUSION

Micronutrient deficiencies, including vitamin D, vitamin B12, and iron, are commonly found among morbidly obese subjects who are potential candidates of bariatric surgery.

Obesity Surgery and the Treatment of Metabolic Diseases

BACKGROUND

3.9% of men and 5.2% of women in Germany suffer from second-degree obesity (body mass index [BMI] ≥ 35 to <40 kg/m2), and 6.5 million persons suffer from diabetes. Obesity surgery has become established as a further treatment option alongside lifestyle changes and pharmacotherapy.

METHODS

The guideline was created by a multidisciplinary panel of experts on the basis of publications retrieved by a systematic literature search. It was subjected to a formal consensus process and tested in public consultation.

RESULTS

The therapeutic aims of surgery for obesity and/or metabolic disease are to improve the quality of life and to prolong life by countering the life-shortening effect of obesity and its comorbidities. These interventions are superior to conservative treatments and are indicated when optimal non-surgical multimodal treatment has been tried without benefit, in patients with BMI ≥ 40 kg/m², or else in patients with BMI ≥ 35 kg/m² who also have one or more of the accompanying illnesses that are associated with obesity. A primary indication without any prior trial of conservative treatment exists if the patient has a BMI ≥ 50 kg/m², if conservative treatment is considered unlikely to help, or if especially severe comorbidities and sequelae of obesity are present that make any delay of surgical treatment inadvisable. Metabolic surgery for type 2 diabetes is indicated (with varying recommendation grades) for patients with BMI ≥ 30 kg/m², and as a primary indication for patients with BMI ≥ 40 kg/m². The currently established standard operations are gastric banding, sleeve gastrectomy, proximal Roux-en-Y gastric bypass, omega-loop gastric bypass, and biliopancreatic diversion.

CONCLUSION

No single standard technique can be recommended in all cases. In the presence of an appropriate indication, the various surgical treatment options for obesity and/or metabolic disease should be discussed with the patient.

Serum Parathyroid Hormone and 25-Hydroxyvitamin D Concentrations Before and After Biliopancreatic Diversion

BACKGROUND

Biliopancreatic diversion with duodenal switch (BPD-DS) decreases vitamin D and calcium absorption, which may result in secondary hyperparathyroidism. This study aimed at evaluating the prevalence of vitamin D deficiency and secondary hyperparathyroidism before and after BPD-DS.

METHODS

A retrospective analysis of patients who had undergone BPD-DS at a tertiary bariatric center between 2003 and 2010 and for whom simultaneous measurements of serum 25-hydroxyvitamin D and parathyroid hormone were available within 5 years post-op was performed. The prevalence of vitamin D deficiency (< 20 ng/ml) and secondary hyperparathyroidism (> 65 pg/mL) at different time points was calculated.

RESULTS

Included were 1436 patients (mean ± SD, age 42.7 ± 10.4 years; BMI 51.5 ± 8.6 kg/m²; 69.8% women). Prevalence of vitamin D deficiency decreased up to 6-12 months after surgery (from 35.8% at baseline down to 6-9%) then rose progressively, plateauing at 15.5% after 36 months. Prevalence of hyperparathyroidism was 28.5% before surgery and rose progressively after surgery, reaching 68.6% at 5 years. Mean serum corrected calcium increased from 0 to 6 months then decreased up to 36 months. Preoperatively, the prevalence of hypocalcemia was 7.3%. It increased after 12 months, attaining 26.9% at 48 months.

CONCLUSIONS

Prevalence of vitamin D deficiency and secondary hyperparathyroidism is high before BPD-DS. Despite a low prevalence of vitamin D deficiency after surgery, prevalence of hyperparathyroidism increased steadily 1 year after surgery, preceded by a decrease in serum calcium. Factors explaining the high prevalence of secondary hyperparathyroidism after BPD-DS and its long-term impact on bone health should be addressed.

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

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

Presurgical Psychological Evaluation: Risk Factor Identification and Mitigation

Presurgical psychological evaluations (PPEs) are becoming an established component of the surgical process, though methods of conducting PPEs are variable. There is a lack of clarity about the goals of PPEs, the types of information that should be included, and the process for integrating information and making recommendations to the referring physicians/surgeons. This review proposes an empirically supported model for PPEs that is systematic, but flexible enough to be utilized across the broad range of surgical evaluations. This five-step method is termed the Risk Identification and Mitigation (RIM) model and is discussed in detail. The RIM model presented in this review can both serve as a structure to be utilized in under-researched PPE areas and as a stimulus for future empirical investigations.

Early gastric cancer successfully treated by endoscopic submucosal resection 1 year after laparoscopic sleeve gastrectomy with duodenal-jejunal bypass

This case involved a 64-year-old female patient with a BMI of 35.3 kg/m² and poorly controlled type 2 diabetes mellitus. Preoperative upper gastrointestinal endoscopy revealed chronic, atrophic gastritis. Helicobacter pylori antibody was negative. The patient underwent laparoscopic sleeve gastrectomy with duodenal-jejunal bypass as a metabolic surgery to treat obesity and type 2 diabetes mellitus. At 1 year postoperatively, routine endoscopy detected a flat elevated lesion at the distal gastric sleeve, near the posterior wall of the antrum; biopsy revealed adenocarcinoma. Endoscopic submucosal resection was performed without complication. This case shows the advantage of laparoscopic sleeve gastrectomy with duodenal-jejunal bypass in screening the excluded stomach as compared to laparoscopic Roux-en-Y gastric bypass. Therefore, laparoscopic sleeve gastrectomy with duodenal-jejunal bypass can be a viable alternative to laparoscopic Roux-en-Y gastric bypass for regions where gastric cancer is endemic.

Severe obesity and vitamin D deficiency treatment options before bariatric surgery: a randomized clinical trial

BACKGROUND

Obesity, which has various complications and co-morbidities, is an epidemic issue worldwide. Vitamin D deficiency (VDD) is a well-known metabolic disorder among patients with severe obesity. While they are good candidates for bariatric surgery, this deficiency can affect the outcome of surgery negatively.

OBJECTIVES

The aim of this study was to compare 3 different VDD treatment strategies for use before bariatric surgery and compare serum vitamin D levels after 7 weeks.

SETTINGS

University hospital, Isfahan, Iran.

METHODS

This was a single-blinded, randomized clinical trial on 100 patients who were referred for bariatric surgery from 2016 to 2018. Vitamin D (VitD) level was checked before surgery for the patients included in the study, if their VitD level was <30 ng/mL. We rechecked their serum VitD in the 8^th week, after 7 weeks of treatment. The participants were randomly allocated into 3 groups: 33 patients were treated with 50,000 units VitD₃ capsules every week for 7 weeks; 33 patients were treated with a single dose of 300,000 units VitD₃ ampoule; and 34 patients were treated with a combination of a half of the injection dose, followed by the oral capsule for 4 weeks.

RESULTS

No case was lost during the follow-up time. No significant differences were found among the 3 groups in terms of their age (P = .654), body mass index (P = .434), sex (P = .799), initial 25(OH) VitD level (P = .273), and history of supplement use (P = .45). Mean serum VitD levels were 15.21, 13.16, and 13.37 ng/mL, respectively, before the surgery and reached 32.91, 24.74, and 29.49 ng/mL after 7 weeks of treatment in oral, injection, and combined groups, respectively. Finally, the 7-week oral treatment option had significantly higher levels of VitD (P value = .034).

CONCLUSION

VDD treatment with 50,000 units VitD₃ capsule every week for 7 weeks before bariatric surgery yields a higher level of VitD. Based on our findings, injectable supplements are not recommended for VDD treatment.

BARIATRIC SURGERY AND BINGE EATING DISORDER: SHOULD SURGEONS CARE ABOUT IT? A LITERATURE REVIEW OF PREVALENCE AND ASSESSMENT TOOLS

BACKGROUND

Eating pathologies among bariatric surgery candidates are common and associated with adverse surgical outcomes, including weight regain and low quality of life. However, their assessment is made difficult by the great variety and inconsistent use of standardized measures.

OBJECTIVE

The purpose of this review was to synthesize current knowledge on the prevalence of binge eating disorder (BED) in presurgical patients and to make a critical appraisal of assessment tools for BED.

METHODS

A search was conducted on PubMed, Scopus, and Web of Science databases from January 1994 to March 2017. Data were extracted, tabulated and summarized using a narrative approach.

RESULTS

A total of 21 observational studies were reviewed for data extraction and analysis. Prevalence of BED in bariatric populations ranged from 2% to 53%. Considerable variation in patient characteristics and in BED assessment measures was evident among the studies. In addition, several methodological weaknesses were recognized in most of the studies. Ten different psychometric instruments were used to assess BED. Clinical interviews were used in only 12 studies, though this is the preferred tool to diagnose BED.

CONCLUSION

Study heterogeneity accounted for the variability of the results from different centers and methodological flaws such as insufficient sample size and selection bias impaired the evidence on the magnitude of BED in surgical settings. For the sake of comparability and generalizability of the findings in future studies, researchers must recruit representative samples of treatment-seeking candidates for bariatric surgery and systematically apply standard instruments for the assessment of BED.

Evaluation of the association of bariatric surgery with subsequent depression

BACKGROUND/OBJECTIVES

Bariatric surgery is helpful in enabling sustained weight loss, but effects on depression are unclear. Reductions in depression-related symptoms and increases in suicide rate have both been observed after bariatric surgery, but these observations are confounded by the presence of pre-existing depression. The goal of this study is to evaluate the effect of bariatric surgery on subsequent depression diagnosis.

SUBJECTS/METHODS

In this observational study, a prospective cohort study was simulated by evaluating depression risk based on diagnostic codes. An administrative database was utilized for this study, containing records and observations between 1 January 2008 through 29 February 2016 of enrolled patients in the United States. Individuals considered in this analysis were enrolled in a commercial health insurance program, observed for at least 6 months prior to surgery, and met the eligibility criteria for bariatric surgery. In all, 777,140 individuals were considered in total.

RESULTS

Bariatric surgery was found to be significantly associated with subsequent depression relative to both non-surgery controls (HR = 1.31, 95% CI, 1.27-1.34, P < 2e-32) and non-bariatric abdominal surgery controls (HR = 2.15, 95% CI, 2.09-2.22, P < 2e-32). Patients with pre-surgical psychiatric screening had a reduced depression hazard ratio with respect to patients without (HR = 0.85, 95% CI, 0.81-0.89, P = 3.208e-12). Men were found to be more susceptible to post-bariatric surgery depression compared with women. Pre-surgical psychiatric evaluations reduced the magnitude of this effect. Relative to bariatric surgeries as a whole, vertical sleeve gastrectomy had a lower incidence of depression, while Roux-en Y Gastric Bypass and revision/removal surgeries had higher rates.

CONCLUSIONS

In individuals without a history of depression, bariatric surgery is associated with subsequent diagnosis of depression. This study provides guidance for patients considering bariatric surgery and their clinicians in terms of evaluating potential risks and benefits of surgery.

Comparison of early type 2 diabetes improvement after gastric bypass and sleeve gastrectomy: medication cessation at discharge predicts 1-year outcomes

BACKGROUND

Although weight loss-dependent type 2 diabetes (T2D) improvement after sleeve gastrectomy (SG) is well documented, whether SG has a weight-independent impact on T2D is less studied.

OBJECTIVES

To evaluate early, weight-independent T2D improvement after SG and Roux-en-Y gastric bypass (RYGB) and its relationship to longer-term T2D outcomes.

SETTING

University Hospital, United States.

METHODS

We completed a retrospective cohort study of patients with T2D who underwent SG (n = 187) or RYGB (n = 246) from 2010 to 2015. Pre- and postoperative parameters, including demographic characteristics, T2D characteristics, and T2D medication requirements, blood glucose, glycosylated hemoglobin, weight, and body mass index, were reviewed.

RESULTS

T2D improved within days after both SG and RYGB, with more patients off T2D medications after SG than RYGB (39% versus 25%, respectively; P < .01) at the time of discharge (2.5 ± .8 versus 2.7 ± 1 d; P = .04). Over the initial postoperative 12 months, T2D medication cessation rates remained relatively stable after SG but continued to improve after RYGB (at 12 mo: 52% versus 68%, respectively; P < .05). T2D medication cessation at discharge predicts 12-month T2D medication cessation (92% [RYGB] and 78% [SG] positive predictive value). In a mixed-effects regression model adjusting for weight loss and severity of diabetes, discharge T2D medication cessation remained a significant predictor of T2D outcomes after both RYGB (odds ratio, 51; 95% confidence interval, 16.1-161; P < .0001) and SG (6.4; 95% confidence interval, 2.8-14.7; P < .0001).

CONCLUSIONS

Both SG and RYGB lead to high rates of T2D medication cessation within days of surgery, suggesting both operations activate weight loss-independent anti-T2D pathways. T2D medication cessation at discharge is predictive of 12-month T2D outcomes, particularly in noninsulin requiring patients. By 1 year after the surgery, RYGB leads to more weight loss and higher rates of T2D medication cessation than SG.

Patient perceptions of primary care providers' knowledge of bariatric surgery

As the rate of obesity continues to rise, primary care providers (PCPs) must be aware and informed of the treatment options available. Bariatric surgery is the most effective long-term treatment for weight loss and improvement of obesity-related comorbidities. The aim of this study was to assess patients' perception of their PCP's opinion, support and knowledge of bariatric surgery and changes over time. In 2009 and 2015, a 27-question survey was developed and mailed to patients who had undergone laparoscopic Roux-en-Y gastric bypass (LRYGB) at our institution. Statistical analysis included chi-square and Fisher's exact test for associations between categorical variables, Wilcoxon rank sum test for comparison of ordinal or continuous variables and sign test for comparison of paired ordinal variables. There were 680 and 1106 patients who met inclusion criteria and were mailed the 2009 and 2015 survey, respectively. The survey response rate was 47% in 2009 and 35% in 2015; 125 patients completed both surveys. In 2009 and 2015, 78% and 80% of patients described their PCP's opinion of bariatric surgery as "very supportive" (P = 0.64), and 29% and 40% described their PCP as "very knowledgeable" about bariatric surgery (P = 0.02), respectively. Post-operative support from PCPs was described as "very supportive" by 77% and 79% of patients in 2009 and 2015, respectively (P = 0.07). Overall, Ninety-seven percent of patients would repeat their LRYGB experience. The majority of patients perceived their PCP as being supportive of bariatric surgery. Physicians' knowledge of bariatric surgery could be improved by establishing more opportunities for education. While patients' perception of their PCP's knowledge increased, no significant improvements in PCP opinion or support of bariatric surgery were observed over time. Patients' willingness to repeat their experience with bariatric surgery remained high.

Metabolic surgery and iron homeostasis

Iron deficiency and anaemia after metabolic surgery, potentially modifiable nutritional complications, are becoming an increasing cause for concern as prevalence increases with time and there is limited evidence supporting the effectiveness of the current guidelines for prophylactic oral iron supplementation and treatment for deficiency. Abnormalities in iron nutrition predisposing to deficiency are common in severely obese patients, and the low-grade systemic inflammation, also common to these patients, reduces the effectiveness of oral iron supplementation. The surgical procedures result in alterations of foregut anatomy and physiology, which limit iron absorptive capacity and daily food intake. These alterations and the limited effects of oral iron supplementation explain the high prevalence of postoperative iron deficiency and anaemia. This review outlines current mechanisms concerning the pathogenesis of disordered iron nutrition in patients with severe obesity, current gaps in knowledge, and opportunities for quality improvement.

Effect of oral ursodeoxycholic acid on cholelithiasis following laparoscopic sleeve gastrectomy for morbid obesity

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a definitive solution for morbid obesity and its related co-morbidities. Cholelithiasis is a postoperative complication of LSG. The use of ursodeoxycholic acid (UDCA) after LSG is a proposed solution to reduce the incidence of cholelithiasis.

OBJECTIVE

To evaluate the effect of UDCA prophylaxis on cholelithiasis following LSG in morbidly obese patients.

SETTING

Two university hospitals in Egypt, Cairo, and Beni Suef Universities' hospitals.

METHODS

This prospective study was conducted between July 2015 and March 2018 and included 200 patients scheduled for LSG. They were randomly divided into 2 groups. The UDCA group received a postoperative prophylaxis regimen for prevention of cholelithiasis in the form of 250 mg twice daily of UDCA for 6 months. The control group did not receive prophylactic treatment. Abdominal ultrasound was done at 3, 6, 9, and 12 months for all patients to detect cholelithiasis. The primary outcome measure was cholelithiasis.

RESULTS

Only 6% of the UDCA group developed cholelithiasis compared with 40% in the control group (P < .001). Age, sex, initial body mass index, and excess weight loss at 6 months did not significantly affect cholelithiasis.

CONCLUSION

UDCA treatment for 6 months after LSG is effective in the prevention of cholelithiasis.

Safety of concomitant cholecystectomy with laparoscopic sleeve gastrectomy and gastric bypass: a MBSAQIP analysis

BACKGROUND

Gallstone disease occurs more commonly in the obese population and is often diagnosed during the preoperative evaluation for bariatric surgery.

OBJECTIVES

This study analyzed outcomes of laparoscopic gastric bypass (LGB) and laparoscopic sleeve gastrectomy (SG), with and without cholecystectomy (LC), using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program.

SETTING

Patients reported to Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program participating centers in the United States and Canada in 2015.

METHODS

All cases of LGB and SG, with and without LC, were analyzed. A 1:1 propensity-matched cohort was created for both SG and LGB, with and without concomitant LC. Multivariate logistic regression stratified by procedure was used to identify predictors of major complications after SG and LGB, using concomitant LC as a predictor. We also constructed a model for surgical site infections (SSIs) for SG group.

RESULTS

Of 98,292 sleeve operations, 2046 (2%) had concomitant LC. Of 44,427 bypass operations, 1426 (3%) had concomitant LC. For the sleeve group, concomitant LC increased operative time by an average of 27 minutes but did not affect length of stay, mortality, or major complications. Concomitant LC was associated with increased SSI (1% versus .4%) and need for reoperation (1.6% versus .7%) in univariate models. After adjusting for other predictors, concomitant LC was associated with increased risk for SSI (odds ratio 2.5, confidence interval 1.0-5.9, P = .04). For the bypass group, concomitant LC increased operative time by an average of 28 minutes to the operation, and postoperative length of stay averaged ∼5 hours longer (2.4 versus 2.2 d, P = .03). Thirty-day complications were similar between the groups. On multivariate analysis, concomitant LC was not a significant risk factor for major complications. Only operative time was an independent factor for major complications.

CONCLUSIONS

Concomitant LC with laparoscopic sleeve gastrectomy or gastric bypass did not affect mortality or risk of major complication. For sleeve patients, concomitant LC was associated with a .6% increased risk (.4% to 1.0%) of SSI. Concomitant LC with laparoscopic sleeve gastrectomy or gastric bypass is safe when indicated for gallstone disease.

Obesity

The role of internists in evaluating obesity is to assess the burden of weight-related disease, mitigate secondary causes of weight gain (medications, sleep deprivation), and solicit patient motivation for weight loss. Internists should assess these factors and emphasize the importance of weight loss for the individual patient. All patients wishing to lose weight should be encouraged to monitor their diet and physical activity and should be referred to high-intensity behavioral programs. Some patients with obesity may also benefit from pharmacotherapy or bariatric surgery.

Transient osteoporosis of the hip after bariatric surgery

Transient osteoporosis is a rare manifestation of acute hip pain which typically resolves with weight-bearing restrictions and pain management. Our case report presents a patient who experienced atraumatic right hip pain a few weeks after an uncomplicated bariatric surgery and was diagnosed with transient osteoporosis of the hip. Her condition resolved after weeks of protected weight-bearing restrictions and nonsteroidal anti-inflammatories. Transient osteoporosis should be considered in the differential diagnosis of hip pain in patients who have undergone previous bariatric surgery.

Exciting advances in GPCR-based drugs discovery for treating metabolic disease and future perspectives

INTRODUCTION

Current pharmacological therapies that target single receptors have limited efficacy for the treatment of diabetes and obesity. Novel approaches with hybrid peptides that activate more than one receptor at once to generate beneficial effects through synergistic effects have shown promising results. Several unimolecular dual and tri-agonists, mainly associated with GPCR like GLP-1/GCG/GIP receptors, have shown exceptional efficacy in preclinical models, and are currently being evaluated in clinical trials to investigate their safety and beneficial effects in humans. Areas covered: Herein, the authors review the development of drugs used in the treatment of metabolic disease, from single agonists to the new generation of tri-agonist peptides and compile the latest knowledge available on GPCR-based drug discovery. The authors also provide the reader with their expert perspectives on this exciting area of drug development. Expert opinion: The co-agonists that have been clinically tested so far have been well tolerated and reduce body weight as well as fasting glucose levels in patients with Type 2 Diabetes Mellitus to a higher degree than single agonists alone. The promising data collected so far now warrant large scale randomized clinical trials to assess whether a unimolecular polypharmacy-based approach could translate into safe and efficacious treatments for obesity and its comorbidities.

Surgical management of obesity

Weight loss surgery is the most effective intervention for addressing obesity and related metabolic disorders such as diabetes. We describe common surgical procedures as well as emerging and investigational procedures in terms of their capacity to induce weight reduction and their risk profiles. We then discuss the impact of weight loss surgery on important obesity related disorders including diabetes, cardiovascular disease, and non-alcoholic fatty liver disease. The question of operative choice is discussed with respect to benefits and risks of common procedures. Reoperative weight loss surgery, an increasingly common element of weight loss surgical practice, is reviewed. We briefly discuss the metabolic mechanism of action of weight loss surgery. Lack of access to and under-utilization of weight loss surgery represent important challenges to adequate obesity treatment, and we review these topics as well.

Does Helicobacter pylori infection influence the major postoperative complication rate after sleeve gastrectomy? A retrospective cohort study in an endemic region

BACKGROUND/AIMS

Helicobacter pylori infection is very common in Eastern countries. Little is known about the impact this infection has on bariatric surgery outcomes. This retrospective cohort study conducted on obese Turkish adults who underwent sleeve gastrectomy at a single center aimed to determine the prevalence of H. pylori infection and the effect of this infection on the rate of early major postoperative complications.

MATERIALS AND METHODS

All consecutive patients who underwent sleeve gastrectomy for obesity between 2014 and 2015 and who had complete data were enrolled. A single surgeon performed all procedures. All resected specimens were sent to pathology for analysis.

RESULTS

Of the 460 patients who met the eligibility criteria, 326 (71%) were female. The average (±standard deviation) age and body mass index were 37.5±10.0 years and 42.7±7.7 kg/m2, respectively. Histology revealed that 150 (33%) patients had H. pylori infection. The H. pylori-infected group developed two complications (leakage and intra-abdominal collection). The uninfected group developed three complications (all bleeding related). The two groups did not differ significantly regarding postoperative complication rates (1.3% vs. 1.0%; p=0.717).

CONCLUSION

H. pylori infection did not affect the rate of early complications after sleeve gastrectomy. This suggests that H. pylori screening or eradication policy is not essential for asymptomatic candidates who have undergone sleeve gastrectomy.