Bariatric Surgery and Endoluminal Procedures: IFSO Worldwide Survey 2014

Preserving β-cell function is the major determinant of diabetes remission following laparoscopic sleeve gastrectomy in Japanese obese diabetic patients

Laparoscopic sleeve gastrectomy has been proven effective in treating obesity-associated type 2 diabetes mellitus (T2DM). However, reports of the effect of laparoscopic sleeve gastrectomy on glucose metabolism in Japanese obese patients with T2DM are rare. The aim of this study was to evaluate the effects of laparoscopic sleeve gastrectomy on glucose tolerance in Japanese obese patients with T2DM, and to analyze factors influencing diabetes remission after surgery. This was a retrospective analysis of data for 24 consecutive patients with T2DM who underwent laparoscopic sleeve gastrectomy. We investigated weight loss and its impact on T2DM 1 year postoperatively. We also compared baseline characteristics and postoperative factors between patients who achieved diabetes remission and patients without remission. Mean body weight loss and percent total weight loss were 23.9 kg and 23.3%, respectively. Mean hemoglobin A1c levels dropped from 7.3 ± 0.3% to 6.1 ± 0.2%, and 18 patients (75%) achieved diabetes remission 1 year postoperatively. Patients achieving remission had significantly lower hemoglobin A1c levels (p = 0.026), higher fasting C-peptide values (p < 0.001), shorter diabetes duration (p < 0.001), lower insulin requirement (p = 0.002), and higher area under the insulin response curve (p < 0.001) and insulinogenic index (p < 0.001) during oral glucose tolerance testing. In conclusion, laparoscopic sleeve gastrectomy is an effective treatment for Japanese obese patients with T2DM. Preserving insulin secretion is the major determinant of diabetes remission.

Efficacy of Postoperative Upper Gastrointestinal Series (UGI) and Computed Tomography (CT) Scan in Bariatric Surgery: a Meta-analysis on 7516 Patients

BACKGROUND

To demonstrate the lack of utility and efficacy of routine early postoperative upper gastrointestinal study (UGI) in obese patients undergoing bariatric surgery and to show the higher efficacy of CT scan in cases of clinical suspicion of a leakage, a meta-analysis was performed.

MATERIALS AND METHODS

A literature search including articles published in last 18 years was performed. For both UGI and CT scan, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. A first analysis considered overall patients, and a second analysis considered only symptomatic patients.

RESULTS

Starting from 1233 eligible citations, 18 articles, including 7516 patients, were left. The pooled sensitivity was 54% for UGI (95% CI 34-74) with a high heterogeneity (I² = 99.8%, p < .001), whereas CT scan showed a pooled sensitivity of 91% (95% CI 89-93) significantly higher than sensitivity of UGI series (p < 0.01), with a high heterogeneity (I² = 98.9%, p < .001). In symptomatic patients the pooled sensitivity of UGI series was significantly lower than sensitivity of CT scan [49% (95% CI 31-68) vs 94% (95% CI 92-96), p < 0.01]. PPV showed a significant difference between UGI series and CT scan (54 vs 100%, p < 0.01). Specificity for UGI series was 98.6%, and specificity for CT scan was 99.7% (p = ns); the mean NPV was 96 and 98% for UGI series and CT scan (p = ns).

CONCLUSIONS

According to our results, a CT scan triggered by clinical suspicion must be considered the first-line procedure to detect a postoperative leak following primary sleeve gastrectomy or Roux-en-Y gastric bypass.

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?

Gut Microbiota Dysbiosis in Human Obesity: Impact of Bariatric Surgery

PURPOSE OF REVIEW

In this review, we summarize what is currently described in terms of gut microbiota (GM) dysbiosis modification post-bariatric surgery (BS) and their link with BS-induced clinical improvement. We also discuss how the major inter-individual variability in terms of GM changes could impact the clinical improvements seen in patients.

RECENT FINDINGS

The persisting increase in severe obesity prevalence has led to the subsequent burst in BS number. Indeed, it is to date the best treatment option to induce major and sustainable weight loss and metabolic improvement in these patients. During obesity, the gut microbiota displays distinctive features such as low microbial gene richness and compositional and functional alterations (termed dysbiosis) which have been associated with low-grade inflammation, increased body weight and fat mass, as well as type-2 diabetes. Interestingly, GM changes post-BS is currently being proposed as one the many mechanism explaining BS beneficial clinical outcomes. BS enables partial rescue of GM dysbiosis observed during obesity. Some of the GM characteristics modified post-BS (composition in terms of bacteria and functions) are linked to BS beneficial outcomes such as weight loss or metabolic improvements. Nevertheless, the changes in GM post-BS display major variability from one patient to the other. As such, further large sample size studies associated with GM transfer studies in animals are still needed to completely decipher the role of GM in the clinical improvements observed post-surgery.

Physical fitness and physical activity in women with obesity: short term effects of sleeve gastrectomy

INTRODUCTION

Introduction: the increase on prevalence of obesity has been linked to a higher number of bariatric surgeries, being sleeve gastrectomy (SG) the most frequent bariatric procedures in the world. However, there are few studies that determine the impact of SG on health's determinants such as physical fitness (PF) and physical activity (PA). Objectives: to describe the changes in PF and PA of patients after SG. Methods: twenty-three women with obesity (mean 36.1 ± 11.1 years old and body mass index [BMI] of 35.1 ± 3.4 kg/m2) were evaluated preoperatively to SG and at one and three months after surgery. An assessment of PF was conducted, including handgrip (HGS) and quadriceps muscle strength (QMS) with dynamometers and cardiorespiratory fitness (CRF) with an ergospirometer. PA was assessed with a three-axis accelerometer. Results: the absolute VO2 peak decreased after the first and third month (p < 0.001) post SG. The VO2 peak relative to body weight showed an increase from baseline after the SG (p = 0.002). After SG, there was a reduction in absolute values for HGS and QMS (p < 0.001) and an increase in relative HGS after three months post-surgery compared to preoperative (p = 0.011), without changes in relative QMS (p = 0.596). No changes in PA were observed. Conclusions: after SG, there is a short term decline on PF when it is expressed on absolute values. However, when it is expressed in relative terms to body weight, some components of PF improve, while others showed no change. There was no modification in PA levels of the participants.

Bone health in diabetes and prediabetes

Bone fragility has been recognized as a complication of diabetes, both type 1 diabetes (T1D) and type 2 diabetes (T2D), whereas the relationship between prediabetes and fracture risk is less clear. Fractures can deeply impact a diabetic patient's quality of life. However, the mechanisms underlying bone fragility in diabetes are complex and have not been fully elucidated. Patients with T1D generally exhibit low bone mineral density (BMD), although the relatively small reduction in BMD does not entirely explain the increase in fracture risk. On the contrary, patients with T2D or prediabetes have normal or even higher BMD as compared with healthy subjects. These observations suggest that factors other than bone mass may influence fracture risk. Some of these factors have been identified, including disease duration, poor glycemic control, presence of diabetes complications, and certain antidiabetic drugs. Nevertheless, currently available tools for the prediction of risk inadequately capture diabetic patients at increased risk of fracture. Aim of this review is to provide a comprehensive overview of bone health and the mechanisms responsible for increased susceptibility to fracture across the spectrum of glycemic status, spanning from insulin resistance to overt forms of diabetes. The management of bone fragility in diabetic patient is also discussed.

Long-term outcomes and frequency of reoperative bariatric surgery beyond 15 years after gastric banding: a high band failure rate with safe revisions

BACKGROUND

Laparoscopic adjustable gastric band (LAGB) has had encouraging early results. However, intermediate and late results were discouraging, and LAGB is presently being replaced by stapled procedures. There is still ongoing debate whether LAGB should be abandoned altogether.

OBJECTIVE

To present our outcomes beyond 15-year follow-up after LAGB.

SETTING

Private hospital, Bern, Switzerland.

METHODS

This is a retrospective review of patients receiving LAGB between 1997 and 2002 with minimum 15-year follow-up. Patient characteristics, co-morbidities, reoperative bariatric surgery (RBS), and weight trends were analyzed.

RESULTS

A total of 387 LAGB patients were identified. Of them, 342 (88.4%) had a minimum of 15 years of follow-up (range, 15-21 yr). There were 270 (78.9%) women with a mean age of 40.3 years (range, 15-62 yr) and body mass index (BMI) of 43.1 kg/m² (range, 30.0-60.1 kg/m²) and 72 (21.1%) men with a mean age of 41.2 years (range, 16-61 yr) and BMI of 43.6 kg/m² (range, 33.0-72.5 kg/m²). During follow-up, 283 (82.7%) patients underwent a mean of 3.3 reoperative bariatric operations (range, 1-5), with 224 (65.5%) converted to Roux-en-Y gastric bypass (RYGB). At the end of the study period, 96 (28%) patients still had a band in place. No deaths were recorded. At most recent follow-up after LAGB, mean excess BMI loss was 65.4% (range, -9.4% to 134.5%) with significant decrease in co-morbidities.

CONCLUSIONS

Only 28% of patients had sufficient weight loss outcomes after LAGB alone and predictive selection criteria are lacking. The majority of LAGB operations fail even with close structured follow-up. RBS can be performed safely.

Metabolic Surgery: Weight Loss, Diabetes, and Beyond

The alarming rise in the worldwide prevalence of obesity is paralleled by an increasing burden of type 2 diabetes mellitus. Metabolic surgery is the most effective means of obtaining substantial and durable weight loss in individuals with obesity. Randomized trials have recently shown the superiority of surgery over medical treatment alone in achieving improved glycemic control, as well as a reduction in cardiovascular risk factors. The mechanisms seem to extend beyond the magnitude of weight loss alone and include improvements in incretin profiles, insulin secretion, and insulin sensitivity. Moreover, observational data suggest that the reduction in cardiovascular risk factors translates to better patient outcomes. This review describes commonly used metabolic surgical procedures and their current indications and summarizes the evidence related to weight loss and glycemic outcomes. It further examines their potential effects on cardiovascular outcomes and mortality and discusses future perspectives.

Roux Limb Motility in Gastric Bypass Patients with Chronic Abdominal Pain-Is There an Association to Prescribed Opioids?

BACKGROUND/AIM

A number of patients continue to suffer from chronic abdominal pain of unknown origin, which may also lead to a prolonged use of opioid analgesics. Symptoms of abdominal pain, nausea and vomiting in this patient group resemble the characteristics of the Roux stasis Syndrome. The aim was to elucidate relationships between chronic abdominal pain, Roux limb motor activity and opioid analgesics.

METHODS

Roux limb high-resolution manometry and ratings of abdominal pain and quality of life were analysed in 15 gastric bypass patients reporting abdominal pain of unknown origin. Effect of acute opiate administration (morphine i.v.) on fasting Roux limb motor activity was assessed in asymptomatic and morphine-naïve gastric bypass patients (n = 9) and compared with an untreated control group (n = 11).

RESULTS

In the symptomatic patient group, we found disturbed Roux limb motor patterns in 10 out of 15 examinations, but no signs of Roux stasis syndrome. A high prevalence of prescribed opioid analgesics as well as a high number of reoperations in this group. The worst quality of life and the highest number of pain-killing medications were observed among the patients with distal pacemaker activity in Roux limb. In the morphine-naïve and asymptomatic patients, morphine increased the muscular tone in the Roux limb during phase III-like motor activity. A majority of the RYGBP patients with chronic abdominal pain had a disturbed Roux limb fasting motility, and there was a high prevalence of prescribed opioid analgesics. In opiate-naïve RYGBP patients, acute morphine intravenously increased the muscular tone of the Roux limb.

Pros and cons of Roux en-Y gastric bypass surgery in obese patients with type 2 diabetes

INTRODUCTION

The worldwide prevalence of obesity and type 2 diabetes (T2D) constitutes an epidemic that is a threat to public health. Bariatric surgery, including Roux en-Y gastric bypass (RYGB), is currently the most effective treatment to induce long-term weight loss and remission of co-morbid conditions. Surgery, however, comes with an added risk of complications, highlighting the need to understand the comparative effectiveness and risks of surgical versus conventional approaches to the treatment of obesity and T2D.

AREAS COVERED

Positive and negative outcomes of RYGB surgery in patients with T2D are assessed, with a primary focus on RYGB surgery versus standard non-surgical treatment of obese patients with T2D in randomized clinical trials or high-quality observational cohorts. Searches were conducted in the PubMed database up to 11 April 2019 for relevant studies.

EXPERT OPINION

High-level evidence reveals that RYGB ameliorates the clinical manifestations of T2D to a significantly higher degree than medical therapy. Postoperative incidence of beneficial effects and complications, however, differ across subgroups of patients with different preoperative characteristics. Key knowledge gaps, particularly on long-term complications, microvascular- and macrovascular events, and mortality should be addressed, so treatment with RYGB can be applied in an individualized approach to maximize benefits and minimize complications.

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.

Copper Deficiency: Causes, Manifestations, and Treatment

BACKGROUND

The metabolism of the essential trace element copper remains incompletely understood and, until recently, nearly ignored in acute medicine. Menkes disease was for long the only known copper deficiency condition, but several case reports and investigations conducted over the last 2 decades have shown that deficiency is more frequent than previously suspected, with devastating individual consequences and potential public health consequences. The copper needs in healthy individuals are 0.9 mg/d, which translates to 0.3 mg/d intravenously in parenteral nutrition; the present review aims at gathering actual knowledge.

METHOD AND RESULTS

A review of literature was conducted in PubMed and Cochrane systematic reviews to identify the most recent information about copper deficiency and generate a narrative review. Copper deficiency has hereditary and acquired origins, the latter being the most frequent. Clinical manifestations are nonspecific but affect all organs and systems, particularly the hematologic (anemia) and the neurologic (myeloneuropathy) systems. Deficiency also affects the cardiovascular, cutaneous, and immune systems. Severe copper deficiency due to reduced absorption after bariatric bypass surgery has become frequent.

CONCLUSION

Deficiency is more frequent than previously recognized, probably because of changing nutrition patterns but also because of some treatments that have become very common such as bypass bariatric surgery and, in acute medicine, prolonged continuous renal replacement therapy. The patients may present with severe hematologic and neurologic complications that go untreated because copper deficiency was not considered in the differential diagnosis: These complications often need active intravenous repletion with doses 4-8 times the usual nutrition recommendations.

Body Contouring Surgery after Massive Weight Loss: Excess Skin, Body Satisfaction, and Qualification for Reimbursement in a Dutch Post-Bariatric Surgery Population

BACKGROUND

Body contouring surgery improves quality of life, weight loss, and body image after bariatric surgery. It is unclear why only a minority of the post-bariatric surgery population undergoes body contouring surgery. This study assesses overhanging skin, body satisfaction, and qualification for reimbursement of body contouring surgery in a Dutch post-bariatric surgery population.

METHODS

Post-bariatric patients were selected from a prospective database. Electronic questionnaires evaluated demographics, desire for body contouring surgery, excess skin, and satisfaction with their body.

RESULTS

A total of 590 patients were included: 368 patients (62.4 percent) desired body contouring surgery, 157 (26.6 percent) did not and 65 (11.0 percent) had undergone body contouring surgery. There were no significant differences between the groups regarding the percentage of patients who met the qualifications for reimbursement. Patients who desired body contouring surgery had more body parts affected by overhanging skin and more often rated the overhanging skin with a Pittsburgh Rating Scale grade 3 compared with patients without a desire to undergo body contouring surgery. The plastic surgeon was never consulted by 39.1 percent of the "desire" population; 44.1 percent of these patients met the weight criteria.

CONCLUSIONS

Post-bariatric patients who desired body contouring surgery had more excess skin than patients without a desire and were less satisfied with their body. Almost half of these patients never consulted a plastic surgeon, partly because of incorrect assumptions regarding reimbursement. Plastic surgeons (together with bariatric teams) should better inform these patients about body contouring surgery possibilities.

EARLY WEIGHT LOSS OUTCOMES AND GLUCOSE METABOLISM PARAMETERS AFTER BANDED VERSUS NON-BANDED ONE ANASTOMOSIS GASTRIC BYPASS: A PROSPECTIVE RANDOMIZED TRIAL

BACKGROUND

The influence of the placement of a band on the outcomes of one anastomosis gastric bypass (OAGB) has not been appropriately studied yet.

OBJECTIVE

To compare early weight loss and glucose metabolism parameters following banded versus non-banded OAGB.

METHODS

A prospective randomized study, which evaluated 20 morbidly obese individuals who underwent banded and non-banded OAGB and were followed-up for three months. Weight loss (percentage of excess weight loss - %EWL and percentage of body mass index loss - %BMIL) and glucose metabolism outcomes (glucose, insulin and homeostasis model assessment - HOMA) were compared.

RESULTS

The banded group presented a significantly higher %EWL at one month (29.6±5.5% vs 17.2±3.4%; P<0.0001) and two months post-surgery (46±7% vs 34.2±9%; P=0.004544), as well as a significantly higher %BMIL at one month (9.7±1.1% vs 5.8±0.8%; P<0.0001), two months (15±1.4% vs 11.5±2.1; P=0.000248), and three months (18.8±1.8% vs 15.7±3.2%; P=0.016637). At three months, banded OAGB led to significant decreases of insulin (14.4±4.3 vs 7.6±1.9; P=0.00044) and HOMA (3.1±1.1 vs 1.5±0.4; P=0.00044), whereas non-banded OAGB also led to significant decreases of insulin (14.8±7.6 vs 7.8±3.1; P=0.006) and HOMA (3.2±1.9 vs 1.6±0.8; P=0.0041). The percent variation of HOMA did not significantly differ between banded and non-banded OAGB (P=0.62414); overall, the percent variation of HOMA was not correlated with %EWL (P=0.96988) or %BMIL (P=0.82299).

CONCLUSION

Banded OAGB led to a higher early weight loss than the standard technique. Banded and non-banded OAGB led to improvements in insulin resistance regardless of weight loss.

Comparative effectiveness of gastric bypass versus gastric banding on acute care use for cardiovascular disease in adults with obesity

BACKGROUND AND AIMS

Gastric bypass is known to have larger effects on weight and metabolism than gastric banding. However, scarce data exist as to whether the differences are translated into differential risks of cardiovascular disease (CVD)-related morbidities. The objective was to examine whether adults with obesity and CVD who underwent gastric bypass have a lower rate of acute care use (emergency department [ED] visit or unplanned hospitalization) for CVD than those with gastric banding.

METHODS AND RESULTS

We performed a comparative effectiveness study of gastric bypass versus banding among adults with obesity and CVD who underwent either surgery, using population-based [ED] and inpatient samples in California, Florida, and Nebraska from 2005 through 2011. The primary outcome was acute care use for CVD during a two-year postoperative period. We constructed negative binomial regression models to compare the event rate during sequential 6-month periods, using gastric banding group as the reference. We identified 11,229 adults with obesity and CVD who underwent gastric bypass and 3896 adults who had gastric banding. Patients with gastric bypass had significantly lower rate of the outcome compared to those with banding in the 7-12 months postoperative period (adjusted rate ratio [aRR] 0.77; 95% confidence interval [CI], 0.61-0.98; P = 0.03). The significant reduction in the rate persisted during 13-18 months (aRR 0.71; 95% CI, 0.57-0.90; P = 0.005) and 19-24 months (aRR 0.66; 95% CI, 0.52-0.82; P < 0.001) after bariatric surgery.

CONCLUSION

In this population-based comparative effectiveness study of adults with obesity and CVD, the rate of acute care use for CVD was lower after gastric bypass compared to gastric banding.

Intragastric single-port surgery (IGS) accesses the gastric remnant and allows ERCP for common bile duct stones after RYGB: a simple solution for a difficult problem

BACKGROUND

Patients who have undergone a Roux-en-Ygastric bypass (RYGB) and suffer from choledocholithiasis postoperatively pose a medical dilemma. Treatment of the cholestasis can be complicated because of the altered anatomy in these patients. The gastric remnant and duodenum are isolated from the pancreaticobiliary limb, making endoscopic retrograde pancreatography (ERCP) challenging and often impossible.

OBJECTIVE

To describe a method for safe introduction of the endoscope into the gastric remnant through intragastric single-port surgery (IGS), thus allowing for simultaneous cholecystectomy.

SETTING

Pilot clinical study.

METHODS

The present study is a nonrandomized clinical series describing our preliminary results using a transgastric inserted single-port device for ERCP after RYGB. The series includes 8 patients who underwent IGS ERCP after RYGB.

RESULTS

The technique was successfully applied for intraoperative ERCP through a transgastric inserted single-port device (Gelpoint Mini, Applied Medical, Rancho Santa Margarita, CA). Papilotomy was easily achieved without complications. Average operative time was 144.75 minutes. The patients recovered without complications and could be discharged after a mean of 4.38 days.

CONCLUSIONS

The novel IGS technique is safe and effective and can be applied to perform ERCP in patients with RYGB anatomy. Transgastric single port ERCP was simple to perform, achieved excellent results, and allowed for endoscopic treatment and cholecystectomy to be performed in a single procedure. The technique can be indicated in patients with complicated gallstone obstruction under altered anatomy after RYGB.

Changes in total sperm count after gastric bypass and sleeve gastrectomy: the BARIASPERM prospective study

BACKGROUND

The massive weight loss induced by bariatric surgery is associated with major benefits, but the effect on semen variables is still uncertain.

OBJECTIVES

To explore semen modifications with gastric bypass and sleeve gastrectomy.

SETTING

Five French University Hospitals.

METHODS

Male candidates for bariatric surgery with no history of infertility were recruited in this controlled prospective study. Sperm characteristics were collected before surgery and then 6 months and up to 12 months after surgery.

RESULTS

Forty-six adult men who underwent gastric bypass (n = 20) or sleeve gastrectomy (n = 26) were included. Total sperm count tended to be lower at 6 months and showed a significant decrease at 12 months in both surgery groups, at -69.5 million (-96.8 to -42.2 million; P = 0.0021). Total sperm count at 12 months relative to baseline was -41.4 million (P = .0391) after gastric bypass and -91.1 million (P = .0080) after sleeve gastrectomy. This was counterbalanced by an associated resolution of hypogonadism and decrease of DNA fragmentation in most patients with time after surgery.

CONCLUSION

Improvement in some semen variables after bariatric surgery observed in 3 previous studies is in contrast to the lower mean total sperm count found in this study at 1 year. The possible reversibility of this effect in the long term and the impact of surgery on fertility both remain unknown.

Laparoscopic Roux-en-Y gastric bypass surgery influenced pharmacokinetics of several drugs given as a cocktail with the highest impact observed for CYP1A2, CYP2C8 and CYP2E1 substrates

There is a lack of information about the changes in drug pharmacokinetics and cytochrome P450 (CYP) metabolism after bariatric surgery. Here, we investigated the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery on pharmacokinetics of nine drugs given simultaneously which may reveal changes in the activities of the main CYPs. Eight obese subjects undergoing LRYGB received an oral cocktail containing nine drugs, substrates of various CYPs: melatonin (CYP1A2), nicotine (CYP2A6), bupropion (CYP2B6), repaglinide (CYP2C8), losartan (CYP2C9), omeprazole (CYP2C19/CYP3A4), dextromethorphan (CYP2D6), chlorzoxazone (CYP2E1) and midazolam (CYP3A). The 6-hours pharmacokinetic profiles in serum and urine of each drug or corresponding metabolite as well as their metabolic ratios were compared before surgery with those at a median 1 year later. LRYGB exerted variable effects on the pharmacokinetics of these drugs. The geometric mean AUC_0-6 (90% confidence interval) of melatonin, bupropion, repaglinide, chlorzoxazone and midazolam after LRYGB was 27 (19%-41%), 54 (43%-67%), 44 (29%-66%), 160 (129%-197%) and 74 (62%-90%) of the pre-surgery values, respectively. The pharmacokinetics of losartan, omeprazole and dextromethorphan did not change in response to surgery. Nicotine was not detected in serum, while geometric mean of AUC_0-6 of its metabolite, cotinine, increased by 1.7 times after surgery. There were 3.6- and 1.3-fold increases in the AUC ratios of 6-hydroxymelatonin/melatonin and hydroxybupropion/bupropion, respectively. The cocktail revealed multiple pharmacokinetic changes occurring after LRYGB with the greatest effects observed for CYP1A2, CYP2C8 and CYP2E1 substrates. Future studies should be focused on CYP1A2, CYP2A6, CYP2C8 and CYP2B6 to clarify the changes in activities of these enzymes after LRYGB.

Comparison of Cardiovascular Benefits of Bariatric Surgery and Abdominal Lipectomy

PURPOSE OF REVIEW

The purpose of this review is to examine recent evidence supporting effectiveness of bariatric surgery and abdominal lipectomy as interventional strategies aimed at reduction in incidence of cardiovascular disease (CVD) and related morbidity and mortality in obese and metabolic syndrome patients.

RECENT FINDINGS

While several studies show reduction in CVD risk factors in patients who have undergone both the Roux-en-Y gastric bypass and sleeve gastrectomy, very few demonstrate actual improvements in cardiovascular function, or a decrease in CVD events or CVD-related mortality. Consequently, the cardiovascular benefits of the less invasive sleeve gastrectomy in comparison to the gastric bypass are also unclear. Striking new data on large patient samples demonstrate significant positive correlation between gastric bypass and CVD risk factor reduction only in patients who are diabetic or > 50 years of age at the time of surgery, with no significant differences in non-diabetic and younger patients and with significant side effects. On the other hand, a markedly less invasive removal of abdominal subcutaneous adipose tissue via lipectomy consistently and significantly improved CVD risk factors as well as cardiovascular function in the very few studies available. Overall, neither the potential nor the definitive cardiovascular benefits of either of the commonly used bariatric surgical or the various lipectomy procedures have been adequately explored. Future basic science and clinical studies have the opportunity to understand the mechanisms and long-term consequences of both approaches and develop personalized approaches with higher benefit to side effect ratios.

Effect of Roux-en-Y gastric bypass surgery on diabetes remission and complications in individuals with type 2 diabetes: a Danish population-based matched cohort study

AIMS/HYPOTHESIS

The aim of this study was to examine the effect of Roux-en-Y gastric bypass (RYGB) surgery on diabetes remission, subsequent diabetes relapse and micro- and macrovascular complications in individuals with type 2 diabetes and obesity (BMI >35 kg/m²) in a real-world setting.

METHODS

This was a population-based cohort study of 1111 individuals with type 2 diabetes treated by RYGB at hospitals in Northern Denmark (2006-2015), and 1074 matched non-operated individuals with type 2 diabetes. Diabetes remission was defined as no glucose-lowering drug use with HbA_1c <48 mmol/mol (<6.5%), or metformin monotherapy with HbA_1c <42 mmol/mol (<6.0%). Data on complications were ascertained from medical registries with complete follow-up.

RESULTS

At 1 year of follow-up, 74% of the cohort treated by RYGB experienced diabetes remission, while 27% had relapsed after 5 years. Predictors of non-remission were age >50 years, diabetes duration >5 years, use of glucose-lowering drugs other than metformin, and baseline HbA_1c >53 mmol/mol (>7.0%). Compared with the non-operated cohort using adjusted Cox regression (5.3 years follow-up), the cohort treated by RYGB had 47% lower risk of microvascular complications (HR 0.53 [95% CI 0.38, 0.73]) and a statistically non-significant 24% lower risk of macrovascular complications (HR 0.76 [95% CI 0.49, 1.18]). Diabetes remission vs non-remission at 1 year was associated with reduced HR of 0.43 (95% CI 0.25, 0.72) for microvascular complications and with HR of 0.76 (95% CI 0.40, 1.45) for macrovascular complications.

CONCLUSIONS/INTERPRETATION

In routine clinical care, three out of four individuals with type 2 diabetes and obesity treated by RYGB experienced diabetes remission after 1 year, whereas 27% of these individuals had relapsed at 5 years follow-up. RYGB was associated with substantially decreased risk of microvascular complications and non-significantly fewer macrovascular complications, with early diabetes remission as a clear predictor of reduced microvascular complications.

Portomesenteric vein thrombosis after laparoscopic sleeve gastrectomy in patient with liver cirrhosis

Laparoscopic sleeve gastrectomy (LSG) has become the dominant bariatric procedure because of its reliable weight loss and low complication rate. Portomesenteric vein thrombosis (PMVT) after LSG is an infrequent complication that can lead to serious consequences. Here, we report a patient who presented with abdominal pain 11 days after LSG for the treatment of morbid obesity. Contrast CT of the abdomen revealed PMVT. The patient had liver cirrhosis, which is a major risk factor for PMVT. When LSG is performed on an obese patient with liver cirrhosis, careful attention must be paid to the onset of PMVT.

Proceedings from the 2018 Association for Chemoreception Annual Meeting Symposium: Bariatric Surgery and Its Effects on Taste and Food Selection

This article provides a summary of the topics discussed at the symposium titled "Bariatric Surgery and Its Effects on Taste and Food Selection," which was held at the Fortieth Annual Meeting of the Association for Chemoreception Sciences. Bariatric surgery such as Roux-en-Y gastric bypass (RYGB) is currently one of the most effective treatments available for weight loss and Type 2 diabetes. For this reason, it is of great interest to clinicians as well as to basic scientists studying the controls of feeding and energy balance. Despite the commonly held view by clinicians that RYGB patients change their food preferences away from fats and sugars in favor of less energy dense alternatives such as vegetables, the empirical support for this claim is equivocal. It is currently thought that the taste and palatability of fats and sugars are affected by the surgery. Some key preclinical and clinical findings addressing these issues were evaluated in this symposium.

Abdominal pain and symptoms before and after Roux-en-Y gastric bypass

Background

Despite increased emphasis on patient‐reported outcomes, few studies have focused on abdominal pain symptoms before and after Roux‐en‐Y gastric bypass (RYGB). The aim of this study was to quantify chronic abdominal pain (CAP) in relation to RYGB.

Methods

Patients with morbid obesity planned for RYGB were invited to participate at a tertiary referral centre from February 2014 to June 2015. Participants completed a series of seven questionnaires before and 2 years after RYGB. CAP was defined as patient‐reported presence of long‐term or recurrent abdominal pain lasting for more than 3 months.

Results

A total of 236 patients were included, of whom 209 (88·6 per cent) attended follow‐up. CAP was reported by 28 patients (11·9 per cent) at baseline and 60 (28·7 per cent) at follow‐up (P < 0·001). Gastrointestinal Symptom Rating Scale (GSRS) scores (except reflux scores) and symptoms of anxiety increased from baseline to follow‐up. Most quality of life (QoL) scores (except role emotional, mental health and mental component scores) also increased. At follow‐up, patients with CAP had higher GSRS scores than those without CAP, with large effect sizes for abdominal pain and indigestion syndrome scores. Patients with CAP had more symptoms of anxiety, higher levels of catastrophizing and lower QoL scores. Baseline CAP seemed to predict CAP at follow‐up.

Conclusion

The prevalence of CAP is higher 2 years after RYGB compared with baseline values.

Sleeve Gastrectomy and Roux-En-Y Gastric Bypass Lead to Comparable Changes in Body Composition in a Multiethnic Asian Population

BACKGROUND

Changes in body composition after bariatric surgery such as a sustained loss of body fat are often associated with an inevitable loss of fat free mass. This can contribute to an undesirable disturbance in resting metabolic rate and weight maintenance. Our aim was to study changes in body composition in a multiethnic Asian cohort following bariatric surgery and to identify differences between laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

METHODS

A retrospective review of prospectively collected data on 295 patients who underwent either laparoscopic sleeve gastrectomy (256 patients) or laparoscopic Roux-en-Y gastric bypass (39 patients) was performed. Body composition variables were measured with the analyzer, GAIA 359 PLUS, which included the parameters; total body weight, body mass index, excess weight, basal metabolic rate, fat-free mass, fat mass, and total body water.

RESULTS

There were no statistical differences in gender, ethnicity, age, weight, height, and body mass index between laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass. At each time point (6, 12, 24, and 36 months) post-operation, there was no significant differences in % total body weight loss, basal metabolic rate, fat mass, fat percentage, and total body water between sleeve gastrectomy and bypass patients. There was significant difference (p < 0.05) in fat free mass only at 3 years post-operation, with sleeve gastrectomy patients having 9.79 kg less fat-free mass than bypass patients. However, after multivariate analysis, we found no statistically significant differences.

CONCLUSION

Sleeve gastrectomy and gastric bypass seemed to give similar changes to body composition.

Psychosocial Concerns Following Bariatric Surgery: Current Status

PURPOSE OF REVIEW

The purpose of this paper is to review the current status of research on psychosocial concerns following bariatric surgery.

RECENT FINDINGS

Bariatric surgery has a positive overall impact on weight and obesity-related comorbidities, as well as a positive short-term impact on mental health and psychosocial functioning. Nonetheless, research has documented a number of different psychosocial concerns that may emerge following surgery including maladaptive eating, substance use disorders, suicide, lack of social support, and excess skin. Moreover, special populations of patients may have distinctive psychosocial concerns based on sociodemographic factors such as age or severity of obesity. Available studies suggest that psychosocial interventions have a positive impact on post-surgery outcomes, particularly maladaptive eating. However, research is limited, and long-term data are lacking. Monitoring patients after bariatric surgery for negative psychosocial outcomes is warranted. Research is needed to develop and evaluate personalized approaches to optimize long-term weight loss and psychosocial adjustment.

Metabolic (Bariatric and Nonbariatric) Surgery for Type 2 Diabetes: A Personal Perspective Review

: Metabolic surgery can cause amelioration, resolution, and possible cure of type 2 diabetes. Bariatric surgery is metabolic surgery. In the future, there will be metabolic surgery operations to treat type 2 diabetes that are not focused on weight loss. These procedures will rely on neurohormonal modulation related to the gut as well as outside the peritoneal cavity. Metabolic procedures are and will always be in flux as surgeons seek the safest and most effective operative modality; there is no enduring gold standard operation. Metabolic bariatric surgery for type 2 diabetes is more than part of the clinical armamentarium, it is an invitation to perform basic research and to achieve fundamental scientific knowledge.

Weight Recidivism After Roux-en-Y Gastric Bypass Surgery: An 11-Year Experience in a Multiethnic Medical Center

OBJECTIVE

Weight recidivism following Roux-en-Y gastric bypass (RYGB) is common and is associated with recurrence of comorbidities. Studies with long-term follow-up of recidivism quantified by weight regain (WR) are lacking. A retrospective review of all RYGB at our center from 2004 to 2015 was performed to examine the effects of race and type 2 diabetes on WR following RYGB.

METHODS

Multivariable linear mixed models were used for the effects of time and race on weight, WR relative to nadir weight (WR/nadir), and WR relative to maximal weight loss, and Cox regressions were used for low, moderate, and high WR/nadir.

RESULTS

A total of 1,395 participants were identified. The sample was limited to African American (AA), Caucasian American (CA), and Hispanic American (HA) participants. The effects of time (P < 0.0001), race (P < 0.0001), and race × time interaction (P = 0.0008) on weight trajectory were significant. AA had significantly more WR than CA (P < 0.01). AA and HA had a higher hazard ratio for having low, moderate, and rapid WR/nadir.

CONCLUSIONS

Racial disparities after RYGB include WR and particularly affect AA. Understanding the etiologic factors that contribute to these disparities is important to optimize the long-term clinical outcomes of bariatric surgery.

Mechanisms underlying the weight loss effects of RYGB and SG: similar, yet different

The worldwide obesity epidemic continues unabated, adversely impacting upon global health and economies. People with severe obesity suffer the greatest adverse health consequences with reduced life expectancy. Currently, bariatric surgery is the most effective treatment for people with severe obesity, resulting in marked sustained weight loss, improved obesity-associated comorbidities and reduced mortality. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), the most common bariatric procedures undertaken globally, engender weight loss and metabolic improvements by mechanisms other than restriction and malabsorption. It is now clear that a plethora of gastrointestinal (GI) tract-derived signals plays a critical role in energy and glucose regulation. SG and RYGB, which alter GI anatomy and nutrient flow, impact upon these GI signals ultimately leading to weight loss and metabolic improvements. However, whilst highly effective overall, at individual level, post-operative outcomes are highly variable, with a proportion of patients experiencing poor long-term weight loss outcome and gaining little health benefit. RYGB and SG are markedly different anatomically and thus differentially impact upon GI signalling and bodyweight regulation. Here, we review the mechanisms proposed to cause weight loss following RYGB and SG. We highlight similarities and differences between these two procedures with a focus on gut hormones, bile acids and gut microbiota. A greater understanding of these procedure-related mechanisms will allow surgical procedure choice to be tailored to the individual to maximise post-surgery health outcomes and will facilitate the discovery of non-surgical treatments for people with obesity.