Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss at 5 Years Among Patients With Morbid Obesity: The SLEEVEPASS Randomized Clinical Trial

Stronger control of eating 3 months after sleeve gastrectomy predicts successful weight loss outcomes at one year

Background

Weight loss response to sleeve gastrectomy (SG) is variable and predicting the effectiveness of surgery is challenging and elusive. The aim of our study was to assess and quantify the association between eating control and weight loss outcomes and identify the control of eating (CoE) attributes during the early postoperative period that might predict good vs. poor response to SG at one year.

Methods

A prospective longitudinal cohort study using the Control of Eating Questionnaire (CoEQ) was designed as a series before and at 3-, 6-, and 12-months post-SG. Primary outcomes were changes in CoE attributes and percent of total weight loss (%TWL) 12-months post-surgery. Subjects were categorized based on %TWL as good (GR, ≥25 %) or poor responders (PR, <25 %). A receiver operating characteristic and logistic regression analyses were performed.

Results

We included 41 participants (80.5% females, 51.2% Hispanic, mean age 41.7±10.6, median baseline body mass index (BMI) 43.6 kg/m2 [range 35.2-66.3]) who completed the CoEQ at all four timepoints. The "Difficulty to control eating" score at 3 months revealed the highest area under the curve (AUC) (AUC 0.711; 95%CI 0.524-0.898; p=0.032). In a trade-off between a high Youden index and high sensitivity, the "Difficulty to control eating" score of 7 at 3 months was identified as the optimal cut-off for distinguishing between GRs and PRs. Score ≤7 at 3 months was strongly independently associated with a successful weight loss target of 25%TWL at one-year post-SG (Relative Risk 4.43; 95%CI 1.06-18.54; p=0.042).

Conclusion

"Difficulty to control eating" score at 3 months post-SG is an independent early predictor of optimal response (achieving a successful TWL target of ≥25 % at one-year post-SG). Our results support the utility of this easy-to-administer validated tool for predicting the effectiveness of SG and may assist in identifying individuals with suboptimal response early and helping them with interventions to attain optimal weight loss targets.

Obesity in adults

Obesity has increased in prevalence worldwide and WHO has declared it a global epidemic. Population-level preventive interventions have been insufficient to slow down this trajectory. Obesity is a complex, heterogeneous, chronic, and progressive disease, which substantially affects health, quality of life, and mortality. Lifestyle and behavioural interventions are key components of obesity management; however, when used alone, they provide substantial and durable response in a minority of people. Bariatric (metabolic) surgery remains the most effective and durable treatment, with proven benefits beyond weight loss, including for cardiovascular and renal health, and decreased rates of obesity-related cancers and mortality. Considerable progress has been made in the development of pharmacological agents that approach the weight loss efficacy of metabolic surgery, and relevant outcome data related to these agents' use are accumulating. However, all treatment approaches to obesity have been vastly underutilised.

Glucagon-like peptide-1 (GLP-1) receptor agonists for weight management: A review for the gynecologic oncologist

The use of glucagon-like peptide-1 receptor agonists (GLP-1RA) has experienced rapid growth amidst the obesity epidemic in the United States. While originally developed for glucose control in Type 2 Diabetes Mellitus, the scope of these agents now extends to encompass weight loss and cardiovascular risk reduction. GLP-1RAs have the potential to induce significant weight loss, in combination with lifestyle modifications, among adults who are overweight or obese. Furthermore, these agents demonstrate efficacy in ameliorating hyperglycemia, enhancing insulin sensitivity, regulating blood pressure, improving cardiometabolic parameters, mitigating kidney dysfunction, and potentially reducing the risk of several obesity-related cancers. Drug-related toxicity is primarily gastrointestinal and active management can prevent drug discontinuation. Obesity is associated both with an increased incidence of malignancy but also with decreased survival. More research is needed to evaluate the potential use of GLP-1RA to modify the endocrine function of adipocytes, regulate the chronic inflammatory state associated with obesity, and prospective applications in oncology. These agents can impact patients with gynecologic malignancies both through their direct mechanism of action as well as potential drug toxicity.

Validation of the Individualized Metabolic Surgery score in predicting long-term remission of diabetes after duodenal switch-type procedures

AIM

To validate the Individualized Metabolic Surgery (IMS) score and assess long-term remission of type 2 diabetes (T2D) after duodenal switch (DS)-type procedures in patients with obesity. In addition, to help guide metabolic procedure selection for those patients categorized as having severe T2D.

MATERIALS AND METHODS

This is a retrospective single cohort study of all patients with T2D and severe obesity, who underwent DS-type procedures at a single institution from December 2010 to December 2018. Study endpoints included validating the IMS score in our cohort and evaluating the impact of DS-type procedures on long-term (≥ 5 years) remission of T2D, especially in patients with severe disease. A receiver operator characteristic curve was used to assess the accuracy of the IMS score using the area under the curve (AUC).

RESULTS

The study cohort included 30 patients with complete baseline and long-term glycaemic data after their index DS-type surgery. Twelve patients (40%) were classified with severe T2D, and the distribution of IMS-based severity groups was similar between our cohort and the original IMS study (P = .42). IMS scores predicted long-term T2D remission with AUC = 0.77. Patients with IMS-based severe diabetes achieved significantly higher long-term remission after DS-type procedures compared with gastric bypass and/or sleeve gastrectomy from the original IMS study (42% vs. 12%; P < .05).

CONCLUSIONS

The IMS score properly classifies the severity of T2D in our study cohort and adequately predicts its long-term remission after DS-type procedures. While T2D remission decreases with more severe IMS scores, long-term remission remains high after DS-type procedures among patients with severe disease.

Optimizing Hospital Performance Evaluation in Total Weight Loss Outcomes After Bariatric Surgery: A Retrospective Analysis to Guide Further Improvement in Dutch Hospitals

INTRODUCTION

Bariatric surgery aims for optimal patient outcomes, often evaluated through the percentage total weight loss (%TWL). Quality registries employ funnel plots for outcome comparisons between hospitals. However, funnel plots are traditionally used for dichotomous outcomes, requiring %TWL to be dichotomized, potentially limiting feedback quality. This study evaluates whether a funnel plot around the median %TWL has better discriminatory performance than binary funnel plots for achieving at least 20% and 25% TWL.

METHODS

All hospitals performing bariatric surgery were included from the Dutch Audit for Treatment of Obesity. A funnel plot around the median was constructed using 5-year %TWL data. Hospitals positioned above the 95% control limit were colored green and those below red. The same hospitals were plotted in the binary funnel plots for 20% and 25% TWL and colored according to their performance in the funnel plot around the median. We explored the hospital's procedural mix in relation to %TWL performance as possible explanatory factors.

RESULTS

The median-based funnel plot identified four underperforming and four outperforming hospitals, while only one underperforming and no outperforming hospitals were found with the binary funnel plot for 20% TWL. The 25% TWL binary funnel plot identified two underperforming and three outperforming hospitals. The proportion of sleeve gastrectomies performed per hospital may explain part of these results as it was negatively associated with median %TWL (β =  - 0.09, 95% confidence interval [- 0.13 to - 0.04]).

CONCLUSION

The funnel plot around the median discriminated better between hospitals with significantly worse and better performance than funnel plots for dichotomized %TWL outcomes.

Short-term effects of Roux-en-Y gastric bypass or gastric sleeve on bone mineral density and calciotropic hormones: a systematic review and meta-analysis

Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS) have been associated with significant reductions in bone mineral density (BMD) and fluctuations in serum levels of calciotropic hormones. These changes pose a risk to bone health. The study assessed the short-term (12 and 24 months) effects of RYGB and GS on BMD and calciotropic hormones. PubMed, Embase, and Cochrane Library databases were searched. Analyses considered follow-up (12 and 24 months) with BMD as main outcome at three sites (femoral neck, total hip, and lumbar spine) and one for each calciotropic hormone (25 OH vitamin D and parathyroid hormone [PTH]). Estimated effect sizes were calculated as standardized mean differences (SMD), confidence interval of 95%, and P value. Nine studies totaling 473 participants (RYGB = 261 and GS = 212) were included. RYGB resulted in lower BMD than GS at 12 months for femoral neck (SMD = -0.485, 95% CI [-0.768, -0.202], P = .001), lumbar spine (SMD = -0.471, 95% CI [-0.851, -0.092], P = .015), and total hip (SMD = -0.616, 95% CI [-0.972, -0.259], P = .001), and at 24 months for total hip (SMD = -0.572, 95% CI [-0.907, -0.238], P = .001). At 24 months, 25 OH vitamin D was lower in RYGB than GS (SMD = -0.958 [-1.670, -0.245], P = .008) and PTH levels were higher in RYGB than in GS (SMD = 0.968 [0.132, 1.804, P = .023]). RYGB demonstrated significant reduction in regional BMD. It also induces lower serum 25 OH vitamin D and higher PTH levels than GS. The results support the need for preventive bone health measures in the short-term postoperative period, especially in the case of RYGB.

Update on comparison of laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass: a systematic review and meta-analysis of weight loss, comorbidities, and quality of life at 5 years

BACKGROUND

Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) are the two most commonly performed bariatric surgeries for the treatment of obesity. This meta-analysis was performed with the aim of summarizing the available evidence on weight loss, remission of comorbidities, and quality of life in LRYGB and LSG, complementing the current literature.

METHODS

We searched PubMed, EMBASE and the Cochrane Library from January 2012 to June 2023 for randomized controlled trials and non-randomized interventional studies. We finally selected 18 eligible studies.

RESULTS

LRYGB resulted in greater weight loss compared with LSG at 5 years [WMD= -7.65 kg/m², 95% confidence interval (CI) -11.54 to -3.76, P = 0.0001], but there exists high heterogeneity with I²=84%. Resolution rate of type 2 diabetes mellitus (T2D) (OR = 0.60, 95%Cl 0.41-0.87, p = 0.007) and dyslipidemia (OR = 0.44, 95%Cl 0.23-0.84, p = 0.01) was higher in the LRYGB group than that in the LSG group at 5 years. There was no difference between LRYGB and LSG for remission of hypertension, and obstructive sleep apnea. No differences were observed in the QoL after LRYGB or LSG. Morbidity was lower in the LSG group (WMD = -0.07, 95% CI: -0.13, -0.02, P = 0.01) than in the LRYGB group. No statistically significant difference was found in mortality between the two procedures.

CONCLUSION

At 5 years after surgery, LRYGB resulted in greater weight loss and achieved better remission rate of T2D and dyslipidemia than LSG. However, LSG has a lower morbidity rate than that of LRYGB.

An Indian multicentre real-world study on long-term quality of life outcomes following bariatric surgery

BACKGROUND

The purpose of this study was to assess the impact of metabolic and bariatric surgery (MBS) on Quality of Life (QoL) in Indian patients with obesity over 10 years.

METHODS

A retrospective chart review was conducted at 11 centres for individuals with MBS between February 2013 and May 2022. Patient medical records provided the source of de-identified data.

RESULTS

Data from 2132 individuals with a mean age of 43.28 ± 11.96 years was analysed. There were 37.43% men and 62.57% females in the study population. The study population had a mean preoperative body mass index (BMI) of 45.71 ± 10.38 kg/m2. The Bariatric Analysis and Reporting Outcome System (BAROS) scoring method showed a higher overall QoL score throughout all follow-up periods, with 'very good' outcomes at one, three and 7 years and 'good' outcomes at 5 and 10 years. Improvements in QoL were associated with a substantial improvement (p < .01) in BMI at every follow-up time point.

CONCLUSIONS

Following MBS, individuals with obesity exhibited a substantial and long-term improvement in their overall QoL for up to 10 years. This study presents Indian data on QoL, which is considered one of the most important decision-making factors for or against an intervention.

Unraveling Postoperative Bleeding Dynamics in Laparoscopic Roux-en-Y Gastric Bypass: Insights from a Single-Center Tranexamic Acid Study

BACKGROUND

The efficacy of postoperative tranexamic acid (TXA) administration in mitigating bleeding after primary laparoscopic Roux-en-Y gastric bypass (RYGB), a prevalent complication associated with significant morbidities and mortality, and the use of sequential laboratory parameter changes in bleeding screening and TXA impact tracking were investigated.

METHODS

This retrospective analysis included RYGB patients (aged 18-65 years, with a body mass index of 35-50 kg/m2) over 5 years who were categorized into three groups by evolving treatment regimens: Group A (n = 42) received standard pre- and postoperative enoxaparin (30 mg) every 12 h; Group B (n = 160) received enoxaparin and postoperative TXA (250 mg every 6 h); and Group C (n = 73) received TXA alone. Postoperative bleeding-related adverse events, vital signs, and laboratory changes were compared.

RESULTS

Postoperative hemorrhage occurred in 3.6% (10/275) of patients, with no significant intergroup differences. Patients who experienced bleeding had greater decreases in hemoglobin (∆Hb) (2.1 vs. 1.4; p = 0.003), greater ∆Hb > 2 (50% vs. 15%; p = 0.013), and greater use of staples than did those who did not experience bleeding (8 vs. 7; p = 0.001). The ∆Hb values were lower in Groups B (1.4) and C (1.3) than in Group A (1.7, p = 0.011). No significant difference was noted between Groups C and B.

CONCLUSION

This study emphasizes the potential of TXA to mitigate postoperative bleeding after RYGB, with no added benefit from excluding enoxaparin. Monitoring patients with a ∆Hb > 2 mg/dl and increased stapler usage is crucial. Further research is needed to validate routine TXA use across different procedures.

BARIATRIC SURGERIES IN THE BRAZILIAN PUBLIC HEALTH SYSTEM FROM 2012 TO 2022: DESCRIPTIVE STUDY OF HOSPITALIZATIONS IN THE STATE OF PARANÁ

BACKGROUND

Obesity is a chronic health condition with a multifactorial etiology, resulting from the interplay of genetic, environmental, and behavioral factors leading to an energy imbalance.

OBJECTIVE

To characterize hospitalizations for bariatric surgeries through the Brazilian Unified Health System (SUS) in the state of Paraná from 2012 to 2022.

METHODS

This is a descriptive and retrospective study, utilizing a time series design, based on secondary data. Public data from the SUS Hospital Information System for the period from 2012 to 2022 were consulted, focusing on the population of obese patients undergoing bariatric surgery.

RESULTS

In Paraná, concerning SUS procedures data from 2012 to 2022, 39,793 hospitalizations for bariatric surgeries were observed. Among the five modalities, Roux-en-Y gastric bypass predominated with 38,849 hospitalizations (97.6%), showing a lower mortality rate.

CONCLUSION

The research highlights a notable variation in costs, emphasizing the importance of economic evaluation. The correlation between obesity and diabetes underscores the complexity of the situation, justifying the superiority of surgical treatment in comorbidity remission. The study reveals a decline in bariatric surgeries in 2020, coinciding with the pandemic, and alerts to the increased vulnerability of obese patients to SARS-CoV-2.

Malnutrition After Single Anastomosis Sleeve Ileal Bypass: A Single-Center Experience

The authors raise concerns regarding the study by Wafa et al. on the high rates of malnutrition and revisional surgery after single anastomosis sleeve ileal (SASI) bypass. The small sample size (30 patients), single-center design, and lack of multicenter data limit the generalizability of the findings. The authors question the learning curve of the surgeon and whether the high complication rates are due to the surgeon's experience or inherent to the SASI technique. The involvement and contribution of co-authors from different institutions are unclear, potentially introducing bias. The study lacks preoperative nutritional assessment data, making it difficult to determine if postoperative deficiencies are due to SASI or preexisting issues. The nutritional management and supplementation protocols are not detailed, and the mechanisms behind the high incidence of malnutrition are not discussed. A comparison with well-established bariatric procedures is missing, making it challenging to assess the relative risks and benefits of SASI. The authors conclude that more extensive, multicenter studies with comprehensive preoperative nutritional assessments, detailed management protocols, and long-term follow-up are needed to fully evaluate SASI. Until such data are available, SASI should be considered experimental and performed only in well-designed clinical trials with rigorous patient selection and monitoring.

Conversion of Sleeve Gastrectomy to Roux-en-Y Gastric Bypass: Is Intrathoracic Migration of the Sleeve of High Incidence?

BACKGROUND

Conversion of SG to Roux-en-Y gastric bypass (RYGB) is increasing. Intrathoracic migration of the sleeve (ITM) often seems associated and is increasingly reported.

MATERIAL AND METHODS

Patients who underwent a conversion of SG to RYGB from August 2013 to December 2022 were included. Two groups were compared: patients operated on for weight loss failure (WLF gp) and those operated on for gastroesophageal reflux disease (GERD gp). Demographic data, the incidence of ITM, weight loss outcomes, resolution of symptoms, and morbidity were analyzed.

RESULTS

Fifty-nine patients were included with an average follow-up of 32 months: 46 patients in the GERD gp (78%) were compared to 13 patients (22%) in the WLF gp. Groups were comparable regarding age and gender, but BMI and commodities were significantly higher in the WLF gp. In the GERD gp, on preoperative gastroscopy, 30% had a esophagitis, 48% had an ITM which required a posterior crural closure versus no esophagitis (p=0.02) and 23% of ITM in the WLF gp (p=0.11). Conversion led to 93% of GERD symptom improvement. In the WLF gp, mean TWL% was 15.3%, significantly greater than in the GERD gp (TWL% = 4.6%, p = 0.01). The complication rate was 10% at 30 days and 3.4% after 30 days, not significantly different between groups.

CONCLUSION

The main indication of conversion of SG to RYGB was because of GERD: in these indications, the incidence of ITM was high requiring a surgical treatment with a very good efficacy on symptoms. Weight loss results were disappointing.

Long-Term Outcomes of Patients with Staple Line Leaks Following Sleeve Gastrectomy

PURPOSE

The long-term outcomes of patients with staple line leaks (SLL) after SG are under-reported. The purpose of this study is to evaluate the long-term outcomes of patients with SLL after SG.

MATERIALS AND METHODS

A retrospective analysis of a maintained patient registry of patients undergoing SG between January 2012 and December 2020 in a single bariatric center was analyzed and included patients with SLL. Outcomes were compared to a group without SLL.

RESULTS

During this period, 1985 patients underwent SG of which 61 patients (3.1%) developed leak. 26 patients (1.3%) had overt SLL and the rest had organ space infection around the staple line. The mean age and body mass index (BMI) were 39.8 ± 11.3 and 41.5 ± 4.7, respectively. 7 patients (11.4%) underwent concomitant surgery and 12 patients (19.7%) had intraoperative complications. Leak was complicated by Clavien-Dindo ≥ 3 in 31 patients (50.8%). Reoperation rate was 27.8% (n = 17). ≥ 2 interventions were required in 26% of patients (n = 16). Two patients died during hospitalization due to septic complications. Long-term follow-up of median 121 months was available in 78% of the cohort (n = 48). The median total weight loss and BMI were 27% and 30.1 kg/m2, respectively. Weight loss outcomes were higher in comparison to patients without SLL. Seven patients (14.6%) underwent SG revision. All associated medical problems improved during follow-up except for gastroesophageal reflux which was found in 50% of cohort.

CONCLUSION

Long-term outcomes of SG patients with SLL are satisfactory in terms of weight loss, resolution of comorbidities, and requirement for surgical revision.

Comparison between total weight loss and other metrics after bariatric surgery using a multilevel mixed-effects linear regression model

BACKGROUND

Several tools are used to assess postoperative weight loss after bariatric surgery, including the percentage of excess body weight loss (%EWL), percentage of total weight loss (%TWL), and percentage of excess body mass index (BMI) loss (%EBMIL). A repeated series of measurements should be considered to assess weight loss as accurately as possible. This study aimed to test weight loss metrics.

METHODS

Data were obtained from a prospective database of patients with obesity who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between 2016 and 2017 in a French tertiary referral bariatric center. A multilevel mixed-effects linear regression model with repeated measures was used to analyze repeated weight measurements over time.

RESULTS

A total of 435 patients underwent LRYGB (n = 266) or LSG (n = 169). At 2 years, the average %EWL, %EBMIL, and %TWL were 56.8%, 61.3%, and 26.6%, respectively. Patients who underwent LSG experienced lower weight loss (β: - 4233 in %TWL model, β: - 6437 in %EWL model, and β: - 6989 in %EBMIL model) than those who underwent LRYGB. In multivariate mixed analysis, preoperative BMI was not significantly associated with %TWL at 2 years (β, - 0.09 [- 0.22-0.03] p = 0.1). Preoperative BMI was negatively associated with both %EWL (β, - 1.61 [- 1.84-- 1.38] p < 0.0001) and %EBMIL (β, - 1.91 [- 2.16-- 1.66] p < 0.0001).

CONCLUSION

This is the first study to assess %TWL use for postoperative weight measurement, using a multilevel mixed-effects linear regression model %TWL is the measure of choice to assess weight loss following bariatric surgery.

Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies

Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.

Comparison of long-term outcomes after laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass for morbid obesity

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most bariatric procedures in Asia. However, a comparison of long-term outcomes is still limited.

OBJECTIVES

To compare the degree of long-term weight loss, remission of comorbidities and complication rates after LRYGB and LSG procedures.

METHODS

A retrospective analysis was conducted for all patients who underwent LSG or LRYGB between May 2005 and May 2018 at a single institute with at least 1-5 years of follow up. Demographic data were collected.

RESULTS

Of the total 342 patients, 159 underwent primary LSG and 183 patients underwent LRYGB. Preoperative BMI in the LSG group was significantly higher than the LRYGB group (54.7 ± 12.6 kg/m2 vs 48.2 ± 8.2 kg/m2, P = 0.001). Comorbidities between LSG and LRYGB groups were similar. Mean percentage of total weight loss (%TWL) at 5 years after was 23.6 ± 1.7 % in the LSG group vs. 29.9 ± 1.3 % in the LRYGB group (P = 0.005) and LRYGB resulted in greater weight loss than LSG at all time points. The remission of comorbidities were similar in both groups, except that dyslipidemia was significantly better in the LRYGB group. Overall complications were 35.2 % in the LSG group vs. 20.8 % in the LRYGB group (P = 0.003).

CONCLUSIONS

Our center revealed that LRYGB had better results than LSG in terms of percentage total weight loss at all time points. In the long term, LSG showed a higher overall complication rate compared to LRYGB.

Significant and distinct impacts of sleeve gastrectomy and Roux-en-Y gastric bypass on esophageal acid exposure, esophageal motility, and endoscopic findings: a systematic review and meta-analysis

BACKGROUND

The lack of standardized objective assessment of esophageal physiology and anatomy contributes to controversies regarding the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on gastroesophageal reflux disease. This study aimed to investigate esophageal acid exposure, esophageal motility, and endoscopic findings before and after SG and RYGB.

METHODS

This was a systematic review and meta-analysis of studies reporting at least 1 objective measure of esophageal physiology and/or esophagogastroduodenoscopy (EGD) at baseline and after SG or RYGB. The changes in pH test, manometry, and EGD parameters were summarized.

RESULTS

Acid exposure time (AET) and DeMeester score (DMS) significantly increased after SG (mean difference [MD]: 2.1 [95% CI, 0.3-3.9] and 8.6 [95% CI, 2.0-15.2], respectively). After RYGB, both AET and DMS significantly decreased (MD: -4.2 [95% CI, -6.1 to -2.3] and -16.6 [95% CI, -25.4 to -7.8], respectively). Lower esophageal sphincter resting pressure and length significantly decreased after SG (MD: -2.8 [95% CI, -4.6 to -1.1] and -0.1 [95% CI, -0.2 to -0.02], respectively). There were no significant changes in esophageal manometry after RYGB. The relative risks of erosive esophagitis were 2.3 (95% CI, 1.5-3.5) after SG and 0.4 (95% CI, 0.2-0.8) after RYGB. The prevalence rates of Barrett esophagus changed from 0% to 3.6% after SG and from 2.7% to 1.4% after RYGB.

CONCLUSION

SG resulted in the worsening of all objective parameters, whereas RYGB resulted in the improvement in AET, DMS, and EGD findings. Determining the risk factors associated with these outcomes can help in surgical choice.

A superior approach? The role of robotic sleeve gastrectomy in patients with super super obesity using the 2019-2022 MBSAQIP database

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) in patients with BMI ≥ 60 presents technical challenges, that might be overcome by robotic surgery, but its effectiveness has not been rigorously evaluated. We compared the 30-day outcomes of LSG and robotic sleeve gastrectomy (RSG) in patients with BMI < 60 versus ≥ 60 and between LSG and RSG in patients with BMI ≥ 60.

METHODS

Patients aged 18-65 years who underwent sleeve gastrectomy were included using the 2019-2022 MBSAQIP database. We performed a Propensity Score Matching analysis, with 21 preoperative characteristics. We compared 30-day postoperative outcomes for patients with BMI < 60 versus ≥ 60 using either a laparoscopic (Analysis 1) or robotic approach (Analysis 2) and compared LSG versus RSG in patients with BMI ≥ 60 (Analysis 3).

RESULTS

297,250 patients underwent LSG and 81,008 RSG. Propensity-matched¸ outcomes in analysis 1 (13,503 matched cases), showed that patients with BMI ≥ 60 had higher rates of mortality (0.1% vs. 0.0%, p = 0.014), staple line leak (0.3% vs. 0.2%, p = 0.035), postoperative bleeding (0.2% vs 0.1%, p = 0.028), readmissions (3.5% vs. 2.4%, p < 0.001), and interventions (0.7% vs. 0.5%, p = 0.028) when compared to patients with BMI < 60. In analysis 2 (4350 matched cases), patients with BMI ≥ 60 demonstrated longer operative times, length of stay, and higher rates of unplanned ICU when compared to patients with BMI < 60. In analysis 3 (4370 matched cases), patients who underwent RSG had fewer readmissions (2.9% vs. 3.7%, p = 0.037), staple line leaks (0.1% vs. 0.3%, p = 0.029), and postoperative bleeding (0.1% vs. 0.3%, p = 0.045), compared to LSG. Conversely, a longer operative time (92.74 ± 38.65 vs. 71.69 ± 37.45 min, p < 0.001) was reported.

CONCLUSION

LSG patients with BMI ≥ 60 have higher rates of complications compared to patients with a BMI < 60. Moreover, some outcomes may be improved with the robotic approach in patients with BMI ≥ 60. These results underscore the importance of considering a robotic approach in this super super obese population.

Staple Line Reinforcement during Sleeve Gastrectomy with SeamGuard: Single-Center Retrospective Case-Control Study over a 5-Year Period

Introduction: Various techniques and reinforcements have been proposed over the years in order to prevent leaks and bleeding after sleeve gastrectomy (LSG). The aim of this study was to retrospectively compare the staple line complication (SLC) rate in patients who underwent LSG with the use of bioabsorbable membrane (GORE® SEAMGUARD®, GoR) for staple line versus those who received no reinforcement. Methods: Data on all consecutive patients undergoing LSG between 1 January 2014 and 31 December 2018 were retrospectively reviewed. Patients were divided into two groups: the GoR+ group if the SeamGuard (GoR) was used and the GoR- group if no reinforcement was applied on the staple line. Preoperative demographics and rate of SLC were compared between groups. All cases of SLC coming from other centers were also reviewed. Results: A total number of 626 LSGs were performed at our institution during the study period. GoR was applied in 450 (71.9%) cases (GoR+ group), while NR was used in 176 (28.1%) patients (GoR- group). Two (1.13%) cases of leaking and two (1.13%) cases of bleeding occurred in the GoR- group, while no SLC was recorded in patients who received GoR (p < 0.05). Thirteen cases of SLC coming from other institutions were treated at our hospital; all these cases were performed without any SLR. Conclusion: In our case series, the use of GoR reduced the rate of SLC after LSG. In all cases of SLC coming from other institutions, no reinforcement had been applied on the staple line during LSG.

Generalizability of Randomized Clinical Trial Outcomes for Diabetes Control Resulting From Bariatric Surgery

Objective

To assess the external validity of randomized controlled trials (RCTs) of bariatric surgical treatment on diabetes control.

Background

Multisite RCTs provide the strongest evidence supporting clinical treatments and have the greatest internal validity. However, characteristics of trial participants may not be representative of patients receiving treatment in the real world. There is a need to assess how the results of RCTs generalize to all contemporary patient populations undergoing treatments.

Methods

All patients undergoing sleeve gastrectomy at University of California Los Angeles (UCLA) between January 8, 2018 and May 19, 2023 had their baseline characteristics, weight change, and diabetes control compared with those enrolled in the surgical treatment and medications potentially eradicate diabetes efficiently (STAMPEDE) and diabetes surgery study (DSS) RCTs of bariatric surgery's effect on diabetes control. Weight loss and diabetes control were compared between UCLA patients who did and did not fit the entry criteria for these RCTs.

Results

Only 65 (17%) of 387 patients with diabetes fulfilled the eligibility criteria for STAMPEDE, and 29 (7.5%) fulfilled the criteria for DSS due to being older, having higher body mass index, and lower HbA1c. UCLA patients experienced slightly less weight loss than patients in the RCTs but had similar diabetes control. The 313 (81%) patients not eligible for study entry into either RCT had similar long-term diabetes control as those who were eligible for the RCTs.

Conclusions

Even though only a very small proportion of patients undergoing bariatric surgery met the eligibility criteria for the 2 major RCTs, most patients in this contemporary cohort had similar outcomes. Diabetes outcomes from STAMPEDE and DSS generalize to most patients undergoing bariatric surgery for diabetes control.

Is YouTube Reliable to Teach Laparoscopic Gastric Bypass?

AIM

 The increasing prevalence of obesity has led to the popularity of bariatric surgery. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most complex methods in bariatric surgery. The main steps of LRYGB were determined in the Delphi Consensus. This study investigated the instructiveness and reliability of YouTube videos about LRYGB based on the Delphi Consensus.

METHODS

In February 2024, three different searches were done in the search bar of the YouTube platform with the terms "laparoscopic gastric bypass" "laparoscopic Roux-en-Y gastric bypass" and "laparoscopic RYGB". The first 50 videos in each search were evaluated. Animations, lectures, advertisements, non-English videos, and non-surgical videos (pre-surgery, post-surgery vlog, etc.) were excluded from the study. Delphi consensus steps were used to determine the reliability of the videos. The quality of the videos was measured using the Global Quality Scale (GQS) and modified DISCERN test.

RESULTS

Forty-five videos were included in the evaluation. While 14 (31.1%) of these videos were classified as reliable, 31 (68.8%) were not found reliable. In reliable videos, video description, high definition (HD) resolution, GQS, and modified DISCERN were significantly higher (p-value 0.023, 0.004, 0.017, and 0.025 respectively).

CONCLUSION

The rate of unreliable videos was higher on the YouTube platform. We conclude that YouTube alone is insufficient to learn LRYGB.

Long-term weight loss of distal gastric bypass is moderately superior compared to proximal gastric bypass in patients with a BMI of 37-44 Kg/m2

PURPOSE

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the standard procedures in metabolic surgery. Different limb lengths have been proposed in the past to maximize weight loss (WL) and reduce metabolic complications. Distal gastric bypass surgery with a very short common channel (CC) (up to 100 cm) has been often criticized due to frequent side effects such as malnutrition, bone weakening and short-bowel syndrome. We introduced a modified version of a distal LRYGB with a 50-70 cm long biliopancreatic limb (BPL) and an intermediate short CC (120-150 cm). Our primary goal was to compare the long-term WL between distal and proximal LRYGB in two cohorts of patients. Secondary outcomes were weight regain (WR), insufficient weight loss (IWL), postoperative complications and metabolic changes 5 years after surgery.

METHODS

In this retrospective study we collected data from 160 patients operated between 2014 and 2015, with a BMI of 37-44 Kg/m2. 101 patients underwent a distal and 59 patients a proximal LRYGB in two bariatric centers. WL was calculated as percent of excess of BMI loss (%EBMIL), loss of body mass index (Delta-BMI), percent of excess weight loss (%EWL) and percent of total weight loss (%TWL). Data were collected 3, 6, 9, 12, 24, 48 and 60 months after surgery.

RESULTS

The distal LRYGB resulted in significantly better 5-year-WL compared to the proximal bypass in terms of %EBMIL (median at 5 years: 83% vs. 65%, p = 0.001), %TWL (median at 5 years: 32% vs. 26%, p = 0.017) and %EWL (median at 5 years: 65% vs. 51%, p = 0.029), with equal major complications and metabolic alterations. In addition, WR was significantly lower in patients with distal bypass (18% vs. 35%, p = 0.032).

CONCLUSIONS

Distal LYRGB with a 120-150 long CC results in better WL and WL-maintenance compared to proximal LRYGB without major side effects after five years.

Evaluation of the effect of sleeve gastrectomy versus Roux-en-Y gastric bypass in patients with morbid obesity: multicenter comparative study

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most performed techniques in bariatric surgery. The aim of this study is to compare two surgical procedures in terms of weight loss and the development of comorbidities such as type II diabetes mellitus T2D, arterial hypertension, sleep apnea (OSAS), and gastroesophageal reflux disease (GERD).

METHODS

Data from the German Bariatric Surgery Registry (GBSR) from 2005 to 2021 were used. 1,392 RYGB and 1,132 SG primary surgery patients were included. Minimum age 18 years; five-year follow-up data available. Tests were performed with a 5% significance level.

RESULTS

Loss of follow-up 95.41% within five years. Five years after surgery, the RYGB showed significant advantages in terms of excess weight loss (%EWL 64.2% vs. 56.9%) and remission rates of the studied comorbidities: hypertension (54.4% vs. 47.8%), OSAS (64.5% vs. 50.1%), and GERD (86.1% vs. 66.9%). Compared to the pre-test, individuals diagnosed with insulin-dependent T2D showed significant improvements with RYGB over a five-year period (remission rate: 75% vs. 63%). In contrast, non-insulin-dependent T2D showed no significant difference between the two approaches (p = 0.125).

CONCLUSION

Both surgical procedures resulted in significant weight loss and improved comorbidities. However, the improvement in comorbidities was significantly greater in patients who underwent RYGB than in those who underwent SG, suggesting that the RYGB technique is preferable. Nevertheless, RYGB requires a high degree of surgical skill. Therefore, acquiring expertise in the technical facets of the surgery is essential to achieving favorable outcomes.

Research on the mechanism of regulating spleen-deficient obesity in rats by bawei guben huashi jiangzhi decoction based on multi-omics analysis

ETHNOPHARMACOLOGY RELEVANCE

Bawei Guben Huashi Jiangzhi Decoction (BGHJ), a traditional Chinese compound formula, comprises eight Chinese medicinal herbs: Codonopsis Radix, Atractylodis Macrocephalae Rhizoma, Cassiae Semen, Lysimachiae Herba, Edgeworthiae Gardner Flos, Oryzae Semen cum Monasco, Nelumbinis Folium, and Alismatis Rhizoma. It has the therapeutic effects of improving digestive and absorptive functions of the gastrointestinal tract, reducing cholesterol levels, and helping to lose weight. Therefore, BGHJ is mainly used to treat spleen-deficient obesity (SDO) clinically.

AIM OF THE STUDY

This study aims to examine the efficacy and mechanism of BGHJ in a model of SDO in rats, as well as the potentially involved constituents entering the blood and differential metabolites.

METHODS

The SDO rat model was replicated utilizing a high-fat and high-sugar diet in conjunction with exhaustive swimming. Subsequently, the rats were subjected to a six-week intervention comprising varying dosages of BGHJ and a positive control, orlistat. To evaluate the efficacy of BGHJ on SDO model rats, we first measured the rats' body weight, body surface temperature, spleen index, as well as biochemical indicators in the serum and colon, and then assessed the pathological state of the colon and liver. Afterward, we analyzed the 16S rDNA gut microbiota, non-targeted serum metabolomics, and serum pharmacology to study the main active components of BGHJ and its action mechanism against SDO model rats. In addition, we constructed a network diagram for overall visualization and analysis, and experimentally verified the predicted results. Finally, we used quantitative polymerase chain reaction (qPCR) to detect the gene expression of proopiomelanocortin (POMC) and neuropeptide Y (NPY) indicators in rat hypothalamic neurons. We quantitatively targeted the detection of neurotransmitters dopamine (DA), acetylcholine (Ach), 5-hydroxytryptamine (5-HT), and noradrenaline (NA) in rat hypothalamus.

RESULTS

The results demonstrated that all dosage regimens of BGHJ exhibited the capacity to moderately modulate parameters including body weight, surface temperature, spleen index, total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), glucagon-like peptide-1 (GLP-1), cholecystokinin (CCK), 5-HT, interleukin 6 (IL-6) and interleukin 17 (IL-17), while concurrently reducing hepatic lipid droplet deposition and restoring intestinal integrity. Subsequent experimental results showed that we successfully identified 27 blood components of BGHJ and identified 52 differential metabolites in SDO model rats. At the same time, the experiment proved that BGHJ could effectively inhibit the metabolic pathway of arachidonic acid. In addition, BGHJ can also restore the intestinal microbiota composition of SDO model rats. Finally, we also found that BGHJ could regulate the expression of hypothalamic neurons and neurotransmitters.

CONCLUSIONS

The research revealed the main active ingredients of BGHJ and its mechanism against SDO model rats through gut microbiota, non-target serum metabolomics, and serum drug chemistry.

Peroperative administration of tranexamic acid in Roux-en-Y and one-anastomosis gastric bypass to reduce haemorrhage in patients with morbid obesity: protocol for randomised controlled trial (PATRY trial)

INTRODUCTION

By implementation of Enhanced Recovery After Bariatric Surgery protocols and day-care surgery, early discharge poses a challenge if excessive bleeding occurs after bariatric surgery. Tranexamic acid (TXA) has demonstrated efficacy in other surgical fields and in bariatric pilot studies. This trial aims to assess the efficacy of peroperative administration of TXA in reducing haemorrhage in patients undergoing gastric bypass surgery.

METHOD AND ANALYSIS

This is a multicentre, phase III, double-blind randomised controlled trial in six high-volume bariatric centres in the Netherlands. A total of 1524 eligible patients, aged 18 years or older, undergoing primary gastric bypass surgery (either Roux-en-Y gastric bypass or one-anastomosis gastric bypass) will be randomised between TXA and placebo (1:1, variable block, stratified for centre, day-care/overnight stay and type of surgery) after obtaining informed consent (2.5% less haemorrhage, power 80%, 2-sided-α 0.05 and 10% dropout). Exclusion criteria are pregnancy, amedical history of acute bleeding (without cause), venous thrombotic events (VTEs), epilepsy, anticoagulant use and iatrogenic bleeding during surgery (aside from staple line). The primary outcome is postoperative haemorrhage requiring intervention within 30 days postoperatively. Secondary outcome measures are staple line reinforcement, blood loss, duration of surgery, postoperative haemoglobin, vital parameters, minor and major complications, side effects of TXA (nausea, hypotension and VTE), length of hospital stay and directly made costs.

ETHICS AND DISSEMINATION

Written informed consent will be obtained from all participants. The protocol has been approved by the Medical Research Ethics Committees United, Nieuwegein, on 7 February 2023 (registration number: R22.102). Results will be disseminated through peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

NCT05464394.

Randomized controlled trials comparing gastric bypass, gastric band, and sleeve gastrectomy: A systematic review examining validity and applicability to wider clinical practice

Consideration of how applicable the results of surgical trials are to clinical practice is important to inform decision-making. Randomized controlled trials comparing at least two surgical interventions (of gastric bypass, gastric band, and sleeve gastrectomy) for severe and complex obesity were examined using the PRagmatic Explanatory Continuum Indicator Summary-2 tool, to consider how applicable the trial results are to clinical practice, and the Risk of Bias 2 tool, to examine validity. MEDLINE, Embase, and CENTRAL databases were searched for studies published between November 2013 and June 2021, and 15 were identified. Using the PRagmatic Explanatory Continuum Indicator Summary-2 tool, three were classified as pragmatic, with good applicability to clinical practice. Ten had more explanatory domains but did include some pragmatic characteristics, and two were predominantly explanatory. This was due to some trial design features that would not be considered applicable to the wider clinical setting, including being single-centered, having prescribed intervention delivery methods, and intensive follow-up regimens. Only two trials had low risk of bias, of which one was considered pragmatic. Three had high risk of bias. Overall, few trials in bariatric surgery are pragmatic with low risk of bias. Well-designed pragmatic trials are needed to inform practice and reduce research waste.

Gastro-esophageal diagnostic workup before bariatric surgery or endoscopic treatment for obesity: position statement of the International Society of Diseases of the Esophagus

Obesity is a chronic and multifactorial condition characterized by abnormal weight gain due to excessive adipose tissue accumulation that represents a growing worldwide challenge for public health. In addition, obese patients have an increased risk of hiatal hernia, esophageal, and gastric dysfunction, as well as gastroesophageal reflux disease, which has a prevalence over 40% in those seeking endoscopic or surgical intervention. Surgery has been demonstrated to be the most effective treatment for severe obesity in terms of long-term weight loss, comorbidities, and quality of life improvements and overall mortality decrease. The recent emergence of bariatric endoscopic techniques promises less invasive, more cost-effective, and reproducible approaches to the treatment of obesity. With the endorsement of the International Society for Diseases of the Esophagus, we started a Delphi process to develop consensus statements on the most appropriate diagnostic workup to preoperatively assess gastroesophageal function before bariatric surgical or endoscopic interventions. The Consensus Working Group comprised 11 international experts from five countries. The group consisted of gastroenterologists and surgeons with a large expertise with regard to gastroesophageal reflux disease, bariatric surgery and endoscopy, and physiology. Ten statements were selected, on the basis of the agreement level and clinical relevance, which represent an evidence and experience-based consensus of the International Society for Diseases of the Esophagus.

Contemporary management of obesity: A comparison of bariatric metabolic surgery and novel incretin mimetic drugs

The global prevalence of obesity has risen sharply during the past half-century, reaching pandemic proportions and creating a public health crisis. Obesity is a recognized risk factor for the development of diabetes, atherosclerosis, hypertension, hepatic steatosis, and many other cardiometabolic disorders with significant resultant morbidity and mortality. Though treatment of obesity can prevent or slow the progression of these aforementioned illnesses, efforts to help patients achieve reliable and sustainable weight loss have had limited success. While improving nutrition and increasing physical activity results in a host of health benefits, the weight loss achieved with lifestyle interventions alone is modest and difficult to sustain. Early attempts at medical and surgical treatment of obesity were plagued with adverse effects and complications. Moreover, these approaches failed to demonstrate long-term health benefits, even when weight loss was achieved. Recently, novel incretin-based therapies targeting glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptors have gained popularity due to their effectiveness in achieving substantial weight loss in patients both with and without diabetes. After many successful clinical trials, there are now multiple GLP-1 and one dual GLP-1-GIP receptor agonists FDA approved for chronic weight management. Advancements in laparoscopic surgical technique and refinements in procedure selection have similarly improved the safety and efficacy of bariatric metabolic surgery for achieving weight reduction in overweight and obese patients. In this review, we discuss the advantages and disadvantages of contemporary pharmacologic and surgical weight management strategies. We review the data regarding expected weight loss, glycemic control, cardiometabolic benefits, and potential adverse effects of various treatment approaches. As obesity rates continue to rise worldwide, it is imperative that clinicians keep these considerations in mind in order to better care for patients.

Effect of oesophagectomy on lipid profiles in patients with oesophageal cancer combined with hyperlipidaemia: a retrospective study

BACKGROUND

Surgery is widely regarded as a pivotal therapeutic approach for treating oesophageal cancer, and clinical observations have revealed that many oesophageal cancer patients also present with concomitant hyperlipidaemia. It is surprising that few studies have been performed to determine how blood lipid levels are affected by oesophageal cancer resection. This research was designed to assess the influence of oesophageal cancer resection on lipid profiles among individuals diagnosed with both oesophageal cancer and hyperlipidaemia.

METHODS

A retrospective analysis was carried out on 110 patients with hyperlipidaemia and oesophageal cancer who had undergone oesophagectomy at the 900th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army. Preoperative and postoperative serological data were collected at seven-, thirty-, sixty-day-, and one-year-long intervals. Changes in lipid levels were compared, the remission of various types of hyperlipidaemia was statistically assessed, and Pearson correlation was used to analyse the association between lipid changes and preoperative body weight. The research sought to assess the reduction in body weight and the proportion of body weight lost one year following surgery.

RESULTS

Noteworthy decreases were observed in total cholesterol (TC), triglyceride (TG), and low-density lipoprotein (LDL) levels, with TC decreasing from 6.20 mmol/L to 5.20 mmol/L, TG decreasing from 1.40 mmol/L to 1.20 mmol/L, and LDL decreasing from 4.50 mmol/L to 3.30 mmol/L. Conversely, there was a notable increase in high-density lipoprotein (HDL) levels, which increased from 1.20 mmol/L to 1.40 mmol/L (P < 0.05) compared to the preoperative levels. Notably, the remission rates for mixed hyperlipidaemia (60.9%) and high cholesterol (60.0%) were considerably greater than those for high triglycerides (16.2%). Alterations in TC at one year postoperatively correlated with preoperative weight and weight loss (r = 0.315, -0.216); changes in TG correlated with preoperative weight, percentage of total weight loss (TWL%), and weight reduction (r = -0.295, -0.246, 0.320); and changes in LDL correlated with preoperative weight, TWL%, and weight loss (r = 0.251, 0.186, and -0.207). Changes in non-high-density lipoprotein(non-HDL) were linked to preoperative weight (r = 0.300), and changes in TG/HDL were correlated with preoperative weight and TWL% (r = -0.424, -0.251).

CONCLUSIONS

Oesophagectomy significantly improved lipid profiles in oesophageal cancer patients, potentially leading to a reduction in overall cardiovascular risk.

Application of Biomarkers in Obese Infertile Women: A Genetic Tool for a Personalized Treatment

This study investigates links between CART and leptin gene expression, FSH receptor Asn680Ser polymorphism, and reproductive hormones in morbidly obese patients under 40 years old, facing infertility, and undergoing bariatric surgery. A total of 29 women were included in this study. A hormonal profile along with detection of CART and leptin gene expression was evaluated before and after bariatric surgery. Additionally, the presence or absence of Asn680Ser of the FSHR gene was studied. Following bariatric surgery, a mean reduction in BMI (16.03 kg/m2) was observed in all women. FSH levels preoperatively varied significantly among genotypes, with medians of 8.1, 9.5, and 10.3 for individuals without polymorphism, heterozygotes, and homozygotes, respectively (p = 0.0408). Post surgery, marginal differences in FSH levels were observed (5.8, 7.1, and 8.2, respectively) (p = 0.0356). E2 and LH levels exhibited no significant genotype-based differences pre and post surgery. Presurgical E2 levels were 29.6, 29.8, and 29.6, respectively (p = 0.91634), while postsurgical levels were 51.2, 47.8, and 47 (p = 0.7720). LH levels followed similar patterns. Our findings highlight bariatric surgery's positive impact on BMI reduction and its potential connection to genetic markers, hormones, and infertility. This suggests personalized treatments and offers a valuable genetic tool for better fertility outcomes in obese individuals.

Genetic risk score based on obesity-related genes and progression in weight loss after bariatric surgery: a 60-month follow-up study

BACKGROUND

Obesity is a polygenic multifactorial disease. Recent genome-wide association studies have identified several common loci associated with obesity-related phenotypes. Bariatric surgery (BS) is the most effective long-term treatment for patients with severe obesity. The huge variability in BS outcomes between patients suggests a moderating effect of several factors, including the genetic architecture of the patients.

OBJECTIVE

To examine the role of a genetic risk score (GRS) based on 7 polymorphisms in 5 obesity-candidate genes (FTO, MC4R, SIRT1, LEP, and LEPR) on weight loss after BS.

SETTING

University hospital in Spain.

METHODS

We evaluated a cohort of 104 patients with severe obesity submitted to BS (Roux-en-Y gastric bypass or sleeve gastrectomy) followed up for >60 months (lost to follow-up, 19.23%). A GRS was calculated for each patient, considering the number of carried risk alleles for the analyzed genes. During the postoperative period, the percentage of excess weight loss total weight loss and changes in body mass index were evaluated. Generalized estimating equation models were used for the prospective analysis of the variation of these variables in relation to the GRS.

RESULTS

The longitudinal model showed a significant effect of the GRS on the percentage of excess weight loss (P = 1.5 × 10-5), percentage of total weight loss (P = 3.1 × 10-8), and change in body mass index (P = 7.8 × 10-16) over time. Individuals with a low GRS seemed to experience better outcomes at 24 and 60 months after surgery than those with a higher GRS.

CONCLUSION

The use of the GRS in considering the polygenic nature of obesity seems to be a useful tool to better understand the outcome of patients with obesity after BS.

A Matched Comparative Analysis of Type-2 Diabetes Mellitus Remission Between Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

OBJECTIVE

Multiple scores validate long-term type-2 diabetes mellitus (T2DM) remission after metabolic and bariatric surgery (MBS). However, studies comparing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) have not adequately controlled for certain parameters, which may influence procedure selection.

METHODS

We conducted a multicenter retrospective review of patients with T2DM who underwent RYGB or SG between 2008 and 2017. Data on demographics, clinical, laboratory, and metabolic values were collected annually for up to 14 years. Each eligible RYGB patient was individually matched to an eligible SG patient based on diabetes severity, weight loss, and follow-up duration.

RESULTS

Among 1149 T2DM patients, 467 were eligible for matching. We found 97 matched pairs who underwent RYGB or SG. RYGB showed significantly higher T2DM remission rates (46.4%) compared to SG (33.0%) after matching. SG patients had higher insulin usage (35.1%) than RYGB patients (20.6%). RYGB patients also experienced greater decreases in HbA1c levels and diabetes medication usage than SG patients.

CONCLUSIONS

RYGB demonstrates higher efficacy for T2DM remission compared to SG, regardless of baseline characteristics, T2DM severity, weight loss, and follow-up duration. Further studies are needed to understand the long-term metabolic effects of MBS and the underlying pathophysiology of T2DM remission after MBS.

Sleeve Gastrectomy Reduces the Need for Liver Transplantation in Patients with Obesity and Non-Alcoholic Steatohepatitis: a Predictive Model

BACKGROUND

Non-alcoholic steatohepatitis (NASH) is one of the leading indications for liver transplantation (LT) in the United States. As with the current obesity epidemic, the incidence of NASH continues to rise. However, the impact of broad utilization of bariatric surgery (BS) for patients with NASH is unknown, particularly in regard to mitigating the need for LT.

METHODS

Markov decision analysis was performed to simulate the lives of 20,000 patients with obesity and concomitant NASH who were deemed ineligible to be waitlisted for LT unless they achieved a body mass index (BMI) < 35 kg/m2. Life expectancy following medical weight management (MWM) and sleeve gastrectomy (SG) were estimated. Base case patients were defined as having NASH without fibrosis and a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed.

RESULTS

Simulated base case analysis patients who underwent SG gained 14.3 years of life compared to patients who underwent MWM. One year after weight loss intervention, 9% of simulated MWM patients required LT compared to only 5% of SG patients. Survival benefit for SG was observed above a BMI of 32.2 kg/m2.

CONCLUSION

In this predictive model of 20,000 patients with obesity and concomitant NASH, surgical weight loss is associated with a reduction in the progression of NASH, thereby reducing the need for LT. A reduced BMI threshold of 32 kg/m2 for BS may offer survival benefit for patients with obesity and NASH.

Effects of Preoperative Quadruple Therapy for Helicobacter pylori on Bariatric Surgery Metabolic Outcomes

PURPOSE

To assess the effects of Helicobacter pylori (HP) eradication with an omeprazole, clarithromycin, amoxicillin, and metronidazole (OCAM) regimen on the metabolic profile and weight loss 12 months after bariatric surgery (BS).

METHODS

Retrospective analysis of a prospective cohort of patients with morbid obesity undergoing BS. HP presence was tested preoperatively by gastric biopsy and treated with OCAM when positive. Short-term metabolic outcomes and weight loss were evaluated.

RESULTS

HP infection was detected in 75 (45.7%) of the 164 patients included. OCAM effectiveness was 90.1%. HP-negative patients had a greater reduction in glucose levels at 3 (-14.6 ± 27.5 mg/dL HP-treated vs -22.0 ± 37.1 mg/dL HP-negative, p=0.045) and 6 months (-13.7 ± 29.4 mg/dL HP-treated vs -26.4 ± 42.6 mg/dL HP-negative, p= 0.021) and greater total weight loss (%TWL) at 6 (28.7 ± 6.7% HP-treated vs 30.45 ± 6.48% HP-negative, p= 0.04) and 12 months (32.21 ± 8.11% HP-treated vs 35.14 ± 8.63% HP-negative, p= 0.023).

CONCLUSIONS

Preoperative treatment with OCAM has been associated to poorer glycemic and weight loss outcomes after BS. More research is needed on the influence of OCAM on gut microbiota, and in turn, the effect of the latter on metabolic and weight loss outcomes after BS.

Characterization of Early Small Bowel Obstructions Following Elective Bariatric Surgery

PURPOSE

Small bowel obstruction (SBO) after bariatric surgery is an uncommon but important complication. We sought to characterize bariatric surgery patients who developed SBO, to compare 30-day complications, and to determine the influence of patient and procedure factors on the development of SBO.

METHODS AND MATERIALS

All data was extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database using the 2020 operative year. Multivariable logistic regression modelling was used to determine the influence of patient and operative factors on the development of SBO.

RESULTS

Of a total of 142 111 patients, 408 (0.3%) were identified as having developed an SBO. SBO patients were older (45.7 ± 11.5 vs. 43.5 ± 11.9 years; p = 0.0002), of reduced BMI (43.6 ± 6.8 vs. 45.1 ± 7.7; p = 0.0001), and more likely to be of female sex (92.2% vs. 81.1%; p < 0.0001). At 30 days post-operation, serious complications were increased in SBO patients. Roux-en-Y gastric bypass (RYGB) was the largest independent predicator of the development of SBO (OR 11.91; 95% CI 8.92-15.90; p < 0.0001). With regard to patient factors, COPD (OR 2.60; 95% CI 1.54-4.38; p < 0.0001) and prior DVT (OR 2.37; 95% CI 1.49-3.77; p < 0.0001) were found to be independently predictive of the development of SBO. Additionally having a lower BMI and being of female sex were found to be independently predictive.

CONCLUSION

SBO occurred in approximately 0.3% of MBSAQIP cases. SBO is associated with serious outcome measures and patients of female sex and reduced index BMI, and those undergoing RYGB may be at an increased risk.

Safety and Efficacy of LSG Versus LRYGB on Patients with Obesity: a Systematic Review and Meta-analysis from RCTs

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the two most frequently performed techniques in treating obesity and its related comorbidities. We aimed to compare the clinical efficacy and safety of LSG with LRYGB in terms of short- and mid-term outcomes of weight loss, obesity-related comorbidities, and post-operative complications via a meta-analysis of RCTs.

METHODS

Clinical comparative RCTs on LSG and LRYGB were searched through PubMed, MEDLINE, and Web of Science databases from inception to August 2022. Pooled outcomes from the selected studies were discussed by the random-effect meta-analysis method. Quality assessment and risk of bias for selected RCTs were implemented, and all the statistical analyses were performed.

RESULTS

Twenty studies, including 1270 patients, were enrolled. Meta-analysis results indicated the great superior efficacy of LRYGB to LSG in BMI loss at 6 (MD -1.35 kg/m2, 95% CI: -2.07 to -0.62, p = 0.0003), 12 months (MD -1.09 kg/m2, 95% CI: -1.86 to -0.33, p = 0.005), and 36 months (MD -1.47 kg/m2, 95% CI: -2.77 to -0.16, p = 0.03) as well as %EWL gaining at 36 months. Significantly higher remission rates of T2DM and dyslipidemia were achieved by LRYGB at 12 months. Besides, better improvements for T2DM-related and lipid biochemical parameters were found favoring LRYGB. However, LSG resulted in a lower post-operative complication rate and shorter operating time.

CONCLUSIONS

Present meta-analysis results suggested that LRYGB was superior to LSG concerning short- and mid-term weight loss, short-term T2DM remission efficacy, and related biochemical parameters. LSG is favored for obviously fewer complications and shorter operating time.

Bariatric surgery post-liver transplantation: A Belgian nationwide study

Weight gain poses a rising concern post-liver transplantation (LT), and metabolic dysfunction-associated steatotic liver disease might impair graft health. The timing is crucial when considering bariatric surgery (BS) in a population with liver disease or transplantation. BS can be considered for post-LT weight gain, although the evidence is limited and the long-term outcome still uncertain. We conducted a national retrospective analysis in 5 Belgian transplant centers and included 25 patients with an LT followed by a bariatric procedure. A total of 187 LT patients without BS were included for comparison. Clinical, biochemical, and outcome data were retrospectively retrieved. In our nationwide cohort, 25 patients had undergone BS post-LT, at a median 3.5 years after LT. Twenty-one (84.0%) patients received a sleeve gastrectomy (SG). Patients were predominantly male (72.0%), with a lower age at time of transplantation compared with the non-BS population (54.5 vs. 60.6, p <0.001). Weight loss was significant and sustained, with a decrease in body mass index from 41.0±4.5 pre-BS to 32.6±5.8 1-3 years post-BS ( p <0.001) and 31.1±5.8 3-5 years post-BS ( p <0.001). Three pre-BS (12.0%) patients presented with recurrent and one (4.0%) de novo metabolic dysfunction-associated steatotic liver disease after LT, with 100% resolution post-BS ( p =0.016). Notable reductions were observed in alanine transaminase levels (40.5±28.5 U/L to 27.1±25.1 U/L post-BS, p =0.05) and HbA1c levels (6.9±1.6 to 6.0±1.4 post-BS, p <0.001). Three patients were re-transplanted, and eight patients died, of which five (20.0%) due to a nonhepatic malignancy and one (4.0%) due to liver failure. SG is the favored BS post-LT and has proven to be safe and feasible in a post-LT setting with favorable metabolic consequences. SG post-LT is a valid treatment for de novo and recurrent metabolic dysfunction-associated steatotic liver disease post-LT. Although we report on the largest cohort to date, there is still a need for larger cohorts to examine the effect of BS on patient and graft survival.

β-Cell Function and Insulin Dynamics in Obese Patients With and Without Diabetes After Sleeve Gastrectomy

Improved β-cell function seems to be essential for better glucose homeostasis after Roux-en-Y gastric bypass but is less studied after sleeve gastrectomy (SG). We evaluated the effects of SG on β-cell function in obese patients with diabetes (DM group) and without (control group) in response to both oral and intravenous glucose stimulation. The DM group demonstrated impaired insulin sensitivity and insulin response to glucose before surgery. The insulin sensitivity index of both groups significantly improved after SG. In addition, the insulin response to glucose (early insulinogenic index in oral glucose tolerance test and acute insulin response to glucose in an intravenous glucose tolerance test) increased in the DM group but decreased in the control group. As a result, β-cell function improved significantly in both groups after SG since the disposition index (DI) increased in both. However, the DI of the DM group was not restored to the level of control group up to 1 year after SG. Our results support that obese patients, with and without diabetes, could benefit from SG in β-cell function. For obese patients at risk for or who have been diagnosed with diabetes, interventions should be recommended early to preserve or restore β-cell function, and SG could be an effective choice. Further studies are needed for long-term effects.

ARTICLE HIGHLIGHTS

Effects of laparoscopic sleeve gastrectomy on thyroid hormones and relationship between metabolic parameters and long-term total weight loss

BACKGROUND

Bariatric surgery has significant effects on metabolic parameters and hormone levels. However, the specific impact of laparoscopic sleeve gastrectomy (LSG) on thyroid hormones and other metabolic parameters remains unclear. This study aimed to investigate the short and long-term effects of LSG on thyroid hormone levels, HbA1c, and other metabolic parameters.

METHODS

A total of 619 euthyroid patients without a history of thyroid disease or thyroid hormone replacement therapy were included in the study. Patients with diabetes were excluded from the study. Preoperative, 1-year postoperative, and 5-year postoperative levels of thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), HbA1c, and other metabolic parameters were recorded and analyzed.

RESULTS

LSG resulted in significant weight loss and improvements in metabolic parameters. At 1 year postoperatively, there were significant reductions in BMI, HbA1c, TSH, fT3, and triglyceride levels, while fT4 levels increased. A statistically significant negative correlation was found between preoperative HbA1c level and percentage of total weight loss (%TWL) value at the fifth postoperative year. Additionally, a statistically significant negative correlation was found between the 5-year change in TSH and %TWL.

CONCLUSION

Being the first study to predict long-term total weight loss based on preoperative HbA1c, it is significant. This finding has important implications for personalized patient management and could aid clinicians in identifying individuals who may benefit most from sleeve gastrectomy as a treatment modality. This is valuable in that it emphasizes multidisciplinary work, including the endocrinologist and dietician.

Comparison of health care costs following sleeve gastrectomy versus Roux-en-Y gastric bypass among patients with type 2 diabetes

OBJECTIVE

The objective of this study was to compare the impact of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on overall and diabetes-specific health care costs among patients with type 2 diabetes.

METHODS

This retrospective cohort study examined patients with type 2 diabetes after SG and RYGB using data from Optum's deidentified Clinformatics® Data Mart database. The matched study group included 9608 patients who underwent SG or RYGB and were enrolled between 2007 and 2019. The primary outcomes assessed were overall and diabetes-specific health care costs.

RESULTS

Health care costs associated with type 2 diabetes declined substantially in the first few years following both SG and RYGB. RYGB was associated with a larger decrease in pharmacy costs, as well as type 2 diabetes-specific office and laboratory costs. SG was associated with lower total health care costs in the first three follow-up periods and lower acute care costs in the first 2 years after surgery.

CONCLUSIONS

In this nationwide study, patients with type 2 diabetes at baseline undergoing RYGB appear to experience a reduced need for ambulatory type 2 diabetes monitoring and reduced requirements for antidiabetes medication but, despite this, did not experience an overall medical cost-benefit in the first few years after RYGB versus SG.

Endoscopic Management of Post-Sleeve Gastrectomy Complications

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

The Art of Sleeve Gastrectomy

Sleeve gastrectomy (SG) has historically evolved from gastroplasty and anti-reflux procedures into one of the most commonly performed primary metabolic surgeries in the United States and worldwide. Initially initiated in the 1980s as part of the duodenal switch procedure, its standalone effectiveness and simplicity have led to increasing popularity globally. The rise in obesity rates transcends age boundaries, alarmingly affecting not only adults but also the younger demographic. This escalating trend is concerning, as it predisposes these populations to numerous future health complications, as well as highlighting the critical necessity for a safe and potent weight loss strategy. Although sleeve gastrectomy carries a higher risk for gastroesophageal reflux disease (GERD) compared to other bariatric procedures, it stands out as a reliable, safe and effective surgical solution for obesity. It is particularly beneficial for adolescents and patients with complex medical comorbidities, including, but not limited to, heart failure and immunocompromisation. It has also served as a bridge for transplants in morbidly obese patients with end-stage heart, liver and kidney disease due to its favorable safety profile.

Roux-en-Y gastric bypass versus fundoplication for gastroesophageal reflux disease in patients with obesity results in comparable outcomes

BACKGROUND

Roux-en-Y gastric bypass and fundoplication are effective treatments for gastroesophageal reflux disease, though the optimal procedure of choice in obesity is unknown. We hypothesize that Roux-en-Y gastric bypass is non-inferior to fundoplication for symptomatic control of gastroesophageal reflux disease in patients with obesity.

METHODS

We conducted a retrospective review of a prospectively maintained quality database. Patients with a body mass index ≥of 35 who presented for gastroesophageal reflux disease and subsequently underwent Roux-en-Y gastric bypass or fundoplication were included. Perioperative outcomes and pH testing data were reviewed. Patient-reported outcomes included Reflux Symptom Index, Dysphagia, Gastroesophageal Reflux Disease-Health Related Quality of Life, and Short Form-36 scores. Data were analyzed using the Wilcoxon rank sum test.

RESULTS

Ninety-five patients underwent fundoplication (n = 72, 75.8%) or Roux-en-Y gastric bypass (n = 23, 24.2%) during the study period. All patients saw an improvement in gastroesophageal reflux disease symptoms and overall quality of life. There were no significant differences in postoperative Reflux Symptom Index, Dysphagia, or Short-Form-36 scores. Significant differences in gastroesophageal reflux disease-Health Related Quality of Life scores were seen at preoperative, 1, 2, and 5 years postoperative (P < .05), with better symptom control in the fundoplication group. No significant difference was noted in postoperative DeMeester scores or percent time pH <4. Weight loss was significantly higher in the Roux-en-Y gastric bypass group at all postoperative time points up to 5 years (P < .05).

CONCLUSION

Roux-en-Y gastric bypass and fundoplication both decrease gastroesophageal reflux disease symptoms. Subjective data shows that patients undergoing Roux-en-Y gastric bypass may complain of worse symptoms compared to patients undergoing fundoplication. Objective data notes no significant difference in postoperative pH testing. Despite previous data, offering fundoplication or Roux-en-Y gastric bypass to patients with a body mass index of ≥35 kg/m2 is appropriate. The choice of surgical approach should be more directed to patient needs and desired goals at the time of the initial clinic visit.

Sleeve Gastrectomy: Literature Results

Sleeve gastrectomy (SG) is the most frequently performed bariatric procedure globally. However, data regarding short- and long-term results remain insufficient. This study aimed to evaluate the short- and longterm effects of SG. We performed a thorough PubMed search for references that mentioned sleeve gastrectomy was carried out. In terms of weight loss and resolution of comorbid disorders, the immediate results have been encouraging. Although long-term results are still being obtained, a large number of individuals have experienced persistent weight loss. Eight short-term studies were extracted for the present review. Each study clarified that SG was utilized as a management technique for a high-risk patient population or as a component of a stepwise therapeutic procedure. The laparoscopic SG method was examined in all studies. The percentage of patients who were followed up for 30 days or longer after LSG was reported. Significant weight loss has been observed in studies that evaluated short-term results. An excess weight loss of 67.3% and a significant decrease in body mass index (BMI) were observed in a systematic evaluation of 5,218 patients. In long-term studies, SG was administered to 2713 patients, of whom 1626 completed the five-year follow-up period. Among all patients, 71.3% were women and 28.7% men. The mean BMI before surgery was 46.9 kg/m². The follow-up durations ranged from 5 to 11 years. The mean five-year follow-up rate was 66% (range 57-100%). At 5, 6, 7, 8 and 11 years, the mean percentage excess weight decreases were 58.4%, 59.5%, 56.6% and 62.5%, respectively. Five years after SG, resolution of type 2 diabetes resolved in 77.8% of patients, and arterial hypertension, dyslipidemia, obstructive sleep apnea, gastroesophageal reflux disease and degenerative joint diseases improved or resolved in 68.0%, 65.9%, 75.8%, 30.6% and 55.7% of patients, respectively. Laparoscopic SG is more technically straightforward and has fewer surgical complications than other more complex surgical techniques. Laparoscopic SG is an effective treatment option for bariatric surgery. It is relatively easy to perform, well tolerated by patients and effective for longterm excessive weight loss and resolution of comorbidities.

Long-term effect of sleeve gastrectomy vs Roux-en-Y gastric bypass in people living with severe obesity: a phase III multicentre randomised controlled trial (SleeveBypass)

Background

Sleeve gastrectomy is the most performed metabolic surgical procedure worldwide. However, conflicting results offer no clear evidence about its long-term clinical comparability to Roux-en-Y gastric bypass. This study aims to determine their equivalent long-term weight loss effects.

Methods

This randomised open-label controlled trial was conducted from 2012 until 2017 in two Dutch bariatric hospitals with a 5-year follow-up (last follow-up July 29th, 2022). Out of 4045 patients, 628 were eligible for metabolic surgery and were randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass (intention-to-treat). The primary endpoint was weight loss, expressed by percentage excess body mass index (BMI) loss. The predefined clinically relevant equivalence margin was -13% to 13%. Secondary endpoints included percentage total kilograms weight loss, obesity-related comorbidities, quality of life, morbidity, and mortality. This trial is registered with Dutch Trial Register NTR4741: https://onderzoekmetmensen.nl/nl/trial/25900.

Findings

628 patients were randomised between sleeve gastrectomy (n = 312) and Roux-en-Y gastric bypass (n = 316) (mean age 43 [standard deviation (SD), 11] years; mean BMI 43.5 [SD, 4.7]; 81.8% women). Excess BMI loss at 5 years was 58.8% [95% CI, 55%-63%] after sleeve gastrectomy and 67.1% [95% CI, 63%-71%] after Roux-en-Y gastric bypass (difference 8.3% [95% CI, -12.5% to -4.0%]). This was within the predefined margin (P < 0.001). Total weight loss at 5 years was 22.5% [95% CI, 20.7%-24.3%] after sleeve gastrectomy and 26.0% [95% CI, 24.3%-27.8%] after Roux-en-Y gastric bypass (difference 3.5% [95% CI, -5.2% to -1.7%]). In both groups, obesity-related comorbidities significantly improved after 5 years. Dyslipidaemia improved more frequently after Roux-en-Y gastric bypass (83%, 54/65) compared to sleeve gastrectomy (62%, 44/71) (P = 0.006). De novo gastro-oesophageal reflux disease occurred more frequently after sleeve gastrectomy (16%, 46/288) vs Roux-en-Y gastric bypass (4%, 10/280) (P < 0.001). Minor complications were more frequent after Roux-en-Y gastric bypass (5%, 15/316) compared to sleeve gastrectomy (2%, 5/312). No statistically significant differences in major complications and health-related quality of life were encountered.

Interpretation

In people living with obesity grades 2 and 3, sleeve gastrectomy and Roux-en-Y gastric bypass had clinically comparable excess BMI loss according to the predefined definition for equivalence. However, Roux-en-Y gastric bypass showed significantly higher total weight loss and significant advantages in secondary outcomes, including dyslipidaemia and GERD, yet at a higher rate of minor complications. Major complications, other comorbidities, and overall HRQoL did not significantly differ between the groups.

Funding

Not applicable.

Bariatric surgery, through beneficial effects on underlying mechanisms, improves cardiorenal and liver metabolic risk over an average of ten years of observation: A longitudinal and a case-control study

BACKGROUND

Bariatric surgery has long-term beneficial effects on body weight and metabolic status, but there is an apparent lack of comprehensive cardiometabolic, renal, liver, and metabolomic/lipidomic panels, whereas the underlying mechanisms driving the observed postoperative ameliorations are still poorly investigated. We aimed to study the long-term effects of bariatric surgery on metabolic profile, cardiorenal and liver outcomes in association with underlying postoperative gut hormone adaptations.

METHODS

28 individuals who underwent bariatric surgery [17 sleeve gastrectomy (SG), 11 Roux-en-Y gastric bypass (RYGB)] were followed up 3, 6 and 12 and at 10 years following surgery. Participants at 10 years were cross-sectionally compared with an age-, sex- and adiposity-matched group of non-operated individuals (n = 9) and an age-matched pilot group of normal-weight individuals (n = 4).

RESULTS

There were durable effects of surgery on body weight and composition, with an increase of lean mass percentage persisting despite some weight regain 10 years postoperatively. The improvements in metabolic and lipoprotein profiles, cardiometabolic risk markers, echocardiographic and cardiorenal outcomes persisted over the ten-year observation period. The robust improvements in insulin resistance, adipokines, activin/follistatin components and postprandial gastrointestinal peptide levels persisted 10 years postoperatively. These effects were largely independent of surgery type, except for a lasting reduction of ghrelin in the SG subgroup, and more pronounced increases in proglucagon products, mainly glicentin and oxyntomodulin, and in the cardiovascular risk marker Trimethylamine-N-oxide (TMAO) within the RYGB subgroup. Despite similar demographic and clinical features, participants 10 years after surgery showed a more favorable metabolic profile compared with the control group, in conjunction with a dramatic increase of postprandial proglucagon product secretion.

CONCLUSIONS

We demonstrate that cardiorenal and metabolic benefits of bariatric surgery remain robust and largely unchanged ten years postoperatively and are associated with durable effects on gastrointestinal- muscle- and adipose tissue-secreted hormones.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04170010.

Standardized Assessment of Metabolic Bariatric Surgery Outcomes: Secondary Analysis of 2 Randomized Clinical Trials

Importance

A standardized definition and reporting of metabolic bariatric surgery (MBS) outcomes is not available for actual clinical practice and science.

Objective

To assess the feasibility of using a clinically relevant and feasible MBS outcome score (Swiss-Finnish Bariatric Metabolic Outcome Score [SF-BARI Score]).

Design, Setting, and Participants

This assessment of a bariatric surgery outcome score is based on the secondary analysis of merged 5-year individual patient data (N = 457) of 2 large randomized clinical trials (Swiss SM-BOSS [Swiss Multicenter Bypass or Sleeve Study], conducted from January 2007 to November 2011, and Finnish SLEEVEPASS [Laparoscopic Gastric Bypass Vs Sleeve Gastrectomy to Treat Morbid Obesity], conducted from March 2008 until June 2010) that compared laparoscopic sleeve gastrectomy with laparoscopic Roux-en-Y gastric bypass in the treatment of severe obesity. This secondary analysis was performed from January 2022 to January 2023.

Main Outcomes and Measures

The main outcome was the feasibility of the SF-BARI Score and the SF-BARI Score QOL (quality of life) as tools to assess MBS outcomes. The score includes percentage of total weight loss (%TWL), 4 obesity-related comorbidities (type 2 diabetes, hypertension, dyslipidemia, and obstructive sleep apnea), complications, and QOL, if available.

Results

Among the 457 included patients, 323 (70.7%) were female and 134 (29.3%) were male, and the mean (SD) age was 45.6 (10.7) years. Outcomes for the SF-BARI Score were available for 435 patients (95.2%) at 1 year and 398 patients (87.1%) at 5 years and for SF-BARI Score QOL in 289 (63.2%) patients at 1 year and 318 patients (69.6%) at 5 years. The SF-BARI Score was correlated with both the SF-BARI Score QOL (r = 0.96; 95% CI, 0.95-0.96; P < .001) and %TWL (r = 0.86; 95% CI, 0.84-0.89; P < .001) and with the Bariatric Analysis and Reporting Outcome System (r = 0.59; 95% CI, 0.51-0.65; P < .001). Score outcomes were categorized as excellent, very good, good, fair, and suboptimal response. There was a statistically significant difference in scores at 1 vs 5 years (4.0; 95% CI, 1.4-6.6; P = .003), and the gastric bypass group had a higher score compared with the sleeve gastrectomy group (7.4; 95% CI, 3.4-11.5; P < .001).

Conclusions and Relevance

These findings indicate that this metabolic bariatric surgery outcome score is a simple, relevant, and feasible composite tool to define and measure MBS outcomes, enabling standardized reporting.

Trial Registration

ClinicalTrials.gov Identifiers: NCT00356213 (SM-BOSS) and NCT00793143 (SLEEVEPASS).

Systematic Review and Meta-analysis of the Effects of Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy on Dyslipidemia

The aim of this meta-analysis was to compare the effects of LRYGB and LSG on dyslipidemia. Studies comparing the effects of LRYGB and LSG on dyslipidemia with follow-up of 12 months or more were included. Twenty-four studies comprising seven RCTs and 17 comparative observational studies were included. Meta-analysis of RCTs (n=487) showed that improvement/resolution of dyslipidemia was better after LRYGB (68.5%, n=161/235) compared to LSG (48.4%, n=122/252). Patients undergoing LRYGB were more than twice as likely to experience improvement/resolution in dyslipidemia compared to those undergoing LSG (OR 2.28, 95% CI 1.21-4.29, p=0.010). Both LRGYB and LSG appears effective in improving dyslipidemia at >12 months after surgery; however, this improvement is more than twice higher after LRYGB compared to LSG.