Long-term outcomes of bariatric surgery: a National Institutes of Health symposium

Update on Endoscopic Treatments for Obesity

PURPOSE OF REVIEW

Increased morbidity seen with rising obesity rates continues to place an unheralded burden on our health system. Lack of higher bariatric surgery utilization and limitations with lifestyle modification and pharmacotherapy highlights the need for additional therapies for obesity. Endoscopic bariatric and metabolic therapies (EBMT) are effective, safe treatments for obesity. Current FDA-approved EBMT are confined to gastric modalities while small bowel directed therapies are still considered investigational. This review highlights current modalities of EBMT.

RECENT FINDINGS

Many randomized controlled trials have been performed, including both open label and sham-controlled, which have demonstrated safety and efficacy of EBMT over lifestyle therapy alone. In addition, emerging evidence from clinical experience further supports EBMT for treatment of obesity. Current evidence supports the safety and efficacy of EBMT for obesity treatment in conjunction with lifestyle therapy. They can also be used concurrently with weight loss medications to increase total weight loss.

Use of polygenic risk scores to assess weight loss after bariatric surgery: a 5-year follow-up study

BACKGROUND

Bariatric surgery (BS) is currently the most effective long-term treatment of severe obesity. However, the interindividual variability observed in surgical outcomes suggests a moderating effect of several factors, including individual genetic background. This study aimed to investigate the contribution of the genetic architecture of body mass index (BMI) to the variability in weight loss outcomes after BS.

METHODS

A total of 106 patients with severe obesity who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy were followed up for 5 years. Changes in BMI (BMIchange) and percentage of total weight loss (%TWL) were evaluated during the postoperative period. Polygenic risk scores (PRSs), including 50 genetic variants, were calculated for each participant to determine their genetic risk of high BMI based on a previous genome-wide association study. Generalized estimating equation models were used to study the role of the individual's polygenic score and other factors on BMIchange and %TWL in the long term after surgery.

RESULTS

This study found an effect of the polygenic score on %TWL and BMIchange, in which patients with lower scores had better outcomes after surgery than those with higher scores. Furthermore, when analyzing only patients who underwent RYGB, the results were replicated, showing greater weight loss after surgery for patients with lower polygenic scores.

DISCUSSION

Our results indicate that genetic background assessed with PRSs, along with other individual factors, such as biological sex, age, and preoperative BMI, has an effect on BS outcomes and could represent a useful tool for estimating surgical outcomes in advance.

Comparative Analysis of Mortality Rates among Morbidly Obese Individuals: A Study of Patients Undergoing Bariatric Surgery, Nonsurgical Morbidly Obese Individuals, and the General Population

INTRODUCTION

Mortality decreases following bariatric surgery. We explored the extent of the reduction and whether or not it reaches the general population level in a large cohort of patients with obesity. This study aimed to compare all-cause mortality between patients with obesity who undergo bariatric surgery and those who do not, with the general Iranian population during the same period.

METHOD

Data from Iran's National Obesity Surgery Database were used to establish a large cohort of patients registered between 2009 and 2019. The current vital status of the patients was determined by utilizing post-surgery follow-up data for those who underwent the operation. For patients without a surgery record, a predefined checklist was filled out through telephone interviews. Death data from the National General Registrar's office were obtained for all cohort members.

RESULTS

Of 13,313 cohort members, 12,915 were eligible for analysis. The median age at the first visit was 38 years, and 78% were women. 6,190 patients (47.9%) underwent bariatric surgery, and 6,725 patients (52.1%) were not yet operated on at the time of analysis. We observed 139 deaths during 53,880 person-years follow-ups. The median follow-ups for operated-on and not operated-on groups were 4 and 4.8 years. The mortality rates among nonoperated patients were 2.89 times higher (standardized mortality ratio [SMR] = 2.89, 95% CI: 2.36-3.53) than those in the general population, while in operated patients, the mortality rate decreased to 1.82 as high (SMR = 1.82, 95% CI: 1.34-2.46).

CONCLUSION

The risk of death has been diminished in the operated-on group. It still remains considerably higher than the risk in the general population.

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.

Microbiota dynamics preceding bariatric surgery as obesity treatment: a comprehensive review

The review present data on the intricate relationship between bariatric surgery, gut microbiota, and metabolic health in obesity treatment. Bariatric surgery, is recognized as an effective intervention for managing morbid obesity, including various techniques with distinct mechanisms of action, efficacy, and safety profiles including Roux-en-Y Gastric Bypass (RYGB), Sleeve Gastrectomy (SG), Laparoscopic Adjustable Gastric Banding (LAGB), and Biliopancreatic Diversion (BPD). RYGB and SG are the most prevalent procedures globally, inducing gut microbiota changes that influence microbial diversity and abundance. Post-surgery, alterations in bacterial communities occur, such as the increased of Escherichia coli inversely correlated with fat mass and leptin levels. During digestion, microbiota produce physiologically active compounds like bile acids (Bas) and short-chain fatty acids (SCFAs). SCFAs, derived by microbial fermentation, influence appetite, energy metabolism, and obesity-related pathways. Bas, altered by surgery, modulate glucose metabolism and insulin sensitivity. Furthermore, SG and RYGB enhance incretin secretion, particularly glucagon-like peptide 1 (GLP-1). Therefore, understanding microbiota changes after bariatric surgery could be crucial for predicting metabolic outcomes and developing targeted interventions for obesity management.

Bariatric Surgery Outcomes in Patients with Inflammatory Bowel Disease in the United States: An Analysis of the Nationwide Readmissions Database

PURPOSE

Bariatric surgery has been reported to produce durable weight loss in the management of obesity; sleeve gastrectomy (SG) is the most common bariatric procedure. Obesity is a common comorbidity of inflammatory bowel disease (IBD), and the impact of IBD on short-term SG outcomes has not been widely reported. This study assessed whether IBD was associated with adverse post-SG outcomes.

MATERIALS AND METHODS

Hospitalizations of patients undergoing SG in the United States were identified using the 2010-2020 Nationwide Readmissions Database (NRD) and stratified by IBD diagnosis. The SG cohort was propensity-matched based on age, biological sex, body mass index (BMI), comorbid diabetes, hypertension, depression, chronic obstructive pulmonary disease, and discharge in quarter four. Primary aims were to compare in-hospital mortality, post-operative complications, and all-cause 90-day readmission between patients with and without IBD. Secondary outcomes were length of stay (LOS) and total hospital cost.

RESULTS

A total of 2030 hospitalizations were matched. The odds of complication were 48% higher for hospitalizations of patients with IBD (11.1% vs. 7.8%; aOR 1.48, aOR 95% CI 1.10-2.00, p = .009). The most common complication was nausea (4.9% vs. 3.7%, p = .187). No statistically significant difference was observed for all-cause 90-day readmissions, LOS, or hospital cost.

CONCLUSION

Hospitalizations of patients with IBD who underwent SG experienced significantly higher post-operative complication rates. However, the similar lengths of stay and readmission rates compared to propensity-matched SG hospitalizations without IBD suggest many complications were minor. SG remains a safe weight loss procedure for patients suffering from IBD and obesity.

Maternal and fetal/neonatal outcomes in pregnancy, delivery and postpartum following bariatric surgery and comparison with pregnant women with obesity: a study protocol for a prospective cohort

BACKGROUND

Being obese can lead to various complications during pregnancy, such as Gestational Diabetes Mellitus (GDM), pregnancy induced hypertension (PIH), Pre-Eclampsia (PE), and Large Gestational Age (LGA). Although bariatric surgery is an effective way to treat obesity, it can also result in complications and may be linked to having small for gestational age (SGA) babies. This cohort study protocol aims to compare the maternal and fetal/neonatal outcomes of two groups of Iranian pregnant women: those who have undergone bariatric surgery and those who are obese but have not had bariatric surgery.

METHODS

In this study Pregnant women (< 14 weeks' gestation) (n = 38 per group) are recruited either from one of the obesity clinic (exposure group = with a history of bariatric surgery) or primary healthcare clinics in Tehran city (comparison group = pregnant women with obesity and and no history of bariatric surgery). Dietary intake and nutrient status are assessed at < 14, 28, and 36 weeks. Maternal and fetal/neonatal outcomes are compared between the two groups, including gestational diabetes, preeclampsia, preterm labor, intrauterine growth restriction, severe nausea and vomiting, abortion, placenta previa and abruption, venous thrombosis, vaginal bleeding, cesarean delivery, meconium aspiration, and respiratory distress. Maternal serum levels of ferritin, albumin, zinc, calcium, magnesium, selenium, copper, vitamins A, B9, B12, and 25-hydroxy Vit D are checked during 24th to 28th weeks. Maternal and neonatal outcomes, including height, weight, head circumference, fetal abnormality, infection, small or large fetus, low birth weight, macrosomia, NICU admission, and total weight gain during pregnancy, are measured at birth. Maternal and offspring outcomes, including weight, height, head circumference, total weight gain during pregnancy, newborn diseases, postpartum bleeding, breastfeeding, and related problems, are assessed 6 weeks after delivery. Child's weight, height, and head circumference are followed at 2, 4, 6, 8, 10, and 12 months after birth. Maternal stress, anxiety, and depression are assessed with the DASS-21 questionnaire, and physical activity is evaluated using the PPAQ questionnaire in the first and third trimesters.

DISCUSSION

By assessing the levels of micronutrients in the blood of pregnant women along with the evaluation of pregnancy outcomes, it is feasible to gain a more accurate understanding of how bariatric surgery affects the health and potential complications for both the mother and the fetus/newborn. This information can help specialists and patients make more informed decisions about the surgery. Additionally, by examining issues such as stress, anxiety, and depression in women undergoing surgery, this study can contribute to recognizing these problems, which can also affect pregnancy outcomes.

Impact of Bariatric Surgery on Left Ventricular Structure and Function

BACKGROUND

Obesity leads to an increased risk of cardiovascular disease morbidity and death, including heart failure. Bariatric surgery has been proven to be the most effective long-term weight management treatment. This study investigated the changes in cardiac structure and function after bariatric surgery, including left ventricular global longitudinal strain.

METHODS AND RESULTS

There were 398 consecutive patients who underwent bariatric surgery with pre- and postoperative transthoracic echocardiographic imaging at a US health system between 2004 and 2019. We compared cardiovascular risk factors and echocardiographic parameters between baseline and follow-up at least 6 months postoperatively. Along with decreases in weight postoperatively, there were significant improvements in cardiovascular risk factors, including reduction in systolic blood pressure levels from 132 mm Hg (25th-75th percentile: 120-148 mm Hg) to 127 mm Hg (115-140 mm Hg; P=0.003), glycated hemoglobin levels from 6.5% (5.9%-7.6%) to 5.7% (5.4%-6.3%; P<0.001), and low-density lipoprotein levels from 97 mg/dL (74-121 mg/dL) to 86 mg/dL (63-106 mg/dL; P<0.001). Left ventricular mass decreased from 205 g (165-261 g) to 190 g (151-236 g; P<0.001), left ventricular ejection fraction increased from 58% (55%-61%) to 60% (55%-64%; P<0.001), and left ventricular global longitudinal strain improved from -15.7% (-14.3% to -17.5%) to -18.6% (-16.0% to -20.3%; P<0.001) postoperatively.

CONCLUSIONS

This study has shown the long-term impact of bariatric surgery on cardiac structure and function, with reductions in left ventricular mass and improvement in left ventricular global longitudinal strain. These findings support the cardiovascular benefits of bariatric surgery.

The Degree of Preoperative Hypoalbuminemia Is Associated with Risk of Postoperative Complications in Metabolic and Bariatric Surgery Patients

BACKGROUND

The incidence and impact of hypoalbuminemia in bariatric surgery patients is poorly characterized. We describe its distribution in laparoscopic sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) patients undergoing primary or revision surgeries and assess its impact on postoperative complications.

METHODS

The Metabolic and Bariatric Surgery Quality Improvement Program Database (2015 to 2021) was analyzed. Hypoalbuminemia was defined as Severe (< 3 g/dL), Moderate (3 ≤ 3.5 g/dL), Mild (3.5 ≤ 4 g/dL), or Normal (≥ 4 g/dL). Multivariable logistic regression was performed to calculate odds ratios of postoperative complications compared to those with Normal albumin after controlling for procedure, age, gender, race, body mass index, functional status, American Society of Anesthesia class, and operative length.

RESULTS

A total of 817,310 patients undergoing Primary surgery and 69,938 patients undergoing Revision/Conversion ("Revision") surgery were analyzed. The prevalence of hypoalbuminemia was as follows (Primary, Revision): Severe, 0.3%, 0.6%; Moderate, 5.2%, 6.5%; Mild, 28.3%, 31.4%; Normal, 66.2%, 61.4%. Primary and Revision patients with hypoalbuminemia had a significantly higher prevalence (p < 0.01) of several co-morbidities, including hypertension and insulin-dependent diabetes. Any degree of hypoalbuminemia increased the odds ratio of several complications in Primary and Revision patients, including readmission, intervention, and reoperation. In Primary patients, all levels of hypoalbuminemia also increased the odds ratio of unplanned intubation, intensive care unit admission, and venous thromboembolism requiring therapy.

CONCLUSION

Over 30% of patients present with hypoalbuminemia. Even mild hypoalbuminemia was associated with an increased rate of several complications including readmission, intervention, and reoperation. Ensuring nutritional optimization, especially prior to revision surgery, may improve outcomes in this challenging population.

Bariatric Surgery for Adults With Class I Obesity and Difficult-to-Manage Type 2 Diabetes: A Health Technology Assessment

Background

Many individuals with type 2 diabetes are classified as either overweight or obese. A patient may be described as having difficult-to-manage type 2 diabetes if their HbA1c levels remain above recommended target levels, despite efforts to treat it with lifestyle changes and pharmacotherapy. Bariatric surgery refers to procedures that modify the gastrointestinal tract. In patients with class II or III obesity, bariatric surgery has resulted in substantial weight loss, improved quality of life, reduced mortality risk, and resolution of type 2 diabetes. There is some evidence suggesting these outcomes may also be possible for patients with class I obesity as well. We conducted a health technology assessment of bariatric surgery for adults with class I obesity and difficult-to-manage type 2 diabetes, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding bariatric surgery, and patient preferences and values.

Methods

We performed a systematic clinical literature review. We assessed the risk of bias of each included study, using the Cochrane Risk of Bias tool for randomized controlled trials, the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool for cohort studies, and the Risk of Bias in Systematic Reviews (ROBIS) tool for systematic reviews; we assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature review and conducted a cost-utility analysis of bariatric surgery in comparison with nonsurgical usual care over a lifetime horizon from a public payer perspective. We also analyzed the budget impact of publicly funding bariatric surgery for adults with class I obesity and difficult-to-manage type 2 diabetes in Ontario. To contextualize the potential value of bariatric surgery, we spoke with people with obesity and type 2 diabetes who had undergone or were considering this procedure.

Results

We included 14 studies in the clinical evidence review. There were large increases in diabetes remission rates (GRADE: Low to Very low) and large reductions in body mass index (GRADE: Low to Very low) with bariatric surgery than with medical management. Bariatric surgery may also reduce the use of medications for type 2 diabetes (GRADE: Low) and may improve quality of life for people with class I obesity and difficult-to-manage type 2 diabetes compared with medical management. (GRADE: Low)Our economic evidence review included 5 cost-effectiveness studies; none were conducted in a Canadian setting, and 4 were considered partially applicable to our research question. Most studies found bariatric surgery to be cost-effective compared to standard care for patients with class I obesity and type 2 diabetes; however, the applicability of these results to the Ontario context is uncertain due to potential differences in clinical practice, resource utilization, and unit costs.Our primary economic evaluation found that over a lifetime horizon, bariatric surgery was more costly (incremental cost: $8,151 per person) but also more effective than current usual care (led to a 0.339 quality-adjusted life-year [QALY] gain per person). The cost increase was driven by costs associated with surgery (before, after, and during surgery), and the QALY gain was due to life-years gained. Results were sensitive to the bariatric surgery cost and assumptions regarding its long-term benefits with respect to weight loss and diabetes remission.Publicly funding 50 bariatric surgeries in year 1, and gradually increasing to 250 surgeries in year 5, for people with class I obesity and difficult-to-manage type 2 diabetes would lead to budget increases of $0.55 million in year 1 to $2.45 million in year 5, for a total of $7.63 million over 5 years.The people with obesity and type 2 diabetes with whom we spoke reported that bariatric surgery was generally seen as a positive treatment option, and those who had undergone the procedure reported positively on its value as a treatment to manage their weight and diabetes.

Conclusions

For adults with class I obesity and difficult-to-manage type 2 diabetes, bariatric surgery may be more clinically effective and cost-effective than medical management. Compared with medical management in people with class I obesity and difficult-to-manage type 2 diabetes, bariatric surgery may result in large increases in diabetes remission rates, large reductions in BMI, and reduced medication use for type 2 diabetes, improved quality of life. Over a lifetime horizon, bariatric surgery led to a cost increase and QALY gain. Bariatric surgery can result in postsurgical complications that are not faced by those receiving medical management. The cost-effectiveness of bariatric surgery depends on its long-term impacts on obesity-related and diabetes-related complications, which could be uncertain.Our budget impact analysis suggests that publicly funding bariatric surgery in Ontario for people with class I obesity and difficult-to-manage type 2 diabetes would lead to a budget increase of $7.63 million over 5 years.For people with obesity and type 2 diabetes, bariatric surgery was seen as a potential positive treatment option to manage their weight and diabetes.

Mechanisms of Action of Bariatric Surgery on Body Weight Regulation

Bariatric surgery is an effective treatment modality for obesity and obesity-associated complications. Weight loss after bariatric surgery was initially attributed to anatomic restriction or reduced energy absorption, but now it is understood that surgery treats obesity by influencing the subcortical areas of the brain to lower adipose tissue mass. There are three major phases of this process: initially the weight loss phase, followed by a phase where weight loss is maintained, and in a subset of patients a phase where weight is regained. These phases are characterized by altered appetitive behavior together with changes in energy expenditure. The mechanisms associated with the rearrangement of the gastrointestinal tract include central appetite control, release of gut peptides, change in microbiota and bile acids. However, the exact combination and timing of signals remain largely unknown.

Depression as a risk factor for adverse outcomes and increased healthcare utilization in bariatric surgery patients

INTRODUCTION

Depression is strongly associated with obesity and is common among patients undergoing bariatric surgery. Little is known about the impact of depression on early postoperative outcomes or its association with substance use.

METHODS

The Michigan Bariatric Surgery Collaborative is a statewide quality improvement program that maintains a large clinical registry. We evaluated patients undergoing primary Roux-en-Y gastric bypass or sleeve gastrectomy between 2017 and 2022. Patients self-reported symptoms of depression (PHQ-8) and use of alcohol (AUDIT-C), smoking, prescription opiates, and marijuana at baseline. Preoperative PHQ-8 scores stratified patients based on severity: no depression (0-4), mild (5-9), moderate (10-14), or severe (15-24). We compared 30-day outcomes and substance use between patients with and without depression.

RESULTS

Among 44,301 patients, 30.8% had some level of depression, with 19.8% mild, 7.5% moderate, and 3.5% severe. Patients with depression were more likely to have an extended length of stay (LOS) (> 3 days) than those without depression (no depression 2.1% vs. severe depression 3.0%, p = 0.0452). There were no significant differences between no depression and severe depression groups in rates of complications (5.7% vs. 5.2%, p = 0.1564), reoperations (0.9%, vs. 0.8%, p = 0.7394), ED visits (7.7% vs. 7.8%, p = 0.5353), or readmissions (3.2% vs. 3.9%, p = 0.3034). Patients with severe depression had significantly higher rates of smoking (9.7% vs. 12.5%, p < 0.0001), alcohol use disorder (8.6% vs. 14.0%, p < 0.0001), opiate use (14.5% vs. 22.4%, p < 0.0001) and marijuana use (8.4%, vs. 15.5%, p = 0.0008).

CONCLUSIONS

This study demonstrated that nearly one-third of patients undergoing bariatric surgery have depression, with over 10% in the moderate to severe range. There was a significant association between preoperative depressive symptoms and extended LOS after bariatric surgery, as well as higher rates of smoking and use of marijuana, prescription opiates and alcohol. There was no significant effect on adverse events or other measures of healthcare utilization.

Long-term outcomes following laparoscopic Roux-en-Y gastric bypass: weight loss and resolution of comorbidities at 15 years and beyond

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold-standard bariatric procedure with proven efficacy in morbidly obese populations. While the short-term benefits of LRYGB have been well-documented, durable weight loss and long-term resolution of obesity-related comorbidities have been less clearly described.

METHODS

This single-center study prospectively reports weight loss and comorbidity resolution in patients undergoing LRYGB between August 2001 and September 2007 with at least 15-year follow-up. Data were collected at the time of surgery; 1, 3, 6, and 12 months postoperatively; and then annually thereafter.

RESULTS

A total of 486 patients were included in this analysis. Patients were predominantly female (88.7%), and the median age was 36.0 [IQR 29.0-45.0] years. Patients were ethnically diverse, including Black/African American (43.6%), White/Caucasian (35.0%), Hispanic (18.3%), and other backgrounds (3.1%). Mean preoperative weight and body mass index were 133.0 ± 21.9 kg and 48.4 ± 6.5 kg/m2, and the median number of comorbidities was 6.0 [IQR 4.0-7.0]. Follow-up rates at 1, 5, 10, and 15 years were 75.3%, 37.2%, 35.2%, and 18.9%, respectively. On average, maximum percentage total weight loss (%TWL) occurred 2 years postoperatively (- 36.2 ± 9.5%), and ≥ 25% TWL was consistently achieved at 1, 5, 10, and 15-year time intervals (- 28.0 ± 13.0% at 15 years). Patients with comorbidities experienced improvement or resolution of their conditions within 1 year, including type 2 diabetes mellitus (83/84, 98.8%), obstructive sleep apnea (112/116, 96.6%), hypertension (142/150, 94.7%), and gastroesophageal reflux disease (217/223, 97.3%). Rates of improved/resolved comorbidities remained consistently high through at least 10 years after surgery.

CONCLUSIONS

LRYGB provides durable weight loss for at least 15 years after surgery, with stable average relative weight loss of approximately 25% from baseline. This outcome corresponds with sustainable resolution of obesity-related comorbidities for at least 10 years after the initial operation.

Bariatric Surgery and Gut-Brain-Axis Driven Alterations in Cognition and Inflammation

Obesity is associated with systemic inflammation, comorbidities like diabetes, cardiovascular disease and several cancers, cognitive decline and structural and functional brain changes. To treat, or potentially prevent these related comorbidities, individuals with obesity must achieve long-term sustainable weight loss. Often life style interventions, such as dieting and increased physical activity are not successful in achieving long-term weight loss. Meanwhile bariatric surgery has emerged as a safe and effective procedure to treat obesity. Bariatric surgery causes changes in physiological processes, but it is still not fully understood which exact mechanisms are involved. The successful weight loss after bariatric surgery might depend on changes in various energy regulating hormones, such as ghrelin, glucagon-like peptide-1 and peptide YY. Moreover, changes in microbiota composition and white adipose tissue functionality might play a role. Here, we review the effect of obesity on neuroendocrine effects, microbiota composition and adipose tissue and how these may affect inflammation, brain structure and cognition. Finally, we will discuss how these obesity-related changes may improve after bariatric surgery.

Pyrrhic victory? Long-term results of biliopancreatic diversion on patients with type 2 diabetes and severe obesity

BACKGROUND

The long-term results after biliopancreatic diversion (BPD) in patients with type 2 diabetes (T2D) and severe obesity is still being debated.

OBJECTIVE

Retrospective evaluation of the long-term metabolic and clinical conditions of patients with T2D following BPD.

SETTING

University hospital.

METHODS

A total of 173 patients with T2D and severe obesity were investigated prior to and at 3-5 and 10-20 years after BPD. Anthropometric, biochemical, and clinical findings preoperatively and throughout follow-up were considered. The long-term data were compared with those of a cohort of 173 T2D patients with obesity treated with conventional therapy.

RESULTS

T2D resolved within the first postoperative phases in most patients, and in the long and very long term, the fasting blood glucose level remained above the normal range in only 8% of patients. Likewise, a stable improvement of blood lipid pattern was observed (follow-up rate 63%). In contrast, in nonsurgical patients in the long term, the glucose and lipid metabolic parameters remained in the pathologic range in all cases. In the BPD group, a very high number of severe BPD-related complications was recorded, and 27% of the BPD patients died, whereas in the control group, 87% of patients were still alive at the end of the follow-up period (P < .02).

CONCLUSION

Despite the high T2D stable resolution rate and the normalization of most metabolic data at 10-20 years following surgery, these results indicate that BPD should be indicated with caution in the surgical treatment of T2D in patients with severe obesity.

Foregut bypass vs. restrictive bariatric procedures for nonalcoholic fatty liver disease: a meta-analysis of 3,355 individuals

Background

Bariatric surgery represents an important treatment option for severely obese patients with nonalcoholic fatty liver disease (NAFLD). However, there remains inadequate data regarding the effects of different bariatric procedures on various NAFLD parameters, especially for histological outcomes. Thus, this meta-analysis aimed to compare the effects of restrictive bariatric procedures and foregut bypass on the metabolic, biochemical, and histological parameters for patients with NAFLD.

Methods

Medline and Embase were searched for articles relating to bariatric procedures and NAFLD. Pairwise meta-analysis was conducted to compare efficacy of bariatric procedures pre- vs. post-procedure with subgroup analysis to further compare restrictive against foregut bypass procedures.

Results

Thirty-one articles involving 3,355 patients who underwent restrictive bariatric procedures (n=1,460) and foregut bypass (n=1,895) were included. Both foregut bypass (P<0.01) and restrictive procedures (P=0.03) significantly increased odds of fibrosis resolution. Compared to restrictive procedures, foregut bypass resulted in a borderline non-significant decrease in fibrosis score (P=0.06) and significantly lower steatosis score (P<0.001). For metabolic parameters, foregut bypass significantly lowered body mass index (P=0.003) and low-density lipoprotein (P=0.008) compared to restrictive procedures. No significant differences were observed between both procedures for aspartate aminotransferase (P=0.17) and alkaline phosphatase (P=0.61). However, foregut bypass resulted in significantly lower gamma-glutamyl transferase than restrictive procedures (P=0.01) while restrictive procedures resulted in significantly lower alanine transaminase than foregut bypass (P=0.02).

Conclusions

The significant histological and metabolic advantages and comparable improvements in biochemical outcomes support the choice of foregut bypass over restrictive bariatric procedures in NAFLD management.

What About My Weight? Insufficient Weight Loss or Weight Regain After Bariatric Metabolic Surgery

Context

This review study aimed to investigate the definition, etiology, risk factors (RFs), management strategy, and prevention of insufficient weight loss (IWL) and weight regain (WR) following bariatric metabolic surgery (BMS).

Evidence Acquisition

Electronic databases were searched to retrieve relevant articles. The inclusion criteria were English articles with adult participants assessing the definition, prevalence, etiology, RFs, management strategy, and prevention of IWL/WR.

Results

Definition: The preferred definition for post-BMS IWL/WR are the terms "Lack of maintenance of total weight loss (TWL)>20%" and "weight change in percentage compared to nadir weight or weight loss". Prevalence: The exact prevalence of IWL/WR is still being determined due to the type of BMS and various definitions. Etiology: Several mechanisms, including hormonal/metabolic, dietary non-adherence, physical inactivity, mental health, and anatomic surgical failure, are possible etiologies of post-BMS IWL/WR. Risk factors: Preoperative body mass index (BMI), male gender, psychiatric conditions, comorbidities, age, poor diet, eating disorders, poor follow-ups, insufficient physical activity, micronutrients, and genetic-epigenetic factors are the most important RFs. Management Strategy: The basis of treatment is lifestyle interventions, including dietary, physical activity, psychological, and behavioral therapy. Pharmacotherapy can be added. In the last treatment line, different techniques of endoscopic surgery and revisional surgery can be used. Prevention: Behavioral and psychotherapeutic interventions, dietary therapy, and physical activity therapy are the essential components of prevention.

Conclusions

Many definitions exist for WR, less so for IWL. Etiologies and RFs are complex and multifactorial; therefore, the management and prevention strategy is multidisciplinary. Some knowledge gaps, especially for IWL, exist, and these gaps must be filled to strengthen the evidence used to guide patient counseling, selection, and improved outcomes.

High-dose liraglutide improves metabolic syndrome in poor responders to bariatric surgery

Background

Bariatric surgery (BS) represents the most effective therapy for obesity class III, or class II with at least one weight-related comorbidity. However, some patients have insufficient weight loss or clinically relevant weight regain after a successful primary procedure. This study aimed to assess the efficacy of liraglutide treatment on weight loss, body composition and improvement of metabolic syndrome (MS) in patients defined as poor responders after BS.

Methods

The study involved 59 non-diabetic adults with obesity (M/F: 17/42, age: 38.6 ± 11.8 years, BMI 38.3 ± 5.5 kg/m2) who had been treated with BS and experienced a poor response, categorized as either IWL (insufficient weight loss) or WR (weight regain). All patients were prescribed pharmacological therapy with liraglutide and attended nutritional counseling. Anthropometric and clinical measurements, body composition and the presence of MS defined according to the ATP-III classification were evaluated before starting liraglutide and after 24 weeks of treatment.

Results

After 24 weeks of treatment with liraglutide, the mean weight loss was 8.4% ± 3.6% with no difference between gender, bariatric procedure, or type of poor response (IWL or WR). A significant decrease in fat mass, free-fat mass and total body water was documented. After 24 weeks, patients presented significantly lowered fasting glucose, total cholesterol, triglycerides, AST and ALT. The prevalence of MS was reduced from 35% at baseline to 1.6% after 24 weeks. No patients discontinued the treatment during the study.

Conclusion

In patients who experience poor response after BS, liraglutide is well tolerated and promotes significant weight loss, ameliorates cardiometabolic comorbidities, and reduces the prevalence of MS.

Ligamentum teres cardiopexy for post vertical sleeve gastrectomy gastroesophageal reflux

PURPOSE

Vertical sleeve gastrectomy (VSG) evolved in the early 2000s into the standalone weight loss procedure we see today. While numerous studies highlight VSG's durability for weight loss, and improvements co-morbidities such as type 2 diabetes mellitus and cardiovascular disease, patients with gastroesophageal reflux disease (GERD) have been counseled against VSG due to the concern for worsening reflux symptoms. When considering anti-reflux procedures, VSG patients are unable to undergo traditional fundoplication due to lack of gastric cardia redundancy. Magnetic sphincter augmentation lacks long-term safety data and endoscopic approaches have undetermined longitudinal benefits. Until recently, the only option for patients with a history of VSG with medically refractory GERD has been conversion to roux en Y gastric bypass (RNYGB), however, this poses other risks including marginal ulcers, internal hernias, hypoglycemia, dumping syndrome, and nutritional deficiencies. Given the risks associated with conversion to RNYGB, we have adopted the ligamentum teres cardiopexy as an option for patients with intractable GERD following VSG.

METHODS

A retrospective chart review was conducted of patients who had prior laparoscopic or robotic VSG and subsequently GERD symptoms refectory to pharmacological management who underwent ligamentum teres cardiopexy between 2017 and 2022. Pre-operative GERD disease burden, intraoperative cardiopexy characteristics, post-operative GERD symptomatology and changes in H2 blocker or PPI requirements were reviewed.

RESULTS

Of the study's 60 patients the median age was 50 years old, and 86% were female. All patients had a diagnosis of GERD through pre-operative assessments and were taking antisecretory medication. Of the 36 patients who have completed their one year follow up, 81% of patients had either a decrease in dosage or cessation of the antisecretory medication at one year following ligamentum teres cardiopexy.

CONCLUSION

Ligamentum teres cardiopexy is a viable alternative to RNYGB in patients with a prior vertical sleeve gastrectomy with medical refractory GERD.

Mechanisms of bariatric surgery for weight loss and diabetes remission

Obesity and type 2 diabetes(T2D) lead to defects in intestinal hormones secretion, abnormalities in the composition of bile acids (BAs), increased systemic and adipose tissue inflammation, defects of branched-chain amino acids (BCAAs) catabolism, and dysbiosis of gut microbiota. Bariatric surgery (BS) has been shown to be highly effective in the treatment of obesity and T2D, which allows us to view BS not simply as weight-loss surgery but as a means of alleviating obesity and its comorbidities, especially T2D. In recent years, accumulating studies have focused on the mechanisms of BS to find out which metabolic parameters are affected by BS through which pathways, such as which hormones and inflammatory processes are altered. The literatures are saturated with the role of intestinal hormones and the gut-brain axis formed by their interaction with neural networks in the remission of obesity and T2D following BS. In addition, BAs, gut microbiota and other factors are also involved in these benefits after BS. The interaction of these factors makes the mechanisms of metabolic improvement induced by BS more complicated. To date, we do not fully understand the exact mechanisms of the metabolic alterations induced by BS and its impact on the disease process of T2D itself. This review summarizes the changes of intestinal hormones, BAs, BCAAs, gut microbiota, signaling proteins, growth differentiation factor 15, exosomes, adipose tissue, brain function, and food preferences after BS, so as to fully understand the actual working mechanisms of BS and provide nonsurgical therapeutic strategies for obesity and T2D.

Long-term effectiveness, outcomes and complications of bariatric surgery

Dietary imbalance and overeating can lead to an increasingly widespread disease - obesity. Aesthetic considerations aside, obesity is defined as an excess of adipose tissue that can lead to serious health problems and can predispose to a number of pathological changes and clinical diseases, including diabetes; hypertension; atherosclerosis; coronary artery disease and stroke; obstructive sleep apnea; depression; weight-related arthropathies and endometrial and breast cancer. A body weight 20% above ideal for age, gender and height is a severe health risk. Bariatric surgery is a set of surgical methods to treat morbid obesity when other treatments such as diet, increased physical activity, behavioral changes and drugs have failed. The two most common procedures currently used are sleeve gastrectomy and gastric bypass. This procedure has gained popularity recently and is generally considered safe and effective. Although current data show that perioperative mortality is low and better control of comorbidities and short-term complications is achieved, more randomized trials are needed to evaluate the long-term outcomes of bariatric procedures. This review aims to synthesize and summarize the growing evidence on the long-term effectiveness, outcomes and complications of bariatric surgery.

The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Bariatric Surgical Risk/Benefit Calculator: 1-year weight

BACKGROUND

Data-driven tools can be designed to provide patient-personalized estimates of health outcomes. Clinical calculators are commonly built to assess risk, but potential benefits of treatment should be equally considered. The American College of Surgeons Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) sought to create a risk and benefit calculator for adult patients considering primary metabolic and bariatric surgery with multiple prediction features: (1) 30-day risk, (2) 1-year body mass index (BMI) projections, and (3) 1-year co-morbidity remission.

OBJECTIVE

To assess the performance of the 1-year BMI projections feature of this tool.

SETTING

Not-for-profit organization, clinical data registry.

METHODS

MBSAQIP data from 596,024 cases across 4.5 years from 882 centers with ∼2.5 million records through 18 months postoperatively were included. A generalized estimating equation model was used to estimate BMI over time for 4 primary procedures: laparoscopic adjustable gastric band, laparoscopic sleeve gastrectomy, laparoscopic Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch.

RESULTS

The mean absolute error (MAE) in BMI predictions through postoperative month 12 was 1.68 units; overall correlation of actual and predicted BMI was .94. MAE of postoperative BMI estimates (1-12 mo) was lowest for laparoscopic sleeve gastrectomy (1.64) and highest for biliopancreatic diversion with duodenal switch (1.99). BMI predictions at 12 months showed MAE = 2.99 units.

CONCLUSIONS

Predicted BMI closely aligned with actual BMI values across the 12-month postoperative period. The MBSAQIP Bariatric Surgical Risk/Benefit Calculator is publicly available with the intent to facilitate patient-clinician communication and guide surgical decision making. This tool can aid in evaluating postoperative risk as well as benefits and long-term expectations.

Comparative Safety of Sleeve Gastrectomy and Gastric Bypass up to 5 Years After Surgery in Patients With Medicaid

OBJECTIVE

Compare adverse outcomes up to 5 years after sleeve gastrectomy and gastric bypass in patients with Medicaid.

BACKGROUND

Sleeve gastrectomy is the most common bariatric operation among patients with Medicaid; however, its long-term safety in this population is unknown.

METHODS

Using Medicaid claims, we performed a retrospective cohort study of adult patients who underwent sleeve gastrectomy or gastric bypass from January 1, 2012, to December 31, 2018. Instrumental variables survival analysis was used to estimate the cumulative incidence and heterogeneity of outcomes up to 5 years after surgery.

RESULTS

Among 132,788 patients with Medicaid, 84,717 (63.8%) underwent sleeve gastrectomy and 48,071 (36.2%) underwent gastric bypass. A total of 69,225 (52.1%) patients were White, 33,833 (25.5%) were Black, and 29,730 (22.4%) were Hispanic. Compared with gastric bypass, sleeve gastrectomy was associated with a lower 5-year cumulative incidence of mortality (1.29% vs 2.15%), complications (11.5% vs 16.2%), hospitalization (43.7% vs 53.7%), emergency department (ED) use (61.6% vs 68.2%), and reoperation (18.5% vs 22.8%), but a higher cumulative incidence of revision (3.3% vs 2.0%). Compared with White patients, the magnitude of the difference between sleeve and bypass was smaller among Black patients for ED use [5-y adjusted hazard ratios: 1.01; 95% confidence interval (CI), 0.94-1.08 vs 0.94 (95% CI, 0.88-1.00), P <0.001] and Hispanic patients for reoperation [5-y adjusted hazard ratios: 0.95 (95% CI, 0.86-1.05) vs 0.76 (95% CI, 0.69-0.83), P <0.001].

CONCLUSIONS

Among patients with Medicaid undergoing bariatric surgery, sleeve gastrectomy was associated with a lower risk of mortality, complications, hospitalization, ED use, and reoperations, but a higher risk of revision compared with gastric bypass. Although the difference between sleeve and bypass was generally similar among White, Black, and Hispanic patients, the magnitude of this difference was smaller among Black patients for ED use and Hispanic patients for reoperation.

Nutritional deficiency in South African adults scheduled for bariatric surgery

Background

Globally, there is a rising trend in obesity, known to increase morbidity and mortality. Metabolic surgery and adequate weight loss decrease mortality but may worsen pre-existing nutrient deficiencies. Most data on pre-existing nutritional deficiencies in the population undergoing metabolic surgery is from the developed world, where an extensive micronutrient assessment is achievable. In resource-constrained environments, the cost of a comprehensive micronutrient assessment must be weighed against the prevalence of nutritional deficiencies and the potential harm if one or more nutritional deficiencies are missed.

Methods

This cross-sectional study investigated the prevalence of micronutrient and vitamin deficiencies in participants scheduled to undergo metabolic surgery in Cape Town, South Africa, a low-middle income country. 157 participants were selected and 154 reported on; who underwent a baseline evaluation from 12 July 2017 to 19 July 2020. Laboratory measurements were conducted, including vitamin B12 (Vit B12), 25-hydroxy vitamin D (25(OH)D), folate, parathyroid hormone (PTH), thyroid-stimulating hormone (TSH), thyroxine (T4), ferritin, glycated haemoglobin (HbA1c), magnesium, phosphate, albumin, iron, and calcium.

Results

Participants were predominantly female, aged 45 years (37-51), with a preoperative BMI of 50.4 kg/m2 (44.6-56.5). A total of 64 individuals had Type 2 diabetes mellitus (T2D), with 28 undiagnosed cases at study entry (18% of study population). 25(OH)D deficiency was most prevalent (57%), followed by iron deficiency (44%), and folate deficiency (18%). Other deficiencies (vitamin B12, calcium, magnesium, phosphate) were rarely encountered and affected ≤1% of participants. Folate and 25(OH)D deficiency were related to obesity classification, with a higher prevalence in participants with a BMI ≥40 kg/m2 (p <0.01).

Conclusion

A higher prevalence of some micronutrient deficiencies was noted compared with data from similar populations in the developed world. The minimum baseline/preoperative nutrient evaluation in such populations should include 25(OH)D, iron studies, and folate. Additionally, screening for T2D is recommended. Future efforts should seek to collate broader patient data on a national scale and include longitudinal surveillance after surgery. This may provide a more holistic picture of the relationship between obesity, metabolic surgery and micronutrient status inform more appropriate evidence-based care.

Long-term weight loss after bariatric procedures for morbidly obese adolescents and youth: a single-institution analysis with up to 19-year follow-up

BACKGROUND

Obesity is a public health concern among adolescents and young adults. Bariatric surgery is the most effective treatment for morbid obesity and has been increasingly utilized in young patients. Long-term outcomes data for bariatric surgery in this age group are limited.

METHODS

This is a single-institution, prospective analysis of 167 patients aged 15-24 years who underwent one of three laparoscopic bariatric procedures between 2001 and 2019: Roux-en-Y gastric bypass (LRYGB, n = 71), adjustable gastric banding (LAGB, n = 22), and sleeve gastrectomy (LSG, n = 74). Longitudinal weight and body mass index (BMI) measurements were compared to evaluate patterns of weight loss.

RESULTS

All operations were completed laparoscopically using the same clinical pathways. Patients were predominantly female (82.6%), had a median age of 22.0 [Q1-Q3 20.0-23.0] years, and had a mean presurgical BMI of 48.5 ± 6.5 kg/m² (range 38.4-68.1 kg/m²). All procedures produced significant weight loss by 1 year, peak weight loss by 2 years, and modest weight regain after 5 years. Mean percent weight/BMI losses at 5 years for LRYGB, LAGB, and LSG were - 36.7 ± 10.8%, - 14.5 ± 15.3%, and - 25.1 ± 13.4%, respectively (p < 0.001). LRYGB patients were most likely to achieve ≥ 25% weight loss at 1, 3, and 5 years and maintained significant average weight loss for more than 15 years after surgery. Reoperations were procedure-specific, with LAGB, LRYGB, and LSG having the highest, middle, and lowest reoperation rates, respectively (40.9% vs. 16.9% vs. 5.4%, p < 0.001).

CONCLUSION

All procedures provided significant and durable weight loss. LRYGB patients achieved the best and most sustained weight loss. LSG patients experienced second-best weight loss between 1 and 5 years, with lowest chance of reoperation. LAGB patients had the least weight loss and the highest reoperation rate. Compared to other factors, type of bariatric procedure was independently predictive of successful weight loss over time. More studies with long-term follow-up are needed.

Comparing Patient Selection and 30-day Outcomes Between Single Anastomosis Gastric Bypass and Roux-en-Y Gastric Bypass: a Retrospective Cohort Study of 47,384 Patients

PURPOSE

Single anastomosis gastric bypass (SAGB) offers a novel bariatric procedure with increasing popularity. However, its adoption, patient selection, and short-term safety remain poorly characterized.

MATERIALS AND METHODS

The 2020 Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) was analyzed comparing SAGB to Roux-en-Y gastric bypass (RYGB). Bivariate analysis and multivariable logistic regression models compared difference between groups and factors associated with 30-day serious complications and mortality.

RESULTS

Overall, 47,384 patients were evaluated, with 1344 (2.8%) undergoing SAGB. SAGB patients had a higher BMI (45.2 ± 7.6 kg/m² vs 44.6 ± 7.9 kg/m², p = 0.006) and younger age (44.3 ± 12.1 years vs. 45.4 ± 11.5 years, p = 0.0008) than RYGB patients respectively. SAGB patients were less likely to have GERD (42.6% SAGB vs. 45.7% RYGB, p = 0.02), sleep apnea (37.8% SAGB vs. 41.1% RYGB, p = 0.02), and chronic steroid use (1.3% SAGB vs. 2.2% RYGB, p = 0.04). There were no significant difference in diabetes, hypertension, or dyslipidemia rates. Operative length for SAGB was significantly less than for RYGB (101 ± 53.7 min SAGB vs. 131.5 ± 63.3 min RYGB, p < 0.0001). SAGB was independently associated with decreased serious complications (4.7% vs. 8.4%, p < 0.0001) within 30 days compared to RYGB. Additionally, SAGB patients were less likely to experience reoperation (1.6% vs. 2.6%, p = 0.03), and readmission (2.2 vs. 5.8%, p < 0.0001) compared to RYGB respectively.

CONCLUSIONS

Compared to RYGB, patients undergoing SAGB were younger with marginally higher BMI. After adjusting for comorbidities, SAGB was associated with decreased odds of serious complications. Ongoing prospective studies analyzing long-term outcomes following SAGB remain needed.

Reasons for Preoperative Patient Attrition among Bariatric Surgery Candidates: Patients' Point of View

PURPOSE

Obesity has become a global health concern, associated with decreased quality of life and life expectancy. Although bariatric surgery has many benefits (e.g., substantial and durable weight loss, amelioration of comorbidities, and improvement in functionality), its patient attrition rate is relatively high. Therefore, we aim to assess the causes of withdrawal from our program.

MATERIALS AND METHODS

We interviewed patients who dropped out of our bariatric surgery program between January 2016 and December 2021. A total of 1999 patients were eligible for bariatric surgery during this period, and 255 patients withdrew from the program. We interviewed patients over the phone to find out the reason for withdrawal. We divided participants into two groups: dropouts before and during the COVID-19 pandemic. Several options explaining the reason for leaving the program were presented to the patients to choose from.

RESULTS

The number of patients who withdrew from the program before and during the COVID-19 pandemic was 135 (8.9%) and 120 (25.2%), respectively. Before the COVID-19 pandemic, most patients (49.1%) stated that the long waiting time was the cause of withdrawal. Even though during the COVID-19 pandemic, the main causes of attrition were the fear of contracting the disease and COVID-19 infection; the most common reason unrelated to COVID-19 was still the long preoperative preparation.

CONCLUSION

Long waiting time was the most common cause of patient attrition before bariatric surgery. To reduce the attrition rate, more studies should be conducted to find an optimized waiting time before bariatric surgery.

Obesity and diabetes: the final frontier

INTRODUCTION

Obesity is a key target in the treatment and prevention of diabetes and independently to reduce the burden of cardiovascular disease. We reviewed the options now available and anticipated to deal with obesity.

AREAS COVERED

We considered the epidemiology, genetics, and causation of obesity and the relationship to diabetes, and the dietary, pharmaceutical, and surgical management of the condition. The literature search covered both popular media via Google Search and the academic literature as indexed on PubMed with search terms including obesity, childhood obesity, adipocytes, insulin resistance, mechanisms of satiety, bariatric surgery, GLP-1 receptor agonists, and SGLT2 inhibitors.

EXPERT OPINION

Although bariatric surgery has been the primary approach to treating obese individuals, the emergence of agents impacting the brain satiety centers now promises effective, non-invasive treatment of obesity for individuals with and without diabetes. The GLP-1 receptor agonists have assumed the primary role in treating obesity with significant weight loss. Long-term results with semaglutide and tirzepatide are now approaching the success seen with bariatric surgery. Future agents combining the benefits of satiety control and thermogenesis to dissipate caloric excess are under investigation.

Factors that influence discharge opioid prescribing among bariatric surgeons across Michigan

BACKGROUND

Opioid prescribing following bariatric surgery has been a focus due to its association with new persistent opioid use (NPOU) and worse outcomes. Guidelines have led to a reduction in opioids prescribed, but there remains variation in prescribing practices.

METHODS

We conducted interviews with 20 bariatric surgeons across Michigan. Transcripts were analyzed using descriptive content analysis.

RESULTS

At the patient level, surgeons described the role of surgical history and pain tolerance. At the provider level, surgeons discussed patient dissatisfaction, reputation, and workload. At the institution level, surgeons discussed colleagues, resources, and administration. At a collaborative level, surgeons described the role of evidence and performance measures. There was lack of consensus on whether NPOU is a problem facing patients undergoing bariatric surgery.

CONCLUSION

Despite efforts aimed at addressing opioid prescribing, variability exists in prescribing practices. Understanding determinants that impact stakeholder alignment is critical to increasing adherence to guideline-concordant care.

Next-Generation Sequencing of a Large Gene Panel for Outcome Prediction of Bariatric Surgery in Patients with Severe Obesity

Obesity is a chronic disease in which abnormal deposition of fat threatens health, leading to diabetes, cardiovascular diseases, cancer, and other chronic illnesses. According to the WHO, 19.8% of the adult population in Italy is obese, and the prevalence is higher among men. It is important to know the predisposition of an individual to become obese and to respond to bariatric surgery, the most up-to-date treatment for severe obesity. To this purpose, we developed an NGS gene panel, comprising 72 diagnostic genes and 244 candidate genes, and we sequenced 247 adult obese Italian patients. Eleven deleterious variants in 9 diagnostic genes and 17 deleterious variants in 11 candidate genes were identified. Interestingly, mutations were found in several genes correlated to the Bardet-Biedl syndrome. Then, 25 patients were clinically followed to evaluate their response to bariatric surgery. After a 12-month follow-up, the patients that carried deleterious variants in diagnostic or candidate genes had a reduced weight loss, as compared to the other patients. The NGS-based panel, including diagnostic and candidate genes used in this study, could play a role in evaluating, diagnosing, and managing obese individuals, and may help in predicting the outcome of bariatric surgery.

Association Between Patient Satisfaction With Their Patient-Physician Relationship and Completion of Bariatric Surgery by Race and Ethnicity Among US Adults

IMPORTANCE

Metabolic and bariatric surgery (MBS) is an effective and safe treatment for obesity and its comorbidities, but less than 50% of those who are eligible and referred for MBS complete the procedure. The patient-physician relationship could be a decisive factor in the decision to complete MBS; however, this relationship has not been explored, particularly among racially and ethnically diverse populations.

OBJECTIVE

To examine the association between patient-reported satisfaction with their patient-physician relationship and MBS completion by self-reported racial and ethnic group.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included 408 patients who were referred to a bariatric surgeon or obesity medicine program between July 24, 2019, and May 19, 2022.

EXPOSURE

Patient satisfaction with their physician was measured by 7 dimensions (general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with physician, and accessibility and convenience) using the Patient Satisfaction Questionnaire Short Form.

MAIN OUTCOMES AND MEASURES

Completion status for MBS (yes or no).

RESULTS

A total of 408 patients (mean [SD] age, 47.3 [11.6] years; among 366 with data available, 317 [86.6%] women and 49 [13.4%] men) were included in the study. Of 363 patients with data available on race and ethnicity, 66 were Hispanic/Latinx (18.2%), 136 (37.5%) were non-Hispanic Black, 146 (40.2%) were non-Hispanic White, and 15 (4.1%) were other race or ethnicity. A total of 124 patients (30.4%) completed MBS. Overall, the mean (SD) patient satisfaction score was significantly greater in MBS completers vs noncompleters (3.86 [0.56] vs 3.61 [0.64]; P < .001). Multivariable logistic regression analysis showed technical quality was the most significant factor for MBS completion (adjusted odds ratio [aOR], 1.99 [95% CI, 1.24-3.19]), followed by communication (aOR, 1.78 [95% CI, 1.16-2.72]) and accessibility and convenience (aOR, 1.61 [95% CI, 1.03-2.53]). The interaction between racial and ethnic groups and patient satisfaction was not significant (eg, mean [SD] score for Hispanic/Latinx completers, 3.95 [0.55] vs 3.77 [0.60] for non-Hispanic White completers; P = .46 for interaction).

CONCLUSIONS AND RELEVANCE

These findings suggest that there is an association between patient satisfaction with the patient-physician relationship and the decision to complete MBS regardless of race and ethnicity. These findings have important implications for strategies to improve the proportion of qualified patients who complete MBS to achieve improved health outcomes.

Is Same-Day Discharge After Roux-en-Y Gastric Bypass Safe? A Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Database Analysis

Purpose

Same-day discharge (SDD) after bariatric surgery is gaining popularity. We aimed to analyze the safety of SDD after Roux-en-Y gastric bypass (RYGB) and compare its outcomes to inpatients discharged on postoperative days 1–2.

Materials and Methods

We performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for the period 2015–2020. Patients who underwent primary laparoscopic RYGB and were discharged the same day of the operation (SDD-RYGB) and inpatients discharged on postoperative days 1–2 (In-RYGB) were compared. Primary outcomes of interest were overall morbidity, serious morbidity, readmission, reoperation, intervention, and mortality rates.

Results

A total of 167,188 patients were included; 2156 (1.3%) SDD-RYGB and 165,032 (98.7%) In-RYGB. Mean age (SDD-RYGB: 44.5 vs. In-RYGB: 44.6 years), proportion of females (SDD-RYGB: 81.4% vs. In-RYGB: 80.6%), and mean body mass index (SDD-RYGB: 45.8 vs. In-RYGB: 45.9 kg/m²) were similar between groups. Overall morbidity (SDD-RYGB: 11.3% vs. In-RYGB: 10.2%; OR: 1.2, p = 0.08), serious morbidity (SDD-RYGB: 3.1% vs. In-RYGB: 3%; OR: 1.03, p = 0.81), reoperation (SDD-RYGB: 1.4% vs. In-RYGB: 1.2%; OR: 1.16, p = 0.42), readmission (SDD-RYGB: 4.8% vs. In-RYGB: 4.8%; OR: 1.01, p = 0.89), and mortality (SDD-RYGB: 0.04% vs. In-RYGB: 0.09%; OR: 0.53, p = 0.53) were comparable between groups. SDD-RYGB had lower risk of 30-day interventions (SDD-RYGB: 1.1% vs. In-RYGB: 1.6%; OR: 0.64, p = 0.04) compared to In-RYGB.

Conclusion

Same-day discharge after RYGB seems to be safe and has comparable outcomes to admitted patients. Standardized patient selection criteria and perioperative management protocols are needed to further increase the safety of this practice.

Graphical abstract

Use and Impact of Type 2 Diabetes Prevention Interventions

INTRODUCTION

RCTs have found that type 2 diabetes can be prevented among high-risk individuals by metformin medication and evidence-based lifestyle change programs. The purpose of this study is to estimate the use of interventions to prevent type 2 diabetes in real-world clinical practice settings and determine the impact on diabetes-related clinical outcomes.

METHODS

The analysis performed in 2020 used 2010‒2018 electronic health record data from 69,434 patients aged ≥18 years at high risk for type 2 diabetes in 2 health systems. The use and impact of prescribed metformin, lifestyle change program, bariatric surgery, and combinations of the 3 were examined. A subanalysis was performed to examine uptake and retention among patients referred to the National Diabetes Prevention Program.

RESULTS

Mean HbA1c values declined from before to after intervention for patients who were prescribed metformin (-0.067%; p<0.001) or had bariatric surgery (-0.318%; p<0.001). Among patients referred to the National Diabetes Prevention Program lifestyle change program, the type 2 diabetes postintervention incidence proportion was 14.0% for nonattendees, 12.8% for some attendance, and 7.5% for those who attended ≥4 sessions (p<0.001). Among referred patients to the National Diabetes Prevention Program lifestyle change program, uptake was low (13% for 1‒3 sessions, 15% for ≥4 sessions), especially among males and Hispanic patients.

CONCLUSIONS

Findings suggest that metformin and bariatric surgery may improve HbA1c levels and that participation in the National Diabetes Prevention Program may reduce type 2 diabetes incidence. Efforts to increase the use of these interventions may have positive impacts on diabetes-related health outcomes.

An innovative endoscopic management strategy for postoperative fistula after laparoscopic sleeve gastrectomy

BACKGROUND

Postoperative fistula is a life-threatening complication that lacks a standard treatment strategy after laparoscopic sleeve gastrectomy (LSG). This observational study is the first to report the efficacy and safety of endoscopic full-thickness resection (EFTR) combined with purse-string sutures in treating this complication.

PATIENTS AND METHODS

The old fistula was resected by EFTR, cut radially, and then sutured with a purse-string. The primary endpoint was complete fistula closure within two months. Endoscopic procedure-related complications were also recorded.

RESULTS

Eight of 788 LSG patients developed fistulas with an incidence of 1.01%, primarily under the gastroesophageal junction, and the average distance from the center of the fistula to the cardia was 30 ± 6.3 mm. Two patients were cured by conservative treatment, and six received endoscopic sutures. The time from LSG to fistula diagnosis was 12.3 ± 14.4 days. The time from fistula diagnosis to endoscopic repair was 43.8 ± 55.8 days and 21.4 ± 10.0 days after eliminating the data of first case. The average fistula size was 12 ± 10 mm, the average endoscopic procedure duration was 40 ± 16 min, and the average number of endoscopic procedures required was 1.6 ± 0.8. Five patients achieved the primary endpoint, and one patient refused a third endoscopic suture after two sutures. The endoscopy success rate was 83.3%. No endoscopic procedure-related complications occurred.

CONCLUSIONS

EFTR combined with purse-string sutures is an innovative, safe, and effective endoscopic strategy for postoperative fistula after LSG, avoiding reoperation and allowing early oral feeding.

The utility of intraoperative endoscopy to assist novice surgeons in the detection of gastric stenosis during laparoscopic sleeve gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a commonly performed bariatric surgery. Gastric stenosis and leaks are 2 major complications associated with LSG and revision surgery might be needed. Herein, we report our experience of intraoperative endoscopy (IOE) to evaluate stenosis and leaks during LSG.

METHODS

LSG was performed by three surgeons. Patients who underwent LSG and IOE between January 2016 and March 2020 were enrolled and assigned to two groups: group 1 (1st-30th LSG case for each surgeon) and group 2 (> 30th LSG for each surgeon). Patients' anthropometric and biochemical data pre- and post-LSG, as well as IOE findings and follow-up esophagogastroduodenoscopy records were reviewed.

RESULTS

In total, 352 patients were enrolled including 90 patients in group 1 and 262 patients in group 2. Three out of 352 patients (0.9%) were found to have stenosis by IOE, which was related to tightly gastropexy stitch or reinforcement stitch, all of which were in group 1. Stenosis was resolved after removal of the stitch during LSG. The incidence of gastric stenosis detected by IOE was 3.3% (3/90) and 0% (0/262) in group 1 and group 2, respectively (P = 0.003). No leakage was found in this study and no patient developed clinical or endoscopic stenosis after LSG.

CONCLUSIONS

The existing evidence showed that IOE can help detect gastric stenosis during LSG, especially for novice surgeons, and the stenosis could be resolved during operation.

Gut Microbiota Patterns Predicting Long-Term Weight Loss Success in Individuals with Obesity Undergoing Nonsurgical Therapy

Background: The long-term success of nonsurgical weight reduction programs is variable; thus, predictors of outcome are of major interest. We hypothesized that the intestinal microbiota known to be linked with diet and obesity contain such predictive elements. Methods: Metagenome analysis by shotgun sequencing of stool DNA was performed in a cohort of 15 adults with obesity (mean body mass index 43.1 kg/m²) who underwent a one-year multidisciplinary weight loss program and another year of follow-up. Eight individuals were persistently successful (mean relative weight loss 18.2%), and seven individuals were not successful (0.2%). The relationship between relative abundancies of bacterial genera/species and changes in relative weight loss or body mass index was studied using three different statistical modeling methods. Results: When combining the predictor variables selected by the applied statistical modeling, we identified seven bacterial genera and eight bacterial species as candidates for predicting success of weight loss. By classification of relative weight-loss predictions for each patient using 2–5 term models, 13 or 14 out of 15 individuals were predicted correctly. Conclusions: Our data strongly suggest that gut microbiota patterns allow individual prediction of long-term weight loss success. Prediction accuracy seems to be high but needs confirmation by larger prospective trials.

Bariatric surgery and the neurohormonal switch: Early insulin resistance recordings after laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is a bariatric operation with a safe risk profile. It has been proven to successfully reduce weight, decrease insulin resistance (IR), and ameliorate diabetes mellitus. The aim of this study was to determine if there is an early improvement in IR after LSG and its association with weight loss. This was a prospective observational study of 32 patients who underwent LSG at a single center over a 3-year period. Serum insulin and fasting glucose levels were recorded preoperatively, on day 1 postoperatively, and 3 weeks after LSG. IR levels were calculated using the Homeostasis Model Assessment 2 Version 2.23. IR levels were compared along with the overall weight loss, via body mass index. β-cell function was the secondary outcome. IR significantly improved the day after surgery with a statistically significant mean difference of 0.89 units (P = .043) and significantly more so 3 weeks postoperatively, with a mean difference of 4.32 units (P < .0005). β-cell function reduced 3 weeks postoperatively, with a mean difference of 23.95 %β (P = .025), while body mass index significantly reduced, with a mean difference of 4.32 kg/m2 (P < .0005). Early improvement of IR was observed on postoperative day 1 after LSG before any weight loss. This raises the possibility of an undetermined, underlying neurohormonal switch that improves IR. Further investigation is needed to determine this mechanism, as it may lead to an improvement in the medical management of diabetes mellitus.

Adipose tissue and ovarian aging: Potential mechanism and protective strategies

Ovarian aging occurs approximately 10 years prior to the natural age-associated functional decline of other organ systems. With the increase of life expectancy worldwide, ovarian aging has gradually become a key health problem among women. Therefore, understanding the causes and molecular mechanisms of ovarian aging is very essential for the inhibition of age-related diseases and the promotion of health and longevity in women. Recently, studies have revealed an association between adipose tissue (AT) and ovarian aging. Alterations in the function and quantity of AT have profound consequences on ovarian function because AT is central for follicular development, lipid metabolism, and hormonal regulation. Moreover, the interplay between AT and the ovary is bidirectional, with ovary-derived signals directly affecting AT biology. In this review, we summarize the current knowledge of the complex molecular mechanisms controlling the crosstalk between the AT and ovarian aging, and further discuss how therapeutic targeting of the AT can delay ovarian aging.

Relationship between Eating Behavior, Quality of Life and Weight Regain in Women after Bariatric Surgery

Individuals undergoing bariatric Surgery (BS) may have long-term weight regain. There is a need to investigate factors that may be related to this and if they can interfere with Quality of Life (QOL). This study aims to evaluate the relationship between eating behavior, perception of QOL, and weight regain in women after 24 months of bariatric surgery. This was a transversal study with 50 adult women residents in the city of Belém, Brazil. Sociodemographic, anthropometric, eating behavior (Three-Factor Eating Questionnaire—TFEQ-21) and perception of QOL (Item Short Form Healthy Survey—SF-36) data were collected. In 60% (n = 30) there was weight regain (≥15%), with a mean weight regain of 23.3% (±18.4). Emotional eating was the most frequent pattern (p = 0.047). Regarding QOL, the functional capacity and limitation due to physical aspects domains had a better perception (p < 0.0001). Women without weight regain showed a better perception of the functional capacity aspects (p = 0.007), limitation due to physical aspects (p = 0.044), social aspects (p = 0.048), and general physical components (p = 0.016) and also had an inverse association with the perception of QOL in physical components (p = 0.008). Patterns of eating behavior and weight regain can damage the perception of QOL, especially physical capacity. Long-term follow-up is essential to evaluate the behavior of people who have undergone BS in order to prevent weight regain and QOL damage.

Obesity and bariatric surgery in adults living with severe mental illness: perceptions and clinical challenges

Overweight and obesity are twice as likely to develop in people living with severe mental illness (SMI), compared with those without. Many factors contribute to this, such as reduced physical activity and the use of certain medications that induce weight gain. Obesity contributes to the premature mortality seen in people living with SMI, as it is one of the fundamental risk factors for cardiovascular disease and diabetes. Bariatric surgery is an effective treatment option, although patients living with SMI might face stigma when being considered for surgical intervention. This article proposes a discussion around obesity and bariatric surgery in patients living with SMI. It will also reflect on the challenges faced by healthcare professionals and patients living with SMI and obesity, when considering appropriate treatments for weight loss. The paper utilises a fictional case, informed by contributions from a lived experience author, to explore bariatric surgery in people living with SMI.

Prevalence and Outcomes of Depression After Bariatric Surgery: A Systematic Review and Meta-Analysis

Surgeons often focus on weight loss and improvement of obesity-related conditions as a primary outcome after bariatric surgery. However, the success of bariatric surgery also relies on the improvement of mental health status. Therefore, the current meta-analysis was carried out to reveal the prevalence of depressive symptoms and their subsequent impact on bariatric surgery outcomes. This study was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist and the recommendation of Cochrane Collaboration. All clinical studies reporting the prevalence and/or the outcomes of depression after bariatric surgery were included in the current meta-analysis. This meta-analysis encompassed 33 articles, including a total of 101,223 patients. The prevalence of post-bariatric surgery depression was 15.3% (95% confidence intervals {CI}: 15.0-15.5%, p<0.001) among which severe, moderate, and minimal depression accounted for 1.9% (95% CI: 1.5-2.4%, p<0.001), 5.1% (95% CI: 4.4-5.8%, p<0.001), and 64.9% (95% CI: 63.3-66.5%, p<0.001), respectively. Depression is negatively correlated with weight loss (correlation -0.135; 95% CI: -0.176 to 0.093; p<0.001) and positively correlated with eating disorder (correlation 0.164; 95% CI: 0.079-0.248; p<0.001). The prevalence of post-bariatric surgery depression is relatively high reaching up to 64.9%, with almost one in five patients affected by it. Depression is associated with weight regain, eating disorders, and quality of life.

Neurohormonal Changes in the Gut–Brain Axis and Underlying Neuroendocrine Mechanisms following Bariatric Surgery

Obesity is a complex, multifactorial disease that is a major public health issue worldwide. Currently approved anti-obesity medications and lifestyle interventions lack the efficacy and durability needed to combat obesity, especially in individuals with more severe forms or coexisting metabolic disorders, such as poorly controlled type 2 diabetes. Bariatric surgery is considered an effective therapeutic modality with sustained weight loss and metabolic benefits. Numerous genetic and environmental factors have been associated with the pathogenesis of obesity, while cumulative evidence has highlighted the gut–brain axis as a complex bidirectional communication axis that plays a crucial role in energy homeostasis. This has led to increased research on the roles of neuroendocrine signaling pathways and various gastrointestinal peptides as key mediators of the beneficial effects following weight-loss surgery. The accumulate evidence suggests that the development of gut-peptide-based agents can mimic the effects of bariatric surgery and thus is a highly promising treatment strategy that could be explored in future research. This article aims to elucidate the potential underlying neuroendocrine mechanisms of the gut–brain axis and comprehensively review the observed changes of gut hormones associated with bariatric surgery. Moreover, the emerging role of post-bariatric gut microbiota modulation is briefly discussed.

History of bariatric surgery and COVID-19 outcomes in patients with type 2 diabetes: Results from the CORONADO study

OBJECTIVE

This study assessed the impact of a history of metabolic and bariatric surgery (MBS) on the clinical outcomes in patients with type 2 diabetes (T2D) and severe obesity hospitalized for COVID-19.

METHODS

In this post hoc analysis from the nationwide observational CORONADO (Coronavirus SARS-CoV2 and Diabetes Outcomes) study, patients with T2D and a history of MBS were matched with patients without MBS for age, sex, and BMI either at the time of MBS or on admission for COVID-19. The composite primary outcome (CPO) combined invasive mechanical ventilation and/or death within 7 and 28 days following admission.

RESULTS

Out of 2,398 CORONADO participants, 20 had a history of MBS. When matching for BMI at the time of MBS and after adjustment for diabetes duration, the CPO occurred less frequently within 7 days (3 vs. 17 events, OR: 0.15 [0.01 to 0.94], p = 0.03) and 28 days (3 vs. 19 events, OR: 0.11 [0.01 to 0.71], p = 0.02) in patients with MBS (n = 16) vs. controls (n = 44). There was no difference in CPO rate between patients with MBS and controls when matching for BMI on admission.

CONCLUSIONS

These data are reassuring regarding COVID-19 prognosis in patients with diabetes and a history of MBS compared with those without MBS.

The Impact of Bariatric Surgery on Bone Health: State of the Art and New Recognized Links

Bariatric surgery (BS) is the most effective therapy for severe obesity, which improves several comorbidities (such as diabetes, hypertension, dyslipidemia, among others) and results in marked weight loss. Despite these consensual beneficial effects, sleeve gastrectomy and Roux-en-Y gastric bypass (the two main bariatric techniques) have also been associated with changes in bone metabolism and progressive bone loss. The objective of this literature review is to examine the impact of bariatric surgery on bone and its main metabolic links, and to analyze the latest findings regarding the risk of fracture among patients submitted to bariatric surgery.

Medication Use for Obesity-Related Comorbidities After Sleeve Gastrectomy or Gastric Bypass

IMPORTANCE

Sleeve gastrectomy and gastric bypass are the most common bariatric surgical procedures in the world; however, their long-term medication discontinuation and comorbidity resolution remain unclear.

OBJECTIVE

To compare the incidence of medication discontinuation and restart of diabetes, hypertension, and hyperlipidemia medications up to 5 years after sleeve gastrectomy or gastric bypass.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness research study of adult Medicare beneficiaries who underwent laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between January 1, 2012, to December 31, 2018, and had a claim for diabetes, hypertension, or hyperlipidemia medication in the 6 months before surgery with a corresponding diagnosis used instrumental-variable survival analysis to estimate the cumulative incidence of medication discontinuation and restart. Data analyses were performed from February to June 2021.

EXPOSURES

Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass.

MAIN OUTCOMES AND MEASURES

The primary outcome was discontinuation of diabetes, hypertension, and hyperlipidemia medication for any reason. Among patients who discontinued medication, the adjusted cumulative incidence of restarting medication was calculated up to 5 years after discontinuation.

RESULTS

Of the 95 405 patients included, 71 348 (74.8%) were women and the mean (SD) age was 56.6 (11.8) years. Gastric bypass compared with sleeve gastrectomy was associated with a slightly higher 5-year cumulative incidence of medication discontinuation among 30 588 patients with diabetes medication use and diagnosis at the time of surgery (74.7% [95% CI, 74.6%-74.9%] vs 72.0% [95% CI, 71.8%-72.2%]), 52 081 patients with antihypertensive medication use and diagnosis at the time of surgery (53.3% [95% CI, 53.2%-53.4%] vs 49.4% [95% CI, 49.3%-49.5%]), and 35 055 patients with lipid-lowering medication use and diagnosis at the time of surgery (64.6% [95% CI, 64.5%-64.8%] vs 61.2% [95% CI, 61.1%-61.3%]). Among the subset of patients who discontinued medication, gastric bypass was also associated with a slightly lower incidence of medication restart up to 5 years after discontinuation. Specifically, the 5-year cumulative incidence of medication restart was lower after gastric bypass compared with sleeve gastrectomy among 19 599 patients who discontinued their diabetes medication after surgery (30.4% [95% CI, 30.2%-30.5%] vs 35.6% [95% CI, 35.4%-35.9%]), 21 611 patients who discontinued their antihypertensive medication after surgery (67.2% [95% CI, 66.9%-67.4%] vs 70.6% [95% CI, 70.3%-70.9%]), and 18 546 patients who discontinued their lipid-lowering medication after surgery (46.2% [95% CI, 46.2%-46.3%] vs 52.5% [95% CI, 52.2%-52.7%]).

CONCLUSIONS AND RELEVANCE

Findings of this study suggest that, compared with sleeve gastrectomy, gastric bypass was associated with a slightly higher incidence of medication discontinuation and a slightly lower incidence of medication restart among patients who discontinued medication. Long-term trials are needed to explain the mechanisms and factors associated with differences in medication discontinuation and comorbidity resolution after bariatric surgery.

The US Prevalence of Metabolic Surgery in Patients with Obesity and Type 2 Diabetes Has Not Increased Despite Recommendations from the American Diabetes Association

PURPOSE

Metabolic surgery dramatically improves type 2 diabetes mellitus (T2DM). In 2017, the American Diabetes Association (ADA) recommended metabolic surgery as the optimal treatment for patients with T2DM and Body Mass Index (BMI) > 40. We sought to evaluate whether or not that recommendation is being implemented. The purpose of this study was to evaluate the trend of bariatric surgery 2 years prior and 2 years following the ADA statement.

MATERIALS AND METHODS

A retrospective analysis of primary bariatric procedures on patients with class III obesity (BMI > 40 kg/m²) and T2DM performed between 2015 and 2018, using the Metabolic and Bariatric Surgery Accreditation Quality and Improvement Project (MBSAQIP) database.

RESULTS

From 2015 to 2018, 164,535 patients with T2DM underwent bariatric surgery. The majority had a BMI > 40 kg/m² (n = 117,422, 71.4%) and most were not using insulin. Majority of the patients with T2D and class III obesity were female (72.1%), Caucasian (71.5%), and mean age (SD) 48.5 (11.5). Although the numbers of patients with T2DM and class III obesity increased during this time period, there was not a significant change in the overall percentage of patients who were treated with surgery: from 25.99% in 2015 to 24.96% in 2018. In addition, this group is associated with higher rates of complications and mortality compared to patients with BMI > 40 kg/m² without T2DM.

CONCLUSION

Utilization of metabolic surgery in patients with obesity and T2DM has not improved following the updated 2017 ADA guidelines. There is a clear need for more awareness of these guidelines among providers, patients, and the public.

Lipocalin, Resistin and Gut Microbiota-Derived Propionate Could Be Used to Predict Metabolic Bariatric Surgery Selected Outcomes

Many patients with clinically severe obesity (CSO) need to undergo bariatric surgery, with possible side effects, so individualized predictive methods are required. Adipocytokines and gut/intestinal microbiota-derived metabolites could be predictive biomarkers of metabolic success post- surgery, but the knowledge in this field is undefined. The objective of this work was to determine whether adipocytokines and microbiota-derived metabolites can be used to predict the metabolic improvement post- surgery in women with CSO. We analyzed circulating levels of some cytokines and some microbiota-derived metabolites at baseline and 12 months post-surgery from 44 women with CSO and 21 women with normal weight. Results showed that glucose, insulin, glycosylated hemoglobin A1c (HbA1c), low-density lipoprotein (LDL-C), and triglycerides levels were decreased post-surgery, while high density lipoprotein increased. Twelve months later, leptin, resistin, lipocalin, PAI-1, TNF-α, and IL-1β levels were lower than baseline, meanwhile adiponectin, IL-8, and IL-10 levels were increased. Moreover, baseline lipocalin levels were associated with HbA1c reduction post-surgery; meanwhile baseline resistin was related to postoperative HOMA2 (insulin resistance) and baseline propionate was associated with LDL-C decrease. To conclude, the detection of lipocalin, resistin, and propionate levels may be used to predict the metabolic success following bariatric surgery, although new knowledge is needed.

First fully endoscopic metabolic procedure with NOTES gastrojejunostomy, controlled bypass length and duodenal exclusion: a 9-month porcine study

We conducted a pilot study of a potential endoscopic alternative to bariatric surgery. We developed a Natural Orifice Transluminal Endoscopic Surgery (NOTES) gastric bypass with controlled bypass limb length using four new devices including a dedicated lumen-apposing metal stent (GJ-LAMS) and pyloric duodenal exclusion device (DED). We evaluated procedural technical success, weight change from baseline, and adverse events in growing Landrace/Large-White pigs through 38 weeks after GJ-LAMS placement. Six pigs (age 2.5 months, mean baseline weight 26.1 ± 2.7 kg) had initial GJ-LAMS placement with controlled bypass limb length, followed by DED placement at 2 weeks. Technical success was 100%. GJ-LAMS migrated in 3 of 6, and DED migrated in 3 of 5 surviving pigs after mucosal abrasion. One pig died by Day 94. At 38 weeks, necropsy showed 100–240 cm limb length except for one at 760 cm. Weight gain was significantly lower in the pigs that underwent endoscopic bypass procedures compared to expected weight for age. This first survival study of a fully endoscopic controlled bypass length gastrojejunostomy with duodenal exclusion in a growing porcine model showed high technical success but significant adverse events. Future studies will include procedural and device optimizations and comparison to a control group.

Bariatric surgery and alcohol and substance abuse disorder: A systematic review

INTRODUCTION

Bariatric surgery is a relatively safe surgical procedure with a high success rate. However, recent reports indicate a higher prevalence of alcohol or substance abuse disorder in this patient group. The purpose of this study was to review the related evidence to serve as a reference for multidisciplinary teams who treat these patients.

METHODS

We searched the PubMed and CENTRAL databases. The odds ratios were extracted from the different articles, comparing the prevalence of the abuse of alcohol or other substances in the postoperative period versus preoperative levels. We also compared the prevalence of alcohol use disorder after different types of bariatric surgery.

RESULTS

A total of 49 121 bariatric patients (80.8% female) were evaluated for alcohol use disorder. In general, bariatric surgery was found to be associated with an increase in the prevalence of alcohol abuse (4.58 ± 5.3 vs. 1.58 ± 10.7% in the preoperative period). We also found that the population of patients who underwent RYGB procedures had a higher prevalence of alcohol use disorder than patients who underwent another type of surgery (OR: 1.83; 95% CI: 1.51-2.21). The prevalence of substance abuse disorder (other than alcohol) after this procedure is less studied, although there appears to be an increased risk of abuse of certain substances.

CONCLUSIONS

Bariatric surgery is the best treatment for obesity and its complications. The evidence reviewed suggests that it correlates with a modest but consistent increase in the prevalence of abuse of alcohol and other substances. Medical teams who treat bariatric patients must be informed about this eventuality for its timely prevention, diagnosis and treatment.