Long-term all-cause and cause-specific mortality for four bariatric surgery procedures

Long-term clinical outcomes of bariatric surgery in adults with severe obesity: A population-based retrospective cohort study

BACKGROUND

Bariatric surgery leads to sustained weight loss in a majority of recipients, and also reduces fasting insulin levels and markers of inflammation. We described the long-term associations between bariatric surgery and clinical outcomes including 30 morbidities.

METHODS

We did a retrospective population-based cohort study of 304,157 adults with severe obesity, living in Alberta, Canada; 6,212 of whom had bariatric surgery. We modelled adjusted time to mortality, hospitalization, surgery and the adjusted incidence/prevalence of 30 new or ongoing morbidities after 5 years of follow-up.

RESULTS

Over a median follow-up of 4.4 years (range 1 day-22.0 years), bariatric surgery was associated with increased risk of hospitalization (HR 1.46, 95% CI 1.41,1.51) and additional surgery (HR 1.42, 95% CI 1.32,1.52) but with a decreased risk of mortality (HR 0.76, 95% CI 0.64,0.91). After 5 years (median of 9.9 years), bariatric surgery was associated with a lower risk of severe chronic kidney disease (HR 0.45, 95% CI 0.27,0.75), coronary disease (HR 0.49, 95% CI 0.33,0.72), diabetes (HR 0.51, 95% CI 0.47,0.56), inflammatory bowel disease (HR 0.55, 95% CI 0.37,0.83), hypertension (HR 0.70, 95% CI 0.66,0.75), chronic pulmonary disease (HR 0.75, 95% CI 0.66,0.86), asthma (HR 0.79, 95% 0.65,0.96), cancer (HR 0.79, 95% CI 0.65,0.96), and chronic heart failure (HR 0.79, 95% CI 0.64,0.96). In contrast, after 5 years, bariatric surgery was associated with an increased risk of peptic ulcer (HR 1.99, 95% CI 1.32,3.01), alcohol misuse (HR 1.55, 95% CI 1.25,1.94), frailty (HR 1.28, 95% 1.11,1.46), severe constipation (HR 1.26, 95% CI 1.07,1.49), sleep disturbance (HR 1.21, 95% CI 1.08,1.35), depression (HR 1.18, 95% CI 1.10,1.27), and chronic pain (HR 1.12, 95% CI 1.04,1.20).

INTERPRETATION

Bariatric surgery was associated with lower risks of death and certain morbidities. However, bariatric surgery was also associated with increased risk of hospitalization and additional surgery, as well as certain other morbidities. Since values and preferences for these various benefits and harms may differ between individuals, this suggests that comprehensive counselling should be offered to patients considering bariatric surgery.

Six-year postoperative associations between the Minnesota Multiphasic Personality Inventory - 3 (MMPI-3) and weight recurrence, eating behaviors, adherence, alcohol misuse, and quality of life

BACKGROUND

Metabolic and bariatric surgery (MBS) leads to beneficial and sustained outcomes. However, many patients evidence weight recurrence and psychosocial functioning may be associated with weight recurrence. The Minnesota Multiphasic Personality Inventory - 3 (MMPI-3) is validated for use in presurgical MBS evaluations and likely has clinical utility in understanding weight recurrence and other aspects of postoperative functioning.

OBJECTIVE

The objective of the current investigation is to understand how postoperative psychosocial functioning relates to weight recurrence and other behaviors and constructs 6 years after MBS.

SETTING

Cleveland Clinic Bariatric and Metabolic Institute.

METHODS

A sample of 163 participants consented to take a battery of self-report measures related to psychological functioning, eating behaviors, adherence, alcohol misuse, and quality of life along with their postoperative weight. MMPI-3 scale scores were prorated from the Minnesota Multiphasic Personality Inventory - 2 - Restructured Form (MMPI-2-RF) or scored from the Minnesota Multiphasic Personality Inventory - 2 - Restructured Form - Expanded (MMPI-2-RF-EX).

RESULTS

Weight recurrence was quite variable in this sample. Postoperative MMPI-3 scales related to emotional/internalizing dysfunction were modestly associated with higher weight recurrence. Postoperative MMPI-3 scale scores also demonstrated associations with other postoperative outcomes including measures of eating behaviors, adherence, alcohol misuse, and quality of life.

CONCLUSIONS

Postoperative psychosocial functioning as assessed by the MMPI-3 was associated with weight recurrence and a number of other problematic psychological outcomes beyond weight recurrence.

Mental health from 5 years before to 10 years after bariatric surgery in adolescents with severe obesity: a Swedish nationwide cohort study with matched population controls

BACKGROUND

The long-term effects of bariatric surgery on the mental health of adolescents with severe obesity remain uncertain. We aimed to describe the prevalence of psychiatric health-care visits and filled prescription psychiatric drugs among adolescents with severe obesity undergoing bariatric surgery in the 5 years preceding surgery and throughout the first 10 years after surgery, and to draw comparisons with matched adolescents in the general population.

METHODS

Adolescents with severe obesity and who underwent bariatric surgery were identified through the Scandinavian Obesity Surgery Registry. We included adolescents who had bariatric surgery between 2007 and 2017 and were younger than 21 years at time of surgery. Each adolescent patient was matched with ten adolescents from the general population by age, sex, and county of residence. Specialist psychiatric care and filled psychiatric prescriptions were retrieved from nationwide data registers.

FINDINGS

1554 adolescents (<21 years) with severe obesity underwent bariatric surgery between 2007 and 2017, 1169 (75%) of whom were female. At time of surgery, the mean age was 19·0 years [SD 1·0], and the mean BMI was 43·7 kg/m2 (SD 5·5). 15 540 adolescents from the general population were matched with adolescents in the surgery group. 5 years before the matched index date, 95 (6·2%) of 1535 surgery patients and 370 (2·5%) of 14 643 matched adolescents had a psychiatric health-care visit (prevalence difference 3·7%; 95% CI 2·4-4·9), whereas 127 (9·8%) of 1295 surgery patients and 445 (3·6%) of 12 211 matched adolescents filled a psychiatric drug prescription (prevalence difference 6·2%; 95% CI 4·5-7·8). The year before the matched index date, 208 (13·4%) of 1551 surgery patients and 844 (5·5%) of 15 308 matched adolescents had a psychiatric health-care visit (prevalence difference 7·9%; 95% CI 6·2-9·6), whereas 319 (20·6%) of 1551 surgery patients and 1306 (8·5%) of 15 308 matched adolescents filled a psychiatric drug prescription (prevalence difference 12·0%; 10·0-14·1). The prevalence difference in psychiatric health-care visits peaked 9 years after the matched index date (12·0%; 95% CI 9·0-14·9), when 119 (17·6%) of 675 surgery patients and 377 (5·7%) of 6669 matched adolescents had a psychiatric health-care visit. The prevalence difference in filled psychiatric drug prescription was highest 10 years after the matched index date (20·4%; 15·9-24·9), when 171 (36·5%) of 469 surgery patients and 739 (16·0%) of 4607 matched adolescents filled a psychiatric drug prescription. The year before the matched index date, 19 (1·2%) of 1551 surgery patients and 155 (1·0%) of 15304 matched adolescents had a health-care visit associated with a substance use disorder diagnosis (mean difference 0·2%, 95% CI -0·4 to 0·8). 10 years after the matched index date, the prevalence difference had increased to 4·3% (95% CI 2·3-6·4), when 24 (5·1%) of 467 surgery patients and 37 (0·8%) of 4582 matched adolescents had a health-care visit associated with a substance use disorder diagnosis.

INTERPRETATION

Psychiatric diagnoses and psychiatric drug prescriptions were more common among adolescents with severe obesity who would later undergo bariatric surgery than among matched adolescents from the general population. Both groups showed an increase in prevalence in psychiatric diagnoses and psychiatric drug prescriptions leading up to the time of surgery, but the rate of increase in the prevalence was higher among adolescents with severe obesity than among matched adolescents. With the exception of health-care visits for substance use disorders, these prevalence trajectories continued in the 10 years of follow-up. Realistic expectations regarding mental health outcomes should be set preoperatively.

FUNDING

Swedish Research Council, Swedish Research Council for Health, Working Life and Welfare.

Modifiable Cardiometabolic Risk Factors in Survivors of Childhood Cancer: JACC: CardioOncology State-of-the-Art Review

The growing community of childhood cancer survivors faces a heavy burden of late onset morbidities and mortality, with cardiovascular diseases being the leading noncancer cause. In addition to demographics and cancer treatment exposures, which cannot be altered, cardiometabolic risk factors (obesity, hypertension, diabetes, and dyslipidemia) and frailty potentiate the risk of morbidity and mortality associated with chronic health conditions. Important opportunities exist to target these risk factors and improve late health outcomes for survivors. Unfortunately, limited evidence exists on the optimal methods to prevent, screen, and treat cardiometabolic risk factors among survivors, resulting in significant underdiagnosis and undertreatment. In this review, we discuss the prevalence of, risk factors for, current survivor-specific recommendations, and gaps in knowledge to mitigate potentially modifiable cardiometabolic risk factors and frailty among survivors of childhood cancer.

Embracing the Pros and Cons of the New Weight Loss Medications (Semaglutide, Tirzepatide, Etc.)

PURPOSE OF REVIEW

The history of multiple weight loss medications has been a concerning paradox based on an increased cardiovascular risk despite significant reductions in adipose tissue and weight. A new class of weight loss medications could change this past narrative based on early preliminary results of cardiovascular risk (not events-still need to be determined) and weight reduction in non-diabetics that acutely competes with results achieved with bariatric surgery. The purpose of this review is to provide a comprehensive summary of the advantages and disadvantages of these newer medications, and how they could impact urology.

RECENT FINDINGS

Weight loss of - 15 to - 20% compared to baseline has become plausible in the short-term and preliminary guidance to reduce acute and chronic adverse events are receiving attention. However, the cost, access, conflicts of interest, supply chain, life-long adherence issues, and the long-term diverse implications on mental and physical health when exposed to this class of medications (GLP-1 agonists) are unknown. The profound caloric reductions should also result in baseline or ongoing nutritional deficiency testing, and general and specific dietary recommendations, which could theoretically mimic some bariatric surgery pre- and post-surgical protocols but has yet to be studied. Regardless, the potential impact of these medicines within a variety of medical specialties needs clinical research. Current and future lifestyle interventions, dietary patterns, and medicines in the weight loss category need to be held to a paradigm whereby cardiovascular health should improve with significant weight loss without a negative impact on mental health. In urology, the ability to impact cancer risk, ED, FSD, incontinence, infertility, nephrolithiasis, and multiple other endpoints are plausible (based on bariatric surgery data) but need preliminary clinical research. Other medicines with a similar or even larger potential impact are in clinical trials, and thus, a concise overview for clinicians and researchers was needed for objective guidance. Currently, comprehensive lifestyle changes utilized with and without these medications continue to garner positive mental, physical, and legacy effects, which suggest that they are as necessary as ever in the treatment of the numerous conditions impacted by unhealthy weight gain.

Prescription drug usage as measure of comorbidity resolution after bariatric surgery: a population-based cohort study

BACKGROUND

Obesity is a chronic and progressive disease associated with significant morbidity, mortality, and health-care costs. Bariatric surgery is the most effective intervention for sustainable weight loss and resolution of obesity-related comorbidities. Studies examining comorbidity resolution largely rely on individual self-reported outcomes and electronic record reviews. We present a population-based study looking at prescription medication utilization before and after bariatric surgery as a measure of comorbidity resolution.

METHODS

All patients enrolled in the Center for Metabolic and Bariatric Surgery who underwent either gastric bypass or sleeve gastrectomy between 2013 and 2019 in Manitoba were included. Demographic information, follow up, and outpatient prescription dispensation data were obtained from the Manitoba Population Research Data Repository housed at the Manitoba Centre for Health Policy for 5 years pre- and post-surgery.

RESULTS

A total of 1184 patients were included. Antidepressants and selective serotonin reuptake inhibitors were the most commonly prescribed classes, and along with thyroid medication, utilization remained stable after bariatric surgery. Proton pump inhibitors and opioid class drugs increased at 1 year after surgery then returned to baseline. Glucose and lipid-lowering medications, including statins, biguanides, sulfonylureas, and insulin, were decreased. Antihypertensives, including ACE inhibitors, calcium channel blockers, angiotensin receptors blockers, thiazides, and beta blockers, similarly decreased.

CONCLUSION

This is the first Canadian study employing a provincial-wide prescription database to measure long-term comorbidity resolution after bariatric surgery. The use of administrative data eliminates potential biases and inaccuracies in follow up and self-reported outcomes. Consistent with the literature, prescriptions for the treatment of metabolic syndrome all decreased and were sustained at long-term follow up. Further studies are needed to delineate the effects of altered pharmaceutical utilization on patient quality of life and health-care expenditures.

MBSAQIP risk calculator use in bariatric surgery is associated with a reduction in serious complications: a retrospective analysis of 210,710 patients

BACKGROUND

The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) Bariatric Surgical Risk/Benefit Calculator was developed to provide patient-specific information to assist surgical decision-making. To date, no study has characterized which patients are being evaluated with this tool.

OBJECTIVE

We sought to characterize the use and impact of the MBSAQIP calculator.

SETTING

MBSAQIP collects data from 955 centers in North America.

METHODS

The 2021 MBSAQIP database was evaluated for the use of the calculator on preoperative counseling for patients undergoing bariatric surgery. Patient characteristics, operative techniques, and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including use of the calculator independently associated with serious complications and mortality.

RESULTS

Our study included 210,710 patients, 35,158 (16.7%) of whom were evaluated using the calculator. Patients with whom the calculator was used preoperatively were older (43.8 ± 11.6 yr versus 43.6 ± 11.7 yr; P < .001) and were more likely to have insulin-dependent diabetes, hypertension, gastroesophageal reflux disease, renal insufficiency, and sleep apnea. More patients underwent Roux-en-Y gastric bypass in the calculator cohort compared with the cohort that did not use the calculator (29.6% versus 28.6%; P < .003). The rate of serious complication was significantly less in the calculator cohort (3.1% versus 3.4%; P < .030). Multivariable modeling evaluating serious complications showed that use of the calculator was independently associated with reduced risk of serious complications (odds ratio .87, CI .82-.93, P < .001) but was not associated with mortality.

CONCLUSION

The use of the risk calculator may help to reduce the incidence of complications by opening a dialogue between healthcare professionals and patients, setting realistic expectations, and identifying modifiable risk factors.

Life expectancy after bariatric surgery or usual care in patients with or without baseline type 2 diabetes in Swedish Obese Subjects

OBJECTIVES

To determine life expectancy and causes of death after bariatric surgery in relation to baseline type 2 diabetes (T2D) in the prospective, Swedish Obese Subjects study.

METHODS

The study included 2010 patients with obesity who underwent bariatric surgery and 2037 matched controls, eligible for surgery. The surgery group underwent gastric bypass (n = 265), banding (n = 376), or vertical banded gastroplasty (n = 1369). The control group (n = 2037) received usual obesity care. Causes of death were obtained from the Swedish Cause of Death Register, case sheets and autopsy reports, in patients with baseline T2D (n = 392 surgery patients/n = 305 controls) or non-T2D (n = 1609 surgery patients/n = 1726 controls) during a median follow-up 26 years.

RESULTS

In T2D and non-T2D subgroups, bariatric surgery was associated with increased life expectancy (2.1, 95% confidence interval (95% CI) 0.2-4.0; and 1.6, 0.5-2.7 years, respectively) and reduced overall mortality (adjusted hazard ratio (adjHR) = 0.77, 95% CI: 0.61-0.97; and 0.82, 0.72-0.94, respectively), and the treatment benefit was similar (interaction p = 0.615). Bariatric surgery was associated with reduced cardiovascular mortality in both subgroups (adjHR = 0.65, 95% CI: 0.46-0.91; and 0.70, 0.55-0.88, respectively (interaction p = 0.516)).

CONCLUSIONS

Bariatric surgery is associated with similar reduction of overall and cardiovascular mortality and increased life expectancy regardless of baseline diabetes status.

Pharmacotherapy for obesity: recent evolution and implications for cardiovascular risk reduction

INTRODUCTION

Obesity is highly prevalent in the U.S. and is associated with an increased risk of major adverse cardiovascular events (MACE). Modalities for the management of obesity include lifestyle intervention, pharmacotherapy, and bariatric surgery.

AREAS COVERED

This review describes the evidence on the effects of weight loss therapies on MACE risk. Lifestyle interventions and older antiobesity pharmacotherapies have been associated with <12% body weight reduction and no clear benefit to reduce MACE risk. Bariatric surgery is associated with substantial weight reduction (20-30%) and markedly lower subsequent risk for MACE. Newer antiobesity pharmacotherapies, particularly semaglutide and tirzepatide, have shown greater efficacy for weight reduction compared with older medications and are being evaluated in cardiovascular outcomes trials.

EXPERT OPINION

Current practice for cardiovascular risk reduction in patients with obesity is lifestyle intervention for weight loss, combined with the treatment of obesity-related cardiometabolic risk factors individually. The use of medications to treat obesity is relatively rare. In part, this reflects concerns about long-term safety and weight loss effectiveness, possible provider bias, as well as lack of clear evidence of MACE risk reduction. If ongoing outcomes trials demonstrate the efficacy of newer agents in reducing MACE risk, this will likely lead to expanded use in obesity management.

Opioid Analgesics after Bariatric Surgery: A Scoping Review to Evaluate Physiological Risk Factors for Opioid-Related Harm

The persisting use of opioids following bariatric surgery has emerged as a prevalent complication, heightening the probability of opioid-related harm (ORM), such as opioid-related fatalities and prescription opioid use disorder (OUD). A comprehensive review of PubMed literature from 1990 to 2023 was conducted to pinpoint physiological influences on postoperative ORM. As a result, we found that patients undertaking bariatric operations often exhibit an inherently higher risk for substance use disorders, likely attributable to genetic predisposition and related neurobiological changes that engender obesity and addiction-like tendencies. Furthermore, chronic pain is a common post-bariatric surgery complaint, and the surgical type impacts opioid needs, with increased long-term opioid use after surgeries. Additionally, the subjective nature of pain perception in patients with obesity can distort pain reporting and the corresponding opioid prescription both before and after surgery. Furthermore, the postoperative alterations to the gastrointestinal structure can affect the microbiome and opioid absorption rates, resulting in fluctuating systemic exposure to orally ingested opioids. The prospect of ORM development post-bariatric surgery appears amplified due to a preexisting susceptibility to addictive habits, surgically induced pain, modified gut-brain interaction and pain management and the changed pharmacokinetics post-surgery. Further research is warranted to clarify these potential risk variables for ORM, specifically OUD, in the bariatric population.

Pre-Operative Substance Use Disorder is Associated with Higher Risk of Long-Term Mortality Following Bariatric Surgery

PURPOSE

Metabolic and bariatric surgery (MBS) has been associated with reduced all-cause mortality. While the number of subjects with substance use disorders (SUD) before MBS has been documented, the impact of pre-operative SUD on long-term mortality following MBS is unknown. This study assessed long-term mortality of patients with and without pre-operative SUD who underwent MBS.

MATERIALS AND METHODS

Two statewide databases were used for this study: Utah Bariatric Surgery Registry (UBSR) and the Utah Population Database. Subjects who underwent MBS between 1997 and 2018 were linked to death records (1997-2021) to identify any death and cause for death following MBS. All deaths (internal, external, and unknown reasons), internal deaths, and external deaths were the primary outcomes of the study. External causes of death included death from injury, poisoning, and suicide. Internal causes of death included deaths that were associated with natural causes such as heart disease, cancer, and infections. A total of 17,215 patients were included in the analysis. Cox regression was used to estimate hazard ratios (HR) of controlled covariates, including the pre-operative SUD.

RESULTS

The subjects with pre-operative SUD had a 2.47 times higher risk of death as compared to those without SUD (HR = 2.47, p < 0.01). Those with pre-operative SUD had a higher internal cause of death than those without SUD by 129% (HR = 2.29, p < 0.01) and 216% higher external mortality risk than those without pre-operative SUD (HR = 3.16, p < 0.01).

CONCLUSION

Pre-operative SUD was associated with higher hazards of all-cause, internal cause, and external cause mortality in patients who undergo bariatric surgery.

Obesity and Cardiovascular Risk: Systematic Intervention Is the Key for Prevention

Obesity is a serious public health issue and associated with an increased risk of cardiovascular disease events and mortality. The risk of cardiovascular complications is directly related to excess body fat mass and ectopic fat deposition, but also other obesity-related complications such as pre-type 2 diabetes, obstructive sleep apnoea, and non-alcoholic fatty liver diseases. Body mass index and waist circumference are used to classify a patient as overweight or obese and to stratify cardiovascular risk. Physical activity and diet, despite being key points in preventing adverse events and reducing cardiovascular risk, are not always successful strategies. Pharmacological treatments for weight reduction are promising strategies, but are restricted by possible safety issues and cost. Nonetheless, these treatments are associated with improvements in cardiovascular risk factors, and studies are ongoing to better evaluate cardiovascular outcomes. Bariatric surgery is effective in reducing the incidence of death and cardiovascular events such as myocardial infarction and stroke. Cardiac rehabilitation programs in obese patients improve cardiovascular disease risk factors, quality of life, and exercise capacity. The aim of this review was to critically analyze the current role and future aspects of lifestyle changes, medical and surgical treatments, and cardiac rehabilitation in obese patients, to reduce cardiovascular disease risk and mortality, and to highlight the need for a multidisciplinary approach to improving cardiovascular outcomes.

Precision Bariatric/Metabolic Medicine and Surgery

Indications and techniques of bariatric surgery (BS) have constantly evolved in recent decades and now face new challenges [...].