Changing Epidemiology of Bariatric Surgery in the UK: Cohort Study Using Primary Care Electronic Health Records

Impact of maternal bariatric surgery on offspring perinatal cardiac function: A prospective study

OBJECTIVE

To assess perinatal cardiac function in offspring of women with previous bariatric surgery and examine its association with maternal glucose control.

DESIGN

Prospective study.

SETTING

Maternity unit, UK.

POPULATION

Fifty-four fetuses/neonates; 29 of post-bariatric surgery women and 25 of women without surgery.

METHODS

Prospective, longitudinal observational study of pregnant women with and without previous bariatric surgery, matched for early pregnancy body mass index. Cardiac function of all offspring was assessed by two-dimensional conventional, spectral tissue Doppler and speckle-tracking echocardiography at 35-37 weeks of gestation and at 5-7 weeks of age. Maternal glycated haemoglobin (HbA1c) was measured at 27-30 weeks of gestation. Maternal demographics and fetal/infant cardiac function indices were compared between the groups. Correlation coefficient (r) is reported.

MAIN OUTCOME MEASURES

Fetal/infant cardiac function indices.

RESULTS

Compared with no-bariatric neonates, offspring of post-bariatric women were smaller at birth (birthweight centiles: 64.96 ± 36.41 versus 40.17 ± 27.99; p = 0.007). There were no significant differences in fetal/infant cardiac function indices and perinatal cardiac changes, between groups. There was a positive correlation between maternal HbA1c and fetal left ventricular (LV) longitudinal strain (r = 0.33) and LV longitudinal strain rate (r = 0.29), suggesting an inverse relation between HbA1c and fetal LV systolic function, but this was mainly seen in offspring of women with no previous bariatric surgery (r = 0.56 and r = 0.50, respectively).

CONCLUSIONS

Maternal bariatric surgery does not appear to inadvertently affect the offspring cardiac performance. We found an inverse correlation between maternal HbA1c levels and fetal LV systolic function but this was mainly seen in the no-bariatric pregnancies.

Clinical outcomes and adverse events of bariatric surgery in adults with severe obesity in Scotland: the SCOTS observational cohort study

Background

Bariatric surgery is a common procedure worldwide for the treatment of severe obesity and associated comorbid conditions but there is a lack of evidence as to medium-term safety and effectiveness outcomes in a United Kingdom setting.

Objective

To establish the clinical outcomes and adverse events of different bariatric surgical procedures, their impact on quality of life and the effect on comorbidities.

Design

Prospective observational cohort study.

Setting

National Health Service secondary care and private practice in Scotland, United Kingdom.

Participants

Adults (age >16 years) undergoing their first bariatric surgery procedure.

Main outcome measures

Change in weight, hospital length of stay, readmission and reoperation rate, mortality, diabetes outcomes (HbA1c, medications), quality of life, anxiety, depression.

Data sources

Patient-reported outcome measures, hospital records, national electronic health records (Scottish Morbidity Record 01, Scottish Care Information Diabetes, National Records Scotland, Prescription Information System).

Results

Between December 2013 and February 2017, 548 eligible patients were approached and 445 participants were enrolled in the study. Of those, 335 had bariatric surgery and 1 withdrew from the study. Mean age was 46.0 (9.2) years, 74.7% were female and the median body mass index was 46.4 (42.4; 52.0) kg/m2. Weight was available for 128 participants at 3 years: mean change was -19.0% (±14.1) from the operation and -24.2% (±12.8) from the start of the preoperative weight-management programme. One hundred and thirty-nine (41.4%) participants were readmitted to hospital in the same or subsequent 35 months post surgery, 18 (5.4% of the operated cohort) had a reoperation or procedure considered to be related to bariatric surgery gastrointestinal complications or revisions. Fewer than five participants (<2%) died during follow-up. HbA1c was available for 93/182 and diabetes medications for 139/182 participants who had type 2 diabetes prior to surgery; HbA1c mean change was -5.72 (±16.71) (p = 0.001) mmol/mol and 65.5% required no diabetes medications (p < 0.001) at 3 years post surgery. Physical quality of life, available for 101/335 participants, improved in the 3 years post surgery, mean change in Rand 12-item Short Form Survey physical component score 8.32 (±8.95) (p < 0.001); however, there was no change in the prevalence of anxiety or depression.

Limitations

Due to low numbers of bariatric surgery procedures in Scotland, recruitment was stopped before achieving the intended 2000 participants and follow-up was reduced from 10 years to 3 years.

Conclusions

Bariatric surgery is a safe and effective treatment for obesity. Patients in Scotland, UK, appear to be older and have higher body mass than international comparators, which may be due to the small number of procedures performed.

Future work

Intervention studies are required to identify the optimal pre- and post surgery pathway to maximise safety and cost-effectiveness.

Study registration

This study is registered as ISRCTN47072588.

Funding details

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 10/42/02) and is published in full in Health Technology Assessment; Vol. 28, No. 7. See the NIHR Funding and Awards website for further award information.

Antral Preservation in Sleeve Gastrectomy Appears to Protect Against Prolonged Vomiting and Gastroesophageal Reflux Disease. A Meta-Analysis of Randomized Controlled Trials

The optimal distance between the starting point of gastric transection and the pylorus during laparoscopic sleeve gastrectomy (LSG), which can be referred to as the distance from pylorus (DFP), is controversial. No consensus exist for what DFP is considered antral preservation, and what DFP is considered antral resection. Some surgeons prefer shorter DFP to maximize excess weight loss percentage (EWL%), while others prefer longer DFP because they believe that it shortens length of stay (LOS) and protects against leaks, prolonged vomiting, and gastroesophageal reflux disease (GERD). We sought to compare 6-cm DFP and 2-cm DFP in postoperative outcomes. In addition, we sought to evaluate the magnitude of any observed benefit through number needed to treat (NNT) analysis.

Access to publicly funded weight management services in England using routine data from primary and secondary care (2007-2020): An observational cohort study

BACKGROUND

Adults living with overweight/obesity are eligible for publicly funded weight management (WM) programmes according to national guidance. People with the most severe and complex obesity are eligible for bariatric surgery. Primary care plays a key role in identifying overweight/obesity and referring to WM interventions. This study aimed to (1) describe the primary care population in England who (a) are referred for WM interventions and (b) undergo bariatric surgery and (2) determine the patient and GP practice characteristics associated with both.

METHODS AND FINDINGS

An observational cohort study was undertaken using routinely collected primary care data in England from the Clinical Practice Research Datalink linked with Hospital Episode Statistics. During the study period (January 2007 to June 2020), 1,811,587 adults met the inclusion criteria of a recording of overweight/obesity in primary care, of which 54.62% were female and 20.10% aged 45 to 54. Only 56,783 (3.13%) were referred to WM, and 3,701 (1.09% of those with severe and complex obesity) underwent bariatric surgery. Multivariable Poisson regression examined the associations of demographic, clinical, and regional characteristics on the likelihood of WM referral and bariatric surgery. Higher body mass index (BMI) and practice region had the strongest associations with both outcomes. People with BMI ≥40 kg/m2 were more than 6 times as likely to be referred for WM (10.05% of individuals) than BMI 25.0 to 29.9 kg/m2 (1.34%) (rate ratio (RR) 6.19, 95% confidence interval (CI) [5.99,6.40], p < 0.001). They were more than 5 times as likely to undergo bariatric surgery (3.98%) than BMI 35.0 to 40.0 kg/m2 with a comorbidity (0.53%) (RR 5.52, 95% CI [5.07,6.02], p < 0.001). Patients from practices in the West Midlands were the most likely to have a WM referral (5.40%) (RR 2.17, 95% CI [2.10,2.24], p < 0.001, compared with the North West, 2.89%), and practices from the East of England least likely (1.04%) (RR 0.43, 95% CI [0.41,0.46], p < 0.001, compared with North West). Patients from practices in London were the most likely to undergo bariatric surgery (2.15%), and practices in the North West the least likely (0.68%) (RR 3.29, 95% CI [2.88,3.76], p < 0.001, London compared with North West). Longer duration since diagnosis with severe and complex obesity (e.g., 1.67% of individuals diagnosed in 2007 versus 0.34% in 2015, RR 0.20, 95% CI [0.12,0.32], p < 0.001), and increasing comorbidities (e.g., 2.26% of individuals with 6+ comorbidities versus 1.39% with none (RR 8.79, 95% CI [7.16,10.79], p < 0.001) were also strongly associated with bariatric surgery. The main limitation is the reliance on overweight/obesity being recorded within primary care records to identify the study population.

CONCLUSIONS

Between 2007 and 2020, a very small percentage of the primary care population eligible for WM referral or bariatric surgery according to national guidance received either. Higher BMI and GP practice region had the strongest associations with both. Regional inequalities may reflect differences in commissioning and provision of WM services across the country. Multi-stakeholder qualitative research is ongoing to understand the barriers to accessing WM services and potential solutions. Together with population-wide prevention strategies, improved access to WM interventions is needed to reduce obesity levels.

Acute intestinal obstruction in pregnancy after previous gastric bypass: A case report

Background

Intestinal obstruction is an extremely rare condition among pregnant women, but it can be life-threatening for both mother and fetus.

Case presentation

A woman in her late twenties with no history of previous pregnancies was admitted to hospital due to regular preterm contractions and cervical shortening. Seven days after her admission, while the contractions had stopped and cervical length was stable, she complained of acute abdominal pain. Bowel obstruction was suspected due to the patient's history of gastric bypass 5 years earlier for weight loss. Computed tomography was not performed due to risk of fetal irradiation. Conservative management was attempted, but the patient stopped passing flatus and started vomiting. The fetus was delivered by emergency exploratory laparotomy, during which small bowel obstruction due to adhesions was identified and resolved.

Conclusion

Although uncommon during pregnancy, small bowel obstruction is far more common in women who have had previous abdominal operations, especially involving the stomach. Obstetricians must maintain a high level of suspicion since this condition can be life-threatening for both the mother and the fetus.

Trends in bariatric surgeries in the Brazilian Federative Units, 2009-2019: a descriptive study

OBJECTIVE

our objective is to describe the epidemiological distribution of hospitalizations and postoperative deaths, as well as the trends of bariatric surgeries performed by SUS in all Brazilian federative units (FUs) from an analysis of the period from 2009 to 2019.

METHODS

This is an observational, descriptive ecological time-series study with quantitative and descriptive analysis, based on secondary data. The period analyzed was from 2009 to 2019. We collected, from DATASUS, data from obese men and women who were hospitalized after undergoing bariatric surgery. Prais-Winsten regression was performed to identify the trends.

RESULTS

In the period, 83,829 bariatric surgeries were performed, of which 161 resulted in death, representing 0.19% of the procedures. We found an increasing trend in the number of surgeries for Brazil (β=0.04; p<0.001), but 11 FUs showed a stationary trend and three, decreasing ones (six UFs did not have enough data to enter the analysis). In the North and Northeast regions, stationary trends prevailed, while in the Center-West, the decreasing trends, and in the South and Southeast, the increasing ones.

CONCLUSIONS

we found an evident disparity between regions, suggesting deficiencies in access to health. By demonstrating which FUs and demographic characteristics have the lowest rates of surgeries, our study is able to direct public policies towards a more egalitarian Brazilian public health.

Maternal cardiovascular adaptation to pregnancy in women with previous bariatric surgery

BACKGROUND

Obesity in pregnancy is associated with substantial risks, notably hypertensive disorders. Bariatric surgery achieves sustained weight loss and has several cardiovascular benefits, including positive effects on blood pressure, cardiac geometry, and both systolic and diastolic function. Pregnancy following bariatric surgery is also associated with improved outcomes, including a reduced risk of hypertensive disorders. The underlying mechanisms, however, remain uncertain. Maternal cardiovascular adaptation plays a vital role in maintaining a healthy pregnancy, and maladaptation has been associated with adverse pregnancy outcomes. However, to date, the maternal cardiovascular adaptation to pregnancy after bariatric surgery has not been investigated.

OBJECTIVE

To investigate the maternal cardiovascular adaptation to pregnancy in women with previous bariatric surgery compared with women with a similar early-pregnancy body mass index, age, and race but no history of weight loss surgery.

STUDY DESIGN

This was a prospective, observational, longitudinal study including pregnant women with (n=41) and without (n=41) a history of bariatric surgery. The participants were seen at 3 time points; at 12 to 14, 20 to 24, and 30 to 32 weeks of pregnancy. At each visit, the blood pressure was measured and the maternal cardiovascular system was assessed using transthoracic echocardiography. Two-dimensional speckle tracking was performed to assess the global longitudinal and circumferential strain on a subset of patients (15 in each group). Offline analysis was performed according to the European and American echocardiography guidelines. Multilevel linear mixed-effect models were used for all the comparisons.

RESULTS

Compared with the no-surgery group, women with previous bariatric surgery, had lower systolic and diastolic blood pressure, heart rate, and cardiac output across all the trimesters (P<.01 for all comparisons), with an evidence of more favorable diastolic indices, including a higher E-wave/A-wave ratio across the mitral valve (P<.001), higher mitral velocity at the lateral and medial annulus (E') (P=.01 and P=.03, respectively), and a lower left atrial volume (P<.05). Furthermore, women with previous bariatric surgery demonstrated lower global longitudinal (P<.01) and circumferential strain (P=.02), which is suggestive of better systolic function.

CONCLUSION

Our findings indicate better cardiovascular adaptation to pregnancy in women with previous bariatric surgery than in pregnant women of a similar early-pregnancy body mass index but no history of surgery.

Tendências das cirurgias bariátricas nas Unidades Federativas brasileiras, 2009-2019: um estudo descritivo

RESUMO Objetivo: nosso objetivo é descrever a distribuição epidemiológica das internações e óbitos pós-operatórios, bem como as tendências das cirurgias bariátricas realizadas pelo SUS em todas as unidades federativas (UFs) brasileiras a partir de uma análise do período de 2009 a 2019. Métodos: trata-se de um estudo observacional descritivo ecológico de série temporal com análise quantitativa e descritiva, com base em dados secundários. O período analisado foi de 2009 a 2019. Coletamos, no DATASUS, dados de homens e mulheres que possuem obesidade e foram internados após terem sido submetidos à cirurgia bariátrica. A regressão de Prais-Winsten foi utilizada para identificar as tendências. Resultados: no período, 83.829 cirurgias bariátricas foram realizadas, tendo 161 evoluído para óbitos, o que representa 0,19% dos procedimentos. Encontramos uma tendência crescente no número de cirurgias para o Brasil (β=0,04; p<0,001), mas 11 UFs apresentaram tendência estacionária e três, decrescente (seis UFs não tinham dados suficientes para entrar na análise). Nas regiões Norte e Nordeste prevaleceram tendências estacionárias, enquanto no Centro-Oeste, as decrescentes, e no Sul e Sudeste, as crescentes. Conclusões: encontramos uma evidente disparidade entre as regiões, sugerindo deficiências de acesso à saúde. Ao demonstrar quais UFs e características demográficas apresentam menores índices de cirurgias, nosso estudo é capaz de direcionar políticas públicas para uma saúde pública brasileira mais igualitária.

Optimising UK training in aesthetic surgery: A prospective national study using operative logbooks and questionnaires to determine factors associated with trainee participation

INTRODUCTION

We aimed to determine the proportion of UK aesthetic surgery training taking place in the independent sector, how this experience is gained, and factors associated with trainee participation. We also aimed to draw comparisons between training in the National Health Services (NHS) and independent sectors.

METHODS

Plastic Surgery Trainees were asked to complete a 10-item questionnaire, in addition to their usual operative entry on eLogbook, when logging a procedure with an aesthetic operative code, prospectively over a 6-month period. Anonymised data was exported and analysed using SPSS.

RESULTS

A total of 285 questionnaires were completed; all UK training regions were represented. The majority were for NHS procedures (88%), of which 56% were for breast surgery, 23% facial surgery, 19% body contouring, and 2% non-surgical. Trainees were significantly more likely to participate in procedures when they were performed in the NHS (odds ratio, OR, 9.7, p < 0.01) or when they were body contouring surgery (OR 1.5, p < 0.01). Trainees were more likely to participate in perioperative care in an NHS setting (p < 0.01). When trainees attend the independent sector, it was usually within contracted training hours (57%) with their consultant trainer with whom they are working in the NHS (63%).

CONCLUSIONS

The majority of aesthetic surgery training occurs in the NHS but this is not representative of UK aesthetic practice. There is a need to engage the independent sector to provide formal aesthetic surgery training as part of the plastic surgery training programme, including procedural participation and perioperative care. Additional aesthetic fellowships and mechanisms for mentorship by established consultants should be developed.

The Bariatric-Metabolic Physician's Role in Managing Clinically Severe Obesity

PURPOSE OF REVIEW

The aim of this review is to outline the obesity physician's role in managing patients with severe obesity with a particular emphasis on bariatric surgery candidates.

RECENT FINDINGS

Obesity is a chronic, relapsing and progressive disease. Scoring systems that evaluate the severity of obesity based on the clinical assessment, rather than the Body Mass Index, are a valuable tool. The clinical assessment should explore the underlying contributors for weight gain and screen for obesity-related complications. Bariatric surgery remains the most effective management approach for severe and complex obesity. Nevertheless, pharmacotherapy and other non-surgical approaches play an important role. The bariatric-metabolic physician's role is paramount in delivering effective care to patients with obesity. The multiple complications of patients with clinically severe obesity highlight the complexity of their management and reinforce the need for adequate assessment and long-term follow-up to ensure optimal clinical outcomes.

SurgiCal Obesity Treatment Study (SCOTS): a prospective, observational cohort study on health and socioeconomic burden in treatment-seeking individuals with severe obesity in Scotland, UK

OBJECTIVES

There is a lack of evidence to inform the delivery and follow-up of bariatric surgery for people with severe obesity. The SurgiCal Obesity Treatment Study (SCOTS) is a national longitudinal cohort of people undergoing bariatric surgery. Here, we describe characteristics of the recruited SCOTS cohort, and the relationship between health and socioeconomic status with body mass index (BMI) and age.

PARTICIPANTS/METHODS

445 participants scheduled for bariatric surgery at any of 14 centres in Scotland, UK, were recruited between 2013 and 2016 for this longitudinal cohort study (1 withdrawal); 249 completed health-related preoperative patient-reported outcome measures. Regression models were used to estimate the effect of a 10-unit increase in age or BMI, adjusting for sex, smoking and socioeconomic status.

RESULTS

Mean age was 46 years and median BMI was 47 kg/m². For each 10 kg/m² higher BMI, there was a change of -5.2 (95% CI -6.9 to -3.5; p<0.0001) in Rand 12-item Short Form Survey Physical Component Summary (SF-12 PCS), -0.1 (95% CI -0.2 to -0.1; p<0.0001) in EuroQoL 5-level EQ-5D version index score and 14.2 (95% CI 10.7 to 17.7; p<0.0001) in Impact of Weight on Quality of Life-Lite Physical Function Score. We observed a 3.1 times higher use of specialist aids and equipment at home (OR: 3.1, 95% CI 1.9 to 5.0; p<0.0001). Broadly, similar results were seen for each 10-year higher age, including a change of -2.1 (95% CI -3.7 to -0.5; p<0.01) in SF-12 PCS.

CONCLUSIONS

A higher BMI combined with older age is associated with poor physical functioning and quality of life in people seeking bariatric surgery treatment. Policy-makers must consider the health and care needs of these individuals and invest to provide increased access to effective weight management.

TRIAL REGISTRATION NUMBER

ISRCTN47072588.

Preoperative Dexamethasone for Airway-Related "Calibration Tube" Complications After Sleeve Gastrectomy: a Randomised Clinical Trial

BACKGROUND

Bariatric surgeries utilise Bougie device to guide stomach resection. The device implementation is associated with many underreported complications. This study aims to compare nebulised vs. intravenous preoperative dexamethasone in mitigating airway-related Bougie complications after sleeve gastrectomy.

METHODOLOGY

This is a prospective double-blinded interventional study conducted by a tertiary hospital. The study involved 105 patients allocated to 3 groups: Group (I) received 8 mg dexamethasone intravenously (IV) preoperatively, group (N) received 8 mg dexamethasone from a nebulizer mask preoperatively, and Group (S) received nebulised normal saline. Outcomes evaluated were postoperative sore throat, odynophagia, change of voice, and nausea and vomiting.

RESULTS

Nebulized dexamethasone was found to be significantly superior to IV dexamethasone in terms of postoperative sore throat at zero-hour (p = 0.001) and 1-h intervals (p = 0.011). No significant difference was found at 6- and 24-h intervals. For odynophagia, post hoc analysis showed there was no significant difference between (I), (N), and (S) groups. Incidence of change of voice was significantly lower in (N) and (I) groups compared to (S) group, with p values of 0.0067 and 0.00014, respectively. The incidence of post-operative sore-throat (PONV) in (I) group was significantly lower than incidences in (S) group (p = 0.00002) and (N) group (p = 0.0004).

CONCLUSION

Preoperative nebulized and IV dexamethasone are effective strategies in mitigating complications related to mechanical effects of Bougie insertion. IV dexamethasone was as effective as nebulized dexamethasone in terms of late postoperative sore throat, and was superior in postoperative nausea and vomiting.

Experiences of the Bariatric Pre-Surgery Evaluation Process in a National Health Service—An Interpretative Phenomenological Analysis

There is currently little understanding of bariatric patients’ experiences and expectations of the bariatric pre-surgery evaluation (PSE) process. This is especially true for patients within the National Health Service (NHS) in the UK. Consequently, this study undertakes a qualitative study to explore the experiences and expectations of the bariatric PSE amongst patients who had undergone bariatric surgery within the NHS in the UK, using the Interpretative Phenomenological Analysis. Three inter-related superordinate themes were presented: (i) ‘PSE was challenging but essential’, (ii) ‘Coping processes to deal with the PSE’, and (iii) ‘Staff and service evaluation’. Most participants had conflicting feelings about the PSE process as it had both positive and negative impacts on their wellbeing. The process was considered essential for preparation and successful post-surgery adjustment, though the uncertainty of approval was experienced as very distressing. Consequently, participants utilised both external and internal coping strategies, such as social support, researching, or ‘toeing the line’. Participants’ experiences encouraged them to provide feedback about the staff and service, which revealed a preference for a tailored evaluation process. The emerged themes represent an initial framework for helping healthcare providers and researchers to involve patients in service delivery thereby facilitating a patient-centred approach. A starting point is to audit patients’ perspectives routinely. Further investigations are needed to better define, validate, and understand constructs and processes identified in this study.

Long-term cardiovascular outcomes after orlistat therapy in patients with obesity: a nationwide, propensity-score matched cohort study

AIMS

The rising prevalence of obesity and its associated comorbidities represent a growing public health issue; in particular, obesity is known to be a major risk factor for cardiovascular disease. Despite the evidence behind the efficacy of orlistat in achieving weight loss in patients with obesity, no study thus far has quantified its long-term effect on cardiovascular outcomes. The purpose of this study is to explore long-term cardiovascular outcomes after orlistat therapy.

METHODS AND RESULTS

A propensity-score matched cohort study was conducted on the nation-wide electronic primary and integrated secondary healthcare records of the Clinical Practice Research Datalink (CPRD). The 36 876 patients with obesity in the CPRD database who had completed a course of orlistat during follow-up were matched on a 1:1 basis with equal numbers of controls who had not taken orlistat. Patients were followed up for a median of 6 years for the occurrence of the primary composite endpoint of major adverse cardiovascular events (fatal or non-fatal myocardial infarction or ischaemic stroke), and a number of secondary endpoints including primary endpoint components individually, the occurrence of new-onset heart failure, coronary revascularization, new chronic kidney disease stage III+ (CKD3+), and all-cause mortality. During the median study follow-up of 6 years, the occurrence of major adverse cardiovascular events was lower in the orlistat cohort [hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.66-0.83, P < 0.001]. Patients who took orlistat experienced lower rates of myocardial infarction (HR 0.77; 95% CI 0.66-0.88, P < 0.001) and ischaemic stroke (HR 0.68; 95% CI 0.56 to -0.84, P < 0.001) as well as new-onset heart failure (HR 0.79; 95% CI 0.67-0.94, P = 0.007). There was no differences in revascularization rates (HR 1.12; 95% CI 0.91-1.38, P = 0.27), but a lower rate of both CKD3+ development (HR 0.78; 95% CI 0.73-0.83, P < 0.001) and mortality (HR 0.39, 95% CI 0.36 to -0.41, P < 0.001) was observed.

CONCLUSION

In this nation-wide, propensity-score matched study, orlistat was associated with lower rates of overall major adverse cardiovascular events, new-onset heart failure, renal failure, and mortality. This study adds to current evidence on the known improvements in cardiovascular risk factor profiles of orlistat treatment by suggesting a potential role in primary prevention.

Validity of bariatric surgery codes in the UK Clinical Practice Research Datalink (CPRD) GOLD compared with Hospital Episodes Statistics

OBJECTIVES

To assess completeness and validity of bariatric surgery codes in the UK Clinical Practice Research Datalink (CPRD) GOLD compared with Hospital Episodes Statistics (HES).

METHODS

We conducted a validation study among patients in the UK-based CPRD GOLD with linkage to HES (1998 to 2017). Since the same surgery codes are used for bariatric and other gastrointestinal surgery we assessed code distribution patterns used in patients with bariatric versus other gastrointestinal surgery by presence of other conditions such as obesity and gastrointestinal cancer. We developed algorithms to identify bariatric surgery and calculated validity measures (ie, positive/negative predictive value [PPV/NPV], sensitivity, and specificity) of each in CPRD GOLD compared with HES (gold standard).

RESULTS

Among 7 357 007 available patients we identified 10 190 patients who had a total of 14 046 potential bariatric surgery codes in CPRD GOLD and/or HES. Surgery code patterns differed between bariatric surgery and assumed other gastrointestinal surgery. The sensitivity of CPRD GOLD bariatric surgery coding improved from an overall of 56% to 69-71% when applying stricter algorithms (ie, in obese patients or obese, gastrointestinal disease/complication free patients) but PPVs remained at 53%-55%. NPVs and specificities of CPRD GOLD bariatric surgery coding achieved ≥99.8% for all algorithms.

CONCLUSION

Our results suggest that using CPRD GOLD and HES data and a wide selection of surgery codes will result in the most complete and accurate capture of bariatric surgery events. Validity measures of CPRD GOLD bariatric surgery codes were identical in obese patients and more restrictive populations.

Transversus Abdominis Plane Block in Laparoscopic Bariatric Surgery-a Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

Effective postoperative analgesia is paramount in patients undergoing bariatric surgery, given their increased predisposition to narcotic-induced respiratory depression. Transversus abdominis plane (TAP) block has shown promise in the enhanced recovery pathway for several abdominal procedures. We performed a systematic review and meta-analysis to compare the effectiveness of TAP block in laparoscopic bariatric surgery.

MATERIALS AND METHODS

PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until June 2020. All randomized trials that compared TAP blocks versus none in laparoscopic bariatric procedures were included. The primary outcome was narcotic consumption at 24 h postoperatively, whilst secondary outcomes included postoperative pain scores at 24 h, time to ambulation, postoperative nausea and vomiting (PONV) and complication rates. Random effects models were used to calculate pooled effect size estimates.

RESULTS

Seven randomized controlled trials were included, capturing 617 patients. There was high statistical heterogeneity across studies. On random effects analysis, there were no significant differences in narcotic consumption (MD -12.63 mg, 95% CI = -31.67 to 6.41, p = 0.19), pain scores (MD -0.71, 95% CI = -1.93 to 0.50, p = 0.25) or complications (RD = -0.00, 95% CI = -0.03 to 0.03, p = 0.87) between TAP and no TAP groups. However, TAP was associated with significantly less time to ambulation (MD -2.22 h, 95% CI = -3.89 to -0.56, p = 0.009) and PONV (OR = 0.13, 95% CI = 0.05 to 0.35, p < 0.0001).

CONCLUSIONS

TAP in laparoscopic bariatric surgery is associated with significantly less PONV and time to ambulation, but similar complication rates, narcotic usage and postoperative pain at 24 h compared to no TAP.

Randomised, double-blinded, placebo-controlled trial to investigate the role of laparoscopic transversus abdominis plane block in gastric bypass surgery: a study protocol

INTRODUCTION

Evaluating the efficacy of a laparoscopically guided, surgical transversus abdominis plane (TAP) and rectus sheath (RS) block in reducing analgesic consumption while improving functional outcomes in patients undergoing laparoscopic bariatric surgery.

METHODS

150 patients Living with obesity undergoing elective laparoscopic Roux-En-Y gastric bypass for obesity will be recruited to this double-blinded, placebo-controlled randomised controlled trial from a Bariatric Centre of Excellence over a period of 6 months. Patients will be electronically randomised on a 1:1 basis to either an intervention or placebo group. Those on the intervention arm will receive a total of 60 mL 0.25% ropivacaine, divided into four injections: two for TAP and two for RS block under laparoscopic visualisation. The placebo arm will receive normal saline in the same manner. A standardised surgical and anaesthetic protocol will be followed, with care in adherence to the Enhanced Recovery after Bariatric Surgery guidelines.

ANALYSIS

Demographic information and relevant medical history will be collected from the 150 patients enrolled in the study. Our primary efficacy endpoint is cumulative postoperative narcotic use. Secondary outcomes are peak expiratory flow, postoperative pain score and the 6 min walk test. Quality of recovery (QoR) will be assessed using a validated questionnaire (QoR-40). Statistical analysis will be conducted to assess differences within and between the two groups. The repeated measures will be analysed by a mixed modelling approach and results reported through publication.

ETHICS AND DISSEMINATION

Ethics approval was obtained (20170749-01H) through our institutional research ethics board (Ottawa Health Science Network Research Ethics Board) and the study results, regardless of the outcome, will be reported in a manuscript submitted for a medical/surgical journal.

TRIAL REGISTRATION NUMBER

Pre-results NCT03367728.

Obesity management for the gastroenterologist

Obesity has reached epidemic levels in the United Kingdom. Obesity is associated with important gastrointestinal and hepatic complications which are common and can present sooner than cardiometabolic disease but often the underlying obesity remains untreated. Given that gastroenterologists and hepatologists will be at the forefront of obesity management we present an overview encompassing obesity pathophysiology, medical and surgical treatment options as well as the role of endobariatrics and the gut microbiome.

Effect of bariatric surgery on long-term cardiovascular outcomes: a nationwide nested cohort study

Aims 

This study aims to evaluate the long-term effect of bariatric surgery on cardiovascular outcomes of patients with obesity.

Methods and results 

A nested cohort study was carried out within the Clinical Practice Research Datalink. The study cohort included the 3701 patients on the database who had undergone bariatric surgery and 3701 age, gender, and body mass index-matched controls. The primary endpoint was the composite of fatal or non-fatal myocardial infarction and fatal or non-fatal ischaemic stroke. Secondary endpoints included fatal or non-fatal myocardial infarction alone, fatal or non-fatal ischaemic stroke alone, incident heart failure, and mortality. The median follow-up achieved was 11.2 years. Patients who had undergone bariatric surgery had a significantly lower occurrence of major adverse cardiovascular events [hazard ratio (HR) 0.410, 95% confidence interval (CI) 0.274–0.615; P &lt; 0.001]. This was mainly driven by a reduction in myocardial infarction (HR 0.412, 95% CI 0.280–0.606; P &lt; 0.001) and not in acute ischaemic stroke (HR 0.536, 95% CI 0.164–1.748; P = 0.301). A reduction was also observed in new diagnoses of heart failure (HR 0.403, 95% CI 0.181–0.897; P = 0.026) and mortality (HR 0.254, 95% CI 0.183–0.353; P &lt; 0.001).

Conclusion 

The results of this large, nationwide cohort study support the association of bariatric surgery with lower long-term risk of major cardiovascular events and incident heart failure in patients with obesity.

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

BACKGROUND

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

OBJECTIVES

To explore semen modifications with gastric bypass and sleeve gastrectomy.

SETTING

Five French University Hospitals.

METHODS

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

RESULTS

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

CONCLUSION

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

Gastric Banding: Complications Identified by CT

PURPOSE

Laparoscopic adjustable gastric banding (LAGB) used to be a common procedure at the turn of the century and is still frequently encountered on CT scans in common clinical practice. Our aim is to present the frequency and spectrum of complication associated with LAGB, as observed in CT.

MATERIALS AND METHODS

After approval of our institutional review board, a retrospective search for LAGB in CT interpretations using the term "band" between December 2011 and April 2017 was conducted. CT scans were reviewed to identify complications. The findings were divided into two groups: symptomatic, in which the complications caused acute symptoms for which CT scans were conducted, and incidental, in which complications were incidentally identified. The frequency of complications was calculated.

RESULTS

We identified 160 patients who underwent LAGB and performed a CT scan. Complications were identified in 69/160 (43.1%) patients, with a total of 83 findings: 47/160 (29.4%) esophageal dilatation, 13/160 (8.2%) pulmonary complications, 6/160 (3.8%) abdominal abscesses, 5/160 (3.1%) small bowel obstructions, 4/160 (2.5%) intragastric band erosions, 4/160 (2.5%) tube disconnections, 3/160 (1.9%) port site and tube course infections, and 1/160 (0.6%) small pouch bezoars. When compared with patients' referral notes, 38/83 (45.8%) of the findings were associated with acute symptoms, whereas 45/83 (54.2%) of the findings were incidental. Eighteen percent of the incidental complications were clinically important.

CONCLUSION

Complications were found in 43% of CT scans of patients who underwent LAGB; less than half of the findings were symptomatic. Some of the incidentally identified complications had substantial clinical importance.

Protocol for a 1-year prospective, longitudinal cohort study of patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy: the BARI-LIFESTYLE observational study

INTRODUCTION

Roux-en-Y gastric bypass and sleeve gastrectomy are the two most common bariatric surgery performed in the UK that result in comparable weight loss and remission of obesity-associated comorbidities. However, there is a paucity of studies examining the impact of these procedures on body composition, physical activity levels, sedentary behaviour, physical function and strength, dietary intake, health-related quality of life and costs.

METHODS AND ANALYSIS

The BARI-LIFESTYLE observational study is a 1-year prospective, longitudinal cohort study within a real-world routine clinical care setting aiming to recruit 100 patients with severe obesity undergoing either primary Roux-en-Y gastric bypass or sleeve gastrectomy from two bariatric centres in London, UK. Participants will be followed up four times during the study period; presurgery baseline (T0) and at 3 (T1), 6 (T2) and 12 months (T3) postsurgery. In addition to the standard follow-up investigations, assessments including dual-energy X-ray absorptiometry scan, bioelectric impedance analysis, 6 min walk test, sit-to-stand test and handgrip test will be undertaken together with completion of questionnaires. Physical activity levels and sedentary behaviour will be assessed using accelerometer, and dietary intake will be recorded using a 3-day food diary. Outcome measures will include body weight, body fat mass, lean muscle mass, bone mineral density, physical activity levels, sedentary behaviour, physical function and strength, dietary intake, health-related quality of life, remission of comorbidities, healthcare resource utilisation and costs.

ETHICS AND DISSEMINATION

This study has been reviewed and given a favourable ethical opinion by London-Dulwich Research Ethics Committee (17/LO/0950). The results will be presented to stakeholder groups locally, nationally and internationally and published in peer-reviewed medical journals. The lay-person summary of the findings will be published on the Centre for Obesity Research, University College London website (http://www.ucl.ac.uk/obesity).

Antral resection versus antral preservation during laparoscopic sleeve gastrectomy for severe obesity: Systematic review and meta-analysis

Although laparoscopic sleeve gastrectomy is an established operation for severe obesity, there is controversy regarding the extent to which the antrum is excised. The objective of this systematic review was to investigate the effect on perioperative complications and medium-term outcomes of antral resecting versus antral preserving sleeve gastrectomy. MEDLINE, EMBASE, and Cochrane databases were searched from 1946 to April 2017. Eligible studies compared antral resection (staple line commencing 2-3 cm from pylorus) with antral preservation (>5 cm from pylorus) in patients undergoing primary sleeve gastrectomy for obesity. Meta-analyses were performed with a random-effects model, and risk of bias within and across studies was assessed using validated scoring systems. Eight studies (619 participants) were included: 6 randomized controlled trials and 2 cohort studies. Overall follow-up was 94% for the specified outcomes of each study. Mean percentage excess weight loss was 62% at 12 months (7 studies; 574 patients) and 67% at 24 months (4 studies; 412 patients). Antral resection was associated with significant improvement in percentage excess weight loss at 24-month follow-up (mean 70% versus 61%; standardized mean difference .95; confidence interval .35-1.58, P<.005), an effect that remained significant when cohort studies were excluded. There was no difference in incidence of perioperative bleeding, leak, or de novo gastroesophageal reflux disease. According to the available evidence, antral resection is associated with better medium-term weight loss compared with antral preservation, without increased risk of surgical complications. Further randomized clinical trials are indicated to confirm this finding.

Nutrition in Pregnancy Following Bariatric Surgery

The widespread use of bariatric surgery for the treatment of morbid obesity has led to a dramatic increase in the numbers of women who become pregnant post-surgery. This can present new challenges, including a higher risk of protein and calorie malnutrition and micronutrient deficiencies in pregnancy due to increased maternal and fetal demand. We undertook a focused, narrative review of the literature and present pragmatic recommendations. It is advisable to delay pregnancy for at least 12 months following bariatric surgery. Comprehensive pre-conception and antenatal care is essential to achieving the best outcomes. Nutrition in pregnancy following bariatric surgery requires specialist monitoring and management. A multidisciplinary approach to care is desirable with close monitoring for deficiencies at each trimester.

Effect of Contemporary Bariatric Surgical Procedures on Type 2 Diabetes Remission. A Population-Based Matched Cohort Study

OBJECTIVE

The objective of the study is to evaluate the effect of gastric banding, gastric bypass and sleeve gastrectomy on medium to long-term diabetes control in obese participants with type 2 diabetes mellitus.

RESEARCH DESIGN AND METHODS

Matched cohort study using primary care electronic health records from the UK Clinical Practice Research Datalink. Obese participants with type 2 diabetes who received bariatric surgery from 2002 to 2014 were compared with matched control participants who did not receive BS. Remission was defined for each year of follow-up as HbA1c <6.5 % and no antidiabetic drugs prescribed.

RESULTS

There were 826 obese participants with T2DM who received bariatric surgery including adjustable gastric banding (LAGB) 220; gastric bypass (GBP) 449; or sleeve gastrectomy (SG) 153; with four procedures undefined. Mean HbA1c declined from 8.0 % before BS to 6.5 % in the second postoperative year; proportion with HbA1c <6.5 % (<48 mmol/mol) increased from 17 to 47 %. The proportion of patients in remission was 30 % in the second year, being 20 % for LAGB, 34 % for GBP and 38 % for SG. The adjusted relative rate of remission over the first six postoperative years was 5.97 (4.86 to 7.33, P < 0.001) overall; for LAGB 3.32 (2.27 to 4.86); GBP 7.16 (5.64 to 9.08); and SG 6.82 (5.05 to 9.19). Rates of remission were maintained into the sixth year of follow-up.

CONCLUSIONS

Remission of diabetes may continue for up to 6 years after bariatric surgical procedures. Diabetes outcomes are generally more favourable after gastric bypass or sleeve gastrectomy than LAGB.

Three-Trocar Sleeve Gastrectomy vs Standard Five-Trocar Technique: a Randomized Controlled Trial

PURPOSE

Bariatric surgery is a treatment for morbid obesity. Different surgical procedures have been described in order to obtain excess weight loss (EWL), but currently laparoscopic sleeve gastrectomy is the most commonly performed procedure throughout the world. Reducing abdominal wall trauma and increasing the aesthetic result are important goals for all bariatric surgeons. We conducted a randomized, controlled trial in order to assess if the three-trocar sleeve gastrectomy can be safely carried out or should be abandoned.

MATERIALS AND METHODS

From September 2016 to February 2017, 90 patients were enrolled in our trial. Each patients was evaluated by a multidisciplinary team before surgery. Two groups were created after application of the inclusion and exclusion criteria. The primary endpoint was to define the features of early post-operative complications of patients in group 1 (the three-trocar technique-the experimental group) compared to group 2 (five-trocar technique-the control group). The secondary endpoints were to evaluate any differences between the two groups concerning post-operative pain and patients' satisfaction with the aesthetic results.

RESULTS

There was no difference between the two groups concerning age, sex distribution, weight, and BMI. The rate of co-morbidities was similar in both groups. Operative time was inferior in the control group, but patient satisfaction was better in the three-trocar sleeve gastrectomy group.

CONCLUSIONS

The three-trocar sleeve gastrectomy can be safely carried out with a modest increase in operative time, without additional early surgical complications and with a greater patient aesthetic satisfaction.

TRIAL REGISTRATION

researchregistry2386.

Costs and Outcomes of Increasing Access to Bariatric Surgery: Cohort Study and Cost-Effectiveness Analysis Using Electronic Health Records

OBJECTIVES

To estimate costs and outcomes of increasing access to bariatric surgery in obese adults and in population subgroups of age, sex, deprivation, comorbidity, and obesity category.

METHODS

A cohort study was conducted using primary care electronic health records, with linked hospital utilization data, for 3,045 participants who underwent bariatric surgery and 247,537 participants who did not undergo bariatric surgery. Epidemiological analyses informed a probabilistic Markov model to compare bariatric surgery, including equal proportions with adjustable gastric banding, gastric bypass, and sleeve gastrectomy, with standard nonsurgical management of obesity. Outcomes were quality-adjusted life-years (QALYs) and net monetary benefits at a threshold of £30,000 per QALY.

RESULTS

In a UK population of 250,000 adults, there may be 7,163 people with morbid obesity including 1,406 with diabetes. The immediate cost of 1,000 bariatric surgical procedures is £9.16 million, with incremental discounted lifetime health care costs of £15.26 million (95% confidence interval £15.18-£15.36 million). Patient-years with diabetes mellitus will decrease by 8,320 (range 8,123-8,502). Incremental QALYs will increase by 2,142 (range 2,032-2,256). The estimated cost per QALY gained is £7,129 (range £6,775-£7,506). Net monetary benefits will be £49.02 million (range £45.72-£52.41 million). Estimates are similar for subgroups of age, sex, and deprivation. Bariatric surgery remains cost-effective if the procedure is twice as costly, or if intervention effect declines over time.

CONCLUSIONS

Diverse obese individuals may benefit from bariatric surgery at acceptable cost. Bariatric surgery is not cost-saving, but increased health care costs are exceeded by health benefits to obese individuals.

Costs and outcomes of increasing access to bariatric surgery for obesity: cohort study and cost-effectiveness analysis using electronic health records

Background

Bariatric surgery is known to be an effective treatment for extreme obesity but access to these procedures is currently limited.

Objective

This study aimed to evaluate the costs and outcomes of increasing access to bariatric surgery for severe and morbid obesity.

Design and methods

Primary care electronic health records from the UK Clinical Practice Research Datalink were analysed for 3045 participants who received bariatric surgery and 247,537 general population controls. The cost-effectiveness of bariatric surgery was evaluated in severe and morbid obesity through a probabilistic Markov model populated with empirical data from electronic health records.

Results

In participants who did not undergo bariatric surgery, the probability of participants with morbid obesity attaining normal body weight was 1 in 1290 annually for men and 1 in 677 for women. Costs of health-care utilisation increased with body mass index category but obesity-related physical and psychological comorbidities were the main drivers of health-care costs. In a cohort of 3045 adult obese patients with first bariatric surgery procedures between 2002 and 2014, bariatric surgery procedure rates were greatest among those aged 35–54 years, with a peak of 37 procedures per 100,000 population per year in women and 10 per 100,000 per year in men. During 7 years of follow-up, the incidence of diabetes diagnosis was 28.2 [95% confidence interval (CI) 24.4 to 32.7] per 1000 person-years in controls and 5.7 (95% CI 4.2 to 7.8) per 1000 person-years in bariatric surgery patients (adjusted hazard ratio was 0.20, 95% CI 0.13 to 0.30;p < 0.0001). In 826 obese participants with type 2 diabetes mellitus who received bariatric surgery, the relative rate of diabetes remission, compared with controls, was 5.97 (95% CI 4.86 to 7.33;p < 0.001). There was a slight reduction in depression in the first 3 years following bariatric surgery that was not maintained. Incremental lifetime costs associated with bariatric surgery were £15,258 (95% CI £15,184 to £15,330), including costs associated with bariatric surgical procedures of £9164 per participant. Incremental quality-adjusted life-years (QALYs) were 2.142 (95% CI 2.031 to 2.256) per participant. The estimated cost per QALY gained was £7129 (95% CI £6775 to £7506). Estimates were similar across gender, age and deprivation subgroups.

Limitations

Intervention effects were derived from a randomised trial with generally short follow-up and non-randomised studies of longer duration.

Conclusions

Bariatric surgery is associated with increased immediate and long-term health-care costs but these are exceeded by expected health benefits to obese individuals with reduced onset of new diabetes, remission of existing diabetes and lower mortality. Diverse obese individuals have clear capacity to benefit from bariatric surgery at acceptable cost.

Future work

Future research should evaluate longer-term outcomes of currently used procedures, and ways of delivering these more efficiently and safely.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme. Martin C Gulliford and A Toby Prevost were supported by the NIHR Biomedical Research Centre at Guy’s and St Thomas’ Hospitals. Peter Littlejohns was supported by the South London Collaboration for Leadership in Applied Health Research and Care. The funders did not engage in the design, conduct or reporting of the research.

The role of routine preoperative upper endoscopy in bariatric surgery: a systematic review and meta-analysis

BACKGROUND

The necessity of routine preoperative esophagogastroduodenoscopy (EGD) before bariatric surgery is controversial. European guidelines recommend routine EGD while North American guidelines recommend a selective approach.

OBJECTIVE

Perform a systematic review and meta-analysis to determine the proportion and scope of clinical findings discovered at preoperative EGD.

SETTING

Academic hospital, Canada.

METHODS

A search of MEDLINE, Embase, and Cochrane databases included MeSH terms "bariatric surgery," "endoscopy," and "preoperative." Inclusion criteria were any case series, cohort study, or clinical trial describing results of preoperative EGD for any bariatric surgery. Exclusion criteria were studies with<10 patients, patients<18 years of age, or revisional operations. Changes in surgical and medical management and proportions of pathologic findings were extracted and combined in a meta-analysis using the random effects model.

RESULTS

Initial search identified 532 citations. Forty-eight were included after full text review. Included studies comprised 12,261 patients with a mean (SD) age of 40.5 (1.3) years and body mass index of 46.3 (1.5) kg/m(2). The majority of patients (77.1%) were female. The proportion of EGDs resulting in a change in surgical management was 7.8%. After removing benign findings with controversial impact on management (hiatal hernia, gastritis, peptic ulcer), this was found to be .4%. Changes in medical management were seen in 27.5%, but after eliminating Helicobacter pylori eradication, this was found to be 2.5%.

CONCLUSION

Preoperative EGD in average-risk, asymptomatic bariatric surgery patients should be considered optional, as the proportion of EGDs that resulted in important changes in management was low.