Bariatric Surgery for Treatment of Hypothalamic Obesity After Craniopharyngioma Therapy: a Matched Case-Control Study

Long-term outcomes after gastric bypass surgery in patients with craniopharyngioma-related hypothalamic obesity-Three cases with 7, 8, and 14 years follow-up

INTRODUCTION

Craniopharyngioma is a brain tumor, resection which often results in hypothalamic damage leading to severe obesity. While small case series and case-control studies have shown the benefits of bariatric surgery in patients with craniopharyngioma-related hypothalamic obesity, long-term results (>5 years) have not been reported so far.

METHODS

We analyzed data from 3 cases with craniopharyngioma-related hypothalamic obesity who had undergone (one proximal, two very long limb distal) Roux-en Y gastric bypass (RYGB) surgery 7, 8, and 14 years before their latest follow-up visit.

RESULTS

Percentage of total weight loss varied across the 3 patients (11%, 26%, 32%). Preexisting type 2 diabetes markedly improved in 2 patients with one showing a temporary and one a persisting remission. At RYGB surgery one patient was diagnosed to have liver cirrhosis (intraoperative biopsy), but liver function remained stable or even improved during a 7-year follow-up period. One patient required proximalisation of lower anastomosis (distal RYGB) because of severe hypoproteinemia and diarrhea which resolved after revision. Another patient temporarily developed alcohol abuse that led to weight regain, but his weight decreased when alcohol consumption became under control. Importantly, all three patients stated in a standardized questionnaire that they have benefited and that they would recommend RYGB surgery to another person.

CONCLUSION

Despite showing an unsatisfying weight loss result in one patient and distinct complications in the other two patients, all patients clearly showed long-term persisting benefits. Moreover, self-reported outcomes confirm that it was the right decision to recommend RYGB to our patients displaying craniopharyngioma-related hypothalamic obesity.

Hypothalamic integrity is necessary for sustained weight loss after bariatric surgery: A prospective, cross-sectional study

OBJECTIVE

The hypothalamus is the main integrator of peripheral and central signals in the control of energy homeostasis. Its functional relevance for the effectivity of bariatric surgery is not entirely elucidated. Studying the effects of bariatric surgery in patients with hypothalamic damage might provide insight.

SUMMARY BACKGROUND DATA

Prospective study to analyze the effects of bariatric surgery in patients with hypothalamic obesity (HO) vs. matched patients with common obesity (CO) with and without bariatric surgery.

METHODS

65 participants were included (HO-surgery: n = 8, HO-control: n = 10, CO-surgery: n = 12, CO-control: n = 12, Lean-control: n = 23). Body weight, levels of anorexic hormones, gut microbiota, as well as subjective well-being/health status, eating behavior, and brain activity (via functional MRI) were evaluated.

RESULTS

Patients with HO lost significantly less weight after bariatric surgery than CO-participants (total body weight loss %: 5.5 % vs. 26.2 %, p = 0.0004). After a mixed meal, satiety and abdominal fullness tended to be lowest in HO-surgery and did not correlate with levels of GLP-1 or PYY. Levels of PYY (11,151 ± 1667 pmol/l/h vs. 8099 ± 1235 pmol/l/h, p = 0.028) and GLP-1 (20,975 ± 2893 pmol/l/h vs. 13,060 ± 2357 pmol/l/h, p = 0.009) were significantly higher in the HO-surgery vs. CO-surgery group. Abundance of Enterobacteriaceae and Streptococcus was increased in feces of HO and CO after bariatric surgery. Comparing HO patients with lean-controls revealed an increased activation in insula and cerebellum to viewing high-caloric foods in left insula and cerebellum in fMRI.

CONCLUSIONS

Hypothalamic integrity is necessary for the effectiveness of bariatric surgery in humans. Peripheral changes after bariatric surgery are not sufficient to induce satiety and long-term weight loss in patients with hypothalamic damage.

Five-Year Changes in Weight and Diabetes Status After Bariatric Surgery for Craniopharyngioma-Related Hypothalamic Obesity: a Case-Control Study

PURPOSE

Craniopharyngiomas are tumors located in the hypothalamic region which leads to obesity in about 50% of cases. Long-term efficacy and safety of bariatric surgery are lacking in this peculiar population. The aim of this study is to determine the 5-year weight loss and resolution of type 2 diabetes (T2D) after bariatric surgery in patients operated on craniopharyngioma who had developed hypothalamic obesity.

MATERIALS AND METHODS

This is a multicenter french retrospective case-control study. Subjects with craniopharyngioma (n = 23) who underwent sleeve gastrectomy (SG) (n = 9) or Roux-en-Y gastric bypass (RYGB) (n = 14) (median age 35 years [25;43] and BMI 44.2 kg/m² [40.7; 51.0]; 8/23 with T2D) were individually matched to 2 subjects with common obesity for age, gender, preoperative body mass index, T2D, and type of surgery.

RESULTS

TWL% after 1 and 5 years was lower in the craniopharyngioma group than in the control group: 23.1 [15.4; 31.1] (23/23) vs 31.4 [23.9; 35.3] at 1 year (p = 0.008) (46/46) and 17.8 [7.1; 21.9] (23/23) vs 26.2 [18.9; 33.9] at 5 years (p = 0.003) (46/46). After RYGB, TWL% was lower in the craniopharyngioma group compared to the control group (p < 0.001) and comparable after SG both at 1 and 5 years. No difference between the two groups was observed in T2D remission rate and in early and late adverse events. No hormonal deficiency-related acute disease was reported.

CONCLUSIONS

Bariatric surgery induced a significant weight loss in the craniopharyngioma group at 1 and 5 years, but less than in common obesity. SG may be more effective than RYGB but this remains to be demonstrated in a larger cohort.

Critical review of bariatric surgical outcomes in patients with Prader-Willi syndrome and other hyperphagic disorders

OBJECTIVE

The aim of this study was to review bariatric procedure outcomes among patients with Prader-Willi syndrome (PWS), melanocortin 4 receptor (MC4R) mutations, Bardet-Biedl syndrome, and hypothalamic obesity.

METHODS

Systematic published literature review used the following search terms: "Prader-Willi syndrome," "Bardet-Biedl syndrome," "hyperphagia," "bariatric surgery," "MC4R"/"melanocortin 4 receptor", "hypothalamic obesity," and "bariatric procedure." Information collected included demographics, genetics, anthropometry, procedure type, outcomes, and complications, with inclusion of case series and clinical reports given the rarity of the disorders. For PWS, postoperative weight-change percentage and BMI up to 14 years following surgery were analyzed using general linear mixed models, with descriptive outcomes for other conditions.

RESULTS

A total of 54 publications were identified, with variable follow-up periods for 202 patients (114 with PWS, 43 with MC4R mutations, 7 with Bardet-Biedl syndrome, and 38 with hypothalamic obesity) among bariatric procedures. Weight loss of patients with PWS was greatest within 1 year of surgery, with weight-change percentage not significantly different from 0 at 5 years. Long-term results in other conditions were variable and featured suboptimal weight loss and increased reoperation risk.

CONCLUSIONS

Bariatric procedures among hyperphagic individuals, including those with PWS, report variable results and outcomes. Benefits of bariatric surgery may be less durable in hyperphagic disorders in comparison with other patients with severe obesity.