How to Choose the Best Metabolic Procedure?

Bariatric surgery reduces colorectal cancer incidence in obese individuals: Systematic review and meta-analysis

BACKGROUND

Colorectal cancer ranks third in global cancer prevalence and stands as the second leading cause of cancer-related mortalities. With obesity recognized as a pivotal risk factor for colorectal cancer, the potential protective role of bariatric surgery, especially laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy, has garnered attention.

AIM

To investigate the Roux-en-Y gastric bypass (RYGB) vs sleeve gastrectomy (SG) effect on colorectal cancer incidence in obese individuals.

METHODS

A systematic review and meta-analysis of the literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Seventeen studies with a total of 12497322 patients were included. The primary outcome was the relative risk (RR) of developing colorectal cancer in obese patients who underwent weight loss surgery compared to those who did not. Secondary outcomes included determining the RR for colon and rectal cancer separately and subgroup analyses by gender and type of weight loss surgery.

RESULTS

The meta-analysis revealed a 54% reduction in colorectal cancer risk in morbidly obese patients who underwent bariatric surgery compared to those who did not. A significant 46% reduction in colorectal cancer risk was observed among female patients. However, no significant differences were found in the meta-analysis for various types of bariatric surgery, such as SG and RYGB.

CONCLUSION

This meta-analysis reveals weight loss surgery, regardless of type, reduces colorectal cancer risk, especially in women, as indicated by RR and hazard ratio assessments. Further validation is essential.

[Pharmacotherapy of obesity-Competition to bariatric surgery or a meaningful supplement?]

Obesity is a complex chronic disease and requires a long-term multimodal approach. The current treatment algorithm for treatment of obesity mainly consists of a stepwise approach, which starts with a lifestyle intervention followed by or combined with medication treatment, whereas bariatric surgery is often reserved for the last option. This article provides an overview of the currently available conservative medicinal treatment regimens and the currently approved medications as well as medications currently undergoing approval studies with respect to the efficacy and possible side effects. Special attention is paid to the importance of combination treatment of pharmacotherapy and surgery in the sense of a multimodal treatment. The data so far show that using a multimodal approach an improvement in the long-term weight loss and metabolic benefits can be achieved for the patients.

Metabolic syndrome and liver disease in the era of bariatric surgery: What you need to know!

Metabolic syndrome (MS) is defined as the constellation of obesity, insulin resistance, high serum triglycerides, low high-density lipoprotein cholesterol, and high blood pressure. It increasingly affects more and more people and progressively evolves into a serious issue with widespread healthcare, cost, and quality of life associated consequences. MS is associated with increased morbidity and mortality due to cardiovascular or chronic liver disease. Conservative treatment, which includes diet, exercise, and antidiabetic agents, is the mainstay of treatment, but depends on patient compliance to medical treatment and adherence to lifestyle modification recommendations. Bariatric surgery has recently emerged as an appropriate alternative treatment with promising long-term results. Sleeve gastrectomy and Roux-en-Y gastric bypass constitute the most commonly performed procedures and have been proven both cost-effective and safe with low complication rates. Liver transplantation is the only definitive treatment for end-stage liver disease and its utilization in patients with non-alcoholic steatohepatitis has increased more than fivefold over the past 15 years. In this review, we summarize current state of evidence on the surgical treatment of MS.

Sleeve gastrectomy or gastric bypass: a "post-code" lottery? A comprehensive national analysis of the utilization of bariatric surgery in Switzerland between 2011-2017

BACKGROUND

Sleeve gastrectomy (SG) recently became the most frequently performed bariatric surgery (BS) worldwide, overtaking the long-time standard Roux-en-Y gastric bypass (RYGB). Main indications for one or the other procedure show large inter-center variations and warrant further investigations.

OBJECTIVES

The aim of this study was to identify the influencers of primary BS selection in Switzerland.

SETTING

Switzerland.

METHODS

Retrospective analysis of all hospitalizations in Switzerland January 1, 2011 through December 31, 2017 with anonymized data provided by the Swiss Federal Statistical Office. BS procedures were identified based on ICD-10 and national surgical codes. Statistical analyses were performed with R.

RESULTS

During the study period 27,375 BS were performed. The annual BS caseload doubled over time, whereas inpatient complications decreased (∼-33%). RYGB was the prevailing procedure, although its annual proportion decreased from 80% to 70% over 7 years. Meanwhile, use of SG increased from 14% to 23%. Primary RYGB and SG had similar rates of inpatient mortality (∼.05%) and morbidity (8.0 versus 7.4%, P =.148), with the exception of higher ileus rates following RYGB (.7 versus .1%, P < .001). Patient-related factors favoring the indication of SG were male sex, extremes of age, and metabolic co-morbidities , while gastroesophageal reflux disease and private insurance-favored RYGB. Strikingly, differences between geographic regions outweighed patient-related factors in procedure selection: inhabitants of German- and Italian-speaking areas had higher likelihood (OR 4.6; 3.9, P < .001) to receive SG than those in French-speaking areas.

CONCLUSION

Geographic differences in primary BS procedure selection indicate a lack of objective rationales. Long-term risk-benefit and cost-effectiveness analyses are needed to assist evidence-based decision making.

Obesity Surgery and Cancer: What Are the Unanswered Questions?

Obesity has become a global epidemic with a soaring economic encumbrance due to its related morbidity and mortality. Amongst obesity-related conditions, cancer is indeed the most redoubtable. Bariatric surgery has been proven to be the most effective treatment for obesity and its associated metabolic and cardiovascular disorders. However, the understanding of whether and how bariatric surgery determines a reduction in cancer risk is limited. Obesity-related malignancies primarily include colorectal and hormone-sensitive (endometrium, breast, prostate) cancers. Additionally, esophago-gastric tumors are growing to be recognized as a new category mainly associated with post-bariatric surgery outcomes. In fact, certain types of surgical procedures have been described to induce the development and subsequent progression of pre-cancerous esophageal and gastric lesions. This emerging category is of great concern and further research is required to possibly prevent such risks. Published data has generated conflicting results. In fact, while overall cancer risk reduction was reported particularly in women, some authors showed no improvement or even increased cancer incidence. Although various studies have reported beneficial effects of surgery on risk of specific cancer development, fundamental insights into the pathogenesis of obesity-related cancer are indispensable to fully elucidate its mechanisms.

Incidence and Risk Factors for Mortality Following Bariatric Surgery: a Nationwide Registry Study

BACKGROUND

Although bariatric surgery (BS) is considered safe, concern remains regarding severe post-operative adverse events and mortality. Using a national BS registry, the aim of this study was to assess the incidence, etiologies, and risk factors for mortality following BS.

METHODS

Prospective data from the National Registry of Bariatric Surgery in Israel (NRBS) including age, gender, BMI, comorbidities, and surgical procedure information were collected for all patients who underwent BS in Israel between June 2013 and June 2016. The primary study outcome was the 3.5-year post-BS mortality rate, obtained by cross-referencing with the Israel population registry.

RESULTS

Of the 28,755 patients analyzed (67.3% females, mean age 42.0 ± 12.5 years, and preoperative BMI 42.14 ± 5.21 kg/m²), 76% underwent sleeve gastrectomy (SG), 99.1% of the surgeries were performed laparoscopically, and 50.8% of the surgeries were performed in private medical centers. Overall, 95 deaths occurred during the study period (146.9/100,000 person years). The 30-day rate of post-operative mortality was 0.04% (n = 12). Male gender (HR = 1.94, 95%CI 1.16-3.25), age (HR = 1.06, 95%CI 1.04-1.09), BMI (HR = 1.08, 95%CI 1.05-1.11), and depression (HR = 2.38, 95%CI 1.25-4.52) were independently associated with an increased risk of all-cause 3.5-year mortality, while married status (HR = 0.43, 95%CI 0.26-0.71) was associated with a decreased risk.

CONCLUSION

Mortality after BS is low. Nevertheless, a variety of risk factors including male gender, advanced age, unmarried status, higher BMI, and preoperative depressive disorder were associated with higher mortality rates. Special attention should be given to these "at-risk" BS patients.

What Makes Bariatric Operations Difficult-Results of a National Survey

Background and objective: The most commonly performed bariatric procedures include laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), and one anastomosis gastric bypass-mini gastric bypass (OAGB-MGB). A study comparing the degree of difficulty among those procedures could serve as a guide for decision making in bariatric surgery and further improve training programs for general surgery trainees. The aim of this study was to compare the subjective level of technical difficulty of LSG, LRYGB, and OAGB-MGB as perceived by surgeons and surgical residents. Materials and Methods: An anonymous internet-based survey was designed to evaluate the subjective opinions of surgeons and surgical residents in training in Poland. It covered baseline characteristics of the participants, difficulty of LSG, OAGB-MGB, LRYGB and particular stages of each operation assessed on a 1-5 scale. Results: Overall, 70 surgeons and residents participated in our survey. The mean difficulty degree of LSG was 2.34 ± 0.89. The reinforcing staple line with sutures was considered most difficult stage of this operation (3.17 ± 1.19). The LRYGB operation had an average difficulty level of 3.87 ± 1.04. Creation of the gastrojejunostomy was considered the most difficult stage of LRYGB with a mean difficulty level (3.68 ± 1.16). Responders to our survey assessed the mean degree of difficulty of OAGB-MGB as 2.34 ± 0.97. According to participating surgeons, creating the gastrojejunostomy is the most difficult phase of this operation (3.68 ± 1.16). Conclusion: The LSG is perceived by surgeons as a relatively easy operation. The LRYGB was considered to be the most technically challenging procedure in our survey. Operative stages, which require intra-abdominal suturing with laparoscopic instruments, seem to be the most difficult phases of each operation.

What is the role of bariatric surgery in the management of obesity?

Diet, exercise, cognitive behavioral therapy and pharmacotherapy are some of the means of assisting patients to lose weight, with bariatric surgery being the most effective. Over the last two decades, the increased awareness of the systemic benefits of bariatric surgery, as well as the improved safety and the wider use of the laparoscopic approach, has made bariatric surgery flourish. In the United Kingdom, the adjustable gastric band (10%), vertical sleeve gastrectomy (37%) and Roux-en-Y gastric bypass (45%) are the three most common procedures. Obesity-associated mortality and co-morbidities such as type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, renal dysfunction and depression improve significantly with bariatric surgery. The mechanisms of weight loss extend beyond restriction and malabsorption and include changes in hunger and satiety, food preferences, and possibly energy expenditure. Despite its safety and efficacy, bariatric surgery is underutilized as less than 1% of adults with obesity receive it. In view of the evolution of obesity into a global threat, access to bariatric surgery should be increased, whilst developing safer and less invasive weight loss treatments.

Surgical Treatment of Metabolic Syndrome

BACKGROUND

Bariatric surgery is gastrointestinal surgery for weight control, and metabolic surgery refers to the use of surgery to primarily and purposely treat type 2 diabetes mellitus (T2DM)/metabolic syndrome mellitus.

METHODS

The most recent literature was reviewed for surgery and T2DM in a non-systematic fashion.

RESULTS

Roux-Y gastric bypass, biliopancreatic diversion with duodenal switch, and sleeve gastrectomy (SG) are the dominant procedures today. SG is emerging as the most popular operation worldwide. Laparoscopy has made metabolic surgery as safe as other common abdominal procedures. A BMI > 60 kg/m², however, exposes a significantly higher perioperative risk. Most patients experience a sustained improvement of glycemic control with subsequent reduction of cardiovascular events. The remission rates depend on the severity and duration of diabetes. Prevention of long-term nutritional deficits and monitoring of metabolism require lifelong medical surveillance of the patients.

CONCLUSIONS

The profound impact of weight reduction surgery on glucose metabolism explains the growing interest in treating T2DM by surgical means. Metabolic surgery is a safe option for carefully selected patients with metabolic syndrome.

Targeting the gastrointestinal tract to treat type 2 diabetes

The rising global rates of type 2 diabetes and obesity present a significant economic and social burden, underscoring the importance for effective and safe therapeutic options. The success of glucagon-like-peptide-1 receptor agonists in the treatment of type 2 diabetes, along with the potent glucose-lowering effects of bariatric surgery, highlight the gastrointestinal tract as a potential target for diabetes treatment. Furthermore, recent evidence suggests that the gut plays a prominent role in the ability of metformin to lower glucose levels. As such, the current review highlights some of the current and potential pathways in the gut that could be targeted to improve glucose homeostasis, such as changes in nutrient sensing, gut peptides, gut microbiota and bile acids. A better understanding of these pathways will lay the groundwork for novel gut-targeted antidiabetic therapies, some of which have already shown initial promise.