Comparative long-term mortality after laparoscopic adjustable gastric banding versus nonsurgical controls

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.

Impact of Bariatric Surgery on the Prevalence and Outcomes of Atrial Fibrillation in Obese Patients

Obesity has been identified as a significant factor contributing to the development of numerous cardiovascular conditions and as a result, the cardiovascular community has prioritized efforts to address obesity and reduce its associated risks. However, despite these efforts, the prevalence of obesity continues to rise steadily, and is projected to double in the upcoming years. Atrial fibrillation is among the most prevalent and extensively researched cardiovascular comorbidities associated with obesity. Several mechanisms have been postulated, including scar tissue formation and fat deposition, which ultimately leads to atrial remodeling and subsequent arrhythmogenesis. Numerous strategies have been implemented to prevent and manage obesity, encompassing lifestyle adjustments, dietary modifications, pharmacological treatments, and surgical interventions. Bariatric surgery has garnered significant recognition over the years due to its promising outcomes, including a decrease in the overall prevalence of atrial fibrillation and other cardiovascular comorbidities in general in obese patients. This study focuses on the current trends regarding the impact of bariatric surgery on obese patients with atrial fibrillation.

Association of prior bariatric surgery with financial and clinical outcomes of acute myocardial infarction

BACKGROUND

Superior clinical outcomes after hospitalization for cardiovascular-related disease such as acute heart failure have been linked with prior history of bariatric surgery, but similar analyses in acute myocardial infarction (MI) are currently limited.

OBJECTIVE

This work examines clinical outcomes and resource utilization in patients with acute MI hospitalizations with a prior history of bariatric surgery.

SETTING

Academic university-affiliated hospital in the United States.

METHODS

All adult patients with hospitalizations with a primary diagnosis of acute MI were queried using the 2016-2020 Nationwide Readmissions Database. The study population was comprised of patients with an International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code for obesity (body mass index ≥35 kg/m2) as well as those with a prior history of bariatric surgery regardless of their body mass index status. Comparison was made between those with a prior history of bariatric surgery and those without. Univariate analysis and multivariate regression models were used to examine the association between bariatric surgery and outcomes of interest, which included in-hospital mortality, medical complications, and resource utilization.

RESULTS

Of an estimated 2,736,606 hospitalizations for acute MI, 296,902 patients (10.8%) had a diagnosis of obesity and/or a prior history of bariatric surgery. The bariatric cohort was more frequently female and had a lower prevalence of congestive heart failure, chronic lung disease, diabetes, and electrolyte derangements than the nonbariatric cohort. After risk adjustment, prior history of bariatric surgery was associated with significantly lower odds of in-hospital mortality, cardiogenic shock, and acute kidney injury. Additionally, prior history of bariatric surgery was linked to a decreased duration of hospital stay and lower hospitalization costs as well as lower odds of nonhome discharge.

CONCLUSION

Among acute MI patients with obesity, prior history of bariatric surgery was associated with decreased odds of in-hospital mortality, improved clinical outcomes, and lower resource utilization. Expansion of bariatric surgery programs may provide improved access to a medical intervention that is intertwined with cardiovascular health.

OUP accepted manuscript

Aims

Obesity is a global health problem, associated with significant morbidity and mortality, often due to cardiovascular (CV) diseases. While bariatric surgery is increasingly performed in patients with obesity and reduces CV risk factors, its effect on CV disease is not established. We conducted a systematic review and meta-analysis to evaluate the effect of bariatric surgery on CV outcomes, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline.

Methods and results

PubMed and Embase were searched for literature until August 2021 which compared bariatric surgery patients to non-surgical controls. Outcomes of interest were all-cause and CV mortality, atrial fibrillation (AF), heart failure (HF), myocardial infarction, and stroke. We included 39 studies, all prospective or retrospective cohort studies, but randomized outcome trials were not available. Bariatric surgery was associated with a beneficial effect on all-cause mortality [pooled hazard ratio (HR) of 0.55; 95% confidence interval (CI) 0.49–0.62, P < 0.001 vs. controls], and CV mortality (HR 0.59, 95% CI 0.47–0.73, P < 0.001). In addition, bariatric surgery was also associated with a reduced incidence of HF (HR 0.50, 95% CI 0.38–0.66, P < 0.001), myocardial infarction (HR 0.58, 95% CI 0.43–0.76, P < 0.001), and stroke (HR 0.64, 95% CI 0.53–0.77, P < 0.001), while its association with AF was not statistically significant (HR 0.82, 95% CI 0.64–1.06, P = 0.12).

Conclusion

The present systematic review and meta-analysis suggests that bariatric surgery is associated with reduced all-cause and CV mortality, and lowered incidence of several CV diseases in patients with obesity. Bariatric surgery should therefore be considered in these patients.

Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants

BACKGROUND

Metabolic-bariatric surgery delivers substantial weight loss and can induce remission or improvement of obesity-related risks and complications. However, more robust estimates of its effect on long-term mortality and life expectancy-especially stratified by pre-existing diabetes status-are needed to guide policy and facilitate patient counselling. We compared long-term survival outcomes of severely obese patients who received metabolic-bariatric surgery versus usual care.

METHODS

We did a prespecified one-stage meta-analysis using patient-level survival data reconstructed from prospective controlled trials and high-quality matched cohort studies. We searched PubMed, Scopus, and MEDLINE (via Ovid) for randomised trials, prospective controlled studies, and matched cohort studies comparing all-cause mortality after metabolic-bariatric surgery versus non-surgical management of obesity published between inception and Feb 3, 2021. We also searched grey literature by reviewing bibliographies of included studies as well as review articles. Shared-frailty (ie, random-effects) and stratified Cox models were fitted to compare all-cause mortality of adults with obesity who underwent metabolic-bariatric surgery compared with matched controls who received usual care, taking into account clustering of participants at the study level. We also computed numbers needed to treat, and extrapolated life expectancy using Gompertz proportional-hazards modelling. The study protocol is prospectively registered on PROSPERO, number CRD42020218472.

FINDINGS

Among 1470 articles identified, 16 matched cohort studies and one prospective controlled trial were included in the analysis. 7712 deaths occurred during 1·2 million patient-years. In the overall population consisting 174 772 participants, metabolic-bariatric surgery was associated with a reduction in hazard rate of death of 49·2% (95% CI 46·3-51·9, p<0·0001) and median life expectancy was 6·1 years (95% CI 5·2-6·9) longer than usual care. In subgroup analyses, both individuals with (hazard ratio 0·409, 95% CI 0·370-0·453, p<0·0001) or without (0·704, 0·588-0·843, p<0·0001) baseline diabetes who underwent metabolic-bariatric surgery had lower rates of all-cause mortality, but the treatment effect was considerably greater for those with diabetes (between-subgroup I² 95·7%, p<0·0001). Median life expectancy was 9·3 years (95% CI 7·1-11·8) longer for patients with diabetes in the surgery group than the non-surgical group, whereas the life expectancy gain was 5·1 years (2·0-9·3) for patients without diabetes. The numbers needed to treat to prevent one additional death over a 10-year time frame were 8·4 (95% CI 7·8-9·1) for adults with diabetes and 29·8 (21·2-56·8) for those without diabetes. Treatment effects did not appear to differ between gastric bypass, banding, and sleeve gastrectomy (I² 3·4%, p=0·36). By leveraging the results of this meta-analysis and other published data, we estimated that every 1·0% increase in metabolic-bariatric surgery utilisation rates among the global pool of metabolic-bariatric candidates with and without diabetes could yield 5·1 million and 6·6 million potential life-years, respectively.

INTERPRETATION

Among adults with obesity, metabolic-bariatric surgery is associated with substantially lower all-cause mortality rates and longer life expectancy than usual obesity management. Survival benefits are much more pronounced for people with pre-existing diabetes than those without.

FUNDING

None.

Compared with Controls, Bariatric Surgery Prevents Long-Term Mortality in Persons with Obesity Only Above Median Age of Cohorts: a Systematic Review and Meta-Analysis

PURPOSE

Compared to medical treatment, bariatric surgery reduces long-term mortality in persons with obesity. Some studies indicate that the effect only applies to patients above median age of cohorts, not to younger patients. Our objective was to assess the role of age in the reduction of mortality (global mortality and mortality for specific causes) through bariatric surgery.

MATERIALS AND METHODS

Data sources: PubMed, Cochrane Library, MEDLINE, and Embase.

STUDY SELECTION

studies reporting mortality in relation to median age of patients.

DATA EXTRACTION AND SYNTHESIS

pooled random effects of estimates of the risk of mortality in participants undergoing surgery compared with controls, as function of median age.

RESULTS

Mortality was lower in patients undergoing surgery than in controls (OR = 0.29, 95% CI 0.17-0.49). Below median age, the difference between surgery patients and controls was nonsignificant (OR = 0.78, 95% CI 0.57-1.06). Above median age, the difference was significant (OR = 0.23, 95% CI 0.12-0.44). In a subset of 5 studies, deaths due to various causes were less, and external causes-related deaths were more frequent in surgery than in controls. Below median age, deaths due to CVD were less frequent in surgery than in controls. Above median age, total deaths and deaths due to various causes (cardiovascular, diabetes, cancer, and other causes) were less in surgery than in controls. Publication bias was absent.

CONCLUSION

Compared with controls, bariatric surgery reduces long-term global mortality only above median age, not below median age. Also mortality due to specific causes is mainly reduced in persons above median age.

Metabolic surgery: A clinical update

Metabolic and bariatric surgery has grown beyond 'experimental' weight-loss surgery. As techniques have advanced over the last few decades, so has the growing body of research and evidence, proving that both weight-loss and metabolic health improvement are induced. Metabolic surgery has become the more appropriate term for weight-loss surgery because of the altered gastrointestinal anatomy and subsequent beneficial metabolic effects. Although the tool of metabolic surgery has been well refined, a large portion of the global population does not have adequate access to it. This clinical update aims to (a) inform healthcare providers from all disciplines about the myriad of benefits of metabolic surgery and (b) equip them with the necessary knowledge to bridge the gap between patients in need of metabolic treatment and the therapies in metabolic surgery available to them.

The role of bariatric surgery in normalization of the coagulation profiles

BACKGROUND

Bariatric surgery achieves appropriate excess weight loss, controlling related co-morbidities, including coagulation abnormalities.

OBJECTIVE

We investigated the change in the coagulation profile after postoperative weight stabilization, correlating between EWL ratio and change in the coagulation profile.

SETTING

This study took place in our teaching institution (university setting).

METHODS

Between the years 2012 and 2014, 67 patients underwent surgery; 47 patients underwent laparoscopic sleeve gastrectomy (SG) and 20 patients underwent Roux-en-Y gastric bypass (RYGB). Average follow-up of postoperative thromboelastography (TEG) parameters was 30 ± 10.8 months (12-77). Average body mass index (BMI) before surgery was 41.7 ± 4.6kg/m², average percentage of EWL at the time of data collection was 79%. Patients were divided into 3 groups, 6 patients had EWL < 50%, 13 had an EWL > 100%, and 48 had EWL between 50% and 100%.

EXCLUSION CRITERIA

use of anticoagulation, antiplatelet, or contraceptive medications; known thrombophilic, renal, hepatic, and hematologic diseases/disorders. Two follow-up groups: 1-2 years and over 2 years. Patients underwent pre and postoperative TEG coagulation studies, including maximal amplitude (MA), and clot strength (G).

RESULTS

Coagulation profile improved after bariatric surgery. Most prominent change seen in MA and G. There was a linear correlation between the EWL ratio and improvement of MA values starting at 50% EWL peaking at 60%-70%. There was no difference in the coagulation profile after surgery in the two surgery groups (SG and RYGB).

CONCLUSIONS

Achieving appropriate weight loss after bariatric surgery improves the coagulation profile as measured by TEG, probably decreasing thromboembolic risk in those patients. We recommend expanding the current indication for bariatric surgery to include patients with altered coagulation profile measured by TEG.

Exercise and apulian hypocaloric diet affect adipokine changes and gastric banding-induced weight loss: A prospective study on severe obese subjects

Background

Adiponectin and Resistin correlate with insulin sensitivity and cardiovascular risk, respectively. This study aimed to identify lifestyle factors that modulate changes in Adiponectin and Resistin levels after gastric banding positioning (LapGB).

Materials and methods

Before (T0), 3 months (T3), 6 months (T6), and 12 months (T12) after LapGB, serum Adiponectin and Resistin levels were evaluated in a single-centre prospective study including a cohort of 27 non-diabetic obese subjects (S-Ob, BMI ≥35 kg/m²). After surgery, a dietitian checked the adherence of S-Ob to an Apulian hypocaloric diet (aphypoD)/physical activity (phA) and, according to their high or low compliance to aphypoD/phA, S-Ob were included in group 1 (n = 14) or 2 (n = 13) respectively. Serum Adiponectin and Resistin were also measured in 10 healthy controls.

Results

At baseline, Resistin levels were significantly higher and Adiponectin levels significantly lower in S-Ob than in controls. After surgery, group 1 showed a 50.2% excess weight loss (%EWL), significantly decreased Resistin levels at T12 and increased Adiponectin levels at both T6 and T12 as compared with baseline. Group 2 showed 24.6 %EWL at T12, decreased Adiponectin levels at T6 and T12 as compared with baseline, but unaltered Resistin levels. After surgery, group 1 followed aphypoD/phA, while group 2 did not.

Conclusions

LapGB fails to improve cardiovascular risk markers (Resistin) in S-Ob not improving lifestyle. Future studies might investigate these findings in a larger cohort and display whether aphypoD is more effective than other dietary intervention on cardiovascular risk in subjects undergoing LapGB or other Bariatric procedures.

•

Gastric banding (LapGB) plus a 12-month lifestyle program was followed by a % excess weight loss >40.

•

Resistin significantly declined in subjects adhering to a 1-year LapGB/lifestyle intervention.

•

In subjects not following any lifestyle program after surgery, Adiponectin unexpectedly decreased.

•

LapGB fails to change cardiovascular risk or insulin sensitivity without a healthy lifestyle.

Risk of Suicide and Self-harm Is Increased After Bariatric Surgery-a Systematic Review and Meta-analysis

BACKGROUND

Bariatric surgery is endorsed by multiple societies as the most effective treatment for obesity. Psychosocial functioning has also been noted to improve for most patients after bariatric surgery. However, some studies have shown an increase in post-operative suicide risk. The aim of this study was to review the published literature and evaluate the association of bariatric surgery with suicide events and suicide/self-harm attempts in patients who have undergone weight loss surgery.

METHODS

MEDLINE and Embase were searched from inception through January 2018 for retrospective or prospective studies reporting mortality outcomes and self-harm or suicide rates after bariatric procedures. The primary outcome was the pooled event rate with 95% confidence interval (95% CI) for suicide. Secondary outcomes were suicide/self-harm attempts after bariatric surgery compared to same population prior to surgery and to matched control subjects, with the respective calculated odds ratios (OR) and 95% CI.

RESULTS

From 227 citations, 32 studies with 148,643 subjects were eligible for inclusion. The patients were predominantly females (76.9%). Roux-en-Y gastric bypass (RYGB) was the most commonly performed procedure (58.9%). The post-bariatric suicide event rate was 2.7/1000 patients (95% CI 0.0019-0.0038), while the suicide/self-harm attempt event rate was 17/1000 patients (95% CI 0.01-0.03). The self-harm/suicide attempt risk was higher after bariatric surgery within the same population with OR of 1.9 (95% CI 1.23-2.95), and compared to matched control subjects, OR 3.8 (95% CI, 2.19-6.59).

CONCLUSIONS

Post-bariatric surgery patients had higher self-harm/suicide attempt risk compared to age-, sex-, and BMI-matched controls. Various pre- and post-surgical psychosocial, pharmacokinetic, physiologic, and medical factors may be involved.

Bariatric surgery is associated with a lower rate of death after myocardial infarction and stroke: A nationwide study

AIM

To assess the potential protective effect of bariatric surgery on mortality after myocardial infarction (MI) or cerebrovascular accident (CVA).

MATERIALS AND METHODS

Using the National Inpatient Sample (2007-2014), 2218 patients with a principal discharge diagnosis of acute MI and 2168 patients with ischaemic CVA who also had history of prior bariatric surgery were identified. Utilizing propensity scores, these patients were matched 1:5 with patients who had similar principal diagnoses but no history of bariatric surgery (controls). Control group-1 included participants with obesity (BMI ≥ 35 kg/m² ) only and participants in control group-2 were matched according to post-surgery BMI with the bariatric surgery group. The primary and secondary endpoints were in-hospital all-cause mortality and length of hospital stay, respectively. Outcomes after MI and CVA were separately compared among groups in multivariate regression models.

RESULTS

A total of 48 300 (weighted) participants were included in the analysis. The distribution of covariates was well balanced after propensity matching. Mortality rates after MI were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.85% vs 3.03%; odds ratio (OR), 0.61; 95% confidence interval (CI), 0.44-0.86; P = 0.004) and with control group-2 (2.00% vs 3.26%; OR, 0.62; 95% CI, 0.44-0.88; P = 0.008). Similarly, in-hospital mortality rates after CVA were significantly lower in patients with a history of bariatric surgery compared with control group-1 (1.43% vs 2.74%; OR, 0.54; 95% CI, 0.37-0.79; P = 0.001) and with control group-2 (1.54% vs 2.59%; OR, 0.61; 95% CI, 0.41-0.91; P = 0.015). Furthermore, length of stay was significantly shorter in the bariatric surgery group for all comparisons (P < 0.001).

CONCLUSION

Prior bariatric surgery is associated with significant protective effect on survival after MI and CVA.

A 23-year study of mortality and development of co-morbidities in patients with obesity undergoing bariatric surgery (laparoscopic gastric banding) in comparison with medical treatment of obesity

Background and aim

Several studies have shown that bariatric surgery reduces long term mortality compared to medical weight loss therapy. In a previous study we have demonstrated that gastric banding (LAGB) is associated with reduced mortality in patients with and without diabetes, and with reduced incidence of obesity co-morbidities (cardiovascular disease, diabetes, and cancer) at a 17 year follow-up. The aim of this study was to verify at a longer time interval (23 years) mortality and incidence of co-morbidities in patients undergoing LAGB or medical weight loss therapy.

Patients and methods

As reported in the previous shorter-time study, medical records of obese patients [body mass index (BMI) > 35 kg/m² undergoing LAGB (n = 385; 52 with diabetes) or medical treatment (controls, n = 681; 127 with diabetes), during the period 1995–2001 (visit 1)] were collected. Patients were matched for age, sex, BMI, and blood pressure. Identification codes of patients were entered in the Italian National Health System Lumbardy database, that contains life status, causes of death, as well as exemptions, prescriptions, and hospital admissions (proxies of diseases) from visit 1 to June 2018. Survival was compared across LAGB patients and matched controls using Kaplan–Meier plots adjusted Cox regression analyses.

Results

Final observation period was 19.5 ± 1.87 years (13.4–23.5). Compared to controls, LAGB was associated with reduced mortality [HR = 0.52, 95% CI 0.33–0.80, p = 0.003], significant in patients with diabetes [HR = 0.46, 95% CI 0.22–0.94, p = 0.034], borderline significant in patients without diabetes [HR = 0.61, 95% CI = 0.35–1.05, p = 0.076]. LAGB was associated with lower incidence of diabetes (15 vs 75 cases, p = 0.001), of CV diseases (61 vs 226 cases, p = 0.009), of cancer (10 vs 35, p = 0.01), and of renal diseases (0 vs 35, p = 0.001), and of hospital admissions (92 vs 377, p = 0.001).

Conclusion

The preventive effect of LAGB on mortality is maintained up to 23 years, even with a decreased efficacy compared with the shorter-time study, while the preventive effect of LAGB on co-morbidities and on hospital admissions increases with time.

Electronic supplementary material

The online version of this article (10.1186/s12933-018-0801-1) contains supplementary material, which is available to authorized users.

Long-term mortality in obese subjects undergoing malabsorptive surgery (biliopancreatic diversion and biliointestinal bypass) versus medical treatment

BACKGROUND AND AIM

Aim of this study was to analyze long-term mortality in obese patients receiving malabsorptive bariatric surgery (BS)[biliopancreatic diversion (BPD) and biliointestinal bypass (BIBP)] in comparison to medical treatment of obesity.

PATIENTS AND METHODS

Medical records of 1877 obese patients [body mass index (BMI) > 35 kg/m², aged 18-65 years, undergoing BS (n = 472, 111 with diabetes) or non-surgical medical treatment (n = 1405, 385 with diabetes), during the period 1999-2008 (visit 1)] were collected; non-surgical patients were matched for age, sex, BMI, and blood pressure, and life status and causes of death were ascertained through December 2016. Survival was compared across surgery patients and non-surgical patients using Kaplan-Meier plots and Cox regression analyses.

RESULTS

Observation period was 12.1 ± 3.41 years (mean ± SD). Compared to non-surgical patients, BS patients had reduced all-cause mortality (34/472 (7.2%) vs 181/1,405 (12.9%) patients, χ² = 11.25, p = 0.001; HR = 0.64, 95% C.I. 0.43-0.93, p = 0.019). Cardiovascular and cancer causes of death were significantly less frequent in surgery vs no-surgery (HR = 0.26, 95% C.I. 0.09-0.72, p = 0.003; HR = 0.21, 95% C.I. 0.09-0.45, p < 0.001, respectively).

CONCLUSION

Patients who have undergone BPD and BIBP have lower long-term all-cause, cardiovascular-caused and cancer-caused mortality compared to non-surgical medical weight-loss treatment patients. Malabsorptive bariatric surgery significantly reduces long-term mortality in severely obese patients.

Prevalence of All-Cause Mortality and Suicide among Bariatric Surgery Cohorts: A Meta-Analysis

INTRODUCTION

Prior meta-analysis has reported mortality rates among post-operative bariatric patients, but they have not considered psychiatric factors like suicide contributing to mortality.

OBJECTIVES

The current meta-analysis aims to determine the pooled prevalence for mortality and suicide amongst cohorts using reported suicides post bariatric surgery. It is also the aim of the current meta-analytical study to determine moderators that could account for the heterogeneity found.

RESULTS

In our study, the pooled prevalence of mortality in the studies which reported suicidal mortality was 1.8% and the prevalence of suicide was 0.3%. Mean body mass index (BMI) and the duration of follow-up appear to be significant moderators.

CONCLUSIONS

Given the prevalence of suicide post bariatric surgery, it is highly important for bariatric teams to consider both the medical and psychiatric well-being of individuals pre- and post-operatively.

Short- and long-term mortality after bariatric surgery: A systematic review and meta-analysis

AIMS

The objective of this study was to investigate short- (≤ 30 days) and long-term (≥ 2 years) all-cause mortality after bariatric surgery among adult patients with obesity.

MATERIALS AND METHODS

For short-term mortality, eligible studies comprised randomized controlled trials (RCTs) reporting perioperative mortality. For long-term mortality, eligible studies comprised RCTs and observational studies comparing mortality between obese patients after bariatric surgery and non-operated controls. Random-effects models using a Bayesian or frequentist approach were used to pool effect estimates of short- and long-term mortality, respectively.

RESULTS

Short-term all-cause mortality based on 38 RCTs involving 4030 patients was 0.18% (95% CI, 0.04%-0.38%) and was higher for open surgeries (0.31%; 95% CI, 0.03%-0.97%) and similar in mixed surgeries (0.17%; 95% CI, 0.03%-0.43%) and restrictive surgeries (0.17%; 95% CI, 0.03%-0.45%). For long-term mortality, 12 observational studies involving 27 258 operated patients and 97 154 non-operated obese controls were included. Of these, 8 studies were eligible for the meta-analysis, which showed a reduction of 41% in all-cause mortality (hazard ratio, 0.59; 95% CI, 0.52-0.67; P < .001). Additionally, operated patients were 0.42 times as likely (95% CI, 0.25-0.72, P < .001) and 0.47 times as likely (95% CI, 0.36-0.63, P < .001) as non-operated obese controls to die from cardiovascular diseases and cancer, respectively.

CONCLUSIONS

Bariatric surgery is associated with low short-term mortality and may be associated with long-term reductions in all-cause, cardiovascular and cancer-related mortality.

Medical devices for the treatment of obesity

Obesity is a major public health concern that leads to numerous metabolic, mechanical and psychological complications. Although lifestyle interventions are the cornerstone of obesity management, subsequent physiological neurohormonal adaptations limit weight loss, strongly favour weight regain and counteract sustained weight loss. A range of effective therapies are therefore needed to manage this chronic relapsing disease. Bariatric surgery delivers substantial, durable weight loss but limited access to care, perceived high risks and costs restrict uptake. Medical devices are uniquely positioned to bridge the gap between more conservative lifestyle intervention and weight-loss pharmacotherapy and more disruptive bariatric surgery. In this Review, we examine the range of gastrointestinal medical devices that are available in clinical practice to treat obesity, as well as those that are in advanced stages of development. We focus on the mechanisms of action as well as the efficacy and safety profiles of these devices. Many of these devices are placed endoscopically, which provides gastroenterologists with exciting opportunities for treatment.

Association of Patient Age at Gastric Bypass Surgery With Long-term All-Cause and Cause-Specific Mortality

IMPORTANCE

Bariatric surgery is effective in reducing all-cause and cause-specific long-term mortality. Whether the long-term mortality benefit of surgery applies to all ages at which surgery is performed is not known.

OBJECTIVE

To examine whether gastric bypass surgery is equally effective in reducing mortality in groups undergoing surgery at different ages.

DESIGN, SETTING, AND PARTICIPANTS

All-cause and cause-specific mortality rates and hazard ratios (HRs) were estimated from a retrospective cohort within 4 categories defined by age at surgery: younger than 35 years, 35 through 44 years, 45 through 54 years, and 55 through 74 years. Mean follow-up was 7.2 years. Patients undergoing gastric bypass surgery seen at a private surgical practice from January 1, 1984, through December 31, 2002, were studied. Data analysis was performed from June 12, 2013, to September 6, 2015. A cohort of 7925 patients undergoing gastric bypass surgery and 7925 group-matched, severely obese individuals who did not undergo surgery were identified through driver license records. Matching criteria included year of surgery to year of driver license application, sex, 5-year age groups, and 3 body mass index categories.

INTERVENTION

Roux-en-Y gastric bypass surgery.

MAIN OUTCOMES AND MEASURES

All-cause and cause-specific mortality compared between those undergoing and not undergoing gastric bypass surgery using HRs.

RESULTS

Among the 7925 patients who underwent gastric bypass surgery, the mean (SD) age at surgery was 39.5 (10.5) years, and the mean (SD) presurgical body mass index was 45.3 (7.4). Compared with 7925 matched individuals not undergoing surgery, adjusted all-cause mortality after gastric bypass surgery was significantly lower for patients 35 through 44 years old (HR, 0.54; 95% CI, 0.38-0.77), 45 through 54 years old (HR, 0.43; 95% CI, 0.30-0.62), and 55 through 74 years old (HR, 0.50; 95% CI, 0.31-0.79; P < .003 for all) but was not lower for those younger than 35 years (HR, 1.22; 95% CI, 0.82-1.81; P = .34). The lack of mortality benefit in those undergoing gastric bypass surgery at ages younger than 35 years primarily derived from a significantly higher number of externally caused deaths (HR, 2.53; 95% CI, 1.27-5.07; P = .009), particularly among women (HR, 3.08; 95% CI, 1.4-6.7; P = .005). Patients undergoing gastric bypass surgery had a significantly lower age-related increase in mortality than severely obese individuals not undergoing surgery (P = .001).

CONCLUSIONS AND RELEVANCE

Gastric bypass surgery was associated with improved long-term survival for all patients undergoing surgery at ages older than 35 years, with externally caused deaths only elevated in younger women. Gastric bypass surgery is protective against mortality even for older patients and also reduces the age-related increase in mortality observed in severely obese individuals not undergoing surgery.

The bariatric surgery and weight losing: a meta-analysis in the long- and very long-term effects of laparoscopic adjustable gastric banding, laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy on weight loss in adults

BACKGROUND

Several studies have been investigated to find the long-term effect of bariatric surgery on weight loss; nevertheless, a meta-analysis can detailedly demonstrate the effect of bariatric surgery on weight in morbidly obese patients. This study aimed to assess the long- and very long-term effects of laparoscopic adjustable gastric banding (LAGB), laparoscopic Roux-en-Y gastric bypass (LRYGB), and laparoscopic sleeve gastrectomy (LSG) on weight loss in adults.

METHODS

An electronic search using PubMed, Scopus, and Google scholar databases was performed for all English-language articles up to May 15, 2016 with no publication date restriction. Outcome was long-term (≥5-10 years) and very long-term (≥10 years) weight reduction that reported as the mean %EWL and changes in BMI from baseline.

RESULTS

Eighty articles with 87 arms were included in this meta-analysis. The excess weight loss percentage (%EWL) was 47.94% and 47.43% after LAGB at ≥5 and ≥10 years, respectively. After LRYGB the %EWL was 62.58% at ≥5 years and 63.52% at ≥10 years. It was 53.25% at ≥5 years after LSG. Results of subgroup analyses have indicated that LRYGB leads to higher %EWL in America and Asia compared with Europe. Meta-regression analyses have shown that there is no significant association between %EWL and baseline age, BMI and length of follow-up after three procedures. However, there is a positive association between gender and %EWL after LRYGB (β = 1.24). No publication bias was found.

CONCLUSIONS

These findings suggest that LRYGB is an effective procedure in morbidly obese patients that leads to sustainable weight loss over the long- and very long-term periods in compared with LAGB and LSG.

All-Cause and Cause-Specific Mortality Associated with Bariatric Surgery: A Review

The question of whether or not nonsurgical intentional or voluntary weight loss results in reduced mortality has been equivocal, with long-term mortality following weight loss being reported as increased, decreased, and not changed. In part, inconsistent results have been attributed to the uncertainty of whether the intentionality of weight loss is accurately reported in large population studies and also that achieving significant and sustained voluntary weight loss in large intervention trials is extremely difficult. Bariatric surgery has generally been free of these conflicts. Patients voluntarily undergo surgery and the resulting weight is typically significant and sustained. These elements, combined with possible non-weight loss-related mechanisms, have resulted in improved comorbidities, which likely contribute to a reduction in long-term mortality. This paper reviews the association between bariatric surgery and long-term mortality. From these studies, the general consensus is that bariatric surgical patients have: 1) significantly reduced long-term all-cause mortality when compared to severely obese non-bariatric surgical control groups; 2) greater mortality when compared to the general population, with the exception of one study; 3) reduced cardiovascular-, stroke-, and cancer-caused mortality when compared to severely obese non-operated controls; and 4) increased risk for externally caused death such as suicide.

Long-term mortality and incidence of cardiovascular diseases and type 2 diabetes in diabetic and nondiabetic obese patients undergoing gastric banding: a controlled study

BACKGROUND AND AIM

Aim of this retrospective study was to compare long-term mortality and incidence of new diseases [diabetes and cardiovascular (CV) disease] in morbidly obese diabetic and nondiabetic patients, undergoing gastric banding (LAGB) in comparison to medical treatment.

PATIENTS AND METHODS

Medical records of obese patients [body mass index (BMI) > 35 kg/m(2) undergoing LAGB (n = 385; 52 with diabetes) or medical treatment (controls, n = 681; 127 with diabetes), during the period 1995-2001 (visit 1)] were collected. Patients were matched for age, sex, BMI, and blood pressure. Identification codes of patients were entered in the Italian National Health System Lumbardy database, that contains life status, causes of death, as well as exemptions, drug prescriptions, and hospital admissions (proxies of diseases) from visit 1 to September 2012. Survival was compared across LAGB patients and matched controls using Kaplan-Meier plots adjusted Cox regression analyses.

RESULTS

Observation period was 13.9 ± 1.87 (mean ± SD). Mortality rate was 2.6, 6.6, and 10.1 % in controls at 5, 10, and 15 years, respectively; mortality rate was 0.8, 2.5, and 3.1 % in LAGB patients at 5, 10, and 15 years, respectively. Compared to controls, surgery was associated with reduced mortality [HR 0.35, 95 % CI 0.19-0.65, p < 0.001 at univariate analysis, HR 0.41, 95 % CI 0.21-0.76, p < 0.005 at adjusted analysis], similar in diabetic [HR 0.34, 95 % CI 0.13-0.87, p = 0.025] and nondiabetic [HR 0.42, 95 % CI 0.19-0.97, p = 0.041] patients. Surgery was also associated with lower incidence of diabetes (15 vs 48 cases, p = 0.035) and CV diseases (52 vs 124 cases, p = 0.048), and of hospital admissions (88 vs 197, p = 0.04).

CONCLUSION

Up to 17 years, gastric banding is associated with reduced mortality in diabetic and nondiabetic patients, and with reduced incidence of diabetes and cardiovascular diseases.

Medico-legal analysis of legal complaints in bariatric surgery: a 15-year retrospective study

BACKGROUND

Bariatric surgery for severe obesity has become an effective and accepted treatment for sustained weight loss.

OBJECTIVES

The aim of our study was to analyze the complications and issues raised by the experts on which jury or judges' decisions were made for the different types of bariatric surgery.

SETTING

University Hospital, France.

MATERIALS AND METHODS

We have carried out a retrospective study of 59 expert review dossiers over a period of 15 years (1999-2014) on the different types of bariatric surgery (laparoscopic adjustable gastric band [LAGB], sleeve gastrectomy [SG], Roux-en-Y gastric bypass [RYGB], vertical banded gastroplasty [VBG], and gastric plication [GP]).

RESULTS

Of the cases, 81% were women and the average age was 39 years old (range 19 to 68 years). Among the procedures giving rise to the complaints, 40% were for LAGB, 28% for RYGB, and 23% for SG. The most common initial complications were perforations (30%), fistulae (27%), bowel obstruction (14%), vascular injuries (9.5%), and infections (peritonitis, pleurisy, abscesses, and so forth) (8%). Revision surgery was required in 78% of patients, and perioperative complications accounted for 28.5% of dossiers. The experts concluded that fault had occurred in 40% of case. Negligence arising from an error deemed to be an act of negligence was found in 30% of cases, 67% of which were because of delayed diagnosis. Major long-term complications accounted for 8% of dossiers and minor long-term complications for 22%. Forty-seven percent of patients completely recovered.

CONCLUSION

Delayed diagnosis was the main error established by the experts. Surgeons should remain vigilant postoperatively after every bariatric surgical procedure.

Laparoscopic gastric banding resolves the metabolic syndrome and improves lipid profile over five years in obese patients with body mass index 30-40 kg/m(2.)

BACKGROUND

Obesity, metabolic syndrome (MS) and dyslipidemia are independent risk factors for cardiovascular disease. Bariatric surgery is increasingly recognized as an effective intervention for improving each of these risk factors. There are sparse data on the long-term durability of metabolic changes associated with bariatric surgery, in particular with laparoscopic gastric banding (LGB). Our objective was to evaluate the durability of metabolic changes associated with LGB in nonmorbid obesity.

METHODS

Fifty obese patients (BMI 30-40) with ≥1 obesity-related comorbidity were prospectively followed for five years. At follow-up, subjects underwent fasting blood measures, including lipid NMR spectroscopy and standard lipid profile.

RESULTS

Forty-seven patients (45 female, mean age 43.8 years) completed four years follow-up (46 completed five years). Baseline BMI was 35.1 ± 2.6. Subjects exhibited mean weight loss of 22.3 ± 7.9 kg (22.9 ± 7.4%) at year one and maintained this (19.8 ± 10.2%) over five years. At baseline, 43% (20/47) of subjects met criteria for MS. This was reduced to 15% (7/47) at year one and remained reduced over five years (13%, 6/46) (p < 0.001). There were reductions in triglycerides (p < 0.001) and increases in HDL cholesterol (HDL-C, p < 0.001) and HDL particle concentration (p = 0.02), with a trend toward increased HDL particle size (p = 0.06) at year five. Changes in triglycerides and HDL-C were more prominent in patients with MS at baseline, but unassociated with weight loss or waist circumference. Changes in HDL particle size and concentration were not associated with MS status, weight loss, waist circumference, or statin use.

CONCLUSIONS

LGB produces significant weight loss, resolution of MS and changes in lipid profile suggestive of beneficial HDL remodeling. These changes persist five years following LGB.

Bariatric surgery and its impact on cardiovascular disease and mortality: a systematic review and meta-analysis

BACKGROUND

Bariatric surgery has been shown to improve cardiovascular risk factors but long term benefits for survival and cardiovascular events are still uncertain.

METHODS

We searched MEDLINE and EMBASE for parallel group studies that evaluated the clinical outcomes associated with bariatric surgery as compared to non-surgical treatment. Relevant studies were pooled using random effects meta-analysis for risk of myocardial infarction, stroke, cardiovascular events and mortality.

RESULTS

14 studies met the inclusion criteria, which included 29,208 patients who underwent bariatric surgery and 166,200 nonsurgical controls (mean age 48 years, 30% male, follow up period ranged from 2 years to 14.7 years). Four studies were considered at moderate-high risk of bias, whilst ten studies were at moderate or lower risk of bias. Compared to nonsurgical controls there was more than 50% reduction in mortality amongst patients who had bariatric surgery (OR 0.48 95% CI 0.35-0.64, I2=86%, 14 studies). In pooled analysis of four studies with adjusted data, bariatric surgery was associated with a significantly reduced risk of composite cardiovascular adverse events (OR 0.54 95% CI 0.41-0.70, I2=58%). Bariatric surgery was also associated with significant reduction in specific endpoints of myocardial infarction (OR 0.46 95% CI 0.30-0.69, I2=79%, 4 studies) and stroke (OR 0.49 95% CI 0.32-0.75, I2=59%, 4 studies).

CONCLUSIONS

Data from observational studies indicates that patients undergoing bariatric surgery have a reduced risk of myocardial infarction, stroke, cardiovascular events and mortality compared to non-surgical controls. Future randomized studies should investigate whether these observations are reproduced in a clinical trials setting.

Patients' perceptions of waiting for bariatric surgery: a qualitative study

BACKGROUND

In Canada waiting lists for bariatric surgery are common, with wait times on average > 5 years. The meaning of waiting for bariatric surgery from the patients' perspective must be understood if health care providers are to act as facilitators in promoting satisfaction with care and quality care outcomes. The aims of this study were to explore patients' perceptions of waiting for bariatric surgery, the meaning and experience of waiting, the psychosocial and behavioral impact of waiting for treatment and identify health care provider and health system supportive measures that could potentially improve the waiting experience.

METHODS

Twenty-one women and six men engaged in in-depth interviews that were digitally recorded, transcribed verbatim and analysed using a grounded theory approach to data collection and analysis between June 2011 and April 2012. The data were subjected to re-analysis to identify perceived health care provider and health system barriers to accessing bariatric surgery.

RESULTS

Thematic analysis identified inequity as a barrier to accessing bariatric surgery. Three areas of perceived inequity were identified from participants' accounts: socioeconomic inequity, regional inequity, and inequity related to waitlist prioritization. Although excited about their acceptance as candidates for surgery, the waiting period was described as stressful, anxiety provoking, and frustrating. Anger was expressed towards the health care system for the long waiting times. Participants identified the importance of health care provider and health system supports during the waiting period. Recommendations on how to improve the waiting experience included periodic updates from the surgeon's office about their position on the wait list; a counselor who specializes in helping people going through this surgery, dietitian support and further information on what to expect after surgery, among others.

CONCLUSION

Patients' perceptions of accessing and waiting for bariatric surgery are shaped by perceived and experienced socioeconomic, regional, and waitlist prioritization inequities. A system addressing these inequities must be developed. Waiting for surgery is inherent in publicly funded health care systems; however, ensuring equitable access to treatment should be a health system priority. Supports and resources are required to ensure the waiting experience is as positive as possible.

Laparoscopic bariatric surgery can be performed safely in secondary health care centres with a dedicated service corridor to an affiliated tertiary health care centre

BACKGROUND

Canada needs to increase capacity for bariatric surgery to reduce the wait for this cost-effective, life-saving surgery. The aim of this study was to test whether laparoscopic bariatric surgery, including gastric bypass, can be delivered safely in secondary health care centres (SHCCs).

METHODS

In this prospective cohort study, patients received bariatric surgery at an SHCC that had no intensive care unit but had a dedicated operating room and ward teams and a patient-monitoring environment. Patients with life-threatening complications were transferred to an affiliated tertiary health care centre (THCC) via a dedicated "service corridor."

RESULTS

In all, 830 patients were treated: 676 at the SHCC and 154 at the THCC. Gastric bypass was performed in 85.4%, gastric band in 11.1% and gastric sleeve in 3.5%. The body mass index (BMI) was significantly higher in the THCC than the SHCC group (mean 54.4 [standard deviation (SD) 9.7] v. 47.5 [SD 7.4]). Obesity-associated diseases were similar between the groups. Major complications occurred in 2.6% of SHCC patients and 1.7% of THCC patients. Seven patients (1%) required direct transfer to the THCC, and all were treated successfully. There were 2 deaths (1.3%) in the THCC and none in the SHCC groups (combined mortality 0.2%). Weight loss was equivalent up to the fourth year of the study.

CONCLUSION

With proper patient selection, a dedicated health care team and a service corridor to an affiliated THCC, laparoscopic bariatric surgery, including gastric bypass can be performed safely in SHCCs. Further study is needed to determine whether the model can be applied across Canada.

Risk of completed suicide after bariatric surgery: a systematic review

Bariatric surgery is one of the most effective treatments for morbid obesity, and a large body of research indicates significant long-term weight loss. While overall mortality decreases in patients who received bariatric surgery, a number of studies have shown that suicide rates are higher in bariatric patients than in control groups. The objective of this study was to present a systematic review of suicide mortality after bariatric surgery and calculate an estimate for the suicide rate. Literature researches of the databases PubMed, Web of Knowledge, PsychInfo, ScienceDirect and Google Scholar were conducted. Thirty studies concerning bariatric surgery and completed suicides met the inclusion criteria. We included 28 studies in the estimation of a suicide rate for the bariatric population. Only one study (Tindle et al.) put a main focus on suicide after bariatric surgery; this was therefore chosen as an adequate reference figure for comparison. The other 27 chosen studies were compared with World Health Organization data and the suicide rate reported by Tindle et al. Twenty-three thousand eight hundred eighty-five people were included in the analysis. In the literature, we found a total of 95 suicides when examining 190,000 person-years of post-bariatric surgery data. Little information was provided describing the reasons for suicide and the time-point of these events after surgery. We estimated a suicide rate of 4.1/10,000 person-years (95% confidence interval [3.2, 5.1]/10,000 person-years). A comparison with Tindle et al. demonstrates that their rate is significantly higher than our estimate (P = 0.03). Bariatric surgery patients show higher suicide rates than the general population. Therefore, there is a great need to identify persons at risk and post-operative psychological monitoring is recommended.

Is the residual gastric volume after laparoscopic sleeve gastrectomy an objective criterion for adapting the treatment strategy after failure?

BACKGROUND

Causes of failure after laparoscopic sleeve gastrectomy (LSG) are not known but may include a high residual gastric volume (RGV). The aim of this study was to use gastric computed tomography volumetry (GCTV) to investigate the RGV and relate the latter parameter to the outcome of LSG.

METHODS

A single-center, prospective study included patients with>24 months of follow-up after LSG. The RGV was measured with a unique GCTV technique. We determined the LSG outcomes according to a variety of criteria and examined potential relationships with the RGV. When the RGV was>250 cc, we offered a repeat LSG (RLSG).

RESULTS

Seventy-six patients were included. The mean RGV was 255 cc but differed significantly when comparing "failure" and "success" subgroups, regardless of whether the latter were defined by a percentage of excess weight loss>50 (309 cc versus 225 cc, respectively; P = .0003), a BAROS score>3 (312 cc versus 234 cc; P = .005), the Reinhold criteria (290 cc versus 235 cc; P = .019), or the Biron criteria (308 cc versus 237 cc; P = .008). The RGV threshold (corresponding to the volume above which the probability of failure after LSG is high) was 225 cc. Fifteen RLSGs were performed during the inclusion period.

CONCLUSION

A high RGV 34 months after LSG is a risk factor for failure. Knowledge of the RGV can be of value in the management of failure after LSG.

Bariatric surgery: cost-effectiveness and budget impact

Bariatric surgery is to date the most effective treatment for morbid obesity and it has been proven to reduce obesity-related comorbidities and total mortality. As any medical treatment, bariatric surgery is costly and doubts about its affordability have been raised. On the other hand, bariatric surgery may reduce the direct and indirect costs of obesity and related comorbidities. The appreciation of the final balance between financial investments and savings is critical from a health economic perspective. In this paper, we try to provide a brief updated review of the most recent studies on the cost-efficacy of bariatric surgery, with particular emphasis on budget analysis. A brief overview of the economic costs of obesity will also be provided. The epidemic of obesity may cause a significant reduction in life expectancy and overwhelming direct and indirect costs for citizens and societies. Cost-efficacy analyses included in this review consistently demonstrated that the additional years of lives gained through bariatric surgery may be obtained at a reasonable and affordable cost. In groups of patients with very high obesity-related health costs, like patients with type 2 diabetes, the use of bariatric surgery required an initial economic investment, but may save money in a relatively short period of time.

Bariatric Surgery is Associated with a Reduced Risk of Mortality in Morbidly Obese Patients with a History of Major Cardiovascular Events

Although the safety of bariatric surgery in patients with established cardiovascular disease has been demonstrated, little is known about the mid- to long-term survival of these patients after surgery. We conducted a retrospective cohort study of bariatric surgical patients (n = 349) compared with morbidly obese surgical controls (n = 903). Data were obtained on all patients 40 to 79 years of age, from 1996 to 2008, with a diagnosis code of morbid obesity, a primary surgical procedure of interest, and a cardiovascular event history. Data sources were the statewide South Carolina UB92 inpatient hospitalization database and death records. The primary outcome was all-cause mortality. A total of 349 bariatric and 903 control patients with cardiovascular event histories were identified. Among bariatric patients, 19 deaths occurred in 986 person-years of follow-up versus 150 deaths among controls in 3138 person-years of follow-up. Unadjusted all-cause mortality was estimated at 7 ± 2 per cent at 5 years in bariatric patients compared with 19 ± 2 per cent ( P < 0.001) in controls. Adjusting for age, comorbidities, and event history, the relative risk of mortality was reduced by 40 per cent in bariatric patients compared with controls [hazard ratios (95% confidence interval): 0.60 (0.36, 0.99)]. In patients with a history of cardiovascular events, bariatric surgery is associated with a significantly decreased risk of all-cause mortality.

Type 2 diabetes after gastric bypass: remission in five models using HbA1c, fasting blood glucose, and medication status

BACKGROUND

The remission rates of type 2 diabetes mellitus (T2DM) after Roux-en-Y gastric bypass (RYGB) vary according to the glycosylated hemoglobin A1c (HbA1c), fasting blood glucose (FG), and medication status. Our objectives were to describe remission using the American Diabetes Association standards for defining normoglycemia and to identify the factors related to the preoperative severity of T2DM that predict remission to normoglycemia, independent of weight loss, after RYGB. The setting was an urban not-for-profit community hospital.

METHODS

We performed a retrospective analysis of prospectively collected data from a cohort of 2275 patients who qualified for bariatric surgery (2001-2008). Five different models for defining remission (no diabetes medication and a FG <100 mg/dL; no diabetes medication and HbA1c <6.0; no diabetes medication and HbA1c <5.7%; no diabetes medication, FG <100 mg/dL, and HbA1c <6.0%; and no diabetes medication, FG <100 mg/dL, and HbA1c <5.7%) were compared in 505 obese patients with T2DM 14 months after RYGB. The secondary aims were to determine the effects of preoperative insulin therapy and the duration of known T2DM on remission.

RESULTS

Of the 505 patients, 43.2% achieved remission using the most stringent criteria (no diabetes medication, HbA1c <5.7%, and FG <100 mg/dL) compared with 59.4% using the most liberal definition (no diabetes medication and FG <100 mg/dL; P < .001). The remission rates were greater for patients not taking insulin preoperatively (53.8% versus 13.5%, P < .001) and for patients with a more recent preoperative T2DM diagnosis (8.9 versus 3.7 yr, P < .001).

CONCLUSION

Remission, defined at a threshold less than what would be expected to result in microvascular damage, was achieved in 43.2% of diabetic patients by 14 months after RYGB. A more recent diagnosis of T2DM and the absence of preoperative insulin therapy were significant predictors, regardless of how remission was defined, independent of the percentage of excess weight loss.

Medical versus surgical treatment of type 2 diabetes: the search for level 1 evidence

Data from observational and nonrandomized comparative studies have shown a dramatic effect of bariatric surgery on type 2 diabetes mellitus (T2DM), including in nonobese patients. However, a relative paucity of level 1 evidence is available to define the exact role of surgery as a treatment modality for T2DM, especially in less obese subjects. Performing randomized clinical trials in this field, however, poses significant and specific challenges for the study design. We have addressed such challenges in a carefully designed randomized controlled trial comparing glycemic control with optimal medical management versus Roux-en-Y gastric bypass in overweight to mildly obese patients with T2DM mellitus (body mass index 26-35 kg/m(2)). The present report describes the rationale and design of the Weill Cornell Medical College study. In addition to glycemic endpoints, however, clinical trials should also investigate the effect of surgery on cardiovascular risk or T2DM-specific morbidity. Addressing these endpoints would entail large, randomized clinical trials with prolonged period of observation and ideally a multicenter study design. Such a multisite trial poses substantial logistical and financial challenges, which would predictably delay rather than accelerate progress of research in this field. A consortium of centers performing independent small and medium size randomized clinical trials may provide a more realistic and feasible approach. In this paper, we present an overview of on-going randomized clinical trials in this field and propose a worldwide consortium of randomized controlled trials (WORLDCoRDS) using the Weill Cornell Medical College protocol. The aim of this consortium is to standardize research in T2DM surgery and timely accumulate homogeneous data that can help assess the effects of GI surgery on cardiovascular risk and T2DM-related mortality and morbidity.

Hepatic left lobe volume is a sensitive index of metabolic improvement in obese women after gastric banding

BACKGROUND

Nonalcoholic fatty liver disease is a common finding in obese subjects. Increasing evidence has been provided suggesting that it represents the hepatic component of the metabolic syndrome.

OBJECTIVE

Aim of this longitudinal study was to evaluate the relationships between several anthropometric measures, including the hepatic left lobe volume (HLLV), and various indicators of the metabolic syndrome in a cohort of severely obese women before and after laparoscopic adjustable gastric banding (LAGB).

STUDY DESIGN AND RESULTS

Seventy-five obese women (mean age 45 ± 10 years and body mass index (BMI) 42.5 ± 4.8 kg m(-2)) underwent LAGB and completed an average (± s.d.) post-surgical follow-up of 24 ± 6 months. Determination of HLLV, subcutaneous and intra-abdominal fat (IAF) was based on ultrasound. The principal component statistical analysis applied to pre-operative measurements, highlighted HLLV as a parameter that clustered with serum insulin, IAF, serum glucose and uric acid, along with triglycerides (TGs), alkaline phosphatase and high-density lipoprotein cholesterol. After LAGB, the average reduction of BMI was 23%, 12% for subcutaneous fat (SCF), 42% for HLLV and 40% for visceral fat. Among body weight, BMI, SCF, IAF and HLLV, reduction of the latter was an independent predictor of reduction of serum transaminases and γ-Glutamyltransferase, glucose, insulin and TGs.

CONCLUSIONS

In severely obese women: (i) HLLV is a sensitive indicator of ectopic fat deposition, clustering with parameters defining the metabolic syndrome; (ii) weight loss achieved by LAGB is associated with a reduction of liver volume as estimated by HLLV; (iii) among various anthropometric parameters measured, reduction of HLLV that follows LAGB represents the best single predictor of improvement of various cardiometabolic risk factors.

Surgical treatment of type 2 diabetes: the surgeon perspective

Type 2 diabetes mellitus (T2DM) is a major health priority globally, having achieved pandemic status in the twenty-first century. Several gastrointestinal procedures that were primarily designed to treat morbid obesity result in dramatic remission of diabetes. Studies in experimental rodent models and humans have shown that the glycemic benefits of surgery are at least in part weight-independent and extend to non-morbidly obese subjects with T2DM. Bariatric procedures differ in their ability to ameliorate type 2 diabetes, with intestinal bypass procedures being more effective than purely restrictive procedures. Several studies have demonstrated that the benefits of bariatric surgery extend beyond amelioration of hyperglycemia and include improvement in other cardiovascular risk factors such as dyslipidemia and hypertension. The safety and cost-effectiveness of bariatric surgery are also well established by several studies. In this paper, the authors present the surgeon perspective on the management of type 2 diabetes focusing on the efficacy, safety and cost-effectiveness of metabolic surgery. The available evidence warrants the inclusion of metabolic surgery in the treatment algorithm of type 2 diabetes.

Laparoscopic Roux-en-Y gastric bypass: significant long-term weight loss, improvement of obesity-related comorbidities and quality of life

OBJECTIVE

To present long-term results of a large series of patients submitted to laparoscopic Roux-en-Y gastric bypass (RYGBP) for morbid obesity.

BACKGROUND

Reports on long-term results of RYGBP are scarce and focus primarily on weight loss. Our aim is to provide mid- to long-term data of RYGBP, with detailed results on weight loss, evolution of comorbidities and quality of life, also using the BAROS score.

METHODS

All patients who underwent a primary RYGBP for morbid obesity in our 2 hospitals between 1999 and August 2008 were included. Data were collected prospectively in a computerized database, and reviewed for the purpose of this study.

RESULTS

A total of 379 patients were included in the analysis of long-term results, 282 women, and 97 men, with a mean BMI of 46.3 kg/m². After 5 years, 74.9% of the patients achieved an excess weight loss of at least 50%, with a mean of 62.7% and 76.8% achieved a BMI <35 kg/m². The corresponding figures after 7 years were 64.9, 58.1, and 71.9, respectively. There was a small but significant long-term weight regain. All comorbidities improved markedly in the vast majority of patients, with no significant difference between the 3- and 5-year terms. Quality of life also improved markedly, and more than 95% of the patients had a good to excellent 5-year overall result according to the BAROS score.

CONCLUSIONS

Laparoscopic RYGBP for morbid obesity results in good and maintained weight loss up to 7 years in the majority of patients, improves quality of life and markedly improves all the evaluated comorbidities, resulting in good to excellent overall 5-year results in 97% of the patients according to the BAROS score.

Surgical approaches to the treatment of obesity

Bariatric surgery, through its efficacy and improved safety, is emerging as an important and broadly available treatment for people with severe and complex obesity that has not responded adequately to other therapy. Established procedures, such as Roux-en-Y gastric bypass and adjustable gastric banding, account for more than 80% of bariatric surgical procedures globally. Sleeve gastrectomy has emerged as a stand-alone procedure. Truly malabsoptive procedures, such as biliopancreatic diversion and its duodenal switch variant, have a diminishing role as primary procedures, but remain an option for patients who do not respond adequately to less disruptive procedures. The procedures vary considerably in their postoperative morbidity and mortality; pattern and extent of weight loss; nature and severity of long-term complications; and nutritional requirements and risks. There is no perfect procedure--an informed risk and benefit assessment should be made by each patient. Gastroenterologists also need to be familiar with the risks and benefits of current and emerging procedures as they are likely to be increasingly involved in the integrated care of these patients.

Prevalence of endocrine diseases in morbidly obese patients scheduled for bariatric surgery: beyond diabetes

BACKGROUND

Bariatric surgery allows stable body weight reduction in morbidly obese patients. In presurgical evaluation, obesity-related co-morbidities must be considered, and a multidisciplinary approach is recommended. Precise guidelines concerning the endocrinological evaluation to be performed before surgery are not available. The aim of this study was to evaluate the prevalence of common endocrine diseases in a series of obese patients scheduled for bariatric surgery.

METHODS

We examined 783 consecutive obese subjects (174 males and 609 females) aged 18-65 years, who turned to the obesity centre of our department from January 2004 to December 2007 for evaluation before bariatric surgery. Thyroid, parathyroid, adrenal and pituitary function was evaluated by measurement of serum hormones. Specific imaging or supplementary diagnostic tests were performed when indicated.

RESULTS

The overall prevalence of endocrine diseases, not including type 2 diabetes mellitus, was 47.4%. The prevalence of primary hypothyroidism was 18.1%; pituitary disease was observed in 1.9%, Cushing syndrome in 0.8%, while other diseases were found in less than 1% of subjects. Remarkably, the prevalence of newly diagnosed endocrine disorders was 16.3%.

CONCLUSIONS

A careful endocrinological evaluation of obese subjects scheduled for bariatric surgery may reveal undiagnosed dysfunctions that require specific therapy and/or contraindicate the surgical treatment in a substantial proportion of patients. These results may help to define the extent of the endocrinological screening to be performed in obese patients undergoing bariatric surgery.

Long-term prevention of mortality in morbid obesity through bariatric surgery. a systematic review and meta-analysis of trials performed with gastric banding and gastric bypass

BACKGROUND

Bariatric surgery has been reported to reduce long-term mortality in operated participants in comparison with nonoperated participants.

METHODS

We performed a systematic review and meta-analysis of clinical trials published as full articles dealing with cardiovascular (CV) mortality, all-cause mortality (noncardiovascular), and global mortality (sum of CV and all-cause mortality). Pooled-fixed effects of estimates of the risk of mortality in participants undergoing surgery were calculated compared with controls.

RESULTS

Of 44,022 participants from 8 trials (14,052 undergoing surgery and 29,970 controls), death occurred in 3317 participants (400 in surgery, 2917 in controls); when the kind of death was specified, 321 CV deaths (118 in surgery, 203 in controls), and 523 all-cause deaths (218 in surgery, 305 in controls) occurred. Compared with controls, surgery was associated with a reduced risk of global mortality (OR = 0.55, CI, 0.49-0.63), of CV mortality (OR = 0.58, CI, 0.46-0.73), and of all-cause mortality (OR = 0.70, CI, 0.59-0.84).Data of all-cause mortality were not heterogeneous; heterogeneity of data of CV mortality decreased when studies were grouped according to size (large vs small studies). The reduction of risk was smaller in large than in small studies (OR = 0.61 vs 0.21, 0.63 vs 0.16, 0.74 vs 0.35 for global, CV, and all-cause mortality, respectively). The effect of gastric banding and gastric by-pass (3797 vs 10,255 interventions) was similar for global and all-cause mortality (OR = 0.57 vs 0.55, and 0.66 vs 0.70, respectively), different for CV mortality (OR = 0.71 vs 0.48). At meta-regression analysis, a trend for a decrease of global mortality (Log OR) linked to increasing BMI appeared.

CONCLUSION

This meta-analysis indicates that (1) bariatric surgery reduces long-term mortality; (2) risk reduction is smaller in large than in small studies; and (3) both gastric banding and gastric by-pass reduce mortality with a greater effect of the latter on CV mortality.