Biliopancreatic diversion with transient gastroplasty and duodenal switch: long-term results of a multicentric study

Consistent gut bacterial and short-chain fatty acid signatures in hypoabsorptive bariatric surgeries correlate with metabolic benefits in rats

OBJECTIVE

The study aimed at comparing how changes in the gut microbiota are associated to the beneficial effects of the most clinically efficient hypoabsorptive bariatric procedures, namely Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS) and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S).

METHODS

Diet-induced obese (DIO) male Wistar rats were divided into seven groups. In addition to the groups subjected to RYGB, BPD-DS and SADI-S, the following four control groups were included: SHAM-operated rats fed a high-fat diet (SHAM HF), SHAM fed a low-fat diet (SHAM LF), SHAM HF-pair-weighed to BPD-DS (SHAM HF-PW) and sleeve-gastrectomy (SG) rats. Body weight, food intake, glucose tolerance, insulin sensitivity/resistance, and L-cell secretion were assessed. The gut microbiota (16 S ribosomal RNA gene sequencing) as well as the fecal and cæcal contents of short-chain fatty acids (SCFAs) were also analyzed prior to, and after the surgeries.

RESULTS

The present study demonstrates the beneficial effect of RYGB, BPD-DS and SADI-S on fat mass gain and glucose metabolism in DIO rats. These benefits were proportional to the effect of the surgeries on food digestibility (BPD-DS > SADI-S > RYGB). Notably, hypoabsorptive surgeries led to consonant microbial signatures characterized by decreased abundance of the Ruminococcaceae (Oscillospira and Ruminococcus), Oscillospiraceae (Oscillibacter) and Christensenellaceae, and increased abundance of the Clostridiaceae (Clostridium), Sutterellaceae (Sutterella) and Enterobacteriaceae. The gut bacteria following hypoabsorptive surgeries were associated with higher fecal levels of propionate, butyrate, isobutyrate and isovalerate. Increases in the fecal SCFAs were in turn positively and strongly correlated with the levels of peptide tyrosine-tyrosine (PYY) and with the beneficial effects of the surgery.

CONCLUSION

The present study emphasizes the consistency with which the three major hypoabsorptive bariatric procedures RYGB, BPD-DS and SADI-S create a gut microbial environment capable of producing a SCFA profile favorable to the secretion of PYY and to beneficial metabolic effects.

Low Risk for Marginal Ulcers in Duodenal Switch and Gastric Bypass in a Well-Defined Cohort of 472 Patients

PURPOSE

Marginal ulcer (MU) is well-known complication in bariatric surgery. Several studies are available in Roux-en-Y gastric bypass (RYGBP), while data on the incidence in duodenal switch (DS) is limited. We aimed to compare the incidence of MU between DS and RYGBP in a well-defined cohort and to identify associative factors.

METHODS

A cohort of 732 patients with BMI ≥ 48 who had undergone primary DS or RYGBP during 2008-2018 received a questionnaire concerning ulcers, PPI therapy, and smoking habits; hereafter, patient charts were reviewed. Incidence rates (IRs) for MU were calculated in our survey and on previous registered data in the national quality register for bariatric surgery (SOReg). A multivariate regression analysis was performed to identify predictive risk factors for MU.

RESULTS

After a mean follow-up of 6.1 years, 472 (64%) patients responded (47 ± 11 years old, 65% women and 42% DS). Of 41 MUs identified, 23 were endoscopically verified. Gastrointestinal bleeding, abdominal pain, and dysphagia were the most common symptoms. IR for MU was 1.4% (DS 1.3% and RYGBP 1.5%) per patient-year, compared with 0.9% according to SOReg-data. Persisting PPI treatment was seen in about three quarter of former MU patients (OR 11.2 [3.6-34.7], p < 0.001), but no other associative factors were found.

CONCLUSION

The overall risk for MU was low, about 1% per patient-year, without difference between DS and RYGBP. Ongoing PPI treatment was frequent in many former MU patients. This study on MU after DS provides reassuring results for future bariatric surgery candidates.

Long-Term Outcomes After Bariatric Surgery: a Systematic Review and Meta-analysis of Weight Loss at 10 or More Years for All Bariatric Procedures and a Single-Centre Review of 20-Year Outcomes After Adjustable Gastric Banding

Introduction

Durability is a key requirement for the broad acceptance of bariatric surgery. We report on durability at and beyond 10 years with a systematic review and meta-analysis of all reports providing data at 10 or more years and a single-centre study of laparoscopic adjustable gastric banding (LAGB) with 20 years of follow-up.

Methods

Systematic review with meta-analysis was performed on all eligble reports containing 10 or more years of follow-up data on weight loss after bariatric surgery. In addition, a prospective cohort study of LAGB patients measuring weight loss and reoperation at up to 20 years is presented.

Results

Systematic review identified 57 datasets of which 33 were eligible for meta-analysis. Weighted means of the percentage of excess weight loss (%EWL) were calculated for all papers included in the systematic review. Eighteen reports of gastric bypass showed a weighted mean of 56.7%EWL, 17 reports of LAGB showed 45.9%EWL, 9 reports of biliopancreatic bypass +/− duodenal switch showed 74.1%EWL and 2 reports of sleeve gastrectomy showed 58.3%EWL. Meta-analyses of eligible studies demonstrated comparable results. Reoperations were common in all groups. At a single centre, 8378 LAGB patients were followed for up to 20 years with an overall follow-up rate of 54%. No surgical deaths occurred. Weight loss at 20 years (N = 35) was 30.1 kg, 48.9%EWL and 22.2% total weight loss (%TWL). Reoperation rate was initially high but reduced markedly with improved band and surgical and aftercare techniques.

Conclusion

All current procedures are associated with substantial and durable weight loss. More long-term data are needed for one-anastomosis gastric bypass and sleeve gastrectomy. Reoperation is likely to remain common across all procedures.

Treatment of Severe Protein Malnutrition After Bariatric Surgery

BACKGROUND

Severe protein malnutrition, with a serum albumin < 25 g/L, is one of the complications that may develop after bariatric surgery. It is associated with increased morbidity and mortality and requires timely diagnosis and appropriate treatment to prevent rapid clinical deterioration. However, evidence-based recommendations for a specific treatment approach are currently not available. The present study describes the efficacy of a newly developed treatment regimen for post-bariatric patients presenting with severe hypoalbuminemia.

METHODS

A single-centre, retrospective analysis of eleven post-bariatric patients presenting with severe hypoalbuminemia, treated with continuous 24 h nasal-jejunal tube feeding of a medium chain triglyceride (MCT) formulation in combination with pancreatic enzyme supplementation every 3 h.

RESULTS

Duration of tube feeding ranged from 25 to 156 days (median 64 days) and pancreatic enzyme was supplemented for 22-195 days (median 75 days). An increase in serum albumin levels of 5 g/L and 10 g/L was achieved after a median period of 20 (range 6-26 days) and 36 days (range 21-57 days), respectively. Albumin levels were > 35 g/L after a median period of 58 days (range 44-171 days).

CONCLUSION

In this case series, a continuous 24-h nasal-jejunal MCT tube feed combined with frequent pancreatic enzyme supplementation was effective in all patients presenting with severe post-bariatric hypoalbuminemia and was not associated with adverse effects.

Long-term follow-up of disease-specific quality of life after bariatric surgery

BACKGROUND

Substantial improvements in health-related quality of life measured by generic questionnaires (most often the Short Form-36) have been noted over the long term in patients with morbid obesity who had undergone bariatric surgery.

OBJECTIVES

To obtain long-term follow-up data on disease-specific quality of life in patients who underwent bariatric surgery (biliopancreatic diversion with duodenal switch) in 2007 to 2008.

SETTING

Québec Heart and Lung Institute, Québec, Canada.

METHODS

This study is a follow-up of the validation study, the Laval Questionnaire, an obesity-specific measure of health-related quality of life developed to be used in clinical trials. Patients who contributed to the validation study in 2007 to 2008 were administered the Laval Questionnaire again at long-term follow-up.

RESULTS

Of 112 patients who contributed to the validation study, 90 were available for this long-term follow-up study (retention rate: 80%). Median follow-up was 8.8 years. For all 6 domains of the Laval Questionnaire, the improvements in quality-of-life scores were much larger than our best estimate of the minimal clinically important difference. In others, we observed some decline in quality-of-life scores over time after initial changes that occurred 1 to 2 years after surgery, during the so-called "honeymoon period." Improvements in quality of life were clearly related to surgery.

CONCLUSION

This study confirms that bariatric surgery using biliopancreatic diversion with duodenal switch improves disease-specific quality of life in the short and long term. It also demonstrates that the Laval Questionnaire is responsive to treatment-induced changes.

Biliopancreatic Diversion with Duodenal Switch: Surgical Technique and Perioperative Care

The goal of this article is to present an overview of selection criteria, surgical technique, and perioperative outcomes of biliopancreatic diversion with duodenal switch. The standard follow-up requirements, including vitamin supplementation, and long-term risks associated with metabolic surgery are also discussed. Most of the data reported here are based on the authors' experience with 4000 biliopancreatic diversions with duodenal switch performed in their institution since 1990.

Long-term outcomes after biliopancreatic diversion with and without duodenal switch: 2-, 5-, and 10-year data

BACKGROUND

There are minimal long-term data on biliopancreatic diversion (BPD) with or without duodenal switch (BPD/DS).

OBJECTIVES

To investigate the long-term weight loss, co-morbidity remission, complications, and quality of life after BPD and BPD/DS.

SETTING

An academic, university hospital in the United States.

METHODS

We conducted a retrospective review of patients who underwent BPD or BPD/DS between 1999 and 2011. Outcomes included weight loss measures at 2, 5, and 10-15 years postoperatively; co-morbidity remission; long-term complications; nutritional deficiencies; and patient satisfaction.

RESULTS

One hundred patients underwent BPD (34%) or BPD/DS (64%). Mean preoperative body mass index (BMI) was 50.2 kg/m². Mean follow up was 8.2 years (range: 1-15 yr) with 72% of eligible patients in active follow up at 10-15 years postoperatively. Excess weight loss (EWL) was 65.1% at 2 years, 63.8% at 5 years, and 67.9% at 10-15 years. Approximately 10% higher %EWL was achieved for those with preoperative BMI<50 kg/m² versus≥50 kg/m² and patients who underwent BPD/DS versus BPD. Although co-morbidities improved, 37% of patients developed long-term complications requiring surgery. There were no 30-day mortalities; however, there was one mortality from severe malnutrition. Nutritional deficiencies in fat-soluble vitamins, anemia, and secondary hyperparathyroidism were common. Overall, 94% of patients reported satisfaction with their choice of surgery.

CONCLUSION

This clinical experience supports the long-term positive safety profile and efficacy of BPD and BPD/DS at a single U.S. center. Higher levels of excess weight loss are achieved by patients with a lower preoperative BMI and BPD/DS. Although nutritional deficiencies and postoperative complications are common, patient satisfaction remains high.

Randomized double-blinded trial of laparoscopic gastric imbrication v laparoscopic sleeve gastrectomy at a single Indian institution

BACKGROUND

Currently, there is a debate whether the laparoscopic gastric imbrication (LGI) offers similar weight loss when compared to the laparoscopic sleeve gastrectomy (LSG). On the surface, they seem to offer similar-sized stomachs after the procedures are performed. We chose to perform a randomized double-blinded trial to see if similar-sized pouches result in similar types of weight loss. Our belief was that sleeve gastrectomy would offer at least a 10% better weight loss over a 3-year period.

METHODS

Thirty patients were randomized to one of two arms. The patients and the third party administrator following the patients were blinded as to which procedure was chosen. The surgeon had full knowledge of the patients' surgery throughout the treatment. The decision of which arm to place them was made by a single employee of the third party administrator and not shared with the employees following the patients. Patients were then followed for 3 years.

RESULTS

There were no differences in weight, age, or BMI preoperatively. There were no differences between the two groups at any follow-up time point from 6 months to 3 years. Follow-up was 100%.

CONCLUSION

Due to the large standard deviations present in both groups, there was no statistical difference between either of the groups in terms of weight loss.

Metabolic changes induced by the biliopancreatic diversion in diet-induced obesity in male rats: the contributions of sleeve gastrectomy and duodenal switch

The mechanisms underlying the body weight and fat loss after the biliopancreatic diversion with duodenal switch (BPD/DS) remain to be fully delineated. The aim of this study was to examine the contributions of the two main components of BPD/DS, namely sleeve gastrectomy (SG) and duodenal switch (DS), on energy balance changes in rats rendered obese with a high-fat (HF) diet. Three different bariatric procedures (BPD/DS, SG, and DS) and three sham surgeries were performed in male Wistar rats. Sham-operated animals fed HF were either fed ad libitum (Sham HF) or pair weighed (Sham HF PW) by food restriction to the BPD/DS rats. A group of sham-operated rats was kept on standard chow and served as normal diet control (Sham Chow). All three bariatric surgeries resulted in a transient reduction in food intake. SG per se induced a delay in body weight gain. BPD/DS and DS led to a noticeable gut malabsorption and a reduction in body weight and fat gains along with significant elevations in plasma levels of glucagon-like peptide-1(7-36) and peptide YY. BPD/DS and DS elevated energy expenditure above that of Sham HF PW during the dark phase. However, they reduced the volume, oxidative metabolism, and expression of thermogenic genes in interscapular brown adipose tissue. Altogether the results of this study suggest that the DS component of the BPD/DS, which led to a reduction in digestible energy intake while sustaining energy expenditure, plays a key role in the improvement in the metabolic profile led by BPD/DS in rats fed a HF diet.

Re-embodying eating: patients' experiences 5 years after bariatric surgery

Health experts advise and expect patients to eat healthily after bariatric surgery. For patients, difficulties with eating might have been a long-standing, problematic part of life-a part that is not necessarily healed by surgery. Empirical research on patients' experiences of eating practices after bariatric surgery is lacking. Aiming to contribute to the development of clinical practice, we explored meanings attached to eating in the long term and sought descriptions of change and bodily sensations. We interviewed 14 patients at least 5 years after bariatric surgery. The surgical restriction forced changes in the way patients sensed their own body in eating, but the uncertainty related to maintaining weight loss in the long term remained. Meanings attached to eating transcended food as choices situated in a nourishment and health perspective, and were not necessarily changed. Eating was an existential and embodied practice, which remained an ambiguous and sensitive matter after surgery.

Preserve common limb in duodenal-jejunal bypass surgery benefits rats with type 2-like diabetes

BACKGROUND

In order to understand the underlying mechanisms by which weight loss surgeries improve metabolic profiles in type 2 diabetes mellitus (T2DM) patients and to evaluate the relevance of the length of the common limb in modulating various aspects of metabolism, we performed regular duodenal-jejunal bypass (DJB) and long-limb DJB (LL-DJB) surgeries in Goto-Kakizaki (GK) rats and compared their effects on glycemic control.

METHODS

Male GK rats at 12 weeks of age were used for this study. Body weight, food intake, fasting glucose, glucagon-like peptide-1 (GLP-1) level, glucose tolerance, insulin sensitivity, cholesterol and triglycerides levels, and fecal energy content were monitored for 26 weeks after the two types of surgeries.

RESULTS

We performed systematic analyses on GK rats after DJB or long-limb surgeries. Both procedures prevented body weight gain, reduced blood glucose and lipid levels, increased GLP-1 levels, and led to better insulin sensitivity. In general, LL-DJB displayed better effects than DJB, except that both surgeries caused similar increase in GLP-1 levels.

CONCLUSIONS

Both DJB and LL-DJB surgeries triggered beneficial effects in GK rats. LL-DJB showed better outcomes than DJB, which may be due to reduced food intake and higher fecal energy content. This indicates that the length of the common limb could influence metabolic profiles of surgery recipients.

Nutrition and metabolic support recommendations for the bariatric patient

Managing the metabolic needs of the patient with obesity is a challenge unto itself without the added demands of accounting for an altered gastrointestinal tract. Nevertheless, with about 200,000 bariatric procedures being performed annually in the United States, clinicians must be prepared to manage the critically ill bariatric surgery patient. This article reviews the recent literature relating to nutrient needs and metabolic support for the bariatric patient. Bariatric patients are at risk for several micronutrient deficiencies, including vitamins D and B₁₂, calcium, and iron; some bariatric procedures affect macronutrient needs as well. Literature on nutrition support guidelines for the bariatric population is limited. However, with an understanding of the anatomical and physiological effects of bariatric surgery, recent guidelines for critically ill patients with obesity can be applied to the bariatric surgery population. The unique needs of the bariatric population, such as susceptibility to micronutrient deficiencies and specialized access routes, must be considered to provide safe and efficacious nutrition support. Further research is necessary to develop specific nutrition support recommendations for the bariatric population.

Patients at risk for trace element deficiencies: bariatric surgery

Obesity is a worldwide epidemic associated with diseases such as diabetes mellitus and cardiovascular disease. Current methods for weight loss are not very effective, particularly for those with morbid obesity. Surgical therapy may be recommended for those with a BMI≥40kg/m(2), or BMI≥35kg/m(2) with co-morbidities. This therapy can produce significant weight loss and improve/resolve co-morbidities including hypertension and hyperlipidemia. Yet successes may be tempered by adverse effects on trace element absorption and status. A PubMed literature search identified studies from January 1980 to February 2013 for inclusion in a meta-analysis. Publications that contained keywords 'bariatric surgery or gastric bypass,' 'trace element or mineral or zinc or iron or copper or iodine or manganese', and 'absorption or status or rate or level' were identified. Inclusion criteria were human markers that reflect changes in trace element status before and after bariatric surgery. The meta-analysis found a decrease in blood copper, zinc, hemoglobin, as well as an increase in iron, regardless of the type of surgery. The pooled effect sizes and 95% confidence intervals were 0.17 and -0.09 to 0.43 for plasma/serum iron (p=0.20); -0.49 and -0.67 to -0.31 for blood hemoglobin (p=0.00); -0.47 and -0.90 to -0.05 for plasma/serum copper (p=0.03); -0.77 and -1.20 to -0.35 for plasma/serum zinc (p=0.00). Differences in levels of these minerals pre- and post-surgery may have been influenced by the time period after surgery, a pre-existing deficiency, type and dose of vitamin-mineral supplements, and malabsorption due to elimination of parts of the gastrointestinal tract.

Intestinal sweet-sensing pathways and metabolic changes after Roux-en-Y gastric bypass surgery

Studies suggest that improvements in type 2 diabetes (T2D) post- Roux-en-Y gastric bypass (RYGB) surgery are attributable to decreased intestinal glucose absorption capacity mediated by exclusion of sweet taste-sensing pathways in isolated proximal bowel. We probed these pathways in rat models that had undergone RYGB with catheter placement in the biliopancreatic (BP) limb to permit post-RYGB exposure of isolated bowel to sweet taste stimulants. Lean Sprague Dawley (n = 13) and obese Zucker diabetic fatty rats (n = 15) underwent RYGB with BP catheter placement. On postoperative day 11 (POD 11), rats received catheter infusions of saccharin [sweet taste receptor (T1R2/3) agonist] or saline (control). Jejunum was analyzed for changes in glucose transporter/sensor mRNA expression and functional sodium-glucose transporter 1 (SGLT1)-mediated glucose uptake. Saccharin infusion did not alter glucose uptake in the Roux limb of RYGB rats. Intestinal expression of the glucose sensor T1R2 and transporters (SGLT1, glucose transporter 2) was similar in saccharin- vs. saline-infused rats of both strains. However, the abundance of SGLT3b mRNA, a putative glucose sensor, was higher in the common limb vs. BP/Roux limb in both strains of bypassed rats and was significantly decreased in the Roux limb after saccharin infusion. We concluded that failure of BP limb exposure to saccharin to increase Roux limb glucose uptake suggests that isolation of T1R2/3 is unlikely to be involved in metabolic benefits of RYGB, as restimulation failed to reverse changes in intestinal glucose absorption capacity. The altered expression pattern of SGLT3 after RYGB warrants further investigation of its potential involvement in resolution of T2D after RYGB.

Malabsorption plays a major role in the effects of the biliopancreatic diversion with duodenal switch on energy metabolism in rats

BACKGROUND

The mechanisms underlying the metabolic benefits of the biliopancreatic diversion with duodenal switch (BPD/DS) have not been clarified. The objective of this study was to investigate the metabolic roles of sleeve gastrectomy (SG) and duodenal switch (DS) as main surgical components of BPD/DS.

METHODS

BPD/DS, SG, and DS surgeries were performed on chow-fed nonobese Wistar rats. Weight and energy intake were recorded during 8 postsurgical weeks. Glucagon-like peptide 1 (GLP-1), peptide tyrosine-tyrosine (PYY), glucose-dependent insulinotropic peptide, and ghrelin were measured pre- and postprandially at weeks 3 and 8, after surgery. Body composition, muscle, liver, and adipose tissue weights were measured. Gut morphometry and the presence and distribution of GLP-1 and PYY (L-cells) in the gut were determined using histochemical techniques.

RESULTS

Compared with sham, BPD/DS and DS led to significant reductions in weight gain, percentage of fat, and adipose tissue weight. These effects were accompanied by a reduction in digestible energy intake associated with fecal energy loss due to DS. BPD/DS and DS produced intestinal hypertrophy, as well as higher plasma GLP-1 and PYY in both fasted and refed states. It is noteworthy that none of those alterations were observed after SG, which nonetheless led to transient postoperative reduction in gross energy intake and weight. Similar to BPD/DS, SG alone produced a reduced meal size and an enhanced postprandial depression of plasma ghrelin.

CONCLUSION

BPD/DS results in metabolic benefits, which appear largely caused by food malabsorption due to DS. The elevation of anorectic GLP-1 and PYY are additional consequences of DS, which, together with malabsorption, could promote the metabolic benefits of BPD/DS.

Effect of Bariatric Surgery on Hypertension

Purpose: Obesity is a growing epidemic leading to worldwide public health concerns. Bariatric surgery is an option for patients with a body mass index (BMI) >40 kg/m2 or BMI of >35 kg/m2 with serious comorbid conditions. This meta-analysis examines the effect of bariatric surgery on the improvement or resolution of hypertension. Methods: Two independent investigators conducted a literature search of PubMed (1990-2013) and Cochrane databases using the terms bariatric surgery and hypertension to identify appropriate human adult studies published in English. Studies were included if they reported the number of patients with hypertension prior to undergoing any bariatric surgery procedure and whether the hypertension improved or resolved postsurgery. The number of patients with hypertension and their response rates were extracted and analyzed using RevMan 5.2.5. Results: In all, 31 prospective and 26 retrospective studies met all criteria. The types of bariatric surgery performed included Roux-en-Y, gastric banding, laparoscopic adjustable gastric banding, vertical gastric banding, sleeve gastrectomy, duodenal switch, and biliopancreatic diversion. The time to first follow-up after surgery varied from 1 week to 7 years. Of the 57 studies, 32 reported improvement of hypertension in 32 628 of 51 241 patients (odds ratio [OR] = 13.24; 95% CI = 7.73, 22.68; P < 0.00001); 46 studies reported the resolution of hypertension in 24 902 of 49 844 patients (OR = 1.70; 95% CI = 1.13, 2.58; P = 0.01). A random-effects model was used because the heterogeneity between the studies was high ( I2 = 97%). Conclusion: The results of this meta-analysis indicate that patients who undergo bariatric surgery experience improvement and resolution of their hypertension.

Biliopancreatic diversion: the effectiveness of duodenal switch and its limitations

The prevalence of morbidly obese individuals is rising rapidly. Being overweight predisposes patients to multiple serious medical comorbidities including type two diabetes (T2DM), hypertension, dyslipidemia, and obstructive sleep apnea. Lifestyle modifications including diet and exercise produce modest weight reduction and bariatric surgery is the only evidence-based intervention with sustainable results. Biliopancreatic diversion (BPD) produces the most significant weight loss with amelioration of many obesity-related comorbidities compared to other bariatric surgeries; however perioperative morbidity and mortality associated with this surgery are not insignificant; additionally long-term complications including undesirable gastrointestinal side effects and metabolic derangements cannot be ignored. The overall quality of evidence in the literature is low with a lack of randomized control trials, a preponderance of uncontrolled series, and small sample sizes in the studies available. Additionally, when assessing remission of comorbidities, definitions are unclear and variable. In this review we explore the pros and cons of BPD, a less well known and perhaps underutilized bariatric procedure.