Prevention and treatment of nutritional complications after bariatric surgery

Hope for the best, but prepare for the worst - Diagnostic accuracy of the American College of Surgeons National Surgical Quality Improvement Program - Risk model for patients undergoing abdominoplasty after massive weight loss - Results from a Retrospective Cohort Study

Background

This study aimed to validate the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) risk calculator for predicting outcomes in patients undergoing abdominoplasty after massive weight loss.

Methods

Patients' characteristics, pre-existing comorbidities and adverse outcomes in our department from 2013 to 2023 were collected retrospectively. Adverse events were defined according to ACS-NSQIP standards and predicted risks were calculated manually using the ACS-NSQIP risk calculator. Binary logistic regression and the Brier score were used to assess the diagnostic accuracy of the model.

Results

Among the 337 individuals who underwent abdominoplasty, 251 had achieved significant weight loss before surgery. After excluding 46 cases due to incomplete data, 205 cases remained for analysis. There were 20% cases of serious complications, 26.3% of some complications, 10.2% of readmissions, 18.8% returned to the operating theatre, 15.6% of surgical site infections and 0.5% each of pneumonia and venous thromboembolism. Although the calculator predicted a 1.5% discharge rate to nursing or rehabilitation facilities and a 0.1% rate of sepsis, neither outcome was observed. Elevated American Society of Anesthesiologists (ASA) status was significantly associated with a higher complication rate, except for surgical site infections (SSI) (p = 0.06). Additionally, an elevated Body Mass Index (BMI) before post-bariatric surgery and a higher resection weight were both associated with increased rates of return to the operating theatre (p = 0.01) and serious complications (p = 0.01). Predicted complication rates (0.1%-8.6%) underestimated actual complication rates (0.5%-26.3%). The Brier scores did not differ significantly from the null model for any outcomes except for general complications (p = 0.001) and logistic regression models demonstrated low sensitivity (0.0-9.8%) and weak odds ratios (1.28-1.46), indicating limited reliability.

Conclusion

The ACS-NSQIP risk calculator does not reliably predict adverse outcomes in this patient cohort.

Current Clinical Practice Guidelines for Nutritional Screening Before and After Sleeve Gastrectomy and Roux-En-Y Gastric Bypass: A Scoping Review

INTRODUCTION

Long-term data indicate that patients who underwent metabolic bariatric surgery have a higher risk of developing nutritional complications. Therefore, it is of utmost importance to monitor their nutritional status.

METHODS

A scoping literature search was conducted in MEDLINE, EMBASE, CINAHL, and TRIP database to identify clinical practice guidelines for nutritional screening before and after metabolic bariatric surgery from learned societies. For full coverage, all websites of learned societies affiliated with the World Obesity Federation were searched. Clinical practice guidelines were eligible if they contained recommendations for nutritional screening before and after sleeve gastrectomy or Roux-en-Y gastric bypass. Content was screened by two reviewers for timing, biochemical markers and cut-off values, and biochemical assays for nutritional screening.

RESULTS

Nine eligible clinical practice guidelines co-authored by 26 learned societies were identified. All guidelines provided recommendations for both bariatric procedures except for one. Majority of guidelines endorsed nutritional screening before surgery and at 3, 6, 12, and 24 months after surgery, and annually thereafter. Pre- and postoperative screening recommendations were available for iron, vitamin B12, folate, calcium and vitamin D, but in a lesser extent for vitamin A, vitamin E, vitamin K, zinc, vitamin B1, copper and magnesium. Two clinical practice guidelines provided cut-off values for the diagnosis of nutritional deficiencies.

DISCUSSION

The clinical practice guidelines exhibited a high level of consistency for timing of screening, but not for the applied biochemical markers. Going forward, the primary focus should be on harmonizing recommendations for biochemical markers, and cut-off values.

The Impact of Cholecystectomy on Bile Reflux After One Anastomosis Gastric Bypass

BACKGROUND

Bile reflux (BR) is an issue after one anastomosis gastric bypass (OAGB). Cholecystectomy can increase BR in patients without a history of metabolic and bariatric surgery. We aimed to evaluate the effect of cholecystectomy on BR after OAGB.

METHODS

This prospective observational study was conducted between March 2017 and December 2022 including 34 matched adult individuals with a body mass index ≥ 40 kg/m2 or ≥ 35 in the presence of comorbidities and gallstone disease in preop evaluations who underwent primary OAGB including 17 patients who had undergone cholecystectomy simultaneously or after OAGB (OAGB + LC) and 17 patients without cholecystectomy (OAGB). All patients underwent evaluations for gastroesophageal reflux disease (GERD) and bile reflux (BR) using various methods including esophagogastroduodenoscopy (EGD), the GERD-Q questionnaire, and a hepatobiliary iminodiacetic acid (HIDA) scan.

RESULTS

Thirty-four patients were included in this study. BR into the esophagus was not detected in both groups. BR to the gastric pouch was observed in 4 patients (23.5%) of the OAGB group and 6 patients (35.3%) of the OAGB + LC group (P = 0.452). BR to gastric remnant was observed in 6 patients (one and five patients in OAGB and OAGB + LC groups respectively) (P = 0.072). There was no statistically significant difference between the two groups, although it was clinically significant.

CONCLUSION

Cholecystectomy after OAGB is not associated with a change in the rate of BR in the gastric pouch but increases the incidence of BR into gastric remnant that may be harmful in the long term.

Liraglutide modulates lipid metabolism via ZBTB20-LPL pathway

OBJECTIVE

To investigate the mechanism of liraglutide affecting lipid metabolism by regulating lipolysis and lipogenesis in cells and ob/ob mice.

METHODS

3 T3-L1 cells were treated with liraglutide in vitro, and differentially expressed genes were screened by RNA sequencing. Gene Ontology (GO) and KEGG (Kvoto Encyclopedia of Genes and Genomes) enrichment analyses identified target genes for lipid regulation of liraglutide. 3 T3-L1 preadipocytes were induced to differentiate into adipocytes using a "cocktail method". Western blot and immunofluorescence were used to detect the expression of target genes and the lipid regulatory effect of liraglutide. 3 T3-L1 preadipocytes were transfected with lentivirus overexpressing Zbtb20 to study its role in adipogenesis, and gene expression was analyzed by RT-qPCR and Western blot. In vivo, ob/ob mice were subcutaneously injected with liraglutide or saline for 4 weeks. Blood lipids, adipose tissue volume and adipocyte size were detected. Immunohistochemical analysis and RT-qPCR were used to detect the expression of target genes in adipose tissue.

RESULTS

Liraglutide reduced lipid droplets and TG levels and altered the expression of genes related to fatty acid metabolism, lipogenesis, fatty acid oxidation, and adipocyte browning. The results of PCR, Western blot and immunofluorescence confirmed that liraglutide could regulate the adipogenesis by downregulating the transcriptional suppressor ZBTB20, and overexpression of Zbtb20 inhibited the expression of LPL, the key enzyme for lipohydrolysis.

CONCLUSIONS

Liraglutide regulates lipid metabolism through ZBTB20-LPL pathway to reveal its molecular mechanism.

A Predictive Nomogram for the Occurrence of Gastroesophageal Reflux Disease After Sleeve Gastrectomy: A Study Based on Preoperative HERM

Purpose

Gastroesophageal reflux disease (GERD) is a common complication after laparoscopic sleeve gastrectomy (LSG); This study aimed to construct a model that can predict the incidence of GERD after LSG by exploring the correlation between the results of high-resolution esophageal manometry (HREM) and the incidence of GERD after LSG.

Patients and Methods

We collected the clinical data of patients who had undergone HREM before bariatric surgery from September 2013 to September 2019 at the bariatric center of our hospital. The Gerd-Q scores during the postoperative follow-up were collected to determine the incidence of GERD. A logistic regression analysis was performed to explore the correlation of the HREM results and general clinical data with the incidence of GERD after LSG.

Results

The percentage of synchronous contractions, lower esophageal sphincter (LES) resting pressure, and history of smoking were correlated with the development of GERD after LSG, with the history of smoking and percentage of synchronous contractions as risk factors and LES resting pressure as a protective factor. The training set showed an area under the ROC curve (AUC) of the nomogram model of 0.847. The validation set showed an AUC of 0.761. The decision and clinical impact curves showed a high clinical value for the prediction model.

Conclusion

The HREM results correlated with the development of GERD after LSG, with the percentage of synchronous contractions and LES resting pressure showing predictive value. Combined with the history of smoking, the predictive model showed a high confidence and clinical value.

Oral vitamin D supplementation for adults with obesity undergoing bariatric surgery

BACKGROUND

Vitamin D deficiency following bariatric surgery is common and is expected to be associated with a deleterious impact on the skeleton. However, the benefits of vitamin D supplementation and the optimal dose in this population is currently unknown. The available guidelines on the topic are derived from experts' opinions, and are not evidence based.

OBJECTIVES

To compare the effects of different doses of vitamin D supplementation (low dose (less than 600 international units (IU)/day), moderate dose (600 IU/day to 3500 IU/day), high dose (greater than 3500 IU/day)) to each other or to placebo in adults living with obesity undergoing bariatric surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, two trial registries, and the reference lists of systematic reviews, articles, and health technology assessment reports without language restrictions. The last search of all databases was 27 June 2023, except Embase, which we searched on 14 August 2015.

SELECTION CRITERIA

We included randomised controlled trials or controlled clinical trials on vitamin D supplementation comparing different doses or comparing vitamin D to placebo in people undergoing bariatric surgery.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Primary outcomes were fractures and adverse events. Secondary outcomes were vitamin D status, all-cause mortality, bone mineral change, secondary hyperparathyroidism, health-related quality of life, and muscle strength. We used GRADE to assess the certainty of the evidence for each outcome in each comparison.

MAIN RESULTS

We identified five trials with 314 participants. We included three trials in the quantitative analysis. Moderate-dose vitamin D compared to placebo One trial compared moderate-dose vitamin D (3200 IU/day) to placebo. Moderate-dose vitamin D, compared to placebo, may improve vitamin D status and may result in little to no difference in the achieved parathyroid hormone level (achieved 25-hydroxyvitamin D level: mean difference (MD) 13.60 ng/mL, 95% confidence interval (CI) 7.94 to 19.26; achieved parathyroid hormone level: -6.60 pg/mL, 95% CI -17.12 to 3.92; 1 study, 79 participants; low-certainty evidence). The trial reported no adverse events in the moderate-dose vitamin D arm, but did not provide any information on adverse events in the placebo arm. There were no data on fractures, all-cause mortality, bone density change, health-related quality of life, and muscle strength. High-dose vitamin D compared to moderate-dose vitamin D Two trials in Roux-en-Y gastric bypass compared moderate-dose (equivalent dose 800 IU/day to 2000 IU/day) to high-dose (equivalent dose 5000 IU/day to 7943 IU/day) vitamin D. The evidence of high-dose vitamin D on adverse events is very uncertain (risk ratio (RR) 5.18, 95% CI 0.23 to 116.56; 2 studies, 81 participants; very low-certainty evidence). High-dose vitamin D may increase 25-hydroxyvitamin D levels compared to a moderate dose at 12 months, but the evidence is very uncertain (MD 15.55 ng/mL, 95% CI 3.50 to 27.61; I2 = 62%; 2 studies, 73 participants; very low-certainty evidence). High-dose vitamin D may have little to no effect on parathyroid hormone levels compared to a moderate dose at 12 months, but the evidence is very uncertain (MD 2.15 pg/mL, 95% CI -21.31 to 17.01; I2 = 0%; 2 studies, 72 participants; very low-certainty evidence). High-dose vitamin D may have little to no effect on mortality and bone mineral density at the lumbar spine, hip, and forearm, but the evidence is very uncertain. There were no data on fractures, health-related quality of life, or muscle strength.

AUTHORS' CONCLUSIONS

No trials reported on fractures and the evidence available on adverse events is scarce. Moderate-dose vitamin D may improve vitamin D status and may result in little to no improvement in parathyroid hormone levels compared with placebo. High-dose vitamin D supplementation (greater than 3500 IU/day) may increase 25-hydroxyvitamin D levels, and may have little to no effect on parathyroid hormone levels, compared to a moderate dose, but the evidence for both is very uncertain. The currently available limited evidence may not have a significant impact on practice. Further studies are needed to explore the impact of vitamin D supplementation on fractures, adverse events, and musculoskeletal parameters in people undergoing bariatric surgery.

The Future of Endobariatrics: Bridging the Gap

With the growing global burden of obesity, the field of endobariatrics has emerged as a promising alternative, filling the void between lifestyle interventions with modest efficacy and more invasive surgical procedures. This article explores the latest advancements in endobariatric therapies, encompassing endoscopic sleeve gastroplasty (ESG), intragastric balloons (IGB), endoscopic metabolic therapies, and promising pharmacologic and surgical combination approaches that integrate multiple therapeutic modalities. It also outlines the critical factors and strategic considerations necessary for the successful integration of endobariatric interventions into clinical practice.

Laparoscopic small bowel length measurement: nonassociative nature of total small bowel length with anthropometric and clinical characteristics in patients undergoing bariatric surgery

BACKGROUND

Small bowel length (SBL) may have an impact on the outcomes of bariatric surgeries, but it can be difficult to make a direct association between SBL and the safety and outcome of bariatric surgeries.

OBJECTIVES

To address this issue, we set out to devise a predictive model for SBL determination based on clinical and anthropometric variables.

SETTING

An academic tertiary medical center.

METHODS

Anthropometric and clinical data, including age, sex, height, weight, and past medical history, were collected upon enrollment. SBL was measured twice during the surgery using a marked grasper. In all cases, measurements were carried out by a single surgeon. To create a predictive model, a 2-step approach was employed. In the first step, linear regression was used to determine influential variables. In the second step, all variables with a P value < .2 were entered into a multivariate regression model.

RESULTS

Overall, 961 bariatric candidates were enrolled. The mean age of the participants was 40.08 years, and 77.5% (n = 745) were female. The mean SBL was 748.90 centimeters. There was a weak but statistically significant positive correlation between SBL with both weight and height. Our univariate linear model determined only anthropometric parameters as a predictor of SBL. The multivariate model also yielded that none of the entered parameters were shown to be accurate predictors of SBL. Moreover, only 4.3% of variances were explainable by this model.

CONCLUSION

Although we found a weak positive association between height and SBL, this association lacked clinical practicality.

Effects of gastric bypass on the digestibility and postprandial metabolic fate of 15N dietary protein in rats

Roux-en-Y Gastric Bypass may be associated with an alteration of protein bioavailability in relation to intestinal remodeling. Our study aimed to test this hypothesis by Roux-en-Y Gastric Bypass. Diet-induced obese rats underwent Roux-en-Y Gastric Bypass surgery (RYGB rats) while a Sham-operated control group was used. All rats received a 15N-labeled protein meal 1 or 3 months after surgery and were euthanized 6h later. Protein digestibility, 15N recovered in organs and urea pool, fractional protein synthesis rate, and intestinal morphometry were assessed. Protein digestibility was similar in all groups (94.2±0.3%). The small intestine was hypertrophied in RYGB rats 1 month after surgery, weighing 9.1±0.2g vs. 7.0±0.3g in Sham rats (P = 0.003). Villus height and crypt depth were increased in the alimentary limb and ileum of RYGB rats. However, Roux-en-Y Gastric Bypass had no impact on the fractional synthesis rate. In the gastrointestinal tract, 15N retention only differed in the ileal mucosa and was higher in RYGB rats at 1 month (0.48±0.2% vs. 0.3±0.09%, P = 0.03). 15N recovery from the liver, muscle, and skin was lower in RYGB rats at 1 month. 15N recovery from urinary and plasma urea was higher in RYGB rats at both times, resulting in increased total deamination (13.2±0.9% vs. 10.1±0.5%, P<0.01). This study showed that Roux-en-Y Gastric Bypass did not affect protein digestibility. Dietary nitrogen sequestration was transitorily and moderately diminished in several organs. This was associated with a sustained elevation of postprandial deamination after Roux-en-Y Gastric Bypass, whose mechanisms merit further studies.

Completeness of intervention reporting of nutrition-focused weight management interventions adjunct to metabolic and bariatric surgery: effect of the TIDieR checklist

Nutrition-focused interventions are essential to optimize the bariatric care process and improve health and weight outcomes over time. Clear and detailed reporting of these interventions in research reports is crucial for understanding and applying the findings effectively in clinical practice and research replication. Given the importance of reporting transparency in research, this study aimed to use the Template for Intervention Description and Replication (TIDieR) checklist to evaluate the completeness of intervention reporting in nutritional weight management interventions adjunct to metabolic and bariatric surgery (MBS). The secondary aim was to examine the factors associated with better reporting. A literature search in PubMed, PsychINFO, EMBASE, Scopus, and the Cochrane Controlled Register of Trials was conducted to include randomized controlled trials (RCT), quasi-RCTs and parallel group trials. A total of 22 trials were included in the final analysis. Among the TIDieR 12 items, 6.6 ± 1.9 items were fully reported by all studies. None of the studies completely reported all intervention descriptors. The main areas where reporting required improvement were providing adequate details of the materials and procedures of the interventions, intervention personalization, and intervention modifications during the study. The quality of intervention reporting remained the same after vs. before the release of the TIDieR guidelines. Receiving funds from industrial organizations (p = 0.02) and having the study recorded within a registry platform (p = 0.08) were associated with better intervention reporting. Nutritional weight management interventions in MBS care are still below the desirable standards for reporting. The present study highlights the need to improve adequate reporting of such interventions, which would allow for greater replicability, evaluation through evidence synthesis studies, and transferability into clinical practice.

Timing Matters: Optimizing the Timeframe for Preoperative Weight Loss to Mitigate Postoperative Infection Risks in Total Knee Arthroplasty

BACKGROUND

We explore the incidence of periprosthetic infections post-total knee arthroplasty (TKA) in morbidly obese patients who achieved weight loss. Current American Academy of Orthopaedic Surgeons guidelines suggest a preoperative body mass index (BMI) below 40 for TKA. This study assesses infection risks in patients initially who had a BMI of 40-50 who reduced their BMI to under 35 at varying intervals prior to surgery.

METHODS

We reviewed a national, all-payer database, PearlDiver, for patients undergoing primary TKA. Patients were stratified based on initial BMI of 40 to 50 and reduction of BMI to less than 35 at 3 months (n = 1,932), 3 to 6 months (n = 794), 6 to 9 months (n = 2,233), and 9 to 12 months (n = 1,194) prior to TKA, as well as patients who had a BMI between 40 to 50 (n = 41,632) on the day of surgery. The nonobese group comprised of patients who had a BMI between 20 and 30 (n = 33,294). Multivariate analyses were performed at one-year follow-up.

RESULTS

We found an increased risk of PJI for patients who had achieved BMI reduction less than nine months prior to TKA, compared to the BMI 20 to 30 cohort at the one-year follow-up (P < .001). Patients who achieved BMI reduction nine to twelve months prior to TKA showed no significant difference in PJI risk compared to the matching nonobese cohort at one-year follow-up (P = .400).

CONCLUSIONS

In conclusion, our results suggest that weight loss should be achieved at least nine months before TKA to decrease infection risks. These findings have significant implications for surgical considerations in obese patients undergoing TKA.

Anemia Status Changes Among Patients With Obesity Following Bariatric Surgery

Objective This study aims to investigate trends in anemia severity among patients with pre-existing anemia who underwent bariatric surgery due to obesity. It also examines how different bariatric surgery techniques impact anemia outcomes. Methods This prospective study included 280 patients aged 18 to 65 with obesity who underwent bariatric surgery. The patients were categorized into three groups based on the type of surgery: sleeve gastrectomy, one-anastomosis gastric bypass, and Roux-en-Y gastric bypass. Anemia severity was evaluated over a 12-month follow-up period. Chi-square tests were used to assess the homogeneity of baseline factors among the groups, and McNemar tests along with generalized estimating equations were used to compare anemia outcomes. Results Before surgery, the rates of moderate anemia across the three surgical groups ranged from 18.2% to 22.4%, with no cases of severe anemia observed. There was no significant difference among the groups (p=0.949). During the 12-month follow-up, the odds ratio for reducing anemia severity in the sleeve gastrectomy and Roux-en-Y gastric bypass groups were 2.13 and 1.91, respectively, compared to the one-anastomosis gastric bypass group. Additionally, the odds ratio for reducing anemia severity in patients with hypothyroidism was 1.84 compared to those without hypothyroidism. Conclusion The choice of bariatric surgery technique significantly affects anemia outcomes, with sleeve gastrectomy showing a higher success rate in reducing anemia severity. The role of hypothyroidism in anemia management also appears to be significant.

Metabolic surgery and oral health: A register-based study

OBJECTIVE

The impact of weight loss surgery on oral health is not clear. The aim of the present study was to investigate its impact on the risk for dental interventions.

MATERIALS AND METHODS

All adults who underwent metabolic surgery in Sweden between January 1, 2009 and December 31, 2018 were identified in the Scandinavian Obesity Surgery Registry (SOReg; n = 53,643). A control cohort from the general population was created, matched 10:1 on sex, age and place of residence (n = 536,430). All individuals were followed in the Swedish Dental Register regarding event rates for four types of dental intervention: restorative, endodontic and periodontal interventions, and tooth extractions.

RESULTS

The surgical cohort had increased interventional rates postoperatively regarding all studied outcomes except periodontal interventions. Dental interventions were more common in the surgical cohort both pre- and postoperatively. The difference between the groups increased markedly in the postoperative period. The between-group comparison postoperatively showed increased event rates for restorations (IRR 1.8; 95% CI 1.7-1.8), extractions (1.9; 95% CI 1.9-2.0) and endodontics (2.1; 95% CI 2.0-2.1).

CONCLUSION

The surgical intervention might cause a substantial negative impact on oral health. These results imply an important role for counselling metabolic surgery patients regarding preventive oral health measures.

The Impact of Preoperative Weight Loss Timing on Surgical Outcomes in Total Hip Arthroplasty

BACKGROUND

Elevated body mass index (BMI) increases surgical complications post-total hip arthroplasty (THA). However, the effects of rapid weight loss pre-THA remain unclear. This study evaluated patients who had initial BMIs between 40 and 50, and then achieved a BMI under 35 at various intervals before their THA. Comparisons were made with consistent obese and nonobese groups to understand potential complications.

METHODS

Using a national database, we categorized THA patients based on initial BMI and weight loss timing before the surgery. These were contrasted with those maintaining a steady BMI of 20 to 30 or 40 to 50. We monitored outcomes like periprosthetic joint infections (PJI), surgical site infections (SSI), and noninfectious revisions for 2 years postsurgery, incorporating demographic considerations. Statistical analyses utilized Chi-square tests for categorical outcomes and Student's t-tests for continuous variables.

RESULTS

Among patients who had a BMI of 45 to 50, weight loss 3 to 9 months presurgery increased PJI risks at 90 days (Odds Ratios [OR]: 2.15 to 5.22, P < .001). However, weight loss a year before the surgery lowered the PJI risk (OR: 0.14 to 0.27, P < .005). Constantly obese patients faced heightened PJI risks 1 to 2 years postsurgery (OR: 1.64 to 1.95, P < .015). Regarding SSI, risks increased with weight loss 3 to 9 months before surgery, but decreased when weight loss occurred a year earlier. In the BMI 40 to 45 group, weight loss 3 to 6 months presurgery showed higher PJI and SSI at 90 days (P < .001), with obese participants consistently at greater risk.

CONCLUSIONS

While high BMI poses THA risks, weight loss timing plays a crucial role in postoperative complications. Weight loss closer to the surgery (0 to 9 months) can heighten risks, but shedding weight a year in advance seems beneficial. Conversely, initiating weight loss approximately a year before surgery offers potential protective effects against postoperative issues. This highlights the importance of strategic weight management guidance for patients considering THA, ensuring optimal surgical results and reducing potential adverse outcomes.

Osteoarthritis in patients with obesity: The bariatric surgery impacts on its evolution

Obesity is one of the main modifiable risk factors for osteoarthritis (OA). Moreover, obesity is associated with greater pain intensity and functional limitation, but also with a significantly lower responder rate to intra-articular treatments. Consequently, an arthroplasty is indicated earlier and more frequently in patients with obesity. However, pain and functional symptoms improve slightly less after arthroplasty in patients with obesity, who display higher incidence of early and late complications following prosthetic surgery. Bariatric surgery (BS) has increased worldwide and is efficient to induce major and sustainable weight-loss. Importantly, BS significantly reduces pain and functional limitation in patients with symptomatic knee OA. Biomarkers analysis also revealed a decrease in catabolic factors and an increase in anabolic one after BS suggesting a structural protective effect in knee OA. Nevertheless, the impact of BS prior to arthroplasty remains unclear. BS seems to decrease short- and mid-term complications such as infections or thrombosis. However, BS does not appear to modify long-term complications rate, and may even increase it, especially revisions and infections. Although few studies have compared the symptomatic and functional outcomes of joint replacement with or without BS, these are not significantly improved by prior BS. Despite these heterogeneous results, medico-economic studies found that BS prior to arthroplasty was cost-effective. To conclude, BS could significantly reduce the symptoms of OA and potentially slow its progression, but appears more disappointing in preventing long-term complications of arthroplasties and improving their functional results.

Racial disparities in selected micronutrient deficiencies after bariatric surgery: A systematic review

BACKGROUND

Bariatric surgery has been associated with numerous micronutrient deficiencies. Several observational studies have found that these deficiencies are more common in racially/ethnically minoritized patients.

OBJECTIVES

To conduct a systematic review to investigate whether racially/ethnically minoritized patients experience worse nutritional outcomes after bariatric surgery.

SETTING

University of Wisconsin-Madison.

METHODS

PubMed, CINAHL, PsychINFO, and Cochrane databases were queried. We searched for manuscripts that reported micronutrient levels or conditions related to micronutrient deficiencies according to race/ethnicity (White, African American/Black, and Hispanic) after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between 2002 and 2022. Eleven micronutrients (vitamins A, B1 [thiamine], B12, D, E, K, calcium, copper, folate, iron, and zinc), and four conditions (anemia, bone loss, fractures, and hyperparathyroidism) were assessed.

RESULTS

Abstracts from 953 manuscripts were screened; 18 full-text manuscripts were reviewed for eligibility, and ten met the inclusion criteria. Compared to White patients, African Americans had a higher prevalence of thiamine, vitamin D, and vitamin A deficiencies. There were no differences in calcium and vitamin B12 deficiencies. The other six micronutrients were not assessed according to race/ethnicity. Hyperparathyroidism was more prevalent in African Americans than White patients in the three studies that evaluated it. The prevalence of fractures was mixed. Anemia and bone loss were not evaluated according to race/ethnicity.

CONCLUSIONS

Although the literature on micronutrient outcomes following bariatric surgery according to race/ethnicity is limited, African Americans appear to experience a higher prevalence of vitamin deficiencies and associated conditions. Qualitative and quantitative research to explore these disparities is warranted.

Development and complications of nutritional deficiencies after bariatric surgery

The clinical effectiveness of bariatric surgery has encouraged the use of bariatric procedures for the treatment of morbid obesity and its comorbidities, with sleeve gastrectomy and Roux-en-Y gastric bypass being the most common procedures. Notwithstanding its success, bariatric procedures are recognised to predispose the development of nutritional deficiencies. A framework is proposed that provides clarity regarding the immediate role of diet, the gastrointestinal tract and the medical state of the patient in the development of nutritional deficiencies after bariatric surgery, while highlighting different enabling resources that may contribute. Untreated, these nutritional deficiencies can progress in the short term into haematological, muscular and neurological complications and in the long term into skeletal complications. In this review, we explore the development of nutritional deficiencies after bariatric surgery through a newly developed conceptual framework. An in-depth understanding will enable the optimisation of the post-operative follow-up, including detecting clinical signs of complications, screening for laboratory abnormalities and treating nutritional deficiencies.

Bariatric Surgery and Gut-Brain-Axis Driven Alterations in Cognition and Inflammation

Obesity is associated with systemic inflammation, comorbidities like diabetes, cardiovascular disease and several cancers, cognitive decline and structural and functional brain changes. To treat, or potentially prevent these related comorbidities, individuals with obesity must achieve long-term sustainable weight loss. Often life style interventions, such as dieting and increased physical activity are not successful in achieving long-term weight loss. Meanwhile bariatric surgery has emerged as a safe and effective procedure to treat obesity. Bariatric surgery causes changes in physiological processes, but it is still not fully understood which exact mechanisms are involved. The successful weight loss after bariatric surgery might depend on changes in various energy regulating hormones, such as ghrelin, glucagon-like peptide-1 and peptide YY. Moreover, changes in microbiota composition and white adipose tissue functionality might play a role. Here, we review the effect of obesity on neuroendocrine effects, microbiota composition and adipose tissue and how these may affect inflammation, brain structure and cognition. Finally, we will discuss how these obesity-related changes may improve after bariatric surgery.

Go Big or Go Home: Obesity and Total Joint Arthroplasty

Obesity is highly prevalent, and it is expected to grow considerably in the United States. The association between obesity and an increased risk of complications following total joint arthroplasty (TJA) is widely accepted. Many believe that patients with body mass index (BMI) >40 have complications rates that may outweigh the benefits of surgery and should consider delaying it. However, the current literature on obesity and outcomes following TJA is observational, very heterogeneous, and full of confounding variables. BMI in isolation has several flaws and recent literature suggests shifting from an exclusively BMI <40 cutoff to considering 5 to 10% preoperative weight loss. BMI cutoffs to TJA may also restrict access to care to our most vulnerable, marginalized populations. Moreover, only roughly 20% of patients instructed to lose weight for surgery are successful and the practice of demanding mandatory weight loss needs to be reconsidered until convincing evidence exists that supports risk reduction as a result of preoperative weight loss. Obese patients can benefit greatly from this life-changing procedure. When addressing the potential difficulties and by optimizing preoperative assessment and intraoperative management, the surgery can be conducted safely. A multidisciplinary patient-centered approach with patient engagement, shared decision-making, and informed consent is recommended.

Changes in Urinary Iodine Levels Following Bariatric Surgery

OBJECTIVE

Obesity has become an epidemic in the United States. Although bariatric surgery can effectively achieve weight loss by altering the gastrointestinal tract, it commonly results in micronutrient deficiency, requiring supplementation. Iodine is an essential micronutrient for the synthesis of thyroid hormones. We aimed to investigate changes in urinary iodine concentrations (UIC) in patients following bariatric surgery.

METHODS

85 adults who underwent either laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass surgery were enrolled. At baseline and 3 months after surgery, we evaluated spot UIC and serum thyroid stimulating hormone (TSH), vitamin D, vitamin B12, ferritin, and folate levels. Participants provided a 24-hour diet recall for iodine-rich foods and information about multivitamin use at each time point.

RESULTS

There was a significant increase in median UIC (201 [120.0 - 288.5] vs 334.5 [236.3 - 740.3] μg/L; P < .001), a significant decrease in mean body mass index (44.0 ± 6.2 vs 35.8 ± 5.9; P < .001) and a significant decrease in TSH levels (1.5 [1.2 - 2.0] vs 1.1 [0.7 - 1.6] uIU/mL; P < .001) at 3 months postoperatively compared to baseline. Body mass index, UIC, and TSH levels before and after surgery did not differ based on the type of weight loss surgery.

CONCLUSION

In an iodine-sufficient area, bariatric surgery does not cause iodine deficiency nor clinically significant changes in thyroid function. Different surgical procedures with different anatomical alterations in the gastrointestinal tract do not significantly affect iodine status.

Impact of Medical and Surgical Obesity Treatment on Dental Caries: A 2-Year Prospective Cohort Study

The objective was to study the long-term effects on oral health of bariatric surgery compared with medical treatment of obesity. Swedish females with morbid obesity (n = 66; 18-35 years at baseline) were followed prospectively from before obesity treatment until 2 years after treatment. The main response variable was dental caries registered according to the ICDAS-II system. Possible confounding factors, such as sociodemographic characteristics, general health, oral health habits, and oral hygiene, were controlled for. The statistical methods included χ2 tests, Student's t tests, one-way ANOVA, Wilcoxon's nonparametric tests, and linear regression models. In the surgically treated patients (n = 40), a significant increase over time in enamel caries (mean increase 4.13 tooth surfaces ICDAS1-2), dentine caries (mean increase 2.18 tooth surfaces ICDAS3-6), and total caries (mean increase 6.30 tooth surfaces ICDAS1-6) was registered (all p < 0.001), which was not seen in the medically treated patients (n = 26). However, the difference between the treatment groups (surgical or medical) was only statistically significant for enamel caries (crude β 4.89, p = 0.003) and total caries (crude β 6.53, p < 0.001). The relationships were stable and independent of differences in confounders as socioeconomy, general health, and oral health behaviors. In conclusion, 2 years after obesity treatment, a significant increase in dental caries was registered in the surgically treated but not in the medically treated women. The dental service should intensify its preventive efforts in individuals undergoing obesity treatment.

Long-term effectiveness, outcomes and complications of bariatric surgery

Dietary imbalance and overeating can lead to an increasingly widespread disease - obesity. Aesthetic considerations aside, obesity is defined as an excess of adipose tissue that can lead to serious health problems and can predispose to a number of pathological changes and clinical diseases, including diabetes; hypertension; atherosclerosis; coronary artery disease and stroke; obstructive sleep apnea; depression; weight-related arthropathies and endometrial and breast cancer. A body weight 20% above ideal for age, gender and height is a severe health risk. Bariatric surgery is a set of surgical methods to treat morbid obesity when other treatments such as diet, increased physical activity, behavioral changes and drugs have failed. The two most common procedures currently used are sleeve gastrectomy and gastric bypass. This procedure has gained popularity recently and is generally considered safe and effective. Although current data show that perioperative mortality is low and better control of comorbidities and short-term complications is achieved, more randomized trials are needed to evaluate the long-term outcomes of bariatric procedures. This review aims to synthesize and summarize the growing evidence on the long-term effectiveness, outcomes and complications of bariatric surgery.

Nutritional Intervention for a Patient With Sleeve Gastrectomy

Bariatric surgery is the most effective treatment for sustained weight reduction, and it can result in substantial improvements in the severity of type 2 diabetes, metabolic syndrome, nonalcoholic fatty liver disease, and quality of life. However, sleeve gastrectomy, a weight loss surgery that removes two-thirds of the stomach, reduces appetite and nutrient absorption, impairing digestion and the absorption of nutrients like iron, vitamin B12, and protein-bound nutrients. This case study aims to demonstrate that patients undergoing sleeve gastrectomy require long-term and periodic monitoring of biochemical data, weight changes, and caloric and protein intake by a professional nutritionist to prevent malnutrition and nutritional deficiencies. In this case study, a 48-year-old woman was diagnosed with morbid obesity, hypertension, sleep apnea syndrome, and chronic gastritis. At initial evaluation, she was 160 cm tall and weighed 89 kg, with a body mass index of 34.8 kg/m2. At 1 postoperative year, she consumed 650 kcal and 25 g of protein per day, the percentage of excess weight loss was 141.1%, and body mass index was 21 kg/m2. Compared to preoperative levels, calcium and folic acid levels did not decrease after 1 postoperative year, but hemoglobin, ferritin, and vitamin B12 levels decreased. In conclusion, when patients experience rapid weight loss after sleeve gastrectomy, follow-up should be frequent and long. Dietary education should be conducted according to digestive symptoms, and oral nutritional supplements, including vitamins and minerals.

Long Biliopancreatic Limb Roux-En-Y Gastric Bypass Versus One-Anastomosis Gastric Bypass: a Randomized Controlled Study

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is the gold standard in bariatric surgery. The one-anastomosis gastric bypass (OAGB) procedure, first introduced by Dr. Rutledge, has demonstrated a 25% greater weight loss efficiency than the traditional Roux-en-Y gastric bypass (RYGB) procedure due to the substantially longer biliopancreatic limb (BPL).

AIM OF THE STUDY

The current work aimed to compare the outcomes of OAGB and long BPL RYGB regarding weight loss and comorbidity resolution.

PATIENTS AND METHODS

This randomized controlled trial was done at our institution between September 2019 and January 2021. Patients who were candidates for bariatric surgery were randomly and equally allocated to two groups. Group A underwent OAGB, while group B underwent long BPL RYGB. Patients were followed up for 6 months postoperatively.

RESULTS

This study included 62 patients equally allocated to OAGB or long BPL RYGB, with no dropouts during follow-up. At 6 months, there was no statistically significant difference between the two groups regarding postoperative BMI (P = 0.313) and the EBWL (P = 0.238). There was comparable remission of diabetes mellitus (P = 0.708), hypertension (P = 0.999), OSA (P = 0.999), joint pain (P = 0.999), and low back pain (P = 0.999). Seven patients in the OAGB group experienced reflux symptoms (P = 0.011), which were managed by proton pump inhibitors.

CONCLUSION

Extending the BPL in RYGB provides weight loss and comorbidity remission comparable to that of OAGB. Some OAGB-related reflux cases remain a concern. However, they were sufficiently controlled with PPIs. Due to OAGB superior technical simplicity, long BPL RYGB should be preserved for cases whom are more risky for bile reflux.

Low dose of liraglutide combined with metformin leads to a significant weight loss in Chinese Han women with polycystic ovary syndrome: a retrospective study

BACKGROUND

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder with complex pathophysiological mechanism. It is reported that even a modest weight loss of 5-10% substantially may improve the reproductive and metabolic profile. This study aims to assess the efficacy of the low dose of liraglutide (0.6 mg QD) combined with metformin (0.85 mg BID) in weight loss in Chinese Han women with PCOS.

METHODS

We included clinical data of 102 obese/overweight (≥18 years, body mass index ≥28 kg/m² or ≥24 kg/m²) women who were diagnosed with PCOS from October 2016 to March 2018 in Wuhan Union Hospital initially. They were treated with dinae-35, low dose of liraglutide (0.6 mg QD) and metformin (0.85 mg BID) for 12 weeks. The demographic and clinical data were retrieved retrospectively, and weight loss was the main outcome measure. Student's paired t-test and Wilcoxon rank sum test were used to compare the differences before and after therapy, p < 0.05 was considered statistically significant.

RESULTS

Participants(n = 102)had lost a mean of 7.20 ± 3.42 kg of body weight (95%CI: 6.55-7.86, p < 0.001), and the mean reduction of BMI was 2.87 ± 1.36 kg/m² (95%CI: 0.02-0.27, p < 0.001). A total of 88.24% of participants lost more than 5% of their body weight.

CONCLUSION

The combination of low dose of liraglutide and metformin was associated with significant reduction of body weight in Chinese Han women with PCOS. Additionally, a larger randomized double-blind multicenter controlled clinical trial is needed to confirm that.

TRIAL REGISTRATION

The study was registered on http://www.chictr.org.cn as ChiCTR1900024384.

360-Degree Perspectives on Obesity

Alarming statistics show that the number of people affected by excessive weight has surpassed 2 billion, representing approximately 30% of the world's population. The aim of this review is to provide a comprehensive overview of one of the most serious public health problems, considering that obesity requires an integrative approach that takes into account its complex etiology, including genetic, environmental, and lifestyle factors. Only an understanding of the connections between the many contributors to obesity and the synergy between treatment interventions can ensure satisfactory outcomes in reducing obesity. Mechanisms such as oxidative stress, chronic inflammation, and dysbiosis play a crucial role in the pathogenesis of obesity and its associated complications. Compounding factors such as the deleterious effects of stress, the novel challenge posed by the obesogenic digital (food) environment, and the stigma associated with obesity should not be overlooked. Preclinical research in animal models has been instrumental in elucidating these mechanisms, and translation into clinical practice has provided promising therapeutic options, including epigenetic approaches, pharmacotherapy, and bariatric surgery. However, more studies are necessary to discover new compounds that target key metabolic pathways, innovative ways to deliver the drugs, the optimal combinations of lifestyle interventions with allopathic treatments, and, last but not least, emerging biological markers for effective monitoring. With each passing day, the obesity crisis tightens its grip, threatening not only individual lives but also burdening healthcare systems and societies at large. It is high time we took action as we confront the urgent imperative to address this escalating global health challenge head-on.

Anaemia in patients with self-reported use of iron supplements in the BAriatric surgery SUbstitution and nutrition study: A prospective cohort study

BACKGROUND AND AIMS

After bariatric surgery, micronutrient deficiencies may lead to anaemia. To prevent post-operative deficiencies, patients are recommended lifelong micronutrient supplementation. Studies investigating the effectiveness of supplementation to prevent anaemia after bariatric surgery are scarce. This study aimed to investigate the relationship between nutritional deficiencies and anaemia in patients who report use of supplementation two years after bariatric surgery versus patients who do not.

METHODS AND RESULTS

Obese (BMI≥35 kg/m²) individuals (n = 971) were recruited at Sahlgrenska University Hospital in Gothenburg, Sweden between 2015 and 2017. The interventions were Roux-en-Y gastric bypass (RYGB), n = 382, sleeve gastrectomy (SG), n = 201, or medical treatment (MT), n = 388. Blood samples and self-reported data on supplements were collected at baseline and two years post treatment. Anaemia was defined as haemoglobin <120 g/L for females and <130 g/L for males. Standard statistical methods, including a logistic regression model and a machine learning algorithm, were used to analyse data. The frequency of anaemia increased from baseline in patients treated with RYGB (3·0% vs 10·5%; p < 0·05). Neither iron-dependent biochemistry nor frequency of anaemia differed between participants who reported use of iron supplements and those who did not at the two-year follow-up. Low preoperative level of haemoglobin and high postoperative percent excessive BMI loss increased the predicted probability of anaemia two years after surgery.

CONCLUSION

The results from this study indicate that iron deficiency or anaemia may not be prevented by substitutional treatment per current guidelines after bariatric surgery and highlights there is reason to ensure adequate preoperative micronutrient levels.

TRIAL REGISTRATION

March 03, 2015; NCT03152617.

Effect of sleeve gastrectomy and Roux-en-Y gastric bypass on gastrointestinal physiology

BACKGROUND

Knowledge regarding the gastrointestinal physiology after sleeve gastrectomy and Roux-en-Y gastric bypass is urgently needed to understand, prevent and treat the nutritional and pharmacological complications of bariatric surgery.

AIM

To investigate the effect of sleeve gastrectomy and Roux-en-Y gastric bypass on gastrointestinal motility (e.g., transit and pressure), pH, and intestinal bile acid concentration.

MATERIAL AND METHODS

An exploratory cross-sectional study was performed in six participants living with obesity, six participants who underwent sleeve gastrectomy, and six participants who underwent Roux-en-Y gastric bypass. During the first visit, a wireless motility capsule (SmartPill©) was ingested after an overnight fast to measure gastrointestinal transit, pH, and pressure. During the second visit, a gastric emptying scintigraphy test of a nutritional drink labeled with ^99mTc-colloid by a dual-head SPECT gamma camera was performed to measure gastric emptying half-time (GET_1/2). During the third visit, two customized multiple lumen aspiration catheters were positioned to collect fasting and postprandial intestinal fluids to measure bile acid concentration.

RESULTS

Immediate pouch emptying (P = 0.0007) and a trend for faster GET_1/2 (P = 0.09) were observed in both bariatric groups. There was a tendency for a shorter orocecal transit in participants with sleeve gastrectomy and Roux-en-Y gastric bypass (P = 0.08). The orocecal segment was characterized by a higher 25th percentile pH (P = 0.004) and a trend for a higher median pH in both bariatric groups (P = 0.07). Fasting total bile acid concentration was 7.5-fold higher in the common limb after Roux-en-Y gastric bypass (P < 0.0001) and 3.5-fold higher in the jejunum after sleeve gastrectomy (P = 0.009) compared to obesity. Postprandial bile acid concentration was 3-fold higher in the jejunum after sleeve gastrectomy (P = 0.0004) and 6.5-fold higher in the common limb after Roux-en-Y gastric bypass (P < 0.0001) compared to obesity.

CONCLUSION

The anatomical alterations of sleeve gastrectomy and Roux-en-Y gastric bypass have an important impact on gastrointestinal physiology. This data confirms changes in transit and pH and provides the first evidence for altered intraluminal bile acid concentration.

Patients' and caregivers' perceptions of bariatric surgery: A France and United States comparative infodemiology study using social media data mining

Background

People are conversing about bariatric surgery on social media, but little is known about the main themes being discussed.

Objective

To analyze discussions regarding bariatric surgery on social media platforms and to establish a cross-cultural comparison of posts geolocated in France and the United States.

Methods

Posts were retrieved between January 2015 and April 2021 from general, publicly accessed sites and health-related forums geolocated in both countries. After processing and cleaning the data, posts of patients and caregivers about bariatric surgery were identified using a supervised machine learning algorithm.

Results

The analysis dataset contained a total of 10,800 posts from 4,947 web users in France and 51,804 posts from 40,278 web users in the United States. In France, post-operative follow-up (n = 3,251, 30.1% of posts), healthcare pathways (n = 2,171, 20.1% of the posts), and complementary and alternative weight loss therapies (n = 1,652, 15.3% of the posts) were among the most discussed topics. In the United States, the experience with bariatric surgery (n = 11,138, 21.5% of the posts) and the role of physical activity and diet in weight-loss programs before surgery (n = 9,325, 18% of the posts) were among the most discussed topics.

Conclusion

Social media analysis provides a valuable toolset for clinicians to help them increase patient-centered care by integrating the patients' and caregivers' needs and concerns into the management of bariatric surgery.

Risk-Benefit Balance Associated With Obstetric, Neonatal, and Child Outcomes After Metabolic and Bariatric Surgery

Importance

Metabolic and bariatric surgery (MBS) is the most efficient therapeutic option for severe obesity. Most patients who undergo MBS are women of childbearing age. Data in the scientific literature are generally of a low quality due to a lack of well-controlled prospective trials regarding obstetric, neonatal, and child outcomes.

Objective

To assess the risk-benefit balance associated with MBS around obstetric, neonatal, and child outcomes.

Design, Setting, and Participants

The study included 53 813 women on the French nationwide database who underwent an MBS procedure and delivered a child between January 2012 and December 2018. Each women was their own control by comparing pregnancies before and after MBS.

Exposures

The women included were exposed to either gastric bypass or sleeve gastrectomy.

Main Outcomes and Measures

The study team first compared prematurity and birth weights in neonates born before and after maternal MBS with each other. Then they compared the frequencies of all pregnancy and child diagnoses in the first 2 years of life before and after maternal MBS with each other.

Results

A total of 53 813 women (median [IQR] age at surgery, 30 [26-35] years) were included, among 3686 women who had 1 pregnancy both before and after MBS. The study team found a significant increase in the small-for-gestational-age neonate rate after MBS (+4.4%) and a significant decrease in the large-for-gestational-age neonate rate (-12.6%). The study team highlighted that compared with pre-MBS births, after MBS births had fewer occurrences of gestational hypertension (odds ratio [OR], 0.16; 95% CI, 0.10-0.23) and gestational diabetes for the mother (OR, 0.39; 95% CI, 0.34-0.45), as well as fewer birth injuries to the skeleton (OR, 0.27; 95% CI, 0.11-0.60), febrile convulsions (OR, 0.39; 95% CI, 0.21-0.67), viral intestinal infections (OR, 0.56; 95% CI, 0.43-0.71), or carbohydrate metabolism disorders in newborns (OR, 0.54; 95% CI 0.46-0.63), but an elevated respiratory failure rate (OR, 2.42; 95% CI, 1.76-3.36) associated with bronchiolitis.

Conclusions and Relevance

The risk-benefit balance associated with MBS is highly favorable for pregnancies and newborns but may cause an increased risk of respiratory failure associated with bronchiolitis. Further studies are needed to better assess the middle- and long-term benefits and risks associated with MBS.

Direct percutaneous endoscopic jejunostomy tube placement in patients post Roux-en-Y gastric bypass, a single tertiary care center experience

Background and study aims Obesity prevalence continues to rise in the United States with Roux-en-Y gastric bypass (RYGB) surgery being one of the most common bariatric procedures. With this trend, more patients with altered upper gastrointestinal (UGI) anatomy have required endoscopic intervention including direct percutaneous endoscopic jejunostomy (DPEJ) placement. We aimed to assess the safety and success rates of DPEJ in RYGB patients. Patients and methods All patients at a tertiary care referral center who underwent DPEJ during an 8-year period were queried from a prospectively maintained registry of all enteroscopy procedures. Duplicate cases and altered upper UGI anatomy subtypes other than RYGB were excluded. The final cohort consisted of two groups: RYGB vs native anatomy (NA). Demographic, procedural, readmission, follow-up, and complication data were recorded. Comparative analysis was performed. Results Seventy-two patients were included where 28 had RYGB and 44 had NA. Both groups had similar baseline and pre-procedure data. Procedure success rate was 89 % in RYGB patients and 98 % in NA patients ( P  = 0.13). There were no intraprocedural complications. Early and late postprocedural complication rates were similar between the groups (both 4 % vs 7 %). Average follow-up times in the RYGB and NA groups were 12.97 ± 9.35 and 13.44 ± 9.21 months, respectively. Although readmission rates at 1 and 6 months were higher in the NA versus the RYGB group (21 % vs 7 % and 25 % vs 15 %), these differences were not significant. Conclusions DPEJ can be successful and safely placed in RYGB patients with no significant difference in procedure success, complication, or readmission rates when compared to control.

Shortening the Biliopancreatic Limb Length of One Anastomosis Gastric Bypass Maintains Glucose Homeostasis Improvement with Limited Weight Loss

One anastomosis gastric bypass (OAGB) is associated with similar metabolic improvements and weight loss as Roux-en-Y gastric bypass (RYGB). However, this bariatric procedure is still controversial as it is suspected to result in undernutrition. Reducing the size of the biliopancreatic limb of OAGB could be essential to maintain positive outcomes while preventing side effects. The objective of this study was to compare and contrast outcomes of OAGB with two different biliopancreatic limb lengths to RYGB and Sham surgery in obese and non-obese rats. Lean and diet-induced obese Wistar rats were operated on RYGB, OAGB with a short (15 cm OAGB-15) or a long (35 cm OAGB-35) biliopancreatic limb or Sham surgery. Body weight and food intake were monitored over 30 weeks, and rats underwent oral glucose and insulin tolerance tests with a pancreatic and gut hormone secretion assay. Macronutrient absorption was determined by fecal analyses. Statistical analyses used non-parametric one-way or two-way ANOVA tests. Compared to Sham rats, RYGB, OAGB-15 and OAGB-35 rats displayed a significant reduced weight. Weight loss was greater after OAGB-35 than after OAGB-15 or Sham surgery because of transient malabsorption. All OAGB- and RYGB-operated rats displayed an improved pancreatic and gut hormone secretion in response to a meal compared to Sham rats, these effects were independent of limb length, rat weight, and maintained overtime. In conclusion, glucose homeostasis was similarly improved in obese and non-obese OAGB-15 and OAGB-35 rats suggesting that shortening the biliopancreatic limb can improve the metabolic parameters without a major influence on weight.

Bile or Acid Reflux Post One-Anastomosis Gastric Bypass: What Must We Do? Still an Unsolved Enigma

Obesity is a global scourge, affecting over 15% of the world's population [...].

Effect of Intragastric Botulinum Type A Injection Combined with a Low-Calorie High-Protein Diet in Adults with Overweight or Obesity

(1) Background/aims: Intragastric botulinum toxin A injection (IGBI) combined with diet control is a new and effective weight loss method for grade 2 obese patients. However, the application of IGIB on overweight or obese adults still needs further research to confirm its efficacy. (2) Methods: We retrospectively collected medical data from 1 July 2021 to 1 January 2022 from a total of 71 patients without diabetes who participated in the bariatric clinic with a body mass index (BMI) > 25 kg/m2. Forty-nine participants opted for intragastric botulinum injection (IGBI) using 300 units of botulinum injected into the antrum, body, and fundus, followed with a low-calorie high-protein diet course. Another 22 people participated only in the low-calorie high-protein diet course as a placebo group. This study analyzes the weight loss percentage of the two groups. Adverse events after IGBI are also reported in a safety assessment. (3) Results: In terms of the characteristics of the two groups, the mean BMI was 29.3 kg/m2 in the IGBI group and 28.0 kg/m in the placebo group (p = 0.63 without significant difference). Comparing the percent weight loss from baseline in the two groups after 12 weeks, the IGBI group lost 11.5% of their body weight and the placebo group lost 1.8%. In terms of group analysis, the percentages of participants with a weight reduction of at least 5% for the IGBI and placebo groups were 95% and 4%, respectively. For weight reduction of at least 10%, these values for the IGBI and placebo groups were 63% and 4%, respectively. In terms of adverse events after IGBI for 12 weeks, 12 participants (24.4%) had constipation, which was the main side effect. No serious adverse events were observed during the study period. (4) Conclusion: The combination of a low-calorie high-protein diet and IGBI is an effective and safe procedure in overweight or obese adults for weight reduction, but further larger studies are needed.

The future of bariatric surgery research: A worldwide mapping of registered trials

The bariatric surgery (BS) research landscape is a continuous evolving. Since the first described procedure, numerous different techniques have been developed by surgical teams. In this context, we conducted a systematic mapping of upcoming randomized controlled trials (RCTs) in BS for people with obesity. In June 2021, we performed a systematic review of RCTs evaluating BS versus another surgical procedure or versus a medical control group, through a search in ClinicalTrials.gov. There was no restriction on outcomes for study selection. A total of 62 RCTs were included, totaling 10,800 potential individuals to be included, with planned Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy surgeries the most common. The median number of patients planned to be enrolled is 78 (IQR: 50-143). Mean follow-up time is 12 months in 55% of trials and 4 years or more in 23%. The most frequent (81% of RCTs) outcomes to be investigated are obesity-related diseases with the study of type 2 diabetes, followed by weight loss, quality of life, and surgical complications. The rising number of BS procedures around the world has been followed by a subsequent surge in BS research. An increase in interest is observed in outcomes such as obesity-related diseases, intermediate metabolic markers, quality of life, and body composition.

Seventy years of bariatric surgery: A systematic mapping review of randomized controlled trials

While research publications on bariatric surgery (BS) have grown significantly over the past decade, there is no mapping of the existing body of evidence on this field of research. We performed a systematic review followed by a mapping of randomized controlled trials (RCTs) in BS for people with obesity. From January 2020 to December 2020, we performed a systematic review of RCTs evaluating BS, versus another surgical procedure, or versus a medical control group, through a search of Embase and PubMed. There was no restriction on outcomes for study selection. A total of 114 RCTs were included, most (73.7%) of which were based on a comparison with Roux-en-Y gastric bypass (RYGB) and conducted between 2010 and 2020. Only 15% of the trials were multicenter and few (3.5%) were international. The median number of patients enrolled was 61 (interquartile range [IQR]: 47.3-100). Follow-up time was 1 to 2 years in 36% and 22.8% of the trials, respectively. Weight loss was the most studied criterion (87% of RCTs), followed by obesity-related diseases, and medical and surgical complications (73%, 54%, and 47% of RCTs, respectively). Nutritional deficiency frequency, body composition, and mental health were little studied (20%, 18% and 5% of RCTs, respectively). Our literature review revealed that much research in BS is wasted because of replication of RCTs on subjects for which there is already body of evidence, with small populations and follow-up times mostly below 2 years. Yet several research questions remain unaddressed, and there are few long-term trials. Future studies should take into account the experience of the past 70 years of research in this field.

Comparing effects of obesity treatment with very low energy diet and bariatric surgery after 2 years: a prospective cohort study

OBJECTIVES

To compare long-term effects and complications of medical treatment (MT) of obesity including very low energy diet with bariatric surgery.

DESIGN AND SETTING

This prospective study conducted in a clinical setting recruited individuals with body mass index (BMI) ≥35 kg/m2 referred for obesity treatment. Demographic and anthropometric data, laboratory samples, and questionnaire replies were collected at baseline and 2 years.

PARTICIPANTS AND INTERVENTIONS

971 individuals were recruited 2015-2017. 382 received MT, 388 Roux-en-Y gastric bypass (RYGB) and 201 sleeve gastrectomy (SG).

MAIN OUTCOME MEASURES

Primary outcomes included changes in anthropometric measures, metabolic variables and safety. These were analysed using a linear regression model. A logistic regression model was used to analyse composite variables for treatment success (secondary outcomes). A random forest (RF) model was used to examine the importance of 15 clinical domains as predictors for successful treatment.

RESULTS

Two-year data were available for 667 individuals (68.7%). Regarding primary outcomes, the decrease in excess BMI was 27.5%, 82.5% and 70.3% and proportion achieving a weight of >10% was 45.3%, 99.6% and 95.6% for MT, RYGB and SG, respectively (p<0.001). The groups were comparable regarding levels of vitamins, minerals and haemoglobin or safety measures. Likelihood for success (secondary outcome) was higher in the surgical groups (RYGB: OR 5.3 (95% CI 3.9 to 7.2) vs SG: OR 4.3 ((95% CI 3.0 to 6.2)) in reference to MT. Baseline anthropometry had the strongest predictive value for treatment success, according to the RF model.

CONCLUSIONS

In clinical practice, bariatric surgery by RYGB or SG is most effective, but meaningful weight loss is achievable by MT with strict caloric restriction and stepwise introduction of a normal diet. All treatments showed positive effects on well-being, cardiovascular risk factors, and levels of vitamins and minerals at 2-year follow-up and groups were similar regarding safety measures.

TRIAL REGISTRATION NUMBER

NCT03152617.

Enteroendocrine System and Gut Barrier in Metabolic Disorders

With the continuous rise in the worldwide prevalence of obesity and type 2 diabetes, developing therapies regulating body weight and glycemia has become a matter of great concern. Among the current treatments, evidence now shows that the use of intestinal hormone analogs (e.g., GLP1 analogs and others) helps to control glycemia and reduces body weight. Indeed, intestinal endocrine cells produce a large variety of hormones regulating metabolism, including appetite, digestion, and glucose homeostasis. Herein, we discuss how the enteroendocrine system is affected by local environmental and metabolic signals. These signals include those arising from unbalanced diet, gut microbiota, and the host metabolic organs and their complex cross-talk with the intestinal barrier integrity.

Neurohormonal Changes in the Gut–Brain Axis and Underlying Neuroendocrine Mechanisms following Bariatric Surgery

Obesity is a complex, multifactorial disease that is a major public health issue worldwide. Currently approved anti-obesity medications and lifestyle interventions lack the efficacy and durability needed to combat obesity, especially in individuals with more severe forms or coexisting metabolic disorders, such as poorly controlled type 2 diabetes. Bariatric surgery is considered an effective therapeutic modality with sustained weight loss and metabolic benefits. Numerous genetic and environmental factors have been associated with the pathogenesis of obesity, while cumulative evidence has highlighted the gut–brain axis as a complex bidirectional communication axis that plays a crucial role in energy homeostasis. This has led to increased research on the roles of neuroendocrine signaling pathways and various gastrointestinal peptides as key mediators of the beneficial effects following weight-loss surgery. The accumulate evidence suggests that the development of gut-peptide-based agents can mimic the effects of bariatric surgery and thus is a highly promising treatment strategy that could be explored in future research. This article aims to elucidate the potential underlying neuroendocrine mechanisms of the gut–brain axis and comprehensively review the observed changes of gut hormones associated with bariatric surgery. Moreover, the emerging role of post-bariatric gut microbiota modulation is briefly discussed.

One-Anastomosis Gastric Bypass Revision for Gastroesophageal Reflux Disease: Long Versus Short Biliopancreatic Limb Roux-en-Y Gastric Bypass

PURPOSE

One-anastomosis gastric bypass (OAGB) may be associated with refractory gastroesophageal reflux disease (GERD). The nature of this GERD remains unclear. This complication can be treated either with an additional enteroenterostomy without shortening of gastric pouch (long biliopancreatic limb Roux-en-Y gastric bypass (L-BPL-RYGB)) or revision to conventional short biliopancreatic limb Roux-en-Y gastric bypass (S-BPL-RYGB). The objective of this study is to compare the aforementioned procedures in terms of efficacy on GERD symptoms.

MATERIALS AND METHODS

Retrospective analysis between October 2012 and June 2020.

RESULTS

Fifty-two patients underwent OAGB revision to S-BPL-RYGB (n = 21) or L-BPL-RYGB (n = 31) secondary to GERD. Investigation with pH impedance prior to revision was performed in 15 patients showing biliary reflux (BR) in 7 (46.6%), acid reflux (AR) in 6 (40%), and no confirmation in 2. Patients with AR had a revision to S-BPL-RYGB, whereas patients with BR underwent L-BPL-RYGB. Among the patients without pH metry results (n = 37), S-BPL-RYGB was performed for associated disabling digestive disorders or nutritional deficiencies. GERD was treated in 68% of patients with L-BPL-RYGB versus 95% of patients after S-BPL-RYGB. Patients, whose decision for revisional procedure was based on the results of pH impedance testing, did not reveal refractory GERD.

CONCLUSION

L-BPL-RYGB seems appropriate in patients with BR, whereas conversion to S-BPL-RYGB should be preferred if AR is present.

One Anastomosis Gastric Bypass Versus Long Biliopancreatic Limb Roux-en-Y Gastric Bypass

Background

Roux-en-Y gastric bypass (RYGB) is one of the most effective bariatric procedures. The study aimed to explore the value of lengthening the biliopancreatic limb (BPL) in RYGB compared to the outcome of one-anastomosis gastric bypass (OAGB).

Methods

This prospective study included morbidly obese patients divided into two groups. The RYGB group (n = 36) was subjected to long biliary limb Roux-en-Y gastric bypass (LPRYGB), and the OAGB Group (n = 36) had one anastomosis gastric bypass. During follow-up, weight, BMI, percentage of excess body weight loss (%EBWL), resolution of obesity-related comorbidities, and quality of life (QoL) were evaluated.

Results

There was no significant difference in weight and BMI after 3 and 6 months. At 12-month follow-up, weight loss was significantly higher in the OAGB group. After 12 months, the two groups showed significant improvement of comorbid conditions without significant difference between the two groups. The Qol was significantly higher in the LPRYGB group 3, 6, and 12 months after surgery compared to the OAGB group.

Conclusions

Extending the BPL length in RYGB to 150 cm is as effective as OAGB in remission of comorbidities, including diabetes. It was also equally effective in weight reduction in the short term. OAGB was more efficient in weight reduction and a significantly faster operation. LPRYGB showed a better QoL of life 1 year after surgery.

Graphical abstract

Late complications of biliopancreatic diversion in an older patient: a case report

BACKGROUND

In the mid-seventies, biliopancreatic diversion became popular as weight-loss surgery procedure. This bariatric procedure combines distal gastric resection and intestinal malabsorption, leading to greater weight loss and improvement of co-morbidities than other bariatric procedures. Nowadays, biliopancreatic diversion has become obsolete due to the high risk of nutritional complications. However, current patients with biliopancreatic diversions are aging. Consequently, geriatricians and general practitioners will encounter them more often and will be faced with the consequences of late complications.

CASE PRESENTATION

A 74-year old female presented with weakness, recurrent falls, confusion, episodes of irresponsiveness, anorexia and weight loss. Her medical history included osteoporosis, herpes encephalitis 8 years prior and a biliopancreatic diversion (Scopinaro surgery) at age 52. Cerebral imaging showed herpes sequelae without major atrophy. Delirium was diagnosed with underlying nutritional deficiencies. Biochemical screening indicated vitamin A deficiency, vitamin E deficiency, zinc deficiency and severe hypoalbuminemia. While thiamin level and fasting blood glucose were normal. However, postprandial hyperinsulinemic hypoglycemia was observed with concomitant signs of confusion and blurred consciousness. After initiating parenteral nutrition with additional micronutrient supplementation, a marked improvement was observed in cognitive and physical functioning.

CONCLUSIONS

Long-term effects of biliopancreatic diversion remain relatively underreported in older patients. However, the anatomical and physiological changes of the gastrointestinal tract can contribute to the development of metabolic and nutritional complications that may culminate in cognitive impairment, functional decline and delirium. Therefore, it is warranted to evaluate the presence of metabolic disturbances and nutritional complications in older patients after biliopancreatic diversion.

Risks and Rewards of Bariatric Surgery in Advanced Chronic Liver Diseases

The burden of obesity and metabolic syndrome has determined a sharp increase in bariatric surgery (BS) procedures, which lead to marked weight loss, improved metabolic syndrome, reduced cardiovascular risk, and even improvement in nonalcoholic steatohepatitis (NASH). Despite these promising results, BS in patients with chronic liver disease can rarely lead to worsening of liver function, progression to cirrhosis and its complications, and even liver transplantation. On the other hand, since obesity in patients with cirrhosis is a major cofactor for progression to a decompensated stage of the disease and a risk factor for hepatocellular carcinoma, BS has been used to achieve weight loss in this population. In this review, we critically analyze the existing data on outcomes of BS in patients with cirrhosis and the possible mechanisms leading to fibrosis progression and worsening liver function in patients undergoing BS. Finally, we propose a set of measures that could be taken to improve the multidisciplinary management of liver disease in patients undergoing BS, including early recognition of malnutrition and alcohol misuse.

Spin occurs in bariatric surgery randomized controlled trials with a statistically nonsignificant primary outcome: A systematic review

OBJECTIVES

To systematically identify the strategy and frequency of spin in reports of bariatric surgery randomized controlled trials (RCTs) with statistically nonsignificant primary endpoint.

STUDY DESIGN AND SETTING

The use of specific reporting strategies to highlight the beneficial effect of an experimental treatment can affect the reader interpretation of trial results, particularly when the primary endpoint is not statistically significant. A literature search was performed to identify RCTs publications assessing the impact of bariatric surgery on obesity-related comorbidities published over the past 10 years (from January 2020 till December 2020) in MEDLINE and EMBASE. RCTs publications with statistically non-significant primary outcomes were included.

RESULTS

Of 46 576 reports screened for title and abstract inclusion, 29 RCT reports met the inclusion criteria for spin analysis. In total, 16 abstracts (55%) and 18 main texts (62%) were classified as having a spin. In abstract results and conclusion sections, the spin was identified in 69% of reports. In main text results, discussion, and conclusion sections, the spin was recognized in 37%, 72%, and 76% of reports respectively. The spin consisted mainly of focusing on within-group improvements and the interpretation of statistically nonsignificant results as showing treatment equivalence.

CONCLUSION

Spin occurred in a high proportion of bariatric surgery RCTs with a statistically nonsignificant primary endpoint.

The Effects of Bariatric Surgery on Vitamin B Status and Mental Health

Diet is a modifiable factor that ensures optimal growth, biochemical performance, improved mood and mental functioning. Lack of nutrients, notably vitamin B, has an impact on human health and wellbeing. The United Arab Emirates is facing a serious problem of micronutrient deficiencies because of the growing trend for bariatric surgery, including Roux-en-Y gastric bypass and sleeve gastrectomy. People undergoing bariatric surgery are at high risk of developing neurological, cognitive, and mental disabilities and cardiovascular disease due to deficiency in vitamin B. Vitamin B is involved in neurotransmitter synthesis, including γ-aminobutyric acid, serotonin, dopamine, and noradrenaline. Deficiency of vitamin B increases the risk of depression, anxiety, dementia and Alzheimer's disease. In addition, vitamin B deficiency can disrupt the methylation of homocysteine, leading to hyperhomocysteinemia. Elevated homocysteine levels are detrimental to human health. Vitamin B deficiency also suppresses immune function, increases the production of pro-inflammatory cytokines and upregulates NF-κB. Considering the important functions of vitamin B and the severe consequences associated with its deficiency following bariatric surgery, proper dietary intervention and administration of adequate supplements should be considered to prevent negative clinical outcomes.

Small and Large Intestine (I): Malabsorption of Nutrients

Numerous disorders can alter the physiological mechanisms that guarantee proper digestion and absorption of nutrients (macro- and micronutrients), leading to a wide variety of symptoms and nutritional consequences. Malabsorption can be caused by many diseases of the small intestine, as well as by diseases of the pancreas, liver, biliary tract, and stomach. This article provides an overview of pathophysiologic mechanisms that lead to symptoms or complications of maldigestion (defined as the defective intraluminal hydrolysis of nutrients) or malabsorption (defined as defective mucosal absorption), as well as its clinical consequences, including both gastrointestinal symptoms and extraintestinal manifestations and/or laboratory abnormalities. The normal uptake of nutrients, vitamins, and minerals by the gastrointestinal tract (GI) requires several steps, each of which can be compromised in disease. This article will first describe the mechanisms that lead to poor assimilation of nutrients, and secondly discuss the symptoms and nutritional consequences of each specific disorder. The clinician must be aware that many malabsorptive disorders are manifested by subtle disorders, even without gastrointestinal symptoms (for example, anemia, osteoporosis, or infertility in celiac disease), so the index of suspicion must be high to recognize the underlying diseases in time.