Bariatric Surgery versus Intensive Medical Therapy for Diabetes - 5-Year Outcomes

Bariatric surgery and all-cause mortality: A methodological review of studies using a non-surgical comparator

AIM

Non-randomized studies on bariatric surgery have reported large reductions in mortality within 6-12 months after surgery compared with non-surgical patients. It is unclear whether these findings are the result of bias.

STUDY DESIGN AND SETTING

We searched PubMed to identify all non-randomized studies investigating the effect of bariatric surgery on all-cause mortality compared with non-surgical patients. We assessed these studies for potential confounding and time-related biases. We conducted bias analyses to quantify the effect of these biases.

RESULTS

We identified 21 cohort studies that met our inclusion criteria. Among those, 11 were affected by immortal time bias resulting from the misclassification or exclusion of relevant follow-up time. Five studies were subject to potential confounding bias because of a lack of adjustment for body mass index (BMI). All studies used an inadequate comparator group that lacked indications for bariatric surgery. Bias analyses to correct for potential confounding from BMI shifted the effect estimates towards the null [reported hazard ratio (HR): 0.78 vs. bias-adjusted HR: 0.92]. Bias analyses to correct for the presence of immortal time also shifted the effect estimates towards the null (adjustment for 2-year wait time: reported HR: 0.57 vs. bias-adjusted HR: 0.81).

CONCLUSION

Several important sources of bias were identified in non-randomized studies of the effectiveness of bariatric surgery versus non-surgical comparators on mortality. Future studies should ensure that confounding by BMI is accounted for, considering the choice of the comparator group, and that the design or analysis avoids immortal time bias from the misclassification or exclusion.

Early marginal ulceration prevalence following primary RYGB: a rare events model of the MBSAQIP 2015-2021

PURPOSE

Marginal ulceration (MU) following Roux-en-Y gastric bypass (RYGB) is an established complication, with early MU (within 30-days of operation) being less understood compared to its late counterpart. This study aims to identify risk factors for early MU in patients undergoing primary RYGB.

METHODS

Utilizing data from the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP 2015-2021), 1,346,468 records were evaluated. After exclusions for revisions, conversions, pediatric cases, nonbinary gender, missing body mass index (BMI) data, and missing operative time; 291,625 cases of primary RYGB were included for full analysis and rare events modeling of early MU.

RESULTS

The prevalence of early MU was .29% (n = 850). Higher rates of early MU were associated with BMI, race, history of diabetes mellitus (DM), prior thrombotic complications (deep vein thrombosis (DVT) and pulmonary embolism (PE)), prior percutaneous cardiac intervention (PTC), immunosuppressive therapy, and anticoagulation status. Additionally, procedural aspects like the nonspecialization of the surgeon and longer operative times also correlated with higher early MU rates. Rare-events regression modeling noted significant associations of early MU with younger age, diabetes requiring insulin, history of PTC, DVT, immunosuppressive therapy, and anticoagulation status.

CONCLUSION

Early MU remains a relatively rare complication. The lower than previously reported occurrence suggests possible improvements in both patient preparation and surgical technique. The identification of relevant risk factors enables better perioperative and intraoperative management of patients at risk of developing early MU.

Bariatric Surgery: Current Trends and Newer Surgeries

Bariatric surgery has evolved and gained in popularity as it has been recognized as the most sustainable and effective treatment for obesity and related diseases. These related diseases are significant causes of obesity related morbidity and mortality. Most bariatric procedures incorporate some component of gastric restriction with or without intestinal bypass, but the full mechanism of these procedures has yet to be elucidated. The most popular surgical procedure remains the sleeve gastrectomy over the last 10 years, while gastric bypass is also still commonly performed. We have also seen growth in revisional bariatric surgery and novel surgical procedures.

Physical Activity and Excess Body Weight and Adiposity for Adults. American College of Sports Medicine Consensus Statement

ABSTRACT

Excessive body weight and adiposity contribute to many adverse health concerns. The American College of Sports Medicine (ACSM) recognizes that the condition of excess body weight and adiposity is complex, with numerous factors warranting consideration. The ACSM published a position stand on this topic in 2001 with an update in 2009, and a consensus paper on the role of physical activity in the prevention of weight gain in 2019. This current consensus paper serves as an additional update to those prior ACSM position and consensus papers. The ACSM supports the inclusion of physical activity in medical treatments (pharmacotherapy, metabolic and bariatric surgery) of excess weight and adiposity, as deemed to be medically appropriate, and provides perspectives on physical activity within these therapies. For weight loss and prevention of weight gain, the effects may be most prevalent when physical activity is progressed in an appropriate manner to at least 150 min·wk-1 of moderate-intensity physical activity, and these benefits occur in a dose-response manner. High-intensity interval training does not appear to be superior to moderate-to-vigorous physical activity for body weight regulation, and light-intensity physical activity may also be an alternative approach provided it is of sufficient energy expenditure. Evidence does not support that any one single mode of physical activity is superior to other modes for the prevention of weight gain or weight loss, and to elicit holistic health benefits beyond the effects on body weight and adiposity, multimodal physical activity should be recommended. The interaction between energy expenditure and energy intake is complex, and the effects of exercise on the control of appetite are variable between individuals. Physical activity interventions should be inclusive and tailored for sex, self-identified gender, race, ethnicity, socioeconomic status, age, and developmental level. Intervention approaches can also include different forms, channels, and methods to support physical activity.

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.

Insurance payor status and risk of major adverse cardiovascular and cerebrovascular events after metabolic and bariatric surgery

BACKGROUND

Patients with Medicare/Medicaid insurance receive metabolic and bariatric surgery (MBS) at lower rates than privately insured (PI) patients. Although studies on some surgical procedures report that Medicare/Medicaid insurance confers increased postoperative complication rates and a longer length of stay, less is known about these outcomes after MBS. Among often-feared postoperative complications are major adverse cardiovascular and cerebrovascular events (MACEs). Although these events are rare after MBS, they have a significant impact on morbidity and mortality.

OBJECTIVES

This study aimed to examine the effect of insurance payor status on MACEs after MBS.

SETTING

The Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS).

METHODS

HCUP-NIS was queried for cases including sleeve gastrectomy or Roux-en-Y gastric bypass between 2012 and 2019. Bivariate associations between patient-level factors and MACEs were assessed via Rao-Scott χ2 tests. Adjusted and unadjusted risks of insurance payor status for MACEs were evaluated using logistic regression.

RESULTS

Incidence of MACEs was higher in both Medicare (.75% versus .11%; P < .001) and Medicaid (.15% versus .11%; P < .001) groups than in the PI group. After adjustment for high-risk demographics, high-risk co-morbidities, socioeconomic variables, and hospital factors, insurance status of Medicare (odds ratio [OR]: 1.60, 95% confidence interval [CI]: 1.23, 2.07; P = .0026) or Medicaid (OR: 1.55, 95% CI: 1.12, 2.16; P = .0026) remained an independent risk factor for MACEs.

CONCLUSIONS

Our findings underscore the significance of Medicaid/Medicare payor status as an independent predictor of postoperative MACEs in MBS. The results of this study can have a significant impact on deepening our understanding of socioeconomic and health system-related issues that can be targeted to improve outcomes in both MBS and other surgical specialties.

Remission and relapse of diabetes after sleeve gastrectomy and one-anastomosis gastric bypass: The Tehran Obesity Treatment Study

AIMS

To evaluate the rates and predictors of remission and relapse of type 2 diabetes mellitus (T2DM) in individuals with T2DM undergoing sleeve gastrectomy (SG) or one-anastomosis gastric bypass (OAGB).

METHODS

An observational prospective study with 5 years of follow-up was conducted in a total of 891 patients (82.5% female) with concomitant T2DM and obesity (body mass index ≥ 30.0 kg/m2) undergoing SG or OAGB between March 2013 and March 2021. T2DM remission was defined as achieving a glycated haemoglobin (HbA1c) level < 48 mmol/mol and a fasting plasma glucose (FPG) level <7 mmol/L, and being off glucose-lowering agents/insulin. T2DM relapse was defined as when FPG or HbA1c reverted to the diabetic range (≥7 mmol/L and ≥48 mmol/mol, respectively), or there was a need for pharmacotherapy.

RESULTS

After bariatric surgery, the overall T2DM remission and relapse rates were 61.4 per 1000 person-months (95% confidence interval [CI] 56.8-66.4) and 5.7 per 1000 person-months (95% CI 4.1-7.9), respectively. These rates were similar in the SG and OAGB groups. Multivariate hazard ratio analysis identified history of insulin therapy and T2DM duration prior to surgery as predictors of remission, while treatment with ≥2 glucose-lowering agents was the only relapse predictor. Additionally, patients undergoing SG experienced either remission or relapse within a significantly shorter time frame compared to those undergoing OAGB.

CONCLUSION

After 5 years of follow-up, there were no significant differences between the SG and OAGB groups with regard to T2DM remission and relapse. Bariatric surgery was less likely to result in remission in patients with a history of insulin therapy and longer durations of T2DM prior to surgery. Furthermore, patients who received ≥2 glucose-lowering agents, despite possible remission, were at a higher risk of experiencing late relapse.

Fat Mass Index Predicts the Effect of Weight Loss and Quality of Life Early After Laparoscopic Sleeve Gastrectomy

BACKGROUND

Fat mass index (FMI) is a body composition indicator that reflects body fat content. Laparoscopic sleeve gastrectomy (LSG) is widely performed in patients with obesity.

OBJECTIVE

This study aimed to evaluate the value of the FMI in predicting weight loss effect and quality of life early after LSG.

MATERIAL AND METHODS

From January 2014 to July 2022, the clinical data and computed tomography (CT) images of patients who underwent LSG at a tertiary referral teaching hospital were analyzed. Body composition indicators were calculated using the SliceOmatic software. Achieving initial body mass index within 6 months postoperatively was defined as early eligible weight loss (EEWL). The relationship between body composition and EEWL was analyzed.

RESULTS

A total of 243 patients were included. Receiver operating characteristic (ROC) curve analysis showed that the predictive value of the FMI for EEWL in patients after LSG was higher than that of other indicators (all P < 0.05; area under the curve = 0.813). The best FMI cut-off point was 13.662. Accordingly, the patients were divided into the high-FMI group and low-FMI group. The %EWL and BMI of patients in the low-FMI group at 1, 3, 6, 9, 12, and 24 months after surgery were better than those in the high-FMI group (all P < 0.001). Patients in the low-FMI group had higher BAROS (Bariatric Analysis and Reporting Outcome System) scores than those in the high-FMI group (P < 0.001).

CONCLUSION

Compared with other body composition indicators, FMI can effectively predict the early effect of weight loss and quality of life after LSG.

Comparative Effects of GLP-1 Agonists, Sleeve Gastrectomy and Roux-en-Y Gastric Bypass on Diabetes Mellitus Outcomes

PURPOSE OF REVIEW

The purpose of this review is to assess the effects of glucagon-like peptide-1 (GLP-1) agonists, sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB) on type 2 diabetes mellitus (T2DM) remission. This review explores the efficacy, safety, and durability of these surgical and medical modalities of diabetes management.

RECENT FINDINGS

Studies have shown that GLP-1 agonists achieve higher rates of T2DM remission compared to standard glucose-lowering medications and lifestyle changes. In addition to weight loss, bariatric surgery has been found to be highly effective in treating and inducing remission of T2DM. Studies suggest that post-surgical patients see enhanced glycemic control. Both surgical interventions and GLP1 agonists are effective in achieving T2DM remission. Long-term follow-up and randomized controlled trials comparing bariatric surgery and GLP-1 agonists are necessary to evaluate their relative effectiveness in T2DM control. Further research is also needed to assess the combined effects of these treatment modalities.

Prognostic Characteristics of Metabolic Dysfunction-Associated Steatotic Liver in Patients with Obesity Who Undergo One Anastomosis Gastric Bypass Surgery: A Secondary Analysis of Randomized Controlled Trial Data

BACKGROUND/OBJECTIVES

Metabolic dysfunction-associated steatotic liver disease (MASLD) is closely associated with obesity and insulin resistance (IR). Identifying characteristics that predict a higher risk of fibrosis using noninvasive methods is particularly important.

METHODS

We performed a secondary analysis of data from an RCT of 48 patients after one anastomosis gastric bypass (OAGB) surgery, supplemented with specifically formulated probiotics and micronutrients or control treatment for 12 weeks. Patients were categorized using alanine aminotransferase (ALAT; >35 U/L for women, >50 U/L for men), higher NAFLD fibrosis score (NFS) > -1.455), and IR (HOMA-IR > 2.0). This trial was registered at Clinicaltrials.gov (ID: NCT03585413).

RESULTS

Abnormal ALAT was associated with high triglycerides, blood pressure (BP), glucose, and fatty liver index (FLI). NFS > -1.455 was linked to higher age, body mass, waist circumference, and FLI, and lower albumin and platelet count. HOMA-IR > 2.0 was associated with higher BP and triglycerides, lower HDL-cholesterol, higher serum transaminases, and higher probabilities of steatosis and fibrosis. Twelve weeks postoperatively, patients with NFS > -1.455 showed greater reductions in body mass, systolic BP, serum insulin, and HbA1c, whereas those with NFS ≤ -1.455 showed improvements in FLI and lipid metabolism but had high glucose concentrations. Patients with HOMA-IR ≤ 2.0 also had high glucose concentrations.

CONCLUSIONS

The evaluation of common biomarker scores for fibrosis and IR may help clinicians to recognize severe NAFLD and improve the outcomes of OAGB surgery.

Glycaemic and weight effects of metabolic surgery or semaglutide in diabetes dosage for patients with type 2 diabetes

AIM

To compare weight and glucometabolic outcomes of semaglutide and metabolic and bariatric surgery (MBS) for patients with type 2 diabetes and obesity.

MATERIALS AND METHODS

Patients treated with either semaglutide for a duration of ≥2 years or MBS in Sweden were identified within the Scandinavian Obesity Surgery Registry and the National Diabetes Registry and matched in a 1:1-2 ratio using a propensity score matching with a generalized linear model, including age, sex, glycated haemoglobin before treatment, duration of type 2 diabetes, use of insulin, presence of comorbidities and history of cancer, with good matching results but with a remaining imbalance for glomerular filtration rate and body mass index, which were then adjusted for in the following analyses. Main outcomes were weight loss and glycaemic control.

RESULTS

The study included 606 patients in the surgical group matched to 997 controls who started their treatment from 2018 until 2020. Both groups improved in weight and glucometabolic control. At 2 years after the intervention, mean glycated haemoglobin was 42.3 ± 11.18 after MBS compared with 50.7 ± 12.48 after semaglutide treatment (p < 0.001) with 382 patients (63.0%) and 139 (13.9%), respectively, reaching complete remission without other treatment than the intervention (p < 0.001). Mean total weight loss reached 26.4% ± 8.83% after MBS compared with 5.2% ± 7.87% after semaglutide (p < 0.001).

CONCLUSION

Semaglutide and MBS were both associated with improvements in weight and improved glycaemic control at 2 years after the start of the intervention, but MBS was associated with better weight loss and glucometabolic control.

Adverse Cardiovascular Outcomes in Patients With Obstructive Sleep Apnea and Obesity: Metabolic Surgery vs Usual Care

BACKGROUND

No therapy has been shown to reduce the risk of major adverse cardiovascular events (MACE) and death in patients with obstructive sleep apnea (OSA).

OBJECTIVES

The authors sought to investigate the long-term relationship between metabolic surgery and incident MACE in patients with OSA and obesity.

METHODS

Adult patients with a body mass index 35 to 70 kg/m2 and moderate-to-severe OSA at a U.S. health system (2004-2018) were identified. Baseline characteristics of patients who underwent metabolic surgery were balanced with a nonsurgical control group using overlap-weighting methods. Multivariable Cox regression analysis estimated time-to-incident MACE. Follow-up ended in September 2022.

RESULTS

A total of 13,657 patients (7,496 [54.9%] men; mean age 52.0 ± 12.4 years; median body mass index 41.0 kg/m2 [Q1-Q3: 37.6-46.2 kg/m2]), including 970 patients in the metabolic surgery group and 12,687 patients in the nonsurgical group, with a median follow-up of 5.3 years (Q1-Q3: 3.1-8.4 years) were analyzed. The mean between-group difference in body weight at 10 years was 26.6 kg (95% CI: 25.6-27.6 kg) or 19.3% (95% CI: 18.6%-19.9%). The 10-year cumulative incidence of MACE was 27.0% (95% CI: 21.6%-32.0%) in the metabolic surgery group and 35.6% (95% CI: 33.8%-37.4%) in the nonsurgical group (adjusted HR: 0.58 [95% CI: 0.48-0.71]; P < 0.001). The 10-year cumulative incidence of all-cause mortality was 9.1% (95% CI: 5.7%-12.4%) in the metabolic surgery group and 12.5% (95% CI: 11.2%-13.8%) in the nonsurgical group (adjusted HR: 0.63 [95% CI: 0.45-0.89]; P = 0.009).

CONCLUSIONS

Among patients with moderate-to-severe OSA and obesity, metabolic surgery, compared with nonsurgical management, was associated with a significantly lower risk of incident MACE and death.

Barriers for bariatric surgery in provincial New Zealand: a qualitative analysis

BACKGROUND

Bariatric surgery is the most effective treatment for people with obesity. It has been shown that there's is a complex psychosocial overlay in the pathophysiology and treatment, which requires specific consideration when delivering care. There is a significant drop out rate for patients accepted on to bariatric programmes in New Zealand, resulting in failure to progress to surgical intervention.

METHODS

We conducted individual, semi-structured interviews with patients who were accepted onto the bariatric surgery programme but did not complete the programme, or receive an operation between 2015 and 2020. Grounded theory methodology was used to create an exploratory framework to identify and describe the themes encountered. An iterative process of thematic analysis and comparison between participants experiences was used to consolidate the shared key barriers. This study aims to explore patients experiences of a bariatric surgery programme to understand barriers and enablers to complete a bariatric programme and receive an operation. Adding to previous qualitative work investigating patients experience of bariatric surgery programmes in New Zealand.

RESULTS

Five themes of barriers that patients face to receiving bariatric surgery were identified. These were preoperative weight loss requirement, experiencing the social stigma of obesity, communication, socioeconomic and geographic barriers, and community support. These five themes often co-exist in patients experiences and combine, to cause patients to disengage with the bariatric service.

CONCLUSION

Many factors contribute to eligible patients not receiving bariatric surgery once accepted onto the programme. Specified weight loss goals was the most significant barrier. Community support and online resources were significant enablers. This study should inform changes to bariatric programmes in New Zealand.

Obesity in adults

Obesity has increased in prevalence worldwide and WHO has declared it a global epidemic. Population-level preventive interventions have been insufficient to slow down this trajectory. Obesity is a complex, heterogeneous, chronic, and progressive disease, which substantially affects health, quality of life, and mortality. Lifestyle and behavioural interventions are key components of obesity management; however, when used alone, they provide substantial and durable response in a minority of people. Bariatric (metabolic) surgery remains the most effective and durable treatment, with proven benefits beyond weight loss, including for cardiovascular and renal health, and decreased rates of obesity-related cancers and mortality. Considerable progress has been made in the development of pharmacological agents that approach the weight loss efficacy of metabolic surgery, and relevant outcome data related to these agents' use are accumulating. However, all treatment approaches to obesity have been vastly underutilised.

Analysis of long-term outcome of modified gastric bypass for type 2 diabetes mellitus in Chinese patients

BACKGROUND

Bariatric and metabolic surgery have been routinely performed following the rapid increase in obesity and metabolic diseases worldwide. Of all evolving procedures, Roux-en-Y gastric bypass (RYGB) is considered the gold standard for surgical treatment of patients with type 2 diabetes mellitus (T2DM) and obesity. RYGB was introduced in China nearly 20 years ago, but the number of RYGB surgeries only accounts for 3.1% of the total number of weight loss and metabolic surgeries in China, it's effect on Chinese people still needs further study.

AIM

To investigate the effect and safety of a modified gastric bypass performed in Chinese patients with T2DM.

METHODS

Patients with obesity and T2DM who underwent modified gastric bypass, with > 5-year follow-up data, were analyzed.

RESULTS

All 37 patients underwent uneventful laparoscopic surgery, no patient was switched to laparotomy during the surgery, and no severe complications were reported. Average weight and body mass index of the patients reduced from 84.6 ± 17.3 (60.0-140.0) kg and 30.9 ± 5.0 (24.7-46.2) kg/m2 to 67.1 ± 12.2 (24.7-46.2) kg and 24.6 ± 3.9 (17.7-36.5) kg/m2, respectively, and fasting plasma glucose and glycated hemoglobin decreased from 7.4 ± 3.4 mmol/L and 8.2% ± 1.7% preoperatively to 6.5 ± 1.3 mmol/L and 6.5% ± 0.9% 5-years postoperatively, respectively. Only 29.7% (11/37) of the patients used hypoglycemic drugs 5-years postoperatively, and the complete remission rate of T2DM was 29.7% (11/37). Triglyceride level reduced significantly but high-density lipoprotein increased significantly (both P < 0.05) compared with those during the preoperative period. Liver and renal function improved significantly postoperatively, and binary logistic regression analysis revealed that the patients' preoperative history of T2DM and fasting C-peptide were significant prognostic factors influencing complete T2DM remission after RYGB (P = 0.006 and 0.012, respectively).

CONCLUSION

The modified gastric bypass is a safe and feasible procedure for Chinese patients with obesity and T2DM, exhibiting satisfactory amelioration of weight problems, hyperglycemia, and combination disease.

The Role of Obesity as a Cardiac Disease Risk Factor in Patients with Type 2 Diabetes

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is the leading cause of death globally and is closely associated with obesity and type 2 diabetes mellitus (T2DM). This review examines the interplay between obesity, T2DM, and CVD, highlighting the increasing prevalence and economic burden of these conditions.

RECENT FINDINGS

Pharmacologic therapies, particularly glucagon-like peptide-1 receptor agonists, show promise in substantial weight loss and subsequent reduction of adverse cardiovascular events in obese individuals with and without diabetes. Obesity significantly contributes to the development of insulin resistance and T2DM, further escalating CVD risk. The common co-occurrence of these three conditions may involve several other pathophysiological mechanisms, such as chronic inflammation, increased visceral adiposity, and endothelial dysfunction. Until recently, lifestyle modifications and bariatric surgery had been the primary methods for weight loss and mitigating obesity-associated cardiovascular risk. Newer pharmacological options have led to a paradigm shift in our approach to obesity management as they provide substantial benefits in weight loss, glycemic control, and cardiovascular risk reduction.

Advances and counterpoints in type 2 diabetes. What is ready for translation into real-world practice, ahead of the guidelines

This review seeks to address major gaps and delays between our rapidly evolving body of knowledge on type 2 diabetes and its translation into real-world practice. Through updated and improved best practices informed by recent evidence and described herein, we stand to better attain A1c targets, help preserve beta cell integrity and moderate glycemic variability, minimize treatment-emergent hypoglycemia, circumvent prescribing to "treatment failure," and prevent long-term complications. The first topic addressed in this review concerns updates in the 2023 and 2024 diabetes treatment guidelines for which further elaboration can help facilitate integration into routine care. The second concerns advances in diabetes research that have not yet found their way into guidelines, though they are endorsed by strong evidence and are ready for real-world use in appropriate patients. The final theme addresses lingering misconceptions about the underpinnings of type 2 diabetes-fundamental fallacies that continue to be asserted in the textbooks and continuing medical education upon which physicians build their approaches. A corrected and up-to-date understanding of the disease state is essential for practitioners to both conceptually and translationally manage initial onset through late-stage type 2 diabetes.

Obesity and Weight Loss Strategies for Patients With Heart Failure

Obesity is a common comorbidity among patients with heart failure with reduced ejection fraction (HFrEF) or heart failure with preserved ejection fraction (HFpEF), with the strongest pathophysiologic link of obesity being seen for HFpEF. Lifestyle measures are the cornerstone of weight loss management, but sustainability is a challenge, and there are limited efficacy data in the heart failure (HF) population. Bariatric surgery has moderate efficacy and safety data for patients with preoperative HF or left ventricular dysfunction and has been associated with reductions in HF hospitalizations and medium-term mortality. Antiobesity medications historically carried concerns for cardiovascular adverse effects, but the safety and weight loss efficacy seen in general population trials of glucagon-like peptide 1 (GLP-1) and gastric inhibitory polypeptide/GLP-1 agonists are highly encouraging. Although there are safety concerns regarding GLP-1 agonists in advanced HFrEF, trials of the GLP-1 agonist semaglutide for treatment of obesity have confirmed safety and efficacy in patients with HFpEF.

Gastric Bypass vs Diet and Cardiovascular Risk Factors: A Nonrandomized Controlled Trial

Importance

Roux-en-Y gastric bypass (RYGB) is associated with reduced cardiovascular (CV) risk factors, morbidity, and mortality. Whether these effects are specifically induced by the surgical procedure or the weight loss is unclear.

Objective

To compare 6-week changes in CV risk factors in patients with obesity undergoing matching caloric restriction and weight loss by RYGB or a very low-energy diet (VLED).

Design, Setting, and Participants

This nonrandomized controlled study (Impact of Body Weight, Low Calorie Diet, and Gastric Bypass on Drug Bioavailability, Cardiovascular Risk Factors, and Metabolic Biomarkers [COCKTAIL]) was conducted at a tertiary care obesity center in Norway. Participants were individuals with severe obesity preparing for RYGB or a VLED. Recruitment began February 26, 2015; the first patient visit was on March 18, 2015, and the last patient visit (9-week follow-up) was on August 9, 2017. Data were analyzed from April 30, 2021, through June 29, 2023.

Interventions

VLED alone for 6 weeks or VLED for 6 weeks after RYGB; both interventions were preceded by 3-week LED.

Main Outcomes and Measures

Between-group comparisons of 6-week changes in CV risk factors.

Results

Among 78 patients included in the analyses, the mean (SD) age was 47.5 (9.7) years; 51 (65%) were women, and 27 (35%) were men. Except for a slightly higher mean (SD) body mass index of 44.5 (6.2) in the RYGB group (n = 41) vs 41.9 (5.4) in the VLED group (n = 37), baseline demographic and clinical characteristics were similar between groups. Major atherogenic blood lipids (low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, apolipoprotein B, lipoprotein[a]) were reduced after RYGB in comparison with VLED despite a similar fat mass loss. Mean between-group differences were -17.7 mg/dL (95% CI, -27.9 to -7.5), -17.4 mg/dL (95% CI, -29.8 to -5.0) mg/dL, -9.94 mg/dL (95% CI, -15.75 to -4.14), and geometric mean ratio was 0.55 U/L (95% CI, 0.42 to 0.72), respectively. Changes in glycemic control and blood pressure were similar between groups.

Conclusions and Relevance

This study found that clinically meaningful reductions in major atherogenic blood lipids were demonstrated after RYGB, indicating that RYGB may reduce CV risk independent of weight loss.

Trial Registration

ClinicalTrials.gov Identifier: NCT02386917.

Assessment of Metabolic and Bariatric Surgery Safety in Patients with Advanced Liver Fibrosis

PURPOSE

The well-established relationship between obesity and metabolic dysfunction-associated steatotic liver disease (MASLD) is a key etiological factor in the development of liver cirrhosis. Bariatric surgery is an effective treatment for weight loss in patients with moderate-to-severe obesity, also playing a role in controlling MASLD. However, surgical safety in patients with advanced fibrosis remains to be established. This study aimed to evaluate the safety and repercussions of bariatric surgery according to fibrosis stage.

MATERIALS AND METHODS

Patients undergoing bariatric surgery who had an intraoperative liver biopsy were retrospectively evaluated. Preoperative and postoperative data were collected from medical records, and results were stratified according to fibrosis stage into early fibrosis (no fibrosis or stages 1 and 2) and advanced fibrosis (stages 3 and 4).

RESULTS

The study included 1185 patients: 1129 with early fibrosis and 56 with advanced fibrosis. The advanced fibrosis group had higher percentage of men (35.7% vs 21.6%, p = 0.014) and of people with diabetes (42.9% vs 16.5%, p < 0.001) and hypertension (57.1% vs 41.4%, p = 0.012). Patients with advanced fibrosis also required longer hospitalizations (4.64 vs 4.06 days, p < 0.001) and were more frequently admitted to the intensive care unit (7.1% vs 2.9%, p = 0.038). The groups did not differ significantly in other outcomes. There were no deaths in either group.

CONCLUSION

Bariatric surgery proved to be safe, with similar complication rates in patients with advanced fibrosis and in those with early fibrosis.

Incidence of ocular pathology following bariatric surgery for with morbid obesity across a large United States National Database

BACKGROUND/OBJECTIVES

Bariatric surgery, as indicated for treatment of morbid obesity, has been studied in association with short term effects on ocular pathology. However, effects of surgery on postoperative disease incidence is largely unknown.

SUBJECTS/METHODS

In this retrospective cohort study, the TriNetX United States Collaborative Network national database, was queried for patients with an ICD-10 code for morbid obesity and a procedural code for bariatric surgery. Patients were propensity score matched across baseline demographics at the time of surgery and compared to those presenting with an ICD10 code for morbid obesity with no records of a procedural code for bariatric surgery, identifying 42,408 patients per cohort. New diagnoses or procedural codes found after the surgical index date for diabetic retinopathy, age-related macular degeneration, glaucoma, low vision, and blindness along with pertinent treatment metrics were monitored.

RESULTS

Bariatric surgery was found to be associated with reduced future risk of diabetic retinopathy (RR: 0.283; 95% CI: 0.252-0.319), macular edema (RR: 0.224; 95% CI: 0.170-0.297), vitreous hemorrhage (RR: 0.459; 95% CI: 0.323-0.653), ocular hypertension (RR: 0.387; 95% CI: 0.387-0.487), glaucoma (RR: 0.360; 95% CI: 0.326-0.399), use of ocular pressure lowering medications (RR: 0.565; 95% CI: 0.496-0.644), age-related macular degeneration (RR: 0.628; 95% CI: 0.447-0.882), cataract surgery (RR: 0.524; 95% CI: 0.448-0.612), and low vision and blindness (RR: 0.328; 95% CI: 0.294-0.365) compared to patients not surgically managed.

CONCLUSIONS

The present analysis comprising a large US cohort of patients suggests that bariatric surgery is associated with a decreased risk of future ocular morbidity and mortality.

Contemporary Management of Obesity: A Comparison of Bariatric Metabolic Surgery and Novel Incretin Mimetic Drugs

The global prevalence of obesity has risen sharply during the past half-century, reaching pandemic proportions and creating a public health crisis. Obesity is a recognized risk factor for the development of diabetes, atherosclerosis, hypertension, hepatic steatosis, and many other cardiometabolic disorders with significant resultant morbidity and mortality. Though treatment of obesity can prevent or slow the progression of the aforementioned illnesses, efforts to help patients achieve reliable and sustainable weight loss have had limited success. Improving nutrition and increasing physical activity results in a host of health benefits; however, the weight loss achieved with lifestyle interventions alone is modest and difficult to sustain. Early attempts at medical and surgical treatment of obesity were plagued with adverse effects and complications. Moreover, these approaches failed to demonstrate long-term health benefits, even when weight loss was achieved. Recently, novel incretin-based therapies targeting glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptors have gained popularity because of their effectiveness in achieving substantial weight loss in patients both with and without diabetes. Following many successful clinical trials, there are now multiple GLP-1 receptor agonists and one dual GLP-1-GIP receptor agonist approved by the Food and Drug Administration for chronic weight management. Advancements in laparoscopic surgical technique and refinements in procedure selection have similarly improved the safety and efficacy of bariatric metabolic surgery for patients with obesity. In this review, we discuss the advantages and disadvantages of contemporary pharmacologic and surgical weight management strategies. We review the data regarding expected weight loss, glycemic control, cardiometabolic benefits, and potential adverse effects of various treatment approaches. As obesity rates continue to rise worldwide, it is imperative that clinicians keep these considerations in mind in order to better care for patients.

Effect of ghrelin on glucose tolerance, gut hormones, appetite, and food intake after sleeve gastrectomy

Ghrelin is an appetite-stimulating hormone secreted from the gastric mucosa in the fasting state, and secretion decreases in response to food intake. After sleeve gastrectomy (SG), plasma concentrations of ghrelin decrease markedly. Whether this affects appetite and glucose tolerance postoperatively is unknown. We investigated the effects of ghrelin infusion on appetite and glucose tolerance in individuals with obesity before and 3 mo after SG. Twelve participants scheduled for SG were included. Before and 3 mo after surgery, a mixed-meal test followed by an ad libitum meal test was performed with concomitant infusions of acyl-ghrelin (1 pmol/kg/min) or placebo. Infusions began 60 min before meal intake to reach a steady state before the mixed-meal and were continued throughout the study day. Two additional experimental days with 0.25 pmol/kg/min and 10 pmol/kg/min of acyl-ghrelin infusions were conducted 3 mo after surgery. Both before and after SG, postprandial glucose concentrations increased dose dependently during ghrelin infusions compared with placebo. Ghrelin infusions inhibited basal and postprandial insulin secretion rates, resulting in lowered measures of β-cell function, but no effect on insulin sensitivity was seen. Ad libitum meal intake was unaffected by the administration of ghrelin. In conclusion, ghrelin infusion increases postprandial plasma glucose concentrations and impairs β-cell function before and after SG but has no effect on ad libitum meal intake. We speculate that the lower concentration of ghrelin after SG may impact glucose metabolism following this procedure.NEW & NOTEWORTHY Ghrelin's effect on glucose tolerance and food intake following sleeve gastrectomy (SG) was evaluated. Acyl-ghrelin was infused during a mixed-meal and ad libitum meals before and 3 mo after surgery. Postprandial glucose concentrations increased during ghrelin infusions, both before and after surgery, while insulin production was inhibited. However, ad libitum meal intake did not differ during ghrelin administration compared with placebo. The decreased ghrelin concentration following SG may contribute to the glycemic control after surgery.

The effect of bariatric surgery on diabetes related foot complications among patients with type 2 diabetes: A systematic review

BACKGROUND

Bariatric surgery leads to considerable weight loss and improved glycaemic control and seems to have a favourable impact on diabetes related foot complications (DFC).

OBJECTIVES

To assess the effect of bariatric surgery on diabetes related foot complications in patients with type 2 diabetes and determine whether DFC symptoms are improved after bariatric surgery.

METHODS

We searched MEDLINE, Embase and Cochrane Central Register of Controlled Trials. The primary outcome was the presence of DFC after bariatric surgery. The secondary outcome was the improvement of DFC after bariatric surgery among patients who already had DFC before surgery.

RESULTS

There were nine studies showing the presence of DFC post bariatric surgery and six detailing the changes in DFC post bariatric surgery. Bariatric surgery was not associated with a lower risk of developing or worsening DFC compared to conventional medical treatment based on 4 randomised control trials (IR 0.87, 95 % CI, 0.26, 2.98), while from observational studies was associated with 51 % lower risk of DFC (IR 0.49, 95 % CI, 0.31, 0.77). Bariatric surgery was associated with improvement in diabetic neuropathy assessment parameters including toe tuning fork score, self-reported neuropathy symptoms, neuropathy symptom score, and neuropathy symptom profile.

CONCLUSION

Bariatric surgery led to a greater reduction in developing or worsening DFC among patients with type 2 diabetes compared to medical treatment in observational studies, but not among RCTs. Bariatric surgery was associated with improvements in diabetic neuropathy related assessment parameters and symptoms. Bariatric surgery could be a promising treatment for patients with type 2 diabetes who are at high risk of DFC.

Changes in thyroid hormones predict weight regain in patients with obesity who undergo metabolic surgery

AIM

To investigate the relationship between thyroid function and weight regain in patients with obesity after metabolic surgery.

METHODS

This retrospective study enrolled 162 patients who underwent metabolic surgery. Correlations between decreases in thyroid hormone levels and changes in weight, waist circumference (WC) and the Chinese visceral adiposity index (CVAI) were assessed. Binary logistic regression and receiver operating characteristic (ROC) curves were used to identify predictors and clinically useful cut-off values, respectively.

RESULTS

The levels of thyroid-stimulating hormone (TSH) and free triiodothyronine (FT3) decreased markedly at 1 year after surgery, as did weight, body mass index (BMI), triglycerides, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, WC and CVAI. Decreases in TSH and FT3 after metabolic surgery were associated with changes in weight, BMI and CVAI. Binary logistic regression and ROC curve analyses confirmed that decreases in TSH can predict good weight loss after metabolic surgery to some extent. Finally, binary logistic regression and ROC curve analyses confirmed that changes in TSH can predict weight regain after metabolic surgery.

CONCLUSIONS

Changes in TSH and FT3 after metabolic surgery were correlated with changes in weight and CVAI. Changes in thyroid hormones can predict weight regain in patients with obesity who underwent metabolic surgery.

A Study of Omentum Reduction on the Improvement of Nausea and vomiting and Gastroesophageal Reflux Symptoms After Laparoscopic Gastric Sleeve Resection

OBJECTIVE

To investigate the effect of omentum reduction in laparoscopic sleeve gastrectomy (LSG) on the improvement of postoperative nausea and vomiting and gastroesophageal reflux symptoms.

METHODS

A retrospective study was performed on the case data of 198 obese patients who underwent LSG in the Department of Obesity and Metabolic Diseases of Xiaolan People's Hospital of Zhongshan from March 2021 to March 2022 and were divided into omentum reduction group and control group, with 99 cases in each group, and the preoperative body mass index (BMI) of the patients was recorded. Age, gender, comorbidities, and comparative analysis of operation time, blood loss, length of hospital stay, postoperative nausea and vomiting score, gastroesophageal reflux GerdQ score, postoperative pain score, weight, and postoperative complications were analyzed.

RESULTS

There were no significant differences in preoperative BMI, age, gender and comorbidities between the two groups (P > 0.05), but there were significant differences in intraoperative blood loss and operation time (P < 0.05). There were differences in postoperative nausea and vomiting scores and VAS pain scores between the two groups (P < 0.05). The GerdQ scores of the omental reduction group were 8.11 ± 2.84 points at 1 year, and those in the control group were 7.56 ± 2.67 points, which were 3.97 ± 4.09 points higher than those in the preoperative omentum reduction group and 3.42 ± 3.41 in the control group, with no significant difference (P > 0.05). There was no significant difference in the postoperative excess weight loss rate %EWL and postoperative complications (p > 0.05).

CONCLUSION

Omentum reduction can improve short-term nausea and vomiting after LSG, but it cannot significantly improve long-term reflux symptoms.

The role of metabolic and bariatric surgery on the obesity pandemic in Latin America: A review of current practices and future directions

Latin America faces a significant public health challenge due to the high prevalence of obesity and its associated diseases. Metabolic and bariatric surgery is effective and safe to treat obesity when other treatments fail; however, its implementation in Latin America remains unsatisfactory. This review explores the current status, challenges, and innovations of metabolic and bariatric surgery in Latin America. We searched peer-reviewed journals in English and Spanish for relevant articles published between 1998 and 2023. We found that more than 20% of the Latin American population is affected by obesity. Unfortunately, only a limited number of patients have access to metabolic and bariatric surgery due to high cost, limited availability, and shortage of specialists. The review found that ongoing clinical trials are being conducted in Brazil, Mexico, Chile, and Venezuela, indicating some regional progress. However, published studies remain low in number compared with other regions. Furthermore, we summarized the clinical outcomes, risks, and perioperative assessments associated with metabolic and bariatric surgery. We discussed potential strategies to enhance the availability and affordability of this intervention. This review emphasizes the significance of metabolic and bariatric surgery in addressing the obesity pandemic, specifically for Latin America, and proposes directions for future research and innovation.

Estimating the Effect of Bariatric Surgery on Cardiovascular Events Using Observational Data?

BACKGROUND

Observational studies have reported strongly protective effects of bariatric surgery on cardiovascular disease, but with oversimplified definitions of the intervention, eligibility criteria, and follow-up, which deviate from those in a randomized trial. We describe an attempt to estimate the effect of bariatric surgery on cardiovascular disease without introducing these sources of bias, which may not be entirely possible with existing observational data.

METHODS

We propose two target trials among persons with diabetes: (1) bariatric operation (vs. no operation) among individuals who have undergone preoperative preparation (lifestyle modifications and screening) and (2) preoperative preparation and a bariatric operation (vs. neither preoperative nor operative component). We emulated both target trials using observational data of US veterans.

RESULTS

Comparing bariatric surgery with no surgery (target trial #1; 8,087 individuals), the 7-year cardiovascular risk was 18.0% (95% CI = 6.9, 32.7) in the surgery group and 18.9% (95% CI = 17.7, 20.1) in the no-surgery group (risk difference -0.9, 95% CI = -12.0, 14.0). Comparing preoperative components plus surgery vs. neither (target trial #2; 10,065 individuals), the 7-year cardiovascular risk was 17.4% (95% CI = 13.6, 22.0) in the surgery group and 18.8% (95% CI = 17.8, 19.9) in the no-surgery group (risk difference -1.4, 95% CI = -5.1, 3.2). Body mass index and hemoglobin A1c were reduced with bariatric interventions in both emulations.

CONCLUSIONS

Within limitations of available observational data, our estimates do not provide evidence that bariatric surgery reduces cardiovascular disease and support equipoise for a randomized trial of bariatric surgery for cardiovascular disease prevention.

Cardiovascular and diabetes outcomes among patients with obesity and type 2 diabetes after metabolic bariatric surgery or glucagon-like peptide 1 receptor agonist treatment

BACKGROUND

With the increasing prevalence of obesity and type 2 diabetes, the availability of different treatment options remains essential. Studies comparing the outcomes of glucagon-like peptide 1 receptor agonists with those of metabolic bariatric surgery in patients with type 2 diabetes and obesity are lacking.

METHODS

Using propensity score matching, based on data from several nationwide clinical registries, patients who underwent primary metabolic bariatric surgery (Roux-en-Y gastric bypass or sleeve gastrectomy) were matched with patients who received glucagon-like peptide 1 receptor agonists. Outcome measures included the occurrence of major cardiovascular events, microvascular complications, and potential side effects (alcohol/substance abuse, self-harm, and fractures).

RESULTS

Over a mean follow-up of 7 years, major cardiovascular events occurred in 191 of 2039 patients (cumulative incidence 14.5%) in the surgery group compared with 247 of 2039 patients (19.6%) in the glucagon-like peptide 1 receptor agonist group (HR 0.75 (95% c.i. 0.62 to 0.91), P = 0.003). Patients in the surgery group had lower haemoglobin A1c values 5 years after treatment (mean difference 9.82 (95% c.i. 8.51 to 11.14) mmol/mol, P < 0.001) and fewer microvascular complications (retinopathy HR 0.88 (95% c.i. 0.79 to 0.99), P = 0.039; nephropathy HR 0.72 (95% c.i. 0.66 to 0.80), P < 0.001; and neuropathy or leg ulcers HR 0.82 (95% c.i. 0.74 to 0.92), P < 0.001), but a higher risk of alcohol/substance abuse (HR 2.56 (95% c.i. 1.87 to 3.50), P < 0.001), self-harm (HR 1.41 (95% c.i. 1.17 to 1.71), P < 0.001), and fractures (HR 1.86 (95% c.i. 1.11 to 3.12), P = 0.019).

CONCLUSION

Compared with glucagon-like peptide 1 receptor agonist treatment, metabolic bariatric surgery is associated with superior metabolic outcomes and a lower risk of major cardiovascular events in patients with type 2 diabetes and obesity, but a higher risk of alcohol/substance abuse, self-harm, and fractures.

Effect of tailoring biliopancreatic limb length based on total small bowel length versus standard limb length in one anastomosis gastric bypass: 1-year outcomes of the TAILOR randomized clinical superiority trial

BACKGROUND

Tailoring the biliopancreatic limb length in one anastomosis gastric bypass is proposed as beneficial in retrospective studies, yet randomized trials are lacking. The aim of this double-blind, single-centre RCT was to ascertain whether tailoring biliopancreatic limb length based on total small bowel length (TSBL) results in superior outcomes after one anastomosis gastric bypass compared with a fixed 150 cm biliopancreatic limb length.

METHODS

Eligible patients, meeting International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) criteria for metabolic bariatric surgery, scheduled for primary one anastomosis gastric bypass surgery, and willing to be randomized, underwent TSBL measurement during surgery. When TSBL measurement was feasible, patients were randomly assigned to a standard 150 cm biliopancreatic limb length or a tailored biliopancreatic limb based on TSBL: TSBL less than 500 cm, biliopancreatic limb 150 cm; TSBL 500-700 cm, biliopancreatic limb 180 cm; and TSBL greater than 700 cm, biliopancreatic limb 210 cm. The primary outcome was percentage total weight loss at 5 years.

RESULTS

Between September 2020 and August 2022, 212 patients were randomized into the standard biliopancreatic limb group (105 patients) or the tailored biliopancreatic limb group (107 patients). The mean(s.d.) TSBL was 657(128) cm (range 295-1020 cm). In the tailored group, 150, 180, and 210 cm biliopancreatic limb lengths were applied to 8.4%, 53.3%, and 38.3% of patients respectively. The mean(s.d.) 1-year percentage total weight loss was 32.8(6.9)% in the standard group and 33.1(6.2)% in the tailored group (P = 0.787). Nutritional deficiencies and short-term complications showed no significant differences.

CONCLUSION

Tailoring biliopancreatic limb length based on TSBL is safe and feasible. One year after surgery, it is not superior to a standard biliopancreatic limb length of 150 cm in terms of percentage total weight loss.

REGISTRATION NUMBER

Dutch Trial Register, NL7945.

Association of changes in appendicular skeletal muscle mass with weight loss and visceral fat reduction after laparoscopic sleeve gastrectomy

PURPOSE

Laparoscopic sleeve gastrectomy (LSG) drastically affects body composition. However, studies focusing on the association between the changes in the pre-and postoperative muscle mass and postoperative results are limited. We evaluated the association between changes in the muscle mass and weight loss and fat reduction.

METHODS

This retrospective study included 29 consecutive patients who underwent both LSG and a bioelectrical impedance analysis (BIA) consecutively. We investigated changes in the body composition on the BIA and visceral fat area (VFA) on computed tomography and correlational changes in muscle mass with weight loss and fat reduction.

RESULTS

The total weight loss (%TWL) 12 months after surgery was 30.9%. The VFAs pre- and postoperatively were 224 and 71.0 cm2, respectively. The fat mass (FM), percentage of FM, appendicular skeletal muscle mass (ASM), and skeletal muscle mass index (SMI) decreased from pre- to postoperatively (54.8 vs. 32.2 kg; 49.0 vs. 41.2%, 26.7 vs. 23.9 kg, 9.24 vs. 8.27, respectively), whereas the percentage of ASM (%ASM) increased (22.1 vs. 28.0%). The rate of change in %ASM positively correlated with weight loss and fat reduction (%TWL, rs = 0.65; %VFA loss, rs = 0.62).

CONCLUSION

The rate of change in %ASM was positively correlated with weight loss and fat reduction.

Metabolic disease remission after Roux-en-Y gastric bypass depends on preoperative disease severity: use of a new objective metabolic scoring system

BACKGROUND

Severity stratification and longitudinal evaluation of metabolic conditions in response to Roux-en-Y gastric bypass (RYGB) are not standardized. Our Assessment of Obesity-related Metabolic Comorbidities (AOMC) scoring tool combines pharmacotherapy and biochemical data to objectively define type 2 diabetes (T2D), hypertension (HTN), and dyslipidemia (DYS) severity. We previously showed that AOMC more accurately describes disease severity than clinical history alone.

OBJECTIVES

We aimed to show that AOMC more precisely and reproducibly measures metabolic disease response to RYGB and preoperative disease severity influences remission rates.

SETTING

University hospital, United States.

METHODS

AOMC scores for T2D, DYS, and HTN were calculated preoperatively and postoperatively (1-, 2-, and 5-years) for patients who underwent RYGB over 14 years. Generalized linear mixed-effect models were used to evaluate AOMC score trends and remission over time.

RESULTS

Of 351 patients, 214, 188, and 303, presented with any T2D, DYS, or HTN respectively. One-year remission rates were: T2D 57.1%, DYS 59.7%, and HTN 29.3%. Over 5 years post-RYGB, remission rates declined for T2D (P < .05) and DYS (P < .05) but remained steady for HTN (P > .05). Remission was associated with preoperative disease severity: those with premetabolic disease had the highest remission rates (i.e., 1-year: pre-T2D 81.4%, pre-DYS 91.4%, pre-HTN 53.5%, all P < .05), while those with most severe scores preoperatively (untreated/uncontrolled) had the lowest remission rates.

CONCLUSIONS

AOMC allows precise assessment of comorbidity severity and disease-specific postoperative quantification of comorbidity responses and remission rates. These findings can guide preoperative metabolic disease optimization and postoperative metabolic recovery expectations and standardize communication regarding comorbidity severity.

Cardioprotective benefits of metabolic surgery and GLP-1 receptor agonist-based therapies

Individuals with excessive adipose tissue and type 2 diabetes mellitus (T2DM) face a heightened risk of cardiovascular morbidity and mortality. Metabolic surgery is an effective therapy for people with severe obesity to achieve significant weight loss. Additionally, metabolic surgery improves blood glucose levels and can lead to T2DM remission, reducing major adverse cardiovascular outcomes (MACE). Glucagon-like peptide 1 (GLP-1) receptor agonists (GLP-1RAs) are a class of medication that effectively reduce body weight and MACE in patients with T2DM. This review explores the potential mechanisms underlying the cardioprotective benefits of metabolic surgery and GLP-1RA-based therapies and discusses recent evidence and emerging therapies in this dynamic area of research.

Rethinking weight loss treatments as cardiovascular medicine in obesity, a comprehensive review

The global escalation of obesity has made it a worldwide health concern, notably as a leading risk factor for cardiovascular disease (CVD). Extensive evidence corroborates its association with a range of cardiac complications, including coronary artery disease, heart failure, and heightened vulnerability to sudden cardiac events. Additionally, obesity contributes to the emergence of other cardiovascular risk factors including dyslipidaemia, type 2 diabetes, hypertension, and sleep disorders, further amplifying the predisposition to CVD. To adequately address CVD in patients with obesity, it is crucial to first understand the pathophysiology underlying this link. We herein explore these intricate mechanisms, including adipose tissue dysfunction, chronic inflammation, immune system dysregulation, and alterations in the gut microbiome.Recent guidelines from the European Society of Cardiology underscore the pivotal role of diagnosing and treating obesity to prevent CVD. However, the intricate relationship between obesity and CVD poses significant challenges in clinical practice: the presence of obesity can impede accurate CVD diagnosis while optimizing the effectiveness of pharmacological treatments or cardiac procedures requires meticulous adjustment, and it is crucial that cardiologists acknowledge the implications of excessive weight while striving to enhance outcomes for the vulnerable population affected by obesity. We, therefore, sought to overcome controversial aspects in the clinical management of heart disease in patients with overweight/obesity and present evidence on cardiometabolic outcomes associated with currently available weight management interventions, with the objective of equipping clinicians with an evidence-based approach to recognize and address CVD risks associated with obesity.

Cardiovascular autonomic neuropathy in diabetes: an update with a focus on management

Cardiovascular autonomic neuropathy (CAN) is an under-recognised yet highly prevalent microvascular complication of diabetes. CAN affects approximately 20% of people with diabetes, with recent studies highlighting the presence of CAN in prediabetes (impaired glucose tolerance and/or impaired fasting glucose), indicating early involvement of the autonomic nervous system. Understanding of the pathophysiology of CAN continues to evolve, with emerging evidence supporting a potential link between lipid metabolites, mitochondrial dysfunction and genetics. Recent advancements, such as streamlining CAN detection through wearable devices and monitoring of heart rate variability, present simplified and cost-effective approaches for early CAN detection. Further research on the optimal use of the extensive data provided by such devices is required. Despite the lack of specific pharmacological interventions targeting the underlying pathophysiology of autonomic neuropathy, several studies have suggested a favourable impact of newer glucose-lowering agents, such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists, where there is a wealth of clinical trial data on the prevention of cardiovascular events. This review delves into recent developments in the area of CAN, with emphasis on practical guidance to recognise and manage this underdiagnosed condition, which significantly increases the risk of cardiovascular events and mortality in diabetes.

Changes in use and hospital outcomes of bariatric surgery in Spain (2016-2022): analysis of the role of type 2 diabetes using propensity score matching

INTRODUCTION

The objectives of this study were to examine temporal trends in the incidence of bariatric surgery (Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG)) in patients with and without type 2 diabetes mellitus (T2DM). Outcomes of hospitalization and the impact of T2DM on these outcomes were also analyzed.

RESEARCH DESIGN AND METHODS

We performed an observational study with the Spanish national hospital discharge database. Obese patients with and without T2DM who underwent RYGB and SG between 2016 and 2022 were identified. Propensity score matching (PSM) and logistic regression were used to compare patients with and without T2DM and to evaluate the effect of T2DM and other variables on outcomes of surgery. A variable "severity" was created to cover patients who died in hospital or were admitted to the intensive care unit (ICU).

RESULTS

A total of 32,176 bariatric surgery interventions were performed (28.86% with T2DM). 31.57% of RYGBs and 25.53% of SG patients had T2DM. The incidence of RYGB and SG increased significantly between 2016 and 2022 (p<0.001), with a higher incidence in those with T2DM than in those without (incidence rate ratio 4.07 (95% CI 3.95 to 4.20) for RYGB and 3.02 (95% CI 2.92 to 3.14) for SG). In patients who underwent SG, admission to the ICU and severity were significantly more frequent in patients with T2DM than in those without (both p<0.001). In the multivariate analysis, having T2DM was associated with more frequent severity in those who received SG (OR 1.23; 95% CI 1.07 to 1.42).

CONCLUSIONS

Between 2016 and 2022, bariatric surgery procedures performed in Spain increased in patients with and without T2DM. More interventions were performed on patients with T2DM than on patients without T2DM. RYGB was the most common procedure in patients with T2DM. The presence of T2DM was associated with more severity after SG.

Continuous Glucose Monitoring Captures Glycemic Variability After Roux-en-Y Gastric Bypass in Patients with and Without Type 2 Diabetes Mellitus: A Prospective Cohort Study

PURPOSE

To evaluate glycemic variability (GV) using continuous glucose monitoring (CGM) in individuals with and without type 2 diabetes mellitus (T2DM) undergoing Roux-en-Y gastric bypass (RYGB).

METHODS

This prospective cohort study compared the CGM data of fourteen patients with T2DM (n = 7) and without T2DM (n = 7) undergoing RYGB. After 6 months, these patients were compared to a non-operative control group (n = 7) matched by BMI, sex, and age to the T2DM group.

RESULTS

Fourteen patients underwent RYGB, with a mean BMI of 46.9 ± 5.3 kg/m2 and an average age of 47.9 ± 8.9 years; 85% were female. After 6 months post-surgery, the total weight loss (TWL) was 27.1 ± 6.3%, with no significant differences between the groups. Patients without diabetes had lower mean interstitial glucose levels (81 vs. 94 and 98 mg/dl, p < 0.01) and lower glucose management indicator (GMI) (5.2 vs. 5.6 and 5.65%, p = 0.01) compared to the control and T2DM groups, respectively. The coefficient of variation (CV) significantly increased only in patients with diabetes (17% vs. 26.7%, p < 0.01). Both groups with (0% vs. 2%, p = 0.03) and without (3% vs. 22%, p = 0.03) T2DM experienced an increased time below range with low glucose (54-69 mg/dL). However, patients without T2DM had significantly less time in rage (70-180 mg/dL) (97% vs. 78%, p = 0.04).

CONCLUSION

Significant differences in CGM metrics among RYGB patients suggest an increase in glycemic variability after surgery, with a longer duration of hypoglycemia, especially in patients without T2DM.

Nutritional Challenges and Treatment After Bariatric Surgery

Bariatric surgery is an important weight loss tool in individuals with severe obesity. It is currently the most effective long-term weight loss treatment that lowers obesity-related comorbidities. It also has significant physiological and nutritional consequences that can result in gastrointestinal complications and micronutrient deficiencies. After gastric bypass, clinical events that negatively affect nutritional status include malabsorption, dumping syndrome, kidney stones, altered intestinal bile acid availability, bowel obstruction, ulcers, gastroesophageal reflux, and bacterial overgrowth. Risk factors for poor nutritional status and excessive loss of lean body mass and bone include reduced dietary quality and inadequate intake, altered nutrient absorption, and poor patient compliance with nutrient supplementation. There are unique concerns in adolescents, older individuals, and individuals who become pregnant postoperatively. With careful management, health-care professionals can assist with long-term weight loss success and minimize the risk of acute and long-term nutrition complications after bariatric surgery.

Targeting the incretin system in obesity and type 2 diabetes mellitus

Obesity and type 2 diabetes mellitus (T2DM) are widespread, non-communicable diseases that are responsible for considerable levels of morbidity and mortality globally, primarily in the form of cardiovascular disease (CVD). Changes to lifestyle and behaviour have insufficient long-term efficacy in most patients with these diseases; metabolic surgery, although effective, is not practically deliverable on the scale that is required. Over the past two decades, therapies based on incretin hormones, spearheaded by glucagon-like peptide 1 (GLP1) receptor agonists (GLP1RAs), have become the treatment of choice for obesity and T2DM, and clinical evidence now suggests that these agents have benefits for CVD. We review the latest advances in incretin-based pharmacotherapy. These include 'GLP1 plus' agents, which combine the known advantages of GLP1RAs with the activity of additional hormones, such as glucose-dependent insulinotropic peptide, glucagon and amylin, to achieve desired therapeutic goals. Second-generation non-peptidic oral GLP1RAs promise to extend the benefits of GLP1 therapy to those who do not want, or cannot have, subcutaneous injection therapy. We conclude with a discussion of the knowledge gaps that must be addressed before incretin-based therapies can be properly deployed for maximum benefit in the treatment of obesity and T2DM.

Validation of the Individualized Metabolic Surgery score in predicting long-term remission of diabetes after duodenal switch-type procedures

AIM

To validate the Individualized Metabolic Surgery (IMS) score and assess long-term remission of type 2 diabetes (T2D) after duodenal switch (DS)-type procedures in patients with obesity. In addition, to help guide metabolic procedure selection for those patients categorized as having severe T2D.

MATERIALS AND METHODS

This is a retrospective single cohort study of all patients with T2D and severe obesity, who underwent DS-type procedures at a single institution from December 2010 to December 2018. Study endpoints included validating the IMS score in our cohort and evaluating the impact of DS-type procedures on long-term (≥ 5 years) remission of T2D, especially in patients with severe disease. A receiver operator characteristic curve was used to assess the accuracy of the IMS score using the area under the curve (AUC).

RESULTS

The study cohort included 30 patients with complete baseline and long-term glycaemic data after their index DS-type surgery. Twelve patients (40%) were classified with severe T2D, and the distribution of IMS-based severity groups was similar between our cohort and the original IMS study (P = .42). IMS scores predicted long-term T2D remission with AUC = 0.77. Patients with IMS-based severe diabetes achieved significantly higher long-term remission after DS-type procedures compared with gastric bypass and/or sleeve gastrectomy from the original IMS study (42% vs. 12%; P < .05).

CONCLUSIONS

The IMS score properly classifies the severity of T2D in our study cohort and adequately predicts its long-term remission after DS-type procedures. While T2D remission decreases with more severe IMS scores, long-term remission remains high after DS-type procedures among patients with severe disease.

Bariatric surgery induces pancreatic cell transdifferentiation as indicated by single-cell transcriptomics in Zucker diabetic rats

AIMS

Bariatric surgery results in rapid recovery of glucose control in subjects with type 2 diabetes mellitus. However, the underlying mechanisms are still largely unknown. The present study aims to clarify how bariatric surgery modifies pancreatic cell subgroup differentiation and transformation in the single-cell RNA level.

METHODS

Male, 8-week-old Zucker diabetic fatty (ZDF) rats with obesity and diabetes phenotypes were randomized into sleeve gastrectomy (Sleeve, n = 9), Roux-en-Y gastric bypass (RYGB, n = 9), and Sham (n = 7) groups. Two weeks after surgery, the pancreas specimen was further analyzed using single-cell RNA-sequencing technique.

RESULTS

Two weeks after surgery, compared to the Sham group, the metabolic parameters including fasting plasma glucose, plasma insulin, and oral glucose tolerance test values were dramatically improved after RYGB and Sleeve procedures (p < .05) as predicted. In addition, RYGB and Sleeve groups increased the proportion of pancreatic β cells and reduced the ratio of α cells. Two multiple hormone-expressing cells were identified, the Gcg+/Ppy + and Ins+/Gcg+/Ppy + cells. The pancreatic Ins+/Gcg+/Ppy + cells were defined for the first time, and further investigation indicates similarities with α and β cells, with unique gene expression patterns, which implies that pancreatic cell transdifferentiation occurs following bariatric surgery.

CONCLUSIONS

For the first time, using the single-cell transcriptome map of ZDF rats, we reported a comprehensive characterization of the heterogeneity and differentiation of pancreatic endocrinal cells after bariatric surgery, which may contribute to the underlying mechanisms. Further studies will be needed to elucidate these results.

Remission of Obesity-Related Sleep Apnea and Its Effect on Mortality and Cardiovascular Events after Metabolic and Bariatric Surgery: A Propensity-Matched Cohort Study

BACKGROUND

Although obstructive sleep apnea (OSA) is common among patients with obesity and linked to cardiovascular disease, there is a lack of studies evaluating the effects of reaching remission from OSA after metabolic and bariatric surgery.

STUDY DESIGN

A registry-based nationwide study including patients operated with sleeve gastrectomy or Roux-en-Y gastric bypass from 2007 until 2019 in Sweden. Patients who reached remission of OSA were compared with those who did not reach remission and a propensity score-matched control group of patients without OSA at the time of operation. The main outcome was overall mortality, and secondary outcome was major cardiovascular events (MACEs).

RESULTS

In total, 5,892 patients with OSA and 11,552 matched patients without OSA completed a 1-year follow-up and were followed for a median of 6.8 years. Remission of OSA was seen for 4,334 patients (74%). Patients in remission had a lower risk for overall mortality (cumulative incidence 6.0% vs 9.1%; p < 0.001) and MACE (cumulative incidence 3.4% vs 5.8%; p < 0.001) at 10 years after operation compared with those who did not reach remission. The risk was similar to that of the control group without OSA at baseline (cumulative incidence for mortality 6%, p = 0.493, for MACE 3.7%, p = 0.251).

CONCLUSIONS

The remission rate of OSA was high after metabolic and bariatric surgery. This was in turn associated with reduced risk for death and MACE compared with patients who did not achieve remission reaching a similar risk seen among patients without OSA at baseline. A diligent follow-up of patients who do not reach remission remains important.

The Efficacy of Roux-en-Y Gastric Bypass in Young-Onset Diabetes Mellitus: A Narrative Review

Type 2 diabetes mellitus (T2DM) in youth is invading the communities because, if not controlled on time, the long-term complications include cardiovascular diseases, nephropathy, neuropathy, and retinopathy that cause immense mortality and morbidity. Lifestyle changes and antidiabetic drugs are considered the foundation of T2DM therapy. However, these adjustments usually do not effectively produce long-term glycemic regulation, especially in patients with obesity of the third and fourth degrees. Bariatric surgery has also been identified as an efficacious intervention for obesity and obesity-related complications such as T2DM. Roux-en-Y gastric bypass (RYGB) has proven to be one of the most effective procedures in causing considerable weight loss and enhancing glycemic changes. This review provides a comprehensive analysis of RYGB in patients with young-onset T2DM regarding the improvement of glycemic control, weight loss, and diabetes comorbidities. RYGB has been established as a practice in the treatment of T2DM and severe obesity. This narrative review underscores the various effects of RYGB, such as enhanced glycemic control, considerable and long-term weight loss, and reduced cardiovascular disease risks. However, the review also points toward the directions and the adverse effects of RYGB regarding metabolic and skeletal health. There are risks of nutritional deficiencies, increased fracture rates, and even relapse to diabetes, which make patient selection, proper pre and postoperative investigation, and critical monitoring.

Obesity and MASLD: Is weight loss the (only) key to treat metabolic liver disease?

Metabolic dysfunction-associated steatotic liver disease (MASLD) closely associates with obesity and type 2 diabetes. Lifestyle intervention and bariatric surgery aiming at substantial weight loss are cornerstones of MASLD treatment by improving histological outcomes and reducing risks of comorbidities. Originally developed as antihyperglycemic drugs, incretin (co-)agonists and SGLT2 inhibitors also reduce steatosis and cardiorenovascular events. Certain incretin agonists effectively improve histological features of MASLD, but not fibrosis. Of note, beneficial effects on MASLD may not necessarily require weight loss. Despite moderate weight gain, one PPARγ agonist improved adipose tissue and MASLD with certain benefit on fibrosis in post-hoc analyses. Likewise, the first THRβ-agonist was recently provisionally approved because of significant improvements of MASLD and fibrosis. We here discuss liver-related and metabolic effects induced by different MASLD treatments and their association with weight loss. Therefore, we compare results from clinical trials on drugs acting via weight loss (incretin (co)agonists, SGLT2 inhibitors) with those exerting no weight loss (pioglitazone; resmetirom). Furthermore, other drugs in development directly targeting hepatic lipid metabolism (lipogenesis inhibitors, FGF21 analogs) are addressed. Although THRβ-agonism may effectively improve hepatic outcomes, MASLD treatment concepts should consider all cardiometabolic risk factors for effective reduction of morbidity and mortality in the affected people.

Primary Versus Revisional Bariatric and Metabolic Surgery in Patients with a Body Mass Index ≥ 50 kg/m2-90-Day Outcomes and Risk of Perioperative Mortality

BACKGROUND

Bariatric and metabolic surgery (BMS) is an effective treatment for patients with severe obesity. Patients with higher body mass index (BMI) and patients undergoing revisional surgery have a higher rate of major complications. This study purpose is to evaluate perioperative outcomes of patients with BMI ≥ 50 kg/m2.

MATERIALS AND METHODS

A retrospective analysis of patients with a BMI ≥ 50 kg/m2 undergoing BMS between 2015 and 2023 was conducted. A comparative analysis was performed between patients undergoing primary versus revisional surgery.

RESULTS

A total of 263 patients were included in the study. Primary procedures were performed in 220 patients (83.7%) and revisional procedures in 43 patients (16.3%). BMS included one anastomosis gastric bypass (n = 183), sleeve gastrectomy (n = 63), and other procedures (n = 17). Mean BMI was 54.6 with no difference between groups. There was no difference in baseline characteristics except the revisional group was older (44.8 ± 9.6 versus 39 ± 13 years; p = 0.006), had higher rates of gastroesophageal reflux disease (21% vs 7.3%; p = 0.005), and fatty liver disease (74% vs 55%; p = 0.02). There was perioperative mortality in three cases (1.1%) with no significant difference between groups. Leak rates were higher, and length of stay (LOS) was longer in the revisional group (4.6% vs 0.45%; p = 0.018 and 2.9 vs 3.7; p = 0.006, respectively).

CONCLUSION

Revisional BMS in patients with a BMI ≥ 50 kg/m2 is associated with increased leak rates and LOS. Mortality rate is 1.1% and is insignificantly different between groups. Further prospective and large-scale studies are needed to clarify the optimal surgical approach to patients with extreme BMI including revisional surgery.