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

Post sleeve gastrectomy-enriched gut commensal Clostridia promotes secondary bile acid increase and weight loss

The gut microbiome is altered after bariatric surgery and is associated with weight loss. However, the commensal bacteria involved and the underlying mechanism remain to be determined. We performed shotgun metagenomic sequencing in obese subjects before and longitudinally after sleeve gastrectomy (SG), and found a significant enrichment in microbial species in Clostridia and bile acid metabolizing genes after SG treatment. Bile acid profiling further revealed decreased primary bile acids (PBAs) and increased conjugated secondary bile acids (C-SBAs) after SG. Specifically, glycodeoxycholic acid (GDCA) and taurodeoxycholic acid (TDCA) were increased at different follow-ups after SG, and were associated with the increased abundance of Clostridia and body weight reduction. Fecal microbiome transplantation with post-SG feces increased SBA levels, and alleviated body weight gain in the recipient mice. Furthermore, both Clostridia-enriched spore-forming bacteria and GDCA supplementation increased the expression of genes responsible for lipolysis and fatty acid oxidation in adipose tissue and reduced adiposity via Takeda G-protein-coupled receptor 5 (TGR5) signaling. Our findings reveal post-SG gut microbiome and C-SBAs as contributory to SG-induced weight loss, in part via TGR5 signaling, and suggest SBA-producing gut microbes as a potential therapeutic target for obesity intervention.

Regional trends and disparities in newer GLP1 receptor agonist initiation among real-world adult patients eligible for obesity treatment

AIMS

To characterize trends in the initiation of newer anti-obesity medications (AOMs) and determine factors associated with their use among obese/overweight populations.

MATERIALS AND METHODS

This study utilized electronic health record data from OneFlorida+ (2015-2024). Adults eligible for AOMs were included, defined as having a body mass index (BMI) ≥30 kg/m2 or a BMI of 27-29.9 kg/m2 with at least one obesity-related comorbidity. The primary outcome was the initiation of newer AOMs, specifically glucagon-like peptide-1 receptor agonists (GLP-1 RAs) including liraglutide, semaglutide and tirzepatide. Trends across years were examined, and a multivariable logistic regression identified sociodemographic, clinical and healthcare utilization factors associated with AOM initiation.

RESULTS

Of 319,949 adults, 1.8% initiated newer AOMs. Semaglutide accounted for 77.9% of initiations, tirzepatide 19.7% and liraglutide 17.8%. Initiation trends showed liraglutide uptake peaked at 5% in 2018 but declined afterward, while semaglutide and tirzepatide uptake increased exponentially since 2022. Odds of initiation were lower for Black (aOR [95% CI]: 0.87 [0.80-0.94]) and Hispanic (0.84 [0.78-0.91]) groups versus Whites, and for Medicaid (0.69 [0.63-0.76]) and uninsured (0.81 [0.74-0.87]) patients versus privately insured. Higher odds were associated with being female, middle-aged, having more outpatient visits and visiting endocrinologists.

CONCLUSIONS

The initiation of newer AOMs among overweight and obese populations remains low, but uptake has increased exponentially since 2022. Our findings reveal significant disparities in obesity care, highlighting the importance of addressing inequities in AOM access to improve obesity outcomes.

Clinical outcomes of roux-en-Y gastric bypass versus medical therapy in type 2 diabetes mellitus: a systematic review and meta-analysis

Background

The growing incidence of obesity has led to a proportionate rise in type 2 diabetes mellitus (T2DM) and its associated complications. We aimed to compare the long-term outcomes of Roux-en-y Gastric Bypass surgery (RYGB) and conventional medical management in T2DM obese patients.

Methods

PubMed, Google Scholar, and Clinicaltrial.gov were searched from inception to September 2023. Randomized Controlled Trials (RCTs) and cohort studies were included in this meta-analysis. The primary outcomes were the T2DM remission at 1, 2, 3, and 5 years and the accomplishment of the ADA composite triple treatment goal. The revised Cochrane risk of bias tool 2.0 and New-Castle Ottawa scale were used to assess the quality of the studies. This meta-analysis was registered prospectively on PROSPERO CRD42023466324.

Results

Of the 3,323 studies yielded from our initial search, 22 were included in this evidence analysis, with 5,176 total patients (1,984 and 3,192 patients in RYGB and conventional medical management groups). A significant increase in the accomplishment in the ADA's composite triple treatment goal was observed in RYGB group as compared to the conventional medical management group (RR 2.41, 95% CI 1.39-4.15, p-value 0.002, I2 35%). Diabetes remission was a clinically successful outcome after 1, 2, 3, and 5 years of the RYGB surgery in the patients (1 year; RR 4.74, 95%CI 2.46-9.12, p-value < 0.00001, I2 0%, 2 years; RR 8.95, 95% CI 1.71-46.71, p-value 0.009, I2 92%3 years; RR 18.18 95%CI 7.57-43.62, p-value < 0.00001, I2 0%, 5 years; RR 0.22, 95% CI 2.31-16.75, p-value 0.0003, I2 = 71%).

Conclusion

The pooled analysis of the given data concluded that the RYGB surgery was more effective in treating T2DM in patients than conventional medical management.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-024-01526-z.

Predictors of diabetes remission after bariatric surgery in patients with type 2 diabetes mellitus duration ≥ 10 years: A retrospective cohort study

OBJECTIVE

Patients with type 2 diabetes mellitus (T2DM) duration ≥ 10 years often have significant β-cell failure. This study aimed to explore predictors of diabetes remission after bariatric surgery in these patients.

METHODS

Patients with T2DM duration ≥ 10 years who underwent bariatric surgery were retrospective included and followed up. Remission of diabetes was defined as an HbA1c < 6.5 % (48 mmol/mol) at least 3 months after the discontinuation of hypoglycemic drugs. An intravenous glucose tolerance test (IVGTT) was performed in patients with diabetes remission.

RESULTS

203 patients with T2DM duration ≥ 10 years were included, 59.6 % were treated with insulin before bariatric surgery. One-, two- and three-year post-surgery remission rates were 65.6 %, 53.8 % and 41.9 %, respectively (∼10 % decrease/year). Cox regression analysis revealed that the odds of remission at one-year post-bariatric surgery were most strongly associated with β-cell function (HR 1.20, 95 % CI 1.03-1.40) and percentage of total weight loss (%TWL) (HR 1.04, 95 % CI 1.01-1.07). The first-phase insulin secretion peak was approximately 5-8 folds of the fasting insulin level in 50 patients with diabetes remission.

CONCLUSIONS

%TWL and β-cell function are significantly associated with diabetes remission after bariatric surgery in long-duration T2DM patients, with restored first-phase insulin secretion still observed.

Meta-analysis of randomized controlled trials for the development of the International Federation for Surgery of Obesity and Metabolic Disorders-European Chapter (IFSO-EC) guidelines on multimodal strategies for the surgical treatment of obesity

BACKGROUND

Randomized, controlled trials (RCTs) comparing the effectiveness of metabolic bariatric surgery (MBS) in addition to one or more treatment interventions for obesity (i.e., lifestyle structured interventions-LSI, medical therapy-MT, obesity management medication-OMM or endobariatric procedures-EP) are lacking. This study aims to assess the effectiveness of multiple simultaneous (before or immediately after MBS) interventions for treating obesity.

METHODS

We performed a meta-analysis including all RCTs enrolling patients undergoing different MBS procedures add-on to other anti-obesity strategies (LSI, MT, OMM or ES) versus MBS alone, with a duration of at least 6 months. The primary outcome was BMI at the end-point; secondary end-points included percentage total and excess weight loss (%TWL%, and EBWL%), total weight loss (TWL), fasting plasma glucose (FPG), HbA1c, surgical and non-surgical severe adverse events (SAE), mortality, remission of type 2 diabetes, hypertension, dyslipidemia and health-related quality of life (HR-QoL).

RESULTS

A total of 25 RCTs were retrieved. The addition of either OMM (i.e., liraglutide) or EP (i.e., intragastric balloon-IB, endosleeve-ES) to MBS was associated with a significantly lower BMI at the end-point (p = 0.040). The addition of liraglutide only to MBS was associated with a greater %EWL%, but not %TWL and TBWL (p = 0.008). Three trials evaluated end-point HbA1c, showing a significant reduction in favour of liraglutide as an add-on therapy to MBS (p = 0.007). There was no mortality.

CONCLUSIONS

MBS combined with non-surgical approaches appears more effective than MBS alone in reducing BMI. Further RCTs on combined therapies to MBS for severe obesity are needed to enhance the tailoring of treatment for severe obesity.

Long-Term Outcomes of Sleeve Gastrectomy at a Veterans Affairs Medical Center

Introduction: Laparoscopic sleeve gastrectomy (LSG) is the most common bariatric procedure for morbid obesity. However, there is limited data on long-term outcomes in the veteran population. This study attempts to determine long-term weight loss and resolution of comorbidities following an LSG in a veteran population. Methods: A retrospective review was performed of a prospectively maintained database of LSG patients at a single veterans Affairs Medical Center from 2013 to 2019. Patient preoperative factors, 5-year weight loss, resolution of comorbidities, and morbidities were collected and analyzed using univariate and multivariate analysis. An alpha level of 0.05 was used to determine significance. Statistical analyses were performed by using SAS version 9.4. Results: A total of 153 patients underwent LSG, with 98.7% completing a 5-year follow-up. At 5 years, rates of diabetes (50.9% versus 37.7%, P < .001), hypertension (59.2% versus 49.7%, P < .001), gastroesophageal reflux disease (51.6% versus 40.9%, P < .001), and sleep apnea (67.3% versus 40.9%, P < .001) were significantly reduced from baseline. Average total weight lost was 13.5% from baseline weight, with no perioperative mortalities. Preoperative body mass index (BMI) was the only factor predictive of postoperative BMI. Conclusions: LSG remains a safe and effective option for veterans with morbid obesity with concurrent resolution of several comorbidities. As the treatment of obesity continues to evolve, postoperative data remains critical to guide patient care.

Approach to Lipid Management in the Patient With Diabetes

Diabetes is associated with increased atherosclerotic cardiovascular disease (ASCVD) risk, a leading cause of morbidity and mortality. Disordered lipid metabolism is a major contributor to ASCVD risk in diabetes. Dyslipidemia in type 2 diabetes is characterized by hypertriglyceridemia, low high-density lipoprotein cholesterol and the presence of small, dense low-density lipoprotein particles. Statins have demonstrated longstanding benefit for reducing ASCVD risk in individuals with diabetes. Newer agents for add-on therapies to statins are now available for additional cardiovascular risk reduction. In this clinical overview, we review the pathogenesis of dyslipidemia in both type 1 and 2 diabetes and provide an update on the management of lipids in the individual with diabetes. We discuss the importance of appropriate risk stratification and individualized treatment selection and the need to avoid therapy inertia to mitigate cardiovascular risk. We also address lipid-related effects of glycemic-lowering therapies.

Patient and operative characteristics of readmission and poly-readmission following metabolic surgery: an MBSAQIP analysis (2015-2021)

BACKGROUND

Recently, same-day Metabolic Surgery (MS) has gained traction, especially to reduce costs and hospital resource utilization. While shorter hospital stays are desirable, accelerated discharge could increase postoperative burden for those patients at risk. This study evaluated whether specific patient characteristics are associated with increased 30-day readmission rates and number of readmissions as a potentially identifying those less suited for same-day discharge.

METHODS

Using the MBSAQIP (2015-2021), 960,757 cases of primary minimally invasive sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and duodenal switch (DS) were included. Readmission characteristics were extracted from ancillary Participant Use Files (PUF) and linked to the main MBSAQIP data. Zero-inflated Poisson (ZIP) models assessed associations between preoperative patient characteristics and readmission risk. The two-stage models analyzed odds of any 30-day readmission and calculated the relative risk (RR) of multiple readmissions.

RESULTS

Several key predictors of single as well as multiple readmissions in the first 30 days following intervention were noted. Black or Hispanic race, BMI, diabetes, COPD, GERD, and therapeutic anticoagulation were associated with increased odds of readmission likelihood after MS. Black race and GERD predicted increased readmission frequency (multiple readmissions) among all readmission cases, while those aged ≥ 40 years and Hispanic race were less likely to require multiple readmissions.

CONCLUSION

This large-scale MS analysis highlights patient characteristics that should be carefully considered by MS providers during patient counseling and consideration of same-day discharge. Readmission poses significant financial, physiological, and psychological burdens emphasizing the need for careful patient evaluation and counseling, particularly for those at higher risk, to optimize patient outcomes in the context of accelerated discharge protocols.

Effect of Gastric Bypass vs Sleeve Gastrectomy on Remission of Type 2 Diabetes Mellitus Among Patients with Severe Obesity: A Meta-Analysis

BACKGROUND

Obesity and type 2 diabetes mellitus (T2DM) are global health crises, with bariatric surgery emerging as a key intervention. However, the comparative efficacy of Roux-en-Y gastric bypass (RYGB) versus sleeve gastrectomy (SG) in achieving diabetes remission remains debated.

METHODS

This PRISMA-compliant meta-analysis included three randomized controlled trials (RCTs, n = 613 patients) comparing RYGB and SG in adults with severe obesity (BMI ≥30 kg/m²) and T2DM.

PRIMARY OUTCOME

diabetes remission (HbA1c 6.0%). Risk of bias was assessed via Cochrane RoB-2 tool; statistical analysis used fixed-effect models (I²=0%).

RESULTS

RYGB demonstrated superior diabetes remission rates vs. SG (OR 2.77, 95% CI 1.83-4.20, p0.001), with no heterogeneity. Subgroup analyses confirmed consistency across studies. Mean follow-up was ≤5 years; baseline demographics were comparable (mean age 46.2 years, 53.4% male).

CONCLUSION

RYGB significantly outperforms SG in achieving T2DM remission, likely due to its combined restrictivemalabsorptive mechanisms and metabolic hormonal effects. These findings support RYGB as the preferred surgical option for obese patients with T2DM, though long-term studies are needed to assess durability.

Assessing academic impact through a bibliometrics analysis: Gastroesophageal reflux disease in the context of obesity treatment and bariatric surgery

Aims

The global rise in obesity rates has led to increased use of bariatric surgery, which can potentially exacerbate or induce gastroesophageal reflux disease. This study aimed to assess the academic impact and trends in research on gastroesophageal reflux disease in the context of obesity treatment and bariatric surgery through a comprehensive bibliometric analysis.

Materials and methods

A bibliometric analysis was conducted using data from Web of Science and Scopus databases, covering publications from 1993 to 2024. The study utilized the Bibliometrix R package to analyze publication trends, collaborative networks, and research topics.

Results

The analysis encompassed 257 documents from 82 sources, with 6192 total citations and an 8.2% annual growth rate in publications. The United States emerged as the leading contributor with 90 publications. Key research topics included bariatric surgery, sleeve gastrectomy, and gastroesophageal reflux disease, with increasing focus on complications and revisional bariatric surgery in recent years. Two main research clusters were identified: one focusing on general health aspects and demographics, and another on specialized bariatric procedures and outcomes. However, the analysis is constrained by its reliance on data from only two bibliographic databases, which may not encompass all pertinent studies, and by a geographic bias toward high-income countries. Moreover, our deep literature reviews highlighted that obesity is a known risk factor for gastroesophageal reflux disease, and while Roux-en-Y gastric bypass often reduces gastroesophageal reflux disease symptoms, sleeve gastrectomy may exacerbate or cause de novo gastroesophageal reflux disease postoperatively.

Conclusions

This bibliometric study reveals a significant increase in research activity on gastroesophageal reflux disease in relation to obesity treatment and bariatric surgery, particularly since 2017. The findings highlight the growing importance of this field and the need for continued international research efforts to optimize surgical protocols and improve patient outcomes.

First-in-Human Linear Magnetic Jejuno-Ileal Bipartition: Preliminary Results with Incisionless, Sutureless, Swallowable Technique

BACKGROUND

Minimally invasive surgery may be further advanced with the novel biofragmentable magnetic anastomosis compression system. Two magnets may be swallowed, or placed by flexible endoscopy, in a side-to-side magnetic jejuno-ileostomy (MagJI) bipartition for weight and type 2 diabetes (T2D) reduction. MagJI markedly reduces the major complications of enterotomy, stapling/suturing, and retained foreign materials.

METHODS

This was a prospective first-in-human investigation of feasibility, safety, and preliminary efficacy in adults with body mass index (BMI, kg/m2) ≥ 30.0- ≤ 40.0. After serial introduction via swallowing or endoscopy, linear magnets were laparoscopically guided to the distal ileum and proximal jejunum where they were aligned. Magnets fused over 7-21 days forming jejuno-ileostomy.

PRIMARY ENDPOINTS

feasibility and severe adverse event (SAEs) incidence (Clavien-Dindo grade); secondary endpoints: weight, T2D reduction.

RESULTS

Between 3-1 - 2024 and 6-30 - 2024, nine patients (mean BMI 37.3 ± 1.1) with T2D (all on T2D medications; mean HbA1C 7.1 ± 0.2%, glucose 144.8 ± 14.3 mg/dL) underwent MagJI. Mean procedure time: both magnets swallowed, 86.7 ± 6.3 min; one magnet swallowed with second delivered endoscopically, 113.3 ± 17.0 min. Ninety-day feasibility confirmed in 100.0%: 0.0% bleeding, leakage, infection, mortality. Most AEs grade I-II; no SAEs. At 6-month radiologic confirmation, all anastomoses were patent. Excess weight loss 17.5 ± 2.8 kg; mean BMI reduction 2.2 ± 0.3, HbA1C 6.1 ± 0.1% (p < 0.01), glucose 115.5 ± 6.5 mg/dL (p = 0.19); 83.0% dropped below 6.5% HbA1C and had markedly reduced anti-T2D medications.

CONCLUSIONS

The swallowable, biofragmentable magnetic anastomosis system appeared to be feasible and safe in achieving incisionless, sutureless jejuno-ileostomy. The first-in-human MagJI procedure may offer minimally complicated anastomosis creation and moderate MBS weight loss and T2D reduction.

Major Adverse Cardiac Events After Gastric Bypass vs Sleeve Gastrectomy

Importance

Metabolic bariatric surgery is the most effective and durable treatment for weight loss and improvement of cardiovascular diseases. With sleeve gastrectomy now surpassing gastric bypass as the most common procedure worldwide, comparing these procedures' associations with major adverse cardiac events (MACE) is needed.

Objective

To compare the risk of MACE among individuals undergoing gastric bypass or sleeve gastrectomy.

Design, Setting, and Participants

This population-based, inverse probability-weighted cohort study was conducted using administrative claims data from Switzerland among adults undergoing gastric bypass or sleeve gastrectomy for obesity treatment between January 2012 and December 2022. Inpatient individuals with a primary or secondary discharge procedure code for gastric bypass or sleeve gastrectomy were eligible for inclusion. Data were analyzed from April 2024 to September 2025.

Exposure

Gastric bypass vs sleeve gastrectomy.

Main Outcomes and Measures

A weighted cohort was analyzed to study the primary outcome of 4-point MACE, including acute myocardial infarction, ischemic stroke, hospitalizations for heart failure, and all-cause mortality. Secondary outcomes were the individual components of MACE, surgical reinterventions, and associated complications.

Results

Of 39 067 patients, 30 270 patients (77.5%) underwent gastric bypass and 8798 patients (22.5%) underwent sleeve gastrectomy. Median (IQR) patient age was 42 (35-50) years, and 28 560 patients (73.1%) were women. A total of 23 708 patients (60.7%) had a body mass index (calculated as weight in kilograms divided by height in meters squared) of 40 or higher. After weighting, over a median (IQR) follow-up of 5.1 years (2.6-7.6), the primary outcome occurred in 577 patients in the gastric bypass group (1.9%) and 264 patients in the sleeve gastrectomy group (3.0%), with incidence rates of 3.96 and 5.10 per 1000 patient-years, respectively (hazard ratio [HR], 0.75; 95% CI, 0.64-0.88). This difference was primarily driven by lower rates of acute myocardial infarction (HR, 0.63; 95% CI, 0.46-0.86). No differences were observed in ischemic stroke, hospitalization for heart failure, and all-cause mortality. Both short- and long-term secondary outcomes favored gastric bypass over sleeve gastrectomy, except for higher rates of revision surgery and immediate postoperative complications.

Conclusions and relevance

In this inverse probability-weighted cohort study, for patients undergoing metabolic bariatric surgery, gastric bypass was associated with lower rates of MACE than sleeve gastrectomy over a follow-up period of up to 11 years. Known postoperative complications were confirmed for both gastric bypass and sleeve gastrectomy.

Clinical staging to guide management of metabolic disorders and their sequelae: a European Atherosclerosis Society consensus statement

Obesity rates have surged since 1990 worldwide. This rise is paralleled by increases in pathological processes affecting organs such as the heart, liver, and kidneys, here termed systemic metabolic disorders (SMDs). For clinical management of SMD, the European Atherosclerosis Society proposes a pathophysiology-based system comprising three stages: Stage 1, where metabolic abnormalities such as dysfunctional adiposity and dyslipidaemia occur without detectable organ damage; Stage 2, which involves early organ damage manifested as Type 2 diabetes, asymptomatic diastolic dysfunction, metabolic-associated steatohepatitis (MASH), and chronic kidney disease (CKD); and Stage 3, characterized by more advanced organ damage affecting multiple organs. Various forms of high-risk obesity, driven by maintained positive energy balance, are the most common cause of SMD, leading to ectopic lipid accumulation and insulin resistance. This progression affects various organs, promoting comorbidities such as hypertension and atherogenic dyslipidaemia. Genetic factors influence SMD susceptibility, and ethnic disparities in SMD are attributable to genetic and socioeconomic factors. Key SMD features include insulin resistance, inflammation, pre-diabetes, Type 2 diabetes, MASH, hypertension, CKD, atherogenic dyslipidaemia, and heart failure. Management strategies involve lifestyle changes, pharmacotherapy, and metabolic surgery in severe cases, with emerging treatments focusing on genetic approaches. The staging system provides a structured approach to understanding and addressing the multi-faceted nature of SMD, which is crucial for improving health outcomes. Categorization of SMD abnormalities by presence and progression is aimed to improve awareness of a multi-system trait and encourage a tailored and global approach to treatment, ultimately aiming to reduce the burden of obesity-related comorbidities.

Indications and Outcomes of Laparoscopic Versus Robotic Conversional Bariatric Surgery: An MBSAQIP Study

BACKGROUND

Conversional bariatric surgeries (CBS) are performed using laparoscopic and robotic techniques, but comprehensive data comparing these approaches remains scarce.

OBJECTIVE

To compare the indications and outcomes of laparoscopic versus robotic CBS.

METHODS

The MBSAQIP database was retrospectively analyzed from 2020 to 2022, comparing laparoscopic and robotic CBS. Primary outcomes were 30-day serious complications and mortality.

RESULTS

Of 72,189 CBS procedures, 75.4% were laparoscopic and 24.6% robotic. Mean age and BMI were similar between groups. The most common indications for both approaches were reflux, weight regain, and inadequate weight loss, with reflux being more prevalent in robotic CBS (38.3% vs 33.2%). Sleeve-to-bypass was the most common procedure in both groups (35.8% laparoscopic, 44.2% robotic). Robotic CBS had longer mean operative times (165.4 vs 121.7 min, p < 0.001) and slightly longer hospital stays (1.7 vs 1.6 days, p < 0.001). The rate of serious complications was slightly higher for robotic CBS, though not statistically significant (6.5% vs 6.1%, p = 0.08). Robotic CBS had higher rates of leak (0.9% vs 0.7%, p = 0.071), reoperation (2.8% vs 2.6%, p = 0.138), and readmission (6.7% vs 5.4%, p < 0.001). Mortality rates were similar (0.1% for both, p = 0.942).

CONCLUSIONS

Both laparoscopic and robotic CBS show similar safety profiles with comparable mortality rates. However, robotic CBS was associated with longer operative times, slightly longer hospital stays, and higher readmission rates. These findings suggest that the choice between approaches should consider individual patient factors and institutional expertise.

Long-term changes in lipid indices following Roux-en-Y gastric bypass: a meta-analysis

INTRODUCTION

Bariatric surgery yields clinically significant long-term weight loss accompanied by marked improvements in numerous weight-related comorbidities including type 2 diabetes, hypertension, dyslipidemia, obstructive sleep apnea, and fatty liver disease.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the effect of (RYGB) surgery on lipid profile.

DATA SOURCE

We searched PubMed, Scopus, Web of Science and Scholar from inception to May 20th, 2024.

STUDIES SELECTION

Clinical studies that reported lipid profile data with a follow-up of at least 5 years after RYGB were eligible.

DATA EXTRACTION

Two independent reviewers extracted data and assessed the risk of bias.

RESULTS

Of the 4922 articles identified from our database search, 38 studies that measured lipid profile following RYGB were identified and selected for the analysis. Compared to pre-surgery, at post-surgery follow-up of ≥ 5 years, RYGB was associated with significant reductions in mean total cholesterol (TC) (WMD: - 17.95 mg/dl, 95% CI: - 22.68, - 13.22, 95% PI: - 46.18, 10.27 p < 0.001; I2:92.3), LDL-cholesterol (WMD: - 18.55 mg/dl, 95% CI: -21.85, -15.25, 95% PI: - 39.01, 1.92 p < 0.001; I2:91.8), and triglycerides (WMD: - 60.76 mg/dl, 95% CI: - 66.29, - 55.22, 95% PI: - 91.24, - 30.27 p < 0.001; I2:83.7), and increase in HDL-cholesterol (WMD: 13.75 mg/dl, 95% CI: 12.38, 15.13, 95% PI: 5.32, 22.19 p < 0.001; I2:91.4).

CONCLUSION

RYBG is associated with clinically significant large improvements in serum lipids at a post-operative follow-up of 5 years or more.

Global status and trends in type 2 diabetes remission from 2002 to 2022: A bibliometric and visual analysis

Type 2 diabetes mellitus (T2DM) is estimated to impact 693 million individuals globally by 2045. Diabetes remission has the potential to slow disease progression, alleviate psychological burdens, minimize complications, and improve quality of life. We aimed to perform a bibliometric analysis of research on T2DM remission. We searched the Web of Science (WoS) database to identify relevant publications on T2DM remission during 2002 to 2022. Research trends and hotspots in T2DM remission were analyzed using Bibliometrix R and CiteSpace. The analysis considered various factors such as publication year, authors, journal, institution, country/region, themes, thematic evolution, keywords, and keyword bursts. The WoS search yielded 2254 articles. The annual scientific output has consistently increased. Lee was the most prolific author (48 papers). Obesity surgery was the leading journal (296 publications), while diabetes care had the highest h_index (43). The University of Copenhagen was the most active institution (116 papers). The most productive countries were the US (476), China (347), the UK (180), Italy (121), and Japan (90). The top 3 keywords were "bariatric surgery," "weight loss," and "remission." From 2013 to 2015, the usage of the term "medical therapy" significantly surged, lasting for 3 years. The term "GLP-I receptor agonists" also had a lasting burst. In the past 5 years, "weight loss" and "low-calorie diets" have emerged as prominent areas of research. This study analyzed the research trends and key factors in the field of type 2 diabetes mitigation through bibliometrics, providing important data support and a basis for decision-making for future research and public health policies.

Effect of gastric bypass versus sleeve gastrectomy on the remission of type 2 diabetes, weight loss, and cardiovascular risk factors at 5 years (Oseberg): secondary outcomes of a single-centre, triple-blind, randomised controlled trial

BACKGROUND

For individuals with obesity and type 2 diabetes, weight loss improves insulin sensitivity and β-cell function and can induce remission of diabetes. However, the long-term comparative effectiveness of standard gastric bypass and sleeve gastrectomy on remission of type 2 diabetes remains unclear. We aimed to compare the effects of gastric bypass and sleeve gastrectomy on type 2 diabetes remission, weight loss, and cardiovascular risk factors 5 years after surgery.

METHODS

We present a secondary analysis of a two-armed, single-centre, triple-blind, randomised controlled trial conducted at a public tertiary obesity centre in Norway. Adults (ie, age ≥18 years) with type 2 diabetes and obesity were randomly assigned (1:1) by a computerised random number generator to laparoscopic gastric bypass or sleeve gastrectomy, with balanced block sizes of ten. Study personnel, participants, and the primary-outcome assessor were all masked to the allocation until 1 year after surgery, after which further follow-up was open label. Changes in key secondary outcomes, including type 2 diabetes remission, weight loss, and cardiovascular risk factors, were assessed 5 years after surgery. The trial procedure estimand assessed treatment effects in all randomised participants, with data collected after conversional surgery removed from analyses. The trial was registered with ClinicalTrials.gov (NCT01778738) and was completed in December, 2022.

FINDINGS

Between Oct 15, 2012, and Sept 1, 2017, 319 patients were assessed for eligibility, resulting in 109 participants who were randomly assigned to gastric bypass (n=54) or sleeve gastrectomy (n=55). The baseline mean age was 47·7 years (SD 9·6), mean BMI 42·3 kg/m2 (SD 5·3), 72 (66%) were women, and 37 (34%) were men. 93 (85%) participants completed 5-year follow-up (47 [85%] in the sleeve gastrectomy group and 46 [85%] in the gastric bypass group). The proportions with remission of type 2 diabetes were higher after gastric bypass than after sleeve gastrectomy (HbA1c ≤6·0% 23 [50%] of 46 vs nine [20%] of 44, risk difference 29·5% [95% CI 10·8 to 48·3]; HbA1c <6·5% 29 [63%] vs 13 [30%], risk difference 33·5% [14·1 to 52·9]). Gastric bypass provided greater loss in bodyweight (mean 22·2% [95% CI 20·3 to 24·1] vs 17·2% [15·3 to 19·1], treatment difference 5·0% [2·4 to 7·7]) and lower LDL-cholesterol (treatment difference -0·5 mmol/L [-0·8 to -0·1]). The prevalence of erosive oesophagitis and Barrett's oesophagus was similar between groups, whereas pathological acid reflux occurred more frequently after sleeve gastrectomy (risk difference 51·1% [28·0 to 74·2]). More participants had symptomatic postprandial hypoglycaemia after gastric bypass than after sleeve gastrectomy (15 [28%] vs one [2%]).

INTERPRETATION

Gastric bypass was superior to sleeve gastrectomy regarding long-term remission of type 2 diabetes, weight loss, and LDL cholesterol concentrations, at the expense of a higher frequency of symptomatic postprandial hypoglycaemia. These findings could inform clinical practice and future guidelines regarding the preferred surgical procedure in patients with type 2 diabetes.

FUNDING

Vestfold Hospital Trust.

TRANSLATION

For the Norwegian translation of the abstract see Supplementary Materials section.

Obesity and Metabolic Health in CKD

Obesity is a worldwide epidemic with a future projected growth of 40% over 10 years. Obesity increases the risk of diabetes, hypertension, and cardiovascular disease, and it also leads to higher risk of CKD, through both direct and indirect mechanisms. Although obesity is a feature of overnutrition and is associated with poor outcomes in the general population, obese individuals with CKD often display complex metabolic patterns such as sarcopenic obesity, and obesity can be associated with better survival in individuals with advanced CKD. Weight loss interventions are proven to improve glycemic control and cardiovascular risk factors, and successful weight loss is associated with improved albuminuria in patients with preexisting CKD. The long-term effects of weight loss interventions on kidney function and on survival in patients with CKD are less well studied, and hence, such interventions should be individualized.

Comparison of SADI-S Versus SG in Chinese with Diabetes and BMI < 35 kg/m2:a Retrospective Study with Medium-Term Outcomes

BACKGROUND

As a modification of the duodenal switch (DS), the single-anastomotic ileo-ileal bypass combined with sleeve gastrectomy (SADI-S) has recently gained popularity and has been successfully employed for weight loss and the remission of type 2 diabetes mellitus (T2DM). However, current studies predominantly focus on patients with severe obesity.

OBJECTIVES

In this study, we present the first comparison of single-anastomotic duodenoileal bypass combined with sleeve gastrectomy (SADI-S) and sleeve gastrectomy (SG) for the mid-term treatment of Chinese diabetic patients with a BMI < 35 kg/m2. This research provides comparative reports on the efficacy of these two surgical approaches.

PATIENTS AND METHODS

We included 53 diabetic patients with BMI < 35 kg/m2 who underwent either SADI-S or SG and were followed for 2 years postoperatively. Demographic characteristics, weight loss, and nutritional and metabolic outcomes were analyzed at 3-month, 6-month, 1-year, and 2-year follow-up intervals. All surgeries were performed by the same surgeon at a single weight loss center in China between July 2015 and November 2022.

RESULTS

A total of 24 patients who underwent Single Anastomosis Duodenal-Ileal Bypass with Sleeve Gastrectomy (SADI-S) and 29 patients who underwent Sleeve Gastrectomy (SG) were included in our analysis. Comparative analysis of the baseline indicators between the two groups revealed no statistically significant differences (P > 0.05).Both patient groups completed a 2-year follow-up. In terms of weight loss, the SADI-S group demonstrated superior outcomes compared to the SG group, with better results in weight, BMI, and total weight loss percentage (%TWL) at the 2-year follow-up, and these differences were statistically significant (66.9 ± 7.9 vs. 61.2 ± 6.6, p = 0.007; 23.8 ± 2.0 vs. 21.7 ± 1.6, p = 0.000; 31.1% ± 6.3% vs. 24.4% ± 6.4%, p = 0.000). Regarding diabetes remission, the SADI-S group also outperformed the SG group (p = 0.000). Specifically, 91.8% of patients in the SADI-S group achieved complete remission of T2DM, compared to 41.4% in the SG group (p = 0.000). Furthermore, the SADI-S group showed significantly better results in the remission of hyperlipidemia compared to the SG group.However, there was no significant difference in hypertension relief between the SADI-S group and the SG group. Additionally, the incidence of postoperative hypozincemia was significantly higher in the SADI-S group compared to the SG group (p = 0.038). No significant differences were observed in other postoperative nutritional outcomes between the two groups.

CONCLUSION

In Chinese diabetic patients with a BMI < 35 kg/m2, both SADI-S and SG were effective in treating obese T2DM.However, compared with SG, primary SADI-S can achieve better weight loss and remission of obesity-related metabolic diseases.Additionally, the rates of postoperative nutritional deficiencies were found to be acceptable. Nonetheless, multicenter studies with larger sample sizes and longer follow-up periods are necessary to draw definitive conclusions.

Sleeve gastrectomy as a bridge to cardiac recovery - A retrospective comparative cohort study

Background

Obesity in patients with heart failure with reduced ejection fraction (HFrEF) increases morbidity and may preclude them from accessing advanced heart failure therapies. Bariatric surgery, specifically sleeve gastrectomy (SG), may improve eligibility for cardiac transplant; however, its impact on heart failure outcomes is not well defined.

Methods

We conducted a retrospective cohort study of patients with obesity (body mass index [BMI] ≥35 kg/m2) and (left ventricular ejection fraction [LVEF] ≤40%) who underwent SG at a tertiary heart transplant center. Outcomes were compared with controls matched for age, sex, LVEF, and BMI receiving standard care. We evaluated BMI, New York Heart Association (NYHA) functional class, medications, echocardiographic parameters, time to advanced heart failure therapies, and survival.

Results

Twenty patients (median BMI 42.8 kg/m², LVEF 25%) underwent SG compared to 40 matched patients. Both groups demonstrated reductions in BMI; however, weight loss was significantly greater in the treatment group (-9.9 [95% CI -12.2, -7.6] vs. -2.7 [-4.3, -1.1] kg/m², p < 0.05). Despite this, improvements in LVEF (+16.6% [10.2, 23.0] vs. +0.1% [-4.4, 4.7], p < 0.05) along with NYHA class (-0.8 [95% CI: -1.3, -0.3] vs. +0.4 [0.1, 0.7], p < 0.05) were only observed in those receiving SG. Overall survival was significantly higher in the treatment group [HR: 0.2 (0.07, 0.62), p < 0.01], which had no deaths compared to 35% in the comparison group.

Conclusion

In patients with HFrEF and obesity, SG is associated with significant improvements in cardiac function and survival compared to standard care, supporting its role as a safe and effective bridge to recovery or candidacy.

Effects of different Metabolic Bariatric Surgeries in Testosterone Levels: A Systematic Review and Meta-Analysis

Obesity, a globally prevalent condition associated with various comorbidities, has significant impacts on male endocrine health, including alterations in testosterone levels. Metabolic Bariatric Surgery stands out as an effective approach to promoting weight loss and improving hormonal outcomes. This study aims to evaluate and compare the effects of Roux-en-Y gastric bypass (RYGB) and Laparoscopic Sleeve Gastrectomy (LSG) or Laparoscopic adjustable gastric banding (LAGB) on testosterone levels in men. This systematic review and meta-analysis followed the Cochrane Handbook and PRISMA guidelines, registered under Id no. CRD42025633946, approved on Jan 29, 2025, in the Prospective International Registry of Systematic Reviews (PROSPERO). The search was conducted in Medline, Embase, and Web of Science platforms (up to July 2024) focused on studies comparing RYGB and LSG or LAGB and reporting pre- and post-surgery testosterone levels. Data on patients, interventions, and outcomes were extracted, and statistical analyses employed random-effects models and heterogeneity assessment. The combined analysis showed a mean difference of 113.07 ng/dL (95% CI: 1.47 to 224.67) favoring RYGB, with high heterogeneity (I2 = 65%). Individual studies suggest a greater increase in testosterone levels in the RYGB group. This review suggests that RYGB may lead to a significant increase in testosterone levels, but the results should be interpreted cautiously due to study limitations and variability, and future studies with larger samples and standardized protocols are needed.

Comparative survival of sleeve gastrectomy versus Roux-en-Y gastric bypass in adults with obesity: a systematic review and meta-analysis

BACKGROUND

The difference in survival between sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) remains controversial.

OBJECTIVE

To investigate the comparative survival difference between SG and RYGB in adults with morbid obesity.

SETTING

A meta-analysis.

METHODS

MEDLINE, EMBASE, and Cochrane Library Central Register of Controlled Trial were searched through June 30th, 2023 to identify studies comparing SG and RYGB. To minimize confounding, only adjusted outcomes were used from observational studies. The primary outcome was all-cause mortality during follow-up. Secondary outcomes were revision, reoperation, reintervention, hospitalization, endoscopic procedure, and emergency department visit.

RESULTS

Twenty-two studies (10 randomized controlled trials [RCTs] and 12 observational studies) met the inclusion criteria. Three RCTs and seven observational studies with 333,713 patients (SG, n = 172,909; RYGB, n = 160,804) were analyzed for all-cause mortality, with a weighted median follow-up of 34.4 months. SG was associated with decreased risks of all-cause mortality during follow-up (hazard ratio [HR]: .85; 95% confidence interval [CI]: .79 to .92), reoperation (HR: .69; 95% CI: .59 to .80), reintervention (HR: .74; 95% CI: .66 to .81), hospitalization (HR: .86; 95% CI: .77 to .97), and endoscopic procedure (HR: .55; 95% CI: 0.40-.76), whereas SG was associated with a higher risk of revision (HR: 2.18, 95% CI: 1.52 to 3.14). Meta-regression suggested consistent survival advantages of SG regardless of the proportion of patients with diabetes or follow-up duration.

CONCLUSION

In adults with morbid obesity undergoing bariatric surgery, SG was associated with a decreased risk of all-cause mortality during follow-up compared with RYGB. A large-scale randomized trial with long-term follow-up is still necessary for validation.

Patients' Expectations and Perspectives on Follow-up Care after Bariatric Surgery in Germany

BACKGROUND

Bariatric surgery is the most effective treatment for patients with obesity. After surgery, lifelong follow-up care is recommended to improve weight-loss outcomes. However, follow-up attendance is low, and the reasons have yet to be determined. Therefore, the present study aimed to identify patients' expectations and perspectives on follow-up care after bariatric surgery to identify current unmet needs and ways to increase follow-up attendance.

METHODS

Patients who underwent bariatric surgery at a university medical center and attended at least one follow-up appointment completed an online questionnaire. The questionnaire consisted of open-ended questions regarding follow-up care. Content analysis was applied to qualitatively analyze the results.

RESULTS

In total, 164 patients responded to at least one question (participation rate 50.1%). On average, patients had attended three follow-up appointments at the time of the study. Expectations concerning the content of follow-up care included regular examinations, blood tests, and psychological and nutritional counseling and support. Notably, the follow-up care was most criticized for its lack of regular psychological and nutritional support, with many suggesting that these services be incorporated. Interestingly, follow-up care appointment attendance was rarely connected with expectations of better outcomes. Regular appointments and laboratory results were among the positive aspects of the current follow-up care.

CONCLUSIONS

Expectations were mostly related to the content of follow-up care. However, few patients seemed to recognize the importance of follow-up care for improved outcomes. Therefore, educating patients about the critical role of follow-up care might improve attendance and also lead to more successful long-term bariatric surgery outcomes.

First-in-human side-to-side linear magnetic compression gastroileostomy: feasibility and early outcomes in adults with obesity

BACKGROUND

Conventional surgical stapling/suturing requires tissue fixation with retained potentially inflammatory materials. A novel minimally invasive magnetic compression anastomosis system that requires no fixation, enterotomy closure, or permanent implant seems to mitigate major complications associated with stapling/suturing. As an option for revision of clinically suboptimal sleeve gastrectomy (SG), the technical feasibility, safety, and preliminary efficacy of magnetic gastroileostomy bipartition (MagGI procedure) were evaluated in a first-in-human case series.

METHODS

In this prospective single-center study, adults with a body mass index (BMI) of ≥30.0 to ≤50.0 kg/m2 who were candidates for SG revision underwent the MagGI procedure. A distal magnet was delivered endoscopically with laparoscopic assistance to the ileum. A proximal magnet was positioned endoscopically in the gastric antrum. The magnets were aligned to gradually fuse, forming a gastroileal bipartition. The primary safety endpoint was minimal incidence of device- and procedure-related severe adverse events (SAEs) (Clavien-Dindo [CD] classification). The primary efficacy endpoint was technical feasibility. The secondary endpoints were reduction of weight and metabolic parameters.

RESULTS

Between November 27, 2023, and May 27, 2024, 7 patients (mean BMI of 38.8 ± 0.9 kg/m2) underwent revisional MagGI. Feasibility was demonstrated, and patent gastroileal anastomoses were confirmed in 100.0% of cases, with no device-related events and 1 SAE with a CD III mild rating. There was no anastomotic leakage, bleeding, obstruction, infection, or stricture. Total weight loss and excess weight loss were 18.9% ± 3.9% and 52.4% ± 11.0%, respectively. A BMI reduction of 7.4 kg/m2 was observed (P <.05). Mild nutritional concerns were treated.

CONCLUSION

At the 6-month interim evaluation, the MagGI procedure was performed to revise clinically suboptimal SG. In addition, the procedure was technically straightforward, incurred no major complications, and renewed clinically meaningful weight loss in a small cohort.

Myosteatosis Predicts Bariatric Surgery Response: A Longitudinal Study in Patients With Morbid Obesity

CONTEXT

Data on the preoperative factors for bariatric surgery response in patients with morbid obesity are limited, and there are no studies on the relationship between myosteatosis and surgery response.

OBJECT

We investigated the preoperative factors determining bariatric surgery response and the impact of preoperative muscle fat infiltration on bariatric surgery response.

METHODS

This retrospective longitudinal cohort study included 125 individuals (37 men, 88 women) with morbid obesity who underwent bariatric surgery. Muscle fat infiltration [skeletal muscle fat index (SMFI)] was evaluated using computed tomography-based psoas muscle mass and density at the fourth lumbar level. A bariatric surgery response was defined as ≥50% excessive weight loss at 1 year postoperatively.

RESULTS

Before bariatric surgery, the patient's mean body weight and body mass index (BMI) were 107.0 kg and 39.0 kg/m2, respectively. After 1 year, the mean body weight was 79.6 kg. The mean excessive weight loss at 1 year was 75.6%, and 102 (81.6%) patients were categorized as responders. There were no statistically significant differences in initial BMI, age, sex, or proportion of diabetes between responders and nonresponders. Responders were more likely to have lower SMFI and triglyceride and glycated hemoglobin A1c levels than nonresponders at baseline (P < .05). Multiple logistic regression analysis showed that a lower baseline SMFI was associated with bariatric surgery response (odds ratio = 0.31, 95% confidence interval = 0.14-0.69, P = .004).

CONCLUSION

Preoperative myosteatosis may determine the response to bariatric surgery.

The role of epicardial adipose tissue remodelling in heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is a growing global health problem characterized by high morbidity and mortality, with limited effective therapies available. Obesity significantly influences haemodynamic and structural changes in the myocardium and vasculature, primarily through the accumulation and action of visceral adipose tissue. Particularly, epicardial adipose tissue (EAT) contributes to HFpEF through inflammation and lipotoxic infiltration of the myocardium. However, the precise signalling pathways leading to diastolic stiffness in HFpEF require further elucidation. This review explores the dynamic role of EAT in health and disease. Drawing upon insights from studies in other conditions, we discuss potential EAT-mediated inflammatory pathways in HFpEF and how they may contribute to functional and structural myocardial and endothelial derangements, including intramyocardial lipid infiltration, fibrosis, endothelial dysfunction, cardiomyocyte stiffening, and left ventricular hypertrophy. Lastly, we propose potential targets for novel therapeutic avenues.

Endogenous Metabolites in Metabolic Diseases: Pathophysiologic Roles and Therapeutic Implications

Breakthroughs in metabolomics technology have revealed the direct regulatory role of metabolites in physiology and disease. Recent data have highlighted the bioactive metabolites involved in the etiology and prevention and treatment of metabolic diseases such as obesity, nonalcoholic fatty liver disease, type 2 diabetes mellitus, and atherosclerosis. Numerous studies reveal that endogenous metabolites biosynthesized by host organisms or gut microflora regulate metabolic responses and disorders. Lipids, amino acids, and bile acids, as endogenous metabolic modulators, regulate energy metabolism, insulin sensitivity, and immune response through multiple pathways, such as insulin signaling cascade, chemical modifications, and metabolite-macromolecule interactions. Furthermore, the gut microbial metabolites short-chain fatty acids, as signaling regulators have a variety of beneficial impacts in regulating energy metabolic homeostasis. In this review, we will summarize information about the roles of bioactive metabolites in the pathogenesis of many metabolic diseases. Furthermore, we discuss the potential value of metabolites in the promising preventive and therapeutic perspectives of human metabolic diseases.

IMPACT OF THE COVID-19 QUARANTINE ON THE MENTAL AND EMOTIONAL HEALTH OF POST-BARIATRIC SURGERY WOMEN: A QUALITATIVE STUDY

BACKGROUND

The coronavirus disease 2019 (COVID-19) greatly impacted patients undergoing bariatric surgery due to prolonged quarantine and lockdown measures.

AIMS

The aim of this study was to qualitatively investigate the impact of the COVID-19 quarantine and lockdown measures on the mental and emotional health of post-bariatric surgery women.

METHODS

A qualitative study was carried out, with individual interviews conducted via video calls using a video-communication service (Google Meet®). The moderator guide inquired about three pre-established topics based on the literature: mental and emotional health, social relationship, and the use of health technology.

RESULTS

A total of 12 women participated in this study, with an average age of 43±9.83 years, a body mass of 82.33±13.83 kg, a height of 1.62±0.06 m, a body mass index of 26.32±2.97 kg/m2, and post-surgery time of 12.83±4.37 months. The interviews had an average duration of 50.71±7.26 min. Our results suggested a negative impact of the COVID-19 pandemic on aspects of mental and emotional health, such as increased anxiety, depressive symptoms, fear, stress, and anguish, which were somehow diminished in patients who were closer to family members. Bariatric surgery was mentioned as a positive aspect by the patients for coping with clinical risk conditions.

CONCLUSIONS

The study showed a negative impact of the COVID-19 pandemic on aspects of mental and emotional health mostly due to lockdown measures, which led to social isolation and an increased burden with household chores.

A multi-omics microbiome signature is associated with the benefits of gastric bypass surgery and is differentiated from diet induced weight loss through 2 years of follow-up

Roux-en-Y gastric bypass (GBP) surgery is an effective treatment for reducing body weight and correcting metabolic dysfunction in individuals with severe obesity. Herein, we characterize the differences between very low energy diet (VLED) and GBP induced weight loss by multi-omic analyses of microbiome and host features in a non-randomized, controlled, single-center study. Eighty-eight participants with severe obesity were recruited into two arms - GBP versus VLED with matching weight loss for 6 weeks and 2-years of follow-up. A dramatic shift in the distribution of gut microbial taxa and their functional capacity was seen in the GBP group at Week 2 after surgery and was sustained through 2 years. Multi-omic analyses were performed after 6 weeks of matching weight loss between the GBP and VLED groups, which pointed to microbiome derived metabolites such as indoxyl sulphate as characterizing the GBP group. We also identified an inverse association between Streptococcus parasanguinis (an oral commensal) and plasma levels of tryptophan and tyrosine. These data have important implications, as they reveal a significant robust restructuring of the microbiome away from a baseline dysbiotic state in the GBP group. Furthermore, multi-omics modelling points to potentially novel mechanistic insights at the intersection of the microbiome and host.

Endoscopic Sleeve Gastroplasty for the Treatment of Metabolic Syndrome: A Systematic Review and Meta-analysis

BACKGROUND

Endoscopic sleeve gastroplasty (ESG) is an incisionless weight loss procedure that has been demonstrated to be safe and effective for the treatment of obesity; however, the efficacy of ESG for the treatment of comorbid type 2 diabetes mellitus (T2DM) and other components of metabolic syndrome (MetS) has been less well studied. We aimed to conduct a systematic review and meta-analysis of available literature to evaluate the outcomes of ESG on T2DM and MetS.

METHODS

Bibliographic databases were systematically searched for studies assessing the outcomes of ESG on T2DM and MetS. Studies were included if they reported at least one objective outcome related to T2DM or other components of MetS, including hyperlipidemia (HLD), hypertriglyceridemia, and hypertension (HTN). This study was deemed IRB exempt.

RESULTS

Ten studies with 4320 patients were included. At 12 months, ESG was associated with significant improvements in T2DM, HLD, and HTN, with risk difference of - 0.72 [95% CI, - 0.87 to - 0.58, p < 0.00001], - 0.65 [95% CI, - 0.78 to - 0.52, p < 0.00001], and - 0.60 [95% CI, - 0.66 to - 0.53, p < 0.00001], respectively. Disease improvement was defined as patients being able to stop some or all of their related treatment medications. Additionally, there were significant reductions in hemoglobin A1c (HGBA1c), fasting blood glucose, homeostatic model assessment for insulin resistance (HOMA-IR), low-density lipoprotein, and triglycerides.

CONCLUSIONS

ESG is an effective modality for the treatment of comorbid T2DM and MetS in patients with obesity. Additional studies are needed to establish long-term responses and to compare ESG against established pharmacologic and surgical techniques.

Obesity and heart failure-the role of GLP-1 receptor agonists

Patients with obesity-driven heart failure with preserved ejection fraction (HFpEF) often suffer from symptoms despite guideline-recommended treatment with diuretics, sodium glucose cotransporter 2 (SGLT2) inhibition, and mineralocorticoid antagonists. Obesity by itself drives heart failure via multiple pathophysiological mechanisms. This review summarizes current data on glucagon-like peptide‑1 (GLP-1) receptor agonists and the dual GIP/GLP‑1 agonist tirzepatide, including symptoms and outcomes in patients with obesity-driven HFpEF with or without diabetes.

Modern Trends of Drain Placement in Primary Bariatric Surgery: An MBSAQIP Analysis of 526,723 Patients

BACKGROUND

Prophylactic drain use during primary bariatric surgeries continues despite previous literature cautioning against their routine use. Modern drain utilization and associated outcomes remain largely poorly studied which limits selective utilization and perhaps may lead to excess morbidity and healthcare resource utilization. This study aimed to reassess current trends of drain use in primary bariatric procedures, factors driving surgeons to place drains, and patient outcomes associated with drain placement.

METHODS

Patients undergoing the most common primary bariatric surgery operations from 2020 to 2022 were included using the Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database. Two cohorts were created, a drain placed (DP) cohort and no drain (ND) cohort, which were then compared in terms of baseline characteristics, rates of complications, and length of stay. Multivariate modeling was performed to assess the effect of drains on various complications and factors associated with drain placement.

RESULTS

Of 526,723 included patients, drain utilization decreased across operative years (8.7% in 2020 to 6.1% in 2022, p < 0.001). Factors associated with drain placement in multivariate models included older age, higher BMI, partially dependent functional status, renal insufficiency, venous thromboembolism, hypoalbuminemia, and non-sleeve anastomotic procedures. Drain placement was associated with increased risk of numerous complications on bivariate analysis, which was still significant in multivariate analysis, including 30-day serious complications (adjusted odds ratio [aOR] 1.24, p < 0.001), anastomotic leak (aOR 2.1, p < 0.001), organ space infection (aOR 2.0, p < 0.001), reoperation (aOR 1.2, p = 0.036), and excess length of stay (LOS, aOR 1.45, p < 0.001).

CONCLUSIONS

The frequency of prophylactic drain placement during primary bariatric surgical procedures has decreased in recent years and patients with drain placement seem to have increased 30-day morbidity, including longer length of stay. Independent predictors of drain placement include increased age and metabolic burden along with anastomotic procedures. Surgeons should be judicious in selecting patients for drain placement and future prospective, controlled studies may better answer drain placement association with complications.

Sleeve Gastrectomy in Patients with Type 2 Diabetes: Anthropometric and Cardiometabolic Improvements at 1, 3, 5, 7, and 9 years-Are the Initial Benefits Sustained?

BACKGROUND

No previous study assessed the outcomes of sleeve gastrectomy (SG) beyond 5 years among adult patients with type 2 diabetes (T2DM). We appraised the evolution of 20 outcomes at 1, 3, 5, 7, and 9 years.

METHODS

This is a retrospective study of 361 consecutive T2DM patients who underwent SG at our institution (April 2011-December 2015). Postoperative data were compared to baseline and to previous time points using paired t tests. Diabetes status was also assessed at each time point.

RESULTS

The sample consisted of 65.37% females. The mean preoperative age was 44.38 ± 9.50 years and body mass index (BMI) was 43.81 ± 6.98 kg/m2. Generally, most improvements occurred in the first year and were sustained on the long term. Postoperatively, there was a significant and sustained weight reduction, amounting to a mean decrease of 9 kg/m2 in BMI at year 9 and associated excess weight loss between 59%year 1 and 46%year 9. Fasting blood glucose decreased significantly across the five time points, from 9.27 ± 4.11preop to 7.06 ± 2.70 year 9 mmol/L. Mean HbA1c significantly decreased from 8.1%preop to 6.77%year 9. The prevalence of complete remission of T2DM was 20.45%, 19.44%, and 20% at 5, 7, and 9 years respectively, with significant reductions in percentages of patients using diabetes medications or insulin. Between 10% and 23% of patients experienced relapse of T2DM by 5-9 years. In comparison to baseline levels, mean blood pressure, triglycerides, high-density lipoprotein, low-density lipoprotein, total cholesterol, and hepatic enzymes levels all showed improvement in the long term.

CONCLUSION

Patients with T2DM experienced substantial improvements in most anthropometric and cardiometabolic outcomes within the first year, and these were sustained in the long term.

Milk-derived bioactive peptides in insulin resistance and type 2 diabetes

Diabetes is a global health issue affecting over 6% of the world and 11% of the US population. It is closely linked to insulin resistance, a pivotal factor in Type 2 diabetes development. This review explores a promising avenue for addressing insulin resistance through the lens of Milk-Derived Bioactive Peptides (MBAPs). Taken from casein or whey fractions of various milks, MBAPs exhibit diverse health-promoting properties. Specific interactions between these peptides and enzymes involved in glucose digestion and metabolism have been examined, leading to the identification of some key peptides exerting the effects. This review emphasizes the positive impact of MBAPs on glycemic control through various mechanisms. Different cell lines have been used to investigate MBAPs' effects on insulin signaling, inflammation, and oxidative stress. Preclinical in vivo studies have also shown that MBAPs lower glucose, stimulate insulin, and reduce inflammation. Human trials further substantiate these findings and suggest the potential utility of milk protein hydrolysates containing MBAPs in individuals with insulin resistance or T2D to improve insulin action and glucose homeostasis.

[Surgical treatment for obesity - metabolic surgery]

BACKGROUND

Over the past 20 years, surgical treatment of obesity, or metabolic surgery, has established itself as an extremely efficient and sustainable therapy for treating severely overweight patients. Compared to non-surgical weight reduction procedures, surgical techniques have been shown to be superior in all studies, both in terms of short-term and long-term effectiveness. On the other hand, the invasiveness of the procedures is something that many patients view critically.

PROCEDURES

Many years of experience with the two most commonly used procedures, laparoscopic sleeve gastrectomy and minimally invasive gastric bypass, show that both procedures are associated with very low morbidity. The comparatively high costs of the surgical procedure are more than offset by the long-term savings in other therapeutic needs (diabetes mellitus, hepatic steatosis, arthritis, osteoarthritis, etc.). The S3 guideline for carrying out metabolic surgical procedures has clear specifications for the criteria to be met. Embedding in a multi-modal concept both pre- and post-operatively is obligatory. The following article provides an overview of the indications, treatment, and aftercare in the field of metabolic surgery.

Effects of Socioeconomic Status on Early Results After Sleeve Gastrectomy

Purpose Obesity and its related metabolic diseases are a widespread public health problem worldwide. In recent years, surgical methods have played a very important role in the treatment of obesity and metabolic diseases. This study aims to investigate the effects of patients' socioeconomic status (SES) on the early results of sleeve gastrectomy (SG), which is the most preferred metabolic bariatric surgery (MBS) procedure in the world. Methods Data of SG patients who were operated on in the general surgery clinic of a tertiary hospital were analyzed retrospectively. A total of 322 patients who completed at least three months of follow-up after surgery were included in the study. Patients were divided into three groups - low, medium, and high - according to their SES. The effects of SES on weight loss and comorbidities associated with obesity were evaluated. The one-way analysis of variance (ANOVA), Kruksal Wallis, and chi-square tests were used in the statistical analysis of the data. Results The groups were homogeneous in terms of age and body mass index (BMI). There was no statistically significant difference among income groups in terms of the age, BMI, and excess weight loss (EWL) variables (p>0.05). In addition, when the relations among income groups and gender, diabetes mellitus (DM), and other diseases were examined, it was concluded that there was no relation between income status and other variables (p>0.05). Conclusion SES of patients has no effect on the early results of SG.

Treatment options for heart failure in individuals with overweight or obesity: a review

Obesity and heart failure are interlaced global epidemics, each contributing to significant morbidity and mortality. Obesity is not only a risk-factor for heart failure, but also complicates its management, by distinctive pathophysiological mechanisms and cumulative comorbidities, requiring tailored treatment plan. To present current treatment options for heart failure in individuals with overweight/obesity, emphasizing available pharmacological therapies, non-pharmacological strategies, and the management of related comorbidities. We conducted a comprehensive literature review regarding the results of heart failure treatments in individuals with overweight/obesity, including cornerstone interventions as well as emerging therapeutic options. Specific drug classes, including angiotensin receptor-neprilysin inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors, have demonstrated consistent efficacy in heart failure irrespective of body mass index, while diuretics remain a key for fluid management. Glucagon-like peptide-1 receptor agonists have shown promising results in improving relevant outcomes and warrant further research. Non-pharmacological approaches, including weight-loss strategies and lifestyle modifications, have shown to improve symptoms, exercise tolerance and quality of life. Managing heart failure in individuals with overweight/obesity requires a multidisciplinary, individualized approach integrating pharmacological and non-pharmacological options. Emerging therapies and preventive strategies arise to address the unique challenges in this population and provide improved outcomes.

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.

Long-Term Outcomes of Laparoscopic Roux-en-Y Gastric Bypass vs Laparoscopic Sleeve Gastrectomy for Obesity: The SM-BOSS Randomized Clinical Trial

Importance

Reports on long-term outcomes from randomized clinical trials comparing laparoscopic sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are scarce.

Objective

To compare long-term weight and metabolic outcomes, reoperation rates, and quality of life for patients undergoing SG vs RYGB at 10 years and beyond.

Design, Setting, and Participants

The SM-BOSS (Swiss Multicenter Bypass or Sleeve Study) randomized clinical trial was conducted from January 2007 to November 2011 at 4 bariatric centers in Switzerland. (The last follow-up was obtained in July 2023.) A total of 3971 patients with severe obesity were assessed, and 217 patients were enrolled and randomized to undergo SG or RYGB.

Interventions

Laparoscopic SG or RYGB.

Main Outcomes and Measures

The primary outcome of the SM-BOSS trial was the percentage excess body mass index loss (%EBMIL) at 5 years. The present study reports on the long-term weight and metabolic outcomes at 10 years and beyond, including changes in weight and obesity-related diseases, reoperation rates, and quality of life.

Results

Of 217 patients randomized to undergo SG or RYGB, mean (SD) age was 42.5 (11.1) years, mean (SD) baseline BMI was 43.9 (5.3), and 156 patients (71.9%) were female. Of 217 patients, 110 patients were randomized to RYGB and 107 to SG. Complete 10-year follow-up is available for 65.4% of patients. In the intention-to-treat population, mean (SD) %EBMIL was 60.6% (25.9) after SG and 65.2% (26.0) after RYGB (P = .29). Patients who underwent SG had significantly higher conversion rates because of insufficient weight reduction or reflux compared to RYGB (29.9% vs 5.5%; P < .001). Patients undergoing RYGB had significantly higher mean (SD) %EBMIL compared to SG after 10 years in the per-protocol (PP) population (65.9% [26.3] vs 56.1% [25.2]; P = .048). However, mean (SD) percentage total weight loss was not significantly different between groups (RYGB: 27.7% [10.8]; SG: 25.5% [15.1]; P = .37). SG patients had significantly more de novo gastroesophageal reflux (GERD) compared with RYGB (P = .02).

Conclusions and Relevance

In the SM-BOSS randomized clinical trial, RYGB led to significantly higher %EBMIL in the PP population compared with SG beyond 10 years of follow-up, with better results for GERD. Patients undergoing SG experienced a significantly higher number of conversions to different anatomy compared with RYGB.

Trial Registration

ClinicalTrials.gov Identifier NCT00356213.

Health-Related Quality of Life and Health Utility After Metabolic/Bariatric Surgery Versus Medical/Lifestyle Intervention in Individuals With Type 2 Diabetes and Obesity: The ARMMS-T2D Study

OBJECTIVE

Type 2 diabetes and obesity are associated with reduced health-related quality of life (HRQoL) and health utility (HU), but long-term effects of metabolic/bariatric surgery (MBS) compared with those of medical/lifestyle intervention (MLI) on these outcomes are unclear.

RESEARCH DESIGN AND METHODS

We studied 228 individuals with type 2 diabetes and obesity randomly assigned to MBS (Roux-en-Y gastric bypass, sleeve gastrectomy, or gastric band; n = 152) or MLI (n = 76) in the ARMMS-T2D study. HRQoL (36-Item Short-Form Health Survey [SF-36], including Physical Component Score [PCS] and Mental Component Score [MCS]) and HU (Short Form 6 Dimensions [SF-6D]) were measured annually up to 12 years.

RESULTS

At baseline, participants' mean ± SD age was 49.2 ± 8.0 years, 68.4% were female, BMI was 36.3 ± 3.4 kg/m2, and HbA1c was 8.7 ± 1.6%. PCS improved significantly more in the MBS versus MLI group over 12 years (+2.37 ± 0.53 vs. -0.95 ± 0.73; difference 3.32 ± 0.85; P < 0.001). MBS was associated with better general health (P < 0.001), physical functioning (P = 0.001), and vitality (P = 0.003). Reduction in BMI was greater after MBS versus MLI (P < 0.001) and correlated with improved PCS (r = -0.43; P < 0.001). Change in PCS was not associated with change in HbA1c. MCS changed minimally from baseline and was similar between MBS and MLI groups during follow-up (-0.21 ± 0.61 vs. -0.89 ± 0.84; difference 0.68 ± 0.97; P = 0.48). Improvements in HU were greater in the MBS versus MLI group over 12 years (+0.02 ± 0.01 vs. -0.01 ± 0.01; difference 0.03 ± 0.01; P = 0.003).

CONCLUSIONS

Metabolic surgery produces sustained weight loss and improves PCS, general health, physical functioning, vitality, and HU in individuals with type 2 diabetes and obesity compared with medical therapy up to 12 years after intervention.

Beyond the decade: unveiling long-term weight and co-morbidity outcomes up to 10 years post laparoscopic sleeve gastrectomy

INTRODUCTION

Despite its effectiveness, long-term data on the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) for morbid obesity are sparce.

METHODS

We collected data through phone interviews and hospital records for patients who had LSG, including those that then underwent revisional bariatric surgery, assessing their weight outcomes, associated health conditions, and complications.

RESULTS

2982 patients (72% female) were included in the study, with a maximum follow-up reached of 13 years. The mean pre-operative age and body mass index (BMI) were 34.7 ± 11.3 years and 45.5 ± 7.7 kg/m2, respectively. The prevalence of obesity classes were as follows: Class I, 3.1%; Class II, 19.2%; and Class III, 75.9%. BMI at nadir was 32.35 Kg/m2 equating to a mean nadir excess weight loss (EWL) of 67.03%. Weight outcomes at 13 years post-LSG showed a mean BMI of 31.83 kg/m2 and total weight loss (TWL) percentage of 31.43%. Weight loss outcomes varied according to pre-operative obesity class, with class I achieving the highest percentage EWL and class III observing the highest TWL at the end of one year. Weight regain occurred in 1.3% of the patient population, with class III experiencing the highest weight regain at 13 years. Significant reductions in comorbidities were observed, while complication rates were low, with 0.4% bleed, 0.5% leak, and 7.9% GERD.

CONCLUSION

LSG demonstrates sustained weight loss and resolution of comorbidities with low complication rates. The influence of initial obesity class on weight loss was found to be significant in the first 18 months post-LSG.

Impact of medical versus surgical weight loss on cardiovascular outcomes

Obesity contributes to cardiovascular disease in two ways - directly, as an independent risk factor, and indirectly, through its contribution to comorbidities such as hypertension, diabetes, dyslipidemia. This cascade of multiplicative effects means that early management of obesity is instrumental in risk reduction and prevention of adverse cardiovascular outcomes. The amount and sustainability of weight loss has been extensively studied and stratified by medical versus surgical weight loss. Medical weight loss has historically been inferior by both parameters; however, new therapies targeting glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) receptors have demonstrated very promising results independently for both weight loss and cardiovascular disease. In this review, we compare cardiovascular outcomes between bariatric surgical approaches and novel GLP-1/GIP medications. We aim to answer the following question: In this era of new pharmacological weight loss options, does the method of weight loss-surgical or medical-impact cardiovascular risk mitigation, or is the key factor the maintenance of a healthier weight, regardless of the method?

Effect of Helicobacter pylori infection on metabolic and bariatric surgical complications: a systematic review and meta-analysis

More papers have discussed the importance of preoperative detection and eradication of Helicobacter pylori (HP) in patients before and after Metabolic and Bariatric Surgery (MBS). This systematic review and meta-analysis aimed to evaluate the role of preoperative H. pylori eradication vs non-treatment in the development of post-op complications in the setting of bariatric and metabolic surgery. This study aimed to evaluate the effect of Helicobacter pylori (HP) on metabolic and bariatric surgical complications through a systematic review and meta-analysis. A systematic search on the influence of HP infection on postoperative complications in bariatric surgery was conducted. The methodological quality of the included studies was rated using the Newcastle-Ottawa Rating scale. In case of consistent reporting of the data, a meta-analysis was performed. A total of 19 studies containing 261,186 patients were included. The mean age of the patients was 41.88 ± 7.40 years with a mean BMI of 45.53 ± 3.16 kg/m2. The mean follow-up was 21.72 months (range: 1-96 months). Testing for HP infections was often done using an esophagogastroduodenoscopy in combination with biopsy (42%). A urea breath test (59%) was the most common tool to confirm eradication. To eradicate HP, 2 weeks of PPI with antibiotics, 1 week of PPI with antibiotics, and PPI alone without antibiotics were used in 18 (67%), 3 (11%), and 6 (22%) studies, respectively. The prevalence of complications among patients with positive/negative HP was not significantly different (P > 0.05). In HP patients without preoperative eradication, odds ratio of bleeding was 1.48 (95% CI 0.80-2.73), ulcer was 6.88 (95% CI 5.60-8.45), leakage was 1.73 (95% CI 0.81-3.68), stricture was 1.13 (95% CI 0.30-4.21), and abscesses was 3.01 (95% CI 0.85-10.65). Helicobacter pylori infection is associated with potential postoperative complications, and therefore, it needs adequate treatment.

Oral microbiome changes in subjects with obesity following bariatric surgery compared to lean counterparts

Introduction

This study aimed to compare oral microbiome profiles between obese and lean individuals without clinical periodontitis, and to assess changes in the oral microbiome of obese subjects following bariatric surgery.

Methods

Individuals with a body mass index (BMI) > 30 were enrolled in the obese group, whereas those with a BMI < 23 served as controls. The obese surgery group, which consented to bariatric surgery, was followed up at 1, 3, and 6 months with clinical examinations. Oral examinations were conducted and periodontal disease was classified based on probing results. Saliva, buccal and subgingival microbiome samples were analyzed for community diversity, relative bacterial abundance, and differential abundance between control (n = 24) and obese group (n = 31). To evaluate effect size and statistical power, we used micropower, a simulation-based method for Permutational Multivariate Analysis of Variance-based β-diversity comparisons.

Results

The obese group exhibited distinct alpha diversity (buccal: Chao1 p = 0.0002, Shannon p = 0.0003, supragingival: Shannon p < 0.0001) compared with the control group. Bray-Curtis distance analysis indicated significant disparities in microbiome composition distribution in saliva (p = 0.003), buccal (p = 0.002), and subgingival plaque samples (p = 0.001). Although the obese and normal weight groups exhibited no significant periodontal differences, the obese group showed distinct species associated with periodontal disease, especially in subgingival plaque including Filifactor alocis, Peptostreptococcaceae spp., Prevotella spp., and Treponema maltophilum. Cluster analysis of the obese surgery group indicated the emergence of microbiomes associated with a healthy state that increased over time including Streptococcus salivarious and various Veillonella spp., whereas clusters containing periodontal pathogens including Porphyromonas spp., tended to diminish.

Discussion

The oral microbiome at 6 months post-bariatric surgery indicates a potential shift toward a healthy periodontal state, suggesting that weight loss interventions may positively impact oral microbial communities even in the absence of clinical periodontitis.

MAGs-based genomic comparison of gut significantly enriched microbes in obese individuals pre- and post-bariatric surgery across diverse locations

Introduction

Obesity, a pressing global health issue, is intricately associated with distinct gut microbiota profiles. Bariatric surgeries, such as Laparoscopic Sleeve Gastrectomy (LSG), Sleeve Gastrectomy (SG), and Roux-en-Y Gastric Bypass (RYGB), induce substantial weight loss and reshape gut microbiota composition and functionality, yet their comparative impacts remain underexplored.

Methods

This study integrated four published metagenomic datasets, encompassing 500 samples, and employed a unified bioinformatics workflow for analysis. We assessed gut microbiota α-diversity, identified species biomarkers using three differential analysis approaches, and constructed high-quality Metagenome-Assembled Genomes (MAGs). Comparative genomic, functional profiling and KEGG pathway analyses were performed, alongside estimation of microbial growth rates via Peak-to-Trough Ratios (PTRs).

Results

RYGB exhibited the most pronounced enhancement of gut microbiota α-diversity compared to LSG and SG. Cross-cohort analysis identified 39 species biomarkers: 27 enriched in the non-obesity group (NonOB_Enrich) and 12 in the obesity group (OB_Enrich). Among the MAGs, 177 were NonOB_Enrich and 14 were OB_Enrich. NonOB_Enrich MAGs displayed enriched carbohydrate degradation profiles (e.g., GH105, GH2, GH23, GH43, and GT0 families) and higher gene diversity in fatty acid biosynthesis and secondary metabolite pathways, alongside significant enrichment in amino acid metabolism (KEGG analysis). Post-surgery, Akkermansia muciniphila and Bacteroides uniformis showed elevated growth rates based on PTRs.

Discussion

These findings underscore RYGB's superior impact on gut microbiota diversity and highlight distinct microbial functional adaptations linked to weight loss, offering insights for targeted therapeutic strategies.