What is the role of bariatric surgery in the management of obesity?

Changes in the Structure, Function, and Fat Content of the Heart in Patients with Obesity After Bariatric Surgery-A Prospective Magnetic Resonance Imaging Study

BACKGROUND

Changes in myocardial fat in addition to changes in cardiac structure and function have not been accurately evaluated in obese patients following surgery.

MATERIALS AND METHODS

Forty-four obese patients who underwent sleeve gastrectomy and completed preoperative and postoperative cardiac magnetic resonance imaging (CMR) before surgery and at 1, 3, and 6 months after surgery were enrolled, and their clinical and laboratory data were collected. The differences and correlations between clinical, laboratory, and CMR parameters between the preoperative and postoperative groups were analysed.

RESULTS

The left ventricular mass (LVM), left ventricle cardiac output (LVCO), pericardial adipose tissue volume (PATV), and myocardial proton density fat fraction (M-PDFF) decreased after surgery (all P < 0.05). The left ventricle global longitudinal strain increased at 6 months after surgery (P = 0.004). A decrease in BMI was positively correlated with the LVCO (r = 0.58, P < 0.001) at 3 months after surgery and was positively correlated with the LVM and PATV (r = 0.54, P < 0.05) at 6 months after surgery. Six months after surgery, the changes in PATV were positively correlated with the changes in triglycerides (r = 0.61, P < 0.01). There was a moderately positive correlation between the decrease in the LVM and PATV (r = 0.54 ~ 0.71, P < 0.02) after surgery.

CONCLUSION

After surgery, the cardiac structure and function of obese patients significantly improved, the PATV and M-PDFF decreased, and there was a correlation between the structure and function of the heart and several clinical and laboratory indicators.

Preoperative comorbidities as a predictor of EBWL after bariatric surgery: a retrospective cohort study

INTRODUCTION

The purpose of this study is to investigate the impact of preoperative comorbidities, including depression, anxiety, type 2 diabetes mellitus, obstructive sleep apnea, hypothyroidism, and the type of surgery on %EBWL (percent estimated body weight loss) in patients 1 year after bariatric surgery. Patients who choose to undergo bariatric surgery often have other comorbidities that can affect both the outcomes of their procedures and the postoperative period. We predict that patients who have depression, anxiety, diabetes mellitus, obstructive sleep apnea, or hypothyroidism will have a smaller change in %EBWL when compared to patients without any of these comorbidities.

METHODS AND PROCEDURES

Data points were retrospectively collected from the charts of 440 patients from March 2012-December 2019 who underwent a sleeve gastrectomy or gastric bypass surgery. Data collected included patient demographics, select comorbidities, including diabetes mellitus, obstructive sleep apnea, hypothyroidism, depression, and anxiety, and body weight at baseline and 1 year postoperatively. Ideal body weight was calculated using the formula 50 + (2.3 × height in inches over 5 feet) for males and 45.5 + (2.3 × height in inches over 5 feet) for females. Excess body weight was then calculated by subtracting ideal body weight from actual weight at the above forementioned time points. Finally, %EBWL was calculated using the formula (change in weight over 1 year/excess weight) × 100.

RESULTS

Patients who had a higher baseline BMI (p < 0.001), diabetes mellitus (p = 0.026), hypothyroidism (p = 0.046), and who had a laparoscopic sleeve gastrectomy rather than Roux-en-Y gastric bypass (p < 0.001) had a smaller %EBWL in the first year after bariatric surgery as compared to patients without these comorbidities at the time of surgery. Controversially, patients with anxiety or depression (p = 0.73) or obstructive sleep apnea (p = 0.075) did not have a statistically significant difference in %EBWL.

CONCLUSION

A higher baseline BMI, diabetes mellitus, hypothyroidism, and undergoing laparoscopic sleeve gastrectomy may lead to lower %EBWL in the postoperative period after bariatric surgery. At the same time, patients' mental health status and sleep apnea status were not related to %EBWL. This study provides new insight into which comorbidities may need tighter control in order to optimize weight loss outcomes after bariatric surgery.

Predictors of Chronic Pain 6 Months and 1 Year After Bariatric Surgery

BACKGROUND

Obesity and chronic pain (CP) represent serious, interrelated global public health concerns that have a profound impact on individuals and society. Bariatric surgery is increasing in popularity and has been proven safe and efficacious, providing long-term weight loss and improvements in many obesity-related co-morbidities. A decrease in CP is often a motivation for bariatric surgery. The purpose of this study was to investigate the changes in CP postoperatively and to examine the relationship between psychosocial measures and pain.

METHODS

A total of 155 adult bariatric surgery patients were recruited and completed self-report measures for CP severity and interference, neuropathic pain, anxiety, depression, emotion regulation and perceived social support at three timepoints preoperative and 6 and 12 months postoperative.

RESULTS

Pain significantly decreased between preoperative and postoperative timepoints, and preoperative pain was the most significant predictor of postoperative pain. Preoperative CP was correlated with anxiety (p < 0.05) and depression (p < 0.01) at 6 months postoperatively and perceived social support (p < 0.01) at 1 year postoperatively. However, regression analyses with psychological variables were not significant.

CONCLUSION

CP decreases after bariatric surgery, but further research with larger sample sizes is needed to establish whether psychosocial characteristics impact this outcome.

Changing Knowledge and Attitudes towards Bariatric Surgery in Primary Care: a 10-Year Cross-Sectional Survey

BACKGROUND

Some 28% of the Scottish population suffer from obesity. Bariatric procedures per population carried out in England when compared to Scotland (NBSR 2018) are significantly higher. Primary care practitioners (PCP) influence equality of access to secondary care bariatrics and frequently manage post-operative bariatric patients. Examining changes in PCP knowledge and attitude could improve access to bariatric procedures in Scotland.

METHODS

Following a sample pilot, all PCPs within three Scottish NHS health boards were emailed a questionnaire-based survey (2011; n = 902). A subsequent 10-year follow-up encompassed a greater scope of practice, additionally distributed to all PCPs in five further health boards (2021; n = 2049).

RESULTS

Some 452 responses were achieved (2011, 230; 2021, 222). PCPs felt bariatric surgery offered a greater impact in both weight management and that of obesity-related diseases (p < .0001). More PCPs were aware of local bariatric surgical referral criteria (2011, 43%; 2021, 57% (p = .003)), and more made referrals (2011, 60%; 2021, 72% (p = .018)) but were less familiar with national bariatric surgical guidelines (2011, 70%; 2021, 48% (p < .001)). Comfort at managing post-operative bariatric surgical patients were unchanged (2011, 24%; 2021, 27% (p = .660)). Minimal progress through dietetic-lead weight management services, plus rejection of patients thought to be good candidates, was reasons for referral hesitancy.

CONCLUSION

Over 10 years, PCPs were more aware of local referral criteria, making increased numbers of referrals. Knowledge deficits of national guidelines remain, and overwhelmingly PCPs do not feel comfortable looking after post-operative bariatric surgical patients. Further research into PCP educational needs, in addition to improving the primary to secondary care interface, is required.

The Effect of Bariatric Surgery on Irisin Level: a Systematic Review and Meta-analysis

This systematic analysis and meta-analysis aimed to assess changes in the plasma levels of irisin after bariatric surgery. Search strategy, study screening, and data gathering were all conducted using a checklist and the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Two researchers independently extracted the data, and a third person was included to resolve disagreements. The results illustrated no statistical difference between before and after surgery irisin plasma levels (P = 0.216, 95% CI = -1.812-0.410, SMD = -0.701, I-squared = 94.9%). BMI exhibited a meaningful decline after surgery compared to preoperative values (SMD = -3.09, 95% CI = -4.59--1.59, I-squared = 95.5%, P<0.05). According to our analysis, it can be concluded that irisin plasma levels are not significantly influenced by bariatric surgery.

Diabetes remission of bariatric surgery and nonsurgical treatments in type 2 diabetes patients who failure to meet the criteria for surgery: a systematic review and meta-analysis

BACKGROUND

The efficacy of bariatric surgery in moderate and severe obesity patients to reach diabetes remission is clear, but for mild obesity patients, the choice of surgical and non-surgical treatment is still unclear. This study we aim to compare the effect of surgical and nonsurgical treatment on patients BMI < 35 kg/m² to reach diabetes remission.

METHOD

We searched relevant articles publish between Jan 1,2010 and Jan 1, 2023 in the following databases: Embase, PubMed/MEDLINE, Scopus, and Cochrane Library. We got the OR, MD and P-value using random effect model to compare the efficiency between bariatric surgery and nonsurgical treatment on diabetes remission, the reduction of BMI, Hb1Ac and FPG.

RESULTS

In 7 included studies including 544 participants, bariatric surgery is more effective than non-surgical treatment to reach diabetes remission [OR 25.06, 95%CL 9.58-65.54]. Bariatric surgery more likely resulted in significant reductions in HbA1c [MD -1.44, 95%CL (-1.84)-(-1.04)] and FPG [MD -2.61, 95%CL (-3.20)-(-2.20)]. Bariatric surgery may resulted in reductions in BMI [MD -3.14, 95%CL (-4.41)-(-1.88)], which more significant in Asian.

CONCLUSION

In type 2 diabetes patients who BMI < 35 kg/m², bariatric surgery is more likely to achieve diabetes remission and better blood glucose control than nonsurgical treatment.

Clinical Outcomes and Hospital Utilization Among Patients Undergoing Bariatric Surgery With Telemedicine Preoperative Care

Importance

Bariatric surgery is the mainstay of treatment for medically refractory obesity; however, it is underutilized. Telemedicine affords patient cost and time savings and may increase availability and accessibility of bariatric surgery.

Objective

To determine clinical outcomes and postoperative hospital utilization for patients undergoing bariatric surgery who receive fully remote vs in-person preoperative care.

Design, Setting, and Participants

This cohort study comparing postoperative clinical outcomes and hospital utilization after telemedicine or in-person preoperative surgical evaluation included patients treated at a US academic hospital. Participants underwent laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy after telemedicine or in-person preoperative surgical evaluation between July 1, 2020, to December 22, 2021, or January 1, 2018, to December 31, 2019, respectively. Follow-up was 60 days from date of surgery.

Exposures

Telemedicine-based preoperative care.

Main Outcomes and Measures

Clinical outcomes, including operating room delay, procedure duration, length of hospital stay (LOS), and major adverse events (MAE), and postoperative hospital resource utilization, including emergency department (ED) visit or hospital readmission within 30 days of the surgical procedure.

Results

A total of 1182 patients were included; patients in the telemedicine group were younger (mean [SD] age, 40.8 [12.5] years vs 43.0 [12.2] years; P = .01) and more likely to be female (230 of 257 [89.5%] vs 766 of 925 [82.8%]; P = .01) compared with the control group. The control group had a higher frequency of comorbidity (887 of 925 [95.9%] vs 208 of 257 [80.9%]; P < .001). The telemedicine group was found to be noninferior to the control group with respect to operating room delay (mean [SD] minutes, 7.8 [25.1]; 95% CI, 5.1-10.5 vs 4.2 [11.1]; 95% CI, 1.0-7.4; P = .002), procedure duration (mean [SD] minutes, 134.4 [52.8]; 95% CI, 130.9-137.8 vs 105.3 [41.5]; 95% CI, 100.2-110.4; P < .001), LOS (mean [SD] days, 1.9 [1.1]; 95% CI, 1.8-1.9 vs 2.1 [1.0]; 95% CI, 1.9-2.2; P < .001), MAE within 30 days (3.8%; 95% CI, 3.0%-5.7% vs 1.6%; 95% CI, 0.4%-3.9%; P = .001), MAE between 31 and 60 days (2.2%; 95% CI, 1.3%-3.3% vs 1.6%; 95% CI, 0.4%-3.9%; P < .001), frequency of ER visits (18.8%; 95% CI, 16.3%-21.4% vs 17.9%; 95% CI, 13.2%-22.6%; P = .03), and hospital readmission (10.1%; 95% CI, 8.1%-12.0% vs 6.6%; 95% CI, 3.9%-10.4%; P = .02).

Conclusions and Relevance

In this cohort study, clinical outcomes in the telemedicine group were not inferior to the control group. This observation suggests that telemedicine can be used safely and effectively for bariatric surgical preoperative care.

Cardiac fat pat change after laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass surgery: a systematic review and meta-analysis

Cardiac fat pad is a metabolically active organ that plays a role in energy homeostasis and cardiovascular diseases and generates inflammatory cytokines. Many studies have shown remarkable associations between cardiac fat thickness and cardiovascular diseases, making it a valuable target for interventions. Our meta-analysis aimed to investigate the effects of the 2 most popular bariatric surgeries (sleeve gastrectomy [SG] and Roux-en-Y gastric bypass [RYGB]) in cardiac fat pad reduction. A systematic review of the literature was done by searching in Scopus, Web of Science, Cochrane, and PubMed for articles published by September 16, 2022. This review followed the meta-analysis rules based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Nineteen studies met the inclusion criteria out of 128 potentially useful studies, including a total number of 822 patients. The results of subgroup analysis on the type of surgery showed that bariatric surgeries decreased the mean fat pad diameter, but the reduction was greater in SG than in RYGB. Epicardial and pericardial fat type showed a significant decrease of fat pad diameter. The results of subgroup analysis indicated RYGB had a significant reduction in mean fat pad volume. Computed tomography scan and cardiac magnetic resonance imaging showed a significant reduction of the mean cardiac fat pad volume. Epicardial and paracardial fat type showed a significant decrease in volume. The cardiac fat pad diameter and volume were significantly reduced after bariatric surgeries. SG showed greater reduction in fat pad diameter in comparison with RYGB, and RYGB had a significant reduction in mean fat pad volume.

Prevalence of Dumping Syndrome and Its Determinants Among Post-Bariatric Surgery Adult Patients at King Fahad General Hospital, Jeddah, 2019-2020

Background Bariatric surgery is one of the most effective interventions for morbid obesity. Despite its benefits, unwanted consequences such as dumping syndrome (DS) have been reported following the procedure. This study aims to estimate the prevalence of DS and identify the factors associated with it in Saudi Arabia. Methodology This cross-sectional study collected data from patients who underwent bariatric surgery at King Fahad General Hospital, Jeddah, Saudi Arabia, in 2019-2020. A validated questionnaire was used to collect the data. The questionnaire included demographic items such as age and sex and items relating to DS such as nausea, vomiting, and palpitations. A modified version of the Sigstad diagnostic scoring system was used to confirm the diagnosis. Results Of the 240 investigated cases, two-thirds (67.5%) were females. The most reported symptoms were nausea (37.9%), vomiting (36.7%), desire to lie down (25.5%), restlessness (25.5%), and abdominal fullness (23.7%). Based on the modified Sigstad diagnostic scoring system, 75 (31.4%) patients met the criteria for DS. The bivariate analysis showed the prevalence was significantly higher in females (36.4%), those with university qualifications (40.3%), and those with high monthly income (62.5%) (p<0.05). Also, dietary behaviors in terms of frequency, size of meals, and drinking liquids with meals were significantly associated with the prevalence of DS, where the lowest prevalence was recorded among those who ate more than one small meal (10.9%), while the highest prevalence was found in those who ate more than one large meal (81.8%); also, the prevalence was significantly higher in patients who drank liquids with meals (40.8%) than those who drank liquids between meals (26.8%) (p<0.05). Conclusion In this single institutional study, we report a 31.4% prevalence of DS among our cohort. The predictors of the syndrome include gender, education level, monthly income, eating more than one large meal per day, and drinking liquids with meals. In the future, these predictors will be explained to patients before and after bariatric surgery to reduce the prevalence of such inconvenient syndromes.

Perception of Bariatric Surgery and Endoscopic Bariatric Therapies Among Primary Care Physicians

INTRODUCTION

In the USA, less than 1% of eligible patients who qualify for bariatric surgery ultimately undergo surgery. Perceptions of endoscopic bariatric therapies (EBTs) for weight management remain unknown.

METHODS

A 22-question survey was distributed to primary care physicians (PCPs) across the Mayo Clinic healthcare system. Survey invitations were sent via email, and all surveys were unanimously conducted electronically.

RESULTS

A total of 130 PCPs participated in the survey (40% response rate). Twenty-four PCPs were between 20 and 24 years out of training (18.5%), and 71 (54.6%) were female. Most providers had a body mass index (BMI) between 18.5 and 24.9 kg/m² (n = 62, 47.7%). Among the weight loss options discussed during clinic visits, PCPs discussed lifestyle modification including diet and exercise (n = 129; 99.2%), and 68 PCPs (52.3%) were not aware of EBTs as weight loss interventions. While 46.2% of the PCPs agreed that a bariatric endoscopy is an effective option for weight loss, only 24.6% of PCPs were familiar with the indications for EBTs. Most of the cohort (n = 69, 53.1%) experienced barriers in referring their patients. Moreover, most of the patients referred to bariatric clinics were from PCPs who had a BMI between 18.5 and 24.9 kg/m² (n = 62, 47.7%) as compared to PCPs with a BMI of 40 kg/m² and greater (n = 5, 3.8%).

CONCLUSIONS

Due to the rise of bariatric therapies in recent years, PCPs are increasingly involved in the referral and management of patients with obesity and obesity-related comorbidities. However, knowledge gaps regarding weight loss options, including EBTs, could limit optimal care to patients desiring medically monitored weight loss.

Patients with Prader-Willi Syndrome (PWS) Underwent Bariatric Surgery Benefit more from High-Intensity Home Care

BACKGROUND

Long-term weight loss effect of bariatric surgeries for patients with Prader-Willi Syndrome (PWS) remains controversial since factors like postoperative home care intensity may impact the outcome. The aim of this study was to evaluate the role of home care intensity on long-term weight loss effect of bariatric surgery in patients with PWS.

METHODS

This was a prospective observational study on patients with PWS undergoing bariatric surgery and patients were enrolled from July 2015 to December 2016. Detailed information of patients' weight and behaviors was recorded by caregivers postoperatively. The intensities of home care applied to patients were classified into four categories (high, moderate, low, and very low) according to the records.

RESULTS

Six cases (3 males, 3 females) were enrolled in this study with LSG (n = 2), RYGB (n = 3), and LSG-DJB (n = 1) as their primary operation. The mean BMI of these participants was 46.78 ± 11.63 kg/m², and the mean age was 17.66 ± 6.59 years. All patients had at least 5 years of follow-ups, and the %EWL were 51.57 ± 23.36%, 64.54 ± 18.97%, 35.34 ± 36.53%, 19.45 ± 41.78%, and - 4.74 ± 71.50% in the half, first, second, third, and fifth year after surgery respectively. Two patients with high-intensity home care achieved a %EWL of 70.57 ± 8.86% in the fifth year after surgery.

CONCLUSIONS

Overall long-term weight loss of bariatric surgery for patients with PWS was not found through the follow-ups. Two patients with high-intensity home care maintained weight loss at the fifth-year follow-up, suggesting a pivotal role of high-intensity home care in long-term outcomes of bariatric surgery in patients with PWS.

Designing Digital Health Technology to Support Patients Before and After Bariatric Surgery: Qualitative Study Exploring Patient Desires, Suggestions, and Reflections to Support Lifestyle Behavior Change

Background

A patient’s capability, motivation, and opportunity to change their lifestyle are determinants of successful outcomes following bariatric surgery. Lifestyle changes before and after surgery, including improved dietary intake and physical activity levels, have been associated with greater postsurgical weight loss and improved long-term health. Integrating patient-centered digital technologies within the bariatric surgical pathway could form part of an innovative strategy to promote and sustain healthier behaviors, and provide holistic patient support, to improve surgical success. Previous research focused on implementing digital technologies and measuring effectiveness in surgical cohorts. However, there is limited work concerning the desires, suggestions, and reflections of patients undergoing bariatric surgery. This qualitative investigation explores patients’ perspectives on technology features that would support behavior changes during the pre- and postoperative periods, to potentially maintain long-term healthy lifestyles following surgery.

Objective

This study aims to understand how digital technologies can be used to support patient care during the perioperative journey to improve weight loss outcomes and surgical success, focusing on what patients want from digital technologies, how they want to use them, and when they would be of most benefit during their surgical journey.

Methods

Patients attending bariatric surgery clinics in one hospital in the North of England were invited to participate. Semistructured interviews were conducted with purposively sampled pre- and postoperative patients to discuss lifestyle changes and the use of digital technologies to complement their care. The interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data. Ethical approval was obtained from the National Health Service Health Research Authority.

Results

A total of 20 patients were interviewed (preoperative phase: 40% (8/20); postoperative phase: 60% (12/20). A total of 4 overarching themes were developed and related to the optimization of technology functionality. These centered on providing tailored content and support; facilitating self-monitoring and goal setting; delivering information in an accessible, trusted, and usable manner; and meeting patient information-seeking and engagement needs during the surgical pathway. Functionalities that delivered personalized feedback and postoperative follow-up were considered beneficial. Individualized goal setting functionality could support a generation of digitally engaged patients with bariatric conditions as working toward achievable targets was deemed an effective strategy for motivating behavior change. The creation of digital package of care checklists between patients and clinicians was a novel finding from this study.

Conclusions

Perceptions of patients undergoing bariatric surgery validated the integration of digital technologies within the surgical pathway, offering enhanced connectedness and support. Recommendations are made relating to the design, content, and functionality of digital interventions to best address the needs of this cohort. These findings have the potential to influence the co-design and integration of person-centered, perioperative technologies.

The Impact of Bariatric Surgery on Cardiovascular Risk Factors and Outcomes: A Systematic Review

Obesity and its complications are increasing in today's era, with cardiovascular health being one of the most significant obesity-related comorbidities. Hypertension in obesity is considered one of the major causes of death and disability due to their negative repercussions on cardiovascular health. Bariatric surgery is an approved therapeutic modality for obese people in classes II and III who have a body mass index (BMI) of more than 35 kg/m2 and 40 kg/m2, respectively. These weight loss surgeries are procedures that alter metabolism by causing weight reduction and altering gastrointestinal physiology, thereby considerably decreasing cardiometabolic risk factors that have been poorly understood to date. The purpose of this review is to explore the impact of bariatric surgery on reducing cardiac risk factors, in turn protecting the heart from succumbing to premature death. A literature search was done in the following databases: PubMed, Google Scholar, and PubMed Central (PMC). The studies taken into account for this review were observational studies published between 2016 and 2021 in the English language, where the quality was assessed using relevant quality appraisal methodologies. Finally, 10 reports were selected as definitive studies. Upon extensive evaluation of the final studies, it can be concluded that bariatric surgery results in significant weight loss, which lowers metabolic syndrome prevalence, cardiovascular risk factors, and major adverse cardiovascular events, particularly acute coronary events, and a favorable improvement in cardiac structure and function, altogether steering to reduced mortality due to cardiovascular diseases in obese patients. It is also worth noting that, while metabolic surgery can help patients with various metabolic comorbidities, the impact on individuals with hypertension is still debatable. Although the studies show significant effects on the cardiovascular system, these were only observational studies in geographically dispersed locations where each patient's lifestyle patterns and motivational levels could vary. Since real-world data are not fully explored due to the limited randomized controlled trials, it is suggested that further human trials on a larger scale be conducted to provide an even more factual conclusion.

Resistance Training Improves Muscle Strength and Function, Regardless of Protein Supplementation, in the Mid- to Long-Term Period after Gastric Bypass

Inadequate protein intake and low levels of physical activity are common long-term sequelae after bariatric surgery and can negatively affect muscle strength (MS) and physical function (PF). The study investigated the effects of resistance training with or without protein supplementation on MS and PF. The study, which involved a 12-week controlled trial (n = 61) of individuals 2-7 years post-Roux-en-Y gastric bypass (RYGB), comprised four groups: whey protein supplementation (PRO; n = 18), maltodextrin placebo (control [CON]; n = 17), resistance training combined with placebo (RTP; n = 11), and resistance training combined with whey protein supplementation (RTP+PRO; n = 15). An isokinetic dynamometer was used to measure MS (peak torque at 60°/s and 180°/s). PF was measured with the 30-s sit-to-stand (30-STS), 6-min walk (6-MWT), and timed up-and-go (TUG) tests. There were improvements in the absolute and relative-to-bodyweight peak torque at 60°/s and 180°/s, TUG, 6-MWT and 30-STS in the RTP and RTP+PRO groups, but not in the CON and PRO groups. Changes in MS were significantly correlated with changes in PF between the pre- and post-intervention periods. A supervised resistance training program, regardless of protein supplementation, improved MS and PF in the mid-to-long-term period after RYGB and can lead to clinical benefits and improved quality of life.

The characterization of metabolites alterations in white adipose tissue of diabetic GK Rats after ileal transposition surgery by an untargeted metabolomics approach

Dysfunction of adipose tissue could lead to insulin resistance, obesity and type 2 diabetes. Thus, our present study aimed to investigate metabolites alterations in white adipose tissue (WAT) of diabetic GK rats after IT surgery. Ten-week-old male diabetic GK rats were randomly subjected to IT and Sham-IT surgery. Six weeks later, the untargeted metabolomics in WAT of diabetic GK rats was performed. Differential metabolites were selected according to the coefficient of variation (CV) of quality control (QC) sample <30%, variable importance in the projection (VIP) >1 and P < 0.05. Then, the hierarchical clustering of differential metabolites was conducted and the KEGG database was used for metabolic pathway analysis. A total of 50 (in positive ion mode) and 68 (in negative ion mode) metabolites were identified as differential metabolites in WAT of diabetic GK rats between IT group and Sham-IT group, respectively. These differential metabolites were well clustered, which in descending order of the number of involved differential metabolites is ubiquinone and other terpenoid-quinone biosynthesis, AMPK signalling pathway, pantothenate and CoA biosynthesis, ferroptosis, vitamin digestion and absorption, glycerophospholipid metabolism, phenylalanine metabolism, steroid hormone biosynthesis, neuroactive ligand–receptor interaction, porphyrin and chlorophyll metabolism and bile secretion, and correlated with the parameters of body weight, food intake, WAT mass and glucose metabolism, which were significantly improved after IT surgery. The differential metabolites in WAT of diabetic GK rats were mainly related to the pathway of energy metabolism, and correlated with the improved phenotypes of diabetic GK rats after IT surgery.

The Impact of Bariatric Surgery on Diverticulitis Outcomes and Risk of Recurrent Hospitalizations in Adults with Clinically Severe Obesity

PURPOSE

Clinically severe obesity (SO) is a known risk factor for worsened outcomes and recurrence of acute diverticulitis. Paucity of data exist on outcomes of diverticulitis after bariatric surgery.

METHODS

The Nationwide Readmissions Database was queried for diverticulitis hospitalizations between the years 2010 and 2014. We restricted analysis to patients with SO and those who had bariatric surgery (BRS). Outcomes of mortality, surgical events, and recurrent diverticulitis admissions were compared using multivariable analysis and one-to-one propensity score matching.

RESULTS

Among 52,274 diverticulitis admissions, 91.2% (47,694) patients had SO and 8.8% (4580) had prior BRS. Patients with SO had higher odds of suffering mortality on index diverticulitis admission when compared to those with prior BRS [adjusted odds ratio (aOR): 10.55; 95%CI 1.45,76.75]. Patients with SO were also more likely to undergo emergency surgery (aOR: 1.71; 95%CI 1.25,2.34) and colectomy (aOR: 1.45; 95%CI 1.26,1.68). Rates of recurrent diverticulitis readmissions within 30 days and 6 months were also higher in patients with SO compared to BRS patients (aOR: 7.94; 95%CI 1.09,57.83 and aOR: 1.98; 95%CI 1.14,3.43, respectively). Propensity score matching confirmed our findings of increased rates of mortality (OR: 17.28; 95%CI 2.02,147.6), recurrent diverticulitis, and worsened surgical outcomes within 30 days in patients with SO compared to BRS.

CONCLUSION

This study is first to show improved outcomes and less recurrent hospitalizations for diverticulitis after bariatric surgery compared to patients with clinically severe obesity. Further studies are needed to understand mechanisms leading to this improvement and the role of weight loss in prevention of severe diverticulitis.

Health Status, Eating, and Lifestyle Habits in the Long Term Following Sleeve Gastrectomy

INTRODUCTION

Sleeve gastrectomy (SG) is an established bariatric procedure. However, long-term data on eating and lifestyle behaviors and their effect on weight outcomes are scarce. Therefore, this study aimed to examine these long-term behaviors and their associations to weight outcomes following SG.

METHODS

A long-term follow-up study (>5 years post-surgery) of 266 adult patients admitted to a primary SG surgery during 2008-2012 and who participated in a pre-surgery study was conducted. Data on pre-surgery demographics, anthropometrics, and medical status were obtained from the patients' medical records. Data on long-term health status, anthropometrics, lifestyle and eating habits, eating pathologies, follow-up regime, and satisfaction from the surgery were collected by an interview phone calls according to a structured questionnaire.

RESULTS

Data of 169 patients were available before and 7.8±1.0 years post-SG. Their baseline mean age was 41.8±11.3 years, and 71.6% of them were females. The mean post-surgery excess weight loss (EWL) was 53.2±31.2%, and 54.2% had EWL of ≥50%. Eating 3-6 meals per day, not having the urge to eat after dinner, separating liquids from solids, avoiding carbonated beverages, and performing physical activity were related to better weight-loss outcomes (P≤0.026). However, frequent need for eating sweets, binge eating, and feeling guilty or sad after eating were related to worse weight-loss outcomes (P≤0.010). Furthermore, only a minority reported taking a multivitamin and participating in follow-up meetings after more than 1 year since the surgery (≤21.3%).

CONCLUSIONS

In the long term following SG, approximately half achieved EWL of ≥50%, and physical activity, certain eating patterns, and eating pathologies were related to weight outcomes.

Enhanced Recovery After Bariatric Surgery: Feasibility and Outcomes in a National Bariatric Centre

PURPOSE

This study aimed to assess outcomes of bariatric surgical procedures after the implementation of an enhanced recovery after bariatric surgery protocol in the National Bariatric Centre in Ireland.

MATERIALS AND METHODS

Data on consecutive bariatric procedures performed over a 36-month period was prospectively recorded. ERABS interventions utilized included preoperative counselling, shortened preoperative fasts, specific anaesthetic protocols, early postop mobilization and feeding, and extended post-discharge thromboprophylaxis.

RESULTS

A total of 280 primary bariatric procedures were performed over a 36-month period. The primary procedures were laparoscopic sleeve gastrectomy (57.5%), laparoscopic one anastomosis gastric bypass (33.2%) and laparoscopic Roux-en-Y gastric bypass (9.3%). Mean (SD) age was 48 (± 10) years, mean (SD) preoperative BMI 49.5 (± 9) kg/m² and 68% were female. Median ASA score was 3, and median OSMRS also 3. Over 50% of patients had a diagnosis of hypertension or OSA, and over one-third had a diagnosis of type 2 diabetes mellitus or dyslipidemia. All procedures were completed laparoscopically and 29 patients underwent a simultaneous procedure. The mean (SD) length of stay was 2.3 (± 1.4) days (median 2 days, range 2-47 days). Overall postoperative morbidity rate was 10.0% (n = 29). The 30-day readmission and reoperation rates were 3.6% and 2.5% respectively. There was no mortality recorded in this series.

CONCLUSION

Implementing an ERABS protocol was feasible, safe, associated with low morbidity, no mortality, acceptable LOS and low readmission and reoperation rates. Although patients with obesity have a spectrum of disease-related complications, this should not preclude the use of an ERABS protocol in bariatric surgery.

Mechanism of Action of Acupuncture in Obesity: A Perspective From the Hypothalamus

Obesity is a prevalent metabolic disease caused by an imbalance in food intake and energy expenditure. Although acupuncture is widely used in the treatment of obesity in a clinical setting, its mechanism has not been adequately elucidated. As the key pivot of appetite signals, the hypothalamus receives afferent and efferent signals from the brainstem and peripheral tissue, leading to the formation of a complex appetite regulation circuit, thereby effectively regulating food intake and energy homeostasis. This review mainly discusses the relationship between the hypothalamic nuclei, related neuropeptides, brainstem, peripheral signals, and obesity, as well as mechanisms of acupuncture on obesity from the perspective of the hypothalamus, exploring the current evidence and therapeutic targets for mechanism of action of acupuncture in obesity.

Baseline Presence of NAFLD Predicts Weight Loss after Gastric Bypass Surgery for Morbid Obesity

Background. Bariatric surgery is a widely used treatment for morbid obesity. Prediction of postoperative weight loss currently relies on prediction models, which mostly overestimate patients’ weight loss. Data about the influence of Non-alcoholic fatty liver disease (NAFLD) on early postoperative weight loss are scarce. Methods. This prospective, single-center cohort study included 143 patients receiving laparoscopic gastric bypass surgery (One Anastomosis-Mini Gastric Bypass (OAGB-MGB) or Roux-en-Y Gastric Bypass (RYGB)). Liver biopsies were acquired at surgery. NAFLD activity score (NAS) assigned patients to “No NAFLD”, “NAFL” or “NASH”. Follow up data were collected at 3, 6 and 12 months. Results. In total, 49.7% of patients had NASH, while 41.3% had NAFL. Compared with the No NAFLD group, NAFL and NASH showed higher body-mass-index (BMI) at follow-up (6 months: 31.0 kg/m² vs. 36.8 kg/m² and 36.1 kg/m², 12 months: 27.0 kg/m² vs. 34.4 and 32.8 kg/m²) and lower percentage of total body weight loss (%TBWL): (6 months: 27.1% vs. 23.3% and 24.4%; 12 months: 38.5% vs. 30.1 and 32.6%). Linear regression of NAS points significantly predicts percentage of excessive weight loss (%EWL) after 6 months (Cologne-weight-loss-prediction-score). Conclusions. Histopathological presence of NAFLD might lead to inferior postoperative weight reduction after gastric bypass surgery. The mechanisms underlying this observation should be further studied.

Follow-up after bariatric surgery: A review

Bariatric surgery is becoming increasingly popular in the treatment of severely obese patients who failed to lose weight with the help of non-surgical interventions. Such patients are at increased risk for premature death, type 2 diabetes, high blood pressure, gallstones, coronary heart disease, dyslipidemia, some cancers, anxiety, depression, and degenerative joint disorders. Although bariatric surgery appears to be the most effective and durable treatment option for obesity, it is associated with a number of surgical and medical complications. These include a range of conditions, of which dumping syndrome and malnutrition due to malabsorption of vitamins and minerals are the most common. To achieve better surgery outcomes, a number of postsurgical strategies must be considered. The aim of this review was to describe possible complications, ailments, and important moments in the follow-up after bariatric surgery. Adequate lifelong monitoring is crucial for the achievement of long-lasting goals and reduction of post-bariatric complications.

Influence of Preoperative Weight Loss on Outcomes of Bariatric Surgery for Patients Under the Enhanced Recovery After Surgery Protocol

INTRODUCTION

The enhanced recovery after surgery (ERAS) protocol, which emphasizes preoperative interventions, is safely implemented in patients undergoing bariatric surgery. Patients are additionally encouraged to achieve weight loss preoperatively. We aimed to identify factors contributing to preoperative weight loss and assess their influence on outcomes of bariatric surgery among patients under the ERAS protocol.

MATERIALS AND METHODS

We reviewed a prospectively created database in two bariatric centers with 909 bariatric patients treated in accordance with ERAS principles. The database included demographic characteristics, factors related to the surgery or perioperative period, and short-term outcomes. Our endpoints included analyses of (1) factors potentially contributing to preoperative weight loss and (2) the influence of preoperative weight loss on short-term outcomes of bariatric treatment.

RESULTS

Diabetes mellitus (p = 0.007), obstructive sleep apnea (p < 0.001), and previous surgery (p = 0.012) were identified as predictors of preoperative weight loss. Steatohepatitis (p < 0.001) and respiratory disorder (p = 0.004) decreased the chance of achieving satisfactory preoperative body mass reduction. Except for operative time, early outcomes of bariatric surgery were not influenced by preoperative weight loss. Patients who achieved preoperative weight loss were less likely to be lost to follow-up (p = 0.023). Postoperative weight loss was better in patients who could lose ≥ 5% total weight preoperatively (p = 0.009).

CONCLUSION

Unsatisfactory preoperative weight loss among patients treated under ERAS principles is not associated with increased risk of complications. Satisfactory preoperative weight loss predicts superior postoperative weight loss and follow-up participation.

The influence of bariatric surgery on serum levels of irisin and nesfatin-1

Introduction: Bariatric surgery is associated with multiple endocrine and metabolic changes. Irisin and nesfatin-1 have recently been described as regulatory peptides involved in obesity-related insulin resistance. Our aim was to analyze the changes of those two molecules observed in patients after bariatric procedures. Materials and methods: This prospective study involved 40 patients treated for morbid obesity. Irisin and nesfatin-1 were measured before, 6 months and 1 year after surgical intervention. We also gathered demographic data, information concerning comorbidities, factors related to the surgery and outcomes of bariatric treatment. Results: Twenty-seven patients completed the study (15 females). The mean age of the group was 43.5 ± 10.4 years. Six (22.2%) patients were submitted to Laparoscopic Sleeve Gastrectomy and 21 (77.8%) patients were submitted to Laparoscopic Roux-en-Y Gastric Bypass. The participants in our study achieved significant weight loss. The irisin level remained stable in the whole study group during all three measurements included in our study protocol (p = .71). Our study group presented a reduction of the nesfatin-1 level 6 months after bariatric surgery and a slight further decrease after one-year observation, although these changes were also not significant (p = .17). Conclusions: We did not find any significant correlation between changes of irisin or nesfatin-1 level and bariatric surgery, as an aid in the regulation of glucose metabolism.

Natural Histogel-Based Bio-Scaffolds for Sustaining Angiogenesis in Beige Adipose Tissue

In the treatment of obesity and its related disorders, one of the measures adopted is weight reduction by controlling nutrition and increasing physical activity. A valid alternative to restore the physiological function of the human body could be the increase of energy consumption by inducing the browning of adipose tissue. To this purpose, we tested the ability of Histogel, a natural mixture of glycosaminoglycans isolated from animal Wharton jelly, to sustain the differentiation of adipose derived mesenchymal cells (ADSCs) into brown-like cells expressing UCP-1. Differentiated cells show a higher energy metabolism compared to undifferentiated mesenchymal cells. Furthermore, Histogel acts as a pro-angiogenic matrix, induces endothelial cell proliferation and sprouting in a three-dimensional gel in vitro, and stimulates neovascularization when applied in vivo on top of the chicken embryo chorioallantoic membrane or injected subcutaneously in mice. In addition to the pro-angiogenic activity of Histogel, also the ADSC derived beige cells contribute to activating endothelial cells. These data led us to propose Histogel as a promising scaffold for the modulation of the thermogenic behavior of adipose tissue. Indeed, Histogel simultaneously supports the acquisition of brown tissue markers and activates the vasculature process necessary for the correct function of the thermogenic tissue. Thus, Histogel represents a valid candidate for the development of bioscaffolds to increase the amount of brown adipose tissue in patients with metabolic disorders.

Early improvement in patient reported disability after bariatric surgery

BACKGROUND

Bariatric surgery is an effective intervention for managing morbid obesity. Little evidence has been reported regarding objective assessments of patient disability after surgery. The World Health Organization Disability Assessment Score 2.0 is a validated tool for assessing the level of disability after surgery, including assessment of difficulty with activities of daily living, social activities, and overall functioning.

OBJECTIVE

Evaluate patient disability after bariatric surgery at a tertiary care medical center.

SETTING

University hospital, United States.

METHODS

An institutional review board-approved prospective cohort study included patients undergoing primary bariatric surgery; patients undergoing a revisional procedure were excluded. Patient-reported disability was assessed using World Health Organization Disability Assessment Score 2.0, administered preoperatively and at 1 and 3 months after surgery. Disability scores (maximum of 48 reflecting extreme disability, minimum of 0) were analyzed for statistically significant trends.

RESULTS

One hundred ten patients enrolled in the study (76% female, 24% male) with 46% sleeve gastrectomy and 54% Roux-en-Y gastric bypass. Preoperative body mass index was 47.08 ± 7.6 (n = 110). The preoperative World Health Organization Disability Assessment Score scores were 6.66 ± 6.10 (n = 110). For those who completed both preoperative and 1-month surveys (n = 53), the scores were 6.60 ± 5.76 and 4.04 ± 4.68, respectively (P < .001). Those completing both preoperative and 3-month surveys (n = 53) had scores of 6.08 ± 5.48 and 2.38 ± 3.74, respectively (P < .001).

CONCLUSION

We report early improvement in disability with a validated tool at 1 and 3 months after bariatric surgery. This equates to global disability in this cohort improving from the 75th percentile of the population norm preoperatively to the 50th percentile at 3 months. Further studies are needed to determine if this is sustained long-term.

Associations between Weight Loss, Food Likes, Dietary Behaviors, and Chemosensory Function in Bariatric Surgery: A Case-Control Analysis in Women

We tested the hypothesis that successful weight loss post-bariatric surgery would be associated with healthier chemosensory function, food likes, and dietary behaviors than either unsuccessful weight loss or pre-surgery morbid obesity. In a case-control design, pre-surgical women with morbid obesity (n = 49) were compared with those 1-year post-surgery (24 Roux-en-Y Bypass, 24 Sleeve Gastrectomy) and defined by excess or percent weight loss as successful/unsuccessful. For self-reported smell/taste perception, more post-surgery than pre-surgery reported improved/distorted perception, especially if weight loss successful. Measured taste function (perceived quinine and NaCl intensity) was lower among weight loss unsuccessful versus pre-surgery patients, yet a genetic variation in taste probe (propylthiouracil bitterness) matched expected frequencies without significant pre/post-surgery difference. Regarding survey-reported liking, higher diet quality was seen in the weight loss successful (independent of surgery type) versus pre-surgical patients, with differences driven by lower sweet and refined carbohydrate liking. The post versus pre-surgical patients had greater restraint but less hunger and disinhibition. Patients reporting both higher diet quality and lower hunger showed greater % weight loss, independent of surgery type. Thus, successful weight loss 1-year post-bariatric surgery was associated with improved or distorted chemosensation and patterns of liking associated with healthier diets, especially if coupled with less hunger.

The Evolution of Bariatric Surgery Publications and Global Productivity: A Bibliometric Analysis

OBJECTIVE

This study aims to report on scientific production in bariatric surgery (BS).

BACKGROUND

BS has gained popularity particularly in the last two decades and its indications have extended with the laparoscopic development and the metabolic activity of the surgical treatment. However, there is still little information on scientific production related to BS.

METHODS

"Bariatric Surgery" or "Obesity Surgery" terms were searched through Web of Science focusing on the period 1980-2016. The analysis also included the correlations between economic productivity, humanity index, technological advancement levels, and performances of the countries in both fields.

RESULTS

A total number of 17,568 publications was found. Of these, 9087 were conducted in the field of surgery. The most prolific journal was Obesity Surgery (4707, 26.8%). The most cited article according to average citations per year was published in the Obesity Surgery (average citations 90.40, total citation 452). Beside the number of publications, the USA was in the leading position in several other fields (active institutions, active journals, active authors, citation analysis, and international cooperation). Sweden was the most productive country in BS publications (4.505). Several factors related to the number of publications in BS demonstrated significant correlations in our study (p < 0.01). The highest correlation was found with GDP (r = 0.763, p < 0.001).

CONCLUSIONS

The present study shows that the studies on BS has mainly been conducted in developed and developing countries.

Perceptions of Success in Bariatric Surgery: a Nationwide Survey Among Medical Professionals

INTRODUCTION

Various definitions for bariatric surgery (BS) success exist, with weight loss and comorbidity resolution outcomes being the most prominent. The study's aim was to compare how various healthcare professionals perceive success in BS.

METHODS

A 29-item, 10-point Likert scale online survey was distributed via email to Israeli healthcare professionals involved in the different BS aspects using common national professional organizations. These included bariatric surgeons, dietitians, social workers, psychologists, psychiatrists, primary care physicians, gastroenterologists, and nurses. Statement relevancy to BS success was rated. An item was classed as "very important" for BS success if at least 70% of participants rated it 8 or higher in each subgroup. Inter-observer agreement was calculated using kappa statistics. Data on specific occupation, years-in-practice, and major workplace were collected as well.

RESULTS

A total of 155 responses was obtained. The majority of respondents were dietitians (34.8%, n = 54), followed by bariatric surgeons (31.0%, n = 48) and nurses (14.8%, n = 23). Most respondents work mainly at public hospitals (32.9%, n = 51), followed by private hospitals (26.5%, n = 41). The mean years-in-practice among all healthcare professionals was 8.5 ± 8.5 years. Overall inter-observer agreement for prioritized items in accordance to BS success among all health professional subgroups was fair (Fleiss kappa = 0.278, P < 0.001), while dietitians and mental health specialists showed the highest agreement rate (Cohen's kappa = 0.592, P < 0.001).

CONCLUSION

The study highlights the various views on defining BS success by different healthcare professionals, although there was some overlap of core outcomes prioritized by all professionals. International uniform definitions for BS success are required.

Deregulation of transcription factors controlling intestinal epithelial cell differentiation; a predisposing factor for reduced enteroendocrine cell number in morbidly obese individuals

Morbidly obese patients exhibit impaired secretion of gut hormones that may contribute to the development of obesity. After bariatric surgery there is a dramatic increase in gut hormone release. In this study, gastric and duodenal tissues were endoscopically collected from lean, and morbidly obese subjects before and 3 months after laparoscopic sleeve gastrectomy (LSG). Tissue morphology, abundance of chromogranin A, gut hormones, α-defensin, mucin 2, Na⁺/glucose co-transporter 1 (SGLT1) and transcription factors, Hes1, HATH1, NeuroD1, and Ngn3, were determined. In obese patients, the total number of enteroendocrine cells (EEC) and EECs containing gut hormones were significantly reduced in the stomach and duodenum, compared to lean, and returned to normality post-LSG. No changes in villus height/crypt depth were observed. A significant increase in mucin 2 and SGLT1 expression was detected in the obese duodenum. Expression levels of transcription factors required for differentiation of absorptive and secretory cell lineages were altered. We propose that in obesity, there is deregulation in differentiation of intestinal epithelial cell lineages that may influence the levels of released gut hormones. Post-LSG cellular differentiation profile is restored. An understanding of molecular mechanisms controlling epithelial cell differentiation in the obese intestine assists in the development of non-invasive therapeutic strategies.