Bariatric surgery: mechanisms, indications and outcomes

Fifteen-year changes in health-related quality of life after bariatric surgery and non-surgical obesity treatment

BACKGROUND

Evidence on the long-term (≥10 years) development of health-related quality of life (HRQoL) following bariatric surgery is still limited and mainly based on small-scale studies. This study aimed to investigate (1) 15-year changes in mental, physical, social, and obesity-related HRQoL after bariatric surgery and non-surgical obesity treatment; and (2) whether sociodemographic factors and pre-operative health status are associated with 15-year HRQoL changes in the surgery group.

METHODS

Participants were from the non-randomized, prospective, controlled Swedish Obese Subjects study. The surgery group (N = 2007, per-protocol) underwent gastric bypass, banding or vertical banded gastroplasty, and matched controls (N = 2040) received usual obesity care. Recruitment took place in 1987-2001 and measurements (including six HRQoL scales) were administered before treatment and after 0.5, 1, 2, 3, 4, 6, 8, 10 and 15 years. Multilevel mixed-effect regression models using all observations for estimation were conducted.

RESULTS

Surgical patients experienced greater 15-year improvements in perceived health and overall mood, and greater reductions in depression, obesity-related problems, and social interaction limitations than controls (all p < 0.001, adjusted for baseline differences). Effect size (ES) was classified as large only for obesity-related problems (ES = 0.82). At the 15-year follow-up, surgical patients reported better perceived health (p < 0.001) and less obesity-related problems (p = 0.020) than controls. In the surgery group, patients with baseline diabetes had smaller 15-year reductions in social interaction limitations (p < 0.001) and depression (p = 0.049) compared to those without baseline diabetes. Although surgical patients with a history of psychiatric disorder reported lower HRQoL than those without such history over the 15-year follow-up, there were no significant differences in the long-term improvements between the two groups (p = 0.211-0.902).

CONCLUSIONS

Over 15 years, surgical patients experienced more positive development of HRQoL compared to those receiving usual care. This difference was large for obesity-related problems, but otherwise the differences were small. Patients with pre-operative diabetes might be at increased risk for smaller long-term HRQoL improvements.

The effect of bariatric surgery type on cardiac reverse remodelling

INTRODUCTION

Bariatric surgery is effective in reversing adverse cardiac remodelling in obesity. However, it is unclear whether the three commonly performed operations; Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Adjustable Gastric Band (LAGB) are equal in their ability to reverse remodelling.

METHODS

Fifty-eight patients underwent CMR to assess left ventricular mass (LVM), LV mass:volume ratio (LVMVR) and LV eccentricity index (LVei) before and after bariatric surgery (26 RYGB, 22 LSG and 10 LAGB), including 46 with short-term (median 251-273 days) and 43 with longer-term (median 983-1027 days) follow-up. Abdominal visceral adipose tissue (VAT) and epicardial adipose tissue (EAT) were also assessed.

RESULTS

All three procedures resulted in significant decreases in excess body weight (48-70%). Percentage change in VAT and EAT was significantly greater following RYGB and LSG compared to LAGB at both timepoints (VAT:RYGB -47% and -57%, LSG -47% and -54%, LAGB -31% and -25%; EAT:RYGB -13% and -14%, LSG -16% and -19%, LAGB -5% and -5%). Patients undergoing LAGB, whilst having reduced LVM (-1% and -4%), had a smaller decrease at both short (RYGB: -8%, p < 0.005; LSG: -11%, p < 0.0001) and long (RYGB: -12%, p = 0.009; LSG: -13%, p < 0.0001) term timepoints. There was a significant decrease in LVMVR at the long-term timepoint following both RYGB (-7%, p = 0.006) and LSG (-7%, p = 0.021), but not LAGB (-2%, p = 0.912). LVei appeared to decrease at the long-term timepoint in those undergoing RYGB (-3%, p = 0.063) and LSG (-4%, p = 0.015), but not in those undergoing LAGB (1%, p = 0.857). In all patients, the change in LVM correlated with change in VAT (r = 0.338, p = 0.0134), while the change in LVei correlated with change in EAT (r = 0.437, p = 0.001).

CONCLUSIONS

RYGB and LSG appear to result in greater decreases in visceral adiposity, and greater reverse LV remodelling with larger reductions in LVM, concentric remodelling and pericardial restraint than LAGB.

Bariatric Surgery: An Opportunity to Improve Quality of Life and Healthy Habits

Bariatric surgery therapy (BST) is an effective treatment for obesity; however, little is known about its impacts on health-related quality of life (HRQoL) and related factors. This study aimed to evaluate changes in HRQoL and its relationship with weight loss, depression status, physical activity (PA), and nutritional habits after BST. Data were obtained before and 18 months postprocedure from 56 obese patients who underwent BST. We administered four questionnaires: Short Form-36 health survey for HRQoL, 14-item MedDiet adherence questionnaire, Rapid Assessment of PA (RAPA) questionnaire, and Beck's Depression Inventory-II. Multivariable linear regression analysis was used to identify factors associated with improvement in HRQoL. After the surgery, MedDiet adherence and HRQoL improved significantly, especially in the physical component. No changes in PA were found. Patients without previous depression have better mental quality of life, and patients who lost more than 25% of %TBWL have better results in physical and mental quality of life. In the multivariable analysis, we found that %TBWL and initial PCS (inversely) were related to the improvement in PCS and initial MCS (inversely) with the MCS change. In conclusion, BST is an effective intervention for obesity, resulting in significant weight loss and improvements in HRQoL and nutritional habits.

Bariatric Surgery and Its Metabolic Echo Effect on Serum Uric Acid Levels

Bariatric surgery (BS) has been a significant means of reducing weight in obese individuals. The metabolic changes after bariatric surgery are crucial as they extend its advantages beyond weight loss. As its name implies, "metabolic surgery" also addresses obesity-related metabolic concerns. Bariatric surgery has always been associated with lessened serum uric acid (SUA) levels. In this review, we examined current studies to understand how surgical therapies impact serum uric acid levels. Strongly minded on the extent and timing of changes in the level of serum uric acid after bariatric surgeries. We conducted a comprehensive search for relevant current studies in PubMed, Google Scholar, JAMA, and the Cochrane Library until February 1, 2024. We aimed to analyze the metabolic advantages of bariatric surgery, focusing on its function in treating hyperuricemia and lowering the risk of associated disorders. Our review elaborates on factors contributing to decreased serum uric acid levels after bariatric surgery, such as alterations in renal function, insulin sensitivity, and inflammatory markers.

Comparing Lifestyle and Behavior of Post-Bariatric Surgery and Participants with Obesity: A Community-Based Cross-Sectional Study

Background

There is a paucity of research dedicated to exploring behavioral change in patients following bariatric surgery. However, there is a need for comparison analysis of individuals with obesity who have received surgical treatment and those who have not opted for any surgical procedures for weight loss. This study is designed to scrutinize the lifestyle choices, behavioral patterns, psychological elements, and eating habits of individuals who have undergone bariatric surgery, in contrast to those with obesity who have not undergone such a procedure.

Methods

This study is a secondary analysis from Sharik Diet and Health National Survey (SDHNS) dataset, which is a cross-sectional investigation covering the period from 2020 to 2022. The study focused on demographic factors like age, gender, educational attainment, and monthly earnings. Furthermore, other variables such as physical activity, leisure and workplace sitting habits, smoking patterns, strategies for managing weight, and eating and consumption behaviors were also examined.

Results

Out of the initial 15,980 participants reached, 4,069 satisfied the study's inclusion criteria. Bariatric surgery was reported by 806 participants (19.8%). Upon comparing three obesity status groups - The participants who underwent bariatric surgery with or without obesity, those with obesity who did not opt for any surgical weight loss measure, the analysis found that the three obesity status groups were significantly different in 21 variables from a total of 26. Moreover, a logistic regression analysis revealed that 11 variables influenced persistent obesity in the post-surgery phase, as opposed to those who successfully lost weight. These variables included advanced age, limited education, being female, lower income, waterpipe smoking habits, and the consumption of carbonated drinks.

Conclusion

This study showed that inability to lose weight after bariatric surgery are linked to poor lifestyle choices and behavior compared to those who were able to lose weight after the surgery.

Comparative analysis of lifestyle behaviors and dietary intake among obese and non-obese individuals following bariatric surgery: a secondary data analysis from 2020 to 2022

Objective

The aim of this research is to perform a comparative examination of lifestyle habits and dietary consumption between obese and non-obese subjects who have undergone bariatric surgery. This is done with the intent of investigating the disparities in obesity outcomes attributable to these elements.

Method

This study involves a secondary analysis of cross-sectional data obtained from the Sharik Diet and Health National Survey (SDHNS). To ensure a representative distribution of participants, the SDHNS employs a proportional quota sampling strategy, with stratification based on age, sex, and geographic location within Saudi Arabia's 13 administrative regions, utilizing the ZDataCloud® system for this purpose. The data, collected between 2020 and 2022 from over 15,000 participants, were screened to identify the eligible records of individuals who underwent bariatric surgery.

Results

Within the entire sample, a mere 5.0% (806 individuals) had undertook bariatric surgery, with females comprising 54% of this specific subgroup. The average age within this group was 38.85 years (SD 13.02) and range (18-87). Post-operative results showed that 33% of these individuals remained classified as obese. Utilizing the backward likelihood ratio regression model, it was determined that factors including age, decreased consumption of fresh juices and chicken, as well as current tobacco use, were significantly associated with persistent obesity.

Conclusion

The findings of this study suggest an association between the non-obese group and healthier lifestyle choices, including the consumption of high-protein diets and fresh juices, alongside a decreased prevalence of smoking. These observations underscore the significance of maintaining a healthy lifestyle for positive weight loss outcomes following bariatric surgery.

Does Significant Weight Loss After Bariatric Surgery Affect Sexual Function and Urinary Symptoms? An Iranian Study

INTRODUCTION

For sexual dysfunction and lower urinary tract symptoms (LUTS), obesity is identified as an independent risk factor. The current study aimed to evaluate the effect of significant rapid weight loss by bariatric surgery on LUTS and sexual function among men and women with class III obesity.

METHOD

A group of patients who were planned to undergo bariatric surgery was enrolled in the study. Male patients were given the International Index of Erectile Function (IIEF) and the International Prostate Symptom Score (IPSS) questionnaires. In the female group, they filled in the female sexual function index (FSFI) and the International Consultation on Incontinence Questionnaire short form (ICIQ-SF) questionnaires. Patients were followed up 1 year after their bariatric surgery.

RESULTS

All questionnaires were completed by eighty-one patients. (mean age ± SD: 39.4 ± 9.2 years; mean body mass index (BMI) ± SD: 47.15 ± 5.4 kg/m2). The total score of the IPSS questionnaire decreased from 5.83 ± 3.01 preoperatively to 2.37 ± 1.66 postoperatively. The weight loss caused significant improvement in the storage phase of LUTS domains, but there were no considerable changes in the voiding phase. In the IIEF questionnaire, domains of sexual desire, overall satisfaction, and orgasmic function improved significantly. There was not a significant change in any FSFI domains after bariatric surgery. Mean ICIQ-SF decreased, but it was not substantial.

CONCLUSION

Bariatric surgery can significantly improve the storage phase in men, but not the voiding phase. Sexual desire, orgasmic function, and overall satisfaction were significantly improved in men. No significant improvement in sexual function and UI in women was observed.

Implementing novel modalities into an institutional enhanced recovery after bariatric surgery (ERABS) protocol

INTRODUCTION

Enhanced recovery after bariatric surgery pathways are associated with improved postoperative outcomes. This study aims to assess efficacy and safety of three novel protocol contributions (transversus abdominis plane blocks, ketamine and fosaprepitant), as well as their impact on length of stay (LOS) and on postoperative complications.

METHODS

Effectiveness and safety were retrospectively investigated in patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) over a 6-year period in a single institution. Group 1 patients were not exposed to any of our suggested interventions, whereas Group 2 were exposed to all of three.

RESULTS

Between January 2015 and August 2021, 1480 patients underwent primary SG (77.6%) or RYGB (22.4%); of those, 1132 (76.5%) and 348 (23.5%) were in Groups 1 and 2, respectively. Mean BMI and age were 45.87 versus 43.65 kg/m² and 45.53 versus 44.99 years in groups 1 and 2, respectively. Suggested interventions were associated with lower operative times (84.79 ± 24.21 vs. 80.78 ± 32.8 min, p = 0.025). In Group 2, the mean LOS decreased in 0.18 day (1.79 ± 1.04 vs. 1.60 ± 0.90; p = 0.004). Overall complication rates were 8% and 8.6% for groups 1 and 2, respectively; readmission rates were 5.7% (64 pts) vs. 7.2% (25 pts), p > 0.05. Reoperations were less prevalent in Group 2 (1.5% vs. 1.1%; p = 0.79).

CONCLUSION

Focus on optimized pain management, allied to a superior PONV control, may be relevant contributors for a lower LOS without negative impacts in complications rates.

Advances in the Prevention and Treatment of Obesity-Driven Effects in Breast Cancers

Obesity and associated chronic inflammation were shown to facilitate breast cancer (BC) growth and metastasis. Leptin, adiponectin, estrogen, and several pro-inflammatory cytokines are involved in the development of obesity-driven BC through the activation of multiple oncogenic and pro-inflammatory pathways. The aim of this study was to assess the reported mechanisms of obesity-induced breast carcinogenesis and effectiveness of conventional and complementary BC therapies. We screened published original articles, reviews, and meta-analyses that addressed the involvement of obesity-related signaling mechanisms in BC development, BC treatment/prevention approaches, and posttreatment complications. PubMed, Medline, eMedicine, National Library of Medicine (NLM), and ReleMed databases were used to retrieve relevant studies using a set of keywords, including "obesity," "oncogenic signaling pathways," "inflammation," "surgery," "radiotherapy," "conventional therapies," and "diet." Multiple studies indicated that effective BC treatment requires the involvement of diet- and exercise-based approaches in obese postmenopausal women. Furthermore, active lifestyle and diet-related interventions improved the patients' overall quality of life and minimized adverse side effects after traditional BC treatment, including postsurgical lymphedema, post-chemo nausea, vomiting, and fatigue. Further investigation of beneficial effects of diet and physical activity may help improve obesity-linked cancer therapies.

Impact of bariatric surgery on depression, anxiety and stress symptoms among patients with morbid obesity: international multicentre study in Poland and Germany

BACKGROUND

There is a need to investigate how adopting different strategies for treating obesity in different countries in the European Union affects the psychological well-being of patients.

AIMS

The aim of this study was to perform a comparative evaluation of psychiatric symptoms (depression, anxiety and stress) in patients undergoing bariatric surgery versus patients receiving conservative treatment for morbid obesity in Poland and Germany.

METHOD

A multicentre international prospective cohort study with 155 patients who underwent bariatric surgery and 409 patients who received conservative weight reduction treatment. Evaluation of the psychiatric symptoms was carried out for each patient at baseline and after 12 months of active treatment using a standardised Depression Anxiety Stress Scale questionnaire (DASS-21) questionnaire.

RESULTS

After 12 months of active treatment, the level of psychiatric symptoms (depression, anxiety and stress) significantly decreased in both groups of patients: surgically treated versus conservatively treated patients from Poland and also from Germany. The median change in level of psychiatric symptoms among patients from both countries was significantly higher among surgically treated patients compared with conservatively treated patients (Poland P < 0.0001; Germany P < 0.0001). Improvements in the patient's mental health as a consequence of treatment were dependent on the specific strategy for treating obesity adopted in the analysed countries, the percentage of total weight loss and on gender.

CONCLUSIONS

The use of bariatric surgery in both Poland and Germany compared with non-surgical treatment for obesity resulted in more measurable benefits in the form of a decrease in psychiatric symptoms (depression, anxiety and stress) and reduction in body weight.

Impact of adaptive gastric electrical stimulation on weight, food intake, and food intake rate in dogs

BACKGROUND

Gastric electrical stimulation (GES) has been studied for decades as a promising treatment for obesity. Stimulation pulses with fixed amplitude and pulse width are usually applied, but these have limitations with regard to overcoming habituation to GES and inter-subject variation. This study aims to analyze the efficacy of an adaptive GES protocol for reducing food intake and maintaining lean weight in dogs.

METHODS

Six beagle dogs were implanted with a remotely programmable gastric stimulator. An adaptive protocol was designed to increase the stimulation energy proportionally to the excess of food consumption, with respect to the dogs' maintenance energy requirements. After surgery and habituation to experimental conditions, the dogs went through both a control and a stimulation period of 4 weeks each, in a randomized order. The stimulation parameters were adapted daily. Body weight, food intake, food intake rate, and postprandial cutaneous electrogastrograms (EGG) were recorded to assess the effect of adaptive GES.

RESULTS

Adaptive GES decreased food intake and food intake rate (p < 0.05) resulting in weight maintenance. In the absence of GES, the dogs gained weight (p < 0.05). Postprandial EGG dominant frequency was accelerated by GES (p < 0.05). The strategy of adapting the stimulation energy was effective in causing significant mid-term changes.

CONCLUSION

Adaptive GES is effective for reducing food intake and maintaining lean weight. The proposed adaptive strategy may offer benefits to counter habituation and adapt to inter-subject variation in clinical use of GES for obesity.

Effectiveness and Safety of Adjustable Gastric Banding in Morbidly Obese Patients After 5 Years of Follow-up

Obesity is a civilization disease that promotes the emergence and development of many diseases, such as type II diabetes, cardiovascular, and some cancers. It directly affects the length and quality of life. The purpose of this retrospective study was to show the short- and long-term results of weight loss after laparoscopic adjustable gastric banding (LAGB) as well as to assess the results of the procedure and the percentage of reoperations. Case series analysis included 228 subsequent patients who underwent LAGB due to obesity. In the postoperative period, there was a gradual reduction in body weight, especially in the first 24 months after surgery. After 3 years, no further weight reduction was observed, and sometimes, a slight increase in weight was observed 5 years after surgery; the trend in weight reduction over the entire time period was significant. A similar result was found for percentage of BMI loss (%BMIL) and percentage of excess body weight loss (%EWL), especially in the first 36 months after surgery. Our study confirmed the good early results and low effectiveness of laparoscopic adjustable gastric banding in the long-term treatment of pathological obesity. On the other hand, the simplicity and safety of the procedure, the minimal effects of malnutrition, the low number of early complications, and the total reversibility or conversion procedure for any other bariatric surgery are the strengths of laparoscopic adjustable gastric banding for a selected group of patients.

Chinese herbal medicine for subfertile women with polycystic ovarian syndrome

BACKGROUND

Polycystic ovarian syndrome (PCOS) is characterised by both metabolic and reproductive disorders, and affects 5% to 15% of women of reproductive age. Different western medicines have been proposed for PCOS-related subfertility, such as oral contraceptives, insulin sensitisers and laparoscopic ovarian drilling (LOD). Chinese herbal medicines (CHM) have also been used for subfertility caused by PCOS for decades, and are expected to become an alternative treatment for subfertile women with PCOS.

OBJECTIVES

To assess the efficacy and safety of Chinese herbal medicine (CHM) for subfertile women with polycystic ovarian syndrome (PCOS).

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register, CENTRAL, MEDLINE, Embase and six other databases, from inception to 2 June 2020. In addition, we searched three trials registries, the reference lists of included trials and contacted experts in the field to locate trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing CHM versus placebo, no treatment or conventional (western) therapies for the treatment of subfertile women with PCOS.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened trials for inclusion, assessed the risk of bias in included studies and extracted data. We contacted primary study authors for additional information. We conducted meta-analyses. We used the odds ratios (ORs) to report dichotomous data, with 95% confidence intervals (CIs). We assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods.

MAIN RESULTS

We included eight RCTs with 609 participants. The comparisons in the included trials were as follows: CHM versus clomiphene, CHM plus clomiphene versus clomiphene (with or without ethinyloestradiol cyproterone acetate (EE/CPA)), CHM plus follicle aspiration plus ovulation induction versus follicle aspiration plus ovulation induction alone, and CHM plus laparoscopic ovarian drilling (LOD) versus LOD alone. The overall certainty of the evidence for most comparisons was very low. None of the included studies reported the primary outcome, live birth rate. Most studies reported the secondary outcomes, and only one study reported data on adverse events. In trials that compared CHM to clomiphene (with or without LOD in both study arms), we are uncertain of the effect of CHM on pregnancy rates (odds ratio (OR) 1.41, 95% confidence interval (CI) 0.63 to 3.19; I² = 28%; 3 studies, 140 participants; very low certainty evidence). Results suggest that if the chance of pregnancy following clomiphene is assumed to be 21.5%, the chance following CHM would vary between 14.7% and 46.7%. No study reported data on adverse events. When CHM plus clomiphene was compared to clomiphene (with or without EE/CPA), there was low certainty evidence of a higher pregnancy rate in the CHM plus clomiphene group (OR 3.06, 95% CI 2.05 to 4.55; I² = 10%; 6 studies, 470 participants; low certainty evidence). Results suggest that if the chance of pregnancy following clomiphene is assumed to be 31.5%, the chance following CHM plus clomiphene would vary between 48.5% and 67.7%. No data were reported on adverse events. In trials that compared CHM plus follicle aspiration and ovulation induction to follicle aspiration and ovulation induction alone, we are uncertain of the effect of CHM on pregnancy rates (OR 1.62, 95% CI 0.46 to 5.68; 1 study, 44 women; very low certainty evidence). Results suggest that if the chance of pregnancy following follicle aspiration and ovulation induction is assumed to be 29.2%, the chance following CHM with follicle aspiration and ovulation induction would vary between 15.9% and 70%. Reported adverse events included severe luteinised unruptured follicle syndrome (LUFS) (Peto OR 0.60, 95% CI 0.06 to 6.14; 1 study, 44 women; very low certainty evidence), ovarian hyperstimulation syndrome (OHSS) (Peto OR 0.16, 95% CI 0.00 to 8.19; 1 study, 44 women; very low certainty evidence) or multiple pregnancy (Peto OR 0.60, 95% CI 0.06 to 6.14; 1 study, 44 women; very low certainty evidence). These results suggest that if the chances of LUFS, OHSS, and multiple pregnancy following follicle aspiration and ovulation induction are assumed to be 8.3%, 4.2%, and 8.3% respectively, the chances following CHM with follicle aspiration and ovulation induction would be 0.5% to 35.8%, 0% to 26.3% and 0.5% to 35.8% respectively.  In trials that compared CHM plus LOD to LOD alone, we are uncertain if CHM improves pregnancy rates (OR 3.50, 95% CI 0.72 to 17.09; 1 study, 30 women; very low certainty evidence). Results suggest that if the chance of pregnancy following LOD is assumed to be 40%, the chance following CHM with LOD would vary between 32.4% and 91.9%. No data were reported on adverse events. We are uncertain of the results in the comparison groups for all outcomes. The certainty of the evidence for all other comparisons and outcomes was very low. The main limitations in the evidence were failure to report live birth or adverse events, failure to describe study methods in adequate detail and imprecision due to very low event rates and wide CIs.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the use of CHM for subfertile women with PCOS. No data are available on live birth. We are uncertain of the effect of CHM on pregnancy rates for there is no consistent evidence to indicate that CHM influences fertility outcomes. However, we find that the addition of CHM to clomiphene may improve pregnancy rates, but there is very limited, low certainty evidence for this outcome. Furthermore, there is insufficient evidence on adverse effects to indicate whether CHM is safe. In the future, well-designed, carefully conducted RCTs are needed, with a particular focus on the live birth rate and other safety indexes.

Optimization and assessment of a novel gastric electrode anchoring system designed to be implanted by minimally invasive surgery

A novel electrode anchoring design and its implantation procedure, aiming for a minimally invasive solution for gastric electrical stimulation, are presented. The system comprises an anchor made of a flexible body embedding two needle-shaped electrodes. The electrodes can easily switch from a parallel position - to pierce the stomach - to a diverging position - enabling them to remain firmly anchored into the muscular layer of the stomach. Key device parameters governing anchoring stability were assessed on a traction test bench, and optimal values were derived. The device was then implanted in six dogs by open surgery to assess its anchoring durability in vivo. Computed tomography images showed that the electrodes remained well placed within the dogs' gastric wall over the entire assessment period (more than one year). Finally, a prototype of a surgical tool for the minimally invasive device placement was manufactured, and the anchoring procedure was tested on a dog cadaver, providing the proof of concept of the minimally invasive implantation procedure. The use of our electrode anchoring system in long-term gastric electrical stimulation is promising in terms of implantation stability (the anchor withstands a force up to 0.81 N), durability (the anchor remains onto the stomach over one year) and minimal invasiveness of the procedure (the diameter of the percutaneous access is smaller than 12 mm). Moreover, the proposed design could have clinical applications in other hollow organs, such as the urinary bladder.

Does bariatric surgery improve cardiac autonomic modulation assessed by heart rate variability? A systematic review

Our study aimed to explore the influence of bariatric surgery (BS) on heart rate (HR) variability (HRV) through a systematic review. Manuscripts were selected based on electronic searches of the MEDLINE, EMBASE, and CINAHL databases from the inception of each database up to year 2020, and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Searching of these studies was systematized using the Population Intervention Comparison Outcome Study Design strategy. We selected randomized and nonrandomized controlled trials and cohorts from prospective studies that reported the influence of BS on HRV. We assessed the quality rating using the Black and Downs questionnaire. Following the screening and eligibility stages, 14 studies were included in the review. All studies agreed that BS promotes an increase in parasympathetic HR control and HRV and a decrease in HR. Yet the literature does not provide evidence that these outcomes are directly caused by the surgical procedure. There is limited evidence to support that patients with type 2 diabetes have greater improvement in HRV as an interim measure, to individuals without. The decrease in insulin resistance was correlated with the increase in HRV in some studies, but, other studies are unsupportive of this outcome. Improvements in 2 metabolic parameters (e.g., leptin, N-terminal pro B-type natriuretic peptide) were connected with superior increases in HRV. This review demonstrated that BS promotes an increase in HRV, indicating improved autonomic control of HR.

Increased Cardiopulmonary Fitness Is Associated with a Greater Reduction in Depression among People Who Underwent Bariatric Surgery

The aim of this study was to determine the effect of changes in cardiopulmonary fitness on the mental health of patients with severe obesity who underwent gastric bypass surgery (prior to and 1, 3, and 6 months after surgery). Study participants were recruited from among patients of a regional hospital in Czechia who underwent gastric bypass surgery between April 2018 and October 2019. They were eligible if they (a) were between 18 and 65 years old, (b) provided written informed consent, and (c) were able to walk independently. Twenty-six patients (age 45.4 ± 9.0 years, body mass index 45.1 ± 7.4 kg·m⁻², body fat 43.8 ± 4.8%) were included in the analysis. The key finding revealed that the greater the increase in cardiopulmonary fitness (i.e., longer distance walked in the six-minute walk test, 6MWT), the better the improvement in depression score among patients who underwent bariatric surgery. In particular, increments of 10 m in the 6MWT lead to the improvement of 0.5 points on the depression subscale of the Hospital Anxiety and Depression Scale (HADS) questionnaire. As the main implication, these results suggest that patients should participate in exercise training programs to increase their fitness status for optimal physical and mental outcomes of bariatric surgery.

Roux-en-Y Gastrointestinal Bypass Promotes Activation of TGR5 and Peptide YY

BACKGROUND

G protein-coupled bile acid receptor (TGR5) is involved in a number of metabolic diseases. The aim of this study was to identify the role of TGR5 after Roux-en-Y gastric bypass (GBP).

METHODS

Wild type and TGR5 knockout mice (tgr5-/-) were fed a high-fat diet (HFD) to establish the obesity model. GBP was performed. The changes in body weight and food intake were measured. The levels of TGR5 and peptide YY (PYY) were evaluated by RT-PCR, Western blot, and ELISA. Moreover, the L-cells were separated from wild type and tgr5-/- mice. The levels of PYY in L-cells were evaluated by ELISA.

RESULTS

The body weights were significantly decreased after GBP in wild type mice (p<0.05), but not tgr5-/- mice (p>0.05). Food intake was reduced after GBP in wild type mice, but also not significantly affected in tgr5-/- mice (p>0.05). The levels of PYY were significantly increased after GBP compared with the sham group (p<0.05); however, in tgr5-/- mice the expression of PYY was not significantly affected (p>0.05). After INT-777 stimulation in L-cells obtained from murine intestines, the levels of PYY were significantly increased in L-cells tgr5+/+ (p<0.05).

CONCLUSION

Our study suggests that GBP up-regulated the expression of TGR5 in murine intestines, and increased the levels of PYY, which further reduced food intake and decreased the body weight.

Using Bayesian Networks to Predict Long-Term Health-Related Quality of Life and Comorbidity after Bariatric Surgery: A Study Based on the Scandinavian Obesity Surgery Registry

Previously published literature has identified a few predictors of health-related quality of life (HRQoL) after bariatric surgery. However, performance of the predictive models was not evaluated rigorously using real world data. To find better methods for predicting prognosis in patients after bariatric surgery, we examined performance of the Bayesian networks (BN) method in predicting long-term postoperative HRQoL and compared it with the convolution neural network (CNN) and multivariable logistic regression (MLR). The patients registered in the Scandinavian Obesity Surgery Registry (SOReg) were used for the current study. In total, 6542 patients registered in the SOReg between 2008 and 2012 with complete demographic and preoperative comorbidity information, and preoperative and postoperative 5-year HROoL scores and comorbidities were included in the study. HRQoL was measured using the RAND-SF-36 and the obesity-related problems scale. Thirty-five variables were used for analyses, including 19 predictors and 16 outcome variables. The Gaussian BN (GBN), CNN, and a traditional linear regression model were used for predicting 5-year HRQoL scores, and multinomial discrete BN (DBN) and MLR were used for 5-year comorbidities. Eighty percent of the patients were randomly selected as a training dataset and 20% as a validation dataset. The GBN presented a better performance than the CNN and the linear regression model; it had smaller mean squared errors (MSEs) than those from the CNN and the linear regression model. The MSE of the summary physical scale was only 0.0196 for GBN compared to the 0.0333 seen in the CNN. The DBN showed excellent predictive ability for 5-year type 2 diabetes and dyslipidemia (area under curve (AUC) = 0.942 and 0.917, respectively), good ability for 5-year hypertension and sleep apnea syndrome (AUC = 0.891 and 0.834, respectively), and fair ability for 5-year depression (AUC = 0.750). Bayesian networks provide useful tools for predicting long-term HRQoL and comorbidities in patients after bariatric surgery. The hybrid network that may involve variables from different probability distribution families deserves investigation in the future.

Selenium Status after Roux-en-Y Gastric Bypass: Interventions and Recommendations

BACKGROUND

Selenium is an essential element that plays a vital role in maintaining human health and its deficiency can lead to cardiovascular and hypothyroidism complications. In this context, the main concern is about morbidly obese patients who undergo a Roux-en-Y Gastric Bypass (RYGB). Although RYGB leads to 60-70% excess weight loss, micronutrient deficiencies are common after this procedure and can be problematic if not promptly detected. This review will therefore examine the evidence regarding selenium deficiency in RYGB patients, as well its nutritional treatment methods.

METHODS

There were a total of 6 studies regarding RYGB and selenium deficiency, which were retrieved from PUBMED and SCOPUS electronic databases, ranging from 2006 to 2017.

CONCLUSION

Selenium deficiency was observed before and after RYGB. Lifelong supplementation and regular patient monitoring after surgery are recommended.

Enhanced Recovery after Bariatric Surgery: 202 Consecutive Patients in an Italian Bariatric Center

BACKGROUND

Enhanced Recovery After Surgery (ERAS) pathways have been shown to improve postoperative outcomes. However, its application in bariatric surgery is still limited. The aim of the study was to define the safety of ERAS in bariatric patients with regard to postoperative complications, length of hospital stay (LOS), and readmission rates within 30 days from surgery.

METHODS

The effectiveness and safety of an ERAS protocol was prospectively investigated in morbidly obese patients who underwent bariatric surgery in a single-institute experience over a 2-year period.

RESULTS

Between June 2016 and September 2018, a total of 89 laparoscopic sleeve gastrectomy (SG), 105 Roux-en-Y gastric bypass (RYGB), and 8 one-anastomosis gastric bypass (OAGB) were performed. Twenty patients (9.9%) were revisional cases. Mean (standard deviation, SD) BMI and age at time of surgery were 43.2 (± 6.2) kg/m² and 46 (± 11.3) years, respectively. Median (range) surgical time was 118 (45-255) minutes. Overall postoperative complication rate was 7.4%, with 6 (3.0%) patients developing grade III-IV complications according to the Clavien-Dindo classification. Median (range) LOS was 2 (1-50) days, with mean (SD) LOS of 2.3 (± 3.6) days. Overall, 36.6% of patients were discharged by first postoperative day and 77.7% by second postoperative day. Readmission rate was 4.5%. No mortality was observed during the study period.

CONCLUSIONS

According to the results of the present study, ERAS in primary and revisional bariatric surgery is safe and feasible, with short LOS, low morbidity and readmission rates, and no mortality. A significant reduction of mean LOS was progressively noted over the study period.

Novel Insights into the Pathogenesis and Management of the Metabolic Syndrome

The metabolic syndrome, by definition, is not a disease but is a clustering of individual metabolic risk factors including abdominal obesity, hyperglycemia, hypertriglyceridemia, hypertension, and low high-density lipoprotein cholesterol levels. These risk factors could dramatically increase the prevalence of type 2 diabetes and cardiovascular disease. The reported prevalence of the metabolic syndrome varies, greatly depending on the definition used, gender, age, socioeconomic status, and the ethnic background of study cohorts. Clinical and epidemiological studies have clearly demonstrated that the metabolic syndrome starts with central obesity. Because the prevalence of obesity has doubly increased worldwide over the past 30 years, the prevalence of the metabolic syndrome has markedly boosted in parallel. Therefore, obesity has been recognized as the leading cause for the metabolic syndrome since it is strongly associated with all metabolic risk factors. High prevalence of the metabolic syndrome is not unique to the USA and Europe and it is also increasing in most Asian countries. Insulin resistance has elucidated most, if not all, of the pathophysiology of the metabolic syndrome because it contributes to hyperglycemia. Furthermore, a major contributor to the development of insulin resistance is an overabundance of circulating fatty acids. Plasma fatty acids are derived mainly from the triglycerides stored in adipose tissues, which are released through the action of the cyclic AMP-dependent enzyme, hormone sensitive lipase. This review summarizes the latest concepts in the definition, pathogenesis, pathophysiology, and diagnosis of the metabolic syndrome, as well as its preventive measures and therapeutic strategies in children and adolescents.

Bariatric Surgery Population at Significantly Increased Risk of Spinal Disorders and Surgical Intervention Compared With Morbidly Obese Patients

INTRODUCTION

Obesity is associated with acceleration of musculoskeletal degenerative diseases and functional impairment secondary to spinal disorders. Bariatric surgery (BS) is an increasingly common treatment for severe obesity but can affect bone and mineral metabolism. The effect of BS on degenerative spinal disorders is yet to be fully described. The aim of our study was to analyze changes in bariatric patients' risk for spinal degenerative diseases and spinal surgery.

METHODS

Retrospective analysis of the prospectively collected New York State Inpatient Database (NYSID) years (2004-2013) using patient linkage codes. The incidence of degenerative spinal diagnoses and spinal surgery was queried using International Classification of Diseases, Ninth Revision (ICD)-9 codes for morbidly obese patients (ICD-9 278.01) with and without a history of BS. The incidence of degenerative spinal diagnoses and spinal surgery was determined using χ tests for independence. Logistic testing controlled for age, sex, and comorbidity burden.

RESULTS

A total of 18,176 patients were identified in the NYSID database with a history of BS and 146,252 patients were identified as morbidly obese without a history of BS. BS patients have a significantly higher rate of spinal diagnoses than morbidly obese patients without BS (19.3% vs. 8.1%, P<0.001). Bariatric patients were more likely to have spinal diagnoses and procedures than nonbariatric obese patients (P<0.001). This was mostly observed in lumbar spinal stenosis (5.0%), cervical disk herniation (3.3%), lumbar disk degeneration (3.4%), lumbar spondylolisthesis (2.9%), lumbar spondylosis (1.9%), and cervical spondylosis with myelopathy (2.0%). Spine procedure rates are higher for bariatric patients than nonbariatric overall (25.6% vs. 2.3, P<0.001) and for fusions and decompressions (P<0.001). When controlling for age, sex, and comorbidities (and diagnosis rate with regards to procedure rates), these results persist, with BS patients having a higher likelihood of spinal diagnoses and procedures. In addition, bariatric patients had a lower comorbidity burden than morbidly obese patients without a history of BS.

CONCLUSIONS

Morbidly obese BS patients have a dramatically higher incidence of spinal diagnoses and procedures, relative to morbidly obese patients without BS. Further study is necessary to determine if there is a pathophysiological mechanism underlying this higher risk of spinal disease and intervention in bariatric patients, and the effect of BS on these rates following treatment.

LEVEL OF EVIDENCE

Level III.

Differences in Calcium Metabolism and Thyroid Physiology After Sleeve Gastrectomy and Roux-En-Y Gastric Bypass

INTRODUCTION

Bariatric surgery may modulate the hormones and elements which maintain thyroid and calcium homeostasis. These adaptations in hormonal and elemental aspects have previously been determined via some studies with variations in their findings. Thyroid volume and 24-h urinary calcium are two parameters which have not been investigated regarding whether they change during the bariatric postsurgical period. This study planned to examine the changes in calcium metabolism and thyroid gland functioning after sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB).

MATERIALS AND METHODS

Seventy-three morbidly obese patients with planned bariatric surgery were enrolled in the study. Before and 12 months after the operation, parathormone (PTH), 25-OH-vitamin D3(25vitD3), TSH, free triiodothyronine (fT3), free thyroxine (fT4), calcium (Ca), 24-h urinary Ca and ultrasonography-guided thyroid volume were measured.

RESULTS

In the beginning, 73 patients were examined and 12 months after surgery out of 25 patients continuing follow-up, 20 (80%) had undergone sleeve gastrectomy (SG) while five (20%) had undergone Roux-en-Y gastric bypass (RYGB). Accompanied by significant BMI decrease, 24-h urinary Ca and thyroid volume did not significantly increase in RYGB, SG, and the whole group after 12 months. The SG group showed a significant drop in TSH (p 0.03) level, while the RYGB group showed significant decreases in fT4 (p 0.00) and fT3 (p 0.00); and significant fT3 decrease (p 0.01) was recorded for the whole group.

CONCLUSION

Bariatric surgery may modify Ca homeostasis and thyroid gland functional status. We documented that these were not statistically significant increases in 24-h urinary Ca level and thyroid volume after 1 year. Further studies are needed to understand the issue, enrolling more patients who underwent the same bariatric procedure and after accounting for the inhibition of supplementary vitamin and mineral effects.

Biofilm-sealed perforation of the gastric body: a rare sequela of gastric band erosion

Laparoscopic Adjustable Gastric Banding is one of the cardinal bariatric interventions and due to its early safety profile, became the mainstay. Major long-term complications of gastric banding include pouch-herniation-dilation and gastric erosion. A 59-year-old female presented to the emergency department with a 2-week history of progressive central abdominal pain and distention on a background history of a laparoscopic adjustable band insertion 11 years previously. Subsequent computed tomography demonstrated an intragastric band erosion. An exploratory laparotomy demonstrated a gastric band eroded through the stomach sealed by a biofilm. Secondary findings included small bowel ischemia and portal vein thrombosis. The gastric band was extracted, and the stomach was repaired. The ischemic small bowel was resected with primary anastomosis. The patient recovered uneventfully. Gastric band erosion should be considered in all patients presenting with abdominal pain and previous weight loss surgery. Prompt recognition may avoid fatal consequences.

Whether a Short or Long Alimentary Limb Influences Weight Loss in Gastric Bypass: a Systematic Review and Meta-Analysis

Roux-en-Y gastric bypass, the most commonly performed procedure in bariatric surgery, still lacks a consensus on whether alimentary limb length (ALL) influences weight loss. Studies were identified by searching multiple electronic databases. Studies with enough data including body mass index (BMI) loss and percent excess weight loss (% EWL) were eligible. The statistical analysis was performed with Stata 14.0. In total, eight studies with 1714 patients were included. The meta-analysis suggested that short ALLs weakened the efficacy of Roux-en-Y gastric bypass in terms of BMI loss (standard mean deviation (SMD), - 0.33 [95% confidence intervals (CI), - 0.60, - 0.05], p = 0.021) with 3 years of follow-up and % EWL (SMD, - 0.17 [95% CI, - 0.31, - 0.04], p = 0.013) with 2 years of follow-up. The subgroup analysis demonstrated that the group with a BMI ≥ 50 kg/m² had a significant SMD between the use of short and the standard ALLs (- 0.71 [95% CI, - 1.07, - 0.35], p = 0.000), while the subgroup with a BMI < 50 kg/m² (SMD, - 0.29 [95% CI, - 0.78, 0.20], p = 0.247) did not. Compared with a standard ALL (130-150 cm), a short ALL (40-100 cm) may reduce the efficacy of the Roux-en-Y gastric bypass surgery, while a long ALL (170-250 cm) did not significantly improve the effects in terms of BMI loss and % EWL. In addition, a potential view of the meta-analysis indicated patients with a BMI < 50 kg/m² might get more benefits with a short ALL, while those patients with a BMI ≥ 50 kg/m² might benefit more from a standard ALL.

Week and Weekend Day Cadence Patterns Long-Term Post-Bariatric Surgery

Obesity can negatively influence walking cadence, reducing the overall intensity of daily activities and increasing the risk of weight gain.

PURPOSE

Objectively describe the walking cadence of individuals' long-term post-bariatric surgery.

METHODS

Fifty-eight participants, 51.2 ± 8.9 years old, with a BMI of 34.6 ± 10.1 kg/m², 10.0 ± 3.1 years post-surgery wore an activPAL accelerometer for 7 consecutive days. Data was analyzed using participants' current BMI, dichotomized by obesity status, < or ≥ 30 kg/m².

RESULTS

On average, participants walked 5124 ± 2549 steps/day on weekdays and 6097 ± 2786 steps/day on weekend days (p = .003). Participants spent the majority (75%) of their daily steps at a slow-walking average cadence (non-obese: week = 65.3 ± 5.0 steps/min and weekend = 63.8 ± 6.7 steps/min; obese: week = 67.8 ± 8.2 steps/min and weekend = 63.3 ± 6.9 steps/min), with no difference between groups for week or weekend days (p = .153 and .774). The cadence of participants with obesity was significantly lower on weekends compared to weekdays for walking events > 30 s (p = .002) and > 60 s (p = .008) in duration. Weekday cadence of participants without obesity was similar to weekend day cadence across all walking event durations. The majority of walking events occurred below 30 s in duration for all participants.

CONCLUSIONS

Long-term post-bariatric surgery, movement occurs in short duration bouts at a slow-walking cadence for the majority of movement. Individuals without obesity had similar movement patterns from week to weekend days while participants with obesity significantly lowered their cadence on weekend days.

Laparoscopic adjustable gastric banding on 3566 patients up to 20-year follow-up: Long-term results of a standardized technique

BACKGROUND

As obesity is a chronic disease, any bariatric procedure should be validated by long-term results.

OBJECTIVE

To present our long-term results after laparoscopic adjustable gastric banding over a period of >20 years and to investigate the outcomes in terms of efficacy, complications, and reoperations.

SETTING

Private practice, Italy.

METHODS

From October 1995 to February 2018, 3566 laparoscopic adjustable gastric banding were performed by a single surgeon. Data were retrieved from a prospectively collected computer database and retrospectively analyzed. Furthermore, patients were stratified according to body mass index and age and results are evaluated for each subgroup.

RESULTS

All the operations were performed laparoscopically without any mortality and/or major specific complications. Nine hundred twenty-six patients (71.6%) completed at least 10-years follow-up and 180 (58.4%) reached 15-years follow-up. There was a mean of 49%, 52.6%, and 59.2% of excess weight loss at 10, 15, and 20 years, respectively. Major late complications were pouch herniation-dilation (5.8%) and erosion (2.5%), both solved by a replicable, less invasive operation. Total reoperation rate was 24.1%.

CONCLUSION

Our experience suggested that the combination of a standardized surgical technique and close patient follow-up, performed in collaboration with an interdisciplinary team, may make the laparoscopic adjustable gastric banding system a powerful long-term surgical tool in the treatment of morbid obesity. The best results were obtained in young patients with high body mass index but results were also satisfactory in elderly patients and in those with low body mass index.

Assessment of Weight Loss With the Intragastric Balloon in Patients With Different Degrees of Obesity

INTRODUCTION

The intragastric balloon (IGB) is an endoscopic device for the treatment of obesity. Best results are observed in patients who follow a dietary program but few studies have assessed the results of this treatment in patients with different degrees of obesity.

AIM

The aim of this study is to compare the efficacy of IGB in patients with different degrees of obesity.

METHOD

A total of 2002 patients with IGB were retrospectively evaluated and were divided into groups according to initial body mass index (BMI) range, as follows: group 1, 27 to 29.9 kg/m; group 2, 30 to 34.9 kg/m; group 3, 35 to 39.9 kg/m; group 4, 40 to 44.9 kg/m; group 5, ≥45 kg/m. Weight was assessed in 3 different times: before (T0), 1 month (T1), 6 months (T2), and 6 months after removal of the IGB (T3).

RESULTS

A total of 946 patients lost follow-up. Overall, 40 (3.78%) removed the device before programmed by intolerance, and 1016 patients completed the 6-month treatment. The mean weight loss was 18.9%, excess weight loss 60.1% and an BMI reduction of 6.76 points. 6 months after removal of the balloon 842 patients had continued follow-up (82.8%). At this time, weight loss was 19.84%, excess weight loss was 59.49%, and BMI reduction of 7.06 points. In all groups there was statistical difference between the times T0 and T1 and between T1 and T2 (P<0.001). There was no statistical difference between T2 and T3, in any group.

CONCLUSION

IGB provided sustained weight loss in patients who remained in dietary follow-up for 1 year.

Gut as an emerging organ for the treatment of diabetes: focus on mechanism of action of bariatric and endoscopic interventions

Increasing worldwide prevalence of type 2 diabetes mellitus and its accompanying pathologies such as obesity, arterial hypertension and dyslipidemia represents one of the most important challenges of current medicine. Despite intensive efforts, high percentage of patients with type 2 diabetes does not achieve treatment goals and struggle with increasing body weight and poor glucose control. While novel classes of antidiabetic medications such as incretin-based therapies and gliflozins have some favorable characteristics compared to older antidiabetics, the only therapeutic option shown to substantially modify the progression of diabetes or to achieve its remission is bariatric surgery. Its efficacy in the treatment of diabetes is well established, but the exact underlying modes of action are still only partially described. They include restriction of food amount, enhanced passage of chymus into distal part of small intestine with subsequent modification of gastrointestinal hormones and bile acids secretion, neural mechanisms, changes in gut microbiota and many other possible mechanisms underscoring the importance of the gut in the regulation of glucose metabolism. In addition to bariatric surgery, less-invasive endoscopic methods based on the principles of bariatric surgery were introduced and showed promising results. This review highlights the role of the intestine in the regulation of glucose homeostasis focusing on the mechanisms of action of bariatric and especially endoscopic methods of the treatment of diabetes. A better understanding of these mechanisms may lead to less invasive endoscopic treatments of diabetes and obesity that may complement and widen current therapeutic options.

Predictors of Vitamin Adherence After Bariatric Surgery

BACKGROUND

Vitamin supplementation in bariatric aftercare is essential to prevent nutrient deficiencies; however, rates of vitamin adherence have been as low as 30 % 6 months post-surgery. Preliminary literature suggests non-adherence to prescribed treatments can be linked to demographic and psychological factors. We aimed to determine the relationship between these factors to vitamin adherence in post-bariatric surgery patients.

METHODS

A total of 92 bariatric patients were assessed 6 months post-surgery. Patients were administered a questionnaire collecting demographic information, psychological scores, and self-reported adherence. Nutrient deficiencies were analyzed through serum vitamin levels measured 3 and 6 months after surgery. Wilcoxon rank-sum and chi-square tests were used for analysis.

RESULTS

Non-adherence was associated with male sex and full-time employment (p = 0.027, p = 0.015). There were no differences with respect to living situation, education level, or relationship type. Non-adherent patients did not have significantly higher scores for generalized anxiety, depressive symptoms, or avoidant behaviors. However, non-adherent patients displayed greater attachment anxiety than their adherent counterparts (p = 0.0186). Non-adherence was also associated with lower vitamin B12 levels 6 months post-surgery (p = 0.001).

CONCLUSIONS

Male gender and full-time work have previously been shown to be associated with non-adherence. This is the first study to demonstrate that attachment anxiety is associated with poor multivitamin adherence in the post-surgical bariatric population. This result is concordant with recent literature that has demonstrated attachment anxiety is associated with poor adherence to dietary recommendations in bariatric patients 6 months postoperatively. Presurgical screening for attachment anxiety could facilitate early interventions to promote better bariatric aftercare in this group.

Mechanisms of weight loss and improved metabolism following bariatric surgery

Bariatric surgery is increasingly recognized as one of the most effective interventions to help patients achieve significant and sustained weight loss, as well as improved metabolic and overall health. Unfortunately, the cellular and physiological mechanisms by which bariatric surgery achieves weight loss have not been fully elucidated, yet are critical to understanding the central role of the intestinal tract in whole-body metabolism and to developing novel strategies for the treatment of obesity. In this review, we provide an overview of potential mechanisms contributing to weight loss, including effects on regulation of energy balance and both central and peripheral nervous system regulation of appetite and metabolism. Moreover, we highlight the importance of the gastrointestinal tract, including alterations in bile acid physiology, secretion of intestinally derived hormones, and the microbiome, as a potent mediator of improved metabolism in postbariatric patients.

Dynamics of Bile Acid Profiles, GLP-1, and FGF19 After Laparoscopic Gastric Banding

CONTEXT

An increase of bile acids (BAs), fibroblast growth factor 19 (FGF19), and glucagon-like peptide 1 (GLP-1) has been implicated in metabolic improvements after Roux-en-Y gastric bypass and vertical sleeve gastrectomy. However, data are still conflicting regarding their role after laparoscopic adjustable gastric banding (LAGB).

OBJECTIVE

To assess the fasting BA, FGF19, and GLP-1 concentrations in plasma before and after LAGB and to test for correlations with immunometabolic parameters. Furthermore, hepatic farnesoid X receptor (FXR) expression and regulation of FXR-dependent genes were analyzed.

DESIGN AND SETTING

Observational study at the University Hospital Innsbruck.

PATIENTS

Twenty obese patients.

INTERVENTIONS

Fasting plasma samples were taken before, 3, 6, and 12 months after LAGB. Liver biopsies were obtained at surgery and after 6 months postoperatively.

MAIN OUTCOME MEASURES

BA profiles, GLP-1 and FGF19 levels, hepatic FXR expression and regulation of FXR target genes were determined.

RESULTS

Total, conjugated, and secondary BAs transiently increased 3 months after LAGB (P < 0.01). Only one BA, glycolithocholic acid sulfate, remained significantly elevated throughout the whole follow-up period (P < 0.05). GLP-1 had increased transiently 3 months after surgery (P < 0.01), whereas FGF19 levels increased continuously (P < 0.05). Insulin, homeostasis model assessment index, C-reactive protein, FGF19, and GLP-1 correlated positively with different BAs. No differences were seen in hepatic FXR expression and FXR-regulated genes.

CONCLUSIONS

Our study results, not only identified LAGB-induced changes in BAs and BA-induced hormones, but also revealed associations between changes in BA profile with GLP-1 and FGF19.

Distinctive microbiomes and metabolites linked with weight loss after gastric bypass, but not gastric banding

Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) are anatomically different bariatric operations. RYGB achieves greater weight loss compared with LAGB. Changes in the gut microbiome have been documented after RYGB, but not LAGB, and the microbial contribution to sustainable surgical weight loss warrants further evaluation. We hypothesized that RYGB imposes greater changes on the microbiota and its metabolism than LAGB, and that the altered microbiota may contribute to greater weight loss. Using multi-omic approaches, we analyzed fecal microbial community structure and metabolites of pre-bariatric surgery morbidly obese (PreB-Ob), normal weight (NW), post-RYGB, and post-LAGB participants. RYGB microbiomes were significantly different from those from NW, LAGB and PreB-Ob. Microbiome differences between RYGB and PreB-Ob populations were mirrored in their metabolomes. Diversity was higher in RYGB compared with LAGB, possibly because of an increase in the abundance of facultative anaerobic, bile-tolerant and acid-sensible microorganisms in the former. Possibly because of lower gastric acid exposure, phylotypes from the oral cavity, such as Escherichia, Veillonella and Streptococcus, were in greater abundance in the RYGB group, and their abundances positively correlated with percent excess weight loss. Many of these post-RYGB microorganisms are capable of amino-acid fermentation. Amino-acid and carbohydrate fermentation products-isovalerate, isobutyrate, butyrate and propionate-were prevalent in RYGB participants, but not in LAGB participants. RYGB resulted in greater alteration of the gut microbiome and metabolome than LAGB, and RYGB group exhibited unique microbiome composed of many amino-acid fermenters, compared with nonsurgical controls.

Randomized trial of Roux-en-Y gastric bypass versus sleeve gastrectomy in achieving excess weight loss

Background

Robust data on quality of life (QoL) after different techniques of bariatric surgery are sparse. This RCT compared excess weight loss (EWL) and QoL after sleeve gastrectomy versus Roux-en-Y gastric bypass (RYGB).

Methods

Obese patients were assigned randomly to RYGB or sleeve gastrectomy. The primary outcome measure was EWL. Secondary outcomes included QoL, co-morbidity, adverse events, vitamin and glycolipid status. QoL was assessed before and annually after surgery, using the Moorehead–Ardelt Quality of Life Questionnaire II (M-A-QoLQII) and Gastrointestinal Quality of Life Index (GIQLI).

Results

One hundred patients were enrolled, 45 in the RYGB group and 55 in the sleeve gastrectomy group. Mean postoperative EWL at 1, 2, 3 and 5 years was 80·4, 79·8, 83·0 and 74·8 per cent respectively after RYGB, and 83·0, 77·8, 66·3 and 65·1 per cent after sleeve gastrectomy (P = 0·017). Mean M-A-QoLQII score before surgery and at 1, 2, 3 and 5 years after operation was 0·5, 1·6, 1·7, 2·1 and 1·4 respectively after RYGB, and 0·3, 1·7, 1·5, 1·5 and 1·2 after sleeve gastrectomy. Mean GIQLI score before and at 1, 2, 3, 5 years after RYGB was 96·4, 113·8, 113·3, 113·4, 111·7, compared with 90·7, 113·9, 114·5, 113·1 and 113·0 for sleeve gastrectomy. The improvement was significant compared with preoperative values (P &lt; 0·001 for M-A-QoLQII and GIQLI), with no difference between groups (P = 0·418 and P = 0·323 respectively). RYGB resulted in higher readmission rates (P = 0·002) and length of hospital stay (P = 0·006) than sleeve gastrectomy.

Conclusion

RYGB and sleeve gastrectomy resulted in equivalent, long-standing QoL improvement. RYGB resulted in more stable weight loss but was associated with higher readmission rates. Registration number: NCT02475590.

Influence of a rural environment on patient access and outcomes for bariatric surgery

BACKGROUND

Despite a higher rate of obesity in rural populations, there is a 23% decrease in performed bariatric procedures. The influence of a rural environment on surgical outcomes and treatment efficacy is unknown.

METHODS

We retrospectively reviewed all bariatric surgeries performed in a large university hospital in West Virginia from September 2012 to September 2014. Patients were categorized based on their rural-urban commuting area codes. Subject demographic characteristics, insurance provider, type of surgery, completion of program, preoperative body mass index (BMI), percent excess weight loss (%EWL), and percent total weight loss (%TWL) at 6 and 12 months postoperatively, and follow-up appointment attendance were collected. Logistic and linear regression analyses were conducted.

RESULTS

A total of 122 patients were evaluated with 82 receiving surgery. Of these patients, 77 had Roux-en-Y gastric bypass, and 5 had Sleeve Gastrectomy. Nine patients out of 82 were lost to follow-up at 6 months (n = 73), and 12 patients out of 62 were lost to follow-up at 12 months (n = 50). Rural patients were .283 times less likely to receive bariatric surgery, (P = .004). However, this relationship was confounded by insurance provider; after controlling for this variable, the relationship between rural status and surgery completion was nonsignificant (P = .066). Rural status did not predict change in BMI, %EWL, or %TWL at 6 months (P = .738; P = .848; P = .334) or 12 months (P = .902; P = .143; P = .195), or compliance for follow-up appointments (P = .232).

CONCLUSIONS

Rural bariatric patients seem to have decreased success at completing bariatric programs, which is likely confounded by insurance type. Yet, when the rural patient is able to realize the benefits of bariatric surgery, their outcomes are unchanged compared with urban patients. Although the study is limited by sample size, it highlights the need for reducing obstacles for bariatric surgery in an already underserved population, the rural community.

Chinese herbal medicine for subfertile women with polycystic ovarian syndrome

BACKGROUND

Polycystic ovarian syndrome (PCOS) is one of the most common reproductive endocrinology abnormalities, and affects 5% to 10% of women of reproductive age. Western medicines, such as oral contraceptives, insulin sensitizers and laparoscopic ovarian drilling (LOD), have been used to treat PCOS. Recently, many studies have been published that consider Chinese herbal medicine (CHM) as an alternative treatment for women with PCOS.

OBJECTIVES

To assess the efficacy and safety of CHM for subfertile women with PCOS.

SEARCH METHODS

We searched sources, including the following databases, from inception to 9 June 2016: the Cochrane Gynaecology and Fertility Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Allied and Complementary Medicine (AMED), PsycINFO, Chinese National Knowledge Infrastructure (CNKI), VIP, Wanfang and trial registries. In addition, we searched the reference lists of included trials and contacted experts in the field to locate trials.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that considered the use of CHM for the treatment of subfertile women with PCOS.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened appropriate trials for inclusion, assessed the risk of bias in included studies and extracted data. We contacted primary study authors for additional information. We conducted meta-analyses. We used the odds ratios (ORs) to report dichotomous data, with 95% confidence intervals (CI). We assessed the quality of the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods.

MAIN RESULTS

We included five RCTs with 414 participants. The comparisons in the included trials were as follows: CHM versus clomiphene, CHM plus clomiphene versus clomiphene (with or without ethinyloestradiol cyproterone acetate (CEA)), CHM plus follicle aspiration plus ovulation induction versus follicle aspiration plus ovulation induction alone, and CHM plus laparoscopic ovarian drilling (LOD) versus LOD alone. The overall quality of the evidence for most comparisons was very low.None of the included studies reported live birth rate, and only one study reported data on adverse events.When CHM was compared with clomiphene (with or without LOD in both arms), there was no evidence of a difference between the groups in pregnancy rates (odds ratio (OR) 1.98, 95% confidence interval (CI) 0.78 to 5.06; two studies, 90 participants, I² statistic = 0%, very low quality evidence). No study reported data on adverse events. When CHM plus clomiphene was compared with clomiphene (with or without CEA), there was low quality evidence of a higher pregnancy rate in the CHM plus clomiphene group (OR 2.62, 95% CI 1.65 to 4.14; three RCTs, 300 women, I² statistic = 0%,low quality evidence). No data were reported on adverse events.When CHM with follicle aspiration and ovulation induction was compared with follicle aspiration and ovulation induction alone, there was no evidence of a difference between the groups in pregnancy rates (OR 1.60, 95% CI 0.46 to 5.52; one study, 44 women, very low quality evidence), severe luteinized unruptured follicle syndrome (LUFS) (OR 0.60, 95% CI 0.06 to 6.14; one study, 44 women, very low quality evidence), ovarian hyperstimulation syndrome (OHSS) (OR 0.16, 95% CI 0.00 to 8.19; one study, 44 women, very low quality evidence) or multiple pregnancy (OR 0.60, 95% CI 0.06 to 6.14; one study, 44 women, very low quality evidence).When CHM with LOD was compared with LOD alone, there was no evidence of a difference between the groups in rates of pregnancy (OR 3.50, 95% CI 0.72 to 17.09; one study, 30 women, very low quality evidence), No data were reported on adverse events.There was no evidence of a difference between any of the comparison groups for any other outcomes. The quality of the evidence for all other comparisons and outcomes was very low. The main limitations in the evidence were failure to report live birth or adverse events, failure to describe study methods in adequate detail and imprecision due to very low event rates and wide CIs.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the use of CHM for women with PCOS and subfertility. No data are available on live birth, and there is no consistent evidence to indicate that CHM influences fertility outcomes. However there is very limited low quality evidence to suggest that the addition of CHM to clomiphene may improve pregnancy rates. There is insufficient evidence on adverse effects to indicate whether CHM is safe.

Investigational glucagon-like peptide-1 agonists for the treatment of obesity

INTRODUCTION

Obesity is a worldwide problem predisposing to type 2 diabetes mellitus (T2DM), hypertension, cardiovascular disease, cancer and other comorbidities. Lifestyle modification is the first line intervention but adjunctive pharmacotherapy is often required. The GLP-1 receptor agonists (GLP-1RAs) were developed primarily for T2DM and they also reduce body weight. Liraglutide was approved for the treatment of obesity and other GLP-1RAs are likely to be suitable for this indication.

AREAS COVERED

This review describes the GLP-1RAs that have been approved for the treatment of T2DM as potential candidates for the treatment of obesity and the new agents currently under development which may have advantages in patient adherence.

EXPERT OPINION

The GLP-1RAs offer a welcome addition to obesity pharmacotherapy. They appear to be free of serious adverse effects although uncertainty remains about possible risks of pancreatitis and neoplasms. However, they have frequent gastrointestinal side effects, particularly nausea, which limits their tolerability. Cardiovascular outcome studies in T2DM support their use and this is likely to increase in both T2DM and obesity. Other GLP-1RAs which can be given by subcutaneous injection once weekly or less frequently or by oral administration would have advantages especially if nausea is less frequent than with liraglutide.

Management of laparoscopic adjustable gastric band erosion

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) was a popular procedure in the USA and Europe in the past decade. However, its use has currently declined. Band erosion (BE) is a rare complication after LAGB with a reported incidence rate of 1.46 %. Controversies exist regarding the management, approach and timing for the band removal. The aim of this study is to describe the rate, clinical presentation and perioperative outcomes of BEs at our institution and provide overall recommendations regarding the diagnosis and management of BE.

MATERIALS AND METHODS

This study is a single-center, retrospective review of a prospectively maintained database. Data were collected from all consecutive patients who underwent a LAGB and band revisional surgeries at the University of Illinois Hospital and Health Sciences System from December 2008 to September 2015. We identified patients who underwent gastric band removal due to a BE and analyzed their outcomes.

RESULTS

A total of 576 LAGBs were performed at our institution. Nine patients underwent surgery for BE at our hospital. The average time between the primary surgery and the removal of the band was 68.5 (42.9) months. Abdominal pain, nausea and/or vomiting were the most frequently mentioned symptoms. In all patients, a minimally invasive approach was used to remove the band. The mean length of hospitalization was 2.6 (1.1) days. The only complication was a pneumonia (n = 1).

CONCLUSIONS

BE is one of the most severe complications of LAGB. The minimally invasive approach provided us with the opportunity to repair the fistula, and it was associated with a prompt recovery with very little morbidity. In general, it is recommended that the band be removed at the time of the diagnosis of the BE. Endoscopic band removal can be utilized with patients who have a more advanced BE and migration into the gastric lumen.

Impact of bariatric surgery on depression and anxiety symptons, bulimic behaviors and quality of life

OBJECTIVE

To assess psychiatric symptoms, substance use, quality of life and eating behavior of patients undergoing bariatric surgery before and after the procedure.

METHODS

We conducted a prospective longitudinal study of 32 women undergoing bariatric surgery. To obtain data, the patients answered specific, self-administered questionnaires.

RESULTS

We observed a reduction in depressive and anxious symptoms and also in bulimic behavior, as well as an improved quality of life in the physical, psychological and environmental domains. There was also a decrease in use of antidepressants and appetite suppressants, but the surgery was not a cessation factor in smoking and / or alcoholism.

CONCLUSION

a decrease in psychiatric symptoms was observed after bariatric surgery, as well as the reduction in the use of psychoactive substances. In addition, there was an improvement in quality of life after surgical treatment of obesity.

Post-Bariatric Surgery Changes in Quinolinic and Xanthurenic Acid Concentrations Are Associated with Glucose Homeostasis

Background

An increase of plasma kynurenine concentrations, potentially bioactive metabolites of tryptophan, was found in subjects with obesity, resulting from low-grade inflammation of the white adipose tissue. Bariatric surgery decreases low-grade inflammation associated with obesity and improves glucose control.

Objective

Our goal was to determine the concentrations of all kynurenine metabolites after bariatric surgery and whether they were correlated with glucose control improvement.

Design

Kynurenine metabolite concentrations, analysed by liquid or gas chromatography coupled with tandem mass spectrometry, circulating inflammatory markers, metabolic traits, and BMI were measured before and one year after bariatric surgery in 44 normoglycemic and 47 diabetic women with obesity. Associations between changes in kynurenine metabolites concentrations and in glucose control and metabolic traits were analysed between baseline and twelve months after surgery.

Results

Tryptophan and kynurenine metabolite concentrations were significantly decreased one year after bariatric surgery and were correlated with the decrease of the usCRP in both groups. Among all the kynurenine metabolites evaluated, only quinolinic acid and xanthurenic acid were significantly associated with glucose control improvement. The one year delta of quinolinic acid concentrations was negatively associated with the delta of fasting glucose (p = 0.019) and HbA1c (p = 0.014), whereas the delta of xanthurenic acid was positively associated with the delta of insulin sensitivity index (p = 0.0018).

Conclusion

Bariatric surgery has induced a global down-regulation of kynurenine metabolites, associated with weight loss. Our results suggest that, since kynurenine monoxygenase diverts the kynurenine pathway toward the synthesis of xanthurenic acid, its inhibition may also contribute to glucose homeostasis.

Bariatric surgery outcomes in black patients with super morbid obesity: a 1-year postoperative review

BACKGROUND

Super morbid obesity (body mass index [BMI] > 50 kg/m²) is associated with significant comorbidities and is disparagingly prevalent among the black population. There is paucity of data regarding bariatric surgery outcomes among super morbid obese (SMO) blacks. Our aim is to evaluate the reduction in weight and resolution of comorbidities after bariatric surgery among SMO black patients at an urban academic institution.

METHODS

A retrospective review of SMO black patients who underwent bariatric surgery from August 2008 to June 2013 at Howard University Hospital. Outcomes of interest include weight loss, improvement or resolution of hypertension, type 2 diabetes, and hyperlipidemia at 12 months.

RESULTS

Eighty-seven patients met our inclusion criteria. Mean preoperative weight and BMI were 347.2 lbs and 56.8 kg/m², respectively. At 12 months, mean weight and BMI were 245.3 lbs and 40.1 kg/m², respectively. There was also significant improvement or resolution of hypertension, type 2 diabetes, and hyperlipidemia.

CONCLUSIONS

Bariatric surgery may result in significant weight loss and improvement or resolution of comorbidities in SMO black patients.

abiliti Closed-Loop Gastric Electrical Stimulation System for Treatment of Obesity: Clinical Results with a 27-Month Follow-Up

Background

The aim of the study was to evaluate the safety and effectiveness of a novel closed-loop gastric electric stimulation device (abiliti^® system) featuring a transgastric sensor to detect food intake and an accelerometer to record physical activity to induce and maintain lifestyle changes to treat obesity.

Methods

In a prospective, multi-center study, 34 obese subjects (BMI of 42.1 ± 5.3 kg/m²) who passed an eligibility evaluation were implanted with the abiliti system. Safety evaluation included an endoscopic exam to assess the intragastric electrode healing. Efficacy evaluation at 1 year of therapy included weight loss, improvements in eating, and exercise behavior and quality of life.

Results

The transgastric implant controlled by endoscopy was stable for all participants. At 12 months (12 M) the mean excess weight loss (EWL) was 28.7 % (95%CI, 34.5 to 22.5 %), and mean reduction in BMI was 4.8 ± 3.2 kg/m². At 27 months (27 M), the EWL was 27.5 % (95 % CI, 21.3 % to 33.7 %). Eating behavior, evaluated by the “Three Factor Eating Questionnaire”, showed a significant increase in the cognition factor and decrease in the disinhibition and hunger factors at 12 M in comparison to baseline (p < 0.001). Participants significantly increased their weekly physical activity (p < 0.001). Quality of life was improved in 55.2 % of the patients.

Conclusions

Gastric electrical stimulation with abiliti system in obese participants is well tolerated and leads to significant 12 M weight loss, which was stable to 27 M. We suggest that weight loss is achieved due to the assessed alteration of eating behavior in particular the reduction in disinhibition and hunger, and the measured increase in physical activity.