Bariatric surgery for obesity and metabolic conditions in adults

Online Search Trends Related to Bariatric Surgery and Their Relationship with Utilization in Australia

PURPOSE

There is an abundance of online information related to bariatric surgery. Patients may prefer a specific type of bariatric surgery based on what they read online. The primary aim of this study was to determine online search trends in bariatric surgery over time in Australia and worldwide. The secondary aim was to establish a relationship between public online search activity and the types of bariatric surgery performed in Australia.

MATERIALS AND METHOD

The terms "adjustable gastric band," "sleeve gastrectomy," and "gastric bypass surgery" were submitted for search volume analysis in Australia and worldwide using the Google Trends "Topic" search function. This was compared alongside the numbers of gastric bandings, sleeve gastrectomies, and gastric bypass surgeries performed in Australia over time to determine if there was a relationship between the two.

RESULTS

Search trends for "adjustable gastric band" and "sleeve gastrectomy" in Australia were similar to trends seen worldwide. However, search trends for "gastric bypass surgery" differ between Australia and the rest of the world. It took at least a year for online searches to reflect the higher number of sleeve gastrectomies performed relative to gastric bandings. There was a lag time of over four years before online searches reflected the higher number of gastric bypass surgery performed compared to gastric banding.

CONCLUSION

Search interests in Australia and worldwide were similar for gastric banding and sleeve gastrectomy but different for gastric bypass surgery. Online search activity did not have a significant association with the types of bariatric surgery being performed in Australia.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical-epidemiological assessment of patients undergoing bariatric and metabolic surgery in a medium-complexity service in Maranhão, Brazil

INTRODUCTION

the obesity is defined as the excessive accumulation of fat in different areas of the body, a condition that causes damage to health and is a critical risk factor for various comorbidities. Bariatric surgery is the therapeutic option with the best results.

METHODS

this is a retrospective descriptive study using data obtained from medical records from January 2018 to December 2020 on patients undergoing bariatric surgery. Statistical analysis used a significance level of p<0.05.

RESULTS

178 medical records were included, 77.5% of which were women. The average age was 35.7 years (± 9.5), 63.8% of the patients were from Imperatriz, 98.3% reported a sedentary lifestyle, 38.7% regular alcohol consumption and 13% smoking. The prevalence of Class III obesity (BMI≥40 kg/m²) was 53.3%. The most common comorbidities were hepatic steatosis (64.6%), type 2 diabetes mellitus (DM2) (40.5%) and hypertension (38.7%). The main type of surgery performed was Roux-en-Y gastric bypass (RYGB) (89.3%). There was an association between median BMI and gender (p=0.008), with women showing higher values [43.4 (IQR 39.1 - 48.8)]. The mean BMI of patients who underwent RYGB was significantly higher compared to those who underwent vertical gastrectomy (VG) (p=0.009). There was a statistical association between DM2 (p=0.033) and depression (p=0.018) and the type of surgery performed.

CONCLUSION

the clinical and epidemiological profile found showed a higher prevalence of females and individuals with Class III obesity. RYGB was the most commonly performed procedure, establishing an association with BMI and some of the patients' comorbidities.

A superior approach? The role of robotic sleeve gastrectomy in patients with super super obesity using the 2019-2022 MBSAQIP database

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) in patients with BMI ≥ 60 presents technical challenges, that might be overcome by robotic surgery, but its effectiveness has not been rigorously evaluated. We compared the 30-day outcomes of LSG and robotic sleeve gastrectomy (RSG) in patients with BMI < 60 versus ≥ 60 and between LSG and RSG in patients with BMI ≥ 60.

METHODS

Patients aged 18-65 years who underwent sleeve gastrectomy were included using the 2019-2022 MBSAQIP database. We performed a Propensity Score Matching analysis, with 21 preoperative characteristics. We compared 30-day postoperative outcomes for patients with BMI < 60 versus ≥ 60 using either a laparoscopic (Analysis 1) or robotic approach (Analysis 2) and compared LSG versus RSG in patients with BMI ≥ 60 (Analysis 3).

RESULTS

297,250 patients underwent LSG and 81,008 RSG. Propensity-matched¸ outcomes in analysis 1 (13,503 matched cases), showed that patients with BMI ≥ 60 had higher rates of mortality (0.1% vs. 0.0%, p = 0.014), staple line leak (0.3% vs. 0.2%, p = 0.035), postoperative bleeding (0.2% vs 0.1%, p = 0.028), readmissions (3.5% vs. 2.4%, p < 0.001), and interventions (0.7% vs. 0.5%, p = 0.028) when compared to patients with BMI < 60. In analysis 2 (4350 matched cases), patients with BMI ≥ 60 demonstrated longer operative times, length of stay, and higher rates of unplanned ICU when compared to patients with BMI < 60. In analysis 3 (4370 matched cases), patients who underwent RSG had fewer readmissions (2.9% vs. 3.7%, p = 0.037), staple line leaks (0.1% vs. 0.3%, p = 0.029), and postoperative bleeding (0.1% vs. 0.3%, p = 0.045), compared to LSG. Conversely, a longer operative time (92.74 ± 38.65 vs. 71.69 ± 37.45 min, p < 0.001) was reported.

CONCLUSION

LSG patients with BMI ≥ 60 have higher rates of complications compared to patients with a BMI < 60. Moreover, some outcomes may be improved with the robotic approach in patients with BMI ≥ 60. These results underscore the importance of considering a robotic approach in this super super obese population.

'Surgery is my only hope': A qualitative study exploring perceptions of living with obesity and the prospect of having bariatric surgery

The health benefits of bariatric surgery are well documented; however, the occurrence of weight-regain after surgery, along with the development of mental health difficulties poses a question of how contemporary psychology could assist to prepare people living with obesity prior to undergoing bariatric surgery. This research explored individuals' (in the immediate pre-operative and post-operative population) attitudes, beliefs and experiences towards obesity and their journey to bariatric surgery. Seventeen adult participants (males n = 4; age range: 26-64 years) were recruited and participated in a semi-structured interview. Twelve individuals participated prior to undergoing bariatric surgery. Five individuals participated in the early post-operative period (<3 months post-surgery). People living with obesity displayed high optimism for positive outcomes, with participants hoping that bariatric surgery would be different to previous attempts at weight regulation, with there being a clear shift in the locus of control for weight management from self to healthcare professionals. Whilst this is adaptive, there was the presence of seemingly unrealistic optimism, with many pre-surgery participants not relaying the realistic possibility of post-surgery weight-regain. Despite the optimism individuals feel about bariatric surgery, participants felt that the psychological factors influencing eating behaviours are not being addressed by healthcare. These findings suggest that mindfulness, mindful eating, and self-compassion approaches should be incorporated into clinical practice to support weight regulation and adaption to physiological changes after bariatric surgery.

Research trends between diabetes mellitus and bariatric surgery researches: Bibliometric analysis and visualization from 1998 to 2023

This study conducted a bibliometric analysis using the Web of Science Core Collection (WOSCC) to explore the relationship between diabetes mellitus and bariatric surgery (BS) from January 1985 to August 2023. No publications were found between 1985 and 1998. However, from 1998 to 2023, a total of 9,496 English articles were identified, accumulating 291,289 citations (241,563 excluding self-citations) and achieving an H-Index of 197. Leading contributors to the field were the United States, China, and Italy. Noteworthy authors in this area of research included Philip R. Schauer, Wei-Jei Lee, and Carel W. le Roux. The major journals that featured this research were 'Obesity Surgery,' 'Diabetes Care,' and 'Surgery for Obesity and Related Diseases.' The most highly cited article focused on lifestyle, diabetes, and cardiovascular risks 10 years after BS, emphasizing the significant attention given to the nutritional, cardiac, and general internal medicine impacts of diabetes and BS. The increase in research output during the review period indicates a growing interest in the relationship between diabetes and BS, providing a valuable reference for future studies in this evolving field.

Attitudes and knowledge about weight management among primary care physicians in Israel: a cross-sectional study

BACKGROUND

The prevalence of obesity has been increasing worldwide and is associated with increased risk of morbidity and mortality. Weight management can reduce the risk of complications and improve the quality of life of patients with obesity. This study explored primary care physicians' (PCPs') attitudes and knowledge about weight management.

METHODS

An anonymous questionnaire was distributed to 400 PCPs between 2020 and 2021. The survey included questions on treatment approaches (pharmaceutical and surgical) and items regarding the respondents' demographic characteristics. We compared PCPs with low or high proactivity toward weight management. We explored attitudes and knowledge with the chi-square test for categorical variables or the Mann-Whitney test for continuous variables.

RESULTS

A total of 145 PCPs answered our survey (a response rate of 36.25%). More than half (53.8%) of the respondents showed low proactivity toward weight management in their practice. Proactive respondents were more likely to believe that pharmaceutical treatment effectively reduces weight and offered medical and surgical treatment options more frequently to their patients. Lack of knowledge was the most predominant reason for PCPs avoiding offering treatment to their patients, especially in less proactive PCPs (33.3% vs. 5.3%, p-value < 0.001). When comparing different pharmaceutical options, 46.6% of PCPs report they tend to prescribe liraglutide to their patients compared with only 11% who prescribe orlistat and 10.3% who prescribe phentermine (p-value < 0.001).

CONCLUSIONS

Many PCPs still do not actively provide obesity treatment despite improved awareness and therapeutic options. PCPs' proactivity and attitudes are vital to this effort.

Plasma SHBG Levels as an Early Predictor of Response to Bariatric Surgery

BACKGROUND

Obesity is a growing global health problem, and currently, bariatric surgery (BS) is the best solution in terms of sustained total weight loss (TWL). However, a significant number of patients present weight regain (WR) in time. There is a lack of biomarkers predicting the response to BS and WR during the follow-up. Plasma SHBG levels, which are low in obesity, increase 1 month after BS but there is no data of plasma SHBG levels at long term. We performed the present study aimed at exploring the SHBG role in predicting TWL and WR after BS.

METHODS

Prospective study including 62 patients with obesity undergoing BS. Anthropometric and biochemical variables, including SHBG were analyzed at baseline, 1, 6, 12, and 24 months; TWL ≥ 25% was considered as good BS response.

RESULTS

Weight loss nadir was achieved at 12 months post-BS where maximum SHBG increase was reached. Greater than or equal to 25% TWL patients presented significantly higher SHBG increases at the first and sixth months of follow-up with respect to baseline (100% and 150% respectively, p = 0.025), than < 25% TWL patients (40% and 50% respectively, p = 0.03). Also, these presented 6.6% WR after 24 months. The first month SHBG increase predicted BS response at 24 months (OR = 2.71; 95%CI = [1.11-6.60]; p = 0.028) and TWL in the 12th month (r = 0.330, p = 0.012) and the WR in the 24th (r =  - 0.301, p = 0.028).

CONCLUSIONS

Our results showed for the first time that increase in plasma SHBG levels within the first month after BS is a good predictor of TWL and WR response after 2 years.

Can Consultation by a Clinical Pharmacist Prevent Morbidity and Mortality in Patients Undergoing Bariatric Surgery?

The purpose of this work was to investigate the effect of clinical pharmacist consultation on the long-term morbidity and mortality outcomes among patients undergoing bariatric surgery. In this retrospective cohort study, 165 bariatric patients at Herzliya Medical Center who were identified as complex cases and were consulted by a clinical pharmacist (2013-2019) were compared with a wider group of bariatric patients with chronic diseases who were recorded in the Israeli General Bariatric Registry during the same years. The primary outcomes were rates of surgical complications, re-hospitalizations, and death up to one year after surgery. The secondary outcome was the rate of re-hospitalizations in different time periods. The twelve (12)-month rate of re-hospitalization in the intervention group was 10.9% vs. 19.5% in the comparison group (p = 0.005); the rate of documented postoperative complications was 2.7% vs. 3.9% (p = 0.462), and mortality was null vs. 0.16%, respectively. As for the secondary outcomes, the rates of re-hospitalizations in the periods of 0-30, 31-90, 91-180, and 181-365 days after surgery were 1.8% vs. 5.3% (p = 0.046), 2.4% vs. 4.1% (p = 0.278), 3.6% vs. 4.8% (p = 0.476), and 7.3% vs. 9.9% (p = 0.256) in the intervention vs. comparison cohorts, respectively. In conclusion, this study demonstrates the importance and benefit of referring to a specialized clinical pharmacist around bariatric surgery for improving patient safety, especially in complex patients. This is the first study to look at the long-term effects of clinical pharmacist consultation on re-hospitalization and mortality among bariatric patients, and our encouraging outcomes should hopefully stimulate more studies to show the invaluable role of specialized clinical pharmacists.

Review on chronic metabolic diseases surrounding bile acids and gut microbiota: What we have explored so far

Bile acid, the final product of cholesterol breakdown, functions as a complex regulator and signaling factor in human metabolism. Chronic metabolic diseases pose significant medical challenges. Growing research underscores bile acids' capacity to enhance metabolism via diverse pathways, regulating disorders and offering treatment potential. Numerous bile-acid-triggered pathways have become treatment targets. This review outlines bile acid synthesis, its role as a signal in chronic metabolic diseases, and highlights its interaction with gut microbiota in different metabolic conditions. Exploring host-bacteria-bile acid links emerges as a valuable future research direction with clinical implications.

8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Clinical outcomes and adverse events of bariatric surgery in adults with severe obesity in Scotland: the SCOTS observational cohort study

Background

Bariatric surgery is a common procedure worldwide for the treatment of severe obesity and associated comorbid conditions but there is a lack of evidence as to medium-term safety and effectiveness outcomes in a United Kingdom setting.

Objective

To establish the clinical outcomes and adverse events of different bariatric surgical procedures, their impact on quality of life and the effect on comorbidities.

Design

Prospective observational cohort study.

Setting

National Health Service secondary care and private practice in Scotland, United Kingdom.

Participants

Adults (age >16 years) undergoing their first bariatric surgery procedure.

Main outcome measures

Change in weight, hospital length of stay, readmission and reoperation rate, mortality, diabetes outcomes (HbA1c, medications), quality of life, anxiety, depression.

Data sources

Patient-reported outcome measures, hospital records, national electronic health records (Scottish Morbidity Record 01, Scottish Care Information Diabetes, National Records Scotland, Prescription Information System).

Results

Between December 2013 and February 2017, 548 eligible patients were approached and 445 participants were enrolled in the study. Of those, 335 had bariatric surgery and 1 withdrew from the study. Mean age was 46.0 (9.2) years, 74.7% were female and the median body mass index was 46.4 (42.4; 52.0) kg/m2. Weight was available for 128 participants at 3 years: mean change was -19.0% (±14.1) from the operation and -24.2% (±12.8) from the start of the preoperative weight-management programme. One hundred and thirty-nine (41.4%) participants were readmitted to hospital in the same or subsequent 35 months post surgery, 18 (5.4% of the operated cohort) had a reoperation or procedure considered to be related to bariatric surgery gastrointestinal complications or revisions. Fewer than five participants (<2%) died during follow-up. HbA1c was available for 93/182 and diabetes medications for 139/182 participants who had type 2 diabetes prior to surgery; HbA1c mean change was -5.72 (±16.71) (p = 0.001) mmol/mol and 65.5% required no diabetes medications (p < 0.001) at 3 years post surgery. Physical quality of life, available for 101/335 participants, improved in the 3 years post surgery, mean change in Rand 12-item Short Form Survey physical component score 8.32 (±8.95) (p < 0.001); however, there was no change in the prevalence of anxiety or depression.

Limitations

Due to low numbers of bariatric surgery procedures in Scotland, recruitment was stopped before achieving the intended 2000 participants and follow-up was reduced from 10 years to 3 years.

Conclusions

Bariatric surgery is a safe and effective treatment for obesity. Patients in Scotland, UK, appear to be older and have higher body mass than international comparators, which may be due to the small number of procedures performed.

Future work

Intervention studies are required to identify the optimal pre- and post surgery pathway to maximise safety and cost-effectiveness.

Study registration

This study is registered as ISRCTN47072588.

Funding details

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 10/42/02) and is published in full in Health Technology Assessment; Vol. 28, No. 7. See the NIHR Funding and Awards website for further award information.

Long term outcomes of metabolic/bariatric surgery in adults

The prevalence of obesity continues to rise around the world, driving up the need for effective and durable treatments. The field of metabolic/bariatric surgery has grown rapidly in the past 25 years, with observational studies and randomized controlled trials investigating a broad range of long term outcomes. Metabolic/bariatric surgery results in durable and significant weight loss and improvements in comorbid conditions, including type 2 diabetes. Observational studies show that metabolic/bariatric surgery is associated with a lower incidence of cardiovascular events, cancer, and death. Weight regain is a risk in a fraction of patients, and an association exists between metabolic/bariatric surgery and an increased risk of developing substance and alcohol use disorders, suicidal ideation/attempts, and accidental death. Patients need lifelong follow-up to help to reduce the risk of these complications and other nutritional deficiencies. Different surgical procedures have important differences in risks and benefits, and a clear need exists for more long term research about less invasive and emerging procedures. Recent guidelines for the treatment of obesity and metabolic conditions have been updated to reflect this growth in knowledge, with an expansion of eligibility criteria, particularly people with type 2 diabetes and a body mass index between 30.0 and 34.9.

Postprandial Triglyceride, Glucose and Insulin Levels 10 Years After Bariatric Surgery in Women With Severe Obesity - A Pilot Study: Part 2 - Biliopancreatic Diversion

Obesity significantly increases the risk of developing metabolic and cardiovascular diseases. The most effective management tool for both obesity and type 2 diabetes (T2D) is bariatric/metabolic surgery. Delayed postprandial plasma triglyceride clearance contributes to the development of atherosclerosis in patients with T2D. Biliopancreatic diversion (BPD) was shown to be the most effective procedure in long-term T2D remission. However, the effect of BPD on postprandial metabolic profile has not been studied so far. In this pilot study, we therefore examined the changes in postprandial glucose, insulin, and triglyceride in women with severe obesity and T2D before surgery and then two and ten years after BPD. The studied cohort included 7 women (mean age at baseline=49.3±8.2 years) with severe obesity (mean BMI= 45.7±2.9 kg/m?) and T2D. A standardized liquid mixed-meal test was carried out in all subjects and the mean postprandial levels of plasma glucose, insulin, and triglyceride were analyzed by standard laboratory procedures. For statistical evaluation, ANOVA with Bonferroni multiple comparisons was used. Ten years after BPD not only a significant reduction of an average BMI (F=32.9, p<0.001) but also significant declines in mean postprandial plasma levels of glucose (F=155.3, p<0.001), insulin (F=69.8, p<0.001), and triglyceride (F=139.9, p<0.001) were demonstrated. The observed changes in postprandial metabolic profile may contribute to improved cardiometabolic health after bariatric surgery.

Alterations in gastric and gut microbiota following sleeve gastrectomy in high-fat diet-induced obese rats

Obesity is considered a high-risk disease and a global epidemic, and the number of obese patients is rising at an alarming rate worldwide. High-fat diet-induced dysbiosis of the intestinal microbiota is considered an essential factor related to obesity. Bariatric surgery induces a sharp decrease in fat content and effectively improves the metabolism of obese individuals. Herein, we aimed to investigate the effects of a high-fat diet-induced obesity and the alterations in gastric and intestinal microbiota resulting from sleeve gastrectomy on clinical outcomes. We performed 16S sequencing of gastric and fecal samples obtained from rats in three treatment groups: normal chow diet, high-fat diet (HFD), and sleeve gastrectomy after HDF for 14 weeks. The area under the curve of fasting glucose and the levels of leptin and low-density lipoproteins were significantly different between groups. Microbial taxa that were highly correlated with several clinical parameters were identified for each group. Glyoxylate and dicarboxylate, taurine and hypotaurine, butanoate, nitrogen, and pyrimidine metabolism and aminoacyl-transfer ribonucleic acid biosynthesis were affected by bariatric surgery and were significantly associated with changes in the composition of gastric and fecal microbiomes. Connectivity and co-occurrence were higher in fecal samples than in gastric tissues. Our results elucidated the positive effects of sleeve gastrectomy in obesity and shed light on changes in the microbiomes of gastric and fecal samples.

Obesity, thrombosis, venous disease, lymphatic disease, and lipedema: An obesity medicine association (OMA) clinical practice statement (CPS) 2023

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians with an overview on obesity, thrombosis, venous disease, lymphatic disease, and lipedema.

Methods

The scientific support for this CPS is based upon published citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

Topics in this CPS include obesity, thrombosis, venous disease, lymphatic disease, and lipedema. Obesity increases the risk of thrombosis and cardiovascular disease via fat mass and adiposopathic mechanisms. Treatment of thrombosis or thrombotic risk includes healthful nutrition, physical activity, and the requisite knowledge of how body weight affects anti-thrombotic medications. In addition to obesity-related thrombotic considerations of acute coronary syndrome and ischemic non-hemorrhagic stroke, this Clinical Practice Statement briefly reviews the diagnosis and management of clinically relevant presentations of deep vein thromboses, pulmonary embolism, chronic venous stasis, varicose veins, superficial thrombophlebitis, lipodermatosclerosis, corona phlebectatica, chronic thromboembolic pulmonary hypertension, iliofemoral venous obstruction, pelvic venous disorder, post-thrombotic syndrome, as well as lymphedema and lipedema - which should be included in the differential diagnosis of other edematous or enlargement disorders of the lower extremities.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) on obesity, thrombosis, and venous/lymphatic disease is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity.

Development and complications of nutritional deficiencies after bariatric surgery

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

Vitamin D status and supplementation before and after Bariatric Surgery: Recommendations based on a systematic review and meta-analysis

Bariatric surgery is associated with a postoperative reduction of 25(OH) vitamin D levels (25(OH)D) and with skeletal complications. Currently, guidelines for 25(OH)D assessment and vitamin D supplementation in bariatric patients, pre- and post-surgery, are still lacking. The aim of this work is to analyse systematically the published experience on 25(OH)D status and vitamin D supplementation, pre- and post-surgery, and to propose, on this basis, recommendations for management. Preoperatively, 18 studies including 2,869 patients were evaluated. Prevalence of vitamin D insufficiency as defined by 25(OH)D < 30 ng/mL (75 nmol/L) was 85%, whereas when defined by 25(OH)D < 20 ng/mL (50 nmol/L) was 57%. The median preoperative 25(OH)D level was 19.75 ng/mL. After surgery, 39 studies including 5,296 patients were analysed and among those undergoing either malabsorptive or restrictive procedures, a lower rate of vitamin D insufficiency and higher 25(OH)D levels postoperatively were observed in patients treated with high-dose oral vitamin D supplementation, defined as ≥ 2,000 IU/daily (mostly D3-formulation), compared with low-doses (< 2,000 IU/daily). Our recommendations based on this systematic review and meta-analysis should help clinical practice in the assessment and management of vitamin D status before and after bariatric surgery. Assessment of vitamin D should be performed pre- and postoperatively in all patients undergoing bariatric surgery. Regardless of the type of procedure, high-dose supplementation is recommended in patients after bariatric surgery.

Intraoperative, sociodemographic, and postoperative parameters in individuals undergoing bariatric surgery

OBJECTIVE

This study aimed to comparatively analyze sociodemographic data and postoperative parameters of patients undergoing bypass and sleeve surgeries in a private hospital in São Luís, MA.

METHODS

The study was descriptive, prospective, observational, and comparative, with a quantitative approach between August 2020 and July 2021. We analyzed 74 participants of both genders, aged between 18 and 70 years, with 31 undergoing Roux-en-Y gastric bypass surgery and 43 undergoing sleeve gastrectomy surgery. In the postoperative period, sociodemographic characteristics, surgery and anesthesia duration, pain levels, adverse effects, weight loss, and complications from the surgical procedure were analyzed.

RESULTS

Males predominated in Roux-en-Y gastric bypass and females in sleeve gastrectomy surgery. Clinical characteristics regarding self-declared ethnicity, age and place of birth, education, and marital status were similar between the studied groups. Roux-en-Y gastric bypass had an average surgery time of 112.14±10.06 min and sleeve gastrectomy 91.11±23.69 min, with a significant difference (p<0.001). Regarding anesthesia time, gastric bypass averaged 160.36±13.99 min and sleeve gastrectomy 154.88±29.10 min, with no statistical difference between groups (p=0.335). Nausea, vomiting, and drowsiness were more common in Sleeve gastrectomy, with no significant difference (p=0.562). Roux-en-Y gastric bypass showed a higher rate of weight loss from 1 month after surgery (14.2±4.15) and more variation in body mass index within 3 months after surgery (32.17±4.76). Complications occurred in a small number of patients.

CONCLUSION

The two surgical techniques proved effective in delivering the best results for patients, with the group undergoing bypass showing statistically significant weight loss from 1 month after the surgical procedure.

BAM15 as a mitochondrial uncoupler: a promising therapeutic agent for diverse diseases

Subcellular organelles dysfunction is implicated in various diseases, including metabolic diseases, neurodegenerative diseases, cancer, and cardiovascular diseases. BAM15, a selective mitochondrial uncoupler, has emerged as a promising therapeutic agent due to its ability to enhance mitochondrial respiration and metabolic flexibility. By disrupting the coupling between electron transport and ATP synthesis, BAM15 dissipates the proton gradient, leading to increased mitochondrial respiration and energy expenditure. This review provides a comprehensive overview of BAM15, including its mechanism of action and potential therapeutic applications in diverse disease contexts. BAM15 has shown promise in obesity by increasing energy expenditure and reducing fat accumulation. In diabetes, it improves glycemic control and reverses insulin resistance. Additionally, BAM15 has potential in non-alcoholic fatty liver disease, sepsis, and cardiovascular diseases by mitigating oxidative stress, modulating inflammatory responses, and promoting cardioprotection. The safety profile of BAM15 is encouraging, with minimal adverse effects and remarkable tolerability. However, challenges such as its high lipophilicity and the need for alternative delivery methods need to be addressed. Further research is necessary to fully understand the therapeutic potential of BAM15 and optimize its application in clinical settings.

Five-Year Physical and Psychosocial Outcomes in Obese Adolescents With and Without Metabolic Bariatric Surgery

PURPOSE

Metabolic bariatric surgery (MBS) is increasingly accepted as a treatment for severely obese adolescents. However, its long-term efficacy and safety are not well characterized, particularly in the Eastern Asian population. We aimed to explore the long-term effects of MBS on Chinese adolescents with severe obesity.

METHODS

A total of 44 obese adolescents (≤18 years old) underwent MBS at our institution from May 2011 to May 2017. A matched nonsurgical control group, including 43 patients, was recruited from lifestyle modification programs in the same period. All patients completed assessments at presurgery/baseline and five years after surgery. The data were collected and analyzed using the χ2 test and an independent sample t-test.

RESULTS

Comparing the surgical and control groups revealed that the surgical patients showed significant weight loss and improvement in comorbidities, while the nonsurgical patients showed a trend of weight gain and increased comorbidities (p < .05). Furthermore, the surgical patients had a higher composite physical quality of life (as determined by the Short Form-36 questionnaire). On the other hand, the patients who underwent MBS had a higher risk of malnutrition.

DISCUSSION

Compared with nonsurgical patients, severely obese adolescents who undergo MBS exhibit more effective long-term weight loss, remission of comorbidities, and improved quality of life. Furthermore, more attention should be paid to helping adolescents avoid malnutrition after they undergo MBS.

Use of quantitative indocyanine green near-infrared fluorescence imaging in bariatric surgery: early results

INTRODUCTION

Indocyanine green fluorescence angiography (ICG-FA) is commonly used in general surgery, but its use in bariatric surgery is still marginal. Moreover, post-operative leaks remain a dramatic complication after this surgery and the leak tests available have poor performance preventing them. The aim of the present paper is to assess the use and utility of a new innovative technology based on quantitative measures of fluorescence signal intensity.

MATERIAL AND METHODS

From January 2022 to June 2022, 40 consecutive patients with a median age of 51 years and a preoperative median body mass index of 45.2 kg/m2 underwent bariatric surgery with quantitative ICG fluorescence angiography in our center. Two different types of surgery, based on the multidisciplinary evaluation, were performed: laparoscopic sleeve gastrectomy (LSG) and one anastomosis gastric bypass (OAGB). For ICG visualization, quantitative laparoscopic ICG platform was used to identify the vascular supply.

RESULTS

Thirteen patients underwent LSG and 27 patients underwent OAGB. ICG was performed in all patients with no adverse events. An adequate and satisfactory blood supply was assessed in each case. No case of post-operative leak was detected.

CONCLUSIONS

The quantitative ICG-FA seems to be a useful and promising tool for the prevention of complications in bariatric surgery but further studies are mandatory.

Micronutrients in Pregnancy after Bariatric Surgery: A Narrative Review

Bariatric surgery is increasingly used in women of childbearing age due to the rising prevalence of obesity and the effectiveness and availability of this treatment. Pregnancy in women with previous bariatric surgery deserves special attention. Weight loss induced by surgery reduces the risks that obesity poses to pregnancy. But on the other hand, decreased intake and malabsorption may increase the risk of malnutrition and micronutrient deficiency and negatively affect maternal and foetal health. The aim of this narrative review is to provide an updated analysis of the impact of different bariatric surgery techniques on mineral and micronutrient nutritional status during pregnancy and the possible effect on maternal-foetal health.

Role of Growth Hormone in Adipose Tissue Insulin Resistance Amelioration After Bariatric Surgery in Adults with Obesity

Background: Bariatric surgery has a significant effect on weight loss and improves adipose tissue insulin resistance (adipose-IR); however, the underlying mechanism remains unclear. This study aimed to investigate the effect of growth hormone (GH) on adipose-IR improvement after bariatric surgery in patients with obesity. Methods: A prospective cohort study with 1-year follow-up was conducted in the China-Japan Friendship Hospital. Pre- and postoperative variables, including the body mass index (BMI), glucose and lipid metabolic indicators, and the adipose-IR index, were collected and analyzed at baseline and 3, 6, and 12 months after surgery in patients with obesity. Results: In total, seventy-two patients, including 25 males and 47 females, were included in the analysis. Furthermore, bariatric surgery resulted in a sharp decline in BMI (kg/m2) (from 39.45 ± 0.51 to 32.00 ± 0.63 at 3 months, 28.73 ± 0.56 at 6 months, and 27.25 ± 0.68 at 12 months) and adipose-IR index (mmol/L × pmol/L) (from 163.8 ± 9.38 to 94.39 ± 16.63, 43.71 ± 5.13, and 27.92 ± 2.67) and an increase in GH (ng/mL) (from 0.16 ± 0.02 to 0.61 ± 0.10, 1.02 ± 0.19, and 0.89 ± 0.20). Partial correlation analyses were performed with reduced BMI as a control, and elevated GH levels (ΔGH) were found to be positively correlated with reduced adipose-IR (absolute value of Δadipose-IR) index at 3 months (r = 0.413, P = 0.005), 6 months (r = 0.432, P < 0.001), and 12 months (r = 0.375, P = 0.031) after bariatric surgery. Conclusions: Bariatric surgery induces GH elevation and adipose-IR amelioration in patients with obesity. GH might be a potential metabolic regulator associated with adipose-IR improvement in patients with obesity after bariatric surgery.

Change in medial frontal cerebral metabolite concentrations following bariatric surgery

Obesity is associated with adverse effects on brain health, including an increased risk of neurodegenerative diseases. Changes in cerebral metabolism may underlie or precede structural and functional brain changes. While bariatric surgery is known to be effective in inducing weight loss and improving obesity-related medical comorbidities, few studies have examined whether it may be able to improve brain metabolism. In the present study, we examined changes in cerebral metabolite concentrations in participants with obesity who underwent bariatric surgery. Thirty-five patients with obesity (body mass index ≥ 35 kg/m2 ) were recruited from a bariatric surgery candidate nutrition class. They completed single voxel proton magnetic resonance spectroscopy at baseline (presurgery) and within 1 year postsurgery. Spectra were obtained from a large medial frontal brain region using a PRESS sequence on a 3-T Siemens Verio scanner. The acquisition parameters were TR = 3000 ms and TE = 37 ms. Tissue-corrected metabolite concentrations were determined using Osprey. Paired t-tests were used to examine within-subject change in metabolite concentrations, and correlations were used to relate these changes to other health-related outcomes, including weight loss and glycated hemoglobin (HbA1c ), a measure of blood sugar levels. Bariatric surgery was associated with a reduction in cerebral choline-containing compounds (Cho; t [34] = - 3.79, p < 0.001, d = -0.64) and myo-inositol (mI; t [34] = - 2.81, p < 0.01, d = -0.47) concentrations. There were no significant changes in N-acetyl-aspartate, creatine, or glutamate and glutamine concentrations. Reductions in Cho were associated with greater weight loss (r = 0.40, p < 0.05), and reductions in mI were associated with greater reductions in HbA1c (r = 0.44, p < 0.05). In conclusion, participants who underwent bariatric surgery exhibited reductions in cerebral Cho and mI concentrations, which were associated with improvements in weight loss and glycemic control. Given that elevated levels of Cho and mI have been implicated in neuroinflammation, reduction in these metabolites after bariatric surgery may reflect amelioration of obesity-related neuroinflammatory processes. As such, our results provide evidence that bariatric surgery may improve brain health and metabolism in individuals with obesity.

Vertical sleeve gastrectomy-derived gut metabolite licoricidin activates beige fat thermogenesis to combat obesity

Obesity is a chronic metabolic disease, affecting individuals throughout the world. Bariatric surgery such as vertical sleeve gastrectomy (VSG) provides sustained weight loss and improves glucose homeostasis in obese mice and humans. However, the precise underlying mechanisms remain elusive. In this study, we investigated the potential roles and the mechanisms of action of gut metabolites in VSG-induced anti-obesity effect and metabolic improvement. Methods: High-fat diet (HFD)-fed C57BL/6J mice were subjected to VSG. Energy dissipation in mice was monitored using metabolic cage experiments. The effects of VSG on gut microbiota and metabolites were determined by 16S rRNA sequencing and metabolomics, respectively. The metabolic beneficial effects of the identified gut metabolites were examined in mice by both oral administration and fat pad injection of the metabolites. Results: VSG in mice greatly increased thermogenic gene expression in beige fat, which was correlated with increased energy expenditure. VSG reshaped gut microbiota composition, resulting in elevated levels of gut metabolites including licoricidin. Licoricidin treatment promoted thermogenic gene expression in beige fat by activating the Adrb3-cAMP-PKA signaling pathway, leading to reduced body weight gain in HFD-fed mice. Conclusions: We identify licoricidin, which mediates the crosstalk between gut and adipose tissue in mice, as a VSG-provoked anti-obesity metabolite. Identification of anti-obesity small molecules should provide new insights into treatment options for obesity and its associated metabolic diseases.

Is prior bariatric surgery associated with poor COVID-19 outcomes? A systematic review and meta-analysis of case-control studies

Background

Obesity is an independent risk factor for severe coronavirus disease 2019 (COVID-19), but there is little evidence on whether prior bariatric surgery benefits the outcomes of patients with COVID-19. We aimed to summarize this relationship by conducting a systematic review and meta-analysis of current case-control studies.

Methods

We searched several electronic databases for case-control studies conducted between January 2020 and March 2022. We compared the rates of mortality, mechanical ventilation, intensive care unit (ICU) admission, dialysis, hospitalization, and length of hospital stay between COVID-19 patients with and without a history of bariatric surgery.

Results

We included six studies with 137 903 patients; 5270 (3.8%) had prior bariatric surgery, while 132 633 (96.2%) did not. COVID-19 patients with a history of bariatric surgery had significantly lower mortality (odds ratio (OR) = 0.42; 95% confidence interval (CI) = 0.23-0.74), ICU admission (OR = 0.48; 95% CI = 0.36-0.65), and mechanical ventilation rates than those with a history of non-bariatric surgery (OR = 0.51; 95% CI = 0.35-0.75).

Conclusions

Prior bariatric surgery was associated with a reduced risk of mortality and reduced severity of COVID-19 in patients with obesity compared to those with no prior bariatric surgery. Further large-sample prospective studies are needed to support these results.

Registration

CRD42022323745.

Oxadiazolopyridine Derivatives as Efficacious Mitochondrial Uncouplers in the Prevention of Diet-Induced Obesity

Small-molecule mitochondrial uncouplers are gaining recognition as potential therapeutics for metabolic diseases such as obesity, diabetes, and nonalcoholic steatohepatitis (NASH). Specifically, heterocycles derived from BAM15, a potent and mitochondria-selective uncoupler, have yielded promising preclinical candidates that are efficacious in animal models of obesity and NASH. In this study, we report the structure-activity relationship studies of 6-amino-[1,2,5]oxadiazolo[3,4-b]pyridin-5-ol derivatives. Using oxygen consumption rate as a readout of mitochondrial uncoupling, we established 5-hydroxyoxadiazolopyridines as mild uncouplers. In particular, SHM115, which contains a pentafluoro aniline, had an EC50 value of 17 μM and exhibited 75% oral bioavailability. SHM115 treatment increased the energy expenditure and lowered the body fat mass in two diet-induced obesity mouse models, including an obesity prevention model and an obesity reversal model. Taken together, our findings demonstrate the therapeutic potential of mild mitochondrial uncouplers for the prevention of diet-induced obesity.

[Pharmacotherapy of obesity-Competition to bariatric surgery or a meaningful supplement?]

Obesity is a complex chronic disease and requires a long-term multimodal approach. The current treatment algorithm for treatment of obesity mainly consists of a stepwise approach, which starts with a lifestyle intervention followed by or combined with medication treatment, whereas bariatric surgery is often reserved for the last option. This article provides an overview of the currently available conservative medicinal treatment regimens and the currently approved medications as well as medications currently undergoing approval studies with respect to the efficacy and possible side effects. Special attention is paid to the importance of combination treatment of pharmacotherapy and surgery in the sense of a multimodal treatment. The data so far show that using a multimodal approach an improvement in the long-term weight loss and metabolic benefits can be achieved for the patients.

The Protective Effect of Bariatric Surgery on the Development of Colorectal Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Obesity is a known risk factor for developing colorectal cancer (CRC) and is associated with the formation of precancerous colonic adenomas. Bariatric surgery (BRS) is considered to reduce the cancer risk in morbidly obese patients. However, the currently available literature yields contradicting results regarding the impact of bariatric surgery on the incidence of CRC.

METHODS

A systematic literature search of the Medline, Embase, CENTRAL, CINAHL, Web of Science, and clinicaltrials.gov databases was undertaken following the PRISMA guidelines. A random effects model was selected.

RESULTS

Twelve retrospective cohort studies, incorporating a total of 6,279,722 patients, were eligible for inclusion in the final quantitative analysis. Eight studies originated from North America, while four reported on European patients. Patients in the Bariatric Surgery group exhibited a significantly reduced risk for developing colorectal cancer (RR 0.56, 95% CI 0.4-0.8, p < 0.001), while sleeve gastrectomy was found to be significantly associated with a smaller incidence of CRC (RR 0.55, 95% CI 0.36-0.83, p < 0.001), and gastric bypass and banding did not.

CONCLUSIONS

A significant protective effect of BRS against the development of CRC is implied. In the present analysis, the incidence rate of colorectal cancer was approximately halved amongst the obese individuals that were operated on.

Factors Affecting Weight Reduction after Intragastric Balloon Insertion: A Retrospective Study

BACKGROUND AND OBJECTIVES

Intragastric balloon (IGB) is a safe option for obesity management. However, studies determining the factors influencing the procedure's outcomes are scarce. Therefore, our goal was to determine the factors affecting weight reduction after IGB insertion.

MATERIALS AND METHODS

This retrospective study included 126 obese patients who underwent IGB treatment using the ORBERA^® Intragastric Balloon System. Patients' records were retrieved; and demographic data, initial body mass index (BMI), complications, compliance with both diet and exercise programs, and percentage of excess weight reduction were recorded.

RESULTS

The study included 108 female (85.7%) and 18 male (14.3%) patients. The mean age was 31.7 ± 8.1 years. The percentage of excess weight loss (EWL) was 55.8 ± 35.7%. The mean weight loss was 13.01 ± 7.51 kg. A significant association was found between EWL and age, initial weight, initial body mass index, and the number of pregnancies. No major complications were observed. However, the balloon had to be removed early in two patients (1.59%) due to its rupture and in two other patients (1.59%) due to severe gastritis.

CONCLUSIONS

IGB therapy is a safe and effective option for obesity management, associated with low rates of complications. The EWL after IGB insertion is significantly higher among older patients, those with a relatively low initial body mass index, those with a longer duration of IGB insertion, and female patients with less parity. Larger prospective studies are needed to support our results.

The effect of Roux-en-Y gastric bypass compared with omega-loop gastric bypass on weight loss, perioperative surgical events, and comorbidities

BACKGROUND

In comparison to conservative therapy, bariatric surgery has shown many reasonable results. The current study investigates whether Omega-loop-gastric-bypass (OAGB) or Roux-en-Y gastric-bypass (RYGB) improves weight loss, comorbidities, and perioperative complications.

METHODS

The study included 28,683 patients after RYGB and OAGB. Outcome criteria were perioperative morbidity, perioperative complications, and remission of comorbidities after one year of follow-up.

RESULTS

Of them 14,253 patients had completed a one-year follow-up (13,483 patients by RYGB and 770 by OAGB). BMI reduction was a significant difference in favor of OAGB (17.5±5.6 kg/m² for OAGB vs. 15.2±5.0 for RYGB; P<0.001). The %EWL was not significantly different between the two groups (P=0.073). There was also no significant difference in perioperative complications between the two groups (overall P>5%). Significant differences in favor of OAGB were observed in remission of insulin-dependent diabetes mellitus (IDDM) (P<0.001), and sleep apnea (P=0.002). Remission of reflux was more observed in RYGB than OAGB (P<0.001). Operating time was significantly higher in RYGB than OAGB (P<0.001).

CONCLUSIONS

Compared with RYGB, OAGB showed significant advantages in many respects. In particular, remission of comorbidities was significantly better after OAGB than in patients after RYGB during the one-year follow-up period. Nevertheless, many other factors such as medical history, long-term expected goals of bariatric surgery, and preexisting comorbidities should be taken into account when determining indications between the two procedures. Further studies with longer follow-up periods should be conducted to determine the efficacy of the two methods more accurately.

Body mass index and risk of mortality in patients undergoing bariatric surgery

BACKGROUND

Prior literature has demonstrated that bariatric surgery is a safe approach for patients with morbid obesity. However, the relationship between body mass index (BMI) and risk of mortality in these patients has not been fully elucidated. Primary objective of this study was to evaluate the relationship between BMI and risk of mortality using data obtained from a national database, with a special focus on patients with BMI ≥ 70.0 kg/m².

METHODS

A retrospective cohort study of patients with morbid obesity (BMI ≥ 40 kg/m²) undergoing first-time bariatric surgery between 2015 and 2018 was performed using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Primary outcome was intra-operative death or death within 30 days post-operatively. Patients were categorized into quartiles according to BMI. Multivariable analysis was performed to evaluate the association of BMI with risk of mortality. Relative risk (RR) and 95% confidence interval (CI) are provided as measures of strength of association and precision, respectively.

RESULTS

A total of 463, 436 patients were included with a 30-day mortality rate of 0.11%. Mean BMI (SD) was 48.2 (7.3) kg/m²; 1.5% of patients had BMI ≥ 70.0 kg/m². On multivariable analysis, highest quartile patients had a significantly higher risk of mortality than lowest quartile patients. For patients with BMI ≥ 70.0 kg/m², the risk of mortality was more pronounced with an eightfold increase compared to the lowest quartile. In patients with BMI ≥ 70.0 kg/m², although sleeve gastrectomy (SG) was the most common procedure, the risk of mortality was significantly higher in patients undergoing Roux-en-Y gastric bypass (RYGB).

CONCLUSIONS

BMI is associated with increased risk of 30-day mortality. The effect of BMI is more pronounced in patients with BMI ≥ 70.0 kg/m². In these patients, RYGB is associated with increased risk of mortality compared to SG.

Effects of gastric bypass surgery on brain connectivity responses to hypoglycemia

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) leads to beneficial effects on glucose homeostasis, and attenuated hormonal counterregulatory responses to hypoglycemia are likely to contribute. RYGB also induces alterations in neural activity of cortical and subcortical brain regions. We aimed to characterize RYGB-induced changes in resting-state connectivity of specific brain regions of interest for energy homeostasis and behavioral control during hypoglycemia.

METHOD

Ten patients with BMI > 35 kg/m² were investigated with brain PET/MR imaging during a hyperinsulinemic normo- and hypoglycemic clamp, before and 4 months after RYGB. Hormonal levels were assessed throughout the clamp. Resting-state (RS) fMRI scans were acquired in the glucose-lowering phase of the clamp, and they were analyzed with a seed-to-voxel approach.

RESULTS

RS connectivity during initiation of hypoglycemia was significantly altered after RYGB between nucleus accumbens, thalamus, caudate, hypothalamus and their crosstalk with cortical and subcortical regions. Connectivity between the nucleus accumbens and the frontal pole was increased after RYGB, and this was associated with a reduction of ACTH (r = -0.639, p = 0.047) and cortisol (r = -0.635, p = 0.048) responses. Instead, connectivity between the caudate and the frontal pole after RYGB was reduced and this was associated with less attenuation of glucagon response during the hypoglycemic clamp (r = -0.728, p = 0.017), smaller reduction in fasting glucose (r = -0.798, p = 0.007) and less excess weight loss (r = 0.753, p = 0.012). No other significant associations were found between post-RYGB changes in ROI-to-voxel regional connectivity hormonal responses and metabolic or anthropometric outcomes.

CONCLUSION

RYGB alters brain connectivity during hypoglycemia of several neural pathways involved in reward, inhibitory control, and energy homeostasis. These changes are associated with altered hormonal responses to hypoglycemia and may be involved in the glucometabolic outcome of RYGB.

Endoscopic management of obesity: Impact of endoscopic sleeve gastroplasty on weight loss and co-morbidities at six months and one year

INTRODUCTION

Endoscopic sleeve gastroplasty (ESG) is one of the new minimally invasive endoscopic treatments aimed at inducing weight loss. Its effectiveness in terms of weight loss is proven. Gastric volume reduction and delayed gastric emptying are the mechanisms that drive weight loss. However, potential benefits for co-morbidities in relation to weight loss after ESG are still being investigated. This study aims to evaluate the effect of ESG procedures on major obesity-associated co-morbidities, and on some biological parameters.

PATIENTS AND METHODS

This is a series of consecutive cases from a prospective observational study carried out in a specialized center that follows a standardized care pathway for the multimodal management of obesity. Patients who have undergone ESG with endoscopic and laboratory follow-up at six and twelve months after this intervention were included in the study. Prospectively recorded data on weight loss, co-morbidities and laboratory parameters at six and twelve months after surgery was analyzed retrospectively. Changes in body mass index (BMI), absolute weight loss (AWL), percent of excess weight loss (%EWL) and percent total weight loss (%TWL) were assessed at six and twelve months. Reduction in various obesity-related co-morbidities (arterial hypertension [AHT], type 2 diabetes mellitus [T2DM], gastroesophageal reflux disease [GERD], obstructive sleep apnea syndrome [OSAS] and dyslipidemia was also evaluated at six and twelve months. Changes in blood glucose, liver function tests and lipid blood tests were also analyzed at six and twelve months.

RESULTS

From October 2016 to July 2021, 99 of the 227 patients who underwent ESG in our unit (43.6%) subsequently underwent a complete endoscopic and laboratory follow-up at six and twelve months. The initial BMI was 42.7±7.8kg/m² and age was 45±12.7 years. Seventy-four patients (74.8%) were female. Total weight loss (%TWL) and excess weight loss (%EWL) were 16.6±7.4% and 43.3±21.2%, respectively, at six months, 16.6±9.6% and 42.9±25.6%, respectively, at one year. At six and twelve month follow-up, a statistically significant reduction was observed for the rates of T2DM (30.8 and 32.7%), hypertension (18.4 and 22.1%), GERD (28 and 25.7%), OSAS (15.8 and 25.5%) and dyslipidemia (69.2 and 77.2%) (P<0.001). A statistically significant difference was found in the reduction in blood glucose between the pre-operative period and six months post-operatively (P<0.01) and between the pre-operative period and twelve months post-operatively (P<0.01). The reduction in triglycerides and total cholesterol between the pre-operative values and at six months was statistically significant (P<0.01) as was the reduction at twelve months (P<0.01) (P=0.017). For liver function tests, the reduction in AST was statistically significant at six and twelve months after ESG (P=0.048) (P=0.048) as was ALT (P<0.01) (P<0.01) respectively. From October 2016 to July 2021, of the 227 patients who underwent ESG, 99 (43.6%) had follow-up gastro-duodenoscopy at 6 and 12 months. %TWL and %EWL were respectively 16.6±7.4% and 43.3%±21.2 at 6 months, 16.6±9.6% and 42.9±25.6% at one year. Statistically significant reduction rates at 6 and 12 months were observed in T2DM (30.8 and 32.7%), AHT (18.4 and 22.1%), GERD (28 and 25.7%), OSAS (15.8 and 25.5%) and dyslipidemia (69.2 and 77.2%) (P<0.001). Moreover, glycemic levels were statistically significantly reduced between the pre-operative period and 6 months post-operative (1.11±0.22mg/L vs. 1.01±0.17mg/L, P<0.01), and between the pre-operative period and 12 months post-operative (1.11±0.22mg/L vs. 1.06±0.32mg/L, P<0.01). A statistically significant reduction was also observed in triglycerides and total cholesterol levels at 6 months (1.52±0.74mmol/L vs. 1.14±0.52mmol/L, P<0.01) (1.94±0.4mmol/L vs. 1.85±0.36mmol/L, P<0.01) and at 12 months (1.52±0.74mmol/L vs. 1.18±0.67mmol/L, P<0.01) (1.94±0.4mmol/L vs. 1.82±0.39mmol/L, P=0.017) and in AST (27.2±11.7 IU/L vs. 23.7 IU/L; P=0.048) (27.2±11.7 IU/L vs. 24.7±14.65 IU/L, P=0.048) and ALAT levels (34±21.32 IU/L vs. 22.3±10.4 IU/L, P<0.01 and 34±21.32 IU/L vs. 27.07±25 IU/L, P<0.01) at 6 and 12 months after ESG, respectively.

CONCLUSION

ESG is a well-tolerated and safe surgical procedure that is effective in terms of weight loss and reduction of obesity-related co-morbidities at six months and one year. This procedure could thus be adopted on a broader clinical scale and be more widely promoted as an effective treatment for morbid obesity.

Effect of bariatric surgery on carotid intima-media thickness: A meta-analysis based on observational studies

Objective

This meta-analysis aimed to investigate the effect of bariatric surgery on CIMT in people with obesity.

Methods

PubMed, Web of Science, Embase, and the Cochrane Library were searched for observational studies assessing the effect of bariatric surgery on CIMT from inception to August 2022. Mean difference (MD) and 95% confidence intervals were calculated to assess CIMT.

Results

A total of 23 studies, including 1,349 participants, were eligible to participate in this meta-analysis. The results revealed that CIMT was significantly decreased at 6 months, 12 months, and more than 18 months after bariatric surgery compared with baseline (6 months: MD = 0.09; P < 0.01; 12 months: MD = 0.12; P < 0.01; more than 18 months: MD = 0.14; P = 0.02). Meanwhile, laparoscopic Roux-en-Y gastric bypass (LRYGB) seemed to be more effective than laparoscopic sleeve gastrectomy (LSG) in lowering CIMT in terms of the type of surgery (LSG: MD = 0.11; P < 0.01; LRYGB: MD = 0.14; P < 0.01). Lastly, the benefits of bariatric surgery on CIMT was independent of gender (Male: MD = 0.06; P = 0.04; Female: MD = 0.08; P = 0.03).

Conclusions

Bariatric surgery is consistently effective in reducing CIMT in people with obesity.

Bariatric surgery volume by hospital and long-term survival: population-based NordOSCo data

BACKGROUND

It is unclear whether annual hospital volume of bariatric surgery influences the long-term survival of individuals who undergo surgery for severe obesity. The hypothesis that higher annual hospital volume of bariatric surgery is associated with better long-term survival was evaluated.

METHODS

This retrospective population-based study included patients who underwent bariatric surgery in Sweden and Finland between 1989 and 2020. Annual hospital volume was analysed for risk of all-cause mortality. Multivariable Cox regression provided HRs with 95 per cent confidence intervals adjusted for age, sex, co-morbidity, country, and type of bariatric procedure.

RESULTS

Weight loss surgery was performed in 77 870 patients with a 0.5 per cent risk of postoperative death (mortality rate (MR) per 100 000 people 592.7, 95 per cent c.i. 575.0 to 610.9). Higher annual hospital volume of bariatric surgery was associated with a lower risk of all-cause mortality. The adjusted HRs were slightly more reduced for each quartile of annual hospital volume compared with the lowest quartile (MR per 100 000 people for lowest quartile 815.1, 95 per cent c.i. 781.7 to 849.9; for quartile II: HR 0.88, 95 per cent c.i. 0.81 to 0.96 (MR per 100 000 people 545.0, 512.0 to 580.1); for quartile III: HR 0.87, 0.78 to 0.97 (MR per 100 000 people 428.8, 395.5 to 465.0); for quartile IV: HR 0.82, 0.73 to 0.93 (MR per 100 000 people 356.0, 324.1 to 391.1)). In analyses restricted to laparoscopic surgery, volume and mortality were related only in the crude model (HR 0.86, 0.75 to 0.98), but not in the multivariable model (HR 0.97, 0.84 to 1.13) that compared highest and lowest quartiles.

CONCLUSION

If there was a survival benefit associated with hospital volume, it may have been due to a faster uptake of laparoscopic surgery in the busier hospitals.

Short-term outcomes of sleeve gastrectomy plus uncut jejunojejunal bypass (SG-uncut JJB) in patients with obesity: a preliminary prospective cohort study

OBJECTIVE

To compare the safety, weight loss, and metabolic outcomes of patients with obesity with sleeve gastrectomy (SG) or sleeve gastrectomy plus uncut jejunojejunal bypass (SG-uncut JJB).

METHODS

This prospective study included patients with BMIs ≥ 32.5 kg/m² or refractory metabolic disorders undergoing SG or SG-uncut JJB between January and December 2020 in our hospital (NCT04534504). Weight loss, metabolic outcomes, surgical results, and complaints during 1-year follow-up were compared between two groups.

RESULTS

Forty-seven patients were enrolled, 26 in the SG and 21 in the SG-uncut JJB groups. A longer operative time was observed in the SG-uncut JJB than in the SG group (140 (110-180) min vs. 90 (70-180) min, P = 0.001). No significant differences were found in complications. Total weight loss (TWL%) and excess weight loss (EWL%) in both groups increased with the duration of follow-up (P = 0.001). TWL% was greater at 1 month ((11.1 ± 2.4)% vs. (8.2 ± 4.4)%, P = 0.011] and 12 months [(29.7 ± 6.9)% vs. (20.3 ± 7.2)%, P = 0.001) with SG-uncut JJB than with SG. SG-uncut JJB and SG had similar metabolic outcomes and complaints during the 1-year follow-up, but less nausea was reported with SG-uncut JJB (9.2% vs. 46.2%, P = 0.006).

CONCLUSION

In short-term follow-up, SG-uncut JJB was a safe and effective bariatric surgery procedure in patients with obesity.

8. Obesity and Weight Management for the Prevention and Treatment of Type 2 Diabetes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Clinicopathological Characteristics and Risk Factors for Rapid eGFR Decline in Chinese Patients with Biopsy-Proven Obesity-Related Glomerulopathy

AIM

To investigate the clinicopathologic features and the related risk factors for rapid estimated glomerular filtration rate (eGFR) decline in Chinese obesity-related glomerulopathy (ORG) patients.

METHODS

A total of 63 ORG patients, who underwent a renal biopsy and received follow-up for at least 12 months, were recruited in our study. These patients were classified as rapid decliners and slow decliners based on the eGFR slope value (-5.0 mL/min/1.73 m²/year). Logistic regression analysis was used to determine the risk factors for rapid eGFR decline.

RESULTS

Of the 63 ORG patients, 48 (76.2%) were male, the mean age was 38.7 ± 9.0 years, the median of urinary protein excretion was 1.62 g/24 h, 27.0% of them had nephrotic-range proteinuria, while hypoalbuminemia was observed in 7.9% of them. The incidence of obvious hypertriglyceridemia, hypertension, glucose dysmetabolism and hyperuricemia were 71.4%, 60.3%, 36.5% and 27.0%, respectively. 13 (20.6%) patients became rapid decliners during the median 45 months of follow-up. Their mean BMI was 31.8 ± 3.6 kg/m², the median of baseline eGFR and urinary protein excretion were 71.8 (range of 30.5-118.2) mL/min/1.73 m²/year and 3.57 g/24 h, respectively. Multivariate logistic regression analysis showed that smoking (OR 9.205, 95% CI 1.704-49.740, P = 0.01), hyperuricemia (OR 5.541, 95% CI 1.079-28.460, P = 0.04) and nephrotic-range proteinuria (OR 6.128, 95% CI 1.311-28.637, P = 0.021) were the independent risk factors for rapid eGFR decline.

CONCLUSION

Chinese ORG patients were more likely to have clinical characteristics with hypertriglyceridemia, hypertension and hyperuricemia, and mild to severe degrees of urinary protein excretion at diagnosis, while patients with nephrotic-range proteinuria lacked hypoalbuminemia and hypercholesterolemia. Smoking, hyperuricemia and nephrotic-range proteinuria were independent risk factors for rapid eGFR decline in ORG patients.

Obesity and diabetes: the final frontier

INTRODUCTION

Obesity is a key target in the treatment and prevention of diabetes and independently to reduce the burden of cardiovascular disease. We reviewed the options now available and anticipated to deal with obesity.

AREAS COVERED

We considered the epidemiology, genetics, and causation of obesity and the relationship to diabetes, and the dietary, pharmaceutical, and surgical management of the condition. The literature search covered both popular media via Google Search and the academic literature as indexed on PubMed with search terms including obesity, childhood obesity, adipocytes, insulin resistance, mechanisms of satiety, bariatric surgery, GLP-1 receptor agonists, and SGLT2 inhibitors.

EXPERT OPINION

Although bariatric surgery has been the primary approach to treating obese individuals, the emergence of agents impacting the brain satiety centers now promises effective, non-invasive treatment of obesity for individuals with and without diabetes. The GLP-1 receptor agonists have assumed the primary role in treating obesity with significant weight loss. Long-term results with semaglutide and tirzepatide are now approaching the success seen with bariatric surgery. Future agents combining the benefits of satiety control and thermogenesis to dissipate caloric excess are under investigation.

Chronic abdominal pain after bariatric surgery: a narrative review

Objective: This paper reviews the prevalence, etiology, risk factors, diagnosis and prevention of chronic abdominal pain after bariatric surgery. Introduction: Chronic pain is a very common and complex problem that has serious consequences on individuals and society. It frequently presents as a result of a disease or an injury. Obesity and obesity-related comorbidities are a major health problem and are dramatically increasing year after year. Dieting and physical exercise show disappointing results in the treatment of obesity. Therefore, bariatric surgery is increasingly widely offered as a weight reducing strategy. In our pain clinic we see a lot of patients who suffer from chronic abdominal pain after bariatric surgery. This review aims to explore the link between chronic abdominal pain and bariatric surgery in this specific type of patients. Method: The review is based on searches in PubMed, Embase and Cochrane databases. Keywords are used in different combinations. We did a cross-reference of the articles included. Results: Chronic abdominal pain after bariatric surgery is very common. Around 30% of the bariatric patients experience persistent abdominal pain. An explanation for the abdominal pain is found in 2/3 of these patients. There is a wide variety of causes including behavioral and nutritional disorders, functional motility disorders, biliary disorders, marginal ulceration and internal hernia. Another, frequently overlooked, cause is abdominal wall pain. Unexplained abdominal pain after bariatric surgery is present in 1/3 of the patients with persistent abdominal pain. More studies are needed on the risk factors and prevention of unexplained abdominal pain in bariatric patients.

Integrative analyses of hub genes and their association with immune infiltration in adipose tissue, liver tissue and skeletal muscle of obese patients after bariatric surgery

Bariatric surgery (BS) is an effective treatment for obesity. Adipose tissue, liver tissue and skeletal muscle are important metabolic tissues. This study investigated hub genes and their association with immune infiltration in these metabolic tissues of obese patients after BS by bioinformatic analysis with Gene Expression Omnibus datasets. Differentially expressed genes (DEGs) were identified, and a protein–protein interaction network was constructed to identify hub genes. As a result, 121 common DEGs were identified and mainly enriched in cytokine–cytokine receptor interactions, chemokine signaling pathway, neutrophil activation and immune responses. Immune cell infiltration analysis showed that the abundance of M1 macrophages was significantly lower in adipose and liver tissue after BS (p<0.05). Ten hub genes (TYROBP, TLR8, FGR, NCF2, HCK, CCL2, LAPTM5, MNDA and S100A9) that were all downregulated after BS were also associated with immune cells. Consistently, results in the validated dataset showed that the expression levels of these hub genes were increased in obese patients and mice, and decreased after BS. In conclusion, this study analysed the potential immune and inflammatory mechanisms of BS in three key metabolic tissues of obese patients, and revealed hub genes associated with immune cell infiltration, thus providing potential targets for obesity treatment.

The incremental value of multislice CT in diagnosis of late bariatric surgery complications

Background

Bariatric surgery has become a widely accepted treatment option among the population for obesity management. Nevertheless, different complications may still be encountered during the late post-operative period. Our prospective cross-sectional study aimed to show the incremental value of multislice CT for diagnosis of such complications.

Results

Within the included twenty patients who underwent multislice CT of upper abdomen, gastric pouch dilatation causing recurrent weight gain was the commonest complication detected in 70% of the studied patients and was found mainly after sleeve gastrectomy in whom mean gastric pouch volume was 248.4 ml. Gastric stricture, gastric herniation through plication suture, hiatus hernia and incisional hernia were less commonly encountered complications.

Conclusion

Multislice CT is a useful non-invasive imaging modality for detection of late bariatric surgery complications.

Seven-Year Durability of Improvements in Urinary Incontinence After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

This cohort study evaluates the durability of improvements in urinary incontinence among women and men who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy.

Differential Gene Expression of Subcutaneous Adipose Tissue among Lean, Obese, and after RYGB (Different Timepoints): Systematic Review and Analysis

The main roles of adipose tissue include triglycerides storage and adipokine secretion, which regulate energy balance and inflammation status. In obesity, adipocyte dysfunction leads to proinflammatory cytokine production and insulin resistance. Bariatric surgery is the most effective treatment for obesity, the gold-standard technique being Roux-en-Y gastric bypass (RYGB). Since metabolic improvements after RYGB are clear, a better understanding of adipose tissue molecular modifications could be derived from this study. Thus, the aim of this systematic review was to find differentially expressed genes in subcutaneous adipose tissue of lean, obese and post-RYGB (distinct timepoints). To address this objective, publications from 2015-2022 reporting gene expression (candidate genes or transcriptomic approach) of subcutaneous adipose tissue from lean and obese individuals before and after RGYB were searched in PubMed, Elsevier, and Springer Link. Excluded publications were reviews, studies analyzing serum, other types of tissues, or bariatric procedures. A risk-of-bias summary was created for each paper using Robvis, to finally include 17 studies. Differentially expressed genes in post-RYGB vs. obese and lean vs. obese were obtained and the intersection among these groups was used for analysis and gene classification by metabolic pathway. Results showed that the lean state as well as the post-RYGB is similar in terms of increased expression of insulin-sensitizing molecules, inducing lipogenesis over lipolysis and downregulating leukocyte activation, cytokine production and other factors that promote inflammation. Thus, massive weight loss and metabolic improvements after RYGB are accompanied by gene expression modifications reverting the "adipocyte dysfunction" phenomenon observed in obesity conditions.

Genipin improves lipid metabolism and sperm parametersin obese mice via regulation of miR-132 expression

Obesity has now surpassed malnutrition and infectious diseases as the most significant contributor to health problems worldwide. In particular, obesity is associated with several metabolic disorders, including hyperlipidemia, hepatic steatosis, and subfertility. Genipin (GNP), the aglycone of geniposide, is isolated from the extract of the traditional Chinese medicine Gardenia jasminoides Ellis and has been used in traditional oriental medicine against several inflammation-driven diseases. However, the effect and molecular mechanism of GNP on obesity-associated dyslipidemia and sperm dysfunction still need to be explored. In this study, we detect the effects of GNP on hyperlipidemia, hepatic lipid accumulation and sperm function using a high-fat diet (HFD)-induced obese mouse model. We find that obese mice treated with GNP show an improvement in body weight, serum triglyceride levels, serum hormone levels, serum inflammatory cytokines, hepatic steatosis and sperm function. At the molecular level, HFD/GNP diversely regulates the expression of miR-132 in a tissue-specific manner. miR-132 further targets and regulates the expression of SREBP-1c in liver cells, as well as the expressions of SREBP-1c and StAR in Leydig cells in the testis, thus modifying lipogenesis and steroidogenesis, respectively. Collectively, our data demonstrate that GNP shows a broad effect on the improvement of HFD-induced metabolic disorder and sperm dysfunction in male mice by tissue-specific regulation of miR-132. Our findings reveal the function GNP in ameliorating hepatic lipid metabolism and sperm function and suggest that this compound is a versatile drug to treat metabolic disorders.

Single Anastomosis Jejuno-ileal (SAJI): a New Model of Malabsorptive Revisional Procedure for Insufficient Weight Loss or Weight Regain After Roux-en-Y Gastric Bypass

BACKGROUND

In case of insufficient weight loss or weight regain or relapse of weight-related comorbidities after Roux-en-Y gastric bypass (RYGB), other procedures such as reduction of a large gastric pouch and stoma, lengthening of the Roux limb, conversion to sleeve gastrectomy and/or bilio-pancreatic diversion with duodenal switch have been advocated. Single anastomosis jejuno-ileal (SAJI) is a new revisional simple operation performed after RYGB failure which adds malabsorption to the previous gastric bypass.

METHODS

SAJI includes a single jejuno-ileal anastomosis specifically joining the ileum 250-300 cm proximal to the ileo-caecal valve and the jejunum 30 cm below the gastro-jejunal anastomosis on the Roux limb of the previous RYGB. Thirty-one patients underwent SAJI for insufficient weight loss and/or weight regain after RYGB. The percent total weight loss (%TWL) after RYGB and before SAJI was 21.8 ± 7.8. All SAJI operations were performed laparoscopically. The SAJI mean operating time was 145 min.

RESULTS

Regarding weight loss after SAJI, %TWL is 27.2 ± 7.4, 31.2 ± 6.4, 33.7 ± 5.9 and 32.9 ± 5.2 at 12, 24, 36 and 48 months, respectively. Our series recorded a low rate of peri-operative and medium-term complications with a low grade of severity (Clavien-Dindo classification grade). One patient required reoperation 36 days after SAJI for epigastrium incarcerated incisional hernia at the previous RYGB laparotomy site. Mortality was 0. Comorbidity reduction/resolution after SAJI is 83.2% for type 2 diabetes mellitus, 42.8% for arterial hypertension, 72.8% for dyslipidemia and 45.3% for OSA.

CONCLUSIONS

Treatment of failed RYGB is challenging. SAJI is a less complicated, purely low invasive malabsorptive operation that should reach satisfactory %TWL and comorbidity reduction/resolution.

Efficacy and safety of pre-operative insertion of inferior vena cava filter in patients undergoing bariatric surgery: a systematic review

Prophylactic placement of inferior vena cava (IVC) filters prior to performing bariatric surgery is an intervention of unclear safety and efficacy with disagreement between current practice guidelines. To better characterize the risk and benefit of IVC filter insertion prior to bariatric surgery based on the current evidence. A systematic review of the literature of patients with prophylactic IVC filter insertion prior to bariatric surgery was performed and 32 studies were identified for inclusion into the review, of which none were randomized controlled trials. Meta-analysis was performed including the high-quality included studies. Seven high quality studies reported thrombotic events in patients undergoing bariatric surgery who had an IVCF and a control group which allowed for meta-analysis. The pooled odds ratio of venous thrombotic events in the IVC filter population versus the group without IVC filters was 1.57 (95%CI 0.89, 2.76). Among high quality studies 5 reported major bleeding with a rate of 0.76% and 6 reported on IVC filter complications with a rate of 0.67%. Overall no significant reduction in the rate of venous thrombosis was found with prophylactic IVC filter insertion. Use of IVC filters for prophylaxis remains a concern given the lack of clear efficacy in this setting and a small but present complication risk.