Effects of Bariatric Surgery in Obese Patients With Hypertension: The GATEWAY Randomized Trial (Gastric Bypass to Treat Obese Patients With Steady Hypertension)

The Pandora's Box of Bariatric Surgery: Unveiling the Association with Kidney Stone Risk-A Cross-Sectional Study

BACKGROUND

Metabolic and bariatric surgery is an effective intervention for severe obesity, known for improving comorbidities such as type 2 diabetes, hypertension, and hyperlipidemia. However, its association with kidney stone formation remains uncertain. This study investigates the relationship between bariatric surgery and kidney stone prevalence using data from NHANES 2015-2018.

METHODS

We conducted a cross-sectional analysis of 8,087 participants from NHANES (2015-2018). Bariatric surgery and kidney stone history were self-reported. Logistic regression models adjusted for demographic, clinical, and lifestyle factors were used to evaluate associations. Stratified analyses explored effect modification by subgroups.

RESULTS

Kidney stones were more prevalent among participants with bariatric surgery (26.57%) compared to those without (10.92%, P < 0.001). Bariatric surgery was associated with increased odds of kidney stones in the crude model (OR: 2.95, 95% CI: 1.57-5.55) and adjusted models (OR: 2.69, 95% CI: 1.27-5.70). Subgroup analyses highlighted stronger associations among females and participants with moderate physical activity.

CONCLUSION

Metabolic and bariatric surgery is linked to an elevated risk of kidney stones, influenced by demographic and clinical factors. Personalized counseling on hydration and dietary modifications is essential for mitigating this risk.

The role of bariatric surgery in hypertension control: a systematic review and meta-analysis with extended benefits on metabolic factors

BACKGROUND

By 2025, global obesity rates are projected to reach 16% in men and 21% in women, imposing a significant public health burden. Obesity is a major contributor to hypertension (HTN), exacerbating cardiovascular risks. This review and meta-analysis evaluated the effectiveness of non-surgical treatments versus bariatric surgery in managing hypertension among obese individuals.

METHODS

We searched PubMed, Scopus, Embase, and Cochrane databases up to May 2024. Randomized controlled trials (RCTs) comparing bariatric surgery (e.g., Roux-en-Y Gastric Bypass (RYGB), Sleeve gastrectomy (SG), Laparoscopic adjustable gastric banding (LAGB), Duodenal-jejunal bypass liner/Biliopancreatic diversion (DJBL/BPD)) with non-surgical interventions (e.g., lifestyle modifications, medications) in hypertensive obese patients were included. Primary outcomes were changes in systolic and diastolic blood pressure. Secondary outcomes included changes in fasting blood sugar (FBS), HbA1c, and lipid profiles. Data were synthesized using a random-effects model, with heterogeneity and publication bias assessed.

RESULTS

From 7,187 records, 29 studies involving 2,548 patients met the inclusion criteria. Bariatric surgery resulted in greater reductions in systolic (MD: -4.506 mmHg; 95% CI: -6.999 to -2.013) and diastolic (MD: -3.040 mmHg; 95% CI: -4.765 to -1.314) blood pressure compared to non-surgical interventions. Roux-en-Y gastric bypass had the most significant impact. Bariatric surgery also led to substantial reductions in FBS (MD: -30.444 mg/dl; 95% CI: -41.288 to -19.601), HbA1c (MD: -1.108%; 95% CI: -1.414 to -0.802), and triglycerides (MD: -39.746 mg/dl; 95% CI: -54.458 to -25.034), and increased HDL levels (MD: 7.387 mg/dl; 95% CI: 5.056 to 9.719). The quality of evidence was high for most outcomes, supporting these findings.

CONCLUSION

Bariatric surgery is superior to non-surgical treatments in managing obesity-related hypertension and metabolic disorders. Reductions in blood pressure, glycemic indexes, and lipid profiles highlight bariatric surgery's critical role in improving cardiovascular health and metabolic outcomes in obese hypertensive patients.

Mechanisms and treatment of obesity-related hypertension-Part 2: Treatments

Hypertension is a frequent comorbidity of obesity that significantly and independently increases the risk of cardiovascular and renal events. Obesity-related hypertension is a major challenge to the healthcare system because of the rapid increase in obesity prevalence worldwide. However, its treatment is still not specifically addressed by current guidelines. Weight loss (WL) per se reduces blood pressure (BP) and increases patient responsiveness to BP-lowering medications. Thus, a weight-centric approach is essential for the treatment of obesity-related hypertension. Diet and physical activity are key components of lifestyle interventions for obesity-related hypertension, but, in real life, their efficacy is limited by poor long-term patient adherence and frequently require pharmacotherapy implementation to achieve target BP. In this context, first-generation anti-obesity drugs such as orlistat, phentermine/topiramate, and naltrexone/bupropion are poorly effective, whereas second-generation incretin receptor agonists, including the GLP-1 receptor agonists liraglutide and semaglutide, and in particular the dual GLP-1/glucose-dependent insulinotropic polypeptide (GIP) co-agonist tirzepatide, substantially contribute to effective WL and BP control in obesity. SGLT2 inhibitors are weak body weight and BP-lowering medications, but clearly synergize the benefits of these medications. Bariatric surgery remains the gold standard treatment for severe "pathological" obesity and related life-threatening complications. Renal denervation is a valuable rescue treatment for drug-resistant hypertension, commonly related to obesity. Integrating a multifaceted weight-based approach with other strategies, such as antihypertensive drugs and renal denervation, could specifically target the main neuro-hormonal and renal pathophysiological mechanisms of obesity-related hypertension, including sympathetic-nervous and renin-angiotensin-aldosterone systems overactivity, salt retention, and volume expansion. This comprehensive strategy can provide a personalized algorithm for managing hypertension in obesity within the context of "precision medicine" principles.

Remission of hypertension after laparoscopic sleeve gastrectomy versus Roux-en-Y-gastric bypass: a systematic review of randomized control trials

BACKGROUND

Besides its benefits for weight loss, current findings suggest that bariatric surgery can induce remission of hypertension. Limited data report the effect of bariatric surgery on this obesity-associated comorbidity.

OBJECTIVE

Compare the short-term, mid-term, and long-term remission of hypertension after sleeve gastrectomy versus Roux-en-Y gastric bypass.

SETTING

Meta-analysis of randomized controlled trials (RCTs).

METHODS

Four databases (Embase, PubMed, Scopus, and Science Direct) were searched for RCTs that compared the effects of sleeve gastrectomy (SG) versus Roux-en-Y gastric bypass (RYGB) on hypertension remission at <1 year, 2-4 years, and ≥5 years. Patients with a history of hypertension and who had primary bariatric surgery were included.

RESULTS

After reviewing 11,814 studies, only 11 RCTs were included. In total, the analysis included 2323 patients, with 1158 in the SG group (49.85%) and 1165 in the RYGB group (50.15%). It was found that SG and RYGB procedures had comparable hypertension remission at ≤1 year (Relative risk: 1.11, 95% CI .83-1.48, P = .49), and between 2 and 4 years (Relative risk: 1.11, 95% CI .90-1.37, P = .34). However, there was a significant difference in hypertension remission at ≥ 5 years, favoring RYGB (relative risk: 1.39, 95% CI 1.06-1.82, P = .02).

CONCLUSION

This systematic review and meta-analysis of RCTs demonstrates that RYGB is superior to SG in resolving hypertension beyond 5 years postoperatively. These findings highlight the long-term benefits of RYGB over SG in managing hypertension, providing valuable insights for surgical decision-making and patient counseling.

Flap Valve-Preserving Vertical Sleeve Gastrectomy (INNOVATE-VSG): Clinical Trial Study Protocol

BACKGROUND

Conventional vertical sleeve gastrectomy (cVSG), the most commonly performed bariatric surgery, is associated with low complications, durable weight loss, and significant improvement of many obesity-related comorbidities. However, numerous studies have reported that patients who underwent the cVSG have worsening or new onset (de novo) gastroesophageal reflux disease (GERD) which could be related to a negative effect of the operative procedure on the geometry of the gastroesophageal junction impacting on the function of the native gastroesophageal valve. It is imperative to innovate the cVSG procedure because chronic GERD is a debilitating condition associated with increased risk for Barrett's esophagus and esophageal cancer. INNOVATE-VSG aims to test whether a modified flap valve-preserving VSG (fvpVSG), compared to cVSG, will be associated with improvement of preexisting GERD.

METHODS

The fvpVSG incorporates the following surgical modifications that strengthen the antireflux barrier: achieving 3 cm intrabdominal esophageal length; repair of the diaphragmatic crura; and preservation of 3 cm length of gastric fundus/cardia during the sleeve gastrectomy procedure which will be used to symmetrically wrap around the distal esophagus (120-160° wrap) to restore the naturally occurring gastroesophageal valve. A total of 44 obese patients (BMI 35-50 kg/m2) with pathologic GERD, confirmed by abnormal acid exposure time (AET), will be randomly assigned to cVSG or fvpVSG in this pilot randomized clinical trial at two academic sites. The primary outcome is the change in AET at 6-9 months after surgery. Secondary outcomes include changes in the lower esophageal sphincter pressure, compliance of the esophagogastric junction, weight loss, and quality of life.

DISCUSSION

Data generated from the INNOVATE-VSG trial will be used to design a larger multi-center randomized clinical trial to confirm the value of preserving a functioning gastroesophageal valve following sleeve gastrectomy.

Treatment of obesity: will incretin agonists make bariatric surgery a thing of the past?

The prevalence of obesity continues to increase worldwide. Obesity is associated with an increased risk of cardiometabolic and other diseases, reduced quality of life and shortened life expectancy. Highly effective therapies are required to achieve meaningful and sustained weight reduction to prevent, slow or reverse disease associated with obesity. Bariatric surgery is a highly effective intervention to induce weight loss, with observational data demonstrating durability of weight loss over 10 or more years. In addition, bariatric surgery improves cardiometabolic risk factors, including hyperglycaemia and type 2 diabetes, hypertension and dyslipidaemia. Observational data have shown a reduction in all-cause mortality, cardiovascular events and mortality and a reduction in cancer risk and mortality in patients who have undergone bariatric surgery compared to matched patients who did not have surgery. The emergence of newer incretin agonists, particularly semaglutide and tirzepatide, have demonstrated remarkable efficacy in inducing and maintaining weight loss with ongoing use. As for bariatric surgery, incretin agonist therapies also improve type 2 diabetes outcomes, cardiovascular mortality and other obesity-related complications, with new evidence emerging and long-term outcome data awaited. This perspective compares bariatric surgery and incretin agonist therapy, assessing their relative efficacies in weight reduction, impact on obesity-related complications, their respective risk profiles and considerations of cost-effectiveness and equity of access. These comparisons seek to evaluate whether these increasingly popular medications could make bariatric surgery a thing of the past.

Effect of semaglutide 2.4 mg on use of antihypertensive and lipid-lowering treatment in five randomized controlled STEP trials

OBJECTIVE

The objective of this study was to assess antihypertensive and lipid-lowering treatment changes in participants receiving semaglutide 2.4 mg versus placebo across pooled populations from five Semaglutide Treatment Effect in People with Obesity (STEP) trials.

METHODS

Efficacy and safety of semaglutide 2.4 mg were evaluated in the STEP clinical trials. In this post hoc analysis, STEP 1, 3, 6, and 8 (which included people with overweight or obesity) and, separately, STEP 2 and 6 (which included people with overweight or obesity and type 2 diabetes) were pooled for analysis. Changes in antihypertensive or lipid-lowering treatment intensity from randomization to end of treatment were evaluated.

RESULTS

In both pooled samples, a higher proportion of participants in the semaglutide 2.4 mg group versus placebo underwent antihypertensive or lipid-lowering treatment intensity reduction by end of treatment. A smaller proportion underwent antihypertensive or lipid-lowering treatment intensification by end of treatment in the semaglutide 2.4 mg group of both samples versus placebo. In participants receiving antihypertensive or lipid-lowering medications in both samples, greater numeric reductions in body weight were observed in the semaglutide 2.4 mg group versus placebo.

CONCLUSIONS

These results support a relationship between semaglutide 2.4 mg treatment of overweight and obesity and reduced need for antihypertensive and lipid-lowering treatment, facilitating treatment intensity reduction/discontinuation and abating treatment intensification.

Comparing International Guidelines for the Remission of Hypertension After Bariatric Surgery

BACKGROUND/OBJECTIVES

Obesity remains a global health concern and is associated with increased risk of type 2 diabetes, hypertension, and cardiovascular disease overall. Dissimilar hypertension guidelines are available for clinicians, namely those prepared by the American Heart Association (AHA) and the European Society of Cardiology (ESC), which may lead to distinctive appreciation of health outcomes of patients with obesity after bariatric and metabolic surgery, such as hypertension remission. The main goal of this study was to compare the effects of applying stricter (AHA) versus looser (ESC) blood pressure criteria on hypertension diagnosis pre-bariatric surgery and remission assessment one year post-op.

METHODS

A retrospective analysis of clinical data from patients who underwent surgical treatment for obesity at a single university hospital was performed. To evaluate the hypertension improvement or remission, two different types of blood pressure (BP) categorization were considered (based on AHA and ESC guidelines), in which each patient would fit according to their BP values pre- (m0) and 12 months postoperative (m12).

RESULTS

From a sample of 153 patients submitted for surgical treatment of obesity, more patients were considered with hypertension based on the AHA guideline (130 vs. 102; p < 0.001), while a higher rate of hypertension remission at 12 months after bariatric surgery was observed when following the ESC guideline (58.82 vs. 53.08%). Baseline patients' clinical characteristics based on each hypertension outcome were mostly independent of the guideline used (p > 0.05), where only age and systolic blood pressure were relatively higher in "ESC groups".

CONCLUSIONS

We conclude that only minor differences exist between the two guidelines used. If evaluated based on ESC guidelines, it is expected that less patients are considered with hypertension, and the remission rate may be, at least numerically, higher.

Integrated Insights into Metabolic and Bariatric Surgery: Improving Life Quality and Reducing Mortality in Obesity

Metabolic and bariatric surgery (MBS) is an effective intervention for patients with severe obesity and metabolic comorbidities, particularly when non-surgical weight loss methods prove insufficient. MBS has shown significant potential for improving quality of life and metabolic health outcomes in individuals with obesity, yet it carries inherent risks. Although these procedures offer a multifaceted approach to obesity treatment and its clinical advantages are well-documented, the limited understanding of its long-term outcomes and the role of multidisciplinary care pose challenges. With an emphasis on quality-of-life enhancements and the handling of postoperative difficulties, the present narrative review seeks to compile the most recent findings on MBS while emphasizing the value of an integrated approach to maximize patient outcomes. Effective MBS and patients' management require a collaborative team approach, involving surgeons, dietitians, psychologists, pharmacists, and other healthcare providers to address not only physiological but also psychosocial patient needs. Comparative studies demonstrate the efficacy of various MBS methods, including Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy that may considerably decrease morbidity and mortality in individuals with obesity. Future studies should target long-term patient treatment, and decision making should be aided by knowledge of obesity, comorbidity recurrence rates, and permanence of benefits.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Arterial hypertension-clinical trials update 2024

Arterial hypertension remains the most important modifiable cardiovascular risk factor for morbidity and mortality worldwide. This review summarizes and discusses major clinical trials published in 2023 and early 2024 in hypertension research. These trials include new epidemiological data, studies investigating the impact of blood pressure cuff size on blood pressure measurements, benefits of salt substitutes, and novel antihypertensive treatment options, including pharmacotherapy and bariatric surgery in patients with obesity. This summary reviews the major clinical trials published in 2023 and early 2024. AHT arterial hypertension, BP blood pressure, HR hazard ratio, OBP office blood pressure, PRA plasma renin activity, SBP systolic blood pressure.

Tirzepatide and blood pressure reduction: stratified analyses of the SURMOUNT-1 randomised controlled trial

BACKGROUND

Treating obesity may be a pathway to prevent and control hypertension. In the SURMOUNT-1 trial in people with obesity or overweight with weight-related complications, 72-week tirzepatide treatment led to clinically meaningful body weight and blood pressure reduction. Post hoc analyses were conducted to further explore the effects of tirzepatide on the pattern of blood pressure reduction and whether the effects were consistent across various subgroups.

METHODS

The mixed effect for repeated measure model was used to compare changes in overall blood pressure, across demographic and clinical subgroups, baseline blood pressure subgroups and hypertension categories between SURMOUNT-1 participants randomised to treatment with tirzepatide and placebo. The association between weight changes and blood pressure and adverse events associated with low blood pressure were also evaluated by mediation analysis.

RESULTS

Tirzepatide treatment was associated with a rapid decline in systolic and diastolic blood pressure over the first 24 weeks, followed by blood pressure stabilisation until the end of the observation period, resulting in a significant net reduction by 72 weeks of 6.8 mm Hg systolic and 4.2 mm Hg diastolic blood pressure versus placebo. Participants randomly assigned to any tirzepatide group were more likely than those assigned to placebo to have normal blood pressure at week 72 (58.0% vs 35.2%, respectively). The effects were broadly consistent across baseline blood pressure subgroups, shifting the blood pressure distribution curve to lower blood pressure levels. The mediation analysis indicated that weight loss explained 68% of the systolic and 71% of the diastolic blood pressure reduction. Low blood pressure adverse events were infrequent, but the rate was higher in the tirzepatide group.

CONCLUSIONS

In these post hoc analyses, in participants with obesity or overweight, tirzepatide was associated with reduced blood pressure consistently across participant groups primarily via weight loss, with relatively few blood pressure-related adverse events.

TRIAL REGISTRATION NUMBER

NCT04184622.

Sleeve Gastrectomy Protects Against Hypertension in Rats due to Changes in the Gut Microbiome

INTRODUCTION

Sleeve gastrectomy (SG), results in improvement in hypertension. We have previously published that rodent SG improves hypertension independent of weight loss associated with unique shifts in the gut microbiome. We tested if the gut microbiome directly improves blood pressure by performing fecal material transfer (FMT) from post-SG rats to surgery-naïve animals.

METHODS

We performed SG or Sham surgery in male, Zucker rats (n = 6-7) with obesity. Stool was collected postop from surgical donors for treatment of recipient rats. Three nonsurgical groups received daily, oral consumption of SG stool, sham stool, or vehicle alone (Nutella) for 10 wk (n = 7-8). FMT treatment was assessed for effects on body weight, food intake, oral glucose tolerance, and blood pressure. Genomic deoxyribonucleic acid of stool from donor and recipient groups were sequenced by 16S ribosomal ribonucleic acid and analyzed for diversity, abundance, and importance.

RESULTS

Ten weeks of SG-FMT treatment significantly lowered systolic blood pressures in surgery-naïve, recipient rats compared to vehicle treatment alone (126.8 ± 13.3 mmHg versus 151.8 ± 12.2 mmHg, P = 0.001). SG-FMT treatment also significantly altered beta diversity metrics compared to Sham-FMT and vehicle treatment. In random forest analysis, amplicon sequence variant level significantly predicted FMT group, P = 0.01.

CONCLUSIONS

We have found a direct link between gut microbial changes after SG and regulation of blood pressure. Future mechanistic studies are required to learn what specific gut microbial changes are required to induce improvements in obesity-associated hypertension and translation to clinical, metabolic surgery.

Comparative Analysis of Bariatric Surgery and Non-surgical Therapies: Impact on Obesity-Related Comorbidities

Obesity is associated with a broad spectrum of comorbidities, including metabolic dysregulation, cardiovascular complications, and socioeconomic impacts. Traditional lifestyle interventions often yield transient results in weight management, while bariatric surgery offers a promising alternative. This systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and focused on randomized controlled trials comparing bariatric surgery (e.g., Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB), and sleeve gastrectomy (SG)) with non-surgical therapies (drug therapy and lifestyle modifications) in the management of obesity-related comorbidities, particularly hypertension and type 2 diabetes mellitus (T2DM). We comprehensively searched databases like PubMed, PMC, and EBSCO using Medical Subject Headings (MeSH) terms related to obesity, bariatric surgery, and non-surgical treatments. We included seven studies involving participants aged 18-64 published within the last six years. We rigorously assessed these studies for quality and extracted data to evaluate outcomes such as weight loss, diabetes remission rates, hypertension management, and renal function. The review found that bariatric surgery consistently resulted in substantial and sustained weight loss compared to non-surgical therapies. Surgical interventions significantly improved hypertension control, reduced cardiovascular risks, and enhanced glycemic control in diabetic patients. The effectiveness of bariatric surgery in promoting diabetes remission was attributed not only to weight loss but also to physiological changes in gastrointestinal anatomy, gut hormones, and energy balance regulation. Limitations identified in the literature included variations in study methodologies, follow-up durations, and patient characteristics, which limited direct comparisons and generalizations. Future research should incorporate more extended follow-up periods and standardized methods to further validate these findings' durability and broad applicability across diverse patient populations. In conclusion, bariatric surgery emerges as an effective treatment option for managing obesity-related comorbidities, particularly hypertension and T2DM. While acknowledging the inherent risks and complexities associated with surgical interventions, ongoing research and clinical innovations are crucial to optimizing patient outcomes and reducing the global burden of obesity-related diseases.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Long-Term Effectiveness and Outcomes of Bariatric Surgery: A Comprehensive Review of Current Evidence and Emerging Trends

Obesity is a global epidemic associated with an increased risk of severe health conditions such as type 2 diabetes, cardiovascular diseases, and certain cancers. Bariatric surgery has become a pivotal treatment for severe obesity, offering significant improvements in weight loss and comorbidity resolution. This comprehensive review aims to assess the long-term effectiveness and outcomes of various bariatric surgical procedures, highlighting current evidence and emerging trends in the field. We extensively reviewed the literature, including randomized controlled trials, cohort studies, and meta-analyses, to evaluate long-term weight loss, resolution of obesity-related comorbidities, quality of life (QoL), and complications associated with different bariatric procedures. Bariatric surgery has demonstrated substantial and sustained weight loss over the long term, with varying degrees of effectiveness among different procedures. Gastric bypass and sleeve gastrectomy are associated with significant improvements in comorbidities such as type 2 diabetes and hypertension. QoL outcomes are generally positive, improving physical health, mental well-being, and social functioning. However, long-term complications, including nutritional deficiencies and the need for reoperations, remain challenges. Emerging trends such as minimally invasive techniques and nonsurgical interventions show promise in enhancing patient outcomes. Bariatric surgery remains a highly effective intervention for managing severe obesity and its related health issues. While long-term outcomes are generally favorable, continued advancements in surgical techniques and postoperative care are crucial for optimizing results and minimizing complications. Future research should focus on personalized approaches to patient management and the development of novel treatment modalities to further improve outcomes in the long term.

Antihypertensive Medication Use Trajectories After Bariatric Surgery: A Matched Cohort Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the most effective and durable treatment for obesity. We aimed to compare the trajectories of antihypertensive medication (AHM) use among obese individuals treated and not treated with MBS.

METHODS

Adults with a body mass index of ≥35 kg/m2 were identified in the Merative Database (US employer-based claims database). Individuals treated with versus without MBS were matched 1:1 using baseline demographic and clinical characteristics as well as AHM utilization. Monthly AHM use was examined in the 3 years after the index date using generalized estimating equations. Subanalyses investigated rates of AHM discontinuation, AHM initiation, and apparent treatment-resistant hypertension.

RESULTS

The primary cohort included 43 206 adults who underwent MBS matched with 43 206 who did not. Compared with no MBS, those treated with MBS had sustained, markedly lower rates of AHM use (31% versus 15% at 12 months; 32% versus 17% at 36 months). Among patients on AHM at baseline, 42% of patients treated with MBS versus 7% treated medically discontinued AHM use (P<0.01). The risk of apparent treatment-resistant hypertension was 3.41× higher (95% CI, 2.91-4.01; P<0.01) 2 years after the index date in patients who did not undergo MBS. Among those without hypertension treated with MBS versus no MBS, 7% versus 21% required AHM at 2 years.

CONCLUSIONS

MBS is associated with lower rates of AHM use, higher rates of AHM discontinuation, and lower rates of AHM initiation among patients not taking AHM. These findings suggest that MBS is both an effective treatment and a preventative measure for hypertension.

Obesity-related cancer and bariatric surgery: A comprehensive systematic review and meta-analysis protocol

INTRODUCTION

Obesity is a silent pandemic affecting all ages and is a component of metabolic syndrome. Its treatment is conducted by lifestyle and behavioral changes, pharmacological therapy, and when correctly indicated, bariatric surgery. In recent years, the procedures for weight loss have been investigated due to their relationship with the development of many types of cancer. Although many studies have shown that bariatric surgery decreases cancer risk, other researchers observed an increase in this association. Carcinogenesis is affected by many factors, such as age, sex, type of cancer, and the bariatric surgery performed on each patient. This systematic review and meta-analysis protocol aims to clarify the association between the different modalities of bariatric surgery and the risk of cancer development in adult patients with metabolic syndrome.

METHOD AND ANALYSIS

The proposed systematic review and meta-analysis will be reported conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-P) guidelines. This research will include observational studies (case-control and cohort studies) about patients who undergo bariatric surgery due to metabolic syndrome. Will be accepted in any language and any year. Publications without peer review will be excluded from this review. Data will be entered into the Review Manager software (RevMan5.2.3). We extracted or calculated the OR and 95% CI for dichotomous outcomes for each study. In case of heterogeneity (I2>50%), the random-effects model will combine the studies to calculate the OR and 95% CI.

ETHICS AND DISSEMINATION

This study will review the published data; Thus, obtaining ethical approval is unnecessary. The findings of this systematic review will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42023432079.

A Review of the Risk Factors and Management of Refractory Hypertension: The Role of Carotid Sinus Stimulation and Renal Nerve Denervation

Hypertension (HTN) is a significant health concern, with a recent increase in HTN-related cardiovascular deaths in the United States. Refractory hypertension, a form of treatment-resistant HTN, poses a challenge for physicians and patients due to its association with increased morbidity and mortality. Risk factors for refractory HTN include African ancestry, female gender, younger age, diabetes mellitus, obesity, obstructive sleep apnea, chronic kidney disease, end-stage renal disease, and smoking. While the exact pathophysiology of refractory HTN is not fully understood, sympathetic overdrive appears to be a significant contributing factor. Arterial stiffness, chronic kidney disease, obstructive sleep apnea, obesity, and diabetes mellitus are comorbid conditions associated with increased sympathetic activity and refractory HTN. The knowledge behind carotid sinus stimulation suggested promising outcomes due to the known physiology. However, the introduction of devices, surgical complications, and the development of new antihypertensive soon took over the innovation of these devices. The authors aim to highlight three important aspects related to refractory hypertension: the risk factors for the development of refractory hypertension, the role of surgery in managing hypertension, and the referral systems available for the management of refractory hypertension.

Remission to normal blood pressure in older adults with hypertension who did not receive antihypertensive medication: analysis of data from two longitudinal cohorts

Background

How often hypertensive patients could achieve remission to normal blood pressure (BP) (i.e., <140/90 mmHg) in the absence of antihypertensive drugs, which is important for the management of hypertension, remains largely unknown. This observational study aimed to investigate the change of BP in older adults with hypertension who did not take antihypertensive drugs and preliminarily examine whether the remission from hypertension to normal BP observed in this setting was associated with lower risk of cardiovascular disease (CVD).

Methods

2760 participants aged 33-99 years (median 60 years, interquartile 54-68 years) from the Health and Retirement Study (wave 2006 to wave 2018) and the English Longitudinal Study of Ageing (wave 1998 to wave 2016), who had no major CVD, were hypertensive, and were not on antihypertensive drugs at the time of baseline BP measurement, and had at least one follow-up BP measurement before which no antihypertensive drugs were taken, were included for analysis. The main outcome was the proportion of patients who achieved remission of hypertension at the last wave of measurement.

Findings

During a median follow-up of six years, 52% of the participants showed a reduction of ≥6 mmHg in systolic BP and 60% a reduction of ≥3 mmHg in diastolic BP. 1171 participants (42%, 95% CI: 41-44%) achieved remission at the last measurement, and by that time 67%, 43%, and 29% of them had maintained the normotensive state for around 4, 8, and 12 years, respectively. Various supplementary analyses that aimed to examine the impact of chance and bias yielded similar results. Preliminary analyses showed that being non-smokers at baseline, achieving a normal body mass index during follow-up, and quitting alcohol drinking during follow-up, among others, were associated with the remission of hypertension. Compared with the participants who remained hypertensive, those who achieved remission had a lower CVD risk (adjusted hazard ratio 0.66, 95% CI: 0.47-0.92).

Interpretation

In many of this study population, hypertension could be reversed without the intervention of drug treatment in the first few years after diagnosis. This finding may have implications for more individualized management of hypertension. Further studies to identify the factors or algorithms predictive of such hypertension remission are warranted.

Funding

The Chinese University of Hong Kong (7106452; 7105959),Shenzhen Science and Technology Program (KQTD20190929172835662), Strategic Priority Research Program of Chinese Academy of Sciences (XDB 38040200), National Institute on Aging (R01AG017644; NIA U01AG009740).

Obesity and the kidney: mechanistic links and therapeutic advances

Obesity is strongly associated with the development of diabetes mellitus and chronic kidney disease (CKD), but there is evidence for a bidirectional relationship wherein the kidney also acts as a key regulator of body weight. In this Review, we highlight the mechanisms implicated in obesity-related CKD, and outline how the kidney might modulate feeding and body weight through a growth differentiation factor 15-dependent kidney-brain axis. The favourable effects of bariatric surgery on kidney function are discussed, and medical therapies designed for the treatment of diabetes mellitus that lower body weight and preserve kidney function independent of glycaemic lowering, including sodium-glucose cotransporter 2 inhibitors, incretin-based therapies and metformin, are also reviewed. In summary, we propose that kidney function and body weight are related in a bidirectional fashion, and that this interrelationship affects human health and disease.

Efficacy and Safety of Bariatric Surgery in Dutch People Living with HIV: a Retrospective Matched Cohort Analysis

PURPOSE

Obesity is rising among people with HIV (PLWH), sparking interest in bariatric surgery (BS) for this group. Yet, large-scale comparative research on BS outcomes in PLWH is lacking.

METHODS

We performed a retrospective, matched cohort analysis in PLWH and HIV uninfected controls. Subjects were retrieved from the Dutch Audit for Treatment of Obesity (DATO) registry. Matching (1:7 ratio) included age (± 5-years), sex, body-mass index (BMI) of ± 3 kg/m2, surgery type, and associated health problems (AHPs) at baseline. The primary endpoint was total weight loss percentage (%TWL) ≥ 20% achieved at 1-year post-BS. Secondary endpoints were cumulative %TWL achieved at 2-years post-BS, a reported remission or improvement in AHPs post-BS, and surgical complications, both at 1-year post-BS. Comparisons were performed using conditional logistic regression.

RESULTS

Twenty-seven PLWH and 168 controls were included. At 1-year post-BS, 89% PLWH achieved ≥ 20%TWL, compared to 94% of controls (p = 0.4). Cumulative %TWL at 2-years post-BS were 82% and 92% in PLWH and controls, respectively (p = 0.2). Improvement rates in hypertension and type 2 diabetes mellitus were 50% and 86% in PLWH, versus 87% and 87% in controls. Full remission occurred in 20% and 71% of PLHIV, versus 49% and 44% of controls, respectively. No improvement or remission was observed for dyslipidaemia in PLHIV compared to 54% improvement and 29% remission in controls. Surgical complications were 0% in PLHIV and 13% (n = 21) in controls.

CONCLUSION

Efficacy and safety outcomes of BS were similar between PLWH and controls except for the lack of improvement in dyslipidaemia in PLWH.

Long-Term Outcomes of Medical Management vs Bariatric Surgery in Type 2 Diabetes

Importance

Randomized clinical trials of bariatric surgery have been limited in size, type of surgical procedure, and follow-up duration.

Objective

To determine long-term glycemic control and safety of bariatric surgery compared with medical/lifestyle management of type 2 diabetes.

Design, Setting, and Participants

ARMMS-T2D (Alliance of Randomized Trials of Medicine vs Metabolic Surgery in Type 2 Diabetes) is a pooled analysis from 4 US single-center randomized trials conducted between May 2007 and August 2013, with observational follow-up through July 2022.

Intervention

Participants were originally randomized to undergo either medical/lifestyle management or 1 of the following 3 bariatric surgical procedures: Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable gastric banding.

Main Outcome and Measures

The primary outcome was change in hemoglobin A1c (HbA1c) from baseline to 7 years for all participants. Data are reported for up to 12 years.

Results

A total of 262 of 305 eligible participants (86%) enrolled in long-term follow-up for this pooled analysis. The mean (SD) age of participants was 49.9 (8.3) years, mean (SD) body mass index was 36.4 (3.5), 68.3% were women, 31% were Black, and 67.2% were White. During follow-up, 25% of participants randomized to undergo medical/lifestyle management underwent bariatric surgery. The median follow-up was 11 years. At 7 years, HbA1c decreased by 0.2% (95% CI, -0.5% to 0.2%), from a baseline of 8.2%, in the medical/lifestyle group and by 1.6% (95% CI, -1.8% to -1.3%), from a baseline of 8.7%, in the bariatric surgery group. The between-group difference was -1.4% (95% CI, -1.8% to -1.0%; P < .001) at 7 years and -1.1% (95% CI, -1.7% to -0.5%; P = .002) at 12 years. Fewer antidiabetes medications were used in the bariatric surgery group. Diabetes remission was greater after bariatric surgery (6.2% in the medical/lifestyle group vs 18.2% in the bariatric surgery group; P = .02) at 7 years and at 12 years (0.0% in the medical/lifestyle group vs 12.7% in the bariatric surgery group; P < .001). There were 4 deaths (2.2%), 2 in each group, and no differences in major cardiovascular adverse events. Anemia, fractures, and gastrointestinal adverse events were more common after bariatric surgery.

Conclusion and Relevance

After 7 to 12 years of follow-up, individuals originally randomized to undergo bariatric surgery compared with medical/lifestyle intervention had superior glycemic control with less diabetes medication use and higher rates of diabetes remission.

Trial Registration

ClinicalTrials.gov Identifier: NCT02328599.

Randomized Trial of Effect of Bariatric Surgery on Blood Pressure After 5 Years

BACKGROUND

Obesity represents a major obstacle for controlling hypertension, the leading risk factor for cardiovascular mortality.

OBJECTIVES

The purpose of this study was to determine the long-term effects of bariatric surgery on hypertension control and remission.

METHODS

We conducted a randomized clinical trial with subjects with obesity grade 1 or 2 plus hypertension using at least 2 medications. We excluded subjects with previous cardiovascular events and poorly controlled type 2 diabetes. Subjects were assigned to Roux-en-Y gastric bypass (RYGB) combined with medical therapy (MT) or MT alone. We reassessed the original primary outcome (reduction of at least 30% of the total antihypertensive medications while maintaining blood pressure levels <140/90 mm Hg) at 5 years. The main analysis followed the intention-to-treat principle.

RESULTS

A total of 100 subjects were included (76% women, age 43.8 ± 9.2 years, body mass index: 36.9 ± 2.7 kg/m2). At 5 years, body mass index was 36.40 kg/m2 (95% CI: 35.28-37.52 kg/m2) for MT and 28.01 kg/m2 (95% CI: 26.95-29.08 kg/m2) for RYGB (P < 0.001). Compared with MT, RYGB promoted a significantly higher rate of number of medications reduction (80.7% vs 13.7%; relative risk: 5.91; 95% CI: 2.58-13.52; P < 0.001) and the mean number of antihypertensive medications was 2.97 (95% CI: 2.33-3.60) for MT and 0.80 (95% CI: 0.51-1.09) for RYGB (P < 0.001). The rates of hypertension remission were 2.4% vs 46.9% (relative risk: 19.66; 95% CI: 2.74-141.09; P < 0.001). Sensitivity analysis considering only completed cases revealed consistent results. Interestingly, the rate of apparent resistant hypertension was lower after RYGB (0% vs 15.2%).

CONCLUSIONS

Bariatric surgery represents an effective and durable strategy to control hypertension and related polypharmacy in subjects with obesity. (GAstric bypass to Treat obEse Patients With steAdy hYpertension [GATEWAY]; NCT01784848).

Short-term cardiovascular events after bariatric surgery in patients with metabolic syndrome

BACKGROUND

Patients with metabolic syndrome (MetS) are at increased risk of developing cardiovascular disease along with other adverse events after bariatric surgery.

OBJECTIVES

The incidence of short-term major adverse cardiovascular events (MACE) in patients with MetS undergoing bariatric surgery is not well characterized.

SETTING

Accredited bariatric surgery centers in the United States and Canada.

METHODS

A total of 760,076 patients aged ≥18 years with body mass index ≥35 kg/m2 who underwent primary bariatric surgery between 2015 and 2018 were included. Patients with both diabetes and hypertension were described as the MetS cohort. Patient characteristics, operative technique, and 30-day outcomes were compared. The primary outcome was incidence of MACE, a composite of myocardial infarction, stroke, and all-cause mortality. Unadjusted and multivariable logistic regression analyses were performed and included an interaction between MetS and hyperlipidemia (HLD).

RESULTS

Of the 577,882 patients included, 111,128 (19.2%) exhibited MetS. Patients with MetS more frequently experienced MACE compared with patients without MetS (.3% versus .1%; P < .001). The odds of MACE were greater for patients with MetS versus Non-MetS (odds ratio [OR] 2.87; 95% CI, 2.49-3.32) in the unadjusted analysis. MetS without HLD, MetS with HLD, and Non-MetS with HLD are significantly associated with MACE when compared with those with non-MetS without HLD.

CONCLUSIONS

Patients with MetS have an increased frequency of cardiac events following bariatric surgery. Future studies should determine if optimization of 1 or more components of MetS or other related co-morbidities reduces the cardiovascular risk for patients.

The cardiovascular effects of novel weight loss therapies

The prevalence of overweight and obesity has reached pandemic proportions. Obesity is known to increase the risk for Type 2 diabetes and hypertension, as well as the risk for overt cardiovascular (CV) disease, including myocardial infarction, heart failure, and stroke. The rising prevalence of obesity may counteract the recent advances in primary and secondary prevention of CV disease. Overweight and obesity are common in patients with CV disease; however, cardiologists face several challenges in managing body weight in this population. Many may not consider obesity as a therapeutic target probably because there were no previous highly effective and safe pharmacologic interventions to consider. In addition, they may not have the expertise or resources to implement lifestyle interventions and may have limited familiarity with obesity pharmacotherapy. Moreover, the long-term CV effects of obesity pharmacotherapy remain uncertain due to limited CV outcome data with weight loss as the primary intervention. Although current CV guidelines recognize the importance of weight loss, they primarily focus on lifestyle modifications, with fewer details on strategies to utilize obesity pharmacotherapy and surgery. However, the recent 2022 American Diabetes Association/European Association for the Study of Diabetes consensus on the management of Type 2 diabetes has moved up weight management to the front of the treatment algorithm, by prioritizing the use of pharmacologic interventions such as glucagon-like peptide-1 receptor agonists and dual glucose-dependent insulinotropic polypeptide/glucagon-like peptide-1 receptor agonists, which have potent weight-lowering effects, in addition to glucose-lowering effects. This review appraises the current evidence regarding the CV effects of weight-loss interventions. Considering this evidence, practical guidance is provided to assist cardiologists in developing and implementing treatment plans, which may allow optimal weight management while maximizing CV benefits and minimizing side effects to improve the overall well-being of people with CV disease.

Comparative Analysis of Hypertension Guidelines: Unveiling Consensus and Discrepancies in Lifestyle Modifications for Blood Pressure Control

Background

Hypertension is a major global health concern, and lifestyle modifications have been recommended as first-line treatment for hypertension in many guidelines. However, different guidelines may recommend different types of lifestyle adjustment, and it is unclear which ones are most effective. In this review, we compared hypertension guidelines to identify any differences and/or consensus in content, efficacy, and timing of initiation of lifestyle modifications.

Methods

We conducted a search of databases to identify hypertension guidelines available in English. We extracted and compared information about lifestyle modifications recommended by the guidelines.

Results

Five hypertension guidelines from America, Europe, the UK, Canada, and the International Society of Hypertension are included. They all recommend diet adaptation, sodium reduction, alcohol restriction, physical exercise, and weight reduction. Other lifestyle interventions emphasized by some guidelines, such as potassium supplementation, smoking cessation, and stress management, are not recommended by all the five guidelines. Among lifestyle changes, the dietary approaches to stop hypertension (DASH) diet may be considered the most effective treatment for reducing blood pressure. These guidelines recommend that for patients with high-normal blood pressure or grade 1 hypertension without high risk factors, lifestyle medicine should be used first for 3-6 months, if blood pressure is still not controlled, then start medication. For those patients who need drug treatment, lifestyle changes can also enhance the effects of antihypertensive therapy.

Conclusion

Lifestyle modifications are crucial in the treatment of hypertension and should be recommended to most hypertensive patients. Among these lifestyle interventions, diet adaptation containing low sodium and alcohol restriction may be the most effective in reducing blood pressure. Physical exercise and weight reduction are also recommended. In some cases, lifestyle modifications should be tried first. They may also enhance the effects of antihypertensive drugs in other patients.

LAPAROSCOPIC SLEEVE GASTRECTOMY VERSUS LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS FOR WEIGHT LOSS IN OBESE PATIENTS: WHICH IS MORE EFFECTIVE? A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

Bariatric surgery is the most effective option to reduce weight in morbid obesity patients. The techniques most employed are the restrictive surgery laparoscopic sleeve gastrectomy (LSG), surgical procedures of intestinal malabsorption, and both types (restrictive and intestinal malabsorption) such as the Roux-en-Y laparoscopic gastric bypass (RYLGB).

AIMS

To determine if LSG is more effective than RYLGB for weight loss.

METHODS

A systematic review and meta-analysis was carried out, including five clinical trials and sixteen cohorts comparing LSG versus RYLGB in weight loss and secondary outcomes: resolution of comorbidities, postoperative complications, operative time, hospital stay, and improvement in quality of life.

RESULTS

Excess weight loss was 10.2% (mean difference [MD] 10.2; 95%CI -10.14; -9.90) higher in patients undergoing LSG than in patients submitted to RYLGB. Diabetes mellitus type 2 was resolved in 17% (relative risk [RR] 0.83; 95%CI 0.77-0.90) of cases, more significantly after LSG, arterial hypertension in 23% (RR 0.77; 95%CI 0.69-0.84), and dyslipidemia in 17% (RR 0.83; 95%CI 0.77-0.90). Postoperative complications were 73% higher in patients undergoing RYLGB (MD 0.73; 95%CI 0.63-0.83). The operative time was 35.76 minutes shorter in the LSG (MD -35.76; 95%CI -37.28; -34.24). Finally, the quality of life improved more in patients operated by LSG (MD 0.37; 95%CI -0.48; -0.26).

CONCLUSIONS

The study demonstrated that LSG could be more effective than RYLGB in reducing the percentage of excess weight, comorbidities, postoperative complications, operative time, hospital stay, and in improving quality of life.

Bariatric Surgery for Patients with Overweight/Obesity. A Comprehensive Grading Methodology and Network Metanalysis of Randomized Controlled Trials on Weight Loss Outcomes and Adverse Events

This study aims to compare different types of metabolic bariatric surgery (MBS) with lifestyle intervention/medical therapy (LSI/MT) for the treatment of overweight/obesity. The present and network meta-analysis (NMA) includes randomized trials. MBS was associated with a reduction of BMI, body weight, and percent weight loss, when compared to LSI/MT, and also with a significant reduction of HbA1c and a higher remission of diabetes. Meta-regression analyses revealed that BMI, a higher proportion of women, and a longer duration of trial were associated with greater effects of MBS. The NMA showed that all surgical procedures included (except greater curvature plication) were associated with a reduction of BMI. MBS is an effective option for the treatment of obesity. The choice of BMI thresholds for eligibility for surgery of patients with different complications should be performed making an evaluation of risks and benefits in each BMI category.

Obesity and hypertension: Obesity medicine association (OMA) clinical practice statement (CPS) 2023

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) provides an overview of the mechanisms and treatment of obesity and hypertension.

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

Mechanisms contributing to obesity-related hypertension include unhealthful nutrition, physical inactivity, insulin resistance, increased sympathetic nervous system activity, renal dysfunction, vascular dysfunction, heart dysfunction, increased pancreatic insulin secretion, sleep apnea, and psychosocial stress. Adiposopathic factors that may contribute to hypertension include increased release of free fatty acids, increased leptin, decreased adiponectin, increased renin-angiotensin-aldosterone system activation, increased 11 beta-hydroxysteroid dehydrogenase type 1, reduced nitric oxide activity, and increased inflammation.

Conclusions

Increase in body fat is the most common cause of hypertension. Among patients with obesity and hypertension, weight reduction via healthful nutrition, physical activity, behavior modification, bariatric surgery, and anti-obesity medications mostly decrease blood pressure, with the greatest degree of weight reduction generally correlated with the greatest degree of blood pressure reduction.

Hepatic Vagotomy in Patients With Obesity Leads to Improvement of the Cholesterol to High-Density Lipoprotein Ratio

INTRODUCTION/PURPOSE

The obesity epidemic is rapidly growing, and visceral adiposity is associated with metabolic consequences secondary to peroxisome proliferator-activated receptor (PPAR)-induced inter-organ signaling pathways. PPARs are ligand-activated transcription factors that modulate vagal pathways which can improve blood pressure, arterial remodeling, cholesterol levels, and insulin sensitivity. However, an obesity-induced inflammatory milieu can interfere with the beneficial effects of PPAR activity, suggesting that a dysregulated PPAR-vagus pathway may play a role in the pathogenesis of obesity-related hypertension. Therefore, we hypothesized that hepatic vagotomy (HV) in patients with obesity would result in a significant reduction in blood pressure and/or the number of hypertension medications compared to control.

METHODS

We conducted a retrospective chart review of 160 patients undergoing laparoscopic sleeve gastrectomy. Patients were divided into HV and control groups, and information was collected at each clinic visit.

RESULTS

At six-months post-operation, the HV group was found to have significantly lower total cholesterol (TC)/high-density lipoprotein (HDL) ratios than the control group. The HV group also had a numerically better blood profile for TC, HDL, low-density lipoprotein (LDL), triglycerides, C-reactive protein, and LDL/HDL ratio. Hypertensive patients in the HV group showed numerically lower hypertension medication counts after six weeks when compared to control.

CONCLUSION

We present the first study to report clinically significant changes related to HV in human subjects. Our results did not support our initial hypothesis but did demonstrate an improvement of the TC/HDL ratio with HV in patients with obesity. Future studies should confirm these findings in a randomized control trial.

Outcomes and Adverse Events After Bariatric Surgery: An Updated Systematic Review and Meta-analysis, 2013-2023

Purpose

Bariatric surgery is an increasingly common treatment for obesity and related comorbidities. This meta-analysis aimed to compare the outcomes of bariatric surgery and medical treatment (MT).

Materials and Methods

A systematic search of articles published from January 2013 to May 2023 identified 20 studies. The treatment arms included Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), gastric banding, and MT. The assessed outcomes included body weight loss, diabetes mellitus (DM) remission, changes in dyslipidemia and hypertension markers, and adverse events.

Results

Bariatric surgery resulted in significantly better short- and long-term weight loss than MT, with RYGB and SG showing the most substantial reduction. The DM remission rates were notably higher in the surgery group, with marked improvements in hemoglobin A1c and fasting glucose levels. Improvements in dyslipidemia were inconclusive, whereas hypertension showed modest improvements, particularly with RYGB. Complication rates varied, with RYGB reporting higher rates of early complications, and SG reporting increased rates of late complications. The perioperative reoperation rates were low across all surgical treatments. Specific adverse events, such as intestinal obstruction and anastomosis site problems, were more common in the RYGB group, whereas reflux symptoms were more common in the SG group.

Conclusion

Bariatric surgery, especially RYGB and SG, provided superior weight loss and DM remission outcomes compared to MT, although with varied complication profiles. These findings underscore the need for careful patient selection and postoperative management in bariatric surgery. Future studies should aim to refine these processes to improve patient outcomes.

Outcomes of Bariatric Surgery in People With Human Immunodeficiency Virus: A Retrospective Analysis From the ATHENA Cohort

BACKGROUND

The implications of bariatric surgery (BS) on virologic and metabolic outcomes in people with human immunodeficiency virus (HIV; PWH) on antiretroviral therapy (ART) are unknown.

METHODS

Here, we report a retrospective analysis up to 18 months post-BS in PWH from the AIDS Therapy evaluation in The Netherlands (ATHENA) cohort with data from all dutch HIV treating Centers. Primary end points were a confirmed virologic failure (2 consecutive HIV-RNA measurements >200 copies/mL) and the percentage of patients who achieved >20% total body weight loss up to 18 months post-BS. Switches from baseline ART and trough plasma concentrations of antiretrovirals were also reported post-BS. Metabolic parameters and medication usage were compared pre- and post-BS.

RESULTS

Fifty-one patients were included. One case of confirmed virologic failure and 3 cases with viral blips were detected in this cohort up to 18 months post-BS. Eighty-five percent of patients achieved >20% total body weight loss at 18 months post-BS, with a mean difference from baseline (95% confidence interval) of -33.5% (-37.7% to -29.3%). Trough plasma concentrations of measured antiretroviral agents were all above minimum effective concentrations, except for 1 sample of darunavir. Lipid profiles, but not serum creatinine and blood pressure, improved significantly (P < .01) post-BS. Total medications and obesity-related comedications declined from 203 to 103 and from 62 to 25, respectively, at 18 months post-BS.

CONCLUSIONS

BS was an effective intervention for weight loss and lipid control in PWH using ART in this cohort with no clear link to poor virologic outcomes.

Prescription drug usage as measure of comorbidity resolution after bariatric surgery: a population-based cohort study

BACKGROUND

Obesity is a chronic and progressive disease associated with significant morbidity, mortality, and health-care costs. Bariatric surgery is the most effective intervention for sustainable weight loss and resolution of obesity-related comorbidities. Studies examining comorbidity resolution largely rely on individual self-reported outcomes and electronic record reviews. We present a population-based study looking at prescription medication utilization before and after bariatric surgery as a measure of comorbidity resolution.

METHODS

All patients enrolled in the Center for Metabolic and Bariatric Surgery who underwent either gastric bypass or sleeve gastrectomy between 2013 and 2019 in Manitoba were included. Demographic information, follow up, and outpatient prescription dispensation data were obtained from the Manitoba Population Research Data Repository housed at the Manitoba Centre for Health Policy for 5 years pre- and post-surgery.

RESULTS

A total of 1184 patients were included. Antidepressants and selective serotonin reuptake inhibitors were the most commonly prescribed classes, and along with thyroid medication, utilization remained stable after bariatric surgery. Proton pump inhibitors and opioid class drugs increased at 1 year after surgery then returned to baseline. Glucose and lipid-lowering medications, including statins, biguanides, sulfonylureas, and insulin, were decreased. Antihypertensives, including ACE inhibitors, calcium channel blockers, angiotensin receptors blockers, thiazides, and beta blockers, similarly decreased.

CONCLUSION

This is the first Canadian study employing a provincial-wide prescription database to measure long-term comorbidity resolution after bariatric surgery. The use of administrative data eliminates potential biases and inaccuracies in follow up and self-reported outcomes. Consistent with the literature, prescriptions for the treatment of metabolic syndrome all decreased and were sustained at long-term follow up. Further studies are needed to delineate the effects of altered pharmaceutical utilization on patient quality of life and health-care expenditures.

A machine learning framework for optimizing obesity care by simulating clinical trajectories and targeted interventions

OBJECTIVE

This study aimed to determine the important clinical management bottlenecks that contribute to underuse of weight loss surgery (WLS) and assess risk factors for attrition at each of them.

METHODS

A multistate conceptual model of progression from primary care to WLS was developed and used to study all adults who were seen by a primary care provider (PCP) and eligible for WLS from 2016 to 2017 at a large institution. Outcomes were progression from each state to each subsequent state in the model: PCP visit, endocrine weight management referral, endocrine weight management visit, WLS referral, WLS visit, and WLS.

RESULTS

Beginning with an initial PCP visit, the respective 2-year Kaplan-Meier estimate for each outcome was 35% (n = 2063), 15.6% (n = 930), 6.3% (n = 400), 4.7% (n = 298), and 1.0% (n = 69) among 5876 eligible patients. Individual providers and clinics differed significantly in their referral practices. Female patients, younger patients, those with higher BMI, and those seen by trainees were more likely to progress. A simulated intervention to increase referrals among PCPs would generate about 49 additional WLS procedures over 3 years.

CONCLUSIONS

This study discovered novel insights into the specific dynamics underlying low WLS use rates. This methodology permits in silico testing of interventions designed to optimize obesity care prior to implementation.

Established and potential cardiovascular risk factors in metabolic syndrome: Effect of bariatric surgery

PURPOSE OF REVIEW

The aim of this review was to provide an overview of the role of novel biomarkers in metabolic syndrome, their association with cardiovascular risk and the impact of bariatric surgery on these biomarkers.

RECENT FINDINGS

Metabolic syndrome encompasses an intricate network of health problems, and its constituents extend beyond the components of its operational definition. Obesity-related dyslipidaemia not only leads to quantitative changes in lipoprotein concentration but also alteration in qualitative composition of various lipoprotein subfractions, including HDL particles, rendering them proatherogenic. This is compounded by the concurrent existence of obstructive sleep apnoea (OSA) and nonalcoholic fatty liver disease (NAFLD), which pave the common pathway to inflammation and oxidative stress culminating in heightened atherosclerotic cardiovascular disease (ASCVD) risk. Bariatric surgery is an exceptional modality to reverse both conventional and less recognised aspects of metabolic syndrome. It reduces the burden of atherosclerosis by ameliorating the impact of obesity and its related complications (OSA, NAFLD) on quantitative and qualitative composition of lipoproteins, ultimately improving endothelial function and cardiovascular morbidity and mortality.

SUMMARY

Several novel biomarkers, which are not traditionally considered as components of metabolic syndrome play a crucial role in determining ASCVD risk in metabolic syndrome. Due to their independent association with ASCVD, it is imperative that these are addressed. Bariatric surgery is a widely recognized intervention to improve the conventional risk factors associated with metabolic syndrome; however, it also serves as an effective treatment to optimize novel biomarkers.

The impact of bariatric surgery on hospitalization due to peripheral artery disease and critical limb ischemia: a nationwide analysis

BACKGROUND

Severe obesity could be an independent risk factor for peripheral artery disease (PAD) and critical limb ischemia (CLI). Bariatric surgery reduces cardiac risk factors, decreasing cardiovascular morbidity and mortality in subjects with severe obesity.

OBJECTIVES

We aimed to describe the impact of bariatric surgery on risk of hospitalization due to PAD and CLI.

SETTING

Academic hospital.

METHODS

The National Inpatient Sample data collected from 2010 to 2015 were examined. Patients were classified as treatment and control groups. Treatment was defined as patients with a previous history of bariatric surgery, and control was defined as patients with a body mass index ≥35 without a history of bariatric surgery. The primary outcome was hospitalization due to PAD; secondary outcomes were CLI, revascularization, major amputation, length of hospital stay (LOS), and total cost of hospitalization. Univariate and multivariate analyses were performed to assess the differences between groups.

RESULTS

There were a total of 2,300,845 subjects: 2,004,804 controls and 296,041 treatment patients. Hospitalization rate for PAD was significantly lower compared to the control group (.10% versus .21%, P < .0001), which was confirmed after adjusting for covariables (control versus treatment: odds ratio= 1.20, confidence interval: 1.15-1.47). Subgroup analysis showed patients without a history of bariatric surgery had a higher prevalence of CLI (59.3% versus 52.4%, P < .0219) and a higher mean LOS (6.7 versus 5.7 days, P = .0023) and cost of hospitalization (78.756 versus 72.621$, P = .0089), with no significant differences in other outcomes. After multivariate analysis, only LOS and total costs were significantly different.

CONCLUSIONS

Bariatric surgery may decrease the risk of hospitalization due to PAD, similarly to the LOS and total cost of hospitalization. Prospective studies should be performed to describe this relationship.

Clinical considerations and pathophysiological associations among obesity, weight loss, heart failure, and hypertension

PURPOSE OF REVIEW

To describe the relationship between three pandemics: hypertension, obesity, and heart failure. From pathophysiology to treatment, understanding how these disease entities are linked can lead to breakthroughs in their prevention and treatment. The relevance of this review lies in its discussion of novel pharmacological and surgical treatment strategies for obesity and hypertension, and their role in the prevention and treatment of heart failure.

RECENT FINDINGS

Novel medications such as GLP-1 agonists have demonstrated sustained weight loss in patients with obesity, and concurrent improvements in their cardiometabolic profile, and possibly also reductions in hypertension-related comorbidities including heart failure. Surgical therapies including laparoscopic bariatric surgery represent an important treatment strategy in obese patients, and recent studies describe their use even in patients with advanced heart failure, including those with ventricular assist devices.

SUMMARY

These developments have deep implications on our efforts to understand, mitigate, and ultimately prevent the three pandemics, and offer promising improvements to quality of life, survival, and the cost burden of these diseases.

Shorter History of Hypertension as a Predictor of Hypertension Remission after 3-years of Bariatric Surgery: Data from the GATEWAY Trial

BACKGROUND

Previous evidence explored predictors of hypertension (HTN) remission after bariatric but data are limited to observational studies and lack of ambulatory blood pressure monitoring (ABPM). This study was aimed to evaluate the rate of HTN remission after bariatric surgery using ABPM and to define predictors of mid-term HTN remission.

METHODS

We included patients enrolled in the surgical arm of the GATEWAY randomized trial. HTN remission was defined as controlled blood pressure (< 130 × 80 mmHg) evaluated by 24-h ABPM while no need of anti-hypertensive medications after 36 months. A multivariable logistic regression model was used to assess the predictors of HTN remission after 36 months.

RESULTS

46 patients submitted Roux-en-Y gastric bypass (RYGB). HTN remission occurred in 39% (n = 14 out of 36 patients with complete data at 36 months). Patients with HTN remission had shorter HTN history than no remission group (5.9 ± 5.5 vs. 12.5 ± 8.1 years; p = 0.01). The baseline insulin levels were lower in patients who presented HTN remission, although not statistically significant (OR: 0.90; CI 95%: 0.80-0.99; p = 0.07). In the multivariate analysis, the HTN history (years) was the only independent predictor of HTN remission (OR: 0.85; 95% CI: 0.70-0.97; p = 0.04). Therefore, for each additional year of HTN history, the chance of HTN remission decreases by approximately 15% after RYGB.

CONCLUSION

After 3 years of RYGB, HTN remission defined by ABPM was common and independently associated with a shorter HTN history. These data underscore the need of early effective approach of obesity aiming greater impact in its comorbidities.

The Impact of Bariatric Surgery on the Incidence of Colorectal Cancer in Patients with Obesity-a Systematic Review and Meta-analysis of Registry Data

PURPOSE

Cancer and obesity represent two of the most significant global health concerns. The risk of malignancy, including colorectal cancer (CRC), increases with obesity. The aim of this study was to perform a systematic review and meta-analysis to determine the value of bariatric surgery in reducing CRC risk in patients with obesity using registry data.

MATERIALS AND METHODS

A systematic review and meta-analysis were performed as per PRISMA guidelines. The risk of CRC was expressed as a dichotomous variable and reported as odds ratios (OR) with 95% confidence intervals (CIs) using the Mantel-Haenszel method. A multi-treatment comparison was performed, examining the risk reduction associated with existing bariatric surgery techniques. Analysis was performed using RevMan, R packages, and Shiny.

RESULTS

Data from 11 registries including 6,214,682 patients with obesity were analyzed. Of these, 14.0% underwent bariatric surgery (872,499/6,214,682), and 86.0% did not undergo surgery (5,432,183/6,214,682). The mean age was 49.8 years, and mean follow-up was 5.1 years. In total, 0.6% of patients who underwent bariatric surgery developed CRC (4,843/872,499), as did 1.0% of unoperated patients with obesity (54,721/5,432,183). Patients with obesity who underwent bariatric surgery were less likely to develop CRC (OR: 0.53, 95% CI: 0.36-0.77, P < 0.001, I2 = 99%). Patients with obesity undergoing gastric bypass surgery (GB) (OR: 0.513, 95% CI: 0.336-0.818) and sleeve gastrectomy (SG) (OR: 0.484, 95% CI: 0.307-0.763) were less likely to develop CRC than unoperated patients.

CONCLUSION

At a population level, bariatric surgery is associated with reduced CRC risk in patients with obesity. GB and SG are associated with the most significant reduction in CRC risk.

PROSPERO REGISTRATION

CRD42022313280.

Influence of weight variation on long-term mortality of patients with heart failure

BACKGROUND

In heart failure, weight loss predicts dismal prognosis. Weight variations have not been addressed in obese patients with heart failure.

AIM

To study the impact of weight variation on heart failure mortality according to body mass index strata.

METHODS

Retrospective study of patients with chronic heart failure with left ventricular ejection fraction<50%. Only patients with ≥1 year of follow-up were included. Patients with missing data for body mass index at the index and 1-year appointments were excluded. Patients were classified into three groups according to weight variation: weight gain>5%; weight loss>5%; and weight stability. Follow-up was set from the 1-year appointment. Cox-regression analysis was used to assess the prognostic impact of weight variation.

RESULTS

We studied 589 patients: 69.8% male; mean age, 69 years. Over 1 year, 148 patients (25.1%) gained>5% weight, 97 (16.5%) lost>5% weight and the remaining 344 were weight-stable. During 49 months of median follow-up, 248 patients died. Patients who lost>5% of their weight presented a higher death risk than the others (hazard ratio 1.61, 95% confidence interval 1.18-2.19). After multivariable adjustment, the hazard ratio for death for low/normal-weight patients who lost>5% of their weight was 1.81 (95% confidence interval 1.02-3.21; P=0.04) compared with the others. Among the overweight, those who lost>5% of their weight had a hazard ratio of 2.34 (95% confidence interval 1.32-4.12). In the initially obese subgroup, weight loss>5% was not associated with prognosis (hazard ratio 1.08, 95% confidence interval 0.53-2.19).

CONCLUSIONS

Weight loss predicted mortality in low/normal-weight and overweight patients with heart failure. However, in obese patients, significant weight loss did not predict poorer survival. Weight loss should not be discouraged in obese patients with heart failure.

Interventions to Address Cardiovascular Risk in Obese Patients: Many Hands Make Light Work

Obesity is a growing public health epidemic worldwide and is implicated in slowing improved life expectancy and increasing cardiovascular (CV) risk; indeed, several obesity-related mechanisms drive structural, functional, humoral, and hemodynamic heart alterations. On the other hand, obesity may indirectly cause CV disease, mediated through different obesity-associated comorbidities. Diet and physical activity are key points in preventing CV disease and reducing CV risk; however, these strategies alone are not always sufficient, so other approaches, such as pharmacological treatments and bariatric surgery, must support them. Moreover, these strategies are associated with improved CV risk factors and effectively reduce the incidence of death and CV events such as myocardial infarction and stroke; consequently, an individualized care plan with a multidisciplinary approach is recommended. More precisely, this review explores several interventions (diet, physical activity, pharmacological and surgical treatments) to address CV risk in obese patients and emphasizes the importance of adherence to treatments.

Obesity-related hypertension and chronic kidney disease: from evaluation to management

With the recent obesity pandemic, obesity-related hypertension and its complications (e.g., heart failure, coronary disease, and chronic kidney disease [CKD]) are gaining attention in clinical and research fields. Obesity-related hypertension frequently precedes the onset of CKD and aggravates its progression. In this review, we discuss the role of visceral fat in the pathophysiology of obesity-related hypertension and the potential therapeutic strategies for its prevention and management. Various factors, including the sympathetic nervous system, renin-angiotensin-aldosterone system, and inflammatory pathways, are intricately involved in the pathogenesis of obesity-related hypertension. These factors individually and jointly contribute to the development of hypertension (usually sodium-sensitive or resistant hypertension) and, ultimately, to the progression of CKD. From a clinical standpoint, a decline in renal function in advanced CKD further makes blood pressure control challenging since only a few options are available for blood pressure-lowering medications. Proactive lifestyle modification, pharmacological treatment for obesity, and bariatric surgery can be considered for obesity control and management. Furthermore, intensive blood pressure control is required to prevent and halt the development and progression of CKD.

Obesity-related hypertension: Implications for advanced nursing practice

ABSTRACT

Obesity increases the risk of hypertension and other cardiometabolic comorbidities. Lifestyle modifications are usually recommended, though lasting effects on weight and BP reduction are limited. Weight-loss medications, especially incretin mimetics, are effective for short- and long-term treatment. Metabolic surgery provides cure of obesity-related hypertension in some patients. NPs are well positioned to manage obesity-related hypertension to improve clinical outcomes of affected individuals.

Effect of weight loss on blood pressure changes in overweight patients: A systematic review and meta-analysis

To determine quantitative differences between weight loss and changes in clinic blood pressure (BP) and ambulatory BP in patients with obesity or overweight, the authors performed a meta-analysis. PubMed, Embase, and Scopus databases were searched up to June 2022. Studies that compared clinic or ambulatory BP with weight loss were included. A random effect model was applied to pool the differences between clinic BP and ambulatory BP. Thirty-five studies, for a total of 3219 patients were included in this meta-analysis. The clinic systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly reduced by 5.79 mmHg (95% CI, 3.54-8.05) and 3.36 mmHg (95% CI, 1.93-4.75) after a mean body mass index (BMI) reduction of 2.27 kg/m² , and the SBP and DBP were significantly reduced by 6.65 mmHg (95% CI, 5.16-8.14) and 3.63 mmHg (95% CI, 2.03-5.24) after a mean BMI reduction of 4.12 kg/m² . The BP reductions were much larger in patients with a BMI decrease ≥3 kg/m² than in patients with less BMI decrease, both for clinic SBP [8.54 mmHg (95% CI, 4.62-12.47)] versus [3.83 mmHg (95% CI, 1.22-6.45)] and clinic DBP [3.45 mmHg (95% CI, 1.59-5.30)] versus [3.15 mmHg (95% CI, 1.21-5.10)]. The significant reduction of the clinic and ambulatory BP followed the weight loss, and this phenomenon could be more notable after medical intervention and a larger weight loss.

Bariatric Surgery and Incident Heart Failure: a Propensity Score Matched Nationwide Cohort Study

BACKGROUND

Bariatric surgery results in significant weight loss and a reduction in the incidence of cardiovascular disease in patients with obesity; however, relatively little research considers its effect on the incidence of heart failure (HF). We aimed to determine whether bariatric surgery reduces the incidence of HF in patients with obesity, compared to non-surgical management.

METHODS

A propensity-score matched, retrospective cohort study using patients records from the nationwide Clinical Practice Research Database (CPRD) was conducted. 3052 patients who received bariatric surgery were matched with 3052 patients who did not, according to propensity to receive bariatric surgery, determined through a logistic regression model. Patients were eligible if >18 years old, BMI > 35 kg/m², and no prior diagnosis of HF. The pre-defined primary endpoint was the development of new HF, and secondary endpoints were all-cause mortality and hospitalisations due to HF.

RESULTS

Patients who received bariatric surgery had a significantly lower incidence of new HF (hazard ratio 0.45, 95% confidence interval 0.28-0.73, p = 0.0011) and all-cause mortality (hazard ratio 0.56, 95% confidence interval 0.38-0.83, p = 0.0036).

CONCLUSIONS

This study provides evidence of lower rates of HF and all-cause mortality in patients who undergo bariatric surgery, compared to propensity-score matched controls. Future studies to understand the mechanism(s) involved in this reduction and explore the lifetime benefits in high-risk cohorts are paramount.

Endoscopic Assessment Prior to Bariatric Surgery in Saudi Arabia

BACKGROUND

There are marked local inconsistencies in the Arabian Peninsula about the role of preoperative esophagogastroduodenoscopy (EGD) in bariatric surgery. Thus, this study was conducted to determine the frequency of endoscopic and histological findings in the Saudi population presenting for pre-bariatric surgery evaluation.

MATERIAL AND METHODS

This was a retrospective study that included all the patients who were evaluated by EGD at Dammam Medical Complex, Dammam, Saudi Arabia, between 2018 and 2021 as a part of their pre-bariatric-surgery evaluation.

RESULTS

A total of 684 patients were included. They consisted of 250 male and 434 female patients (36.5% and 63.5%, respectively). The mean ± standard deviation for the patients' age and body mass index (BMI) were 36.4±10.6 years and 44.6±5.1 kg/m², respectively. Significant endoscopic or histopathological findings as defined by the presence of large (≥ 2 cm) hiatus hernia, esophagitis, gastroesophageal reflux disease (GERD), Barrett esophagus, gastric ulcer, duodenal ulcer, or intestinal metaplasia were found in 143 patients (20.9%); 364 patients (53.2%) were diagnosed to have Helicobacter pylori infection.

CONCLUSION

The high number of significant endoscopic and histopathological findings in our study supports the routine use of preoperative EGD in all bariatric surgery patients. However, omitting EGD before Roux-en-Y gastric bypass (RYGB) in asymptomatic patients is still reasonable as the most frequently found significant findings, esophagitis, and hiatus hernia, are less likely to impact the operative plans in RYGB. Similarly, active surveillance and treatment of H. pylori infections in obese patients are important but it is not clear whether H. pylori eradication should be done before bariatric surgery.

Epigenetic Signatures in Arterial Hypertension: Focus on the Microvasculature

Systemic arterial hypertension (AH) is a multifaceted disease characterized by accelerated vascular aging and high cardiometabolic morbidity and mortality. Despite extensive work in the field, the pathogenesis of AH is still incompletely understood, and its treatment remains challenging. Recent evidence has shown a deep involvement of epigenetic signals in the regulation of transcriptional programs underpinning maladaptive vascular remodeling, sympathetic activation and cardiometabolic alterations, all factors predisposing to AH. After occurring, these epigenetic changes have a long-lasting effect on gene dysregulation and do not seem to be reversible upon intensive treatment or the control of cardiovascular risk factors. Among the factors involved in arterial hypertension, microvascular dysfunction plays a central role. This review will focus on the emerging role of epigenetic changes in hypertensive-related microvascular disease, including the different cell types and tissues (endothelial cells, vascular smooth muscle cells and perivascular adipose tissue) as well as the involvement of mechanical/hemodynamic factors, namely, shear stress.