Cost-efficacy of surgically induced weight loss for the management of type 2 diabetes: a randomized controlled trial

Bariatric Surgery for Adults With Class I Obesity and Difficult-to-Manage Type 2 Diabetes: A Health Technology Assessment

Background

Many individuals with type 2 diabetes are classified as either overweight or obese. A patient may be described as having difficult-to-manage type 2 diabetes if their HbA1c levels remain above recommended target levels, despite efforts to treat it with lifestyle changes and pharmacotherapy. Bariatric surgery refers to procedures that modify the gastrointestinal tract. In patients with class II or III obesity, bariatric surgery has resulted in substantial weight loss, improved quality of life, reduced mortality risk, and resolution of type 2 diabetes. There is some evidence suggesting these outcomes may also be possible for patients with class I obesity as well. We conducted a health technology assessment of bariatric surgery for adults with class I obesity and difficult-to-manage type 2 diabetes, which included an evaluation of effectiveness, safety, cost-effectiveness, the budget impact of publicly funding bariatric surgery, and patient preferences and values.

Methods

We performed a systematic clinical literature review. We assessed the risk of bias of each included study, using the Cochrane Risk of Bias tool for randomized controlled trials, the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool for cohort studies, and the Risk of Bias in Systematic Reviews (ROBIS) tool for systematic reviews; we assessed the quality of the body of evidence according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. We performed a systematic economic literature review and conducted a cost-utility analysis of bariatric surgery in comparison with nonsurgical usual care over a lifetime horizon from a public payer perspective. We also analyzed the budget impact of publicly funding bariatric surgery for adults with class I obesity and difficult-to-manage type 2 diabetes in Ontario. To contextualize the potential value of bariatric surgery, we spoke with people with obesity and type 2 diabetes who had undergone or were considering this procedure.

Results

We included 14 studies in the clinical evidence review. There were large increases in diabetes remission rates (GRADE: Low to Very low) and large reductions in body mass index (GRADE: Low to Very low) with bariatric surgery than with medical management. Bariatric surgery may also reduce the use of medications for type 2 diabetes (GRADE: Low) and may improve quality of life for people with class I obesity and difficult-to-manage type 2 diabetes compared with medical management. (GRADE: Low)Our economic evidence review included 5 cost-effectiveness studies; none were conducted in a Canadian setting, and 4 were considered partially applicable to our research question. Most studies found bariatric surgery to be cost-effective compared to standard care for patients with class I obesity and type 2 diabetes; however, the applicability of these results to the Ontario context is uncertain due to potential differences in clinical practice, resource utilization, and unit costs.Our primary economic evaluation found that over a lifetime horizon, bariatric surgery was more costly (incremental cost: $8,151 per person) but also more effective than current usual care (led to a 0.339 quality-adjusted life-year [QALY] gain per person). The cost increase was driven by costs associated with surgery (before, after, and during surgery), and the QALY gain was due to life-years gained. Results were sensitive to the bariatric surgery cost and assumptions regarding its long-term benefits with respect to weight loss and diabetes remission.Publicly funding 50 bariatric surgeries in year 1, and gradually increasing to 250 surgeries in year 5, for people with class I obesity and difficult-to-manage type 2 diabetes would lead to budget increases of $0.55 million in year 1 to $2.45 million in year 5, for a total of $7.63 million over 5 years.The people with obesity and type 2 diabetes with whom we spoke reported that bariatric surgery was generally seen as a positive treatment option, and those who had undergone the procedure reported positively on its value as a treatment to manage their weight and diabetes.

Conclusions

For adults with class I obesity and difficult-to-manage type 2 diabetes, bariatric surgery may be more clinically effective and cost-effective than medical management. Compared with medical management in people with class I obesity and difficult-to-manage type 2 diabetes, bariatric surgery may result in large increases in diabetes remission rates, large reductions in BMI, and reduced medication use for type 2 diabetes, improved quality of life. Over a lifetime horizon, bariatric surgery led to a cost increase and QALY gain. Bariatric surgery can result in postsurgical complications that are not faced by those receiving medical management. The cost-effectiveness of bariatric surgery depends on its long-term impacts on obesity-related and diabetes-related complications, which could be uncertain.Our budget impact analysis suggests that publicly funding bariatric surgery in Ontario for people with class I obesity and difficult-to-manage type 2 diabetes would lead to a budget increase of $7.63 million over 5 years.For people with obesity and type 2 diabetes, bariatric surgery was seen as a potential positive treatment option to manage their weight and diabetes.

Bariatric and metabolic surgery in patients with low body mass index: an online survey of 543 bariatric and metabolic surgeons

BACKGROUND

Metabolic and bariatric surgery (MBS) in patients with low body mass index patients is a topic of debate. This study aimed to address all aspects of controversies in these patients by using a worldwide survey.

METHODS

An online 35-item questionnaire survey based on existing controversies surrounding MBS in class 1 obesity was created by 17 bariatric surgeons from 10 different countries. Responses were collected and analysed by authors.

RESULTS

A total of 543 bariatric surgeons from 65 countries participated in this survey. 52.29% of participants agreed with the statement that MBS should be offered to class-1 obese patients without any obesity related comorbidities. Most of the respondents (68.43%) believed that MBS surgery should not be offered to patients under the age of 18 with class I obesity. 81.01% of respondents agreed with the statement that surgical interventions should be considered after failure of non-surgical treatments.

CONCLUSION

This survey demonstrated worldwide variations in metabolic/bariatric surgery in patients with class 1 obesity. Precise analysis of these results is useful for identifying different aspects for future research and consensus building.

Cost-effectiveness of metabolic surgery for the treatment of type 2 diabetes and obesity: a systematic review of economic evaluations

AIM

To systematically identify and appraise the international literature on the cost-effectiveness of metabolic surgery for the treatment of comorbid type 2 diabetes (T2D) and obesity.

METHODS

A systematic search was conducted in electronic databases and grey literature sources up to 20 January 2021. Economic evaluations in a T2D population or a subpopulation with T2D were eligible for inclusion. Screening, data extraction, critical appraisal of methodological quality (Consensus Health Economic Criteria list) and assessment of transferability (International Society for Pharmacoeconomics and Outcomes Research questionnaire) were undertaken in duplicate. The incremental cost-effectiveness ratio (ICER) was the main outcome. Costs were reported in 2020 Irish Euro. Cost-effectiveness was interpreted using willingness-to-pay (WTP) thresholds of €20,000 and €45,000/quality-adjusted life year (QALY). Due to heterogeneity arising from various sources, a narrative synthesis was undertaken.

RESULTS

Thirty studies across seventeen jurisdictions met the inclusion criteria; 16 specifically in a T2D population and 14 in a subpopulation with T2D. Overall, metabolic surgery was found to be cost-effective or cost-saving. Where undertaken, the results were robust to sensitivity and scenario analyses. Of the 30 studies included, 15 were considered high quality. Identified limitations included limited long-term follow-up data and uncertainty regarding the utility associated with T2D remission.

CONCLUSION

Published high-quality studies suggest metabolic surgery is a cost-effective or cost-saving intervention. As the prevalence of obesity and obesity-related diseases increases worldwide, significant investment and careful consideration of the resource requirements needed for metabolic surgery programmes will be necessary to ensure that service provision is adequate to meet demand.

A review on the beneficial effects of bariatric surgery in the management of obesity

INTRODUCTION

Obesity is a chronic disease with a complex interplay of multiple factors such as genetic, metabolic, behavioral, and environmental factors. The management of obesity includes; lifestyle modification, psychological therapy, pharmacological therapy, and bariatric surgery. To date, bariatric surgery is the most effective treatment for obesity by offering a long-term reduction in weight, remission of obesity-related complications, and improving quality of life. However, bariatric surgery is not equally effective in all patients. Thus, if we can predict who would benefit most, it will improve the risk versus benefit ratio of having surgery.

AREAS COVERED

In this narrative review, we explore the question on who will benefit the most from bariatric surgery by examining the recent evidence in the literature. In addition, we investigate the predisposing predictors of bariatric surgery response. Finally, we offer the best strategies in the clinic to explain the potential benefits of bariatric surgery to patients.

EXPERT OPINION

Bariatric surgery is an effective obesity management approach. Despite its efficacy, considerable variation of individual response exists. Thus, it is important to recognize patients that will benefit most, but at present very few predictors are available which can be clinically useful.

Resource utilization and disaggregated cost analysis of bariatric surgery in the Australian public healthcare system

OBJECTIVES

To present a comprehensive real-world micro-costing analysis of bariatric surgery.

METHODS

Patients were included if they underwent primary bariatric surgery (gastric banding [GB], gastric bypass [GBP] and sleeve gastrectomy [SG]) between 2013 and 2019. Costs were disaggregated into cost items and average-per-patient costs from the Australian healthcare systems perspective were expressed in constant 2019 Australian dollars for the entire cohort and subgroup analysis. Annual population-based costs were calculated to capture longitudinal trends. A generalized linear model (GLM) predicted the overall bariatric-related costs.

RESULTS

N = 240 publicly funded patients were included, with the waitlist times of ≤ 10.7 years. The mean direct costs were $11,269. The operating theatre constituted the largest component of bariatric-related costs, followed by medical supplies, salaries, critical care use, and labour on-costs. Average cost for SG ($12,632) and GBP ($15,041) was higher than that for GB ($10,049). Operating theatre accounted for the largest component for SG/GBP costs, whilst medical supplies were the largest for GB. We observed an increase in SG and a decrease in GB procedures over time. Correspondingly, the main cost driver changed from medical supplies in 2014-2015 for GB procedures to operating theatre for SG thereafter. GLM model estimates of bariatric average cost ranged from $7,580 to $36,633.

CONCLUSIONS

We presented the first detailed characterization of the scale, disaggregated profile and determinants of bariatric-related costs, and examined the evolution of resource utilization patterns and costs, reflecting the shift in the Australian bariatric landscape over time. Understanding these patterns and forecasting of future changes are critical for efficient resource allocation.

Bariatric surgery, lifestyle interventions and orlistat for severe obesity: the REBALANCE mixed-methods systematic review and economic evaluation

BACKGROUND

Adults with severe obesity [body mass index (BMI) of ≥ 35 kg/m2] have an increased risk of comorbidities and psychological, social and economic consequences.

OBJECTIVES

Systematically review bariatric surgery, weight-management programmes (WMPs) and orlistat pharmacotherapy for adults with severe obesity, and evaluate the feasibility, acceptability, clinical effectiveness and cost-effectiveness of treatment.

DATA SOURCES

Electronic databases including MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials and the NHS Economic Evaluation Database were searched (last searched in May 2017).

REVIEW METHODS

Four systematic reviews evaluated clinical effectiveness, cost-effectiveness and qualitative evidence for adults with a BMI of ≥ 35 kg/m2. Data from meta-analyses populated a microsimulation model predicting costs, outcomes and cost-effectiveness of Roux-en-Y gastric bypass (RYGB) surgery and the most effective lifestyle WMPs over a 30-year time horizon from a NHS perspective, compared with current UK population obesity trends. Interventions were cost-effective if the additional cost of achieving a quality-adjusted life-year is < £20,000-30,000.

RESULTS

A total of 131 randomised controlled trials (RCTs), 26 UK studies, 33 qualitative studies and 46 cost-effectiveness studies were included. From RCTs, RYGB produced the greatest long-term weight change [-20.23 kg, 95% confidence interval (CI) -23.75 to -16.71 kg, at 60 months]. WMPs with very low-calorie diets (VLCDs) produced the greatest weight loss at 12 months compared with no WMPs. Adding a VLCD to a WMP gave an additional mean weight change of -4.41 kg (95% CI -5.93 to -2.88 kg) at 12 months. The intensive Look AHEAD WMP produced mean long-term weight loss of 6% in people with type 2 diabetes mellitus (at a median of 9.6 years). The microsimulation model found that WMPs were generally cost-effective compared with population obesity trends. Long-term WMP weight regain was very uncertain, apart from Look AHEAD. The addition of a VLCD to a WMP was not cost-effective compared with a WMP alone. RYGB was cost-effective compared with no surgery and WMPs, but the model did not replicate long-term cost savings found in previous studies. Qualitative data suggested that participants could be attracted to take part in WMPs through endorsement by their health-care provider or through perceiving innovative activities, with WMPs being delivered to groups. Features improving long-term weight loss included having group support, additional behavioural support, a physical activity programme to attend, a prescribed calorie diet or a calorie deficit.

LIMITATIONS

Reviewed studies often lacked generalisability to UK settings in terms of participants and resources for implementation, and usually lacked long-term follow-up (particularly for complications for surgery), leading to unrealistic weight regain assumptions. The views of potential and actual users of services were rarely reported to contribute to service design. This study may have failed to identify unpublished UK evaluations. Dual, blinded numerical data extraction was not undertaken.

CONCLUSIONS

Roux-en-Y gastric bypass was costly to deliver, but it was the most cost-effective intervention. Adding a VLCD to a WMP was not cost-effective compared with a WMP alone. Most WMPs were cost-effective compared with current population obesity trends.

FUTURE WORK

Improved reporting of WMPs is needed to allow replication, translation and further research. Qualitative research is needed with adults who are potential users of, or who fail to engage with or drop out from, WMPs. RCTs and economic evaluations in UK settings (e.g. Tier 3, commercial programmes or primary care) should evaluate VLCDs with long-term follow-up (≥ 5 years). Decision models should incorporate relevant costs, disease states and evidence-based weight regain assumptions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016040190.

FUNDING

The National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit and Health Economics Research Unit are core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate.

Patient Characteristics, Procedural and Safety Outcomes of Bariatric Surgery in England: a Retrospective Cohort Study-2006-2012

BACKGROUND

The objective of the study is to analyze procedural and safety outcomes associated with bariatric surgery and describe the characteristics of patients undertaking bariatric procedures in England between April 2006 and March 2012.

METHODS

This is a retrospective cohort study of all adult patients in England diagnosed with obesity and undergoing bariatric surgery as a primary procedure in NHS-funded sites between April 2006 and March 2012 using data sourced from the Hospital Episode Statistics dataset. Length of stay (LOS), 30-day readmission, and post-surgery complication were analyzed as primary outcomes. Socio-demographic background, provider type, procedure volume, and comorbidities were all analyzed as potential explanatory variables.

RESULTS

Gastric bypass (GBP, 12,628) was the most utilized procedure, followed by gastric banding (GB, 6872) and sleeve gastrectomy (SG, 3251). The most prevalent comorbidity was type 2 diabetes (23%). Inpatient mortality was low (≤ 0.15%) for all procedure types. LOS and the risks of both post-operative complication and 30-day readmission were significantly lower for GB, relative to those for GBP and SG. Ethnicity, geographical area, surgery type, and volume were all associated with LOS, risk of readmission, and complication. Provider type and deprivation were further associated with LOS while age correlated with readmission only. An increasing comorbidity burden was associated with an increased risk of both readmission and complication.

CONCLUSIONS

Gastric bypass was the most frequently reported procedure in England across the observation period. While utilization across all procedure types increased between 2007 and 2010, overall uptake of bariatric surgery in England represents only a small proportion of the eligible population. Readmission and complication rates were lower for gastric banding relative to those for either gastric bypass or sleeve gastrectomy. The observed inpatient mortality rate was low across all procedure types.

Obesity surgery makes patients healthier and more functional: real world results from the United Kingdom National Bariatric Surgery Registry

BACKGROUND

The National Bariatric Surgery Registry (NBSR) is the largest bespoke database in the field in the United Kingdom.

OBJECTIVES

Our aim was to analyze the NBSR to determine whether the effects of obesity surgery on associated co-morbidities observed in small randomized controlled clinical trials could be replicated in a "real life" setting within U.K. healthcare.

SETTING

United Kingdom.

METHODS

All NBSR entries for operations between 2000 and 2015 with associated demographic and co-morbidity data were analyzed retrospectively.

RESULTS

A total of 50,782 entries were analyzed. The patients were predominantly female (78%) and white European with a mean age of 45 ± 11 years and a mean body mass index of 48 ± 8 kg/m². Over 5 years of follow-up, statistically significant reductions in the prevalence of type 2 diabetes, hypertension, dyslipidemia, sleep apnea, asthma, functional impairment, arthritis, and gastroesophageal reflux disease were observed. The "remission" of these co-morbidities was evident 1 year postoperatively and reached a plateau 2 to 5 years after surgery. Obesity surgery was particularly effective on functional impairment and diabetes, almost doubling the proportion of patients able to climb 3 flights of stairs and halving the proportion of patients with diabetes related hyperglycemia compared with preoperatively. Surgery was safe with a morbidity of 3.1% and in-hospital mortality of .07% and a reduced median inpatient stay of 2 days, despite an increasingly sick patient population.

CONCLUSIONS

Obesity surgery in the U.K. results not only in weight loss, but also in substantial improvements in obesity-related co-morbidities. Appropriate support and funding will help improve the quality of the NBSR data set even further, thus enabling its use to inform healthcare policy.

What Are the Real Procedural Costs of Bariatric Surgery? A Systematic Literature Review of Published Cost Analyses

This review aims to evaluate the current literature on the procedural costs of bariatric surgery for the treatment of severe obesity. Using a published framework for the conduct of micro-costing studies for surgical interventions, existing cost estimates from the literature are assessed for their accuracy, reliability and comprehensiveness based on their consideration of seven ‘important’ cost components. MEDLINE, PubMed, key journals and reference lists of included studies were searched up to January 2017. Eligible studies had to report per-case, total procedural costs for any type of bariatric surgery broken down into two or more individual cost components. A total of 998 citations were screened, of which 13 studies were included for analysis. Included studies were mainly conducted from a US hospital perspective, assessed either gastric bypass or adjustable gastric banding procedures and considered a range of different cost components. The mean total procedural costs for all included studies was US$14,389 (range, US$7423 to US$33,541). No study considered all of the recommended ‘important’ cost components and estimation methods were poorly reported. The accuracy, reliability and comprehensiveness of the existing cost estimates are, therefore, questionable. There is a need for a comparative cost analysis of the different approaches to bariatric surgery, with the most appropriate costing approach identified to be micro-costing methods. Such an analysis will not only be useful in estimating the relative cost-effectiveness of different surgeries but will also ensure appropriate reimbursement and budgeting by healthcare payers to ensure barriers to access this effective treatment by severely obese patients are minimised.

Bariatric surgery revisions and private health insurance

OBJECTIVE

To identify: 1. The percentage of bariatric procedures that are revisions; 2. What proportion of bariatric revision procedures in public hospitals are for patients whose primary weight loss procedure occurred in a private hospital; 3. The age, sex and level of socioeconomic disadvantage of patients needing revisions.

METHODS

An analysis of patient level admission data from the Integrated South Australian Activity Collection (ISAAC) was performed. Data were collected on all revisions for weight loss related procedures at all South Australian public and private hospitals, between 2000-2015 using the ISAAC codes for revision procedures.

RESULTS

12,606 bariatric procedures occurred in hospitals; ∼27% of which represent a revision (n=3366). Of these revisions, ∼82% occurred in a private hospital (n=2771), and ∼18% occurred in a public hospital (n=595). Of the 595 revisions in a public hospital, 51% of patients had their original bariatric procedure performed in a private hospital. The majority of patients who had a revision procedure are female (≥82%) with a mean age of ∼45. Individuals from the lowest 2 IRSD quintiles were over-represented for public hospital revisions and primary bariatric procedures.

CONCLUSION

Further investigation is needed to identify: 1. Why 27% of bariatric procedures are revisions; 2. Why at least 51% of revisions in public hospitals are on patients whose original primary bariatric procedure was done in a private hospital; 3. The impact that revision procedures in public hospitals, particularly for originally private weight loss procedures, is having on public hospital wait times; 4. The impact of socioeconomic disadvantage on weight loss procedure outcomes.

Diverse approaches to the health economic evaluation of bariatric surgery: a comprehensive systematic review

BACKGROUND

Health economic evaluations inform healthcare resource allocation decisions for treatment options for obesity including bariatric/metabolic surgery. As an important advance on existing systematic reviews, we aimed to capture, summarize and synthesize a diverse range of economic evaluations on bariatric surgery.

METHODS

Studies were identified by electronic screening of all major biomedical/economic databases. Studies included if they reported any quantified health economic cost and/or consequence with a measure of effect for any type of bariatric surgery from 1995 to September 2015. Study screening, data extraction and synthesis followed international guidelines for systematic reviews.

RESULTS

Six thousand one hundred eighty-seven studies were initially identified. After two levels of screening, 77 studies representing 17 countries (56% USA) were included. Despite study heterogeneity, common themes emerged, and important gaps were identified. Most studies adopted the healthcare system/third-party payer perspective; reported costs were generally healthcare resource use (inpatient/shorter-term outpatient). Out-of-pocket costs to individuals, family members (travel time, caregiving) and indirect costs due to lost productivity were largely ignored. Costs due to reoperations/complications were not included in one-third of studies. Body-contouring surgery included in only 14%. One study evaluated long-term waitlisted patients. Surgery was cost-effective/cost-saving for severely obese with type 2 diabetes mellitus. Study quality was inconsistent.

DISCUSSION

There is a need for studies that assume a broader societal perspective (including out-of-pocket costs, costs to family and productivity losses) and longer-term costs (capture reoperations/complications, waiting, body contouring), and consequences (health-related quality-of-life). Full economic evaluation underpinned by reporting standards should inform prioritization of patients (e.g. type 2 diabetes mellitus with body mass index 30 to 34.9 kg/m(2) or long-term waitlisted) for surgery. © 2016 World Obesity.

The evolving role of bariatric surgery in patients with type 1 diabetes and obesity

Bariatric surgery has emerged as a viable treatment option in morbidly obese individuals with type 2 diabetes. Concomitant with societal lifestyle changes and the increased emphasis on achieving metabolic targets, there has been a rise in the number of patients with type 1 diabetes (T1DM) who are overweight and obese. Preliminary experience based on a limited number of observational reports points to substantial weight loss and amelioration of comorbid conditions such as blood pressure and dyslipidemia in patients with T1DM who undergo weight loss surgery. However, there is little evidence to suggest significant improvement in glycemic control and lowering of glycosylated hemoglobin, and bariatric surgical procedures do not necessarily lead to enhanced diabetes management. and improved quality of life. The potential possibility of micronutrient deficiency, weight regain, and psychobehavioral issues post-bariatric surgery also exists. An individualized evaluation of the risks and benefits should be considered, using a a multidisciplinary team approach with expertise in patient selection, surgical technique, and follow-up. A crucial component is the availability of a diabetes care specialist or endocrinologist experienced in intensive, tailored, modifiable insulin regimens who maintains close and careful monitoring during all phases of management. Reliable data from a prospective, longitudinal perspective is required to provide guidelines for clinicians and informed choices for obese patients with T1DM who are contemplating bariatric surgery.

Bariatric Surgery can Lead to Net Cost Savings to Health Care Systems: Results from a Comprehensive European Decision Analytic Model

BACKGROUND

The objective of the present study was to evaluate the cost-utility of bariatric surgery in a lifetime horizon from a Swedish health care payer perspective.

METHODS

A decision analytic model using the Markov process was developed covering cardiovascular diseases, type 2 diabetes, and surgical complications. Clinical effectiveness and safety were based on the literature and data from the Scandinavian Obesity Surgery Registry. Gastric bypass, sleeve gastrectomy, and gastric banding were included in the analysis. Cost data were obtained from Swedish sources.

RESULTS

Bariatric surgery was cost saving in comparison with conservative management. It also led to a substantial reduction in lifetime risk of events: from a 16 % reduction in the risk of transient ischaemic attacks to a 62 % reduction in the incidence of type 2 diabetes. Over a lifetime, surgery led to savings of euro 8408 and generated an additional 0.8 years of life and 4.1 quality-adjusted life years (QALYs) per patient, which translates into gains of 32,390 quality-adjusted person-years and savings of euro 66 million for the cohort, operated in 2012. Analysis of the consequences of a 3-year delay in surgery provision showed that the overall lifetime cost of treatment may be increased in patients with diabetes or a body mass index >40 kg/m(2). Delays in surgery may also lead to a loss of clinical benefits: up to 0.6 life years and 1.2 QALYs per patient over a lifetime.

CONCLUSION

Bariatric surgery, over a lifetime horizon, may lead to significant cost savings to health care systems in addition to the known clinical benefits.

Activation of natriuretic peptides and the sympathetic nervous system following Roux-en-Y gastric bypass is associated with gonadal adipose tissues browning

Objective

Roux-en-Y gastric bypass (RYGB) is an effective method of weight loss and remediation of type-2 diabetes; however, the mechanisms leading to these improvements are unclear. Additionally, adipocytes within white adipose tissue (WAT) depots can manifest characteristics of brown adipocytes. These ‘BRITE/beige’ adipocytes express uncoupling protein 1 (UCP1) and are associated with improvements in glucose homeostasis and protection from obesity. Interestingly, atrial and B-type natriuretic peptides (NPs) promote BRITE/beige adipocyte enrichment of WAT depots, an effect known as “browning.” Here, we investigate the effect of RYGB surgery on NP, NP receptors, and browning in the gonadal adipose tissues of female mice. We propose that such changes may lead to improvements in metabolic homeostasis commonly observed following RYGB.

Methods

Wild type, female, C57/Bl6 mice were fed a 60% fat diet ad libitum for six months. Mice were divided into three groups: Sham operated (SO), Roux-en-Y gastric bypass (RYGB), and Weight matched, sham operated (WM-SO). Mice were sacrificed six weeks following surgery and evaluated for differences in body weight, glucose homeostasis, adipocyte morphology, and adipose tissue gene expression.

Results

RYGB and calorie restriction induced similar weight loss and improved glucose metabolism without decreasing food intake. β3-adrenergic receptor expression increased in gonadal adipose tissue, in addition to Nppb (BNP), and NP receptors, Npr1, and Npr2. The ratio of Npr1:Npr3 and Npr2:Npr3 increased in RYGB, but not WM-SO groups. Ucp1 protein and mRNA, as well as additional markers of BRITE/beige adipose tissue and lipolytic genes increased in RYGB mice to a greater extent than calorie-restricted mice.

Conclusions

Upregulation of Nppb, Npr1, Npr2, and β3-adrenergic receptors in gonadal adipose tissue following RYGB was associated with increased markers of browning. This browning of gonadal adipose tissue may underpin the positive effect of RYGB on metabolic parameters and may in part be mediated through upregulation of natriuretic peptides.

[Challenges in building a surgical obesity center]

BACKGROUND

It is estimated that approximately 1 million adults in Germany suffer from grade III obesity. The aim of this article is to describe the challenges faced when constructing an operative obesity center.

METHODS

The inflow of patients as well as personnel and infrastructure of the interdisciplinary Diabetes and Obesity Center in Heidelberg were analyzed. The distribution of continuous data was described by mean values and standard deviation and analyzed using variance analysis.

RESULTS

The interdisciplinary Diabetes and Obesity Center in Heidelberg was founded in 2006 and offers conservative therapeutic treatment and all currently available operative procedures. For every operative intervention carried out an average of 1.7 expert reports and 0.3 counter expertises were necessary. The time period from the initial presentation of patients in the department of surgery to an operation was on average 12.8 months (standard deviation SD ± 4.5 months). The 47 patients for whom remuneration for treatment was initially refused had an average body mass index (BMI) of 49.2 kg/m(2) and of these 39 had at least the necessity for treatment of a comorbidity. Of the 45 patients for whom the reason for the refusal of treatment costs was given as a lack of conservative treatment, 30 had undertaken a medically supervised attempt at losing weight over at least 6 months. Additionally, 19 of these patients could document participation in a course at a rehabilitation center, a Xenical® or Reduktil® therapy or had undertaken the Optifast® program. For the 20 patients who supposedly lacked a psychosomatic evaluation, an adequate psychosomatic evaluation was carried out in all cases.

CONCLUSIONS

The establishment of an operative obesity center can last for several years. A essential prerequisite for success seems to be the constructive and targeted cooperation with the health insurance companies.

Influence of peri-duodenal non-constrictive cuff on the body weight of rats

BACKGROUND

Weight loss has been found to improve or resolve cardiovascular comorbidities. There is a significant need for reversible device approaches to weight loss.

METHODS

Non-constrictive cuff (NCC) is made of implantable silicone rubber with an internal diameter greater than the duodenum. Ten or 11 NCC were individually mounted along the duodenum from the pyloric sphincter toward the distal duodenum to cover ~22 mm in the length. Twelve Wistar rats were implanted with NCC, and six served as sham, and both groups were observed over 4 months. Six rats with implant had their NCC removed and were observed for additional 4 weeks.

RESULTS

The food intake decreased from 40.1 to 28.1 g/day after 4 months of NCC implant. The body weight gain decreased from 1.76 to 0.46 g/day after 4 months of NCC implant. The fasting glucose decreased from 87.7 to 75.3 mg/dl at terminal day. The duodenal muscle layer covered by the NCC increased from 0.133 to 0.334 mm. After 4 weeks of NCC removal, the food intake, body weight gain, and fasting glucose recovered to 36.2, 2.51 g/day, and 83.9 mg/dl. The duodenal muscle layer covered by the NCC decreased to 0.217 mm.

CONCLUSION

The NCC implant placed on the proximal duodenum is safe in rats for a 4-month period. The efficacy of the NCC implant is significant for decrease in food intake, body weight gain, and fasting glucose in a normal rat model. The removal of NCC implant confirmed a cause-effect relation with food intake and hence body weight.

Surgery for weight loss in adults

BACKGROUND

Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and most recently updated in 2009.

OBJECTIVES

To assess the effects of bariatric surgery for overweight and obesity, including the control of comorbidities.

SEARCH METHODS

Studies were obtained from searches of numerous databases, supplemented with searches of reference lists and consultation with experts in obesity research. Date of last search was November 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing surgical interventions with non-surgical management of obesity or overweight or comparing different surgical procedures.

DATA COLLECTION AND ANALYSIS

Data were extracted by one review author and checked by a second review author. Two review authors independently assessed risk of bias and evaluated overall study quality utilising the GRADE instrument.

MAIN RESULTS

Twenty-two trials with 1798 participants were included; sample sizes ranged from 15 to 250. Most studies followed participants for 12, 24 or 36 months; the longest follow-up was 10 years. The risk of bias across all domains of most trials was uncertain; just one was judged to have adequate allocation concealment.All seven RCTs comparing surgery with non-surgical interventions found benefits of surgery on measures of weight change at one to two years follow-up. Improvements for some aspects of health-related quality of life (QoL) (two RCTs) and diabetes (five RCTs) were also found. The overall quality of the evidence was moderate. Five studies reported data on mortality, no deaths occurred. Serious adverse events (SAEs) were reported in four studies and ranged from 0% to 37% in the surgery groups and 0% to 25% in the no surgery groups. Between 2% and 13% of participants required reoperations in the five studies that reported these data.Three RCTs found that laparoscopic Roux-en-Y gastric bypass (L)(RYGB) achieved significantly greater weight loss and body mass index (BMI) reduction up to five years after surgery compared with laparoscopic adjustable gastric banding (LAGB). Mean end-of-study BMI was lower following LRYGB compared with LAGB: mean difference (MD) -5.2 kg/m² (95% confidence interval (CI) -6.4 to -4.0; P < 0.00001; 265 participants; 3 trials; moderate quality evidence). Evidence for QoL and comorbidities was very low quality. The LRGYB procedure resulted in greater duration of hospitalisation in two RCTs (4/3.1 versus 2/1.5 days) and a greater number of late major complications (26.1% versus 11.6%) in one RCT. In one RCT the LAGB required high rates of reoperation for band removal (9 patients, 40.9%).Open RYGB, LRYGB and laparoscopic sleeve gastrectomy (LSG) led to losses of weight and/or BMI but there was no consistent picture as to which procedure was better or worse in the seven included trials. MD was -0.2 kg/m² (95% CI -1.8 to 1.3); 353 participants; 6 trials; low quality evidence) in favour of LRYGB.  No statistically significant differences in QoL were found (one RCT). Six RCTs reported mortality; one death occurred following LRYGB. SAEs were reported by one RCT and were higher in the LRYGB group (4.5%) than the LSG group (0.9%). Reoperations ranged from 6.7% to 24% in the LRYGB group and 3.3% to 34% in the LSG group. Effects on comorbidities, complications and additional surgical procedures were neutral, except gastro-oesophageal reflux disease improved following LRYGB (one RCT). One RCT of people with a BMI 25 to 35 and type 2 diabetes found laparoscopic mini-gastric bypass resulted in greater weight loss and improvement of diabetes compared with LSG, and had similar levels of complications.Two RCTs found that biliopancreatic diversion with duodenal switch (BDDS) resulted in greater weight loss than RYGB in morbidly obese patients. End-of-study mean BMI loss was greater following BDDS: MD -7.3 kg/m² (95% CI -9.3 to -5.4); P < 0.00001; 107 participants; 2 trials; moderate quality evidence). QoL was similar on most domains. In one study between 82% to 100% of participants with diabetes had a HbA1c of less than 5% three years after surgery. Reoperations were higher in the BDDS group (16.1% to 27.6%) than the LRYGB group (4.3% to 8.3%). One death occurred in the BDDS group.One RCT comparing laparoscopic duodenojejunal bypass with sleeve gastrectomy versus LRYGB found BMI, excess weight loss, and rates of remission of diabetes and hypertension were similar at 12 months follow-up (very low quality evidence). QoL, SAEs and reoperation rates were not reported. No deaths occurred in either group.One RCT comparing laparoscopic isolated sleeve gastrectomy (LISG) versus LAGB found greater improvement in weight-loss outcomes following LISG at three years follow-up (very low quality evidence). QoL, mortality and SAEs were not reported. Reoperations occurred in 20% of the LAGB group and in 10% of the LISG group.One RCT (unpublished) comparing laparoscopic gastric imbrication with LSG found no statistically significant difference in weight loss between groups (very low quality evidence).  QoL and comorbidities were not reported. No deaths occurred. Two participants in the gastric imbrication group required reoperation.

AUTHORS' CONCLUSIONS

Surgery results in greater improvement in weight loss outcomes and weight associated comorbidities compared with non-surgical interventions, regardless of the type of procedures used. When compared with each other, certain procedures resulted in greater weight loss and improvements in comorbidities than others. Outcomes were similar between RYGB and sleeve gastrectomy, and both of these procedures had better outcomes than adjustable gastric banding. For people with very high BMI, biliopancreatic diversion with duodenal switch resulted in greater weight loss than RYGB. Duodenojejunal bypass with sleeve gastrectomy and laparoscopic RYGB had similar outcomes, however this is based on one small trial. Isolated sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. This was based on one trial only.  Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial. Across all studies adverse event rates and reoperation rates were generally poorly reported. Most trials followed participants for only one or two years, therefore the long-term effects of surgery remain unclear.

Multidisciplinary diabetes care with and without bariatric surgery in overweight people: a randomised controlled trial

BACKGROUND

Bariatric surgery improves glycaemia in obese people with type 2 diabetes, but its effects are uncertain in overweight people with this disease. We aimed to identify whether laparoscopic adjustable gastric band surgery can improve glucose control in people with type 2 diabetes who were overweight but not obese.

METHODS

We did an open-label, parallel-group, randomised controlled trial between Nov 1, 2009, and June 30, 2013, at one centre in Melbourne, Australia. Patients aged 18-65 years with type 2 diabetes and a BMI between 25 and 30 kg/m2 were randomly assigned (1:1), by computer-generated random sequence, to receive either multidisciplinary diabetes care plus laparoscopic adjustable gastric band surgery or multidisciplinary diabetes care alone. The primary outcome was diabetes remission 2 years after randomisation, defined as glucose concentrations of less than 7.0 mmol/L when fasting and less than 11.1 mmol/L 2 h after 75 g oral glucose, at least two days after stopping glucose-lowering drugs. Analysis was by intention to treat. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12609000286246.

FINDINGS

51 patients were randomised to the multidisciplinary care plus gastric band group (n=25) or the multidisciplinary care only group (n=26), of whom 23 participants and 25 participants, respectively, completed follow-up to 2 years. 12 (52%) participants in the multidisciplinary care plus gastric band group and two (8%) participants in the multidisciplinary care only group achieved diabetes remission (difference in proportions 0.44, 95% CI 0.17-0.71; p=0.0012). One (4%) participant in the gastric band group needed revisional surgery and four others (17%) had a total of five episodes of food intolerance due to excessive adjustment of the band.

INTERPRETATION

When added to multidisciplinary care, laparoscopic adjustable gastric band surgery for overweight people with type 2 diabetes improves glycaemic control with an acceptable adverse event profile. Laparoscopic adjustable gastric band surgery is a reasonable treatment option for this population.

FUNDING

Monash University Centre for Obesity Research and Education and Allergan.

Systematic review of economic evaluation of laparotomy versus laparoscopy for patients submitted to Roux-en-Y gastric bypass

Background

Because of the high prevalence of obesity, there is a growing demand for bariatric surgery worldwide. The objective of this systematic review was to analyze the difference in relation to cost-effectiveness of access route by laparoscopy versus laparotomy of Roux en-Y gastric bypass (RYGB).

Methods

A systematic review was conducted in the electronic databases MEDLINE, Embase, Scopus, Cochrane and Lilacs in order to identify economic evaluation studies that compare the cost-effectiveness of laparoscopic and laparotomic routes in RYGB.

Results

In a total of 494 articles, only 6 fulfilled the eligibility criteria. All studies were published between 2001 and 2008 in the United States (USA). Three studies fulfilled less than half of the items that evaluated the results quality; two satisfied 5 of the required items, and only 1 study fulfilled 7 of 10 items. The economic evaluation of studies alternated between cost-effectiveness and cost-consequence. Five studies considered the surgery by laparoscopy the dominant strategy, because it showed greater clinical benefit (less probability of post-surgical complications, less hospitalization time) and lower total cost.

Conclusion

This review indicates that laparoscopy is a safe and well-tolerated technique, despite the costs of surgery being higher when compared with laparotomy. However, the additional costs are compensated by the lower probability of complications after surgery and, consequently, avoiding their costs.

Intensive medical weight loss or laparoscopic adjustable gastric banding in the treatment of mild to moderate obesity: long-term follow-up of a prospective randomised trial

BACKGROUND

Proven short-term effectiveness of obesity therapy should be re-evaluated in the long-term. The objective of this paper is to determine the long-term (10 years) outcome for patients from a randomised controlled trial (RCT).

METHODS

A RCT in 2002 compared laparoscopic adjustable gastric band (LAGB) for obesity with non-surgical therapy. Follow-up has been conducted at 10 years. Eighty patients (BMI 30-35) were randomised to a non-surgical or a surgical program. Outcome data are available on 37 (92.5 %) of the surgical patients and 27 (62.5 %) of the non-surgical patients at 10 years.

RESULTS

Weight change, the metabolic syndrome, quality of life, adverse events and direct costs of the surgical cohort were the main results of the study. A durable weight loss is present in the surgical group with a mean (SD) 10-year weight loss of 14.1 (7.7) kg (63.4 % EWL), better than the non-surgical group (mean (SD) = 0.4 (10.5) kg; p < 0.001). The metabolic syndrome was reduced from 14 to 4 of the 37 patients who completed 10 years within the LAGB groups. Proximal gastric enlargements occurred in 17 (30 %) of the 57 who had LAGB and removal of the band occurred in 7 (12 %). The annual maintenance costs including additional surgery was AUD $765 per patient per year.

CONCLUSIONS

Bariatric surgery with the LAGB can achieve long-term weight reduction which is better than a program of non-surgical therapy. There is also a sustained reduction of the metabolic syndrome. There is a significant maintenance requirement after LAGB.

Implementing laparoscopy in Brazil's National Public Health System: the bariatric surgeons' point of view

BACKGROUND

Although Brazilian National Public Health System (BNPHS) has presented advances regarding the treatment for obesity in the last years, there is a repressed demand for bariatric surgeries in the country. Despite favorable evidences to laparoscopy, the BNPHS only performs this procedure via laparotomy.

AIM

1) Estimate whether bariatric surgeons would support the idea of incorporating laparoscopic surgery in the BNPHS; 2) If there would be an increase in the total number of surgeries performed; 3) As well as how BNPHS would redistribute both procedures.

METHODS

A panel of bariatric surgeons was built. Two rounds to answer the structured Delphi questionnaire were performed.

RESULTS

From the 45 bariatric surgeons recruited, 30 (66.7%) participated in the first round. For the second (the last) round, from the 30 surgeons who answered the first round, 22 (48.9%) answered the questionnaire. Considering the possibility that BNPHS incorporated laparoscopic surgery, 95% of surgeons were interested in performing it. Therefore, in case laparoscopic surgery was incorporated by the BNPHS there would be an average increase of 25% in the number of surgeries and they would be distributed as follows: 62.5% via laparoscopy and 37.5% via laparotomy.

CONCLUSION

1) There was a preference by laparoscopy; 2) would increase the number of operations compared to the current model in which only the laparotomy is available to users of the public system; and 3) the distribution in relation to the type of procedure would be 62.5% and 37.5% for laparoscopy laparotomy.

The business case for bariatric surgery revisited: a non-randomized case-control study

BACKGROUND AND AIM

Prior studies reporting that bariatric surgery (including laparoscopic adjustable gastric band (LAGB) and [laparoscopic Roux-en-Y] Gastric Bypass (LRYGB)) is cost-saving relied on a comparison sample of those with a morbid obesity (MO) diagnosis code, a high cost group who may not be reflective of those who opt for the procedures. We re-estimate net costs and time to breakeven using an alternative sample that does not rely on this code.

MATERIALS AND METHODS

Non-randomized case-control study using medical claims data from a commercial database in the USA. LAGB and LRYGB claimants were propensity score matched to two control samples: one restricted to those with a MO diagnosis code and one without this restriction.

RESULTS

When using the MO sample, costs for LAGB and LRYGB are recovered in 1.5 (Confidence Interval [CI]: 1.45 to 1.55) and 2.25 years (CI: 2.07 to 2.43), and 5 year savings are $78,980 (CI: 62,320 to 100,550) for LAGB and $61,420 (CI: 44,710 to 82,870) for LRYGB. Without the MO requirement, time to breakeven for LAGB increases to 5.25 (CI: 4.25 to 10+) years with a 5 year net cost of $690 (CI: 6,800 to 8.400). For LRYGB, time to breakeven exceeds 10 years and 5 year net costs are $18,940 (CI: 10,390 to 26,740).

CONCLUSIONS

The net costs and time to breakeven resulting from bariatric surgery are likely less favorable than has been reported in prior studies, and especially for LRYGB, with a time to breakeven of more than twice the 5.25 year estimate for LAGB.

The cost-effectiveness of laparoscopic adjustable gastric banding in the morbidly obese adult population of Australia

BACKGROUND

To examine the cost-effectiveness of providing laparoscopic adjustable gastric banding (LAGB) surgery to all morbidly obese adults in the 2003 Australian population.

METHODS AND FINDINGS

Analyzed costs and benefits associated with two intervention scenarios, one providing LAGB surgery to individuals with BMI >40 and another to individuals with BMI >35, with each compared relative to a 'do nothing' scenario. A multi-state, multiple cohort Markov model was used to determine the cost-effectiveness of LAGB surgery over the lifetime of each cohort. All costs and health outcomes were assessed from an Australian health sector perspective and were discounted using a 3% annual rate. Uncertainty and sensitivity analyzes were conducted to test the robustness of model outcomes. Incremental cost-effectiveness ratios (ICERs) were measured in 2003 Australian dollars per disability adjusted life year (DALY) averted. The ICER for the scenario providing LAGB surgery to all individuals with a BMI >40 was dominant [95% CI: dominant -$588] meaning that the intervention led to both improved health and cost savings. The ICER when providing surgery to those with a BMI >35 was $2,154/DALY averted [95% CI: dominant -$6,033]. Results were highly sensitive to changes in the likelihood of long-term complications.

CONCLUSION

LAGB surgery is highly cost-effective when compared to the $50,000/DALY threshold for cost-effectiveness used in Australia. LAGB surgery also ranks highly in terms of cost-effectiveness when compared to other population-level interventions for weight loss in Australia. The results of this study are in line with other economic evaluations on LAGB surgery. This study recommends that the Australian federal government provide a full subsidy for LAGB surgery to morbidly obese Australians with a BMI >40.

Evaluating the cost-effectiveness of laparoscopic adjustable gastric banding versus standard medical management in obese patients with type 2 diabetes in the UK

AIM

To evaluate the cost-effectiveness of laparoscopic adjustable gastric banding (LAGB) versus standard medical management (SMM) in obese patients with type 2 diabetes from a UK healthcare payer perspective.

METHODS

A validated computer model of diabetes was used to project outcomes reported from a randomized clinical trial of LAGB versus SMM in obese patients with type 2 diabetes. Two-year follow-up data from the trial were projected over a 40-year time horizon and cost-effectiveness was assessed from the perspective of the National Health Service. Future costs and clinical outcomes were discounted at 3.5% annually and all costs were reported in 2010 pounds sterling. A series of sensitivity analyses were performed.

RESULTS

LAGB was associated with benefits in HbA1c, systolic blood pressure, body mass index and serum lipid concentrations, which led to significant increases in discounted life expectancy (an increase of 0.64 years) and quality-adjusted life expectancy (an increase of 0.92 quality-adjusted life years, QALYs) and reduced incidence of diabetes complications relative to SMM. Treatment costs in the LAGB arm increased by 4552 Great British Pounds (GBP), but this was partially offset by cost savings resulting from a reduction in the incidence of all modelled diabetes complications. The incremental cost-effectiveness ratio of GBP 3602 per QALY in the base case fell well below commonly quoted willingness-to-pay thresholds in the UK setting.

CONCLUSIONS

On the basis of data from a recent randomized controlled trial, LAGB is likely to be considered cost-effective from the healthcare payer perspective when compared with SMM of obesity in patients with type 2 diabetes in the UK setting.

Bariatric surgery for adolescents

Obesity is no longer just an adult disease. An increasing number of youth are overweight, defined as body mass index (BMI) at or greater than the 95th percentile for age (1). Between 2009 and 2010, 16.9% of children aged 2–19 yr were classified as overweight based on BMI (2), as compared with only 5% of children affected by obesity in 1976–1980 (3). This is a problem of enormous proportion from a public health standpoint, as without intervention these children will grow up to become overweight and obese adults. For an obese child, the risk of becoming an obese adult may be as high as 77%, compared with 7%for a child of healthy weight (4). Morbid obesity is a major risk factor for later complications such as cardiovascular disease, type 2 diabetes, obstructive sleep apnea (OSA), polycystic ovary syndrome (PCOS), and degenerative joint disease (4–10). Obesity is also an expensive problem: the US government spends $147 billion yearly on obesity-related healthcare costs (11). Thus, there is an urgent need to target obesity in the pediatric population, before the expensive and life-threatening consequences of obesity manifest. Unfortunately, the effectiveness of medical treatments for obesity is limited. Behaviorally based dietary and physical activity interventions offer little benefit for pediatric obesity, while pharmacologic therapy is also limited and carries low success rates and recidivism (12–14) (Table 1).

Weight loss surgery for mild to moderate obesity: a systematic review and economic evaluation

BACKGROUND

A systematic review and economic evaluation was commissioned to determine the effectiveness and cost-effectiveness of bariatric surgery for mild [class I, body mass index (BMI) 30 to 34.99] or moderate (class II, BMI 35 to 39.99) obesity.

METHODS

We searched 17 electronic resources (to February 2010) and other sources. Studies meeting predefined criteria were identified, data-extracted and assessed for risk of bias using standard methodology. A model was developed to estimate cost-effectiveness.

RESULTS

Two RCTs were included. Evidence from both indicated a statistically significant benefit from laparoscopic adjustable banding (LAGB) compared to a non-surgical comparator for weight loss and in obesity-related comorbidity. Both interventions were associated with adverse events. LAGB costs more than non-surgical management. For people with class I or II obesity and type 2 diabetes (T2D), the incremental cost-effectiveness ratio (ICER) at 2 years is £20,159, reducing to £4,969 at 5 years and £1,634 at 20 years. Resolution of T2D makes the greatest contribution to this reduction. In people with class I obesity, the ICER is £63,156 at 2 years, £17,158 at 5 years, and £13,701 at 20 years. Cost-effectiveness results are particularly sensitive to utility gain from reduction in BMI, factors associated with poorer surgical performance and diabetes health state costs.

CONCLUSIONS

Bariatric surgery appears to be a clinically effective and cost-effective intervention for people with class I or II obesity who also have T2D but is less likely to be cost-effective for people with class I obesity.

Bariatric surgery or medicine for type 2 diabetes?

Diet and medical treatment are the standard treatment for type 2 diabetes. In obese subjects with type 2 diabetes, bariatric surgery is effective in resolving diabetes. Two clinical trials comparing bariatric surgery to medical treatment were evaluated. Both the Surgical Treatment And Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial (laparoscopic Roux-En Y gastric bypass and sleeve gastrectomy) and the DIet and medical therapy versus BAriatric SurgerY in type 2 diabetes (DIBASY) trial (laparoscopic gastric bypass and biliopancreatic-diversion) showed that surgery was more effective than medical care in resolving or managing type 2 diabetes. Larger studies, or a compilation of studies, are needed to determine whether one of these procedures is better, or if they are all similarly effective, and this should also be weighed against the risk of the operations.

Bariatric surgery: cost-effectiveness and budget impact

Bariatric surgery is to date the most effective treatment for morbid obesity and it has been proven to reduce obesity-related comorbidities and total mortality. As any medical treatment, bariatric surgery is costly and doubts about its affordability have been raised. On the other hand, bariatric surgery may reduce the direct and indirect costs of obesity and related comorbidities. The appreciation of the final balance between financial investments and savings is critical from a health economic perspective. In this paper, we try to provide a brief updated review of the most recent studies on the cost-efficacy of bariatric surgery, with particular emphasis on budget analysis. A brief overview of the economic costs of obesity will also be provided. The epidemic of obesity may cause a significant reduction in life expectancy and overwhelming direct and indirect costs for citizens and societies. Cost-efficacy analyses included in this review consistently demonstrated that the additional years of lives gained through bariatric surgery may be obtained at a reasonable and affordable cost. In groups of patients with very high obesity-related health costs, like patients with type 2 diabetes, the use of bariatric surgery required an initial economic investment, but may save money in a relatively short period of time.

Direct and indirect costs and potential cost savings of laparoscopic adjustable gastric banding among obese patients with diabetes

OBJECTIVE

To estimate the time to breakeven and 5-year net costs for laparoscopic adjustable gastric banding among obese patients with diabetes taking direct and indirect costs into account.

METHODS

Indirect cost savings were generated by quantifying the cross-sectional relationship between medical expenditures and absenteeism and between medical expenditures and presenteeism (reduced on-the-job productivity) and simulating indirect cost savings based on these multipliers and reductions in direct medical costs available in the literature.

RESULTS

Time to breakeven was estimated to be nine quarters with and without the inclusion of indirect costs. After 5 years, net savings increase from $26570 (±$9000) to $34160 (±$10 380) when indirect costs are included.

CONCLUSION

This study presented a novel approach for incorporating indirect costs into cost-benefit analyses. Application to gastric banding revealed that inclusion of indirect costs improves the financial outlook for the procedure.

A pathway to endoscopic bariatric therapies

The American Society for Gastrointestinal Endoscopy (ASGE) is dedicated to advancing patient care and digestive health by promoting excellence in gastrointestinal endoscopy. The American Society for Metabolic and Bariatric Surgery (ASMBS) is dedicated to improving public health and well-being by lessening the burden of the disease of obesity and related diseases. They are the largest professional societies for their respective specialties of gastrointestinal endoscopy and bariatric surgery in the world. The ASGE/ASMBS task force was developed to collaboratively address opportunities for endoscopic approaches to obesity, reflecting the strengths of our disciplines, to improve patient and societal outcomes. This white paper is intended to provide a framework for, and a pathway towards, the development, investigation, and adoption of safe and effective endoscopic bariatric therapies (EBT).

Laparoscopic Roux-en-Y gastric bypass for the treatment of type II diabetes mellitus in Chinese patients with body mass index of 25-35

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) can dramatically ameliorate type 2 diabetes mellitus (T2DM) in morbidly obese patients. However, there is little evidence supporting the effectiveness of LRYGB in low body mass index (BMI) patients. The study was designed to evaluate the safety and results of LRYGB for achieving T2DM remission in patients with BMI in the range of 25-35 kg/m(2).

METHODS

Twenty-two patients (two men and 20 women) with T2DM underwent LRYGB. Data on patient demographics, BMI, co-morbidities, and details of diabetes mellitus, including disease duration, family history, medication use, and remission, were prospectively collected and analyzed.

RESULTS

The mean age was 47 years (range, 28-63 years), mean BMI was 30.81 (range, 25.00-34.80 kg/m(2)), and mean duration of T2DM onset was 6.57 years (range, 1-20 years). Sixteen (72.27%) patients had a family history of T2DM. There was no mortality, but two (9%) patients experienced complications: an early gastrojejunostomy hemorrhage and frequent loose stools that required revision surgery. At 12 months, 14 (63.6%) patients showed T2DM remission, six (27.3%) showed glycemic control, and two (9.1%) showed improvement. The group achieving remission had a higher BMI (p = 0.001), younger age (p = 0.002), and shorter duration of diabetes (p = 0.001). These three factors may be predictors of diabetes resolution at 12 months.

CONCLUSION

Early intervention in low-BMI patients yields better remission rates because age, BMI, and duration of T2DM predict glycemic outcomes.

Distension-induced gastric contraction is attenuated in an experimental model of gastric restraint

BACKGROUND

Gastric distension has important implications for motility and satiety. The hypothesis of this study was that distension affects the amplitude and duration of gastric contraction and that these parameters are largely mediated by efferent vagus stimulation.

METHODS

A novel isovolumic myograph was introduced to test these hypotheses. The isovolumic myograph isolates the stomach and records the pressure generated by the gastric contraction under isovolumic conditions. Accordingly, the phasic changes of gastric contractility can be documented. A group of 12 rats were used under in vivo conditions and isolated ex vivo conditions and with two different gastric restraints (small and large) to determine the effect of degree of restraint.

RESULTS

The comparison of the in vivo and ex vivo contractility provided information on the efferent vagus mediation of gastric contraction, i.e., the in vivo amplitude and duration reached maximum of 12.6 ± 2.7 mmHg and 19.8 ± 5.6 s in contrast to maximum of 5.7 ± 0.9 mmHg and 7.3 ± 1.3 s in ex vivo amplitude and duration, respectively. The comparison of gastric restraint and control groups highlights the role of distension on in vivo gastric contractility. The limitation of gastric distension by restraint drastically reduced the maximal amplitude to below 2.9 ± 0.2 mmHg.

CONCLUSIONS

The results show that distension-induced gastric contractility is regulated by both central nervous system and local mechanisms with the former being more substantial. Furthermore, the gastric restraint significantly attenuates gastric contractility (decreased amplitude and shortened duration of contraction) which is mediated by the efferent vagus activation. These findings have important implications for gastric motility and physiology and may improve our understanding of satiety.

Preoperative factors predicting remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass surgery for obesity

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective treatment for morbid obesity. This bariatric procedure has also been noted to resolve hyperglycaemia in up to 70% of obese diabetics. We evaluated outcomes in diabetic patients undergoing RYGB in our institution, aiming to identify factors predicting diabetes remission.

METHODS

One hundred ten type 2 diabetic (T2DM) patients undergoing RYGB were studied. Baseline demographics, diabetic status pre- and post-surgery and outcomes were evaluated. Outcomes were compared to a matched non-diabetic cohort.

RESULTS

The mean age of the patients was 45 +/- 11. The majority (70%; n = 77) were female and the mean baseline body mass index was 47 +/- 7. Mean (+/-SD range) excess weight loss at 6, 12 and 24 months was 58.3 +/- 26.4% (30.5-167%), 63.2 +/- 17.2% (0-99.2%) and 84.1 +/- 21.3% (16.5-121%), respectively. Diabetic medication was discontinued in 68.4% patients and reduced in a further 14.3%. Mean preoperative HbA1c was 7.1 +/- 2.0 and mean postoperative HbA1c 5.48 +/- 0.2. Patients with a baseline HbA1c >10 had a 50% rate of remission compared to 77.3% with an HbA1c of 6.5-7.9. The mean duration of T2DM preoperatively was 5.5 +/- 7 years. A preoperative duration of T2DM greater than 10 years was shown to significantly reduce the chances of remission (p = 0.005).

CONCLUSIONS

RYGB for morbid obesity achieves significant weight reduction in diabetic patients with remission of pre-surgical hyperglycaemia in the majority. The study supports findings that a shorter duration and better control of diabetes prior to surgery corresponds to a higher rate of remission. It supports the argument for early surgical intervention in the morbidly obese diabetic patient.

An Anticipatory Geriatric Strategy: To Better Care for Those Americans Not Yet Old

Current US public policy decisions will have impact on national plans to care for the aging American baby boomer population over the next several decades. The recent health care legislative debate has been largely about the structure of health care for those still too young to be covered by Medicare, but the legislation may have important implications for the average rates of accumulating chronic illness and disability in midlife and influence the care needs for that cohort of individuals even after they become elderly.