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Poirier P. Impact of Bariatric Surgery on Coronary Microvascular Function: When Lower Weight Means Better Flow! JACC Cardiovasc Imaging 2024:S1936-878X(24)00348-6. [PMID: 39365238 DOI: 10.1016/j.jcmg.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Accepted: 08/07/2024] [Indexed: 10/05/2024]
Affiliation(s)
- Paul Poirier
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec, Canada; Laval University, Faculty of Pharmacy, Quebec, Canada.
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Courcoulas AP, Patti ME, Hu B, Arterburn DE, Simonson DC, Gourash WF, Jakicic JM, Vernon AH, Beck GJ, Schauer PR, Kashyap SR, Aminian A, Cummings DE, Kirwan JP. Long-Term Outcomes of Medical Management vs Bariatric Surgery in Type 2 Diabetes. JAMA 2024; 331:654-664. [PMID: 38411644 PMCID: PMC10900968 DOI: 10.1001/jama.2024.0318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 01/10/2024] [Indexed: 02/28/2024]
Abstract
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.
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Affiliation(s)
| | - Mary Elizabeth Patti
- Research Division, Joslin Diabetes Center, and Harvard Medical School, Boston, Massachusetts
| | - Bo Hu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | | | - Donald C. Simonson
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - William F. Gourash
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John M. Jakicic
- Department of Internal Medicine, Division of Physical Activity and Weight Management, University of Kansas Medical Center, Kansas City
| | - Ashley H. Vernon
- Division of General & GI Surgery, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Gerald J. Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Philip R. Schauer
- Metamor Institute, Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | - Sangeeta R. Kashyap
- Weill Cornell Medicine-New York Presbyterian, Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, New York, New York
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | - David E. Cummings
- Department of Medicine, University of Washington and VA Puget Sound Health Care System, Seattle
| | - John P. Kirwan
- Pennington Biomedical Research Center, Baton Rouge, Louisiana
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Rouhi AD, Choudhury RA, Hoeltzel GD, Ghanem YK, Bababekov YJ, Suarez-Pierre A, Yule A, Vigneshwar NG, Williams NN, Dumon KR, Nydam TL. Ventricular Remodeling Following Metabolic and Bariatric Surgery Decreases Need for Heart Transplantation: A Predictive Model. Obes Surg 2024; 34:15-21. [PMID: 38017330 DOI: 10.1007/s11695-023-06948-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 11/03/2023] [Accepted: 11/13/2023] [Indexed: 11/30/2023]
Abstract
PURPOSE For patients with obesity and congestive heart failure (CHF) who require heart transplantation (HT), aggressive weight loss has been associated with ventricular remodeling, or subclinical alterations in left and right ventricular structure that affect systolic function. Many have suggested offering metabolic and bariatric surgery (MBS) for these patients. As such, we evaluated the role of MBS in HT for patients with obesity and CHF using predictive modelling techniques. MATERIALS AND METHODS Markov decision analysis was performed to simulate the life expectancy of 30,000 patients with concomitant obesity, CHF, and 30% ejection fraction (EF) who were deemed ineligible to be waitlisted for HT unless they achieved a BMI < 35 kg/m2. Life expectancy following diet and exercise (DE), Roux-en-Y gastric bypass (RYGB), and sleeve gastrectomy (SG) was estimated. Base case patients were defined as having a pre-intervention BMI of 45 kg/m2. Sensitivity analysis of initial BMI was performed. RESULTS RYGB patients had lower rates of HT and received HT quicker when needed. Base case patients who underwent RYGB gained 2.2 additional mean years survival compared with patients who underwent SG and 10.3 additional mean years survival compared with DE. SG patients gained 6.2 mean years of life compared with DE. CONCLUSION In this simulation of 30,000 patients with obesity, CHF, and reduced EF, MBS was associated with improved survival by not only decreasing the need for transplantation due to improvements in EF, but also increasing access to HT when needed due to lower average BMI.
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Affiliation(s)
- Armaun D Rouhi
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Rashikh A Choudhury
- Division of Transplantation, Department of Surgery, University of Colorado Hospital, Aurora, CO, USA
| | - Gerard D Hoeltzel
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Yazid K Ghanem
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Yanik J Bababekov
- Division of Transplantation, Department of Surgery, University of Colorado Hospital, Aurora, CO, USA
| | - Alejandro Suarez-Pierre
- Division of Transplantation, Department of Surgery, University of Colorado Hospital, Aurora, CO, USA
| | - Arthur Yule
- Division of Transplantation, Department of Surgery, University of Colorado Hospital, Aurora, CO, USA
| | - Navin G Vigneshwar
- Division of Transplantation, Department of Surgery, University of Colorado Hospital, Aurora, CO, USA
| | - Noel N Williams
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kristoffel R Dumon
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Trevor L Nydam
- Division of Transplantation, Department of Surgery, University of Colorado Hospital, Aurora, CO, USA
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Poirier P. Comment on: Bariatric surgery improves outcomes of hospitalizations for acute heart failure: a contemporary, nationwide analysis. Surg Obes Relat Dis 2023; 19:688-689. [PMID: 36759273 DOI: 10.1016/j.soard.2022.12.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 12/27/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Paul Poirier
- Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec, Quebec, Canada
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Efficacy of Bariatric Surgery in COVID-19 Patients: An Updated Systematic Review and Meta-Analysis. SURGERY IN PRACTICE AND SCIENCE 2022; 11:100140. [PMID: 36337713 PMCID: PMC9616481 DOI: 10.1016/j.sipas.2022.100140] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/17/2022] [Accepted: 10/20/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Obesity is linked with poor prognostic outcomes in patients with SARS-CoV-2 infection. In patients with BMI>35 kg/m2, increased rates of hospital and subsequently ICU admissions have been noted. Bariatric surgery resulting in sustained weight loss is hypothesized to decrease the morbid outcomes associated with COVID. In this review, we planned to update the evidence on the topic presented by Aminian et al. Methods An extensive literature search was conducted of the electronic databases. Screening of the articles based on the eligibility criteria was followed by relevant data extraction. Other than the articles used in the previous meta-analysis, relevant databases were searched to filter for any new articles. Initially, two independent reviewers screened Pubmed and Cochrane database followed by a thorough search of additional databases such as Google scholar and Medrxiv. The articles were first screened using title and abstract, followed by a full text read. Duplicates, meta-analysis, letter to the editors, and commentaries were excluded. No language restrictions were placed. Results A total of nine articles with a population of 1,130,341 were entered into the RevMan. Patients with bariatric surgery were significantly associated with decreased hospitalizations (OR: 0.52, 95% CI [0.45, 0.61]), less likely to be admitted to the ICU (OR: 0.44, 95% CI [0.29,0.67]), and reported reduced overall mortality (OR: 0.42, 95% CI [0.25, 0.70]). Conclusion Surgically induced weight loss is more beneficial in reducing the morbidity and mortality burden of COVID-19. More studies are needed to stratify the effect of demographics and metabolic profiles on disease progression.
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Kirwan JP, Courcoulas AP, Cummings DE, Goldfine AB, Kashyap SR, Simonson DC, Arterburn DE, Gourash WF, Vernon AH, Jakicic JM, Patti ME, Wolski K, Schauer PR. Diabetes Remission in the Alliance of Randomized Trials of Medicine Versus Metabolic Surgery in Type 2 Diabetes (ARMMS-T2D). Diabetes Care 2022; 45:1574-1583. [PMID: 35320365 PMCID: PMC9490448 DOI: 10.2337/dc21-2441] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/22/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The overall aim of the Alliance of Randomized Trials of Medicine versus Metabolic Surgery in Type 2 Diabetes (ARMMS-T2D) consortium is to assess the durability and longer-term effectiveness of metabolic surgery compared with medical/lifestyle management in patients with type 2 diabetes (NCT02328599). RESEARCH DESIGN AND METHODS A total of 316 patients with type 2 diabetes previously randomly assigned to surgery (N = 195) or medical/lifestyle therapy (N = 121) in the STAMPEDE, TRIABETES, SLIMM-T2D, and CROSSROADS trials were enrolled into this prospective observational cohort. The primary outcome was the rate of diabetes remission (hemoglobin A1c [HbA1c] ≤6.5% for 3 months without usual glucose-lowering therapy) at 3 years. Secondary outcomes included glycemic control, body weight, biomarkers, and comorbidity reduction. RESULTS Three-year data were available for 256 patients with mean 50 ± 8.3 years of age, BMI 36.5 ± 3.6 kg/m2, and duration of diabetes 8.8 ± 5.7 years. Diabetes remission was achieved in more participants following surgery than medical/lifestyle intervention (60 of 160 [37.5%] vs. 2 of 76 [2.6%], respectively; P < 0.001). Reductions in HbA1c (Δ = -1.9 ± 2.0 vs. -0.1 ± 2.0%; P < 0.001), fasting plasma glucose (Δ = -52 [-105, -5] vs. -12 [-48, 26] mg/dL; P < 0.001), and BMI (Δ = -8.0 ± 3.6 vs. -1.8 ± 2.9 kg/m2; P < 0.001) were also greater after surgery. The percentages of patients using medications to control diabetes, hypertension, and dyslipidemia were all lower after surgery (P < 0.001). CONCLUSIONS Three-year follow-up of the largest cohort of randomized patients followed to date demonstrates that metabolic/bariatric surgery is more effective and durable than medical/lifestyle intervention in remission of type 2 diabetes, including among individuals with class I obesity, for whom surgery is not widely used.
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Affiliation(s)
- John P Kirwan
- Cleveland Clinic, Cleveland, OH.,Pennington Biomedical Research Center, Baton Rouge, LA
| | | | - David E Cummings
- University of Washington, Seattle, WA.,VA Puget Sound Health Care System, Seattle, WA
| | | | | | - Donald C Simonson
- Harvard Medical School, Boston, MA.,Brigham and Women's Hospital, Boston, MA
| | | | | | - Ashley H Vernon
- Harvard Medical School, Boston, MA.,Brigham and Women's Hospital, Boston, MA
| | | | | | | | - Philip R Schauer
- Cleveland Clinic, Cleveland, OH.,Pennington Biomedical Research Center, Baton Rouge, LA
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Stenberg E, Cao Y, Jernberg T, Näslund E. Safety of bariatric surgery in patients with previous acute coronary events or heart failure: nationwide cohort study. BJS Open 2022; 6:6604476. [PMID: 35676239 PMCID: PMC9177412 DOI: 10.1093/bjsopen/zrac083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/26/2022] [Accepted: 05/16/2022] [Indexed: 11/30/2022] Open
Abstract
Background Metabolic (bariatric) surgery for patients with severe obesity and pre-existing heart disease has been reported to reduce the risk for cardiovascular events and mortality; however, concerns of short- and mid-term complications may limit the utility of metabolic surgery for these patients. Method This was an observational, nationwide, matched study, including all adult patients operated with a primary gastric bypass or sleeve gastrectomy procedure in Sweden from January 2011 until October 2020. Patients with or without previous acute coronary syndrome or heart failure were matched 1:5 using propensity scores. The primary outcome was serious postoperative complications, and secondary outcomes were the occurrence of any short-term complications, mid-term complications, weight loss, and health-related quality of life estimates after surgery Results Of patients who underwent metabolic surgery, 1165 patients with previous acute coronary syndrome or heart failure and 5825 without diagnosed heart disease were included in matched analyses. No difference was seen between the groups at risk for serious postoperative complications within 30 days of surgery (OR 1.33, 95 per cent c.i. 0.95 to 1.86, P = 0.094), whereas heart disease was associated with an increased risk for cardiovascular complications (incidence 1.1 per cent versus 0.2 per cent, P < 0.001). No differences in overall mid-term complications, weight loss, or improvement of health-related quality of life were seen. Pre-existing heart disease was associated with an increased risk for bowel obstruction and strictures (OR 1.89, 95 per cent c.i. 1.20 to 2.99, P = 0.006). Conclusion Patients with severe obesity and heart disease undergoing metabolic surgery have an increased risk of postoperative cardiovascular complications compared with patients with severe obesity without heart disease. A careful preoperative cardiovascular work-up is needed but patients with severe obesity and heart disease should not be excluded from undergoing metabolic surgery.
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Affiliation(s)
- Erik Stenberg
- Department of Surgery, Faculty of Medicine and Health, Örebro University , Örebro , Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University , Örebro , Sweden
| | - Tomas Jernberg
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet , Stockholm , Sweden
| | - Erik Näslund
- Division of Surgery, Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet , Stockholm , Sweden
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8
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Stenberg E, Cao Y, Jernberg T, Näslund E. Major cardiovascular events after metabolic surgery in patients with previous heart disease with or without type 2 diabetes - a nationwide cohort study. Surg Obes Relat Dis 2022; 18:935-942. [DOI: 10.1016/j.soard.2022.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 03/28/2022] [Accepted: 04/09/2022] [Indexed: 01/12/2023]
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Aminian A, Wilson R, Zajichek A, Tu C, Wolski KE, Schauer PR, Kattan MW, Nissen SE, Brethauer SA. Cardiovascular Outcomes in Patients With Type 2 Diabetes and Obesity: Comparison of Gastric Bypass, Sleeve Gastrectomy, and Usual Care. Diabetes Care 2021; 44:2552-2563. [PMID: 34503954 DOI: 10.2337/dc20-3023] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 07/29/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine which one of the two most common metabolic surgical procedures is associated with greater reduction in risk of major adverse cardiovascular events (MACE) in patients with type 2 diabetes mellitus (T2DM) and obesity. RESEARCH DESIGN AND METHODS A total of 13,490 patients including 1,362 Roux-en-Y gastric bypass (RYGB), 693 sleeve gastrectomy (SG), and 11,435 matched nonsurgical patients with T2DM and obesity who received their care at the Cleveland Clinic (1998-2017) were analyzed, with follow-up through December 2018. With multivariable Cox regression analysis we estimated time to incident extended MACE, defined as first occurrence of coronary artery events, cerebrovascular events, heart failure, nephropathy, atrial fibrillation, and all-cause mortality. RESULTS The cumulative incidence of the primary end point at 5 years was 13.7% (95% CI 11.4-15.9) in the RYGB groups and 24.7% (95% CI 19.0-30.0) in the SG group, with an adjusted hazard ratio (HR) of 0.77 (95% CI 0.60-0.98, P = 0.04). Of the six individual end points, RYGB was associated with a significantly lower cumulative incidence of nephropathy at 5 years compared with SG (2.8% vs. 8.3%, respectively; HR 0.47 [95% CI 0.28-0.79], P = 0.005). Furthermore, RYGB was associated with a greater reduction in body weight, glycated hemoglobin, and use of medications to treat diabetes and cardiovascular diseases. Five years after RYGB, patients required more upper endoscopy (45.8% vs. 35.6%, P < 0.001) and abdominal surgical procedures (10.8% vs. 5.4%, P = 0.001) compared with SG. CONCLUSIONS In patients with obesity and T2DM, RYGB may be associated with greater weight loss, better diabetes control, and lower risk of MACE and nephropathy compared with SG.
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Affiliation(s)
- Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Rickesha Wilson
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | - Alexander Zajichek
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Chao Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Kathy E Wolski
- Cleveland Clinic Coordinating Center for Clinical Research, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | | | - Michael W Kattan
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Steven E Nissen
- Cleveland Clinic Coordinating Center for Clinical Research, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Stacy A Brethauer
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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Effect of Bariatric Surgery on Survival and Hospitalizations in Patients with Severe Obesity. A Retrospective Cohort Study. Nutrients 2021; 13:nu13093150. [PMID: 34579025 PMCID: PMC8464847 DOI: 10.3390/nu13093150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/02/2021] [Accepted: 09/06/2021] [Indexed: 11/17/2022] Open
Abstract
Bariatric surgery (BS) confers a survival benefit in specific subsets of patients with severe obesity; otherwise, effects on hospital admissions are still uncertain. We assessed the long-term effect on mortality and on hospitalization of BS in patients with severe obesity. This was a retrospective cohort study, including all patients residing in Piedmont (age 18-60 years, BMI ≥ 40 kg/m2) admitted during 2002-2018 to the Istituto Auxologico Italiano. Adjusted hazard ratios (HR) for BS were estimated for mortality and hospitalization, considering surgery as a time-varying variable. Out of 2285 patients, 331 (14.5%) underwent BS; 64.4% received sleeve gastrectomy (SG), 18.7% Roux-en-Y gastric bypass (RYGB), and 16.9% adjustable gastric banding (AGB). After 10-year follow-up, 10 (3%) and 233 (12%) patients from BS and non-BS groups died, respectively (HR = 0.52; 95% CI 0.27-0.98, by a multivariable Cox proportional-hazards regression model). In patients undergoing SG or RYGB, the hospitalization probability decreased significantly in the after-BS group (HR = 0.77; 0.68-0.88 and HR = 0.78; 0.63-0.98, respectively) compared to non-BS group. When comparing hospitalization risk in the BS group only, a marked reduction after surgery was found for all BS types. In conclusion, BS significantly reduced the risk of all-cause mortality and hospitalization after 10-year follow-up.
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Aminian A, Kashyap SR, Wolski KE, Brethauer SA, Kirwan JP, Nissen SE, Bhatt DL, Schauer PR. Patient-reported Outcomes After Metabolic Surgery Versus Medical Therapy for Diabetes: Insights From the STAMPEDE Randomized Trial. Ann Surg 2021; 274:524-532. [PMID: 34132694 PMCID: PMC8373787 DOI: 10.1097/sla.0000000000005003] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the long-term effects of medical and surgical treatments of type 2 diabetes mellitus (T2DM) on patient-reported outcomes (PROs). BACKGROUND Robust data on PROs from randomized trials comparing medical and surgical treatments for T2DM are lacking. METHODS The Surgical Treatment And Medications Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial showed that 5 years after randomization, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) were superior to intensive medical therapy (IMT) alone in achieving glycemic control in patients with T2DM and obesity. A subset of 104 patients participating in the STAMPEDE trial were administered two generic health-related quality of life (QoL) questionnaires (RAND-36 and EQ-5D-3L) and a diabetes-specific instrument at baseline, and then on an annual basis up to 5 years after randomization. RESULTS On longitudinal analysis, RYGB and SG significantly improved the domains of physical functioning, general health perception, energy/fatigue, and diabetes-related QoL compared with IMT group. In the IMT group, none of the QoL components in the generic questionnaires improved significantly from baseline. No significant long-term differences were observed among the study groups in measures of psychological and social aspects of QoL. On multivariable analysis, independent factors associated with improved general health perception at long-term included baseline general health (P < 0.001), insulin independence at 5 years (P = 0.005), RYGB versus IMT (P = 0.005), and SG versus IMT (P = 0.034). Favorable changes following RYGB and SG were comparable. CONCLUSIONS In patients with T2DM, metabolic surgery is associated with long-term favorable changes in certain PROs compared with IMT, mainly on physical health and diabetes-related domains. Psychosocial well-being warrants greater attention after metabolic surgery.
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Affiliation(s)
- Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Kathy E. Wolski
- Cleveland Clinic Coordinating Center for Clinical Research, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Stacy A. Brethauer
- Department of Surgery, Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Steven E. Nissen
- Cleveland Clinic Coordinating Center for Clinical Research, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA
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Guerrón AD, Davis GM, Pasquel FJ. Advances in Pharmacotherapeutics, Metabolic Surgery, and Technology for Diabetes. Endocrinol Metab Clin North Am 2021; 50:457-474. [PMID: 34399956 DOI: 10.1016/j.ecl.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Remarkable advances in diabetes management have occurred since the discovery of insulin 100 years ago. Advances across a therapeutic spectrum, including pharmacotherapy, metabolic surgery, and diabetes technology, offer superior treatment options for diabetes management. New medication classes (glucagon-like peptide-1 receptor analogs and SGLT-2 inhibitors) have demonstrated cardiorenal benefits beyond glycemic control in type 2 diabetes mellitus, while evolving metabolic surgical interventions also help patients achieve diabetes remission. The use of artificial pancreas systems has shown consistent improvement in glycemic control in type 1 diabetes mellitus. It is time for policy changes to expand access to such advantageous therapies.
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Affiliation(s)
- Alfredo Daniel Guerrón
- Division of Metabolic and Bariatric Surgery, Duke University, 407 Crutchfield Street, Durham, NC 27704, USA
| | - Georgia M Davis
- Division of Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Drive SE, GA 30030, USA
| | - Francisco J Pasquel
- Division of Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Drive SE, GA 30030, USA.
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Arterburn D, Aminian A, Nissen S, Schauer P, Haneuse S. Bias in electronic health record-based studies: Seeing the forest for the trees. Diabetes Obes Metab 2021; 23:1692-1693. [PMID: 33852201 DOI: 10.1111/dom.14403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 03/30/2021] [Accepted: 04/08/2021] [Indexed: 11/26/2022]
Affiliation(s)
- David Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | | | | | - Phil Schauer
- Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
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Albaugh VL, Kindel TL, Nissen SE, Aminian A. Cardiovascular Risk Reduction Following Metabolic and Bariatric Surgery. Surg Clin North Am 2021; 101:269-294. [PMID: 33743969 DOI: 10.1016/j.suc.2020.12.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality in developed countries, with worsening pandemics of type 2 diabetes mellitus and obesity as major cardiovascular (CV) risk factors. Clinical trials of nonsurgical obesity treatments have not shown benefits in CVD, although recent diabetes trials have demonstrated major CV benefits. In many retrospective and prospective cohort studies, however, metabolic (bariatric) surgery is associated with substantial and reproducible CVD benefits. Despite a lack of prospective, randomized clinical trials, data suggest metabolic surgery may be the most effective modality for CVD risk reduction, likely through weight loss and weight loss-independent mechanisms.
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Affiliation(s)
- Vance L Albaugh
- Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tammy L Kindel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Steven E Nissen
- Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ali Aminian
- Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH 44195, USA.
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Preventing Diabetes and Atherosclerosis in the Cardiometabolic Syndrome. Curr Atheroscler Rep 2021; 23:16. [PMID: 33686460 DOI: 10.1007/s11883-021-00913-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Cardiometabolic syndrome is characterized by abdominal adiposity, insulin resistance, hypertension, and dyslipidemia. There is a growing burden of cardiometabolic disease in many parts of the world. This review highlights the critical preventive and therapeutic measures that need to be implemented to reduce the impact of cardiometabolic syndrome on cardiovascular health. RECENT FINDINGS Recent cardiovascular outcome trials demonstrated that newer glucose-lowering medications reduce cardiovascular and renal events in patients with type 2 diabetes mellitus (T2DM). These medications should be considered in patients with T2DM and atherosclerotic cardiovascular disease (ASCVD). These novel drugs may also play a role in primary prevention of cardiovascular disease (CVD) and renal disease in high-risk patients without T2DM. To manage dyslipidemia associated with cardiometabolic syndrome, in addition to lifestyle interventions and statin therapy, ezetimibe, and proprotein convertase subtilisin/Kexin type 9 (PCSK9), inhibitors can be used to reduce the risk of major adverse cardiovascular outcomes (MACE) especially in patients with T2DM and coronary artery disease (CAD). The residual risk of MACE in such a high-risk population can be further mitigated by treatment with an omega-3 fatty acid such as icosapent ethyl. Lifestyle modifications and the use of proven pharmacological therapies are essential for the prevention and progression of diabetes and ASCVD in those with the cardiometabolic syndrome.
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Wilson R, Aminian A, Tahrani AA. Metabolic surgery: A clinical update. Diabetes Obes Metab 2021; 23 Suppl 1:63-83. [PMID: 33621412 DOI: 10.1111/dom.14235] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/11/2020] [Accepted: 10/23/2020] [Indexed: 02/06/2023]
Abstract
Metabolic and bariatric surgery has grown beyond 'experimental' weight-loss surgery. As techniques have advanced over the last few decades, so has the growing body of research and evidence, proving that both weight-loss and metabolic health improvement are induced. Metabolic surgery has become the more appropriate term for weight-loss surgery because of the altered gastrointestinal anatomy and subsequent beneficial metabolic effects. Although the tool of metabolic surgery has been well refined, a large portion of the global population does not have adequate access to it. This clinical update aims to (a) inform healthcare providers from all disciplines about the myriad of benefits of metabolic surgery and (b) equip them with the necessary knowledge to bridge the gap between patients in need of metabolic treatment and the therapies in metabolic surgery available to them.
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Key Words
- adjustable gastric banding, atrial fibrillation, bariatric surgery, cancer, cardiovascular disease, gastric bypass, heart failure, hypertension, mortality, obesity, obstructive sleep apnoea, reflux disease, sleeve gastrectomy, type 2 diabetes
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Affiliation(s)
- Rickesha Wilson
- Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ali Aminian
- Department of General Surgery, Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham, UK
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism (CEDAM), Birmingham Health Partners, Birmingham, UK
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Association of Bariatric Surgery with Clinical Outcomes of SARS-CoV-2 Infection: a Systematic Review and Meta-analysis in the Initial Phase of COVID-19 Pandemic. Obes Surg 2021; 31:2419-2425. [PMID: 33420671 PMCID: PMC7792914 DOI: 10.1007/s11695-020-05213-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 12/24/2022]
Abstract
Introduction Obesity worsens clinical outcomes of coronavirus disease 2019 (COVID-19). The aim of this study was to measure the association between history of bariatric surgery and the severity of COVID-19. Methods Data source included PubMed/MEDLINE, Scopus, Google Scholar, and pre-print servers between January and November 1, 2020. Literature was screened and selected to extract the relevant data. The two outcomes of this meta-analysis were the difference in mortality and hospitalization rates in patients with SARS-CoV-2 infection with and without history of bariatric surgery. Random-effect models were used to estimate the pooled effects. Results The systematic review yielded 3 retrospective studies on 9022 patients. The risk of mortality without previous bariatric surgery was 133 per 1000 cases and its risk with previous bariatric surgery was 33 per 1000 (summary OR 0.22, 95% CI 0.19–0.26). No heterogeneity was observed between the included studies (I2 = 0%, P = 0.98 for heterogeneity). In the pooled analysis, the hospitalization rate in patients without previous bariatric surgery was 412 per 1000 cases and its rate in patients with previous bariatric surgery was 164 per 1000 (summary OR 0.28, 95% CI 0.12–0.65). No heterogeneity was observed between the included studies (I2 = 0%, P = 0.71 for heterogeneity). There was a substantial risk of bias across the studies for confounding and selection bias. Conclusion Findings of this meta-analysis of observational studies suggest that prior bariatric surgery is associated with a lower rate of mortality and hospital admission in patients with obesity who become infected with SARS-CoV-2. Confirmation of these findings will require larger studies with better quality data.
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Aminian A, Fathalizadeh A, Tu C, Butsch WS, Pantalone KM, Griebeler ML, Kashyap SR, Rosenthal RJ, Burguera B, Nissen SE. Association of prior metabolic and bariatric surgery with severity of coronavirus disease 2019 (COVID-19) in patients with obesity. Surg Obes Relat Dis 2020; 17:208-214. [PMID: 33243670 PMCID: PMC7682430 DOI: 10.1016/j.soard.2020.10.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 10/22/2020] [Accepted: 10/25/2020] [Indexed: 02/07/2023]
Abstract
Background Obesity is a risk factor for poor clinical outcomes in patients with coronavirus disease 2019 (COVID-19). Objectives To investigate the relationship between prior metabolic surgery and the severity of COVID-19 in patients with severe obesity. Setting Cleveland Clinic Health System in the United States. Methods Among 4365 patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) between March 8, 2020 and July 22, 2020 in the Cleveland Clinic Health System, 33 patients were identified who had a prior history of metabolic surgery. The surgical patients were propensity matched 1:10 to nonsurgical patients to assemble a cohort of control patients (n = 330) with a body mass index (BMI) ≥ 40 kg/m2 at the time of SARS-CoV-2 testing. The primary endpoint was the rate of hospital admission. The exploratory endpoints included admission to the intensive care unit (ICU), need for mechanical ventilation and dialysis during index hospitalization, and mortality. After propensity score matching, outcomes were compared in univariate and multivariate regression models. Results The average BMI of the surgical group was 49.1 ± 8.8 kg/m2 before metabolic surgery and was down to 37.2 ± 7.1 at the time of SARS-CoV-2 testing, compared with the control group’s BMI of 46.7 ± 6.4 kg/m2. In the univariate analysis, 6 (18.2%) patients in the metabolic surgery group and 139 (42.1%) patients in the control group were admitted to the hospital (P = .013). In the multivariate analysis, a prior history of metabolic surgery was associated with a lower hospital admission rate compared with control patients with obesity (odds ratio, 0.31; 95% confidence interval, 0.11−0.88; P = .028). While none of the 4 exploratory outcomes occurred in the metabolic surgery group, 43 (13.0%) patients in the control group required ICU admission (P = .021), 22 (6.7%) required mechanical ventilation, 5 (1.5%) required dialysis, and 8 (2.4%) patients died. Conclusion Prior metabolic surgery with subsequent weight loss and improvement of metabolic abnormalities was associated with lower rates of hospital and ICU admission in patients with obesity who became infected with SARS-CoV-2. Confirmation of these findings will require larger studies. Is there an association between prior metabolic surgery and severity of COVID-19 in patients with obesity? In this matched cohort study of 363 patients with COVID-19 (including 33 patients who underwent metabolic surgery and 330 matched controls with obesity), metabolic surgery was significantly associated with near three times lower odds of hospital admission (odds ratio 0.31, P=0.028). While none of the 4 exploratory outcomes occurred in the metabolic surgery group, 43 (13.0%) patients in the control group required ICU admission (P=0.021), 22 (6.7%) required mechanical ventilation, 5 (1.5%) required dialysis, and 8 (2.4%) patients died. Among patients with obesity, metabolic surgery was significantly associated with a lower risk of hospital and intensive care unit admission.
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Affiliation(s)
- Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio.
| | - Alisan Fathalizadeh
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Chao Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - W Scott Butsch
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kevin M Pantalone
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marcio L Griebeler
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sangeeta R Kashyap
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | - Raul J Rosenthal
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Weston, Florida
| | - Bartolome Burguera
- Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio
| | - Steven E Nissen
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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20
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How Much Weight Loss is Required for Cardiovascular Benefits? Insights From a Metabolic Surgery Matched-cohort Study. Ann Surg 2020; 272:639-645. [PMID: 32932320 DOI: 10.1097/sla.0000000000004369] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of this study was to determine the minimum amount of weight loss required to see a reduction in major adverse cardiovascular events (MACE). BACKGROUND Although obesity is an established risk factor for morbidity and mortality, the minimum amount of weight loss to have a meaningful impact on cardiovascular health and survival is unknown. METHODS Patients with obesity (body mass index ≥30 kg/m) and type 2 diabetes who underwent metabolic surgery in an academic center (1998-2017) were propensity-matched 1:5 to nonsurgical patients who received usual care. The adjusted linear and nonlinear effects of weight loss (achieved in the first 18 months after the index date) were studied to identify cut-offs for the minimum weight loss to achieve decreased risk of all-cause mortality and MACE (composite of all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation). RESULTS A total of 7201 patients (1223 surgical and 5978 nonsurgical) with a median follow-up time of 4.9 years (interquartile range, 3.5-7) were included. The positive effect of metabolic surgery was still present after adjusting for weight loss amounts, suggesting that there are weight loss-independent factors contributing to a reduction in risk of MACE and all-cause mortality in the surgical cohort. After considering the weighted estimates from a diverse set of models, the risk of MACE decreases after approximately 10% of weight is lost in the surgical group and approximately 20% in the nonsurgical group. For all-cause mortality, the threshold for benefit appeared to be approximately 5% weight loss after metabolic surgery and 20% in the nonsurgical group. CONCLUSIONS This large matched-cohort study identified the minimum weight loss thresholds for reduction in risk of MACE and all-cause mortality in patients with obesity and diabetes. Furthermore, in our analysis, the effect of surgery was still present after accounting for weight loss, which may suggest the presence of weight-independent beneficial effects of metabolic surgery on MACE and survival.
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Cummings DE, Rubino F, Schauer PR, Cohen RV. Bariatric and metabolic surgery during and after the COVID-19 pandemic - Authors' reply. Lancet Diabetes Endocrinol 2020; 8:743-744. [PMID: 32822597 PMCID: PMC7434384 DOI: 10.1016/s2213-8587(20)30279-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 07/28/2020] [Indexed: 11/26/2022]
Affiliation(s)
- David E Cummings
- University of Washington Medicine Diabetes Institute, University of Washington, Seattle, WA, USA; Weight Management Program, Veteran Affairs Puget Sound Health Care System, University of Washington, Seattle, WA, USA
| | - Francesco Rubino
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK; Bariatric and Metabolic Surgery, King's College Hospital, London, UK
| | - Philip R Schauer
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, USA
| | - Ricardo V Cohen
- Center for the treatment of Obesity and Diabetes, Oswaldo Cruz German Hospital, São Paulo, Brazil.
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22
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Rubino F, Cohen RV, Mingrone G, le Roux CW, Mechanick JI, Arterburn DE, Vidal J, Alberti G, Amiel SA, Batterham RL, Bornstein S, Chamseddine G, Del Prato S, Dixon JB, Eckel RH, Hopkins D, McGowan BM, Pan A, Patel A, Pattou F, Schauer PR, Zimmet PZ, Cummings DE. Bariatric and metabolic surgery during and after the COVID-19 pandemic: DSS recommendations for management of surgical candidates and postoperative patients and prioritisation of access to surgery. Lancet Diabetes Endocrinol 2020; 8:640-648. [PMID: 32386567 PMCID: PMC7252156 DOI: 10.1016/s2213-8587(20)30157-1] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 04/23/2020] [Accepted: 04/24/2020] [Indexed: 01/08/2023]
Abstract
The coronavirus disease 2019 pandemic is wreaking havoc on society, especially health-care systems, including disrupting bariatric and metabolic surgery. The current limitations on accessibility to non-urgent care undermine postoperative monitoring of patients who have undergone such operations. Furthermore, like most elective surgery, new bariatric and metabolic procedures are being postponed worldwide during the pandemic. When the outbreak abates, a backlog of people seeking these operations will exist. Hence, surgical candidates face prolonged delays of beneficial treatment. Because of the progressive nature of obesity and diabetes, delaying surgery increases risks for morbidity and mortality, thus requiring strategies to mitigate harm. The risk of harm, however, varies among patients, depending on the type and severity of their comorbidities. A triaging strategy is therefore needed. The traditional weight-centric patient-selection criteria do not favour cases based on actual clinical needs. In this Personal View, experts from the Diabetes Surgery Summit consensus conference series provide guidance for the management of patients while surgery is delayed and for postoperative surveillance. We also offer a strategy to prioritise bariatric and metabolic surgery candidates on the basis of the diseases that are most likely to be ameliorated postoperatively. Although our system will be particularly germane in the immediate future, it also provides a framework for long-term clinically meaningful prioritisation.
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Affiliation(s)
- Francesco Rubino
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK; Bariatric and Metabolic Surgery, King's College Hospital, London, UK.
| | - Ricardo V Cohen
- Center for the treatment of Obesity and Diabetes, Oswaldo Cruz German Hospital, Sao Paulo, Brazil
| | - Geltrude Mingrone
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK; Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carel W le Roux
- Diabetes Complications Research Centre, Conway Institute, University College of Dublin, Dublin, Ireland
| | - Jeffrey I Mechanick
- The Marie-Josee and Henry R Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, NY, USA; Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA; Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Josep Vidal
- Endocrinology and Nutrition Department, Hospital Clinic Universitari, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi Sunyer, Barcelona, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Madrid, Spain
| | - George Alberti
- Department of Endocrinology and Metabolism, Imperial College, London, UK
| | - Stephanie A Amiel
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK
| | - Rachel L Batterham
- Centre for Obesity Research, University College London, London, UK; University College London Hospitals Bariatric Centre for Weight Management and Metabolic Surgery, London, UK; National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK
| | - Stefan Bornstein
- Paul Langerhans Institute Dresden, Helmholtz Center Munich at the University Hospital Carl Gustav Carus and Faculty of Medicine, Technical University Dresden, Dresden, Germany
| | | | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Metabolic Diseases and Diabetes, University of Pisa, Pisa, Italy
| | - John B Dixon
- Iverson Health Innovation Research Institute, Swinburne University, Melbourne, VIC, Australia
| | - Robert H Eckel
- Division of Endocrinology, Metabolism and Diabetes and Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - David Hopkins
- King's Health Partners' Institute of Diabetes, Endocrinology and Obesity, London, UK
| | - Barbara M McGowan
- Institute of Diabetes, Endocrinology and Obesity, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - An Pan
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ameet Patel
- Bariatric and Metabolic Surgery, King's College Hospital, London, UK
| | - François Pattou
- European Genomic Institute for Diabetes, Lille, France; Translational Research for Diabetes, University of Lille, Inserm, Centre Hospitalier Regional Universitaire, Lille, France
| | - Philip R Schauer
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, USA
| | - Paul Z Zimmet
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - David E Cummings
- University of Washington Medicine Diabetes Institute, University of Washington, Seattle, WA, USA; Weight Management Program, Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, WA, USA
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