Care of the Patient After Metabolic and Bariatric Surgery

Risk of suicide after metabolic bariatric surgery: a meta-analysis of matched cohort studies and population-based studies

BACKGROUND

Metabolic bariatric surgery (MBS) remains the optimal treatment for patients with severe obesity. However, concern is growing about the risk of suicide after MBS.

OBJECTIVES

To compare the risk of suicide in adult patients with obesity, treated with or without MBS.

SETTING

University-affiliated hospital, China.

METHODS

PubMed and Embase were searched through April 30, 2024. Eligible studies were matched cohort studies and population-based studies (PROSPERO ID: CRD42024561042). Effects were pooled using a random-effects model. Subgroup analysis was performed based on study type.

RESULTS

A total of 3 matched cohort studies (4 matched cohorts) and 2 population-based studies, involving 114,615 adult patients with obesity treated with MBS (272 suicides) and 552,642 nonsurgery counterparts (622 suicides), met the selection criteria. Patients treated with MBS had a pooled hazard ratio (HR) of suicide of 2.12 (95% confidence interval [CI] 1.54-2.92, P < .01, I2 = 24%) and a pooled risk ratio (RR) of suicide of 2.32 (95% CI 1.55-3.45, P < .01, I2 = 58%) compared with those treated without MBS. In the subgroup analysis, relatively higher pooled HR (2.64 [1.84-3.77] versus 1.67 [1.32-2.12]) and RR (2.98 [2.02-4.41] versus 1.48 [.80-2.75]) were observed in the subgroup of matched cohort studies compared with the subgroup of population-based studies.

CONCLUSIONS

Adult patients treated with MBS are at more than double the risk of suicide than those treated without MBS in terms of both HR and RR. However, the absolute risk was low and did not warrant a general discouragement of MBS.

[Research progress of probiotics regulating intestinal micro-ecological environment in obese patients after bariatric surgery]

Bariatric surgery may cause intestinal microecological environment imbalance due to changes in gastrointestinal anatomy. Some patients may have compli-cations, even regain weight. Probiotics can act on intestinal mucosa, epithelium and gut-associated lymphoid tissue to improve the intestinal microecological environment of obese patients after bariatric surgery. Probiotics can promote the production of short-chain fatty acids, stimulate intestinal cells to release glucagon-like peptide-1, peptide tyrosine-tyrosine, insulin and other endocrine hormones, affect the function of the central nervous system through the gut-brain axis, make patients after bariatric surgery feel full, and reduce blood sugar at the same time. Probiotics can produce lactic acid, acetic acid and lactase, to inhibit the growth of harmful bacteria and to improve gastrointestinal symptoms of patients after bariatric surgery. Probiotics can activate the AMP-activated protein kinase signaling pathway, improve lipid metabolism, and promote the recovery of symptom indicators of nonalcoholic fatty liver disease after bariatric surgery. Probiotics can regulate the release of neurotransmitters or metabolites by the microbiota through the gut-brain axis to affect brain activity and behavior, thus helping patients improve negative emotions after bariatric surgery. This article describes the intestinal microecological environment of obese patients and mechanism of the change after bariatric surgery and summarizes the effects and possible mechanisms of probiotics in improving the intestinal microecological environment of obese patients after bariatric surgery, to provide references for promoting the clinical application of probiotics.

[When should a patient with obesity be referred to endocrinology? Current indications for bariatric surgery]

Bariatric surgery (BS) has been shown to be effective and efficient, but only 1% of selected patients will ever receive it. Compared to medical treatment of obesity, BS has demonstrated greater long-term sustained weight loss, a reduction in both total and cardiovascular (CV) mortality, improvement or remission of CV risk factors and other comorbidities associated with obesity, as well as improved mobility and quality of life. BS presents similar risks to other abdominal surgeries, with obesity as an added risk factor. However, mortality after this type of surgery is less than 1%, being in specialised centres even lower than 0.3%, with a morbidity of less than 7%. The most commonly performed surgical procedures at present are vertical gastrectomy and Roux---Y gastric bypass, preferably by laparoscopic approach.

Obesity

Obesity is a common condition and a major cause of morbidity and mortality. Fortunately, weight loss treatment can reduce obesity-related complications. This review summarizes the evidence-based strategies physicians can employ to identify, prevent, and treat obesity, including best practices to diagnose and counsel patients, to assess and address the burden of weight-related disease including weight stigma, to address secondary causes of weight gain, and to help patients set individualized and realistic weight loss goals and an effective treatment plan. Effective treatments include lifestyle modification and adjunctive therapies such as antiobesity medications and metabolic and bariatric surgery.

Obesity Management in Adults: A Review

Importance

Obesity affects approximately 42% of US adults and is associated with increased rates of type 2 diabetes, hypertension, cardiovascular disease, sleep disorders, osteoarthritis, and premature death.

Observations

A body mass index (BMI) of 25 or greater is commonly used to define overweight, and a BMI of 30 or greater to define obesity, with lower thresholds for Asian populations (BMI ≥25-27.5), although use of BMI alone is not recommended to determine individual risk. Individuals with obesity have higher rates of incident cardiovascular disease. In men with a BMI of 30 to 39, cardiovascular event rates are 20.21 per 1000 person-years compared with 13.72 per 1000 person-years in men with a normal BMI. In women with a BMI of 30 to 39.9, cardiovascular event rates are 9.97 per 1000 person-years compared with 6.37 per 1000 person-years in women with a normal BMI. Among people with obesity, 5% to 10% weight loss improves systolic blood pressure by about 3 mm Hg for those with hypertension, and may decrease hemoglobin A1c by 0.6% to 1% for those with type 2 diabetes. Evidence-based obesity treatment includes interventions addressing 5 major categories: behavioral interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric procedures. Comprehensive obesity care plans combine appropriate interventions for individual patients. Multicomponent behavioral interventions, ideally consisting of at least 14 sessions in 6 months to promote lifestyle changes, including components such as weight self-monitoring, dietary and physical activity counseling, and problem solving, often produce 5% to 10% weight loss, although weight regain occurs in 25% or more of participants at 2-year follow-up. Effective nutritional approaches focus on reducing total caloric intake and dietary strategies based on patient preferences. Physical activity without calorie reduction typically causes less weight loss (2-3 kg) but is important for weight-loss maintenance. Commonly prescribed medications such as antidepressants (eg, mirtazapine, amitriptyline) and antihyperglycemics such as glyburide or insulin cause weight gain, and clinicians should review and consider alternatives. Antiobesity medications are recommended for nonpregnant patients with obesity or overweight and weight-related comorbidities in conjunction with lifestyle modifications. Six medications are currently approved by the US Food and Drug Administration for long-term use: glucagon-like peptide receptor 1 (GLP-1) agonists (semaglutide and liraglutide only), tirzepatide (a glucose-dependent insulinotropic polypeptide/GLP-1 agonist), phentermine-topiramate, naltrexone-bupropion, and orlistat. Of these, tirzepatide has the greatest effect, with mean weight loss of 21% at 72 weeks. Endoscopic procedures (ie, intragastric balloon and endoscopic sleeve gastroplasty) can attain 10% to 13% weight loss at 6 months. Weight loss from metabolic and bariatric surgeries (ie, laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass) ranges from 25% to 30% at 12 months. Maintaining long-term weight loss is difficult, and clinical guidelines support the use of long-term antiobesity medications when weight maintenance is inadequate with lifestyle interventions alone.

Conclusion and Relevance

Obesity affects approximately 42% of adults in the US. Behavioral interventions can attain approximately 5% to 10% weight loss, GLP-1 agonists and glucose-dependent insulinotropic polypeptide/GLP-1 receptor agonists can attain approximately 8% to 21% weight loss, and bariatric surgery can attain approximately 25% to 30% weight loss. Comprehensive, evidence-based obesity treatment combines behavioral interventions, nutrition, physical activity, pharmacotherapy, and metabolic/bariatric procedures as appropriate for individual patients.

[Postoperative management]

Bariatric surgery results in significant weight loss, reduction or even remission of obesity-associated comorbidities, reduced mortality, and improved quality of life in many patients; however, obesity is a chronic disease, thus follow-up care is required after bariatric surgery. Furthermore, specific issues, such as micronutrient deficiencies and subsequent complications, can arise both in the short-term and the long-term. Abdominal pain after bariatric surgery must always be regarded as a serious symptom. A further focus should be on the diagnosis and treatment of dumping syndrome. Patients with type 2 diabetes should be regularly screened for recurrent hyperglycemia as well as specific sequelae, even though blood glucose levels may be substantially improved or normalized. In addition to centers with multidisciplinary teams, primary care and, in particular, general practitioners will play an increasingly more important role in the follow-up care after bariatric surgery.

Renal Dysfunction Phenotypes in Patients Undergoing Obesity Surgery

Obesity surgery candidates are at an increased risk of kidney injury, but pre-operative evaluation usually neglects kidney function assessment. This study aimed to identify renal dysfunction in candidates for bariatric surgery. To reduce the sources of bias, subjects with diabetes, prediabetes under metformin treatment, neoplastic or inflammatory diseases were excluded. Patients' (n = 192) average body mass index was 41.7 ± 5.4 kg/m². Among these, 51% (n = 94) had creatinine clearance over 140 mL/min, 22.4% (n = 43) had proteinuria over 150 mg/day and 14.6% (n = 28) albuminuria over 30 mg/day. A creatinine clearance higher than 140 mL/min was associated with higher levels of proteinuria and albuminuria. Univariate analysis identified sex, glycated hemoglobin, uric acid, HDL and VLDL cholesterol as being associated with albuminuria, but not with proteinuria. On multivariate analysis, glycated hemoglobin and creatinine clearance as continuous variables were significantly associated with albuminuria. In summary, in our patient population prediabetes, lipid abnormalities and hyperuricemia were associated with albuminuria, but not with proteinuria, suggesting different disease mechanisms might be implicated. Data suggest that in obesity-associated kidney disease, tubulointerstitial injury precedes glomerulopathy. A significant proportion of obesity surgery candidates present clinically relevant albuminuria and proteinuria along with renal hyperfiltration, suggesting that routine pre-operative assessment of these parameters should be considered.

Long-term complications of significant weight loss: lessons learned from bariatric surgery

The increasing prevalence of worldwide obesity calls for a comprehensive understanding of available treatment options. Bariatric surgery remains a very effective obesity treatment, showing substantial effects on obesity-related complications, including type 2 diabetes mellitus and cardiovascular disease, mainly related to significant long-term weight loss. Besides the benefits, weight loss can lead to some deleterious consequences, such as gallstones, constipation, muscle mass loss, bone fractures, vitamin deficiencies, peripheral neural palsy, suicide, eating disorders, alcohol dependency syndrome, and increased divorce. Those consequences may also be seen after long-term effective pharmacotherapy for obesity. Understanding these risks will lead to improved awareness and successful treatment with both surgical and nonsurgical treatments.

Metabolic and bariatric surgery in China: A summary of the Greater China Metabolic and Bariatric Surgery Database and comparison with other international registry databases

AIMS

To summarize the Greater China Metabolic and Bariatric Surgery Database (GC-MBD) and to compare patient characteristics and different procedures performed with data from published reports from other international bariatric surgery registries.

MATERIALS AND METHODS

Data were extracted from the GC-MBD registry in 2021. Baseline demographic characteristics, obesity-related comorbidities and operational information were analysed. Descriptive comparisons of these data were made with the published reports from four other international/national databases, including the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) registry, the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database of the United States, the National Bariatric Surgical Registry (NBSR) of the United Kingdom, and the Scandinavian Obesity Surgery Registry (SOReg).

RESULTS

Fifty-three centres in China registered 6807 cases in the GC-MBD. Compared with published data from the IFSO registry, MBSAQIP, NBSR and SOReg, patients in China undergoing surgery were younger and had a lower body mass index. The incidence of other obesity-related comorbidities, except for gastroesophageal reflux disease, was also higher than in Western countries. Furthermore, more patients underwent sleeve gastrectomy, less revisional bariatric surgery was reported in China, and jejunojejunal bypass with sleeve gastrectomy, uncommon in other countries, was China's second-leading bariatric procedure.

CONCLUSIONS

By establishing comprehensive national registries such as the GC-MBD, real-world information can be gathered on clinical practice and patient outcomes. Insights into variations in clinical practice can be identified by comparing reports from different countries, which can help in making and evaluating healthcare policies on the best clinical practices at a national level.

Role of bile acids in overweight and obese children and adolescents

Bile acids (BAs) are amphipathic molecules synthetized in the liver. They are primarily involved in the digestion of nutrients. Apart from their role in dietary lipid absorption, BAs have progressively emerged as key regulators of systemic metabolism and inflammation. In the last decade, it became evident that BAs are particularly important for the regulation of glucose, lipid, and energy metabolism. Indeed, the interest in role of BA in metabolism homeostasis is further increased due to the global public health increase in obesity and related complications and a large number of research postulating that there is a close mutual relationship between BA and metabolic disorders. This strong relationship seems to derive from the role of BAs as signaling molecules involved in the regulation of a wide spectrum of metabolic pathways. These actions are mediated by different receptors, particularly nuclear farnesoid X receptor (FXR) and Takeda G protein coupled receptor 5 (TGR5), which are probably the major effectors of BA actions. These receptors activate transcriptional networks and signaling cascades controlling the expression and activity of genes involved in BA, lipid and carbohydrate metabolism, energy expenditure, and inflammation. The large correlation between BAs and metabolic disorders offers the possibility that modulation of BAs could be used as a therapeutic approach for the treatment of metabolic diseases, including obesity itself. The aim of this review is to describe the main physiological and metabolic actions of BA, focusing on its signaling pathways, which are important in the regulation of metabolism and might provide new BA -based treatments for metabolic diseases.

Integrated Care Model of Adiposity-Related Chronic Diseases

PURPOSE OF REVIEW

Although obesity is a disease, most patients with obesity do not undergo effective treatment nor adhere to long-term care. We examine the barriers that patients with obesity confront when searching for effective treatment and propose an integrated care model of adiposity-related chronic diseases in a cardio-renal metabolic unit.

RECENT FINDINGS

The current care of obesity is fragmented between primary care providers, medical specialists and metabolic bariatric surgeons with little or no coordination of care between these providers. The current care of obesity heavily focuses on weight loss as the primary aim of treatment thereby reenforcing the weight stigma and turning patients away from effective therapy like metabolic bariatric surgery. An interdisciplinary cardio-renal metabolic unit that, besides weight loss, emphasizes prevention/remission of adiposity-related chronic diseases may deliver thorough and rewarding care to most patients with obesity.