Multimodal approach utilising a weight management programme prior to bariatric surgery in patients with BMI ≥50 kg/m2: A propensity score matching retrospective cohort study

We evaluated preoperative weight loss and days from initial consult to surgery in patients with BMI ≥50 kg/m2 who were and were not enrolled in medical weight management (MWM) prior to laparoscopic sleeve gastrectomy. We retrospectively identified patients with BMI ≥50 kg/m2 who had primary sleeve gastrectomy between 2014 and 2019 at two bariatric surgery centres in our healthcare system. Patients presenting after 2017 that received preoperative MWM (n = 28) were compared to a historical cohort of non-MWM patients (n = 118) presenting prior to programme initiation in 2017 on preoperative percent total body weight loss (%TBWL) and days from initial consult to surgery. A total of 151 patients (MWM, 33; non-MWM, 118) met inclusion criteria. BMI was significantly greater in MWM versus non-MWM (p = .018). After propensity score matching, median BMI at initial consult in non-MWM versus MWM no longer differed (p = .922) neither were differences observed on the basis of weight, age, sex, race or ethnicity. After PSM, MWM had significantly lower BMI at surgery (p = .018), lost significantly more weight from consult to surgery (p < .001) and achieved significantly greater median %TBWL from consult to surgery (p < .001). We noted no difference between groups on 6-month weight loss (p = .533). Days from initial consult to surgery did not differ between groups (p < .863). A preoperative MWM programme integrated into multimodal treatment for obesity in patients with a BMI ≥50 kg/m2 resulted in clinically significant weight loss without prolonging time to surgery.

Five-year outcomes of revisional bariatric surgery: gastric band to sleeve gastrectomy or to Roux-en-Y gastric bypass

BACKGROUND

Revisional bariatric surgery after an index adjustable gastric band (AGB) may be indicated to remedy weight relapse or band-related complications. We examined outcomes five years following revision from AGB to laparoscopic sleeve gastrectomy (AGB-LSG) or to Roux-en-Y gastric bypass (AGB-RYGB).

METHODS

We conducted a retrospective review to identify patients (men and women, age 18-80) who underwent one revisional bariatric procedure with AGB as the index procedure at two medical centers in our healthcare system between January 2012 and February 2017. We only included patients with a pre-revision BMI > 30 kg/m2 for whom 5-year follow-up data were available. We compared 5-year weight loss and remission of comorbidities in patients undergoing AGB-LSG and AGB-RYGB conversion.

RESULTS

A total of 114 patients met inclusion criteria (65 AGB-LSG, 49 AGB-RYGB). At 5-year post-revision, percent total weight loss (3.4% vs 19.9%; p < 0.001), percent excess weight loss (7.0% vs 50.8%; p < 0.001) and decrease in BMI (1.5 vs 8.8; p < 0.001) was greater in AGB-RYGB vs. AGB-LSG. No significant difference in remission or development of new comorbidities was observed.

CONCLUSION

Conversion of AGB to RYGB is associated with superior intermediate-term weight loss compared to conversion of AGB to LSG. Future multicenter studies with larger sample sizes are necessary to further describe the intermediate-term outcomes of revisional bariatric surgery.

Incidence of Hiatal Hernia Repair During Primary Bariatric Surgery Conversion: an Analysis of the 2020 MBSAQIP Database

The rate of hiatal hernia (HH) repair during conversion bariatric surgery is largely unknown. We sought to determine this rate in 12,788 patients undergoing conversion surgery using the 2020 participant use file of the MBSAQIP database. Concurrent HH repair was performed in 24.1% of conversion cases; most commonly during SG to RYGB (33.1%), followed by AGB to SG conversion (20.2%). The remaining conversion pathways had a repair rate around 13%. Only 12.1% of HH repairs were performed using a mesh. GERD was the primary indication for conversion in 65% of the SG to RYGB cases. A much higher proportion of patients with concomitant HH repair reported GERD as the main reason for conversion than those without a HH repair (44.5% vs. 23.7%; p<0.001).

A randomized controlled trial of an enhanced recovery after surgery protocol in patients undergoing laparoscopic sleeve gastrectomy

BACKGROUND

The purpose of this study was to evaluate the effect of an enhanced recovery after surgery (ERAS) protocol on opioid and anti-emetic use, length of stay and safety after laparoscopic sleeve gastrectomy (LSG).

METHODS

Patients who underwent LSG between March 2018 and January 2019 at our accredited, high-volume bariatric surgery center were randomized to either standard of care (SOC) or ERAS. ERAS included a pre- and post-surgical medication regimen designed to reduce postoperative nausea, vomiting and pain. Outcomes included post-operative symptom scores, opioid use, anti-emetic use, time to achieve readiness for discharge (RFD) and inpatient and 30-day adverse events, readmissions and emergency department visits.

RESULTS

The final analysis included 130 patients, (SOC 65; ERAS 65). Groups did not differ on demographics or comorbidities. Relative to SOC, fewer ERAS patients utilized opioids in the hospital ward (72.3% vs. 95.4%; p < .001), peak pain scores were significantly lower, and median time to achieve RFD was shorter (28.0 h vs. 44.4 h; p = 0.001). More ERAS patients were discharged on post-operative day 1 (38.5% vs. 15.4%; p < .05). The overall use of rescue anti-emetic medications was not different between groups. Rates of postoperative 30-day events, readmissions, and emergency department visits did not differ between groups.

CONCLUSION

Relative to SOC, ERAS was associated with earlier discharge, lower pain scores, less frequent use of opioids and use in lower amounts after LSG with no differences in 30 day safety outcomes.

Weight stigma and posttraumatic stress disorder symptoms in individuals seeking bariatric surgery

BACKGROUND

After bariatric surgery, some patients experience adverse psychiatric outcomes, including substance use, suicidality, and self-harm. These factors are commonly associated with posttraumatic stress disorder (PTSD) and related symptoms (PTSD-S) that develop following adverse childhood experiences (ACEs) and traumatic events. However, emerging evidence suggests that chronic discrimination also may contribute to PTSD-S. Weight-based discrimination is salient for people with obesity but has received little attention in relation to PTSD-S.

OBJECTIVE

Our study examined factors that may contribute to the link between experienced weight stigma (WS), which is common in individuals seeking bariatric surgery, and PTSD-S.

SETTING

Teaching hospital and surgical weight loss center in the United States.

METHODS

A total of 217 participants completed self-report surveys of experienced and internalized WS, ACEs, and PTSD-S. Demographics and trauma history were obtained from patient medical records. A stepwise multiple regression examined associations between experienced WS and internalized WS with PTSD-S, co-varying demographics, ACEs, and trauma, followed by examination of whether findings held co-varying anxiety/depressive symptoms in a participant subset (n = 189).

RESULTS

After accounting for covariates in step 1 and ACEs and trauma in step 2 (ΔR² = .14), experienced WS and internalized WS accounted for substantial PTSD-S variance in steps 2 and 3 (ΔR² = .12 and .13, respectively; overall model R² =.44; P < .001). Findings held after co-varying anxiety/depressive symptoms.

CONCLUSIONS

Over and above ACEs and trauma, experienced WS and internalized WS may contribute to PTSD-S. Longitudinal research is needed to better elucidate the pathways underlying these associations.

Shame and Self-compassion as Risk and Protective Mechanisms of the Internalized Weight Bias and Emotional Eating Link in Individuals Seeking Bariatric Surgery

BACKGROUND

Emotional eating in bariatric surgery patients is inconsistently linked with poor post-operative weight loss and eating behaviors, and much research to date is atheoretical. To examine theory-informed correlates of pre-operative emotional eating, the present cross-sectional analysis examined paths through which experienced weight bias and internalized weight bias (IWB) may associate with emotional eating among individuals seeking bariatric surgery.

METHODS

We examined associations of experienced weight bias, IWB, shame, self-compassion, and emotional eating in patients from a surgical weight loss clinic (N = 229, 82.1% female, M. BMI: 48 ± 9). Participants completed a survey of validated self-report measures that were linked to BMI from the patient medical record. Multiple regression models tested associations between study constructs while PROCESS bootstrapping estimates tested the following hypothesized mediation model: IWB ➔ internalized shame ➔ self-compassion ➔ emotional eating. Primary analyses controlled for adverse childhood experiences (ACE), a common confound in weight bias research. Secondary analyses controlled for depressive/anxiety symptoms from the patient medical record (n = 196).

RESULTS

After covariates and ACE, each construct accounted for significant unique variance in emotional eating. However, experienced weight bias was no longer significant and internalized shame marginal, after controlling for depressive/anxiety symptoms. In a mediation model, IWB was linked to greater emotional eating through heightened internalized shame and low self-compassion, including after controlling for depressive/anxiety symptoms.

CONCLUSIONS

Pre-bariatric surgery, IWB may signal risk of emotional eating, with potential implications for post-operative trajectories. Self-compassion may be a useful treatment target to reduce IWB, internalized shame, and related emotional eating in bariatric surgery patients. Further longitudinal research is needed.

Weight Bias, Shame, and Self-Compassion: Risk/Protective Mechanisms of Depression and Anxiety in Prebariatic Surgery Patients

OBJECTIVE

Psychopathology in bariatric surgery patients may contribute to adverse postoperative sequelae, including weight regain, substance use, and self-harm. This cross-sectional study aimed to advance the understanding of the risk and protective paths through which weight bias associates with depressive and anxiety symptoms in bariatric surgery candidates (BSC).

METHODS

BSC recruited from a surgical clinic (N = 213, 82.2% women, 43  [SD 12] years, mean BMI: 49  [SD 9] kg/m² ) completed measures of experienced weight bias (EWB), internalized weight bias (IWB), body and internalized shame, and self-compassion; anxiety and depression screeners were accessed from medical charts. Multiple regression and PROCESS bootstrapping estimates tested our hypothesized mediation model as follows: EWB→IWB→body shame→shame→self-compassion→symptoms.

RESULTS

After accounting for EWB and IWB, internalized shame accounted for greater variance in both end points than body shame. EWB was associated with greater anxiety through risk paths implicating IWB, body shame, and/or internalized shame. Protective paths associated EWB with fewer depressive and anxiety symptoms among those with higher self-compassion.

CONCLUSIONS

The findings suggest a potentially important role for weight bias and shame in psychological health among BSC and implicate self-compassion, a trainable affect-regulation strategy, as a protective factor that may confer some resiliency. Future research using longitudinal and causal designs is warranted.

Robot-assisted sleeve gastrectomy and Roux-en-y gastric bypass: results from the metabolic and bariatric surgery accreditation and quality improvement program data registry

BACKGROUND

A stronger evidence base is needed to more fully understand the precise role that robot-assisted (RA) approaches may play in bariatrics.

OBJECTIVE

To investigate the utilization and safety of RA-sleeve gastrectomy (RA-SG) and RA-Roux-en-Y gastric bypass (RA-RYGB) using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry.

SETTING

National Database.

METHODS

We queried the MBSAQIP 2015 through 2016 registry for patients who underwent primary conventional laparoscopic or RA-SG and RA-RYGB. We compared pre- and perioperative characteristics and 30-day outcomes using logistic regression where number of events met statistical guidelines.

RESULTS

We included 126,987 cases: conventional laparoscopic SG (n = 83,940), RA-SG (n = 6,780), conventional laparoscopic RYGB (n = 33,525), and RA-RYGB (n = 2,742). The RA significantly lengthened operation time by 24 and 23 minutes for SG and RYGB, respectively. Mortality and serious adverse events were similar for the 2 techniques. RA-SG was associated with higher rates of 30-day intervention (1.3% versus .8%, OR: 1.38, P < .05) and hospital stay >2 days (12.1% versus 9.3%, OR: 1.30, P < .001). RA-RYGB was associated with higher 30-day rates of reoperation (2.6% versus 2.0%, OR: 1.37, P < .05) and readmission (7.0% versus 5.8%, OR:1.21, P < .05) and lower rates of transfusion (0.62% versus 1.12%, OR: .54, P < .05) and hospital stay >2 days (15.7% versus 17%, OR: .89, P < .05).

CONCLUSION

RA is as safe as the conventional laparoscopic approach in terms of mortality and serious adverse events.

Ethnic variation in weight loss, but not co-morbidity remission, after laparoscopic gastric banding and Roux-en-Y gastric bypass

BACKGROUND

Demographic factors such as ethnicity may affect bariatric surgery outcomes. We examined weight loss and co-morbidities outcomes in African American, Caucasian, and Hispanic patients who underwent laparoscopic gastric banding (LAGB) and Roux-en-Y gastric bypass (RYGB). The primary aim was to investigate demographic differences in weight loss and co-morbidities outcomes.

METHODS

We retrospectively examined weight change and co-morbidities outcomes in our prospective database. A total of 1,903 patients underwent LAGB or RYGB between January 1, 2005 and March 31, 2012. Of those, 1828 completed their 1-year follow-up visit (9-15 mo) and had complete data. We excluded patients who were missing ethnicity information, resulting in a final cohort of 1,684 patients. Multivariate analyses and χ2 tests were used to examine demographic variables in body mass index (BMI) change, percent excess weight loss (%EWL), and remission of co-morbidities. We also examined weight loss outcomes at 2- and 3-year follow-up.

RESULTS

Overall, those who underwent RYGB had a lower BMI and greater %EWL at 1, 2, and 3 years compared to those who had undergone LAGB. Overall, African American patients had a higher postoperative BMI than either Caucasian or Hispanic patients. African American patients also showed less %EWL than Caucasian and Hispanic patients. When we examined within surgery type, ethnic differences between African American and Caucasian patients were present across all 3 years in RYGB, but there were no ethnic differences by year 3 in LAGB. Additionally, African American and Hispanic patients no longer differed by year 3 in RYGB and by year 2 in LAGB. There were no significant ethnic differences in remission of diabetes, hyperlipidemia, hypertension, and sleep apnea at 1 year.

CONCLUSION

Our study found significant ethnic differences in the postoperative BMI and %EWL, which were more pronounced in patients undergoing RYGB than LAGB at the 3-year time point. These weight loss differences did not translate to a lower rate of co-morbidities remission.

Donor T cell activation initiates small bowel allograft rejection through an IFN-gamma-inducible protein-10-dependent mechanism

The poor success in controlling small bowel (SB) allograft rejection is partially attributed to the unique immune environment in the donor intestine. We hypothesized that Ag-induced activation of donor-derived T cells contributes to the initiation of SB allograft rejection. To address the role of donor T cell activation in SB transplantation, SB grafts from DO11.10 TCR transgenic mice (BALB/c, H-2L(d+)) were transplanted into BALB/c (isografts), or single class I MHC-mismatched (L(d)-deficient) BALB/c H-2(dm2) (dm2, H-2L(d-)) mutant mice (allografts). Graft survival was followed after injection of control or antigenic OVA(323-339) peptide. Eighty percent of SB allografts developed severe rejection in mice treated with antigenic peptide, whereas <20% of allografts were rejected in mice treated with control peptide (p < 0.05). Isografts survived >30 days regardless of OVA(323-339) administration. Activation of donor T cells increased intragraft expression of proinflammatory cytokine (IFN-gamma) and CXC chemokine IFN-gamma-inducible protein-10 mRNA and enhanced activation and accumulation of host NK and T cells in SB allografts. Treatment of mice with neutralizing anti-IFN-gamma-inducible protein-10 mAb increased SB allograft survival in Ag-treated mice (67%; p < 0.05) and reduced accumulation of host T cells and NK cells in the lamina propria but not mesenteric lymph nodes. These results suggest that activation of donor T cells after SB allotransplantation induces production of a Th1-like profile of cytokines and CXC chemokines that enhance infiltration of host T cells and NK cells in SB allografts. Blocking this pathway may be of therapeutic value in controlling SB allograft rejection.