Preoperative risk factors for early postoperative bleeding after Roux-en-Y gastric bypass surgery: a systematic review and meta-analysis

PURPOSE

Although bariatric surgery is an effective intervention for obesity, it comes with risks such as early postoperative bleeding (EPB). Identifying preoperative risk factors for this complication can help patients' risk stratification and optimization. We performed a systematic review and meta-analysis to find predictors for early postoperative bleeding after Roux-en-Y gastric bypass (RYGB).

METHODS

We conducted a systematic review, searching PubMed, Cochrane Library, and Web of Science until November 2023. We performed a random-effects meta-analysis to explore preoperative risk factors associated with early postoperative bleeding after RYGB. Sources of heterogeneity were explored by leave-one-out analyses.

RESULTS

23 studies were included, comprising 232,488 patients. Male gender (meta-analytical RR = 1.42, 95%CI = 1.21-1.66, I2 = 18%, Q Cochran test p-value = 0.29) and revisional surgery (meta-analytical RR = 1.35, 95%CI = 1.12-1.62, I2 = 22%, Q Cochran test p = 0.21) were associated with higher risk of EPB. On average, patients with EPB were older than the remainder (MD for the mean age = 2.82 years, 95%CI = 0.97-4.67, I2 = 0.00%, Q Cochran test p = 0.46). Except for hypertension (meta-analytical RR = 1.33, 95%CI = 1.02-1.73, I2 = 66%, Q Cochran test p < 0.0001), comorbidities were not associated with a higher risk of EPB.

CONCLUSION

Preoperative risk factors, including age, gender, hypertension, and revisional bariatric surgery, are associated with early postoperative bleeding after RYGB. Further primary studies, with higher methodological quality, are required to detail more risk factors.

Impact of a Multicomponent Exercise Training Program on Muscle Strength After Bariatric Surgery: A Randomized Controlled Trial

PURPOSE

This study examined the benefits of an 11-months multicomponent exercise program (MEP) on muscular strength (MS) after bariatric surgery.

METHODS

Of the 84 randomized patients, 41 participants from the exercise group (EG) and 20 participants from the control group (CG) were included in the analysis. The EG received supervised MEP for 11 months, starting 1-month post-bariatric surgery (BS) in addition to standard medical care, while the CG received medical care recommendations only. Knee and trunk MS was assessed by isokinetic dynamometry pre-surgery, 1-, 6-, and 12-month post-surgery, while body composition was assessed by dual-energy X-ray absorptiometry.

RESULTS

The MEP did not significantly impact absolute MS in the dominant knee and trunk regions at 6- and 12-month post-BS. However, relative MS showed significant improvements. At 6-month post-BS, knee flexion at 60°/s relative to body weight (BW) increased significantly (p = 0.047), as did knee extension at 180°/s relative to BW (p = 0.009), and knee extension at 60°/s relative to total lean mass (p=0.040). At 12-month post-BS, knee flexion at 60°/s relative to BW also significantly improved (p=0.038).

CONCLUSION

While absolute MS was not significantly improved with MEP, this study found significant enhancements in relative MS, particularly in dominant knee flexion post-MEP participation. Further research should explore different exercise intensities and frequencies to optimize postoperative MS recovery post-BS.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT02843048).

Comparison between the open and the laparoscopic approach in the primary ventral hernia repair: a systematic review and meta-analysis

BACKGROUND

Ventral hernia repair underwent various developments in the previous decade. Laparoscopic primary ventral hernia repair may be an alternative to open repair since it prevents large abdominal incisions. However, whether laparoscopy improves clinical outcomes has not been systematically assessed.

OBJECTIVES

The aim is to compare the clinical outcomes of the laparoscopic versus open approach of primary ventral hernias.

METHODS

A systematic search of MEDLINE (PubMed), Scopus, Web of Science, and Cochrane Central Register of Controlled Trials was conducted in February 2023. All randomized controlled trials comparing laparoscopy with the open approach in patients with a primary ventral hernia were included. A fixed-effects meta-analysis of risk ratios was performed for hernia recurrence, local infection, wound dehiscence, and local seroma. Meta-analysis for weighted mean differences was performed for postoperative pain, duration of surgery, length of hospital stay, and time until return to work.

RESULTS

Nine studies were included in the systematic review and meta-analysis. The overall hernia recurrence was twice less likely to occur in laparoscopy (RR = 0.49; 95%CI = 0.32-0.74; p < 0.001; I2 = 29%). Local infection (RR = 0.30; 95%CI = 0.19-0.49; p < 0.001; I2 = 0%), wound dehiscence (RR = 0.08; 95%CI = 0.02-0.32; p < 0.001; I2 = 0%), and local seroma (RR = 0.34; 95%CI = 0.19-0.59; p < 0.001; I2 = 14%) were also significantly less likely in patients undergoing laparoscopy. Severe heterogeneity was obtained when pooling data on postoperative pain, duration of surgery, length of hospital stay, and time until return to work.

CONCLUSION

The results of available studies are controversial and have a high risk of bias, small sample sizes, and no well-defined protocols. However, the laparoscopic approach seems associated with a lower frequency of hernia recurrence, local infection, wound dehiscence, and local seroma.

Roux-en-Y gastric bypass and sleeve gastrectomy as revisional bariatric procedures after adjustable gastric banding: a retrospective cohort study

INTRODUCTION

The frequency of revisional bariatric surgery is increasing, but its effectiveness and safety are not yet fully established. The aim of our study was to compare short-term outcomes of primary (pRYGB and pSG) and revisional bariatric surgeries (rRYGB and rSG).

METHODS

We performed a retrospective cohort study assessing all patients submitted to primary and revisional (after a failed AGB) RYGB and SG in 2019. Each patient was followed-up at 6 months and 12 months after surgery. We compared pRYGB vs. rRYGB, pSG vs. rSG and rRYGB vs. rSG on weight loss, surgical complications, and resolution of comorbidities.

RESULTS

We assessed 494 patients, of which 18.8% had undergone a revisional procedure. Higher weight loss at 6 and 12 months was observed in patients undergoing primary vs. revisional procedures. Patients submitted to rRYGB lost more weight than those with rSG (%EWL 12 months = 82.6% vs. 69.0%, p < 0.001). Regarding the resolution of obesity-related comorbidities, diabetes resolution was more frequent in pRYGB than rRYGB (54.2% vs. 25.0%; p = 0.038). Also, 41.7% of the patients who underwent rRYGB had dyslipidemia resolution vs. 0% from the rSG group (p = 0.035). Dyslipidemia resolution was also more common in pSG vs. rSG (68.6% vs. 0.0%; p = 0.001). No significant differences in surgical complications were found.

CONCLUSION

Revisional bariatric surgery is effective and safe treating obesity and related comorbidities after AGB. Primary procedures appear to be associated with better weight loss outcomes. Further prospective studies are needed to better understand the role of revisional bariatric surgery.

Effects of a supervised exercise training on body composition after bariatric surgery: a randomized controlled trial

OBJECTIVE

This study aimed to determine the effects of a multicomponent exercise intervention during the first year post-bariatric surgery (BS) on body composition, weight loss (WL), energy expenditure, and nutrient intake.

METHODS

A total of 84 patients were included in this study and were randomly assigned to either an exercise group (n = 41) or a control group (n = 20). The exercise group participated in a multicomponent exercise program that began 1-month post-BS, whereas the control group received only standard medical care post-BS. Body composition was assessed by dual-energy x-ray absorptiometry, and physical activity energy expenditure was assessed by accelerometers. Nutritional intake was assessed through a 4-day food diary.

RESULTS

A total of 6-months post-BS, exercise was found to be effective in mitigating the loss of lower-limb and appendicular lean mass (LM), as well as favoring trunk fat mass (FM) loss. Moreover, it further decreased percent FM and promoted additional excess WL. After 12 months, exercise not only reduced waist circumference but also helped to lessen the loss of total, trunk, and appendicular LM.

CONCLUSIONS

Exercise further induced trunk fat mass, percent FM, excess WL, and waist circumference reductions. Moreover, exercise attenuated the loss of total and regional LM.

Incidence of symptomatic gallstones after bariatric surgery: the impact of expectant management

BACKGROUND

Bariatric surgery is the most effective treatment for sustained weight reduction and obesity-related comorbidities. The development of gallstones as a result of rapid weight loss is a well-known consequence of bariatric procedures. It remains unclear, if there is an increased risk of these gallstones becoming symptomatic.

METHODS

A retrospective analysis of 505 consecutive patients submitted to either Roux-en-Y Gastric Bypass or Sleeve Gastrectomy between January and December 2019 was performed. The aim of our study was to determine the incidence of symptomatic cholelithiasis in asymptomatic patients with their gallbladder in situ after bariatric surgery and to identify potential risk factors for its development.

RESULTS

Of the 505 patients included, 79 (15.6%) underwent either previous cholecystectomy. (n = 67, 84.8%) or concomitant cholecystectomy during bariatric surgery (n = 12, 15.2%). Among the remaining 426 (84.4%) patients, only 8 (1.9%) became symptomatic during the 12-month follow-up period. When compared with patients who remained asymptomatic, they had a higher median preoperative BMI (47.0 vs. 42.8, p = 0.046) and prevalence of cholelithiasis on preoperative ultrasound (62.5% vs. 10.7%, p = 0.001). Multivariate analysis revealed preoperative BMI and cholelithiasis on preoperative ultrasound as independent risk factors for symptomatic biliary disease (OR 1.187, 95%CI 1.025-1.376, p = 0.022 and OR 10.720, 95%CI 1.613-71.246, p = 0.014, respectively).

CONCLUSION

Considering a low incidence of symptomatic gallstones after bariatric surgery, concomitant cholecystectomy should only be performed in symptomatic patients undergoing bariatric surgery. Preoperative factors, such as a higher BMI and positive ultrasound for cholelithiasis, may be related to the development of symptomatic gallstones.

Using Raw Accelerometer Data to Predict High-Impact Mechanical Loading

The purpose of this study was to develop peak ground reaction force (pGRF) and peak loading rate (pLR) prediction equations for high-impact activities in adult subjects with a broad range of body masses, from normal weight to severe obesity. A total of 78 participants (27 males; 82.4 ± 20.6 kg) completed a series of trials involving jumps of different types and heights on force plates while wearing accelerometers at the ankle, lower back, and hip. Regression equations were developed to predict pGRF and pLR from accelerometry data. Leave-one-out cross-validation was used to calculate prediction accuracy and Bland-Altman plots. Body mass was a predictor in all models, along with peak acceleration in the pGRF models and peak acceleration rate in the pLR models. The equations to predict pGRF had a coefficient of determination (R²) of at least 0.83, and a mean absolute percentage error (MAPE) below 14.5%, while the R² for the pLR prediction equations was at least 0.87 and the highest MAPE was 24.7%. Jumping pGRF can be accurately predicted through accelerometry data, enabling the continuous assessment of mechanical loading in clinical settings. The pLR prediction equations yielded a lower accuracy when compared to the pGRF equations.

Risk and Prophylactic Management of Gallstone Disease in Bariatric Surgery: a Systematic Review and A Bayesian meta-analysis

BACKGROUND

The frequency and management of gallstone disease (GD) in bariatric patients, including the role of routine prophylactic concomitant cholecystectomy (CCY), are still a matter of debate. This study aims to assess the risk of de novo GD in patients undergoing bariatric surgery (BS) and their predictive factors, as well as mortality and morbidity in prophylactic CCY compared to BS alone.

METHODS

We performed a systematic review, searching PubMed, EMBASE, and Web of Science until April 2021. We performed a Bayesian meta-analysis to estimate the risk of GD development after BS and the morbidity and mortality associated with BS alone versus BS + prophylactic CCY. Sources of heterogeneity were explored by meta-regression analysis.

RESULTS

The risk of de novo post bariatric GD was 20.7% (95% credible interval [95% CrI] = 13.0-29.7%; I² = 75.4%), and that of symptomatic GD was 8.2% ([95% CrI] = 5.9-11.1%; I² = 66.9%). Pre-operative average BMI (OR = 1.04; 95% CrI = 0.92-1.17) and female patients' proportion (OR = 1.00; 95% CrI = 0.98-1.04) were not associated with increased risk of symptomatic GD. BS + prophylactic CCY was associated with a 97% probability of a higher number of postoperative major complications compared to BS alone (OR = 1.74, 95% CrI = 0.97-3.55; I² = 56.5%). Mortality was not substantially different between the two approaches (OR = 0.79; 95% CrI = 0.03-3.02; I² = 20.7%).

CONCLUSION

The risk of de novo symptomatic GD after BS is not substantially high. Although mortality is similar between groups, odds of major postoperative complications were higher in patients submitted to BS + prophylactic CCY. It is still arguable if prophylactic CCY is a fitting approach for patients with a preoperative lithiasic gallbladder.

Impact of serum albumin concentration and neutrophil-lymphocyte ratio score on gastric cancer prognosis

INTRODUCTION/AIM

Serum albumin concentration (COA) and neutrophil-lymphocyte ratio (NLR) could reflect immunological and nutritional status. We aim to evaluate the impact of COA-NLR score on the prognosis of gastric cancer (GC).

MATERIAL AND METHODS

We perform a retrospective analysis on a database of 637 GC cases, between January 2010 and December 2017. In 396 patients, the inclusion criteria for this study were met (non-resectional or palliative surgery were excluded). Analytic data was only available in 203 patients. COA-NLR score was defined as follows: COA under 35 g/L and NLR value of 2.585 or higher, score 2; one of these conditions, score 1; and neither, score 0.

RESULTS

In our population (n = 203), 87 patients were classified as score 0, 82 as score 1 and 34 as score 2. COA-NLR score was significantly associated with DFS (HR 1.674; CI 95% 1.115-2.513; p = 0.013) and with OS (HR 2.072; CI 95% 1.531-2.805; p < 0.001). Kaplan-Meier curve analysis (log rank test) revealed that a higher score of COA-NLR predicted a worse OS (p < 0.001) and DFS (p = 0.03). COA-NLR was an independent prognostic factor for OS when adjusted to pStage and age (adjusted HR 1.566; CI 95% 1.145-2.143; p = 0.005).

CONCLUSIONS

Preoperative COA-NLR score was significantly associated with worse OS and DFS and, in this way, with worse prognosis on GC patients submitted to curative-intent resectional surgery.

Late Recurrence of Pancreatic Solid Pseudopapillary Neoplasm With Peritoneal Carcinomatosis Treated With Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC): A Case Report

Pancreatic solid pseudopapillary neoplasm (SPN) is a rare malignant tumour predominantly affecting young women. The occurrence of peritoneal carcinomatosis (PC) in this setting is an even rarer condition, usually related to perioperative tumour rupture. We present a case of a 43-year-old woman who previously underwent distal splenopancreatectomy after the diagnosis of a pancreatic SPN. Thirteen years later, the patient underwent a radical hysterectomy due to a uterine myoma. Intraoperatively, a peritoneal mass was additionally found and resected. Histological examination revealed an implant with morphology compatible with pancreatic SPN. The patient was then referred to our institution. Staging MRI and CT revealed multiple nodular lesions adjacent to the left colon, suggestive of peritoneal implants. The patient was then submitted to cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin and irinotecan. Histological examination confirmed peritoneal involvement by a pancreatic SPN. The postoperative course was unremarkable. Two years after surgery, the patient remains asymptomatic with no evidence of relapse. Despite SPN being cancer with a relatively indolent evolution, one needs to be aware of a possible recurrence several years after the primary resection, mainly in patients with evidence of intraoperative tumour rupture.

The impact of the prognostic nutritional index (PNI) in gastric cancer

BACKGROUND

Regarding the assessment of patients' immune and nutritional status, prognostic nutritional index (PNI) has been reported as a predictive marker for surgical outcomes in various types of cancer. The aim of our study was to evaluate the effect of PNI in prognosis of gastric cancer patients submitted to curative-intent resectional surgery.

MATERIAL AND METHODS

A retrospective analysis with 637 gastric cancer cases submitted to curative-intent surgery, between 2010 and 2017, in an upper GI surgery unit. We analyzed 396 patients that met the inclusion criteria for this study. The median follow-up was 37 (0-113) months.

RESULTS

According to Youden's method, the optimal PNI cutoff for OS was 41.625 (sensitivity 89.3% and specificity 41.3%). OS was significantly shorter in the lower-PNI group of patients when compared to the higher-PNI group (40.26 vs 77.49 months; p < 0.001). Higher PNI had a positive impact on OS in univariable analysis. When adjusted to pStage, higher PNI was still significantly associated with better OS (HR 0.405; CI 95% 0.253-0.649; p < 0.001). Regarding DFS, higher PNI was associated with better DFS (HR 0.421; CI 95% 0.218-0.815; p = 0.010). Higher-PNI group had a protective effect regarding postoperative morbidity and mortality.

CONCLUSIONS

In this cohort, PNI was disclosed to significantly impact GC patients' OS and DFS, including in multivariable analysis when adjusting for classical prognostic features. PNI can be used to predict patients at increased risk of postoperative morbidity and mortality. This index may be of use in identifying candidate patients who would benefit from perioperative nutritional support to improve surgical outcomes.

Impact of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy in the Treatment of Gastric Cancer with Peritoneal Carcinomatosis: A Systematic Review and Meta-analysis

BACKGROUND

Despite promising results, the effectiveness of cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with gastric cancer with peritoneal carcinomatosis (GCPC) has not been systematically evaluated. The aim of this systematic review is to compare the survival, complications and risk of recurrence between CRS + HIPEC versus CRS alone in GCPC.

PATIENTS AND METHODS

A systematic review was performed in MEDLINE and Web of Science according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Primary studies with patients with GCPC older than 18 years were included. Methodological Index for Non-randomized Studies (MINORS) criteria were used to assess the quality of the studies. We performed random-effects meta-analysis of risk ratios (RR). We assessed heterogeneity using the I² statistic.

RESULTS

Five studies were included in the qualitative and four in the quantitative analysis. The overall survival (OS) rate after 1 year was 3.65 times higher for CRS + HIPEC than CRS alone [RR = 3.65, 95% confidence interval (95% CI) = 1.01-13.26, I² = 73%]. The OS rate after 5 years was more than three times higher for CRS + HIPEC than for CRS alone (RR = 3.25, 95% CI = 1.28-8.26, I² = 8%). No significant differences between CRS + HIPEC and CRS alone related to complications were found (RR = 1.05, 95% CI = 0.83-1.33, I² = 0%). The risk of peritoneal recurrence was significantly lower for CRS + HIPEC than for CRS alone (RR = 0.23, 95% CI = 0.11-0.48, I² = 40%). The results may be associated with some information or indication bias.

CONCLUSIONS

Results should be analysed cautiously given the detected heterogeneity and limitations of included studies. However, treatment with CRS + HIPEC seems to increase the survival of patients with GCPC, more than treatment with CRS alone, decrease the risk of peritoneal recurrence and not be associated with more complications.

Mechanical loading prediction through accelerometry data during walking and running

Currently, there is no way to assess mechanical loading variables such as peak ground reaction forces (pGRF) and peak loading rate (pLR) in clinical settings. The purpose of this study was to develop accelerometry-based equations to predict both pGRF and pLR during walking and running. One hundred and thirty one subjects (79 females; 76.9 ± 19.6kg) walked and ran at different speeds (2-14km·h^-1) on a force plate-instrumented treadmill while wearing accelerometers at their ankle, lower back and hip. Regression equations were developed to predict pGRF and pLR from accelerometry data. Leave-one-out cross-validation was used to calculate prediction accuracy and Bland-Altman plots. Our pGRF prediction equation was compared with a reference equation previously published. Body mass and peak acceleration were included for pGRF prediction and body mass and peak acceleration rate for pLR prediction. All pGRF equation coefficients of determination were above 0.96, and a good agreement between actual and predicted pGRF was observed, with a mean absolute percent error (MAPE) below 7.3%. Accuracy indices from our equations were better than previously developed equations. All pLR prediction equations presented a lower accuracy compared to those developed to predict pGRF. Walking and running pGRF can be predicted with high accuracy by accelerometry-based equations, representing an easy way to determine mechanical loading in free-living conditions. The pLR prediction equations yielded a somewhat lower prediction accuracy compared with the pGRF equations.

Effects of a Multicomponent Exercise Training Program on Balance Following Bariatric Surgery

Patients who undergo bariatric surgery (BS) have an increased risk of falls. Our aim was to determine if a multicomponent exercise intervention after BS improves balance. Eighty-four patients with obesity enrolled for BS were recruited and 1 month after BS randomly allocated to a control (CG; standard medical care) or exercise group (EG; exercise plus standard medical care) consisting of a supervised multicomponent training program (3d/week; 75 min/session; 5 months). Anthropometry, lower limb muscle strength (isokinetic dynamometer), vitamin D (ELISA) and balance in bipedal stance (force platform) were assessed pre-BS, 1 month and 6 months post-BS. One month post-BS, significant balance improvements were observed, namely in antero-posterior center of gravity (CoG) displacement and velocity, and medio-lateral and total CoG velocity. Between 1- and 6-months post-BS, improvements in balance were observed only in the EG, with a significant treatment effect on CoG displacement area and antero-posterior CoG displacement. No significant differences were observed between EG and CG over time in any of the anthropometric, muscle strength, and vitamin D variables assayed. In conclusion, a multicomponent exercise intervention program improves some balance parameters in patients with severe obesity following BS and therefore should be part of post-BS follow-up care as a potential strategy to reduce falls and associated injuries.

Vitamin B Complex Deficiency After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy-a Systematic Review and Meta-Analysis

Bariatric surgery, although an effective method, still has complications, like nutritional deficiencies. Our aim was to summarize the evidence on the frequency of complex B vitamin deficiencies in studies comparing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). We included 25 studies for qualitative synthesis and 21 studies for quantitative synthesis. Relevant data was extracted, including proportion of patients with deficiency and mean serum vitamin values in 3 different timeframes. B12 and folate were the most prevalent deficiencies. B12 deficiency was more common after RYGB and folate serum mean levels were higher after RYGB. SG causes less nutrient deficiency and is therefore a better technique from this point of view. More studies are needed on B2, B3, and B6 vitamins to draw better conclusions.

The effect of bariatric surgery on gravitational loading and its impact on bone mass

INTRODUCTION

Mechanical unloading associated with weight loss might be one of the main causes for bariatric surgery (BS) induced bone loss. However, no study has tested this hypothesis through objectively measured accelerometry-derived gravitational loading. We aimed to assess how gravitational loading changes following BS and how this correlates with bone mass losses.

METHODS

Twenty-one patients submitted to gastric bypass were assessed before, 1, 6 and 12 months after BS for areal bone mineral density (BMD), calciotropic hormones, sclerostin, body composition and daily physical activity. Gravitational loading was determined as the sum of ground reaction forces assessed by accelerometer which considered the interaction between weight and daily ambulation.

RESULTS

Mechanical stimuli promoted through the significant increase in steps number counterbalanced the gravitational loading decreases derived from the significant weight loss after BS. Gravitational loading volume decreased between pre-BS and 1 month post-BS (-2215 kN·d^-1; p = .023), but remained stable between 6 and 12 months post-BS, despite decreases on hip (-7.0%; p < .001), femoral neck (-8.8%; p < .001) and lumbar spine (-5.2%; p < .001) BMD. Serum sclerostin increased from pre-BS to 1 month post-BS (+0.118 ng·mL^-1; p = .021), returning to pre-BS levels 6 months after surgery. Neither vitamin D nor parathyroid hormone were affected by BS. Weight variation was a predictor of BMD decreases at total hip (R² = 0.06; p = .026) and femoral neck (R² = 0.12; p = .022), whereas daily gravitational loading volume was not. Fat and lean mass changes were also predictors of BMD decrease at total hip (R² = 0.05; p = .031) and femoral neck (R² = 0.14; p = .010), respectively.

CONCLUSION

Our findings suggest that gravitational loading only decreased during the first month after surgery remaining stable thereafter, and these changes do not seem to explain BS-induced bone loss. The association between weight and bone loss seems to result from other physiological aspects, fat and lean mass loss, rather than from gravitational loading decrease.

Clinical Outcome of Patients Submitted to Liver Resection in the Context of Metastatic Breast Cancer: A Study of a Tertiary Hospital Center

Introduction: Breast cancer is the most incident cancer in the world, accounting for 25% of new cancers per year in females. It is the most frequent malignancy in women, being the fifth cause of death from cancer worldwide. Approximately 5 to 10% of patients already present with metastases at diagnosis, and the liver is the site of metastases in half of these cases. Liver metastasis (LM) resection, performed after neoadjuvant systemic treatment, has been reported to increase median overall survival in this population. Aim: The aim of this analysis is to assess the outcomes of patients undergoing breast cancer liver metastasis surgical resection, including impact on survival, compared to patients where metastasectomy was not performed. Methods: retrospective review of 55 female patients with breast cancer liver metastases, diagnosed and treated in a single tertiary university hospital from January 2011 to December 2016 was performed. Results: In 32/55 patients (58.2%), multi-organ metastases were identified (the most common sites being bone, lungs, and lymph nodes). Of the remaining 23 patients, the liver was the unique metastatic site; thirteen patients had diffuse bilobar hepatic metastases. The remaining ten patients were proposed for surgical treatment; three of them had peritoneal carcinomatosis identified during surgery, and no hepatic metastasectomy was performed. As a result, only seven (12.7%) patients underwent liver metastasectomy. Overall survival was higher in patients who had LM surgery (65 months [Interquartile Range (IQR) 54–120]), in comparison to those diagnosed with diffuse bilobar hepatic metastases (17.5 months [IQR 11–41]), and with those showing concurrent liver and bone metastases (16.5 months [IQR 6–36]) (p = 0.012). In univariable analysis, the latter two groups showed worse overall survival outcomes (Hazard Ratio (HR) = 3.447, 95%CI: 1.218–9.756, p = 0.02 and HR = 3.855, 95% Confidence Interval (CI): 1.475–10.077, p = 0.006, respectively) when compared to patients with LM. Conclusion: In our series, patients submitted to metastasectomy had a median overall survival after diagnosis of LM three times greater than the non-operated patients with isolated LM, or concurrent LM and bone metastases (65 vs. 17.5 and 16.5 months, respectively). As is vastly known for colorectal cancer liver metastasis, resection of breast cancer liver metastasis may reduce tumor burden, and therefore may improve patient outcome.

Comparative Effectiveness of Bariatric Surgeries in Patients with Type 2 Diabetes Mellitus and BMI ≥ 25 kg/m2: a Systematic Review and Network Meta-Analysis

PURPOSE

In patients with type 2 diabetes mellitus (T2DM), bariatric surgery appears to be more effective than medical treatment (MT) at improving glycaemic control and decreasing cardiovascular risk. However, long-term effectiveness has not been systematically assessed using randomised controlled trials. In this study, we aimed to systematically assess randomised controlled trials, with at least 5 years of follow-up, on bariatric surgery in patients with T2DM and BMI ≥ 25 kg/m², as well as to compare different bariatric procedures.

MATERIAL AND METHODS

PubMed, SCOPUS and Web of Science were searched. We performed a network meta-analysis to evaluate the comparative effectiveness of the different procedures and MT in terms of full T2DM remission, weight loss, complications and cardiometabolic biomarkers. The quality of evidence was assessed using the Cochrane Risk of Bias Tool and CINeMA.

RESULTS

We included 11 primary studies. Laparoscopic one-anastomosis gastric bypass (LOAGB) was found to be one of the most effective treatments for full remission of T2DM (I² = 0, inconsistency p value = 0.9223). Biliopancreatic diversion without duodenal switch was found to be more effective than laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding regarding percent total cholesterol and low-density lipoprotein change. Regarding percent high-density lipoprotein and weight change, all analysed surgical treatments were shown to be more effective than MT. The confidence rating in our results was overall moderate, but most studies had high risk of performance and detection bias.

CONCLUSION

Bariatric surgery seems to be effective for T2DM remission. LOAGB appears to be a good option in this context, and a possible alternative to laparoscopic duodenal switch, but the included primary studies in our review are not sufficiently powered to establish a more definitive conclusion. More studies with longer follow-up times are needed to comprehensively assess bariatric surgery in T2DM.

How Does Bariatric Surgery Affect Fall Risk Factors?

PURPOSE

This study aimed to assess bariatric surgery (BS) effect on fall risk factors.

MATERIALS AND METHODS

Fifteen patients undergoing BS (intervention group, IG) and 10 non-surgical obese patients (control group, CG) were recruited. IG was assessed at pre-surgery and 6 months after BS, while CG was assessed at baseline and reassessed after 6 months. At both time-points, anthropometry, lower limbs muscle strength (isokinetic dynamometer), balance in bipedal stance (force platform), daily physical activity (accelerometry), and health-related quality of life (SF-36 questionnaire) were assessed.

RESULTS

At baseline, there were no differences between CG and IG for all parameters analyzed. Compared to CG, 6 months post-BS, the IG decreased weight, body mass index, waist and hip circumference. Balance showed limited improvements, with gains observed only on antero-posterior and total center of pressure velocity. Muscle strength displayed a divergent evolution 6 months after BS, with a decrease in absolute strength but an increase in relative strength. Although BS did not induce significant changes in time spent in different physical activity intensities, it decreased time in sedentary behavior and increased number of daily steps. Post-BS patients reported substantial improvements in quality-of-life, especially in physical function.

CONCLUSION

Patients seem to overestimate their actual physical fitness improvements attained after BS, which combined with increases in physical activity, might increase the likelihood of engaging in risky daily tasks to what they are physically not prepared to, consequently increasing fall risk.

The Effect of an Exercise Intervention Program on Bone Health After Bariatric Surgery: A Randomized Controlled Trial

Exercise has been suggested as a therapeutic approach to attenuate bone loss induced by bariatric surgery (BS), but its effectiveness remains unclear. Our aim was to determine if an exercise-training program could induce benefits on bone mass after BS. Eighty-four patients, submitted to gastric bypass or sleeve gastrectomy, were randomized to either exercise (EG) or control group (CG). One month post-BS, EG underwent a 11-month supervised multicomponent exercise program, while CG received only standard medical care. Patients were assessed before BS and at 1, 6, and 12 months post-BS for body composition, areal bone mineral density (BMD), bone turnover markers, calciotropic hormones, sclerostin, bone material strength index, muscle strength, and daily physical activity. A primary analysis was conducted according to intention-to-treat principles and the primary outcome was the between-group difference on lumbar spine BMD at 12 months post-BS. A secondary analysis was also performed to analyze if the exercise effect depended on training attendance. Twelve months post-BS, primary analysis results revealed that EG had a higher BMD at lumbar spine (+0.024 g∙cm^-2 [95% confidence interval (CI) 0.004, 0.044]; p = .015) compared with CG. Among total hip, femoral neck, and 1/3 radius secondary outcomes, only 1/3 radius BMD improved in EG compared with CG (+0.013 g∙cm^-2 [95% CI 0.003, 0.023]; p = .020). No significant exercise effects were observed on bone biochemical markers or bone material strength index. EG also had a higher lean mass (+1.5 kg [95% CI 0.1, 2.9]; p = .037) and higher number of high impacts (+51.4 [95% CI 6.6, 96.1]; p = .026) compared with CG. In addition, secondary analysis results suggest that exercise-induced benefits may be obtained on femoral neck BMD but only on those participants with ≥50% exercise attendance compared with CG (+5.3% [95% CI 2.0, 8.6]; p = .006). Our findings suggest that an exercise program is an effective strategy to ameliorate bone health in post-BS patients. © 2020 American Society for Bone and Mineral Research (ASBMR).

Bariatric Surgery Induces Retinal Thickening Without Affecting the Retinal Nerve Fiber Layer Independent of Diabetic Status

PURPOSE

Obese patients have neurodegeneration of the optic nerve demonstrated by decreased peripapillary nerve fiber layer. Whether bariatric surgery reverses this neurodegenerative process has not been explored. We aimed to evaluate the impact of bariatric surgery in the structure of the retina and optic nerve.

METHODS

Multicentric observational study. Obese patients scheduled for bariatric surgery were consecutively recruited and included in the study and evaluated before and 6-12 months after the intervention. The retinal structure was evaluated as retinal thickness in the different retinal layers in the foveal, perifoveal, and parafoveal regions using optical coherence tomography. Choroidal thickness and optic nerve retinal nerve fiber layer thickness were also evaluated.

RESULTS

Eighty eyes from 40 participants were included. Globally, we found a significant thickening of the retina after bariatric surgery (foveal: 273.5 (21.5) μm vs 280.0 (28.8) μm, p < 0.001; parafoveal 332.4 ± 17.8 μm vs 336.6 ± 15.9 μm, p = 0.003; perifoveal: 293.4 ± 13.8 μm vs 295.7 ± 14.9 μm; p = 0.001), whereas no significant differences were found for the ganglion cell layer, choroid, or peripapillary nerve fiber layer thickness. The retinal thickening was confined to inner retinal layers and was independent of the diabetic status of the patients. After multivariate adjustment, HbA1c variation, preoperative C-peptide, preoperative hypertension, preoperative OSA, and preoperative LDL and TG levels seem to be clinical predictors of retinal thickening.

CONCLUSIONS

We found a significant thickening of the retina after bariatric surgery that was independent of the diabetic status. The thickening was confined to inner retinal layers and may represent and improve perfusion. The peripapillary nerve fiber layer remained unchanged after the surgery.

Accelerometer-based prediction of skeletal mechanical loading during walking in normal weight to severely obese subjects

There is no objective way to monitor mechanical loading characteristics during exercise for bone health improvement. We developed accelerometry-based equations to predict ground reaction force (GRF) and loading rate (LR) in normal weight to severely obese subjects. Equations developed had a high and moderate accuracy for GRF and LR prediction, respectively, thereby representing an accessible way to determine mechanical loading characteristics in clinical settings.

INTRODUCTION

There is no way to objectively prescribe and monitor exercise for bone health improvement in obese patients based on mechanical loading characteristics. We aimed to develop accelerometry-based equations to predict peak ground reaction forces (pGRFs) and peak loading rate (pLR) on normal weight to severely obese subjects.

METHODS

Sixty-four subjects (45 females; 84.6 ± 21.7 kg) walked at different speeds (2-6 km·h^-1) on a force plate-equipped treadmill while wearing accelerometers at lower back and hip. Regression equations were developed to predict pGRF and pLR from accelerometry data. Leave-one-out cross-validation was used to calculate prediction accuracy and Bland-Altman plots. Actual and predicted values at different speeds were compared by repeated measures ANOVA.

RESULTS

Body mass and peak acceleration were included for pGRF prediction and body mass and peak acceleration transient rate for pLR prediction. All pGRF equation coefficients of determination were above 0.89, a good agreement between actual and predicted pGRFs, with a mean absolute percent error (MAPE) below 6.7%. No significant differences were observed between actual and predicted pGRFs at each walking speed. Accuracy indices from our equations were better than previously developed equations for normal weight subjects, namely a MAPE approximately 3 times smaller. All pLR prediction equations presented a lower accuracy compared to those developed to predict pGRF.

CONCLUSION

Walking pGRF and pLR in normal weight to severely obese subjects can be predicted with moderate to high accuracy by accelerometry-based equations, representing an easy and accessible way to determine mechanical loading characteristics in clinical settings.

Retinal Nerve Fiber Layer Thickness Decrease in Obesity as a Marker of Neurodegeneration

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a serious condition that is frequently associated with irreversibly vision loss, having a higher incidence among obese women. Our aims were to screen subclinical IIH in obese patients scheduled to bariatric surgery using peripapillary retinal nerve fiber layer (RNFL) thickness and to evaluate if the findings demand the possible need of a preoperative evaluation in this population.

METHODS

This study included 111 eyes from 36 obese patients (86% female, body mass index > 35 kg/m²) scheduled to bariatric surgery and 20 non-obese (body mass index < 25 kg/m²) age-matched controls. We measured sectorial and mean RNFL thickness in a 3.5-mm-diameter circular scan centered on the optic nerve head, using optical coherence tomography (Heidelberg Spectralis SD-OCT) in all participants. Multivariate linear regression was used for adjustments.

RESULTS

No patient had subclinical IIH corresponding to increased RNFL thickness. However, in obese individuals, global peripapillary RNFL was thinner than in controls (104 ± 6 μm versus 99 ± 12 μm, p = 0.005). Overall, RNFL thickness was superior in the control group for all sectors. The differences reached significance for the nasal, temporal, superior temporal, and inferior temporal sectors. These differences remained even after adjusting for possible confounders (hypertension, dyslipidemia, diabetes, age, sleep apnea syndrome, and sex).

CONCLUSIONS

Routine screening asymptomatic obese patients undergoing bariatric surgery for IIH using RNFL thickness was not clinically relevant in our study. However, we found that severe obesity is associated with neurodegeneration independently of the other components of the metabolic syndrome, what may justify future investigation on the need of monitoring these patients.

Accelerometry calibration in people with class II-III obesity: Energy expenditure prediction and physical activity intensity identification

BACKGROUND

Almost all accelerometer calibration studies were developed for non-obese people, which hampers an accurate prediction of energy expenditure (EE) and induces a misclassification of sedentary activity (SA) and physical activity intensities (PAI) in class II-III obese people.

RESEARCH QUESTION

The purpose of this study was to develop regression equations to predict EE and cut-points to classify SA and PAI in severe obese people based on several metrics obtained from hip and back accelerometer placement data.

METHODS

43 class II-III obese participants performed a protocol that included sitting and standing positions and walking at several speeds. During the protocol participants wore an accelerometer at hip and back, and respiratory gas exchange was measured by indirect calorimetry. Accelerometer metrics analyzed were: activity counts, mean amplitude deviation and euclidean norm minus one. EE was predicted through linear mixed models while cut-points to classify SA and PAI were obtained applying receiver operating characteristic curves. Leave-one-out cross-validation data was used to calculate Bland-Altman plots, prediction accuracy, Kappa statistic and percent agreement.

RESULTS

All prediction models presented a quadratic equation that had as predictors body mass and one of the accelerometer metrics. Predicted EE indicated a good agreement and a root mean square error below 1.02 kcal min^-1. Global classification agreement from developed cut-points was categorized as almost perfect with a percent agreement above 84 %. Prediction accuracy and classification agreement were similar among accelerometer metrics in each position and between them in hip and back placement.

SIGNIFICANCE

Hip and back accelerometer data collected in severe obese people allow to accurately estimate EE and to correctly classify SA and PAI. These results enable future studies to adopt appropriate regression equations and cut-points developed for class II-III obese people rather than those established for non-obese people.

Glycoproteomic analysis of serum from patients with gastric precancerous lesions

Gastric cancer is preceded by a carcinogenesis pathway that includes gastritis caused by Helicobacter pylori infection, chronic atrophic gastritis that may progress to intestinal metaplasia (IM), dysplasia, and ultimately gastric carcinoma of the more common intestinal subtype. The identification of glycosylation changes in circulating serum proteins in patients with precursor lesions of gastric cancer is of high interest and represents a source of putative new biomarkers for early diagnosis and intervention. This study applies a glycoproteomic approach to identify altered glycoproteins expressing the simple mucin-type carbohydrate antigens T and STn in the serum of patients with gastritis, IM (complete and incomplete subtypes), and control healthy individuals. The immunohistochemistry analysis of the gastric mucosa of these patients showed expression of T and STn antigens in gastric lesions, with STn being expressed only in IM. The serum glycoproteomic analysis using 2D-gel electrophoresis, Western blot, and MALDI-TOF/TOF mass spectrometry led to the identification of circulating proteins carrying these altered glycans. One of the glycoproteins identified was plasminogen, a protein that has been reported to play a role in H. pylori chronic infection of the gastric mucosa and is involved in extracellular matrix modeling and degradation. Plasminogen was further characterized and showed to carry STn antigens in patients with gastritis and IM. These results provide evidence of serum proteins displaying abnormal O-glycosylation in patients with precursor lesions of gastric carcinoma and include a panel of putative targets for the non-invasive clinical diagnosis of individuals with gastritis and IM.