Metabolic Surgery Research Articles

A second chance for a new heart? The role of metabolic and bariatric surgery in patients with end-stage heart failure

Obesity is an independent risk factor for heart failure (HF). Substantial weight loss has been shown to reverse obesity-related cardiomyopathy. This study aimed to report our institution's experience with laparoscopic sleeve gastrectomy (LSG) in patients with morbid obesity and end-stage HF. Between 2018 and 2022, 26 patients with end-stage HF were referred for LSG. Of 26 patients, 16 underwent an operation, and 10 did not. After institutional review board approval, a retrospective electronic medical record review was performed to evaluate (i) age, (ii) preoperative weight, (iii) decrease in body mass index (BMI) score, (iv) whether the patient underwent heart transplantation, and (v) mortality. Data analysis was performed using Stata/SE (version 17.0; StataCorp). The Wilcoxon rank-sum test was used to compare continuous variables between the cohorts, and the Pearson chi-square test was used for binary variables with Bonferroni correction applied. The LSG and non-LSG cohorts had comparable ages (P=.088) and starting BMI score (P=.918), and a proportion of patients had a ventricular assist device (P=.191). Patients who underwent LSG lost significantly more weight than the patients who did not, with an average decrease in BMI score of 8.9kg/m2 (SD, ±6.13) and 1.1kg/m2 (SD, ±4.10), respectively (P=.040). Of note, 6 patients (37.5%) who underwent LSG eventually underwent transplantation, compared with 2 patients (20.0%) from the matched cohort (P=.884). Of the 26 patients, there were 6 deaths: 2 (12.5%) in the LSG cohort and 4 (40.0%) in the non-LSG cohort (P=.525). LSG may be safe and effective for weight loss in patients with HF. This operation may provide patients affected by obesity with end-stage HF the lifesaving opportunity to achieve transplant candidacy.

Psychologic assessment in patients undergoing bariatric surgery.

Psychological Clearance level (PCL) for patients undergoing metabolic and bariatric surgery (MBS) is a critical step for successful postoperative outcomes. This study aims to assess the relationship between the level of psychologic fitness and postoperative outcomes in patients undergoing MBS. We retrospectively analyzed the data of patients who underwent MBS (laparoscopic sleeve gastrectomy [LSG] and laparoscopic Roux-en-Y Gastric Bypass [LRYGB]) and completed two years follow-up, between 2012 and 2019, in a single medical center. The patients were divided into four groups based on PCL, suggesting level of readiness for surgery: Group A (PCL-0: guarded), group B (PCL-1: Fair/reasonable), group C (PCL-2: Good/appropriate), and group D (PCL-3: Strong/excellent). Primary outcome was the percent of total body weight loss (%TWL), and the absolute change in BMI units. Secondary outcomes were missed postoperative visits and patient compliance. Differences between the groups were analyzed using a generalized linear model (GLM), chi-squared and exact Fisher tests, as appropriate. Of 1411 total patients, 607 (43.20%) had complete data at two years follow-up. 512 (84.34%) were females. LSG was performed in 361 (59.5%). No difference was found in %TWL between the four groups (22.14% vs. 28.0% vs. 26.0% vs. 24.8%, p = 0.118). We found a small difference in the mean (SD) of absolute change in BMI between the groups, and on post-hoc analysis it was found between groups B (PCL-1) and D (PCL-3). Overall, no difference between the groups in number of follow-up visits, or compliance issues. However, patients who attended more follow-up visits had less compliance issues (p < 0.001). PCL is inversely correlated with number of psychologic diagnoses (r = -0.41, p < 0.001) and medical comorbidities (r = -0.20, p < 0.001). We found no difference in the percent of TWL in patients who underwent MBS based on PCL at two -years follow-up. Medical comorbidities and psychiatric diagnoses impact the PCL.

Psychopathology, disordered eating, and impulsivity as predictors of weight loss 24 months after metabolic and bariatric surgery

BackgroundThe relationship between theoretically relevant psychosocial and behavioral variables and outcomes of metabolic and bariatric surgery remains unclear. Some studies have found that the presence of psychopathology, disordered eating, and impulsivity, either before surgery or during the early postoperative period, is associated with suboptimal postoperative weight loss. Other studies have not found these relationships. ObjectiveExamine the relationship between psychopathology, disordered eating, impulsivity, and weight loss 24 months postoperatively. SettingTwo large, urban university health systems. MethodsParticipant characteristics were collected using validated interviews, patient-reported outcome measures, and computerized assessment methods. Linear mixed effect models were used to test the association of the variables of interest on percent weight loss (%WL). ResultsThree hundred participants were enrolled at baseline; weight data at 24 months were available for 227 participants; between 181 and 53 individuals completed other outcome measures. The mean %WL was 23.3 ± 9.9% at 24 months. Patients who underwent Roux-en-Y gastric bypass lost more weight than those who underwent sleeve gastrectomy. The presence of subjective binge episodes at baseline was related to a greater %WL at 24 months; there were no other baseline predictors. The presence of eating disorder diagnoses and disordered eating symptoms after surgery were associated with smaller weight losses over 24 months. Current and lifetime psychopathology and impulsivity were unrelated to %WL at 24 months. ConclusionDisordered eating after bariatric surgery was associated with a smaller %WL at postoperative year 2. Additional monitoring of these symptoms in the early postoperative period is recommended. Psychotherapeutic and/or dietary interventions may promote more optimal weight loss outcomes.

Implementation of an ERAS protocol for pediatric metabolic and bariatric surgery: A single institutional perspective and lessons learned

BackgroundEnhanced recovery after surgery (ERAS) protocols have gained popularity in many surgical specialties. The overarching goals of ERAS include the use of comprehensive perioperative interventions to minimize postoperative nausea and vomiting (PONV), incorporate multimodal pain control, including reduced postoperative opioid utilization, encourage early postoperative mobilization and ambulation, and achieve prompt re-initiation of enteral nutrition. While many adult surgical programs have demonstrated successful implementation of ERAS protocols, there have been few descriptions in pediatric surgical literature focused on implementation of such strategies. In this review, we provide an overview of current pediatric-focused ERAS literature and highlight our institution's experience with implementing an ERAS protocol in our pediatric metabolic and bariatric surgery program. MethodsA literature search was conducted to review ERAS experience in adult and pediatric surgery. Our institution's bariatric surgery program is described from the pre-ERAS period to the inception of our ERAS protocol, and the evolution into its current form. Over this time, we eliminated the routine use of nasogastric tubes and urinary catheters, expanded our pre-operative initiatives, limited intra-operative fluids, updated the intraoperative anesthetic regimen, broadened our multimodal pain and PONV management, and developed post-operative recovery-focused patient goals to improve fluid intake, increase early ambulation and pulmonary toilet resulting in a shortened hospital length of stay. ConclusionPediatric surgical programs can benefit from utilization of ERAS strategies to decrease the time to enteral nutrition, provide comprehensive pain and PONV control, facilitate early ambulation, and reduction in hospital length of stay. Our a single-institutional experience deploying ERAS within the pediatric metabolic and bariatric surgery service has been successful and serves as a model for other surgical sub-specialty service lines within our organization.

Applying Opioid Free Anesthesia (Ofa) In Combination with Enhanced Recovery Anesthesia (Eras) In Bariatric-Metabolic Surgery: Evaluation at One Year Follow-Up with A Propensity Score

Since its introduction, laparoscopic bariatric metabolic surgery (BMS) has witnessed a consistant decrease in complications. Recently, enhanced recovery after surgery (ERAS) and opioid free (OFA) protocols have been developed separately to further improve outcomes. To assess the surgical outcomes after ERAS in combination with OFA (ERAS+OFA) in BMS. High volume bariatric metabolic center in Belgium. A retrospective observational study comparing by propensity score matching the outcomes of our center (ERAS+OFA) with the outcomes of an Italian center of excellence adhering to opioid sparing, but not opioid free ERAS (ERAS-OFA). Primary endpoints were: length of hospital stay, number of readmissions and complications including leaks and bleedings. Secondary endpoints were: the number and severity of complications as evaluated by the Clavien-Dindo score. Over a 12-month period, 341 consecutive patients treated according to ERAS+OFA in our center, were compared to 109 according to ERAS-OFA in the Italian center. Propensity matching resulted in comparable groups. Primary and secondary endpoints showed no significant difference between the 2 groups. Our study shows no statistically significant difference in BMS outcomes between ERAS+OFA compared to ERAS- OFA

Adipocyte-Specific Hnrnpa1 Knockout Aggravates Obesity-Induced Metabolic Dysfunction via Upregulation of CCL2.

Heterogeneous nuclear ribonucleoprotein A1 (HNRNPA1) is involved in lipid and glucose metabolism via mRNA processing. However, whether and how HNRNPA1 alters adipocyte function in obesity remain obscure. Here, we found that obese state downregulated HNRNPA1 expression in white adipose tissue (WAT). The depletion of adipocyte HNRNPA1 promoted markedly increased macrophage infiltration, proinflammatory and fibrosis genes expression in WAT of obese mice, eventually leading to exacerbated insulin sensitivity, glucose tolerance, and hepatic steatosis. Mechanistically, HNRNPA1 interacted with Ccl2 and regulated its mRNA stability. Intraperitoneal injection of CCL2-CCR2 signaling antagonist improved adipose tissue inflammation and systemic glucose homeostasis. Furthermore, HNRNPA1 expression in human WAT was negatively correlated with BMI, fat percentage, and subcutaneous fat area. Among individuals with 1-year metabolic surgery follow-up, HNRNPA1 expression was positively related to percentage of total weight loss. These findings identify adipocyte HNRNPA1 as a link between adipose tissue inflammation and systemic metabolic homeostasis, which might be a promising therapeutic target for obesity related disorders.

Intestinal heat shock proteins in metabolic syndrome: Novel mediators of obesity and its comorbidities resolution after metabolic surgery.

Over the past 40 years, the prevalence of obesity has risen dramatically, reaching epidemic proportions. Metabolic surgery has proven to be highly effective in treating obesity, leading to significant improvements or complete resolution of obesity-related comorbidities. Research conducted in both animals and humans suggests that the metabolic benefits achieved through metabolic surgery cannot be solely attributed to weight loss. Indeed, there has been an increasing recognition of intestinal inflammation as a novel factor influencing obesity. The gastrointestinal tract is continuously exposed to dietary components, particularly diets rich in saturated fats, which are known to contribute to obesity. It is now widely accepted that heat shock proteins can be released from various cells including intestinal epithelial cells and act as proinflammatory signals. Several studies have shown that circulating levels of glucose-regulated protein 78 (GRP78) are increased in subjects with obesity and correlate with the severity of the disease. Moreover, mice with a partial knockout of GRP78 are protected from diet-induced obesity. In this review, we discuss the role of GRP78 in the development of obesity. Several evidence suggests that GRP78 can influence adipogenesis, lipid droplets stabilization, insulin resistance, and liver steatosis. We also provide an update on GRP78 regulation following metabolic surgery, focusing on the bypass of the small intestine as a key factor for GRP78 secretion. Finally, we discuss the potential role of monoclonal antibodies against GRP78 as a treatment for obesity.

Leptin receptor deficiency impedes metabolic surgery related-weight loss through inhibition of energy expenditure in db/db mice

BackgroundRoux-en-Y gastric bypass (RYGB) surgery is an effective metabolic surgery against diabetes and obesity. Clinical evidence indicates that patients with severe obesity have a poor curative effect in losing weight if they suffer from leptin or its receptor deficiency, but the underlying mechanism remains elusive. Here, we investigated the effect of leptin receptor deficiency on metabolic dysfunction in db/db mice treated by RYGB surgery.MethodsThe db/db mice and their heterozygote control db/m mice were subjected to RYGB or sham surgery. Body weight, blood glucose, food intake and glucose tolerance were evaluated. Micro-PET/CT and histological analysis were performed to examine the glucose uptake of tissues and the fat changes in mice. The key factors in glucose and fatty acid metabolism were detected by western blot analysis.ResultsCompared with the sham group, the db/db mice in the RYGB group showed more significant weight regain after surgical recovery and improvement in hyperinsulinemia and glucose tolerance. However, the total body fat and multiple organ lipid deposition of RYGB-treated db/db mice was increased. The underlying mechanism studies suggested that the activation of AMPK regulated GLUT4 to increase glucose uptake, but AMPK could not promote fatty acid oxidation through the JAK2/STAT3 pathway under leptin receptor deficiency in db/db mice.ConclusionWe conclude that leptin receptor deficiency impedes the AMPK activation-mediated fat catabolism but does not affect AMPK-related glucose utilization after metabolic surgery in db/db mice. This result helps select surgical indications for patients with obesity and diabetes.

Pre-surgical factors related to latent trajectories of 5-year weight loss for a diverse bariatric surgery population

BackgroundAnalyzing trajectories of weight loss may address how particular groups of patients respond to metabolic and bariatric surgery. ObjectivesThe Bariatric Experience Long Term (BELONG) study was designed to use a theoretical model to examine determinants of weight loss and recurrence. SettingLarge integrated health system in Southern California with 11 surgical practices and 23 surgeons. MethodsA total of n = 1338 patients who had metabolic and bariatric surgery were surveyed before surgery to measure factors related to median percent total weight loss (%TWL) over 5 years. Longitudinal weight data were available for n = 1024 (76.5% of the sample). Data were analyzed using latent growth mixture models (GMM) to estimate trajectories of weight change separately for gastric sleeve and bypass operations. These trajectories were then described using relevant variables from the baseline survey. ResultsFor both gastric sleeve (n = 733) and bypass (n = 291) operations, 3 latent trajectories of median %TWL were found corresponding to most, moderate, and least %TWL. Sleeve trajectories were distinguished by body mass index at surgery and geocoded environmental factors. Bypass trajectories varied by self-reported and geocoded environmental factors, comorbidity burden, race, experiential avoidance, and weight control strategies. ConclusionsFuture research should examine the role of the built and perceived environment in surgical weight loss. Bariatric practices should focus less on the presurgical period for predictors of long-term weight loss and begin efforts to monitor real-time patient-reported outcomes to help tailor intervention strategies for patients who either do not lose an expected amount of weight or who begin to experience weight recurrence.

Early postoperative COVID infection is associated with significantly increased risk of venous thromboembolism after metabolic and bariatric surgery

BackgroundPatients who undergo metabolic and bariatric surgery (MBS) are at risk for thromboembolism. Patients are susceptible to coronavirus throughout the perioperative period, which also has a well-known association with thrombotic complications. ObjectivesTo identify and define the association between venous thromboembolism (VTE) and postoperative coronavirus diagnosis in bariatric surgery patients. SettingUnited States. MethodsWe conducted a retrospective cohort study using the MBS Accreditation and Quality Improvement Program (MBSAQIP) 2021 database to analyze the incidence of VTE within 30 days of surgery. VTE was a composite variable defined as either postoperative pulmonary embolism or postoperative venous thrombus requiring treatment. Cohorts were stratified by whether the patient was diagnosed with postoperative coronavirus. We created a multivariable logistic regression model to determine the adjusted odds of postoperative VTE based on various factors. Additionally, we conducted subset analyses of sleeve gastrectomy and Roux-en-Y bypass cases, the 2 most frequent bariatric operations in the United States. ResultsPatients diagnosed with postoperative coronavirus were significantly more likely to develop postoperative VTE (1.1% versus .3%, P < .001). In our logistic regression model, the adjusted odds of postoperative VTE for patients with postoperative coronavirus was 3.55 (95% CI: 2.15–5.87, P < .001). For patients who underwent Roux-en-Y bypass, the adjusted odds was even greater at 5.69 (95% CI: 2.76–11.70, P < .001). ConclusionsEarly postoperative coronavirus infection after MBS is associated with higher odds of postoperative VTE. This persisted on subset analyses of the 2 most common procedures and appeared particularly important for Roux-en-Y bypass. COVID infection after MBS may warrant prolonged VTE prophylaxis.

Readmission and reoperation rates after laparoscopic bariatric surgery in an Italian center of excellence.

The aim of this study was to analyze short-term outcomes focusing on readmissions after laparoscopic bariatric metabolic surgery (BMS) in an Italian academic Bariatric Center of Excellence IFSO-European Chapter (EC). This is a retrospective study based on the analysis of a prospectively maintained institutional database. Patients aged between 18 and 65 years who underwent primary BMS and/or revisional BMS (RBMS) between 2012 and 2021 were included. Primary endpoint was to analyze the readmission rate at 30 postoperative days. The secondary endpoint involved assessing the causes of readmission within 30 days of discharge, the rates, and types of reoperations and/or additional procedures related to the first surgery, and the outcomes of readmitted patients. A total of 2297 patients were included in the study. Among them, 2143 underwent primary surgery and 154 patients underwent RBMS. Eighty-two percent of the Enhanced Recovery after Surgery (ERAS) protocol items were applied starting from 2016. Within 30 days after discharge, 48 patients (2.09%) were readmitted. Overall readmission rate following primary and revisional BMS was 2.15%, respectively 1.30%. Ten readmitted patients (20.8%) had complications graded IIIb or more (Clavien-Dindo classification) and needed additional procedures. Mortality rate was 4.17% among readmitted patients. Only 2.09% of patients undergoing laparoscopic bariatric surgery were readmitted. Of these, 20.8% required additional procedures. Standardization of surgical techniques and perioperative protocols in a bariatric center of excellence resulted in a low readmission rate even in RBMS.

Effect of Preoperative Very Low-Calorie Diets on Hepatic Steatosis, Fibrosis, and Perioperative Outcomes of Bariatric Surgery.

Introduction: Preoperative weight loss through a very low-calorie diet (VLCD) has been shown to reduce liver volume and technical difficulty in patients undergoing metabolic and bariatric surgery (MBS). However, the effect of preoperative VLCD on liver histology and other outcomes is not well demonstrated. Our study aimed to explore the effect of a 2-week preoperative VLCD, compared with no-dietary intervention, on hepatic steatosis, fibrosis, weight loss, and other postoperative outcomes of MBS. Materials and Methods: This retrospective study was conducted at the Chulalongkorn Bariatric and Metabolic Institute, King Chulalongkorn Memorial Hospital, Bangkok, Thailand. The medical records of patients with severe obesity (body mass index ≥50 kg/m2) attending the clinic from January 2005 to December 2020 were reviewed. Clinical data and laboratory investigations were collected at baseline and at each follow-up visit, up to 5 years postoperatively. Hepatic steatosis and fibrosis were assessed by liver biopsy intraoperatively. Results: A total of 181 patients were included in this study. Preoperative VLCD was prescribed in 65 patients (VLCD group) and 116 patients received their usual diet (control group). Mean preoperative weight loss was 9.1 ± 6.1 kg in the VLCD group versus 0.0 ± 0.0 kg in the control group (P = .000). The VLCD group had significantly less number of patients with moderate and severe liver steatosis from the liver biopsy specimens (16.2% versus 46.3%; P = .008). However, there was no significant difference in fibrosis grade between those with VLCD and control (≥F2-fibrosis; 2.7% versus 7.5%; P = .118). Moreover, preoperative VLCD could reduce operating time in patients who underwent both laparoscopic Roux-en-Y gastric bypass (LRYGB; VLCD 163.4 ± 38.2 minutes versus control 215.1 ± 67.4 minute, P = .000) and laparoscopic sleeve gastrectomy (LSG; VLCD 110.8 ± 20.0 minutes versus control 131.0 ± 38.1 minutes, P = .004). During the 5-year follow-up, there were a significant difference of HbA1C between the VLCD and the control group (coefficient: -0.24 with 95% confidence interval [CI]: -0.44 to -0.04, P = .019), particularly in patients who underwent LRYGB (Coefficient: -0.26 with 95% CI: -0.49 to -0.03, P = .028), but not LSG. However, long-term weight loss outcomes and other biochemical outcomes were not different between the VLCD and the control group. Conclusion: Preoperative VLCD was associated with reduced liver steatosis and operative time in patients who underwent LRYGB and LSG. Moreover, preoperative VLCD significantly decreased HbA1C during a 5-year follow-up period. Therefore, it should be considered in patients with severe obesity, who will undergo MBS.

The risk and benefit of revisional vs. primary metabolic- bariatric surgery and drug therapy - A narrative review

Metabolic and bariatric surgery (MBS) leads to long-term weight loss, reduced risk of cardiovascular events and cancer, and reduced mortality. Sleeve gastrectomy and Roux-en-Y gastric bypass are currently the most common surgical techniques.Weight loss after MBS was previously believed to work through restriction and malabsorption, however, mechanistic studies show that MBS techniques with long term efficacy instead alter physiological signaling between the gut and the brain.In revisional MBS, the initial surgical technique is corrected, modified, or converted to a new one. The indication for revisional MBS can be to achieve further weight loss or improvement in obesity comorbidity, but it may be necessary due to complications (e.g., gastroesophageal reflux or obstruction). Revisional MBS is associated with an increased risk of surgical complications and often less weight loss compared to the results following primary surgery.This narrative review summarizes data from revisional MBS where information is often presented with inconsistent definitions for indications and outcomes, making comparison between strategies difficult. In summary, we suggest careful weighing of potential benefits and risks with revisional MBS, bearing in mind the option of add-on therapy with new anti-obesity drugs.

Comparison of Histological Skin Changes After Massive Weight Loss in Post-bariatric and Non-bariatric Patients.

Changes in the skin structure, including the collagen and elastin content, have been reported with massive weight loss (MWL) following bariatric metabolic surgery (BMS) and have been correlated to a higher risk of complications after body-contouring surgery (BCS). This study aimed at comparing the histological characteristics of the skin of patients having surgical MWL (SMWL) post-BMS to those with non-surgical massive weight loss (NSMWL). This prospective study compared the epidermal thickness, and collagen and elastin fibers content in 80 skin biopsies obtained from BCS procedures performed to patients who experienced MWL defined more than 50% of excess weight loss (%EWL) either SMWL (40 biopsies) or NSMWL (40 biopsies). Twenty biopsies in each group were obtained from abdominoplasties and 20 from breast reductions. Epidermal thickness was measured in H&E-stained sections, collagen fibers were assessed using Masson trichrome-stained sections, and elastin fibers were assessed using Modified Verhoeff's stained sections. Image analysis software was used to calculate the fractions of collagen and elastin fibers. This study included 77 patients, 38 SMWL patients, and 39 NSMWL patients. The SMWL group had a significantly higher age (p < 0.001), a longer time interval from intervention (p < 0.001), higher initial weight (p < 0.001), higher initial BMI (p < 0.001), lower current weight (p = 0.005), lower current BMI (p < 0.001), and significantly higher %EWL than NSMWL group (p < 0.001). No significant differences were detected between the two groups regarding complications after abdominoplasty (p = 1.000). The elastic fibers content in the dermis was significantly higher in the abdominal region of the NSMWL group than SMWL (p = 0.029). All other parameters showed non-significant differences between NSMWL and SMWL in the skin of abdomen and breast. The SMWL group had a significant reduction in elastic fiber content in the skin of the abdomen compared to the NSMWL group. The collagen content was equally reduced in both groups with non-significant differences in both breast and abdomen regions in both groups.

Further evidence regarding the convergent and discriminant validity of Minnesota Multiphasic Personality Inventory-3 (MMPI-3) scores in the preoperative psychological evaluation of patients seeking metabolic and bariatric surgery

BackgroundPsychological testing is used in some preoperative psychological evaluations of patients seeking metabolic and bariatric surgery. The Minnesota Multiphasic Personality Inventory-3 (MMPI-3) contains new norms, updated item content, and new scales such as Eating Concerns and Impulsivity, which are relevant to the assessment of patients seeking metabolic and bariatric surgery. ObjectiveThe goal of this investigation was to establish convergent and discriminant properties of the MMPI-3 scales with relevant clinical interview and medical record data from electronic medical records. SettingAcademic medical center in the Midwest. MethodsA sample of 790 consecutive patients who completed a preoperative psychological evaluation and took the MMPI-3 were included. Data from medical records and the assessment report were coded by a trained research assistant. ResultsMMPI-3 scale scores demonstrated good convergent and discriminant validity. For instance, the Emotional/Internalizing Dysfunction scales correlated with depression and anxiety disorder, suicide history, sexual abuse history, psychotropic medication use, and eating behaviors. Behavioral/Externalizing Dysfunction scales correlated with alcohol, nicotine, and substance use and eating behaviors such as loss-of-control overeating. The Eating Concerns scale demonstrated the highest correlational patterns with various eating behaviors such as loss-of-control overeating, binge eating, and stress eating. ConclusionsMMPI-3 scale scores perform as well as their Minnesota Multiphasic Personality Inventory-2 Restructured Form counterparts. Newer scales, such as Eating Concerns and Impulsivity, perform particularly well in the assessment of various eating behaviors.

Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60kg/m2): a Modified Delphi Study.

Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved. A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations. This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

Post metabolic bariatric surgery weight regain: the importance of GLP-1 levels.

Weight regain and insufficient weight loss are essential problems after metabolic bariatric surgery (MBS) in people living with obesity. Changes in the level of glucagon-like peptide-1 (GLP-1) secreted from the gut after bariatric surgery are one of the underlying mechanisms for successful initial weight loss. Studies and meta-analyses have revealed that postprandial GLP-1 levels increase after the Roux-en-Y gastric bypass and sleeve gastrectomy, but fasting GLP-1 levels do not increase significantly. Some observational studies have shown the relationship between higher postprandial GLP-1 levels and successful weight loss after bariatric surgery. There is growing evidence that GLP-1-receptor agonist (GLP-1-RA) use in patients who regained weight after bariatric surgery has resulted in significant weight loss. In this review, we aimed to summarize the changes in endogenous GLP-1 levels and their association with weight loss after MBS, describe the effects of GLP-1-RA use on weight loss after MBS, and emphasize metabolic adaptations in light of the recent literature. We hypothesized that maintaining higher basal-bolus GLP-1-RA levels may be a promising treatment choice in people with obesity who failed to lose weight after bariatric surgery.

The Effects of Preoperative Glycaemic Control (HbA1c) on Bariatric and Metabolic Surgery Outcomes: Data from a Tertiary-Referral Bariatric Centre in the UK

BackgroundCurrent recommendations advocate the achievement of an optimal glucose control (HbA1c < 69 mmol/mol) prior to elective surgery to reduce risks of peri- and post-operative complications, but the relevance for this glycaemic threshold prior to Bariatric Metabolic Surgery (BMS) following a specialist weight management programme remains unclear.MethodsWe undertook a retrospective cohort study of patients with type 2 diabetes mellitus (T2DM) who underwent BMS over a 6-year period (2016–2022) at a regional tertiary referral following completion of a specialist multidisciplinary weight management. Post-operative outcomes of interest included 30-day mortality, readmission rates, need for Intensive Care Unit (ICU) care and hospital length of stay (LOS) and were assessed according to HbA1c cut-off values of < 69 (N = 202) and > 69 mmol/mol (N = 67) as well as a continuous variable.ResultsA total of 269 patients with T2D were included in this study. Patients underwent primary Roux en-Y gastric bypass (RYGB, n = 136), Sleeve Gastrectomy (SG, n = 124), insertion of gastric band (n = 4) or one-anastomosis gastric bypass (OAGB, n = 4). No significant differences in the rates of complications were observed between the two groups of pre-operative HbA1c cut-off values. No HbA1c threshold was observed for glycaemic control that would affect the peri- and post-operative complications following BMS.ConclusionsWe observed no associations between pre-operative HbA1C values and the risk of peri- and post-operative complications. In the context of a specialist multidisciplinary weight management programme, optimising pre-operative HbA1C to a recommended target value prior to BMS may not translate into reduced risks of peri- and post-operative complications.Graphical

Type-2 diabetes mellitus remission prediction models after Roux-En-Y gastric bypass and sleeve gastrectomy based on disease severity scores

AimMetabolic and bariatric surgery (MBS) is considered one of the most effective interventions for weight loss and associated type-2 diabetes mellitus (T2DM) remission. Multiple scores including the Individualized Metabolic Surgery (IMS), DiaRem, advanced DiaRem, and Robert et al. scores, have been developed predict T2DM remission after MBS. We aim to validate each of these scores in our cohort of patients undergoing MBS with long-term follow-up and assess their efficacy based on procedure type and preoperative BMI. MethodsWe conducted a multicenter cohort study including patients with T2DM undergoing either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Areas under the receiver operating characteristics (ROC) curve (AUC) were calculated to assess the discriminatory ability of the four models to detect T2DM remission. ResultsA total of 503 patients (67 % females, mean age 53.5 [11] years, BMI 46.2 [8.8] kg/m2) with T2DM were included. The majority (78 %) underwent RYGB, while the rest (28 %) had SG. All four scores predicted T2DM remission in our cohort with an ROC AUC of 0.79 for IMS, 0.78 for both DiaRem and advanced-DiaRem, and 0.75 for Robert et al. score. Specific subgroups for each of these scores demonstrated higher T2DM remission rates after RYGB compared to SG. ConclusionWe demonstrate the ability of the IMS, DiaRem, advanced-DiaRem and Robert et al. scores to predict T2DM remission in patients undergoing MBS. T2DM remission rates was demonstrated to decrease with more severe IMS, DiaRem and advanced-DiaRem scores and lower Robert et al. scores.

One Anastomosis Gastric Bypass as Revisional Surgery Following Sleeve Gastrectomy: A Systematic Review and Meta-Analysis.

Although sleeve gastrectomy (SG) is the most performed metabolic and bariatric surgery (MBS) worldwide, some patients require conversional procedures due to weight recurrence or late complications. Recently, one-anastomosis gastric bypass (OAGB) gained popularity as a viable option to address those problems. The aim of this meta-analysis is to assess the safety and efficacy of conversional OAGB after primary SG in the management of patients with obesity. Cochrane, Embase, PubMed, Scopus, and Web of Science were searched for articles from their inception to February 2023 by two independent reviewers using the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) system. The review was registered prospectively with PROSPERO (CRD42023403528). From 1,117 studies screened, twenty studies met the eligibility criteria, with a total of 1,057 patients with obesity undergoing conversional OAGB after primary SG. The mean age ranged from 28.2 to 49.5years, and 744 patients (75.2%) were women. At one year after revisional OAGB, the pooled mean percent excess weight loss (%EWL) was 65.2% (95%CI: 56.9, 73.4, I2 = 97%). The pooled mean %EWL after conversional OAGB was 71.1% (95%CI: 62.2, 80.0, I2 = 90%) at two years and 71.6% (95%CI: 61.0, 82.2, I2 = 50%) at five years. Additionally, resolution rates of diabetes and hypertension were 65.4% (95%CI: 0.522, 0.785, I2 = 65%) and 58.9% (95%CI: 0.415, 0.762, I2 = 89%), respectively. Our meta-analysis demonstrated OAGB as an effective conversional procedure after primary SG in terms of weight loss and obesity-associated medical problems for selected patients. Despite the promising results, further randomized controlled studies with larger sample sizes and more extended follow-up periods are necessary to determine if the OAGB is the best conversional surgery after SG.