Remission Of Obesity-related Comorbidities Research Articles

Metabolic surgery results in greater metabolic benefits in patients who achieve healthy weight

BackgroundA percentage of total weight loss (%TWL) >20% as the expected weight loss target after metabolic surgery might be insufficient to produce adequate metabolic benefits. ObjectivesThis study identified the optimal weight loss target to achieve substantial benefits from metabolic surgery. SettingUniversity-affiliated tertiary care center. MethodsIn this retrospective study, participants were categorized into healthy weight (18.5 kg/m2 ≤ body mass index [BMI] < 24 kg/m2), overweight (24 kg/m2 ≤ BMI < 28 kg/m2), and obesity groups (BMI ≥28 kg/m2) according to their BMI 1 year after metabolic surgery. The weight loss and remission of obesity-related comorbidities were evaluated. Ordinal logistic regression analysis was used to identify predictors for achieving healthy weight 1 year postoperatively. ResultsOverall, 125 patients (112 sleeve gastrectomies, 13 Roux-en-Y gastric bypasses) were recruited in this study. Forty-two participants achieved healthy weight, 38 were overweight, and 45 had obesity. Type 2 diabetes mellitus and obstructive sleep apnea were relieved in all groups. Individuals who achieved healthy weight showed more improvements in nonalcoholic fatty liver disease, hypertension, and hyperuricemia than those who did not. Preoperative BMI was an independent predictor for the BMI achieved postoperatively, and the optimal cut-off point for achieving healthy weight was 34.9 kg/m2. ConclusionsHealthy weight was a more stringent target for patients who underwent metabolic surgery than the %TWL. Populations with a preoperative BMI of <34.9 kg/m2 were prone to realize the goal. Additional weight loss interventions could be considered for those with higher preoperative BMIs and enforced within 1 year postoperatively.

Biliopancreatic diversion for severe obesity: long-term weight maintenance and occurrence of nutritional complications are two facets of the same coin.

Despite the widespread clinical use of hypoabsorptive metabolic bariatric surgery, very long-term outcomes are still lacking. The aim of the study was to assess the long-term safety and efficacy of biliopancreatic diversion at 30 years in patients with class 3 obesity (BMI over 40 kg/m2). This retrospective single-centre study used data from a prospectively collected database on a sample of consecutive patients submitted to biliopancreatic diversion with a minimum follow-up of 30 years. Outcomes assessed included overall survival, long-term weight loss and weight maintenance, remission of obesity-related co-morbidities, and short- and long-term surgical and/or nutritional or metabolic complications. Among 199 consecutive patients (136 female, 63 male) who had surgery between November 1992 and April 1994, the mean age at operation was 38 (range 14-69) years and mean preoperative BMI was 48.7 (32.0-74.3) kg/m2. At baseline, 91 of 199 patients (45.7%) had type 2 diabetes. At 20 and 30 years, 122 (61%) and 38 (19%) of the 199 patients respectively were available for follow-up. At 30 years, the overall mortality rate was 12% (23 of 199). Surgical complications were concentrated in the short-term follow-up, whereas nutritional or metabolic complications increased progressively over time. A nutritional complication was diagnosed in 73 of 122 patients (60%) at 20 years and 28 of 38 (74%) at 30 years. Weight loss and glycaemic control were maintained throughout the follow-up; mean % total weight loss was 32.8 (range 14.1-50.0) at 1 year and 37.7 (range 16.7-64.8) at 30 years. One patient presented with recurrence of type 2 diabetes at 20 and 30 years; there were no patients with new-onset type 2 diabetes. Biliopancreatic diversion leads to good and sustained weight maintenance up to 30 years with low perioperative risk, but at the cost of a high long-term prevalence of nutritional complications.

Health-related quality of life outcomes following Roux-en-Y gastric bypass versus one anastomosis gastric bypass.

Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) are effective standard bariatric surgeries with comparable weight loss and remission of obesity-related comorbidities. As procedure-specific health-related quality of life (HrQoL) outcomes have not been directly compared thus far, we conducted this questionnaire-based study. Two hundred forty patients after undergoing either RYGB or OAGB between 2011 and 2016 were contacted and asked to fill out SF36 and BAROS questionnaires. All statistical analysis was performed with Microsoft Excel and GraphPad Prism. Primary objectives were procedure-dependent differences in HrQoL. Secondary objectives were weight loss and remission of comorbidities. One hundred nineteen of 240 contacted patients (49.6%) replied, 58 after RYGB (48.7%) and 61 after OAGB (51.3%). Follow-up period was < 24months in 52 and > 24months in 64 evaluable patients. The mean age was 46years (range 23 to 71). Regarding the < 24months groups, both physical and psychological SF36 sum scales were comparably high. Only the subcategory "general health perception" was significantly better after RYGB. Significantly higher excess weight loss (EWL) after RYGB (88.81%) compared to OAGB (66.25%) caused significantly better global < 24months BAROS outcomes, whereas remission of comorbidities and HrQoL was similar. Both > 24months groups showed high SF36-HrQoL sum scales. Global mean BAROS results after > 24months were "very good" in both procedures. EWL in RYGB (80.81%) and in OAGB (81.36%) were comparably excellent. Concerning SF36 and BAROS evaluated HrQoL in early and late postoperative phases, both procedures demonstrated comparable and relevant improvements. Further (preferably randomized) studies should include evaluation of preoperative HrQoL.

Effect of Laparoscopic Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Weight Loss, Comorbidities, and Reflux at 10 Years in Adult Patients With Obesity

Long-term results from randomized clinical trials comparing laparoscopic sleeve gastrectomy (LSG) with laparoscopic Roux-en-Y-gastric bypass (LRYGB) are limited. To compare long-term outcomes of weight loss and remission of obesity-related comorbidities and the prevalence of gastroesophageal reflux symptoms (GERD), endoscopic esophagitis, and Barrett esophagus (BE) after LSG and LRYGB at 10 years. This 10-year observational follow-up evaluated patients in the Sleeve vs Bypass (SLEEVEPASS) multicenter equivalence randomized clinical trial comparing LSG and LRYGB in the treatment of severe obesity in which 240 patients aged 18 to 60 years with median body mass index of 44.6 were randomized to LSG (n = 121) or LRYGB (n = 119). The initial trial was conducted from April 2008 to June 2010 in Finland, with last follow-up on January 27, 2021. LSG or LRYGB. The primary end point was 5-year percentage excess weight loss (%EWL). This current analysis focused on 10-year outcomes with special reference to reflux and BE. At 10 years, of 240 randomized patients (121 randomized to LSG and 119 to LRYGB; 167 women [69.6%]; mean [SD] age, 48.4 [9.4] years; mean [SD] baseline BMI, 45.9 [6.0]), 2 never underwent surgery and there were 10 unrelated deaths; 193 of the remaining 228 patients (85%) completed follow-up on weight loss and comorbidities, and 176 of 228 (77%) underwent gastroscopy. Median (range) %EWL was 43.5% (2.1%-109.2%) after LSG and 50.7% (1.7%-111.7%) after LRYGB. Mean estimate %EWL was not equivalent between the procedures; %EWL was 8.4 (95% CI, 3.1-13.6) higher in LRYGB. After LSG and LRYGB, there was no statistically significant difference in type 2 diabetes remission (26% and 33%, respectively; P = .63), dyslipidemia (19% and 35%, respectively; P = .23), or obstructive sleep apnea (16% and 31%, respectively; P = .30). Hypertension remission was superior after LRYGB (8% vs 24%; P = .04). Esophagitis was more prevalent after LSG (31% vs 7%; P < .001) with no statistically significant difference in BE (4% vs 4%; P = .29). The overall reoperation rate was 15.7% for LSG and 18.5% for LRYGB (P = .57). At 10 years, %EWL was greater after LRYGB and the procedures were not equivalent for weight loss, but both LSG and LRYGB resulted in good and sustainable weight loss. Esophagitis was more prevalent after LSG, but the cumulative incidence of BE was markedly lower than in previous trials and similar after both procedures. ClinicalTrials.gov Identifier: NCT00793143.

Current Status of Robot-Assisted Revisional Bariatric Surgery

Bariatric surgery has been demonstrated to be effective in achieving significant weight loss and remission of obesity-related comorbidities. However, a percentage of patients fail to lose enough weight, regain weight, or experience postoperative complications, requiring additional interventions. Revisional bariatric surgeries (RBS) involve the wide spectrum of procedures that aim to treat complications of the index operation or achieve further weight loss. These are technically challenging procedures due to adhesions of the internal organs, reduced working space, and a distorted anatomy. Indications, timing, and type of operation for RBS are not standardized, and there is no consensus on the best surgical approach. Some authors claim a robotic platform could be advantageous in these types of procedures that are performed in reduced, deep operating fields, or those requiring precision and accuracy. This review examines the most current and representative literature on the outcomes of robot-assisted RBS. Included studies demonstrate the safety and feasibility of the robotic approach for RBS. However, long operative times and high costs remain major drawbacks of the device. Finally, if we consider that many centers have not yet completed the learning curve for robot-assisted RBS, the potential for improved outcomes seems promising.

Comparative study between sleeve gastrectomy with cruroplasty and Roux-en-Y gastric bypass in morbid obese patients with gastro-esophageal reflux disease

Background: Obesity is a worldwide pandemic and one of the most serious public health issues and causes a lot of complications to obese patients as gastroesophageal reflux disease (GERD). Bariatric surgery proves more effectiveness for morbid obese patients to lose weight and is demonstrated to include significant and long term remission of obesity related comorbidities. Methods: This a controlled clinical trial study involved 50 patients, who are diagnosed as a morbidly obese patients with GERD grade(A) and (B) by endoscopy according to their BMI (&gt;40) or &gt;35 with one or two of obesity related co-morbidities such as diabetes mellitus. Patients were divided into 2 groups, group (A) (25 patients) underwent LSG with cruroplasty, and group (B) (25 patients) underwent LRYGB. Results: There was no statistically significant difference found between the two studied groups regarding EBW loss percentage at 1 month while there was statistically significant increase in the EBW loss percentage at 3 months, 6 months and at 1 year in LRYGB group than LSG with cururoplasty group.

Characteristics of Childhood Onset and Post-Puberty Onset Obesity and Weight Regain after Laparoscopic Sleeve Gastrectomy in Japanese Subjects: A Subgroup Analysis of J-SMART

Introduction: The psychosocial background of subjects with severe obesity developed from childhood onset obesity (CO) and their outcomes after bariatric surgery have not been fully investigated. Methods: 305 subjects were enrolled in the J-SMART study, which examined the effects of laparoscopic sleeve gastrectomy (LSG) in Japan, and categorized into two groups: CO defined as onset up to 13 years of age (CO group) and post-puberty onset obesity defined as onset after 13 years of age (PPO group). The subjects were followed up for at least 2 years and up to 5 years after LSG. Changes in physical parameters and remission of obesity-related comorbidities were assessed at 2 years after LSG. Weight regain (WR) was also assessed by evaluating the nadir weight after LSG and maximum weight thereafter during follow-up period. Results: The mean postoperative follow-up period was 3.0 ± 1.1 years. 40.0% of the subjects had CO and these subjects had higher BMI and HOMA-β and lower age, HbA1c, HDL cholesterol, and visceral/subcutaneous fat area ratio compared to those with PPO. The CO group was also characterized by having higher rates of mental retardation, developmental disorders, and obesity in either parent and lower rate of marriage compared to the PPO group. Two years after LSG, there were no differences in total weight loss and remission rates of diabetes, dyslipidemia, and sleep apnea syndrome between the two groups, although remission rate of hypertension was higher in the CO group. The CO group also had a higher rate of WR after LSG than the PPO group, with CO, BMI, mental disorder, and binge eating contributing to WR. Conclusion: This study suggests that CO might be associated with genetic and psychosocial factors. CO and PPO probably differ in pathogenesis and may require different treatment strategies.

Gastric volvulus after laparoscopic sleeve gastrectomy managed by conversion to Roux-en-Y gastric bypass. A case report and literature review.

Introduction and importanceOne of the most performed bariatric procedures, Laparoscopic sleeve gastrectomy (LSG) can be utilized not only as a primary bariatric procedure to achieve weight loss but also as a staged procedure, as it attains durable weight loss on long term follow up with remission of obesity-related comorbidities. There are several complications associated with LSG in the short and long terms, including hemorrhage, gastric leakage, and gastroesophageal reflux disease (GERD), yet gastric volvulus after sleeve gastrectomy is a rare entity.Case presentation and clinical discussionWe present a morbid obese female patient 32 years old -with no known medical comorbidity- presented to our bariatric outpatient clinic after laparoscopic sleeve gastrectomy with a chronic progressive history of vomiting, regurgitation, and heartburn of three months which started once/week then progress to 3 times/week duration. After a normal abdominal x-ray, Pelvi-abdominal ultrasound showed mild colonic gaseous distension. The CT virtual gastroscopy with 3D reconstruction revealed significant mid-body kinking with a wavy appearance. A decision was made on a multi-disciplinary approach to do a diagnostic laparoscopy for the patient with a revision of the previous sleeve gastrectomy. Upon entering the intra-abdominal there were extensive adhesions between the sleeved stomach, liver, and pancreas. Intra-operative upper endoscopy was done, and the scope didn't pass at the mid-portion of the sleeved stomach. Conversion to Roux-en-Y gastric bypass had been done with successful results.ConclusionGastric volvulus after sleeve gastrectomy is a rare entity presenting vague symptoms and signs and requires a high index of suspicion from the physicians for the proper diagnosis.

The influence of gender and age on laparoscopic sleeve gastrectomy short-term outcomes in type 2 diabetic obese patients

Background: Bariatric surgery has come out as an effective treatment for morbid obesity due to its effects as stabilized weight loss and remission of obesity related comorbidities like type 2 diabetes. Postoperative weight loss is affected by many factors and predictors of weight loss after bariatric surgery are controversial.This study has been performed to evaluate the impact of gender and age on the short-term outcomes of laparoscopic sleeve gastrectomy (LSG) in type 2 diabetic(T2D) obese patients.&#x0D; &#x0D; Material and Methods: In this retrospective study, the records of morbidly obese patients with a body mass index(BMI)≥40 kg/m2, aged between 18-65 years old who underwent LSG and were followed-up for at least 6 months postoperatively were reviewed.Patients were subdivided into two groups according to age(≥50 y,

Short Term Outcomes of Laparoscopic Roux-En-Y Gastric Bypass Versus Laparoscopic One Anastomosis Gastric Bypass in Super Obese Patients: Randomized Clinical Trial

Background: One anastomosis gastric bypass (OAGB) has several apparent advantages over Roux-En-Y Gastric Bypass (RYGB). However, symptomatic biliary reflux and its potential risks have prevented its widespread adoption. The aim of this study was to assess the short term outcomes of LOAGB in comparison to LRYGB in treatment of patients with super obesity regarding weight loss, resolution/improvement of co-morbidities and impact on patients’ quality of life (QoL). Methods: One hundred adult patients with super obesity were randomly divided into 2 matched groups, 50 patients each; group I underwent LRYGB and group II underwent LOAGB. Results: The operative time was significantly longer in LRYGB (176.4±27.29 vs. 110.5±14.13 minutes, p<0.05). The frequency and severity of the early postoperative complications were comparable between both groups. No mortality or re-admission was reported in both groups. There are no patients lost to follow-up. Although, the mean Excess weight loss percent (EWL%) was 57% vs 64.7% and 69.7% vs 75.5% at one and two years follow-up in group I and II respectively, the differences were statistically insignificant. T2DM remission/improvement rates at 12th month were 88.9% and 94.1% in group I and II respectively without a statistically insignificant difference. In comparison to the preoperative Qol score, the postoperative score showed a statistically significant improvement (from 0.31 to 6 and from 0.41 to 6.32 in group I and II respectively). Conclusions: LOAGB had a shorter operative time and a tendency towards a higher EWL%, a better remission of obesity-related comorbidities and improvement in the patients QoL with comparable short term operative and postoperative complications. Thus, LOAGB can be considered an acceptable alternative to LRYGB in management of super obese patients.

Sex disparity in laparoscopic bariatric surgery outcomes: a matched-pair cohort analysis

Men have been historically considered to be higher-risk patients for bariatric surgery compared to women, the perception of which is suggested to be a barrier to bariatric surgery in men. The purpose of this study is to conduct a matched-pair analysis to evaluate sex disparities in laparoscopic bariatric surgery outcomes. Data on patients who underwent laparoscopic bariatric surgery from March 2013 to 2017 was collected prospectively. Then, 707 men and 707 women pair-matched for age, preoperative body mass index (BMI) and the procedure type (i.e., sleeve gastrectomy, Roux-en-Y, or one-anastomosis gastric bypass) were compared in terms of weight loss, remission of obesity-related comorbidities, and postoperative complications classified according to the Clavien–Dindo classification. There was no difference between the two sexes regarding the operation time, bleeding during surgery and length of postoperative hospital stay. We observed similar total weight loss, BMI loss, and percentage of excess BMI loss at 12, 24, and 36 months postoperatively between men and women, with no difference in remission of diabetes mellitus, hypertension and dyslipidemia at 12 months. The rate of in-hospital, 30-day and late complications according to Clavien–Dindo classification grades was similar between men and women. Our matched-pair cohort analysis demonstrated that bariatric surgery results in comparable short- and mid-term efficacy in men and women, and is associated with similar rate and severity of postoperative complications between sexes. These findings suggest bariatric surgeons not to consider sex for patient selection in bariatric surgery.

Different limb lengths in gastric bypass surgery: study protocol for a Swiss multicenter randomized controlled trial (SLIM)

BackgroundObesity and type 2 diabetes mellitus are reaching epidemic proportions. In morbidly obese patients, bariatric operations lead to sustained weight loss and relief of comorbidities in the majority of patients. Laparoscopic Roux-Y-gastric bypass (RYGB) is one of the most frequently performed operations, but it is still unknown why some patients respond better than others. Therefore, a number of variations of this operation have been introduced. Recent evidence suggests that a longer bypassed biliopancreatic limb (BPL) has the potential to be more effective compared to the standard RYGB with a shorter BPL length. This article describes the design and protocol of a randomized controlled trial comparing the outcome of a RYGB operation with a long versus short BPL.Methods/designThe trial is designed as a multicenter, randomized, patient- and observer-blinded trial. The relevant ethics committee has approved the trial protocol. To demonstrate that long BPL RYGB is superior compared to short BPL RYGB in terms of weight loss and resolution of T2DM, the study is conducted as a superiority trial. Postoperative percent total weight loss and nutritional deficiency rate are the primary endpoints, whereas morbidity, mortality, remission of obesity-related comorbidities and quality of life are secondary endpoints. Eight hundred patients, between 18 and 65 years and with a body mass index (BMI) from 35 to 60 kg/m2 who meet the regulatory rules for bariatric surgery in Switzerland, will be randomized. The endpoints and baseline measurements will be assessed pre-, intra-, and postoperatively.DiscussionWith its high number of patients and a 5-year follow-up, this study will answer questions about effectiveness and safety of long BPL RYGB and provide level I evidence for improvement of the standard RYGB. These findings might therefore potentially influence global bariatric surgery guidelines.Trial registrationClinicalTrials.gov NCT04219787. Registered on 7 January 2020.

Bariatric surgery is associated with reduced admission for aortic dissection: a nationwide case-control analysis.

Aortic dissection (AD) is an uncommon but life-threatening condition associated with high morbidity and mortality. Hypertension (HTN) and hyperlipidemia (HLD) are common modifiable risk factors. Since bariatric surgery is associated with remission of obesity-related co-morbidities, we hypothesize that surgical weight loss might be protective against this feared aortic pathology. A cross-sectional analysis was performed using the National Inpatient Sample database from 2010 to2015. The treatment group included bariatric patients and the control group patients with obesity (body mass index [BMI] ≥ 35kg/m2) without previous bariatric surgery. Analyzed covariates included demographics, co-morbidities, aortic diseases, and AD. A multivariate logistic regression analysis (MLRA) was performed to assess the odds of admission for AD in both groups. A total of 2,300,845 patients were identified (2,004,804 controls and 296,041 cases). The mean (SEM) age was 54.4 (.05) versus 51.9 (.05) years, for the control and treatment groups, respectively (P < .0001). Bariatric patients posed a significantly lower prevalence of type 2 diabetes (T2D), HTN, HLD, aortic aneurysm, and bicuspid aortic valve (P < .0001) than control subjects. In the control group, 1411 individuals (.070%) had AD, whereas only 94 patients (.032%) in the bariatric surgery group had such diagnosis (P < .0001). The MLRA showed that non-bariatric obese patients had a significantly higher likelihood of suffering from AD (OR = 1.8 [95%CI 1.44-2.29] P < .0001). Considering different age groups, bariatric surgery was found to be less associated with admission for AD for individuals below and above 40 yearsof age (OR = 2.95 [95%CI 1.09-7.99] P = .0345) and (OR = 1.75 [95%CI 1.38-2.22] P < .0001), respectively. Bariatric surgery could be a protective factor against aortic dissection and should be considered in patients with obesity and risk factors for this cardiovascular complication.

Primary Roux-en-Y Gastric Bypass Results in Greater Weight Loss at 15-Year Follow-Up Compared with Secondary Roux-en-Y Gastric Bypass After Failure of Gastric Band or Mason McLean Vertical Gastroplasty.

The aim of the study is to compare the outcomes of patients treated with secondary Roux-en-Y gastric bypass (RYGB) after adjustable gastric banding (AGB) or vertical banded gastroplasty (VBG) with those of patients having primary RYGB. Patients undergoing secondary RYGB after AGB or VBG between 1997 and 2004 with a minimal follow-up of 15years were matched using a propensity score (according to gender, age, BMI, duration of follow-up) with comparable patients who underwent primary RYGB. The mean follow-up was 16.50years in the secondary RYGB group (N = 32) versus 16.33years in the primary RYGB group (N = 32). Early postoperative complications rate was 6.25% in the secondary RYGBs versus 9.38% in the primary RYGBs (P = 1). Late postoperative complications and additional surgical procedures were 56.25% and 37.5% in the secondary and primary RYGB group, respectively (P = 0.21). Long-term (at 16-20years) %TWL and %EWL were significantly lower (P < 0.01 and P = 0.013, respectively) after secondary RYGB (%TWL = 7.56%; %EWL = 17.15%) than after primary RYGB (%TWL = 24.51%; %EWL = 55.61%). Remission of obesity-related comorbidities was comparable (P > 0.05). Gastroesophageal reflux was more frequent after secondary RGYB-43.75% versus 25%, P < 0.05. Quality of life-Morehead-Ardelt II score (0.02 in secondary RYGB versus 0.69 in primary RYGB, P = 0.13), general self-assessment of health status and weight satisfaction were comparable. Secondary RYGB after AGB or VBG is less efficient at weight loss, GERD remission and energy expenditure at 15years after conversion. However, it is as effective for improvement/resolution of obesity-related comorbidities and is associated with similar QoL scores.

Cost-effectiveness of Bariatric Surgery for People with Morbid Obesity in South Korea.

This study aimed to evaluate the cost-effectiveness of bariatric surgery (BS) compared to non-surgical treatment (NST) in Korean people with morbid obesity according to comorbidities and body mass index (BMI) severity. The target cohort was people with morbid obesity, defined as BMI of ≥ 35kg/m2, or obese people with BMI of 30-34.9kg/m2 having obesity-related comorbidities. A decision-tree model for 1-year obesity treatment and Markov model for the rest of life were used. In the decision-tree model, the comorbidity remission rate and BMI change after 1-year treatment were decided based on a prospective clinical trial. In the Markov model, the transition probabilities were calculated considering the BMI level and age. The starting age of 20years, a cycle length of 1year, a time horizon of 80years, and a 5% discount rate were applied for the base case from the healthcare system perspective. In the base case, BS improved quality-adjusted life years (QALYs) and was the cost-effective option in total cohort (incremental cost-effectiveness ratio of BS vs. NST was 674 USD/QALY). It was shown to be cost-effective in all subgroup analyses based on BMI level. In particular, BS was a dominant alternative for the subgroup with basal BMI of 35.0-37.4kg/m2. Various sensitivity analyses showed the robustness of results indicating the cost-effectiveness of BS. BS at BMI of > 30kg/m2 was more effective than NST for a reduction in BMI and remission of obesity-related comorbidities and was cost-effective in Korea.

Bone metabolism, bone mineral density and low-energy fractures 10 years after Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass (RYGB) is a common surgical procedure for treatment of morbid obesity. RYGB induces considerable and sustained weight loss, and remission of obesity related-comorbidities. While studies have suggested negative effects of RYGB on bone health, long-term data are lacking. We aimed to evaluate the prevalence of aBMD below the expected range for age, osteopenia, osteoporosis and low-energy fractures in a defined patient cohort 10 years after RYGB. Secondly, we wanted to identify factors associated with increased risk of aBMD z-score or t-score of -1.1 or lower 10 years after RYGB. Patients undergoing RYGB surgery from June 2004 to December 2006 at the Department of Morbid Obesity and Bariatric Surgery, Oslo University Hospital, a tertiary referral centre for treatment of morbid obesity, were invited to a 10 year follow-up. Follow-up visits included morning fasting blood samples, clinical examination, anthropometric measures and dual energy X-ray absorptiometry (DXA). Out of 194 patients eligible for the study, 124 attended the 10 year follow-up and 122 (63%) were examined with DXA. Mean (SD) age was 50.3 (9.0) years, 118 (97%) were of Caucasian ethnicity, 94 were females (77%), of whom 41 (44%) were postmenopausal. Secondary hyperparathyroidism (SHPT) was noted in 37 participants (31%) and vitamin D deficiency (value below 50 nmol/L) and insufficiency (value below 75 nmol/L) in 40 (33%) and 91 (75%), respectively. Among the 63 participants who were premenopausal females or males 49 years or younger the prevalence of areal bone mineral density (aBMD) in the lower range of normal (z-score -1.1- to -1.9) was 30% (n = 19) and aBMD below the expected range for age (z-score ≤ -2.0) was noted in 8% (n = 5). Among the 59 participants who were postmenopausal females or males 50 years or older, the prevalence of osteopenia (t-score -1.1 to -2.4) was 51% (n = 30) and osteoporosis (t-score ≤ -2.5) was 27% (n = 16). The bone resorption markers CTX-1 and PINP were higher in participants with aBMD z-score or t-score of -1.1 or lower compared to participants with aBMD z-score or t-score of -1.0 or higher. Preoperative hypothyroidism, or higher age, postmenopausal status, BMI < 35 kg/m2, SHPT or higher PINP levels at 10 year follow-up were independently associated with aBMD z-score or t-score of -1.1 or lower 10 years after RYGB. Eighteen participants (15%) reported a clinical low-energy fracture after RYGB. In addition, vertebral fracture assessment by DXA revealed that 10 participants (8%) had experienced at least one moderate to severe morphometric vertebral fracture. Ten years after RYGB 27% of postmenopausal females and males 50 years or older were osteoporotic, and 8% of premenopausal females and males 49 years or younger exhibited aBMD below the expected range for age. The prevalence of fragility fractures was high. SHPT, higher age, postmenopausal status or higher PINP levels at 10 years and preoperative hypothyroidism were all independent risk factors for aBMD z-score or t-score of -1.1 or lower 10 years after RYGB.

Seven-Year Outcomes of Laproscopic Sleeve Gastectomy in Indian Patients with Different Classes of Obesity.

The aim of the study was to assess the long-term outcome in terms of weight loss and remission of comorbidities among the patients who hadundergone LSG in an Indian setting. This is a retrospective observational study of patients (BMI > 30kg/m2) who underwent LSG having a minimum 6months of follow-up data. Based on preoperative BMI, patients were grouped as class 1, 30 < BMI < 35kg/m2; class 2, 35 < BMI < 40kg/m2; and class 3, BMI > 40kg/m2. Data on BMI and %EWL between three classes and among genders at different follow-up points for 7years were compared. Study included 95 patients (mean age of 33.7 ± 11years), and the preoperative mean BMI was 40.2 ± 5.1kg/m2. At oneyear of surgery, 85.5% patients achieved > 50%EWL. The highest mean %EWL was found in class 1 (66.19%), followed by class 2 (56.73%) and class 3 (46.59%) at the sixth month follow-up. At the seventh year, %EWLs were 85.11% (class 1), 76.69% (class 2), and 62.98% (class 3) and the mean BMIs were 25.13 ± 3.09kg/m2 (class 1), 26.86 ± 2.12kg/m2 (class 2), and 31.07 ± 3.39kg/m2 (class 3) and were significantly different (p < 0.05). At the last follow-up, though, the males showed slight weight regain; however, there were no statisticaldifferences between the genders (p = 0.065). Outcome from LSG was better in patients with BMI < 40kg/m2 compared to the patients with BMI > 40kg/m2. Remission of obesity-related comorbidities was observed with LSG in all groups and gender did not influence the outcome significantly.

Systematic assessment of decision analytic models for the cost-effectiveness of bariatric surgery for morbid obesity

Bariatric surgery among patients with morbid obesity is very effective for providing long-term weight loss and remission of obesity-related co-morbidities. However, it is very expensive and its cost effectiveness is commonly argued. Long-term cost-effectiveness evaluations of bariatric surgery have often relied on decision models. A systematic review was performed on the methodologic approaches and their quality, evaluated the quality of reporting, and summarized findings and conclusions in published cost-effectiveness models of bariatric surgery for morbid obesity. A search from different databases with an end date of October 15, 2017 was completed. The initial search for title and abstract screening resulted in 741 articles. A total of 50 articles were included for full-text review and 23 economic evaluation studies were included in the systematic review. The reporting quality scores of most articles were rated as acceptable between 61% and 100%. Most studies (89%) were modeled for adult patients with age range between 25 and 75 years old. Sixty-one percent of studies defined their health states by the existence or absence of different obesity-related co-morbidities. Eleven percent of studies took the societal perspective. Most studies (61%) used a lifetime horizon. Thirty-nine percent of studies identified the extent of weight loss as the most sensitive and influential parameter. Seventeen (74%) did not report a formal model validation. Laparoscopic Roux-en-Y gastric bypass was reported as the most cost-effective strategy most often when it compared with no treatment or medical management. While most had acceptable quality of reporting levels, several gaps in the quality of reporting and quality of methods emerged, which led to recommendations for how to improve quality in future studies.

Surgical management of obesity.

Obesity is a spreading epidemic associated with significant morbidity and mortality with a prevalence of over 36% worldwide. In the face of a growing epidemic, increasing medical costs, and the disappointing limitations of medical and lifestyle modification bariatric surgery was found to consistently lead to significant weight loss and improvement in obesity-associated comorbidities when compared to non-surgical interventions. Bariatric procedures fall within three basic categories: restrictive procedures, malabsorptive procedures, and procedures that combine both restrictive and malabsorptive mechanisms. Four major procedures are currently performed (most often laparoscopically): Roux-en-Y gastric bypass, biliopancreatic diversion with duodenal switch, adjustable gastric banding, and sleeve gastrectomy. Although the laparoscopic Roux-en-Y gastric bypass was the most frequently performed bariatric procedure, the laparoscopic sleeve gastrectomy has since become the most popular. Bariatric surgery currently has similar mortality rates to standard general surgical operations. Morevoer, bariatric surgery reduces mortality by the improvement and remission of obesity-related comorbidities. Newer minimally-invasive weight loss procedures and endoscopic methods continue to evolve as we expand our understanding of the intricacies of obesity and the effects of currently available surgical treatments.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic mini gastric bypass in the treatment of obesity: study protocol for a randomized controlled trial

BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the gold standard in bariatric surgery, achieving durable long-term weight loss with improvement of obesity-related comorbidities. Lately, the laparoscopic mini gastric bypass (LMGB) has gained worldwide popularity with similar results to LRYGB in terms of weight loss and comorbidity resolution. However, there is a lack of randomized controlled trials (RCT) comparing LMGB and LRYGB. This article describes the design and protocol of a randomized controlled trial comparing the outcomes of these two bariatric procedures.Methods/DesignThe trial is designed as a single center, randomized, patient and observer blinded trial. The relevant ethics committee has approved the trial protocol. To demonstrate that LMGB is not inferior to LRYGB in terms of excess weight loss (EWL) the study is conducted as a non-inferiority trial with the sample-size calculations performed accordingly. EWL 12 months after surgery is the primary endpoint, whereas 3-year EWL, morbidity, mortality, remission of obesity related comorbidities, quality of life (QOL) and hormonal and lipid profile changes are secondary endpoints. Eighty patients, 18 years or older and with a body mass index (BMI) between 35 and 50 kg/m2 who meet the Swiss guidelines for the surgical treatment of morbid obesity will be randomized. The endpoints and baseline measurements will be assessed pre-surgery, peri-surgery and post-surgery (fixed follow up measurements are at discharge and at the time points 6 weeks and 12 and 36 months postoperatively).DiscussionWith its 3-year follow up time, this RCT will provide important data on the impact of LMGB and LRYGB on EWL, remission of comorbidities, QOL and hormonal and lipid profile changes.Trial registrationClinicalTrials.gov, NCT02601092. Registered on 28 September 2015.