Roux-en-Y Gastric Bypass Patients Research Articles

"Innocent as a LAMS": Does Spontaneous Fistula Closure (Secondary Intention), After EUS-Directed Transgastric ERCP (EDGE) via 20-mm Lumen-Apposing Metal Stent, Confer an Increased Risk of Persistent Fistula and Unintentional Weight Gain?

Persistent gastrogastric or jejunogastric fistula is theoretically a concerning sequela of EUS-directed transgastric ERCP/EUS (EDGE), as it may functionally reverse the malabsorptive mechanism of Roux-en-Y gastric bypass (RYGB). Prior EDGE studies, using predominantly 15-mm (diameter) lumen-apposing metal stents (LAMS) and fistula closure by primary intent, collectively report 9% persistent fistula rate, without a clear weight gain association. Our study determines the incidence of persistent fistula, and its association with unintentional weight gain, among recipients of EDGE via 20-mm LAMS followed by spontaneous fistula closure (secondary intent). We conducted a dual-center prospective cohort study of 22 RYGB patients who underwent EDGE using 20-mm between 3/2018 and 10/2019. After LAMS extraction, all GGFs/JGFs were allowed to heal spontaneously. Objective testing for persistent fistula and total body weight (TBW) occurred a minimum of 8 weeks after LAMS extraction. Persistent fistula was identified in 9 patients (41%). Longer LAMS dwell time (median 77-days) was observed in the persistent fistula group, compared to those with durable spontaneous fistula closure (median 35-days) (p = 0.03). Weight gain of ≥ 5% TBW occurred in 56% (n = 5) of patients with persistent fistula, compared to 15% (n = 2) of patients with spontaneous fistula closure (p = 0.128). Four patients with symptomatic persistent fistulas underwent attempted endoscopic fistula closure a median 7.5 months after LAMS extraction. Durable fistula closure occurred in the single patient who received argon plasma coagulation plus endoscopic suturing, whereas fistula dehiscence occurred in 3/3 (100%) patients with endoscopic suturing monotherapy. Larger LAMS diameter (20-mm), longer LAMS dwell time, and spontaneous fistula closure may be technical factors that increase the likelihood of post-EDGE persistent fistula. Post-EDGE persistent fistula has not been shown by ours or other studies to be significantly associated with unintentional weight gain; however, this may be due to small sample size. We question the utility of routine fistula closure by primary intent and suggest a personalized approach to post-EDGE fistula management.

Roux-en-Y gastric bypass-induced bacterial perturbation contributes to altered host-bacterial co-metabolic phenotype

BackgroundBariatric surgery, used to achieve effective weight loss in individuals with severe obesity, modifies the gut microbiota and systemic metabolism in both humans and animal models. The aim of the current study was to understand better the metabolic functions of the altered gut microbiome by conducting deep phenotyping of bariatric surgery patients and bacterial culturing to investigate causality of the metabolic observations.MethodsThree bariatric cohorts (n = 84, n = 14 and n = 9) with patients who had undergone Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) or laparoscopic gastric banding (LGB), respectively, were enrolled. Metabolic and 16S rRNA bacterial profiles were compared between pre- and post-surgery. Faeces from RYGB patients and bacterial isolates were cultured to experimentally associate the observed metabolic changes in biofluids with the altered gut microbiome.ResultsCompared to SG and LGB, RYGB induced the greatest weight loss and most profound metabolic and bacterial changes. RYGB patients showed increased aromatic amino acids-based host-bacterial co-metabolism, resulting in increased urinary excretion of 4-hydroxyphenylacetate, phenylacetylglutamine, 4-cresyl sulphate and indoxyl sulphate, and increased faecal excretion of tyramine and phenylacetate. Bacterial degradation of choline was increased as evidenced by altered urinary trimethylamine-N-oxide and dimethylamine excretion and faecal concentrations of dimethylamine. RYGB patients’ bacteria had a greater capacity to produce tyramine from tyrosine, phenylalanine to phenylacetate and tryptophan to indole and tryptamine, compared to the microbiota from non-surgery, normal weight individuals. 3-Hydroxydicarboxylic acid metabolism and urinary excretion of primary bile acids, serum BCAAs and dimethyl sulfone were also perturbed following bariatric surgery.ConclusionAltered bacterial composition and metabolism contribute to metabolic observations in biofluids of patients following RYGB surgery. The impact of these changes on the functional clinical outcomes requires further investigation.1v6mePHgvKoyyAii3YMczBVideo abstract

Endoscopic versus surgical gastrojejunal revision for weight regain in Roux-en-Y gastric bypass patients: 5-year safety and efficacy comparison

An enlarged gastrojejunal anastomosis (GJA) is associated with weight regain after Roux-en-Y gastric bypass (RYGB) and can be corrected with endoscopic or surgical revision; however, there has been no direct comparison between techniques. This study aims to compare serious adverse event (AE) rates and weight loss profiles between endoscopic and surgical revisional techniques over a 5-year period. This is a retrospective matched cohort study of RYGB patients who underwent endoscopic or surgical revision for weight regain with an enlarged GJA (>12mm). Patients who underwent endoscopic revision (ENDO group) were matched 1:1 to those undergoing surgical revision (SURG group) based on completion of 5-year follow-up, age, sex, body mass index, initial weight loss, and weight regain. Demographics, GJA size, serious AEs, and weight profiles were collected. The primary outcome was comparison of serious AE rates between groups. Secondary outcomes included weight loss comparisons. A Fisher exact test was used to compare the serious AE rate, and a Student t test was used for weight comparisons. Sixty-two RYGB patients with weight regain and an enlarged GJA (31 ENDO, 31 matched SURG) were included. Baseline characteristics were similar between groups. The AE rate in the ENDO group (6.5%) was lower than the SURG group (29.0%, P= .043). Zero and 6 (19.4%) serious (severe) AEs occurred in the ENDO and SURG groups, respectively (P= .02). There was no significant difference in weight loss at 1, 3, and 5 years. Endoscopic revision of the GJA is associated with significantly fewer total and serious AEs and similar long-term weight loss when compared with surgical revision.

Acute Care Utilization and Costs Up to 4 Years After Index Sleeve Gastrectomy or Roux-en-Y Gastric Bypass: A National Claims-based Study.

To compare acute care utilization and costs following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Comparing postbariatric emergency department (ED) and inpatient care use patterns could assist with procedure choice and provide insights about complication risk. We used a national insurance claims database to identify adults undergoing SG and RYGB between 2008 and 2016. Patients were matched on age, sex, calendar-time, diabetes, and baseline acute care use. We used adjusted Cox proportional hazards to compare acute care utilization and 2-part logistic regression models to compare annual associated costs (odds of any cost, and odds of high costs, defined as ≥80th percentile), between SG and RYGB, overall and within several clinical categories. The matched cohort included 4263 SG and 4520 RYGB patients. Up to 4 years after surgery, SG patients had slightly lower risk of ED visits [adjusted hazard ratio (aHR): 0.90; 95% confidence interval (CI): 0.85,0.96] and inpatient stays (aHR: 0.80; 95% CI: 0.73,0.88), especially for events associated with digestive-system diagnoses (ED aHR: 0.68; 95% CI: 0.62,0.75; inpatient aHR: 0.61; 95% CI: 0.53,0.72). SG patients also had lower odds of high ED and high total acute costs (eg, year-1 acute costs adjusted odds ratio (aOR) 0.77; 95% CI: 0.66,0.90) in early follow-up. However, observed cost differences decreased by years 3 and 4 (eg, year-4 acute care costs aOR 1.10; 95% CI: 0.92,1.31). SG may have fewer complications requiring emergency care and hospitalization, especially as related to digestive system disease. However, any acute care cost advantages of SG may wane over time.

Is Bariatric Surgery Brain Surgery?

Roux-en-Y gastric bypass (RYGB) reliably produces sustained weight losses, reduces circulating blood glucose, and lowers risk of type 2 diabetes (1). Accompanying these benefits, however, is symptomatic hypoglycemia, reported by up to one-third of post–bariatric surgery patients (2,3). In an estimated <1% of RYGB patients (4), postprandial hyperinsulinemic hypoglycemia causes severe symptoms including neuroglycopenia with significant morbidity. New mechanistic insights and treatment options for these patients are needed. Potential contributors include rapid glucose delivery into the bloodstream, improved β-cell function, and gut adaptations, but the role of the central nervous system (CNS) is an important and underdeveloped area of research (3). In their article in this issue of Diabetes , Almby et al. (5) investigate whether RYGB alters the brain response to hypoglycemia in humans—a topic with further relevance to the CNS contribution to RYGB’s modification of overall glucose homeostasis. Human neuroimaging studies document RYGB-induced changes in brain function and suggest reversibility of obesity-associated findings (6–8). Studies of cerebral metabolism measuring [18F]-fluorodeoxyglucose uptake by positron emission tomography (FDG-PET) show that brain glucose uptake is elevated in participants with obesity and partially reversed post-RYGB (6,7), but controlled studies of the cerebral metabolic response to insulin-induced hypoglycemia are lacking. Cerebral blood flow response to insulin-induced hypoglycemia assessed by arterial spin labeling (ASL) showed increased regional blood flow (vs. euglycemia) in the cortex, thalamus (9), and hypothalamus (10) in healthy adults. Almby et al. provide novel data on the effect of RYGB on brain response to hypoglycemia (5). Almby et al. included 11 participants that underwent, before and …

ID: 3526790 ERCP APPROACH FOR PATIENTS WITH A RYGB: A COMPARATIVE RETROSPECTIVE STUDY BETWEEN FOUR ERCP TECHNIQUES WITH PROPOSED MANAGEMENT APPROACH

Endoscopic Retrograde Cholangiopancreatography (ERCP) is technically challenging in patients with Roux-en y gastric bypass (RYGB) due to altered anatomy. Current techniques either have a low success rate, are invasive, associated with high cost, or have an unclear long-term safety profile. The main aim of our study is to compare the procedural and clinical outcomes of four ERCP techniques in RYGB patients.

ID: 3520457 OUTCOMES OF LAPAROSCOPIC-ASSISTED ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY VERSUS PERCUTANEOUS TRANSHEPATIC BILIARY DRAINAGE IN PATIENTS WITH ROUX-EN-Y GASTRIC BYPASS SURGERY

Patients with history of Roux-en-Y gastric bypass (RYGB) surgery are not candidates for standard endoscopic retrograde cholangiopancreatography (ERCP) due to their surgically altered gastrointestinal anatomy. There are a number of alternative approaches in such patients including device-assisted ERCP, laparoscopy-assisted ERCP (LA-ERCP), endoscopic ultrasound-guided biliary drainage (EUS-BD), percutaneous transhepatic biliary drainage (PTBD) and surgical drainage. The aim of our study was to compare clinical outcomes in RYGB patients undergoing LA-ERCP versus PTBD for management of pancreatobiliary diseases.

The role of citrulline, intestinal fatty acid-binding protein, and D-dimer as potential biomarkers in the diagnosis of internal herniation after Roux-en-Y gastric bypass.

Diagnosing internal herniation (IH) in Roux-en-Y gastric bypass (RYGB) patients with acute abdominal pain poses a diagnostic challenge. Diagnostic laparoscopy is often required for a definitive diagnosis. We hypothesized that intestinal ischemia biomarkers would aid in the diagnosing of IH. To explore intestinal ischemia biomarkers in diagnosing IH. University Hospital, Sweden. Prospective inclusion of 46 RYGB patients admitted for acute abdominal pain between June 2015 and December 2017. Blood samples for analysis of citrulline, intestinal fatty acid-binding protein (I-FABP), and D-dimer were drawn <72 hours from admission and compared between patients with IH (n = 8), small bowel obstruction (SBO) (n = 5), other specified diagnoses (n = 12), or unspecified abdominal pain (n = 21). Levels of white blood cell count (WBC), C-reactive protein (CRP), and lactate at admission were compared. A prospective pain questionnaire for time of pain onset and level of pain at onset and at admission was analyzed. None of the investigated biomarkers differed significantly between diagnosis categories. Most patients with IH had normal CRP, WBC, and D-dimer levels while their lactate levels were significantly lower (P = .029) compared with the rest of the cohort. Neither pain level nor pain duration differed between the groups. This study shows that citrulline, I-FABP, and D-dimer cannot be used to diagnose IH and indicates that CRP, D-dimer, and lactate are rarely elevated by an IH. Furthermore, pain intensity and duration cannot differentiate patients with IH. A diagnostic laparoscopy remains the gold standard to diagnose and rule out an IH.

Controlling Nutritional Status (CONUT) Score and Micronutrient Deficiency in Bariatric Patients: Midterm Outcomes of Roux-en-Y Gastric Bypass Versus One Anastomosis Gastric Bypass/Mini Gastric Bypass.

Two of the most common bariatric procedures performed worldwide are Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB). Comparative data regarding nutritional status are lacking and no previous study focus on malnutrition according to a validated score. Retrospective data from a single institution were reviewed. Anthropometric variables and nutritional data were assessed. The primary aim was to analyze and compare the nutritional status before and 3 years after RYGB vs OAGB using the controlling nutritional status (CONUT) score. The incidence of micronutrient deficiency and the remission of comorbidities in each group were defined as secondary outcomes. Fifty-seven patients in each arm were enrolled. A 3-year mild malnutrition (CONUT score 2-3) was found in 38% and 37.05% in the RYGB and OAGB groups, respectively (p > 0.05). In terms of percentage of total weight loss (%TWL) and percentage of adjustable weight loss (%AWL), no differences were found between OAGB and RYGB groups. OAGB and RYGB patients had similar vitamin deficiencies. Anemia, hypoproteinemia, hypoalbuminemia, and hypocalcemia were comparable between groups. At 3-year follow-up, total protein and albumin values were similar between arms while prealbumin deficit was more frequent after OAGB than after RYGB. The rate of type 2 diabetes (87.5% in OAGB and 92% in RYGB), arterial hypertension (51.6% in OAGB and 58.3% in RYGB), and dyslipidemia (69.7% in OAGB and 78.6% in RYGB) remission was not significantly different between the two groups. Postoperative CONUT score, micronutrient deficiency, comorbidity remission, and improvement of anthropometric parameters 3 years postoperatively were comparable between RYGB and OAGB groups.

Impact of bariatric surgery on surveillance and treatment outcomes of Barrett's esophagus: A stage-matched cohort study.

Obesity could increase the risk of Barrett's esophagus (BE). Roux-en-Y gastric bypass (RYGB) could alter the natural course of BE. Data on BE progression after RYGB are scarce. To study endoscopic surveillance and endoscopic eradication therapy (EET) outcomes of BE in post-RYGB patients versus controls with obesity. Academic referral centers, a retrospective cohort study. Patients who underwent RYGB with biopsy-proven BE or intramucosal esophageal adenocarcinoma (IM-EAC) with an endoscopic follow-up of at least 12 months were identified from a prospectively maintained database between January 1992 and February 2019 at 3 tertiary care centers. RYGB patients were matched 1-to-2 to patients with obesity (body mass index > 30 kg/m2) by the initial BE stage at diagnosis. Surveillance and EET outcomes were compared. A total of 147 patients were included (49 RYGB and 98 BE stage-matched controls with obesity). For endoscopic surveillance, the rate of disease progression to high-grade dysplasia /IM-EAC was significantly lower in the RYGB patients than controls (2.6% versus 40.2%, respectively; P < .0001), with a comparable median follow-up time (85 months versus 80 months, respectively). This effect persisted in a multivariate analysis, with a hazard ratio of .09 (95% confidence interval, .01-.69). For EET, no difference in the rate of achieving complete remission of intestinal metaplasia was observed between the RYGB and control groups (71.2% versus 81.3%, respectively; P = .44). RYGB appears to be a protective factor for disease progression to neoplastic BE during endoscopic surveillance. However, disease progression was still observed after RYGB, warranting continuing endoscopic surveillance. EET appeared to be equally effective between RYGB patients and controls with obesity.

The influence of preoperative carbohydrate loading on postoperative outcomes in bariatric surgery patients: a randomized, controlled trial.

Preoperative carbohydrate loading is a component of Enhanced Recovery After Surgery (ERAS) protocols, but there is limited literature in bariatric surgery patients. The objective of this study was to characterize the impact of preoperative carbohydrate loading on postoperative bariatric surgery outcomes. University Hospital. Patients undergoing a primary minimally invasive Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2018 and 2020 were randomized to standard management or intervention. Standard management patients were nothing by mouth (NPO) after midnight prior to surgery. Intervention patients consumed 2 carbohydrate drinks: 1 the night before and another 3 hours prior to surgery. Primary outcomes analyzed included postoperative nausea and vomiting (PONV), length of stay, and overall complications. In total, 134 patients were analyzed: 64 intervention (47.8%) and 70 (52.2%) standard. In the end, 7% and 15% of patients were lost to follow-up at 6-weeks and 3-months, respectively. There was no statistically significant difference in length of stay (2.0 ± 1.2 vs 2.1 ± .9 d; P = .65) or postoperative outcomes between the 2 groups. There were no episodes of aspiration among the intervention group. Among RYGB patients, intervention patients had a shorter duration of nausea compared with standard patients. There was no significant difference in glycemic control among patients with and without diabetes. Preoperative carbohydrate drinks can be administered to bariatric surgery patients without significant risks. Carbohydrate loading preoperatively can decrease the duration of PONV in RYGB patients. Carbohydrate drinks can be safely included in bariatric ERAS protocols for patients with and without diabetes, although the benefits remain unknown.

Effect of Preoperative Weight Loss and Baseline Comorbidity on Short-Term Complications and Reoperations After Laparoscopic Roux-en-Y Gastric Bypass in 2,067 Patients

Decreasing popularity of Roux-en-Y gastric bypass (RYGB) in bariatric-metabolic surgery may be due to higher perceived peri-operative complications. There are few studies on whether preoperative weight loss can reduce complications or reoperations following RYGB. We investigated this using a standardised operative technique. Retrospective single-centre study of RYGB from 2004 to 2019 using a prospective database. Preoperative behavioural management included intentional weight loss. Maximum preoperative weight, weight on the day of operation, and Obesity-Surgery Mortality Risk Score (OS-MRS) class were recorded. Short-term outcomes (post-operative stay, 30-day complication and reoperation rates) were analysed. In 2,067 RYGB patients (1,901 primary and 166 revisional), median preoperative total body weight loss (TWL) was 6.2% (IQR: 2.5-10.7%). The median age was 46 (interquartile range (IQR) 38-54) and 80.4% were female (n=1,661). For primary surgery, the median body mass index (BMI) was 47.6 kg/m2 (IQR: 43.1-53.3). Excluding the 100-procedure learning curve, the complication rate for primary cases was 4.4% and reoperation rate of 2.8% and one peri-operative mortality (0.06%). OS-MRS ≥2 (class B or C) predicted higher risk of complications (6.1%) compared to those with a score <2 (class A) (3.8%, p=0.021), but not reoperations. Five percent preoperative TWL did not decrease complications compared to <5% TWL. Patients with ≥10% TWL had greater baseline risk and had an increased risk of complications (6.6% vs 3.7%, p=0.017) and reoperations (4.5% vs 2.7%, p<0.001). RYGB performed using a standardised technique has low overall risk. The influence of preoperative weight loss on outcomes was inconsistent.

Sleeve Gastrectomy Is Associated with a Greater Reduction in Plasma Liver Enzymes Than Bypass Surgeries-A Registry-Based Two-Year Follow-Up Analysis.

Bariatric surgeries may lead to an improvement in metabolic fatty liver disease, and a reduction in the levels of the hepatic enzyme Alanine Aminotransferase (ALT). We compared the effects of Sleeve Gastrectomy (SG), Roux en Y Gastric Bypass (RYGB) and One Anastomosis Gastric Bypass (OAGB) on the levels of ALT by analysis of two-year follow-up data from 4980 patients in the Israeli Bariatric Registry that included laboratory tests and demographic information. Pre-operative characteristics of patients, and particularly levels of liver enzymes, were similar across surgery types. Regression modeling and retrospective matching showed that SG was superior to RYGB and OAGB in reducing ALT levels, and in reducing the fraction of patients with abnormally high ALT levels. Two-year post-surgery, an increase in ALT levels from normal to abnormal levels was observed in 5% of SG patients, and in 18% and 23% of RYGB and OAGB patients. In conclusion, SG leads to a greater reduction in ALT levels compared with bypass surgeries and a lower incidence of post-surgical elevation of ALT levels. Further studies are required to identify the cause for the rise in liver enzymes, and to determine whether ALT levels correlate with liver pathology especially following bariatric surgery.

Leaky Gut as a Potential Culprit for the Paradoxical Dysglycemic Response to Gastric Bypass-Associated Ileal Microbiota.

Altered host-intestinal microbiota interactions are increasingly implicated in the metabolic benefits of Roux-en-Y gastric bypass (RYGB) surgery. We previously found, however, that RYGB-associated ileal microbiota can paradoxically impair host glycemic control when transferred to germ-free mice. Here we present complementary evidence suggesting that this could be due to the heightened development of systemic endotoxemia. Consistently, application of ileal content from RYGB-treated compared with sham-operated rats onto Caco-2 cell monolayers compromised barrier function and decreased expression of the barrier-stabilizing proteins claudin-4 and desmoglein-2. Our findings raise the possibility that RYGB-associated ileal microbiota produce and release soluble metabolites which locally increase intestinal permeability to promote systemic endotoxemia-induced insulin resistance, with potential implications for the treatment of RYGB patients who eventually relapse onto type 2 diabetes.

Propensity Score-Matching Sleeve Gastrectomy (SG) vs. Gastric Bypass (RYGB) in Patients ≥ 60 Years.

Since 1 January 2005, the practice of bariatric surgery has been examined with the help of the German Bariatric Surgery Registry (GBSR) in Germany. The focus of the study was to evaluate if sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) has the best benefit in terms of perioperative risk in patients over 60 years of age. Data collection includes patients over the age of 60 years who underwent SG or RYGB between 2005 and 2017. The bougie is limited to 33-40 French for SG. Furthermore, the RYGB is determined to be 120-180 cm alimentary and 40-60 cm biliopancreatic length. Outcome criteria are perioperative morbidity, postoperative complications, 30-day mortality, and postoperative length of stay. The study analyzes data from 3561 patients beyond the age of 60 years who underwent SG (1970 patients) and RYGB (1591 patients). Mean age of the patients was 63.4 ± 3.2 in the RYGB group and 63.8 ± 3.5 in the SG group. Mean BMI was 46.4 ± 6.8 in the RYGB group and 49.1 ± 8.0 in the SG group. The average number of comorbidities was 4.5 ± 2.4 for RYGB and 4.5 ± 2.3 for SG. For the 30-day mortality, identical results were found SG vs. RYGB (0.31 vs. 0.38, p = 1.000). Based on the results of this study, it can be concluded that both SG and RYGB in patients ≥ 60 years can be considered safe surgical procedures.

Test Characteristics of Abdominal Computed Tomography for the Diagnosis of Gastro-gastric Fistula in Patients with Roux-en-Y Gastric Bypass.

Gastrogastric fistulae (GGF) occur in 1-6% of Roux-en-Y gastric bypass (RYGB) patients. Many patients undergo abdominal computed tomography (CT) as an initial test owing to its wide availability; however, CT diagnostic accuracy for GGF is unclear. Our aim was to evaluate test characteristics of abdominal CT compared to upper gastrointestinal series (UGI) and esophagogastroduodenoscopy (EGD) for diagnosing GGF using surgery as a gold standard. Retrospective review of RYGB patients who underwent abdominal CT with oral contrast within 1 year. Demographics, weight parameters, and symptoms were collected. Surgery within 1 year of the diagnostic tests was included as the gold standard comparison. Primary outcomes included CT sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy (DA) for GGF. One hundred thirty-seven patients were included, where 42 (30.1%) had positive CT and 95 (69.3%) had negative CT for GGF. Compared to surgical confirmation, CT abdomen with PO contrast had sensitivity of 73.1% (59-84.4), specificity of 95.2% (88.3-98.7), PPV 90.5% (77.4-97.3), NPV of 85.1% (76.3-91.2), and DA 89.7%. UGI series had sensitivity of 58.5% (42.1-73.7), specificity of 98.8% (93.5-99.9), PPV of 96% (79.7-99.9), NPV of 82.8% (73.9-89.7), and diagnostic accuracy (DA) of 85.4%. EGD had sensitivity of 78.3% (63.6-89.1), specificity of 98.8% (93.5-99.9), PPV 97.3 (85.8-99.9), and DA 91.5%. There were no significant differences in diagnostic test characteristics among modalities. Abdominal CT with oral contrast has similar diagnostic test characteristics to UGI and EGD at detecting GGF when using surgical diagnosis as a gold standard.

Metabolic effects of bariatric surgery on patients with type 2 diabetes: a population-based study.

Bariatric surgery among patients with obesity and type 2 diabetes (T2D) can induce complete remission. However, it remains unclear whether sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) has better T2D remission within a population-based daily practice. To compare patients undergoing RYGB and SG on the extent of T2D remission at the 1-year follow-up. Nationwide, population-based study including all 18 hospitals in the Netherlands providing metabolic and bariatric surgery. Patients undergoing RYGB and SG between October 2015 and October 2018 with 1 year of complete follow-up data were selected from the mandatory nationwide Dutch Audit for Treatment of Obesity (DATO). The primary outcome is T2D remission within 1 year. Secondary outcomes include ≥20% total weight loss (TWL), obesity-related co-morbidity reduction, and postoperative complications with a Clavien-Dindo (CD) grade ≥III within 30 days. We compared T2D remission between RYGB and SG groups using propensity score matching to adjust for confounding by indication. A total of 5015 patients were identified from the DATO, and 4132 (82.4%) had completed a 1-year follow-up visit. There were 3350 (66.8%) patients with a valid T2D status who were included in the analysis (RYGB = 2623; SG = 727). RYGB patients had a lower body mass index than SG patients, but were more often female, with higher gastroesophageal reflux disease and dyslipidemia rates. After adjusting for these confounders, RYGB patients had increased odds of achieving T2D remission (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.14-2.1; P < .01). Groups were balanced after matching 695 patients in each group. After matching, RYGB patients still had better odds of T2D remission (OR, 1.91; 95% CI, 1.27-2.88; P < .01). Also, significantly more RYGB patients had ≥20%TWL (OR, 2.71; 95% CI, 1.96-3.75; P < .01) and RYGB patients had higher dyslipidemia remission rates (OR, 1.96; 95% CI, 1.39-2.76; P < .01). There were no significant differences in CD ≥III complications. Using population-based data from the Netherlands, this study shows that RYGB leads to better T2D remission rates at the 1-year follow-up and better metabolic outcomes for patients with obesity and T2D undergoing bariatric surgery in daily practice.

One anastomosis gastric bypass versus Roux-en-Y gastric bypass: a 30-day follow-up review.

One anastomosis gastric bypass (OAGB) type procedures have been widely adopted outside the United States. International experience of OAGB commonly suggests improved early postoperative safety with OAGB over Roux-en-Y gastric bypass (RYGB). This study aims to report on the early experience with OAGB in Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) accredited centers, and compare with RYGB in terms of complication rates. The MBSAQIP public use files from 2015 to 2018 were used to identify adult patients who underwent primary OAGB and RYGB. Propensity score analysis was used to estimate the marginal population-average differences between OAGB and RYGB patients. Based on the matched samples, McNemar's tests and Wilcoxon signed rank test were carried out for binary and continuous outcomes. P-value < 0.05 was considered statistically significant. Propensity score matching analysis resulted in 279 matched pairs for OAGB and RYGB. Twelve OAGB patients (4.3%) experienced a complication; 3 of them (1.1%) were diagnosed with anastomotic leaks. Compared to 14 (5%) of RYGB patients experiencing a complication; 5 (1.8%) were diagnosed with anastomotic leaks. Reintervention, reoperation and readmission rates for OAGB were 2.5%, 3.2% and 5%, compared to 1.8%, 1.8%, and 3.2% for RYGB. Our study supports previous data that suggests OAGB has a similar early safety profile compared to RYGB and perioperative risks of OAGB should not be of a concern regarding its adoption. Conversely, OAGB does not seem to be associated with an improved safety profile over RYGB.

Patterns of Weight Loss Medication Utilization and Outcomes Following Bariatric Surgery

BackgroundBariatric surgery is the most effective treatment for obesity; however, some patients experience significant weight regain. Weight loss medications (WLM) are being increasingly used in surgery patients with limited evidence. We examine weight loss outcomes in patients using WLM after bariatric surgery. MethodsIn a retrospective study, 197 bariatric surgery patients who started WLM between 2016 and 2019 at a single center were analyzed. Patients were categorized into 3 groups based on outcomes of the initial surgery: (1) Weight regainers (WR) = achieved goal weight loss after surgery (15% total body weight loss (TBWL) for sleeve gastrectomy (SG) and 25% TBWL for Roux-en-Y gastric bypass (RYGB)) with subsequent regain of > 20% of weight lost; (2) Adequate weight loss (AWL) = achieved goal weight loss without > 20% weight regain; (3) Non-responders (NR) = never achieved goal weight loss. Weight loss and medication use patterns were analyzed. ResultsAmong the three categories, there was no significant difference in duration of medical therapy or %TBWL with medications. RYGB patients lost more weight than SG patients using WLM (p = 0.03). Of the medications used, patients treated with phentermine + topiramate had the highest likelihood of achieving 5%, 10%, and 15% weight loss. Compared to other 2 groups, AWL group initiated WLM earlier and experienced more weight loss when compared to their pre-operative weight or post-operative nadir. ConclusionsRYGB patients respond better to WLM than SG patients. Those who had started WLM before regaining weight (AWL) experienced greater overall weight loss, suggesting that proactive medical therapy at the time of weight plateau can help with greater total weight loss. Phentermine + topiramate is the most effective WLM in post-bariatric surgery patients.

Vagotomy increases alcohol intake in female rats in diet dependent manner: Implications for increased alcohol use disorder after roux-en-y gastric bypass surgery

A variety of weight loss surgeries have been developed to fight the obesity epidemic, with Roux-en-Y gastric bypass (RYGB) being one of the most effective and popular procedures. However, the underlying mechanisms behind its efficacy are still not well understood. Furthermore, growing clinical evidence suggests that RYGB may result in increased risk for development of alcohol use disorder (AUD). The vagus nerve is a potentially critical contributor to increased risk of AUD following RYGB due to the potential for significant damage to the vagus during surgery, which has been confirmed in rodent studies. Studies aiming at the mechanisms underlying development of alcohol or substance use disorders following the surgery have exclusively used male rats, despite the majority of RYGB patients being female. Thus, the current study had two objectives: 1) to investigate the effect of RYGB on ethanol (EtOH) intake in female rats using a protocol previously established in male rats, and 2) to test the effect of vagal damage and high fat diet (HFD) on EtOH intake in female rats. In the first study, 22 female rats were maintained on HFD for four weeks and then split into two surgical groups, RYGB (n = 10) and Sham (n = 12). All rats then underwent a two-bottle choice test of increasing EtOH concentrations: 2%, 4%, 6%, 8%. Rats were then forced to abstain from EtOH for two weeks, after which access to 8% EtOH was reinstated. The RYGB female rats significantly increased their intake for low concentrations of EtOH (2% and 4%) and during the reinstatement period for 8%. These results mirror those seen in male rats, and thus, confirms RYGB in female rats as an equally viable model to males. In the second study, 40 female rats were separated into four groups: HFD/Sham, HFD/Vagotomy, normal diet (ND)/Sham, and ND/Vagotomy. All rats then were subjected to the same two-bottle choice test protocol as in the previous study. Rats in the vagotomy condition had significantly greater preference for 2% and 4% EtOH compared with Sham-operated controls. EtOH intake, either in ml or adjusted for body weight, was greater in rats maintained on ND compared with rats maintained on HFD. These data suggest that vagal damage may, at least in part, contribute to increased preference for EtOH. Furthermore, this increase in EtOH preference is counter to the blunting effect of HFD. In conclusion, the data presented here suggest a role for vagal damage in risk of AUD after weight loss surgery.