Surgical Weight Loss Research Articles

MECHANISMS IN ENDOCRINOLOGY: Human brown adipose tissue as a therapeutic target: warming up or cooling down?

Excessive accumulation of white adipose tissue leads to obesity and its associated metabolic health consequences such as type 2 diabetes and cardiovascular disease. Several approaches to treat or prevent obesity including public health interventions, surgical weight loss, and pharmacological approaches to reduce caloric intake have failed to substantially modify the increasing prevalence of obesity. The (re-)discovery of active brown adipose tissue (BAT) in adult humans approximately 15 years ago led to a resurgence in research into whether BAT activation could be a novel therapy for the treatment of obesity. Upon cold stimulus, BAT activates and generates heat to maintain body temperature, thus increasing energy expenditure. Activation of BAT may provide a unique opportunity to increase energy expenditure without the need for exercise. However, much of the underlying mechanisms surrounding BAT activation are still being elucidated and the effectiveness of BAT as a therapeutic target has not been realised. Research is ongoing to determine how best to expand BAT mass and activate existing BAT; approaches include cold exposure, pharmacological stimulation using sympathomimetics, browning agents that induce formation of thermogenic beige adipocytes in white adipose depots, and the identification of factors secreted by BAT with therapeutic potential. In this review, we discuss the caloric capacity and other metabolic benefits from BAT activation in humans and the role of metabolic tissues such as skeletal muscle in increasing energy expenditure. We discuss the potential of current approaches and the challenges of BAT activation as a novel strategy to treat obesity and metabolic disorders.

Abstract PS17-29: Surgically induced weight loss corrects obesity associated tumor progression and improves responsiveness to immunotherapy

Abstract Background: Obesity leads to a higher risk of cancer invasion, metastases, recurrence, mortality, and impaired therapeutic response through various mechanisms. One of these mechanisms is microenvironment dysfunction, where changes in immune cells, microbes, metabolites, and growth factors contribute to tumor aggressiveness. We study obesity-induced changes to the tumor microenvironment in Triple Negative Breast Cancer (TNBC), an aggressive subtype associated with obesity. The goal to compare tumor progression in lean vs. obese vs. weight loss manipulations to identify causal and targetable pathways associated with reprogramming the tumor microenvironment. Clinically, bariatric surgery induced weight loss reduced the risk of BC, with the greatest benefit detected in pre-menopausal patients with ER- tumors, like TNBC. We hypothesize surgically-induced weight loss will diminish obesity-associated tumor progression. Methods: To study weight gain and loss that best mimics human adiposity, we utilized obesogenic C57BL/6 females with a syngeneic orthotopic transplant of TNBC cells. Female mice placed on a high fat diet (HFD) at weaning became obese compared to mice on a low fat diet (LFD). After 16 weeks on an HFD diet, mice underwent the bariatric surgery Vertical Sleeve Gastrectomy (VSG). The VSG resulted in reduced body weight, adiposity, and correction of metabolic profiles compared to obese mice. Two weeks post-surgery, TNBC cells were OT into the mammary fat. Results: As expected, tumor growth was increased in obese mice compared to lean. Importantly, surgical weight loss rescued obese tumor progression. We identified key changes in tumor infiltrating of immune cells that could be responsible for the beneficial effects of bariatric surgery on tumor progression. We then exploited these changes with immunotherapy, which was uniquely effective in mice that underwent bariatric surgery. Conclusions: In conclusion obesity promotes a pro-tumor microenvironment, that can be corrected through surgically induced weight loss. Citation Format: Laura Sipe, Mehdi Chaib, Emily B Korba, Mary C Lovely, Jared C Clements, Neena A John, Ajeeth K Pingili, Joseph F Pierre, Liza Makowski. Surgically induced weight loss corrects obesity associated tumor progression and improves responsiveness to immunotherapy [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS17-29.

The Effect of Bariatric Surgery and Endoscopic Procedures on Gastroesophageal Reflux Disease.

Obesity is a global epidemic posing a significant burden on patients and healthcare systems. Gastroesophageal reflux disease is associated with obesity and its prevalence is also growing worldwide. Numerous bariatric surgeries and endoscopic procedures have arisen to assist with weight loss and management of obesity-related conditions. However, the effect of these interventions on reflux is variable and the evidence is often conflicting. To date, Roux-en-Y gastric bypass remains the gold-standard for attaining both reflux and weight loss management, however novel endoscopic techniques are quickly becoming more prevalent as an alternative to surgery. This review aims to summarize currently available endoscopic and surgical weight loss procedures and their impact on reflux symptoms while emphasizing areas requiring additional investigation.

The first modified Delphi consensus statement on sleeve gastrectomy.

Sleeve gastrectomy (SG) is the commonest bariatric procedure worldwide. Yet there is significant variation in practice concerning its various aspects. This paper report results from the first modified Delphi consensus-building exercise on SG. We established a committee of 54 globally recognized opinion makers in this field. The committee agreed to vote on several statements concerning SG. An agreement or disagreement amongst ≥ 70.0% experts was construed as a consensus. The committee achieved a consensus of agreement (n = 71) or disagreement (n = 7) for 78 out of 97 proposed statements after two rounds of voting. The committee agreed with 96.3% consensus that the characterization of SG as a purely restrictive procedure was inaccurate and there was 88.7% consensus that SG was not a suitable standalone, primary, surgical weight loss option for patients with Barrett's esophagus (BE) without dysplasia. There was an overwhelming consensus of 92.5% that the sleeve should be fashioned over an orogastric tube of 36-40 Fr and a 90.7% consensus that surgeons should stay at least 1cm away from the angle of His. Remarkably, the committee agreed with 81.1% consensus that SG patients should undergo a screening endoscopy every 5years after surgery to screen for BE. A multinational team of experts achieved consensus on several aspects of SG. The findings of this exercise should help improve the outcomes of SG, the commonest bariatric procedure worldwide, and guide future research on this topic.

Survey of perceptions and educational needs of primary care providers regarding management of patients with class II and III obesity in Ontario, Canada

BackgroundPrimary care providers (PCPs) are typically the primary contact for patients with obesity seeking medical and surgical weight loss interventions; however, previous studies suggest that fewer than 7% of eligible adult patients are referred to publically funded medical and surgical weight loss interventions (MSWLI).MethodsWe performed an anonymous survey study between October 2017 and June 2018 to explore the knowledge, experiences, perceptions, and educational needs of PCPs in Southeastern Ontario in managing patients with class II and III obesity.ResultsSurveys were distributed to 591 PCPs (n = 538 family physicians; n = 53 nurse practitioners) identified as practicing in the Southeastern Ontario and 92 (15.6%) participated. PCPs serving a rural population estimated that 14.2 ± 10.9% of patients would qualify for MSWLI compared to 9.9 ± 8.5% of patients of PCPs serving an urban population (p = .049). Overall, 57.5% of respondents did not feel competent prescribing MSWLI to patients with class II/III obesity, while 69.8% stated they had ‘good’ knowledge of the referral criteria for MSWLI. 22.2% of respondents were hesitant to refer patients for bariatric surgery (BS) due to concerns about postoperative surgical complications and risks associated with surgery. Only 25% of respondents were comfortable providing long-term follow up after BS, and only 39.1% had participated in continuing education on management of patients with class II/III obesity in the past 5 years.ConclusionThe majority of PCPs believe there is a need for additional education about MSWLI for patients with class II/III obesity. Future studies are needed to develop and compare the effectiveness of additional education and professional development around risks of contemporary BS, indications to consider referral for MSWLI, management and long-term follow-up of patients after BS.

High prevalence of neurodevelopmental problems in adolescents eligible for bariatric surgery for severe obesity

AimTo assess the prevalence of neurodevelopmental problems in adolescents with severe obesity and their associations with binge eating and depression.MethodsData were collected at inclusion in a randomised study of bariatric surgery in 48 adolescents (73% girls; mean age 15.7 ± 1.0 years; mean body mass index 42.6 ± 5.2 kg/m2). Parents completed questionnaires assessing their adolescents’ symptoms of attention‐deficit/hyperactivity disorder and autism spectrum disorder and reported earlier diagnoses. Patients answered self‐report questionnaires on binge eating and depressive symptoms.ResultsThe parents of 26/48 adolescents (54%) reported scores above cut‐off for symptoms of the targeted disorders in their adolescents, but only 15% reported a diagnosis, 32% of adolescents reported binge eating, and 20% reported symptoms of clinical depression. No significant associations were found between neurodevelopmental problems and binge eating or depressive symptoms. Only a third of the adolescents reported no problems in either area.ConclusionTwo thirds of adolescents seeking surgical weight loss presented with substantial mental health problems (reported by themselves or their parents). This illustrates the importance of a multi‐professional approach and the need to screen for and treat mental health disorders in adolescents with obesity.

Presence of Liver Steatosis Is Associated With Greater Diabetes Remission After Gastric Bypass Surgery.

Type 2 diabetes mellitus (T2DM) is characterized by insulin resistance (IR) and β-cell dysfunction. Ectopic fat accumulation in liver and muscle causes IR. Since bariatric and metabolic surgery significantly improves fatty liver disease, we hypothesized that coexistence of liver steatosis (i.e., when hepatic IR contributes in T2DM) would be associated with greater diabetes improvement after surgery. A total of 519 patients with T2DM who underwent Roux-en-Y gastric bypass and simultaneous liver biopsy and had a minimum 5-year follow-up were analyzed to assess the independent association between biopsy-proven liver steatosis and postoperative long-term diabetes remission (glycated hemoglobin <6.5% [48 mmol/mol] off medications). Of the 407 patients with biopsy-proven liver steatosis, long-term diabetes remission was achieved in 211 (52%) patients compared with remission in 44 out of 112 (39%) patients without steatosis (P = 0.027). In multivariable analysis, presence of liver steatosis was an independent predictor of long-term diabetes remission (odds ratio 1.96 [95% CI 1.04-3.72]; P = 0.038). Hepatocyte ballooning, lobular inflammation, or fibrosis at baseline did not predict diabetes remission. This study, for the first time, suggests that in patients with T2DM who are considering bariatric and metabolic surgery, coexistence of liver steatosis is associated with better long-term glycemic outcomes. Furthermore, our data suggest that there are distinct variants of T2DM in which metabolic responses to surgical weight loss are different. A subgroup of patients whose T2DM is characterized by the presence of hepatic steatosis (presumably associated with worse IR) experience better postoperative metabolic outcomes.

The Dynamic Platelet Transcriptome in Obesity and Weight Loss.

Adiposity is associated with oxidative stress, inflammation, and glucose intolerance. Previous data suggest that platelet gene expression is associated with key cardiometabolic phenotypes, including body mass index but stable in healthy individuals over time. However, modulation of gene expression in platelets in response to metabolic shifts (eg, weight reduction) is unknown and may be important to defining mechanism. Approach and Results: Platelet RNA sequencing and aggregation were performed from 21 individuals with massive weight loss (>45 kg) following bariatric surgery. Based on RNA sequencing data, we measured the expression of 67 genes from isolated platelet RNA using high-throughput quantitative reverse transcription quantitative PCR in 1864 FHS (Framingham Heart Study) participants. Many transcripts not previously studied in platelets were differentially expressed with bariatric surgical weight loss, appeared specific to platelets (eg, not differentially expressed in leukocytes), and were enriched for a nonalcoholic fatty liver disease pathway. Platelet aggregation studies did not detect alteration in platelet function after significant weight loss. Linear regression models demonstrated several platelet genes modestly associated with cross-sectional cardiometabolic phenotypes, including body mass index. There were no associations between studied transcripts and incident diabetes or cardiovascular end points. In summary, while there is no change in platelet aggregation function after significant weight loss, the human platelet experiences a dramatic transcriptional shift that implicates pathways potentially relevant to improved cardiometabolic risk postweight loss (eg, nonalcoholic fatty liver disease). Further studies are needed to determine the mechanistic importance of these observations.

Dysregulated appetitive leptin signaling in male rodent offspring from post-bariatric dams.

Bariatric surgery produces significant positive benefits to recipients such as resolution of various obesity-related comorbidities, including improved reproductive function. Females of childbearing age seek bariatric surgical remedies to improve their chance of successful pregnancy; however, limited knowledge exists on the impact of surgical weight loss to subsequently born offspring.We previously reported that circulating leptin levels were reduced in pregnant females having previously received vertical sleeve gastrectomy (VSG) in comparison to control dams having received Sham surgery. Furthermore, the levels of leptin receptors in the VSG placenta were also reduced in comparison to controls in. These data suggest there may be a significant difference in leptin signaling during pregnancy that may produce an altered developmental environment for the offspring.Here, we investigate the adult offspring of dams having received VSG or Sham-VSG prior to pregnancy. Endogenous fasting plasma leptin levels were not different between Sham and VSG offspring. Fasting leptin receptor mRNA in the medial basal hypothalamus (MBH) was elevated in VSG offspring in comparison to Sham. Intraperitoneal administration of exogenous leptin produced reductions in acute food intake in male Sham offspring, but did not reduce food intake at any time point measured in male VSG offspring. Using Western blot, we identified elevated pSTAT3 and pSTAT3/STAT3 ratios in the MBH of post-VSG offspring in comparison to controls. Using immunohistochemistry, we found an increased number of pSTAT positive cells in the arcuate nucleus in the Sham offspring in comparison to VSG. In contrast, within the paraventricular and ventromedial hypothalamic nuclei the VSG offspring had elevated numbers of pSTAT-positive cells in comparison to controls. Collectively, these data support our hypothesis that leptin signaling is dysregulated in VSG offspring and may be partially responsible for the long-term impact of maternal bariatric surgery on the metabolic health of offspring.

The Effect of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease.

The laparoscopic sleeve gastrectomy (LSG) has become one of the most popular surgical weight loss options. Since its inception as a procedure intended to promote durable weight loss, the association between LSG and gastroesophageal reflux disease (GERD) has been a point of debate. First and foremost, it is known that GERD occurs more frequently in the obese population. With the sleeve gastrectomy growing to be the predominant primary bariatric operation in the United States, it is imperative that we understand the impact of LSG on GERD. To examine the effects of LSG on GERD symptoms. One hundred and ninety-one bariatric surgery candidates completed a Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire before and after undergoing elective LSG (mean follow-up time of 20.4 ± 2.7months). Values were stratified by the presence or absence of preoperative GERD, GERD medications, age, gender, crural repair, patient satisfaction with present condition, and percent total weight loss (%TWL). For the entire group, mean weight loss, %TWL, and reduction in BMI were 79 pounds, 28.1%, and 12.7kg/m2 respectively. Within the overall cohort, there was no significant change in GERD symptoms from before to after surgery (mean GERD-HRQL scores were 6.1 before and after surgery, p = 0.981). However, in a subgroup analysis, patients without GERD preoperatively demonstrated a worsening in mean GERD-HRQL scores after surgery (from 2.4 to 4.5, p = 0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, p = 0.233). The percent of patients satisfied with their condition postoperatively was significantly increased in those with preoperative GERD, older age, crural repair intraoperatively, and in those with the highest %TWL. These results suggest that while overall LSG does not significantly affect GERD symptoms, patients without GERD preoperatively may be at risk for developing new or worsening GERD symptoms after surgery. It is important to remark that this is a review of the patient's clinical symptoms of GERD, not related to any endoscopic, pathological, or manometry studies. Such studies are necessary to fully establish the effect of LSG on esophageal health.

Abstract 13594: Adverse Right Ventricular Remodelling, Function and Stress Responses in Obesity: Implications for Severe Acute Respiratory Illness

Introduction: The mechanisms linking obesity to increased mortality in patients with coronavirus-disease 2019 (COVID-19) are unclear. Hypothesis: We hypothesised that obesity would be associated with adverse right ventricular (RV) remodelling and function which might be further exacerbated by COVID-19 associated increases in RV afterload/demand. Methods: We used echocardiography and computed tomography to establish links between RV dimensions and function and bodyweight in patients with severe COVID-19. In obese and non-obese participants without COVID-19, we used cardiovascular magnetic resonance to define the effects of obesity upon RV volumes, energetics, systolic function and stress reserve. Results: In patients with severe COVID-19, increasing bodyweight was associated with disproportionate RV dilatation (n=26, echocardiography, R=0.42, P=0.03, CT n=34, R=0.23, P=0.004) and impairment of RV systolic function (fractional area change (FAC) R=-0.45, P=0.04); obesity (BMI &gt;30kg/m2) was associated with a 32% reduction in RV FAC (P=0.03). Similar associations were seen in a validation cohort (n=91, all P&lt;0.05). In participants without COVID-19, class III obesity (n=54, BMI 47±4 kg/m 2 ) was associated with RV remodelling, impaired cardiac energetics (PCr/ATP ratio 23% lower, P&lt;0.001) and reduction in RV systolic function at rest (by 3±1%, P=0.01), which was related to reduced energetics (R=0.3, P=0.04). Participants with class I-II obesity (BMI 35±5 kg/m 2 , n=27) had impaired RV diastolic filling rate at rest (P&lt;0.001) and blunted RV dobutamine stress systolic response (by 68%, P=0.03) and diastolic response (by 78%, P=0.008). Surgical weight loss in patients obesity (n=37, 34±15kg weight loss) was associated with improvement in RV volume (12±26 ml lower, P=0.006) and function (ejection fraction 2±5% higher, P=0.03). Conclusions: Increasing body weight is associated with both significant alterations in RV volumes, systolic function and stress responses which are mitigated with weight loss and also with disproportionate RV dilatation and dysfunction in severe COVID-19. RV dysfunction is a modifiable mechanism which might link obesity to adverse outcomes in patients with COVID-19 and other disorders stressing the right heart.

Percutaneous transcatheter bariatric embolotherapy for weight loss in obesity: two year data from a prospective RCT

Abstract Background/Introduction Obesity is an important risk factor associated with poor cardiovascular and metabolic outcomes. Dietary, medical, and surgical weight loss strategies are often unsuccessful, unsustainable or accompanied by risks. Pre-clinical and early case series reported that transcatheter bariatric embolotherapy (TBE) of the left gastric artery reduces weight, by reducing “hunger” hormones from the gastric fundus. We studied TBE in a double-blind, sham procedure, first in human RCT of patients (pts) with obesity, and following completion of the initial study we asked subjects to return after 2 years post-embolization for further evaluation. Purpose The purpose of this extension study was to assess the long-term weight loss and other outcomes in subjects who underwent TBE for weight loss. Methods In the initial RCT subjects were randomized 1:1 to either a Sham (skin nick &amp; 1 hr wait) or TBE following IV Propofol sedation. All pts received Lifestyle Therapy (behavioral and diet education); these staff following the pts were also blinded to treatment. Subjects completed the initial study when reaching the 1 year-follow-up visit. Subjects were then invited to return to the weight loss clinic at 2 years post-embolization for further evaluation on weight loss, blood pressure, pre-diabetic clinical status, satiety, and quality of life. Results A total of 44 pts (age 45.5±9.8; 36/8 M/F; BMI 39.6±3.8) were enrolled, of which 40 pts were randomized equally to groups, with no major complications. Mild, transient epigastric pain was seen, but EGDs showed no major abnormalities. Weight loss was improved with TBE by 6 mo, and maintained over the full 12 mo by both intention-to-treat and per-protocol analyses. At 2 years post-embolization, subjects treated with TBE demonstrated a mean 9% TBWL and 25% EBWL. Conclusion(s) Bariatric embolization is safe and when used along with lifestyle therapy, results in clinically significant weight loss. Long-term data demonstrates evidence that subjects treated with TBE continue to maintain their weight loss up to 2 years post-treatment. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Endobar Solutions LLC

S1197 An Appraisal of the Morbidity Risk After Intragastric Balloon Placement for Weight Loss: A Systematic Review

INTRODUCTION: Surgical management is considered the most effective treatment for obesity; major series have estimated overall postoperative morbidity between 0.1 and 0.15%. Intragastric balloon (IGB) placement represents an endoscopic intervention that has shown efficacy at inducing weight loss. This study aimed to review the incidence of morbidity after IGB placement. METHODS: A systematic literature search was conducted on MEDLINE using the PICO framework and is reported under the PRISMA framework (Figure 1). Clinical trials (randomized and non-randomized) comparing intragastric balloon with medical management, placebo, or dietary restriction were included. Studies with non-FDA approved devices, on non-human subjects, or not in English were excluded. Adverse events were then classified by severity into Clavien-Dindo grades to standardize outcomes. RESULTS: Of the 49 studies screened after a systematic literature search, 23 clinical trials (n = 1996) met the inclusion criteria; 1327 of these patients underwent endoscopic intragastric balloon placement (Table 1). Six trials compared IGB with medical management, 8 with placebo, 7 trials did not have a comparison group, and 2 compared saline with air-filled balloons. Dietary restriction was included in the study protocol for 92.89% of the patients. The majority of the trials (n = 15) used saline-filled balloons, whereas the rest used air or nitrogen-filled balloons. The mean follow-up after the procedure was 13.60 ± 11.3 months. The pooled range of Clavien-Dindo grade III morbidity was 3.33%–19.37%, grade IV was 0.5%–4.76%, and grade V was 0%. Mild post-procedural morbidity had a wide spectrum ranging from 11.6% to 100%. CONCLUSION: The incidence of moderate to severe morbidity from an intragastric balloon appears to be comparable to published morbidity and mortality data for bariatric surgery. However, complications of mild severity are more common. Clinical trials comparing IGB with surgical weight loss are needed.Figure 1Table 1

The Gravitostat theory: Body fat is lost but is fat-free mass preserved?

The Gravitostat theory: Body fat is lost but is fat-free mass preserved?

Screening Esophagogastroduodenoscopy Before Laparoscopic Sleeve Gastrectomy: Results in 819 Patients.

Aim: The routine use of esophagogastroduodenoscopy (EGD) during the preoperative evaluation of surgical weight loss candidates is controversial. The aim of this study is to evaluate the findings of preoperative EGD in patients who are scheduled for a primary laparoscopic sleeve gastrectomy (LSG). The probable effect of these findings on the medical and surgical strategy that was followed is assessed. Methods: Findings of EGD obtained from consecutive LSG candidates and all data were prospectively recorded and retrieved from the database. Results: A total of 819 patients underwent EGD successfully. Mean age and body mass index were 38 ± 11.3 and 43.17 ± 7.2 kg/m2, respectively. Fifty-eight percent were female. EGD of 263 (32.1%) patients was normal and 687 (84%) patients were asymptomatic. At least one abnormal finding was detected in 65% of the asymptomatic patients. Abnormal findings that did not change the surgical strategy were found in 550 patients (67.2%). Findings such as gastritis or duodenitis that changed the medical management before surgery were found in 309 patients (38.2%). Helicobacter pylori was positive in 218 (26.6%) patients but eradication treatment was not applied in the preoperative period. No pathology was detected that would create absolute contraindication or change the type of surgery in any patient. Only technical modifications were required in 13% due to hiatal hernia. The timing of the planned surgery has changed in only 6 patients (0.74%) (early stage neuroendocrine tumor, leiomyoma, severe ulcer). Conclusions: Routine EGD performed before LSG did not change the planned bariatric option in any patient, but led to 13% rate of technical modifications due to the presence of hiatal hernia. At least one abnormal finding was detected in 65% of asymptomatic patients. Due to endoscopic findings, the rate of patients who started medical acid-suppression treatment in the preoperative period was 38%.

Laparoscopic sleeve gastrectomy in patients with complex abdominal wall hernias.

Patients with severe obesity and complex abdominal wall hernias (CAWH) present a challenging clinical dilemma. Their body mass index (BMI) is often prohibitive of successful ventral hernia repair (VHR) and the CAWH presents technical challenges when pursuing bariatric surgery. Our hernia center policy is to refer patients with severe obesity for evaluation with the surgical weight loss program. This study describes outcomes of laparoscopic sleeve gastrectomy (LSG) in patients with both severe obesity and CAWH. A retrospective analysis was performed on data prospectively collected between 2014 and 2020. CAWH patients referred for and undergoing LSG were included. Revisional bariatric surgery patients were excluded. The dataset was augmented with operative time, BMI changes, length of stay (LOS), hernia characteristics, postoperative complications, time from referral to weight loss surgery, and time from LSG to VHR. Twenty patients (10 males, mean age 54.3years) met inclusion criteria. Mean BMI at LSG was 45.6 ± 6.1kg/m2. Mean hernia area was 494.9 ± 221.2 cm2 and 90% had hernia extension into the subxiphoid and/or epigastric regions. Mean time from bariatric referral to LSG was 10.5 ± 5.4months. Mean LSG operative time was 121.2 ± 50.3min, and mean LOS was 1.6 ± 0.8days. One patient had postoperative bleeding necessitating laparoscopic re-exploration. There were no readmissions. Sixteen patients subsequently underwent VHR on average13.5 ± 11.7months later and on average 22.6 ± 12.5months after initial hernia consultation. Two patients had a hernia-related complication between the period of initial hernia consultation and ultimate repair. Mean BMI was 37.5 ± 7.5kg/m2 (mean 20.7 ± 12.3% decrease, p < 0.0001) at mean follow-up of 27.2 ± 17.2months. LSG can be performed successfully even in patients with CAWH. Outcomes do not appear to differ significantly from typical patients undergoing LSG. Further study with larger cohorts is warranted to better delineate complication rates in this population as well as to determine long-term outcomes.

Do Adults Utilizing Intermittent Fasting Improve Lipids More Than Those Following a Restricted-Calorie Diet? A Clin-IQ.

With approximately 95 million Americans diagnosed with high cholesterol, and many searching for a nonmedicinal treatment, intermittent fasting as a method to improve health has become increasingly popular in the lay public. We conducted a clinical inquiry to determine whether intermittent fasting is superior to a low-calorie diet in improving lipids, searching the Cochrane, EBSCOhost, Embase, MEDLINE, and Scopus databases using the terms intermittent fasting, lipids, and calorie-restricted diet. Studies that included surgical weight loss or medicine-assisted weight loss were excluded. We identified 6 published studies, 5 of which were randomized controlled trials. In reviewing the selected studies, there did not appear to be a consistent difference in lipid change between restricted-calorie diet and intermittent fasting. Because of differences in study methods and in how intermittent fasting was defined, additional studies are needed.

Safety of bariatric surgery in patients with coronary artery disease.

Patients with obesity and established coronary artery disease (CAD) may benefit from surgical weight loss; however, its safety is unknown in this population. To assess the association between CAD and the incidence of 30-day postoperative mortality and major adverse cardiac events (MACEs) in patients undergoing bariatric surgery. Multicenter cohort study. We used the 2017 MBSAQIP database to study patients undergoing bariatric surgery from accredited centers in the United States and Canada between Jan 1, 2017, and Dec 31, 2017. Multivariate logistic regression was used to determine whether established CAD was independently associated with 30-day mortality and MACE, a composite endpoint that included myocardial infarction and/or cardiac arrest. We reviewed data from 167,819 patients from 832 centers. There were 4172 patients with diagnosed CAD, and 163,647 without it. At 30-day follow-up, the endpoints of mortality, cardiac arrest, myocardial infarction, and MACE occurred in 172 (.10%), 82 (.05%), 57 (.03%), and 135 (.08%) patients, respectively. The endpoints occurred more significantly in patients with CAD compared with patients without CAD; 22 (.53%) versus 150 (.09%) for mortality, 13 (.31%) versus 69 (.04%) for cardiac arrest, 17 (.41%) versus 40 (.02%) for myocardial infarction, and 28 (.67%) versus 107 (.07%) for MACE (P < .001 for all comparisons). Postoperative mortality and MACE following bariatric surgery are higher in patients with CAD than those without; however, the absolute incidence is low (<1%). The decision to pursue bariatric surgery and/or preoperative cardiac testing in patients with CAD should include consideration of the overall incidence of adverse cardiac outcomes and the stability of CAD.

Should bariatric surgery be offered for hepatocellular adenomas in obese patients?

Obesity and metabolic syndrome are increasingly recognized as risk factors for development of hepatocellular adenoma (HCA). The implications of weight loss on HCA regression has not been previously reviewed. To analyze the effects of surgical and nonsurgical weight loss on HCA. University Tertiary Hospital. Literature review of full-text articles from PubMed and Scopus on patients with HCA who underwent surgical or nonsurgical weight loss was performed. Only English language articles were included and editorial comments were excluded. Wilcoxon signed rank test was used for paired data analysis. Spearman correlation was used for correlation between percent excess weight loss (%EWL) and number and size of HCA lesions. Out of 4 studies, 7 patients were included in this review, all of whom were female. The median preintervention body mass index was 41 kg/m2 compared with the postintervention body mass index of 28 kg/m2 (P = .002). The %EWL following intervention positively correlated to reduction in number of HCA lesions (%) postintervention, with a Spearman correlation of .78 (P = .04). Similarly, %EWL postintervention was positively correlated, though not statistically significant, to reduction in lesion size (%), with a Spearman correlation of .46 (P = .29). All patients who were candidates for liver resection preintervention based on lesion size > 5 cm avoided liver resection postintervention following surgical and nonsurgical weight loss. Effective long-term weight loss by surgical and nonsurgical methods result in regression of HCAs. Weight loss could avoid major liver resections or decrease the morbidity associated with liver surgery. Bariatric surgery should be considered as an option for management of surgically challenging HCAs in carefully selected obese patients. Multicenter long-term trials, while adjusting for cofounding factors, are required to determine the effects of surgical compared with nonsurgical weight loss on maintenance of HCA regression.

Meta-analysis on the long-term effectiveness of psychological and medical treatments for binge-eating disorder.

Long-term effectiveness is a critical aspect of the clinical utility of a treatment; however, a meta-analytic evaluation of psychological and medical treatments for binge-eating disorder (BED), including weight loss treatments, is outstanding. This meta-analysis sought to provide a comprehensive evaluation of the long-term effectiveness in diverse treatments for BED regarding a range of clinically relevant outcomes. Based on a systematic search up to February 2018, 114 published and unpublished randomized-controlled (RCTs), nonrandomized, and uncontrolled treatment studies, totaling 8,862 individuals with BED (DSM-IV, DSM-5), were identified and analyzed using within-group random-effect modeling. Effectiveness (regarding binge-eating episodes and abstinence, eating disorder and general psychopathology) up to 12 months following treatment was demonstrated for psychotherapy, structured self-help treatment, and combined treatment, while the results regarding body weight reduction were inconsistent. These results were confirmed in sensitivity analyses with RCTs on the most common treatments-cognitive-behavioral therapy and self-help treatment based on this approach. Follow-up intervals longer than 12 months were rarely reported, mostly supporting the long-term effectiveness of psychotherapy. Few follow-up data were available for pharmacotherapy, and behavioral and self-help weight loss treatment, while follow-up data were lacking for pharmacological and surgical weight loss treatment. Study quality varied widely. This comprehensive meta-analysis demonstrated the medium-term effectiveness of psychotherapy, structured self-help treatment, and combined treatment for patients with BED, and supported the long-term effectiveness of psychotherapy. The results were derived from uncontrolled comparisons over time. Further long-term high quality research on psychological and medical treatments for BED is required.