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1.
Long alimentary limb duodenal switch (LADS): a short-term prospective randomized trial.
Cloutier, A, Lebel, S, Hould, F, Julien, F, Marceau, S, Bouvet, L, Simard, S, Biertho, L
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2018;(1):30-37
Abstract
BACKGROUND Biliopancreatic diversion with duodenal switch (BPD-DS) is one of the most effective bariatric surgeries, in terms of weight loss and remission of co-morbidities. It is however associated with a significant risk of protein and nutritional deficiency, as well as gastrointestinal side effects. OBJECTIVES To assess the effect of increasing the strict alimentary limb on weight loss, nutritional deficiency and quality of life, compared with standard BPD-DS. SETTINGS University-affiliated tertiary care center. METHODS Prospective randomized double blind (patient-evaluator) trial in which patients were assigned in a 1:1 ratio to undergo a modified BPD-DS with a long alimentary limb (1 m from Treitz ligament, n = 10) or a standard biliopancreatic diversion (strict alimentary limb of 1.5 m, n = 10). Common channel was kept at 100 cm in both groups. Follow-up at 12 months was completed in all patients. RESULTS Initial weight (126 ± 10 versus 125 ± 17, P = .92), age (40 ± 7 versus 37 ± 8, P = .35), and sex ratio (1 female/9 males) were similar in both groups. Excess weight loss and total weight loss were significantly higher in the standard BPD-DS group (93.4 ± 12% versus 73.3 ± 7%, P = .0007 and 46 ± 5.6% versus 37 ± 3.4%, P = .0004). The study group had significantly higher vitamin D, manganese, and copper levels at 12 months. Both groups had similar drop in glycated hemoglobin, cholesterol levels, and resolution of co-morbidities at 12 months. Long alimentary limb was associated with significantly less bowel movements a day (1.6 ± .97 versus 2.55 ± 1.01, P = .01), less gastrointestinal side effects (bloating and gas, P<.05) and required less pancreatic enzymes supplements (0 versus 40%, P = .04) and calcium supplement. Quality of life was significantly improved in both groups in all domains (all P<.05). CONCLUSION At 12 months, weight loss was lesser in the long alimentary limb group. There was however no difference in the remission of co-morbidities and higher levels of vitamin D, manganese, and copper. Gastrointestinal adverse effects and the need for pancreatic enzymes were less with similarly excellent quality of life at 12 months. Longer follow-up is necessary to evaluate long-term weight loss and nutritional deficiencies.
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2.
Bariatric surgery and birth defects: A systematic literature review.
Benjamin, RH, Littlejohn, S, Mitchell, LE
Paediatric and perinatal epidemiology. 2018;(6):533-544
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Abstract
BACKGROUND Bariatric procedures are on the rise. The risk of birth defects in pregnancies following such procedures may be increased (eg, due to nutrient deficiencies) or decreased (eg, due to decreased maternal body mass index, BMI). METHODS We conducted a systematic literature review of the association between bariatric surgery and birth defects using Ovid MEDLINE and PubMed (1946-2017). Information was abstracted on study design, exposures, outcomes, covariates and estimates of association. RESULTS Fifteen studies met our inclusion criteria: 14 evaluated the outcome of any birth defect, and one evaluated neural tube defects. Estimates of association between bariatric surgery and birth defects were available for nine studies and ranged from 0.6 to 1.9 (all 95% confidence intervals included 1.0). When studies were stratified by surgery type, there was no obvious pattern of association. When stratified by the approach used to account for BMI, positive associations were observed in studies that did not account for maternal prepregnancy BMI or used women with normal BMI as the reference group (range: 1.3-1.9). Estimates from studies that either matched or adjusted for prepregnancy BMI were closer to the null (range: 1.1-1.2) and studies that compared to morbidly obese women reported protective associations (range: 0.6-0.7). CONCLUSIONS Studies of the association between bariatric surgery and birth defects vary with respect to the surgical procedures included, birth defects ascertainment methods and approaches used to account for maternal BMI. Consequently, it is not possible to draw a conclusion regarding the association between bariatric surgery and birth defects. Additional studies are warranted.
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Bariatric surgery and gene expression in the gut.
Sala, P, Corrêa-Giannella, ML, Waitzberg, DL
Current opinion in clinical nutrition and metabolic care. 2018;(4):246-251
Abstract
PURPOSE OF REVIEW The current review provides an overview of recent literature on new findings related to bariatric surgery and gut gene expression. RECENT FINDINGS Bariatric surgery modulates the expression of intestinal genes. Experimental and clinical investigations have demonstrated the association of gut rearrangement with changes in intestinal expression of genes related to glucose metabolism. Recent data suggest that bariatric surgery also affects expression of genes belonging to other pathways, including nutrient transporters and metabolism of vitamin B12, decreasing pathway-encoding genes that may contribute to vitamin B12 deficiency in the postoperative period. SUMMARY Bariatric surgery is an effective intervention strategy against severe obesity, resulting in sustained weight loss and reduction of comorbidities. Nutritional genomic changes appear in response to bariatric surgery, possibly due to adaptive gut response. Improved understanding of the molecular pathways modulated by this intervention may facilitate weight and comorbidities management.
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Longitudinal assessment of renal function in native kidney after bariatric surgery.
Favre, G, Schiavo, L, Lemoine, S, Esnault, VLM, Iannelli, A
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2018;(9):1411-1418
Abstract
The epidemic of obesity parallels that of chronic kidney disease (CKD). Obesity worsens the course of CKD, mainly defined by an abnormal glomerular filtration rate (GFR). Patients with severe obesity stages (II and III with body mass index >35 kg/m2) are eligible for bariatric surgery (BS), which is the most efficient method of achieving durable weight loss. BS may reverse glomerular hyperfiltration and albuminuria, improve adipocytokine profile, and relieve diabetes and hypertension. Obesity remission after BS might prevent the progression of renal failure in populations with morbid obesity. However, evidence for the beneficial effect of BS on renal function is scant. This lack of knowledge is mainly due to methodologic reasons, which are addressed in this review. The reversibility of hyperfiltration due to the presence of functional renal reserve hampers the interpretation of changes in true GFR after BS. This true GFR is only obtained with the renal clearance of an exogenous filtration marker. Estimation of GFR is generally provided by prediction equations, namely by modification of diet in renal diseases or by chronic kidney disease-epidemiology collaborative group. These equations are not accurate because the serum levels of both creatinine and cystatin C depend on extrarenal factors, which are modified by BS. Comparing the slopes of measured GFR according to various durations of exposure with morbid obesity would be critical in providing reliable data. Herein, we review the current knowledge on the effects of BS on kidney function; we specify the methodologic issues and particularities of the dietary management of CKD patients to propose reliable directions for future clinical research.
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Treatment Options for Severe Obesity in the Pediatric Population: Current Limitations and Future Opportunities.
Ryder, JR, Fox, CK, Kelly, AS
Obesity (Silver Spring, Md.). 2018;(6):951-960
Abstract
OBJECTIVE Severe obesity is the only obesity classification increasing in prevalence among children and adolescents. Treatment options that produce meaningful and sustained weight loss and comorbidity resolution are urgently needed. METHODS The purpose of this review is to provide a brief overview of the current treatment options for pediatric severe obesity and offer suggestions regarding future opportunities for accelerating the development and evaluation of innovative treatment strategies. RESULTS At present, there are three treatment options for youth with severe obesity: lifestyle modification therapy, pharmacotherapy, and bariatric surgery. Lifestyle modification therapy can be useful for improving many chronic disease risk factors and comorbid conditions but often fails to achieve clinically meaningful and sustainable weight loss. Pharmacotherapy holds promise as an effective adjunctive treatment but remains in the primordial stages of development in the pediatric population. Bariatric surgery provides robust weight loss and risk factor/comorbidity improvements but is accompanied by higher risks and lower uptake compared to lifestyle modification therapy and pharmacotherapy. New areas worth pursuing include combination pharmacotherapy, device therapy, identification of predictors of response aimed at precision treatment, and interventions in the postbariatric surgical setting to improve long-term outcomes. CONCLUSIONS Treating pediatric severe obesity effectively and safely is extremely challenging. Some progress has been made, but substantially more effort and innovation are needed in the future to combat this serious and ongoing medical and public health issue.
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The case for stepped care for weight management after bariatric surgery.
Kalarchian, MA, Marcus, MD
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2018;(1):112-116
Abstract
Among carefully screened patients, bariatric surgery has proven safe and efficacious in the management of clinically severe obesity and poorly controlled type 2 diabetes. Nonetheless, individual outcomes vary, suggesting the need for interventions to maximize and sustain the health benefits of surgery. In this short review, we synthesize findings from the extant research literature to suggest the potential utility of a stepped care approach to optimize the postsurgery weight trajectory, which requires further research using adaptive designs. Starting with low-intensity, cost-effective interventions, such as self-weighing and self-monitoring, interventions that increase in intensity, such as counseling, meal replacements, or weight loss medications, could be added strategically according to predetermined decision rules based on patient weight change. Interventions could subsequently be withdrawn if no longer indicated, or reinstituted when appropriate, allowing for efficient allocation of resources in a personalized approach to postsurgery weight management over time.
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Abdominal Pain After Roux-En-Y Gastric Bypass for Morbid Obesity.
Mala, T, Høgestøl, I
Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society. 2018;(4):277-284
Abstract
BACKGROUND AND AIMS Roux-en-Y gastric bypass is widely used as treatment of morbid obesity. Weight loss, effects on obesity-related co-morbidities and quality of life are well documented post Roux-en-Y gastric bypass. Other outcome measures are less well studied. This review explores aspects of prevalence, diagnostic evaluations, etiology, and treatment of abdominal pain specific to Roux-en-Y gastric bypass. METHODS The review is based on PubMed searches and clinical experience with Roux-en-Y gastric bypass. Symptoms in the early postoperative phase (<30 days) were not included. RESULTS Based on limited evidence, up to about 30% of the patients may perceive recurrent abdominal pain post Roux-en-Y gastric bypass in the long term. A substantial subset of patients will need health-care evaluation for acute abdominal pain and hospital admission. The etiology of abdominal pain is heterogeneous and includes gallstone-related disease, intestinal obstruction, anastomotic ulcerations and strictures, intestinal dysmotility, dysfunctional eating, and food intolerance. Surgical treatment and guidance on diet and eating habits may allow symptom relief. The cause of pain remains undefined for a subset of patients. Impact of abdominal pain post Roux-en-Y gastric bypass on the perception of well-being, quality of life, and patient satisfaction with the procedure needs to be further evaluated and may be influenced by complex interactions between new symptoms post Roux-en-Y gastric bypass and relief of pre-existing symptoms. CONCLUSION Abdominal pain should be part of follow-up consultations post Roux-en-Y gastric bypass. Future studies should focus on combined evaluations before and after surgery to enlighten potential casual relationships between abdominal pain and Roux-en-Y gastric bypass.
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Totally endoscopic implant to effect a gastric bypass: 12-month safety and efficacy outcomes.
Sandler, BJ, Biertho, L, Anvari, M, Rumbaut, R, Morales-Garza, LA, Torres-Barrera, G, Marceau, S, Hong, D, Smith, CD, Horgan, S
Surgical endoscopy. 2018;(11):4436-4442
Abstract
BACKGROUND Only a small percentage of candidates for bariatric surgery ever undergo a procedure for weight loss. Devices duplicating key effects of bariatric surgeries with removable, fully trans-oral implants could extend their benefits to patients unwilling to undergo anatomy-altering abdominal surgeries. METHODS Thirty-two obese subjects (mean BMI: 42.3) were enrolled in a prospective, multicenter, single-arm, feasibility trial of the first fully trans-oral endoscopic gastrointestinal bypass device. The device is a cuff attached to the distal esophagus by transmural anchors and connected to a 120-cm sleeve diverting undigested nutrients to the jejunum. Bodyweight, vital signs, adverse events, medications, HbA1c, fasting glucose, and lipids were collected at baseline and follow-up visits. Device status was endoscopically assessed every 6 months. RESULTS The fully trans-oral procedure was successful in all subjects without intraoperative adverse events or postoperative infections. Twenty-eight of 32 subjects (88%) remained implanted with continuing follow-up beyond their 12-month visit. At 12 months, the 32 subjects had lost an average of 44.8% of excess body weight, 17.6% of total body weight, 20.8 kg, and 7.5 BMI points. Weight loss depended on capture of ingesta by the esophageal cuff, with 18 of 32 subjects without visible gaps around their cuffs at the 6 month endoscopy having significantly greater EWL (53.6 vs. 33.4% in the remaining subjects, p < 0.002). Mean HbA1c and fasting glucose declined by 1.1% points and 29 mg/dL in type 2 diabetic subjects, 80% of whom had remission of their diabetes at 12 months. CONCLUSION This study demonstrates the feasibility, safety, and efficacy of a fully trans-oral gastrointestinal bypass implant. This purely endoscopic device may provide a valuable addition to the armamentarium of treatment available for the management of morbid obesity.
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The pressures of obesity: The relationship between obesity, malnutrition and pressure injuries in hospital inpatients.
Ness, SJ, Hickling, DF, Bell, JJ, Collins, PF
Clinical nutrition (Edinburgh, Scotland). 2018;(5):1569-1574
Abstract
BACKGROUND Pressure injuries (PI) are a significant clinical problem across all healthcare facilities, associated with poor patient outcomes, increased length of stay and healthcare costs. Whilst it is known that underweight (Body Mass Index (BMI) < 18.5 kg/m2) and malnourished individuals have an increased risk of developing PI, few studies have investigated the effects of obesity (BMI ≥ 30 kg/m2) and morbid obesity (BMI ≥ 40 kg/m2) on PI prevalence. This study aimed to determine whether PI prevalence was associated with levels of obesity; the complex association between morbid obesity, malnutrition and PI prevalence in hospital inpatients was also explored. METHODS Data collected from annual Queensland Patient Safety Bedside Audits conducted between 2010 and 2015 was used to examine the outcomes of interest (n = 2479). Bivariate tests were used to explore relationships between age, gender, BMI, malnutrition and PI prevalence. Regression analysis explored associations between BMI, malnutrition and PI, adjusting for potential confounders. RESULTS Overall PI prevalence was 6.9% and was significantly higher in the underweight and morbidly obese groups (underweight 12.7%, healthy weight 7.8%, overweight 5.7%, obese 4.8%, morbidly obese 12%; p = 0.001). In addition to BMI, malnutrition and age were significantly associated with PI prevalence. After adjusting for confounders, morbidly obese inpatients had over three times the odds of developing a PI compared to healthy weight inpatients (OR = 3.478, 95% CI 1.657-7.303; p = 0.001). Morbidly obese inpatients who were also malnourished had eleven-fold greater odds of developing a PI compared to the morbidly obese well-nourished in logistic regression analysis (OR = 11.143, 95% CI 2.279-54.481, p = 0.003). CONCLUSIONS Morbid obesity is a significant and independent risk factor for PI development. However, the clustering of nutritional risk factors (morbid obesity and malnutrition) substantially increases this risk. Therefore, routine and formal assessment of both BMI and malnutrition status are important to enable the identification of patients at high risk of PI.
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Treatment of Vitamin and Mineral Deficiencies After Biliopancreatic Diversion With or Without Duodenal Switch: a Major Challenge.
Homan, J, Schijns, W, Aarts, EO, Janssen, IMC, Berends, FJ, de Boer, H
Obesity surgery. 2018;(1):234-241
Abstract
BACKGROUND Vitamin and mineral deficiencies are a major concern after biliopancreatic diversion (BPD) and BPD with duodenal switch (BPD/DS). Evidence-based guidelines how to prevent or how to treat deficiencies in these patients are currently lacking. The aim of the current study is to give an overview of postsurgical deficiencies and how to prevent and treat these deficiencies. METHODS Retrospective evaluation of a 1-year structured monitoring and treatment schedule for various deficiencies in 34 patients after BPD or BPD/DS. RESULTS Patients were introduced into the program 12-90 months after surgery. Vitamin B1, B6, B9, and B12 deficiencies could be prevented by mean daily doses of 2.75 mg, 980 μg, 600 μg, and 350 μg, respectively. However, many patients continued to develop deficiencies of vitamin A, D, iron, calcium, and zinc despite major dose adjustments. Current observations suggest that at least total daily doses of 200 mg Fe in premenopausal women and 100 mg in men, 100 mg of Zinc, 3000 mg of calcium, and weekly doses of at least 50,000 IU solubilized vitamin A and vitamin D are needed to prevent the occurrence of major deficiencies. CONCLUSION Exceptionally high supplementation doses are needed to prevent and treat vitamin and mineral deficiencies in patients after BPD or BPD/DS. Further refinement and simplification of treatment schedules is needed. Focus on improvement of compliance to treatment is recommended.