Background
Criteria for bariatric weight loss success are numerous. Most of them are arbitrary. None of them is evidence-based. Our objective was to determine their sensitivity and specificity.
...Methods
Thirteen common bariatric weight loss criteria were compared to a benchmark reflecting the gold standard in bariatric surgery. We used an elaborate baseline BMI-independent weight loss percentile chart, based on retrospective data after laparoscopic Roux-en-Y gastric bypass (LRYGB), performed between 2007 and 2017. Percentile curves p31.6 (patients’ expectation), p25 (interquartile range), p15.9 (1 standard deviation (SD) below median), and p10.9 (surgeons’ goal) were used as possible cutoff for success to determine true or false positive and negative results beyond 1 year.
Results
We operated 4497 primary LRYGB patients, with mean follow-up 22 (± 1 SD 19; range 0–109) months, 3031 patients with last result ≥ 1 year, 518 ≥ 5 years. For all four cutoff percentile curves for success, specificities were low (2–72%) for criteria < 35 body mass index (BMI), ≥ 25percentage excess BMI loss (%EBMIL), ≥ 50%EBMIL, ≥ 15 percentage total weight loss (%TWL), ≥ 20%TWL, ≥ 25 percentage excess weight loss (%EWL), and high (83–96%) for < 30 BMI. No criterion had > 80% specificity and sensitivity for a cutoff above p15.9. For p15.9, they were both > 80% for criteria ≥ 10 BMI reduction and ≥ 50%EWL, both > 90% for ≥ 25%TWL and ≥ 35 percentage alterable weight loss (%AWL). All criteria had high sensitivities for all cutoff percentile curves (87–100%), except < 30 BMI (65–78%).
Conclusions
For the first time, common bariatric criteria for weight loss success were systematically validated. Most criteria recognized success very well (high sensitivities), but ≥ 15%TWL, ≥ 20%TWL, < 35BMI, ≥ 25%EWL, ≥ 25%EBMIL, and ≥ 50%EBMIL left too many poor responders unnoticed (low specificities). Bariatric weight loss success is best assessed by comparing results to percentile curve 1 SD below median (p15.9) in a bariatric baseline BMI-independent weight loss percentile chart. Criteria ≥ 35%AWL and ≥ 25%TWL came close to that curve, both with > 90% sensitivity and specificity. Among others, criterion ≥ 50%EBMIL did not.
Percentage total weight loss (%TWL) might be better than percentage excess weight loss to express weight loss in bariatric surgery. In this systematic review, performed according to the PRISMA ...statement, results of laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB) are assessed in %TWL. A total of 13,426 studies were screened and 49 included, reporting data of 24,760 patients. The results show that, despite limiting data, LRYGB is favorable over LSG in terms of weight loss in short-term follow-up. Although recent guidelines recommend to use %TWL when reporting outcome in bariatric surgery, this study shows that there is still insufficient quality data in %TWL, especially on LSG. The use of %TWL as the primary outcome measure in bariatric surgery should be encouraged.
Graphical abstract
Background
In addition to the reduction of symptomatic gallstone disease, ursodeoxycholic acid (UDCA) might also have beneficial metabolic effects after bariatric surgery. We examined the impact of ...UDCA on liver enzymes, hemoglobin A1c (HbA1c), lipids, and inflammation markers.
Methods
Patients in the UPGRADE trial (placebo-controlled, double-blind) were randomized between UDCA 900 mg daily or placebo pills for 6 months after bariatric surgery. Patients without blood measurements pre- or 6 months postoperatively were excluded. The change in liver enzymes, Hba1c, lipids, and inflammation markers after surgery were compared between the UDCA and placebo group, followed by a postoperative cross-sectional comparison.
Results
In total, 513 patients were included (age mean ± SD 45.6 ± 10.7 years; 79% female). Preoperative blood values did not differ between UDCA (
n
= 266) and placebo (
n
= 247) groups. Increase of alkaline phosphatase (ALP) was greater in the UDCA group (mean difference 3.81 U/l 95%CI 0.50 7.12). Change in other liver enzymes, HbA1c, lipids, and CRP levels did not differ. Postoperative cross-sectional comparison in 316 adherent patients also revealed a higher total cholesterol (mean difference 0.25 mg/dl 95%CI 0.07–0.42), lower aspartate aminotransferase (mean difference −3.12 U/l −5.16 – −1.08), and lower alanine aminotransferase level (mean difference −5.89 U/l −9.41 – −2.37) in the UDCA group.
Conclusion
UDCA treatment leads to a higher, but clinically irrelevant increase in ALP level in patients 6 months after bariatric surgery. No other changes in metabolic or inflammatory markers were observed. Except for the reduction of gallstone formation, UDCA has no effects after bariatric surgery.
Graphical Abstract
Prevailing recommendations on reporting weight loss after bariatric and metabolic surgery are not evidence-based. They promote the outcome metric percentage excess weight loss (%EWL), sometimes ...indicated as percentage excess body mass index loss (%EBMIL). Many studies proved that this popular outcome measure, in contrast to other weight loss metrics, is inaccurate and error-sensitive when comparing weight loss within and between studies. It is inappropriate for assessing poor weight loss response and weight regain as well. The percentage (total) weight loss metric is the best alternative. The Dutch Society for Metabolic and Bariatric Surgery (DSMBS) recommends to stop using the %EWL (or %EBMIL) metric as primary outcome measure in all cases and calls on the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) to propagate this evidence-based recommendation.
Graphical Abstract
Background
Staple line leakage after bariatric surgery can be treated by endoscopic placement of a self-expandable stent. The success rate of stent placement is generally high, but migration is a ...frequent adverse event that hampers successful treatment. The Niti-S Beta stent is a fully covered double-bump stent that was specifically designed to prevent migration. This study aimed to evaluate the effectiveness and adverse event rate of the Niti-S Beta stent.
Methods
A retrospective study was performed in three high-volume bariatric centers. All consecutive patients between 2009 and 2016 who underwent placement of a Beta stent for staple line leakage were included. Primary outcome was resolution of the leakage; secondary outcome was the adverse event rate including migration.
Results
Thirty-eight patients were included. Twenty-five (66%) had resolution of the leakage. Success rate was higher in patients who were treated with implantation of a Beta stent as initial treatment (100%) than in patients who were treated with a stent after revisional surgery had failed (55%,
p
= 0.013). Migration occurred in 12 patients (32%). There were two severe adverse events requiring surgical intervention, including a bleeding from an aorto-esophageal fistula.
Conclusions
The success rate and the migration rate of the Beta stent seem comparable to other stents in this retrospective study. Despite the novel double-bump structure of the stent, the migration rate does not seem to be decreased.
The number of bariatric interventions for morbid obesity is increasing worldwide. Rapid weight loss is a major risk factor for gallstone development. Approximately 11 % of patients who underwent ...Roux-en-Y gastric bypass develop symptomatic gallstone disease. Gallstone disease can lead to severe complications and often requires hospitalization and surgery. Ursodeoxycholic acid (UDCA) prevents the formation of gallstones after bariatric surgery. However, randomized controlled trials with symptomatic gallstone disease as primary endpoint have not been conducted. Currently, major guidelines make no definite statement about postoperative UDCA prophylaxis and most bariatric centers do not prescribe UDCA.
A randomized, placebo-controlled, double-blind multicenter trial will be performed for which 980 patients will be included. The study population consists of consecutive patients scheduled to undergo Roux-en-Y gastric bypass or sleeve gastrectomy in three bariatric centers in the Netherlands. Patients will undergo a preoperative ultrasound and randomization will be stratified for pre-existing gallstones and for type of surgery. The intervention group will receive UDCA 900 mg once daily for six months. The placebo group will receive similar-looking placebo tablets. The primary endpoint is symptomatic gallstone disease after 24 months, defined as admission or hospital visit for symptomatic gallstone disease. Secondary endpoints consist of the development of gallstones on ultrasound at 24 months, number of cholecystectomies, side-effects of UDCA and quality of life. Furthermore, cost-effectiveness, cost-utility and budget impact analyses will be performed.
The UPGRADE trial will answer the question whether UDCA reduces the incidence of symptomatic gallstone disease after Roux-en-Y gastric bypass or sleeve gastrectomy. Furthermore it will determine if treatment with UDCA is cost-effective.
Netherlands Trial Register (trialregister.nl) 6135 . Date registered: 21-Nov-2016.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Background
Patients who have undergone bariatric surgery are at risk for subsequent cholecystectomy. We aimed to identify risk factors for cholecystectomy after laparoscopic Roux-en-Y gastric bypass ...(LRYGB).
Methods
We conducted a retrospective case-control study of patients who underwent LRYGB between 2013 and 2015. Cases underwent cholecystectomy because of biliary symptoms after LRYGB. For each case, two controls were selected without subsequent cholecystectomy. Logistic regression analyses were used to identify risk factors.
Results
Between 2013 and 2015, 1780 primary LRYGBs were performed. We identified 233 (13.1%) cases who had undergone cholecystectomy after a median (IQR) of 12 (8–17) months, and 466 controls. Female gender (OR (95% CI) 1.83 (1.06–3.17)), Caucasian ethnicity (OR (95% CI) 1.82 (1.10–3.02)), higher percent total weight loss (%TWL) at 12 months (OR (95% CI) 1.06 (1.04–1.09)), and preoperative pain syndrome (OR (95% CI) 2.72 (1.43–5.18)) were significantly associated with an increased risk for cholecystectomy. Older age (OR (95% CI) 0.98 (0.96–0.99)) and preoperative statin use were associated with a reduced risk (OR (95% CI) 0.56 (0.31–1.00)). A dose-effect relationship was found between the intensity of preoperative statin and risk for cholecystectomy.
Conclusions
In our study, higher %TWL and preoperative pain syndrome were associated with an increased risk for cholecystectomy besides the traditional risk factors female gender and Caucasian ethnicity. These factors can be used to identify high-risk patients, who might benefit from preventive measures. Whether statins can protect bariatric patients from developing gallstones should be investigated prospectively.
Objective
To investigate whether patients’ psychological well‐being (depression, quality of life, body image satisfaction) and functioning (self‐efficacy for eating and exercising behaviours and food ...cravings) improve 12 months after bariatric surgery and whether self‐compassion is associated with better psychological outcomes and lower weight after bariatric surgery.
Design
Longitudinal, prospective observational study.
Methods
Bariatric patients (n = 126, 77.8% female, 46.4 ± 10.8 years) completed the Self‐compassion Scale, Center for Epidemiology Studies Depression Scale, Impact of Weight on Quality‐of‐Life questionnaire, Body Image Scale, Weight Efficacy Lifestyle Questionnaire, Spinal Cord Injury Exercise Self‐Efficacy Scale, and G‐Food Craving Questionnaire pre‐operatively and 12 months post‐operatively. A medical professional measured patients’ weight during each assessment. Data were analysed using repeated measures t‐tests and multivariate regression analyses with Benjamini–Hochberg correction for multiple testing.
Results
Patients’ BMI, depression, and food cravings decreased significantly after surgery while quality of life, body image satisfaction, and self‐efficacy to exercise improved. Higher self‐compassion was associated with lower post‐operative depression, greater quality of life, higher body image satisfaction, and better self‐efficacy for eating behaviours (p‐values <.05) but not with post‐operative BMI, self‐efficacy to exercise, or food cravings.
Conclusions
Even though pre‐operative self‐compassion was not directly associated with a lower 12‐month post‐operative BMI, it had a positive relationship with patients’ post‐operative well‐being and self‐efficacy for controlling eating behaviour. In turn, this could help patients to manage their health long after bariatric surgery. Further work regarding the role of self‐compassion on long‐term health outcomes would be worthwhile.
Background
The frequently used 35 kg/m
2
body mass index (BMI) and 50 % excess weight loss (%EWL) criteria are no longer adequate for defining the success of a bariatric or metabolic surgery. It is ...not clear whether they are still useful to simply determine the sufficiency of a patient’s postoperative weight loss. An alternative way of defining sufficient weight loss is presented, using weight loss percentile charts of large representative series as a benchmark.
Methods
Gastric bypass weight loss results from the Bariatric Outcomes Longitudinal Database (BOLD) with ≥2 years of follow-up are presented with percentiles in function of postoperative time and their nadir results in function of initial BMI using different outcome metrics. These percentiles are compared with the BMI35 and 50 %EWL criteria.
Results
Of 49,098 patients eligible for ≥2 years of follow-up, 8,945 had reported weight loss at ≥2 years (20.0 % male, mean initial BMI 47.7 kg/m
2
). They reached nadir BMI at a mean of 603 days. Their 50th percentiles surpassed both 50 %EWL and BMI35 after 135 days. More than 95 % achieved 50 %EWL; more than 75 % achieved BMI35. BMI and %EWL results are influenced more by initial BMI than total weight loss (%TWL) results.
Conclusions
BOLD gastric bypass weight loss data are presented with percentile curves. BMI and %EWL are clearly not suited for this purpose. Provided that follow-up data are solid, %TWL-based percentile charts can constitute neutral benchmarks for defining sufficient postoperative weight loss over time. Criteria for overall success, however, should consider clear goals of health improvement, including metabolic aspects. Frequently used criteria 50 %EWL and BMI35 are inadequate for both. Their static weight loss components do not match the found percentiles and their health improvement components do not match known metabolic criteria.
Retinol‐binding protein‐4 (RBP4) is elevated in serum and adipose tissue (AT) in obesity‐induced insulin resistance and correlates inversely with insulin‐stimulated glucose disposal. But its role in ...insulin‐mediated suppression of lipolysis, free fatty acids (FFA), and endogenous glucose production (EGP) in humans is unknown. RBP4 mRNA or protein levels were higher in liver, subcutaneous adipose tissue (SAT), and visceral adipose tissue (VAT) in morbidly obese subjects undergoing Roux‐en‐Y gastric bypass surgery compared to lean controls undergoing elective laparoscopic cholecystectomy. RBP4 mRNA expression in SAT correlated with the expression of several macrophage and other inflammation markers. Serum RBP4 levels correlated inversely with glucose disposal and insulin‐mediated suppression of lipolysis, FFA, and EGP. Mechanistically, RBP4 treatment of human adipocytes in vitro directly stimulated basal lipolysis. Treatment of adipocytes with conditioned media from RBP4‐activated macrophages markedly increased basal lipolysis and impaired insulin‐mediated lipolysis suppression. RBP4 treatment of macrophages increased TNFα production. These data suggest that elevated serum or adipose tissue RBP4 levels in morbidly obese subjects may cause hepatic and systemic insulin resistance by stimulating basal lipolysis and by activating macrophages in adipose tissue, resulting in release of pro‐inflammatory cytokines that impair lipolysis suppression. While we have demonstrated this mechanism in human adipocytes in vitro, and correlations from our flux studies in humans strongly support this, further studies are needed to determine whether this mechanism explains RBP4‐induced insulin resistance in humans.
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