Query: bariatric surgery and obesity

title: Association of Bariatric Surgery vs Medical Obesity Treatment With Long term Medical Complications and Obesity Related Comorbidities
abstract: The association of bariatric surgery and specialized medical obesity treatment with beneficial and detrimental outcomes remains uncertain.  To compare changes in obesity related comorbidities in patients with severe obesity (body mass index =40 or =35 and at least 1 comorbidity) undergoing bariatric surgery or specialized medical treatment.  July 2010 and follow up data from 2006 until death or through December 2015 at a tertiary care outpatient center, Vestfold Hospital Trust, Norway. Consecutive treatment seeking adult patients (n 2109) with severe obesity assessed (221 patients excluded and 1888 patients included) Exposures Bariatric surgery (n 932, 92% gastric bypass) or specialized medical treatment (n 956) including individual or group based lifestyle intervention programs.  Prespecified secondary outcomes included changes in comorbidities. Adverse events included complications retrieved from the Norwegian Patient Registry and a local laboratory database.  Among 1888 patients included in the study, the mean (SD) age was 43.5 (12.3) years (1249 women [66% mean [SD] baseline BMI, 44.2 [6.1] 100% completed follow up at a median of 6.5 years [range, 0.2 10.1] Surgically treated patients had a greater likelihood of remission and lesser likelihood for new onset of hypertension (remission: absolute risk [AR] 31.9% vs 12.4% risk difference [RD] 19.5% [95% CI, 15.8% 23.2% relative risk [RR] 2.1 [95% CI, 2.0 2.2] new onset: AR, 3.5% vs 12.2% RD, 8.7% [95% CI, 6.7% 10.7% RR, 0.4 [95% CI, 0.3 0.5] greater likelihood of diabetes remission: AR, 57.5% vs 14.8% RD, 42.7% [95% CI, 35.8% 49.7% RR, 3.9 [95% CI, 2.8 5.4] greater risk of new onset depression: AR, 8.9% vs 6.5% RD, 2.4% [95% CI, 1.3% 3.5% RR, 1.5 [95% CI, 1.4 1.7] and treatment with opioids: AR, 19.4% vs 15.8% RD, 3.6% [95% CI, 2.3% 4.9% RR, 1.3 [95% CI, 1.2 1.4] Surgical patients had a greater risk for undergoing at least 1 additional gastrointestinal surgical procedure (AR, 31.3% vs 15.5% RD, 15.8% [95% CI, 13.1% 18.5% RR, 2.0 [95% CI, 1.7 2.4] The proportion of patients with low ferritin levels was significantly greater in the surgical group (26% vs 12% P .001)  Among patients with severe obesity followed up for a median of 6.5 years, bariatric surgery compared with medical treatment was associated with a clinically important increased risk for complications, as well as lower risks of obesity related comorbidities. The risk for complications should be considered in the decision making process.

title: Bariatric surgery and prevention of cardiovascular events and mortality in morbid obesity: mechanisms of action and choice of surgery.
abstract: Obesity is associated with increased cardiovascular (CV) morbidity and mortality. Weight loss improves several risk factors for CV diseases, but anti obesity medications and lifestyle interventions have failed to modify primary CV endpoints. This paper reviews bariatric surgery in prevention of CV diseases and CV mortality, and analyzes the possible mechanisms involved.  In morbidly obese patients bariatric surgery results in stable weight loss and in long term reduction in the prevalence and incidence of obesity related comorbidities; controlled trials have shown superiority of bariatric surgery over medical therapy in inducing significant weight loss and improvement of CV risk factors. Bariatric surgery induces several metabolic improvements (resolution of type 2 diabetes mellitus, improvement of lipid metabolism and of insulin resistance, reduction of visceral fat, of subclinical endothelial dysfunction and inflammation) and functional improvements (reduction of hypertension, of sympathetic overactivity, of left and right ventricular hypertrophy) which can explain the protective effect towards CV disease.  Reduction of CV diseases is mediated by the pleiotropic effects of weight loss through surgery. Available data do not allow conclusions on the comparative efficacy of different surgical techniques; the choice of the surgical technique for a single patient remains an open question, and it is likely that the degree of prevention of CV diseases depends, among other factors, on the baseline conditions of patients. Large prospective studies are needed to address this issue in morbidly obese patients.

title: The effects of bariatric surgery on gut microbiota in patients with obesity: a review of the literature
abstract: Obesity is a disease with a rapidly increasing prevalence all over the world in recent years. Genetic and environmental factors are involved in the etiology of obesity, and the effect of microbiota on obesity is becoming increasingly clear. Obesity treatment has various treatment modalities such as behavior modification, medical nutrition therapy, physical activity enhancement, and surgical intervention. When other treatment methods are not successful, bariatric surgery is usually resorted to as the treatment method. Some changes such as food choices, the level of hormones and enzymes due to anatomical changes, pH of the stomach, and microbiota are observed after bariatric surgery. Alteration in the microbiota composition after bariatric surgery has also been reported to be important in achieving body weight loss and preserving body weight loss.

title: Bariatric Surgery and the Risk of Cancer in a Large Multisite Cohort
abstract: To determine whether bariatric surgery is associated with a lower risk of cancer.  Obesity is strongly associated with many types of cancer. Few studies have examined the relationship between bariatric surgery and cancer risk.  We conducted a retrospective cohort study of patients undergoing bariatric surgery between 2005 and 2012 with follow up through 2014 using data from a large integrated health insurance and care delivery systems with 5 study sites. The study included 22,198 subjects who had bariatric surgery and 66,427 nonsurgical subjects matched on sex, age, study site, body mass index, and Elixhauser comorbidity index. Multivariable Cox proportional hazards models were used to examine incident cancer up to 10 years after bariatric surgery compared to the matched nonsurgical patients.  After a mean follow up of 3.5 years, we identified 2543 incident cancers. Patients undergoing bariatric surgery had a 33% lower hazard of developing any cancer during follow up [hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.60, 0.74, P 0.001) compared with matched patients with severe obesity who did not undergo bariatric surgery, and results were even stronger when the outcome was restricted to obesity associated cancers (HR 0.59, 95% CI 0.51, 0.69, P 0.001) Among the obesity associated cancers, the risk of postmenopausal breast cancer (HR 0.58, 95% CI 0.44, 0.77, P 0.001) colon cancer (HR 0.59, 95% CI 0.36, 0.97, P 0.04) endometrial cancer (HR 0.50, 95% CI 0.37, 0.67, P 0.001) and pancreatic cancer (HR 0.46, 95% CI 0.22, 0.97, P 0.04) was each statistically significantly lower among those who had undergone bariatric surgery compared with matched nonsurgical patients.  In this large, multisite cohort of patients with severe obesity, bariatric surgery was associated with a lower risk of incident cancer, particularly obesity associated cancers, such as postmenopausal breast cancer, endometrial cancer, and colon cancer. More research is needed to clarify the specific mechanisms through which bariatric surgery lowers cancer risk.

title: Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient 2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic Bariatric Surgery.
abstract: The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG) Each recommendation was re evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type 2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2% are EL 1, 131 (32.5% are EL 2, 170 (42.2% are EL 3, and 69 (17.1% are EL 4. There is a relatively high proportion (40.4% of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE TOS ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

title: Major microbiota dysbiosis in severe obesity: fate after bariatric surgery
abstract: Decreased gut microbial gene richness (MGR) and compositional changes are associated with adverse metabolism in overweight or moderate obesity, but lack characterisation in severe obesity. Bariatric surgery (BS) improves metabolism and inflammation in severe obesity and is associated with gut microbiota modifications. Here, we characterised severe obesity associated dysbiosis (ie, MGR, microbiota composition and functional characteristics) and assessed whether BS would rescue these changes.  Sixty one severely obese subjects, candidates for adjustable gastric banding (AGB, n=20) or Roux en Y gastric bypass (RYGB, n=41) were enrolled. Twenty four subjects were followed at 1, 3 and 12 months post BS. Gut microbiota and serum metabolome were analysed using shotgun metagenomics and liquid chromatography mass spectrometry (LC MS) Confirmation groups were included.  Low gene richness (LGC) was present in 75% of patients and correlated with increased trunk fat mass and comorbidities (type 2 diabetes, hypertension and severity) Seventy eight metagenomic species were altered with LGC, among which 50% were associated with adverse body composition and metabolic phenotypes. Nine serum metabolites (including glutarate, 3 methoxyphenylacetic acid and L histidine) and functional modules containing protein families involved in their metabolism were strongly associated with low MGR. BS increased MGR 1 year postsurgery, but most RYGB patients remained with low MGR 1 year post BS, despite greater metabolic improvement than AGB patients.  We identified major gut microbiota alterations in severe obesity, which include decreased MGR and related functional pathways linked with metabolic deteriorations. The lack of full rescue post BS calls for additional strategies to improve the gut microbiota ecosystem and microbiome host interactions in severe obesity.

title: Association of Bariatric Surgery Using Laparoscopic Banding, Roux en Y Gastric Bypass, or Laparoscopic Sleeve Gastrectomy vs Usual Care Obesity Management With All Cause Mortality
abstract: Importance Bariatric surgery is an effective and safe approach for weight loss and short term improvement in metabolic disorders such as diabetes. However, studies have been limited in most settings by lack of a nonsurgical group, losses to follow up, missing data, and small sample sizes in clinical trials and observational studies.  To assess the association of 3 common types of bariatric surgery compared with nonsurgical treatment with mortality and other clinical outcomes among obese patients.  Retrospective cohort study in a large Israeli integrated health fund covering 54% of Israeli citizens with less than 1% turnover of members annually. Obese adult patients who underwent bariatric surgery between January 1, 2005, and December 31, 2014, were selected and compared with obese nonsurgical patients matched on age, sex, body mass index (BMI) and diabetes, with a final follow up date of December 31, 2015. A total of 33 540 patients were included in this study. Exposures Bariatric surgery (laparoscopic banding, Roux en Y gastric bypass, or laparoscopic sleeve gastrectomy) or usual care obesity management only (provided by a primary care physician and which may include dietary counseling and behavior modification) Main Outcomes and Measures The primary outcome, all cause mortality, matched and adjusted for BMI prior to surgery, age, sex, socioeconomic status, diabetes, hyperlipidemia, hypertension, cardiovascular disease, and smoking.  The study population included 8385 patients who underwent bariatric surgery (median age, 46 [IQR, 37 54] years; 5490 [65.5% women; baseline median BMI, 40.6 [IQR, 38.5 43.7] laparoscopic banding [n 3635] gastric bypass [n 1388] laparoscopic sleeve gastrectomy [n 3362] and 25 155 nonsurgical matched patients (median age, 46 [IQR, 37 54] years; 16 470 [65.5% women; baseline median BMI, 40.5 [IQR, 37.0 43.5] The availability of follow up data was 100% for all cause mortality. There were 105 deaths (1.3% among surgical patients during a median follow up of 4.3 (IQR, 2.8 6.6) years (including 61 [1.7% who underwent laparoscopic banding, 18 [1.3% gastric bypass, and 26 [0.8% sleeve gastrectomy) and 583 deaths (2.3% among nonsurgical patients during a median follow up of 4.0 (IQR, 2.6 6.2) years. The absolute difference was 2.51 (95% CI, 1.86 3.15) fewer deaths/1000 person years in the surgical vs nonsurgical group. Adjusted hazard ratios (HRs) for mortality among nonsurgical vs surgical patients were 2.02 (95% CI, 1.63 2.52) for the entire study population; by surgical type, HRs were 2.01 (95% CI, 1.50 2.69) for laparoscopic banding, 2.65 (95% CI, 1.55 4.52) for gastric bypass, and 1.60 (95% CI, 1.02 2.51) for laparoscopic sleeve gastrectomy.  Among obese patients in a large integrated health fund in Israel, bariatric surgery using laparoscopic banding, gastric bypass, or laparoscopic sleeve gastrectomy, compared with usual care nonsurgical obesity management, was associated with lower all cause mortality over a median follow up of approximately 4.5 years. The evidence of this association adds to the limited literature describing beneficial outcomes of these 3 types of bariatric surgery compared with usual care obesity management alone.

title: Obesity Management Task Force of the European Association for the Study of Obesity Released "Practical Recommendations for the Post Bariatric Surgery Medical Management"
abstract: Bariatric patients may face specific clinical problems after surgery, and multidisciplinary long term follow up is usually provided in specialized centers. However, physicians, obstetricians, dieticians, nurses, clinical pharmacists, midwives, and physical therapists not specifically trained in bariatric medicine may encounter post bariatric patients with specific problems in their professional activity. This creates a growing need for dissemination of first level knowledge in the management of bariatric patients. Therefore, the Obesity Management Task Force (OMTF) of the European Association for the Study of Obesity (EASO) decided to produce and disseminate a document containing practical recommendations for the management of post bariatric patients. The list of practical recommendations included in the EASO/OMTF document is reported in this brief communication.

title: American Society for Metabolic and Bariatric Surgery 2018 estimate of metabolic and bariatric procedures performed in the United States.
abstract: Metabolic and bariatric surgery, despite being the only effective durable treatment for obesity, remains underused as approximately 1% of all patients who qualify undergo surgery. The American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization for obesity treatment interventions and to determine if patients in need are receiving appropriate therapy.  The objective of this study was to provide the best estimated number of metabolic and bariatric procedure performed in the United States in 2018.  States.  We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program, National Surgical Quality Improvement Program, Bariatric Outcomes Longitudinal Database, and Nationwide Inpatient Sample. In addition, data from industry and outpatient centers were used to estimate outpatient center activity. Data from 2018 were compared mainly with data from the previous 2 years.  Compared with 2017, the total number of metabolic and bariatric procedures performed in 2018 increased from approximately 228,000 to 252,000. The sleeve gastrectomy continues to be the most common procedure. The gastric bypass procedure trend remained relatively stable and the gastric band procedure trend continued to decline. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Finally, intragastric balloons placement continues as a significant contributor to the cumulative total number of procedures performed but declined from the previous year.  There was a 10.8% increase in the number of metabolic and bariatric procedures performed in 2018, compared with 2017, with an overall increase of approximately 60% since 2011. When taking into account primary procedures only, approximately 1.1% of patients who qualified for metabolic and bariatric surgery were treated with surgery in 2018.

title: Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient 2013 update: Cosponsored by american association of clinical endocrinologists, The obesity society, and american society for metabolic bariatric surgery*
abstract: The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG) Each recommendation was re evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type 2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2% are EL 1, 131 (32.5% are EL 2, 170 (42.2% are EL 3, and 69 (17.1% are EL 4. There is a relatively high proportion (40.4% of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE TOS ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.