STUDY ROUNDUP

Published in February Issue             


Mental Health Conditions Among Patients Seeking and Undergoing
Bariatric Surgery
(JAMA)

A meta-analysis of 68 studies found depression and binge-eating disorders are more than twice as common among bariatric surgery candidates compared to the general population. About one-quarter (19%) of bariatric surgery candidates had mood-related disorders and 17% had a binge-eating disorder. However, neither depression nor binge eating disorder was associated with differences in weight outcomes. Bariatric surgery was associated with decreases in the prevalence of depression and the severity of depressive symptoms. Across seven studies, prevalence of depression dropped by anywhere between 8% to 74% after surgery. The severity of patients' depressive symptoms also fell by 40% to 70%.

Prevalence of Self-reported Symptoms After Gastric Bypass Surgery for Obesity (JAMA Surgery)


A survey of 2,238 patients examined overall well-being and the prevalence and predictors of medical, nutritional, and surgical symptoms after RYGB surgery, and patients’ association with quality of life. The survey was conducted from March 3 to July 31, 2014, among patients who had surgery between January 1, 2006, and December 31, 2011. A comparison cohort of 89 individuals who had not had bariatric surgery were matched with patients according to sex and BMI. Of the patients undergoing surgery, 88.6% reported 1 or more symptoms a median of 4.7 years after RYGB and 67.6% of those patients had been in contact with the health care system about their symptoms versus 34.8% of those in the comparison group. About 29% had been hospitalized versus 6.7% of those in the comparison group. The symptoms most commonly leading to health care contact after surgery were abdominal pain (34.2%), fatigue (34.1%), and anemia (27.7%). The risk of symptoms was higher among women, among patients younger than 35 years-old, among smokers, among unemployed persons, and in those with surgical symptoms before RYGB surgery. Quality of life was inversely associated with the number of symptoms. A total of 87.4% reported that their well-being was improved after surgery versus before RYGB, while 8.1% reported reduced well-being.


Effect of Bariatric Surgery vs Medical Treatment on Type 2 Diabetes in Patients With Body Mass Index Lower Than 35  (JAMA Surgery)


This retrospective cohort study compares long-term outcomes for mildly obese patients (BMI lower than 35) with T2DM receiving metabolic surgery (n = 52) versus medical treatment (n = 299). The surgical group, enrolled from August 20, 2007, to June 25, 2008 and followed up through December 31, 2013, received standard sleeve gastrectomy (n = 19) or bypass (n = 33) procedures. The medical group, selected from a nationwide community cohort that was recruited from August 27, 2003, to December 31, 2005 and followed up through December 31, 2012, was matched with the surgical group by age, BMI, and diabetes duration. At the end of the fifth year, the surgical group had a mean weight loss of 21.0% (BMI of 31.0 to 24.5), their mean HbA1c decreased from 9.1% to 6.3% of total Hb, 18 participants (36%) had complete remission, 28% had partial remission, 1.9% had end-stage renal disease and 1.9% did not survive. In the same follow-up period in the medical group, 1.2% had complete remission, 1.6% had partial remission, 0.7% had end-stage renal disease and 3% did not survive. In the medical group, the mean HbA1c remained around 8% of total Hb and BMI also stayed similar. The HbA1c reduction and complete and partial remission rates were all significantly larger in the surgical group as compared with the medical group. However, the mortality rate and end-stage renal disease incidence were not significantly different. For mildly obese patients with T2DM, the improvement in glycemic control from metabolic surgery lasts at least 5 years.


Long-term Outcomes After Roux-en-Y Gastric Bypass: 10- to 13-Year Data (SOARD)


This is an investigation of long-term weight loss, co-morbidity remission, nutritional status, and complication rates among 328 patients with a mean BMI of 47.5 undergoing RYGB between October 2000 and January 2004. The mean %EWL was 58.9% at 10+years. Higher %EWL was achieved by non–super-obese patients versus patient with super-obesity (61.3% versus 52.9%, respectively). Blood pressure, lipid panel, and hemoglobin A1c improved significantly. Also at 10 years, remission of co-morbidities was 46% for hypertension and hyperlipidemia and 58% for diabetes mellitus. Thirty patients (9%) had revisional surgery for weight regain. Sixty-four patients (19.5%) had long-term complications requiring surgery. Nutritional deficiencies were seen in 87% of patients. All-cause mortality was 2.7%. Weight loss after RYGB appears to be significant and sustainable, especially in the non–super-obese. Co-morbidities are improved, with a substantial number in remission a decade later.


Quality and Safety in Obesity Surgery—15 Years of Roux-en-Y Gastric Bypass Outcomes from a Longitudinal Database (SOARD)


This longitudinal population study examined the longitudinal outcomes of 129,432 RYGB patients. Rates of laparoscopy increased from 3% to 35% from 1995 to 2004 and then steeply increased to 80% in 2005 and to 93% in 2009. Overall mortality rate at 1, 5, and 10 years was 2.2%, 4.4%, and 8.1%, respectively. The rates of marginal ulcer were .3%, .7%, and 1%, respectively and the reoperation rates were .3%, .8%, and 1.2%, respectively. Predictors of poor outcomes were male gender, age, smoking, alcohol, Medicare, Medi-Cal insurance, and Asian or Native American race. The laparoscopic approach was protective against death and long-term complications. High rates of mortality were seen following RYGB, with improved long-term outcomes when the laparoscopic approach was used.


Early Effect of Roux-en-Y Gastric Bypass on Insulin Sensitivity and Signaling  (SOARD)


The study examined the underlying physiologic mechanisms that result in improved glycemic control following RYGB. Ten morbidly obese patients, before and 4 weeks after RYGB, and 10 healthy controls were studied. Insulin sensitivity was measured as the homeostasis model assessment–estimated insulin resistance and by the euglycemic hyperinsulinemic clamp, and phosphorylation of protein kinase B (Akt). Before RYGB, patients with obesity displayed reduced insulin sensitivity and clearance and increased fasting protein kinase B (Akt) compared with controls. Insulin sensitivity significantly increased after surgery (from 2.6 to 2.8 mg/kg fat free mass/min) but remained far below the values in controls (10.0 mg/kg fat free mass/min). Insulin clearance increased from 453.5 to 555.2, becoming similar to that of controls 582.2 mU/m2/min. Homeostasis model assessment–estimated insulin resistance (HOMA-IR) decreased from 4.1 to 2.3, becoming comparable with controls (2.2). Following RYGB, a prompt improvement of hepatic insulin resistance with normalization of hepatic insulin clearance and a small amelioration of whole-body insulin sensitivity. Although other mechanisms of action, such as the effect of weight loss and reduced food intake, cannot be excluded, the reduction of muscle Akt hyperphosphorylation on the serine residue can play a role in the early improvement of insulin sensitivity.


30-day Readmissions Following Sleeve Gastrectomy versus Roux-en-Y
Gastric Bypass
 (SOARD)


This study compared 30-day readmission rate and etiology following SG and RYGB. Patients undergoing elective laparoscopic SG and RYGB in 2012 and 2013 were identified from the ACS-NSQIP Participant Use File. Demographics, co-morbidities and 30-day readmissions were analyzed. A total of 34,983 patients underwent bariatric surgery (46.0% SG, 54.0% RYGB). Readmission was reported in 1,773 (5.1%) patients. Readmission was more common following RYGB compared to SG (6.1% vs 3.8%, respectively). Postoperative pain, bleeding, intestinal obstructions and wound occurrences were more commonly a readmission cause for RYGB compared to SG. Nausea, vomiting and dehydration were more commonly a reason for readmission following SG than RYGB (30.4% vs 18.8%, respectively). Additionally, venous thromboembolism was a more frequent readmission cause for SG compared to RYGB patients (7.2% vs 3.6%, respectively). The study concluded that while reasons for readmission differ between procedure, hospital readmissions are more common following RYGB than SG. Given the progressive increase in the proportion of bariatric patients undergoing SG, hospital programs that aim to decrease readmissions following bariatric surgery need to focus on prevention and control of postoperative nausea and dehydration.


Long-term Health-Related Quality of Life in Bariatric Surgery Patients:
A Systematic Review and Meta-Analysis
(Obesity)


The study assesses the quality of evidence and effectiveness of surgery in health-related quality of life (HRQoL) >=5 using a systematic literature review and a separate meta-analysis. The systematic review (which included 9 studies) showed inconsistent results for long-term improvements in physical and mental health. In contrast, the separate meta-analysis of 6 articles found significant improvements in these domains >=5 years after surgery. The full study findings show provide evidence for substantial and significant improvement in physical and mental health favoring surgical groups compared with controls spanning 5 to 25 years after surgery.


Laparoscopic Sleeve Gastrectomy in Children Younger Than 14 Years:
Refuting the Concerns
(Annals of Surgery)


The study evaluated the effect of laparoscopic SG on growth in children younger than 14 years. A multidisciplinary program database was used to extract data of young nonsyndromic children under the age of 14 who underwent SG. Patients were age, sex, and height matched with those on nonsurgical weight management. Results were compared with those of adolescents older than 14 who underwent LSG. One hundred sixteen children younger than 14 years (mean age 11.2?±?2.5 years) underwent SG. Compared with the 1:1 matched group of nonsurgical weight management, children who underwent surgery experienced significantly higher growth, gaining 0.9?mm more per month on average. Compared with 158 adolescents (mean age 17.3?±?2.0 years) who underwent SG, children younger than 14 years had a significantly lower prevalence of comorbidities, but similar resolution rates. There was no significant difference in the rate of complications, and no mortality or significant morbidity was observed in any of the groups. SG is safe and effective in this age group, resulting in significant weight loss, improved growth, and resolution of comorbidities without mortality or significant morbidity.