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Study Roundup

Published in October Issue             

Prevalence of Anemia 10 Years After Roux-en-Y Gastric Bypass in a Single Veterans Affairs Medical Center  (JAMA Surgery)

A retrospective review examined long-term outcomes in 78 U.S. veterans who had RYGB at a single Veterans Affairs Medical Center (2002-2006) to evaluate the prevalence of anemia 10 years after surgery and to assess whether postoperative bariatric follow-up influences rates of anemia. Patients who did not have follow-up with a bariatric specialist (n = 58) were compared with patients who had at least one visit after five years (n = 16). Patients’ (58 men and 16 women, mean [SD] age, 51 [11] year) had a mean preoperative BMI of 46.2. At 10 years, the mean BMI was 33.7, with 60% excess BMI loss.
The mean rate of preoperative anemia was 20% (15 patients); and the rate increased after RYGB to 28% at 1 year (21 patients), 31% at 5 years (23 patients), and 47% at 10 years
(35 patients). At 10 years after RYGB, the anemia rate in the cohort without bariatric specialist follow-up increased to 33 patients (57%), from 13 (22%) before surgery. The rate of anemia in the cohort with bariatric specialist follow-up did not increase significantly after 10 years (3 [19%] vs. 2 [13%]). Compared to patients with bariatric specialist follow-up, patients without bariatric specialist follow-up had significantly higher odds of anemia at 10 years after adjusting for preoperative anemia. The study suggests that follow-up with bariatric specialists more than 5 years after surgery, rather than with specialists with no bariatric expertise, can decrease long-term anemia risk.

Weight and Metabolic Outcomes 12 Years after Gastric Bypass (NEJM)

An observational, prospective study examined the presence of type 2 diabetes, hypertension and dyslipidemia 12 years after RYGB. Clinical examinations at baseline, and at 2 years, 6 years and 12 years were completed for 1,156 patients with severe obesity. Patients were comprised of three groups: 418 patients who sought and underwent RYGB (surgery group), 417 patients who sought but did not undergo surgery primarily for insurance reasons (nonsurgery group one), and 321 patients who did not seek surgery (nonsurgery group two). The follow-up rate exceeded 90% at 12 years. The adjusted mean change from baseline in body weight in the surgery group was -45.0 kg (mean percent change, -35.0) at 2 years,
-36.3 kg (mean percent change, -28.0) at 6 years, and -35.0 kg (mean percent change, -26.9) at 12 years; the mean change at 12 years in nonsurgery group one was -2.9 kg (mean percent change, -2.0), and the mean change at 12 years in nonsurgery group two was 0 kg (mean percent change, -0.9). Among the patients in the surgery group who had type 2 diabetes at baseline, type 2 diabetes remitted in 66 of 88 patients (75%) at 2 years, in 54 of 87 patients (62%) at 6 years, and in 43 of 84 patients (51%) at 12 years. The odds ratio for the incidence of type 2 diabetes at 12 years was 0.08 for the surgery group versus nonsurgery group one and 0.09 for the surgery group versus nonsurgery group two. The surgery group had higher remission rates and lower incidence rates of hypertension and dyslipidemia than did nonsurgery group one.

Individualized Metabolic Surgery Score: Procedure Selection Based on Diabetes Severity (Annals of Surgery)

Data from the largest reported cohort (n = 900) with long-term postoperative glycemic follow-up was used to construct and validate a scoring system for evidence-based selection of bariatric and metabolic procedures according to severity of diabetes. The study is the first to categorize type 2 diabetes into thee validated severity stages for evidence-based procedure selection. The study cohort included 659 patients with type 2 diabetes who underwent RYGB and sleeve gastrectomy at a U.S. academic center between 2005 and 2011. The validation dataset consisted of 241 patients from an academic center in Spain where similar criteria were applied. At median postoperative follow-up of 7 years (range 5–12), diabetes remission (HbA1C < 6.5% off medications) was observed in 49% after RYGB and 28% after sleeve gastrectomy. Four independent predictors of long-term remission including preoperative duration of type 2 diabetes, preoperative number of diabetes medications, insulin use and glycemic control (HbA1C < 7%) were used to develop the Individualized Metabolic Surgery (IMS) score using a nomogram. Patients were then categorized into three stages of diabetes severity mild, severe and intermediate. Both procedures significantly improved type 2 diabetes in patients categorized as “mild” (IMS score ≤25). In “severe”
(IMS score > 95) patients, when clinical features suggest limited functional B-cell reserve, both procedures had similarly low efficacy for diabetes remission. Among the intermediate group RYGB was significantly more effective than sleeve gastrectomy, likely related to its more pronounced neurohormonal effects.

Health Disparities in Adolescent Bariatric Surgery: Nationwide Outcomes and Utilization (Journal of Adolescent Health)

This retrospective analysis (2007–2014) examined the impact of race and sex on preoperative characteristics, outcomes, and utilization of adolescent bariatric surgery using the Bariatric Outcomes Longitudinal Database. Researchers assessed the relationships between baseline characteristics and outcomes including weight loss and remission of obesity-related conditions. The National Health and Nutrition Examination Survey and U.S. census data was used to assess disparities in severe obesity and bariatric procedures among races. Among the 1,539 adolescents who underwent bariatric surgery, males had higher preoperative BMI
(51.8 vs. 47.1) and higher rates of obstructive sleep apnea and dyslipidemia. Blacks had higher preoperative BMI compared to whites, Hispanics, and others (52.4 vs. 47.3, 48.7, and 48.2, respectively) and higher rates of hypertension, obstructive sleep apnea, and asthma. Weight loss and remission rates of obesity-related conditions did not differ between sexes or races after accounting for the rate of severe obesity in each racial group. White adolescents underwent bariatric surgery at a higher proportion than blacks and Hispanics (2.5 and 2.3 times higher, respectively). The findings show minority adolescents undergo bariatric surgery at lower-than-expected rates.

All-Cause and Specific-Cause Mortality Risk After Roux-en-Y Gastric Bypass in Patients With and Without Diabetes (Diabetes Care)

This study assessed all-cause and specific-cause mortality between RYGB patients and control subjects with and without diabetes. Surgery patients were matched by age, BMI, sex, and diabetes status at time of surgery to control subjects using data from the electronic health record. Of the 3,242 eligible RYGB patients enrolled from January 2004 to December 2015, control subjects were identified for 2,428 (n = 625 with diabetes and n = 1,803 without diabetes). Median postoperative follow-up was 5.8 years for patients with diabetes and
6.7 years for patients without diabetes. All-cause mortality was reduced in RYGB patients compared with control subjects only for those with diabetes at the time of surgery (adjusted hazard ratio 0.44). Mortality was not significantly improved in RYGB patients without diabetes compared with control subjects without diabetes (adjusted hazard ratio 0.84). Deaths from cardiovascular diseases, respiratory conditions, and diabetes were more frequent in control subjects with diabetes than in RYGB patients with diabetes. RYGB patients without diabetes were less likely to die of cancer and respiratory diseases than control subjects without diabetes but were at higher risk of death from external causes, including intentional self-harm, than control subjects without diabetes. Preliminary data from this study was presented in 2016 at the ASMBS annual meeting.

Biomarkers of Colorectal Cancer Risk Decrease 6 months After Roux-en-Y Gastric
Bypass Surgery
(Obesity Surgery)

This study aimed to investigate the impact of RYGB on biomarkers of obesity-related colorectal cancer risk. Markers of systemic inflammation and glucose homeostasis were measured using mucosal biopsies and blood tests obtained from patients undergoing RYGB (n = 22) and non-obese control participants (n = 20) at baseline and at a median of
6.5 months after surgery. At 6.5 months post-surgery, participants had lost 29 kg body mass and showed improvements in markers of glucose homeostasis and in systemic inflammation. Consistent findings of reduced markers of tumorigenic potential suggest that surgically induced weight loss may lower colorectal cancer risk.

Diabetes Outcomes More than a Decade Following Sustained Weight Loss After Laparoscopic Adjustable Gastric Band Surgery (Obesity Surgery)

Clinical and biochemical measures from 113 patients with obesity and type 2 diabetes who underwent laparoscopic adjustable gastric banding (LAGB) procedures in 2003 and 2004 were used to determine long-term outcomes of diabetes remission. Seventy-nine patients had weight data at 10 years and attained a median weight loss of 16 percent. Of the 16 patients that attended a follow-up assessment, HbA1c had decreased to 6.6 percentage units from 7.8 despite no significant change in glucose-lowering therapy. Eleven patients (18%) were in diabetes remission and another 18 had HbA1c <= 6.5%. Significant improvements in physical measures of quality of life, blood pressure, and lipid profile were also observed but there was no change in the proportion of patients with albuminuria and a significant decline in estimated glomerular filtration rate. Twelve patients in the follow-up cohort (20%) required anti-reflux medication after surgery and 26 (43%) underwent gastric band revision surgery. The findings suggest weight loss over 10 years after gastric band surgery delivers clinically meaningful improvements in HbA1c at the cost of a high rate of revision surgery and increased use of anti-reflux medication.

Efficacy of Intragastric Balloon Treatment for Adolescent Obesity (Obesity Surgery)

A retrospective longitudinal study followed 27 adolescents (14–19 years; 23 female) for up to 6 months to evaluate the safety and efficacy of intragastric balloon treatment for weight loss. Participants had a BMI >=29 kg/m2 and were referred to intragastric balloon treatment by their attending physician after failure to lose weight in clinical treatments. A liquid-filled nonadjustable intragastric balloon with a volume of 600 to 700 ml was used for 6 months along with a multidisciplinary program. There were no serious complications or deaths. BMI decreased from 37.04 to 31.18 kg/m2, body weight decreased from 102.21 to 86.23 kg, and excess weight diminished from 35.18 to 19.12 kg. The percentage excess weight loss was
56.19 and percentage total weight loss 16.35. The findings showed that endoscopic treatment of obesity with an intragastric balloon is safe, effective, and may be an emerging therapeutic option for adolescents.

The Impact of Bariatric Surgery on Pulmonary Function: A Meta-Analysis (SOARD)

A systematic review and meta-analysis of 23 studies published prior to September 31, 2016 were used to evaluate the impact of bariatric surgery on pulmonary function. Among the 1,013 patients included in the studies, overall pulmonary function score was significantly improved after bariatric surgery, with pooled standardized mean difference of 0.59. No statistically significant difference was found when data was stratified by age, pre-surgery BMI, post-surgery BMI, study design, female studies only, study continent, asthmatic patient in the study, and the type of bariatric surgery. Findings show that bariatric surgery significantly improved overall pulmonary functions score in patients with morbid obesity.

Surgery Type and Psychosocial Factors Contribute to Poorer Weight Loss Outcomes in Persons with a Body Mass Index Greater than 60 kg/m2 (SOARD)

To predict three-year post-surgical percent total weight loss among bariatric surgery patients with super-super obesity (body mass index >60 kg/m2), study participants with a baseline BMI ≥60 (n=164) were compared to those with a BMI < 60 (n=1,067) on psychosocial and demographic factors, the MMPI-2-RF, and in the subset that had surgery (n=870) percentage of total weight loss extending to the 3-year follow-up. Patients who had a BMI >=60 were younger, less educated and more likely to be male compared to lower BMI patients. Patients with a BMI ≥60 had greater psychosocial sequelae as evidenced by being more likely to have a history of sexual abuse, history of psychiatric hospitalization, more binge eating episodes, and higher prevalence of Major Depression Disorder and Binge Eating Disorder. Those with BMI >=60 reported greater demoralization, low positive emotions, ideas of persecution, and dysfunctional negative emotions. After controlling for surgery type, weight loss for individuals with BMI ≥60 did not greatly differ from weight loss in patients with BMI < 60. Variables predictive of less weight loss at 3-years regardless of pre-surgical BMI included being older, having a sexual abuse history, and higher Ideas of Persecution scores.

Impact of Bariatric Surgery on Outcomes of Patients with Non-Alcoholic Fatty Liver Disease: A Nationwide Inpatient Sample Analysis, 2004-2012 (SOARD)

Data from the Nationwide Inpatient Sample database was used to assess the relationship between bariatric surgery and clinical outcomes in hospitalized patients with non-alcoholic fatty liver disease (NAFLD). Among 45,462 patients with a discharge diagnosis of NAFLD and morbid obesity, 18,618 patients (41.0%) had prior-bariatric surgery between 2004 and 2012. Prior-bariatric surgery was associated with decreased inpatient mortality compared to no bariatric surgery (Incidence Risk Ratios=0.08). Prior-bariatric surgery was also associated with decreased IRR for cirrhosis, myocardial infarction, stroke, and renal failure. In addition, data revealed that the proportion of NAFLD patients with bariatric surgery declined from
2004 to 2012.