Sympathomimetic increases resting energy expenditure following bariatric surgery: A randomized controlled clinical trial.

Resting energy expenditure (REE) declines during weight loss because of both organ-tissue mass loss and adaptive thermogenesis, but their relative contributions after bariatric surgery remain unclear. Our primary aim was to quantify these components during the first postoperative year and secondarily to compare Roux-en-Y gastric bypass (RYGB) with one-anastomosis gastric bypass (OAGB). Forty-two adults with obesity (RYGB, n = 21; OAGB, n = 21) underwent dual-energy X-ray absorptiometry (DXA) before surgery and at 6 and 12 mo, and organ-tissue masses were estimated using MRI-derived prediction equations. A smaller subset of 29 participants (RYGB, n = 15; OAGB, n = 14) had valid indirect calorimetry measurements for REE analysis. Participants lost 27.3 kg (21%) of baseline body weight at 6 mo and 32.3 kg (25%) at 12 mo, with no significant differences between procedures in the DXA-measured body composition outcomes or calculated organ-tissue masses. Measured REE decreased by 383 kcal/day at 6 mo (P < 0.001), of which 168 kcal/day [95% confidence interval (CI): 59-276, P = 0.004] was attributed to adaptive thermogenesis. At 12 mo, REE remained 315 kcal/day below baseline (P < 0.001), but adaptive thermogenesis was not statistically detectable (89 kcal/day; 95% CI: -19 to 198, P = 0.11). Adaptive thermogenesis did not significantly differ between procedures. In conclusion, ∼44% of the early 6-mo postoperative decline in REE was associated with adaptive thermogenesis, with the remaining ∼56% associated with organ-tissue mass loss. Adaptive thermogenesis was no longer clearly evident at 12 mo. RYGB and OAGB resulted in similar changes in body composition and REE.NEW & NOTEWORTHY Resting energy expenditure declines after bariatric surgery, but the relative roles of tissue loss and adaptive thermogenesis are unclear. Using DXA-based organ-tissue estimates with indirect calorimetry, we show that adaptive thermogenesis accounted for ∼44% of the 6-mo postoperative REE decline, with the remainder due to tissue loss. Adaptive thermogenesis was not robustly detectable at 12 mo. Roux-en-Y and one-anastomosis gastric bypass show similar body composition and REE changes.

β-cell dysfunction and insulin resistance are the main mechanisms causing glucose intolerance in type 2 diabetes (T2D). Bariatric surgeries, i.e., sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), are procedures both known to induce weight loss, increase insulin action, and enhance β-cell function, but hepatic insulin extraction and glucose effectiveness may also play a role. To determine the contribution of these regulators on glucose tolerance after bariatric surgery, an oral glucose tolerance test (OGTT) was performed before and 2 months after surgery in 9 RYGB and 7 SG subjects. Eight healthy subjects served as metabolic controls. Plasma glucose, insulin, C-peptide, GLP-1, and GIP were measured during each OGTT. Insulin sensitivity and secretion, glucose effectiveness, and glucose rate of appearance were determined via oral minimal models. RYGB and SG resulted in similar weight reductions (13%, RYGB (p < 0.01); 14%, SG (p < 0.05)). Two months after surgery, insulin secretion (p < 0.05) and glucose effectiveness both improved equally in the two groups (11%, RYGB (p < 0.01); 8%, SG (p > 0.05)), whereas insulin sensitivity remained virtually unaltered. Bariatric surgery resulted in a comparable increase in the GLP-1 response during the OGTT, whereas GIP concentrations remained unaltered. Following surgery, oral glucose intake resulted in a comparable increase in hepatic insulin extraction, the response in both RYGB and SG patients significantly exceeding the response observed in the control subjects. These results demonstrate that the early improvement in glucose tolerance in obese T2D after RYGB and SG surgeries is attributable mainly to increased insulin secretion and glucose effectiveness, while insulin sensitivity seems to play only a minor role. This trial is registered with NCT02713555.

BackgroundStaple line reinforcement during surgery may decrease morbidity or reduce the risk of staple line leaks and bleeding. There is debate regarding the benefit, safety, and best form of reinforcement. This case series characterizes the safety of a stapler with a pre-attached buttress in bariatric surgeries. MethodsThis prospective, multicenter, post-market study examined the use of stapler reloads with built in reinforcement material. The primary endpoint is the incidence of reported device-related adverse events up to 30 days after laparoscopic Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (SG) surgeries. Specific outcomes included bleeding (≥50 mL), leaks, and 30-day readmissions. OutcomesA total of 51 patients (19 RYGB, 32 SG) were assessed after exclusion criteria were applied. Intraoperatively, no leaks or bleeding related to the staple line occurred. Four patients (8% overall, 3 RYGB, 1 SG) experienced bleeding unrelated to the staple line and staple line intervention, in these cases, was not required. Four subjects (8%, all SG) required readmission and each were attributed as unrelated to the investigational device. No unanticipated device-related events were observed. Two adverse events (bleeding) occurred post-operatively that were attributed as possibly related to the device; both were endoscopically managed. ConclusionsThis study demonstrates that there were no serious safety concerns from the AEs observed related to reinforced reload use during or in the 30-day course after 51 common bariatric procedures in a multicenter setting. Trial registrationThe study was registered with clinicaltrials.gov (NCT02500537). Thoracic subjects from this study are described in a separate manuscript.

Morbid obesity is a well-defined chronic disease, the incidence of which is constantly rising. Surgical treatment of morbid obesity has produced superior outcomes compared to conventional weight loss measures. Currently, there is a gap in the literature regarding long-term outcomes. Our single-institution, retrospective cohort study aims to evaluate weight loss outcomes, comorbidity reduction, and adverse effects at 10 years following Roux-en-Y Gastric Bypass (RYGB), Biliopancreatic Diversion (BPD), and Sleeve Gastrectomy (SG). We included all consecutive patients with 10-year follow-up records operated on within our institution. The comparison was carried out on the average percentage of weight and BMI loss. Nausea and vomiting were evaluated through self-reporting Likert scales. Diabetes resolution and nutritional deficiencies were also evaluated. A total of 490 patients from 1995 up to 2011 were included in our study. Of these, 322 underwent RYGB, 58 underwent long-limb BPD, 34 underwent laparoscopic RYGB with fundus excision, 47 underwent laparoscopic SG, and 29 underwent laparoscopic RYGB as a revision of prior SG. RYGB and BPD were significantly associated with higher percentages of weight loss (37.6% and 37.5%), but were not found to be independent predictors of weight loss. Nausea and vomiting were associated with SG and laparoscopic RYGB with fundus excision, more so than the other operations. No differences were observed regarding diabetes resolution and nutritional deficiencies. Longer follow-up reports are important for the comparison of outcomes between different types of bariatric operations. BPD and RYGB resulted in superior weight loss, with no observed differences in diabetes resolution and adverse outcomes.

IntroductionOne way to lose weight is bariatric surgery. Various studies have shown that after Roux-en-Y gastric bypass (RYGB), resting energy expenditure (REE) decreased may be a result of changes in fat-free mass (FFM) and thyroid-stimulating hormone levels. The aim of our study was to assess changes in body composition, REE, and thyroid hormones in patients undergoing RYGB.MethodsA total of 42 patients participated (21 undergoing RYGB and 21 age- and weight-matched subjects as controls) in our study. Weight, body-mass index, body composition, resting metabolic rate, physical activity, and thyroid hormones were measured at baseline in cases and 3 months after surgery in case and control groups.ResultsAt 3 months after surgery, patients lost an average of 21.7±1.4 kg weight, and fat mass, FFM, and REE decreased significantly. REE was higher in cases compared to controls. T4, T3, and thyroid-stimulating hormone at 3 months after RYGB decreased, but the decrease was significant only in T4 compared to controls. FFM was higher and fat mass lower in cases compared to controls.ConclusionWe detected a meaningful difference in REE before and after surgery, but we did not detect any meaningful difference in REE between controls and cases.

Background: The effectiveness of bariatric surgery in reducing remnant cholesterol (RC) levels, particularly when obesity is accompanied by elevated glycated hemoglobin (HbA1c), is insufficiently investigated. In this study, we aimed to examine the impacts of two common bariatric procedures, Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), as regards their effects on RC and HbA1c levels. Methods: Adult morbidly obese subjects were included and assigned to receive either RYGB or SG. The levels of RC and HbA1c were determined 6 and 12 months after surgery and compared to preoperative levels to assess the efficacy of these surgical methods. In the statistical evaluation of covariations between RC and other biomarkers, previously determined C-reactive protein (CRP), triglycerides, apolipoprotein B, apolipoprotein A1, and low- and high-density lipoprotein cholesterol 6 and 12 months after surgery were included. A linear mixed regression model for repeated analyses was used. Results: The RC levels were markedly reduced both after RYGB and SG but without significant differences between the RYGB and the SG surgery. Furthermore, the RC values were strongly associated with the levels of CRP and HbA1c. Conclusions: A significant lowering of RC values after bariatric surgery appeared paralleled by concomitant reductions in HbA1c values and CRP levels. Together, these effects lead to a lower risk of cardiovascular disease.

Analysis of emergent reoperations after bariatric surgery: an important metric for safe same-day surgery

Bariatric surgery in patients with preoperative therapeutic anticoagulation: a 2015–2021 MBSAQIP database study

The weight-loss surgery Roux-en Y gastric bypass (RYGB) is a relatively effective, long-term treatment option for patients with morbid obesity. However, accumulating clinical evidence suggests that patients receiving RYGB may be at increased risk of developing alcohol use disorder. This observation has been repeatedly supported by preclinical studies showing rodents increase intake of ethanol (EtOH) after RYGB, and has been further confirmed by human studies. A promising alternative to RYGB is sleeve gastrectomy (SG), which has resulted in decreased EtOH consumption in some rodent studies. The exact mechanism underlying the differential alcohol outcomes after RYGB versus SG has yet to be elucidated. However, the gut hormone ghrelin has emerged as a potential candidate from previous preclinical studies specific to RYGB surgeries and due to its action to stimulate food and alcohol intake and cravings. To directly assess changes in plasma ghrelin levels following weigh loss surgeries in the context of alcohol intake, 24 female rats were separated into three surgical groups receiving RYGB, SG, or Sham surgery followed by caloric restriction to produce adiposity matched controls (Sham-AM). Blood was drawn for fasted and fed plasma ghrelin (acyl and des-acyl) assays at multiple time points: while on a normal diet (ND), after 5-week exposure to a high fat diet (HFD), following surgery, and after a series of two-bottle alcohol choice test with increasing concentrations (2%, 4%, 6%, 8%) of EtOH. Consistent with previous observations, RYGB rats drank more EtOH than SG rats across all concentrations. As expected, fasted ghrelin levels were blunted after HFD feeding, compared to normal diet baseline. After RYGB, fasted ghrelin levels returned to higher levels while remained blunted after SG and Sham-AM. Fed acyl ghrelin levels were significantly increased to above “normal” levels after RYGB, but remain low after SG and Sham-AM. Given that post-RYGB acyl ghrelin levels are raised to a fasted state regardless of actual prandial status, we conclude that RYGB may results in a hormonal state reminiscence of a fasted state with the inability of feeding to inhibit ghrelin production, an effect which could potentially contribute to increased EtOH intake following the surgery. In contrast, following SG, ghrelin levels in rats remain consistent with the fed state regardless of prandial status, potentially explaining lower alcohol intake and lower risk of developing AUD.

&lt;p&gt;Enhanced secretion of glucagon-like peptide-1 (GLP-1) seems to be essential for improved postprandial β-cell function after Roux-en-Y gastric bypass (RYGB) but is less studied after sleeve gastrectomy (SG). Moreover, the role of the other major incretin hormone, glucose-dependent insulinotropic polypeptide (GIP), is relatively unexplored after bariatric surgery. We studied the effects of separate and combined GLP-1 receptor (GLP-1R) and GIP receptor (GIPR) blockade during mixed meal tests in unoperated (CON), SG-operated, and RYGB-operated people with no history of diabetes. Postprandial GLP-1 concentrations were highest after RYGB but also higher after SG compared with CON. In contrast, postprandial GIP concentrations were lowest after RYGB. The effect of GLP-1R versus GIPR blockade differed between groups. GLP-1R blockade reduced β-cell glucose sensitivity and increased or tended to increase postprandial glucose responses in the surgical groups but had no effect in CON. GIPR blockade reduced β-cell glucose sensitivity and increased or tended to increase postprandial glucose responses in the CON and SG groups but had no effect in the RYGB group. Our results support that GIP is the most important incretin hormone in unoperated people, whereas GLP-1 and GIP are equally important after SG, and GLP-1 is the most important incretin hormone after RYGB.&lt;/p&gt;

The timing of bleeding after bariatric surgery and subsequent management (characterized as surgical versus non-surgical (i.e., interventions including endoscopic or interventional radiology approaches)) has not been thoroughly studied. As such, we sought to describe the rates of reoperation or non-operative intervention after bleeding following sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). The Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) database was queried between 2015 and 2018 for any bleeding after SG or RYGB and subsequent reoperation or non-operative intervention. Multivariable Fine-Gray models were used to compare the hazard of reoperation/non-operative intervention. Multivariable generalized linear regression models were used to test the number of subsequent reoperations/non-operative interventions depending on initial management. 6251 patients with bleeding after SG or RYGB were identified, of which 2653 patients underwent subsequent procedures (n = 1375 [51.83%] RYGB index procedure, n = 1278 [48.17%] SG index procedure). 1892 (71.32%) and 761 (28.68%) patients had reoperation and non-operative intervention, respectively. For patients who developed bleeding, SG was associated with significantly higher reoperation risk, while RYGB was associated with significantly higher risk of non-operative intervention. Early bleeding was associated with significantly increased risk of reoperation and decreased risk of non-operative intervention, regardless of initial procedure. The total number of subsequent reoperations/non-operative interventions did not differ significantly depending on whether the patients had non-operative intervention or reoperation first [ratio 1.01, 95% CI (0.75, 1.36), p value 0.9418]. Patients after SG who experience bleeding are more likely to undergo reoperation than RYGB patients. On the other hand, patients with bleeding after RYGB are more likely to undergo non-operative intervention compared to SG patients. Early bleeding is associated with higher risk of reoperation and lower risk of non-operative intervention both after SG and RYGB. The initial approach did not play a role in the total number of subsequent reoperations/non-operative interventions.

Sexual Activity After Bariatric Surgery: A Prospective Monocentric Study Using the PISQ-IR Questionnaire

Bariatric surgeries, such as Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), improve obesity and type 2 diabetes (T2D). Both surgeries affect the gut microbiota, but their contribution to T2D remission remains unclear. In this subanalysis (RYGB, n = 39; SG, n = 38) of the randomized controlled Oseberg trial ( NCT01778738 ), in which participants underwent either RYGB or SG surgery, we profiled the faecal microbiome of individuals with obesity and T2D before and 12 months after surgery. We show that both surgeries altered the microbiome in the same direction, but with larger changes after RYGB. The SG-associated altered microbiome composition correlated positively with circulating glucagon-like peptide 1 levels, beta-cell function and 5 year T2D remission. Remission was also linked to increased gene richness and metabolic potential for fermentation, methanogenesis and butyrate production. Notably, these associations persisted after accounting for the extent of weight loss. Our findings indicate that surgery-specific microbial adaptations influence metabolic improvements and may help to explain heterogeneity in T2D remission after bariatric surgery.

Obesity and steatotic liver disease are associated with excess morbidity and mortality from cardiovascular, pulmonary, metabolic, and hepatic causes. Bariatric surgery has demonstrated long-term benefits in terms of weight loss and mortality rates, but barriers to its utilization persist. To evaluate the impact of bariatric surgery on outcomes and cost-effectiveness among patients with obesity, focusing on those with cirrhosis. This economic evaluation was a retrospective cohort study including US veterans older than 18 years with a body mass index (BMI) higher than 35 or with a BMI higher than 30 and more than 1 major metabolic comorbidity. These veterans were referred to a structured lifestyle modification program (MOVE!), and a subset proceeded to bariatric surgery, including sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from 2008 to 2020. Risk set matching was used to match bariatric surgery cases 1:5 with nonsurgical controls. Data were analyzed from September 2008 to September 2023. Bariatric surgery (SG or RYGB) or structured lifestyle intervention (MOVE!). The primary outcomes were the incremental cost-effectiveness ratio (ICER) of SG or RYGB vs MOVE! over 10 years. Secondary outcomes included overall survival, quality-adjusted survival, and weight loss achieved. The final cohort included 4301 SG, 1906 RYGB, and 31 055 MOVE! participants, among whom 64, 8, and 354, respectively, had cirrhosis. The median (IQR) age of the cohort was 52 (44-59) years; there were 25 581 male patients (68.7%) and 11 681 female (31.3%). Compared with MOVE!, bariatric surgery was associated with longer observed survival (9.67 years vs 9.46 years overall; 9.09 years vs 8.23 years in cirrhosis). The ICER was $132 207 for SG and $159 027 for RYGB in the overall cohort, and $18 679 for SG and $44 704 for RYGB in the cirrhosis cohorts. Bariatric surgery was cost-effective at a willingness-to-pay threshold of $100 000 per quality-adjusted life-year among patients with cirrhosis. Bariatric surgery was associated with improved survival and expected weight loss and was cost-effective. These findings support the expanded use of bariatric surgery in appropriately selected patients, including those with cirrhosis, to improve outcomes and reduce long-term health care costs.

Introduction: Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are 2 common bariatric surgeries for treatment of obesity. Although the complication rate for post-bariatric surgery gastric leaks are low, given how frequently these surgeries are being performed, having safe and effective therapies available for complications is crucial for patient outcomes. Revisional surgeries can significantly increase the risk of mortality in these patients so avoiding them is ideal but if revisional surgery does occur, having post-op management options would be valuable. Endoscopic vacuum therapy (EVT) has emerged in recent years as a potential option for management of luminal wounds. EVT is based upon endoscopically applying sponges to the area of a leak and negative pressure is applied to draw off fluid and promote granulation tissue formation along with healing. In this study we aim to review and analyze all currently available data on applying EVT to post-bariatric surgery leaks specifically focusing on success rate, complication rate, mean duration of therapy, and number of sponge changes to see if it’s a therapy warranting further research. Methods: Pubmed, Embase, and Cochrane were searched from inception to through May 2022 for studies reporting success and complication rates for EVT used for bariatric surgery associated gastric leaks whether it was for initial therapy or after revisional therapy for SG and RYGB surgeries. We included both retrospective and prospective studies in our analysis. Using I2 we assessed heterogeneity and calculated 95% confidence intervals using fixed or random effect models. Results: Six studies, totaling 81 patients, were included in the analysis. The total clinical success rate was 89.5% (CI: 83-96%. P < 0.001). The adverse event rate among all studies was 4.5% (95% CI: 0.2-8.7%. P = 0.041). There were 6 adverse events related to EVT noted in this review. The one mortality event that occurred in this review was presumed to be secondary to deconditioning during the recovery period and not EVT itself and thus wasn’t counted in adverse outcomes. EVT associated complications were related to bleeding and abscess formation. Conclusion: Based upon our currently available data, EVT appears to be a viable and safe option for the treatment of post-bariatric surgery (specifically SG and RYGB) gastric leaks. Larger prospective studies appear reasonable and would allow for a more powerful meta-analysis to further evaluate EVT as a potential therapy.Figure 1.: Success and adverse event rates for endoscopic vacuum therapy