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Journal Watch 07/06/2023

Welcome to our weekly round-up of the latest bariatric and obesity-related papers published in the medical literature. As ever, we have looked far and wide to give you an overview of papers including indocyanine green (ICG) fluorescence angiography in revisional surgery, long-term recurrence of internal herniation after RYGB, readability of patient education materials for bariatric surgery, tirzepatide slows the estimated glomerular filtration rate (eGFR) decline rate, and hyperoxaluria after malabsorptive bariatric surgery, and more (please note, log-in maybe required to access the full paper).

Assessment of gastric pouch blood supply with indocyanine green fluorescence in conversional and revisional bariatric surgery: a prospective comparative study

Researchers from Locarno Regional Hospital, Locarno, Switzerland, have reported indocyanine green (ICG) fluorescence angiography might not be useful for assessing the blood supply of the gastric pouch in patients who underwent re-operative bariatric surgery.

Writing in Scientific Reports, the study aimed to evaluate the usefulness of ICG angiography during conversional or revisional bariatric surgery and included 32 patients scheduled for re-operative bariatric surgery with gastric pouch resizing and ICG assessment. The patients were then compared with a retrospective series of similar patients who did not receive ICG. The patient characteristics were similar in both groups. The primary outcome was the rate of intraoperative change in the surgical strategy due to the ICG test.

The ICG angiography was successfully conducted in all patients, and no change of the surgical strategy was necessary. Postoperative complications were similar in both groups (6.2% vs. 8.3%, p=0.846), as well as operative time (125 ± 43 vs. 133 ± 47 min, p=0.454) and length of hospital stay (2.8 ± 1.0 vs. 3.3 ± 2.2 days, p=0.213).

“Therefore, it remains uncertain whether the application of this technique is indicated,” they concluded.

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Long-Term Follow-up and Risk of Recurrence of Internal Herniation after Roux-en-Y Gastric Bypass

Investigators from Lund University, Malmö, Sweden, have determined that surgery for internal herniation (IH) had a low risk of recurrence at the treated mesenteric gap, but a 14% recurrence risk at the other mesenteric gap.

Reporting in Obesity Surgery, the retrospective study aimed to investigate long-term follow-up and recurrence risk of IH surgery. Status of primary closure of mesenteric gaps, time since RYGB and findings at IH surgery were retrieved from medical records.

They found that IH (n=44) occurred almost equally in Petersen’s space (n=24) and beneath the jejunojejunostomy (n=20). Long-term follow-up (median 75 months) of 43 patients registered an IH recurrence rate of 14% (n=6). All recurrences occurred in the other mesenteric gap. During follow-up, 56% (n=24) had ER visits for abdominal pain, 47% (n=20) had ≥ 1 abdominal CT scan, and 40% (n=17) were readmitted. A third of readmitted (6/17) patients suffered a recurrence of internal herniation. Two other patients were readmitted ≥ 10 times for chronic abdominal pain.

This study emphasises the importance of carefully investigating weaknesses or gaps at the other mesenteric defect during surgery for IH, the researchers concluded.

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Readability of patient education materials for bariatric surgery

Researchers at the University of Alabama at Birmingham, Birmingham, AL, have reported that surgeon curated bariatric surgery webpages have advanced reading levels above recommended thresholds, compared to standardised patient education materials (PEM) from an electronic medical record (EMR).

The study, published in Surgical Endoscopy, aimed to assess and compare the readability of webpages and EMR bariatric surgery PEM from the University of Alabama at Birmingham. Readability of online bariatric surgery and standardized perioperative EMR PEM were analysed and compared. Text readability was assessed by validated instruments and mean readability scores were calculated with standard deviations and compared using unpaired t-tests.

32 webpages and seven EMR education documents were analyzed. Webpages were overall “difficult to read” compared to “standard/average” readability EMR. All webpages were at or above high school reading level and the webpages with highest reading levels were nutrition information and lowest were patient testimonials.

They concluded that the readability gap may unintentionally contribute to barriers to surgery and affect postoperative outcomes therefore, streamlined efforts are needed to create materials that are easier to read and comply with recommendations.

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Effects of Tirzepatide Versus Insulin Glargine on Cystatin C–Based Kidney Function: A SURPASS-4 Post Hoc Analysis

An ad-hoc analysis of the SURPASS-4 study by researchers University of Groningen, Groningen, the Netherlands has concluded Tirzepatide slows the estimated glomerular filtration rate (eGFR) decline rate, supporting a kidney-protective effect.

Writing in Diabetes Care, they assessed effects of tirzepatide on eGFR-creatinine and cystatin C–derived eGFR (eGFR-cystatin C) and the primary outcome was eGFR change from baseline at 52 weeks with pooled tirzepatide (5, 10, and 15 mg) and titrated insulin glargine in adults with type 2 diabetes and high cardiovascular risk (SURPASS-4).

Least squares mean (SE) eGFR-creatinine (mL/min/1.73 m2) changes from baseline with tirzepatide and insulin glargine were −2.5 (0.38) and −3.9 (0.38) (between-group difference, 1.4 [95% CI 0.3–2.4]) and −3.5 (0.37) and −5.3 (0.37) (between-group difference, 1.8 [95% CI 0.8–2.8]) for eGFR-cystatin C.

At baseline, 1-year and 1-year change from baseline values significantly correlated between eGFR-cystatin C and -creatinine. Measures of eGFR changes did not correlate with body weight changes.

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Delta weight loss unlike genetic variation associates with hyperoxaluria after malabsorptive bariatric surgery

Researchers at the University of Leipzig Medical Center, Leipzig, Germany, have reported that the degree of postsurgical weight loss and levels of malabsorption parameters may allow for predicting the risk of enteric hyperoxaluria and consecutive kidney stone formation.

Writing in Scientific Reports , the investigators sought to identify clinical and genetic factors and their contributions to the development of post-surgical hyperoxaluria. They determined the prevalence of hyperoxaluria and nephrolithiasis after MBS by 24-h urine samples and clinical questionnaires. Both hyperoxaluric and non-hyperoxaluric patients were screened for sequence variations in known and candidate genes implicated in hyperoxaluria (AGXT, GRHPR, HOGA1, SLC26A1, SLC26A6, SLC26A7) by targeted next generation sequencing (tNGS).

The cohort comprised 67 patients, 49 females (73%) and 18 males (27%). While hyperoxaluria was found in 29 patients (43%), only one patient reported postprocedural nephrolithiasis within 41 months of follow-up. Upon tNGS, they did not find a difference regarding the burden of (rare) variants between hyperoxaluric and non-hyperoxaluric patients.

However, patients with hyperoxaluria showed significantly greater weight loss accompanied by markers of intestinal malabsorption compared to non-hyperoxaluric controls. While enteric hyperoxaluria is very common after MBS, genetic variation of known hyperoxaluria genes contributes little to its pathogenesis.

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Effect of pelvic floor muscle training on reports of urinary incontinence in obese women undergoing a low-calorie diet before bariatric surgery — protocol of a randomized controlled trial

Investigators at the University of Sao Paulo, São Paulo, Brazil, have initiated a study to assess the effect of a low-calorie diet plus Pelvic floor muscle training (PFMT) prior to bariatric surgery on women’s urinary incontinence (UI).

Writing in BMC Trials, they hypothesise that a low-calorie diet in combination with PFMT would result in additional beneficial effects to urinary symptoms in women with UI compared would with weight loss alone. The participants will be randomly allocated in two groups: group 1 will participate in a 12-week protocol of low-calorie diet delivered by a multi-professional team at a tertiary hospital; group II will receive the same low-calorie diet protocol during 12 weeks and will additionally participate in 6 group sessions of supervised PFMT delivered by a physiotherapist.

The primary outcome of the study is self-reported UI, and severity and impact of UI on women’s quality of life will be assessed by the ICIQ-SF score. The secondary outcomes will be adherence to the protocols assessed using a home diary, pelvic floor muscle function assessed by bidigital vaginal palpation and the modified Oxford grading scale, and women’s self-perception of their PFM contraction using a questionnaire.

The statistical analysis will be performed by intention to treat and multivariate analysis of mixed effects will be used to compare outcomes. The complier average causal effects (CACE) method will be used to assess adherence.

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