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Journal Watch 13/04/2023

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 OAGB vs SG for revisional LAGB, surgery and NAFLD, breast cancer after bariatric surgery, surgery provides net social benefit despite high procedural costs, births after bariatric surgery, impact of COVID-19 on surgical patient’s experience and Previous and repeated weight loss may increase all-cause and cardiovascular disease (CVD) mortality, and more (please note, log-in maybe required to access the full paper).

Comparison of One Anastomosis Gastric Bypass and Sleeve Gastrectomy for Revision of Laparoscopic Adjustable Gastric Banding: 5-Year Outcomes

One anastomosis gastric bypass (OAGB) for revision after laparoscopic adjustable gastric banding (LAGB) due to insufficient weight loss or weight regain is safe and has better effectiveness in weight reduction and resolution of type 2 diabetes than sleeve gastrectomy (SG).

Researchers from Tel Aviv University, Israel, writing in Obesity Surgery, retrospective analysed 276 LAGB patients who were converted to OAGB (n=125) and SG (n=151). Body mass index (BMI) at revision was 41.3 ± 6.6 and 42.3 ± 9.6 kg/m2 (p=0.34) in OAGB and SG patients, respectively. Time interval was longer in OAGB patients (p<0.001) and the major early complication rates were comparable (2.4% and 4%; p=0.46).

At five-years, OAGB patients had lower BMI (31.9 vs. 34.5 kg/m2; p=0.002) and a higher total weight loss (25.1% vs. 18.8%; p=0.003), compared with SG patients. Resolution of type 2 diabetes was higher in OAGB patients (93.3% vs. 66.6%; p=0.047), while resolution of hypertension was not significantly different (84.6% and 80.5%; p=0.68). Revision due to delayed complications was required in five (4%) OAGB patients and nine (8.6%) SG patients (p=0.14).

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Cardiovascular Outcomes and Mortality After Bariatric Surgery in Patients With Nonalcoholic Fatty Liver Disease and Obesity

Bariatric surgery is significantly associated with lower risk of major adverse cardiovascular events and all-cause mortality in patients with nonalcoholic fatty liver disease (NAFLD) and obesity, according to US researchers writing in JAMA Network Open.

For their study, they investigate the association of BS with the incidence of adverse cardiovascular events and all-cause mortality in patients with NAFLD and obesity. They matched bariatric surgery patients with patients who did not undergo surgery (non-BS group) according to age, demographics, comorbidities, and medication by using 1:1 propensity matching.

From 152,394 eligible adults, 4,687 patients who underwent surgery were matched with 4,687 non-surgical individuals. The surgical group had significantly lower risk of new-onset of HF (HR, 0.60; 95% CI, 0.51-0.70), cardiovascular events (HR, 0.53; 95% CI, 0.44-0.65), cerebrovascular events (HR, 0.59; 95% CI, 0.51-0.69), and coronary artery interventions (HR, 0.47; 95% CI, 0.35-0.63) compared with the non-BS group. Similarly, all-cause mortality was substantially lower in the BS group (HR, 0.56; 95% CI, 0.42-0.74). These outcomes were consistent at follow-up duration of one, three, five and seven years.

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Residual Risk of Breast Cancer After Bariatric Surgery

Bariatric surgery is associated with a reduced risk of developing breast cancer for women with prior obesity equivalent to that of a woman with a BMI<25 and a lower risk when compared with all groups with BMI>25.

Writing in JAMA Surgery, researchers from McMaster University, Hamilton, Ontario, Canada, matched 69,260 women who underwent bariatric surgery for obesity to women without a history of bariatric surgery according to age and breast cancer screening history. Nonsurgical controls were divided into 4 BMI categories (<25, 25-29, 30-34, and ≥35). A total of 13,852 women in each of the five study cohorts.

In the postsurgical cohort vs the overall nonsurgical cohort (n=55 408), there was an increased hazard for incident breast cancer in the nonsurgical group after washout periods of one year, two years and five years. When the postsurgical cohort was compared with the nonsurgical cohort with BMI<25, the hazard of incident breast cancer was not significantly different regardless of the washout period, whereas there was a reduced hazard for incident breast cancer among postsurgical patients compared with nonsurgical patients in all high BMI categories (BMI ≥25).

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The Long-term Value of Bariatric Surgery Interventions for American Adults With Type 2 Diabetes Mellitus

Diabetes remission following bariatric surgery improves healthy life expectancy and provides net social benefit despite high procedural costs, investigators from the University of Southern California.

Reporting in the Annals of Surgery, they estimated the individual-level net social value benefits of diabetes remission through bariatric surgery and compared the population-level effects of expanding eligibility alone versus improving utilization for currently eligible individuals. They then compared the projected lifetime surgical outcomes to conventional management at individual and population levels for current utilisation (1%) and eligibility (BMI ≥35 kg/m2) and expansions of both (>1% and BMI≥30).

The per capita net social value of bariatric surgery-related diabetes remission was $264,670 under current and $227,114 under expanded eligibility, an 11.1% and 9.16% improvement over conventional management. Quality-adjusted life expectancy represented the largest gains (current: $194,706; expanded: $169,002); followed by earnings ($51,395 and $46,466), and medical savings ($41,769 and $34,866) balanced against the surgery cost ($23,200). Doubling surgical utilisation for currently eligible patients provides higher population gains ($34.9B) than only expanding eligibility at current utilisation ($29.0B).

Per capita benefits appear greater among currently eligible individuals, the authors concluded, therefore, policies that increase utilisation may produce larger societal value than expanding eligibility criteria alone.

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Births After Bariatric Surgery in the United States - Incidence, Obstetric Outcomes, and Reinterventions

University of Michigan have reported that giving birth within the first two years after bariatric surgery was not associated with an increased risk of reinterventions.

Writing in the Annals of Surgery, the retrospective cohort study included 1,464 women who gave birth after undergoing laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass from 2011 to 2017, from a total of 69,503 patients who underwent bariatric surgery.

Overall, 85% of births occurred within 21 months after surgery. For 38,922 patients with full 2-year follow-up, adverse obstetric event rates were 4.5% for gestational diabetes and 14.2% for hypertensive disorders. In all, 48.5% were first-time caesarean deliveries. Almost all reinterventions during pregnancy were biliary. Multivariable logistic regression analysis showed no association between post-bariatric birth and reintervention rate.

The researchers concluded that clinicians should consider shifting the dialogue surrounding pregnancy after surgery to shared decision-making with maternal safety as one component.

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Impact of COVID-19 on the Postoperative Bariatric Surgery Patient Experience

Bariatric surgery patients need ongoing support to access mental health professionals, develop new physical activity routines and counteract increased food insecurity, after considering the impact of COVID-19 on weight loss following surgery.

Researchers from the University of Wisconsin, reporting in the Annals of Surgery, conducted semi-structured interviews with bariatric surgery patients, primary care providers and health psychologists.

In total, 34 participants were interviewed: 24 patients (12 Roux-en-Y gastric bypass and 12 sleeve gastrectomy), six primary care providers and four health psychologists. They found that COVID-19 affected the postoperative bariatric surgery patient experience via three mechanisms: (1) it disrupted dietary and physical activity routines due to facility closures and fear of COVID-19 exposure; (2) it required patients to transition their follow-up care to telemedicine delivery; and (3) it increased stress due to financial and psychosocial challenges.

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Prospective study of weight loss and all-cause-, cardiovascular-, and cancer mortality

Previous and repeated weight loss may increase all-cause and cardiovascular disease (CVD) mortality, especially in men, according to researchers from the Karolinska Institutet, Stockholm, Sweden.

Writing in Scientific Reports, the authors followed 34,346 individuals from 1997 to 2018 for all-cause mortality, and 2016 for cause-specific mortality. At baseline, participants self-reported amount and frequency of prior weight loss. During 20.6 (median) years of follow-up, they identified 5,627 deaths - 1,783 due to cancer and 1,596 due to CVD. Participants with a weight loss >10 kg had higher rates of all-cause and CVD mortality vs. individuals with no weight loss.

Men who had lost >10 kg had higher all-cause and CVD mortality vs. men with no weight loss. Participants who had lost ≥ 5kg three times or more prior to baseline had increased rates of all-cause and CVD mortality vs. participants with no weight loss. They reported no association between weight loss and cancer mortality.

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