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Journal Watch 18/10/2023

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 SURMOUNT-3 outcomes, revisional-LSG after LAGB, concomitant approach is appropriate for hernias that the surgeon feels do not require mesh, single-port laparoscopic sleeve gastrectomy (SILSG) is a viable alternative procedure to multiport conventional sleeve gastrectomy (CLSG), dasiglucagon effectively reduced clinically relevant post-RYGB hypoglycemia and open-capsule PPI (OC-PPI) significantly improved marginal ulcer (MU) healing times compared to intact-capsule PPI (IC-PPI) in RYGB patients, and more (please note, log-in maybe required to access the full paper).

Tirzepatide after intensive lifestyle intervention in adults with overweight or obesity: the SURMOUNT-3 phase 3 trial

An international team of researchers have reported results from the phase 3 SURMOUNT-3 clinical trial - evaluating tirzepatide in adults with obesity or overweight with weight-related comorbidities, excluding type 2 diabetes - reveal Tirzepatide met both co-primary endpoints.


SURMOUNT-3 was a multi-centre, randomised, double-blind, parallel, placebo-controlled trial comparing the efficacy and safety of tirzepatide to placebo for 72 weeks after a 12-week intensive lifestyle intervention lead-in period in adults with obesity or overweight with weight-related comorbidities, excluding type 2 diabetes.


After 12 weeks, 579 participants achieved at least 5% body weight reduction and were randomised in a 1:1 ratio to receive tirzepatide or placebo. The co-primary objectives of the study were to demonstrate that tirzepatide is superior in percent change in body weight from randomisation and percentage of participants achieving ≥5% body weight reduction from randomisation at 72 weeks compared to placebo.


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Long-term Outcomes of Laparoscopic Sleeve Gastrectomy as a Revisional Procedure Following Adjustable Gastric Banding: Variations in Outcomes Based on Indication

Researchers from Monash University, Australia, have reported revisional-LSG (RLSG) after failed LAGB provides long-term weight loss, although peri-operative complications are significantly elevated compared to primary LSG (PLSG).


Writing in Obesity Surgery, they sought to determine the long-term outcomes of sleeve gastrectomy as a revisional procedure after LAGB across a range of measures and determine predictors of outcomes.


Six hundred RLSG and 1,200 controls PLSG were included. The median length of stay was significantly longer in RLSG vs the controls (3 days vs 2 days, p<0.001) and RLSG patients with post-operative complications had a longer length of stay (4 days vs 3 days, p<0.001) vs the controls. Furthermore, the RLSG group also had overall higher complications (4.8% vs 2.0%, p<0.0001) and re-admissions (4.3% vs 2.4%, p<0.012). The RLSG group had more frequent staple line leaks, compared to the control group (0.9% vs 2.5%, p<0.011). Interestingly, the leak site was at the proximal compartment of the sleeve in all patients. RLSG reported lower quality of life scores (SF-12 physical component scores 75.9 vs 88%, p = 0.001), satisfaction (69 vs 93%, p = 0.001) and more frequent regurgitation (58% vs 42%, p = 0.034).


The authors concluded that longer-term re-operation rates are elevated compared to PLSG, with four variables predicted worse outcomes: eroded band, multiple prior bands, severe oesophageal dysmotility and elevated baseline weight.


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Hernia Repair in the Bariatric Patient: A Systematic Review and Meta-Analysis

Investigators from the University of South Florida Morsani College of Medicine, FL, have suggested a concomitant approach is appropriate for hernias that the surgeon feels do not require mesh, while the staged (bariatric surgery first) approach is more appropriate if the hernia requires mesh placement.


Reporting in SOARD, the meta-analysis aimed to determine which surgical approach is best for bariatric patients with hernias. A total of 27 studies included with 8,548 staged patients (6,458 BS-first) and 3,528 concomitant patients. The concomitant approach was associated with decreased odds of experiencing SSI, reoperation and seromas.


The staged approach (BS-first) was associated with decreased odds of mesh infection. The single-arm studies suggest a lower incidence of hernia recurrence in a staged BS-first approach than in a concomitant approach.


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Single Incision Versus Conventional Multiport Laparoscopic Sleeve Gastrectomy: Meta-Analysis and Systematic Review

Single-port laparoscopic sleeve gastrectomy (SILSG) is a viable alternative procedure to multiport conventional sleeve gastrectomy (CLSG) with comparable outcomes and better cosmetic satisfaction scores, according to the outcomes of a meta-analysis and systematic review by researchers from King's College Hospital, London, and the American University of Beirut Medical Center, Beirut, Lebanon.


Reporting in Cureus, they found 14 articles that met the inclusion criteria and were included in the meta-analysis. They noted that the average body mass index (BMI) was 40 for the multiport group and 42.2 for the single-port group. The mean operative time ranged from 42 to 170 min in the multiport group and from 45 to 148.7 min in the single-port group with no statistically significant difference between the two procedures (p=0.2). From the 14 studies included, ten discussed the length of hospital stay, involving a total of 1,174 patients in the multiport group and 1,157 in the single-port group. The mean length of hospital stay was comparable for both groups ranging from 1.75 to six days in the multiport group and from 1.7 to five days in the single-port group (p=0.24).


“The findings of this systematic review indicate that SILSG is technically feasible and increasingly practiced internationally. It appears to yield clinical outcomes comparable to those of conventional multiport sleeve gastrectomy,” they concluded. “While we caution against drawing definitive conclusions from this study, we believe there is a viable future for single-incision laparoscopic surgery as more data emerge on its safety and feasibility.”


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Dasiglucagon Treatment for Postprandial Hypoglycemia After Gastric Bypass: A Randomized, Double-Blind, Placebo-Controlled Trial

Compared with placebo, four weeks of self-administered dasiglucagon effectively reduced clinically relevant hypoglycemia in individuals who had undergone Roux-en-Y gastric bypass surgery, according to Danish researchers.


Reporting in Diabetes Care, they conducted a randomized, double-blind, placebo-controlled, crossover, proof-of-concept study that included 24 individuals who had undergone Roux-en-Y gastric bypass surgery (n=23 women) with continuous glucose monitor–verified postbariatric hypoglycemia (≥15 min at <3.9 mmol/L three or more times per week) randomly assigned to two treatment periods of four weeks of self-administered subcutaneous dasiglucagon at 120 μg or placebo.


Compared with placebo, treatment with dasiglucagon significantly reduced time in level 1 hypoglycemia by 33% (−1.2 percentage points; 95% CI −2.0 to −0.5; p=0.002) and time in level 2 hypoglycemia by 54% (−0.4 percentage points; 95% CI −0.6 to −0.2; p<0.0001). Furthermore, dasiglucagon corrected hypoglycemia within 15 min in 401 of 412 self-administrations, compared with 104 of 357 placebo self-administrations (97.3% vs. 29.1% correction of hypoglycemia rate; p<0.001). Dasiglucagon was generally well tolerated, with mostly mild to moderate adverse events of nausea.


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Is Open-Capsule Proton Pump Inhibitor Associated with Faster Healing Time for Marginal Ulceration After Roux-en-Y Gastric Bypass?

Investigators from the Cleveland Clinic Foundation, Cleveland, OH, have reported open-capsule PPI (OC-PPI) significantly improved marginal ulcer (MU) healing times compared to intact-capsule PPI (IC-PPI) in RYGB patients.


Writing in SOARD, they compared healing times of MU after RYGB when treated with OC- versus IC-PPI in 108 patients (38 received OC-PPI and 70 received IC-PPI). Treatment with OC-PPI significantly decreased MU healing time compared to IC-PPI (146.18 vs. 226.14 days [p=0.018]). However, when stratified by PPI potency, the positive effect of opening the capsule lost significance. In a subgroup analysis comparing therapy with similar PPI potency, the MU healing time did not differ with respect to administration method.


They concluded these results highlight the need for a prospective, randomised trial to compare the true effect of administration method.


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