Journal Watch 26/01/2022

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 a study that reports bariatric surgery reduces the risk of follow-up overall coronary revascularisation, the latest paper from the PCORnet Bariatric Study, Lipocalin -2 level and hepatic steatosis after LSG, a comparison of opioid free and loco-regional anaesthesia after LSG under ERAS protocol, a pilot study on postural stability after bariatric surgery, 12 year outcomes from the RALF trial and the study protocol of an RCT assessing novel wireless remote monitoring system versus current standard of care to detect short-term complications after bariatric surgery (please note, log-in maybe required to access the full paper).

Bariatric surgery reduces the risk of follow-up overall coronary revascularization

Researchers from Stony Brook University Medical Center, Stony Brook, NY, have reported that bariatric surgery is associated with reduced risk of future coronary revascularization (CR), percutaneous coronary revascularization (PCI) and coronary artery bypass grafting (CABG).

Writing in SOARD, their study explored the impact of metabolic surgery on the risk of follow-up CR; including PCI and CABG. They carried out a retrospective analysis of patients living with obesity between 2006 and 2015. Patients were divided into those with history of metabolic surgery and those without. Patient were also stratified by bariatric surgery type. All study groups were followed till 2018 and for at least three years to monitor the development of the primary endpoint— any CR including PCI or CABG.

The study population living with obesity was 515,307 patients; 95,901 with history of surgery versus 419,406 matched patients without. The group with history of surgery had a reduced risk of future CR (p<0.0001), PCI (p<0.0001) and CABG (p<0.0001).

In sub-group analysis, laparoscopic adjustable gastric banding compared to Roux-en-Y Gastric Bypass (RYGB) was associated with higher follow-up CR and PCI.

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Preoperative Depression Status and Five Year Metabolic and Bariatric Surgery Outcomes in the PCORnet Bariatric Study Cohort

Published in the Annals of Surgery, investigators writing on behalf of the PCORnet Bariatric Study Collaborative, examine whether depression status before metabolic and bariatric surgery (MBS) influenced five-year weight loss, diabetes and safety/utilisation outcomes in the PCORnet Study.

Data were extracted from 23 health systems on 36,871 patients who underwent sleeve gastrectomy (SG; n=16,158) or gastric bypass (RYGB; n=20,713) from 2005–2015. Patients with and without a depression diagnosis in the year prior to MBS were evaluated for % total weight loss (%TWL), diabetes outcomes, and postsurgical safety/utilisation (reoperations, revisions, endoscopy, hospitalisations, mortality) at one, three and five years after MBS.

A total of 27.1% of SG and 33.0% of RYGB patients had preoperative depression, and they had more medical and psychiatric comorbidities than those without depression. At five years of follow-up, those with depression, versus those without depression, had slightly less %TWL after RYGB, but not after SG (p=0.04). However, patients with depression had slightly larger HbA1c improvements after RYGB but not after SG (p=0.04). Baseline depression did not moderate diabetes remission or relapse, reoperations, revision, or mortality across operations; however, baseline depression did moderate the risk of endoscopy and repeat hospitalization across RYGB versus SG. The effects of depression were clinically small compared to the choice of operation.

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The relationship between Lipocalin-2 level and hepatic steatosis in obese patients with NAFLD after bariatric surgery

Published in the journal Lipids in Health and Disease, researchers from Tongji University School of Medicine, Shanghai, China, on analysed serum Lipocalin-2 (LCN2) levels of obese patients with nonalcoholic fatty liver disease (NAFLD) to determine the relationship of hepatic steatosis improvement with LCN2 levels after laparoscopic sleeve gastrectomy (LSG).

The study included 23 patients who underwent LSG. Anthropometric and biochemical parameters and serum LCN2 levels were determined at baseline and those at six-month post-LSG.

Liver function, glucose and lipid levels were significantly improved after LSH. Serum LCN2 levels significantly decreased (119.74 ± 36.15 ng/mL vs. 87.38 ± 51.65 ng/mL, p=0.001). Decreased CAP indicated a significant decrease in liver fat content (358.48 ± 46.13 dB/m vs. 260.83 ± 69.64 dB/m, P<0.001). The decrease in LCN2 levels was significantly related to the reduced hepatic fat content and improvement in steatosis grade after adjusting for gender, age, and BMI decrease.

The authors concluded that serum LCN2 levels are related to obesity and NAFLD. The decreased serum LCN2 levels could be an indicator of hepatic steatosis improvement.

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Combined opioid free and loco-regional anaesthesia enhances the quality of recovery in sleeve gastrectomy done under ERAS protocol: a randomized controlled trial

A team led by researchers at Zagazig University, Zagazig, Egypt, writing in BMC Anesthesiology, report that while regional anaesthesia achieved most of the intraoperative analgesia, avoiding intraoperative opioids with the help of this opioid-free anaesthesia (OFA) protocol was able to improve several sensible parameters of postoperative functional recovery, thus improving knowledge on the OFA effects.

In all patients, anaesthesia was conducted with an i.v. induction with propofol (2mg. kg-1), myorelaxation with cisatracurium (, in addition to an ultrasound-guided bilateral oblique subcostal transverse abdominis plane block. In addition, patients in the OFA group (n=51) received i.v. dexmedetomidine 0.1 μ and ketamine (0.5mg. kg-1) at induction, then dexmedetomidine 0.5μg. kg-1.h-1, ketamine, and lidocaine 1mg. kg-1.h-1 for maintenance, while patients in the multimodal analgesia (MMA) group (n=52) had only i.v. fentanyl (1μg. kg-1) at induction.

At the 6th hour, the QoR-40 was higher in the OFA than in the MMA group (respective median [IQR] values: 180 [173–195] vs. 185 [173–191], p < 0.0001), but no longer difference was found at the 24th hour (median values = 191 in both groups). OFA also significantly reduced postoperative pain and morphine consumption (20 mg [1–21] vs. 10 mg [1–11], p = 0.005), as well as time to oral fluid tolerance (238 [151–346] vs. 175 min [98–275], p = 0.022), and readiness for discharge (505 [439–626] vs. 444 min [356–529], p = 0.001), but did not influence time to ambulate.

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Bariatric surgery and exercise: A pilot study on postural stability in obese individuals

Reporting in PLOS One, researcher from Prague, Czech Republic, have analysed the changes in postural stability of individuals with obesity after bariatric surgery, and the effect of three months of regular exercise on the static postural stability.

Twenty-two subjects (seven females) aged 31 to 68 years (Body mass index 35–55 kg.m-2) completed the study. Participants were divided into two groups: one group participated in an exercise programme after the bariatric surgery (n=10; age 48.9 ± 7.5 years; Body mass index 42 ± 5.6 kg.m-2) while the second group did not exercise at all after bariatric surgery (n=12; age 44.7 ± 13.6 years, Body mass index 42.6 ± 6.0 kg.m-2).

Static postural stability was measured using a Tekscan MobileMat pressure plate before and four months after the bariatric surgery. The exercise programme included exercising three times a week including: one hour of strengthening, one hour of aerobic group exercise and at least one session of individual exercise at home.

They reported that there were no significant differences in Center of force sway, Center of force ranges and average speed before and four months after bariatric surgery. No effect of exercise was found. Post-pre differences of some parameters were negatively related to age (r from—0.46 to—0.72). Further studies are needed to explore this topic in depth.

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Randomized controlled trial of robotic-assisted versus conventional laparoscopic fundoplication: 12 years follow-up

Researchers from Heidelberg University Hospital, Heidelberg, Germany, examined the feasibility and safety of robotic-assisted (RALF) and conventional laparoscopic fundoplication (CLF). The aim of the study was to assess long-term disease-specific symptoms and quality of life (QOL) in patients with gastroesophageal reflux disease (GERD) treated with RALF or CLF after 12 years in the randomised ROLAF trial.

In the ROLAF trial, 40 patients with GERD were randomized to RALF (n=20) or CLF (n=20) between August 2004 and December 2005. At 12 years after surgery, all patients were invited to complete the standardized Gastrointestinal Symptom Rating Scale (GSRS) and the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD). Failure of treatment was assessed according to Lundell score.

The GSRS score was similar for RALF (n=15) and CLF (n=15) at 12 years´ follow-up (2.1±0.7 vs. 2.2±1.3, p=0.740). There was no difference in QOLRAD score (p=0.656) and the QOLRAD score sub items. Long-term failure of treatment according to the definition by Lundell was not different between RALF and CLF [46% (6/13) vs. 33% (4/12), p=0.806].

They concluded that the long-term results 12 years after surgery showed no difference between RALF and CLF regarding postoperative symptoms, QOL and failure of treatment. Relief of symptoms and patient satisfaction were high after both procedures on the long-term.

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Postbariatric EArly discharge Controlled by Healthdot (PEACH) trial: study protocol for a preference-based randomized trial

Investigators from the Catharina Hospital, Eindhoven, The Netherlands, will evaluate a combined outcome measurement in outpatient bariatric surgery supplemented by a novel wireless remote monitoring system versus current standard of care to detect short-term complications.

Writing in Trials, the study protocol explains that the trial will include a total of 200 patients with multidisciplinary team approval for primary bariatric surgery and will be assigned based on their preference to one of two postoperative trajectories: (1) standard of in-hospital care with discharge on the first postoperative day or (2) same day discharge with ongoing telemonitoring up to seven days after surgery.

The device (Healthdot R Philips) transfers heart rate, respiration rate, activity, and body posture of the patient continuously by LoRaWan network to our hospital’s dashboard (Philips Guardian). The primary outcome is a composite outcome measure within 30 days postoperative based on mortality, mild and severe complications, readmission, and prolonged length-of-stay. Secondary outcomes include patients’ satisfaction and data handling dimensions.

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