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 IFSO/ASMBS guidelines for BMS, five-year outcomes from duodenal switch vs. single-anastomosis duodenal switch, bariatric surgery type may result in selective improvements in cognition during the first year following surgery, bariatric surgery type may result in improvements in cognition during the first year following surgery, the latest paper from the GENEVA Collaborators and the study protocol of the DIABAR-trial (please note, log-in maybe required to access the full paper).
2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery
The International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) and the American Society for Metabolic and Bariatric Surgery (ASMBS) have published the first new guidelines of international, evidence-based guideline recommendations for bariatric and metabolic surgery (BMS) in over 30 years. The guidelines were published in the journals Surgery for Obesity and Related Diseases (SOARD) and Obesity Surgery.
The guidelines were developed by 24 international experts in obesity, bariatric and metabolic Surgery, to provide healthcare practitioners with an overview of the current evidence-based recommendations. The guidelines replace the 1991 consensus statement from the National Institutes of Health and include multiple changes, including expanding the patient population for metabolic and bariatric surgery to include patients with type 2 diabetes and a BMI of 30kg/m2 or greater.
In summary, the guidelines include:
Metabolic and bariatric surgery is recommended for individuals with a BMI at or exceeding 35 kg/m2, regardless of presence, absence, or severity of co-morbidities.
Metabolic and bariatric surgery should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2.
BMI thresholds should be adjusted in the Asian population such that a BMI at or exceeding 25 kg/m2 suggests clinical obesity, and individuals with BMI at or exceeding 27.5 kg/m2 should be offered metabolic and bariatric surgery.
Long-term results of metabolic and bariatric surgery consistently demonstrate safety and efficacy.
Appropriately selected children and adolescents should be considered for metabolic and bariatric surgery.
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Duodenal Switch vs. Single-Anastomosis Duodenal Switch (SADI-S) for the Treatment of Grade IV Obesity: 5-Year Outcomes of a Multicenter Prospective Cohort Comparative Study
Spanish investigators have reported that at five years duodenal switch (DS) and single-anastomosis duodenal switch (SADI-S) allowed good weight control and resolution of comorbidities.
The study, published in Obesity Surgery, sought to compare the five-year outcomes of the two procedures in terms of weight loss; remission of comorbidities; nutritional status short- and long-term complications; postoperative mortality; and need for revisional surgery.
A total of 87 patients were included in the study, 43 submitted to DS and 44 to SADI-S, with similar basal characteristics, nutritional parameters and BMI. Short-term complications were similar for DS and SADI-S, both overall (11.8% vs. 11.6%) and ranged as Clavien-Dindo > II (4.5% vs. 4.7%), with no mortality. At five years, DS and SADI-S results were as follows: BMI 30.6 vs. 33.3 kg/m2 (p=0.023); %EWL 80.5% vs. 68.6% (p=0.006); and %TWL 42.1 vs. 36.0 (p=0.006). Comorbidity remission rates for DS and SADI-S were as follows: for diabetes 92.8% vs. 85.7%, hypertension 95.2% vs. 85.1%, sleep apnoea 75% vs. 73.3% and dyslipidaemia 76.4% vs. 73.3%. DS showed lower levels of vitamin B12, iron, vitamin E and zinc than SADI-S (p=<0.005). There were four surgical reinterventions (due to one internal hernia in the DS group and one internal hernia and two biliary refluxes in the SADI-S group) with no cases of persistent diarrhoea or malnutrition.
The authors concluded that DS achieved a greater weight loss compared to SADI-S, at the expense of longer operative time and lower vitamin and mineral levels.
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The relationship between weight loss and cognitive function in bariatric surgery
Writing in Surgical Endoscopy, authors from the Johns Hopkins University School of Medicine, Baltimore, MD, bariatric surgery type may result in selective improvements in cognition during the first year following surgery.
They investigated the relationship between weight loss and cognitive performance in patients one year following vertical sleeve gastrectomy (VSG, n=17) and Roux-en Y gastric bypass (RYGB, n=18) surgery and sought to determine whether preoperative cognitive performance predicted weight loss.
All patients completed a cognitive battery prior to and at two, 12, 24 and 52 weeks following surgery and scores from each task were assigned to one of the following cognitive domains: auditory attention, processing speed, memory, and executive functioning. Weight loss and cognitive scores for each domain were calculated and compared between cohorts.
They found RYGB surgery resulted in greater weight loss at one-year follow-up relative to VSG. Both VSG and RYGB procedures resulted in improved performance on different measures of auditory attention and both surgery groups improved across all processing speed tasks. Within the executive function domain, both groups showed improvements, but only the RYGB procedure resulted in improved performance in the Trail Making Test. Baseline auditory attention and memory performance predicted weight loss at 1 year following RYGB but not VSG surgery. Controlling for baseline cognitive performance, percent total weight loss predicted auditory attention at one-year following RYGB but not VSG surgery.
They concluded that presurgical cognitive performance as well as surgery type appears to influence weight loss outcomes.
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Handling of the Covid-19 Pandemic and Its Effects on Bariatric Surgical Practice: Analysis of GENEVA Study Database
The latest paper from the GENEVA (Global 30-day outcomes after bariatric surgery during the COVID-19 pandemic) Collaborators, published in Obesity Surgery, provides global, real-world data regarding the recovery of BMS services following the COVID-19 pandemic.
This latest paper is a subset analysis of the GENEVA study which was an international cohort study between 01/05/2020 and 31/10/2020. Data were specifically analysed regarding the timing of BMS suspension, patterns of service recovery, and precautionary measures deployed.
A total of 527 surgeons from 439 hospitals in 64 countries submitted data regarding their practices and handling of the pandemic. Smaller hospitals (with less than 200 beds) were able to restart BMS programmes more rapidly (time to BMS restart 60.8 ± 38.9 days) than larger institutions (over 2000 beds) (81.3 ± 30.5 days) (p=0.032). There was a significant difference in the time interval between cessation/reduction and restart of bariatric services between government-funded practices (97.1 ± 76.2 days), combination practices (84.4 ± 47.9 days), and private practices (58.5 ± 38.3 days) (p<0.001).
Precautionary measures adopted included patient segregation, utilisation of personal protective equipment, and preoperative testing. Following service recovery, 40% of the surgeons operated with a reduced capacity. Twenty-two percent gave priority to long waiters, 15.4% gave priority to uncontrolled diabetics, and 7.6% prioritised patients requiring organ transplantation.
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The effects of laparoscopic Roux-en-Y gastric bypass and one-anastomosis gastric bypass on glycemic control and remission of type 2 diabetes mellitus: study protocol for a multi-center randomized controlled trial (the DIABAR-trial)
Researcher from Denmark, Sweden and The Netherlands have initiated the DIABAR-trial - a randomised controlled trial to evaluate the glycaemic response after the RYGB and OAGB in patients with severe obesity diagnosed with T2DM.
DIABAR-trial is an open, multi-centre, RCT trial with ten years follow-up which will be performed in 220 patients who will randomised in a 1:1 ratio to undergo RYGB or OAGB. The primary outcome is glycaemic control at 12 months follow-up. Secondary outcome measures include weight loss, surgical complications, psychologic status and quality of life, dietary behaviour, gastrointestinal symptoms, repetitive bloodwork to identify changes over time, glucose tolerance and insulin sensitivity as measured by mixed meal tests, remission of T2DM, presence of non-alcoholic fatty liver disease/non-alcoholic steatohepatitis in liver biopsy, oral and faecal microbiome, cardiovascular performance, composition of bile acids and the tendency to develop gallstones.
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