Journal Watch 26/3/2025

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 tirzepatide betters BMS, BMS and the path to kidney transplantation, management of gastric leak after LSG, White Paper on the use of potassium-competitive acid blockers (P-CABs) in the treatment of GERD, suicide and self-harm events with GLP-1s, GLP-1RAs is associated with increased retention of gastric contents, and maternal and neonatal outcomes of pregnancies post-BMS, and more (please note, log-in maybe required to access the full paper).

Comparing clinical outcomes of adults with obesity receiving tirzepatide versus bariatric metabolic surgery: A multi-institutional propensity score-matched study

Researchers from Taiwan have reported tirzepatide demonstrated superior clinical outcomes compared with BMS in adults with obesity, including significant reductions in all-cause mortality, MACEs and MAKEs.

Reporting in Diabetes, Obesity and Metabolism, this real-world study compared clinical outcomes between tirzepatide treatment and BMS in adults with obesity. After exclusions and 1:1 propensity score matching (PSM), 84884 matched pairs were analysed.

The incidence of all-cause mortality was 0.19 per 100 person-years in the tirzepatide group compared with 0.57 in the BMS group. Tirzepatide was associated with a significantly lower risk of all-cause mortality compared with BMS (p < 0.0001). The mortality benefits were consistent across age groups, genders and BMI categories. Tirzepatide also reduced the risk of MACEs (p < 0.0001) and MAKEs (p < 0.0001).

These findings suggest that tirzepatide may serve as an effective non-surgical alternative to BMS, with broad applicability across diverse patient populations.

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Metabolic and Bariatric Operation and the Path to Kidney Transplantation

BMS significantly improves access to kidney transplantation and long-term survival for obese patients with end-stage renal disease (ESRD), US researchers have reported.

The retrospective cohort study, published in the Journal of the American College of Surgeons, used data from 64 US healthcare organizations included 132,989 individuals with obesity (BMI ≥ 30 kg/m²) and ESRD requiring dialysis, of whom 6,263 (4.6%) underwent BMS.

Propensity score matching produced 1:1 matched groups of 6,238 patients each, analysed for ten years. Primary outcomes included rates of kidney transplant waitlist placement, transplantation and overall mortality. Secondary outcomes focused on 22,979 transplant recipients, including 1,701 (7.4%) patients who underwent BMS, to evaluate post-transplant adverse events.

During a median follow-up of 33.3 months (MBS) and 28.5 months (controls), patients who underwent BMS demonstrated higher rates of waitlist placement (19.12% vs 10.53%, hazard ratio [HR] 1.800, 95% CI 1.636 to 1.980, p < 0.001) and transplantation (27.06% vs 16.09%, HR 1.712, 95% CI 1.584 to 1.852, p < 0.001) at 10 years, with benefits evident within 1-month post-operation.

Mortality was lower in the BMS group (30.55% vs 36.44%, HR 0.768, 95% CI 0.723 to 0.817, p < 0.001). In transplant recipients, patients who underwent BMS had lower cardiovascular complications (37.3% vs 40.6%, risk ratio 0.92, p = 0.007) and all-cause mortality (16.70% vs 20.88%, HR 0.82, p < 0.001), with no significant differences in graft rejection or failure.

Patients who underwent MBS demonstrated notable improvements in cardiovascular health, potentially leading to a better quality of life and survival and these findings suggest that MBS should be considered as part of the comprehensive care for this high-risk population.

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Management of Gastric Leak after Sleeve Gastrectomy: A 13-year Experience in a Tertiary Referral Center

Investigators from the Centre Hospitalier Universitaire de Rouen, Rouen, France, have said that surgical intervention alone may be sufficient in 30% of cases of gastric leaks after sleeve gastrectomy however, for most patients, a multidisciplinary approach in a referral centre is recommended.

Published in Obesity Surgery, they retrospectively analysed the characteristics, treatments, and outcomes of patients managed for gastric leaks after sleeve gastrectomy at their centre. From 2009 to 2022, 43 patients were managed in their centre for gastric leak after sleeve gastrectomy. Among them, 21 patients were referred from other centres.

In 86% of cases, the gastric leak developed within the first 15 days. It was located at the proximal staple line in 84% of cases. Associated stenosis or twisting was observed in 18% of cases. Surgical treatment alone was used in 32% of patients, while 59% received combined management. Three patients (6.8%) were managed exclusively by endoscopy. The overall healing rate was 91%, with a median healing time of 89 days.

The management of gastric leaks after sleeve gastrectomy depends on their location and clinical presentation and should not be limited to a solely endoscopic or surgical approach, they concluded.

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Maternal and neonatal outcomes of pregnancies after metabolic bariatric surgery: a retrospective population-based study

French researchers have reported that post-BMS compared with pre-BMS or control pregnancies were associated with reduced risk of maternal adverse outcomes but increased risk of neonatal adverse events.

Reporting in The Lancet Regional Health Europe, they compared 55,941 post-BMS pregnancies with 223,712 controls matched on delivery date, parity, age, obesity, hypertension, diabetes, and socio-economic status (1:4 ratio) using generalized estimating equations. We also compared 11,777 post-BS pregnancies with 11,777 pre-BS pregnancies in the same women, using conditional logistic regression.

Post-BS pregnancies were associated with reduced risk of gestational hypertension, preeclampsia and gestational diabetes vs the control group. The risk of SGA was increased vs controls and pre-BS pregnancies. Risk of prematurity was increased compared with controls but not pre-BS pregnancies. Compared with controls, risk of stillbirth was increased mediated by SGA, as was perinatal death mediated by both prematurity and SGA.

The risks of SGA and prematurity are higher with shorter intervals between BS and conception, gastric bypass and malnutrition, therefore post-BS pregnancies could be considered high risk, requiring close nutritional and obstetrical monitoring, the researchers concluded.

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Effects of Glucagon-Like Peptide-1 Receptor Agonists on Upper Gastrointestinal Endoscopy: A Meta-Analysis

An international team of researchers has found that the use of GLP-1RAs is associated with increased retention of gastric contents (RGC) and more frequent aborted procedures during upper endoscopy, however, the adverse event and aspiration rates do not seem different.

Reporting in Clinical Gastroenterology and Hepatology, their analysis included 13 studies involving a total of 84,065 patients. Patients receiving GLP-1RA therapy exhibited significantly higher rates of RGC. In addition, rates of aborted and repeated procedures were higher in the GLP-1RA user group. However, no significant differences were found in AE and aspiration rates between the 2 groups.

The authors conclude that adjusting fasting time instead of routinely withholding GLP-1RAs could be reasonable in these patients.

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Suicide and Self-Harm Events With GLP-1 Receptor Agonists in Adults With Diabetes or Obesity - A Systematic Review and Meta-Analysis

An international team of researchers  have concluded that it is unlikely that there will be an increase in the very low incidence of suicide-related adverse events among individuals receiving GLP-1 RAs within the context of RCTs.

The study, published in JAMA Psychiatry, evaluated the risk of suicidality and self-harm in randomised, placebo-controlled trials of GLP-1 RAs in adults with diabetes or obesity. A total of 27 of 144 RCTs meeting inclusion criteria systematically recorded suicide and/or self-harm-related events and included 32,357 individuals receiving GLP-1 RAs and 27,046 treated with placebo, over 74,740 and 68,095 person-years of follow-up, respectively.

Event incidence was very low in the GLP-1 RA (0.044 per 100 person-years) and placebo (0.040 per 100 person-years) groups, with no statistically significant difference (rate ratio [RR], 0.76; 95% CI, 0.48-1.21; p=0.24). Subgroup analyses did not suggest differences in outcomes based on diabetes status or GLP-1 RA used.

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American Foregut Society White Paper Report on the Use of Potassium-Competitive Acid Blockers in the Treatment of Gastroesophageal Reflux Disease

US researchers have published a White Paper on the use of potassium-competitive acid blockers (P-CABs) in the treatment of gastroesophageal reflux disease (GERD), in Foregut: The Journal of the American Foregut Society.

P-CABs can inhibit gastric acid production faster, longer and more potently than PPIs. In November 2023, vonoprazan became the first P-CAB to receive FDA approval for GERD treatment.

Subsequently, the American Foregut Society  convened a 13-member panel of expert gastroenterologists and foregut surgeons to produce a white paper report on how clinicians might use P-CABs to treat GERD. After conducting a comprehensive literature review, panelists proposed 20 total statements on key aspects of P-CAB pharmacokinetics, use of P-CABs for erosive esophagitis and non-erosive reflux disease, and P-CAB safety, as well as 13 recommendation statements on how to use a P-CAB in clinical practice.

Twenty-three statements were finally accepted (3 on P-CAB pharmacokinetics, 5 on P-CABs for erosive esophagitis, 3 on P-CABs for non-erosive reflux disease, 4 on P-CAB safety, 8 on how to use P-CABs in clinical practice).

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