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Journal Watch 3/4/2024

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 30 years Biliopancreatic diversion outcomes, Improvements in discharge education for bariatric patients would alleviate unnecessary burdens on emergency departments, capsule-based pH test prior to sleeve gastrectomy may aid procedure choice, higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery, bariatric and kidney transplant surgery, understanding coping mechanisms for weight stigma, and hepatic branch of the Vagus nerve in upper gastrointestinal surgeries, and more (please note, log-in maybe required to access the full paper).

Biliopancreatic diversion for severe obesity: long-term weight maintenance and occurrence of nutritional complications are two facets of the same coin

Biliopancreatic diversion leads to good and sustained weight maintenance up to 30 years with low perioperative risk, but at the cost of a high long-term prevalence of nutritional complications, according to researchers from the University of Genoa, Genoa, Italy.

Reporting in the British Journal of Surgery, their retrospective single-centre study used data from a prospectively collected database on a sample of 199 consecutive patients (136 female, 63 male) who had surgery between November 1992 and April 1994. Outcomes assessed included overall survival, long-term weight loss and weight maintenance, remission of obesity-related co-morbidities, and short- and long-term surgical and/or nutritional or metabolic complications.

The mean age at operation was 38 (range 14–69) years and mean preoperative BMI was 48.7 (32.0–74.3) kg/m2. At baseline, 91 of 199 patients (45.7%) had type 2 diabetes. At 20 and 30 years, 122 (61%) and 38 (19%) of the 199 patients respectively were available for follow-up. At 30 years, the overall mortality rate was 12% (23 of 199). Surgical complications were concentrated in the short-term follow-up, whereas nutritional or metabolic complications increased progressively over time. A nutritional complication was diagnosed in 73 of 122 patients (60%) at 20 years and 28 of 38 (74%) at 30 years.

Weight loss and glycaemic control were maintained throughout the follow-up; mean % total weight loss was 32.8 (range 14.1–50.0) at 1 year and 37.7 (range 16.7–64.8) at 30 years. One patient presented with recurrence of type 2 diabetes at 20 and 30 years; there were no patients with new-onset type 2 diabetes.

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Examining emergency department utilization following bariatric surgery

Improvements in discharge education and early post-discharge communication to bariatric surgery patients would alleviate unnecessary burdens on emergency departments (EDs) allowing them to focus on the acutely ill, researchers from Geisinger Medical Center, Danville, PA, have reported.

Writing in Surgical Endoscopy, their retrospective study sought to quantify ED utilisation following bariatric procedures to identify causes and areas of improvement. The study included 4,703 patients across eight hospitals who returned to the ED within 30 and 90 days, who were analysed for relation to surgery and preventability.

In total, 907 (19.3%) visited the ED at least once within 90 days and 350 (7.4%) required hospital readmission. The median length between discharge and ED visit was 19 days. Under 50% of patients called prior to ED presentation and 61% of these ED visits resulted in discharge.

While hospital readmissions following MBS have been scrutinised in literature, the researchers concluded, the investigation of ED utilisation remains scarce.

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Use of Preoperative Endoscopic Capsule-Based pH Testing Before Bariatric Surgery

Using a capsule-based pH test prior to sleeve gastrectomy may aid in the procedure decision and informed consent process, according to investigators from Prisma Health, Greenville, SC.

Writing in the Journal of the American College of Surgeons, they compared capsule-based pH testing vs GERD symptom scoring to determine extent of preoperative GERD to aid in procedure selection for bariatric surgery.

During initial consultation for bariatric surgery, a validated GERD symptom subjective survey was administered. Sixty-two patients demonstrating interest in sleeve gastrectomy or had a history of reflux underwent upper endoscopy with capsule-based pH testing.

Median BMI was 43.4 kg/m2 and 66.1% of patients were not taking a proton-pump inhibitor before performance of pH testing. They reported that there was negligible linear association between the objective DeMeester score obtained by capsule-based pH probe and GERD symptom survey scores. Median GERD symptom survey scores did not differ between patients with and without a diagnosis of GERD based on pH testing (all p values >0.11).

“Patients with significant preoperative GERD may be at higher risk for future GERD-related sleeve complications,” they concluded. “Capsule-based pH testing may prove to be superior to subjective symptom scoring systems in this patient population.

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Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study

There is a higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery compared with after sleeve gastrectomy, according to researchers from Kershus University Hospital HF, Lørenskog, Norway.

Reporting in BMC Pregnancy and Childbirth, the researchers assessed the impact of bariatric surgery on micronutrients in post-bariatric pregnancy and possible differences between gastric bypass surgery and sleeve gastrectomy. The study included 204 pregnant women (bariatric surgery n=59 [gastric bypass surgery n=26, sleeve gastrectomy n=31, missing n=2] and controls n=145) from Akershus University Hospital.

They found that women with bariatric surgery had a higher pre-pregnant BMI than controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m2, p<0.001), although there were no differences between groups regarding maternal weight gain (bariatric surgery 13.3 kg (9.6) vs. control 14.8 kg (6.5), p=0.228) or development of gestational diabetes (n=3 [5%] vs. n=7 [5%], p=1.000). Mean levels of vitamin K1 was lower after bariatric surgery compared with controls (0.29 [0.35] vs. 0.61 [0.65] ng/mL, p<0.001) and there was a fivefold increased risk of vitamin K1 deficiency in post-bariatric pregnancies compared with controls (OR 5.69 [1.05, 30.77] p=0.044), compared with sleeve gastrectomy having a previous gastric bypass surgery was associated with higher risk of vitamin K1 deficiency (p=0.030).

The researchers concluded that vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be explored in future studies.

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Collaborative Approach Toward Transplant Candidacy for Obese Patients with End-Stage Renal Disease

A collaborative approach between bariatric and transplant surgery teams offers a pathway toward transplant for patients with obesity and ESRD, and potentially alleviates existing healthcare disparities, researchers from Tulane University School of Medicine, New Orleans, LA, have found.

Reporting in the Journal of the American College of Surgeons, they studied the outcomes of these patients after MBS and transplant surgery. One hundred eighty-three patients with ESRD were referred to the bariatric team by the transplant team between January 2019 and June 2023. Of these, 36 patients underwent MBS (20 underwent Roux-en-Y gastric bypass and 16 underwent sleeve gastrectomy), and 1ten underwent subsequent transplantation, with another 15 currently waitlisted. Both surgical teams shared resources, including dieticians, social workers, and a common database, for easy transition between teams.

The average number of hypertension medications decreased from two (range 2-4) pre-surgery to 1 (range 1 to 3) post-surgery. Similarly, haemoglobin A1C levels improved, with preoperative averages at 6.2 (range 5.4 to 7.6) and postoperative levels at 5.2 (range 4.6 to 5.8) All transplants are currently functioning, with a median creatinine of 1.5 (1.2 to 1.6) mg/dL (glomerular filtration rate 46 [36.3 to 71]).

They researchers concluded that ESRD patients who undergo MBS have unique complications to be aware of and the improvement in comorbidities may lead to superior post-transplant outcomes.

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‘My goal was to become normal’—A qualitative investigation of coping with stigma, body image and self-esteem long-term after bariatric surgery

Understanding adaptive coping strategies can be useful to develop interventions to reduce negative consequences of weight stigma on body image and self-esteem, according to Swedish researchers.

Writing in Clinical Obesity, they explored body image, self-esteem, weight stigma and coping strategies in 18 individuals who underwent MBS more than ten years ago. Using reflexive thematic analysis, two primary themes were identified: ‘Experiences of living with a stigmatised body’ and ‘Coping with weight stigma, body image and self-esteem’, and eight sub-themes.

They found patients had frequent experiences of weight stigma before bariatric surgery, the need for coping with stigma and body dissatisfaction before and after MBS, and how different coping strategies are related to participants' perceptions of their bodies and self-concepts.

They concluded that more adaptive coping strategies, such as confrontation and cognitive restructuring may facilitate more positive body image outcomes, than more ruminative and avoidant strategies.

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A Systematic Review and Meta-Analysis on the Impact of Preserving the Hepatic Branch of the Vagus Nerve in Upper Gastrointestinal Surgeries

Hepatic branch preservation is associated with favourable post-surgical metabolic outcomes, notably appetite preservation, researchers from Nanyang Technological University, Singapore, have reported.

Writing in the journal Foregut, this systematic review and meta-analysis compared hepatic nerve preservation and division during upper gastrointestinal surgery in 13 studies involving 3001 participants.

Hepatic branch preservation was linked to a decrease in appetite loss (OR 0.04, 95% CI 0.01-0.18), reflux symptoms (OR 0.16, 95% CI 0.06-0.43) and gallstone formation (OR 0.25, 95% CI 0.09-0.69). However, preservation was associated with an increased incidence of Clavien-Dindo Grade 2 complications (OR 1.73, 95% CI 1.01-2.96) in gastrectomies.

Preserving the hepatic branch may facilitate brain-liver crosstalk, thus, influencing homeostatic processes like appetite control and glucose metabolism. Reduced gallstone incidence is likely due to preservation of gallbladder motility and function, achieved through retention of parasympathetic innervation, they concluded.

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