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Journal Watch 31/01/2024

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 real-time patient-reported outcomes, RYGB vs LSG, MBS cures NASH, progression or non-progression to bariatric surgery, decreasing postoperative constipation, post-op weight loss is sex- and procedure-dependent, GLP1 agonists may result in a lower risk of major adverse liver outcomes and post-surgical Saudi female sexual dysfunction, and more (please note, log-in maybe required to access the full paper).

Pre-surgical Factors Related to Latent Trajectories of 5-Year Weight Loss for a Diverse Bariatric Surgery Population

US researchers have reported that bariatric practices should focus less on the pre-surgical period for predictors of long-term weight loss and begin efforts to monitor real-time patient-reported outcomes to help design intervention strategies for patients who either do not lose an expected amount of weight or who begin to experience weight recurrence.

Writing in SOARD, the Bariatric Experience Long Term (BELONG) study was designed to use a theoretical model to examine determinants of weight loss and recurrence. In total, 1,338 patients who had surgery were surveyed before surgery to measure factors related to median percent total weight loss (%TWL) over five years (n=1,024 (76.5% of the sample).

For both gastric sleeve (n=733) and bypass (n=291) operations, the authors identified latent trajectories of median %TWL were found corresponding to most, moderate, and least %TWL. Sleeve trajectories were distinguished by body mass index at surgery and geocoded environmental factors. Bypass trajectories varied by self-reported and geocoded environmental factors, comorbidity burden, race, experiential avoidance and weight control strategies.

The researchers concluded that future research should examine the role of the built and perceived environment in surgical weight loss.

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Comparison of Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass

A randomised clinical trial of 1,735 patients undergoing primary bariatric surgery has found that both SG and RYGB were performed with a low perioperative risk without clinically significant differences between groups.

The BEST Study Group, writing in JAMA Network Open, compared the perioperative complications as all adverse events and serious adverse events (Clavien-Dindo grade >IIIb) assessed and 90-day mortality. Patients underwent SG (n=878) or RYGB (n=857).

The 30-day readmission rate was 3.1% after SG and 4.0% after RYGB (p=0.33). There was no 90-day mortality. The 30-day incidence of any adverse event was 40 (4.6%) and 54 (6.3%) in the SG and RYGB groups, respectively (p=0.11). Corresponding figures for serious adverse events were 15 (1.7%) for the SG group and 23 (2.7%) for the RYGB group (p=0.19).

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Can Nonalcoholic Steatohepatitis Be Surgically Cured? Liver Histologic Comparison After Metabolic Surgery Versus Usual Care

Patients with nonalcoholic steatohepatitis (NASH) who had metabolic surgery experienced simultaneous NASH resolution and fibrosis improvement in half of patients, according to investigators led by the Cleveland Clinic, Cleveland, OH.

Writing in the Annals of Surgery, the authors compared histologic outcomes in patients with fibrotic NASH and obesity after metabolic surgery versus nonsurgical care. In total, 133 patients (42 metabolic surgery and 91 nonsurgical controls) had a repeat liver biopsy with a median interval of two years. Overlap weighting provided balance for baseline histologic disease activity, fibrosis stage, and time interval between liver biopsies. In overlap-weighted patients, 50.1% in the surgical and 12.1% in the nonsurgical group met the primary endpoint (p<0.001).

Importantly, NASH resolution and fibrosis improvement occurred in 68.5% and 64.1% of surgical patients, respectively. Surgical and nonsurgical patients who met the primary endpoint lost more weight than their counterparts who did not meet the primary endpoint.

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Factors associated with progression or non-progression to bariatric surgery in adults: A systematic review

Researchers from the University of Adelaide, Adelaide, Australia, has reported that there were no factors reliably associated with progression or non-progression to bariatric surgery.

Writing in Obesity reviews, this systematic review was conducted to deduce the factors associated with progression or non-progression to bariatric surgery.

They identified 57 studies with 15 key factors were found: age, sex, BMI, race and ethnicity, distance to clinic, socio-economic status, insurance coverage, physical health, psychological health, eating history and habits, substance use and smoking, social influence and relationships, pre-surgery process and requirements, surgery-related concerns and choice of surgery.

In addition, six less frequently studied factors were identified: emergency room visitation, COVID-19 virus, health literacy, appearance perceptions, time-off work and stigma related to surgery.

Further studies are required to elucidate potential inequities in bariatric surgery access and educate policymakers and health professionals, the researchers concluded.

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Efficacy of Bowel Regimen in Decreasing Postoperative Constipation in Bariatric Surgery Patients

The implementation of a polyethylene glycol (PEG)-based bowel regimen did not eliminate self-reported constipation, according to researchers from Stony Brook University Hospital, Stony Brook, NY. However, there were significant differences in rates of constipation-related ED visits and hospital readmissions, suggesting that the bowel regimen decreases rates of severe constipation.

Writing in Obesity Surgery, this retrospective study explored the efficacy of PEG in reducing constipation frequency and severity after bariatric surgery.

Patients during the first 3 months after PEG implementation were surveyed for postoperative constipation. For the year after implementation, patients were followed for 30-day emergency room visits or hospitalisation secondary to constipation. This cohort was compared to historical controls from the previous year. Student t-tests were used for statistical analysis.

After three-months, 28/49 (57.14%) patients fully completed the bowel regimen. In total, 0/56 (0%) patients reported preoperative constipation and 5/28 (17.9%) patients reported constipation at the three-week follow-up. In the one-year post-implementation cohort, 2/234 (0.85%) patients had constipation-related occurrences at 30-day follow-up, compared to 8/219 patients (3.65%) in the historical cohort (p=0.04).

Nevertheless, the authors stated patient compliance in this study was limited and future work should aim towards increasing compliance.

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Sex- and operation-dependent effects on five-year weight loss results of bariatric surgery

Weight loss after bariatric surgery is sex- and procedure-dependent, according to researchers from Vanderbilt University Medical Center, Nashville, TN, and there is an association suggesting a clinically insignificant difference in weight loss between RYGB and SG among male patients at both the two and five-year post-surgery periods.

Writing in SOARD, this retrospective, observational cohort study including RYGB (n=5,057) and VSG (n=2,041) patients from a single, academic health centre.

TWL demonstrated a strong sex-by-procedure interaction, interestingly women had a significant advantage with RYGB compared to SG (p<0.001) and although males also experienced greater TWL over time with RYGB or SG, but the difference was less and clinically insignificant (p<0.001; p-interaction between sex and procedure type=0.0001]. Patients with diabetes lost less weight compared to those without (p<0.0001).

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Glucagon-like peptide-1 receptor agonists and risk of major adverse liver outcomes in patients with chronic liver disease and type 2 diabetes

Patients who take GLP1 agonists with chronic liver disease and type 2 diabetes may result in a lower risk of major adverse liver outcomes (MALO), according to Karolinska Institutet, Stockholm, Sweden.

Writing in BMJ, they sought to determine the long-term causal effect of GLP1 agonists on the risk of MALO (decompensated cirrhosis, hepatocellular carcinoma, liver transplantation or MALO-related death) in this group of patients.

They reported that GLP1 agonist initiators had a ten-year risk of MALO at 13.3% (42/1026) vs 14.6% in non-initiators (1079/15 633) in intention-to-treat analysis. The corresponding 10-year per-protocol risk estimates were 7.4% (22/1026) and 14.4% (1079/15 633), respectively. The per-protocol risk estimates at six years were 5.4% (21/1026) vs 9.0% (933/15 633) and at 8 years 7.2% (22/1026) vs 11.7% (1036/15 633).

The authors concluded that their findings suggest GLP1 agonists are promising agents to reduce risk of chronic liver disease progression in patients with concurrent type 2 diabetes, although this needs to be corroborated in randomised trials.

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Saudi Female Sexual Dysfunction After Bariatric Surgery: A Cross-Sectional Survey

Investigators from Saudi Arabia have reported that bariatric surgery was associated with the improvement of female sexual function.

Writing in Cureus, the aim of the study was to investigate the effects of substantial weight loss after bariatric surgery on sexual function, psychological health, and the overall quality of sexual life in a group of Saudi females, using the Sexual Quality of Life for Female (SQoL-F) and the Female Sexual Function Index (FSFI) questionnaires to collect data.

In total, 100 participants were included in this study, all the samples underwent vertical sleeve gastrectomy, their mean age was 36.7±9.3, 94% (n=94) of the respondents had high school education or above, 50.0% (n=50) were unemployed, and around 13% (n=13) of the samples had a psychiatric history.

The median of the FSFI and SQoL-F was 47.0 and 24.5, respectively. Approximately 66% of the respondents agreed that their sexual lives improved after surgery, 22% did not feel any difference before and after surgery, and 9% witnessed deterioration. In total, 61.0% had female sexual dysfunction (FSD) (25% had no dysfunction afterward, 45% had mild dysfunction, 27% suffered mild to moderate dysfunction, and only 2% had severe dysfunction).

Regarding SQoL-F, the mean score was 5.59 for sexual repression, 6.1 for self-worthlessness, 18.56 for sexual and relationship satisfaction, and 16.4 for psychological feelings.

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