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Journal Watch 6/09/2023

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 bariatric surgery and pulmonary hypertension, bougie size and weight loss, cost-effectiveness of AOMs in adolescents, cognition in PBH patients, SOPHIA outcomes and more (please note, log-in maybe required to access the full paper).

Bariatric Surgery and Cardiovascular Disease Risk in Patients with Pulmonary Hypertension: A Propensity Score Matched Analysis of US National Inpatient Sample

Researchers led by Mashhad University of Medical Sciences, Mashhad, Iran, have reported that bariatric surgery is independently associated with a reduced rate of in-hospital mortality and coronary artery diseases (CAD) hospital admission in patients with pulmonary hypertension (PH) however, the risk of atrial fibrillation and acute pulmonary embolism was higher in these patients.

Writing in Obesity Surgery, the authors sought to evaluate the association of surgery and CAD, heart failure with reduced ejection fraction (HFrEF), heart failure with preserved ejection fraction (HFpEF), cardiac valve diseases, cardiac rhythm disorders, acute pulmonary embolism, and in-hospital mortality in patients with PH.

In total, 3,605 patients with a history of surgery and 501,419 patients without surgery were included. After propensity matching, surgery was independently associated with a lower CAD hospital admission and a lower rate of in-hospital mortality. However, it was associated with a higher prevalence of atrial fibrillation and acute pulmonary embolism in patients with PH. HFpEF, HFrEF, other cardiac rhythm disorders, complete heart block, cardiac valve diseases, and ischemic stroke were not significantly different between the two groups in patients with PH.

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The impact of the bougie size and the extent of antral resection on weight-loss and postoperative complications following sleeve gastrectomy: results from the Scandinavian Obesity Surgery Registry

The latest outcomes from the Scandinavian Obesity Surgery Registry have reported that using a narrow bougie and initiating resection closer to the pylorus were associated with greater maximum weight loss.

Researchers from the Örebro University, Örebro, Sweden, writing in SOARD, evaluated the influence of bougie size and antral resection distance from the pylorus on postoperative complications and weight-loss results in LSG. Data were obtained from the Scandinavian Obesity Surgery Registry. Reference bougie size of 35–36 Fr and an antral resection distance of 5 cm from the pylorus were compared to narrower bougie size (30–32 Fr), shorter distances (1–4 cm), and extended distances (6–8 cm) from the pylorus in assessing postoperative complications and weight loss as the outcomes of LSG. The study included 9,360 patients with postoperative follow-up rates of 96%, 79%, and 50% at 30 days, 1 year, and 2 years, respectively.

They found that narrow bougie and short antral resection distance from the pylorus were significantly associated with increased postoperative weight loss. Bougie size was not associated with increased early or late complications. Conversely, short antral resection distance was associated with high risk of overall early complications [odds ratio: 1.46 (1.17–1.82, p=0.001)], although no impact on late complications at 1 and 2 years was observed.

They concluded that a closer resection to the pylorus was associated with an increased risk of early postoperative complications, but no association was observed with the use of narrow bougie for LSG.

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Cost-Effectiveness of Pharmacotherapy for the Treatment of Obesity in Adolescents

Top-dose phentermine and topiramate as adjunct to lifestyle counselling is cost-effective after five years, according to investigators from Columbia University Irving Medical Center, New York.

Reporting in JAMA Network Open, they estimated the cost-effectiveness of lifestyle counselling alone and as adjunct to liraglutide, mid-dose phentermine and topiramate (7.5mg phentermine and 46mg topiramate), top-dose phentermine and topiramate (15mg phentermine and 92mg topiramate) or semaglutide among adolescent patients with obesity.

This economic evaluation used a microsimulation model to project health and cost outcomes of lifestyle counselling alone and adjunct to liraglutide, mid-dose phentermine and topiramate, top-dose phentermine and topiramate, or semaglutide over 13 months, 2 years, and 5 years among a hypothetical cohort of 100 000 adolescents with obesity.

The simulated model of 100,000 adolescents found that at 13 months and 2 years, lifestyle counselling was estimated to be the preferred strategy. At 5 years, top-dose phentermine and topiramate was projected to be the preferred strategy with an ICER of $56 876 per QALY gained vs lifestyle counselling. Semaglutide yielded the most QALYs, but with an unfavourable ICER of $1.1 million per QALY gained vs. top-dose phentermine and topiramate.

They concluded that long-term clinical trials in adolescents are needed to fully evaluate the outcomes of pharmacotherapy, especially into adulthood.

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Cognition in patients with post-bariatric hypoglycemia

Post-bariatric hypoglycemia (PBH) individuals may be at greater risk for cognitive impairment compared patients without PBH, according to researchers from Joslin Diabetes Center, Boston, MA.

Reporting in the journal Obesity, the authors sought to determine whether individuals with PBH display reduced cognitive function compared with postsurgical counterparts without hypoglycemia. For the study, 14 adults with a history of Roux-en-Y gastric bypass with hypoglycemia (PBH+, n=7) or without PBH (PBH−, n=7) completed assessments of memory, executive function, attention, and psychomotor speed.

They found that PBH+ individuals displayed significantly decreased performance in category fluency (p<0.01), category switching (p<0.01) and category switching accuracy (p<0.01), compared with PBH− individuals. Performance in the first (p=0.03) and third intervals (p=0.045) of verbal fluency was significantly lower in PBH+ individuals versus PBH− individuals. All other assessments did not differ.

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Development and validation of an interpretable machine learning-based calculator for predicting 5-year weight trajectories after bariatric surgery: a multinational retrospective cohort SOPHIA study

A machine learning-based model developed by a team of researchers at the University of Lille in Lille, Hauts-de-France, France, can predict individual weight-loss trajectories up to five years after bariatric surgery simultaneously for RYGB (Roux-en-Y gastric bypass), SG (sleeve gastrectomy) and AGB (adjustable gastric banding).

For this multinational retrospective observational study, the researchers enrolled adult participants (aged ≥18 years) from ten prospective cohorts. In total, 10,231 patients from 12 centres in ten countries were included in the analysis, corresponding to 30,602 patient-years.

At five years, across external testing cohorts the overall mean MAD BMI was 2.8 kg/m2 (95% CI 2.6–3.0) and mean RMSE BMI was 4.7 kg/m2 (4.4–5.0), and the mean difference between predicted and observed BMI was –0.3 kg/m2 (SD 4.7). This model is incorporated in an easy to use and interpretable web-based prediction tool to help inform clinical decision before surgery, the authors noted.

“In summary, we have developed and validated an easy-to-use and interpretable model that provides individual predictions of weight loss trajectory after bariatric surgery. We have shown its generalisability and transportability across multiple cohorts in Europe, the Americas, and Asia, as well as its performance in intervention clinical trials,” the authors concluded. “Individual weight loss trajectory prediction appears to be an accurate and simple strategy to inform clinical decisions for both health-care providers and patients before surgery. Our model can also be used postoperatively to identify patients whose actual weight loss trajectories differ from their predicted trajectory, thus allowing the timely implementation of appropriate clinical interventions.”

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Preventing alcohol use post-bariatric surgery: patient perspectives on a technology-based approach

US researchers have concluded that web- and text message-based interventions may be an acceptable approach to prevent alcohol use post-bariatric surgery.

Reporting in Surgical Endoscopy, they highlight that nearly two-thirds of patients engage in alcohol use after bariatric surgery, while a substantial number meet criteria for alcohol use disorder after their procedure. They tested a technology-based intervention to reduce alcohol use for individuals who have undergone bariatric surgery. Twenty patients who consumed alcohol post-surgery completed qualitative interviews where they provided opinions on sample intervention content, delivery method, timing, and other aspects of a two-session web-based intervention followed by tailored text messaging for six months.

The outcomes showed that the participants strongly endorsed using technology to deliver an alcohol intervention, citing the interactivity and personal tailoring available in the proposed software. Interestingly, education about the effects of post-surgical drinking and learning new coping strategies for social situations were the two most salient themes to emerge from questions about intervention content.

They also felt that text messages could extend what they had learned, but also requested additional non-alcohol content (e.g., recipes, exercise tips). Most participants agreed that an online forum consisting of peers and professionals with whom they could ask questions and interact would be useful.

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A Prospective Cohort of Alcohol Use and Alcohol-related Problems Before and After Metabolic and Bariatric Surgery in Adolescents

US researchers have reported that nearly half of those who underwent metabolic and bariatric surgery (MBS) as adolescents screened positively for alcohol use disorders (AUD), symptoms of alcohol-related harm or alcohol-related problems 8 years post-MBS, highlighting the risk for alcohol use and AUD after MBS in adolescents.

Writing in the Annals of Surgery, the study included 217 adolescents (aged 13–19 y) enrolled in a 5-center prospective cohort study who underwent Roux-en-Y gastric bypass or vertical sleeve gastrectomy (2007–2011). They found that alcohol use frequency and average quantity of drinks per drinking day increased postoperatively (2% consumed alcohol 2–4 times/month 6 months versus 24% 8 years postoperatively, p<0.001; 2% consumed≥3 drinks per drinking day 6 months versus 35% 8 years postoperatively, p<0.001).

They concluded that AUD evaluation and treatment should be integrated into routine long-term care for adolescents undergoing MBS.

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UK cost-effectiveness analysis of endoscopic sleeve gastroplasty versus lifestyle modification alone for adults with class II obesity

Endoscopic sleeve gastroplasty (ESG) is highly cost effective versus lifestyle modification (LM) alone for the treatment of adults with class II obesity in England, according to UK researchers.

Writing in the International Journal of Obesity, they conducted the first cost-effectiveness analysis of ESG versus LM alone in adults with class II obesity (BMI 35.0–39.9 kg/m2) from a national healthcare system perspective in England.

They found that ESG resulted in higher overall costs than LM alone but led to an increase in quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) for ESG vs LM alone was £2453/QALY gained. Furthermore, ESG was consistently cost effective across a wide range of sensitivity analyses, with no ICER estimate exceeding £10,000/QALY gained.

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