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Journal Watch 8/11/2023

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 decreased risk of esophageal adenocarcinoma after gastric bypass surgery, simultaneous bariatric surgery and ventral hernia repair, Semaglutide 2.4 mg/wk for weight loss with or without a history of bariatric surgery, visceral adipose tissue and adiponectin predicts excess weight loss after surgery, comparison of eastern and western patients undergoing bariatric, transit of oral premedication beyond the stomach in patients undergoing LSG and what matters to adolescents with obesity, and more (please note, log-in maybe required to access the full paper).

Decreased Risk of Esophageal Adenocarcinoma After Gastric Bypass Surgery in a Cohort Study From 3 Nordic Countries

Scandinavian researchers have reported that gastric bypass surgery may counteract the development of oesophageal adenocarcinoma in individuals living with morbid obesity..

Writing in the Annals of Surgery, they assessed whether bariatric surgery decreases the risk of esophageal and cardia adenocarcinoma (ECA) in participants who had bariatric surgery and a non-surgical group.

Among 748,932 participants with an obesity diagnosis, 91,731 underwent bariatric surgery, predominantly gastric bypass (n=70,176; 76.5%). The standardized incidence ratios (SIR) of ECA decreased over time after gastric bypass, from SIR=2.2 (95% CI, 0.9–4.3) after 2 to 5 years to SIR=0.6 (95% CI, <0.1–3.6) after 10 to 40 years. They also found that gastric bypass patients were also at a decreased risk of ECA compared with non-operated patients with obesity [adjusted HR=0.6, 95% CI, 0.4–1.0 (0.98)], with decreasing point estimates over time. Gastric bypass was followed by a strongly decreased adjusted risk of esophageal adenocarcinoma (HR=0.3, 95% CI, 0.1–0.8) but not of cardia adenocarcinoma (HR=0.9, 95% CI, 0.5–1.6), when analysed separately.

There were no consistent associations between other bariatric procedures (mainly gastroplasty, gastric banding, sleeve gastrectomy, and biliopancreatic diversion) and ECA.

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Is simultaneous bariatric surgery and ventral hernia repair a safe and effective approach?

Simultaneous ventral hernia repair with bariatric surgery had a low rate of infection, and a low mesh explant rate, even when coupled with resection bariatric surgery in this series, according to researchers from the University of New South Wales, Sydney, Australia.

Writing in SOARD, they compared outcomes between patients undergoing simultaneous and selectively deferred ventral hernia repair and bariatric surgery.

In total, 111 patients underwent simultaneous repair and 23 had a deferred procedure. Of the simultaneous patients, 95 (85.6%) underwent resection bariatric surgery. There was one (0.9%) mesh infection requiring explant, in an open, simultaneous repair undertaken in a gastric band patient, 3 (2.8%) infected seromas, 1 (0.9%) surgical site infection, and 8 (7.5%) hernia recurrences in the simultaneous group.

The deferred group has had no mesh infections, no hernia recurrence and 2 (9.5%) infected seromas to date. There was one mortality in the simultaneous cohort (simultaneous gastric bypass group), from a massive Pulmonary Embolism (<30 days post-operatively) and one in the deferred group from an interval small bowel obstruction.

They concluded that a combined approach may be safe, even in the clean-contaminated surgical context.

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Semaglutide 2.4 mg/wk for weight loss in patients with severe obesity and with or without a history of bariatric surgery

Researchers from the University Hospital of Montpellier, Montpellier, France, who compared semaglutide 2.4 mg in patients who had surgery with non-surgical patients found semaglutide treatment resulted in significant 9.1% weight loss in the BS+ group, with no significant difference in weight loss between the BS+ and BS− groups.

The retrospective cohort study analysed data from 129 patients with a BMI ≥ 40 kg/m2, including 39 with (BS+) and 90 without (BS−) a history of surgery. The patients received semaglutide treatment for 24 weeks starting at 0.25mg/wk and gradually increasing to reach a final dose of 2.4mg/wk. The treatment outcomes were assessed based on the percentage of weight loss, changes in BMI, and waist circumference.

“This study is the first, to the authors’ knowledge, to compare the effectiveness of semaglutide treatment in patients with versus those without a history of BS, providing valuable evidence of its efficacy. By focusing on individuals with severe obesity (BMI > 40 kg/m2 and associated comorbidities), it fills a gap in the current literature and highlights the potential of semaglutide 2.4 mg as a treatment option for this specific population,” they concluded.

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Visceral adipose tissue adiponectin predicts excess weight loss after bariatric surgery in females with severe obesity

Italian researchers have reported adiponectin (APN) in visceral adipose tissue (VAT) rather than its circulating or subcutaneous levels predicts EWL after bariatric surgery as an independent factor in the female sex only, thus contributing to identify those patients who could much benefit from surgery.

Writing in International Journal of Obesity, they assessed the predicting value of pre-operative APN locally produced in abdominal visceral (VAT) and subcutaneous (SAT) adipose tissue versus plasma levels as a novel sex-linked biomarker of EWL at different time points of follow up (6–24 months) after bariatric surgery in 43 patients (56% females) affected by severe obesity undergoing a small pilot observational study.

They found that VAT-APN was lower in females and represented the only marker significantly correlated with EWL. In females, VAT-APN in the distribution upper quartile but not baseline BMI retained a statistically significant correlation with EWL at any time points (6–24 months) at multivariate analysis. The best VAT-APN cut-off value to predict 95% EWL at 12 months from surgery (98% accuracy, 100% sensitivity, 94% specificity, p=0.010) was 5.1µg/mg.

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Comparison of Eastern and Western patients undergoing bariatric surgery at two US and Korean institutions: a retrospective analysis of differing bariatric patient populations

Researchers from Kosin University, Busan, Republic of Korea, who compared post-operative outcomes between Korean and American bariatric programs in order to assess how bariatric surgery differently affects these populations, have reported that there were no significant differences in operation time and complications.

Writing in Surgical Endoscopy, they enrolled 540 patients who underwent bariatric surgery at University of California, Los Angeles (UCLA) and 85 patients who underwent surgery at Kosin University Gospel Hospital (KUGH) between January 2019 and December 2020.

There was a difference in age between the UCLA and KUGH patient groups (44.3 years vs 37.6 years, p<0.01). Frequencies of T2DM and OSA were also different (4.2% vs 50.6%, 34.1% vs 85.9% p<0.01. Length of hospital stay varied (1.55 days vs 6.68 days, p<0.01), but there was no difference in operating time and complications. There was no difference in percent of excess weight loss between the two groups at 6 months (29.7 vs 33.8, p=0.13). Hepatic steatosis index (HSI) was higher in the UCLA group both before (54.2 vs 51.5, p<0.01) and after (44.4 vs 40.0, p=0.02) surgery. LSG was the most frequently performed operation, and robotic surgery and revisions were performed only in the UCLA program.

There were differences in age, BMI, length of stay, and choice of operation between Korean and American bariatric patients. There were also differences in the degree of fatty liver disease using HSI and liver enzymes before and after surgery. There was no significant differences in operation time and complications.

“These findings suggest differences in bariatric practices and reactions to bariatric surgery in Eastern and Western settings,” they concluded.

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The transit of oral premedication beyond the stomach in patients undergoing laparoscopic sleeve gastrectomy: a retrospective observational multicentre study

Australian investigators have reported pre-operative oral analgesia and antiemetics did not transit beyond the stomach in 38% of patients undergoing laparoscopic sleeve gastrectomy (LSG).

Reporting on BMC Surgery, this retrospective cohort study was performed on patients undergoing LSG and receiving oral premedication (slow-release tapentadol and netupitant/palonosetron) as part of enhanced recovery after bariatric surgery program. Patients were stratified into the Transit group (premedication absent in the resection specimen) and Failure-to-Transit group (premedication present in the resection specimen).

One hundred consecutive patients were included in the analysis – 99 patients (99%) were morbidly obese and 17 patients (17%) had Type 2 diabetes mellitus. One hundred patients (100%) received tapentadol and 89 patients (89%) received netupitant/palonosetron. One or more tablets were discovered in the resected specimens of 38 patients (38%). The median (Q1‒Q3) premedication lead time was 80 min (57.8‒140.0) in the Failure-to-Transit group and 119.5 min (85.0‒171.3) in the Transit group; p=0.006. The lead time required to expect complete absorption in 80% of patients was 232 min (95%CI:180‒310).

“When given orally in combination, tapentadol and netupitant/palonosetron should be administered at least 4 hours before surgery to ensure transition beyond the stomach,” they concluded. “Future enhanced recovery after bariatric surgery guidelines may benefit from the standardization of premedication lead times to facilitate increased absorption.”

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What matters to adolescents with obesity, and their caregivers, when considering bariatric surgery or weight loss devices? A qualitative evidence synthesis

Researchers at the University of Sheffield, Sheffield, UK, report that supportive interventions accompanying bariatric surgery should be in place to offer: practical help; address anxieties and uncertainties; and facilitate both appropriate decision-making and the achievement of young people's desired outcomes.

Writing in Obesity Reviews, they conducted a systematic review and qualitative evidence synthesis of factors affecting adolescent and caregiver decision-making processes around such interventions, as well as post-surgery demands and challenges, so that their experiences might be better understood and improved support given. No previous qualitative evidence synthesis has been published on this topic.

They identified 19 primary qualitative research studies in adolescents aged 13 years or older and found diverse motivations and incentives for considering these interventions, including the physical and social problems resulting from living with obesity, and an awareness of the benefits and limitations of interventions. They reported that they need: information, physical and emotional support and, in some cases, financial assistance.

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