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Journal Watch 9/08/2023

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 three papers reporting on revisional bariatric surgery, the risk of micronutrient deficiency after bariatric surgery, weight stigma and post-RYGB hypoglycemia, and more (please note, log-in maybe required to access the full paper).

Comparative Analysis of Sleeve Conversions of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2020 Database

US investigators, writing in SOARD, have reported that sleeve gastrectomy (SG) is the most common procedure is converted to is the Roux-en-Y gastric bypass (RYGB) and gastroesophageal reflux disease (GERD) was the most common reason for conversion, followed by weight recurrence (WR) and insufficient weight loss (IWL).

Prior to 2020, details on why conversions were being performed were not collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use Data File (PUF). Now, the indication for sleeve conversion is noted in the PUF, allowing identification and reporting sleeve conversion reasons. Subsequently, the investigators reported on the reasons why SGs were converted to other operations.

In the 2020 PUF, there were 7,181 SG that were converted to other operations - the most common conversion (86.2%) was to RYGB and the main reason for SG conversion was GERD at 48.4%, followed by WR/IWL (41.9%). The authors noted that biliopancreatic diversion with duodenal switch and single-anastomosis duodenoileal bypass with sleeve patients differed significantly from RYGB patients in specific preoperative characteristics and operative outcomes.

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Revisional surgery after restrictive surgery: midterm outcomes of a tertiary center

Revisional bariatric surgery (RBS) after laparoscopic sleeve gastrectomy (LSG) seems to lead to higher overall morbidity whereas RBS after laparoscopic adjustable gastric banding (LAGB) lead to more perioperative issues, according to French researchers.

Reporting in Surgical Endoscopy, they examined data from 252 patients undergoing RBS after LAGB or LSG at two years of follow up. A subgroup analysis of third procedure was also performed.

Overall morbidity occurred in 35 patients (37%) in the LSG group and 40 patients (25%) in the LAGB group (p=0.045). At two years, mean weight was 92.8±26.7kg, BMI was 33.1±8.56kg/m2 for patients who had RBS after LSG. When RBS was performed after LAGB, mean weight at 2 years was 90.1±20.7kg and BMI was 32.5±6.45kg/m2. Total weight loss for RBS performed after LSG was 12.7±16.4% compared to 25.5±10.3% after LAGB (p<0.001).

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Roux-en-Y Gastric Bypass as Conversion Procedure of Failed Gastric Banding: Short-Term Outcomes of 1295 Patients in One Single Center

Conversion to LRYGB from LAGB can be considered as a safe and effective option with low complication rate and good weight loss outcomes at one year, according to Belgian researchers.

Writing in Obesity Surgery, they evaluated one-year morbidity, mortality, and weight loss of LRYGB as a feasible conversion strategy. Patients had a conversion to LRYGB at the same time (one-stage approach) or with a minimum of three months in between (two-stage approach).

A total of 1295 patients underwent a conversion from LAGB to LRYGB: 1167 patients (90.1%) in one stage and 128 patients (9.9%) in two stages. Thirty-day postoperative complication occurred in 93 patients (7.2%), with no significant difference found between groups. Haemorrhage was reported as the most common complication in 39 patients (3.0%), and the reoperation was required in 19 patients (1.4%).

At one year postoperatively, the mean BMI was 28.0kg/m2, the mean %EWL 72.8% and the mean %EBMIL 87.0%. No statistically significant difference was found between the groups.

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Monitoring for micronutrient deficiency after bariatric surgery—what is the risk?

In the setting of prophylactic post-surgical micronutrient prescription, few nutrients are at risk of de novo deficiency, according to researchers from the University of Queensland, Brisbane, Australia.

Reporting in the European Journal of Clinical Nutrition, they examined the impact of bariatric surgeries, supplementation and inflammation on micronutrient deficiency. Participants were recruited to an observational study monitoring biochemical micronutrient outcomes, supplementation dose, inflammation and glycaemic control, pre-operatively and at one to three, six and 12 months after gastric (n=66) or sleeve gastrectomy (n=144).

They reported that pre-operative micronutrient deficiency was common, for vitamin D (29–30%), iron (13–22%) and selenium (39% GB cohort). Although supplement intake increased after surgery the dose was <50% of target for most nutrients. After SG, folate was vulnerable to deficiency at six months (p=0.007), with folic acid supplementation being independently associated with reduced risk. Within one to three months of GB, three nutrients had higher deficiency rates compared to pre-operative levels; vitamin B1 (21% vs. 6%, p<0.01), vitamin A (21% vs. 3%, p<0.01) and selenium (59% vs. 39%, p<0.05). Vitamin B1 deficiency was independently associated with surgery and inflammation, selenium deficiency with improved glycaemic control after surgery and inflammation, whilst vitamin A deficiency was associated with inflammation only.

“Although micronutrient supplementation and monitoring remains important, rationalising high-frequency biochemical testing protocols in the first year after surgery may be warranted,” they concluded.

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Weight stigma experienced by patients with obesity in healthcare settings: A qualitative evidence synthesis

Researchers from the University of Ireland, Galway, Ireland, have reported that weight stigma experienced within interpersonal interactions migrates to the provision of care, mediates gaining equitable access to services and perpetuates a poor systemic infrastructure to support the needs of patients with obesity.

Writing in Obesity reviews, the analysis included 32 studies and generated three overarching analytical themes: (1) verbal and non-verbal communication of stigma, (2) weight stigma impacts the provision of care, and (3) weight stigma and systemic barriers to healthcare.

The first theme relates to the communication of weight stigma perceived by patients within patient–provider interactions. The second theme describes the patients' perceptions of how weight stigma impacts upon care provision. The third theme highlighted the perceived systemic barriers faced by patients when negotiating the healthcare system.

They concluded that a non-collaborative approach to practice and treatment renders patients feeling they have no control over their own healthcare requirements.

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Relationship Between Symptom Perception and Postprandial Glycemic Profiles in Patients With Postbariatric Hypoglycemia After Roux-en-Y Gastric Bypass Surgery

Investigators from the University of Bern, Bern, Switzerland, who evaluated the relationship between self-reported symptoms and postprandial sensor glucose profiles, have concluded that the relationship between symptom perception and post–bariatric surgery hypoglycemia (PBH) is complex, challenging clinical judgement and decision-making in this population.

In the study, thirty patients with PBH after RYGB wore a blinded Dexcom G6 sensor while recording autonomic, neuroglycopenic, and gastrointestinal symptoms over 50 days. Symptoms (overall and each type) were categorised into those occurring in postprandial periods (PPPs) without hypoglycemia or in the preceding dynamic or hypoglycaemic phase of PPPs with hypoglycaemia

From 5,851 PPPs, 775 symptoms were reported of which 30.6 (0.0–59.9)% were perceived in PPPs without hypoglycaemia, 16.7 (0.0–30.1)% in the preceding dynamic phase and 45.0 (13.7–84.7)% in the hypoglycaemic phase of PPPs with hypoglycaemia. Per symptom type, 53.6 (23.8–100.0)% of the autonomic, 30.0 (5.6–80.0)% of the neuroglycopenic and 10.4 (0.0–50.0)% of the gastrointestinal symptoms occurred in the hypoglycaemic phase of PPPs with hypoglycemia.

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