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Updated: Nov 12, 2019

Relationship between metabolic surgery and major adverse cardiovascular events (MACE) in patients with type 2 diabetes and obesity.

2287 patients of the total of 2,87,438 adult patients with diabetes in the Cleveland Clinic Health System in the United States between 1998 and 2017 underwent metabolic surgery. These patients were matched 1:5 to non-surgical patients (n= 11,435 control patients) with diabetes and obesity (body mass index [BMI] ≥30) with follow-up through December 2018. The primary outcome was the incidence of extended MACE (composite of 6 outcomes), defined as first occurrence of all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation. Secondary end points included 3-component MACE (myocardial infarction, ischemic stroke, and mortality) and the 6 individual components of the primary end point. In total of 13,722 study patients, sex, median age, BMI and glycated hemoglobin level were comparable. Median follow up duration was 3.9 years. At the end of the study period, 385 patients in the surgical group and 3243 patients in the nonsurgical group experienced a primary end point (cumulative incidence at 8-years, 30.8% in the surgical group and 47.7% in the nonsurgical group [P < .001, adjusted hazard ratio [HR], 0.61]. All 7 prespecified secondary outcomes showed statistically significant differences in favor of metabolic surgery, including mortality. They concluded that in patients with obesity and T2DM, metabolic surgery was associated with a significantly lower risk of incident MACE compared to the non-surgical group.

Aminian, A., Zajichek, A., Arterburn, D. E., Wolski, K. E., Brethauer, S. A., Schauer, P. R., ... & Nissen, S. E. (2019). Association of metabolic surgery with major adverse cardiovascular outcomes in patients with type 2 diabetes and obesity. Jama, 322(13), 1271-1282.

Bariatric Surgery reduces the need for invasive intervention in severe obese with osteoarthritis

Osteoarthritis (OA) affects 56 million Americans. Each extra kilogram weight increases the risk of OA to 13%. The authors retrospectively analyzed their 486 patients who had OA diagnosed before their bariatric surgery (Gastric band, sleeve gastrectomy and roux-en y gastric bypass). Invasive intervention (INI) for OA was defined as need for surgical drainage; articular injection; and surgical interventions such as meniscectomy, total hip replacement and total knee replacement.

The mean BMI for this group was 44.7kg/m2 and total weight loss was 14.29%. At 12 months follow up, 66.7% did not require any INI. A total of 35.2% required pain management for OA. Of these, 90% required only INI and 5.6% required only pain management. As 24 months, 64.3% did not require INI. The risk to require INI was reduced by 69.9% at 12 months and 80% at 24 months. Need for pain medications at 12 months reduced by 96.9%. They concluded that bariatric surgery reduced the need for INI and this was related to the amount of weight loss.

Fonseca, M. M., Milla, M. C., Ferri, F., Lo, M. E., Szmostein, S., & Rosenthal, R. J. (2019). Reduction of invasive interventions in severely obese with osteoarthritis after bariatric surgery. Surgical endoscopy.

Pre-operative low-calorie diet: Its effect on liver and weight loss

Nonalcoholic fatty liver disease (NAFLD) effects 75%-100% of individuals undergoing bariatric surgery. The authors aimed to study the effect of preoperative low-calorie diet (LCD) on liver. Total of 40 patients had intraoperative liver biopsy during bariatric surgery (20 had preoperative LCD and 20 did not have LCD). The LCD group had pre-operative weight loss of 3.43 kgs. The LCD group had significantly less steatosis, fewer foci of lobular inflammation and less hepatocellular ballooning compared with the non-LCD group on histology. There was no difference in degree of fibrosis. Fewer patients in the LCD group had nonalcoholic steatohepatitis with ballooning. They also concluded that preoperative weight loss was predictive of improved weight loss 6 months after surgery and improved liver functions.

Wolf, R. M., Oshima, K., Canner, J. K., & Steele, K. E. (2019). Impact of a preoperative low-calorie diet on liver histology in patients with fatty liver disease undergoing bariatric surgery. Surgery for Obesity and Related Diseases.

Risk factors for postoperative venous thromboembolism after bariatric surgery.

The aim of the study was to identify risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE) after sleeve gastrectomy (LSG) and roux-en-y gastric bypass (RYGB), as venous thromboembolism is the leading causes of morbidity and mortality after bariatric surgery. Analyzing 369,032 bariatric cases (72% LSG, 28% LRYGB) they found that the incidence of DVT was similar between LSG and LRYGB (0.2% vs. 0.2%) and the incidence of PE was significantly decreased for LSG compared to LRYGB (0.1% vs. 0.2%). Prolonged operative length was associated with increased risk of postoperative DVT (OR 1.1) and postoperative PE (OR 1.4) after surgery. LSG was associated with a decreased risk of PE compared to RYGB. The largest independent risk factors for DVT and PE were history of DVT and transfusion.

Gambhir, S., Inaba, C. S., Alizadeh, R. F., Nahmias, J., Hinojosa, M., Smith, B. R., ... & Daly, S. (2019). Venous thromboembolism risk for the contemporary bariatric surgeon. Surgical Endoscopy, 1-6.

Roux-en-Y Gastric bypass is feasible and safe on ambulatory outpatient basis in selected patients.

The authors performed retrospective review on their 362 patient who underwent primary RYGB on ambulatory outpatient basis to assess its feasibility and safety. Inclusion criteria included age > 18 and < 65 years, ASA class less than 3, completion of a bariatric surgery preparation program, no history of major cardiovascular events, and no prior major open abdominal operations. Males with > 55 years, men with BMI > 55 and women with BMI > 60 were excluded. The median BMI was 46.7 kg/m2 and mean age was 42 years. 1.93% patients were directly admitted to the hospital and 3.59% represented after initial discharge. They had 0.83% leaks, 1.11% bleeds requiring transfusion, 0.28% obstruction, 0.28% venous thrombotic event +/- pulmonary embolism and 2.49% reoperations. There were no wound infections and 0% mortality. They concluded that RYGB is feasible and safe on ambulatory outpatient basis in carefully selected group of patients.

Leepalao, M. C., Arredondo, D., Speights, F., & Duncan, T. D. (2019). Same-day discharge on laparoscopic Roux-en-Y gastric bypass patients: an outcomes review. Surgical endoscopy, 1-4.

Distal gastric bypass: Constant 200cm biliopancreatic limb construction with varying lengths of common channel.

A high-volume unit from Norway studied the importance of total alimentary limb length in Roux en Y gastric bypass (RYGB) with constant biliopancreatic limb (BPL) of 200cm and varying common limb length (CL). Total of 187 patients were divided in three groups in this retrospective study. Group 1 (n = 69; Roux limb = 150 cm, BPL = 60 cm), Group 2 (n = 88; BPL = 200 cm, CL = 150 cm), and Group 3 (n = 30; BPL = 200 cm, CL = 200 cm). There was no clinically significant difference between the 3 groups except the preoperative body mass index (BMI) which was higher in group 2 (58.5) and 3 (57.4) compared to group 1 (54.6). Follow-up rate was 95% at 2 years, 74% at year 5, and 52% at 10 years. At 10-year follow-up, excess weight loss (EWL) and total weight loss (TWL) was higher in group 2 (70.4%; 40.3%) and 3 (64.0%; 35.9%) compared with group 1 (55.9%; 29.2%). Excess weight loss failure was higher in group 1 versus 2 (30% versus 8.3%, P < .001). No difference in short- or long-term complications was seen except higher occurrence of internal hernia in distal Roux-en-Y gastric bypass groups (11.4%, 6.7%). Patients with shorter CL had more vitamin and mineral deficiencies.

Shah, K., Nergård, B. J., Fagerland, M. W., & Gislason, H. (2019). Distal gastric bypass: 2-m biliopancreatic limb construction with varying lengths of common channel. Surgery for Obesity and Related Diseases.

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