R. Ahmed

The hundred most cited articles in bariatric surgery

BackgroundMany studies quantitatively analyzing scientific papers have appeared in the last 2xa0years. Citation analysis is a commonly used bibliometric method. In spite of some limitations, it remains a good measure of the impact an article has on a specific field, specialty, or a journal. The aim of this study was to analyze the qualities and characteristics of the 100 most cited articles in the field of bariatric surgery.MethodsThe Thomson Reuters Web of Knowledge was used to list all bariatric surgery-related articles (BSRA) published from 1945 to 2014. The top 100 most cited BSRA in 354 surgical and high impact general journals were selected for further analysis.ResultsMost of the articles were published in the 2000s (60xa0%). The top 100 most cited were published in 17 of the 354 journals. Leading countries were USA followed by Canada and Australia. Most of the articles published (76xa0%) were clinical experience articles. The most common level of evidence was IV (42xa0%).ConclusionsMany of the milestone papers in bariatric surgery have been included in this bibliometric study. A huge increase in research activity during the last decade is clearly visible in the field. It is apparent that the number of citations of an article is not related to its level of evidence; a fact that is increasingly being emphasized in surgical research.

Systematic review of risk prediction models for diabetes after bariatric surgery

Diabetes remission is an important outcome after bariatric surgery. The purpose of this study was to identify risk prediction models of diabetes remission after bariatric surgery.

Cost analysis of leak after sleeve gastrectomy

BackgroundLeaks after laparoscopic sleeve gastrectomy (LSG) are serious complications of this procedure. The objective of the present study was to evaluate the costs of leaks after LSG.SettingPrivate hospital, France.MethodsA retrospective analysis was conducted on a prospective cohort of 2012 cases of LSG between September 2005 and December 2014. Data were collected on all diagnostic and therapeutic measures necessary to manage leaks, ward, and intensive care unit (ICU) length of stay. Additional outpatient care was also analyzed.ResultsTwenty cases (0.99%) of gastric leak were recorded. Fifteen patients had available data for cost analysis. Of these, 13 patients were women (86.7%) with a mean age of 41.4xa0years (range 22–61) and mean BMI of 43.2xa0kg/m2 (range 34.8–57.1). The leaks occurred after 7.4xa0days (±2.3) postoperatively. Only one gastric leak was recorded for the last 800 cases in which absorbable staple line reinforcement was used. Mean intra-hospital cost was 34398xa0€ (range 7543–91,632xa0€). Prolonged hospitalization in ICU accounted for the majority of hospital costs (58.9%). Mean additional outpatient costs for leaks were 41,284xa0€ (range 14,148–75,684€).ConclusionsLeaks after LSG are an expensive complication. It is therefore important to take all necessary measures to reduce their incidence. Our data should be considered when analyzing the cost effectiveness of staple line reinforcement usage.

Limitations of the DiaRem Score in Predicting Remission of Diabetes Following Roux-En-Y Gastric Bypass (RYGB) in an ethnically Diverse Population from a Single Institution in the UK

PurposeThis study aimed to determine the predictive power of the DiaRem score following Roux-en-Y gastric bypass to identify patients who would have diabetes remission at 1xa0year in an ethnically diverse population.MethodsWe performed a retrospective review of 262 patients with type 2 diabetes mellitus who underwent RYGB at the Imperial Weight Centre, UK, from 2007 to 2014. Data was collected on the parameters required to calculate the DiaRem score as well as pre- and post-surgical weight and the ethnicity of the subjects.ResultsThe studied cohort was ethnically diverse (61.3xa0% Caucasian, 10.3xa0% Asian, 5.3xa0% black, 2.6xa0% mixed and 20.6xa0% other). At 1-year post-surgery, there were significant reductions in mean weight (133.4 to 94.3xa0kg) and BMI (46.7 to 33.3xa0kg/m2). The mean HbA1c decreased from 8.2 to 6.1xa0%, and 32.5xa0% of the cohort underwent either partial or complete remission. 67.8xa0% of the patients that were classified in group 1 of the DiaRem score (most likely to have remission) had complete remission. However, 22.9xa0% of the patients predicted to have the least chance of remission had either partial or complete remission.ConclusionsIn this ethnically diverse cohort, the DiaRem score remains a useful tool to predict diabetes remission in those that have a low DiaRem score (high chance for remission) but was more limited in its predictive power in those with a high DiaRem score (least likely to have remission). Caution must be used in the application of this model in populations other than the US white Caucasian population used to derive the score.

Roles of increased glycaemic variability, GLP-1 and glucagon in hypoglycaemia after Roux-en-Y gastric bypass

Objective Roux-en-Y gastric bypass (RYGB) surgery is currently the most effective treatment for diabetes and obesity. An increasingly recognized and highly disabling complication of RYGB is postprandial hypoglycaemia (PPH). The pathophysiology of PPH remains unclear with multiple mechanisms suggested including nesidioblastosis, altered insulin clearance and increased glucagon-like peptide-1 (GLP-1) secretion. Whilst many PPH patients respond to dietary modification, some have severely disabling symptoms. Multiple treatments are proposed, including dietary modification, GLP-1 antagonism, GLP-1 analogues and even surgical reversal, with none showing a more decided advantage over the others. A greater understanding of the pathophysiology of PPH could guide the development of new therapeutic strategies. Methods We studied a cohort of PPH patients at the Imperial Weight Center. We performed continuous glucose monitoring to characterize their altered glycaemic variability. We also performed a mixed meal test (MMT) and measured gut hormone concentrations. Results We found increased glycaemic variability in our cohort of PPH patients, specifically a higher mean amplitude glucose excursion (MAGE) score of 4.9. We observed significantly greater and earlier increases in insulin, GLP-1 and glucagon in patients who had hypoglycaemia in response to an MMT (MMT Hypo) relative to those that did not (MMT Non-Hypo). No significant differences in oxyntomodulin, GIP or peptide YY secretion were seen between these two groups. Conclusion An early peak in GLP-1 and glucagon may together trigger an exaggerated insulinotropic response to eating and consequent hypoglycaemia in patients with PPH.

Reversal to normal anatomy after failed gastric bypass: systematic review of indications, techniques, and outcomes

BACKGROUNDnRoux-en-Y gastric bypass (RYGB) is one of the most common and most effective procedures performed to combat obesity and obesity-related metabolic disease. In a small proportion of patients, however, complications may necessitate the attempted reversal of RYGB to normal anatomy. The indications for this procedure, as well as technique, complication rate, and success in resolving symptoms are not clearly defined.nnnOBJECTIVEnTo assess current literature describing outcomes after reversal of RYGB.nnnMETHODSnA systematic search of online databases was conducted. Two independent researchers identified and extracted data for studies describing outcomes after RYGB reversal surgery. Indications, techniques, and outcomes were compared, with results pooled where possible.nnnRESULTSnEight articles were included in the final data synthesis, incorporating data for 46 patients. Reversal was undertaken due to metabolic, physical, nutritional, or other complications. All successfully underwent RYGB reversal with no reported mortality. Surgical technique varied greatly across the included studies. Postoperative morbidity was high, with 42% suffering complications (56% of which were major). Symptom relief or improvement was achieved in 82% of cases.nnnCONCLUSIONnReversal of RYGB may be undertaken for a variety of indications after RYGB. Though this may successfully eliminate or improve symptoms in a large proportion of patients, the risk of morbidity is high. Surgery should be undertaken after careful patient selection and in appropriately skilled centers only.

Laparoscopic sleeve gastrectomy using a synthetic bioabsorbable staple line reinforcement material: Post-operative complications and 6 year outcomes

Background Gastric leak after laparoscopic sleeve gastrectomy (LSG) is a serious complication. Currently, the literature lacks long-term outcomes in LSG and leak rates after reinforcement of the staple line. The aims are two-fold: to present leak rates from using staple line reinforcement and six year outcomes of LSG in relation to resolution of obesity-related comorbidities and long-term weight loss. Materials and methods This is a single-institution, retrospectively reviewed study of 204 patient case files. Data from all patients undergoing LSG between December 2007 and May 2013 was collected. Results The total complication rate was 6.9% (14/204), with no recorded staple line leaks. The mean postoperative Body Mass Index (BMI) at 1 year, 2 years, 3 years, 4 years, 5 years, and 6 years was 39.3 ± 8, 38.7 ± 8, 40.4 ± 9, 40.5 ± 10, 43.0 ± 10, and 42.4 ± 7, respectively. The mean % excess weight loss at 1 year, 3 years, and 6 years was 48.4 ± 19, 51.7 ± 28, and 41.0 ± 21, respectively. There were no significant differences between follow-ups at year 1 and 3 (p > 0.05), and between year 3 and 6 (p > 0.05) for the mean % excess weight loss. The resolution rates for all patients were 74%, 61%, 79%, and 90% for hypertension, hypercholesterolemia, diabetes mellitus type 2 and obstructive sleep apnea, respectively. Conclusion The synthetic bioabsorbable reinforcement material shows no staple line leaks making it safe to use. LSG as a procedure had a high resolution of obesity-related comorbidities as well as sustainable long-term weight loss.

Beyond Weight Loss: Establishing a Postbariatric Surgery Patient Support Group—What Do Patients Want?

Purpose There are limited resources for long-term specialist follow-up after bariatric surgery. In selected centres, patients can access a postoperative support group, but there is no clear evidence to guide their delivery. Materials and Methods A retrospective study of bariatric surgery patients (nu2009=u2009152) who had been discharged from specialist follow-up (mean time since surgery 5.5 years), covering weight history, physical and psychosocial comorbidities, and the need for a postoperative bariatric support group. Results Fifty-eight percent wanted a postbariatric surgery patient support group. This was not associated with operation type or the amount of weight lost or regained. However, those who wanted a support group were significantly more likely to be struggling to keep the weight off, to be unhappy with the way they look, or to be experiencing difficulties returning to work. Conclusions These data point to an unmet patient requirement for a postoperative support group that is independent of weight loss success. More research is required to ascertain how such a group should be delivered, but our data would suggest that supporting patients with weight loss maintenance, body image, and return to work is an important part of postoperative care, and these needs extend well beyond the immediate period of specialist follow-up.

Patient Characteristics, Procedural and Safety Outcomes of Bariatric Surgery in England: a Retrospective Cohort Study—2006–2012

BackgroundThe objective of the study is to analyze procedural and safety outcomes associated with bariatric surgery and describe the characteristics of patients undertaking bariatric procedures in England between April 2006 and March 2012.MethodsThis is a retrospective cohort study of all adult patients in England diagnosed with obesity and undergoing bariatric surgery as a primary procedure in NHS-funded sites between April 2006 and March 2012 using data sourced from the Hospital Episode Statistics dataset. Length of stay (LOS), 30-day readmission, and post-surgery complication were analyzed as primary outcomes. Socio-demographic background, provider type, procedure volume, and comorbidities were all analyzed as potential explanatory variables.ResultsGastric bypass (GBP, 12,628) was the most utilized procedure, followed by gastric banding (GB, 6872) and sleeve gastrectomy (SG, 3251). The most prevalent comorbidity was type 2 diabetes (23%). Inpatient mortality was low (≤xa00.15%) for all procedure types. LOS and the risks of both post-operative complication and 30-day readmission were significantly lower for GB, relative to those for GBP and SG. Ethnicity, geographical area, surgery type, and volume were all associated with LOS, risk of readmission, and complication. Provider type and deprivation were further associated with LOS while age correlated with readmission only. An increasing comorbidity burden was associated with an increased risk of both readmission and complication.ConclusionsGastric bypass was the most frequently reported procedure in England across the observation period. While utilization across all procedure types increased between 2007 and 2010, overall uptake of bariatric surgery in England represents only a small proportion of the eligible population. Readmission and complication rates were lower for gastric banding relative to those for either gastric bypass or sleeve gastrectomy. The observed inpatient mortality rate was low across all procedure types.

A randomised controlled trial of a duodenal-jejunal bypass sleeve device (EndoBarrier) compared with standard medical therapy for the management of obese subjects with type 2 diabetes mellitus

Introduction The prevalence of obesity and obesity-related diseases, including type 2 diabetes mellitus (T2DM), is increasing. Exclusion of the foregut, as occurs in Roux-en-Y gastric bypass, has a key role in the metabolic improvements that occur following bariatric surgery, which are independent of weight loss. Endoscopically placed duodenal-jejunal bypass sleeve devices, such as the EndoBarrier (GI Dynamics, Lexington, Massachusetts, USA), have been designed to create an impermeable barrier between chyme exiting the stomach and the mucosa of the duodenum and proximal jejunum. The non-surgical and reversible nature of these devices represents an attractive therapeutic option for patients with obesity and T2DM by potentially improving glycaemic control and reducing their weight. Methods and analysis In this multicentre, randomised, controlled, non-blinded trial, male and female patients aged 18–65 years with a body mass index 30–50 kg/m2 and inadequately controlled T2DM on oral antihyperglycaemic medications (glycosylated haemoglobin (HbA1c) 58–97 mmol/mol) will be randomised in a 1:1 ratio to receive either the EndoBarrier device (n=80) for 12 months or conventional medical therapy, diet and exercise (n=80). The primary outcome measure will be a reduction in HbA1c by 20% at 12 months. Secondary outcome measures will include percentage weight loss, change in cardiovascular risk factors and medications, quality of life, cost, quality-adjusted life years accrued and adverse events. Three additional subgroups will investigate the mechanisms behind the effect of the EndoBarrier device, looking at changes in gut hormones, metabolites, bile acids, microbiome, food hedonics and preferences, taste, brain reward system responses to food, eating and addictive behaviours, body fat content, insulin sensitivity, and intestinal tissue gene expression. Trial registration number ISRCTN30845205, ClinicalTrials.gov Identifier NCT02459561.