Alpana Shukla

Initial experience with endoscopic sleeve gastroplasty: technical success and reproducibility in the bariatric population.

BACKGROUND AND AIMS Novel endoscopic techniques have been developed as effective treatments for obesity. Recently, reduction of gastric volume via endoscopic placement of full-thickness sutures, termed endoscopic sleeve gastroplasty (ESG), has been described. Our aim was to evaluate the safety, technical feasibility, and clinical outcomes for ESG. PATIENT AND METHODS Between August 2013 and May 2014, ESG was performed on 10 patients using an endoscopic suturing device. Their weight loss, waist circumference, and clinical outcomes were assessed. RESULTS Mean patient age was 43.7 years and mean body mass index (BMI) was 45.2 kg/m(2). There were no significant adverse events noted. After 1 month, 3 months, and 6 months, excess weight loss of 18 %, 26 %, and 30 %, and mean weight loss of 11.5 kg, 19.4 kg, and 33.0 kg, respectively, were observed. The differences observed in mean BMI and waist circumference were 4.9 kg/m(2) (P = 0.0004) and 21.7 cm (P = 0.003), respectively. CONCLUSIONS ESG is effective in achieving weight loss with minimal adverse events. This approach may provide a cost-effective outpatient procedure to add to the steadily growing armamentarium available for treatment of this significant epidemic.

Bariatric, metabolic, and diabetes surgery: what's in a name?

Objective:This study investigated the practical clinical consequences of offering surgery for metabolic disease and diabetes as opposed to weight loss. Background:The terms “metabolic” and “diabetes surgery” indicate a surgical approach whose primary intent is the control of metabolic alterations/hyperglycemia in contrast to “bariatric surgery,” conceived as a mere weight-reduction therapy. Methods:A “metabolic surgery” program distinct from the “bariatric surgery” program was recently established at a tertiary US academic medical center. The 2 programs differ in their stated goals but offer the same procedures and use identical eligibility criteria for patients with morbid obesity. Demographics, clinical characteristics, and 30-day postoperative morbidity and mortality were assessed from a prospective database of 200 consecutive patients who underwent surgery at these units. Results:Metabolic surgery patients were older (45.8 ± 13.4 v 41.8 ± 11.7, P < 0.05), had a lower body mass index (42.4 ± 7.1 vs 48.6 ± 9.5 kg/m2; P < 0.01), and a higher prevalence of being of the male sex (42% vs 26%, P < 0.05), having diabetes (62% vs 35%; P < 0.01), hypertension (68% vs 52%; P < 0.05), dyslipidemia (48% vs 31%; P < 0.05), and cardiovascular disease (14% vs 5%; P < 0.05). Diabetes was more severe among metabolic surgery patients (higher glycated hemoglobin levels; greater percentage of insulin use). There was no mortality, and there were no differences in perioperative complications. Conclusions:Offering surgery to treat metabolic disease or diabetes rather than as a mere weight-reduction therapy changes demographical and clinical characteristics of surgical candidates. This has important and practical ramifications for clinical care and support consideration of metabolic/diabetes surgery as a novel practice distinct from traditional bariatric surgery.

Percutaneous Gastrostomy Device for the Treatment of Class II and Class III Obesity: Results of a Randomized Controlled Trial

Objectives:The AspireAssist System (AspireAssist) is an endoscopic weight loss device that is comprised of an endoscopically placed percutaneous gastrostomy tube and an external device to facilitate drainage of about 30% of the calories consumed in a meal, in conjunction with lifestyle (diet and exercise) counseling.Methods:In this 52-week clinical trial, 207 participants with a body-mass index (BMI) of 35.0–55.0 kg/m2 were randomly assigned in a 2:1 ratio to treatment with AspireAssist plus Lifestyle Counseling (n=137; mean BMI was 42.2±5.1 kg/m2) or Lifestyle Counseling alone (n=70; mean BMI was 40.9±3.9 kg/m2). The co-primary end points were mean percent excess weight loss and the proportion of participants who achieved at least a 25% excess weight loss.Results:At 52 weeks, participants in the AspireAssist group, on a modified intent-to-treat basis, had lost a mean (±s.d.) of 31.5±26.7% of their excess body weight (12.1±9.6% total body weight), whereas those in the Lifestyle Counseling group had lost a mean of 9.8±15.5% of their excess body weight (3.5±6.0% total body weight) (P<0.001). A total of 58.6% of participants in the AspireAssist group and 15.3% of participants in the Lifestyle Counseling group lost at least 25% of their excess body weight (P<0.001). The most frequently reported adverse events were abdominal pain and discomfort in the perioperative period and peristomal granulation tissue and peristomal irritation in the postoperative period. Serious adverse events were reported in 3.6% of participants in the AspireAssist group.Conclusions:The AspireAssist System was associated with greater weight loss than Lifestyle Counseling alone.

Surgical control of obesity and diabetes: The role of intestinal vs. gastric mechanisms in the regulation of body weight and glucose homeostasis

To elucidate the specific role of gastric vs. intestinal manipulations in the regulation of body weight and glucose homeostasis.

Surgical control of obesity and diabetes

To elucidate the specific role of gastric vs. intestinal manipulations in the regulation of body weight and glucose homeostasis.

Endoscopic Sleeve Gastroplasty Significantly Reduces Body Mass Index and Metabolic Complications in Obese Patients

BACKGROUND & AIMS Endoscopic sleeve gastroplasty (ESG) is an incisionless, minimally invasive bariatric procedure that reduces the length and width of the gastric cavity to facilitate weight loss. We performed a prospective study to evaluate the effects of ESG on total body weight loss and obesity‐related comorbidities. METHODS We collected data from 91 consecutive patients (mean age, 43.86 ± 11.26 years; 68% female) undergoing ESG from August 2013 through March 2016. All patients had a body mass index (BMI) greater than 30 kg/m2 and had failed noninvasive weight‐loss measures or had a BMI greater than 40 kg/m2 and were not considered as surgical candidates or refused surgery. All procedures were performed with a cap‐based flexible endoscopic suturing system to facilitate a triangular pattern of sutures to imbricate the greater curvature of the stomach. Patients were evaluated after 6 months (n = 73), 12 months (n = 53), and 24 months (n = 12) for anthropometric features (BMI, weight, waist circumference, blood pressure) and underwent serologic (hemoglobin A1c), lipid panel, serum triglycerides, and liver function tests. The primary outcomes were total body weight loss at 6, 12, and 24 months. Secondary outcomes were the effects of ESG on metabolic factors (blood pressure, diabetes, hyperlipidemia, steatohepatitis) and safety. RESULTS The patients’ mean BMI before the procedure was 40.7 ± 7.0 kg/m2. Patients had lost 14.4% of their total body weight at 6 months (80% follow‐up rate), 17.6% at 12 months (76% follow‐up rate), and 20.9% at 24 months (66% follow‐up rate) after ESG. At 12 months after ESG, patients had statistically significant reductions in levels of hemoglobin A1c (P = .01), systolic blood pressure (P = .02), waist circumference (P < .001), alanine aminotransferase (P < .001), and serum triglycerides (P = .02). However, there was no significant change in low‐density lipoprotein after vs before ESG (P = .79). There was one serious adverse event (1.1%) (perigastric leak) that occurred that was managed non‐operatively. CONCLUSIONS ESG is a minimally invasive and effective endoscopic weight loss intervention. In addition to sustained total body weight loss up to 24 months, ESG reduced markers of hypertension, diabetes, and hypertriglyceridemia.

Surgical treatment of type 2 diabetes: the surgeon perspective

Type 2 diabetes mellitus (T2DM) is a major health priority globally, having achieved pandemic status in the twenty-first century. Several gastrointestinal procedures that were primarily designed to treat morbid obesity result in dramatic remission of diabetes. Studies in experimental rodent models and humans have shown that the glycemic benefits of surgery are at least in part weight-independent and extend to non-morbidly obese subjects with T2DM. Bariatric procedures differ in their ability to ameliorate type 2 diabetes, with intestinal bypass procedures being more effective than purely restrictive procedures. Several studies have demonstrated that the benefits of bariatric surgery extend beyond amelioration of hyperglycemia and include improvement in other cardiovascular risk factors such as dyslipidemia and hypertension. The safety and cost-effectiveness of bariatric surgery are also well established by several studies. In this paper, the authors present the surgeon perspective on the management of type 2 diabetes focusing on the efficacy, safety and cost-effectiveness of metabolic surgery. The available evidence warrants the inclusion of metabolic surgery in the treatment algorithm of type 2 diabetes.

Food Order Has a Significant Impact on Postprandial Glucose and Insulin Levels.

Postprandial hyperglycemia is an important therapeutic target for optimizing glycemic control and for mitigating the proatherogenic vascular environment characteristic of type 2 diabetes. Existing evidence indicates that the quantity and type of carbohydrate consumed influence blood glucose levels and that the total amount of carbohydrate consumed is the primary predictor of glycemic response (1). Previous studies have shown that premeal ingestion of whey protein, as well as altering the macronutrient composition of a meal, reduces postmeal glucose levels (2–4). There are limited data, however, regarding the effect of food order on postprandial glycemia in patients with type 2 diabetes (5). In this pilot study, we sought to examine the effect of food order, using a typical Western meal, incorporating vegetables, protein, and carbohydrate, on postprandial glucose and insulin excursions in overweight/obese adults with type 2 diabetes. A total of 11 subjects (6 female, 5 male) with metformin-treated type 2 diabetes were studied …

The utility of weight loss medications after bariatric surgery for weight regain or inadequate weight loss: A multi-center study

BACKGROUND Patients who undergo bariatric surgery often have inadequate weight loss or weight regain. OBJECTIVES We sought to discern the utility of weight loss pharmacotherapy as an adjunct to bariatric surgery in patients with inadequate weight loss or weight regain. SETTING Two academic medical centers. METHODS We completed a retrospective study to identify patients who had undergone bariatric surgery in the form of a Roux-en-Y gastric bypass (RYGB) or a sleeve gastrectomy from 2000-2014. From this cohort, we identified patients who were placed on weight loss pharmacotherapy postoperatively for inadequate weight loss or weight regain. We extracted key demographic data, medical history, and examined weight loss in response to surgery and after the initiation of weight loss pharmacotherapy. RESULTS A total of 319 patients (RYGB = 258; sleeve gastrectomy = 61) met inclusion criteria for analysis. More than half (54%; n = 172) of all study patients lost≥5% (7.2 to 195.2 lbs) of their total weight with medications after surgery. There were several high responders with 30.3% of patients (n = 96) and 15% (n = 49) losing≥10% (16.7 to 195.2 lbs) and≥15% (25 to 195.2 lbs) of their total weight, respectively, Topiramate was the only medication that demonstrated a statistically significant response for weight loss with patients being twice as likely to lose at least 10% of their weight when placed on this medication (odds ratio = 1.9; P = .018). Regardless of the postoperative body mass index, patients who underwent RYGB were significantly more likely to lose≥5% of their total weight with the aid of weight loss medications. CONCLUSIONS Weight loss pharmacotherapy serves as a useful adjunct to bariatric surgery in patients with inadequate weight loss or weight regain.

Low adoption of weight loss medications: A comparison of prescribing patterns of antiobesity pharmacotherapies and SGLT2s

To characterize the adoption of antiobesity pharmacotherapies, as compared with that of the newest antidiabetes pharmacotherapy, subtype 2 sodium‐glucose transport protein inhibitors (SGLT2s), among prescribers in the United States.