Evangelos Efthimiou

Bariatric Surgery and Non-Alcoholic Fatty Liver Disease: a Systematic Review of Liver Biochemistry and Histology

BackgroundNon-alcoholic fatty liver disease (NAFLD) is becoming a leading cause of global liver disease that is associated with the rising prevalence of obesity worldwide. There is now increasing clinical and mechanistic evidence reporting on the metabolic and weight loss effects of bariatric surgery on improving NAFLD in obese patients.ObjectivesThe aim of this paper was to quantify the effects of bariatric surgery on NAFLD by appraising the modulation between pre- and post-operative liver enzyme levels (as markers of liver injury) and liver histology.MethodsA systematic review of studies reporting pre-operative and post-operative liver enzymes or liver histology was done in obese patients with NAFLD undergoing bariatric surgery. Data were meta-analysed using random-effects modelling. Subgroup analysis, quality scoring and risk of bias were assessed.ResultsBariatric surgery is associated with a significant reduction in the weighted incidence of a number of histological features of NAFLD including steatosis (50.2 and 95xa0%CI of 35.5–65.0), fibrosis (11.9 and 95xa0%CI of 7.4–16.3xa0%), hepatocyte ballooning (67.7 and 95xa0%CI 56.9–78.5) and lobular inflammation (50.7 and 95xa0%CI 26.6–74.8xa0%). Surgery is also associated with a reduction in liver enzyme levels, with statistically significant reductions in ALT (11.36xa0u/l, 95xa0%CI 8.36–14.39), AST (3.91xa0u/l, 95xa0%CI 2.23–5.59), ALP (10.55xa0u/l, 95xa0%CI 4.40–16.70) and gamma-GT (18.39xa0u/l, 95xa0%CI 12.62–24.16). Heterogeneity in results was high.ConclusionsBariatric surgery is associated with a significant improvement in both histological and biochemical markers of NAFLD. Future studies must focus on higher levels of evidence to better identify the benefits of bariatric surgery on liver disease in order to enhance future treatment strategies in the management of NAFLD.

The Effects of Bariatric Surgery on Cardiac Structure and Function: a Systematic Review of Cardiac Imaging Outcomes

BackgroundObesity is associated with cardiac dysfunction, atherosclerosis, and increased cardiovascular risk. It can be lead to obesity cardiomyopathy and severe heart failure, which in turn raise morbidity and mortality while carrying a negative impact on quality of life. There is increasing clinical and mechanistic evidence on the metabolic and weight loss effects of bariatric surgery on improving cardiac structure and function in obese patients.ObjectivesThe objective of this study was to quantify the effects of bariatric surgery on cardiac structure and function by appraising cardiac imaging changes before and after metabolic operations.MethodsThis is a comprehensive systematic review of studies reporting pre-operative and post-operative echocardiographic or magnetic resonance cardiac indices in obese patients undergoing bariatric surgery. Studies were quality scored, and data were meta-analyzed using random effects modeling.ResultsBariatric surgery is associated with significant improvements in the weighted incidence of a number of cardiac indices including a decrease in left ventricular mass index (11.2xa0%, 95xa0% confidence intervals (CI) 8.2–14.1xa0%), left ventricular end-diastolic volume (13.28xa0ml, 95xa0% CI 5.22–21.34xa0ml), and left atrium diameter (1.967xa0mm, 95xa0% CI 0.980–2.954). There were beneficial increases in left ventricular ejection fraction (1.198xa0%, 95xa0%CI −0.050–2.347) and E/A ratio (0.189xa0%, 95xa0%CI −0.113–0.265).ConclusionsBariatric surgery offers beneficial cardiac effects on diastolic function, systolic function, and myocardial structure in obese patients. These may derive from surgical modulation of an enterocardiac axis. Future studies must focus on higher evidence levels to better identify the most successful bariatric approaches in preventing and treating the broad spectrum of obesity-associated heart disease while also enhancing treatment strategies in the management of obesity cardiomyopathy.

Magnesium deficiency in patients with chronic pancreatitis identified by an intravenous loading test.

Magnesium deficiency is a common clinical condition that may exist despite a normal serum magnesium concentration. Patients with chronic pancreatitis could develop magnesium deficiency due to either malabsorption, diabetes mellitus, or chronic alcoholism. Since serum levels of magnesium are a poor indicator of magnesium deficiency, the retention of a low-dose intravenous magnesium load (0.1 mmol/kg body weight) was determined in 13 patients with chronic pancreatitis (10 due to alcoholism) and eight healthy controls. Percentage magnesium retention was greater in patients with chronic pancreatitis than controls (59.8+/-37.3% S.D. versus 22.0+/-38.2% S. D.: P=0.038), and 10 of 13 patients showed evidence of magnesium deficiency. Routine evaluation of magnesium status could allow appropriate supplementation and conceivably symptomatic improvement in patients with severe chronic pancreatitis.

Comparison of Gastrojejunal Anastomosis Techniques in Laparoscopic Roux-en-Y Gastric Bypass: Gastrojejunal Stricture Rate and Effect on Subsequent Weight Loss

BackgroundDifferent gastrojejunal anastomotic (GJA) techniques have been described in laparoscopic Roux-en-Y gastric bypass (LRYGB). There is conflicting data on whether one technique is superior to the other. We aimed to compare hand-sewn (HSA), circular-stapled (CSA) and linear-stapled (LSA) anastomotic techniques in terms of stricture rates and their impact on subsequent weight loss.MethodsA prospectively collected database was used to identify patients undergoing LRYGB surgery between March 2005 and May 2012. Anastomotic technique (HSA, CSA, LSA) was performed according to individual surgeon preference. The database recorded patient demographics, relevant comorbidities and the type of GJA performed. Serial weight measurements and percentage excess weight loss (%EWL) were available at defined follow-up intervals.ResultsIncluded in the data were 426 patients, divided between HSA (nu2009=u2009174, 40.8xa0%), CSA (nu2009=u2009110, 25.8xa0%) and LSA (nu2009=u2009142, 33.3xa0%). There was no significant difference in the stricture rates (HSA nu2009=u200917, 9.72xa0%; CSA nu2009=u20099, 8.18xa0%; LSA nu2009=u20098, 5.63xa0%; pu2009=u20090.4006). Weight loss was similar between the three techniques (HSA, CSA and LSA) at 3xa0months (40.6xa0%u2009±u200916.2xa0% vs 35.92xa0%u2009±u200921.42xa0% vs 48.21xa0%u2009±u200914.79xa0%; pu2009=u20090.0821), 6xa0months (61.48xa0%u2009±u200923.94xa0% vs 58.16xa0%u2009±u200927.31xa0% vs 60.18xa0%u2009±u200922.26xa0%; pu2009=u20090.2296), 12xa0months (72.94xa0%u2009±u200919.93xa0% vs 69.72u2009±u200921.42xa0% vs 66.05xa0%u2009±u200917.75xa0%; pu2009=u20090.0617) and 24xa0months (73.29xa0%u2009±u200922.31xa0% vs 68.75xa0%u2009±u200924.71xa0% vs 69.40xa0%u2009±u200923.10xa0%; pu2009=u20090.7242), respectively.The stricture group lost significantly greater weight (%EWL) within the first 3xa0months compared to the non-stricture group (45.39xa0%u2009±u200916.82xa0% vs 39.22xa0%u2009±u200921.93xa0%; pu2009=u20090.0340); however, this difference had resolved at 6xa0months (61.29xa0%u2009±u200918.50xa0% vs 59.79xa0%u2009±u200923.03xa0%; pu2009=u20090.8802) and 12xa0months (71.59xa0%u2009±u200918.67xa0% vs 68.69xa0%u2009±u200922.19xa0%; pu2009=u20090.5970).ConclusionsThere was no significant difference in the rate of strictures between the three techniques, although the linear technique appears to have the lowest requirement for post-operative dilatation. The re-intervention rate will, in part, be dictated by the threshold for endoscopy, which will vary between units. Weight loss was similar between the three anastomotic techniques. Surgeons should use techniques that they are most familiar with, as stricture and weight loss rates are not significantly different.

Bariatric surgery and nonalcoholic fatty liver disease.

The rising prevalence of nonalcoholic fatty liver disease (NAFLD) is associated with the increasing global pandemic of obesity. These conditions cluster with type II diabetes mellitus and the metabolic syndrome to result in obesity-associated liver disease. The benefits of bariatric procedures on diabetes and the metabolic syndrome have been recognized for some time, and there is now mounting evidence to suggest that bariatric procedures improve liver histology and contribute to the beneficial resolution of NAFLD in obese patients. These beneficial effects derive from a number of weight-dependent and weight-independent mechanisms including surgical BRAVE actions (bile flow changes, restriction of stomach size, anatomical gastrointestinal rearrangement, vagal manipulation, enteric hormonal modulation) and subsequent effects such as reduced lipid intake, adipocytokine secretion, modulation of gut flora, improvements in insulin resistance and reduced inflammation. Here, we review the clinical investigations on bariatric procedures for NAFLD, in addition to the mounting mechanistic data supporting these findings. Elucidating the mechanisms by which bariatric procedures may resolve NAFLD can help enhance surgical approaches for metabolic hepatic dysfunction and also contribute toward developing the next generation of therapies aimed at reducing the burden of obesity-associated liver disease.

Bariatric Surgery or Non-surgical Weight Loss for Idiopathic Intracranial Hypertension? A Systematic Review and Comparison of Meta-analyses

BackgroundIdiopathic intracranial hypertension (IIH) is associated with obesity and weight loss by any means is considered beneficial in this condition.ObjectivesThis study aims to appraise bariatric surgery vs. non-surgical weight-loss (medical, behavioural and lifestyle) interventions in IIH management.MethodsA systematic review and meta-analyses of surgical and non-surgical studies.ResultsBariatric surgery achieved 100% papilloedema resolution and a reduction in headache symptoms in 90.2%. Non-surgical methods offered improvement in papilloedema in 66.7%, visual field defects in 75.4% and headache symptoms in 23.2%. Surgical BMI decrease was 17.5 vs. 4.2 for non-surgical methods.ConclusionsWhilst both bariatric surgery and non-surgical weight loss offer significant beneficial effects on IIH symptomatology, future studies should address the lack of prospective and randomised trials to establish the optimal role for these interventions.

Type 1 Diabetes Mellitus and Bariatric Surgery: A Systematic Review and Meta-Analysis

BackgroundType 1 diabetes mellitus (T1DM) has a rising global prevalence. Although it is vastly outnumbered by type 2 diabetes mellitus rates, it remains a persistent worldwide source of morbidity and mortality. Increasingly, its sufferers are afflicted by obesity and its complications. The objective of the study is to quantify the effects of bariatric surgery on T1DM by appraising the primary outcomes of glycosylated haemoglobin (HbA1c), insulin requirements and body mass index (BMI). Secondary outcomes included blood pressure, triglycerides and cholesterol biochemistry.MethodsA systematic review of studies reporting pre-operative and post-operative outcomes in T1DM patients undergoing bariatric surgery was done. Data were meta-analysed using random effects modelling. Subgroup analysis and quality scoring were assessed.ResultsBariatric surgery in obese T1DM patients is associated with a significant reduction in insulin requirement (−48.95 units, 95xa0% CI of −56.27, −41.62), insulin requirement per kilogramme (−0.391, 95xa0% CI of −0.51, −0.27), HbA1c (−0.933, 95xa0% CI of −1.604, −0.262) and BMI (−11.04xa0kg/m2, 95xa0% CI of −13.49, −8.59). Surgery is also associated with a statistically significant reduction in systolic and diastolic blood pressure and a significant beneficial rise in HDL. Heterogeneity in these results was high, and study quality was low overall.ConclusionsBariatric surgery in obese T1DM patients is associated with a significant improvement in insulin requirement and a significant though modest effect on HbA1c. These early results require further substantiation with future studies focusing on higher levels of evidence. This may offer a deeper understanding of diabetogenesis and can contribute to better selection and stratification of diabetic patients for metabolic surgery and future metabolic treatment strategies.

Is Social Deprivation Associated with Weight Loss Outcomes Following Bariatric Surgery? A 10-Year Single Institutional Experience

BackgroundSocial deprivation is associated with a greater morbidity and shorter life expectancy. This study evaluates differences in weight loss following bariatric surgery and deprivation, based on UK deprivation measures in a London bariatric centre.MethodsAll patients undergoing bariatric surgery between 2002 and 2012 were retrospectively identified. Demographic details, type of surgery and percentage excess weight loss data were collected. UK Index of Multiple Deprivation (IMD, 2010) and IMD domain of the Health Deprivation and Disability (HDD) scores were used to assess deprivation (where 1 is the most deprived in rank order and 32,482 is the least deprived). Two-way between-subjects analysis of variance (ANOVA) was performed to examine the effect of IMD score, deprivation, procedure type and gender on percentage excess weight loss.ResultsData were included from 983 patients (178 male, 805 female) involving 3,663 patient episodes. Treatments comprised laparoscopic gastric bands (nu2009=u2009533), gastric bypass (nu2009=u2009362) and gastric balloons (nu2009=u200988). The average percentage excess weight loss across all procedures was 38xa0% over a follow-up period (3xa0months–9xa0years). There was no correlation between weight loss and IMD/HDD rank scores. Gastric bypass was significantly more effective at achieving weight loss than the other two procedures at 3-, 6- and 9-month and 1-year follow-up.ConclusionsSocial deprivation does not influence weight loss after bariatric surgery, suggesting that all socioeconomic groups may equally benefit from surgical intervention. Social deprivation should not therefore negatively influence the decision for surgical intervention in these patients.

Intragastric balloon outcomes in super-obesity: a 16-year city center hospital series

BACKGROUNDnIntragastric balloons represent an endoscopic therapy aimed at achieving weight loss by mechanical induction of satiety. Their exact role within the bariatric armamentarium remains uncertain.nnnOBJECTIVEnOur study aimed to evaluate the use of intragastric balloon therapy alone and before definitive bariatric surgery over a 16-year period.nnnSETTINGnA large city academic bariatric center for super-obese patients.nnnMETHODSnBetween January 2000 and February 2016, 207 patients underwent ORBERA intragastric balloon placement at esophagogastroduodenoscopy. Four surgeons performed the procedures, and data were entered prospectively into a dedicated bariatric database. Patients weight loss data were measured through body mass index (BMI) and excess weight loss and recorded at each clinic review for up to 5 years (60 mo). Treatment arms included intragastric balloon alone with lifestyle therapy or intragastric balloon and definitive bariatric surgery: gastric banding, sleeve gastrectomy, or Roux-en-Y gastric bypass. An additional treatment arm of analysis included the overall results from intragastric balloon followed by stapled procedure.nnnRESULTSnOne hundred twenty-nine female and 78 male patients had a mean age of 44.5 (±11.3) years and a mean BMI of 57.3 (±9.7) kg/m2. Fifty-eight percent of patients suffered from type 2 diabetes. Time from initial or first balloon insertion to definitive surgical therapy ranged between 9 and 13 months. Seventy-six patients had intragastric balloon alone, and 131 had intragastric balloon followed by definitive procedure. At 60 months postoperatively the intragastric balloon alone with lifestyle changes demonstrated an excess weight loss of 9.04% and BMI drop of 3.8; intragastric balloon with gastric banding demonstrated an excess weight loss of 32.9% and BMI drop of 8.9. Intragastric balloon and definitive stapled procedure demonstrated a BMI drop of 17.6 and an excess weight loss of 52.8%. Overall, there were 3 deaths (1.4%), 2 within 10 days due to acute gastric perforation secondary to vomiting and 1 cardiac arrest at 4 weeks postoperatively.nnnCONCLUSIONnIntragastric balloons can offer effective weight loss in selected super-obese patients within a dedicated bariatric center offering multidisciplinary support. Balloon insertion alone offers only short-term weight loss; however, when combined with definitive bariatric surgical approaches, durable weight loss outcomes can be achieved. A strategy of early and continual vigilance for side effects and a low threshold for removal should be implemented. Surgeon and unit experience with intragastric balloons can contribute to kick starting successful weight loss as a bridge to definitive therapy in an established bariatric surgical pathway.

Management of Bariatric Emergencies by the General Surgeon

The epidemic of obesity affects almost all countries of the developed world and has led to a dramatic increase in the number of bariatric procedures worldwide. In the United Kingdom (UK), the adoption of weight loss surgery has been via dedicated regional bariatric centres, and there is a drive for shorter stays in hospital after surgery. Both these factors make it inevitable that almost every doctor sooner or later will encounter a patient who has undergone bariatric surgery, even if they do not work in a bariatric centre. Although safe, bariatric surgery has potential complications, which if recognised early and treated promptly can minimise the negative impact on outcomes.