Marco Adamo

Type 2 diabetes remission 2 years post Roux‐en‐Y gastric bypass and sleeve gastrectomy: the role of the weight loss and comparison of DiaRem and DiaBetter scores

The comparative efficacy of Roux‐en‐Y gastric bypass (RYGB) and sleeve gastrectomy on Type 2 diabetes remission and the role of weight loss are unclear. The DiaRem diabetes remission prediction score uses HbA1c, age and diabetes medications but not diabetes duration. The aim of this study was to compare the DiaRem with the DiaBetter score that includes diabetes duration, upon combined (complete plus partial) 2‐year post‐surgery diabetes remission in people following RYGB and sleeve gastrectomy, and to investigate the relationship between weight loss and diabetes remission.

A case of severe anorexia, excessive weight loss and high peptide YY levels after sleeve gastrectomy

Summary Sleeve gastrectomy (SG) is the second most commonly performed bariatric procedure worldwide. Altered circulating gut hormones have been suggested to contribute post-operatively to appetite suppression, decreased caloric intake and weight reduction. In the present study, we report a 22-year-old woman who underwent laparoscopic SG for obesity (BMI 46 kg/m2). Post-operatively, she reported marked appetite reduction, which resulted in excessive weight loss (1-year post-SG: BMI 22 kg/m2, weight loss 52%, >99th centile of 1-year percentage of weight loss from 453 SG patients). Gastrointestinal (GI) imaging, GI physiology/motility studies and endoscopy revealed no anatomical cause for her symptoms, and psychological assessments excluded an eating disorder. Despite nutritional supplements and anti-emetics, her weight loss continued (BMI 19 kg/m2), and she required nasogastric feeding. A random gut hormone assessment revealed high plasma peptide YY (PYY) levels. She underwent a 3 h meal study following an overnight fast to assess her subjective appetite and circulating gut hormone levels. Her fasted nausea scores were high, with low hunger, and these worsened with nutrient ingestion. Compared to ten other post-SG female patients, her fasted circulating PYY and nutrient-stimulated PYY and active glucagon-like peptide 1 (GLP1) levels were markedly elevated. Octreotide treatment was associated with suppressed circulating PYY and GLP1 levels, increased appetite, increased caloric intake and weight gain (BMI 22 kg/m2 after 6 months). The present case highlights the value of measuring gut hormones in patients following bariatric surgery who present with anorexia and excessive weight loss and suggests that octreotide treatment can produce symptomatic relief and weight regain in this setting. Learning points Roux-en-Y gastric bypass and SG produce marked sustained weight reduction. However, there is a marked individual variability in this reduction, and post-operative weight loss follows a normal distribution with extremes of ‘good’ and ‘poor’ response. Profound anorexia and excessive weight loss post-SG may be associated with markedly elevated circulating fasted PYY and post-meal PYY and GLP1 levels. Octreotide treatment can produce symptomatic relief and weight regain for post-SG patients that have an extreme anorectic and weight loss response. The present case highlights the value of measuring circulating gut hormone levels in patients with post-operative anorexia and extreme weight loss.

Laparoscopic Heller's myotomy for achalasia after gastric bypass: A case report

INTRODUCTION Disorders of the oesophagus have been linked to surgical bariatric procedures and obesity. However the relationship between achalasia and gastric bypass is not clearly understood and has only recently been reported following gastric bypass. PRESENTATION OF CASE We present the case of a 53-year-old woman who re-presented following a gastric bypass with a new diagnosis of achalasia. This was treated successfully with laparoscopic Hellers Myotomy with discharge from hospital 10 days post operatively. DISCUSSION It is not clear whether achalasia is a complication of gastric bypass procedures. This is only the second reported case of the condition developing after this operation. The mechanism by which it may develop is yet to be clearly established. CONCLUSION This case highlights the need to investigate further a possible link between achalasia and gastric bypass and to manage susceptible patients accordingly in the pre-operative stage.

Early Effect of Bariatric Surgery on Urogenital Function in Morbidly Obese Men

INTRODUCTION Obesity is an independent risk factor for erectile dysfunction (ED) and lower urinary tract symptoms (LUTS). Bariatric surgery has been shown to improve erectile function and urinary symptoms in medium- to long-term studies (3- to 12-month postoperative follow-up). AIM To investigate the early effect (1 month postoperatively) of bariatric surgery on ED and LUTS, which has not previously been investigated. METHODS Morbidly obese men (body mass index > 35 kg/m2) undergoing bariatric surgery were asked to complete the International Index of Erectile Function (IIEF) and International Prostate Symptom Score (IPSS) questionnaires before surgery and 1, 3, and 6 months after surgery. MAIN OUTCOME MEASURE The influence of bariatric surgery on urogenital function, body mass index, fasting blood glucose, and glycated hemoglobin were analyzed using parametric and non-parametric tests for paired samples. RESULTS Of 30 patients who completed the study, 18 reported ED (IIEF score < 25) and 14 reported moderate or severe LUTS (IPSS ≥ 8) before the operation. Twelve patients had ED and moderate or severe LUTS. IIEF score, IPSS, body mass index, percentage of weight loss, fasting blood glucose, and glycated hemoglobin showed significant and rapid improvement after bariatric surgery starting at the 1-month postoperative time point and improvement continued throughout the study in all patients with ED or moderate to severe LUTS. CONCLUSION This is the first study showing improvement in erectile and urinary function within 1 month after bariatric surgery, an effect that was parallel to glycemic improvement and weight loss.

Single-stage conversions from failed gastric band to sleeve gastrectomy versus Roux-en-Y gastric bypass: results from the United Kingdom National Bariatric Surgical Registry

BACKGROUND For patients in whom laparoscopic adjustable gastric band has failed, conversion to Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy are both options for further surgical treatment. There are limited data comparing these 2 procedures. The National Bariatric Surgery Registry is a comprehensive United Kingdom-wide database of bariatric procedures, in which preoperative demographic characteristics and clinical outcomes are prospectively recorded. OBJECTIVES To compare perioperative complication rate and short-term outcomes of patients undergoing single-stage conversion of gastric band to Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy. SETTING United Kingdom national bariatric surgery database. METHODS From the National Bariatric Surgical Registry data set, we identified 141 patients undergoing single-stage conversion from gastric band to either gastric bypass (113) or sleeve gastrectomy (28) between 2009 and 2014, and analyzed their clinical outcomes. RESULTS With respect to perioperative outcomes gastric bypass was associated with a higher incidence of readmission or reintervention postoperatively (16 versus 0; P = .04). There was no difference in percentage excess weight loss between sleeve gastrectomy and gastric bypass at final follow-up at 1 year (52.1% versus 57.1% respectively; P = .4). CONCLUSIONS Conversion from band to sleeve or bypass give comparable good early excess weight loss; however, conversion to sleeve is associated with a better perioperative safety profile.

Gastro-cutaneous fistula 4 years after a fully resolved staple line leak in sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) has become a mainstream procedure in the management of obesity. Staple line leak is a challenging complication. We report a unique case of successfully treated leak after sleeve gastrectomy, presented ex novo 4 years later as a gastro-cutaneous fistula (GCF). Nothing similar was found in the literature. A 31-year-old woman underwent an LSG, complicated by an early type I leak treated successfully. After 4 years of clinical remission, the leak presented as a GCF. The conservative approach failed and a laparoscopic fistulectomy was first attempted, but after recurrence a completion gastrectomy was performed. A staple line leak is one of the most important complications after sleeve gastrectomy. Once chronic it evolves into GCF, the treatment of which is challenging. Given the absence of guidelines, experience is fundamental in its management. In our case, eventually a total gastrectomy was required.

Timing of pregnancy in obese women after bariatric surgery.

AIMS There is an increased risk of preterm and small-for-gestational-age births associated with bariatric surgery, especially if maternal early pregnancy body mass index (BMI) is <30.0kg/m(2). However, the relationship between timing of pregnancy post-bariatric surgery and effects on pregnancy outcome are unknown. The aim of this study was to investigate the timing of pregnancy post-bariatric surgery and compare early pregnancy BMI between women who became pregnant before or after the recommended 12month postoperative window. METHODS/RESULTS Women who underwent either sleeve gastrectomy or gastric bypass and subsequently became pregnant were offered antenatal care in a multidisciplinary high-risk clinic. There were 50 such pregnancies in women who attended our high-risk clinic (n=26 <12months and n=24 >12months postoperatively, mean estimated times to conception 31.9±12.6weeks and 102.8±37.7weeks respectively). There was no significant difference in early pregnancy BMI between groups (33.2±6.8kg/m(2) and 32.5+2.1kg/m(2) respectively, p=0.78). There were 6 miscarriages in each group, however more women in the <12month (n=8) than in the >12months group (n=2) were lost-to-follow-up (likelihood ratio 4.2, p=0.04). CONCLUSIONS Women who became pregnant <12months post-bariatric surgery were, for unknown reasons, less likely to attend follow-up in a specialist antenatal clinic than those who became pregnant >12months postoperatively. Further research is required to explore the relationship between timing of pregnancy post-bariatric surgery and pregnancy outcome and to identify predictors more clinically useful than early pregnancy BMI, in this high-risk pregnancy group.

Practices Concerning Revisional Bariatric Surgery: a Survey of 460 Surgeons

BackgroundThere is currently little evidence available on various aspects of Revisional Bariatric Surgery (RBS) and no published consensus amongst experts. The purpose of this study was to understand variation in practices concerning RBS.MethodsBariatric surgeons from around the world who perform RBS were invited to participate in a questionnaire-based survey on SurveyMonkey®.ResultsA total of 460 respondents from 62 countries took the survey. For revision after gastric banding, Roux-en-Y gastric bypass (RYGB) (75.5%, n = 345) emerged as the commonest choice followed by sleeve gastrectomy (SG) (56.9%, n = 260) and one anastomosis gastric bypass (OAGB) (37.2%, n = 170). For revision after SG, RYGB (77.7%, n = 355) was the commonest option followed by OAGB (42.45%, n = 194) and re-sleeve (22.32%, n = 102). For revision after RYGB, surgical pouch reduction (49.1%, n = 223), prolongation of bilio-pancreatic limb (30.0%, n = 136), and surgical stoma size reduction (26.43%, n = 120) were the most preferred options. Approximately 90.0% of respondents (n = 406/454) routinely perform an upper gastrointestinal endoscopy before an RBS, and 85.6% (n = 388/453) routinely perform a contrast study. Ninety percent (n = 403/445) reported that the demand for RBS was usually patient-driven, and there was wide variation in criteria used to define successful response, non-responders, and significant weight regain.ConclusionsThis survey is the first attempt to understand various aspects of RBS. The findings will help in identifying areas for research and allow consensus building amongst experts.

日 本 語 要 約 Epigenome ­ wide association study of body mass index , and the adverse outcomes of adiposity

Approximately 1.5 billion people worldwide are overweight or affected by obesity, and are at risk of developing type 2 diabetes, cardiovascular disease and related metabolic and inflammatory disturbances. Although the mechanisms linking adiposity to associated clinical conditions are poorly understood, recent studies suggest that adiposity may influence DNA methylation, a key regulator of gene expression and molecular phenotype. Here we use epigenome-wide association to show that body mass index (BMI; a key measure of adiposity) is associated with widespread changes in DNA methylation (187 genetic loci with P < 1 × 10−7, range P = 9.2 × 10−8 to 6.0 × 10−46; n = 10,261 samples). Genetic association analyses demonstrate that the alterations in DNA methylation are predominantly the consequence of adiposity, rather than the cause. We find that methylation loci are enriched for functional genomic features in multiple tissues (P < 0.05), and show that sentinel methylation markers identify gene expression signatures at 38 loci (P < 9.0 × 10−6, range P = 5.5 × 10−6 to 6.1 × 10−35, n = 1,785 samples). The methylation loci identify genes involved in lipid and lipoprotein metabolism, substrate transport and inflammatory pathways. Finally, we show that the disturbances in DNA methylation predict future development of type 2 diabetes (relative risk per 1 standard deviation increase in methylation risk score: 2.3 (2.07–2.56); P = 1.1 × 10−54). Our results provide new insights into the biologic pathways influenced by adiposity, and may enable development of new strategies for prediction and prevention of type 2 diabetes and other adverse clinical consequences of obesity.

Outcomes of 50 patients entering an adolescent bariatric surgery programme

Objective Bariatric surgery is the most effective intervention for weight loss and obesity-related comorbidities currently available. Little is known about adolescents entering National Health Service (NHS) bariatric programmes. We aimed to characterise those entering a pathway and report their outcomes. Design Prospective service evaluation of patients assessed within a single NHS adolescent bariatric service. Results 50 patients assessed between 26 July 2007 and 27 January 2014; 6 (12%) were not eligible for surgery, 7 (14%) actively opted out, 8 (16%) were lost to follow-up and 29 (58%) underwent surgery (18 sleeve gastrectomy (SG) 11 Roux-en-y gastric bypass (RYGB) and 0 adjustable gastric band). Mean (SD) age at initial assessment was 16.0 (1.3) years and 18.3 (1.3) at surgery (youngest 15.7 years). Mean time taken to surgery was 1.8 years; longer in those with higher body mass index (BMI) and aged below 14 at first assessment. Mean (SD) BMI at surgery was 53.1 (8.3) kg/m2, lower in those undergoing RYGB (−5.2, 95% CI −11.6 to 1.13). Follow-up was inconsistent and challenging; 1/29 (3.5%) was transferred to a regional centre, 10/29 (34.5%) attended ongoing follow-up within our protocol, 6/29 (20.7%) had intermittent monitoring and 12/29 (41.4%) were lost to follow-up. Mean BMI change at 1 year (−14.0 kg/m2) and complications were similar to published cohorts. Data from 11 lost to follow-up were obtained and outcomes appeared similar to those who actively followed up. Conclusion Adolescent bariatric surgery in the NHS appears effective, with outcomes similar to those reported internationally. Further work is needed to optimise postsurgical surveillance and reduce age at surgery.