Long-term improvement of adipocyte insulin action during body weight relapse after bariatric surgery: a longitudinal cohort study

BackgroundThere are few long-term mechanistic studies in adipose tissue that investigate the metabolic effects of bariatric surgery. Changes in lipogenesis may be involved in long-term weight development.ObjectivesTo investigate the long-term effect of bariatric surgery on lipogenesis in abdominal fat cells and whether surgical treatment could induce an epigenetic memory that would maintain improved lipogenesis in spite of body weight relapse.SettingKarolinska University Hospital in Stockholm County, Sweden.MethodsA total of 22 women with obesity living in the Stockholm area were examined before, 2, 5, and 10 years after bariatric surgery. Abdominal adipose tissue biopsies were obtained. Fat cells were isolated and spontaneous and insulin stimulated glucose incorporation into lipids were assayed. CpG-methylation profiling was performed on adipocytes using the Infinium EPIC BeadChips.ResultsBariatric surgery was associated with improvement in adipocyte spontaneous and insulin stimulated lipogenesis, which was maintained despite some later weight regain (29 % of initial weight loss). There was also an increase in fat cell size between 2- and 10-year follow-up, albeit not to presurgery levels. There were 7729 differentially methylated CpG sites (DMS) at 2 years that showed no sign of return to baseline at either 5 or 10 years. Merging results with expression profiles identified 1259 genes with DMS which showed early response or continual change in expression in one direction after surgery. Upregulated genes with DMS were enriched in gene sets linked to cellular response to insulin stimulus (e.g., IRS1, IRS2, PDE3B, and AKT2) and regulation of lipid metabolic processes.ConclusionBariatric surgery leads to long-term improvement of lipogenesis and insulin responsiveness in subcutaneous adipocytes in women in spite of some partial body weight regain postoperatively. This may to some extent be explained by epigenetic modifications of fat cell function.     

Method of venous thromboembolism prophylaxis is not a predictor of pulmonary embolus following elective bariatric surgery: a retrospective cohort study of 135,409 patients

BackgroundPatients with obesity are at increased risk of pulmonary embolus (PE), a risk that increases perioperatively and is challenging to manage.ObjectiveAn analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database was performed to determine predictors of PE in patients undergoing elective bariatric surgery.SettingNorth American accredited bariatric surgery institutions included in the MBSAQIP database from 2020–2021.MethodsWe extracted data from the MBSAQIP database (2020–2021) on patients who underwent elective Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Data were extracted on patient co-morbidities, race, prior history of deep vein thrombosis (DVT), and type of DVT prophylaxis. A multivariate logistic regression model was developed to determine predictors of PE and impact of PE on 30-day serious complications and mortality.ResultsIn the MBSAQIP database, a total of 135,409 patients underwent SG or RYGB from 2020 to 2021. PE was reported in 194 patients (.14%). Prior history of DVT (odds ratio [OR] = 3.28; 95% confidence interval [CI]: 1.85–5.83; P < .0001), Black race (OR = 3.03; 95% CI: 2.22–4.13; P < .0001), gastroesophageal reflux disease (OR = 1.51; 95% CI: 1.11–2.04; P = .008), higher body mass index (OR = 1.11; 95% CI: 1.01–1.20; P = .023), male sex (OR = 1.76; 95% CI: 1.26–2.45; P = .001), and older age (OR = 1.27; 95% CI: 1.10–1.46; P = .001) were associated with increased odds of PE. Chronic obstructive pulmonary disease, sleep apnea, and hypertension were not significant predictors of PE (P > .05). Neither combined mechanical and pharmacologic DVT prophylaxis nor pharmacologic prophylaxis alone was a significant predictor of PE (P > .05).ConclusionPrior history of DVT is the strongest predictor of PE after bariatric surgery. African American race, male sex, and gastroesophageal reflux disease are additional risk factors. Method of venous thromboembolism prophylaxis was not identified as significant predictor of PE. Further, studies on the evaluation and optimization of venous thromboembolism prophylaxis are required.     

Glycemic outcomes in patients with type 2 diabetes after bariatric surgery compared with routine care: a population-based,real-world cohort study in the United Kingdom

BackgroundClinical trials have shown that bariatric surgery (BS) is associated with better glycemic control and diabetes remission in patients with type 2 diabetes (T2D) compared with routine care.ObjectiveWe conducted a real-world population-based study examining the impact of BS on glycemic control and medications in patients with T2D.Setting and MethodsThis was a retrospective, matched, controlled cohort study conducted between January 1, 1990, and January 31, 2018, using IQVIA Medical Research Data, a primary care electronic records database. Adults with body mass index (BMI) ≥30 kg/m² and T2D who had BS (surgical) were matched for age, sex, BMI, and diabetes duration to two controls (with T2D and no BS).ResultsA total of 1126 patients in the surgical group and 2219 patients in the control group were analyzed. Mean (standard deviation) age was 50.0 (9.3) years, 67.6% were women, baseline glycocylated hemoglobin (HbA1C) was 7.8% (1.7 mmol/mol), and diabetes duration was 4.7 years (range, 2.0–8.4 years). Over a median (interquartile range) follow-up of 3.6 years (1.7–5.9 years), a higher proportion of patients in the surgical group achieved an HbA1C of ≤6.0% than the control group (65.8% versus 22.8%). The surgical group showed a decrease in mean HbA1C of 1.5% (95% confidence interval [CI]: 1.4%–1.7%), 1.4% (1.2%–1.5%), and 1.3% (1.1%–1.5%) at 1-, 2-, and 3-year follow-up, respectively, whereas HbA1C increased in the control group. The proportion of patients receiving glucose-lowering medications decreased in the surgical group (92.2% to 66.5%) but increased in the control group (85.3% to 90.2%).ConclusionBS is associated with significant improvement in glycemic control, achievement of normal HbA1C levels, and reduced need for glucose-lowering therapy in patients with T2D.     

Major cardiovascular events after metabolic surgery in patients with previous heart disease with or without type 2 diabetes: a nationwide cohort study

BackgroundWhile metabolic surgery is known to improve type 2 diabetes (T2D) as well as established heart disease separately, it is not known whether the outcome is influenced by T2D status in patients with established heart disease.ObjectivesTo evaluate the risks for major cardiovascular events (MACE) or mortality in patients with established heart disease with or without T2D.SettingNationwide and registry-based (Sweden).MethodsPatients with established heart disease operated with sleeve gastrectomy or Roux-en-Y gastric bypass in Sweden from 2007–2019 were matched 1:1 to normal population controls using 2-staged matching (exact matching on T2D, followed by optimal matching on propensity score for age, sex, dyslipidemia, chronic obstructive pulmonary disease, type of heart disease, T2D duration, county of residence, and level of education). The risk for MACE was evaluated separately depending on T2D status.ResultsIn total, 1513 patients who underwent surgery and 1513 matched controls were included. Reduced risk for MACE and mortality were seen after metabolic surgery for patients with heart disease and T2D compared with controls (adjusted hazard ratio [HR] = .59, 95% confidence interval [CI]: .48–.72, P < .001, and adjusted HR = .52, 95% CI: .40–.67, P < .001, respectively), and for patients with heart disease alone compared with controls (adjusted HR = .73, 95% CI: .57–.94, P = .016, and adjusted HR = .63, 95% CI: .45–.89, P = .008, respectively).ConclusionMetabolic surgery was associated with a reduced risk for MACE and mortality in patients with preexisting heart disease and T2D as well as in patients with heart disease without T2D. Patients with heart disease and T2D seem to experience the highest risk reduction.     

Association between preoperative serum albumin levels with risk of death and postoperative complications after bariatric surgery: a retrospective cohort study

BackgroundHypoalbuminemia is common among individuals with obesity who qualify for bariatric surgery, but its relevance to clinical outcomes after bariatric surgery remains to be established.ObjectivesTo examine the association of preoperative serum albumin with 30-day postoperative outcomes.SettingData from the 2015–2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Files were used.MethodsPreoperative serum albumin level was categorized as hypoalbuminemia (<3.5 g/dL), and normoalbuminemia (3.5–5.5 g/dL) among patients who underwent bariatric surgery. Multivariate logistic regression models were used to determine the association of preoperative hypoalbuminemia with 30-day postoperative mortality and other co-morbid outcomes.ResultsAmong 633,011 adult patients, 85.1% were women and the mean (standard deviation) age was 44.8 (12.0) years. The prevalence of hypoalbuminemia was 6.13% (n = 38,792). After adjustment for procedure type and demographic, lifestyle, and co-morbidity covariates, the odds ratio (OR) (95% confidence interval [CI]) for mortality was 1.42 (1.10, 1.82) for hypoalbuminemia. For all other outcomes, the ORs (95% CIs) for hypoalbuminemia ranged from 1.03 (.67–1.60) for cardiac arrest requiring CPR to 2.32 (1.66–3.25) for failure to be discharged by day 30. The ORs for several associations were higher for severe hypoalbuminemia than marginal hypoalbuminemia.ConclusionPreoperative hypoalbuminemia was associated with several negative 30-day postoperative bariatric surgery outcomes and tended to be worse for severe hypoalbuminemia compared with marginal hypoalbuminemia. These findings suggest that serum albumin may be a useful biomarker to screen for negative bariatric surgery outcomes.     

Sleeve gastrectomy in patients with severe obesity and baseline chronic kidney disease improves kidney function independently of weight loss: a propensity score matched analysis

BackgroundIn the last 10 years, severe obesity and the associated metabolic syndrome have reached pandemic proportions and consequently have significantly increased the prevalence of related co-morbidities such as chronic kidney disease (CKD). One in 7 people in the United States have CKD, and 90% of those are not aware of it.ObjectivesFollowing sleeve gastrectomy (SG) in patients with severe obesity and baseline CKD stage ≥2, to determine improvement of glomerular function and analyze the relationship between kidney function and weight loss.SettingUS Hospital, Academic Institution.MethodsWe retrospectively reviewed the charts of all patients who underwent SG at our institution from 2010 to 2019. Kidney function assessment using the Chronic Kidney Disease Epidemiology Collaboration Study (CKD-EPI) equation and classification was carried out preoperatively and postoperatively at 12-months follow-up. Propensity score matching (1:1 ratio) was used to balance the distribution of covariates between patients with a baseline estimated glomerular filtration rate (eGFR) <90 mL/min/1.73 m² and patients with normal kidney function.ResultsWe calculated the eGFR of 1330 bariatric patients who underwent SG. Of these patients, 18.79% (n = 250) met the criteria for CKD-EPI eGFR calculation preoperatively and at 12-months follow-up after SG. From the 250 patients included in the analysis, 42% (n = 105) were classified as CKD stage ≥2. When comparing the baseline preoperative eGFR at 12-months follow-up after SG, we observed an improvement of 8.26 ± 11.89 mL/min/1.73 m² in CKD stage ≥2 (eGFR <90 mL/min/1.73 m²) as compared with 1.98 ± 10.25 mL/min/1.73 m² in patients with eGFR >90 mL/min/1.73 m² (P < .001).ConclusionThere is short-term improvement of the eGFR in patients with severe obesity following SG. This improvement is significant in CKD stages ≥2 and seems unrelated to weight loss.     

Minimalinvasive operative Korrektur von Kleinzehenfehlstellung

Lesser toe deformities are among the more frequent problems that need operative corrections. Common procedures are an Arthrodesis of the PIP-Joint, a flexor tendon transfer or a resection arthroplasty of the PIP-Joint. Recently, minimally invasive techniques have gained popularity. The main advantage of these techniques is that they are possible even with critical soft tissue conditions due to their less invasive character, a reduced infection rate and a reduction in operative time.Its main disadvantages are a steep learning curve and the need for special equipment like rotating burrs and image intensifiers.In this article, operative techniques are outlined and discussed. Clinical situations which can be solved with minimally invasive techniques are presented.     

Beiträge der Österreichischen Fußchirurgie zum Thema Osteotomien an den distalem Metatarsalia 2-5

Metatarsalgia is a common and well-known problem in the orthopedic office. Since 1916 metatarsal osteotomies are described for the treatment of this pathology. Austrian orthopedic surgeons and Foot & Ankle specialists have worked on this topic. A special focus was on the clinical and biomechanical analysis of the Weil osteotomy. Also, the next step of the evolution of the treatment of metatarsalgia, the DMMO (Distal Metaphyseal Metatarsal Osteotomy) was accompanied with clinical studies. Recent literature shows that if the criteria of indications are respected, the DMMO is a reproducible and safe technique. Since this technique has shown a learning curve, thorough training is necessary.     

机器人与腹腔镜手术治疗造口旁疝18例临床分析

目的探讨达芬奇机器人和腹腔镜微创手术在造口旁疝治疗中的应用。 方法回顾性分析2018年4月至2022年4月在福建医科大学附属协和医院使用达芬奇机器人系统和腹腔镜行微创造口旁疝无张力修补术的18例患者资料。记录并比较两组手术时间、术中出血量、恢复进食时间、术后切口感染、麻痹性肠梗阻、引流管拔除时间、住院天数等,远期随访指标包括复发、补片感染、慢性疼痛。 结果18例均顺利完成造口旁疝无张力修补术,合并行造口重建术4例（22.2%）。Sugarbaker法修补13例（72.2%）,其中使用达芬奇机器人系统2例,使用腹腔镜11例;Keyhole法修补5例（27.7%）,其中使用达芬奇机器人系统1例,使用腹腔镜4例。手术时间191~406 min,平均（276.8±71.3）min。术中出血量20~100 ml,平均（29.3±22.2）ml。术后第2天恢复流质饮食,第3天进食半流质;放置引流管病例,术后5~7 d拔除引流管;常规腹带束缚3~6个月。术后住院时间3~19 d,平均（8.2±4.7）d。术后复发1例（5.6%）,切口感染1例（5.6%）,麻痹性肠梗阻3例（16.7%）,肺部感染6例（33.3%）,切口感染及麻痹性肠梗阻病例均经过非手术治疗后痊愈出院。随访期间均未出现复发、补片感染、慢性疼痛。 结论使用达芬奇机器人系统和腹腔镜进行微创造口旁疝无张力修补术均安全可行,围手术期并发症少,术后恢复快,疗效确切。