Principles and results of bariatric surgery

Bariatric surgery is followed by substantial and durable weight loss and associated with it favorable metabolic effects far beyond those achieved by lifestyle modifications and pharmacological treatments. The perioperative and postoperative morbidity and mortality have decreased significantly over the years to the level that bariatric surgery now can compare with other frequently recommended and well-accepted procedures such as cholecystectomy and hysterectomy. In fact, the postoperative mortality risk of bariatric surgery is far lower than that of coronary artery bypass surgery but with significantly greater improvement in long-term mortality. Much of the improvement in perioperative morbidity and mortality can be attributed to advances in many components of the care chain such as the introduction of laparoscopic surgery, as well as establishment of a nationwide center of excellence network and required outcome reporting. Extensive evidence on safety and efficacy supports bariatric surgery as the standard of care for treatment of severe obesity. Bariatric surgery reduces the risk of global mortality, all-cause mortality and cardiovascular mortality when compared to obese control patients. Both gastric banding and gastric bypass seem to reduce mortality risk.     

Syncope Secondary to Obesity?

The frequency of obesity is increasing worldwide. The relationship between obesity and mortality is known. Bariatric surgery is well established in the treatment of morbid obesity to reduce weight permanently. Bariatric procedures are effective and influencing associated comorbidities. Adjustable gastric banding is a popular and effective bariatric operation in Europe for more than 10 years. Classic complications of gastric banding are known, but here we describe one more example. In this study, we report the case of a patient with gastric banding who presented with syncope after a meal.     

Bariatric surgery and the kidneys

Overweight and obesity are connected with increased risk of obesity related co-morbidities, such as T2DM, hypertension, cardiovascular diseases, dyslipidaemia and others, as well as in higher risk of some malignant diseases. In obese population there is 2.5-3.3 fold increased risk of renal cell carcinoma in comparison with non-obese population of similar age. It has been proven in many studies that for severely obese patients there is no other more effective treatment of their obesity and co-morbidities than bariatric. Bariatric surgery decreases mortality risks, treat existing, obesity related co-morbidities, and can act as prevention of onset of new obesity related co-morbidities. Moreover at the end bariatric surgery lowers economic burden of health care systems. Nowadays, bariatric surgery is considered to be standard treatment option and pathway in complex management of morbidly obese patients.     

Adipositaschirurgie

Every fifth German is obese, which means that 20% of male and 21.1% of female adults have a BMI of more than 30. In total 1.02 million adults in Germany are morbidly obese (BMI>40). This pandemic situation of obesity and morbid obesity is similar to the incidence of obesity in North America. In consideration of the increasing incidence of obesity the long-term success rate of conservative obesity treatment of 1?C2% does not ease this situation. Widespread prevention programs are not planned. The current only, as well long-term, effective therapy against morbid obesity is bariatric surgery. There is an arsenal of restrictive (e.g. gastric band, gastric sleeve) and combinations of restrictive and malabsorptive procedures (Roux-en-Y gastric bypass, biliopancreatic diversion) available to treat morbid obesity. Bariatric surgery can not only induce excess weight loss of 75?C80% but also a remission of co-morbidities, such as type 2 diabetes mellitus or metabolic syndrome. Even the tremendously reduced life expectancy of morbidly obese patients could be adapted to normal weight subjects by bariatric surgery.     

腹腔镜Roux-en-Y胃旁路术规范化手术操作指南（2019版）

目前中国肥胖症和2型糖尿病（T2DM）的患病人数已居全球首位，大量的循证医学证据表明腹腔镜Roux-en-Y胃旁路手术（LRYGB）可显著减轻病态肥胖症患者体重，并有效改善T2DM等一系列肥胖相关合并症。尽管LRYGB手术在国内已有超过14年历史，然而仍缺少规范化的手术操作指南，因此，中国医师协会外科医师分会肥胖和糖尿病外科医师委员会（CSMBS）发起编写首版《腹腔镜Roux-en-Y胃旁路术规范化手术操作指南》，旨在推荐标准化的LRYGB手术操作，为肥胖与代谢病外科领域的临床医生提供规范化手术操作的参考。     

Bariatric surgery for obese children and adolescents: a systematic review and meta‐analysis

The number of obese young people continues to rise, with a corresponding increase in extreme obesity and paediatric‐adolescent bariatric surgery. We aimed to (i) systematically review the literature on bariatric surgery in children and adolescents; (ii) meta‐analyse change in body mass index (BMI) 1‐year post‐surgery and (iii) report complications, co‐morbidity resolution and health‐related quality of life (HRQoL). A systematic literature search (1955–2013) was performed to examine adjustable gastric band, sleeve gastrectomy, Roux‐en‐Y gastric bypass or biliopancreatic diversions operations among obese children and adolescents. Change in BMI a year after surgery was meta‐analysed using a random effects model. In total, 637 patients from 23 studies were included in the meta‐analysis. There were significant decreases in BMI at 1 year (average weighted mean BMI difference: ?13.5 kg m^?2; 95% confidence interval [CI] ?14.1 to ?11.9). Complications were inconsistently reported. There was some evidence of co‐morbidity resolution and improvements in HRQol post‐surgery. Bariatric surgery leads to significant short‐term weight loss in obese children and adolescents. However, the risks of complications are not well defined in the literature. Long‐term, prospectively designed studies, with clear reporting of complications and co‐morbidity resolution, alongside measures of HRQol, are needed to firmly establish the harms and benefits of bariatric surgery in children and adolescents.     

Future role for endoluminal procedures in “high-risk” bariatric patients

Bariatric surgery remains the gold standard for therapy of the morbidly obese patient. However, these procedures are not without risk. Risk factors for adverse events and readmission after bariatric surgery are well studied. Included in these risk factors are preoperative weight, liver size, and medical comorbidities that can be improved with modest weight loss before bariatric surgery and other major abdominal procedures. This article reviews intragastric space-occupying devices, endoluminal gastric volume reduction procedures, gastric content aspiration therapy, and endoluminal duodenal exclusion as possible choices to “bridge” the high-risk patient to bariatric surgery and as a possible alternative to bariatric surgery. The current state of the literature is robust for the intragastric balloon, supporting both primary and preoperative indications. The limited literature support for gastric volume reduction, gastric content aspiration, and endoluminal barrier therapy is reviewed.     

Bariatric surgery for morbidly obese adolescents: Is there a rationale for early intervention?

Obesity is one of the most common metabolic disorders affecting the US population: 31% of adults and 16% of adolescents now meet the criteria for obesity. Similar to the rising prevalence of morbid obesity in adults, the prevalence of more severe obesity is also increasing in pediatric patients. The most effective treatment for morbid obesity is bariatric surgery, a procedure most commonly performed in the fifth and sixth decades of life. Although it is clear that rapid, profound weight loss can significantly improve multiple comorbid conditions in adults, including disordered carbohydrate metabolism, obstructive sleep apnea, and cardiovascular risk factors, it is not clear to what degree similar comorbidities are affected in adolescents undergoing surgical weight loss. In this paper, the indications, contraindications, and early surgical outcomes of gastric bypass surgery for morbidly obese adolescents are reviewed, and important directions for future research are discussed.     

Considerations for bariatric surgery in patients with cirrhosis

With the ever increasing global obesity pandemic, clinical burden from obesity related complications are anticipated in parallel. Bariatric surgery, a treatment approved for weight loss in morbidly obese patients, has reported to be associated with good outcomes, such as reversal of type two diabetes mellitus and reducing all-cause mortality on a long term basis. However, complications from bariatric surgery have similarly been reported. In particular, with the onslaught of non-alcoholic fatty liver disease(NAFLD) epidemic, in associated with obesity and metabolic syndrome, there is increasing prevalence of NAFLD related liver cirrhosis, which potentially connotes more risk of specific complications for surgery. Bariatric surgeons may encounter, either expectedly or unexpectedly, patients with non-alcoholic steatohepatitis(NASH) and NASH related cirrhosis more frequently. As such, the issues and considerations surrounding their medical care/surgery warrant careful deliberation to ensure the best outcomes. These considerations include severity of cirrhosis, liver synthetic function, portal hypertension and the impact of surgical factors. This review explores these considerations comprehensively and emphasizes the best approach to managing cirrhotic patients in the context of bariatric surgery.     

Molecular insights from bariatric surgery

Bariatric surgical procedures have become important therapeutic options for treatment of morbid obesity in both adults and adolescents co-morbidities of obesity such as glucose intolerance, type 2 diabetes (T2DM), metabolic syndrome, steatohepatitis, hyperlipidemia and cardiovascular disease. These co-morbidities of obesity have significant impacts on the overall quality of life of the individual and our society at large. Roux-en-Y gastric bypass (RYGB) and the relatively newer procedures of gastric banding (GB) and vertical sleeve gastrectomy (VSG) have proven to be efficacious in achieving rapid weight loss and reversing the comorbidities of obesity. Unfortunately, bariatric procedures are not without risks including micronutrient deficiency, failure to maintain lost weight, and mortality. Further, the resolution of T2DM has long been understood to precede weight loss, and this finding provides important clues about the physiologic underpinnings of the observation. In order to design more effective, safe, and widely available therapeutics for obesity, important and highly relevant questions need to be addressed regarding mechanisms behind the weight-loss-independent benefits of bariatric surgical procedures. This review will provide an overview of the molecular changes occurring across all biological systems after bariatric surgery including the changes in hepatic, adipocyte and gut derived signals after surgery. We will also discuss existing literature regarding the weight-loss-independent metabolic benefits including improvement in insulin sensitivity and central nervous system integration of these signals.     

Laparoscopic sleeve gastrectomy for morbid obesity

The incidence of obesity is steadily rising, and it has been estimated that 40% of the US population will be obese by the year 2025 if the current trend continues. In recent years there has been renewed interest in the surgical treatment of morbid obesity in concomitance with the epidemic of obesity. Bariatric surgery proved effective in providing weight loss of large magnitude, correction of comorbidities and excellent short-term and long-term outcomes, decreasing overall mortality and providing a marked survival advantage. The Laparoscopic Sleeve Gastrectomy （LSG） has increased in popularity and is currently very ＂trendy＂ among laparoscopic surgeons involved in bariatric surgery. As LSG proved to be effective in achieving considerable weight loss in the short-term, it has been proposed by some as a sole bariatric procedure. This editorial focuses on the particular advantages of LSG in the treatment of morbid obesity.     

Medical and surgical management of obesity and diabetes: what's new?

We conducted a narrative review of the medical and surgical management of people with obesity and diabetes. Results of this review showed that a 5–10% loss in body weight can be achieved with a change in lifestyle, diet and behaviour and with approved pharmacological therapies in people with obesity and diabetes. New targeted therapies are now available for patients with previously untreatable genetic causes of obesity. Compared to medical treatment, metabolic and bariatric surgery is associated with significantly higher rates of remission from type 2 diabetes and lower rates of incident macrovascular and microvascular complications and mortality. The National Institute for Health and Care Excellence and the American Diabetes Association endorse metabolic and bariatric surgery in obese adults with type 2 diabetes and there may also be a role for this in obese individuals with type 1 diabetes. The paediatric committee of the American Society for Metabolic and Bariatric Surgery have recommended metabolic and bariatric surgery in obese adolescents with type 2 diabetes. Earlier and more aggressive treatment with metabolic and bariatric surgery in obese or overweight people with diabetes can improve morbidity and mortality.     

Gastrointestinal and nutritional complications after bariatric surgery

The prevalence of obesity has increased to epidemic proportions, making obesity and its comorbid conditions a major public health concern. Bariatric surgery is the most effective treatment, but it carries substantial morbidity. The subsequent gastrointestinal and nutritional complications are often not recognized or properly managed. As part of the multidisciplinary team taking care of obese patients, gastroenterologists should be familiar with the types of bariatric surgery and their associated complications. We review the most common gastrointestinal and nutritional complications after bariatric procedures and examine how gastroenterologists may best prevent, investigate, and treat them.     

Endoscopic bariatric procedures: Assessment of postintervention safety and success

Morbid obesity has become one of the largest health care crises facing modern medicine. Medical intervention alone has proven inadequate in addressing this issue. Although bariatric surgery has been proven to be the most effective treatment for the medical comorbidities associated with morbid obesity, only a fraction of obese patients will undergo bariatric surgery owing to fear, financial restraint, and limited access to surgical expertise. There exists a void for which endoscopic therapies can provide substantial improvements in the care of the morbidly obese patient. Compared to traditional surgical therapies, endoscopic approaches may potentially speed recovery with decreased pain, incisional hernia development, and surgical site infections. Primary endoscopic bariatric procedures can be classified as space-occupying, restrictive, or bypass. These procedures, as well as foresight into endoscopic bridges to surgery and revisional approaches, are discussed herein.     

Obesity – an indication for GLP‐1 treatment? Obesity pathophysiology and GLP‐1 treatment potential

Obesity is common and associated with a high rate of morbidity and mortality; therefore, treatment is of great interest. At present, bariatric surgery is the only truly successful treatment of severe obesity. Mimicking one of the effects of bariatric surgery, namely the increased secretion of glucagon‐like peptide (GLP)‐1, by artificially increasing the levels of GLP‐1 might prove successful as obesity treatment. Recent studies have shown that GLP‐1 is a physiological regulator of appetite and food intake. The effect on food intake and satiety is preserved in obese subjects and GLP‐1 may therefore have a therapeutic potential. The GLP‐1 analogues result in a moderate average weight loss, which is clinically relevant in relation to reducing the risk of type 2 diabetes and cardiovascular disease. Inspired by the hormone profile after gastric bypass, a future strategy in obesity drug development could be to combine several hormones, and thereby produce a superior appetite suppressing hormone profile that may result in a weight loss exceeding that seen in single‐agent trials. In conclusion, with the GLP‐1 analogues combining a moderate weight loss with beneficial effects on metabolic and cardiovascular risk factors, it seems that we are on the right track for future treatment of obesity.     

Oral Anticoagulant Use in Morbid Obesity and Post Bariatric Surgery: A Review

Bariatric surgery has emerged as a therapy for obesity and the associated comorbidities. Obesity has been shown to be a risk factor for atrial fibrillation as well as venous thromboembolism, both of which are conditions that warrant anticoagulation. There is significant underrepresentation of the morbidly obese population in prospective trials that evaluated direct oral anticoagulants and vitamin K antagonists in atrial fibrillation and venous thromboembolism. We aim to review all the available data that assessed these oral anticoagulants in the morbidly obese population (body mass index >40 kg/m² and weight >120 kg) and in the post-bariatric surgery population. Our findings suggest that direct oral anticoagulants may be safe and effective for anticoagulation in morbidly obese patients for both atrial fibrillation and venous thromboembolism. However, warfarin is the preferred agent in the post-bariatric surgery population, given the limited number of studies on direct oral anticoagulants in this population. Further adequately powered randomized control trials are needed to confirm the safety and efficacy of these oral anticoagulants in the morbidly obese and post-bariatric surgery population.     

Surgical treatment of obesity

More than half of the European population are overweight (body mass index (BMI) > 25 and < 30 kg/m2) and up to 30% are obese (BMI > or = 30 kg/m2). Being overweight and obesity are becoming endemic, particularly because of increasing nourishment and a decrease in physical exercise. Insulin resistance, type 2 diabetes, dyslipidemia, hypertension, cholelithiasis, certain forms of cancer, steatosis hepatis, gastroesophageal reflux, obstructive sleep apnea, degenerative joint disease, gout, lower back pain, and polycystic ovary syndrome are all associated with overweight and obesity. The endemic extent of overweight and obesity with its associated comorbidities has led to the development of therapies aimed at weight loss. The long-term effects of diet, exercise, and medical therapy on weight are relatively poor. With respect to durable weight reduction, bariatric surgery is the most effective long-term treatment for obesity with the greatest chances for amelioration and even resolution of obesity-associated complications. Recent evidence shows that bariatric surgery for severe obesity is associated with decreased overall mortality. However, serious complications can occur and therefore a careful selection of patients is of utmost importance. Bariatric surgery should at least be considered for all patients with a BMI of more than 40 kg/m2 and for those with a BMI of more than 35 kg/m2 with concomitant obesity-related conditions after failure of conventional treatment. The importance of weight loss and results of conventional treatment will be discussed first. Currently used operative treatments for obesity and their effectiveness and complications are described. Proposed criteria for bariatric surgery are given. Also, some attention is devoted to more basic insights that bariatric surgery has provided. Finally we deal with unsolved questions and future directions for research.     

Bariatric surgery: a review of procedures and outcomes

The prevalence of obesity has increased in recent decades, and obesity is now one of the leading public health concerns on a worldwide scale. There is accumulating agreement that bariatric surgery is currently the most efficacious and enduring treatment for clinically severe obesity, and as a result, the number of bariatric surgery procedures performed has risen dramatically in recent years. This review will summarize historic and contemporary bariatric surgical techniques, including gastric bypass (open and laparoscopic), laparoscopic adjustable gastric banding, and biliopancreatic diversion (with or without duodenal switch). Data are presented on bariatric surgery outcomes, focusing on weight loss and obesity-related comorbidities. We also review possible complications from surgery. Bariatric surgery patients undergo many dramatic lifestyle changes, and comprehensive presurgical screening conducted by a multidisciplinary team is important to prepare patients for the numerous changes necessary for successful outcome. In addition, comprehensive presurgical screening can aid the treatment team in identifying patients who would benefit from additional services prior to or following surgery. Further research focused on presurgical variables that predict outcome-especially the longer term outcome-of bariatric surgery is needed. At present, approximately 1% of eligible individuals with morbid obesity receive bariatric surgery. In addition, there appears to be inequity in access to weight loss surgery. Given the accumulating evidence that bariatric surgery is efficacious in producing significant and durable weight loss, improving obesity-related comorbidities, and extending survival, the U.S. healthcare system should examine ways to improve access to this treatment for obesity.     

Current status of bariatric surgery in the treatment of type 2 diabetes

Bariatric surgery (from the Greek words baros meaning ‘weight’ and iatrikos‘the art of healing’) is a rapidly evolving branch of surgical science. The aim is to induce major weight loss in those whose obesity places them at high risk of serious health problems. In an attempt to balance the risks of surgery against the benefits of weight loss, bariatric operations are currently performed only in the morbidly obese, or those with a body mass index (BMI) > 35 kgm^?2 who already have developed comorbidity such as type 2 diabetes. Although weight loss is beneficial for obese patients with diabetes, current medical treatment for obesity is difficult. In contrast, observational studies show a major impact of bariatric surgery on diabetes, raising the question whether this approach should be used more widely to treat diabetes in obese patients? If bariatric surgery were shown to be the best way to treat diabetes in obese subjects the implications for health services would be wide‐ranging. Bariatric surgery leads to withdrawal of diabetic treatment in about 60% or more of patients, and reductions of therapy for many others. Although data on bariatric surgery in subjects with diabetes are provocative, most studies have been uncontrolled or flawed in other ways. Most importantly, bariatric surgery has not yet been compared against standard medical treatment for diabetes in randomized controlled trials with diabetes‐specific endpoints in all relevant patient groups. Potential indications for bariatric surgery are discussed, and the unanswered questions that need to be addressed by clinical trials are summarized. Although small numbers of patients may be interested in bariatric surgery for type 2 diabetes, current data are insufficient to endorse its wide scale use for this indication. Until essential studies are undertaken the role and economics of bariatric surgery in the diabetic clinic will remain uncertain.     

Collaboration between basic science researchers and bariatric surgeons is a win/win proposition: view from the chair

Bariatric surgery in humans offers a window of opportunity to further our understanding of obesity and associated diseases. In the morbidly obese subjects, physiological disturbances are amplified and their extreme manifestations are more easily measured. The significant and predictable effects of bariatric surgery present a striking contrast to preoperative morbid conditions. The bariatric procedure is a reproducible therapy occurring at a precise time point; this facilitates the recording of preoperative and postoperative parameters over a short period of time, with some assurance that the contrasted conditions will confirm or disprove hypotheses with manageable numbers of subjects, thus providing an economy of means and efforts in a shorter time frame.