“It’s a tool,not a cure”: the preoperative teen perspective on bariatric surgery

BackgroundBariatric surgery is well established in adults as the most effective tool for sustained weight loss and reduction of obesity-related co-morbidities, and is an emerging option for adolescents in whom conservative approaches have failed. Narratives are vital in understanding the motivating reasons and psychosocial profiles of adolescents considering bariatric surgery during a developmental period of evolving self-concept, body image sensitivity, peer pressure, and increased opportunity for risky behaviors.ObjectivesTo explore preoperative adolescent patient perspectives on their decision to pursue bariatric surgery, anticipated physical and psychosocial effects, and preparation process.SettingsThe Hospital for Sick Children (SickKids) in Toronto, Ontario, Canada.MethodsWe conducted 14 semi-structured interviews with adolescents (16–18 yr old) 2–4 months before bariatric surgery. A theoretical thematic analysis was conducted with 3 independent reviewers (interrater reliability, Cronbach’s α= .81) and conflicts were resolved through discussion.ResultsPatients’ perspectives are captured in 4 themes: motivation for surgery, effects on health and habits, psychosocial changes, and support systems during preparation. Participants perceived surgery as a tool but not a solution for weight loss. Most were motivated for health and daily functional improvement rather than aesthetic reasons, and some anticipated improved social interactions while maintaining their self-identity. Participants were selective in sharing news of their surgery, and received varying levels of support from families, friends, and healthcare teams.ConclusionAdolescents seem generally prepared for and informed about surgery, with expectations for weight loss and psychosocial improvements, although uncertainty and contradictory thoughts were prevalent. Insights provided by these adolescent patients will help optimize bariatric surgery assessments and support from clinical teams and inform preoperative education for future patients and families.     

Remote unaffiliated presurgical psychosocial evaluations: a qualitative assessment of the attitudes of ASMBS members

BackgroundA psychosocial evaluation is an important component of the preoperative assessment process for people seeking metabolic and bariatric surgery (MBS), and is required for accreditation of MBS programs. Recently, independent companies without affiliations with MBS programs have been marketing remotely administered, unaffiliated psychosocial evaluations for MBS (RUS), and American Society for Metabolic and Bariatric Surgery (ASMBS) members have raised concerns about these evaluations.ObjectivesTo explore ASMBS members’ beliefs about RUS.SettingOnline survey.MethodsWe developed a survey to evaluate ASMBS members’ opinions, experiences, and/or concerns about in-person and RUS psychosocial evaluations for MBS.ResultsIn total, 635 ASMBS members responded to the online survey and 156 responded to an open-ended question on RUS. Responses were coded based on a manual developed for this study, yielding themes of concerns about the quality of RUS, lack of ongoing relationships in RUS, and conditions under which/reasons why RUS evaluations could be acceptable.ConclusionRespondents expressed both interest in and concerns about RUS in pre-MBS psychosocial evaluations. Use of RUS has the potential to improve access to MBS by providing a convenient and efficient means of completing the psychosocial evaluation. Conversely, respondents expressed concerns about the background and training of RUS providers, the quality of the reports, and the limited relationships between the RUS provider and both the MBS patient and the MBS team. We discuss the clinical and research implications of response themes, particularly for patients in rural areas or those who have other barriers to care.     

Effects of bariatric surgery on patients with obesity and polycystic ovary syndrome: a meta-analysis

BackgroundBariatric surgery is effective for polycystic ovary syndrome (PCOS), while the exact mechanism remains unclear.ObjectivesTo assess the impact of bariatric surgery on PCOS patients and further explore the possible mechanism.SettingA meta-analysis.MethodsWe searched PubMed, Web of Science, The Cochrane Library, and Embase to identify relevant studies published before November 2020.ResultsTwenty-one studies met our inclusion criteria, and we identified 552 patients with PCOS study. Results showed that the prevalence of preoperative PCOS, menstrual irregularity, hirsutism, type 2 diabetes (T2D), hypertension, infertility, and depression significantly decreased after bariatric surgery. Levels of total testosterone, fasting insulin, and luteinizing hormone (LH) decreased and estradiol increased, while levels of follicle-stimulating hormone (FSH) and LH/FSH did not show significant changes during the 3-month follow-up. There were decreases in testosterone and fasting insulin levels when the postoperative follow-up time was 6 months or ≥12 months. Levels of fasting blood glucose and triglycerides were significantly reduced after 6 months or ≥12 months of bariatric surgery. High-density lipoprotein (HDL) and sex hormone-binding globulin (SHBG) significantly improved ≥12 months after bariatric surgery.ConclusionSymptoms of PCOS and related complications are significantly alleviated after bariatric surgery. In addition, we found a significant improvement on anomalous secretion of gonadotropins, glucose metabolism, and lipid metabolism in patients with PCOS after bariatric surgery.     

Hypothyroidism and levothyroxine therapy following bariatric surgery: a systematic review,meta-analysis,network meta-analysis,and meta-regression

BackgroundMany health benefits of bariatric surgery are known and well-studied, but there is scarce data on the benefits of bariatric surgery on the thyroid function.ObjectiveWe aimed to make a meta-analysis regarding the impact of bariatric surgery on thyroid-stimulating hormone (TSH) levels, levothyroxine dose, and the status of subclinical hypothyroidism.SettingSystematic review and meta-analysis.MethodsPubMed, EMBASE, and Cochrane Library were searched up to December 2020 for relevant clinical studies. Random-effects model was used to pool results. Network meta-analysis was performed, incorporating direct and indirect comparisons among different types of bariatric surgery. Meta-regression analysis was performed to evaluate the impact of moderator variables on TSH levels and required levothyroxine dose after surgery. We followed the PRISMA guidelines for data selection and extraction. PROSPERO registry number: CRD42018105739.ResultsA total of 28 studies involving 1284 patients were included. There was a statistically significant decrease in TSH levels after bariatric surgery (mean difference = ?1.66 mU/L, 95%CI [?2.29, ?1.03], P < .0001). In meta-regression analysis, we found that the following moderator variables: length of follow-up, mean age, baseline TSH, and preoperative thyroid function, could explain 1%, 43%, 68%, and 88% of the between-study variance, respectively. Furthermore, subclinical hypothyroidism was completely resolved in 87% of patients following bariatric surgery. In addition, there was a statistically significant decrease of levothyroxine dose in frank hypothyroid patients following bariatric surgery (mean difference = ?13.20 mcg/d, 95%CI [?19.69, ?6.71]). In network meta-analysis, we found that discontinuing or decreasing levothyroxine dose was significant following Roux-en-Y gastric bypass, 1 anastomosis gastric bypass, and sleeve gastrectomy, (OR = 31.02, 95%CI [10.34, 93.08]), (OR = 41.73, 95%CI [2.04, 854.69]), (OR = 104.03, 95%CI [35.79, 302.38]), respectively.ConclusionsBased on our meta-analysis, bariatric surgery is associated with the resolution of subclinical hypothyroidism, a decrease in TSH levels, and a decrease in levothyroxine dose.     

Obstructive sleep apnea remission following bariatric surgery: a national registry cohort study

BackgroundObstructive sleep apnea (OSA) is strongly associated with metabolic syndrome. Bariatric surgery is an effective available treatment for OSA; however, limited research predicts which patients undergoing bariatric surgery will undergo OSA resolution.ObjectivesTo determine perioperative predictors for OSA resolution following bariatric surgery using a national database.SettingUnited Kingdom national bariatric surgery database.MethodsThe UK National Bariatric Surgery Registry (NBSR) was interrogated to identify all patients with OSA that underwent primary bariatric surgery between January 2009 and June 2017. Those with at least 1 follow-up recording postoperative OSA status were selected for further analysis. Demographic, pre- and postoperative outcomes were collected and analyzed. Poisson multivariate regression was conducted to identify predictors of OSA remission.ResultsA total of 4015 bariatric cases were eligible for inclusion: 2482 (61.8%) patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), 1196 (29.8%) sleeve gastrectomy (LSG), and 337 (8.4%) adjustable gastric banding (LAGB). Overall, the mean excess weight loss (EWL) % for the whole group was 61.2 (SD ± 27.2). OSA resolution was recorded in 2377 (59.2%) patients. Following Poisson regression, LRYGB (risk ratio [RR], 1.49 confidence interval [CI] 1.25–1.78) and LSG (RR, 1.46 [CI 1.22–1.75] were associated with approximately 50% increased likelihood of OSA remission compared with LAGB. Greater weight loss following intervention was associated with greater likelihood of OSA remission, while both greater age and greater preoperative body mass index (BMI) were associated with reduced likelihood of OSA remission (P < .001).ConclusionThis study demonstrated that metabolic surgery results in OSA remission in the majority of patients with obesity. Younger age, lower BMI preprocedure, greater %EWL and the use of LSG or LRYGB positively predicted OSA remission.     

Postbariatric hypoglycemia: symptom patterns and associated risk factors in the Longitudinal Assessment of Bariatric Surgery study

BackgroundPostbariatric hypoglycemia (PBH) can be a devastating complication for which current therapies are often incompletely effective. More information is needed regarding frequency, incidence, and risk factors for PBH.ObjectivesTo examine hypoglycemia symptoms following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) and baseline and in-study risk factors.SettingMulticenter, at 10 US hospitals in 6 geographically diverse clinical centers.MethodsA prospective, longitudinal cohort study of adults undergoing RYGB or LAGB as part of clinical care between 2006 and 2009 were recruited and followed until January 31, 2015, with baseline and annual postoperative research assessments. We analyzed baseline prevalence and post-operative incidence and frequency of self-reported hypoglycemia symptoms as well as potential preoperative risk factors.ResultsIn all groups, postoperative prevalence of hypoglycemia symptoms was 38.5%. Symptom prevalence increased postoperatively from 2.8%–36.4% after RYGB in patients without preoperative diabetes (T2D), with similar patterns in prediabetes (4.9%–29.1%). Individuals with T2D had higher baseline hypoglycemia symptoms (28.9%), increasing after RYGB (57.9%). Hypoglycemia symptoms were lower after LAGB, with 39.1% reported hypoglycemia symptoms at only 1 postoperative visit with few (4.0%) having persistent symptoms at 6 or more annual visits. Timing of symptoms was not restricted to the postprandial state. Symptoms of severe hypoglycemia were reported in 2.6–3.6% after RYGB. The dominant risk factor for postoperative symptoms was preoperative symptoms; additionally, baseline selective serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitor use was also associated with increased risk in multivariable analysis. Weight loss and regain were not related to hypoglycemia symptom reporting.ConclusionHypoglycemia symptoms increase over time after RYGB, particularly in patients without diabetes. In a small percentage, symptoms can be persistent or severe and require hospitalization. Preoperative hypoglycemia symptoms and SSRI/SNRI use in RYGB patients without diabetes is associated with increased risk of symptoms.     

The influence of bariatric surgery on hip and knee joint pain: a systematic review

Obesity increases the risk of osteoarthritis and the chance of needing joint replacement arthroplasty to reduce lower limb joint pain. Although nonsurgical weight loss interventions can reduce hip and knee joint pain, bariatric surgery may be a more feasible treatment option for people with severe obesity. However, it is unclear whether weight loss through bariatric surgery can positively influence hip and knee joint pain. Our objective was to evaluate the influence of bariatric surgery on hip and knee joint pain in people with obesity by conducting a systematic review of the literature. The PubMed, EMBASE, and Cochrane bibliographic databases were searched for studies published between 1947 and September 2019. Risk of bias of the identified studies was independently assessed by 2 reviewers using JBI’s Critical Appraisal Checklist for Case Series and the Newcastle-Ottawa Scale. This review included 23 studies, all of which evaluated knee pain and 9 of which also evaluated hip pain. Reported results regarding hip pain intensity and the proportion of participants with hip pain were too limited to draw useful conclusions. Reported results regarding knee pain suggest that weight loss after bariatric surgery reduced knee pain intensity, as well as the proportion of participants with knee pain. The overall risk of bias of the majority of included studies (83%; n = 19) was judged to be unclear to high. Four small studies were judged as having a low risk of bias. Results of this systematic review suggest that bariatric surgery can positively influence hip and knee joint pain, but conclusive evidence is lacking because most of the included studies were judged as having plausible bias overall and in their key domains. Well-designed randomized controlled trials evaluating the influence of bariatric surgery on hip and knee joint pain using standardized joint pain measures are needed.     

Outcomes of bariatric surgery in extreme obesity: results from the United Kingdom National Bariatric Surgery Registry for patients with a body mass index >70 kg/m2

BackgroundBariatric and metabolic surgery (BMS) is an established safe, effective, and durable treatment for obesity and its complications. However, there is still a paucity of evidence on surgery outcomes in patients suffering from extreme obesity.ObjectivesThis study aimed to evaluate outcomes of BMS in weight loss and the resolution of co-morbidities in patients with a body mass index (BMI) ≥70kg/m².SettingNational Health Service and private hospitals in the United Kingdom.MethodsThis cohort study analyzed prospectively collected records from the UK National Bariatric Surgery Registry of patients with a BMI ≥70 kg/m² undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or adjustable gastric band (AGB) between January 2009 and June 2014.ResultsThere were 230 patients (64% female) eligible for inclusion in the study: 22 underwent AGB; 102 underwent SG, and 106 underwent RYGB. Preoperative weight and BMI values were comparable (76 ± 7 kg/m² for AGB; 75 ± 5 kg/m² for SG; 74 ± 5 kg/m² for RYGB). The median postoperative follow-up was 13 months for AGB (10–22 mo), 18 for SG (6–28 mo), and 15 for RYGB (6–24 mo). Patients undergoing RYGB and SG exhibited the greatest postoperative total body weight loss (35 ± 13% and 31 ± 15%, respectively; P = .14), which led to postoperative BMIs of 48 ± 10 kg/m² and 51 ± 11 kg/m², respectively (P = .14). All procedures conferred a reduction in the incidence of co-morbidities, including type 2 diabetes, and led to improved functional statuses. The overall complication rate was 7%, with 3 deaths (1%) within 30 days of surgery.ConclusionThis study found that primary BMS in patients with a BMI >70kg/m² has an acceptable safety profile and is associated with good medium-term clinical outcomes. RYGB and SG are associated with better weight loss and great improvements in co-morbidities than AGB. Given the noninferiority of SG outcomes and SG’s potential for further conversion to other BMS procedures if required, SG may be the best choice for primary BMS in patients with extreme obesity.     

A prospective longitudinal study of chronic abdominal pain and symptoms after sleeve gastrectomy

BackgroundSleeve gastrectomy (SG) is widely applied. Few studies have evaluated patient-reported abdominal symptoms after SG.ObjectiveTo evaluate the prevalence of chronic abdominal pain (CAP) and symptom characteristics after SG.SettingOslo University Hospital and Voss Hospital.MethodsWe performed a longitudinal prospective cohort study of patients operated on with SG at two tertiary referral centers. For broad assessments of abdominal pain and symptoms, consultations were performed and questionnaires retrieved before and 2 years after SG. The definition of CAP or recurrent abdominal pain lasting for more than 3 months was sustained. Preoperative predictors of CAP were explored.ResultsOf 249 patients at baseline, 207 (83.1%) had follow-up consultations. Mean preoperative body mass index was 43.9 (6.0) kg/m², and 181 patients (72.7%) were female. Total weight loss was 31.9% (10.4%). CAP was reported in 32 of 223 patients (14.3%) before and in 50 of 186 patients (26.9%) after SG (P =.002). All mean gastrointestinal symptoms rating scale questionnaire scores increased after SG, and they were higher in patients with CAP. Symptoms of depression decreased but were more prevalent in patients with CAP at follow-up. Most quality-of-life scores increased after SG. However, patients with CAP had lower scores (except for physical functioning). Preoperative bothersome Gastrointestinal Symptom Rating Scale reflux symptoms, study center, and younger age seemed to predict CAP after SG.ConclusionThe prevalence of patient-reported CAP increased after SG. Patients reporting CAP had reduced quality-of-life scores.