Effects of preoperative oral single-dose and double-dose carbohydrates on insulin resistance in patients undergoing gastrectomy:a prospective randomized controlled trial.

BACKGROUND & AIMS: Preoperative oral carbohydrates are strongly recommended for routine use before various elective procedures. The regimen mainly includes preoperative oral single-dose carbohydrate (2-3 h before surgery) and preoperative oral double-dose carbohydrates (10 h before surgery and 2-3 h before surgery). The choice between the two options is still controversial. METHODS: A total of 139 patients with gastric cancer who underwent radical gastrectomy were recruited from a hospital in Sichuan Province, China. The patients were randomly assigned to a single-dose group (n = 70) or a double-dose group (n = 69). Insulin resistance indicators, subjective comfort indicators, inflammatory mediators, immunological indicators, postoperative recovery indexes, and complications were compared between the two groups. RESULTS: There were no differences in insulin resistance indicators (fasting plasma glucose, fasting insulin, and homeostasis model assessment indexes), inflammatory mediators (C-reactive protein, interleukin-6, and tumor necrosis factor-α), immunological indicators (CD3+, CD4+, CD8+, and CD4+/CD8+) between the single-dose group and double-dose group (all P > 0.05) at preoperative day 1, preoperative 3 h, and postoperative day 1. There were no differences in subjective comfort indicators (thirst, hunger, anxiety, nausea, fatigue, and weakness) between the two groups (all P > 0.05) at preoperative day 1, preoperative 3 h, preoperative 1 h, and postoperative day 1. The postoperative recovery indexes and complications (exhaust time, liquid intake time, postoperative hospital stay, complication incidence, unplanned readmission rate, and unplanned reoperation rate 30 days after operation) did not significantly differ between the two groups (all P > 0.05). The number of preoperative nighttime urinations in the double-dose group was higher than that in the single-dose group (88.3% VS 48.5%, P < 0.001), and the number of hours of preoperative sleep in the double-dose group was lower than that in the single-dose group (4.56 ± 0.68 VS 5.71 ± 0.57, P < 0.001). CONCLUSION: Oral carbohydrates administered the night before surgery did not enhance the effects of oral carbohydrates administered 2-3 h before surgery on insulin resistance, subjective comfort, inflammation, and immunity and might affect the patients' night rest. In making a decision between oral carbohydrate regimes, evening carbohydrates could be omitted. TRIAL REGISTRATION: ChiCTR, ChiCTR1900020608. Registered January 10, 2019, http://www.chictr.org.cn: ChiCTR1900020608.

Changes in fasting bile acid profiles after Roux-en-Y gastric bypass and sleeve gastrectomy.

BACKGROUND: Bile acid is an essential factor that plays a role in metabolic regulation, but how bile acid is regulated after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) remains unclear. This meta-analysis aimed to investigate changes in the levels of fasting bile acids following RYGB and SG. METHODS: A systematic literature search of the PubMed, EMBASE, Cochrane Library and Web of Science databases through July 2020 was performed in accordance with the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The concentrations of bile acids were evaluated. RESULTS: Thirteen studies with 289 patients were included. Our results showed that patients who underwent RYGB had increased levels of fasting total bile acids, primary bile acids, secondary bile acids, conjugated bile acids, and unconjugated bile acids, but no significant differences in all these bile acid levels were observed in patients who underwent SG. Furthermore, 12a-hydroxylated bile acid levels and the 12a-hydroxylated/non-12a-hydroxylated bile acid ratio also increased following RYGB. CONCLUSION: In this study, we found that fasting bile acid levels, especially 12a-hydroxylated bile acids levels, were increased after RYGB. However, no differences in fasting bile acid levels were observed following SG.

Personalized trimodal prehabilitation for gastrectomy.

BACKGROUND: Surgery is the only potentially curative treatment for gastric cancer, however, it bears a high postoperative morbidity and mortality rate. A recent randomized control trial proposed prehabilitation to reduce the postoperative morbidity in patients undergoing major abdominal surgery. Currently, there is a lack of evidence of using prehabilitation for patients undergoing gastrectomy for gastric cancer. The aim of our study is to demonstrate that home-based prehabilitation can reduce postoperative morbidity after gastrectomy for gastric cancer. METHODS: PREFOG is a multi-center, open-label randomized control trial comparing 90-days postoperative morbidity rate after gastrectomy for gastric cancer between patients with or without prehabilitation. One-hundred twenty-eight patients will be randomized into an intervention or control group. The intervention arm will receive trimodal home-based prehabilitation including nutritional, psychological and exercise interventions. Secondary outcomes of the study will include physical and nutritional status, anxiety and depression level, quality of life, postoperative mortality rates and full completion of the oncological treatment as determined by the multidisciplinary tumor board. DISCUSSION: PREFOG study will show if home-based trimodal prehabilitation is effective to reduce postoperative morbidity after gastrectomy for gastric cancer. Moreover, this study will allow us to determine whether prehabilitation can improve physical fitness and activity levels, nutritional status and quality of life as well as reducing anxiety and depression levels after gastrectomy for gastric cancer. TRIAL REGISTRATION: ClinicalTrials.gov NCT04223401 (First posted: 10 January 2020).

Tolerability of early oral nutrition and factors predicting early oral nutrition failure after gastrectomy.

BACKGROUND & AIMS: Many studies have suggested the feasibility and safety of early oral nutrition after gastrectomy; however, the tolerability of early oral nutrition has rarely been investigated. This study aimed to investigate the tolerability of early oral nutrition and factors affecting early oral nutrition failure after gastrectomy. METHODS: We retrospectively reviewed 565 patients with gastric cancer who had undergone gastrectomy and who had received oral nutrition on postoperative day 1. Failure of early oral nutrition was defined as cessation of at least one meal for any reason. Preoperative clinical information and operative factors were analyzed concerning an association with early oral nutrition failure. RESULTS: The tolerability of early oral nutrition after gastrectomy was 74.7%. Of 565 patients, 72 (12.7%) failed early oral nutrition due to adverse gastrointestinal symptoms, 52 (9.2%) failed due to gastric stasis or ileus, and 19 (3.4%) patients failed due to other postoperative complications. In the univariate analysis, age (≥70 years), male sex, preoperative tumor obstruction, remnant stomach cancer, open surgery, operating time (≥4 h), and an advanced preoperative stage were associated with failed early oral nutrition. Multivariable analysis of these factors revealed that male sex, preoperative tumor obstruction, operating time, and advanced preoperative stage were independent predictive factors for early oral nutrition failure after gastrectomy. CONCLUSIONS: The tolerability of early oral nutrition after gastrectomy was comparable to that of other gastrointestinal surgeries. A tailored approach for postoperative oral nutrition is required based on identified risk factors for early oral nutrition failure.

Lipoprotein(a) Change After Sleeve Gastrectomy Is Affected by the Presence of Metabolic Syndrome.

BACKGROUND: Patients with metabolic syndrome (MetS) are at high risk of developing cardiovascular disease (CVD) and lipoprotein(a) (Lp(a)) is an independent risk factor for CVD. This study aimed to determine the effect of vertical sleeve gastrectomy (VSG)-induced weight loss on Lp(a) levels in obese individuals. METHODS: Patients submitted to VSG from January 2011 to July 2015 were included. Anthropometric and metabolic parameters were recorded before and 12 months after surgery. Univariate analysis identified associations between Lp(a) and anthropometry and metabolic parameters, and the logistic regression predictors of Lp(a) decrease after VSG. RESULTS: MetS was present in 47% of the 330 patients involved. Patients with MetS had higher body mass index (BMI) and triglyceride levels and were more insulin-resistant. No differences were found between groups respecting Lp(a) levels prior to surgery (15.2 mg/dL vs. 15.0 mg/dL, p = 0.795). After surgery, patients without MetS had a decrease in Lp(a) levels (14.7 mg/dL vs. 12.3 mg/dL, p = 0.006), while MetS patients showed no differences (13.9 mg/dL vs. 14.6 mg/dL, p = 0.302). The regression model evidenced that older age and Δ HDL-c were predictors of Lp(a) decrease, whereas the greater the number of MetS components and lower estimated BF% loss, the lesser odds of decreasing Lp(a) after surgery. CONCLUSIONS: Despite a global improvement of conventional CVD risk factors, only individuals without MetS showed a decrease of Lp(a) levels after VSG. Further studies should explore not only the pathophysiological mechanisms underlying the absence of decrease of Lp(a) levels in MetS patients, but also its impact on the metabolic beneficial changes usually observed after VSG.

Changes in Left Ventricular Mechanics After Sleeve Gastrectomy.

OBJECTIVE: The aim of this study was to examine echocardiographic parameters of left ventricle (LV) mechanics in obese patients before and after sleeve gastrectomy (SG). DESIGN AND METHODS: Twenty-five obese individuals submitted to laparoscopic SG were enrolled in this study. Echocardiography was performed before and after the procedure, and left ventricle mechanics were evaluated by speckle tracking imaging. RESULTS: Before surgery, altered global longitudinal strain (GLS) values were present in 56% of the patients. In a mean follow-up of 3.6 ± 0.5 months after surgery, there was an increase in GLS values (from 17.4 ± 3.2 to 19.3 ± 2.7%, P = 0.01). There was an inverse correlation between the absolute values of GLS in the preoperative period and the variation in the GLS at follow-up (r = 0.577, P = 0.002). Measurements of global circumferential strain (GCS), global radial strain (GRS), and LV twist were normal preoperatively and did not change after surgery. CONCLUSIONS: Altered global longitudinal strain values were common in young obese patients. Sleeve gastrectomy increased global longitudinal strain even in the early postoperative phase without promoting changes in global radial strain, global circumferential strain, and left ventricle twist measurements.

Analysis of the Association between Eating Behaviors and Weight Loss after Laparoscopic Sleeve Gastrectomy.

SETTING: In a private medical center, 300 patients who underwent a laparoscopic sleeve gastrectomy (LSG) were classified into 4 groups according to their eating behaviors (EB) preoperatively. During a 3-year postoperative follow-up, dietary changes in relation to weight loss were studied. OBJECTIVES: To explore the influence of abnormal EB on the outcome of sleeve gastrectomy. BACKGROUND: Patients with morbid obesity often suffer from abnormal EB. After LSG, the outcome depends largely on improvement of the feeding behaviors acquired. METHODS: This prospective study includes 300 patients who underwent LSG from 2013 to 2014, divided into the following 4 groups: binge eaters, snack eaters, sweet eaters, and volume eaters. RESULTS: The average age was 41.65 years, the ratio of male to females was 1 to 2. The average baseline body mass index (BMI) was 42.02. After 3 years, no significant change was found in the number of binge eaters (p = 0.396), but there was an 8.9% increase in snack eaters (p < 0.001), a 12.9% increase in sweet eaters (p < 0.001), and 17.2% increase in healthy eating habits (p < 0.001). Sixty-five (24.8%) patients did not experience changes in their eating patterns. However, after surgery, 24.6% of the patients continued with the same EB and 125 (49.5%) patients changed from one EB to another unhealthy EB. Weight loss, measure as ΔBMI, was similar in each group after 3 years, with a mean BMI of 29.8. When eating habits were related to different features such as gender, sports practice, type of work, smoking, marital status, comorbidities, no influence on the operative results were found. CONCLUSION: LSG promotes the reduction of overeaters; however, it promotes a switch between other unhealthy EB. The significant increase in snack eaters and sweet eaters is outstanding, although it did not affect weight loss in the midterm follow-up. Worsening of eating habits after LSG is a common fact.

Prospective Longitudinal Trends in Body Composition and Clinical Outcomes 3 Years Following Sleeve Gastrectomy.

BACKGROUND AND AIMS: Longitudinal assessment of body composition following bariatric surgery allows monitoring of health status. Our aim was to elucidate trends of anthropometric and clinical outcomes 3 years following sleeve gastrectomy (SG). METHODS: A prospective cohort study of 60 patients who underwent SG. Anthropometrics including body composition analysis measured by multi-frequency bioelectrical impedance analysis, blood tests, liver fat content measured by abdominal ultrasound and habitual physical activity were evaluated at baseline and at 6 (M6), 12 (M12), and 36 (M36) months post-surgery. RESULTS: Sixty patients (55% women, age 44.7 ± 8.7 years) who completed the entire follow-up were included. Fat mass (FM) was reduced significantly 1 year post-surgery (55.8 ± 11.3 to 26.7 ± 8.3 kg; P < 0.001) and then increased between 1 and 3 years post-operatively, but remained below baseline level (26.7 ± 8.3 to 33.1 ± 11.1 kg; P < 0.001). Fat free mass (FFM) decreased significantly during the first 6 months (64.7 ± 14.3 to 56.9 ± 11.8 kg; P < 0.001), slightly decreased between M6 and M12 and then reached a plateau through M36. Weight loss "failure" (< 50% excess weight loss) was noticed in 5.0% and 28.3% of patients at M12 and M36, respectively. Markers of lipid and glucose metabolism changed thereafter in parallel to the changes observed in FM, with the exception of HDL-C, which increased continuingly from M6 throughout the whole period analyzed (45.0 ± 10.2 to 59.5 ± 15.4 mg/dl; P < 0.001) and HbA1c which continued to decrease between M12 and M36 (5.5 ± 0.4 to 5.3 ± 0.4%; P < 0.001). There were marked within-person variations in trends of anthropometric and clinical parameters during the 3-year follow-up. CONCLUSIONS: Weight regain primarily attributed to FM with no further decrease in FFM occurs between 1 and 3 years post-SG. FM increase at mid-term may underlie the recurrence of metabolic risk factors and can govern clinical interventions.

Impact of enhanced recovery after surgery on postoperative rehabilitation, inflammation, and immunity in gastric carcinoma patients: a randomized clinical trial.

We determined the effects of enhanced recovery after surgery (ERAS) in patients undergoing radical surgery for gastric carcinoma. Sixty patients undergoing radical gastrectomy for gastric carcinoma in Lishui Hospital between March and October 2016 were randomized to receive either ERAS (30 patients) or conventional care (30 patients, controls). Clinical, economic, and laboratory indices were analyzed. ERAS patients showed faster recovery and shorter postoperative hospital stays than the controls (P<0.05). Some clinical indices (i.e., time to first flatus and defecation, time to removal of drainage tubes, time to resumption of oral feeding, time to postoperative mobilization, and postoperative complications) were significantly better in ERAS patients than in controls. Duration of postoperative infusion was lower in ERAS patients than in controls (P<0.05). In ERAS patients, serum albumin and prealbumin were higher on postoperative day 7, C-reactive protein was lower on postoperative days 3 and 7, and neutrophil count was lower on postoperative day 3 compared to the values in controls (P<0.05 for all). IgM levels were higher in ERAS patients on postoperative days 3 and 7 (P<0.05), while IgG levels were higher on postoperative day 3 (P<0.05). Total T lymphocytes were higher in ERAS patients on postoperative day 3, while helper T cells and CD4+/CD8+ ratio were higher on postoperative days 3 and 7 (P<0.05 for all). In gastric carcinoma patients, ERAS may reduce perioperative inflammation, improve immunity and postoperative nutrition, shorten hospitalization, and enhance rehabilitation.

[Analysis of the effects of different nutritional support methods on postoperative recovery in patients with gastric cancer].

Objective: To assess the effects of different nutritional support methods on postoperative recovery in patients with gastric cancer. Methods: 98 patients who received radical gastrectomy were divided into three groups: parenteral nutrition group (PN group) (n=36), early enteral nutrition group (EEN group) (n=33) and early oral feeding group (EON group) (n=29). Tolerance of enteral nutrition, postoperative recovery and economic indicators were compared. Results: The number of laparoscopic-assisted surgeries was 18, 17 and 25 in PN group, EEN group and EON group, respectively. There was no significant difference in sex, age and body mass index(BMI) among the three groups. Gastrointestinal function recovered slowly in 3 cases, including 2 cases in EEN group and 1 case in EON group. 1 case in EON group had abdominal hemorrhage. Median postoperative hospital stay in PN, EEN and EON group was 11.0, 11.0 and 8.0 days respectively, and significant reduction can be found in EON group(P<0.001). The complication rates were 30.5% (11 cases), 12.1% (4 cases), and 13.8% (4 cases), respectively, with no statistically significant difference(P=0.102). The median nutritional support costs for PN group, EEN group, and EON group were 4 543.3, 974.2, and 265.0 yuan, respectively. The median albumin consumption was 90.0, 40.0, and 0 g, respectively. The EON groups were significantly lower (P<0.001). The results of the laparoscopic assisted subgroup and the ones of whole group were consistent. Conclusion: Compared with parenteral nutrition and early enteral nutrition, early oral feeding can reduce the amount of albumin consumption, decrease the cost of nutrition support and shorten the average hospital stay after surgey without increasing the incidence of complications.

SCCA-IgM as a Potential Biomarker of Non-Alcoholic Fatty Liver Disease in Patients with Obesity, Prediabetes and Diabetes Undergoing Sleeve Gastrectomy.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) has a high prevalence in obesity and its presence should be screened. Laparoscopic sleeve gastrectomy (LSG) is an effective treatment for obesity, but its effects on NAFLD are still to be firmly established. The diagnosis of non-alcoholic steatohepatitis (NASH) is currently performed by liver biopsy, a costly and invasive procedure. Squamous cell carcinoma antigen-IgM (SCCA-IgM) is a biomarker of viral hepatitis to hepatocellular carcinoma development and its role in NAFLD to NASH progression has not yet been investigated. OBJECTIVE: The aim of this study was to evaluate SCCA-IgM as a non-invasive biomarker of NAFLD/NASH in patients with different degrees of metabolic-complicated obesity before and after LSG. METHOD: Fifty-six patients with obesity were studied before and 12 months after LSG; anthropometric, biochemical, clinical, and imaging data were collected. RESULTS: At baseline steatosis was strongly associated with the glycaemic profile (p = 0.016) and was already present in prediabetic patients with obesity (82%). Only 3 patients had an SCCA-IgM level above the normal cut-off. SCCA-IgM titre did not change according to glycaemic profile or steatosis. Metabolic and inflammatory factors and transaminases significantly reduced after LSG-induced weight loss, except for SCCA-IgM. The ALT/AST ratio decreased post-LSG correlated with BMI (r = 0.297, p = 0.031), insulin (r = 0.354, p = 0.014), and triglycerides (r = 0.355, p = 0.009) reduction. CONCLUSIONS: Our results confirm the tight link between NAFLD and metabolic complications, suggesting prediabetes as a new risk factor of steatosis. SCCA-IgM does not seem to have a role in the identification and prognosis of NAFLD.

Quality of Life 10 Years after Sleeve Gastrectomy: A Multicenter Study.

OBJECTIVE: Sleeve gastrectomy (SG) has recently become the most commonly applied bariatric procedure worldwide. Substantial regaining of weight or severe reflux might compromise quality of life (QOL) after SG in the long-term follow-up. Long-term data on patients' QOL is limited, even though the persistent improvement in QOL is one of the aims of bariatric surgery. The objective of this study was to present patients' QOL 10 years after SG. METHODS: Of 65 SG patients with a follow-up of ≥10 years after SG who were asked to fill out the Bariatric Quality of Life Index (BQL) and Short Form 36 (SF36) questionnaires, 48 (74%) completed them. This multicenter study was performed in a university hospital setting in Austria. RESULTS: The BQL score revealed nonsignificant differences between the patients with > 50% or < 50% excess weight loss (EWL). It did show significant differences between patients with and without any symptoms of reflux. Patients with < 50% EWL scored significantly lower in 3/8 categories of SF36. Patients suffering from reflux had significantly lower scores in all categories. CONCLUSIONS: EWL and symptomatic reflux impair patients' long-term QOL after SG.

Comparison of Energy and Food Intake Between Gastric Bypass and Sleeve Gastrectomy: a Meta-analysis and Systematic Review.

AbstractObesity is a developed nutritional problem, and today, surgery is one of the approaches to cure it. A good understanding of the variations in food intake will be beneficial for sustaining long-term weight loss post-surgery and for improving nutrition care strategies. The purpose of this review was the comparison of the impact of two methods of gastric bypass (GBP) and sleeve gastrectomy (SG) on dietary intake. Databases of PubMed, Embase, Scopus, Google Scholar, and Web of science were used for the literature search up to June 2018. We concluded the studies that measured mean daily energy intake and the percent of macronutrients from total calorie intake of before and after GBP and SG. A total of 18 studies were finally included in the meta-analysis for the effect of bariatric surgery on food intake. Bariatric surgery significantly decreased energy intake by 1050.04 kcal/day (p < 0.001) compared with the baseline values of energy intake. The pooled effect of bariatric surgery on protein intake was 0.82 g/day (p = 0.004) compared with the baseline values. The pooled analysis found no significant impact of bariatric surgery on carbohydrate intake (WMD = 0.56 g/day; p = 0.40) compared with the baseline values. The pooled estimate of effect for bariatric surgery on fat intake was - 1.34 g/day (p = 0.006). This study demonstrates that bariatric surgery might be effective on energy and fat intake; however, there was no effect on carbohydrate intake.

Impact of enhanced recovery after surgery on postoperative rehabilitation, inflammation, and immunity in gastric carcinoma patients: a randomized clinical trial

We determined the effects of enhanced recovery after surgery (ERAS) in patients undergoing radical surgery for gastric carcinoma. Sixty patients undergoing radical gastrectomy for gastric carcinoma in Lishui Hospital between March and October 2016 were randomized to receive either ERAS (30 patients) or conventional care (30 patients, controls). Clinical, economic, and laboratory indices were analyzed. ERAS patients showed faster recovery and shorter postoperative hospital stays than the controls (P<0.05). Some clinical indices (i.e., time to first flatus and defecation, time to removal of drainage tubes, time to resumption of oral feeding, time to postoperative mobilization, and postoperative complications) were significantly better in ERAS patients than in controls. Duration of postoperative infusion was lower in ERAS patients than in controls (P<0.05). In ERAS patients, serum albumin and prealbumin were higher on postoperative day 7, C-reactive protein was lower on postoperative days 3 and 7, and neutrophil count was lower on postoperative day 3 compared to the values in controls (P<0.05 for all). IgM levels were higher in ERAS patients on postoperative days 3 and 7 (P<0.05), while IgG levels were higher on postoperative day 3 (P<0.05). Total T lymphocytes were higher in ERAS patients on postoperative day 3, while helper T cells and CD4+/CD8+ ratio were higher on postoperative days 3 and 7 (P<0.05 for all). In gastric carcinoma patients, ERAS may reduce perioperative inflammation, improve immunity and postoperative nutrition, shorten hospitalization, and enhance rehabilitation.

Safety of Blood Glucose Response Following Exercise Training After Bariatric Surgery.

INTRODUCTION: Safety of exercise training in relationship with the risk of hypoglycemia post-bariatric surgery is unknown. OBJECTIVE: To evaluate the safety and magnitude of changes in blood glucose levels during exercise training following bariatric surgery. MATERIAL AND METHODS: Twenty-nine severely obese patients undergoing either sleeve gastrectomy (SG) (n = 16) or biliopancreatic diversion with duodenal switch (BPD-DS) (n = 13) were prospectively enrolled. Three months after surgery, patients participated in a 12-week supervised exercise training program, (35-min aerobic training with a 25-min resistance exercises) three times a week. Capillary blood glucose (CBG) levels were measured immediately before and after each exercise session. RESULTS: Seven patients (24%) had type 2 diabetes before surgery (mean duration: 10 years); four patients still have type 2 diabetes 3 months post-bariatric surgery. A total of 577 exercise training sessions with CBG monitoring were recorded. Only seven sessions (1.2%) were associated with an episode of asymptomatic hypoglycemia (CBG ≤ 3.9 mmol/L). Patients with type 2 diabetes at baseline showed a larger decrease in CBG with pre-exercise CBG being between 6.1 and 8.0 mmol/L (- 1.6 ± 1.2 vs. - 1.1 ± 0.9 mmol/L, p = 0.02). BPD-DS patients with CBG ≥ 6.1 mmol/L showed higher reduction in CBG following exercise vs. SG patients (- 1.7 ± 1.0 vs. - 1.1 ± 1.1 mmol/L; p < 0.001 and - 4.3 ± 1.0 vs. - 2.2 ± 1.4 mmol/L, p < 0.001, respectively). CONCLUSION: Three months after bariatric surgery, exercise training program in patients without and with type 2 diabetes is safe, and is associated with a desirable glycemic profile, with few episodes of asymptomatic hypoglycemia.

Fat-Free Mass and Skeletal Muscle Mass Five Years After Bariatric Surgery.

OBJECTIVE: This study investigated changes in fat-free mass (FFM) and skeletal muscle 5 years after surgery in participants from the Longitudinal Assessment of Bariatric Surgery-2 trial. METHODS: A three-compartment model assessed FFM, and whole-body magnetic resonance imaging (MRI) quantified skeletal muscle mass prior to surgery (T0) and 1 year (T1), 2 years (T2), and 5 years (T5) postoperatively in 93 patients (85% female; 68% Caucasian; age 44.2 ± 11.6 years) who underwent gastric bypass (RYGB), sleeve gastrectomy, or adjustable gastric band. Repeated-measures mixed models were used to analyze the data. RESULTS: Significant weight loss occurred across all surgical groups in females from T0 to T1. FFM loss from T0 to T1 was greater after RYGB (mean ± SE: -6.9 ± 0.6 kg) than adjustable gastric band (-3.5 ± 1.4 kg; P < 0.05). Females with RYGB continued to lose FFM (-3.3 ± 0.7 kg; P < 0.001) from T1 to T5. A subset of males and females with RYGB and MRI-measured skeletal muscle showed similar initial FFM loss while maintaining FFM and skeletal muscle from T1 to T5. CONCLUSIONS: Between 1 and 5 years following common bariatric procedures, FFM and skeletal muscle are maintained or decrease minimally. The changes observed in FFM and muscle during the follow-up phase may be consistent with aging.

A Randomised Trial of Text Message Support for Reducing Weight Regain Following Sleeve Gastrectomy.

INTRODUCTION: Sleeve gastrectomy (SG) is a common bariatric procedure with high rates of weight regain (WR). Clinicians and patients have identified a lack of follow-up support and maladaptive lifestyle behaviours as potential causes for WR. While text message support has been shown to be effective for weight loss in non-surgical patients, it has not been investigated for reducing WR in bariatric patients. PURPOSE: To determine the effectiveness of text message support in reducing weight regain following sleeve gastrectomy. METHODS: A text message intervention was designed. The effectiveness of the intervention was investigated by a randomised trial powered to detect a 15% difference in the primary outcome of percent excess weight loss (84 participants required). Secondary outcomes were the Bariatric Analysis and Reporting System (BAROS) score and patient satisfaction. Outcomes were assessed at 6 and 12 months. RESULTS: Ninety-five participants were randomised to either standard care or text message support (daily text message for 1 year). While there was no significant difference in the primary outcome at 6 or 12 months, patients who received the intervention tended to have less WR and a significantly better BAROS score at 12 months. Participants who received text message support found it beneficial, would have liked the messages to continue, and felt WR was reduced by having the text message support. CONCLUSION: Text message support following SG is feasible, may reduce weight regain, improves the BAROS score and is valued by patients. TRIAL REGISTRATION: NCT02341001.

Evaluation of Nutritional Status Post Laparoscopic Sleeve Gastrectomy-5-Year Outcomes.

INTRODUCTION: Obesity is considered a public health problem and has led to advancements in bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) had become the most performed procedure worldwide; however, its consequences on nutritional status in the short and long term are of concern. METHODS: A retrospective analysis of medical records and bariatric database of patients who underwent LSG from October 2008-September 2015 at Al-Amiri Hospital, Kuwait, was performed. Data regarding nutritional status along with demographic data were collected over a 5-year follow-up period. RESULTS: One thousand seven hundred ninety-three patients comprising of 74% females and 26% males were included. The greatest % total body weight loss (%TBWL) was at 18 months post-LSG (33%), corresponding to a % excess weight loss (%EWL) of 73.8%. With regard to nutritional status, vitamin B1 showed a significant drop at 3-5 years post-op in comparison to pre-op value, but stayed within the normal range throughout the study. Red blood cells count, hemoglobin, and hematocrit also showed a significant drop starting from 6 months post-op until the fifth year of follow-up. On the other hand, vitamins B6 and B12 showed a significant increase at 6 months post-op and decreased afterwards, but did not reach pre-op values. Vitamin D also showed a significant increase throughout the study period from deficient value at the pre-op time, but remained insufficient. Albumin, transferrin, folate, ferritin, iron, and vitamin B2 showed no significant changes at 5 years post-LSG compared to pre-op values. CONCLUSION: Little is known about the nutritional status and optimal nutritional care plan post-LSG, especially in the longer term. Nutritional deficiencies were prevalent prior and post-LSG. Some of the nutritional parameters improved and even reached the abnormal high level post-LSG. These observations highlight the importance of pre- and post-operative nutritional assessment and tailored supplementation to ensure optimal nutritional status.

Postoperative Care and Functional Recovery After Laparoscopic Sleeve Gastrectomy vs. Laparoscopic Roux-en-Y Gastric Bypass Among Patients Under ERAS Protocol.

BACKGROUND: The most commonly performed bariatric procedures are laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). There are major differences between LSG and LRYGB during postoperative period. Optimization of the postoperative care may be achieved by using enhanced recovery after surgery (ERAS) protocol, which allows earlier functional recovery. PURPOSE: The aim was to assess differences in the course of postoperative care conducted in accordance with ERAS protocol among patients after LSG and LRYGB. MATERIAL AND METHODS: Data concerning patients treated for morbid obesity were prospectively gathered in one academic center. Patients were divided into two groups: LSG (n = 364, 63.41%) and LRYGB (n = 210, 36.59%). Multiple factors were used as endpoints to determine the influence of the type of bariatric procedure on postoperative course. RESULTS: The rate of postoperative nausea and vomiting and incidence of intravenous fluid administration during the operation was higher in LSG group. LRYGB patients were able to tolerate higher oral fluid intake volumes during the first and the second postoperative day. Mean diuresis during the second and the third postoperative day was significantly higher in LRYGB group. Administration of diuretics and painkillers was comparable between groups, while the risk of fever after the operation was higher in LRYGB group. Mean length of stay was higher in LSG group (LRYGB vs. LSG, 3.46 days ± 1.58 vs. 3.64 days ± 4.41, p = 0.039). CONCLUSIONS: In our opinion, postoperative treatment after LSG requires more supervision and longer time until functional recovery is achieved.

Altered glucose metabolism after bariatric surgery: What's GLP-1 got to do with it?

Bariatric surgery is an effective treatment for obesity. The two widely performed weight-loss procedures, Roux-en-Y gastric bypass (GB) and sleeve gastrectomy (SG), alter postprandial glucose pattern and enhance gut hormone secretion immediately after surgery before significant weight loss. This weight-loss independent glycemic effects of GB has been attributed to an accelerated nutrient transit from stomach pouch to the gut and enhanced secretion of insulinotropic gut factors; in particular, glucagon-like peptide-1 (GLP-1). Meal-induced GLP-1 secretion is as much as tenfold higher in patients after GB compared to non-surgical individuals and inhibition of GLP-1 action during meals reduces postprandial hyperinsulinemia after GB two to three times more than that in persons without surgery. Moreover, in a subgroup of patients with the late complication of postprandial hyperinsulinemic hypoglycemia after GB, GLP1R blockade reverses hypoglycemia by reducing meal stimulated insulin secretion. The role of enteroinsular axis activity after SG, an increasingly popular alternative to GB, is less understood but, similar to GB, SG accelerates nutrient delivery to the intestine, improves glucose tolerance, and increases postprandial GLP-1 secretion. This review will focus on the current evidence for and against the role of GLP-1 on glycemic effects of GB and will also highlight differences between GB and SG.