Metabolic and Bariatric Surgery in Patients with Obesity Class V (BMI > 60 kg/m2): a Modified Delphi Study.

BACKGROUND: Metabolic and bariatric surgery (MBS) is the preferred method to achieve significant weight loss in patients with Obesity Class V (BMI > 60 kg/m2). However, there is no consensus regarding the best procedure(s) for this population. Additionally, these patients will likely have a higher risk of complications and mortality. The aim of this study was to achieve a consensus among a global panel of expert bariatric surgeons using a modified Delphi methodology. METHODS: A total of 36 recognized opinion-makers and highly experienced metabolic and bariatric surgeons participated in the present Delphi consensus. 81 statements on preoperative management, selection of the procedure, perioperative management, weight loss parameters, follow-up, and metabolic outcomes were voted on in two rounds. A consensus was considered reached when an agreement of ≥ 70% of experts' votes was achieved. RESULTS: A total of 54 out of 81 statements reached consensus. Remarkably, more than 90% of the experts agreed that patients should be notified of the greater risk of complications, the possibility of modifications to the surgical procedure, and the early start of chemical thromboprophylaxis. Regarding the choice of the procedure, SADI-S, RYGB, and OAGB were the top 3 preferred operations. However, no consensus was reached on the limb length in these operations. CONCLUSION: This study represents the first attempt to reach consensus on the choice of procedures as well as perioperative management in patients with obesity class V. Although overall consensus was reached in different areas, more research is needed to better serve this high-risk population.

An Update on Semaglutide Research: A Bibliometric Analysis and a Literature Review.

This study analyzes the most relevant authors, sources, cooccurrence of keywords, thematic map, and trend topics of the most recent and most cited research papers on semaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1 RA). Also, the content of the 25 most cited papers is summarized. A total of 2995 results appeared in an online electronic search performed on 14 August 2023 in the Scopus database using the term semaglutide. The most recently published 500 articles and most cited 200 documents were selected for bibliometric analysis. Network analysis visualization was conducted with the help of the VOSviewer software (version 1.6.18) (Centre for Science and Technology Studies, Leiden, the Netherlands) and Biblioshiny (it is a shiny application providing a web interface for bibliometrix) (Department of Economics and Statistics, University of Naples Federico II, Naples, Italy). After excluding duplicates and editorials, the data analysis found that 495 most recent documents were published in 279 journals by 2461 authors, and 200 most cited papers were published in 103 sources by 1241 authors. There is an increasing trend in the number of research papers from 2014 to 2022, with a peak in 2022. The most relevant authors in the most recent semaglutide research papers are Chen and Zhang. The pertinent authors of the most cited research papers on semaglutide are Lingvay and Khunti. The most common keywords used in the most recent and most cited research papers are semaglutide, obesity, diabetes mellitus type 2, glucagon-like peptide-1, glucagon-like peptide-1 receptor agonist, antidiabetic agent, liraglutide, and cardiovascular disease (CVD). The most relevant source is "Diabetes, Obesity and Metabolism" for the research papers on semaglutide. Trend topic analysis suggests that most of the research between 2020 and 2022 on semaglutide was done on non-insulin-dependent diabetes mellitus. The most cited papers provide essential insights into using semaglutide in managing type 2 diabetes mellitus (T2DM), obesity, and related conditions, along with their potential benefits, side effects, and possible mechanisms of action. This analysis highlights that the pharmacological effects of semaglutide extend beyond its role as a glycemic regulator.

Severe Acute Bronchial Asthma with Sepsis: Determining the Status of Biomarkers in the Diagnosis of the Disease.

Bronchial asthma is a widely prevalent illness that substantially impacts an individual's health standard worldwide and has a significant financial impact on society. Global guidelines for managing asthma do not recommend the routine use of antimicrobial agents because most episodes of the condition are linked to viral respiratory tract infections (RTI), and bacterial infection appears to have an insignificant impact. However, antibiotics are recommended when there is a high-grade fever, a consolidation on the chest radiograph, and purulent sputum that contains polymorphs rather than eosinophils. Managing acute bronchial asthma with sepsis, specifically the choice of whether or not to initiate antimicrobial treatment, remains difficult since there are currently no practical clinical or radiological markers that allow for a simple distinction between viral and bacterial infections. Researchers found that serum procalcitonin (PCT) values can efficiently and safely minimize antibiotic usage in individuals with severe acute asthma. Again, the clinical manifestations of acute asthma and bacterial RTI are similar, as are frequently used test values, like C-reactive protein (CRP) and white blood cell (WBC) count, making it harder for doctors to differentiate between viral and bacterial infections in asthma patients. The role and scope of each biomarker have not been precisely defined yet, although they have all been established to aid healthcare professionals in their diagnostics and treatment strategies.

Detecting Diabetic Ketoacidosis with Infection: Combating a Life-Threatening Emergency with Practical Diagnostic Tools.

BACKGROUND: Diabetic ketoacidosis (DKA) is a life-threatening acute complication of diabetes mellitus and can lead to patient demise if not immediately treated. From the recent literature, the diabetic ketoacidosis mortality rate, depending on age, is 2-5%. Insulin discontinuation and infection remain the two most common triggers for diabetic ketoacidosis. About 50% of cases of ketoacidosis result from bacterial infections like urinary tract infections and pneumonia. It is also important to diagnose the presence of infection in diabetic ketoacidosis patients to prevent the excessive use of antibiotics, which may lead to antibiotic resistance. Although performing bacterial culture is confirmatory for the presence or absence of bacterial infection, the time required to obtain the result is long. At the same time, emergency treatment needs to be started as early as possible. METHODS: This narrative review examines various septic markers to identify the appropriate tools for diagnosis and to distinguish between diabetic ketoacidosis with and without infection. Electronic databases were searched using the Google engine with the keywords "Diabetes Mellitus", "Diabetic Ketoacidosis", "Infection with Diabetic Ketoacidosis", "biomarkers for infection in Diabetic Ketoacidosis", "Procalcitonin", "Inflammatory cytokines in DKA", "Lactic acidosis in DKA", and "White blood cell in infection in DKA". RESULTS: This narrative review article presents the options for diagnosis and also aims to create awareness regarding the gravity of diabetic ketoacidosis with infection and emphasizes the importance of early diagnosis for appropriate management. Diabetes mellitus is a clinical condition that may lead to several acute and chronic complications. Acute diabetic ketoacidosis is a life-threatening condition in which an excess production of ketone bodies results in acidosis and hypovolemia. Infection is one of the most common triggers of diabetic ketoacidosis. When bacterial infection is present along with diabetic ketoacidosis, the mortality rate is even higher than for patients with diabetic ketoacidosis without infection. The symptoms and biomarkers of diabetic ketoacidosis are similar to that of infection, like fever, C reactive protein, and white blood cell count, since both create an environment of systemic inflammation. It is also essential to distinguish between the presence and absence of bacterial infection to ensure the appropriate use of antibiotics and prevent antimicrobial resistance. A bacterial culture report is confirmatory for the existence of bacterial infection, but this may take up to 24 h. Diagnosis needs to be performed approximately in the emergency room upon admission since there is a need for immediate management. Therefore, researching the possible diagnostic tools for the presence of infection in diabetic ketoacidosis patients is of great importance. Several of such biomarkers have been discussed in this research work.

Early Experience of High-dose Intravenous Mycobacterium w in Critically Ill Patients of COVID-19.

BACKGROUND: Immune dysregulation is one of the main reasons for mortality and morbidity in coronavirus disease 2019 (COVID-19). Mycobacterium w (Mw) is recently approved for gram-negative sepsis. Moreover, it is also found effective in COVID-19 patients in previous studies. The traditional route of administration for Mw is intradermal, which has a limitation of administering 0.1 mL per injection and local injection site reaction. Intravenous (IV) administration of Mw has not been explored in COVID-19. We report the retrospective analysis of six critically ill COVID-19 patients who received Mw (IV). PATIENTS AND METHODS: At baseline, all patients in this case series required O2 supplementation, and their inflammatory biomarkers were elevated. All patients received 0.6 mL Mw (high-dose) in normal saline along with the standard-of-care treatment. RESULTS: After Mw administration, gradual improvement in O2 requirement was observed and patients were discharged from the hospital with no mortality. A reduction in mean C-reactive protein (CRP) (51.48-18.52 mg/dL), interleukin-6 (IL-6) (260.22-14.47 pg/mL), and FiO2 (81.67-43.33) was also observed. No side effects were observed with the use of Mw by IV route. CONCLUSION: Use of 0.6 mL Mw by IV route in this case series was associated with decreased O2 supplementation without any side effects in critically ill patients of COVID-19. HOW TO CITE THIS ARTICLE: Patel PS, Patel S, Shah V, Aswani V, Narwaria M. Early Experience of High-dose Intravenous Mycobacterium w in Critically Ill Patients of COVID-19. Indian J Crit Care Med 2021;25(9):1066-1068.

Impact of COVID-19 pandemic on bariatric surgery in India: An obesity and metabolic surgery society of India survey of 1307 patients.

BACKGROUND: Although safe practice guidelines were issued by the Obesity and Metabolic Surgery Society of India (OSSI) in the end of May 2020, surgeons have been in a dilemma about risk of subjecting patients to hospitalisation and bariatric surgery. This survey was conducted with the objective to evaluate the risk of coronavirus disease-19 (COVID-19) infection in peri- and post-operative period after bariatric and metabolic surgery (BMS). METHODS: A survey with OSSI members was conducted from 20 July 2020 to 31 August 2020 in accordance with EQUATOR guidelines. Google Form was circulated to all surgeon members through E-mail and WhatsAppTM. In the second phase, clinical details were captured from surgeons who reported positive cases. RESULTS: One thousand three hundred and seven BMS were reported from 1 January 2020 to 15 July 2020. Seventy-eight per cent were performed prior to 31 March 2020 and 276 were performed after 1 April 2020. Of these, 13 (0.99%) patients were reported positive for COVID-19 in the post-operative period. All suffered from a mild disease and there was no mortality. Eighty-seven positive cases were reported from patients who underwent BMS prior to 31 December 2019. Of these, 82.7% of patients had mild disease, 13.7% of patients had moderate symptoms and four patients succumbed to COVID-19. CONCLUSION: BMS may be considered as a safe treatment option for patients suffering from clinically severe obesity during the COVID-19 pandemic. Due care must be taken to protect patients and healthcare workers and all procedures must be conducted in line with the safe practice guidelines.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries.

BACKGROUND: There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates. METHODS: We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020. RESULTS: Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country. CONCLUSIONS: BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

Trends and progress of bariatric and metabolic surgery in India.

Bariatric and metabolic surgery are being performed in India for 2 decades. Aim of this paper is to evaluate the changing clinical trends over the last 5 years and to present the other aspects helmed by Obesity and Metabolic Surgery Society of India (OSSI) to aid the growth of research, education, data management and registry, quality control, insurance-related issues and policy change. OSSI conducts an annual survey to collect data pertaining to numbers of surgical procedures. With the approval of the executive committee, data collected from 2014 to 2018 were retrieved and analysed. 20,242 surgical procedures were performed in 2018 which is an 86.7% increase from 2014. Laparoscopic sleeve gastrectomy continued to remain the most popular procedure, it's percent share saw a steady decline from 68 to 48%. One anastomosis gastric bypass showed an unprecedented growth from 14 to 34%. Numbers of laparoscopic Roux en y gastric bypass remained constant at 15-16%. OSSI has also initiated a COE program along with training fellowships and focus on registry and inclusion in insurance coverage. National trends over the past 5 years in bariatric surgery have shown emergence of newer procedures like OAGB, although LSG continues to be the most popular procedure performed These trends give an insight on how the field is evolving and the implications for any distinctive requirements unique to this region These will lay out important directives for not only ensuring good treatment outcomes but also increasing awareness about the disease on the whole.

Circulatory Omentin-1 levels but not genetic variants influence the pathophysiology of Type 2 diabetes.

OBJECTIVE: Omentin-1, an anti-inflammatory protein, is secreted by the visceral adipose tissue. Altered levels of Omentin-1 are associated with obesity and Type 2 Diabetes (T2D). Although Omentin-1 is implicated in the insulin signaling pathway, the relationship between the genetic variants of Omentin-1 and T2D is not yet explored. The current study evaluates the association of Omentin-1 polymorphisms (rs2274907 A/T and rs1333062 G/T), its transcript and protein levels, and genotype-phenotype correlation with metabolic parameters and T2D susceptibility. METHODS: Plasma and Peripheral Blood Mononuclear Cells (PBMCs) were separated from venous blood taken from 250 controls and 250 T2D patients recruited from Gujarat, India. Genomic DNA was isolated from PBMCs and genotyping of Omentin-1 variants was performed by Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP). RNA was isolated from Visceral Adipose Tissue (VAT) samples of 12 controls and 10 patients, and transcript levels of Omentin-1 were assessed by qPCR. Plasma Omentin-1 levels were estimated by ELISA. Fasting Blood Glucose, Body Mass Index (BMI) and plasma lipid profile were considered for the genotype-phenotype correlation analysis. RESULTS: Our study revealed no association of Omentin-1 genetic variants with T2D risk (p > 0.05). However, the AT genotype of Omentin-1 rs2274907 A/T polymorphism was associated with increased BMI (p = 0.0247). Plasma Omentin-1 levels were significantly decreased (p < 0.0001) however, increased VAT Omentin-1 transcript levels (p = 0.0127) were observed in T2D patients. CONCLUSION: Our findings suggest that decreased circulatory Omentin-1 levels could pose a risk towards T2D susceptibility.

A Systematic Review of Bariatric Surgery in Patients with Liver Cirrhosis.

Nonalcoholic steatohepatitis is becoming a common cause of liver cirrhosis and a significant number of patients undergoing bariatric surgery suffer with it. There is currently lack of consensus among surgeons regarding safety of bariatric surgery in patients with liver cirrhosis and the best bariatric procedure in these patients. This review investigates published English language scientific literature systematically in an attempt to answer these questions. Eleven studies that reported experience of bariatric surgery in cirrhotic obese patients were included in this review. This review shows an acceptably higher overall risk of complications and perioperative mortality with bariatric surgery in cirrhotic patients. Surgeons must discuss the possibility of an unexpected intraoperative diagnosis of cirrhosis preoperatively with all bariatric surgery patients and agree on a course of action.

Randomized double-blinded trial of laparoscopic gastric imbrication v laparoscopic sleeve gastrectomy at a single Indian institution.

BACKGROUND: Currently, there is a debate whether the laparoscopic gastric imbrication (LGI) offers similar weight loss when compared to the laparoscopic sleeve gastrectomy (LSG). On the surface, they seem to offer similar-sized stomachs after the procedures are performed. We chose to perform a randomized double-blinded trial to see if similar-sized pouches result in similar types of weight loss. Our belief was that sleeve gastrectomy would offer at least a 10% better weight loss over a 3-year period. METHODS: Thirty patients were randomized to one of two arms. The patients and the third party administrator following the patients were blinded as to which procedure was chosen. The surgeon had full knowledge of the patients' surgery throughout the treatment. The decision of which arm to place them was made by a single employee of the third party administrator and not shared with the employees following the patients. Patients were then followed for 3 years. RESULTS: There were no differences in weight, age, or BMI preoperatively. There were no differences between the two groups at any follow-up time point from 6 months to 3 years. Follow-up was 100%. CONCLUSION: Due to the large standard deviations present in both groups, there was no statistical difference between either of the groups in terms of weight loss.

IFSO-APC consensus statements 2011.

Associations of BMI with body composition and health outcomes may differ between Asian and European populations. Asian populations have also been shown to have an elevated risk of type 2 diabetes, hypertension, and hyperlipidemia at a relatively low level of BMI. New surgical indication for Asian patients should be discussed by the expert of this field. Forty-four bariatric experts in Asia-Pacific and other regions were chosen to have a voting privilege for IFSO-APC Consensus at the 2nd IFSO-APC Congress. A computerized audience-response voting system was used to analyze the agreement with the sentence of the consensus. Of all delegates, 95% agreed with the necessity of the establishment of IFSO-APC consensus statements, and 98% agreed with the necessity of a new indication for Asian patients. IFSO-APC Consensus statements 2011. Bariatric surgery should be considered for the treatment of obesity for acceptable Asian candidates with BMI ≥ 35 with or without co-morbidities. Bariatric/GI metabolic surgery should be considered for the treatment of T2DM or metabolic syndrome for patients who are inadequately controlled by lifestyle alternations and medical treatment for acceptable Asian candidates with BMI ≥ 30. The surgical approach may be considered as a non-primary alternative to treat inadequately controlled T2DM, or metabolic syndrome, for suitable Asian candidates with BMI ≥ 27.5. Other eight sentences are agreed with by majority of the voting delegates to form IFSO-APC consensus statements. This will help to make safe and wholesome the progress of bariatric and metabolic surgery in Asia.

Autosomal recessive hypercholesterolemia and bilio-pancreatic diversion: A case report.

SUMMARY: Familial hypercholesterolemia (FH) is typically an autosomal dominant disorder but a rare variant, autosomal recessive FH (ARH) does also exist. The most serious symptom is sudden death, myocardial infarction, or angina due to atherosclerotic coronary artery disease. Therefore, treatment of ARH is aimed to alter the course of disease before the onset of CAD. Multiple treatment options available varying from life style modification to organ replacement with favourable outcome. We report a case of autosomal recessive hypercholesterolemia (ARH) who was treated with bilio-pancreatic diversion (BPD) with satisfying results.:

A prospective randomized, controlled study comparing low pressure versus high pressure pneumoperitoneum during laparoscopic cholecystectomy.

BACKGROUND: The increase in intra-abdominal pressure by insufflation of carbon dioxide during laparoscopy brings certain changes in function of organ systems and also leads to postoperative pain. Degree of intra-abdominal pressure is directly related with such change. Laparoscopic cholecystectomy can be performed at low pressure pneumoperitoneum. However, available space for dissection is less than the high pressure pneumoperitoneum. METHODS: Twenty-six patients for elective laparoscopic cholecystectomy were studied in a prospective, randomized, patient, and surgeon blinded manner. The intra-abdominal pressure was kept either in low pressure (8 mm Hg) or in high pressure (12 mm Hg). All patients underwent two dimensional echocardiography, pulmonary function test and color Doppler examination of lower limb vessels preoperatively and postoperatively. Arterial blood gas analysis and End Tidal CO2 monitored before insufflation, during surgery and after deflation. Pain score was measured by visual analog scale and surgeon's comfort level was recorded. Postoperative analgesia requirement, complications, and hospital stay were recorded. Student t test used for the statistical analysis. RESULTS: Both groups match for the demographic parameters. Four patients required conversion to high pressure. Intraoperative pO2 level, postoperative pain, analgesic requirement, pulmonary function, and hospital stay were favoring low pressure pneumoperitoneum in a statistically significant manner. There was no difference between 2 groups for duration of surgery, intraoperative, and postoperative complications. However, the technical difficulties were graded more (statistically nonsignificant) with low pressure pneumoperitoneum. CONCLUSIONS: An uncomplicated gall stone disease can be treated by low pressure laparoscopic cholecystectomy with reasonable safety by an experienced surgeon. Though surgeons experience more difficulty in dissection during low pressure pneumoperitoneum, it is significantly advantageous in terms of postoperative pain, use of analgesics, preservation of pulmonary function, and hospital stay.

Cefoperazone-sulbactam for treatment of intra-abdominal infections: results from a randomized, parallel group study in India.

BACKGROUND: Combinations of a third-generation cephalosporin and metronidazole, with or without an aminoglycoside, often are used for the treatment of intra-abdominal infections in surgical settings. Simpler regimens that preserve an adequate spectrum of coverage, but allow easier administration and have fewer side effects, may be a more desirable option. METHODS: This randomized, open-label, active comparator study evaluated the effectiveness (non-inferiority hypothesis) of the beta-lactam/beta-lactamase inhibitor combination cefoperazone-sulbactam (2-8 g/day), compared with ceftazidime (2-6 g/day)-amikacin (15 mg/kg/day)-metronidazole (500 mg three times daily) in 154 and 152 subjects, respectively, having intra-abdominal infections. The study was conducted at 17 centers in India. RESULTS: Non-inferiority of cefoperazone-sulbactam (91.9%) compared with ceftazidime-amikacin-metronidazole (81.8%) was demonstrated for continued resolution of clinical signs and symptoms at the 30-day follow-up (primary endpoint) with a treatment difference of 10.1% (95% confidence interval 2.1%, 18.1%; pre-defined non-inferiority limit > -12.5%). Superiority of cefoperazone-sulbactam also was demonstrated for this endpoint, with significantly more subjects achieving continued resolution at the 30-day follow-up than in the comparator group (p = 0.015). On microbiologic outcomes, cefoperazone-sulbactam had higher success rates than ceftazidime-amikacin-metronidazole (92.9% vs. 80.0%). The pathogens (202 isolated) isolated most commonly were Escherichia coli (38.6%) and Klebsiella spp. (12.9%). The incidence of treatment-related adverse events was 6.5% and 16.4% in the cefoperazone-sulbactam and ceftazidime-amikacin-metronidazole groups, respectively, with more discontinuations due to treatment-related adverse events in the comparator arm (3.2% vs. 9.9%). CONCLUSION: Empirical cefoperazone-sulbactam monotherapy could be a useful adjunct to surgical intervention for intra-abdominal infections.