Stage of fibrosis is not a predictive determinant of weight loss in patients undergoing bariatric surgery.

BACKGROUND: Obesity and nonalcoholic fatty liver disease (NAFLD) are an increasing health care burden worldwide. Weight loss is currently the best option to alleviate NAFLD and is efficiently achieved by bariatric surgery. Presence of NAFLD seems to be predictive for postoperative weight loss. To date, only few predictive factors for postbariatric weight loss (age, diabetes, psychiatric disorders) are established. OBJECTIVES: Since liver fibrosis is the pathogenic driver for the progression of liver disease, we investigated its role in predicting postoperative weight loss. This study focuses on the correlation between fibrosis stage and weight loss. SETTING: University and university-affiliated cooperation, Germany. METHODS: We used a prospective, single-center cohort study including 164 patients who underwent bariatric surgery with simultaneous liver biopsies. Liver fibrosis was determined histologically according to Kleiner score and noninvasively by APRI and FIB-4 score. Percentage of total body weight loss was calculated at 1-year follow up visit. RESULTS: Thirty-two patients were found without fibrosis, whereas 91 patients showed mild fibrosis (F1), 37 significant fibrosis (F2), and only 4 patients presented advanced fibrosis (F3) at the time of bariatric surgery. Weight loss was similar across different degrees of fibrosis stage. Accordingly, linear regression analysis did not identify predictors of weight loss among fibrosis scores. In multivariable analysis, age and presence of diabetes showed the strongest predictive value. CONCLUSIONS: Baseline presence of fibrosis was not associated with postoperative weight loss, while age and diabetes were independent predictors of weight loss. Bariatric surgery should be applied independently of the fibrosis stage.

Health-related quality of life outcomes following Roux-en-Y gastric bypass versus one anastomosis gastric bypass.

PURPOSE: Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) are effective standard bariatric surgeries with comparable weight loss and remission of obesity-related comorbidities. As procedure-specific health-related quality of life (HrQoL) outcomes have not been directly compared thus far, we conducted this questionnaire-based study. METHODS: Two hundred forty patients after undergoing either RYGB or OAGB between 2011 and 2016 were contacted and asked to fill out SF36 and BAROS questionnaires. All statistical analysis was performed with Microsoft Excel and GraphPad Prism. Primary objectives were procedure-dependent differences in HrQoL. Secondary objectives were weight loss and remission of comorbidities. RESULTS: One hundred nineteen of 240 contacted patients (49.6%) replied, 58 after RYGB (48.7%) and 61 after OAGB (51.3%). Follow-up period was < 24 months in 52 and > 24 months in 64 evaluable patients. The mean age was 46 years (range 23 to 71). Regarding the < 24 months groups, both physical and psychological SF36 sum scales were comparably high. Only the subcategory "general health perception" was significantly better after RYGB. Significantly higher excess weight loss (EWL) after RYGB (88.81%) compared to OAGB (66.25%) caused significantly better global < 24 months BAROS outcomes, whereas remission of comorbidities and HrQoL was similar. Both > 24 months groups showed high SF36-HrQoL sum scales. Global mean BAROS results after > 24 months were "very good" in both procedures. EWL in RYGB (80.81%) and in OAGB (81.36%) were comparably excellent. CONCLUSION: Concerning SF36 and BAROS evaluated HrQoL in early and late postoperative phases, both procedures demonstrated comparable and relevant improvements. Further (preferably randomized) studies should include evaluation of preoperative HrQoL.

A Long-Term Comparative Study Between One Anastomosis Gastric Bypass and Sleeve Gastrectomy.

BACKGROUND: One anastomosis gastric bypass (OAGB) has become increasingly accepted in bariatric surgery and meanwhile represents the third most common procedure worldwide. While it shows promising weight loss results and comorbidity resolution, questions about issues such as reflux or nutritional deficiencies (ND) persist in the long term. On the other hand, the most frequently performed sleeve gastrectomy (SG) has to accept growing criticism regarding long-term results and reflux issues. There is a particular lack of long-term comparative data for both procedures. This study presents our long-term experience. METHODS: We evaluated OAGB and SG patients retrospectively comparing for weight loss and resolution of comorbidities as well as perioperative and long-term complications in a follow-up period of 5 years. RESULTS: Nine hundred eleven OAGB and 241 SG were included in the study. OAGB had a shorter operation time and hospital stay. Overall complication rate did not differ in both groups. Ulcers were more frequent in OAGB (7.7% vs. 1.7%, p = 0.001), whereas insufficient weight loss (IWL)/weight regain (WR) proved to be more prevalent in SG (25.7% vs. 6.4%, p < 0.001). The same held true for reflux (17.8% vs. 8.3%, p < .001). On the other hand, ND were more common in OAGB (20.0% vs. 12.0%, p = 0.005). Revisional surgery was more often indicated after SG. Analysis by linear mixed model showed that OAGB achieved a lower BMI/higher loss of BMI. Improvement of T2DM (94.6% vs. 85.2%, p = 0.008) and sleep apnea (88.8% vs. 78.8%, p = 0.01) was superior in OAGB. CONCLUSIONS: OAGB had a superior effect on weight loss as well as improvement of T2DM and sleep apnea. Furthermore, long-term problems such as IWL/WR and reflux were more related to SG. On the other hand, a malabsorptive procedure such as OAGB showed a higher risk for ND. Our findings support the available data in the literature.

Roux-en-Y Versus One Anastomosis Gastric Bypass as Redo-Operations Following Sleeve Gastrectomy: A Retrospective Study.

BACKGROUND: Aim of this study was to improve knowledge about the best conversional bariatric procedure following sleeve gastrectomy (SG). METHODS: Data of conversional Roux-en-Y gastric bypass (RYGB) and of one anastomosis gastric bypass (OAGB) after SG were collected prospectively and analyzed retrospectively. Weight loss parameters, gastroesophageal reflux disease (GERD) and comorbidities outcomes were recorded. RESULTS: Total of 123 patients (90 female, mean age 44 ± 0.9 years, mean body mass index (BMI) 42 ± 0.8 kg/m2) had either RYGB (n = 68) or OAGB (n = 55). Perioperative mortality was zero. Mean surgery time was significantly shorter for OAGB (168 ± 7.2 vs. 201 ± 6.8 min). Perioperative complication rates were not significantly (ns) different between RYGB and OAGB. Total body weight loss (TBWL) in RYGB and OAGB was 18 ± 2.2% and 18 ± 1.9% (12 months) and 18 ± 3.0% and 23 ± 2.6% (24 months; ns), respectively. Length of (individualized) biliopancreatic limb (BPL) correlated significantly with weight loss. Remission rates after 12 months of RYGB and OAGB for arterial hypertension (aHt) were 89% and 92%, for obstructive sleep apnea (OSAS) 56% and 82%, for Type 2 diabetes mellitus (T2DM) 100% and 92%, for osteoarthritis 64% and 85% and for GERD 89% versus 87% (ns), respectively. Nutritional deficiencies were comparable in RYGB (n = 11) and OAGB (n = 14) group (ns). CONCLUSION: Both RYGB and OAGB are effective conversional procedures after SG, leading to comparable TBWL, BMI-loss and high remission rates of comorbidities including GERD. Significantly shorter operation times were in favor of OAGB. BPL, which was longer in OAGB was significantly related to higher %TBWL and %BMI-loss compared to RYGB.

Clinical outcomes after one anastomosis gastric bypass versus sleeve gastrectomy in super-super-obese patients.

BACKGROUND: Bariatric surgery in super-super-obese (SSO) patients remains a continuous challenge due to intraabdominal fat masses, higher liver volume and existing comorbidities. A convenient procedure in SSO patients is one anastomosis gastric bypass (OAGB). The aim of this study was to compare the outcome of SSO patients undergoing OAGB in comparison to laparoscopic sleeve gastrectomy (LSG). METHODS: We retrospectively reviewed data from SSO patients who underwent OAGB and LSG in our institution between 2008 and 2020. Primary endpoints included percentage total body weight loss and percentage BMI loss at 12, 24, and 36 months after the operation. Secondary endpoints were perioperative complications, procedure length, length of hospital stay and outcome of comorbidities. RESULTS: 243 patients were included in this study. 93 patients underwent LSG and 150 underwent OAGB. At any of the time points evaluated, weight loss in patients after OAGB was greater than in LSG patients, while procedure length was significantly shorter for OAGB than LSG (81.4 vs. 92.1 min, p-value < 0.001). Additionally, mean length of hospital stay was shorter in the OAGB group (3.4 vs. 4.5 days, p-value < 0.001). There were more severe complications (Clavien-Dindo ≥ 3a) in the LSG group (11.8% vs 2.7%, p-value = 0.005). CONCLUSION: In this retrospective analysis, OAGB was superior to LSG in terms of weight loss in SSO patients. Procedure length and hospital stay were shorter after OAGB in comparison to LSG and there were fewer severe complications. OAGB can therefore be regarded a safe and effective treatment modality for SSO patients.

A Specifically Tailored Multistrain Probiotic and Micronutrient Mixture Affects Nonalcoholic Fatty Liver Disease-Related Markers in Patients with Obesity after Mini Gastric Bypass Surgery.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is frequent among patients undergoing bariatric surgery. Beyond weight reduction, dietary supplements like micronutrients or probiotics that modify insulin resistance and lipotoxicity can be used to prevent or delay the progression of liver disease. OBJECTIVES: We evaluated the effect of a dietary approach with a specifically tailored multistrain probiotic and micronutrient mixture compared with a basic care micronutrient supplement on serum alanine aminotransferase (ALAT) in obese patients after mini gastric bypass (MGB) surgery. METHODS: This randomized, double-blind, controlled trial included 60 obese patients (age: 40 ± 10 y; BMI: 44 ± 3 kg/m²). Patients received a combination of specifically tailored multistrain probiotic powder and a specific micronutrient mixture (Pro+SM) or a control treatment consisting of a placebo and a basic care micronutrient mixture (Con+BM), with some micronutrients in lower doses than SM, for 12 wk after hospital discharge. Primary (serum ALAT) and secondary outcomes [serum aspartate aminotransferase (ASAT), fatty liver index, NAFLD fibrosis score, glucose metabolism, blood pressure (BP), heart rate] were assessed at week 0 and week 12. Data were analyzed using unpaired Student's t-tests or Mann-Whitney U tests to compare the changes due to each treatment to one another. RESULTS: A total of 48 patients were included in the analyses. Changes in serum ALAT concentrations did not differ between groups. Compared with Con+BM, Pro+SM improved serum ASAT (difference: -8.0 U/L, 95% CI: -17.0, -4.0; P = 0.043), NAFLD fibrosis score (difference: -0.39; 95% CI: -0.78, 0; P = 0.048), serum triglycerides (difference: -22.8 mg/dL; 95% CI: -45.6, -0.1; P = 0.049) and the visceral adiposity index (difference: -0.70; 95% CI: -1.31, -0.08; P = 0.027). CONCLUSION: Supplementation with a specifically tailored probiotic and micronutrient mixture improved NAFLD-related markers more than a basic micronutrient mixture in obese patients following MGB surgery. The trial was registered under clinicaltrials.gov as NCT03585413.

Baseline Presence of NAFLD Predicts Weight Loss after Gastric Bypass Surgery for Morbid Obesity.

BACKGROUND: Bariatric surgery is a widely used treatment for morbid obesity. Prediction of postoperative weight loss currently relies on prediction models, which mostly overestimate patients' weight loss. Data about the influence of Non-alcoholic fatty liver disease (NAFLD) on early postoperative weight loss are scarce. METHODS: This prospective, single-center cohort study included 143 patients receiving laparoscopic gastric bypass surgery (One Anastomosis-Mini Gastric Bypass (OAGB-MGB) or Roux-en-Y Gastric Bypass (RYGB)). Liver biopsies were acquired at surgery. NAFLD activity score (NAS) assigned patients to "No NAFLD", "NAFL" or "NASH". Follow up data were collected at 3, 6 and 12 months. RESULTS: In total, 49.7% of patients had NASH, while 41.3% had NAFL. Compared with the No NAFLD group, NAFL and NASH showed higher body-mass-index (BMI) at follow-up (6 months: 31.0 kg/m2 vs. 36.8 kg/m2 and 36.1 kg/m2, 12 months: 27.0 kg/m2 vs. 34.4 and 32.8 kg/m2) and lower percentage of total body weight loss (%TBWL): (6 months: 27.1% vs. 23.3% and 24.4%; 12 months: 38.5% vs. 30.1 and 32.6%). Linear regression of NAS points significantly predicts percentage of excessive weight loss (%EWL) after 6 months (Cologne-weight-loss-prediction-score). CONCLUSIONS: Histopathological presence of NAFLD might lead to inferior postoperative weight reduction after gastric bypass surgery. The mechanisms underlying this observation should be further studied.

The Role of Macrophage-Inducible C-Type Lectin in Different Stages of Chronic Liver Disease.

The macrophage-inducible C-type lectin (mincle) is part of the innate immune system and acts as a pattern recognition receptor for pathogen-associated molecular patterns (PAMPS) and damage-associated molecular patterns (DAMPs). Ligand binding induces mincle activation which consequently interacts with the signaling adapter Fc receptor, SYK, and NF-kappa-B. There is also evidence that mincle expressed on macrophages promotes intestinal barrier integrity. However, little is known about the role of mincle in hepatic fibrosis, especially in more advanced disease stages. Mincle expression was measured in human liver samples from cirrhotic patients and donors collected at liver transplantation and in patients undergoing bariatric surgery. Human results were confirmed in rodent models of cirrhosis and acute-on-chronic liver failure (ACLF). In these models, the role of mincle was investigated in liver samples as well as in peripheral blood monocytes (PBMC), tissues from the kidney, spleen, small intestine, and heart. Additionally, mincle activation was stimulated in experimental non-alcoholic steatohepatitis (NASH) by treatment with mincle agonist trehalose-6,6-dibehenate (TDB). In human NASH, mincle is upregulated with increased collagen production. In ApoE deficient mice fed high-fat western diet (NASH model), mincle activation significantly increases hepatic collagen production. In human cirrhosis, mincle expression is also significantly upregulated. Furthermore, mincle expression is associated with the stage of chronic liver disease. This could be confirmed in rat models of cirrhosis and ACLF. ACLF was induced by LPS injection in cirrhotic rats. While mincle expression and downstream signaling via FC receptor gamma, SYK, and NF-kappa-B are upregulated in the liver, they are downregulated in PBMCs of these rats. Although mincle expressed on macrophages might be beneficial for intestinal barrier integrity, it seems to contribute to inflammation and fibrosis once the intestinal barrier becomes leaky in advanced stages of chronic liver disease.

Impact of sleeve gastrectomy and dietary change on metabolic and hepatic function in an obesity rat model - Experimental research.

PURPOSE: Sleeve gastrectomy (SG) is an effective procedure to treat morbid obesity. SG induces remission of type 2 diabetes and metabolic syndrome and improves non-alcoholic fatty liver disease (NAFLD). However, it is imperative to clarify the extent to which these beneficial effects may be attributed to SG among other concomitant changes including postoperative diet. The current study addresses this question in a rodent model of obesity by subjecting it to SG, normal diet, or a combination of the two. METHODS: Male Wistar-rats were fed with either high fat diet (HF, n = 32) or received chow diet (CD, n = 8). After 15 weeks, the HF-fed rats underwent either SG or sham operation, following which they were randomised to either continue HF or switched to CD for another 6 weeks. Body weight, fasting blood glucose level, blood pressure, and adipokine expression (leptin, adiponectin, MCP-1) in the adipose tissue along with triglycerides level in the blood serum were assessed to evaluate metabolic function. Hepatic function was assessed by histological evaluation of liver fibrosis (Hydroxyproline, Sirius Red) and reverse transcription polymerase chain reaction (RT-PCR) of the inflammation marker monocyte chemoattractant protein-1 (MCP-1). RESULTS: Postoperative dietary change improved adipose tissue inflammation and arterial blood pressure regardless of the surgical intervention, while SG improved hyperglycaemia, blood triglyceride levels and, regardless of the postoperative diet, hepatic inflammation and fibrosis. However, combined administration of SG with post-operative normal diet was the most effective with regard to reducing the body weight. CONCLUSION: HF for 15 weeks induced obesity with metabolic syndrome and NAFLD in rats. SG and dietary intervention improved metabolic state and NAFLD; however, their combination was significantly more effective.

Banding the Pouch with a Non-adjustable Ring as Revisional Procedure in Patients with Insufficient Results After Roux-en-Y Gastric Bypass: Short-term Outcomes of a Multicenter Cohort Study.

BACKGROUND: After laparoscopic Roux-en-Y gastric bypass (RYGB), approximately 10-35% of patients with morbid obesity regain weight after an initial good result or fail to achieve a sufficient amount of weight loss. Patients in which conservative measures are not successful may potentially benefit from revisional surgery. OBJECTIVE: To evaluate the effect of a non-adjustable ring placed around the gastric pouch in patients with insufficient weight loss or weight regain after RYGB. SETTING: Four specialized bariatric hospitals in The Netherlands, Germany, and Switzerland. METHODS: From 2011 to 2017, 79 patients underwent revisional surgery using a non-adjustable silicone ring because of insufficient results after RYGB. Data on weight loss and complications up to 2 years after revisional surgery was collected and analyzed retrospectively. RESULTS: A follow-up percentage of 86% after 1 year and 61% after 2 years was achieved. In 75% of patients, further weight regain was prevented. Percentage total body weight loss improved by 7 to 26% 1 year after revisional surgery and remained stable during 2 years of follow-up. The additional weight loss effect of placing a non-adjustable ring was more pronounced in patients with an initial good result after primary RYGB. Eighteen (23%) rings were removed, most often due to dysphagia. CONCLUSION: Especially for patients who experience weight regain after initial good weight loss, placing a non-adjustable silicone ring around the gastric pouch results in modest improvements in weight loss. To prevent the risk of ring removal due to dysphagia, surgeons should take notice not to place the ring too tight around the gastric pouch during revisional surgery.

One Anastomosis Gastric Bypass-Mini-Gastric Bypass (OAGB-MGB) Versus Roux-en-Y Gastric Bypass (RYGB)-a Mid-Term Cohort Study with 612 Patients.

BACKGROUND: OAGB-MGB emerged as a standard procedure, albeit RYGB remains the most frequently performed gastric bypass. Comparative studies are scarce. METHODS: Prospectively collected data (July 2006 to November 2017) from a large sample size and adequate follow-up were analyzed using logistic regression and linear mixed models. Total weight loss (TWL) within the first 3 years was defined as primary outcome and duration of operation, perioperative, and late complications and comorbidity remission as secondary outcomes. RESULTS: Three hundred twenty-four OAGB-MGBs (age 42.51 ± 11.36 years, 74.69% females) presented with higher preoperative BMI (53.75 ± 6.51 kg/m2 vs. 44.53 ± 3.65 kg/m2, p < 0.0001) and higher comorbidity prevalence than 288 RYGBs (age 41.4 ± 10.04 years, 79.86% females). Duration of operation was 80.28 ± 20.31 min in OAGB-MGB and 103.36 ± 29.69 min in RYGB (p < 0.0001). Intraoperative complications (4.63% resp. 8.68%), early re-laparoscopy (0.62% resp. 0.69%), leakage (1.23% resp. 1.74%), internal hernias (IH) (0.32% resp. 3.85%), marginal ulcers (3.23% resp. 5.59%), gastroesophageal reflux (3.55% resp. 0.70%), and insufficient weight loss at 3 years (4.19% resp. 5.59 %) were comparable in OAGB-MGB resp. RYGB. Follow-up rates at 1 and 3 years declined from 76.71 to 42.86% (OAGB-MGB) resp. 79.15 to 50.00% (RYGB). TWL (OAGB-MGB, 36.18 ± 9.18%; RYGB, 33.8 ± 8.75%), malnutrition (OAGB-MGB, 4.19%; RYGB, 2.45%), and comorbidity remission 3 years postoperatively revealed comparable robust data. Anastomotic stenosis (1.94% resp. 14.69%) and dumping syndrome (3.55% resp. 6.64%) were less frequent in OAGB-MGB. CONCLUSIONS: TWL, malnutrition, and comorbidity remission 3 years postoperatively were comparable. Gastroesophageal reflux was less frequent after RYGB (p = 0.0729), whereas shorter operation times (p < 0.0001), less frequent stenosis (p < 0.0001), and dumping syndrome (p = 0.0018) were found in OAGB-MGB. Further RCTs are required.

Combination of CCl4 with alcoholic and metabolic injuries mimics human liver fibrosis.

Metabolic and alcoholic liver injuries result in nonalcoholic (NAFLD) or alcoholic (ALD) fatty liver disease, respectively. In particular, presence of fibrosis in NAFLD and ALD requires treatment, but development of drugs is hampered by the lack of suitable models with significant fibrosis. The carbon tetrachloride (CCl4) liver fibrosis model does not reflect human NAFLD or ALD, but CCl4 may serve as a fibrosis accelerator in addition to another injury. Ethanol in drinking water (16%) or Western diet (WD) were administered for 7 wk in mice either alone or in combination with CCl4 intoxications. Extent of fibrosis, steatosis, and inflammation was assessed by histology, transcription, and biochemistry. Furthermore, transcription of fibrosis, proliferation, and inflammation-related genes was studied on human liver samples with fibrosis resulting from hepatitis C virus infection (n = 7), NAFLD (n = 8), or ALD (n = 7). WD or ethanol alone induced only mild steatosis and inflammation. Combination of CCl4 and WD induced the most severe steatosis together with significant liver fibrosis and moderate inflammation. Combination of CCl4 and ethanol induced the strongest inflammation, with significant liver fibrosis and moderate steatosis. The relationship pattern between fibrosis, proliferation, and inflammation of human ALD was mostly similar in mice treated with CCl4 and ethanol. The combination of CCl4 intoxication with WD validates previous data suggesting it as an appropriate model for human nonalcoholic steatohepatitis. Especially, CCl4 plus ethanol for 7 wk induces ALD in mice, providing a model suitable for further basic research and drug testing.NEW & NOTEWORTHY Alcoholic fatty liver disease with significant fibrosis is generated within 7 wk using carbon tetrachloride as a fibrosis accelerator and administering gradually ethanol (up to 16%) in mice. The similarity in the pattern of steatosis, inflammation, and fibrosis involved in alcoholic fatty liver disease to those of the human condition renders this mouse model suitable as a preclinical model for drug development.

Comparison of mini-gastric bypass with sleeve gastrectomy in a mainly super-obese patient group: first results.

INTRODUCTION: Whereas sleeve gastrectomy (SG) in its beginnings was mainly performed to treat super-obesity, it has become as popular as gastric bypass in the treatment of obesity of any class. In contrast to this, the persisting problems of early staple line leaks and poor long-term results of SG regarding weight loss and new onset of gastroesophageal reflux have become increasingly obvious. The mini-gastric bypass (MGB) with its low complication rates and possibly better long-term results may be a good alternative to SG, especially in super-obesity. METHODS: In this context, two groups of mostly super-obese patients (SG and MGB) of a single bariatric center were retrospectively analyzed and compared for perioperative and early postoperative outcomes. RESULTS: Between August 2007 and March 2015, 169 patients underwent MGB, while 118 patients were operated by SG. Both groups were comparable for BMI at baseline (MGB = 54.1 kg/m2 vs. SG = 54.6 kg/m2, p = 0.657). Mean operation time (81.7 vs. 112.1 min, p < 0.0001) as well as hospital stay was lower in the MGB-group (4.5 vs. 7.2 days, p < 0.0001). Perioperative (30 days) mortality was 0 % in MGB versus 0.8 % in SG (one patient). Perioperative complication rate was also lower in the MGB-group (3.0 vs. 9.3 %, p = 0.449). %EWL was significantly better after 1 year in MGB: 66.2 % (±13.9 %) versus 57.3 % (±19.0 %) in SG (p < 0.0001), as well as BMI which was 34.9 kg/m2 (±4.8 kg/m2) in MGB versus 38.5 kg/m2 (±8.6 kg/m2) in SG (p = 0.001). CONCLUSIONS: MGB achieved superior weight loss at 1 year and had a lower 30-day complication rate in comparison with SG for super-obese patients. Thus, MGB might be superior to SG regarding the treatment of super-obesity.