Novel Nutritional and Dietary Approaches to Weight Loss for the Prevention of Cardiovascular Disease: Ketogenic Diet, Intermittent Fasting, and Bariatric Surgery.

PURPOSE OF REVIEW: Cardiovascular disease (CVD) is highly associated with obesity and cardiometabolic dysfunction. This review will focus on three novel therapies that have been identified for potential treatment of obesity and its associated CVD risk factors. RECENT FINDINGS: Intermittent fasting (IF) studies in animal models have shown improvements in cardiometabolic factors, including improved glucose metabolism, reduced inflammation, and reduced blood pressure. However, there is still a lack of prospective human trials to support results from animal-based studies and observational data. Studies of ketogenic diets in humans have produced mixed effects in CVD risk factors. It has been shown that the ketogenic diet (KD) increases low-density lipoprotein cholesterol (LDL-C) but decreases triglycerides. Additionally, implementation of KD in rodent studies have demonstrated increased insulin resistance and glucose intolerance. Bariatric surgery is a useful tool to help patients with obesity lose significant amounts of weight while alleviating CVD risk factors such as hypertension, LDL-C levels, triglyceride levels, and diabetes. The type of procedure influences degree of improvement in weight and CVD risk factors, yet complications remain possible. IF and bariatric surgery offer potential for weight loss and treatment of CVD risk factors. Negative cardiovascular effects of KD have been noted and should be considered before recommending this diet to patients, particularly those with established cardiovascular disease.

Obesity/Bariatric Surgery and Crohn's Disease.

BACKGROUND: Crohn's disease (CD) following bariatric surgery has been previously described. It is not clear whether the clinical entity is due to rapid metabolism of fat, change in the bacterial milieu of the bowel, the loss of defense mechanisms of the stomach, or even a coincidence. OBJECTIVES: To present observations which might serve to sort out these various etiologies. DESIGN: We present 5 cases of colitis, ileocolitis or enteritis, some with fistula formation, with clinical onset following bariatric surgery and add these to the 7 cases previously identified as CD reported elsewhere. We provide the clinical features of these 12 cases to reconcile with causative mechanisms. LIMITATIONS: It remains possible that the onset of CD (or other inflammatory bowel disease) precedes the bariatric surgery which then accelerates the clinical manifestations described. Furthermore, without controls the association could remain a coincidence. CONCLUSIONS: We review the evidence for release of proinflammatory cells and cytokines contained in fat following the bariatric surgery, and also consider the roles that the surgical resection of stomach and shortening of the bowel may also bring about this syndrome. The earlier onset is more likely due to surgical loss of defenses of the stomach and the later onset to a metabolic alteration of the presurgical obesity, involving fat metabolism, and/or the microbiome. The role of characteristic creeping fat of CD is also addressed.

Bariatric surgery in managing diabetes mellitus.

PURPOSE OF REVIEW: Obesity is a worldwide epidemic, having profound effects on Western populations. Bariatric surgery has long been employed to treat obesity and its related comorbidities. Over time, researchers have amassed significant data to support bariatric surgery in the pursuit of treating diabetes mellitus. This review serves to introduce the most recent findings and their relation to the various bariatric surgical options as bariatric surgery will continue to cement itself in the treatment paradigm of diabetes mellitus. RECENT FINDINGS: Numerous studies performed in the past 10 years have demonstrated the improvement or cessation of diabetes with bariatric surgical intervention. In comparing the vertical sleeve gastrectomy and Roux-en-Y gastric bypass, data demonstrate a more beneficial response of diabetes to the Roux-en-Y gastric bypass, and an even further exaggerated response with the biliopancreatic diversion/duodenal switch. The benefit has long been established, but what causes the improvement in diabetes mellitus after bariatric surgery? Recent data suggest a decrease in circulating bile salts as well as changes to inflammatory markers and circulating cytokines. Furthermore, tailoring of existing surgical procedures has led to the development of the SIPS procedure, and its benefit is demonstrated in bypassing a large portion of intestine while eliminating an enteroenterostomy, helping to reduce short gut syndrome and resultant diarrhea. SUMMARY: The surgical climate within the bariatric field is changing and will continue to do so in the future. As the understanding of the causes or mechanisms in which bariatric surgery improves metabolic disorders becomes more evident, the process of individualizing care for specific patients will become more prevalent.

Endoluminal Treatments for Obesity and Related Hypertension: Updates, Review, and Clinical Perspective.

PURPOSE OF REVIEW: Obesity is a global epidemic that continues to grow and results in related conditions such as hypertension and diabetes despite established interventions, thus suggesting the importance of new technologies. RECENT FINDINGS: Endoscopic interventions are vast in scope and effectiveness. Intra-gastric balloons appear to dominate the field at this time, but a recent FDA-approved technique, the Aspire device, may soon cause a shift in the treatment paradigm. Short-term studies demonstrate optimistic results, yet long-term studies have not been performed. In addition, complications from these procedures are severe, resulting in significant morbidity when they occur. Treatment of bariatric surgery complications with endoscopic techniques is an expanding field that relies heavily on new innovation. The next few years in bariatric endoscopy promise to be turbulent and controversial. Endoscopic procedures for obesity will undoubtedly increase but are anticipated to do so at a slower rate than many projects. Bariatric surgery complications will continue to be treated by endoscopic means, and optimization of these procedures is on the horizon. This review will provide those who treat obesity-related hypertension on the current state of bariatric endoluminal procedures.

Bariatric and metabolic surgery: current trends and what's to follow.

PURPOSE OF REVIEW: Obesity is a global epidemic and bariatric surgery remains an underperformed modality for its treatment. Even though the dangers of obesity are well understood, surgical intervention is underestimated. The purpose of this review is to discuss emerging trends in bariatric surgery. RECENT FINDINGS: Studies suggest that different operations have different effects on both obesity and its comorbidities. Combining the concepts of malabsorption and restriction, we are looking toward more advanced and efficient treatment options. Less-invasive techniques such as endoscopic devices are under investigation and their results remain to be determined. SUMMARY: A paradigm shift is occurring and both obesity and diabetes will be increasingly treated with surgical and endoscopic procedures. Bariatric care is a growing field for surgeons and therapeutic endoscopists with many future opportunities for improvement.

Endoscopic suturing for transoral outlet reduction increases weight loss after Roux-en-Y gastric bypass surgery.

BACKGROUND & AIMS: Weight regain or insufficient loss after Roux-en-Y gastric bypass (RYGB) is common. This is partially attributable to dilatation of the gastrojejunostomy (GJ), which diminishes the restrictive capacity of RYGB. Endoluminal interventions for GJ reduction are being explored as alternatives to revision surgery. We performed a randomized, blinded, sham-controlled trial to evaluate weight loss after sutured transoral outlet reduction (TORe). METHODS: Patients with weight regain or inadequate loss after RYGB and GJ diameter greater than 2 cm were assigned randomly to groups that underwent TORe (n = 50) or a sham procedure (controls, n = 27). Intraoperative performance, safety, weight loss, and clinical outcomes were assessed. RESULTS: Subjects who received TORe had a significantly greater mean percentage weight loss from baseline (3.5%; 95% confidence interval, 1.8%-5.3%) than controls (0.4%; 95% confidence interval, 2.3% weight gain to 3.0% weight loss) (P = .021), using a last observation carried forward intent-to-treat analysis. As-treated analysis also showed greater mean percentage weight loss in the TORe group than controls (3.9% and 0.2%, respectively; P = .014). Weight loss or stabilization was achieved in 96% subjects receiving TORe and 78% of controls (P = .019). The TORe group had reduced systolic and diastolic blood pressure (P < .001) and a trend toward improved metabolic indices. In addition, 85% of the TORe group reported compliance with the healthy lifestyle eating program, compared with 53.8% of controls; 83% of TORe subjects said they would undergo the procedure again, and 78% said they would recommend the procedure to a friend. The groups had similar frequencies of adverse events. CONCLUSIONS: A multicenter randomized trial provides Level I evidence that TORe reduces weight regain after RYGB. These results were achieved using a superficial suction-based device; greater levels of weight loss could be achieved with newer, full-thickness suturing devices. TORe is one approach to avoid weight regain; a longitudinal multidisciplinary approach with dietary counseling and behavioral changes are required for long-term results. ClinicalTrials.gov identifier: NCT00394212.

Response to glucose tolerance testing and solid high carbohydrate challenge: comparison between Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and duodenal switch.

BACKGROUND: Hyperinsulinemic hypoglycemia is common after Roux-en-Y gastric bypass (RYGB) and may result in weight regain. The purpose of our investigation was to compare the effect of RYGB, vertical sleeve gastrectomy (VSG), and duodenal switch (DS) on insulin and glucose response to carbohydrate challenge. METHODS: Patients meeting National Institutes of Health criteria for bariatric surgery selected their bariatric procedure after evaluation and education in this prospective nonrandomized study. Preoperatively and at 6, 9, and 12 months' follow-up, patients underwent blood draw to determine levels of fasting glucose, fasting insulin, glycated hemoglobin (HbA1c), C-peptide, and 2-h oral glucose challenge test. Homoeostatic Model Assessment (HOMA)-IR, fasting to 1-h and 1- to 2-h ratios of glucose and insulin, were calculated. Statistical analysis was performed using ANOVA and Student's paired t test. All procedures were performed via a laparoscopic technique at a single institution. RESULTS: Data from a total of 38 patients (13 RYGB, 12 VSG, 13 DS) were available for analysis. At baseline, all groups were similar; the only statistically significant difference was that DS patients had a higher preoperative weight and body mass index (BMI). All operations caused weight loss (BMI 47.7 ± 10-30.7 ± 6.4 kg/m(2) in RYGB; 45.7 ± 8.5-31.1 ± 5.5 kg/m(2) in VSG; 55.9 ± 11.4-27.5 ± 5.6 kg/m(2) in DS), reduction of fasting glucose, and improved insulin sensitivity. RYGB patients had a rapid rise in glucose with an accompanying rise in 1-h insulin to a level that exceeded preoperative levels. This was followed by a rapid decrease in glucose level. In comparison, DS patients had a lower increase in glucose and 1-h insulin, and the lowest HbA1c. These differences were statistically significant at various data points. For VSG, the results were intermediary. CONCLUSIONS: Compared to gastric bypass, DS results in greater weight loss and improves insulin sensitivity and glucose homeostasis without causing a hyperinsulinemic response. Because the response to challenge after VSG is intermediary, pyloric preservation alone cannot account for this difference.

Exploring Bariatric Surgery's Impact on Weight Loss and Diabetes: Sodium and Glucose Receptor Modulation.

Sodium-glucose cotransporters (SGLT) and glucose transporters (GLUT) have been shown to influence diabetes management by modulating glucose uptake by the intestine. Therefore, alterations in gastrointestinal anatomy during bariatric surgery can change SGLT and GLUT receptor activity. These changes offer an additional mechanism for weight loss and may explain the differential impact of the various bariatric surgical procedures. This review examines the current literature on SGLT and GLUT receptors and their effects on weight loss through genetic studies, pharmacologic inhibition, and how SGLT/GLUT receptors impact surgical physiologic modulation. A better understanding of Type I sodium-glucose cotransport receptors (SGLT-1), GLUT-2, and GLUT-5 could provide insight for improved procedures and allow us to determine the best method to tailor operations to a patient's individual needs.

Hypoglycemia and Dysautonomia After Bariatric Surgery: a Systematic Review and Perspective.

INTRODUCTION: With the increasing performance of bariatric surgery, rare complications are becoming prevalent. We review the diagnosis and treatment of dysautonomia after bariatric surgery and the limited treatment options available. We summarize the suggested mechanisms and explain why a complete understanding of the etiology has yet to be determined. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was performed. RESULTS: Of 448 studies identified in the literature search, 4 studies were reviewed, describing 87 patients diagnosed with dysautonomia. We present a patient who developed severe dysautonomia following conversion of sleeve gastrectomy to gastric bypass. CONCLUSION: Treatment needs to focus on optimizing nutrition, avoiding hypoglycemia, and optimizing volume status.

Continuous glucose monitoring reveals similar glycemic variability in individuals with obesity despite increased HOMA-IR.

Background/aims: Continuous glucose monitoring is a well-tolerated and versatile tool for management of diabetes and metabolic disease. While its use appears to be feasible to monitor glycemic profiles in diabetics, there is a paucity of data in individuals with obesity and normal glucose tolerance. The aim of this study is to investigate glucose fluctuations and insulin resistance patterns in normoglycemic participants with obesity vs. without obesity and contextualize these results against leading models for obesity. Materials and methods: We designed a prospective, observational pilot study of two cohorts including 14 normoglycemic participants with obesity and 14 normoglycemic participants without obesity. Participants were monitored with continuous glucose monitoring (CGM) for five consecutive days. Insulin resistance levels were measured and glucometric data were extracted from CGM for all participants. Results: Fasting serum insulin and homeostasis model assessment of insulin resistance (HOMA-IR) were significantly higher in the group with obesity (P < 0.05). While the group with obesity had a higher mean blood glucose (MBG), mean amplitude of glycemic excursions (MAGE), and continuous overall glycemic action-1 h (CONGA-1), these differences were not significant. On univariate linear regression, insulin resistance (HOMA-IR) was associated with body mass index (BMI), waist circumference (WC), cohort with obesity, cohort consuming a high glycemic diet, hemoglobin A1c (HbA1c), and fasting insulin levels. WC and fasting insulin levels remained predictors of HOMA-IR in our multivariable model. Conclusion: While there is much excitement surrounding the use of commercial CGM products in obesity management, our results suggest that fasting insulin and HOMA-IR values may be more clinically useful than CGM data alone.

The Safety and Efficacy of Apixaban (Eliquis) in 5017 Post-bariatric Patients with 95.3% Follow-up: a Multicenter Study.

BACKGROUND: Thromboprophylaxis in bariatric surgery is widely debated; however, few large articles evaluate treatment plans and their efficacy. Herein, we make the first large-scale report of the safety and efficacy of apixaban (Eliquis) for thrombus prevention following bariatric surgery. PURPOSE: To evaluate the safety and efficacy of apixaban following bariatric surgery. SETTING: Three private institutes, USA. MATERIALS AND METHODS: Data from 5017 consecutive bariatric patients that were placed on postoperative apixaban for thromboprophylaxis were used for retrospective analysis. The dose prescribed to patients was 2.5 mg PO BID for a total of 30 days starting on day 3 postoperatively. RESULTS: In total, of the 5017 patients, 59.7%, 31.2%, 4.4%, 2.5%, 1.8%, and 0.1% of the patients had undergone sleeve gastrectomy (SG), single-anastomosis duodeno-ileal bypass with SG (SADI-S), Roux-en-Y gastric bypass (RYGB), conversion from SG to SADI, small bowel reconstruction, and RYGB reversal, respectively. The 30-day follow-up rate was 95.3%. In total, 1.7% of patients experienced apixaban-related side effects. The most common side effects were menorrhagia and rash. Two (0.03%) side effects developed into Clavien-Dindo grade II complications. Overall, 10 (0.1%) patients experienced thromboembolic complications (five (0.09%) PVTs and five (0.09%) PEs). In each case, the protocol was not followed for extenuating circumstances. There were no deaths or thromboembolic events in cases where the protocol was able to be fully followed. CONCLUSIONS: In conclusion, 30 days of postoperative apixaban appears to be safe and effective with minimal side effects while preventing thromboembolic events.

Abnormal glucose tolerance testing following gastric bypass demonstrates reactive hypoglycemia.

BACKGROUND: Symptoms of reactive hypoglycemia have been reported by patients after Roux-en-Y gastric bypass (RYGB) surgery who experience maladaptive eating behavior and weight regain. A 4-h glucose tolerance test (GTT) was used to assess the incidence and extent of hypoglycemia. METHODS: Thirty-six patients who were at least 6 months postoperative from RYGB were administered a 4-h GTT with measurement of insulin levels. Mean age was 49.4±11.4 years, mean preoperative body mass index (BMI) was 48.8±6.6 kg/m2, percent excess BMI lost (%EBL) was 62.6 ± 21.6%, mean weight change from nadir weight was 8.2±8.6 kg, and mean follow-up time was 40.5±26.7 months. Twelve patients had diabetes preoperatively. RESULTS: Thirty-two of 36 patients (89%) had abnormal GTT. Six patients (17%) were identified as diabetic based on GTT. All six of these patients were diabetic preoperatively. Twenty-six patients (72%) had evidence of reactive hypoglycemia at 2 h post glucose load. Within this cohort of 26 patients, 14 had maximum to minimum glucose ratio (MMGR)>3:1, 5 with a ratio>4:1. Eleven patients had weight regain greater than 10% of initial weight loss (range 4.9-25.6 kg). Ten of these 11 patients (91%) with weight recidivism showed reactive hypoglycemia. CONCLUSIONS: Abnormal GTT is a common finding post RYGB. Persistence of diabetes was noted in 50% of patients with diabetes preoperatively. Amongst the nondiabetic patients, reactive hypoglycemia was found to be more common and pronounced than expected. Absence of abnormally high insulin levels does not support nesidioblastosis as an etiology of this hypoglycemia. More than 50% of patients with reactive hypoglycemia had significantly exaggerated MMGR. We believe this may be due to the nonphysiologic transit of food to the small intestine due to lack of a pyloric valve after RYGB. This reactive hypoglycemia may contribute to maladaptive eating behaviors leading to weight regain long term. Our data suggest that GTT is an important part of post-RYGB follow-up and should be incorporated into the routine postoperative screening protocol. Further studies on the impact of pylorus preservation are necessary.

BMI as a Risk Factor for Clinical Outcomes in Patients Hospitalized with COVID-19 in New York.

OBJECTIVE: This study examined the association between BMI and clinical outcomes among patients with coronavirus disease 2019 (COVID-19) infection. METHODS: A total of 10,861 patients with COVID-19 infection who were admitted to the Northwell Health system hospitals between March 1, 2020, and April 27, 2020, were included in this study. BMI was classified as underweight, normal weight, overweight, and obesity classes I, II, and III. Primary outcomes were invasive mechanical ventilation (IMV) and death. RESULTS: A total of 243 (2.2%) patients were underweight, 2,507 (23.1%) were normal weight, 4,021 (37.0%) had overweight, 2,345 (21.6%) had obesity class I, 990 (9.1%) had obesity class II, and 755 (7.0%) had obesity class III. Patients who had overweight (odds ratio [OR] = 1.27 [95% CI: 1.11-1.46]), obesity class I (OR = 1.48 [95% CI: 1.27-1.72]), obesity class II (OR = 1.89 [95% CI: 1.56-2.28]), and obesity class III (OR = 2.31 [95% CI: 1.88-2.85]) had an increased risk of requiring IMV. Underweight and obesity classes II and III were statistically associated with death (OR = 1.44 [95% CI: 1.08-1.92]; OR = 1.25 [95% CI: 1.03-1.52]; OR = 1.61 [95% CI: 1.30-2.00], respectively). Among patients who were on IMV, BMI was not associated with inpatient deaths. CONCLUSIONS: Patients who are underweight or who have obesity are at risk for mechanical ventilation and death, suggesting that pulmonary complications (indicated by IMV) are a significant contributor for poor outcomes in COVID-19 infection.

Single Anastomosis Duodenal Switch: 1-Year Outcomes.

INTRODUCTION: Single-anastomosis duodenal switch has been suggested to be an effective bariatric procedure that offers excellent weight loss and by lengthening the common channel the potential to reduce micronutrient deficiencies. PURPOSE: To evaluate the weight loss, comorbidity resolution and the 1-year nutritional outcomes of the single-anastomosis duodenal switch (SADS) procedure. SETTING: Multiple US Hospitals. METHODS: From October 2014 to January 2017, 120 patients were enrolled at six sites across the USA and underwent the SADS procedure. Weight loss, comorbidities, quality of life, and adverse events were followed post-procedure for 12 months. RESULTS: At 1, 6, and 12 months, 98.3%, 85.5%, and 77.1% of the patients were available for assessment, respectively. At 12 months, patients showed significantly reduced body mass index when compared to baseline (46.8 ± 5.8 vs 29.8 ± 4.4, P < 0.001 respectively). Sixty-five patients had type 2 diabetes at baseline; however, 11 patients lost to follow-up. Of the available data (54 patients), 96.3% of the patients had a resolution of type 2 diabetes by 12 months with a mean A1C reduction from 7.8 ± 1.6 to 5.3 ± 0.7. Additionally, there were reductions in hyperlipidemia, sleep apnea, and hypertension at 12 months. Patient gastroesophageal reflux disease satisfaction and quality of life (SF-36) scores were significantly higher at 12 months post-procedure (P < 0.001 in all cases) while 12-month protein levels remained at normal values. There were abnormalities of parathyroid hormone and vitamin D at 1 year with all other nutritional markers being not significantly different at 1 year from baseline. There were 10, IIIb, or greater complications according to the Clavien-Dindo scoring system during the study period, not all of which were related to the surgery. CONCLUSIONS: SADS is a highly efficacious weight loss procedure with significant comorbidity reduction at 1 year. At 1 year, complications and vitamin and mineral deficits appear to be consistent with other malabsorption operations. Long-term follow-up is needed, especially around complications and vitamin deficiencies.

Conversion of Laparoscopic Roux en Y Gastric Bypass (RYGB) to Single Anastomosis Duodenal Switch (SADS).

BACKGROUND: The surgical management of weight regain following RYGB remains controversial. Simpler modifications such as endoscopic suturing and banding the bypass have had variable efficacy. Distalization of the bypass has resulted in a high risk of malabsorption-related complications as reported by Amor et al. (Obes Surg. 27(1):273-274, 2017); Borbély et al. (Obes Surg. 27(2):439-444, 2017); Thomopoulos et al. (Surg Laparosc Endosc Percutan Tech. 0(0):1, 2018); and Tran et al. (Obes Surg. 26(7):1627-1634, 2016). Conversion to a procedure such as duodenal switch (DS) or SADS with greater average weight loss would be logical but is technically challenging and is related to a high complication rate especially with the reformation of the stomach. In this video, we present the technique that we have adapted to make this complex case reproducible minimizing operative risk. METHODS: A 49-year-old female weighing 154 kg (BMI 57 kg/m2) with sleep apnea disease underwent a laparoscopic RYGB in 2009. She had an initial weight loss of 47 kg but had complete recidivism with a weight of 151 kg (BMI 56 kg/m2). Upper gastrointestinal (barium swallow study) and esophagogastroduodenoscopy showed no evidence of fistula, with a normal pouch diameter and length with stoma size of 2 cm. Blood test showed no significant micro/macronutrient deficiencies. With super morbid obesity refractory to RYGB, it was our belief that conversion to SADS was the best alternative. RESULTS: We introduced a subcostal camera trocar with Optiview and we observed epiploic adherences to the previous anastomosis. We placed an additional trocar to remove adhesions in the re-operative field. We measured the 300 cm of the small bowel proximal to the ileocecal valve. We next divided the antecolic Roux limb from the gastric remnant preserving the left gastric artery and divided the pouch proximal to the gastrojejunal anastomosis. We identified and mobilized the remnant stomach preserving the 8 lowest branches of the right gastroepiploic artery. After reaching the angle of His, we were able to separate the remnant and the pouch. The pouch was reshaped using a 42Fr bougie for guidance. A gastrostomy was made and a matching opening was created near the lesser curvature on the remnant. We then began gastrogastric anastomosis. First, the posterior layer was done and then the bougie was placed through into the remnant. The sleeve and fundic resection was done. The bougie was replaced by an oral gastric tube and the anterior layer of the anastomosis completed. This was tested with methylene blue. We next divided the duodenum postpylorus, preserving the right gastric artery. We performed and tested a hand-sewn duodeno-ileal anastomosis with a common limb length of 300 cm. There were no intra- or postoperative complications and the patient was discharged after 2 days. CONCLUSIONS: We believe that this video shows a reproducible technique for this complex anastomosis. Preservation of the distal epiploics makes the gastro-gastric anastomosis safer but requires direct dissection of the duodenum.

Outcomes After Laparoscopic Conversion of Failed Adjustable Gastric Banding (LAGB) to Laparoscopic Sleeve Gastrectomy (LSG) or Single Anastomosis Duodenal Switch (SADS).

BACKGROUND: Inadequate weight loss following LAGB (laparoscopic adjusted gastric banding) requiring band removal and conversion to another bariatric procedure is common. There is a paucity of objective data to guide procedure selection. Single anastomosis modifications (SIPS, SADI, SADS) of the duodenal switch biliopancreatic division (DS-BPD) are being investigated. Laparoscopic sleeve gastrectomy (LSG) has become the most prevalent primary bariatric procedure and has been used for revision following LAGB. PURPOSE: The purpose is to investigate single-stage LAGB removal to LSG SADS (single anastomosis duodenal switch). A matched cohort analysis compared each revision to a similar patient having a primary procedure. This was performed to understand the impact of prior banding on outcomes with each procedure. MATERIALS AND METHODS: This is a retrospective study to investigate the outcomes of revision of LAGB for inadequate weight loss to LSG or SADS. To determine whether prior banding impairs results, a matched cohort was done comparing each revision to a patient that had a primary procedure. RESULTS: As expected, patients who had SADS had greater weight loss than LSG. There was no difference in peri-operative and early complications. Both procedures resulted in weight loss. Importantly, with matched cohort, prior LAGB decreased weight loss outcomes in LSG, but not SADS. CONCLUSION: Conversion of LAGB to LSG or SADS results in weight loss. The presence of LAGB decreases weight loss in LSG, but not in SADS. This can have important implications for long-term outcomes.

Correction to: Outcomes After Laparoscopic Conversion of Failed Adjustable Gastric Banding (LAGB) to Laparoscopic Sleeve Gastrectomy (LSG) or Single Anastomosis Duodenal Switch (SADS).

In the original article the Conflict of Interest statement was incomplete. Dr. Roslin discloses that he is a teaching consultant for Ethicon and Medtronics. He also has received research funding from Medtronics.

Is There a Better Design for a Bariatric Procedure? The Case for a Single Anastomosis Duodenal Switch.

The majority of bariatric surgical stapling procedure concepts were developed prior to the understanding of obesity as an energy storage disease. Conventional treatments did not consider the impact of macronutrients on hormones and glucose variability. Current recommendations suggest diets low in glycemic load, with moderate protein and unsaturated fat. Roux-en-Y gastric bypass promotes glucose variability which can be harmful for health and encourage weight regain. Classic duodenal switch with short common channels may prevent absorption of measurable fat-soluble vitamins and frequently untested essential fatty acids. The purpose of this review is to discuss these factors and explain why single anastomosis duodenal switch reduces glucose variability, allows for absorption of critical fats and fat-soluble vitamins, and has potential to offer better weight loss and metabolic outcomes.

Obesity in the Workplace: Impact, Outcomes, and Recommendations.

OBJECTIVE: To conduct a comprehensive literature review to develop recommendations for managing obesity among workers to improve health outcomes and to explore the impact of obesity on health costs to determine whether a case can be made for surgical interventions and insurance coverage. METHODS: We searched PubMed from 2011 to 2016, and CINAHL, Scopus, and Cochrane Registry of Clinical Trials for interventions addressing obesity in the workplace. RESULTS: A total of 1419 articles were screened, resulting in 275 articles being included. Several areas were identified that require more research and investigation. CONCLUSIONS: Our findings support the use of both lifestyle modification and bariatric surgery to assist appropriate patients in losing weight.

The incidence of complications associated with loop duodeno-ileostomy after single-anastomosis duodenal switch procedures among 1328 patients: a multicenter experience.

BACKGROUND: The single-anastomosis duodenal switch procedure is a type of duodenal switch that involves a loop anastomosis rather than traditional Roux-en-Y reconstruction. To date, there have been no multicenter studies looking at the complications associated with post-pyloric loop reconstruction. OBJECTIVES: The aim of the study was to report the incidence of complications associated with loop duodeno-ileostomy (DI) following single-anastomosis duodenal switch (SADS) procedures. SETTING: Mixed of private and teaching facilities. METHODS: The medical records of 1328 patients who underwent primary SADS procedure (single-anastomosis duodeno-ileal bypass with sleeve gastrectomy or stomach intestinal pylorus-sparing surgery) by 17 surgeons from 3 countries (United States, Spain, and Australia) at 9 centers over a 6-year period were retrospectively reviewed, and their results were compared with articles in the literature. RESULTS: Mean preoperative body mass index was 51.6 kg/m2. Of 1328 patients, 123 patients received a linear stapled duodeno-ileostomy (DI) and 1205 patients a hand-sewn DI. In the overall series, the anastomotic leak, ulcer, and bile reflux occurred in .6% (9/1328), .1% (2/1328), and .1% (2/1328), respectively. None of our patients experienced volvulus at the DI or an internal hernia. Overall, 5 patients (.3%) (3/123 [2.4%] with linear stapled DI versus 2/1205 [.1%] with hand-sewn DI [P<.05]) experienced stricture at the DI in this series. CONCLUSIONS: The overall incidence of complications associated with loop DI was lower than the reported incidence of anastomotic complications after Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch. SADS procedures may cause much fewer anastomotic complications compared with Roux-en-Y gastric bypass and biliopancreatic diversion with duodenal switch.