Laparoscopic Removal of a Non-Adjustable Gastric Band and Conversion to a Gastric Sleeve: A Case Report.

Obesity has long been recognized as a global epidemic. One of the most effective treatments is bariatric surgery. Since the first modern procedure was reported, it has evolved over time, and multiple techniques have emerged. More than 20 years ago, one of the most widely used techniques was the non-adjustable gastric band (NAGB), which showed very promising short-term results. However, over time, it became apparent that it was not as effective in the long term. Associated gastrointestinal symptoms, such as reflux and constant vomiting, along with considerable weight regain, caused this technique to fall out of favor and be replaced by other procedures like the gastric sleeve (GS). Although the technique has fallen into disuse and is no longer recommended in the literature, there are still patients with associated complications. Few recent cases associated with these complications have been reported. Most undergo band removal, and whether to perform another procedure remains with limited evidence. We present the case of a patient who underwent an NAGB procedure 10 years ago and later experienced symptoms (reflux) and weight regain. She successfully underwent band removal and conversion to a GS at our institute in Mexico.

Ileal obstruction caused by migration of deflated intragastric balloon after bariatric surgery treated with laparotomy and semicircular ileotomy: Case report.

INTRODUCTION: Obesity is a major global health issue with serious consequences, including death. The intragastric balloon (IGB) is a bariatric surgery option but is limited to 6-12 months due to risks such as deflation, migration, and, rarely, intestinal obstruction. These complications are difficult to diagnose and manage. PRESENTATION OF CASE: A 46-year-old woman with an intragastric balloon for ten months experienced gastric distension, excessive salivation, and nausea, leading to hospitalization. Abdominal radiography and a CT scan revealed a small bowel obstruction caused by the balloon, located 40 cm before the ileocecal junction. A laparotomy was performed to explore the surgical site further. An ileotomy was conducted to remove the balloon during the surgery. The patient was discharged in stable condition after five days. DISCUSSION: Complete small bowel obstruction due to intragastric balloon migration in bariatric surgery is very rare. Initial symptoms include mid-gut dilation, nausea, and vomiting. A CT scan is the best method to locate and identify the cause of intragastric balloon migration. Laparoscopy can be challenging in acute obstruction cases due to limited space, increasing the risk of iatrogenic bowel injury. Therefore, laparotomy with a semi-circular ileotomy is a safe treatment option. CONCLUSION: Ileal obstruction due to intragastric balloon migration is a rare but serious complication of bariatric surgery, which requiring immediate surgical intervention. The use of a semi-circular ileotomy during laparotomy has proven to be an effective and safe treatment option for complete obstruction.

Prior Bariatric Surgery is Associated with Improved Total Hip Arthroplasty Outcomes in Patients Who Have Obesity: A National Cohort Study with 6 Years of Follow-Up.

BACKGROUND: Obesity is a risk factor for end-stage hip osteoarthritis (OA). While total hip arthroplasty (THA) is commonly performed to reduce pain and improve function associated with OA, obesity has been associated with an increased risk of complications after THA. Although bariatric surgery may also be utilized to reduce weight, the impact of bariatric surgery on THA outcomes remains inadequately understood. METHODS: This retrospective cohort analysis utilized multicenter electronic medical record data ranging from 2003 to 2023. Patients who have obesity who underwent THA were stratified based on prior bariatric surgery. The final bariatric cohort comprised 451 patients after propensity score matching. Complication rates and revision risks were compared between cohorts at six, 24, and 72 months. Additional analysis stratified patients by interval between bariatric surgery and THA. RESULTS: At six-month follow-up, the bariatric cohort had significantly lower risks of surgical site infection (SSI), wound dehiscence, and deep vein thrombosis (DVT). At 24 months, the bariatric cohort had a lower risk of DVT. At 72 month follow-up, the bariatric cohort had reduced rates of revision, mortality, cardiac morbidity, and Clavien-Dindo grade IV complications. CONCLUSION: Obese patients who underwent bariatric surgery prior to THA experienced reduced medical complications at all time points and reduced rates of revision at 72 months relative to a matched cohort who did not undergo bariatric surgery.

Banded versus non-banded Roux-en-Y gastric bypass: short, mid, and long-term surgical outcomes - a systematic review and meta-analysis.

BACKGROUND: The Roux-en-Y gastric bypass (RYGB) is considered as one of the most effective treatments for people with obesity. A variant of this procedure, the banded-RYGB, may present several advantages over the standard technique. These potential benefits include enhanced weight loss, decreased recurrent weight gain, a lower incidence of dumping syndrome, and less distention of the jejunum below the gastrojejunostomy. OBJECTIVES: The objective of this meta-analysis is to compare the surgical outcomes of RYGB procedures with a band (banded-RYGB) and without a band (RYGB) in the management of individuals with obesity. SETTING: A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane protocol (PROSPERO ID: CRD42023439874). METHOD: The systematic review process led to the identification of 13 comparative studies involving 3230 patients who underwent banded-RYGB and 5302 who received RYGB, all of which were eligible for inclusion and meta-analysis. RESULTS: Four studies reported data on 1-year postoperative percent excess weight loss (%EWL), demonstrating a significant increase of 6.03 %EWL in patients who underwent banded-RYGB. Four studies reported the 2-year postoperative %EWL, showing that patients who had banded-RYGB experienced a 5.32 greater %EWL compared to those who received RYGB, even if this was not statistically significant. For 5-year %EWL after bariatric surgery, 5 studies were included for continuous outcome meta-analysis. The average 5-years %EWL difference was 7.6 in favor of banded-RYGB. Patients who had banded-RYGB presented a nonsignificant 1.45 OR of developing postoperative complications compared to patients receiving RYGB. CONCLUSION: This meta-analysis demonstrates that, compared to RYGB, patients who underwent banded-RYGB surgery showed a statistically significant increase in the %EWL at 1, 2, and 5 years postoperatively. Moreover, the banding procedure does not significantly increase the risk of postoperative complications.

Sociodemographic factors leading to preventable emergency department visits after bariatric surgery: a single-institution analysis.

BACKGROUND: An important quality benchmark after bariatric surgery is 30-day emergency department (ED) visits. OBJECTIVES: We aimed to identify risk factors for ED visits not requiring readmission and thus deemed preventable. SETTING: University Hospital. METHODS: Patients who underwent a minimally invasive sleeve gastrectomy between 2017 and 2022 at a single institution were identified. Among these patients, those who presented to the ED within 30 days after surgery were matched 3:1 to controls. Sociodemographic and clinical variables were collected from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database and the electronic medical record. Univariate conditional logistic regression analysis was performed to determine predictive factors of ED visits. RESULTS: Overall, 648 patients underwent sleeve gastrectomy, of which 53 (8.2%) presented to the ED within 30 days postoperatively without requiring readmission. Patients who presented to the ED were more likely to be unemployed (42% versus 24%, P = .04) and have government insurance (68% versus 41%, P = .001). Significant risk factors included lower versus upper socioeconomic bracket (odds ratio [OR] 3.6, P = .042), primary care physician (PCP) outside the health system versus within (OR 2.15, P = .032), greater number of PCP visits within the past year (OR 1.27, P < .001), and greater number of postoperative clinic phone calls (OR 2.04, P < .001). The number of ED visits within 1 year before surgery was a significant risk factor, with an OR of 1.44 for each visit (P < .001). CONCLUSIONS: Modifiable and unmodifiable risk factors contribute to ED visits after bariatric surgery. Identifying these risk factors can aid in the development of quality improvement initiatives.

Effect of Bariatric Surgery on the Sonographic Grade of Metabolic-Associated Fatty Liver Disease at 12-Month Follow-Up.

BACKGROUND: Metabolic-associated fatty liver disease (MAFLD) is the most prevalent liver disease across the globe. One of the most effective treatments for this disease is weight loss. This study aimed to determine how metabolic and bariatric surgery (MBS) affects MAFLD sonographic grades. METHODS: In 2021, a pre-post study was conducted on 73 patients who underwent MBS. The study collected demographic information and ultrasound grades of MAFLD before and after MBS. RESULTS: A total of 73 patients underwent MBS, with 58 females and 15 males. The patients had a mean age of 39.8 ± 8.88 years and a mean BMI of 42.12 ± 5.98 kg/m2. Of these patients, 53 (72.6%) underwent SG, while 20 (27.4%) underwent RYGB. The preoperative BMI for females and males decreased significantly at the 12-month follow-up (P = 0.0001). However, males experienced more prominent weight changes (P = 0.009), but there was no statistically significant difference in fatty liver grade changes after MBS between males and females (P = 0.056), which suggests that the effect of MBS on fatty liver grades is not gender-specific. There was a significant reduction in BMI and fatty liver grade for patients under and over 40 years old after surgery (P = 0.0001). However, there was no statistically significant difference in fatty liver grade and BMI changes after MBS between the two age groups. RYGB was found to be more effective than SG in reducing fatty liver grade, BMI, and %TWL (P < 0.05). CONCLUSION: Bariatric surgery can play a vital role in reducing the weight and severity of metabolic-associated fatty liver disease.

How does sutures pattern influence stomach motility after endoscopic sleeve gastroplasty? A computational study.

The relatively recent adoption of Endoscopic Sleeve Gastroplasty (ESG) amongst obese patients has gained approval within the surgical community due to its notable benefits, including significant weight loss, safety, feasibility, repeatability, and potential reversibility. However, despite its promising clinical outcomes and reduced invasiveness, there is still a lack of standardised procedures for performing ESG. Multiple suture patterns and stitching methods have been proposed over time, yet rational tools to quantify and compare their effects on gastric tissues are absent. To address this gap, this study proposed a computational approach. The research involved a case study analyzing three distinct suture patterns (C-shaped, U-shaped and Z-shaped) using a patient-specific computational stomach model generated from magnetic resonance imaging. Simulations mimicked food intake by placing wire features in the intragastric cavity to replicate sutures, followed by applying a linearly increasing internal pressure up to 15 mmHg. The outcomes facilitated comparisons between suture configurations based on pressure-volume behaviours and the distribution of maximum stress on biological tissues, revealing the U-shaped as the more effective in terms of volume reduction, even if with reduced elongation strains and increased tissues stresses, whereas the Z-shaped is responsible of the greatest stomach shortness after ESG. In summary, computational biomechanics methods serve as potent tools in clinical and surgical settings, offering insights into aspects that are challenging to explore in vivo, such as tissue elongation and stress. These methods allow for mechanical comparisons between different configurations, although they might not encompass crucial clinical outcomes.

Case report: Concurrent intussusception and bleeding marginal ulcer in a patient with gastric bypass.

INTRODUCTION: The source of abdominal pain in patients with a history of gastric bypass can be difficult to determine. Synchronous disease processes may ultimately be the cause of their symptoms. Among the etiologies for hematemesis and obstruction in this population are the diagnoses of marginal ulcer and internal hernia. Given the potential complications of bariatric surgery, it is important to maintain a broad differential diagnosis during the workup of these patients. PRESENTATION: A female with history of laparoscopic Roux-en-Y gastric bypass (RYGB) presented with abdominal pain and hematemesis. Intraoperative findings revealed intussusception of the jejunojejunostomy resulting in obstruction and ischemic bowel. Additionally, a perforated marginal ulcer of the Roux-limb was found to be present. This patient underwent esophagogastroduodenoscopy, bowel resection, jejunojejunostomy revision, and Graham patch repair. DISCUSSION: This case highlights a patient with history of RYGB presenting with obstruction and gastrointestinal bleeding. Although initially diagnosed with internal hernia and Mallory-Weiss hematemesis, surgical exploration revealed concurrent intussusception and marginal ulceration. While intussusception is a rare complication of bariatric surgery, it can occur secondary to mesenteric thinning and motility dysfunction from significant weight loss. It is imperative to maintain a broad differential diagnosis for the causes of obstruction and GI bleeding that include adhesive disease, abdominal wall hernia, internal hernia, intussusception, and marginal ulcers. CONCLUSION: Findings of obstruction or GI bleeding after bariatric surgery may represent a surgical emergency. While these symptoms may be attributed to a single diagnosis, clinicians must consider the presence of synchronous pathologies during the workup of patients.

The impact of COVID-19 pandemic on patient selection and access to care, approach type, and postoperative outcomes in bariatric surgery.

BACKGROUND: The COVID-19 pandemic had affected the health systems across the world since early 2020 with a concern about access to medical care during the first wave of COVID-19 pandemic. OBJECTIVES: The objective of this study was to examine how the COVID-19 pandemic influenced patient selection, approach type, and postoperative outcomes in elective bariatric surgery. SETTING: United States. METHODS: Data from the MBSAQIP database for the years 2016-2020 were queried. Wilcoxon rank-sum test and Fisher's exact test were employed for continuous and categorical variables, respectively. Postoperative outcomes within 30 days were assessed separately and based on the Clavien-Dindo (CD) classification of III-V. χ2 test and logistic regression were used to compare outcomes between procedure and approach types, as well as surgical operation periods. RESULTS: A total of 741,620 patients underwent robotic and laparoscopic sleeve gastrectomy and Roux-en-Y gastric-bypass. The cases performed in 2020 exhibited lower comorbidities and postoperative complications compared to prepandemic years, regardless of the approach type. Notably, the proportion of White patients decreased during the pandemic, while there was an increase in the number of African American and Hispanic patients who had bariatric surgery. CONCLUSIONS: Patients who underwent bariatric surgery during the COVID-19 pandemic appeared to be healthier with fewer comorbidities and experienced fewer adverse postoperative outcomes compared to those who had surgery prior to the pandemic. This study highlights the limited access to bariatric surgery for high-risk patients during the pandemic.

Testosterone levels increase following bariatric surgery - validation of preceding literature in a large-scale population analysis.

BACKGROUND: The effects of bariatric surgery on testosterone levels in men with obesity and hypogonadism have not been thoroughly explored yet. OBJECTIVES: To investigate the possible effects of bariatric surgery on T levels in obese hypogonadal men by comparing T levels before and after surgery using a comprehensive claims database. MATERIALS AND METHODS: The TriNetX US Collaborative Network database was used to identify men ages 18-80 who underwent a bariatric procedure and had a serum T value of < 350 ng/dL prior to surgery. Men who received testosterone therapy before/or after surgery were excluded. We conducted a retrospective self-matched cohort analysis to examine the difference in serum T levels before and after bariatric surgery. A sub-analysis was carried out to explore differences between men who reached eugonadal status or maintained low T levels following surgery. Descriptive statistics detailed sociodemographic and clinical characteristics, with continuous and categorical data compared using unpaired t-tests and chi-square analysis, respectively. Changes in T levels and body mass index (BMI) before and after surgery were compared using an unpaired t-test with a < 0.05 set for significance. All analyses were conducted using the TriNetX platform which utilizes both Python and R software. RESULTS: The study analyzed 69 hypogonadal men who underwent bariatric surgery and had T levels assessed before and after the procedure. The mean (standard deviation) pre-surgery serum T level was 208 ± 79 ng/dL, which post-surgery increased to 371 ± 164 ng/dL, marking an average increase of 163 ± 164 ng/dL. Likewise, the mean (standard deviation) body mass index decreased from 42.9 ± 9.0 to 38.8 ± 5.7 kg/m2. Post-surgery, 45% (31 men) achieved eugonadal status, while 55% (38 men) continued to have low T levels. A comparison between the post-surgery eugonadal cohort and the persistent low T cohort revealed that the former had higher pre-surgery serum T levels (235 ± 71 ng/dL vs. 184 ± 80.4 ng/dL, p = 0.007), a higher pre-surgery body mass index (45.5 ± 4.5 kg/m2 vs. 41.1 ± 11.5 kg/m2, p = 0.041), and a significantly greater reduction in body mass index post-surgery (7.3 ± 7.2 kg/m2 vs. 2.0 ± 12.8 kg/m2, p = 0.04). Notably, the increase in T was significantly higher in the eugonadal cohort compared to the persistent low testosterone cohort (257 ± 143 ng/dL vs. 95 ± 178 ng/dL, p < 0.0001). CONCLUSION: This study provides evidence of bariatric surgery's positive effect on serum T levels in obese men with baseline low T. Almost one out of two men with low T reached normal T levels after bariatric surgery. As the most comprehensive study to date, it validates and substantiates previous work suggesting that weight loss can improve T levels physiologically.

Impact of Bariatric Surgery on metabolic health in a Uruguayan cohort and the emerging predictive role of FSTL1.

Obesity poses significant challenges, necessitating comprehensive strategies for effective intervention. Bariatric Surgery (BS) has emerged as a crucial therapeutic approach, demonstrating success in weight loss and comorbidity improvement. This study aimed to evaluate the outcomes of BS in a cohort of 48 Uruguayan patients and investigate the interplay between BS and clinical and metabolic features, with a specific focus on FSTL1, an emerging biomarker associated with obesity and inflammation. We quantitatively analyzed BS outcomes and constructed linear models to identify variables impacting BS success. The study revealed the effectiveness of BS in improving metabolic and clinical parameters. Importantly, variables correlating with BS success were identified, with higher pre-surgical FSTL1 levels associated with an increased effect of BS on BMI reduction. FSTL1 levels were measured from patient plasma using an ELISA kit pre-surgery and six months after. This research, despite limitations of a small sample size and limited follow-up time, contributes valuable insights into understanding and predicting the success of BS, highlighting the potential role of FSTL1 as a useful biomarker in obesity.

Predictors of complete remission of hypertension in patients over 65 years of age after bariatric surgery - a multicenter study.

Introduction: In the era of an aging society and a growing number of obese people, an increasing number of older patients are consulting bariatric surgeons. The incidence of hypertension (HT) also rises with age and body weight, making the treatment of the elderly a significant challenge. Aim: To identify predictors of HT remission after bariatric surgery in patients over 65 years of age. Material and methods: A retrospective study analyzed patients over 65 years old with HT who underwent laparoscopic bariatric procedures in Poland between 2008 and 2022. The data came from 11 bariatric centers. Patients were categorized into two groups: responders (R) and non-responders (NR). A multivariate logistic regression analysis was conducted to identify significant independent risk factors. Results: The study analyzed 244 patients, with complete HT remission observed in 55 (22.5%) patients. Almost 90% of patients showed improvement in HT. The mean follow-up time was 47.4 months. Factors contributing to HT remission included HT duration of less than 5 years, the use of single medication, and a significant correlation with %EWL. Conclusions: Bariatric surgery in patients aged over 65 has a positive effect on HT remission. The chance of HT remission increases with fewer medications, shorter HT duration, and greater weight loss after surgery.

Prediction Model for Chronological Weight Loss After Bariatric Surgery in Korean Patients.

Purpose: This study aimed to develop a predictive model for monitoring chronological weight loss during the early postoperative period following bariatric surgery in Korean patients with morbid obesity. Materials and Methods: The baseline characteristics and postoperative weight loss outcomes were collected for up to 24 months after surgery in patients who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). The factors influencing weight loss outcomes were analyzed, and longitudinal percentile charts were plotted using quantile regression models adjusted for the identified independent factors. Results: The analysis included 491 and 274 patients who underwent SG and RYGB, respectively, of whom 225 (29.4%) were men. A positive association was found between the maximum percentage of total weight loss (%TWL) and female sex, body mass index (BMI) ≥40, and age <40 years. Among patients who reached nadir BMI or had at least 12 months of follow-up data (n=304), 7.6% exhibited inadequate weight loss (TWL <20%). The predictors of insufficient weight loss were older age (>40 years), male sex, and psychological problems. Centile charts were generated for the entire cohort, incorporating age, sex, and the type of procedure as covariates. Conclusion: The percentile charts proposed in the present study can assist surgeons and healthcare providers in gauging patients' progress toward their weight loss goals and determining the timing of adjunctive intervention in poor responders during early postoperative follow-up.

Abdominal Drains After Laparoscopic Sleeve Gastrectomy: Should They Be Used?

Purpose: Laparoscopic sleeve gastrectomy (LSG) is one of the most common surgical procedures worldwide for the treatment of morbid obesity. Blake-type drains are widely used in this procedure despite the lack of clear evidence regarding their benefits in the diagnosis and treatment of common postoperative complications such as gastric suture line leak (GSLL) and postoperative bleeding (PB). Materials and Methods: A retrospective descriptive study with prospective case registry was conducted, analyzing all patients who underwent LSG between January 2012 and December 2022 at a high-volume center. Our primary outcome was to evaluate the role of drains for diagnosis and treatment of GSLL and PB in LSG. Our secondary outcome was to determine drain related surgical site infection (DRSSI) rate. Results: A total of 335 LSG were performed in the studied period. In all patients one abdominal drain was placed during surgery. Six GSLL (1.79%) and 5 PB (1.49%) were recorded. Drain placement did not prove to ensure early diagnosis or conservative management of GSLL or PB after LSG. Furthermore, an incidence of DRSSI of 4.1% (14 patients) was found. Conclusion: In our study, no clear diagnostic or therapeutic benefits of the systematic use of drains for GSLL or PB in LSG was found; but drain use did show a considerable rate of DRSSI, which must be taken into consideration prior to considering drain systematic use. While no randomized prospective trials have been performed, the retrospective data does not support drain systematic use.

Different effects of bariatric surgery on epigenetic plasticity in skeletal muscle of individuals with and without type 2 diabetes.

AIM: Bariatric surgery is highly effective for the treatment of obesity in individuals without (OB1) and in those with type 2 diabetes (T2D2). However, whether bariatric surgery triggers similar or distinct molecular changes in OB and T2D remains unknown. Given that individuals with type 2 diabetes often exhibit more severe metabolic deterioration, we hypothesized that bariatric surgery induces distinct molecular adaptations in skeletal muscle, the major site of glucose uptake, of OB and T2D after surgery-induced weight loss. METHODS: All participants (OB, n=13; T2D, n=13) underwent detailed anthropometry before and one year after the surgery. Skeletal muscle biopsies were isolated at both time points and subjected to transcriptome and methylome analyses using a comprehensive bioinformatic pipeline. RESULTS: Before surgery, T2D had higher fasting glucose and insulin levels but lower whole-body insulin sensitivity, only glycemia remained higher in T2D than in OB after surgery. Surgery-mediated weight loss affected different subsets of genes with 2,013 differentially expressed in OB and 959 in T2D. In OB differentially expressed genes were involved in insulin, PPAR signaling and oxidative phosphorylation pathways, whereas ribosome and splicesome in T2D. LASSO regression analysis revealed distinct candidate genes correlated with improvement of phenotypic traits in OB and T2D. Compared to OB, DNA methylation was less affected in T2D in response to bariatric surgery. This may be due to increased global hydroxymethylation accompanied by decreased expression of one of the type 2 diabetes risk gene, TET2, encoding a demethylation enzyme in T2D. CONCLUSION: OB and T2D exhibit differential skeletal muscle transcriptome responses to bariatric surgery, presumably resulting from perturbed epigenetic flexibility.

Low-calorie diets are effective for weight loss in patients undergoing benign upper gastrointestinal surgery: a systematic review and meta-analysis.

BACKGROUND: Obesity may increase surgical complexity in patients undergoing abdominal surgery by limiting visualization and increasing the risk of peri-operative complications. A preoperative reduction in weight and liver volume may improve surgical outcomes. The aim of our study was to evaluate the efficacy of a low-calorie diet (LCD) versus a very low-calorie diet (VLCD) in reducing weight and liver volume prior to laparoscopic surgery. METHODS: A systematic search was conducted using the following inclusion criteria: obese patients undergoing preoperative weight loss using a VLCD or LCD, evaluation of liver volume reduction, and the use of an imaging modality before and after the diet. RESULTS: A total of 814 patients from 21 different studies were included in this systematic review and meta-analysis, with 544 female patients (66.8%) and a mean age range between 24 and 54 years old. There was a total mean weight loss of 6.42% and mean liver volume reduction of 16.7%. Meta-analysis demonstrated that a preoperative diet (LCD or VLCD) significantly reduced weight [SMD = - 0.68; 95% CI (- 0.93, - 0.42), I2 = 82%, p ≤ 0.01] and liver volume [SMD = - 2.03; 95% CI (- 4.00, - 0.06), I2 = 94%, p ≤ 0.01]. When assessed individually, a VLCD led to significant weight reduction [SMD = - 0.79; CI (- 1.24; - 0.34), p ≤ 0.01, I2 = 90%], as did an LCD [SMD = - 0.60; CI (- 0.90; - 0.29), p ≤ 0.01, I2 = 68%). Similarly, there was a significant reduction in liver volume following a VLCD [SMD = - 1.40; CI (- 2.77, - 0.03), p ≤ 0.01, I2 = 96%], and an LCD [SMD = - 2.66; CI (- 6.13, 0.81), p ≤ 0.01, I2 = 93%]. However, there was no significant difference between the two regimens. CONCLUSIONS: Preoperative restrictive calorie diets are effective in reducing weight and liver volume prior to laparoscopic surgery. Whilst a VLCD was better than an LCD at reducing both weight and liver volume, the difference was not significant.

Bariatric Surgery Effect on the Crosstalk of PAI-1 and PCSK9 to Regulate the Metabolic Changes in Patients with Obesity.

BACKGROUND: Adiposity favors several metabolic disorders with an exacerbated chronic pro-inflammatory status and tissue damage, with high levels of plasminogen activator inhibitor type 1 (PAI-1) and proprotein convertase subtilisin/kexin type 9 (PCSK9). OBJECTIVE: To demonstrate the influence of bariatric surgery on the crosstalk between PAI-1 and PCSK9 to regulate metabolic markers. METHODS: Observational and longitudinal study of 190 patients with obesity and obesity-related comorbidities who underwent bariatric surgery. We measured, before and after bariatric surgery, the anthropometric variables and we performed biochemical analysis by standard methods (glucose, insulin, triglycerides [TG], total cholesterol, high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C] and TG/HDL-C ratio, PAI-1 and PCSK9 were measured by ELISA). RESULTS: PAI-1 levels decreased significantly after bariatric surgery, and were positively correlated with lipids, glucose, and TG, with significance on PCSK9 and TG/HDL-C alleviating the insulin resistance (IR) and inducing a state reversal of type 2 diabetes (T2D) with a significant decrease in body weight and BMI (p <0.0001). Multivariate regression analysis predicted a functional model in which PAI-1 acts as a regulator of PCSK9 (p <0.002), TG (p <0.05), and BMI; at the same time, PCSK9 modulates LDL-C HDL-C and PAI-1. CONCLUSIONS: After bariatric surgery, we found a positive association and crosstalk between PAI-1 and PCSK9, which modulates the delicate balance of cholesterol, favoring the decrease of circulating lipids, TG, and PAI-1, which influences the glucose levels with amelioration of IR and T2D, demonstrating the crosstalk between fibrinolysis and lipid metabolism, the two main factors involved in atherosclerosis and cardiovascular disease in human obesity.

Beyond race: social vulnerability and access to metabolic and bariatric surgery.

BACKGROUND: Metabolic and bariatric surgery (MBS) is under-accessed by non-White patients, who are disproportionately affected by obesity. We hypothesized that unique barriers experienced by socially vulnerable patients drive disparate MBS utilization. OBJECTIVES: To determine whether socially vulnerable patients experience greater attrition and face more insurance-mandated medical weight management (MWM) requirements. SETTING: Urban, academic center. METHODS: This retrospective cohort study included adults evaluated for MBS in 2018. Social vulnerability was determined using the 2018 Social Vulnerability Index. Outcomes included attrition, or failure to undergo surgery within 1year, and the number and duration of MWM requirements. Multivariable logistic regression and negative binomial regression tested these associations. RESULTS: In 2018, 339 patients were evaluated for MBS (83% female, 70% Black). The attrition rate was 57%. On adjusted analyses, patients in the highest social vulnerability quartile had double the odds of attrition compared to their least vulnerable counterparts (OR 2.33, 95% CI 1.11-4.92, P = .03). Highly vulnerable patients had double the number (IRR 2.29, 95% CI 1.42-3.72, P = .001) and nearly quadruple the duration (IRR 3.90, 95% CI 1.93-7.86, P < .001) of MWM requirements compared to those with low social vulnerability. Odds of attrition increased by 11% and 20% for each additional MWM visit (OR 1.11, 95% CI 1.02-1.20, P = .02) and month (OR 1.20, 95% CI 1.08-1.33, P = .001), respectively. CONCLUSIONS: Patients with high social vulnerability were less likely to undergo MBS and faced more insurance-mandated preoperative requirements, which independently predicted attrition. Insurance-mandated MWM is inequitable and may contribute to disparate care of patients with severe obesity.