Epicardial Adipose Tissue Changes After Bariatric and Metabolic Surgery: a Systematic Review and Meta-analysis.

Epicardial adipose tissue (EAT) is a visceral fat depot located between the myocardium and visceral epicardium. Emerging evidence suggests that excessive EAT is linked to increased risk of cardiovascular conditions and other metabolic diseases. A literature search was conducted from the earliest studies to the 26th of November 2022 on PubMed, Embase, and the Cochrane. All the studies evaluating changes in EAT, pericardial adipose tissue (PAT), or total cardiac fat loss before and after BS were included. From 623 articles, 35 were eventually included in the systematic review. Twenty-one studies showed a significant reduction of EAT after BS, and only one study showed a non-significant reduction (p = 0.2).

Epicardial adipose tissue, obesity, and the occurrence of atrial fibrillation: an overview of pathophysiology and treatment methods.

INTRODUCTION: Obesity is a chronic disease, which has significant health consequences and is a staggering burden to health care systems. Obesity can have harmful effects on the cardiovascular system, including heart failure, hypertension, coronary heart disease, and atrial fibrillation (AF). One of the possible substrates might be epicardial adipose tissue (EAT), which can be the link between AF and obesity. EAT is a fat deposit located between the myocardium and the visceral pericardium. Numerous studies have demonstrated that EAT plays a pivotal role in this relationship regarding atrial fibrillation. AREAS COVERED: This review will focus on the role of obesity and the occurrence of atrial fibrillation (AF) and examine the connection between these and epicardial adipose tissue (EAT). The first part of this review will explain the pathophysiology of EAT and its association with the occurrence of AF. Secondly, we will review bariatric and metabolic surgery and its effects on EAT and AF. EXPERT COMMENTARY: In this review, the epidemiology, pathophysiology, and treatment methods of AF are explained. Secondly, the effects on EAT were elucidated. Due to the complex pathophysiological link between EAT, AF, and obesity, it is still uncertain which treatment strategy is superior.

Safe Surgery During the COVID-19 Pandemic.

PURPOSE OF REVIEW: Coronavirus Disease-2019 (COVID-19) has had an enormous impact on all aspects of healthcare, but its effect on patients needing surgery and surgeons has been disproportionate. In this review, we aim to understand the impact of the pandemic on surgical patients and teams. We compiled the emerging data on pre-operative screening methods, vaccinations, safe-surgery pathways and surgical techniques and make recommendations for evidence-based safe-surgical pathways. We also present surgical outcomes for emergency, oncological and benign surgery in the context of the pandemic. Finally, we attempt to address the impact of the pandemic on patients, staff and surgical training and provide perspectives for the future. RECENT FINDINGS: Surgical teams have developed consensus guidelines and established research priorities and safety precautions for surgery during the COVID-19 pandemic. Evidence supports that surgery in patients with a peri-operative SARS-CoV-2 infection carries substantial risks, but risk mitigation strategies are effective at reducing harm to staff and patients. Surgery has increased risk for patients and staff, but this can be mitigated effectively, especially for elective surgery. Elective surgery can be safely performed during the COVID-19 pandemic employing the strategies discussed in this review.

Portomesenteric Vein Thrombosis after Bariatric Surgery: An Online Survey.

Portomesenteric vein thrombosis (PMVT) is a rare post-operative complication of bariatric procedures, occurring in between 0.3% and 1% of cases. A structured questionnaire consisting of 27 items was available online to members of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) to investigate the occurrence of PMVT. A total of 89 bariatric surgeons from 61 countries participated. Twenty-six (29.21%) reported at least one case of PMVT (46.15% males; 53.84% females). The surgery most associated with PMVT occurrence was sleeve gastrectomy (84.6%), followed by Roux-en-Y gastric bypass (RYGB) (7.69%), and laparoscopic adjustable gastric banding (LAGB) (7.69%). The time gap between surgery and PMVT was 19.28 ± 8.72 days. The predominant symptom was abdominal pain in 96.15% of patients, followed by fever in 26.9%. Complete occlusion of the portal vein was reported in 34.6% of cases, with involvement of the portal system in 69%, extension to the superior mesenteric district in 23%, and extension to the splenic vein in two patients (7.7%). Our survey, which is the largest regarding PMVT to date, revealed a diffuse lack of standardization in the choice, duration, and dosing of prophylaxis regimens as well as treatment modalities, reflecting the literature gap on the topic.

Gastro-colo-diaphragmatic fistula after sleeve gastrectomy.

INTRODUCTION: Postsleeve gastrectomy fistula is a serious complication, and its management remains quite challenging. The clinical presentation of chronic fistula after sleeve gastrectomy (SG) varies widely and depends on the type of fistula. Management requires a multidisciplinary approach and patient cooperation. CASE PRESENTATION: We present a case of a 41-year-old woman with a body mass index (BMI) of 46 kg/m2 who initially underwent laparoscopic sleeve gastrectomy in our hospital. Later, she developed a gastro-colo-diaphragmatic fistula (GCD), which was successfully treated using an endolaparoscopic approach. Follow-up imaging and endoscopy showed complete healing of the fistula, as well as a marked clinical improvement of the patient. DISCUSSION: Gastro-colo-diaphragmatic fistula following sleeve gastrectomy is an extremely rare complication. This is the first case of a GCD fistula after sleeve gastrectomy that has been reported in the literature. CONCLUSION: One staged endolaparoscopic management was successful approach in our case and can be considered for complex gastric fistula following sleeve gastrectomy.

Remission of Food Addiction Does Not Induce Cross-Addiction after Sleeve Gastrectomy and Gastric Bypass: A Prospective Cohort Study.

BACKGROUND: The hypothesis of "cross-addiction" has never been validated, and numerous aspects speak against it. OBJECTIVES: To compare the differences between sleeve gastrectomy (SG) and gastric bypass (GB) procedures concerning cross-addiction. SETTING: Center for maximum care in Germany. METHODS: We performed a prospective analysis of patients undergoing SG or GB as the first surgical treatment for severe obesity. All patients completed validated questionnaires to evaluate food intake (Yale Food Addiction Scale, YFAS), alcohol intake (Alcohol Use Disorders Identification Test), nicotine use (Fagerstrom Test for Nicotine Dependence), exercise (Exercise Addiction Inventory), drug addiction (20-item Drug Abuse Screening Test), and Internet use disorder (Internet Addiction Test) before the operation (T0) and 6 (T6) and 24 (T24) months postoperatively (ClinicalTrials.gov identifier: NCT02757716). RESULTS: One hundred thirteen patients underwent SG (n = 68) or GB (n = 45). At the follow-up, 61% completed the questionnaires at T6 and 44% at T24. In the YFAS, the percentage of patients diagnosed with food addiction decreased from 69 to 10%, and the mean symptom count decreased from 3.52 ± 1.95 to 1.26 ± 0.99 at T24 (p < 0.0001); these values did not differ between the surgical groups (p = 0.784). No significant evidence of cross-addiction was observed for use of alcohol, nicotine, drugs, the Internet, or exercise in either surgical group. The percentage of patients with moderate nicotine dependence increased in the SG group (+8.9%) at T24, but this was not significant. CONCLUSION: In this single-center cohort study, surgery for obesity caused significant addiction remission regarding food but without inducing cross-addiction after 2 years. Importantly, no significant differences were seen between the SG and GB procedures.

Antidiabetic efficacy of obesity surgery in Germany: a quality assurance nationwide survey.

BACKGROUND: Obesity and diabetes usually co-exist. Obesity surgery seems to offer solutions for both. The objective of this study was to show the effect of obesity surgery on the diabetic profile. METHODS: Data on obesity surgery in Germany (2005-2011) were collected from the Institute of Quality Assurance at the research university. Follow-up of the diabetic profile at 1, 2, and up to 6 years after surgery was done. RESULTS: Among 17,670 patients, 5,506 (31.2%) were diabetics. Follow-up was accomplished in 87.4%, 82.5%, and 68.9% of eligible patients at 1, 2, and up to 6 years, respectively, after surgery. Of the study participants, 38.2% were insulin-treated (IT) patients and 61.8% were noninsulin-treated patients (NIT). Of the patients' procedures, 2878 (52.3%) Roux-en-Y gastric bypasses (RYGB), 1711 (31.1%) sleeve gastrectomies (SG), 679 (12.3%) laparoscopic adjustable gastric bands (LAGB), 165 (3%) biliopancreatic diversions with duodenal switch (BPD/DS), and 68 (1.3%) biliopancreatic diversions (BPD) were performed. Female gender percentage and mean body mass index (BMI) were significantly higher in the RYGB and LAGB groups. Mean age was significantly higher in BPD/DS group. At 1 year, remission/improvement (RI) percentage was 83.5%, 82.5%, 67.8%, 93.4%, and 84.8% after RYGB, SG, LAGB, BPD, and BPD/DS, respectively. At 2 years, RI% was 84.9%, 79.5%, 67.7%, 94.5%, and 90.9% after RYGB, SG, LAGB, BPD, and BPD/DS, respectively. At late follow-up, RI% was 83.2%, 59.5%, 58.9%, 100%, and 86.4% after RYGB, SG, LAGB, BPD, and BPD/DS, respectively. IT patients showed insignificantly higher RI% than NIT patients at all follow-up points. Malabsorptive procedures (RYGB, BPD, and BPD/DS) showed a significantly higher RI% than restrictive procedures (LAGB and SG) at late follow-up. CONCLUSION: Obesity surgery has promising antidiabetic efficacy, especially in IT patients. Malabsorptive procedures show higher, gradually descending, but durable antidiabetic efficacy.

Early post-operative complications: incidence, management, and impact on length of hospital stay. A retrospective comparison between laparoscopic gastric bypass and sleeve gastrectomy.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the most common obesity surgeries. Their early complications may prolong hospital stay (HS). METHODS: Data for patients who underwent LRYGB and LSG in our clinic from 2009 through August 2012 were collected. Early post-operative complications prolonging HS (>5 days) were retrospectively analyzed, highlighting their relative incidence, management, and impact on length of HS. RESULTS: Sixty-six patients (4.9 %) after 1,345 LRYGB operations vs. 49 patients (7.14 %) after 686 LSG operations developed early complications. This difference is statistically significant (p = 0.039). Male gender percentage was significantly higher in complicated LSG group vs. complicated LRYGB group [23 patients (46.9 %) vs. 16 patients (24.2 %)] (p = 0.042). Mean BMI was significantly higher in the complicated LSG group (54.2 ± 8.3) vs. complicated LRYGB group (46.8 ± 5.7; p = 0.004). Median length of HS was not longer after complicated LSG compared with complicated LRYGB (11 vs. 10 days; p = 0.287). Leakage and bleeding were the most common complications after either procedure. Leakage rate was not higher after LSG (12 patients, 1.7 %) compared with LRYGB (22 patients, 1.6 %; p = 0.304). Bleeding rate was significantly higher after LSG (19 patients, 2.7 %) than after LRYGB (10 patients, 0.7 %; p = 0.004). Prolonged elevation of inflammatory markers was the most common presentation for complications after LSG (18 patients, 36.7 %) and LRYGB (31 patients, 46.9 %). CONCLUSIONS: LSG was associated with more early complications. This may be attributed to higher BMI and predominance of males in LSG group.

Failure of laparoscopic sleeve gastrectomy--further procedure?

BACKGROUND: Worldwide, the incidence of morbid obesity is increasing, and surgery is the only effective longterm treatment. Laparoscopic sleeve gastrectomy (LSG) is associated with acceptable weight loss and reduced comorbidities. It is considered a safe procedure with sporadic complications. This publication aims to describe failures of LSG in terms of ineffective weight loss or early weight regain, and analyze secondary treatment options. METHODS: From October 2001 to December 2010, 937 patients underwent LSG in our department. Initially, all procedures were scheduled as a two-stage procedure (LSG followed by biliopancreatic diversion with duodenal switch). However, the second procedure was not performed in 64 patients (body mass index > 60 kg/m(2)). Since 2005, the frequency of second stage procedures after weight regain has been increasing; their outcome is analyzed. RESULTS: Of the 937 patients, 17 (1.8%) experienced staple line leakage. Mean time to first reintervention or endoscopic stent placement was 15.6 ± 22 days (range 2-78). From 2005 to 2010, 106 secondary procedures were performed. Insufficient weight loss or weight regain were the indications in 88 cases. Sixteen (15%) patients had severe gastroesophageal reflux which was resolved by Roux-en-Y gastric bypass (RYGB). Stenosis was observed in 2 (2.6%) patients, which required endoscopic dilatation and stent placement in one case and gastric bypass in the other. CONCLUSIONS: LSG is a feasible and popular bariatric procedure. Mortality (0.4%) was much higher than after gastric bypass (0.03%) and gastric banding (0%) The knowledge of potential complications and their management is crucial. All restrictive procedures require patient compliance, but increased food uptake after RYGB and LSG is common. Malabsorptive procedures are more effective for long-term weight loss. Duodenal switch and omega-loop gastric bypass are more efficient second stage procedures than re-sleeve or RYGB.

Analysis of safety and efficacy of intragastric balloon in extremely obese patients.

BACKGROUND: The implantation of an intragastric balloon constitutes a short-term effective non-surgical intervention to lose weight. The aim of this study was to evaluate retrospectively the clinical outcome and safety of gastric balloon therapy (GBT) in extremely obese patients. METHODS: One hundred and nine super- and super-super-obese patients, 64 males and 45 females, mean age 39.1+/-8.4 years, mean body mass index (BMI) 68.8+/-8.9 kg/m2, who underwent GBT for weight loss, were studied retrospectively. GBT was assessed in massively obese patients concerning tolerance, weight loss, number of comorbidities and complications. RESULTS: A significant reduction in patients' weight and BMI was evident after GBT. Regarding safety, no major complications occurred. Minor complications at balloon placement and removal occurred in one (0.9%) and three patients (2.8%) respectively. Mean duration of GBT was 177.6+/-56.8 days. After GBT, the mean weight loss was 26.3+/-15.2 kg (p<0.001) and the mean BMI reduction was 8.7+/-5.1 kg/m2 (p<0.001) representing a mean percentage of excess BMI lost (%EBL) of 19.7+/-10.2. The highest BMI loss was observed in patients with BMI>80 kg/m2. A noteworthy improvement of comorbidities in 56.8% of the patients was also noted. Of the 109 patients, 69 received subsequent bariatric surgery. All the procedures were performed laparoscopically. Ten patients, with a mean BMI of 68.6+/-10.6 kg/m2 after the removal of the first BIB, received a second BIB resulting in a non-significant weight and BMI loss of 6.3+/-9.4 kg and 1.8+/-2.9 kg/m2, respectively. CONCLUSIONS: Our study indicates the safety and efficacy of GBT in extremely obese patients particularly as a first step before a definitive anti-obesity operation. GBT appears to be a safe, tolerable, and potentially effective procedure for the initial treatment of morbid obesity.

[The gastric balloon--a retrospective cohort analysis of 634 patients]. / Der Magenballon--eine retrospektive Kohortenanalyse mit 634 Patienten.

BACKGROUND: The temporary use of a gastric balloon for the treatment of obesity grade 1 and 2 is increasing worldwide,whereas in grade 3 obesity, it is implanted as a tool for preoperative adjuvant weight loss. The aim of this retrospective cohort analysis is to evaluate the effectiveness of weight reduction and to describe the risk profile of the method. METHODS: Retrospective cohort analysis of 4 obesity centers where gastric balloons had been regularly implanted since 2001. RESULTS: Between February 2001 and April 2008, the gastric balloon(BIB Intragastric Balloon System; Allergan Medical,Irvine, CA, USA) was implanted in 634 patients. The gender ratio was 31.5% males to 68.5% females; the average age was 41.5 years. The average initial weight was 126 kg. The initial BMI at implantation of the gastric balloon was 42.5 kg/m2.The implantation of the prosthesis was uncomplicated in all cases. Average weight loss was 20.75 kg or 7.05 BMI points, respectively.

Validity of the Czech, German, Italian, and Spanish version of the Moorehead-Ardelt II questionnaire in patients with morbid obesity.

BACKGROUND: The Moorehead-Ardelt II (MA-II) questionnaire is the most frequently applied instrument to assess quality of life (QoL) in bariatric surgery patients. Our aim was to validate the Czech, German, Italian, and Spanish version of the MA-II. METHODS: A total of 893 patients were enroled in a prospective cross-sectional European study. Two thirds of the patients(n = 591) were postsurgical cases. In addition to demographicand clinical data, QoL data was collected using the MA-II questionnaire, the EuroQoL-5D (EQ-5D), and the Short Form 36 Health Survery (SF-36). Statistical parameters for contingency (Cronbach's alpha), construct and criterion validity(Pearson's r), and responsiveness (standardised effect sizes) were calculated for each language version. RESULTS: In the different languages, Cronbach's alpha ranged from 0.817 to 0.885 for the MA-II. These values were higher than those obtained for the SF-36 (0.418-0.607). The MA-II was well correlated to the EQ-5D (r = 0.662) and to 3 of the 8 health domains of the SF-36 (0.615, 0.548, and 0.569 for physical functioning,physical role, and general health, respectively). As expected, there was a negative correlation between the MA-II and the BMI (r = -0.404 for all patients), but no significant correlation with age was found.When comparing both the heaviest and the lightest third of the patients, mean responsiveness was higher for the MA-II (-1.138) than for the domains of the SF-36 (range -0.111 to -1.070) and the EQ-5D (-0.874). CONCLUSION: The Czech, German, Italian, and Spanish version of the MA-II questionnaire are valid instruments and should be preferred to generic questionnaires as they provide better responsiveness.

Validation of the adapted Bariatric Quality of Life Index (BQL) in a prospective study in 446 bariatric patients as one-factor model.

BACKGROUND: The Bariatric Quality of Life Index (BQL) was created and validated as a nine-factor model in 2005 for the measurement of quality of life (QoL) in patients before and after bariatric surgery.Even though the results were acceptable, the statistical structure of the test was very unclear. METHODS: A total of 466 patients were enrolled in an ongoing prospective longitudinal German study. The assessment took place preoperatively and at 1, 3,6, 9, and 12 months postoperatively. After that period, reevaluations were done on a yearly basis. In addition to demographic and clinical data, QoL data were collected using the BQL, the Short Form 12 (SF-12v2), the Gastrointestinal Quality of Life Index(GIQLI), and the Bariatric Analysis and Reporting Outcome System(BAROS; old version since the study started in 2001). Statistical parameters for contingency (Cronbach's a), construct and criterion validity (Pearson's r), and responsiveness (standardized effect sizes) were calculated. The data of the assessments conducted preoperatively and after 6 and 12 months were used for the validation. RESULTS: The factor analysis and the screeplot showed that a one-factor solution explained 45.37% of variance. The selectivity of the items ranged between 0.61 and 0.85, and Cronbach's a was 0.898. The measurements showed similar excellent results with the analysis of all measurement points. Pearson's test showed a good retest reliability (r = 0.9). The correlations with the SF-12 and the Moorehead-Ardelt I questionnaire(MA-I) were significant, while the correlation with the GIQLI was low. The results of the correlation with the excess weight loss(EWL) (0.45 and 0.49) and the BMI (-0.38 and -0.47) were good. CONCLUSION: The BQL is a valid instrument and should be preferred over generic questionnaires as it provides better responsiveness.

Mapping utility scores from a disease-specific quality-of-life measure in bariatric surgery patients.

OBJECTIVES: To develop algorithms for a conversion of disease-specific quality-of-life into health state values for morbidly obese patients before or after bariatric surgery. METHODS: A total of 893 patients were enrolled in a prospective cross-sectional multicenter study. In addition to demographic and clinical data, health-related quality-of-life (HRQoL) data were collected using the disease-specific Moorehead-Ardelt II questionnaire (MA-II) and two generic questionnaires, the EuroQoL-5D (EQ-5D) and the Short Form-6D (SF-6D). Multiple regression models were constructed to predict EQ-5D- and SF-6D-based utility values from MA-II scores and additional demographic variables. RESULTS: The mean body mass index was 39.4, and 591 patients (66%) had already undergone surgery. The average EQ-5D and SF-6D scores were 0.830 and 0.699. The MA-IIwas correlated to both utility measures (Spearman's r = 0.677 and 0.741). Goodness-of-fit was highest (R(2) = 0.55 in the validation sample) for the following item-based transformation algorithm: utility (MA-II-based) = 0.4293 + (0.0336 x MA1) + (0.0071 x MA2) + (0.0053 x MA3) + (0.0107 x MA4) + (0.0001 x MA5). This EQ-5D-based mapping algorithm outperformed a similar SF-6D-based algorithm in terms of mean absolute percentage error (P = 0.045). CONCLUSIONS: Because the mapping algorithm estimated utilities with only minor errors, it appears to be a valid method for calculating health state values in cost-utility analyses. The algorithm will help to define the role of bariatric surgery in morbid obesity.