LSG vs OAGB: 7-Year Follow-up Data of a Randomised Control Trial and Comparative Outcome Based on BAROS Score.

BACKGROUND: This study aims to evaluate and compare long-term results of laparoscopic sleeve gastrectomy (LSG) and one anastomosis gastric bypass (OAGB) based on bariatric analysis reporting and outcome system (BAROS) score. MATERIALS AND METHODS: Patients operated for morbid obesity between 2013 and 2015 were randomised to LSG and OAGB groups. Based on inclusion and exclusion criteria, 201 patients (100 LSG and 101 OAGB) were analysed for changes in total body weight (TBW), body mass index (BMI), percent excess weight loss (%EWL), percent total weight loss (%TWL), QoL (quality of life) scores, comorbidity resolution and outcome based on BAROS at 7 years. RESULTS: Sixty-six LSG and 64 OAGB patients were followed up at 7 years. Mean pre-operative TBW and BMI were 119 ± 28.2 and 44.87 ± 7.71 for LSG group and 113.25 ± 23.74 and 44.71 ± 8.75 for OAGB group respectively. At 7 years after surgery, there was significant drop in mean TBW and BMI in both groups. Mean %EWL for LSG and OAGB patients was 50.78 ± 28.48 and 59.99 ± 23.32 and mean %TWL for LSG and OAGB patients was 23.22 ± 12.66 and 27.71 ± 12.27 respectively. Mean QoL scores at 7 years were significantly higher than the pre-operative scores and most of the patients in both groups had remission or improvement in their comorbidities. 68.76% OAGB patients had very good or excellent outcome on BAROS score while only 36.37% LSG patients had similar outcome. CONCLUSIONS: LSG and OAGB are successful bariatric procedures over the long term. OAGB outperforms LSG and has significantly higher %EWL and %TWL over the long term.

An overview of therapeutic options of obesity management in India: the Integrated Diabetes and Endocrinology Academy (IDEA) 2023 Congress update.

INTRODUCTION: With newer anti-obesity medications (AOMs) being introduced at a rapid pace, it is prudent to make a concise and updated clinical practice document that may help busy clinicians in daily clinical practice. A group of metabolic physicians, diabetologists, endocrinologists, and bariatric surgeons assembled during the Integrated Diabetes and Endocrine Academy 2023 Congress (IDEACON, July 2023, Kolkata, India) to compile an update of pharmacotherapeutic options for managing people with obesity in India. AREAS COVERED: After an extensive review of the literature by experts in different domains, this update provides all available information on the management of obesity, with a special emphasis on both currently available and soon-to-be-available AOMs, in people with obesity. EXPERT OPINION: Several newer AOMs have been shown to reduce body weight significantly, thus poised to make a paradigm shift in the management of obesity. While the tolerability and key adverse events associated with these AOMs appear to be acceptable in randomized controlled trials, pharmacovigilance is vital in real-world settings, given the absence of sufficiently long-term studies. The easy availability and affordability of these drugs is another area of concern, especially in developing countries like India.

Mitochondrial sourcing of interferogenic ligands and an autoantigen in human obesity-associated metaflammation.

OBJECTIVE: Visceral adipose tissue (VAT) inflammation contributes to metabolic dysregulation in obesity. VAT recruitment and activation of plasmacytoid dendritic cells (pDCs) through toll-like receptor 9 (TLR9) recognition of self-DNA, leading to induction of type I interferons, are crucial innate triggers for this VAT inflammation. It was hypothesized that mitochondrial DNA (mtDNA) can contribute to TLR9 activation in VAT-recruited pDCs in obesity, and this study aimed to identify the carrier protein for ligand access to TLR9 and to explore whether this also provides for a source of autoantigens in this context. METHODS: VAT samples, used for gene expression studies as well as adipose explant cultures, were collected from patients with obesity (n = 54) and lean patients (n = 10). Supernatants from human pDC cultures, treated with adipose explant culture supernatants, were used for interferon α ELISA. Venous plasma, from patients with (n = 114) and without (n = 45) obesity, was used for an ELISA for autoantibodies. RESULTS: MtDNA from VAT in obesity, in complex with mitochondrial transcription factor A protein (TFAM), acts as interferogenic ligands for pDCs. Humoral autoreactivity against TFAM is also induced in obesity. CONCLUSIONS: Interferogenic ligands and an autoantigen can be sourced from dysfunctional mitochondria in VAT of humans with obesity. Further therapeutic and prognostic potential for this immune mechanism in obesity warrants exploration.

Tailored one anastomosis gastric bypass - Subgroup analysis of a randomised control trial based on bilio-pancreatic limb length with long-term results of 101 patients.

Background: : Ideal bilio-pancreatic limb (BPL) length is a highly debatable issue in one anastomosis gastric bypass (OAGB). Whether to use a tailored BPL or a fixed-length BPL needs to be answered. Materials and Methods: : One-hundred and one patients who have undergone tailored OAGB based on basal metabolic index (BMI) and type 2 diabetes mellitus (T2DM) were analysed. Sixty-three patients had BPL of 150 cm and 38 patients had BPL of 180 cm. Mean pre-operative BMI of BPL 150 and 180 cm groups were 39.73 and 51.92 kg/m2, respectively. Results: There was a significant drop in mean total body weight, BMI and excess body weight of both the groups at 1 year which persisted for 5 years post-operatively. The mean BMI of BPL 150 and BPL 180 cm group at 5 years was 29.17 and 32.88 kg/m2, respectively. Although mean percentage excess weight loss (%EWL) and percentage of excess BMI loss in the two groups was similar, the mean percentage total weight loss (%TWL) was significantly higher for the BPL 180 cm group. There was no difference between the two groups in the number of patients who had >50% EWL and >20% TWL. At 5 years of follow-up, the mean serum iron level was significantly low in BPL 180 cm group. There was a significant drop in mean haemoglobin A1c values postoperatively, with no difference between the two groups. Conclusions: Tailored BPL of 150 and 180 cm do not show any difference in the number of patients achieving >50% EWL or >20% TWL and so increasing limb length may not increase the number of good responders for weight loss. Although the resolution of T2DM and improvement of QoL score do not change significantly with increase in BPL length, mean serum iron levels may be lower with longer BPL.

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

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

LSG vs MGB-OAGB: 5-Year Follow-up Data and Comparative Outcome of the Two Procedures over Long Term-Results of a Randomised Control Trial.

BACKGROUND: Bariatric surgery is a durable and effective way for the management of obesity and resolution of related comorbidities. The aim of this study is to evaluate the outcome of laparoscopic sleeve gastrectomy (LSG) and one-anastomosis gastric bypass (OAGB) over long term in a South Asian population. MATERIALS AND METHODS: This is a prospective randomised trial comparing the outcome of 100 and 101 LSG and OAGB patients respectively after 5-year follow-up. This study is in continuity with previous published papers with 1- and 3-year follow-up. 71 LSG and 73 OAGB patients followed at 5 years. The results of these patients were analysed and compared in terms of %EWL, comorbidity resolution and quality of life (QoL) at 5 years. Bariatric analysis reporting and outcome system (BAROS) was used to assess the outcome of patients. RESULTS: At 5-year follow-up, both LSG and OAGB patients performed well and patients had significant improvement in BMI (kg/m2). The mean preoperative BMI of LSG and OAGB patients was 44.89 ± 7.94 and 45.32 ± 8.24, and their mean BMI at 5 years was 33.41 ± 6.02, 30.80 ± 3.40 respectively. At 5 years, %EWL was 55.95 ± 27.01 and 65.28 ± 13.98 for LSG and OAGB patients respectively. The QoL score of LSG and OAGB patients was 1.86 ± 0.56 and 2.35 ± 0.41 while comorbidity score was 1.84 ± 0.68 and 2.24 ± 0.62 respectively at 5 years. CONCLUSIONS: Both LSG and OAGB are effective bariatric procedures over long term with respect to weight loss, comorbidity resolution and improvement in QoL. OAGB is significantly better than LSG in all the three parameters at 5 years.

Trends and progress of bariatric and metabolic surgery in India.

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

Increased Plasma Dipeptidyl Peptidase-4 (DPP4) Activity Is an Obesity-Independent Parameter for Glycemic Deregulation in Type 2 Diabetes Patients.

Background: Increase in circulating dipeptidyl peptidase-4 (DPP4) activity and levels has been reported to associate both with hyperglycemia and obesity. Here we aim to decipher the role of enhanced plasma DPP4 activity in obese type 2 diabetes (T2DM) patients. Materials and methods: Plasma DPP4 levels and activity were measured in obese and non-obese newly diagnosed T2DM patients (n = 123). Visceral and subcutaneous adipose tissue DPP4 expression and activity were determined in 43 obese subjects (T2DM = 21 and non-T2DM = 22). 20 subjects undergoing Mini-Gastric Bypass (MGB) surgery were followed up over 4-6 weeks for plasma DPP4. Results: Plasma DPP4 levels and activity both were increased in T2DM patients compared to control group. However, DPP4 levels and not DPP4 activity were increased in obese T2DM patients compared to non-obese T2DM (62.49 ± 26.27 µg/ml vs. 48.4 ± 30.98 µg/ml, respectively, p = 0.028). DPP4 activity in visceral adipose tissue (VAT) from obese T2DM and obese non-T2DM groups were similar (5.05 ± 3.96 nmol/min/ml vs. 5.83 ± 4.13 nmol/min/ml respectively, p = 0.548) in spite of having increased DPP4 expression in the obese T2DM group. Moreover, in obese patients, plasma DPP4 levels and activity did not show any significant change after weight reduction and glycemic control following MGB surgery. Conclusion: Enhanced plasma DPP4 activity in T2DM occurs independently of obesity. Thus, adipose derived DPP4 may not be playing any significant role in glycemic deregulation in obese T2DM patients.

MGB-OAGB: Effect of Biliopancreatic Limb Length on Nutritional Deficiency, Weight Loss, and Comorbidity Resolution.

INTRODUCTION: Mini gastric bypass-one anastomosis gastric bypass (MGB-OAGB) has been approved as a mainstream metabolic/bariatric procedure by IFSO. Still there are lots of concerns regarding nutritional deficiency after MGB-OAGB. The purpose of this retrospective analysis is to evaluate the effect of biliopancreatic limb (BPL) length on weight loss, comorbidity resolution, and nutritional deficiencies in patients 1 year after MGB-OAGB and to find suitable BPL length. MATERIAL AND METHODS: One hundred and one patients who underwent MGB-OAGB were divided into three groups of 150 cm, 180 cm, and 250 cm depending on the length of BPL bypassed. The nutritional parameters (vitamin D3, vitamin B12, serum iron, serum ferritin, total protein, serum albumin, serum globulin), anthropometric measurements (weight, BMI), and comorbidity resolution (T2DM, hypertension) were compared between the three groups at 1-year follow-up. RESULTS: There was statistically significant difference in number of patients having deficiencies in all the nutritional parameters except globulin between 150 cm and 250 cm groups (P < 0.05). While on comparing 180- and 250-cm group, a statistically significant difference was present in vitamin D3, vitamin B12, and total protein (P < 0.05) only. The difference was statistically insignificant between the three groups on T2DM, hypertension resolution, and %EWL but TWL between 150 cm vs 180 cm and 150 cm vs 250 cm showed significant difference. CONCLUSION: A 150-cm BPL length is adequate with very minimal nutritional complications and good results. A 180-cm BPL can be used in super obese while a 250-cm BPL should be used with utmost care as it results in significant nutritional deficiencies.

LSG vs MGB-OAGB-3 Year Follow-up Data: a Randomised Control Trial.

AIM: The objective of this study is to compare 3-year follow-up results of one anastomosis gastric bypass (MGB-OAGB) and laparoscopic sleeve gastrectomy (LSG) in terms of weight loss, complications, resolution of comorbidities and quality of life. MATERIALS AND METHODS: A prospective randomised study of results between 100 LSG patients and 101 MGB-OAGB patients was done from 2012 to 2015. The results were compared regarding operative outcomes, percentage of excess weight loss (%EWL), complications, resolution of comorbidities and quality of life (BAROS score) at 3 years follow-up. RESULTS: Follow-up was achieved in 93 MGB-OAGB vs 92 LSG patients for 3-year period. The average %EWL for MGB-OAGB vs LSG was 66.48 vs 61.15% at the end of 3 years respectively, which was statistically insignificant. Diabetes remission was seen in 89.13% of MGB-OAGB patients and 81.82% of LSG patients. Remission of hypertension was seen in 74% of MGB-OAGB patients and 72.22% of LSG patients. Bariatric analysis reporting and outcome system (BAROS) with comorbidity in LSG patients and MGB-OAGB patients was 6.03 and 6.96 respectively, whereas in patients without comorbidity, BAROS score was 3.86 in LSG group and 4.34 in MGB-OAGB group. CONCLUSIONS: In our study, at 36 months follow up, there was no significant difference between LSG and MGB-OAGB in %EWL and remission of HTN. Type 2 diabetes mellitus (T2DM) remission rates were higher after MGB-OAGB as compared to LSG but the difference was statistically insignificant. MGB-OAGB patients with comorbidities have a better quality of life and BAROS score compared to LSG patients.

Predicting remission of diabetes post metabolic surgery: a comparison of ABCD, diarem, and DRS scores.

BACKGROUND: Obesity is one of the major causes for development of T2DM. Metabolic surgery has been proved to be a successful and cost-effective treatment modality for managing the patients with obesity and T2DM. Many scoring systems and models have been described in literature to predict the outcome of T2DM after metabolic surgery. The aim of this study is to compare the efficacy of Diarem, DRS, and ABCD score in predicting the T2DM remission. METHODS: A total number of 102 diabetic patients, who underwent LMGB/LOAGB, were selected for this study. A retrospective analysis of the three scoring systems when applied to these patients and their predictive abilities were analyzed. RESULTS: At 1 year after surgery, 72 (70.59%) patients achieved remission of T2DM. Though the pairwise comparisons between AUC on ROC analysis of ABCD, Diarem, and DRS scores does not show statistically significant difference between them, Diarem score has the maximum relative area under ROC curves. By multivariate analysis, it was found that factors significantly associated with T2DM remission were duration of T2DM, C-peptide, and Pre-Op HbA1c. CONCLUSIONS: Among the three scoring systems, though DiaRem score has the best sensitivity and specificity and maximum AUC, no statistically significant difference was found in their diabetes remission predicting abilities. A shorter duration of T2DM, a lower HbA1C, and higher levels of C-peptide were significantly associated with a higher chance of T2DM remission.

LSG vs OAGB-1 Year Follow-up Data-a Randomized Control Trial.

OBJECTIVES: Laparoscopic sleeve gastrectomy (LSG) is one of the most popular bariatric procedure. One anastomosis gastric bypass (OAGB) is rapidly emerging as a safe and effective metabolic procedure. This study aims at comparing the 1-year follow-up results of OAGB and LSG in terms of excess weight loss, complications, resolution of comorbidities, and quality of life. METHODS: A prospective randomized study of results between 100 LSG and 101 OAGB patients was done from 2012 to 2015. The results were compared regarding operative outcomes, percentage of excess weight loss, complications, resolution of comorbidities, and quality of life (BAROS score). RESULTS: The mean BMI for the OAGB and LSG group was 44.31 and 43.75 kg/m2, respectively. Percentage of excess weight loss (%EWL) for OAGB vs LSG was 66.87 ± 10.87 vs 63.97 ± 13.24 at 1 year (p > 0.05), respectively. Diabetes remission was 83.63 % in OAGB patients and 76.58 % in LSG patients. Remission of hypertension is 64.15 % in OAGB patients and 66.07 % in LSG patients. Bariatric Analysis Reporting and Outcome System (BAROS) was 3.71 in LSG and 3.96 in OAGB. CONCLUSIONS: In our study, there was no significant difference between LSG and OAGB in outcome at 1 year follow-up in % excess weight loss, remission of HTN, and quality of life. OAGB has marginally better outcome in T2 DM remission. However, a longer follow-up is required to establish a correct comparative result.

Adipose Recruitment and Activation of Plasmacytoid Dendritic Cells Fuel Metaflammation.

In obese individuals, visceral adipose tissue (VAT) is the seat of chronic low-grade inflammation (metaflammation), but the mechanistic link between increased adiposity and metaflammation largely remains unclear. In obese individuals, deregulation of a specific adipokine, chemerin, contributes to innate initiation of metaflammation by recruiting circulating plasmacytoid dendritic cells (pDCs) into VAT through chemokine-like receptor 1 (CMKLR1). Adipose tissue-derived high-mobility group B1 (HMGB1) protein activates Toll-like receptor 9 (TLR9) in the adipose-recruited pDCs by transporting extracellular DNA through receptor for advanced glycation end products (RAGE) and induces production of type I interferons (IFNs). Type I IFNs in turn help in proinflammatory polarization of adipose-resident macrophages. IFN signature gene expression in VAT correlates with both adipose tissue and systemic insulin resistance (IR) in obese individuals, which is represented by ADIPO-IR and HOMA2-IR, respectively, and defines two subgroups with different susceptibility to IR. Thus, this study reveals a pathway that drives adipose tissue inflammation and consequent IR in obesity.

Acute small intestinal obstruction-an unusual complication of capsule endoscopy.

We report a case of endoscopic capsule impaction causing acute small intestinal obstruction in a patient with Crohn's disease (CD), having obscure gastrointestinal bleeding. A 57-year old female presented with features of acute small bowel obstruction 2 days after capsule endoscopy elsewhere for the evaluation of intermittent bleeding per rectum and iron deficiency anemia. Patient underwent an exploratory laparotomy with right hemicolectomy for the diseased ileocecal region which mimicked malignancy. The capsule was found to be impacted in the strictured lumen of the terminal ileum. Post operative histopathological examination revealed it to be Crohn's disease.

A Rare Variant of Diaphragmatic Hernia through the Central Tendon: A Case Report.

Diaphragmatic hernia through the central tendon is a very rare entity. We report on a case that developed to acute intestinal obstruction, secondary to herniation of the small intestine through a small defect in the central tendon of the diaphragm. The patient never had any trauma to his chest or abdomen and had no history suggestive of congenital nature of the diaphragmatic hernia. However, he had coronary artery bypass grafting with saphenous vein used as a graft, done almost 17 years back; hence, we suspect it to be an iatrogenic hernia. A laparoscopic herniorrhaphy of the diaphragmatic defect was carried out after reducing the herniated organ. The postoperative course was uneventful. Iatrogenic diaphragmatic hernias are a very rare entity. We are reporting on a central tendon hernial defect in the diaphragm after coronary artery bypass with saphenous vein as a graft material. There are reported cases with post coronary artery bypass graft diaphragmatic hernia in which the right gastroepiploic artery was taken as the graft material. Late diagnosis of iatrogenic diaphragmatic hernias is frequent. CT scan is helpful for diagnosis. Surgery is the treatment of diaphragmatic hernia at the time of diagnosis, even with asymptomatic patients.

Is resected stomach volume related to weight loss after laparoscopic sleeve gastrectomy?

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) was initially performed as the first stage of biliopancreatic diversion with duodenal switch for the treatment of super-obese or high-risk obese patients but is now most commonly performed as a standalone operation. The aim of this prospective study was to investigate outcomes after LSG according to resected stomach volume. METHODS: Between May 2011 and April 2013, LSG was performed in 102 consecutive patients undergoing bariatric surgery. Two patients were excluded, and data from the remaining 100 patients were analyzed in this study. Patients were divided into three groups according to the following resected stomach volume: 700-1,200 mL (group A, n = 21), 1,200-1,700 mL (group B, n = 62), and >1,700 mL (group C, n = 17). Mean values were compared among the groups by analysis of variance. RESULTS: The mean percentage excess body weight loss (%EBWL) at 3, 6, 12, and 24 months after surgery was 37.68 ± 10.97, 50.97 ± 13.59, 62.35 ± 11.31, and 67.59 ± 9.02 %, respectively. There were no significant differences in mean %EBWL among the three groups. Resected stomach volume was greater in patients with higher preoperative body mass index and was positively associated with resected stomach weight. CONCLUSIONS: Mean %EBWL after LSG was not significantly different among three groups of patients divided according to resected stomach volume. Resected stomach volume was significantly greater in patients with higher preoperative body mass index.

Laparoscopic repair of right sided bochdalek hernia - a case report.

Right-sided Bochdalek hernia in adults is a very rare clinical entity. A case of a 50-year-old female patient is reported, who presented with long history of intermittent breathlessness and right-sided thoracoabdominal pain. The hernia was managed laparoscopically. Contents were colon, omentum, and right kidney. It was successfully repaired using a polypropylene mesh.

Omental gangrene and porto-mesenteric thrombosis in a patient of protein C and protein s deficiency.

Omental gangrene is an infrequent cause of acute abdomen with unclear etiology. Hypercoagualable states like protein C or protein S deficiency have never been implicated in the etiology of omental gangrene. We present this case report of a patient having protein C and protein S deficiency presenting with omental gangrene and extensive porto mesenteric thrombosis.