Non-alcoholic fatty liver disease phosphoproteomics: A functional piece of the precision puzzle.

BACKGROUND: Molecular signaling events associated with the necroinflammatory changes in nonalcoholic steatohepatitis (NASH) are not well understood. AIMS: To understand the molecular basis of NASH, we evaluated reversible phosphorylation events in hepatic tissue derived from Class III obese subjects by phosphoproteomic means with the aim of highlighting key regulatory pathways that distinguish NASH from non-alcoholic fatty liver disease (also known as simple steatosis; SS). MATERIALS & METHODS: Class III obese subjects undergoing bariatric surgery underwent liver biopsy (eight normal patients, eight with simple steatosis, and eight NASH patients). Our strategy was unbiased, comparing global differences in liver protein reversible phosphorylation events across the 24 subjects. RESULTS: Of the 3078 phosphorylation sites assigned (2465 phosphoserine, 445 phosphothreonine, 165 phosphotyrosine), 53 were altered by a factor of 2 among cohorts, and of those, 12 were significantly increased or decreased by ANOVA (P < 0.05). DISCUSSION: Statistical analyses of canonical signaling pathways identified carbohydrate metabolism and RNA post-transcriptional modification among the most over-represented networks. CONCLUSION: Collectively, these results raise the possibility of abnormalities in carbohydrate metabolism as an important trigger for the development of NASH, in parallel with already established abnormalities in lipid metabolism.

Lessons learned from the metabolic and bariatric surgery accreditation and quality improvement program site surveys: common deficiencies and corrective actions.

BACKGROUND: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) is a joint program between the American Society for Metabolic and Bariatric Surgery (ASMBS) and the American College of Surgeons (ACS). On-site surveys of the applicant programs to determine adherence to the MBSAQIP standards are a hallmark of the accreditation process. OBJECTIVES: A retrospective review of 619 site surveys completed over 2 years was performed to include analysis of reviewer decisions, tabulation and cross-reference of identified deficiencies to the MBSAQIP standards and determine final disposition of corrective actions and overall accreditation rates. SETTING: Accredited Hospitals (Community and Academic) within MBSAQIP. METHODS: This is a retrospective review of site surveys by expert panel. RESULTS: ≥1 MBSAQIP Standards deficiencies were present at 149 of the 619 program site surveys (24.07%). The 3 leading Standards in Deficiency were in order: Commitment to Quality Care, Continuous Quality Improvement Process, and Data Collection. Within a year following initial site survey of the149 programs with Standards deficiencies, 59 programs demonstrated compliance, 83 programs were placed on probation (with a specific time-frame to demonstrate compliance) and 7 programs were denied accreditation. Ultimately, 98.9% of programs were able to gain or maintain MBSAQIP accreditation. CONCLUSIONS: The MBSAQIP accreditation through on-site surveys can identify and improve program adherence to MBSAQIP standards.

Non-Operative Approach to Contained Perforated Marginal Ulcers: A Systematic Review and Case Series.

BACKGROUND: Perforated marginal ulcers (PMUs) are a rare but known complication of bariatric surgery. Management typically involves prompt surgical intervention, but limited data exists on non-operative approaches. This study reviews published data on non-operative management of PMUs and presents a case series of patients who were managed non-operatively. Our hypothesis is that certain patients with signs of perforation can be successfully managed non-operatively with close observation. METHODS: We completed a systematic review searching PubMed, Embase, Web of Science, Cochrane, and clinicaltrials.gov. Ultimately 3 studies described the presentation and non-operative management of 5 patients. Additionally, we prospectively collected data from our institution on all patients who presented between Dec. 2022 and Dec. 2023 with PMUs confirmed on imaging and managed non-operatively. RESULTS: In our literature review, three patients had Roux-en-Y gastric bypass (RYGB), while two had one anastomosis gastric bypass. One patient required surgery two days after admission. Another underwent elective conversion surgery weeks later for a non-healing ulcer. Two received endoscopic interventions. One patient recovered with nil-per-os (NPO) status, and intravenous proton pump inhibitor (PPI) treatment. The patients in our case series presented with normal vital signs, an average of 30 months after RYGB, and with CT scan signs of perforation. None of these patients required surgical or endoscopic intervention. CONCLUSION: In conclusion, while perforated marginal ulcers have traditionally been considered a surgical emergency, some patients can be successfully treated with non-operative management. More research is needed to identify the clinical presentation features, comorbidities, and imaging findings of this group.

Comparative analysis of sleeve conversions of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2020 Database.

BACKGROUND: Although the sleeve gastrectomy (SG) is the dominant bariatric procedure, studies have shown conversion rates of up to 30%. These conversions are generally for weight regain (WR), insufficient weight loss (IWL) or gastroesophageal reflux disease (GERD). Before 2020, details on why conversions were being performed were not collected in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Participant Use Data File (PUF). Now, the indication for sleeve conversion is noted in the PUF, allowing identification and reporting sleeve conversion reasons. OBJECTIVE: We aimed to examine the reasons for SG conversions nationwide. SETTING: The 2020 MBSAQIP PUF. METHODS: The 2020 MBSAQIP PUF was examined to determine the reasons why SG were converted to other operations. The data field of "Revision/Conversion Final Indication" was used along with "Procedure type." Primary bariatric operations were excluded. Descriptive statistics were applied. Different reasons for conversion and operations were compared by preoperative characteristics and operative outcomes. RESULTS: There were 103,782 primary SG reported in the 2020 PUF. There were 7181 SG that were converted to other operations. The most common conversion (86.2%) was to Roux-en-Y gastric bypass (RYGB). The main reason for SG conversion was GERD at 48.4%, followed by WR/IWL (41.9%). Biliopancreatic diversion with duodenal switch and single-anastomosis duodenoileal bypass with sleeve patients differed significantly from RYGB patients in specific preoperative characteristics and operative outcomes. CONCLUSION: The most common procedure SG is converted to is the RYGB. GERD was the most common reason for SG conversion, followed by WR/IWL.

Medical and Surgical Weight Loss as a Pathway to Renal Transplant Listing.

PURPOSE: Severe obesity is a barrier to listing for kidney transplantation due to concern for poor outcomes. This study aims to compare bariatric surgery with medical weight loss as a means of achieving weight loss and subsequent listing for renal transplant. We hypothesize that bariatric surgery will induce greater frequency of listing for transplant within 18 months of study initiation. MATERIALS AND METHODS: We performed a randomized study of metabolic bariatric surgery (MBS) vs medical weight loss (MM) in patients on dialysis with a body mass index (BMI) of 40-55 kg/m2. The primary outcome was suitability for renal transplant within 18 months of initiating treatment. Secondary outcomes included weight loss, mortality, and complications. RESULTS: Twenty patients enrolled, only 9 (5 MBS, 4 MM) received treatment. Treated groups did not differ in age, gender, or race (P ≥ .44). There was no statistically significant difference in the primary endpoint: 2 MBS (40%) and 1 MM (25%) listed for transplant ≤18 months (P = 1.00). With additional time, 100% MBS and 25% MM patients achieved listing status (P = .048); 100% of MBS and 0 MM received kidney transplants to date (P = .008). Weight, weight loss, and BMI trajectories differed between the groups (P ≤ .002). One death from COVID-19 occurred in the MM group, and 1 MBS patient had a myocardial infarction 3.75 years after baseline evaluation. CONCLUSION: These results suggest MBS is superior to MM in achieving weight loss prior to listing for kidney transplantation. Larger studies are needed to ensure the safety profile is acceptable in patients with ESRD undergoing bariatric surgery.

Sex- and operation-dependent effects on 5-year weight loss results of bariatric surgery.

BACKGROUND: Weight loss response after bariatric surgery is highly variable, and several demographic factors are associated with differential responses to surgery. Preclinical studies demonstrate numerous sex-specific responses to bariatric surgery, but whether these responses are also operation dependent is unknown. OBJECTIVE: To examine sex-specific weight loss outcomes up to 5 years after laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). SETTING: Single center, university, United States. METHODS: Retrospective, observational cohort study including RYGB (n = 5057) and vertical SG (n = 2041) patients from a single, academic health center. Percentage total weight loss (TWL) over time was examined with generalized linear mixed models to determine the main and interaction effects of surgery type on weight loss by sex. RESULTS: TWL demonstrated a strong sex-by-procedure interaction, with women having a significant advantage with RYGB compared with SG (adjusted difference at 5 yr: 8.0% [95% CI: 7.5-8.5]; P < .001). Men also experienced greater TWL over time with RYGB or SG, but the difference was less and clinically insignificant (adjusted difference at 5 yr: 2.9% [2.0-3.8]; P < .001; P interaction between sex and procedure type = .0001). Overall, women had greater TWL than men, and RYGB patients had greater TWL than SG patients (adjusted difference at 5 yr: 3.1% [2.4-3.2] and 6.9% [6.5-7.3], respectively; both P < .0001). Patients with diabetes lost less weight compared with those without (adjusted difference at 5 yr: 3.0% [2.7-3.2]; P < .0001). CONCLUSIONS: Weight loss after bariatric surgery is sex- and procedure-dependent. There is an association suggesting a clinically insignificant difference in weight loss between RYGB and SG among male patients at both the 2- and 5-year postsurgery time points.

American Society for Metabolic and Bariatric Surgery 2022 estimate of metabolic and bariatric procedures performed in the United States.

BACKGROUND: Metabolic and bariatric surgery (MBS), despite being the most effective durable treatment for obesity, remains underused as approximately 1% of all qualified patients undergo surgery. The American Society for Metabolic and Bariatric Surgery established a Numbers Taskforce to specify the annual rate of obesity treatment interventions utilization and to determine if patients in need are receiving appropriate treatment. OBJECTIVE: To provide the best estimated number of metabolic and bariatric procedures being performed in the United States in 2022. SETTING: United States. METHODS: We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and National Surgical Quality Improvement Program. In addition, data from industry and state databases were used to estimate activity at non-accredited centers. Data from 2022 were compared mainly with data from the previous 2 years. RESULTS: Compared with 2021, the total number of MBS performed in 2022 increased from approximately 262,893 to 280,000. The sleeve gastrectomy (SG) continues to be the most commonly performed procedure. The gastric bypass procedure trend remained relatively stable. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Intragastric balloon placement increased from the previous year. Endoscopic sleeve gastroplasty increased in numbers. CONCLUSIONS: There was a 6.5% increase in MBS volume from 2021 to 2022 and a 41% increase from 2020, which demonstrates a recovery from the COVID-19 pandemic. SG continues to be the most dominant MBS procedure.

Reduced Risk of Cardiovascular Diseases after Bariatric Surgery Based on the New PREVENT Equations.

Background: We applied the novel Predicting Risk of Cardiovascular Disease EVENTs (PREVENT) equations to evaluate cardiovascular-kidney-metabolic (CKM) health and estimated CVD risk, including heart failure (HF), after bariatric surgery. Methods: Among 7804 patients (20-79 years) undergoing bariatric surgery at Vanderbilt University Medical Center during 1999-2022, CVD risk factors at pre-surgery, 1-year, and 2-year post-surgery were extracted from electronic health records. The 10- and 30-year risks of total CVD, atherosclerotic CVD (ASCVD), coronary heart disease (CHD), stroke, and HF were estimated for patients without a history of CVD or its subtypes at each time point, using the social deprivation index-enhanced PREVENT equations. Paired t-tests or McNemar tests were used to compare pre- with post-surgery CKM health and CVD risk. Two-sample t-tests were used to compare CVD risk reduction between patient subgroups defined by age, sex, race, operation type, weight loss, and history of diabetes, hypertension, and dyslipidemia. Results: CKM health was significantly improved after surgery with lower systolic blood pressure, non-high-density-lipoprotein cholesterol (non-HDL), and diabetes prevalence, but higher HDL and estimated glomerular filtration rate (eGFR). The 10-year total CVD risk decreased from 6.51% at pre-surgery to 4.81% and 5.08% at 1- and 2-year post-surgery (relative reduction: 25.9% and 16.8%), respectively. Significant risk reductions were seen for all CVD subtypes (i.e., ASCVD, CHD, stroke, and HF), with the largest reduction for HF (relative reduction: 55.7% and 44.8% at 1- and 2-year post-surgery, respectively). Younger age, White race, >30% weight loss, diabetes history, and no dyslipidemia history were associated with greater HF risk reductions. Similar results were found for the 30-year risk estimates. Conclusions: Bariatric surgery significantly improves CKM health and reduces estimated CVD risk, particularly HF, by 45-56% within 1-2 years post-surgery. HF risk reduction may vary by patient's demographics, weight loss, and disease history, which warrants further research.

Cardiometabolic Improvements After Metabolic Surgery and Related Presurgery Factors.

Context: Metabolic surgery remains the most effective and durable treatment for severe obesity and related metabolic diseases. Objective: We examined cardiometabolic improvements after metabolic surgery and associated presurgery demographic and clinical factors in a large multiracial cohort. Methods: Included were 7804 patients (20-79 years) undergoing first-time metabolic surgery at Vanderbilt University Medical Center from 1999 to 2022. Pre- and 1-year postsurgery cardiometabolic profiles were extracted from medical records, including body mass index (BMI), blood pressure, blood lipids, glucose, and hemoglobin A1c. The 10-year atherosclerotic cardiovascular disease (ASCVD) risk was estimated per American College of Cardiology/American Heart Association equations. Pre- to postsurgery cardiometabolic profiles were compared by paired t-test, and associated factors were identified by multivariable linear and logistic regression. Results: Among 7804 patients, most were women and White, while 1618 were men and 1271 were Black; median age and BMI were 45 years [interquartile range (IQR): 37-53] and 46.4 kg/m2 (IQR: 42.1-52.4). At 1-year postsurgery, patients showed significant decreases in systolic blood pressure (10.5 [95% confidence interval: 10.1, 10.9] mmHg), total cholesterol (13.5 [10.3, 16.7] mg/dL), glucose (13.6 [12.9, 14.4] mg/dL), hemoglobin A1c (1.13% [1.06, 1.20]), and 10-year ASCVD risk (absolute reduction: 1.58% [1.22, 1.94]; relative reduction: 34.4% [29.4, 39.3]); all P < .0001. Older, male, or Black patients showed less reduction in 10-year ASCVD risk and lower odds of diabetes/hypertension/dyslipidemia remission than younger, female, or White patients. Patients with a history of diabetes, hypertension, dyslipidemia, or cardiovascular disease showed less cardiometabolic improvements than those without. Results were similar with or without further adjusting for weight loss and largely sustained at 2-year postsurgery. Conclusion: Metabolic surgery results in significant cardiometabolic improvements, particularly among younger, female, or White patients and those without comorbidities.

Enhanced Patient Portal Engagement Associated with Improved Weight Loss Outcomes in Post-Bariatric Surgery Patients.

Background: Bariatric surgery is an effective intervention for obesity, but it requires comprehensive postoperative self-management to achieve optimal outcomes. While patient portals are generally seen as beneficial in engaging patients in health management, the link between their use and post-bariatric surgery weight loss remains unclear. Objective: This study investigated the association between patient portal engagement and postoperative body mass index (BMI) reduction among bariatric surgery patients. Methods: This retrospective longitudinal study included patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) at Vanderbilt University Medical Center (VUMC) between January 2018 and March 2021. Using generalized estimating equations, we estimated the association between active days of postoperative patient portal use and the reduction of BMI percentage (%BMI) at 3, 6, and 12 months post-surgery. Covariates included duration since surgery, the patient's age at the time of surgery, gender, race and ethnicity, type of bariatric surgery, severity of comorbid conditions, and socioeconomic disadvantage. Results: The study included 1,415 patients, mostly female (80.9%), with diverse racial and ethnic backgrounds. 805 (56.9%) patients underwent RYGB and 610 (43.1%) underwent SG. By one-year post-surgery, the mean (SD) %BMI reduction was 31.1% (8.3%), and the mean (SD) number of patient portal active days was 61.0 (41.2). A significantly positive association was observed between patient portal engagement and %BMI reduction, with variations revealed over time. Each 10-day increment of active portal use was associated with a 0.57% ([95% CI: 0.42- 0.72], P < .001) and 0.35% ([95% CI: 0.22- 0.49], P < .001) %BMI reduction at 3 and 6 months postoperatively. The association was not statistically significant at 12 months postoperatively (ß=-0.07, [95% CI: -0.24- 0.09], P = .54). Various portal functions, including messaging, visits, my record, medical tools, billing, resources, and others, were positively associated with %BMI reduction at 3- and 6-months follow-ups. Conclusions: Greater patient portal engagement, which may represent stronger adherence to postoperative instructions, better self-management of health, and enhanced communication with care teams, was associated with improved postoperative weight loss. Future investigations are needed to identify important portal features that contribute to the long-term success of weight loss management.

The transcription factor ZNF469 regulates collagen production in liver fibrosis.

Non-alcoholic fatty liver disease (NAFLD) - characterized by excess accumulation of fat in the liver - now affects one third of the world's population. As NAFLD progresses, extracellular matrix components including collagen accumulate in the liver causing tissue fibrosis, a major determinant of disease severity and mortality. To identify transcriptional regulators of fibrosis, we computationally inferred the activity of transcription factors (TFs) relevant to fibrosis by profiling the matched transcriptomes and epigenomes of 108 human liver biopsies from a deeply-characterized cohort of patients spanning the full histopathologic spectrum of NAFLD. CRISPR-based genetic knockout of the top 100 TFs identified ZNF469 as a regulator of collagen expression in primary human hepatic stellate cells (HSCs). Gain- and loss-of-function studies established that ZNF469 regulates collagen genes and genes involved in matrix homeostasis through direct binding to gene bodies and regulatory elements. By integrating multiomic large-scale profiling of human biopsies with extensive experimental validation we demonstrate that ZNF469 is a transcriptional regulator of collagen in HSCs. Overall, these data nominate ZNF469 as a previously unrecognized determinant of NAFLD-associated liver fibrosis.

Safety culture and complications after bariatric surgery.

OBJECTIVE: To assess relationships between safety culture and complications within 30 days of bariatric surgery. BACKGROUND: Safety culture refers to the quality of teamwork, coordination, and communication, as well as responses to error in health care settings. Although safety culture is thought to be an important determinant of surgical outcomes, few studies have examined this empirically. METHODS: We surveyed staff from 22 Michigan hospitals participating in a statewide bariatric surgery collaborative. Each safety culture survey item was rated on a 1 to 5 Likert scale with lower scores representing better patient safety culture. These data were linked to clinical registry data for 24,117 bariatric surgery patients between 2007 and 2010. We used negative binomial regression to calculate incidence rates and incidence rate ratios measuring the increase in hospitals' rate of complications per unit increase in safety culture (individual items as well as hospital and operating room-specific subscales), controlling for patient risk factors, procedure mix, and bariatric procedure volume. RESULTS: All 22 hospitals participated in this study, submitting safety culture ratings from 53 surgeons, 102 nurses, and 29 operating room administrators. Rates of serious complications were significantly lower among hospitals receiving an overall safety rating of excellent from nurses (1.5%), compared with those receiving a very good (2.6%) or acceptable (4.6%) rating (P = <0.0001). Surgeons' overall safety ratings were also associated with rates of serious complications (2.1% excellent, 2.6% very good, 4.7% acceptable, P = 0.011). Nurses' ratings of the hospital-specific subscale (P = 0.002) and surgeons' ratings of the operating room-specific subscale (P = 0.045) were also associated with rates of serious complications. Of the individual items, those related to coordination and communication between hospital units were the most strongly associated with rates of complications. Operating room administrator ratings of safety culture were not related to rates of complications for any of the domains of safety culture studied. CONCLUSIONS: Safety culture is associated with rates of serious surgical complications in bariatric surgery. Although nurses provide better information about hospital safety culture, surgeons are better judges of safety culture in the operating room. Interventions targeting safety culture, particularly coordination and communication, seem to be important for quality improvement.

The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity.

OBJECTIVE: To evaluate the comparative effectiveness of sleeve gastrectomy (SG), laparoscopic gastric bypass (RYGB), and laparoscopic adjustable gastric banding (LAGB) procedures. BACKGROUND: Citing limitations of published studies, payers have been reluctant to provide routine coverage for SG for the treatment of morbid obesity. METHODS: Using data from an externally audited, statewide clinical registry, we matched 2949 SG patients with equal numbers of RYGB and LAGB patients on 23 baseline characteristics. Outcomes assessed included complications occurring within 30 days, and weight loss, quality of life, and comorbidity remission at 1, 2, and 3 years after bariatric surgery. RESULTS: Matching resulted in cohorts of SG, RYGB, and LAGB patients that were well balanced on baseline characteristics. Overall complication rates among patients undergoing SG (6.3%) were significantly lower than for RYGB (10.0%, P < 0.0001) but higher than for LAGB (2.4%, P < 0.0001). Serious complication rates were similar for SG (2.4%) and RYGB (2.5%, P = 0.736) but higher than for LAGB (1.0%, P < 0.0001). Excess body weight loss at 1 year was 13% lower for SG (60%) than for RYGB (69%, P < 0.0001), but was 77% higher for SG than for LAGB (34%, P < 0.0001). SG was similarly closer to RYGB than LAGB with regard to remission of obesity-related comorbidities. CONCLUSIONS: With better weight loss than LAGB and lower complication rates than RYGB, SG is a reasonable choice for the treatment of morbid obesity and should be covered by both public and private payers.

An analysis of enhanced recovery pathways for bariatric surgery-preoperative fasting, carbohydrate loading, and aspiration risk: a position statement from the International Society for the Perioperative Care of Patients with Obesity.

Enhanced recovery pathways (ERPs) and recommendations have become widely accepted for metabolic and bariatric surgery, including recommendations for preoperative carbohydrate loading and duration of fasting status. There is still a lack of consensus regarding such protocols and the underlying issues of gastric emptying time, resting gastric volume and pH, and risk of aspiration in patients with severe obesity and in patients undergoing bariatric surgery. The goal of this position statement by the International Society for the Perioperative Care of Patients with Obesity (ISPCOP) is to provide an analysis of available data on preoperative fasting and loading with oral complex clear carbohydrate drinks as well its potential effects on perioperative risk of aspiration in the context of Enhanced Recovery Pathways for Metabolic and Bariatric Surgery (ERAMBS).

One- versus two-stage conversions of adjustable gastric bands: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database.

BACKGROUND: Laparoscopic adjustable gastric bands (AGB) are converted at high rates to secondary bariatric procedures. The available literature on the safety of converting in 1- versus 2-stage processes has not included large databases. OBJECTIVE: To evaluate the safety of a 1- versus 2-stage conversion of AGB. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), United States. METHODS: The MBSAQIP database for the years 2020 and 2021 was evaluated. One-stage AGB conversions were identified using Current Procedural Terminology codes and database variables. Multivariable analysis was performed to determine whether 1- or 2-stage conversions were associated with 30-day serious complications. RESULTS: There were 12,085 patients who underwent conversion from previous AGB to sleeve gastrectomy (SG) (63.0%) or Roux-en-Y gastric bypass (RYGB) (37.0%), of whom 41.0% underwent conversion in 1 stage and 59.0% in 2 stages. Patients who underwent 2-stage conversions had higher body mass indexes. Rates of serious complications were higher for patients undergoing RYGB compared with SG (5.2% versus 3.3%, P < .001) but were similar between 1-stage and 2-stage conversions in both cohorts. In both cohorts, there were similar rates of anastomotic leaks, postoperative bleeding, reoperation, and readmissions. Mortality was rare and similar between conversion groups. CONCLUSIONS: There was no difference in outcomes or complications in 30 days between 1- and 2-stage conversions of AGB to RYGB or SG. Conversions to RYGB have higher complication and mortality rates than to SG, but there was no statistically significant difference between staged procedures. One- and 2-stage conversions from AGB are equivalent in safety.

Benefits of Adjuvant Medical Weight Loss Intervention in Setting of Weight Regain and Inadequate Weight Loss After Weight Loss Surgery.

BACKGROUND: Currently, there is no nationally accepted protocol for addressing weight regain or inadequate weight loss after MBS. OBJECTIVES: To devise, implement, and evaluate a protocol targeting weight regain or inadequate weight loss in MBS patients at our institution. SETTING: Vanderbilt University Medical Center, Nashville, TN, United States. METHODS: Patients at least 6 months following primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) who achieved or were trending toward <50% excess body weight loss or who regained ≥10% of their lowest postoperative weight, were identified and referred for medical weight loss (MWL) intervention. Exclusion criteria were body mass index (BMI) ≤ 27 kg/m2, treatment with adjustable gastric banding, and conversion from SG to RYGB. RESULTS: 2274 patients who were >6 months out from surgery were evaluated over 12 months. 93 patients (86% female) met criteria for inclusion. 69 (74%) patients agreed to intervention and were followed for an average of 165 days (SD 106.89 days), demonstrating a mean weight change of -5.11 kg (SD 6.86 kg), and BMI change of -1.81 kg/m2 (SD 2.37 kg/m2). Patients who spent <90 days in a MWL program demonstrated less average weight loss (1.75 kg vs 6.48 kg) (P = .0042), and less change in BMI (-.63 kg/m2 vs -2.29 kg/m2) (P = .0037) when compared to patients who spent >90 days in the MWL intervention. CONCLUSIONS: This study identifies criteria for intervention in patients suffering weight regain or inadequate weight loss after MBS and demonstrates that standardized identification and referral for treatment results in modest weight loss.

Combination anti-obesity medications to effectively treat bariatric surgery weight regain at an academic obesity center.

Background: Combination anti-obesity medications (AOMs) to treat postoperative bariatric surgery weight regain have limited data on their use in the clinical setting. Understanding the optimal treatment protocol in this cohort will maximize weight loss outcomes. Methods: A retrospective review of bariatric surgery patients (N = 44) presenting with weight regain at a single academic multidisciplinary obesity center who were prescribed AOM(s) plus intensive lifestyle modification for 12 months. Results: Age: 28-76 years old, 93% female, mean weight 110.2 ± 20.3 kg, BMI 39.7 ± 7.4 kg/m2, presenting 5.2 ± 1.6 years post-bariatric surgery [27 (61.4%), 14 (31.8%), and 3 (6.8%) laparoscopic Roux-en-Y gastric bypass (RYGB), laparoscopic vertical sleeve gastrectomy (VSG), and open RYGB, respectively], with 15.1 ± 11.1 kg mean weight gain from nadir. Mean weight loss after medical intervention at 3-, 6-, and 12-month time points was 4.4 ± 4.6 kg, 7.3 ± 7.0 kg, and 10.7 ± 9.2 kg, respectively. At 12 months, individuals prescribed 3 or more AOMs lost more weight than those prescribed one (-14.5 ± 9.0 kg vs. -4.9 ± 5.7 kg, p < 0.05) irrespective of age, gender, number of comorbidities, initial weight or BMI, type of surgery, or GLP1 use. RYGB patients lost less weight overall (7.4% vs. 14.8% VSG respectively; p < 0.05). Conclusions: Combination AOMs may be needed to achieve optimal weight loss results to treat post-operative weight regain.

Predicting risk for venous thromboembolism with bariatric surgery: results from the Michigan Bariatric Surgery Collaborative.

OBJECTIVE: We sought to identify risk factors for venous thromboembolism (VTE) among patients undergoing bariatric surgery in Michigan. BACKGROUND: VTE remains a major source of morbidity and mortality after bariatric surgery. It is unclear which factors should be used to identify patients at high risk for VTE. METHODS: The Michigan Bariatric Surgery Collaborative maintains a prospective clinical registry of bariatric surgery patients. For this study, we identified all patients undergoing primary bariatric surgery between June 2006 and April 2011 and determined rates of VTE. Potential risk factors for VTE were analyzed using a hierarchical logistic regression model, accounting for clustering of patients within hospitals. Significant risk factors were used to develop a risk calculator for development of VTE after bariatric surgery. RESULTS: Among 27,818 patients who underwent bariatric surgery during the study period, 93 patients (0.33%) experienced a VTE complication, including 51 patents with pulmonary embolism. There were 8 associated deaths. Significant risk factors included previous history of VTE (OR 4.15, CI 2.42-7.08); male gender (OR 2.08, CI 1.36-3.19); operative time more than 3 hours (OR 1.86, CI 1.07-3.24); BMI category (per 10 units) (OR 1.37, CI 1.06-1.75); age category (per 10 years) (OR 1.25, CI 1.03-1.51); and procedure type (reference adjustable gastric band): duodenal switch (OR 9.45, CI 2.50-35.97); open gastric bypass (OR 6.48, CI 2.17-19.41); laparoscopic gastric bypass (OR 3.97, CI 1.77-8.91); and sleeve gastrectomy (OR 3.50, CI 1.30-9.34). Nearly 97% of patients had a predicted VTE risk less than 1%. CONCLUSIONS: In this population-based study, overall VTE rates were low among patients undergoing bariatric surgery. The use of an empirically based risk calculator will allow for the development of a risk-stratified approach to VTE prophylaxis.

American Society for Metabolic and Bariatric Surgery 2020 estimate of metabolic and bariatric procedures performed in the United States.

BACKGROUND: Metabolic and bariatric surgery (MBS), despite being the only effective durable treatment for obesity, remains underused as approximately 1% of all patients who qualify undergo surgery. The American Society for Metabolic and Bariatric Surgery created a Numbers Taskforce to specify annual rate of utilization for obesity treatment interventions and to determine if patients in need are receiving appropriate treatment. OBJECTIVE: The objective of this study was to provide the best estimated number of metabolic and bariatric procedures performed in the United States in 2020. SETTING: United States. METHODS: We reviewed data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP), National Surgical Quality Improvement Program, Bariatric Outcomes Longitudinal Database, and Nationwide Inpatient Sample. In addition, data from industry and state databases were used to estimate activity at nonaccredited centers. Data from 2020 were compared mainly with data from the previous 2 years. RESULTS: Compared with 2019, the total number of MBS performed in 2020 decreased from approximately 256,000 to 199,000. Sleeve gastrectomy continues to be the most common procedure. The gastric bypass procedure trend remained relatively stable, and the gastric band procedure trend continued to decline. The percentage of revision procedures and biliopancreatic diversion with duodenal switch procedures increased slightly. Single-anastomosis duodeno-ileostomy was listed for the first time in 2020. Intragastric balloons placement declined from the previous year. CONCLUSION: There was a 22.5% decrease in MBS volume from 2019 to 2020, which coincided with the COVID-19 pandemic. Sleeve gastrectomy continues to be the dominant procedure, and for the first time, single-anastomosis duodeno-ileostomy is reported in the MBSAQIP database.