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VTE risk after bariatric surgery should be assessed
SEATTLE – Preop thromboelastometry can identify patients who need extra according to a prospective investigation of 40 patients at Conemaugh Memorial Medical Center in Johnstown, Pa.
Enoxaparin 40 mg twice daily just wasn’t enough for people who were hypercoagulable before surgery. The goal of the study was to find the best way to prevent venous thromboembolism (VTE) after weight loss surgery. At present, there’s no consensus on prophylaxis dosing, timing, duration, or even what agent to use for these patients. Conemaugh uses postop enoxaparin, a low-molecular-weight heparin. Among many other options, some hospitals opt for preop dosing with traditional heparin, which is less expensive.
The Conemaugh team turned to thromboelastometry (TEM) to look at the question of VTE risk in bariatric surgery patients. The test gauges coagulation status by measuring elasticity as a small blood sample clots over a few minutes. The investigators found that patients who were hypercoagulable before surgery were likely to be hypercoagulable afterwards. The finding argues for baseline TEM testing to guide postop anticoagulation.
The problem is that bariatric services don’t often have access to TEM equipment, and insurance doesn’t cover the $60 test. In this instance, the Lake Erie College of Osteopathic Medicine in Erie, Pa., had the equipment and covered the testing for the study.
The patients had TEM at baseline and then received 40 mg of enoxaparin about 4 hours after surgery – mostly laparoscopic gastric bypasses – and a second dose about 12 hours after the first. TEM was repeated about 2 hours after the second dose.
At baseline, 2 (5%) of the patients were hypocoagulable, 15 (37.5%) were normal, and 23 (57.5%) were hypercoagulable. On postop TEM, 17 patients (42.5%) were normal and 23 (57.5%) were hypercoagulable: “These 23 were inadequately anticoagulated,” said lead investigator Daniel Urias, MD, a general surgery resident at the medical center.
“There was an association between being normal at baseline and being normal postop, and being hypercoagulable at baseline and hypercoagulable postop. We didn’t anticipate finding such similarity between the numbers. Our suspicion that baseline status plays a major role is holding true,” Dr. Urias said at the World Congress of Endoscopic Surgery hosted by SAGES & CAGS.
When patients test hypercoagulable at baseline, “we are [now] leaning towards [enoxaparin] 60 mg twice daily,” he said.
Ultimately, anticoagulation TEM could be used to titrate patients into the normal range. For best outcomes, it’s likely that “obese patients require goal-directed therapy instead of weight-based or fixed dosing,” he said, but nothing is going to happen until insurance steps up.
The patients did not have underlying coagulopathies, and 33 (82.5%) were women; the average age was 44 years and average body mass index was 43.6 kg/m2. The mean preop Caprini score was 4, indicating moderate VTE risk. Surgery lasted about 200 minutes. Patients were out of bed and walking on postop day 0.
The investigators had no relevant disclosures.
SOURCE: Urias D et al. World Congress of Endoscopic Surgery hosted by SAGES & CAGS abstract S023.
SEATTLE – Preop thromboelastometry can identify patients who need extra according to a prospective investigation of 40 patients at Conemaugh Memorial Medical Center in Johnstown, Pa.
Enoxaparin 40 mg twice daily just wasn’t enough for people who were hypercoagulable before surgery. The goal of the study was to find the best way to prevent venous thromboembolism (VTE) after weight loss surgery. At present, there’s no consensus on prophylaxis dosing, timing, duration, or even what agent to use for these patients. Conemaugh uses postop enoxaparin, a low-molecular-weight heparin. Among many other options, some hospitals opt for preop dosing with traditional heparin, which is less expensive.
The Conemaugh team turned to thromboelastometry (TEM) to look at the question of VTE risk in bariatric surgery patients. The test gauges coagulation status by measuring elasticity as a small blood sample clots over a few minutes. The investigators found that patients who were hypercoagulable before surgery were likely to be hypercoagulable afterwards. The finding argues for baseline TEM testing to guide postop anticoagulation.
The problem is that bariatric services don’t often have access to TEM equipment, and insurance doesn’t cover the $60 test. In this instance, the Lake Erie College of Osteopathic Medicine in Erie, Pa., had the equipment and covered the testing for the study.
The patients had TEM at baseline and then received 40 mg of enoxaparin about 4 hours after surgery – mostly laparoscopic gastric bypasses – and a second dose about 12 hours after the first. TEM was repeated about 2 hours after the second dose.
At baseline, 2 (5%) of the patients were hypocoagulable, 15 (37.5%) were normal, and 23 (57.5%) were hypercoagulable. On postop TEM, 17 patients (42.5%) were normal and 23 (57.5%) were hypercoagulable: “These 23 were inadequately anticoagulated,” said lead investigator Daniel Urias, MD, a general surgery resident at the medical center.
“There was an association between being normal at baseline and being normal postop, and being hypercoagulable at baseline and hypercoagulable postop. We didn’t anticipate finding such similarity between the numbers. Our suspicion that baseline status plays a major role is holding true,” Dr. Urias said at the World Congress of Endoscopic Surgery hosted by SAGES & CAGS.
When patients test hypercoagulable at baseline, “we are [now] leaning towards [enoxaparin] 60 mg twice daily,” he said.
Ultimately, anticoagulation TEM could be used to titrate patients into the normal range. For best outcomes, it’s likely that “obese patients require goal-directed therapy instead of weight-based or fixed dosing,” he said, but nothing is going to happen until insurance steps up.
The patients did not have underlying coagulopathies, and 33 (82.5%) were women; the average age was 44 years and average body mass index was 43.6 kg/m2. The mean preop Caprini score was 4, indicating moderate VTE risk. Surgery lasted about 200 minutes. Patients were out of bed and walking on postop day 0.
The investigators had no relevant disclosures.
SOURCE: Urias D et al. World Congress of Endoscopic Surgery hosted by SAGES & CAGS abstract S023.
SEATTLE – Preop thromboelastometry can identify patients who need extra according to a prospective investigation of 40 patients at Conemaugh Memorial Medical Center in Johnstown, Pa.
Enoxaparin 40 mg twice daily just wasn’t enough for people who were hypercoagulable before surgery. The goal of the study was to find the best way to prevent venous thromboembolism (VTE) after weight loss surgery. At present, there’s no consensus on prophylaxis dosing, timing, duration, or even what agent to use for these patients. Conemaugh uses postop enoxaparin, a low-molecular-weight heparin. Among many other options, some hospitals opt for preop dosing with traditional heparin, which is less expensive.
The Conemaugh team turned to thromboelastometry (TEM) to look at the question of VTE risk in bariatric surgery patients. The test gauges coagulation status by measuring elasticity as a small blood sample clots over a few minutes. The investigators found that patients who were hypercoagulable before surgery were likely to be hypercoagulable afterwards. The finding argues for baseline TEM testing to guide postop anticoagulation.
The problem is that bariatric services don’t often have access to TEM equipment, and insurance doesn’t cover the $60 test. In this instance, the Lake Erie College of Osteopathic Medicine in Erie, Pa., had the equipment and covered the testing for the study.
The patients had TEM at baseline and then received 40 mg of enoxaparin about 4 hours after surgery – mostly laparoscopic gastric bypasses – and a second dose about 12 hours after the first. TEM was repeated about 2 hours after the second dose.
At baseline, 2 (5%) of the patients were hypocoagulable, 15 (37.5%) were normal, and 23 (57.5%) were hypercoagulable. On postop TEM, 17 patients (42.5%) were normal and 23 (57.5%) were hypercoagulable: “These 23 were inadequately anticoagulated,” said lead investigator Daniel Urias, MD, a general surgery resident at the medical center.
“There was an association between being normal at baseline and being normal postop, and being hypercoagulable at baseline and hypercoagulable postop. We didn’t anticipate finding such similarity between the numbers. Our suspicion that baseline status plays a major role is holding true,” Dr. Urias said at the World Congress of Endoscopic Surgery hosted by SAGES & CAGS.
When patients test hypercoagulable at baseline, “we are [now] leaning towards [enoxaparin] 60 mg twice daily,” he said.
Ultimately, anticoagulation TEM could be used to titrate patients into the normal range. For best outcomes, it’s likely that “obese patients require goal-directed therapy instead of weight-based or fixed dosing,” he said, but nothing is going to happen until insurance steps up.
The patients did not have underlying coagulopathies, and 33 (82.5%) were women; the average age was 44 years and average body mass index was 43.6 kg/m2. The mean preop Caprini score was 4, indicating moderate VTE risk. Surgery lasted about 200 minutes. Patients were out of bed and walking on postop day 0.
The investigators had no relevant disclosures.
SOURCE: Urias D et al. World Congress of Endoscopic Surgery hosted by SAGES & CAGS abstract S023.
REPORTING FROM SAGES 2018
Key clinical point: Preoperative thromboelastometry identifies patients who need extra anticoagulation against venous thromboembolism following bariatric surgery.
Major finding: Baseline and postop coagulation were similar: 37.5% vs. 42.5% were normal and 57.5% vs 57.5% were hypercoagulable.
Study details: Prospective study of 40 bariatric surgery patients.
Disclosures: The investigators did not have any relevant disclosures. The Lake Erie College of Osteopathic Medicine paid for the testing.
Source: Urias D et al. World Congress of Endoscopic Surgery hosted by SAGES & CAGS abstract S023.
PVT after sleeve gastrectomy treatable with anticoagulants
can be effectively treated with extended postoperative anticoagulation therapy, findings from a large-scale, retrospective study indicate.
The research was conducted using data from medical records of created by physicians from five Australian bariatric centers, reported Stephanie Bee Ming Tan, MBBS, of the Gold Coast University Hospital, Queensland, Australia, and her associates in the journal Surgery for Obesity and Related Diseases. Following elective laparoscopic sleeve gastrectomy (LSG), a total of 18 (0.3%) of the 5,951 obese patients were diagnosed with portomesenteric vein thrombosis (PVT). The PVT-affected population was a mean age of 44 years and 61% were women. All of these patients had at least one venous thrombosis systematic predisposition factor such as morbid obesity (50%), smoking (50%), or a personal or family history of a clotting disorder (39%).
All study patients were given thromboprophylaxis of low-molecular-weight heparin (LMWH) or unfractionated heparin plus mechanical thromboprophylaxis during admission for LSG and at discharge when surgeons identified them as high risk.
PVT following LSG can be difficult to diagnose because presenting symptoms tend to be nonspecific. Within an average of 13 days following surgery, 77% of patients diagnosed with PVT reported abdominal pain, 33% reported nausea and vomiting, and also reported less common symptoms that included shoulder tip pain, problems in tolerating fluids, constipation, and diarrhea. Final diagnosis of PVT was determined with independent or a combination of CT and duplex ultrasound.
Complications from PVT can have serious consequences, including abdominal swelling from fluid accumulation, enlarged esophageal veins, terminal esophageal bleeding, and bowel infarction. As with admission thromboprophylaxis treatments, patients diagnosed with PVT received varied anticoagulation treatments with most, in equal numbers, receiving either LMWH or a heparin infusion, and the remaining 12% receiving anticoagulation with rivaroxaban and warfarin. Adjustments were made following initial treatments such that 37% and 66% of patients continued with longer-term therapy on LMWH or warfarin, respectively. Treatments generally lasted 3-6 months with only 11% continuing on warfarin because of a history of clotting disorder. The anticoagulation treatments were successful with the majority (94%) of patients with only one patient requiring surgical intervention.
Follow-up with the patients who had a PVT diagnosis of more than 6 months (with an average of 10 months) showed the overall success of the post-LSG anticoagulation and surgical therapies, without any mortalities.
The authors summarized earlier theories about confounding health conditions that may contribute to the development of PVT and the risks for PVT linked to laparoscopic surgery. In this retrospective study, they noted that PVT incidence following LSG was low at 0.3% but was still higher than with two other bariatric operative methods and suggested intraoperative and postoperative factors that could contribute to this difference. Because of the nonspecific early symptoms and the difficulty of diagnosing PVT, the investigators recommended that physicians be vigilant for this postoperative complication in LSG patients, and use “cross-sectional imagining with CT of the abdomen” for diagnosis. Furthermore, with diagnosed PVT “anticoagulation for 3 to 6 months with a target international normalized ratio of 2:3 is recommended unless the patient has additional risk factors and [is] therefore indicated for longer treatment.”
The authors reported that they had no conflicts of interest.
SOURCE: Tan SBM et al. Surg Obes Relat Dis. 2018 Mar;14:271-6.
can be effectively treated with extended postoperative anticoagulation therapy, findings from a large-scale, retrospective study indicate.
The research was conducted using data from medical records of created by physicians from five Australian bariatric centers, reported Stephanie Bee Ming Tan, MBBS, of the Gold Coast University Hospital, Queensland, Australia, and her associates in the journal Surgery for Obesity and Related Diseases. Following elective laparoscopic sleeve gastrectomy (LSG), a total of 18 (0.3%) of the 5,951 obese patients were diagnosed with portomesenteric vein thrombosis (PVT). The PVT-affected population was a mean age of 44 years and 61% were women. All of these patients had at least one venous thrombosis systematic predisposition factor such as morbid obesity (50%), smoking (50%), or a personal or family history of a clotting disorder (39%).
All study patients were given thromboprophylaxis of low-molecular-weight heparin (LMWH) or unfractionated heparin plus mechanical thromboprophylaxis during admission for LSG and at discharge when surgeons identified them as high risk.
PVT following LSG can be difficult to diagnose because presenting symptoms tend to be nonspecific. Within an average of 13 days following surgery, 77% of patients diagnosed with PVT reported abdominal pain, 33% reported nausea and vomiting, and also reported less common symptoms that included shoulder tip pain, problems in tolerating fluids, constipation, and diarrhea. Final diagnosis of PVT was determined with independent or a combination of CT and duplex ultrasound.
Complications from PVT can have serious consequences, including abdominal swelling from fluid accumulation, enlarged esophageal veins, terminal esophageal bleeding, and bowel infarction. As with admission thromboprophylaxis treatments, patients diagnosed with PVT received varied anticoagulation treatments with most, in equal numbers, receiving either LMWH or a heparin infusion, and the remaining 12% receiving anticoagulation with rivaroxaban and warfarin. Adjustments were made following initial treatments such that 37% and 66% of patients continued with longer-term therapy on LMWH or warfarin, respectively. Treatments generally lasted 3-6 months with only 11% continuing on warfarin because of a history of clotting disorder. The anticoagulation treatments were successful with the majority (94%) of patients with only one patient requiring surgical intervention.
Follow-up with the patients who had a PVT diagnosis of more than 6 months (with an average of 10 months) showed the overall success of the post-LSG anticoagulation and surgical therapies, without any mortalities.
The authors summarized earlier theories about confounding health conditions that may contribute to the development of PVT and the risks for PVT linked to laparoscopic surgery. In this retrospective study, they noted that PVT incidence following LSG was low at 0.3% but was still higher than with two other bariatric operative methods and suggested intraoperative and postoperative factors that could contribute to this difference. Because of the nonspecific early symptoms and the difficulty of diagnosing PVT, the investigators recommended that physicians be vigilant for this postoperative complication in LSG patients, and use “cross-sectional imagining with CT of the abdomen” for diagnosis. Furthermore, with diagnosed PVT “anticoagulation for 3 to 6 months with a target international normalized ratio of 2:3 is recommended unless the patient has additional risk factors and [is] therefore indicated for longer treatment.”
The authors reported that they had no conflicts of interest.
SOURCE: Tan SBM et al. Surg Obes Relat Dis. 2018 Mar;14:271-6.
can be effectively treated with extended postoperative anticoagulation therapy, findings from a large-scale, retrospective study indicate.
The research was conducted using data from medical records of created by physicians from five Australian bariatric centers, reported Stephanie Bee Ming Tan, MBBS, of the Gold Coast University Hospital, Queensland, Australia, and her associates in the journal Surgery for Obesity and Related Diseases. Following elective laparoscopic sleeve gastrectomy (LSG), a total of 18 (0.3%) of the 5,951 obese patients were diagnosed with portomesenteric vein thrombosis (PVT). The PVT-affected population was a mean age of 44 years and 61% were women. All of these patients had at least one venous thrombosis systematic predisposition factor such as morbid obesity (50%), smoking (50%), or a personal or family history of a clotting disorder (39%).
All study patients were given thromboprophylaxis of low-molecular-weight heparin (LMWH) or unfractionated heparin plus mechanical thromboprophylaxis during admission for LSG and at discharge when surgeons identified them as high risk.
PVT following LSG can be difficult to diagnose because presenting symptoms tend to be nonspecific. Within an average of 13 days following surgery, 77% of patients diagnosed with PVT reported abdominal pain, 33% reported nausea and vomiting, and also reported less common symptoms that included shoulder tip pain, problems in tolerating fluids, constipation, and diarrhea. Final diagnosis of PVT was determined with independent or a combination of CT and duplex ultrasound.
Complications from PVT can have serious consequences, including abdominal swelling from fluid accumulation, enlarged esophageal veins, terminal esophageal bleeding, and bowel infarction. As with admission thromboprophylaxis treatments, patients diagnosed with PVT received varied anticoagulation treatments with most, in equal numbers, receiving either LMWH or a heparin infusion, and the remaining 12% receiving anticoagulation with rivaroxaban and warfarin. Adjustments were made following initial treatments such that 37% and 66% of patients continued with longer-term therapy on LMWH or warfarin, respectively. Treatments generally lasted 3-6 months with only 11% continuing on warfarin because of a history of clotting disorder. The anticoagulation treatments were successful with the majority (94%) of patients with only one patient requiring surgical intervention.
Follow-up with the patients who had a PVT diagnosis of more than 6 months (with an average of 10 months) showed the overall success of the post-LSG anticoagulation and surgical therapies, without any mortalities.
The authors summarized earlier theories about confounding health conditions that may contribute to the development of PVT and the risks for PVT linked to laparoscopic surgery. In this retrospective study, they noted that PVT incidence following LSG was low at 0.3% but was still higher than with two other bariatric operative methods and suggested intraoperative and postoperative factors that could contribute to this difference. Because of the nonspecific early symptoms and the difficulty of diagnosing PVT, the investigators recommended that physicians be vigilant for this postoperative complication in LSG patients, and use “cross-sectional imagining with CT of the abdomen” for diagnosis. Furthermore, with diagnosed PVT “anticoagulation for 3 to 6 months with a target international normalized ratio of 2:3 is recommended unless the patient has additional risk factors and [is] therefore indicated for longer treatment.”
The authors reported that they had no conflicts of interest.
SOURCE: Tan SBM et al. Surg Obes Relat Dis. 2018 Mar;14:271-6.
FROM SURGERY FOR OBESITY AND RELATED DISEASES
Key clinical point: Anticoagulation treatments effectively managed most portomesenteric vein thrombosis cases following laparoscopic sleeve gastrectomy.
Major finding: PVT is rare (0.3%) but occurs more frequently with laparoscopic sleeve gastrectomy, compared with other bariatric surgery procedures.
Study details: A multicenter, retrospective study conducted in Australia from 2007 to 2016 with 5,951 adult obese patients who received elective laparoscopic sleeve gastrectomy.
Disclosures: The authors reported no conflicts of interest.
Source: Tan SBM et al. Surg Obes Relat Dis. Mar 2018;14:271-6.
VIDEO: Intestinal remodeling contributes to HbA1c drop after Roux-en-Y gastric bypass
CHICAGO – Of medical and surgical tactics to tackle long-term weight loss, , and gene expression in the Roux limb may hold the key to the surgery’s efficacy, according to an ongoing study.
“We know that Roux-en-Y gastric bypass surgery is highly effective as not only a weight-loss therapy, but more and more we’re appreciating its role as a diabetes therapy as well,” said Margaret Stefater, MD, PhD, speaking in an interview at the annual meeting of the Endocrine Society.
The study, she said, was designed to learn more about the intestine’s contribution to the salubrious effect that Roux-en-Y surgery has on diabetes.
“We used microarray in order to characterize gene expression in the intestine” to gain a broad understanding of the processes that are altered after surgery, said Dr. Stefater, a pediatric endocrinology fellow at Boston Children’s Hospital. More specifically, though, the study looked at an individual’s changes in gene expression over time and correlated those changes with that patient’s clinical picture.
The data reported by Dr. Stefater and shared in a press conference, represent part of an ongoing longitudinal prospective study of 32 patients.
“The study aims to characterize gene expression for the first postoperative year,” and findings from the first 6 postoperative months of 19 patients were shared at the meeting, said Dr. Stefater. “This is the first look at our cohort.”
So far, she and her colleagues have compared gene expression using microarray at 1 month and 6 months post-surgery, comparing change across time and change from baseline data.
From hundreds of candidate genes, Dr. Stefater and her colleagues have developed a smaller gene list that, even in the first postoperative month, is predictive of changes in hemoglobin A1c levels over time. “Remarkably, the changes in a select list of genes out to 1 month is actually able to predict hemoglobin A1c levels out to 1 year,” she said. “This speaks to the fact that biological reprogramming in the intestine is somehow related to glycemic response in patients.
“We hope that by understanding these processes, we can home in on those processes that are most likely to be mechanistically responsible for these changes, and then to reverse-engineer this surgery to identify processes or targets which may be good places to start when we think about creating better, or nonsurgical, therapies for people who have obesity and diabetes,” said Dr. Stefater.
Dr. Stefater reported no relevant financial disclosures.
SOURCE: Stefater MA et al. ENDO 2018, Abstract OR 12-6.
CHICAGO – Of medical and surgical tactics to tackle long-term weight loss, , and gene expression in the Roux limb may hold the key to the surgery’s efficacy, according to an ongoing study.
“We know that Roux-en-Y gastric bypass surgery is highly effective as not only a weight-loss therapy, but more and more we’re appreciating its role as a diabetes therapy as well,” said Margaret Stefater, MD, PhD, speaking in an interview at the annual meeting of the Endocrine Society.
The study, she said, was designed to learn more about the intestine’s contribution to the salubrious effect that Roux-en-Y surgery has on diabetes.
“We used microarray in order to characterize gene expression in the intestine” to gain a broad understanding of the processes that are altered after surgery, said Dr. Stefater, a pediatric endocrinology fellow at Boston Children’s Hospital. More specifically, though, the study looked at an individual’s changes in gene expression over time and correlated those changes with that patient’s clinical picture.
The data reported by Dr. Stefater and shared in a press conference, represent part of an ongoing longitudinal prospective study of 32 patients.
“The study aims to characterize gene expression for the first postoperative year,” and findings from the first 6 postoperative months of 19 patients were shared at the meeting, said Dr. Stefater. “This is the first look at our cohort.”
So far, she and her colleagues have compared gene expression using microarray at 1 month and 6 months post-surgery, comparing change across time and change from baseline data.
From hundreds of candidate genes, Dr. Stefater and her colleagues have developed a smaller gene list that, even in the first postoperative month, is predictive of changes in hemoglobin A1c levels over time. “Remarkably, the changes in a select list of genes out to 1 month is actually able to predict hemoglobin A1c levels out to 1 year,” she said. “This speaks to the fact that biological reprogramming in the intestine is somehow related to glycemic response in patients.
“We hope that by understanding these processes, we can home in on those processes that are most likely to be mechanistically responsible for these changes, and then to reverse-engineer this surgery to identify processes or targets which may be good places to start when we think about creating better, or nonsurgical, therapies for people who have obesity and diabetes,” said Dr. Stefater.
Dr. Stefater reported no relevant financial disclosures.
SOURCE: Stefater MA et al. ENDO 2018, Abstract OR 12-6.
CHICAGO – Of medical and surgical tactics to tackle long-term weight loss, , and gene expression in the Roux limb may hold the key to the surgery’s efficacy, according to an ongoing study.
“We know that Roux-en-Y gastric bypass surgery is highly effective as not only a weight-loss therapy, but more and more we’re appreciating its role as a diabetes therapy as well,” said Margaret Stefater, MD, PhD, speaking in an interview at the annual meeting of the Endocrine Society.
The study, she said, was designed to learn more about the intestine’s contribution to the salubrious effect that Roux-en-Y surgery has on diabetes.
“We used microarray in order to characterize gene expression in the intestine” to gain a broad understanding of the processes that are altered after surgery, said Dr. Stefater, a pediatric endocrinology fellow at Boston Children’s Hospital. More specifically, though, the study looked at an individual’s changes in gene expression over time and correlated those changes with that patient’s clinical picture.
The data reported by Dr. Stefater and shared in a press conference, represent part of an ongoing longitudinal prospective study of 32 patients.
“The study aims to characterize gene expression for the first postoperative year,” and findings from the first 6 postoperative months of 19 patients were shared at the meeting, said Dr. Stefater. “This is the first look at our cohort.”
So far, she and her colleagues have compared gene expression using microarray at 1 month and 6 months post-surgery, comparing change across time and change from baseline data.
From hundreds of candidate genes, Dr. Stefater and her colleagues have developed a smaller gene list that, even in the first postoperative month, is predictive of changes in hemoglobin A1c levels over time. “Remarkably, the changes in a select list of genes out to 1 month is actually able to predict hemoglobin A1c levels out to 1 year,” she said. “This speaks to the fact that biological reprogramming in the intestine is somehow related to glycemic response in patients.
“We hope that by understanding these processes, we can home in on those processes that are most likely to be mechanistically responsible for these changes, and then to reverse-engineer this surgery to identify processes or targets which may be good places to start when we think about creating better, or nonsurgical, therapies for people who have obesity and diabetes,” said Dr. Stefater.
Dr. Stefater reported no relevant financial disclosures.
SOURCE: Stefater MA et al. ENDO 2018, Abstract OR 12-6.
REPORTING FROM ENDO 2018
VIDEO: It is an exciting time in obesity treatment
BOSTON – For those in obesity treatment, things are looking up, said Reem Z. Sharaiha, MD, MSc, in a video interview at the AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology. There are several new therapies to choose from, said Dr. Sharaiha, assistant professor of medicine at Cornell University, New York – and a variety of therapies coming down the pipeline. The key is to choose the right treatment, or right combination of treatments – surgical, endoscopic, or medical – for the right patient at the right time and to follow up. Obesity is a chronic disease that needs long-term, team treatment. With obesity treatments there is sometimes a trade-off between risk and results, but the innovations coming along may balance that risk-results equation for some patients, she said.
BOSTON – For those in obesity treatment, things are looking up, said Reem Z. Sharaiha, MD, MSc, in a video interview at the AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology. There are several new therapies to choose from, said Dr. Sharaiha, assistant professor of medicine at Cornell University, New York – and a variety of therapies coming down the pipeline. The key is to choose the right treatment, or right combination of treatments – surgical, endoscopic, or medical – for the right patient at the right time and to follow up. Obesity is a chronic disease that needs long-term, team treatment. With obesity treatments there is sometimes a trade-off between risk and results, but the innovations coming along may balance that risk-results equation for some patients, she said.
BOSTON – For those in obesity treatment, things are looking up, said Reem Z. Sharaiha, MD, MSc, in a video interview at the AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology. There are several new therapies to choose from, said Dr. Sharaiha, assistant professor of medicine at Cornell University, New York – and a variety of therapies coming down the pipeline. The key is to choose the right treatment, or right combination of treatments – surgical, endoscopic, or medical – for the right patient at the right time and to follow up. Obesity is a chronic disease that needs long-term, team treatment. With obesity treatments there is sometimes a trade-off between risk and results, but the innovations coming along may balance that risk-results equation for some patients, she said.
REPORTING FROM 2018 AGA TECH SUMMIT
Pre–bariatric surgery weight loss improves outcomes
Preoperative weight loss improves bariatric surgery outcomes, according to findings from a single-institution retrospective analysis. The weight loss came from following a 4-week low-calorie diet (LCD) and was of greatest benefit to patients who lost 8% or more of their excess weight. These patients had a greater loss of excess weight in the 12 months following surgery, as well as shorter average hospital length of stay.
Preliminary studies indicated that short-term weight loss before surgery might reduce surgical complexity by reducing the size of the liver and intra-abdominal fat mass, but it remained uncertain what effect weight loss might have on long-term outcomes.
The LCD included 1,200 kcal/day (45% carbohydrates, 35% protein, 20% fat), which were consumed through five meal-replacement products and one food-based meal. Liquids included at least 80 ounces of calorie-free, caffeine-free, carbonation-free beverages per day. Patients were also instructed to conduct 30 minutes of moderate to vigorous activity per day.
Deborah A. Hutcheon, DCN, and her fellow researchers analyzed data from their own institution, where a presurgical 4-week LCD with a target loss of 8% or more of excess weight had been standard policy already. The population included 355 patients who underwent sleeve gastrectomy (n = 167) or Roux-en-Y gastric bypass (n = 188) between January 2014 and January 2016.
Almost two-thirds (63.3%) of patients achieved the target weight loss before surgery. There were some differences between the two groups. The group that achieved the target contained a greater proportion of men than did the other group (25.5% vs. 13.7%, respectively; P = .013), a higher proportion of white patients (84.8% vs. 74.1%; P = .011), and a higher proportion of patients taking antihypertensive medications (68.3% vs. 57.3%; P = .048). The two groups had similar rates of preoperative comorbidities and surgery types.
Those who achieved the target weight loss had a shorter hospital length of stay (1.8 days vs. 2.1 days; P = .006). They also had a higher percentage loss of excess weight at 3 months (42.3% vs. 36.1%; P less than .001), 6 months (56.0% vs. 47.5%; P less than .001), and at 12 months (65.1% vs. 55.7%; P = .003).
After controlling for patient characteristics, insurance status, 12-month diet compliance, and surgery type, successful presurgery weight loss was associated with greater weight loss at 12 months.
SOURCE: Hutcheon DA et al. J Am Coll Surgeons. 2018 Jan 31. doi: 10.1016/j.jamcollsurg.2017.12.032.
Preoperative weight loss improves bariatric surgery outcomes, according to findings from a single-institution retrospective analysis. The weight loss came from following a 4-week low-calorie diet (LCD) and was of greatest benefit to patients who lost 8% or more of their excess weight. These patients had a greater loss of excess weight in the 12 months following surgery, as well as shorter average hospital length of stay.
Preliminary studies indicated that short-term weight loss before surgery might reduce surgical complexity by reducing the size of the liver and intra-abdominal fat mass, but it remained uncertain what effect weight loss might have on long-term outcomes.
The LCD included 1,200 kcal/day (45% carbohydrates, 35% protein, 20% fat), which were consumed through five meal-replacement products and one food-based meal. Liquids included at least 80 ounces of calorie-free, caffeine-free, carbonation-free beverages per day. Patients were also instructed to conduct 30 minutes of moderate to vigorous activity per day.
Deborah A. Hutcheon, DCN, and her fellow researchers analyzed data from their own institution, where a presurgical 4-week LCD with a target loss of 8% or more of excess weight had been standard policy already. The population included 355 patients who underwent sleeve gastrectomy (n = 167) or Roux-en-Y gastric bypass (n = 188) between January 2014 and January 2016.
Almost two-thirds (63.3%) of patients achieved the target weight loss before surgery. There were some differences between the two groups. The group that achieved the target contained a greater proportion of men than did the other group (25.5% vs. 13.7%, respectively; P = .013), a higher proportion of white patients (84.8% vs. 74.1%; P = .011), and a higher proportion of patients taking antihypertensive medications (68.3% vs. 57.3%; P = .048). The two groups had similar rates of preoperative comorbidities and surgery types.
Those who achieved the target weight loss had a shorter hospital length of stay (1.8 days vs. 2.1 days; P = .006). They also had a higher percentage loss of excess weight at 3 months (42.3% vs. 36.1%; P less than .001), 6 months (56.0% vs. 47.5%; P less than .001), and at 12 months (65.1% vs. 55.7%; P = .003).
After controlling for patient characteristics, insurance status, 12-month diet compliance, and surgery type, successful presurgery weight loss was associated with greater weight loss at 12 months.
SOURCE: Hutcheon DA et al. J Am Coll Surgeons. 2018 Jan 31. doi: 10.1016/j.jamcollsurg.2017.12.032.
Preoperative weight loss improves bariatric surgery outcomes, according to findings from a single-institution retrospective analysis. The weight loss came from following a 4-week low-calorie diet (LCD) and was of greatest benefit to patients who lost 8% or more of their excess weight. These patients had a greater loss of excess weight in the 12 months following surgery, as well as shorter average hospital length of stay.
Preliminary studies indicated that short-term weight loss before surgery might reduce surgical complexity by reducing the size of the liver and intra-abdominal fat mass, but it remained uncertain what effect weight loss might have on long-term outcomes.
The LCD included 1,200 kcal/day (45% carbohydrates, 35% protein, 20% fat), which were consumed through five meal-replacement products and one food-based meal. Liquids included at least 80 ounces of calorie-free, caffeine-free, carbonation-free beverages per day. Patients were also instructed to conduct 30 minutes of moderate to vigorous activity per day.
Deborah A. Hutcheon, DCN, and her fellow researchers analyzed data from their own institution, where a presurgical 4-week LCD with a target loss of 8% or more of excess weight had been standard policy already. The population included 355 patients who underwent sleeve gastrectomy (n = 167) or Roux-en-Y gastric bypass (n = 188) between January 2014 and January 2016.
Almost two-thirds (63.3%) of patients achieved the target weight loss before surgery. There were some differences between the two groups. The group that achieved the target contained a greater proportion of men than did the other group (25.5% vs. 13.7%, respectively; P = .013), a higher proportion of white patients (84.8% vs. 74.1%; P = .011), and a higher proportion of patients taking antihypertensive medications (68.3% vs. 57.3%; P = .048). The two groups had similar rates of preoperative comorbidities and surgery types.
Those who achieved the target weight loss had a shorter hospital length of stay (1.8 days vs. 2.1 days; P = .006). They also had a higher percentage loss of excess weight at 3 months (42.3% vs. 36.1%; P less than .001), 6 months (56.0% vs. 47.5%; P less than .001), and at 12 months (65.1% vs. 55.7%; P = .003).
After controlling for patient characteristics, insurance status, 12-month diet compliance, and surgery type, successful presurgery weight loss was associated with greater weight loss at 12 months.
SOURCE: Hutcheon DA et al. J Am Coll Surgeons. 2018 Jan 31. doi: 10.1016/j.jamcollsurg.2017.12.032.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
Key clinical point: Weight loss before bariatric surgery boosts results.
Major finding: Patients who lost at least 8% of excess body weight had an average of 65.1% loss of excess weight at 12 months, compared with the 55.7% seen in those who did not.
Data source: Retrospective, single-center analysis (n = 355).
Disclosures: No source of funding was disclosed.
Source: Hutcheon DA et al. J Am Coll Surgeons. 2018 Jan 31. doi: 10.1016/j.jamcollsurg.2017.12.032.
Morbid, super obesity raises laparoscopic VHR risk
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
JACKSONVILLE, FLA. – Super-obese patients who have laparoscopic repair for ventral hernias have complications at a rate more than twice that for overweight individuals undergoing the same operation, according to an analysis of 10-year data presented at the Association for Academic Surgery/Society of University Surgeons Academic Surgical Congress.
“Patients with a body mass index of 40 kg/m2 or greater were found to be significantly more likely to have a complication following laparoscopic ventral hernia repair,” said Robert A. Swendiman, MD, of the University of Pennsylvania, Philadelphia.
Dr. Swendiman and his colleagues analyzed outcomes of 57,957 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who had laparoscopic ventral hernia repair (VHR) from 2005 to 2015. The dataset was stratified into seven different BMI classes, and by hernia type (reducible or strangulated) and time of repair (initial or recurrent).
The overall complication rate for the study population was 4%, ranging from 3% in overweight patients (BMI of 25-29.99 kg/m2) to 6.9% for the super obese (BMI of 50 kg/m2 or greater); 61.4% of the study population was obese. “Initial repair and reducible hernias had lower complication rates than recurrent and incarcerated/strangulated hernias,” Dr. Swendiman said. The study considered 1 of 19 different complications within 30 days of the operation.
Three weight groups had the highest odds ratios (OR) for complications: underweight patients (less than 18.5 kg/m2, OR 1.46, P = .283); morbidly obese (40-50 kg/m2, OR 1.28, P = .014); and super obese (greater than or equal to 50 kg/m2, OR 1.76, P = less than .0001). However, Dr. Swendiman noted, “Overweight patients had a lower rate of overall complications compared to normal-weight individuals.”
These findings were consistent with a prior analysis the group did that found patients with BMI greater than 30 kg/m2 was associated with increased risk of complications after open VHR, Dr. Swendiman noted (Surgery. 2017;162[6]:1320-9).
“Future studies should be considered to evaluate the role of weight reduction prior to hernia repair as a method to reduce patient risk,” Dr. Swendiman said. Laparoscopic repair may be preferable to open VHR in obese patients, depending on the clinical context, he said.
Dr. Swendiman and coauthors reported having no financial disclosures.
SOURCE: Academic Surgical Congress. Abstract 50.02.
REPORTING FROM THE ANNUAL ACADEMIC SURGICAL CONGRESS
Key clinical point: Laparoscopic ventral hernia repair is associated with a significantly increased risk of complications in the morbidly and super obese.
Major finding: Individuals with a body mass index in the overweight range (BMI 25 to 29.99 kg/m2) had a complication rate of 3% vs. 6.9% for those with BMI greater than or equal to 50 kg/m2.
Story details: A retrospective analysis of 57,957 patients in the NSQIP database who had laparoscopic ventral hernia repair between 2005 and 2015.
Disclosures: Dr. Swendiman and coauthors reported having no financial disclosures.
Source: Academic Surgical Congress. Abstract 50.02.
Sleeve gastrectomy studied as an option for obese HIV-infected patients
according to the results of a small prospective trial conducted from 2009 to 2015 at a single institution in France.
Ten patients were followed before and after sleeve gastrectomy. Eight were women and half were of African origin. The median patient age was 48.5 years, and the median time since HIV infection was 7.5 years. Patients had a median body mass index of 48.5 kg/m2 at the time of their procedure, according to Guillaume Pourcher, MD, PhD, of Paris-Sud University and his colleagues.
The median postoperative weight loss was 43 kg, while the median percentage of excess weight loss was 82.5% at the latest follow-up. In addition, all comorbidities were resolved with weight loss. With regard to HIV status, there was no significant modification of the CD4 cell count in the patients before and after surgery. Importantly, the pharmacokinetics of the patients’ antiretroviral drugs remained “adequate and efficacious,” according to Dr. Pourcher and his colleagues.
“For HIV-infected patients,we need to choose a safe procedure, with no disruption of intestinal continuity, without implanted foreign material, resulting in less malabsorption, and with long-term weight loss efficacy,” the authors stated.
Taking this into account, optimal management of HIV-infected patients with morbid obesity may include classical surgical procedures such as sleeve gastrectomy as with non-HIV obese patients, as long as close drug monitoring and immunovirologic follow-up are maintained, they suggested.
Sleeve gastrectomy “appears to be a good therapeutic option in morbidly obese HIV-infected patients, because it avoids malabsorption and possible modification of antiretroviral drug absorption,” the researchers concluded.
The authors reported that they had no commercial conflicts of interest relative to their study.
SOURCE: Pourcher G et al. Surgery for Obesity and Related Diseases. 2017;13:1990-6.
according to the results of a small prospective trial conducted from 2009 to 2015 at a single institution in France.
Ten patients were followed before and after sleeve gastrectomy. Eight were women and half were of African origin. The median patient age was 48.5 years, and the median time since HIV infection was 7.5 years. Patients had a median body mass index of 48.5 kg/m2 at the time of their procedure, according to Guillaume Pourcher, MD, PhD, of Paris-Sud University and his colleagues.
The median postoperative weight loss was 43 kg, while the median percentage of excess weight loss was 82.5% at the latest follow-up. In addition, all comorbidities were resolved with weight loss. With regard to HIV status, there was no significant modification of the CD4 cell count in the patients before and after surgery. Importantly, the pharmacokinetics of the patients’ antiretroviral drugs remained “adequate and efficacious,” according to Dr. Pourcher and his colleagues.
“For HIV-infected patients,we need to choose a safe procedure, with no disruption of intestinal continuity, without implanted foreign material, resulting in less malabsorption, and with long-term weight loss efficacy,” the authors stated.
Taking this into account, optimal management of HIV-infected patients with morbid obesity may include classical surgical procedures such as sleeve gastrectomy as with non-HIV obese patients, as long as close drug monitoring and immunovirologic follow-up are maintained, they suggested.
Sleeve gastrectomy “appears to be a good therapeutic option in morbidly obese HIV-infected patients, because it avoids malabsorption and possible modification of antiretroviral drug absorption,” the researchers concluded.
The authors reported that they had no commercial conflicts of interest relative to their study.
SOURCE: Pourcher G et al. Surgery for Obesity and Related Diseases. 2017;13:1990-6.
according to the results of a small prospective trial conducted from 2009 to 2015 at a single institution in France.
Ten patients were followed before and after sleeve gastrectomy. Eight were women and half were of African origin. The median patient age was 48.5 years, and the median time since HIV infection was 7.5 years. Patients had a median body mass index of 48.5 kg/m2 at the time of their procedure, according to Guillaume Pourcher, MD, PhD, of Paris-Sud University and his colleagues.
The median postoperative weight loss was 43 kg, while the median percentage of excess weight loss was 82.5% at the latest follow-up. In addition, all comorbidities were resolved with weight loss. With regard to HIV status, there was no significant modification of the CD4 cell count in the patients before and after surgery. Importantly, the pharmacokinetics of the patients’ antiretroviral drugs remained “adequate and efficacious,” according to Dr. Pourcher and his colleagues.
“For HIV-infected patients,we need to choose a safe procedure, with no disruption of intestinal continuity, without implanted foreign material, resulting in less malabsorption, and with long-term weight loss efficacy,” the authors stated.
Taking this into account, optimal management of HIV-infected patients with morbid obesity may include classical surgical procedures such as sleeve gastrectomy as with non-HIV obese patients, as long as close drug monitoring and immunovirologic follow-up are maintained, they suggested.
Sleeve gastrectomy “appears to be a good therapeutic option in morbidly obese HIV-infected patients, because it avoids malabsorption and possible modification of antiretroviral drug absorption,” the researchers concluded.
The authors reported that they had no commercial conflicts of interest relative to their study.
SOURCE: Pourcher G et al. Surgery for Obesity and Related Diseases. 2017;13:1990-6.
FROM SURGERY FOR OBESITY AND RELATED DISEASES
Key clinical point: HIV-infected patients lost weight after sleeve gastrectomy and maintained their viral status.
Major finding: Median postoperative weight loss was 43 kg and median percentage of excess weight loss was 82.5%.
Study details: Ten HIV-infected patients were prospectively followed before and after sleeve gastrectomy.
Disclosures: The authors reported that they had no commercial conflicts of interest relative to their study.
Source: Pourcher G et al. Surg Obes Relat Dis. 2017;13:1990-6.
Gastric bypass T2D benefit can fade over time
but the effect diminished over time, according to findings published Jan. 16 in JAMA.
In a randomized study of 113 obese patients with diabetes, about 50% of those who received gastric bypass in addition to lifestyle and medical management achieved the composite endpoint of a hemoglobin A1c (HbA1c) value of less than 7%, an LDL cholesterol level of less than 100 mg/dL, and a systolic blood pressure of less than 130 mm Hg after 1 year, reported Sayeed Ikramuddin, MD, FACS, of the department of surgery at the University of Minnesota, Minneapolis, and his coauthors. For comparison, just 16% in the lifestyle/medical management group achieved the endpoint (difference, 34%; 95% confidence interval, 14%-54%; P = .003) .
At 5 years’ follow-up, about 23% of patients in the gastric bypass group and 4% in the lifestyle/medical management group achieved the composite triple endpoint (difference, 19%; 95% CI, 4%-34%; P = .01), the authors reported.
The study included 120 patients at four sites in the United States and Taiwan, 7 of whom either died or were lost to follow-up before completion of the study. Participants had an HbA1c level of 8% or higher and a body mass index between 30 and 39.9 kg/m2.
Patients were randomized to receive either 2 years of lifestyle and medical management alone or in conjunction with standardized Roux-en-Y gastric bypass. During the first 2 years of intervention, patients were told to record weight, exercise, and food intake and were prescribed 325 minutes of physical activity per week. Participants also met regularly with a trained interventionist and an endocrinologist and were given pharmacologic therapy for hyperglycemia, cholesterol, and hypertension, the authors said. Aside from usual visits with a primary physician, all study interventions ceased after the initial 2-year period.
At baseline, the group that received only lifestyle/medical management had a mean BMI of 34.4 and HbA1c level of 9.6%, compared with a mean BMI of 34.9 and HbA1c level of 9.6% in the gastric bypass group.
Primary endpoint success rates decreased in both groups between years 1 and 3, going from 50% to 23% in the gastric bypass group and from 16% to 4% in the lifestyle/medical management group, but it remained stable from year 3 through year 5, Dr. Ikramuddin and his coauthors said in the report.
Overall, 26% of patients who had gastric bypass surgery during the first year achieved the triple endpoint at 5 years, compared with 8% of those who did not have surgery (difference, 18%; 95% CI, 6%-32%; P = .04).
The mean weight loss for participants in the gastric bypass group was 21.8% at 5 years, compared with 9.6% in the lifestyle/medical management group (difference, 12.2%; 95% CI, 8.9%-15.5%).
The results suggest that “gastric bypass provides significant benefit but with a smaller and less durable effect size than what is seen in the evaluation of glycemic control alone,” the authors wrote.
“Because the effect size diminished over 5 years, further follow-up is needed to understand the durability of the improvement,” Dr. Ikramuddin and his colleagues concluded.
Dr. Ikramuddin disclosed relationships with Novo Nordisk, USGI Medical, Medica, Metamodix, Medtronic, ReShape Medical, and EnteroMedics.
SOURCE: Ikramuddin S. JAMA. 2018;319(3):266-278.
but the effect diminished over time, according to findings published Jan. 16 in JAMA.
In a randomized study of 113 obese patients with diabetes, about 50% of those who received gastric bypass in addition to lifestyle and medical management achieved the composite endpoint of a hemoglobin A1c (HbA1c) value of less than 7%, an LDL cholesterol level of less than 100 mg/dL, and a systolic blood pressure of less than 130 mm Hg after 1 year, reported Sayeed Ikramuddin, MD, FACS, of the department of surgery at the University of Minnesota, Minneapolis, and his coauthors. For comparison, just 16% in the lifestyle/medical management group achieved the endpoint (difference, 34%; 95% confidence interval, 14%-54%; P = .003) .
At 5 years’ follow-up, about 23% of patients in the gastric bypass group and 4% in the lifestyle/medical management group achieved the composite triple endpoint (difference, 19%; 95% CI, 4%-34%; P = .01), the authors reported.
The study included 120 patients at four sites in the United States and Taiwan, 7 of whom either died or were lost to follow-up before completion of the study. Participants had an HbA1c level of 8% or higher and a body mass index between 30 and 39.9 kg/m2.
Patients were randomized to receive either 2 years of lifestyle and medical management alone or in conjunction with standardized Roux-en-Y gastric bypass. During the first 2 years of intervention, patients were told to record weight, exercise, and food intake and were prescribed 325 minutes of physical activity per week. Participants also met regularly with a trained interventionist and an endocrinologist and were given pharmacologic therapy for hyperglycemia, cholesterol, and hypertension, the authors said. Aside from usual visits with a primary physician, all study interventions ceased after the initial 2-year period.
At baseline, the group that received only lifestyle/medical management had a mean BMI of 34.4 and HbA1c level of 9.6%, compared with a mean BMI of 34.9 and HbA1c level of 9.6% in the gastric bypass group.
Primary endpoint success rates decreased in both groups between years 1 and 3, going from 50% to 23% in the gastric bypass group and from 16% to 4% in the lifestyle/medical management group, but it remained stable from year 3 through year 5, Dr. Ikramuddin and his coauthors said in the report.
Overall, 26% of patients who had gastric bypass surgery during the first year achieved the triple endpoint at 5 years, compared with 8% of those who did not have surgery (difference, 18%; 95% CI, 6%-32%; P = .04).
The mean weight loss for participants in the gastric bypass group was 21.8% at 5 years, compared with 9.6% in the lifestyle/medical management group (difference, 12.2%; 95% CI, 8.9%-15.5%).
The results suggest that “gastric bypass provides significant benefit but with a smaller and less durable effect size than what is seen in the evaluation of glycemic control alone,” the authors wrote.
“Because the effect size diminished over 5 years, further follow-up is needed to understand the durability of the improvement,” Dr. Ikramuddin and his colleagues concluded.
Dr. Ikramuddin disclosed relationships with Novo Nordisk, USGI Medical, Medica, Metamodix, Medtronic, ReShape Medical, and EnteroMedics.
SOURCE: Ikramuddin S. JAMA. 2018;319(3):266-278.
but the effect diminished over time, according to findings published Jan. 16 in JAMA.
In a randomized study of 113 obese patients with diabetes, about 50% of those who received gastric bypass in addition to lifestyle and medical management achieved the composite endpoint of a hemoglobin A1c (HbA1c) value of less than 7%, an LDL cholesterol level of less than 100 mg/dL, and a systolic blood pressure of less than 130 mm Hg after 1 year, reported Sayeed Ikramuddin, MD, FACS, of the department of surgery at the University of Minnesota, Minneapolis, and his coauthors. For comparison, just 16% in the lifestyle/medical management group achieved the endpoint (difference, 34%; 95% confidence interval, 14%-54%; P = .003) .
At 5 years’ follow-up, about 23% of patients in the gastric bypass group and 4% in the lifestyle/medical management group achieved the composite triple endpoint (difference, 19%; 95% CI, 4%-34%; P = .01), the authors reported.
The study included 120 patients at four sites in the United States and Taiwan, 7 of whom either died or were lost to follow-up before completion of the study. Participants had an HbA1c level of 8% or higher and a body mass index between 30 and 39.9 kg/m2.
Patients were randomized to receive either 2 years of lifestyle and medical management alone or in conjunction with standardized Roux-en-Y gastric bypass. During the first 2 years of intervention, patients were told to record weight, exercise, and food intake and were prescribed 325 minutes of physical activity per week. Participants also met regularly with a trained interventionist and an endocrinologist and were given pharmacologic therapy for hyperglycemia, cholesterol, and hypertension, the authors said. Aside from usual visits with a primary physician, all study interventions ceased after the initial 2-year period.
At baseline, the group that received only lifestyle/medical management had a mean BMI of 34.4 and HbA1c level of 9.6%, compared with a mean BMI of 34.9 and HbA1c level of 9.6% in the gastric bypass group.
Primary endpoint success rates decreased in both groups between years 1 and 3, going from 50% to 23% in the gastric bypass group and from 16% to 4% in the lifestyle/medical management group, but it remained stable from year 3 through year 5, Dr. Ikramuddin and his coauthors said in the report.
Overall, 26% of patients who had gastric bypass surgery during the first year achieved the triple endpoint at 5 years, compared with 8% of those who did not have surgery (difference, 18%; 95% CI, 6%-32%; P = .04).
The mean weight loss for participants in the gastric bypass group was 21.8% at 5 years, compared with 9.6% in the lifestyle/medical management group (difference, 12.2%; 95% CI, 8.9%-15.5%).
The results suggest that “gastric bypass provides significant benefit but with a smaller and less durable effect size than what is seen in the evaluation of glycemic control alone,” the authors wrote.
“Because the effect size diminished over 5 years, further follow-up is needed to understand the durability of the improvement,” Dr. Ikramuddin and his colleagues concluded.
Dr. Ikramuddin disclosed relationships with Novo Nordisk, USGI Medical, Medica, Metamodix, Medtronic, ReShape Medical, and EnteroMedics.
SOURCE: Ikramuddin S. JAMA. 2018;319(3):266-278.
FROM JAMA
Key clinical point: Adding gastric bypass surgery to lifestyle and medical management improves diabetes outcomes – but with diminished effect over time.
Major finding: Primary endpoint success rates decreased in both groups between years 1 and 3, going from 50% to 23% in the gastric bypass group and from 16% to 4% in the lifestyle/medical management group.
Data source: A randomized study of 113 patients at four sites in the United States and Taiwan with a HbA1c level of 8% or higher and a BMI of 30-39.9 kg/m2.
Disclosures: Dr. Ikramuddin disclosed relationships with Novo Nordisk, USGI Medical, Medica, Metamodix, Medtronic, ReShape Medical, and EnteroMedics
SOURCE: Ikramuddin S et al. JAMA. 2018;319(3):266-278.
Bariatric surgery comes with some risk of complications
that should acknowledged by clinicians and understood by patients, a large cohort study has shown.
Gunn Signe Jakobsen, MD, of Vestfold Hospital Trust, Tønsberg, Norway, and her colleagues wrote in an article published in JAMA, “Few studies report long-term complication rates. ... No large-scale clinical practice–based study has compared the long-term association of bariatric surgery and specialized medical obesity treatment with obesity-related somatic and mental comorbidities, nor the irrespective complication rates.”
The investigators compared outcomes from 932 patients who underwent bariatric surgery and 956 who underwent specialized medical treatment that involved either individual or group lifestyle intervention programs. The study population included 1,249 women and 639 men with an average age of 44 years and an average baseline body mass index of 44 kg/m2.
The surgery patients were more likely than the medical treatment patients to have hypertension remission (absolute risk 32% vs. 12%, respectively), and less likely to develop new-onset hypertension (absolute risk 4% vs. 12%, respectively). Diabetes remission was significantly higher among surgery patients, compared with medical treatment patients (58% vs. 13%) as was the likelihood of dyslipidemia remission (43% vs. 13%). Surgery patients also were less likely to develop new-onset diabetes or dyslipidemia than the medical treatment patients.
However, more patients who underwent bariatric surgery had low ferritin levels, compared with the medical treatment patients (26% vs. 12%). The surgery patients were significantly more likely than the medical treatment patients to develop new-onset depression (adjusted relative risk, 1.5; 95% confidence interval, 1.4-1.7), anxiety and sleep disorders (aRR, 1.3; 95% CI, 1.2-1.5), and treatment with opioids (aRR, 1.3; 95% CI, 1.2-1.4). In addition, bariatric patients were more likely to have at least one additional gastrointestinal surgical procedure (aRR, 2.0; 95% CI, 1.7-2.4), an operation for intestinal obstruction (aRR, 10.5; 95% CI, 5.1-21.5), abdominal pain (aRR, 1.9; 95% CI, 1.6-2.3), and gastroduodenal ulcers (aRR, 3.4; 95% CI 2.0-5.6).
The study was limited by several factors, including selection bias of younger, heavier patients in the bariatric surgery group, the lack of data on actual weight loss, incomplete laboratory data, and a relatively homogeneous white population, the researchers noted. However, the nearly 100% follow-up over approximately 6 years adds to the strength of the findings, which suggest that “the risk for complications should be considered in the decision-making process,” for obese patients considering bariatric surgery, they said.
Dr. Jakobsen was supported by the Vestfold Hospital Trust, with no financial conflicts to disclose.
SOURCE: Jakobsen G et al. JAMA. 2018 Jan 16;319(3):291-301.
that should acknowledged by clinicians and understood by patients, a large cohort study has shown.
Gunn Signe Jakobsen, MD, of Vestfold Hospital Trust, Tønsberg, Norway, and her colleagues wrote in an article published in JAMA, “Few studies report long-term complication rates. ... No large-scale clinical practice–based study has compared the long-term association of bariatric surgery and specialized medical obesity treatment with obesity-related somatic and mental comorbidities, nor the irrespective complication rates.”
The investigators compared outcomes from 932 patients who underwent bariatric surgery and 956 who underwent specialized medical treatment that involved either individual or group lifestyle intervention programs. The study population included 1,249 women and 639 men with an average age of 44 years and an average baseline body mass index of 44 kg/m2.
The surgery patients were more likely than the medical treatment patients to have hypertension remission (absolute risk 32% vs. 12%, respectively), and less likely to develop new-onset hypertension (absolute risk 4% vs. 12%, respectively). Diabetes remission was significantly higher among surgery patients, compared with medical treatment patients (58% vs. 13%) as was the likelihood of dyslipidemia remission (43% vs. 13%). Surgery patients also were less likely to develop new-onset diabetes or dyslipidemia than the medical treatment patients.
However, more patients who underwent bariatric surgery had low ferritin levels, compared with the medical treatment patients (26% vs. 12%). The surgery patients were significantly more likely than the medical treatment patients to develop new-onset depression (adjusted relative risk, 1.5; 95% confidence interval, 1.4-1.7), anxiety and sleep disorders (aRR, 1.3; 95% CI, 1.2-1.5), and treatment with opioids (aRR, 1.3; 95% CI, 1.2-1.4). In addition, bariatric patients were more likely to have at least one additional gastrointestinal surgical procedure (aRR, 2.0; 95% CI, 1.7-2.4), an operation for intestinal obstruction (aRR, 10.5; 95% CI, 5.1-21.5), abdominal pain (aRR, 1.9; 95% CI, 1.6-2.3), and gastroduodenal ulcers (aRR, 3.4; 95% CI 2.0-5.6).
The study was limited by several factors, including selection bias of younger, heavier patients in the bariatric surgery group, the lack of data on actual weight loss, incomplete laboratory data, and a relatively homogeneous white population, the researchers noted. However, the nearly 100% follow-up over approximately 6 years adds to the strength of the findings, which suggest that “the risk for complications should be considered in the decision-making process,” for obese patients considering bariatric surgery, they said.
Dr. Jakobsen was supported by the Vestfold Hospital Trust, with no financial conflicts to disclose.
SOURCE: Jakobsen G et al. JAMA. 2018 Jan 16;319(3):291-301.
that should acknowledged by clinicians and understood by patients, a large cohort study has shown.
Gunn Signe Jakobsen, MD, of Vestfold Hospital Trust, Tønsberg, Norway, and her colleagues wrote in an article published in JAMA, “Few studies report long-term complication rates. ... No large-scale clinical practice–based study has compared the long-term association of bariatric surgery and specialized medical obesity treatment with obesity-related somatic and mental comorbidities, nor the irrespective complication rates.”
The investigators compared outcomes from 932 patients who underwent bariatric surgery and 956 who underwent specialized medical treatment that involved either individual or group lifestyle intervention programs. The study population included 1,249 women and 639 men with an average age of 44 years and an average baseline body mass index of 44 kg/m2.
The surgery patients were more likely than the medical treatment patients to have hypertension remission (absolute risk 32% vs. 12%, respectively), and less likely to develop new-onset hypertension (absolute risk 4% vs. 12%, respectively). Diabetes remission was significantly higher among surgery patients, compared with medical treatment patients (58% vs. 13%) as was the likelihood of dyslipidemia remission (43% vs. 13%). Surgery patients also were less likely to develop new-onset diabetes or dyslipidemia than the medical treatment patients.
However, more patients who underwent bariatric surgery had low ferritin levels, compared with the medical treatment patients (26% vs. 12%). The surgery patients were significantly more likely than the medical treatment patients to develop new-onset depression (adjusted relative risk, 1.5; 95% confidence interval, 1.4-1.7), anxiety and sleep disorders (aRR, 1.3; 95% CI, 1.2-1.5), and treatment with opioids (aRR, 1.3; 95% CI, 1.2-1.4). In addition, bariatric patients were more likely to have at least one additional gastrointestinal surgical procedure (aRR, 2.0; 95% CI, 1.7-2.4), an operation for intestinal obstruction (aRR, 10.5; 95% CI, 5.1-21.5), abdominal pain (aRR, 1.9; 95% CI, 1.6-2.3), and gastroduodenal ulcers (aRR, 3.4; 95% CI 2.0-5.6).
The study was limited by several factors, including selection bias of younger, heavier patients in the bariatric surgery group, the lack of data on actual weight loss, incomplete laboratory data, and a relatively homogeneous white population, the researchers noted. However, the nearly 100% follow-up over approximately 6 years adds to the strength of the findings, which suggest that “the risk for complications should be considered in the decision-making process,” for obese patients considering bariatric surgery, they said.
Dr. Jakobsen was supported by the Vestfold Hospital Trust, with no financial conflicts to disclose.
SOURCE: Jakobsen G et al. JAMA. 2018 Jan 16;319(3):291-301.
FROM JAMA
Key clinical point: Bariatric surgery was associated with reduced hypertension but more complications, including iron deficiency and ulcers.
Major finding: Obese adults who had bariatric surgery were at greater risk for new-onset depression (aRR, 1.5), anxiety and sleep disorders (aRR, 1.3), and ulcers (aRR 3.4).
Study details: A cohort study of 1,888 adults treated with bariatric surgery or medical therapy.
Disclosures: Dr. Jakobsen was supported by the Vestfold Hospital Trust, with no financial conflicts to disclose.
Source: Jakobsen G et al. JAMA. 2018 Jan 16;319(3):291-301.
Metabolic and bariatric surgery reduces CVD risk in severely obese adolescents
Weight loss caused by metabolic and bariatric surgery (MBS) independently predicts the normalization of dyslipidemia, elevated blood pressure (EPB), hyperinsulinemia, diabetes, and elevated high-sensitivity C-reactive protein (hs-CRP) in severely obese adolescents, according to results of a longitudinal, multicenter prospective study.
In the study of 242 severely obese adolescents undergoing MBS between Feb. 28, 2007, and Dec. 30, 2011, Marc Michalsky, MD, of Nationwide Children’s Hospital, Columbus, Ohio, and his colleagues found that with every 10% increase in weight loss, patients were 24%, 11%, 14%, 13%, and 19% more likely to resolve dyslipidemia, EBP, hyperinsulinemia, diabetes, and elevated hs-CRP, respectively.
One of the most important facets of this study is the predictive nature of different patient risk factors on the future remission of cardiovascular disease symptoms.
For example, “the evidence suggests that better long-term outcomes may be anticipated among individuals undergoing MBS at lower BMI levels (i.e., less than 50),” they reported in the journal Pediatrics. “Increasing age at the time of MBS was associated with a reduced likelihood of dyslipidemia remission and normalization of hs-CRP,” which was true even in the narrow age range of this group of adolescents.
“The identification of specific predictors of CVD-RF [cardiovascular disease risk factors] normalization and/or remission on the basis of sex, race, preoperative BMI, and age at surgery may serve to improve future study design and insights regarding the optimization of treatment strategies,” wrote Dr. Michalsky and his colleagues. “Collectively, these data demonstrate a reduction in the risk for development of CVD in adulthood and offer additional, compelling support for MBS in adolescents.”
Dr. Inge has worked as a consultant for Standard Bariatrics, UpToDate, and Independent Medical Expert Consulting Services; all of these companies are unrelated to this research. John B. Dixon, PhD, has received support for his research through a National Health and Medical Research Council research fellowship. Anita Courcoulas, MD, has received grants from various health care groups and companies. All other authors had no relevant financial disclosures. The study was funded by a variety of institutional grants and the National Institutes of Health.
SOURCE: M Michalsky et al. Pediatrics. 2018 Jan 8. doi: 10.1542/peds.2017-2485.
Weight loss caused by metabolic and bariatric surgery (MBS) independently predicts the normalization of dyslipidemia, elevated blood pressure (EPB), hyperinsulinemia, diabetes, and elevated high-sensitivity C-reactive protein (hs-CRP) in severely obese adolescents, according to results of a longitudinal, multicenter prospective study.
In the study of 242 severely obese adolescents undergoing MBS between Feb. 28, 2007, and Dec. 30, 2011, Marc Michalsky, MD, of Nationwide Children’s Hospital, Columbus, Ohio, and his colleagues found that with every 10% increase in weight loss, patients were 24%, 11%, 14%, 13%, and 19% more likely to resolve dyslipidemia, EBP, hyperinsulinemia, diabetes, and elevated hs-CRP, respectively.
One of the most important facets of this study is the predictive nature of different patient risk factors on the future remission of cardiovascular disease symptoms.
For example, “the evidence suggests that better long-term outcomes may be anticipated among individuals undergoing MBS at lower BMI levels (i.e., less than 50),” they reported in the journal Pediatrics. “Increasing age at the time of MBS was associated with a reduced likelihood of dyslipidemia remission and normalization of hs-CRP,” which was true even in the narrow age range of this group of adolescents.
“The identification of specific predictors of CVD-RF [cardiovascular disease risk factors] normalization and/or remission on the basis of sex, race, preoperative BMI, and age at surgery may serve to improve future study design and insights regarding the optimization of treatment strategies,” wrote Dr. Michalsky and his colleagues. “Collectively, these data demonstrate a reduction in the risk for development of CVD in adulthood and offer additional, compelling support for MBS in adolescents.”
Dr. Inge has worked as a consultant for Standard Bariatrics, UpToDate, and Independent Medical Expert Consulting Services; all of these companies are unrelated to this research. John B. Dixon, PhD, has received support for his research through a National Health and Medical Research Council research fellowship. Anita Courcoulas, MD, has received grants from various health care groups and companies. All other authors had no relevant financial disclosures. The study was funded by a variety of institutional grants and the National Institutes of Health.
SOURCE: M Michalsky et al. Pediatrics. 2018 Jan 8. doi: 10.1542/peds.2017-2485.
Weight loss caused by metabolic and bariatric surgery (MBS) independently predicts the normalization of dyslipidemia, elevated blood pressure (EPB), hyperinsulinemia, diabetes, and elevated high-sensitivity C-reactive protein (hs-CRP) in severely obese adolescents, according to results of a longitudinal, multicenter prospective study.
In the study of 242 severely obese adolescents undergoing MBS between Feb. 28, 2007, and Dec. 30, 2011, Marc Michalsky, MD, of Nationwide Children’s Hospital, Columbus, Ohio, and his colleagues found that with every 10% increase in weight loss, patients were 24%, 11%, 14%, 13%, and 19% more likely to resolve dyslipidemia, EBP, hyperinsulinemia, diabetes, and elevated hs-CRP, respectively.
One of the most important facets of this study is the predictive nature of different patient risk factors on the future remission of cardiovascular disease symptoms.
For example, “the evidence suggests that better long-term outcomes may be anticipated among individuals undergoing MBS at lower BMI levels (i.e., less than 50),” they reported in the journal Pediatrics. “Increasing age at the time of MBS was associated with a reduced likelihood of dyslipidemia remission and normalization of hs-CRP,” which was true even in the narrow age range of this group of adolescents.
“The identification of specific predictors of CVD-RF [cardiovascular disease risk factors] normalization and/or remission on the basis of sex, race, preoperative BMI, and age at surgery may serve to improve future study design and insights regarding the optimization of treatment strategies,” wrote Dr. Michalsky and his colleagues. “Collectively, these data demonstrate a reduction in the risk for development of CVD in adulthood and offer additional, compelling support for MBS in adolescents.”
Dr. Inge has worked as a consultant for Standard Bariatrics, UpToDate, and Independent Medical Expert Consulting Services; all of these companies are unrelated to this research. John B. Dixon, PhD, has received support for his research through a National Health and Medical Research Council research fellowship. Anita Courcoulas, MD, has received grants from various health care groups and companies. All other authors had no relevant financial disclosures. The study was funded by a variety of institutional grants and the National Institutes of Health.
SOURCE: M Michalsky et al. Pediatrics. 2018 Jan 8. doi: 10.1542/peds.2017-2485.
FROM PEDIATRICS
Key clinical point:
Major finding: With every 10% increase in weight loss, patients were 24%, 11%, 14%, 13%, and 19% more likely to resolve dyslipidemia, elevated BP, hyperinsulinemia, diabetes and elevated high-sensitivity C-reactive protein, respectively.
Study details: This study was a longitudinal, multicenter prospective study of 242 severely obese adolescents undergoing metabolic and bariatric surgery between February 28, 2007 and December 30, 2011.
Disclosures: Dr. Inge has worked as a consultant for Standard Bariatrics, UpToDate, and Independent Medical Expert Consulting Services; all of these companies are unrelated to this research. John B. Dixon, PhD, has received support for his research through a National Health and Medical Research Council research fellowship. Anita Courcoulas, MD, has received grants from various healthcare groups and companies. All other authors had no relevant financial disclosures. The study was funded by a variety of institutional grants and the National Institutes of Health.
Source: M Michalsky et al. Pediatrics. 2018 Jan 8. doi: 10.1542/peds.2017-2485