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Bariatric surgery candidates show high prevalence of thrombophilia
LAS VEGAS – More than half the patients seeking laparoscopic sleeve gastrectomy at a pair of large U.S. programs tested positive for thrombophilia, and for most of these patients, their thrombophilia stemmed from an abnormally elevated level of clotting factor VIII. This thrombophilia seemed to link with a small, but potentially meaningful, excess of portomesenteric venous thrombosis that could warrant treating patients with an anticoagulation regimen for an extended, 30-day period post surgery, Manish S. Parikh, MD, said at a meeting presented by The Obesity Society and the American Society for Metabolic and Bariatric Surgery.
Although measurement of factor VIII excess can be done with a test that costs about $25, Dr. Parikh suggested that giving extended, 30-day anticoagulant prophylaxis to all patients undergoing laparoscopic sleeve gastrectomy (LSG) is a reasonable alternative to screening all patients first. “You could use our data to support 30-day prophylaxis for all LSG patients,” said Dr. Parikh, a metabolic and bariatric surgeon at NYU Langone Health in New York. He acknowledged that some logistic barriers can hamper the efficacy of extended prophylaxis.
The factor VIII elevations seen in many of these obese patients seeking metabolic surgery seems to be inherent and independent of their current weight. Although Dr. Parikh and his associates do not have long-term follow-up for all their LSG patients, “we’ve followed some patients, and their factor VIII is still elevated years later, after they’ve lost weight. We encourage lifelong anticoagulation [for these patients] because of their high risk for recurrent clot. This reflects their factor VIII and is independent of weight,” he said.
For their study, the researchers considered a factor VIII level above 150% of the normal level as abnormally elevated and prothrombotic.
The increased rate of portomesenteric venous thrombosis (PMVT) seen in the thrombophilic patients after LSG “is strongly related to the sleeve specifically,” added Dr. Parikh. He suggested that “something related to redirection of blood flow by taking the branches of the gastroepiploic arcade may lead to this.”
The interest of Dr. Parikh and his associates in thrombophilia and factor VIII excess began with a review they ran of more than 25,000 patients who underwent bariatric surgery at six U.S. centers during 2006-2016 that identified 40 patients who developed PMVT, all from the subgroup of nearly 10,000 patients who had LSG for their bariatric procedure. The prevalence of thrombophilia among those 40 patients with PMVT was 92%, with 76% having excess factor VIII (Surg Obes Relat Dis. 2017;13[11]:1835-9).
Based on those findings, the researchers began a practice of prospectively testing for thrombophilia in all patients who were assessed for LSG at two New York centers during August 2018–March 2019, a total of 1,075 patients, of whom 745 subsequently underwent the procedure. They tested the patients for factor VIII and four additional proteins in the clotting cascade that flag thrombophilia, a test panel that cost $103 per patient. That identified 563 surgery candidates (52%) with any thrombophilia, of whom 92% had excess factor VIII (48% of the total cohort of 1,075). Those patients received an extended, 30-day anticoagulant regimen.
To estimate the impact of this approach, the researchers compared the incidence of PMVT among the recent 745 patients who underwent LSG with a historic control group of 4,228 patients who underwent LSG at the two centers during the 4.5 years before routine thrombophilia screening. None of those 4,228 controls received extended anticoagulation.
During 30-day follow-up, 1 patient in the recent group of 745 patients (0.1%) developed PMVT, whereas 18 of the controls (0.4%) had PMVT. The incidence of bleeding was 0.6% in the recent patients and 0.4% in the controls. The researchers did not report a statistical analysis of these data, because the number of PMVT episodes was too small to allow reliable calculations, Dr. Parikh said. He also cautioned that the generalizability of the finding of thrombophilia prevalence is uncertain because the study population of 1,075 patients considering LSG was 84% Hispanic and 15% non-Hispanic African American.
Dr. Parikh had no disclosures.
SOURCE: Parikh MS et al. Obesity Week 2019, Abstract A109.
Vivek N. Prachand, MD , is professor of surgery and director of minimally invasive surgery at the University of Chicago. He had no disclosures. He made these comments as designated discussant for the report.
Vivek N. Prachand, MD , is professor of surgery and director of minimally invasive surgery at the University of Chicago. He had no disclosures. He made these comments as designated discussant for the report.
Vivek N. Prachand, MD , is professor of surgery and director of minimally invasive surgery at the University of Chicago. He had no disclosures. He made these comments as designated discussant for the report.
LAS VEGAS – More than half the patients seeking laparoscopic sleeve gastrectomy at a pair of large U.S. programs tested positive for thrombophilia, and for most of these patients, their thrombophilia stemmed from an abnormally elevated level of clotting factor VIII. This thrombophilia seemed to link with a small, but potentially meaningful, excess of portomesenteric venous thrombosis that could warrant treating patients with an anticoagulation regimen for an extended, 30-day period post surgery, Manish S. Parikh, MD, said at a meeting presented by The Obesity Society and the American Society for Metabolic and Bariatric Surgery.
Although measurement of factor VIII excess can be done with a test that costs about $25, Dr. Parikh suggested that giving extended, 30-day anticoagulant prophylaxis to all patients undergoing laparoscopic sleeve gastrectomy (LSG) is a reasonable alternative to screening all patients first. “You could use our data to support 30-day prophylaxis for all LSG patients,” said Dr. Parikh, a metabolic and bariatric surgeon at NYU Langone Health in New York. He acknowledged that some logistic barriers can hamper the efficacy of extended prophylaxis.
The factor VIII elevations seen in many of these obese patients seeking metabolic surgery seems to be inherent and independent of their current weight. Although Dr. Parikh and his associates do not have long-term follow-up for all their LSG patients, “we’ve followed some patients, and their factor VIII is still elevated years later, after they’ve lost weight. We encourage lifelong anticoagulation [for these patients] because of their high risk for recurrent clot. This reflects their factor VIII and is independent of weight,” he said.
For their study, the researchers considered a factor VIII level above 150% of the normal level as abnormally elevated and prothrombotic.
The increased rate of portomesenteric venous thrombosis (PMVT) seen in the thrombophilic patients after LSG “is strongly related to the sleeve specifically,” added Dr. Parikh. He suggested that “something related to redirection of blood flow by taking the branches of the gastroepiploic arcade may lead to this.”
The interest of Dr. Parikh and his associates in thrombophilia and factor VIII excess began with a review they ran of more than 25,000 patients who underwent bariatric surgery at six U.S. centers during 2006-2016 that identified 40 patients who developed PMVT, all from the subgroup of nearly 10,000 patients who had LSG for their bariatric procedure. The prevalence of thrombophilia among those 40 patients with PMVT was 92%, with 76% having excess factor VIII (Surg Obes Relat Dis. 2017;13[11]:1835-9).
Based on those findings, the researchers began a practice of prospectively testing for thrombophilia in all patients who were assessed for LSG at two New York centers during August 2018–March 2019, a total of 1,075 patients, of whom 745 subsequently underwent the procedure. They tested the patients for factor VIII and four additional proteins in the clotting cascade that flag thrombophilia, a test panel that cost $103 per patient. That identified 563 surgery candidates (52%) with any thrombophilia, of whom 92% had excess factor VIII (48% of the total cohort of 1,075). Those patients received an extended, 30-day anticoagulant regimen.
To estimate the impact of this approach, the researchers compared the incidence of PMVT among the recent 745 patients who underwent LSG with a historic control group of 4,228 patients who underwent LSG at the two centers during the 4.5 years before routine thrombophilia screening. None of those 4,228 controls received extended anticoagulation.
During 30-day follow-up, 1 patient in the recent group of 745 patients (0.1%) developed PMVT, whereas 18 of the controls (0.4%) had PMVT. The incidence of bleeding was 0.6% in the recent patients and 0.4% in the controls. The researchers did not report a statistical analysis of these data, because the number of PMVT episodes was too small to allow reliable calculations, Dr. Parikh said. He also cautioned that the generalizability of the finding of thrombophilia prevalence is uncertain because the study population of 1,075 patients considering LSG was 84% Hispanic and 15% non-Hispanic African American.
Dr. Parikh had no disclosures.
SOURCE: Parikh MS et al. Obesity Week 2019, Abstract A109.
LAS VEGAS – More than half the patients seeking laparoscopic sleeve gastrectomy at a pair of large U.S. programs tested positive for thrombophilia, and for most of these patients, their thrombophilia stemmed from an abnormally elevated level of clotting factor VIII. This thrombophilia seemed to link with a small, but potentially meaningful, excess of portomesenteric venous thrombosis that could warrant treating patients with an anticoagulation regimen for an extended, 30-day period post surgery, Manish S. Parikh, MD, said at a meeting presented by The Obesity Society and the American Society for Metabolic and Bariatric Surgery.
Although measurement of factor VIII excess can be done with a test that costs about $25, Dr. Parikh suggested that giving extended, 30-day anticoagulant prophylaxis to all patients undergoing laparoscopic sleeve gastrectomy (LSG) is a reasonable alternative to screening all patients first. “You could use our data to support 30-day prophylaxis for all LSG patients,” said Dr. Parikh, a metabolic and bariatric surgeon at NYU Langone Health in New York. He acknowledged that some logistic barriers can hamper the efficacy of extended prophylaxis.
The factor VIII elevations seen in many of these obese patients seeking metabolic surgery seems to be inherent and independent of their current weight. Although Dr. Parikh and his associates do not have long-term follow-up for all their LSG patients, “we’ve followed some patients, and their factor VIII is still elevated years later, after they’ve lost weight. We encourage lifelong anticoagulation [for these patients] because of their high risk for recurrent clot. This reflects their factor VIII and is independent of weight,” he said.
For their study, the researchers considered a factor VIII level above 150% of the normal level as abnormally elevated and prothrombotic.
The increased rate of portomesenteric venous thrombosis (PMVT) seen in the thrombophilic patients after LSG “is strongly related to the sleeve specifically,” added Dr. Parikh. He suggested that “something related to redirection of blood flow by taking the branches of the gastroepiploic arcade may lead to this.”
The interest of Dr. Parikh and his associates in thrombophilia and factor VIII excess began with a review they ran of more than 25,000 patients who underwent bariatric surgery at six U.S. centers during 2006-2016 that identified 40 patients who developed PMVT, all from the subgroup of nearly 10,000 patients who had LSG for their bariatric procedure. The prevalence of thrombophilia among those 40 patients with PMVT was 92%, with 76% having excess factor VIII (Surg Obes Relat Dis. 2017;13[11]:1835-9).
Based on those findings, the researchers began a practice of prospectively testing for thrombophilia in all patients who were assessed for LSG at two New York centers during August 2018–March 2019, a total of 1,075 patients, of whom 745 subsequently underwent the procedure. They tested the patients for factor VIII and four additional proteins in the clotting cascade that flag thrombophilia, a test panel that cost $103 per patient. That identified 563 surgery candidates (52%) with any thrombophilia, of whom 92% had excess factor VIII (48% of the total cohort of 1,075). Those patients received an extended, 30-day anticoagulant regimen.
To estimate the impact of this approach, the researchers compared the incidence of PMVT among the recent 745 patients who underwent LSG with a historic control group of 4,228 patients who underwent LSG at the two centers during the 4.5 years before routine thrombophilia screening. None of those 4,228 controls received extended anticoagulation.
During 30-day follow-up, 1 patient in the recent group of 745 patients (0.1%) developed PMVT, whereas 18 of the controls (0.4%) had PMVT. The incidence of bleeding was 0.6% in the recent patients and 0.4% in the controls. The researchers did not report a statistical analysis of these data, because the number of PMVT episodes was too small to allow reliable calculations, Dr. Parikh said. He also cautioned that the generalizability of the finding of thrombophilia prevalence is uncertain because the study population of 1,075 patients considering LSG was 84% Hispanic and 15% non-Hispanic African American.
Dr. Parikh had no disclosures.
SOURCE: Parikh MS et al. Obesity Week 2019, Abstract A109.
REPORTING FROM OBESITY WEEK 2019
Score predicts bariatric surgery’s benefits for obesity, type 2 diabetes
LAS VEGAS –
The Individualized Diabetes Complications risk score “can provide personalized, evidence-based risk information for patients with type 2 diabetes and obesity about their future cardiovascular disease outcomes and mortality with and without metabolic surgery,” Ali Aminian, MD, said at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
Although the calculator needs validation in a prospective, randomized study to document its impact on practice, it is now available on two separate websites and as a downloadable app, said Dr. Aminian, a surgeon at the Cleveland Clinic.
The calculator inputs data for 26 distinct, “readily available” demographic and clinical entries, and based on that, estimates the patient’s 10-year risk for all-cause death, diabetic kidney disease, cerebrovascular disease, heart failure, and coronary artery disease if no surgery occurs or after some type of metabolic or bariatric surgery. The calculator does not currently have the ability to individualize predicted risks based on the specific type of metabolic surgery performed, but that is planned as a future refinement of the score.
“We validated the model in the nonsurgical patients, which showed it was very accurate. The next step is to run a randomized trial to see how useful the calculator is” for assisting in patients’ decision making, Dr. Aminian said.
The data for deriving the risk calculator, and for a preliminary validation of it, came from 13,722 patients with obesity (body mass index, 30 kg/m2 or greater) and type 2 diabetes, who were managed at the Cleveland Clinic during 1998-2017, drawn from more than 287,000 such patients in the clinic’s database. The study focused on 2,287 patients who underwent metabolic (bariatric) surgery and 11,435 patients from the same database who did not have surgery and matched by propensity scoring on a 5:1 basis with those who had surgery. The two cohorts this created matched well for age (about 54 years), sex (about two-thirds women), body mass index (about 44 kg/m2), and the prevalence of various comorbidities at baseline.
Dr. Aminian and associates then analyzed the incidence of all-cause mortality and various cardiovascular disease endpoints, as well as nephropathy during follow-up, through December 2018. Patients who had undergone metabolic surgery showed statistically significant reductions in the incidence of each of those events, compared with patients who did not have surgery (JAMA. 2019;322[13]:1271-82).
The investigators used these findings to create their model for calculating a patient’s risk score. For example, to calculate an estimate for the 10-year risk from all-cause mortality, the results showed that the most powerful risk factors were age; baseline body mass index, heart failure, and need for insulin; and smoking status. For the endpoint of nephropathy, the most important factors were estimated glomerular filtration rate at baseline and age. Identified risk factors could account for about 80% of the 10-year risk for all-cause death and for about 75% of the risk for developing nephropathy during 10 years, based on the area-under-the-curve values the model produced.
The risk score may help patients better understand the potential role that metabolic surgery can have in reducing their future event risk, thereby helping them better appreciate the benefit they stand to gain from undergoing surgery, Dr. Aminian said.
The calculator is available at a website maintained by the Cleveland Clinic, at a site of the American Society for Metabolic and Bariatric Surgery, and in app stores, he said.
The work was partially funded by Medtronic. Dr. Aminian has received grants from Medtronic.
SOURCE: Aminian A et al. Obesity Week 2019, Abstract A101.
LAS VEGAS –
The Individualized Diabetes Complications risk score “can provide personalized, evidence-based risk information for patients with type 2 diabetes and obesity about their future cardiovascular disease outcomes and mortality with and without metabolic surgery,” Ali Aminian, MD, said at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
Although the calculator needs validation in a prospective, randomized study to document its impact on practice, it is now available on two separate websites and as a downloadable app, said Dr. Aminian, a surgeon at the Cleveland Clinic.
The calculator inputs data for 26 distinct, “readily available” demographic and clinical entries, and based on that, estimates the patient’s 10-year risk for all-cause death, diabetic kidney disease, cerebrovascular disease, heart failure, and coronary artery disease if no surgery occurs or after some type of metabolic or bariatric surgery. The calculator does not currently have the ability to individualize predicted risks based on the specific type of metabolic surgery performed, but that is planned as a future refinement of the score.
“We validated the model in the nonsurgical patients, which showed it was very accurate. The next step is to run a randomized trial to see how useful the calculator is” for assisting in patients’ decision making, Dr. Aminian said.
The data for deriving the risk calculator, and for a preliminary validation of it, came from 13,722 patients with obesity (body mass index, 30 kg/m2 or greater) and type 2 diabetes, who were managed at the Cleveland Clinic during 1998-2017, drawn from more than 287,000 such patients in the clinic’s database. The study focused on 2,287 patients who underwent metabolic (bariatric) surgery and 11,435 patients from the same database who did not have surgery and matched by propensity scoring on a 5:1 basis with those who had surgery. The two cohorts this created matched well for age (about 54 years), sex (about two-thirds women), body mass index (about 44 kg/m2), and the prevalence of various comorbidities at baseline.
Dr. Aminian and associates then analyzed the incidence of all-cause mortality and various cardiovascular disease endpoints, as well as nephropathy during follow-up, through December 2018. Patients who had undergone metabolic surgery showed statistically significant reductions in the incidence of each of those events, compared with patients who did not have surgery (JAMA. 2019;322[13]:1271-82).
The investigators used these findings to create their model for calculating a patient’s risk score. For example, to calculate an estimate for the 10-year risk from all-cause mortality, the results showed that the most powerful risk factors were age; baseline body mass index, heart failure, and need for insulin; and smoking status. For the endpoint of nephropathy, the most important factors were estimated glomerular filtration rate at baseline and age. Identified risk factors could account for about 80% of the 10-year risk for all-cause death and for about 75% of the risk for developing nephropathy during 10 years, based on the area-under-the-curve values the model produced.
The risk score may help patients better understand the potential role that metabolic surgery can have in reducing their future event risk, thereby helping them better appreciate the benefit they stand to gain from undergoing surgery, Dr. Aminian said.
The calculator is available at a website maintained by the Cleveland Clinic, at a site of the American Society for Metabolic and Bariatric Surgery, and in app stores, he said.
The work was partially funded by Medtronic. Dr. Aminian has received grants from Medtronic.
SOURCE: Aminian A et al. Obesity Week 2019, Abstract A101.
LAS VEGAS –
The Individualized Diabetes Complications risk score “can provide personalized, evidence-based risk information for patients with type 2 diabetes and obesity about their future cardiovascular disease outcomes and mortality with and without metabolic surgery,” Ali Aminian, MD, said at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
Although the calculator needs validation in a prospective, randomized study to document its impact on practice, it is now available on two separate websites and as a downloadable app, said Dr. Aminian, a surgeon at the Cleveland Clinic.
The calculator inputs data for 26 distinct, “readily available” demographic and clinical entries, and based on that, estimates the patient’s 10-year risk for all-cause death, diabetic kidney disease, cerebrovascular disease, heart failure, and coronary artery disease if no surgery occurs or after some type of metabolic or bariatric surgery. The calculator does not currently have the ability to individualize predicted risks based on the specific type of metabolic surgery performed, but that is planned as a future refinement of the score.
“We validated the model in the nonsurgical patients, which showed it was very accurate. The next step is to run a randomized trial to see how useful the calculator is” for assisting in patients’ decision making, Dr. Aminian said.
The data for deriving the risk calculator, and for a preliminary validation of it, came from 13,722 patients with obesity (body mass index, 30 kg/m2 or greater) and type 2 diabetes, who were managed at the Cleveland Clinic during 1998-2017, drawn from more than 287,000 such patients in the clinic’s database. The study focused on 2,287 patients who underwent metabolic (bariatric) surgery and 11,435 patients from the same database who did not have surgery and matched by propensity scoring on a 5:1 basis with those who had surgery. The two cohorts this created matched well for age (about 54 years), sex (about two-thirds women), body mass index (about 44 kg/m2), and the prevalence of various comorbidities at baseline.
Dr. Aminian and associates then analyzed the incidence of all-cause mortality and various cardiovascular disease endpoints, as well as nephropathy during follow-up, through December 2018. Patients who had undergone metabolic surgery showed statistically significant reductions in the incidence of each of those events, compared with patients who did not have surgery (JAMA. 2019;322[13]:1271-82).
The investigators used these findings to create their model for calculating a patient’s risk score. For example, to calculate an estimate for the 10-year risk from all-cause mortality, the results showed that the most powerful risk factors were age; baseline body mass index, heart failure, and need for insulin; and smoking status. For the endpoint of nephropathy, the most important factors were estimated glomerular filtration rate at baseline and age. Identified risk factors could account for about 80% of the 10-year risk for all-cause death and for about 75% of the risk for developing nephropathy during 10 years, based on the area-under-the-curve values the model produced.
The risk score may help patients better understand the potential role that metabolic surgery can have in reducing their future event risk, thereby helping them better appreciate the benefit they stand to gain from undergoing surgery, Dr. Aminian said.
The calculator is available at a website maintained by the Cleveland Clinic, at a site of the American Society for Metabolic and Bariatric Surgery, and in app stores, he said.
The work was partially funded by Medtronic. Dr. Aminian has received grants from Medtronic.
SOURCE: Aminian A et al. Obesity Week 2019, Abstract A101.
REPORTING FROM OBESITY WEEK 2019
Bariatric surgery tied to fewer cerebrovascular events
PHILADELPHIA – Obese people living in the United Kingdom who underwent bariatric surgery had a two-thirds lower rate of major cerebrovascular events than that of a matched group of obese residents who did not undergo bariatric surgery, in a retrospective study of 8,424 people followed for a mean of just over 11 years.
Although the cut in cerebrovascular events that linked with bariatric surgery shown by the analysis was mostly driven by a reduced rate of transient ischemic attacks, a potentially unreliable diagnosis, the results showed consistent reductions in the rates of acute ischemic strokes as well as in acute, nontraumatic intracranial hemorrhages, two other components of the combined primary endpoint, Maddalena Ardissino, MBBS, said at the American Heart Association scientific sessions.
This finding of an apparent benefit from bariatric surgery in obese patients in a large U.K. database confirms other findings from a “fast-growing” evidence base showing benefits from bariatric surgery for reducing other types of cardiovascular disease events, said Dr. Ardissino, a researcher at Imperial College, London. However, the impact of bariatric surgery specifically on cerebrovascular events had not received much attention in published studies, she noted.
Her study used data collected by the Clinical Practice Research Datalink, which has primary and secondary care health records for about 42 million U.K. residents. The researchers focused on more than 251,000 obese U.K. adults (body mass index of 30 kg/m2 or greater) without a history of a cerebrovascular event who had at least 1 year of follow-up, a data file that included 4,212 adults who had undergone bariatric surgery. Their analysis matched these surgical patients with an equal number of obese adults who did not have surgery, pairing the cases and controls based on age, sex, and BMI. The resulting matched cohorts each averaged 50 years old, with a mean BMI of 40.5 kg/m2.
During just over 11 years of average follow-up, the incidence of acute ischemic stroke, acute intracranial hemorrhage, subarachnoid hemorrhage, or transient ischemic attack was about 1.3% in those without bariatric surgery and about 0.4% in those who had surgery, an absolute risk reduction of 0.9 linked with surgery and a relative risk reduction of 65% that was statistically significant, Dr. Ardissino reported. All-cause mortality was about 70% lower in the group that underwent bariatric surgery compared with those who did not have surgery, a finding that confirmed prior reports. She cautioned that the analysis was limited by a relatively low number of total events, and by the small number of criteria used for cohort matching that might have left unadjusted certain potential confounders such as the level of engagement people had with their medical care.
SOURCE: Ardissino M. AHA 2019, Abstract 335.
PHILADELPHIA – Obese people living in the United Kingdom who underwent bariatric surgery had a two-thirds lower rate of major cerebrovascular events than that of a matched group of obese residents who did not undergo bariatric surgery, in a retrospective study of 8,424 people followed for a mean of just over 11 years.
Although the cut in cerebrovascular events that linked with bariatric surgery shown by the analysis was mostly driven by a reduced rate of transient ischemic attacks, a potentially unreliable diagnosis, the results showed consistent reductions in the rates of acute ischemic strokes as well as in acute, nontraumatic intracranial hemorrhages, two other components of the combined primary endpoint, Maddalena Ardissino, MBBS, said at the American Heart Association scientific sessions.
This finding of an apparent benefit from bariatric surgery in obese patients in a large U.K. database confirms other findings from a “fast-growing” evidence base showing benefits from bariatric surgery for reducing other types of cardiovascular disease events, said Dr. Ardissino, a researcher at Imperial College, London. However, the impact of bariatric surgery specifically on cerebrovascular events had not received much attention in published studies, she noted.
Her study used data collected by the Clinical Practice Research Datalink, which has primary and secondary care health records for about 42 million U.K. residents. The researchers focused on more than 251,000 obese U.K. adults (body mass index of 30 kg/m2 or greater) without a history of a cerebrovascular event who had at least 1 year of follow-up, a data file that included 4,212 adults who had undergone bariatric surgery. Their analysis matched these surgical patients with an equal number of obese adults who did not have surgery, pairing the cases and controls based on age, sex, and BMI. The resulting matched cohorts each averaged 50 years old, with a mean BMI of 40.5 kg/m2.
During just over 11 years of average follow-up, the incidence of acute ischemic stroke, acute intracranial hemorrhage, subarachnoid hemorrhage, or transient ischemic attack was about 1.3% in those without bariatric surgery and about 0.4% in those who had surgery, an absolute risk reduction of 0.9 linked with surgery and a relative risk reduction of 65% that was statistically significant, Dr. Ardissino reported. All-cause mortality was about 70% lower in the group that underwent bariatric surgery compared with those who did not have surgery, a finding that confirmed prior reports. She cautioned that the analysis was limited by a relatively low number of total events, and by the small number of criteria used for cohort matching that might have left unadjusted certain potential confounders such as the level of engagement people had with their medical care.
SOURCE: Ardissino M. AHA 2019, Abstract 335.
PHILADELPHIA – Obese people living in the United Kingdom who underwent bariatric surgery had a two-thirds lower rate of major cerebrovascular events than that of a matched group of obese residents who did not undergo bariatric surgery, in a retrospective study of 8,424 people followed for a mean of just over 11 years.
Although the cut in cerebrovascular events that linked with bariatric surgery shown by the analysis was mostly driven by a reduced rate of transient ischemic attacks, a potentially unreliable diagnosis, the results showed consistent reductions in the rates of acute ischemic strokes as well as in acute, nontraumatic intracranial hemorrhages, two other components of the combined primary endpoint, Maddalena Ardissino, MBBS, said at the American Heart Association scientific sessions.
This finding of an apparent benefit from bariatric surgery in obese patients in a large U.K. database confirms other findings from a “fast-growing” evidence base showing benefits from bariatric surgery for reducing other types of cardiovascular disease events, said Dr. Ardissino, a researcher at Imperial College, London. However, the impact of bariatric surgery specifically on cerebrovascular events had not received much attention in published studies, she noted.
Her study used data collected by the Clinical Practice Research Datalink, which has primary and secondary care health records for about 42 million U.K. residents. The researchers focused on more than 251,000 obese U.K. adults (body mass index of 30 kg/m2 or greater) without a history of a cerebrovascular event who had at least 1 year of follow-up, a data file that included 4,212 adults who had undergone bariatric surgery. Their analysis matched these surgical patients with an equal number of obese adults who did not have surgery, pairing the cases and controls based on age, sex, and BMI. The resulting matched cohorts each averaged 50 years old, with a mean BMI of 40.5 kg/m2.
During just over 11 years of average follow-up, the incidence of acute ischemic stroke, acute intracranial hemorrhage, subarachnoid hemorrhage, or transient ischemic attack was about 1.3% in those without bariatric surgery and about 0.4% in those who had surgery, an absolute risk reduction of 0.9 linked with surgery and a relative risk reduction of 65% that was statistically significant, Dr. Ardissino reported. All-cause mortality was about 70% lower in the group that underwent bariatric surgery compared with those who did not have surgery, a finding that confirmed prior reports. She cautioned that the analysis was limited by a relatively low number of total events, and by the small number of criteria used for cohort matching that might have left unadjusted certain potential confounders such as the level of engagement people had with their medical care.
SOURCE: Ardissino M. AHA 2019, Abstract 335.
REPORTING FROM AHA 2019
Bariatric surgery shows metabolic benefits in lower-BMI patients
LAS VEGAS – It’s time to take bariatric out of bariatric surgery.
“The way forward is to not call it bariatric surgery or weight-loss surgery but surgery to treat diabetes, hypertension, hyperlipidemia, and other metabolic diseases,” said Oliver A. Varban, MD, at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “We need to reframe the conversation with patients about what success [with bariatric surgery] looks like. Weight loss can be a side effect of the operation if patients have surgery to resolve their diabetes. It’s not about BMI; it’s about treating metabolic disease.”
Dr. Varban, a bariatric surgeon at the University of Michigan in Ann Arbor, reported data showing that bariatric surgery with sleeve gastrectomy in patients with baseline body mass index (BMI) levels below 35 kg/m2 was as effective at normalizing a range of metabolically associated disorders as it was in more obese patients in an observational study of more than 45,000 patients who underwent surgery in Michigan.
The findings add to an already extensive pool of evidence for loosening current guidelines that restrict bariatric surgery to patients with a BMI of 35 kg/m2 or greater, Dr. Varban said. But an influential bariatric surgery consensus statement from the National Institutes of Health that dates from 1991 and remains in place, recommends this surgery only for people with a BMI of at least 35 kg/m2, and this guidance often limits access to the surgery for patients at lower BMI, he noted.
A more inclusive assessment of patients as potential candidates for bariatric surgery should include a range of considerations in addition to weight and height, he explained in an interview. “Even if people have a BMI of less than 30 kg/m2 but have, or are at high risk for developing, metabolic disease, they should also be offered the operation.”
The guidance from the NIH results in a U.S. bariatric surgery population that effectively centers mainly on women with a BMI of 40 kg/m2 or greater and makes procedures like sleeve gastrectomy unavailable to many other types of patients who could benefit from it, Dr. Varban said. In 2018, the American Society for Metabolic and Bariatric Surgery released a position statement that summarized the evidence for the safety and efficacy of bariatric surgery in people with a BMI of 30-34 kg/m2, and cited the lingering and restrictive impact of the 1991 NIH consensus statement.
The study run by Dr. Varban and his associates used data collected by 43 programs in the Michigan Bariatric Surgery Collaborative during 2006-2018 that included 1,073 patients who had a BMI of less than 35 kg/m2 on the day they underwent sleeve gastrectomy, and 44,511 patients who had the same procedure and had a BMI of at least 35 kg/m2. The operations were performed by any one of 81 surgeons who worked at the centers during this time.
The patients with lower BMIs were older, with an average age of 51 years, compared with 45 years in the higher-BMI group, and they had higher prevalences of certain metabolic disorders. Diabetes affected 37% of those in the lower-BMI group and 31% of those with higher BMIs; hyperlipidemia affected 57% and 45%, respectively; and gastroesophageal reflux disease affected 56% and 49%, respectively. Obstructive sleep apnea was more common in the group with higher BMIs, at 47%, compared with 41% of those with lower BMIs.
The average BMI in the lower group was 33.7 kg/m2; in the higher group it was 46.7 kg/m2. Dr. Varban did not have data on whether any patients in the lower-BMI group had a BMI below 30 kg/m2. Roughly a third of the patients in the lower-BMI group had a BMI of less than 35 kg/m2 at the time of their initial examination, whereas the other two-thirds had a BMI that low only on the day of their surgery.At follow-up 1 year after their surgery, patients who started with lower BMIs had, in general, a very similar pattern of responses as those who started with higher BMIs, with rates of discontinuation of treatments for diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, and gastroesophageal reflux of about 50%-80% and similar in both treatment arms. For example, discontinuation of oral diabetes drugs occurred in 79% and 78% of those with low and high BMIs, respectively, and discontinuation of hypertension medications occurred in 60% and 54%, respectively. Although the average absolute weight loss in the patients with lower BMIs was nearly half that of patients with higher starting BMIs, a much greater percentage of patients in the lower-BMI group achieved a BMI of less than 25 kg/m2, compared with the higher-BMI group (36% vs. 6%, respectively).
Patients from the lower-BMI group also showed high levels of satisfaction with their surgery and its results after 1 year. Questionnaire results from roughly half the patients in each treatment group showed that 90% were very satisfied in the lower-BMI group, compared with 84% of those who began with higher BMIs, with a dissatisfaction rate of 1% and 2%, respectively. The average body-image score at 1 year follow-up was significantly higher in those who started with lower BMIs. The rate of complications was low and similar in the two groups, with a 6% rate in the lower-BMI group and 5% in those with higher BMIs.
The study received no commercial funding. Dr. Varban receives salary support from Blue Cross Blue Shield of Michigan.
SOURCE: Varban et al. Obesity Week 2019, Abstract A105.
This article was updated 11/8/2020.
This is a very important topic and study, and its findings are very positive and reinforcing for more liberal use of bariatric surgery. Results from several prior studies had documented the safety and efficacy of bariatric surgery in patients with lower body mass index, and its fantastic to now have additional data that show the same outcomes. A major challenge is making patients and more physicians aware of the range of comorbidities that can be effectively managed with bariatric surgery, even in patients with lower body mass index.
Mona Misra, MD, is associate director of the Bariatric Program at Cedars-Sinai Marina Del Rey Hospital in Los Angeles. She had no relevant disclosures. She made these comments as designated discussant for the study.
This is a very important topic and study, and its findings are very positive and reinforcing for more liberal use of bariatric surgery. Results from several prior studies had documented the safety and efficacy of bariatric surgery in patients with lower body mass index, and its fantastic to now have additional data that show the same outcomes. A major challenge is making patients and more physicians aware of the range of comorbidities that can be effectively managed with bariatric surgery, even in patients with lower body mass index.
Mona Misra, MD, is associate director of the Bariatric Program at Cedars-Sinai Marina Del Rey Hospital in Los Angeles. She had no relevant disclosures. She made these comments as designated discussant for the study.
This is a very important topic and study, and its findings are very positive and reinforcing for more liberal use of bariatric surgery. Results from several prior studies had documented the safety and efficacy of bariatric surgery in patients with lower body mass index, and its fantastic to now have additional data that show the same outcomes. A major challenge is making patients and more physicians aware of the range of comorbidities that can be effectively managed with bariatric surgery, even in patients with lower body mass index.
Mona Misra, MD, is associate director of the Bariatric Program at Cedars-Sinai Marina Del Rey Hospital in Los Angeles. She had no relevant disclosures. She made these comments as designated discussant for the study.
LAS VEGAS – It’s time to take bariatric out of bariatric surgery.
“The way forward is to not call it bariatric surgery or weight-loss surgery but surgery to treat diabetes, hypertension, hyperlipidemia, and other metabolic diseases,” said Oliver A. Varban, MD, at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “We need to reframe the conversation with patients about what success [with bariatric surgery] looks like. Weight loss can be a side effect of the operation if patients have surgery to resolve their diabetes. It’s not about BMI; it’s about treating metabolic disease.”
Dr. Varban, a bariatric surgeon at the University of Michigan in Ann Arbor, reported data showing that bariatric surgery with sleeve gastrectomy in patients with baseline body mass index (BMI) levels below 35 kg/m2 was as effective at normalizing a range of metabolically associated disorders as it was in more obese patients in an observational study of more than 45,000 patients who underwent surgery in Michigan.
The findings add to an already extensive pool of evidence for loosening current guidelines that restrict bariatric surgery to patients with a BMI of 35 kg/m2 or greater, Dr. Varban said. But an influential bariatric surgery consensus statement from the National Institutes of Health that dates from 1991 and remains in place, recommends this surgery only for people with a BMI of at least 35 kg/m2, and this guidance often limits access to the surgery for patients at lower BMI, he noted.
A more inclusive assessment of patients as potential candidates for bariatric surgery should include a range of considerations in addition to weight and height, he explained in an interview. “Even if people have a BMI of less than 30 kg/m2 but have, or are at high risk for developing, metabolic disease, they should also be offered the operation.”
The guidance from the NIH results in a U.S. bariatric surgery population that effectively centers mainly on women with a BMI of 40 kg/m2 or greater and makes procedures like sleeve gastrectomy unavailable to many other types of patients who could benefit from it, Dr. Varban said. In 2018, the American Society for Metabolic and Bariatric Surgery released a position statement that summarized the evidence for the safety and efficacy of bariatric surgery in people with a BMI of 30-34 kg/m2, and cited the lingering and restrictive impact of the 1991 NIH consensus statement.
The study run by Dr. Varban and his associates used data collected by 43 programs in the Michigan Bariatric Surgery Collaborative during 2006-2018 that included 1,073 patients who had a BMI of less than 35 kg/m2 on the day they underwent sleeve gastrectomy, and 44,511 patients who had the same procedure and had a BMI of at least 35 kg/m2. The operations were performed by any one of 81 surgeons who worked at the centers during this time.
The patients with lower BMIs were older, with an average age of 51 years, compared with 45 years in the higher-BMI group, and they had higher prevalences of certain metabolic disorders. Diabetes affected 37% of those in the lower-BMI group and 31% of those with higher BMIs; hyperlipidemia affected 57% and 45%, respectively; and gastroesophageal reflux disease affected 56% and 49%, respectively. Obstructive sleep apnea was more common in the group with higher BMIs, at 47%, compared with 41% of those with lower BMIs.
The average BMI in the lower group was 33.7 kg/m2; in the higher group it was 46.7 kg/m2. Dr. Varban did not have data on whether any patients in the lower-BMI group had a BMI below 30 kg/m2. Roughly a third of the patients in the lower-BMI group had a BMI of less than 35 kg/m2 at the time of their initial examination, whereas the other two-thirds had a BMI that low only on the day of their surgery.At follow-up 1 year after their surgery, patients who started with lower BMIs had, in general, a very similar pattern of responses as those who started with higher BMIs, with rates of discontinuation of treatments for diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, and gastroesophageal reflux of about 50%-80% and similar in both treatment arms. For example, discontinuation of oral diabetes drugs occurred in 79% and 78% of those with low and high BMIs, respectively, and discontinuation of hypertension medications occurred in 60% and 54%, respectively. Although the average absolute weight loss in the patients with lower BMIs was nearly half that of patients with higher starting BMIs, a much greater percentage of patients in the lower-BMI group achieved a BMI of less than 25 kg/m2, compared with the higher-BMI group (36% vs. 6%, respectively).
Patients from the lower-BMI group also showed high levels of satisfaction with their surgery and its results after 1 year. Questionnaire results from roughly half the patients in each treatment group showed that 90% were very satisfied in the lower-BMI group, compared with 84% of those who began with higher BMIs, with a dissatisfaction rate of 1% and 2%, respectively. The average body-image score at 1 year follow-up was significantly higher in those who started with lower BMIs. The rate of complications was low and similar in the two groups, with a 6% rate in the lower-BMI group and 5% in those with higher BMIs.
The study received no commercial funding. Dr. Varban receives salary support from Blue Cross Blue Shield of Michigan.
SOURCE: Varban et al. Obesity Week 2019, Abstract A105.
This article was updated 11/8/2020.
LAS VEGAS – It’s time to take bariatric out of bariatric surgery.
“The way forward is to not call it bariatric surgery or weight-loss surgery but surgery to treat diabetes, hypertension, hyperlipidemia, and other metabolic diseases,” said Oliver A. Varban, MD, at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “We need to reframe the conversation with patients about what success [with bariatric surgery] looks like. Weight loss can be a side effect of the operation if patients have surgery to resolve their diabetes. It’s not about BMI; it’s about treating metabolic disease.”
Dr. Varban, a bariatric surgeon at the University of Michigan in Ann Arbor, reported data showing that bariatric surgery with sleeve gastrectomy in patients with baseline body mass index (BMI) levels below 35 kg/m2 was as effective at normalizing a range of metabolically associated disorders as it was in more obese patients in an observational study of more than 45,000 patients who underwent surgery in Michigan.
The findings add to an already extensive pool of evidence for loosening current guidelines that restrict bariatric surgery to patients with a BMI of 35 kg/m2 or greater, Dr. Varban said. But an influential bariatric surgery consensus statement from the National Institutes of Health that dates from 1991 and remains in place, recommends this surgery only for people with a BMI of at least 35 kg/m2, and this guidance often limits access to the surgery for patients at lower BMI, he noted.
A more inclusive assessment of patients as potential candidates for bariatric surgery should include a range of considerations in addition to weight and height, he explained in an interview. “Even if people have a BMI of less than 30 kg/m2 but have, or are at high risk for developing, metabolic disease, they should also be offered the operation.”
The guidance from the NIH results in a U.S. bariatric surgery population that effectively centers mainly on women with a BMI of 40 kg/m2 or greater and makes procedures like sleeve gastrectomy unavailable to many other types of patients who could benefit from it, Dr. Varban said. In 2018, the American Society for Metabolic and Bariatric Surgery released a position statement that summarized the evidence for the safety and efficacy of bariatric surgery in people with a BMI of 30-34 kg/m2, and cited the lingering and restrictive impact of the 1991 NIH consensus statement.
The study run by Dr. Varban and his associates used data collected by 43 programs in the Michigan Bariatric Surgery Collaborative during 2006-2018 that included 1,073 patients who had a BMI of less than 35 kg/m2 on the day they underwent sleeve gastrectomy, and 44,511 patients who had the same procedure and had a BMI of at least 35 kg/m2. The operations were performed by any one of 81 surgeons who worked at the centers during this time.
The patients with lower BMIs were older, with an average age of 51 years, compared with 45 years in the higher-BMI group, and they had higher prevalences of certain metabolic disorders. Diabetes affected 37% of those in the lower-BMI group and 31% of those with higher BMIs; hyperlipidemia affected 57% and 45%, respectively; and gastroesophageal reflux disease affected 56% and 49%, respectively. Obstructive sleep apnea was more common in the group with higher BMIs, at 47%, compared with 41% of those with lower BMIs.
The average BMI in the lower group was 33.7 kg/m2; in the higher group it was 46.7 kg/m2. Dr. Varban did not have data on whether any patients in the lower-BMI group had a BMI below 30 kg/m2. Roughly a third of the patients in the lower-BMI group had a BMI of less than 35 kg/m2 at the time of their initial examination, whereas the other two-thirds had a BMI that low only on the day of their surgery.At follow-up 1 year after their surgery, patients who started with lower BMIs had, in general, a very similar pattern of responses as those who started with higher BMIs, with rates of discontinuation of treatments for diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, and gastroesophageal reflux of about 50%-80% and similar in both treatment arms. For example, discontinuation of oral diabetes drugs occurred in 79% and 78% of those with low and high BMIs, respectively, and discontinuation of hypertension medications occurred in 60% and 54%, respectively. Although the average absolute weight loss in the patients with lower BMIs was nearly half that of patients with higher starting BMIs, a much greater percentage of patients in the lower-BMI group achieved a BMI of less than 25 kg/m2, compared with the higher-BMI group (36% vs. 6%, respectively).
Patients from the lower-BMI group also showed high levels of satisfaction with their surgery and its results after 1 year. Questionnaire results from roughly half the patients in each treatment group showed that 90% were very satisfied in the lower-BMI group, compared with 84% of those who began with higher BMIs, with a dissatisfaction rate of 1% and 2%, respectively. The average body-image score at 1 year follow-up was significantly higher in those who started with lower BMIs. The rate of complications was low and similar in the two groups, with a 6% rate in the lower-BMI group and 5% in those with higher BMIs.
The study received no commercial funding. Dr. Varban receives salary support from Blue Cross Blue Shield of Michigan.
SOURCE: Varban et al. Obesity Week 2019, Abstract A105.
This article was updated 11/8/2020.
REPORTING FROM OBESITY WEEK 2019
Key clinical point:
Major finding: Discontinuation of hypertension drugs occurred in 60% of patients with lower BMIs at baseline and 54% of those with higher BMIs.
Study details: Review of prospectively collected data from 45,584 patients who underwent sleeve gastrectomy in Michigan during 2006-2018.
Disclosures: The study received no commercial funding. Dr. Varban receives salary support from Blue Cross Blue Shield of Michigan. Dr. Misra had no relevant disclosures.
Source: Varban OA et al. Obesity Week 2019, Abstract A105.
Greater weight loss with sleeve gastroplasty than with diet therapy
Endoscopic sleeve gastroplasty achieves significantly greater weight loss than that of a high-intensity diet and lifestyle therapy program, according to a study published in Gastrointestinal Endoscopy.
In the retrospective case-matched study, 105 patients who underwent endoscopic sleeve gastroplasty, in combination with a low-intensity diet and lifestyle therapy, were compared with 281 patients who participated in a high-intensity diet and lifestyle therapy program.
“As ESG [endoscopic sleeve gastroplasty] continues to gain traction worldwide, a comprehensive understanding of its outcomes and relative place among the battery of weight loss treatments is important,” wrote Lawrence J. Cheskin, MD, of Johns Hopkins Bloomberg School of Public Health, Baltimore, and coauthors, noting that only two studies have compared endoscopic sleeve gastroscopy with another weight loss therapy.
The high-intensity program involved patients being prescribed a low-calorie, high-protein diet of 800-1,200 calories a day, and taking part in behavioral, nutritional, and exercise counseling as well as optional support from psychotherapy, support groups, and meal replacements.
The study found that patients who underwent the gastroplasty lost significantly greater mean percentage of body weight compared with those who participated in the therapy program.
At 1 month, mean percentage body weight loss was 9.3% in the gastroplasty group compared with 7% in the therapy group. At 3 months it was 14% compared with 11.3%, at 6 months it was 17.7% compared with 14.7%, and at 12 months it was 20.6% compared with 14.3%. Significantly more patients in the gastroplasty group reached 5%, 10%, and 20% weight loss compared with the therapy group.
The authors noted that high-intensity diet and lifestyle therapy programs had “notoriously” high rates of noncompliance and withdrawal from treatment; adherence rates of 63.1% and 59.6% had been seen in previous observational studies.
“Therefore, ESG may be a valuable alternative for patients who have had trouble adhering to HIDLT [high-intensity diet and lifestyle therapy],” they wrote. “Given the diversity of the obese population, ESG may begin to fill some gaps in the obesity treatment arsenal.”
A subgroup analysis looked at patients with a baseline body mass index below or above 40 kg/m2, and found even after adjustment for age and sex, both groups showed significantly more weight loss at 1 and 3 months for patients who underwent gastroplasty. However, at 6 and 12 months, the study saw no significant difference between gastroplasty and the therapy program for patients with a baseline BMI above 40 kg/m2.
While the cause of this difference in effect in higher BMI patients was unknown, it may be that sleeve gastroplasty is less effective because it is counteracted by neurohormonal effects that are altered with bariatric surgery, the authors wrote.
“This is worth exploring in future randomized control trials because it will give us insight into which patients are superior candidates for endoscopic bariatric therapy,” they wrote.
There were five moderate to severe adverse events in the gastroplasty cohort and none in the therapy group. There were three cases of upper gastrointestinal bleeding caused by gastric ulceration. In one case, the patient underwent diagnostic endoscopy, admission, and 48-hour monitoring. Another patient developed perigastric fluid collection, and one was admitted for intravenous hydration after experiencing dehydration. Despite this, the authors suggested the adverse event rate associated with the procedure may be acceptable to patients because of the superior weight loss effect compared with therapy programs.
No funding was declared. Three authors declared consultancies, advisory board positions, and personal fees from medical device companies including those in the endoscopy space. No other conflicts of interest were declared.
SOURCE: Cheskin L et al. Gastrointest Endosc. 2019 Sep 27. doi: 10.1016/j.gie.2019.09.029.
Endoscopic sleeve gastroplasty achieves significantly greater weight loss than that of a high-intensity diet and lifestyle therapy program, according to a study published in Gastrointestinal Endoscopy.
In the retrospective case-matched study, 105 patients who underwent endoscopic sleeve gastroplasty, in combination with a low-intensity diet and lifestyle therapy, were compared with 281 patients who participated in a high-intensity diet and lifestyle therapy program.
“As ESG [endoscopic sleeve gastroplasty] continues to gain traction worldwide, a comprehensive understanding of its outcomes and relative place among the battery of weight loss treatments is important,” wrote Lawrence J. Cheskin, MD, of Johns Hopkins Bloomberg School of Public Health, Baltimore, and coauthors, noting that only two studies have compared endoscopic sleeve gastroscopy with another weight loss therapy.
The high-intensity program involved patients being prescribed a low-calorie, high-protein diet of 800-1,200 calories a day, and taking part in behavioral, nutritional, and exercise counseling as well as optional support from psychotherapy, support groups, and meal replacements.
The study found that patients who underwent the gastroplasty lost significantly greater mean percentage of body weight compared with those who participated in the therapy program.
At 1 month, mean percentage body weight loss was 9.3% in the gastroplasty group compared with 7% in the therapy group. At 3 months it was 14% compared with 11.3%, at 6 months it was 17.7% compared with 14.7%, and at 12 months it was 20.6% compared with 14.3%. Significantly more patients in the gastroplasty group reached 5%, 10%, and 20% weight loss compared with the therapy group.
The authors noted that high-intensity diet and lifestyle therapy programs had “notoriously” high rates of noncompliance and withdrawal from treatment; adherence rates of 63.1% and 59.6% had been seen in previous observational studies.
“Therefore, ESG may be a valuable alternative for patients who have had trouble adhering to HIDLT [high-intensity diet and lifestyle therapy],” they wrote. “Given the diversity of the obese population, ESG may begin to fill some gaps in the obesity treatment arsenal.”
A subgroup analysis looked at patients with a baseline body mass index below or above 40 kg/m2, and found even after adjustment for age and sex, both groups showed significantly more weight loss at 1 and 3 months for patients who underwent gastroplasty. However, at 6 and 12 months, the study saw no significant difference between gastroplasty and the therapy program for patients with a baseline BMI above 40 kg/m2.
While the cause of this difference in effect in higher BMI patients was unknown, it may be that sleeve gastroplasty is less effective because it is counteracted by neurohormonal effects that are altered with bariatric surgery, the authors wrote.
“This is worth exploring in future randomized control trials because it will give us insight into which patients are superior candidates for endoscopic bariatric therapy,” they wrote.
There were five moderate to severe adverse events in the gastroplasty cohort and none in the therapy group. There were three cases of upper gastrointestinal bleeding caused by gastric ulceration. In one case, the patient underwent diagnostic endoscopy, admission, and 48-hour monitoring. Another patient developed perigastric fluid collection, and one was admitted for intravenous hydration after experiencing dehydration. Despite this, the authors suggested the adverse event rate associated with the procedure may be acceptable to patients because of the superior weight loss effect compared with therapy programs.
No funding was declared. Three authors declared consultancies, advisory board positions, and personal fees from medical device companies including those in the endoscopy space. No other conflicts of interest were declared.
SOURCE: Cheskin L et al. Gastrointest Endosc. 2019 Sep 27. doi: 10.1016/j.gie.2019.09.029.
Endoscopic sleeve gastroplasty achieves significantly greater weight loss than that of a high-intensity diet and lifestyle therapy program, according to a study published in Gastrointestinal Endoscopy.
In the retrospective case-matched study, 105 patients who underwent endoscopic sleeve gastroplasty, in combination with a low-intensity diet and lifestyle therapy, were compared with 281 patients who participated in a high-intensity diet and lifestyle therapy program.
“As ESG [endoscopic sleeve gastroplasty] continues to gain traction worldwide, a comprehensive understanding of its outcomes and relative place among the battery of weight loss treatments is important,” wrote Lawrence J. Cheskin, MD, of Johns Hopkins Bloomberg School of Public Health, Baltimore, and coauthors, noting that only two studies have compared endoscopic sleeve gastroscopy with another weight loss therapy.
The high-intensity program involved patients being prescribed a low-calorie, high-protein diet of 800-1,200 calories a day, and taking part in behavioral, nutritional, and exercise counseling as well as optional support from psychotherapy, support groups, and meal replacements.
The study found that patients who underwent the gastroplasty lost significantly greater mean percentage of body weight compared with those who participated in the therapy program.
At 1 month, mean percentage body weight loss was 9.3% in the gastroplasty group compared with 7% in the therapy group. At 3 months it was 14% compared with 11.3%, at 6 months it was 17.7% compared with 14.7%, and at 12 months it was 20.6% compared with 14.3%. Significantly more patients in the gastroplasty group reached 5%, 10%, and 20% weight loss compared with the therapy group.
The authors noted that high-intensity diet and lifestyle therapy programs had “notoriously” high rates of noncompliance and withdrawal from treatment; adherence rates of 63.1% and 59.6% had been seen in previous observational studies.
“Therefore, ESG may be a valuable alternative for patients who have had trouble adhering to HIDLT [high-intensity diet and lifestyle therapy],” they wrote. “Given the diversity of the obese population, ESG may begin to fill some gaps in the obesity treatment arsenal.”
A subgroup analysis looked at patients with a baseline body mass index below or above 40 kg/m2, and found even after adjustment for age and sex, both groups showed significantly more weight loss at 1 and 3 months for patients who underwent gastroplasty. However, at 6 and 12 months, the study saw no significant difference between gastroplasty and the therapy program for patients with a baseline BMI above 40 kg/m2.
While the cause of this difference in effect in higher BMI patients was unknown, it may be that sleeve gastroplasty is less effective because it is counteracted by neurohormonal effects that are altered with bariatric surgery, the authors wrote.
“This is worth exploring in future randomized control trials because it will give us insight into which patients are superior candidates for endoscopic bariatric therapy,” they wrote.
There were five moderate to severe adverse events in the gastroplasty cohort and none in the therapy group. There were three cases of upper gastrointestinal bleeding caused by gastric ulceration. In one case, the patient underwent diagnostic endoscopy, admission, and 48-hour monitoring. Another patient developed perigastric fluid collection, and one was admitted for intravenous hydration after experiencing dehydration. Despite this, the authors suggested the adverse event rate associated with the procedure may be acceptable to patients because of the superior weight loss effect compared with therapy programs.
No funding was declared. Three authors declared consultancies, advisory board positions, and personal fees from medical device companies including those in the endoscopy space. No other conflicts of interest were declared.
SOURCE: Cheskin L et al. Gastrointest Endosc. 2019 Sep 27. doi: 10.1016/j.gie.2019.09.029.
FROM GASTROINTESTINAL ENDOSCOPY
Prior maternal gastric bypass surgery tied to fewer birth defects
according to data from a cohort study of 2,921 women with a history of gastric bypass surgery and 30,573 matched controls.
“Obesity is associated with poor glucose control, which is teratogenic. Bariatric surgery results in weight loss and glucose normalization but is also associated with nutritional deficiencies and substance abuse, which could cause birth defects as hypothesized based on case series,” wrote Martin Neovius, PhD, of Karolinska Institutet, Stockholm, Sweden, and colleagues.
To determine the risk of birth defects for infants born to women after gastric bypass surgery, the researchers used the Swedish Medical Birth Register to identify singleton infants born between 2007 and 2014 to women who underwent Roux-en-Y gastric bypass surgery and matched controls. The findings were published in a research letter in JAMA.
In the surgery group, the mean interval from surgery to conception was 1.6 years, and the mean weight loss was 40 kg for these women. In addition, the use of diabetes drugs decreased from 10% before surgery to 2% during the 6 months before conception.
Overall, major birth defects occurred in 3% of infants in the gastric bypass groups versus 5% of infants in the control group (risk ratio, 0.67). No neural tube defects occurred in the surgery group and 20 cases of neural tube defects were noted in the control group.
The study was limited by several factors including the lack of data on pregnancy termination, exclusion of stillbirths, and inability to analyze individual birth defects because of small numbers, the researchers noted.
Nonetheless, the results suggest that “a mechanism could be that surgery-induced improvements in glucose metabolism, and potentially other beneficial physiologic changes, led to a reduction of major birth defect risk to a level similar to that of the general population,” they said.
Dr. Neovius disclosed advisory board fees from Itrim and Ethicon Johnson & Johnson. Three coauthors reported grants or other fees from a variety of pharmaceutical companies. The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health, by the Swedish Research Council, and by the Swedish Research Council for Health, Working Life, and Welfare.
SOURCE: Neovius M et al. JAMA. 2019 Oct 15; 322:1515-17.
according to data from a cohort study of 2,921 women with a history of gastric bypass surgery and 30,573 matched controls.
“Obesity is associated with poor glucose control, which is teratogenic. Bariatric surgery results in weight loss and glucose normalization but is also associated with nutritional deficiencies and substance abuse, which could cause birth defects as hypothesized based on case series,” wrote Martin Neovius, PhD, of Karolinska Institutet, Stockholm, Sweden, and colleagues.
To determine the risk of birth defects for infants born to women after gastric bypass surgery, the researchers used the Swedish Medical Birth Register to identify singleton infants born between 2007 and 2014 to women who underwent Roux-en-Y gastric bypass surgery and matched controls. The findings were published in a research letter in JAMA.
In the surgery group, the mean interval from surgery to conception was 1.6 years, and the mean weight loss was 40 kg for these women. In addition, the use of diabetes drugs decreased from 10% before surgery to 2% during the 6 months before conception.
Overall, major birth defects occurred in 3% of infants in the gastric bypass groups versus 5% of infants in the control group (risk ratio, 0.67). No neural tube defects occurred in the surgery group and 20 cases of neural tube defects were noted in the control group.
The study was limited by several factors including the lack of data on pregnancy termination, exclusion of stillbirths, and inability to analyze individual birth defects because of small numbers, the researchers noted.
Nonetheless, the results suggest that “a mechanism could be that surgery-induced improvements in glucose metabolism, and potentially other beneficial physiologic changes, led to a reduction of major birth defect risk to a level similar to that of the general population,” they said.
Dr. Neovius disclosed advisory board fees from Itrim and Ethicon Johnson & Johnson. Three coauthors reported grants or other fees from a variety of pharmaceutical companies. The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health, by the Swedish Research Council, and by the Swedish Research Council for Health, Working Life, and Welfare.
SOURCE: Neovius M et al. JAMA. 2019 Oct 15; 322:1515-17.
according to data from a cohort study of 2,921 women with a history of gastric bypass surgery and 30,573 matched controls.
“Obesity is associated with poor glucose control, which is teratogenic. Bariatric surgery results in weight loss and glucose normalization but is also associated with nutritional deficiencies and substance abuse, which could cause birth defects as hypothesized based on case series,” wrote Martin Neovius, PhD, of Karolinska Institutet, Stockholm, Sweden, and colleagues.
To determine the risk of birth defects for infants born to women after gastric bypass surgery, the researchers used the Swedish Medical Birth Register to identify singleton infants born between 2007 and 2014 to women who underwent Roux-en-Y gastric bypass surgery and matched controls. The findings were published in a research letter in JAMA.
In the surgery group, the mean interval from surgery to conception was 1.6 years, and the mean weight loss was 40 kg for these women. In addition, the use of diabetes drugs decreased from 10% before surgery to 2% during the 6 months before conception.
Overall, major birth defects occurred in 3% of infants in the gastric bypass groups versus 5% of infants in the control group (risk ratio, 0.67). No neural tube defects occurred in the surgery group and 20 cases of neural tube defects were noted in the control group.
The study was limited by several factors including the lack of data on pregnancy termination, exclusion of stillbirths, and inability to analyze individual birth defects because of small numbers, the researchers noted.
Nonetheless, the results suggest that “a mechanism could be that surgery-induced improvements in glucose metabolism, and potentially other beneficial physiologic changes, led to a reduction of major birth defect risk to a level similar to that of the general population,” they said.
Dr. Neovius disclosed advisory board fees from Itrim and Ethicon Johnson & Johnson. Three coauthors reported grants or other fees from a variety of pharmaceutical companies. The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health, by the Swedish Research Council, and by the Swedish Research Council for Health, Working Life, and Welfare.
SOURCE: Neovius M et al. JAMA. 2019 Oct 15; 322:1515-17.
FROM JAMA
Key clinical point: Infants whose mothers previously underwent gastric bypass surgery had a lower risk of birth defects than did the infants of matched controls.
Major finding: Major birth defects occurred in 3% of infants whose mothers had gastric bypass surgery, compared with 5% of infants born to control women.
Study details: The data come from a cohort study of 2,921 women with history of gastric bypass surgery and 30,573 matched controls.
Disclosures: Dr. Neovius disclosed advisory board fees from Itrim and Ethicon Johnson & Johnson. Three coauthors reported grants or other fees from a variety of pharmaceutical companies. The study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases at the National Institutes of Health, by the Swedish Research Council, and by the Swedish Research Council for Health, Working Life, and Welfare.
Source: Neovius M et al. JAMA. 2019 Oct 15; 322:1515-17.
Weight loss surgery linked to lower CV event risk in diabetes
, compared with nonsurgical management, according to data presented at the annual congress of the European Society of Cardiology.
The retrospective cohort study, simultaneously published in JAMA, looked at outcomes in 13,722 individuals with type 2 diabetes and obesity, 2,287 of whom underwent metabolic surgery and the rest of the matched cohort receiving usual care.
At 8 years of follow-up, the cumulative incidence of the primary endpoint – a composite of first occurrence of all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation – was 30.8% in the weight loss–surgery group and 47.7% in the nonsurgical-control group, representing a 39% lower risk with weight loss surgery (P less than .001).
The analysis failed to find any interaction with sex, age, body mass index (BMI), HbA1c level, estimated glomerular filtration rate, or use of insulin, sulfonylureas, or lipid-lowering medications.
Metabolic surgery was also associated with a significantly lower cumulative incidence of myocardial infarction, ischemic stroke and mortality than usual care (17% vs. 27.6%).
In particular, researchers saw a significant 41% reduction in the risk of death at eight years in the surgical group compared to usual care (10% vs. 17.8%), a 62% reduction in the risk of heart failure, a 31% reduction in the risk of coronary artery disease, and a 60% reduction in nephropathy risk. Metabolic surgery was also associated with a 33% reduction in cerebrovascular disease risk, and a 22% lower risk of atrial fibrillation.
In the group that underwent metabolic surgery, mean bodyweight at 8 years was reduced by 29.1 kg, compared with 8.7 kg in the control group. At baseline, 75% of the metabolic surgery group had a BMI of 40 kg/m2 or above, 20% had a BMI between 35-39.9, and 5% had a BMI between 30-34.9.
The surgery was also associated with significantly greater reductions in HbA1c, and in the use of noninsulin diabetes medications, insulin, antihypertensive medications, lipid-lowering therapies, and aspirin.
The most common surgical weight loss procedure was Roux-en-Y gastric bypass (63%), followed by sleeve gastrectomy (32%), and adjustable gastric banding (5%). Five patients underwent duodenal switch.
In the 90 days after surgery, 3% of patients experienced bleeding that required transfusion, 2.5% experienced pulmonary adverse events, 1% experienced venous thromboembolism, 0.7% experienced cardiac events, and 0.2% experienced renal failure that required dialysis. There were also 15 deaths (0.7%) in the surgical group, and 4.8% of patients required abdominal surgical intervention.
“We speculate that the lower rate of [major adverse cardiovascular events] after metabolic surgery observed in this study may be related to substantial and sustained weight loss with subsequent improvement in metabolic, structural, hemodynamic, and neurohormonal abnormalities,” wrote Ali Aminian, MD, of the Bariatric and Metabolic Institute at the Cleveland Clinic, and coauthors.
“Although large and sustained surgically induced weight loss has profound physiologic effects, a growing body of evidence indicates that some of the beneficial metabolic and neurohormonal changes that occur after metabolic surgical procedures are related to anatomical changes in the gastrointestinal tract that are partially independent of weight loss,” they wrote.
The authors, however, were also keen to point out that their study was observational, and should therefore be considered “hypothesis generating.” While the two study groups were matched on 37 baseline covariates, those in the surgical group did have a higher body weight, higher BMI, higher rates of dyslipidemia, and higher rates of hypertension.
“The findings from this observational study must be confirmed in randomized clinical trials,” they noted.
The study was partly funded by Medtronic, and one author was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Five authors declared funding and support from private industry, including from Medtronic, and one author declared institutional grants.
SOURCE: Aminian A et al. JAMA 2019, Sept 2. DOI: 10.1001/jama.2019.14231.
Despite a focus on reducing macrovascular events in individuals with type 2 diabetes, none of the major randomized controlled trials of glucose-lowering interventions that support current treatment guidelines have achieved this outcome. This study of bariatric surgery in obese patients with diabetes, however, does show reductions in major adverse cardiovascular events, although these outcomes should be interpreted with caution because of their observational nature and imprecise matching of the study groups.
Despite this, the many known benefits associated with bariatric surgery–induced weight loss suggest that for carefully selected, motivated patients with obesity and type 2 diabetes – who have been unable to lose weight by other means – this could be the preferred treatment option.
Dr. Edward H. Livingston is the deputy editor of JAMA and with the department of surgery at the University of California, Los Angeles. These comments are adapted from an accompanying editorial (JAMA 2019, Sept 2. DOI:10.1001/jama.2019.14577). No conflicts of interest were declared.
Despite a focus on reducing macrovascular events in individuals with type 2 diabetes, none of the major randomized controlled trials of glucose-lowering interventions that support current treatment guidelines have achieved this outcome. This study of bariatric surgery in obese patients with diabetes, however, does show reductions in major adverse cardiovascular events, although these outcomes should be interpreted with caution because of their observational nature and imprecise matching of the study groups.
Despite this, the many known benefits associated with bariatric surgery–induced weight loss suggest that for carefully selected, motivated patients with obesity and type 2 diabetes – who have been unable to lose weight by other means – this could be the preferred treatment option.
Dr. Edward H. Livingston is the deputy editor of JAMA and with the department of surgery at the University of California, Los Angeles. These comments are adapted from an accompanying editorial (JAMA 2019, Sept 2. DOI:10.1001/jama.2019.14577). No conflicts of interest were declared.
Despite a focus on reducing macrovascular events in individuals with type 2 diabetes, none of the major randomized controlled trials of glucose-lowering interventions that support current treatment guidelines have achieved this outcome. This study of bariatric surgery in obese patients with diabetes, however, does show reductions in major adverse cardiovascular events, although these outcomes should be interpreted with caution because of their observational nature and imprecise matching of the study groups.
Despite this, the many known benefits associated with bariatric surgery–induced weight loss suggest that for carefully selected, motivated patients with obesity and type 2 diabetes – who have been unable to lose weight by other means – this could be the preferred treatment option.
Dr. Edward H. Livingston is the deputy editor of JAMA and with the department of surgery at the University of California, Los Angeles. These comments are adapted from an accompanying editorial (JAMA 2019, Sept 2. DOI:10.1001/jama.2019.14577). No conflicts of interest were declared.
, compared with nonsurgical management, according to data presented at the annual congress of the European Society of Cardiology.
The retrospective cohort study, simultaneously published in JAMA, looked at outcomes in 13,722 individuals with type 2 diabetes and obesity, 2,287 of whom underwent metabolic surgery and the rest of the matched cohort receiving usual care.
At 8 years of follow-up, the cumulative incidence of the primary endpoint – a composite of first occurrence of all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation – was 30.8% in the weight loss–surgery group and 47.7% in the nonsurgical-control group, representing a 39% lower risk with weight loss surgery (P less than .001).
The analysis failed to find any interaction with sex, age, body mass index (BMI), HbA1c level, estimated glomerular filtration rate, or use of insulin, sulfonylureas, or lipid-lowering medications.
Metabolic surgery was also associated with a significantly lower cumulative incidence of myocardial infarction, ischemic stroke and mortality than usual care (17% vs. 27.6%).
In particular, researchers saw a significant 41% reduction in the risk of death at eight years in the surgical group compared to usual care (10% vs. 17.8%), a 62% reduction in the risk of heart failure, a 31% reduction in the risk of coronary artery disease, and a 60% reduction in nephropathy risk. Metabolic surgery was also associated with a 33% reduction in cerebrovascular disease risk, and a 22% lower risk of atrial fibrillation.
In the group that underwent metabolic surgery, mean bodyweight at 8 years was reduced by 29.1 kg, compared with 8.7 kg in the control group. At baseline, 75% of the metabolic surgery group had a BMI of 40 kg/m2 or above, 20% had a BMI between 35-39.9, and 5% had a BMI between 30-34.9.
The surgery was also associated with significantly greater reductions in HbA1c, and in the use of noninsulin diabetes medications, insulin, antihypertensive medications, lipid-lowering therapies, and aspirin.
The most common surgical weight loss procedure was Roux-en-Y gastric bypass (63%), followed by sleeve gastrectomy (32%), and adjustable gastric banding (5%). Five patients underwent duodenal switch.
In the 90 days after surgery, 3% of patients experienced bleeding that required transfusion, 2.5% experienced pulmonary adverse events, 1% experienced venous thromboembolism, 0.7% experienced cardiac events, and 0.2% experienced renal failure that required dialysis. There were also 15 deaths (0.7%) in the surgical group, and 4.8% of patients required abdominal surgical intervention.
“We speculate that the lower rate of [major adverse cardiovascular events] after metabolic surgery observed in this study may be related to substantial and sustained weight loss with subsequent improvement in metabolic, structural, hemodynamic, and neurohormonal abnormalities,” wrote Ali Aminian, MD, of the Bariatric and Metabolic Institute at the Cleveland Clinic, and coauthors.
“Although large and sustained surgically induced weight loss has profound physiologic effects, a growing body of evidence indicates that some of the beneficial metabolic and neurohormonal changes that occur after metabolic surgical procedures are related to anatomical changes in the gastrointestinal tract that are partially independent of weight loss,” they wrote.
The authors, however, were also keen to point out that their study was observational, and should therefore be considered “hypothesis generating.” While the two study groups were matched on 37 baseline covariates, those in the surgical group did have a higher body weight, higher BMI, higher rates of dyslipidemia, and higher rates of hypertension.
“The findings from this observational study must be confirmed in randomized clinical trials,” they noted.
The study was partly funded by Medtronic, and one author was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Five authors declared funding and support from private industry, including from Medtronic, and one author declared institutional grants.
SOURCE: Aminian A et al. JAMA 2019, Sept 2. DOI: 10.1001/jama.2019.14231.
, compared with nonsurgical management, according to data presented at the annual congress of the European Society of Cardiology.
The retrospective cohort study, simultaneously published in JAMA, looked at outcomes in 13,722 individuals with type 2 diabetes and obesity, 2,287 of whom underwent metabolic surgery and the rest of the matched cohort receiving usual care.
At 8 years of follow-up, the cumulative incidence of the primary endpoint – a composite of first occurrence of all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation – was 30.8% in the weight loss–surgery group and 47.7% in the nonsurgical-control group, representing a 39% lower risk with weight loss surgery (P less than .001).
The analysis failed to find any interaction with sex, age, body mass index (BMI), HbA1c level, estimated glomerular filtration rate, or use of insulin, sulfonylureas, or lipid-lowering medications.
Metabolic surgery was also associated with a significantly lower cumulative incidence of myocardial infarction, ischemic stroke and mortality than usual care (17% vs. 27.6%).
In particular, researchers saw a significant 41% reduction in the risk of death at eight years in the surgical group compared to usual care (10% vs. 17.8%), a 62% reduction in the risk of heart failure, a 31% reduction in the risk of coronary artery disease, and a 60% reduction in nephropathy risk. Metabolic surgery was also associated with a 33% reduction in cerebrovascular disease risk, and a 22% lower risk of atrial fibrillation.
In the group that underwent metabolic surgery, mean bodyweight at 8 years was reduced by 29.1 kg, compared with 8.7 kg in the control group. At baseline, 75% of the metabolic surgery group had a BMI of 40 kg/m2 or above, 20% had a BMI between 35-39.9, and 5% had a BMI between 30-34.9.
The surgery was also associated with significantly greater reductions in HbA1c, and in the use of noninsulin diabetes medications, insulin, antihypertensive medications, lipid-lowering therapies, and aspirin.
The most common surgical weight loss procedure was Roux-en-Y gastric bypass (63%), followed by sleeve gastrectomy (32%), and adjustable gastric banding (5%). Five patients underwent duodenal switch.
In the 90 days after surgery, 3% of patients experienced bleeding that required transfusion, 2.5% experienced pulmonary adverse events, 1% experienced venous thromboembolism, 0.7% experienced cardiac events, and 0.2% experienced renal failure that required dialysis. There were also 15 deaths (0.7%) in the surgical group, and 4.8% of patients required abdominal surgical intervention.
“We speculate that the lower rate of [major adverse cardiovascular events] after metabolic surgery observed in this study may be related to substantial and sustained weight loss with subsequent improvement in metabolic, structural, hemodynamic, and neurohormonal abnormalities,” wrote Ali Aminian, MD, of the Bariatric and Metabolic Institute at the Cleveland Clinic, and coauthors.
“Although large and sustained surgically induced weight loss has profound physiologic effects, a growing body of evidence indicates that some of the beneficial metabolic and neurohormonal changes that occur after metabolic surgical procedures are related to anatomical changes in the gastrointestinal tract that are partially independent of weight loss,” they wrote.
The authors, however, were also keen to point out that their study was observational, and should therefore be considered “hypothesis generating.” While the two study groups were matched on 37 baseline covariates, those in the surgical group did have a higher body weight, higher BMI, higher rates of dyslipidemia, and higher rates of hypertension.
“The findings from this observational study must be confirmed in randomized clinical trials,” they noted.
The study was partly funded by Medtronic, and one author was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Five authors declared funding and support from private industry, including from Medtronic, and one author declared institutional grants.
SOURCE: Aminian A et al. JAMA 2019, Sept 2. DOI: 10.1001/jama.2019.14231.
AT THE ESC CONGRESS 2019
Key clinical point: Bariatric surgery may reduce the risk of cardiovascular events in people with type 2 diabetes.
Major finding: Bariatric surgery is associated with a 39% reduction in risk of major cardiovascular events.
Study details: Retrospective cohort study in 13,722 individuals with type 2 diabetes and obesity.
Disclosures: The study was partly funded by Medtronic, and one author was supported by the National Institute of Diabetes and Digestive and Kidney Diseases. Five authors declared funding and support from private industry, including from Medtronic, and one author declared institutional grants.
Source: Aminian A et al. JAMA 2019, September 2. DOI: 10.1001/jama.2019.14231.
Adding drugs to gastric balloons increases weight loss
SAN DIEGO – In a multicenter study involving four academic medical centers, the addition of weight loss drugs to intragastric balloons resulted in better weight loss 12 months after balloon placement.
In a video interview at the annual Digestive Disease Week, study investigator Reem Sharaiha, MD, explained that one of the drawbacks of intragastric balloons is that, although they produce weight loss for the 6 or 12 months that they are in place, patients tend to regain that weight after they are removed. The study, involving 111 patients, was designed to determine whether the addition of weight loss drugs could mitigate this effect and improve weight loss, said Dr. Sharaiha of Weill Cornell Medical Center, New York.
Adding drugs such as metformin or weight loss drugs tailored to patients’ particular weight issues (cravings, anxiety, or fast gastric emptying) at the 3- or 6-month mark while the intragastric balloon was in place helped patients continue losing weight after balloon removal. At 12 months, the percentage of total body weight lost was significantly greater in the intragastric balloon group with concurrent pharmacotherapy (21.4% vs. 13.1%).
SOURCE: Shah SL et al. DDW 2019, Abstract 1105.
SAN DIEGO – In a multicenter study involving four academic medical centers, the addition of weight loss drugs to intragastric balloons resulted in better weight loss 12 months after balloon placement.
In a video interview at the annual Digestive Disease Week, study investigator Reem Sharaiha, MD, explained that one of the drawbacks of intragastric balloons is that, although they produce weight loss for the 6 or 12 months that they are in place, patients tend to regain that weight after they are removed. The study, involving 111 patients, was designed to determine whether the addition of weight loss drugs could mitigate this effect and improve weight loss, said Dr. Sharaiha of Weill Cornell Medical Center, New York.
Adding drugs such as metformin or weight loss drugs tailored to patients’ particular weight issues (cravings, anxiety, or fast gastric emptying) at the 3- or 6-month mark while the intragastric balloon was in place helped patients continue losing weight after balloon removal. At 12 months, the percentage of total body weight lost was significantly greater in the intragastric balloon group with concurrent pharmacotherapy (21.4% vs. 13.1%).
SOURCE: Shah SL et al. DDW 2019, Abstract 1105.
SAN DIEGO – In a multicenter study involving four academic medical centers, the addition of weight loss drugs to intragastric balloons resulted in better weight loss 12 months after balloon placement.
In a video interview at the annual Digestive Disease Week, study investigator Reem Sharaiha, MD, explained that one of the drawbacks of intragastric balloons is that, although they produce weight loss for the 6 or 12 months that they are in place, patients tend to regain that weight after they are removed. The study, involving 111 patients, was designed to determine whether the addition of weight loss drugs could mitigate this effect and improve weight loss, said Dr. Sharaiha of Weill Cornell Medical Center, New York.
Adding drugs such as metformin or weight loss drugs tailored to patients’ particular weight issues (cravings, anxiety, or fast gastric emptying) at the 3- or 6-month mark while the intragastric balloon was in place helped patients continue losing weight after balloon removal. At 12 months, the percentage of total body weight lost was significantly greater in the intragastric balloon group with concurrent pharmacotherapy (21.4% vs. 13.1%).
SOURCE: Shah SL et al. DDW 2019, Abstract 1105.
REPORTING FROM DDW 2019
Diabetes, hypertension remission more prevalent in adolescents than adults after gastric bypass
according to two related studies of 5-year outcomes after Roux-en-Y gastric bypass.
However, despite adolescents’ better outcomes for diabetes and hypertension, their rate of abdominal reoperations was significantly higher during the 5-year follow-up period, and at 2 years post surgery, they were found to have low ferritin levels. The rates of death were similar in the two groups at 5 years.
“We have documented similar and durable weight loss after gastric bypass in adolescents and adults, but important differences between these cohorts were observed in specific health outcomes,” wrote Thomas H. Inge, MD, PhD, of the University of Colorado at Denver, Aurora, and his coauthors. The study was published in the New England Journal of Medicine.
To evaluate and compare outcomes after bariatric surgery, the researchers undertook the Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study and the LABS study. The two were related but independent observational studies of postsurgery patient cohorts. The Teen-LABS study included 161 adolescents with severe obesity, and the LABS study included 396 adults who reported becoming obese during adolescence.
At 5-year follow-up, there was no significant difference in mean percentage weight change between adolescents (−26%; 95% confidence interval, −29 to −23) and adults (−29%; 95% CI, −31 to −27; P = .08). Adolescents were more likely than were adults to have remission of type 2 diabetes (86% vs. 53%, respectively; risk ratio, 1.27; 95% CI, 1.03 to 1.57; P = .03) as well as hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88; P less than .001).
In addition, 20% of adolescents and 16% of adults underwent intra-abdominal procedures within 5 years of surgery, with cholecystectomy being the most common, followed by surgery for bowel obstruction or hernia repair, and gastrostomy. At 2 years, ferritin levels were lower in adolescents than in adults (48% of patients vs. 29%, respectively). Five-year ferritin levels were not assessed.
In all, three adolescents (1.9%) and seven adults (1.8%) died over the 5-year period. Among the adolescents, one patient with type 1 diabetes died 3 years after surgery from complications after a hypoglycemic episode, and the other two deaths, both 4 years after surgery, were consistent with overdose. Among the adults, three of the deaths occurred within 3 weeks of surgery and were related to gastric bypass, two were of indeterminate cause (at 11 months and 5 years after surgery), one was by suicide at 3 years, and one was from colon cancer at 4 years.
The authors acknowledged the limitations of their study, including its observational design, low counts for some of the outcomes, and a lack of nonsurgical controls. They also noted potential unmeasured biases in the adult cohort, including the effects of weight cycling and inaccuracies in recalling adolescent weight issues.
The study and several of its authors were supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases. Several authors reported receiving grants, honoraria, and consulting fees from medical technology and pharmaceutical companies.
SOURCE: Inge TH et al. N Engl J Med. 2019 May 16. doi: 10.1056/NEJMoa1813909.
For obese adolescents, making a decision with lifelong consequences, as is the case with bariatric surgery, should still be handled on a case-by-case basis, according to Ted D. Adams, PhD, of the University of Utah, Salt Lake City.
In general, treatment approaches for children and adults differ because of their physiological and psychological differences, but that does not apply in the case of obesity, wrote Dr. Adams, who noted the similarities in obesity across age groups. In addition, he said, most adolescents who are obese remain obese into adulthood, and obese adults who were obese when they were younger face worse outcomes than do those who become obese in adulthood.
As such, this study from Dr. Inge and his colleagues is clinically important given the prevalence of obesity in the United States and a step in the right direction. However, Dr. Adams acknowledged concerns over certain elements, including the higher rate of abdominal reoperations in adolescents during the 5-year postsurgery period.
For now, a case-by-case basis remains his recommendation. “More complete data will be required to fully inform clinicians, parents, and adolescents whether to embark on surgical intervention or to postpone it,” he wrote, adding that “the 5-year data look promising but ... the lifetime outcome is unknown.”
These comments are adapted from an editorial (N Engl J Med. 2019 May 16. doi: 10.1056/NEJMe1905778 ). Dr. Adams reported receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases as well as the Intermountain Research Foundation and Ethicon Endo-Surgery, a subsidiary of Johnson & Johnson.
For obese adolescents, making a decision with lifelong consequences, as is the case with bariatric surgery, should still be handled on a case-by-case basis, according to Ted D. Adams, PhD, of the University of Utah, Salt Lake City.
In general, treatment approaches for children and adults differ because of their physiological and psychological differences, but that does not apply in the case of obesity, wrote Dr. Adams, who noted the similarities in obesity across age groups. In addition, he said, most adolescents who are obese remain obese into adulthood, and obese adults who were obese when they were younger face worse outcomes than do those who become obese in adulthood.
As such, this study from Dr. Inge and his colleagues is clinically important given the prevalence of obesity in the United States and a step in the right direction. However, Dr. Adams acknowledged concerns over certain elements, including the higher rate of abdominal reoperations in adolescents during the 5-year postsurgery period.
For now, a case-by-case basis remains his recommendation. “More complete data will be required to fully inform clinicians, parents, and adolescents whether to embark on surgical intervention or to postpone it,” he wrote, adding that “the 5-year data look promising but ... the lifetime outcome is unknown.”
These comments are adapted from an editorial (N Engl J Med. 2019 May 16. doi: 10.1056/NEJMe1905778 ). Dr. Adams reported receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases as well as the Intermountain Research Foundation and Ethicon Endo-Surgery, a subsidiary of Johnson & Johnson.
For obese adolescents, making a decision with lifelong consequences, as is the case with bariatric surgery, should still be handled on a case-by-case basis, according to Ted D. Adams, PhD, of the University of Utah, Salt Lake City.
In general, treatment approaches for children and adults differ because of their physiological and psychological differences, but that does not apply in the case of obesity, wrote Dr. Adams, who noted the similarities in obesity across age groups. In addition, he said, most adolescents who are obese remain obese into adulthood, and obese adults who were obese when they were younger face worse outcomes than do those who become obese in adulthood.
As such, this study from Dr. Inge and his colleagues is clinically important given the prevalence of obesity in the United States and a step in the right direction. However, Dr. Adams acknowledged concerns over certain elements, including the higher rate of abdominal reoperations in adolescents during the 5-year postsurgery period.
For now, a case-by-case basis remains his recommendation. “More complete data will be required to fully inform clinicians, parents, and adolescents whether to embark on surgical intervention or to postpone it,” he wrote, adding that “the 5-year data look promising but ... the lifetime outcome is unknown.”
These comments are adapted from an editorial (N Engl J Med. 2019 May 16. doi: 10.1056/NEJMe1905778 ). Dr. Adams reported receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases as well as the Intermountain Research Foundation and Ethicon Endo-Surgery, a subsidiary of Johnson & Johnson.
according to two related studies of 5-year outcomes after Roux-en-Y gastric bypass.
However, despite adolescents’ better outcomes for diabetes and hypertension, their rate of abdominal reoperations was significantly higher during the 5-year follow-up period, and at 2 years post surgery, they were found to have low ferritin levels. The rates of death were similar in the two groups at 5 years.
“We have documented similar and durable weight loss after gastric bypass in adolescents and adults, but important differences between these cohorts were observed in specific health outcomes,” wrote Thomas H. Inge, MD, PhD, of the University of Colorado at Denver, Aurora, and his coauthors. The study was published in the New England Journal of Medicine.
To evaluate and compare outcomes after bariatric surgery, the researchers undertook the Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study and the LABS study. The two were related but independent observational studies of postsurgery patient cohorts. The Teen-LABS study included 161 adolescents with severe obesity, and the LABS study included 396 adults who reported becoming obese during adolescence.
At 5-year follow-up, there was no significant difference in mean percentage weight change between adolescents (−26%; 95% confidence interval, −29 to −23) and adults (−29%; 95% CI, −31 to −27; P = .08). Adolescents were more likely than were adults to have remission of type 2 diabetes (86% vs. 53%, respectively; risk ratio, 1.27; 95% CI, 1.03 to 1.57; P = .03) as well as hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88; P less than .001).
In addition, 20% of adolescents and 16% of adults underwent intra-abdominal procedures within 5 years of surgery, with cholecystectomy being the most common, followed by surgery for bowel obstruction or hernia repair, and gastrostomy. At 2 years, ferritin levels were lower in adolescents than in adults (48% of patients vs. 29%, respectively). Five-year ferritin levels were not assessed.
In all, three adolescents (1.9%) and seven adults (1.8%) died over the 5-year period. Among the adolescents, one patient with type 1 diabetes died 3 years after surgery from complications after a hypoglycemic episode, and the other two deaths, both 4 years after surgery, were consistent with overdose. Among the adults, three of the deaths occurred within 3 weeks of surgery and were related to gastric bypass, two were of indeterminate cause (at 11 months and 5 years after surgery), one was by suicide at 3 years, and one was from colon cancer at 4 years.
The authors acknowledged the limitations of their study, including its observational design, low counts for some of the outcomes, and a lack of nonsurgical controls. They also noted potential unmeasured biases in the adult cohort, including the effects of weight cycling and inaccuracies in recalling adolescent weight issues.
The study and several of its authors were supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases. Several authors reported receiving grants, honoraria, and consulting fees from medical technology and pharmaceutical companies.
SOURCE: Inge TH et al. N Engl J Med. 2019 May 16. doi: 10.1056/NEJMoa1813909.
according to two related studies of 5-year outcomes after Roux-en-Y gastric bypass.
However, despite adolescents’ better outcomes for diabetes and hypertension, their rate of abdominal reoperations was significantly higher during the 5-year follow-up period, and at 2 years post surgery, they were found to have low ferritin levels. The rates of death were similar in the two groups at 5 years.
“We have documented similar and durable weight loss after gastric bypass in adolescents and adults, but important differences between these cohorts were observed in specific health outcomes,” wrote Thomas H. Inge, MD, PhD, of the University of Colorado at Denver, Aurora, and his coauthors. The study was published in the New England Journal of Medicine.
To evaluate and compare outcomes after bariatric surgery, the researchers undertook the Teen–Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study and the LABS study. The two were related but independent observational studies of postsurgery patient cohorts. The Teen-LABS study included 161 adolescents with severe obesity, and the LABS study included 396 adults who reported becoming obese during adolescence.
At 5-year follow-up, there was no significant difference in mean percentage weight change between adolescents (−26%; 95% confidence interval, −29 to −23) and adults (−29%; 95% CI, −31 to −27; P = .08). Adolescents were more likely than were adults to have remission of type 2 diabetes (86% vs. 53%, respectively; risk ratio, 1.27; 95% CI, 1.03 to 1.57; P = .03) as well as hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88; P less than .001).
In addition, 20% of adolescents and 16% of adults underwent intra-abdominal procedures within 5 years of surgery, with cholecystectomy being the most common, followed by surgery for bowel obstruction or hernia repair, and gastrostomy. At 2 years, ferritin levels were lower in adolescents than in adults (48% of patients vs. 29%, respectively). Five-year ferritin levels were not assessed.
In all, three adolescents (1.9%) and seven adults (1.8%) died over the 5-year period. Among the adolescents, one patient with type 1 diabetes died 3 years after surgery from complications after a hypoglycemic episode, and the other two deaths, both 4 years after surgery, were consistent with overdose. Among the adults, three of the deaths occurred within 3 weeks of surgery and were related to gastric bypass, two were of indeterminate cause (at 11 months and 5 years after surgery), one was by suicide at 3 years, and one was from colon cancer at 4 years.
The authors acknowledged the limitations of their study, including its observational design, low counts for some of the outcomes, and a lack of nonsurgical controls. They also noted potential unmeasured biases in the adult cohort, including the effects of weight cycling and inaccuracies in recalling adolescent weight issues.
The study and several of its authors were supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases. Several authors reported receiving grants, honoraria, and consulting fees from medical technology and pharmaceutical companies.
SOURCE: Inge TH et al. N Engl J Med. 2019 May 16. doi: 10.1056/NEJMoa1813909.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Bariatric surgery found to be effective in IBD patients
SAN DIEGO – In carefully selected patients with well-controlled inflammatory bowel disease (IBD), bariatric surgery results in sustained weight loss over a 2-year period, results from a retrospective study suggest.
“Obesity is increasing in patients with inflammatory bowel disease at a rate similar to that seen in the general population,” the study’s primary author, Nicholas P. McKenna, MD, said in an interview in advance of the annual Digestive Disease Week. “While bariatric surgery is a well-accepted therapy for obesity in patients without IBD, its use in patients with IBD is less well studied.”
For the current study, Dr. McKenna, a resident in the department of surgery at the Mayo Clinic in Rochester, Minn., and colleagues collected data on 33 patients who underwent bariatric surgery with a pre- or postoperative diagnosis of IBD across three academic centers between August 2006 and December 2017. They evaluated IBD characteristics and medications; postoperative complications; the need for future IBD-related surgery; and weight loss at 6, 12, and 24 months.
The patients underwent 34 bariatric operations. Their median age was 51 years and their median duration of IBD was 13 years. Of the 33 patients, 16 underwent a Roux-en-Y gastric bypass procedure: 9 who had ulcerative colitis, 6 who had Crohn’s disease, and 1 who had indeterminate colitis. A total of 14 patients underwent sleeve gastrectomy: 7 who had ulcerative colitis and 7 who had Crohn’s disease. Four patients underwent a gastric band procedure, all of whom had ulcerative colitis. The mean body mass index of patients prior to their bariatric procedures was 42.7 kg/m2. A total of 31 patients had an existing diagnosis of IBD, and 2 were diagnosed with Crohn’s disease after Roux-en-Y gastric bypass. In addition, 9 patients were on preoperative immunosuppression for IBD, and 11 had undergone prior intestinal resection for IBD.
Dr. McKenna reported that the average hospitalization for all patients was 3.6 days and that only four 30-day infectious complications occurred: two superficial surgical site infections, one infected intra-abdominal hematoma, and one hepatic abscess. In the long term, seven patients required reoperation: three for failed gastric band, two for reduction of internal hernia, and two for cholelithiasis. The researchers found that the mean percentage of overall excess weight loss was 57.5% at 6 months, 63.3% at 12 months, and 58.6% at 24 months. During a mean follow-up of 3.4 years, no IBD flares requiring surgery were observed.
“Our hypothesis based on the existing literature was that bariatric surgery would be safe in carefully selected patients with IBD and result in sustained weight loss, so we were not surprised with these results,” Dr. McKenna said. “We were not sure if medication requirements would change after surgery as the literature is conflicted on this. We observed that most patients continued to require no immunosuppression for control of their IBD after surgery. Further, we did not observe that any patients required future surgery at the time of last follow-up for an IBD flare.”
He acknowledged certain limitations of the study, including its retrospective design. “Additionally, though it is a relatively large sample, compared to the existing literature on bariatric surgery in IBD, it is still only 33 patients. This limits the comparisons that can be performed between patients with ulcerative colitis and Crohn’s disease and between the operation choices.”
The study’s secondary author, Alaa Sada, MD, a surgery resident at Mayo, presented the findings at the meeting. The researchers reported having no financial disclosures.
SAN DIEGO – In carefully selected patients with well-controlled inflammatory bowel disease (IBD), bariatric surgery results in sustained weight loss over a 2-year period, results from a retrospective study suggest.
“Obesity is increasing in patients with inflammatory bowel disease at a rate similar to that seen in the general population,” the study’s primary author, Nicholas P. McKenna, MD, said in an interview in advance of the annual Digestive Disease Week. “While bariatric surgery is a well-accepted therapy for obesity in patients without IBD, its use in patients with IBD is less well studied.”
For the current study, Dr. McKenna, a resident in the department of surgery at the Mayo Clinic in Rochester, Minn., and colleagues collected data on 33 patients who underwent bariatric surgery with a pre- or postoperative diagnosis of IBD across three academic centers between August 2006 and December 2017. They evaluated IBD characteristics and medications; postoperative complications; the need for future IBD-related surgery; and weight loss at 6, 12, and 24 months.
The patients underwent 34 bariatric operations. Their median age was 51 years and their median duration of IBD was 13 years. Of the 33 patients, 16 underwent a Roux-en-Y gastric bypass procedure: 9 who had ulcerative colitis, 6 who had Crohn’s disease, and 1 who had indeterminate colitis. A total of 14 patients underwent sleeve gastrectomy: 7 who had ulcerative colitis and 7 who had Crohn’s disease. Four patients underwent a gastric band procedure, all of whom had ulcerative colitis. The mean body mass index of patients prior to their bariatric procedures was 42.7 kg/m2. A total of 31 patients had an existing diagnosis of IBD, and 2 were diagnosed with Crohn’s disease after Roux-en-Y gastric bypass. In addition, 9 patients were on preoperative immunosuppression for IBD, and 11 had undergone prior intestinal resection for IBD.
Dr. McKenna reported that the average hospitalization for all patients was 3.6 days and that only four 30-day infectious complications occurred: two superficial surgical site infections, one infected intra-abdominal hematoma, and one hepatic abscess. In the long term, seven patients required reoperation: three for failed gastric band, two for reduction of internal hernia, and two for cholelithiasis. The researchers found that the mean percentage of overall excess weight loss was 57.5% at 6 months, 63.3% at 12 months, and 58.6% at 24 months. During a mean follow-up of 3.4 years, no IBD flares requiring surgery were observed.
“Our hypothesis based on the existing literature was that bariatric surgery would be safe in carefully selected patients with IBD and result in sustained weight loss, so we were not surprised with these results,” Dr. McKenna said. “We were not sure if medication requirements would change after surgery as the literature is conflicted on this. We observed that most patients continued to require no immunosuppression for control of their IBD after surgery. Further, we did not observe that any patients required future surgery at the time of last follow-up for an IBD flare.”
He acknowledged certain limitations of the study, including its retrospective design. “Additionally, though it is a relatively large sample, compared to the existing literature on bariatric surgery in IBD, it is still only 33 patients. This limits the comparisons that can be performed between patients with ulcerative colitis and Crohn’s disease and between the operation choices.”
The study’s secondary author, Alaa Sada, MD, a surgery resident at Mayo, presented the findings at the meeting. The researchers reported having no financial disclosures.
SAN DIEGO – In carefully selected patients with well-controlled inflammatory bowel disease (IBD), bariatric surgery results in sustained weight loss over a 2-year period, results from a retrospective study suggest.
“Obesity is increasing in patients with inflammatory bowel disease at a rate similar to that seen in the general population,” the study’s primary author, Nicholas P. McKenna, MD, said in an interview in advance of the annual Digestive Disease Week. “While bariatric surgery is a well-accepted therapy for obesity in patients without IBD, its use in patients with IBD is less well studied.”
For the current study, Dr. McKenna, a resident in the department of surgery at the Mayo Clinic in Rochester, Minn., and colleagues collected data on 33 patients who underwent bariatric surgery with a pre- or postoperative diagnosis of IBD across three academic centers between August 2006 and December 2017. They evaluated IBD characteristics and medications; postoperative complications; the need for future IBD-related surgery; and weight loss at 6, 12, and 24 months.
The patients underwent 34 bariatric operations. Their median age was 51 years and their median duration of IBD was 13 years. Of the 33 patients, 16 underwent a Roux-en-Y gastric bypass procedure: 9 who had ulcerative colitis, 6 who had Crohn’s disease, and 1 who had indeterminate colitis. A total of 14 patients underwent sleeve gastrectomy: 7 who had ulcerative colitis and 7 who had Crohn’s disease. Four patients underwent a gastric band procedure, all of whom had ulcerative colitis. The mean body mass index of patients prior to their bariatric procedures was 42.7 kg/m2. A total of 31 patients had an existing diagnosis of IBD, and 2 were diagnosed with Crohn’s disease after Roux-en-Y gastric bypass. In addition, 9 patients were on preoperative immunosuppression for IBD, and 11 had undergone prior intestinal resection for IBD.
Dr. McKenna reported that the average hospitalization for all patients was 3.6 days and that only four 30-day infectious complications occurred: two superficial surgical site infections, one infected intra-abdominal hematoma, and one hepatic abscess. In the long term, seven patients required reoperation: three for failed gastric band, two for reduction of internal hernia, and two for cholelithiasis. The researchers found that the mean percentage of overall excess weight loss was 57.5% at 6 months, 63.3% at 12 months, and 58.6% at 24 months. During a mean follow-up of 3.4 years, no IBD flares requiring surgery were observed.
“Our hypothesis based on the existing literature was that bariatric surgery would be safe in carefully selected patients with IBD and result in sustained weight loss, so we were not surprised with these results,” Dr. McKenna said. “We were not sure if medication requirements would change after surgery as the literature is conflicted on this. We observed that most patients continued to require no immunosuppression for control of their IBD after surgery. Further, we did not observe that any patients required future surgery at the time of last follow-up for an IBD flare.”
He acknowledged certain limitations of the study, including its retrospective design. “Additionally, though it is a relatively large sample, compared to the existing literature on bariatric surgery in IBD, it is still only 33 patients. This limits the comparisons that can be performed between patients with ulcerative colitis and Crohn’s disease and between the operation choices.”
The study’s secondary author, Alaa Sada, MD, a surgery resident at Mayo, presented the findings at the meeting. The researchers reported having no financial disclosures.
REPORTING FROM DDW 2019