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Journal Watch—June 2016

| June 1, 2016

 A quick look at the noteworthy articles in bariatric and metabolic research

Timing of bariatric surgery for severely obese adolescents: a Markov decision-analysis.
Stroud AM, Parker D, Croitoru DP. J Pediatr Surg. 2016;51(5):853–858.
Synopsis: The authors developed a model to simulate the effect of timing of gastric bypass in obese adolescents on quantity and quality of life.

A Markov state-transition model was constructed comparing two treatment strategies: gastric bypass surgery at age 16 versus delayed surgery in adulthood. The model simulated a hypothetical cohort of adolescents with body mass index of 45kg/m2. Model inputs were derived from current literature. The main outcome measure was quality and quantity of life, measured using quality-adjusted life-years (QALYs).

For females, early gastric bypass surgery was favored by 2.02 QALYs compared to delaying surgery until age 35 (48.91 vs. 46.89 QALYs). The benefit was even greater for males, where early surgery was favored by 2.9 QALYs (48.30 vs. 45.40 QALYs). The absolute benefit of surgery at age 16 increased; the later surgery was delayed into adulthood. Sensitivity analyses demonstrated that adult surgery was favored only when the values for adverse events were unrealistically high.
In the authors’ model, early gastric bypass in obese adolescents improved both quality and quantity of life. These findings are useful for surgeons and pediatricians when counseling adolescents considering weight loss surgery.
PMID: 27261561

Rationale and design of the Early Sleeve gastrectomy In New Onset Diabetic Obese Patients (ESINODOP) trial.
Trastulli S, Desiderio J, Grandone I, et al. Endocrine. 2016 Jun 3. [Epub ahead of print]
Synopsis: The aim of this multicenter RCT was to compare bariatric surgery, particularly laparoscopic sleeve gastrectomy (LSG), with conventional medical therapy (CMT) in obese patients (body mass index between 30 and 42 kg/m2) newly diagnosed with T2DM and without any diabetes-related complications at any stage. A total of 100 eligible patients will be randomized at a 1:1 ratio to undergo one of the two planned treatments and will be followed for at least 6 years after randomization. The main objective of the ESINODOP trial is to investigate the efficacy of LSG compared with CMT alone in inducing and maintaining a remission of T2DM (defined as HbA1c levels ≤6.0 %, without active pharmacologic therapy after 1 year). The remission of T2DM will also be evaluated with the criteria provided by the American Diabetes Association (ADA), and the additional parameters such as adverse event rates, micro- and macrovascular complications, weight loss, gastrointestinal hormones, and quality of life will be compared. The study started on September 2015 and the planned recruitment period is 3 years. Patient recruitment and follow-up take place in the two diabetology and nutrition centers participating in the study, which are performed on a national basis. The ESINODOP trial is designed with the intent of comparing the efficacy of CMT alone to that of CMT in conjunction with LSG performed at the time of diabetes diagnosis in mildly obese diabetic patients. Currently, patients with these characteristics are not eligible for bariatric/metabolic surgery.
PMID: 27259508

Costs and outcomes of increasing access to bariatric surgery for obesity: cohort study and cost-effectiveness analysis using electronic health records.
Gulliford MC, Charlton J, Booth HP, Fildes A, Khan O, Reddy M, Ashworth M, Littlejohns P, Prevost AT, Rudisill C. Southampton (UK): NIHR Journals Library; 2016 May. Health Services and Delivery Research.
Synopsis: This study aimed to evaluate the costs and outcomes of increasing access to bariatric surgery for severe and morbid obesity.

Primary care electronic health records from the UK Clinical Practice Research Datalink were analysed for 3045 participants who received bariatric surgery and 247,537 general population controls. The cost-effectiveness of bariatric surgery was evaluated in severe and morbid obesity through a probabilistic Markov model populated with empirical data from electronic health records.

In participants who did not undergo bariatric surgery, the probability of participants with morbid obesity attaining normal body weight was 1 in 1290 annually for men and 1 in 677 for women. Costs of health-care utilisation increased with body mass index category but obesity-related physical and psychological comorbidities were the main drivers of health-care costs. In a cohort of 3045 adult obese patients with first bariatric surgery procedures between 2002 and 2014, bariatric surgery procedure rates were greatest among those aged 35–54 years, with a peak of 37 procedures per 100,000 population per year in women and 10 per 100,000 per year in men. During 7 years of follow-up, the incidence of diabetes diagnosis was 28.2 [95% confidence interval (CI) 24.4 to 32.7] per 1000 person-years in controls and 5.7 (95% CI 4.2 to 7.8) per 1000 person-years in bariatric surgery patients (adjusted hazard ratio was 0.20, 95% CI 0.13 to 0.30; p < 0.0001). In 826 obese participants with type 2 diabetes mellitus who received bariatric surgery, the relative rate of diabetes remission, compared with controls, was 5.97 (95% CI 4.86 to 7.33; p < 0.001). There was a slight reduction in depression in the first 3 years following bariatric surgery that was not maintained. Incremental lifetime costs associated with bariatric surgery were £15,258 (95% CI £15,184 to £15,330), including costs associated with bariatric surgical procedures of £9164 per participant. Incremental quality-adjusted life-years (QALYs) were 2.142 (95% CI 2.031 to 2.256) per participant. The estimated cost per QALY gained was £7129 (95% CI £6775 to £7506). Estimates were similar across gender, age and deprivation subgroups.

Intervention effects were derived from a randomised trial with generally short follow-up and non-randomised studies of longer duration.
The authors concluded that bariatric surgery is associated with increased immediate and long-term health-care costs but these are exceeded by expected health benefits to obese individuals with reduced onset of new diabetes, remission of existing diabetes and lower mortality. Diverse obese individuals have clear capacity to benefit from bariatric surgery at acceptable cost.
PMID: 27253004

Current status of mini-gastric bypass.
Mahawar KK, Kumar P, Carr WR, Jennings N, Schroeder N, Balupuri S, Small PK. J Minim Access Surg. 2016 Apr 28. [Epub ahead of print]
Synopsis: Mini-gastric bypass (MGP) is a promising bariatric procedure. Tens of thousands of this procedure have been performed throughout the world since Rutledge performed the first procedure in the United States of America in 1997. Several thousands of these have even been documented in the published scientific literature. Despite a proven track record over nearly two decades, this operation continues to polarise the bariatric community. A large number of surgeons across the world have strong objections to this procedure and do not perform it. The risk of symptomatic (bile) reflux, marginal ulceration, severe malnutrition, and long-term risk of gastric and oesophageal cancers are some of the commonly voiced concerns. Despite these expressed fears, several advantages such as technical simplicity, shorter learning curve, ease of revision and reversal, non-inferior weight loss and comorbidity resolution outcomes have prompted some surgeons to advocate a wider adoption of this procedure. This review examines the current status of these controversial aspects in the light of the published academic literature in English.
PMID: 27251826

Management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity: A tertiary care experience and design of a management algorithm.
Praveenraj P, Gomes RM, Kumar S, Senthilnathan P, Parthasarathi R, Rajapandian S, Palanivelu C. J Minim Access Surg. 2016 Apr 27.  [Epub ahead of print]
Synopsis: The aim of this retrospective study was to analyse the management of patients with a gastric leak after LSG for morbid obesity at the authors’ institution.
From February 2008 to 2014, 650 patients with different degrees of morbid obesity underwent LSG. Among these, all those diagnosed with a gastric leak were included in the study. Patients referred to the authors’ institution with gastric leak after LSG were also included. The time of presentation, site of leak, investigations performed, treatment given and time of closure of all leaks were analysed.
Among the 650 patients who underwent LSG, 3 (0.46%) developed a gastric leak. Two patients were referred after LSG was performed at another institution. The mean age was 45.60 ± 15.43 years. Mean body mass index (BMI) was 44.79 ± 5.35. Gastric leak was diagnosed 24 h to 7 months after surgery. One was early, two were intermediate and two were late leaks. Two were type I and three were type II gastric leaks. Endoscopic oesophageal stenting was used variably before or after re-surgery. Re-surgery was performed in all and included stapled fistula excision (re-sleeve), suture repair only or with conversion to Roux-en-Y gastric bypass or fistula jujenostomy. There was no mortality.

The authors concluded that leakage closure time may be shorter with intervention than expectant management. Sequence and choice of endoscopic oesophageal stenting and/or surgical re-intervention should be individualized according to clinical presentation.
PMID: 27251808

Recent advances in the modification of taste and food preferences following bariatric surgery.
Primeaux SD, de Silva T, Tzeng TH, Chiang MC, Hsia DS. Rev Endocr Metab Disord. 2016 Jun 1. [Epub ahead of print]

Synopsis: The goal of this review is to discuss the physiological and behavioral consequences of bariatric surgery as a treatment for obesity and T2D, with particular emphasis on recent studies describing bariatric surgery-induced modifications in taste perception and food preferences.
PMID: 27245858

Category: Journal Watch, Past Articles

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