Journal Watch—February 2015

| February 1, 2015

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

Bariatric outcomes are significantly improved in hospitals with Fellowship Council-accredited bariatric fellowships.
Kim PS, Telem DA, Altieri MS, Talamini M, Yang J, Zhang Q, Pryor AD. J Gastrointest Surg. 2015 Feb 10. [Epub ahead of print]
Synopsis: With the increasing demand of bariatric surgery, there is a need to train more surgeons, while identifying institutional factors associated with improved outcomes. Little is known regarding the impact of a fellowship training program on institutional outcomes. This study examines the effect of bariatric fellowship program status on perioperative outcomes within New York state.
Using the New York statewide planning and research cooperative system, 47,342 adult patients in 91 hospitals were identified who underwent a laparoscopic bariatric surgery over a 6-year period. Hospitals with fellowships were identified from the Fellowship Council. Statistical comparison between patient demographics, payer source, comorbidities, bariatric procedure performed, and perioperative outcomes in hospitals with and without fellowship were performed.

On univariate analysis, fellowship accreditation status was found to be associated with increased rates of cardiac complications and shock and decreased rates of pneumonia. Overall complication rate was not significantly different in fellowship versus non-fellowship institutions. However, when controlled for patient demographic, payer source, comorbidity, and operative procedure, there were significantly improved bariatric outcomes among institutions with fellowship programs.
The authors concluded that the presence of a fellowship program correlates with improved hospital outcomes, mitigating potential concerns about possible negative effects of trainees on hospitals and patients.
PMID: 25666098

Exercise improves quality of life in bariatric surgery candidates: Results from the Bari-Active trial.
Bond DS, Thomas JG, King WC, Vithiananthan S, Trautvetter J, Unick JL, Ryder BA, Pohl D, Roye GD, Sax HC, Wing RR. Obesity (Silver Spring). 2015 Jan 22. [Epub ahead of print]
Synopsis: In this article, the authors examine the impact of a pre-bariatric surgery physical activity intervention (PAI), designed to increase bout-related (≥10 min) moderate to vigorous PA (MVPA), on health-related quality of life (HRQoL). Analyses included 75 adult participants (86.7% female; BMI= 45.0 ± 6.5 kg/m2 ) who were randomly assigned to six weeks of PAI (n = 40) or standard pre-surgical care (SC; n = 35). PAI received 6 individual weekly counseling sessions to increase walking exercise. Participants wore an objective PA monitor for seven days and completed the SF-36 Health Survey at baseline and post-intervention to evaluate bout-related MVPA and HRQoL changes, respectively. PAI increased bout-related MVPA from baseline to post-intervention (4.4 ± 5.5 to 21.0 ± 21.4 min day-1 ) versus no change (7.9 ± 16.6 to 7.6 ± 11.5 min day-1 ) for SC (P = 0.001). PAI reported greater improvements than SC on all SF-36 physical and mental scales (P < 0.05), except role-emotional. In PAI, better baseline scores on the physical function and general health scales predicted greater bout-related MVPA increases (P < 0.05), and greater bout-related MVPA increases were associated with greater post-intervention improvements on the physical function, bodily pain, and general health scales (P < 0.05). Increasing PA preoperatively improves physical and mental HRQoL in bariatric surgery candidates. Future studies should examine whether this effect improves surgical safety, weight loss outcomes, and postoperative HRQoL.
PMID: 25611582

Insulin cessation and diabetes remission after bariatric surgery in insulin-treated type 2 diabetic adults.
Ardestani A, Rhoads D, Tavakkoli A3. Diabetes Care. 2015 Jan 8. [Epub ahead of print]
Synopsis: Objective: The impact of bariatric surgeries on insulin-treated type 2 diabetes (I-T2D) in the general population is largely undocumented. We assessed changes in insulin treatment after bariatric surgery in a large cohort of I-T2D patients, comparing Roux-en-Y gastric bypass surgery (RYGB) with laparoscopic adjustable gastric banding (LAGB), controlling for differences in weight loss between procedures.
Research Design and Methods: Of 113,638 adult surgical patients in the Bariatric Outcomes Longitudinal Database (BOLD), 10% had I-T2D. Analysis was restricted to 5,225 patients with I-T2D and at least 1 year of postoperative follow-up. Regression models were used to identify factors that predict cessation of insulin therapy. To control for differences in weight loss patterns between RYGB and LAGB, a case-matched analysis was also performed.
Results: Of I-T2D patients who underwent RYGB (n = 3,318), 62% were off insulin at 12 months compared with 34% (n = 1,907) after LAGB (P < 0.001). Regression analysis indicated that RYGB strongly predicted insulin cessation at both 1 and 12 months postoperatively. In the case-matched analysis at 3 months, the proportion of insulin cessation was significantly higher in the RYGB group than in the LAGB group (P = 0.03), and the diabetes remission rate was higher at all time points after this surgery. RYGB was a weight-independent predictor of insulin therapy cessation early after surgery, whereas insulin cessation after LAGB was linked to weight loss.
Conclusions: I-T2D patients have a greater probability of stopping insulin after RYGB than after LAGB (62% vs. 34%, respectively, at 1 year), with weight-independent effects in the early months after surgery. These findings support RYGB as the procedure of choice for reversing I-T2D.
PMID: 25573879

Face lifting in the massive weight loss patient: modifications of our technique for this population.
Narasimhan K, Ramanadham S, Rohrich RJ. Plast Reconstr Surg. 2015 Feb;135(2):397–405.
Synopsis: The authors evaluated their experience with facial rejuvenation in the massive weight loss patient. A retrospective chart review of the senior author’s (R.J.R) face-lift patients was conducted. Data on patient age and body mass index, surgical techniques used (when available), and intraoperative and postoperative complications were collected.

Of the senior author’s 25-year database of 1089 patients, 22 were identified (15 women and seven men). Nineteen patients had primary face lifts performed; three patients were secondary cases. Average age at face lift was 52.7 years (range, 41.0 to 67.0 years). Body mass index at the time of surgery was 26.0. There were no intraoperative complications. Postoperative complications included one hematoma that responded to drainage. Nineteen patients (86 percent) had volume loss in the midface and nasolabial groove regions. Thirteen patients (59 percent) had perioral volume loss, all had skin excess and redundancy in the jowl and submental region, and 18 (82 percent) had documented platysmal bands. The superficial musculoaponeurotic system (SMAS) was addressed in 20 patients (91 percent) with a SMASectomy. Fat augmentation was performed in all patients. On average, almost twice as much fat was used (22 ml versus 12 ml in non-massive weight loss patients).

In the massive weight loss population, there are common techniques that can enhance results. (1) Individualized components analysis can be used; (2) to treat laxity of skin and deflation of fat compartments, twice as much fat augmentation is needed; (3) SMASectomy is used for redundant skin; and (4) SMAS neck suspension sutures are used in thicker-skinned patients.
Clinical Question/Level of Evidence:
Therapeutic, IV.
PMID: 25626786

Rapid and body weight-independent improvement of endothelial and HDL function after Roux-en-Y gastric bypass: Role of glucagon-like peptide-1.
Osto E, Doytcheva P, Corteville C, et al. Circulation. 2015 Feb 11. [Epub ahead of print].
Synopsis: Roux-en-Y gastric bypass (RYGB) reduces body weight and cardiovascular mortality in morbidly obese patients. Glucagon-like peptide-1 (GLP-1) seems to mediate the metabolic benefits of RYGB partly in a weight loss-independent manner. The present study investigated in rats and patients whether obesity-induced endothelial and HDL dysfunction are rapidly improved after RYGB via a GLP-1-dependent mechanism.

Eight days after RYGB in diet-induced obese rats, higher plasma levels of bile acids and GLP-1 were associated with improved endothelium-dependent relaxation compared to sham-operated controls fed ad libitum and sham-operated rats that were weight-matched to those undergoing RYGB. Compared to sham-operated rats, RYGB improved nitric oxide (NO) bioavailability due to higher endothelial Akt/NO synthase activation, reduced JNK-phosphorylation and decreased oxidative stress. The protective effects of RYGB were prevented by the GLP-1 receptor antagonist exendin9-39 (10ug/kg/h). Further, in patients and rats RYGB rapidly reversed HDL dysfunction and restored the endothelium-protective properties of the lipoprotein, including eNOS activation, NO production as well as anti-inflammatory, anti-apoptotic and anti-oxidant effects. Finally, RYGB restored HDL-mediated cholesterol efflux capacity. To demonstrate the role of increased GLP-1 signaling, sham-operated control rats were treated for eight days with the GLP-1 analog liraglutide (0.2 mg/kg twice daily), which restored NO bioavailability, improved endothelium-dependent relaxations and HDL endothelium-protective properties, mimicking the effects of RYGB.

RYGB rapidly reverses obesity-induced endothelial dysfunction and restores the endothelium-protective properties of HDL via a GLP-1-mediated mechanism. The present translational findings in rats and patients unmask novel, weight-independent mechanisms of cardiovascular protection in morbid obesity.
PMID: 25673670

Image analyzer study of the skin in patients with morbid obesity and massive weight loss.
Sami K, Elshahat A, Moussa M, Abbas A, Mahmoud A. Eplasty. 2015 Jan 23;15:e4. eCollection 2015.
Synopsis: Studies in literature on skin of patients with massive weight loss are limited and somehow conflicting in their results. The aim of this study was to quantitatively assess the skin change after massive weight loss.

This study was performed on 30 patients from whom skin biopsies were taken from the skin excised during operations, divided into 3 main groups. The first included patients who were undergoing cosmetic contouring procedures without history of massive weight loss. The second included patients with morbid obesity, who were undergoing bariatric surgery. The third included patients with massive weight loss submitted to cosmetic contouring procedures after stable weight reduction for 6 months. Biopsies were taken from the skin for histological testing. Hematoxylin and Eosin, Mallory, and Aldehyde fuchsin Stains were used to assess the skin collagen and elastic fibers. For quantitative assessment, the Image Analyzer System (Leica Q 500 MC program) was employed. Tensile tests were applied to skin samples using (Instron 5500R) Universal testing machine to measure the skin tensile strength to determine the maximum stress (Burst strength) that skin can induce before damage.

Collagen was significantly thinner in massive weight loss group in both papillary and reticular dermis and significantly less dense in reticular dermis with damage to the elastic fiber network.

The skin of the patients with massive weight loss is weak due to lower density and thickness of collagen fibers and damage to its elastic fibers.
PMID: 25671051

New-onset mania following bariatric surgery.
Nepal H, Bhattarai M, Agustin ET. Psychiatry Investig. 2015;12(1):152–154. Epub 2015 Jan 12.
Synopsis: Outcomes from bariatric surgery have become a significant area of scrutiny because it is also associated with several medical and psychological complications. Out of those complications, there are descriptions of neuropsychiatric disorders and psycho-behavioral symptoms after surgery. Meanwhile, few reports of acute psychosis are described. This is, to the authors’ knowledge, the first case report of primary mania following bariatric surgery. They present an unusual and challenging case of primary mania in a 57-year-old woman who underwent bariatric surgery two months prior. Patient responded well initially to antipsychotic followed by mood stabilizer.
PMID:25670960

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