The Research Grant Report: Omar M. Ghanem and Tammy Kindel

| September 1, 2022

by Omar M. Ghanem, MD, FACS and Tammy Kindel, MD, FACS, FASMBS

Dr. Ghanem is a bariatric surgeon at the Mayo Clinic in Rochester, Minnesota. Dr. Kindel is Assistant Professor of Surgery at Medical College of Wisconsin in Milwaukee, Wisconsin.

Bariatric Times. 2022;19(9):12.


Vance Albaugh MD, PhD, is the recipient of the 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) research grant funded by the ASMBS Foundation for his study, titled “Functional Brain Imaging Characterization of Weight Regain and Weight Loss Maintenance Patients following Metabolic/Bariatric Surgery.” The grant amount in full is $25,000. We aim to highlight his career, research, and the clinical implications of his study. Additionally, we will explore the vital role that the ASMBS Foundation grant will have in helping him execute his research study. 

Dr. Albaugh, can you please share your background as a bariatric surgeon-researcher and kindly elaborate on the scope of your current practice?

Dr. Albaugh: Currently, I’m an Assistant Professor of Metabolic Surgery at Pennington Biomedical Research Center of Louisiana State University (LSU), a dedicated obesity and nutritional research institute. My scientific background is a bit atypical for a surgeon, but it has been a great experience over the last 20 years.

I was a PhD student in the Medical Scientist Training Program at Penn State Hershey in the early 2000s, working in a basic science lab studying obesity and diabetes. I always loved exercise physiology and metabolism, especially body weight regulation, which drew me to obesity science. My dissertation focused on weight gain side effects of antipsychotics, but I was serendipitously involved with another project exploring preclinical models of bariatric surgery. At the time, there were numerous reports that bariatric surgery patients had resolution of diabetes, and potentially other diseases, early after surgery, before weight loss (which sounded completely crazy back then!). People were hesitant to believe much of it because it didn’t make any sense to have disease resolution before weight loss. Regardless, I worked closely with a surgeon-scientist at Pennyslvania State University, Dr. Robert Cooney, on these preclinical models and was completely amazed at how quickly we saw postoperative changes. After I completed my PhD, I fell in love with general surgery during my clinical rotations, and when I heard about this “new” field of metabolic surgery, it sounded like a perfect fit for me. 

I subsequently matched in general surgery at Vanderbilt University and studied surgical metabolism and bariatric surgery with Naji Abumrad, MD, as part of a dedicated National Institutes of Health (NIH)-supported postdoctoral fellowship. The lab was phenomenal; we worked closely with bariatric surgery patients, as well as preclinical models. My postdoctoral and residency training completely cemented my decision to pursue metabolic/bariatric surgery clinically. While completing my complex bariatric fellowship at Cleveland Clinic, I was fortunate that Pennington Biomedical Research Center was recruiting academic surgeons for a new obesity research and treatment center led by Dr. Phil Schauer. As a scientist, I was quite familiar with Pennington Biomedical and its long-standing history of excellence in obesity research. The opportunity to join the faculty and help build this new comprehensive medical and surgical clinic from the ground up with Dr. Schauer felt like a once-in-a-lifetime opportunity, and it has been a fantastic experience all around.

My current clinical practice runs the gamut of metabolic/bariatric surgery in adults and adolescents, including primary, conversional, and revisional surgery. I also take general surgery and emergency call and work closely with our LSU general surgery residents and bariatric fellows at Our Lady of the Lake Regional Medical Center, the major academic referral hospital in Baton Rouge.

You have recently received the ASMBS 2022 grant, funded fully by the ASMBS Foundation. Please explain the focus of the research topic.

Dr. Albaugh: This year’s call for applications emphasized the interest in funding projects focused on weight regain, a topic that we know very little about scientifically. Weight regain is interesting because when we think about surgical options for weight regain, we tend to think in the antiquated terms of restriction and malabsorption, such as conversions of sleeves to bypasses or sleeves to single anastomosis duodenalileal bypass (SADI) or duodenal switch. Now, I hope most surgeons realize that pure restriction and malabsorption are not the driving forces of weight loss in primary sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB), though we are still trying to identify these important drivers. Regardless, the degree to which restriction and malabsorption drives weight loss in weight regain surgery remains unclear. The fact that we intentionally create controlled, short gut-like anatomy suggests that malabsorption might have more importance in most primary surgeries. However, data in recent years has shown clear changes in intestinal physiology and brain function following primary metabolic surgery, and augmenting these factors with conversion operations for weight regain is a real possibility.

One of the biggest neuroscience advances over the last 20 years is the development of functional magnetic resonance imaging (fMRI), a technique that allows us to study real-time brain function in response to various stimuli. With respect to weight loss, there have been a few studies demonstrating changes in brain activity that differ greatly between low calorie diets and bariatric surgery. In fact, these changes in brain activity might explain why individuals who have surgery experience so much more weight loss and are able to maintain weight loss better than those who receive medical or lifestyle treatments alone. These findings are very exciting, and the fMRI techniques lend themselves to numerous questions regarding the gut-brain axis and how primary and conversion surgery alters these effects in humans.

The current focus of my research program is the gut-brain axis and how the brain interprets nutrient signals from the gastrointestinal (GI) tract to regulate body weight and metabolism. I work closely with behavioral and neuroscience colleagues at Pennington in preclinical models examining the gut-brain axis. The studies that are being supported by the ASMBS Foundation Research Award are a natural extension of this preclinical work and will begin to focus on two important questions: 1) How does the gut-brain “phenotype” of someone who has maintained weight loss long-term differ compared to someone who has regained significant weight? and 2) Does weight regain surgery alter the gut-brain signaling axis? The second question is essentially trying to provide a biological basis for weight regain surgery, other than presumed malabsorption. 

How will the funds from the ASMBS Foundation help you execute this research, and how do you plan to use these funds?

Dr. Albaugh: Whether it’s clinical or basic scientific research, funding is needed to begin to proceed with these types of sophisticated studies. The funds provided by the ASMBS research grant are critical and will directly support the science, specifically the biochemical characterization of patients participating in this research and the costs of the fMRI brain imaging. Most importantly, however, these funds will also help compensate our research subjects for their time. These types of studies take up a significant amount of time for people, and for many, participating in the research is prohibitive unless there is adequate compensation for volunteering time away from other activities. 

What are the implications of this project to clinical care? 

Dr. Albaugh: The question of what the implications are for clinical care is probably one of the most common questions that I receive when people hear about our research. In general, we are always striving to better understand why surgery has such dominant long-term efficacy, compared to nonsurgical therapies. It’s quite possible that by understanding these changes in the gut-brain axis, specifically in patients who experience weight regain compared to patients who maintain weight loss, we can begin to identify either a behavioral or genetic predisposition or some other type of predictive factor that could be measured preoperatively. As bariatric surgeons, we’ve all had patients who seem to do much better than we had expected following surgery. On the flip side, we’ve all had patients not do as well as expected. While many patients see this as a failure, I would argue that there’s a biological basis for this variability in response. If we could understand this variability and potentially predict who would or would not have a good weight loss or metabolic response to surgery, we could individualize pharmacologic, surgical, and other obesity treatments to optimize the care of our patients. Clearly, the metabolic/bariatric operations that do exist have profound effects on cravings, food taste/choice, and other processes that emanate from the brain. Focusing on how the brain changes in response to surgery and how we can mimic or modify this response could allow us to optimize both surgical and nonsurgical weight loss treatments.

Obesity is a complex disease, and your research will focus on the gut-brain axis aspect of it. Do you believe targeted pharmaceuticals and medications are the future in managing this disease, or will bariatric surgery continue to be the most sustainable and effective modality for weight loss?  

Dr. Albaugh: The one thing we have learned in the last 40 years is that obesity is a complex disease, and it is much more than just “calories in, calories out.” Being able to use targeted pharmaceuticals and other medications both before and after surgery is going to be the future of our field in my opinion. Only having surgery might be an option for some, but for others, combination therapies will be key. As seen in surgical and nonsurgical studies, obesogenic environmental pressures continue to promote weight gain over time, and that continues regardless of whether or not someone has bariatric surgery; that is, the natural tendency for everyone is for body weight to increase over time. Unfortunately, these environmental pressures in combination with our genetic makeup aren’t going to be changing anytime soon. All physicians treating obesity need to use all the tools in the toolbox if we’re going to adequately prevent and treat obesity in the future.

Is the future of bariatric surgery research in understanding the physiology of obesity or in perfecting the technical parts of the available surgeries? 

Dr. Albaugh: I think the future of bariatric surgery research is potentially a little of both. Focusing on the most effective treatment (i.e., surgery) is bound to uncover additional targets and strategies for obesity prevention and cure; this is a common strategy for disease-focused research. With bariatric surgery, ample data and clinical experience suggests that surgery alters many behavioral, sensory, reward, and other homeostatic pathways that originate in the brain, which is potentially why surgical treatments have such marked efficacy. I think over the next decade, we will begin to see an increasing shift in treatments targeting these brain pathways. 

On the other hand, tweaking the components of bariatric operations, especially as we begin to better appreciate how operations differ with respect to gut-brain signaling, might also be advantageous. For example, we know that sleeve gastrectomy and RYGB have similar effects clinically. With respect to metabolic disease resolution and weight loss, though, gastric bypass clearly has the advantage. If we could identify the mechanistic differences driving the superiority of gastric bypass, then we could devise either a modification of the sleeve gastrectomy or, alternatively, a slightly different gastric bypass to maximize patient benefit and minimize short- and long-term risks.  

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Category: ASMBS Foundation News and Update, Current Issue

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