Hypoglycemia and Dysautonomia After Bariatric Surgery: a Systematic Review and Perspective

Obesity Surgery - With the increasing performance of bariatric surgery, rare complications are becoming prevalent. We review the diagnosis and treatment of dysautonomia after bariatric surgery and...     

Incidence of Cancer Following Bariatric Surgery: Systematic Review and Meta-analysis

Obesity is linked to the development of cancer. Previous studies have suggested that there is a relationship between bariatric surgery and reduced cancer risk. Data sources were from Medline, Embase, and Cochrane Library. From 951 references, 13 studies met the inclusion criteria (54,257 participants). In controlled studies, bariatric surgery was associated with a reduction in the risk of cancer. The cancer incidence density rate was 1.06 cases per 1000 person-years within the surgery groups. In the meta-regression, we found an inverse relationship between the presurgical body mass index and cancer incidence after surgery (beta coefficient ?0.2, P?相似文献   

Stent Management of Leaks After Bariatric Surgery: a Systematic Review and Meta-analysis

Obesity Surgery - Despite the low rates of complications of bariatric surgery, gastrointestinal leaks are major adverse events that increase post-operative morbidity and mortality. Endoscopic...     

Type 1 Diabetes Mellitus and Bariatric Surgery: A Systematic Review and Meta-Analysis

Background

Type 1 diabetes mellitus (T1DM) has a rising global prevalence. Although it is vastly outnumbered by type 2 diabetes mellitus rates, it remains a persistent worldwide source of morbidity and mortality. Increasingly, its sufferers are afflicted by obesity and its complications. The objective of the study is to quantify the effects of bariatric surgery on T1DM by appraising the primary outcomes of glycosylated haemoglobin (HbA1c), insulin requirements and body mass index (BMI). Secondary outcomes included blood pressure, triglycerides and cholesterol biochemistry.

Methods

A systematic review of studies reporting pre-operative and post-operative outcomes in T1DM patients undergoing bariatric surgery was done. Data were meta-analysed using random effects modelling. Subgroup analysis and quality scoring were assessed.

Results

Bariatric surgery in obese T1DM patients is associated with a significant reduction in insulin requirement (?48.95 units, 95 % CI of ?56.27, ?41.62), insulin requirement per kilogramme (?0.391, 95 % CI of ?0.51, ?0.27), HbA1c (?0.933, 95 % CI of ?1.604, ?0.262) and BMI (?11.04 kg/m², 95 % CI of ?13.49, ?8.59). Surgery is also associated with a statistically significant reduction in systolic and diastolic blood pressure and a significant beneficial rise in HDL. Heterogeneity in these results was high, and study quality was low overall.

Conclusions

Bariatric surgery in obese T1DM patients is associated with a significant improvement in insulin requirement and a significant though modest effect on HbA1c. These early results require further substantiation with future studies focusing on higher levels of evidence. This may offer a deeper understanding of diabetogenesis and can contribute to better selection and stratification of diabetic patients for metabolic surgery and future metabolic treatment strategies.

     

Rhabdomyolysis in Bariatric Surgery: a Systematic Review

Background

Rhabdomyolysis (RML) is a rare complication of bariatric surgery. A systematic review was performed to identify risk factors and patient outcomes in morbidly obese patients undergoing bariatric surgery who develop RML.

Methods

A comprehensive search was performed between January 1990 and March 2012 using relevant MeSH terms. Studies were chosen based on predefined inclusion criteria. RML was defined as a creatine kinase of more than 1,000 IU/L. The parameters assessed included patient characteristics of the RML population, type of bariatric surgery performed, operating time, complications, presentation and diagnosis of RML.

Results

Twenty-two studies were analysed which included 11 case reports, two case series, six prospective and three retrospective comparative studies. Overall 145 patients with RML were reported following bariatric surgery. Acute renal failure was found in 20 patients (14 %) and was significantly more likely to occur in patients with postoperative muscle pain (p?<?0.05). The mortality rate after renal failure was 25 % (n?=?5). In the comparative studies, 87 RML patients were compared with 325 non-RML patients. The RML patients were more likely to be male, had a greater mean body mass index (BMI) (52 vs 48 kg/m², p?<?0.01) and underwent a longer operation (255 vs 207 min, p?<?0.01) compared to non-RML patients.

Conclusions

Risk factors of developing RML following bariatric surgery include male gender, elevated BMI and prolonged operating time. Patients with a biochemical diagnosis of RML and postoperative myalgia after bariatric surgery are at increased risk of developing acute renal failure and mortality. These patients must be identified and treated promptly.     

Postoperative Atrial Fibrillation After Cardiac Surgery: A Systematic Review and Meta-Analysis

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Survival After Thoracoscopic Surgery or Open Lobectomy: Systematic Review and Meta-Analysis

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Exercise Following Bariatric Surgery: Systematic Review

The contribution of physical activity on the degree of weight loss following bariatric surgery is unclear. To determine impact of exercise on postoperative weight loss. Medline search (1988–2009) was completed using MeSH terms including bariatric procedures and a spectrum of patient factors with potential relationship to weight loss outcomes. Of the 934 screened articles, 14 reported on exercise and weight loss outcomes. The most commonly used instruments to measure activity level were the Baecke Physical Activity Questionnaire, the International Physical Activity Questionnaire, and a variety of self-made questionnaires. The definition of an active patient varied but generally required a minimum of 30 min of exercise at least 3 days per week. Thirteen articles reported on exercise and degree of postoperative weight loss (n?=?4,108 patients). Eleven articles found a positive association of exercise on postoperative weight loss, and two did not. Meta-analysis of three studies revealed a significant increase in 1-year postoperative weight loss (mean difference = 4.2% total body mass index (BMI) loss, 95% confidence interval (CI; 0.26–8.11)) for patients who exercise postoperatively. Exercise following bariatric surgery appears to be associated with a greater weight loss of over 4% of BMI. While a causal relationship cannot be established with observational data, this finding supports the continued efforts to encourage and support patients’ involvement in post-surgery exercise. Further research is necessary to determine the recommended activity guidelines for this patient population.     

Female Pelvic Floor Symptoms Before and After Bariatric Surgery

Background

Obesity is a risk factor for female pelvic floor disorders. The study objective was to determine whether there was a difference in the subjective reporting of pelvic symptoms before and after bariatric surgery.

Methods

This was a prospective cohort study of female patients that underwent bariatric surgery. Patients completed a demographic questionnaire, the Pelvic Floor Distress Inventory-20 (PFDI-20), and the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) before surgery and at 6 and 12?months following surgery. Body mass index (BMI) was compared between time points using Student??s t tests (P?P?Results At 12?months after surgery, 63 patients had completed the study. Even with significant weight loss (BMI, 43.7?kg/m² to BMI, 29?kg/m²; P?P?=?0.2). Prevalence of pelvic floor symptom impact on quality of life did significantly decrease after surgery (56% to 30%; P?=?0.004). Baseline PFDI-20 and PFIQ-7 scores were low; however, there was still a significant reduction in PFDI-20 and PFIQ-7 scores after surgery (P?Conclusions Prevalence of pelvic floor symptoms did not vary greatly after surgery; however, significant weight reduction did improve the degree of bother and quality of life related to these symptoms.     

Zinc Deficiency: A Frequent and Underestimated Complication After Bariatric Surgery

Background  

Although zinc deficiency is common after bariatric surgery, its incidence is underestimated. The objective was to monitor zinc and nutritional status before and 6, 12 and 24 months (M6, M12 and M24) after gastric bypass (Roux-en-Y gastric bypass), sleeve gastrectomy and biliopancreatic diversion with duodenal switch (DS) in patients receiving systematised nutritional care.     

Behavioural Interventions for Severe Obesity Before and/or After Bariatric Surgery: a Systematic Review and Meta-analysis

Background

Significant, sustained weight loss through conventional, non-surgical interventions is often unattainable for people with severe obesity (e.g. BMI ≥40 or ≥35 kg/m² with co-morbidities). Bariatric surgery is effective in treating severe obesity, but surgery alone without additional behaviour change management may not result in optimum long-term weight loss and maintenance. This systematic review and meta-analysis of randomised controlled trials evaluated the effectiveness of lifestyle interventions before and/or after bariatric surgery.

Methods

MEDLINE, Embase, Cochrane Central Register of Controlled Trials and clinical trials registers were searched for eligible studies. Key journals were handsearched. Last search date was on December 2014. Eligible interventions had the explicit aim of changing behaviour related to diet and/or physical activity, starting within 12 months of surgery, either pre- or post-operatively, and with at least 6 months’ follow-up. The primary outcome was weight change; secondary outcomes included surgical complications, quality of life and changes in co-morbidities. Random effect meta-analyses were undertaken. Study quality was assessed with the Cochrane Collaboration’s risk of bias tool.

Results

Eleven trials met the inclusion criteria. Behavioural interventions appear to improve weight loss at 12 months after bariatric surgery. Secondary outcome data were lacking and weight outcomes were reported inconsistently. Overall, the methodological quality of the identified trials was low.

Conclusions

The strength of evidence is limited by the relatively small number of trials identified and by their low methodological quality and short follow-up duration. Well-designed randomised controlled trials (RCTs) with long-term follow-up are required.

     

Esophageal Motility and Reflux Symptoms Before and After Bariatric Surgery

Background: Surgical treatment is the most effective method for weight reduction in morbid obesity. The most common operations are gastric banding and gastric bypass. The effect of these interventions on esophageal function and gastroesophageal reflux symptoms has not been adequately investigated. Methods: Patients undergoing obesity surgery were prospectively included in an observational study. Before surgery, each of the 53 patients underwent pulmonary function tests, esophageal manometry, and gastroscopy. Drug medication and esophageal symptoms were recorded. "Non-sweet eater" patients with good compliance underwent laparoscopic adjustable gastric banding (LAGB). In "sweet-eating" or non-compliant patients, gastric bypass (GBP) was carried out. Results: Between July 1997 and April 2000, 53 patients (9 males and 44 females) were consecutively operated on. 32 patients (median BMI 46.4 kg/m² ±5.4 SD) received LAGB, and 21 patients (BMI 54.0 kg/m² ±10.7) GBP. Median follow-up was 22 months, and only 3 patients were lost to yearly follow-up. Preoperatively, 6 LAGB patients had reflux symptoms, which postoperatively resolved in 3 of them, while the other 3 noted no change. Three patients who had no preoperative reflux symptoms developed them after LAGB. In the GBP group, no patient had esophageal dysmotility or incompetent esophageal sphincter function pre- or postoperatively. The incidence of postoperative esophageal symptoms was independent of operative technique (Wilcoxon U-Test: p= 0.75). Conclusion: The present results do not show any effect of gastric reduction surgery on postoperative esophageal function or gastroesophageal reflux symptoms.     

Acute Pancreatitis in Patients After Bariatric Surgery: Incidence,Outcomes, and Risk Factors

Background

The incidence of acute pancreatitis (AP) in bariatric surgery patients is not known. Ouraim was to determine the incidence, outcomes, and risk factors of AP in post-bariatric surgery patients.

Methods

An historical cohort study was conducted of all patients who underwent Roux-en-Y gastric bypass, sleeve gastrectomy, adjustable gastric banding, and revisional procedures at our institution from January 2004 to September 2011. Patients who developed AP were identified by review of the electronic medical record. A nested case-control study using Cox regression analysis was done to identify risk factors.

Results

A total of 2695 patients underwent bariatric surgery. Twenty-eight patients (1.04 %) developed AP during a median follow-up of 3.5 years (interquartile range [IQR] 1.9–5.8). One patient had severe AP, and there was one AP-related death. In the case-control study, the only baseline variable that predicted post-operative AP was a prior history of AP. Three other variables identified after surgery were associated with AP: (1) rapid weight loss as measured by percent of excess weight loss (EWL) at the first post-operative visit, (2) abnormal findings on post-operative ultrasound (stones, sludge or ductal dilation), and (3) post-operative complications of bowel leak or anastomotic stricture.

Conclusions

The incidence of AP in this cohort is 1.04 %, which is higher than that reported for the general population (~17/100,000, 0.017 %). Most cases were clinically mild and managed conservatively with good outcomes. Rapid post-operative weight loss and the presence of gallstones or sludge on post-operative ultrasound were significant risk factors for AP.     

Diabetes and Weight in Comparative Studies of Bariatric Surgery vs Conventional Medical Therapy: A Systematic Review and Meta-Analysis

We performed a meta-analysis of weight loss and remission of type 2 diabetes mellitus (T2DM) evaluated in randomized controlled trials (RCTs) and observational studies of bariatric surgery vs conventional medical therapy. English articles published through June 10, 2013 that compared bariatric surgery with conventional therapy and included T2DM endpoints with ≥12-month follow-up were systematically reviewed. Body mass index (BMI, in kilogram per square meter), glycated hemoglobin (HbA_1C, in degree), and fasting plasma glucose (FPG, in milligram per deciliter) were analyzed by calculating weighted mean differences (WMDs) and pooled standardized mean differences and associated 95 % confidence intervals (95 % CI). Aggregated T2DM remission event data were analyzed by calculating the pooled odds ratio (POR) and 95 % CI. Random effects assumptions were applied throughout; I ²?≥?75.0 % was considered indicative of significant heterogeneity. Systematic review identified 512 articles: 47 duplicates were removed, 446 failed inclusion criteria (i.e., n?<?10 per arm, animal studies, reviews, case reports, abstracts, and kin studies). Of 19 eligible articles, two not focused on diagnosed T2DM and one with insufficient T2DM data were excluded. In the final 16 included papers, 3,076 patients (mean BMI, 40.9; age, 47.0; 72.0 % female) underwent bariatric surgery; 3,055 (39.4; 48.6, 69.0 %) received conventional or no weight-loss therapy. In bariatric surgery vs conventional therapy groups, the mean 17.3?±?5.7 month BMI WMD was 8.3 (7.0, 9.6; p?<?0.001; I ²?=?91.8), HbA_1C was 1.1 (0.6, 1.6; p?<?0.001; I ²?=?91.9), and FPG, 24.9 (15.9, 33.9; p?<?0.001; I ²?=?84.8), with significant differences favoring surgery. The overall T2DM remission rate for surgery vs conventional group was 63.5 vs 15.6 % (p?<?0.001). The Peto summary POR was 9.8 (6.1, 15.9); inverse variance summary POR was 15.8 (7.9, 31.4). Of the included studies, 94.0 % demonstrated a significant statistical advantage favoring surgery. In a meta-analysis of 16 studies (5 RCTs) with 6,131 patients and mean 17.3-month follow-up, bariatric surgery was significantly more effective than conventional medical therapy in achieving weight loss, HbA_1C and FPG reduction, and diabetes remission. The odds of bariatric surgery patients reaching T2DM remission ranged from 9.8 to 15.8 times the odds of patients treated with conventional therapy.     

Short- and Long-Term Oncological Outcome After Rectal Cancer Surgery: a Systematic Review and Meta-Analysis Comparing Open Versus Laparoscopic Rectal Cancer Surgery

Background

While several trials have compared laparoscopic to open surgery for colon cancer showing similar oncological results, oncological quality of laparoscopic versus open rectal resection is not well investigated.

Methods

A systematic literature search for randomized controlled trials was conducted in MEDLINE, the Cochrane Library, and Embase. Qualitative and quantitative meta-analyses of short-term (rate of complete resections, number of harvested lymph nodes, circumferential resection margin positivity) and long-term (recurrence, disease-free and overall survival) oncologic results were conducted.

Results

Fourteen randomized controlled trials were identified including 3528 patients. Patients in the open resection group had significantly more complete resections (OR 0.70; 95% CI 0.51–0.97; p?=?0.03) and a higher number of resected lymph nodes (mean difference ??0.92; 95% CI ??1.08 to 0.75; p?<?0.001). No differences were detected in the frequency of positive circumferential resection margins (OR 0.82; 95% CI 0.62–1.10; p?=?0.18). Furthermore, no significant differences of long-term oncologic outcome parameters after 5 years including locoregional recurrence (OR 0.95; 95% CI 0.44–2.05; p?=?0.89), disease-free survival (OR 1.16; 95% CI 0.84–1.58; p?=?0.36), and overall survival (OR 1.04; 95% CI 0.76–1.41; p?=?0.82) were found. Most trials exhibited a relevant risk of bias and several studies provided no information on the surgical expertise of the participating surgeons.

Conclusion

Differences in oncologic outcome between laparoscopic and open rectal surgery for rectal cancer were detected for the complete resection rate and the number of resected lymph nodes in favor of the open approach. No statistically significant differences were found in oncologic long-term outcome parameters.

     

Incidence of Venous Thromboembolism After Bariatric Surgery: A Population-Based Cohort Study

Background

The incidence of venous thromboembolism (VTE) after bariatric surgery is uncertain.

Methods

Using the resources of the Rochester Epidemiology Project and the Mayo Bariatric Surgery Registry, we identified all residents of Olmsted County, Minnesota, with incident VTE after undergoing bariatric surgery from 1987 through 2005. Using the dates of bariatric surgery and VTE events, we determined the cumulative incidence of VTE after bariatric surgery by using the Kaplan–Meier estimator. Cox proportional hazards modeling was used to assess patient age, sex, weight, and body mass index as potential predictors of VTE after bariatric surgery.

Results

We identified 396 residents who underwent 402 bariatric operations. The most common operation was an open Roux-en-Y gastric bypass (n?=?228). Eight patients had VTE that developed within 6 months (7 within 1 month) after surgery; five events occurred after hospital discharge but within 1 month after bariatric surgery. The cumulative incidence of VTE at 7, 30, 90, and 180 days was 0.3, 1.9, 2.1, and 2.1 %, respectively (180-day 95 % confidence interval (CI), 0.7–3.6 %). Patient age was a predictor of postoperative VTE (hazard ratio, 1.89 per 10-year increase in age; 95 % CI, 1.01–3.55; P?=?0.05).

Conclusions

In our population-based study, bariatric surgery had a high risk of VTE, especially for older patients. Because most VTE events occurred after hospital discharge, a randomized controlled trial of extended outpatient thromboprophylaxis is warranted in patients undergoing open Roux-en-Y gastric bypass for medically complicated obesity.     

Oesophageal and Gastric Cancer After Bariatric Surgery: an Up-to-Date Systematic Scoping Review of Literature of 324 Cases

Obesity Surgery - This review aimed to give an updated overview of the occurrence, diagnosis, treatment and outcome of oesophageal and gastric cancer after bariatric and metabolic surgery (BMS)....