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Published by the, "American society for metabolic and bariatric surgery"

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American Society for Metabolic and Bariatric Surgery

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Overview

Metabolic/bariatric surgery is the most effective and long-lasting treatment for severe obesity resulting in significant weight loss and the improvement, prevention or resolution of many related diseases including type 2 diabetes, heart disease, hypertension, sleep apnea and certain cancers.
Studies show bariatric surgery may reduce a patient's risk of premature death by 30-50%.

Bariatric surgery is as safe or safer than some of the most commonly performed surgeries in America including gallbladder surgery, appendectomy and knee replacement.

Effectiveness

Studies show patients typically lose the most weight 1-2 years after bariatric surgery and see substantial weight improvements in obesity-related conditions.

Patients may lose as much as 60% of excess weight six months after surgery, and 77% of excess weight as early as 12 months after surgery.

On average, five years after surgery, patients maintain 50% of their excess weight loss.

Majority of bariatric surgery patients with diabetes, dyslipidemia, hypertension, and obstructive sleep apnea experience remission of these obesity-related diseases.

Safety and Risks

The risks of severe obesity outweigh the risks of metabolic/bariatric surgery for many patients.
The risk of death associated with bariatric surgery is about 0.1% and the overall likelihood of major complications is about 4%.

Economics of Bariatric Surgery

The average cost of bariatric surgery ranges between $17,000 and $26,000.

Because of the reduction or elimination of obesity-related conditions and associated treatment-costs:

Estimates suggest third-party payers will recover bariatric surgery costs within 2 to 4 years.

Healthcare costs are reduced by 29% within five years of bariatric surgery.

Estimate of Bariatric Surgery Numbers, 2011-2019

The ASMBS total bariatric procedure numbers are based on the best estimate from available data (BOLD, ACS/MBSAQIP, National Inpatient Sample Data and outpatient estimations).

* New methodology for estimating outpatient procedures done at non-accredited centers.

ASMBS Approved Procedures and Devices

Roux-en-Y Gastric Bypass

Stomach reduced to size of walnut and then attached to middle of small intestine, bypassing a section of the small intestine (duodenum and jejunum) and limiting absorption of calories

Risks include allergic reactions to medicines, blood clots in the legs, blood loss, breathing problems, heart attack or stroke during or after surgery and infection

Sleeve Gastrectomy

Stomach divided and stapled vertically, removing more than 85%, creating tube or banana-shaped pouch restricting amount of food that can be consumed and absorbed by the body

Risks include gastritis, heartburn, stomach ulcers; injury to the stomach; intestines, or other organs during surgery; leakage from the line where parts of the stomach have been stapled together; poor nutrition, scarring inside the belly that could lead to a future blockage in the bowel; and vomiting

Gastric Banding

Adjustable silicone band filled with saline wrapped around upper part of stomach, creating small pouch that restricts food intake

Risks include the gastric band eroding through the stomach, the gastric band slipping partly out of place, gastritis, heartburn, stomach ulcers, infection in the port, injury to the stomach, intestines, or other organs during surgery, poor nutrition, and scarring inside the belly

Duodenal Switch

The majority of the most stretchable portion of the stomach is permanently removed and roughly twothirds to three-fourths of the upper small intestines are bypassed.

Intragastric Balloon

Saline-filled silicone balloons temporarily placed in the stomach, limiting amount of food one can eat.

References

View attached PDF for a full list of References

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Metabolic and Bariatric Surgery - American Society for Metabolic and Bariatric Surgery

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Download Overview Metabolic/bariatric surgery is the most effective and long-lasting treatment for severe obesity resulting in significant weight loss and the improvement, prevention or resolution of many related diseases including type 2 diabetes, heart disease, hypertension, sleep apnea and certain cancers. Studies show bariatric surgery may reduce a patient's risk of premature death...

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Twelve-Month Outcomes in Patients with Obesity Following Bariatric Surgery-A single centre Experience

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Twelve-Month Outcomes in Patients with Obesity Following Bariatric Surgery-A single centre Experience

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Published by the National Library of Medicine

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Eric Raynaud De Mauverger, Academic Editor and Jean Frédéric Brun, Academic Editor

Abstract

Background: As obesity rates continue to rise worldwide, many surgeons consider bariatric procedures as a possible cure for the upcoming obesity pandemic. Excess weight represents a risk factor for multiple metabolic disorders, especially for type 2 diabetes mellitus (T2DM). There is a strong correlation between the two pathologies. The aim of this study is to highlight the safety and short-term results of laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB, laparoscopic gastric plication (LGP) and intragastric balloon (IGB) as methods used in the treatment of obesity. We followed the remission or amelioration of comorbidities, tracked metabolic parameters, weight loss curves and hoped to outline the profile of the obese patient in Romania. Methods: The target population of this study was represented by patients (n = 488) with severe obesity who qualified for the metabolic surgery criteria. Starting from 2013 to 2019, patients underwent four types of bariatric procedures and were subsequently monitored over the course of 12 months in the 3rd Surgical Clinic at "Sf. Spiridon" Emergency Hospital Iași. Descriptive evaluation indicators, as well as those of analytical evaluation were used as statistical processing methods. Results: A significant decrease in body weight was recorded during monitoring and was more pronounced for patients who underwent LSG and RYGB. T2DM was identified in 24.6% of patients. Partial remission of T2DM was present in 25.3% of cases, and total remission was identified in 61.4% of patients. Mean blood glucose levels, triglycerides, LDL and total cholesterol levels decreased significantly during monitoring. Vitamin D increased significantly regardless of the type of surgery performed, while mean levels of vitamin B12 decreased significantly during monitoring. Post-operative intraperitoneal bleeding occurred in 6 cases (1.22%) and a reintervention for haemostasis was required. Conclusions: All procedures performed were safe and effective methods of weight loss and improved associated comorbidities and metabolic parameters.

Keywords: obesity, bariatric surgery, diabetes, weight loss, body composition, T2DM, LSG, RYGB

1. Introduction

As the prevalence of obesity nearly tripled during the last three decades, it has become a global public health issue. Obesity is associated with considerable morbidity and mortality rates and could reverse the current trend of increasing life expectancy [ 1]. Prevention efforts are difficult due to the multifactorial nature of the disease and treatment is always challenging. Obesity is a result of the complex interaction between human behaviour, environmental factors and genetic predisposition. It represents the most important risk factor for multiple chronic diseases, such as T2DM, cardiovascular, pulmonary, renal and oncological pathologies [ 2, 3, 4]. The World Health Organization reported more than 1.9 billion overweight and 650 million obese adults in 2016 [ 5]. It already represents a burden to the economy with massive healthcare costs. Therefore, obesity prevention and treatment demand the attention of researchers and the scientific community [ 6]. Obesity is classified with the aid of the body mass index (BMI).

Available treatment for obesity includes lifestyle changes through diet and physical exercise, medication and invasive procedures known as bariatric or metabolic surgery. Numerous studies report that the surgical approach has superior results compared to non-surgical controls [ 7, 8, 9].

To date, bariatric surgery is the most effective treatment both in terms of weight loss and weight loss maintenance. Literature data also show amelioration or remission of weight associated comorbidities [ 2, 3, 4]. Bariatric surgery is considered complex due to the anatomical and physiological changes that develop in the gastrointestinal tract. The morbid profile of the obese patient is also a challenge. Technical advances, especially the introduction of laparoscopy, have substantially reduced the risks associated with these procedures [ 10].

Although bariatric surgery is very efficient, there is still controversy regarding what the optimal type of procedure is. For patients with severe clinical obesity and high anaesthetic risk, Douglas Hess described biliopancreatic diversion with duodenal switch (BPD-DS). This procedure was developed as an improvement to BPD. By preserving the pylorus, Hess has eliminated some common shortcomings such as dumping syndrome, biliary reflux and anastomotic ulcerations [ 11]. The surgery was performed in two steps in order to minimize perioperative risk related to technical complexity and long operative time. A longitudinal sleeve gastrectomy (LSG) that removed over 80% of the stomach was initially performed. Satisfied by the results, both in weight loss and comorbidity improvement, many of the patients never came back and LSG became a standalone procedure. It has become one of the most performed procedures worldwide due to reduced technical difficulty and optimal results. It is a purely restrictive procedure and can be easily converted to Roux-en-Y gastric bypass (RYGB) if results are inadequate or complications arise [ 12]. LSG is not recommended in patients with gastroesophageal reflux disease (GERD) or hiatal hernias (HH) because it can worsen their symptoms.

RYGB was initially described in the 1970s based on observations regarding unintentional weight loss in patients with peptic ulcer disease who underwent gastric resections. It combines the principles of restriction and malabsorption and is, to this day, one of the most efficient procedures both in terms of weight loss and remission rates of associated comorbidities [ 13].

Laparoscopic gastric plication was introduced in 2007 as a more conservative, reversible and cheaper alternative to LSG. It is a restrictive procedure in which a double plication of the greater curvature of the stomach is performed. It is preferred by patients because it does not alter the physiology of the stomach and does not require a resection. However, long-term results are debatable [ 14].

Endoscopic treatment is the least invasive option. The intragastric balloon (IGB) is a temporary restrictive procedure that occupies part of the stomach and induces early satiety. Aimed to fill the gap between surgery and medication, it is the preferred method for patients with low grade obesity or for those reluctant to undergo more invasive procedures [ 15].

Depending on the BMI and associated comorbidities, the surgeon together with the patient will choose the most appropriate procedure.

Consulting a multidisciplinary team in a specialized centre before surgery can help to manage the patient's modifiable risk factors, reduce perioperative complications and optimize outcomes.

2. Materials and Methods

The target population of this study consisted of patients with obesity who failed to lose weight through diet and physical exercise. They underwent four types of bariatric surgical procedures from 2013 to 2019 and were subsequently monitored over the course of 12 months in "St. Spiridon" Emergency Clinical Hospital Iași, 3rd Surgical Clinic.

The subject selection was performed by non-random sampling and data collection was performed retrospectively, longitudinally, based on the information contained in the medical documents of each patient.

We included 488 patients who underwent bariatric surgery during the study period. They were followed up at 1, 3, 6 and 12 months after the procedure. LSG was performed on 443 patients, RYGB on 30 patients, 7 patients opted for LGP and 8 patients for IGB ( Figure 1 ).

At the time of the study, eligibility conditions for bariatric procedures were in accordance with the 1991 National Institutes of Health (NIH) Consensus Statement recommendations, as follows [ 16]:

patients with a BMI > 40 kg/m ² with or without coexisting medical conditions and who do not present a high anaesthetic-surgical risk;

patients with a BMI > 34.9 kg/m ² with one or more obesity-related comorbidities or with a significant impairment in quality of life (T2DM, essential hypertension, dyslipidaemia, sleep apnoea syndrome or non-alcoholic fatty liver disease-NAFLD);

patients over 18 years old.

The procedures performed were LSG (n = 443), RYGB (n = 30), LGP (n = 7) and IGB (n = 8).

During the study period, we monitored the main demographic and morphological characteristics, the evolution of comorbidities associated with obesity and the biological parameters in each of the surgical groups.

The data were extracted from medical charts, then uploaded and processed using the statistical functions in SPSS 18.0. Due to the longitudinal data collection, all patient data protection provisions were enforced, as the medical team in the teaching hospital were well informed on data and patients' rights protection.

In calculating the differences between two or more groups at the 95% significance threshold, depending on the distribution of the value series, the t-Student test, the F test (ANOVA), the χ ² test, the Pearson correlation coefficient (r) and the ROC curve were applied to the quantitative variables.

3. Results

3.1. Patient Distribution

In our centre, the first LSG procedures were performed in 2013. Since then, the number of procedures performed annually has followed an increasing trend ( Figure 2 ). Most of the interventions were performed in 2019 (n = 106), until all elective surgeries were prohibited at the beginning of 2020 due to the global COVID-19 pandemic.

3.2. Demographic Characteristics

In the study group, 63.9% of the patients were female, with a sex ratio of F/M = 1.8/1.

The age of the patients ranged from 18 to 70 years, with a mean of 40.81 years, close to the median of 41 years, suggesting a normal distribution of the series of values. The highest frequency was registered in the fourth decade of life (31.4%).

3.3. Distribution by Type of Procedure Performed

The most common procedure was LSG, with a proportion of 90.8% (443 patients). RYGB represented 6.14% of the interventions (30 patients), 1.4% were LGP (7 patients) and 1.6% were IGB (8 patients). The average post-operative length of stay was 2.79 days.

3.4. Preoperative Comorbidities and Morphologic Characteristics

Patient weights ranged from 77 to 216 kg, with an overall average of 132.33 ± 23.07 kg.

Preoperative BMI ranged from 29.11 to 66.48 kg/m ², with a mean of 45.69 ± 10.81 kg/m ² in patients treated with RYGB and 45.01 ± 6.84 kg/m ² in patients treated with LSG. These values were significantly higher than those recorded in patients treated with LGP (35.20 ± 1.92 kg/m ²) or IGB (32.13 ± 1.70 kg/m ²) ( p = 0.001).

Essential hypertension was identified in 30.53% of patients. Of them, 27.66% of patients had stage I hypertension, 1.84% had stage II and 1.02% had stage III. All patients were under chronic antihypertensive medication.

Dyslipidaemia was present in 48.77% of patients, hepatomegaly in 66.8% of cases and NAFLD in 81.76% of patients.

Vitamin D deficiency was identified in 53.07% of the cases, and 30 patients (6.14%) presented gastroesophageal reflux disease (GERD) symptoms.

T2DM was identified in 1/4 of the patients in the study group (24.6%), with slightly higher frequencies in the group of patients who underwent IGB (37.5%) and in the patients who underwent LSG (25.3%). The differences were not statistically significant ( p = 0.313).

Sleep apnoea syndrome (SAS) was identified in 88.1% of the study group, with 69.9% of patients having a severe form. It occurred more frequently in women (62.6% vs. 37.4%; p = 0.078) in the over 40 age group (46% vs. 54%; p = 0.571) and in those with urban residence (61.6% vs. 38.4%; p = 0.564).

3.5. Outcomes

Regardless of the type of procedure performed and the age and gender of the patient, the mean BMI has decreased from one follow-up to another during the 12 months ( p < 0.001): from 45.01 ± 6.84 kg/m ² to 31.27 ± 4.46 kg/m ² for LSG, from 48.69 ± 10.81 kg/m ² to 31.33 ± 4.63 kg/m ² for RYGB, from 35.20 ± 1.92 kg/m ² to 26.04 ± 3.18 kg/m ² for LGP and from 32.13 ± 1.70 kg/m ² to 25.58 ± 1.30 kg/m ² for IGB ( Figure 3 ).

Partial remission of T2DM was present in 25.3% of the study group and total remission was identified in 61.4% of patients. Plotting the ROC curve, it is highlighted that neither the preoperative weight (G0-AUC = 0.493; 95% CI: 0.433-0.553; p = 0.819) nor the excess weight (EW-AUC = 0.527; 95% CI: 0.469-0.586; p = 0.369) were good predictors for partial or total remission of T2DM ( Figure 4 ). Fasting glucose levels at 12 months in the presence or absence of glucose-lowering pharmacologic treatment were used to define total or partial remission.

The mean preoperative weight was significantly higher in patients with apnoea than in those without apnoea (133.55 vs. 123.31 kg; p = 0.001). Lower follow-up weight loss is also identified throughout the monitoring. One year after the procedure, the average weight remained significantly higher in patients with apnoea syndrome (92.41 vs. 86.45 kg; p = 0.003), but the percentage of weight lost at 12 months (%EWL12) did not differ significantly compared to patients without apnoea syndrome ( p > 0.05).

Plotting the ROC curve highlights that both the preoperative weight (G0-AUC = 0.623; 95% CI: 0.551-0.696; p = 0.002) and the excess weight (EW-AUC = 0.615; 95% CI: 0.542-0.687; p = 0.004) were good predictors of the presence of sleep apnoea syndrome ( Figure 5 ).

Total cholesterol and LDL cholesterol levels decreased significantly during monitoring, from an average of 248.51 ± 46.04 mg/dL to 193.43 ± 41.11 mg/dL ( p = 0.001) and from 227.85 ± 77.63 mg/dL to 97.42 ± 17.52 mg/dL, respectively ( p = 0.001), and did not correlate with any specific type of intervention.

Triglyceride levels decreased significantly during monitoring, from a mean value of 350.40 ± 160.77 mg/dL to 212.81 ± 136.73 mg/dL ( p = 0.001) at the end of the follow-up.

Mean blood glucose levels decreased significantly during monitoring, from an average of 112.53 ± 60.88 mg/dL to 91.38 ± 15.77 mg/dL ( p = 0.001).

Vitamin D was dosed before surgery and at 3, 6 and 12 months. During monitoring, values increased significantly regardless of the type of surgery applied from 21.43 ± 11.36 ng/dL to 35.31 ± 11.39 ng/dL ( p < 0.001). At the same time, the mean vitamin B12 levels decreased significantly during monitoring, from an average of 497.60 ± 215.83 pg/dL to 463.81 ± 211.41 pg/dL ( p = 0.001). All monitored metabolic parameters were centralised in the adjacent table ( Table 1 ).

We consider it necessary to define the parameters used to describe weight loss:

Body Mass Index (BMI) = Weight (kg)/Height ² (m);

Ideal Body Weight (IBW) = 50 + [0.91 × (height in cm − 152.4)] in men;

Ideal Body Weight (IBW) = 45.5 + [0.91 × (height in cm − 152.4)] in women;

Excess Weight (EW) = Actual weight − IBW;

Percentage of Weight Loss (%EWL) = (postoperative weight loss)/(preoperative EW) × 100.

4. Discussion

The aim of the study is to report clinically relevant data and to highlight the results of bariatric surgical procedures regarding weight loss and the subsequent effect on ameliorating comorbidities and metabolic parameters. The validation of our results by comparison is challenging, as populations have different social, economic, and cultural backgrounds and eating habits. We thus hope to outline the metabolic profile and morphological characteristics of the patient with obesity in a middle-income Eastern European country.

The first bariatric procedures were performed in 2013 and were exclusively LSG for the first two years. This procedure was also performed the most during the span of the study (90.8%). The number of procedures performed increased annually. LSG is currently the most practiced procedure worldwide. This is due to the safety profile of the intervention, with a steeper learning curve and lower rates of intraoperative and postoperative complications. Comparable efficiency and results as RYGB are proven in numerous studies [ 17, 18, 19]. As the experience of the surgical team grew, more complex bariatric procedures were performed. In addition, patients became more aware that obesity is a serious health problem and started asking for a surgical solution. LSG does not require gastro-intestinal anastomoses and there are fewer short- and long-term complications associated with the procedure.

Initially described by E. Mason in 1967, perfected and standardized by Griffin et al. in 1977, RYGB remains the cornerstone of metabolic surgery to this day, combining both the principles of restriction and malabsorption. RYGB was gradually introduced in our centre and performed more often alongside some redo procedures, surgical management of complications (migrated adjustable gastric bands) and 14 Single Anastomosis Duodeno-Ileal Switch (SADIS), but these patients were not included in the current study.

Analysing the demographic characteristics of the patients in this study, especially gender distribution, we can observe that 63.9% of patients were female, with a sex ratio of F/M = 1.8/1. Other studies also confirm a higher prevalence of obesity among the female population: 42.48 vs. 33.85% [ 20, 21].

One cross-sectional study carried out on a cohort of 3361 patients follows the association between BMI and depressive disorder. It emphasizes a U-shaped relationship between the two pathologies. They tend to be more strongly associated in underweight male patients and in female patients with a higher BMI. This may be due to the social promotion of a more muscular body type among men, while a leaner body type is more desirable among females. This may contribute to a higher addressability to bariatric surgery for females [ 22].

A closer analysis pertaining to the age of our patients highlights that almost 60% are between the ages of 30 and 49, a socio-economically active population, thus emphasizing the importance of finding the optimal solution.

The mean weight at the time of surgery is higher among patients who underwent RYGB. This is in line with the literature data, as this type of intervention is especially indicated for patients with higher levels of obesity and those for whom LSG is not recommended. Contraindications for LSG include addictive behaviour towards sweet foods with a high caloric index, symptomatic GERD or hiatal hernias. In these cases, LSG would aggravate the symptoms [ 23, 24]. In addition, while LSG is exclusively a restrictive procedure, RYGB also adds malabsorption to the equation. This is achieved by altering the anatomy of the digestive tract, shortening the path that food has to travel and implicitly lowering the amount of nutrients that are being absorbed [ 25].

Although the long-term results are comparable between LSG and RYGB, the associated comorbidities and the particularities of each patient must be considered. Regardless of the type of surgery chosen, the best results will be obtained by patients who understand the risks, benefits and assume responsibility for their diet and regular post-operative clinical and biological follow-ups [ 26].

The most important parameters that describe the dynamics of the weight curve are represented by BMI and %EWL. In this study, there were no significant differences gender-wise. The BMI values had a favourable trend at all timepoints, regardless of the type of intervention performed. This uniform variation can be attributed to the fact that patients with LGP and IGB had lower mean weight values at the time of surgery than those with LSG and RYGB and associated fewer comorbidities. Similar results are reported in some long-term studies [ 27, 28].

The role of bariatric surgery in the partial or total remission of T2DM is already well established and some guidelines even recommend extending surgical indications to patients with class I obesity in whom glycaemic control under optimal drug treatment is inadequate [ 2, 7]. In our study group, T2DM was identified in 24.6% of patients, with a slightly higher frequency in the LSG group. For these patients, the mean preoperative weight was similar to that of non-diabetic patients, but %EWL12 was slightly higher in the T2DM group. Plotting the ROC curve highlighted that neither preoperative weight nor excess weight were good predictors of partial or total remission of T2DM. Remission criteria were defined as follows [ 29]:

complete T2DM remission-fasting plasma glucose < 100 mg/dL and/or HbA1c < 6% for at least 1 year after surgery in the absence of glucose-lowering pharmacologic treatment;

partial T2DM remission-fasting plasma glucose < 126 mg/dL and/or HbA1c < 6.5% without antidiabetic medication for at least 1 year.

Complete remission spanning over 5 years or more is considered curative [ 29]. A randomized clinical trial reports a remission rate of 66.7% at two years after surgery, similar to our investigation [ 30]. However, some patients relapsed during the 10-year monitoring period, but glycaemic control remained satisfactory. It seems that one important factor leading to remission is the hypocaloric state induced by the prolonged caloric deficit following bariatric procedures. Some studies on patients with T2DM highlighted the immediate improvement of insulin sensitivity similar to their surgical counterparts just by having a caloric restriction, similar to that in the first 10 to 20 days after bariatric surgery [ 31]. This effect was mainly attributed to the amelioration of the hepatic insulin sensitivity. The favourable effects of insulin on skeletal muscles were observed later on and were more weight loss dependent. Incretin and insulin levels are both severely altered in obese patients with T2DM. However, they seem to return to normal values shortly after bariatric surgery, especially in those who underwent RYGB [ 32]. The factors and action mechanisms leading to remission are still unclear. It seems that patients with a more substantial weight loss have higher chances than others. In addition, the duration of T2DM prior to surgery, poor glycaemic control and intensive use of insulin seem to negatively influence remission rates. These patients also have a higher chance of relapse [ 33, 34]. Lack of remission should not be considered as a failure of bariatric surgery. Long term control of all metabolic comorbidities is equally as important and the International Diabetes Federation even advocates for the complementary use of medication to prolong and enhance the effects of surgical procedures [ 34]. As of November 2022, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the criteria for bariatric surgical procedures as follows:

patients with a BMI > 35 kg/m ² with or without coexisting medical conditions and who do not present a high anaesthetic-surgical risk;

patients with a BMI of 30-34.9 kg/m ² with one or more obesity-related comorbidities or with a significant impairment in quality of life (T2DM, essential hypertension, dyslipidaemia, sleep apnoea syndrome or NAFLD).

Due to numerous studies that demonstrate the efficacy, long-term results and safety, bariatric surgery may now be considered for adolescents and patients over 70 years that are appropriately selected. These indications are widely accepted and the evidence indicates superior results compared to non-surgical interventions in terms of both weight loss and glycaemic control [ 35].

All interventions had a favourable outcome on total and LDL cholesterol at all time-points. The lipid profile improved or normalized during the 12-month period of monitoring.

In our study group, obstructive sleep apnoea (OSA) was the main factor that delayed the surgical procedure. As seen in the data presented above, severe forms were diagnosed in patients unaware of this pathology. They required continuous positive airway pressure (CPAP) treatment and re-evaluation from the pneumonologist in order to assess the improvement in the apnoea-hypopnea index (AHI). Poor oxygenation may be responsible for ischaemia in sutured, resected or anastomosed tissue which is a predisposing factor to anastomotic leaks. Undiagnosed patients present higher risks of postoperative cardiac events and respiratory failure [ 36]. These are the main reasons bariatric candidates require preoperative screening, treatment, postoperative monitoring and extensive follow-ups. Polysomnography is the gold standard for diagnosing OSA [ 36]. Although few studies focus on sleep apnoea improvement in patients who underwent bariatric procedures, they demonstrate the superior outcomes in the surgical group compared to the common medical care group [ 37, 38]. At the end of the monitoring period, some patients in the control group had an AHI increased by five and a higher BMI than the baseline values. In contrast, RYGB had a significant impact on OSA remission or improvement in moderate and severe forms [ 38]. Regarding our patients, the ROC curve highlights that both the preoperative and the excess weight were good predictors of the presence of OSA. The obstructive aetiology of apnoea syndrome may explain this result. In patients with severe obesity, excess fat in the cervical extremity may cause compression of the upper airways when in the supine position.

A randomized, double-blind clinical study among patients with obesity, altered basal blood glucose and hypovitaminosis D observed that correcting vitamin D deficiency improves insulin resistance and reduces the risk of progression to T2DM [ 39]. Furthermore, our patients' serum levels of vitamin D show a significant increase during monitoring due to the initiation of nutritional supplementation aimed to correct hypovitaminosis and protein deficiency starting with the first month postoperatively.

The role of vitamin D in modulating the immune system has been proven in numerous studies. The low vitamin D levels among the European general population represent a public health problem. They have been associated with a predisposition to infections and chronic diseases [ 40]. A recent study concludes that individuals with low vitamin D levels are 80% more likely to acquire a COVID-19 infection compared to a control group with normal levels. Moreover, obesity and overweight are positively associated with higher rates of mortality in SARS-CoV-2 infections. A strong association is also underlined in previous MERS and SARS epidemics [ 41]. Vitamin D can be obtained from exogenous sources (nutrition or supplementation) or synthetized in the presence of UV-B light, but the levels vary depending on season and latitude of residence [ 42]. Some studies report that the effects of vitamin D deficiency could be reversible. Supplementation proved a favourable outcome increasing both the size and number of aged skeletal muscle fibres. It also improved muscle strength and balance in laboratory animals [ 43]. Among several murine animal models, some studies mention the beneficial effects of prolonged vitamin D administration on adipose tissue remodelling. The histological findings suggest that it can regulate adiposity, decrease lipid accumulation and prevent sarcopenia [ 44, 45].

Micronutrient deficiencies are common after bariatric surgery. Therefore, many patients need routine vitamin and mineral supplementation. These changes can also be seen in our study, especially in the case of vitamin B12 found only in exogenous sources. These deficiencies could be explained by reduced dietary intake and anatomical and physiological changes in the gastrointestinal tract, especially in the case of malabsorptive procedures. However, the incidence of vitamin and mineral deficiencies following LSG compared to RYGB have yet to be reported [ 46]. At the end of the study, the levels of vitamin B12 decreased significantly, thus confirming the necessity of long-term supplementation with iron and vitamin B12 in addition to multivitamins and general minerals. Unmonitored patients may develop anaemia caused by altered gastrointestinal absorption.

Short term complications consisted of six post-operative intraperitoneal bleedings in patients with LSG. Laparoscopic reintervention during post-operative day 1 for definitive haemostasis was required in all cases. Bleeding occurred either from the trocar site, divided gastro-colic ligament or at the level of the remaining stomach due to imperfect stapling. Pertaining long-term complications, we could mention a case of small bowel volvulus caused by an entero-parietal flange and a case of common bile duct obstruction due to migrated gall stones. Both patients had underwent RYGB and the latter was treated through a laparoscopic gastrotomy in the excluded part of the stomach to allow access to the duodenum and to endoscopically remove the gall stones. This was caused by the anatomical changes in the GI tract that occur as a consequence of RYGB.

Limitations of the study include incomplete data availability. Although the patient pool was higher, some were not compliant with the follow-up program and could not be included in the study. Some patients had their residency abroad or in other regions. Long term results are not reported. Although our recommendation for post-bariatric follow-up is every 6 months after the first year, few patients presented long-term. A more procedure-oriented comparison could not be performed as the vast majority of our patients underwent LSG.

Strengths include the large sample size, the close monitoring of the main metabolic parameters throughout the first 12 months, and outlining the profile of the patient with obesity in a developing Eastern European country. This study is also among the first reports of bariatric surgery outcomes in Romania. We hope to continue following our patients further in order to gain a better understanding of their needs and expectations.

5. Conclusions

At 12 months after surgery, the weight loss percentage was not significantly correlated with a lower or higher preoperative weight.

All bariatric procedures were effective methods of weight loss and improved weight associated comorbidities and laboratory parameters. The outcomes of LSG and RYGB were comparable and both procedures had better outcomes in terms of weight loss than LGP and IGB.

Choosing the right type of bariatric surgery should take into account each patient's comorbidities, weight loss goals and the individual anaesthetic-surgical risk.

Situations where patients did not have associated weight-related comorbidities were very rare. Patients were usually underdiagnosed, and some pathologies were diagnosed during preoperative investigations, sometimes postponing the surgical procedure. Most frequently, patients associated high blood pressure, dyslipidaemia, hepatomegaly, NAFLD, vitamin D deficiency, OSA and T2DM.

After more than half a century of research, an ideal solution is yet to be found. Obesity is a progressive chronic disease with complex and incompletely elucidated mechanisms. Complete treatment cannot be achieved by restrictive or malabsorptive surgery alone. The best results can be achieved by having an informed patient, a well-trained surgeon and a multidisciplinary team.

Acknowledgments

We want to thank Oana Olariu for her indispensable support and technical assistance throughout this project. We would also like to highlight the efforts of the Romanian Society for Metabolic Surgery (RSMS), member of IFSO, in implementing a national registry of the obese patient, in an effort for bariatric surgery to be included in the national health policies.

Funding Statement

This research received no external funding.

Author Contributions

Conceptualization, R.P.S., D.V.T. and D.A.; methodology, R.P.S. and D.A.; software, R.L.P., M.M. and V.V.; validation, A.C.P. and B.M.C.; formal analysis, A.C., A.S. and V.V.; investigation, R.P.S., M.M., R.L.P., V.V. and A.S.; resources, D.V.T., D.A., B.M.C. and A.C.; data curation, A.C. and V.V.; writing-original draft preparation, R.P.S. and A.S.; writing-review and editing, R.P.S., A.S., A.C.P. and I.S.; visualization, B.M.C., A.C.P., A.S., M.M., I.S. and R.L.P.; supervision, D.V.T., D.A. and I.S.; project administration, R.P.S., D.V.T. and D.A. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The study was conducted following the Declaration of Helsinki, and approved by the Institutional Ethics Committee of "Grigore T. Popa" University of Medicine and Pharmacy and "St. Spiridon" Clinical Emergency Hospital, Nr. 137/25.01.2022 and Nr. 34/17.03.2022, respectively, for studies involving humans.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest.

Footnotes

Disclaimer/Publisher's Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

References

Articles from Nutrients are provided here courtesy of Multidisciplinary Digital Publishing Institute (MDPI)

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Twelve-Month Outcomes in Patients with Obesity Following Bariatric Surgery-A Single Centre Experience

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Background: As obesity rates continue to rise worldwide, many surgeons consider bariatric procedures as a possible cure for the upcoming obesity pandemic. Excess weight represents a risk factor for multiple metabolic disorders, especially for type 2 diabetes ...

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Recovery of brain structural abnormalities in morbidly obese patients after bariatric surgery

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Recovery of brain structural abnormalities in morbidly obese patients after bariatric surgery

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Published by Nature Publishing Group

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Metabolic outcomes 1 year after gastric bypass surgery in obese people with type 2 diabetes.

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Metabolic outcomes 1 year after gastric bypass surgery in obese people with type 2 diabetes.

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Published by Karger Country of Publication

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The Origins of the Obesity Epidemic in the USA–Lessons for Today

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The Origins of the Obesity Epidemic in the USA–Lessons for Today

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Published by MDPI

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Nutrients. 2022 Oct; 14(20): 4253.

Rosa Casas, Academic Editor, Lindsay Brown, Academic Editor, and Javier Gomez-Ambrosi, Academic Editor

Abstract

The obesity epidemic appeared in the USA in 1976-1980 and then spread across Westernized countries. This paper examines the most likely causes of the epidemic in the USA. An explanation must be consistent with the emergence of the epidemic in both genders and in all age groups and ethnicities at about the same time, and with a steady rise in the prevalence of obesity until at least 2016. The cause is closely related to changes in the American diet. There is little association with changes in the intake of fat and carbohydrate. This paper presents the opinion that the factor most closely linked to the epidemic is ultra-processed foods (UPFs) (i.e., foods with a high content of calories, salt, sugar, and fat but with very little whole foods). Of particular importance is sugar intake, especially sugar-sweetened beverages (SSBs). There is strong evidence that consumption of SSBs leads to higher energy intake and more weight gain. A similar pattern is also seen with other UPFs. Factors that probably contributed to the increased intake of UPFs include their relatively low price and the increased popularity of fast-food restaurants. Other related topics discussed include: (1) the possible importance of Farm Bills implemented by the US Department of Agriculture; (2) areas where further research is needed; (3) health hazards linked to UPFs; and (4) the need for public health measures to reduce intake of UPFs.

Keywords: food prices, obesity, sugar, sugar-sweetened beverages, fast foods

1. Introduction

Many thousands of research studies have been carried out on the causes of obesity and effective forms of treatment [ 1, 2]. However, there is still a great deal to be learned. Starting around 1980, an obesity epidemic emerged that spread across the Western world. There has been much speculation as to the true cause of this epidemic but, as yet, no explanation has gained wide acceptance. This paper examines the evidence in an attempt to identify which factors are most likely to be responsible. The major focus is on the USA. The findings are potentially important as by identifying the major factors that triggered the obesity epidemic, this may suggest how obesity can be prevented.

2. Emergence of the Epidemic

The obesity epidemic emerged in Westernized countries during the 1980s [ 3, 4]. Our best evidence is that this major event started a few years earlier in the USA, namely in 1976-1980 [ 5, 6]. Obesity is defined as a BMI ≥ 30. There was only a small rise (approximately 0.5%) in the prevalence of obesity among American adults in the years 1971-1974 to 1976-1980, but this was followed by a rapid rise that continued for at least 20 years. The prevalence of obesity in American adults (age 20-74, both genders) rose from 15.0% in 1976-1980, to 23.3% in 1988-1994, and to 30.9% in 1999-2000. What is especially noteworthy is that this fast-rising prevalence among American adults was similar in all age groups, in both men and women, and in all major ethnic groups including Caucasian Americans, African Americans, and Mexican Americans [ 6]. This rise in the prevalence of obesity continued in both genders during the period 1999 to 2016 [ 7].

The data from the USA come from regular surveys that assess the health and nutritional status of adults and children. These surveys are known as the National Health and Nutrition Examination Survey (NHANES). They are carried out by the National Center for Health Statistics (NCHS), which is part of the Centers for Disease Control and Prevention (CDC).

3. Possible Causes of the Epidemic

Based on the information stated above, an explanation for the epidemic must be consistent with the following:

The appearance of the epidemic in the USA in the years 1976-1980;

Its appearance in both genders and in all age groups and ethnicities at about the same time;

A steady increase in the prevalence of obesity that continued until at least 2016.

Where information was needed on particular topics, a literature search was carried out using the PubMed database. As this paper is an opinion piece rather than a review, I have been very selective regarding what information is included or excluded.

Several factors can be immediately eliminated as they do not act across the population in a mere five years or so. This includes genetics and epigenetics. The latter factors are certainly of much relevance in helping to explain why one person develops obesity but not another person who leads a similar lifestyle. However, the distribution of these factors is fairly stable across the population and for that reason cannot explain the sudden emergence of the obesity epidemic. Similarly, we can exclude maternal factors that act before birth or in early infancy. As with genetics these factors are certainly relevant in explaining person-to-person variation in the development of obesity. However, these factors cannot explain why the obesity epidemic appeared in different age groups at around the same time.

A reduction in physical activity seems to have played, at most, only a minor role [ 3]. Manual labor has steadily decreased in the USA over many decades. A significant decrease was seen during the 1960s and 1970s, but this shows only a weak association with the rapid increase in obesity that started in the late 1970s [ 3]. Moreover, the magnitude of the decrease in work-related physical activity is too small to have been an important factor in the increase in obesity. Another argument against a significant role for the decrease in work-related physical activity is that the rise in obesity was also seen among persons who were not of working age (i.e., those aged under 18 or over 65). Over the decades, the need for physical activity also steadily fell outside of work. In particular, the population had greater access to cars and public transport.

Finally, it is noteworthy that there is no evidence indicating a fall in leisure-time physical activity at around the time that the obesity epidemic started. Indeed, the late 1970s and 1980s was when exercise became more popular (e.g., jogging).

Obesity occurs when energy intake (food) is substantially higher than energy expenditure (in particular physical activity). The cause of the obesity epidemic must therefore be due to either an increase in energy intake from food or a decrease in physical activity (or a combination). As noted above it is unlikely that a decrease in physical activity played a significant role in the epidemic. From this, we can assume that the most likely explanation for the epidemic is changes in the American diet. A large body of evidence has linked the diet with body weight and risk of excess weight gain. Many changes have taken place in the American diet over the past several decades. We now explore how changes in the American diet may have led to the obesity epidemic.

3.1. Dietary Fat

A hypothesis that gained wide support during the 1970s was that the diets commonly eaten in the USA and across the Western world had an excessively high content of fat and that this played a major role in various chronic diseases of lifestyle. This hypothesis was extended to obesity. In 1977, the Senate Select Committee on Nutrition and Human Needs translated this hypothesis into actual policy with the publication of Dietary Goals for the United States [ 8, 9]. One of the recommendations in this report was that Americans should reduce the fat content of their diet. This advice was repeated in 1980 with the publication of the first edition of Dietary Guidelines for Americans [ 10]. Recommendations for a reduced intake of fat steadily permeated to the general population [ 11]. The food industry responded by marketing such foods as lean meat and low-fat milk.

Despite these various actions it is unclear if there was an actual fall in fat intake after 1980. Findings from NHANES surveys (of 8600-10,000 persons) suggest that American adults reduced their fat intake as a proportion of energy during the years 1976-1980 to 1999-2000 (36.7% to 32.3% in men; 36.0% to 32.4% in women) [ 12]. However, there was a significant rise in energy intake at the same time. The net effect is that the quantity of fat in the diet appears to have risen slightly.

Another study used the findings from the Nationwide Food Consumption Survey (NFCS) of >10,000 American adults [ 13, 14]. The data cover the period from 1977-1978 to 1987-1988. Fat intake as a proportion of energy fell from 41.0% to 36.6%. There was also a modest (approximately 4%) fall in energy intake. The net result is an approximate 14% fall in the quantity of fat in the diet. These findings must be viewed with some suspicion as they indicate that energy intake was falling while the prevalence of obesity was increasing.

The findings regarding changes in intake of fat and energy lack consistency between the above two studies. As the NFCS data may be unreliable, more reliance should be placed on the NHANES data. This suggests, therefore, that the fat intake of American adults was quite stable during the years 1976-1980 to 1999-2000. The findings from randomized controlled studies (RCTs) show that small changes in fat intake have little impact on body weight [ 15]. Taking these findings as a whole, we can conclude that there is, at most, only a very small relationship between changes in the fat content of the American diet and the appearance of the obesity epidemic.

As stated above the findings from NHANES indicate that there was a significant rise in energy intake at the same time as the fat intake of American adults was quite stable (1976-1980 to 1999-2000). This suggests that there was an increase in the quantity of carbohydrates in the diet. Many investigators have been quick to conclude that this increase in dietary carbohydrates was an important factor in the obesity epidemic [ 16]. However, that is a serious mistake as it ignores the major differences between different food sources of carbohydrates. When attention is turned away from the quantity of carbohydrate in the diet, and to the nature of the foods being eaten, the probable cause of the epidemic starts to emerge.

3.2. Sugar and Sugar-Sweetened Beverages

Sugar intake in the USA was fairly stable in the 1970s but then rose sharply after 1978. Per capita intake of total caloric sweeteners was 124.6 pounds in 1978, 132.7 pounds in 1988, and 154.1 pounds in 1997 [ 17]. This indicates an increase of 36.7 g/day (147 kcal/day) between 1978 and 1997. The increase in energy intake is sufficiently high to explain the increase in the average weight of the population [ 18]. One important factor that brought about the growth in sugar intake was a major drop in the price of sugar that occurred after 1980 [ 19].

The above data refers to total caloric sweeteners. However, there was a large shift from sucrose to high-fructose corn syrup, but there is no hard evidence that this is a significant factor in the obesity epidemic [ 20].

Surveys of the American diet document a large rise in the consumption of sugar-sweetened beverages (SSBs) during the time period 1977-1978 to 1994-1996 [ 21]. This accounts for much of the increase in sugar intake. During this time period the proportion of energy obtained from soft drinks increased from 4.1% to 7.0% at age 19-39 and from 1.9% to 4.0% at age 40-59.

RCTs and prospective cohort studies have generated strong evidence that consumption of SSBs leads to higher energy intake and more weight gain [ 22, 23]. Findings from RCTs have reported that the addition of SSBs to the diet of adults leads to a 0.85 kg increase in body weight [ 22]. Findings from cohort studies indicate that an extra serving per day of SSB is associated with an increase in body weight in adults of around 0.12 to 0.22 kg [ 22]. This is probably also the case in the area of sugar intake in general; however, there are far fewer research studies [ 23]. This evidence strongly suggests that SSBs are a major factor responsible for the obesity epidemic.

3.3. Ultra-Processed Foods

SSBs are a type of food commonly referred to as ultra-processed foods (UPFs) [ 24]. UPFs are typically prepared from mostly cheap sources of dietary energy and nutrients plus additives. They are mostly high in calories, salt, sugar, and fat but contain minimal amounts of whole foods. As a result, they have a low content of dietary fiber, phytochemicals (for example, lutein, lycopene, and anthocyanins), and of various micronutrients, such as potassium, magnesium, and vitamin C. Examples of UPFs include white bread, sweetened breakfast cereals, cookies, savory snacks, cakes, candy, ice cream, margarine, sausages, and pizza.

There is impressive evidence that UPFs play a major role in the obesity epidemic [ 25]. The above-mentioned surveys of the American diet that documented a large rise in the consumption of SSBs during the time period 1977-1978 to 1994-1996 also revealed a similar increase in the intake of other UPFs [ 21]. The largest increases were seen for salty snacks and pizza. During this time period, the proportion of energy obtained from various types of UPFs in the age group 40-59 increased from 1.4% to 3.8% for salty snacks, from 0.5% to 1.7% for pizza, from 0.5% to 1.4% for candy, and from 1.2% to 1.6% for French fries.

The following RCT demonstrates the potential of UPFs to cause one to be overweight and obese [ 26]. Subjects were fed two nutritionally similar diets for 2 weeks. The diets differed only in their degree of processing: one comprised UPFs while the other was based on minimally processed foods. Subjects were instructed to consume as much or as little as desired. The UPF diet resulted in, on average, a 508 kcal/day higher energy intake than the other diet. It also resulted in a commensurate amount of weight gain (an average of 0.9 kg).

These findings are consistent with those from prospective cohort studies. The combined results of three cohort studies conducted on 121,000 men and women in the USA reported a positive association of weight change with intake of potato chips (a UPF) but a negative association with intake of several minimally processed foods, namely fruits, vegetables, whole grains, and nuts [ 27]. Findings from cross-sectional studies (analyzed as part of a systematic review and meta-analysis) indicate that that a relatively high consumption of UPFs is associated with a 39% higher risk of overweight/obesity and of high waist circumference [ 28]. Another systematic review and meta-analysis of observational studies also concluded that there is a strong association between the intake of UPFs and risk of overweight and obesity [ 29].

One factor that may have been driving the upward consumption of UPFs is the strong trend towards eating at fast-food restaurants. The surveys of the American diet that were discussed earlier reported that the proportion of energy in the American diet that was obtained from eating out, including at fast-food restaurants, went from 9.4% to 21.3% during the years 1977-1978 to 1994-1996 [ 19]. Fast-food restaurants may be of particular importance as most of the food sold there is UPF (e.g., burger, fries, and a cola drink at McDonald's). Evidence from prospective cohort studies have reported that more frequent eating at these restaurants is associated with a greater increase in body weight and of waist circumference [ 30].

3.4. The Role of Farm Bills and Food Prices

Analyses of food prices has clearly shown that healthier diets cost significantly more than less healthy diets. For example, an international study compared the cost of healthy vs. less healthy food-based diet patterns. The researchers concluded that the top (most healthy) quantile cost $1.54 more per 2000 kcal (based on 2011 prices) [ 31]. It is well established that shoppers tend to buy less expensive foods. As UPFs are a feature of less healthy diets, shoppers will therefore frequently select these foods. These findings strongly indicate, therefore, that relatively low food prices encourage the general population to eat UPFs which, in turn, play a major role in obesity.

It has been suggested many times that a key event leading to the supply of large quantities of UPFs at relatively low prices was a major policy change by the Nixon administration in the early 1970s. Farm Bills implemented by the US Department of Agriculture (USDA) gave increased subsidies to farmers. This may have directly led to a large increase in the supply of agricultural products that food manufacturers then turned into UPFs which were sold at a relatively low price. This triggered and has sustained the obesity epidemic. This hypothesis has been the subject of much investigation, but no firm conclusions have been reached [ 31, 32].

4. Research Challenges

The most plausible explanation for the obesity epidemic in the USA is that around 1978-1980 there was a major increase in the consumption of UPFs. However, this hypothesis is still far from proven. There is a need for further research in the following key areas:

1. The change in intake of different types of food in the American diet, especially after 1978. In particular, information is needed on the changing intake of different types of UPFs in different sections of the US population from the 1970s to the present;

2. The factors that explain the increase in intake of UPFs (e.g., subsidies given to farmers by the USDA, changing food prices, and trends in the number of meals purchased at fast-food restaurants);

3. Changes in energy intake across the population and whether this is consistent with increases in the prevalence of obesity;

4. Whether findings from the US population also explain the obesity epidemic that occurred in other Westernized countries;

5. How different types of UPFs affect energy intake and lead to weight gain. A RCT that investigated this was described earlier [ 26]. However, while highly informative, its duration was only 2 weeks;

6. The most effective means to reduce the prevalence of obesity by reducing intake of UPFs across the population;

7. To determine whether a diet with a low content of UPFs is effective in aiding weight loss.

5. A Brief Overview of Ultra-Processed Foods and Health

The evidence presented in this paper strongly suggests that UPFs are a major factor responsible for the obesity epidemic. However, the negative impact of UPFs on health extends well beyond obesity. Observational evidence has revealed a clear association between the intake of UPFs and several disorders including cancer [ 33], type 2 diabetes [ 34], cardiovascular disease [ 28], and depression [ 28]. A recent systematic review and meta-analysis of 40 prospective cohort studies concluded that high consumption of UPFs (comparing highest vs. lowest intake groups) is associated with a 29% higher all-cause mortality [ 35].

UPFs are certain to have a major negative impact on the nutritional status of American adults as they comprise an estimated 57.0% of energy intake whereas minimally processed foods represent only 27.4% [ 36]. These data are from the NHANES survey in 2017-2018. As mentioned earlier, this will inevitably result in the diet having a low content of dietary fiber, phytochemicals, and of various micronutrients.

6. Ultra-Processed Foods and Public Health: The Need for Serious Action

These findings compel the conclusion that priority must be given to efforts that will reduce the consumption of UPFs, both in the USA and internationally. One strategy is a health education approach. Nutrition advice is delivered to the general public in diverse ways. Of particular importance governments deliver nutrition advice by way of food guides. These need to explicitly emphasize the importance of reducing the intake of UPFs. Similarly, the addition of labels to the front of food packages may help shoppers make healthier food choices [ 37]. Warning labels is one design that shows much promise (e.g., warning shoppers that a food has a high content of sugar).

Unfortunately, much evidence clearly demonstrates that delivering nutrition advice to the population achieves only modest success. A much more effective strategy is one based on policies implemented by governments that impose regulations on various organizations including food companies [ 38]. For example, schools can be ordered to cease selling UPFs in vending machines. Similarly, the amount of UPFs in school meals should be minimized.

Manipulation of food price is another policy approach that has much potential. It is well established that an increase in price leads to a decrease in sales (and vice versa). This is known as price elasticity. Accordingly, taxes and subsidies can be used in order to achieve a desired effect on food consumption [ 39, 40, 41]. More specifically, the price of UPFs, especially sugar-rich foods, can be increased while the price of healthy foods, such as fruit, vegetables, and whole grains, can be reduced.

It is very probable that policies implemented by governments are not only more effective than those based on nutrition education, but they are also much more cost-effective. This strategy has a long history and has achieved great success. Prominent examples include providing the population with safe drinking water, the addition of various micronutrients to particular foods, and the removal of trans fatty acids from foods [ 39].

7. Conclusions

The evidence presented here supports the case that the large quantities of UPFs in the diet have played a dominant role in the obesity epidemic. While the main focus here has been on the situation in the USA, it seems highly likely that UPFs are also heavily involved in the epidemic of obesity that has spread across the Western world, starting around 1980. However, there are still many gaps in the evidence and much more research is therefore needed.

A high dietary intake of UPFs is closely associated with a range of damaging effects on health in addition to obesity. For that reason, dietary advice should emphasize a reduction in the intake of UPFs across the population. While health education, such as food guides and food labels, is a useful way to work towards that goal, much evidence indicates this strategy achieves only limited success. A more effective strategy is one based on policies and regulations implemented by governments. Examples of such policies include removing UPFs from school meals, increasing the price of SSBs by adding a tax, and using subsidies to reduce the price of fruit and vegetables.

Funding Statement

This research received no external funding.

Data Availability Statement

Not applicable.

Conflicts of Interest

The author declares no conflict of interest.

Footnotes

Publisher's Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References

8. U.S. Senate Select Committee on Nutrition and Human Needs . Dietary Goals for the United States. 2nd ed. U.S. Government Printing Office; Washington, DC, USA: 1977. [ Google Scholar]

10. U.S. Department of Agriculture. U.S. Department of Health and Human Services . Dietary Guidelines for Americans. U.S. Government Printing Office; Washington, DC, USA: 1980. [ Google Scholar]

14. Human Nutrition Information Service . Nationwide Food Consumption Survey 1987-1988. US Department of Agriculture; Washington, DC, USA: 1993. Food and nutrient intakes by individuals in the United States, 1 day, 1987-1988. Report No. 87-l-l. [ Google Scholar]

17. Wells H.F., Buzby J.C. Dietary Assessment of Major Trends in US Food Consumption, 1970-2005. Economic Research Service, US Department of Agriculture; March 2008. Economic Information Bulletin No. 33. [(accessed on 2 July 2022)]; Available online: http://www.ers.usda.gov/Publications/EIB33

Articles from Nutrients are provided here courtesy of Multidisciplinary Digital Publishing Institute (MDPI)

# data[].attributes.attachment_link.title
The Origins of the Obesity Epidemic in the USA-Lessons for Today

# data[].attributes.attachment_link.description
The obesity epidemic appeared in the USA in 1976-1980 and then spread across Westernized countries. This paper examines the most likely causes of the epidemic in the USA. An explanation must be consistent with the emergence of the epidemic in ...

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26th World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) - Obesity, bariatric surgery 'cuts' the risk of cancer: -25%.

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26th World Congress of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) - Obesity, bariatric surgery 'cuts' the risk of cancer: -25%.

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Published by the Canada News Wire Group

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Direct medical costs of obesity in the United States and the most populous states

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Direct medical costs of obesity in the United States and the most populous states

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Published by the Journal of Managed Care & Specialty Pharmacy

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Long-term effectiveness, outcomes and complications of bariatric surgery

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Long-term effectiveness, outcomes and complications of bariatric surgery

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Published by Baishideng Publishing Group Inc

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Milena Gulinac, Dimitrina Georgieva Miteva, Monika Peshevska-Sekulovska, Ivan P Novakov, Svetozar Antovic, Milena Peruhova, Violeta Snegarova, Plamena Kabakchieva, Yavor Assyov, Georgi Vasilev, Metodija Sekulovski, Snezhina Lazova, Latchezar Tomov, and Tsvetelina Velikova

Abstract

Dietary imbalance and overeating can lead to an increasingly widespread disease - obesity. Aesthetic considerations aside, obesity is defined as an excess of adipose tissue that can lead to serious health problems and can predispose to a number of pathological changes and clinical diseases, including diabetes; hypertension; atherosclerosis; coronary artery disease and stroke; obstructive sleep apnea; depression; weight-related arthropathies and endometrial and breast cancer. A body weight 20% above ideal for age, gender and height is a severe health risk. Bariatric surgery is a set of surgical methods to treat morbid obesity when other treatments such as diet, increased physical activity, behavioral changes and drugs have failed. The two most common procedures currently used are sleeve gastrectomy and gastric bypass. This procedure has gained popularity recently and is generally considered safe and effective. Although current data show that perioperative mortality is low and better control of comorbidities and short-term complications is achieved, more randomized trials are needed to evaluate the long-term outcomes of bariatric procedures. This review aims to synthesize and summarize the growing evidence on the long-term effectiveness, outcomes and complications of bariatric surgery.

Keywords: Bariatric surgery, Long-term outcomes, Obesity, Roux-en-Y gastric bypass, sleeve gastrectomy, Effectiveness, Safety, Quality of life

Core Tip: The method of bariatric surgery is associated with dramatic weight loss, overall health improvement and, in many cases curing obesity-related comorbidities ( i.e., diabetes, high blood pressure, sleep apnea, asthma and other breathing disorders, arthritis, cholesterol problems, gastroesophageal reflux disease, fatty liver, urinary stress incontinence, brain pseudotumor, and more). Furthermore, in cases with a high degree of obesity, undergoing this type of surgical intervention also decreases overall mortality. Simultaneously, physical quality of life improved faster than mental quality of life.

INTRODUCTION

An imbalance in dietary patterns and excessive nutritional intake may give rise to ailments such as obesity. Despite any purely aesthetic considerations, obesity can be described as an excess of adipose tissue that endangers a person's health; specifically, a body weight exceeding 20% of the ideal weight determined by age, gender, and height is deemed to pose a significant health risk[ 1].

Bariatric surgery is a set of surgical methods for treating morbid obesity. This procedure has gained popularity recently and is generally considered safe and effective. In addition, some of the authors in recent scientific studies claim that it is effective in the short term, although long-term complications have not been described or are rare[ 1].

The method is associated with dramatic weight loss, improvement and, in many cases curing obesity-related comorbidities. These diseases include diabetes, hypertension, sleep apnea, bronchial asthma and other respiratory disorders, arthritis, cholesterol-related disorders, gastroesophageal reflux disease, fatty liver disease, urinary stress incontinence, brain pseudotumor, and more. Furthermore, in cases with a high degree of obesity, undergoing this type of surgical intervention also decreases overall mortality[ 2]. Because of this, the term "metabolic surgery" is becoming more and more critical.

There are many different causes of obesity, but it is a fact that the number of people suffering from obesity is constantly increasing. According to the World Health Organization, obesity has tripled in many countries of the European region since 1980, with overweight and obesity affecting 50% of the population in most European countries. Furthermore, it is projected that a significant portion of the global population, precisely 60%, or 3.3 billion individuals, may suffer from the effects of excessive weight gain, with 2.2 billion individuals deemed overweight and an additional 1.1 billion individuals classified as obese, by the year 2030[ 3].

Bariatric surgery is applied to people who cannot lose weight with diets and sports; have a body mass index (BMI) of 35 or higher, and have accompanying diseases such as metabolic syndrome, diabetes, hypertension, and others; as well as people who have an index above 40 but do not have accompanying diseases. Generally speaking, bariatric surgery aims at one single thing - to reduce the volume of food taken in and its absorption[ 3].

The global guidelines for bariatric surgery were established after a National Institutes of Health consensus conference in 1991. Even then, early bariatric procedures such as jejunoileal bypass were recognized to carry substantial long-term risks. However, the idea of surgical obesity treatment was primarily rejected. Over the next several years, the limited evidence regarding the safety and effectiveness of bariatric surgery was denied. Subsequently, a consensus panel decided that procedures such as Roux-en-Y gastric bypass (RYGB) and vertical banded gastroplasty (VGB) are safe and effective for patients with body mass index (BMI) ≥ 40 kg/m ² or with BMI ≥ 35 kg/m ² and concomitant medical complications of obesity[ 4].

In this way, a practice standard was established that had previously been lacking, and at the same time, this type of surgery was legitimized as a surgical discipline. Since then, the clinical evidence base for bariatric surgery has grown tremendously.

Bariatric surgery has significant health benefits, such as lowering hyperglycemia or normalizing blood glucose levels, lowering blood pressure and cholesterol, and improving obstructive sleep apnea and diabetes-related micro- and macrovascular complications. The surgical techniques involved in bariatric interventions are varied and involve different interventions[ 5]. When they include "bypassing" the duodenum, there is also a decrease in the hormone ghrelin and an increase in GLP-1 (Glucagon-like peptide 1) and PYY (Gut hormone peptide, tyrosine-tyrosine peptide), which improves insulin sensitivity, as well as other metabolic parameters. Two recently published meta-analyses of studies following patients for up to 5 years also showed reasonable glycemic control in patients with type 2 diabetes after bariatric surgery[ 5- 8].

During the coronavirus disease 2019 (COVID-19), most surgical procedures, especially elected, were postponed because of the health crisis and public health measures[ 9], including bariatric surgery.

Studies have shown that bariatric surgery leads to more significant weight loss and is more effective in treating type 2 diabetes in obese patients than non-surgical treatments. Long-term observations have also shown that these benefits persist for over five years after the surgery. However, the predicting factors of long-term complications, long-term survival, and the impact on patient mental health and costs must be constantly updated[ 10].

Nevertheless, like any other surgical procedure, this one hides its own risks, some of which are life-threatening, long-term nutritional complications. Often after this procedure, patients develop anemia and have calcium and vitamin losses, which must be compensated by taking substitutes throughout their lives. Some of the potentially severe complications of bariatric surgery are micro- and macronutrient deficiencies. In addition, stenosis and ulceration of the anastomosis, reflux esophagitis, cholelithiasis, steatohepatitis, and altered pharmacokinetics and dynamics may occur[ 11- 13].

Two additional risks are often overlooked: recurrent calcium oxalate urolithiasis and osteoporosis. Both complications are described more often after RYGB, which bypasses the duodenum, where the calcium is mainly absorbed. Unfortunately, an elevated oxalate excretion after RYGB was described, which is usually challenging to treat. Consistent with calcium malabsorption is the low level of urine calcium. Even so, RYGB-related osteoporosis is not associated with changes in weight or vitamin D metabolism[ 14].

In this review, we focus on the long-term outcomes, complications - rates and management, and quality of life (QoL) and psychological aspects in patients after bariatric surgery.

LONG-TERM OUTCOMES AFTER BARIATRIC SURGERY

A systematic review by O'Brien et al[ 15] reviewed 33 datasets reporting data beyond 10 years after bariatric surgery. There were no surgical fatalities. At 20 years, the weight reduction was 30.1 kg, excess weight loss (EWL) was 48.9%, and total weight loss (%TWL) was 22.2%. Although the reoperation rate was first high, currently, it is significantly lowered with a better band and aftercare follow-up.

They included 18 gastric bypass reports, 16 of which were RYGB and two for the laparoscopic One-Anastomosis Gastric Bypass (OAGB) version. At 10 years or longer, the mean %EWL for all gastric bypass combinations was 56.7%, with a mean of 55.4% EWL (for RYGB), 80.9% EWL (for OAGB) and 45.9% (for laparoscopic adjustable gastric banding, LAGB). In addition, the mean weight reduction in the two randomized control trials (RCTs) with LAGB was 55.9% EWL [ 15].

While long-term efficacy was encouraging, most studies exerted inadequate quality, with typically absent controls and several data gaps (incl. missing % follow-up, reoperation rates, perioperative mortality and morbidity, etc.) in most publications. Just two RCTs were included[ 16, 17]. Angrisani et al[ 17] found 69% EWL and 46% EWL in RYGB and LAGB, respectively. At 10 years in Australian research comparing LAGB to optimum medical care, the LAGB group had 63% EWL. Three noteworthy RCTs of 5-year results with RYGB vs SG have been reported[ 18- 20]. In 5 years, the SLEEVEPASS research[ 18] revealed 57% and 49% EWL for RYGB and SG, respectively. The SM BOSS research[ 19] found that RYGB had a 68% excess BMI loss (EBMIL), and the SG had a 61% EBMIL. Finally, the STAMPEDE research[ 20] found that RYGB had a TWL of 21.7% and SG had a TWL of 18.5%. We anticipate a lengthier follow-up from this and other similar research. Likely, widespread adoption of bariatric surgery will not occur until more high-quality evidence is released.

Van Veldhuisen et al[ 21] also performed a systematic review and meta-analysis of cardiovascular diseases and bariatric surgery. They include 39 prospective or retrospective cohort studies, but no RCTs. Bariatric surgery lowered the risk of all-cause death [pooled hazard ratio (HR) of 0.55, P < 0.001 vs controls] and cardiovascular mortality [HR 0.59, P < 0.001]. Moreover, bariatric surgery lowered the incidence of heart failure [HR 0.50, P < 0.001], myocardial infarction [HR 0.58, P < 0.001], and stroke [HR 0.64, P < 0.001], but not atrial fibrillation (HR 0.82, P = 0.12) [ 21].

The extent to which the favorable impact of bariatric surgery is related to total weight loss or if additional ancillary benefits also play a role is an essential consideration. According to a new small mechanistic investigation, the advantages of bariatric surgery are entirely connected to weight loss, with no additional objective benefits[ 22]. However, numerous other studies have shown that ancillary aspects of the surgery, such as a changed gut hormone production, increased insulin sensitivity, and altered gut microbiome[ 23], impact the outcomes. Therefore, bariatric surgery is referred to as metabolic surgery[ 20].

Nonetheless, there is no doubt that the degree of weight loss is critical. For example, one study demonstrated that in non-surgical obese patients, a 20% weight loss was required though rarely achieved, to decrease the long-term major cardiovascular events rate. In contrast, at least 10% weight loss was needed in surgical patients, which is usually easily accomplished[ 23] and supports the hypothesis that additional metabolic processes improve the benefits of surgery[ 21]. Despite the potential benefits of bariatric surgery for preventing (and maybe treating) cardiovascular illness, no randomized controlled trials have primarily studied the influence of surgery on cardiovascular events or outcomes.

According to the European Society of Cardiology's newly issued guideline for cardiovascular disease prevention, "bariatric surgery for obese high-risk people should be considered when lifestyle adjustment does not result in maintained weight loss," i.e., it is a 2A recommendation[ 24]. This is a significant departure from the former guideline of 2016[ 25], in which diet and lifestyle changes were encouraged as mainstay therapeutic choices, and bariatric surgery was not formally recommended. Therefore, preventing or treating cardiovascular illness has had little effect on surgical recommendations thus far[ 26]. The most significant advice for metabolic surgery is for individuals with obesity and Type 2 diabetes. It is currently regarded as a suitable adjunct to existing conventional care in this patient population[ 27].

In summary, the findings of this systematic review and meta-analysis demonstrate that bariatric surgery, compared to non-surgical therapy, lowers mortality and the incidence of cardiovascular diseases in individuals with obesity. Therefore, in some instances, bariatric surgery should be explored[ 21].

In their systematic review and meta-analysis, Buchwald et al[ 28] focused on the 30-d surgical mortality of 0.1%, 0.5% and 1.1% for simply restrictive surgeries, gastric bypass, and biliopancreatic diversion or duodenal switch, respectively. Diabetes, sleep apnea and hypertension were cured in 76.8%, 85.7% and 61.7%, and improved in 86.0%, 83.6% and 78.5% of patients, respectively. Seventy percent or more of individuals observed an improvement in their hyperlipidemia. The authors concluded that after bariatric surgery, morbidly obese people lost weight effectively. Furthermore, most individuals with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea had their symptoms entirely resolved or improved[ 28].

Kang et al's systematic review and meta-analysis examined the efficacy and safety of the three most popular bariatric surgery procedures: RYGB, SG, and LAGB[ 29]. The findings revealed that BMI reduction and %EWL differed substantially between RYGB and LAGB but not between RYGB and SG. No significant difference in weight loss between RYGB and SG was demonstrated, even though they showed superiority to LAGB. While less efficient in weight reduction, LAGB caused fewer problems than the other two surgical techniques[ 29].

Still, the outcomes of bariatric surgery depend primarily on the multidisciplinary approach[ 30]. The desirable outcomes following bariatric surgery are presented in Figure ​Figure1 1 .

COMPLICATIONS AFTER BARIATRIC SURGERY

Bariatric surgery is generally safe and, in most cases, effective, but this type of surgical procedure can be associated with severe complications, some of which can be fatal[ 31].

In general, the complications of bariatric surgery are divided into two major groups: early and late. Early postoperative complications include leaks, stenoses, bleeding, and venous thromboembolic events, while late complications include band erosion, acute obstruction, gallstone disease, Dumping syndrome, ischemia, and megaesophagus or pseudoachalasia and death. Regarding the complications of this type of operative manipulation, many scientific groups work in the field, and publications are increasing yearly. One of the most detailed publications on this topic is the following.

Chang et al[ 32] evaluated 30-d significant complications related to bariatric surgeries. This study comprised 71 American studies from 2003 to 2014 and 107874 patients with a mean age of 44 years and a pre-surgery BMI of 46.5 kg m-2. They received gastric bypass, adjustable gastric banding, or SG[ 32]. The rate of less than 30-day anastomotic leak was 1.15%, of myocardial infarction - 0.37%; and of pulmonary embolism - 1.17%, where the death rates were 0.12%, 0.37%, and 0.18%, respectively, among all patients[ 33]. Although, among surgical procedures, SG had a greater anastomotic leak rate (1.21%) than gastric bypass (1.14%), gastric bypass exerted a higher risk for myocardial infarction and pulmonary embolism than other techniques. However, we discovered that complication reporting is poorer than other outcomes. The 30-d rates of the three primary problems following each operation vary from 0% to 1.55%, and the mortality rate after these complications ranges from 0% to 0.64%. Future research documenting issues following bariatric surgery should increase the quality of their reporting[ 32].

On the other hand, in the scientific work of Stone et al[ 33], a fascinating relationship between the skin color of the patients, respectively the nationality, with the complications that have occurred. They demonstrated that most studies revealed that Black patients had higher 30-d mortality, morbidity, and duration of stay than White patients. The differences between White and Hispanic patients were mainly non-significant in these outcomes. In conclusion, during 30-d of bariatric surgery, black individuals may encounter a greater risk of adverse events than white patients. Explanations for this discrepancy were limited due to the limits of large multicenter datasets. Longer-term studies that cover additional races and ethnicities and take socioeconomic considerations might help future studies[ 33].

Chierici et al[ 34] included 39 papers in their systematic review and meta-analysis to demonstrate that biliopancreatic diversion with duodenal switch provides the best weight loss results (total weight loss on the 1 st and 3 rd year, %TWL 12.38 and 28.42), followed by single-anastomosis duodenoileal bypass (%TWL 9.24 and 19.13), one-anastomosis gastric bypass (%TWL 7.16 and 13.1), and RYGB (%TWL 4.68 and 7.3) were all superior to re-SG. Furthermore, compared to re-SG, duodenal switch and RYGB are linked with an increased risk of late morbidity (OR: 3.07 and 2.11, respectively). However, no significant difference was seen for the other surgeries. In addition, weight recidivism is most common after re-SG; individuals receiving single-anastomosis duodenal bypass had the lowest rate[ 34].

Poole et al[ 35] conducted a survey completed by 138/715 eligible surgeons (19.3%) to evaluate the management of bariatric surgery complications. Approximately 54.3% of respondents had not received training in bariatric surgery during their residency or fellowship. Among the 108 respondents, 66.7% believed that general surgeons should handle post-bariatric surgery complications, while 25.9% lacked confidence in addressing such issues. Most respondents (65.7%) expressed interest in pursuing additional continuing professional development options for managing these complications. The most preferred educational modalities for this purpose included hands-on workshops, online resources, and live webinars, with 67.1% of the participants willing to invest 1-3 h and 42.9% ready to pay over $100 for such resources[ 35].

Some of the complications following bariatric surgery are presented in Figure ​Figure2 2 .

QUALITY OF LIFE AFTER BARIATRIC SURGERY

A systematic review by Hachem and Brennan revealed that bariatric surgery improved QoL more than other obesity therapies. There were significant disparities in QoL improvements across various forms of bariatric surgery. Improvements in QoL were more likely to happen within the first 2 years after surgery, with physical QoL improving faster than mental QoL[ 36].

According to the study of 18 identified papers by Sierżantowicz et al[ 37], bariatric therapy appears to produce a long-term advantage in health-related (HRQOL), particularly its physical component score. However, due to psychological predispositions, certain individuals are less likely to benefit from bariatric therapy, whether in terms of HRQOL or weight loss. In addition, studies with inconsistent and imprecise designs may limit the usefulness of the conclusions. Therefore, the author concluded that early identification of such individuals and providing physical and psychological counseling would improve bariatric treatment results[ 37].

The first systematic evaluation to present data from all quantitative designs on studies that assessed personality traits was conducted by Summerville et al[ 38]. Overall, neuroticism appeared to be related to worse HRQOL, whereas extraversion was shown to be associated with greater HRQOL. However, null relationships for these two qualities were also detected.

Many authors claim that patients frequently rated bariatric surgery as a life-changing intervention that reduces weight, improves obesity-related comorbidities, and improves the QoL. Yet, many poll respondents considered bariatric surgery hazardous or harmful. Patients from racial minority groups expressed more anxiety about mortality risk, lower weight reduction goals, and varied reasons for pursuing bariatric surgery. Female patients were likelier to have good impressions of bariatric surgery and higher weight loss aspirations[ 39]. The research revealed a disparity between patient views and bariatric surgery's clinical safety and effectiveness profile. Overestimation of the hazards, false expectations, and unfamiliarity with the outcomes of bariatric surgery were all prevalent findings. These negative attitudes toward bariatric surgery may contribute to its underutilization among eligible patients. In addition, views and motives frequently differed by race, location, gender, and age, highlighting the importance of patient-centered education during the prereferral stage. The literature also revealed widespread misunderstandings about bariatric surgery. More studies should be conducted to investigate the influence of education on patient and public attitudes[ 39].

Despite the good results of bariatric procedures, the current data show that in a small part of all cases, the most severe complication is a fatal outcome. Perioperative mortality rates improved significantly since the early 2000s, ranging from 0.03% to 0.2%[ 40]. However, as Chang et al[ 32] maintained, the mortality rate after late complications ranges from 0% to 0.64%. Based on the meta-analysis by Robertson and colleagues and their studies involving over 3.6 million patients, the deaths were 4707. The pooled analysis showed an overall mortality of 0.08 percent. They found no statistically significant difference between overall, 30-d, 90-d, or in-hospital mortality. However, they found a relationship between the types of surgical interventions and mortality, such as 0.03% for gastric band, 0.05% for SG, 0.09% for one-anastomosis gastric bypass, 0.09% for RYGB, and 0.41% for duodenal switch[ 41].

CONCLUSION

Studies demonstrate that bariatric surgery, compared to non-surgical therapy, lowers mortality and the incidence of cardiovascular diseases in individuals with obesity. Most individuals with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea had their symptoms entirely resolved or improved. At the same time, the mortality rate after these complications ranges from 0% to 0.64%. QoL improvements, especially mental health.

In conclusion, we could say that, according to the literature, bariatric surgery is relatively safe. However, there is still a lack of data describing the frequency of obesity recurrences and persistent conditions. We believe there should be an individual selection of a surgical approach for different patients, according to the degree of obesity, because, as we have seen, some procedures have a much higher risk of complications. But following the analyzes described in detail regarding the ratio of long-term complications and mortality, it becomes clear that these complications have decreased to the extent that the benefit of the manipulation itself is greater than the risks involved. That is the main reason why bariatric surgery is increasingly used every year as a means of choice for patients with morbid obesity.

Footnotes

Conflict-of-interest statement: The authors declare no conflict of interest.

Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Peer-review started: April 1, 2023

First decision: April 13, 2023

Article in press: June 6, 2023

Specialty type: Surgery

Country/Territory of origin: Bulgaria

Peer-review report's scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): 0

Grade C (Good): C

Grade D (Fair): D

Grade E (Poor): 0

P-Reviewer: Emran TB, Bangladesh; Gupta R, India S-Editor: Liu JH L-Editor: A P-Editor: Liu JH

Contributor Information

Milena Gulinac, Department of General and Clinical Pathology, Medical University of Plovdiv, Plovdiv 4000, Bulgaria. moc.liamtoh@canilugm.

Dimitrina Georgieva Miteva, Department of Genetics, Sofia University "St. Kliment Ohridski", Faculty of Biology, Sofia 1164, Bulgaria.

Monika Peshevska-Sekulovska, Department of Gastroenterology, University Hospital Lozenetz, Sofia 1407, Bulgaria.

Ivan P Novakov, Department of Thoraco-abdominal Surgery, Medical University Plovdiv, Plovdiv 6000, Bulgaria.

Svetozar Antovic, University Clinic for Digestive Surgery, Medical Faculty, Skopje, Skopje 1000, North Macedonia.

Milena Peruhova, Department of Gastroenterology, Heart and Brain Hospital, Burgas, Burgas 1000, Bulgaria.

Violeta Snegarova, Clinic of Internal Diseases, Naval Hospital - Varna, Military Medical Academy, Medical Faculty, Medical University, Varna 9000, Bulgaria.

Plamena Kabakchieva, Clinic of Internal Diseases, Naval Hospital - Varna, Military Medical Academy, Varna 9010, Bulgaria.

Yavor Assyov, Clinic of Endocrinology, University Hospital "Alexandrovska, Sofia 1431, Bulgaria. Department of Internal Diseases, Medical University - Sofia, Sofia 1431, Bulgaria.

Georgi Vasilev, Clinic of Endocrinology and Metabolic Disorders, UMHAT "Sv. Georgi", Plovdiv 4000, Bulgaria.

Metodija Sekulovski, Department of Anesthesiology and Intensive Care, University Hospital Lozenetz, Sofia 1407, Bulgaria. Medical Faculty, Sofia University, St. Kliment Ohridski, Sofia 1407, Bulgaria.

Snezhina Lazova, Department of Pediatric, University Hospital "N. I. Pirogov", Sofia 1606, Bulgaria. Department of Healthcare, Faculty of Public Health "Prof. Tsekomir Vodenicharov, MD, DSc", Sofia 1527, Bulgaria.

Latchezar Tomov, Department of Informatics, New Bulgarian University, Sofia 1618, Bulgaria.

Tsvetelina Velikova, Medical Faculty, Sofia University St. Kliment Ohridski, Sofia 1407, Bulgaria.

References

1. Alfonso Enrique Martínez-Núñez, Oscar Ernesto Gamboa-López, Montserrat Bacardí-Gascón, Arturo Jiménez-Cruz Long-term complications and side effects of bariatric surgery: a systematic review. [ JONNPR 2017; 2: 410-415. Google Scholar]

Articles from World Journal of Clinical Cases are provided here courtesy of Baishideng Publishing Group Inc

# data[].attributes.attachment_link.title
Long-term effectiveness, outcomes and complications of bariatric surgery

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Dietary imbalance and overeating can lead to an increasingly widespread disease - obesity. Aesthetic considerations aside, obesity is defined as an excess of adipose tissue that can lead to serious health problems and can predispose to a number of pathological ...

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Treatment of Obesity: Weight Loss and Bariatric Surgery

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Treatment of Obesity: Weight Loss and Bariatric Surgery

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Published by PubMed Central

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Circ Res. Author manuscript; available in PMC 2017 May 27.

Published in final edited form as:

Abstract

This review focuses on the mechanisms underlying, and indications for, bariatric surgery in the reduction of cardiovascular disease (CVD) as well as other expected benefits of this intervention. The fundamental basis for bariatric surgery for the purpose of accomplishing weight loss is the determination that severe obesity is a disease associated with multiple adverse effects on health which can be reversed or improved by successful weight loss in patients who have been unable to sustain weight loss by non-surgical means. An explanation of possible indications for weight loss surgery as well as specific bariatric surgical procedures is presented, along with review of the safety literature of such procedures. Procedures that are less invasive or those that involve less gastrointestinal rearrangement accomplish considerably less weight loss but have substantially lower perioperative and longer-term risk.

The ultimate benefit of weight reduction relates to the reduction of the co-morbidities, quality of life and all-cause mortality. With weight loss being the underlying justification for bariatric surgery in ameliorating CVD risk, current evidence-based research is discussed concerning body fat distribution, dyslipidemia, hypertension, diabetes, inflammation, obstructive sleep apnea and others.

The rationale for bariatric surgery reducing CVD events is discussed and juxtaposed with impacts on all-cause mortalities. Given the improvement of established obesity-related CVD risk factors following weight loss, it is reasonable to expect a reduction of CVD events and related mortality following weight loss in populations with obesity. The quality of the current evidence is reviewed and future research opportunities and summaries are stated.

Keywords: Obesity, inflammation, hypertension, cardiac metabolism, sleep apnea

Indications for Bariatric Surgery

The fundamental basis for bariatric surgery for the purpose of accomplishing weight loss is the determination that severe obesity is a disease associated with multiple adverse effects on health which can be reversed or improved by successful weight loss in patients who have been unable to sustain weight loss by non-surgical means. The criteria for surgical intervention were established by a NIH consensus panel in 19911. Failure of medical treatment to accomplish sustained weight loss is common among persons with severe obesity. The biologic factors involved in the limitations associated with maintaining weight loss are powerful2,3. Intense lifestyle intervention can produce averages of approximately 10% at 1 year and maintain weight loss at 5.3% over 8 years. The weight loss accomplished is highly variable but is sufficient to accomplish improvement in medical and comorbidity control4. Pharmacotherapy may enhance short-term as well as longer-term weight loss5. Specific criteria established by the NIH consensus panel indicated that bariatric surgery is appropriate for all patients with BMI (kg/m ²) >40 and for patients with BMI 35-40 with associated comorbid conditions. These criteria have held up over the ensuing 24 years to the present, although specific indications for bariatric/metabolic surgical intervention have been identified for persons with less severe obesity, such as persons with BMI 30-35 with type 2 diabetes. The indications for bariatric surgery are evolving rapidly to consider the presence or absence of comorbid conditions as well as the severity of the obesity, as reflected by BMI6.

Obesity-related comorbidity is defined as conditions either directly caused by overweight/obesity or known to contribute to the presence or severity of the condition. These comorbid conditions are expected to improve or go into remission in the presence of effective and sustained weight loss.

Obesity-related comorbid conditions are listed in Table 1

Table 1

Premature Mortality

Cardiovascular

- Hypertension

- Atherosclerotic CVD, myocardial infarction, stroke

- Congestive heart failure

- Cardiac arrhythmias

Metabolic

- Type 2 Diabetes, prediabetes

- Dyslipidemia

- Non-alcoholic Fatty Liver Disease (NAFLD)/Steatohepatitis

- Inflammation

Pulmonary

- Obstructive Sleep Apnea

- Asthma

Musculoskeletal

- Degenerative Arthritis

- Immobility

- Pain

Reproductive

- Polycystic Ovarian Syndrome (female)

- Infertility

- Sexual Dysfunction

Genitourinary

- Impaired Renal Function

- Nephrolithiasis

- Stress Urinary Incontinence

Central Nervous System

- Impaired Cognition

- Headache

- Pseudotumor Cerebri

Psychosocial

- Impaired Quality of Life

- Depression

- Other Psychopathology

Cancer

The requirements for patient selection include the BMI criteria described above and failure of medical therapy. Specific criteria regarding designation of the failure of medical therapy have not been formalized but generally include treatment in a variety of medically supervised settings. An understanding or insight into the pathogenesis of obesity and the requirement to reduce energy intake substantially if major weight loss is to be achieved is a requisite7. Candidates for bariatric surgery must be assessed for appropriate surgical risk, including the presence of cardiovascular, pulmonary other system disease and control of these comorbid conditions. These principles apply to surgical procedures in general. It is entirely possible, for example, that patients with an exceedingly high risk profile for cardiovascular disease will have experienced end events that indicate that perioperative risk is excessive and the likelihood of reversing cardiovascular disease by improving the risk profile is unlikely to be successful. However, examples of the most severely obese patients whose perioperative risk may be improved by weight loss include patients with congestive heart failure, related anasarca, respiratory failure and inability to ambulate.

Pre-operative psychological assessment is commonly done to identify patients who require preoperative intervention or disqualification altogether. Active substance abuse is a standard contraindication to surgery. Although a requirement for mandatory preoperative weight loss among all patients is not justified by published literature, individual patients deemed to be at exceedingly high risk due to the severity of obesity and its comorbid conditions are appropriate in selected cases. The literature surrounding psychological evaluation and its likelihood to predict success is evolving8. Psychological assessment prior to bariatric surgery may identify patients with psychopathology such as major depression, binge eating disorder, substance abuse, among others that may impact the decision to proceed with surgery or indicate referral for further preoperative assessment and intervention9. In addition, psychological assessment may contribute to predicting postoperative weight loss9-11.

Specific Bariatric Surgical Procedures

Surgical procedures in the past have been considered to function as restrictive in which the size of the gastric pouch is greatly reduced, malabsorptive in which malabsorption of nutrients contributes to weight loss, and a combination of restrictive and malabsorptive components. It is now clear that this construct is an oversimplification and, to some extent, inaccurate. There is ample evidence that neural and endocrine signaling pathways affecting eating behaviors, reduction of appetite, satiety, energy intake, and possibly physical activity are all operative to a variable extent.

Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass was developed by Mason in the 1970's in response to unacceptable complication rates that followed ileojejunal intestinal bypass, a procedure which resulted in malabsorption, diminished food intake, and substantial weight loss with its associated benefits but unacceptable complication rates12. In this procedure, the stomach is transected creating a gastric pouch of approximately one ounce capacity. A Roux-en-Y gastrojejunostomy is done, thus diverting ingested nutrients from the body of the stomach, duodenum, and proximal jejunum. The vagal trunks are not disturbed but a variable number of branches to the body of the stomach are divided in the process of dividing the stomach. Associated endocrine changes are described below. While malabsorption of energy-containing nutrients is minimal, if any, malabsorption of calcium, iron and vitamin B12 and possibly other micronutrients occurs.

Sleeve Gastrectomy

In this procedure, approximately 80% of the body of the stomach is resected, creating a tubular stomach based on the lesser curvature of the stomach. No gastrointestinal to small intestine anastomosis is required. Although some restriction on food intake may occur, gastric emptying is accelerated.

Biliopancreatic diversion with duodenal switch

This is a more complex procedure in which a sleeve gastrectomy is done. An anastomosis between the proximal duodenum and bypassed intestine is accomplished, thereby creating a degree of malabsorption of nutrients. This procedure is infrequently performed due to higher incidence of short- and long-term complications.

Implantation of Devices

Adjustable Gastric Banding

An adjustable gastric band is placed about the proximal stomach to constrict the size of the gastric pouch and outlet. The rate of gastric emptying can be adjusted by a balloon connected to a subcutaneous port.

Intermittent vagal blockade

In this procedure, leads are placed about the vagal trunks at the diaphragm to produce intermittent vagal blockade. Weight loss occurs by reduction of appetite and establishment of early satiety. The intermittent blockade is hypothesized to avoid neural adaptation as occurred in the past with truncal vagatomy. A device for this purpose has been approved by the Food and Drug Administration13.

Gastrointestinal Endoscopic Devices

While several endoscopically placed devices or suturing procedures are under development, placement of gastric balloon(s) has recently been approved by the Food and Drug Administration14.

Bariatric Surgery Safety

While the benefits of weight loss among individuals with severe obesity, particularly those with comorbid conditions, are unquestioned, these benefits must be considered in the context of surgical complications. In the past, complications including perioperative mortality were as much as tenfold more frequent than occur at the present time. For example, a population based study by Flum and Dellinger reported 2% mortality following gastric bypass, considerably higher than 0.5% commonly reported by those surgeons who chose to report their outcomes15. In response, the bariatric surgical community enacted a number of changes to result in this improved safety record. Included was the identification of the importance of surgeon and center experience, the establishment of pathways, care protocols, and quality initiatives and incorporation of all of these aspects of care into an accreditation of centers program, presently administered by the American Society for Metabolic and Bariatric Surgery and the American College of Surgeons16. The transition to laparoscopic methodology occurred during the same time period and also contributed to the improved safety.

Incomplete retention or follow-up in reported clinical series has been a limitation to interpretation of registry-based reports on bariatric surgical safety17. The multi-center bariatric surgery research consortium funded by NIH, known as LABS, however achieved 100% 30-day follow-up among 2,458 participants18. The LABS Consortium reported 30-day mortality was 0.3% in all patients, 0.2% for laparoscopic gastric bypass (RYGB), 2.1% for open gastric bypass. There was no mortality among LAGB patients. A serious complication occurred in 4.1% of all patients, 4.8% laparoscopic gastric bypass, 7.8% open gastric bypass, 1.0% LAGB. Patient factors in this study that predicted major complication include extremes of BMI, obstructive sleep apnea, inability to walk 200 feet and a history of deep vein thrombosis (DVT). Factors in other studies include age, gender (male), other comorbidities, and smoking19. Provider factors predicting complications include surgeon and center experience20. Registries report slightly lower perioperative mortality as well as data regarding less severe complications such as wound infection or dehydration, although among patients with 80-85% 30-day follow-up17,20. These mortality and complication rates compare very favorably to multiple commonly performed surgical procedures such as coronary bypass graft, arthroplasty, cholecystectomy and hysterectomy21,22.

Mid- and longer-term complications have been well described although determination of their incidence is limited by progressively greater numbers of patients lost to follow-up23. These include intestinal obstruction, marginal ulcer, ventral hernia, and gallstones. Metabolic complications reported include nephrolithiasis and hypoglycemia. Mineral and vitamin deficiencies as well as weight regain are reported in variable numbers of patients. Reports of micronutrient deficiencies vary substantially as follows: Iron, 33-55%; calcium/vitamin D, 24-60%; vitamin B12, 24-70%; copper, 10-15%; thiamine, <5%24. Established guidelines recommend routine nutrient supplementation to include multivitamins, iron, minerals, calcium, and vitamin D25.

Complications specific to LAGB placement continue to occur in the longer-term at approximately 2% per year. These long-term complications include erosion of the gastric wall by the band, slippage or herniation of the body of the stomach thereby creating obstruction within the band, and complications of the port, including infection. Combined with disappointing long-term weight loss (see below), application of LAGB in the US and Europe has diminished dramatically recently26.

Regarding gastrointestinal endoscopic devices, the literature looks promising but does not have long-term data13. Weight loss is modest while the device safety is good. The safety record of the FDA-approved device is excellent but the sustainability of the long-term weight loss following the approved 6 month intervention remains to be determined27.

In summary, both perioperative and long-term complications occur following all bariatric surgical procedures. Multiple steps have been taken in the recent years to reduce perioperative mortality to the presently reported minimum comparable to other commonly performed surgical procedures. Longer-term complications requiring reoperation or micronutrient deficiencies require careful surveillance and prompt intervention. These complications are generally judged to occur with sufficiently low frequency and severity so as to not constitute a contraindication to the performance of bariatric surgery in general.

Weight loss following bariatric surgery

Weight loss following bariatric surgery has been studied and reported both short- and longer-term following all surgical procedures undertaken, as weight loss is the primary objective of bariatric surgery. Mean weight loss is uniformly reported. It is important to recognize, however, the high variability of weight loss following apparently standardized operative procedures such as RYGB or LAGB28. Following RYGB, the LABS consortium reported similar and rapid weight loss 6 months following surgery by stratifying of weight loss into five separate trajectories ranging from 12% total body weight (TBW) loss to 45% TBW 3 years following surgery. Similarly, for LAGB, trajectories are identified for most but not all patients 1 year following surgery. Factors involved in the high degree of variation of weight loss have been examined and reported but do not fully explain the extent of the variability. Predictors of weight loss vary among several reports and include both patient and provider factors. These factors include but are not limited to the presence of specific comorbid conditions such as diabetes, gender, age and behavioral variables, including physical activity and eating behaviors10. Weight loss following RYGB at years 1, 2, and 3 reported in the 30-35% TBW range29. Initial reports of weight loss following LAGB in Australia suggested weight loss was similar to that seen following RYGB. Data from the US as well as Europe, however, have not confirmed comparable weight loss following LAGB, closer to 15.9% TBW at 3 years21. As noted earlier, this lesser weight loss, compared to RYGB, has led to a substantial reduction in the application of LAGB as treatment for severe obesity. The weight loss following biliopancreatic diversion/duodenal switch tends to be slightly greater than that following RYGB while weight loss following sleeve gastrectomy is comparable or is slightly less than RYGB in several reports30-33. Those studies with non-surgical comparator groups, primarily the Swedish Obese Subjects trial and a prospective clinical trial with a population base comparator from Utah, indicate that the non-surgical patients do not experience long-term weight loss. This is not unexpected, given the requirement that patients selected for surgery undergo and fail medical treatment prior to selection for surgical intervention. Longer-term follow-up has been reported by Pories as well as the Swedish and Utah studies. All show rapid weight loss during the first 12 months following RYGB followed by modest regain of weight until approximately Year 3-5. Following Year 3-5, weight loss tends to be maintained in the 30% TBW range34-36. Thus, it is well established that maintenance of weight loss following RYGB at 10-20 years is maintained.

In general, procedures less invasive or those that involve less gastrointestinal rearrangement such as LAGB, vagal blocking, and endoscopic procedures such as balloon placement accomplish considerably less weight loss but have substantially lower perioperative and longer-term risk. A research need is a more effective determination of the likely weight loss that will be achieved following any of these interventions including lifestyle intervention and medication, and the amount of weight loss needed to achieve a specific response such as improved control or remission of a specific comorbid condition. At such time, as a more accurate identification of the weight loss required to achieve a specific clinical outcome and the relative risk involved is determined, it will be possible to more accurately identify appropriate candidates for specific procedures, taking into account the expected weight loss and risk profiles.

Expected benefit on CVD risk factors

The ultimate benefit of weight reduction, whether medical or surgical, relates to the reduction of the co-morbidities, quality of life and all-cause mortality. Despite the importance of assessing these risks and taking steps to implement effective medical management with variable success37, surgery has proven to be more effective35,36. To be covered in this section are the following: body fat distribution, dyslipidemia defined as hypertriglyceridemia and/or low HDL cholesterol (HDL-C) and variably increases in LDL cholesterol (LDL-C), hypertension and prehypertension, insulin resistance, diabetes and prediabetes, non-alcoholic fatty liver disease (NAFLD), inflammation [high sensitivity C-reactive protein (hsCRP), interleukin-6 (IL-6), white blood cell count (WBC), oxidized LDL, intracellular adhesion molecule-1 (ICAM-1) and adiponectin], vascular reactivity and obstructive sleep apnea.

Body fat distribution

The relationship of obesity to CVD events relate in part to alterations in body fat distribution, i.e. increased central/visceral vs. subcutaneous/peripheral, the so-called metabolic syndrome phenotype38-40. This distribution of excess body fat relates to an excess delivery of free fatty acids (FFA) to the liver wherein defects in insulin action result with subsequent impact on other components of the metabolic syndrome, i.e. dyslipidemia, glucose intolerance, NAFLD and inflammation among others41. With medical weight loss, percentage reductions in visceral adipose tissue are similar to or exceed other adipose tissue depots but this relative benefit is somewhat reduced with more weight loss42.

In general, in patients without diabetes the relative amounts of loss of visceral adipose tissue from 3 to 12 months post-bariatric surgery are similar or greater than the percentage loss of total or subcutaneous adipose tissue43-45, but at 24 months were variably greater in the visceral depot46,47. Following LABG, a preferential mobilization of visceral fat was observed at 2 and 6 months, as compared with total and subcutaneous AT; but this outcome was reserved only for patients with excessive amounts of visceral adipose tissue before surgery and this preferential visceral fat reduction occurs only in those47. When changes in body composition were compared after malabsorptive biliointestinal bypass (BIBP) and restrictive LAGB during a 4-year follow-up, the effects of BIBP were greater on total fat loss and trunk fat49. When omentectomy accompanies a laparoscopic Roux-en-Y gastric bypass (RYGB) procedure, changes in glucose homeostasis, lipid levels, and adipokine profile at 90 days postoperatively have been variably reported50,51.

Dyslipidemia

The dyslipidemia of obesity reflects mostly the insulin resistant metabolic environment that accompanies excess body fat. This includes hypertriglyceridemia, lower levels of HDL-C, variable increases in apolipoprotein B and VLDL-C, and small dense LDL and HDL52. Although LDL-C can be increased in moderately to severely obese patients, this is not nearly as prevalent as the aforementioned lipid and lipoprotein abnormalities. In a meta-analysis of 75 papers in which follow-up lipids were measured up to 4 years post RYGB, baseline and follow-up levels of LDL-C were reported in 48 studies, and baseline LDL-C was123± 7 mg/dL53. Although heterogeneity among studies for LDL-C and all other lipids was high, subgroup analyses revealed reductions in LDL-C by intervals of 1 month up until 4 years [standard mean difference (SMD) −1.31 to −0.52, 95 th% confidence intervals (CI), p<0.00001]. HDL-C levels were assessed in 47 studies. Herein, a time dependent trend was noted. At an interval up to 6 months, no significant change in HDL-C was seen however by 12 months an increase was seen (SMD +1.10, +0.57 to +1.63 95 % CI, p<0.0001), an effect maintained through all subsequent time points assessed including at 4 years. Plasma triglycerides were examined in 55 studies with no change at 1 month but highly significant effects of RYGB on triglycerides were seen up to 4 years (SMD -0.57, 95 % CI, -0.76 to -0.37,p<0.00001).

From another large series that included 73 studies in which patients were examined for nearly 4 years, metabolic surgery produced a decrease in LDL-C from 116 to 90mg/dL and triglycerides from 188 to 127mg/dl, and an increase in HDL-C from 46 to 55mg/dL54. When data from the LABS-2 study were examined the prevalence of dyslipidemia improved at 3 years post RYGB in 62% of patients28 and fasting hypertriglyceridemia (>200 mg/dl) remitted in 86% patients, while low HDL-C (<40mg/dl) in 86%24. Important to consider is that all of these studies did not report data about the use of lipid-altering medications post-surgery55.

The reduction in LDL-C up to 2 years post metabolic surgery, however, only appears to occur for operations with more weight reduction, i.e. RYGB or biliopancreatic diversion vs. sleeve gastrectomy or LAGB although increases in HDL-C and reductions in triglycerides can occur with all56-59. Plasma levels of the pro-atherogenic lipoprotein, lipoprotein (a), are not changed after metabolic surgery60,61.

Hypertension

Obesity is often associated with hypertension (BP>140/90) and in the Edmonton Obesity Staging System, 98% of 5787 obese patients had at least one comorbidity and hypertension was present in 76%62. Although difficult to assess from many publications that cite population statistics, the prevalence of hypertension in the severely obese population is ~65%63, not that different from the prevalence in Edmonton. However, from the most recent data from NHANES (2010), 52% of American subjects with a BMI ≥35 kg/m ² had treated or untreated hypertension vs. 43% with a BMI ≥30 but ≤35 kg/m 2 64. Now, how effective is metabolic surgery in correcting this common co-morbidity of excess body fat?

The effects of metabolic surgery on the prevalence of hypertension are variable, procedure-related and time-dependent. During the active weight loss phase blood pressure decreases and anti-hypertensive drugs are often discontinued65. However, after weight stabilization the results are less clear, perhaps related to the duration of hypertension pre-operatively. In a systematic review and meta-analysis of 21 studies using a variety of surgical approaches reduced the relative risk of hypertension at intervals between 24-50 months by 46±8% and hypertension risk reached a nadir when BMI was reduced by 10 kg/m 2,66. Data from LABS-2 demonstrated that cohort persistent remediation from hypertension at 3 and 6 years was nearly 40%28 and the Utah-Obesity study demonstrated a 2 and 6 year relative risk of remission of hypertension of 8.2 and 2.90, respectively67. However, the Swedish Obesity Study revealed recidivism of hypertension at 6-8 years of follow-up with no significant difference from baseline68. Whether or not this relates to permanent changes in the arterial wall based on years of hypertension pre-operatively remains unclear.

Diabetes and prediabetes

The last decade has been one to not only document the benefit of metabolic surgery in patients with type 2 diabetes and glucose tolerance, but produce sufficient data from randomized controlled trials to render metabolic surgery as an option for the treatment of type 2 diabetes. The most recent update and convincing study is from the Rubino group that carried out an open-label, randomized controlled trial to compare medical or surgery by RYGB or biliopancreatic diversion in 60 patients aged 30-60 years with a BMI of 35 kg/m ² or more and a history of type 2 diabetes of at least 5 years, and 53 completed a 5 year follow-up69. Diabetes remission was defined at 2 years, as an HbA1c concentration of ≤6·5% and a fasting plasma glucose of ≤5·6 mmol/L without pharmacological treatment for 1 year. Overall, 50% of the 38 surgical patients sustained a diabetes remission at 5 years, compared with none of the 15 medically treated patients (p=0·0007). A similar medical vs. surgical trial for the treatment of type 2 diabetes was carried out in 150 patients with uncontrolled type 2 diabetes (HbA1c - 9.3±1.5%) by Schauer et al. with a 91% follow-up at 3 years70. The primary end point of an HbA1C of ≤6.0% was met by only 5% of the medical group vs. 38% of RYGB patients and 24% with sleeve gastrectomy, all in the setting of much less use of glucose-lowering medications in the surgical groups than in the medical-therapy group. As expected the amount of weight reduction was only ~4.0% in the medical group vs. 22-24% in the surgical groups. In 4 randomized trials wherein RYGB was further compared with sleeve gastrectomy, there was no significant difference between procedures with the reduction in HbA1c or fasting plasma glucose or the in change in weight, BMI or the number or type of drugs used to treat type 2 diabetes30,31. Overall, the amounts of weight loss have been a definite predictor of diabetes remission. When LABG vs. RYGB was controlled for weight loss, RYGB was clearly superior to LABG in the induction of remission. It has, therefore, been demonstrated that both weight loss and RYGB contribute to the superior remission of diabetes following gastric bypass compared to LABG71. Recurrence of diabetes following induction of remission may occur in as many as 58% of patients 15 years after bariatric surgery, predominantly in those who had gastric banding72. Further research is needed to determine the long-term benefit of gastric bypass and sleeve gastrectomy in patients with type 2 diabetes.

A related glucose-centric topic is the prevention of type 2 diabetes in severely obese patients by metabolic surgery. Using a systematic review and meta-analysis wherein medical vs. surgical approaches were examined in patients with impaired fasting glucose or impaired glucose tolerance, non-surgical approaches reduced new onset type 2 diabetes by 14-56% using a number of different interventions whereas bariatric surgery was 90% effective73. The factors that were associated with effectiveness were weight loss, young age and fasting insulin levels. In a systematic review and meta-analysis that extended the outcome to an admixture of patients with normal glucose tolerance, impaired fasting glucose with or without impaired glucose tolerance at baseline, medical strategies reduced new onset type 2 diabetes from 15-63% based on the various types of intervention whereas metabolic surgery was 84% successful74.

Non-alcoholic fatty liver disease (NAFLD)

NAFLD is diagnosed by either imaging or histology with no alternative explanation for fatty liver including alcoholic liver disease. Of interest many times liver transaminases are normal with biopsy-proven NAFLD75. The prevalence varies around the world but is typically more common in Western nations (20-40%) and using proton magnetic resonance spectroscopy in 2,287 subjects from a multiethnic, population-based sample (32% white, 48% black, and 18% Hispanic) the prevalence was highest in Hispanics (45%) with 33% in whites and 24% in blacks76. This high prevalence is similar to that of the metabolic syndrome and reflects the insulin resistance related to both. NAFLD is present in ~90% of patients who qualify for metabolic surgery and approximately 33% of these have biopsy proven non-alcoholic steatohepatitis (NASH)77, a precursor of more serious liver disease including cirrhosis and need for transplantation. In fact patients with NASH by biopsy have an increased risk of death within a median follow-up of 10.2 years after bariatric surgery78. Although medical management including weight loss, pioglitazone, vitamin E, pentoxifylline, ursodeoxycholic acid and most recently liraglutide has had variable effect, bariatric surgery has proven more effective79.

Data from the Swedish Obesity Study, a non-randomized study of 3,570 obese subjects which compared several types of bariatric operations including RYGB and gastric banding to medical management for up to 10 years, revealed a reduction in ALT at 2 years that was maintained at 10 years vs. the non-surgical control group80. Retrospective or cohort studies in general have demonstrated that improvement of NAFLD is more likely after RYGB than after other interventions, however, data at present are insufficient to indicate reductions in liver-specific mortality, liver transplantation, or quality of life81. One study examined the impact of metabolic surgery on NAFLD in 381 patients at baseline with second and third biopsies at 1 and 5 years, post-operatively82. At both 1 and 5 years, major reductions in steatosis and ballooning degeneration ensued with no change in inflammation. And in the 27% of patients diagnosed with NASH, steatosis and ballooning also improved after 5 years, but fibrosis and inflammation did not. In some patients fibrosis actually increased, an outcome that was associated with more severe obesity and insulin resistance. Perhaps the largest study to examine the benefit of bariatric surgery was carried out in 1236 obese patients (BMI - 48.4±7.6 kg/m ²) wherein RYGB (n=681) was compared to adjustable gastric banding (n=555)83. At baseline, NAFLD was present in 86%, and as severe in 22% patients. In general RYGB patients had a higher BMI and more severe NAFLD. All NAFLD parameters improved after surgery (P<0.001) but improved more after RYGB than after gastric banding, and the amount of weight loss related to this benefit. Overall, metabolic surgery appears to be the best treatment for NAFLD in patients who qualify for surgery.

Inflammation

Systemic inflammation is routinely assessed by non-specific metrics such as the erythrocyte sedimentation rate (ESR) or high sensitivity C-reactive protein (hsCRP) but other biomarkers can also be utilized, i.e. interleukin-6 (IL-6), white blood cell count (WBC), oxidized LDL, intracellular adhesion molecule-1 (ICAM-1) and adiponectin. Following medically-managed weight reduction, in general the fall in hsCRP relates to the amount of weight reduction84,85. Adiponectin is an adipokine that is not pro-inflammatory but anti-inflammatory and also is associated with insulin sensitivity. A systematic review that examined weight loss using low calorie diets and exercise reported an 18-48% increase in adiponectin86. Of note, the one study that reported an increase in adiponectin by 48% was a Mediterranean diet that resulted in a 15% weight reduction, suggesting this change is also related to the amount of weight loss87.

Subjects undergoing metabolic surgery that lost 33% of their original weight had a highly significant median hsCRP reduction from 0.83 to 0.18 mg/d ensued88. In another study wherein gastric stapling was compared to gastric banding and patients were defined at baseline as low vs. high CVD risk based on a hsCRP of <1.0 mg/mL vs. >3.0 mg/mL, the mean reduction in hsCRP for high CVD risk patients was greater for gastric stapling vs. gastric banding, −1.10 ± 0.94 mg/L vs −0.67 ± 0.82 mg/L, respectively89. Following sleeve gastrectomy levels of hsCRP and IL-6 decreased and adiponectin increased, however, these measurements were made at 1 year, a time at which nadir weight and weight stability may have not been assured90. In another one year analysis following metabolic surgery, there was a significant decrease in levels of IL-6 (p < 0.001), hsCRP (p < 0.001), and increase in plasma levels of adiponectin (p < 0.001), and levels of IL-6 and hsCRP correlated with BMI91. However, in another study, 1 year post gastric banding, hsCRP levels decreased from 1.33+/−1.21 mg/dl to 0.40+/−0.61 mg/dl but. IL-6 and TNF-α levels did not change92. Additional data also support the variability of metabolic surgery to decrease levels of IL-692-94. In a retrospective study in which 62 subjects that underwent a RYGB and a median follow-up of 15 months, there was a greater reduction in hsCRP with more surgical weight loss95. This relationship between change in BMI/weight post-operatively and reduced inflammation also relates to adiponectin96. Of interest when patients with or without remission of type 2 diabetes post RYGB were compared up to 24 months post-operatively, the non-remission group had a higher number of leukocytes (6,867 vs. 5,424), and hsCRP (0.27 vs. 0.12 mg/dL), MCP-1 (118 vs. 64 ng/mL), and lower adiponectin (9.4 vs. 15.4 ng/mL) than the remission group97. Additional benefits of gastric bypass on inflammation and CVD risk may also relate to reduced levels of oxidized LDL and lipoprotein-associated phospholipase A298.

Vascular reactivity

Endothelial dysfunction, a nitric oxide-dependent component of reduced vascular reactivity, is defined as an imbalance between relaxing and contractile endothelial factors that is common in patients with severe obesity99,100. Following weight loss, there is evidence that improvements in endothelial function can occur, but this outcome is inconsistently apparent and convincing evidence for normalization is lacking101.

At a very early interval after RYGB, weight loss led to significant improvements in brachial artery diameter and endothelial independent vasodilation102. A similar reduction in flow mediated dilatation was noted at 6 months S/P gastric banding103. When subjects lost an average of 33% of their original weight, flow-mediated dilation (FMD) showed significant improvements after surgery from 7.4 % to 18.9 % (p < 0.001)88. A recent systematic review included 8 studies on FMD (9 data sets; 269 patients) and 4 on nitrate-mediated dilation (NMD) (4 data sets; 149 patients). After 3-24 months following 4 different types of bariatric surgery (mostly RYGB), there was a significant improvement in FMD (MD: 5.65%; 95% CI: 2.87, 8.03; P<0.001), whereas NMD did not change (MD: 2.173%; 95% CI: −0.796, 5.142; P=0.151), and the percentage change in BMI was associated with changes in FMD (Z=−4.26, P<0.001) and NMD (Z=−3.81, P<0.001)104. Most of these observations of vascular reactivity were performed at relatively brief intervals after surgery; thus, as for hypertension, the duration of reduced vascular reactivity associated with obesity may contribute to the response post metabolic surgery.

Obstructive sleep apnea

Obstructive sleep apnea (OSA) is common in patients with severe obesity, ~35-45% of patients at the time of bariatric surgery105,106. With non-surgical approaches to weight reduction and OSA, the benefit typically relates to the amount of weight reduction and the severity of the OSA and in general metabolic surgery is more successful than non-surgical approaches106. A systematic review of the metabolic surgical literature examined 69 studies in which 13,900 patients were included and RYGB, sleeve gastrectomy, gastric banding and BPD were compared107. Although BPD was associated with the best results and gastric banding with the least beneficial outcome on OSA, all operations realized major reductions with >75% of patients experiencing resolution or at least some improvement.

When a systematic review of the surgical vs. non-surgical approach to modifying obesity-related sleep disordered breathing (not OSA) was inspected, 19 surgical (n=525) and 20 non-surgical (n=825) studies reporting primary endpoints of change in BMI and apnea hypopnea index (AHI) were examined108. Unfortunately, the surgical vs. non-surgical groups were not matched in terms of BMI or the amount of weight reduction, 51.3 vs. 38.3 kg/m ² and −11.9 vs. −3.1 kg/m ² BMI units, respectively. However, both groups experienced a benefit in AHI, 29/hour vs. 11/hour, respectively. Despite AHI being substantially reduced, clinical OSA indicating continued CPAP use was common109.

Mechanisms for cardiometabolic benefit of metabolic surgery

Gut hormones, changes in bile acid metabolism and the microbiome all relate to the benefits of metabolic surgery on cardiometabolic risk110. Changes in gut hormones relate to changes in energy balance and include increases in peptides that increase satiety, i.e. GLP-1, GIP, PYY ₃₋₃₆, oxyntomodulin and gastrin) and those that reduce hunger-promoting factors, i.e. ghrelin111. Moreover, although studies done at intervals up to 12 months post-metabolic surgery have demonstrated reductions in energy expenditure when expressed per fat free mass, modest increases were identified when data were expressed per body weight112. Thus, some contribution from both sides of the energy balance equation may be operational in maintaining reduced weight after surgery.

Bile acid metabolism clearly changes post-metabolic surgery and mechanisms to implicate these alterations to benefit include their beneficial effects on satiety, gut hormones, incretins, energy metabolism and the gut microbiome, with the majority of these effects mediated via the bile acid receptors FXR and TGR5111. Elevation of bile acids is commonly seen post-metabolic surgery113, and in murine models of atherogenesis activation of FXR and TGR5 reduced the expression of pro-inflammatory cytokines and chemokines within the arterial wall and atherosclerotic plaque volume 114. Finally, the gut microbiome is modified following metabolic surgery and this change seems to play an important role in the metabolic benefits gained from bariatric surgery. Two types of surgeries, RYGB and VBG, result in similar changes in the microbiome, an effect that can be maintained for at least a decade. Moreover, when microbiota from bariatric surgery patients are transferred into germ-free mice, decreases in fat mass ensue115. All of these mechanisms may be closely related and reflect changes in glucose, lipid/lipoprotein metabolism and inflammation that ultimately may be the mediators of reduced CVD risk. This is clearly an incredibly important area of research that may be applicable far beyond metabolic surgery and related weight reduction.

Current evidence for reduction in CVD events vs. impact on all-cause mortality

Effect of bariatric surgery on long-term survival

It has not been possible to conduct a prospective randomized clinical trial of bariatric surgery vs. continued non-surgical treatment (usual care) of severe obesity adequately powered and of sufficient duration to assess the impact on CVD events and longevity. Given the improvement of established obesity-related CVD risk factors following weight loss, it is reasonable to expect a reduction of CVD events and related mortality following weight loss in populations with obesity. The Look AHEAD trial randomized 5,145 individuals with obesity and with type 2 diabetes to intensive lifestyle intervention (ILI) or usual care116. Following median follow-up of 9.6 years, weight loss was 6.0% in the ILI group versus 3.5% in the usual care participants. Despite improved CVD risk factor status for all metrics except LDL-C, a reduction of CVD events or mortality was not demonstrated. In contrast, the Swedish Obese Subjects (SOS) study reported weight loss following a variety of bariatric surgical procedures to be 17% 5 years following surgery, 16% in 15 years, and 18% in 20 years post-surgery117. Weight was essentially unchanged in the usual care group matched for multiple clinical parameters. This weight loss in the surgical group was associated with a reduction of CVD events: adjusted HR 0.67; 95% CI 0.54-0.83, p <.001. In addition, mortality was reduced: HR 0.71, p = .001118. More recently, a systematic review and meta-analysis of 14 studies included 29,208 patients who underwent bariatric surgery, with a follow-up 2-14.7 years119. These studies took place in the US, Canada, Italy, Australia, and Sweden. Although not analyzed or reported by Kwok et al, weight loss among the studies varied from 15-30% or more depending primarily on the specific bariatric surgical procedure performed. Overall mortality was reduced more than 50% (OR 0.48). The incidence of myocardial infarction (OR 0.46) and stroke (OR 0.49) was also reduced120.

Quality of Evidence

The great majority of published literature regarding bariatric surgery consists of observational data29,35. A limited number of these observational trials with several-year follow-up have constructed comparator groups, matched from non-surgical populations. Medical and ethical considerations have prevented conduct of an adequately powered randomized control trial (RCT) to test the hypothesis that bariatric surgery is superior to usual care54,67. However, recently, several RCTs have successfully been conducted evaluating medical vs. surgical intervention as primary treatment for type 2 diabetes69,117.

Summary and Conclusions

It is reasonable to hypothesize that the greater improved CVD and mortality following bariatric surgery compared to lifestyle intervention is a function of the substantially greater weight loss that follows surgery, although neuroendocrine factors following gastrointestinal modification may also contribute. The survival benefit occurs primarily as the result of reduced CVD death although reduced death due to all types of cancers also contributes substantially to this survival benefit121-123.

Nonstandard Abbreviations and Acronyms

NIH

National Institutes of Health

BMI

Body Mass Index

CVD

Cardiovascular Disease

LABS

Longitudinal Assessment of Bariatric Surgery

LAGB

Laparoscopic Adjustable Gastric Banding

TBW

Total Body Weight

US

United States

VLDL-C

Very Low Density Lipoprotein-Cholesterol

BP

Blood Pressure

NHANES

National Health and Nutrition Examination Survey

HbA1c

Hemoglobin A1c

ALT

Alanine Aminotransferase

TNF-α

Tumor necrosis factor alpha

CPAP

Continuous Positive Airway Pressure

GLP-1

Glucagon-like peptide-1

GIP

Gastric inhibitory polypeptide

PYY ₃₋₃₆

peptide tyrosine tyrosine or pancreatic peptide YY ₃₋₃₆

FXR

Farnesoid X Receptor

TGR5

Transmembrane Bile Acid Receptor 5

Look AHEAD

Look AHEAD (Action for Health in Diabetes)

References (in order of citation appearance)

5. Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. J Amer Med Assoc. 2014:311-74-86. PMID: 24231879. [[ PMC free article] [ PubMed] Google Scholar]

52. Feingold KR, Grunfeld C. Obesity and Dyslipidemia. Endotext. 2015 PMID: 26247088. [ Google Scholar]

# data[].attributes.attachment_link.title
Treatment of Obesity: Weight Loss and Bariatric Surgery

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This review focuses on the mechanisms underlying, and indications for, bariatric surgery in the reduction of cardiovascular disease (CVD) as well as other expected benefits of this intervention. The fundamental basis for bariatric surgery for the purpose ...

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The long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery

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The long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery

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Published by PLOS ONE

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Marek A. Paul,

Jakub Opyrchał,

Michał Knakiewicz,

Paweł Jaremków,

Łukasz Duda-Barcik,

Ahmed M. S. Ibrahim,

Samuel J. Lin

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Abstract

Introduction

There has been a significant increase in the number of body contouring procedures performed worldwide. This study aimed to evaluate the long-term psychosocial effects of these procedures among patients who undergone weight loss surgery and maintained their body mass for a minimum of one year.

Material and methods

Post-bariatric patients undergoing body contouring procedures were recruited for the study consecutively. Inclusion criteria: BMI < 30 following bariatric surgery, weight maintenance for a minimum of 12 months, and completion of all follow up questionnaires (6 and 12 months). Patients were surveyed 24 hours before, 6-months, and 12-months post-procedure using a Polish validated version of BODY-Q.

Results

30 consecutive patients with a mean age of 38 years (SD 5,91) were included in this study. The BODY-Q questionnaire revealed statistically significant improvements in the acceptance of body appearance after 12 months of follow up. In the abdominal area, the rise in scores achieved 90 from the starting level of 13, and the overall body image increased from 24 to 67. Moreover, in patients with postoperative complications (one hematoma and four minor wound dehiscence), the overall score did not differ from uncomplicated patients.

Conclusions

Body contouring procedures after massive weight loss significantly improve the general perception of personal appearance as well as both the psychological and social aspects of life in patients, already significantly stigmatized by their appearance. Body contouring procedures have essential value and should be widely offered as a step in the treatment of morbidly obese patients.

Citation: Paul MA, Opyrchał J, Knakiewicz M, Jaremków P, Duda-Barcik Ł, Ibrahim AMS, et al. (2020) The long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery. PLoS ONE 15(2): e0229138. https://doi.org/10.1371/journal.pone.0229138

Editor: Anca Mihaela Pantea-Stoian, Universitatea de Medicina si Farmacie Carol Davila Biblioteca, ROMANIA

Received: August 27, 2019; Accepted: January 30, 2020; Published: February 21, 2020

Copyright: © 2020 Paul et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: No funding.

Competing interests: No - The authors have declared that no competing interests exist

Introduction

Obesity and being overweight contribute to more deaths in a majority of the World's population than undernourishment. [ 1] As a result, interest in bariatric surgery within this patient population has risen. However, this method of treatment exhibits various consequences, among which the skin excess and loss of its elasticity are the most common. Up to 89% of post-bariatric patients develop sagging of the skin most prominent in the upper arms and abdominal area. [ 2] It does not only affect self-perception, but it also influences psychological, social, and sexual well-being. [ 3] According to the latest available ISAPS global statistics, body and extremities procedures increased by 7% within just one year, reaching the total number of almost three and a half million surgeries performed annually.

What is more, in 2017, the lower body lift showed the second largest, after vaginal rejuvenation, an increase in a number of procedures with a 22% rise. [ 4] It is an excellent example of how body contouring procedures continue to gain popularity. In Poland, surgical removal of skin excess in patients after massive weight loss, with appropriate qualification, is covered by the National Healthcare Insurer. Body contouring procedures aim to help overweight and obese patients to regain self-confidence.

Thus far, we have limited data on the long-term psychosocial outcomes in patients who have undergone massive weight loss, followed by a body contouring procedure. Klassen et al. noted a shortage of evidence on meaningful patient outcomes within the literature for this patient population, in particular, health-related quality of life (HRQoL), body image, and satisfaction with appearance. To evaluate relevant results a highly specific patient-reported outcomes instrument is required. As such, we utilized a previously developed official Polish translation of the BODY-Q questionnaire-a Patient-Reported Outcome (PRO) Instrument for Weight Loss and Body Contouring (BC) treatments. [ 5- 7] Our study aimed to evaluate the long-term psychosocial outcomes of body contouring procedures using the BODY-Q questionnaire, by comparing pre- and post- BC results with 12 months of follow up, among post-bariatric patients recruited consecutively over 2-year-period.

Materials and methods

Patient population and enrollment

A prospective, single-institution study was conducted among 30 consecutive patients that underwent a body-contouring procedure between 2015 and 2017. Inclusion criteria comprised patients older than 18 years old, with BMI less than 30, and having a stable weight for 12 months following bariatric surgery who presented skin sagging and redundancy resulting in clinical manifestations such as chronic skin infections, prolonged skin rashes, ulcerations, and functional limitations. Data regarding demographics and medical history were collected from patient records. All patients received at least a minimum of a 12-month follow-up postoperatively. The study was granted an exemption in writing by the Lower Silesian Hospital Board of Quality Control and Study IRB Department, represented by the Chief of the Medical Section of the Hospital. This study followed the Declaration of Helsinki on medical protocol and ethics. All patients signed the informed consent about the study at the time of enrollment before any study procedures were done. All data were deidentified after study end, and all patients completed the study.

Clinical outcomes assessment

For the study, an official Polish translation and language validation of the Body-Q was done in adherence to the Translation and Cultural Adaptation group (TCA group) principles and World Health Organization (WHO) guidelines on translation and adaptation of instruments. [ 8, 9] Twenty-four hours before surgical intervention, all participants completed the validated Polish version of BODY-Q questionnaire. The structure of the BODY-Q survey used in this study adheres to the recommended methods for the development of a patient-reported outcomes instrument. [ 10, 11] The goal of the questionnaire was to ascertain patients' perceptions of weight loss and body contouring based on three metrics: health-related quality of life, physical appearance, and the process of care.

The preoperative surveys were conducted in a pen-and-paper format. In the postoperative period, the survey was sent to patients via a secured email. Patients were contacted by phone a week before emails were sent out and informed to check their inbox. If no information was received within two weeks, patients were contacted and reminded with another phone call. The preoperative survey contained an additional title page with demographic information, type of bariatric surgery as well as weight before and after massive weight loss ( Table 1). The preoperative module consisted of 14 metrics: appearance scales (body, abdomen, buttocks, back, outer thighs/hips, inner thighs, upper arms, skin excess) and HRQoL scales (body image, psychological function, social function, sexual well-being, physical function, physical symptoms related to obesity). Although the last two subscales are specific to patients with obesity, we used them to assess the persistence of any symptoms in post-bariatric patients. The postoperative module included an additional four scales inquiring about patients' experiences related to treatment, and appraisal of body contouring scars. When the postoperative module was being filled out, patients were not permitted to reference their preoperative answers.

Body contouring procedures

Three plastic surgeons from our department performed all surgeries. Patients underwent various body contouring procedures, depending on the preoperative assessment and the best-predicted outcome for the patient. Our patient population was subject to a vast array of body contouring procedures depending on the surgical indication. Procedures were performed in a standard fashion using high lateral tension abdominoplasties without liposuction, and quilting sutures used. [ 12] Each of our patients was asked to use compression garments for four weeks after surgery. Some of our patients had a lower body lift procedure performed. The operation was executed in a standard fashion as described by Aly et al.; a 360-degree incision was used to resect excess tissue in the abdominal, thigh, and buttock areas. [ 13] No liposuction was performed in these patients. Additional contouring operations included thigh lift and brachioplasty. Thigh lifts were performed using a full T incision as described by Hurwitz with additional liposuction or only inguinal resection with liposuction. [ 14] Brachioplasty was performed according to Hurwitz et al.; utilizing liposuction and an L shaped skin incision in all patients. [ 15]

All patients had preoperative compression garment thromboembolism prophylaxis, and low molecular weight heparin (LMWH) administered following hospital protocols. We used the Caprini Risk Score to stratify our patients for venous thromboembolism risk. LMWH was given to all the patients with Caprini score at least 3 or higher. [ 16] Depending on the patient's risk group, we administered the first dose 12 hours before surgery, and it was continued daily for 7-14 days. Due to higher probability of DVT rate in abdominal and lower-body lift procedures the LMWL prophylaxis was given 14 days in comparison to 7 days in other body contouring procedures. All patients were mobilized the same day after the procedure to lower their risk of a possible thromboembolic incident.

Statistical analysis

Data were compared using the t-test. The raw scores from the tables were converted into a scale ranging from 0 to 100 by the Rasch model. [ 17] Data analyses were performed using IBM SPSS Statistics, version 24.0 (Armonk, NY: IBM Corp.) A value of p <0,05 was considered statistically significant.

Results

Patient characteristics

A total of 30 patients met our inclusion criteria and were enrolled in the study. The overall survey response rate was 86%. All male patients (n = 2) refused to fill out the BODY-Q questionnaire and were excluded from the analysis. As such, the final study group consisted of female patients only. Patients undergoing BC were, on average, 38 years old (SD 5.91) with an average weight loss of 53.1 kg (SD 5.02). Detailed characteristics of our patient population are presented in Table 1.

Procedures performed

Participants have undergone laparoscopic sleeve gastrectomy (LSG), adjustable gastric banding (AGB), and Roux-en-Y gastric bypass (RYGB) with the mean period of 34 months from body contouring ( Table 2). A total of 41 BC procedures were performed in 30 patients ( Table 3). The most common body contouring procedure was abdominoplasty (n = 22; 54%) followed by lower-body lift (n = 7; 17%). The three fourth of patients (n = 22; 73%) underwent a single BC procedure. The remaining eight had anywhere from 2 to 4 surgeries performed. The mean operative time (MOT) for lower body lift was 217.5 minutes, and length of hospital stay (LOS) was five days followed by abdominoplasty patients with MOT of 133.9 minutes and LOS of 4.9 days. Complications occurred in five patients (16.7%), one hematoma (3.3%), and wound dehiscence in four patients (13.3%). As hematoma required wound revision in the OR in the third postoperative day, it was classified as a major complication. Nevertheless, the patient did not demand blood transfusion. All other patients with wound dehiscence were classified as minor complications, treated conservatively with dressing change.

Outcomes of the Body-Q questionnaire

The maximum number of points on each scale is 100. Higher scores correlate with greater satisfaction. There were statistically significant improvements observed in the acceptance and evaluation of body appearance in the postoperative module (p<0,001) ( Fig 1). The worst satisfaction at baseline was observed in the abdominal and thigh region.

Moreover, health-related quality of life was significantly enhanced (≥ 20 points) with regards to psychological well-being, social functioning, sexual well-being, and body image (p<0,001) ( Fig 2). Furthermore, in 15 (50%) of the studied patients, surgery in at least one region positively affected the perception of the rest of the body. In three patients (10%), we noted a decreased satisfaction with untreated body areas. Our analysis did not show any significant difference in the final satisfaction rate between patients who underwent only one BC procedure and those who had multiple procedures performed (71.36±17.15 vs. 73.38±19.02; p = 0,79).

Discussion

The emergence of body contouring procedures has paralleled the rising trend in bariatric surgery for massive weight loss. [ 18, 19] Patients seek a solution for redundant, unattractive, and loose skin, refractory to diet and physical exercise to achieve what is deemed a "natural look." Studies have shown that this, in turn, improves functional and aesthetic results and reduces psychological burden. [ 20- 22] These procedures have the potential to restore proper form and tissue structure. [ 23, 24]

We believe that our high response rate (86%), despite the time-consuming survey, is associated with collecting the questionnaires in pen-and-paper form. On the other hand, it is hard to analyze hand-written data in bigger study groups, so it is more convenient and accurate to obtain electronic data capture for further studies. Also, as reported by Geerards et al., reduced assessment length using BODY-Q computerized adaptive testing could reduce patient burden while preserving the accuracy of clinical patient-reported outcomes. [ 25]

In our study, average weight loss was 53.1 kg. Weight loss was achieved following a bariatric operation as previously described, and after that weight remained stable for at least 12 months. It is contrary to reports by Balagué et al., and Felsenreich et al., that 5 percent of patients regain weight a year after surgery; this was not observed in our cohort. [ 26- 28] The mean age of patients in our study was 38 years old, which is younger than in previously published studies. [ 29- 31] Perhaps, this can be attributed to the ease of access to care and increased knowledge about weight loss options in Poland. The significance of patients supports groups that share information about post-bariatric treatment might also be an essential factor. Although the first procedures performed in Poland were described in the 1970s, an early survey defining the current status of bariatric operations was popularized in 2007, and a substantial rise in the number of surgeries performed was observed in 2014. [ 32, 33] A majority of study participants underwent abdominoplasty followed by the lower body lift. It is consistent with previously reported problematic parts of the body following massive weight loss surgery. Mitchell et al., found abdominoplasty to be the most commonly performed procedure following bariatric surgery, accounting for 24.3 percent. [ 23] This notion is echoed by Giordano et al., who observed that the waist/abdominal region was operated on in 62.2 percent of post-bariatric patients. [ 24]

Our study objectively assesses whether body contouring procedures positively impacted the lives of patients after bariatric surgery. It was achieved using the BODY-Q survey. Interestingly the lowest preoperative (13 points) and highest postoperative (90 points) scores for appearance satisfaction were observed for abdominoplasty. It is reinforced in a study by Poulsen et al. [ 34] Moreover, there was a statistically significant improvement in body perception across all operated body regions postoperatively. However, it is essential to note that the quality of life in the postoperative period was not linked to the number of regions operated. None of the surveyed patients was dissatisfied with the outcome of the procedure. Health-related quality of life was significantly enhanced in all operated-on body areas across all life scales, with the highest change noted in the body image. Song et al. noted a similar observation despite the use of a different, less coherent, assessment scale-the Body Image and Satisfaction Assessment scale (BISA) on a smaller patients' sample. Although, we did not observe that surgical modification of one area led to dissatisfaction in other parts of body, rather we noted opposite reaction when patient was more satisfied with the rest of the body. However, based on clinical experience may suggest that as proposed by Song et al. correction of one body part my lead to exposure of other parts and consequently result in dissatisfaction. [ 29] As we noted in the results, the surgery in at least one region positively affected the perception of the rest of the body.

In our group, the complication rate was found to be 16.7%. We did not observe any correlation between lower satisfaction rates in patients with those minor or even major complications. This is comparable to complication rates reported by Winocour et al., and Chong et al., and lower than that in a study done by Au et al. [ 35, 36] The mean hospital stay in our group was around five days, which is longer than presented in other studies, which is contributed by a more extended pre- and postoperative stay, mainly due to the reimbursement requirements set by the National Health Fund regarding the LOS. [ 37] The main discharge criterion was the drain removal, with fluid output less than 30-40cc. Our choice of BODY-Q survey was preceded by a long data base search. Currently, BODY- Q seems the most universal questionnaire that may be applied to patients worldwide after careful and validated translation. In 2014, Klassen et al compared BODY-Q to other HR-QOL surveys such as Moorehead-Ardelt Quality of Life Instrument (MAQOL), Quality of Life-Lite (IWQOL-Lite) instrument or Swedish Obese Subjects Obesity. [ 6] The major benefit of BODY-Q is that it allows to measure not only HR-QOL but also appearance-related concerns and the patient experience of health care. The versatility and precision of this instrument was reported later by Poulsen et al. who compared BODY‐Q with Moorehead‐Ardelt quality of life questionnaire‐II (MAQOL‐II) proving MAQOL‐II hat does not meet today's standards for a rigorously developed PRO measure. [ 38]

The strength of this study was using a worldwide approved validated questionnaire, long-term follow up (up to 12 months), and a high response rate of 86%. In contrast to previously published BODY-Q questionnaire-related studies, which are cross-sectional and lack longitudinal assessment, the survey was administered to our patient population 24 hours before, six, and twelve months after their body contouring procedure. [ 34, 39]

The limitation of this study was a relatively small number of surveyed patients (30), only females, the possible impact of "no pay" procedure as paid by the National Health Insurance.

Moreover, this study showed the highest satisfaction rate for abdominoplasty patients. It could be biased as the abdominoplasty had the highest number of procedures done among the small group, and other surgeries may not achieve enough statistical power. We plan to focus our subsequent studies on the least reported body contouring surgeries to gain more knowledge about those specific procedures. For future studies, we plan on using a more efficient means of data acquisition such as EDC software (IBM Watson Health), rather than "pen and paper" approach or manually emailed surveys. It will better ensure data safety and minimize human error.

Conclusions

As the study presents, Poland does not differ from other countries in the growing demand for bariatric and post-bariatric procedures. We proved the significant impact of improved body assessment after body contouring procedures. We still need more data on the specific characteristics of patients that profoundly change their perception of their surgical outcomes.

We have shown that these procedures lead to a significant improvement in both the psychological and social aspects of patients' lives. Finally, the BODY-Q is an easy and efficient tool that may provide greater insight for result optimization within this patient population.

References

1. 1. WHO. Obesity and overweight. http://www.who.int/mediacentre/factsheets/fs311/en.

2. 4. ISAPS. Plastic Surgery Statistics | Global Plastic Surgery Statistics. ISAPS. 2018; https://www.isaps.org/medical-professionals/isaps-global-statistics.

3. 9. WHO. WHO | Process of translation and adaptation of instruments. http://www.who.int/substance_abuse/research_tools/translation/en.

4. 17. Tennant A., McKenna S.P., and Hagell P., Application of Rasch analysis in the development and application of quality of life instruments. Value Health, 2004. 7 Suppl 1: p. S22-6.

5. 19. Surgery, A.S.f.M.a.B. Estimate of Bariatric Surgery Numbers, 2011-2016. Published July 6, 2016; https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers.

6. 22. Song P., et al., Body Image & Quality of Life: Changes With Gastric Bypass and Body Contouring. Ann Plast Surg, 2016. 76 Suppl 3: p. S216-21.

7. 29. Song A.Y., et al., Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring), 2006. 14(9): p. 1626-36.

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surgical and invasive medical procedures

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plastic surgery and reconstructive techniques

# data[].attributes.attachment_link.title
The long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery

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Introduction There has been a significant increase in the number of body contouring procedures performed worldwide. This study aimed to evaluate the long-term psychosocial effects of these procedures among patients who undergone weight loss surgery and maintained their body mass for a minimum of one year.