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BACKGROUND: Hormonal factors behind weight regain (WR) after surgical weight loss remain inadequately understood. Growth/differentiation factor 15 (GDF15) has emerged as a potential therapeutic target in obesity treatment. Cortisol, another stress hormone, has also been associated with weight gain at both low and high circulating concentrations. We aimed to compare meal-stimulated GDF15 and cortisol response in adults with and without WR after sleeve gastrectomy (SG). We hypothesized that GDF15 and cortisol response to meal tolerance test (MTT) will be lower in those with versus without WR after SG. METHODS: Cross-sectional study comprised 21 adults without diabetes, who underwent SG. WR was defined as 100 × (current weight − nadir)/(preoperative weight − nadir) > 10%. GDF15, cortisol, insulin, glucose, and incretins (total glucagon-like peptide (GLP)-1 and glucose-dependent insulinotropic polypeptide (GIP) circulating concentrations) were measured during MTT (0–240 min) after 3–6 years post-bariatric surgery. RESULTS: All participants were 48% White, 85% female, with mean (SD) age: 43(10) years, and BMI: 36.2(7.6) kg/m(2). Compared to the non-WR group (n = 6), the WR group (n = 15) had significantly higher BMI (WR: 38.6 ± 7.6 kg/m(2), non-WR: 30.3 ± 3.5 kg/m(2), p = 0.02) and showed lower GDF15 response (WR AUC vs non-WR AUC (116143 ± 13973 vs 185798 ± 38884 ng*min/L, p = 0.047)) and lower cortisol response (WR AUC vs non-WR AUC (3492 ± 210 vs 4880 ± 655 μg*min/dL, p = 0.015)). Incretin response did not differ between the groups. CONCLUSIONS: GDF15 and cortisol responses to MTT were lower in those who regained the weight after SG compared to those who did not, suggesting that dysregulation in GDF15 and cortisol response following bariatric surgery.

Gut microbiota likely impact obesity and metabolic diseases. We evaluated the changes in gut microbiota after surgical versus medical weight loss in adults with diabetes and obesity. We performed 16S rRNA amplicon sequencing to identify the gut microbial composition at baseline and at 10% weight loss in adults with diabetes who were randomized to medical weight loss (MWL, n = 4), adjustable gastric banding (AGB, n = 4), or Roux-en-Y gastric bypass (RYGB, n = 4). All participants were female, 75% reported black race with mean age of 51 years. At similar weight loss amount and glycemic improvement, the RYGB group had the most number of bacterial species (10 increased, 1 decreased) that significantly changed (p

Bariatric surgery leads to more rapid and greater weight loss (WL) compared to medical weight loss (MWL), but the differences in body composition (BC) changes for these modalities remain unclear. Due to the known health risks associated with central adiposity, we compared the changes in regional distribution of fat mass (FM) and lean mass (LM) after surgical versus MWL. In this 1:1:1 randomized trial among 15 persons with type 2 diabetes and body mass index (BMI) 30–39.9 kg/m2, we compared changes in BC, by dual-energy X-ray absorptiometry and abdominal computerized tomography, at time of 10%WL or 9 months after intervention (whichever came first). Participants underwent MWL, adjustable gastric banding (AGB), or Roux-en-Y gastric bypass (RYGB). Non-parametric tests evaluated BC differences (FM, LM, and visceral adipose tissue [VAT]) within and across all three arms and between pair-wise comparisons. Twelve female participants (75% African American) completed the study. Patient age, BMI, and baseline anthropometric characteristics were similar across study arms. AGB lost more LM (MWL − 5.2%, AGB − 10.3%, p = 0.021) and VAT (MWL + 10.9%, AGB − 28.0%, p = 0.049) than MWL. RYGB tended to lose more VAT (MWL +10.9%, RYGB − 20.2%, p = 0.077) than MWL. AGB tended to lose more LM than RYGB (AGB − 12.38%, RYGB − 7.29%, p = 0.15). At similar WL, AGB lost more LM and VAT than MWL; RYGB similarly lost more VAT. Given the metabolic benefits of reducing VAT and retaining LM, larger studies should confirm the changes in BC after surgical versus medical WL. NCTDK089557 – ClinicalTrials.gov

Gastric stenosis (GS) is a potential adverse event post-laparoscopic sleeve gastrectomy (LSG). Endoscopic management is preferred; however, there is significant variation in therapeutic strategies with no defined algorithm. This study aims to describe the safety and efficacy of a predefined step-wise algorithm for endoscopic management of GS post-LSG. Consecutive patients with symptomatic GS post-LSG, presenting between July 2015 and August 2016, were subjected to a predefined treatment algorithm of serial dilations using achalasia balloons, followed by a fully covered self-expanding metal stent (FCSEMS) if dilations were inadequate. Patients who did not respond or opted out of ongoing endoscopic therapy were offered revision Roux-en-Y gastric bypass (RYGB). Total of 17 patients underwent a median of 2 (range 1–4) balloon dilations. Twelve patients (70.6%) reported clinical improvement with balloon dilation alone, while 3 (17.6%) required subsequent FCSEMS placement. One patient suffered a tear to the muscularis propria with balloon dilation, which was managed conservatively. Overall, 15 (88.2%) reported clinical improvement with endoscopic management. PAGI-SYM scores revealed that the strongest response to therapy, based on mean reduction of score ± SD, was in the following items: nausea (3 ± 1.9, P

New approaches for refractory stenosis in post-bariatric surgical patients include fully covered lumen-apposing metallic stents (LAMS); however, stent migration continues to be a problem. Endoscopic suture placement to LAMS can reduce the migration. Aiming to assess the feasibility and safety of the procedure, we evaluated nine consecutive patients with inability to tolerate a solid diet due to a benign gastrointestinal stricture recalcitrant to previous attempts at endoscopic therapy. All patients were symptom-free starting from 1-week follow-up. Median stent dwell time was nearly 3 months. During the removal procedures, three incidental foreign bodies were found and removed. No stent migration was observed in any patients. Suturing LAMS is a feasible technique allowing for prolonged stent dwell times; however, it requires a high level of expertise plus additional procedure time.

Since obesity increases vitamin D deficiency (VDD) risk, bariatric surgery candidates are high-risk. Previously, we documented 71.4% VDD at our center.To investigate diagnosis and treatment for VDD in our bariatric candidates.25(OH)D, if pending, and supplementation (form, dosing, frequency) were prospectively documented in 265 candidates.Candidates were 83.0% female, 48.9% white, age 43 ± 13 years and BMI 46.3 ± 10.5 kg/m(2). 25(OH)D was available for 18.5%: 35.7% VDD 39.3% insufficiency. VDD history did not differ by demographics or procedure, as with those tested versus not.VDD testing was lower than clinically-indicated. Of those tested, 35.7% were deficient and 39.3% insufficient. We previously reported higher rates: 71.4% deficiency, 92.9% insufficiency. Thus, many candidates are untested but high-risk.

Management options for marginal ulcers (MU) vary from medical therapy to revision surgery. Medical therapy is often ineffective and revision surgery is associated with a high morbidity and possible recurrence. To evaluate technical feasibility, efficacy, and safety of endoscopic management of MU by covering the ulcer bed using oversewing and/or deploying a fully covered self-expandable metallic stent (FCSEMS). Medical records of consecutive patients who underwent endoscopic suturing and/or FCSEMS deployment for recalcitrant MU between August 2016 and June 2017 at a single academic center were reviewed. Recalcitrant MU was defined as an ulcer that persists after 6 to 8 weeks despite maximal medical therapy (open capsule PPI, 40 mg bid as well as sucralfate qid), cessation of smoking and nonsteroidal anti-inflammatory drugs (NSAIDs), and Helicobacter pylori eradication. Eleven patients (age range 31–60; all females) with mean BMI of 27.72 ± 5.93 kg/m2 underwent endoscopic suturing and/or stent deployment for recalcitrant MU with abdominal pain at a median of 50 months (range 3–120) post-Roux-en-Y gastric bypass (RYGB). Seven patients were managed by oversewing, two were managed by FCSEMS, and two patients required both. Technical success was 100%. All patients reported resolution of abdominal pain at 1 week. Surveillance endoscopy performed in 10/11 (90.9%) patients at 8 weeks revealed complete ulcer healing in 9/10 (90%). No adverse events were reported. Endoscopic management is an effective and safe method to treat MU and should be considered an alternative to surgical revision. It appears effective for perforated and recalcitrant MU.

Partially covered self-expandable metallic stents (PCSEMS), although an effective treatment for anastomotic/staple line leaks and strictures, can be difficult to remove. This study examines the effectiveness of the inversion technique for the removal of PCSEMS in the treatment of leaks and strictures that occurred post-sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Consecutive patients who underwent PCSEMS removal for a leak and/or stricture post-SG or RYGB between July 2013 and December 2016 at the Johns Hopkins Medical Institutions were reviewed. All PCSEMS removals were first attempted via the inversion technique, which involves grasping the distal end of the stent and inverting it through itself. Fourteen patients (four males) underwent PCSEMS removal via the inversion technique for an anastomotic/staple line leak (50%), stricture (29%) or both (21%) post-SG (79%) or RYGB (21%). Technical success (successful removal of the stent) was achieved in one endoscopic session for 13 of the 14 PCSEMS (93%). One PCSEMS required the use of the stent-in-stent technique for removal. The median dwell time was 47 days (range 5–72). A distal partial occlusion developed in five patients (35%) due to tissue overgrowth and one PCSEMS (7%) migrated, necessitating premature removal. Eight patients (57%) experienced clinical success at follow-up, and six patients (43%) required subsequent treatment due to persistence or recurrence of the pathology. The inversion technique is a safe, effective, and efficient method of removing PCSEMS placed to correct anastomotic/staple line leaks and strictures post-SG and RYGB.

It may be difficult to distinguish between adults with type 1 diabetes and type 2 diabetes by clinical assessment. In patients undergoing bariatric surgery, it is critical to correctly classify diabetes subtype to prevent adverse perioperative outcomes including diabetic ketoacidosis. This study aimed to determine whether testing for C-peptide and islet cell antibodies during preoperative evaluation for bariatric surgery could improve the classification of type 1 versus type 2 diabetes compared to clinical assessment alone. This is a retrospective analysis of the Improving Diabetes through Lifestyle and Surgery trial, which randomized patients with clinically diagnosed type 2 diabetes and BMI 30–40 kg/m2 to medical weight loss or bariatric surgery; one participant was discovered to have type 1 diabetes after experiencing postoperative diabetic ketoacidosis. Using blood samples collected prior to study interventions, we measured islet cell antibodies and fasting/meal-stimulated C-peptide in all participants. The participant with type 1 diabetes was similar to the 11 participants with type 2 diabetes in age at diagnosis, adiposity, and glycemic control but had the lowest C-peptide levels. Among insulin-treated participants, fasting and stimulated C-peptide correlated strongly with the C-peptide area-under-the-curve on mixed meal tolerance testing (R = 0.86 and 0.88, respectively). Three participants, including the one with type 1 diabetes, were islet cell antibody positive. Clinical characteristics did not correctly identify type 1 diabetes in this study. Preoperative C-peptide testing may improve diabetes classification in patients undergoing bariatric surgery; further research is needed to define the optimal C-peptide thresholds.

Marginal ulceration post Roux-en-Y gastric bypass (RYGB) with associated bleeding, although infrequently encountered, can be challenging to treat. Flexible endoscopic therapy is preferred over surgery due to its minimally invasive nature. Bleeding ulcers have traditionally been treated endoscopically by injecting epinephrine, bipolar hemostasis, or clips. Here, we describe our treatment with endoscopic suturing for a massively bleeding marginal ulcer after RYGB. A 56-year-old female 10 days post RYGB underwent her fourth endoscopy for investigation and management of hematemesis and was found to have a large bleeding anastomotic ulcer. A Rothnet was utilized to remove large blood clots which obstructed endoscopic visualization. Two marginal ulcers were noted, and these were successfully oversewn with endoscopic suturing. The multimedia video (7 min) demonstrates the management of massively bleeding marginal ulcer after RYGB by endoscopic suturing. Patient had no further bleeding and tolerated diet the subsequent day. She was discharged home with no further episodes of hematemesis, and follow-up at 6 weeks showed well-healed ulcer on endoscopy. Endoscopic suturing of a bleeding marginal ulcer appears technically feasible and safe. It should be considered in the treatment algorithm prior to emergency surgery.

The effects of surgical weight loss (WL) on inflammatory biomarkers associated with sleep apnea remain unknown. We sought to determine if any biomarkers can predict amelioration of sleep apnea achieved by bariatric surgery. We hypothesized that surgical WL would substantially reduce severity of sleep apnea and levels of proinflammatory cytokines.Twenty-three morbidly obese adults underwent anthropometric measurements, polysomnography, and serum biomarker profiling prior to and 1 year following bariatric surgery. We examined the effect of WL and amelioration of sleep apnea on metabolic and inflammatory markers.Surgical WL resulted in significant decreases in BMI (16.7 ± 5.97 kg/m(2)/median 365 days), apnea-hypopnea index (AHI), CRP, IL-6, sTNFαR1, sTNFαR2, and leptin levels, while ghrelin, adiponectin, and soluble leptin receptor concentrations increased significantly. Utilizing an AHI cutoff of 15 events/h, we found significantly elevated levels of baseline sTNFαR2 and greater post-WL sTNFαR2 decreases in subjects with baseline AHI ≥15 events/h compared to those with AHI15 events/h despite no significant differences in baseline BMI, age, and ΔBMI. In a multivariable linear regression model adjusting for sex, age, impaired glucose metabolism, ΔBMI, and follow-up period, the post-WL decreases in AHI were an independent predictor of the decreases in sTNFαR2 and altogether accounted for 46% of the variance of ΔsTNFαR2 (P = 0.011) in the entire cohort.Of all the biomarkers, the decrease in sTNFαR2 was independently determined by the amelioration of sleep apnea achieved by bariatric surgery. The results suggest that sTNFαR2 may be a specific sleep apnea biomarker across a wide range of body weight.

While bariatric surgery has proved highly successful at producing sustained weight loss, variability in treatment response persists. A better understanding of the pathophysiology of appetite and obesity may improve patient selection and management. Research into feeding behavior and satiety has focused on the role of dopamine in reward-based behaviors. Specifically, positron-emission computed tomography (PET) has demonstrated reduced brain dopamine receptor availability in obese subjects compared to controls. This may be due to a primary deficiency in dopamine receptors or to secondary dopamine receptor downregulation. We performed a preliminary study to investigate dopamine D2 receptor activity in obese subjects before and after laparoscopic Roux-en Y gastric bypass (LGBP). Five female subjects, ages 20 to 38 years old with a mean body mass index of 45, underwent PET with [C-11] raclopride injection. Five regions of interest were studied: ventral striatum, anterior and posterior putamen, and anterior and posterior caudate nucleus. Repeat PET was performed at 6 weeks following LGBP. D2 receptor binding was compared within subjects pre- and post-surgery. Baseline D2 binding was also compared to historical nonobese controls. D2 receptor availability increased 6 weeks after gastric bypass surgery. The increase in receptor availability appeared roughly proportional to the amount of weight lost. No significant difference in D2 binding was seen between the obese subjects and historical nonobese controls. Brain available dopamine D2 binding appears to increase following GBP. This preliminary finding needs to be replicated in a larger population but suggests that diminished D2 binding in the obese may be due to D2 receptor downregulation. Changes in available dopamine receptor binding may play an important role in centrally mediated appetite suppression and resultant weight loss after LGBP.

Over 78 million American adults have obesity. Bariatric surgery is the leading means of durable weight loss. Nutritional deficiencies are commonly treated post-operatively but are often undiagnosed pre-operatively. Malnutrition is correlated with adverse surgical outcomes. The aim of this study is to assess pre-operative nutritional status in our bariatric surgery candidates in a cross-sectional study. We recruited 58 bariatric candidates approved to undergo the Roux-en Y gastric bypass. Nutritional status was determined for vitamins A, B12, D, E-α, and E-β/γ as well as thiamine, folate, and iron. We used clinical as well as frank deficiency cut-offs based on the Institute of Medicine and the World Health Organization guidelines. This cohort was largely female (77.6 %) and white (63.8 %). Median age was 42.2 years. Median body mass index (BMI) was 46.3 kg/m2. Multiple comorbidities (MCM) were present in 41.4 %, 54.0 % hypertension, 42.0 % diabetic, 34.0 % sleep apnea. Men had more comorbidities, 69.2 % with MCM. Folate and iron saturation varied significantly by sex. Vitamins A, D, E-α, and thiamine significantly varied by race. Vitamin D negatively correlated with BMI (p = 0.003) and age (p = 0.030). Vitamin A negatively correlated with age (p = 0.001) and number of comorbidities (p = 0.003). These pre-operative bariatric candidates had significant malnutrition, particularly in vitamin D (92.9 %) and iron (36.2 to 56.9 %). Multiple micronutrient deficiency (MMND) was more common in blacks (50.0 versus 39.7 % overall). Number of comorbidities did not correlate with MMND. Malnutrition in one or multiple micronutrients is pervasive in this pre-operative bariatric cohort. The effect of pre-operative supplementation, especially vitamin D and iron, should be explored.

Intermittent, reversible intraabdominal vagal blockade (VBLOC® Therapy) demonstrated clinically important weight loss in feasibility trials. EMPOWER, a randomized, double-blind, prospective, controlled trial was conducted in USA and Australia. Five hundred three subjects were enrolled at 15 centers. After informed consent, 294 subjects were implanted with the vagal blocking system and randomized to the treated (n = 192) or control (n = 102) group. Main outcome measures were percent excess weight loss (percent EWL) at 12 months and serious adverse events. Subjects controlled duration of therapy using an external power source; therapy involved a programmed algorithm of electrical energy delivered to the subdiaphragmatic vagal nerves to inhibit afferent/efferent vagal transmission. Devices in both groups performed regular, low-energy safety checks. Data are mean ± SEM. Study subjects consisted of 90 % females, body mass index of 41 ± 1 kg/m2, and age of 46 ± 1 years. Device-related complications occurred in 3 % of subjects. There was no mortality. 12-month percent EWL was 17 ± 2 % for the treated and 16 ± 2 % for the control group. Weight loss was related linearly to hours of device use; treated and controls with ≥12 h/day use achieved 30 ± 4 and 22 ± 8 % EWL, respectively. VBLOC® therapy to treat morbid obesity was safe, but weight loss was not greater in treated compared to controls; clinically important weight loss, however, was related to hours of device use. Post-study analysis suggested that the system electrical safety checks (low charge delivered via the system for electrical impedance, safety, and diagnostic checks) may have contributed to weight loss in the control group.

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality following bariatric surgery. The exact duration and magnitude of post-surgery risk for VTE, however, is unclear. We analyzed a large administrative database to determine the long-term risk and predictors for VTE in patients undergoing bariatric surgery. A private insurance claims database was used to identify 17,434 patients who underwent bariatric surgery. Longitudinal data were available for each patient for up to 12 months post-surgery. We used logistic regression to identify independent predictors for VTE events. The incidence of VTE during the index surgical hospitalization was .88%. This cumulative rate rose to 2.17% at 1 month and 2.99% by 6 months post-surgery. Over 74% of VTE events occurred after discharge. Risk factors identified for VTE developing by 6 months post-surgery included male sex (odds ratio (OR) = 1.68; confidence limits (CL) = 1.37–2.07), age ≥ 55 years (OR = 2.18; CL = 1.56–3.03), smoking (OR = 1.86; CL = 1.06–3.27), and previous VTE (OR = 7.48; CL = 5.78–9.67). The laparoscopic adjustable gastric band was less likely to result in VTE compared to open or laparoscopic gastric bypass (OR = .31; CL = .13–.75). The period of increased risk for VTE following bariatric surgery extends well beyond the initial hospital discharge and 30 days after surgery. The high frequency of VTE up to 6 months following bariatric surgery suggests that more aggressively extended prophylaxis should be considered in patients at higher risk for VTE.