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The case demonstrates the use of bariatric surgery to improve a patient’s candidacy for surgical treatment for endometrial cancer (EC). A 50-year-old morbidly obese woman with early-stage EC was initially treated with levonorgestrel-releasing intrauterine system (52 mg) . She had to reduce her body mass index (BMI) to become eligible for definite EC treatment. Using conservative methods, she was unable to lose weight effectively. She then underwent bariatric surgery that reduced her BMI from 71.3 to 54.3 kg/m2. She maintained her weight and was eligible for total hysterectomy and bilateral salpingo-oopherectomy. Her procedure was successful and had no complications. She has 6-monthly follow-ups, and the most recent review showed no evidence of recurrence.

To compare safety and healthcare utilization after sleeve gastrectomy versus Roux-en-Y gastric bypass in a national Medicare cohort.Though bariatric surgery is increasing among Medicare beneficiaries, no long-term, national studies examining comparative effectiveness between procedures exist. Bariatric outcomes are needed for shared decision-making and coverage policy concerns identified by the cMS Medicare Evidence Development and Coverage Advisory Committee.Retrospective instrumental variable analysis of Medicare claims (2012-2017) for 30,105 bariatric surgery patients entitled due to disability or age. We examined clinical safety outcomes (mortality, complications, and reinterventions), healthcare utilization [Emergency Department (ED) visits, rehospitalizations, and expenditures], and heterogeneity of treatment effect. We compared all outcomes between sleeve and bypass for each entitlement group at 30 days, 1 year, and 3 years.Among the disabled (n = 21,595), sleeve was associated with lower 3-year mortality [2.1% vs 3.2%, absolute risk reduction (ARR) 95% confidence interval (CI): -2.2% to -0.03%], complications (22.2% vs 27.7%, ARR 95%CI: -8.5% to -2.6%), reinterventions (20.1% vs 27.7%, ARR 95%CI: -10.7% to -4.6%), ED utilization (71.6% vs 77.1%, ARR 95%CI: -8.5% to -2.4%), and rehospitalizations (47.4% vs 52.3%, ARR 95%Ci: -8.0% to -1.7%). Cumulative expenditures were $46,277 after sleeve and $48,211 after bypass (P = 0.22). Among the elderly (n = 8510), sleeve was associated with lower 3-year complications (20.1% vs 24.7%, ARR 95%CI: -7.6% to -1.7%), reinterventions (14.0% vs 21.9%, ARR 95%CI: -10.7% to -5.2%), ED utilization (51.7% vs 57.2%, ARR 95%CI: -9.1% to -1.9%), and rehospitalizations (41.8% vs 45.8%, ARR 95%Ci: -7.5% to -0.5%). Expenditures were $38,632 after sleeve and $39,270 after bypass (P = 0.60). Procedure treatment effect significantly differed by entitlement for mortality, revision, and paraesophageal hernia repair.Bariatric surgery is safe, and healthcare utilization benefits of sleeve over bypass are preserved across both Medicare elderly and disabled subpopulations.

Background The prevalence of childhood obesity in the U.S. has tripled over the last three decades. However, fewer than 1% of children with severe obesity undergo surgical weight loss interventions each year. Materials and methods All patients age 10 to 19 years old who underwent laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2015 through 2018 in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database were included in this retrospective cohort analysis. The primary outcomes were mortality and overall complications. Procedural trends, readmission and reoperation rates were also examined using a multivariate regression model. Results Patients had a mean BMI of 47.3 kg/m2 and 80.0% were either 18 or 19 years old (n = 4,051). There were two reported deaths. Reoperation within 30 days occurred in 1.1% of patients, readmission in 3.5%, and complications in 1.2%. Among all readmissions, primary reasons included nausea/vomiting or nutritional depletion (41.3%) and abdominal pain (16.3%). RYGB was associated with higher odds for readmission (p = 0.006) and complications (p = 0.005). Higher BMI and younger age were not associated with an increased likelihood to experience poorer outcomes. The proportion of patients undergoing SG increased yearly over RYGB from 73.9% in 2015 to 84.3% in 2018. Conclusions Bariatric surgery appears to be low risk for adolescents and SG has become the operation of choice. More research on early consideration of surgical therapy in adolescents with severe obesity is needed given the safety profile. Level of Evidence III

BACKGROUND: Treatment options for adolescents with obesity are limited. Yet, therapies previously reserved for adults, such as medications and bariatric surgery, are increasingly available to adolescents in tertiary obesity treatment settings. We aimed to identify the factors associated with selecting an advanced obesity treatment (diets, medications, and surgery) beyond lifestyle therapy among adolescents presenting to a tertiary, pediatric weight management program. METHODS: We conducted a secondary analysis of adolescents (N = 220) who participated in a longitudinal, observational case–control study within a pediatric weight management program. The exposures were potential individual and clinical factors, including sociodemographic characteristics and comorbidities. The outcome was treatment selection, dichotomized into lifestyle vs. advanced treatment. We modeled associations between these factors and treatment selection using logistic regression, controlling for confounding variables (age, race/ethnicity, sex, and insurance). RESULTS: The study population included a majority of non-Hispanic Black (50.5%) and Hispanic/Latino (19.5%) adolescents, of whom 25.5% selected advanced treatment. Adolescents were more likely to choose an advanced treatment option if they had a greater BMI [odds ratio (OR) 1.09, 95% confidence interval (95% CI) 1.04–1.15], lived further from the clinic (OR 1.03, 95% CI 1.00–1.05), and had an elevated glycohemoglobin level (OR 2.46, 95% CI 1.24–4.92). CONCLUSIONS: A significant fraction of adolescents seeking obesity treatment in a specialized care setting chose new and emerging obesity treatments, particularly those at high risk of developing diabetes. These findings can inform patient–clinician obesity treatment discussions in specialty care settings. Clinical Trial Registration number: NCT03139877.

Background: Protein intake and physical activity have a substantial impact on body composition and weight loss outcomes after bariatric surgery. The 24-h dietary recall and 6-min walk test (6mWT) are frequently used to monitor protein intake and physical activity, respectively. Despite its frequent use, it is unknown whether these tests can predict long-term weight loss. Methods: This retrospective study included 85 patients who underwent laparoscopic Roux-en-Y gastric bypass. Protein intake was recorded using the 24-h dietary recall and physical function was measured using the 6mWT. Data about total weight loss (TWL) and nonresponse (i.e., insufficient weight loss and weight regain) were collected up to 5 years. Multiple regression analyses were performed to examine the predictive value of the 24-h dietary recall and 6mWT on weight loss outcomes. Results: The mean protein intake 1 year postoperatively was 68.1 +/- 15.0 g/day and the mean distance covered during the 6mWT was 591.7 +/- 67.9 m. Both the 24-h dietary recall and 6mWT were not significantly associated with TWL and neither with nonresponse. Conclusions: The 24-h dietary recall and 6mWT are poor predictors for long-term weight loss outcomes after gastric bypass. Despite the well-known advantages of these clinical tests, other monitoring tests are suggested for future research.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD), often associated with obesity and metabolic syndrome, manifests itself as steatosis, hepatic fibrosis, cirrhosis, or even end-stage liver disease. NAFLD causes inflammation, insulin resistance and cardiovascular complications. The current study aimed to evaluate the beneficial effects of bariatric surgery on biochemical parameters of hepatic functions in obese patients by comparing them before and one-year after the surgery. METHODS: A total of 72 morbidly obese patients underwent bariatric surgery between 2016 and 2018. The incidence of diabetes mellitus in this group was 29%, median body weight was 124.5 kg (109.0-140.0) and mean body mass index (BMI) was 44.38 ± 6.770 kg/m2. The used surgical procedures included gastric bypass, sleeve gastrectomy, laparoscopic gastric plication, and single anastomosis duodeno-ileal bypass-sleeve gastrectomy. Biochemical parameters including ALT/AST ratio (AAR), NAFLD fibrosis score (NFS), hepatic fibrosis index (FIB-4) and Fatty Liver Index (FLI) were evaluated in all patients at the time of surgery and one year after the intervention. RESULTS: Significant improvement after the intervention was observed in 64 patients. A significant reduction in body weight (P, University of Ostrava in The Czech Republic

Background Bariatric surgery can influence the presentation, diagnosis, and management of gastrointestinal cancers. Oesophago-Gastric (OG) malignancies in patients who have had a prior bariatric procedure have not been fully characterised. Objective To characterise OG malignancies after bariatric procedures. Setting University Hospital, United Kingdom. Methods We performed a retrospective, multi-centre observational study of patients with OG malignancies after bariatric surgery to characterise this condition. Results This study includes 170 patients from 75 centres in 25 countries who underwent bariatric procedures between 1985 and 2020. At the time of the bariatric procedure, the mean age was 50.2 ± 10 years and the mean weight 128.8 ± 28.9 kg. Females comprised 57.3% (n=98) of the population. Most (n=64) patients underwent a Roux-en-Y Gastric Bypass (RYGB) followed by Adjustable Gastric Band (AGB) (n = 46) and Sleeve Gastrectomy (SG) (n = 43). Time to cancer diagnosis after bariatric surgery was 9.5 ± 7.4 years and mean weight at diagnosis was 87.4 ± 21.9 kg. The time lag was 5.9 ± 4.1 years after SG compared to 9.4 ± 7.1 years after RYGB and 10.5 ± 5.7 years after AGB. One-third of patients presented with metastatic disease. The majority of tumours were adenocarcinoma (82.9%). Approximately 1 in 5 patients underwent palliative treatment from the outset. Time from diagnosis to mortality was under one year for most patients who died over the intervening period. Conclusions The OGMOS (Oesophago-Gastric Malignancies after Obesity/ Bariatric Surgery) study presents the largest series to date of patients developing OG malignancies after bariatric surgery and attempts to characterise this condition.

Reducing the risk of death due to cardiovascular disease (CVD) is an important direction for diabetes prevention and treatment. The Chinese population with type 2 diabetes (T2D) has a high risk of developing CVD at relatively low body mass index (BMI) levels. Currently, no studies have evaluated the effect of bariatric surgery versus medical therapy on long-term CVD risk in patients with T2D and low BMI.To compare bariatric surgery versus medical therapy for long-term CVD risk in Chinese patients with T2D and low BMI by using the China Prediction for ASCVD Risk equations and the United Kingdom Prospective Diabetes Study risk engine.University hospital, China.Medical records of patients with T2D with a BMI35 kg/mA total of 684 patients with T2D underwent bariatric surgery (n = 75) or medical therapy (n = 609), and 52 pairs of matched subjects were selected from both groups after propensity score matching. The 10-year and lifetime atherosclerotic CVD risk by using the China Prediction for ASCVD Risk equation at 5 years follow-up period in the bariatric surgery group improved significantly compared with the medical therapy group. In the fifth year of follow-up, the 10-year risk of coronary heart disease, fatal coronary heart disease, stroke, and fatal stroke by using the United Kingdom Prospective Diabetes Study risk engine were much lower in the bariatric surgery group than in the medical therapy group (10.37 ± 5.64% versus 27.25 ± 7.28%, P = .004; 6.3 ± 4.5% versus 22.3 ± 7.35%, P = .002; 4.97 ± 3.73% versus 15.05 ± 3.63%, P = .001; .59 ± .45% versus 1.52 ± .14%, P.001. respectively). The use of glucose-lowering medications, including insulin, was reduced from baseline in both groups, and patients in the bariatric surgery group required significantly fewer of these medications than those in the medical therapy group.Bariatric surgery in patients with T2D and low BMI conferred a lower calculated risk of CVD compared with medical therapy over 5 years of follow-up.

Objectives. This study aims to evaluate the need to modify the total and weight-adjusted doses of levothyroxine after bariatric surgery, identify predictors, and assess the influence of the weight loss on the levothyroxine requirements. Methods. A retrospective study in patients with treated hypothyroidism that underwent bariatric surgery. The modification of the levothyroxine dose and its association with the weight loss and other potential predictors were evaluated at 6, 12, and 24 months post-surgery. Results. Among the 63 patients included, 82.54% needed an adjustment of levothyroxine dose during the follow-up. The total weekly dose of levothyroxine (µg) decreased post-surgery at 6 months (β= −49.1; 95%CI-93.7 to −4.5; p=0.031) and 12 months (β=−54.9; 95%CI-102 to −7.8; p=0.022), but did not significantly change at 24 months (p=0.114). The weekly weight-adjusted dose (µg/k) increased at 6 months (β=1.37; 95%CI 0.91 to 1.83; p Conclusions. This study shows a significant decrease in the total dose of levothyroxine requirements change after bariatric surgery during the first year of the follow-up and an increase in the weight-adjusted dose over the first two years. No predictors of modification of the total dose of levothyroxine were identified.

Background The laparoscopic approach is a very popular technique for many gastrointestinal operations and barbed sutures may improve the difficulties of intracorporeal anastomosis by eliminating the need for knot tying. The aim of this systematic review with a meta-analysis is to explore literature to establish the security profile of barbed suture compared with conventional laparoscopic sutures. Materials and methods A systematic search was performed in all electronic databases (PubMed, Web of Science, Scopus, EMBASE) and 12 studies were included in the analysis, involving 27,133 patients, whereof 3372 cases (patients undergone barbed suture usage) and 23,761 controls (patients undergone conventional suture usage). We found 3 studies discussing differences between barbed and conventional sutures in colorectal surgery and 8 studies presenting results in bariatric surgery, both in Roux-en-y gastric bypass and Mini Gastric/One Anastomosis Gastric Bypass. Results We found comparable rate of leaks, bleedings and stenosis. The meta-regression analysis demonstrated that, both in case of bariatric and colorectal surgery, the demographic characteristic of patients and the oncological features of neoplasms did not impact of these findings. As expected, operative time is significantly shorter when barbed suture is used. Conclusion Our analysis on current literature define an acceptable security profile for barbed suture with effective results particularly in terms of shorter operative time.

Background Obesity is a complex health disorder that significantly increases the risk of several chronic diseases, and it has been associated with a 5–20-year decrease in life expectancy. The prevalence of obesity is increasing steadily worldwide and Italy follows this trend with an increase of almost 30% in the adult obese population in the last 3 decades. Previous studies estimated that 2–4% of the total health expenditure in Europe is attributed to obesity and it is projected to double by 2050. Currently, there is a lack of sufficient knowledge on the burden of obesity in Italy and most relevant estimates are derived from international studies. The aim of this study is to estimate the direct and indirect costs of obesity in Italy, taking 2020 as the reference year. Methods Based on data collected from the literature, a quantitative cost-of-illness (COI) study was performed from a societal perspective focussing on the adult obese population (Body Mass Index (BMI) ≥ 30 kg/m2) in Italy. Results The study indicated that the total costs attributable to obesity in Italy amounted to €13.34 billion in 2020 (95% credible interval: €8.99 billion Conclusions Obesity is associated with high direct and indirect costs, and cost-effective prevention programmes are deemed fundamental to contain this public health threat in Italy.

One anastomosis gastric bypass (OAGB) is the third most common (4%) primary bariatric procedure worldwide but is seldom performed in the United States and is currently under consideration for endorsement by the American Society for Metabolic and Bariatric Surgery. Evidence from the United States on safety of OAGB compared to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) is limited.To compare the short-term safety outcomes of the three primary bariatric procedures.Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP)-accredited hospitals in the United States and Canada.Using the 2015-2019 MBSAQIP database, we compared the safety outcomes of adult patients who underwent primary laparoscopic OAGB, RYGB, and SG. Exclusion criteria included age over 80 years, emergency operation, conversion, and incomplete follow-up. The primary outcome was 30-day overall complication. Secondary outcomes were 30-day surgical and medical complications and hospitalization length.A total of 341 patients underwent primary OAGB. Using propensity scores, we matched the OAGB cohort 1:1 with two cohorts of similar baseline characteristics who underwent RYGB and SG, respectively. The OAGB cohort had a lower overall complication rate than the RYGB cohort (6.7% versus12.3%, P = .02) and a similar rate to the SG cohort (5.0%, P = .43). The OAGB cohort had a similar rate of surgical complication to the RYGB cohort (5.0% versus 8.5%, P = .1) and a higher rate than the SG group (1.2%, P = .009). The OAGB cohort had a shorter median hospitalization than the RYGB cohort (1 d [interquartile range (IQR) 1-2 d] versus 2 d [IQR 1-2 d], P.001) and a similar hospitalization length to the SG cohort ([1-2 d], P = .46).Using the largest and the most current U.S. data, this study demonstrated that the short-term safety profile of primary OAGB is acceptable, but future studies should determine the long-term safety.

Background Pre-surgical psychopathology does not consistently predict post-surgical outcomes in patients who undergo metabolic and bariatric (MBS) surgery. Individuals with elevated pre-MBS psychopathology may be less likely to undergo surgery, which may create a floor effect due to the limited range of scores on measures of psychopathology included in post-surgical analyses, thereby decreasing power to detect clinically significant differences between groups. Objectives We compared rates of clinically significant pre-MBS psychopathology across domains of functioning in patients who did and did not undergo MBS: surgical completers (SC, n = 286) and non-surgical completers (NSC, n = 125). Setting Academic Medical Center, United States Methods Participants (N = 411) were a racially diverse sample of MBS candidates who completed a pre-surgical psychosocial evaluation including measures of disordered eating, alcohol and tobacco use, pain catastrophizing, anxiety, and depressive symptomatology. Results Compared to SC, NSC had larger scale score variance on measures of psychopathology and were more likely to be African-American, to report clinically significant scores on measures of binge eating, depression, anxiety, and pain catastrophizing, and to use tobacco. Conclusions Results support the presence of a restriction of range effect, but do not demonstrate a floor effect. These data suggest that current outcome data for MBS patients may not generalize to those who report clinically significant psychopathology at the pre-MBS psychosocial evaluation, and warrant caution when using the current literature to inform clinical decision-making for this group. Findings also suggest a need for interventions that will better engage African-American patients.

Background Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in morbid obesity (MO). A considerable proportion of patients with MO have non-alcoholic steatohepatitis (NASH). Liver biopsy (LB) is the only procedure that reliably differentiates NASH from other stages of NAFLD, but its invasive nature prevents it from being generalisable. Hence, non-invasive assessment is critical in this group of patients. Objectives To report NAFLD/NASH prevalence in a cohort of patients with MO and to identify predictors of NASH. Methods Fifty-two consecutive patients subjected to bariatric surgery in a University hospital in Spain underwent LB. Anthropometric, clinical and biochemical variables were registered. According of the results of the LB, individuals were classified by whether they had NASH or not. Multiple logistic regression analysis was performed to identify independent factors associated with NASH. Results NAFLD was reported in 94.2% of the patients, simple steatosis was present in 51.92% and NASH in 42.31%. Meanwhile, 17.3% of patients exhibited significant fibrosis (≥F2). HIGHT score for NASH risk was established using five independent predictors: systemic Hypertension, Insulin resistance, Gamma-glutamyl transferase, High density lipoprotein cholesterol and alanine Transaminase. This score ranges from 0 to 7 and was used to predict NASH in our cohort (area under the receiver operator characteristic curve 0.846). A score of 4 or greater implied high risk (sensitivity 77.3%, specificity 73.3%, positive predictive value 68%, negative predictive value 81.5%, accuracy 75%). Conclusions NAFLD is practically a constant in MO with a considerable proportion of patients presenting NASH. The combination of five independent predictors in a scoring system may help the clinician optimise the selection of patients with MO for LB.

Background Risk prediction models that estimate patient probabilities of adverse events are commonly deployed in bariatric surgery. The objective was to validate a machine learning (Super Learner) prediction model of 30-day readmission after bariatric surgery in comparison with a traditional logistic regression. Methods This prognostic study for validation of risk prediction models used data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Patients who underwent elective laparoscopic gastric bypass or laparoscopic sleeve gastrectomy between 2015 and 2018 were included. Models used 5-fold cross-validation and were evaluated using the area under the receiver operating characteristic curve, the net reclassification index, and the integrated discrimination improvement. Results The 30-day readmission rate among 393,833 patients was 3.9%. Super Learner area under the receiver operating characteristic curve was 0.674 (95% confidence interval 0.670–0.679), compared to 0.650 (95% confidence interval 0.645–0.654) for logistic regression. The net reclassification index was 0.239 (95% confidence interval 0.223–0.254), and 0.252 (95% confidence interval 0.249–0.255) for those who were and were not readmitted within 30 days. The integrated discrimination improvement was 0.0032 (95% confidence interval 0.0030–0.0033). Conclusion The Super Learner outperformed traditional logistic regression in predicting risk of 30-day readmission after bariatric surgery. Machine learning models may help target high-risk patients more optimally and prevent unnecessary readmissions.

Background: Approximately 25% of patients after bariatric surgery either do not lose enough weight or regain a considerable amount of weight, both are referred to as nonresponse. This study aimed to describe the added value of a multidisciplinary approach on treatment strategies in patients with nonresponse.Materials and Methods: The primary outcome of this retrospective cohort study was the initiated treatment by the multidisciplinary team (MDT). Outcomes were described separately for patients with primary (i.e., = 50% EWL followed by >5% regain).Results: Of the 83 included patients, 10 patients underwent revisional surgery. A total of 73 patients received a conservative treatment as they either had not been able to change their lifestyle or due to certain behavioral factors. Conservatively treated patients stabilized in weight after 2 years (-0.9 kg +/- 5.8, n = 27), while surgically treated patients did lose weight (-12.1 kg +/- 16.9, n = 7). One patient suffered from an ulcerative stenosis at the gastroenterostomy after limb length alteration.Conclusions: a conservative treatment was the most frequently advocated treatment by the MDT. A surgical treatment resulted in successful weight loss, although only a few patients were selected for this by the MDT. A multidisciplinary approach can be beneficial for the identification of lifestyle and behavioral factors.

In a patient with a history of bariatric surgery, severe copper deficiency presenting with macrocytic hyperregenerative anaemia was diagnosed. Besides the impaired intestinal absorption due to a short bowel syndrome, the enteral zinc supplementation competitively decreased the intestinal copper uptake. Once the zinc supplementation was stopped, enteral copper replacement ensued and normalised haemoglobin levels with decreasing median corpuscular volume were observed during follow-up visits.

Objective: To investigate whether patients’ psychological well-being (depression, quality of life, body image satisfaction) and functioning (self-efficacy for eating and exercising behaviours and food cravings) improve 12 months after bariatric surgery and whether self-compassion is associated with better psychological outcomes and lower weight after bariatric surgery. Design: Longitudinal, prospective observational study. Methods: Bariatric patients (n = 126, 77.8% female, 46.4 ± 10.8 years) completed the Self-compassion Scale, Center for Epidemiology Studies Depression Scale, Impact of Weight on Quality-of-Life questionnaire, Body Image Scale, Weight Efficacy Lifestyle Questionnaire, Spinal Cord Injury Exercise Self-Efficacy Scale, and G-Food Craving Questionnaire pre-operatively and 12 months post-operatively. A medical professional measured patients’ weight during each assessment. Data were analysed using repeated measures t-tests and multivariate regression analyses with Benjamini–Hochberg correction for multiple testing. Results: Patients’ BMI, depression, and food cravings decreased significantly after surgery while quality of life, body image satisfaction, and self-efficacy to exercise improved. Higher self-compassion was associated with lower post-operative depression, greater quality of life, higher body image satisfaction, and better self-efficacy for eating behaviours (p-values

Objective Obesity is globally recognized as a critically important disease by professional medical organizations in addition to the World Health Organization and American Medical Association, but the health care systems, medical teams, and the public have been slow to embrace this concept. Methods American Association of Clinical Endocrinology (AACE) staff drafted the survey, and two endocrinologists independently reviewed the survey questions and modified the survey instrument. The survey included inquiries related to practice and patient demographics, awareness of obesity, treatment of obesity, barriers to improving obesity outcomes, digital health, cognitive behavioral therapy, lifestyle medicine, anti-obesity medications, weight stigma, and social determinants of health. The survey was emailed to 493 endocrinologists, with 305 completing the study (62%). Results Ninety-eight percent of the responders agree that obesity is a disease, while 2% neither agree nor disagree. 53% of respondents are familiar with the term "adiposity-based chronic disease." 13% of the respondents are certified by the American Board of Obesity Medicine (ABOM). 57% of the respondents use published obesity guidelines as a resource for treating patients with obesity. Most endocrinologists recommend dietary and lifestyle changes, but fewer prescribe anti-obesity medication (AOM) or recommend bariatric surgery. ABOM-certified endocrinologists are more likely to use a multidisciplinary approach. Conclusion Self-reported knowledge and practices in the management of obesity highlight the importance of a multimodal approach to obesity and foster collaboration among healthcare professionals. It is necessary to raise awareness about obesity among clinicians, identify knowledge gaps and create educational tools to address those gaps.

Obesity and its associated comorbidities are rapidly increasing in the US population. Therefore, metabolic associated fatty liver disease (MAFLD), previously known as nonalcoholic fatty liver disease (NAFLD), has become a leading indication for liver transplantation. Lifestyle modifications as a sole therapy have been insufficient to reduce the burden of chronic liver disease secondary to MAFLD. Endoscopic bariatric interventions (EBI) appear to be safe and effective therapies for obesity and chronic liver disease secondary to MAFLD. Gastric EBI include endoscopic sleeve gastroplasty (ESG) and intragastric balloons (IGB). Small bowel EBI are also evolving in the field of bariatric endoscopy.

Background Small bowel obstruction (SBO) is a late complication of Roux-en-Y gastric bypass (RYGB). In non-pregnant patients, computed tomography (CT) is the first choice of imaging. During pregnancy, magnetic resonance imaging (MRI) is preferred to limit exposure to ionizing radiation. However, literature regarding the diagnostic accuracy of MRI for SBO is scarce. Objective To describe the diagnostic accuracy of MRI for SBO during pregnancy. Methods Pregnant women with RYGB suspected for SBO who presented at our center between September 2015 and April 2020 and who received an MRI scan (index) and underwent surgery (reference) were included. Original reports were retrospectively evaluated. Available MRI scans were structurally reinterpreted by two experienced radiologists. Statistical analysis included sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and Cohen's kappa. Results Twenty-seven original MRI reports were included. Twenty-four (89%) MRIs were of good quality. Sensitivity was 67% (confidence interval (CI) 0.43-0.85), specificity 67% (CI 0.13-0.98), PPV 93% (CI 0.66-0.99), and NPV 22% (CI 0.04-0.60). MRI was unable to detect SBO in 1 out of 3 patients. The presence of swirl sign, SBO sign, or clustered loop sign increases the likelihood of SBO. The interobserver agreement was overall wide, with the highest score for swirl sign (κ 0.762). Discussion MRI is a safe and feasible alternative for CT. The value is doubtful as diagnostic accuracy shows wide ranges with considerable variability in the interobserver agreement. We would cautiously advise to perform MRI in case of a mild clinical presentation, but in case of a severe clinic, the diagnostic laparoscopy should remain the gold standard.

Background Obese individuals are thought to be higher risk for complications after excisional abdominal body contouring (EAC) due to co-morbidities and significant tissue resection. Objectives We comparatively analyzed EAC patients with Body Mass Index (BMI) ≥35 kg/m2 and BMI Methods Patients ≥18 years-old undergoing EAC by a single surgeon from 01/2018-01/2020 were identified and separated into cohorts based on BMI ( Results 70 total patients with median BMIs of 30[26-32] and 41[37-45] kg/m2 in each cohort, were identified. Patients with BMI ≥35 kg/m2 were more likely to have higher ASA (P 0.05) between cohorts. Multivariate logistic regression showed that BMI ≥35 kg/m2, iNPWD and liposuction were not associated with the development of complications. PROs demonstrated improvement in multiple domains despite BMI. Conclusion There was no association with BMI ≥35 kg/m2 and the development of complications within our cohort. We encourage preoperative weight loss when possible, however these procedures can be performed safely with acceptable outcomes even in individuals who are obese and/or require extensive tissue removal.

BACKGROUND: Research shows that surgery patients who have undergone Roux-en-Y gastric bypass (RYGB) are at increased risk for an alcohol use disorder (AUD). However, the mechanisms through which this increased risk is incurred are poorly understood. A host of variables have been proposed as potentially causal in developing AUDs, but empirical examination of many of these variables in human samples is lacking. OBJECTIVES: Our objective was to examine the extent to which alcohol pharmacokinetics (PK), the rewarding effects of alcohol, and the relationship between these variables change from before to after weight loss surgery. SETTING: Large healthcare facility in the Midwest United States METHODS: Thirty-four participants completed assessments prior to, and one year after, RYGB. They completed laboratory sessions and provided data on the PK of alcohol and the extent to which alcohol was reinforcing to them at each timepoint. RESULTS: Findings show that the PK effects of alcohol (p

Background The prevalence of obesity in type I diabetes mellitus has been increasing over the past decades. Multiple studies have demonstrated suboptimal outcomes with dietary control and medical management for obesity and diabetes mellitus type II. This study's objective was to evaluate insulin and diabetic medication requirements in patients with type I diabetes mellitus two years after bariatric surgery. Methods This was a retrospective chart review study from 2002-2019 at Geisinger health system. Of 4549 total bariatric surgeries, 38 bariatric surgery patients were confirmed to have type I diabetes mellitus. Type I diabetes mellitus was confirmed by chart review and/or presence of c-peptide Results The patient cohort had a mean age of 41 years, with 87% being female. The mean BMI was 43.0, with a mean Hb A1c of 8.4% before surgery. During follow-up the insulin requirements improved from 114 units preoperatively to 60 units at 1 year postoperatively (SD= 54.5, p= 0.0018) and 60 units at 2-years postoperatively (SD= 60.3, p= 0.0033). Though not significant, the number of patients on more than one diabetic medication decreased from 66% preoperatively to 53% 1-year postoperatively (p=0.343) and 52% at 2-years (p=0.149). Discussion This study demonstrated significant improvement in the insulin and the total number of diabetic medication requirements after bariatric surgery, suggesting that bariatric surgery may be a viable treatment within patients that have type I diabetes mellitus.

Background Obesity is considered a major cardiovascular risk factor. The excess of pericardial fat (PF) in patients with obesity has been associated with a variety of electrocardiographic alterations. In previous studies, we demonstrated that rapid weight loss and bariatric interventions result in decreased PF. Objectives The aim of this study is to report the changes in PF after bariatric surgery and its effect on ventricular conduction. Setting US hospital, academic institution. Methods A linear measurement of PF thickness on computed tomography scans was obtained for 81 patients, as well as a retrospective review of electrocardiographic changes before and after bariatric surgery. We compared the changes in PF thickness and electrocardiographic components before and after procedures. Common demographics and co-morbidities were collected along with lipid profiles preoperative and postoperative. Results A total of 81 patients had electrocardiograms done before and 1 year after bariatric surgery. Females comprised 67.9% (n = 55), and the average age for our population was 55.07 ± 14.17 years. Pericardial fat thickness before surgery was 5.6 ± 1.84 and 4.5 ± 1.62 mm after surgery (P = .0001). Ventricular conduction (QT and QT corrected [QTc] intervals) showed a significant improvement from 438.7 + 29 before to 426.8 + 25.3 after bariatric surgery (P = .006). We found a statistically significant association between the decrease in PF and the decrease in QTc intervals (P = .002). Conclusion Obesity is a risk factor for arrhythmias and sudden cardiac death. Bariatric surgery and its effect on PF produce an improvement in ventricular conduction, which may reduce the ventricular electrical instability in patients with obesity.

Background With a growing bariatric population, a better understanding of the patient and health provider-related factors associated with later reoperations could help providers enhance follow-up and develop reliable benchmarking targets. Objectives To investigate the patient and provider-related risk factors associated with abdominal reoperations in bariatric patients. Setting This is a cohort study using data from a large clinical registry of Ontario bariatric patients between 2010 and 2016. Methods A multilevel mixed effect logistic regression model using hospital and surgeon identifiers as random effects was performed to adjust for clustering of patients. The primary outcome was any abdominal operation performed within 2 years of primary bariatric surgery. Results Among a cohort of 10,946 bariatric patients (86.6% receiving gastric bypass surgery), 15.8% underwent an abdominal operation within 2 years and about a third of these were urgent. The multilevel analysis demonstrated that 98% of patient variation among reoperations was a result of patient characteristics rather than disparities between surgeons or center experience. Type of procedure was not a significant factor after adjustment for surgeon and hospital level experience (OR [odds ratio] .85, 95% CI [confidence interval] .70-1.03). Concurrent abdominal wall (OR 2.40, 95% CI 1.26-4.59), hiatal hernia repairs (OR 1.29, 95% CI 1.02-1.62), and previously higher health care users (OR 1.30, 95% CI 1.15-1.46) were most significantly associated with reoperations. Conclusion Reoperations are significantly more common among certain bariatric patients, especially those undergoing concurrent hernia procedures. Reoperations were not associated with provider-related factors and may not be a suitable target for health provider benchmarking.

Background Rapid weight loss after bariatric surgery is a risk factor for gallstone formation. There are different strategies regarding its management in bariatric patients, including prophylactic cholecystectomy (CCE) in all patients, concomitant CCE only in symptomatic patients, or concomitant CCE in all patients with known gallstones. We present the safety and long-term results of the last concept. Method Retrospective single-center analysis of a prospective database on perioperative and long-term results of patients with laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) over a 15-year period. The minimal follow-up was 24 months. Concomitant CCE was intended for all patients with gallstones detected by preoperative sonography. Setting Academic teaching hospital in Switzerland. Results After exclusion of patients with a history of CCE (11.5%), a total of 1174 patients (69.6% LRYGB, 30.4% LSG) were included in the final analysis. Preoperative gallbladder pathology was detected in 21.2% of patients, of whom 98.4%, or 20.9% of the total patients, received a concomitant CCE. The additional procedure prolonged the average operation time by 38 minutes (not significant) and did not increase the complication rate compared with bariatric procedure without CCE (3.7% versus 5.7%, P = .26). No complication was directly linked to the CCE. Postoperative symptomatic gallbladder disease was observed in 9.3% of patients (LRYGB 7.0% versus LSG 2.3%, P = .15), with 19.8% of those patients initially presenting with a complication. Conclusion The concept of concomitant CCE in primary bariatric patients with gallstones was feasible and safe. Nevertheless, 9.3% of primary gallstone-free patients developed postoperative symptomatic gallbladder disease and required subsequent CCE despite routine ursodeoxycholic acid prophylaxis.

Background Spinal epidural lipomatosis (SEL) is characterized by symptomatic neurogenic compression from adipose tissue in the spinal canal. The question arises whether patients with morbid obesity have higher volumes of epidural adipose tissue (EAT) in their lumbar spinal canal compared to patients with a normal weight and to which extent this decreases after bariatric surgery. Methods In this explorative study the lumbar EAT volume was assessed in 25 patients with morbid obesity (Body Mass Index (BMI)>40) using available lumbar magnetic resonance imaging (MRI) prior to their bariatric surgery. An age and gender matched control group (n=25) of patients with a normal weight (BMI 20-25) was used for comparison. Participants from the obesity group underwent a post-operative control MRI. Results The mean volume of EAT per MRI-slice of the group of patients with obesity was significantly higher than for the group of patients with normal weight (mean 83.3 mm3 ± 30.7 versus mean 56.5 mm3 ± 25; p Conclusions Patients with obesity have significantly larger volumes of EAT in comparison to patients with normal weight. After bariatric surgery, a significant weight loss coincided with a significant volumetric reduction of this adipose tissue in the spinal canal. Future prospective studies in patients with symptomatic SEL may elucidate whether decreases in EAT volume influence concurrent neurogenic claudication symptoms.

Background The increase in obesity has become a major public health concern. Morbid obesity is associated with co-morbidities, reduced quality-of-life, and death. Metabolic surgery (MS) is the most effective treatment for obesity. Objectives The aim of this study was to evaluate the costs and outcomes of MS compared with no surgery in patients with a body mass index ≥30 kg/m2. Setting Health care system, Austria Methods A total of 177 patients who underwent MS were documented retrospectively, based on the hospital records of 2 specialized centers in Austria, over a 1-year period. At baseline 26.0% of patients exhibited type 2 diabetes (T2D), 52.5% cardiovascular disease (CVD), 23.2% hyperlipidemia, and 23.7% depression. Following the observation period, a Markov chain simulation model was developed to analyze the long-term consequences of T2D, including diabetic complications, CVD, hyperlipidemia, depression, non-alcoholic steatohepatitis (NASH), myocardial infarction, and stroke, over a total of 20 years. Direct medical costs were expressed in 2017 euros from the payer’s perspective. Quality-adjusted life years (QALYs), life years (LYs), and costs were discounted. Results MS led to costs of €40,427 and 9.58 QALYs (15.58 LYs) per patient over 20 years. No MS was associated with €64,819 and 6.33 QALYs (13.92 LYs). Total cost-savings amounted to €24,392, which offset the cost of the procedure including re-operations. Over 20 years MS saved –6.7 patient-years per patient with T2D, –5.8 patient-years with CVD, –1.5 patient-years with hyperlipidemia, –1.8 patient-years with depression, and –3.8 patient-years with NASH. Conclusion MS is associated with substantial savings in long-term costs, expected health benefits, and reduced onset of complications. MS significantly increases quality of life.

Background Bariatric surgery is the most effective treatment for patients with severe obesity, but success rates vary substantially. Exercise is recommended after bariatric surgery to reduce weight regain but the effectiveness remains undetermined on weight loss due to conflicting results. It is also unclear what should be the optimal exercise prescription for these patients. A systematic review and meta‐analysis of randomized controlled trials on the effects of exercise on body weight (BW), anthropometric measures, and body composition after bariatric surgery was performed. Methods PubMed/MEDLINE®, EBSCO®, Web of Science® and Scopus® databases were searched to identify studies evaluating exercise effectiveness. Results The analysis comprised 10 studies (n = 487 participants). Exercise favored BW (−2.51kg; p = 0.02), waist circumference (−4.14cm; p = 0.04) and body mass index (−0.84kg·m−2; p = 0.02) reduction but no improvements in body composition. Combined exercise interventions were the most effective in reducing BW (−5.50kg; p 6‐months after bariatric surgery were more successful in reducing BW (−5.02kg; p 6‐months after bariatric surgery were effective in promoting BW, waist circumference and body mass index reduction. Exercise following bariatric surgery does not seem to favor body composition improvements.

Background Biliopancreatic diversion with duodenal switch (BPD/DS) is a procedure that has long been considered to have a higher early postoperative morbidity than Roux-En-Y gastric bypass (RYGB). However, patients who undergo BPD/DS have more baseline co-morbidities that may affect the reported early postoperative morbidity. Objective To compare 30-day postoperative morbidity and mortality between BPD/DS and RYGB propensity score-matched cohorts obtained from the MBSAQIP database. Setting Analysis of data obtained from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Methods Retrospective analysis of 21-variable propensity score-matched patients in the BPD/DS and RYGB groups obtained from the MBSAQIP database between 2015 and 2019. Variables included age, sex, body mass index, American Society of Anesthesiologists (ASA) class, and pertinent medical co-morbidities. Data were analyzed for 30-day postoperative morbidity, mortality, reoperation, reintervention, and readmissions. Results Before matching, RYGB and BPD/DS cohorts contained 134 188 and 5079 patients, respectively. After multivariable propensity score matching, each cohort contained 5050 patients. The RYGB group had a higher rate of surgical-site infections than the BPD/DS group (1% versus .5%, P = .007) and a higher rate of blood product transfusions (1.1% versus .6%, P = .018). The rate of other early postoperative complications was similar between the 2 groups (P > .05). There was no statistically significant difference in the 30-day mortality, readmission rate, reoperation rate, or reintervention rate between the 2 groups (P > .05). Conclusion When matched for baseline body mass index and co-morbidities, BPD/DS does not lead to a higher 30-day postoperative morbidity and mortality than RYGB. Patients can be counseled that in the short term, BPD/DS is as safe as RYGB.

Metabolic and bariatric surgery helps women achieve a healthier weight, reduce co-morbid conditions, increase fertility rates, and improve pregnancy outcomes compared with counterparts who are obese. Breastfeeding is known to provide both infant and maternal health benefits as well. Less is known about the impact of bariatric surgery on breastfeeding. The objective of this study was to review the impact of bariatric surgery on breastfeeding following the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. PubMed and Medline databases were searched using terms such as “bariatric surgery,” “postnatal care,” “lactation,” and “breastfeeding.” Reference lists were also used to find relevant articles. A total of 49 records were identified. Abstracts were screened, and 11 observational studies were identified after meeting inclusion criteria, which included the use of original research on breastfeeding and women who have had bariatric surgery. The available research shows that breast milk after bariatric surgery is adequate in nutrients and that no long-term effects were reported in cases studies when nutrient deficiencies were corrected. Limitations include observational study design and small sample sizes. This systematic review suggests that breastfeeding after bariatric surgery should be recommended along with monitoring and micronutrient supplementation. However, additional research and increased sample sizes are needed to further examine the relationship, and such studies should be conducted to strengthen the evidence and explore ways to improve breastfeeding rates in this population.

Background Bariatric surgery outcomes in elderly patients have been shown to be safe, but with a higher rate of adverse outcomes compared with nonelderly patients. The impact of race on bariatric surgery outcomes continues to be explored, with recent studies showing higher rates of adverse outcomes in black patients. Perioperative outcomes in racial cohorts of elderly bariatric patients are largely unexplored. Objective The goal of this study was to compare outcomes between elderly non-Hispanic black (NHB) and non-Hispanic white (NHW) bariatric surgery patients to determine whether outcomes are mediated by race. Setting Academic hospital. Methods Patients who had a primary Roux-en-Y (RYGB) and sleeve gastrectomy (SG) in the period 2015-2018 and were at least 65 years of age were identified from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Participant Use Data File (MBSAQIP PUF). Selected cases were stratified by race. Outcomes were compared between matched racial cohorts. Multivariate regression analyses were performed to determine whether race independently predicted morbidity. Results From 2015 to 2018, 29,394 elderly NHW (90.8%) and NHB (9.2%) patients underwent an RYGB or SG. At baseline, NHB elderly patients had a higher burden of co-morbid conditions, resulting in higher rates of overall (7.7% versus 6.4%, P = .009) and bariatric-related (5.4% versus 4.1%, P = .001) morbidity. All outcome measures were similar between propensity-score-matched racial elderly bariatric patient cohorts. On regression analysis, NHB race remained independently correlated with morbidity (odds ratio [OR] 1.3, 95% CI 1.08-1.47, P = .003). Conclusion RYGB and SG are safe in elderly patient cohorts, with no differences in adverse outcomes between NHB and NHW patients, accounting for confounding factors. While race does not appear to impact outcomes in the elderly cohorts, NHB race may play a role in access.