Response to Sleeve gastrectomy may double the risk of esophageal adenocarcinoma in morbidly obese patients

We would like to thank Papadia et al. for their interest in our article, “Esophageal Adenocarcinoma After Sleeve Gastrectomy: Actual or Potential Threat? Italian Series and Literature Review” [1]. We also greatly appreciated their attempt at evaluating the relative risk (RR) of developing esophageal adenocarcinoma (EAC) in patients who undergo sleeve gastrectomy (SG). To do so, they extrapolated the reported number of SGs performed in Italy over the 3-year period (2012–2015) in which the EAC cases belonging to our series occurred. Papadia et al. [1] show how SG may raise the risk of developing EAC by an estimated 11-fold compared with the general population. Furthermore, they highlight how the RR of EAC in the SG subpopulation appears to be substantially greater compared with patients affected by morbid obesity (RR of 11.9 versus 4.8, respectively). The authors also share our concern regarding the young age (40.3 ± 16.7 yr) and early presentation (27.3 ± 7.6 mo) of EAC after surgery, pointing out how the progression from a normal esophageal mucosa to Barrett’s esophagus (BE) generally befalls over a considerably longer timeframe in patients with GERD that did not have SG. This observation is supported by several studies published by our group demonstrating how the incidence of BE, 58 months after SG, is as high as 17.2%—consistent with other reported rates (i.e., 15%–18.8%) [2,3]—and is correlated to the increased presence of a biliary-type refluxate [[4], [5], [6]], likely to be responsible for the accelerated mucosal injury of the distal esophagus [7]. Emblematic is the case reported in literature of the patient who had a preoperatively diagnosed short-segment BE and who inevitably developed an EAC 36 months later [8]. Although a sporadically reported case, this further emphasizes not only the importance of performing a preoperative esophagogastroduodenoscopy (EGD) to detect any mucosal lesion, but also how BE should constitute an absolute contraindication to SG due to its innate risk of malignant evolution. Finally, loss to follow-up still represents a major, long-standing issue after bariatric surgery, which contributes to precluding the chance of performing protocols of secondary prevention for the identification of any esophageal malignancy at its earliest stages. To this regard, close endoscopic surveillance is of paramount importance for a prompt detection. We also would like to reiterate the necessity of having international online registries, which could allow physicians to determine the actual incidence of EAC after SG and to comprehend its pathogenesis, management, and outcomes possibly better. Despite this potential downside, SG persists as a safe and effective procedure for the cure of obesity and its co-morbid conditions, concurrently carrying low rates of long-term complications and nutritional deficiencies. Additionally, due to its greater technical simplicity and shorter operative time compared with other common bariatric procedures, SG is also the treatment of choice in the super-obese group, easily granting the option for revisional surgery (i.e., RYGB, one anastomosis gastric bypass [OAGB], duodenal switch [DS], single anastomosis duodeno-ileal sleeve [SADI-S]) in case of weight regain or insufficient weight loss. Hence, SG should yet be regarded as a fundamental and valuable bariatric operation to be performed after a thorough preoperative workup and a close endoscopic follow up

Esophageal adenocarcinoma after sleeve gastrectomy. Actual or potential threat? Italian series and literature review

Background:Sleeve gastrectomy (SG) leads to esophageal mucosal damage in an elevated percent-age of cases, configuring a clinical condition of Barrett’s esophagus (BE) in a proportion as high as15–18.8%. BE may rarely evolve into esophageal adenocarcinoma (EAC).Objectives:To raise awareness of BE as a precancerous lesion which may progress toward malig-nancy after this popular bariatric procedure.Setting:Bariatric referral centers, Italy.Methods:All patients referred to our bariatric center who developed an EAC after SG between 2012and 2019 were reviewed and consecutively included in this study. The available scientific literatureregarding this complication is additionally reviewed.Results:The 3 male patients comprised in this case series underwent laparoscopic SG between 2012and 2015 in different bariatric referral centers. Age and body mass index at baseline ranged from 21–54 years and 43.1–75.6 kg/m2, respectively. All patients were lost to follow-up early after surgery (3.761.4 months), and were diagnosed with EAC at a mean of 27.367.6 months after SG. The 4 re-ported cases in the scientific literature developed an EAC at a mean of 32.5623 months fromSG. Overall, a diagnosis of EAC was made approximately 30.3617.1 months postoperatively, whichseems relatively and worryingly early after surgery. Conclusion:Although the rate and probability of progression from BE to EAC is still not well defined,assuming that the rising popularity and execution of SG leads to a growth in the BE incidence, then thepreoperative identification and stratification of cancer risk factors in this subset of patients is stronglyencouraged. Clinical and endoscopic follow-ups are essential to allow for prevention and early diag-nosis and for epidemiologic data collection purposes

Very-Low-Calorie Ketogenic Diets with Whey, Vegetable or Animal Protein in Patients with Obesity: A Randomized Pilot Study

Context We compared the efficacy, safety and effect of 45-day isocaloric very-low-calorie ketogenic diets (VLCKDs) incorporating whey, vegetable or animal protein on the microbiota in patients with obesity and insulin resistance to test the hypothesis that protein source may modulate the response to VLCKD interventions. Subjects and Methods Forty-eight patients with obesity [19 males and 29 females, HOMA index ≥ 2.5, age 56.2±6.1 years, body mass index (BMI) 35.9±4.1 kg/m2] were randomly assigned to three 45-day isocaloric VLCKD regimens (≤800 kcal/day) containing whey, plant or animal protein. Anthropometric indexes; blood and urine chemistry, including parameters of kidney, liver, glucose and lipid metabolism; body composition; muscle strength; and taxonomic composition of the gut microbiome were assessed. Adverse events were also recorded. Results Body weight, BMI, blood pressure, waist circumference, HOMA index, insulin, and total and LDL cholesterol decreased in all patients. Patients who consumed whey protein had a more pronounced improvement in muscle strength. The markers of renal function worsened slightly in the animal protein group. A decrease in the relative abundance of Firmicutes and an increase in Bacteroidetes were observed after the consumption of VLCKDs. This pattern was less pronounced in patients consuming animal protein. Conclusions VLCKDs led to significant weight loss and a striking improvement in metabolic parameters over a 45-day period. VLCKDs based on whey or vegetable protein have a safer profile and result in a healthier microbiota composition than those containing animal proteins. VLCKDs incorporating whey protein are more effective in maintaining muscle performance

Predictors of weight loss in patients with obesity treated with a Very Low-Calorie Ketogenic Diet

IntroductionThe Very Low-Calorie Ketogenic Diet (VLCKD) has emerged as a safe and effective intervention for the management of metabolic disease. Studies examining weight loss predictors are scarce and none has investigated such factors upon VLCKD treatment. Among the molecules involved in energy homeostasis and, more specifically, in metabolic changes induced by ketogenic diets, Fibroblast Growth Factor 21 (FGF21) is a hepatokine with physiology that is still unclear.MethodsWe evaluated the impact of a VLCKD on weight loss and metabolic parameters and assessed weight loss predictors, including FGF21. VLCKD is a severely restricted diet (<800 Kcal/die), characterized by a very low carbohydrate intake (<50 g/day), 1.2–1.5 g protein/kg of ideal body weight and 15–30 g of fat/day. We treated 34 patients with obesity with a VLCKD for 45 days. Anthropometric parameters, body composition, and blood and urine chemistry were measured before and after treatment.ResultsWe found a significant improvement in body weight and composition and most metabolic parameters. Circulating FGF21 decreased significantly after the VLCKD [194.0 (137.6–284.6) to 167.8 (90.9–281.5) p < 0.001] and greater weight loss was predicted by lower baseline FGF21 (Beta = −0.410; p = 0.012), male sex (Beta = 0.472; p = 0.011), and central obesity (Beta = 0.481; p = 0.005).DiscussionVLCKD is a safe and effective treatment for obesity and obesity related metabolic derangements. Men with central obesity and lower circulating FGF21 may benefit more than others in terms of weight loss obtained following this diet. Further studies investigating whether this is specific to this diet or to any caloric restriction are warranted

Intragastric occupying space devices

In 2016, 39% of adults were overweight, and about 13% of the world’s adult population were obese. Obesity represents a growing global public health despite the availability of diet and lifestyle counseling, pharmacologic therapy, and bariatric surgery. Endoscopic bariatric therapies (EBTs) encompass a wide range of devices requiring flexible endoscopy for placement or removal and procedures performed via flexible endoscopy for the treatment of obesity. Current primary EBTs can be classified as space-occupying or non-space-occupying devices (restrictive, bypass, or aspiration therapy). Intragastric balloons (IBG) act as space-occupying devices, reducing stomach capacity and inducing satiety by several mechanisms. To date, ORBERA® Intragastric Balloon System, RESHAPE DUO Intragastric Balloon, and OBALON Balloon System are approved by the US Food and Drug Administration (FDA) based on demonstrated safety and efficacy in randomized controlled trials (RCTs). Two other balloons are currently under FDA investigation: the Spatz Adjustable (Spatz Medical, Great Neck, NY) and the Elipse Balloon (Allurion, Natick, MA). TransPyloric Shuttle consists of two bulbs connected by a flexible silicone tether which facilitates partial gastric obstruction resulting in delayed gastric emptying and early satiety. Space-occupying devices represent a good therapeutic option in the treatment of morbid patients, above all if used as obesity prevention tool. Some of those devices need to demonstrate greater reliability in terms of safety