The management and survival outcomes of nasopharyngeal cancer in the Nordic countries

Peer reviewe

Morbidly Obese Patients—Who Undergoes Bariatric Surgery?

Treatment seeking patients with severe obesity might choose between specialized medical treatment and surgical treatment. Knowledge of what distinguishes patients that choose either treatment is sparse, with greater understanding also needed on what consequences this choice has for the prevalence, remission and new onset of comorbidities, as well as for the bioavailability of drugs. This has prompted the studies in Gunn Signe Jakobsen and her coauthors work on treatment seeking patients with severe obesity focusing on the prevalence of comorbidities, changes in the use of drugs for hypertension, diabetes and dyslipidaemia, as well as changes in bioavailability of atorvastatin. The methods used in the studies in the thesis; "Bariatric surgery and specialized medical treatment for severe obesity Impact on cardiovascular risk factors and postsurgical pharmacokinetics of atorvastatin "; are a cross-sectional study, a registry based cohort study and a prospective pharmacokinetic study. The results of the studies presented were: - The type and number of comorbidities associated with morbid obesity did not necessarily impact upon choice of treatment, but there was an increased odds for choosing surgery for patients with higher BMI, younger age and earlier onset of obesity. - Patients opting for bariatric surgery as opposed to specialized medical treatment had higher odds of experiencing remission, and significantly lower odds for new-onset of drug treated hypertension, diabetes and dyslipidaemia. Bariatric surgery seemed to not only induce remission but was also effective in preventing disease. - The bioavailability of atorvastatin was increased after bariatric surgery, with a normalization in the long term. This knowledge can give a better understanding of the population of patients seeking treatment for severe obesity and should be included in the shared decision process when helping the patient identify their preferences for treatment of severe obesity in the context of their values

Can medical therapy mimic the clinical efficacy or physiological effects of bariatric surgery?

The number of bariatric surgical procedures performed has increased dramatically. This review discusses the clinical and physiological changes, and in particular, the mechanisms behind weight loss and glycaemic improvements, observed following the gastric bypass, sleeve gastrectomy and gastric banding bariatric procedures. The review then examines how close we are to mimicking the clinical or physiological effects of surgery through less invasive and safer modern interventions that are currently available for clinical use. These include dietary interventions, orlistat, lorcaserin, phentermine/topiramate, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase-4 inhibitors, pramlintide, dapagliflozin, the duodenal–jejunal bypass liner, gastric pacemakers and gastric balloons. We conclude that, based on the most recent trials, we cannot fully mimic the clinical or physiological effects of surgery; however, we are getting closer. A ‘medical bypass' may not be as far in the future as we previously thought, as the physician's armamentarium against obesity and type 2 diabetes has recently got stronger through the use of specific dietary modifications, novel medical devices and pharmacotherapy. Novel therapeutic targets include not only appetite but also taste/food preferences, energy expenditure, gut microbiota, bile acid signalling, inflammation, preservation of β-cell function and hepatic glucose output, among others. Although there are no magic bullets, an integrated multimodal approach may yield success. Non-surgical interventions that mimic the metabolic benefits of bariatric surgery, with a reduced morbidity and mortality burden, remain tenable alternatives for patients and health-care professionals