Analysis of the Variability in Different Criteria to Define the Success of Bariatric Surgery : Retrospective Study 5-Year Follow-Up after Sleeve Gastrectomy and Roux-en-Y Gastric Bypass

(1) Background: The current criteria for defining good or bad responders to bariatric surgery based on the percentage of weight loss do not properly reflect the therapeutic impact of the main bariatric techniques. At present there is an urgent need to fill this gap and provide scientific evidence that better define the success or failure of bariatric surgery in the long term. (2) Methods: This is a retrospective database study of a prospective cohort with 5-year follow-up. We established the success or failure of bariatric surgery in terms of weight loss according to a selected criterion: (1) Halverson and Koehler; (2) Reinhold modified by Christou; (3) Biron; (4) TWL > 20%; (5) percentage of changeable weight (AWL > 35%). We analyzed sensitivity and specificity for successful weight loss. (3) Results: 223 (38.7%) patients underwent sleeve gastrectomy (LSG) and 353 (61.2%) underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP). The success rates at 5 years are: EWL > 50% 464 (80%), Reinhold 436 (75.6%), Biron 530 (92%), TWL > 20% 493 (85.5%), AWL 35 were the most adequate criteria as their specificities and sensibility were far above >80%. (4) Conclusions: The present study shows how the different definitions of success or failure are inconsistent in relation to the outcomes of BS. However, there are some criteria that associate statistically significant differences for the resolution of comorbidities and show the highest sensitivity and specificity rates

Memory and strategic processing in first-degree relatives of obsessive compulsive patients

Background: the same executive dysfunctions and alterations in neuroimaging tests (both functional and structural) have been found in obsessive-compulsive patients and their first-degree relatives. These neurobiological findings are considered to be intermediate markers of the disease. The aim of our study was to assess verbal and non-verbal memory in unaffected first-degree relatives, in order to determine whether these neuropsychological functions constitute a new cognitive marker for obsessive-compulsive disorder (OCD). Method: recall and use of organizational strategies in verbal and non-verbal memory tasks were measured in 25 obsessive-compulsive patients, 25 unaffected first-degree relatives and 25 healthy volunteers. Results: first-degree relatives and healthy volunteers did not show differences on most measures of verbal memory. However, during the recall and processing of non-verbal information, deficits were found in first-degree relatives and patients compared with healthy volunteers. Conclusions: the presence of the same deficits in the execution of non-verbal memory tasks in OCD patients and unaffected first-degree relatives suggests the influence of certain genetic and/or familial factors on this cognitive function in OCD and supports the hypothesis that deficits in non-verbal memory tasks could be considered as cognitive markers of the disorder

Role of adipose tissue GLP-1R expression in metabolic improvement after bariatric surgery in patients with type 2 diabetes

We aimed to explore the relationship between GLP-1 receptor (GLP-1R) expression in adipose tissue (AT) and incretin secretion, glucose homeostasis and weight loss, in patients with morbid obesity and type 2 diabetes undergoing bariatric surgery. RNA was extracted from subcutaneous (SAT) and visceral (VAT) AT biopsies from 40 patients randomized to metabolic gastric bypass, sleeve gastrectomy or greater curvature plication. Biochemical parameters, fasting plasma insulin, glucagon and area under the curve (AUC) of GLP-1 following a standard meal test were determined before and 1 year after bariatric surgery. GLP-1R expression was higher in VAT than in SAT. GLP-1R expression in VAT correlated with weight (r = -0.453, p = 0.008), waist circumference (r = -0.494, p = 0.004), plasma insulin (r = -0.466, p = 0.007), and systolic blood pressure (BP) (r = -0.410, p = 0.018). At 1 year, GLP-1R expression in VAT was negatively associated with diastolic BP (r = -0.361, p = 0.039) and, following metabolic gastric bypass, with the increase of GLP-1 AUC, (R-2 = 0.46, p = 0.038). Finally, GLP-1R in AT was similar independently of diabetes outcomes and was not associated with weight loss after surgery. Thus, GLP-1R expression in AT is of limited value to predict incretin response and does not play a role in metabolic outcomes after bariatric surgery

Principales medidas de profilaxis en endoscopia bariátrica. Guía Española de Recomendación de Expertos

Bariatric endoscopy (BE) encompasses a number of techniques -some consolidated, some under development- aiming to contribute to the management of obese patients and their associated metabolic diseases as a complement to dietary and lifestyle changes. To date different intragastric balloon models, suture systems, aspiration methods, substance injections and both gastric and duodenal malabsorptive devices have been developed, as well as endoscopic procedures for the revision of bariatric surgery. Their ongoing evolution conditions a gradual increase in the quantity and quality of scientific evidence about their effectiveness and safety. Despite this, scientific evidence remains inadequate to establish strong grades of recommendation allowing a unified perspective on prophylaxis in BE. This dearth of data conditions leads, in daily practice, to frequently extrapolate the measures that are used in bariatric surgery (BS) and/or in general therapeutic endoscopy. In this respect, this special article is intended to reach a consensus on the most common prophylactic measures we should apply in BE. The methodological design of this document was developed while attempting to comply with the following 5 phases: Phase 1: delimitation and scope of objectives, according to the GRADE Clinical Guidelines. Phase 2: setup of the Clinical Guide-developing Group: national experts, members of the Grupo Español de Endoscopia Bariátrica (GETTEMO, SEED), SEPD, and SECO, selecting 2 authors for each section. Phase 3: clinical question form (PICO): patients, intervention, comparison, outcomes. Phase 4: literature assessment and synthesis. Search for evidence and elaboration of recommendations. Based on the Oxford Centre for Evidence-Based Medicine classification, most evidence in this article will correspond to level 5 (expert opinions without explicit critical appraisal) and grade of recommendation C (favorable yet inconclusive recommendation) or D (inconclusive or inconsistent studies). Phase 5: External review by experts. We hope that these basic preventive measures will be of interest for daily practice, and may help prevent medical and/or legal conflicts for the benefit of patients, physicians, and BE in general

Lower gastrointestinal bleeding due to colonic fistula caused by a gossypiboma : Case report and literature review

Even in modern surgery, human mistakes cannot be totally avoided. Retained surgical items are among the most feared ones. Forgotten sponges inside patients can cause a wide range of complications due to the foreign body reaction, called gossypiboma. The incidence of gossypibomas in the literature is probably underreported due to its legal implications; however, we must know its consequences and highlight the importance of the prevention strategies. We present a case where only preventive measures would have avoided its fatal outcome. An 85-year-old male, previous left nephrectomy 12 years before, came to the emergency room with hematochezia and hemodynamic instability. An emergent angio-CT revealed a 12 cm mass due to a gossypiboma near the descending colon; the presence of air suggested an infection and/or fistulization to the bowel. It was decided not to perform invasive procedures, resulting in the patient's death. Gossypibomas can remain asymptomatic for years, being diagnosed when causing an obstruction, malabsorption, septic symptoms or even spontaneously. This may lead to high morbidity and mortality rates. In order to prevent it, different strategies have been described, with the objective to intensify surveillance. When diagnosed, laparotomy, laparoscopic and even endoscopic procedures have been performed successfully. We suggest putting all our efforts in identifying high risk patients and surgeries, training the OR team and enhancing protocols and checklists to minimize any preventable errors

Evaluation of bariatric surgery patients at the emergency department of a tertiary referral hospital

Objective: To describe the profile of the bariatric surgery patients that were admitted to the Emergency Department (ED). Method: A retrospective review of the reasons why bariatric surgery patients go to our ED. We analyzed the first 30 days after the surgery. We evaluated the number and indications of admissions, the examinations ordered, and final diagnosis and destination of the patients. Results: From January 2010 to July 2012, 320 patients underwent bariatric surgery at our Institution. Fifty three patients (16.6 %) were admitted to the ED at leas t once. We found 58 admissions (1.1 admissions by patient). Patients who had duodenal switch and Roux-en-Y gastric bypass were the most representative (74 %). The main indications for admission were abdominal pain (50 %), and problems related to the surgical wounds (22.4 %). Blood test was the most performed examination (75.9 %). The most frequent final diagnosis was unspecific abdominal pain in 27 cases (46.6 %), and complications of the surgical wound in 10 patients (17.2 %). Nineteen patients (35.84 %) were admitted to the surgical ward from the ED, and 5 of them required surgical revision (9.4 %). Multivariate analyses showed that the type of surgery was the only predictor variable for the ED admission. Conclusions: Attending ED after bariatric surgery is not common, and less than a third of the patients required hospital admission. Just a small percentage of the examinations showed any pathological value. Readmission rate is very low. Surgical procedure is the only predictor for ED admission

Principales medidas de profilaxis en endoscopia bariátrica. Guía Española de Recomendación de Expertos

Bariatric endoscopy (BE) encompasses a number of techniques -some consolidated, some under development- aiming to contribute to the management of obese patients and their associated metabolic diseases as a complement to dietary and lifestyle changes. To date different intragastric balloon models, suture systems, aspiration methods, substance injections and both gastric and duodenal malabsorptive devices have been developed, as well as endoscopic procedures for the revision of bariatric surgery. Their ongoing evolution conditions a gradual increase in the quantity and quality of scientific evidence about their effectiveness and safety. Despite this, scientific evidence remains inadequate to establish strong grades of recommendation allowing a unified perspective on prophylaxis in BE. This dearth of data conditions leads, in daily practice, to frequently extrapolate the measures that are used in bariatric surgery (BS) and/or in general therapeutic endoscopy. In this respect, this special article is intended to reach a consensus on the most common prophylactic measures we should apply in BE. The methodological design of this document was developed while attempting to comply with the following 5 phases: Phase 1: delimitation and scope of objectives, according to the GRADE Clinical Guidelines. Phase 2: setup of the Clinical Guide-developing Group: national experts, members of the Grupo Español de Endoscopia Bariátrica (GETTEMO, SEED), SEPD, and SECO, selecting 2 authors for each section. Phase 3: clinical question form (PICO): patients, intervention, comparison, outcomes. Phase 4: literature assessment and synthesis. Search for evidence and elaboration of recommendations. Based on the Oxford Centre for Evidence-Based Medicine classification, most evidence in this article will correspond to level 5 (expert opinions without explicit critical appraisal) and grade of recommendation C (favorable yet inconclusive recommendation) or D (inconclusive or inconsistent studies). Phase 5: External review by experts. We hope that these basic preventive measures will be of interest for daily practice, and may help prevent medical and/or legal conflicts for the benefit of patients, physicians, and BE in general

A multimodal MRI study of the neural mechanisms of emotion regulation impairment in women with obesity

Maladaptive emotion regulation contributes to overeating and impedes weight loss. Our study aimed to compare the voluntary downregulation of negative emotions by means of cognitive reappraisal in adult women with obesity (OB) and female healthy controls (HC) using a data-driven, multimodal magnetic resonance imaging (MRI) approach. Women with OB (n = 24) and HC (n = 25) carried out an emotion regulation task during functional MRI scanning. Seed-to-voxel resting-state connectivity patterns derived from activation peaks identified by this task were compared between groups. Diffusion tensor imaging (DTI) was used to examine white matter microstructure integrity between regions exhibiting group differences in resting-state functional connectivity. Participants in the OB group presented reduced activation in the ventromedial prefrontal (vmPFC) cortex in comparison to the HC group when downregulating negative emotions, along with heightened activation in the extrastriate visual cortex (p < 0.05, AlphaSim-corrected). Moreover, vmPFC peak activity levels during cognitive reappraisal were negatively correlated with self-reported difficulties in emotion regulation. OB patients exhibited decreased functional connectivity between the vmPFC and the temporal pole during rest (peak-pFWE = 0.039). Decreased fractional white-matter track volume in the uncinate fasciculus, which links these two regions, was also found in participants with OB. Taken together, our findings are indicative of emotion regulation deficits in OB being underpinned by dysfunctional hypoactivity in the vmPFC and hyperactivity in the extrastriate visual cortex. Our results provide a potential target circuit for neuromodulatory interventions to improve emotion regulation skills and weight-loss intervention outcomes