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Background and Aims: Bariatric surgical options in obese patients include sleeve gastrectomy (SG) and roux-en-Y gastric bypass (RYGB), which may not be equivalent in risk of postoperative reflux symptoms. We evaluated risk and predictive factors for postbariatric surgery reflux symptoms., Methods: Patients with obesity evaluated for bariatric surgery over a 15-month period were prospectively followed with validated symptom questionnaires (GERDQ, dominant symptom index: product of symptom frequency and intensity from 5-point Likert scores) administered before and after SG and RYGB. Esophageal testing included high-resolution manometry in all patients, and ambulatory reflux monitoring off therapy in those with abnormal GERDQ or prior reflux history. Univariate comparisons and multivariable analysis were performed to determine if preoperative factors predicted postoperative reflux symptoms., Results: Sixty-four patients (median age 49.0 years, 84% female, median BMI 46.5 kg/m 2 ) fulfilled inclusion criteria and underwent follow-up assessment 4.4 years after bariatric surgery. Baseline GERDQ and dominant symptom index for heartburn were significantly higher in RYGB patients ( P ≤0.04). Despite this, median GERDQ increased by 2 (0.0 to 4.8) following SG and decreased by 0.5 (-1.0 to 5.0) following RYGB ( P =0.02). GERDQ became abnormal in 43.8% after SG and 18.8% after RYGB ( P =0.058); abnormal GERDQ improved in 12.5% and 37.5%, respectively ( P =0.041). In a model that included age, gender, BMI, acid exposure time, and type of surgery, multivariable analysis identified SG as an independent predictor of postoperative heartburn (odds ratio 16.61, P =0.024)., Conclusions: Despite preferential RYGB when preoperative GERD was identified, SG independently predicted worsening heartburn symptoms after bariatric surgery., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

BackgroundThe effects of diet-induced weight loss (WL) and WL after Roux-en-Y gastric bypass (RYGB) surgery on β cell function (BCF) are unclear because of conflicting results from different studies, presumably because of differences in the methods used to measure BCF, the amount of WL between treatment groups, and baseline BCF. We evaluated the effect of WL after RYGB surgery or reduced energy intake alone on BCF in people with obesity with and without type 2 diabetes.MethodsBCF (insulin secretion in relationship to plasma glucose) was assessed before and after glucose or mixed-meal ingestion before and after (a) progressive amounts (6%, 11%, 16%) of WL induced by a low-calorie diet (LCD) in people with obesity without diabetes, (b) ~20% WL after RYGB surgery or laparoscopic adjustable gastric banding (LAGB) in people with obesity without diabetes, and (c) ~20% WL after RYGB surgery or LCD alone in people with obesity and diabetes.ResultsDiet-induced progressive WL in people without diabetes progressively decreased BCF. Marked WL after LAGB or RYGB in people without diabetes did not alter BCF. Marked WL after LCD or RYGB in people with diabetes markedly increased BCF, without a difference between groups.ConclusionMarked WL increases BCF in people with obesity and diabetes but not in people with obesity without diabetes. The effect of RYGB-induced WL on BCF is not different from the effect of matched WL after LAGB or LCD alone.trial registrationNCT00981500, NCT02207777, NCT01299519.FundingNIH grants R01 DK037948, P30 DK056341, P30 DK020579, UL1 TR002345.

Background: The childhood obesity epidemic has grown exponentially and is known to disproportionately affect minority groups. Successful treatment of this complex health issue requires a multidisciplinary approach including metabolic and bariatric surgery (MBS) for qualifying pediatric patients. This study examines current national trends in pediatric bariatric surgery from 2010 to 2017 using the National Inpatient Sample., Methods: This study analyzed MBS among pediatric patients <19 years old using weighted discharge data from 2010 to 2017. The primary outcome was national procedure rates. Secondary analyses included procedure type, demographics, BMI, comorbidities, length of stay, and complication rates., Results: From 2010 to 2017, annual bariatric procedure rates increased from 2.29 to 4.62 per 100 000 (P < .001). Laparoscopic sleeve gastrectomy outpaced Roux-en-Y gastric bypass and laparoscopic adjustable gastric band over time (0.31-3.99 per 100 000, P < .0001). The mean age was stable over time 18.10-17.96 (P = .78). The cohort was primarily female (76.5% to 75.4%), white (54.0% to 45.0%), and privately-insured (59.9% to 53.4%). Preoperative BMI increased from 2010 to 2017 (P < .001), whereas number of obesity-related comorbidities was stable (P > .05). Length of stay was <2 days (2.02-1.75, P = .04) and in-hospital complication rates were low (7.2% to 6.45%, P = .88)., Conclusions: Pediatric MBS is underutilized nationally with disproportionately lower rates among minority groups. Despite incremental progress, further investigation into the racial and social determinants that limit access to pediatric weight loss surgery is critical., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: In the US, obesity continues to be a severe health issue now affecting adolescents. Bariatric surgery remains the most effective treatment for obesity, but use among adolescents remains low. The objective of this study was to identify current national trends in bariatric surgery among adolescents., Study Design: Using the Nationwide Inpatient Sample database, adolescents aged 9 to 19 with a diagnosis of morbid obesity who underwent a laparoscopic gastric bypass (Roux-en-Y gastric bypass) or laparoscopic sleeve gastrectomy (SG) between 2015 and 2018 were identified. Demographics, comorbidities, and in-hospital complications were collected. National estimates were calculated. The trend of annual number of operations was determined by Kruskal-Wallis rank test., Results: Between 2015 and 2018, 1,203 adolescents were identified, resulting in a nationwide estimate of 4,807 bariatric cases. The number of bariatric operations increased annually from 1,360 in 2015 to 1,740 operations in 2018 (p = 0.0771). The majority of patients were female (76%), 17 to 19 years old (84.1%), and White (47.9%). Most patients underwent SG (82.0%). Black and Hispanic patients comprised 40.2% of the cohort. Significant comorbidities included diabetes, dyslipidemia, nonalcoholic fatty liver disease, hypertension, and sleep apnea. The average length of stay decreased from 2.12 days to 1.64 days. There were no in-hospital mortalities, and complications were less than 1%., Conclusions: With the increasing prevalence of obesity among adolescents in the US, bariatric surgery increased over time but was performed less in patients younger than 16 years of age and racial minorities. Bariatric surgery among adolescents remains safe, with extremely low complication rates and zero in-hospital mortality., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Long-term durability of weight loss is a prerequisite for a greater acceptance of bariatric surgery., Objectives: To examine long-term weight trajectory in patients undergoing Roux-en-Y gastric bypass (RYGB) and determine factors predicting long-term follow-up and weight outcomes., Setting: University hospital., Methods: A retrospective cohort of adults who underwent RYGB during 1997-2010 were identified and followed until 2017. Predictors for attendance at periodic follow-up visits, reduction in body mass index (BMI), and percent excess BMI lost were determined using multivariable logistic regression and linear mixed-effects models. The latter was used to predict long-term weight outcomes for a typical patient., Results: The study included 1104 patients with a mean age of 45.5 (standard deviation [SD] 9.9) years and a preoperative BMI of 54.7 (SD 10.9) kg/m 2 . Follow-up data were available for 92.8% of the patients after 1 year, 50.0% after 5 years, and 35.2% after 10 years post-surgery. Black patients, compared with White patients, were less likely to attend follow-up visits. Attendance at follow-up visits at least every other year was not associated with larger weight loss, but higher preoperative BMI, being White (versus Black), and female sex were. Predicted BMI reduction for a typical patient, a 45-year-old White female with a preoperative BMI of 54.7 kg/m 2 and private health insurance, undergoing laparoscopic RYGB in 2004, was 18.3 (standard error [SE] .36) kg/m 2 at year 5 and 17.6 (SE .49) kg/m 2 at year 10., Conclusion: RYGB results in clinically significant and durable weight loss. Attendance at periodic follow-up visits does not appear to be associated with long-term weight loss outcomes. Future work should focus on strategies to remove barriers to post-operative care., (Copyright © 2021 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The role of robotic surgery in bariatrics remains controversial. Patient selection for robotic surgery is not well-studied. The objective of this study was to identify factors associated with robotic surgery and its temporal trends., Methods: The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database from 2015 to 2018 was used. Adult patients undergoing primary sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) using the laparoscopic or robotic approach were identified. Revisional, hybrid, or those with concomitant procedures were excluded. Logistic regression was conducted to identify factors associated with undergoing robotic-assisted surgery., Results: Among 211,568 patients who underwent SG, 9.1% underwent a robotic SG; among 76,805 patients who underwent RYGB, 7.9% of patients underwent a robotic RYGB. During 2015-2018, robotics increased from 7.1 to 11.3% for SG and 7.4 to 8.6% for RYGB. After controlling for patient characteristics, there was still an increasing trend in the use of robotic surgery: SG (multivariable-adjusted odds ratio, aOR, 1.18; 95% confidence interval, CI, 1.17-1.20) and RYGB (aOR, 1.05; 95% CI, 1.03-1.08). For both robotic SG and RYGB, functional status and African American race were associated with undergoing robotic surgery, while races other than White or African American and Hispanic ethnicity were not. Pre-operative IVC filter was associated with robotic SG, while the presence of GERD, diabetes, and COPD were associated with robotic RYGB., Conclusions: Robotic bariatric surgery has increased over time. Our findings identified factors associated with the receipt of robotic surgery. Reasons for these factors require further investigation to better delineate indications for this technology.

Introduction: Nephrolithiasis is common after malabsorptive bariatric surgery; however, the comparative risk of stone formation after different bariatric surgeries remains unclear. We seek to compare the risk of stone diagnosis and stone procedure after gastric banding (GB), sleeve gastrectomy (SG), short-limb Roux-en-Y (SLRY), long-limb Roux-en-Y (LLRY), and biliopancreatic diversion with duodenal switch (BPDDS). Patients and Methods: Using an administrative database, we retrospectively identified 116,304 patients in the United States, who received bariatric surgery between 2007 and 2014, did not have a known kidney stone diagnosis before surgery, and were enrolled in the database for at least 1 year before and after their bariatric surgery. We used diagnosis and procedural codes to identify comorbidities and events of interest. Our primary analysis was performed with extended Cox proportional hazards models using time to stone diagnosis and time to stone procedure as outcomes. Results: The adjusted hazard ratio of new stone diagnosis from 1 to 36 months, compared to GB, was 4.54 for BPDDS (95% confidence interval [CI] 3.66-5.62), 2.12 for LLRY (95% CI 1.74-2.58), 2.15 for SLRY (95% CI 2.02-2.29), and 1.35 for SG (95% CI 1.25-1.46). Similar results were observed for risk of stone diagnosis from 36 to 60 months, and for risk of stone removal procedure. Male sex was associated with an overall 1.63-fold increased risk of new stone diagnosis (95% CI 1.55-1.72). Conclusions: BPDDS was associated with a greater risk of stone diagnosis and stone procedures than SLRY and LLRY, which were associated with a greater risk than restrictive procedures. Nephrolithiasis is more common after more malabsorptive bariatric surgeries, with a much greater risk observed after BPDDS and for male patients.

Background: Postoperative nausea and vomiting (PONV) is known to occur after bariatric surgery, with over two thirds of patients affected. However, variability exists in how to objectively measure PONV., Objectives: The goals of the present study were to use a validated, patient-centered scoring tool, the Rhodes Index of Nausea, Vomiting, and Retching to measure the severity of PONV after bariatric surgery, to directly compare PONV between patients who underwent laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), and to identify risk factors for the development of PONV after bariatric surgery., Setting: Barnes-Jewish Hospital/Washington University School of Medicine, St. Louis, Missouri, United States of America., Methods: The Washington University Weight Loss Surgery team prospectively surveyed patients from January 1, 2017 to December 1, 2018 at the following 6 different timepoints: postoperative day (POD) 0, POD 1, POD 2, POD 3 to 4, the first postoperative outpatient visit (POV 1: POD 5-25), and the second postoperative visit (POV 2: POD 25-50). At each timepoint, a cumulative Rhodes score was calculated from the sum of 8 questions. The American Society for Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database was used to collect patient demographic characteristics and perioperative clinical data., Results: A total of 274 patients met study criteria and completed 605 Rhodes questionnaires. Two hundred fifty Rhodes questionnaires were completed by patients after SG and 355 were completed by patients after LRYGB. Total Rhodes scores are statistically higher in LSG patients compared with patients who underwent LRYGB (LSG = 5.45 ± 6.27; LRYGB = 3.08 ± 4.19, P = .0002). Additionally, at the earlier timepoints, scores were higher among patients who underwent LSG than those who had undergone LRYGB as follows: POD 0 (LSG = 6.96 ± 6.50; LRYGB = 2.89 ± 2.90, P = .0115), POD 1 (LSG = 8.20 ± 6.76; LRYGB = 2.88 ± 3.44, P < .0001), and POD 2 (LSG = 4.05 ± 4.88; LRYGB = 2.06 ± 3.43, P = .05). On subset analysis, examining patients who either underwent an LSG or LRYGB, both procedures had a statistically significant PONV peak emerge on POV 2. Last, overall Rhodes scores were statistically higher in female patients compared with male patients (female: 4.43 ± 5.46; male: 2.35 ± 3.90, P = .021). Although the magnitude of the difference varied somewhat across POD time intervals, the difference was most pronounced at POV 2., Conclusions: This is the largest study using a validated nausea and vomiting questionnaire to objectively measure PONV after bariatric surgery. The factors found to be most associated with increased PONV were LSG and female sex. Ultimately, these data can help bariatric surgery programs, including Washington University Weight Loss Surgery, identify patients who may require more intensive treatment of PONV, particularly POD 0 to 2, and help to identify patients that continue to struggle with PONV in the later surgical recovery phase., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Some studies have suggested that in people with type 2 diabetes, Roux-en-Y gastric bypass has therapeutic effects on metabolic function that are independent of weight loss., Methods: We evaluated metabolic regulators of glucose homeostasis before and after matched (approximately 18%) weight loss induced by gastric bypass (surgery group) or diet alone (diet group) in 22 patients with obesity and diabetes. The primary outcome was the change in hepatic insulin sensitivity, assessed by infusion of insulin at low rates (stages 1 and 2 of a 3-stage hyperinsulinemic euglycemic pancreatic clamp). Secondary outcomes were changes in muscle insulin sensitivity, beta-cell function, and 24-hour plasma glucose and insulin profiles., Results: Weight loss was associated with increases in mean suppression of glucose production from baseline, by 7.04 μmol per kilogram of fat-free mass per minute (95% confidence interval [CI], 4.74 to 9.33) in the diet group and by 7.02 μmol per kilogram of fat-free mass per minute (95% CI, 3.21 to 10.84) in the surgery group during clamp stage 1, and by 5.39 (95% CI, 2.44 to 8.34) and 5.37 (95% CI, 2.41 to 8.33) μmol per kilogram of fat-free mass per minute in the two groups, respectively, during clamp stage 2; there were no significant differences between the groups. Weight loss was associated with increased insulin-stimulated glucose disposal, from 30.5±15.9 to 61.6±13.0 μmol per kilogram of fat-free mass per minute in the diet group and from 29.4±12.6 to 54.5±10.4 μmol per kilogram of fat-free mass per minute in the surgery group; there was no significant difference between the groups. Weight loss increased beta-cell function (insulin secretion relative to insulin sensitivity) by 1.83 units (95% CI, 1.22 to 2.44) in the diet group and by 1.11 units (95% CI, 0.08 to 2.15) in the surgery group, with no significant difference between the groups, and it decreased the areas under the curve for 24-hour plasma glucose and insulin levels in both groups, with no significant difference between the groups. No major complications occurred in either group., Conclusions: In this study involving patients with obesity and type 2 diabetes, the metabolic benefits of gastric bypass surgery and diet were similar and were apparently related to weight loss itself, with no evident clinically important effects independent of weight loss. (Funded by the National Institutes of Health and others; ClinicalTrials.gov number, NCT02207777.)., (Copyright © 2020 Massachusetts Medical Society.)

Background: Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), the most common bariatric surgeries performed worldwide, increase the risk to develop an alcohol use disorder. This might be due, in part, to surgery-related changes in alcohol pharmacokinetics. Another risk factor, unexplored within this population, is having a reduced subjective response to alcohol's sedative effects., Objectives: To assess whether the alcohol sensitivity questionnaire (ASQ), a simple self-report measure, could pinpoint reduced alcohol sensitivity in the bariatric population., Setting: University medical centers in Missouri and Illinois., Methods: Women who had RYGB (n = 16), SG (n = 28), or laparoscopic adjustable gastric banding surgery (n = 11) within the last 5 years completed the ASQ for both pre- and postsurgical timeframes, and 45 of them participated in oral alcohol challenge testing postsurgery. Blood alcohol concentration (BAC) and subjective stimulation and sedation were measured before and for 3.5 hours after drinking., Results: In line with faster and higher peak BACs after RYGB and SG than laparoscopic adjustable gastric banding surgery (P < .001), postsurgery ASQ scores were more reduced from presurgery scores after RYGB/SG than after laparoscopic adjustable gastric banding surgery (-2.3 ± .3 versus -1.2 ± .2; P < .05). However, despite the dramatic changes in BAC observed when ingesting alcohol after RYGB/SG surgeries, which resulted in peak BAC that were approximately 50% above the legal driving limit, a third of these women felt almost no alcohol-related sedative effects., Conclusions: Although RYGB/SG dramatically increased sensitivity to alcohol in all participants, meaningful interindividual differences remained. The ASQ might help identify patients at increased risk to develop an alcohol use disorder after surgery., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Diabetes remission is greater after biliopancreatic diversion (BPD) than Roux-en-Y gastric bypass (RYGB) surgery. We used a mixed-meal test with ingested and infused glucose tracers and the hyperinsulinemic-euglycemic clamp procedure with glucose tracer infusion to assess the effect of 20% weight loss induced by either RYGB or BPD on glucoregulation in people with obesity (ClinicalTrials.gov number: NCT03111953). The rate of appearance of ingested glucose into the circulation was much slower, and the postprandial increases in plasma glucose and insulin concentrations were markedly blunted after BPD compared to after RYGB. Insulin sensitivity, assessed as glucose disposal rate during insulin infusion, was ∼45% greater after BPD than RYGB, whereas β cell function was not different between groups. These results demonstrate that compared with matched-percentage weight loss induced by RYGB, BPD has unique beneficial effects on glycemic control, manifested by slower postprandial glucose absorption, blunted postprandial plasma glucose and insulin excursions, and greater improvement in insulin sensitivity., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Roux-en-Y gastric bypass surgery (RYGB) increases the rate of alcohol absorption so that peak blood alcohol concentration is 2-fold higher after surgery compared with concentrations reached after consuming the same amount presurgery. Because high doses of alcohol can lead to hypoglycemia, patients may be at increased risk of developing hypoglycemia after alcohol ingestion., Objectives: We conducted 2 studies to test the hypothesis that the consumption of approximately 2 standard drinks of alcohol would decrease glycemia more after RYGB than before surgery., Setting: Single-center prospective randomized trial., Methods: We evaluated plasma glucose concentrations and glucose kinetics (assessed by infusing a stable isotopically labelled glucose tracer) after ingestion of a nonalcoholic drink (placebo) or an alcoholic drink in the following groups: (1) 5 women before RYGB (body mass index = 43 ± 5 kg/m 2 ) and 10 ± 2 months after RYGB (body mass index = 31 ± 7 kg/m 2 ; study 1), and (2) 8 women who had undergone RYGB surgery 2.2 ± 1.2 years earlier (body mass index = 30 ± 5 kg/m 2 ; study 2) RESULTS: Compared with the placebo drink, alcohol ingestion decreased plasma glucose both before and after surgery, but the reduction was greater before (glucose nadir placebo = -.4 ± 1.0 mg/dL versus alcohol = -9.6 ± 1.5 mg/dL) than after (glucose nadir placebo = -1.0 ± 1.6 mg/dL versus alcohol = -5.5 ± 2.6 mg/dL; P < .001) surgery. This difference was primarily due to an alcohol-induced early increase followed by a subsequent decrease in the rate of glucose appearance into systemic circulation., Conclusion: RYGB does not increase the risk of hypoglycemia after consumption of a moderate dose of alcohol., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: While it is well established that Roux-en-Y gastric bypass (RYGB) causes a rapid and heightened peak blood alcohol concentration (BAC), results from previous studies on the effects of sleeve gastrectomy (SG) on alcohol pharmacokinetics are conflicting. Data from 2 studies found SG did not affect BAC, whereas another study found SG caused a heightened peak BAC after alcohol ingestion. Moreover, these 3 studies estimated BAC from breathalyzers, which might not reliably estimate peak BAC., Objectives: The aims of this study were to evaluate (1) the effect of SG, relative to RYGB and a presurgery group, on alcohol pharmacokinetics and subjective effects, and (2) whether breathalyzers are reliable in this population., Setting: Single-center prospective nonrandomized trial., Methods: We performed alcohol challenge tests in 11 women who had SG surgery 1.9 ± .1 years ago (body mass index = 35.1 ± 6.6 kg/m 2 ), 8 women who had RYGB surgery 2.2 ± .4 years ago (body mass index = 30.0 ± 5.2 kg/m 2 ), and 9 women who were scheduled for bariatric surgery (body mass index = 44.1 ± 4.0 kg/m 2 ). BACs were estimated from breath samples and measured by gas chromatography at various times after consuming approximately 2 standard drinks., Results: BAC increased faster, peak BAC was approximately 2-fold higher, and feelings of drunkenness were heightened in both SG and RYGB groups relative to the presurgery group (P values<.001). BAC estimated from breath samples underestimated BAC by 27% (standard deviation = 13%) and missed peak BACs postsurgery., Conclusions: SG, similar to RYGB, causes marked alterations in the response to alcohol ingestion manifested by a faster and higher peak BAC. The breathalyzer is invalid to assess effects of gastric surgeries on pharmacokinetics of ingested alcohol., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

The goal of this study was to test the hypothesis that weight loss induced by Roux-en-Y gastric bypass (RYGB) has greater effects on taste perception and eating behavior than comparable weight loss induced by sleeve gastrectomy (SG). We evaluated the following outcomes in 31 subjects both before and after ~20% weight loss induced by RYGB ( n = 23) or SG ( n = 8): (1) sweet, savory, and salty taste sensitivity; (2) the most preferred concentrations of sucrose and monosodium glutamate; (3) sweetness palatability, by using validated sensory testing techniques; and (4) eating behavior, by using the Food Craving Inventory and the Dutch Eating Behavior Questionnaire. We found that neither RYGB nor SG affected sweetness or saltiness sensitivity. However, weight loss induced by either RYGB or SG caused the same decrease in: (1) frequency of cravings for foods; (2) influence of emotions and external food cues on eating behavior; and (3) shifted sweetness palatability from pleasant to unpleasant when repetitively tasting sucrose (all p -values ≤ 0.01). Therefore, when matched on weight loss, SG and RYGB cause the same beneficial effects on key factors involved in the regulation of eating behavior and hedonic component of taste perception., Competing Interests: The authors declare no conflict of interest.

Context: Fibroblast growth factor (FGF)19 and FGF21 are secreted by the intestine and liver in response to macronutrient intake. Intestinal resection and reconstruction via bariatric surgery may alter their regulation., Objective: We tested the hypothesis that weight loss induced by Roux-en-Y gastric bypass (RYGB) surgery, but not matched weight loss induced by laparoscopic adjustable gastric banding (LAGB), increases postprandial plasma FGF19 and FGF21 concentrations., Design: Glucose kinetics and plasma FGF19 and FGF21 responses to mixed meal ingestion and to glucose-insulin infusion during a hyperinsulinemic-euglycemic clamp procedure, with stable isotope tracer methods, were evaluated in 28 adults with obesity before and after 20% weight loss induced by RYGB (n = 16) or LAGB (n = 12)., Results: LAGB- and RYGB-induced weight loss increased postprandial plasma FGF19 concentrations (P < 0.05). However, weight loss after RYGB, but not LAGB, increased postprandial plasma FGF21 concentrations (1875 ± 330 to 2976 ± 682 vs 2150 ± 310 and 1572 ± 265 pg/mL × 6 hours, respectively). The increase in plasma FGF21 occurred ∼2 hours after the peak in delivery of ingested glucose into systemic circulation. Glucose-insulin infusion increased plasma FGF21, but not FGF19, concentrations. The increase in plasma FGF21 during glucose-insulin infusion was greater after than before weight loss in both surgery groups without a difference between groups, whereas plasma FGF19 was not affected by either procedure., Conclusions: RYGB-induced weight loss has unique effects on postprandial FGF21 metabolism, presumably due to rapid delivery of ingested macronutrients to the small intestine and delivery of glucose to the liver., (Copyright © 2017 Endocrine Society)

Background: Data from studies conducted in animal models suggest that intestinal glucose uptake and metabolism are upregulated after Roux-en-Y gastric bypass (RYGB) surgery, which contributes to a weight-loss-independent improvement in glycemic control., Objective: We conducted a cohort study to evaluate whether an increase in gastrointestinal metabolism of ingested glucose occurs in obese people who underwent RYGB compared with those who underwent laparoscopic adjustable gastric banding (LAGB)., Design: A mixed meal containing stable isotope-labeled glucose was used to determine the gastrointestinal (small intestine and liver) retention, and presumably metabolism, of ingested glucose in obese subjects before and after matched weight loss (∼21%) induced by RYGB (n = 16) or LAGB (n = 9)., Results: The total percentage of ingested glucose that appeared in the systemic circulation was slightly lower after than before RYGB (85% ± 9% and 90% ± 8%, respectively) but was slightly higher after than before LAGB (89% ± 3% and 85% ± 4%, respectively) (P-interaction < 0.05). Accordingly, gastrointestinal clearance of ingested glucose (cumulative percentage cleared over 6 h postprandially) increased after RYGB (from 10% ± 8% before to 15% ± 9% after surgery) but decreased after LAGB (from 15% ± 4% before to 11% ± 3% after surgery) (P < 0.05). Surgery-induced weight loss caused a similar decrease in the 6-h postprandial plasma glucose area under the curve in both RYGB and LAGB groups (-4% ± 9% and -6% ± 5%, respectively; P = 0.475)., Conclusions: These data support the notion that intestinal glucose disposal increases after RYGB surgery. However, the magnitude of the effect was small and did not result in weight-loss-independent therapeutic effects on postprandial glycemic control. This trial was registered at clinicaltrials.gov as NCT00981500., (© 2016 American Society for Nutrition.)

Introduction: Growing number of patients requires revisional bariatric surgery. This study compares perioperative course and outcomes of revisional versus primary bariatric surgery., Methods: Patients who underwent revisional bariatric surgery from Jan 1997 to Sept 2012 were reviewed retrospectively. Every revisional patient with BMI >35 and age <70 was matched with a primary Roux-en-Y gastric bypass control patient based on preoperative BMI, age, sex, and year of surgery. Patients' preoperative indications, intraoperative/postoperative course, and complications were analyzed., Results: Two hundred and fifty five patients underwent revisional bariatric surgery with resulting Roux-en-Y gastric bypass anatomy while 1,674 patients underwent primary gastric bypass in the same time interval. Of 255 patients, 172 patients were paired with 172 primary gastric bypass patients. Revisional bariatric group had preoperative BMI 48 ± 9, age 52 ± 9 years, 93 % female, 44 % laparoscopic, 30 % diabetic, 60 % hypertensive. Primary bypass patients had preoperative BMI 49 ± 8, age 52 ± 9 years, 93 % female, 97 % laparoscopic, 49 % diabetic, 67 % hypertensive. Compared to primary bypass patients, revisional patients had significantly higher estimated blood loss (463.7 vs. 113.3 mL), longer operative time (272.5 vs. 175.5 min), greater risk for ICU stay (N = 24, 14 % vs. N = 2, 1 %), and longer hospital stay (5.6 vs. 2.5 days). There were significantly more intraoperative liver (N = 13, 8 % vs. N = 1, 1 %) and spleen (N = 18, 10 % vs. N = 0) injuries, and more enterotomies (N = 9, 5 % vs. N = 0) in the revisional group. There were also significantly more postoperative complications (N = 94, 55 % vs. N = 48, 28 %), readmissions (N = 27, 16 % vs. N = 12, 7 %), and reoperations (N = 16, 9 % vs. N = 3, 2 %) within 30 days of surgery. Mean percentage weight loss at 1 year was significantly less for revisional patients (27 vs. 37 %). There was no significant difference in 30 day mortality between the two groups (N = 6 vs. 0)., Conclusion: Even in experienced hands, complex revisional bariatric surgery should be approached with significant caution, especially given that weight loss is less substantial.

Objective: The effects of marked weight loss, induced by Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgeries, on insulin sensitivity, β-cell function and the metabolic response to a mixed meal were evaluated., Methods: Fourteen nondiabetic insulin-resistant patients who were scheduled to undergo SG (n = 7) or RYGB (n = 7) procedures completed a hyperinsulinemic-euglycemic clamp procedure and a mixed-meal tolerance test before surgery and after losing ∼20% of their initial body weight., Results: Insulin sensitivity (insulin-stimulated glucose disposal during a clamp procedure), oral glucose tolerance (postprandial plasma glucose area under the curve), and β-cell function (insulin secretion in relationship to insulin sensitivity) improved after weight loss, and were not different between surgical groups. The metabolic response to meal ingestion was similar after RYGB or SG, manifested by rapid delivery of ingested glucose into the systemic circulation and a large early postprandial increase in plasma glucose, insulin, and C-peptide concentrations in both groups., Conclusions: When matched on weight loss, RYGB and SG surgeries result in similar improvements in the two major factors involved in regulating plasma glucose homeostasis, insulin sensitivity and β-cell function in obese people without diabetes., (© 2014 The Obesity Society.)

Objective: To test the hypotheses that bariatric surgery-induced weight loss: induces remission of food addiction (FA), and normalizes other eating behaviors associated with FA., Methods: Forty-four obese subjects (BMI= 48 ± 8 kg/m(2) ) were studied before and after ∼20% weight loss induced by bariatric surgery (25 Roux-en-Y gastric bypass, 11 laparoscopic adjustable gastric banding, and eight sleeve gastrectomy). We assessed: FA (Yale Food Addiction Scale), food cravings (Food Craving Inventory), and restrictive, emotional and external eating behaviors (Dutch Eating Behavior Questionnaire)., Results: FA was identified in 32% of subjects before surgery. Compared with non-FA subjects, those with FA craved foods more frequently, and had higher scores for emotional and external eating behaviors (all P-values <0.01; all Cohen's d >0.8). Surgery-induced weight loss resulted in remission of FA in 93% of FA subjects; no new cases of FA developed after surgery. Surgery-induced weight loss decreased food cravings, and emotional and external eating behaviors in both groups (all P-values < 0.001; all Cohen's d ≥ 0.8). Restrictive eating behavior did not change in non-FA subjects but increased in FA subjects (P < 0.01; Cohen's d>1.1)., Conclusion: Bariatric surgery-induced weight loss induces remission of FA and improves several eating behaviors that are associated with FA., (Copyright © 2014 The Obesity Society.)

Objective: Roux-en-Y gastric bypass (RYGB) surgery causes greater weight loss than laparoscopic adjustable gastric banding (LAGB). We tested the hypothesis that RYGB has weight loss-independent effects on taste perception, which influence eating behavior and contribute to the greater weight loss., Methods: Subjects were studied before and after ∼20% weight loss induced by RYGB (n = 17) or LAGB (n = 10). The following have been evaluated: taste sensitivity for sweet, salty and savory stimuli, sucrose and monosodium glutamate (MSG) preferences, sweetness palatability, eating behavior, and expression of taste-related genes in biopsies of fungiform papillae., Results: Weight loss induced by both procedures caused the same decrease in: preferred sucrose concentration (-12 ± 10%), perceived sweetness of sucrose (-7 ± 5%), cravings for sweets and fast-foods (-22 ± 5%), influence of emotions (-27 ± 5%), and external food cues (-30 ± 4%) on eating behavior, and expression of α-gustducin in fungiform papillae (all P values <0.05). RYGB, but not LAGB, shifted sweetness palatability from pleasant to unpleasant when repetitively tasting sucrose (P = 0.05). Neither procedure affected taste detection thresholds nor MSG preferences., Conclusions: LAGB and RYGB cause similar alterations in eating behaviors, when weight loss is matched. These changes in eating behavior were not associated with changes in taste sensitivity, suggesting other, as yet unknown, mechanisms are involved., (Copyright © 2013 The Obesity Society.)

It has been hypothesized that a greater decline in circulating branched-chain amino acids (BCAAs) after weight loss induced by Roux-en-Y gastric bypass (RYGB) surgery than after calorie restriction alone has independent effects on glucose homeostasis, possibly by decreased signaling through the mammalian target of rapamycin (mTOR). We evaluated plasma BCAAs and their C3 and C5 acylcarnitine metabolites, muscle mTOR phosphorylation, and insulin sensitivity (insulin-stimulated glucose Rd) in obese subjects before and after ~20% weight loss induced by RYGB (n = 10, BMI 45.6 ± 6.7 kg/m(2)) or laparoscopic adjustable gastric banding (LAGB) (n = 10, BMI 46.5 ± 8.8 kg/m(2)). Weight loss increased insulin-stimulated glucose Rd by ~55%, decreased total plasma BCAA and C3 and C5 acylcarnitine concentrations by 20-35%, and did not alter mTOR phosphorylation; no differences were detected between surgical groups (all P values for interaction >0.05). Insulin-stimulated glucose Rd correlated negatively with plasma BCAAs and with C3 and C5 acylcarnitine concentrations (r values -0.56 to -0.75, P < 0.05). These data demonstrate that weight loss induced by either LAGB or RYGB causes the same decline in circulating BCAAs and their C3 and C5 acylcarnitine metabolites. Plasma BCAA concentration is negatively associated with skeletal muscle insulin sensitivity, but the mechanism(s) responsible for this relationship is not known.

Context: It has been hypothesized that increased plasma bile acids (BAs) contribute to metabolic improvements after Roux-en-Y gastric bypass (RYGB) surgery by the G protein-coupled receptor TGR5-mediated effects on glucagon-like peptide-1 secretion and thyroid hormones., Objective: The objective of this study was to evaluate the importance of bariatric surgery-induced alterations in BA physiology on factors that regulate glucose homeostasis (insulin secretion and sensitivity) and energy metabolism (resting energy expenditure and thyroid hormone axis). DESIGN, PARTICIPANTS, INTERVENTION, AND MAIN OUTCOME MEASURE: Eighteen extremely obese subjects were studied before and after 20% weight loss, induced by either laparoscopic adjustable gastric banding (LAGB) (n = 10) or RYGB surgery (n = 8)., Results: Plasma BAs more than doubled after RYGB [fasting: 1.08 (0.26-1.42) to 2.28 (1.59-3.28) μmol/L, P = .03; postprandial: 2.46 ± 1.59 to 6.00 ± 2.75 μmol/L, P = .01] but were either lower or did not change after LAGB [fasting: 1.80 (1.49-2.19) to 0.92 (0.73-1.15) μmol/L, P = .02; postprandial: 3.71 ± 2.61 to 2.82 ± 1.75 μmol/L, P = .14]. Skeletal muscle expression of TGR5 targets, Kir6.2 and cyclooxygenase IV, increased after RYGB but not LAGB. Surgery-induced changes in BAs were associated with increased peak postprandial plasma glucagon-like peptide-1 (r(2) = 0.509, P = .001) and decreased serum TSH (r(2) = 0.562, P < .001) but did not correlate with the change in insulin response to a meal (r(2) = 0.013, P = .658), insulin sensitivity (assessed as insulin stimulated glucose disposal during a hyperinsulinemic-euglycemic clamp procedure) (r(2) = 0.001, P = .995), or resting energy expenditure (r(2) = 0.004, P = .807)., Conclusions: Compared with LAGB, RYGB increases circulating BAs and TGR5 signaling, but this increase in BAs is not a significant predictor of changes in glucose homeostasis or energy metabolism.

Bariatric surgery in obese patients is a highly effective method of preventing or resolving type 2 diabetes mellitus (T2DM); however, the remission rate is not the same among different surgical procedures. We compared the effects of 20% weight loss induced by laparoscopic adjustable gastric banding (LAGB) or Roux-en-Y gastric bypass (RYGB) surgery on the metabolic response to a mixed meal, insulin sensitivity, and β cell function in nondiabetic obese adults. The metabolic response to meal ingestion was markedly different after RYGB than after LAGB surgery, manifested by rapid delivery of ingested glucose into the systemic circulation, by an increase in the dynamic insulin secretion rate, and by large, early postprandial increases in plasma glucose, insulin, and glucagon-like peptide-1 concentrations in the RYGB group. However, the improvement in oral glucose tolerance, insulin sensitivity, and overall β cell function after weight loss were not different between surgical groups. Additionally, both surgical procedures resulted in a similar decrease in adipose tissue markers of inflammation. We conclude that marked weight loss itself is primarily responsible for the therapeutic effects of RYGB and LAGB on insulin sensitivity, β cell function, and oral glucose tolerance in nondiabetic obese adults.

Objective: Obesity is associated with insulin resistance and type 2 diabetes, although the mechanisms linking these pathologies remain undetermined. Recent studies in rodent models revealed endoplasmic reticulum (ER) stress in adipose and liver tissues and demonstrated that ER stress could cause insulin resistance. Therefore, we tested whether these stress pathways were also present in obese human subjects and/or regulated by weight loss., Research Design and Methods: Eleven obese men and women (BMI 51.3 +/- 3.0 kg/m2) were studied before and 1 year after gastric bypass (GBP) surgery. We examined systemic insulin sensitivity using hyperinsulinemic-euglycemic clamp studies before and after surgery and collected subcutaneous adipose and liver tissues to examine ER stress markers., Results: Subjects lost 39 +/- 9% body wt at 1 year after GBP surgery (P < 0.001), which was associated with a marked improvement in hepatic, skeletal muscle, and adipose tissue insulin sensitivity. Markers of ER stress in adipose tissue significantly decreased with weight loss. Specifically, glucose-regulated protein 78 (Grp78) and spliced X-box binding protein-1 (sXBP-1) mRNA levels were reduced, as were phosphorylated elongation initiation factor 2alpha (eIF2alpha) and stress kinase c-Jun NH2-terminal kinase 1 (JNK1) (all P values <0.05). Liver sections from a subset of subjects showed intense staining for Grp78 and phosphorylated eIF2alpha before surgery, which was reduced in post-GBP sections., Conclusions: This study presents important evidence that ER stress pathways are present in selected tissues of obese humans and that these signals are regulated by marked weight loss and metabolic improvement. Hence, this suggests the possibility of a relationship between obesity-related ER stress and metabolic dysfunction in obese humans.

Background: Roux-en-Y gastric bypass is the most frequently performed bariatric surgery for morbid obesity. Gastrojejunal anastomotic strictures are a relatively frequent postoperative complication., Objective: To evaluate the clinical outcomes and therapeutic response to through-the-scope balloon dilation performed to treat anastomotic strictures after Roux-en-Y gastric bypass surgery., Design: Single-center, retrospective study., Setting: Academic medical center., Patients: Between 1997 and 2005, 801 patients with morbid obesity underwent Roux-en-Y gastric bypass surgery at our institution., Main Outcome Measurements: The development of an anastomotic stricture after Roux-en-Y gastric bypass surgery. The response to through-the-scope balloon dilation after diagnosis., Results: Forty-three of 801 patients (5.4%) developed an anastomotic stricture (26 of 294 open surgeries [8.8%]; 17 of 507 laparoscopic surgeries [3.4%]; P < .001). Strictures were dilated to 15.5 +/- 0.4 mm. There were no perforations or clinically significant bleeding after dilation; 93% of the strictures were successfully managed with 1 or 2 endoscopic sessions. Dilation to at least 15 mm did not affect weight loss at 1 year when compared with the group without a stricture (percentage excess weight loss: stricture group, 76%; no stricture group, 74%)., Limitations: Single-center, retrospective study., Conclusions: Endoscopic balloon dilation is a safe and effective method for the management of gastrojejunostomy strictures after Roux-en-Y gastric bypass. Dilation to at least 15 mm is safe and decreases the need for further endoscopic dilation.

Background & Aims: Most patients with extreme obesity have nonalcoholic fatty liver disease (NAFLD). Although gastric bypass (GBP) surgery is the most common bariatric operation performed in obese patients in the United States, the effect of GBP surgery-induced weight loss on the metabolic and hepatic abnormalities associated with NAFLD are not clear., Methods: Whole-body glucose, fatty acid and lipoprotein kinetics, liver histology, and hepatic cellular factors involved in inflammation and fibrogenesis were evaluated in 7 extremely obese subjects (body mass index, 58 +/- 4 kg/m(2)) before and 1 year after GBP surgery., Results: At 1 year after surgery, subjects lost 29% +/- 5% of initial body weight (P < .01); palmitate rate of appearance in plasma, an index of adipose tissue lipolysis, decreased by 47% +/- 4% (P < .01); endogenous glucose production rate decreased by 27% +/- 7% (P < .01); and very-low-density lipoprotein-triglyceride secretion rate decreased by 44% +/- 9% (P < .05). In addition, GBP surgery-induced weight loss decreased hepatic steatosis but did not change standard histologic assessments of inflammation and fibrosis. However, there was a marked decrease in hepatic factors involved in regulating fibrogenesis (collagen-alpha1(I), transforming growth factor-beta1, alpha-smooth muscle actin, and tissue inhibitor of metalloproteinase 1 expression and alpha-smooth muscle actin content) and inflammation (macrophage chemoattractant protein 1 and interleukin 8 expression) (P < .05, compared with values before weight loss)., Conclusions: These data demonstrate that weight loss induced by GBP surgery normalizes the metabolic abnormalities involved in the pathogenesis and pathophysiology of NAFLD and decreases the hepatic expression of factors involved in the progression of liver inflammation and fibrosis.