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Introduction: Patients with body mass index (BMI) ≥ 50 kg/m 2 , classified with obesity class IV/V, require complex treatments. Intragastric balloon (IGB) is a possible treatment before metabolic bariatric surgery (MBS) that may reduce peri-operative complications. This study evaluates IGB outcomes and complications before MBS in patients with Obesity IV/V, and subsequent MBS results, regarding weight loss and comorbidity resolution., Methods: Retrospective cohort study of all patients with BMI above 50 kg/m 2 submitted to IGB before MBS between 2009 and 2023 in a high-volume center. Variables analyzed included weight loss after IGB and MBS, IGB complications, and comorbidity resolution. Suboptimal clinical responses were defined as %TWL < 5% for IGB, %TWL < 20% for MBS, and %TWL < 25% or BMI ≥ 35 kg/m 2 for IGB + MBS., Results: Seventy-four patients (mean BMI 58.8 ± 8 kg/m 2 ) were included. After IGB, the mean %TWL was 14.2 ± 8.5%, with a 21.6% complication rate, predominantly nausea and vomiting, and one death. Suboptimal clinical response of IGB affected 13.5% of patients, and 5.4% required early removal. Two years after MBS, the mean %TWL was 38.2 ± 11.6%, mainly due to MBS, yet approximately one-third of %TWL was attributed to IGB. No correlation was found between IGB and MBS outcomes. At 2-year follow-up, 45.1% patients had %TWL ≥ 25 and BMI < 35 kg/m 2 ., Conclusion: The IGB is a treatment option before MBS in patients with Obesity Class IV/V, with acceptable weight loss outcomes but not infrequent complications. A multidisciplinary approach is mandatory, and all treatments must be considered in this difficult subset of patients., (© 2024. The Author(s).)

Background: Metabolic surgery is the foremost treatment for obesity and its associated medical conditions. Nonetheless, post-bariatric hypoglycemia (PBH) emerges as a prevalent complication. PBH pathophysiology implicates heightened insulin and glucagon-like peptide 1 (GLP-1) levels, with bile acids (BA) contributing to GLP-1 release. A plausible association exists between cholecystectomy and PBH, which is attributed to alterations in BA metabolism and ensuing hormonal responses. The objective of this retrospective cohort study was to evaluate the impact of cholecystectomy on PBH pharmacological treatment, diagnostic timelines and metabolic parameters., Materials and Methods: Patients diagnosed with PBH after bariatric surgery were evaluated based on their history of cholecystectomy. Demographic, anthropometric and clinical data were collected. Mixed meal tolerance tests (MMTT) results were compiled to assess metabolic responses., Results: Of the 131 patients with PBH included in the study, 29 had prior cholecystectomy. The time to PBH diagnosis was similar across groups. Patients with prior cholecystectomy required higher doses of acarbose (p = 0.046), compared to those without prior cholecystectomy. Additionally, MMTT revealed higher insulin (t = 60 min: p = 0.010 and t = 90 min: p = 0.034) and c-peptide levels (t = 60 min: p = 0.008) and greater glycemic variability in patients with prior cholecystectomy (p = 0.049), highlighting the impact of cholecystectomy on glucose metabolism., Conclusion: Our study offers novel insights into PBH pharmacotherapy, indicating that PBH patients with a history of cholecystectomy require elevated doses of acarbose for symptom control than PBH patients without such surgical history. Furthermore, our findings underscore the pivotal role of hyperinsulinism in PBH aetiology, emphasizing the significance of the BA-GLP-1-insulin axis., (© 2024. The Author(s).)

Purpose: This study examined the benefits of an 11-months multicomponent exercise program (MEP) on muscular strength (MS) after bariatric surgery., Methods: Of the 84 randomized patients, 41 participants from the exercise group (EG) and 20 participants from the control group (CG) were included in the analysis. The EG received supervised MEP for 11 months, starting 1-month post-bariatric surgery (BS) in addition to standard medical care, while the CG received medical care recommendations only. Knee and trunk MS was assessed by isokinetic dynamometry pre-surgery, 1-, 6-, and 12-month post-surgery, while body composition was assessed by dual-energy X-ray absorptiometry., Results: The MEP did not significantly impact absolute MS in the dominant knee and trunk regions at 6- and 12-month post-BS. However, relative MS showed significant improvements. At 6-month post-BS, knee flexion at 60°/s relative to body weight (BW) increased significantly (p = 0.047), as did knee extension at 180°/s relative to BW (p = 0.009), and knee extension at 60°/s relative to total lean mass (p=0.040). At 12-month post-BS, knee flexion at 60°/s relative to BW also significantly improved (p=0.038)., Conclusion: While absolute MS was not significantly improved with MEP, this study found significant enhancements in relative MS, particularly in dominant knee flexion post-MEP participation. Further research should explore different exercise intensities and frequencies to optimize postoperative MS recovery post-BS., Clinical Trial Registration: ClinicalTrials.gov (NCT02843048)., (© 2024. The Author(s).)

Background: Bariatric surgery is the most effective treatment for sustained weight reduction and obesity-related comorbidities. The development of gallstones as a result of rapid weight loss is a well-known consequence of bariatric procedures. It remains unclear, if there is an increased risk of these gallstones becoming symptomatic., Methods: A retrospective analysis of 505 consecutive patients submitted to either Roux-en-Y Gastric Bypass or Sleeve Gastrectomy between January and December 2019 was performed. The aim of our study was to determine the incidence of symptomatic cholelithiasis in asymptomatic patients with their gallbladder in situ after bariatric surgery and to identify potential risk factors for its development., Results: Of the 505 patients included, 79 (15.6%) underwent either previous cholecystectomy. (n = 67, 84.8%) or concomitant cholecystectomy during bariatric surgery (n = 12, 15.2%). Among the remaining 426 (84.4%) patients, only 8 (1.9%) became symptomatic during the 12-month follow-up period. When compared with patients who remained asymptomatic, they had a higher median preoperative BMI (47.0 vs. 42.8, p = 0.046) and prevalence of cholelithiasis on preoperative ultrasound (62.5% vs. 10.7%, p = 0.001). Multivariate analysis revealed preoperative BMI and cholelithiasis on preoperative ultrasound as independent risk factors for symptomatic biliary disease (OR 1.187, 95%CI 1.025-1.376, p = 0.022 and OR 10.720, 95%CI 1.613-71.246, p = 0.014, respectively)., Conclusion: Considering a low incidence of symptomatic gallstones after bariatric surgery, concomitant cholecystectomy should only be performed in symptomatic patients undergoing bariatric surgery. Preoperative factors, such as a higher BMI and positive ultrasound for cholelithiasis, may be related to the development of symptomatic gallstones., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: The frequency and management of gallstone disease (GD) in bariatric patients, including the role of routine prophylactic concomitant cholecystectomy (CCY), are still a matter of debate. This study aims to assess the risk of de novo GD in patients undergoing bariatric surgery (BS) and their predictive factors, as well as mortality and morbidity in prophylactic CCY compared to BS alone., Methods: We performed a systematic review, searching PubMed, EMBASE, and Web of Science until April 2021. We performed a Bayesian meta-analysis to estimate the risk of GD development after BS and the morbidity and mortality associated with BS alone versus BS + prophylactic CCY. Sources of heterogeneity were explored by meta-regression analysis., Results: The risk of de novo post bariatric GD was 20.7% (95% credible interval [95% CrI] = 13.0-29.7%; I 2  = 75.4%), and that of symptomatic GD was 8.2% ([95% CrI] = 5.9-11.1%; I 2  = 66.9%). Pre-operative average BMI (OR = 1.04; 95% CrI = 0.92-1.17) and female patients' proportion (OR = 1.00; 95% CrI = 0.98-1.04) were not associated with increased risk of symptomatic GD. BS + prophylactic CCY was associated with a 97% probability of a higher number of postoperative major complications compared to BS alone (OR = 1.74, 95% CrI = 0.97-3.55; I 2  = 56.5%). Mortality was not substantially different between the two approaches (OR = 0.79; 95% CrI = 0.03-3.02; I 2  = 20.7%)., Conclusion: The risk of de novo symptomatic GD after BS is not substantially high. Although mortality is similar between groups, odds of major postoperative complications were higher in patients submitted to BS + prophylactic CCY. It is still arguable if prophylactic CCY is a fitting approach for patients with a preoperative lithiasic gallbladder., (© 2023. The Author(s).)

Purpose: Early postoperative bleeding is a common complication after laparoscopic Roux-en-Y gastric bypass (LRYGB) and is associated with significant morbidity. We aimed to identify predictors of early postoperative bleeding after LRYGB and characterize hemorrhagic events and 30-day postoperative outcomes., Material and Methods: We conducted a retrospective cohort study regarding all patients submitted to LRYGB in 2019 at a high-volume obesity center. Early postoperative bleeding was defined as any clinically significant evidence of hemorrhage in the early postoperative period. Demographic, preoperative, and intraoperative factors were evaluated for associations with postoperative bleeding. Postoperative outcomes were compared between patients with and without hemorrhage., Results: Of 340 patients submitted to LRYGB, 14 (4.1%) had early postoperative bleeding. Patients with bleeding had an increased preoperative left hepatic lobe diameter (8.4 vs. 7.3 cm, p = 0.048). Prior cholecystectomy (28.6 vs. 14.5%) and previous bariatric surgery (35.7 vs. 23.9%) tended to be more prevalent among these patients. Bleeding occurred at a median time of 31.2 [IQR 19.7-38.5] h. Thirteen patients presented with intraluminal bleeding and one with extraluminal bleeding. Melena was the most common symptom. All hemorrhages were clinically diagnosed, and 92.9% were managed conservatively. Postoperative bleeding was associated with longer hospital stay (3.5 vs. 2.0 days), higher reintervention (7.1 vs. 0%), and readmission (14.3 vs. 0%), all p < 0.05., Conclusions: Bleeding was the most frequent early complication after LRYGB. Patients with hepatomegaly and prior surgeries may have technically challenging LRYGB and should be carefully assessed. Perioperative strategies should be encouraged in high-risk patients to prevent bleeding., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Bariatric surgery, although an effective method, still has complications, like nutritional deficiencies. Our aim was to summarize the evidence on the frequency of complex B vitamin deficiencies in studies comparing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). We included 25 studies for qualitative synthesis and 21 studies for quantitative synthesis. Relevant data was extracted, including proportion of patients with deficiency and mean serum vitamin values in 3 different timeframes. B12 and folate were the most prevalent deficiencies. B12 deficiency was more common after RYGB and folate serum mean levels were higher after RYGB. SG causes less nutrient deficiency and is therefore a better technique from this point of view. More studies are needed on B2, B3, and B6 vitamins to draw better conclusions., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: In patients with type 2 diabetes mellitus (T2DM), bariatric surgery appears to be more effective than medical treatment (MT) at improving glycaemic control and decreasing cardiovascular risk. However, long-term effectiveness has not been systematically assessed using randomised controlled trials. In this study, we aimed to systematically assess randomised controlled trials, with at least 5 years of follow-up, on bariatric surgery in patients with T2DM and BMI ≥ 25 kg/m 2 , as well as to compare different bariatric procedures., Material and Methods: PubMed, SCOPUS and Web of Science were searched. We performed a network meta-analysis to evaluate the comparative effectiveness of the different procedures and MT in terms of full T2DM remission, weight loss, complications and cardiometabolic biomarkers. The quality of evidence was assessed using the Cochrane Risk of Bias Tool and CINeMA., Results: We included 11 primary studies. Laparoscopic one-anastomosis gastric bypass (LOAGB) was found to be one of the most effective treatments for full remission of T2DM (I 2  = 0, inconsistency p value = 0.9223). Biliopancreatic diversion without duodenal switch was found to be more effective than laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding regarding percent total cholesterol and low-density lipoprotein change. Regarding percent high-density lipoprotein and weight change, all analysed surgical treatments were shown to be more effective than MT. The confidence rating in our results was overall moderate, but most studies had high risk of performance and detection bias., Conclusion: Bariatric surgery seems to be effective for T2DM remission. LOAGB appears to be a good option in this context, and a possible alternative to laparoscopic duodenal switch, but the included primary studies in our review are not sufficiently powered to establish a more definitive conclusion. More studies with longer follow-up times are needed to comprehensively assess bariatric surgery in T2DM., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Obesity is a significant risk factor for cancer incidence and mortality. The number of patients with obesity who undergo bariatric surgery is increasing; however, the impact of such a procedure in affecting the risk of cancer is not completely understood yet., Methods: We conducted a retrospective unicentric cohort study to characterize the occurrence of cancer in patients who underwent bariatric surgery from January 2010 to December 2018. For cases of cancer identified after bariatric surgery, we performed a cancer-free survival analysis over time. We also performed a cross-sectional analysis of demographic and clinical characteristics at the time of surgery and compared patients with or without a cancer diagnosis., Results: Of the 2578 patients who underwent bariatric surgery, 117 patients (4.5%) were diagnosed with a cancer. Fifty-nine cases were diagnosed before surgery, and the remaining 58 cases occurred after the bariatric procedure. The prevalence of cancer was more accentuated in women (4.9%) than among men (2.7%). Thyroid and breast cancer were the most frequent before and after bariatric surgery, respectively. On average, patients with cancer diagnosis were older (49.0 vs 43.3 years, p<0.001) and with a lower level of education (7.4 vs 8.6 school years, p=0.002)., Conclusion: Almost all the cases of cancer identified in this study were obesity-related cancers. Further prospective studies are needed to extend the current knowledge regarding the cancer risk profile of patients who undergo bariatric surgery., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Obesity is a multifactorial disease, which is strongly associated to other metabolic disorders. Bariatric surgery is the most effective treatment of morbid obesity. The role of beta cell function in weight loss after bariatric surgery is uncertain., Aim: To evaluate the association between beta cell function and percentage of total body weight loss (TBWL%) 1, 2, 3, and 4 years after bariatric surgery in patients with morbid obesity., Methods: Retrospective longitudinal study in patients with morbid obesity followed in our center between January 2010 and July 2018. Patients were excluded if they had diabetes at baseline or missing data on the needed parameters. We evaluated baseline Homeostatic Model Assessment of IR, Homeostatic Model Assessment of β-cell function (HOMA-beta), Quantitative Insulin Sensitivity Check Index, and Matsuda and DeFronzo index, and TBWL% at years 1 to 4. Linear regression models were used to evaluate the association of indexes of insulin resistance with TBWL% (unadjusted and adjusted for age, sex, BMI, and type of surgery)., Results: There were 1,561 patients included in this analysis. HOMA-beta was negatively associated with TBWL% at second, third, and fourth years post-surgery (β = -1.04 [-1.82 to -0.26], p<0.01; β = -1.16 [-2.13 to -0.19], p=0.02; β = -1.29 [-2.64 to 0.06], p=0.061, respectively). This was not observed in the first year post-surgery nor for the other indexes. Glycemia at baseline was positively associated to EWL% at second and third years post-surgery., Conclusion: β-cell function at baseline seems to be associated to long-term weight loss, explicitly after the first year post bariatric surgery. This might be a helpful predictor of weight loss in clinical practice., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Borges-Canha, Neves, Mendonça, Silva, Costa, M. Cabral, Guerreiro, Lourenço, Meira, Salazar, Ferreira, Pedro, Barkoudah, Sande, Lau, B. Souto, Preto, Freitas and Carvalho.)

Purpose: This study aimed to assess bariatric surgery (BS) effect on fall risk factors., Materials and Methods: Fifteen patients undergoing BS (intervention group, IG) and 10 non-surgical obese patients (control group, CG) were recruited. IG was assessed at pre-surgery and 6 months after BS, while CG was assessed at baseline and reassessed after 6 months. At both time-points, anthropometry, lower limbs muscle strength (isokinetic dynamometer), balance in bipedal stance (force platform), daily physical activity (accelerometry), and health-related quality of life (SF-36 questionnaire) were assessed., Results: At baseline, there were no differences between CG and IG for all parameters analyzed. Compared to CG, 6 months post-BS, the IG decreased weight, body mass index, waist and hip circumference. Balance showed limited improvements, with gains observed only on antero-posterior and total center of pressure velocity. Muscle strength displayed a divergent evolution 6 months after BS, with a decrease in absolute strength but an increase in relative strength. Although BS did not induce significant changes in time spent in different physical activity intensities, it decreased time in sedentary behavior and increased number of daily steps. Post-BS patients reported substantial improvements in quality-of-life, especially in physical function., Conclusion: Patients seem to overestimate their actual physical fitness improvements attained after BS, which combined with increases in physical activity, might increase the likelihood of engaging in risky daily tasks to what they are physically not prepared to, consequently increasing fall risk., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Bariatric surgery has proven its effectiveness in the treatment of obesity and related comorbidities. However, several procedures may be required to treat this chronic disease and/or complications after bariatric surgery. The most frequent revisional surgeries performed after failed laparoscopic adjustable gastric banding (AGB) have been Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). The aim of this study is to compare medium-term outcomes of primary and revisional bariatric procedures., Material and Methods: Single institution, matched case-control study of obese patients submitted to bariatric surgery, divided into four groups of 50 patients: (A) primary RYGB; (B) primary SG; (C) revisional Roux-en-Y gastric bypass (rRYGB) after failed laparoscopic AGB; (D) revisional sleeve gastrectomy (rSG) after failed laparoscopic AGB. Demographic variables, surgical procedures characteristics and complications, weight loss outcomes and resolution of comorbidities were compared., Results: Mortality and morbidity were comparable between primary and revisional procedures. Weight loss outcomes were inferior in patients submitted to rRYGB when compared to those submitted to RYGB, with no significant differences found when comparing the other groups. Regarding comorbidities' outcomes, only patients submitted to rSG had lower odds of comorbidities' improvement. Patients submitted to rRYGB had an odd 7 times higher of comorbidities' improvement than those submitted to rSG, independent of weight loss outcomes., Conclusion: Revisional surgeries are safe procedures with adequate weight loss outcomes in this difficult set of patients. The choice of revisional procedure may not influence weight loss outcomes, but rRYGB seems to be a better option regarding comorbidities' resolution.

Purpose: Obese patients have neurodegeneration of the optic nerve demonstrated by decreased peripapillary nerve fiber layer. Whether bariatric surgery reverses this neurodegenerative process has not been explored. We aimed to evaluate the impact of bariatric surgery in the structure of the retina and optic nerve., Methods: Multicentric observational study. Obese patients scheduled for bariatric surgery were consecutively recruited and included in the study and evaluated before and 6-12 months after the intervention. The retinal structure was evaluated as retinal thickness in the different retinal layers in the foveal, perifoveal, and parafoveal regions using optical coherence tomography. Choroidal thickness and optic nerve retinal nerve fiber layer thickness were also evaluated., Results: Eighty eyes from 40 participants were included. Globally, we found a significant thickening of the retina after bariatric surgery (foveal: 273.5 (21.5) μm vs 280.0 (28.8) μm, p < 0.001; parafoveal 332.4 ± 17.8 μm vs 336.6 ± 15.9 μm, p = 0.003; perifoveal: 293.4 ± 13.8 μm vs 295.7 ± 14.9 μm; p = 0.001), whereas no significant differences were found for the ganglion cell layer, choroid, or peripapillary nerve fiber layer thickness. The retinal thickening was confined to inner retinal layers and was independent of the diabetic status of the patients. After multivariate adjustment, HbA1c variation, preoperative C-peptide, preoperative hypertension, preoperative OSA, and preoperative LDL and TG levels seem to be clinical predictors of retinal thickening., Conclusions: We found a significant thickening of the retina after bariatric surgery that was independent of the diabetic status. The thickening was confined to inner retinal layers and may represent and improve perfusion. The peripapillary nerve fiber layer remained unchanged after the surgery.

Introduction: Childhood obesity is a significant health problem worldwide, associated with significant metabolic and cardiovascular morbidity. Recent evidence points to metabolic and bariatric surgery as a safe and effective treatment for morbidly obese adolescents. We aim to report the initial results after laparoscopic sleeve gastrectomy (LSG) for adolescent patients in a pediatric center., Material and Methods: Retrospective data review of patients younger than 19 years who underwent LSG for treatment of morbid obesity between 2013 and 2019., Results: A total of 16 adolescents (12 female, 4 male) with a median age of 17.5 years underwent LSG. Median preoperative weight and body mass index were 129kg and 48.6kg/m -2 , respectively. All patients had at least one comorbidity. Median follow-up was 18.5 months. The overall percent total weight loss was 32.5% and percent excess weight loss was 68%. Resolution of comorbidities was noted in the majority of patients. No perioperative complications were reported., Conclusions: Laparoscopic sleeve gastrectomy is a safe and effective option for treatment of morbidly obese adolescents, resulting in significant weight loss and comorbidity resolution with a low risk of complications., (Copyright © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

A worldwide rise in weight and obesity is taking place, associated with an increase in several comorbid conditions, such as Obstructive Sleep Apnea (OSA). Bariatric surgery is an effective treatment approach for obesity, with resultant improvement in obesity-related comorbidities. However, the relationship between this type of treatment and OSA is not well established. This systematic review aims to assess and characterize the impact that different types of bariatric surgery have on obese OSA patients. 22 articles with stated preoperative apnea-hypopnea index (AHI), apnea index (AI) or respiratory disturbance index (RDI) were analyzed in this review. A significant improvement in AHI/AI/RDI occurred after surgery, in addition to the foreseeable reduction in body mass index (BMI). Moreover, almost every study stated a postoperative reduction of the AHI to < 20/h and/or a >50% postoperative reduction of AHI, with few exceptions. The interventions with a combined malabsorptive and restrictive mechanism, like roux-en-Y gastric bypass (RYGB), were more efficacious in resolving and improving OSA than purely restrictive ones, like laparoscopic adjustable gastric banding (LAGB). In conclusion, bariatric surgery has a significant effect on OSA, leading to its resolution or improvement, in the majority of cases, at least in the short/medium term (1-2 years). However, the different results must be interpreted with caution as there are many potential biases resulting from heterogeneous inclusion criteria, duration of follow-up, diagnostic methodology and assessed variables., (Copyright © 2016 Sociedade Portuguesa de Pneumologia. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Bariatric surgery improves lipid profile. A still unanswered question is whether this improvement is merely weight-dependent or also results from factors inherent to specificities of the bariatric procedure. We aimed to study lipid profile 1 year after bariatric surgery and compare its changes between the different procedures in patients matched for initial weight and weight loss., Methods: We retrospectively analysed patients submitted to Roux-en-Y gastric bypass (RYGB), adjustable gastric banding (AGB) or sleeve gastrectomy (SG) between 2010 and 2013. Patients were matched for age (±5 years), sex, pre-surgery body mass index (BMI) (±2 Kg/m(2)) and excess weight loss (EWL) (±5%). Baseline and 1-year lipid profile, its variation and percentage of variation was compared between surgeries., Results: We analysed 229 patients: 72 pairs RYGB-AGB, 47 pairs RYGB-SG and 33 pairs AGB-SG. The median age was 41 (35-52) years and 11.8% were male. Pre-operative BMI was 44.0 ± 4.6 and 32.1 ± 4.4 Kg/m(2) at 1 year. EWL at 1 year was 64.2 ± 18.9%. There were no differences in baseline lipid profile between patients submitted to different types of bariatric surgery. At 1 year, high-density lipoprotein cholesterol (HDL) and triglycerides (TG) improved similarly with all surgeries. Total cholesterol (TC) and low-density lipoprotein cholesterol (LDL) at 1 year decreased significantly more in patients submitted to RYGB than in weight-matched patients undergoing AGB or SG., Conclusions: RYGB is the only bariatric surgery that reduces TC and LDL in age-, sex-, BMI- and EWL-matched patients. All three procedures improved TG and HDL similarly when the confounding effect of weight loss is eliminated.

Introduction: Our objective is to determine which complications lead to reoperation, and the outcomes of reoperation using laparoscopic adjustable gastric banding, laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy at Centro Hospitalar de São João., Material and Methods: Observational study. Patients included were aged 18 to 65 years at first gastric banding, underwent removal from March 21st 2007 to January 23rd 2014 and were subsequently converted to gastric banding, gastric bypass or sleeve gastrectomy. Women who got pregnant during the initial gastric banding follow-up and patients that performed more than one conversion were excluded., Results: A total of 103 patients were included. Fifteen underwent revision to gastric banding, 71 to gastric bypass and 17 to sleeve gastrectomy. Respectively, percentage of excess weight loss at 1 month were 1.9 ± 12.2% in 6 patients, 36.9 ± 18.2% in 49 patients and 27.1% (13.3 - 68.6) in 11 patients (laparoscopic adjustable-gastric banding-laparoscopic Roux-en-Y gastric bypass p < 0.001, laparoscopic adjustable-gastric banding-laparoscopic sleeve gastrectomy p = 0.002 and laparoscopic Roux-en-Y gastric bypass-laparoscopic sleeve gastrectomy p = 0.474). At 3 months there were 12.8% (5.7 - 84.8) in 6 patients, 44.8 ± 19.7% in 24 patients and 48 ± 20.1% in 8 patients (laparoscopic adjustable-gastric banding-laparoscopic Roux-en-Y gastric bypass p = 0.017, laparoscopic adjustable-gastric banding-laparoscopic sleeve gastrectomy p = 0.039 and laparoscopic Roux-en-Y gastric bypass-laparoscopic sleeve gastrectomy p = 0.691)., Discussion: At revision, ages and body mass indices are higher than other studies. Gastric bypass is the preferred revision surgery, because combines restriction and malabsorption, surgeons have more experience and long term outcomes are better described., Conclusions: The main indications for reoperation were inadequate weight loss (37.4%) and band slippage (30%). At short term, in our patients, gastric banding as a revision surgery was not effective, as opposed to gastric bypass and sleeve gastrectomy.

Background: Despite its widespread clinical use, both body mass index (BMI) and waist circumference have been reported as inaccurate methods to measure abdominal obesity. The main objective of this study was to determine the relation between visceral fat area and fatty liver infiltration with the expression of metabolic syndrome (MS) in morbidly obese patients., Methods: We recruited a random selection of 100 morbidly obese patients on pre-operative evaluation for bariatric surgery. A pre-operative CT slice at L4-L5 level, was performed to measure visceral fat and at T12 level to measure hepatic attenuation., Results: Patients with MS had lower hepatic attenuation values (median 49.9 vs 55.5HU; p = .018) and had more VAT (242 vs 172 cm(2);p = .001). Conventional measures (BMI: p = .729 and waist circumference: p = .356), were not useful in discriminating morbidly obese patients with MS. By multivariable logistic regression, fatty liver infiltration (OR = 5.3; p = .03) and age (OR = 1.08; p = .04) were the only factors independently related to the presence of MS. MS prevalence was 100%, 71% and 55%, respectively for patients with both fatty liver and visceral adiposity; one; or none of this findings (AUC - .715; p = .016)., Conclusion: CT scan seems to measure 2 important markers of MS: visceral adiposity and hepatic fatty infiltration. In morbidly obese patients, both visceral adiposity and hepatic fatty infiltration increase the risk for the presence of MS., (Copyright © 2015 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Metabolic syndrome (MetS) clusters the most dangerous cardiovascular disease risk factors. Although insulin resistance and central obesity play an important role in the pathogenesis, the factors that determine its development and ultimate remission after Roux-en-Y gastric bypass (RYGB) are not fully understood., Methods: We recruited a prospective cohort of 210 consecutive patients after RYGB between January 2010 and December 2011. Patients were evaluated clinically and with a biochemical profile preoperatively and at 12 months after surgery. Visceral adipose tissue and subcutaneous abdominal adipose tissue samples were collected at surgical intervention. We aimed to identify factors associated with MetS in morbidly obese patients and predictors of its remission 12 months after RYGB., Results: Increasing age (>40 years), male sex, alanine aminotransferase levels and visceral adipose tissue/subcutaneous adipocyte size ratio were independently related to the expression of MetS at the moment of surgery.One year after RYGB, there was a significant decrease in the prevalence of MetS (63.3%-10%; P < 0.001) and in each of its components. A multivariable analysis for the remission of MetS identified that only fasting glucose levels (OR = 13.4; P = 0.01) and duration of obesity (OR = 1.08; P = 0.04) were independently related to the persistence of MetS. A metabolic score (scale of 1-10), consisting of duration of obesity, fasting blood glucose levels, the presence of high blood pressure and low levels of high-density lipoprotein identified 4 different risk categories for the persistence of MetS (area under the curve = 0.848)., Conclusions: The metabolic score can be used to predict the remission of MetS after RYGB with high accuracy. Patients in high-risk groups might be managed more aggressively and low-risk patients may have their medication discontinued earlier with extra safety.

Background: Preoperative prediction of weight loss after Roux-en-Y gastric bypass (RYGB) could help surgeons in managing surgical lists and patients' expectations. The objective of this study was to understand if preoperative metabolic control might improve surgical results., Methods: Prospective cohort of 163 consecutive patients who underwent RYGB with at least 1 year of follow-up., Results: Most patients were female (90.2%), with a mean age of 38 (19-60) and a BMI of 46.0 (34.3-59.9) kg/m(2). After 12 months, the mean body mass index (BMI) was 29.7 kg/m(2) (21.5-39.9) with a corresponding percentage of excess weight lost (%EWL) of 78.8% and a percentage of weight loss (%WL) of 35.1%. Patients with the highest preoperative fasting blood glucose (FBG) were older (42 versus 36; P<.001); were more likely to have type 2 diabetes (T2 DM, 40% versus 6.8%; P<.001) and metabolic syndrome (89% versus 25%; P<.001), had a slightly higher BMI (30.8 versus 29.3 kg/m(2); P = .03), and had achieved a significantly lower %EWL and %WL at 12 months (72.5% versus 81.2%; P = .004; 33.2 versus 35.9%; P = .03, respectively). We observed a dose-response effect with increasing FBG (<85 mg/dL, 85-100 mg/dL, and ≥ 100 mg/dL, respectively), with 83.5%, 80.0%, and 72.5% (P = .009) of %EWL at 12 months. By multivariate logistic regression, initial BMI and FBG>100, were the only variables related (inversely) with the probability of achieving a %EWL>80 or %WL>35. This effect was not detected in patients receiving oral antidiabetic medications., Conclusion: Higher preoperative FBG is independently related to a poorer weight loss 12 months after RYGB; this suggests the need to offer earlier surgical intervention for severely obese patients with impairment of glucose metabolism. The potential for less weight loss in patients with a higher FBG should not discourage RYGB, given the significant metabolic improvement after surgery., (© 2013 American Society for Bariatric Surgery Published by American Society for Metabolic and Bariatric Surgery All rights reserved.)

Background: Although medium- to long-term improvement in insulin resistance and T2DM after Roux-en-Y gastric bypass (RYGB) is well documented, few studies have analyzed the acute effects after surgery. Understanding these effects might help explain the physiologic adjustments after surgery and help in managing insulin resistance and controlling the hypoglycemic treatment for bariatric patients., Methods: We recruited a prospective cohort of 55 consecutive female patients that underwent primary laparoscopic RYGB between January and June/2011. Blood samples were collected preoperatively and at the first, third, and fifth post-operative days after an overnight fast., Results: There was a significant increase in homeostasis model assessment for insulin resistance (HOMA-IR) on day 1 (2.36 vs 3.12; p = 0.032), followed by a rapid decrease from day 3 onward (3.12 vs 1.70; <0.001). We found a statistically significant difference (p < 0.05) at all time points compared with baseline. HOMA-IR levels at POD5 were 47 % lower than baseline values and were not significantly different from values at 6 months (1.24 vs 0.93; p = 0.09). The blood levels of glucose and insulin closely matched those of HOMA-IR., Conclusions: RYGB results in a rapid improvement in insulin resistance and a clinically significant decrease in fasting glucose and insulin levels. This improvement is significant at the 3rd post-operative day, and by the 5th day, patients express insulin resistance levels that are similar to those expressed at 6 months after surgery. This work highlights the acute metabolic impact of surgery. Understanding the behavior of insulin and glucose after surgery might improve our knowledge of the pathophysiology of diabetes and lead to novel therapies and tailored surgical approaches.