Bariatric Surgery in Children and Adolescents with Cognitive Impairment and/or Developmental Delay: Current Knowledge and Clinical Recommendations Abstract Bariatric surgery is an effective treatment for children and adolescents with severe obesity. However, outcomes in youth with cognitive impairments and/or developmental delays are understudied. This paper reviewed the literature on bariatric surgery within this population. Fourteen studies published from 1975 to 2019 were identified. The majority (93%) of studies included patients with genetic disorders. Most studies reported no peri-operative complications (69%) and improved health outcomes (79%), with variable weight-loss results (29.2–86.2% excess weight loss). No significant differences were reported for youth with and without cognitive impairment and/or developmental delay in two studies. Limited available data suggest bariatric surgery may promote weight loss and improve health comorbidities for youth, irrespective of cognitive or developmental functioning. Clinical recommendations for working with patients and families are included.

What Is the Role of the New Index Relative Fat Mass (RFM) in the Assessment of Nonalcoholic Fatty Liver Disease (NAFLD)? Abstract Introduction Nonalcoholic fatty liver disease (NAFLD) is the liver manifestation of adiposopathy. Recently, a new score was developed to estimate body fat percentage (relative fat mass, RFM). We aimed to evaluate the value of RFM in predicting the presence and severity of NAFLD, compared with other anthropometric measurements. Methods RFM, body mass index (BMI), and other anthropometric measurements were evaluated in two cohorts of subjects: a cohort from a Portuguese prospective epidemiological study (e_Cor) and morbidly obese patients with biopsy-proven NAFLD. We evaluated if RFM and BMI were related with the presence and severity of liver disease, which was assessed by noninvasive tools in the first cohort and by liver histology in the morbidly obese cohort. The independence of relations found in univariate analysis was assessed with multivariable logistic regression analysis. Results In the general population cohort, 744 subjects (48% male) were enrolled. BMI-defined obesity was present in 23% and RFM-defined obesity in 86%. Insulin resistance (IR) related with BMI-defined obesity (OR 4.37 [2.16–8.84]) and weight (OR 1.05 [1.02–1.08]) in men, and waist circumference (WC) (OR 1.07 [1.03–1.11]) in women. Dyslipidemia and hypertension related with RFM-defined obesity in men (OR 2.96 [1.36–6.47] and OR 5.37 [1.31–22.06], respectively). Ultrasound-diagnosed NAFLD in 33% related with weight in men (OR 1.03 [1.003–1.06] and WC in women (OR 1.06 [1.02–1.10]). In men, ALT elevation related with weight (OR 1.04 [1.02–1.07]). In women, advanced fibrosis (estimated by NAFLD Fibrosis Score) associated with BMI-defined obesity (OR 42.43 [3.61–498.13]). In the morbidly obese cohort, 152 subjects were enrolled, of whom 84% were female, 37% had steatohepatitis, and 9.4% had advanced fibrosis. Adiponectin associated inversely and leptin positively with RFM in men. The severity of steatosis increased linearly with BMI and WC in women. Higher BMI associated with steatohepatitis in women and advanced fibrosis in men. Conclusion RFM-defined obesity better predicted dyslipidemia and hypertension (though not IR) and adipokine imbalance; however, it did not add value to BMI-defined obesity in predicting NAFLD or liver injury.

Presence of CC Genotype for rs17773430 Could Affect the Percentage of Excess Weight Loss 1 Year After Bariatric Surgery: Tehran Obesity Treatment Study (TOTS) Abstract Background Morbid obesity could last for a long period of life and increase the risk of morbidity as well as premature mortality. Although bariatric surgery benefits patients by quick weight loss, not all bariatric patients lose the same percentage of weight after a long time from surgery, which may be the result of diet, physical activity, and genetic components. Objectives In this study, we evaluated the association between the MC4R gene and both excess weight loss percentage (EWL%) and excess BMI loss percentage (EBMIL%) in a cohort of bariatric surgery patients after 6 and 12 months from surgery. Methods A total of 424 bariatric surgery patients who had participated in the Tehran Obesity Treatment Study and had weight measurements after 6 and 12 months from surgery were included in the study. Four SNPs in the MC4R gene were selected for evaluating the associations. Results We found that rs17773430 had a significant effect on both EWL% and EBMIL%, especially after 12 months of bariatric surgery. Furthermore, three other SNPs, rs17782313, rs476828, and rs11152213, did not show any significant association with EWL% and EBMIL%. Conclusion This study was the first to report on the association of rs17773430 with both EWL% and EBMIL% in a cohort of patients after bariatric surgery. We found that weight loss after surgery is influenced by genetic factors, and there were significant differences between the distribution of EWL% and EBMIL% in morbid obese bariatric patients who have two minor alleles of the rs17773430 and other SNPs.

Reply to a Letter to Editor About the Manuscript: Unsedated Transnasal Endoscopy for Preoperative Examination of Bariatric Patients—a Prospective Study

Laparoscopic Sleeve Gastrectomy After Endoscopic Sleeve Gastroplasty: Does Only Restriction Counts?

Surgical Mouse Models of Vertical Sleeve Gastrectomy and Roux-en Y Gastric Bypass: a Review Abstract Reviewed here are multiple mouse models of vertical sleeve gastrectomy (VSG) and Roux-en Y gastric bypass (RYGB) that have emerged over the past decade. These models use diverse approaches to both operative and perioperative procedures. Scrutinizing the benefits and pitfalls of each surgical model and what to expect in terms of post-operative outcomes will enhance our assessment of studies using mouse models, as well as advance our understanding of their translational potential. Two mouse models of bariatric surgery, VSG-lembert and RYGB-small pouch, demonstrate low mortality and most closely recapitulate the human forms of surgery. The use of liquid diets can be minimized, and in mice, RYGB demonstrates more reliable and longer lasting effects on weight loss compared to that of VSG.

Relationship Between Bariatric Surgery and Gastroesophageal Reflux Disease: a Systematic Review and Meta-analysis Abstract The purpose of this study was to investigate the relationship between bariatric surgery (laparoscopic sleeve gastrectomy [LSG] and laparoscopic Roux-en-Y gastric bypass [LRYGB]) and gastroesophageal reflux disease (GERD). The number of obese patients with newly onset, worsened, or improved GERD after bariatric surgery in each article were extracted. In the pooled analysis, LSG was associated with a higher risk of GERD than LRYGB (odds ratio [OR] = 5.10, 95% confidence interval [CI] 3.60–7.23, p < 0.001). Compared with LSG, LRYGB had a better effect on GERD (OR = 0.19, 95% CI 0.12–0.30, p < 0.001). LRYGB was more effective for treating GERD in obese patients than LSG and the incidence of newly onset GERD after LRYGB was lower.

Training in Bariatric Surgery: a National Survey of German Bariatric Surgeons Abstract Introduction Skill in bariatric surgery has been associated with postoperative outcome. Appropriate surgical training is of paramount importance. In order to continuously improve training strategies, it is necessary to assess current practices. Aim To determine how German bariatric surgeons have been trained and to assess current training strategies. Methods Between February 2017 and March 2017, an online census of surgeons registered as members of the German Society for Bariatric and Metabolic Surgery was conducted. A total of three reminders were sent out. Data were analyzed using descriptive statistics. Data was reported as median (interquartile range); percentages were adjusted for completed answers only. Results A response rate of 51% (n = 214) was achieved. Surgeons reported a median of 14.5 (8–20) years of surgical experience after initial training, with a specific bariatric experience of 7 (4–13) years. The total cumulative bariatric case volume was 240 (80–500) cases, with an annual case volume of 50 (25–80). The most commonly applied approaches to bariatric skills acquisition were “learning by doing” (71%), “course participation” (70%) and “observerships” (70%). Fellowships and the use of operating videos were less frequently applied strategies (19%/ 47%). Interestingly, observerships (94%) and course participation (89%) were rated as very important/important, whereas “learning by doing” (62%), watching operation videos (59%), and fellowships (48%) were less frequently perceived as important/very important training strategies. Conclusions The majority of surgeons performing bariatric cases were senior surgeons with more than 10 years of post-training experience; nevertheless, the survey revealed a lack of structured approaches to bariatric specialization training.

Primary Care Physicians’ Perceptions of Bariatric Surgery and Major Barriers to Referral Abstract Background Each year from 2011 to 2017, fewer than 1% of eligible Americans underwent bariatric surgery to treat obesity and obesity-related comorbidities. Recent studies have suggested that a lack of knowledge within the primary care specialty about the safety and efficacy of bariatric surgery greatly affects referral. This study aimed to analyze a large cohort of primary care physicians’ (PCPs) clinical perceptions regarding bariatric surgery and to identify major barriers to referral that could inform the implementation of a future educational strategy to address underutilization of bariatric surgery. Study Design A prospective anonymous electronic survey was sent to all primary care physicians at a multicenter community-based academic hospital system between March and June of 2018, with 150 respondents, a response rate of 28%. The survey was composed of eleven questions in total, the first eight utilizing a five-point Likert scale, with answers including strongly disagree, disagree, neutral, agree, and strongly agree. The final three questions utilized freeform answers of numbers or text where appropriate. Results Between 83 and 88% of PCPs responded favorably, either agree or strongly agree, to questions regarding the utility of bariatric surgery as an efficacious and valuable tool for the treatment of obesity and related comorbidities. PCPs reported an average body mass index (BMI) of 40.4 ± 5.0 kg/m2 at which bariatric surgery is a patient’s best option for weight loss and an average BMI of 38.0 ± 5.6 kg/m2 at which surgery is the best option for management of comorbidities. Eighty-six percent of PCPs agree that having a BMI over 40 kg/m2 is a greater risk to a patient’s long-term health than undergoing bariatric surgery. However, only 46.6% of PCPs claimed any familiarity with the NIH eligibility criteria for bariatric surgery and only 59.5% responded affirmatively that they were comfortable participating in the long-term care of a postoperative bariatric patient. The two highest reported barriers to referral for bariatric surgery together account for 40% of PCPs responses: 21.5% of PCPs report concern regarding surgical complications and/or long-term side effects as the primary barrier for referral, and 18.5% report concern for ineffective weight loss after bariatric surgery as a primary barrier to referral. Conclusion Results of this study indicate that despite largely positive attitudes toward the use of bariatric surgery in a patient population with obesity, primary care physicians report significant barriers to confidently referring their own patients. Further, bariatric surgery is overlooked in a large group of patients with BMIs between 35 and 40 kg/m2. Educational strategies to address these barriers should target rates of specific surgical complications and weight loss outcomes.

Metabolic Syndrome, as Defined Based on Parameters Including Visceral Fat Area, Predicts Complications After Surgery for Rectal Cancer Abstract Background/Objectives Metabolic syndrome (MetS) has become a major public health problem. However, few studies have examined the impact of MetS on the postoperative complications of colorectal cancer and the conclusions remain controversial. The present study aimed to investigate whether MetS, as defined based on visceral fat area (VFA) instead of BMI or waist circumference, would predict complications after surgery for rectal cancer. Subjects/Methods We conducted a retrospective study of patients who underwent surgery for rectal cancer at our department between January 2013 and August 2018. Univariate and multivariate analyses evaluating the risk factors for postoperative complications were performed. A receiver operating characteristic curve analysis was used to determine the gender-specific cut-off values for VFA. Results A total of 381 patients were included in the study. The optimal cut-off values for VFA were 117.9 cm2 for men and 76.9 cm2 for women, and 153 patients were diagnosed as having MetS. The rate of postoperative complication was significantly higher in the MetS group than that in the non-MetS group (34.6% versus 15.8%, P < 0.001). The multivariate logistic regression analysis demonstrated that MetS (OR 3.712, P < 0.001), NRS 2002 scores ≥ 3 (OR 2.563, P = 0.001), and tumor located at the lower 1/3 (OR 3.290, P = 0.001) were independent risk factors for complications after surgery for rectal cancer. Conclusion Metabolic syndrome, as defined based on parameters including visceral fat area, was an independent risk factor for complications after surgery for rectal cancer.