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Association of metabolic–bariatric surgery with long-term survival in adults with and without diabetes: a one-stage meta-analysis of matched cohort and prospective controlled studies with 174772 participants

Author/s: 
Syn, N.L, Cummings, D. E., Wang, L. Z., Lin, D. J., Zhao, J. J., Loh, M., Koh, Z. J., Chew, C. A., Kim, G., Bok-Yan So, J., Kaplan, L. M., Dixon, J. B., Shabbir, A.

Summary Background Metabolic–bariatric surgery delivers substantial weight loss and can induce remission or improvement of obesity-related risks and complications. However, more robust estimates of its effect on long-term mortality and life expectancy—especially stratified by pre-existing diabetes status—are needed to guide policy and facilitate patient counselling. We compared long-term survival outcomes of severely obese patients who received metabolic–bariatric surgery versus usual care. Methods We did a prespecified one-stage meta-analysis using patient-level survival data reconstructed from prospective controlled trials and high-quality matched cohort studies. We searched PubMed, Scopus, and MEDLINE (via Ovid) for randomised trials, prospective controlled studies, and matched cohort studies comparing all-cause mortality after metabolic–bariatric surgery versus non-surgical management of obesity published between inception and Feb 3, 2021. We also searched grey literature by reviewing bibliographies of included studies as well as review articles. Shared-frailty (ie, random-effects) and stratified Cox models were fitted to compare all-cause mortality of adults with obesity who underwent metabolic–bariatric surgery compared with matched controls who received usual care, taking into account clustering of participants at the study level. We also computed numbers needed to treat, and extrapolated life expectancy using Gompertz proportional-hazards modelling. The study protocol is prospectively registered on PROSPERO, number CRD42020218472. 

Keywords 
gastric bypass obesity proportional hazard models bariatric surgery gastrectomy weight loss

5-year mental health and eating pattern outcomes following bariatric surgery in adolescents: a prospective cohort study

Author/s: 
Järvholm, K, Bruze, G, Peltonen, M, Marcus, C, Flodmark, CE, Henfridsson, P, Beamish, AJ, Gronowitz, E, Dahlgren, J, Karlsson, J, Olbers, T

BACKGROUND:

Mental health problems are prevalent among adolescents with severe obesity, but long-term mental health outcomes after adolescent bariatric surgery are not well known. We aimed to assess mental health outcomes over 5 years of follow-up after Roux-en-Y gastric bypass surgery in adolescents who participated in the Adolescent Morbid Obesity Surgery (AMOS) study.

METHODS:

This was a non-randomised matched-control study in adolescents aged 13-18 years who had a BMI of 40 kg/m2 or higher, or 35 kg/m2 or higher in addition to obesity-related comorbidity; who had previously undergone failed comprehensive conservative treatment; and were of pubertal Tanner stage III or higher, with height growth velocity beyond peak. A contemporary control group, matched for BMI, age, and sex, who underwent conventional obesity treatment, was obtained from the Swedish Childhood Obesity Treatment Register. Data on dispensed psychiatric drugs and specialist treatment for mental disorders were retrieved from national registers with complete coverage. In the surgical group only, questionnaires were used to assess self-esteem (Rosenberg Self-Esteem [RSE] score), mood (Mood Adjective Checklist [MACL]), and eating patterns (Binge Eating Scale [BES] and Three-Factor Eating Questionnaire-R21 [TFEQ]). This study is registered with ClinicalTrials.gov (NCT00289705).

FINDINGS:

Between April 10, 2006, and May 20, 2009, 81 adolescents (53 [65%] female) underwent Roux-en-Y gastric bypass surgery, and 80 control participants received conventional treatment. The proportion of participants prescribed psychiatric drugs did not differ between groups in the years before study inclusion (pre-baseline; absolute risk difference 5% [95% CI -7 to 16], p=0·4263) or after intervention (10% [-6 to 24], p=0·2175). Treatment for mental and behavioural disorders did not differ between groups before baseline (2% [-10 to 14], p=0·7135); however, adolescents in the surgical group had more specialised psychiatric treatment in the 5 years after obesity treatment than did the control group (15% [1 to 28], p=0·0410). There were few patients who discontinued psychiatric treatment post-surgery (three [4%] receiving psychiatric drug treatment and six [7%] receiving specialised care for a mental disorder before surgery). In the surgical group, self-esteem (RSE score) was improved after 5 years (mixed model mean 21·6 [95% CI 19·9 to 23·4]) relative to baseline (18·9 [17·4 to 20·4], p=0·0059), but overall mood (MACL score) was not (2·8 [2·7 to 2·9] at 5 years vs 2·7 [2·6 to 2·8] at baseline, p=0·0737). Binge eating was improved at 5 years (9·3 [7·4 to 11·2]) relative to baseline (15·0 [13·5 to 16·5], p<0·0001). Relative changes in BMI were not associated with the presence or absence of binge eating at baseline.

INTERPRETATION:

Mental health problems persist in adolescents 5 years after bariatric surgery despite substantial weight loss. Although bariatric surgery can improve many aspects of health, alleviation of mental health problems should not be expected, and a multidisciplinary bariatric team should offer long-term mental health support after surgery.

FUNDING:

Swedish Research Council, VINNOVA, Västra Götalandsregionen, ALF VG-region, Region Stockholm, Swedish Child Diabetes Foundation, Swedish Heart and Lung Foundation, Tore Nilsson's Foundation, SUS Foundations and Donations, Capio Research Foundation, and Mary von Sydow's Foundation.

Keywords 
mental health children adolescent bariatric surgery obesity

Five-Year Outcomes of Gastric Bypass in Adolescents as Compared with Adults

Author/s: 
Inge, Thomas H., Courcoulas, Anita P., Jenkins, Tod M., Michalsky, Marc P., Brandt, Mary L., Xanthakos, Stavra A., Dixon, John B., Harmon, Carroll M., Chen, Mike K., Xie, Changchun, Evans, Mary E., Helmrath, Michael A.

BACKGROUND

Bariatric surgery results in weight loss and health improvements in adults and adolescents. However, whether outcomes differ according to the age of the patient at the time of surgery is unclear.

METHODS

We evaluated the health effects of Roux-en-Y gastric bypass in a cohort of adolescents (161 patients enrolled from 2006 through 2012) and a cohort of adults (396 patients enrolled from 2006 through 2009). The two cohorts were participants in two related but independent studies. Linear mixed and Poisson mixed models were used to compare outcomes with regard to weight and coexisting conditions between the cohorts 5 years after surgery. The rates of death and subsequent abdominal operations and selected micronutrient levels (up to 2 years after surgery) were also compared between the cohorts.

RESULTS

There was no significant difference in percent weight change between adolescents (−26%; 95% confidence interval [CI], −29 to −23) and adults (−29%; 95% CI, −31 to −27) 5 years after surgery (P=0.08). After surgery, adolescents were significantly more likely than adults to have remission of type 2 diabetes (86% vs. 53%; risk ratio, 1.27; 95% CI, 1.03 to 1.57) and of hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88). Three adolescents (1.9%) and seven adults (1.8%) died in the 5 years after surgery. The rate of abdominal reoperations was significantly higher among adolescents than among adults (19 vs. 10 reoperations per 500 person-years, P=0.003). More adolescents than adults had low ferritin levels (72 of 132 patients [48%] vs. 54 of 179 patients [29%], P=0.004).

CONCLUSIONS

Adolescents and adults who underwent gastric bypass had marked weight loss that was similar in magnitude 5 years after surgery. Adolescents had remission of diabetes and hypertension more often than adults. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases; ClinicalTrials.gov number, NCT00474318.)

Keywords 
gastric bypass

Short- and Long-Term Outcomes after Bariatric Surgery in the Medicare Population

Author/s: 
Orestis, A. Panagiotou, Markozannes, Georgios, Kowalski, Rishi, Di, Mengyang, Bond, Dale S., Ryder, Beth A., Adam, Gaelen P., Trikalinos, Thomas A.

Introduction. We conducted a technology assessment to summarize and appraise the current evidence regarding the effectiveness and safety of bariatric surgery in the Medicare-eligible population.

Data Sources. We searched six bibliographic databases and the reference lists of published clinical practice guidelines, relevant narrative and systematic reviews, and scientific information packages from manufacturers and other stakeholders on the outcomes and prediction models of different bariatric procedures studied in the Medicare-eligible population.

Results. Of 126 eligible studies, 83 described outcomes after bariatric therapy and 43 described predictors of body weight loss or absolute body weight after bariatric therapy. We did not identify any randomized clinical trials in the Medicare-eligible population. Studies examined surgical modalities. There were no studies on endoscopically-performed bariatric procedures. Only 15 studies had a design and/or analytical approach that allowed inferences for causal treatment effects on weight loss outcomes, adverse events/complications, or other non-weightloss outcomes. Bariatric surgery in the Medicare-eligible population leads to improvements in weight loss and non-weight-loss outcomes, particularly mortality, metabolic, cardiovascular, respiratory, and musculoskeletal outcomes, and polypharmacy but the strength of evidence is low to moderate. There is moderate evidence that Roux-en-Y gastric bypass performs better compared to sleeve gastrectomy or adjustable gastric banding for metabolic, cardiovascular, and renal function outcomes and for postoperative complications. Finally, no models to predict weight loss have undergone internal or external validation.

Conclusions. Relatively few nonrandomized studies examine the comparative effectiveness and safety of bariatric therapies in the Medicare population. Large gaps remain in regard to comparisons of individual bariatric surgical procedures to each other, and very limited evidence exists in regard to patient-centered outcomes such as quality of life after surgery.

Keywords 
medicare gastric bypass weight loss bariatric surgery
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