Bariatric and endo-bariatric interventions for diabetes:What is the current evidence?

Bariatric interventions have shown the best therapeutic benefits in individuals with obesity.They can be classified into surgical procedures(bariatric/metabolic surgery)and endoscopic procedures.Common surgical procedures include sleeve gastrectomy,Roux-en-Y gastric bypass,bilio-pancreatic diversion with or without duodenal switch and Stomach Intestinal Pylorus Sparing Surgery.Endoscopic procedures include intragastric balloons,transpyloric shuttle,endoscopic gastroplasties,aspiration therapy,duodenal mucosal resurfacing,duodeno-jejunal bypass liner,gastro-duodeno-jejunal bypass and incisionless magnetic anastomosis system among others.However,these procedures are limited by lack of wide availability,high costs,immediate and long-term complications and poor acceptability in some regions.Weight re-gain is a common concern and revisional metabolic surgery is often required.Appropriate pre-operative evaluation and correction of nutritional deficiencies post-surgery are very important.The most appropriate procedure for a person would depend on multiple factors like the intended magnitude of weight-loss,comorbidities and surgical fitness,as well as choice of the patient.Recently,glucagon-like insulinotropic peptide-1 receptor agonists(GLP)and the GLP-1/gastric inhibitory polypeptide co-agonist-Tirzepatide have shown remarkable weight loss potential,which is at par with bariatric interventions in some patients.How far these can help in avoiding invasive bariatric procedures in near future remains to be explored.An updated and comprehensive clinical review by He et al in the recent issue of World Journal of Diabetes address has addressed the avenues and challenges of currently available bariatric surgeries which will enable clinicians to make better decisions in their practice,including their applicability in special populations like the elderly and pediatric age groups,type 1 diabetes mellitus,and non-diabetics.

How to establish an endoscopic bariatric practice

Obesity is a chronic,progressive,and relapsing disease of excess adiposity that contributes to more than two hundred medical conditions and is projected to affect more than half the adult population of the United States by the year 2030.Given the limited penetrance of traditional bariatric surgery,as well as the cost and adherence barriers to anti-obesity medications,there is growing interest in the rapidly evolving field of endoscopic bariatric therapies(EBTs).EBTs are minimally invasive,same-day,per-oral endoscopic procedures and include endoscopic sleeve gastroplasty,intragastric balloons,and endoscopic bariatric revisional procedures.This field represents an exciting and innovative subspe-cialty within gastroenterology.However,building a successful endoscopic bariatric practice requires intentional,coordinated,and sustained efforts to overcome the numerous obstacles to entry.Common barriers include acquisition of the technical and cognitive skillset,practice limitations including the availability of nutrition counseling,facility capabilities,direct-to-consumer marketing,and financial pressures such as facility and anesthesia fees.As the highest-volume center for metabolic and bariatric endoscopy in the United States,we provide insights into successfully establishing an endoscopic bariatric program.

Bariatric surgery and diabetes:Current challenges and perspectives

Diabetes mellitus(DM)and obesity have become public issues of global concern.Bariatric surgery for the treatment of obesity combined with type 2 DM has been shown to be a safe and effective approach;however,there are limited studies that have systematically addressed the challenges of surgical treatment of obesity combined with DM.In this review,we summarize and answer the most pressing questions in the field of surgical treatment of obesity-associated DM.I believe that our insights will be of great help to clinicians in their daily practice.

Effect of bariatric surgery on metabolism in diabetes and obesity comorbidity:Insight from recent research

Obesity is a prevalent cause of diabetes mellitus(DM)and is a serious danger to human health.Type 2 DM(T2DM)mostly occurs along with obesity.Foodborne obesity-induced DM is caused by an excessive long-term diet and surplus energy.Bariatric surgery can improve the symptoms of T2DM in some obese patients.But different types of bariatric surgery may have different effects.There are some models built by researchers to discuss the surgical procedures’effects on me-tabolism in diabetes animal models and diabetes patients.It is high time to conclude all this effects and recommend procedures that can better improve metabolism.

Diabetes and obesity:A debate on bariatric interventions and its implications

In this editorial,we comment on an article by Tang et al published in the World Journal of Diabetes.Obesity and diabetes are two pathological situations that are intrinsically related.Neither lifestyle changes nor pharmacological treatments have achieved diabetes remission.From this perspective,bariatric surgery has been widely used as an approach for weight loss in obese patients and as a strategy to promote metabolic modulation.The main effects of bariatric surgery involve direct action in improving cardiovascular function and endothelial function and reducing insulin resistance,leading to diabetes remission in the short term following surgery.In this context,it has been observed that hormones from the gastrointestinal tract and endothelium play a prominent role in this process.By reversing endothelial dysfunction,it is possible to balance pro-inflammatory cytokine production,improving the availability of nitric oxide and inhibiting vascular oxidative stress.Furthermore,it can be considered an efficient anti-inflammatory strategy,alleviating interferon-gamma-mediated adipose tissue inflammation.The current challenge must be to unravel the pathophysiological mechanisms and potential targets for treating metabolic diseases.

Alcohol associated liver disease and bariatric surgery:Current perspectives and future directions

Bariatric surgery is a routinely performed procedure and is associated with a reduction in all-cause mortality in patients with obesity.However,bariatric sur-gery has also been linked to increased alcohol use with up to 30%of these patients developing alcohol use disorder(AUD).The mechanism of AUD after bariatric surgery is multifactorial and includes anatomic,metabolic,and neurohumoral changes associated with post-surgical anatomy.These patients are at increased risk of alcohol associated liver disease and,in some cases,require liver trans-plantation.In this article,we provide a scoping review of epidemiology,patho-physiology,and clinical outcomes of alcohol-related health conditions after bariatric surgery.

Pyloric Sympathectomy: A Novel Way to Get Pylorus Relaxation? Report of Two Bariatric Cases

Objective: This case report aimed to demonstrate a possible neuromuscular effect of pyloric sympathectomy on the pylorus motility, leading to its permanent relaxation, observed in two bariatric surgical cases, one primary and the other, revisional. Background: Pyloric sphincter is a physiological barrier to free gastric emptying. In sleeve gastrectomy and in Roux-en-Y gastric bypass revisions, that put the remnant stomach in transit, the pylorus can contribute to generate a high intragastric pressure, which could lead to acute gastric fistulas and/or chronic gastroesophageal reflux disease. The possibility of functionally relaxing the pylorus, promoting intragastric pressure reduction, could represent a protective maneuver against these complications. Methods: We describe herein a surgical maneuver applied in two cases of bariatric surgeries, with the intention of facilitating antrum-duodenal region exposure, in a sleeve gastrectomy and in a Roux-en-Y gastric bypass conversion to SADI-S. For this, a ligation of terminal peripyloric vessels was done, allowing a passage of a tape, which surrounded the pylorus, for its traction. In both cases, 30-day and 1-year endoscopic evaluations were done, to assess esophagitis signs, anastomosis healing and anatomical pouch aspect. A clinical evaluation was also done, to assess gastroesophageal symptoms (validated questionnaire). Results: In the postoperative endoscopic evaluations, no esophagitis were observed in any case and the gastric pouches had normal aspect, with the expected anatomical findings, compatible with the surgeries performed. The anastomosis healed without problems, in the revisional case. Interestingly, in both cases, it was observed a complete pyloric sphincter relaxation, which lasted until 1-year endoscopic evaluation. There were no fistulas, nor esophagitis in any of these cases. Clinically, there were no symptoms of gastroesophageal reflux disease (validated questionnaire). Conclusion: The observation of a pyloric durable atomy, that followed peripyloric dissection and vessels ligation (arterial branches), with its concomitant sympathectomy, can represent a new way of decompressing gastric chamber, either in primary or revisional bariatric surgeries. This maneuver can be protective against acute fistulas and gastroesophageal disease. Additional studies are necessary to confirm this hypothesis.

Long-term effectiveness,outcomes and complications of bariatric surgery

Dietary imbalance and overeating can lead to an increasingly widespread disease-obesity.Aesthetic considerations aside,obesity is defined as an excess of adipose tissue that can lead to serious health problems and can predispose to a number of pathological changes and clinical diseases,including diabetes;hypertension;atherosclerosis;coronary artery disease and stroke;obstructive sleep apnea;depression;weight-related arthropathies and endometrial and breast cancer.A body weight 20%above ideal for age,gender and height is a severe health risk.Bariatric surgery is a set of surgical methods to treat morbid obesity when other treatments such as diet,increased physical activity,behavioral changes and drugs have failed.The two most common procedures currently used are sleeve gastrectomy and gastric bypass.This procedure has gained popularity recently and is generally considered safe and effective.Although current data show that perioperative mortality is low and better control of comorbidities and short-term complications is achieved,more randomized trials are needed to evaluate the long-term outcomes of bariatric procedures.This review aims to synthesize and summarize the growing evidence on the long-term effectiveness,outcomes and complications of bariatric surgery.

Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas:Basic principles and recommendations

Post-surgical leaks and fistulas are the most feared complication of bariatric surgery.They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat.These two related conditions must be distinguished and characterized to guide the appropriate treatment.Leak is defined as a transmural defect with communication between the intra and extraluminal compartments,while fistula is defined as an abnormal communication between two epithelialized surfaces.Traditionally,surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates.However,with the development of novel devices and techniques,endoscopic therapy plays an increasingly essential role in managing these conditions.Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas.Several endoscopic techniques are available with different mechanisms of action,including direct closure,covering/diverting or draining.The treatment should be individualized by considering the characteristics of both the patient and the defect.Although there is a lack of high-quality studies to provide standardized treatment algorithms,this narrative review aims to provide a summary of the current scientific evidence and,based on this data and our extensive experience,make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.

Impact of bariatric surgery on glucose and lipid metabolism and liver and kidney function in food-induced obese diabetic rats

BACKGROUND Obesity usually causes diabetes mellitus(DM)and is a serious danger to human health.Type 2 DM(T2DM)mostly occurs along with obesity.Foodborne obesityinduced DM is caused by an excessive long-term diet and surplus energy.Bariatric surgery can improve the symptoms of T2DM in some obese patients.But different types of bariatric surgery may have different effects.AIM To investigate the effect of bariatric surgery on glucose and lipid metabolism and liver and kidney function in rats.METHODS Male Sprague-Dawley rats aged 6-8 wk underwent Roux-en-Y gastric bypass surgery(RYGB),sleeve gastrectomy(SG),or gastric banding(GB).Glucose and insulin tolerance tests,analyses of biochemical parameters,histological examination,western blot,and quantitative real-time polymerase chain reaction were conducted.RESULTS In comparison to the sham operation group,the RYGB,SG,and GB groups had decreased body weight and food intake,reduced glucose intolerance and insulin insensitivity,downregulated biochemical parameters,alleviated morphological changes in the liver and kidneys,and decreased levels of protein kinase Cβ/P66shc.The effect in the RYGB group was better than that in the SG and GB groups.CONCLUSION These results suggest that RYGB,SG and GB may be helpful for the treatment of foodborne obesity-induced DM.

Weight loss maintenance after bariatric surgery

Metabolic and bariatric surgery(MBS)is an effective treatment for patients with morbid obesity and its comorbidities.However,many patients experience weight regain(WR)after achieving their nadir weight.Establishing the definition of WR is challenging as postoperative WR has various definitions.Risk factors for WR after MBS include anatomical,racial,hormonal,metabolic,behavioral,and psychological factors,and evaluating such factors preoperatively is necessary.Long-term regular follow-up and timely treatment by a multidisciplinary team are important because WR after surgery is multi-factorial.Although lifestyle interventions that focus on appropriate dietary education,physical activity education or interventions,and behavioral psychological interventions are suggested,more well-designed studies are needed because studies evaluating intervention methods and the effectiveness of WR prevention are lacking.Antiobesity drugs can be used to prevent and manage patients with WR after MBS;however,more research is needed to determine the timing,duration,and type of anti-obesity drugs used to prevent WR.

Fertility outcomes following bariatric surgery

Obesity impacts human health in more than one way.The influence of obesity on human reproduction and fertility has been extensively examined.Bariatric surgery(BS)has been used as an effective tool to achieve long-term weight loss in both sexes.BS improves hormonal profiling,increasing the odds of spontaneous pregnancy and success rates following assisted reproductive techniques in infertile females.For obese males,BS does improve sexual function and hormonal profile;however,conflicting reports discuss reduced sperm parameters following BS.Although the benefits of BS in the fertility field are acknowledged,many areas call for further research,like choosing the safest surgical techniques,determining the optimal timing to get pregnant,and resolving the uncertainty of sperm parameters.

Impact of Ursodeoxycholic Acid on Gall Stone Formation Post Bariatric Surgery

Introduction: Bariatric surgery is identified as highly effective therapy for obesity and help to loss wight that is become important public health priority because it increases the risk of condition including diabetes, cardiovascular disease, and several types of cancer whether by accomplishing mini-gastric bypass, Gastric bypass (Roux-en-Y) and sleeve gastrectomy [1] rapid weight loss increased incidence risk of gall stone formation [2]. Ursodeoxycholic acid is a bile acid which affect a reduction in cholesterol in biliary fluid primary by dispersing the cholesterol and forming a liquid-crystal phase [2], it’s can play a significant role in preventing of gall stone formation. Objective: Study potential effect of Ursodeoxycholic acid (UDCA) on gall stone formation after bariatric surgery. Methods: This study Cross-sectional Trials, review of all patient underwent bariatric surgery November 2021-Jun 2022, Taif Military Hospital in the department of surgery, the sample of study will be around 143 participants or more, data collection all patient underwent bariatric surgery. Results: A Total of 160 patients underwent bariatric surgery in Taif Armed Forces Hospitals from 2015 to 2021. Of these, 53 were male (33.1%) and 107 were female (66.9%). only 33 patients (20.6%) received Ursodeoxycholic acid, and 127 patients (79.4%) weren’t proscribed for them. However, 40 patients (25%) develop gall stone and underwent cholecystectomy, three of them were on Ursodeoxycholic acid (9%) and 37 patients weren’t on Ursodeoxycholic acid (29%). which shows that Ursodeoxycholic acid remarkable reduce the risk of gall stone formation post wight reduction surgery. Conclusion: In conclusion, bariatric procedures come with the risk of leading to the formation of gallstones. This is especially in the stage when a patient experiences rapid loss of weight. This is why a preventive measure is necessary and UDCA have been considered for this purpose. This study has shown that patients who use UDCA are less bound to have gallstone formations.

More than Meets the Eye: A Qualitative Investigation of the Complex Weight History Constructions of Brazilian Women Who Underwent Bariatric Surgery

Most studies on bariatric surgery identify personal factors such as“non-compliance”to lifestyle changes as the cause of weight gain and subsequent inability to lose weight.Prior qualitative studies suggest that weight loss patients have complicated relationships with both self and weight,with significant emotional and psychological implications.But how do patients themselves understand the trajectories of their weight gain as related to intrinsic versus extrinsic factors?A qualitative analysis examined the aspects involved in the construction of higher body weight from the perspectives and life experiences of Brazilian women who underwent bariatric surgery,considering that Brazil has previously been reported as a highly anti-fat society.Individual,semi-structured interviews were conducted with thirty women(15 aged 33-59 and 15 aged 63-72).Data were analyzed identifying the regular,expressive,and meaningful significance units identified through the interviews.Although it was expected that different life events were reported as crucial to the perceived aetiology of individual weight gain stories,the participants reported that the emotional aspects had more impact.The extremely high value attached to having a particular body weight negatively influenced the participants’concept of identity and harmed their interactions and understanding of what it meant to be fully loved and accepted.Most of the participants underscored the importance of food in women’s lived experiences and explanations of weight gain.Despite this somatic response being dysfunctionally directed to food,this mechanism seemed to be vital to keeping them alive and engaged in the world.Finally,the participants faced layered vulnerabilities,which decreased their opportunities to access resources aimed at better body weight management.Broad approaches that consider emotional and physical care strategies must be proposed to this population.

Analysis of Changes in BDNF Levels Before and After Bariatric Surgery in Obese Patients

Objectives:The rate of obesity has been increasing globally,so is the number of obese patients undergoing bariatric surgery.The relationship between brain-derived neurotrophic factor(BDNF)and body weight has been highlighted in recent years,but there are few related studies in China.The purpose of this study was to investigate the changes of BDNF in obese patients before and after bariatric surgery and to provide evidence for obesity-related mechanisms.Methods:The BDNF levels in 44 obese patients who underwent bariatric surgery were measured by enzyme-linked immunosorbent assay(ELISA)before and 4.5 months after surgery.SPSS 27.0 was used for statistical analysis.Results:Among the 44 patients,30 were female and 14 were male.The body mass index(BMI)decreased significantly after bariatric surgery(P<0.001);the serum BDNF of the patients significantly increased(P<0.001)after surgery.There was no significant difference in BDNF among patients with different degrees of obesity before and after surgery(P>0.05).There were no significant differences in BMI and BDNF levels between different sexes before and after surgery(P>0.05).Conclusion:The BDNF levels of obese patients increased significantly after bariatric surgery,which proved that bariatric surgery has an effect on BDNF levels.

Organization of future training in bariatric gastroenterology

A world-wide rise in the prevalence of obesity continues. This rise increases the occurrence of, risks of, and costs of treating obesity-related medical conditions. Diet and activity programs are largely inadequate for the long-term treatment of medically-complicated obesity. Physicians who deliver gastrointestinal care after completing traditional training programs, including gastroenterologists and general surgeons, are not uniformly trained in or familiar with available bariatric care. It is certain that gastrointestinal physicians will incorporate new endoscopic methods into their practice for the treatment of individuals with medically-complicated obesity, although the longterm impact of these endoscopic techniques remains under investigation. It is presently unclear whether gastrointestinal physicians will be able to provide or coordinate important allied services in bariatric surgery, endocrinology, nutrition, psychological evaluation and support, and social work. Obtaining longitudinal results examining the effectiveness of this ad hoc approach will likely be difficult, based on prior experience with other endoscopic measures, such as the adenoma detection rates from screening colonoscopy. As a longterm approach, development of a specific curriculum incorporating one year of subspecialty training in bariatrics to the present training of gastrointestinal fellows needs to be reconsidered. This approach should be facilitated by gastrointestinal trainees' prior residency training in subspecialties that provide care for individuals with medical complications of obesity, including endocrinology, cardiology, nephrology, and neurology. Such training could incorporate additional rotations with collaborating providers in bariatric surgery, nutrition, and psychiatry. Since such training would be provided in accredited programs, longitudinal studies could be developed to examine the potential impact on accepted measures of care, such as complication rates, outcomes, and costs, in individuals with medically-complicated obesity.

Endoluminal solutions to bariatric surgery complications:A review with a focus on technical aspects and results

Obesity is a growing problem in developed countries,and surgery is the most effective treatment in terms of weight loss and improving medical comorbidity in a high proportion of obese patients.Despite the advances in surgical techniques,some patients still develop acute and late postoperative complications,and an endoscopic evaluation is often required for diagnosis.Moreover,the high morbidity related to surgical reintervention,the important enhancement of endoscopic procedures and technological innovations introduced in endoscopic equipment have made the endoscopic approach a minimally-invasive alternative to surgery,and,in many cases,a suitable first-line treatment of bariatric surgery complications.There is now evidence in the literature supporting endoscopic management for some of these complications,such as gastrointestinal bleeding,stomal and marginal ulcers,stomal stenosis,leaks and fistulas or pancreatobiliary disorders.However,endoscopic treatment in this setting is not standardized,and there is no consensus on its optimal timing.In this article,we aim to analyze the secondary complications of the most expanded techniques of bariatric surgery with special emphasis on those where more solid evidence exists in favor of the endoscopic treatment.Based on a thorough review of the literature,we evaluated the performance and safety of different endoscopic options for every type of complication,highlighting the most recent innovations and including comparative data with surgical alternatives whenever feasible.

Endoscopic management of post-bariatric surgery complications

Understanding the technical constructs of bariatric surgery is important to the treating endoscopist to maximize effective endoluminal therapy. Post-operative complication rates vary widely based on the complication of interest, and have been reported to be as high as 68% following adjustable gastric banding. Similarly, there is a wide range of presenting symptoms for post-operative bariatric complications, including abdominal pain, nausea and vomiting, dysphagia, gastrointestinal hemorrhage, and weight regain, all of which may provoke an endoscopic assessment. Bleeding and anastomotic leak are considered to be early(< 30 d) complications, whereas strictures, marginal ulcers, band erosions, and weight loss failure or weight recidivism are typically considered late(> 30 d) complications. Treatment of complications in the immediate post-operative period may require unique considerations. Endoluminal therapies serve as adjuncts to surgical and radiographic procedures. This review aims to summarize the spectrum and efficacy of endoscopic management of post-operative bariatric complications.

Is gastroscopy necessary before bariatric surgery?

Obesity is the abnormal accumulation of fat or adipose tissue in the body.It has become a serious health problem in the world in the last 50 years and is considered a pandemic.Body mass index is a widely used classification.Thus,obese individuals can be easily classified and standardized.Obesity is the second cause of preventable deaths after smoking.Obesity significantly increases mortality and morbidity.We thought of preparing a publication about routine procedures for the preoperative evaluation of obesity.The question that we asked as bariatric and metabolic surgeons but which was not exactly answered in the literature was“Is esophagogastroduodenoscopy(EGD)necessary before bariatric surgery?”We found different answers in our literature review.The European Association of Endoscopic Surgery guidelines recommend EGD for all bariatric procedures.They strongly recommend it for Roux-en-Y gastric bypass(RYGB).As a result of a recent study by the members of the British Obesity&Metabolic Surgery Society,preoperative EGD is routinely recommended for patients und-ergoing sleeve gastrectomy,even if they are asymptomatic,but not recommended for RYGB.It is recommended for symptomatic patients scheduled for RYGB.According to the International Sleeve Gastrectomy Expert Panel Consensus Statement,preoperative EGD is definitely recommended for patients scheduled for sleeve gastrectomy,but its routine use for RYGB is controversial.However,a different view is that the American Society for Gastrointestinal Endoscopy recom-mends endoscopy only for symptomatic patients scheduled for bariatric surgery.In the literature,the primary goal of EGD recommended for sleeve gastrectomy has been interpreted as determining esophagitis caused by gastroesophageal reflux.In the light of the literature,it is stated that this procedure is not necessary in America,while it is routinely recommended in the European continent.Considering medicolegal cases that may occur in the future,we are in favor of performing EGD before bariatric surgery.In conclusion,EGD before bariatric surgery is insurance for both patients and physicians.There is a need for larger and prospective studies to reach more precise conclusions on the subject.

Gastroesophageal reflux disease and severe obesity:Fundoplication or bariatric surgery?

Increases in the prevalence of obesity and gastroesophageal reflux disease (GERD) have paralleled one another over the past decade, which suggests the possibility of a linkage between these two processes. In both instances, surgical therapy is recognized as the most effective treatment for severe, refractory disease. Current surgical therapies for severe obesity include (in descending frequency) Roux-en-Y gastric bypass, adjustable gastric banding, sleeve gastrectomy, and biliopancreatic diversion with duodenal switch, while fundoplication remains the mainstay for the treatment of severe GERD. In several large series, however, the outcomes and durability of fundoplication in the setting of severe obesity are not as good as those in patients who are not severely obese. As such, bariatric surgery has been suggested as a potential alternative treatment for these patients. This article reviews current concepts in the putative pathophysiological mechanisms by which obesity contributes to gastroesophageal reflux and their implications with regards to surgical therapy for GERD in the setting of severe obesity.