Endoscopic therapy of weight regain after bariatric surgery

Weight regain following primary bariatric surgery occurs in a significant proportion of patients and is attributed to epidemiological,anatomical and metabolic factors.Surgical revision of these patients has significant risks and limited benefits.Endoscopic revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective,safe,less invasive and even reproducible treatment.We herein discuss the indication,selection and feasibility of different endoscopic techniques that could be used in the management of weight regain following primary bariatric surgery.Future research could optimize a personalized approach not only in the endoscopic management but also in combination with other therapeutic modalities for weight regain after bariatric surgery.

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.

Weight regain after bariatric surgery: Promoters and potential predictors

Obesity is globally viewed as chronic relapsing disease.Bariatric surgery offers the most efficient and durable weight loss approach.However,weight regain after surgery is a distressing issue as obesity can revert.Surgical procedures were originally designed to reduce food intake and catalyze weight loss,provided that its role is marginalized in long-term weight maintenance.Consequently,it is essential to establish a scientifically standardized applicable definitions for weight regain,which necessitates enhanced comprehension of the clinical situation,as well as have realistic expectations concerning weight loss.Moreover,several factors are proposed to influence weight regain as psychological,behavioral factors,hormonal,metabolic,anatomical lapses,as well as genetic predisposition.Recently,there is a growing evidence of utilization of scoring system to anticipate excess body weight loss,along with characterizing certain biomarkers that identify subjects at risk of suboptimal weight loss after surgery.Furthermore,personalized counseling is warranted to help select bariatric procedure,reinforce self-monitoring skills,motivate patient,encourage mindful eating practices,to avoid recidivism.

Bariatric surgery and long-term nutritional issues

Bariatric surgery is recognized as a highly effective therapy for obesity since it accomplishes sustained weight loss, reduction of obesity-related comorbidities and mortality, and improvement of quality of life. Overall, bariatric surgery is associated with a 42% reduction of the cardiovascular risk and 30% reduction of all-cause mortality. This review focuses on some nutritional consequences that can occur in bariatric patients that could potentially hinder the clinical benefits of this therapeutic option. All bariatric procedures, to variable degrees, alter the anatomy and physiology of the gastrointestinal tract; this alteration makes these patients more susceptible to developing nutritional complications, namely, deficiencies of macro-and micro-nutrients, which could lead to disabling diseases such as anemia, osteoporosis, protein malnutrition. Of note is the evidence that most obese patients present a number of nutritional deficits already prior to surgery, the most important being vitamin D and iron deficiencies. This finding prompts the need for a complete nutritional assessment and, eventually, an adequate correction of pre-existing deficits before surgery. Another critical issue that follows bariatric surgery is post-operative weight regain, which is commonly associated with the relapse of obesity-related comorbidities. Nu-tritional complications associated with bariatric surgery can be prevented by life-long nutritional monitoring with the administration of multivitamins and mineral supplements according to the patient's needs.

Therapeutic endoscopy for the treatment of post-bariatric surgery complications

Obesity rates continue to climb worldwide.Obesity often contributes to other comorbidities such as type 2 diabetes,hypertension,heart disease and is a known risk factor for many malignancies.Bariatric surgeries are by far the most invasive treatment options available but are often the most effective and can result in profound,durable weight loss with improvement in or resolution of weight associated comorbidities.Currently performed bariatric surgeries include Rouxen-Y gastric bypass,sleeve gastrectomy,and laparoscopic gastric banding.These surgeries are associated with significant weight loss,but also with significant rates of major complications.The complexity of these patients and surgical anatomies makes management of these complications by a multidisciplinary team critical for optimal outcomes.Minimally invasive treatments for complications are typically preferred because of the high risk associated with repeat operations.Endoscopy plays a large role in both the diagnosis and the management of complications.Endoscopy can provide therapeutic interventions for many bariatric surgical complications including anastomotic strictures,anastomotic leaks,choledocholithiasis,sleeve stenosis,weight regain,and eroded bands.Endoscopists should be familiar with the various surgical anatomies as well as the various therapeutic options available.This review article serves to delineate the current role of endoscopy in the management of complications after bariatric surgery.

Status of bariatric endoscopy–what does the surgeon need to know? A review

BACKGROUND Obesity is a chronic and multifactorial disease with a variety of potential treatment options available.Currently,there are several multidisciplinary therapeutic options for its management,including conservative,endoscopic,and surgical treatment.AIM To clarify indications,technical aspects,and outcomes of bariatric endoscopy.METHODS Narrative review of current literature based on electronic databases including MEDLINE(PubMed),Cochrane Library,and SciELO.RESULTS Bariatric endoscopy is in constant development and comprises primary and revisional treatment options as well as management of surgical complications.Various devices act upon different mechanisms of action,which may be individualized to each patient.Despite favorable results for the endoscopic treatment of obesity,prospective randomized studies with long-term follow-up are required to fully validate primary and revisional endoscopic therapies.Regarding the management of bariatric surgery complications,endoscopic therapy may be considered the procedure of choice in a variety of situations.Still,as there is no standardized algorithm,local experience should be considered in decision-making.CONCLUSION The treatment of patients with obesity is complex,and a multidisciplinary approach is essential.Bariatric endoscopy has shown impressive results both in the treatment of obesity and its surgical complications,and therefore,must be part of the armamentarium in the fight against this disease.

CD4+T cells memorize obesity and promote weight regain

Body weight regain often causes failure of obesity therapies while the underlying mechanism remains largely unknown.In this study,we report that immune cells,especially CD4+T cells,mediate the‘memory’of previous obese status.In a weight gain-loss-regain model,we found that C57BL/6J mice with an obesity history showed a much faster rate of body weight regain.This obesity memory could last for at least 2 months after previously obese mice were kept at the same body weight as non-obese mice.Surprisingly,such obesity memory was abrogated by dexamethasone treatment,whereas immunodeficient Rag1−/−and H2A−/−mice failed to establish such memory.Rag1−/−mice repossessed the obesity memory when immune cells or CD4+T cells isolated from previously obese mice were transferred.Furthermore,depletion of CD4+T cells led to obesity memory ablation.Taken together,we conclude that CD4+T cells mediate obesity memory and promote weight regain.