Long Term Effects Of Weight Loss Surgery – Dr Tabet is a staff specialist in the Department of Endocrinology at the Royal Prince Alfred Hospital; and Clinical Associate Lecturer at the University of Sydney, Sydney. Professor Catterson is Bowden Professor of Human Nutrition and Director of the Bowden Collaboration for Obesity, Nutrition, Exercise and Eating Disorders at the University of Sydney, Sydney; and an endocrinologist at the Royal Prince Alfred Hospital, Sydney. Dr Markovic is Director of Metabolism and Obesity Services at the Royal Prince Alfred Hospital, Sydney; and Clinical Associate Professor, Bowden Collaboration for Obesity, Nutrition, Exercise and Eating Disorders at the University of Sydney, Sydney, NSW.
Bariatric surgery is recognized as a legitimate treatment for obesity. Knowledge of its key long-term outcomes, such as durability of weight loss, remission of obesity-related comorbidities and surgical complications, has grown rapidly in recent years. Further knowledge of the physiological mechanisms of the underlying outcomes will drive more effective and less invasive techniques that can be personalized to the patient’s needs.
Long Term Effects Of Weight Loss Surgery
Obesity ranges from metabolic disorders (type 2 diabetes, non-alcoholic steatohepatitis, cardiovascular disease), malignancies (colorectal, breast, uterine, oesophageal, renal and pancreatic), hypoventilation and respiratory failure, muscle failure and blood diseases. K increases the risk of many serious medical conditions. Depression Importantly, it is independently associated with reduced life expectancy. Obesity is a major health problem worldwide and in Australia it affects 31% of the adult population and 8% of children and adolescents.
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Despite clinical advances in our understanding of energy balance regulation, effective therapeutic outcomes elude many obese and overweight patients. The traditional approach of recommending improvements in diet and exercise patterns does not lead to sustained weight loss for most individuals. Newer pharmacological therapies have relatively limited efficacy and are expensive, and may be poorly tolerated due to side effects.
A paradigm shift has legitimized bariatric surgery as an effective treatment for obesity, and evidence for its efficacy and safety has grown rapidly. Results of randomized controlled trials have demonstrated clear superiority for bariatric surgery over nonsurgical strategies, at least for short-term outcomes such as remission of type 2 diabetes. Evidence for long-term outcomes comes mostly from observational studies. Ongoing challenges include identifying patients eligible for bariatric surgery and selecting the most appropriate procedure for each individual and ensuring equitable access to this treatment modality for those most in need.
Based on the most recent Australian Bariatric Surgery Registry data, laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric operation in Australia and accounts for approximately 70% of surgeries, followed by Roux-en- Y gastric bypass (RYGB) and an anastomosis gastric bypass (OAGB), which together account for only 20% of surgeries.
Laparoscopic adjustable gastric banding (LAGB) has declined in popularity, in part related to the need for revisional surgery and poor long-term outcomes in the hands of many surgical units, as it accounts for 2% of bariatric surgical cases. . Procedures Notably, 6% of bariatric surgery performed in Australia is revisional. These processes and their effects are described in Figures 1a to c and Table 1. LSG has dominated weight loss surgeries in both Australia and the US because it is less invasive and more straightforward than gastric bypass with good long-term results. However, bypass procedures have greater metabolic benefits and somewhat more sustained weight loss, so are favorable for people with type 2 diabetes.
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OAGB is the newest procedure and has some advantages over RYGB, such as single anastomosis, a short learning curve for surgeons, fewer defects leading to herniation and easier reversal.
Compared to conventional treatments, bariatric surgery can provide long-term weight loss that is greater and more sustainable. Data from the large observational Swedish Obese Subjects (SOS) study published in 2012 showed that bariatric surgery (mainly the older procedure vertical banded gastroplasty [VBG], called ‘stomach stapling’), which creates a proximal gastric pouch is, and has been largely superseded by the simpler and safer LSG) was associated with greater weight loss than standard care at two years (23% vs. 0%) and 20 years (18% vs. 1%).
The prospective Utah Obesity Study demonstrated more effective weight loss for a group of patients undergoing RYGB (27.7%) compared to a nonsurgical control group (0.2% weight gain) after six years of follow-up.
An analysis of UK data documented a four-year weight loss of 38 kg for RYGB, 31 kg for LSG and 20 kg for LAGB.
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In an Australian study, patients undergoing LAGB were able to lose more than 50% of their weight (defined as the proportion of weight greater than a patient’s BMI of 25 kg/m
However, in the Longitudinal Evaluation of Bariatric Surgery, a multicenter observational study from the US, mean weight loss seven years after surgery was 28.4% for RYGB and 14.9% for LAGB. LAGB was associated with a one-third diabetes remission rate compared to RYGB (RYGB 60.2%).
There have been two recent randomized controlled trials comparing RYGB with LSG, and although there was greater weight loss with RYGB, it was not statistically significant in either study. Five years after surgery, RYGB resulted in a greater weight loss of 68.3% compared with 61.1% for LSG in one study and 57% compared with 49% in another study.
Although the metabolic benefits of bariatric surgery-induced weight loss are well documented, only a few patients with type 2 diabetes are offered this therapy. It could be argued that the mortality risk from diabetes far outweighs the mortality risk in specialist centers performing bariatric surgery – a 2015 review reported a surgical mortality rate of 0.44% for RYGB.
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The rapidity of the effect on glucose homeostasis after RYGB or LSG implies that it is mediated independently of weight loss. In contrast, improvements in glucose regulation after LAGB are entirely dependent on weight loss. Hyperinsulinaemic–euglycaemic clamp studies have shown increased insulin sensitivity with LSG and RYGB compared with LAGB; Whether this is due to the greater weight loss achieved with these procedures or due to hormonal changes is unclear. LSG and RYGB have each been shown to induce changes in gut hormones, such as glucagon-like peptide-1 (GLP-1) and gastric inhibitory polypeptide, as well as insulin, which may reduce postprandial glucose levels. .
GLP-1 also aids in appetite control by inhibiting gastric emptying and acting centrally to reduce food intake. These processes have also been shown to decrease another anorectic hormone, peptide YY, and, at least in the short term, the orexigenic hormone ghrelin.
Several high-quality randomized controlled trials have shown significant rates of diabetes remission at one or two years, with positive although lower rates of remission at three to five years of follow-up. The type 2 diabetes remission rates observed in these clinical trials are summarized in Table 2.
An Australian study in patients with diabetes of short duration (less than two years) observed a remission rate of 73% after two years of LAGB compared with 13% after conventional therapy.
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In one of these trials, a single-center open-label study of patients with diabetes (over five years) in Italy, diabetes remission (defined as fasting glucose levels below 5.6 mmol/L and HbA )
Less than 6.5% [<48 mmol/mol] while off glucose-lowering medication for at least 12 months) rate was 75% in patients treated with RYGB and 0% in patients treated with conventional medical therapy at two years. was
At five years, 37% of the RYGB group maintained remission compared with none of the medically treated patients.
(The study also included a group undergoing biliopancreatic diversion, a procedure now rarely performed in Australia.) A study at three sites in the US and one in Taiwan included 120 people with diabetes ( Means HBA
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9.6% [81 mmol/mol], about 50% of those taking insulin) were randomized to RYGB or intensive medical management, 35% of those who had RYGB (defined as HbA)
Less than 6.5% [48 mmol/mol] while off glucose-lowering therapy for at least 12 months) at two years and 16% at five years, whereas none of the patients on medical management alone had any ‘ and did not receive forgiveness.
In the Stampede trial, a randomized, nonblinded, single-center trial comparing bariatric surgery with intensive medical therapy for diabetes (n = 150) in the US, 42% of patients undergoing RYGB one year after randomization and 37% of patients undergoing LSG achieved The primary end point (HbA
Less than 6% [<42 mmol/mol] whether or not on glucose-lowering therapy, a more lenient endpoint than previous studies) compared with 12% of patients receiving medical therapy alone.
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The corresponding figures at five years were 29% for those who had RYGB, 23% for LSG and 5% in those who received medical therapy alone.
The average duration of diabetes in the Stampede study population was 8.3 years; At baseline, the mean HbA
Overall, lower fasting glycemia at baseline, shorter duration of diabetes and procedures that divert gastric contents to the small intestine, such as RYGB, are predictors of diabetes remission with bariatric surgery.
These findings mean that bariatric surgery should be more widely available for people with type 2 diabetes and is now included in guidelines for diabetes management. for
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