Determinants of Cardiorespiratory Fitness After Bariatric Surgery: Insights From a Randomised Controlled Trial of a Supervised Training Program.

BACKGROUND: Severely obese patients have decreased cardiorespiratory fitness (CRF) and poor functional capacity. Bariatric surgery-induced weight loss improves CRF, but the determinants of this improvement are not well known. We aimed to assess the determinants of CRF before and after bariatric surgery and the impact of an exercise training program on CRF after bariatric surgery. METHODS: Fifty-eight severely obese patients (46.1 ± 6.1 kg/m2, 78% women) were randomly assigned to either an exercise group (n = 39) or usual care (n = 19). Exercise training was conducted from the 3rd to the 6th months after surgery. Anthropometric measurements, abdominal and mid-thigh computed tomographic scans, resting echocardiography, and maximal cardiopulmonary exercise testing was performed before bariatric surgery and 3 and 6 months after surgery. RESULTS: Weight, fat mass, and fat-free mass were reduced significantly at 3 and 6 months, without any additive impact of exercise training in the exercise group. From 3 to 6 months, peak aerobic power (V̇O2peak) increased significantly (P < 0.0001) in both groups but more importantly in the exercise group (exercise group: from 18.6 ± 4.2 to 23.2 ± 5.7 mL/kg/min; control group: from 17.4 ± 2.3 to 19.7 ± 2.4 mL/kg/min; P value, group × time = 0.01). In the exercise group, determinants of absolute V̇O2peak (L/min) were peak exercise ventilation, oxygen pulse, and heart rate reserve (r2 = 0.92; P < 0.0001), whereas determinants of V̇O2peak indexed to body mass (mL/kg/min) were peak exercise ventilation and early-to-late filling velocity ratio (r2 = 0.70; P < 0.0001). CONCLUSIONS: A 12-week supervised training program has an additive benefit on cardiorespiratory fitness for patients who undergo bariatric surgery.

Second-stage duodenal switch for sleeve gastrectomy failure: A matched controlled trial.

BACKGROUND: Sleeve gastrectomy (SG) has become the predominant bariatric surgery worldwide. However, the surgical management in case of failure is still debated. OBJECTIVES: To evaluate the risks and benefits of converting SG to biliopancreatic diversion with duodenal switch (BPD-DS) for suboptimal outcome after SG. SETTING: University-affiliated tertiary care center. METHODS: We included all patients who underwent a laparoscopic second-stage duodenal switch (DS) for weight loss failure after SG and had a minimal follow-up of 2 years. Patients were matched 1:1 for age, sex, body mass index, and year of surgery with a group of patients who underwent a single-stage laparoscopic BPD-DS. Data were obtained from our prospective electronic database and are reported as the mean ± standard deviation, comparing 2- versus 1-stage BPD-DS. RESULTS: A total of 118 patients were included (59 in each group). There was no significant difference in initial body mass index (53.8 ± 9.7 versus 52.7 ± 7.8 kg/m2, P = .4), age (44.0 ± 10.2 versus 43.4 ± 9.6 yr, P = .5), and sex ratio (37 female/22 male, P > .9) between the 2 groups. Mean follow-up was 59.9 ± 27 months, with an 85% (n = 100) follow-up rate. Patients were converted to BPD-DS after a mean 24.4 ± 10.2 months. There was no short- or long-term mortality. Major 90-days complications occurred in 2%, 5%, and 5% after SG, second-stage DS and single-stage BPD-DS, respectively (P > .05). At the time of conversion, the excess weight loss for SG was 39 ± 17% and total weight loss was 20 ± 9%. After DS or single-stage BPD-DS, the excess weight loss was 74.8 ± 18% versus 87.9 ± 18% at 1 year (n = 107, P = .00021), 80.2 ± 17% versus 92.3 ± 14% at 2 years (n = 100, P = .002), and 80.2 ± 18% versus 87.2 ± 16% at 3 years (n = 70, P = .6). Total weight loss was 38.7 ± 9% versus 44.5 ± 8% at 1 year (P = .0004), 41.2 ± 9% versus 46.8 ± 7% at 2 years (P = .001), and 42.3 ± 9% versus 45.1 ± 9% at 3 years (P = .2). The incidence of type 2 diabetes and hypertension before surgery were 61% versus 54% and 58% versus 47%. Remission rate for type 2 diabetes increased from 59% to 94% after second-stage DS (P = .001), which is identical to first-stage BPD-DS (94%). Remission of hypertension increased from 42% to 77% after second-stage DS (P = .03) and was 71% after first-stage BPD-DS (P = .8). CONCLUSION: Second-stage DS is an effective option for the management of suboptimal outcomes of SG, with an additional 41% excess weight loss and 35% remission rate for type 2 diabetes. At 3 years, the global outcomes of staged approach did not significantly differ from single-stage BPD-DS; however, longer-term outcomes are still needed.

Long alimentary limb duodenal switch (LADS): a short-term prospective randomized trial.

BACKGROUND: Biliopancreatic diversion with duodenal switch (BPD-DS) is one of the most effective bariatric surgeries, in terms of weight loss and remission of co-morbidities. It is however associated with a significant risk of protein and nutritional deficiency, as well as gastrointestinal side effects. OBJECTIVES: To assess the effect of increasing the strict alimentary limb on weight loss, nutritional deficiency and quality of life, compared with standard BPD-DS. SETTINGS: University-affiliated tertiary care center. METHODS: Prospective randomized double blind (patient-evaluator) trial in which patients were assigned in a 1:1 ratio to undergo a modified BPD-DS with a long alimentary limb (1 m from Treitz ligament, n = 10) or a standard biliopancreatic diversion (strict alimentary limb of 1.5 m, n = 10). Common channel was kept at 100 cm in both groups. Follow-up at 12 months was completed in all patients. RESULTS: Initial weight (126 ± 10 versus 125 ± 17, P = .92), age (40 ± 7 versus 37 ± 8, P = .35), and sex ratio (1 female/9 males) were similar in both groups. Excess weight loss and total weight loss were significantly higher in the standard BPD-DS group (93.4 ± 12% versus 73.3 ± 7%, P = .0007 and 46 ± 5.6% versus 37 ± 3.4%, P = .0004). The study group had significantly higher vitamin D, manganese, and copper levels at 12 months. Both groups had similar drop in glycated hemoglobin, cholesterol levels, and resolution of co-morbidities at 12 months. Long alimentary limb was associated with significantly less bowel movements a day (1.6 ± .97 versus 2.55 ± 1.01, P = .01), less gastrointestinal side effects (bloating and gas, P<.05) and required less pancreatic enzymes supplements (0 versus 40%, P = .04) and calcium supplement. Quality of life was significantly improved in both groups in all domains (all P<.05). CONCLUSION: At 12 months, weight loss was lesser in the long alimentary limb group. There was however no difference in the remission of co-morbidities and higher levels of vitamin D, manganese, and copper. Gastrointestinal adverse effects and the need for pancreatic enzymes were less with similarly excellent quality of life at 12 months. Longer follow-up is necessary to evaluate long-term weight loss and nutritional deficiencies.