The Impact of Bariatric Surgery on Nitrogen Balance at Six months Post-surgery.

PURPOSE: Obesity, defined as abnormal or excessive fat accumulation that presents a risk to health, rose from 8.6 to 10.5% in Singapore's residents. Bariatric surgery, the primary treatment for severe obesity, induces fat and muscle loss. Adequate protein intake is vital for preventing muscle loss. This study examines nitrogen balance in individuals with obesity pre- and post-surgery. MATERIALS AND METHODS: Sixteen participants with severe obesity (BMI ≥ 32.5 kg/m2) undergoing bariatric surgery (14 sleeve gastrectomy, 2 Roux-en-Y gastric bypass) and 20 normal-weight controls (BMI < 25 kg/m2) were recruited. Nitrogen balance, calculated from dietary protein intake and urine nitrogen excretion, was assessed. Participants with obesity were re-evaluated 6 months post-surgery. Data were analyzed using parametric methods. RESULTS: At baseline, controls had a BMI of 20.8 ± 2.1 kg/m2; those with obesity had 40.9 ± 7.3. Daily calorie and protein intake for participants with obesity were not statistically significantly different from controls (calorie intake at 1467 ± 430 vs. 1462 ± 391 kcal, p = 0.9701, protein intake 74.2 ± 28.7 vs. 64.6 ± 18.3 g, p = 0.2289). Post-surgery, BMI, fat-free mass, fat mass, total energy intake, carbohydrate, and protein intake decreased significantly (p < 0.01). Protein oxidation and urine nitrogen excretion did not change after bariatric surgery. However, nitrogen balance significantly reduced from 2.62 ± 5.07 to - 1.69 ± 5.07 g/day (p = 0.025). CONCLUSION: Dietary protein intake is inadequate in individuals with obesity at 6 months post-bariatric surgery and contributes to a state of negative nitrogen balance.

Collaborative Prescribing Practice in Managing Patients Post-Bariatric Surgery in a Tertiary Centre in Singapore.

Background: A collaborative prescribing (CP) practice model, established by the endocrinologists, pharmacists, and advanced practice nurses, aims to provide for the postoperative monitoring and medical and nutritional management of stable patients after bariatric surgery. Method: Under the CP agreement, endocrinologists refer patients who have undergone bariatric surgery with stable medical conditions to CP practitioners, comprising senior pharmacists and advanced practice nurses. CP practitioners review the patient's weight loss progress, blood test results and vitals, the sufficiency of micronutrient repletion, adherence to supplements and medications, and chronic disease control. CP practitioners can prescribe and adjust the medications and supplements, in accordance with a clinical evaluation and standard guidance. Patients who require immediate attention due to complications or red flags are referred to the primary endocrinologist for further management. Results: From 5 May 2020 to 30 September 2023, CP practitioners provided 672 consultations. At least 68% and 80% of patients achieved appropriate weight loss post-surgery during the acute and maintenance phases, respectively. Less than 10% of the patients presented with anaemia and iron deficiency, and vitamin B12, folate and vitamin D deficiency. More than 80% of patients achieved a HbA1c of less than 7%. Conclusions: The CP practice framework provides a sustainable and viable model to facilitate optimal outcomes after bariatric surgery.

Protocol update and baseline characteristics for the TRIal to slow the Progression of Diabetes (TRIPOD) randomized controlled trial.

BACKGROUND: Type 2 diabetes (T2D), a major risk factor for cardiovascular disease and other adverse health conditions, is on the rise in Singapore. TRIPOD is a randomized controlled trial aimed to determine whether complementing usual care with an evidence-based diabetes management package (DMP) -comprising access to an evidence-based app, health coaching, pedometer, glucometer and weighing scale, with or without a financial rewards scheme (M-POWER rewards), can improve mean HbA1c levels at months 6 and 12. METHODS: The protocol was published in Trials, accessible via https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-019-3749-x 1. This manuscript updates the protocol with changes to the study design due to challenges with recruitment and presents baseline characteristics. Key updates include changing the arm allocation ratio from 1:1:1 (Arm 1-Usual Care: Arm 2-DMP: Arm 3-DMP+M-POWER rewards) to 10:1:10, the sample size from 339 to 269, the intervention period from two to one year, and the primary hypothesis to focus solely on differences between Usual Care and DMP+M-POWER rewards. Recruitment for the study began on 19 October 2019 and ended on 4 June 2022. RESULTS: The average age of participants was 55.0 (SD9.7) years old and 64.2% were male. The majority of participants (76.8%) were Chinese, 4.9% Malay and 18.3% Indian and of other ethnicities. 67.0% had a monthly household income of SGD$4000 or more. The mean baseline HbA1c was 8.10% (SD 0.95) and the mean body mass index was 26.8 kg/m2 (SD 5.3). DISCUSSION: The final participant completed month 12 follow-up data collection on 8 June 2023. All pre-planned analyses will be conducted and final results reported. TRIAL REGISTRATION: ClinicalTrials.gov NCT03800680 . Registered on 11 January 2019.

Cost-savings of short stay sleeve gastrectomy and walk-in hydration clinic versus conventional inpatient care.

OBJECTIVE: We aim to evaluate the cost-saving of the short stay ward (SSW) versus conventional inpatient care following sleeve gastrectomy (LSG). We also compared the readmission rates pre- and post-inception of the intravenous hydration clinic and analyzed the cost-savings. METHODS: Patients who underwent LSG between December 2021 to March 2022 with SSW care were compared with standard inpatient care. Total costs were analyzed using univariate analysis. With a separate cohort of patients, 30-day readmission rates in the 12-months preceding and following implementation of the IV hydration clinic and associated cost-savings were evaluated. RESULTS: After matching on the propensity score to within ± 0.1, 20-subjects pairs were retained. The total cost per SSW-subject was significantly lower at $13,647.81 compared to $15,565.27 for conventional inpatient care (p = 0.0302). Lower average ward charges ($667.76 vs $1371.34, p < 0.0001), lower average daily treatment fee per case ($235.68 vs $836.54, p < 0.0001), and lower average laboratory investigation fee ($612.31 vs $797.21, p < 0.0001) accounted for the difference in costs between the groups. Thirty-day readmission rate reduced from 8.9 to 1.8% after implementation of the hydration clinic (p < 0.01) with decreased 30-day readmission cost (S$96,955.57 vs. S$5910.27, p < 0.01). CONCLUSION: SSW for LSG is cost-effective and should be preferred to inpatient management. Walk-in hydration clinics significantly reduced readmission rates and result in tremendous cost-savings.

Development and validation of an interpretable machine learning-based calculator for predicting 5-year weight trajectories after bariatric surgery: a multinational retrospective cohort SOPHIA study.

BACKGROUND: Weight loss trajectories after bariatric surgery vary widely between individuals, and predicting weight loss before the operation remains challenging. We aimed to develop a model using machine learning to provide individual preoperative prediction of 5-year weight loss trajectories after surgery. METHODS: In this multinational retrospective observational study we enrolled adult participants (aged ≥18 years) from ten prospective cohorts (including ABOS [NCT01129297], BAREVAL [NCT02310178], the Swedish Obese Subjects study, and a large cohort from the Dutch Obesity Clinic [Nederlandse Obesitas Kliniek]) and two randomised trials (SleevePass [NCT00793143] and SM-BOSS [NCT00356213]) in Europe, the Americas, and Asia, with a 5 year follow-up after Roux-en-Y gastric bypass, sleeve gastrectomy, or gastric band. Patients with a previous history of bariatric surgery or large delays between scheduled and actual visits were excluded. The training cohort comprised patients from two centres in France (ABOS and BAREVAL). The primary outcome was BMI at 5 years. A model was developed using least absolute shrinkage and selection operator to select variables and the classification and regression trees algorithm to build interpretable regression trees. The performances of the model were assessed through the median absolute deviation (MAD) and root mean squared error (RMSE) of BMI. FINDINGS: 10 231 patients from 12 centres in ten countries were included in the analysis, corresponding to 30 602 patient-years. Among participants in all 12 cohorts, 7701 (75·3%) were female, 2530 (24·7%) were male. Among 434 baseline attributes available in the training cohort, seven variables were selected: height, weight, intervention type, age, diabetes status, diabetes duration, and smoking status. At 5 years, across external testing cohorts the overall mean MAD BMI was 2·8 kg/m2 (95% CI 2·6-3·0) and mean RMSE BMI was 4·7 kg/m2 (4·4-5·0), and the mean difference between predicted and observed BMI was -0·3 kg/m2 (SD 4·7). This model is incorporated in an easy to use and interpretable web-based prediction tool to help inform clinical decision before surgery. INTERPRETATION: We developed a machine learning-based model, which is internationally validated, for predicting individual 5-year weight loss trajectories after three common bariatric interventions. FUNDING: SOPHIA Innovative Medicines Initiative 2 Joint Undertaking, supported by the EU's Horizon 2020 research and innovation programme, the European Federation of Pharmaceutical Industries and Associations, Type 1 Diabetes Exchange, and the Juvenile Diabetes Research Foundation and Obesity Action Coalition; Métropole Européenne de Lille; Agence Nationale de la Recherche; Institut national de recherche en sciences et technologies du numérique through the Artificial Intelligence chair Apprenf; Université de Lille Nord Europe's I-SITE EXPAND as part of the Bandits For Health project; Laboratoire d'excellence European Genomic Institute for Diabetes; Soutien aux Travaux Interdisciplinaires, Multi-établissements et Exploratoires programme by Conseil Régional Hauts-de-France (volet partenarial phase 2, project PERSO-SURG).

Multiparametric Magnetic Resonance Imaging and Magnetic Resonance Elastography to Evaluate the Early Effects of Bariatric Surgery on Nonalcoholic Fatty Liver Disease.

Background: Bariatric surgery is the most effective treatment for morbid obesity and reduces the severity of nonalcoholic fatty liver disease (NAFLD) in the long term. Less is known about the effects of bariatric surgery on liver fat, inflammation, and fibrosis during the early stages following bariatric surgery. Aims: This exploratory study utilises advanced imaging methods to investigate NAFLD and fibrosis changes during the early metabolic transitional period following bariatric surgery. Methods: Nine participants with morbid obesity underwent sleeve gastrectomy. Multiparametric MRI (mpMRI) and magnetic resonance elastography (MRE) were performed at baseline, during the immediate (1 month), and late (6 months) postsurgery period. Liver fat was measured using proton density fat fraction (PDFF), disease activity using iron-correct T1 (cT1), and liver stiffness using MRE. Repeated measured ANOVA was used to assess longitudinal changes and Dunnett's method for multiple comparisons. Results: All participants (Age 45.1 ± 9.0 years, BMI 39.7 ± 5.3 kg/m2) had elevated hepatic steatosis at baseline (PDFF >5%). In the immediate postsurgery period, PDFF decreased significantly from 14.1 ± 7.4% to 8.9 ± 4.4% (p = 0.016) and cT1 from 826.9 ± 80.6 ms to 768.4 ± 50.9 ms (p = 0.047). These improvements continued to the later postsurgery period. Bariatric surgery did not reduce liver stiffness measurements. Conclusion: Our findings support using MRI as a noninvasive tool to monitor NAFLD in patient with morbid obesity during the early stages following bariatric surgery.

Study on weight loss outcomes after bariatric surgery to determine a metric least influenced by preoperative BMI.

BACKGROUND: Percentage excess weight loss (%EWL) and percentage total weight loss (%TWL) are used for reporting outcomes after bariatric surgery. However, they are not ideal for comparing outcomes on populations of varied initial body mass index (BMI). This study aimed to validate a recently introduced metric - percentage alterable weight loss (%AWL), after laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB). METHODS: Analysis of weight data of all patients who had undergone LSG and LRYGB until the end of the year 2021. Outcomes for both procedures were analyzed separately. The patients were divided into quartile subgroups Q1 (lowest BMI) to Q4 (highest BMI) and weight loss up to 5 years postoperatively was compared using %EWL, %TWL and %AWL metrics. An intermediary metric was also tested for its effect on the weight loss patterns for both procedures. RESULTS: The cohort included 1020 LSG and 322 LRYGB patients, with initial mean BMI of 43.5 ± 7.5 and 41.9 ± 8.3 kg/m2, respectively. %EWL significantly favors lower BMI subgroups for both procedures. %TWL is ideal for comparing weight loss during the first 6 months but it then favors higher BMI subgroups beyond 6 months. %AWL with reference BMI of 13 kg/m2 seems the best metric for medium-term comparison of weight loss for LRYGB and an intermediary metric based on BMI 8 kg/m2 provides the best fit for medium-term comparison for LSG. CONCLUSIONS: %TWL is least influenced by initial BMI during short-term follow-up after LSG and LRYGB. For medium-term comparison, %AWL is best suited for LRYGB while an intermediary metric is found to provide the best fit for LSG.

Examining spousal and family support as predictors of long-term weight loss and remission of type 2 diabetes following bariatric surgery in Singapore: a retrospective cohort study.

OBJECTIVES: Postoperative outcomes vary considerably across bariatric patients and may be related to psychosocial factors. In this study, we examined whether a patient's family support predicts postsurgical weight loss and the remission of type 2 diabetes mellitus (T2DM). DESIGN: Retrospective cohort study in Singapore. SETTING: Participants were recruited from a public hospital in Singapore. PARTICIPANTS: Between 2008 and 2018, 359 patients completed a presurgical questionnaire before undergoing gastric bypass or sleeve gastrectomy. OUTCOME MEASURES: As part of the questionnaire, patients described their family support in terms of structure (marital status, number of family members in the household) and function (marriage satisfaction, family emotional support, family practical support). Linear mixed-effects and Cox proportional-hazard models were used to examine whether these family support variables predicted percent total weight loss or T2DM remission up to 5 years postsurgery. T2DM remission was defined as glycated haemoglobin (HbA1c) <6.0% without medications. RESULTS: Participants had a mean preoperative body mass index of 42.6±7.7 kg/m2 and HbA1c (%) of 6.82±1.67. Marital satisfaction was found to be a significant predictor of postsurgical weight trajectories. Namely, patients who reported higher marital satisfaction were more likely to sustain weight loss than patients who reported lower marital satisfaction (ß=0.92, SE=0.37, p=0.02). Family support did not significantly predict T2DM remission. CONCLUSIONS: Given the link between marital support and long-term weight outcomes, providers could consider asking patients about their spousal relationships during presurgical counselling. TRIAL REGISTRATION NUMBER: NCT04303611.

Pepsin in saliva for the diagnosis of erosive esophagitis post-sleeve gastrectomy: a prospective observational study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, new onset erosive esophagitis (EE) is a major shortcoming. Current recommendation is esophago-gastro-duodenoscopy (EGD) should be performed routinely at 1 year and subsequently every 2-3 years to enable the early detection of Barrett's or esophageal adenocarcinoma. This would put significant strains on resources and costs of bariatric program. Our study assesses the association between and diagnostic value of salivary pepsin concentration and endoscopically proven EE in post-LSG patients as a surrogate for EGD. METHODS: Twenty patients on routine post-LSG endoscopy between June and September 2022 were recruited for this correlational pilot study. Under supervision, fasting and post-prandial saliva sample was collected and analyzed by Peptest lateral flow device. EGD examinations were performed, and patients completed a validated 25-item QoLRAD questionnaire. RESULTS: We found a significant correlation between positive endoscopy findings of EE and salivary pepsin concentrations. The normal group had a lower mean fasting pepsin level (13.13 ng/mL ± 18.97) versus the EE-group (90.55 ng/mL ± 81.28, p = 0.009) and lower mean post-prandial pepsin level (30.50 ng/mL ± 57.72) versus the EE-group (135.09 ng/mL ± 130.17, p = 0.02). The predictive probabilities from the binary regression of fasting and post-prandial pepsin concentrations yield AUC of 0.955 ± 0.044 (95% CI 0.868 to 1.000, p < 0.001). CONCLUSION: Our study distinctively identified salivary pepsin to have excellent sensitivity and negative predictive value in EE, potentially useful to preclude the need for post-LSG EGD in asymptomatic patients with low salivary pepsin.

Current treatment landscape for obesity in Singapore.

The rising prevalence of obesity in Singapore is a harbinger for a corresponding increase in obesity-related complications such as type 2 diabetes mellitus (T2DM) and coronary heart disease. Obesity is a complex disease driven by multiple factors, and hence, treatment cannot follow a 'one-size-fits-all' approach. Lifestyle modifications involving dietary interventions, physical activity and behavioural changes remain the cornerstone of obesity management. However, similar to other chronic diseases such as T2DM and hypertension, lifestyle modifications are often insufficient on their own, hence the importance of other treatment modalities including pharmacotherapy, endoscopic bariatric therapy and metabolic-bariatric surgery. Weight loss medications currently approved in Singapore include phentermine, orlistat, liraglutide and naltrexone-bupropion. In recent years, endoscopic bariatric therapies have evolved as an effective, minimally invasive and durable therapeutic option for obesity. Metabolic-bariatric surgery remains the most effective and durable treatment for patients with severe obesity, with an average weight loss of 25%-30% after one year.

Telemonitoring With a Connected Glucose Meter Improves Glycemia Among People With Insulin-Treated Type 2 Diabetes.

BACKGROUND: Delayed initiation and inadequate titration remain critical challenges to optimizing insulin therapy in type 2 diabetes (T2D). We aimed to study whether hemoglobin A1c (HbA1c) can be lowered in people with insulin-treated T2D using telemonitoring. METHODS: This single-center study recruited adults with greater than or equal to six months of diabetes, greater than or equal to three months of insulin therapy, HbA1c ≥8.5% and ≤12.5%, and body mass index (BMI) ≤40 kg/m2. All participants received a connected glucose meter and the accompanying smartphone application. Participants sent weekly blood glucose (BG) diary to their primary endocrinologist via email. Adjustments in insulin doses were communicated to the participants. HbA1c, proportion of BG readings in range (70-180 mg/dL, PIR), below range (<70 mg/dL, PBR) and above range (>180 mg/dL, PAR), and glycemic variability as the coefficient of variation (% CV) were measured at baseline, week 12, and week 24 and compared using repeated-measures analysis of variance (ANOVA) or Friedman's ANOVA. RESULTS: We recruited 40 people (55% women). Mean age was 57.9 years, BMI 27.8 kg/m2, and baseline HbA1c 9.8% (83.7 mmol/mol). Mean HbA1c improved by 1.7%, % CV reduced from 32.9% to 30.7%, PIR increased from 58.8% to 67.1% (all P <.01) by week 24, without any change in PBR. This was achieved with a 0.04 U/kg/d median increase in total daily dose of insulin and 0.9 kg weight gain over 24 weeks. CONCLUSION: Telemonitoring and titration of insulin using a connected glucose meter resulted in significant improvements in glycemia, characterized by a reduction in HbA1c, increase in PIR, and reduction in glycemic variability without any increase in hypoglycemia.

Bariatric Surgery in Kidney Transplant Candidates and Recipients: Experience at an Asian Center.

Background: Kidney transplant (KT) candidates and recipients with obesity experience more frequent complications such as infection, poorer allograft outcomes, diabetes, and mortality, limiting their eligibility for transplantation. Bariatric surgery (BS) is not commonly performed among KT patients given concerns about immunosuppression absorption, wound healing, infections, and graft outcomes. Its role has not been described before in an Asian KT patient setting. Methods: A retrospective review of patients who underwent BS at the largest KT center in Singapore from 2008 to 2020 was conducted. Metabolic outcomes, immunosuppression doses, graft outcomes, and mortality were studied. Results: Seven patients underwent BS and KT (4 underwent BS before KT, 3 underwent BS after KT; 4 underwent sleeve gastrectomy, 3 underwent gastric bypass). Mean total weight losses of 23.8% at 1 year and 18.6% at 5 years post-BS were achieved. Among the five patients with diabetes, glycemic control improved after BS. There were no deaths in the first 90 days or graft loss in the first year after KT and BS. Patients who underwent BS after KT had no significant changes in immunosuppression dose. Conclusion: BS can be safely performed in KT recipients and candidates and results in sustainable weight losses and improvements in metabolic comorbidities. Although no major complications were observed in our study, close monitoring of this complex group of patients is imperative.

Revisional Surgery or Pharmacotherapy for Insufficient Weight Loss and Weight Regain After Primary Bariatric Procedure: a Descriptive Study.

PURPOSE: Bariatric surgery is the most effective and durable treatment option for clinically severe obesity. Unfortunately, some degree of weight regain (WR) is common after nadir weight is achieved. Pharmacotherapy and revision surgery are potential options to treat this phenomenon. We aim to determine the efficacy of both approaches in patients with WR versus insufficient weight loss (IWL). MATERIALS AND METHODS: We retrospectively reviewed a prospectively collected database of patients who underwent bariatric surgery from 2008 to 2018 with IWL or WR. RESULTS: Of 422 patients with WR or IWL after bariatric surgery, 150 patients were placed on pharmacotherapy and 27 underwent revisional surgeries. Mean age of patients was 41.4 years and mean BMI was 42.1 kg/m2. The most common conversion surgery was LSG to RYGB. % Total weight loss (TWL) was higher in IWL group (23.8% ± 11.0) compared to WR group (17.2% ± 7.9) in revisional surgery (p = 0.02). The converse was observed for pharmacotherapy, with %TWL 1.9% in the WR group compared to 0.7% in the IWL group (p = 0.0067). CONCLUSION: Patients with IWL or WR had modest weight loss with adjunctive use of pharmacotherapy after primary bariatric surgery. Conversely, revisional surgery is an effective treatment for both IWL and WR.

Safety and early efficacy of endoscopic sleeve gastroplasty (ESG) for obesity in a multi-ethnic Asian population in Singapore.

BACKGROUND AND AIM: Endoscopic sleeve gastroplasty (ESG) is an alternative nonsurgical treatment option for obesity. However, most studies on the utility and efficacy of ESG are derived from the Western population. It is unknown if ESG elicits similar results in Asians with different fat distribution, sociocultural customs, and dietary practices. Our study aims to assess the safety and efficacy of ESG among a multi-ethnic Asian population. METHODS: We reviewed 35 patient records who underwent primary ESG for obesity at our unit. We followed a U-shaped suture pattern. Our primary outcome was to assess technical feasibility and safety. The secondary outcome was to determine the percentage total body weight loss (TBWL) at the last follow-up. RESULTS: The mean ± SD age and body mass index were 43.6 ± 11.3 years and 34 ± 4.9 kg/m2, respectively. The majority were female (57%) and of Chinese ethnicity (51%). The procedure was technically successful in all patients. We used an average of five sutures (range, 4-7), and the mean ± SD procedure time was 65 ± 10 min. No major complications occurred, and the average length of stay was 1 day. Twenty-one patients completed 3 months of follow-up, and 10 patients 6 months. The mean ± SD TBWL at 3 and 6 months were 14.5 ± 4.8% and 16.2 ± 4.9%, respectively. We observed improvement in diabetes mellitus (87%), fatty liver (86%), and hypertension (58%) during the follow-up. CONCLUSION: ESG is a safe and effective option for promoting weight loss in a multi-ethnic Asian population. ESG-induced weight loss may improve obesity-related comorbidities.

Renal Outcomes 1 Year After Metabolic Bariatric Surgery in a Multi-ethnic Asian Cohort.

PURPOSE: Obesity increases the risk of incident chronic kidney disease (CKD) and is one of the strongest risk factors for new-onset CKD even in the absence of metabolic risk factors. Weight loss has been shown to reduce renal hyperfiltration and proteinuria. Metabolic bariatric surgery (MBS) remains an effective treatment for obesity and its metabolic-related complications. However, literature on its impact on renal function remains limited. MATERIALS AND METHODS: This was an observational retrospective study in a tertiary centre in Singapore. MBS cases performed at the centre between 2008 and 2019 were included. The primary outcome measures were estimated glomerular filtration rate (eGFR), calculated using the CKD epidemiology collaboration equation, and albuminuria (defined as urine albumin-creatinine ratio (uACR) > 3.5 mg/mmol) at baseline and 1-year post-MBS. RESULTS: Five hundred fifty-seven patients were included. One-year post-MBS, median eGFR increased from 110.9 mL/min/1.73 m2 (IQR 92.4 to 121.5) to 112.6 mL/min/1.73 m2 (IQR 97.3 to 122.3), p < 0.001. Median uACR decreased from 1.00 mg/mmol (IQR 0.40 to 3.55) to 0.70 mg/mmol (IQR 0.40 to 1.80) 1-year post-MBS (p = 0.001). 12.9% of patients had improved CKD staging. The proportion of patients with albuminuria decreased from 24.8% at baseline to 1.89% 1-year post-MBS (p < 0.001). One-year post-MBS, the subgroup with reduced eGFR had significant increases in eGFR (p < 0.001), with a trend towards a reduction in uACR. CONCLUSIONS: MBS had a positive impact on renal function with modest but statistically significant improvement in eGFR and reduction in albuminuria at 1-year post-surgery. Longer-term data is required to investigate the durability of this impact.

Centile Charts for Monitoring of Weight Loss Trajectories After Bariatric Surgery in Asian Patients.

BACKGROUND: Following bariatric surgery, accurate charting of weight loss and regain is crucial. Various preoperative factors affect postoperative weight loss, including age, sex, ethnicity, and surgical type. These are not considered by current weight loss metrics, limiting comparison of weight loss outcomes between patients or centers and across time. METHODS: Patients (n=1022) who underwent sleeve gastrectomy (n=809) and gastric bypass (n=213) from 2008 to 2020 in a single center were reviewed. Weight loss outcomes (% total weight loss) were measured for 60 months postoperatively. Longitudinal centile lines were plotted using the post-estimation predictions of quantile regression models, adjusted for type of procedure, sex, ethnicity, and baseline BMI. RESULTS: Median regression showed that %TWL was 1.0% greater among males than females (ß = +1.1, 95% CI: +0.6 to +1.7, P = <0.0001). Participants who underwent SG had less %TWL compared to GB (ß = -1.3, 95% CI: -1.9 to -0.8, P < 0.0001). There was a trend towards less %TWL among the Indian and Malay participants compared to Chinese. Age and diabetes were not significant predictors. Reference centile charts were produced for the overall cohort, as well as specific charts adjusted for type of bariatric procedure, sex, ethnicity, and baseline BMI. CONCLUSION: Centile charts provide a clinically relevant method for monitoring of weight trajectories postoperatively and aid in realistic and personalised goal setting, and the early identification of "poor responders". This is the first study to present post-bariatric surgery centile charts for an Asian cohort.

The Impact of Bariatric Surgery Compared to Medical Therapy on Health-Related Quality of Life in Subjects with Obesity and Type 2 Diabetes Mellitus.

INTRODUCTION: The adverse implications of obesity extend beyond physical health to include negative impact on quality of life (QoL), mood, and eating habits. While bariatric surgery provides successful weight loss and metabolic benefits, studies describe conflicting results on QoL and mood-related outcomes. METHODS: Patients (n = 140) with class II/III obesity and T2DM were recruited from 2015 to 2019, and stratified based on medical or surgical treatment. Questionnaires including the Hospital Anxiety and Depression Scale, Euro QoL visual analogue scale (EQ-VAS), and Revised 21-item Three-Factor Eating Questionnaire (TFEQ-R21) were recorded at baseline, 6 months, and 12 months after treatment. RESULTS: At baseline, the surgical group (n = 55) and medical group (n = 85) had no significant difference in questionnaire outcomes. At 6 and 12 months, EQ-VAS was higher in the surgical group (12 months surgical 82.00 ± 12.64, medical 72.81 ± 16.56, p = 0.001), with greater improvement from baseline. HADS-D scores at 12 months were lower in the surgical group (surgical 2.60 ± 2.88, medical 3.90 ± 3.58, p = 0.025). At 12 months, the surgical group also had better TFEQ-R21 scores, with higher cognitive restraint scores (surgical 19.09 ± 3.00, medical 16.69 ± 3.61, p < 0.001), and lower scores for uncontrolled eating (surgical 14.96 ± 3.87, medical 17.89 ± 5.34, p = 0.001). CONCLUSION: In the treatment of patients with obesity and T2DM, bariatric surgery resulted in improved QoL outcomes at 12 months compared to medical therapy. This could be related to improvement in weight and metabolic outcomes, and altered gut-brain axis communication. This is the first prospective study assessing the impact of bariatric surgery on health-related QoL in Asia compared against a control group who received medical therapy.

Resolution of Erosive Esophagitis After Conversion from Vertical Sleeve Gastrectomy to Roux-en-Y Gastric Bypass.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become the preferred bariatric procedure in many countries. However, there is one shortcoming of LSG in the long-term follow-up, and this is the onset of gastro-esophageal reflux disease (GERD) and erosive esophagitis (EE). Conversion to Roux-en-Y gastric bypass (RYGB) is considered an option in patients unresponsive to medical therapy. Currently, there is no evidence of EE improvement or resolution after conversion surgery. In this study, we objectively evaluate the effectiveness of RYGB in management of EE with upper endoscopy (EGD) to identify the significant variables in patients with GERD symptoms post LSG refractory to medical therapy and require conversion surgery. METHODS: Over a period of 11 years (2008-2019) at Singapore General Hospital, we retrospectively reviewed a prospectively collected database of a cohort of patients whom had conversion surgery to RYGB for refractory GERD and EE after LSG. Patient's endoscopic findings and demographic and anthropometric data were analyzed. RESULTS: We identified a total of 14 patients who underwent LSG to RYGB conversions for endoscopic proven erosive esophagitis in our unit during the study period. Eight patients (57.1%) had concurrent hiatal hernia repaired. Nine (64.3%) patients were females. The median age of patients in this cohort was 44 (range 30-61) years. Mean weight and BMI were 87.7 kg (± 19.2) and 32.8 (± 3.09) kg/m2, respectively, on the day of conversion surgery. The median time between LSG and revision to RYGB was 36 (range 6-68) months. Seven patients (50%) had complete resolution of GERD symptoms after conversion, and 6 patients (42.9%) had partial resolution. Six out of 7 patients had complete resolution of EE. There were 4 anastomotic strictures (28.6%). Older patients, Indian ethnicity, present of hiatal hernia and lower weight loss after initial LSG were more likely to undergo conversion surgery. CONCLUSION: Conversion to RYGB after LSG is clinically relevant and may be a feasible solution if patients have ongoing GERD refractory to medical therapy. Ninety-three percent of our patients achieved complete resolution of their GERD symptoms and significant improvement of erosive esophagitis with significant weight loss after conversion. This study has important implications as LSG is increasingly being performed and a proportion of these will need revision surgery for various reasons, particularly GERD which is extremely prevalent.

Patient Preferences for Medications in Managing Type 2 Diabetes Mellitus: A Discrete Choice Experiment.

OBJECTIVES: To quantify patients' maximum acceptable risk (MAR) of urinary and genital tract infections (UGTI) in exchange for benefits associated with treatments for managing type 2 diabetes mellitus (T2DM). METHODS: In a discrete choice experiment, adult patients with T2DM and currently on metformin and/or sulphonylurea (first-line treatments) were asked to choose between 2 hypothetical medications defined by 6 attributes: years of medication effectiveness in controlling blood glucose, weight reduction, UGTI risk, risk of hospitalization from heart failure, all-cause mortality risk, and out-of-pocket medication cost. We used latent class logistic regression parameters to estimate the conditional relative importance of treatment attributes and MAR of UGTI for various treatment benefits. RESULTS: A 2-class latent class model was identified as the best fit for the responses from 147 patients. The first class (49% of sample), termed as "survival-conscious," stated that they were willing to accept 46% (95% confidence interval [CI]: 2%-90%) UGTI risk in exchange for a reduction from 6% to 1% in all-cause mortality risk. The second class (51% of sample), termed as "UGTI/cost-conscious" were willing to accept significantly lower (6%; CI: 2%-11%, and 5%; CI: 2%-8%) UGTI risk in exchange for the same reduction in all-cause mortality and hospitalization risks, respectively. CONCLUSIONS: On average, patients were willing to trade higher UGTI risk for a more effective medication. Our findings suggest that physicians should present the benefits and potential side effects of all available treatments and consider patient preferences in their treatment recommendations.

Associations of Bariatric Interventions With Micronutrient and Endocrine Disturbances.

Importance: Few studies have described the longitudinal trajectories of serum levels of micronutrients whose deficiencies are associated with serious sequelae following bariatric procedures, such as anemia, osteoporotic fractures, and neuropathies. Furthermore, previous studies comparing laparoscopic sleeve gastrectomy (LSG) vs Roux-en-Y gastric bypass (LRYGB) or one-anastomosis gastric bypass (OAGB) procedures may have been limited by selection and confounding biases. Objective: To appraise the spectrum and temporal course of micronutrient deficiencies associated with bone metabolism and erythropoiesis after LSG vs OAGB or LRYGB procedures, using the propensity score as a balancing score. Design, Setting, and Participants: This prospective, longitudinal comparative effectiveness study was conducted at a high-volume bariatric unit in Singapore from September 1, 2008, to November 30, 2017, with a cutoff date for analysis of September 2018. Patients who underwent adjustable gastric banding, biliopancreatic diversion procedures, and intragastric balloon procedures were excluded. All other patients who underwent bariatric procedures were included. Data were analyzed from September 23 to 30, 2018. Main Outcomes and Measures: Serial assessment of 13 biochemical parameters at 12 time points for up to 5 years after bariatric procedure. Inverse probability-of-treatment weights were used to obtain estimates of the mean associations of variables assessed with the bariatric surgical interventions. Longitudinal trajectories were analyzed using mixed-effects generalized linear models to apportion the temporal variation of serum micronutrients into fixed-effects and random-effects components. Results: A total of 688 patients were included in this study, of whom 499 underwent LSG (mean [SD] age, 41.5 [11.3] years; 318 [63.7%] women) and 189 underwent OAGB or LRYGB (mean [SD] age, 48.6 [9.4] years; 112 [59.3%] women). There were no differences during follow-up among patients who underwent LSG vs those who underwent OAGB or LRYGB in intact parathyroid hormone levels (mean difference, 7.05 [95% CI, -28.67 to 42.77] pg/mL; P = .70), serum 25-hydroxyvitamin D levels (mean difference, -0.72 [95% CI, -1.56 to 0.12] ng/mL; P = .09), or phosphate levels (mean difference, 0.006 [95% CI, -0.052 to 0.064] mg/dL; P = .83). Hemoglobin levels were a mean 0.63 (95% CI, 0.41 to 0.85) g/dL higher among patients who underwent LSG compared with those who underwent OAGB or LRYGB (P < .001), despite no differences in iron concentration levels (mean difference, 1.50 [95% CI, -1.39 to 4.39] µg/dL; P = .31), total iron-binding capacity (mean difference, 4.36 [95% CI, -5.25 to 13.98] µg/dL; P = .37), or ferritin levels (mean difference, 3.0 [95% CI, -13.0 to 18.9] ng/mL; P = .71). Compared with patients who underwent LSG procedures, patients who underwent OAGB or LRYGB had higher folate levels (mean difference, 2.376 [95% CI, 1.716 to 3.036] ng/mL; P < .001) but lower serum magnesium levels (mean difference, -0.25 [95% CI, -0.35 to -0.16] mg/dL; P < .001) and zinc levels (mean difference, -7.58 [95% CI, -9.92 to -5.24] µg/dL; P < .001). Conclusions and Relevance: These findings suggest that LSG vs OAGB or LRYGB procedures have differential associations with various micronutrient and metabolic parameters. These differences should be recognized in guidelines for postbariatric nutritional surveillance and prevention.