Methodology and Results of a Joint IFSO-WGO Delphi Survey of 94 Intercontinental, Interdisciplinary Experts in Obesity Management.

BACKGROUND: Obesity affects 1.5 billion people worldwide, yet few are treated effectively and considerable variability exists in its management. In 2020, a joint International Federation of Surgery for Obesity and Metabolic Diseases (IFSO) and World Gastroenterology Organization (WGO) advisory committee initiated the drafting of consensus guidelines on obesity management, to be based on detailed literature reviews and the results of an extensive multi-disciplinary survey of intercontinental experts. This paper reports on the latter. The objective of this study is to identify areas of consensus and non-consensus among intercontinental, inter-disciplinary experts in obesity management. METHODS: Guided by an international consensus-survey expert, a three-round online Delphi survey was conducted in the summer of 2021 of international obesity-management experts spanning the fields of medicine, bariatric endoscopy and surgery, psychology, and nutrition. Issues like epidemiology and risk factors, patient selection for metabolic and bariatric surgery (ASMBS-Clinical-Issues-Committee, Surg Obes Relat Dis : Off J Am Soc Bariatric Surg. 8:e27-32, 1), psychological issues, patient preparation for MBS, bariatric endoscopy, and outcomes and follow-up were addressed. RESULTS: Ninety-four experts from six continents voted on 180 statements, with consensus reached on 158, including consensus agreement with 96 and disagreement with 24 statements (38 had other response options besides agree/disagree). Among unanimous opinions were the need for all medical societies to work together to address obesity, for regular regional and national obesity surveillance, for multi-disciplinary management, to recognize the increasing impact of childhood and adolescent obesity, to accept some weight regain as normal after MBS, and for life-long follow-up of MBS patients. CONCLUSIONS: Obesity is a major health issue that requires aggressive surveillance and thoughtful multidisciplinary management.

Banding Together: An Investigation of Post-Surgery Support Groups for Laparoscopic Adjustable Gastric Banding Patients.

Though advocated as useful for patients, there is little in the literature regarding the use and effectiveness of bariatric support groups. This study investigated characteristics and experiences of bariatric patients who did and did not attend offered groups. Seventy-eight postoperative laparoscopic adjustable gastric banding patients from a private bariatric clinic completed mailed self-report questionnaires. Almost 60% reported having attended the clinic groups, with most wanting to meet other patients and obtain information rather than access psychological assistance. Participants reported generally positive experiences of attending. Nonattendance was often attributed to practical barriers. Satisfaction with support from others was not related to past or predicted future attendance, but higher psychological distress was related to and predictive of greater intention to attend future groups. Likely future attenders also held more positive beliefs about the groups than those who were unlikely to attend. Further research is required into potential positive and negative consequences of attendance, and characteristics of those who are likely to benefit or be harmed by attending. Interventions addressing stereotypes about support groups may help patients make informed decisions about whether to attend a bariatric support group.

Evaluation of the Swedish adjustable gastric band VC (SAGB-VC) in an Australian population: early results.

BACKGROUND: The Swedish adjustable gastric band VC (SAGB-VC) has been in use in Australia since 2007. We evaluated its efficacy and safety. METHODS: We retrospectively analyzed the prospective clinical data of patients who received the implant between November 2007 and June 2009 at 3 Australian bariatric centres. RESULTS: In all, 1176 patients (mean age 45.9 [standard deviation (SD) 12.3] yr, mean body mass index 43.4 [SD 7.6]) received the SAGB-VC. At a mean follow-up of 11 (SD 3) months, weight reduced by a mean of 18.4 (SD 11.1) kg with an excess weight loss of 37.8% (SD 19.9%). Body mass index decreased (from mean 43.4 [SD 7.7] to mean 36.7 [SD 6.5], p < 0.001). Type 2 diabetes (T2DM) was reported in 167 patients and hypertension in 373. Improvement occurred in 73.5% of patients with T2DM and 31% with hypertension, with patient-reported reduction or cessation of medication. Metabolic syndrome indices improved during follow-up: high-density lipoprotein cholesterol (mean 1.3 [SD 0.3] v. mean 1.4 [SD 0.3] mmol/L, p < 0.001), triglycerides (mean 1.6 [SD 0.8] v. mean 1.3 [SD 0.7] mmol/L, p < 0.001), waist circumference (men 141 [SD 103] to 121 [SD 15] cm, women 117 [SD 14] to 105 [SD 14] cm, both p < 0.001), C-reactive protein (90.5 [SD 75.2] v. 53.3 [SD 61.9] nmol/L, p < 0.001). The complication rate was 4.2%. CONCLUSION: The SAGB-VC is safe and effective for treating obesity and its comorbidities. The results are reproducible in separate Australian centres and consistent with published literature.

Abdominal adiposity and liver fat content 3 and 12 months after gastric banding surgery.

Weight loss after laparoscopic adjustable gastric banding surgery (LAGB) is associated with mobilization of adipose tissue from a variety of depots. We sought to evaluate and relate abdominal and hepatic lipid deposition in an obese female population 3 and 12 months after LAGB. We related changes in these depots to markers of insulin sensitivity. Eighteen female obese subjects underwent magnetic resonance imaging and spectroscopy before and 3 and 12 months after LAGB for the quantification of abdominal subcutaneous (ABSAT) and visceral (VAT) adipose tissue areas and liver fat content (LFAT). Fasting blood free fatty acids (FFA) were analyzed. Insulin sensitivity was assessed by the homeostasis model assessment of insulin resistance index (HOMA-R). Mean weight loss 3 and 12 months after LAGB was 9.8 +/- 1.1 kg and 20.0 +/- 2.2 kg, respectively. Postoperatively, VAT area loss exceeded ABSAT area loss in the cohort as a whole and when divided according to preoperative liver fat stores. Three months after LAGB, reductions had occurred in VAT and ABSAT areas (both P < .01) and in FFA (P < .05). Twelve months after LAGB, further significant reductions (P < .01) occurred in VAT and ABSAT areas but not in FFA. No significant reduction occurred in LFAT at either time point in the group as a whole. In those with preoperative hepatic steatosis (LFAT > approximately 5%, n = 7), LFAT fell by 42% (P = .036) 3 months after LAGB, with a total reduction of 50% (P = .027 cf baseline) occurring by 12 months. There was an improvement in HOMA-R at 12 months (1.9 +/- 0.3 cf 2.9 +/- 0.5 at baseline, P = .04) but not 3 months (2.7 +/- 0.4). Preoperatively, LFAT related significantly to VAT area (r = 0.67, P = .003) and HOMA-R (r = 0.497, P = .04) but not ABSAT area. Postoperatively at both 3 and 12 months, LFAT continued to relate to VAT area (r = 0.63, P < .01 at both time points) but not HOMA-R. The changes in LFAT and VAT area were unrelated postoperatively. Abdominal adipose tissue loss was greater from the visceral than subcutaneous depots, suggesting that insulin sensitivity may not be an important determinant of selective lipid depot loss. The lack of a significant change in liver fat in the group as a whole may relate to low preoperative liver fat stores and to high postoperative dietary fat intakes. Preoperative liver fat stores did not influence insulin sensitivity or abdominal lipid changes during weight loss. Liver fat content and VAT area interrelated more closely than either related to ABSAT area, suggesting differing regulatory pathways for fat mobilization from ABSAT and VAT depots but possibly similar pathways for storage and mobilization of fat in the liver and viscerally.

Efficacy of a low-pressure laparoscopic adjustable gastric band for morbid obesity: patients at long term in a multidisciplinary center.

BACKGROUND: Obesity is an increasingly common condition with serious associated morbidity and decreased life expectancy. Laparoscopic adjustable gastric banding (LAGB) has demonstrated its safety and efficacy as a surgical therapy for morbid obesity over the short term. The current study sought to determine the long-term safety and efficacy of a low-pressure LAGB. METHODS: Between August 1996 and July 2007, 1,000 consecutive patients underwent LAGB implantation with the Swedish Adjustable Gastric Band (SAGB). This series was retrospectively reviewed with regard to weight loss and morbidity. Patients served as their own controls. RESULTS: Preoperatively, there were 808 women (81.0%) and 192 men (19.0%) with a mean age of 46 +/- 11 years (range 13-81 yrs) and mean body mass index (BMI) of 42.0 +/- 7.0 kg/m2 (range 27-82 kg/m2). At 1-, 3-, 6-, and 8-year follow-up, mean percent excess weight loss was 41% (n = 600), 56% (n = 367), 51% (n = 114), and 52% (n = 43), respectively. At the same time points, BMI decreased, from 42.0 to 31.0, 32.5, and 30.5 kg/m2, respectively. Complications occurred in 197 patients. There were 2 operative complications (i.e., stomach perforation and vascular injury) and 25 conversions (2.4%) to open surgery. Major and minor wound infection in the perioperative period occurred in 47 (4.7%) and 43 (4.3%) patients, respectively. There was 1 death from a myocardial infarct 1 week after surgery. Long term, there were 30 (3.0%) band slippages, 31 (3.1%) erosions, 67 (6.7%) port problems, and 12 (1.2%) incisional hernias. CONCLUSION: LAGB with the SAGB is effective in achieving a mean sustainable weight loss of >50% at 8 years after surgery, with an acceptably low morbidity.

Rapid significant weight loss and regional lipid deposition: Implications for insulin sensitivity.

AIM: To compare regional lipid deposition and insulin sensitivity after differing weight loss strategies: very low calorie diet (VLCD) and laparoscopic adjustable gastric banding (LAGB). METHOD: Thirty-nine obese women underwent anthropometry, proton magnetic resonance (MR) spectroscopy for assessment of liver fat (LFAT) and MR imaging for visceral (VAT) and subcutaneous abdominal fat volume (SAT) determination. Fasting blood was taken for insulin, glucose and free fatty acid (FFA) analysis. Measurements were repeated after 6-weeks Optifast VLCD (n = 14) or 3 months after LAGB (n = 25). RESULTS: Similar, significant (p < 0.001) weight loss occurred after VLCD (8%) and LAGB (9%). Both interventions induced significant (p < 0.001) and similar reductions in body mass index (BMI) and waist circumference, and in SAT and VAT (VLCD p < 0.05, LAGB p < 0.001). LFAT fell only after VLCD (p < 0.05). Plasma FFA only fell after LAGB (p < 0.05). Homeostasis model assessment (HOMA-R) improved only following VLCD (p < 0.05). No relations were detected between the changes in LFAT, VAT and SAT. The change in LFAT related to the change in HOMA-R in both interventions combined (r = 0.410, p = 0.013) and in the VLCD group (r = 0.660, p = 0.020). There was no change in relative dietary fat intake after LAGB (p = 0.11). CONCLUSION: Caloric and fat restriction for 6 weeks (VLCD) reduces weight, SAT, VAT, LFAT and HOMA-R. Less severe caloric restriction for 12 weeks (LAGB) causes significant loss of weight, VAT and SAT but no detectable change in LFAT and HOMA-R. Following weight loss, a change in LFAT is related more to changes in insulin sensitivity or dietary fat than to abdominal adiposity loss.

Change in liver size and fat content after treatment with Optifast very low calorie diet.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) requires surgical access to the gastroesophageal junction, which may be compromised by the enlarged, fatty liver that is frequently encountered in the obese. Liver size appears reduced and surgical access improved following preoperative weight loss with Optifast Very Low Calorie Diet (VLCD). The aim of this study was to assess the effects of 6 weeks Optifast VLCD on liver volume and fat content. METHODS: 18 morbidly obese subjects underwent magnetic resonance imaging and spectroscopy to measure liver size and fat content before and after intensive treatment with Optifast VLCD for 6 weeks. RESULTS: All subjects completing 6 weeks Optifast VLCD lost weight. Body weight and BMI (median [interquartile range]) reduced from 119.7 [111.9-131.3] kg and 44 [40-51] kg/m(2) respectively, to 110.6 [98.0124.5] kg and 40 [36-47] kg/m(2), P<0.001. Median excess weight loss (EWL) was 15.1 [9.6-21.1]%. Baseline liver volume and fat content were related (r=0.633, P=0.005). After 6 weeks Optifast VLCD, there was a 14.7% reduction in mean liver volume (P<0.001) and a 43% reduction in mean liver fat (P=0.016). The change in liver volume was predicted by the change in the liver fat (r = 0.610, P=0.012). CONCLUSION: This study has demonstrated that a 6 week diet with Optifast VLCD results in significant related reductions in liver size and liver fat content. This suggests that the reduction in liver volume is due to loss of fat. The reduction in liver fat and volume likely accounts for the perceived improved operability in patients undergoing LAGB.

The early effects of weight loss surgery on regional adiposity.

BACKGROUND: Weight loss beyond 6 months following laparoscopic adjustable gastric banding (LAGB) is associated with a preferential mobilization of visceral adipose tissue and an improvement in insulin sensitivity in insulin resistant subjects. Because the rate of weight loss is greatest in the first 3 months after LAGB, we investigated the impact of LAGB on changes in regional lipid deposition and insulin sensitivity over this period. METHODS: 10 female obese non-diabetic subjects underwent magnetic resonance (MR) imaging and spectroscopy before and 12 weeks after LAGB (using the Swedish band), for the quantification of abdominal subcutaneous and visceral adipose tissue areas and intrahepatic lipid. Fasting blood free fatty acids were analyzed. Insulin sensitivity was monitored by fasting insulin and homeostasis model assessment (HOMA). RESULTS: Median weight loss 12 weeks after gastric banding was 9.5 kg [interquartile range (IQR): -16.5 to -6]. There were significant reductions in median abdominal subcutaneous (-20% [IQR: -24 to -13]) and visceral (-15% [IQR: -49 to -8]) adipose tissue depots as well as plasma free fatty acids (-34% [IQR: -79 to -8]). The amount of weight lost was directly proportional to the initial BMI (r=0.778; P=0.008). Visceral fat loss was proportional to initial visceral adiposity (r=0.80, P=0.01). There was no significant improvement in insulin sensitivity. CONCLUSION: Significant fat loss occurs 3 months after LAGB. The absence of a concurrent improvement in insulin sensitivity may reflect the relatively small reduction in visceral adipose tissue at this stage. Improvement in insulin sensitivity beyond 3 months after LAGB may be due to the continued loss of visceral adipose tissue.