The Potential Mechanism of Remission in Type 2 Diabetes Mellitus After Vertical Sleeve Gastrectomy.

In recent years, there has been a gradual increase in the prevalence of obesity and type 2 diabetes mellitus (T2DM), with bariatric surgery remaining the most effective treatment strategy for these conditions. Vertical sleeve gastrectomy (VSG) has emerged as the most popular surgical procedure for bariatric/metabolic surgeries, effectively promoting weight loss and improving or curing T2DM. The alterations in the gastrointestinal tract following VSG may improve insulin secretion and resistance by increasing incretin secretion (especially GLP-1), modifying the gut microbiota composition, and through mechanisms dependent on weight loss. This review focuses on the potential mechanisms through which the enhanced action of incretin and metabolic changes in the digestive system after VSG may contribute to the remission of T2DM.

The Weight of Bariatric Surgery: Wernicke-Korsakoff Syndrome after Vertical Sleeve Gastrectomy-A Case Series.

In this case series, the simultaneous occurrence of Wernicke's encephalopathy (WE) and dry beriberi was reported in three patients who underwent vertical sleeve gastrectomy (VSG) between May 2021 and May 2023. All patients were obese women who underwent vertical sleeve gastrectomy (VSG) without immediate postoperative complications, but two weeks later, hyperemesis and subsequent encephalopathy with ocular movement abnormalities and weakness were observed over the following thirty days. Patients were referred to neurology, where due to the high suspicion of WE, thiamine replacement therapy was initiated; meanwhile, diagnostic neuroimaging and blood tests were conducted. Neurological and psychiatric evaluations and neuroconduction studies were performed to assess the clinical evolution and present sequelae. One year after diagnosis, all patients exhibited affective and behavioral sequelae, anterograde memory impairment, and executive functioning deficits. Two patients met the criteria for Korsakoff syndrome. Additionally, peripheral nervous system sequelae were observed, with all patients presenting with sensorimotor polyneuropathy. In conclusion, Wernicke's encephalopathy requires a high diagnostic suspicion for timely intervention and prevention of irreversible sequelae, which can be devastating. Therefore, raising awareness among medical professionals regarding the significance of this disease is essential.

Roux-en-Y Gastric Bypass vs Vertical Sleeve Gastrectomy in the Remission of Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis.

<b><br>Introduction:</b> Obesity's associated comorbidities and treatment costs have risen significantly, highlighting the importance of early weight loss strategies. Bariatric surgeries like Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) have been effective in promoting weight loss and improving type 2 diabetes mellitus (T2DM) management.</br> <b><br>Aim:</b> The aim was to determine whether Roux-en-Y gastric bypass is more effective than vertical sleeve gastrectomy in the remission of type 2 diabetes mellitus (T2DM).</br> <b><br>Methods:</b> A systematic review and meta-analysis was performed. A literature search was performed in the databases Web of Science, Medline/PubMed, Embase, Scopus, and Medline/Ovid. A total of 1323 results were identified; after screening, 14 articles were selected and included in the systematic review. Primary and secondary outcomes were measured by RR with a 95% CI.</br> <b><br>Results:</b> The primary outcome of T2DM remission was 15% in favor of VSG (RR: 1.15, [95% CI: 1.04-1.28]). For secondary outcomes, hypertension remission was 7% in favor of VSG (RR: 1.07, [95% CI: 1.00-1.16]). Remission of dyslipidemia was 16% in favor of VSG (RR: 1.16, [95% CI: 1.06-1.26]). BMI after surgery was in favor of RYGB (MD: -1.31, [95% CI: -1.98 to -0.64]). For weight loss, the results favored VSG (MD: 6.50, [95% CI: 4.99-8.01]). In relation to total cholesterol, they were 65% favorable for RYGB (MD: -0.35, [95% CI: -0.46 to -0.24]), with a value of p <0.05. For LDL values, our results were 69% favorable for RYGB (MD: -0.31, [95% CI: -0.45 to -0.16]), p <0.01 value.</br> <b><br>Conclusions:</b> Laparoscopic sleeve gastrectomy is more effective in T2DM remission, hypertension remission, dyslipidemia remission, and weight loss compared to Roux-en-Y gastric bypass. Roux-en-Y gastric bypass is more effective at lowering BMI, total cholesterol, LDL, and TG compared to laparoscopic sleeve gastrectomy.</br>.

Vertical Sleeve Gastrectomy Reduces Gut Luminal Deoxycholic Acid Concentrations in Mice.

BACKGROUND: Bariatric surgery alters bile acid metabolism, which contributes to post-operative improvements in metabolic health. However, the mechanisms by which bariatric surgery alters bile acid metabolism are incompletely defined. In particular, the role of the gut microbiome in the effects of bariatric surgery on bile acid metabolism is incompletely understood. Therefore, we sought to define the changes in gut luminal bile acid composition after vertical sleeve gastrectomy (VSG). METHODS: Bile acid profile was determined by UPLC-MS/MS in serum and gut luminal samples from VSG and sham-operated mice. Sham-operated mice were divided into two groups: one was fed ad libitum, while the other was food-restricted to match their body weight to the VSG-operated mice. RESULTS: VSG decreased gut luminal secondary bile acids, which was driven by a decrease in gut luminal deoxycholic acid concentrations and abundance. However, gut luminal cholic acid (precursor for deoxycholic acid) concentration and abundance did not differ between groups. Therefore, the observed decrease in gut luminal deoxycholic acid abundance after VSG was not due to a reduction in substrate availability. CONCLUSION: VSG decreased gut luminal deoxycholic acid abundance independently of body weight, which may be driven by a decrease in gut bacterial bile acid metabolism.

Alcohol associated liver disease and bariatric surgery: Current perspectives and future directions.

Bariatric surgery is a routinely performed procedure and is associated with a reduction in all-cause mortality in patients with obesity. However, bariatric surgery has also been linked to increased alcohol use with up to 30% of these patients developing alcohol use disorder (AUD). The mechanism of AUD after bariatric surgery is multifactorial and includes anatomic, metabolic, and neurohumoral changes associated with post-surgical anatomy. These patients are at increased risk of alcohol associated liver disease and, in some cases, require liver transplantation. In this article, we provide a scoping review of epidemiology, pathophysiology, and clinical outcomes of alcohol-related health conditions after bariatric surgery.

Intestinal epithelial adaptations to vertical sleeve gastrectomy defined at single-cell resolution.

The gut plays a key role in regulating metabolic health. Dietary factors disrupt intestinal physiology and contribute to obesity and diabetes, whereas bariatric procedures such as vertical sleeve gastrectomy (VSG) cause gut adaptations that induce robust metabolic improvements. However, our understanding of these adaptations at the cellular and molecular levels remains limited. In a validated murine model, we leverage single-cell transcriptomics to determine how VSG impacts different cell lineages of the small intestinal epithelium. We define cell type-specific genes and pathways that VSG rescues from high-fat diet perturbation and characterize additional rescue-independent changes brought about by VSG. We show that Paneth cells have increased expression of the gut peptide Reg3g after VSG. We also find that VSG restores pathways pertaining to mitochondrial respiration and cellular metabolism, especially within crypt-based cells. Overall, our study provides unprecedented molecular resolution of VSG's therapeutic effects on the gut epithelium.

Sleeve gastrectomy for the treatment of adolescent obesity in children aged 13 and under: a retrospective study.

BACKGROUND: Sleeve gastrectomy (SG) induces weight reduction and improves metabolic co-morbidities in children with severe obesity but remains underutilized, especially for young adolescents and preadolescents. OBJECTIVE: We hypothesized there would be no differences in weight loss or co-morbidity resolution at 1 year post-SG in children who underwent SG at 13 years or younger compared to children who underwent SG at 17-18 years old. SETTING: Academic medical center, United States. METHODS: Medical records of children who underwent laparoscopic SG at a quaternary academic center from September 2014 to October 2022 were reviewed. A cohort of 15 patients, ≤13 years of age, was compared to a matched cohort of 15 older adolescent patients. Preoperative characteristics and postoperative outcomes were collected. RESULTS: Both cohorts had similar baseline characteristics. Median preoperative body mass index (BMI) was 51.8 kg/m2 for the ≤13 cohort compared to 50.9 kg/m2 in the older cohort (P = .87). Time to postoperative enteral feeds and length of stay were similar between both groups, and there were no 30-day readmissions or immediate postoperative complications. Median percentage excess BMI loss at 1 year postoperation was 54% (IQR, 25.5%-94.5%) for the ≤13 cohort compared with 44% (IQR, 34.0%-51.0%) for the older cohort (P = .34). Two of 11 patients were lost to follow-up in the younger group compared to 4 of 15 in the older group (P = .61). Both groups demonstrated significant improvement in metabolic syndrome co-morbidities after SG. CONCLUSION: SG in younger children is associated with successful postsurgical outcomes compared with adolescents, with effective weight loss and improvement of obesity-related metabolic co-morbidities.

Gender, BMI, Patient Comorbidities, and Hospital Characteristics Influence 30-Day Readmission Following Vertical Sleeve Gastrectomy.

PURPOSE: Obesity impacts 300 million people worldwide and the number continues to increase. Laparoscopic sleeve gastrectomy (LSG) is one of several bariatric procedures offered to help these individuals achieve a healthier life. Here, we report 30-day readmission rates and risk factors for readmission after gastrectomy. MATERIALS AND METHODS: We used the US Healthcare Utilization Project's Nationwide Readmission Database (NRD) from 2016 to 2019 for patients who underwent laparoscopic gastrectomy and evaluated 30-day readmission rates, comparing readmitted patients to non-readmitted patients. Confounder adjusted and unadjusted analysis were proceeded to the potential factors. RESULTS: The study population consisted of 235,563 patients, with a 3.0% readmission rate. Factors associated with a higher readmission rate included older age, male gender, higher BMI, Medicare as the primary payer, longer length of stay, higher total charge, higher Charlson Comorbidity Index, higher Elixhauser-Comorbidity Index, lower household income, non-elective admission type, and non-routine disposition. Additionally, larger hospital bed size, and private, invest-own hospital ownership were associated with higher readmission rates. After adjusting for confounders, several comorbidities and complications were found to be significantly associated with readmission, including ileus, abnormal weight loss, postprocedural complications of digestive system, acute posthemorrhagic anemia, and history of pulmonary embolism (all p < 0.001). CONCLUSIONS: Patient characteristics including age, BMI, and payment source, as well as hospital characteristics, can impact the 30-day readmission after LSG. Such factors should be considered by CMS when deciding on penalties related to readmission.

Gut microbiota turn up the heat after bariatric surgery.

Bariatric surgeries like vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) cause well-established shifts in the gut microbiota, but how this contributes to their unique metabolic benefits is poorly understood. Jin et al and Yadav et al now provide two complementary lines of evidence suggesting that gut microbiota-derived metabolites after VSG and RYGB activate thermogenesis in fat through distinct mechanisms, to in turn promote weight loss and/or improvements in glycemic control.

Altered Estrous Cyclicity and Feeding Neurocircuitry, but Not Cardiovascular Indices in Female Offspring from Dams with Previous Vertical Sleeve Gastrectomy Surgery.

Metabolic syndrome (MetS), which includes obesity, diabetes, hypertension, hyperlipidemia, and fatty-liver disease, affects more than two-thirds of the U.S. population. Surgical weight loss has been popularized in the last several decades as a means to produce significant weight loss and improvements in the comorbidities of MetS. Women are by far the most common recipients of these surgeries (more than 85%). Women of childbearing age are very likely to pursue surgical weight loss to improve their reproductive function and fertility for childbearing purposes. Significant research using pre-clinical models from our laboratory and clinical data from around the world suggest that surgical weight loss before pregnancy may have negative consequences for offspring. The present study investigates the metabolic endpoints in female-rodent offspring born to dams who had previously received vertical sleeve gastrectomy (VSG) before pregnancy. Comparisons were made to offspring from lean and obese dams. In the adult offspring of either maternal VSG or sham surgery, no differences in body weight, body fat, or lean body mass between groups were identified. The blood pressure measured in a subset of female offspring showed no differences between the VSG and the sham groups. Estrus cyclicity measured by lavage on serial days showed altered cycles in the VSG offspring compared to the controls. For animals that had previously only been exposed to chow, rats were fasted overnight and then given a 1 g meal of either chow or a novel high-fat diet (HFD). The animals were euthanized and paraformaldehyde (PFA)-perfused to perform brain immunohistochemistry for c-Fos, an immediate-early gene activated by novel stimuli. In the VSG rats exposed to either the chow or the HFD meal, the c-Fos-activated cells were significantly blunted in the nucleus of the solitary tract (p < 0.05), the paraventricular nucleus of the hypothalamus (PVN) (p < 0.05), and the dorsal medial nucleus of the hypothalamus (DMH) (p < 0.05) in comparison to the sham controls. These data suggest that the hypothalamic wiring within the brain that controls the response to nutrients and reproductive function was significantly altered in the VSG offspring compared to the offspring of the dams that did not receive weight-loss surgery.

Vertical sleeve gastrectomy-derived gut metabolite licoricidin activates beige fat thermogenesis to combat obesity.

Obesity is a chronic metabolic disease, affecting individuals throughout the world. Bariatric surgery such as vertical sleeve gastrectomy (VSG) provides sustained weight loss and improves glucose homeostasis in obese mice and humans. However, the precise underlying mechanisms remain elusive. In this study, we investigated the potential roles and the mechanisms of action of gut metabolites in VSG-induced anti-obesity effect and metabolic improvement. Methods: High-fat diet (HFD)-fed C57BL/6J mice were subjected to VSG. Energy dissipation in mice was monitored using metabolic cage experiments. The effects of VSG on gut microbiota and metabolites were determined by 16S rRNA sequencing and metabolomics, respectively. The metabolic beneficial effects of the identified gut metabolites were examined in mice by both oral administration and fat pad injection of the metabolites. Results: VSG in mice greatly increased thermogenic gene expression in beige fat, which was correlated with increased energy expenditure. VSG reshaped gut microbiota composition, resulting in elevated levels of gut metabolites including licoricidin. Licoricidin treatment promoted thermogenic gene expression in beige fat by activating the Adrb3-cAMP-PKA signaling pathway, leading to reduced body weight gain in HFD-fed mice. Conclusions: We identify licoricidin, which mediates the crosstalk between gut and adipose tissue in mice, as a VSG-provoked anti-obesity metabolite. Identification of anti-obesity small molecules should provide new insights into treatment options for obesity and its associated metabolic diseases.

Milkshake Acutely Stimulates Dopamine Release in Ventral and Dorsal Striatum in Healthy-Weight Individuals and Patients with Severe Obesity Undergoing Bariatric Surgery: A Pilot Study.

The overconsumption of palatable energy-dense foods drives obesity, but few human studies have investigated dopamine (DA) release in response to the consumption of a palatable meal, a putative mediator of excess intake in obesity. We imaged [11C]raclopride in the brain with positron emission tomography (PET) to assess striatal dopamine (DA) receptor binding pre- and post-consumption of a highly palatable milkshake (250 mL, 420 kcal) in 11 females, 6 of whom had severe obesity, and 5 of whom had healthy-weight. Those with severe obesity underwent assessments pre- and 3 months post-vertical sleeve gastrectomy (VSG). Our results demonstrated decreased post- vs. pre-meal DA receptor binding in the ventral striatum (p = 0.032), posterior putamen (p = 0.012), and anterior caudate (p = 0.018), consistent with meal-stimulated DA release. Analysis of each group separately suggested that results in the caudate and putamen were disproportionately driven by meal-associated changes in the healthy-weight group. Baseline (pre-meal) DA receptor binding was lower in severe obesity than in the healthy-weight group. Baseline DA receptor binding and DA release did not change from pre- to post-surgery. The results of this small pilot study suggest that milkshake acutely stimulates DA release in the ventral and dorsal striatum. This phenomenon likely contributes to the overconsumption of highly palatable foods in the modern environment.

Mechanisms underlying the efficacy of a rodent model of vertical sleeve gastrectomy - A focus on energy expenditure.

OBJECTIVE: Bariatric surgery remains the only effective and durable treatment option for morbid obesity. Vertical Sleeve Gastrectomy (VSG) is currently the most widely performed of these surgeries primarily because of its proven efficacy in generating rapid onset weight loss, improved glucose regulation and reduced mortality compared with other invasive procedures. VSG is associated with reduced appetite, however, the relative importance of energy expenditure to VSG-induced weight loss and changes in glucose regulation, particularly that in brown adipose tissue (BAT), remains unclear. The aim of this study was to investigate the role of BAT thermogenesis in the efficacy of VSG in a rodent model. METHODS: Diet-induced obese male Sprague-Dawley rats were either sham-operated, underwent VSG surgery or were pair-fed to the food consumed by the VSG group. Rats were also implanted with biotelemetry devices between the interscapular lobes of BAT to assess local changes in BAT temperature as a surrogate measure of thermogenic activity. Metabolic parameters including food intake, body weight and changes in body composition were assessed. To further elucidate the contribution of energy expenditure via BAT thermogenesis to VSG-induced weight loss, a separate cohort of chow-fed rats underwent complete excision of the interscapular BAT (iBAT lipectomy) or chemical denervation using 6-hydroxydopamine (6-OHDA). To localize glucose uptake in specific tissues, an oral glucose tolerance test was combined with an intraperitoneal injection of 14C-2-deoxy-d-glucose (14C-2DG). Transneuronal viral tracing was used to identify 1) sensory neurons directed to the stomach or small intestine (H129-RFP) or 2) chains of polysynaptically linked neurons directed to BAT (PRV-GFP) in the same animals. RESULTS: Following VSG, there was a rapid reduction in body weight that was associated with reduced food intake, elevated BAT temperature and improved glucose regulation. Rats that underwent VSG had elevated glucose uptake into BAT compared to sham operated animals as well as elevated gene markers related to increased BAT activity (Ucp1, Dio2, Cpt1b, Cox8b, Ppargc) and markers of increased browning of white fat (Ucp1, Dio2, Cited1, Tbx1, Tnfrs9). Both iBAT lipectomy and 6-OHDA treatment significantly attenuated the impact of VSG on changes in body weight and adiposity in chow-fed animals. In addition, surgical excision of iBAT following VSG significantly reversed VSG-mediated improvements in glucose tolerance, an effect that was independent of circulating insulin levels. Viral tracing studies highlighted a patent neural link between the gut and BAT that included groups of premotor BAT-directed neurons in the dorsal raphe and raphe pallidus. CONCLUSIONS: Collectively, these data support a role for BAT in mediating the metabolic sequelae following VSG surgery, particularly the improvement in glucose regulation, and highlight the need to better understand the contribution from this tissue in human patients.

Vertical Sleeve Gastrectomy Offers Protection against Disturbed Flow-Induced Atherosclerosis in High-Fat Diet-Fed Mice.

Bariatric surgery reduces body weight, enhances metabolic and diabetic control, and improves outcomes on obesity-related comorbidities. However, the mechanisms mediating this protection against cardiovascular diseases remain unclear. We investigated the effect of sleeve gastrectomy (SG) on vascular protection in response to shear stress-induced atherosclerosis using an overweighted and carotid artery ligation mouse model. Eight-week-old male wild-type mice (C57BL/6J) were fed a high-fat diet (HFD) for two weeks to induce weight gain and dysmetabolism. SG was performed in HFD-fed mice. Two weeks after the SG procedure, partial carotid-artery ligation was performed to promote disturbed flow-induced atherosclerosis. Compared with the control mice, HFD-fed wild-type mice exhibited increased body weight, total cholesterol level, hemoglobin A1c, and enhanced insulin resistance; SG significantly reversed these adverse effects. As expected, HFD-fed mice exhibited greater neointimal hyperplasia and atherosclerotic plaques than the control group, and the SG procedure attenuated HFD-promoted ligation-induced neointimal hyperplasia and arterial elastin fragmentation. Besides, HFD promoted ligation-induced macrophage infiltration, matrix metalloproteinase-9 expression, upregulation of inflammatory cytokines, and increased vascular endothelial growth factor secretion. SG significantly reduced the above-mentioned effects. Moreover, HFD restriction partially reversed the intimal hyperplasia caused by carotid artery ligation; however, this protective effect was significantly lower than that observed in SG-operated mice. Our study demonstrated that HFD deteriorates shear stress-induced atherosclerosis and SG mitigates vascular remodeling, and this protective effect was not comparable in HFD restriction group. These findings provide a rationale for using bariatric surgery to counter atherosclerosis in morbid obesity.

Bariatric Surgery: Targeting pancreatic ß cells to treat type II diabetes.

Pancreatic ß-cell function impairment and insulin resistance are central to the development of obesity-related type 2 diabetes mellitus (T2DM). Bariatric surgery (BS) is a practical treatment approach to treat morbid obesity and achieve lasting T2DM remission. Traditionally, sustained postoperative glycemic control was considered a direct result of decreased nutrient intake and weight loss. However, mounting evidence in recent years implicated a weight-independent mechanism that involves pancreatic islet reconstruction and improved ß-cell function. In this article, we summarize the role of ß-cell in the pathogenesis of T2DM, review recent research progress focusing on the impact of Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) on pancreatic ß-cell pathophysiology, and finally discuss therapeutics that have the potential to assist in the treatment effect of surgery and prevent T2D relapse.

Gastroesophageal reflux management after vertical sleeve gastrectomy.

VSG is the most used surgical procedure in the world. Among the main complications linked to this procedure is GERD. It is apparent that endoscopic control protocols should be undertaken in all patients recovering from a VSG procedure. This is particularly key when taking into account the large number of patients suffering from GERD that show no symptoms, a situation that in many cases leads to severe esophagitis or even adenocarcinoma. Once the pertinent diagnostic tests have been carried out, the specialist should seek a conservative medical treatment including PPI. In the event that this treatment should fail, the next step to be considered should be a surgical procedure. In this case, the ideal procedure would be a reconversion to gastric bypass due to its low-risk and its results. There are other alternatives such as the Stretta, Linx or ARMS procedures; however, further research is necessary to prove their reliability.

Antibodies to sclerostin or G-CSF receptor partially eliminate bone or marrow adipocyte loss, respectively, following vertical sleeve gastrectomy.

Vertical sleeve gastrectomy (VSG), the most utilized bariatric procedure in clinical practice, greatly reduces body weight and improves a variety of metabolic disorders. However, one of its long-term complications is bone loss and increased risk of fracture. Elevated circulating sclerostin (SOST) and granulocyte-colony stimulating factor (G-CSF) concentrations have been considered as potential contributors to VSG-associated bone loss. To test these possibilities, we administrated antibodies to SOST or G-CSF receptor and investigated alterations to bone and marrow niche following VSG. Neutralizing either SOST or G-CSF receptor did not alter beneficial effects of VSG on adiposity and hepatic steatosis, and anti-SOST treatment provided a further improvement to glucose tolerance. SOST antibodies partially reduced trabecular and cortical bone loss following VSG by increasing bone formation, whereas G-CSF receptor antibodies had no effects on bone mass. The expansion in myeloid cellularity and reductions in bone marrow adiposity seen with VSG were partially eliminated by treatment with Anti-G-CSF receptor. Taken together, these experiments demonstrate that antibodies to SOST or G-CSF receptor may act through independent mechanisms to partially block effects of VSG on bone loss or marrow niche cells, respectively.

Utilization of an Enhanced Recovery After Surgery (ERAS) protocol for pediatric metabolic and bariatric surgery.

INTRODUCTION: Enhanced recovery after surgery (ERAS) protocols for pediatric metabolic and bariatric surgery are limited. In 2018, an ERAS protocol for patients undergoing robotically assisted vertical sleeve gastrectomy (r-VSG) was instituted. This study's aim was to compare outcomes before and after ERAS initiation. METHODS: A single institution retrospective review of patients undergoing r-VSG from July 2015 to July 2021 was performed. The multimodal ERAS protocol focused on limiting post-operative nausea and narcotic utilization. Subjects were categorized into non-ERAS (July 2015-July 2018) and ERAS (August 2018-July 2021) groups. In-hospital and 30-day outcomes were compared. RESULTS: 110 subjects (94 females) with a median age of 17.6 years (range 12.5-22.0 years) were included (60 non-ERAS, 50 ERAS). Demographics were similar except for a higher proportion of females in the non-ERAS group (97% vs 72%, p < 0.001). A significant decrease in narcotic use (p < 0.001) and higher utilization of acetaminophen (p < 0.001) and ketorolac (p < 0.001) was observed in the ERAS group. Additionally, median time to oral intake, a proxy for postoperative nausea and vomiting [2:00 h (1:15, 2:30) vs. 3:22 h (2:03, 6:15), p < 0.001] and hospital length of stay (LOS) [1.25 days (1.14, 1.34) vs. 2.16 days (1.48, 2.42), p < 0.001] were shorter in the ERAS group. Eleven subjects (10%; ERAS = 5, non-ERAS = 6) experienced post-discharge dehydration, prompting readmission 8 times for 7 (6%) individuals. CONCLUSION: Utilization of ERAS led to a significant decrease narcotic utilization, time to first oral intake, and hospital LOS with no change in adverse events following pediatric metabolic and bariatric surgery. Larger studies, including comparative analysis of health care utilization, should be carried out. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Treatment Study.

Benefits of Adjuvant Medical Weight Loss Intervention in Setting of Weight Regain and Inadequate Weight Loss After Weight Loss Surgery.

BACKGROUND: Currently, there is no nationally accepted protocol for addressing weight regain or inadequate weight loss after MBS. OBJECTIVES: To devise, implement, and evaluate a protocol targeting weight regain or inadequate weight loss in MBS patients at our institution. SETTING: Vanderbilt University Medical Center, Nashville, TN, United States. METHODS: Patients at least 6 months following primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) who achieved or were trending toward <50% excess body weight loss or who regained ≥10% of their lowest postoperative weight, were identified and referred for medical weight loss (MWL) intervention. Exclusion criteria were body mass index (BMI) ≤ 27 kg/m2, treatment with adjustable gastric banding, and conversion from SG to RYGB. RESULTS: 2274 patients who were >6 months out from surgery were evaluated over 12 months. 93 patients (86% female) met criteria for inclusion. 69 (74%) patients agreed to intervention and were followed for an average of 165 days (SD 106.89 days), demonstrating a mean weight change of -5.11 kg (SD 6.86 kg), and BMI change of -1.81 kg/m2 (SD 2.37 kg/m2). Patients who spent <90 days in a MWL program demonstrated less average weight loss (1.75 kg vs 6.48 kg) (P = .0042), and less change in BMI (-.63 kg/m2 vs -2.29 kg/m2) (P = .0037) when compared to patients who spent >90 days in the MWL intervention. CONCLUSIONS: This study identifies criteria for intervention in patients suffering weight regain or inadequate weight loss after MBS and demonstrates that standardized identification and referral for treatment results in modest weight loss.

The relationship between weight loss and cognitive function in bariatric surgery.

BACKGROUND: Previously, we reported short-term improvements in auditory attention, oromotor processing speed, and executive function during the active weight loss phase following bariatric surgery that persisted out to 3 months. In this study, our aims were to investigate the relationship between weight loss and cognitive performance in these patients 1 year following vertical sleeve gastrectomy (VSG) and Roux-en Y gastric bypass (RYGB) surgery and to determine whether preoperative cognitive performance predicted weight loss. METHODS: Adult women ages 18-55 approved for bariatric surgery completed a cognitive battery prior to and at 2, 12, 24, and 52 weeks following VSG (N = 17) or RYGB (N = 18). Scores from each task were assigned to one of the following cognitive domains: auditory attention, processing speed, memory, and executive functioning. Weight loss and cognitive scores for each domain were calculated and compared between cohorts. RESULTS: RYGB surgery resulted in greater weight loss at 1-year follow-up relative to VSG. Both VSG and RYGB procedures resulted in improved performance on different measures of auditory attention and both surgery groups improved across all processing speed tasks. Within the executive function domain, both groups showed improvements, but only the RYGB procedure resulted in improved performance in the Trail Making Test. Baseline auditory attention and memory performance predicted weight loss at 1 year following RYGB but not VSG surgery. Controlling for baseline cognitive performance, percent total weight loss predicted auditory attention at 1 year following RYGB but not VSG surgery. CONCLUSIONS: Bariatric surgery type may result in selective improvements in cognition during the first year following surgery. Presurgical cognitive performance as well as surgery type appears to influence weight loss outcomes.