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IFSO-EC Live Streaming Symposium a great success

More than 400 experts from around the world attended the IFSO-European Chapter Live Streaming Symposium, taking place during the Spanish Bariatric Surgery Society (SECO) Congress on May 28, 2015 in Vitoria, Spain. The symposium focuses on the management and treatment of sleeve leaks and fistulas. The congress programme proceeded without any complications, and its size exceeded the expectations. The event included distinguished speakers from numerous countries. This live streaming symposium was chaired by Alberic Fiennes -President of IFSO-EC-, accompanied by Dr Joan Pujol Rafols – Chairman of Development & Communication Committee IFSO-EC- and Dr. Antonio Torres Garcia. The meeting was broadcast live on the Internet. The organizers established an online forum, where people from all parts of the world connected through the chat. The success of this event is a part of the many activities for this year by IFSO-EC.

Liraglutide lowers weight and HbA1c in T2DM Arab patients

Liraglutide is effective in reducing weight, HbA1c as well as other metabolic parameters in Arab population with type2 diabetes, according to a study ‘Liraglutide effect in reducing Hba1c and weight in Arab population with type2 diabetes, a prospective observational trial’, published in the Journal of Diabetes & Metabolic Disorders. The investigators from the United Arab Emirates said that they believed this was the first trial ever conducted to specifically look at the efficacy of liraglutide in Arab population.

It is known that pathophysiology of type2 diabetes differs between different ethnic groups, and that Asians develop type2 diabetes at younger age, lower body mass index and in relatively short time. In addition, some ethnicities have different responses and dosing regimens to different classes of anti-diabetic agents. For example, data from Japanese population showed that the optimal doses of liraglutide used are smaller than other populations and that weight loss is not as effective as seen in Caucasians.

As a result, the researchers assessed the efficacy of liraglutide in reducing weight and HbA1c in Arab population when used as add on to other anti-diabetic agents. They prospectively followed patients who were recruited to treatment with liraglutide for a six months period. Patients were checked at three months and at the end of the study at six months.

The dose of liraglutide started at 0.6mg once per day subcutaneously and increased after one week to 1.2mg and after another week to 1.8mg per day. Those who did not tolerate the 1.2mg were excluded from the study, while those who did not tolerate the 1.8mg were advised to continue with 1.2mg per day (1.2–1.8mg were the doses used in LEAD trials).

New obesity treatment prevents bone loss during weight loss

Using the intestinal hormone glucagon-like peptide 1 (GLP-1) in obesity treatment prevents the loss of bone mass otherwise frequently associated with major weight loss, according to a study from the University of Copenhagen, Hvidovre and Glostrup Hospital, Denmark. According to the researchers behind the study, the results may have a significant bearing on future obesity treatment.

It is known that rapid weight loss can lead to a loss of bone mass and an increased risk of bone fractures. The Danish research shows that treating obesity with the GLP-1 hormone helps prevent loss of bone mass in addition to having a number of positive effects on the formation of new bone and on blood sugar levels.

“GLP-1 analogues like liraglutide are today widely used in the treatment of type 2 diabetes and have been shown not to increase the risk of bone fractures, unlike other diabetes drugs,” said physician and PhD student, Eva Winning Jepsen from the Department of Biomedical Sciences and the Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen. “Liraglutide has just been approved for obesity treatment because of its appetite-inhibiting effects, but its effect on the bones of overweight patients who are not suffering from type 2 diabetes has so far been unknown.”

The study looked at 37 women who achieved a large weight loss of 12kg by eating a low-calorie diet. The women were divided into two groups: one which was given the GLP-1 analogue liraglutide, and a control group. Over a one-year period, the women were given frequent dietary advice to help them maintain their weight loss; and if they gained weight, they could replace up to two meals with a low-calorie powder.

The researchers recorded the total, pelvic and arm-leg bone mineral content (BMC) and bone markers (CTX-1 and P1NP) before, after weight loss and after 52 weeks weight maintenance. Primary end points were the change in BMC and bone markers after 52 weeks weight maintenance with or without GLP-1 RA treatment.

They report that total, pelvic and arm-leg BMC decreased during weight maintenance in the control group (p

Therefore, the study showed that the liraglutide group had not lost any bone mass and had increased blood levels of bone formation markers as opposed to the control group which had lost bone mass.

“Menopausal women have an increased risk of osteoporosis and bone fractures. If they try to lose weight and thus lose even more bone mass, they are at an even higher risk,” said lead researcher, Associate Professor Signe Soerensen Torekov from the Department of Biomedical Sciences and the Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen. “The study shows that overweight women can now lose weight with liraglutide without increasing the risk of losing bone mass. At the same time, they also achieve a number of other positive effects on their sugar metabolism which are not achieved through a diet-induced weight loss alone,”

The importance of intestinal hormones on bone formation and breakdown has long been a focus area and this study now opens up for exploiting the beneficial effect of intestinal hormones on the bones.

“Overweight is a protective factor for osteoporosis and bone fractures, but it increases the risk of other diseases such as cardiovascular diseases and type 2 diabetes. It appears that treatment with liraglutide makes it possible to lose weight and maintain the beneficial effect on the bones, while at the same time reducing the risk of cardiovascular disease and type 2 diabetes. This may have a significant bearing on our future approach to obesity treatment,” added Torekov.

The study, GLP-1 receptor agonist treatment increases bone formation and prevents bone loss in weight-reduced obese women., has been published in the Journal of Clinical Endocrinology and Metabolism and was presented at the American Diabetes Association (ADA) in Boston on 6th June 2015.

Obese Patients at High Risk of Post-surgery Complications

Research from the University of Alberta’s Faculty of Medicine & Dentistry is revealing the heavy surgical consequences of severe obesity.

The study, published in the February edition of the Canadian Journal of Surgery, looked at the results of severely obese patients in need of emergency surgery. Of the patients studied, nearly half (40 per cent) needed to be admitted to an intensive care unit (ICU), and just under one in five (17 per cent) did not survive to be discharged home.

“This is one of the first studies to show in an emergency surgical population that the severely obese patients have such risk for major complications and death,” says Rachel Khadaroo, an assistant professor in the Department of Surgery at the U of A, and co-author of the study.

The study involved 111 patients treated at the University of Alberta hospital between 2009 and 2011 who had a body mass index of 35 or higher. The study also found that one-third of patients required multiple surgeries and that the heaviest patients had the highest complication rates.

The researchers say several factors may play a role in the findings. The severely obese often have underlying health conditions such as high blood pressure or diabetes that increase their risk of post-surgery complications. Many also suffer from sarcopenia–a deficiency in muscle–which can have an impact on recovery. The poor results may also be partially explained because of problems with malnutrition among severely obese patients.

“Even though these patients are taking in a lot of calories, a lot of them are empty calories,” explains Suzana Kupper, a general surgery resident at the U of A and lead author of the study. “They are not coming with associated vitamins and minerals and essential fatty acids that the body needs to run well.

“Because of this, they have impaired healing essentially relating to this malnutrition of obesity. A diminished ability to heal may explain the substantial need for ICU support, reoperation and the high mortality observed in our study.”

According to Statistics Canada, in 2013, 19 per cent of Canadians aged 18 and older–roughly 4.9 million adults–reported height and weight that classified them as obese. It’s estimated by the World Health Organization that excess body weight is responsible for 2.8 million deaths each year.

The researchers, who are all part of the Acute Care and Emergency Surgery (ACES) Group at the university, say educating physicians and surgeons about the risk factors for severely obese patients is a key step moving forward.

“It’s a vulnerable population of frail individuals and I think it’s important for us to recognize that as clinicians so that we can treat them appropriately,” says Sandy Widder, an associate professor in the Department of Surgery and senior author of the study. “This knowledge can help us allocate resources and specialized equipment in the future to better meet their unique needs.”

Fresh NEWS from the Chapter

Dr. Joan Pujol Rafols (Barcelona) lead the Communication and Development Subcommittee.
Dr Rachel Batterham (London) & Dr Ralph Peterli (Zurich) lead the Science Subcommittee
Prof Michel Suter (Lausanne) represents the Chapter on the newly formed IFSO world-wide registry committee (agreed in March 2015).

Shaw Somers (UK) and Jean-Marc Chevalier(France) represent the Chapter on the IFSO world-wide Membership Subcommittee (agreed in March 2015).

Obesity continues to increase in Europe

Overweight and obesity is increasing in the EU with 53% of adults in the EU now either overweight or obese, according to the third edition of ‘Health at a Glance: Europe 2014’ report. There are considerable variations between countries, the report states. For example, the prevalence of overweight and obesity among adults exceeds 50% in no less than 17 of EU member states. Obesity varies threefold among countries, from a low of around 8% in Romania to 25% or over in Hungary and the UK, although some of the variations across countries are due to different methodologies in data collection.

Obesity has grown fairly quickly over the past ten years in countries like France, Luxembourg, some Nordic countries (Denmark, Finland, as well as Iceland), and the Czech Republic. It has grown more moderately in other countries such as Italy, Sweden, Belgium, Norway and Switzerland. In the UK, the obesity rate has increased moderately over the past decade, although it remains the second highest among EU countries.

On average across EU member states, one in six adult (16.7%) was obese around the year 2012, an increase from one in eight a decade ago.

There is little difference in obesity rate among men and women on average across EU countries . However, there are notable differences in certain countries. Obesity among men is much greater in countries such as Slovenia, Luxembourg and Malta, whereas the opposite is true in Latvia, Hungary and Turkey where the obesity rate is much higher among women.

The rise in obesity has affected all population groups, but to different extents. Evidence from a range of OECD countries indicates that obesity tends to be more common in disadvantaged socio-economic groups, especially among women. There is also a relationship between the number of years of education and obesity, with the most educated people having lower rates. Again, the gradient in obesity is stronger in women than in men.

A number of behavioural and environmental factors have contributed to the long-term rise in overweight and obesity rates in industrialised countries, including the widespread availability of energy dense foods and more time spent being physically inactive. The economic crisis is also likely to have contributed to further growth in obesity.

Evidence from Germany, Finland and the United Kingdom shows a link between financial distress and obesity. Regardless of their income or wealth, people who experience periods of financial hardship are at an increased risk of obesity, and the increase is greater for more severe and recurrent hardship.

Surgical patients may have different psychological profiles

The researchers from the Charité—Universitätsmedizin Berlin, Berlin, Germany, published in PlosOne, have concluded that psychological factors are independent of somatic conditions in surgical patients compared to obese patients who prefer conservative treatment.

The authors claim that identifying predictors that could then be addressed prior to surgery could improve pre-surgical screening and the selection process, resulting in maintained weight loss after surgery. They claim that this treatment pathway may result in a more personalised medicine course, although longitudinal studies are required to assess the effectiveness of identifying psychological factors.

The authors stated that although psychological factors could influence the choice of treatment, to date, very few studies have been reported. The aim of this study was to analyse whether surgical patients differ from those who require a conservative treatment in regard to psychological and socio-demographic factors, regardless of their somatic conditions, such as personal and social resources, physical discomfort and mood.

In total, 244 patients (189 women), with a mean BMI 45.1, underwent a weight reduction treatment, with 126 patients undergoing bariatric surgery and 118 patients conservative treatment. In Germany, health insurance companies demand that patients who want to undergo surgery must be evaluated by a psychiatrist, clinical psychologist or a physician who specialises in psychosomatic medicine to determine their mental condition. All surgically treated patients has psychosomatic evaluation after the consultation by the surgeon, but prior to the operation.

Overall, 122 out of the 126 surgical patients underwent bariatric surgery and 4 patients received a gastric balloon. Restrictive surgery was performed in 110 patients (10 received laparoscopic adjustable gastric banding, 100 received laparoscopic Sleeve Gastrectomy). Twelve patients underwent a laparoscopic Roux-en-Y Gastric Bypass.

The one-year multimodal, conservative outpatient weight reduction programme was divided into four areas of intervention and application: advice on diet and training, movement therapy and training, psycho-education and behavioural therapy interventions, as well as Jacobson’s progressive muscle relaxation.

The outcomes revealed that surgically and conservatively treated obese patients differ in socio-demographic and somatic factors. Surgical patients were younger and more often male, had a lower educational level and were more likely to be unemployed.

Surgical patients also weighed significantly more, had higher BMIs and consulted more physicians due to their current complaints than the conservatively treated patients did. They also suffered significantly more often from type 2 diabetes mellitus, hypertension and coronary heart disease and less often from dyslipidaemia

Surgical patients also had less favourable scores on almost all of the psychological variables including having:

  • more “perceived feelings of hunger”
  • more “drive for thinness”
  • more “ineffectiveness”
  • more “perceived stress”
  • less “joy”
  • higher scores for “complaints” overall
  • more negative and less positive “mood”
  • more psychopathology
  • higher sub-scores for “anxiety syndrome” or “somatoform syndrome”.
  • more “depression”
  • less “mental health” and “physical health” (SF-8)
  • less “sense of coherence”
  • more “pessimism”; and
  • more “avoidant coping” and “delegated active coping”

After controlling for the confounding factors of BMI and type 2 diabetes mellitus, hypertension and coronary heart disease, the psychological differences persisted between the groups, which indicates that the differences are independent of these somatic conditions.

As shown in Table 2, the likelihood of having surgery increase by a factor of 54.34 if coupled with type 2 diabetes mellitus, apathy 47.2 times, degree of complaints by a factor of 1.15, sense of coherence by a factor of 8.35, delegated active coping increase the odds by 28.52 times, although age decreases the factor by 0.9 for each year the age increased.

The researchers report that psychological and somatic factors that equally predicted the choice of surgery were:

  • apathy
  • delegated active coping
  • a sense of coherence
  • complaints
  • type 2 diabetes mellitus
  • BMI; and
  • age

“In the present study, we found a great number of differences between surgically and conservatively treated obese patients regarding the psychological, somatic and socio-demographic factors,” the researchers note. “We demonstrated that psychological differences between the two groups persisted, even after controlling for BMI and obesity-related co-morbidities.”

They reported that surgical patients had significantly worse physical conditions before the intervention and that patients may expect surgery to result in rapid weight loss and pain relief. They also add that these patients may “tend to more strongly act out conflicts and the related negative emotions on a somatic level”. Nevertheless, they add that “it remains doubtful that bariatric surgery alone is a sufficient intervention strategy.”

There were no differences between the groups with regards to the prevalence of hyperphagic eating disorder, binge eating disorder, or other specific eating behaviours.

“The current study identified that psychological factors are independent of somatic conditions in obese patients who seek a surgical, rather than a conservative, weight reduction treatment.…The identification of predictors that can be therapeutically addressed before surgery to secure sufficient and sustained weight loss after the bariatric surgery is essential when determining treatment pathways for patients and may result in a more personalised medicine course,” the authors conclude.

Surgery can benefit some obese pediatric patients

As a last resort when conservative interventions have failed, bariatric surgery can improve liver disease and other obesity-related health problems in severely obese children and adolescents, according to a position paper in the Journal of Pediatric Gastroenterology and Nutrition, official journal of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.

Due to the potential for serious complications, an expert panel recommends that bariatric surgery be reserved for carefully selected subgroups of young children with severe or morbid obesity and associated medical conditions. The recommendations appear in a new position paper authored by the ESPGHAN Hepatology Committee, under the leadership of Prof Valerio Nobili of Bambino Gesù Children’s Hospital, Rome.

The Committee, made up of 12 European specialists in paediatric liver disease, was tasked with reviewing and analyzing the available evidence on bariatric surgery for obese children and adolescents. The epidemic of childhood obesity has brought an increase in obesity-related diseases, including type 2 diabetes and nonalcoholic fatty liver disease (NAFLD).

“Recent evidence suggests that in carefully selected patients an early intervention by bariatric surgery can strongly reduce the risk of adulthood obesity and obesity-related diseases, including NAFLD,” Nobili and colleagues write.

Yet the appropriate use of bariatric surgery in paediatric patients remains unclear, mainly because of limited research data and the known risks of the procedure. Based on the available evidence and expert opinion, the position paper outlines a standardised approach to considering bariatric surgery in children and adolescents.

Single-anastomosis bypass – an attractive alternative?

According to a paper published in the Scandinavian Journal of Surgery, the single-anastomosis gastric bypass “may be an attractive alternative metabolic operation”. Also known as the one-anastomosis gastric bypass or mini gastric bypass, the procedure can result in a shorter operative time, fewer short- and long-term complications, improved and sustained excess weight loss and is more effective in terms of resolutions of comorbidities compared to standard RYGB, the paper states.

Introduced by Dr Robert Rutledge in 2001, the single-anastomosis bypass has increased in popularity due to its simplicity and apparent safety and effectiveness. The benefits include:

  • fewer sites for leakage and internal hernia
  • easier and faster to learn and perform
  • easier to reverse and revise

Despite such benefits, the author of the paper, Professor Mikael Victorzon from Vaasa Central Hospital, Vaasa, Finland, warns there is a risk of symptomatic biliopancreaticoduodenal reflux, iron deficiency anaemia and marginal ulcers, and further studies with vigorous long-term follow-up are required.

Therefore, he undertook a literature review to ascertain current date on the clinical outcomes. In total, he identified 73 articles and after removal of case studies, duplicates, and irrelevant articles, ten articles remained for closer review, including only one randomised study (in total 7,287 patients).

Outcomes

In terms of morbidity, mortality, conversion rates, los, and follow-up, from the fivecentres with ~1,000 or more patients, the mortality rate is reported at 0.0%–0.18%, with a 30-day morbidity rate of 2.7% to 6.7%, leakage (from the gastric tube or anastomosis) rate as 0.2%–1.3%, conversion 0.0% and 1.2%, mean operative time between 37.5 and 115.3 min. The mean hospital length of stay was between one and four days. Victorzon notes that the follow-up rate of 5–6 years is “incomplete in most studies”, varying between 56% and 84%. Excessive weight loss occurred in 0.1%–1.28% of the patients.