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This study evaluated the metabolic effects of Roux-en-Y gastric bypass or diet alone in patients with diabetes who had lost matched amounts of weight. The primary outcome, the change in hepatic insulin sensitivity, was similar in the two groups. Thus, weight loss itself, not effects independent of weight loss, accounted for the results.

Abstract Many insurance plans impose strict criteria mandating preoperative weight loss attempts to limit patient’s access to surgery. Preoperative acute weight loss has been hypothesized to reduce perioperative risk and to identify compliant patients who may have improved long-term weight loss. In this review, the evidence from studies examining clinical and weight loss outcomes both with and without preoperative weight loss are summarized. Although preoperative weight loss may have modest impact on some factors related to perioperative conduct, the evidence does not support these programs’ effectiveness at promoting long-term weight loss. Provision of weight loss surgery should not be contingent on completion of insurance-mandated weight loss goals preoperatively, and these programs may, through patient attrition, actually do more harm than good.

Visceral Fat Adipokine Secretion Is Associated With Systemic Inflammation in Obese Humans Luigi Fontana 1 2 , J. Christopher Eagon 1 , Maria E. Trujillo 3 4 , Philipp E. Scherer 3 4 and Samuel Klein 1 1 Center for Human Nutrition, Washington University School of Medicine, St. Louis, Missouri 2 Division of Food Science, Human Nutrition, and Health, Istituto Superiore di Sanitá, Rome, Italy 3 Department of Cell Biology, Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, New York 4 Department of Medicine, Diabetes Research and Training Center, Albert Einstein College of Medicine, Bronx, New York Address correspondence and reprint requests to Samuel Klein, MD, Washington University School of Medicine, Campus Box 8031, 660 South Euclid Ave., St. Louis, MO 63110. E-mail: sklein{at}im.wustl.edu Abstract Although excess visceral fat is associated with noninfectious inflammation, it is not clear whether visceral fat is simply associated with or actually causes metabolic disease in humans. To evaluate the hypothesis that visceral fat promotes systemic inflammation by secreting inflammatory adipokines into the portal circulation that drains visceral fat, we determined adipokine arteriovenous concentration differences across visceral fat, by obtaining portal vein and radial artery blood samples, in 25 extremely obese subjects (mean ± SD BMI 54.7 ± 12.6 kg/m 2 ) during gastric bypass surgery at Barnes-Jewish Hospital in St. Louis, Missouri. Mean plasma interleukin (IL)-6 concentration was ∼50% greater in the portal vein than in the radial artery in obese subjects ( P = 0.007). Portal vein IL-6 concentration correlated directly with systemic C-reactive protein concentrations ( r = 0.544, P = 0.005). Mean plasma leptin concentration was ∼20% lower in the portal vein than in the radial artery in obese subjects ( P = 0.0002). Plasma tumor necrosis factor-α, resistin, macrophage chemoattractant protein-1, and adiponectin concentrations were similar in the portal vein and radial artery in obese subjects. These data suggest that visceral fat is an important site for IL-6 secretion and provide a potential mechanistic link between visceral fat and systemic inflammation in people with abdominal obesity. CRP, C-reactive protein IL, interleukin FFA, free fatty acid HMW, high molecular weight LMW, low molecular weight MCP-1, macrophage chemoattractant protein-1 TNF-α, tumor necrosis factor-α Footnotes Published ahead of print at http://diabetes.diabetesjournals.org on 2 February 2007. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Accepted January 14, 2007. Received November 27, 2006. DIABETES

Endoplasmic Reticulum Stress Is Reduced in Tissues of Obese Subjects After Weight Loss Margaret F. Gregor 1 , Ling Yang 1 , Elisa Fabbrini 2 , B. Selma Mohammed 2 , J. Christopher Eagon 2 , Gökhan S. Hotamisligil 1 and Samuel Klein 2 1 Department of Genetics and Complex Diseases, Harvard School of Public Health, Boston, Massachusetts 2 Center for Human Nutrition, Washington University School of Medicine, St. Louis, Missouri Corresponding author: Samuel Klein, sklein{at}wustl.edu , or Gökhan S. Hotamisligil, ghotamis{at}hsph.harvard.edu Abstract OBJECTIVE— Obesity is associated with insulin resistance and type 2 diabetes, although the mechanisms linking these pathologies remain undetermined. Recent studies in rodent models revealed endoplasmic reticulum (ER) stress in adipose and liver tissues and demonstrated that ER stress could cause insulin resistance. Therefore, we tested whether these stress pathways were also present in obese human subjects and/or regulated by weight loss. RESEARCH DESIGN AND METHODS— Eleven obese men and women (BMI 51.3 ± 3.0 kg/m 2 ) were studied before and 1 year after gastric bypass (GBP) surgery. We examined systemic insulin sensitivity using hyperinsulinemic-euglycemic clamp studies before and after surgery and collected subcutaneous adipose and liver tissues to examine ER stress markers. RESULTS— Subjects lost 39 ± 9% body wt at 1 year after GBP surgery ( P < 0.001), which was associated with a marked improvement in hepatic, skeletal muscle, and adipose tissue insulin sensitivity. Markers of ER stress in adipose tissue significantly decreased with weight loss. Specifically, glucose-regulated protein 78 (Grp78) and spliced X-box binding protein-1 (sXBP-1) mRNA levels were reduced, as were phosphorylated elongation initiation factor 2α (eIF2α) and stress kinase c-Jun NH 2 -terminal kinase 1 (JNK1) (all P values <0.05). Liver sections from a subset of subjects showed intense staining for Grp78 and phosphorylated eIF2α before surgery, which was reduced in post-GBP sections. CONCLUSIONS— This study presents important evidence that ER stress pathways are present in selected tissues of obese humans and that these signals are regulated by marked weight loss and metabolic improvement. Hence, this suggests the possibility of a relationship between obesity-related ER stress and metabolic dysfunction in obese humans. Footnotes Published ahead of print at http://diabetes.diabetesjournals.org on 9 December 2008. M.F.G. and L.Y. contributed equally to this work. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. See accompanying commentary, p. 518 . Accepted November 24, 2008. Received September 3, 2008. DIABETES

BackgroundSurgical site infections (SSI) are one of the most common complications of bariatric surgery. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement (QI) Program (MBSAQIP) allows accredited programs to develop processes for quality improvement based on data collection. The objective of this study was to decrease SSI rates in patients undergoing bariatric surgery at an accredited MBSAQIP center.MethodsUsing the MBSAQIP semiannual report, SSI rates were retrospectively reviewed. Baseline SSI rates were collected from 01/01/2014–12/31/2015. On 01/01/2016, the first infection prevention protocol (IPP-1) was created that included 4% chlorhexidine gluconate (CHG) showers, CHG wipes immediately prior to surgery, and routine cultures of SSIs. An updated IPP (IPP-2) was implemented on 09/01/2016, which discontinued routine surgical drain placement and broadened antibiotic coverage for penicillin allergic patients.ResultsDuring baseline data collection, SSI rates were 5.1%. After the implementation of IPP-1, SSI rates trended down to 2.5%. After implementation of IPP-2, SSI rates decreased significantly to 1.5%, a 66% relative risk reduction in SSIs from baseline. On multivariate regression analysis, the perioperative factors associated with an increased risk for SSIs included diabetes mellitus, intraoperative surgical drain placement, the number of hypertension medications prior to bariatric surgery, and an open approach.ConclusionsOur study demonstrates that the implementation of a specific protocol for reducing SSIs is safe and feasible in patients undergoing bariatric surgery. We also identified that the success of the IPP is likely centered on the elimination of routine drain placement during primary bariatric procedures.

BackgroundThe role of robotic surgery in bariatrics remains controversial. Patient selection for robotic surgery is not well-studied. The objective of this study was to identify factors associated with robotic surgery and its temporal trends.MethodsThe Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database from 2015 to 2018 was used. Adult patients undergoing primary sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) using the laparoscopic or robotic approach were identified. Revisional, hybrid, or those with concomitant procedures were excluded. Logistic regression was conducted to identify factors associated with undergoing robotic-assisted surgery.ResultsAmong 211,568 patients who underwent SG, 9.1% underwent a robotic SG; among 76,805 patients who underwent RYGB, 7.9% of patients underwent a robotic RYGB. During 2015-2018, robotics increased from 7.1 to 11.3% for SG and 7.4 to 8.6% for RYGB. After controlling for patient characteristics, there was still an increasing trend in the use of robotic surgery: SG (multivariable-adjusted odds ratio, aOR, 1.18; 95% confidence interval, CI, 1.17–1.20) and RYGB (aOR, 1.05; 95% CI, 1.03–1.08). For both robotic SG and RYGB, functional status and African American race were associated with undergoing robotic surgery, while races other than White or African American and Hispanic ethnicity were not. Pre-operative IVC filter was associated with robotic SG, while the presence of GERD, diabetes, and COPD were associated with robotic RYGB.ConclusionsRobotic bariatric surgery has increased over time. Our findings identified factors associated with the receipt of robotic surgery. Reasons for these factors require further investigation to better delineate indications for this technology.

Background Intermittent, reversible intraabdominal vagal blockade (VBLOC® Therapy) demonstrated clinically important weight loss in feasibility trials. EMPOWER, a randomized, double-blind, prospective, controlled trial was conducted in USA and Australia. Methods Five hundred three subjects were enrolled at 15 centers. After informed consent, 294 subjects were implanted with the vagal blocking system and randomized to the treated ( n  = 192) or control ( n  = 102) group. Main outcome measures were percent excess weight loss (percent EWL) at 12 months and serious adverse events. Subjects controlled duration of therapy using an external power source; therapy involved a programmed algorithm of electrical energy delivered to the subdiaphragmatic vagal nerves to inhibit afferent/efferent vagal transmission. Devices in both groups performed regular, low-energy safety checks. Data are mean ± SEM. Results Study subjects consisted of 90 % females, body mass index of 41 ± 1 kg/m 2 , and age of 46 ± 1 years. Device-related complications occurred in 3 % of subjects. There was no mortality. 12-month percent EWL was 17 ± 2 % for the treated and 16 ± 2 % for the control group. Weight loss was related linearly to hours of device use; treated and controls with ≥12 h/day use achieved 30 ± 4 and 22 ± 8 % EWL, respectively. Conclusions VBLOC® therapy to treat morbid obesity was safe, but weight loss was not greater in treated compared to controls; clinically important weight loss, however, was related to hours of device use. Post-study analysis suggested that the system electrical safety checks (low charge delivered via the system for electrical impedance, safety, and diagnostic checks) may have contributed to weight loss in the control group.

BACKGROUNDThere is considerable heterogeneity in the effect of weight loss on metabolic function in people with obesity.METHODSWe evaluated muscle and liver insulin sensitivity, body composition, and circulating factors associated with insulin action before and after approximately 20% weight loss in women identified as \"Responders\" (n = 11) or \"Non-responders\" (n = 11), defined as the top (>75% increase) and bottom (<5% increase) quartiles of the weight loss-induced increase in glucose disposal rate (GDR) during a hyperinsulinemic-euglycemic clamp procedure, among 43 women with obesity (BMI: 44.1 ± 7.9 kg/m2).RESULTSAt baseline, GDR, which provides an index of muscle insulin sensitivity, and the hepatic insulin sensitivity index were more than 50% lower in Responders than Non-responders, but both increased much more after weight loss in Responders than Non-responders, which eliminated the differences between groups. Weight loss also caused greater decreases in intrahepatic triglyceride content and plasma adiponectin and PAI-1 concentrations in Responders than Non-responders and greater insulin-mediated suppression of plasma free fatty acids, branched-chain amino acids, and C3/C5 acylcarnitines in Non-responders than Responders, so that differences between groups at baseline were no longer present after weight loss. The effect of weight loss on total body fat mass, intra-abdominal adipose tissue volume, adipocyte size, and circulating inflammatory markers were not different between groups.CONCLUSIONThe results from our study demonstrate that the heterogeneity in the effects of marked weight loss on muscle and hepatic insulin sensitivity in people with obesity is determined by baseline insulin action, and reaches a ceiling when \"normal\" insulin action is achieved.TRIAL REGISTRATIONNCT00981500, NCT01299519, NCT02207777.FUNDINGNIH grants P30 DK056341, P30 DK020579, P30 DK052574, UL1 TR002345, and T32 HL13035, the American Diabetes Association (1-18-ICTS-119), the Longer Life Foundation (2019-011), and the Atkins Philanthropic Trust.

Background Internal drainage of pancreatic pseudocysts can be accomplished by traditional open or minimally invasive laparoscopic or endoscopic approaches. This study aimed to evaluate the primary and overall success rates and clinical outcomes after laparoscopic, endoscopic, and open pancreatic cystgastrostomy for pancreatic pseudocysts. Methods Records of 83 patients undergoing laparoscopic ( n  = 16), endoscopic ( n  = 45), and open ( n  = 22) pancreatic cystgastrostomy were analyzed on an intention-to-treat basis. Results There were no significant differences ( p  < 0.05) in the mean patient age (years), gender, body mass index (BMI) (kg/m 2 ), etiology of pancreatitis (% gallstone), or size (cm) of pancreatic pseudocyst between the groups. Grade 2 or greater complications occurred within 30 days of the primary procedure for 31.5% of the laparoscopic patients, 15.6% of the endoscopic patients, and 22.7% of the open patients (nonsignificant differences). The follow-up evaluation for 75 patients (90.4%) was performed at a mean interval of 9.5 months (range, 1–40 months). The primary compared with the overall success rate, defined as cyst resolution, was 51.1% vs. 84.6% for the endoscopic group, 87.5% vs. 93.8% for the laparoscopic group, and 81.2% vs. 90.9% for the open group. The primary success rate was significantly higher ( p  < 0.01) for laparoscopic and open groups than for the endoscopic group, but the overall success rate was equivalent across the groups (nonsignificant differences). Primary endoscopic failures were salvaged by open pancreatic cystgastrostomy ( n  = 13), percutaneous drainage ( n  = 3), and repeat endoscopic drainage ( n  = 6). Conclusions Laparoscopic and open pancreatic cystgastrostomy both have a higher primary success rate than endoscopic internal drainage, although repeat endoscopic cystgastrostomy provides overall success for selected patients.

BackgroundThe effects of diet-induced weight loss (WL) and WL after Roux-en-Y gastric bypass (RYGB) surgery on β cell function (BCF) are unclear because of conflicting results from different studies, presumably because of differences in the methods used to measure BCF, the amount of WL between treatment groups, and baseline BCF. We evaluated the effect of WL after RYGB surgery or reduced energy intake alone on BCF in people with obesity with and without type 2 diabetes.MethodsBCF (insulin secretion in relationship to plasma glucose) was assessed before and after glucose or mixed-meal ingestion before and after (a) progressive amounts (6%, 11%, 16%) of WL induced by a low-calorie diet (LCD) in people with obesity without diabetes, (b) ~20% WL after RYGB surgery or laparoscopic adjustable gastric banding (LAGB) in people with obesity without diabetes, and (c) ~20% WL after RYGB surgery or LCD alone in people with obesity and diabetes.ResultsDiet-induced progressive WL in people without diabetes progressively decreased BCF. Marked WL after LAGB or RYGB in people without diabetes did not alter BCF. Marked WL after LCD or RYGB in people with diabetes markedly increased BCF, without a difference between groups.ConclusionMarked WL increases BCF in people with obesity and diabetes but not in people with obesity without diabetes. The effect of RYGB-induced WL on BCF is not different from the effect of matched WL after LAGB or LCD alone.trial registrationNCT00981500, NCT02207777, NCT01299519.FundingNIH grants R01 DK037948, P30 DK056341, P30 DK020579, UL1 TR002345.