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Background This is the second updated Enhanced Recovery After Surgery (ERAS®) Society guideline, presenting a consensus for optimal perioperative care in bariatric surgery and providing recommendations for each ERAS item within the ERAS® protocol. Methods A principal literature search was performed utilizing the Pubmed, EMBASE, Cochrane databases and ClinicalTrials.gov through December 2020, with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohort studies. Selected studies were examined, reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. After critical appraisal of these studies, the group of authors reached consensus regarding recommendations. Results The quality of evidence for many ERAS interventions remains relatively low in a bariatric setting and evidence-based practices may need to be extrapolated from other surgeries. Conclusion A comprehensive, updated evidence-based consensus was reached and is presented in this review by the ERAS® Society.

BackgroundFive International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) surveys since 1998 have estimated the volume and type of bariatric surgery being done in constituent member countries. These reports did not include baseline demographic descriptions.MethodsAn IFSO Global Registry pilot project in 2014 demonstrated that it was possible to amalgamate large numbers of individual patient data from different local and national database systems. Here we describe demographic data from the second report for 54,490 patients from 31 countries operated in the 3 calendar years 2013–2015 and follow up data from 66,560 of 112,544 patients in 2009–2015.ResultsMost procedures (97.8%) were performed laparoscopically and 73.3% (95% CI: 73.0–73.7%, range 54.2 to 80.3%) were female. The average age was 42.0 years (95% CI 41.9–42.1, inter-quartile range 33.0–51.0 years) and the median body mass index was 43.3 kg/m2 (inter-quartile range 39.4–48.8 kg/m2). Before surgery, 22.0% patients had type 2 diabetes (inter-country variation 7.4–63.2%); 31.9% were hypertensive (15.8–92.7%); 17.6% had depression (0.0–46.3%); 27.8% took medication for musculoskeletal pain (0.0–58.9%); 18.9% had sleep apnea (0.0–63.2%); and 29.6% of patients had gastro-esophageal reflux disease (9.1–90.9%). Gastric bypass was the most prevalent operation (49.4%), followed by sleeve gastrectomy (40.7%) and gastric banding (5.5%). The 1-year total weight loss for patients with available data was 30.53% (95% CI: 30.22–30.84%) and in the cohort 2009–15 was 30.4% with a follow-up rate of 59.14%. In the 2009–2015 cohort, 64.7% of patients on treatment for diabetes preoperatively were not on treatment postoperatively.ConclusionsThere is widespread variation in access to surgery and in baseline patient characteristics in the countries submitting data to the IFSO Global Registry.

Background Endometrial cancer is the most common gynaecological cancer in high-income countries. Elevated body mass index (BMI) is an established modifiable risk factor for this condition and is estimated to confer a larger effect on endometrial cancer risk than any other cancer site. However, the molecular mechanisms underpinning this association remain unclear. We used Mendelian randomization (MR) to evaluate the causal role of 14 molecular risk factors (hormonal, metabolic and inflammatory markers) in endometrial cancer risk. We then evaluated and quantified the potential mediating role of these molecular traits in the relationship between BMI and endometrial cancer using multivariable MR. Methods Genetic instruments to proxy 14 molecular risk factors and BMI were constructed by identifying single-nucleotide polymorphisms (SNPs) reliably associated ( P < 5.0 × 10 −8 ) with each respective risk factor in previous genome-wide association studies (GWAS). Summary statistics for the association of these SNPs with overall and subtype-specific endometrial cancer risk (12,906 cases and 108,979 controls) were obtained from a GWAS meta-analysis of the Endometrial Cancer Association Consortium (ECAC), Epidemiology of Endometrial Cancer Consortium (E2C2) and UK Biobank. SNPs were combined into multi-allelic models and odds ratios (ORs) and 95% confidence intervals (95% CIs) were generated using inverse-variance weighted random-effects models. The mediating roles of the molecular risk factors in the relationship between BMI and endometrial cancer were then estimated using multivariable MR. Results In MR analyses, there was strong evidence that BMI (OR per standard deviation (SD) increase 1.88, 95% CI 1.69 to 2.09, P = 3.87 × 10 −31 ), total testosterone (OR per inverse-normal transformed nmol/L increase 1.64, 95% CI 1.43 to 1.88, P = 1.71 × 10 −12 ), bioavailable testosterone (OR per natural log transformed nmol/L increase: 1.46, 95% CI 1.29 to 1.65, P = 3.48 × 10 −9 ), fasting insulin (OR per natural log transformed pmol/L increase: 3.93, 95% CI 2.29 to 6.74, P = 7.18 × 10 −7 ) and sex hormone-binding globulin (SHBG, OR per inverse-normal transformed nmol/L increase 0.71, 95% CI 0.59 to 0.85, P = 2.07 × 10 −4 ) had a causal effect on endometrial cancer risk. Additionally, there was suggestive evidence that total serum cholesterol (OR per mg/dL increase 0.90, 95% CI 0.81 to 1.00, P = 4.01 × 10 −2 ) had an effect on endometrial cancer risk. In mediation analysis, we found evidence for a mediating role of fasting insulin (19% total effect mediated, 95% CI 5 to 34%, P = 9.17 × 10 −3 ), bioavailable testosterone (15% mediated, 95% CI 10 to 20%, P = 1.43 × 10 −8 ) and SHBG (7% mediated, 95% CI 1 to 12%, P = 1.81 × 10 −2 ) in the relationship between BMI and endometrial cancer risk. Conclusions Our comprehensive MR analysis provides insight into potential causal mechanisms linking BMI with endometrial cancer risk and suggests targeting of insulinemic and hormonal traits as a potential strategy for the prevention of endometrial cancer.

PurposeBariatric and metabolic surgery is an effective treatment for severe and complex obesity; however, robust long-term data comparing operations is lacking. Clinical registries complement clinical trials in contributing to this evidence base. Agreement on standard data for bariatric registries is needed to facilitate comparisons. This study developed a Core Registry Set (CRS) — core data to include in bariatric surgery registries globally.Materials and MethodsRelevant items were identified from a bariatric surgery research core outcome set, a registry data dictionary project, systematic literature searches, and a patient advisory group. This comprehensive list informed a questionnaire for a two-round Delphi survey with international health professionals. Participants rated each item’s importance and received anonymized feedback in round 2. Using pre-defined criteria, items were then categorized for voting at a consensus meeting to agree the CRS.ResultsItems identified from all sources were grouped into 97 questionnaire items. Professionals (n = 272) from 56 countries participated in the round 1 survey of which 45% responded to round 2. Twenty-four professionals from 13 countries participated in the consensus meeting. Twelve items were voted into the CRS including demographic and bariatric procedure information, effectiveness, and safety outcomes.ConclusionThis CRS is the first step towards unifying bariatric surgery registries internationally. We recommend the CRS is included as a minimum dataset in all bariatric registries worldwide. Adoption of the CRS will enable meaningful international comparisons of bariatric operations. Future work will agree definitions and measures for the CRS including incorporating quality-of-life measures defined in a parallel project.

ObjectiveTo determine if oesophago-gastro-duodenoscopy (OGD) generates increased levels of aerosol in conscious patients and identify the source events.DesignA prospective, environmental aerosol monitoring study, undertaken in an ultraclean environment, on patients undergoing OGD. Sampling was performed 20 cm away from the patient’s mouth using an optical particle sizer. Aerosol levels during OGD were compared with tidal breathing and voluntary coughs within subject.ResultsPatients undergoing bariatric surgical assessment were recruited (mean body mass index 44 and mean age 40 years, n=15). A low background particle concentration in theatres (3 L−1) enabled detection of aerosol generation by tidal breathing (mean particle concentration 118 L−1). Aerosol recording during OGD showed an average particle number concentration of 595 L−1 with a wide range (3–4320 L−1). Bioaerosol-generating events, namely, coughing or burping, were common. Coughing was evoked in 60% of the endoscopies, with a greater peak concentration and a greater total number of sampled particles than the patient’s reference voluntary coughs (11 710 vs 2320 L−1 and 780 vs 191 particles, n=9 and p=0.008). Endoscopies with coughs generated a higher level of aerosol than tidal breathing, whereas those without coughs were not different to the background. Burps also generated increased aerosol concentration, similar to those recorded during voluntary coughs. The insertion and removal of the endoscope were not aerosol generating unless a cough was triggered.ConclusionCoughing evoked during OGD is the main source of the increased aerosol levels, and therefore, OGD should be regarded as a procedure with high risk of producing respiratory aerosols. OGD should be conducted with airborne personal protective equipment and appropriate precautions in those patients who are at risk of having COVID-19 or other respiratory pathogens.

There is a growing need for treatments for patients who would benefit from further weight loss following bariatric surgery or weight loss maintenance/long-term disease remission. Currently, therapeutic options are limited. Although largely dismissed previously, advances in weight loss pharmacotherapy now offer the possibility of achieving clinically significant weight loss. Historical comparisons drawn between the effects of medications vs surgery are generally inaccurate as novel classes of antiobesity pharmacotherapy have since been developed and moreover, reflect an outdated approach in comparing medicine with surgery. Herein, we provide an overview of the most recently developed anti-obesity medications which may not only present a potentially innovative approach to medical treatment of obesity but may also inspire renewed enthusiasm for investigating what can be achieved through multimodal care.

Roux-en-Y gastric bypass (RYGB) is an effective method to attain sustained weight loss and diabetes remission. We aimed to elucidate early changes in the plasma metabolome and lipidome after RYGB. Plasma samples from 16 insulin-resistant morbidly obese subjects, of whom 14 had diabetes, were subjected to global metabolomics and lipidomics analysis at pre-surgery and 4 and 42 days after RYGB. Metabolites and lipid species were compared between time points and between subjects who were in remission and not in remission from diabetes 2 years after surgery. We found that the variables that were most discriminatory between time points were decanoic acid and octanoic acid, which were elevated 42 days after surgery, and sphingomyelins (18:1/21:0 and 18:1/23:3), which were at their lowest level 42 days after surgery. Insulin levels were lower at 4 and 42 days after surgery compared with pre-surgery levels. At 4 days after surgery, insulin levels correlated positively with metabolites of branched chain and aromatic amino acid metabolism and negatively with triglycerides with long-chain fatty acids. Of the 14 subjects with diabetes prior to surgery, 7 were in remission 2 years after surgery. The subjects in remission displayed higher pre-surgery levels of tricarboxylic acid cycle intermediates and triglycerides with long-chain fatty acids compared with subjects not in remission. Thus, metabolic alterations are induced soon after surgery and subjects with diabetes remission differ in the metabolic profiles at pre- and early post-surgery time points compared to patients not in remission.

Introduction The associations between excess adiposity and endometrial cancer (EC) risk may be mediated by altered metabolic profiles. Here, we triangulated evidence from observational and Mendelian randomisation (MR) analyses to investigate the relationship between adiposity traits, circulating metabolites, and their effects on endometrial cancer. Methods Observational analyses were performed in UK Biobank (N cases and controls = 1,005 and 215,339, respectively). Univariable and multivariable MR analyses were performed using female-specific summary statistics for adiposity traits (GIANT consortium; N BMI and WHR = 434,793 and 281,153, respectively), circulating metabolites (UK Biobank; N  = 140,768) and EC (Endometrial Cancer Association Consortium; N cases and controls = 12,906 and 108,979, respectively). Results Higher body mass index (BMI) was associated with increased odds of overall EC, endometrioid EC, and non-endometrioid EC in both observational and MR analyses; however, there was weaker evidence for waist-hip-ratio (WHR). BMI was associated with 165 metabolites, 25 of which were associated with EC risk. Multivariable MR analyses suggest that several lipid metabolites and ratios may mediate the association between BMI and non-endometrioid EC, although analyses using Phenoscanner suggest that alternative pathways such as height and blood cell traits could influence the EC risk. Conclusion Evidence here suggests that higher BMI causes a higher risk of overall and all histological subtypes of EC and variation in numerous circulating metabolites. Several of these metabolites showed relationships consistent with an intermediate role between BMI and non-endometrioid EC, however, further analyses highlighted other potential shared mechanisms that could influence the risk of EC.

ObjectivesTo quantify the economic investment required to increase bariatric surgery (BaS) capacity in National Health Service (NHS) England considering the growing obesity prevalence and low provision of BaS in England despite its high clinical effectiveness.DesignData were included for the patients with obesity who were eligible for BaS. We used a decision-tree approach including four distinct steps of the patient pathway to capture all associated resource use. We estimated total costs according to the current capacity (current scenario) and three BaS scaling up strategies over a time horizon of 20 years (projected scenario): maximising NHS capacity (strategy 1), maximising NHS and private sector capacity (strategy 2) and adding infrastructure to NHS capacity to cover the entire prevalent and incident obesity populations (strategy 3).SettingBaS centres based in NHS and private sector hospitals in England.Main outcome measuresNumber of BaS procedures (including revision surgery), cost (GBP) and resource utilisation over 20 years.ResultsAt current capacity, the number of BaS procedures and the total cost over 20 years were estimated to be 140 220 and £1.4 billion, respectively. For strategy 1, these values were projected to increase to 157 760 and £1.7 billion, respectively. For strategy 2, the values were projected to increase to 232 760 and £2.5 billion, respectively. Strategy 3 showed the highest increase to 564 784 and £6.4 billion, respectively, with an additional 4081 personnel and 49 facilities required over 20 years.ConclusionsThe expansion of BaS capacity in England beyond a small proportion of the eligible population will likely be challenging given the significant upfront economic investment and additional requirement of personnel and infrastructure.

BackgroundThere is increasing evidence to suggest vitamin D plays a role in immune and vascular function; hence, it may be of biological and clinical relevance for patients undergoing major surgery. With a greater number of randomised studies being conducted evaluating the impact of vitamin D supplementation on surgical patients, it is an opportune time to conduct further analysis of the impact of vitamin D on surgical outcomes.MethodsMEDLINE, EMBASE and the Cochrane Trials Register were interrogated up to December 2023 to identify randomised controlled trials of vitamin D supplementation in surgery. The risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool. A narrative synthesis was conducted for all studies. The primary outcome assessed was overall postoperative survival.ResultsWe screened 4883 unique studies, assessed 236 full-text articles and included 14 articles in the qualitative synthesis, comprising 1982 patients. The included studies were highly heterogeneous with respect to patient conditions, ranging from open heart surgery to cancer operations to orthopaedic conditions, and also with respect to the timing and equivalent daily dose of vitamin D supplementation (range: 0.5–7500 mcg; 20–300 000 IU). No studies reported significant differences in overall survival or postoperative mortality with vitamin D supplementation. There was also no clear evidence of benefit with respect to overall or intensive care unit length of stay.DiscussionNumerous studies have reported the benefits of vitamin D supplementation in different surgical settings without any consistency. However, this systematic review found no clear evidence of benefit, which warrants the supposition that a single biological effect of vitamin D supplementation does not exist. The observed improvement in outcomes in low vitamin D groups has not been convincingly proven beyond chance findings.Trial registration numberCRD42021232067.