Obesity is a public health problem with increasing incidence. In this article we will discuss its concept, etiology, classification and consequences.

1. Concept and epidemiology
2. Consequences of obesity
   • Metabolic syndrome
3. Classification
4. Etiology

1. Concept and epidemiology

Obesity can be defined by the accumulation of localized or generalized fatty tissue, caused by nutritional imbalance, associated or not with genetic or endocrine-metabolic disorder.

Obesity is a chronic disease whose prevalence is increasing in adults, children and adolescents and is currently considered a global epidemic. Once considered a problem of developed countries, obesity is now becoming a major health problem also in developing countries.

Obesity in adults is related to reduced life expectancy

The sedentary lifestyle associated with diets high in calories including not only carbohydrates, but also saturated fats, sugar and salt, has contributed to the increase in obesity, especially after the 80s.

• According to the WHO, in 2015 there were 600 million adults with obesity.

• In the USA, 9.2% of the population are morbidly obese (class III), (BMI > 40 kg/m2).

• In Brazil obesity affected 12.2% of the adult population in 2002-2003 and rose to 26.8% in 2020, according to IBGE

• 29.5% of women are obese — practically one in three — compared to 21.8 of men.

• Overweight, on the other hand, was found in 62.6% of women and 57.5% of men.

2. Consequences of obesity

Severe obesity (type III) is associated with a significant increase in morbidity and mortality. On the other hand, weight loss is associated with a reduction in morbidity associated with obesity.

These are pathological states aggravated by the presence of obesity and that are improved by its control, among the most frequent:

• HAS
• DM II
• Peripheral vascular insufficiency
• Cholelithiasis
• Arthropathies
• Coronary insufficiency
• Dyslipidemias
• Hepatic steatosis
• Sleep apnea
• Urinary incontinence
• GERD
• Physical limitation conditions and others.

The mortality of severe obese is 250% higher than non-severe.

Mortality from cancer, especially endometrial, is also increased for obese.

Metabolic syndrome

Metabolic Syndrome corresponds to a set of diseases whose basis is insulin resistance. When present, Metabolic Syndrome is related to a general mortality twice as high as in the normal population and cardiovascular mortality three times higher.

According to Brazilian Consensus, Metabolic Syndrome occurs when three of the five criteria below are present:

• Central obesity – waist circumference greater than 88 cm in women and 102 cm in men;
• Arterial Hypertension – systolic blood pressure ? 130 and/or diastolic blood pressure ? 85 mmHg;
• Altered glycemia (glycemia ? 110 mg/dl) or diagnosis of Diabetes;
• Triglycerides ? 150 mg/dl;
• HDL cholesterol ? 40 mg/dl in men and ? 50 mg/dl in women

* If BMI >30, the abdominal circumference does not need to be determined as central obesity is presumed.

3. Classification

The main index to measure and classify the degree of obesity is the BMI, due to its ease of application and correlation with morbidity and mortality risks.

Another useful measure, especially in Asians and patients with BMI between 25-35 is the measurement of abdominal circumference, since central obesity (associated with higher cardiometabolic risks) may not be captured in these patients.

• AC > 102 cm male sex
• AC > 88 cm female sex

Note: Asian population admits > 90 (male) and >80 (female)

4. Etiology

There are multiple factors that can contribute to the development of obesity

• Genetics: child with an obese parent has a 3-4 x higher risk of developing obesity. Two obese parents, the risk is 10 x higher
• Age: tendency to weight gain
• Habits and lifestyle: consumption of caloric, fatty foods, salt, sugar, sedentary lifestyle
• Medications: some antidepressants, antipsychotics, anticonvulsants, hypoglycemic agents (insulin and sulfonylureas), contraceptive hormones
• Comorbidities: hypothyroidism, cushing’s syndrome
• Intestinal microbiota: increasing evidence of the role of the microbiota

How to cite this article

Martins BC. Obesity: concept, consequences and classification. Gastropedia, vol I, 2023. Available at: gastropedia.com.br/cirurgia/obesidade/obesidade-conceito-consequencia-classificacao

Vertical Gastrectomy (VG) has quickly become the most performed bariatric surgery in the world. However, little is known about long-term results when compared to Roux-en-Y Gastric Bypass (RYGB).

In August 2022, an article was published in JAMA Surgery with the results of 10 years of follow-up of SLEEVEPASS, a randomized study comparing VG and RYGB. In this post, we will comment on the findings of this article.

Introduction

Vertical Gastrectomy already represents more than 60% of bariatric procedures performed in the USA and worldwide. Its long-term follow-up results are still unknown. Recent studies have shown a high incidence of GERD and even Barrett’s Esophagus.

The SLEEVEPASS trial showed equivalent results for both techniques in terms of weight loss, diabetes control, complications, and quality of life in the 5 and 7-year follow-ups.

Methods

A prospective multicenter randomized clinical study conducted in Finland from March 2008 to June 2010 with 240 patients with BMI > 40 or > 35  associated with comorbidities.  In relation to the initial protocol, an addendum was made for the 10-year study including the performance of upper digestive endoscopy.

The primary outcome was weight loss through the calculation of excess weight loss (%EWL). The secondary outcomes were remission of comorbidities, quality of life, postoperative morbidity, and mortality. For this 10-year analysis, there was a special focus on reflux-related outcomes, with symptoms, esophagitis, and Barrett’s esophagus.

Results

Of the 238 patients initially allocated to the study, 193 completed 10 years of clinical follow-up and 176 the endoscopic.

• Weight loss

The weight loss through %EWL was 43.5% for VG and 51.9% for RYGB. Despite a difference of 8.4% for RYGB, after imputing missing data in the analysis, the results were similar. Regarding weight regain, it was 35% for VG and 24.7% for RYGB, without statistical significance.

• GERD and Endoscopy

The prevalence of esophagitis was significantly higher in the sleeve than in the bypass, with 31% vs. 7%, respectively (p < 0.001). Patients in the VG group also had significantly more use of PPI (64% vs. 36%, p < 0.001), worse reflux-related quality of life score (10.5 vs. 0.0, p < 0.001), and more reflux symptoms than those in the RYGB group.

• Remission of comorbidities

Diabetes remission was seen in 26% of those who underwent sleeve and 33% of the bypass, with no statistical difference. There was also no difference in fasting blood glucose and glycated hemoglobin values between the groups in the 10-year follow-up.

Dyslipidemia was only in remission in 19% for VG and 35% for RYGB, without statistical significance. Regarding arterial hypertension, only 8% of those who underwent VG were without medication in the 10-year follow-up, while 24% of those who underwent RYGB (p = 0.04).

• Quality of life

Measured through the Moorehead-Ardelt score, the quality of life in 10 years significantly improved for both groups compared to the beginning of the study. There was no difference between the techniques.

• Morbidity and mortality

For the analysis of the 10 years of studies, all complications occurring between 30 days and 10 years were evaluated cumulatively. The rate of severe complication (Clavien-Dindo >= IIIb) was 15.7% for VG and 18.5% for RYGB (p = 0.57). Most of the sleeve reoperations were due to GERD and the bypass ones were due to internal hernia.

Discussion

The results of this 10-year comparative analysis between Sleeve and Bypass show that both techniques resulted in significant and sustained weight loss. There was no significant difference in the improvement of comorbidities, except for HAS, whose remission was superior in the bypass group.

The weight loss trajectories for VG and RYGB were consistent over the 5, 7, and 10-year follow-up periods. When analyzed together with another large trial (SM-BOSS), the bypass showed superior weight loss through the loss of excess BMI, despite there being no statistical difference in the trials separately.

Use of PPI, esophagitis, and reflux symptoms were significantly more frequent in VG compared to RYGB. However, Barrett’s Esophagus was equally uncommon (4%) in both groups, compared to alarming results published in other studies, which reached 17% of Barrett after Vertical Gastrectomy.

This is important considering the growing prevalence of obesity in the world and the large proportion of VG performed, which could impact a higher risk of Barrett and Esophageal Adenocarcinoma in the long term. Another recent study with 10.5 years of follow-up showed a 4% incidence of Barrett. This discrepancy in the results may be due to variability in the diagnostic criteria for Barrett, selection bias in cases submitted to endoscopy in smaller studies, or even population differences.

An important limitation of this study was the lack of criteria for analyzing reflux at the beginning of the study, considering symptoms, questionnaires, and endoscopy only in the long-term follow-up.

Conclusions

In 10 years of follow-up, the excess weight loss was superior in Bypass compared to Sleeve. There was no statistical difference in the remission of comorbidities, except for hypertension.

The cumulative incidence of Barrett’s Esophagus was much lower than reported in other studies, but symptoms of reflux, use of PPI, and diagnosis of esophagitis were significantly more prevalent after Vertical Gastrectomy, reinforcing the importance of GERD evaluation in the preoperative period for adequate patient selection and procedure choice.

Reference

Salminen P, Grönroos S, Helmiö M, Hurme S, Juuti A, Juusela R, Peromaa-Haavisto P, Leivonen M, Nuutila P, Ovaska J. Effect of Laparoscopic Sleeve Gastrectomy vs Roux-en-Y Gastric Bypass on Weight Loss, Comorbidities, and Reflux at 10 Years in Adult Patients With Obesity: The SLEEVEPASS Randomized Clinical Trial. JAMA Surg. 2022 Aug 1;157(8):656-666. doi: 10.1001/jamasurg.2022.2229. PMID: 35731535; PMCID: PMC9218929.

How to cite this article

Dantas ACB,. Vertical Gastrectomy and Roux-en-Y Gastric Bypass. Is there a difference in long-term results? Gastropedia; 2022. Available at: gastropedia.com.br/surgery/obesity/vertical-gastrectomy-and-roux-en-y-gastric-bypass-is-there-a-difference-in-long-term-results

A 65-year-old male patient, underwent Vertical Gastrectomy in 2017 for the treatment of Morbid Obesity. Lost follow-up during the COVID-19 pandemic, having only done a follow-up endoscopy in the first postoperative year.

Returns to the clinic with significant symptoms of heartburn and daily regurgitation, impacting quality of life and food tolerance. EDA requested, with the finding of a projection of columnar mucosa, salmon-pink in color in the distal third of the esophagus, measuring about 10 mm circumferentially. Biopsies were performed with confirmation of intestinal columnar metaplasia, compatible with the diagnosis of Barrett’s Esophagus.

Although uncommon in our environment, the diagnosis of Barrett’s Esophagus after VG has been increasingly reported in the literature. A recent meta-analysis showed a prevalence of 11.4%, with a grouped Barrett rate in patients with GERD symptoms of 18.2% (95% CI, 12.4% – 26%). Such a study also showed that there was no significant difference in the likelihood of having Barrett based on GERD symptoms.

Therefore, to make an early diagnosis of Barrett after Vertical Gastrectomy and maintain adequate clinical and endoscopic follow-up, we should follow the IFSO recommendation to perform upper digestive endoscopy annually in patients undergoing sleeve regardless of symptoms.

References

1. Qumseya BJ, Qumsiyeh Y, Ponniah SA, Estores D, Yang D, Johnson-Mann CN, Friedman J, Ayzengart A, Draganov PV. Barrett’s esophagus after sleeve gastrectomy: a systematic review and meta-analysis. Gastrointest Endosc. 2021 Feb;93(2):343-352.e2. doi: 10.1016/j.gie.2020.08.008. Epub 2020 Aug 14. PMID: 32798535.
2. Brown WA, Johari Halim Shah Y, Balalis G, Bashir A, Ramos A, Kow L, Herrera M, Shikora S, Campos GM, Himpens J, Higa K. IFSO Position Statement on the Role of Esophago-Gastro-Duodenal Endoscopy Prior to and after Bariatric and Metabolic Surgery Procedures. Obes Surg. 2020 Aug;30(8):3135-3153. doi: 10.1007/s11695-020-04720-z. PMID: 32472360.

How to cite this article

Dantas ACB, Vertical Gastrectomy and risk of Barrett’s Esophagus. Gastropedia; 2022. Available at: https://gastropedia.com.br/cirurgia/obesidade/gastrectomia-vertical-e-risco-de-esofago-de-barrett/

Gastroesophageal Reflux Disease (GERD) is quite common in the general population, with a prevalence of 10 to 20%. In patients with obesity, this prevalence can be double.

The mechanisms involved in the increased risk of GERD in obesity are due to increased abdominal pressure, leading to:

• Increased transient relaxation of the lower esophageal sphincter
• Hiatal hernia
• Decreased esophageal clearance

The prevalence of GERD is directly related to the severity of obesity and BMI (Body Mass Index). Patients with obesity (BMI > 30) have more episodes of reflux and worse DeMeester score than those who are overweight (BMI > 25). In candidates for bariatric surgery, those with BMI > 50 have erosive esophagitis with higher prevalence than those with BMI > 40 and so on. Despite this, it is uncommon to find severe esophagitis (C/D) or even the diagnosis of Barrett’s Esophagus.

How should GERD investigation be in the preoperative period of bariatric surgery?

Although it is routine in most bariatric services in Brazil, until recently there was great controversy in the international literature regarding Upper Digestive Endoscopy (EDA) in preparation for bariatric surgery.

The current recommendation according to international society consensus is as follows:

• EDA should be considered for all patients with gastrointestinal symptoms who plan to undergo bariatric surgery due to the frequency of findings that can change conduct
• EDA should also be considered for those without symptoms due to the chance of 25% of incidental endoscopic findings that can change conduct or even contraindicate bariatric surgery

How does the presence of GERD influence the technical choice of bariatric surgery?

Currently, Vertical Gastrectomy (GV) is the most performed bariatric surgery in the world. However, with long-term follow-up, we have seen more frequently cases with GERD postoperatively. In some situations, very symptomatic and refractory to clinical treatment, with the need for revision surgery for conversion to Roux-en-Y Gastric Bypass (BGYR).

There is no conduit, strong evidence regarding preoperative risk factors that can predict which patients will evolve with de novo reflux. We only know that those with pathological GERD, according to Lyon criteria, tend to worsen after GV.

For all this, the presence of GERD should be weighed in the joint decision with the patient between GV or Bypass. In general, but not necessarily, we should favor Gastric Bypass in case of:

• Los Angeles grades C or D Erosive Esophagitis
• Barrett’s Esophagus
• Hiatal hernia
• Esophageal motor alterations

How to cite this article

Dantas, A. Gastroesophageal reflux disease in the patient with obesity. Gastropedia; 2022 Available at: https://gastropedia.com.br/cirurgia/obesidade/doenca-do-refluxo-gastroesofagico-no-paciente-com-obesidade/

References:

1. Ayazi S, Hagen JA, Chan LS, DeMeester SR, Lin MW, Ayazi A, Leers JM, Oezcelik A, Banki F, Lipham JC, DeMeester TR, Crookes PF. Obesity and gastroesophageal reflux: quantifying the association between body mass index, esophageal acid exposure, and lower esophageal sphincter status in a large series of patients with reflux symptoms. J Gastrointest Surg. 2009 Aug;13(8):1440-7.
2. Derakhshan MH, Robertson EV, Fletcher J, Jones GR, Lee YY, Wirz AA, McColl KE. Mechanism of association between BMI and dysfunction of the gastro-oesophageal barrier in patients with normal endoscopy. Gut. 2012 Mar;61(3):337-43.
3. Brown WA, Johari Halim Shah Y, Balalis G, Bashir A, Ramos A, Kow L, Herrera M, Shikora S, Campos GM, Himpens J, Higa K. IFSO Position Statement on the Role of Esophago-Gastro-Duodenal Endoscopy Prior to and after Bariatric and Metabolic Surgery Procedures. Obes Surg. 2020 Aug;30(8):3135-3153. doi: 10.1007/s11695-020-04720-z. PMID: 32472360.
4. Bolckmans, R., Roriz-Silva, R., Mazzini, G.S. et al. Long-Term Implications of GERD After Sleeve Gastrectomy. Curr Surg Rep 9, 7 (2021).
5. Sebastianelli L, Benois M, Vanbiervliet G, Bailly L, Robert M, Turrin N, Gizard E, Foletto M, Bisello M, Albanese A, Santonicola A, Iovino P, Piche T, Angrisani L, Turchi L, Schiavo L, Iannelli A. Systematic Endoscopy 5 Years After Sleeve Gastrectomy Results in a High Rate of Barrett’s Esophagus: Results of a Multicenter Study. Obes Surg. 2019 May;29(5):1462-1469.