In this installment of “Expert Picks,” Shelby Sullivan, MD, the director of the Gastroenterology Metabolic and Bariatric Program at the University of Colorado School of Medicine Anschutz Medical Campus, in Aurora, highlights important research on bariatric therapies presented at the 2021 virtual Digestive Disease Week.
Abstract 2. Black patients suffer significantly higher adverse events from bariatric surgery despite better 30-day decrease in BMI—An analysis of the MBSAQIP data registry (Badurdeen D, et al)
Disparities in surgical outcomes across racial lines are well documented. While the technical aspects of bariatric surgical procedures have improved over the years, rates of adverse events (AEs) vary considerably between Black and white patients. Badurdeen and colleagues looked at disparities in outcomes among white patients (n=341,380) and Black patients (n=107,449) undergoing bariatric procedures, including Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG), by reviewing five years of data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.
The researchers found that from 2015 to 2019, Black patients had a 24% higher risk for serious morbidity and AEs even after correcting for baseline characteristics, type of surgery and use of a robot. At 30 days, the mean decrease in BMI was 2.68 versus 2.53 kg/m2 (P<0.001) for Black and white patients, respectively, and 2.64 versus 2.55 kg/m2 (P<0.001) after RYGB and LSG.
Dr. Sullivan: Racial disparities are apparent throughout medicine, and it is crucial that these are addressed. The first step of addressing disparities is understanding how race affects medical treatments. Dr. Badurdeen and colleagues’ findings of greater risk for serious morbidity and AEs in Black patients provides a foundation that will inform future research investigating the underlying causes of these differences in serious morbidity and AEs and how to reduce them.
Abstract 53. Endoscopic Versus Surgical Gastrojejunal Revision for Weight Regain In Roux-En-Y Gastric Bypass Patients: 5-year Safety and Efficacy Comparison (Dolan RD, et al)
Dilated gastrojejunal anastomosis (GJA) is an anatomic cause of weight regain following RYGB that can be corrected with diameter reduction through endoscopic or surgical revision. The transoral outlet reduction (or TORe) endoscopic revision technique is associated with an 8.8% total weight loss at five years with few AEs, but no studies have directly compared this technique with surgical revision.
Dolan et al compared rates of serious AEs and weight loss profiles between endoscopic and surgical revisional techniques over a five-year period. The retrospective matched cohort study included RYGB patients who underwent endoscopic or surgical revision for weight regain that was at least partly attributable to an enlarged GJA (>12 mm) at two tertiary referral centers. Endoscopic patients were matched 1:1 to surgical revision patients based on age, sex, BMI and weight regain.
The study included 122 RYGB patients with weight regain and an enlarged GJA who underwent endoscopy (n=61) or surgical revision (n=61). Patients in the endoscopy group were more likely to complete the five-year follow-up (n=53 vs. 28). Pre-revision age, sex, time since RYGB, percent weight regain from initial weight loss, weight, BMI and GJA diameter were similar between groups.
Patients who underwent surgical revision were more likely to experience serious AEs (26.2% vs. 4.9%; P=0.002), according to the researchers. Serious AEs in the endoscopic group included GJA stenosis requiring balloon dilation (n=1), esophageal perforation requiring endoscopic clip closure (n=1), and gastrointestinal bleeding (n=1). Serious AEs in the surgical group included leak (n=3), GJA stenosis requiring balloon dilation (n=2), intraabdominal infection (n=2), superficial wound infection (n=2), ulcer (n=3), severe abdominal pain (n=3), GI bleeding (n=2), high-grade small bowel obstruction (n=1), pancreas injury causing pancreatitis (n=1), subcutaneous neck emphysema (n=1), and postoperative pulmonary embolism (n=1). The surgical group lost significantly more weight at one year post-procedure (44.3 vs. 23.7 lb; P=0.003), but no significant differences were observed at three and five years.
Dr. Sullivan: Although RYGB is one of the most successful treatments for obesity, significant weight regain can occur in up to 20% to 30% of patients over time. This has negative effects on obesity-related comorbidities and quality of life. Both endoscopic and surgical revisions have been studied for the treatment of weight regain after RYGB, but no studies have directly compared safety and efficacy between surgical and endoscopic revisions in patients with weight regain after RYGB.
Although this study was retrospective, the authors matched patients for comparison and found that endoscopic RYGB revision resulted in less weight loss in the first year of therapy, but had significantly less risk for serious AEs than surgical RYGB revision. Moreover, there was no significant difference in weight loss between the groups at three and five years. The reasons for the similar weight loss efficacy at three and five years are not clearly understood, but there was a high rate of follow-up in the endoscopic revision group, which may have resulted in more contact with the weight loss team, which is known to increase weight loss.
Abstract 757. Barrett’s Esophagus After Sleeve Gastrectomy: An Analysis of Incidence and Diagnostic Upper Endoscopy Rates Using Statewide Claims Data (Swei E, et al)
Recent studies have suggested that laparoscopic sleeve gastrectomy (LSG) is associated with the development of Barrett’s esophagus, even when symptoms of gastroesophageal reflux disease (GERD) are absent. Despite this, no consensus exists on the use of upper endoscopy (by EGD) to screen for Barrett’s in patients who have undergone LSG. This study aimed to shed light on this issue by assessing the rates of upper endoscopy and incidence of new Barrett’s esophagus diagnoses in patients undergoing LSG.
The researchers identified 5,562 obese patients who underwent LSG during 2012-2017 while enrolled in the Colorado All Payer Claims Database. Of this group, 35.5% had at least one diagnostic record of EGD. The researchers found that the incidence of EGD was highest in the year immediately before surgery (22.1%) and decreased to 5.67% by one year after LSG. The median annual incidence of EGD was 2.21% before surgery and 4.41% after surgery.
Over the entire study period, 81 patients had a new diagnosis of Barrett’s esophagus within one year of an EGD, for a cumulative incidence of 1.45% among all patients and 4.11% among only patients who underwent EGD. The cumulative incidence of a new diagnosis of Barrett’s esophagus after LSG was 1.6% at two years and 6.0% at five years, according to the researchers.
Dr. Sullivan: Increased rates of GERD have been seen after sleeve gastrectomy; however, studies have only recently reported increased rates of Barrett’s esophagus after sleeve gastrectomy regardless of GERD symptoms. Dr. Swei and colleagues found that there was an increasing cumulative incidence of new diagnoses of Barrett’s esophagus over time after sleeve gastrectomy in a large database, which is consistent with the current published literature on Barrett’s esophagus after sleeve gastrectomy. Possibly more importantly, however, they found that there was a low rate of diagnostic EGD after sleeve gastrectomy, which is worrisome for missing the diagnosis of Barrett’s esophagus in patients who have undergone sleeve gastrectomy.
Abstract Su548. Semaglutide in Association to Endoscopic Sleeve Gastroplasty: Taking Endoscopic Bariatric Procedures Outcomes to the Next Level (Hoff AC, et al)
This clinical prospective double-blind study involved patients who underwent ESG with the same suturing patterns, and diet and exercise prescriptions. One cohort received semaglutide (Wegovy, Novo Nordisk) and the other received a placebo after the fifth month of ESG completion. Doses were adjusted to symptoms, with an initial dose of 0.25 mg and maximum dose of 1.5 mg.
Among the 27 patients who received semaglutide, the mean age was 34 years and 20 were women. In the placebo group of 28 patients, the mean age was 36 years and 21 were women. The researchers found that loss of body weight was greater in the semaglutide group than the placebo group (26.7% vs. 19.6%; P<0.0001), as were the percent extra weight loss (86.3% vs. 60.4%; P<0.001), change in body fat mass (12.7% vs. 9%; P<0.001), and change in HbA1c (0.95% vs. 0.61%; P=0.0394). All doses of the drug were generally well tolerated, with no new safety concerns, according to the researchers. The most common AEs were dose-related GI symptoms, particularly nausea.
Dr. Sullivan: The holy grail of endoscopic bariatric therapies and weight loss medications is to reach the level of weight loss seen with bariatric surgery with fewer AEs and shorter recovery time for patients. While no individual medication or endoscopic bariatric therapy has reached this level of weight loss effectiveness, combination therapy has that potential. Endoscopic sleeve gastroplasty has demonstrated short-term weight loss benefit in large meta-analyses and medium-term weight loss at five years at a single center.
Semaglutide has been approved in the United States and abroad for the treatment of diabetes, and was just recently approved for the treatment of obesity in the United States. Currently, semaglutide is the most effective medication to treat obesity. The study by Dr. Hoff and colleagues evaluates in a double–blind, randomized controlled trial the effects of ESG alone or in combination with semaglutide. Although the study was small, the authors were able to demonstrate significantly more weight loss in the combination therapy group than with ESG alone. Moreover, the amount of weight loss achieved is closer to the weight loss achieved with sleeve gastrectomy and RYGB, suggesting that reaching surgical levels of weight loss with the combination therapy of endoscopic bariatric therapies and weight loss medications may be within our grasp.
—Compiled and written by Kate O’Rourke
Dr. Sullivan was a co-author of abstract 757.
This article is from the August 2021 print issue.