Global obesity rates have risen dramatically, now exceeding deaths from starvation. Metabolic and bariatric surgery (MBS), initially for severe obesity (BMI ≥35 kg/m2), is performed globally over 500 000 times annually, offering significant metabolic benefits beyond weight loss. However, varying eligibility criteria globally impact patient care and healthcare resources. Updated in 2022, ASMBS and IFSO guidelines aim to standardise MBS indications, reflecting current understanding and emphasising comprehensive preoperative assessments. Yet, clinical variability persists, necessitating consensus-based recommendations. This modified Delphi study engaged 45 global experts to establish consensus on perioperative management in MBS. Experts selected from bariatric societies possessed expertise in MBS and participated in a two-round Delphi protocol. Consensus was achieved on 90 of 169 statements (53.3%), encompassing multidisciplinary team composition, patient selection criteria, preoperative testing, and referral pathways. The agreement highlighted the critical role of comprehensive preoperative assessments and the integration of healthcare professionals in MBS. These findings offer essential insights to standardise perioperative practices and advocate for evidence-based guidelines in MBS globally. The study underscores the need for unified protocols to optimise outcomes and guide future research in MBS.
BACKGROUND: Minimally invasive surgery may be further advanced with the novel biofragmentable magnetic anastomosis compression system. Two magnets may be swallowed, or placed by flexible endoscopy, in a side-to-side magnetic jejuno-ileostomy (MagJI) bipartition for weight and type 2 diabetes (T2D) reduction. MagJI markedly reduces the major complications of enterotomy, stapling/suturing, and retained foreign materials. METHODS: This was a prospective first-in-human investigation of feasibility, safety, and preliminary efficacy in adults with body mass index (BMI, kg/m2) ≥ 30.0- ≤ 40.0. After serial introduction via swallowing or endoscopy, linear magnets were laparoscopically guided to the distal ileum and proximal jejunum where they were aligned. Magnets fused over 7-21 days forming jejuno-ileostomy. PRIMARY ENDPOINTS: feasibility and severe adverse event (SAEs) incidence (Clavien-Dindo grade); secondary endpoints: weight, T2D reduction. RESULTS: Between 3-1 - 2024 and 6-30 - 2024, nine patients (mean BMI 37.3 ± 1.1) with T2D (all on T2D medications; mean HbA1C 7.1 ± 0.2%, glucose 144.8 ± 14.3 mg/dL) underwent MagJI. Mean procedure time: both magnets swallowed, 86.7 ± 6.3 min; one magnet swallowed with second delivered endoscopically, 113.3 ± 17.0 min. Ninety-day feasibility confirmed in 100.0%: 0.0% bleeding, leakage, infection, mortality. Most AEs grade I-II; no SAEs. At 6-month radiologic confirmation, all anastomoses were patent. Excess weight loss 17.5 ± 2.8 kg; mean BMI reduction 2.2 ± 0.3, HbA1C 6.1 ± 0.1% (p < 0.01), glucose 115.5 ± 6.5 mg/dL (p = 0.19); 83.0% dropped below 6.5% HbA1C and had markedly reduced anti-T2D medications. CONCLUSIONS: The swallowable, biofragmentable magnetic anastomosis system appeared to be feasible and safe in achieving incisionless, sutureless jejuno-ileostomy. The first-in-human MagJI procedure may offer minimally complicated anastomosis creation and moderate MBS weight loss and T2D reduction.
- MeSH
- anastomóza chirurgická metody MeSH
- diabetes mellitus 2. typu * chirurgie MeSH
- dospělí MeSH
- hmotnostní úbytek MeSH
- ileum * chirurgie MeSH
- index tělesné hmotnosti MeSH
- jejunostomie * metody přístrojové vybavení MeSH
- jejunum * chirurgie MeSH
- laparoskopie metody MeSH
- lidé středního věku MeSH
- lidé MeSH
- magnetismus MeSH
- magnety * MeSH
- prospektivní studie MeSH
- studie proveditelnosti MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
BACKGROUND: Randomized, controlled trials (RCTs) comparing the effectiveness of metabolic bariatric surgery (MBS) in addition to one or more treatment interventions for obesity (i.e., lifestyle structured interventions-LSI, medical therapy-MT, obesity management medication-OMM or endobariatric procedures-EP) are lacking. This study aims to assess the effectiveness of multiple simultaneous (before or immediately after MBS) interventions for treating obesity. METHODS: We performed a meta-analysis including all RCTs enrolling patients undergoing different MBS procedures add-on to other anti-obesity strategies (LSI, MT, OMM or ES) versus MBS alone, with a duration of at least 6 months. The primary outcome was BMI at the end-point; secondary end-points included percentage total and excess weight loss (%TWL%, and EBWL%), total weight loss (TWL), fasting plasma glucose (FPG), HbA1c, surgical and non-surgical severe adverse events (SAE), mortality, remission of type 2 diabetes, hypertension, dyslipidemia and health-related quality of life (HR-QoL). RESULTS: A total of 25 RCTs were retrieved. The addition of either OMM (i.e., liraglutide) or EP (i.e., intragastric balloon-IB, endosleeve-ES) to MBS was associated with a significantly lower BMI at the end-point (p = 0.040). The addition of liraglutide only to MBS was associated with a greater %EWL%, but not %TWL and TBWL (p = 0.008). Three trials evaluated end-point HbA1c, showing a significant reduction in favour of liraglutide as an add-on therapy to MBS (p = 0.007). There was no mortality. CONCLUSIONS: MBS combined with non-surgical approaches appears more effective than MBS alone in reducing BMI. Further RCTs on combined therapies to MBS for severe obesity are needed to enhance the tailoring of treatment for severe obesity.
- MeSH
- bariatrická chirurgie * metody MeSH
- hmotnostní úbytek MeSH
- index tělesné hmotnosti MeSH
- kombinovaná terapie MeSH
- kvalita života MeSH
- lidé MeSH
- obezita * chirurgie terapie MeSH
- randomizované kontrolované studie jako téma MeSH
- směrnice pro lékařskou praxi jako téma MeSH
- výsledek terapie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- metaanalýza MeSH
Background: The prevalence of obesity is already a worldwide health concern. The development of straightforward guidelines regarding the whole available armamentarium (i.e., medical, endoscopic, and surgical interventions in conjunction with a guidance program) is paramount to offering the best multimodal approach to patients with obesity. Methods: The International Federation for Surgery of Obesity and Metabolic Disorders-European Chapter (IFSO-EC) identified a panel of experts to develop the present guidelines. The panel formulated a series of clinical questions (based on the patient, intervention, comparison, and outcome conceptual framework), which have been voted on and approved. A GRADE methodology will be applied to assess the quality of evidence and formulate recommendations employed to minimize selection and information biases. This approach aims to enhance the reliability and validity of recommendations, promoting greater adherence to the best available evidence. Results: These guidelines are intended for adult patients with a body mass index (BMI) ≥ 30 kg/m2 who are candidates for metabolic bariatric surgery (MBS). The expert panel responsible for developing these guidelines comprised 25 panelists (92% were bariatric surgeons) and 3 evidence reviewers, with an average age of 50.1 ± 10.2 years. The panel focused on 3 key questions regarding the combined use of structured lifestyle interventions, approved obesity management medications, and endoscopic weight loss procedures with MBS. Conclusions: The complexity of obesity as a chronic disease requires a comprehensive knowledge of all the available and feasible therapeutic options. The IFSO-EC society felt the urgent need to develop methodologically valid guidelines to give a full picture and awareness of the possible surgical and non-surgical therapeutic strategies employed with a multimodal approach.
- Publikační typ
- časopisecké články MeSH
PURPOSE: With the global epidemic of obesity, the importance of metabolic and bariatric surgery (MBS) is greater than ever before. Performing these surgeries requires academic training and the completion of a dedicated fellowship training program. This study aimed to develop guidelines based on expert consensus using a modified Delphi method to create the criteria for metabolic and bariatric surgeons that must be mastered before obtaining privileges to perform MBS. METHODS: Eighty-nine recognized MBS surgeons from 42 countries participated in the Modified Delphi consensus to vote on 30 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus. RESULTS: Consensus was reached on 29 out of 30 statements. Most experts agreed that before getting privileges to perform MBS, surgeons must hold a general surgery degree and complete or have completed a dedicated fellowship training program. The experts agreed that the learning curves for the various operative procedures are approximately 25-50 operations for the LSG, 50-75 for the OAGB, and 75-100 for the RYGB. 93.1% of experts agreed that MBS surgeons should diligently record patients' data in their National or Global database. CONCLUSION: MBS surgeons should have a degree in general surgery and have been enrolled in a dedicated fellowship training program with a structured curriculum. The learning curve of MBS procedures is procedure dependent. MBS surgeons must demonstrate proficiency in managing postoperative complications, collaborate within a multidisciplinary team, commit to a minimum 2-year patient follow-up, and actively engage in national and international MBS societies.
- MeSH
- bariatrická chirurgie * normy výchova MeSH
- chirurgové normy výchova MeSH
- delfská metoda * MeSH
- klinické kompetence normy MeSH
- konsensus * MeSH
- křivka učení MeSH
- lidé MeSH
- morbidní obezita chirurgie MeSH
- stipendia normy MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Zvyšující se prevalence obezity a komplikací s ní spojených vede k nutnosti zintenzivnění její prevence a léčby. V léčbě obezity se v současnosti uplatňuje především úprava životního stylu, která však mnohdy dlouhodobě selhává. Pro příští desetiletí se jeví jako nezbytná součást léčby obezity – spolu s chirurgickým přístupem – dlouhodobé podávání antiobezitik, tedy léků, které příznivě ovlivňují nejen pokles nadměrné hmotnosti, ale i zdravotní rizika s obezitou spojená. Tento text podává přehled o současných možnostech farmakoterapie obezity včetně jejich indikací, vhodném výběru pacienta a nežádoucích účincích léčby. Přináší také přehled studií, které prokazují dlouhodobou účinnost a bezpečnost této léčby. Přestože účinná a bezpečná antiobezitika jsou v současné době k dispozici, není ani částečně hrazena ze všeobecného zdravotního pojištění. Náklady na léčbu jsou však pro velkou část obézních dlouhodobě neúnosné. Faktická nedostupnost účinných antiobezitik pro indikované pacienty má závažné zdravotně-ekonomické dopady. Nevyužívání účinných možností terapie, potvrzených postupy medicíny založené na důkazech, má za následek vysokou prevalenci s obezitou spojených nemocí, jejichž léčení je ekonomicky ještě nákladnější a v případě diabetu 2. typu dokonce méně efektivní. Alespoň částečnou úhrada antiobezitik z prostředků všeobecného zdravotního pojištění pro spolupracující pacienty za jasně vymezených podmínek považujeme za nezbytný krok ke zlepšení situace, ve svých důsledcích jednoznačně ekonomicky efektivní.
The increasing prevalence of obesity and its associated complications leads to the need to intensify its prevention and treatment. The treatment of obesity is currently based on lifestyle modification, which often fails in the long term. For the next decade, the long-term administration of anti-obesity drugs, i.e. drugs that have a positive effect not only on the reduction of excess weight but also on the health risks associated with obesity, seems to be a necessary part of obesity treatment, along with surgical approaches. This text provides an overview of the current options for the pharmacotherapy of obesity, including their indications, appropriate patient selection and adverse effects of treatment. It also provides an overview of studies that demonstrate the long-term efficacy and safety of these treatments. Although effective and safe anti-obesity drugs are currently available, it is not even partially covered by general health insurance. However, the cost of treatment is unaffordable in the long term for a large proportion of the obese. The virtual unavailability of effective antiobesity drugs for indicated patients has serious health-economic consequences. Failure to take advantage of effective therapeutic options, confirmed by evidence-based medicine, results in a high prevalence of obesity-related diseases, which are even more costly to treat economically and, in the case of type 2 diabetes, even less effective. We consider at least partial reimbursement of antiobesity drugs from general health insurance for cooperating patients under clearly defined conditions to be a necessary step towards improving the situation, and clearly cost-effective in its consequences.
- MeSH
- komorbidita MeSH
- kontraindikace MeSH
- látky proti obezitě aplikace a dávkování farmakologie terapeutické užití MeSH
- lidé MeSH
- liraglutid aplikace a dávkování farmakologie terapeutické užití MeSH
- nežádoucí účinky léčiv MeSH
- obezita * farmakoterapie komplikace terapie MeSH
- rizikové faktory MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- přehledy MeSH
- směrnice pro lékařskou praxi MeSH
BACKGROUND: Dysfunctional adipose tissue (AT) is known to contribute to the pathophysiology of metabolic disease, including type 2 diabetes mellitus (T2DM). This dysfunction may occur, in part, as a consequence of gut-derived endotoxaemia inducing changes in adipocyte mitochondrial function and reducing the proportion of BRITE (brown-in-white) adipocytes. Therefore, the present study investigated whether endotoxin (lipopolysaccharide; LPS) directly contributes to impaired human adipocyte mitochondrial function and browning in human adipocytes, and the relevant impact of obesity status pre and post bariatric surgery. METHODS: Human differentiated abdominal subcutaneous (AbdSc) adipocytes from participants with obesity and normal-weight participants were treated with endotoxin to assess in vitro changes in mitochondrial function and BRITE phenotype. Ex vivo human AbdSc AT from different groups of participants (normal-weight, obesity, pre- and 6 months post-bariatric surgery) were assessed for similar analyses including circulating endotoxin levels. RESULTS: Ex vivo AT analysis (lean & obese, weight loss post-bariatric surgery) identified that systemic endotoxin negatively correlated with BAT gene expression (p < 0.05). In vitro endotoxin treatment of AbdSc adipocytes (lean & obese) reduced mitochondrial dynamics (74.6% reduction; p < 0.0001), biogenesis (81.2% reduction; p < 0.0001) and the BRITE phenotype (93.8% reduction; p < 0.0001). Lean AbdSc adipocytes were more responsive to adrenergic signalling than obese AbdSc adipocytes; although endotoxin mitigated this response (92.6% reduction; p < 0.0001). CONCLUSIONS: Taken together, these data suggest that systemic gut-derived endotoxaemia contributes to both individual adipocyte dysfunction and reduced browning capacity of the adipocyte cell population, exacerbating metabolic consequences. As bariatric surgery reduces endotoxin levels and is associated with improving adipocyte functionality, this may provide further evidence regarding the metabolic benefits of such surgical interventions.
[New perspectives in bariatric-metabolic treatment]
Souhrn: Obezita je multifaktoriálně způsobené, chronické a v čase progredující onemocnění, které postihuje stovky milionů obyvatel na všech kontinentech. Onemocnění obezitou je přímo spojeno s řadou závažných zdravotních komplikací a přidružených onemocnění, které ve svých důsledcích vedou k mnohem častější nemocnosti, pracovní neschopnosti a v konečném důsledku ke zkrácení průměrné délky dožití v řádu let v porovnání se stejně starou, neobézní populací. Velmi účinným terapeutickým postupem jsou bariatrické a metabolické zákroky, avšak vzhledem k multifaktoriálním příčinám a charakteru onemocnění obezitou jsou jakékoli terapeutické intervence, pokud se použijí jako monoterapie, v dlouhodobém horizontu, a to i po počátečních úspěších, nakonec relativně málo účinné. A to jak v oblasti hmotnostních redukcí, tak i v metabolické efektivitě. Vzhledem k novým poznatkům a k pokroku ve farmaceutickém vývoji antiobezitik a také k výsledkům výzkumu a technickému pokroku v chirurgii obezity se v současné době jeví jako optimální postup kombinace co nejméně invazivních, přesto však stále ještě dostatečně efektivních metabolických zákroků s moderní farmakologickou léčbou antiobezitiky. Taková multimodální, kombinovaná léčba je výhodná především z hlediska co nejmenší operační zátěže nemocného a nabízí možnosti provedení anatomicky šetřících, vratných operací, spolu s využitím terapeutického potenciálu nových farmak. Kromě výše uvedených výhod je kombinovaná léčba výhodná i v tom, že multifaktoriálně podmíněné onemocnění obezitou terapeuticky ovlivňuje na několika metabolických a fyziologických úrovních. V posledních letech sílí tlak i přání ze strany pacientů i kolegů jiných lékařských specializací na další snížení invazivity bariatricko-metabolických zákroků, a to jak z pohledu operační zátěže, tak i na co nejmenší anatomickou ireverzibilitu výkonu. Kromě významných pokroků v oblasti farmakoterapie obezity se rychlým tempem rozvíjí i stále méně invazivní intervenční postupy ve spolupráci s dalšími nechirurgickými specializacemi (gastroenterologové-endoskopisté, intervenční radiologové a další). Vývoj se ubírá zejména dvěma směry – endoskopické provedení operací dosud prováděných pouze laparoskopicky (např. endoskopická plikace žaludku či částečná, magnetickým postupem provedená jejuno-ileální diverze [PJID]) – nebo jako zcela nové terapeutické zákroky (např. embolizace levé gastrické arterie). Jak ukazují např. pilotní střednědobé výsledky PJID uvedené v následujícím článku, i tyto nízce invazivní výkony jsou terapeuticky efektivní. U nemocných sledovaných 5 let po operaci došlo ke změně BMI o –12,4 %. Průměrný pokles HbA1c za 2 roky od operace byl –2,48 (–32,3 %), po 5 letech od výkonu –3,51 (–45,8 %) a za 7 let od operace tento pokles stále ještě činil –2,39 (–31,2 %). Glykemie se snížila v průměru 2,5 mmol /l. Za 5 let od operace tento pokles činil průměrně –4,1 mmol/l (–37,6 %), za 5 let od výkonu byl –4, 8 (–44,0 %) a po 7 letech dosáhly hodnoty –5,5 mmol /l (–50,4 %) oproti předoperačnímu stavu. Všechny zmíněné zákroky vykazují v krátko- a střednědobém sledování, na základě multicentrických, mezinárodních studií a také po zavedení do klinické praxe dobré výsledky a představují trendy do budoucích let. Důraz se klade zejména na minimální invazivitu a maximální anatomickou šetrnost výkonů. Výsledky léčby jsou zatím povzbudivé a důležitým aspektem je i aktivní přímá účast některých dalších lékařských specializací v léčebném algoritmu obezity. Jako terapeuticky vhodná i výhodná se jeví kombinace těchto intervencí a nových možností farmakoterapie.
Summary: Obesity is a chronic disease that affects millions of people worldwide and is associated with many health complications. The main goal of obesity treatment is to improve health by achieving and maintaining weight loss or through imposing metabolic changes. For treatment, there are several interventions available, such as diet and exercise, drug therapy, surgical procedures. If used as MONO therapy, they often show insufficiency to achieve/maintain adequate weight loss and/or metabolic improvement in long term. Patients seeking low invasive, however still efficient treatment or those with insufficient treatment results or side effects may, under view of new developments both in pharma and surgery, benefit from combined approach of both, anti-obesity medications and very low invasive bariatric-metabolic surgery, such as gastric plication (namely endoscopic plication), partial jejuno-ileal diversion and left gastric artery embolization. There are several new anti-obesity drugs that have been developed or are in development. These drugs target different pathways in the body, such as hormones, neurotransmitters, receptors, enzymes, i.e. to reduce food intake, increase energy expenditure, alter nutrient absorption. In bariatric-metabolic surgery new understanding of the mechanisms of action, which involve not only mechanical restriction or malabsorption, but also neurohormonal modulation, gut microbiome alteration, immune system regulation, and epigenetic changes is being applied to the treatment pathways. For optimal success, heterogeneity of treatment response needs to be incorporated into management plans. Low invasive bariatric-metabolic surgery combined with pharmacotherapy can lead to additive weight-loss benefits and less side effects and it usually works in synergy with medications. Thus, combined approach to obesity treatment that involves anti-obesity medications and BMS are complementary to each other. Laparoscopic PJID seems to be one of the promising non-drug interventions, especially for type 2 diabetic patients with poorly controlled diabetes. Pilot results at two, five and seven years are presented in the article. In 5 years after PJID mean BMI decreased by –12.4%. Mean HbA1c decreased in 2 years after the operation by mean of –2.48 (–32.3%), after 5 years by –3,51 (–45.8%) and in 7 years still decrease of –2.39 (–31.2%) was noted. Glycaemia decreased by mean of –2.5 mmol/l in 2 years, in 5 years postoperatively mean decrease was –4.8 (–44.0%) a in 7 years the mean decrease was – 5.5 mmol/l (–50.4%) in comparison with the pre-op values. Partial jejunal diversion provides an anatomy sparing, low risk, potentially reversible, metabolic procedure, especially in a view of potential use of magnetic approach. The operation does not neccessitate significant alterations in lifestyle, mineral and/or vitamin supplementation and offers rapid recovery. Anti-obesity medications may help prepare patients for bariatric surgery by inducing preoperative weight loss and reducing surgical risk and/or through leveraging treatment outcomes if used in the immediate postoperative period. May also help to prevent or treat weight regain after bariatric surgery by enhancing satiety and reducing hunger. In non-responders to medication before they get surgery may trigger respond to the medication after surgery. New obesity treatment model that utilizes combination of new drugs and low invasive treatment (such as surgical, endoscopic and other new technologies, e.i.magnetic surgery), can enhance and leverage treatment outcomes without increasing risks.
- MeSH
- bariatrická chirurgie metody MeSH
- farmakoterapie metody MeSH
- kombinovaná terapie MeSH
- lidé MeSH
- obezita * terapie MeSH
- Check Tag
- lidé MeSH
