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Comment on: early weight loss after laparoscopic sleeve gastrectomy predicts midterm weight loss in morbidly obese Asians
Surgery for Obesity and Related Diseases ] (2017) 00–00
Editorial comment
Comment on: early weight loss after laparoscopic sleeve gastrectomy predicts midterm weight loss in morbidly obese Asians It is well known that responses to surgery may vary from individual to individual based on presumed various genetic profiles. Surgery is not like giving a medicine capsule to someone (even if dosage is adjusted to proper weight), but instead is a series of complex physical gestures, instrumental manipulations that are not necessarily reproducible with identical motions each time. Many variables on the surgeon’s side may influence the outcome of surgery, like experience, knowledge, physical, and psychological status of the surgeon; manual abilities; judgment; 3-dimensional space orientation; and so on. Numerous differences are also found in patient characteristics, like age, sex, body mass index, tissue thickness and vascular supply, co-morbidities, medications, chronic diseases, smoking, chemicals, and so on. It is also well known that surgeons cannot guarantee or promise a specific outcome of surgery, but have an obligation of means, to do their best. How do we answer patients who ask how much weight they will lose? According to the recent paper entitled “Early weight loss after laparoscopic sleeve gastrectomy predicts midterm weight loss in morbidly obese Asians” [1], we could predict their outcome. A linear regression analysis of 272 Asian patients revealed that percent excess weight loss (%EWL) at 3 months will predict weight loss at up to 3 years [1]. This is consistent with the studies of McNickle et al. [2] and Hindle et al. [3], where early weight loss was the most consistent predictor of successful mediumterm weight outcome at approximately 24 months; however, evidence is lacking on early eating adaptation and late weight loss outcome. Certain studies have hinted that early improvements in eating behavior have additive effects on weight loss [4]. Area under the curve (of % EWL) may be a better predictor than a simple drop in %EWL. [5] For Roux-en-Y gastric bypass, early %EWL had a better correlation with late outcomes. For example, at 6 months, those who had lost 445% were unlikely to have lost o50% of their excess weight, and in contrast, 71% of those who had lost o30% of their initial excess weight had not lost ≥50% at 24 months [6].
The Longitudinal Assessment of Bariatric Surgery study—a National Institutes of Health–sponsored prospective study encompassing 10 centers (I was an original coinvestigator and know the study well), in which most patients had either a gastric bypass or adjustable gastric banding—used multivariable linear and logistic regression models and found that the effect of baseline preoperative variables on 3-year weight change was minimal and had very little predictive value for a successful weight loss outcome after weight loss surgery [7]. Specific genotypes may have better weight loss [8]. However, weight is not the only thing you can improve, and preoperative triglyceride and low HbAlC levels may predict excellent success [9]. Others have found that weight loss predicted in conjunction with physical/medical health, psychological health, interpersonal support, and presence of eating disorders, taken together, showed a correlation of .54 with BMI change [10]. However, personality traits themselves did not predict short-term weight outcome. This may suggest that personality assessment is of little use for the prediction of a poor or successful weight outcome after weight loss surgery [11]. So, in the end, we have not found a specific strong predictor of weight loss, and I suspect this is because none of us are doing routine preoperative genetic profiles of patients. This is where the holy grail of bariatric surgery responses lie, as seen in some case reports and small series, as we are on the verge of a new era of personalized surgery [12,13]. Michel Gagner, M.D., F.R.C.S.C., F.A.C.S., F.A.S.M.B.S Herbert Wertheim College of Medicine Florida International University Miami, Florida, Hopital du Sacre Coeur Montreal, Canada References [1] Chew CAZ, Tan IJ, Tan HJH, Lomanto D, So J, Shabbir A. Early weight loss after laparoscopic sleeve gastrectomy predicts midterm
http://dx.doi.org/10.1016/j.soard.2017.07.033 1550-7289/r 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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[2] [3]
[4]
[5]
[6]
[7]
M. Gagner / Surgery for Obesity and Related Diseases ] (2017) 00–00 weight loss in morbidly obese Asians. Surg Obes Relat Dis. Epub 2017 May 19. McNickle AG, Bonomo SR. Predictability of first-year weight loss in laparoscopic sleeve gastrectomy. Surg Endosc. Epub 2017 Mar 9. Hindle A, de la Piedad Garcia X, Brennan L. Early post-operative psychosocial and weight predictors of later outcome in bariatric surgery: a systematic literature review. Obes Rev 2017;18(3):317–34. Stotland SC, Larocque M. Early treatment response as a predictor of ongoing weight loss in obesity treatment. Br J Health Psychol 2005;10(Pt 4):601–14. Thomas DM, Ivanescu AE, Martin CK, et al. Predicting successful long-term weight loss from short-term weight-loss outcomes: new insights from a dynamic energy balance model (the POUNDS Lost study). Am J Clin Nutr 2015;101(3):449–54. Ritz P, Caiazzo R, Becouarn G, et al. Early prediction of failure to lose weight after obesity surgery. Surg Obes Relat Dis 2013;9 (1):118–21. Courcoulas AP, Christian NJ, O'Rourke RW, et al. Preoperative factors and 3-year weight change in the Longitudinal Assessment of
[8]
[9]
[10] [11]
[12]
[13]
Bariatric Surgery (LABS) consortium. Surg Obes Relat Dis 2015;11 (5):1109–18. Lee YC, Liew PL, Lee WJ, et al. Prediction of successful weight reduction after laparoscopic adjustable gastric banding. Hepatogastroenterology 2009;56(93):1222–6. Lee YC, Lee WJ, Lee TS, et al. Prediction of successful weight reduction after bariatric surgery by data mining technologies. Obes Surg 2007;17(9):1235–41. Lanyon RI, Maxwell BM. Predictors of outcome after gastric bypass surgery. Obes Surg 2007;17(3):321–8. Larsen JK, Geenen R, Maas C, et al. Personality as a predictor of weight loss maintenance after surgery for morbid obesity. Obes Res 2004;12(11):1828–34. Bandstein M, Mwinyi J, Ernst B, Thurnheer M, Schultes B, Schiöth HB. A genetic variant in proximity to the gene LYPLAL1 is associated with lower hunger feelings and increased weight loss following Roux-en-Y gastric bypass surgery. Scand J Gastroenterol 2016;51(9):1050–5. Sevilla S, Hubal MJ. Genetic modifiers of obesity and bariatric surgery outcomes. Semin Pediatr Surg 2014;23(1):43–8.
Editorial comment
Comment on: early weight loss after laparoscopic sleeve gastrectomy predicts midterm weight loss in morbidly obese Asians It is well known that responses to surgery may vary from individual to individual based on presumed various genetic profiles. Surgery is not like giving a medicine capsule to someone (even if dosage is adjusted to proper weight), but instead is a series of complex physical gestures, instrumental manipulations that are not necessarily reproducible with identical motions each time. Many variables on the surgeon’s side may influence the outcome of surgery, like experience, knowledge, physical, and psychological status of the surgeon; manual abilities; judgment; 3-dimensional space orientation; and so on. Numerous differences are also found in patient characteristics, like age, sex, body mass index, tissue thickness and vascular supply, co-morbidities, medications, chronic diseases, smoking, chemicals, and so on. It is also well known that surgeons cannot guarantee or promise a specific outcome of surgery, but have an obligation of means, to do their best. How do we answer patients who ask how much weight they will lose? According to the recent paper entitled “Early weight loss after laparoscopic sleeve gastrectomy predicts midterm weight loss in morbidly obese Asians” [1], we could predict their outcome. A linear regression analysis of 272 Asian patients revealed that percent excess weight loss (%EWL) at 3 months will predict weight loss at up to 3 years [1]. This is consistent with the studies of McNickle et al. [2] and Hindle et al. [3], where early weight loss was the most consistent predictor of successful mediumterm weight outcome at approximately 24 months; however, evidence is lacking on early eating adaptation and late weight loss outcome. Certain studies have hinted that early improvements in eating behavior have additive effects on weight loss [4]. Area under the curve (of % EWL) may be a better predictor than a simple drop in %EWL. [5] For Roux-en-Y gastric bypass, early %EWL had a better correlation with late outcomes. For example, at 6 months, those who had lost 445% were unlikely to have lost o50% of their excess weight, and in contrast, 71% of those who had lost o30% of their initial excess weight had not lost ≥50% at 24 months [6].
The Longitudinal Assessment of Bariatric Surgery study—a National Institutes of Health–sponsored prospective study encompassing 10 centers (I was an original coinvestigator and know the study well), in which most patients had either a gastric bypass or adjustable gastric banding—used multivariable linear and logistic regression models and found that the effect of baseline preoperative variables on 3-year weight change was minimal and had very little predictive value for a successful weight loss outcome after weight loss surgery [7]. Specific genotypes may have better weight loss [8]. However, weight is not the only thing you can improve, and preoperative triglyceride and low HbAlC levels may predict excellent success [9]. Others have found that weight loss predicted in conjunction with physical/medical health, psychological health, interpersonal support, and presence of eating disorders, taken together, showed a correlation of .54 with BMI change [10]. However, personality traits themselves did not predict short-term weight outcome. This may suggest that personality assessment is of little use for the prediction of a poor or successful weight outcome after weight loss surgery [11]. So, in the end, we have not found a specific strong predictor of weight loss, and I suspect this is because none of us are doing routine preoperative genetic profiles of patients. This is where the holy grail of bariatric surgery responses lie, as seen in some case reports and small series, as we are on the verge of a new era of personalized surgery [12,13]. Michel Gagner, M.D., F.R.C.S.C., F.A.C.S., F.A.S.M.B.S Herbert Wertheim College of Medicine Florida International University Miami, Florida, Hopital du Sacre Coeur Montreal, Canada References [1] Chew CAZ, Tan IJ, Tan HJH, Lomanto D, So J, Shabbir A. Early weight loss after laparoscopic sleeve gastrectomy predicts midterm
http://dx.doi.org/10.1016/j.soard.2017.07.033 1550-7289/r 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.
2
[2] [3]
[4]
[5]
[6]
[7]
M. Gagner / Surgery for Obesity and Related Diseases ] (2017) 00–00 weight loss in morbidly obese Asians. Surg Obes Relat Dis. Epub 2017 May 19. McNickle AG, Bonomo SR. Predictability of first-year weight loss in laparoscopic sleeve gastrectomy. Surg Endosc. Epub 2017 Mar 9. Hindle A, de la Piedad Garcia X, Brennan L. Early post-operative psychosocial and weight predictors of later outcome in bariatric surgery: a systematic literature review. Obes Rev 2017;18(3):317–34. Stotland SC, Larocque M. Early treatment response as a predictor of ongoing weight loss in obesity treatment. Br J Health Psychol 2005;10(Pt 4):601–14. Thomas DM, Ivanescu AE, Martin CK, et al. Predicting successful long-term weight loss from short-term weight-loss outcomes: new insights from a dynamic energy balance model (the POUNDS Lost study). Am J Clin Nutr 2015;101(3):449–54. Ritz P, Caiazzo R, Becouarn G, et al. Early prediction of failure to lose weight after obesity surgery. Surg Obes Relat Dis 2013;9 (1):118–21. Courcoulas AP, Christian NJ, O'Rourke RW, et al. Preoperative factors and 3-year weight change in the Longitudinal Assessment of
[8]
[9]
[10] [11]
[12]
[13]
Bariatric Surgery (LABS) consortium. Surg Obes Relat Dis 2015;11 (5):1109–18. Lee YC, Liew PL, Lee WJ, et al. Prediction of successful weight reduction after laparoscopic adjustable gastric banding. Hepatogastroenterology 2009;56(93):1222–6. Lee YC, Lee WJ, Lee TS, et al. Prediction of successful weight reduction after bariatric surgery by data mining technologies. Obes Surg 2007;17(9):1235–41. Lanyon RI, Maxwell BM. Predictors of outcome after gastric bypass surgery. Obes Surg 2007;17(3):321–8. Larsen JK, Geenen R, Maas C, et al. Personality as a predictor of weight loss maintenance after surgery for morbid obesity. Obes Res 2004;12(11):1828–34. Bandstein M, Mwinyi J, Ernst B, Thurnheer M, Schultes B, Schiöth HB. A genetic variant in proximity to the gene LYPLAL1 is associated with lower hunger feelings and increased weight loss following Roux-en-Y gastric bypass surgery. Scand J Gastroenterol 2016;51(9):1050–5. Sevilla S, Hubal MJ. Genetic modifiers of obesity and bariatric surgery outcomes. Semin Pediatr Surg 2014;23(1):43–8.