Journal Club

1. Journal Club Inge TH, Courcoulas AP, Jenkins TM, Michalsky MP, Brandt ML, Xanthakos SA, Dixon JB, Harmon CM, Chen MK, Xie C, Evans ME, Helmrath MA; Teen–LABS Consortium. Five-Year Outcomes of Gastric Bypass in Adolescents as Compared with Adults. N Engl J Med. 2019 May 30;380(22):2136-2145. doi: 10.1056/NEJMoa1813909. Epub 2019 May 16. 埼玉医科大学　総合医療センター　内分泌・糖尿病内科 Department of Endocrinology and Diabetes, Saitama Medical Center, Saitama Medical University 松田　昌文　 Matsuda, Masafumi 2019年6月27日　8:30-8:55 ４階　カンファレンス室

2. SLEEVE Adjustable gastric banding BYPASS Biliopancreatic diversion Roux-en-Y gastric bypass Sleeve gastrectomy Vertical banded gastroplasty with duodenal switch A meta-analysis from University of California, Los Angeles reports the following weight loss at 36 months Biliopancreatic diversion - 53 kg Roux-en-Y gastric bypass (RYGB) - 41 kg Open - 42 kg Laparoscopic - 38 kg Adjustable gastric banding - 35 kg Vertical banded gastroplasty - 32 kg Sleeve gastrectomy ?

3. From the University of Colorado, Denver and Children’s Hospital Colorado, Aurora (T.H.I.); University of Pittsburgh Medical Center, Pittsburgh (A.P.C.); Cincinnati Children’s Hospital Medical Center (T.M.J., S.A.X., M.A.H.) and University of Cincinnati (C.X.), Cincinnati, and Nationwide Children’s Hospital and the Ohio State University College of Medicine, Columbus (M.P.M.) — all in Ohio; Texas Children’s Hospital, Baylor College of Medicine, Houston (M.L.B.); Baker Heart and Diabetes Institute, Melbourne, VIC, Australia (J.B.D.); John R. Oishei Children’s Hospital and Jacobs School of Medicine and Biosciences–SUNY University at Buffalo, Buffalo, NY (C.M.H.); the University of Alabama at Birmingham, Birmingham (M.K.C.); and the National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD (M.E.E.) N Engl J Med. 2019 May 30;380(22):2136-2145.

4. Background Bariatric surgery results in weight loss and health improvements in adults and adolescents. However, whether outcomes differ according to the age of the patient at the time of surgery is unclear.

5. Methods We evaluated the health effects of Roux-en-Y gastric bypass in a cohort of adolescents (161 patients enrolled from 2006 through 2012) and a cohort of adults (396 patients enrolled from 2006 through 2009). The two cohorts were participants in two related but independent studies. Linear mixed and Poisson mixed models were used to compare outcomes with regard to weight and coexisting conditions between the cohorts 5 years after surgery. The rates of death and subsequent abdominal operations and selected micronutrient levels (up to 2 years after surgery) were also compared between the cohorts.

6. Study Design and Participants The Teen–Longitudinal Assessment of Bariatric Surgery (Teen–LABS) study and the LABS study (ClinicalTrials.gov number, NCT00465829) were designed similarly as prospective, multicenter, observational studies of consecutive cases of bariatric surgery. The Teen–LABS study incorporated the design features and data collection forms of the LABS study in order to facilitate valid comparisons between the two cohorts. The Teen–LABS study enrolled adolescents (19 years of age or younger) at five clinical centers from 2006 through 2012. The LABS study enrolled patients 18 years of age or older who were undergoing any first-time bariatric surgical procedure at one of 10 clinical centers from 2006 through 2009. Adult study participants completed a weight-history questionnaire in which they characterized their body weight at age 18, which permitted the selection of adults whose BMI was 30 or more at age 18 for the current analysis. Comparisons were limited to adult participants 25 to 50 years of age at the time of surgery who had gastric bypass surgery as their primary bariatric operation, since this was the predominant bariatric operation in adolescents when the study was designed.

8. ？

10. Figure 1. Weight Change and Remission of Diabetesand Hypertension during the 5-Year Period after Gastric Bypass Surgery. Line graphs represent modeled mean percent changes in weight from baseline to 5 years for gastric bypass surgery in adult and adolescent cohorts, and dots represent observed values from individual participants (Panel A). Also shown is the modeled remission of type 2 diabetes (Panel B) and hypertension (Panel C) at each study visit during the 5 years after gastric bypass surgery in the two cohorts. I bars in all panels represent 95% confidence intervals.

16. Diabetes mellitus (DM). DM at baseline was defined by study investigators taking into consideration patient self-report of prior diagnosis as well as prior medical records from referring physician, use of medications for DM, baseline HbA1c of ≥6.5%, or fasting glucose of ≥126 mg/dL, or oral glucose tolerance results in the prior 6 months. Participants reporting having polycystic ovary syndrome who did not meet laboratory criteria for DM and were not taking a DM medication other than metformin were not considered to have diabetes. Participants who were on metformin at baseline for weight management or for insulin resistance with no other indication of a prior diagnosis of DM documented and no laboratory findings consistent with the diagnosis of DM were not considered to have DM. Remission of DM: Unless otherwise noted, remission of DM was defined as no use of medication for DM, and HbA1c < 6.5% (if HbA1c was not available, remission also required FBG <126mg/dL). In instances where specified laboratory and/or medication use data were unavailable, subject-reported declarations of presence of or absence of diabetes were used (as documented prospectively at each study visit on “medical assessment baseline” and “medical assessment follow-up” case report forms). Subject reported information was required for defining cases in 3.6% of Teen-LABS and 21% of LABS participants. Hypertension. Blood pressure (BP) was measured at the time of the study visit and use of medications for control of BP was recorded on medication use form (MED). For this analysis, hypertension was defined in a manner consistent with that used to clinically define hypertension: use of BP medications or systolic BP>140 mmHg or diastolic BP > 90 mmHg. Remission of hypertension (HTN): Unless otherwise noted, remission of HTN required that no medications for BP were being used and systolic BP < 140 mmHg and diastolic BP < 90 mmHg. Specifically, the data for this variable were obtained as described below: • Systolic and diastolic BP were measured using a Welch Allyn Spot Vital Signs monitor 4200B. For home visits, a monitor was shipped to the field examiner. • Measurement of BP was done with appropriately sized cuff and after the patient has been seated quietly, with feet flat on the floor, in an erect but comfortable posture for at least five minutes, and for at least thirty minutes since the patient has smoked or consumed caffeine containing beverages. Hypertriglyceridemia. Hypertriglyceridemia was defined for those <21 years of age as fasting triglycerides (TG) ≥130 mg/dL, or for those 21 and older, hypertriglyceridemia was defined as fasting TG ≥200 mg/dL. Remission of hypertriglyceridemia was defined as TG < 130 mg/dL for those < 21 years of age, and TG <200 mg/dL for those ≥ 21 years of age, in an individual who met criteria for hypertriglyceridemia at baseline. Low high-density lipoprotein cholesterol. High density lipoprotein cholesterol (HDL-C) was considered abnormally low if the measured HDL-C was < 40 mg/dL for males or was <50 mg/dL for females. Remission of low HDL was defined as HDL-C ≥40 mg/dL (males) or HDL-C ≥50 mg/dL (females), in an individual who had previously met criteria for low HDL-C at baseline. Remission of dyslipidemia: If <21 years of age, at follow-up, remission of dyslipidemia was defined as TG <130 mg/dL, and LDL-C <130 mg/dL, and HDL-C ≥40 mg/dL, and no use of LLM. If age was ≥ 21 years, resolution of dyslipidemia was defined as TG <200 mg/dL, and LDL-C <160 mg/dL, and HDL-C ≥40 mg/dL (males) or HDL-C ≥50 mg/dL (females), and no use of LLM. Specifically, the data for this variable were obtained as follows: • Central laboratory measured triglyceride, LDL cholesterol, HDL cholesterol at baseline and follow-up; • LLM assessment was derived during analysis from Comorbidity Assessment-Baseline (CAB) or follow up (CAF) form, Question 5 – selection equals: “treatment with single medication for dyslipidemia” or “treatment with two or more medications for dyslipidemia”; • Medications (MED) form, subject-reported use of any antilipidemic medication.

17. Results There was no significant difference in percent weight change between adolescents (−26%; 95% confidence interval [CI], −29 to −23) and adults (−29%; 95% CI, −31 to −27) 5 years after surgery (P=0.08). After surgery, adolescents were significantly more likely than adults to have remission of type 2 diabetes (86% vs. 53%; risk ratio, 1.27; 95% CI, 1.03 to 1.57) and of hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88). Three adolescents (1.9%) and seven adults (1.8%) died in the 5 years after surgery. The rate of abdominal reoperations was significantly higher among adolescents than among adults (19 vs. 10 reoperations per 500 person-years, P=0.003). More adolescents than adults had low ferritin levels (72 of 132 patients [48%] vs. 54 of 179 patients [29%], P=0.004).

18. Conclusions Adolescents and adults who underwent gastric bypass had marked weight loss that was similar in magnitude 5 years after surgery. Adolescents had remission of diabetes and hypertension more often than adults. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases; ClinicalTrials.gov number, NCT00474318.)

19. From the Intermountain Live Well Center, Intermountain Healthcare, and the Division of Epidemiology and Division of Nutrition and Integrative Physiology, University of Utah — both in Salt Lake City. In parallel with the well-documented, long-term favorable weight change outcomes of bariatric surgery in adults, bariatric surgery in adolescents who are severely obese is equally successful with respect to weight loss and appears to be associated with an even greater long-term disease remission if surgery is not delayed until adulthood; however, negative health outcomes of bariatric surgery reported in adolescents also mirror those reported in adults — including, for example, potential for self-harm (including suicide) and increased risk of alcohol or drug abuse. In addition, the clinical risk of nutritional deficiencies and abdominal reoperations is even greater among adolescents who have undergone bariatric surgery than among adults who have undergone similar surgery. For now, while we hope to identify new, effective, and less-invasive therapies and effective adjuncts to bariatric surgery in adolescents (i.e., pharmacotherapy and multispecialty lifestyle integration), decisions should be made on a case-by-case basis, with the knowledge that the 5-year data look promising but that the lifetime outcome is unknown.

20. Message 胃バイパス術、青年患者で健康効果大きい 　ルーワイ胃バイパス術を受けた思春期青年コホート（161例）と成人コホート（396例）を5年間追跡し、コホート間の転帰の差異を検討した。 　その結果、術後5年の体重変化率は青年－26％、成人－29％で、有意差はなかった（P＝0.08）。術後の2型糖尿病寛解率は青年86％、成人53％（リスク比1.27、95％CI 1.03-1.57）、高血圧寛解率は青年68％、成人41％（同1.51、1.21-1.88）で、青年の寛解率は有意に高かった。青年は成人に比べて、腹部再手術率が有意に高かった（500人年当たり再手術19件 vs. 10件、P＝0.003）。 https://www.m3.com/clinical/journal/20438