Bariatric Times

JUL 2017

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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Editorial Message 3 Bariatric Times • July 2017 Dear Friends and Readers, I just returned from Japan where I attended the 35th Annual Meeting of the Japanese Society for Treatment of Obesity (JSTO35) held in Morioka, Japan. I really enjoyed visiting this phenomenal country and cherished every minute of the great hospitality delivered by Professors Akira Sasaki, MD, Congress President, and Kazunori Kasama, MD, a leading bariatric surgeon in Japan who is also a dear friend. The highlight of the meeting was a roundtable discussion addressing the ideal body mass index (BMI) and surgical procedure to treat the diabetes epidemic in this part of the world. The Asia-Pacific region is projected to have over 190 million individuals with diabetes by 2030, 1 a problem that surgery alone will certainly not be able to handle. Nevertheless, because of the low BMI at which severe obesity is diagnosed in this region (BMI >25kg/m 2 is considered obesity), the choice of gastric bypass versus sleeve gastrectomy is a subject of debate. Regardless of the evidence, sleeve gastrectomy has become the most prevalent procedure in the Asia-Pacific region. I thank Terrence Fullum, MD, for his contributed letter on intravenous micronutrient supplementation in gastric bypass patients to treat undetectable deficiencies. Indeed, some subtle deficiencies in vitamins and minerals cannot always be detected with regular laboratory analysis, and the empiric treatment of those has become common practice among most bariatric centers. We give, regardless of the blood levels, a cocktail of multiple vitamins and minerals to most patients that get readmitted to prevent the development of those deficiencies. Next, Ann Rogers, MD, and Jared Cappelli, RN, BS, address a very important subject—chronic abdominal pain in patients after undergoing Roux-en-Y gastric bypass. Between gastro-gastric fistulae, dumping syndrome, marginal ulceration, biliary tract disease, intussusceptions, and bowel obstructions, the differential diagnosis and treatment algorithms are colorful and can become a real challenge for the on-call surgeon and emergency room physician. It is our obligation to educate general surgeons, emergency room physicians, and gastroenterologists to better understand the pathophysiology and best management of these potentially life-saving surgical emergencies. This month, we present an interview with Esteban Varela, MD, FACS, FASMBS, and Carlos Chaux, MD. They discuss the fascinating research on metabolic surgery and stem cell transplantation. Camillo Riccordi, MD, who delivered the Mason Lecture during ObesityWeek 2016, is a leading scientist conducting pancreatic islet cell transplantation. I believe this work, combined with our outstanding surgical approaches, can become another excellent option to treat the patients with types 1 and 2 diabetes. I very much look forward to the results of future clinical trial in this Dear Readers, The Endocrine Society recently issued a scientific statement calling for more research aimed at understanding the underlying mechanisms that make it difficult for individuals to maintain long- term weight loss. 1 To summarize, the authors acknowledged that although research and billions of dollars are spent each year on obesity treatment, the health and economic burden of the disease in the United States has not improved. They assessed the current available literature and concluded that weight regain remains a large part of the problem, with effective options for long-term weight reduction lacking. They call for more research on obesity pathogenesis and list specific areas, such as energy homeostasis; genetic, developmental, and environmental forces; and biological markers and predictors for obesity's associated comorbid conditions. This statement is telling of the chronic and relapsing nature of this disease; we have decades of evidence and still do not fully understand all of the factors that contribute to the perfect obesity storm. I believe this is a very important area of study for a few reasons. For one, more research will uncover even more information, which will hopefully continue to drive the message to the public that obesity is complicated and requires serious treatment. Second, a better understanding of obesity will hopefully translate into developments in treatment pathways that will elicit more weight loss/maintenance success for our patients. Weight recidivism is a common problem post-bariatric surgery that confounds patients and clinicians alike, and the complexity of the disease is likely influential in this phenomenon. More information on the factors that influence the body to defend weight or reach plateau may allow us to pinpoint exact factors during this stage and customize care. For instance, perhaps more research into the gut microbiota changes postoperatively will cause clinicians to become more proactive in monitoring this area during follow up and prescribe adjunct therapies that act on it. The list of underlying factors that contribute to obesity is long and further research is likely to add to it. Just genetic influence alone is a vast area of research not only in obesity but in other diseases as well. Other areas mentioned in the Endocrine Society statement include genetic, developmental, and environmental forces. This brings to mind a great quote by obesity researcher George Bray, MD: the genetic background loads the gun, but the environment pulls the trigger. Research into genetics has ushered in the age of personalized medicine. As we learn more about individual influences on health states, it becomes quite clear that we cannot treat obesity with a shotgun or one-size-fits-all approach. Michael W. Schwartz, MD, It is Our Obligation to Educate Colleagues on Chronic Abdominal Pain after Roux-en- Y Gastric Bypass for Best Management The Endocrine Society's Scientific Statement Calling for More Research into Underying Mechanisms of Weight Maintenance is Telling of the Chronic and Relapsing Nature of Obesity A Message from Dr. Christopher Still Christopher Still, DO, FACN, FACP, Co-Clinical Editor, Bariatric Times; Medical Director for the Center for Nutrition and Weight Management, and Director for Geisinger Obesity R esearch Institute, Geisinger Medical Center, Danville, Pennsylvania. Continued on following page... Continued on following page... A Message from Dr. Raul J. Rosenthal Raul J. Rosenthal, MD, FACS, FASMBS, Clinical Editor, Bariatric Times; Professor of Surgery and Chairman, Department o f General Surgery; Director of Minimally Invasive Surgery and The Bariatric and Metabolic Institute; General Surgery Residency Program Director; and Director, Fellowship in MIS and Bariatric Surgery, Cleveland Clinic Florida, Weston, Florida

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