Surgery for Obesity and Related Diseases

Editorial board

2010-01-01

Updated Position Statement on Sleeve Gastrectomy as a Bariatric Procedure

2009-11-18

The American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published a position statement on the use of sleeve gastrectomy (SG) as a bariatric procedure . These position statements have been developed in response to inquiries made to the Society by patients, physicians, hospitals, health insurance payors, the media, and others regarding new procedures or issues within our specialty that require close evaluation and evidence-based scrutiny. In the rapidly changing field of bariatric surgery, it is necessary to periodically review previously published statements and provide updated position statements from a growing or changing body of evidence. The Clinical Issues Committee and Executive Council have determined that, since the initial position statement on SG was issued, the published data have grown and the use of this procedure has become more widespread such that a revised position statement is warranted. Since the original position statement was published (15 studies, 775 patients, 3 years of follow-up), an additional 21 studies have been published with 1795 patients (excluding studies with duplicate patient groups) with follow-up data available for 5 years after SG for some patients. The purpose of the present updated statement is to review the currently available data regarding the safety, efficacy, and durability of the SG procedure as a primary or staged operation. Recommendations have been from published, peer-reviewed scientific evidence and expert opinion. The statement is not intended as, and should not be construed as, stating or establishing a local, regional, or national standard of care for any bariatric procedure.

Socioeconomic disparities and access to bariatric surgery

Daniel M. Herron — 2009-09-28

As bariatric surgeons, we are certainly aware that the incidence of obesity is continuing to increase—in 2009, almost 28% of U.S. adults qualified as obese . However, it is still alarming to learn from the analysis presented by Martin et al. that fully 22 million people in the United States are candidates for bariatric surgery. Even more concerning is that, in 2008, 43.6 million people in the United States had no health insurance . This represents 17% of the U.S. population. Thus, the major findings of the study should come as no surprise: substantial numbers of severely obese individuals who would benefit from bariatric surgery are not able to undergo it.

Socioeconomic disparities in eligibility and access to bariatric surgery: a national population-based analysis

Matthew Martin, Alec Beekley, Randy Kjorstad, James Sebesta — 2009-07-21

Abstract: Background: To analyze the socioeconomics of the morbidly obese patient population and the impact on access to bariatric surgery using 2 nationally representative databases. Bariatric surgery is a life-changing and potentially life-saving intervention for morbid obesity. Access to bariatric surgical care among eligible patients might be adversely affected by a variety of socioeconomic factors.Methods: The national bariatric eligible population was identified from the 2005–2006 National Health and Nutrition Examination Survey and compared with the adult noneligible population. The eligible cohort was then compared with patients who had undergone bariatric surgery in the 2006 Nationwide Inpatient Sample, and key socioeconomic disparities were identified and analyzed.Results: A total of 22,151,116 people were identified as eligible for bariatric surgery using the National Institutes of Health criteria. Compared with the noneligible group, the bariatric eligible group had significantly lower family incomes, lower education levels, less access to healthcare, and a greater proportion of nonwhite race (all P <.001). Bariatric eligibility was associated with significant adverse economic and health-related markers, including days of work lost (5 versus 8 days, P <.001). More than one third (35%) of bariatric eligible patients were either uninsured or underinsured, and 15% had incomes less than the poverty level. A total of 87,749 in-patient bariatric surgical procedures were performed in 2006. Most were performed in white patients (75%) with greater median incomes (80%) and private insurance (82%). Significant disparities associated with a decreased likelihood of undergoing bariatric surgery were noted by race, income, insurance type, and gender.Conclusion: Socioeconomic factors play a major role in determining who does and does not undergo bariatric surgery, despite medical eligibility. Significant disparities according to race, income, education level, and insurance type continue to exist and should prompt focused public health efforts aimed at equalizing and expanding access.

Perceived barriers to bariatric surgery among morbidly obese patients

Bianca B. Afonso, Raul Rosenthal, Ka Ming Li, Jorge Zapatier, Samuel Szomstein — 2009-10-05

Abstract: Background: Obesity has become a worldwide problem. Surgery has been shown to be a safe and effective therapy. We sought to identify those factors that patients regard as barriers to undergoing a bariatric surgical procedure.Methods: Morbidly obese patients were asked to complete a 2-page questionnaire during routine outpatient appointments or hospitalization for other reasons. Patients were enrolled from February 2007 to April 2008. The differences between groups were assessed using univariate analysis.Results: A total of 77 patients (41 women and 36 men) were enrolled. Their median age was 51 years, and 49% of the patients were white, followed by Hispanic (23%), and other ethnicities. Of the 77 patients, 9% were supermorbidly obese (body mass index >50 kg/m2), and 62% reported having used dieting to lose weight, with greater reports among the women (P = .01). White patients and those >55 years old were more likely to be using some type of weight loss program. Only 40% were physically active. African Americans reported greater rates of regular exercise (P <.01). Of the 77 patients surveyed, 8% had never heard of bariatric surgery. Finally, only 30% of our patient population considered themselves to be morbidly obese.Conclusion: The results from the present survey have demonstrated that a lack of insurance coverage is not the main reason for patients not consulting a center to be evaluated for bariatric surgery. Perceived barriers and lack of knowledge exist in both the minds of the general public and physicians.

Comment on: Perceived barriers to bariatric surgery among morbidly obese patients

Michel M. Murr — 2009-10-05

Access to care has become one of the critical aspects of the dialogue on healthcare. The authors discuss the perceived barriers to metabolic surgery in a small cohort of patients in a metropolitan area. The critical issue, however, is access to comprehensive obesity management. Bariatric surgeons have delivered care of a high caliber and relief of obesity-related co-morbidities. Even if we were able to double the number of patients undergoing metabolic surgery from 1 to 2/1000, we would still be left with the remainder of the 7% fraction of the U.S. population with a BMI >40 kg/m2 who are not receiving definitive management of their obesity. We should continue to maintain a leadership position in advocating for comprehensive treatment and prevention of obesity.

Comparison of 30-day outcomes after non-LapBand primary and revisional bariatric surgical procedures from the Longitudinal Assessment of Bariatric Surgery study

2009-11-23

Abstract: Background: The goals were to compare the morbidity and mortality between primary and revisional bariatric surgery and to identify the clinical predictors of adverse outcomes among patients undergoing revisional surgery in the Longitudinal Assessment of Bariatric Surgery consortium. The study was multi-institutional at university hospitals in the United States.Methods: Data from the LABS-1 (safety) cohort were analyzed, excluding primary gastric banding patients. A total of 3802 LABS-1 patients were included: 3577 who underwent primary surgery and 225 who underwent revisional surgery. The demographic, clinical, operative, and 30-day outcome data were compared between the 2 groups. A nonlinear mixed effects logit model was used to identify independent risk factors for adverse outcomes (death, deep vein thrombosis, pulmonary embolism, reintubation, reoperation, or discharge after 30 days).Results: Compared with those undergoing revisional surgery, the primary surgery patients were younger (median age 44 versus 49 years, P <.0001) and more likely to be male (20.5% versus 12.7%, P = .006) and heavier (median body mass index 47.3 versus 41.2 kg/m2, P <.0001) and to have more co-morbidities (P <.0001), including hypertension (56.0% versus 46.0%, P = .0044), diabetes (35.7% versus 20.0%, P <.0001), and sleep apnea (50.3% versus 27.2%, P <.0001). The operative time for the revisional procedures was longer (median 181 versus 135 min, P <.0001) and associated with greater blood loss (median 100 versus <50 mL, P <.0001). Adverse outcomes were more likely after revisional surgery (15.1% versus 5.3%, P <.0001, odds ratio 2.4, 95% confidence interval 1.6–3.6). After adjusting for patient characteristics previously shown to be associated with adverse outcomes, this difference remained statistically significant (odds ratio 2.3, 95% confidence interval 1.5–3.8). The 30-day mortality rate was similar in the 2 groups (.4%).Conclusion: Revisional surgery was performed without substantial mortality but with a greater incidence of adverse outcomes than was primary bariatric surgery.

Adjustable gastric banding as revisional bariatric procedure after failed gastric bypass—intermediate results

2009-10-12

Abstract: Background: Although gastric bypass is the most common bariatric procedure in the United States, it is has been associated with a failure rate of 15% (range 5–40%). The addition of an adjustable gastric band to Roux-en-Y gastric bypass has been reported to be a useful revision strategy in a small series of patients with inadequate weight loss after proximal gastric bypass.Methods: We report on 22 patients who presented with inadequate weight loss or significant weight regain after proximal gastric bypass. All patients underwent revision with the placement of an adjustable silicone gastric band around the proximal gastric pouch. The bands were adjusted at 6 weeks postoperatively and beyond, as needed. Complications and weight loss at the most recent follow-up visit were evaluated.Results: The mean age and body mass index at revision was 41.27 years (range 25–58) and 44.8 ± 6.34 kg/m2, respectively. Patients had experienced a loss of 19%, 27%, 47.3%, 42.3%, 43%, and 47% of their excess weight at 6, 12, 24, 36, 48, and 60 months after the revisional procedure, respectively. Three major complications occurred requiring reoperation. No band erosions have been documented.Conclusion: The results from this larger series of patients have also indicated that the addition of the adjustable silicone gastric band causes significant weight loss in patients with poor weight loss outcomes after gastric bypass. That no anastomosis or change in absorption is required makes this an attractive revisional strategy. As with all revisional procedures, the complication rates appear to be increased compared with a similar primary operation.

Peroral endoscopic anastomotic reduction improves intractable dumping syndrome in Roux-en-Y gastric bypass patients

Gloria Fernández-Esparrach, David B. Lautz, Christopher C. Thompson — 2009-04-24

Abstract: Background: Dumping syndrome is a well-described consequence of Roux-en-Y gastric bypass. Although the condition can benefit some patients with morbid obesity, a subset will develop intractable dumping syndrome characterized by symptomatic episodes with most meals. We describe the first series of patients successfully treated endoscopically for intractable dumping syndrome.Methods: Endoscopic gastrojejunal anastomotic reduction was performed in patients with intractable dumping syndrome after Roux-en-Y gastric bypass using a combination of argon plasma coagulation, endoscopic suturing, and fibrin glue. The technical feasibility of endoscopic anastomotic reduction and the clinical improvement in dumping symptoms were assessed by clinical follow-up.Results: Endoscopic anastomotic reduction was technically successful in 6 consecutive patients with a dilated gastrojejunal anastomosis and intractable dumping syndrome. One patient reported hematemesis 2 days after the procedure that was treated endoscopically. No other significant complications occurred. Complete and persistent resolution of the dumping symptoms was achieved in all patients, with a median follow-up of 636 days.Conclusion: Endoscopic anastomotic reduction appears technically feasible and safe and might be a minimally invasive treatment option for patients who experience intractable dumping symptoms after Roux-en-Y gastric bypass. Additional studies are needed to determine the long-term efficacy of this procedure.

Laparoscopic single-site surgery for placement of adjustable gastric band—a series of 22 cases

Julio Teixeira, Kevin McGill, Nina Koshy, James McGinty, George Todd — 2009-04-17

Abstract: Background: We present a series of 22 patients who underwent laparoendoscopic single-site (LESS) surgery for placement of an adjustable gastric band at a U.S. university hospital.Methods: From December 2007 to December 2008, LESS surgery, through a transumbilical incision, to place an adjustable gastric band was performed on 22 patients under institutional review board approval. Multiple ports were placed through a single incision in the umbilicus to allow for liver retraction, visualization, and the working instruments. None of the critical steps of the standard pars flaccida technique were altered.Results: A total of 22 patients were carefully selected and included 20 women and 2 men, with an age range of 18–67 years (mean 42). The mean body mass index was 42 kg/m2 (range 35–45). The exclusion criteria included hepatomegaly, central obesity, previous abdominal surgery, and super-obesity. The mean operative time was 84 minutes (range 53–111). All patients were discharged home within the 23-hour admission, and no perioperative complications were noted. In addition, no wound-related complications developed. One patient required conversion to conventional laparoscopy. No intraoperative or postoperative complications occurred.Conclusion: In our experience, LESS surgery for adjustable gastric band placement shows this technique to be both feasible and safe in selected patients to date. Although technical limitations exist that will be improved on, additional studies are needed to compare LESS surgery for placement of an adjustable gastric band with traditional laparoscopic techniques.

Fibrin sealant associated with increased body temperature and leukocytosis after laparoscopic gastric bypass

Evangelos Efthimiou, Salman Al-Sabah, John S. Sampalis, Nicolas V. Christou — 2009-03-18

Abstract: Background: Fibrin sealants (FSs) have been used in both open and laparoscopic bariatric surgery to decrease the anastomotic leak rate; however, conclusive evidence to recommend routine use is still lacking. We studied FS use and its effect on the clinical inflammatory response after laparoscopic Roux-en-Y gastric bypass.Methods: Of 474 consecutive patients scheduled to undergo laparoscopic Roux-en-Y gastric bypass, 158 were assigned to group 1 (no FS used), 158 were assigned to group 2 (FS used at the gastrojejunal anastomosis and gastric staple line), and 158 patients were assigned to group 3 (reverting back to no FS use).Results: The mean age of all patients was 40.7 years (range 18–64), and the mean body mass index was 51.9 kg/m2 (range 36.7–107). The FS group had a statistically significant higher pulse rate (P = .001), recorded temperature (P = .001), and white blood cell count (P = .001) in the first 48 hours after surgery. The overall leak rate was 4.2% (20 of 474 cases). The mortality rate was 0% in all 3 groups. FS use had no effect on the anastomosis or staple line leak rate. An evaluation for fever of unknown origin was required in 6 patients in the FS group with no evidence of leak. Of these 6 patients, 4 had no evidence of leak on upper gastrointestinal series or computed tomography and 2 underwent surgical exploration with a subphrenic collection found but no evidence of leak intraoperatively (negative findings for pneumatic and methylene blue tests).Conclusion: FS use in laparoscopic Roux-en-Y gastric bypass is associated with an increased clinical inflammatory response mimicking anastomotic leak. FS had no effect on the anastomotic leak rate.

Mucosal and serosal changes after gastric stapling determined by a new “real-time” surface tissue oxygenation probe: a pilot study

2009-10-05

Abstract: Background: Although tissue ischemia at surgical anastomoses can cause leakage, stricture, and ulceration, surgeons rely on nonquantitative measures of detecting ischemia (e.g., color changes, pulsation), which are not likely to detect transient or small degrees of ischemia. A new microvascular tissue oximeter probe (T-Stat) provides noninvasive real-time measurement of tissue hemoglobin oxygen saturation (StO2). We measured local gastric StO2 during stapling for transection/pouch creation to assess the reproducibility of measurements, the sensitivity of the mucosa versus serosa to ischemia, and the effect of the proximity to the staple line on the measurement.Methods: Anesthetized adult swine (n = 8) underwent laparotomy to transect gastric tissue in vivo with measurements made in 2 locations using 4.8-mm staple height cartridges.Results: Both mucosal and serosal StO2 decreased significantly when measured adjacent to the staple line compared with baseline (mucosa 3.0% ± 5.6% versus 42.1% ± 13.5%, serosa 48.2% ± 15.1% versus 64.9% ± 7.6%, P .05). No color or pulsation changes were observed.Conclusion: Although significant reproducible mucosal and serosal decreases in StO2 were seen in proximity to the gastric staple lines, the decrease in mucosal StO2 was dramatic in the absence of any visible changes. The persistence of tissue ischemia with gastric stapling or in the creation of an anastomosis might contribute to the development of complications. The use of a real-time, noninvasive tissue probe could ultimately assist surgeons in identifying patients at risk of complications.

Incidence of postoperative gallstone disease after antiobesity surgery: population-based study from Sweden

Eduard Jonas, Richard Marsk, Finn Rasmussen, Jacob Freedman — 2009-04-27

Abstract: Background: Patients who have undergone antiobesity surgery are at risk of developing gallstones postoperatively. The aim of the present study was to assess the incidence of symptomatic gallstone disease in patients who have undergone antiobesity surgery compared with that of the general population.Methods: We performed a population-based cohort study of antiobesity surgery in Sweden from 1980 to 2006. A total of 8901 patients who had undergone antiobesity surgery and had not previously been treated for gallstone disease were indentified from the Inpatient Care Register. For each subject, 10 controls matched for age and gender, were identified in the register of the total population (89,010). Censoring occurred at the end of the study (December 31, 2006), date of emigration, or date of death (9.1 ± 6.6 years of follow-up).Results: The incidence of gallstone disease was 122.2/10,000 person-years in the surgical group compared with 22.2/10,000 person-years in the controls. The incidence of cholecystectomy was greater in the surgical group than in the controls (106.1 versus 19.5/10,000 person-years). The incidence ratio for gallstone disease was 5.5 (range 5.05.9) and for cholecystectomy was 5.4 (range 5.0–5.9).Conclusion: A fivefold increased risk of symptomatic gallstone disease was found after antiobesity surgery compared with that in the general population.

Should biliopancreatic diversion with duodenal switch be done as single-stage procedure in patients with BMI ≥50 kg/m2?

Philippe Topart, Guillaume Becouarn, Patrick Ritz — 2009-05-14

Abstract: Background: Biliopancreatic diversion with or without the duodenal switch (BPD-DS) is a major bariatric procedure. The morbidity and mortality are likely to increase with an increasing body mass index (BMI), especially when >50 kg/m2. Controversy exists regarding the potentially increased risks of a single-stage procedure compared with the risks of sleeve gastrectomy first followed by the malabsorptive procedure after an initial weight loss.Methods: From March 2003 to October 2008, 90 patients with a BMI ≥50 kg/m2 were candidates for single-stage BPD-DS. Two study periods were identified: before and after February 2007, corresponding to the periods during and after the learning curve. The results were analyzed globally and by comparing the 2 periods using Fisher's exact test and the t test for unpaired values.Results: Of the 90 patients, 79 were women, the average BMI was 55.2 ± 4.7 kg/m2, 13 patients were super-super obese, and 4 patients underwent laparoscopic sleeve gastrectomy only. Of the 86 patients who underwent single-stage BPD-DS, 37 underwent surgery before (31 laparoscopically; group 1) and 49 after (48 laparoscopically; group 2) February 2007. BPD-DS was done as revision surgery for 14 patients with a failed restrictive procedure. The global rate of conversion to open surgery was 13.9%; 35.5% for group 1 versus 2% for group 2 (P = .0001). The morbidity decreased significantly between the 2 periods, with a rate of 16.3% for group 2 compared with 45.9% for group 1. Also, 1 postoperative death occurred in group 1.Conclusion: Single-stage BPD-DS in the super obese appears to be a relatively safe procedure with a low rate of conversion when a laparoscopic approach is used. Although from the published data, the morbidity and mortality are increased for super obese patients, especially men, the BMI itself cannot be considered a contraindication for single-stage BPD-DS, because other factors such as surgical experience also influence the outcome. Despite these variables, performing a sleeve gastrectomy first should be considered for heavier, male, and at-risk patients.

Effect of circular staple line buttressing material on gastrojejunostomy failure in laparoscopic Roux-en-Y gastric bypass

Anna Ibele, Michael Garren, Jon Gould — 2009-06-04

Abstract: Background: To determine the effect of bovine pericardium strip (BPS) reinforcement of the circular stapler on the gastrojejunostomy leak rates and staple line failure after laparoscopic Roux-en-Y gastric bypass (LRYGB) at a university hospital in the United States. Gastrojejunostomy leak after LRYGB is a devastating complication. Various techniques, including buttressing the gastrojejunostomy staple line with biomaterial, have been used in an effort to minimize leaks.Methods: A total of 350 consecutive patients underwent LRYGB without staple line buttressing. After this initial experience, BPS reinforcement of the gastrojejunostomy was conducted in 81 consecutive patients. BPS reinforcement was not used for the final 69 consecutive patients in this 500 patient series. Circular staple line failures (intraoperative immediate and complete failure of the anastomosis) and leaks were evaluated retrospectively.Results: Three leaks (and no intraoperative staple line failures) occurred in 419 patients without BPS buttressing, all in the first 100 cases of our experience, and 3 leaks and an anastomotic staple line failure occurred in the 81 patients with BPS buttressing (.7% versus 4.9%, P = .02). The body mass index and other potential leak risk factors did not differ between the 2 groups.Conclusion: In our experience, buttressing of the circular staple line with BPS during LRYGB was associated with an increased staple line adverse event rate. BPS buttressing of the gastrointestinal circular staple lines should be used with caution.

Experimental in vivo canine model for gastric prolapse of laparoscopic adjustable gastric band system

2009-09-11

Abstract: Background: The most prevalent long-term complications in patients undergoing laparoscopic adjustable gastric band (LAGB) surgery are symmetric pouch dilation and gastric prolapse (slippage). However, no published data or a reliable model are available to evaluate the actual mechanism of band slippage or how to prevent it. The objective of the present study was to construct an animal model of anterior gastric band prolapse and to use this model to evaluate the effectiveness of various arrangements of gastrogastric sutures and gastric wraps in preventing prolapse.Methods: The esophagus of male mongrel dogs was accessed through the left chest, and a pressure transducer and an insufflation catheter were introduced. An AP-S Lap-Band (Allergan, Irvine, CA) filled to 10 cm3 was placed using the pars flaccida technique. A standardized cut of meat was placed into the esophagus to simulate food impaction at a tight LAGB. After the placement of multiple different gastrogastric suture configurations, air was insufflated into the gastric pouch by way of the esophagus.Results: Prolapse, identical to that seen in clinical practice, was reliably reproduced in this model by increased esophageal pressure acting on a LAGB outlet obstruction. In addition, prolapse was reproduced with all gastrogastric configurations that did not secure the anterior gastric wall to within 1.5 cm of the lesser curve.Conclusion: The results of the present study support the theory that prolapse is caused by esophageal peristalsis against an occlusion at the level of the LAGB. In this canine model, gastrogastric sutures encompassing the anterior gastric wall were integral to preventing prolapse.

Objective quantification of physical activity in bariatric surgery candidates and normal-weight controls

2009-09-11

Abstract: Background: Physical activity (PA) is an important component of weight loss programs and should be encouraged for severely obese patients undergoing bariatric surgery. However, few studies have determined the amount and intensity of activities undertaken preoperatively by bariatric surgery patients using objective measures.Methods: Using RT3 tri-axial accelerometers, the present study compared 38 bariatric surgery candidates and 20 normal weight controls on activity counts/hr; the number of minutes daily spent in moderate-to-vigorous intensity PA (MVPA) and vigorous intensity PA; and the level of compliance with national recommendations to accumulate 150 min/wk of MVPA in bouts of ≥10 minutes.Results: Surgery candidates, compared with controls, recorded significantly (P <.01) fewer activity counts/hr (13,799 ± 3758 counts/hr versus 19,462 ± 4259 counts/hr) and spent fewer minutes per day engaged in MVPA (26.4 ± 23.0 min/d versus 52.4 ± 24.7 min/d) and vigorous PA (1.2 ± 3.4 min/d vs 11.8 ± 9.0 min/d). More than two thirds (68%) of the surgery candidates versus 13% of the normal weight controls did not accumulate any MVPA in bouts of ≥10 minutes and only 4.5% of obese patients met the weekly MVPA recommendation versus 40% of the controls.Conclusion: The results of our study have shown that bariatric surgery candidates have low PA levels and rarely engage in PA bouts of sufficient duration and intensity to maintain and improve health. Additional research is needed to determine how best to increase PA in bariatric surgery candidates.

Comprehensive interview assessment of eating behavior 18–35 months after gastric bypass surgery for morbid obesity

2009-09-07

Abstract: Background: Weight loss surgery induces a marked change in eating behavior. However, not much work has been done characterizing the eating behavior after weight loss surgery. We conducted a detailed analysis of patients' eating behavior 18–35 months after Roux-en-Y gastric bypass surgery, determined whether preoperative eating disorders might be associated with non-normative postoperative eating, and examined the association of such eating behaviors with weight loss and psychopathology.Methods: A sample of 59 patients who had undergone Roux-en-Y gastric bypass was interviewed in person after surgery about a range of eating behaviors, including binge eating, chewing and spitting out food, picking at and nibbling food, and nocturnal eating and compensatory behaviors such as vomiting and laxative and diuretic misuse. An established semistructured interview was used. The prevalence of preoperative eating disorders was assessed retrospectively. The eating-related and general psychopathology and quality of life were assessed using self-report questionnaires before and after surgery.Results: Subjective bulimic episodes were reported by 25% and vomiting for weight and shape reasons by 12% of the participants, on average, 2 years after surgery. Subjective bulimic episodes were significantly associated with a preoperative binge eating disorder, with more eating-related and general psychopathology after surgery, and with less weight loss.Conclusion: A substantial subgroup of patients with a preoperative eating disorder will develop binge eating after surgery that might be associated with less weight loss. A subsample will start vomiting for weight and shape reasons after bariatric surgery. Clinicians must probe carefully for these behaviors postoperatively to identify patients in need of treatment of pathological eating behaviors.

Comment on: Comprehensive interview assessment of eating behavior 18–35 months after gastric bypass surgery for morbid obesity

Stephanie Sogg — 2009-09-22

In this issue, de Zwaan et al. report on a study of postoperative eating behaviors and their relationships to both preoperative pathologic eating behaviors and postoperative weight loss outcomes. This study is important, because there is a dearth of empirical data concerning the nature, prevalence, predictors, and effect of maladaptive eating behaviors after Roux-en-Y gastric bypass (RYGB). Their use of a validated, widely accepted, standardized measure is laudable and lends credibility to the results. The authors note that one goal for the study was to determine the types of eating behaviors that are normative or problematic after RYGB, and their findings have contributed significantly to our knowledge.

Laparoscopic repair of internal hernia during pregnancy after Roux-en-Y gastric bypass

2009-06-22

Laparoscopic Roux-en-Y gastric bypass as a treatment of severe obesity has increased dramatically in the past decade, and most of the patients have been women . The health risks experienced by obese women during pregnancy can be reduced by the weight loss induced by bariatric surgery , but these patients are at risk of bariatric surgical complications during their pregnancies. Women who have undergone Roux-en-Y gastric bypass for morbid obesity are at risk of internal hernias, intussusception, and small bowel obstruction during pregnancy, which can lead to maternal and/or fetal death . We report the cases of 4 patients with a history of gastric bypass who presented with internal hernias during their pregnancy.

Laparoscopic adjustable gastric banding after previous Roux-en-Y gastric bypass

Robert Owens Carpenter, David Brandon Williams, William Owen Richards — 2009-06-22

Weight regain and inadequate weight loss after gastric bypass remain significant concerns, with potential effects on multiple quality measures. Poor restriction of oral intake owing to dilation of the small gastric pouch or the gastrojejunostomy is a potential cause of recidivism. Operative revision of the pouch or anastomosis can be technically difficult, carrying significant perioperative risk. Placement of a laparoscopic adjustable gastric band around the gastric pouch is an alternative for intervention in this patient population.

Laparoscopic revision of biliopancreatic diversion with duodenal switch and management of postoperative complications

Winnie Tong, Jayleen Grams, Daniel Herron — 2009-07-06

Biliopancreatic diversion with duodenal switch (BPD-DS) is a bariatric operation with restrictive and malabsorptive effects. It includes sleeve gastrectomy with division of the first portion of the duodenum and reconnection to the distal 250 cm of ileum. The bypassed duodenum, jejunum, and proximal ileum (biliopancreatic limb) are reconnected to create a Y-shaped anatomy with a common channel of 50–150 cm.

Chondrodysplasia punctata associated with malabsorption from bariatric procedures

2009-05-25

Bariatric surgery numbers continue to increase, and bariatric procedures are being performed in patients at younger ages, including adolescents and women during the years of fertility . Because of this, clinicians must remain vigilant regarding the consequences of weight loss surgery and the subsequent nutritional deficiencies on the growing embryo and fetus. Most bariatric centers recommend waiting 18–24 months after surgery before patients consider pregnancy postoperatively. Vitamin K and other fat soluble vitamins can become deficient after bariatric surgery. Maternal vitamin K deficiency or exposure to the teratogen warfarin, which inhibits the vitamin K cycle, have been reported to cause a phenotype of stippled epiphyses termed “chondrodysplasia punctata” (CDP) . We present 2 similar cases of extensively stippled epiphyses, likely secondary to maternal vitamin K deficiency caused by maternal malabsorption after weight loss surgery.

Life-threatening postoperative hypoventilation after bariatric surgery

Scott F. Gallagher, Krista L. Haines, Lynn Osterlund, Michel Murr, John B. Downs — 2009-04-27

Anesthetic agents and narcotics, often administered to surgical patients, are potent respiratory depressants. Unrecognized respiratory depression can lead to profound hypoventilation, hypoxemia, brain damage, and death. It is assumed that careful monitoring and clinical vigilance will allow for the detection of significant postoperative hypoventilation and lead to appropriate intervention before damage occurs. The present report illustrates the fallacy of the existing dogma with respect to monitoring and prophylactic administration of supplemental oxygen. This clinical report brings attention to the necessity of properly assessing ventilation in patients at risk of postoperative hypoventilation, particularly obese and bariatric surgical patients.

Thiamine deficiency in a gastric bypass patient leading to acute neurologic compromise after plastic surgery

Jeffrey L. Sebastian, Joseph Michaels V, Lawton W. Tang, J. Peter Rubin — 2009-05-18

With the exponential growth of bariatric surgery, increasing numbers of patients are presenting to plastic surgeons for body contouring procedures. A thorough history and physical examination and nutritional evaluation with specific detail regarding the timing of bariatric surgery in relation to the plastic surgery consultation, the type of bariatric procedure, constitutional symptoms, and protein intake is very important. These patients are at risk for macro- and micronutrient deficiencies, which contribute significantly to the development of long-term complications after bariatric surgery. To underscore the importance of a complete history and physical examination in these patients, we report the case of severe thiamine deficiency that initially posed a diagnostic quandary.

Acute mesenteric vein thrombosis after laparoscopic gastric sleeve surgery for morbid obesity

Parminder Singh, Mala Sharma, Kaushang Gandhi, John Nelson, Ashoutosh Kaul — 2009-08-20

Mesenteric vein thrombosis has not been reported as complication of laparoscopic gastric sleeve surgery for morbidly obese patients. A 50-year-old morbidly obese man of Italian descent with a medical history of high cholesterol, chronic back pain, hypothyroidism, idiopathic deep venous thrombosis, who had undergone laparoscopic gastric sleeve surgery 3 weeks previously, was admitted to the hospital with ongoing abdominal pain postoperatively. The pain had progressively worsened during the week before admission, but with a significant increase in the 24 hours before admission. The pain was described as severe (10 of 10 on a pain scale), sharp, stabbing, epigastric in location, and radiating to the back and flanks. The pain was associated with nausea, vomiting, and anorexia. The patient denied any fevers, chills, or rigors, bright red blood per rectum, and hematemesis. The patient said he was passing flatus but no stools. The patient had had idiopathic deep venous thrombosis before surgery and was taking warfarin. The hypercoagulable workup, including factor V Leiden, prothrombin gene 20210A, lupus anticoagulant, and antinuclear antibody screening findings were negative. The patient was switched to a therapeutic dose of enoxaparin before surgery, and an inferior vena cava filter was placed. The patient was discharged with instructions to take enoxaparin 100 mg twice daily and was also taking fenofibrate tablets, zolpidem, and methadone. Because of insurance-related issues, the patient was switched to 40 mg enoxaparin for 1 week before this admission. On physical examination, the patient had tachycardia at 142 beats/min, afebrile, and normotensive. His abdomen was tender at the epigastrium with no rebound or guarding. The bowel sounds were normal. Hyperpigmentation from venous stasis was noted on the bilateral lower extremities, but no tenderness was present in the calves.

Mesenteric venous thrombosis after laparoscopic sleeve gastrectomy

Drake E. Bellanger, Andrew G. Hargroder, Frank L. Greenway — 2009-08-28

Mesenteric venous thrombosis (MVT) was first described as a distinct cause of mesenteric ischemia by Warren and Eberhard in 1935 . MVT accounts for 5–15% of all cases of mesenteric ischemia . Laparoscopic vertical sleeve gastrectomy (LSG) has become an alternative bariatric procedure in select patients . Our practice has performed >800 LSG procedures for weight loss, with 3 cases of MVT involving the superior mesenteric vein. Cases of MVT have been described after Roux-en-Y gastric bypass . However, we have seen no reports of MVT after LSG. We present 3 cases of MVT after LSG, with an argument for nonoperative therapy and anticoagulation as the first-line of treatment for this condition.

Erratum

2009-12-07

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient.

“Yes, it's amazing…”

2010-01-04