Surgery for Obesity and Related Diseases

Editorial Board

2012-05-01

Updated position statement on sleeve gastrectomy as a bariatric procedure

ASMBS Clinical Issues Committee — 2012-02-13

The American Society for Metabolic and Bariatric Surgery (ASMBS) has previously published 2 position statements on the use of sleeve gastrectomy (SG) as a bariatric procedure . These position statements were developed in response to inquiries made to the ASMBS by patients, physicians, hospitals, health insurance payers, the media, and others regarding new procedures or issues within our specialty that require close evaluation and evidence-based scrutiny. In the evolving field of bariatric surgery, it is periodically necessary to provide updated position statements based on a growing or changing body of evidence. The Clinical Issues Committee and Executive Council have determined that since the 2009 position statement on SG was issued, substantial changes have been published regarding SG and that the number and quality of the publications evaluating SG warrant publication of an updated statement. Specifically, multiple studies evaluating co-morbidity improvement after SG, comparative studies with other accepted bariatric procedures, and long-term outcome data have emerged since the 2009 position statement. Recommendations are made based on 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.

Peri-operative management of obstructive sleep apnea

ASMBS Clinical Issues Committee — 2012-03-21

Obstructive sleep apnea (OSA) is prevalent in the bariatric surgical population. The condition has a negative effect on long-term health. OSA may require treatment with ventilatory aids such as continuous positive airway pressure (CPAP) machines. Surgical treatment of OSA is also possible. Bariatric operations, and the weight loss they produce, result in improvements in various measurable parameters of OSA. This guideline is a summary of recommendations for the peri-operative management of OSA based on currently available 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. The statement may be revised in the future as additional evidence becomes available.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: a case-control study and 3 years of follow-up

2011-09-22

Abstract: Background: Laparoscopic sleeve gastrectomy (LSG) has become a popular surgical procedure among bariatric surgeons. Few studies have compared the efficacy of the procedure to laparoscopic Roux-en-Y gastric bypass (LRYGB). We performed a case-control study to assess the surgical results, weight progression, and remission of co-morbid conditions. Methods: From January 2006 to September 2009, we selected 811 patients undergoing LSG as a primary procedure. These patients were matched by age, body mass index, and gender to 786 patients undergoing LRYGB. The complication rate, mortality, and percentage of excess weight loss after 1, 2, and 3 years were analyzed. Results: The mean age for the LRYGB and LSG groups was 37.0 ± 10.3 and 36.4 ± 11.7 years, respectively (P = .120). Most of the patients were women (LRYGB 76.6% versus LSG 76.2%; P = .855). The preoperative body mass index before surgery was similar in both groups (LRYGB 38.0 ± 3.2 versus LSG 37.9 ± 4.6 kg/m2; P = .617). The mean operative time was longer for LRYGB (106.2 ± 33.2 versus 76.6 ± 28.0 min; P <.001), and the hospital stay was longer for LRYGB (3.4 ± 4.4 versus 2.8 ± .8 for LSG; P <.001). The early complication rate was 7.1% for LRYGB and 2.9% for LSG (P <.001), and the suture leak rate was .7% for LRYGB and .5% for LSG (P = NS). The percentage of excess weight loss for LRYGB versus LSG at 1, 2, and 3 years was 97.2% ± 24.3% versus 86.4% ± 26.4% (P <.001), 94.6% ± 30.2% versus 84.1% ± 28.3% (P <.001), and 93.1% ± 25.0% versus 86.8% ± 27.1% (P = .082), respectively. The total cholesterol level at 1 year for LRYGB versus LSG was 169.0 ± 32.9 versus 193.6 ± 38.7 mg/dL, respectively (P <.001), and the rate of diabetes remission was similar in both groups (LRYGB 86.6% versus LSG 90.9%). Conclusion: LSG has become an acceptable primary bariatric procedure for obesity, with results comparable to LRYGB in this population.

Comparative early outcomes of three laparoscopic bariatric procedures: sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch

Philippe Topart, Guillaume Becouarn, Patrick Ritz — 2011-06-03

Abstract: Background: Since the introduction of the isolated sleeve gastrectomy in 1997, this procedure has gained immense popularity in the hopes of reducing the operative risks with a less complex operation. We reviewed our recent 2-year experience with bariatric surgery to compare the early outcomes of the 3 complex procedures routinely performed by our private practice at a single institution: sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch (BPD-DS). Methods: The 30-day morbidity and 90-day mortality rates were retrospectively reviewed among a total of 507 primary bariatric procedures. The early postoperative outcomes of 360 RYGB, 88 SG, and 59 BPD-DS procedures performed during this period were compared. Results: The patients weighed more in the BPD-DS and SG groups. The SG patients were significantly older than the RYGB and BPD-DS patients. Co-morbidities were significantly more frequent in the SG and BPD-DS patients. One patient died after RYGB but none did so after BPD-DS or SG. The global complication rate was significantly increased after BPD-DS (P = .0017) compared with RYGB; however, no difference was found between RYGB and SG, although bleeding was likely to appear more frequent, not only after BPD-DS, but also after SG compared with RYGB. Conclusion: Although no fatal outcomes occurred after SG, this procedure did not demonstrate a reduced risk of postoperative complications compared with RYGB with a significantly greater rate of bleeding. RYGB appears to be a relatively safe bariatric procedure, although the groups were not comparable in terms of the preoperative body mass index or co-morbidities, the exact role of which on postoperative morbidity remains controversial. Although the increased risk of RYGB to BPD-DS was confirmed, SG failed to live up to its “more benign” reputation.

Comparison of fat-free mass in super obesity (BMI ≥50 kg/m2) and morbid obesity (BMI <50 kg/m2) in response to different weight loss surgeries

2011-10-24

Abstract: Background: Differences in excess weight loss, body mass index (BMI) change, and body composition have been related to different types of bariatric procedures. Our objective was to explore these alterations related to body mass in superobese (SO) and morbidly obese (MO) patients in a university hospital setting. Methods: Patients provided written informed consent and had their body composition measured before and after surgery using bioimpedance (Tanita 310). The t test was used to compare MO and SO. Pearson's correlations were used to examine the BMI, excessive BMI loss, percentage of body fat (BF) change, and fat-free mass. Results: A total of 133 MO patients had a BMI of 43.3 kg/m2 and 88 SO patients had a BMI of 59.4 kg/m2. The percentage of BF was 46.7% and 51.9% (P < .0001). The differences in the follow-up period after surgery (21.5 and 20.6 months; P = .62) and patient age (43.4 and 42.5 yr) were not significant, but the gender distribution was significant (P = .003). After surgery, the MO patients had a BMI of 30.9 ± 5.7 kg/m2 and the SO patients had a BMI of 37.3 ± 9.0 kg/m2. The percentage of BF was not different between the 2 groups (MO, 33.1% ± 9.6% and SO, 35.0% ± 12.4%; P = .21). Gender differences in the percentage of BF were present before surgery; however, after surgery, these were absent for the men in the 2 groups (24.8% and 26.6%; P = .51). The change in the BMI and the change in the BF had a stronger correlation for the MO patients (r = .83 versus r = .53) than for the SO patients. The fat-free mass loss correlated with the change in BMI without regard to procedure. The percentage of excessive BMI loss was 65.1% for the MO and 63.4% for the SO patients (P = .64). Conclusions: The SO patients achieved excessive BMI loss similar to that of the MO patients, with more SO men choosing biliopancreatic diversion/duodenal switch. At a BMI of 37.3 kg/m2, the SO patients had a percentage of BF that was not different from that of the MO patients at 30.9 kg/m2. The fat-free mass losses correlated with the change in BMI.

Improvement in health-related quality of life in first year after laparoscopic adjustable gastric banding

2012-01-27

Abstract: Background: We analyzed the health-related quality of life (HRQOL) and its determinants in the first year after laparoscopic adjustable gastric banding (LAGB). The setting was 10 Italian public and private bariatric surgery centers. Methods: Data collected in an ongoing, prospective, 3-year multicenter Italian study on the changes in HRQOL after LAGB were used. HRQOL was investigated using the Medical Outcomes Study Short-Form 36 questionnaire. Hunger, satiety, and the self-perceived effects of LAGB were recorded. Results: A total of 334 patients were enrolled. The follow-up rate was 92.2%. The percentage of excess weight loss was 39.6% ± 25.8%, with very few side effects or complications. Hunger in the morning (0–10 scale) was 4.5 ± 2.7 before surgery and 3.8 ± 2.4 after 1 year (P <.001). Satiety after a meal (0–10 scale) was 7.1 ± 2.7 before surgery and 8.2 ± 1.9 at 1 year (P <.001). The self-perceived effect of LAGB on caloric intake (0–10 scale) was 8.4 ± 1.9 after 1 year. The scores for the 8 Medical Outcomes Study Short-Form 36 subscales were significantly improved after surgery. The physical component summary score was 52.6 ± 11.9 at baseline and 79.1 ± 15.6 after 1 year (P <.001). The corresponding mental component summary scores were 52.2 ± 12.3 and 76.5 ± 17.2 (P <.001). Greater physical component summary improvement was independently associated with a low initial physical component summary (P <.001), high satiety (P = .002), a high percentage of excess weight loss (P = .013), and a high self-perceived effect of the LAGB (P = .026). Greater mental component summary improvement was associated with a low initial mental component summary (P <.001), high satiety (P <.001), a low frequency of heartburn (P = .004), and a high percentage of excess weight loss (P = .012). Conclusions: Significant improvements in HRQOL were observed in the first year after LAGB. A poor baseline HRQOL, a high efficacy of the banding in eating control, and better weight loss might influence HRQOL changes.

Short-term medication cost savings for treating hypertension and diabetes after gastric bypass

Saber Ghiassi, John Morton, Nina Bellatorre, Dan Eisenberg — 2011-05-27

Background: The cost of medication for the treatment of hypertension and diabetes in the morbidly obese is a significant economic healthcare burden. In the present study, we assessed the effect of gastric bypass surgery on the average annual costs for hypertension and diabetes medication. Methods: A prospective database of gastric bypass patients at the Palo Alto Veterans Affairs Health Care System was reviewed. The preoperative and postoperative medication requirements to treat hypertension and diabetes were identified before surgery and at 1 year postoperatively. Comparisons were made between the annual costs of the antihypertensive and diabetic medications before and after bariatric surgery using the Student paired t test. Results: Of 106 patients who had undergone gastric bypass, 90 (85%) had either hypertension or diabetes. Of these 90 patients, 88 (98%) had hypertension and 60 (67%) had diabetes before surgery. Complete remission of hypertension occurred in 44% and remission of diabetes in 80% at 1 year after surgery. The annual cost of medications to treat hypertension was reduced by 65% at 1 year after surgery ($63.52 compared with $20.50, P < .0001). To treat diabetes, the annual medication cost was reduced by 88% at 1 year after gastric bypass surgery ($532.06 compared with $64.58, P < .0001). In the subset of patients with persistent hypertension or diabetes after surgery, the annual cost reduction for antihypertensive medications was 58% ($87.14 versus $36.82, P < .002). The annual cost reduction for diabetic medications was 69% ($1036.60 versus $322.90, P < .02). Conclusion: Gastric bypass surgery resulted in a significant reduction in the cost of medications to treat hypertension and diabetes in the morbidly obese at 1 year after surgery. These cost savings were also significant in the subset of patients who had persistent hypertension and diabetes after surgery.

Comparative study of laparoscopic sleeve gastrectomy with and without partial enterectomy and omentectomy

Jia Wu, Huan Ye, Yuedong Wang, Yangwen Zhu, Zhijie Xie, Xiaoli Zhan — 2011-07-15

Abstract: Background: Laparoscopic sleeve gastrectomy (LSG) is a novel bariatric surgical procedure that constitutes the first-stage procedure of laparoscopic Roux-en-Y gastric bypass in high-risk patients, the long-term results of which are unknown. Our objective was to establish whether partial enterectomy and omentectomy are necessary in addition to LSG to achieve weight loss in obese patients. The setting was a case series in a provincial hospital. Methods: A total of 40 obese patients (29 women and 11 men) were separated into 2 equal groups according to patient choice. Group 1 underwent LSG alone, and group 2 underwent LSG plus partial enterectomy and omentectomy. The partial enterectomy left the first 100 cm of the jejunum and the last 200 cm of the ileum. The data were collected during the follow-up examinations, performed at 1, 3, 6, and 12 months postoperatively. Results: The body mass index loss (BMIL) was 3.9 ± .5 kg/m2 and 9.4 ± 1.3 kg/m2 at 1 and 12 months in group 1, respectively. The BMIL was 4.5 ± .9 kg/m2 and 10.4 ± 1.9 kg/m2 at 1 and 12 months in group 2, respectively. At 1 and 12 months postoperatively, the percentage of excess body weight loss was 32.2% ± 12.6% and 81.5% ± 20.4% in group 1 and 35.5% ± 10.5% and 83.8% ± 24.5% in group 2, respectively. Except for the BMIL at 1 month after surgery, no significant differences were found in the BMIL or percentage of excess body weight loss. Conclusion: LSG with and without partial enterectomy and omentectomy in our study was an effective method of bariatric surgery, but they did not differ in their effect on weight loss. However, the long-term effect of weight loss with LSG alone or combined with partial enterectomy and omentectomy needs additional study.

Comment on: Comparative study of laparoscopic sleeve gastrectomy with and without partial enterectomy and omentectomy

Alfons Pomp — 2011-09-19

Wu et al. have written an interesting study of Asian patients who underwent to 2 different procedures with a much different safety profile that, in the end, does not result in a different clinical outcome.

Stoma size critical to 12-month outcomes in endoscopic suturing for gastric bypass repair

Christopher C. Thompson, Garth R. Jacobsen, Gregory L. Schroder, Santiago Horgan — 2011-04-20

Abstract: Background: Roux-en-Y gastric bypass (RYGB) is the most frequently performed bariatric procedure. However, weight regain after RYGB is common and often associated with pouch and stoma dilation. Historically, revision surgery has a greater risk of morbidity and mortality than the primary procedure. Endoscopic repair appears to be a safer option; however, current knowledge is limited regarding the longer term outcomes. Our objective was to prospectively collect the 12-month post-RYGB outcomes data after repair of dilated gastric tissue with an incisionless tissue approximation system in an open-label, single-group study at 9 U.S. sites. Methods: Adults ≥2 years after RYGB, with weight regain and pouch and/or stoma dilation underwent tissue plication with an endolumenal anchoring system to tighten dilated gastric tissue. The outcomes were captured, with statistical modeling used to identify the predictors of success. Results: Of the 116 subjects, 112 (97%) had anchors successfully placed (mean 5.9 anchors/subject). The mean stoma diameter and pouch length after the procedure was 11.5 mm (50% reduction) and 3.3 cm (44% reduction), respectively. At 12 months after repair (n = 73), the mean weight loss and percentage of excess weight loss was 5.9 ± 1.1 kg and 14.5% ± 3.1%, respectively. Anchor presence was confirmed endoscopically in 61 (92%) of 66 patients at 1 year. Those with a dilated stoma (>12 mm) who had a postrepair diameter of <10 mm (n = 22, 30% of 66) had more than double the excess weight loss compared with the rest of the cohort (24% versus 10%, P = .03). No serious adverse events occurred. Conclusion: The 12-month outcomes have demonstrated the safety and durability of this method of gastric bypass repair. Aggressive reduction of stoma dilation was associated with superior weight loss.

Clinical outcomes of the REALIZE adjustable gastric band-C at one year in a U.S. population

2011-05-25

Abstract: Background: In 2008, the REALIZE Band (RB) adopted a precurved design (RB-C). The present study is the first multi-institutional report of RB-C outcomes. Our objective was to analyze the 1-year weight loss and safety data from adult RB-C patients treated at multiple U.S. centers (7 typical U.S. bariatric practices, including academic, nonacademic, public, and private practice). Methods: Patients implanted with the RB-C (preoperative body mass index ≥40 kg/m2 or >35 kg/m2 with co-morbidity) were recruited. The exclusion criteria included the RB-C label contraindications for use. The outcomes parameters were the percentage of excess weight loss (%EWL), change in body mass index, number and volume of band adjustments, and incidence of complications. Results: Of the 239 patients enrolled in the 2-year study, 158 had 1-year data available for analysis in November 2010. The mean %EWL was 39.2% ± 20.5% (range −7.7 to −116.8, P < .0001). The body mass index decreased from 44.4 ± 5.5 kg/m2 to 36.4 ± 5.8 kg/m2 (P < .0001). The variability in the %EWL was significant among the study centers (P < .0001). The average band fill volume at 1 year was 8.0 ± 2.0 mL (range .0–11.1). The total fill volume was >11 mL in 1 patient. No band erosions/migrations, explants, or deaths occurred. Conclusion: RB-C appears to be as safe and effective as the first-generation RB. The near 40% EWL at 1 year was consistent with other high-quality publications of the RB. Good weight loss results are achievable, despite the varying postoperative management practices. The low morbidity and the absence of mortality at 12 months reflect positively on the RB-C characteristics. Our findings suggest that the learning curve, related to the postoperative management of the RB-C, might vary by practice and that a greater frequency and smaller band fills might result in better weight loss at 12 months.

Transoral gastric volume reduction as intervention for weight management: 12-month follow-up of TRIM trial

Stacy A. Brethauer, Bipan Chand, Philip R. Schauer, Christopher C. Thompson — 2011-11-10

Abstract: Background: The aim of the present pilot study was to evaluate the safety and weight loss efficacy of endoscopic transoral gastric volume reduction using an endoscopic suturing system. Methods: Patients with a body mass index (BMI) of 30–45 kg/m2 were enrolled in the present institutional review board-approved study. Anterior to posterior gastric plications were placed in the gastric fundus and body using the suturing device. The endpoints were procedure time, adverse events, weight loss, and endoscopic findings at 1, 6, and 12 months after the procedure. The nominal P values are presented. Results: A total of 18 patients underwent the procedure (9 at each site). The mean age and BMI was 40 years and 38 kg/m2, respectively. The average number of plications placed per patient was 6, and the mean procedure time was 2.1 hours (range 1.5–2.8). At 12 months of follow-up (n = 14), decreases in the mean weight (−11.0 ± 10.0 kg, P = .0006), mean BMI (−4.0 ± 3.5 kg/m2, P = .0006), and mean waist circumference (−12.6 ± 9.5 cm, P = .0004) were observed. The mean excess weight loss at 12 months was 27.7% ± 21.9%. The proportion of patients with an EWL of ≥20% or ≥30% was 57% and 50%, respectively. The mean systolic and diastolic blood pressure decreased by 15.2 mm Hg (P = .0012) and 9.7 mm Hg (P = .0051), respectively. No device- or procedure-related serious adverse events. Endoscopy at 12 months of follow-up showed partial or complete release of plications in 13 patients. Conclusion: Transoral gastric volume reduction procedure using the RESTORe Suturing System device proved to be safe and well tolerated. Procedural technical success was achieved for all subjects. Modest decreases in weight, BMI, and waist circumference were observed, as was a decline in the frequency of hypertension. Despite some overall positive clinical findings, the plications were not durable, and the effects of the procedure varied widely among the study participants. Additional research is needed to provide a more reproducible and durable effect.

Comment on: Transoral gastric volume reduction as an intervention for weight management: 12 month follow-up of the TRIM trial

Lee L. Swanstrom — 2011-12-02

The authors present an early prospective trial of an endoscopic suturing gastroplasty technique for the treatment of morbid obesity . Eighteen patients underwent the procedure at 2 institutions. Using an updated version of the EndoCynch (Bard Medical, Murray Hill, NJ) to approximate the anterior and posterior walls of the stomach, an average of 6 sutures were placed, all with the patient under general anesthesia and with an average of 2 hours operating time. Unlike the precedent report of this approach by Fogel et al. , which reported an astonishing 85% ± 24% excess weight loss at 12 months in 64 patients in a similar patient population, the authors found that only 50% of their patients had any significant weight loss (>30% excess weight loss). Also, overall, minimal improvement was found in the co-morbidities, except for blood pressure. This is undoubtedly because by 1 month, only 2 patients still had all the sutures intact and by 12 months almost all the sutures had pulled free. The procedure was, however, safe and well tolerated.

Risk of complications after bariatric surgery among individuals with and without type 2 diabetes mellitus

2011-06-15

Abstract: Background: Type 2 diabetes mellitus is highly prevalent in obese individuals. Bariatric surgery, promoted for reducing the medical problems of morbid obesity, has been increasingly recognized for its particular efficacy in treating diabetes. However, before bariatric surgery can be recommended for the treatment of diabetes, its safety in the diabetic population must be known. We assessed the odds of complications after bariatric surgery in patients with and without diabetes. Methods: This was a retrospective cohort study. Using an administrative database from 7 Blue Cross/Blue Shield plans, we identified 22,288 subjects who had undergone bariatric surgery from 2002 to 2008. From this cohort, we selected 6754 pairs of surgical patients (1 with and 1 without diabetes) matched by age, gender, health plan, and year of surgery. With conditional logistic regression analysis, we determined the relative odds of postoperative complications for ≤12 months after surgery in the 2 groups. Results: The mean age of the surgical patients was 46 years, and 79% were women. Postoperative complications were rare and comparable in those with and without diabetes. The most common complications were nausea, vomiting, and abdominal pain (8.8%), the need for a gastric revision procedure (5.0%), and upper endoscopy (2.3%). Select cardiac, infectious, and renal complications occurred more frequently in the diabetic group. The incidence of cardiac complications was greater in the 2–3-month and 4–6-month postoperative periods (odds ratio [OR] 1.7, P < .001), the incidence of infectious complications was greater in the 0–1-month (OR 1.3, P < .02) and 4–6-month (OR 1.8, P < .001) periods, and the incidence of renal complications was greater in the 2–3-month postoperative period (OR 4.6, P = .01). Conclusions: Our findings support the safety of bariatric surgery in obese individuals with diabetes, although management strategies to avert postoperative cardiac, infectious, and renal complications in this population might be warranted.

Dietary assessment of adolescents undergoing laparoscopic Roux-en-Y gastric bypass surgery: macro- and micronutrient, fiber, and supplement intake

2011-12-12

Background: Extremely obese adolescents are increasingly undergoing bariatric procedures, which restrict dietary intake. However, as yet, no data are available describing the change in caloric density or composition of the adolescent bariatric patient's diet pre- and postoperatively. Our objective was to assess the 1-year change in the dietary composition of adolescents undergoing bariatric surgery at a tertiary care children's hospital. Methods: A total of 27 subjects (67% female, 77% white, age 16.7 ± 1.4 yr, baseline body mass index 60.1 ± 14.1 kg/m2) were prospectively enrolled into an observational cohort study 1 month before undergoing laparoscopic Roux-en-Y gastric bypass from August 2005 to March 2008. The 3-day dietary intake was recorded at baseline (n = 24) and 2 weeks (n = 16), 3 months (n = 11), and 1 year (n = 9) postoperatively. The dietary record data were verified by structured interview and compared with the Dietary Reference Intake values for ages 14–18 years. Results: By 1 year after surgery, the mean caloric intake, adjusted for body mass index was 1015 ± 182 kcal/d, a 35% reduction from baseline. The proportion of fat, protein, and carbohydrate intake did not differ from baseline. However, the protein intake was lower than recommended postoperatively. The calcium and fiber intake was also persistently lower than recommended. Calcium and vitamin B12 supplementation increased the likelihood of meeting the daily minimal recommendations (P ≤ .02). Conclusion: At 1 year after Roux-en-Y gastric bypass, the adolescents' caloric intake remained restricted, with satisfactory macronutrient composition but a lower than desirable intake of calcium, fiber, and protein.

Comment on: Dietary assessment of adolescents undergoing laparoscopic Roux-en-Y gastric bypass surgery: macro- and micronutrient, fiber and supplement intake

Marc Michalsky — 2011-12-12

Recent data have indicated that 4% of children and adolescents have extreme obesity (body mass index [BMI] >99th percentile), more than those affected by childhood cancer, cystic fibrosis, human immunodeficiency virus, and diabetes combined . In addition, a mounting body of evidence has demonstrated that children with a BMI greater than the 99th percentile for age have a high probability of becoming correspondingly obese adults (BMI ≥30 kg/m2) and that the weight loss associated with behavioral and/or pharmacologic interventions (i.e., nonoperative weight loss) is modest at best . The combination of these observations, the increasing number of reports citing the existence of significant co-morbid disease burden in association with extreme childhood obesity , and a recent meta-analysis supporting the use of surgical weight reduction strategies in this emerging patient population has not surprisingly led to an increase in the number of adolescent bariatric procedures being performed within the United State . As the overall number of surgical procedures being performed in the adolescent population is increasing, so is the need to examine a number of critically related perioperative and long-term metabolic and behavioral risk factors. Although current data have demonstrated a reversal and/or resolution of a number of obesity-related co-morbid diseases, including type 2 diabetes, insulin resistance, hypertriglyceridemia, and obstructive sleep apnea, to name a few , information regarding the baseline dietary composition (including micro- and macronutrient intake) of extremely obese adolescents undergoing bariatric surgery and the longitudinal changes observed after surgical weight loss are presently lacking.

Superior weight loss and lower HbA1c 3 years after duodenal switch compared with Roux-en-Y gastric bypass—a randomized controlled trial

Jakob Hedberg, Magnus Sundbom — 2012-02-03

Background: Obesity is a rising threat to public health. The relative increase in the incidence of morbid obesity is most pronounced in the most severely obese. Roux-en-Y gastric bypass (RYGB) results in inferior weight loss in this group. Therefore, we have offered biliopancreatic diversion with duodenal switch (BPD/DS) as an alternative for this patient category. Our objective was to compare BPD/DS and RYGB in the surgical treatment of morbid obesity in patients with a body mass index (BMI) >48 kg/m2. The setting was a university hospital in Sweden. Methods: In a controlled trial (registration number ISRCTN10940791), 47 patients (25 men, BMI 54.5 ± 6.1 kg/m2) were randomized to RYGB (n = 23) or BPD/DS (n = 24). Biochemical data were collected preoperatively and 1 and 3 years postoperatively. A questionnaire addressing weight, general satisfaction, and gastrointestinal symptoms was distributed a median of 4 years postoperatively. Results: Both procedures were safe. The duration of surgery and postoperative morphine consumption were greater after BPD/DS than after RYGB (157 versus 117 min and 140 versus 93 mg, respectively). BPD/DS resulted in greater weight loss than RYGB (−23.2 ± 4.9 versus −16.2 ± 6.9 BMI units or 80% ± 15% versus 51% ± 23% excess BMI loss, P 48 kg/m2. Both operations yield high satisfaction rates. However, diarrhea tended to be more common after BPD/DS.

Comment on: Superior weight loss and lower HbA1c three years after duodenal switch compared to Roux-en-Y gastric bypass—a randomized controlled trial

Mitchell S. Roslin — 2012-02-23

A common conversation at bariatric meetings is that we will have the data and method to match the procedure and patient. Toward this goal, Hedberg and Sundbom compared open Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion/duodenal switch (BPD/DS) in a prospective randomized trial of patients with a body mass index (BMI) of 48 kg/m2. Because of an unwillingness to be subjected to randomization, they had to terminate the trial after 47 patients were enrolled. Even with this small number, they were able to show that the BPD/DS patients had a statistically significant increase in weight loss, albeit with a tendency to have more bowel movements and malodorous stool. Although designed to help clarify the complex issue of procedure selection, in my estimation, these results will just reinforce a bariatric surgeon's previous opinion of the 2 bariatric procedures. There is an old cliché, “Beauty is in the eye of the beholder.” It is my guess that readers whose preferential operation is RYGB will conclude that they already know more weight loss occurs with BPD/DS but that the quality of life issues caused by the more frequent and malodorous stool are not worth the cost. They will add that the finding that the glycosylated hemoglobin is lower after BPD/DS is meaningless, because what is the value of “more normal?” For the few who perform BPD/DS, these results will galvanize their spirit, and they will state that their procedure is a far superior operation for those with super morbid obesity and even those with morbid obesity. The results are better and more durable, and the risk of protein malnutrition is minimal with proper education and an adequate common channel. The greater improvement in glycosylated hemoglobin shows that BPD/DS is a better procedure for those with diabetes and metabolic syndrome and representative of the superior results for metabolic parameters.

Rapid changes in gait, musculoskeletal pain, and quality of life after bariatric surgery

2012-01-18

Abstract: Background: Joint pain is a common musculoskeletal complaint of morbidly obese patients that can result in gait abnormalities, perceived mobility limitations, and declining quality of life (QOL). It is not yet known whether weight loss 3 months after bariatric surgery can induce favorable changes in joint pain, gait, perceived mobility, and QOL. Our objectives were to examine whether participants who had undergone bariatric surgery (n = 25; laparoscopic Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding) demonstrate improvements in joint pain, gait (speed, stride/step length, width of base of support, toe angles, single/double support, swing and stance time, functional ambulatory profile), mobility, and QOL by 3 months compared with nonsurgical controls (n = 20). The setting was an orthopedics laboratory at a university hospital in the United States. Methods: The present study was a prospective, comparative study. Numeric pain scales (indicating the presence and severity of pain), mobility-related surveys, and the Medical Outcomes Study short-form 36-item questionnaire (SF-36) were completed, and gait and walking speed were assessed at baseline and at month 3. Results: The bariatric group lost an average of 21.6 ± 7.7 kg. Significant differences existed between the 2 groups at month 3 in step length, heel to heel base of support, and the percentage of time spent in single and double support during the gait cycle (all P <.05). The severity of low back pain and knee pain decreased by 54% and 34%, respectively, with no changes in the control group (P = .05). The walking speed increased by 15% in the bariatric group (108–123 cm/s; P <.05) but not in the control group. Compared with the control group, fewer bariatric patients perceived limitations with walking and stair climbing by month 3. The bariatric group had a 4.8-cm increase in step length, 2.6% increase in single support time during the gait cycle, and 2.5-cm reduction in the base of support (all P <.05). The SF-36 physical component scores increased 11.8 points in the bariatric group compared with the control group, which showed no improvement by month 3 (P <.0001). Conclusions: Improvements in some, but not all, gait parameters, walking speed, and QOL and of perceived functional limitations occur by 3 months after a bariatric procedure.

Comment on: Rapid changes in gait, musculoskeletal pain, and quality of life after bariatric surgery

Wendy C. King — 2012-01-16

Severe obesity is associated with significant joint pain , gait abnormalities , and physical limitations that negatively affect health-related quality of life (HRQOL) and are associated with less physical activity . Several studies have shown improvements in joint pain, physical function, and HRQOL after bariatric surgery. However, most studies have measured postoperative status ≥1 years after surgery. Determining whether early (i.e., 3 mo) changes occur, and to what degree, is important for better educating patients regarding realistic expectations, and for informing physical activity counseling and the need for physical therapy referral during the first postoperative year.

Alcohol and bariatric surgery: review and suggested recommendations for assessment and management

Leslie J. Heinberg, Kathleen Ashton, Janelle Coughlin — 2012-02-06

Abstract: Background: Established clinical guidelines identify current alcohol abuse and dependence as contraindications for weight loss surgery. However, guidance on how to best assess alcohol use in bariatric patients has not been elucidated. Furthermore, concerns with postoperative alcohol use/abuse and increased sensitivity warrant the development of recommendations on appropriate interventions for patients pursuing weight loss surgery. Our objective was to review the current data on bariatric surgery and substance abuse/addiction, with an emphasis on alcohol use, offer guidance on how to assess the risk of such problems, and provide preliminary recommendations on treating high-risk patients. Methods: The relevant published data on alcohol use, abuse, and dependence in pre- and postoperative bariatric patients was reviewed. Also, the putative mechanisms of increased alcohol sensitivity after weight loss surgery were examined. Results: Although current alcohol abuse/dependence is less than that in population-base rates, bariatric surgery candidates have a greater history of alcohol use disorders. Physiologic changes after surgery can also change vulnerability to problematic alcohol use, and many patients continue to consume alcohol after surgery. Assessment techniques and strategies to provide informed consent and education on alcohol were included from the Bariatric and Metabolic Institute at the Cleveland Clinic. Conclusion: Weight loss surgery candidates might have a greater lifetime risk of alcohol use disorders and greater sensitivity to the intoxicating effects of alcohol after surgery. Adequate screening, assessment, and preoperative preparation could help mitigate this risk. Future research should examine the efficacy of such risk management strategies.

“Inverted corner” for sleeve gastrectomy

Milton Owens, John Sczepaniak, Arash Mahdavi — 2012-01-18

Sleeve gastrectomy is an appealing weight loss operation. Patients lose approximately 60% of their excess weight in 1 year , and weight regain, which is a complication of all procedures, is amenable to a variety of different surgical approaches . Moreover, long-term complications, such as bowel obstruction, iron deficiency, and marginal ulcer after gastric bypass or erosion or slippage after adjustable gastric banding, seem unlikely or impossible. Leakage after sleeve gastrectomy occurs in approximately 2% of cases and is difficult to treat . Heartburn, affecting 25–40% of patients after surgery, is a lesser, but clearly troublesome, side effect of sleeve surgery . We have developed a modification to the usual surgical technique that we believe minimizes both leaks and heartburn.

Gastric band slippage at 30 weeks' gestation: diagnosis and laparoscopic management

Muhammad Tabrez Suffee, Christophe Poncelet, Christophe Barrat — 2012-01-16

Band slippage is not a rare complication after laparoscopic adjustable gastric banding (LAGB). The rates of reported band slippage range from <1% to >20%. Everyone should be aware of this life-threatening complication that can develop even years after the device's implantation. Multidisciplinary management for early diagnosis and surgical approach is necessary to reduce the morbidity and mortality.

Laparoscopic adjustable gastric banding over previous duodenal switch: weight results from short-term follow-up

Shankar R. Raman, Spencer Holover, Shawn Garber — 2011-07-21

Obesity is a major health concern for the Western hemisphere. Although medical and lifestyle interventions have not shown consistent and long-term results in the management of obesity, surgical approaches have yielded better results. Confidence in the surgical management of obesity has been tempered by the incidence of complications and weight regain in the long term. Weight regain after bariatric surgery remains one of the challenging problems for bariatric surgeons and for obese patients. Although Roux-en-Y gastric bypass is the most commonly performed procedure for morbid obesity in the United States, it is associated with weight regain in as much as 35–50% of patients at the 5–10-year mark . Surgical management of obesity can be classified as either restrictive or malabsorptive. The restrictive procedures aim to reduce the size of the stomach with the idea of achieving an earlier sensation of satiety. Some examples include laparoscopic adjustable gastric banding, vertical banded gastroplasty, and horizontal gastroplasty. The malabsorptive procedures (e.g., jejunoileal bypass) aim to bypass the long segment of the small intestine to decrease nutrient absorption. A combination of both approaches resulted from the lack of long-lasting success with either alone. The duodenal switch with biliopancreatic diversion (BPD/DS) offers a combination of both approaches. Although the incidence of inadequate weight loss after BPD/DS is low, a small subset of patients requires a revision bariatric procedure . The placement of adjustable gastric banding is probably the least invasive of the primary bariatric surgical procedures and has a reasonable outcome profile. Although the placement of gastric bands over gastric bypass has been reported in published data, no previous reports have been published of placement of gastric bands over a DS to the best of our knowledge.

Acute pancreatitis after Roux-en-Y gastric bypass surgery due to reflux into biliopancreatic limb

Silvio Däster, Yves Borbély, Ralph Peterli — 2011-02-28

Laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) is the most commonly performed bariatric surgical procedure . It has become a low-risk intervention, with low mortality and morbidity . Several different variations of LRYGB have been developed, each with specific advantages. However, all procedures share the typical anastomosis-related complications of bleeding, leak, or stenosis, as well as early intestinal obstruction . Perioperative acute pancreatitis is uncommon, although bile stones after bariatric procedures are known sequelae in the long term . We describe a rare case of acute pancreatitis shortly after RYGB due to reflux of the intestinal contents into the biliopancreatic limb.

Intraoperative fetal monitoring an invaluable tool in pregnant patients with internal hernia after gastric bypass and review of literature

Harsha V. Polavarapu, Ashwin Kurian, Gintaras Antanavicius, Victoria S. Myers — 2011-03-25

Internal hernia (IH) with its potential for closed loop obstruction and bowel ischemia is a possible sequela in the increasing number of women of child-bearing age who have undergone Roux-en-Y gastric bypass (RYGB).

Adding estrogens growth hormone and antibiotics

2010-12-30

Retraction: Shang E, Hasenberg T. Aerobic endurance training improves weight loss, body composition, and co-morbidities in patients after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2010;6:260–6

2012-04-27

The article, “Aerobic Endurance Training Improves Weight Loss, Body Composition, and Co-morbidities in Patients After Laparoscopic Roux-en-Y Gastric Bypass,” has been retracted at the request of the Editor-in-Chief.