Surgery for Obesity and Related Diseases

Editorial Board

2012-01-01

ASMBS pediatric committee best practice guidelines

Marc Michalsky, Kirk Reichard, Thomas Inge, Janey Pratt, Carine Lenders — 2011-09-26

The prevalence of obesity among children and adolescents is rapidly increasing and is associated with substantial co-morbid disease states . At present, a mounting body of evidence supports the use of modern surgical weight loss procedures for carefully selected, extremely obese adolescents . Scientific evidence demonstrating the high propensity of severely obese adolescents to become severely obese adults and the greater associated risk among adults with “juvenile-onset” obesity (i.e., obese adults who became obese during childhood; approximately 25%) combined with the evidence demonstrating improvement in obesity-related co-morbid diseases after weight loss induced by bariatric surgery support the concept of “early” intervention in carefully selected adolescents patients . Although current evidence is not sufficiently robust to allow a precise discrimination or recommendations among specific bariatric procedures, an increasing body of data demonstrating evidence of safety and efficacy exists for 2 of the more commonly performed bariatric procedures for this age group (i.e., Roux-en-Y gastric bypass [RYGB] and adjustable gastric band [AGB]) .

International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases

Raul J. Rosenthal, International Sleeve Gastrectomy Expert Panel — 2011-11-11

Abstract: Background: Laparoscopic sleeve gastrectomy (LSG) is an emerging surgical approach, but 1 that has seen a surge in popularity because of its perceived technical simplicity, feasibility, and good outcomes. An international expert panel was convened in Coral Gables, Florida on March 25 and 26, 2011, with the purpose of providing best practice guidelines through consensus regarding the performance of LSG. The panel comprised 24 centers and represented 11 countries, spanning all major regions of the world and all 6 populated continents, with a collective experience of >12,000 cases. It was thought prudent to hold an expert consensus meeting of some of the surgeons across the globe who have performed the largest volume of cases to discuss and provide consensus on the indications, contraindications, and procedural aspects of LSG. The panel undertook this consensus effort to help the surgical community improve the efficacy, lower the complication rates, and move toward adoption of standardized techniques and measures. The meeting took place at on-site meeting facilities, Biltmore Hotel, Coral Gables, Florida. Methods: Expert panelists were invited to participate according to their publications, knowledge and experience, and identification as surgeons who had performed >500 cases. The topics for consensus encompassed patient selection, contraindications, surgical technique, and the prevention and management of complications. The responses were calculated and defined as achieving consensus (≥70% agreement) or no consensus (<70% agreement). Results: Full consensus was obtained for the essential aspects of the indications and contraindications, surgical technique, management, and prevention of complications. Consensus was achieved for 69 key questions. Conclusion: The present consensus report represents the best practice guidelines for the performance of LSG, with recommendations in the 3 aforementioned areas. This report and its findings support a first effort toward the standardization of techniques and adoption of working recommendations formulated according to expert experience.

Type 2 diabetes in obese patients with body mass index of 30–35 kg/m2: sleeve gastrectomy versus medical treatment

2011-07-11

Abstract: Background: Type 2 diabetes mellitus (T2DM) and obesity are diseases of epidemic proportions. Long-term realistic weight loss by nonsurgical methods has a variable effect on glycemic control, and only a proportion of patients with T2DM have a worthwhile response. Laparoscopic sleeve gastrectomy (LSG) has been proposed as an advantageous bariatric procedure for patients with a lower body mass index (BMI). Our objective was to compare the effects of LSG and medical therapy on patients with T2DM and a BMI of <35 kg/m2. Methods: A total of 18 nonmorbidly obese patients with T2DM, diagnosed according to the American Diabetes Association guidelines, were consecutively enrolled. Of these patients, 9 underwent LSG (group A) and 9 underwent conventional medical therapy (group B). The 2 groups were matched for BMI, glycated hemoglobin (HbA1c) and C-peptide levels, pretrial therapy type, and number of patients with a T2DM duration of >10 years. Results: In group A, T2DM resolution was achieved in 8 (88.8%) of the 9 patients (T2DM duration 5.2 yr). Hypertension was controlled in all 8 of 9 patients. Dyslipidemia was corrected. In 1 patient, obstructive sleep apnea syndrome improved. In group B, all 9 patients continued to have T2DM and required hypertensive and hypolipemic therapies throughout the observation period. At baseline, 3 patients were affected by obstructive sleep apnea syndrome and remained affected 1 year later. Conclusion: The results of the present study have confirmed the efficacy of LSG in the treatment of nonmorbidly obese T2DM patients, with a remission rate of 88.8% without undesirable excessive weight loss. The results in this group of patients add to those obtained by us in patients with a BMI >35 kg/m2.

Outcomes of bariatric surgery in patients with body mass index <35 kg/m2

2011-08-29

Abstract: Background: Patients who are categorized with class I obesity have a body mass index (BMI) of 30–34.99 kg/m2. This population of patients has a predisposition to diabetes, hypertension, and dyslipidemia. The aim of the present study was to investigate the improvements of these co-morbidities in a class I obese population that had undergone a bariatric procedure. Methods: After internal review board approval and with adherence to the Health Insurance Portability and Accountability Act guidelines, a retrospective review was performed of a prospectively maintained database of 42 class I obese patients who underwent a bariatric procedure at our institution during a 10-year period, from February 2000 to May 2010. The fasting glucose level, glycosylated hemoglobin level, lipid profile, initial weight, and BMI were measured in the preoperative and postoperative periods. Results: Our patient population consisted of 30 women and 12 men, with a preoperative mean BMI of 33.9 kg/m2. Laparoscopic sleeve gastrectomy was performed in 24 patients (57%), laparoscopic Roux-en-Y gastric bypass in 8 (19%), and laparoscopic adjustable gastric banding in 10 (24%). Of these 42 patients, 25 (60%) had type 2 diabetes, 1 patient was glucose intolerant, 27 (64%) had arterial hypertension, 25 (60%) had dyslipidemia, 17 (40%) had sleep apnea, and 8 (19%) had osteoarthritis. The postoperative findings included a mean BMI of 26.5 kg/m2 and a mean weight loss of 41.4 lb. Of the 25 diabetic patients, 5 (20%) gained remission and 12 (48%) improvement of their diabetic status. The single patient with glucose intolerance showed improvement. Of the 27 patients with arterial hypertension, 9 (33%) showed remission and 13 (52%) improvement. Dyslipidemia resolved in 5 patients (20%) and improved in 13 (52%). Obstructive sleep apnea resolved in 10 (59%) and improvement was seen in 1 patient (6%). Finally, osteoarthritis resolved in 1 patient (12%) and improved in 5 (63%). Conclusion: Bariatric surgery can significantly improve or resolve co-morbid metabolic conditions in patients with class I obesity.

Quality of life after sleeve gastrectomy and adjustable gastric banding

2011-03-30

Abstract: Background: With the addition of laparoscopic vertical sleeve gastrectomy (SG) to the bariatric surgery procedural toolkit, patients desiring a restrictive bariatric procedure often choose between adjustable gastric banding (LAGB) and SG. One study compared quality of life after these 2 procedures and found no difference. The purpose of our study was to re-evaluate the postoperative quality of life in LAGB and SG patients at a military teaching hospital in the United States. Methods: A retrospective review of 108 consecutive laparoscopic restrictive bariatric procedures performed within 15 months at a Department of Defense hospital was conducted. Of these 108 patients, 69 had undergone laparoscopic vertical SG and 39 LAGB. A validated quality of life questionnaire (Bariatric Quality of Life) was conducted a mean of 9.3 ± 3.2 months (range 5–16) postoperatively. The weight loss and standard laboratory parameters were measured at 0, 1, 3, 6, and 12 months. Results: The quality of life assessment revealed significantly better scores after SG than after LAGB (66.5 versus 57.9, P = .0002). The excess weight loss and excess body mass index loss at 3, 6, and 12 months postoperatively were significantly greater in the laparoscopic SG group. The patients demonstrated a clear preference over time for SG once it was offered. Conclusion: Early postoperative quality of life was superior after SG than after LAGB. SG also resulted in superior early excess weight loss. In a practice not constrained by reimbursement, these findings were associated with increased patient choice of SG after it began to be offered.

Novel bariatric technology: laparoscopic adjustable gastric banded plication: technique and preliminary results

Chih-Kun Huang, Chi-Hsien Lo, Asim Shabbir, Chi-Ming Tai — 2011-03-25

Abstract: Background: The laparoscopic adjustable gastric band has been widely accepted as 1 of the safest bariatric procedures to treat morbid obesity. However, because of variations in the results and the complications that tend to arise from port adjustment, alternative procedures are needed. We have demonstrated, in a university hospital setting, the safety and feasibility of a novel technique, laparoscopic adjustable gastric banded plication, designed to improve the weight loss effect and decrease gastric band adjustment frequency. Methods: We enrolled 26 patients from May 2009 to August 2010. Laparoscopic adjustable gastric banded plication was performed using 5-port surgery. We placed Swedish bands using the pars flaccida method, divided the greater omentum, and performed gastric plication below the band to 3 cm from the pylorus using a single-row continuous suture. The data were collected and analyzed pre- and postoperatively. Results: The mean operative time was 87.3 minutes without any intraoperative complications. The average postoperative hospitalization was 1.33 days. The mean excess weight loss at 1, 3, 6, 9, and 12 months after surgery was 21.9%, 31.9%, 41.3%, 55.2%, and 59.5%, respectively. The mean follow-up time was 8.1 months (range 2–15), and the gastric band adjustment rate was 1.1 times per patient during this period. Two complications developed: gastrogastric intussusception and tube kinking at the subcutaneous layer. Both cases were corrected by reoperation. No mortality was observed. Conclusion: Laparoscopic adjustable gastric banded plication provides both restrictive and reductive effects and is reversible. The technique is safe, feasible, and reproducible and can be used as an alternative bariatric procedure. Comparative studies and long-term follow-up are necessary to confirm our findings.

Comment on: Novel bariatric technology: laparoscopic adjustable gastric banded plication: technique and preliminary results

Bipan Chand — 2011-04-29

This original report by Huang et al. describes a novel technique of using the Swedish adjustable gastric band combined with gastric plication. An initial report was described by this group of a patient who had reached a percentage of excess weight loss of 52%; however, he had reached a plateau and desired additional weight loss . Building on that initial report, 26 patients participated in an institutional review board-approved study and underwent laparoscopic adjustable gastric band plication. This study reports on the safety and short-term follow-up with regard to weight loss and subsequent adjustments of the band. The reports of weight loss are provided at various intervals ranging from 1 to 12 months and compared with the number of required adjustments. As part of the follow-up protocol, scheduled visits occurred every 3 months after the initial month. The decision for an adjustment was determined by the patients reaching a weight loss plateau. On average, only 1 adjustment per patient was required during the study follow-up period.

Walking capacity of bariatric surgery candidates

2011-07-21

Abstract: Background: This study characterizes the walking limitations of bariatric surgery candidates by age and body mass index (BMI) and determines factors independently associated with walking capacity. The setting was multi-institutional at research university hospitals in the United States. Methods: Participants of the Longitudinal Assessment of Bariatric Surgery study (n=2458; age 18–78 yr, BMI 33–94 kg/m2) attended a preoperative research visit. Their walking capacity was measured by self-report and the 400 m Long Distance Corridor Walk (LDCW). Results: Almost two thirds (64%) of subjects reported limitations with walking several blocks, 48% had an objectively defined mobility deficit, and 16% reported at least some walking aid use. In multivariate analysis, BMI, older age, lower income, and greater bodily pain were independently associated (P < .05) with walking aid use, physical discomfort during the LDCW, an inability to complete the LDCW, and a slower time to complete the LDCW. Female gender, Hispanic ethnicity (but not race), greater heart rate at rest, a history of smoking, several co-morbidities (history of stroke, ischemic heart disease, diabetes, asthma, sleep apnea, venous edema with ulcerations), and depressive symptoms were also independently related (P < .05) to at least one measure of reduced walking capacity. Conclusions: Walking limitations are common in bariatric surgery candidates, even among the least severely obese and youngest patients. Physical activity counseling must be tailored to individuals' abilities. Although several factors identified in the present study (eg, BMI, age, pain, co-morbidities) should be considered, directly assessing the patient's walking capacity will facilitate appropriate goal setting.

Comment on: Walking capacity of bariatric surgery candidates

Dale S. Bond — 2011-07-21

Mounting evidence suggests that increasing bariatric surgery patients' physical activity (PA) can optimize weight loss and other postoperative outcomes . Moreover, because greater preoperative PA levels might help to reduce short-term postoperative complications and facilitate greater postoperative PA levels , it is recommended that patients be counseled to adopt a preoperative PA routine that includes walking and other sustained moderate activities . However, recent studies using objective measures of PA have suggested that this might be a formidable challenge, given that most preoperative patients do not accumulate any moderate PA in sustained bouts lasting ≥10 minutes and spend the vast majority of their time in sedentary behavior . The study by King et al. seeks to enhance understanding of these findings by characterizing the walking limitations of bariatric surgery candidates, identifying the factors associated with these limitations, and describing the extent to which walking limitations influence objectively measured free-living PA.

Preliminary comparison of sertraline levels in postbariatric surgery patients versus matched nonsurgical cohort

2010-12-17

Abstract: Background: Roux-en-Y gastric bypass (RYGB) is the most frequent bariatric procedure performed in the United States, with thousands performed. Because of the changes to the gastrointestinal tract, the potential exists for clinically significant alterations in the absorption/bioavailability of ingested medications. The purpose of the present pilot trial was to determine to what extent RYGB alters the area under the plasma concentration/time curve (AUC0–10.5) of the antidepressant, sertraline at a community research center. Methods: After an overnight fast, 5 postbariatric surgery and 5 nonsurgical control subjects matched for body mass index, age, and gender received 100 mg of sertraline. Plasma samples were obtained for 10.5 hours. The mean AUC0–10.5, maximal plasma concentration, and the interval to the peak plasma level were obtained for both groups. Results: The mean AUC0–10.5 was significantly smaller for the postbariatric surgery group (124.4 ± 55.5 ng-hr/mL, range 62.0–198.1; P = .043) compared with the nonsurgical control group (314.8 ± 129.6 ng-hr/mL, range 194.8–508.7). The maximal plasma concentration was also significantly smaller for the postbariatric surgery group than for the nonsurgical control group (P = .043). Conclusion: To our knowledge, this is the first reported study exploring antidepressant pharmacokinetics after bariatric surgery. In the present trial, the AUC0–10.5 and maximal plasma concentration were significantly smaller in the subjects who had undergone RYGB than in the matched subjects who had not. Additional investigation of the effects of bariatric surgery (RYGB, sleeve gastrectomy, and gastric banding) on the antidepressant pharmacokinetic parameters is warranted.

Biochemical control of bone loss and stone-forming propensity by potassium-calcium citrate after bariatric surgery

Khashayar Sakhaee, Carolyn Griffith, Charles Y.C. Pak — 2011-05-19

Abstract: Background: Patients undergoing Roux-en-Y gastric bypass (RYGB) surgery are prone to developing bone loss and kidney stones. The goal of the present study was to test the hypothesis that an effervescent formulation of potassium calcium citrate (PCC) would avert metabolic complications by providing bioavailable calcium and alkali. Methods: A total of 24 patients with RYGB underwent a 2-phase crossover randomized trial comparing PCC and placebo. During the last 2 days of each 2-week phase, the serum and 24-hour urine samples were analyzed for calcium and bone turnover markers, acid base status, and urinary stone risk factors. Results: Compared with placebo, PCC marginally reduced the serum parathyroid hormone level and significantly decreased urinary deoxypyridinoline by 12% (P <.001) and serum type 1 collagen C-telopeptide by 22% (P <.01). PCC significantly increased the net gastrointestinal alkali absorption, citrate, and pH and significantly lowered the urinary net acid excretion (P <.001). The urinary saturation of uric acid decreased significantly (P <.001). The supersaturation of calcium oxalate and brushite did not change despite an increase in calcium and pH. In untreated urine samples with citrate concentrations altered to mimic those of placebo and PCC, calcium oxalate agglomeration was significantly inhibited by PCC. Conclusion: In RYGB patients, PCC supplementation inhibited bone resorption by providing bioavailable calcium, reduced the urinary saturation of uric acid, and increased the inhibitor activity against calcium oxalate agglomeration by providing alkali that increased urinary pH and citrate.

Diet-induced obesity associated with steatosis, oxidative stress, and inflammation in liver

Yanhua Peng, Drew Rideout, Steven Rakita, James Lee, Michel Murr — 2011-08-29

Abstract: Background: Obesity induces steatosis and increases oxidative stress, as well as chronic inflammation in the liver. The balance between lipogenesis and lipolysis is disrupted in obese animals. At a cellular level, the changes in metabolic sensors and energy regulators are poorly understood. We hypothesized that diet-induced steatosis increases oxidative stress, inflammation, and changes the metabolic regulators to promote energy storage in mice. The setting was a university-affiliated basic science research laboratory. Methods: Four-week-old C57BL mice were fed a high-fat diet (n = 8) or regular chow (n = 8) for 7 weeks. The liver sections were stained for fat content and immunofluorescence. Liver homogenates were used for protein analysis by immunoblotting and mRNA analysis by reverse transcriptase-polymerase chain reaction. The gels were quantified using densitometry P ≤ .05 was considered significant. Results: The high-fat diet upregulated protein kinase-C atypical isoforms ζ and λ and decreased glucose tolerance and the interaction of insulin receptor substrate 2 with phosphoinositide kinase-3. The high-fat diet increased the transcriptional factors liver X receptor (4321 ± 98 versus 2981 ± 80) and carbohydrate response element-binding protein (5132 ± 135 versus 3076 ± 91), the lipogenesis genes fatty acid binding protein 5, stearoyl-co-enzyme A desaturase-1, and acetyl-co-enzyme A carboxylase protein, and fatty acid synthesis. The high-fat diet decreased 5′-adenosine monophosphate-activated protein kinase (2561 ± 78 versus 1765 ± 65), glucokinase-3β (2.214 ± 34 versus 3356 ± 86), and SIRT1 (2015 ± 76 versus 3567 ± 104) and increased tumor necrosis factor-α (3415 ± 112 versus 2042 ± 65), nuclear factor kappa B (5123 ± 201 versus 2562 ± 103), cyclooxygenase-2 (4230 ± 113 versus 2473 ± 98), nicotinamide-adenine dinucleotide phosphate oxidase (3501 ± 106 versus 1600 ± 69) and reactive oxygen species production (all P < .001, obese mice versus lean mice). Conclusion: A high-fat diet impairs glucose tolerance and hepatic insulin signaling, upregulates transcriptional and translational activities that promote lipogenesis, cytokine production, proinflammatory signaling, and oxidative stress, and downregulates lipolysis. Understanding the complex cellular signals triggered by obesity might have profound clinical implications.

Comment on: Diet-induced obesity associated with steatosis, oxidative stress and inflammation in liver

Hazem A. Elariny, Ancha Baranova — 2011-10-10

Hepatic steatosis has a wide spectrum of pathophysiologic manifestations, broadly termed “nonalcoholic fatty liver disease” (NAFLD) and ranging from mild hepatic steatosis to nonalcoholic steatohepatitis (NASH) to fibrosis (15% of patients with NASH) to cirrhosis . The advanced stages of NAFLD substantially contribute to liver-related mortality, which results from both the nonmalignant loss of liver function and the increase in the occurrence of hepatocellular carcinoma . Importantly, NAFLD is an extremely common condition that affects 70 million adults in the United States or 30% of the U.S. adult population. It is estimated that 14 million (6%) of these patients have NASH. These rates are significantly greater in morbidly obese patients undergoing weight reduction surgery.

Effects of bariatric surgery on food cravings: do food cravings and the consumption of craved foods “normalize” after surgery?

2011-08-10

Abstract: Background: The reported effects of bariatric surgery on food cravings have been inconsistent. Moreover, research has been largely limited to sweet cravings, and no study has examined whether surgery patients' cravings differ from those of normal weight (NW) controls. Our objective was to use an empirically validated instrument to examine changes in bariatric surgery patients' frequency of food cravings and consumption of craved foods from before to 3 and 6 months after surgery and to compare surgery patients' frequency of food cravings to those of NW controls. The setting was private hospitals and research center in the United States. Methods: Bariatric surgery patients (n = 32) and NW controls (n = 20) completed the Food Cravings Inventory and had their height and weight measured. Results: Before surgery, the patients reported more overall cravings and cravings for high fat and fast foods and a greater consumption of craved high-fat foods than the NW controls. From before to 3 and 6 months after surgery, the patients had significant reductions in overall cravings for, and consumption of, craved foods, with specific effects for sweets and fast food; however, surgery had virtually no effect on the cravings for high-fat foods. Moreover, high-fat and fast food cravings did not reduce to normative levels. The postoperative patients were less likely to consume craved sweets than NW controls, and the patients' postoperative weight loss was largely unrelated to food cravings. Conclusion: Bariatric surgery is associated with significant reductions in food cravings and consumption of craved foods, with the exception of high-fat foods. Despite these decreases, patients' cravings do not fully reduce to “normative” levels and are not associated with postoperative weight loss.

Predictors of satisfaction with excess skin and desire for body contouring after bariatric surgery

2011-08-08

Abstract: Background: Bariatric surgery (BS) produces rapid, massive weight loss, often leaving patients with excess skin that can be esthetically disappointing and can present barriers to physical and psychosocial functioning. Thus, body contouring surgery (BCS) is frequently sought by post-BS patients. The objectives of the present study were to characterize the frequency at which post-BS patients desire BCS and the extent to which patients are satisfied with the excess skin in specific body regions before and after contouring. Furthermore, the present study sought to identify the predictors of which patients might be most desirous of BCS. This was a study conducted at 2 academic research centers. Methods: Patients approximately 2 years or 6–10 years after BS were recruited and completed the Post-Bariatric Surgery Appearance Questionnaire. Results: The participants expressed the greatest dissatisfaction with the skin at the waist/abdomen and thigh regions. The most commonly contoured site was the waist/abdomen, and patients rated greater satisfaction with this body region after BCS. Few significant predictor variables were identified. A greater BMI at survey completion was independently associated with lower satisfaction with excess skin, and the time elapsed since BS predicted the desire for contouring. Conclusion: These findings underscore the importance of educating BS candidates about the issues with redundant skin after weight loss and the possible need for subsequent BCS. With this education, patients might have more realistic expectations concerning BS outcomes and be better positioned to seek BCS when indicated.

Weighing the evidence for an association between obesity and suicide risk

2011-10-24

Abstract: Chronic illness is an important risk factor for suicidal behavior. Obesity is perhaps the most prevalent chronic disease at present, although the contribution of obesity to fatal and nonfatal suicide is controversial. Several large population-based studies have shown that obesity is independently linked to an increased risk of suicide. However, this association has been challenged by reports demonstrating a paradoxical relationship between an increasing body mass index and suicide. Recently, it has also been suggested that bariatric surgery patients are at increased risk of death by suicide postoperatively. We reviewed the heterogeneous data concerning the relationship between obesity and suicide. We also critically examined recent reports describing the incidence of fatal suicide events after bariatric surgery. From the present review, it appears that a positive association between obesity and suicide has been observed more frequently than a negative or absent association. This implies that obese individuals are indeed at an increased risk of suicide. This risk seems to persist despite treatment of obesity with bariatric surgery.

Venous thromboembolism after laparoscopic bariatric surgery for morbid obesity: clinical burden and prevention

2011-09-19

Abstract: Background: The clinical benefit of prophylaxis for venous thromboembolism (VTE) in laparoscopic bariatric surgery is unclear. Our objective was to assess the clinical burden of VTE after laparoscopic bariatric surgery. Methods: We performed a systematic review and meta-analysis. Studies were considered for the review if they reported on the methods used for antithrombotic prophylaxis and on the incidence of objectively confirmed VTE in patients who had undergone laparoscopic bariatric surgery. Results: Overall, 19 studies were included in the analysis. The weighted mean incidence (WMI) of pulmonary embolism was .5% (12 events in 3991 patients, 12 studies; 95% confidence interval [CI] .2–.9%; I2 38%) with unfractionated heparin (5000 UI twice or 3 times daily) or low-molecular-weight heparin (30 mg twice daily or 40 mg once daily). The WMI of major bleeding as originally reported in 7 of these studies was 3.6% (2741 patients; 95% CI .9–7.95; I2 94%). The WMI of screened VTE in 3 high-quality studies with different regimens of heparin prophylaxis was 2.0% (8 events in 458 patients; 95% CI .9–3.5%; I2 0%). The WMI of symptomatic VTE was .6% (4 studies; 7 events in 1328 patients; 95% CI .3–1.1%; I2 0%) and that of major bleeding was 2.0% (95% CI 1.0–3.4%; I2 55%), with weight-adjusted doses of heparin prophylaxis. Conclusion: The rate of VTE after laparoscopic bariatric surgery seems to be relatively low with standard regimens for antithrombotic prophylaxis. The incidence of major bleeding seems to increase using weight-adjusted doses of heparin with no advantage in terms of VTE reduction.

Stapling of orogastric tube during gastrojejunal anastomosis: an unusual complication after conversion of sleeve gastrectomy to laparoscopic Roux-en-Y gastric bypass

Guillermo Higa, Samuel Szomstein, Raul Rosenthal — 2011-06-10

The number of laparoscopic Roux-en-Y gastric bypass (LRYGB) cases performed annually in the United States has significantly increased. With the increased number of laparoscopic cases in bariatric surgery, LRYGB has become one of the most technically demanding operations performed in minimally invasive surgery .

Laparoscopic revision of common channel length for chronic diarrhea and malnutrition complicating distal gastric bypass

Ovie Appresai, Michel Murr — 2011-08-18

A 60-year-old woman who had undergone distal Roux-en-Y gastric bypass at our institution 9 years earlier presented after an 8-year absence with chronic diarrhea that had been disturbing her quality of life for the year before presentation. Her prebypass body mass index had been 65 kg/m2. She had received a 150-cm common channel constructed at the bypass. Her present weight was about 81 kg. She was having 3–4 watery bowel movements daily. She had used antidiarrheal agents, tried avoiding lactose, had undergone repeated colonoscopies, and had been treated with antibiotics by her primary care physician; all to no avail. Her laboratory workup revealed consistently and progressively low serum albumin (<3.0 g/dL) and prealbumin (<15 g/dL). We therefore discussed with her the option of elongating her common channel as a treatment of her malnutrition and diarrhea.

Late gastric perforation after insertion of intragastric balloon for weight loss—video case report and literature review

Michalis P. Charalambous, Jeremy Thompson, Evangelos Efthimiou — 2011-10-10

The BioEnterics intragastric balloon (BIB) is used in the treatment of morbid obesity, as a method for short-term weight loss, especially before definitive surgery. Previous studies have demonstrated that patients who have a BIB inserted can achieve ≤48% reduction of their excess weight, although this is not maintained in the long term . The BIB is recommended to stay in place for 6 months and either removed or replaced after that period, because the risk of spontaneous rupture owing to material degradation increases.

Clinical case report: psychosocial issues in adolescent bariatric surgery

David B. Sarwer, Amy von Sydow Green, Noel N. Williams — 2010-08-20

During the past several decades, the prevalence of obesity among children and adolescents has steadily increased . Approximately 4% of American children and adolescents are extremely obese, defined as having a body mass index (BMI) ≥99th percentile for their age. Obese children and adolescents are likely to become obese adults and, as a result, be at risk of premature morbidity and mortality .

Chylous ascites mimicking peritonitis after laparoscopic Roux-en-Y gastric bypass for morbid obesity

Megan Hanson, Jeffrey Chao, Robert B. Lim — 2010-08-12

Our patient was a 22-year-old woman who had undergone laparoscopic Roux-en-Y gastric bypass (RYGB) in California in 2007. Her medical history included hypertension and pseudotumor cerebri for which she had had a ventriculoperitoneal shunt placed. Her surgical history also included a cesarean section. She had done well since her surgery and maintained a weight loss of 90 lb. Her preoperative weight had been 210 lb and at presentation was 120 lb. Her husband's work had caused her to move to Guam approximately 1 year before presentation.

Management of bleeding from gastric remnant after Roux-en-Y gastric bypass

Vichin Puri, Annamalai Alagappan, Moshe Rubin, Stephen Merola — 2010-09-17

Endoscopic evaluation of the excluded stomach after Roux-en-Y gastric bypass surgery (RYGB) for morbid obesity is a challenge. Until recently, these patients have been undergone intraoperative gastrotomy and intraoperative endoscopy through the gastrotomy in the hope of finding the etiology of the bleeding not seen on routine endoscopy. Such procedures come with their own morbidity and risk of complications. We present a case in which the use of double balloon enteroscopy made the clinical evaluation of such a patient easier, with less associated risk and morbidity.

Laparoscopic sleeve gastrectomy on heart transplant recipient with body mass index of 34 kg/m2 and metabolic syndrome

José Pablo Vélez, Rafael H. Arias, Pastor Olaya — 2010-12-06

Bariatric surgery has demonstrated great benefits for patients with severe obesity in terms of better control of co-morbidities and an improved quality of life . Sleeve gastrectomy has been used for high-risk patients, given its effect on weight loss, with a lower risk than gastric bypass . In some patients, a body mass index (BMI) of <35 kg/m2 can be associated with significant co-morbidities. These patients could benefit from bariatric surgery.

Laparoscopic sleeve gastrectomy is a misnomer

Aniceto Baltasar — 2011-08-02

Laparoscopic sleeve gastrectomy has become very popular as an isolated procedure or as a staging operation before a more complex procedure in patients with a high body mass index. The name of this operation remains controversial. Marceau et al was the first to describe it in 1991, within the context of the duodenal switch and termed it “parietal gastrectomy.” Hess and Hess termed it “vertical gastrectomy” in 1998, and Almogy et al used the term “longitudinal gastrectomy” in 2004.

Laparoscopic sleeve gastrectomy is the right terminology

Michel Gagner — 2011-09-28

The term “sleeve gastrectomy” has been used in the English language to describe resection of the stomach that leaves a portion of the lesser curvature. It has been used liberally for other organs as well, such as sleeve resection of the main bronchus , sleeve colic anastomosis , sleeve lobectomy or pneumonectomy and sleeve resection of large vessels .

Attitudes toward obese persons and controllability beliefs: clarifying previously reported data

Stuart Flint — 2011-07-11

Very recently, Gujral et al. reported data representative of attitudes toward obese persons and beliefs about the controllability of obesity in a sample of nurses from 2 hospitals (1 that offered bariatric sensitivity training and 1 that did not). The authors used the Attitudes Towards Obese Persons (ATOP) and Beliefs About Obese Persons (BAOP) scales , which have a score range of 0–120 and 0–48, respectively. The ATOP measures both positive and negative attitudes about obese persons, and the BAOP measures beliefs about the controllability of obesity, with greater scores for both scales representative of a more positive response.

Evaluation of nurses' attitudes toward adult obese patients: erratum

Harpreet Gujral, Christine Tea, Michael Sheridan — 2011-11-02

We would like to submit our response to Mr. Flint's letter to the editor dated June 29, 2011, titled “Attitudes towards obese persons and controllability beliefs: clarifying previously reported data.”

How to use the Bariatric Analysis and Reporting Outcome System

Horacio E. Oria — 2011-10-07

The Bariatric Analysis and Reporting Outcome System (BAROS) is a simple, 1-page scoring instrument developed to evaluate and present the results from obesity surgery . It analyzes 3 domains: weight loss, changes in co-morbidities, and changes in quality of life, assigning a maximum of 3 points to each of the domains. Complications and reoperations deduct points from the subtotal, leading to a final score. This is used to objectively classify the results in 5 outcomes groups.

My husband looked it up in Google

2010-12-30