Surgery for Obesity and Related Diseases

Editorial Board

2010-07-01

Consensus statement on the adoption of the COPE guidelines

Dr. Harvey Sugerman — 2010-05-31

We, the undersigned editors of the member journals of the Surgery Journal Editors Group, in the furtherance of integrity in surgical and scientific publication, agree to adopt the guidelines established by the Committee on Publication Ethics (COPE) . The COPE guidelines represent a method of addressing a variety of ethical concerns, including duplicate publication and authorship misconduct issues, which have, unfortunately, become more prevalent.

Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m2

Shashank S. Shah, Jayashree S. Todkar, Poonam S. Shah, David E. Cummings — 2009-09-07

Abstract: Background: Roux-en-Y gastric bypass (RYGB) benefits patients with type 2 diabetes mellitus (T2DM) and a body mass index (BMI) >35 kg/m2; however, its effectiveness in patients with T2DM and a BMI <35 kg/m2 is unclear. Asian Indians have a high risk of T2DM and cardiovascular disease at relatively low BMI levels. We examined the safety and efficacy of RYGB in Asian Indian patients with T2DM and a BMI of 22–35 kg/m2 in a tertiary care medical center.Methods: A total of 15 consecutive patients with T2DM and a BMI of 22–35 kg/m2 underwent RYGB. The data were prospectively collected before surgery and at 1, 3, 6, and 9 months postoperatively.Results: Of the 15 patients, 8 were men and 7 were women (age 45.6 ± 12 years). Their preoperative characteristics were BMI 28.9 ± 4.0 kg/m2, body weight 78.7 ± 12.5 kg, waist circumference 100.2 ± 6.8 cm, and duration of T2DM 8.7 ± 5.3 years. At baseline, 80% of subjects required insulin, and 20% controlled their T2DM with oral hypoglycemic medication. The BMI decreased postoperatively by 20%, from 28.9 ± 4.0 kg/m2 to 23.0 ± 3.6 kg/m2 (P <.001). All antidiabetic medications were discontinued by 1 month after surgery in 80% of the subjects. At 3 months and thereafter, 100% were euglycemic and no longer required diabetes medication. The fasting blood glucose level decreased from 233 ± 87 mg/dL to 89 ± 12 mg/dL (P <.001), and the hemoglobin A1c decreased from 10.1% ± 2.0% to 6.1% ± 0.6% (P <.001). Their waist circumference, presence of dyslipidemia, and hypertension improved significantly. The predicted 10-year cardiovascular disease risk (calculated using the United Kingdom Prospective Diabetes Study equations) decreased substantially for fatal and nonfatal coronary heart disease and stroke. No mortality, major surgical morbidity, or excessive weight loss occurred.Conclusion: RYGB safely and effectively eliminated T2DM in Asian Indians with a BMI <35 kg/m2. Larger, longer term studies are needed to confirm this benefit.

Comment on: Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m2

Scott A. Shikora — 2009-09-28

By this time, everyone involved in healthcare is aware of the twin epidemics of obesity and type 2 diabetes mellitus (T2DM). Tens of millions of humans have one, and often both, of these conditions. Additionally, most predictions have suggested that within the next few decades, the numbers will likely grow into the hundreds of millions. Because the cost of treating the consequences of obesity in America is already >100 billion dollars, the magnitude of the future cost increase is unfathomable. Now, expand this crisis globally because neither disease is the unique property of the United States. In India alone, the prevalence of T2DM will be >100 million before the close of 2010 .

Early insulin sensitivity after restrictive bariatric surgery, inconsistency between HOMA-IR and steady-state plasma glucose levels

2009-12-10

Abstract: Background: The low-grade inflammatory condition present in morbid obesity is thought to play a causative role in the pathophysiology of insulin resistance (IR). Bariatric surgery fails to improve this inflammatory condition during the first months after surgery. Considering the close relation between inflammation and IR, we conducted a study in which insulin sensitivity was measured during the first months after bariatric surgery. Different methods to measure IR shortly after bariatric surgery have given inconsistent data. For example, the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) levels have been reported to decrease rapidly after bariatric surgery, although clamp techniques have shown sustained insulin resistance. In the present study, we evaluated the use of steady-state plasma glucose (SSPG) levels to assess insulin sensitivity 2 months after bariatric surgery.Methods: Insulin sensitivity was measured using HOMA-IR and SSPG levels in 11 subjects before surgery and at 26% excess weight loss (approximately 2 months after restrictive bariatric surgery).Results: The SSPG levels after 26% excess weight loss did not differ from the SSPG levels before surgery (14.3 ± 5.4 versus 14.4 ± 2.7 mmol/L). In contrast, the HOMA-IR values had decreased significantly (3.59 ± 1.99 versus 2.09 ± 1.02).Conclusion: During the first months after restrictive bariatric surgery, we observed a discrepancy between the HOMA-IR and SSPG levels. In contrast to the HOMA-IR values, the SSPG levels had not improved, which could be explained by the ongoing inflammatory state after bariatric surgery. These results suggest that during the first months after restrictive bariatric surgery, HOMA-IR might not be an adequate marker of insulin sensitivity.

Comment on: Insulin sensitivity during first months after restrictive bariatric surgery, inconsistency between HOMA-IR and steady-state plasma glucose levels

Sayeed Ikramuddin — 2010-04-05

It is well known that type 2 diabetes mellitus (T2DM) is a significant clinical concern. The disease results from the imbalance of insulin secretion and glucose disposal. The observation that bariatric surgery results in marked improvement in the markers of glycemia has generated a great deal of interest in the pathogenesis of bariatric surgery-induced improvement of T2DM . In the absence of surgery, weight loss and caloric restriction provide improvement in glycemia, dyslipidemia, and hypertension . The precise etiology of improvement of T2DM after bariatric surgery remains unclear, and several mechanisms have been proposed, including weight reduction, caloric restriction, the effect of intestinal rearrangement, and malabsorption . Multiple mechanisms could be involved. Intuitively, the former 2 mechanisms would be limited to restrictive procedures such as laparoscopic adjustable gastric banding, vertical banded gastroplasty, and sleeve gastrectomy. Although all mechanisms could apply to Roux-en-Y gastric bypass and duodenal switch/biliopancreatic diversion. Ultimately, these interventions must improve beta cell function, reduce insulin resistance, and restore “gut hormone” secretion to be effective. Clinical targets such as the fasting plasma glucose level and hemoglobin A1c are standard markers of glycemic effectiveness of therapy, regardless of the approach. Additional markers such as blood pressure and low-density lipoprotein cholesterol with hemoglobin A1c have formed a composite endpoint for the treatment of T2DM . Recently, bariatric surgery has been added as a consideration for those patients not reaching the diabetes goals for patients with a body mass index >35 kg/m2. Surgery can be quite effective in reaching therapeutic targets . Although clinically pertinent, these outcomes do not shed light on the mechanisms of improved glucose homeostasis.

Baseline data from American Society for Metabolic and Bariatric Surgery-designated Bariatric Surgery Centers of Excellence using the Bariatric Outcomes Longitudinal Database

Eric J. DeMaria, Virginia Pate, Michael Warthen, Deborah A. Winegar — 2009-12-14

Abstract: Background: The Bariatric Outcomes Longitudinal Database (BOLD) is a registry of self-reported bariatric surgery patient information from the American Society for Metabolic and Bariatric Surgery Bariatric Surgery Center of Excellence participants. The present study was undertaken to define the baseline characteristics of the patients with data entered into BOLD.Methods: The data submitted by >800 surgeons and >450 facilities using BOLD before May 20, 2009, were analyzed.Results: A total of 57,918 research-consented patients with surgical procedure data were included. Of the 57,918 patients, 41,243 were adults aged 26–55 years, with few patients aged ≤18 years (.14%) or ≥66 years (5.67%). Females constituted a significant majority of the study population (45,619 [78.76%]). Of the 57,918 patients, 78.12% registered were described as Caucasian, 10.52% as African-American, 6.02% as Hispanic, .20% as Asian, and .46% as Native American. The most common bariatric surgical procedure was some form of gastric bypass (31,668 [54.68%]), followed by some form of gastric banding (22,947 [39.62%]), sleeve gastrectomy (1,328 [2.29%]), and biliopancreatic diversion (517 [.89%]). The vast majority of index procedures were completed using laparoscopic surgery techniques, except for biliopancreatic diversion, which was primarily done with an open approach. Through May 2009, 78 deaths were reported at any point after the index procedure, for a mortality rate of .13%. The 90-day mortality rate was .11%, and the 30-day mortality rate was .09%.Conclusion: This is the first report of data from BOLD. The data have revealed important characteristics of patients undergoing bariatric surgery across the United States in centers participating in the Bariatric Surgery Center of Excellence program. Future analyses of BOLD data are likely to have a major effect on the specialty of bariatric surgery.

Pre–Lap-Band group education in Medicaid population: does it really make a difference?

2009-12-23

Abstract: Background: The effect of group education classes before a Lap-Band procedure has not been well defined. We hypothesized that in a Medicaid population, the completion of a standardized 12-week multidisciplinary preoperative program (SMPP) would significantly improve the preoperative and early postoperative weight loss. All procedures were performed at a University-affiliated community hospital from 2006 to 2007.Methods: A prospectively collected database of 292 patients who underwent Lap-Band placement was retrospectively reviewed. All patients in the study cohort were encouraged to participate in the SMPP, which included medical, psychological, and nutritional interventions. The patients were divided into 2 groups according to their participation in the SMPP program: SMPP compliant and non-SMPP compliant. The postoperative weight loss of these 2 groups was then compared using the general linear models for repeated measures statistical analysis.Results: No significant difference was found in the mean baseline excess body weight between the 2 groups (74 ± 20 kg in the SMPP-compliant and 76 ± 20 kg in the non–SMPP-compliant participants). The mean baseline body mass index (47 ± 7 versus 48 ± 72 kg/m2 for the SMPP-compliant and non–SMPP-compliant participants) was also similar in the 2 groups. The postoperative follow-up rate was 94.5% at 1 month, 72.3% at 6 months, and 52.7% at 12 months. The excess weight loss was significantly greater in the SMPP compliant group than in the noncompliant group during the observed 12-month follow-up period (P = .04, by general linear models for repeated measures).Conclusion: In a Medicaid population, implementation of an intensive preoperative SMPP resulted in a significant improvement in the short-term weight loss after Lap-Band placement.

Physical activity and physical function changes in obese individuals after gastric bypass surgery

Deborah A. Josbeno, John M. Jakicic, Andrea Hergenroeder, George M. Eid — 2008-08-15

Abstract: Background: Little is known about the effects of gastric bypass surgery (GBS) on physical activity and physical function. We examined the physical activity, physical function, psychosocial correlates to physical activity participation, and health-related quality of life of patients before and after GBS.Methods: A total of 20 patients were assessed before and 3 months after GBS. Physical activity was assessed using the 7-day physical activity recall questionnaire and a pedometer worn for 7 days. Physical function was assessed using the 6-minute walk test, Short Physical Performance Battery, and the physical function subscale of the Medical Outcomes Short Form-36 (SF-36). The Physical Activity Self-Efficacy questionnaire, the Physical Activity Barriers and Outcome Expectations questionnaire, the SF-36, and the Numeric Pain Rating Scale were also administered.Results: Physical activity did not significantly increase from before (191.1 ± 228.23 min/wk) to after (231.7 ± 230.04 min/wk) GBS (n = 18); however, the average daily steps did significantly increase (from 4621 ± 3701 to 7370 ± 4240 steps/d; n = 11). The scores for the 6-minute walk test (393 ± 62.08 m to 446 ± 41.39 m; n = 17), Short Physical Performance Battery (11.2 ± 1.22 to 11.7 ± .57; n = 18), physical function subscale of the SF-36 (65 ± 18.5 to 84.1 ± 19.9), and the total SF-36 (38.2 ± 23.58 to 89.7 ± 15.5; n = 17) increased significantly. The Numeric Pain Rating Scale score decreased significantly for low back (3.5 ± 1.8 to 1.7 ± 2.63), knee (2.4 ± 2.51 to 1.0 ± 1.43), and foot/ankle (2.3 ± 2.8 to 0.9 ± 2.05) pain. No significant changes were found in the Physical Activity Self-Efficacy questionnaire or the Physical Activity Barriers and Outcome Expectations questionnaire.Conclusion: GBS improves physical function, health-related quality of life, and self-reported pain and results in a modest improvement in physical activity. These are important clinical benefits of surgical weight loss. Long-term follow-up is needed to quantify the ability to sustain or further improve these important clinical outcomes.

Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index

2009-12-11

Abstract: Background: The current National Institutes of Health guidelines have recommended bariatric surgery for patients with a body mass index (BMI) >40 kg/m2 or BMI >35 kg/m2 with significant co-morbidities. However, some preliminary studies have shown that patients with a BMI that does not meet these criteria could also experience similar weight loss and the benefits associated with it.Methods: An institutional review board-approved protocol was obtained to study the effectiveness of laparoscopic adjustable gastric banding in patients with a low BMI. A total of 66 patients with a BMI of 30–35 kg/m2 and co-morbidities (n = 22) or a BMI of 35–40 kg/m2 without co-morbidities (n = 44) underwent laparoscopic adjustable gastric banding. These patients were compared with 438 standard patients who had undergone laparoscopic adjustable gastric banding who met the National Institutes of Health criteria for bariatric surgery. The excess weight loss at 3, 6, 12, and 18 months and the status of their co-morbidities were compared between the 2 groups.Results: The average BMI for the study group was 36.1 ± 2.6 kg/m2 compared with 46.0 ± 7.3 kg/m2 for the control group. Both groups had significant co-morbidities, including hypertension, diabetes, hyperlipidemia, arthritis, gastroesophageal reflux disease, stress incontinence, and obstructive sleep apnea. The mean percentage of excess weight loss was 20.3% ± 9.0%, 28.5% ± 14.0%, 44.7% ± 19.3%, and 42.2% ± 33.7% at 3, 6, 12, and 18 months, respectively. This was not significantly different from the excess weight loss in the control group, except for at 12 months. Both groups showed similar improvement of most co-morbidities.Conclusion: Moderately obese patients whose BMI is less than the current guidelines for bariatric surgery will have similar weight loss and associated benefits. Laparoscopic adjustable gastric banding is a safe and effective treatment for patients with a BMI of 30–35 kg/m2.

Comment on: Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index

Christine Ren-Fielding — 2009-11-09

This study is a single-institution retrospective review of a single cohort of patients with a body mass index (BMI) 30–40 kg/m2 who underwent laparoscopic adjustable gastric banding. This observational experience is clinically relevant owing to the ever-growing controversy regarding the relevance of the BMI to health and when surgical intervention is indicated. Many reports have been published on the safety and efficacy of laparoscopic adjustable gastric banding in patients with a lower BMI . However, Choi et al. have introduced an interesting and different component of study, specifically comparing the outcomes of the low-BMI laparoscopic adjustable gastric banding patients with those of a National Institutes of Health-appropriate “control group” (BMI >40 kg/m2, BMI 35–40 kg/m2 with co-morbidities).

Five-year outcomes of patients with type 2 diabetes who underwent laparoscopic adjustable gastric banding

2010-03-02

Abstract: Background: Evidence of the positive effects of gastric banding on patients with diabetes has continued to increase. The long-term follow-up of such patients, however, has been limited. The purpose of the present study was to provide the long-term outcomes of patients with diabetes undergoing laparoscopic adjustable gastric banding at our institution.Methods: From January 2002 through June 2004, 102 patients with type 2 diabetes mellitus underwent laparoscopic adjustable gastric banding. The study parameters included preoperative age, gender, race, body mass index, duration of diabetes before surgery, fasting glucose level, hemoglobin A1c (HbA1c), and medications used. Preoperative data from all patients were collected prospectively and entered into an institutional review board-approved database. Beginning in 2008, efforts were made to collect the 5-year follow-up data.Results: Of the 102 patients, 7 were excluded because they had not reached the 5-year follow-up point (2 patients had had the band removed early and 5 patients had died; 2 of cancer and 3 of unknown causes), leaving 95 patients for the present study. The mean preoperative age was 49.3 years (range 21.3–68.4). The mean preoperative body mass index was 46.3 kg/m2 (range 35.1–71.9) and had decreased to 35.0 kg/m2 (range 21.1–53.7) by 5 years of follow-up, yielding a mean percentage of excess weight loss of 48.3%. The mean duration of the diabetes diagnosis before surgery was 6.5 years. Of 94 patients, 83 (88.3%) were taking medications preoperatively, with 14.9% overall taking insulin. At 5 years postoperatively, 33 (46.5%) of 71 patients were taking medications, with 8.5% taking insulin. The mean fasting preoperative glucose level was 146.0 mg/dL. The glucose level had decreased to 118.5 mg/dL at 5 years postoperatively (P = .004). The mean HbA1c level was 7.53 preoperatively in 72 patients and was 6.58 at 5 years postoperatively in 64 patients (P <.001). Overall, diabetes had resolved (no medication requirement, with HbA1c <6 and/or glucose <100 mg/dL) in 23 (39.7%) of 58 patients and had improved (use of fewer medications and/or fasting glucose levels of 100–125 mg/dL) in 41 (71.9%) of 57 patients. The combined improvement/remission rate was 80% (64 of 80 patients).Conclusion: Our data have demonstrated that laparoscopic adjustable gastric banding results in a substantial sustained positive effect on diabetes in morbidly obese patients, with a significant reduction in HbA1c and an 80% overall rate of improvement/remission.

Assessing cost-effectiveness in obesity: laparoscopic adjustable gastric banding for severely obese adolescents

Jaithri Ananthapavan, Marjory Moodie, Michelle Haby, Robert Carter — 2010-03-02

Abstract: Background: To assess, from a societal perspective, the incremental cost-effectiveness of laparoscopic adjustable gastric banding for severely obese adolescents in Australia.Methods: The intervention, modeled as a part of the Assessing Cost-Effectiveness in Obesity project, used evidence of the effectiveness and costs from a case series of 28 adolescents who had undergone gastric banding in Melbourne and extrapolated the data to the eligible Australian adolescent population. The cost offsets and disability-adjusted life year benefits (determined by the change in body mass index at 3 years after surgery) were tracked until the cohort had reached the age of 100 years or death and were discounted at 3% per annum. Simulation-modeling techniques were used to present a 95% uncertainty interval (UI) around the cost-effectiveness ratio. The intervention was also assessed against second-stage filter criteria (“equity,” “strength of evidence,” “acceptability,” “feasibility,” “sustainability,” and “side effects”).Results: The intervention reached 4120 severely obese, privately insured adolescents. It cost AUD130M (95% UI 52–265) and resulted in an incremental savings of 55,400 body mass index units (95% UI 12,600–140,000) at 3 years after surgery, which translated into 12,300 disability-adjusted life years (95% UI 5000–24,670) saved during their lifetime. The cost-offsets totaled AUD75M (95% UI 30.5–150), resulting in a net cost per disability-adjusted life year saved of AUD4400 (95% UI 2900–6120).Conclusions: Although the intervention was cost-effective using the current modeling assumptions, it is unlikely to be acceptable to all stakeholders, including some severely obese adolescents. Nevertheless, gastric banding has an important role in the management of morbid obesity in adolescents.

Evaluating gastric erosion in band management: an algorithm for stratification of risk

2009-12-21

Abstract: Background: Laparoscopic gastric banding has several known complications, including gastric erosion. No clear factors have been determined for the development of band erosion, but technical factors such as covering the buckle of the band have been implicated. The objective of the present study was to determine whether band management after surgery, band size, or filling beyond the manufacturer-determined maximal volume has an effect on the incidence of erosion at a university hospital in the United States.Methods: We performed a retrospective review of a prospective institutional review board–approved database. All patients who had been followed from 2002 to 2008 were identified. The maximal band volume was 4 cm3 for the 9.75-cm/10-cm band and 10 cm3 for the Vanguard band. The bands were considered overfilled if they had been filled to greater than the maximal volume for ≥3 months.Results: A total of 2437 patients had undergone Lap-Band surgery. Of these 2437 patients, 14 developed erosion (.57%). The primary erosion rate was .39% (9 of 2359). These patients were divided into 3 groups according to the type of band placed: group 1, Vanguard (n = 735); group 2, 9.75-cm/10-cm band (n = 1624); and group 3, revisions to Vanguard, including a band placed around a bypass (n = 78). The incidence of gastric erosion by group was .95% (7 of 735) in group 1, .12% (2 of 1624) in group 2, and 6.41% (5 of 78) in group 3. The difference in the erosion rate among the groups was significant (group 1 versus 2, P = .005; group 3 versus 1, P = .003; and group 3 versus 2, P = .001). Erosions developed in each group without overfilling. Also, comparing the erosion rate in the overfilled versus underfilled bands, statistical significance was found only for group 1 at 3.18% versus .35% (P = .006). The erosion rate in the overfilled versus underfilled was 1.01% versus .07% in group 2 and 11.11% versus 3.92% in group 3.Conclusion: A band that needs to be overfilled might be a sign of erosion, and patients should undergo endoscopy. Band revision has a greater rate of erosion than primary banding. The Vanguard band has a greater risk of erosion than the 4-cm3 bands.

Comment on: Evaluating gastric erosion in band management: an algorithm for stratification of risk

Jaime Ponce — 2009-12-10

Erosions are a rare complication of the laparoscopic adjustable gastric banding procedure. Technique and band device improvements have decreased the occurrence of this problem significantly. We still do not know the exact cause of how and why erosions develop. The questions posted in the report “Evaluating gastric erosion in band management: an algorithm for stratification of risk” are very valid: does postoperative management, band type, or overinflation have an effect?

Reasons and outcomes of laparoscopic revisional surgery after laparoscopic adjustable gastric banding for morbid obesity

2010-01-27

Abstract: Background: Laparoscopic adjustable gastric banding (LAGB) is a purely restrictive procedure that has been proved to be an effective tool in achieving weight loss. The low operative morbidity and reversibility are often seen as advantages of this procedure compared with other bariatric approaches. We have attempted to define the reasons for revisional surgery after LAGB and the outcomes.Methods: A retrospective review of a prospectively maintained database was performed from February 2001 to October 2008 at a center of excellence after institutional review board approval. The patients who had undergone revisional surgery after primary LAGB were evaluated.Results: Of 343 patients who had undergone primary LAGB, 60 subsequently underwent a revisional procedure. In addition, 28 revisional procedures were performed on patients who had undergone primary LAGB at an outside institution. These procedures included 39 (44.3%) band removals alone, 12 (13.6%) band removals with conversion to sleeve gastrectomy, 13 (14.8%) band removals with conversion to Roux-en-Y gastric bypass, 9 (10.2%) band repositioning, and 2 (2.3%) band replacements. In addition, 13 (14.8%) port-related procedures (3 relocations, 6 reconnections, and 4 replacements/removals) were performed.Conclusion: Although reversible and efficacious, LAGB appears to have a high incidence of complications requiring revisional surgery and/or band removal. The results of our study have shown that laparoscopic revisional surgery after primary LAGB is safe and can be performed with minimal morbidity.

Path to bariatric nurse certification: the practice analysis

2010-04-26

Abstract: Background: In 2005, the American Society for Metabolic and Bariatric Surgery (ASMBS) nursing membership embarked on a journey to develop a specialty certification program for nurses caring for morbidly obese and bariatric surgical patients. In keeping with the certification industry best practices, a practice analysis study was conducted to create an empirically sound foundation for the new nursing specialty certification examination.Methods: Task force meetings, subject-matter expert interviews, and an external review process were implemented to create a definition of the specialty in terms of 4 domains of practice, 45 nursing tasks, and 54 knowledge areas. The definition encompassed the work of bariatric nurse coordinators, bariatric program directors, and floor nurses caring for morbidly obese and bariatric surgical patients. A survey was administered to 1084 nurses practicing in the specialty to validate the domains, tasks, and knowledge.Results: Some differences in the time spent in each of the domains and tasks were noted for the survey respondents in the different job roles. Nevertheless, the respondents for all job roles rated the domains and tasks moderately or highly important in optimizing the outcomes for morbidly obese and bariatric surgery patients. In addition, most respondents agreed that the 54 knowledge areas were acquired during the first 2 years of practice in the specialty.Conclusion: The survey results validated a specialized body of nursing knowledge rooted in the tasks that define professional practice. The results are being used to guide the development of a certification program for nurses practicing in the specialty and to provide guidance for education and training initiatives.

Laparoscopic biliopancreatic diversion/duodenal switch or laparoscopic Roux-en-Y gastric bypass for super-obesity—weight loss versus side effects

Anna Laurenius, Osama Taha, Almantas Maleckas, Hans Lönroth, Torsten Olbers — 2010-04-09

Abstract: Background: Laparoscopic biliopancreatic diversion/duodenal switch (LDS) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the main surgical options for super-obese patients (body mass index >50 kg/m2).Methods: We performed a medium long-term evaluation of 13 super-obese patients who had undergone LDS compared with a control group of 19 patients who had undergone LRYGB. The patients were assessed 31 months (range 17–38) and 34 months (range 26–62) after LDS and LRYGB, respectively, for body mass index changes, relief of co-morbidities, nutrition, quality of life, postoperative bowel function, and accumulated healthcare consumption.Results: The mean body mass index decreased from 54.9 to 30.0 kg/m2 in the LDS group and 57.8 to 39.8 kg/m2 in the LRYGB group (P = .005). The hemoglobin A1c level was lower in the LDS group than in the LRYGB group (3.8 ± .31% versus 4.3 ± .43%, respectively; P = .01). The LDS patients reported greater energy intake than the LRYGB patients (3132 ± 1392 kcal versus 2014 ± 656 kcal, respectively; P = .021). The number of stools daily was 4.1 ± 3.3 in the LDS group and 1.9 ± 1.1 in the LRYGB group, P = .0482). Of the 12 patients in the LDS group, 6 reported fecal incontinence or soiling compared with 2 of 16 in the LRYGB group (P = .034). The number of outpatient visits was 5.6 ± 4.6 for the LDS group and 2.0 ± 1.9 for the LRYGB group (P = .016), and the number of telephone consultations was 5.0 ± 5.6 and 1.4 ± 1.6 for the LDS and LRYGB groups, respectively (P = .043).Conclusion: LDS resulted in greater weight loss than LRYGB in super-obese patients. However, the LDS patients in our series had more frequent gastrointestinal side effects, required greater doses of calcium and vitamin supplementation, and required more postoperative monitoring. Patient satisfaction was high in both groups.

Comment on: Laparoscopic biliopancreatic diversion/duodenal switch or laparoscopic Roux-en-Y gastric bypass for super-obesity—weight loss versus side effects

Philippe A. Topart — 2010-05-10

Biliopancreatic diversion with duodenal switch (DS) (and the original biliopancreatic diversion as described by Scopinaro referred to as BPD) and Roux-en-Y gastric bypass (RYGB) are the 2 most effective procedures in today's bariatric surgical armamentarium, which is still largely dominated by gastric bypass. Laurenius et al. have presented the latest of several other studies published during the past 6 years that have compared the postoperative outcomes, effectiveness, gastrointestinal consequences, nutritional side effects, and overall patient satisfaction and quality of life after RYGB and DS. Although both procedures rely on combined restriction and malabsorption, the predominant malabsorptive aspect of the DS has always raised concerns about the bowel function changes, with the risk of diarrhea and the potential nutritional side effects. Thus, DS has been regarded as a major bariatric procedure and has usually been offered to patients with a body mass index of ≥50 kg/m2, with all comparative studies referring to superobese patients.

History of substance abuse relates to improved postbariatric body mass index outcomes

Leslie J. Heinberg, Kathleen Ashton — 2010-04-26

Abstract: Background: Recent clinical guidelines have identified current alcohol or substance abuse as contraindications for weight loss surgery. Past research has indicated that a lifetime history of any substance use disorder is significantly greater in those seeking weight loss surgery than the population base rate. However, current substance abuse has been reported to be remarkably low (<1%). The objective was to examine whether a history of substance abuse/dependence is associated with differing weight loss outcomes after bariatric surgery.Methods: A total of 413 patients who had undergone weight loss surgery (75.8% women, 77.7% white, mean age 47.72 years, mean body mass index 50.27 kg/m2) at the Cleveland Clinic Bariatric and Metabolic Institute completed a psychological evaluation before surgery, and a history of substance abuse and/or dependence was determined.Results: A series of analyses of covariance examining group differences in the percentage of excess weight loss (%EWL) at 1, 3, 6 , 9, and 12 months after surgery were conducted comparing a history of substance abuse/dependence (SA+; n = 45) with the absence of a substance abuse/dependence history (SA−; n = 368), controlling for the baseline body mass index. The groups did not differ in the type of surgery or %EWL at 1 and 3 months of follow-up. However, after adjusting for the baseline body mass index, the patients with a substance abuse history had a significantly greater %EWL at 6 and 9 months postoperatively, with a trend toward significance at the 12-month follow-up visit.Conclusion: Patients with a substance abuse/dependence history had a greater %EWL from 6 months postoperatively onward. Future research should examine longer term outcomes among SA+ patients and the possible explanations for their short-term improved outcomes compared with SA− patients.

Comment on: History of substance abuse relates to improved postbariatric body mass index outcomes

Stephanie Sogg — 2010-05-05

In this issue of the Journal, Heinberg and Ashton describe the findings of a study in which they examined the relationship between a preoperative history of substance abuse and postoperative weight loss in the first year after weight loss surgery (WLS). This study is a welcome contribution to the published data, because, in general, the empirical WLS data have included very little examination of substance abuse before and after surgery.

Endoscopic removal of eroded adjustable gastric band: lessons learned after 5 years and 78 cases

2009-10-07

Abstract: Background: One of the complications of laparoscopic adjustable gastric banding is intragastric erosion, leading to a revisional procedure to remove the band. Our aim was to present the procedure and results of endoscopic band removal in a 5-year multicenter experience from the Gastro Obeso Center and Universidade de São Paulo, São Paulo, and Universidade Federal de Pernambuco, Recife, Brazil.Methods: From 2003 to 2008, 82 patients were diagnosed with band erosion. The clinical data concerning the endoscopic procedure were prospectively recorded and retrospectively reviewed.Results: The average preoperative body mass index was 43.2 kg/m2 (range 34–50). At the diagnosis of intragastric erosion, the body mass index was 24–41 kg/m2 (average 31.8). The erosion occurred an average of 16.3 months (range 6–36) postoperatively. The symptoms included pain in 25 (31%), port infection in 21 patients (27%), and weight regain in 20 (25%), and 12 patients (15%) were asymptomatic. Endoscopic removal was possible for 78 patients (95%). In 85% of patients, the band was removed in the first session, with an average duration of 55 minutes (range 25–150). Five cases of pneumoperitoneum occurred after the procedure. Of these, 3 were treated conservatively, 1 was treated by laparoscopy, and 1 was treated by abdominal puncture using the Veress needle.Conclusion: Endoscopic removal of eroded laparoscopic adjustable gastric banding is safe and effective. It can be used as a first choice procedure in clinical practice.

Comment on: Endoscopic removal of eroded adjustable gastric band: lessons learned after 5 years and 78 cases

Paul O'Brien — 2009-11-09

Erosion of the band into the stomach is an uncommon, but serious, complication of laparoscopic adjustable gastric banding. The overall incidence in large series has been 1–2%, but, in small series, it has been as great as 12%, suggesting significant operator dependency. All who perform the laparoscopic adjustable gastric banding technique should determine the best approach to treating these patients. The current standard is laparoscopic with removal of the band and repair of the stomach.

Technique for nonfascial fixation of the laparoscopic adjustable gastric band access port

James Clay Wellborn, Suzan Hayden Wellborn, Trey Wellborn — 2010-02-16

Abstract: Background: Access port complications occur in 10–20% of patients undergoing laparoscopic adjustable gastric banding (LAGB). These have included infection, leakage, difficult access, erosion, pain, and poor cosmetic results requiring revision. Additionally, traditional fascial fixation techniques require longer operative times and fluoroscopic or ultrasound localization, increasing the time, expense, and discomfort associated with LAGB. We report a technique of nonfascial fixation of the LAGB access port with minimal complications.Methods: From August 2001 to August 2007, 1027 consecutive patients underwent LAGB. Of the 1027 patients, 1008 (97%) were available for follow-up for >1 year. The access port was placed in a subcutaneous pocket created 2 cm deep to the skin anterior to the sutures. The group was analyzed for complications requiring revision, operative placement time, ease of access, and the need for radiographic localization of the port.Results: A total of 0 (0%) early postoperative infections and 6 (.6%) late postoperative infections developed. Other complications requiring revision were follows: skin erosions in 2 (.2%), poor cosmetic results in 2 (.2%), malposition in 2 (.2%), and leakage from access trauma in 3 (.3%). Overall, 15 access port complications (1.5%) developed. The port placement time averaged 5 minutes, and no patient required ultrasound or fluoroscopic guidance for access.Conclusions: Nonfascial fixation of the LAGB access port, using a technique familiar to most general surgeons, was associated with fewer complications than traditional fascial fixation. Additionally, the operative time, ease of access, and patient comfort and expense were positively affected by this technique.

Sleeve gastrectomy strictures: technique for robotic-assisted strictureplasty

Ranjan Sudan, George Kasotakis, Allison Betof, Alene Wright — 2010-05-24

With laparoscopic sleeve gastrectomy increasingly used as either a primary bariatric procedure or a component of biliopancreatic diversion with duodenal switch (BPD-DS), complications such as leaks, fistulas, bleeding, and strictures are also becoming evident . Strictures related to the sleeve gastrectomy are an uncommon complication; however, when they occur, they can cause either delayed gastric emptying or gastric obstruction, adding significantly to morbidity. The treatment options for gastric strictures and leaks in the past have included endoscopic dilations and gastrointestinal stents . Conversion to Roux-en-Y gastric bypass proximal to the stricture is also an option; however, strictureplasty of the stenotic area preserves the anatomic configuration and physiologic intent of the original operation. We report on 2 patients with gastric sleeve strictures that were successfully managed with robot-assisted strictureplasties after endoscopic dilation failed.

Laparoscopic technique for redo gastrojejunostomy

Minhao Zhou, John J. Kelly — 2010-05-24

Long-term complications after laparoscopic Roux-en-Y gastric bypass includes gastric pouch dilation, anastomotic stricture, and postprandial nausea and vomiting. Gastric pouch dilation is 1 of the factors that lead to weight regain and can contribute to poor pouch emptying and food stasis. Anastomotic stricture at the gastrojejunal (GJ) anastomosis can usually be treated with endoscopic dilation; however, after repeated dilations, the stricture can become refractory. Laparoscopic revision of the gastric pouch and the GJ anastomosis can be done safely and can be effective in such patients. We present a video demonstrating our technique.

The Dangers of Broccoli

Karen E. Gibbs — 2009-09-22

Limiting oral intake in terms of portion size is one of the means by which weight loss operations such as the gastric bypass are successful. Patients are instructed on learning to improve food selections and how to approach eating after surgery. We present a case of a patient who developed a gastrointestinal perforation after consuming a healthy meal.

Hyperinsulinemic hypoglycemia and liver cirrhosis presenting after duodenal switch: a case report

2009-11-26

Gastric bypass and biliopancreatic diversion with duodenal switch are 2 of the more potent surgical treatment options for morbid obesity . Both techniques are associated with a remarkable improvement of type 2 diabetes . The antidiabetic effects of the procedures can actually be so powerful that, in some cases, patients develop overt hypoglycemia . We report a patient who developed symptomatic hypoglycemia after duodenal switch surgery in the context of compensated liver failure.

Single-incision laparoscopic biliopancreatic diversion

Roberto M. Tacchino, Francesco Greco, Daniele Matera — 2009-11-26

We recently performed the first-single incision laparoscopic Scopinaro biliopancreatic diversion with preservation of the stomach. To our knowledge, this is the first report of a malabsorptive procedure performed using this advanced laparoscopic technique.

Petersen's hernia after laparoscopic Roux-en-Y gastric bypass—case report, diagnostic sign, and proposed classification system

Conor Magee, Robert Macadam, David D. Kerrigan — 2010-05-24

The adoption of laparoscopic Roux-en-Y gastric bypass (LRYGB) has been driven by clear benefits compared with the open procedure, including fewer perioperative complications, a shorter hospital stay, and more rapid recovery . Moreover, the weight loss outcomes have been similar to those achieved with the open approach .

Surgical management of gastric varices and morbid obesity: a novel approach

2010-04-30

Abstract: Background: Morbid obesity is a growing pandemic. The greater prevalence of chronic conditions such as diabetes, hypertension, and heart and liver disease has made management of obesity challenging. Many surgical techniques are in practice, each with some elements of restrictive or malabsorptive components. Nonalcoholic steatohepatitis can lead to portal hypertension, which can further manifest as upper gastrointestinal bleeding.Methods: We performed sleeve gastrectomy at a nonuniversity tertiary care center, as a novel approach for the management of isolated gastric varices, in a morbidly obese cirrhotic patient.Results: The operating time was 142 minutes. The estimated blood loss was 150 mL. The patient did not receive intraoperative or postoperative transfusions. The length of stay was prolonged to 10 days because of an ischemic cardiac event that was managed by coronary angioplasty on postoperative day 7. The patient did not develop any other complications. During the next couple of months, the patient lost significant weight and had no complaints.Conclusion: Sleeve gastrectomy with devascularization is a durable approach that will address the problems of both portal hypertension and morbid obesity, with the desired effect of weight reduction and treatment of gastric varices using a single surgical approach.

Effects of bariatric surgery on joint pain: a review of emerging evidence

2010-03-29

Morbid obesity has been defined as a body mass index (BMI) of >40 kg/m2 and is a serious pubic health concern. Worldwide, >315 million adults are obese . Also, 20% of children have a BMI greater than the 85th percentile, and 77% of these children will carry their excessive weight into adulthood . The prevalence of obesity has been increasing even in the elderly population . Although medical advances in managing the obesity-related metabolic issues have occurred , musculoskeletal conditions and related pain are becoming more prevalent. The prevalence of joint pain increases with a progressively greater BMI . The risk of developing painful joint conditions such as osteoarthritis is increased by 36% for every 2-unit increase (5 kg) in BMI . Joint pain symptoms are particularly prevalent in the load-bearing segments of the body, including the low back and lower limbs . Incapacitation owing to pain contributes to worsening of obesity, gait abnormalities, weakness, and physical disability . Importantly, pain can mediate obesity-induced impairment of physical functioning and deterioration of health-related quality of life (QOL) .

Bariatric surgery, proton pump inhibitors, and possibility of osteoporosis

Mervyn Deitel — 2010-04-26

Bone physiology is affected by a number of complex issues. Obese individuals have increased bone calcium and bone mineral density, related to the increased mechanical load. However, morbidly obese patients frequently develop decreased bone mineral density owing to their lack of activity. Furthermore, obese individuals often avoid exposure of the skin to sunlight because of the potential embarrassment. Thus, patients presenting for bariatric surgery frequently have low serum vitamin D levels owing to a lack skin exposure to ultraviolet sunlight, especially in winter . Low serum vitamin D levels are more prevalent in dark-skinned individuals, who have increased melanin, which blocks the effect of the ultraviolet B radiation on the deeper layers of the epidermis, where vitamin D is converted to its active circulating form, 25-OH vitamin D3. Some bariatric surgery candidates already have secondary hyperparathyroidism because of their low vitamin D3 levels .

Substitution of dalteparin with enoxaparin—a cautionary note

Conor Magee, Jonathan Barry, Shafiq Javed, Robert Macadam, David D. Kerrigan — 2010-05-19

Currently in the United Kingdom, the National Institute for Health and Clinical Excellence guidelines for venous thromboembolism prophylaxis do not discriminate between different low-molecular-weight heparins . Dalteparin was the low-molecular-weight heparin used in our recently published study demonstrating a symptomatic venous thromboembolism incidence of zero .

Erratum

2010-06-21

Relationship between surgeon volume and adverse outcomes after RYGB in Longitudinal Assessment of Bariatric Surgery (LABS) study. Smith MD, Patterson E, Wahed AS, et al. Surg Obes Relat Dis, 2010;6:118–25.

I'm going to divorce him

2010-05-24