Surgery for Obesity and Related Diseases - Articles in Press

Gastric pouch resizing for Roux-en-Y gastric bypass failure in patients with dilated pouch - Accepted Manuscript

Antonio Iannelli, Anne-Sophie Schneck, Xavier Hébuterne, Jean Gugenheim — 2012-05-14

Abstract: Background: Insufficient weight loss or weight regain a few years after laparoscopic Roux-en-Y gastric bypass (RYGB) is becoming a serious problem given the large diffusion of this procedure. In the present paper we analyzed the feasibility and safety of pouch resizing for RYGB failure in a consecutive series of 20 patients. Methods: A prospective held database was questioned regarding patients’ demographic, indication for revision morbidity, % EWL, and evolution of comorbidities. Setting: University Hospital Results/Discussion: Twenty patients, 18 women and 2 men with a mean age of 44 years and a mean body mass index (BMI) at 45.8 kg/m2, underwent pouch resizing. There was no mortality and 6 patients (30 %) developed complications (acute abdomen due to volvulus of the small bowel 1; intra-abdominal abscess 3; pulmonary embolus 2). At a mean follow-up of 20 months percent of excess weight loss (% EWL) is on average 69.1 % and persistent comorbidities improved or resolved. Conclusion: Pouch resizing may be a valuable option in case of weight loss failure or regain in patients with LRYGB dilated gastric pouch and in the short term. Long-term efficacy of this procedure needs to be shown.

Legal And Policy Approaches To The Obesity Epidemic - Accepted Manuscript

Michelle Mello — 2012-05-11

Abstract: Although 85% of the American public believes that obesity is an “epidemic,” there is great controversy over what role the government, public policy, and the law should play in addressing the problem. This keynote address discusses philosophical and economic justifications for treating obesity as a public health problem meriting government intervention and explores possible legal and policy solutions.

Frequencies of obesity susceptibility alleles among ethnically and racially diverse bariatric patient populations - Accepted Manuscript

2012-05-10

Abstract: Background: Genetic factors likely play a role in obesity and outcomes after bariatric surgery. Single Nucleotide Polymorphisms (SNP) in or near the insulin induced gene 2 (INSIG-2), fat mass and obesity-associated gene (FTO), melanocortin 4 receptor gene (MC4R), and proprotein convertase subtilisn/kexin type 1 gene (PCSK-1) have been associated with Class III obesity in Caucasians. There is minimal data regarding genetic susceptibility to obesity in Class III obese non-Caucasians, especially Hispanics. Objective: Comparative analysis of 4 common genetic variants (INSIG-2, FTO, MC4R and PCSK-1) associated with obesity in a diverse population of bariatric surgery patients to determine if a difference exists by ethnicity (White vs. Hispanic). Setting: 2 University Hospitals, United States Methods: Bariatric surgery patients from two different institutions were enrolled prospectively and genotyping was performed. Differences in the distribution of INSIG-2, FTO, MC4R and PCSK-1SNPs among the different ethnicities (Whites and Hispanics) were compared using an additive model (0, 1, or 2 risk alleles). A propensity-matched analysis was used to account for cohort differences. Results: 1276 bariatric patients were genotyped for the INSIG-2, FTO, MC4R and PCSK-1obesity SNPs. Statistically significant differences in FTO, INSIG-2, MC4R, and PCSK-1were seen using an additive model. FTO, PCSK-1, and MC4R (test for trend) remained significantly different in the propensity analysis. Conclusion: Significant difference in the frequencies of several common obesity susceptibility variants in or near FTO, PCSK-1,and MC4R were found in White and Hispanic patients with Class III obesity undergoing bariatric surgery. Larger studies in more Class III obese Hispanics of different nationalities are needed.

Why Won’t My Patients Do What’s Good For Them? Motivational Interviewing and Treatment Adherence - Accepted Manuscript

Allan Zuckoff — 2012-05-07

Abstract: Limited adherence to healthy habits in adults at risk for lifestyle diseases, some of whom become candidates for bariatric surgery, is paralleled by high rates of non-adherence to post-bariatric surgery behavioral recommendations, which comprise a specific case of the more general problem of non-adherence to medical treatments for chronic conditions. An adequate understanding of the problem of non-adherence requires an understanding of the motivational factors that influence whether or not people implement healthy behavior. Motivational interviewing, an empirically supported counseling style for strengthening a person’s own motivation and commitment to change, offers a model for understanding and intervening with non-adherence to behavioral recommendations that emphasizes the role of clinician communication in both increasing and inadvertently decreasing patient motivation. A conceptual account of patient motivation for healthy change, highlighting the centrality of resolution of patient ambivalence through targeted conversation, is illustrated with thought exercises for the reader and supplemented by references to the empirical literature. Recommendations for changes in clinical practice to improve patient adherence to behavioral recommendations are offered.

Editorial comment - Uncorrected Proof

Robert O. Carpenter — 2012-04-23

Laparoscopic placement of adjustable gastric banding (LAGB) was first reported in the early 1990s, with wide application in European countries during the waning years of the 20th century. After Food and Drug Administration approval of the first LAGB device for use in the United States on June 5, 2001, the operation rapidly gained market share and remains 1 of the most common bariatric procedures selected by Americans in their personal struggle with obesity. LAGB is purported, in both the lay press and medical reports, to have a lower perioperative risk profile than many other operative options available while offering sustained weight loss and acceptable co-morbidity remission in well-selected patients . However, questions remain regarding the long-term implications and merits of banding. The role of aftercare compliance, including the frequency of formal assessment and adherence to lifestyle changes, are arguably even more essential in the post-LAGB population than among patients who choose other procedures. Although longitudinal studies do exist, they have tended to focus their efforts on detailing the technical results, such as the degree of weight lost, co-morbidity improvement, and medium-term sustainment trends. However, rare is the insight provided into the more difficult issues of true reoperative rates, delayed recidivism, and the frequency of complications many years postoperatively. Despite being touted as “easily reversible,” LABG is undertaken to treat a chronic disease and its co-morbidities during a postoperative lifetime of decades . Furthermore, after LAGB reversal, weight regain is common, and the patient has undergone 2 operations, often without a therapeutic effect. If the patient requires conversion to another procedure, the risk of morbidity might be greater than if that procedure had been performed initially. A better understanding of these facts is increasingly important, as the number of procedures and diversity of the patient population are increasing, given the Food and Drug Administration's approval for use of 1 LAGB device among patients with a body mass index of 30 and 35 kg/m2, as well as ongoing efforts by the manufacturer for use in obese adolescents .

Patients' experience and outcomes after laparoscopic adjustable gastric banding in Washington state - Corrected Proof

2012-04-16

Abstract: Background: There is very little evidence regarding the real world experience and outcomes after laparoscopic adjustable gastric banding (LAGB). Our objective was to estimate the amount of postoperative weight loss, change in co-morbidity status, and complications after LAGB. The setting was LAGB surgical centers in Washington state. Methods: A cross-sectional survey was developed to collect primary data from patients who had undergone LAGB in Washington state from 2004 to 2010. The survey contained questions on patient characteristics, weight change, co-morbidities, and complications after LAGB surgery. We used descriptive and other statistical tests to evaluate our key research questions by the period since LAGB. Results: A total of 1556 surveys were sent out, and 790 were returned (response rate 50.8%). Responders were categorized into 4 groups according to the follow-up period: <2, 2–3, 3–4, and >4 years. The corresponding average body mass index reduction in each group was 21.0%, 22.5%, 21.3%, and 20.4%. Of the respondents, 21.7%, 34.8%, 44.6%, and 38.7% indicated they did not have any adjustments in the year preceding the survey. The percentage of respondents who had undergone additional operations related to LAGB was 8.6%. Specifically, 3.6% of the respondents had undergone either band removal or conversion to another type of bariatric operation. Conclusion: We found that although LAGB appeared to be beneficial for weight reduction and improving co-morbidities, the underuse of band adjustments and significant rate of treatment failure might limit the long-term effectiveness of LAGB.

Outcomes of bariatric surgery in patients >70 years old - Uncorrected Proof

2012-04-16

Abstract: Background: The aim of the present study was to report the outcomes of bariatric surgery in patients >70 years of age at a community hospital in the United States. Methods: A retrospective review was performed of prospectively collected data from patients aged >70 years who had undergone bariatric surgery at a single institution from 2002 to 2008. The data analyzed included age, preoperative and postoperative weight and body mass index, postoperative complications, and co-morbidities. Results: Of 42 patients aged >70 years who underwent bariatric surgery, 22 patients (52.4%) had undergone laparoscopic gastric banding, 12 patients (28.6%) laparoscopic sleeve gastrectomy, and 8 patients (19%) laparoscopic Roux-en-Y gastric bypass. The mean preoperative weight and body mass index was 127.4 ± 25.5 kg and 46.8 ± 9.3 kg/m2, respectively. The mean postoperative weight and body mass index was 100.2 ± 17 kg and 35.5 ± 5.4 kg/m2, respectively. The median length of follow-up was 12 months (range 1–66). The mean percentage of excess weight loss was 47.7% at 12 months, with 73.1% follow-up data. Complications included wound infections in 4 patients (9.5%), band removal in 3 patients (7.1%), anastomotic leak in 1 patient (2.3%), and megaesophagus in 1 patient (2.3%). No mortality occurred. The postoperative use of medications for hypertension, hyperlipidemia, diabetes mellitus, and degenerative joint disease were reduced by 56%, 54%, 53%, 66%, and 50%, respectively. Conclusion: Bariatric surgery in carefully screened patients aged >70 years can be performed safely and can achieve modest improvement in co-morbidities.

Effect of bariatric surgery-induced weight loss on renal and systemic inflammation and blood pressure: a 12-month prospective study - Corrected Proof

2012-04-12

Abstract: Background: Bariatric surgery improves arterial hypertension and renal function; however, the underlying mechanisms and effect of different surgical procedures are unknown. In the present prospective study, we compared the 12-month follow-up results after Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, and laparoscopic sleeve gastrectomy on weight loss, hypertension, renal function, and inflammatory status. Methods: A total of 34 morbidly obese patients were investigated before, one and 12 months after Roux-en-Y gastric bypass (n = 10), laparoscopic adjustable gastric banding (n = 13), and laparoscopic sleeve gastrectomy (n = 11) for hypertension, kidney function, urinary and serum cytokine levels of macrophage migration inhibitory factor, monocyte chemotactic protein-1, and chemokine ligand-18. Results: At 12 months after surgery, the patients in all 3 treatment arms showed a significant decrease in the mean body mass index, mean arterial pressure, and urinary and serum inflammatory markers (all P < .001). The reduction in urinary and serum cytokine levels correlated directly with body weight loss (P < .05). Patients with impaired renal function at baseline (corresponding to serum cystatin C >.8 mg/L) had a marked improvement in renal function 12 months after surgery (P < .05). Conclusion: Surgically induced weight loss is associated with a marked decrease in renal and systemic inflammation and arterial hypertension and improvement in renal function in patients with pre-existing renal impairment. These effects appear to be independent of surgical procedure. The improvement in renal inflammation could be 1 of the mechanisms contributing to the beneficial effects of bariatric surgery on arterial blood pressure, proteinuria, and renal function.

Endoscopic neogastrogastrostomy in a postgastric bypass patient by application of an endoscopic antegrade–retrograde rendezvous technique - Corrected Proof

Shahzad Iqbal, Marc Bessler, Peter D. Stevens, Amrita Sethi — 2012-04-12

The patient, a 45-year-old woman, initially underwent Roux-en-Y gastric bypass for morbid obesity. Three years later, it was complicated by a gastrojejunostomy ulcer with perforation requiring local repair. Additional complications with ischemic bowel and subsequent surgical revisions resulted in complete gastric outlet obstruction. A venting gastrostomy tube was placed in the gastric pouch, and a feeding gastrostomy tube was surgically placed in the gastric remnant. After some time, the patient strongly expressed her desire to eat orally. Because of the previous surgical complications and scar tissue, the surgical team requested an endoscopic attempt to reconnect the gastric pouch and excluded gastric remnant.

Robotic bariatric surgery: a systematic review - Corrected Proof

Matthew M. Fourman, Alan A. Saber — 2012-04-05

Abstract: Background: Obesity is a nationwide epidemic, and the only evidence-based, durable treatment of this disease is bariatric surgery. This field has evolved drastically during the past decade. One of the latest advances has been the increased use of robotics within this field. The goal of our study was to perform a systematic review of the recent data to determine the safety and efficacy of robotic bariatric surgery. The setting was the University Hospitals Case Medical Center (Cleveland, OH). Methods: A PubMed search was performed for robotic bariatric surgery from 2005 to 2011. The inclusion criteria were English language, original research, human, and bariatric surgical procedures. Perioperative data were then collected from each study and recorded. Results: A total of 18 studies were included in our review. The results of our systematic review showed that bariatric surgery, when performed with the use of robotics, had similar or lower complication rates compared with traditional laparoscopy. Two studies showed shorter operative times using the robot for Roux-en-Y gastric bypass, but 4 studies showed longer operative times in the robotic arm. In addition, the learning curve appears to be shorter when robotic gastric bypass is compared with the traditional laparoscopic approach. Most investigators agreed that robotic laparoscopic surgery provides superior imaging and freedom of movement compared with traditional laparoscopy. Conclusion: The application of robotics appears to be a safe option within the realm of bariatric surgery. Prospective randomized trials comparing robotic and laparoscopic outcomes are needed to further define the role of robotics within the field of bariatric surgery. Longer follow-up times would also help elucidate any long-term outcomes differences with the use of robotics versus traditional laparoscopy.

Gastric emptying is not prolonged in obese patients - Corrected Proof

2012-04-05

Abstract: Background: Obesity is associated with a poor anesthetic risk, in part because of the greater aspiration rates. A greater gastric residue and lower stomach pH have been implicated. The relationship of obesity to gastric emptying is ill-defined. with contradicting reports stating shorter, similar, and longer times compared with nonobese subjects. The aim of the present study was to compare gastric emptying in obese and nonobese subjects at a university hospital. Methods: A total of 19 obese (body mass index [BMI] >40 kg/m2) and 20 nonobese (BMI <30 kg/m2) subjects underwent a standardized scintigraphic gastric emptying study. The participants consumed a standard semisolid, technetium-99m-labeled meal. Images were acquired immediately and 1, 2, and 4 hours after meal completion. The interval to evacuate one half of the counts measured at meal completion) and retention (the percentage of counts in stomach at each measurement point) were recorded. Results: The mean age and BMI was 35 years and 45 kg/m2 in the obese and 44 years and 26 kg/m2 in the nonobese group, respectively. No differences were found between the 2 groups regarding gastric emptying. Regression analysis showed no statistical association between the BMI and gastric emptying, including multivariate analysis, considering BMI, age, and gender. Conclusion: A scintigraphy test of a labeled meal was used to evaluate gastric emptying in obese and nonobese subjects. In accordance with other published data, no significant difference was found between the 2 groups. The anesthetic risks in the obese should be attributed to factors other than delayed gastric emptying (i.e., anatomic variation, increased rates of hiatal hernia and reflux).

Changes in weight and co-morbidities among adolescents undergoing bariatric surgery: 1-year results from the Bariatric Outcomes Longitudinal Database - Corrected Proof

2012-03-30

Abstract: Background: Bariatric surgery is 1 of the few effective treatments of morbid obesity. However, the weight loss and other health-related outcomes for this procedure in large, diverse adolescent patient populations have not been well characterized. Our objective was to analyze the prospective Bariatric Outcomes Longitudinal Database (BOLD) to determine the weight loss and health related outcomes in adolescents. The BOLD data are collected from 423 surgeons at 360 facilities in the United States. Methods: The main outcome measures included the anthropometric and co-morbidity status at baseline (n = 890) and at 3 (n = 786), 6 (n = 541), and 12 (n = 259) months after surgery. Adolescents (75% female; 68% non-Hispanic white, 14% Hispanic, 11% non-Hispanic black, and 6% other) aged 11 to 19 years were included in the present analyses. Results: The overall 1-year mean weight loss for those who underwent gastric bypass surgery was more than twice that of those who underwent adjustable gastric band surgery (48.6 versus 20 kg, P < .001). Similar results were found for all other anthropometric changes and comparisons within 1 year between surgery types (P < .001). In general, the gastric bypass patients reported more improvement than the adjustable gastric band patients in co-morbidities at 1 year after surgery. A total of 45 readmissions occurred among gastric bypass patients and 10 among adjustable gastric band patients, with 29 and 8 reoperations required, respectively. Conclusions: The weight loss at 3, 6, and 12 months after surgery is approximately double in adolescent males and females who underwent gastric bypass surgery versus those who underwent adjustable gastric band surgery. Bariatric surgery can safely and substantially reduce weight and related co-morbidities in morbidly obese adolescents for ≥1 year.

Long-term results 11 years after primary gastric bypass in 384 patients - Uncorrected Proof

2012-03-26

Abstract: Background: Roux-en-Y gastric bypass surgery (RYGB) as treatment of morbid obesity results in substantial weight loss. Most published long-term studies have included few patients at the last follow-up point. The aim of the present study was to explore long-term results in a large cohort of patients 7–17 years after gastric bypass. Methods: All 539 patients who had undergone primary RYGB from 1993 to 2003 at Uppsala and Örebro University Hospitals received a questionnaire regarding their postoperative status. Blood samples were obtained and the medical charts studied. Results: Of the 539 patients, 384 responded (71.2% response rate, mean age 37.9 yr, body mass index 44.5 kg/m2 at surgery, 317 women, and 67 men). At a mean follow-up of 11.4 years (range 7–17), the body mass index had decreased to 32.5 kg/m2, corresponding to an excess body mass index loss of 63.3%. Similar weight loss was observed, regardless of the length of follow-up. Orally treated diabetes resolved in 72% and sleep apnea and hyperlipidemia were improved. Revisional bariatric surgery had been performed in 2.1% and abdominoplasty in 40.2%. The gastrointestinal symptoms were considered tolerable. The overall result was satisfactory for 79% of the patients and 92% would recommend Roux-en-Y gastric bypass to a friend. Attendance to the annual checkups was 37%. Vitamin B12 supplements were taken by 72% and multivitamins by 24%. Conclusion: At 11 years, substantial weight loss was maintained and revisional surgery was rare. Surprisingly few patients were compliant with the recommendation of lifelong supplements and yearly evaluations; however, patient satisfaction was high.

Medical versus surgical treatment of type 2 diabetes: the search for level 1 evidence - Uncorrected Proof

2012-03-23

Abstract: Data from observational and nonrandomized comparative studies have shown a dramatic effect of bariatric surgery on type 2 diabetes mellitus (T2DM), including in nonobese patients. However, a relative paucity of level 1 evidence is available to define the exact role of surgery as a treatment modality for T2DM, especially in less obese subjects. Performing randomized clinical trials in this field, however, poses significant and specific challenges for the study design. We have addressed such challenges in a carefully designed randomized controlled trial comparing glycemic control with optimal medical management versus Roux-en-Y gastric bypass in overweight to mildly obese patients with T2DM mellitus (body mass index 26–35 kg/m2). The present report describes the rationale and design of the Weill Cornell Medical College study. In addition to glycemic endpoints, however, clinical trials should also investigate the effect of surgery on cardiovascular risk or T2DM-specific morbidity. Addressing these endpoints would entail large, randomized clinical trials with prolonged period of observation and ideally a multicenter study design. Such a multisite trial poses substantial logistical and financial challenges, which would predictably delay rather than accelerate progress of research in this field. A consortium of centers performing independent small and medium size randomized clinical trials may provide a more realistic and feasible approach. In this paper, we present an overview of on-going randomized clinical trials in this field and propose a worldwide consortium of randomized controlled trials (WORLDCoRDS) using the Weill Cornell Medical College protocol. The aim of this consortium is to standardize research in T2DM surgery and timely accumulate homogeneous data that can help assess the effects of GI surgery on cardiovascular risk and T2DM-related mortality and morbidity.

Importance of hospital versus surgeon volume in predicting outcomes for gastric bypass procedures - Corrected Proof

Justin E. Torrente, Robert N. Cooney, Ann M. Rogers, Christopher S. Hollenbeak — 2012-03-23

Abstract: Background: A relationship between surgical volume and improved surgical outcomes has been described in gastric bypass patients but the relative importance of surgeon versus hospital volume is unknown. Our objective was to examine whether in-hospital and 30-day mortality are determined more by surgeon volume or hospital volume or whether each has an independent effect. A retrospective cohort study was performed of all hospitals in Pennsylvania providing gastric bypass surgery from 1999 to 2003. Methods: Data from the Pennsylvania Health Care Cost Containment Council included 14,714 gastric bypass procedures in patients aged >18 years. In-hospital and 30-day mortality were stratified by hospital volume categories (high [≥300], medium [125–299], and low [< 125]) and surgeon volume categories (high [≥50] and low [< 50]). Multivariate analyses were performed using logistic regression analysis to control for patient demographics and severity. Results: High-volume surgeons at high-volume hospitals had the lowest in-hospital mortality rates of all categories (.12%) and low-volume surgeons at low-volume hospitals had the poorest outcomes (.57%). The same trend was observed for 30-day mortality (.30% versus .98%). After controlling for other covariates, high-volume surgeons at high-volume hospitals also had significantly lower odds of both in-hospital (odds ratio 20, P = .002) and 30-day mortality (odds ratio .30, P = .001). This relationship held true even after excluding surgeons who only performed procedures within a single year. Conclusion: In Pennsylvania, both higher surgeon and hospital volume were associated with better outcomes for bariatric surgical procedures. Although a high-surgeon volume correlated with lowered mortality, we also found that high-volume hospitals demonstrated improved outcomes, highlighting the importance of factors other than surgical expertise in determining the outcomes.

Risk factors for acute respiratory failure in bariatric surgery: data from the Nationwide Inpatient Sample, 2006–2008 - Corrected Proof

2012-03-23

Abstract: Background: Acute respiratory failure (ARF) can be a life-threatening postoperative complication after bariatric surgery and is defined as the presence of acute respiratory distress or pulmonary insufficiency. We sought to identify predictors of ARF in patients who underwent bariatric surgery. Methods: Using the Nationwide Inpatient Sample database, from 2006 to 2008, the clinical data from morbidly obese patients who underwent bariatric surgery were examined. Multivariate regression analysis was performed to identify the independent factors predictive of ARF. The factors examined included patient characteristics, co-morbidities, payer type, teaching status of hospital, surgical techniques (laparoscopic versus open), and type of bariatric operation (gastric bypass versus nongastric bypass). Results: A total of 304,515 patients underwent bariatric surgery during the 3-year period. The overall ARF rate was 1.35%. The greatest rate of ARF (4.10%) was observed after open gastric bypass surgery. The ARF rate was lower after laparoscopic than after the open surgical technique (.94% versus 3.87%, respectively; P < .01) and after nongastric bypass versus gastric bypass (.82% versus 1.54%, respectively; P < .01). Using multivariate regression analysis, congestive heart failure (adjusted odds ratio [AOR] 5.1), open surgery (AOR 3.3), chronic renal failure (AOR 2.9), gastric bypass (AOR 2.5), peripheral vascular disease (AOR 2.4), male gender (AOR 1.9), age >50 years (AOR 1.8), Medicare payer (AOR 1.8), alcohol abuse (AOR 1.8), chronic lung disease (AOR 1.6), diabetes mellitus (AOR 1.2), and smoking (AOR 1.1) were factors associated with greater rates of ARF. Compared with patients without ARF, patients with ARF had significantly greater in-hospital mortality (5.69% versus .04%, P < .01). Conclusion: We identified multiple risk factors that have an effect on the development of acute respiratory failure after bariatric surgery. Surgeons should consider these factors in surgical decision-making and inform patients of their risk of this potentially life-threatening complication.

Comment on: Risk factors for acute respiratory failure in bariatric surgery: data from the Nationwide Inpatient Sample (NIS), 2006-2008 - Uncorrected Proof

R. Armour Forse — 2012-03-23

Bariatric surgery is relatively safe. Complications are relatively infrequent; however, the most common complications are pulmonary. As we meet with our preoperative patient, it is important to be able to predict the patients at risk of pulmonary complications, not only in terms of informed consent and choosing a specific operation, but also in terms of realizing the opportunities to provide optimal preoperative preparation for the bariatric surgery. The report titled “Risk Factors for Acute Respiratory Failure in Bariatric Surgery: Data from the Nationwide Inpatient Sample, 2006–2008,” published in this issue of the Journal is a clinical study of bariatric patients undergoing surgery using a large database of insurance data to determine the risk factors for pulmonary complications. The study used the Nationwide Inpatient Sample database, from 2006 to 2008, and the clinical data of 304,515 morbidly obese patients who underwent bariatric surgery, an impressive number of patients. However, a database of this size is required for such a study. The authors used multivariate regression analysis and identified independent factors that appeared predictive of acute respiratory failure. They found that overall pulmonary complications were relatively infrequent but that when pulmonary complications occurred, the mortality from bariatric surgery greatly increased. The major factors that played a role included open surgery and the type of surgical procedure. In addition, they found that congestive heart failure, chronic renal failure, peripheral vascular disease, male gender, age >50 years, Medicare insurance, alcohol abuse, chronic lung disease, diabetes mellitus, and smoking were all factors associated with a greater rate of acute respiratory failure. The authors concluded that patients undergoing bariatric surgery must have their respiratory risk calculated and that surgeons should use these risk factors in surgical decision making and when providing informed consent.

A pilot study investigating the efficacy of postoperative dietary counseling to improve outcomes after bariatric surgery - Uncorrected Proof

2012-03-23

Abstract: Background: Bariatric surgery is a powerful treatment of severe obesity. During the past several years, a greater appreciation for the need for multidisciplinary care to optimize outcomes has developed, and a number of studies have been started to examine the role of postoperative interventions used in combination with surgery. The purpose of the present study was to investigate the hypothesis that the provision of postoperative dietary counseling, delivered by a registered dietitian, would lead to greater weight loss and more positive improvements in dietary intake and eating behavior compared with standard postoperative care. The study was performed at an academic medical center. Methods: Eighty-four individuals who underwent bariatric surgery were randomly assigned to receive either dietary counseling or standard postoperative care for the first 4 months after surgery. The participants completed measures of macronutrient intake and eating behavior at baseline and 2, 4, 6, 12, 18, and 24 months after surgery. Results: The patients who received dietary counseling achieved greater weight loss than those who received standard postoperative care that did not involve this counseling, although this difference did not reach statistical significance. Patients in the dietary counseling arm did report significant changes in several eating behaviors believed to be important to successful long-term weight maintenance. Conclusion: The results of our pilot study provide some support for the efficacy of early postoperative dietary counseling to improve outcomes after bariatric surgery.

Treatment of leaking gastrojejunostomy after gastric bypass surgery with special emphasis on stenting - Corrected Proof

2012-03-22

Abstract: Background: Gastric bypass is one of the most common operations for morbid obesity. One of the most feared complications is a leak, most commonly encountered in the gastrojejunal anastomosis (GJA), leading to significant morbidity and increased costs. Our objective was to evaluate the effectiveness of stenting leaks in the GJA. The setting was a university hospital in Stockholm, Sweden. Methods: We performed a retrospective analysis of all gastric bypasses from January 2001 to August 2011, with special reference to the treatment of leaks in the GJA. Results: A postoperative leak in the GJA occurred in 69 of 2214 patients. The risk was greater with open surgery and revisional surgery. The risk was also greater with age >50 years but not with a body mass index >50 kg/m2. There was no mortality. In the later part of the series, stents were used, with a stent time of 2 weeks. The migration rate was 23%, and need for restenting was 20%. Conclusion: It is safe and advantageous to use stents in the treatment of leaks at the GJA. Patients can be on oral nutrition and oral medication, reducing the need for in-hospital care.

Pancreaticoduodenectomy for pancreatic carcinoma after complicated open Roux-en-Y gastric bypass surgery: an alternative approach to reconstruction - Corrected Proof

Ioannis Theodoropoulos, Charles Franco, James E. Gervasoni — 2012-03-22

Roux-en-Y gastric bypass surgery is 1 of the most effective weight loss procedures performed to date in bariatric surgery. This type of procedure has proved to offer reliable weight loss in all age groups. Its efficacy relies on a restrictive (gastric pouch) and a malabsorptive (long Roux limb) component. In the past, Roux-en-Y gastric bypass operations were performed almost exclusively using an open laparotomy incision. Now, however, most are performed laparoscopically. Subsequent surgery in the upper abdomen becomes extremely complicated if the gastric bypass procedure was performed using an open approach and especially if several laparotomies were needed for revision of the anastomoses, obstruction, or perforations. In such cases, the surgeon should anticipate the formation of extensive adhesions and disruption of the planes in the lesser sack and distorted anatomy. We report on a patient who underwent pancreaticoduodenectomy for pancreatic carcinoma after open gastric bypass surgery and subsequent laparotomy for revision of the gastric remnant several years later. The published data on these complicated bariatric patients is lacking and needs enhancement.

Multiple transient small bowel intussusceptions encountered during laparoscopic Roux-en-Y gastric bypass - Corrected Proof

Yves Borbély, Philipp Nett, Daniel Candinas — 2012-03-14

Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric procedure. A comprehensive preoperative evaluation is performed to detect possible gastrointestinal irregularities. However, except for the duodenum, an assessment of the small bowel is usually not performed. Few reports regarding the management of intraoperative detected pathologies of the small bowel have been published.

Exploration of esophageal hiatus: does crural repair reduce proximal pouch distension? - Corrected Proof

John B. Dixon, Christopher S. Cobourn — 2012-03-14

Abstract: Background: Repair of a hiatal hernia during laparoscopic adjustable gastric banding is advisable; however, the practice of more active esophageal hiatus exploration and repair has been promoted with an expectation of reducing proximal gastric pouch distension (PPD). Our objective was to explore the relationship between crural exploration and repair (CR) and PPD in a private practice in Canada. Methods: The data from 3000 consecutive patients who underwent primary laparoscopic adjustable banding procedures at a single center from February 2005 to May 2011 were examined. Several analyses were performed, with the PPD cases carefully matched to historic (time-of-placement) and historic-, age-, and gender-matched controls. Results: Throughout the series, the PPD rates decreased and the CR rates increased. Revision for PPD was performed in 132 patients (4.4%). The patients with PPD were more likely to have undergone CR during primary surgery (odds ratio 1.5, 95% confidence interval 1.2–2.2, P = .001) compared with historic, and historic-, age-, and gender-matched controls (odds ratio 2.3, 95% confidence interval 1.4–3.8, P < .001). The findings were confirmed using adjusted binary logistic regression analysis controlling for age, gender, body mass index, and time-of-placement. This increased risk was most evident early in the series when incident PPD cases were greater. However, at no stage did CR reduce the risk of symmetric or asymmetric PPD. Conclusion: The results of the present analysis do not support the theory that increased exploration and repair of the esophageal hiatus reduces the incidence of PPD. There might be a role for CR at surgery for specific clinical indications. CR increases the complexity and possibly the risk of the procedure.

Comment on: Effect of primary versus revisional Roux-en-Y gastric bypass: inferior weight loss of revisional surgery after gastric banding - Corrected Proof

Bipan Chand — 2012-03-14

I would like to congratulate the authors of this report on a well-executed and important study. With the dramatic increase in the prevalence of obesity, as well as the increase in the number of different surgical modalities used in its treatment, it is our obligation to continually re-evaluate our successes and failures. Inevitably, there will be failures with each of these therapies and the need for revisional surgery. The authors retrospectively reviewed a group of patients who had undergone adjustable gastric banding and then required conversion to gastric bypass for either inadequate weight loss or complications related to the band. They compared this group of revisions to patients undergoing primary gastric bypass and described the perioperative outcomes, medical co-morbidity changes, and short-term weight loss. The report also focused on the surgical differences in pouch creation between the 2 groups and infers that this might subsequently lead to the difference in weight loss between the 2 groups.

Routine single-port sleeve gastrectomy: a study of 60 consecutive patients - Corrected Proof

2012-03-14

Abstract: Background: Single-port surgery has been developed for many digestive procedures, such as cholecystectomy and colectomy. Our objective was to present our preliminary results for laparoscopic single-port sleeve gastrectomy (SPSG), performed in our department for the treatment of morbid obesity, at Antoine Beclere Hospital and Paris XI University. Methods: From July 2010 to February 2011, all patients evaluated by our multidisciplinary team for morbid obesity and eligible for sleeve gastrectomy underwent SPSG. The data were collected prospectively. Results: Sixty consecutive patients underwent SPSG. The median age was 40.1 years; 6 patients were men and 48 were white. The median body mass index was 46.5 kg/m2. The co-morbidities included diabetes in 12, essential hypertension in 31, sleep apnea in 39, dyslipidemia in 33, and coronary artery disease in 9. Of the 60 patients, 9 had previously undergone laparotomy and 5 had undergone bariatric surgery. The median operating time was 86 minutes. All procedures were achieved laparoscopically, with 10 patients requiring a second trocar and 3 patients 2 additional trocars. No conversion to open surgery was required. One leak was reported, and 1 patient experienced cubital nerve compression. The median hospital stay was 4 days. During a median follow-up of 8 months, most preoperative co-morbidities resolved, and the Bariatric Analysis and Reporting Outcome System score for care efficacy was 6.8 of 9. Conclusion: SPSG is feasible in routine bariatric surgery. The results for weight loss and co-morbidity resolution seem to be equivalent to those with “multiple port” laparoscopy. New instruments and specific training are required. We believe that this technique is a natural evolution of minimally invasive surgery requiring additional investigation in prospective studies.

Abdominal compartment syndrome after laparoscopic Roux-en-Y gastric bypass: a case report - Corrected Proof

Chih-Kun Huang, Rajat Goel, Po-Chih Chang — 2012-03-14

Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass (LRYGB) can be attributed to internal hernias, adhesions, or jejunojejunostomy stricture . An underlying etiology or acquired abnormal anatomy, such as previous abdominal surgery, the creation of the Roux limb-related mesenteric defect, or luminal stricture due to mechanical stapling, can complicate postoperative recovery and predispose to this intractable condition . However, abdominal compartment syndrome (ACS), a rare abdominal pathologic finding, has never been reported to be associated with small bowel obstruction after bariatric surgery . We report the case of a 55-year-old woman who developed ACS secondary to jejunojejunal anastomotic stricture after LRYGB.

Is bariatric surgery safe in patients who refuse blood transfusion? - Corrected Proof

Seiichi Kitahama, Mark D. Smith, David R. Rosencrantz, Emma J. Patterson — 2012-03-14

Abstract: Background: A small, but significant, number of patients undergoing bariatric surgery refuse blood transfusion for religious or other personal reasons. Jehovah's Witnesses number more than 1 million members in the United States alone. The reported rates of hemorrhage vary from .5% to 4% after bariatric surgery, with transfusion required in one half of these cases. Pharmacologic prophylaxis against venous thromboembolism could further increase the perioperative bleeding risk. Our objective was to report the perioperative outcomes of bariatric surgery who refuse blood transfusion at a bariatric center of excellence, private practice in the United States. Methods: A retrospective review of all patients who refused blood transfusion when undergoing bariatric surgery during a 10-year period was conducted. Patients were identified from a prospectively maintained database by the bloodless surgery program at Legacy Good Samaritan Hospital. Data were collected on demographics, co-morbidities, laboratory values, medication use, blood loss, and 30-day complications. Results: Thirty-five bloodless surgery patients underwent bariatric surgery from 2000 to 2009. Of these 35 patients, 21 underwent laparoscopic adjustable gastric banding and 14 Roux-en-Y gastric bypass. Before 2006, only pneumatic compression devices were applied for venous thromboembolism prophylaxis (n = 6). Subsequently, combination venous thromboembolism prophylaxis was performed with fondaparinux sodium 2.5 mg for RYGB or enoxaparin 40 mg for LAGB (n = 29). One RYGB patient developed postoperative hemorrhage requiring reoperation. No venous thromboembolisms or deaths occurred. Conclusion: Bariatric surgery can be performed in patients who refuse blood transfusion with acceptable postoperative morbidity. Larger studies are necessary to confirm the safety of this approach and to examine the effect of pharmacologic thromboprophylaxis in this patient group.

Effect of primary versus revisional Roux-en-Y gastric bypass: inferior weight loss of revisional surgery after gastric banding - Corrected Proof

2012-03-09

Abstract: Background: Laparoscopic adjustable gastric banding is a popular and effective restrictive bariatric procedure. However, with longer follow-up, it has become clear that a considerable number of patients require revisional surgery, of which Roux-en-Y gastric bypass (RYGB) is the most commonly performed procedure. Studies that compared the outcomes of primary RYGB and revisional RYGB have not been conclusive. Our objective was to determine whether significant differences exist in the 1-year outcomes between primary RYGB (prim-RYGB) and revisional RYGB after laparoscopic adjustable gastric banding (rev-RYGB) at a major training hospital in The Netherlands. Methods: All prim-RYGB and rev-RYGB procedures performed from 2007 to 2009 were analyzed. Data were collected regarding weight loss, hospitalization, operative time, postoperative complications, and co-morbidities. Results: A total of 292 RYGB procedures were performed: 66 rev-RYGB and 226 prim-RYGB procedures. The operative time was significantly shorter in the prim-RYGB group (136.6 ± 37.5 versus 167.5 ± 40.6 min; P < .0001). No significant differences were found in hospitalization time (4.4 ± 1.7 versus 4.9 ± 2.4 d; P = .063) or complication rate (14.7% versus 15.2%; P = .962). No deaths occurred in either group. The number of patients with resolved diabetes and hypertension did not differ between the 2 groups (50.1% versus 23.1%; P = .116; and 40.7% versus 25.0%; P = .384, respectively). Weight loss was significantly greater in the prim-RYGB group in terms of excess weight loss (71.6% ± 20.8% versus 48.4% ± 26.8%; P < .0001), body mass index reduction (13.0 ± 3.8 versus 10.2 ± 5.6 kg/m2; P < .0001), absolute weight loss (37.4 ± 11.5 versus 29.3 ± 17.2 kg; P = .001), and percentage of weight loss (29.7% ± 8% versus 21.7% ± 11.5%; P < .0001). Conclusion: rev-RYGB is a safe procedure with outcomes similar to those of prim-RYGB in terms of complication rate, hospitalization time, and effect on co-morbidity. Weight loss, however, was significantly less after rev-RYGB than after prim-RYGB.

Comment on: Revisional surgery after adjustable gastric banding: A growing practice - Corrected Proof

Melissa Bagloo — 2012-03-05

Revisional surgery is a growing concern in the field of bariatrics. Regardless of the procedure, there are a percentage of patients who experience poor weight loss or weight regain. Weight loss failure, however, is more prominent for the laparoscopic adjustable gastric band (LAGB) than for Roux-en-Y gastric bypass (RYGB) . The adjustable gastric band was approved by the Food and Drug Administration for clinical use in the United States in 2001. It has been used for an additional decade in Europe and Australia. Initially, the adjustable gastric band was met with great enthusiasm, given the low operative complication rate and effective weight loss profile. Recently, increasing studies have discussed the long-term complications and weight loss failure associated with the adjustable gastric band .

Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Roux-en-Y gastric bypass in superobese patients - Corrected Proof

Philippe Topart, Guillaume Becouarn, Patrick Ritz — 2012-03-05

Abstract: Background: Although biliopancreatic diversion with duodenal switch (BPD-DS) is not the most performed procedure, Roux-en-Y gastric bypass (RYGB) is challenged by weight regain and insufficient weight loss, especially in patients with a body mass index >50 kg/m2. The aim of our retrospective study was to compare the weight loss after 2 types of primary bariatric surgery. A total of 83 BPD-DS and 97 RYGB procedures were performed from March 2002 to October 2009 for an initial mean body mass index of 55 kg/m2. Methods: All RYGB patients underwent surgery at a private practice hospital and BPD-DS patients underwent surgery at a university hospital before February 2007 and at the same private hospital thereafter. The patients were seen in follow-up every 4 months the first year, every 6 months the second, and yearly thereafter. The maximum weight loss was assessed, as well as the weight regain beyond the first postoperative year. Weight loss success was defined as a percentage of excess weight loss (%EWL) of ≥50%. Results: The patients did not differ by age, gender, or length of follow-up (mean 46 mo, range .5–102 for RYGB and 44.3 mo, range 9–111 for BPD-DS). Of the patients, 17 RYGB and 7 BPD-DS patients were lost to follow-up within 3 years postoperatively. At 3 years of follow-up, the mean %EWL was 63.7% ± 17.0% after RYGB and 84.0% ± 14.5% after BPD-DS (P < .0001). Weight loss success was achieved by 83.5% of the RYGB and 98.7% of the BPD-DS patients (P = .0005). Conclusion: After 12 months postoperatively, the number of patients regaining 10% of the weight lost during the first postoperative year was significantly greater after RYGB than after BPD-DS.

Effect of bypassing proximal gut on gut hormones involved with glycemic control and weight loss - Corrected Proof

2012-03-02

Abstract: Background: The reported remission of type 2 diabetes in patients undergoing Roux-en-Y gastric bypass has brought the role of the gut in glucose metabolism into focus. Our objective was to explore the differential effects on glucose homeostasis after oral versus gastrostomy glucose loading in patients with Roux-en-Y gastric bypass at an academic health science center. Methods: A comparative controlled investigation of oral versus gastrostomy glucose loading in 5 patients who had previously undergone gastric bypass and had a gastrostomy tube placed in the gastric remnant for feeding. A standard glucose load was administered either orally (day 1) or by the gastrostomy tube (day 2). The plasma levels of glucose, insulin, glucagon-like peptide 1 and peptide YY were measured before and after glucose loading. Results: Exclusion of the proximal small bowel from glucose passage induced greater plasma insulin, glucagon-like peptide 1, and peptide YY responses compared with glucose loading by way of the gastrostomy tube (P <.05). Conclusions: Exclusion of glucose passage through the proximal small bowel results in enhanced insulin and gut hormone responses in patients after gastric bypass. The gut plays a central role in glucose metabolism and represents a target for future antidiabetes therapies.

Laparoscopic sleeve gastrectomy followed by duodenal switch in selected patients versus single-stage duodenal switch for superobesity: case–control study - Corrected Proof

2012-03-02

Abstract: Background: The prevalence of superobesity (body mass index [BMI] ≥50 kg/m2) has increased steadily during the past decade, and the most suitable surgical strategy for these patients is still controversial. Our objective was to test the hypothesis that in selected superobese patients, laparoscopic sleeve gastrectomy (SG) followed by laparoscopic duodenal switch (DS) might reduce the rate of postoperative complications and the need for the second step duodenal switch. The setting was a university hospital in France. Methods: A retrospective analysis was performed of a prospective database of 110 consecutive patients with a BMI of ≥50 kg/m2 undergoing the staged approach and matched for age, gender, and BMI with 110 consecutive patients undergoing single-stage DS. The excess weight loss (EWL), co-morbidity improvement, and incidence of postoperative complications were compared between the 2 groups. Results: One patient died in the staged strategy group (mortality rate .9%). The postoperative complication rate was 8.2% in the staged strategy group (110 patients) and 15.5% in the single-stage DS group (110 patients; P = 1). Multivariate analysis showed that single-stage DS surgery is the only variable significantly associated with the occurrence of postoperative complications (odds ratio 2.36; 95% confidence interval 1.001–5.61). In the staged strategy group, at a mean follow-up of 36.4 ± 13 months, 39 patients (35.5%) required the second-stage procedure. The mean %EWL was 50.8% ± 17.5% for SG alone (35% failed to maintain 50% EWL after SG), 61.5% ± 19.3% for the staged strategy, 72.7% ± 14.1% for 2-step DS (3.3% failed to maintain 50% EWL after 2-step DS), and 73.3% ± 17.6% for single-stage DS (7.3% failed to maintain 50% EWL after single-stage DS). Conclusions: At 3 years of follow-up, staged DS surgery avoided biliopancreatic diversion in 72.7% of the patients. Single-stage DS increases the risk of postoperative complications but not of anastomotic leak.

Predictors of a difficult intubation in the bariatric patient: does preoperative body mass index matter? - Corrected Proof

2012-03-02

Abstract: Background: The incidence of difficult intubations in morbidly obese patients has been reported to be 12–20%; however, no well-established predictors of a difficult intubation exist for this patient population. Our objective was to evaluate the factors associated with a difficult intubation in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass at an integrated multispecialty health system with a 325-bed community teaching hospital serving 19 counties. Methods: The anesthetic records of patients undergoing LRYGB from 2001 to 2010 were reviewed. Difficult intubations were defined as direct laryngoscopy graded ≥1 on a 0–2 difficulty scale and unplanned fiberoptic intubations. Statistical analysis included chi-square, univariate, and multivariate logistic regression. Results: A total of 915 consecutive patients underwent LRYGB during the study period. Of these, 3 patients were excluded because of incomplete data. Of the 912 included patients, 25 (2.7%) underwent planned fiberoptic intubation, 830 (91%) had an uneventful intubation, and 57 (6.3%) had a difficult intubation. Difficult intubations were more common in men than in women (11% versus 6%, P = .027). Difficult intubations were not associated with an increasing preoperative body mass index (P = .073), the presence of obstructive sleep apnea (P = .784), or the presence of gastroesophageal reflux disease (P = .335). Multivariate predictors of a difficult intubation were Mallampati class 4 (odds ratio [OR] 2.76, P = .035), abnormal thyromental distance (OR 4.39, P = .001), restricted jaw mobility (OR 3.26, P = .018), and a history of a difficult intubation (OR 4.17, P = .002). Conclusions: An increased Mallampati class, abnormal thyromental distance, restricted jaw mobility, and a history of difficult intubations were independent predictors of a difficult intubation. An increasing body mass index did not predict for a difficult intubation.

Optimizing screening of severe obstructive sleep apnea in patients undergoing bariatric surgery - Corrected Proof

2012-02-13

Abstract: Background: Obstructive sleep apnea is common in patients waiting for bariatric surgery (BS). International consensuses have recommended assessment of obstructive sleep apnea in the preoperative evaluation to avoid perioperative complications. Polysomnography is the standard diagnostic method but is expensive and time-consuming. The aim of our study was to detect those patients who merit treatment before BS using a simple predictor model. The study was conducted at 3 university hospitals (Hospital de Bellvitge, Hospital de la Santa Creu i Sant Pau, Hospital Clinic de Barcelona). Methods: A prospective cross-sectional study was conducted of 136 consecutive bariatric subjects. The outcome variable was severe obstructive sleep apnea, defined as an apnea-hypoapnea index of ≥30 events/hr by polysomnography. The predictors evaluated were anthropometric and clinical in the first model, with an oxygen desaturation index of ≥3% added to the second model. Predictive models were constructed using multivariate logistic regression analysis. The best model was selected according to the area under the receiver operating characteristic curve. Results: The first model identified 4 independent factors: age, waist circumference, systolic blood pressure, and witnessed apnea episodes, with a sensitivity of 78%, specificity of 68%, and area under the receiver operating characteristic curve of .83 (95% confidence interval .76–.90, P < .001). The second model identified 2 independent factors (witness apnea episodes, oxygen desaturation index of ≥3%), with a sensitivity of 91%, specificity of 85%, and area under the receiver operating characteristic curve of .94 (95% confidence interval .89–.98, P < .001). The 2-step model predictive values were sensitivity of 90%, specificity of 91%, and accuracy of 90% (95% confidence interval 84–94%). After applying the first model and then the second, 45% of subjects would have been ruled out (15% and 30%, respectively) and 55% would require additional sleep management before BS. Conclusion: The proposed model could be useful for improving the management of complex patients before BS and optimizing limited polysomnography resources.

Roux-en-Y gastric bypass as revisional procedure after gastric banding: leaving the band in place - Corrected Proof

2012-02-13

Abstract: Background: Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) are frequently used bariatric procedures. With both techniques, LAGB more than RYGB, failures occur. After years of experience with both techniques, we present a series of patients who underwent RYGB after failed LAGB. The band was kept in place. Our objective was to evaluate the safety and short-term effectiveness of RYGB after failed LAGB, without removing the band. The setting was a large teaching hospital in Heerlen, The Netherlands. Methods: We first retrospectively considered the efficacy and complication rate of adding an adjustable band to RYGB. This was safe and effective. The patients lost a median of 7.6 kg within a median period of 21 months. The complication rate was low. Observing the positive results in this group, we began to leave the band in place when converting patients from LAGB to RYGB. Results: A total of 12 patients underwent revision of LAGB to RYGB. There was no mortality. The complication rate and severity were low. During a median period of 16 months, the patients lost a median of 23 kg or 8 points in the body mass index. Also, additional improvement in co-morbidities was observed. Conclusion: Our results suggest that performing RYGB after LAGB and leaving the band in place is feasible, safe, and effective in the short term.

Psychological risk may influence drop-out prior to bariatric surgery - Corrected Proof

Julie Merrell, Kathleen Ashton, Amy Windover, Leslie Heinberg — 2012-02-10

Abstract: Background: Factors necessitating a delay before psychological clearance for bariatric surgery have been previously identified; however, research has not examined why patients who begin the preoperative evaluation fail to complete surgery or drop-out of bariatric programs. This study sought to explore the potential psychosocial reasons for a failure to reach bariatric surgery. The setting was an academic medical center. Methods: Data were analyzed from 129 patients psychologically evaluated for bariatric surgery who had failed to reach surgery after 15 months. Medical records were reviewed for demographics, body mass index, and psychiatric variables. Results: The most common reasons for not reaching surgery included withdrawal from the program, outstanding program requirements, self-canceled surgery, moving out of the area, insurance denial, switching to non-surgical weight management, or death. Patients with outstanding program requirements were psychosocially different from patients who had not achieved surgery for other reasons. They were significantly more likely to be involved in outpatient behavioral health treatment (chi-square = 12.90, P < .05), to be taking psychotropic medications (chi-square = 15.17, P < .05), and to have met the criteria for current or past alcohol abuse/dependence (chi-square = 23.70, P < .01), and there was a trend for previous inpatient hospitalizations (chi-square = 11.59, P < .07). Conclusion: Patients who failed to complete outstanding program requirements often had significant psychiatric and/or substance abuse/dependence issues that required additional treatment. It is possible that these patients drop-out of the program due to unwillingness to complete psychiatric treatment recommendations. Continued screening of high-risk patients and the education of patients on the importance of managing these risks is indicated. However, patients may choose to leave programs once education has been provided or treatment mandated.

Psychosocial correlates of pelvic floor disorders in women seeking bariatric surgery - Corrected Proof

Julie Merrell, Stacy Brethauer, Amy Windover, Kathleen Ashton, Leslie Heinberg — 2012-02-10

Abstract: Background: Women who struggle with obesity are at a significant risk for pelvic floor disorders (PFDs), defined as urinary incontinence, pelvic organ prolapse, and/or fecal incontinence. The association between PFDs and reduced quality of life has been demonstrated; however, the psychosocial correlates of PFDs in women undergoing bariatric surgery have yet to be examined. The present study explored the potential psychosocial correlates of PFD. The setting was an academic medical center. Methods: Data were analyzed from 421 female patients evaluated for bariatric surgery. Based upon a screening questionnaire, participants were dichotomized as women with PFDs (n = 121) and women without PFDs (n = 300). Patients completed the “Minnesota Multiphasic Personality Inventory, 2nd ed., Restructured Form (MMPI-2-RF),” and medical records were reviewed for demographic data, body mass index, substance abuse/dependence history, history of physical and/or sexual abuse, psychiatric medication usage, and psychiatric diagnoses. MMPI-2-RF scales measuring depression, anxiety, somatic symptoms, and social support were examined. Results: Women with PFDs were significantly older (F1,420 = 3.87, P < .05) and more likely to evidence a history of substance abuse/dependence (chi-square = 4.53, P < .05) and depression (chi-square = 4.31, P < .05) than women without PFDs. There also was a trend for previous inpatient hospitalization (chi-square = 2.93, P < .09), outpatient behavioral health treatment (chi-square = 2.89, P < .09), and psychotropic medication usage (chi-square = 3.32, P < .07). No differences were found in the objective psychological testing. Conclusion: Women with PFDs may be more psychiatrically vulnerable than other bariatric surgery candidates. Additional research on the association among PFDs, substance abuse, and depression is warranted. Future research should consider whether this potential relationship changes postoperative bariatric surgery.

Comment on: Blood clot obstruction of the jejunojejunostomy after laparoscopic gastric bypass - Corrected Proof

Michael Schweitzer — 2012-02-06

The authors performed a retrospective review of their own database and found a .5% (5 of 1066 patients) rate of obstruction at the JJ due to hematoma. In all 5 cases, reoperation was necessary. Intestinal obstruction after gastric bypass can be due to internal hernia, stricture, adhesions, intussusception, bezoar, blood clot, or a ventral (trocar site) hernia . A study of the American College of Surgeons Bariatric Surgery Network database of 109 hospitals with 28,616 patients showed a 30-day complication rate due to intestinal obstruction requiring reoperation of .78% . In another study, Koppman et al. reviewed the published data and their own database, specifically studying small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. They found 342 postoperative intestinal obstructions (3.6%) in 9527 patients. The rate of hemobezoar reported was <.17%.

Blood clot obstruction of the jejunojejunostomy after laparoscopic gastric bypass - Corrected Proof

Tom Mala, Torgeir T. Søvik, Carl Fredrik Schou, Jon Kristinsson — 2012-02-06

Abstract: Background: Acute jejunojejunostomy (JJ) obstruction after laparoscopic gastric bypass secondary to the formation of an intraluminal blood clot is a rare event. We analyzed our experience with such complications from a large consecutive patient series at a university hospital that is a referral center for bariatric surgery. Methods: A retrospective review of patient data in a register of all patients who had undergone gastric bypass from June 2004 to March 2011 was performed. Reoperations were analyzed for the cause and findings. The patients received routine postoperative administration of low-molecular-weight heparin. Results: Of 1066 patients, 5 (.5%; 4 women and 1 man), who had undergone laparoscopic gastric bypass, with a median body mass index of 42 kg/m2 (range 40–46), underwent reoperation for obstruction of the JJ secondary to a blood clot. The indications for reoperation were signs of bleeding, nausea, or findings on abdominal computed tomography. The time of reoperation was 1, 1, 2, 3, and 11 days after the primary procedure. All patients underwent reoperation by laparoscopy, with evacuation of the blood clot through an opening of the suture or staple lines without additional revision of the JJ. The gastric remnant was decompressed using a percutaneously placed gastrostomy tube. One patient had gastric leakage from the staple lines (blowout) that necessitated several later revisions for subcutaneous abscesses. Another patient developed acute pancreatitis. Conclusion: Blood clots can cause early obstruction of the JJ after gastric bypass. Awareness of this potentially rapidly progressive and life-threatening complication will allow immediate intervention and reduce the risk of serious sequelae.

Glycemic control after stomach-sparing duodenal-jejunal bypass surgery in diabetic patients with low body mass index - Corrected Proof

2012-02-06

Background: Bariatric surgery frequently results in the resolution of type 2 diabetes mellitus (T2DM). One of the many factors that could explain such findings is the duodenal exclusion of the alimentary tract. To test this hypothesis, a surgical model that induces glycemic control without significant weight loss would be ideal. In the present study, we evaluated the early metabolic changes that occur in overweight diabetic patients after laparoscopic duodenal-jejunal bypass (DJB) and determined the factors associated with success in T2DM resolution. The setting was a private practice. Methods: A total of 35 patients (20 men and 15 women) were included in the present study. The mean preoperative body mass index was 28.4 ± 2.9 kg/m2. DJB was performed in all patients, and the anthropometric data and blood samples were collected at baseline (preoperatively) and 3, 6, 9, and 12 months after surgery. Success was defined when patients reached a glycated hemoglobin level of <7% without diabetic medication. Results: T2DM remission was observed in 14 (40%) of 35 patients. No differences in the homeostasis model assessment insulin resistance index levels and patient weight were observed before and 12 months after DJB surgery. Gender, duration of T2DM, previous use of insulin, preoperative homeostasis model assessment insulin resistance index, and C-peptide levels were not significant predictive factors of success or nonsuccess. The only factor that significantly predicted postoperative positive outcomes was a waist circumference reduction of ≥7% compared with baseline within the first 6 months after surgery. Conclusion: DJB improves glycemic control; however, it does not increase insulin sensitivity in overweight diabetic patients. These changes were observed without significant weight loss.

Evaluation of nutrient status after laparoscopic sleeve gastrectomy 1, 3, and 5 years after surgery - Corrected Proof

2012-02-03

Background: Laparoscopic sleeve gastrectomy evolved as a primary bariatric procedure with little information on its nutritional effects. Our objective was to assess the longer term micronutrient and vitamin status after laparoscopic sleeve gastrectomy at a university hospital. Methods: Measurements of ferritin, iron, total iron binding capacity, hemoglobin, hematocrit, parathyroid hormone, albumin, calcium, magnesium, phosphorus, zinc, folate, and vitamins A, B1, B12, and D were obtained at baseline and 1, 3, and 5 years after surgery. Two-sample t tests with multiple adjusted comparisons and Fisher's exact test were used to determine deficiency. Results: A total of 82 patients (67% women), with a mean age of 46.4 years and a baseline body mass index 55.7 kg/m2 were included in the present study (35 at 1, 27 at 3, and 30 at 5 years postoperatively). The percentage of excess body mass index loss was 58.5% at year 1 in 35 patients, 63.1% at year 3 in 27 patients, and 46.1% at year 5 in 30 patients. The parathyroid hormone level decreased from 75.0 to 49.6 ng/mL in year 1 to 40.7 ng/mL in year 3. The year 5 levels increased to 99.6 ng/mL. The mean vitamin D level increased from 23.6 ng/mL to 35.0, 32.1 and 34.8 at years 1, 3, and 5 (P = .05 for baseline to year 1). The vitamin D level was less than normal in 42% of the patients at year 5. After normalization from baseline, by year 5, parathyroid hormone had increased in 58.3% of patients. At year 5, vitamin B1 was less than normal in 30.8% of patients, and hemoglobin and hematocrit were less than normal in for 28.6% and 25% of patients, respectively. Finally, 28.9% of patients reported taking supplements in year 1, 42.9% in year 3, and 63.3% in year 5. The other variables were not significantly different. Conclusions: Laparoscopic sleeve gastrectomy resulted in health improvements through year 3. At year 5, the nutrient levels had reverted toward the baseline values. These observations provide focus for necessary clinical monitoring.

Physicians' attitudes about referring their type 2 diabetes patients for bariatric surgery - Corrected Proof

2012-02-01

Abstract: Background: Despite increasing evidence about the beneficial effects of bariatric surgery, little is known about physicians' attitudes toward it as a treatment of type 2 diabetes. Our objective was to investigate physicians' attitudes about referring patients with type 2 diabetes for bariatric surgery. Methods: Physicians were identified from the Pennsylvania Integrated Clinical and Administrative Research Database and other databases. Physicians at an academic medical center (n = 142) and community-based physicians (n = 197) in the Philadelphia area in specialties likely to treat type 2 diabetes were sent a survey about their perceptions of the safety and efficacy of bariatric surgery as a treatment for obesity and type 2 diabetes. Results: Of the physicians, 93 returned the survey, for a combined response rate of 27.4%. Respondents reported having positive impressions of bariatric surgery as a treatment for obesity and type 2 diabetes (79.6% and 67.4%, respectively). Only 20.8% of respondents indicated that they would be likely to refer their patients with type 2 diabetes with a body mass index of 30–34.9 kg/m2 to a randomized research trial of bariatric surgery. Conclusion: In general, physicians who treat patients with type 2 diabetes had favorable impressions about bariatric surgery as a treatment for obesity and type 2 diabetes. However, only a few were willing to refer their patients with type 2 diabetes and a body mass index of 30–34.9 kg/m2 to randomized research trials of bariatric surgery. This reluctance to refer patients represents an important barrier to the successful completion of studies of the efficacy of bariatric surgery for those with type 2 diabetes and a body mass index <35 kg/m2.

Abnormal glucose tolerance testing after gastric bypass - Corrected Proof

2012-01-30

Abstract: Background: Symptoms secondary to dumping have been suggested to help patients refrain from simple carbohydrate ingestion after Roux-en-Y gastric bypass (RYGB). During follow-up examinations, we noted many patients with weight regain complaining of fatigue shortly after eating. Thus, we decided to study the glucose tolerance test (GTT) results in a cohort of post-RYGB patients. Methods: A total of 63 RYGB patients, >6 months postoperatively, were studied with a GTT and measurement of insulin levels. The mean age was 48.5 ± 10.8 years, mean preoperative body mass index was 49.0 ± 6.5 kg/m2, mean percentage of excess body mass index lost was 64.5% ± 29.0%, mean weight regain at follow-up was 11.6 ± 12.4 lb, and mean follow-up period was 47.9 months. Results: Of the 63 patients, 49 had abnormal GTT results. Of the 63 patients, 6 were diabetic; however, only 1 of these patients had an elevated fasting glucose level. All 6 patients were diabetic preoperatively. Of the 63 patients, 43 had evidence of reactive hypoglycemia at 1–2 hours after the glucose load. Of these patients, 22 had a maximum/minimum glucose ratio >3:1, including 7 with a ratio >4:1. Conclusion: The results of the present study have demonstrated that an abnormal GTT result is a common finding after RYGB. Reactive hypoglycemia was found in 43 of 63 patients, with insulin values that do not support nesidioblastosis. It is our hypothesis, that rather than preventing simple carbohydrate ingestion, the induced hypoglycemia that occurs might contribute to weight regain and maladaptive eating in certain post-RYGB patients.

Evaluation and treatment of patients with cardiac disease undergoing bariatric surgery - Corrected Proof

2012-01-30

Abstract: Background: Bariatric surgery is a proven tool in reducing the co-morbidities associated with morbid obesity. The aim of the present review was to assess the current data and discuss the strategies for preoperative evaluation, preoperative treatment, and intraoperative management of the obese patient with cardiac disease seeking bariatric surgery, including those who have undergone previous angiographic intervention with coronary stenting and/or antiplatelet therapy. The setting was a university hospital in the United States. Methods: A search of the English-language reports using the keywords morbid obesity, bariatric surgery, perioperative risk assessment, coronary artery disease, coronary stents, and antiplatelet therapy was conducted. Results: The methods of preoperative cardiac risk assessment found in the published studies included the use of certain criteria, stress echocardiography, and single-photon emission computed tomography. Preoperative medical treatment optimization with β-blockers and statins is recommended. Perioperative antiplatelet therapy in the form of aspirin 81 mg can be safely continued, but clopidogrel should be stopped and reinitiated with caution. Conclusion: Preoperative assessment of morbidly obese patients with coexisting cardiac issues presents unique challenges. Safe patient care and good clinical outcomes can be achieved with adherence to evidence-based practice.

Six-year changes in health-related quality of life in gastric bypass patients versus obese comparison groups - Corrected Proof

2012-01-27

Abstract: Background: Few studies have evaluated the long-term outcomes of bariatric surgery patients in relation to obese individuals not participating in weight loss interventions. Our objective was to evaluate the 6-year changes in health-related quality of life (HRQOL) in gastric bypass (GB) patients versus 2 obese groups not undergoing surgical weight loss. The study setting was a bariatric surgery practice. Methods: A total of 323 GB patients were compared with 257 individuals who sought but did not undergo gastric bypass and 272 population-based obese individuals using weight-specific (Impact of Weight on Quality of Life-Lite) and general (Medical Outcomes Study Short-Form 36 Health Survey) HRQOL questionnaires at baseline and 2 and 6 years later. Results: At 6 years, compared with the controls, the GB group exhibited significant improvements in all domains of weight-specific and most domains of general HRQOL (i.e., all physical and some mental/psychosocial). The 6-year percentage of excess weight loss correlated significantly with improvements in both weight-specific and physical HRQOL. The HRQOL scores were fairly stable from 2 to 6 years for the GB group, with small decreases in HRQOL corresponding to some weight regain. Conclusions: GB patients demonstrated significant improvements in most aspects of HRQOL at 6 years compared with 2 nonsurgical obese groups. Despite some weight regain and small decreases in HRQOL from 2 to 6 years postoperatively, the HRQOL was relatively stable. These results support the effectiveness of weight loss achieved with gastric bypass surgery for improving and maintaining long-term HRQOL.

Roux-en-Y gastric bypass achieves substantial resolution of migraine headache in the severely obese: 9-year experience in 81 patients - Corrected Proof

2012-01-24

Abstract: Background: Although migraine headache (MH) is more severe in the obese, the risk of developing MH in the obese population is controversial. The effect of surgical weight loss on morbidly obese patients with MH provides a unique opportunity to evaluate this potential association. Methods: We analyzed the data from 702 morbidly obese patients who underwent Roux-en-Y gastric bypass (RYGB) from 2000 to 2009. We identified patients with physician-diagnosed MH taking antimigraine medication. Results: The data are presented as the mean ± SEM, with the range in parentheses. Of the 102 patients with preoperative MH, 21 were excluded because they had <12-month follow-up data and 81 were followed up for 38.6 ± 3 months (range 12–123). Of the 81 patients, 90% were women. Their body mass index was 48 ± 1 kg/m2 (range 37–85), and their age was 40 ± 1 years (range 18–62). After surgical weight loss, clinical improvement in MH was seen in 89% of patients within 5.6 ± .9 months (range 1–36; P < .01, chi-square test), with 57 reporting total resolution and 15 reporting partial resolution (9 experienced no change). Using logistic regression analysis, we showed that the improvement in MH after RYGB was independent of the improvement in migraine-associated co-morbidities, such as sleep apnea, menstrual dysfunction, depression, and anxiety. We also compared patients who developed MH after obesity onset with those who had MH before obesity. The MH after obesity onset group included 51 patients, of whom 48 showed clinical improvement (41 complete, 7 partial, and 3 no improvement). The MH before obesity group included 24 patients, of whom 18 showed clinical improvement (11 complete, 7 partial, and 6 no improvement). The MH after obesity group showed a greater rate of complete resolution of MH after RYGB than did the MH before obesity group (P < .01; chi-square test). Conclusions: Weight loss after RYGB substantially resolves MH, especially when obesity onset precedes MH onset. It remains to be determined whether RYGB-induced endocrine alterations or a reduction in adipokine burden contribute to migraine improvement.

Robotic sleeve gastrectomy after liver transplantation - Corrected Proof

E. Fernando Elli, Mario A. Masrur, Pier C. Giulianotti — 2012-01-24

Obesity represents a worldwide health issue, with nearly one quarter of the adult world population considered overweight and almost 10% considered obese . In the United States, the prevalence of obesity is increasing and, if this trend continues, by 2030, 51.1% of adults will be obese .

Body mass trajectories through midlife among adults with class I obesity - Corrected Proof

Eric A. Finkelstein, Truls Østbye, Rahul Malhotra — 2012-01-18

Abstract: Background: Little is known about the body mass trajectories for adults with class I obesity. Our objective was to map the body mass trajectories through midlife for young adults with class I obesity in the United States. Methods: Data from the National Longitudinal Study of Youth 1979 was used to generate a cohort of 1058 men and women, aged 25–33 years with class I obesity in 1990. Group-based trajectory modeling was used to identify the number and shape of the body mass index trajectories from 1990 to 2008 for this cohort. Results: By 2008, about 15% of men and women with class I obesity in 1990 experienced a body mass index increase to >40 kg/m2. The trajectory analyses showed that roughly one third of the sample were on 1 of 2 body mass index trajectory groups that culminated with an average BMI well above 35 kg/m2. Conclusion: The large majority of young adults with class I obesity are likely to gain weight over time. For many, the weight gain will be significant and greatly increase their risk of obesity-related co-morbidities and reduced life expectancy. As a result, bariatric surgery or other intensive weight management options might be warranted.

Comment on: Robotic-assisted Roux-en-Y gastric bypass: an update from two high volume centers - Corrected Proof

William Richards — 2012-01-18

The inexorable drive to reduce complications and produce the best surgical outcomes is exemplified by continuous improvements in surgical techniques. This series of robotic gastric bypass surgery performed at 2 institutions demonstrates the ability of the robotic surgeon to achieve very high quality with low complication rates .

Treatment of gastric leaks after Roux-en-Y gastric bypass: a paradigm shift - Corrected Proof

Robert E. Brolin, Jeffrey M. Lin — 2012-01-18

Abstract: Background: During the past decade, nonoperative treatment of leaks after bariatric surgery has been deemed acceptable in selected patients. The setting of our study was 2 university affiliated hospitals. Methods: We reviewed gastric leaks in 1069 consecutive bariatric operations that were performed by 1 surgeon during the past 8 years, including 836 primary laparoscopic Roux-en-Y gastric bypass (RYGB), 114 primary open RYGBs, and 119 revisional procedures. Drains were used routinely in the laparoscopic and revision groups and selectively in the open group. Perforations and jejunojejunostomy leaks were excluded. Results: There were no leaks after open RYGB, 8 leaks (.95%) after laparoscopic RYGB, and 5 leaks (4.2%) after the revisional procedures. Of the 13 leaks, 7 occurred at the gastrojejunostomy, 6 at the staple line of the upper pouch, and none in the excluded stomach. Of the 8 postlaparoscopic RYGB leaks, 3 required reoperation versus 2 of 5 postrevision leaks. There were no perioperative deaths. All but 2 patients in the nonoperative group were treated with endoscopic injection of fibrin sealant (EIFS). Of the 4 leaks in the laparoscopic RYGB group, 2 treated by EIFS closed after 1 treatment; however, all leaks in the revision group required >1 EIFS treatment. The mean length of stay was 36 ± 34 days in the operative group and 33 ± 7 days in the EIFS patients. Operation for failure of EIFS was not required in any patient. Conclusion: EIFS provides safe and successful treatment of patients who develop gastric leaks after bariatric operations. We recommend EIFS for all patients with endoscopically accessible leaks who can safely be treated nonoperatively.

Robotic-assisted Roux-en-Y gastric bypass: update from 2 high-volume centers - Corrected Proof

Ken Tieu, Nathan Allison, Brad Snyder, Todd Wilson, Michelle Toder, Erik Wilson — 2012-01-18

Abstract: Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) is a challenging operation in the most experienced hands. Robotic surgery allows the capabilities of the minimally invasive surgeon to be extended. An increasing number of robotic gastric bypasses are being performed each year with the assumption that the complication rates are decreased. The objectives of the present study were to review the results of robotic-assisted RYGB (RARYGB) from 2 high-volume centers, including 1 university and 1 private practice. Methods: We report the most recently compiled, largest series of RARYGB in the world to show the effectiveness, morbidity, and mortality of this method. Databases were searched for patients undergoing RARYGB from 2002 to 2010, and the endpoints were recorded. Results: A total of 1100 RARYGBs matched our search. The patients had a mean preoperative age of 46.9 years, mean weight of 131.9 kg, and mean body mass index of 47.9 kg/m2. The mean operative time was 155 minutes. There were no conversions. The mean body mass index was 39.8 kg/m2 at 3 months postoperatively (79% follow-up). Complications were few, and included 2 cases of pulmonary embolism (.19%), 3 cases of deep venous thrombosis (.27%), 1 case of gastrojejunal anastomotic leak (.09%), and 9 cases of staple line bleeding (.82%). No patients died. Conclusion: RARYGB is safe and effective. Although the operative time might be increased, the complication rates, most notably of anastomotic leak, are extremely low.