Surgery for Obesity and Related Diseases - Articles in Press

An Evaluation Of Nutrient Status After Laparoscopic Sleeve Gastrectomy (Lsg) 1, 3, And 5 Years After Surgery - Accepted Manuscript

T. Saif, G.W. Strain, G. Dakin, M. Gagner, R. Costa, A. Pomp — 2012-02-03

Abstract: Background: Laparoscopic sleeve gastrectomy (LSG) evolved as a primary bariatric procedure with little information on its nutritional effects. Objectives: To assess longer term micro-nutrient and vitamin status after LSG. Setting: University Hospital Methods: Measurements for Ferritin, Iron, Total Iron Binding Capacity(TIBC), Hemoglobin(Hgb), Hematocrit(Hct), parathyroid hormone(PTH), Albumin, Calcium, Magnesium, Phosphorus, Zinc, Vitamins A, B1, B12, Folate, and D were obtained at Baseline, 1, 3, & 5 years(Y). Two-sample t-tests with multiple adjusted comparisons and Fisher’s exact test determined deficiency. Results: Eighty-two patients (67% females) mean age 46.4, and pre-BMI 55.7 kg/m2, had a % Excess BMI Loss of 58.5%(Y 1, 35 patients [pt], 63.1%(Y 3, 27 pt) and 46.1%(Y 5, 30 pt). PTH decreased from 75.0 ng/mL to 49.6ng/mL (Y 1) and 40.7ng/mL(Y 3). Year 5 levels increased to 99.6ng/mL. Mean Vitamin D increased from 23.6 ng/mL to 35.0, 32.1 and 34.8 at Y 1, 3, and 5(p= 0.05 for 0 to Y 1). D was below normal in 42% of patients yr 5. After normalization from baseline, by Y 5 PTH increased in 58.3% of patients. At Y 5, B1 was below normal in 30.8% of patients as was Hgb for 28.6% and Hct for 25% of patients. 28.9% of patients reported taking supplements Y 1, 42.9% Y 3, and 63.3% Y 5. Other variables were not significantly different. Conclusion: LSG resulted in health improvements through Y 3. At Y 5 nutrient levels reverted toward pre-surgery values. These observations provide focus for necessary clinical monitoring.

Superior weight loss and lower HbA1c three years after duodenal switch compared to Roux-en-Y gastric bypass - a randomized controlled trial - Accepted Manuscript

Jakob Hedberg, Magnus Sundbom — 2012-02-03

Abstract: Background: Obesity is a rising threat to public health. The relative increase in incidence of morbid obesity is most pronounced in the most severely obese. Roux-en-Y gastric bypass (RYGB) has inferior weight result in this group and we have therefore offered biliopancreatic diversion with duodenal switch (BPD/DS) as an alternative in this patient category. Objective: To compare BPD/DS and RYGB in the surgical treatment of morbid obesity in patients with body mass index (BMI)>48 kg/m2. Setting: University hospital, Sweden. Methods: In a controlled trial (registration number ISRCTN10940791), 47 patients (25 men, BMI 54.5±6.1 kg/m2) were randomized to RYGB (n=23) or BPD/DS (n=24). Biochemical data was collected preoperatively, at one and three years postoperatively. A questionnaire addressing weight, general satisfaction and gastrointestinal symptoms was distributed in median 4 years postoperatively. Results: Both procedures were safe. Duration of surgery and postoperative morphine consumption were higher after BPD/DS as compared to RYGB (157 vs. 117 min and 140 vs. 93 mg respectively). BPD/DS resulted in greater weight reduction compared to RYGB (-23.2±4.9 vs. -16.2± 6.9 BMI units or 80%±15% vs. 51%±23% excess BMI loss, p<0.001). BPD/DS yielded lower glucose- and glycated hemoglobine-levels at three years. More patients listed troublesome diarrhea and malodorous flatus in a questionnaire after BPD/DS, but no significant difference was seen (p=0.078 and 0.073 respectively). Conclusions: BPD/DS produces superior weight results and lower glycated hemoglobine-levels as compared to RYGB in patients with BMI>48. Both operations yield high satisfaction-rates. However, diarrhea tends to be more common after BPD/DS.

Physicians’ Attitudes about Referring their Type 2 Diabetes Patients for Bariatric Surgery - Accepted Manuscript

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 for type 2 diabetes. Objective: To investigate physicians' attitudes about referring patients with type 2 diabetes for bariatric surgery. Setting: Physicians at an academic medical center (142) and community-based physicians (197) in the Philadelphia area in specialties likely to treat type 2 diabetes. Methods: Physicians identified from the Pennsylvania Integrated Clinical and Administrative Research Database (PICARD) and non-PICARD databases were surveyed about perceptions of the safety and efficacy of bariatric surgery as a treatment for obesity and type 2 diabetes. Results: Ninety-three physicians 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 type 2 diabetes patients with body mass index (BMI) of 30 to 34.9 kg/m2 to a randomized research trial of bariatric surgery. Conclusions: In general, physicians who see patients with type 2 diabetes had favorable impressions about bariatric surgery as a treatment for obesity and type 2 diabetes. However, only a minority were willing to refer their type 2 diabetic patients with BMIs 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 persons with type 2 diabetes and BMIs < 35 kg/m2.

Abnormal Glucose Tolerance Testing Following Gastric Bypass - Accepted Manuscript

2012-01-30

Abstract: Background: Symptoms secondary to dumping have been suggested to help patients refrain from simple carbohydrate ingestion following rygb. During follow up exams, we noted many patients with weight regain complaining of fatigue shortly after eating,. As a result, we decided to study GTT in a cohort of post rygb patients. Methods: 63 RYGB patients, > 6 months post-op, were studied with a glucose tolerance test (GTT) with measurement of insulin levels. Mean age 48.5+/- 10.8 years, mean pre-operative Body Mass Index (BMI) 49.0 +/- 6.5 kg.m2, mean percent excess BMI lost 64.5 +/- 29.0%, mean weight regain at follow-up 11.6 +/- 12.4 lbs, mean follow-up time 47.9 months. Results: 49/63 patients had an abnormal GTT. 6/63 patients were diabetic yet only 1 of these patients had an elevated fasting glucose level (FBS). All 6 patients were diabetic pre-operatively. 43/63 had evidence of reactive hypoglycemia at 1-2 hrs post-glucose load. Of these patients, 22 had a maximum to minimum glucose ratio > 3:1 including 7 with a ratio > 4:1. Conclusion: This study demonstrates that an abnormal GTT is a common finding post-RYGB. Reactive hypoglycemia was found in 43/63 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 may contribute to weight regain and maladaptive eating in certain post rygb patients.

Evaluation and Management of Patients with Cardiac Disease Undergoing Bariatric Surgery - Accepted Manuscript

2012-01-30

Abstract: Background: Bariatric surgery is a proven tool in reducing co-morbidities associated with morbid obesity. The aim of this review is to assess the current literature 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 had prior angiographic intervention with coronary stenting and/or anti-platelet therapy. Methods: A literature search of English-language articles using the keywords morbid obesity, bariatric surgery, perioperative risk assessment, coronary artery disease, coronary stents, and anti-platelet therapy was conducted. Setting: University Hospital, United States Results: Methods of pre-operative cardiac risk assessment found in literature included the use of certain criteria, stress echocardiography, and SPECT scan. Preoperative medical treatment optimization with betablockers and statins is recommended. Perioperative anti-platelet therapy in the form of aspirin 81mg can be safely continued while clopidogrel should be stopped and reinitiated with caution. Conclusions: Pre-operative 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 - Accepted Manuscript

2012-01-27

Abstract: Background: Few studies evaluate long-term outcomes in bariatric surgery patients in relation to obese individuals not participating in weight loss interventions. Objectives: To evaluate six-year changes in health-related quality of life (HRQOL) in gastric bypass patients (GBP) versus two obese groups not undergoing surgical weight loss. Setting: Bariatric surgery practice. Methods: A total of 323 GBP were compared with 257 individuals who sought but did not have gastric bypass (No GBP) and 272 population-based obese individuals (Pop Ob) using weight-specific (Impact of Weight on Quality of Life-Lite) and general (Medical Outcomes Study 36-item Short-Form Health Survey) HRQOL questionnaires at baseline and two and six years later. Results: At 6 years, compared to controls, the GBP group exhibited significant improvements in all domains of weight-specific and most domains of general HRQOL (i.e. all physical and some mental/psychosocial). Six year percent excess weight loss correlated significantly with improvements in both weight-specific and physical HRQOL. HRQOL scores were fairly stable from two to six years for the GBP group, with small decreases in HRQOL corresponding to some weight regain. Conclusions: Gastric bypass patients demonstrated significant improvements in most aspects of HRQOL at six years compared with two non-surgical obese groups. Despite some weight regain and small decreases in HRQOL between two and six years, HRQOL was relatively stable during this period. Results support the effectiveness of weight loss achieved with gastric bypass surgery for improving and maintaining long-term HRQOL.

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

2012-01-27

Abstract: Introduction: We analyzed health-related quality of life (HR-QoL) HR-QoL and its determinants in the first year after laparoscopic adjustable gastric banding (LAGB). Setting: Ten Italian public and private bariatric surgery centers. Methods: Data collected in an ongoing prospective 3-year multicenter Italian study on changes of HR-QoL after LAGB were used. HR-QoL was investigated with the SF-36 questionnaire. Hunger, satiety and the self-perceived effects of LAGB were recorded. Results: 334 patients were enrolled. Follow-up rate was 92.2%. Percent excess weight loss (%EWL) was 39.6±25.8%, with very few side effects and complications. Hunger at morning (0-10 scale) was 4.5±2.7 before surgery and 3.8±2.4 after 1 year (p<0.001). Satiety after meal (0-10 scale) was 7.1±2.7 and 8.2±1.9 (p<0.001) respectively. The self-perceived effect of LAGB on own caloric intake (0-10 scale) was 8.4±1.9 after 1 year. Scores in the 8 SF-36 subscales were significantly improved after surgery. Physical component summary score (PCS) was 52.6±11.9 at baseline and 79.1±15.6 after 1 year (p<0.001). Mental component (MCS) was 52.2±12.3 and 76.5±17.2 (p<0.001) respectively. A higher PCS improvement was independently associated with low initial PCS (p<0.001), high satiety (p=0.002), high %EWL (p=0.013) and high self-perceived effect of the LAGB (p=0.026). A higher MCS improvement was associated with low initial MCS (p<0.001), high satiety (p<0.001), low frequency of heartburn (p=0.004) and high %EWL (p=0.012). Conclusion: Significant improvements of HR-QoL were observed in the first year after LAGB. Poor baseline HR-QoL, high efficacy of the banding in eating control and better weight loss may influence HR-QoL changes.

Roux-en-Y Gastric Bypass Achieves Substantial Resolution of Migraine Headache in the Severely Obese: a 9-year experience in 81 patients - Accepted Manuscript

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 migraineurs provides a unique opportunity to evaluate this potential association. Methods: We analyzed data on 702 morbidly obese patients who underwent Roux-en-Y gastric bypass (RYGB) between 2000-09. We identified patients with physician-diagnosed MH on anti-migraine medication. Results: Data are Mean±SEM (range). Out of 102 patients with preoperative MH, 21 were excluded due to <12-month follow-up while 81 were followed-up for 38.6±3 (12–123) months [90% female, body mass index (BMI) 48±1 (37-85) kg/m2, age 40±1 (18-62) yrs]. Following surgical weight loss, clinical improvement of MH was seen in 89% of patients within 5.6±0.9 (1-36) months (p<0.01; chi-squared 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 following RYGB was independent of the improvement of migraine-associated comorbidities such as sleep apnea, menstrual dysfunction, depression or anxiety. We also compared patients that developed MH after obesity onset (MHAO Group) to those who had MH before obesity onset (MHBO Group). The MHAO Group had 51 patients where 48 showed clinical improvement (41 complete, 7 partial and 3 no improvement). The MHBO Group had 24 patients where 18 showed clinical improvement (11 complete, 7 partial and 6 no improvement). The MHAO Group showed greater rate of complete resolution of MH after RYGB compared to the MHBO Group (p<0.01; chi-squared test). Conclusion: Weight loss following RYGB substantially resolves MH, especially when obesity onset precedes migraine. It remains to be determined whether RYGB-induced endocrine alterations or reduction of adipokine burden may contribute to migraine improvement.

Robitic Sleeve Gastrectomy Following Liver Transplantation - Accepted Manuscript

E.F. Elli, M.A. Masrur, P.C. Giulianotti — 2012-01-24

Rapid Changes in Gait, Musculoskeletal Pain and Quality of Life After Bariatric Surgery - Accepted Manuscript

2012-01-18

Abstract: Background: Joint pain is a common musculoskeletal complaint for morbidly obese patients which can result in gait abnormalities, perceived mobility limitations and declining quality of life (QOL). It is not yet known whether weight loss three months following bariatric surgery can induce favorable changes in joint pain, gait, perceived mobility and QOL. Objectives: To examine whether participants who have had bariatric surgery (n=25; BAR, laparascopic Roux-en-Y gastric bypass and laparascopic adjustable gastric banding) demonstrate improvements in joint pain, gait (speed, stride/ step lengths, width of base of support, toe angles, single/ double support, swing and stance time, functional ambulatory profile), mobility and QOL by month three compared to non-surgical controls (n=20; CON). Setting: University hospital, United States; orthopedics laboratory. Methods: This is a prospective, comparative study. Numerical pain scales (indicating the presence and severity of pain), mobility-related surveys, and the Medical Outcomes Short Form-36 (SF-36) were completed, and gait and walking speed were assessed at baseline and month three. Results: The BAR group lost an average of 21.6±7.7 kg. Significant differences existed between groups at month three with step length, heel to heel base of support, and the percent of time spent in single and double support during the gait cycle (all p<0.05). The severity of low back pain and knee pain decreased by 54% and 34% respectively, with no change in the control group (p=0.05). Walking speed increased by 15% in the BAR group (108 to 123 cm/sec; p<0.05) but not the CON group. Compared to the CON, fewer BAR patients perceived limitations with walking and stair climbing by month three. The BAR group concomitant with a 4.8cm increase in step length, a 2.6% increase in single support time during the gait cycle and a 2.5cm reduction in base of support (all p<0.05). SF-36 Physical component scores increased 11.8 points in the BAR group compared to the CON group which did not improve by month three (p<0.0001). Conclusions: Improvements in some, but not all, gait parameters, walking speed, QOL and perceived functional limitations occur by three months following a bariatric procedure.

Body Mass Trajectories through Mid-Life among Adults with Class I Obesity - Accepted Manuscript

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

Abstract: Background: Little is known about body mass trajectories for adults with Class I obesity. Objectives: To map body mass trajectories through mid-life for young adults with Class I obesity. Setting: United States. Methods: Data from the National Longitudinal Study of Youth 1979 was utilized to generate a cohort of 1058 males and females, aged 25-33 years with Class I obesity in 1990. Group-based trajectory modeling was used to identify the number and shape of body mass index (BMI) trajectories from 1990 to 2008 for this cohort. Results: By 2008, around 15% of males and females with Class I obesity in 1990 experienced a BMI increase beyond 40kg/m2. The trajectory analyses showed that roughly 1/3rd of the sample were on one of two BMI trajectory groups that culminated with average BMI values well above 35kg/m2. Conclusions: 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 comorbidities and reduced life expectancy. As a result, bariatric surgery or other intensive weight management options may be warranted.

Is Robotic-Assisted Roux-en-Y Gastric Bypass Better Than Laparoscopic Gastric Bypass? - Accepted Manuscript

William Richards — 2012-01-18

Treatment of Gastric Leaks After Roux-En-Y Gastric Bypass: A Paradigm Shift - Accepted Manuscript

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

Abstract: Background: During the past decade nonoperative treatment of leaks after bariatric operations has been deemed acceptable in selected patients. Setting: Two university affiliated hospitals Methods: We reviewed gastric leaks in 1069 consecutive bariatric operations that were performed by one surgeon during the past 8 years including 836 primary lap Roux-en-Y gastric bypass’ (RYGB), 114 primary open RYGB’s and 119 revisional procedures. Drains were used routinely in lap and revision groups, selectively in open patients. Perforations and jejunojejunostomy leaks were excluded. Results: There were no leaks after open RYGB, 8 leaks (0.95%) after lap RYGB and 5 leaks (4.2%) after revisions. Seven leaks occurred at the gastrojejunostomy, 6 at the staple line of the upper pouch, none in the excluded stomach. Three of the 8 post lap RYGB leaks required reoperation vs 2 of 5 post revision leaks. There were no perioperative deaths. All but 2 patients in nonoperative group were treated with endoscopic injection of fibrin sealant (EIFS). Two of 4 leaks in lap RYGB patients treated by EIFS closed after one treatment where as all leaks in the revision group required more than one EIFS treatment. Mean length of stay (LOS) was 36 ± 34 days in the operative group and 33 ± 7 days in EIFS patient. Operation for failure of EIFS was not required in any patient. Conclusion: EIFS provides safe and successful treatment in patients who develop gastric leaks after bariatric operations. We recommend EIFS in all patients with endoscopically accessible leaks who can safely be treated nonoperatively.

Robotic-Assisted Roux-en-Y Gastric Bypass: An Update from Two High Volume Centers - Accepted Manuscript

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

Abstract: Background: Laparoscopic Roux-en-Y gastric bypass 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 complication rates are decreased. Objectives: This study reviews the results of robotic-assisted Roux-en-Y gastric bypass from two high volume centers. Setting: Two high volume centers including one university and one private practice. Methods: We report the most recently compiled, largest series of robotic assisted Roux-en-Y gastric bypasses (RARYGB) in the world to show effectiveness, morbidity and mortality of this method. Databases were searched for patients receiving RARYGB between the years 2002-2010, and the end points were recorded. Results: 1100 RARYGB matched our search. The patients had a mean preoperative age of 46.9 years, mean weight of 293 lbs, a mean body mass index (BMI) of 47.9 kg/m2. Mean operative time was 155 minutes. There were no conversions. Mean BMI was 39.8 kg/m2 at 3 months (79% follow up). Complications were few and included 2 pulmonary embolisms (0.19%), 3 deep venous thrombosis (0.27%), 1 gastro-jejunal anastomotic leak (0.09%), 9 staple line bleeds (0.82%). There were no deaths. Conclusion: Robotic assisted Roux-en-Y gastric bypass is safe and effective. While operative time may be increased, rates of complications, most notably anastomotic leak rates are extremely low.

The ‘Inverted Corner’ For Sleeve Gastrectomy - Accepted Manuscript

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

Case report: Roux-en-Y gastric bypass in a patient with morphea - Accepted Manuscript

Sarah Lomas, Patrick Forgione — 2012-01-18

Comment on: Rapid Changes in Gait, Musculoskeletal Pain and Quality of Life after Bariatric Surgery - Accepted Manuscript

Wendy C. King — 2012-01-16

Efficacy of sleeve gastrectomy as sole procedure in patients with clinically severe obesity (BMI ≤ 50 kg/m 2) - Accepted Manuscript

2012-01-16

Abstract: Background: Sleeve gastrectomy (SG) is increasingly indicated as a stand-alone procedure for the treatment of clinically severe obesity. Objectives: To present outcomes of SG in relation to weight loss, resolution of comorbidities, and procedural morbidity/ mortality, for up to 5 years postoperatively. Setting: University hospital, bariatric referral center. Methods: Between January, 2005 and December, 2010, 208 patients underwent SG at our institution. Per standard protocol, SG was the sole surgery indicated for weight reduction in patients with body mass index (BMI) ≤50 kg/m2 who were not “sweet-eaters” and had no symptoms of gastroesophageal reflux disease (GERD). Study end points were weight loss, perioperative and late morbidity/mortality, as well as clinical improvement in comorbidities and consequential nutritional deficiencies. Results: SG was performed laparoscopically (LSG) in 203 of the patients. Mean age and BMI were 34.3 ± 10.3 years and 43.2 ± 2.8 kg/m2, respectively. No deaths were recorded. Early morbidity (≤30 days) was 9.6%, chiefly due to staple line closure leaks, while late morbidity was at 4.8%. A mean excess weight loss of 71.1% was documented in 90 out of 106 patients (89.4%), available for follow-up after three years, slowly declining to 57.6% in 21 out of 27 patients at five-year follow-up (77.7%). No major metabolic deficiencies were apparent. Statistically significant improvements in pre-existing hypertension, diabetes mellitus, and dyslipidemia were achieved. Post-LSG GERD symptoms developed in 9.8% of patients within the first postoperative year but lessened over time to 7.4% at the 5-year mark. Conclusions: SG is a reproducible procedure associated with significant weight reduction, resolution of obesity–related comorbidities, and minor nutritional deficits in a 5-year follow-up period. LSG may thus be safely used as sole surgical treatment of clinically severe obesity (BMI ≤ 50 kg/m2). The chief complication of postoperative leakage can be managed non-surgically in the majority of patients.

Sleeve Gastrectomy in Adolescents: The Answer to Pediatric Obesity? Editorial Response to: Laparoscopic sleeve gastrectomy in adolescents. Results in 51 patients - Accepted Manuscript

Daniel M. Herron — 2012-01-16

Laparoscopic Sleeve Gastrectomy in Obese Adolescents. Results in 51 Patients - Accepted Manuscript

2012-01-16

Abstract: Background: Adolescent obesity has become an important health problem. Bariatric surgery in this population continues to be a matter of debate. Objectives: The aim of this study was to present our experience and results of laparoscopic sleeve gastrectomy (LSG) in obese adolescents. Setting: Digestive Surgery Department, Hospital Clínico Pontificia Universidad Católica de Chile Methods: Obese adolescent patients < 19 years of age underwent LSG from January 2006 to October 2009. Percent excess weight loss (%EWL) and quality of life were analyzed. Results: Fifty-one patients less than 19 years of age underwent LSG. Of these, 80.4% were female and between 15 and 19 years of age (mean age: 18 ± 1.45 years). Mean preoperative weight and BMI were 98 ± 13.3 kg and 38.5 ± 3.7 kg/m2, respectively. Of these patients, 76% had preoperative comorbidities, with insulin resistance in 59.2%, dyslipidemia in 23.5%, hepatic steatosis in 16%, and 3.9% with type 2 diabetes mellitus. Operative time was 69 ± 24 minutes with a 2.8 ± 20.6 day postoperative hospital stay. There was no conversion to open surgery. One patient had a suture line leak that required both endoscopic and laparoscopic treatment. %EWL at 6 months and 1 and 2 years was 94.6%, 96.2%, and 92.9%, respectively. Of the 76% of patients with preoperative comorbidities, all resolved or improved their condition. In the quality of life survey (Moorehead-Ardelt Quality of Life Questionnaire) conducted, all reported a very good or good quality of life after surgery (40 and 60%, respectively). Conclusion: In our experience, LSG as a treatment for obese adolescent patients is safe, with good short-term weight loss and resolution of comorbidities.

Gastric band slippage at 30 weeks of gestation: diagnosis and laparoscopic management - Accepted Manuscript

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

Intestinal occlusion as unusual complication of new intragastric balloon Spatz Adjustable Balloon system for treatment of morbid obesity - Corrected Proof

Ramon Vilallonga, Silvia Valverde, Enric Caubet — 2011-12-26

Intragastric balloons (IGBs) have been used since 1985 to treat obesity and are a nonsurgical temporary measure indicated for patients who have not achieved weight reduction through dietary and medical measures . The primary endpoint was the absence of bowel perforation, obstruction, or hemorrhage. The migration of the balloon and the resulting intestinal occlusion requiring surgery is a rare complication .

Comment on: Temporal changes in glucose and insulin homeostasis following biliopancreatic diversion and laparoscopic adjustable gastric banding - Corrected Proof

Raul J. Rosenthal — 2011-12-26

In an effort to help elucidate the mechanisms involved in the rapid remission of type 2 diabetes mellitus in morbidly obese patients who undergo bariatric surgery, Imran et al. compared the outcomes of 2 different bariatric procedures—adjustable gastric banding and biliopancreatic diversion. Measurements of insulin resistance, glucose insulin, leptin, and tumor necrosis factor-α were conducted postoperatively and analyzed. The conclusions of their study were that malabsorptive procedures, such as biliopancreatic diversion, had a faster and longer lasting effect on decreased insulin resistance, as determined by the hormonal changes, possibly related to the changes in body mass index, leptin, and tumor necrosis factor-α. They also concluded that purely restrictive procedures, such as adjustable gastric banding, had slower onset and shorter lasting effects on decreased insulin resistance based on weight loss and diminished calorie intake.

Downsizing pregnancy complications: a study of paired pregnancy outcomes before and after bariatric surgery - Corrected Proof

Barak Aricha-Tamir, Adi Y. Weintraub, Isaac Levi, Eyal Sheiner — 2011-12-26

Abstract: Background: Overweight and obesity have been shown to be associated with increased adverse pregnancy outcomes. Weight reduction improves maternal health status and reduces the risk of pregnancy complications, as well as long-term consequences. Our objective was to compare the pregnancy outcomes of the same women who delivered before and after bariatric surgery. Methods: A retrospective study comparing pregnancy outcomes, of the same women, delivered before and after a bariatric surgery was conducted. The observed deliveries occurred from 1988 to 2008 at Soroka University Medical Center, the sole tertiary hospital in the southern region of Israel. Results: The present study included 288 paired pregnancies: 144 deliveries before and 144 after bariatric surgery. A significant reduction in the prepregnancy and predelivery maternal body mass index was noted after bariatric surgery (36.37 ± 5.2 versus 30.50 ± 5.4 kg/m2, P < .001; and 40.15 ± 4.92 versus 34.41 ± 5.42 kg/m2, P < .001; respectively). Only 8 patients (5.6%) were admitted during their pregnancy for bariatric complications. Pregnancy complications, such as hypertensive disorders (31.9% versus 16.6%; P = .004) and diabetes mellitus (20.8% versus 7.6%; P = .001), were significantly reduced after bariatric surgery. The rate of cesarean deliveries because of labor dystocia was significantly lower after bariatric surgery (5.6% versus 2.1%, P < .05). Using a multiple logistic regression model, controlling for maternal age, the reduction in hypertensive disorders (odds ratio .4, 95% confidence interval .2–.8) and diabetes mellitus (odds ratio .15, 95% confidence interval .1–.4) remained significant. Conclusion: A significant decrease in pregnancy complications, such as hypertensive disorders and diabetes mellitus, is achieved after bariatric surgery.

Proposal for a bariatric mortality risk classification system for patients undergoing bariatric surgery - Uncorrected Proof

2011-12-26

Abstract: Background: An obesity surgery mortality risk score derived from a single clinical series can be used to stratify the mortality risk of patients undergoing gastric bypass. However, such a scoring system does not take into account 2 important factors in contemporary bariatric surgery—increased use of the laparoscopic approach and laparoscopic adjustable gastric banding. The present study analyzed the preoperative factors that might predict in-hospital mortality after bariatric surgery using data from academic medical centers and proposes a classification system for predicting mortality. Methods: Using the “International Classification of Diseases, 9th revision,” diagnosis and procedural codes, the data for all patients who underwent bariatric surgery for the treatment of morbid obesity from 2002 to 2009 were obtained from the University HealthSystem Consortium database. The limitations of this database included the lack of the body mass index and the underestimation of some co-morbidities, such as sleep apnea. Multiple regression analyses were performed to determine the factors predictive of greater in-hospital mortality. The factors examined included race, gender, age, co-morbidities, surgical technique (laparoscopic versus open), bariatric operation (gastric bypass versus nongastric bypass), and payer type. A scoring system was devised by assigning 1 point for each major factor (those with an adjusted odds ratio [AOR] of ≥2.0) and .5 point for each minor factor (those with an AOR <2.0). Using contemporary data from 2007 to 2009, the in-hospital mortality was analyzed according to the classification: class I, 0-0.5 point; class II, 1.0–1.5 points; class III, 2.0–3.0 points; and class IV, ≥ 3.5 points. Results: During the 8-year period, 105,287 patients underwent bariatric surgery. The operations included laparoscopic gastric bypass (45%), open gastric bypass (41%), and laparoscopic gastric banding or gastroplasty (14%). The overall in-hospital mortality rate was .17%. The number of deaths per 1000 bariatric operations decreased from 4.0 in 2002 to .6 in 2009. Using regression analyses, the factors predictive of greater in-hospital mortality were male gender (AOR 3.2), gastric bypass procedure (AOR 5.8), open surgical technique (AOR 4.8), Medicare payer (AOR 3.0), diabetes (AOR 1.6), and age >60 years (AOR 1.9). The mortality rate was .10% for class I patients, .15% for class II, .33% for class III, and .70% for class IV (P < .05 among all classes). Conclusion: Within the context of academic centers, the mortality after bariatric surgery has decreased substantially since 2002, with an increase in the use of the laparoscopic technique and laparoscopic gastric banding. A bariatric mortality risk classification system was developed to stratify mortality, given the limits of this database, which does not include the body mass index and underestimates the incidence of sleep apnea. It might be useful to aid surgeons in surgical decision-making, to inform patients of their risks, and for quality improvement reporting purposes.

Gastrostomy tube placement in gastric remnant at gastric bypass: a rat model for selective gut stimulation - Corrected Proof

2011-12-22

Abstract: Background: Roux-en-Y gastric bypass (RYGB) surgery achieves high remission rates of type 2 diabetes mellitus in obese diabetic patients. It has been hypothesized that the changes in bowel nutrient exposure after RYGB results in altered release of gut hormones and improved glucose homeostasis. Our objective was to assess the feasibility of, and report on, our technique and initial experience with selective gut stimulation in a gastric bypass rat model at an academic medical center in the United States. Methods: We performed RYGB with simultaneous placement of a gastrostomy tube in the excluded gastric remnant in 8 obese Sprague-Dawley rats. A second group of 8 obese Sprague-Dawley rats underwent gastrostomy tube placement without gastric bypass and served as the controls. Each rat was tested for oral glucose tolerance preoperatively. On postoperative days 14 and 28, glucose tolerance was re-evaluated using the oral and gastrostomy tube routes. Results: The gastrostomy tubes were successfully inserted in all the rats with no tube-related complications. The area under the curve after oral glucose gavage decreased significantly after gastric bypass (P = .01 at 14 d and P = .003 at 28 d). The gastric remnant glucose gavage after RYGB essentially reversed the effects of surgery on glucose metabolism. The areas under the curve showed no significant differences in the control group between the preoperative and postoperative oral or tube results. Conclusion: Placing a gastrostomy tube into the gastric remnant at RYGB in a rat model is technically feasible. Our initial findings support the role of duodenal exclusion in improving glucose metabolism after RYGB.

Comment on: Halitosis in obese patients and those undergoing bariatric surgery - Corrected Proof

L.E. Sasha Stiles — 2011-12-21

So where does it come from? The lore of it, as expressed by many of my postoperative bariatric surgery patients, is that oral malodor often embarrassingly increases after weight loss surgery. The study by Souza et al. is important in that it loans accepted scientific tools from the oral disease data for evaluating mouth odor to our obese population. The authors conducted a series of precise scientific measurements in the oral cavity containing minimal oral disease. For example, volatile super compounds (VSC), tongue coating index, plaque index, and salivary flow rates (SFR) were precisely evaluated. The vomiting frequency was also assessed. They found that no statistically significant difference was found in the frequency between the cases and controls of halitosis by their measurements of the VSC, tongue coating index, and SFR. The control group exhibited a decreased SFR that was credited to the increase in hyposalivant medications in the presumed more ill preoperative patients from the increased doses of antidepressant, anithypertensive, and diabetes medications. The case group showed a greater correlation with VSC and negatively with SFR. Patients who did not brush their tongues and vomited more had increased VSCs. Questions: So halitosis does not exist? Translation: what causes vomiting pre- versus postoperatively? What causes low SFR pre- versus postoperatively, and, what else are we missing?

Reduced cardiovascular risk after bariatric surgery is linked to plasma ceramides, apolipoprotein-B100, and ApoB100/A1 ratio - Corrected Proof

2011-12-21

Background: Obesity-associated hyperlipidemia and hyperlipoproteinemia are risk factors for cardiovascular disease (CVD). Recently, ceramide-derived sphingolipids were identified as a novel independent CVD risk factor. We hypothesized that the beneficial effect of Roux-en-Y gastric bypass (RYGB) on CVD risk is related to ceramide-mediated improvement in lipoprotein profile. Methods: A prospective study of patients undergoing RYGB was conducted. The patients' clinical data and biochemical markers related to cardiovascular risk were documented. Plasma ceramide subspecies (C14:0, C16:0, C18:0, C18:1, C20:0, C24:0, and C24:1), apolipoprotein (Apo)B100 and ApoA1 were quantified preoperatively and 3 and 6 months after RYGB, as was the Framingham risk score. Brachial artery reactivity testing was performed before and 6 months after RYGB. Results: Ten patients (9 women; age 48.6 ± 9.6 yr; body mass index, 48.5 ± 5.8 kg/m2) were included in the present study. At 6 months postoperatively, the mean body mass index had decreased to 35.7 ± 5.0 kg/m2, corresponding to 51.3% ± 10.0% excess weight loss. The fasting total cholesterol, triglycerides, low-density lipoprotein, free fatty acids, ApoB100, ApoB100/ApoA1 ratio and insulin resistance estimated from Homeostasis Model of Assessment of Insulin Resistance were significantly reduced compared with the preoperative values. The ApoB100/ApoA1 ratio correlated with a reduction in ceramide subspecies (C18:0, C18:1, C20:0, C24:0, and C24:1; P < .05). ApoB100 and the ApoB100/ApoA1 ratio also correlated positively with the reduction in triglycerides, low-density lipoprotein, and Homeostasis Model of Assessment of Insulin Resistance (P < .05). Brachial artery reactivity testing correlated inversely with ApoB100 and total ceramide (P = .05). Furthermore, the change in brachial artery reactivity testing correlated with the decrease in C16:0 (P < .03). Conclusion: Our data suggest that improvements in lipid profiles and CVD risk factors after gastric bypass surgery could be linked to changes in ceramide lipids. Mechanistic studies are needed to determine whether this link is causative or purely correlative.

Comment on: Older bariatric surgery candidates: is there greater psychological risk than young and mid-life candidates? - Corrected Proof

Katherine L. Applegate — 2011-12-16

Given the growing evidence in the surgical data on the safety and efficacy of bariatric surgery for older adults (age ≥65 years) and the Medicare's 2006 decision to cover weight loss surgery in this population, the frequency with which older patients present for a preoperative evaluation is likely to increase . Assessing and treating this distinct subgroup of patients could involve some tailoring of the standard preoperative workup and treatment planning process to assist older patients in maximizing their chances of long-term success. Until recently, little guidance was available in the published data for behavioral health providers that specifically addressed clinical work with older bariatric surgery patients. Henrickson et al. at the Cleveland Clinic presented excellent suggestions on this topic in a recent report focusing on a patient-centered approach that includes psychosocial and cognitive factors to be considered during the evaluation of older bariatric patients.

Comment on: Outcomes of bariatric surgery in patients with BMI less than 35 kg/m2 - Corrected Proof

John Morton — 2011-12-16

Dr. Gianos and colleagues present very important findings in their report, Outcomes of Bariatric Surgery in Patients with BMI <35 kg/m2. In this timely study, we are able to discern several key conclusions: class 1 obesity should be treated, bariatric surgery is safe for these patients, and surgical weight loss results in significant co-morbidity remission in patients with a body mass index (BMI) <35 kg/m2. As the authors point out, many patients have class 1 obesity, and we also know that the advance of obesity is relentless, once the “tipping point” of a BMI of 30 kg/m2 is passed. Given our knowledge regarding the harmful effect of class 1 obesity, should patients with a BMI 30–35 kg/m2 be deferred treatment until their disease has advanced?

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

Marc Michalsky — 2011-12-12

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

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

2011-12-12

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

American Society of Metabolic and Bariatric Surgery patient safety committee policy statement on the qualifications of expert witnesses in bariatric surgery medicolegal matters - Corrected Proof

2011-12-12

The Patient Safety Committee of the American Society for Metabolic and Bariatric Surgery (ASMBS) encourages its members to testify in court to promote safe and responsible bariatric surgical care. The widespread availability of expert opinion to both defendants and plaintiffs is critical in meeting the Society's social responsibility. The expert witness in a medical malpractice suit is of critical importance. The purpose of expert witness testimony in medical malpractice matters is to describe the standards of care relevant to a given case, identify any breaches in those standards, and, if so noted, render an opinion as to whether those breaches were the most likely cause of injury. The expert must be able to distinguish between negligence (substandard medical care that results in harm) and an unfortunate medical outcome (recognized complications as a result of medical uncertainty). Defendants and plaintiffs deserve expert witnesses who demonstrate integrity and expertise in the field for which the opinion is being rendered.

Greater than expected prevalence of pseudotumor cerebri: a prospective study - Corrected Proof

2011-12-12

Abstract: Background: The overall incidence of pseudotumor cerebri (PTC) has been estimated at 1 per 100,000 in the general population, with an increase to 19 per 100,000 among overweight patients. About 25% of affected patients are asymptomatic until they present with vision loss. We hypothesized that PTC would be highly prevalent among obese patients seeking bariatric surgery. The setting of our study was a university hospital. Methods: During a 2-year period, clinical data were collected from candidates for bariatric surgery. A group of the study population was concurrently screened for papilledema using fundus imaging. All images were reviewed by a single neuro-ophthalmologist. All patients with abnormal images were referred for neuro-ophthalmic evaluation. Results: The imaging group (78% women) had a mean age of 45.4 ± 10.7 years, and the mean body mass index of 47.8 ± 8.7 kg/m2. High definition nonmydriatic fundus imaging was normal in 489 patients (91.9%) and abnormal in 43 patients (8.9%). The subsequent evaluation by the neuro-ophthalmologist revealed ocular abnormalities other than optic disc edema in 27 patients (5.1%) and normal findings in 7 patients (1.3%). Five patients (.9%) declined additional evaluation. Four patients (.8%) had confirmed optic disc edema and normal brain magnetic resonance imaging findings. Of these patients, 3 underwent lumbar puncture, which confirmed the diagnosis of PTC. Conclusion: We identified a greater prevalence of PTC overall (.65%) and in the imaging group (.9%) than previously reported or would have been predicted from the current data. Although routine funduscopic examination is of limited utility, these findings warrant additional investigation into the utility of, and optimal method for, screening morbidly obese patients for this co-morbidity.

Offspring outcomes after maternal BPD: euphenics for the epidemic? - Corrected Proof

Laura Dhariwal, John G. Kral — 2011-12-12

It is with great interest we read the report of Barisione et al. from the birthplace of biliopancreatic diversion, with the longest clinical observations of outcomes. Nicola Scopinaro, the father, is congratulated for this achievement although he was not acknowledged: not unusual in matters of paternity. Clinical research is very difficult and also typically does not receive the credit it is due; this study embodies the difficulties of clinical research in surgical populations.

Survey of bariatric surgical patients' experiences with behavioral and psychological services - Corrected Proof

Jessica C. Peacock, Sam J. Zizzi — 2011-12-09

Abstract: Background: Bariatric surgery continues to grow in popularity as a treatment of obesity; however, weight regain and noncompliance with behavioral recommendations remain an issue. Little is known about the type and frequency of services completed by bariatric patients and their satisfaction with these services. However, preliminary research has shown that the use of behavioral and psychological services is less common after surgery. We assessed the behavioral and psychological services completed by bariatric patients before and after surgery, patient satisfaction with the surgery and services, and the relationship between the completed services and the outcomes. The participants were solicited for participation using an on-line support Web site dedicated to obesity and bariatrics. Methods: A convenience sample of 380 subjects were included in the present study. They completed an Internet-based survey that assessed the psychological, dietary, exercise, and lifestyle services completed before and after surgery, their satisfaction with these services, and their weight loss outcomes. Results: Overall, the participants reported completing more services before surgery. After surgery, the most frequently reported services completed were support groups and dietary consultation. More than one half of the participants did not meet with either a mental health professional or an exercise professional after surgery. The participants expressed high satisfaction with their surgery and services, with exercise services receiving the lowest satisfaction rating. A statistically significant relationship was found between the total number of postoperative psychological and behavioral services completed and a greater percentage of excess weight lost. The t tests showed that participants who completed group exercise sessions and nutritional consultation after surgery lost more weight than did those who did not complete these services. Conclusion: The participants in the present sample reported completing few behavioral and psychological services after surgery. However, our findings showed that these services could promote greater weight loss and maintenance. Thus, it is recommended that bariatric facilities and insurance providers consider requiring patients to complete postoperative behavioral modification programs that target improvement in diet and physical activity behaviors.

Petersen hernia complicating laparoscopic duodenal switch - Corrected Proof

2011-12-08

Petersen type hernias have become increasingly recognized with the worldwide adoption of laparoscopic gastric bypass. So-called Petersen's hernia (PH) is contemporarily defined as an internal hernia through the space between the mesentery of the alimentary limb and the transverse mesocolon. PH can be classified by type and symptoms . No level I data are available to inform surgeons whether Petersen's space should be closed at primary surgery, and this has led to a lively debate in published studies . However, it is clear that PH can present nonspecifically, is diagnostically challenging, and can rapidly cause fatal complications. Our unit policy is to close Petersen's space at gastric bypass.

Superior calcium bioavailability of effervescent potassium calcium citrate over tablet formulation of calcium citrate after Roux-en-Y gastric bypass - Corrected Proof

Khashayar Sakhaee, Charles Pak — 2011-12-05

Abstract: Background: Calcium supplementation is commonly recommended for patients after Roux-en-Y gastric bypass to avert bone loss. To test the hypothesis that effervescent (liquid) potassium-calcium-citrate (PCC) might be more bioavailable than a tablet formulation of calcium citrate (Citracal Petite), the present study compared a single dose response of the 2 compounds. The present study was conducted at the University of Texas Southwestern Medical School at Dallas. Methods: A total of 15 patients who had undergone Roux-en-Y gastric bypass were included in a 2-phase, crossover, randomized study comparing the single-dose bioavailability of PCC versus Citracal Petite. After following a restricted diet for 1 week, the participants ingested either a single dose of 400 mg elemental calcium as PCC or Citracal Petite. Sequential serum and urine samples were collected for a 6-hour period after the dose and analyzed for calcium, parathyroid hormone, and acid-base parameters. Results: Compared with citracal petite, PCC significantly increased the serum calcium concentrations at 2, 3, and 4 hours after the oral load. The peak to baseline variation and increment in serum calcium (area under the curve) were significantly greater after PCC (P = .015 and P = .002, respectively). Concurrently, the baseline to nadir variation and decrement in serum parathyroid hormone (area over the curve) were significantly greater after PCC (P = .004 and P = .005, respectively). Moreover, compared with Citracal Petite, PCC caused a significantly greater increment in urinary citrate (P < .0001) and potassium (P = .0004) and a significantly lower increase in urinary ammonium (P = .045). Conclusion: In patients who have undergone Roux-en-Y gastric bypass, PCC was superior to Citracal Petite in conferring bioavailable calcium and suppressing parathyroid hormone secretion. PCC also provided an alkali load.

Comment on: The effects of surgically-induced weight loss via Roux-en-Y gastric bypass on cardiovascular autonomic nerve function - Corrected Proof

Gavin W. Lambert — 2011-12-05

The pathophysiologic mechanisms underlying obesity and its complications are complex and extend beyond the triumvirate of a sedentary lifestyle, poor diet, and genetic predisposition. It is becoming evident that the sympathetic nervous system is important in the generation of obesity and obesity-related illness. Although the cardiovascular consequences of sympathetic nervous activation are readily apparent and underpin the development of recent advances in hypertension therapy , it is less well appreciated that the sympathetic nervous system also exerts substantial metabolic effects. Compelling evidence has shown that elevated sympathetic activity and blunted sympathetic neural responsiveness play a role in the etiology and target organ complications of obesity . Furthermore, very recent studies have identified baseline and oral glucose stimulated sympathetic nervous activity as a determinant of successful diet-induced weight loss . Biochemical, neurophysiologic, and indirect assessments of autonomic activity have indicated that visceral obesity and the metabolic syndrome are associated with enhanced sympathetic neural drive, particularly to the kidney and skeletal muscle vascular beds . A combination of metabolic, cardiovascular, medical, genetic, psychological, and lifestyle factors might be involved, acting exclusively or in concert, to enhance sympathetic drive and also blunt vagal activity. As demonstrated recently, even in young, overweight adults, obesity-related sympathetic activation is associated with subclinical alterations in renal and endothelial function and in the structure and function of the heart, even in the absence of hypertension . The consequences of this sympathoexcitation might, in part, explain the increased cardiovascular risk that is evident in young individuals with excess weight .

Effects of surgically induced weight loss by Roux-en-Y gastric bypass on cardiovascular autonomic nerve function - Corrected Proof

2011-12-05

Abstract: Background: Obesity is associated with autonomic imbalance. With respect to cardiovascular autonomic dysfunction, this is characterized by reduced heart rate variability (HRV). Our objective was to determine the effect of surgically induced weight loss on cardiovascular autonomic nerve fiber function in subjects with severe obesity and examine whether an association with reduced insulin resistance exists. The setting was a hospital and private practice in the United States. Methods: A total of 32 morbidly obese patients (body mass index 51 ± 11 kg/m2) underwent laparoscopic Roux-en-Y gastric bypass. Measures of HRV (e.g., power spectral analysis, RR variation during deep breathing) were used to evaluate autonomic function before and 6 months after surgery. The homeostasis model assessment of insulin resistance index (HOMA-IR) was used to assess insulin resistance. Results: At 6 months after bariatric surgery, the patients had lost 58% excess body mass index with improvement in the HOMA-IR (3.0 ± 1.4 versus 1.1 ± .7; P < .001). Measures of RR variation during deep breathing and total spectral power, low frequency (LF) power (influenced by sympathetic and parasympathetic activity), and high frequency (HF) power (parasympathetic activity) increased with weight loss. The LF/HF ratio was lower (1.5 ± 1.5 versus .9 ± .7, P < .05) with a reduction in weight. Spectral analysis of HRV combined with spectral analysis of respiratory activity generated the respiration frequency area (RFA) and low frequency area. The RFA was increased, and the LFA/RFA ratio was reduced with weight loss. HOMA-IR and HRV did not correlate. Conclusion: Surgically induced weight loss has a favorable effect on autonomic function, but it does not appear to be directly attributable to reduced insulin resistance.

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

Lee L. Swanstrom — 2011-12-02

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

Comments regarding a recent article comparing gastric bypass and duodenal switch and its questionable method and results - Corrected Proof

Picard Marceau, Simon Biron — 2011-12-02

Last September a group from Norway and Sweden reported in the Annals of Internal Medicine a clinical randomized trial comparing Roux-en-Y gastric bypass and duodenal switch (DS) . This report was accompanied by an editorial by Livingston from the University of Texas. The report is remarkable for its presentation, and these investigators are to be congratulated for their courage in undertaking a pioneering task. However, we would like to express our reservation concerning both the use of randomization in this context and, in particular, the view presented in the accompanying editorial, which limits the role of bariatric surgery to saving lives.

Comment on: Early prediction of the failure to lose weight after obesity surgery - Corrected Proof

Pavlos Papasavas — 2011-11-30

The success of bariatric surgery is not well defined in the published data, and arbitrary numbers of the percentage of excess weight loss (%EWL) have been used without taking into consideration the improvement of co-morbidities or quality of life. The failure of bariatric surgery is a complex and not well-understood entity with several components, including dietary, behavioral, anatomic, genetic, ethnic, physical, and psychological [].

Halitosis in obese patients and those undergoing bariatric surgery - Corrected Proof

2011-11-28

Abstract: Background: Patients undergoing bariatric surgery often complain of bad breath. However, the relationship between bariatric surgery and halitosis is relatively unknown. The purpose of the present study was to evaluate and compare the occurrence of halitosis among patients before and after a specific type of bariatric surgery, Roux-en-Y gastric bypass, and its relationship with the tongue coating index, plaque index, and salivary flow rate. Methods: A total of 62 patients with good oral health and in treatment for obesity at the walk-in clinic of Santa Casa Hospital, Belo Horizonte, Brazil, were selected. Of this sample, 31 were bariatric surgery candidates (control group) and 31 had already undergone Roux-en-Y gastric bypass surgery (case group). After completing a questionnaire, all patients underwent an oral clinical examination. Halitosis was measured using an organoleptic scale and a portable sulfide monitor. Results: The Spearman correlation demonstrated a strong positive relation between the organoleptic rates and the concentration of volatile sulfur compounds determined using the sulfide monitor (rs = .58; P = .0001). No difference was found in the prevalence of halitosis between the 2 groups (P = .48). Only the salivary flow rate was significantly reduced in the control group compared with the case group (P = .02). In the case group, the concentration of volatile sulfur compounds correlated negatively with the salivary flow rate (P = .04) and positively with the tongue coating index (P = .005). The tongue coating index was significantly increased in those patients who did not brush the tongue (P < .04) and who had had episodes of vomiting (P = .02). Conclusion: These data suggest that no significant association exists between halitosis and Roux-en-Y gastric bypass. However, they do highlight the possible effect of this surgery on the oral cavity.

Older bariatric surgery candidates: is there greater psychological risk than for young and midlife candidates? - Corrected Proof

Leslie J. Heinberg, Kathleen Ashton, Amy Windover, Julie Merrell — 2011-11-28

Abstract: Background: Although severe obesity is dramatically increasing in older adults, many bariatric programs use age cutoffs due to concerns about greater perioperative morbidity and mortality risks. More recently, surgical outcomes have been reported in older adults. However, a paucity of data is available on the psychological risks of older bariatric candidates. Our objective is to examine psychiatric risk factors and weight loss outcomes in older (≥65 yr) versus midlife (40–55 yr) versus young adult (18–29 yr) patients. Methods: Older, midlife, and young adults (n = 608) who underwent weight loss surgery (74.6% women, 75.6% white, mean body mass index 48.07 ± 9.61 kg/m2) at the Cleveland Clinic Bariatric and Metabolic Institute completed a psychiatric diagnostic interview, and the Minnesota Multiphasic Personality Inventory-2-Restructured Form, Binge Eating Scale, and Cleveland Clinic Behavioral Rating Scale before surgery. The data gathered from follow-up visits and weight loss outcomes at 1, 3, 6, 9, 12, and 18 months after surgery were measured. Results: Young adults had a greater reduction in excess body mass index than those at midlife in the first 6 months but no age differences were noted in the following year. Older patients were less likely to have a suicide history but the groups were equivalent on other psychiatric variables and self-report measures. Psychologist evaluators rated older adults less favorably on the capacity to consent and realistic nature of expectations. Conclusion: Although medical risks may cause concern, older adults do not demonstrate any increased psychological risk factors compared with midlife or young adult surgical candidates and evidenced equivalent weight loss. However, concerns with lower ratings on consent and expectations warrant additional research.

Comment on: Cognitive function predicts weight loss following bariatric surgery - Corrected Proof

Katherine L. Applegate — 2011-11-28

As the field of bariatric surgery progresses, practitioners are seeing some clinically significant variability in patients' long-term success after surgery. This finding is now being explored in an exciting area of research examining the diverse possible explanations and mechanisms for this observed variability in postoperative outcomes. These lines of inquiry are investigating possible anatomic (i.e., gastrojejunal stoma size), genetic (e.g., obesity genes), behavioral (e.g., food urges, well-being, and concern about addictive behaviors), demographic (e.g., age, gender), and dietary (e.g., protein intolerances) factors that might affect a patient's tendency or risk of weight regain after weight loss surgery .

Early prediction of failure to lose weight after obesity surgery - Corrected Proof

2011-11-28

Abstract: Background: After Roux-en-Y gastric bypass (RYGB), failing to lose enough weight or regaining weight is a concern for both patients and healthcare professionals. Our objective was to report the criteria for an early prediction of the failure to lose enough weight in the setting of a private practice and an academic center of obesity surgery. Patients and Methods: A retrospective analysis of the 2-year weight loss profiles of patients after RYGB was performed using nonlinear mixed models. A total of 375 morbidly obese adult patients, with a body mass index of 49.3 ± 7.7 kg/m2, were included. Weight loss success was determined 2 years after surgery using the percentage of excess weight loss criteria. The surgical treatment and the main outcome measurement was standardized RYGB and the percentage of excess weight loss time profiles. Results: The patients who failed, succeeded, or had intermediate results at 2 years after surgery had different percentage of excess weight loss profiles during this period. At 6 months, 71% of those who had lost <30% of their initial excess weight had not lost ≥50% at 24 months. In contrast, those who had lost >45% were unlikely to have lost <50% of their excess weight. Conclusion: An early (month 6) prediction of failure to lose significant weight after RYGB can be made, with the threshold at 30% of the initial excess weight loss. Patients who have lost <30% of their initial excess weight are unlikely to have lost ≥50% at 24 months.

Editorial comment - Uncorrected Proof

Leslie J. Heinberg — 2011-11-28

Although adolescents have long been examined in the field of body image, very little is known about the body image experiences of severely obese persons across the age spectrum. Furthermore, adolescents are a largely understudied area of bariatric surgery. In this issue of the Journal, Ratcliff et al. explore the changes in the perceptions of actual and ideal body sizes preoperatively and 6 and 12 months postoperatively using schematic line drawings of body shapes of increasing gradations (i.e., figural rating scales). This study, along with other prospective work by the investigative team , is an important contribution, given the influence of body image on self-esteem, depression, eating behaviors, and quality of life .

Comment on: An online bariatric surgery information session is as effective as an in-person information session - Corrected Proof

Barbara N. Metcalf — 2011-11-17

This is an interesting study, because many of us are already using on-line education in preparing our patients for bariatric surgery. The comparison between on-line and in-person education reconfirms that patients who use the Internet before selecting a bariatric surgeon or procedure are often more educated when they come into our individual practices.

Reversal of gastric plication after laparoscopic adjustable gastric banded plication - Corrected Proof

Rajat Goel, Po-Chih Chang, Chih-Kun Huang — 2011-11-17

Laparoscopic adjustable gastric banded plication (LAGBP) is a novel, restrictive, reversible bariatric procedure that theoretically combines the advantages of gastric banding and plication. The initial results in terms of feasibility, safety, and patient compliance have been encouraging . There have been doubts regarding the reversibility of this procedure. We report on 2 patients in whom we were able to reverse the procedure.