Showing papers in "Obesity Surgery in 2006"

A prospective randomized study between laparoscopic gastric banding and laparoscopic isolated sleeve gastrectomy: results after 1 and 3 years.

Abstract: Background: Laparoscopic adjustable gastric banding (GB) is the most popular restrictive procedure for obesity in Europe. Isolated sleeve gastrectomy (SG), is less common, but more invasive and with a higher learning curve. The aim of this prospective randomized study was to compare the results of GB and SG after 1 and 3 years of surgery. Methods: 80 patient candidates for laparoscopic restrictive surgery were operated consecutively and randomly, between January and December 31, 2002, by GB (7M, 33F) or by SG (9M, 31F) (NS). Median age was 36 (20-61) for GB versus 40 (22-65) for SG (NS). Median BMI was 37 (30-47) for GB versus 39 (30-53) for SG (NS). After 1 and 3 years: weight loss, feeling of hunger, sweet eating, gastroesophageal reflux disease (GERD), complications and re-operations were recorded in both groups. Results: Median weight loss after 1 year was 14 kg (−5 to +38) for GB and 26 kg (0 to 46) for SG (P<0.0001); and after 3 years was 17 kg (0 to 40) for GB and 29.5 kg (1 to 48) for SG (P<0.0001). Median decrease in BMI after 1 year was 15.5 kg/m 2 (5 to 39) after GB and 25 kg/m2 (0 to 45) after SG (P<0.0001); and after 3 years was 18 kg/m2 (0 to 39) after GB and 27.5 kg/m 2 (0 to 48) after SG (P=0.0004). Median %EWL at 1 year was 41.4% (−11.8 to +130.5) after GB and 57.7% (0 to 125.5) after SG (P=0.0004); and at 3 years was 48% (0 to 124.8) after GB and 66% (−3.1 to +152.4) after SG (P=0.0025). Loss of feeling of hunger after 1 year was registered in 42.5% of patients with GB and in 75% of patients with SG (P=0.003); and after 3 years in 2.9% of patients with GB and 46.7% of patients with SG (P<0.0001). Loss of craving for sweets after 1 year was achieved in 35% of patients with GB and 50% of patients with SG (NS); and after 3 years in 2.9% of patients with GB and 23% of patients with SG (NS). GERD appeared de novo after 1 year in 8.8% of patients with GB and 21.8% of patients with SG (NS); and after 3 years in 20.5% of patients with GB and 3.1% of patients with SG (NS). Postoperative complications requiring re-operation were necessary for 2 patients after SG. Late complications requiring re-operation after GB included 3 pouch dilations treated by band removal in 2 and 1 laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP), 1 gastric erosion treated by conversion to RYGBP, and 3 disconnections of the system treated by reconnection. Inefficacy affected 2 patients after GB, treated by conversion into RYGBP and 2 patients after SG treated by conversion to duodenal switch. Conclusion: Weight loss and loss of feeling of hunger after 1 year and 3 years are better after SG than GB. GERD is more frequent at 1 year after SG and at 3 years after GB. The number of re-operations is important in both groups, but the severity of complications appears higher in SG.

Systematic review of medium-term weight loss after bariatric operations.

Abstract: Background: Although bariatric surgery is known to be effective in the short term, the durability of that effect has not been convincingly demonstrated over the medium term (>3 years) and the long term (>10 years). The authors studied the durability of weight loss after bariatric surgery based on a systematic review of the published literature. Methods: All reports published up to September, 2005 were included if they were full papers in refereed journals published in English, of outcomes after Roux-en-Y gastric bypass (RYGBP), and its hybrid procedures of banded bypass (Banded RYGBP) and longlimb bypass (LL-RYGBP), biliopancreatic diversion with or without duodenal switch (BPD±DS) or laparoscopic adjustable gastric banding (LAGB). All reports that had at least 100 patients at commencement, and provided ≥3 years of follow-up data were included. Results: From a total of 1,703 reports extracted, 43 reports fulfilled the entry criteria (18 RYGBP; 18 LAGB; 7 BPD). Pooled data from all the bariatric operations showed effective and durable weight loss to 10 years. Mean %EWL for standard RYGBP was higher than for LAGB at years 1 and 2 (67 vs 42; 67 vs 53) but not different at 3, 4, 5, 6 or 7 years (62 vs 55; 58 vs 55; 58 vs 55; 53 vs 50; and 55 vs 51). There was 59 %EWL for LAGB at 8 years, and 52 %EWL for RYGBP at 10 years. Both the BPD±DS and the Banded RYGBP appeared to show better weight loss than standard RYGBP and LAGB, but with statistically significant differences present at year 5 alone. The LL-RYGBP was not associated with improved %EWL. Important limitations include lack of data on loss to follow-up, failure to identify numbers of patients measured at each data point and lack of data beyond 10 years. Conclusions: All current bariatric operations lead to major weight loss in the medium term. BPD and Banded RYGBP appear to be more effective than both RYGBP and LAGB which are equal in the medium term.

A 10-year experience with laparoscopic gastric banding for morbid obesity: high long-term complication and failure rates.

Abstract: Background: Since its introduction about 10 years ago, and because of its encouraging early results regarding weight loss and morbidity, laparoscopic gastric banding (LGB) has been considered by many as the treatment of choice for morbid obesity. Few long-term studies have been published. We present our results after up to 8 years (mean 74 months) of follow-up. Methods: Prospective data of patients who had LGB have been collected since 1995, with exclusion of the first 30 patients (learning curve). Major late complications are defined as those requiring band removal (major reoperation), with or without conversion to another procedure. Failure is defined as an excess weight loss (EWL) of 50%), LGB should no longer be considered as the procedure of choice for obesity. Until reliable selection criteria for patients at low risk for long-term complications are developed, other longer lasting procedures should be used.

Effectiveness of Laparoscopic Sleeve Gastrectomy (First Stage of Biliopancreatic Diversion with Duodenal Switch) on Co-Morbidities in Super-Obese High-Risk Patients

Abstract: Background: We evaluated laparoscopic sleeve gastrectomy (LSG) on major co-morbidities (hypertension, type 2 diabetes / impaired glucose tolerance, obstructive sleep apnea syndrome (OSAS) and on American Society of Anesthesiologists (ASA) operative risk score in high-risk super-obese patients undergoing two-stage laparoscopic biliopancreatic diversion with duodenal switch (LBPD-DS). Methods: 41 super-obese high-risk patients (mean BMI 57.3±6.5 kg/m2, age 44.6±9.7 years) were entered into a prospective study (BMI ≥60, or BMI ≥50 with at least two severe co-morbidities, no Prader-Willi syndrome, no conversion, minimum follow-up 12 months). 9 patients had BMI ≥60. 17 patients (41.4%) had OSAS on C-PAP therapy. In 10 patients, at least one intragastric balloon had been positioned and 4 had undergone laparoscopic adjustable gastric banding, all with unsatisfactory results. At surgery, 41.5% were classified ASA 4 and 58.5% as ASA 3 (mean ASA score 3.4±0.5). Patients underwent evaluation every 3 months postoperatively and were restaged at 12 months and/or before the second step. Results: 60% of major co-morbidities were cured and 24% improved. Average BMI after 6 and 12 months was 44.5±8.1 and 40.8±8.5 respectively (mean follow-up 22.2±7.1 months). After 12 months, 57.8% of the patients were co-morbidity-free and 31.5% had only one major co-morbid condition. At restaging, 20% of patients were still classified as ASA score 4 (OSAS on C-PAP therapy). 3 patients showed BMI <30 and were co-morbidity-free 12 months after LSG. Conclusions: LSG represents a safe and effective procedure to achieve marked weight loss as well as significant reduction of major obesity-related co-morbidities. The procedure reduced the operative risk (ASA score) in super-obese patients undergoing two-stage LBPD-DS.

Psychosocial predictors of weight loss after bariatric surgery.

Abstract: Background: The authors investigated the predictive value of various parameters such as age, preoperative weight, eating behavior, psychiatric disorders, adverse childhood experiences and self-efficacy with regard to weight loss after gastric restrictive surgery. Methods: After a minimum follow-up of 30 months (median follow-up 50 months; range 30-84 months), a questionnaire concerning extent of, satisfaction with, and consequences of weight loss was mailed to 220 morbidly obese female patients following laparoscopic Swedish adjustable gastric banding (SAGB). Results: Questionnaires were completed and returned by 140 patients (63%). Average BMI loss was 14.6 kg/m2. Most patients (85%) were happy with the extent of weight loss. Satisfaction with weight loss showed a significant correlation with extent of weight loss. BMI loss was greatest in the obese with an atypical eating disorder (20.0 kg/m2), and BMI loss was least in the obese with no eating-disordered behavior before surgery (13.4 kg/m2). Obese patients with two or more psychiatric disorders showed significantly less weight loss than did obese patients with one or no psychiatric disorder (BMI units 10.8 vs 14.0 vs 16.1; P=.047). Conclusions: The findings indicate a less successful outcome for obese patients with psychiatric disorders (particularly adjustment disorders, depression and/or personality disorders), compared to patients not mentally ill. An eating disorder preceding surgery, however, was not a negative predictor of success following bariatric surgery. To improve outcome of bariatric surgery in obese patients with psychiatric disorders, more individual psychosocial intervention strategies are necessary.

Laparoscopic sleeve gastrectomy as treatment for morbid obesity: technique and short-term outcome.

Abstract: Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic adjustable gastric banding (LAGB) are the most commonly performed surgical procedures for weight reduction in the United States. Currently, laparoscopic sleeve gastrectomy (LSG) is being explored. The aim of this study was to assess the safety and short-term efficacy of LSG as a treatment option for weight reduction. Methods: Data of all patients who underwent LSG for treatment of morbid obesity between November 2004 and March 2006 and completed the 3- and 6-month follow-up visits at the time of the study, were retrospectively reviewed. Data collected included demographics, operative time, length of stay, postoperative complications, and degree of weight reduction. Results: Of the 62 patients who underwent LSG performed by two surgeons, the data of 30 patients (7 males and 23 females) were further analyzed. Mean preoperative BMI was 41.4 (33-59) kg/m2. Mean operative time was 80 min (range 65-130). Mean hospital stay was 3.2 days (range 2 to 25). Mean weight loss at 3 and 6 months following the procedure was 22.7 kg and 30.5 kg respectively, and mean % excess weight loss (EWL) was 40.7 and 52.8, respectively. Three patients were considered to have mild complications, and one patient had a major complication that necessitated surgical intervention. There was no mortality. Conclusions: In the short-term, LSG is a safe and effective treatment option.

Does Gastric Dilatation Limit the Success of Sleeve Gastrectomy as a Sole Operation for Morbid Obesity

Abstract: Background: Sleeve gastrectomy as the sole bariatric operation has been reported for high-risk super-obese patients or as first-step followed by Roux-en-Y gastric bypass (RYGBP) or duodenal switch (DS) in super-super obese patients. The efficacy of laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients with a BMI of 12 months. Results: Patients who underwent LSG achieved a mean excess weight loss (EWL) at 6 and 12 months postoperatively of 46% and 56%, respectively. No significant differences were observed in %EWL comparing obese and super-obese patients. At a mean follow-up of 20 months, dilatation of the gastric sleeve was found in 1 patient and weight regain after initial successful weight loss in 3 of the 23 patients. Conclusion: LSG has been highly effective for weight reduction for morbid obesity even as the sole bariatric operation. Gastric dilatation was found in only 1 patient in this short-term follow-up. Weight regain following LSG may require conversion to RYGBP or DS. Follow-up will be necessary to evaluate long-term results.

Change in liver size and fat content after treatment with Optifast very low calorie diet.

Abstract: Mark C. Lewis, Madeleine L. Phillips, John P. Slavotinek, Lilian Kow, Campbell H. Thompson and Jim Toouli

Peptide YY(1-36) and peptide YY(3-36): Part I. Distribution, release and actions.

Abstract: Peptide YY (PYY) is a 36 amino acid, straight chain polypeptide, which is co-localized with GLP-1 in the L-type endocrine cells of the GI mucosa. PYY shares structural homology with neuropeptide Y (NPY) and pancreatic polypeptide (PP), and together form the Neuropeptide Y Family of Peptides, which is also called the Pancreatic Polypeptide-Fold Family of Peptides. PYY release is stimulated by intraluminal nutrients, including glucose, bile salts, lipids, short-chain fatty acids and amino acids. Regulatory peptides such as cholecystokinin (CCK), vasoactive intestinal polypeptide (VIP), gastrin and GLP-1 modulate PYY release. The proximal GI tract may also participate in the regulation of PYY release through vagal fibers. After release, dipeptidyl peptidase IV (DPP-IV; CD 26) cleaves the N-terminal tyrosine-proline residues forming PYY(3-36). PYY(1-36) represents about 60% and PYY(3-36) 40% of circulating PYY. PYY acts through Y-receptor subtypes: Y1, Y2, Y4 and Y5 in humans. PYY(1-36) shows high affinity to all four receptors while PYY(3-36) is a specific Y2 agonist. PYY inhibits many GI functions, including gastric acid secretion, gastric emptying, small bowel and colonic chloride secretion, mouth to cecum transit time, pancreatic exocrine secretion and pancreatic insulin secretion. PYY also promotes postprandial naturesis and elevates systolic and diastolic blood pressure. PYY(1-36) and PYY(3-36) cross the blood-brain barrier and participate in appetite and weight control regulation. PYY(1-36) acting through Y1- and Y5-receptors increases appetite and stimulates weight gain. PYY(3-36) acting through Y2-receptors on NPY-containing cells in the arcuate nucleus inhibits NPY release and, thereby, decreases appetite and promotes weight loss. PYY may play a primary role in the appetite suppression and weight loss observed after bariatric operations.

Sleeve gastrectomy in the high-risk patient.

Abstract: Background: One of the surgical options available for the super-obese patient is the sleeve gastrectomy We present results of this operation in a series of 118 patients Methods: The charts of all patients who have had the sleeve gastrectomy performed were reviewed for demographic data, complications, weight, and nutritional parameters Results: Median age was 47 years (16-70) Median BMI was 55 kg/m2 (37-108), with 73% of patients having a BMI ≥50 kg/m2 41% of the patients were male The operation was performed by laparotomy in all but three cases, which were performed laparoscopically Median hospital stay was 6 days (3-59) There was one perioperative death (085%) 18 patients (153%) had postoperative complications Median percent excess weight loss was 378% at 6 months, 494% at 12 months, and 473% at 24 months Median follow-up was 13 months (1-66) At 1 year postoperatively, the percentage of patients with normal serum levels of albumin was 100%, hemoglobin 861%, and calcium 872%, compared to 981%, 856%, and 943% preoperatively 6 patients requested conversion to a duodenal switch during the follow-up period; all left the hospital in 4-6 days without major complication Conclusions: Although the sleeve gastrectomy does not result in as much weight loss as the duodenal switch or gastric bypass, it can be used as a stand-alone operation or as a bridge to more complex procedures in the high-risk super-obese patient

Weight Loss and Non-alcoholic Fatty Liver Disease: Falls In Gamma-Glutamyl Transferase Concentrations are Associated with Histologic Improvement

Abstract: Background: The ability for aminotransferase levels to track histological features of non-alcoholic fatty liver disease (NAFLD) with weight loss has not been examined. Methods: We examined the effect of weight loss following laparoscopic adjustable gastric banding surgery on the histological features of NAFLD and plasma aminotransferase concentrations (AST, ALT and GGT) in 60 (12M, 48F) selected severely obese patients. All 120 paired biopsies were deidentified and scored for lobular steatosis, fibrosis, inflammation, Mallory bodies and NASH. Results: 30 patients (50%) had baseline histological features of non-alcoholic steatohepatitis (NASH). Repeat biopsies were taken at 29.5±10 months after baseline. Mean weight loss was 31.5±18 kg. There were improvements in AST, ALT, GGT, lobular steatosis, inflammation and fibrosis between baseline and follow-up (P<0.001 for all). Only 6 (10%) of repeat biopsies showed NASH. No change in aminotransferase concentrations predicted the change in steatosis, but changes in AST and GGT predicted improved scores for inflammation, fibrosis, Mallory bodies and NASH. The lowering of GGT best predicted the improvements in inflammation, fibrosis and NASH. Conclusion: With weight loss, falls in GGT and, to a lesser extent, in AST, are predictive of improved lobular inflammation and fibrosis, key prognostic features of NAFLD.

Vitamin and trace mineral levels after laparoscopic gastric bypass.

Abstract: Background: Nutritional deficiencies are a concern after any bariatric surgery procedure. Restriction of oral intake and/or decreased absorption may cause vitamin abnormalities. Prevention of these vitamin deficiencies includes both supplementation and routine measuring of serum values. An investigation was undertaken to examine preoperative and short-term (1-year) postoperative levels of vitamins/trace minerals in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: Serum preoperative and postoperative vitamin/trace element levels of LRYGBP patients were recorded in a retrospective chart review (n = 100). Unavailable and undrawn levels were not included in the results. Results: Preoperative and 1-year postoperative percentage of abnormal levels were: vitamin A 11% and 17%, vitamin B12 13% and 3%, vitamin D-25 40% and 21%, zinc 30% and 36%, iron 16% and 6%, ferritin 9% and 3%, selenium 58% and 3%, and folate 6% and 11%. Conclusions: Abnormal vitamin and trace mineral values are common both preoperatively and postoperatively in a bariatric surgery patient population. Routine evaluation of serum levels should be performed in this specific patient population.

How do mental health professionals evaluate candidates for bariatric surgery? Survey results.

Abstract: Background: The prevalence of extreme obesity and the popularity of bariatric surgery have increased dramatically in recent years. Many surgery programs require that candidates undergo a preoperative psychological evaluation, but no consensus exists for guiding mental health professionals in the conduct of these evaluations. Method: A survey was sent to bariatric surgeons, who were asked to distribute the surveys to the mental health professionals to whom they refer surgery candidates for preoperative evaluations. 194 respondents provided information on the assessment methods they use, which psychosocial domains are the focus of their evaluations, and what they consider to be contraindications to surgery. Responses to open-ended questions were coded for content. Results: Most respondents reported using clinical interviews (98.5%), symptom inventories (68.6%), and objective personality/psychopathology tests (63.4%). A minority used tests of cognitive function (38.1%) and projective personality tests (3.6%). Over 90% of respondents listed mental health issues among the most important areas to assess. Similarly, 92.3% listed psychiatric issues as "clear contraindications" to surgery, but no specific disorder was listed by a majority of respondents. Issues related to informed consent and treatment adherence were the non-psychiatric domains most frequently listed as important areas to assess and as contraindications to surgery. Conclusion: The assessment practices of mental health professionals who evaluate bariatric surgery candidates vary widely. No consensus is likely to emerge until large long-term studies identify consistent psychosocial predictors of poor postoperative outcomes.

Internal Hernia after Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Abstract: Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is associated with a relatively high incidence of internal hernias (IH) when compared to the open operation. Methods: A search in PubMed MEDLINE from January 1994 through January 2006 was performed (keywords: obesity, laparoscopy, gastric bypass and internal hernia). Results: 26 studies with a total of 11,918 patients were considered. 300 cases of IH occurred (rate 2.51%). IH occurred 116 times at the level of the transverse colon mesentery (69%), 30 at the Petersen's space (18%), and 22 at the entero-enterostomy site (13%). 142 re-operations were performed laparoscopically (85.6%), and 24 by laparotomy (14.4%). Bowel resection was done in 5 cases (4.7%). Mortality was 1.17%. Conclusions: IH after LRYGBP has an incidence of 2.51%. Closure of mesenteric defects with non-absorbable running suture and antecolic Roux limb are recommended. Surgical exploration for suspicion of IH after LRYGBP should be first done by laparoscopy.

Estimating blood volume in obese and morbidly obese patients.

Abstract: Preoperative assessment of blood volume (BV) is important for patients undergoing surgery. The mean value for indexed blood volume ((In)BV) in normal weight adults is 70 mL/kg. Since (In)BV decreases in a non-linear manner with increasing weight, this value cannot be used for obese and morbidly obese patients. We present an equation that allows estimation of (In)BV over the entire range of body weights.

Psychosocial functioning following bariatric surgery.

Abstract: Morbid obesity is associated with an increased risk of morbidity and mortality as well as psychosocial problems and poor quality of life. The ultimate goal of bariatric surgery is not only reduced weight and reduction of co-morbidities, but also improved psychosocial functioning and quality of life. However, not all patients are successful. A systematic literature search of recent articles identified relevant variables reflecting postoperative psychosocial functioning. Most studies showed that bariatric surgery does not only lead to substantial weight reduction, but also to improvement or cure of physical as well as psychological co-morbidities. Although most studies are optimistic and report broad psychosocial improvement, a significant minority of patients do not benefit psychologically from surgery. Although there are mixed results, the overall improvements in psychosocial functioning provide additional justification for surgical treatment of morbid obesity.

The impact of bariatric surgery on menstrual patterns.

Abstract: Background: Obesity and anovulation are common medical problems in the United States. Anovulation in obese patients primarily manifests with irregular, sporadic or absent menstrual bleeding. Weight loss of at least 5% has been shown to reverse obesity-related anovulation. The aim of this study was to assess the impact of bariatric surgery on infertility in morbidly obese women and to identify factors associated with return of normal menses following bariatric surgery. Methods: A survey of patients was collected from the bariatric surgery data-base at the Hospital of the University of Pennsylvania. 410 women under the age of 40 were sent questionnaires. 195 patients completed the questionnaire, and 29 patients had incorrect addresses without a forwarding address, resulting in a 51.2% response rate. Patients who reported menstrual cycle lengths >35 days were considered abnormal. 92 of the 195 responders were considered anovulatory preoperatively, based on menstrual history. Results: There was no significant difference in postoperative BMI, BMI decrease or age at surgery between the survey responders and non-responders. There was a significant difference between these 2 groups in time since surgery (P=.01). Both groups had a decrease in BMI of >18 kg/m2. The mean menstrual cycle length preoperatively among those categorized as ovulatory and anovulatory was 27.3 and 127.5 days, respectively. Of the 98 patients who were anovulatory preoperatively, 70 patients (71.4%) regained normal menstrual cycles after surgery. Those patients who regained ovulation had greater weight loss than those who remained anovulatory (61.4 kg vs 49.9 kg, P=0.02). Conclusions: Anovulation resulting in abnormal menses is a common problem in morbidly obese premenopausal women. The menstrual cycle disorders may completely resolve after bariatric surgery. Thus, infertility due to anovulation among morbidly obese women could potentially be viewed as an additional indication for bariatric surgery.

Predictors of weight status following laparoscopic gastric bypass.

Abstract: Background: Weight loss after bariatric surgery varies and depends on many factors, such as time elapsed since surgery, baseline weight, and co-morbidities. Methods: We analyzed weight data from 494 patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) by one surgeon at an academic institution between June 1999 and December 2004. Linear regression was used to identify factors in predicting % excess weight loss (%EWL) at 1 year. Results: Mean patient age at time of surgery was 44 ± 9.6 (SD), and the majority were female (83.8%). The baseline prevalence of co-morbidities included 24% for diabetes, 42% for hypertension, and 15% for hypercholesterolemia. Baseline BMI was 51.5 ± 8.5 kg/m2. Mean length of hospital stay was 3.8 ± 4.6 days. Mortality rate was 0.6%. Follow-up weight data were available for 90% of patients at 6 months after RYGBP, 90% at 1 year, and 51% at 2 years. Mean %EWL at 1 year was 65 ± 15.2%. The success rate (≥50 %EWL) at 1 year was 85%. Younger age and lower baseline weight predicted greater weight loss. Males lost more weight than females. Diabetes was associated with a lower %EWL. Depression did not significantly predict %EWL. Conclusion: The study demonstrated a 65 %EWL and 85% success rate at 1 year in our bariatric surgery program. Our finding that most pre-surgery co-morbidities and depression did not predict weight loss may have implications for pre-surgery screening.

Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity: a continuous challenge in bariatric surgery.

Abstract: Background: Roux-en-Y gastric bypass (RYGBP) has long been associated with the possible development of internal hernias, with a reported incidence of 1-5%. Because it induces fewer adhesions than laparotomy, the laparoscopic approach to this operation appears to increase the rate of this complication, which can present dramatically. Methods: Data from all patients undergoing bariatric surgery are introduced prospectively in a data-base. Patients who were reoperated for symptoms or signs suggestive of an internal hernia were reviewed retrospectively, with special emphasis on clinical and radiological findings, and surgical management. Results: Of 607 patients who underwent laparoscopic primary or reoperative RYGBP in our two hospitals between June 1999 and January 2006, 25 developed symptoms suggestive of an internal hernia, 2 in the immediate postoperative period, and 23 later on, after a mean of 29 months and a mean loss of 14.5 BMI units. 9 of the latter presented with an acute bowel obstruction, of which 1 required small bowel resection for necrosis. Recurrent colicky abdominal pain was the leading symptom in the others. Reoperation confirmed the diagnosis of internal hernia in all but 1 patient. The most common location was the meso-jejunal mesenteric window (16 patients, 56%), followed by Petersen's window (8 patients, 27%), and the mesocolic window (5 patients, (17%). Patients in whom the mesenteric windows had been closed using running non-absorbable sutures had fewer hernias than patients treated with absorbable sutures at the primary procedure (1.3% versus 5.6%, P=0.03). Except in the acute setting, clinical and radiological findings were of little help in the diagnosis. Conclusions: Except in the setting of acute obstruction, clinical and radiological findings usually do not help in the diagnosis of internal hernia. A high index of suspicion, based mainly on the clinical history of recurrent colicky abdominal pain, is the only means to reduce the number of acute complications leading to bowel resection by offering the patient an elective laparoscopic exploration with repair of all the defects. Prevention by carefully closing all potential mesenteric defects with running non-absorbable sutures during laparoscopic RYGBP, which we consider mandatory, seems appropriate in reducing the incidence of this complication.

GLP-1 and changes in glucose tolerance following gastric bypass surgery in morbidly obese subjects.

Abstract: Background: It has been proposed, that the dramatic amelioration of type 2 diabetes following Roux-en-Y gastric bypass (RYGBP) could by accounted for, at least in part, by changes in glucagon-like peptide-1 (GLP-1) secretion. However, human data supporting this hypothesis is scarce. Methods: A 12-month prospective study on the changes in glucose homeostasis, and active GLP-1 in response to a standard test meal (STM) was conducted in 34 obese subjects (BMI 49.1±1.0 kg/m2) who had different degrees of glucose tolerance: normal glucose tolerance (NGT, n=12), impaired glucose tolerance (IGT, n=12), and type 2 diabetes (n=10). Results: At 6 weeks after RYGBP, despite the subjects still being markedly obese (BMI 43.5±0.9 kg/m2), fasting plasma glucose and HbA1c decreased in the 3 study groups (P<0.05). Insulin sensitivity improved, but was still abnormal in a comparable proportion of subjects among groups (P=0.717). When insulin secretion was accounted for the prevailing insulin sensitivity, an increase was found in subjects with diabetes (P<0.05) although it remained lower compared to NGT- and IGT-subjects (P<0.01). At 12 months follow-up, no differences among groups were found in the evaluated glucose homeostasis parameters. Compared to baseline, at 6 weeks the incremental AUC0-120' of active GLP-1 in response to the STM increased in NGT and IGT (P<0.05) but not in subjects with diabetes (P=0.285). However, the GLP-1 response to a STM was comparable among groups at 12 months follow-up (P=0.887). Conclusions: 1) RYGBP was associated with an improvement but not complete restoration of glucose homeostasis at 6 weeks after surgery. 2) GLP-1 is not a critical factor for the early changes in glucose tolerance.

Risk of Venous Thromboembolism and Efficacy of Thromboprophylaxis in Hospitalized Obese Medical Patients and in Obese Patients Undergoing Bariatric Surgery

Abstract: Background: Obesity is considered a highly prevalent risk factor for venous thromboembolism (VTE) in hospitalized patients. However, recommendations for VTE prophylaxis in obese patients are not clear. Methods: To evaluate obesity as a risk factor for VTE in medical and bariatric patients and the efficacy of VTE prophylaxis, we performed a systematic review in MEDLINE, Cochrane Database of Systematic Reviews and LILACS from 1976 to 2006. Evidence was evaluated independently by 2 authors and presented descriptively. Results: Of the 124 studies found, 87 were excluded based on predefined criteria. There is no consensus among studies, but prospective cohorts show that obesity is associated with a higher risk of VTE in medical patients. There is evidence that the risk of VTE exceeds that attributable to the surgical procedure alone in bariatric surgery. Only 6 studies evaluated prophylactic methods (unfractionated heparin, low molecular weight heparin and sequential compression devices) in obese patients. Although these studies have some methodological flaws, they suggest efficacy of VTE prophylaxis in medical and surgical obese patients. Conclusions: Obesity is a risk factor for VTE in obese medical patients and patients undergoing bariatric surgery. Obesity appears to play an adjuvant role for the development of VTE in hospitalized patients with other risk factors. The small number of prospective trials in this population prevents a definite conclusion about the most effective and safe VTE prophylactic method for obese patients. Thus, randomized clinical trials to compare VTE prophylactic methods in obese patients are still highly warranted.

Body Composition and Metabolic Changes following Bariatric Surgery: Effects on Fat Mass, Lean Mass and Basal Metabolic Rate: Six Months to One-Year Follow-up

Abstract: Background: With the failure of traditional weight loss plans, bariatric surgery has become the treatment of choice for morbid obesity. The primary objective of this study was to track body composition and metabolic changes for 1 year following bariatric surgery. Methods: 19 bariatric patients (14 female, 5 male) began the study and completed 12 months of testing, which included data collection within 1 week preoperatively and 1, 3, 6 and 12 months postoperatively. 2 female subjects were lost to the study between 6 months and 1 year, resulting in 17 subjects (12 female, 5 male) completing the entire 12-month follow-up. Variables measured in this study included weight, lean body mass (LBM), fat mass (FM), % body fat and basal metabolic rate (BMR). Results: Analysis of variance (ANOVA) using the general linear model indicated significant (P<.05) losses for weight, FM, and % fat for all time periods. Significant losses in LBM were observed in all time periods except 6-12 months, where no change in LBM (60.6 vs 61.1 kg) was observed. A significant decrease (P<.05) in BMR (2091 vs 1758) was observed only from pre-surgery to 1 month post-surgery. Thereafter, there was no significant change in BMR (1758 vs 1647 vs 1651 vs 1674) respectively. Changes in LBM were correlated with changes in BMR at both 6-12 months (r=.545, P=.024) and preoperatively to 12 months postoperatively (r=.608, P=.01). There were no significant changes in the BMR/LBM ratio over the 12-month period (28.3 vs 25.0 vs 27.3 vs 27.2 vs 27.4), indicating no adaptation of the body to an energy-conserving mechanism. Conclusion: Bariatric surgery appears to have been highly successful over the 12-month follow-up period, with 50.9 kg weight loss, 38.3 kg (75.2%) FM loss, and 12.6 kg (24.8%) LBM loss. The 417 kcal loss in BMR (2091 to 1674), while significant, was not greater than what would be predicted from loss of LBM.

Serum ghrelin, leptin and adiponectin levels before and after weight loss: comparison of three methods of treatment--a prospective study.

Abstract: Background: Ghrelin is a peptide hormone with orexigenic properties, primarily produced by the stomach. Leptin and adiponectin are the two adiposity products that participate in body weight control. Leptin always decreases and adiponectin increases after weight loss. Different changes in fasting ghrelin levels have been reported following bariatric surgery. In this study, we compare the changes in fasting ghrelin, leptin and adiponectin levels in 3 groups of patients who achieved weight loss by either diet, MacLean vertical banded gastroplasty (VBG) or biliopancreatic diversion with duodenal switch (BPD-DS). Methods: Serum fasting ghrelin, leptin and adiponectin concentration was measured in 40 obese patients who achieved weight loss by either diet (n=14), VBG (n=13) or BPD-DS (n=13), before and after weight loss. The follow-up period was 18 months for BPD-DS and VBG and 6 months for diet. Serum ghrelin level was measured by ELISA. Results: BMI was significantly decreased in all 3 groups: 9.2±2.4% (P<0.01) following diet, 38.47±7.26% (P<0.01) after VBG, and 42.88±9.09% after BPD-DS (P<0.01). Serum fasting ghrelin level increased after diet (110.45±117.84%, P=0.002) and VBG (65.48±92.93%, P=0.001),but decreased after BPD-DS (−21.63±28.63%, P=0.019). Leptin concentration decreased and adiponectin increased in all groups. Conclusions: Unlike after diet or gastric restrictive surgery, BPD-DS is associated with markedly suppressed ghrelin levels, possibly contributing to the weight-reducing effect of this operation. Sleeve gastrectomy seems to be the main cause of this reduction.

Re-Sleeve Gastrectomy

Abstract: Background: Laparoscopic sleeve gastrectomy (LSG) started as the restrictive part of the more complex laparoscopic duodenal switch (LDS) operation. There is no long-term experience with the isolated LSG. The main concern about the isolated LSG is the possibility of dilatation of the gastric pouch, long-term loss of restrictive function and weight regain. Laparoscopic re-sleeve gastrectomy (LRSG) has been used sparingly, but it also may become a possibility if more patients have the isolated LSG. Methods: 2 patients with BMI 58 and 65 respectively, underwent LSG as the first stage of the LDS. Later, when the patients regained some weight and their gastric pouch was found to be too large, the LRSG/DS was done. Results: The patient with BMI 58 had an initial drop to BMI 34 and regained weight to BMI 46, but after the LRSG/DS her BMI is 36 at 4 months. The BMI patient with BMI 65 had a drop to BMI 42, and after the LRSG/DS his BMI is 33 at 3 months later. Conclusion: LRSG may become necessary after gastric tube dilatation or insufficient original gastric volume reduction. LRSG is feasible, available and easy to perform when the resulting gastric pouch is too large or dilates after the original LSG.

Laparoscopic Surgery for Morbid Obesity: 1,001 Consecutive Bariatric Operations Performed at the Bariatric Institute, Cleveland Clinic Florida

Abstract: Background: Morbid obesity is an epidemic in America. This series evaluates the safety and efficacy in the first 1,001 laparoscopic bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida. Methods: A retrospective review was conducted examining all patients undergoing a primary bariatric procedure (either laparoscopic gastric bypass or laparoscopic gastric banding) from July 2000 to December 2003. Results: 2 surgeons performed 1,001 laparoscopic bariatric operatons. Average age was 47 (19-75) years, average BMI was 55.6 (35-97) kg/m2, and average ASA class was III. Excess weight loss was 51% at 6 months, 73.4% at 1 year for the gastric bypass group and 54% at 1 year for the laparoscopic banding group. The overall complication rate was 31.8% (12.4% major and 19.4% minor) in the gastric bypass group and 13% in the laparoscopic banding group. There was no postoperative mortality. Conclusion: Laparoscopic bariatric surgery is feasible and safe for weight loss. Results obtained have been comparable to those reported for the open approach for weight loss, with a similar major morbidity rate and an improved mortality rate.

Obesity and the White Blood Cell Count: Changes With Sustained Weight Loss

Abstract: Background: Obesity is a chronic inflammatory condition, and elevated white blood cell counts (WBC) have widely recognized associations with inflammatory conditions. The authors explored the relationship between the WBC and degree of obesity, basic anthropometry, and clinical and biochemical markers of the metabolic syndrome at baseline, and with weight loss following Lap-Band® surgery. Methods: 477 patients with complete biochemical and clinical data at baseline and at 2 years were selected for analysis. Paired analysis assessed the change in WBC at 2 years, and stepwise linear regression assessed factors independently associated with baseline counts and any change at 2 years. Results: Mean ± SD weight loss at 2 years was 29.3 ± 16.2 kg. There were significant decreases in total WBC (−12.2%), and major components, neutrophils (11.7%) and lymphocytes (6.9%), at 2 years (P<0.001 for all). Baseline WBC, neutrophils and lymphocyte counts increased with increasing BMI and decreased with age. Insulin levels were independently positively associated with higher neutrophil counts and triglycerides with higher lymphocyte counts. Age, gender, BMI and components of the metabolic syndrome when modeled together accounted for <10% of the variance of baseline counts. Higher BMI predicted a greater fall in the neutrophil counts at 2 years. Change in BMI at 2 years was the only independent predictor of the change in both neutrophils and lymphocytes, but accounted for <10% of the variance of change. Conclusion: BMI contributes to both baseline and weight loss WBC. However, crude WBC counts are influenced in minor ways by obesity markers and have limited value as clinical markers.

Gene expression of leptin, resistin, and adiponectin in the white adipose tissue of obese patients with non-alcoholic fatty liver disease and insulin resistance.

Abstract: Background: Adipose tissue is an active endocrine organ that secretes a variety of metabolically important substances including adipokines. These factors affect insulin sensitivity and may represent a link between obesity, insulin resistance, type 2 diabetes (DM), and nonalcoholic fatty liver disease (NAFLD). This study uses real-time polymerase chain reaction (PCR) quantification of mRNAs encoding adiponectin, leptin, and resistin on snap-frozen samples of intra-abdominal adipose tissue of morbidly obese patients undergoing bariatric surgery. Methods: Morbidly obese patients undergoing bariatric surgery were studied. Patients were classified into two groups: Group A (with insulin resistance) (N=11; glucose 149.84 ± 40.56 mg/dL; serum insulin 8.28 ± 3.52 μU/mL), and Group B (without insulin resistance) (N=10; glucose 102.2 ± 8.43 mg/dL; serum insulin 3.431 ± 1.162 μU/mL). Results: Adiponectin mRNA in intra-abdominal adipose tissue and serum adiponectin levels were significantly lower in Group A compared to Group B patients (P<0.016 and P<0.03, respectively). Although serum resistin was higher in Group A than in Group B patients (P<0.005), resistin gene expression was not different between the two groups. Finally, for leptin, neither serum level nor gene expression was different between the two groups. Serum adiponectin level was the only predictor of nonalcoholic steatohepatitis (NASH) in this study (P=0.024). Conclusions: Obese patients with insulin resistance have decreased serum adiponectin and increased serum resistin. Additionally, adiponectin gene expression is also decreased in the adipose tissue of these patients. This low level of adiponectin expression may predispose patients to the progressive form of NAFLD or NASH.

Cost-effectiveness and Budget Impact of Obesity Surgery in Patients with Type 2 Diabetes in Three European Countries(II)

Abstract: Background This study aimed to establish a payer-perspective cost-effectiveness and budget impact model of adjustable gastric banding (AGB) and gastric bypass (GBP) vs. conventional treatment (CT) in patients with a body mass index (BMI) ≥ 35 kg.m−2 and type 2 diabetes mellitus (T2DM) in Austria, Italy, and Spain.

Weight, dietary and physical activity behaviors two years after gastric bypass.

Abstract: Background: This cross-sectional survey was designed to determine the self-reported weight management, dietary and physical activity behaviors of Roux-en-Y gastric bypass (RYGBP) patients who were 1 to 4 years after the RYGBP operation, and to identify gaps in follow-up nutrition-related chronic disease prevention. Methods: Questionnaires including behavioral items from the 2003 and 2004 Behavioral Risk Factor Surveillance System (BRFSS) were mailed to all RYGBP patients in a clinically active outpatient database. Results: Of 212 patients, 140 (66%) returned completed questionnaires. Responders were 24.2 ± 7.9 months postoperatively. They were older than nonresponders (45.2 ± 9.9 vs 38.5 ± 8.9 years, P<.001). Responders had an average weight loss of 55.8 ± 15.2 kg, and most (81%) reported that they were still trying to lose weight. The most frequently reported dietary behavior for weight loss was decreasing calorie and fat intakes. However, in addition to avoiding sodas and sweet desserts, responders were also excluding nutrient-dense foods high in vitamins and minerals such as milk and dairy products, red meats, breads, cereals and nuts. Remarkably, only 25 (17.9%) engaged in regular exercise activities before surgery, while 116 (82.9%) indicated a moderate level of current physical activity averaging 54.7 ± 38.5 minutes per episode. Multivariable linear regression analyses identified age, weight at age 21, pre-surgery BMI and time in regular physical activities as the four significant predictors of BMI after weight loss stabilization. Conclusion: Postoperative RYGBP patients engage in various weight management behaviors, some of which could offer greater health benefits with follow-up intervention from dietitians and exercise specialists to prevent adverse outcomes such as weight regain and micronutrient deficiencies.

Revision of Failed Laparoscopic Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Abstract: Background: The most common bariatric surgical operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss. Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery. Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5±2.0 years. For the RYGBP, mean operating time was 161±53 minutes, estimated blood loss was 219±329 ml, and hospital stay was 6.7±4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%) – a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2±9.3 kg/m2, and decreased to 45.8±8.9 kg/m2 after LAGB and was again reduced to 37.7±8.7 kg/m2 after RYGBP within our follow-up period. Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.