Surgical options for obesity

Non-invasive cooling wear as an effective means of reducing subcutaneous adipose tissue mass: an in-vivo study

Objective

The increasing prevalence of obesity is a major health problem worldwide. Several non-surgical treatments are now available that reduce body and subcutaneous fat mass. We aimed to determine the efficacy of mild cold for body mass reduction.

Methods

Novel cooling wear, which induces mild cooling via evaporation, was worn by 29 women with overweight for 4 weeks. Specifically, the participants wore a cooling waist belt and chaps for 1 hour per day. Non-invasive lipometry was used to determine their subcutaneous adipose tissue thicknesses, and the total weight loss, abdominal circumference, and body mass index (BMI) of the participants were measured.

Results

The participants achieved a significant total weight loss of 0.7 kg (0.9%), and significant reductions in BMI (0.2 kg/m²) and abdominal circumference (1.9 cm, 1.7%). Furthermore, there was a trend towards a reduction in abdominal subcutaneous fat thickness and a significant reduction in thickness of the anterior thigh was noted. A questionnaire-based evaluation indicated high usability and comfort of the cooling wear.

Conclusion

There is a high and growing demand for non-invasive treatment strategies for obesity. Cooling wear represents a novel and promising approach that may be of particular use for individuals who do not require bariatric surgery.

EndoBarrier®: a Safe and Effective Novel Treatment for Obesity and Type 2 Diabetes?

Background and Aims

Obesity associated with diabetes mellitus is a significant worldwide problem associated with considerable health care costs. Whilst surgical intervention is effective, it is invasive, costly and associated with complications. This study aims to evaluate the safety and efficacy of the EndoBarrier®, a duodenal-jejunal sleeve bypass as an alternative treatment of diabetes mellitus in obese patients.

Materials and Methods

This was a multi-centre, non-randomised trial recruiting obese patients with type 2 diabetes from three sites in the UK. Eligible participants had a BMI of 30–50 kg/m² and HbA1c levels of 7.5–10%. The study comprised a 12-month period with the EndoBarrier® inserted and a 6-month follow-up period after it had been explanted. The primary study outcomes were weight, BMI, HbA1c levels and fasting insulin and glucose levels.

Results

Forty-five patients were recruited and 31 patients (69%) completed the 12-month study period. Significant reductions in weight (95%CI 0.62–29.38; p < 0.05) and BMI (95%CI 1.1–8.7; p < 0.005) were documented 12 months after device insertion. The mean HbA1c was significantly reduced (95%CI 0.1–1.6; p < 0.05) after the device insertion period and reductions in metabolic parameters (fasting insulin and glucose levels) were also documented during the study. Adverse events were also assessed in all patients, the vast majority of which were reported as mild.

Conclusions

The EndoBarrier® appears to be a safe and effective treatment strategy in overweight patients with poor glycaemic control despite medical therapy, or in those who are eligible but decline bariatric surgery.

Liver Function in Patients With Nonalcoholic Fatty Liver Disease Randomized to Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy: A Secondary Analysis of a Randomized Clinical Trial

OBJECTIVES

The aim of the study was to compare the influence of sleeve gastrectomy (SG) versus Roux-en-Y gastric bypass (RYGB) on liver function in bariatric patients with non-alcoholic fatty liver disease (NAFLD) in a randomized clinical trial (NCT01806506).

BACKGROUND

Rapid weight loss and malabsorption after bariatric surgery in patients with NAFLD or steatohepatitis (NASH) may impair liver function.

METHODS

Sixty-six morbidly obese patients randomized to SG or RYGB were included in a secondary outcome analysis. Intraoperative liver biopsies were categorized with NAFLD Activity Score (NAS) and liver function tests were done before surgery and after 1, 6 and 12 months.

RESULTS

NASH was present in 54.5% RYGB and 51.5% SG patients (P > 0.05). At 12 months excess weight loss was 68.7 ± 19.7% after SG and 62.8 ± 18.5% after RYGB (P > 0.05). At 1 month international normalized ratio (INR) increased after RYGB (0.98 ± 0.05 vs 1.14 ± 0.11; P < 0.05) and SG (0.99 ± 0.06 vs 1.04 ± 0.06; P < 0.05), RYGB induced significantly greater increase in INR in the whole group and NASH patients than SG. After RYGB albumin decreased at 1 month (41.2 ± 2.7 vs 39.0 ± 3.2 g/L; P < 0.05). At 12 months, INR and albumin returned to baseline. At 12 months in NASH group, SG induced significant improvement in aspartate aminotransferase (32.4 ± 17.4 vs 21.5 ± 6.9U/L), alanine aminotransferase (39.9 ± 28.6U/L vs 23.8 ± 14.1U/L), gamma-glutamyl transpeptidase (34.3 ± 16.6 vs 24.5 ± 16.8U/L), and lactate dehydrogenase (510.8 ± 33 vs 292.4 ± 29). Variables predictive of INR change after 1 month included operation type, NAS ≥ 5, bilirubin, body mass index, hemoglobin A1C, and dyslipidemia.

CONCLUSIONS

Patients with NASH undergoing RYGB are more susceptible to early transient deterioration of liver function than after SG.

Kidney stone risk following modern bariatric surgery

Over the past 10 years, a variety of reports have linked bariatric surgery to metabolic changes that alter kidney stone risk. Most of these studies were retrospective, lacked appropriate controls, or involved bariatric patients with a variety of inclusion criteria. Despite these limitations, recent clinical and experimental research has contributed to our understanding of the pathophysiology of stone disease in this high-risk population. This review summarizes the urinary chemistry profiles that may be responsible for the increased kidney stone incidence seen in contemporary epidemiological bariatric studies, outlines the mechanisms of hyperoxaluria and potential therapies through a newly described experimental bariatric animal model, and provides a focused appraisal of recommendations for reducing stone risk in bariatric stone formers.

Bioelectrical impedance vector analysis in obese women before and after bariatric surgery: changes in body composition

OBJECTIVE

Because of the inefficacy of standard methods for the evaluation of body composition of grade III obese individuals, it is difficult to analyze the quality of weight loss after bariatric surgery in these patients. Electrical bioimpedance vector analysis and the RXc graph uses crude resistance (R) and reactance (Xc) values, like components of the Z vector, to monitor variations in body fluid and the nutritional status of obese individuals. Using bioelectrical impedance vector analysis (BIVA) and the RXc graph, the objective of the present study was to evaluate long-term changes in weight and body composition of obese women after Roux-en-Y bariatric surgery.

METHODS

A study was conducted on 43 grade III obese women submitted to bariatric surgery. Anthropometric and bioimpedance (800 mA-50 kHz) data were obtained during the preoperative period and 1, 2, 3, and 4 y after surgery. BIVA was performed by plotting resistance and reactance values corrected for body height (R/H and Xc/H, Ohm/m) as bivariates on the RXc graph. BIVA software was used to plot the vectors of the RXc plane.

RESULTS

Surgery promoted changes in body composition, with a reduction of fat mass and of fat-free mass. During the postoperative period, the vectors demonstrated migration to the right lower quadrant of the graph, corresponding to the classification of cachexia and water retention.

CONCLUSION

Weight loss due to surgery results in an important reduction of fat-free mass characterized by the position of most individuals in the cachexia quadrant throughout the postoperative period.

Single-port Roux-en-Y gastric bypass: toward a less invasive procedure with the same surgical results and a better cosmesis

BACKGROUND

The current tendency to use increasingly less aggressive procedures has facilitated the development of new minimally invasive techniques. In this context, single-port (SP) access procedures can become an alternative to the conventional laparoscopic approach.

METHODS

A total of 22 morbidly obese patients were submitted to pure SP Roux-en-Y gastric bypass without additional ports. Selection for this approach was based on distance from the xiphoid to the umbilicus less than 28 cm, body mass index (BMI) lower than 50 kg/m(2), and preferably peripheral obesity. Access to the cavity was obtained through a single transverse, transumbilical incision, with placement of a SILS Port device.

RESULTS

The mean age of the patients was 41 ± 8.98 years, and 95 % of the patients were women. The mean BMI of the series was 42.68 ± 2.28 kg/m(2), and the mean body weight was 111.34 ± 10.66 kg. Surgery was performed successfully in all cases through a transumbilical incision with a mean length of 26.68 ± 5.27 mm. The mean surgical time was 114.05 ± 21 min, and the mean hospital stay was 3.27 ± 1.01 days. No intraoperative or immediate postoperative deaths or complications occurred. The median postoperative BMI during a mean follow-up period of 12 months was 28 kg/m(2) (range, 18-35 kg/m(2)). The median weight loss was 39 kg, and the percentage loss of excess body weight was 86 %. In relation to improvement of the comorbidities, two of the three patients with arterial hypertension showed normalization of their blood pressure values. Likewise, the blood glucose levels were corrected in two of the three diabetic patients, as well as in the patient with altered fasting blood glucose.

CONCLUSIONS

Single-port Roux-en-Y gastric bypass surgery seems to be a safe, viable, and reproducible technique, but randomized studies involving larger patient series and longer follow-up periods are needed to compare the SP access and the multiple-port laparoscopic approach.

Alterações dos parâmetros clínicos e laboratoriais em pacientes obesos com diabetes melito tipo 2 submetidos à derivação gastrojejunal em y de Roux sem anel

OBJETIVOS: Verificar as alterações do peso e índice de massa corporal em pacientes obesos grau II e III com diabete melito tipo 2 nos períodos pré e pós-operatório e as alterações dos parâmetros laboratoriais de glicemia de jejum, glicemia pós-prandial, hemoglobina glicada, insulina nos períodos pré e pós-operatório. MÉTODOS: Realizou-se estudo prospectivo selecionando 40 pacientes com obesidade grau II e III, submetidos à derivação gastrojejunal em Y-de-Roux sem anel. Analisou-se no pré e pós-operatório de 60 dias o peso, índice de massa corporal, glicemia de jejum, glicemia pós-prandial, hemoglobina glicada e insulina. RESULTADOS: O peso médio pré-operatório foi de 107,3Kg diminuindo para 89,5Kg no pós-operatório. O índice de massa corporal médio inicial foi de 39,5Kg/m2 e 32,9Kg/m2 com 60 dias de pós-operatório. A glicemia de jejum no pré-operatório foi de 132 mg/dl e no pós-operatório diminuiu 40,4 mg/dl em média. A glicemia pós-prandial foi de 172 mg/dl no pré-operatório e 111,6 mg/dl no controle pós-operatório. A hemoglobina glicada inicial foi de 7% declinando para 5,7% no pós-operatório. A insulina pré-operatória foi 29,6 uIU/ml e a pós-operatória 13,9 uIU/ml. Todas as variáveis apresentaram significância estatística com p<0,001. CONCLUSÃO: Houve significante diminuição de peso e no índice de massa corporal entre os períodos pré e pós-operatórios e diminuição também significante dos parâmetros laboratoriais de glicemia de jejum, glicemia pós-prandial, hemoglobina glicada, insulina entre os mesmos períodos.

Controlled metabolic diet reduces calcium oxalate supersaturation but not oxalate excretion after bariatric surgery

OBJECTIVE

To identify the effect of a controlled metabolic diet on reducing urinary calcium oxalate (CaOx) supersaturation in subjects with hyperoxaluric nephrolithiasis after potentially malabsorptive forms of bariatric surgery.

METHODS

Subjects with a history of CaOx kidney stones and mild hyperoxaluria after bariatric surgery (n = 9) collected baseline 24-hour urine samples while consuming a free choice diet. They were then instructed to consume a controlled diet low in oxalate (70-80 mg/d), normal in calcium (1000 mg/d), and moderate in protein before 2 final 24-hour urine collections.

RESULTS

Overall, the urinary CaOx supersaturation decreased from 1.97 ± 0.49 delta Gibbs (DG) with the free choice diet to 1.13 ± 0.75 DG with the controlled diet (P < .01). This occurred in the absence of a significant change in urinary oxalate excretion (0.69 ± 0.29 mmol/d with the free choice diet compared with 0.66 ± 0.38 mmol/d with the controlled diet). Urinary volume, citrate, and pH all increased, although not significantly (P > .05), contributing to the significant CaOx supersaturation change.

CONCLUSION

A controlled metabolic diet normal in calcium, moderate in protein, and reduced in oxalate can positively affect urinary CaOx supersaturation after bariatric surgery. However, this diet did not appear to decrease urinary oxalate excretion. Therefore, restriction of dietary oxalate alone might not be enough to reduce urinary oxalate excretion to normal levels in this group of patients with known enteric hyperoxaluria. Additional strategies could be necessary, such as the use of oral calcium supplements as oxalate binders and a lower fat diet.

Weight reduction for non-alcoholic fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is becoming a wide spread liver disease. The present recommendations for treatment are not evidence-based. Some of them are various weight reduction measures with diet, exercise, drug, or surgical therapy.

OBJECTIVES

To assess the benefits and harms of intended weight reduction for patients with NAFLD.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, PubMed, EMBASE, Science Citation Index Expanded, Chinese Biomedicine Database, and ClinicalTrials.gov until February 2011.

SELECTION CRITERIA

We included randomised clinical trials evaluating weight reduction with different measures versus no intervention or placebo in NAFLD patients.

DATA COLLECTION AND ANALYSIS

We extracted data independently. We calculated the odds ratio (OR) for dichotomous data and calculated the mean difference (MD) for continuous data, both with 95% confidence intervals (CI).

MAIN RESULTS

The review includes seven trials; five on aspects of lifestyle changes (eg, diet, physical exercise) and two on treatment with a weight reduction drug 'orlistat'. In total, 373 participants were enrolled, and the duration of the trials ranged from 1 month to 1 year. Only one trial on lifestyle programme was judged to be of low risk of bias. We could not perform meta-analyses for the main outcomes as they were either not reported or there were insufficient number of trials for each outcome to be meta-analysed. We could meta-analyse the available data for body weight and body mass index only. Adverse events were poorly reported.

AUTHORS' CONCLUSIONS

The sparse data and high risk of bias preclude us from drawing any definite conclusion on lifestyle programme or orlistat for treatment of NAFLD. Further randomised clinical trials with low risk of bias are needed to test the beneficial and harmful effects of weight reduction for NAFLD patients. The long-term prognosis of development of fibrosis, mortality, and quality of life should be studied.

Metabolic syndrome and bariatric surgery in stone disease etiology

PURPOSE OF REVIEW

To review the prevalence and mechanisms of stone formation in patients with metabolic syndrome and in those submitted to bariatric surgery.

RECENT FINDINGS

MetS is associated with urinary stone disease, which appears to be sustained by dietetic factors and insulin resistance. The latter represented in obesity and diabetes favors uric acid precipitation in urine via a more acidic urinary load. Patients submitted to modern bariatric surgery are at risk of nephrolithiasis and nephropathy as a consequence of malabsorption and hyperoxaluria, which are more consistent after Roux-en-Y gastric bypass than after gastric banding. Other stone risk factors such as hypocitraturia may also be present.

SUMMARY

Patients with metabolic syndrome and those submitted to modern bariatric surgery are both at risk of nephrolithiasis and nephropathy. Accurate stone screening careful monitoring of renal function and diet counseling are strongly encouraged in these patients.

A novel surgical technique: single-incision transumbilical laparoscopic Roux-en-Y gastric bypass

Conventional laparoscopic Roux-en-Y gastric bypass (LRYGB) is a gold standard for bariatric surgery, but the procedure requires five to seven incisions for placement of multiple trocars and thus may produce less-than-ideal cosmetic results. We have developed a new approach, single-incision transumbilical LRYGB (SITU-LRYGB) to treat morbid obesity. We compared the surgical results and patient satisfaction in a study of five-port LRYGB and SITU-LRYGB. Fifty morbidly obese patients (14 males, 36 females) underwent either Roux-en-Y gastric bypass with five-port LRYGB or the SITU-LRYGB approach. During the operation, we used a novel intraoperative liver traction method with a “liver suspension tape” that we specifically designed for SITU-LRYGB. Compared to five-port surgery with SITU-LRYGB, there were no intraoperative complications, wound healing was excellent, and there was no abdominal scarring. SITU surgical time was longer than that with five-port LRYGB (99.8 vs. 67.6 min, P < 0.001). Patients treated with the five-port method were more obese than those in the SITU group (127.9 vs. 112.4 kg, P = 0.016). After the bariatric surgery, no difference in comorbidity was found in both groups. Patient satisfaction was greater with SITU than with the five-port method (4.48 vs. 3.96, P = 0.006). Roux-en-Y gastric bypass can be successfully achieved via a single umbilical incision, a method that provides a short operative time and good recovery and eliminates abdominal scarring.

Biomechanical properties of skin in massive weight loss patients

BACKGROUND

The aim of this study is to assess skin strength in MWL patients relative to control cosmetic abdominoplasty patients biophysically, biochemically, and histologically. Growing success of weight loss programs has brought about an increase in the MWL population. Skin quality is thought to be impaired by MWL, but there are no compelling studies that have fully addressed the structural mechanisms involved.

METHODS

Skin from the medial and lateral abdomen was harvested fresh from patients undergoing cosmetic abdominoplasty (n = 6) or abdominal panniculectomy for MWL (n = 35), and burst strength was tested in the horizontal and vertical directions. Collagen content was measured, and histological studies were performed to assess epidermal and dermal thickness, vascularity as well as the morphology and density of the collagen fibers.

RESULTS

In all groups, skin stretched horizontally was stronger than skin stretched vertically (p < 0.001). The skin of MWL patients was stronger medially compared to the skin of cosmetic patients. (p = 0.047) Newly formed collagen was diminished in MWL than that in the control group, but the results were not statistically significant. Epidermal thickness was significantly higher medially in MWL (p = 0.049). Elastin fibers were decreased in the MWL group, while dermal vascularity was higher in the MWL group.

CONCLUSIONS

The skin of MWL patients demonstrated stronger mechanical parameters than that of cosmetic patients in the medial part of the abdomen; however, the decrease in elastic fibers associated with a decrease in newly formed collagen seemingly provides a contradiction. Skin changes with MWL merits further study to understand it more completely.

Two important criteria for reducing the risk of postoperative ulcers at the gastrojejunostomy site after gastric bypass: patient compliance and type of gastric bypass

BACKGROUND

Ulcers at the gastrojejunostomy site are a common problem after gastric surgery. Their postoperative development seems to be associated with Helicobacter pylori-related gastritis or abuse of nicotine, alcohol or non-steroidal anti-inflammatory drugs (NSAIDs), but is also dependent on the choice of surgical method (Roux-en-Y or B-II gastric bypass).

PATIENTS AND METHODS

This study evaluated the follow-up of 1,908 patients over a period of 5 years (January 2006-December 2010). In 1,861 cases, we performed a Roux-en-Y gastric bypass, and in 47 cases a B-II gastric bypass.

RESULTS

All patients (n = 407) with symptoms such as dysphagia, reflux, nausea, vomiting or epigastric pain underwent gastroscopy. In 52 cases, ulcers were found at the gastrojejunostomy site. Of these patients, 39 (75%; p < 0.0001) had consumed alcohol, nicotine or NSAIDs; in 14 patients (27%; p < 0.0001) we detected H. pylorirelated gastritis. A total of 2.4% of the patients after Roux-en-Y gastric bypass (45/1,861) and 14.9% of the patients after B-II gastric bypass (7/47) developed ulcers at the gastroenteral junction. The difference is clearly significant (Fisher's exact test, p = 0.0002). Furthermore, there were significant differences regarding the recurrence rate: 86% of the B-II gastric bypass group and 13.3% of the Roux-en-Y gastric bypass group needed to be treated several times.

CONCLUSIONS

Every patient needs to be informed preoperatively that there is a markedly increased risk of ulcers at the gastroenteral junction, particularly if the patient cannot avoid potential risk factors (nicotine, alcohol, NSAIDs). Preoperative gastroscopy with H. pylori testing and subsequent eradication can also reduce the risk of ulcers. An increased incidence of peptic ulcers after B-II gastric bypass was noted. All of these patients were converted to Roux-en-Y.

Metabolic and nutritional changes after bariatric surgery

Bariatric surgery is the most durable intervention for severe obesity. Appropriate candidates for surgery include those with a body mass index over 40 kg/m(2), or those with a BMI over 35 kg/m(2) who also have weight-related comorbidities. Bariatric procedures are categorized as restrictive, where food intake is limited by a small gastric 'pouch'; malabsorptive, where the length of intestine available for nutrient absorption is decreased; or a combination of both. Although pure malabsorptive procedures, such as the now-historical jejunoileal bypass, achieve greater weight loss than restrictive procedures, they are generally associated with more postoperative metabolic problems. The Roux-en-Y gastric bypass is currently considered the gold standard bariatric procedure for most patients. It results in excellent weight loss with minimal complications, but does require life-long vitamin supplementation. Compliance with vitamins and supplements is also mandatory after malabsorptive procedures. With these procedures, decreased oral intake, as well as altered absorption of nutrients from the GI tract, results in potentially low blood levels of a variety of micronutrients, especially iron, vitamin B12 and folate. Bariatric surgery also improves the comorbid conditions that are associated with obesity, such as diabetes, hypertension, dyslipidemia, obstructive sleep apnea, obesity hypoventilation, gastroesophageal reflux disease, asthma, venous stasis, polycystic ovary syndrome and pseudotumor cerebri. The resolution of diabetes is secondary to weight loss and may also be due to alteration of the enteroinsular axis.

Validation of a novel physical activity assessment device in morbidly obese females

Assessment of physical activity in morbidly obese subjects is important especially in bariatric surgery. We examined the validity of Intelligent Device for Energy Expenditure and Activity (IDEEA) for measuring physical activity and sedentary behavior in morbidly obese women. Activity types, gait counts, and speed detected by the IDEEA monitor were compared to those reported by an observer. The IDEEA monitor detected activity types and gait counts with relatively high accuracy, although slightly lower in extremely obese women than in normal weight controls. The IDEEA monitor accurately estimated gait speeds in both groups. Since gait speed predicts energy expenditure more accurately than gait counts, it is of greater clinical relevance. Reliability of the IDEEA monitor was excellent. The IDEEA monitor is a valid instrument for measuring physical activity and sedentary behavior in extremely obese women, and therefore has potential applications in bariatric surgery both in preoperative evaluation and long-term follow-up.

Visual Loss Due to Wernicke Syndrome Following Gastric Bypass

PURPOSE

To report a case of Wernicke encephalopathy after gastric bypass surgery resulting in vision loss, ophthalmoplegia, and ataxia, all of which reversed with a single dose of IV thiamine.

METHODS

Observational case report.

RESULTS

A 34-year-old woman presented with decreased vision and intermittent diplopia after gastric bypass surgery. She was found to have bilateral limitation of horizontal gaze, decreased vision with bilateral central scotoma and mild disc edema OU. Her cranial magnetic resonance imaging (MRI) was normal. A presumptive diagnosis of Wernicke encephalopathy was made. The patient was admitted, and a single dose of IV thiamine reversed the ophthalmoplegia and vision loss within 24 hours.

CONCLUSION

Wernicke encephalopathy should be considered in patients with vision loss after gastric bypass surgery. The classic triad of confusion, ataxia, and ophthalmoplegia may not be present and, although uncommon, the findings of optic disc edema and vision loss should not deter the clinician from making the diagnosis. Replacement thiamine if given promptly may rapidly reverse the findings.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Clinical application of laparoscopic bariatric surgery: an evidence-based review

BACKGROUND

Approximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation.

METHODS

This evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery.

RESULTS

Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk-benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy.

CONCLUSIONS

Laparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

Association of carotid intima-media thickness and cardiovascular risk factors in women pre- and post-bariatric surgery

BACKGROUND

Obesity is associated with cardiovascular risk factors (CVRFs), such as hypertension, hypertriglyceridemia, and low levels of high-density cholesterol (HDL-C). In obese patients with a body mass index (BMI) of >or=40 kg/m2 or 35-40 kg/m2 associated with CVRFs, weight loss may be achieved more effectively by bariatric surgery on reducing several CVRFs. Carotid intima-media thickness (C-IMT) is an indicator of early atherosclerosis, and may be correlated with CVRFs. Our objective was to correlate C-IMT with CVRFs before (baseline data) and after surgery, and to observe whether weight loss is followed by a regression of C-IMT.

METHODS

Eighteen women who had undergone bariatric surgery participated in this study. Assessments were carried out on the baseline date, and 3, 6, and 12 months after surgery. Some of the CVRFs analyzed were: total cholesterol (TC) levels, HDL-C, triglycerides to HDL-C ratio (TG/HDL-C) and fasting plasma glucose. C-IMT was measured by B-mode ultrasound.

RESULTS

A positive correlation was found between C-IMT and age and triglyceride level (p=0.002 and p=0.02, respectively). Six months after surgery, we found a significant reduction in C-IMT (p<0.05), which was significantly correlated with TG level and systolic pressure (p<0.05).

CONCLUSION

The weight loss achieved with bariatric surgery resulted in regression of C-IMT. This regression could be observed 6 months following surgery, with an additional benefit at 12 months. Also, this finding was correlated with a reduction in triglyceride levels and systolic blood pressure.

Internal hernia at Petersen's space after laparoscopic Roux-en-Y gastric bypass: 6.2% incidence without closure--a single surgeon series of 1047 cases

BACKGROUND

Recent reports describing a gastric bypass technique and the need for closure at Petersen's space using an antecolic antegastric laparoscopic method have differed in the incidence of internal hernia. We report a 6.2% incidence without closure of Petersen's space in a 1047-case, single-surgeon practice.

METHODS

The data from 1047 patients undergoing antecolic antegastric gastric bypass between January 2001 and December 2006 were prospectively collected and retrospectively evaluated for formation of an internal hernia at Petersen's space. All cases were performed by a single surgeon using an antecolic antegastric technique without closure of the mesenteric space and with division of 5 cm of small bowel mesentery. The biliopancreatic limb length was created at 50 cm during the first 2 years of the study and then at 50 or 100 cm depending on the patient's body mass index.

RESULTS

Of the 1047 patients, 73 underwent laparoscopic exploration for varying degrees of abdominal pain, unexplained nausea or vomiting, or radiographic evidence of an internal hernia. Of the 73 cases, 65 were Petersen's space hernias, for an incidence of 6.2%, 7 were mesenteric enteroenterostomy hernias, for an incidence of .7%, and 1 was negative for intra-abdominal pathologic findings. A direct relationship was found between the biliopancreatic limb length and the frequency of biliopancreatic internal hernia formation (P = .0194), and a high rate of false-negative radiographic reports were noted. Subsequent to these 1047 patients, we have had no internal hernias with space closure in 339 cases.

CONCLUSION

Closure of Petersen's space is important in preventing the morbidity of reoperation and the incidence of internal hernia.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Nephrolithiasis after bariatric surgery for obesity

Surgical intervention has become an accepted therapeutic alternative for the patient with medically complicated obesity. Multiple investigators have reported significant and sustained weight loss after bariatric surgery that is associated with improvement of many weight-related medical comorbidities, and statistically significant decreased overall mortality for surgically treated as compared with medically treated subjects. Although the Roux-en-Y gastric bypass (RYGB) is considered an acceptably safe treatment, an increasing number of patients are being recognized with nephrolithiasis after this, the most common bariatric surgery currently performed. The main risk factor appears to be hyperoxaluria, although low urine volume and citrate concentrations may contribute. The incidence of these urinary risk factors among the total post-RYGB population is unknown, but may be more than previously suspected based on small pilot studies. The etiology of the hyperoxaluria is unknown, but may be related to subtle and seemingly subclinical fat malabsorption. Clearly, further study is needed, especially to define better treatment options than the standard advice for a low-fat, low-oxalate diet, and use of calcium as an oxalate binder.

[Laparoscopic mini-gastric bypass: an effective option for the treatment of morbid obesity]

OBJECTIVE

To evaluate laparoscopic Mini-Gastric Bypass in the treatment of morbid obesity.

PATIENTS AND METHODS

Thirty patients with a mean BMI of 41.84.5 Kg/M2 underwent a laparoscopic Mini-Gastric Bypass between March 2005 and February 2006. A laparoscopic approach with five trocar incisions was used to create a long narrow gastric tube; this was then anastomosed ante-colically to a loop of jejunum 200 cm. distal to the ligament of Treitz Peri-operative and short-term follow-up results up to May 2006 are reported.

RESULTS

Conversion to open mini-gastric bypass was necessary in one case (3.3%). Mean operative time was 135 45 minutes. There were no deaths. There were no anastomotic leakages. Two patients developed obstruction at the gastrojejunostomy requiring laparoscopic correction in one case and accounting for an overall morbidity of 6.6%. Mean hospital stay was 3 0.25 days. One patient developed marginal ulcer which resolved with medical treatment; no patients developed symptoms of reflux esophagitis. Mean loss of excess weight was 67.6% at one year and was accompanied by resolution of obesity-associated medical illness in 85% of patients.

CONCLUSION

Laparoscopic Mini-Gastric Bypass is a technically simple, safe, and effective procedure in the treatment of morbid obesity and its associated medical illnesses. Moreover, the procedure is easily reversible laparoscopically when post-operative complication occurs.

Weight loss and body composition during the first postoperative year of a laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Weight loss in patients undergoing gastric bypass should be primarily from fat mass (FM), minimizing the fat-free mass (FFM) loss. The aim of this study was to analyze changes in body weight and body composition during the first postoperative year in 50 morbidly obese patients undergoing a Laparoscopic Roux-en-Y gastric bypass (LRYGBP) at the Obesity Clinic of the ABC Medical Center.

METHODS

Patient's weight and body composition were obtained before surgery and 1 year later using bioelectrical impedance analysis (BIA). Weight, FM, FMM, and total body water (TBW) were measured before and 1 year after surgery. Changes in body composition were particularly analyzed.

RESULTS

There were 29 females and 21 males with mean age of 41 +/- 12 years. Mean BMI before surgery and 1 year after surgery was 44.4 +/- 7.4 kg/m(2) and 28.3+/-4.3 kg/m(2), respectively. The percentage of excess body weight loss at the 1-year period was 86% for women and 79.6% for men. The percentage of FM before surgery was 47.7 +/- 5.1, and 1 year later it was 28.8 +/- 8. The percentage of FFM was 66.5 +/- 16.5 before surgery and 58.3 +/- 13 at 1 year.

CONCLUSIONS

There is a significant weight loss in patients undergoing LRYGBP. Weight loss mainly occurs as a consequence of reduction in the FM with less impact on the FFM.

Surgical management of gastro-gastric fistula after divided laparoscopic Roux-en-Y gastric bypass for morbid obesity

BACKGROUND

Gastro-gastric fistula (GGF) formation is uncommon after divided laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. Optimal surgical management remains controversial.

METHODS

A retrospective review was performed of a prospectively maintained database of patients undergoing LRYGB from January 2001 to October 2006.

RESULTS

Of 1,763 primary procedures, 27 patients (1.5%) developed a GGF and 10 (37%) resolved with medical management, whereas 17 (63%) required surgical intervention. An additional seven patients requiring surgical intervention for GGF after RYGB were referred from another institution. Indications for surgery included weight regain, recurrent, or non-healing gastrojejunal anastomotic (GJA) ulceration with persistent abdominal pain and/or hemorrhage, and/or recurrent GJA stricture. Remnant gastrectomy with GGF excision or exclusion was performed in 23 patients (96%) with an average in-hospital stay of 7.5 days (range, 3-27). Morbidity in six patients (25%) was caused by pneumonia, n=2; wound infection, n=2; staple-line bleed, n=1; and subcapsular splenic hematoma, n=1. There were no mortalities. Complete resolution of symptoms and associated ulceration was seen in the majority of patients.

CONCLUSION

Although uncommon, GGF formation can complicate divided LRYGB. Laparoscopic remnant gastrectomy with fistula excision or exclusion can be used to effectively manage symptomatic patients who fail to respond to conservative measures.

Gender differences in early outcomes following hand-assisted laparoscopic Roux-en-Y gastric bypass surgery : gender differences in bariatric surgery

BACKGROUND

Male gender has been associated with a higher morbidity and mortality rate after bariatric surgery including laparoscopic and open procedures. This study focused on hand-assisted laparoscopic Roux-en-Y gastric bypass and morbidity and mortality among genders.

METHODS

Hand-assisted laparoscopic Roux-en-Y gastric bypass operations (N = 319) were evaluated from October 2003 to March 2006. Comparison between males (N = 54) and females (N = 265) were conducted using t test or Fishers exact test and chi-square analysis.

RESULTS

Patients' average age was 42.3 +/- 10.3 and the average body mass index (BMI) was 49.2 +/- 7.9. There was no significant difference between males and females in age or BMI. Males had a significantly greater average weight than females (p < 0.001) and were significantly more likely to experience sleep apnea (p = 0.006) and have heart disease (p = 0.017). For operative risk factors, males had a significantly longer anesthesia time (p = 0.003), operative time (p = 0.027), and length of roux limb (p = 0.038). At 6 and 12 months postsurgery, there was no significant difference between males and females with complications. Although BMI did not differ significantly, males continued to weigh significantly more than females and lost significantly more pounds than did females at both 6 and 12 months postoperation.

CONCLUSION

Given their larger size and tendency to accumulate fat in the abdominal compartment that increases the technical difficulty of the procedure, males are historically associated with a higher morbidity and mortality following bariatric surgery. Based on the current study, however, there is no difference in outcome among genders following hand-assisted laparoscopic Roux-en-Y gastric bypass.

Hyperoxaluric nephrolithiasis is a complication of Roux-en-Y gastric bypass surgery

Roux-en-Y bypass surgery is the most common bariatric procedure currently performed in the United States for medically complicated obesity. Although this leads to a marked and sustained weight loss, we have identified an increasing number of patients with episodes of nephrolithiasis afterwards. We describe a case series of 60 patients seen at Mayo Clinic-Rochester that developed nephrolithiasis after Roux-en-Y gastric bypass (RYGB), including a subset of 31 patients who had undergone metabolic evaluation in the Mayo Stone Clinic. The mean body mass index of the patients before procedure was 57 kg/m(2) with a mean decrease of 20 kg/m(2) at the time of the stone event, which averaged 2.2 years post-procedure. When analyzed, calcium oxalate stones were found in 19 and mixed calcium oxalate/uric acid stones in two patients. Hyperoxaluria was a prevalent factor even in patients without a prior history of nephrolithiasis, and usually presented more than 6 months after the procedure. Calcium oxalate supersaturation, however, was equally high in patients less than 6 months post-procedure due to lower urine volumes. In a small random sampling of patients undergoing this bypass procedure, hyperoxaluria was rare preoperatively but common 12 months after surgery. We conclude that hyperoxaluria is a potential complicating factor of RYGB surgery manifested as a risk for calcium oxalate stones.

Surgery for obesity: a review of the current state of the art and future directions

The number of patients undergoing surgery for the treatment of obesity, and the proportion of the health care budget dedicated to this health problem, is growing exponentially. There are several competing surgical approaches for the management of morbid obesity. We review the literature relating to four of these: gastric bypass, biliopancreatic diversion, gastric banding, and gastric pacing. Our review finds that while enhancing the malabsorptive activity of these procedures may induce an incremental increase in excess body weight loss, the proportion of patients who fail to lose more than 50% of their excess body weight is similar no matter how radical is the surgery performed. There is little guidance from the literature as to appropriate patient selection for the varying procedures, and anonymously reported registries have yet to show that patients who undergo bariatric surgery have enhanced longevity. To date, the bariatric surgical community has not conducted adequately powered randomized prospective trials to elucidate key elements of the surgical procedure such as optimal bypass length, to determine whether mixed operations are superior to those that offer intake restriction only, and to define what constitutes success after bariatric surgery. As a public health measure, bariatric surgery in the United States is being pursued in an irrational manner, being concentrated in areas where there are fewer morbidly obese patients, and used disproportionately among the population of white obese females.

Relationship between varying Roux limb lengths and weight loss in gastric bypass

BACKGROUND

The optimal Roux limb length for gastric bypass is unknown. Therefore, the effect of Roux limb length on weight loss and nutritional deficiency after a Roux-en-Y gastric bypass procedure was studied.

METHODS

From September 2000 to February 2004, 165 Roux-en-Y gastric bypass surgeries were performed at William Beaumont Army Medical Center. One-year follow-ups were completed on 97 patients. Roux limbs varied from 100 cm to 150 cm, based on the patient's body mass index (BMI). Roux limb lengths were compared with 1-year changes in absolute weight, BMI, and nutritional levels.

RESULTS

In the 97 patients, average age at the time of surgery was 44 years (range, 20-63). Average BMI was 46.7 +/- 6.6 kg/m(2) before surgery and 30.9 +/- 5.8 kg/m(2) at 1-year follow-up. Average absolute weight loss at 1 year was 43.7 +/- 12.8 kg. A statistically significant linear relationship existed between Roux limb length and reductions in BMI and absolute weight. No relationship existed between Roux limb length and changes in nutrient levels.

CONCLUSION

A linear relationship exists between Roux limb length and 1-year weight loss.

Bariatric surgery trends: an 18-year report from the International Bariatric Surgery Registry

BACKGROUND

The epidemic of morbid obesity has increased bariatric procedures performed. Trend analyses provide important information that may impact individual practices.

METHODS

Patient data from 137 surgeons were examined from 1987 to 2004 (41,860 patients) using Cochran-Armitage Trend test and Generalized Linear Model.

RESULTS

Over an 18-year period, surgeon preference for combined restrictive-malabsorptive procedures increased from 33% to 94%, while simple gastric restriction decreased correspondingly (P < .0001). Surgeons per worksite doubled and cases per surgeon increased 71%. Laparoscopic procedures increased to 24%. The percentage of males, mean operative age, and initial body mass index (BMI) increased significantly (P < .0001). Postoperative hospital stay decreased from 5.0 to 3.9 days (P < .0001). The most common procedure in 2004 was Roux-en-Y gastric bypass (RYGB) (59%).

CONCLUSION

Bariatric surgery patients are now older and heavier, length of stay is shorter, and the laparoscopic approach is more frequent. From 1987 to 2004, the general trend shows a clear preference for combined restrictive-malabsorptive operations.