Improvement in infertility and pregnancy outcomes after weight loss surgery

The Influence of Laparoscopic Sleeve Gastrectomy on Pregnancy, Delivery, and Infant: Does Timing of Pregnancy Following Laparoscopic Sleeve Gastrectomy Affect Outcomes?

PURPOSE

Maternal obesity is associated with newborn morbidity and mortality; however, the literature discussing bariatric surgical effects on women's fertility and pregnancy has reached diverse conclusions. We examined the effect of laparoscopic sleeve gastrectomy (LSG) on pregnancy, birth, and newborn outcomes regarding the time of conception.

MATERIALS AND METHODS

We conducted a retrospective review of women who had LSG and conceived between 2007 and 2017. Data included maternal parameters, pregnancy progression, delivery, and newborn status. Pregnancies were divided into subgroups according to surgery to conception interval (≤ 12, 12-24, ≥ 24 months).

RESULTS

We reviewed 68 patients: 48 (70%) conceived once, 13 (19%) conceived twice, 7 women (10%) conceived three times. There were 95 pregnancies and 80 live births. The group sizes were 18 (18.9%), 29 (30.5%), and 48 (50.5%) pregnancies for ≤ 12, 12-24, and 24 months after surgery, respectively. No difference was found between the subgroups regarding basic characteristics at time of surgery (age (p = 0.100), weight (p = 0.180), BMI (p = 0.616); and at beginning of pregnancy weight (p = 0.309), BMI (p = 0.707), %EBMIL (p = 0.321)). No significant differences were found concerning pregnancy progression, complications, and the newborns' weight (p = 0.41), GCT (p > 0.99), preeclampsia (p = 0.492), eclampsia (p > 0.99), Pre-term (p = 0.428), live birth (p = 0.432), LGA (p > 0.99), SGA (p = 0.732). A statistically significant trend of increased rates of caesarean section in subject with longer surgery-to-conception intervals was detected (P = 0.022).

CONCLUSIONS

Our results did not show that the interval between LSG and conception affects the pregnancy and newborn outcomes. Therefore, we believe that early conception following LSG does not increase the risk of maternal or neonatal morbidity or mortality.

Contraception, Menstruation, and Sexuality after Bariatric Surgery: a Prospective Cohort Study

BACKGROUND

Women with a history of bariatric surgery are recommended to avoid pregnancy at least 12 months after surgery. Evidence on the impact of bariatric surgery on contraception, menstrual cycle, and sexuality in the first year postoperative is therefore indispensable.

OBJECTIVES

The objective of this paper is to prospectively study changes in contraception, menstrual cycle and sexuality in women of reproductive age following bariatric surgery.

SETTING

The study was conducted in two secondary medical centers and a tertiary academic medical center.

METHODS

Women attending for bariatric surgery or who recently underwent bariatric surgery completed online questionnaires about contraception, menstrual cycle, and sexual behavior before surgery and 6 and 12 months after surgery.

RESULTS

The study included data from 71 women, including 70 and 47 women at 6 and 12 months after bariatric surgery, respectively. Preoperatively, 43.6% (n = 31/71) used a short-acting hormonal contraceptive, the usage of which decreased significantly to, respectively, 32.8% (n = 23/70; p = .031) and 27.7% (n = 13/47; p = .022) 6 and 12 months post-surgery. Usage of long-acting contraceptive methods increased from 26.7% (n = 19/71) preoperatively to 38.6% (n = 27/70; p = .021) and 42.6% (n = 20/47; p = .004) at 6 and 12 months. Combined oral contraceptives (COC) remained used (39.4% preoperatively, 27.1 and 14.9% at 6 and 12 months postoperatively). Menstrual cycle (frequency, pattern, duration of the cycle, and the menstruation itself) and sexual behavior (intimate relationship, frequency of intercourse, and satisfaction) did not differ significantly before and after surgery.

CONCLUSIONS

Women undergoing bariatric surgery appear to switch their type of contraceptive from oral, short-acting hormonal contraceptives to non-oral, long-acting contraceptives. No changes in menstrual cycle and sexual behavior were shown.

Healthcare provider knowledge regarding oral contraception effectiveness for women with a history of bariatric malabsorptive procedures

BACKGROUND

Clinical practice guidelines that recommend women avoid pregnancy immediately after bariatric surgery, highlighting the need for effective contraception. However, women with a history of malabsorptive bariatric procedures should generally not use oral contraceptives, as these procedures may decrease oral contraceptive effectiveness.

OBJECTIVES

To identify provider characteristics associated with knowledge of combined oral contraceptive (COC) effectiveness.

SETTING

United States.

METHODS

We analyzed weighted survey data collected from national samples of public-sector health centers and office-based physicians who regularly provide family planning services (N = 2060). We asked providers about the effectiveness of COCs for women with a history of malabsorptive procedures compared with healthy women, giving them the response options of more/equally effective, less effective, and do not know. We used multinomial logistic regression to calculate adjusted odds ratios and 95% confidence intervals to identify characteristics associated with knowledge of COC effectiveness.

RESULTS

Approximately 55% of providers correctly answered that COCs are less effective for women with malabsorptive procedures; 25% considered COCs more/equally effective, and 20% were uncertain. Among public-sector providers, the adjusted odds of uncertainty were significantly higher for those whose clinical focus was not reproductive health, for nurses versus advanced practice clinicians, and for providers working in clinics without Title X funding. For office-based physicians, adolescent medicine providers had higher odds of uncertainty versus obstetrician-gynecologists. Physicians practicing in settings classified as "other" (such as community health centers) had higher odds of considering COCs effective compared with those practicing in hospital or university clinics.

CONCLUSIONS

Substantial proportions of surveyed providers had inadequate knowledge of COC effectiveness for women with a history of malabsorptive procedures.

Bariatric Surgery Reduces Serum Anti-mullerian Hormone Levels in Obese Women With and Without Polycystic Ovarian Syndrome

PURPOSE

Obesity in fertile women has negative effect on fertility. Anti-mullerian hormone (AMH) represents a good index of fertility, and it is considered a marker of ovarian reserve and of polycystic ovarian syndrome (PCOS) gravity. Previous studies evaluated the relationship between obesity and AMH with contradictory results. The aim of the study was to investigate the relationship between obesity and AMH and the changes of AMH in obese women in reproductive age submitted to bariatric surgery.

MATERIALS AND METHODS

Fifty-five obese patients between 18 and 39 years with (29 patients) and without PCOS (26 patients) were compared with a control group of normal weight women with (24 patients) and without PCOS (19 patients). Fourteen obese women with PCOS and 18 without PCOS underwent to bariatric surgery. Serum AMH, testosterone, androstenedione, and DHEAS were performed in all patients before and 1 year after surgical intervention.

RESULTS

AMH was significantly higher in the PCOS groups (p < 0.001), both in obese (5.84 ± 3.94 ng/ml) and non-obese women (7.35 ± 4.39 ng/ml). AMH was positively related to testosterone (p < 0.0001), androstenedione (p = 0.0005), and DHEAS (p = 0.003). After bariatric surgery, AMH levels were reduced in the both PCOS (p = 0.02) and non-PCOS group (p = 0.04).

CONCLUSIONS

AMH levels are elevated in PCOS patients regardless of the body weight. Bariatric surgery is effective in the normalization of AMH levels (a possible indirect marker of better fertility) only in obese patients with PCOS.

Does weight loss in overweight or obese women improve fertility treatment outcomes? A systematic review

This systematic review assessed the effect of weight loss in overweight and/or obese women undergoing assisted reproductive technology (ART) on their subsequent pregnancy outcome. Weight losses achieved by diet and lifestyle changes, very-low-energy diets, non-surgical medical interventions and bariatric surgery translated into significantly increased pregnancy rates and/or live birth in overweight and/or obese women undergoing ART in 8 of the 11 studies reviewed. In addition, regularization of the menstrual pattern, a decrease in cancellation rates, an increase in the number of embryos available for transfer, a reduction in the number of ART cycles required to achieve pregnancy and a decrease in miscarriage rates were reported. There were also a number of natural conceptions in five of the six studies that reported this outcome. Non-surgical medical weight loss procedures and bariatric surgery induced the greatest weight losses, but their use, as well as that of very-low-energy diets, for weight loss prior to ART requires careful consideration. While the overall quality of the studies included in this review was poor, these results support the clinical recommendation of advising overweight and/or obese women to lose weight prior to ART. Prospective randomized controlled trials are required to establish efficacious evidence-based guidelines for weight loss interventions in overweight and/or obese women prior to ART treatment.

Roles of the pharmacist in the use of safe and highly effective long-acting reversible contraception: an opinion of the women's health practice and research network of the American College of Clinical Pharmacy

The U.S. population continues to experience an alarmingly high rate of unintended pregnancies that have an impact on individual families and society alike. Lack of effective contraception accounts for most unintended pregnancies, along with incorrect use of contraceptives. The most common reversible contraceptive method used in the United States is the oral contraceptive pill, which has significant failure and discontinuation rates. Use of long-acting reversible contraceptive (LARC) methods has been increasing in recent years after efforts to educate providers and patients. Women are more likely to use LARC methods when barriers such as access and cost are removed. An uptake in the use of LARC methods would allow for markedly reduced contraception failure rates and higher user satisfaction and thus higher continuation rates than those seen with current contraception use. Promoting the use of LARC methods is an important strategy in improving both individual and public health outcomes by reducing unintended pregnancies. The pharmacist's role in family planning is expanding and can contribute to these efforts. Although knowledge regarding LARC has not been studied among pharmacists, a knowledge deficit exists among health care professionals in general. Thus pharmacist education and training should include LARC methods along with other contraceptives. The American College of Clinical Pharmacy Women's Health Practice and Research Network advocates for the pharmacist's role in the use of safe and highly effective LARC methods. These roles include educating patients, informing providers, facilitating access by providing referrals, and modifying institutional procedures to encourage provision of LARC methods.

Contraception and the obese woman

PURPOSE

Obesity has reached epidemic rates among U.S. women of reproductive age, many of whom want to use contraception. However, some forms of contraception can have adverse effects on an obese woman's health. This article explores risks of contraception available in the United States and provides clinical recommendations for use by obese women.

DATA SOURCES

Information was compiled by reviewing the scientific literature on contraception and female obesity using CINAHL, MEDLINE, PubMed search engines.

CONCLUSIONS

The evidence is largely supportive of combined oral contraceptive (COC) use in carefully screened obese women without known risks factors for cardiovascular disease. The efficacy of COCs may be slightly reduced in obese women because of increased body mass. Other types of hormonal contraceptives have varying safety and efficacy reports when used by obese women. Intrauterine devices do not have reduced efficacy nor increased risks for obese women but insertion may be more difficult. Obesity has no effect on efficacy of barrier methods of contraception.

IMPLICATIONS

Clinicians should conduct a careful history and physical exam with selected supporting laboratory tests when considering prescription of hormonal contraceptives for obese women. Obese women require health counseling to carefully follow directions for contraceptive use to avoid unintended pregnancy.

Obesity and oral contraceptives: a clinician's guide

Obesity and unintended pregnancy are two of the major health epidemics we are currently facing worldwide. Patient education is a clinician's greatest tool in combating both epidemics but many clinicians may be uncomfortable with counselling and prescribing contraception for obese women. Overall, the prevention of unintended pregnancy in obese women far outweighs any risk associated with oral contraceptive use. This review aims to provide the clinician with a practical guide to the use of oral contraceptive pills in obese women.

Pregnancy and foetal outcome after bariatric surgery: a review of recent studies

It is well known that maternal obesity has adverse effects on the health of offspring, causing immediate and long-term morbidities. The various types of procedure coming under the heading of bariatric surgery have proved effective in preventing some maternal and foetal complications in morbidly obese pregnant women. This review aims to assess the role, the risks and the benefits of bariatric surgery for mothers and offspring. According to recent findings, pregnancy and neonatal outcomes in morbidly obese women who have undergone bariatric surgery depend to some extent on the type of surgery used. Maternal complications, nutritional defects and intestinal obstruction are more frequently reported after Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) than after laparoscopic adjustable gastric banding (LAGB) procedures, whereas caesarean section, preterm delivery and neonatal death are more commonly reported after RYGB than after LAGB. The authors of the only long-term follow-up study conducted on this subject reported that the rate of obesity in the children dropped by 52% after bariatric surgery for the mother, and the cases of severe obesity decreased by 45%. Data on pregnancy and bariatric surgery confirm that the procedure is more effective than dietary measures alone in morbidly obese women, and that pregnancy outcome is generally favorable after surgery. Some studies have indicated, nonetheless, that pregnancies after bariatric surgery are at higher risk: the women affected require special medical attention, particularly as concerns gastrointestinal symptoms and vitamin deficiencies, warranting nutritional/dietary counselling by a multidisciplinary team before, during and after pregnancy.

Pregnancy after bariatric surgery: a current view of maternal, obstetrical and perinatal challenges

With the increase in the number of bariatric surgeries being performed in women of childbearing age, physicians must have concerns regarding the safety of pregnancy after bariatric surgery. The aim of this review is to summarize the literature reporting on maternal, obstetrical and perinatal implications of pregnancy following BS.

METHODS

English, Spanish and Portuguese-language articles were identified in a PUBMED search from 2005 to February 2011 using the keywords for pregnancy and bariatric surgery or gastric bypass or gastric banding.

RESULTS

The studies show improved fertility and a reduced risk of gestational diabetes, pregnancy-induced hypertension and pre-eclampsia, macrosomia in pregnant women after bariatric surgery. The incidence of intrauterine growth restriction and small for gestational age are increased. No conclusions can be drawn concerning the risk for cesarean delivery and the best surgery-to-conception interval. Deficiencies in iron, vitamin A, vitamin B12, vitamin K, folate and calcium can result in maternal and fetal complications.

CONCLUSIONS

Pregnancy outcome of women who delivered after BS, as compared to obese populations, is better and safer and comparable to the general population. Close supervision before, during and after pregnancy following bariatric surgery and nutrient supplementation adapted to the patient's individual requirements can prevent nutrition-related complications and improve maternal and fetal health.

The potential role of intragastric balloon in the treatment of obese-related infertility: personal experience

The prevalence of people who are overweight or obese has increased dramatically in high-income countries over the past 20 years. There is a strong association between obesity and infertility, and weight loss can result in increased fecundity in obese women. The aim of this study is to demonstrate the potential role of intragastric balloon in the treatment of obese-related infertility. This is a retrospective study. A chart review of 27 obese women seen between September 2003 and July 2008 was performed. They all presented with the diagnosis of infertility and had undergone endoscopic intragastric balloon positioning. Among these women who tried unsuccessfully to become pregnant before weight loss, 15 became pregnant afterward. The pregnancies proceeded without complications and ended with live births. An improvement in the fertility status after weight loss has been described, although data on fertility after weight loss following bariatric surgery are still limited. The results obtained in our experience are not different from data reported in literature for bariatric surgery. Therefore, balloon treatment might be effective in young infertile obese women who wish to become pregnant.

Pregnancy after prophylactic total gastrectomy

Hereditary diffuse gastric cancer is an autosomal dominant inherited cancer predisposition syndrome characterized by susceptibility to diffuse gastric and lobular breast cancers. Since current screening options for diffuse gastric cancer are ineffective, prophylactic total gastrectomy (PTG) is a recommended option for unaffected germline CDH1 mutation carriers. It is unknown whether pregnancy after surgery is possible or advisable due to potential maternal nutritional deficiencies. In this report we describe the pregnancy outcomes in three CDH1 mutation positive women after PTG and in a CDH1 mutation negative woman after total gastrectomy for early gastric cancer.

In vitro fertilization after bariatric surgery

Few data exist regarding IVF in women who have undergone bariatric surgery. Our experience with five patients suggests that IVF is a safe and effective fertility treatment for these women, although special considerations should be made when treating patients who have undergone bariatric surgery. Considering the type of bypass procedure the patient underwent is particularly important should a patient develop concerning symptoms during her IVF cycle.

Reduced incidence of gestational diabetes with bariatric surgery

BACKGROUND

Obesity is a risk factor for gestational diabetes mellitus (GDM), and bariatric surgery is an effective treatment for obesity. Our objective was to determine the association of bariatric surgery with the incidence of GDM and related complications.

STUDY DESIGN

We performed a retrospective study comparing rates of GDM and related outcomes (including cesarean section, large-for-gestational-age infant, shoulder dystocia, and infection) between a group of women with a delivery before bariatric surgery and a group with a delivery after bariatric surgery. We used a private insurance claims database with information on 23,594 women who had bariatric surgery between 2002 and 2006. The dataset was searched to identify women with codes for bariatric surgery and a pregnancy resulting in a delivery at greater than 22 weeks gestation. Incidences of GDM and selected delivery complications for delivery before versus after bariatric surgery were compared using Fisher exact test and logistic regression.

RESULTS

There were 346 women who had a delivery before bariatric surgery, and 354 had a delivery after bariatric surgery. Women with delivery after bariatric surgery had lower incidences of GDM (8% vs 27%, odds ratio (OR) 0.23, (95% CI 0.15 to 0.36) and cesarean section (28% vs 43%, OR0.53, 95% CI 0.39 to 0.72) than those with delivery before bariatric surgery.

CONCLUSIONS

Bariatric surgery is associated with a decreased incidence of GDM and cesarean section in subsequent pregnancies. This potential effect of bariatric surgery should be considered in the management of obese women of childbearing age. Prospective studies are needed to confirm these findings.

Contraceptive use among women with a history of bariatric surgery: a systematic review

BACKGROUND

Weight loss after bariatric surgery often improves fertility but can pose substantial risks to maternal and fetal outcomes. Women who have undergone a bariatric surgical procedure are currently advised to delay conception for up to 2 years.

STUDY DESIGN

We conducted a systematic review of the literature, from database (PubMed) inception through February 2009, to evaluate evidence on the safety and effectiveness of contraceptive use among women with a history of bariatric surgery.

RESULTS

From 29 articles, five met review inclusion criteria. One prospective, noncomparative study reported 2 pregnancies among 9 (22%) oral contraceptive (OC) users following biliopancreatic diversion, and one descriptive study reported no pregnancies among an unidentified number of women taking OCs following laparoscopic adjustable gastric banding. Of two pharmacokinetic studies, one found lower plasma levels of norethisterone and levonorgestrel among women having had a jejunoileal bypass, as compared to nonoperated, normal-weight controls. The other study found no difference in plasma levels of D-norgestrel between women having a jejunoileal bypass of either 1:3 or 3:1 ratio between the length of jejunum and ileum left in continuity, but women with a 1:3 ratio had significantly higher plasma levels of D-norgestrel than extremely obese controls not operated upon.

CONCLUSIONS

Evidence regarding OC effectiveness following a bariatric surgical procedure is quite limited, although no substantial decrease in effectiveness was identified from available studies. Evidence on failure rates for other contraceptive methods and evidence on safety for all contraceptive methods was not identified.

Obesity and bariatric surgery

Laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are the most commonly performed weight reduction operations in the United States. Preoperative assessment and selection should be performed by a multidisciplinary team to obtain optimal results. The most devastating complication of bariatric surgery is leak, which can carry a high risk of mortality if not detected and treated expediently. New nationwide databases have been developed to monitor outcomes and facilitate better understanding of the mechanisms of bariatric surgery. New horizons for the advancement of bariatric surgery are in the realm of surgery in adolescent and geriatric populations, the use of weight-loss surgery in lower body mass index (<35 kg/m(2)) populations, and the use of surgery to cure the comorbidities of obesity.

Reproductive health of women electing bariatric surgery

OBJECTIVE

To describe the reproductive health history and characteristics of women having bariatric surgery and to determine whether this differs by age of onset of obesity.

DESIGN

Retrospective and cross-sectional analyses of self-reported survey data.

SETTING

Six sites of the Longitudinal Assessment of Bariatric Surgery-2 study.

PATIENT(S)

The study included 1,538 females having bariatric surgery.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Reported polycystic ovary syndrome (PCOS), pregnancy and fertility history, contraceptive use, and plans for pregnancies.

RESULT(S)

Mean age was 44.8 years (range, 18-78 years); mean body mass index was 47.2 kg/m2 (range, 33.8-87.3 kg/m2). PCOS had been diagnosed by a health care provider in 13.1% of subjects. Of women who had tried to conceive, 41.9% experienced infertility and 61.4% had a live birth after experiencing infertility. In the whole group, prior live birth was reported by 72.5%. Women who were obese by 18 years old were more likely to report PCOS and infertility and less likely to have ever been pregnant, compared with women who became obese later in life. Future pregnancy was important to 30.3% of women younger than 45 years, whereas 48.6% did not plan to become pregnant in the future. In the year before surgery, 51.8% used contraception.

CONCLUSION(S)

Self-reporting of obesity by age 18 appears to be related to reproductive morbidity. Women undergoing bariatric surgery have important reproductive health care needs, including reliable contraception and counseling about plans for postoperative pregnancy.

Reproductive outcome after bariatric surgery: a critical review

BACKGROUND

After many cycles of weight loss and weight gain, more and more morbidly obese patients undergo bariatric surgery, like gastric banding or gastric bypass, as the ultimate treatment for their obesity-problem. Since women of reproductive age are candidates for bariatric surgery, concerns arise regarding the potential impact on future pregnancy.

METHODS

English-language articles were identified in a PUBMED search from 1982 to January 2008 using the keywords for pregnancy and bariatric surgery or gastric bypass or gastric banding.

RESULTS

The few reported case-control and cohort studies clearly show improved fertility and a reduced risk in obstetrical complications, including gestational diabetes, macrosomia and hypertensive disorders of pregnancy, in women after operatively induced weight loss when compared with morbidly obesity women. The incidence of intrauterine growth restriction (IUGR) appears to be increased, however. No conclusions can be drawn concerning the risk for preterm labour and miscarriage, although these risks are probably increased compared with controls matched for body mass index. Operative complications are not uncommon with bariatric surgery and several cases have pointed to the increased risk for intestinal hernias and nutritional deficiencies in subsequent pregnancy. Deficiencies in iron, vitamin A, vitamin B(12), vitamin K, folate and calcium can result in both maternal complications, such as severe anaemia, and fetal complications, such as congenital abnormalities, IUGR and failure to thrive.

CONCLUSIONS

Close supervision before, during and after pregnancy following bariatric surgery and nutrient supplementation adapted to the patient's individual requirements can help to prevent nutrition-related complications and improve maternal and fetal health, in this high-risk obstetric population.

Medical issues from preconception through delivery: a roadmap for the internist

The age of the pregnant population and the number of pregnant women with medical issues are increasing. It is widely recognized that internists have the unique opportunity to identify potential pregnancy issues and address them before a problem arises. Therefore, it's important that we become aware of how to approach these issues. In addition to addressing medical issues in a currently pregnant woman, doctors also have the opportunity to identify issues that occurred during a prior pregnancy, such as gestational diabetes, preeclampsia, or pregnancy loss, and to decrease the risk of complications in future pregnancies. The goal of this article is to provide a roadmap to practicing internists so they will incorporate pregnancy planning into their everyday care plans. The approach is similar to that used when performing a preoperative risk assessment: We want to optimize our patients medically for pregnancy.

Pregnancy outcomes after laparoscopic Roux-en-Y gastric bypass

BACKGROUND

Early reports described adverse perinatal outcomes of pregnancies after weight loss surgery (WLS), which subsequently raised concerns regarding safety. Our objective was to investigate, in a community-based, academic, tertiary care center, the safety of pregnancies after laparoscopic Roux-en-Y gastric bypass (LRYGB) and its potential effect on obesity-related perinatal complications.

METHODS

The pregnancy outcomes of patients delivering infants after LRYGB at our institution were compared with those of control subjects (stratified by body mass index) who had not undergone WLS. The charts were retrospectively reviewed for demographics, delivery route, and perinatal complications.

RESULTS

A total of 26 patients who delivered after LRYGB and 254 controls were identified. The mean interval from LRYGB to conception was 25.4 +/- 13.0 months. In general, the perinatal complications in the LRYGB patients were similar to those in the nonobese controls and lower than in the obese and severe obese controls, although statistical significance was not noted for all complications. No spontaneous abortions or stillbirths occurred in the LRYGB patients. No LRYGB patients required intravenous nutrition or hydration. The overall incidence of cesarean section in the LRYGB patients was similar to that in the obese and severely obese controls but significantly greater than that in the nonobese controls. The complication rates were similar in pregnancies occurring "early" (<12 mo) versus "late" (>18 mo) after LRYGB.

CONCLUSION

The results of our study have shown that pregnancy after LRYGB is safe, with an incidence of perinatal complications similar to that of nonobese patients, and lower than that of obese and severely obese patients, who had not undergone WLS. Larger studies are required to demonstrate statistically significant improvements in outcome in patients treated with WLS.