Metabolic and psychosocial effects of minimal invasive gastric banding for morbid obesity

Effect of Bariatric Surgery on Thyroid Function in Obese Patients: a Systematic Review and Meta-Analysis

We aimed to make a meta-analysis regarding the effect of bariatric surgery on thyroid function in obese patients. PubMed, EMBASE, CENTRAL, and four Chinese databases were searched for clinical studies. Data were pooled using Review Manager 5.3, and subgroup and sensitivity analyses were performed if necessary and feasible. As a result, 24 articles were included into meta-analysis. Bariatric surgery was associated with significant decrease in TSH, FT3, and T3 levels. However, FT4, T4, and rT3 levels were not significantly changed postoperatively. In addition, bariatric surgery had a favorable effect on overt and subclinical hypothyroid, with reduction of thyroid hormone requirements postoperatively. In conclusion, TSH, FT3, and T3 decrease are expected following bariatric surgery, as well as non-significant change of T4, FT4, and rT3 levels.

The impact of obesity surgery on musculoskeletal disease

Obesity is an important modifiable risk factor for musculoskeletal disease. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic review of bariatric surgery on musculoskeletal disease symptoms was performed. One thousand nineteen papers were identified, of which 43 were eligible for data synthesis. There were 79 results across 24 studies pertaining to physical capacity, of which 53 (67 %) demonstrated statistically significant post-operative improvement. There were 75 results across 33 studies pertaining to musculoskeletal pain, of which 42 (56 %) demonstrated a statistically significant post-operative improvement. There were 13 results across 6 studies pertaining to arthritis, of which 5 (38 %) demonstrated a statistically significant post-operative improvement. Bariatric surgery significantly improved musculoskeletal disease symptoms in 39 of the 43 studies. These changes were evident in a follow-up of 1 month to 10 years.

Surgery for obesity

BACKGROUND

Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and previously updated in 2005.

OBJECTIVES

To assess the effects of bariatric surgery for obesity.

SEARCH STRATEGY

Studies were obtained from computerized searches of multiple electronic bibliographic databases, supplemented with searches of reference lists and consultation with experts in obesity research.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing different surgical procedures, and RCTs, controlled clinical trials and prospective cohort studies comparing surgery with non-surgical management for obesity.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and checked independently by two reviewers. Two reviewers independently assessed trial quality.

MAIN RESULTS

Twenty six studies were included. Three RCTs and three prospective cohort studies compared surgery with non-surgical management, and 20 RCTs compared different bariatric procedures. The risk of bias of many trials was uncertain; just five had adequate allocation concealment. A meta-analysis was not appropriate.Surgery results in greater weight loss than conventional treatment in moderate (body mass index greater than 30) as well as severe obesity. Reductions in comorbidities, such as diabetes and hypertension, also occur. Improvements in health-related quality of life occurred after two years, but effects at ten years are less clear.Surgery is associated with complications, such as pulmonary embolism, and some postoperative deaths occurred.Five different bariatric procedures were assessed, but some comparisons were assessed by just one trial. The limited evidence suggests that weight loss following gastric bypass is greater than vertical banded gastroplasty or adjustable gastric banding, but similar to isolated sleeve gastrectomy and banded gastric bypass. Isolated sleeve gastrectomy appears to result in greater weight loss than adjustable gastric banding. Evidence comparing vertical banded gastroplasty with adjustable gastric banding is inconclusive. Data on the comparative safety of the bariatric procedures was limited.Weight loss and quality of life were similar between open and laparoscopic surgery. Conversion from laparoscopic to open surgery may occur.

AUTHORS' CONCLUSIONS

Surgery is more effective than conventional management. Certain procedures produce greater weight loss, but data are limited. The evidence on safety is even less clear. Due to limited evidence and poor quality of the trials, caution is required when interpreting comparative safety and effectiveness.

Health-related quality of life following a surgical weight loss intervention

Nursing is concerned with the well-being of the whole person; therefore, understanding the patient's perspective of the impact of a surgical weight loss intervention (SWLI) is essential. The purpose of this study was to examine the self-reported health-related quality of life of individuals after a SWLI. A convenience sample of participants in a post-SWLI support group completed the SF-12v2, a demographic form and a global quality of life measure. Findings indicate that although overall quality of life was rated excellent or very good, self-report of health-related quality on social functioning, vitality, and mental health was less positive. The findings of this pilot study indicate the need for research regarding the understanding of the meaning of psychosocial and physiological well-being to the person who undergoes a SWLI and a need for a more holistic support focus inclusive of psychosocial development strategies. As nurses committed to the wholeness of individuals, it is critical that we recognize the social and emotional needs of this emerging group of patients and implement strategies to enhance individual wholeness and well-being after SWLI.

Improvement in comorbid illness after placement of the Swedish Adjustable Gastric Band

BACKGROUND

Obesity and its related comorbid illnesses have become a national health priority. We report comorbidity and quality of life (QoL) data after weight loss with gastric banding using the Swedish Adjustable Gastric Band (SAGB).

METHODS

Data were collected prospectively for 838 consecutive morbidly obese patients who underwent laparoscopic adjustable gastric banding (LAGB) between January 2001 and July 2007. Patients were followed-up by a multidisciplinary team consisting of a surgeon, physician, dietician, and exercise consultant, all of whom were involved in the evaluation of clinical outcomes. Continuous data were reported as mean +/- SD; categorical data were reported as number and percentage. Patients served as their own controls.

RESULTS

Respective preoperative mean age, weight, and body mass index (BMI) were 44 years (range 16-76), 122 kg (range 86-240), and 44 kg/m2 (range 35-86), respectively. SAGB implantation was accomplished by the pars flaccida technique with no conversion to an open procedure. Mature follow-up data were available for 35% of patients at 24 months and 21% at 36 months. In the total cohort of 838 patients, BMI (mean +/- SD) decreased to 32 +/- 5 kg/m2 and 32 +/- 7 kg/m2 at 24 months and 36 months, respectively. Percentage excess weight loss (%EWL) (mean +/- SD) was 32% +/- 14% (n = 506), 47% +/- 15% (n = 461), 52% +/- 16% (n = 291), and 54% +/- 23% (n = 175) at 6, 12, 24, and 36 months, respectively (P < .001). There were 545 patients identified with comorbid illness at >6-month follow-up. After a median follow-up of 13 months (range 6-36 months), resolution and/or improvement of comorbidities was as follows: type 2 diabetes mellitus, 79%; metabolic syndrome, 78%; hypertension, 67%; dyslipidemia, 66%; gastroesophageal reflux, 66%; asthma, 57%; arthritis/joint pain, 70%; polycystic ovarian syndrome, 48%; and depression, 57%. There was a significant improvement in QoL (as measured by the Short Form-36 Health Survey [SF-36]), bringing patients' QoL to a level consistent with that of community norms in all 8 domain scores. Of 342 patients surveyed with the Beck Depression Inventory (BDI-II), a statistically significant improvement in depressive mood was also observed (P < .001).

CONCLUSION

Weight loss achieved by use of the SAGB provides a dramatic reduction in many serious comorbid illnesses as well as improvement in the psychosocial wellbeing of morbidly obese patients.

Metformin treatment of polycystic ovary syndrome improves health-related quality-of-life, emotional distress and sexuality

BACKGROUND

In polycystic ovary syndrome (PCOS), changes in physical appearance, menstrual disturbances and infertility result in psychological distress and reduced quality-of-life. Metformin improves biochemical, clinical and reproductive parameters in PCOS women. In a prospective, observational study, we analysed the effects of metformin treatment on health-related quality-of-life (HRQL), emotional well-being and sexuality in PCOS. No placebo-treated control group was included.

METHODS

Before, during and after 6 months of treatment, changes in clinical and endocrine parameters, quality-of-life, psychological disturbances and sexuality were assessed in 64 PCOS patients using validated questionnaires (SF-36, SCL-90-R) and visual analogue scales. Patients were also compared with published normative data for the validated questionnaires.

RESULTS

During treatment, HRQL, particularly the psychosocial aspects (indicated by significant increases in SF-36 scales Vitality, Social Function, Emotional Role Function, Mental Health, Psychological Sum scale) and emotional well-being (reflected by significant lowering of SCL-90-R scales) improved. These improvements in HRQL were significantly correlated with a reduction in body weight and significantly more pronounced in patients with normalized menstrual cycles. In addition, PCOS women were significantly more satisfied with their sex life and reported higher frequencies of sexual intercourse following treatment.

CONCLUSION

Treatment can improve the psychosocial, emotional and psychosexual situation of PCOS patients. Although at least some of these effects may be related to the reduction of individual clinical symptoms (i.e. weight loss, normalization of menstrual disturbances, improvement of acne), this observational study does not allow us to clearly discern the role of symptom constellation and does not preclude non-specific and/or placebo effects. Nevertheless, emotional distress and reduced quality-of-life are clearly not an inevitable consequence of PCOS and should be considered as adjunct treatment goals in future studies.

Psychosocial morbidity of Graves' orbitopathy

OBJECTIVE

Ocular diseases markedly impair daily function. In Graves' orbitopathy (GO), an associated psychosocial burden is present due to disfiguring proptosis and/or diplopia, signs with significant impact on functional status and well-being. We have therefore surveyed and assessed the psychosocial morbidity of GO.

DESIGN

A prospective controlled study on subjects with GO using internationally validated, self-reporting questionnaires.

PATIENTS

One hundred and two consecutive patients with varying degrees of severity and activity of GO. Measurements Emotional distress, coping styles and quality of life (QoL) were assessed by the Hospital Anxiety and Depression Scale, by a German adaptation of the Ways-of-Coping Checklist, and with the 36-item Short Form, respectively. Stressful events in the 6 months preceding diagnosis were registered with the Life Experience Survey. QoL findings were compared to German reference values, as well as to 102 age- and gender-matched patients, each with type 1 diabetes (insulin-dependent diabetes mellitus, IDDM) and inflammatory bowel disease (IBD), respectively.

RESULTS

Compared to the German reference population, all QoL scales were at a lower rate and were especially decreased in subjects with active and/or severe GO, orbital pain, diplopia and stressful life events. Compared to diabetics, psychosocial scales were considerably reduced in GO (z = -1 vs. 0.1, P < 0.001) and higher scores for depressive coping (2.32 vs. 1.71, P < 0.001) and trivializing (2.37 vs. 1.97, P < 0.006) were noted. In GO, depressive coping and trivializing were negatively correlated with the mental (r = -0.603 and r =-0.411, both P < 0.001) and physical (r = -0.487 and r = -0.354, both P < 0.001) components of QoL. Depressive coping also positively correlated with anxiety (r = 0.636) and depression (r = 0.590), respectively, both P < 0.001. Emotional distress noted in 46 subjects, mostly with active and severe GO, was associated with poor QoL. Anxiety and depression were present in 41 and 24 GO patients, respectively. The number of stressful events positively correlated with the scores of anxiety (r = 0.3335) and depression (r = 0.3178), both P = 0.001. Foremost emotional distress, but also diplopia, stressful events and depressive coping had a major impact on QoL (proportion of variance explained = 13.1%, P < 0.001, multiple regression analysis). More than 75% of the psychosocial impairment in GO (R2= 0.76, P < 0.001) was associated with seven variables only (e.g. depression and anxiety). Six months prior to GO onset, 74 patients experienced a mean of 4 (range 0-13) stressful life events. Subjects with optic neuropathy had more stressful events than those without nerve involvement (5.1 vs. 2.7, P = 0.0425).

CONCLUSIONS

Psychosocial morbidity is present in severe and/or active GO, which negatively affects QoL. The patients are not only physically ill, they also exhibit emotional distress. Accompanying psychosomatic treatment is indicated among about half of all GO patients.

Nutrient deficiencies secondary to bariatric surgery

PURPOSE OF REVIEW

The number of adolescent and adult patients submitting to bariatric surgery is increasing rapidly around the world. This review describes the literature published in the last few years concerning nutritional deficiencies after bariatric surgery as well as their etiology, incidence, treatment and prevention.

RECENT FINDINGS

Although bariatric surgery was first introduced in the 1950s, safe and successful surgical management has progressed over the last two decades and longer post-surgical follow-up data are now available. Most of the patients undergoing malabsorptive procedures will develop some nutritional deficiency, justifying mineral and multivitamin supplementation to all postoperatively. Nutrient deficiency is proportional to the length of absorptive area and to the percentage of weight loss. Low levels of iron, vitamin B12, vitamin D and calcium are predominant after Roux-en-Y gastric bypass. Protein and fat-soluble vitamin deficiencies are mainly detected after biliopancreatic diversion. Thiamine deficiency is common in patients with frequent vomiting. As the incidence of these deficiencies progresses with time, the patients should be monitored frequently and regularly to prevent malnutrition.

SUMMARY

Nutritional deficiencies can be prevented if a multidisciplinary team regularly assists the patient. Malnutrition is generally reverted with nutrient supplementation, once it is promptly diagnosed. Especial attention should be given to adolescents, mainly girls at reproductive age who have a substantial risk of developing iron deficiency. Future studies are necessary to detect nutrient abnormalities after new procedures and to evaluate the safety of bariatric surgery in younger obese patients.