Medical management of obesity

Utility of routine versus selective upper gastrointestinal series to detect anastomotic leaks after laparoscopic gastric bypass

BACKGROUND

In up to 4% of laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures, anastomotic leaks occur. Early detection of gastrointestinal leakage is important for successful treatment. Consequently, many centers advocate routine postoperative upper gastrointestinal (UGI) series. The aim of this study was to determine the utility of this practice after LRYGB.

METHODS

Eight hundred four consecutive patients undergoing LRYGB from June 2000 to April 2010 were analyzed prospectively. The first 382 patients received routine UGI series between the third and fifth postoperative days (group A). Thereafter, the test was only performed when clinical findings (tachycardia, fever, and drainage content) were suspicious for a leak of the gastrointestinal anastomosis (group B; n = 422).

RESULTS

Overall, nine of 804 (1.1%) patients suffered from leaks at the gastroenterostomy. In group A, four of 382 (1%) patients had a leak, but only two were detected by the routine UGI series. This corresponds to a sensitivity of 50%. In group B, the sensitivity was higher with 80%. Specificities were comparable with 97% and 91%, respectively. Routine UGI series cost only 1.6% of the overall costs of a non-complicated gastric bypass procedure. With this leak rate and sensitivity, US $86,800 would have to be spent on 200 routine UGI series to find one leak which is not justified.

CONCLUSIONS

This study shows that routine UGI series have a low sensitivity for the detection of anastomotic leaks after LRYGB. In most cases, the diagnosis is initiated by clinical findings. Therefore, routine upper gastrointestinal series are of limited value for the diagnosis of a leak.

Hypocaloric considerations in patients with potentially hypometabolic disease States

The provision of nutrition has traditionally been driven by the desire to provide adequate calories. However, over the past decade it has become evident that provision of excess calories can be detrimental to patients' outcomes in both critical care and long-term care settings. This review examines patient populations for whom hypocaloric nutrition can be both appropriate and beneficial. In specific situations, critically ill patients, such as those with obesity, stroke, and spinal cord injury, may have decreased energy requirements. In patients with spinal cord injury, the level of injury significantly correlates with the extent of reduced caloric energy expenditure. Ventilator-dependent patients with amyotrophic lateral sclerosis (ALS) have decreased energy needs; energy expenditure for ALS patients is lower than the predictive equation value. Aging patients will have decreased energy needs relative to a reduction in lean body mass. Patients with cerebral palsy (CP) have significantly lower caloric requirements than anticipated using predictive equations. Patients with CP pose a particular challenge in nutrition assessment. Several studies demonstrate that patients with CP have significantly lower caloric requirements than anticipated using predictive equations; thus, patients with CP benefit from indirect calorimetry. Provision of nutrition for obese patients is briefly addressed, as this is an increasingly important consideration for nutrition support in both the critical care and long-term care settings. When indirect calorimetry is not available, clinicians should remember that most patients will have low resting energy expenditure regardless of functional status and require frequent evaluation during institution of nutrition recommendations to guard against overfeeding and obesity.

Surgical treatment for obesity: ensuring success

In the United States, obesity has reached epidemic proportions. Serious medical complications, impaired quality of life, and premature mortality are all associated with obesity. Medical conditions such as type 2 diabetes mellitus, hypertension, hyperlipidemia, or sleep apnea can improve or be cured with weight loss. Medical treatment programs focused on diet, behavior modification, and/or pharmacologic intervention have met with limited long-term success. Although surgical treatments for obesity have become popular in recent years, they should only be used as a last resort for weight loss. Not all patients can be considered appropriate candidates for surgery; therefore, guidelines based on criteria from the National Institutes of Health should be used preoperatively to help identify suitable persons. Most individuals who opt for weight-loss surgery have usually struggled for many years with losing weight and keeping it off, but surgery alone will not ensure successful weight loss. Patient education is imperative for long-term success. Moreover, any such educational regimen should include information on diet, vitamin and mineral supplementation, and lifestyle changes, as well as expected weight-loss results and improvements in comorbid conditions. Patients must be willing to commit to a long-term follow-up program intended to promote successful weight loss and weight maintenance and to prevent metabolic and nutritional complications.

Quality of Life After Roux-en-Y Gastric Bypass Surgery

The incidence of obesity is rising worldwide, leading to a related increase in obesity-associated comorbidities that directly affect longevity and quality of life. Surgical interventions, including the Roux-en-Y gastric bypass procedure, are available for those who have increased risk for morbidity and mortality as a result of repeatedly failed medical management of obesity. Three months after undergoing gastric bypass surgery, patients were sent a survey based on the Impact of Weight on Quality of Life-Lite instrument. The survey results demonstrated marked improvement in overall quality of life and physical function in this population, as well as the ability to decrease or discontinue medications for obesity-related comorbid conditions.

Assessment and management of the obese adult female: a clinical update for providers

Obesity is epidemic in the United States, affecting 61% of adults and 14% of children. Today's health care providers should recognize obesity as a chronic disease and offer up-to-date information and management. Treatment options currently available are diet and behavior modification, medications, and surgical procedures. Implications for clinical practice include recognition of the problems associated with obesity, education of current patients as well as young women who may become patients, and appropriate diagnosis and management or referral.

Obesity is not a contraindication to laparoscopic Nissen fundoplication

Obesity has been shown to be a significant predisposing factor for gastroesophageal reflux disease (GERD). However, obesity is also thought to be a contraindication to antireflux surgery. This study was undertaken to determine if clinical outcomes after laparoscopic Nissen fundoplications are influenced by preoperative body mass index (BMI). From a prospective database of patients undergoing treatment for GERD, 257 consecutive patients undergoing laparoscopic Nissen fundoplication were studied. Patients were stratified by preoperative BMI: normal (<25), overweight (25-30), and obese (>30). Clinical outcomes were scored by patients with a Likert scale. Overweight and obese patients had more severe preoperative reflux, although symptom scores for reflux and dysphagia were similar among all weight categories. There was a trend toward longer operative times for obese patients. Mean follow-up was 26+/-23.9 months. Mean heartburn and dysphagia symptom scores improved for patients of all BMI categories (P<0.001). Postoperative symptom scores and clinical success rates did not differ among BMI categories. Most patients undergoing laparoscopic Nissen fundoplication are overweight or obese with moderate dysphagia and severe acid reflux. Clinical outcomes after laparoscopic Nissen fundoplication did not differ among patients stratified by preoperative BMI. Obesity is not a contraindication to laparoscopic Nissen fundoplication.

Assessing quality of life in gastric bypass clients

Obesity is currently an epidemic in the United States. Gastric bypass surgery has been a topic of increased interest in the last two decades. Some hospitals started intestinal bypass surgeries in the late 1960s. Gastric bypass has been in the media in the last couple of years because certain popular magazines have reported a variety of actresses obtaining resectional gastric bypass (RGB) surgery. However, little long-term research (greater than 5 years) has been done with a view of quality of life issues surrounding gastric bypass. This article explores the long-term effects of obesity and RGB surgery. The barriers to obesity and quality of life are also investigated in this review.

A comparison of laparoscopic adjustable gastric banding in adolescents and adults

BACKGROUND

Laparoscopic adjustable gastric banding (AGB) induces effective weight loss in adults, but its efficacy in adolescents has yet to be determined.

METHODS

Since 1996, data have been collected prospectively on all patients undergoing laparoscopic AGB procedures performed at our hospital by a single surgeon (G.F.). Patients <20 years old at surgery (adolescents) were compared with- patients >20 years old (adults) who were matched for sex and body mass index (BMI).

RESULTS

Seventeen adolescents with a median age of 17 years (range, 12-19) and a BMI of 42.2 kg/m2 (range, 30.3-70.5) were compared to 17 adults with a median age of 41 years (range, 23-70) and a BMI of 41.8 kg/m2 (range, 30.1-71.5). There were no significant differences between the adolescents and the adults in complications or weight loss. The BMI dropped to 30.1 kg/m2 (range, 22.6-39.4) in adolescents and 33.1 kg/m2 (range, 28.4-41.3) in adults at 2-month follow-up.

CONCLUSION

Laparoscopic AGB is as effective in adolescents as it is in adults.

Gastrointestinal symptoms are more intense in morbidly obese patients

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass is an effective treatment for morbid obesity. However, little information is available on gastrointestinal (GI) symptomatology in this population. This study compares GI symptoms in morbidly obese patients to that of control subjects.

METHODS

A previously validated, 19-point GI symptom questionnaire was administered prospectively to each patient seen for surgical consultation for morbid obesity. The symptoms were then grouped into 6 clusters as follows: (1) abdominal pain, (2) irritable bowel, (3) GERD, (4) reflux, (5) sleep disturbance, (6) dysphagia. The result of each cluster of symptoms expressed as mean +/- standard deviation of obese versus control is compared using student's t-test with significance p = 0.05.

RESULTS

Forty-three patients (40 female, 3 male) age 37.3 +/- 8.6 with BMI 47.8 +/- 4.9, and 36 healthy control subjects (23 female, 13 male), age 39.8 +/- 11.2, completed the questionnaire. Results of each cluster for morbid obese vs control subjects are expressed as mean +/- standard deviation: Abdominal pain 25.3 +/- 18.0 vs 12.1 +/- 11.4, p = 0.0002; irritable bowel 23.0 +/- 14.8 vs 15.6 +/- 13.3, p = 0.02; GERD 40.3 +/- 18.9 vs 22.3 +/- 16.1, p = 0.0001; reflux 29.9 +/- 19.0 vs 11.8 +/- 13.4, p = 0.0001; sleep disturbance 50.6 +/- 28.9 vs 32.9 +/- 26.8, p = 0.006; dysphagia 10.9 +/- 15.6 vs 7.2 +/- 10.6, p = NS.

CONCLUSIONS

Morbidly obese patients experience more intense GI symptoms than normal subjects, whereas dysphagia is equivalent to normal subjects. These data may be important in counseling patients and understanding that their complaints are legitimate. Follow-up in the postoperative period is needed to determine if these symptoms are improved with an operation.

Management of obesity as a chronic disease: nonpharmacologic, pharmacologic, and surgical options

The successful management of obesity requires a long-term approach that is tailored to an individual's lifestyle and needs. Initial treatment should focus on lifestyle modifications-dietary interventions and increased physical activity-with behavioral modification strategies used adjunctively. Several antiobesity drugs are approved by the Food and Drug Administration for use in obese patients, as well as in overweight individuals with at least one obesity-related comorbidity. Most are approved only for short-term weight loss, but sibutramine and orlistat are approved for long-term weight loss and maintenance. In addition to weight reduction, in clinical trials these drugs provided beneficial actions on several cardiovascular risk factors. Several other drugs currently approved for other uses show promise in their ability to cause weight loss. Surgical options should be reserved for severely obese patients with significant medical comorbidities or physical conditions.

Is Bariatric Surgery Safe in Academic Centers?

Contemporary outcomes of bariatric surgery are not well defined. Our aim was to document the outcomes of bariatric surgery on the basis of surgeon caseload and affiliation. We analyzed prospectively collected Florida-wide hospital discharge data. Forty-four surgeons undertook bariatric surgery in 933 patients during 1999. The ten surgeons who averaged more than two operations/month undertook 764 operations; 162 (17%) were done by academic surgeons. Complications [14% vs 7% ( P = 0.008, chi-square)], length of stay (5 ± 0.7 vs 4 ± 0.1 days), and hospital charges (in thousands) ($31 ± 4.0 vs $24 ± 0.4) were greater in academic than in community-based centers ( P < 0.05, Wilcoxon rank-sum). However, 36 per cent of patients operated upon by academic surgeons had a high Severity Index compared with only 16 per cent of patients operated upon by community-based surgeons ( P < 0.001, chi-square). In high-risk patients complications (40% vs 46%), length of stay (7 ± 1.0 vs 6 ± 0.4 days), and hospital charges (in thousands) ($42 ±6 vs $35 ± 2) were similar between academic and community-based surgeons. We conclude that outcomes of bariatric surgery in high-risk patients are similar among academic and community-based surgeons. Academic surgeons undertake bariatric surgery in high-risk patients more frequently than community-based surgeons, which underlies their increased complication rate. These prospectively collected data reflect surgical outcomes more accurately than clinical series and will impact our practice of bariatric surgery.