Surgery for obesity

SAFETY AND EFFECTIVENESS OF SINGLE ANASTOMOSIS DUODENAL SWITCH PROCEDURE: PRELIMINARY RESULT FROM A SINGLE INSTITUTION

Background

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) was introduced into bariatric surgery by Sanchez-Pernaute et al. as an advancement of the biliopancreatic diversion with duodenal switch.

Aim

To evaluate the SADI-S procedure with regard to weight loss, comorbidity resolution, and complication rate in the super obese population.

Methods

A retrospective chart review was performed on initial 72 patients who underwent laparoscopic or robot-assisted laparoscopic SADI-S between December 17th, 2013 and July 29th, 2015.

Results

A total of 48 female and 21 male patients were included with a mean age of 42.4±10.0 years (range, 22-67). The mean body mass index (BMI) at the time of procedure was 58.4±8.3 kg/m2 (range, 42.3-91.8). Mean length of hospital stay was 4.3±2.6 days (range, 3-24). Thirty-day readmission rate was 4.3% (n=3), due to tachycardia (n=1), deep venous thrombosis (n=1), and viral gastroenteritis (n=1). Thirty-day reoperation rate was 5.8% (n=4) for perforation of the small bowel (n=1), leakage (n=1), duodenal stump leakage (n=1), and diagnostic laparoscopy (n=1). Percentage of excess weight loss (%EWL) was 28.5±8.8 % (range, 13.3-45.0) at three months (n=28), 41.7±11.1 % (range, 19.6-69.6) at six months (n=50), and 61.6±12.0 % (range, 40.1-91.2) at 12 months (n=23) after the procedure. A total of 18 patients (26.1%) presented with type II diabetes mellitus at the time of surgery. Of these patients, 9 (50.0%) had their diabetes resolved, and six (33.3%) had it improved by 6-12 months after SADI-S.

Conclusions

SADI-S is a feasible operation with a promising weight loss and diabetes resolution in the super-obese population.

Metabolic changes induced by the biliopancreatic diversion in diet-induced obesity in male rats: the contributions of sleeve gastrectomy and duodenal switch

The mechanisms underlying the body weight and fat loss after the biliopancreatic diversion with duodenal switch (BPD/DS) remain to be fully delineated. The aim of this study was to examine the contributions of the two main components of BPD/DS, namely sleeve gastrectomy (SG) and duodenal switch (DS), on energy balance changes in rats rendered obese with a high-fat (HF) diet. Three different bariatric procedures (BPD/DS, SG, and DS) and three sham surgeries were performed in male Wistar rats. Sham-operated animals fed HF were either fed ad libitum (Sham HF) or pair weighed (Sham HF PW) by food restriction to the BPD/DS rats. A group of sham-operated rats was kept on standard chow and served as normal diet control (Sham Chow). All three bariatric surgeries resulted in a transient reduction in food intake. SG per se induced a delay in body weight gain. BPD/DS and DS led to a noticeable gut malabsorption and a reduction in body weight and fat gains along with significant elevations in plasma levels of glucagon-like peptide-1(7-36) and peptide YY. BPD/DS and DS elevated energy expenditure above that of Sham HF PW during the dark phase. However, they reduced the volume, oxidative metabolism, and expression of thermogenic genes in interscapular brown adipose tissue. Altogether the results of this study suggest that the DS component of the BPD/DS, which led to a reduction in digestible energy intake while sustaining energy expenditure, plays a key role in the improvement in the metabolic profile led by BPD/DS in rats fed a HF diet.

Nutrition and metabolic support recommendations for the bariatric patient

Managing the metabolic needs of the patient with obesity is a challenge unto itself without the added demands of accounting for an altered gastrointestinal tract. Nevertheless, with about 200,000 bariatric procedures being performed annually in the United States, clinicians must be prepared to manage the critically ill bariatric surgery patient. This article reviews the recent literature relating to nutrient needs and metabolic support for the bariatric patient. Bariatric patients are at risk for several micronutrient deficiencies, including vitamins D and B₁₂, calcium, and iron; some bariatric procedures affect macronutrient needs as well. Literature on nutrition support guidelines for the bariatric population is limited. However, with an understanding of the anatomical and physiological effects of bariatric surgery, recent guidelines for critically ill patients with obesity can be applied to the bariatric surgery population. The unique needs of the bariatric population, such as susceptibility to micronutrient deficiencies and specialized access routes, must be considered to provide safe and efficacious nutrition support. Further research is necessary to develop specific nutrition support recommendations for the bariatric population.

Surgical weight loss: impact on energy expenditure

Diet-induced weight loss is often limited in its magnitude and often of short duration, followed by weight regain. On the contrary, bariatric surgery now commonly used in the treatment of severe obesity favors large and sustained weight loss, with resolution or improvement of most obesity-associated comorbidities. The mechanisms of sustained weight loss are not well understood. Whether changes in the various components of energy expenditure favor weight maintenance after bariatric surgery is unclear. While the impact of diet-induced weight loss on energy expenditure has been widely studied and reviewed, the impact of bariatric surgery on total energy expenditure, resting energy expenditure, and diet-induced thermogenesis remains unclear. Here, we review data on energy expenditure after bariatric surgery from animal and human studies. Bariatric surgery results in decreased total energy expenditure, mainly due to reduced resting energy expenditure and explained by a decreased in both fat-free mass and fat mass. Limited data suggest increased diet-induced thermogenesis after gastric bypass, a surgery that results in gut anatomical changes and modified the digestion processes. Physical activity and sustained intakes of dietary protein may be the best strategies available to increase non-resting and then total energy expenditure, as well as to prevent the decline in lean mass and resting energy expenditure.

Increased postprandial energy expenditure may explain superior long term weight loss after Roux-en-Y gastric bypass compared to vertical banded gastroplasty

Background and Aims

Gastric bypass results in greater weight loss than Vertical banded gastroplasty (VBG), but the underlying mechanisms remain unclear. In addition to effects on energy intake the two bariatric techniques may differentially influence energy expenditure (EE). Gastric bypass in rats increases postprandial EE enough to result in elevated EE over 24 hours. This study aimed to investigate alterations in postprandial EE after gastric bypass and VBG in humans.

Methods

Fourteen women from a randomized clinical trial between gastric bypass (n = 7) and VBG (n = 7) were included. Nine years postoperatively and at weight stability patients were assessed for body composition and calorie intake. EE was measured using indirect calorimetry in a respiratory chamber over 24 hours and focused on the periods surrounding meals and sleep. Blood samples were analysed for postprandial gut hormone responses.

Results

Groups did not differ regarding body composition or food intake either preoperatively or at study visit. Gastric bypass patients had higher EE postprandially (p = 0.018) and over 24 hours (p = 0.048) compared to VBG patients. Postprandial peptide YY (PYY) and glucagon like peptide 1 (GLP-1) levels were higher after gastric bypass (both p<0.001).

Conclusions

Gastric bypass patients have greater meal induced EE and total 24 hours EE compared to VBG patients when assessed 9 years postoperatively. Postprandial satiety gut hormone responses were exaggerated after gastric bypass compared to VBG. Long-term weight loss maintenance may require significant changes in several physiological mechanisms which will be important to understand if non-surgical approaches are to mimic the effects of bariatric surgery.

Increased energy expenditure in gastric bypass rats is not caused by activated brown adipose tissue

OBJECTIVE

To investigate whether gastric bypass induces a higher activity of brown adipose tissue and greater levels of the brown adipose tissue-specific protein uncoupling protein-1 (UCP-1) in rats.

METHODS

Gastric bypass rats and sham-operated controls (each n = 8) underwent whole body (1)H-MR spectroscopy for analysis of body composition and (18)F-fluorodeoxyglucose positron emission tomography combined with computed tomography ((18)F-FDG PET/CT) imaging for measurement of the metabolic activity of brown adipose tissue. Brown adipose tissue was harvested and weighed, and UCP-1 mRNA content was measured by Northern Blot technique.

RESULTS

Gastric bypass rats had a significantly lower percentage of whole body adipose tissue mass compared to sham-operated rats (p = 0.001). There was no difference in brown adipose tissue activity between the two groups (standardised uptake value sham 2.81 ± 0.58 vs. bypass 2.56 ± 0.46 ; p = 0.73). Furthermore, there was no difference in the UCP-1 mRNA content of brown adipose tissue between the two groups (sham 49.5 ± 13.2 vs. bypass 43.7 ± 13.1; p = 0.77).

CONCLUSION

Gastric bypass does not increase the activity of brown adipose tissue in rats suggesting that other mechanisms are involved to explain the increased energy expenditure after bypass surgery. Our results cannot justify the radiation dose of (18)F-FDG PET/CT studies in humans to determine potential changes in brown adipose tissue after gastric bypass surgery.

Gastrointestinal hormones, energy balance and bariatric surgery

Despite increasing understanding of the changes in gastrointestinal and central neuroendocrine signaling following gastric bypass surgery (GBP) in morbidly obese patients, the mechanisms underlying weight loss and weight loss maintenance are not completely understood. Changes in energy expenditure are increasingly recognized as an important factor contributing to weight loss and metabolic effects in patients following GBP surgery. Experimental data regarding changes in energy balance following metabolic surgery in animal models suggest increased energy expenditure postoperatively as an important factor in the process of weight loss. However, the underlying neuroendocrine mechanisms are not well understood, and data regarding changes in energy expenditure in humans after GBP are inconsistent because of heterogenic patient populations and variable techniques. Nevertheless, a growing body of knowledge and understanding of the complex entero-neurohumoral interaction with its consequences in appetite, satiety and energy expenditure will help reveal the mechanisms of weight loss and weight loss maintenance following GBP surgery. Here we review how gastrointestinal hormones potentially regulate energy balance, and summarize current available experimental and clinical data on energy expenditure following obesity surgery.

Pharmacokinetic pilot study of the antiangiogenic activity of standardized platycodi radix

INTRODUCTION

Platycodi radix is a radish used in food, such as Korean kimchi, and has been shown to cause weight loss in rodents. Platycodin D is considered its active ingredient and has been shown to inhibit lipases. The authors hypothesized that platycodi radix and the platycodin D it contains inhibit angiogenesis; another mechanism for weight loss.

METHODS

This study tested platycodi radix extract, platycodin D, and an extract of platycodi radix standardized to platycodin D for their ability to inhibit angiogenesis in a human adipose tissue assay. This study treated five healthy volunteers, orally, with platycodi radix extract standardized to 414 mg of platycodin D. Three volunteers were treated under fasting conditions, one volunteer with a 400 kcal meal, and one volunteer treated with a placebo. Blood was drawn over 5 hours to compare serum inhibition of the human adipose tissue angiogenesis.

RESULTS

Platycodin radix extract, platycodin D, and platycodi radix extract standardized to platycodin D all inhibited angiogenesis. The three volunteers who consumed platycodi radix extract standardized to 414 mg of platycodin D had a 25.76% reduction in angiogenesis from baseline at 60 minutes (P<0.002), and had a statistically significant reduction in angiogenesis from 30 to 240 minutes (P<0.05 to P<0.002). The placebo decreased angiogenesis by 5.6% between 30 and 240 minutes, compared with 17.8% by the extract. The meal delayed absorption by approximately 3.5 hours.

CONCLUSION

Platycodi radix extract standardized to platycodin D inhibited angiogenesis in human volunteers, and paves the way for a dose-response study and a human clinical obesity trial.

Gastric bypass increases energy expenditure in rats

BACKGROUND & AIMS

Mechanisms underlying weight loss maintenance after gastric bypass are poorly understood. Our aim was to examine the effects of gastric bypass on energy expenditure in rats.

METHODS

Thirty diet-induced obese male Wistar rats underwent either gastric bypass (n = 14), sham-operation ad libitum fed (n = 8), or sham-operation body weight-matched (n = 8). Energy expenditure was measured in an open circuit calorimetry system.

RESULTS

Twenty-four-hour energy expenditure was increased after gastric bypass (4.50 +/- 0.04 kcal/kg/h) compared with sham-operated, ad libitum fed (4.29 +/- 0.08 kcal/kg/h) and sham-operated, body weight-matched controls (3.98 +/- 0.10 kcal/kg/h, P < .001). Gastric bypass rats showed higher energy expenditure during the light phase than sham-operated control groups (sham-operated, ad libitum fed: 3.63 +/- 0.04 kcal/kg/h vs sham-operated, body weight-matched: 3.42 +/- 0.05 kcal/kg/h vs bypass: 4.12 +/- 0.03 kcal/kg/h, P < .001). Diet-induced thermogenesis was elevated after gastric bypass compared with sham-operated, body weight-matched controls 3 hours after a test meal (0.41% +/- 1.9% vs 10.5% +/- 2.0%, respectively, P < .05). The small bowel of gastric bypass rats was 72.1% heavier because of hypertrophy compared with sham-operated, ad libitum fed rats (P < .0001).

CONCLUSIONS

Gastric bypass in rats prevented the decrease in energy expenditure after weight loss. Diet-induced thermogenesis was higher after gastric bypass compared with body weight-matched controls. Raised energy expenditure may be a mechanism explaining the physiologic basis of weight loss after gastric bypass.

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.

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.

Need for parenteral iron therapy after bariatric surgery

BACKGROUND

Malabsorptive bariatric procedures such as Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch expose the patient to malnutrition and commonly cause iron deficiency. The optimal replacement and monitoring method remain undetermined. To identify high-risk patients who might need intravenous iron supplementation after bariatric surgery, we evaluated bariatric surgery patients who received parenteral iron at a university hospital-affiliated hematology center.

METHODS

We performed a retrospective analysis and reviewed the records of 165 patients who had received parenteral iron from May 2004 to June 2007. Of the 165 patients, 42 bariatric surgery patients were identified. The type of bariatric procedure and menstrual status of the patients were compared.

RESULTS

The average patient age was 40 years. Of the 42 patients, 2 were men and 40 were women. Of the 40 women, 32 were premenopausal and 8 were postmenopausal. The patients in the biliopancreatic diversion/duodenal switch group had a significantly lower hemoglobin at presentation (P = .02), relatively lower ferritin levels, and required more additional parenteral iron treatment after the initial resolution of anemia (P = .001). The premenopausal women required earlier parenteral replacement (P = .008) and were at a greater risk of anemia-related hospitalization (P = .00033).

CONCLUSION

The available published studies lack any data regarding parenteral iron replacement needs after bariatric surgery. Our results have identified the need for long-term parenteral iron replacement therapy after malabsorptive bariatric procedures, especially in premenopausal women. Patients who do not respond to oral iron therapy should be referred early for parenteral iron replacement therapy to prevent anemia-related complications and to maintain patients' quality of life. Iron monitoring should continue indefinitely even after the initial repletion of iron stores and the resolution of anemia.

Laparoscopic gastric bypass with subtotal gastrectomy for a super-obese patient with Biermer anemia

Laparoscopic Roux-en-Y gastric bypass (RYGBP) is a common procedure for morbid obesity. After RYGBP, the bypassed stomach is unavailable for follow-up. Biermer anemia is an autoimmune atrophic gastritis inducing vitamin B12 deficiency and it is a risk factor for gastric carcinoma. A 41-year-old woman with a long history of morbid obesity presented with a BMI of 56 kg/m2. She had anemia (Hb 9.9 g/dL), and atrophic gastritis was found endoscopically. We performed a laparoscopic RYGBP with subtotal gastrectomy, to avoid the risk of gastric carcinoma in the bypassed stomach. The patient was discharged 9 days after the operation without complication. At 18 months follow-up, her BMI was 39 kg/m2 (50% excess weight loss). Laparoscopic RYGBP with subtotal gastrectomy is a safe treatment for morbid obesity, which should be considered for patients with a risk factor for gastric carcinoma.

Effect of location and speed of diagnosis on anastomotic leak outcomes in 3828 gastric bypass cases

INTRODUCTION

Leaks after Roux-en-Y gastric bypass are a major cause of mortality. This study attempts to define the relationship between the leak site, time from surgery to detection, and outcome.

METHODS

Retrospective review of 3,828 gastric bypass procedures.

RESULTS

Of the leaks (3.9% overall), 60/2,337 (2.6%) occurred after open gastric bypass, 57/1,080 (5.2%) after laparoscopic gastric bypass, and 33/411 (8.0%) after revisions. Overall leak-related mortality after Roux-en-Y gastric bypass was 0.6% (22/3,828). Mortality rate from gastrojejunostomy leaks (38 in the open gastric bypass, and 43 in the laparoscopic) was higher in the open group than the laparoscopic group (18.4 vs 2.3%, p = 0.015). Median time of detection for a gastrojejunostomy leak in the open group was longer than in the laparoscopic group (3 vs 1 days, Wilcoxon score p < 0.001). Jejunojejunostomy (JJ) leak was associated with a 40% mortality rate. Initial upper gastrointestinal series did not detect 9/10 jejunojejunostomy leaks. Median detection time was longer in the jejunojejunostomy leak group than the gastrojejunostomy leak group (4 vs 2 days, p = 0.037).

DISCUSSION

Leak mortality and time of detection was higher after open gastric bypass than laparoscopic gastric bypass. GBP patients with normal upper gastrointestinal (UGI) studies may harbor leaks, especially at the JJ or excluded stomach. Normal UGI findings should not delay therapy if clinical signs suggest a leak.

Electrical stimulation as treatment for obesity and diabetes

The prevalence of obesity is growing, is driving an increase in the prevalence of diabetes, and is creating a major public health crisis in the United States. Lifestyle and behavior therapy rarely give durable weight loss. There are few medications approved for the treatment of obesity. Those that exist are limited in efficacy and using them in combination does not result in greater weight loss. Surgical treatments for obesity are effective and give durable weight loss, but are accompanied by measurable morbidity and mortality. Several pacing approaches are being tried and are an outgrowth of pacing for gastroparesis. The Transcend(R) pacemaker blocks vagal efferents and delays gastric emptying, giving a 40% loss of excess body weight, if certain screening procedures are employed. The Tantulus pacemaker is still in development but increases antral muscular contractions and delays gastric emptying by stimulation during the absolute refractory period. Weight loss has been 30% of excess body weight, and glycohemoglobin decreased 1.6% in a trial of obese type 2 diabetes. Stimulation to the subdiaphragmatic sympathetics, vagal nerve stimulation with or without unilateral vagotomy, and intestinal pacing are other approaches that are still being evaluated preclinically. Clearly a safe, effective, and durable treatment for obesity is desperately needed. Electrical pacing of the gastrointestinal tract is promising therapeutically, and because pacemakers work through different mechanisms, combining pacemaker treatments may be possible. Rapid progress is being made in the field of electrical stimulation as a treatment for obesity and even greater progress can be expected in the foreseeable future.

Rimonabant for overweight or obesity

BACKGROUND

Worldwide, the prevalence of obesity and overweight in industrialized countries and in a substantial number of developing countries is increasing at an alarming rate. Rimonabant is a selective cannabinoid-1 receptor antagonist that has been investigated for its efficacy in reducing body weight and associated risk factors in obese people. Phase III trials are now under way to test the use of rimonabant for long-term weight-loss. Given the prevalence of overweight and obesity, it is important to establish the efficacy and safety of rimonabant.

OBJECTIVES

To assess the effects of rimonabant in overweight and obese people.

SEARCH STRATEGY

MEDLINE, EMBASE, The Cochrane Library, LILACS, databases of ongoing trials and reference lists were used to identify relevant trials. The last search was conducted in June 2006.

SELECTION CRITERIA

Randomised controlled trials comparing rimonabant with placebo or other weight loss interventions in overweight or obese adults.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed all potentially relevant citations for inclusion and methodological quality. The primary outcome measures were weight loss change, morbidity and adverse effects occurrence.

MAIN RESULTS

Four studies evaluating rimonabant 20 mg versus rimonabant 5 mg versus placebo in addition to a hypocaloric diet lasting at least one year were included. Compared with placebo, rimonabant 20 mg produced a 4.9 kg greater reduction in body weight in trials with one-year results. Improvements in waist circumference, high-density lipoprotein cholesterol, triglyceride levels and systolic and diastolic blood pressure were also seen. However, the results with rimonabant 5 mg demonstrated a weight reduction which was only 1.3 kg greater when compared with placebo. No clinically relevant effects on plasma lipids and blood pressure were found. Rimonabant 20 mg caused significant more adverse effects both of general and serious nature, especially of nervous system, psychiatric or gastro-intestinal origin. Attrition rates were approximately 40% at the end of one year.

AUTHORS' CONCLUSIONS

The use of rimonabant after one year produces modest weight loss of approximately 5%. Even modest amounts of weight loss may be potentially beneficial. The observed results should be interpreted with some caution, though, since the evaluated studies presented some deficiencies in methodological quality. Studies with longer follow-ups after the end of treatment and of more rigorous quality should be done before definitive recommendations can be made regarding the role of this new medication in the management of overweight or obese patients.

Water-Soluble Upper GI Based on Clinical Findings is Reliable to Detect Anastomotic Leaks after Laparoscopic Gastric Bypass

Anastomotic leak after laparoscopic Roux- en-Y gastric bypass (LGB) is a major complication that must be recognized and treated early for best results. There is controversy in the literature regarding the reliability of upper GI series (UGI) in diagnosing leaks. LGB was performed in patients meeting NIH criteria for the surgical treatment of morbid obesity. All leaks identified at the time of surgery were repaired with suture and retested. Drains were placed at the surgeon's discretion. Postoperatively, UGI was performed by an experienced radiologist if there was a clinical suspicion of leak. From September 2001 until October 2004, a total of 553 patients (age 40.4 ± 9.2 years, BMI 48.6 ± 7.2) underwent LGB at UAB. Seventy-eight per cent (431 of 553) of patients had no clinical evidence suggesting anastomotic leak and were managed expectantly. Twenty-two per cent (122 of 553) of patients met at least one inclusion criteria for leak and underwent UGI. Four of 122 patients (3.2%) had a leak, two from anastomosis and two from the perforation of the stapled end of the Roux limb. No patient returned to the operating room without a positive UGI. High clinical suspicion and selectively performed UGI based on clinical evidence is reliable in detecting leaks.

Do psychosocial variables predict weight loss or mental health after obesity surgery? A systematic review

OBJECTIVE

The objective of this study was to present a systematic review of psychological and psychosocial predictors of weight loss and mental health after bariatric surgery. This systematic review included all controlled and noncontrolled trials of the last 2 decades with either a retrospective or prospective design and a follow-up period of at least 1 year.

RESEARCH METHODS AND PROCEDURES

The relevant literature was identified by a search of computerized databases. All articles published in English and German between 1980 and 2002 were reviewed.

RESULTS

Using the above inclusion/exclusion criteria, 29 articles were identified focusing on psychosocial predictors of weight loss and mental health after obesity surgery.

DISCUSSION

Personality traits have no predictive value for the postoperative course of weight or mental state. Apart from serious psychiatric disorders including personality disorders, psychiatric comorbidity seems to be of more predictive value for mental and physical well-being as two essential aspects of quality of life than for weight loss postsurgery. However, depressive and anxiety symptoms as correlates of psychological stress with regard to obesity seem to be positive predictors of weight loss postsurgery. The severity of the symptoms or the disorder is more relevant for the outcome of obesity surgery than the specificity of the symptoms. It is also not solely the consumption of distinct "forbidden" foods, such as sweets or soft drinks, but rather a general hypercaloric eating behavior, either as an expression of the patient's inadequate compliance or a dysregulation in energy balance, which is associated with a poor weight loss postsurgery.

The state of the art in bariatric surgery for weight loss in the morbidly obese patient

Bariatric surgery is a safe and effective method for achieving durable weight loss for patients with morbid obesity. Gastric restrictive procedures include vertical banded gastroplasty and gastric banding. Malabsorptive procedures include long-limb gastric bypass, biliopancreatic diversion, and biliopancreatic diversion with duodenal switch. The gastric bypass has features of both restriction and malabsorption. The laparoscopic approach to bariatric surgery has substantially improved postoperative recovery. Careful patient selection and preoperative work-up are extremely important. A number of medical comorbidities are improved after surgically-induced weight loss.

Long-term pharmacotherapy for obesity and overweight

BACKGROUND

Worldwide prevalence rates of obesity and overweight are rising and safe and effective treatment strategies are urgently needed. A number of anti-obesity agents have been studied in short-term clinical trials, but long-term efficacy and safety need to be established.

OBJECTIVES

To assess/compare the effects and safety of approved anti-obesity medications in clinical trials of at least one-year duration.

SEARCH STRATEGY

MEDLINE, EMBASE, the Cochrane Controlled Trials Register, the Current Science Meta-register of Controlled Trials, and reference lists of original studies and reviews were searched. Date of last search was December 2002. Drug manufacturers and two obesity experts were contacted in to detect unpublished trials. No language restrictions were imposed.

SELECTION CRITERIA

Double-blind, randomised controlled weight loss and weight maintenance trials of approved anti-obesity agents that 1) enrolled adult overweight or obese patients, 2) included a placebo control group or compared two or more anti-obesity drugs 3) used an intention-to-treat analysis, and 4) had a minimum follow-up period of one year. Abstracts and pseudo-randomised trials were not included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed all potentially relevant citations for inclusion and methodological quality. The primary outcome measure was weight loss.

MAIN RESULTS

Of the eight anti-obesity agents investigated, only orlistat and sibutramine trials met inclusion criteria. Eleven orlistat weight loss studies (four of which reported a second year weight maintenance phase) and five sibutramine studies (three weight loss and two weight maintenance trials) were included. Attrition rates averaged 33% during the weight loss phase of orlistat trials and 43% in sibutramine studies. All patients received lifestyle modification as a co-intervention. Compared to placebo, orlistat-treated patients lost 2.7 kg (95% CI: 2.3 kg to 3.1 kg) or 2.9% (95% CI: 2.3 % to 3.4%) more weight and patients on sibutramine experienced 4.3 kg (95% CI: 3.6 kg to 4.9 kg) or 4.6% (95% CI: 3.8% to 5.4%) greater weight loss. The number of patients achieving ten percent or greater weight loss was 12% (95% CI: 8% to 16%) higher with orlistat and 15% (95% CI: 4% to 27%) higher with sibutramine therapy. Weight loss maintenance results were similar. Orlistat caused gastrointestinal side effects and sibutramine was associated with small increases in blood pressure and pulse rate.

REVIEWERS' CONCLUSIONS

Studies evaluating the long-term efficacy of anti-obesity agents are limited to orlistat and sibutramine. Both drugs appear modestly effective in promoting weight loss; however, interpretation is limited by high attrition rates. Longer and more methodologically rigorous studies of anti-obesity drugs that are powered to examine endpoints such as mortality and cardiovascular morbidity are required to fully evaluate any potential benefit of such agents.

Management of the bariatric surgery patient

Morbid obesity has reached epidemic proportions in the United States. Unfortunately, medical interventions have been largely ineffective in this growing population. Currently bariatric surgery is the most effective intervention in managing morbid obesity and its comorbidities. As more patients become eligible for and pursue weight reduction surgery, it becomes important for the clinician to possess a thorough understanding of the different procedures available and the management of patients before, during, and after these surgeries. Significant weight loss and improvement in weight-related comorbidities are possible, with the best results available to the well-informed patient whose care is provided by a dedicated multidisciplinary team.

Clinical predictors of leak after laparoscopic Roux-en-Y gastric bypass for morbid obesity

BACKGROUND

Gastrointestinal leak is a complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). Contrast studies may underdiagnose leaks, forcing surgeons to rely solely on clinical data. This study was designed to evaluate various clinical signs for detecting leakage after LRYGB.

METHODS

We retrospectively reviewed 210 consecutive patients who underwent LRYGB between April 1999 and September 2001. There were nine documented leaks (4.3%). Clinical signs between patients with leaks (group 1) and those without leaks (group 2) were compared using univariate and multivariate logistic regression analysis.

RESULTS

Evidence of respiratory distress and a heart rate exceeding 120 beats per min were the two most sensitive indicators of gastrointestinal leak. Routine upper gastrointestinal contrast imaging detected only two of nine leaks (22%).

CONCLUSION

Leak after LRYGB may be difficult to detect. Evidence of respiratory distress and tachycardia exceeding 120 beats per min may be the most useful clinical indicators of leak after laparoscopic Roux-en-Y gastric bypass.

Long-term pharmacotherapy for obesity and overweight

BACKGROUND

Worldwide prevalence rates of obesity and overweight are rising and safe and effective treatment strategies are urgently needed. A number of anti-obesity agents have been studied in short-term clinical trials, but long-term efficacy and safety need to be established.

OBJECTIVES

To assess/compare the effects and safety of approved anti-obesity medications in clinical trials of at least one-year duration.

SEARCH STRATEGY

MEDLINE, EMBASE, the Cochrane Controlled Trials Register, the Current Science Meta-register of Controlled Trials, and reference lists of original studies and reviews were searched. Date of last search was December 2002. Drug manufacturers and two obesity experts were contacted in to detect unpublished trials. No language restrictions were imposed.

SELECTION CRITERIA

Double-blind, randomised controlled weight loss and weight maintenance trials of approved anti-obesity agents that 1) enrolled adult overweight or obese patients, 2) included a placebo control group or compared two or more anti-obesity drugs 3) used an intention-to-treat analysis, and 4) had a minimum follow-up period of one year. Abstracts and pseudo-randomised trials were not included.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed all potentially relevant citations for inclusion and methodological quality. The primary outcome measure was weight loss.

MAIN RESULTS

Of the eight anti-obesity agents investigated, only orlistat and sibutramine trials met inclusion criteria. Eleven orlistat weight loss studies (four of which reported a second year weight maintenance phase) and five sibutramine studies (three weight loss and two weight maintenance trials) were included. Attrition rates averaged 33% during the weight loss phase of orlistat trials and 43% in sibutramine studies. All patients received lifestyle modification as a co-intervention. Compared to placebo, orlistat-treated patients lost 2.7 kg (95% CI: 2.3 kg to 3.1 kg) or 2.9% (95% CI: 2.3 % to 3.4%) more weight and patients on sibutramine experienced 4.3 kg (95% CI: 3.6 kg to 4.9 kg) or 4.6% (95% CI: 3.8% to 5.4%) greater weight loss. The number of patients achieving ten percent or greater weight loss was 12% (95% CI: 8% to 16%) higher with orlistat and 15% (95% CI: 4% to 27%) higher with sibutramine therapy. Weight loss maintenance results were similar. Orlistat caused gastrointestinal side effects and sibutramine was associated with small increases in blood pressure and pulse rate.

REVIEWER'S CONCLUSIONS

Studies evaluating the long-term efficacy of anti-obesity agents are limited to orlistat and sibutramine. Both drugs appear modestly effective in promoting weight loss; however, interpretation is limited by high attrition rates. Longer and more methodologically rigorous studies of anti-obesity drugs that are powered to examine endpoints such as mortality and cardiovascular morbidity are required to fully evaluate any potential benefit of such agents.

American College of Preventive Medicine Practice Policy statement. Weight management counseling of overweight adults

On the basis of a review of the current literature and recommendations, the American College of Preventive Medicine presents a practice policy statement on weight management counseling of overweight adults.

Surgical treatment of morbid obesity

The prevalence of obesity is increasing rapidly, and it is a major health problem, especially in Western countries. Bariatric surgery causes significant and permanent weight loss and improves the quality of life. It ameliorates or eliminates most of the obesity-related comorbidities. Isolated gastric restriction procedures are technically easy to perform, the morbidity and mortality are low, but the weight loss is unsatisfactory in patients who ingest high-energy food. Combined gastric restriction with gastric bypass or intestinal malabsorption procedures cause greater weight loss, but more nutritional complications.

New developments in obesity

Obesity is an important health problem. Worldwide epidemiological data show that its frequency is rising steeply, probably because of a reduction in physical activity and bad eating habits. Health risks are most prominent in the central type of obesity, due to the relatively increased lipolytic activity, which leads to a series of events. The overall results of treatment are not satisfactory. Drugs, such as orlistat, fluoxetine, and ephedrine/caffeine, may be useful. The first results with leptin treatment are encouraging, but not yet optimal. Research on various neuropeptides and beta3-agonists is promising. Prevention of obesity is extremely important but difficult.

Depressive disorders as psychiatric complications after obesity surgery

Three case reports of morbidly obese patients (two women and a man) who underwent vertical banded gastroplasty and who subsequently fell into depression, are presented here. The psychiatric diagnosis according to DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised), the eating pattern before obesity surgery, the past history of mental disorder, social adaptation before surgery, psychological gain from their obese state, and the presence of unrealistic expectations of obesity surgery were investigated. Case 1 was diagnosed postoperatively as having a major depressive episode without a personality disorder. Case 2 was diagnosed post-operatively as having a major depressive episode. Case 3 had a depressive disorder not otherwise specified. Cases 2 and 3 had a social phobia with comorbidity of personality disorders. Binge eating disorder was confirmed in all patients before obesity surgery. There were differences between case 1 and cases 2 and 3 based on the presence of personality disorder and the time of onset of depression. When some psychiatric characteristics are confirmed in obese patients, obesity surgery should be undertaken more prudently because the patients may manifest depression postoperatively. The pre-operative psychiatric assessment is essential for a decision on indication of obesity surgery.