Randomized trial of diet and gastroplasty compared with diet alone in morbid obesity

Benefits of dexmedetomidine on postoperative analgesia after bariatric surgery: a systematic review and meta-analysis

INTRODUCTION

Anesthetic management of morbidly obese patients is challenging, particularly in those undergoing bariatric surgery. Dexmedetomidine is a α2-adrenergic receptor agonist that is increasingly used in the perioperative setting for its beneficial properties including sedation, anxiolysis, analgesia with opioid-sparing effects, and minimal impact on respiration. The objective of this study was to evaluate the effect of dexmedetomidine on postoperative analgesia and recovery-related outcomes among patients undergoing bariatric surgery.

EVIDENCE ACQUISITION

We conducted a systematic review and meta-analysis of MEDLINE, EMBASE, and CENTRAL databases from conception to September 2021 for randomized controlled trials (RCTs) using dexmedetomidine in bariatric patients on postoperative outcomes. Outcomes were pooled using random effects model and presented as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CI).

EVIDENCE SYNTHESIS

In total, 20 RCTs with 665 patients in the dexmedetomidine group and 671 patients in the control groups were included. Among RCTs, the dexmedetomidine group had significantly lower opioid usage at 24-hours postoperatively (MD: -5.14, 95%CI: -10.18 to -0.10; moderate certainty), reduced pain scores on a 10-point scale at PACU arrival (MD: -1.69, 95%CI: -2.79 to -0.59; moderate certainty) and 6 hours postoperatively (MD: -1.82, 95%CI: - 3.00 to -0.64; low certainty), and fewer instances of nausea (RR: 0.59, 95%CI: 0.45 to 0.75; moderate certainty) and vomiting (RR: 0.25, 95%CI: 0.15 to 0.43; moderate certainty), compared to control groups.

CONCLUSIONS

Dexmedetomidine is an efficacious anesthesia adjunct in patients undergoing bariatric surgery. These benefits of dexmedetomidine may be considered in the multi-modal analgesic management and enhanced recovery pathways in this high-risk population.

A Meal Replacement Program for the Treatment of Obesity: A Cost-Effectiveness Analysis from the Swiss Payer's Perspective

BACKGROUND

Obesity is a disease associated with high direct medical costs and high indirect costs resulting from productivity loss. The high prevalence of obesity generates the need for payers to identify cost-effective weight loss approaches. Among various weight management techniques, the OPTI (Optifast®) program is a clinically recognised total meal replacement diet that can lead to significant weight loss and reduction in complications. This study's objective is to assess OPTI program's cost-effectiveness in Switzerland in comparison to "no intervention" and pharmacotherapy.

METHODS

An event-driven decision-analytic model was used to estimate the payer's cost savings through the reimbursement of OPTI program over a 1-year period as well as a lifetime in Switzerland. The analysis was performed on a broad population of people with obesity with a body mass index (BMI) higher than 30 kg/m2 following the OPTI program vs two comparators (liraglutide and "no intervention"). The model incorporated a higher risk of complications due to an increased BMI and their related healthcare costs. Data sources included published literature, clinical trials, official Swiss price/tariff lists and national population statistics. The primary perspective was that of a Swiss payer. Scenario analyses - for example, for patients with existing complications (such as myocardial infarction, stroke, type 2 diabetes mellitus) or severe obesity - were conducted to test the robustness of the results.

RESULTS

The OPTI program results in cost savings of CHF 20,886 (€ 18,724) and CHF 15,382 (€ 13,790) per person compared with "no intervention" and liraglutide 3 mg, respectively. In addition, OPTI program led to 1.133 and 0.734 quality-adjusted life years (QALYs) gained respectively against its comparators. Scenario analyses showed similar outcomes with cost savings and QALYs gained.

CONCLUSION

OPTI program is a dominant strategy compared to "no intervention" and liraglutide 3 mg as it leads to both cost savings and QALY gain. Therefore, reimbursing the OPTI program for patients with obesity would be cost-effective for Swiss payers.

Application of BAROS' questionnaire in obese patients undergoing bariatric surgery with 2 years of evolution

BACKGROUND:

-In recent decades, the high prevalence of obesity in the general population has brought serious concerns in terms of public health. Contrarily to conventional treatment involving dieting and physical exercising, often ineffective in generating long term results, bariatric opera-tions have been an effective method for sustained weight loss in morbidly obese individuals. The Bariatric Analysis and Reporting Outcome System (BAROS) is an objective and recognized system in the overall evaluation of results after bariatric surgery.

OBJECTIVE

- To investigate results concerning a casuistic of morbidly obese patients undergoing bariatric surgery over a 2-year follow-up in terms of weight loss, related medical conditions, safety and changes in quality of life.

METHODS

- A total of 120 obese (17 male and 103 female) patients, who underwent bariatric surgery, were assessed and investigated using the BAROS system after a 2- year follow-up.

RESULTS

- Patients obtained a mean excess weight loss of 74.6 (±15.9) % and mean body mass index reduction of 15.6 (±4.4) Kg/m2. Pre-surgical comorbidities were present in 71 (59%) subjects and they were totally (86%) or partially (14%) resolved. Complications resulting specifically from the surgical procedure were observed in 4.2% of cases (two bowel obstructions requiring re-operation, and three stomal stenosis treated with endoscopic dilation). Sixteen subjects (13% of total number of patients) presented minor clinical complications managed through outpatient care. The final scores for the BAROS questionnaire showcased excellent to good results in 99% of cases (excellent 44%, very good 38%, good 23%, acceptable 1%).

CONCLUSION

- According to the BAROS questionnaire, bariatric surgery is a safe and effective method for managing obesity and associated clinical comorbidities, allowing for satisfactory results after a 2-year follow-up. Future studies should address other clinical and psychosocial variables that impact outcome as well as allow for longer follow-ups.

The Heterogeneity of Obesity: Fitting Treatments To Individuals - Republished Article

Body weight is regulated by a complex interaction of biological, behavioral, and cultural factors. The population as a whole is at risk for obesity because of increased intake of dietary fat, the consumption of calories in fewer meals per day, striking accessibility to palatable foods, and decreased physical activity. This risk may become a reality in individuals with certain biological predispositions (genetic tendency, low metabolic rate, increased fat cell number), specific eating patterns, and susceptibility to the extreme cultural pressure to be lean. These factors must be considered in establishing goals for treatment, which fall into medical and psychosocial categories. This includes defining a "reasonable" as opposed to "ideal" weight. A three-stage process is proposed for identifying the best treatment for an individual. This involves a classification decision, a stepped care decision, and then a matching decision. Criteria are provided for a comprehensive assessment of the overweight individual, and treatment options are reviewed for programs of varying intensity, cost, and risk.

Long-term effects of weight reduction on the severity of psoriasis in a cohort derived from a randomized trial: a prospective observational follow-up study

BACKGROUND

Weight reduction may reduce the severity of psoriasis, but little is known about the long-term effects.

OBJECTIVE

We aimed to investigate long-term effects of weight reduction in psoriasis.

DESIGN

We previously conducted a randomized trial (n = 60) involving patients with psoriasis who were allocated to a control group or a low-energy diet (LED) group. Here we followed the participants for an additional 48-wk period. In total, 56 patients with psoriasis [mean ± SD body mass index (in kg/m(2)): 34.4 ± 5.3] underwent a 64-wk weight-loss program consisting of an initial 16-wk randomized phase with an LED for 8 wk and 8 wk of normal food intake combined with 2 LED products/d, followed by a 48-wk period of weight maintenance with the latter diet. After the randomization phase, the control group received the same 8 + 8-wk LED intervention, and all patients were then followed for 48 wk while on the weight-loss maintenance diet. The main outcome was the Psoriasis Area and Severity Index (PASI), and secondary outcome was the Dermatology Life Quality Index (DLQI).

RESULTS

For the present study, 56 patients were eligible, 38 agreed to participate, and 32 completed. After the 16-wk LED-only period, the mean weight loss was -15.0 kg (95% CI: -16.6, -13.4 kg), and PASI and DLQI were reduced by -2.3 (95% CI: -3.1, -1.5) and -2.3 (95% CI: -3.2, -1.4), respectively. At week 64, the mean weight loss compared with baseline was -10.1 kg (95% CI: -12.0, -8.1 kg), and PASI and DLQI were maintained at -2.9 (95% CI: -3.9, -1.9) and -1.9 (95% CI: -3.0, -0.9), respectively.

CONCLUSION

Long-term weight loss in patients with psoriasis has long-lasting positive effects on the severity of psoriasis. This trial was registered at clinicaltrials.gov as NCT01137188.

Subcutaneous and segmental fat loss with and without supportive supplements in conjunction with a low-calorie high protein diet in healthy women

BACKGROUND

Weight loss benefits of multi-ingredient supplements in conjunction with a low-calorie, high-protein diet in young women are unknown. Therefore, the purpose of this study was to investigate the effects of a three-week low-calorie diet with and without supplementation on body composition.

METHODS

Thirty-seven recreationally-trained women (n = 37; age = 27.1 ± 4.2; height = 165.1 ± 6.4; weight = 68.5 ± 10.1; BMI = 25.1 ± 3.4) completed one of the following three-week interventions: no change in diet (CON); a high-protein, low-calorie diet supplemented with a thermogenic, conjugated linoleic acid (CLA), a protein gel, and a multi-vitamin (SUP); or the high-protein diet with isocaloric placebo supplements (PLA). Before and after the three-week intervention, body weight, %Fat via dual X-ray absorptiometry (DXA), segmental fat mass via DXA, %Fat via skinfolds, and skinfold thicknesses at seven sites were measured.

RESULTS

SUP and PLA significantly decreased body weight (SUP: PRE, 70.47 ± 8.01 kg to POST, 67.51 ± 8.10 kg; PLA: PRE, 67.88 ± 12.28 kg vs. POST, 66.38 ± 11.94 kg; p ≤ 0.05) with a greater (p ≤ 0.05) decrease in SUP than PLA or CON. SUP and PLA significantly decreased %Fat according to DXA (SUP: PRE, 34.98 ± 7.05% to POST, 32.99 ± 6.89%; PLA: PRE, 34.22 ± 6.36% vs. POST, 32.69 ± 5.84%; p ≤ 0.05), whereas only SUP significantly decreased %Fat according to skinfolds (SUP: PRE, 27.40 ± 4.09% to POST, 24.08 ± 4.31%; p ≤ 0.05). SUP significantly (p ≤ 0.05) decreased thicknesses at five skinfolds (chest, waist, hip, subscapular, and tricep) compared to PLA, but not at two skinfolds (axilla and thigh).

CONCLUSIONS

The addition of a thermogenic, CLA, protein, and a multi-vitamin to a three-week low-calorie diet improved weight loss, total fat loss and subcutaneous fat loss, compared to diet alone.

Tier 3 multidisciplinary medical weight management improves outcome of Roux-en-Y gastric bypass surgery

INTRODUCTION

In 2013 the Department of Health specified eligibility for bariatric surgery funded by the National Health Service. This included a mandatory specification that patients first complete a Tier 3 medical weight management programme. The clinical effectiveness of this recommendation has not been evaluated previously. Our bariatric centre has provided a Tier 3 programme six months prior to bariatric surgery since 2009. The aim of our retrospective study was to compare weight loss in two cohorts: Roux-en-Y gastric bypass only (RYGB only cohort) versus Tier 3 weight management followed by RYGB (Tier 3 cohort).

METHODS

A total of 110 patients were selected for the study: 66 in the RYGB only cohort and 44 in the Tier 3 cohort. Patients in both cohorts were matched for age, sex, preoperative body mass index and pre-existing co-morbidities. The principal variable was therefore whether they undertook the weight management programme prior to RYGB. Patients from both cohorts were followed up at 6 and 12 months to assess weight loss.

RESULTS

The mean weight loss at 6 months for the Tier 3 cohort was 31% (range: 18-69%, standard deviation [SD]: 0.10 percentage points) compared with 23% (range: 4-93%, SD: 0.12 percentage points) for the RYGB only cohort (p=0.0002). The mean weight loss at 12 months for the Tier 3 cohort was 34% (range: 17-51%, SD: 0.09 percentage points) compared with 27% (range: 14-48%, SD: 0.87 percentage points) in the RYGB only cohort (p=0.0037).

CONCLUSIONS

Our study revealed that in our matched cohorts, patients receiving Tier 3 specialist medical weight management input prior to RYGB lost significantly more weight at 6 and 12 months than RYGB only patients. This confirms the clinical efficacy of such a weight management programme prior to gastric bypass surgery and supports its inclusion in eligibility criteria for bariatric surgery.

Interdisciplinary European guidelines on metabolic and bariatric surgery

In 2012, an expert panel composed of presidents of each of the societies, the European Chapter of the International Federation for the Surgery of Obesity (IFSO-EC), and of the European Association for the Study of Obesity (EASO), as well as of the chair of EASO Obesity Management Task Force (EASO OMTF) and other key representatives from IFSO-EC and EASO, devoted the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery in advance of the 2013 European Congress on Obesity held in Liverpool. This meeting was prompted by the extraordinary advancement made in the field of metabolic and bariatric surgery during the past decade. It was agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced by focusing in particular on the evidence gathered in relation to the effects on diabetes and the changes in the recommendations of patient eligibility criteria. The expert panel allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.

Interdisciplinary European Guidelines on metabolic and bariatric surgery

In 2012, an outstanding expert panel derived from IFSO-EC (International Federation for the Surgery of Obesity-European Chapter) and EASO (European Association for the Study of Obesity), composed by key representatives of both Societies including past and present presidents together with EASO's OMTF (Obesity Management Task Force) chair, agreed to devote the joint Medico-Surgical Workshop of both institutions to the topic of metabolic surgery as a pre-satellite of the 2013 European Congress on Obesity (ECO) to be held in Liverpool given the extraordinarily advancement made specifically in this field during the past years. It was further agreed to revise and update the 2008 Interdisciplinary European Guidelines on Surgery of Severe Obesity produced in cooperation of both Societies by focusing in particular on the evidence gathered in relation to the effects on diabetes during this lustrum and the subsequent changes that have taken place in patient eligibility criteria. The expert panel composition allowed the coverage of key disciplines in the comprehensive management of obesity and obesity-associated diseases, aimed specifically at updating the clinical guidelines to reflect current knowledge, expertise and evidence-based data on metabolic and bariatric surgery.

Bariatric surgery: a systematic review and network meta-analysis of randomized trials

The clinical efficacy and safety of bariatric surgery trials were systematically reviewed. MEDLINE, EMBASE, CENTRAL were searched to February 2009. A basic PubCrawler alert was run until March 2010. Trial registries, HTA websites and systematic reviews were searched. Manufacturers were contacted. Randomized trials comparing bariatric surgeries and/or standard care were selected. Evidence-based items potentially indicating risk of bias were assessed. Network meta-analysis was performed using Bayesian techniques. Of 1838 citations, 31 RCTs involving 2619 patients (mean age 30-48 y; mean BMI levels 42-58 kg/m(2) ) met eligibility criteria. As compared with standard care, differences in BMI levels from baseline at year 1 (15 trials; 1103 participants) were as follows: jejunoileal bypass [MD: -11.4 kg/m(2) ], mini-gastric bypass [-11.3 kg/m(2) ], biliopancreatic diversion [-11.2 kg/m(2) ], sleeve gastrectomy [-10.1 kg/m(2) ], Roux-en-Y gastric bypass [-9.0 kg/m(2) ], horizontal gastroplasty [-5.0 kg/m(2) ], vertical banded gastroplasty [-6.4 kg/m(2) ], and adjustable gastric banding [-2.4 kg/m(2) ]. Bariatric surgery appears efficacious compared to standard care in reducing BMI. Weight losses are greatest with diversionary procedures, intermediate with diversionary/restrictive procedures, and lowest with those that are purely restrictive. Compared with Roux-en-Y gastric bypass, adjustable gastric banding has lower weight loss efficacy, but also leads to fewer serious adverse effects.

Study of the effects of transoral gastroplasty on insulin sensitivity and secretion in obese subjects

BACKGROUND AND AIMS

Transoral gastroplasty (TOGA) recently emerged as a new, feasible and relatively safe technique for the surgical treatment of obesity. However, so far there are no data on the effects on insulin sensitivity in the literature. Our aim is to evaluate the effect of TOGA on insulin sensitivity and secretion.

METHODS AND RESULTS

Nine glucose normo-tolerant obese subjects (age:41+/-6 years; BMI:42.49+/-1.03 kg/m(2)) were studied. Fat-free mass (FM) and fat mass (FM) were assessed by bioelectrical impedance; plasma glucose, insulin, and C-peptide were measured during an oral glucose tolerance test (OGTT) before and 3 months after the operation. Insulin sensitivity was calculated using the oral-glucose insulin-sensitivity index, and insulin secretion by C-peptide deconvolution. Three months after surgery, a significant (P=0.008) reduction of BMI to 35.65+/-0.65 kg/m(2), with a decrease of FM and FFM from 57.22+/-2.19 to 41.46+/-3.02 kg (P=0.008) and from 59.52+/-1.36 to 56.67+/-1.10 kg (P=0.048) respectively, was observed. Insulinemia was significantly reduced at fast and at 120 min after OGTT; in contrast, no significant change in glucose concentration was observed. Insulin sensitivity significantly increased (348.45+/-20.08 vs. 421.18+/-20.84 ml/min/m(2), P=0.038) and the incremental area of insulin secretion rate (total ISR) significantly decreased (from 235.05+/-27.50 to 124.77+/-14.50 nmol/min/m(2), P=0.021). Total ISR correlated with weight, BMI and FM (r=0.522, P=0.028; r=0.541, P=0.020; r=0.463, P=0.049, respectively). BMI represented the most powerful predictor of ISR decrease (R(2)=0.541, P=0.020).

CONCLUSION

Transoral gastroplasty allows a significant weight loss 3 months after the intervention as well as an amelioration of insulin sensitivity with subsequent reduction of the insulin secretion.

The relationship between QTc changes and nutrition during weight loss after gastroplasty

Electrocardiograms, serum electrolytes, plasma concentrations of pre-albumin and retinol-binding globulin, and dietary intakes were analyzed in 22 women during weight loss after gastroplasty surgery for morbid obesity. QT interval corrected for heart rate (QTc) was prolonged (greater than 0.44 sec) in 32% (95% confidence limits 14-55%) on one or more occasions. No clinical or electrocardiographic complications were seen. Occurrence of QTc prolongation was significantly (p less than 0.05) associated with protein intake below recommendation and with low plasma pre-albumin concentrations. QTc prolongation was not associated with mineral intake and occurred in spite of normal serum levels of calcium (uncorrected and albumin-corrected), magnesium, potassium and sodium. Because QTc prolongation may precede fatal arrhythmias, adequate protein intake is mandatory during weight reduction.

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.

Interdisciplinary European guidelines on surgery of severe obesity

In 2005, for the first time in European history, an extraordinary expert panel named BSCG (Bariatric Scientific Collaborative Group), was appointed through joint effort of the major European scientific societies which are active in the field of obesity management. Societies that constituted this panel were: IFSO - International Federation for the Surgery of Obesity, IFSO-EC - International Federation for the Surgery of Obesity - European Chapter, EASO - European Association for Study of Obesity, ECOG - European Childhood Obesity Group, together with the IOTF (International Obesity Task Force) which was represented during the completion process by its representative. The BSCG was composed not only of the top officers representing the respective scientific societies (four acting presidents, two past presidents, one honorary president, two executive directors), but was balanced with the presence of many other key opinion leaders in the field of obesity. The BSCG composition allowed the coverage of key disciplines in comprehensive obesity management, as well as reflecting European geographical and ethnic diversity. This joint BSCG expert panel convened several meetings which were entirely focused on guidelines creation, during the past 2 years. There was a specific effort to develop clinical guidelines, which will reflect current knowledge, expertise and evidence based data on morbid obesity treatment.

Safety, feasibility and weight loss after transoral gastroplasty: First human multicenter study

OBJECTIVE

To evaluate the safety and feasibility in human subjects of a new transoral restrictive procedure for the treatment of obesity.

METHODS

The protocol was approved by the institutional review boards (IRBs) of both centers involved, and all patients gave informed consent. Patients met established inclusion criteria for bariatric surgery. The TOGa system (Satiety Inc., Palo Alto, CA), a set of transoral endoscopically guided staplers, was used to create a stapled restrictive pouch along the lesser curve of the stomach. Patients were hospitalized overnight for observation and underwent barium upper gastrointestinal (UGI) the next morning. Post procedure, all patients were placed on a liquid diet for 1 month and asked to begin an exercise program. Follow-up was carried out at 1 week and 1, 3, 4, 5, and 6 months.

RESULTS

Twenty one patients were enrolled [17 female, age 43.7 (22-57) years, BMI 43.3 (35-53) kg/m(2)]. Device introduction was completed safely in all patients. There were no serious adverse events (AEs). The most commonly reported procedure or device related adverse events were vomiting, pain, nausea, and transient dysphagia. At 6 month endoscopy, all patients had persistent full or partial stapled sleeves. Gaps in the staple line were evident in 13 patients. Patients lost an average 17.6 pounds at 1 month, 24.5 pounds at three months, and 26.5 pounds at 6 months post-treatment [excess weight loss (EWL) of 16.2%, 22.6%, and 24.4%, respectively].

CONCLUSIONS

There is great interest in new procedures for morbid obesity that could offer lower morbidity than current options. Early experience with the TOGa procedure indicates that this transoral approach may be safe and feasible. Further experience with the device and technique should improve anatomic and functional outcomes in the future. Additional studies are underway.

Treating morbid obesity with laparoscopic adjustable gastric banding

BACKGROUND

Morbid obesity results in multiple comorbidities and an increased mortality rate. The National Institutes of Health has stated that surgery is the most effective long-term therapy; therefore, we evaluated a laparoscopically implantable adjustable gastric band.

METHODS

We reviewed 2 multicenter prospective, open-label, single-arm surgical trials--trial A (3 years) and trial B (1 year)--with ongoing safety follow-up. These trials were conducted in United States community and university hospitals (trial A = 8 sites and trial B = 12 sites). Trial A comprised 292 subjects (mean +/- SD preoperative weight: 133 kg +/- 24.4), and trial B comprised 193 subjects (129 kg +/- 20.8). Intervention included placement of a constrictive, adjustable band around the upper stomach to limit food intake and induce weight loss. Main outcome measures were the primary efficacy end point of weight loss. Secondary end-points were change in quality-of-life, safety parameters, and complications, including band slippage, reoperation, and device explantation.

RESULTS

In the 2 trials, 485 devices were implanted (92% laparoscopically), and no deaths occurred. Of the patients in trial A, 206 (70.5%) completed the 3-year follow-up, and 142 (73.6%) of patients in trial B completed the 1-year follow-up. Weight-loss results, using the last value carried forward, for all 292 patients in trial A and all 193 patients in trial B demonstrated a change in mean body mass index (kg/m2) +/- SD from 47.4 +/- 7.0 to 39.0 +/- 7.3 in trial A and from 46.7 +/- 7.8 to 38.4 +/- 7.6 in trial B subjects at 1 year (P < .001 for both trials A and B), with minimal further change at 3 years (39.0 +/- 8.5) in trial A subjects. The percentage of initial body weight lost at 1 year was 17.7% +/- 9.4% for trial A subjects and 18.2% +/- 8.9% for trial B subjects, whereas the 3-year total for trial A subjects was 18.3% +/- 13.1%. At 1 year, 76% of patients in trial A and 66% of patients in trial B had complications, mostly related to upper gastrointestinal symptoms. By 9 years after surgery, 33% (96 of 292) of trial A subjects had their devices explanted because of complications or inadequate weight loss.

CONCLUSIONS

These first-generation implantable adjustable gastric band results suggest that this is a viable bariatric surgery therapeutic option for the treatment of obesity.

Inter-disciplinary European guidelines on surgery of severe obesity

In 2005, for the first time in European history, an extraordinary Expert panel named 'The BSCG' (Bariatric Scientific Collaborative Group), was appointed through joint effort of the major European Scientific Societies which are active in the field of obesity management. Societies that constituted this panel were: IFSO - International Federation for the Surgery of Obesity, IFSO-EC - International Federation for the Surgery of Obesity - European Chapter, EASO - European Association for Study of Obesity, ECOG - European Childhood Obesity Group, together with the IOTF (International Obesity Task Force) which was represented during the completion process by its representative. The BSCG was composed not only of the top officers representing the respective Scientific Societies (four acting presidents, two past presidents, one honorary president, two executive directors), but was balanced with the presence of many other key opinion leaders in the field of obesity. The BSCG composition allowed the coverage of key disciplines in comprehensive obesity management, as well as reflecting European geographical and ethnic diversity. This joint BSCG expert panel convened several meetings which were entirely focused on guidelines creation, during the past two years. There was a specific effort to develop clinical guidelines, which will reflect current knowledge, expertise and evidence based data on morbid obesity treatment.

Dietary treatments of obesity

Dietary treatment of obesity is based on one or another of two premises: that the obese eat too much or that they eat the wrong things. The first is a tautology lacking explanatory power. The second is a meaningful and promising hypothesis but has yet to be effectively applied. At present, virtually all outpatient treatments of obesity, including behavior modification, are based on the first premise and consist of strategies for reducing the subject's caloric intake. Most such interventions produce short-term weight loss. Regain after the end of treatment remains the usual outcome. A survey of studies published in the period 1977-1986 and reporting on dietary or behavioral treatment of obesity reveals that the maximum percentage of body weight lost is, on average, 8.5 percent--no different from the value, 8.9%, in similar studies from 1966-1976, as reviewed by Wing and Jeffery. The principal determinant of success in such programs appears to be the intake weight of the subjects: the higher the intake weight, the more successful the intervention will appear to be. The goals and research methods of studies on dietary treatments for obesity are overdue for ethical as well as scientific reevaluation. The same may be said for the numerous programs providing such treatment outside the context of research.

Long-term outcome of bariatric surgery: an interim analysis

With the increasing number of bariatric surgical procedures being performed, outcome assessment is of even greater importance. Few randomized, controlled prospective trials have compared bariatric surgery to nonsurgical weight-loss treatments, and the quality of current outcome data is suboptimal. However, the available evidence suggests that bariatric surgery, and particularly gastric bypass, is the most effective weight-loss treatment for people with extreme (class III) obesity. In addition to reduced energy intake and to a lesser extent malabsorption, numerous other potential mechanisms related to bariatric surgery may play a role in promoting weight loss and improving comorbidities. After bariatric surgery, clinical improvement or resolution has been reported in 64% to 100% of patients with diabetes mellitus, 62% to 69% of patients with hypertension, 85% of patients with obstructive sleep apnea, 60% to 100% of patients with dyslipidemia, and up to 90% of patients with nonalcoholic fatty liver disease. A wide range of other weight-related conditions also appear to improve, and limited data suggest that overall mortality may decrease in patients undergoing bariatric surgery. Although not conclusive, evidence from available studies indicates that bariatric surgery is cost-effective. Further research with improved methodology is needed to define the mechanisms of action of bariatric surgery; to document its effect on long-term weight loss, comorbid conditions, and overall mortality; and to determine its cost-effectiveness.

The Implantable Gastric Stimulator for Obesity

OBJECTIVE

To evaluate the efficacy of a gastric stimulation procedure for the treatment of morbid obesity.

METHODS

All implantable gastric stimulator systems were implanted in a laparoscopic procedure. We focused on the results of the LOSS (Laparoscopic Obesity Stimulation Survey) study, which was a multicenter European survey of 16 hospitals. To date, 91 patients have undergone implantable gastric stimulator implantation in the LOSS study.

RESULTS

The patient population was comprised of 62 (68%) women and 29 (32%) men. The mean age was 41 years, mean weight was 116kg, and mean body mass index was 41 kg/m(2). All surgical procedures were successfully completed. There were no deaths, and no severe peri- or postoperative complications. The mean excess weight loss (EWL) was 20% at 12 months after surgery and about 25% at 2 years after implantation. Baroscreen-selected patients achieved a 31.4% EWL, which was significantly different to the EWL of those patients who were not selected by this screening (15% EWL) [p < 0.01].

CONCLUSION

Gastric pacing is a promising, minimally invasive, safe, and effective surgical method that results in very little impairment of the patient. Patient selection for gastric stimulation therapy seems to be an important determinant of treatment outcome.

Surgery for morbid obesity

BACKGROUND

Obesity is associated with increased morbidity and mortality. Surgery for morbid obesity is considered when other treatments have failed. A number of procedures are available, but the effects of these surgical procedures compared with medical management and with each other are uncertain.

OBJECTIVES

To assess the effects of surgery for morbid obesity.

SEARCH STRATEGY

Studies were obtained from computerized searches of multiple electronic bibliographic databases, supplemented with hand searches of selected journals and consultation with experts in obesity research. Date of the most recent searches: December 2004.

SELECTION CRITERIA

Randomised controlled trials comparing different surgical procedures, and randomised controlled trials and prospective cohort studies comparing surgery with non-surgical management for morbid 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 trials were included. Two randomised controlled trials and three prospective cohort studies compared surgery with non-surgical management, and 21 randomised controlled trials compared different surgical procedures. The quality of most of the trials was poor; just three trials had adequate allocation concealment. A meta-analysis was not possible due to differences in the surgical procedures performed, measures of weight change and length of follow-up. Compared with conventional management, surgery resulted in greater weight loss (21 kg weight loss at eight years versus weight gain), with improvements in quality of life and comorbidities. Some complications of surgery occurred, such as wound infection. Gastric bypass was associated with greater weight loss, better quality of life and fewer revisions, reoperations and/or conversions than gastroplasty, but had more side-effects. Greater weight loss and fewer side-effects and reoperations occurred with adjustable gastric banding than vertical banded gastroplasty, but laparoscopic vertical banded gastroplasty produced more patients with an excellent or good result and fewer late complications than laparoscopic adjustable silicone gastric banding. Vertical banded gastroplasty was associated with greater weight loss but more vomiting than horizontal gastroplasty. Some postoperative deaths occurred in the studies. Weight loss was similar between open and laparoscopic procedures. Fewer serious complications occurred with laparoscopic surgery, although conversion to open surgery was sometimes required. Most studies found that laparoscopic surgery had a longer operative time. But, it resulted in reduced blood loss and quicker recovery.

AUTHORS' CONCLUSIONS

The limited evidence suggests that surgery is more effective than conventional management for weight loss in morbid obesity. The comparative safety and effectiveness of different surgical procedures is unclear.

Nutritional concerns related to Roux-en-Y gastric bypass: what every clinician needs to know

Weight loss surgery, particularly the Roux-en-Y gastric bypass (REYGB), has become a popular treatment strategy for obesity. Often the only measure of success is the amount of weight lost following surgery. Unfortunately the nutritional adequacy of the postoperative diet has frequently been overlooked, and in the months to years that follow, nutritional deficiencies have become apparent, including protein-calorie malnutrition and various vitamin and mineral deficiencies contributing to medical illnesses and limiting optimal health. Therefore, patients require close monitoring following REYGB, with special regard to the rapidity of weight loss and vigilant screening for signs and symptoms of subclinical and clinical nutritional deficiencies. Several specific nutrients require close surveillance postoperatively to prevent life-threatening complications related to deficient states. This article addresses nutritional concerns associated with REYGB with fastidious focus on recognition and treatment of the nutritional deficiencies and promotion of nutritional health following REYGB. Recommendations regarding nutritional intake following REYGB are based on available scientific data, albeit limited. In cases where data do not exist, expert or consensus opinion is provided and recommendations for future research are given. Ultimately, clinical application of this information will contribute to the prevention of nutrition-related illness associated with REYGB.

[Plastic surgical considerations of conservative weight loss in the treatment of morbid obesity]

BACKGROUND

According to the literature, conservative weight loss seems to be ineffective for morbidly obese subjects. Nevertheless, the significance of nonsurgical strategies for the treatment of morbid obesity is still unclear.

PATIENTS

From 1999 to 2003, 197 reconstructive operations were performed on 120 morbidly obese patients. Initial body mass index (BMI) was higher than 35-40, and weight loss exceeded 40% of the original body weight.

RESULTS

Gastric banding was performed in 66% of the patients; 34% reduced their body weight by conservative means. Conservative weight loss could be achieved at each level of BMI.

CONCLUSION

Conservative weight loss is a valuable option for the treatment of morbid obesity in a selected group of patients. Condiolates candidates for conservative weight loss should be selected carefully by a multidisciplinary team with psychiatric expertise.

Trends in Insurance Coverage for Bariatric Surgery and the Impact of Evidence-Based Reviews

The recent increase in demand for bariatric surgery has placed mounting economic pressure on insurance companies and other third-party payers (TPPs). As a result, some of the TPPs have responded by excluding or limiting their coverage of all or certain types of bariatric surgical procedures, and cite as their reason, a lack of evidence that supports the safety and efficacy of such procedures. Over the years, so-called "evidence-based reviews" have been used to back these claims. Some of these reviews have significant flaws and limitations that are discussed.

Psychologic Issues in Bariatric Surgery—the Surgeon's Perspective

The consensus that obesity surgery is superior to medical intervention is growing and is supported by abundant evidence. Most patients lose a significant amount of weight, maintain their weightloss long-term, and therefore have improved quality of life with decreased comorbidities and enhanced psychosocial functioning. Despite these benefits from surgery, 5% to 30% of patients lose little weight or are unable to maintain their weight loss postoperatively. This article discusses the psychologic issues involved in bariatric surgery and particularly the absence of psychologically related positive or negative predictors of successful outcome.

[Evidential basis in bariatric surgery]

Bariatric surgery is currently considered the best treatment option for morbid obesity. With the rapid development of laparoscopic techniques, a significant increase in the number bariatric procedures in recent years can be observed. Various surgical techniques to treat morbid obesity have been described, but only few prospective studies compare the different procedures, leading to a lack of evidence for their use. However, from the available literature some general recommendations can be given: (a) preoperative workup in an interdisciplinary team is mandatory, (b) primary bariatric procedures should be performed laparoscopically, and (c) the combination of restrictive and malabsorptive techniques is more efficient than a purely restrictive method, which is also true for the treatment of comorbid diabetes and arterial hypertension. In this paper, we present recent developments in bariatric surgery, with special emphasis on the available evidence for the best treatment of morbidly obese patients.

Evidence-based medicine reports on obesity surgery: a critique

OBJECTIVE

To evaluate evidence in recent authoritative 'Evidence-Based Medicine' (EBM) reports on surgery for severe obesity.

METHODS

Focused review of Index Medicus citations and authors' own databases of publications on surgery for obesity, 1978-2004.

RESULTS

EBM criteria for assessment of strength of evidence requiring randomized controlled studies (RCTs) in these reports are inappropriate for evaluating invasive treatments such as surgery, which have robust physiological effects, are difficult to reverse and may have more serious side effects than the drug studies for which the criteria were promulgated. Flaws in these reports include omissions of important studies demonstrating improvements in comorbidity, factual errors in descriptions of operations and faulty analyses of outcomes of laparoscopic approaches. There are misinterpretations of cited papers, and inclusion of obsolete operations as well as a study generated during the 'learning curve' of an avowed complex procedure.

CONCLUSION

EBM analyses of surgical modalities affecting access to care require relevant evaluation criteria, true peer review and expert consultation. Authors' claims of objectivity by invoking use of evidence-based criteria applicable to drug treatment and other easily reversible forms of therapy are questionable. Decisions based on flawed EBM reports may adversely affect access to care for millions of severely obese patients.

Obesity surgery: evidence-based guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

The increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectiveness and surrounding circumstances of the various types of obesity surgery.

METHODS

A consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued.

RECOMMENDATIONS

After the patient's multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.

Health-related quality-of-life in patients with morbid obesity after gastric banding for surgically induced weight loss

BACKGROUND

Physical, emotional, and social functioning are impaired in obesity. It is unknown whether and, if so, to what extent and in which domain obese subjects who lose weight may catch up to normal-weight levels. Our objective was to compare the health-related quality-of-life (HRQL) of obese subjects with that of a normal-weight reference group before and 1 year after a weight loss program that centered around laparoscopic and open gastric banding.

METHODS

An HRQL questionnaire consisting of a battery of both generic and specific measures was administered to 50 morbidly obese subjects on 2 occasions and to 100 healthy, normal-weight subjects, matched for age, gender, education, and vocational training. In addition to weight loss and health gain, the influences of achieved weight loss goals, satisfaction with outcome and operative approach (laparoscopy/laparotomy) were assessed.

RESULTS

Quality-of-life was significantly impaired in obese subjects. With a substantial weight loss of 35 kg and 42% loss of excessive weight, and correction of disturbed metabolic parameters, they significantly improved in general well-being, health distress, and perceived attractiveness, approaching halfway the values of a normal-weight reference group. Improvement in values for depression and self-regard lagged behind. In physical activity, they bypassed the reference group. Days of sick leave decreased to the level of the reference group. Improvements in HRQL paralleled the rate of weight loss. Personal satisfaction and surgical approach were of minor influence.

CONCLUSIONS

The obese subjects' impaired physical and social functioning improved considerably, catching up midway to normal-weight reference values after weight loss. Psychologic amelioration lagged behind. Whether the latter will catch up later and physical/social improvements will be maintained is the subject of further studies.

The management of the obese diabetic patient

The prevalence of obesity and diabetes is increasing in the United States and worldwide. These diseases are predicted to explode to epidemic proportions, unless appropriate counteractive measures are taken. Several large studies (DCCT, UKPDS, Kumamoto) clearly showed that intensive glycemic control in the diabetic patient reduced microvascular complications and improved mortality. Despite this, the NHANES III showed that only 50% of diabetics have been able to achieve a HgbAic level that is less than 7%; this suggests the need for a re-evaluation of our approach to these patients. The management of the obese diabetic patient involves glycemic control and weight reduction. These goals are particularly difficult to achieve in the obese diabetic patient because progressive beta-cell dysfunction and increasing insulin resistance necessitates the administration of increasingly higher dosages of insulin, which, in turn, promotes weight gain. A vicious cycle may ensue. Lifestyle modifications with diet and exercise are an essential part of the management of the obese diabetic patient. These measures alone are often insufficient and concomitant pharmacologic therapy is usually required to achieve glycemic and weight control. Oral agents that improve glycemia, decrease insulin resistance, and limit weight gain are desirable. Because of the progressive nature of diabetes, glycemic control with monotherapy often deteriorates over time, which necessitates the addition of other pharmacologic agents, including insulin. When insulin therapy is required in the treatment of the obese diabetic patient, combinations with oral agents that have been shown to minimize the amount of exogenous insulin that is required, may minimize weight gain. In addition, the obese diabetic patient who is poorly controlled with maximum oral hypoglycemic therapy may benefit from weight-reducing agents, such as sibutramine or orlistat. The introduction of these agents at other points in the management of the obese diabetic patients have been successful. Finally, for the severely obese diabetic patient, bariatric surgery may be the only effective treatment. Gastric bypass has been unequivocally shown to produce significant weight loss and improve glycemic control on a long-term basis in the obese diabetic patient. It is recommended that physicians avail themselves of all of these strategies in the management of the obese patient who has type 2 diabetes.

Clinical and cost effectiveness of surgery for morbid obesity: a systematic review and economic evaluation

OBJECTIVE

To assess the clinical and cost effectiveness of surgery for people with morbid obesity.

DESIGN

A systematic review of randomised control trials (RCTs), prospective clinical trials and economic evaluations identified from 14 electronic databases (including Medline, Cochrane library and Embase from their inception to October 2001), bibliographies and consultation with experts and manufacturers was performed to assess the clinical and cost effectiveness of different surgical procedures and nonsurgical management for morbid obesity. An economic evaluation was undertaken to assess cost effectiveness in the UK.

SUBJECTS

People diagnosed as morbidly obese, defined as a body mass index (BMI) (weight in kilograms/height in metres(2)) >40 kg/m(2), or with a BMI>35 kg/m(2) with serious comorbid disease, in whom previous nonsurgical interventions had failed.

MEASUREMENTS

The outcomes assessed included weight change, quality of life, peri- and postoperative morbidity and mortality, revision rates and obesity comorbidities. Cost effectiveness was modelled from these data and presented as cost per quality-adjusted life year (QALY).

RESULTS

Included studies differed in methodological quality. Surgery resulted in a significantly greater loss of weight (23-37 kg more weight) than nonsurgical treatment, which was maintained to 8 years and led to improvements in quality of life and comorbidities. The economic evaluation of surgery compared with nonsurgical management suggested that surgery was cost effective at pound 11000 per QALY. Comparisons of the different types of surgery were equivocal.

CONCLUSION

Surgery for morbid obesity appears to be clinically and cost effective. Because of the nature of the evidence, particularly the uncertainty in the clinical and economic evaluations, it is difficult to distinguish between the different surgical procedures.

A comparison of diet and exercise therapy versus laparoscopic Roux-en-Y gastric bypass surgery for morbid obesity: a decision analysis model

BACKGROUND

In the absence of randomized controlled trials that directly compare medical versus surgical treatment of morbid obesity, decision analysis is a useful tool to help determine the optimal treatment strategy. Using decision analysis we simulated a trial comparing diet and exercise therapy to laparoscopic gastric bypass surgery to determine which approach resulted in longer life expectancy.

STUDY DESIGN

A Markov decision analysis model was constructed to evaluate survival after laparoscopic Roux-en-Y gastric bypass surgery compared with a diet and exercise program for a 45-year-old woman with a body mass index (BMI) of 40 kg/m(2). Baseline mortality data were derived from published tables of vital statistics, and the relative risks of death associated with obesity (relative to normal weight) were taken from epidemiologic studies. We assumed that successful surgery resulted in a reduction of BMI to 30 kg/m(2). The baseline assumptions were: an operative mortality of 0.4%; a probability of weight loss after surgery of 80%; a rate of weight loss on a diet and exercise program, 20% at two years; a rate of regain of lost weight, 95% at two years; a relative risk of death for a BMI of 40 kg/m(2), 2.70; and a relative risk of death for a BMI of 30 kg/m(2), 1.51.

RESULTS

The undiscounted life expectancy after surgery was 69.7 years compared with 67.3 years for a diet and exercise program (an absolute increase in life expectancy of 2.4 years, a relative increase in life expectancy of 10.8%). Sensitivity analyses assumed discounting at 5%/y, and showed that surgery was associated with a longer expectation of life when the risk of operative mortality was less than 10%, and when the probability of weight loss after surgery was greater than 4%.

CONCLUSIONS

In a decision analysis model, laparoscopic gastric bypass surgery for morbid obesity was associated with a substantially longer survival than diet and exercise therapy.

Obesity and its surgical management

Obesity is increasing in epidemic proportions world-wide. Even mild degrees of obesity have adverse health effects and are associated with diminished longevity. For this reason aggressive dietary intervention is recommended. Patients with body mass indices exceeding 40 have medically significant obesity in which the risk of serious health consequences is substantial, with concomitant significant reductions in life expectancy. For these patients, sustained weight loss rarely occurs with dietary intervention. For the appropriately selected patients, surgery is beneficial. Various operations have been proposed for the treatment of obesity, many of which proved to have serious complications precluding their efficacy. A National Institutes of Health Consensus Panel reviewed the indications and types of operations, concluding that the banded gastroplasty and gastric bypass were acceptable operations for treating seriously obese patients. Surgical treatment is associated with sustained weight loss for seriously obese patients who uniformly fail nonsurgical treatment. Following weight loss there is a high cure rate for diabetes and sleep apnea, with significant improvement in other complications of obesity such as hypertension and osteoarthritis.

Long-term weight-loss maintenance: a meta-analysis of US studies

BACKGROUND

Current perception is that participants of a structured weight-loss program regain all of their weight loss within 5 y.

OBJECTIVE

The objective was to examine the long-term weight-loss maintenance of individuals completing a structured weight-loss program.

DESIGN

Studies were required to 1) have been conducted in the United States, 2) have included participants in a structured weight-loss program, 3) have provided follow-up data with variance estimates for > or =2 y. Primary outcome variables were weight-loss maintenance in kilograms, weight-loss maintenance as a percentage of initial weight loss, and weight loss as a percentage of initial body weight (reduced weight).

RESULTS

Twenty-nine studies met the inclusion criteria. Successful very-low-energy diets (VLEDs) were associated with significantly greater weight-loss maintenance than were successful hypoenergetic balanced diets (HBDs) at all years of follow-up. The percentage of individuals at 4 or 5 y of follow-up for VLEDs and HBDs were 55.4% and 79.7%, respectively. The results for VLEDs and HBDs, respectively, were as follows: weight-loss maintenance, 7.1 kg (95% CI: 6.1, 8.1 kg) and 2.0 (1.5, 2.5) kg; percentage weight-loss maintenance, 29% (25%, 33%) and 17% (13%, 22%); and reduced weight, 6.6% (5.7%, 7.5%) and 2.1% (1.6%, 2.7%). Weight-loss maintenance did not differ significantly between women and men. Six studies reported that groups who exercised more had significantly greater weight-loss maintenance than did those who exercised less.

CONCLUSIONS

Five years after completing structured weight-loss programs, the average individual maintained a weight loss of >3 kg and a reduced weight of >3% of initial body weight. After VLEDs or weight loss of > or =20 kg, individuals maintained significantly more weight loss than after HBDs or weight losses of <10 kg.

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.

[Laparoscopic gastroplasty for morbid obesity: prospective study of 300 cases]

STUDY AIM

Laparoscopic gastric banding for morbid obesity is noninvasive and reversible. The aim of this prospective study was to report the preliminary results of this procedure in the first 300 patients.

PATIENTS AND METHODS

From April 1997 to January 2000, 300 patients were laparoscopically operated for severe obesity: 266 women, 34 men, with a mean age of 40.1 years (range: 16-66). The mean preoperative weight was 118 kg (range: 85-195) and the mean body mass index (BMI) was 43.6 kg/m2 (range: 35.1-65.8). This is a recent and complete series with a mean follow-up of 10 months (range: 3-31). The primary endpoint was excessive weight loss (EWL) and the secondary endpoints were tolerance and morbidity.

RESULTS

There were no postoperative deaths. The mean operating time was 129 minutes (range: 50-380). A conversion to laparotomy was necessary in 11 patients. The mean hospital stay was 4.76 days (range: 3-42). There were 29 complications (9.6%), 16 among the first 50 procedures: 14 patients underwent an abdominal reoperation (2 perforations, 3 early slippages, 7 late slippages, 2 incisional hernias); 6 had respiratory complications with 2 ARDS and 9 developed a complication related to the port. At one year, BMI decreased from 43.6 to 33.7 kg/m2 and EWL reached 44.2%; 80% of the patients lost 60% of their excess weight.

CONCLUSION

Our experience is encouraging with an acceptable complication rate (5%) after 50 procedures. Slippage remains the main reason for close surveillance. Half of the excess weight can be comfortably lost in one year when the whole medical and surgical staff provide close support for each patient.

Surgery for obesity

The medical risks of obesity increase exponentially as weight increases, and these risks are reduced by sustained weight loss. Behavior modification and dieting provide an approximately 6% loss of body weight at 1 year. Fenfluramine provides an approximately 8% weight loss at 1 year, which can be doubled to 16% when a drug such as phentermine, which works through a different biochemical mechanism, is added to it. This amount of weight loss is insufficient for many severely obese individuals. It was with these facts in mind that the National Institutes of Health Consensus Conference in 1992 recommended that obesity surgery is an appropriate treatment for patients with a body mass index greater than 40 kg/m2 who had failed in attempts at medical treatment and for patients with a body mass index greater than 35 kg/m2 with severe complications of obesity. Vertically banded gastroplasty and Roux-en-Y gastric bypass are the two operations presently recommended because of their relative safety and effectiveness. This article reviews previous procedures that have provided insight into the mechanisms by which these surgeries cause weight loss. The presently used surgeries and their results also are reviewed because until medical therapy improves substantially, surgery remains the most reasonable treatment option for most morbidly obese patients.

Usefulness of fluoxetine in obese non-insulin-dependent diabetics: a multicenter study

Weight reduction is essential in the management of most non-insulin-dependent diabetics, but this therapeutical goal is difficult to obtain. In this double-blind parallel study, 82 non-insulin-dependent diabetics, moderately obese (BMI = 30 - 39 kg/m2), were given for an 8-week period either placebo (P) or fluoxetine (F), a specific serotonin reuptake inhibitor, in addition to their usual antidiabetic treatment. Thirty-nine of them received 60 mg fluoxetine a day and 43 were given the placebo. At admission, both groups had similar weight excess, metabolic control and serum lipid values. In comparison with the P-treated subjects, those treated with fluoxetine (F) lost more weight after 3 weeks (-1.9 vs. -0.7 kg, p < -0.0009) and after 8 weeks (-3.1 vs. -0.9 kg, p < 0.0007). Fasting blood glucose decreased in group F after 3 weeks (-1.5 vs -0.4 mmol/L, p < 0.003) and after 8 weeks (-1.7 vs. -0.02 mmol/L, p < 0.0004). HbAlc decreased from 8.5% to 7.7% in group F and from 8.6% to 8.3% in group P (p = 0.057). Mean triglyceride level was also reduced in group F after 8 weeks (p = 0.042). Fasting C-peptide did not change in either group, but fasting insulin values decreased in group F after 3 weeks (p < 0.02) and after 8 weeks (p < 0.05). The insulin/C-peptide molar ratio decreased significantly in group F after 3 weeks (p < 0.04) and after 8 weeks (p < 0.05) in comparison with group P. The drug was generally well tolerated and no major side effects were reported. In conclusion, the addition of fluoxetine to the usual oral hypoglycemic agent therapy might be beneficial in obese non-insulin-dependent diabetics, at least on a short-term basis.

Sertraline and relapse prevention training following treatment by very-low-calorie diet: a controlled clinical trial

This study examined the combination of sertraline, a selective serotonin reuptake inhibitor, and relapse prevention training in the maintenance of weight loss following treatment by a very-low-calorie diet. A total of 53 women who had lost a mean (+/- SD) of 22.9 +/- 7.1 kg from a pretreatment weight of 103.1 +/- 17.8 kg were randomly assigned to a 54-week weight maintenance program that was combined with either: 1) 200 mg/d of sertraline; or 2) placebo. During the first 6 weeks, sertraline subjects lost significantly more weight and reported significantly greater reductions in hunger and preoccupation with food than did subjects on placebo. After this time, however, women in both conditions regained weight steadily. The 13 sertraline subjects who completed the 54-week study regained 17.7 +/- 10.6 kg of their original 26.3 +/- 7.6 kg loss, equal to a regain of 70.9 +/- 41.7%. The 17 placebo completers regained 11.8 +/- 9.0 kg of their 23.4 +/- 7.8 kg loss, equal to a 46.5 +/- 34.6% regain. End-of-treatment differences between groups in weight change were not statistically significant. Nor were there significant differences between the two conditions at any time in changes in fat-free mass, resting metabolic rate or dysphoria, all of which tended to increase with weight regain. The results are discussed in relation to findings from other long-term studies that combined diet and medication.

Surgical treatment of morbid obesity

Morbid obesity significantly reduces life span and is associated with much co-morbid pathology. Diet, behavioural therapy and drug therapy are largely unsuccessful. Surgical treatment offers the best hope. This review summarizes the rationale for treatment and the available surgical options.

Relationship of weight loss to cardiovascular risk factors in morbidly obese individuals

OBJECTIVES

This study critically examined the relationships between weight loss and changes in serum lipid and blood pressure levels.

DESIGN

Eighty morbidly obese women and men were treated with an intensive very-low-calorie diet (VLCD) and behavioral education program. Body weight and blood pressure were measured weekly. Serum lipids were measured biweekly.

RESULTS

Patients lost an average of 35.3 kg in 25.6 weeks. These values decreased significantly: fasting serum cholesterol, 15.1%; low density lipoprotein cholesterol, 17.0%; triglycerides, 14.2%; systolic blood pressure, 8.7%; and diastolic blood pressure, 10.2%. Changes in serum lipids and blood pressure were significantly (p < 0.001) correlated with baseline values and with changes in body mass index (BMI) after adjustment for baseline values. Patients maintained an average of 19.7 kg of their weight loss at the 2-year follow-up.

CONCLUSIONS

Weight reduction through a multidisciplinary VLCD program significantly reduces risk factors for cardiovascular disease; for morbidly obese individuals, improvements in risk factors were significantly and linearly related to changes in the BMI.

Morbid obesity: selection of patients for surgery

Massive obesity is associated with serious co-morbidities. After failure of extensive conservative measures, surgical procedures have developed as the only successful method for sustained weight loss. Criteria for operation are: presence of serious diseases associated with morbid obesity; greater than 45 kg above ideal weight or body mass index greater than 40 kg/m2 for usually greater than 5 years; failure of sustained weight loss on extensive conservative regimens; commitment to lifelong follow-up; and acceptable operative risk. Angina pectoris itself is not a contraindication to these operations. Patients who do not quite meet the weight criteria may still be candidates for an obesity operation in certain instances, e.g., debilitating musculoskeletal pains in weight-bearing joints, diabetes, significant hypertension, reflux esophagitis, urinary stress incontinence. Although current operations result in lasting weight loss of greater than 50% of excess weight in the majority of patients, the surgical candidate must understand and accept the principles of the procedures, the potential for serious complications, the dietary necessities, and occasional failures.