Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity

Distress Tolerance and Psychological Comorbidity in Patients Seeking Bariatric Surgery

INTRODUCTION/PURPOSE

Distress intolerance is characterized by a low threshold for negative emotional experiences and lack of emotion regulation and has been shown to predict various health outcomes. As such, the primary aim of this study was to determine the association between distress tolerance and psychological variables (eating behaviors, mood, substance use, trauma history), completion of bariatric surgery, and post-bariatric surgery weight loss outcomes and follow up with a provider.

MATERIALS AND METHODS

Two hundred forty-eight patients (75 % female, 89 % Caucasian) underwent a multidisciplinary evaluation for bariatric surgery and were assessed for psychiatric disorders via semi-structured clinical interview and psychometric questionnaires.

RESULTS

Low distress tolerance was associated with symptoms of depression (p ≤ 0.001), anxiety (p ≤ 0.001), disordered eating behaviors (p ≤ 0.001), substance abuse (p ≤ 0.001), a history of being the victim of childhood sexual abuse (p ≤ 0.001), and with high BMI (p < .05). Patients endorsing higher levels of distress tolerance were more likely to undergo bariatric surgery (p < .01). Distress tolerance was not related to 2-year post-surgical weight loss outcomes or follow up with a provider.

CONCLUSION

The ability to tolerate negative affect may be a variable that differentiates which patients undergo bariatric surgery rather than early postoperative outcomes.

Comparison Between Marital Satisfaction and Self-Esteem Before and After Bariatric Surgery in Patients With Obesity

Background

Obesity is one of the most common chronic diseases with important medical effects, as well as mental and social health problems. Bariatric surgery is one of the most effective treatments of morbid obesity.

Objectives

Because of the possible psychological changes, and its effects on weight loss after surgery, the current study aimed to compare marital satisfaction and self-confidence in patients with obesity before and after bariatric surgery in Rasoul-e-Akram hospital in 2013.

Materials and Methods

This prospective observational study was conducted on 69 candidates for bariatric surgery. Marital satisfaction and self-confidence were assessed before and six months after the surgery by Enrich marital satisfaction scale and Coopersmith self-esteem inventory. Descriptive statistics and T-tests were utilized to analyze data. Values of P ≤ 0.01 were considered statistically significant.

Results

Despite the improvement of sexual relationship, marital satisfaction scores significantly decreased from141.26 ± 12.75 to 139.42 ± 12.52 six months after the surgery (P = 0.002). Satisfaction in scales of conflict resolution and communication showed a descending pattern (P < 0.001). No significant difference was found between self-esteem before and after the surgery (P = 0.321).

Conclusions

Weight loss after bariatric surgery did not improve self-esteem and marital satisfaction six months post operatively; therefore, psychiatric assessment of patients before and after the surgery is crucial; since even if they are not associated with prognosis of the surgery, it is important to provide treatment for psychiatric problems. Prospective studies are recommended to assess post-operative changes of other psychological aspects.

Presence of Serum Ferritin before and after Bariatric Surgery: Analysis in Dentate and Edentulous Patients

Society has changed its own lifestyle, specially its eating habits and physical activities, leading to excessive weight and a sedentary behavior, which has contributed to obesity increase. Bariatric surgery is the most effective treatment to obesity, allowing weight loss and its maintenance. However, it has been related high levels of iron deficiency after surgery. A person's nutritional status might be affected by total or partial tooth loss. The aim of this longitudinal prospective cohort study was to evaluate the levels of serum ferritin before and after bariatric surgery and to identify if there is a relation with tooth loss. The sample was composed of 50 patients selected and assisted at Amaral Carvalho Hospital, located in Jaú city, Brazil. The use and necessity of prosthesis, dental absence or presence, and serum ferritin dosage were evaluated. Student's t test, Univariate analysis, Chi-square and Odds Ratio were adopted (p<0.05). There was no significant difference regarding the serum ferritin levels between dentate and edentulous patients prior to surgery (p = 0.436). After surgery, the serum ferritin levels were higher in edentulous patients (prosthesis users) when compared to the pre-surgical levels, and the post-surgical levels presented significant difference regarding the dentate patients (p = 0.024). It can be concluded that rehabilitated patients in postoperative period showed better levels of serum ferritin after surgical intervention.

Mechanism Underlying the Weight Loss and Complications of Roux-en-Y Gastric Bypass. Review

Various bariatric surgical procedures are effective at improving health in patients with obesity associated co-morbidities, but the aim of this review is to specifically describe the mechanisms through which Roux-en-Y gastric bypass (RYGB) surgery enables weight loss for obese patients using observations from both human and animal studies. Perhaps most but not all clinicians would agree that the beneficial effects outweigh the harm of RYGB; however, the mechanisms for both the beneficial and deleterious (for example postprandial hypoglycaemia, vitamin deficiency and bone loss) effects are ill understood. The exaggerated release of the satiety gut hormones, such as GLP-1 and PYY, with their central and peripheral effects on food intake has given new insight into the physiological changes that happen after surgery. The initial enthusiasm after the discovery of the role of the gut hormones following RYGB may need to be tempered as the magnitude of the effects of these hormonal responses on weight loss may have been overestimated. The physiological changes after RYGB are unlikely to be due to a single hormone, or single mechanism, but most likely involve complex gut-brain signalling. Understanding the mechanisms involved with the beneficial and deleterious effects of RYGB will speed up the development of effective, cheaper and safer surgical and non-surgical treatments for obesity.

Multicenter prospective evaluation of a new articulating 5-mm endoscopic linear stapler

Background

The objective of this study was to evaluate the safety and efficacy of a novel 5-mm laparoscopic linear stapler in clinical gastrointestinal surgical applications.

Methods

A prospective, single-arm study with an open enrollment of subjects requiring stapling of the gastrointestinal (GI) tract was performed. The study endpoints were the number of complications and technical failures associated with the use of a novel stapler when compared to similar events with conventional staplers as described in the medical literature.

Results

Seven centers enrolled 160 subjects, 150 of which were followed up to at least 30 days postoperatively. Intraoperative success: In 423 deployments, there were two staple line leaks and five staple line bleeds, all of which were intraoperatively resolved. In addition, incomplete staple lines were noted as a result of user error (n = 15) or device-related issues (n = 22), all of which were immediately resolved and none of which resulted in a complication or a change of the surgical procedure. Late outcomes: A total of 13 surgical complications in 160 patients were related to a GI transection or anastomosis, 12 of which related to a hand-sewn anastomosis or use of other commercially available staplers. One event (1/153, 0.065 %) on POD 1, involving bleeding of the staple line, was felt to be related to the use of the new stapler.

Conclusion

The study confirmed that the new device was user-friendly (9 % incidence of problems firing the device), reliable (3 % device failures) and safe (<1 % complication rate related to the stapler). Based on these results, it would seem that this new 5-mm stapler is a safe and effective alternative to standard 12-mm staplers.

Anaemia and related nutrient deficiencies after Roux-en-Y gastric bypass surgery: a systematic review and meta-analysis

OBJECTIVE

To obtain a pooled risk estimate on the long-term impact of anaemia and related nutritional deficiencies in patients receiving Roux-en-Y gastric bypass (RYGB) surgery.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, EMBASE and Cochrane databases were searched to identify English reports published before 16 May 2014.

ELIGIBILITY CRITERIA

Articles with case numbers >100, follow-up period >12 months, and complete data from both before and after surgery were selected. Outcomes of interest were changes in baseline measurements of proportion of patients with anaemia, by haemoglobin, haematocrit, ferritin, iron, vitamin B12 and folate levels.

DATA COLLECTION AND ANALYSIS

Two reviewers independently reviewed data and selected six prospective and nine retrospective studies with a total of 5909 patients. A random effect model with inverse variance weighting was used to calculate summary estimates of outcomes at 6, 12, 24 and 36 months postoperatively.

RESULTS

Proportion of patients with anaemia was 12.2% at baseline, which, respectively, increased to 20.9% and 25.9% at 12 and 24 months follow-up, consistent with decreases in haemoglobin and haematocrit levels. Although the serum iron level did not change substantially after surgery, the frequency of patients with ferritin deficiency increased from 7.9% at baseline to 13.4% and 23.0% at 12 and 24 months, respectively, postoperation. Vitamin B12 deficiency increased from 2.3% at baseline to 6.5% at 12 months after surgery in those subjects receiving RYGB. There was no obvious increase in folate deficiency.

CONCLUSIONS

RYGB surgery is associated with an increased risk of anaemia and deficiencies of iron and vitamin B12, but not folate. Ferritin is more sensitive when serum iron level is within normal range.

Single-access laparoscopic adjustable gastric band removal: technique and initial experience

BACKGROUND

Single-access laparoscopy (SAL) has gained significant interest in recent years. Potential benefits, beyond cosmetic outcomes, could be reduction of abdominal trauma, decreased risk of incisional hernia and diminished postoperative pain. Technique and initial experience in patients submitted to laparoscopic adjustable gastric band removal (LAGBR) through SAL is reported here.

METHODS

Between December 2009 and March 2012, 14 patients (9 females, 5 males) underwent LAGBR through SAL. Indications for operation were band intolerance (11), pouch dilatation (2) and insufficient weight loss (1). The mean age was 40.3 ± 9.1 years (range 26-57), and the mean interval time between LAGB placement and removal was 94.7 ± 41.9 months (range 37-157). The mean weight and the mean body mass index at the time of LAGBR were 89.3 ± 17.6 kg (range 65-119) and 30.6 ± 4.5 kg/m(2) (range 25.3-36.7), respectively. Technically, the previous port site scar was used as the single-access site to the abdominal cavity. An 11-mm reusable trocar was adopted for a 10-mm regular scope, besides curved reusable instruments.

RESULTS

No patients required conversion to open surgery and none necessitated additional trocars. The mean laparoscopic time was 24.6 ± 7.9 min (range 13-37), and the mean final scar length was 3.6 ± 0.3 cm (range 3-4). Two patients experienced early postoperative complications. The mean hospital stay was 1.3 ± 1.1 days (range 1-5). The mean follow-up time was of 18 ± 9.8 months (range 3-30), and there were no late complications.

CONCLUSIONS

LAGBR can be safely performed through SAL. Thanks to this technique, the laparoscopic working triangulation is established as well as the ergonomic positions of the surgeon. Due the use of only reusable material, the cost of this SAL remains similar to multiport laparoscopy.

Response to dietary oxalate after bariatric surgery

BACKGROUND AND OBJECTIVES

Bariatric surgery (BS) may be associated with increased oxalate excretion and a higher risk of nephrolithiasis. This study aimed to investigate urinary abnormalities and responses to an acute oxalate load as an indirect assessment of the intestinal absorption of oxalate in this population.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Twenty-four-hour urine specimens were collected from 61 patients a median of 48 months after BS (post-BS) as well as from 30 morbidly obese (MO) participants; dietary information was obtained through 24-hour food recalls. An oral oxalate load test (OLT), consisting of 2-hour urine samples after overnight fasting and 2, 4, and 6 hours after consuming 375 mg of oxalate (spinach juice), was performed on 21 MO and 22 post-BS patients 12 months after BS. Ten post-BS patients also underwent OLT before surgery (pre-BS).

RESULTS

There was a higher percentage of low urinary volume (<1.5 L/d) in post-BS versus MO (P<0.001). Hypocitraturia and hyperoxaluria (P=0.13 and P=0.36, respectively) were more frequent in BS versus MO patients. The OLT showed intragroup (P<0.001 for all periods versus baseline) and intergroup differences (P<0.001 for post-BS versus MO; P=0.03 for post-BS versus pre-BS). The total mean increment in oxaluria after 6 hours of load, expressed as area under the curve, was higher in both post-BS versus MO and in post-BS versus pre-BS participants (P<0.001 for both).

CONCLUSIONS

The mean oxaluric response to an oxalate load is markedly elevated in post-bariatric surgery patients, suggesting that increased intestinal absorption of dietary oxalate is a predisposing mechanism for enteric hyperoxaluria.

Surgical treatment for morbid obesity: the laparoscopic Roux-en-Y gastric bypass

Over the past 20 years bariatric surgery proved to be a valid treatment for reduction and elimination of obesity-related diseases and long-term sustainable weight loss. Minimally invasive or laparoscopic techniques such as laparoscopic Roux-en-Y (LRNY) have replaced open procedures. Many factors play important roles in the small intricacies and variations of the procedure, chief of which is the creation and size of the gastrojejunostomy. Regardless of the variations in technique, the LRNY remains the gold standard for the surgical treatment of clinically severe or morbid obesity, with relatively low morbidity and mortality.

Prevalence of nutrient deficiencies in bariatric patients

OBJECTIVE

The aims of this study were to determine the prevalence of nutrient deficiencies in patients who present for bariatric surgery, assess nutritional status after surgery, and compare these with preoperative levels.

METHODS

A retrospective study was conducted to identify preoperative and 1-year postoperative nutrition deficiencies in patients undergoing bariatric surgery. The screening included serum ferritin, vitamin D, vitamin B(12), homocysteine, folate, red blood cell folate, and hemoglobin. Results were available for 232 patients preoperatively and 149 patients postoperatively. Two-tailed chi(2) tests and paired-sample t tests were used.

RESULTS

Preoperatively, vitamin D deficiency was noted at 57%. The prevalence of abnormalities 1 year after roux-en-Y gastric bypass was higher compared with preoperative levels (P < .05). After surgery, anemia was detected in 17%, elevated homocysteine levels (women only) in 29%, low ferritin in 15%, low vitamin B(12) in 11%, and low RBC folate in 12%. Mean hemoglobin, ferritin, and RBC folate levels deteriorated significantly but remained well within normal ranges. The prevalence of vitamin D deficiencies decreased, but not significantly. In sleeve gastrectomy patients, mean ferritin levels decreased (P < .05), without any patient developing a deficiency.

CONCLUSION

Vitamin D deficiency is common among morbidly obese patients seeking bariatric surgery. Because the prevalence of micronutrient deficiencies persists or worsens postoperatively, routine nutrition screening, recommendation of appropriate supplements, and monitoring adherence are imperative in this population.

Comparison of the absorption of calcium carbonate and calcium citrate after Roux-en-Y gastric bypass

INTRODUCTION

Roux-en-Y gastric bypass (RYGB) restricts food intake. Consequently, patients consume less calcium. In addition, food no longer passes through the duodenum, the main site of calcium absorption. Therefore, calcium absorption is significantly impaired. The goal of this study is to compare two common calcium supplements in gastric bypass patients.

METHOD

Nineteen patients were enrolled in a randomized, double-blinded, crossover study comparing the absorption of calcium from calcium carbonate and calcium citrate salts. Serum and urine calcium levels were assessed for peak values (C (max)) and cumulative calcium increment (area under the curve [AUC]). Serum PTH was assessed for minimum values (PTH(min)) and cumulative PTH decrement (AUC). Statistical analysis was performed using a repeated analysis of variance model.

RESULTS

Eighteen subjects completed the study. Calcium citrate resulted in a significantly higher serum C (max) (9.4 + 0.4 mg/dl vs. 9.2 + 0.3 mg/dl, p = 0.02) and serum AUC (55 + 2 mg/dl vs. 54 + 2 mg/dl, p = 0.02). Calcium citrate resulted in a significantly lower PTH(min) (24 + 11 pg/ml vs. 30 + 13 pg/ml, p = 0.01) and a higher AUC (-32 + 51 pg/ml vs. -3 + 56 pg/ml, p = 0.04). There was a non-significant trend for higher urinary AUC in the calcium citrate group (76.13 + 36.39 mg/6 h vs. 66.04 + 40.82, p = 0.17).

CONCLUSION

Calcium citrate has superior bioavailability than calcium carbonate in RYGB patients.

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.

Nephrolithiasis after bariatric surgery for obesity

Surgical intervention has become an accepted therapeutic alternative for the patient with medically complicated obesity. Multiple investigators have reported significant and sustained weight loss after bariatric surgery that is associated with improvement of many weight-related medical comorbidities, and statistically significant decreased overall mortality for surgically treated as compared with medically treated subjects. Although the Roux-en-Y gastric bypass (RYGB) is considered an acceptably safe treatment, an increasing number of patients are being recognized with nephrolithiasis after this, the most common bariatric surgery currently performed. The main risk factor appears to be hyperoxaluria, although low urine volume and citrate concentrations may contribute. The incidence of these urinary risk factors among the total post-RYGB population is unknown, but may be more than previously suspected based on small pilot studies. The etiology of the hyperoxaluria is unknown, but may be related to subtle and seemingly subclinical fat malabsorption. Clearly, further study is needed, especially to define better treatment options than the standard advice for a low-fat, low-oxalate diet, and use of calcium as an oxalate binder.

An analysis of gastric pouch anatomy in bariatric surgery

BACKGROUND

The goal of most bariatric surgeons has been to construct small volume pouches in the proximal stomach to restrict the intake of food. The purpose of this study is to demonstrate that in addition to pouch volume, specific gastric pouch anatomy plays a significant role in weight loss.

MATERIALS AND METHODS

The physical properties and dynamics of the pouch in our form of gastric bypass were compared with those in the most commonly performed bariatric procedures by creating a model. Our weight loss data were reviewed and compared with data reported in the literature.

RESULTS

According to LaPlace's and Poiseulle's Laws, a long narrow cylinder will have less wall tension and slower flow rate of material than a wider cylinder. Bariatric procedures with narrow pouches appear to produce better weight loss.

CONCLUSIONS

Long narrow pouches should have less tendency to enlarge and should delay the transit of material to a greater degree than wider pouches according to the LaPlace's and Poiseuille's Laws. Our data and the data of others strongly suggest that long narrow pouches are the most effective operations in bariatric surgery.

Nonalcoholic fatty liver disease in Japanese patients with severe obesity who received laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) in comparison to non-Japanese patients

BACKGROUND

The number of patients with morbid obesity is increasing worldwide. However, the prevalence of morbid obesity is still low in Japan, and therefore few systematic investigations of liver dysfunction in this population have so far been carried out. This study aimed to investigate the clinical characteristics in severe obese Japanese patients undergoing laparoscopic Roux-en-Y gastric bypass surgery (LRYGB).

METHODS

Eighty-four patients with severe obesity, including 61 Japanese and 23 non-Japanese patients, were analyzed.

RESULTS

The mean body mass index (BMI) was 43.7 +/- 7.8 kg/m(2), and there was no difference between Japanese and non-Japanese patients. Nonalcoholic fatty liver disease (NAFLD) was observed in 45/59 (76.2%) of the Japanese patients. Although there were no differences in the BMI and body weight, serum ALT was higher in Japanese patients in comparison to non-Japanese patients (P < 0.05). The indices for insulin resistance were significantly higher in the Japanese patients in comparison to non-Japanese patients (P < 0.01). The liver/spleen computed tomography (CT) ratios were lower in Japanese patients (P < 0.05). The laboratory data and BMI significantly improved at 1 year after LRYGB in both groups.

CONCLUSIONS

Racial difference may exist difference may exist in NAFLD in patients with severe obesity. When the BMI is similar, liver dysfunction among Japanese patients with severe obesity tends to be higher than in non-Japanese patients. Japanese patients with severe obesity must therefore reduce their body weight to a greater degree in comparison to non-Japanese patients with the same BMI. LRYGB can achieve effective weight control and lower ALT levels in Japanese patients with severe obesity.

Obesity and obstructive sleep apnea: pathogenic mechanisms and therapeutic approaches

Obstructive sleep apnea is a common disorder whose prevalence is linked to an epidemic of obesity in Western society. Sleep apnea is due to recurrent episodes of upper airway obstruction during sleep that are caused by elevations in upper airway collapsibility during sleep. Collapsibility can be increased by underlying anatomic alterations and/or disturbances in upper airway neuromuscular control, both of which play key roles in the pathogenesis of obstructive sleep apnea. Obesity and particularly central adiposity are potent risk factors for sleep apnea. They can increase pharyngeal collapsibility through mechanical effects on pharyngeal soft tissues and lung volume, and through central nervous system-acting signaling proteins (adipokines) that may affect airway neuromuscular control. Specific molecular signaling pathways encode differences in the distribution and metabolic activity of adipose tissue. These differences can produce alterations in the mechanical and neural control of upper airway collapsibility, which determine sleep apnea susceptibility. Although weight loss reduces upper airway collapsibility during sleep, it is not known whether its effects are mediated primarily by improvement in upper airway mechanical properties or neuromuscular control. A variety of behavioral, pharmacologic, and surgical approaches to weight loss may be of benefit to patients with sleep apnea, through distinct effects on the mass and activity of regional adipose stores. Examining responses to specific weight loss strategies will provide critical insight into mechanisms linking obesity and sleep apnea, and will help to elucidate the humoral and molecular predictors of weight loss responses.

Cost-effectiveness analysis of laparoscopic gastric bypass, adjustable gastric banding, and nonoperative weight loss interventions

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most commonly performed bariatric procedures. Although both procedures likely reduce healthcare expenditures related to the resolution of co-morbid conditions, they have different rates of perioperative risks and different rates of associated weight loss. We designed a model to evaluate the incremental cost-effectiveness of these procedures compared with nonoperative weight loss interventions and with each other.

METHODS

We used a deterministic, payer-perspective model comparing the lifetime expected costs and outcomes of LAGB, LRYGB, and nonoperative treatment. The major endpoints were survival, health-related quality of life, and weight loss. Life expectancy and lifetime medical costs were calculated across age, gender, and body mass index (BMI) strata using previously published data.

RESULTS

For both men and women, LRYGB and LAGB were cost-effective at <$25,000/quality-adjusted life-year (QALY) even when evaluating the full range of baseline BMI and estimates of adverse outcomes, weight loss, and costs. For base-case scenarios in men (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $11,604/QALY for LAGB compared with $18,543/QALY for LRYGB. For base-case scenarios in women (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $8878/QALY for LAGB compared with $14,680/QALY for LRYGB.

CONCLUSION

The modeled cost-effectiveness analysis showed that both operative interventions for morbid obesity, LAGB and RYGB, were cost-effective at <$25,000 and that LAGB was more cost-effective than RYGB for all base-case scenarios.

Sexual abuse survivors and psychiatric hospitalization after bariatric surgery

BACKGROUND

Some investigators have postulated that a history of being the victim of childhood sexual abuse may impact outcome of bariatric surgery.

METHODS

In this retrospective chart review, we examined the electronic medical records of 152 adults with morbid obesity who underwent Roux-en-Y gastric bypass and who had a weight recorded in their medical record or reported in a follow-up surgery at 2 years after the RYGBP. The purpose of this retrospective chart review was to examine the relationship between psychosocial factors assessed preoperatively and the percent of excess weight lost (%EWL) at 2 years after bariatric surgery.

RESULTS

We found a high prevalence of being the victim of childhood sexual abuse (27%), adult sexual trauma (9%), and/or physical abuse (19%) at the initial evaluation. There was no association between these factors and %EWL at 2 years. However, when we examined participants' medical records for post-operative psychiatric hospitalizations at our medical center, 8 of 11 hospitalized patients reported a history of childhood sexual abuse (73%).

CONCLUSIONS

History of being the victim of childhood sexual abuse is reported frequently by patients seeking bariatric surgery. Our finding that having been the victim of childhood sexual abuse may be associated with increased risk of psychiatric hospitalization after RYGBP has several clinical implications. First, we recommend that clinicians assess carefully for a history of sexual or physical abuse, and secondly, abuse survivors may need to be told that there is an increased risk of psychiatric morbidity after bariatric surgery. Finally, perhaps close monitoring of these patients may prevent psychiatric difficulties after surgery. Further research to verify these preliminary findings is clearly needed.

Laparoscopic revision from LAP-BAND to gastric bypass

BACKGROUND

While the majority of patients achieve good outcomes with the LAP-BAND, there is a subset of patients who experience complications or fail to lose sufficient weight after the banding procedure. This study examines the feasibility and outcome of performing laparoscopic Roux-en-Y gastric bypass (RYGBP) as a single-step revision surgery after a failed LAP-BAND procedure.

METHODS

In the past five years we have performed more than 1400 LAP-BAND procedures. We laparoscopically converted 33 (30 females) of these patients (mean age = 43.8 years) from LAP-BAND to RYGBP because of inadequate weight loss and/or complications. Key steps in the revision procedures were (1) identification and release of the band capsule; (2) careful dissection of the gastrogastric sutures; (3) creation of a small gastric pouch; and (4) Roux-en-Y anterior colic anterior gastric pouch-jejunum anastomosis. Revisions took place at a mean 28.2 months (range = 11-46; SD = 11.3) after the original gastric banding. Change in body mass index (BMI) between pre- and postrevision was evaluated with paired t tests.

RESULTS

Among the 33 patients who would undergo revision surgery, the mean BMI before the LAP-BAND procedure was 45.7 kg/m2 (range = 39.9-53.0; SD = 3.4) and the mean weight was 126 kg (range = 99-155; SD = 17). The lowest BMI achieved by this group with the LAP-BAND before revision was 39.7 kg/m2 (range = 30-49.2; SD = 4.9); however, the mean BMI at the time of revision was 42.8 kg/m2 (range = 33.1-50; SD = 4.8). The mean revision operative time was 105 min (range = 85-175), and the mean hospital stay was 2.8 days (range = 1-10). Complications included one patient who underwent open reoperation and splenectomy for a bleeding spleen and one patient who required repair of an internal hernia. After conversion to RYGBP, mean BMI decreased to 33.9 kg/m2 at 6 months (p < 0.001) and 30.7 kg/m2 (range = 22-39.6; SD = 5.3) at 12 months or more of followup (average = 15.7 months; p < 0.0001).

CONCLUSIONS

Laparoscopic conversion from LAP-BAND to RYGBP is safe and can be an alternative for patients who failed the LAP-BAND procedure. However, revision surgery is technically challenging and should be performed only by surgeons who have completed the learning curve for laparoscopic RYGBP.

The Obese Surgical Patient: A Susceptible Host for Infection

BACKGROUND

Obesity is common in the Western world, and obese persons constitute a growing population of surgical patients for both bariatric and non-bariatric operations. It is the traditional perception that obese patients have a higher risk of perioperative morbidity and mortality, although different studies show contradictory results.

PURPOSE

To better delineate the perioperative morbidity and mortality in obese patients.

METHODS

Review of the pertinent English-language literature

RESULTS

Obesity is a risk factor for nosocomial infection, particularly surgical site infection (SSI). The mechanisms by which obese patients may be at higher risk for SSI are reviewed, and specific recommendations are outlined that should be implemented when treating obese patients to minimize potentially preventable SSIs.

CONCLUSION

The growing prevalence of obesity and the increasing number of operations performed on obese patients, whether to achieve weight loss or for other purposes, will have a substantial impact on health care resources. Vigilant identification of high-risk patients and provision of all proved preventive measures must suffice until new methods of prevention are identified and validated.

Perioperative outcomes and risk factors in gastric surgery for morbid obesity: a 9-year experience

OBJECTIVE

Surgical treatment of severe obesity is the most rapidly growing specialty area of surgery. The rapid expansion of bariatric surgery has raised questions and concerns regarding possible increased surgical mortality and morbidity rates in both academic and community settings. The purpose of this study was to evaluate postoperative outcomes and risk factors for bariatric gastric surgery for severe obesity.

METHODS

A community experience of 1009 consecutive patients who underwent open surgical treatment of morbid obesity during a 9-year period was reviewed from a prospective database. The series included 858 primary gastric bypass operations and 151 revision operations. Perioperative outcomes, late complications, and weight loss results were recorded. Morbidity and mortality rates were analyzed according to patient age, body mass index (BMI), and gender.

RESULTS

The mortality rate in the series was 0.6%, and the morbidity rate was 20%. The major complication rate was 6.6%. There were no deaths in the 151 revision patients. The gastrointestinal leak rate was 0.8%, and the thromboembolism rate was 1%. Statistical analysis indicates that BMI is a risk factor for surgical complications.

CONCLUSION

Open gastric surgery for morbid obesity can be carried out in the community setting with low mortality and morbidity rates. BMI is a proven surgical risk factor.

Complications of bariatric surgery

The rise in bariatric operations has been exponential because of the greater acceptance for these procedures. Although complication rates are relatively low, they can result in formidable disability. Adverse outcomes also result in medical malpractice claims that are particularly problematic for bariatric surgery practices. For these reasons, surgeons performing these operations must be knowledgeable and must possess the technical skills required for managing complications when they occur. The purpose of this article is to review the major complications that occur following anti-obesity procedures and to provide recommendations regarding their management.

Is Roux-en-Y gastric bypass safe after previous antireflux surgery? Technical feasibility and postoperative symptom assessment

BACKGROUND

Clinically significant morbid obesity is associated with an increased risk of gastroesophageal reflux disease. Vertical Roux-en-Y gastric bypass (RYGBP) is known to eliminate acid (and bile) in the pouch of cardia, which would provide control of reflux symptoms. The aim of our study was to assess the technical considerations, morbidity, and safety of RYGBP after previous antireflux surgery and evaluate postoperative reflux symptoms.

METHODS

Retrospective review of all patients undergoing RYGBP after previous antireflux surgery from three institutions. Follow-up (mean 18 months) data were obtained from medical records and by questionnaire.

RESULTS

A total of 19 patients (18 women and 1 man) underwent standard (n = 18) or distal (n = 1) RYGBP 8 +/- 1 years after Nissen (n = 18) or Toupet (n = 1) fundoplication. Open RYGBP was undertaken in 17 of 19 patients. No postoperative deaths occurred. Substantive complications occurred in 4 patients (21%) and included hemorrhage requiring transfusion, concomitant splenectomy, and reoperation for suspected leak in 2. Of the 19 patients, 16 returned the questionnaire, 15 of whom reported subjective improvement in reflux symptoms after RYGBP compared with after antireflux surgery. No patient in this series required medical therapy for reflux symptoms at the last follow-up visit. The body mass index decreased from 42 +/- 2 kg/m(2) to 32 +/- 2 kg/m(2) (mean +/- SEM); all patients with >or=1 year of follow-up had a body mass index of <or=32 kg/m(2). At last follow-up, 88% of patients were very satisfied subjectively with their outcome.

CONCLUSIONS

RYGBP after previous antireflux surgery is technically feasible and safe, but it is associated with greater complication rates than those seen with other forms of reoperative bariatric procedures. RYGBP results in effective weight loss, controls reflux symptoms, and may be the procedure of choice in morbidly obese patients with previous antireflux surgery, and obese patients requiring surgical treatment for gastroesophageal reflux disease.

Enteric hyperoxaluria, nephrolithiasis, and oxalate nephropathy: potentially serious and unappreciated complications of Roux-en-Y gastric bypass

BACKGROUND

Neither the presence nor prevalence of enteric hyperoxaluria has been recognized after Roux-en-Y gastric bypass (RYGBP). We have noted a high rate of oxalate nephrolithiasis and even 2 patients with oxalate nephropathy in this patient population postoperatively. Our aim was to determine the frequency of the occurrence and effects of enteric hyperoxaluria after RYGBP.

METHODS

Retrospective review of all patients at our institution diagnosed with calcium oxalate nephrolithiasis or oxalate nephropathy after standard (n = 14) or distal (n = 9) RYGBP. The mean postoperative follow-up was 55 months.

RESULTS

A total of 23 patients (14 men and 9 women; mean age 45 years; mean preoperative body mass index 55 kg/m(2)) developed enteric hyperoxaluria after RYGBP, defined by the presence of oxalate nephropathy (n = 2) or calcium oxalate nephrolithiasis (n = 21) and increased 24-hour excretion of urinary oxalate and/or calcium oxalate supersaturation. Enteric hyperoxaluria was recognized after a mean weight loss of 46 kg at 29 months (range 2-85) after RYGBP. Two patients developed renal failure and required chronic hemodialysis. Of the 21 patients with nephrolithiasis, 14 had no history of nephrolithiasis preoperatively, and 19 of 21 required lithotripsy or other intervention. Of the 23 patients, 20 tested had increased oxalate excretion, and 14 of 15 tested had high urine calcium oxalate supersaturation.

CONCLUSION

Enteric hyperoxaluria, nephrolithiasis, and oxalate nephropathy must be considered with the other risks of RYGBP. Efforts should be made to identify factors that predispose patients to developing hyperoxaluria.

National trends in utilization and outcomes of bariatric surgery

BACKGROUND

Because of the growing interest in surgery to treat morbid obesity, this study examined changes in the utilization and in-hospital outcomes of bariatric surgery in the United States over a 10-year period.

METHODS

Data were obtained from the Nationwide Inpatient Sample, the largest all-payer discharge database in the United States. International Classification of Disease (ICD-9) codes were used to identify all bariatric procedures performed for adults from 1990 to 2000. Population-based rates of surgery for each year were calculated by applying sampling weights and U.S. Census data. Secular trends in annual rates of surgery, changes in patient characteristics, and in-hospital mortality and complications were analyzed.

RESULTS

From 1990 to 2000, the national annual rate of bariatric surgery increased nearly six fold, from 2.4 to 14.1 per 100,000 adults (p = 0.001). There has been more than a ninefold increase in the use of gastric bypass procedures (1.4 to 13.1 per 100,000; p < 0.001). This represents an increase from 55% of all bariatric procedures in 1990 to 93% of such procedures in 2000 (p < 0.001). The rates of in-hospital mortality were low (0.4% overall), but increased slightly over time (0.2% in 1990 to 0.5% in 2000; p = 0.009). There is no significant difference in adjusted mortality for the past 8 years, but a slight rise did occur over the full 10-year period. The rates for reoperation (1.3%) and pulmonary emboli (0.3%) remained stable. The rates for respiratory failure associated with bariatric surgery declined from 7.7% in 1990 to 4.5% in 2000 (p < 0.001). Over this time, the mean length of hospital stay declined from 6.0 to 4.1 days (p < 0.001).

CONCLUSIONS

The annual rate of bariatric surgery in the United States increased nearly six fold between 1990 and 2000, with little change in in-hospital morbidity and mortality. This appears to be driven largely by the increasing popularity of gastric bypass procedures.

The impact of laparoscopy on bariatric surgery

The rising popularity of bariatric surgery over the past several years is attributable in part to the development of laparoscopic bariatric surgery. Morbidly obese patients have associated comorbid conditions that may predispose them to postoperative morbidity. The laparoscopic approach to bariatric surgery offers a minimally invasive option that reduces the physiologic stress and provides clinical benefits, as compared with the open approach. This review summarizes the impact of laparoscopic surgery on bariatric surgery, the various risk factors that could potentially predispose morbidly obese patients to postoperative morbidity, the fundamental differences between laparoscopic and open bariatric surgery, and the physiology of reduced tissue injury associated with laparoscopic bariatric surgery.

The efficacy of fibrin sealant in prevention of anastomotic leak after laparoscopic gastric bypass

BACKGROUND

Anastomotic leak after laparoscopic gastric bypass (GBP) can result in significant morbidity, mortality, and consumption of healthcare resources. Fibrin sealant has been used clinically in the prevention of leak; however, its efficacy has not been clearly demonstrated. The aims of this study were to (1) develop an iatrogenic leak model in swine, (2) examine the efficacy of fibrin sealant in sealing iatrogenic anastomotic leak, and (3) review our experience with the use of fibrin sealant in 66 patients who underwent laparoscopic GBP.

METHODS

This study was performed in three phases. In phase 1, laparoscopic gastrojejunostomy was performed in adult swine with iatrogenic disruption of the anastomotic staple line. The size of disruption was sequentially increased (6- to 12-F opening) until a leak model was developed. In phase 2, 16 animals underwent laparoscopic gastrojejunostomy with a 12-F disruption of the anastomosis; 10 animals (study group) had fibrin sealant (Tisseel VH) applied on the disrupted anastomosis and 6 animals (control group) did not receive fibrin sealant. Animals were sacrificed on postoperative day 5 or earlier if peritonitis developed and were examined for sealing of the anastomotic disruption and the presence of intraabdominal abscess. In phase 3, the outcome of 66 consecutive patients who underwent laparoscopic GBP with fibrin sealant applied at the gastrojejunostomy was reviewed.

RESULTS

In phase 1, an anastomotic leak model was developed with a 12-F disruption of the staple line. In phase 2, two control animals required early sacrifice for bile peritonitis; three control animals had intraabdominal abscess discovered at sacrifice and one animal did not have any evidence of intraabdominal abscess or leak. Of the 10 animals in the study group, all survived until sacrifice and none of these animals had evidence of intraabdominal abscess or persistent leak. Therefore, 83% of animals in the control group developed either leak or abscess compared to 0% in the study group (P < 0.01, Fisher's exact test). Clinically, no leak or intraabdominal abscess developed in 66 patients who underwent laparoscopic GBP with the use of fibrin sealant.

CONCLUSIONS

An anastomotic leak model was developed in swine with disruption of the stapled gastrojejunostomy to a 12-F opening. The use of fibrin sealant significantly reduces leak and abscess complication. Our results support the tissue sealing property of fibrin sealant and its use on high-risk gastrointestinal anastomosis.

Incidence and outcome of anastomotic stricture after laparoscopic gastric bypass

Anastomotic stricture is a frequent complication after Roux-en-Y gastric bypass (GBP). We evaluated the frequency of anastomotic stricture following laparoscopic GBP using a 21 mm. vs. a 25 mm circular stapler for construction of the gastrojejunostomy and the safety and efficacy of endoscopic balloon dilation in the management of anastomotic stricture. We reviewed data on 29 patients in whom anastomotic strictures developed after laparoscopic GBP. All strictures were managed with endoscopic balloon dilation using an 18 mm balloon catheter under fluoroscopic guidance. Main outcome measures were the number of anastomotic strictures in patients in whom the 21 mm (vs. 25 mm) circular stapler was used to create the gastrojejunostomy, time interval between the primary operation and symptoms, complications of endoscopic balloon dilation, the number of patients with resolution of obstructive symptoms, and body weight loss. There were 28 females with a mean age of 39 years and a mean body mass index of 48 kg/m(2). Anastomotic stricture occurred significantly more frequently with the use of the 21 mm compared to the 25 mm circular stapler (26.8% vs. 8.8%, respectively; P<0.01). The median time interval between the primary operation and presentation of stricture was 46 days. After the initial dilation, recurrent stricture developed in 5 (17.2%) of 29 patients. These five patients underwent a second endoscopic dilation, and only one of these five patients required a third endoscopic dilation. None of the 29 patients required more than three endoscopic dilations. The mean percentage of excess body weight loss at 1 year for patients in whom the 21 mm circular stapler was used for creation of the gastrojejunostomy was similar to that for patients in whom the 25 mm circular stapler was used (68.2% vs. 70.2%, P=0.8). In this series the rate of anastomotic stricture significantly decreased with the use of the 25 mm circular stapler for construction of the gastrojejunostomy without compromising weight loss. Endoscopic balloon dilation is a safe and effective option in the management of anastomotic stricture following laparoscopic GBP.

Steatohepatitis in obese individuals

Nonalcoholic steatohepatitis (NASH), which is the most severe histological form of nonalcoholic fatty liver disease (NAFLD), is emerging as the most common clinically important form of liver disease in developed countries. Although its prevalence is 3% in the general population, this increases to 20-40% in obese patients. Since NASH is associated with obesity, prevalence has been predicted to increase along with the arsent epidemic of obesity and type II diabetes mellitus. The importance of this observation comes from the fact that NASH is a progressive fibrotic disease, in which cirrhosis and liver-related death occur in 25% and 10% in these patients respectively over a 10-year period. This is of particular concern given the increasing recognition of NASH in children. Treatment consists of treating obesity and its co-morbidities; diabetes and hyperlipidemia. Nascent studies suggest that a number of pharmacological therapies may be effective, but all remain unproven at present. Histological and laboratory improvement occurs with a 10% decrease in body weight. Bariatric surgery is indicated in selected patients.A greater understanding of the pathophysiological progression of NASH in obese patients must be obtained in order to develop more focused and improved therapy.

Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs

OBJECTIVE

To compare outcomes, quality of life (QOL), and costs of laparoscopic and open gastric bypass (GBP).

SUMMARY BACKGROUND DATA

Laparoscopic GBP has been reported to be a safe and effective approach for the treatment of morbid obesity. The authors performed a prospective randomized trial to compare outcomes, QOL, and costs of laparoscopic GBP with those of open GBP.

METHODS

From May 1999 to March 2001, 155 patients with a body mass index (BMI) of 40 to 60 kg/m2 were randomly assigned to undergo laparoscopic (n = 79) or open (n = 76) GBP. The two groups were similar in age, sex ratio, mean BMI, and comorbidities. Main outcome measures included operative time, estimated blood loss, length of hospital stay, operative complications, percentage of excess body weight loss, and time to return to activities of daily living and work. Changes in QOL were assessed using the SF-36 Health Survey and the bariatric analysis of reporting outcome system (BAROS). Operative and hospital costs of the two operations were also compared.

RESULTS

There were no deaths in either group. Mean operative time was longer for laparoscopic GBP than for open GBP, but operative blood loss was less. Two (2.5%) of the 79 patients in the laparoscopic group required conversion to laparotomy. Median length of hospital stay was shorter for laparoscopic GBP patients (3 vs 4 days). The rate of postoperative anastomotic leak was similar between groups. Wound-related complications such as infection (10.5 vs 1.3%) and incisional hernia (7.9 vs 0%) were more common after open GBP; late anastomotic stricture was less frequent after open GBP (2.6 vs 11.4%). Time to return to activities of daily living and work were shorter after laparoscopic GBP than after open GBP. Weight loss at 1 year was similar between groups. Preoperative SF-36 scores were similar between groups; however, at 1 month after surgery, laparoscopic patients had better physical conditioning, social functioning, general health, and less body pain than open GBP patients. At 6 months, the BAROS outcome was classified as good or better in 97% of laparoscopic GBP patients compared with 82% of open GBP patients. Operative costs were higher for laparoscopic GBP patients, but hospital costs were lower.

CONCLUSIONS

Laparoscopic GBP is a safe and cost-effective alternative to open GBP. Despite a longer operative time, patients undergoing laparoscopic GBP benefited from less blood loss, a shorter hospital stay, and faster convalescence. Laparoscopic GBP patients had comparable weight loss at 1 year but a more rapid improvement in QOL than open GBP patients. The higher initial operative costs for laparoscopic GBP were adequately offset by the lower hospital costs.