Bariatric Surgery Research Papers - Academia.edu (original) (raw)

The rising prevalence of obesity has reached pandemic proportions, with an associated cost estimated at up to 7% of health expenditures worldwide. Bariatric surgery is currently the only effective long-term treatment for obesity and... more

The rising prevalence of obesity has reached pandemic proportions, with an associated cost estimated at up to 7% of health expenditures worldwide. Bariatric surgery is currently the only effective long-term treatment for obesity and obesity-related co-morbidities in clinically severely obese patients. However, the precise physiological mechanisms underlying the postsurgical reductions in caloric intake and body weight are poorly comprehended. It has been suggested that changes in hormones involved in hunger, food intake and satiety via the neurohormonal network may contribute to the efficacy of bariatric procedures. In this review, we consider how gastrointestinal hormone concentrations, involved in appetite and body weight regulation via the gut-brain axis, are altered by different bariatric procedures. Special emphasis is placed on neurohormonal changes following Roux-en-Y gastric bypass surgery, which is the most common and effective procedure used today.

The exclusion of the proximal small intestine is thought to play a major role in the rapid improvement in the metabolic control of diabetes after gastric bypass. Objective: In this randomized, prospective, parallel group study, we sought... more

The exclusion of the proximal small intestine is thought to play a major role in the rapid improvement in the metabolic control of diabetes after gastric bypass. Objective: In this randomized, prospective, parallel group study, we sought to evaluate and compare the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) with those of laparoscopic sleeve gastrectomy (LSG) on fasting, and meal-stimulated insulin, glucose, and glucagon-like peptide-1 (GLP-1) levels. Methods: Thirteen patients were randomized to LRYGB and 14 patients to LSG. The mostly nondiabetic patients were evaluated before, and 1 week and 3 months after surgery. A standard test meal was given after an overnight fast, and blood samples were collected before and after food intake in both groups for insulin, GLP-1, glucose, PYY, and ghrelin concentrations. This trial was registered in www.clinicaltrials.gov (NCT00356213) before the first patient was randomized. Results: Body weight and body mass index decreased markedly (P Ͻ 0.002) and comparably after either procedure. Excess BMI loss was similar at 3 months (43.3 Ϯ 12.1% vs. 39.4 Ϯ 9.4%, P Ͼ 0.36). After surgery, patients had markedly increased postprandial plasma insulin and GLP-1 levels, respectively (P Ͻ 0.01) after both of these surgical procedures, which favor improved glucose homeostasis. Compared with LSG, LRYGB patients had early and augmented insulin responses as early as 1-week postoperative; potentially mediating improved early glycemic control. After 3 months, no significant difference was observed with respect to insulin and GLP-1 secretion between the 2 procedures. Conclusion: Both procedures markedly improved glucose homeostasis: insulin, GLP-1, and PYY levels increased similarly after either procedure. Our results do not support the idea that the proximal small intestine mediates the improvement in glucose homeostasis. (Ann Surg 2009;250: 234 -241) From the 234 | www.annalsofsurgery.com

obesity reviews Potential mechanisms of bariatric surgery C. S. Tam et al. 9

Over the past several decades, excessive body weight has become a major health concern. As the obesity epidemic continues to expand, metabolic disorders associated with excess body weight, including type 2 diabetes, dyslipidemia,... more

Over the past several decades, excessive body weight has become a major health concern. As the obesity epidemic continues to expand, metabolic disorders associated with excess body weight, including type 2 diabetes, dyslipidemia, hypertension, and cardiovascular disease, have exponentially increased. Dysregulation of satiety hormones and factors that regulate long-term energy storage can disrupt normal metabolic functions and lead to excess body fat. While diet and exercise seem to provide a logical means for weight loss, an unhealthy lifestyle coupled to responses initiated by perceived energy deficit impede sustained long term weight loss. Furthermore, because of the additional lack of effective pharmaceutical interventions to treat excess body weight, patients with severe obesity resort to bariatric surgery as an effective alternative for treatment of obesity and resolution of its associated comorbidities. Interestingly, the precise method by which bariatric surgery promotes rapid improvement in systemic metabolism and long-term weight loss remains incompletely understood and may vary between procedures. Multiple mechanisms likely contribute to the improved glucose metabolism seen after bariatric surgery, including caloric restriction, changes in the enteroinsular axis, alterations in the adipoinsular axis, release of nutrient-stimulated hormones from endocrine organs, stimulation from the nervous system, and psychosocial aspects including a dramatic improvement in quality of life. The current review will highlight the potential contribution of these responses to the improvement in systemic energy metabolism elicited by bariatric surgery. (Translational Research 2013;161:63-72) Abbreviations: BMI ¼ body mass index; BPD/DS ¼ biliopancreatic diversion/duodenal switch (BPD/DS); GIP ¼ glucose-dependent polypeptide; GLP-1 ¼ glucagon-like peptide 1 (GLP-1); HOMA ¼ homeostasis model assessment; LAGB ¼ laparoscopic adjustable gastric band; PYY3-36 ¼ peptide YY 3-36; RYBG ¼ Roux-en-Y gastric bypass; SG ¼ sleeve gastrectomy; VLCD ¼ very low calorie diet

Background: The effect of biphasic positive airway pressure (BPAP) at individualized pressures on the postoperative pulmonary recovery of morbidly obese patients (MOP) undergoing open bariatric surgery (OBS) and possible placebo... more

Background: The effect of biphasic positive airway pressure (BPAP) at individualized pressures on the postoperative pulmonary recovery of morbidly obese patients (MOP) undergoing open bariatric surgery (OBS) and possible placebo device-related effects (sham BPAP) were investigated.
Methods: Forty-eight MOP scheduled for OBS were initially enrolled. Subjects were randomly assigned to: A) the BPAP group in which BPAP, at individualized inspiratory positive airway pressure/expiratory positive airway pressure (IPAP/EPAP), was applied for 3 days postoperatively and B) the sham BPAP group in which sham BPAP was applied for the same time. Pulmonary function was assessed by spirometry 24 h prior to surgery and at 24, 48 and 72 h postoperatively and respiratory complications were recorded.
Results: Thirty-five subjects, 21 in the BPAP group and 14 in the sham BPAP group, completed the study. Baseline characteristics and pulmonary function were similar between groups preoperatively. Subjects in the BPAP group showed in general better spirometric performance and SpO2 values postoperatively and expedited pulmonary recovery. Atelectasis combined with respiratory distress syndrome (RDS) symptoms was observed in 21% of subjects in the sham BPAP group and one of these subjects developed lower respiratory tract infection. No respiratory complications were recorded in the BPAP group. Use of higher BPAP pressures was not associated with anastomosis leakage or disruption in any patient.
Conclusion: Use of BPAP, at individualized pressures, expedites postoperative pulmonary recovery and eliminates respiratory complications in MOP who have undergone OBS.

Obstructive sleep apnoea (OSA) and obstructive sleep apnoea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences amongst the general public as well as the majority of primary care physcians... more

Obstructive sleep apnoea (OSA) and obstructive sleep apnoea syndrome (OSAS) are subsets of sleep-disordered breathing. Awareness about OSA and its consequences amongst the general public as well as the majority of primary care physcians across India is poor. This necessiated the development of the INdian initiative on Obstructive Sleep Apnoea (INOSA) guidelines under the auspices of Department of Health Research, Ministry of Health & Family Welfare, Government of India. OSA is the occurrence of an average five or more episodes of obstructive respiratory events per hour of sleep with either sleep related symptoms or comorbidities or ≥ 15 such episodes without any sleep related symptoms or comorbidities. OSAS is defined as OSA associated with daytime symptoms, most often excessive sleepiness. Patients undergoing routine health check-up with snoring, daytime sleepiness, obesity, hypertension, motor vehicular accidents and high risk cases should undergo a comprehensive sleep evaluation....

We report preliminary data on the effects of massive weight loss on gait kinematics and kinetics. There were substantial readaptations after weight loss in gait kinematics and kinetics, including increases in stride length and gait speed... more

We report preliminary data on the effects of massive weight loss on gait kinematics and kinetics. There were substantial readaptations after weight loss in gait kinematics and kinetics, including increases in stride length and gait speed as well as reductions in vertical ground reaction forces, frontal plane adduction torques, and normalized ankle plantarflexion torques.

Background: Laparoscopic sleeve gastrectomy (LSG) started as the restrictive part of the more complex laparoscopic duodenal switch (LDS) operation. There is no long-term experience with the isolated LSG. The main concern about the... more

Background: Laparoscopic sleeve gastrectomy (LSG) started as the restrictive part of the more complex laparoscopic duodenal switch (LDS) operation. There is no long-term experience with the isolated LSG. The main concern about the isolated LSG is the possibility of dilatation of the gastric pouch, long-term loss of restrictive function and weight regain. Laparoscopic re-sleeve gastrectomy (LRSG) has been used sparingly, but it also may become a possibility if more patients have the isolated LSG. Methods: 2 patients with BMI 58 and 65 respectively, underwent LSG as the first stage of the LDS. Later, when the patients regained some weight and their gastric pouch was found to be too large, the LRSG/DS was done. Results: The patient with BMI 58 had an initial drop to BMI 34 and regained weight to BMI 46, but after the LRSG/DS her BMI is 36 at 4 months. The BMI patient with BMI 65 had a drop to BMI 42, and after the LRSG/DS his BMI is 33 at 3 months later. Conclusion: LRSG may become necessary after gastric tube dilatation or insufficient original gastric volume reduction. LRSG is feasible, available and easy to perform when the resulting gastric pouch is too large or dilates after the original LSG.

Background The enzyme 11-β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) catalyzes intracellular glucocorticoid reactivation by conversion of cortisone to cortisol in different tissues and have been implicated in several metabolic... more

Background The enzyme 11-β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) catalyzes intracellular glucocorticoid reactivation by conversion of cortisone to cortisol in different tissues and have been implicated in several metabolic disorders associated with obesity. The aim of this study was to evaluate the 11β-HSD1 expression in liver, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) in morbidly obese patients undergoing bariatric surgery and its correlations with clinical, anthropometric, and biochemical variables. Methods A prospective study was conducted over a 27-month period. Hepatic, VAT, and SAT samples were obtained at the time of surgery. 11β-HSD1 and 18S gene expression was measured using real-time quantitative reverse transcriptase-polymerase chain reaction. Results Forty nine patients met the inclusion criteria [mean age: 42.2 ± 10 years, body mass index (BMI): 42 ± 6 kg/m2, 71% women and 63% with metabolic syndrome (MS)]. 11β-HSD1 mRNA levels were higher in liver than fat tissue (p < 0.001), being higher in SAT than in VAT (p < 0.001) without gender-specific differences. Hepatic expression of 11β-HSD1 correlated positively with SAT and VAT, alanine aminotransferase (ALT), and serum glucose and was inversely associated with BMI. 11β-HSD1 mRNA in VAT correlated positively with insulinemia, ALT, and LDL cholesterol. There were no associations between 11β-HSD1 mRNA in SAT and the variables analyzed. Conclusions 11β-HSD1 expression is higher in liver in comparison to adipose tissue in obese patients. The observed correlations between hepatic and VAT 11β-HSD1 expression with dyslipidemia and insulin resistance suggest that this enzyme might have a pathogenic role in obesity and related metabolic disorders.

Background Psychological and behavioural factors seem to influence the results of bariatric surgery and the ability to achieve sustained weight loss and subjective wellbeing after the operation. Adequate pre-and postoperative... more

Background Psychological and behavioural factors seem to influence the results of bariatric surgery and the ability to achieve sustained weight loss and subjective wellbeing after the operation. Adequate pre-and postoperative psychological counselling are suggested to improve the results of surgery. However, some patients are reluctant to participate in pre-and postoperative counselling. The aim of the present study was to investigate the possible influence of psychiatric disorders on willingness to participate in group counselling in patients accepted for bariatric surgery. Methods One hundred and forty-one patients referred to bariatric surgery (F/M: 103/38) with mean body mass index (BMI) of 45.2 kg/m 2 (SD=5.3) and mean age of 42.0 years (SD = 10.4) were interviewed with Mini International Neuropsychiatric Interview (M.I.N.I.) and Structured Clinical Interview (SCID-II) preoperatively.

Background This is the largest single-centre series of single-stage laparoscopic sleeve gastrectomy (LSG) reporting on perioperative outcomes, weight loss, comorbidity resolution including urological outcomes and results in the super... more

Background This is the largest single-centre series of single-stage laparoscopic sleeve gastrectomy (LSG) reporting on perioperative outcomes, weight loss, comorbidity resolution including urological outcomes and results in the super obese. Review of prospectively collected data for patients who underwent LSG from March 2007-August 2009. Methods There were 253 patients with a mean age of 44 years (SD, 9) and a mean preoperative body mass index (BMI) of 50 kg/m 2 (SD, 7). There were 17 (7%) major complications and no deaths. The mean follow-up was 9 months. One hundred and seventy-one patients with a mean follow-up of 12 months had a mean postoperative weight loss of 41 kg (SD, 16) and mean excess BMI (meBMI) loss of 59% (SD, 22). Results One hundred fourteen patients were super obese (BMI, >50 kg/m 2 ). The mean weight loss was 45 kg (SD, 18), and the meBMI lost was 49% (SD, 21). Super-obese patients experienced more complications (p=0.02) and lost less eBMI (49% vs. 61%; p<0.01). Fifty-three patients (46%) remained morbidly obese (BMI, >40 kg/m 2 ) postoperatively. Hypertension and diabetes improved or resolved in 73 (79%) and 73 (90%) patients, respectively. Stress urinary incontinence was reported preoperatively in 60 (32%) females, and complete resolution or improvement was reported in 54 (90%) patients.

Several studies have shown that physical and/or sexual abuse during childhood may lead to the development of obesity later in life. Despite these consistent findings, the mechanism for the increased risk of obesity following developmental... more

Several studies have shown that physical and/or sexual abuse during childhood may lead to the development of obesity later in life. Despite these consistent findings, the mechanism for the increased risk of obesity following developmental trauma is unknown. It has been suggested that psychological dysfunction, including the presence of disordered eating behavior, may account for the added risk of adult obesity. To test this hypothesis, we analyzed the prevalence and severity of different types of early traumatic life events, assessed the presence of coexisting psychiatric disorders and measured adult attachment style in a sample of 200 subjects including nonobese healthy volunteers and obese participants undergoing a psychiatric assessment to determine suitability for bariatric surgery. Participants who scored higher on a scale measuring the severity of traumatic events experienced during the first 15 years of their lives were more likely to be obese at the time of testing. The exclusion of the participants who experienced physical and/or sexual abuse did not change the results of statistical analysis. Severity of early trauma remained a significant predictor of adult obesity when the influence of psychiatric diagnosis and anxious attachment was taken into account. These findings suggest that: (1) not only sexual or physical abuse but also less severe forms of early-life stress are linked to the development of obesity later in life; and (2) psychological dysfunction is not the only mechanism mediating the elevated risk of obesity in persons exposed to early-life trauma.

Background: Vertical Banded Gastroplasty (VBG) is one of the most common bariatric operations. It can be performed by open or laparoscopic methods. The purpose of this study was to analyze and compare the 1-year results of 40 patients who... more

Background: Vertical Banded Gastroplasty (VBG) is one of the most common bariatric operations. It can be performed by open or laparoscopic methods. The purpose of this study was to analyze and compare the 1-year results of 40 patients who underwent laparoscopic (20) and open (20).

PURPOSE A case representative of issues dental practitioners may face when providing care to patients with a history of bariatric surgery is reviewed. Meta-analysis shows that, following bariatric surgery, 43 to 79% of diabetes,... more

PURPOSE A case representative of issues dental practitioners may face when providing care to patients with a history of bariatric surgery is reviewed. Meta-analysis shows that, following bariatric surgery, 43 to 79% of diabetes, hyperlipidemia and hypertension in patients resolved to normal levels or no longer required therapy. However, bariatric surgery side effects have implications for oral health, including nutrient deficiencies impacting healing of oral tissues and gastroesophageal reflux, resulting in tooth erosion. Patients who have undergone bariatric surgery are seen with increasing frequency in dental offices and dental professionals need to be familiar with the challenges these patients present.

Background Obesity in pediatric and adolescent population has reached a universal pandemic. This study aimed to summarize the literature on the longest available outcome of bariatric surgery in morbidly obese adolescents. Methods A... more

Background Obesity in pediatric and adolescent population has reached a universal pandemic. This study aimed to summarize the literature on the longest available outcome of bariatric surgery in morbidly obese adolescents. Methods A systematic review was conducted to pool available data on the longest available (>3 years) weight loss and comorbidity resolution outcome in adolescent bariatric surgery. Results A total of 14 studies reporting the result of bariatric surgery after 3 years in 950 morbidly obese adolescents were included. Preoperative age and BMI ranged from 12 to 19 years and from 26 to 91 kg/m 2 , respectively. Females were the predominant gender (72.8%). Laparoscopic roux-en-Y gastric bypass (n = 453) and adjustable gastric banding (n = 265) were the most common bariatric procedure performed. The number of patients at the latest follow-up was 677 (range from 2 to 23 years). On average, patients lost 13.3 kg/m 2 of their BMI. Among comorbidities, only diabetes mellitus resolved or improved dramatically. Of 108 readmissions, 91 led to reoperation. There was a weight regain < 5 kg/m 2 between 5 and 6 years of follow-up. Removal, exchange, or conversion of the previous band constituted the majority of the revisional procedures. Three deaths were reported. No long-term data was obtainable on nutritional deficiency or growth status of adolescents who underwent a bariatric procedure. Conclusion Although bariatric surgery is a safe and effective procedure in the treatment of adolescent morbid obesity, longterm data is scarce regarding its nutritional and developmental complication in this growing population of patients.

Bariatric surgery is now the treatment of choice for morbid obesity, but is not without risk. Patients are cared for in specialised centres, but complications can present to non-specialised centres. We describe life-threatening re-feeding... more

Bariatric surgery is now the treatment of choice for morbid obesity, but is not without risk. Patients are cared for in specialised centres, but complications can present to non-specialised centres. We describe life-threatening re-feeding oedema in a patient following routine deflation of a gastric band. Band deflation or removal may be required for various reasons, but rapid release of the band without additional supplementation of electrolytes may be dangerous due to re-feeding syndrome.

Morbidly obese patients undergoing general anesthesia for laparoscopic bariatric surgery are considered at increased risk of a postoperative decrease in lung function. The purpose of this study was to determine whether a systematic use of... more

Morbidly obese patients undergoing general anesthesia for laparoscopic bariatric surgery are considered at increased risk of a postoperative decrease in lung function. The purpose of this study was to determine whether a systematic use of incentive spirometry (IS) prior to surgery could help patients to preserve their respiratory function better in the postoperative period. Forty-one morbidly obese (body mass index [BMI] . 40 kg/m 2 ) candidates for laparoscopic bariatric surgery were consented in the study. All patients were taught how to use an incentive spirometer but then were randomized blindly into 2 groups. The control group was instructed to use the incentive spirometer for 3 breaths, once per day. The treatment group was requested to use the incentive spirometer for 10 breaths, 5 times per day. Twenty experimental (mean BMI of 48.9 6 5.67 kg/m 2 ) and 21 control patients (mean BMI of 48.3 6 6.96 kg/ m 2 ) were studied. The initial mean inspiratory capacity (IC) was 2155 6 650.08 (SD) cc and 2171 6 762.98 cc in the experimental and control groups, respectively. On the day of surgery, the mean IC was 2275 6 777.56 cc versus 2254.76 6 808.84 cc, respectively. On postoperative day 1, both groups experienced a significant drop of their IC, with volumes of 1458 6 613.87 cc (t test P , 0.001) and 1557.89 6 814.67 cc (t test P , 0.010), respectively. Our results suggest that preoperative use of the IS does not lead to significant improvements of inspiratory capacity and that it is a not a useful resource to prevent postoperative decrease in lung function. (Translational Research 2010;156:265-272) Abbreviations: ABG ¼ arterial blood gases; BiPAP ¼ bilevel positive airway pressure; BMI ¼ body mass index; CPAP ¼ continuous positive airway pressure; FEV1 ¼ forced expiratory volume in 1 s; FiO 2 ¼ fraction of inspired oxygen; FRC ¼ functional residual capacity; IC ¼ inspiratory capacity; IS ¼ incentive spirometry; OHS ¼ obesity hypoventilation syndrome; PACU ¼ postanesthesia care unit; PEEP ¼ positive end-expiratory pressure

Background Obesity is a major public health concern on a global scale. Bariatric surgery is among the treatment options, resulting in significant and sustainable weight loss as well as amelioration of comorbidities. The purpose of this... more

Background Obesity is a major public health concern on a global scale. Bariatric surgery is among the treatment options, resulting in significant and sustainable weight loss as well as amelioration of comorbidities. The purpose of this study was to evaluate whether a 12-week aerobic exercise program positively impacts heart rate variability (HRV) and functional capacity after gastric bypass surgery (GBS) in a female cohort. Methods Of the 52 patients initially recruited, 21 were randomized to a training group (TG) or control group and successfully completed the study. Patients were tested on two occasions: 1 week before GBS and 4 months after GBS. Anthropometric variables, body composition, record of heart rate and R-R intervals, and 6-min walk test (6MWT) were assessed at both time points. The TG underwent an aerobic exercise training program on a treadmill (1-h session, totaling 36 sessions over 12 weeks). Results The main findings from this study were: (1) only the TG demonstrated a significant increase (p<0.05) in all indexes of heart rate variability (HRV) after 12 weeks of aerobic exercise training and only the TG demonstrated a significant increase (p<0.05) in 6MWT distance and decrease in diastolic blood pressure after aerobic exercise training. Conclusions We conclude that 12 weeks of aerobic exercise training improves cardiac autonomic modulation and functional capacity 4 months after GBS.

The advent of laparoscopic adjustable gastric banding (LAGB) during the latter part of the 20th century represents a watershed in the management of chronic obesity. In this paper we provide an overview of LAGB with respect to its... more

The advent of laparoscopic adjustable gastric banding (LAGB) during the latter part of the 20th century represents a watershed in the management of chronic obesity. In this paper we provide an overview of LAGB with respect to its development, clinical outcomes, and future role. We also address current controversies, including a comparison of LAGB with Roux-en-Y gastric bypass (RYGBP). At present LAGB seems to be increasing in popularity in the United States, whereas in Europe there seems to be a trend away from gastric banding toward RYGBP. Optimal outcomes after LAGB are a function of correct laparoscopic technique, an experienced surgical team, a well-engineered device, and intensive long-term follow-up. The majority of studies show that LAGB is an extremely safe and effective procedure, with an operative mortality of 0-0.1% and excess weight loss (%EWL) of 50-60%. Commensurate with this degree of weight loss, almost all studies show substantial improvements in obesity-related co-morbidities, such as hypertension, type II diabetes, and dyslipidemia. In addition, LAGB has been shown to be both safe and effective in the super-obese, in adolescents, and in older patients and can be delivered as an ambulatory procedure. Operative mortality and early complication rates are significantly higher for RYGBP and, whilst gastric bypass results in greater weight loss than LAGB in the first 2 years, at 3 years and beyond the difference appears to be less marked. Overall, LAGB provides a safe, effective intervention for obese patients and remains our first-choice procedure for bariatric surgery.

Background. When other weight loss attempts have failed, bariatric surgery offers a successful alternative for obesity. Since operations are performed during women's reproductive years, the number of pregnant women with prior bariatric... more

Background. When other weight loss attempts have failed, bariatric surgery offers a successful alternative for obesity. Since operations are performed during women's reproductive years, the number of pregnant women with prior bariatric surgery is increasing. Bariatric surgery results in restriction of food intake and/or malabsorption leading to weight loss, but may induce a risk for malnutrition and pregnancy complications. Method. Systematically conducted review addressing pregnancy after bariatric surgery using the PubMed and Cochrane databases. Main outcome measures. Birthweight, gestational age, birth defects, preeclampsia, gestational diabetes mellitus, and mode of delivery. Results. We included 17 articles in English, comparing pregnancies in women with prior bariatric surgery to pregnancies in a control group without this. There was considerable heterogeneity in study design and six of the studies included <50 women with bariatric surgery. Eight studies described lower birthweight and lower risk of macrosomia after bariatric surgery, but in six there was no difference. Five studies indicated a higher risk of small-for-gestational age infants, but only compared with non-obese women or severely obese controls. There was no difference in gestational length. Only one study suggested a higher risk of birth defects after surgery. The maternal risk of preeclampsia and gestational diabetes mellitus was lower after bariatric surgery. Results regarding mode of delivery are conflicting. Conclusion. Pregnancy after bariatric surgery seems safe but larger studies matching or adjusting for body mass index are needed to improve the surveillance of these pregnancies and to assist in preventing adverse outcomes.

Background: Bariatric surgery has the potential for serious complications. A case is presented of unilateral lower extremity compartment syndrome after a laparoscopic Roux-en-Y gastric bypass performed in the modified lithotomy position.... more

Background: Bariatric surgery has the potential for serious complications. A case is presented of unilateral lower extremity compartment syndrome after a laparoscopic Roux-en-Y gastric bypass performed in the modified lithotomy position. Case report: A 38-year-old female (weight 134.5 kg, BMI 49.6) underwent a laparoscopic Roux-en-Y gastric bypass (operating time 375 min). Postoperatively, she complained of bilateral lower extremity pain that gradually subsided over the course of the day. However, on the 1st postoperative day she developed numbness on the dorsum of the foot and compartment syndrome was diagnosed (anterior compartment pressure 71 mmHg). She underwent emergency fasciotomy,which resulted in a reduction of the pain and numbness on the dorsum of the foot. The next day she ambulated without difficulty and was discharged home on the 5th postoperative day. 12 days after her operation, delayed primary closure of the fasciotomy wound was done with the assistance of a novel device (Proxiderm) that applies constant tension to the wound edges. Subsequent recovery was uneventful, and at 4- month follow-up the patient had a weight loss of 28 kg without any right leg motor or sensory deficits. Conclusion: Bariatric surgeons should be aware of compartment syndrome as a rare but serious complication. Prevention, early recognition, and prompt fasciotomy are crucial for a favorable outcome.

Background Recent evidence suggests that bariatric patients may be overrepresented in inpatient substance abuse treatment, but the reasons for this are unclear. Patients' perceptions of this problem may be of heuristic value. Using a... more

Background Recent evidence suggests that bariatric patients may be overrepresented in inpatient substance abuse treatment, but the reasons for this are unclear. Patients' perceptions of this problem may be of heuristic value. Using a qualitative approach, the present study evaluated bariatric patients' impressions of how their postsurgical substance use disorders emerged and their future recommendations for those working with bariatric patients. Methods Semi-structured interviews were conducted with 24 bariatric patients in an inpatient substance abuse treatment program. Seven prominent themes emerged, four referring to etiology of substance use (unresolved psychological problems, addiction transfer/substitution, faster onset or stronger effects from substances, and increased availability of pain medications) and three pertaining to future recommendations (counseling preand/or postsurgery, increased knowledge of the associated risks of substance use postsurgery, and greater "honesty"). Blind coders rated the presence or absence of each theme in each interview. Results Of the four etiology themes, 75 % of patients acknowledged unresolved psychological problems, 83.33 % identified addiction transfer/substitution, 58.33 % noticed faster onset or stronger effects from substances, and 45.83 % identified increased availability of pain medications. For future recommendations, 41.67 % suggested counseling pre-and/or postsurgery, 70.83 % suggested increased education about the associated risks of substance use postsurgery, and 41.67 % identified a need for greater "honesty." Conclusions Patient perceptions suggest that several common themes may be related to risk for the development of postsurgical substance use disorders.

Lifestyle modification therapy for overweight and obese patients combines specific recommendations on diet and exercise with behavioral and cognitive procedures and strategies. In completers it produces a mean weight loss of 8-10 % in... more

Lifestyle modification therapy for overweight and obese patients combines specific recommendations on diet and exercise with behavioral and cognitive procedures and strategies. In completers it produces a mean weight loss of 8-10 % in about 30 weeks of treatment. However, two main issues still to be resolved are how to improve dissemination of this approach, and how to help patients maintain the healthy behavioral changes and avoid weight gain in the long term. In recent years, several strategies for promoting and maintaining lifestyle modification have been evaluated, and promising results have been achieved by individualising the treatment, delivering the intervention by phone and internet or in a community setting, and combining lifestyle modification programs with residential treatment and bariatric surgery. These new strategies raise optimistic expectations for the effective management of obesity through lifestyle modification.

Background: This qualitative study aims to understand academic physicians' attitudes towards the treatment of pediatric obesity in Canada. Methods: A stratified sample of 24 participants (surgeons, pediatricians, family practitioners)... more

Background: This qualitative study aims to understand academic physicians' attitudes towards the treatment of pediatric obesity in Canada. Methods: A stratified sample of 24 participants (surgeons, pediatricians, family practitioners) were recruited from 4 Canadian regions. Semi-structured interviews were conducted and transcribed. A codebook was developed through iterative data reduction and conceptual saturation ensured. Validity was ensured through triangulation, audit trail, and member-checking. Results: This study revealed 45 themes with regional, specialty, and experiential differences. Quebec and Ontario emphasized education of physicians and parents to improve treatment and favored surgical intervention. Half of surgeons felt surgery was the only successful treatment option, while non-surgeons favored behavioral interventions. Experienced physicians in Western Canada desired more evidence to improve patient care, while inexperienced physicians focused on early detection and home environments. Across Canada participants advocated for program development and system change. Respondents expressed family involvement as integral to treatment success and shifting away from blame and moving towards a healthy lifestyles approach. Conclusions: Canadian regional differences in physicians' attitudes towards pediatric obesity treatment exist, influenced by experience and specialty. We will understand how themes identified in this study influence real life clinical decision making by applying these results to create a discrete choice-based conjoint survey.

Background Bariatric approach to obesity provides substantial weight loss and comorbidity resolution. Our unique service includes pre-and postoperative visits to the Health and Nutrition Clinic headed by a specialist in gastroenterology... more

Background Bariatric approach to obesity provides substantial weight loss and comorbidity resolution. Our unique service includes pre-and postoperative visits to the Health and Nutrition Clinic headed by a specialist in gastroenterology and nutrition. We compared patients attending regular clinic routine with those who were lost to follow-up with regard to anthropometry, comorbidity, quality of life, and food tolerance and determined who benefited most from the operation. Methods A retrospective review was performed on patients 30 months after undergoing sleeve gastrectomy. Body mass index was used to report weight loss. Bariatric Analysis and Reporting Outcome System (BAROS) and Food Tolerance Score were (FTS) completed by all patients at the 30-month follow-up visit and compared between two groups (group I-30 months of active postoperative follow-up; group IIwithout). Results A total of 119 patients participated in the study. For groups I and II, the mean percentage of excess BMI loss at 30 months was 82.08±9.83 and 74.88±8.75, respectively, with better comorbidity improvement in group I. BAROS scores were 7.62±0.72 and 6.92±0.92. FTS was 24.30± 2.09 and 22.55±2.27, respectively. Conclusions From our experience, getting the most from the sleeve is attributed to two main factors: surgery and nutrition. Surgery results in optimal restriction and im-proved satiety, whereas nutrition relies on a professional medical team providing constant, ongoing patient support throughout all the bariatric process stages. These teams of surgeons and gastroenterologists specializing in nutrition, working side by side, each in their area of specialty, are the main pillars leading to the success of the sleeve.

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is being performed widely as a treatment of choice for morbid obesity. We present our method and experience with the first 150 consecutive cases of laparoscopic RYGBP with a 2-m... more

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is being performed widely as a treatment of choice for morbid obesity. We present our method and experience with the first 150 consecutive cases of laparoscopic RYGBP with a 2-m long biliopancreatic limb (BP-limb). Methods: Between November 2001 and November 2003, a prospective analysis of 150 patients was performed identifying technical success and complications. Before surgery, patients underwent a strict multidisciplinary behavioral program. At operation the stomach was transected proximally with a linear stapler (60-mm, Endo-GIA) to create a prolongation of the esophagus (gastric tube) along the lesser curvature, resulting in a 40-50 ml pouch. Two meters of the proximal jejunum were bypassed (BP-limb), creating an antecolic Roux-en-Y gastro-jejunostomy to the posterior wall of the gastric tube using a 45-mm linear Endo-GIA stapler. The entero-anastomosis was created 50 cm below the gastro-jejunostomy, also with a 45-mm linear Endo-GIA. Results: Mean BMI was 50.0, and 78% of patients were females. With 100% follow-up, we found an EWL of 50% 6 months after surgery, gradually rising to 80% after 18 months. The mean operating time was 116 min for the first 50 cases and decreased to 82 min for the last 50 cases. Intestinal leakage occurred in 5 patients (3%) and bleeding in 5 (3%). Most of these complications occurred in the first 50 cases, and all but one were treated successfully with an early laparoscopic re-operation. Marginal ulcers were found in 16.6% of patients. No internal hernias have occurred. Conclusion: The operation demands advanced laparoscopic skills, but technically it is relatively simple and has an acceptable complication rate. Short-term results regarding excess weight loss are at least comparable to the RYGBP with a long alimentary limb.

Background: In Prader-Willi Syndrome (PWS), mental retardation and compulsive hyperphagia cause early obesity, the co-morbidities of which lead to short life-expectancy, with death usually occurring in their 20s. Long-term weight loss is... more

Background: In Prader-Willi Syndrome (PWS), mental retardation and compulsive hyperphagia cause early obesity, the co-morbidities of which lead to short life-expectancy, with death usually occurring in their 20s. Long-term weight loss is mandatory to lengthen the survival; therefore, the lack of compliance in voluntary food restriction requires a surgical malabsorptive approach.

Background: Binge-eating disorder (BED) may be associated with unsatisfactory weight loss in obese patients submitted to bariatric procedures. This study aims to investigate whether the presence of binge eating before Roux-en-Y gastric... more

Background: Binge-eating disorder (BED) may be associated with unsatisfactory weight loss in obese patients submitted to bariatric procedures. This study aims to investigate whether the presence of binge eating before Roux-en-Y gastric bypass (RYGBP) influences weight outcomes.

Body image disturbance is a significant maintenance and prognosis factor in eating disorders. Hence, existing eating disorder treatments can benefit from direct intervention in patients' body image. No controlled studies have yet compared... more

Body image disturbance is a significant maintenance and prognosis factor in eating disorders. Hence, existing eating disorder treatments can benefit from direct intervention in patients' body image. No controlled studies have yet compared eating disorder treatments with and without a treatment component centered on body image. This paper includes a controlled study comparing Cognitive Behavioral Treatment (CBT) for eating disorders with and without a component for body image treatment using Virtual Reality techniques. Thirty-four participants diagnosed with eating disorders were evaluated and treated. The clinical improvement was analyzed from statistical and clinical points of view. Results showed that the patients who received the component for body image treatment improved more than the group without this component. Furthermore, improvement was maintained in post-treatment and at one year follow-up. The results reveal the advantage of including a treatment component addressing body image disturbances in the protocol for general treatment of eating disorders. The implications and limitations of these results are discussed below.

Obesity is a chronic and endemic disease in developed countries, there is an inverse relationship between the socio-economic level and the prevalence of this disease. Their costs are responsible from 2 to 7% of the total health costs. The... more

Obesity is a chronic and endemic disease in developed countries, there is an inverse relationship between the socio-economic level and the prevalence of this disease. Their costs are responsible from 2 to 7% of the total health costs. The prevalence of obesity in the world is so high that the World Health Organization considered this disease as the global epidemic of the XXI century. In Portugal it's estimated that around 16.5% of the population aged over 18 years, has obesity, and due to the morbidity and mortality associated with this pathology, this constitutes a serious public health issue. There are several ancient references to obesity and its consequences, with descriptions of different therapeutic attitudes. But only in 1965 the term bariatric was introduced and consequently the term bariatric surgery. Mason, the father of bariatric surgery, started its history in 1966. Several surgical techniques were subsequently developed, but currently the most used are the gastric b...

In 2011, laparoscopic sleeve gastrectomy (LSG) became the most commonly performed bariatric procedure in France [1] and 2 years later also in the United States [2]. Its frequency has been constantly increasing worldwide. This growth can... more

In 2011, laparoscopic sleeve gastrectomy (LSG) became the most commonly performed bariatric procedure in France [1] and 2 years later also in the United States [2]. Its frequency has been constantly increasing worldwide. This growth can be explained by several advantages that LSG carries over more complex bariatric procedures, such as Roux-en-Y gastric bypass or duodenal switch, including the absence of most side effects of bypass procedures such as dumping syndrome, marginal ulcers, malabsorption, small bowel obstruction, and internal hernia, and a better quality of life over gastric banding .

Introduction Data on vegetarianism and bariatric surgery (BS) are scarce. We herein describe the health and nutritional status of vegetarian patients who plan to undergo BS and propose combined recommendations for vegetarian patients who... more

Introduction Data on vegetarianism and bariatric surgery (BS) are scarce. We herein describe the health and nutritional status of vegetarian patients who plan to undergo BS and propose combined recommendations for vegetarian patients who undergo BS, based on our clinical experience and current scientific literature in both nutrition fields. Methods Cross-sectional analysis of a prospectively maintained database of all primary laparoscopic sleeve gastrecto-mies (LSG) performed at a bariatric center of excellence between January 2014 and November 2016 was carried out querying patients who declared a vegetarian or vegan lifestyle before surgery. Preoperative data collected included demographics, anthropometrics, dietary patterns, supplemen-tation use, physical activity, smoking habits, co-morbidities, and blood tests. Each vegetarian was matched to five different omnivores based on age, gender, and BMI. Results During the study period, 1470 patients underwent primary LSG surgery (63.7% females). Twenty-one declared a vegetarian or vegan lifestyle (1.4%) pre-surgery. Most were classified as lacto-ovo (57.1%) and were driven from ethical reasons (85.7%). No differences were found between vegetarian and omnivore LSG candidates regarding co-morbidities and nutritional deficiencies, except for lower prevalence of impaired fasting glucose (14.3 vs. 47.1%;P = 0.007), lower ferritin levels (54.3 ± 50.5 vs. 96.8 ± 121.8 ng/ml;

Background: Although low back (LBP) pain is not a lifethreatening disease, it is a source of significant discomfort and disability and accounts for work absences. It has been shown previously that morbid obesity is associated with... more

Background: Although low back (LBP) pain is not a lifethreatening disease, it is a source of significant discomfort and disability and accounts for work absences. It has been shown previously that morbid obesity is associated with increased frequency of LBP and that surgical weight loss improves the symptomatology. However, there are no studies to quantitatively assess the exact degree of functional disability caused by severe obesity and the degree of improvement of LBP that follows weight loss from bariatric surgery.

Morbid obesity is an epidemic in the United States and parts of Europe, with severe health consequences. As the number of patients undergoing bariatric surgery has increased dramatically, it is crucial for the gastroenterologist caring... more

Morbid obesity is an epidemic in the United States and parts of Europe, with severe health consequences. As the number of patients undergoing bariatric surgery has increased dramatically, it is crucial for the gastroenterologist caring for these patients to have a better understanding of the procedures, their unique complications and the proper management for these complications.

Background. Polycystic ovary syndrome (PCOS) is the commonest cause of female infertility. Visceral obesity and insulin resistance are key pathophysiological mechanisms behind PCOS. Women suffering from this syndrome and infertility often... more

Background. Polycystic ovary syndrome (PCOS) is the commonest cause of female infertility. Visceral obesity and insulin resistance are key pathophysiological mechanisms behind PCOS. Women suffering from this syndrome and infertility often seek bariatric surgery hoping that they would be able to conceive postoperatively. Objective. At present, there is no consensus on the role of bariatric surgery in the management of PCOS-associated infertility within the medical community, making it difficult to give specific advice to these women, so a review of the literature was necessary. Results. A detailed review of the literature was performed. Only 6 manuscripts were relevant and contained quantitative data. They demonstrated that bariatric surgery results in postoperative conception rates varying from 33% to 100%. Surgery is also associated with amelioration of menstrual irregularities, hormonal abnormalities, and hirsutism that are associated with PCOS. These studies were retrospective an...

Background: Abnormalities in calcium and vitamin D metabolism are observed early after gastric bypass, whereas clinical or biochemical evidence of metabolic bone disease might not be detected until many years after the procedure. The aim... more

Background: Abnormalities in calcium and vitamin D metabolism are observed early after gastric bypass, whereas clinical or biochemical evidence of metabolic bone disease might not be detected until many years after the procedure. The aim of the present study was to evaluate the impact of bariatric surgery on bone metabolism determined on the basis of postoperative laboratory changes in calcium, phosphorus, magnesium, alkaline phosphatase and parathormone (PTH) levels. Methods: 110 patients submitted to Roux-en-Y gastric bypass (RYGBP) were followed after surgery, and the following parameters were determined: intact PTH molecule (PTHi; chemiluminescence), alkaline phosphatase (colorimetric method), ionic calcium (selective electrode), phosphorus and magnesium (colorimetric method). Results: Elevated serum PTHi levels were observed in 29% of the patients and hypocalcemia in 0.9% from the 3rd postoperative month and afterwards (3 to 80 months after surgery). Conclusion: There is a need for careful evaluation of bone metabolism and for routine calcium replacement after RYGBP.

This presentation was prepared by RUTAYISIRE François Xavier and ISHIMWE Diane, Medical students in Year 4(Doctorate 2) at University of RWANDA school of medicine and Pharmacy, Department of Medicine and Surgery. we did the work under... more

This presentation was prepared by RUTAYISIRE François Xavier and ISHIMWE Diane, Medical students in Year 4(Doctorate 2) at University of RWANDA school of medicine and Pharmacy, Department of Medicine and Surgery. we did the work under supervision of Dr Ntakiyiruta Georges,Mmed,FCSECSA

About 2.6 million stillbirths annually are estimated to occur worldwide, mainly in developing countries, although much of the data is incomplete. The aim of the present study was to analyze cases of stillbirth examined in an Institute of... more

About 2.6 million stillbirths annually are estimated to occur worldwide, mainly in developing countries, although much of the data is incomplete. The aim of the present study was to analyze cases of stillbirth examined in an Institute of Forensic Medicine of the Federal District (IML-DF), Brazil. A total of 38 cases were analyzed, mostly male, with a mean gestational age of 32.9 ± 6.38 weeks. Maternal causes predominated, with hypertensive disorders during pregnancy and trauma as the leading causes; placental causes followed, the most frequent being premature detachment of the placenta. Fetal causes occurred in three cases (one of the case is cardiac malformation and two are kidney disease). In nine cases, the cause of stillbirth could not be determined. The authors call attention to the importance of stillbirth rate, which is considered one of the best indicators of quality of life in a population; to the lack of reliable data for assessing such rate; and to the main factors associated with fetal death and the measures that could be taken to prevent such death. The occurrence of a stillbirth affects the mother, the family, the professionals responsible, the community, and the society. It is a heavy burden for the affected families, and psychological symptoms often persist long after the death of the babies. The authors believe that stigmas and taboos exacerbate the trauma for the families and that fatalism undermines the prevention of stillbirths, which in most cases is possible with the improvement of health services.

BACKGROUND: Short-segment Barrett's esophagus (SSBE) or long-segment Barrett's esophagus (LSBE) is the consequence of chronic gastroesophageal reflux disease (GERD), which is frequently associated with obesity. Obesity is a... more

BACKGROUND: Short-segment Barrett's esophagus (SSBE) or long-segment Barrett's esophagus (LSBE) is the consequence of chronic gastroesophageal reflux disease (GERD), which is frequently associated with obesity. Obesity is a significant risk factor for the development of GERD symptoms, erosive esophagitis, Barrett's esophagus, and esophageal adenocarcinoma. Morbidly obese patients who submitted to gastric bypass have an incidence of GERD as high as 50% to 100% and Barrett's esophagus reaches up to 9% of patients. METHODS: In this prospective study, we evaluate the postoperative results after three different procedures-calibrated fundoplication + posterior gastropexy (CFPG), fundoplication + vagotomy + distal gastrectomy + Roux-en-Y gastrojejunostomy (FVDGRYGJ), and laparoscopic resectional Roux-en-Y gastric bypass (LRRYGBP)-among obese patients. RESULTS: In patients with SSBE who submitted to CFPG, the persistence of reflux symptoms and endoscopic erosive esophagi...

Obesity Surgery,[962][963][964][965][966][967][968][969] The rising prevalence of morbid obesity and the increased incidence of super-obese patients (BMI >50 kg/m 2 ) seeking surgical treatments has led to the search for surgical... more

Obesity Surgery,[962][963][964][965][966][967][968][969] The rising prevalence of morbid obesity and the increased incidence of super-obese patients (BMI >50 kg/m 2 ) seeking surgical treatments has led to the search for surgical techniques that provide adequate EWL with the least possible morbidity. Sleeve gastrectomy (SG) was initially added as a modification to the biliopancreatic diversion (BPD) and then combined with a duodenal switch (DS) in 1988. It was first performed laparoscopically in 1999 as part of a DS and subsequently done alone as a staged procedure in 2000. With the revelation that patients experienced weight loss after SG, interest in using this procedure as a bridge to more definitive surgical treatment has risen. Benefits of SG include the low rate of complications, the avoidance of foreign material, the maintenance of normal gastro-intestinal continuity, the absence of malabsorption and the ability to convert to multiple other operations. Reduction of the ghrelinproducing stomach mass may account for its superiority to other gastric restrictive procedures. SG should be in the armamentarium of all bariatric surgeons. Nonetheless, long-term studies are necessary to see if it is a durable procedure in the treatment of morbid obesity.