Outcome Following Bariatric Surgery in Super versus Morbidly Obese Patients: Does Weight Matter?

Background: Numerous investigators have attempted to identify prognostic indicators for successful outcome following bariatric surgery. The purpose of this study was to determine whether degree of obesity affects outcome in super obese [>225% ideal body weight (IBW)] versus morbidly obese patients (160-225% IBW) undergoing gastric restrictive/bypass procedures. Methods: Since 1984, 157 patients underwent either gastric bypass or vertical banded gastroplasty. Super obese (78) and morbidly obese (79) patients were followed prospectively, documenting outcome and complications. Results: Super obese patients reached maximum weight loss 3 years following bariatric surgery, exhibiting a decrease in body mass index (BMI) from 61 to 39 kg/m² and an average loss of 42% excess body weight (EBW). Morbidly obese patients had a decrease in BMI from 44 to 31 kg/m² and carried 39% EBW at 1 year. After their respective nadirs, each group began to regain the lost weight with the super obese exhibiting a current BMI of 45 kg/m² (61% EBW) versus 34 kg/m² (52% EBW) in the morbidly obese at 72 months cumulative follow-up. Currently, loss of 50% or more of EBW occurred in 53% of super obese patients versus 72% of morbidly obese (P < 0.01). Twenty-six percent of super obese patients returned to within 50% of ideal body weight (IBW) while 71% of morbidly obese were able to reach this goal (P < 0.01). Co-morbidities and complications related to surgery were similar in each group. Conclusions: Super obese patients have a greater absolute weight loss after bariatric surgery than do morbidly obese patients. Using commonly utilized measures of success based on weight, morbidly obese patients tend to have better outcomes following bariatric surgery.     

Gastric Bypass in a Japanese Man with Prader-Willi Syndrome and Morbid Obesity

Background: In Prader-Willi syndrome (PrWS), marked obesity is the most serious and common complication, contributing significantly to morbidity and mortality. Because of the associated psychosocial difficulties, bariatric surgery appears to be the only effective treatment. Case Report: A 30-year-old man with PrWS weighing 108 kg (BMI 50 kg/m²), underwent Roux-en-Y gastric bypass (RYGBP). 3 months before the RYGBP, he weighed 146 kg (BMI 68.5), partly because of heart failure. 18 months after RYGBP, he weighed 92.4 kg (BMI 43.3), with no postoperative complications. Moreover, he showed considerable increase in serum HDL-cholesterol levels with reciprocal reduction in LDL-cholesterol after the surgery. Conclusion: RYGBP resulted in satisfactory weight loss and improvement in serum lipid profile in a Japanese morbidly obese patient with PrWS.     

MMPI-2 Scores in the Outcome Prediction of Gastric Bypass Surgery

Background: A psychological assessment is critical for morbidly obese patients seeking Roux-en-Y gastric bypass (RYGBP) surgery. The Minnesota Multiphasic Personality Inventory (MMPI) has been widely used in past psychological studies of bariatric surgery patients, but, to date, there is no published research on the more recent version of the MMPI, the Minnesota Multiphasic Personality Inventory-2 (MMPI2), and its relation to RYGBP outcome.This investigation was designed to evaluate the predictive validity of the MMPI-2 with respect to outcome of RYGBP for morbid obesity. Methods: The research involved a retrospective analysis of MMPI-2 scores of 2 groups of patients 1 year following RYGBP: 1) those who lost ≥ 50% of their excess weight and 2) those who lost <50% of their excess weight. Subjects were 52 morbidly obese patients (mean age 44 years, mean BMI 56 kg/m2).The measurement of psychological variables consisted of the MMPI-2 scores of 3 validity scales, 10 clinical scales, and 3 Content Scales, and BMI. Results: Those who lost <50% excess weight scored significantly higher than those who lost >50% excess weight on the F,Hysteria, Paranoia, and Health Concerns scales of the MMPI-2, and significantly lower on the Masculinity-femininity scale. Stepwise regression analysis found that a combination of the Health Concerns and Masculinity-femininity scales was the most accurate predictor model for 1-year post-surgery weight loss. Conclusion: A standard personality measure, the MMPI-2, appears to be associated with weight loss outcome 1 year after RYGBP. Psychological traits such as anxiety and excessive health concerns are likely to influence bariatric surgical outcome.     

Does Gastric Dilatation Limit the Success of Sleeve Gastrectomy as a Sole Operation for Morbid Obesity?

Background: Sleeve gastrectomy as the sole bariatric operation has been reported for high-risk super-obese patients or as first-step followed by Roux-en-Y gastric bypass (RYGBP) or duodenal switch (DS) in super-super obese patients. The efficacy of laparoscopic sleeve gastrectomy (LSG) for morbidly obese patients with a BMI of <50 kg/m² and the incidence of gastric dilatation following LSG have not yet been investigated. Methods: 23 patients (15 morbidly obese, 8 super-obese) were studied prospectively for weight loss following LSG. The incidence of sleeve dilatation was assessed by upper GI contrast studies in patients with a follow-up of >12 months. Results: Patients who underwent LSG achieved a mean excess weight loss (EWL) at 6 and 12 months postoperatively of 46% and 56%, respectively. No significant differences were observed in %EWL comparing obese and super-obese patients. At a mean follow-up of 20 months, dilatation of the gastric sleeve was found in 1 patient and weight regain after initial successful weight loss in 3 of the 23 patients. Conclusion: LSG has been highly effective for weight reduction for morbid obesity even as the sole bariatric operation. Gastric dilatation was found in only 1 patient in this short-term follow-up. Weight regain following LSG may require conversion to RYGBP or DS. Follow-up will be necessary to evaluate long-term results.     

Impact of Laparoscopic Roux-en-Y Gastric Bypass on Metabolic Syndrome, Inflammation, and Insulin Resistance in Super Versus Morbidly Obese Women

Background  Although Roux-en-Y gastric bypass (RYGBP) is one of the preferred bariatric procedures in obese individuals, the efficacy of this procedure in the setting of super-obesity [body mass index (BMI) ≥50] is unclear. The aim of this study was to compare the efficacy of laparoscopic (L) RYGBP to reverse metabolic syndrome, inflammation, and insulin resistance in super-obese women compared to morbidly obese women. Methods  Seventy-three consecutive women were enrolled in this prospective study. Anthropometric, metabolic, and inflammatory biological parameters were assessed in 18 super-obese and 55 morbidly obese women before LRYGBP and 1 year after surgery. Metabolic syndrome was diagnosed according to the International Diabetes Federation definition. Results  Before surgery, super-obese women had a higher BMI, fat mass, blood insulin, and HOMA1-IR than morbidly obese women. Both groups had similar serum levels of C-reactive protein and orosomucoid. The incidence of metabolic syndrome, type 2 diabetes, and increased liver enzymes was comparable in the two groups. One year after LRYGBP, metabolic syndrome, type 2 diabetes, metabolic and inflammatory biological parameters were improved in the whole study population. A similar degree of improvement was observed in super-obese and morbidly obese women, although BMI and fat mass were persistently higher in super-obese patients. Conclusions  One year after surgery, LRYGBP was equally effective at reversing metabolic syndrome, inflammation, and insulin resistance in morbidly obese and super-obese women.     

Bariatric Re-operations: Are They Preventable?

Background: Many operations are currently used for morbid obesity, and every procedure appears to have advantages, drawbacks and failures. Re-operation is a part of bariatric surgery practice that is necessary in the event of failure. We analyzed the reasons for failure in the bariatric re-operation group. Methods: From June 1998 to April 2000, 17 morbidly obese patients had a bariatric re-operation. Of 203 bariatric operations performed in our institution, 12 patients had a re-operation (5.9%), and 5 patients had their primary procedure performed elsewhere. Mean age was 36.5 ±11 years, mean original weight 151.3 ± 44.3 kg, mean BMI 58.4±16.9 kg/m2 and mean excess body weight (EBW) 94.4±43.5 kg. Mean height was 161±7.7 cm, and 15 patients were female (88.2%).The primary bariatric operation was vertical banded gastroplasty (VBG) in 15 patients (88.2%), Roux-en-Y gastric bypass (RYGBP) in 1 patient (5.9%), and gastric banding in 1 patient (5.9%). Duration since the primary surgery was a mean of 15.6 months (range 1-72 months). Results: Reasons for re-operation were inadequate weight loss (47%) or food intolerance (53%). 11 patients had VBG converted to RYGBP,1 patient had a gastric banding converted to a BPD, 4 patients had their VBG converted to a gastro-gastrostomy, and 1 patient had a RYGBP staple dehiscence re-stapled. Conclusion: Incidence of bariatric re-operations may be decreased if super-obese patients, older patients, and sweets-consuming individuals undergo RYGBP or BPD as the primary operation rather than VBG or gastric banding. The use of staplers transecting and separating the gastric pouch from the remaining stomach can decrease staple dehiscence.     

Prevalence of Subclinical Hypothyroidism in a Morbidly Obese Population and Improvement after Weight Loss Induced by Roux-en-Y Gastric Bypass

Background:There are many studies concerning thyroid function in obesity, and some of them describe higher TSH levels in obese subjects. Few studies evaluated long-term changes in thyroid function caused by weight loss after bariatric surgery. Our aims were to evaluate the prevalence of subclinical hypothyroidism (SH) in a morbidly obese population and to analyze the effect of weight loss induced by Roux-en-Y gastric bypass (RYGBP) on TSH and thyroid hormone (TH) levels. Methods: TSH, free thyroxine (fT4) and total triiodothyronine (T3) levels were analyzed before and 12 months after RYGBP in patients with grade III or grade II obesity with co-morbidities. Subjects taking TH and/or with positive antithyroid antibodies and/or with overt hypothyroidism were excluded. Results: 72 subjects (62F/10M), with mean age 39.6±9.8 years and mean BMI 53.0±10.4 kg/m² were studied. The prevalence of SH before RYGBP was 25% (n=18). There was a significant post-surgical decrease in BMI in the whole population, as well as in SH patients. In the SH group and normal TSH group, there was a decrease in TSH and T3, but not in fT4. TSH was not correlated with initial BMI or percent change in BMI. TSH concentrations reached normal values in all SH patients after RYGBP. Conclusion: Our data confirm that severe obesity is associated with increased TSH. The decrease in TSH was independent of BMI, but occurred in all SH patients. A putative effect of weight reduction on the improvement of SH in all patients may be an additional benefit of bariatric surgery.     

Quality of life in bariatric surgery

Background: Bariatric surgery is the treatment of choice for morbid obesity.Since bariatric operations alter gastrointestinal anatomy, they may induce symptoms that have a negative impact on quality of life (QOL).The aim of this study was to prospectively analyze QOL after bariatric surgery. Methods: The QOL index questionnaire (GIQLI) was applied to 45 surgically treated morbidly obese patients (15 vertical banded gastroplasty, 15 Roux-en-Y gastric bypass (RYGBP), and 15 distal RYGBP) and to 15 non-operated morbidly obese controls. Follow-up was of 1-year minimum. The GIQLI evaluates physical and mental well-being, digestion and bowel habits. Results: Physical and mental well-being as well as the overall QOL were significantly higher in the operated patients. There were no significant differences in digestion and bowel habits between the groups. Differences in QOL were not related to the type of surgical procedure. Conclusion. Overall QOL was significantly better in operated than in non-operated patients. There is no negative impact of bariatric surgery on QOL related to GI symptoms.     

Potential nutritional conflicts in bariatric and renal transplant patients

An increasing number of morbidly obese patients with end stage renal disease (ESRD) are sequentially undergoing bariatric surgery followed by renal transplantation. Discrepancies between the nutritional recommendations for obesity and chronic kidney disease (CKD) are often confusing for the obese patient in renal failure. However, when recommendations are structured according to stage and treatment of disease, a consistent plan can be clearly communicated to the patient. Therefore, to optimize patient and graft outcomes we present nutritional recommendations tailored to three patient populations: obese patients with ESRD, patients post Roux-en-Y gastric bypass (RYGBP) with ESRD, and patients post RYGBP and post renal transplantation.     

Revision of Failed Laparoscopic Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Background: The most common bariatric surgical operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss. Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery. Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5±2.0 years. For the RYGBP, mean operating time was 161±53 minutes, estimated blood loss was 219±329 ml, and hospital stay was 6.7±4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%) – a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2±9.3 kg/m², and decreased to 45.8±8.9 kg/m² after LAGB and was again reduced to 37.7±8.7 kg/m² after RYGBP within our follow-up period. Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.     

Relationship between Obstructive Sleep Apnea and Liver Abnormalities in Morbidly Obese Patients: A Prospective Study

Background Morbid obesity is a risk factor of nonalcoholic steatohepatitis (NASH). Obstructive sleep apnea (OSA) could also be an independent risk factor for elevated liver enzymes and NASH. The relationships between liver injuries and OSA in morbidly obese patients requiring bariatric surgery were studied prospectively. Methods Every consecutive morbidly obese patient (BMI ≥40 kg/m² or ≥35 kg/m² with severe comorbidities) requiring bariatric surgery was included between January 2003 and October 2004. Polygraphic recording, serum aminotransferases (ALT, AST), γ-glutamyltransferase (GGT) and liver biopsy were systematically performed. OSA was present when the apnea–hypopnea index (AHI) was >10/h. Results 62 patients (54 F; age 38.5 ± 11.0 (SD) yrs; BMI 47.8 ± 8.4 kg/m²) were included. Liver enzymes (AST, ALT or GGT) were increased in 46.6%. NASH was present in 34.4% and OSA in 84.7%. Patients with OSA were significantly older (P = 0.015) and had a higher BMI (P = 0.003). In multivariate analysis, risk factors for elevated liver enzymes were the presence of OSA and male sex.The presence of NASH was similar in patients with or without OSA (32.7% vs 44.4% of patients, P = 0.76). Conclusion In this cohort of morbidly obese patients requiring bariatric surgery, one-third of patients had NASH, a prevalence similar to previous studies. OSA was found to be a risk factor for elevated liver enzymes but not for NASH.     

Different effects of vertical banded gastroplasty and Roux-en-Y gastric bypass on meal inhibition of ghrelin secretion in morbidly obese patients.

A decrease in ghrelin plasma levels in morbidly obese patients subjected to bariatric surgery has been considered to help increase body weight loss. Contradictory results have been described after Roux-en-Y gastric bypass (RYGBP), and no study to date has compared RYGBP and vertical banded gastroplasty (VBG), the two main operations performed in the United States. We investigated the effects of RYGBP (10 patients) and VBG (12 patients) on basal and postmeal ghrelin plasma levels in 22 morbidly obese patients (20 F and 2 M), mean age 42.1 +/- 3.7 years, mean weight 115 +/- 3.9 kg, mean body mass index (BMI) 43.5 +/- 1.7. Before surgery and after a 20% reduction in BMI, ghrelin concentrations (pg/mL; radioimmunoassay [RIA], DRG Diagnostics, Germany) were measured in all patients 45 min before and for 3 h after a standard liquid meal (Osmolite RTH solution, 500 mL, 504 kcal). The results were expressed as mean +/- SD. Differences between times and groups were evaluated by Student's t-test and one-way analysis of variance (ANOVA). We found that basal ghrelin plasma levels were reduced after RYGBP (to 73.1 +/- 6 pg/mL, p < .05) but increased after VBG (to 172 +/- 26 pg/mL, p < .0009). After a standard liquid meal, ghrelin plasma levels decreased significantly over 1 h in VBG patients, whereas they remained unchanged in RYGBP patients. Since these results were obtained under the same metabolic and anthropometric conditions, we conclude that RYGBP acts through permanent inhibition of ghrelin secretion, whereas VBG merely restores the mechanisms of ghrelin regulation by nutrients.     

The Impact of Bariatric Surgery on Menstrual Patterns

Background: Obesity and anovulation are common medical problems in the United States. Anovulation in obese patients primarily manifests with irregular, sporadic or absent menstrual bleeding. Weight loss of at least 5% has been shown to reverse obesity-related anovulation. The aim of this study was to assess the impact of bariatric surgery on infertility in morbidly obese women and to identify factors associated with return of normal menses following bariatric surgery. Methods: A survey of patients was collected from the bariatric surgery data-base at the Hospital of the University of Pennsylvania. 410 women under the age of 40 were sent questionnaires. 195 patients completed the questionnaire, and 29 patients had incorrect addresses without a forwarding address, resulting in a 51.2% response rate. Patients who reported menstrual cycle lengths >35 days were considered abnormal. 92 of the 195 responders were considered anovulatory preoperatively, based on menstrual history. Results: There was no significant difference in postoperative BMI, BMI decrease or age at surgery between the survey responders and non-responders. There was a significant difference between these 2 groups in time since surgery (P=.01). Both groups had a decrease in BMI of >18 kg/m². The mean menstrual cycle length preoperatively among those categorized as ovulatory and anovulatory was 27.3 and 127.5 days, respectively. Of the 98 patients who were anovulatory preoperatively, 70 patients (71.4%) regained normal menstrual cycles after surgery. Those patients who regained ovulation had greater weight loss than those who remained anovulatory (61.4 kg vs 49.9 kg, P=0.02). Conclusions: Anovulation resulting in abnormal menses is a common problem in morbidly obese premenopausal women. The menstrual cycle disorders may completely resolve after bariatric surgery. Thus, infertility due to anovulation among morbidly obese women could potentially be viewed as an additional indication for bariatric surgery.     

Laparoscopic Roux-en-Y gastric bypass

Background: Roux-en-Y gastric bypass (RYGBP)—essentially a restrictive bariatric procedure—is currently considered the gold standard for the surgical treatment of morbid obesity. Open surgery in obese patients is associated with a high risk of cardiopulmonary complications, wound infection, and late incisional hernia. Laparoscopic surgery has been shown to reduce perioperative morbidity and to improve postoperative recovery for various procedures. Herein we present our results with laparoscopic RYGBP after an initial 2-year experience. Methods: A prospective database was created in our department beginning without the first laparoscopic bariatric procedure. To provide a complete follow-up of ?6 months, the results of all patients operated on between June 1999 and August 2001 were reviewed. Early surgical results, weight loss, correction of comorbidities, and improvement of quality of life were evaluated. Results: A total of 107 patients were included. There were 82 women and 25 men, with a mean age of 39.7 years (range, 19–58). RYGBP was a primary procedure in 80 cases (49 morbidly obese and 31 superobese patients) and a reoperation after failure or complication of another bariatric operation in 27 cases. Mean duration of surgery was 168 min for morbidly obese patients, 196 min for surperobese patients, and 205 min for reoperated patients (p <0.01). Conversion to open surgery was necessary in two cases. A total of 22 patients (20.5%) developed complication. Nine of them (8.4%) required reoperation for leak (five cases, or 4.6%), bowel occlusion (three cases, or 2.8%), or subphrenic abscess (one case, or 0.9%). mortality was 0.9%. Major morbidity decreased over time (first two-thirds, 12.5%, last third, 2.7%). major morbidity decreased over time (first two-thirds, 12.5%; last third, 2.7%). Excess weight loss of -50% was achieved in >80% of the patients, corresponding to a loss of 15 body mass index (BMI) units in morbidly obese patients and 20 BMI units in superobese patients. In the vast majority of patients, comorbidities improved or disappeared over time and quality of life improved. Conclusions: Laparoscopic Roux-en-Y gastric bypass is feasible, but it is a very complex operation. Indeed, it is associated with a long and steep learning curve, as reflected in the high number of major complications among our first 70 patients. The learning curve probably includes between 100 and 150 patients. With increasing experience, the morbidity rate becomes more acceptable and comparable to that of open RYGBP. The results in terms of weight loss and correction of comorbidities are similar to those obtained after open surgery, at least in the short term. However, only surgeons with extensive experience in advanced laparoscopic as well as bariatric surgery should attempt this procedure.     

Different Effects of Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass on Meal Inhibition of Ghrelin Secretion in Morbidly Obese Patients

A decrease in ghrelin plasma levels in morbidly obese patients subjected to bariatric surgery has been considered to help increase body weight loss. Contradictory results have been described after Roux-en-Y gastric bypass (RYGBP), and no study to date has compared RYGBP and vertical banded gastroplasty (VBG), the two main operations performed in the United States. We investigated the effects of RYGBP (10 patients) and VBG (12 patients) on basal and postmeal ghrelin plasma levels in 22 morbidly obese patients (20 F and 2 M), mean age 42.1 ± 3.7 years, mean weight 115 ± 3.9 kg, mean body mass index (BMI) 43.5 ± 1.7. Before surgery and after a 20% reduction in BMI, ghrelin concentrations (pg/mL; radioimmunoassay [RIA], DRG Diagnostics, Germany) were measured in all patients 45 min before and for 3 h after a standard liquid meal (Osmolite RTH solution, 500 mL, 504 kcal). The results were expressed as mean ± SD. Differences between times and groups were evaluated by Student's t-test and one-way analysis of variance (ANOVA). We found that basal ghrelin plasma levels were reduced after RYGBP (to 73.1 ± 6 pg/mL, p <. 05) but increased after VBG (to 172 ± 26 pg/mL, p <. 0009). After a standard liquid meal, ghrelin plasma levels decreased significantly over 1 h in VBG patients, whereas they remained unchanged in RYGBP patients. Since these results were obtained under the same metabolic and anthropometric conditions, we conclude that RYGBP acts through permanent inhibition of ghrelin secretion, whereas VBG merely restores the mechanisms of ghrelin regulation by nutrients.     

The Importance of Routine Liver Biopsy in Diagnosing Nonalcoholic Steatohepatitis in Bariatric Patients

Background: Nonalcoholic Steatohepatitis (NASH) commonly occurs in obese patients and predisposes to cirrhosis. Prevalence of NASH in bariatric patients is unknown. Our aim was to determine the role of routine liver biopsy in managing bariatric patients. Methods: Prospective data on patients undergoing Roux-en-Y gastric bypass (RYGBP) was analyzed. One pathologist graded all liver biopsies as mild, moderate or severe steatohepatitis. NASH was defined as steatohepatitis without alcoholic or viral hepatitis. Consecutive liver biopsies were compared to those liver biopsies selected because of grossly fatty livers. Results: 242 patients underwent open and laparoscopic RYGBP from 1998-2001. Routine liver biopsies (68 consecutive patients) and selective liver biopsies (additional 86/174, 49%) were obtained. Findings of cirrhosis on frozen section changed the operation from a distal to a proximal RYGBP. The two groups were similar in age, gender, and BMI. The group with the routine liver biopsies showed a statistically significant larger preponderance of NASH (37% vs 32%). Both groups had a similar prevalence of cirrhosis. Neither BMI nor liver enzymes predicted the presence or severity of NASH. Conclusions: Routine liver biopsy documented significant liver abnormalities in a larger group of patients compared with selective liver biopsies, thereby suggesting that liver appearance is not predictive of NASH. Liver biopsy remains the gold-standard for diagnosing NASH. We recommend routine liver biopsy during bariatric operations to determine the prevalence and natural history of NASH, which will have important implications in directing future therapeutics for obese patients with NASH and for patients undergoing bariatric procedures.     

Mild Elevation of Fasting Plasma Glucose is a Strong Risk Factor for Postoperative Complications in Gastric Bypass Patients

Background: Bariatric surgery may be associated with surgical complications. The aim of the study was to identify significant risk factors for postoperative complications in patients undergoing Roux-en-Y gastric bypass (RYGBP). Methods: The study consisted of 75 consecutive patients undergoing RYGBP. Full medical examination was performed, and the following parameters were assessed in the fasting state: plasma glucose, insulin, leptin, serum lipids, liver function tests, and lipoprotein Lp(a). All subjects had oral 75 g glucose tolerance test before the surgery. All complications occurring within 6 months after the RYGBP were recorded. The patients were divided into Group 1 - patients in whom complications occurred, and Group 2 - patients with no complications in the 6-month period. Results: Postoperative complications occurred in 16 patients (wound infection, hernia, splenic injury, gastro-jejunal obstruction, duodenal ulcer, lower limb deep vein thrombosis). 3 significant risk factors for postoperative complications within 6 months after gastric bypass were found: 1) fasting plasma glucose ≥ 6.0 mmol/l (OR 11.0; 95% confidence interval (CI) 2.1-77.3), 2) age ≥40 years (OR 5.89, 95% CI 1.35-29.4), and 3) BMI ≥45 kg/m² (OR 4.1, 95% CI 1.04-17.2). Conclusion: RYGBP is associated with increased risk of developing early postoperative complications in subjects with even slightly elevated fasting plasma glucose, age ≥40 and BMI ≥45 kg/m².     

The physiologic effects of pneumoperitoneum in the morbidly obese

OBJECTIVE: To review the physiologic effects of carbon dioxide (CO2) pneumoperitoneum in the morbidly obese. SUMMARY BACKGROUND DATA: The number of laparoscopic bariatric operations performed in the United States has increased dramatically over the past several years. Laparoscopic bariatric surgery requires abdominal insufflation with CO2 and an increase in the intraabdominal pressure up to 15 mm Hg. Many studies have demonstrated the adverse consequences of pneumoperitoneum; however, few studies have examined the physiologic effects of pneumoperitoneum in the morbidly obese. METHODS: A MEDLINE search from 1994 to 2003 was performed using the key words morbid obesity, laparoscopy, bariatric surgery, pneumoperitoneum, and gastric bypass. The authors reviewed papers evaluating the physiologic effects of pneumoperitoneum in morbidly obese subjects undergoing laparoscopy. The topics examined included alteration in acid-base balance, hemodynamics, femoral venous flow, and hepatic, renal, and cardiorespiratory function. RESULTS: Physiologically, morbidly obese patients have a higher intraabdominal pressure at 2 to 3 times that of nonobese patients. The adverse consequences of pneumoperitoneum in morbidly obese patients are similar to those observed in nonobese patients. Laparoscopy in the obese can lead to systemic absorption of CO2 and increased requirements for CO2 elimination. The increased intraabdominal pressure enhances venous stasis, reduces intraoperative portal venous blood flow, decreases intraoperative urinary output, lowers respiratory compliance, increases airway pressure, and impairs cardiac function. Intraoperative management to minimize the adverse changes include appropriate ventilatory adjustments to avoid hypercapnia and acidosis, the use of sequential compression devices to minimizes venous stasis, and optimize intravascular volume to minimize the effects of increased intraabdominal pressure on renal and cardiac function. CONCLUSIONS: Morbidly obese patients undergoing laparoscopic bariatric surgery are at risk for intraoperative complications relating to the use of CO2 pneumoperitoneum. Surgeons performing laparoscopic bariatric surgery should understand the physiologic effects of CO2 pneumoperitoneum in the morbidly obese and make appropriate intraoperative adjustments to minimize the adverse changes.     

Gastro-Esophageal Reflux and Esophageal Motility Disorders in Morbidly Obese Patients before and after Bariatric Surgery

Background Obesity is a predisposing factor to gastro- esophageal reflux disease (GERD), but esophageal function remains poorly studied in morbidly obese patients and could be modified by bariatric surgery. Methods Every morbidly obese patient (BMI ≥40 kg/m² or ≥35 in association with co-morbidity) was prospectively included with an evaluation of GERD symptoms, endoscopy, 24-hour pH monitoring and esophageal manometry before and after adjustable gastric banding (AGB) or Roux-en-Y gastric bypass (RYGBP). Results Before surgery, 100 patients were included (84 F, age 38.4 ± 10.9 years, BMI 45.1 ± 6.02 kg/m2), of whom 73% reported GERD symptoms. Endoscopy evidenced hiatus hernia in 39.4% and esophagitis in 6.4%. The DeMeester score was pathological in 53.3%; 69% of patients had lower esophageal sphincter (LES) pressure <15 mmHg and 7 had esophageal dyskinesia. BMI was significantly related to the DeMeester score (P = 0.018) but not to LES tone or esophageal dyskinesia. Postoperative data were available in 27 patients (AGB n = 12/60, RYGBP n = 15/36). The DeMeester score (normal <14.72) was significantly decreased after RYGBP (24.8 ± 13.7 before vs 5.8 ± 4.9 after; P < 0.001) but tended to increase after AGB (11.5 ± 5.1 before vs 51.7 ± 70.7 after; P = 0.09), with severe dyskinesia in 2 cases. Conclusion: GERD and LES incompetence are highly prevalent in morbidly obese patients. Preliminary postoperative data show different effects of RYGBP and AGB on esophageal function, with worsening of pH-metric data with occasional severe dyskinesia after AGB.