The effect of Roux limb lengths on outcome after Roux-en-Y gastric bypass: a prospective,randomized clinical trial

Background:The effect of limb-length on weight loss after Roux-en-Y gastric bypass (RYGBP) is controversial; hence, the optimal limb-lengths have not been determined. This study evaluated the effect of different limb-lengths on weight loss after RYGBP. Methods:The study was a prospective randomized clinical trial in which patients undergoing RYGBP (110 F,24 M; mean age 39.7) were randomized as follows: BMI ≤ 50 (N=69): A-75 cm (N=35) vs B-150 cm alimentary limb (N=34) and C-150 cm (N=33) vs D250 cm alimentary limb (N=31). All other aspects of the operation were identical. Patients were followed at 2 weeks, 6 weeks, 6 months, 12 months, 18 months, 24 months and yearly thereafter. Results: There were no significant differences in age, sex, race, initial BMI, or excess weight between patients assigned to groups A vs B and C vs D. Postoperative nutritional intake was also similar between groups. Within each weight category, there were no differences in mean weight loss, change in BMI, and % excess weight lost (EWL) over time. When the number of patients achieving 50% EWL was evaluated, there was no difference between groups with a BMI ≤ 50 kg/m2; however, among patients with a BMI >50 kg/m2, a significantly greater percentage of those having a 250-cm limb achieved >50% EWL at 18 months postoperatively.This difference was lost at 24 and 36 months, possibly due to the small sample size. Conclusions: In patients with a BMI ≤ 50, there appears to be no advantage to longer limb-lengths. In patients with BMI >50, however, these data suggest that longer alimentary limb-lengths may be associated with a higher percent of patients achieving >50% EWL. Longer follow-up studies of the effects of limb-length on success of RYGBP are indicated.     

BioEnterics Intragastric Balloon: Clinical Outcomes of the First 100 Patients—A Turkish Experience

BACKGROUND: The BioEnterics Intragrastric Balloon (BIB(R)) together with restricted diet has been used for the treatment of obesity and morbid obesity. METHODS: A prospective study was conducted on 100 patients who had undergone the BIB procedure between February 2005 and February 2007. RESULTS: Mean age, mean weight, and mean BMI of the patients were 35.35 +/- 9.25 years, 113.23 +/- 24.76 kg (range 73-200 kg), and 39.28 +/- 6.98 kg/m(2) (range 30-69.2 kg/m(2)), respectively. Six months after the BIB procedure, mean weight and mean BMI were reduced to 100.46 +/- 26.05 kg (range 58-178 kg) and 34.70 +/- 11 kg/m(2) (range 21.83-61.59 kg/m(2)), respectively. There was a statistically significant reduction in weight and BMI at 6 months after the BIB procedure (p < 0.01). Excess weight loss (EWL) at 6 months ranged between 0 and 28 kg, with a mean value of 12.68 +/- 7.70 kg. The subjects had 0 to 99.2% %EWL (mean 28.63 +/- 19.29). Reduction in BMI at 6 months ranged between 0 and 12.3 kg/m(2), with a mean value of 4.51 +/- 2.85 kg/m(2), and percent excess body mass index loss (%EBMIL) was 38.20 +/- 28.78% (range 0-158%). At 6 months, there was a significant reduction in body weight and BMI (p < 0.01) in both groups. The reduction in BMI of the morbidly obese group was significantly greater than that of the obese group (p = 0.035), and both the %EWL and %EBMIL of the morbidly obese patients were significantly lower than those of the obese patients at 6 months (p = 0.001). CONCLUSIONS: BIB application is a reasonable weight loss method with few complications.     

Initiation and progression of physical activity after laparoscopic and open gastric bypass surgery

This study compared postoperative physical activity participation among patients who underwent laparoscopic (LGBS) or open gastric bypass surgery (OGBS). Postoperative physical activity participation is considered important for achieving optimal weight loss and maintenance after gastric bypass surgery. However, no study has examined the relationship between surgery type and postoperative physical activity. Minimal invasiveness and reduced recovery time associated with LGBS compared with OGBS may permit earlier initiation and faster progression of postsurgical physical activity and potentially contribute to greater long-term adherence rates. Self-reported physical activity participation and aerobic physical activity hours per week at 2-weeks, 3-months, and 6-months postsurgery were assessed among LGBS and OGBS patients (presurgical body mass index of 35 to 70 kg/m(2)) at a university hospital from 1988-2002. Of the 2,235 patients, 531 (24%) and 1704 (76%) underwent LGBS and OGBS, respectively. A greater proportion of LGBS patients reported physical activity participation at each time point compared with OGBS patients (2 week, 76% vs 62%; 3 months, 84% vs 74%; 6 months, 85% vs 76%). Furthermore, LGBS patients reported a significantly greater physical activity duration at 2-weeks postsurgery compared with OGBS patients. A nonsignificant trend toward greater physical activity duration was observed in the LGBS patients at 3 months, whereas 6-month physical activity duration was similar between groups. LGBS, compared with OGBS, may promote earlier onset, progression, and maintenance of physical activity until 6 months postsurgery. Future studies need to prospectively determine whether LGBS, via facilitation of greater engagement in postsurgical physical activity, contributes to more successful weight loss and weight maintenance compared with OGBS.     

One Year After Laparoscopic “Tight” Sleeve Gastrectomy: Technique and Outcome

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is currently gaining ground as a new option for the treatment of morbid obesity. The main advantages of this procedure are less postoperative food restrictions, no vomiting, and absence of late complications due to the lack of foreign implants. The aim of this study is to present our experience with this new bariatric technique. METHODS: Ninety three obese patients (65 females and 28 males) who underwent LSG between September 2005 and September 2007 were studied in terms of postoperative complications and weight loss. RESULTS: Mean age was 38.37 +/- 10.81 years (range 19-69) and mean preoperative weight and body mass index (BMI) were 139.12 +/- 24.03 kg (range 100-210) and 46.86 +/- 6.48 kg/m(2) (range 37-66), respectively. Mean follow-up was 12.51 +/- 4.15 months (range 3-24). There were no mortalities, but there were four major and four minor postoperative complications. The mean postoperative excess weight loss (EWL) was 58.32 +/- 16.54%, while mean BMI dropped to 32.98 +/- 6.54 kg/m(2). Mean EWL 3, 6, 12, and 24 months after the operation was 31%, 53%, 67%, and 72%, respectively. Superobese patients (BMI > 50 kg/m(2)) lost less weight. CONCLUSION: In the short term, LSG is a safe and highly effective bariatric operation more suitable for intermediate morbidly obese patients with BMI between 40 and 50 kg/m(2).     

Cardiovascular risk profile in nondiabetic renal transplant patients: cyclosporine versus tacrolimus

Calcineurin inhibitors (CIs) contribute to cardiovascular risk (CR) in renal transplant (RT) patients. However, the CR profile in RT patients without preexistent diabetes is not well known. We compared CR factors in 191 nondiabetic RT recipients with functioning grafts beyond 1 year, receivingly either CsA (Neoral; n=100) or tacrolimus (Tac; n= 91). Clinical data and pretransplant CR profiles were similar in both groups. There were no differences in acute rejection episodes and graft survival rates during follow-up. The overall proportions of posttransplant diabetes (9% versus 6%), and of hypertension (73% vs 63%) were similar in both groups. Hyperlipidemia was more frequent in the CsA group (58% vs 31%; P=.0001). The cholesterol levels in the CsA group showed at 3 months (232+/-47 vs 202+/-42 m/dL; P=.0001), 6 months (232+/-49 vs 205+/-41 mg/dL; P=.0001), and 12 months (217+/-50 vs 202+/-40 mg/dL; P=.028), despite receiving a greater proportion of lipid-lowering drugs (49% vs 15%; P=.0001). Logistic regression analysis showed that CsA was an independent predictor of posttransplant hyperlipidemia (OR: 5.8, CI 95%; 3.3-10.7; P=.0001) as were age, female gender, pretransplant dyslipidemia, and body mass index (BMI). Interestingly, an interaction was observed between pretransplant BMI and CIs: Among pretransplant normal weight patients (BMI <25 kg/m2), CsA produced a greater incidence of hyperlipidemia than tacrolimus (58% vs 23%; P=.0001) while not among patients who were overweight (BMI >25 kg/m2: pretransplant 58% vs 42%; P=.341). In conclusion, CsA confers a higher risk of hyperlipidemia after RT in nondiabetic patients, particularly those with normal pretransplant weight.     

Participation in 150 min/wk of moderate or higher intensity physical activity yields greater weight loss after gastric bypass surgery.

BACKGROUND: The American College of Sports Medicine's position stand on weight loss and prevention of weight regain in adults has suggested that overweight adults should participate in a minimum of 150 min/wk of moderate intensity physical activity (PA). This study compared the 3-, 6-, and 12-month postoperative weight loss between gastric bypass surgery (GBS) patients who met or exceeded the recommended 150 min/wk of moderate or higher PA and those not meeting the recommendation. METHODS: The self-administered short version of the International Physical Activity Questionnaire was used to assess moderate or higher intensity PA participation at 3 (n = 178), 6 (n = 128), and 12 months (n = 209) after GBS. The patients' height and body weight were obtained to determine the kilograms of weight lost, percentage of excess weight loss, body mass index change, and total weight loss percentage. The weight loss differences were analyzed using analysis of covariance at each point, with age and preoperative body mass index as covariates. RESULTS: Patients reporting 150 min/wk of moderate or higher PA had significantly (P <.05) greater weight lost, percentage of excess weight loss, change in body mass index, and total weight loss percentage at 6 and 12 months postoperatively. The percentage of excess weight loss was 56.0% +/- 11.5% versus 50.5% +/- 11.6% and 67.4% +/- 14.3% versus 61.7% +/- 17.0% for the group meeting and not meeting the PA requirement at 6 and 12 months after GBS, respectively. No significant difference existed at 3 months after GBS. CONCLUSION: Participation in a minimum of 150 min/wk of moderate or higher intensity PA was associated with greater postoperative weight loss at 6 and 12 months postoperatively. Patients should be encouraged to meet or exceed this recommendation until prospective, randomized studies have definitively established a link between PA and greater postoperative weight loss and maintenance.     

Physical activity stage of readiness predicts moderate–vigorous physical activity participation among morbidly obese gastric bypass surgery candidates

BACKGROUND: Despite the ever-growing body of literature linking stage of physical activity readiness (PAR) with physical activity (PA) participation in overweight and obese populations, this relationship has not been examined among individuals seeking gastric bypass surgery (GBS). Furthermore, little is known about the specific intensity of activities undertaken by GBS candidates. Therefore, this study sought to determine whether greater PAR was associated with greater moderate-vigorous physical activity (MVPA) participation among GBS candidates. METHODS: The International Physical Activity Questionnaire (IPAQ), administered 2-weeks presurgery to 87 GBS candidates, determined MVPA participation using a formula based on metabolic equivalents (MET)-minutes/week. A stages-of-change measure categorized each candidate into one of five PAR stages: precontemplation, contemplation, preparation, action, or maintenance. RESULTS: The proportion of individuals in each PAR stage and the corresponding MVPA was as follows: contemplation (5.7%, 48.0 MET-minutes/week), preparation (46%, 394.0 MET-minutes/week), action (34.5%, 1614.0 MET-minutes/week), and maintenance (13.8%, 2056.7 MET-minutes/week). MVPA was significantly greater in candidates in the action or maintenance stages compared with those in contemplation (P =.008 and .025 for action and maintenance, respectively) or preparation (P < .0001 and .006 for action and maintenance, respectively). CONCLUSIONS: This study is the first to demonstrate a relationship between PAR and PA among GBS candidates, with 100% of the sample reporting either an intention to engage in PA or actual engagement in PA. This finding, coupled with the recent support for the importance of PA for weight loss/maintenance in GBS patients, warrants an investigation into the effectiveness of presurgical and postsurgical PA interventions matched to patients' PAR levels.     

The Effect of Loss of Excess Weight on the Metabolic Risk Factors after Bariatric Surgery in Morbidly and Super-Obese Patients

BACKGROUND: Changes in metabolic risk factors such as dyslipidemia and hyperinsulinemia as well as levels of sex hormones and leptin were studied in morbidly obese (MO) and super-obese (SO) patients during excess weight loss (EWL), separately in males and females. METHODS: In this prospective clinical intervention study, 431 patients were included (361 females and 70 males). There were 217 patients with MO (BMI 40-49.9 kg/m2) and 214 patients with SO (BMI > or =50 kg/m2). All patients underwent restrictive bariatric operations. Metabolic parameters (lipids, insulin, leptin, hepatic transaminases, uric acid, and sex hormones) were measured before obesity surgery and at defined postoperative points of EWL (25%, 50%, 75% and 100%). RESULTS: Successful weight reduction of 25% EWL was achieved by 94% of patients at 2 months. With this moderate EWL, most of the patients already improved their risk profile considerably, including normalization of insulin levels. Additional EWL led to a further amelioration of risk profile in all patients, including normalization of triglyceride levels. Male MO and SO patients had a worse metabolic situation preoperatively and a greater benefit after weight loss. Even though SO patients did not lose as much excess weight as MO patients, they did profit comparably. CONCLUSION: Bariatric surgery is a valuable tool not only to reduce excess weight in severely obese patients but also to improve the metabolic risk profile within a short time-frame. This benefit is most pronounced in high-risk males.     

Outcome and Complications after Laparoscopic Swedish Adjustable Gastric Banding: 5-Year Results of a Prospective Clinical Trial

BACKGROUND: Bariatric surgery is currently the only effective treatment for morbid obesity in terms of inducing and maintaining satisfactory weight loss and decreasing weight-related co-morbidities. A study was conducted to assess the effects, complications and outcome after laparoscopic Swedish adjustable gastric banding (SAGB) to 5 years. METHODS: Between June 1998 and December 2005, all patients with implantation of a SAGB were enrolled in a prospective clinical trial. Results were recorded and classified, with special regard to long-term complications and re-operation rate. RESULTS: SAGB was performed in 128 patients (87 female, 41 male). Mean age was 40.2 +/- 5.3 years, with mean preoperative BMI 44.5 +/- 3.9 kg/m2. Overall mortality was 0%. Patient follow-up was 94.5%. BMI after 1, 2 and 5 years was 35.7 +/- 3.7 kg/m2 (P < 0.005), 33.7 +/- 3.8 kg/m2 (P < 0.001) and 31.8 +/- 3.8 kg/m2 (P < 0.001), respectively. Mean EWL after 1, 2 and 5 years was 33.3 +/- 6.8% (P < 0.005), 45.5 +/- 6.4% (P < 0.001) and 57.4 +/- 6.5% (P < 0.001), respectively. The nonresponder rate (EWL < 30%) after 2 and 5 years was 17.0% and 6.8%, respectively. The early complication rate (< 30 d) was 6.25% (8/128), with 5 minor and 3 major complications. Late complications (> 30 d) occurred in 10.9% (14/128), of whom 2 were minor and 12 were major complications. The overall re-operation rate was 11.7% (15/128). CONCLUSIONS: At 5-year follow-up, laparoscopic SAGB is a safe and effective surgical treatment for morbid obesity. Our results appear to confirm that SAGB is a safer surgical treatment regarding rate and severity of complications compared with gastric bypass and malabsorptive procedures.     

Laparoscopic gastric bypass versus laparoscopic adjustable gastric banding: a comparative study of 1,200 cases

BACKGROUND: Indications for and results of laparoscopic adjustable gastric banding (LAGB) and laparoscopic gastric bypass (LGB) are still controversial, especially between Europe and the United States. The recent availability of gastric bandings in the United States made it necessary to compare the two techniques. STUDY DESIGN: We compared a series of 456 LGB to a series of 805 LAGB performed in two different institutions. Body mass index (BMI), complication rate, mortality, and excess weight loss (EWL) after 3, 6, 12, and 18 months were obtained. A Fischer's exact test and a Student t test with covariance analysis were used for statistical analysis. RESULTS: Results are expressed as a mean +/- standard deviation, comparing LGB with LAGB. Preoperative BMI was 49.4 +/- 8.3 kg/m(2) versus 42.2 +/- 4.9 kg/m(2) (p = 0.0001), respectively. Perioperative major complication rates were 2.0% versus 1.3% (NS), and the early postoperative major complication rates were 4.2% versus 1.7% (p = 0.02), respectively. Mortality rate was 0.4% versus 0% (NS), respectively.The global EWL was 36.3% for LGB versus 14.7% for LAGB at 3 months (p < 0.0001), 51.6% versus 21.9% at 6 months (p < 0.0001), 67.0% versus 33.3% at 12 months (p < 0.0001), and 74.6% versus 40.4% at 18 months (p < 0.0001), respectively. Longterm followup for the LAGB group showed an EWL of 47% at 2 years, 56% at 3 years, and 58% at 4 years.Patients were sorted after their preoperative BMI (30 to 40, 40 to 50, and 50 to 60 kg/m(2)). The EWL at 3, 6, 12, and 18 months was statistically superior in the LGB group, for any BMI ranges. CONCLUSIONS: These data suggest that LGB provides a higher EWL at 18 months, compared with LAGB, and this was true for any preoperative BMI range. It is associated with a higher early postoperative complication rate.     

beta-cell function in morbidly obese subjects during free living: long-term effects of weight loss

Insulin hypersecretion and insulin resistance are physiologically linked features of obesity. We tested whether extreme hypersecretion impairs beta-cell function under free-living conditions and whether major weight loss modifies insulin hypersecretion, insulin sensitivity, and beta-cell function. Plasma glucose, C-peptide, and free fatty acid concentrations were measured at hourly intervals during 24 h of normal life (including calorie-standardized meals) in 20 morbidly obese nondiabetic patients (BMI 48.4 +/- 1.7 kg/m2) and 7 nonobese age- and sex-matched control subjects; 8 of the obese patients were restudied 6 months and 2 years following biliopancreatic diversion. Insulin secretion was reconstructed from C-peptide levels by deconvolution and related to concurrent glucose levels through a mathematical model incorporating key features of beta-cell function: rate sensitivity, beta-cell glucose sensitivity, and potentiation. Insulin sensitivity (by the euglycemic insulin clamp technique) was reduced by 50% in obese subjects (23.1 +/- 2.5 of obese subjects vs. 52.9 +/- 4.9 micromol.min(-1) . kg(FFM)(-1) of control subjects, means +/- SE, P = 0.0004) as was mean 24-h insulin clearance (median 809 [interquartile range 451] vs. 1,553 [520] ml.min(-1) . m(-2), P < 0.001) due to a 50% reduction in hepatic insulin extraction (P < 0.01). Over 24 h, insulin secretion was doubled in obese subjects (468 nmol [202] in obese subjects vs. 235 [85] of control subjects, P=0.0002). Despite the hypersecretion, beta-cell glucose sensitivity, rate sensitivity, and potentiation were similar in obese and control subjects. Six months postoperatively (weight loss = 33 +/- 3 kg), both insulin hypersecretion (282 nmol [213]) and insulin sensitivity (51.6 +/- 3.7 micromol.min(-1).kg(FFM)(-1)) were normalized. At 2 years (weight loss = 50 +/- 8 kg), insulin sensitivity was supernormal (68.7 +/- 3.3 micromol.min(-1).kg(FFM)(-1)) and insulin secretion was lower than normal (167 nmol [37]) (both P < 0.05 vs. control subjects). In conclusion, severe uncomplicated obesity is characterized by gross insulin hypersecretion and insulin resistance, but the dynamic aspects of beta-cell function are intact. Malabsorptive bariatric surgery corrects both the insulin hypersecretion and the insulin resistance at a time when BMI is still high. With continued weight loss over a 2-year period, moderately obese subjects become supersensitive to insulin and, correspondingly, insulin hyposecretors.     

Lower extremity arterial revascularization in obese patients

BACKGROUND: Obesity and associated comorbidities are associated with a high rate of complications and technical difficulties after a number of surgical procedures. We studied the role of obesity in outcomes in lower extremity arterial revascularization. METHODS: We reviewed all lower extremity arterial revascularizations performed at our institution in 2000. Body mass index (BMI) greater than or equal to 30 kg/m(2) defined obesity. Perioperative outcomes, long-term survival, and graft patency were evaluated in obese and nonobese patients by using linear regression, the Fisher exact test, and Kaplan-Meier analysis. RESULTS: The study population consisted of 74 (26%) obese and 207 (74%) nonobese patients. Patient demographics of the obese and nonobese populations were similar. The mean BMI for obese patients was 35 +/- 5 kg/m(2) and in nonobese patients was 25 +/- 3 kg/m(2). The mean age of each group was 67 +/- 10 years (BMI > or =30 kg/m(2)) and 70 +/- 13 years (BMI <30 kg/m(2)). There were 45 (61%) obese men and 29 (39%) obese women. There were 128 (62%) nonobese men and 79 (38%) nonobese women. Diabetes was present in 76% of the obese and 70% of the nonobese patients. Perioperative myocardial infarction, 30-day mortality, and rate of reoperation within 30 days were not significantly different. Obese patients had higher increased postoperative wound infection rates (16% vs 7%; P = .04). Survival analysis showed 81% +/- 5% and 85% +/- 3% 1-year survival and 66% +/- 6% and 62% +/- 3% 3-year survival in obese and nonobese patients (P = .58), respectively. Kaplan-Meier estimates showed no effect of obesity on long-term graft patency, with 1-year graft patency rates of 82% +/- 6% and 81% +/- 4% in obese and nonobese patients, respectively (P = .79). CONCLUSIONS: Obese patients have similar limb salvage rates, perioperative cardiac morbidity, long-term survival rates, and long-term graft patency but have increased perioperative wound infections.     

Obese teenagers treated by Lap-Band System: the Italian experience

BACKGROUND: Little is known about obesity surgery in young and adolescent patients. The aim of this study is to evaluate results of laparoscopic adjustable gastric banding in obese teenagers. METHODS: Patients < or = 19 years old selected from the database of the Italian Collaborative Study Group for Lap-Band were analyzed according to mortality, comorbidities, laparotomic conversion, intra- and postoperative complications, body mass index (BMI), and % excess weight loss (EWL) at different times of follow-up. Data were expressed as mean +/- SD. RESULTS: Fifty-eight (1.5%) of 3813 patients who underwent operation with the Lap-Band System were < or = 19 years old: 47F/11M; mean age, 17.96 +/- 0.99 years (range, 15-19); mean BMI, 46.1 +/- 6.31 Kg/m2 (range, 34.9 - 69.25); mean % excess weight, 86.4 +/- 27.1 (range, 34 - 226.53). Sixteen (27.5%) of the 58 patients were superobese (BMI > or = 50). In 27/58 (46.5%) patients, 1 or more comorbidities were diagnosed. Mortality was absent. Laparotomic conversion was necessary in 1 patient with gastric perforation on the anterior wall. Overall postoperative complications occurred in 6/58 (10.3%). The band was removed in 6/58 (10.3%) patients for gastric erosion (3 patients), psychologic, intolerance (2 patients), and in the remaining patient was converted 2 years after surgery (BMI 31) to gastric bypass or gastric pouch dilatation. Patient follow-up at 1, 3, 5, and 7 years was 48/52 (92.3%), 37/42 (88.1%), 25/33 (75.7%), and 10/10, respectively. At these times, mean BMI was 35.9 +/- 8.4, 37.8 +/- 11.27, 34.9 +/- 12.2, and 29.7 +/- 5.2 Kg/m2. Mean %EWL at the same time was 45.6 +/- 29.6, 39.7 +/- 29.8, 43.7 +/- 38.1, and 55.6 +/- 29.2. Five/25 (20%) patients had < or = 25% EWL at 5 years follow-up, while none of the 10 patients subject to follow-up at 7 years had < or = 25% EWL. CONCLUSIONS: Lap-Band System is an interesting option for teenagers suffering obesity and its related comorbidities, which deserves further investigation.     

Comparison of effects of gastric bypass and biliopancreatic diversion with duodenal switch on weight loss and body composition 1-2 years after surgery.

BACKGROUND: Gastric bypass (GB) is the most common surgical procedure for weight loss in the United States. Biliopancreatic diversion with duodenal switch (BPD/DS) is less routinely performed, perhaps because of its technical difficulty and metabolic concerns. The objective of this study was to determine whether these procedures had differential effects on weight loss and body composition. METHODS: Body composition was measured by bioimpedance (Tanita 310) at the initial consultation, and follow-up measurements were completed 1-2 years after surgery. RESULTS: Of the 72 patients in the study, 50, aged 46.2 +/- 8.5 years, had undergone GB and were measured 15.5 +/- 5.2 months after surgery and 22, aged 40.6 +/- 7.9 years, had undergone BPD/DS and were measured 19.5 +/- 7.5 months after surgery. Patient age and time after surgery were significantly different between the 2 groups. The body mass index (BMI) for the BPD/DS group was 53.6 +/- 11.9 kg/m(2), significantly greater than the BMI of the GB group (48.0 +/- 6.3 kg/m(2); P = .009). However, the percentage of body fat did not differ between the 2 groups (P = .515). Postoperatively, the BMIs for the GB group (31.5 +/- 5.0 kg/m(2)) and BPD/DS group (30.3 +/- 6.1 kg/m(2)) were not significantly different (P = .384). The percentage of body fat for the GB and BPD/DS groups had changed from 49.2% +/- 8.3% to 32.1% +/- 10.6% and 47.9% +/- 5.9% to 23.8% +/- 10.4%, respectively (P = .002). The BMI had decreased by 16.5 +/- 4.8 kg/m(2)after GB and 23.3 +/- 6.8 kg/m(2) after BPD/DS (P <.001). The decrease in fat was 17.1% +/- 8.2% after GB and 24.2% +/- 7.2% after BPD/DS (P <.001). CONCLUSION: The BPD/DS procedure is more effective in reducing the BMI and promoting fat loss than is GB. The assessment of the impact of these two operations on an individualized basis offers additional information to assist in the evaluation of these procedures.     

Maintenance of weight loss in patients with body mass index >60 kg/m2: importance of length of small bowel bypassed.

BACKGROUND: It is commonly believed that weight loss after biliopancreatic diversion/duodenal switch is inversely related to the length of the alimentary limb and the common channel. However, the effect of the biliopancreatic limb length (BPL) on weight loss has received little attention. METHODS: A total of 1001 patients after biliopancreatic diversion/duodenal switch (209 men and 792 women, mean age 42 +/- 10 yr, mean body mass index [BMI] 52 +/- 9 kg/m(2)) were divided into 2 groups according to the ratio of the BPL to the total small bowel length (SBL): a BPL < or =45% of the SBL versus a BPL >45% of the SBL. The nutritional parameters and percentage of excess weight loss were compared between the 2 groups. RESULTS: In patients with a BMI of < or =60 kg/m(2), the percentage of excess weight loss at 1 year postoperatively was 66.8% for those with a BPL < or =45% of the SBL and 69.3% for those with a BPL >45% of the SBL (P = NS). At 2 years, the corresponding percentages were 73.7% and 79.5% (P = NS) and, at 3 years, were 73.4% and 75.2% (P = NS). In patients with a BMI >60 kg/m(2), the corresponding percentages of excess weight loss was 56.8% versus 61.4% (P = .07) at 1 year, 62.2% versus 77.5% (P = .04) at 2 years, and 59.8% versus 77.5% at 3 years (P = .05). CONCLUSION: The results of our study have shown that amount of weight lost after biliopancreatic diversion/duodenal switch is directly related to the proportion of small bowel bypassed in patients with a BMI >60 kg/m(2). Also, the effect increased with the duration of follow-up. In less heavy patients, the BPL/SBL ratio had a minimal effect on long-term weight loss and a more pronounced effect on nutritional parameters.     

Effect of body weight on testosterone/estradiol ratio in oligozoospermic patients

To evaluate the effect of body mass on the hormonal and semen profiles of subfertile men with oligozoospemia, sperm concentration and reproductive hormone levels were compared in two body mass index (BMI) groups: underweight or normal weight patients (BMI = 25 kg/m2) vs. overweight or obese patients (BMI > 25 kg/m2). The mean BMI was 27 +/- 4.6 kg/m2. The testosterone/estradiol ratio was significantly reduced in the high BMI group as compared to the low BMI group (17 +/- 4 vs. 12 +/- 3; p < 0.05). A similar difference was found in the sperm concentration (11.2 +/- 3.16 x 10(6)/ml vs. 8.1 +/- 2.6 x 10(6)/ml). A nonsignificant difference was found in the LH/FSH ratio (1.41 +/- 0.64 vs. 1.63 +/- 0.72). We concluded that obesity and the consequent estrogen excess decrease the sperm concentration by influencing the hypothalamo-pituitary system.     

Biliopancreatic diversion with duodenal switch or gastric bypass for failed gastric banding: retrospective study from two institutions with preliminary results.

BACKGROUND: Of patients who have undergone gastric banding, 11-25% will require a major reoperation with band removal and conversion to another bariatric procedure after they have failed to lose sufficient weight or have developed dysphagia or reflux. The aim of this study was to evaluate the respective benefits of Roux-en-Y gastric band (RYGB) or biliopancreatic diversion with duodenal switch (BPD-DS) after failed gastric banding and whether 1 of the 2 procedures might be a better procedure for such cases. METHODS: RYGB or BPD-DS was performed according to the institutional protocols with synchronous band removal, irrespective of the reason for failure. RESULTS: Of the 53 patients, 32 underwent laparoscopic RYGB for a body mass index (BMI) of 43.1 +/- 6.4 kg/m(2) (BMI 45.8 +/- 6.4 kg/m(2) before laparoscopic adjustable gastric banding) and 21 underwent BPD-DS for a BMI of 46.0 +/- 5.5 kg/m(2) (BMI 49.6 +/- 5.2 kg/m(2) before laparoscopic adjustable gastric banding). BPD-DS required significantly longer operative times (239.7 +/- 55.8 versus 135 +/- 26.7 minutes) and resulted in more complications (62% versus 12.5%; P <.002). No patients died postoperatively. The 2 groups of patients had a similar BMI at 12 and 18 months after revision (BMI 33.4 +/- 5.6 kg/m(2) and 31.4 +/- 3.5 kg/m(2)). The weight loss was greater after BPD-DS than after RYGB compared with the prerevision weight loss (66.2% versus 58.8% excess weight loss) or initial weight (73% versus 61.8%), although this was not significant. CONCLUSION: Despite an excessive rate of complications that were, in part, related to the learning curve in this series, BPD-DS resulted in greater weight loss compared with RYGB. However, both procedures were successful after failed gastric banding. A more accurate definition of failure could help to determine the respective indications for revisional surgery.     

Body mass index influences palpability but not stage of breast cancer at diagnosis

Body mass index (BMI) is associated with breast cancer risk, but its relationship with stage at diagnosis is unclear. BMI was calculated for patients in the North American Fareston and Tamoxifen Adjuvant trial, and was correlated with clinicopathologic factors, including stage at diagnosis. One thousand eight hundred fourteen patients were enrolled in the North American Fareston and Tamoxifen Adjuvant study; height and weight were recorded in 1451 (80%) of them. The median BMI was 27.1 kg/m2 (range, 14.7-60.7). The median patient age was 68 years (range, 42-100); median tumor size was 1.3 cm (range, 0.1-14 cm). One thousand seven hundred ninety-three (99.0%) patients were estrogen receptor positive, and 1519 (84.7%) were progesterone receptor positive. There was no significant relationship between BMI (as a continuous variable) and nodal status (P = 0.469), tumor size (P = 0.497), American Joint Committee on Cancer stage (P = 0.167), grade (P = 0.675), histologic subtype (P = 0.179), or estrogen receptor status (P = 0.962). Patients with palpable tumors, however, had a lower BMI than those with nonpalpable tumors (median 26.4 kg/m2 vs 27.5 kg/m2, P < 0.001). Similar results were found when BMI was classified as a categorical variable (<25 vs 25-29.9 vs > or =30). Increased BMI does not lead to a worse stage at presentation. Obese patients, however, tend to have nonpalpable tumors. Mammography in this population is especially important.     

Evaluation of nutrition assessment tools compared with body cell mass for the assessment of malnutrition in chronic kidney disease.

OBJECTIVE: We compared the subjective global assessment (SGA) and a range of SGA-based assessment tools with body cell mass (BCM) in patients with stage IV and V predialysis chronic kidney disease (CKD). STUDY DESIGN: This was a cross-sectional, observational study. SETTING: The study took place at a public tertiary hospital predialysis outpatient clinic. PATIENTS: A total of 56 consecutive consenting patients with CKD (61% were male; age [mean +/- standard deviation] 70.2 +/- 11.6 years; glomerular filtration rate 22.2 +/- 6.8 mL/min). MAIN OUTCOME MEASURE: Nutrition status was the main outcome measure. RESULTS: In this population, the prevalence of malnutrition was 19.6% (n = 11, SGA B; no C ratings). Malnutrition was associated with lower BCM (mean BCM, 26.3 vs. 33.4 kg, P = .007, measured by total body potassium), body weight (64.8 vs. 76.1 kg, P = .042), body mass index (23.7 vs. 27.6 kg/m(2), P = .015), and greater weight loss over the previous 6 months (-6.2 vs. -0.1 kg, P = .004). BCM had a weak relationship with 7-point SGA (P = .267), malnutrition inflammation score (r = -0.27 P = .063), and patient-generated SGA (r = -0.27 P = .060). There was no association for either measure of nutrition status (SGA or BCM) with albumin, glomerular filtration rate, or C-reactive protein. CONCLUSION: SGA in its original form most accurately delineated malnutrition by depleted BCM and is the most appropriate tool for cross-sectional assessment of nutrition status in patients with predialysis CKD.     

Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial.

BACKGROUND: To perform a prospective, randomized comparison of laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: LAGB, using the pars flaccida technique, and standard LRYGB were performed. From January 2000 to November 2000, 51 patients (mean age 34.0 +/- 8.9 years, range 20-49) were randomly allocated to undergo either LAGB (n = 27, 5 men and 22 women, mean age 33.3 years, mean weight 120 kg, mean body mass index [BMI] 43.4 kg/m(2); percentage of excess weight loss 83.8%) or LRYGB (n = 24, 4 men and 20 women, mean age 34.7, mean weight 120 kg, mean BMI 43.8 kg/m(2), percentage of excess weight loss 83.3). Data on the operative time, complications, reoperations with hospital stay, weight, BMI, percentage of excess weight loss, and co-morbidities were collected yearly. Failure was considered a BMI of >35 at 5 years postoperatively. The data were analyzed using Student's t test and Fisher's exact test, with P <.05 considered significant. RESULTS: The mean operative time was 60 +/- 20 minutes for the LAGB group and 220 +/- 100 minutes for the LRYGB group (P <.001). One patient in the LAGB group was lost to follow-up. No patient died. Conversion to laparotomy was performed in 1 (4.2%) of 24 LRYGB patients because of a posterior leak of the gastrojejunal anastomosis. Reoperations were required in 4 (15.2%) of 26 LAGB patients, 2 because of gastric pouch dilation and 2 because of unsatisfactory weight loss. One of these patients required conversion to biliopancreatic diversion; the remaining 3 patients were on the waiting list for LRYGB. Reoperations were required in 3 (12.5%) of the 24 LRYGB patients, and each was because of a potentially lethal complication. No LAGB patient required reoperation because of an early complication. Of the 27 LAGB patients, 3 had hypertension and 1 had sleep apnea. Of the 24 LRYGB patients, 2 had hyperlipemia, 1 had hypertension, and 1 had type 2 diabetes. Five years after surgery, the diabetes, sleep apnea, and hyperlipemia had resolved. At the 5-year (range 60-66 months) follow-up visit, the LRYGB patients had significantly lower weight and BMI and a greater percentage of excess weight loss than did the LAGB patients. Weight loss failure (BMI >35 kg/m(2) at 5 yr) was observed in 9 (34.6%) of 26 LAGB patients and in 1 (4.2%) of 24 LRYGB patients (P <.001). Of the 26 patients in the LAGB group and 24 in the LRYGB group, 3 (11.5%) and 15 (62.5%) had a BMI of <30 kg/m(2), respectively (P <.001). CONCLUSION: The results of our study have shown that LRYGB results in better weight loss and a reduced number of failures compared with LAGB, despite the significantly longer operative time and life-threatening complications.