Postural Changes in Morbidly Obese Patients

Background: Postural deviations in morbidly obese individuals may contribute to low self-esteem and to long-term adverse effects on bones and joints. In a case-control study, the axial skeleton was investigated, to disclose the main abnormalities found in obese compared to non-obese groups. Methods: 2 groups were compared. Group 1, severely obese patients (n= 32), age 41.5 ± 8.2 years, BMI 49.4 ± 6.6 kg/m², 93.8% females, and group 2 non-obese (n= 30), age 43.5 ± 5.8 years, BMI 24.6 ± 5.1 kg/m², 96.7% females, had their posture analyzed through clinical examination and radiological imaging. Variables measured were anterior, lateral and posterior angular deviation from the vertical body axis at the head, shoulders, pelvis, Thales triangle, spine, knees, ankles and feet. Data are shown as a percentage of abnormal angles in the 2 groups. Results: On anterior analysis of the 2 groups, disturbances affected head (37.5% vs 13.3%), Thales angle (78.1% vs 53.3%), knees (84.4% vs 33.3%), legs (59.4% vs 30.0%) and support base (59.4% vs 26.7%) (P<0.05). On posterior view, the spine was the deranged segment (87.5% vs 36.7%) (P<0.05), and on lateral assessment, 100% of the results were abnormal. Conclusions: 1) Individuals with morbid obesity present important postural alterations. 2) Seriously altered posture was the rule for the obese population in this study, especially in the spine, knees and feet. 3) Most patients had compatible clinical complaints, but they rarely associated the bone and joint pain with the obesity and axial skeleton deviations. 4) Planned physical activity should be part of the treatment of severe obesity, in order to correct deviations, prevent new ones, and improve quality of life.     

Gastro-esophageal Reflux and Esophageal Motility Disorders in Morbidly Obese Patients

Background: Morbid obesity has long been considered as a contributing factor to gastro-esophageal reflux, but the literature contains conflicting data on the subject. The authors studied a large number of morbidly obese candidates for bariatric surgery with objective means, in order to better define the incidence of gastro-esophageal reflux disease (GERD) and esophageal motility disorders in this population. Methods: Morbidly obese patients, in whom indication for bariatric surgery was confirmed after complete evaluation, were included consecutively during a 4-year period. The evaluation included history of reflux symptoms, upper GI endoscopy, 24-hour pH monitoring, and stationary esophageal manometry. Results: 345 patients were studied, of whom 35.8% reported reflux symptoms. Endoscopy showed a hiatus hernia in 181 patients (52.6%), and reflux esophagitis in 108 (31.4%). 24-hour pH monitoring revealed an elevated De Meester score in 163 patients (51.7%). Manometry was normal in 247 patients (74.4%), and showed a decreased lower esophageal sphincter pressure in 59 (17.7%). Esophagitis and abnormal pH testing were more common in patients with symptoms or hiatus hernia, and the incidence of esophagitis was higher with abnormal pH testing. Esophagitis was associated with increased weight and abdominal obesity. Conclusions: This study confirms the increased prevalence of GERD in the morbidly obese population. Upper GI endoscopy should be performed routinely during evaluation of morbidly obese patients for bariatric surgery. When both conditions coexist, effective treatment is probably best provided by Roux-en-Y gastric bypass, which produces effective weight loss and correction of pathological reflux.     

Altered Olfactory Acuity in the Morbidly Obese

Background: Obese individuals have been reported to have a heightened desire for and ability to identify sweets when compared with leaner persons. Smell, like taste, may also be altered in obese persons compared with leaner subjects. This study was designed to determine if the sense of smell is different between morbidly obese and moderately obese individuals. Methods: 101 adult volunteers undergoing preoperative evaluation completed the 12-item Cross-Cultural Smell Identification Test (CC-SIT) before surgical intervention. Age, BMI, and smoking history were also obtained. Results: 101 subjects completed the preoperative CC-SIT (87 female, 14 male). Mean age of the subjects was 40 ± 12 years. Mean BMI was 42.5 ± 12.5 kg/m². 46 subjects (46%) had a BMI >45. 21 were smokers (21%). 9 subjects (9%), all female non-smokers, had a CC-SIT score representing olfactory dysfunction. Subjects with BMI >45 were more likely to have olfactory dysfunction than subjects with BMI <45 (16% vs 4%, P <0.05). Conclusion: Morbidly obese individuals are more likely than moderately obese individuals to demonstrate CC-SIT scores consistent with olfactory dysfunction. The reason for this is unclear but is probably related to metabolic changes occurring in morbidly obese individuals.     

Induction of Pneumoperitoneum in Morbidly Obese Patients

Background: Induction of pneumoperitoneum can be a difficult, time-consuming, and occasionally hazardous task in a morbidly obese patient. Methods: We have induced pneumoperitoneum in 600 consecutive morbidly obese patients using a 120 mm Veress needle inserted <1 mm beneath the left costal margin, between the mid-clavicular and anterior axillary lines. Absolute muscular relaxation was necessary. Results: A distinct "pop" was felt on entering the peritoneal cavity. The expected intraperitoneal pressure was 7-14 mmHg. A pressure >20 mmHg indicated that the Veress needle was in the abdominal wall. CO2 infusion began at a flow of <1 L/min. "Shaking" the Veress needle to-and-fro improved flow to 1-2 L/min. Complete filling of the abdomen occurred at 4.0 L or more at a pressure limit of 15 mmHg. Increasing the pressure limit to 17 mmHg did not change the rate or final volume of CO₂ infusion. After initial trocar placement, the Veress needle was observed. Frequently it was in the omentum and there was CO₂ beneath the omentum. There was one visceral injury in the 600 patients - a puncture wound to the muscularis, but not the lumen, of the transverse colon. It was repaired laparoscopically with a single stitch. There have been no episodes of perforation of a hollow viscus, no unusual bleeding from the abdominal wall or viscera, and no injuries to the liver or spleen. Conclusion: Percutaneous induction of a pneumoperitoneum with the Veress needle in the left upper quadrant is a safe and effective technique in morbidly obese patients.     

Treatment of Urolithiasis in the Morbidly Obese

Background: Morbidly obese patients with urolithiasis present a therapeutic and diagnostic challenge to the Urologist. Management is reported and potential difficulties discussed. Methods: Morbidly obese patients (body mass index ≥ 40kg/m2) with stone disease were identified by retrospective review. Stone load was calculated and treatment modalities noted. Results: 18 renal units (kidneys) were treated in 17 patients. Of these, 2 required no treatment, 2 had open procedures, and 15 were treated with flexible ureteroscopy. Mean stone burden in patients treated with flexible ureteroscopy was 18 mm, but 8 patients had stone loads >15 mm and in these patients mean stone burden was 23 mm. All were successfully treated or rendered asymptomatic. There were no major complications. Conclusion: Obesity is increasingly prevalent and associated with a high incidence of co-morbidity and complications. Imaging can be difficult and treatment options are limited. Flexible ureteroscopy has proven to be the most successful treatment option, and can avoid the need for more invasive procedures. Furthermore, stone loads greater than normally acceptable can be successfully undertaken in these patients, and should be attempted due to problems associated with other techniques.     

Anesthetic Management of Morbidly Obese and Super-Morbidly Obese Patients Undergoing Bariatric Operations: Hospital Course and Outcomes

Background: Although the implications for the anesthetic and perioperative care of severely obese patients undergoing weight loss operations are considerable, current anesthetic management of super-obese (SO) patients (BMI ≥50 kg/m²), including super-super-obese (BMI ≥60) derives from experience with morbidly obese (MO) patients (BMI 40-49.9 kg/m²). We compared anesthetic and perioperative data of SO patients and MO patients undergoing weight loss operations to evaluate if anesthetic management influenced outcome. Methods: A retrospective analysis was performed on data from 150 consecutive patients (119 MO, 31 SO) undergoing bariatric surgery between May 2000 and March 2005. Data analyzed included preoperative anesthetic assessment, anesthetic management, postoperative care, and intra- or postoperative complications. Results: There were no differences in anesthetic management or in postoperative course or outcome between MO and SO patients. Intraoperative surgical complications occurred in 26% (n=8) in the SO group and 14% (n=15) in the MO group (P<0.01). Conclusions: No differences in outcome occurred between MO and SO patients undergoing bariatric operations under similar anesthetic management. Anesthesia for weight loss surgery can be safely performed on SO patients with the understanding that these patients are not at risk per se due to their higher BMI. The degree of obesity influenced only the incidence of intraoperative surgical complications.     

Intra-abdominal Pressure in the Morbidly Obese

Background: Recent data suggests that increased intra-abdominal pressure (IAP) is one factor associated with the morbidity of morbidly obese patients, who have a BMI >35 kg/m². IAP has been proposed to be an abdominal compartment syndrome (ACS). This study investigated the characteristics of IAP in morbidly obese patients. Methods: 45 morbidly obese patients (mean BMI 55±2 kg/m²) had IAP measured using urinary bladder pressure. Results: The mean IAP for the morbidly obese group was 12±0.8 cmH₂O, increased when compared to controls (IAP=0±2 cmH₂O). The IAP correlated to the sagittal abdominal diameter, an index of the degree of central obesity (r=+0.83, P<0.02); however, it did not correlate to basal insulin, body weight, or BMI. The end-expiratory IAP did not change when measured after the laparotomy incision was made, but IAP measured in the last 15 patients increased during the first 2 postoperative days. The IAP for patients with pressure-related morbidity (gastroesophageal reflux disease, hernia, stress incontinence, diabetes, hypertension, and venous insufficiency) was 12±1 cmH₂O, while those without these morbidities had an IAP of 9±0.8 cmH₂O. Conclusion: We conclude that IAP is increased in morbid obesity. This increased IAP is a function of central obesity and is associated with increased morbidity. The degree of IAP elevation correlates with increased co-morbidities. We also conclude that elevation in IAP in morbid obesity is not a true ACS but represents a direct mass effect of the visceral obesity.     

Psychotherapeutic Treatment of Morbidly Obese Patients after Gastric Banding

Background: Surgery is the most effective therapeutic option for weight reduction in carefully selected patients with morbid obesity resistant to conventional treatment. However, surgical treatment is not the solution but an important precondition for successful management of morbid obesity. Methods: All patients undergo a psychiatric examination before laparoscopic gastric banding. At the first examination we inform all patients about the various forms of psychological support offered before and especially after gastric banding. Results: A majority of the obese individuals are interested in psychological support postoperatively, but only a minority of this patient group (about onequarter) ultimately enlists psychological support on a regular or irregular basis. Some specific psychological topics have proved to be particularly important such as change of self-esteem as a consequence of weight loss, problems in adopting new eating behaviors and the risk for developing a new eating disordered behavior, and problems involving adequate problem-solving. Conclusions: In many cases, some form of psychological support is necessary in order to cope with the new postoperative demands and to find more adequate coping strategies for underlying psychological, psychosocial and environmental problems. The different kinds of psychological support and psychotherapeutic treatment available at Innsbruck University Hospital for obese patients after gastric banding are discussed here.     

Predictors of Nonalcoholic Steatohepatitis and Advanced Fibrosis in Morbidly Obese Patients

Background: Nonalcoholic fatty liver disease (NAFLD) is a common form of chronic liver disease in the United States. It is commonly associated with the components of the metabolic syndrome including obesity. From the spectrum of NAFLD, only patients with nonalcoholic steatohepatitis (NASH) have been convincingly shown to have a potential for progression to cirrhosis. We report the prevalence of NAFLD and NASH as well as predictors of NASH and advanced fibrosis in morbidly obese patients. Methods: 212 consecutive patients who underwent bariatric surgery were enrolled in the study. A liver biopsy was performed at the time of the surgery. Causes of chronic liver disease other than NAFLD were excluded by clinical and laboratory evaluation. Results: The prevalence of NAFLD was 93%. Of those with NAFLD, 26% had NASH. 17 patients (9%) had advanced fibrosis (i.e., bridging fibrosis or cirrhosis). Male gender, AST, and type 2 diabetes mellitus were independently associated with NASH. Waistto-hip ratio, AST, and focal hepatocyte necrosis on liver biopsy were independently associated with advanced fibrosis. Interestingly, while AST was associated with NASH and advanced fibrosis, the majority of the patients with either NASH or advanced fibrosis had normal AST. Conclusions: NAFLD and NASH are very common in morbidly obese patients undergoing bariatric surgery. Features associated with the metabolic syndrome and liver cell injury are independently associated with either NASH or advanced fibrosis.     

Gastric Bypass for Morbidly Obese Patients with Established Cardiac Disease

Background: Bariatric surgery has often been avoided in patients with known cardiac disease because of the risks inherent in this patient population. This study was done to evaluate both the risks and benefits of Roux-en-Y gastric bypass (RYGBP) in morbidly obese patients with established cardiac disease. Methods: Data were analyzed to compare preoperative with postoperative co-morbid cardiac risk factors, peri-operative and postoperative complications, and change in body mass index (BMI) in 77 consecutive patients who had a preoperative diagnosis of cardiac disease and underwent RYGBP between March 1998 and January 31, 2006. Findings were compared to a concomitant control group without cardiac disease. Results: The preoperative presence of cardiac disease was manifested primarily as coronary artery disease (CAD) (45 patients) or as congestive heart failure (CHF) (32 patients). Of the patients with CAD, 60% had diabetes, 91% had hypertension and 39% had hyperlipidemia. 58% had one or more prior invasive cardiac procedures. In the CHF group, 50% had diabetes, 71% had hypertension and 44% had hyperlipidemia. The average length of stay was 3.7 days for CAD patients and 3.3 days for CHF compared to 3.0 days for controls. All co-morbid conditions were improved, and no patient died from cardiac disease. However, one patient died as a complication of GI bleeding, one patient subsequently underwent revascularization and another underwent stenting. Other complications up to 5 years postoperatively were frequent but seldom life-threatening. Conclusion: RYGBP surgery in patients with existing cardiac disease appears to have acceptable risk and is effective in reducing the co-morbid conditions of diabetes, hypertension, hyperlipidemia, sleep apnea and arthritis, but longer term data are needed.     

Liver Pathology in Morbidly Obese Patients Undergoing Roux-en-Y Gastric Bypass Surgery

Background: Non-alcoholic fatty liver disease is common. However,little is known about liver disease in the morbidly obese. Methods: 75 subjects (78% female, mean BMI 57 [40-108]) who had intra-operative liver biopsies at the time of Roux-en-Y gastric bypass surgery were studied. Results: 84% of subjects had steatosis while only about 20% had moderate to severe inflammation and fibrosis. 8% had bridging fibrosis or cirrhosis. The presence of fibrosis correlated strongly with the presence of inflammation (p<0.001) and steatosis (p=0.0011), but weakly with ALT (p=0.02) and not with AST (p= 0.12) or with BMI (p=0.34). Steatosis correlated with AST (p=0.04) and ALT (p=0.055), but not with BMI. Conclusion: Liver disease is not rare in the morbidly obese. The exact causes and mechanisms that lead from the very common isolated steatosis to inflammation and fibrosis remain unclear. Intra-operative liver biopsies during bariatric surgery may be helpful to screen for the presence of steatohepatitis and fibrosis.     

Eating Patterns in Morbidly Obese Patients Before and After a Gastric Restrictive Operation

Background: The present study was set up to analyze the relationships between eating patterns in morbidly obese patients who had undergone an adjustable silicone gastric banding (ASGB) followed for at least 2 years and morbidly obese patients without a gastric restrictive procedure. Methods: Eating pattern was monitored by using the Dutch Eating Behavior Questionnaire in 99 morbidly obese patients (BMI ≥ 35 kg/m²) preoperatively and in 31 patients who had undergone a stomach reduction by the Lap-Band? followed at least 2 years. Both groups were compared to the Dutch normative scores. Results: In the preoperative group, the scores on emotional eating and external eating were significantly higher than the Dutch normative scores. The scores on restrained eating were preoperatively equal to the Dutch normative scores. Although not significant, the scores in the postoperative group on external eating were lower than the Dutch normative scores and equal on emotional eating. The variable restrained eating postoperatively was significantly higher compared with the preoperative group. On emotional and external eating, the scores postoperatively were significantly lower compared with the preoperative group. Conclusions: According to the results, surgical treatment using an ASGB or another gastric restrictive operation could be the right solution in patients with an emotional and external eating behavior. Placement of the ASGB has a negative effect on restrained eating behavior.     

Manometric Abnormalities and Gastroesophageal Reflux Disease in the Morbidly Obese

Background: Obesity is an epidemic in the USA. Many disorders are associated with obesity including gastroesophageal reflux disease (GERD). However, the prevalence of GERD and esophageal motility disorders in the morbidly obese population is unclear. Methods: During evaluation for bariatric surgery, 61 morbidly obese patients underwent preoperative 24-hr pH and esophageal manometry. A single reviewer evaluated all 24-hr pH and manometric tracings. Johnson-DeMeester score >14.7 was considered diagnostic of GERD. Manometric criteria for motility disorders were from published values. All values are given as mean ± SD. Results: Mean age was 44.4 + 10.3 years. 55 of the patients (90%) were female. Mean BMI was 50.1 ± 7.2 kg/m². 23 patients (38%) complained of GERD symptoms (reflux and/or heartburn). 1 patient (2%) complained of noncardiac chest pain. Mean Johnson-DeMeester score was 19.6 ± 17.8. Mean intragastric and intrabolus pressures were both elevated (8.3 ± 1.6 mmHg and 15 ± 9 mmHg). 33 patients (54%) had abnormal manometric findings: 10 had a mechanically defective LES, 11 had a hypertensive LES, 2 had diffuse esophageal spasm, 3 had nutcracker esopha gus,1 had ineffective esophageal disorder and 14 had nonspecific esophageal motility disorder. Some patients had more than one disorder. 20 patients (33%) had significantly elevated (>180 mmHg) contraction amplitudes at the most distal channel (210.0 ± 28.7 mmHg). Conclusions: Prevalence of manometric abnormalities in the morbidly obese is high. Presence of a nut cracker-like distal esophagus in the morbidly obese is significant and warrants further evaluation.     

Laparoscopic Cholecystectomy in Obese Patients

Background: Laparoscopic cholecystectomy (LC) is the treatment of choice for gallstones. Obesity was initially considered a contraindication to this approach. The aim of this report is to review our experience with LC, to evaluate the role of BMI in the outcome. Methods: The records of 1,804 patients who underwent LC for symptomatic cholelithiasis from May 1992 to January 2004 were analyzed retrospectively. Patients were divided into 5 groups according to their BMI: ≤24.9, 25.0-29.9, 30.0-34.9, 35.0-39.9 and ≥40 kg/m². Results: Of the 1,804 patients [1,379 females (76.4%) and 425 males (23.6%)] who underwent LC, 431(23.9%), 924 (51.2%), 355 (19.7%), 68 (3.8%) and 26 (1.4%) had BMI values of ≤24.9, 25.0-29.9, 30.0-34.9, 35.0-39.9 and ≥40 kg/m², respectively. Conversion to open cholecystectomy was required in 94 patients (5.2%), and complications occurred in 39 patients (2.2%). There was no correlation between BMI and the conversion rate (P=0.593) and complication rate (P=0.944), while the hospital stay was similar between the groups with successful LC. The only significant difference was the longer operating time in the two obesity groups (P<0.001). Conclusions: LC is effective and safe in patients with morbid obesity. As it carried low risks of conversion and perioperative complications, we suggest that LC is the select approach for these patients. Moreover, the rapid mobilization and hospital discharge following LC may provide extra benefit to these patients.     

Histological Behavior of Hepatic Steatosis in Morbidly Obese Patients after Weight Loss Induced by Bariatric Surgery

Background: Hepatic steatosis has a high prevalence among morbidly obese patients. Its relation to steatohepatitis and cirrhosis has been extensively studied among these patients. The aim of this study was to evaluate the behavior of hepatic steatosis with weight loss 1 year after bariatric surgery. Methods: This study is a historical cohort that compared liver biopsies obtained from morbidly obese patients during the bariatric operation, with percutaneous biopsies taken from the same patient 1 year after surgery. The results were compared with weight loss, patients' profile (gender, age, body mass index (BMI) and waist/hip ratio), and with the presence of co-morbidities such as diabetes, hypertension, and dyslipidemia. Results: 90 patients who had liver biopsies taken at the operation and postoperative period for bariatric surgery were included. The prevalence of hepatic steatosis was 87.6%. The average percent of excess weight loss was 81.4%. On the second biopsy, 16 patients (17.8%) of the total had the same degree of steatosis, 25 (27.8%) improved their steatosis pattern and 49 (54.4%) had normal hepatic tissue. There was no statistical difference regarding age, BMI, waist/hip ratio, and co-morbidities (P>0.05), but there was a difference in gender (P=0.044). Conclusion: Significant improvement in the hepatic histology of steatosis was observed after weight loss induced by bariatric surgery in most patients. There was no patient with a worsening in the histology.     

Intragastric Balloon in Obese Patients

Background: Since March 1998, 143 BioEnterics? Intragastric Balloons (BIB) were placed in 132 obese and morbidly obese patients, to study the clinical possibilities of a new system, both from the point of view of the materials used and the application method. Methods: 36 patients were male and 96 female; mean age was 43 years (21-70); mean weight was 115.4 kg (67-229), and mean BMI was 41.0 (29-81). 8 patients were affected by severe respiratory insufficiency. We placed and removed the balloon endoscopically under conscious sedation or general anesthesia. BIB was removed in the majority of patients 4 months after insertion. The patients were given a balanced diet of 800-1000 kcal/day; follow-up involved a monthly check-up (routine blood tests, weight control) and a visit every 15 days with the dietitian. Results: Mean weight loss was 14.4 kg; mean reduction in BMI was 5.2.Weight loss was much better in males. The weight loss produced an improvement of the complications associated with the obesity. Complications observed were: balloon intolerance (9 early removals), 1 balloon deflated and passed, 2 cases of gastric ulcer at balloon removal. Conclusions:The most correct indications for BIB should be: extremely obese patients (BMI>40) in preparation for a bariatric operation; obese patients with BMI 30-35 with a chronic disease otherwise unresolved; patients with BMI< 30 in a multidisciplinary approach.     

The Role of Ultrasound in the Diagnosis of Hepatic Steatosis in Morbidly Obese Patients

Background: Hepatic steatosis is prevalent in obese patients. Although it requires histology for diagnosis, ultrasound may indicate its presence. We evaluated the importance of ultrasound in the diagnosis of steatosis in morbidly obese patients, and considered its clinical relevance for patients with BMI of 35-40 kg/m² without co-morbidities. Methods: 187 morbidly obese patients submitted to bariatric surgery were prospectively studied. All patients had ultrasound before the operation, and hepatic biopsies during the operation, which were compared. Results: The prevalence of steatosis histologically was 91.4%. The sensitivity and specificity of ultrasound in diagnosing steatosis was 49.1% and 75%, respectively,with a positive predictive value of 95.4%. Conclusion: The biopsies found a very high prevalence of steatosis in the studied population. The ultrasound results yielded a high positive predictive value (95.4%), suggesting its use as a diagnostic tool for this co-morbidity in morbidly obese patients.The low sensitivity of the method could be related to the lack of objective criteria for the ultrasound diagnosis of steatosis, and probably, technical problems in performing ultrasound in such patients. We believe that in patients with a BMI of 35-40 kg/m² without other comorbidities, the ultrasound finding of steatosis could be of value as an indication for bariatric surgery.     

Gait Cinematic Analysis in Morbidly Obese Patients

Background: Functional co-morbidities of excess body weight such as gait problems are never life-threatening like those associated with certain metabolic sequelae. Nevertheless, they may interfere with quality of life and also act as a mirror of muscle, bone and joint stress. In this prospective study, the goal was to document dynamic aspects of gait in severely obese subjects. Methods: An outpatient population (age 47.2 ± 12.9 years, 94.1% females, BMI 40.1 ± 6.0 kg/m², n= 34) had their gait analyzed by an experienced physical therapist. Variables included speed, cadence, stride, support base and foot angle, which were compared to reference values for the Brazilian population. Results: All variables were significantly lower in the obese patients, except for support base which was increased. Speed was 73.3±16.3 vs 130 cm/s, cadence was 1.4±0.2 vs 1.8 steps/s, stride was 106.8±13.1 vs 132.0 cm, and support was 12.5±3.5 vs 10.0 cm (P<0.05). Conclusions: 1) Widespread cinematic impairment was the rule in the studied population. 2) These findings are consistent with poor skeletal muscle performance, high metabolic expenditure and constant physical exhaustion. 3) Attention should be paid not only to the metabolic management but also to the physical rehabilitation required in cases of advanced obesity.     

Effects of Weight Loss on QT Interval in Morbidly Obese Patients

Background: Obesity causes structural changes to the heart that may influence its function. Furthermore, morbid obesity is associated with an acquired prolongation of the QTc interval that may lead to potentially hazardous arrhythmias. The present study investigated the effect of body weight loss following vertical banded gastroplasty (VBG) on the QTc interval. Methods: 17 morbidly obese patients, scheduled for elective VBG, were studied before the operation and 8-10 months postoperatively, when each patient had achieved a weight loss of ≥ 25% of the preoperative body weight. Results: 15 patients achieved significant body weight loss of ≥ 25% within the first 8-10 postoperative months (P <0.001).This weight loss, corresponding to an excess weight loss of 48.7% and a mean body mass index (BMI) reduction from 49.7 kg/m² to 36.6 kg/m², was followed by significant shortening of the QTc interval from 428 msec to 393 msec (P <0.001). Conclusions: The significant postoperative weight loss following VBG was accompanied by shortening of the QTc interval. This effect is expected to reduce the incidence of fatal conditions associated with the long QT syndrome, such as malignant ventricular arrhythmias and sudden death, and therefore improve morbidity and mortality.     

Gallstone Formation after Weight Loss following Gastric Banding in Morbidly Obese Dutch Patients

Background: Obesity is a risk factor for the development of gallstones. Rapid weight loss may be an even stronger risk factor. We retrospectively assessed the prevalence and risk factors of gallstone formation after adjustable gastric banding (AGB) in a Dutch population. Methods: All patients who underwent AGB between Jan 1992 and Dec 2000 for morbid obesity were invited to take part in this study. Transabdominal ultrasonography of the gallbladder was performed in those patients without a prior history of cholecystectomy (Group A). Additionally, 45 morbidly obese patients underwent ultrasonography of the gallbladder before weight reduction surgery (Group B). Results: 120 patients were enrolled in the study (Group A). Prior history of cholecystectomy was present in 21 patients: 16 before and 5 after AGB. Ultrasonography was performed in 98 patients: gallstones were present in 26 (26.5%). On multivariate analysis, neither preoperative weight, nor maximum weight loss, nor the interval between operation and the postoperative ultrasonography were determinants of the risk for developing gallstone disease. Prevalence of gallstones was significantly lower in the morbidly obese patients who had not yet undergone weight reduction surgery (Group B). Conclusions: Rapid weight loss induced by AGB, is an important risk factor for the development of gallstones. No additional determinants were found. Every morbidly obese patient undergoing bariatric surgery must be considered at risk for developing gallstone disease.