Impact of Rapid Weight Reduction on Risk of Cholelithiasis after Bariatric Surgery

Background: Obesity alone and rapid weight loss induced by bariatric surgery are recognized risk factors for the development of cholelithiasis. The decision to perform prophylactic cholecystectomy at the time of bariatric operations remains controversial and at the surgeon's discretion. Methods: From June 1998 to April 2001, 103 patients underwent Roux-en-Y gastric bypass (RYGBP) in Hospital das Clinicas/Unicamp (SP). 88 of these 103 patients had their preoperative ultrasonography of gallbladder recovered. 19 of these 88 patients showed gallstones before RYGBP, and the remaining 69 did not have ultrasonographic evidence of cholelithiasis. 36 of these 69 patients were followed with ultrasonography during the 12 postoperative months. They were divided into 2 groups: those who formed gallstones (n=19) and those who did not (n=17), to evaluate the importance of sex, age, preoperative BMI, preoperative excess weight and postoperative percent excess weight loss as risk factors in the gallstone formation. Results: Preoperative incidence of cholelithiasis in the 88 operated patients was 21.6% and postoperative incidence in the 36 patients followed by ultrasonograph was 52.8%. There was no statistical evidence that postoperative gallstone formation is associated significantly with the variables studied. Conclusion: This study confirms the high correlation between morbid obesity, rapid weight loss and gallbladder disease. Predictive risk factors for gallstone formation were not found.     

Renal Cell Carcinoma Following Bariatric Surgery

Background: Obesity, hypertension, smoking, and amphetamine diet pills increase the risk for renal cell carcinoma (RCC). Obesity causes a four-fold increase. We report our 11-year experience with RCC after bariatric operations. Methods: 5 patients with RCC were identified out of 2,287 bariatric surgical patients since 1993 on retrospective chart review. Results: 4 of the 5 patients were females. At time of their bariatric operation, patients were age 29-52 (43.4) years, weighed 109-158 (129.8) kg, and BMI was 43-60 (49.4). All tumors were incidentally discovered 8-66 (27.4) months postoperatively when the patients weighed 54-94 (71.4) kg, with BMI 21-34 (26.6). Preoperative renal ultrasound obtained within 3 months of the bariatric operation was normal in 4; the other did not have a preoperative study. The latter patient had a vertical banded gastroplasty 12 years before and the RCC was discovered 5 1/2 years later during work-up for a revision. 3 had a distal gastric bypass and 1 underwent adjustable gastric banding. 4 of the patients had a radical nephrectomy and 1 underwent a partial nephrectomy. Tumors were 2.0-8.7 (4.4) cm in size, and all were clear-cell RCC without vascular or extrarenal involvement. None has had recurrence at 3-67 (30.8) months follow-up. 1 patient died from a stroke 18 months later. Conclusion: Reversal of obesity following bariatric surgery does not eliminate risk for RCC. Preoperative and annual postoperative ultrasonography may be useful in identifying early stage RCC. Lesions that are not pure cysts must be evaluated with CT scans or MRI. Nephrectomy may be curative.     

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.     

Changes in Insulin Resistance Following Bariatric Surgery: Role of Caloric Restriction and Weight Loss

The prevalence of type 2 diabetes mellitus (T2DM) and obesity in the western world is steadily increasing. Bariatric surgery is an effective treatment of T2DM in obese patients. The mechanism by which weight loss surgery improves glucose metabolism and insulin resistance remains controversial. In this review, we propose that two mechanisms participate in the improvement of glucose metabolism and insulin resistance observed following weight loss and bariatric surgery: caloric restriction and weight loss. Nutrients modulate insulin secretion through the entero-insular axis. Fat mass participates in glucose metabolism through the release of adipocytokines. T2DM improves after restrictive and bypass procedures, and combinations of restrictive and bypass procedures in morbidly obese patients. Restrictive procedures decrease caloric and nutrient intake, decreasing the stimulation of the entero-insular axis. Gastric bypass (GBP) operations may also affect the entero-insular axis by diverting nutrients away from the proximal GI tract and delivering incompletely digested nutrients to the distal GI tract. GBP and biliopancreatic diversion combine both restrictive and bypass mechanisms. All procedures lead to weight loss and decrease in the fat mass. Decrease in fat mass significantly affects circulating levels of adipocytokines, which favorably impact insulin resistance. The data reviewed here suggest that all forms of weight loss surgery lead to caloric restriction, weight loss, decrease in fat mass and improvement in T2DM. This suggests that improvements in glucose metabolism and insulin resistance following bariatric surgery result in the short-term from decreased stimulation of the entero-insular axis by decreased caloric intake and in the long-term by decreased fat mass and resulting changes in release of adipocytokines. Observed changes in glucose metabolism and insulin resistance following bariatric surgery do not require the posit of novel regulatory mechanisms.     

Body Composition and Metabolic Changes Following Bariatric Surgery: Effects on Fat Mass, Lean Mass and Basal Metabolic Rate

Background: Bariatric surgery has become the method of choice for weight loss in severely obese patients. While the incidence of obesity and its co-morbidities have been well-documented, less is known about the outcomes of the surgery as it relates to body composition and metabolic changes. Methods: 19 bariatric surgery patients (14 female, 5 male) were assessed for basal metabolic rate (BMR), percent fat, fat mass, and lean body mass (LBM) just prior to surgery and at 1, 3 and 6 months after surgery. Results: Analysis of Variance (ANOVA) using the general linear model indicated significant changes in all measures of body composition for each time period. Linear regression was developed for each of these measures. Of the 39.7-kg weight loss, 26.4 kg (66.5%) was fat mass loss and 13.3 kg (33.5%) was LBM loss. BMR significantly decreased from pre-surgery (2091 kcals) to 1 month post-surgery (1758 kcals), with no significant changes in subsequent time periods. Repeated measures ANOVA for the ratio of BMR/LBM indicated no significant differences for any comparison of time periods (F=2.29, P=.111), suggesting that there is no adaptation of an energy-conserving mechanism in these patients. Conclusion: Bariatric surgery was highly successful in inducing significant changes in body weight (39.7 kg), fat mass (26.4 kg), % body fat (7.9%) but also lean body mass (13.3 kg). The 440 kcal decrease in BMR, while significant, was not greater than expected due to significant decreases in LBM.     

Dermalipectomy for Body Contouring after Bariatric Surgery in Aegean Region of Turkey

Background: The only proven effective long-term treatment for morbid obesity is bariatric surgery. After surgery, additional problems may arise such as redundant hanging skin and a poor body image. The patient's quality of life and social acceptance may thus still be hindered. Body contouring operations remain the only hope here. Methods: Body contouring surgery was performed on 11 patients out of 38 who had had vertical banded gastroplasty. General self-consciousness, social self-consciousness of appearance and sexual and bodily self-consciousness of appearance were measured with a retrospective questionnaire. Results: Timing of body contouring surgery was determined according to the demand of the patient and stabilization of the patient's weight status. On average the first plastic surgery operation was performed after 17 (12-25) months. Mean age was 37.4 (34-65) and mean excess weight loss was 57.6 (37-129). In the 11 patients who underwent plastic procedures, a total of 23 such operations were performed, and 8 complications were encountered in these 23 operations. General self-consciousness and sexual bodily self-consciousness of appearance showed improvement after bariatric surgery and further improvement after the plastic surgery. Conclusion: For markedly redundant skin after massive weight loss, dermalipectomy is the only treatment. This improves the patient's general, sexual and bodily self-consciousness.     

Psychiatric Diagnosis and Weight Loss following Gastric Surgery for Obesity

Background: The authors examined associations between lifetime Axis I and Axis II disorders and weight loss following gastric surgery for morbid obesity. Methods: 44 morbidly obese subjects who had undergone vertical banded gastroplasty (VBG) were systematically interviewed with the Diagnostic Interview Schedule (DIS) and were administered the Personality Diagnostic Questionnaire (PDQ). Subjects were followed-up 6 months post-VBG to determine weight loss. Results: The subjects had a mean ± SD age of 37.7 ± 10.6 years.Their baseline weight was 135.3 ± 28.0 kg and their baseline body mass index (BMI) was 50.0 ± 7.4. 34 (77%) were female. Results of linear regressions show a significant association between baseline BMI and weight loss at 6-month follow-up. After adjustment for baseline BMI, there was a non-significant trend toward increased weight loss in association with alcohol abuse/dependence. Similarly, among our analysis of 41 subjects who had received the PDQ, we found a non-significant trend toward increased weight loss in association with "any" PDQ diagnosis and with antisocial personality disorder/trait after adjusting for baseline BMI. Conclusion: The data suggest that Axis I and Axis II diagnoses were not predictive of weight loss following VBG during a 6-month follow-up.     

Bariatric Surgery for Morbid Obesity

Background: Bariatric surgery is a treatment for severely obese patients.We examined the efficacy of bariatric surgery, addressing three questions: 1) "What is the overall weight reduction following bariatric surgery?" 2) "What complications are associated with bariatric surgery?" 3) "What impact does weight loss have on obesity-related comorbidity?" Methods: Fixed and random effects meta-analyses were used to determine the amount of weight reduction following bariatric surgery. The influence of a variety of co-variates that could affect study results was examined. Information from evidencebased sources was used to explore the impact of weight loss on comorbidities. Results: Meta-analyses results were affected by loss to follow-up, and within-study heterogeneity of variance. Therefore, results were pooled from studies with complete patient follow-up. Meta-analysis of six studies reporting weight loss at 1 year and four studies with mean follow-up of 9 months to 7 years demonstrated BMI reductions of 16.4 kg/m² and 13.3 kg/m², respectively. Weight reduction following bariatric surgery may be associated with improvements in risk factors for cardiac disease including hypertension, type 2 diabetes and lipid abnormalities, and may decrease the severity of obstructive sleep apnea. Conclusion: Bariatric surgery is appropriate for obese patients (BMI>40 kg/m² or ≥35 kg/m² with obesity-related comorbidity) in whom non-surgical treatment options were unsuccessful. Additional research is needed to examine the long-term benefits of weight loss following bariatric surgery, particularly with respect to obesity-related comorbidities.     

Patient Motivation for Bariatric Surgery: Characteristics and Impact on Outcomes

Background: Motivation for seeking obesity surgery has not been studied. The authors explored the patient's motivation for selecting surgery and examined for a relationship between primary motivating factors and weight outcomes. Methods: 208 (177F: 31M) unselected participants followed at least 1 year after Lap-Band? placement completed a short questionnaire. 6 statements were scored 1-6 from the most important through to the least important. Statements included appearance, embarrassment, medical conditions, health concerns, physical fitness and physical limitation. Any additional factors were also sought. Results: Mean age, weight and BMI before surgery were 41±10 years, 129±16 kg and 46±8 kg/m² respectively. Responses to appearance and embarrassment correlated strongly and were grouped together. Medical conditions and health concerns account for 52%, appearance and embarrassment for 32%, and poor physical fitness and physical limitation for 16% of first choices. Those who scored 1 for appearance or embarrassment (n=67) had a lower presenting BMI (44 kg/m², P=0.03) and all but 1 were female (P<0.001). This group reported more depressive symptoms, poorer mental quality of life and poorer body image preoperatively. Men were more likely than women to be motivated by medical problems (P=0.007). Subjects motivated by a medical condition were more likely to have hypertension or diabetes and less likely to smoke. This group tended to be older. Weight history did not influence motivation. The first choice of motivating factor was not associated with weight outcomes at 1-3 years following surgery. Conclusion: Health issues dominate the motivation for seeking surgery. Weight outcomes do not appear to be affected by the patient's primary motivating factor.     

A Comparison of Two Different Prophylactic Dose Regimens of Low Molecular Weight Heparin in Bariatric Surgery

Background: Deep venous thrombosis (DVT) is a significant risk in patients undergoing surgery for morbid obesity and may be associated with significant morbidity and mortality. In a consecutive group of patients in one bariatric surgery practice, the initial group of patients who received prophylaxis for DVT was given enoxaparin 30 mg q12h while the later group was given enoxaparin 40 mg q12h. Methods: 481 patients who underwent primary and revisional bariatric surgery over 38 months (October 1997 - December 2000) were evaluated. All patients received a multi-modality DVT prophylaxis protocol that included: early ambulation, graduated compression stockings, intermittent pneumatic compression, and enoxaparin (LMWH) in two dosage groups. The first 92 patients (19%) in the series (Group I) received LMWH 30 mg q12h while the subsequent 389 patients (81%) (Group II) received LMWH 40 mg q12h. Results: Group I patients were not different from Group II patients in body mass index (BMI) (51.7 vs 50.3 kg/m²), age (43.7 vs 44.3 yrs), sex (men 20.2% vs 15.8%) or history of previous DVT (3.2% vs 3.9%). Group I patients did have significantly longer procedure times (213 vs 175 min, p<0.05) and hospital stays (5.67 d vs 3.81 d, p<0.05) than Group II. There were a total of 7 (1.4%) postoperative DVT complications. 5 DVT complications occurred in Group I (5.4%) compared with 2 DVT complications in Group II (0.6%) (p < 0.01 by Fisher Exact Test two-tailed). One patient in each group required treatment for hemorrhage. Conclusion: A multi-modality prophylaxis treatment protocol in patients undergoing bariatric surgery is feasible and achieves a low incidence of postoperative DVT complications. The use of a higher dose of enoxaparin, 40 mg q12h, may reduce the incidence of DVT complications in patients following bariatric surgery without an increase in bleeding complications.     

Long-Term Weight Loss after Bariatric Surgery in Patients Visited at Home Outside the Study Environment

Background: Bariatric surgery results in sustained weight loss in the majority of patients. The controlled setting of a trial, however, does not necessarily reflect the everyday routine practice. Therefore, to investigate the results of bariatric surgery in a more natural setting, patients were visited at home, outside a study and hospital environment. Methods: Patients who underwent a vertical banded gastroplasty or a gastric bypass between 1980 and 1997 were eligible. Body weight and height were measured. Patients filled out general and health status questionnaires (Nottingham Health Profile (NHP)). Results: Responses were obtained from 236/313 subjects (75%) with a mean ± SD age of 42.9 ± 10.2 years and a mean current body weight of 100.3 ± 20.7 kg. A maximum weight loss of 48.2 ± 18.4 kg or 70.8 ± 22.4% excess weight loss was obtained after 17 ± 15 months, of which 32.1 ± 22.6 kg or 45.2 ± 29.3%, respectively, was maintained at 8.2 ± 4.5 years after the intervention. Males and females did not differ in weight loss. The type of operation had no influence. Age >50 years and a BMI >50 kg/m² were not related to a poor outcome, but a time lapse of >5 years since the operation resulted in a less well sustained weight loss. The subjective health status improved considerably, but less so with a smaller weight loss and longer lapse of time since the operation. Especially in females, the NHP still deviated substantially from Dutch norm values. Conclusions: Surgically obtained weight loss is satisfactory in patients outside a strictly controlled study setting. Health benefits are substantial, but are adversely affected by weight gain and time elapsed since the operation.     

Prevention of Rhabdomyolysis in Bariatric Surgery

Background: Rhabdomyolysis (RML) is a clinical and biochemical syndrome caused by skeletal muscle necrosis that results in extravasation of toxic intracellular contents from the myocytes into the circulatory system. Postoperative RML in bariatric surgery occurs with various non-physiological surgical positions, with prolonged muscle compression. The potential consequences may lead to death. The purpose of this study is to review its pathophysiology and the best ways to prevent RML in bariatric surgery. Methods: We searched the literature and reviewed all relevant articles, by searching for the keywords: rhabdomyolysis, morbid obesity, prevention and bariatric surgery, giving a total of 39 articles. Results: Prevention may be enhanced by careful padding on the operative table at all pressure-points. Changing patient position, both intraoperatively and postoperatively, also reduces RML. A potential new solution to decrease the longer operative time and avoid RML is to perform the bariatric operation in two stages. Another way to limit the duration of surgery in high-risk patients is to alert surgeons not to select super-obese high-risk patients early in the learning curve. Conclusion: As RML is an important and potentially fatal complication of bariatric surgery, the best way to avoid it is effective prevention. More research on this subject is necessary.     

Predictors of Weight Status following Laparoscopic Gastric Bypass

Background: Weight loss after bariatric surgery varies and depends on many factors, such as time elapsed since surgery, baseline weight, and co-morbidities. Methods: We analyzed weight data from 494 patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) by one surgeon at an academic institution between June 1999 and December 2004. Linear regression was used to identify factors in predicting % excess weight loss (%EWL) at 1 year. Results: Mean patient age at time of surgery was 44 ± 9.6 (SD), and the majority were female (83.8%). The baseline prevalence of co-morbidities included 24% for diabetes, 42% for hypertension, and 15% for hypercholesterolemia. Baseline BMI was 51.5 ± 8.5 kg/m². Mean length of hospital stay was 3.8 ± 4.6 days. Mortality rate was 0.6%. Follow-up weight data were available for 90% of patients at 6 months after RYGBP, 90% at 1 year, and 51% at 2 years. Mean %EWL at 1 year was 65 ± 15.2%. The success rate (≥50 %EWL) at 1 year was 85%. Younger age and lower baseline weight predicted greater weight loss. Males lost more weight than females. Diabetes was associated with a lower %EWL. Depression did not significantly predict %EWL. Conclusion: The study demonstrated a 65 %EWL and 85% success rate at 1 year in our bariatric surgery program. Our finding that most pre-surgery co-morbidities and depression did not predict weight loss may have implications for pre-surgery screening.     

Asthma and Sleep Apnea in Patients with Morbid Obesity: Outcome after Bariatric Surgery

Background: Asthma and sleep apnea syndrome (SAS) are frequently reported in obese patients. The authors determined the prevalence of asthma and SAS in morbidly obese patients and the effect of biliopancreatic diversion with duodenal switch (BPD-DS) on these conditions. Methods: 398 patients were evaluated for bariatric surgery in a university-affiliated tertiary care center. All patients completed a written questionnaire on asthma and SAS before BPD-DS. In addition, 139 patients also completed a questionnaire on their general health status, including asthma and SAS, 2 years after the procedure. Results: For the cohort of 398 patients, the prevalence of self-reported asthma was 30.4% and that of SAS, 32.2%. No significant association was found between asthma and SAS diagnosis (P =0.10). Significant relationships were observed between the diagnosis of asthma and age, hip circumference, waist/hip ratio, weight and BMI of the patients as well as between a diagnosis of SAS and gender, waist circumference, hip circumference, waist/hip ratio, weight and BMI. 2 years after surgery (mean BMI was reduced from 51.4 to 30.5 kg/m²), asthma was reported improved in 79.3% of patients and SAS was improved in all but one with this condition; among 29 SAS patients using CPAP before surgery, only 4 were still using this treatment after 2 years. Conclusion: The prevalence of asthma and SAS is high in the morbidly obese population and is associated with markers of obesity. We found no association between the diagnosis of asthma and SAS diagnosis in this population. BPD-DS improved self-reported severity of asthma and SAS symptoms.     

Bariatric Surgery: Asia-Pacific Perspective

Background: There is a world-wide epidemic of overweight, obesity and morbid obesity. Bariatric surgery today, as the only effective therapy for morbid obesity, is expanding exponentially to meet the global epidemic of morbid obesity. Bariatric surgeons in the Asia-Pacific region had founded the Asia-Pacific Bariatric Surgery Group (APBSG) at Seoul, Korea on October 6, 2004. Methods: E-mail requests for information were sent to the national bariatric surgery leaders. These requests were followed, if necessary, by second e-mail requests and communications seeking clarification. The summary data was also discussed at the 1st Asia-Pacific Bariatric Consensus Meeting held in Taipei, February 27, 2005. Results: 11 countries or areas in Asia had started bariatric surgery and responded to the general questions. In 2004, 636 bariatric operations were performed by 61 bariatric surgeons. The earliest data for starting bariatric surgery was in 1974 in Taiwan. Following the development of gastric partition, Taiwan performed the first case in 1981, Japan in 1982 and Singapore in 1987. In 2004, 11 countries have started bariatric surgery. The APBSG was founded in 2004. In 2004, 12.1% of operations were open and 87.9% laparoscopic. The 6 most popular operations were: laparoscopic adjustable banding 42.3%; laparoscopic gastric bypass 34.2%; open vertical banded gastroplasty 7.5%; laparoscopic vertical banded gastroplasty 6.3%; laparoscopic sleeve gastrectomy 6.3%; open gastric bypass 4.2%. Pooling open and laparoscopic procedures, relative percentages were gastric banding 42.3%; gastric bypass 38.4%; vertical banded gastroplasty 13.8%. The APBSG consensus meeting recommended bariatric surgery in Asian patients with BMI >37 or >32 with diabetes or two other obesity-related co-morbidities. Conclusions: Bariatric surgery is expanding rapidly in Asia to meet rapidly increasing obesity. The modification of the indications for bariatric surgery in the Asian is proposed.     

Adolescent Bariatric Surgery: Treatment Delayed, Treatment Denied, a Crisis Invited

Adolescent obesity has serious immediate and long-term health consequences. There are no effective behavioral or pharmacologic treatments of extreme obesity among adolescents. Bariatric surgery is the most effective means to achieve durable weight loss, with amelioration or resolution of most obesity-related co-morbidities. Surgery should be performed when: 1) the risk of operative complications and of recidivism is lowest; 2) the outcomes of the operation are likely to be the best possible; and 3) there is little need to consider subsequent bariatric surgery for weight regain and reappearance of co-morbidities. A higher BMI is an independent risk factor for operative morbidity and mortality, and is associated with less weight loss and greater likelihood of weight regain. The higher BMI criterion for adolescent bariatric surgery exposes the adolescent to a higher risk for operative death and complications, and suboptimal outcomes following bariatric surgery.     

Impact of Patient Follow-Up on Weight Loss after Bariatric Surgery

Background: Postoperative follow-up after bariatric surgery is important. Because of the need for adjustments, follow-up after gastric banding may have a greater impact on weight loss than after Roux-en-Y gastric bypass.We reviewed all patients at 1 year after these two operations. Methods: During the first year after surgery, laparoscopic adjustable gastric banding (LAGB) patients were followed every 4 weeks and Roux-en-Y gastric bypass (RYGBP) patients were followed at 3 weeks postoperatively and then every 3 months.The number of follow-up visits for each patient was calculated, and 50% compliance for follow-up and weight loss was compared. Results: Between October 2000 and September 2002, 216 LAGB and 139 RYGBP operations were performed. Of these patients, 186 LAGB patients and 115 RYGBP patients were available for 1-year follow-up. Age and BMI were similar for each group. Overall excess weight loss (EWL) after LAGB was 44.5%. 130 (70%) returned 6 or less times in the first year and achieved 42% EWL. 56 patients (30%) returned more than 6 times and had 50% EWL (P=0.005). Overall %EWL after RYGBP was 66.1%. 53 patients (46%) returned 3 or less times in the first year, achieving 66.1% EWL. 62 patients (54%) returned more than 3 times after surgery and achieved 67.6% EWL (P=NS). Conclusion: Patient follow-up plays a significant role in the amount of weight lost after LAGB, but not after RYGBP. Patient motivation and surgeon commitment for long-term follow-up is critical for successful weight loss after LAGB surgery.     

Psychosocial Outcome of Gastric Bypass Surgery for Patients With and Without Binge Eating

Background: There is limited data on the prevalence of eating disorder pathology in morbidly obese patients undergoing Roux-en-Y gastric bypass (RYGBP) and the degree to which this may affect surgical outcome. The present study examined surgical outcome between 2 groups of patients undergoing RYGBP: those with pre-surgical binge eating (BE) and those without pre-surgical binge eating (NBE). Methods: This study tested the hypothesis that the BE group would demonstrate greater pathology on measures of eating pathology, psychological wellbeing, and quality of life than the NBE group both pre- and post-surgery. Results: Compared with the NBE group, the BE group had significantly higher levels of disinhibited eating, and hunger, and significantly lower levels of social functioning at pre-surgery and 6 months post-surgery. The BE group had a significantly lower percentage of excess weight lost than the NBE group at 6 months post-surgery. Conclusions: These findings indicate a less successful outcome for the BE patients compared with the NBE patients. While there were more distinct differences between the BE and NBE groups before surgery, they were largely impossible to differentiate on psychosocial measures at post-surgery.     

Ghrelin: a Gut-Brain Hormone: Effect of Gastric Bypass Surgery

Background: Ghrelin is a newly recognized gastric hormone with orexigenic and adipogenic properties, produced primarily by the stomach. Ghrelin is reduced in obesity.Weight loss is associated with an increase in fasting plasma ghrelin. We assessed the effect of massive weight loss on plasma ghrelin concentrations and its correlation with serum leptin levels and the presence of type 2 diabetes mellitus (DM) in severely obese patients. Methods: A prospective study was conducted on 28 morbidly obese women (BMI 56.3±10.2 kg/m²) who underwent gastric bypass, divided into 2 groups: 14 non-diabetics (NGT) and 14 type 2 diabetics (DM2). Ghrelin and leptin were evaluated before silastic ring transected vertical gastric bypass, and again 12 months postoperatively. Results: Fasting plasma ghrelin concentrations were 56% lower in NGT and 59% lower in DM2 compared with a lean control group (P<0.001). There was no difference in ghrelin levels between NGT and DM2 groups before and after surgery (P>0.05). Ghrelin was negatively correlated with leptin before gastric bypass surgery (r=0.51, P<0.01). The mean plasma ghrelin concentration decreased significantly after surgery in both groups (P<0.001). Conclusion: Ghrelin was inversely related to leptin concentrations. Presence of diabetes did not affect the ghrelin pattern. Reduced production of ghrelin after gastric bypass could be partly responsible for the lack of hyperphagia and thus for the weight loss.     

One-Anastomosis Gastric Bypass by Laparoscopy: Results of the First 209 Patients

Background: One-Anastomosis Gastric Bypass (OAGB) by laparoscopy consists of constructing a divided 25-ml (estimated) gastric pouch between the esophago-gastric junction and the crow's foot level, parallel to the lesser curvature, which is anastomosed latero-laterally to a jejunal loop 200 cm distal to the ligament of Treitz. Methods: The results of our first 209 OAGB patients operated from July 2002 to June 2004 are reported. Mean age was 41 years (14-66), BMI 48 (39-86) and mean excess body weight 66 kg (35-220). In 144 patients, OAGB was the only operation performed, and in 61 patients it was accompanied by other surgery (18 cholecystectomies, 5 incisional hernia repairs, and 38 adhesiolysis), and in 4 patients a restrictive bariatric operation had been performed previously. Results: 2 patients (0.9%) were converted to open surgery due to uncontrollable bleeding. 3 patients (1.4%) needed re-operation in the immediate postoperative period. 5 patients (2.3%) needed prolonged hospital stay due to acute pancreatitis in 1 and anastomotic leakage in 4, all resolving with conservative treatment. 2 patients died (0.9%), 1 from fulminant pulmonary thromboembolism and 1 from nosocomial pneumonia. Long-term complications have occurred in only 2 patients who developed clinically significant iron-deficiency anemia. Mean excess weight loss was 75% after 1 year and >80% at 2 years. Conclusion: OAGB is a simple, safe and effective operation with less perioperative risk than conventional gastric bypass, quicker return to normal activities, and better quality of life.