Gastric Emptying of Solids and Semi-solids in Morbidly Obese and Non-obese Subjects: An Assessment Using the <Superscript>13</Superscript>C-Octanoic Acid and <Superscript>13</Superscript>C-Acetic Acid Breath Tests

Background It has been suggested that obesity is associated with an altered rate of gastric emptying. The objective of the present study was to determine whether the rates of solid and semi-solid gastric emptying differ between morbidly obese patients and lean subjects. Methods The Gastric-emptying time (GET) of solid and semi-solid meals were compared between lean healthy subjects and morbidly obese patients enrolled in two previously published studies. GET of solid and semi-solid meals was measured using the ¹³C-octanoic acid breath test and ¹³C-acetic acid breath test, respectively, in 24 lean and 14 morbidly obese individuals of both sexes. Student t-test was used to compare the mean data between the lean and morbidly obese groups. The influence of sex, gender, BMI and morbid obesity on the GET of solid meals was verified by linear regression analysis. Results Mean t(1/2) values of solid GET (± standard deviation) were 203.6 ±  76.0 min and 143.5 ± 19.1 min for lean and obese subjects, respectively (P = 0.0010). Mean t(lag) values of solid GET were 127.3 ± 42.7 min and 98.4 ± 13.0 min for lean and obese subjects, respectively (P = 0.0044). No significant difference in semi-solid GET was observed between the lean and morbidly obese groups. Conclusion The present study demonstrated a significantly enhanced gastric emptying of the solid meal test in morbidly obese patients when compared to lean subjects. This finding is compatible with the hypothesis that rapid gastric emptying in morbidly obese subjects increases caloric intake due to a more rapid loss of satiety.     

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

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

Gastroesophageal Reflux in Patients with Morbid Obesity: A Role of Obstructive Sleep Apnea Syndrome?

Background  Obesity is a risk factor for gastroesophageal reflux disease (GERD) and for obstructive sleep apnea (OSA). Our aim was to evaluate in morbidly obese patients the prevalence of OSA and GERD and their possible relationship. Methods  Morbidly obese patients [body mass index (BMI) >40 or >35 kg/m² in association with comorbidities] selected for bariatric surgery were prospectively included. Every patient underwent a 24-h pH monitoring, esophageal manometry, and nocturnal polysomnographic recording. Results  Sixty-eight patients [59 women and 9 men, age 39.1 ± 11.1 years; BMI 46.5 ± 6.4 kg/m² (mean ± SD)] were included. Fifty-six percent of patients had an abnormal Demester score, 44% had abnormal time spent at pH <4, and 80.9% had OSA [apnea hypopnea index (AHI) >10] and 39.7% had both conditions. The lower esophageal sphincter (LES) pressure was lower in patients with GERD (11.6 ± 3.4 vs 13.4 ± 3.6 mm Hg, respectively; P = 0.039). There was a relationship between AHI and BMI (r = 0.337; P = 0.005). Patients with OSA were older (40.5 ± 10.9 vs 33.5 ± 10.4 years; P = 0.039). GERD tended to be more frequent in patients with OSA (49.1% vs 23.1%, respectively; P = 0.089). There was no significant relationship between pH-metric data and AHI in either the 24-h total recording time or the nocturnal recording time. In multivariate analysis, GERD was significantly associated with a low LES pressure (P = 0.031) and with OSA (P = 0.045) but not with gender, age, and BMI. Conclusion  In this population of morbidly obese patients, OSA and GERD were frequent, associated in about 40% of patients. GERD was significantly associated with LES hypotonia and OSA independently of BMI.     

Relationship between the Upper Airway and Obstructive Sleep Apnea-Hypopnea Syndrome in Morbidly Obese Women

Background The authors studied changes in the upper airway in morbidly obese women and the relationship to sleep apnea-hypopnea syndrome (OSAS). Methods Patients underwent a cardiorespiratory polygraphic study, respiratory function test (spirometry, plethysmography, maximum inspiratory pressures and arterial blood gas analysis), and computed tomographic studies of the upper airway. Results 40 morbidly obese women being evaluated for bariatric surgery (mean age 39.6 ± 9.6 years old, BMI 48.7 ± 5.6 kg/m²) were studied. 37 women had OSAS, and 14 had severe OSAS. Results on respiratory function tests were normal. BMI and weight had a positive correlation with apnea-hypopnea index (AHI), apnea index (AI), desaturation index (DI), lowest oxygen saturation and CT90. Uvula diameter had a negative correlation with FEV₁, FVC, VC IN and a positive correlation with TLC. Retropharynx soft tissue at the retropalatal level had a negative correlation with FEV₁, FVC and VC IN. The oropharynx area at maximal inspiration (total lung capacity) obtained a negative correlation with the AHI (r = −0.423, P = 0.044), AI (r = −0.484, P = 0.042) and DI (r = −0.484, P = 0.019). Conclusions Prevalence of OSAS in morbidly obese women is very high. Our results show the significant correlation between BMI and AHI in morbidly obese women. Uvula diameter and retropharynx soft tissue are the upper airway parameters with higher relationship with pulmonary function. A reduction in the cross-sectional area of the airway at the level of the oropharynx could be related to the severity of OSAS in morbidly obese women.     

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

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

Lipoprotein Lipase but Not Hormone-Sensitive Lipase Activities Achieve Normality After Surgically Induced Weight Loss in Morbidly Obese Patients

Background  Although bariatric surgery is currently the most common practice for inducing weight loss in morbidly obese patients (BMI > 40 kg/m²), its effect on the lipid content of adipose tissue and its lipases (lipoprotein lipase [LPL] and hormone-sensitive lipase [HSL]) are controversial. Methods  We analyzed LPL and HSL activities and lipid content from plasma as well as subcutaneous (SAT) and visceral (VAT) adipose tissue of 34 morbidly obese patients (MO) before and after (6 and 12 months) Roux-en-Y gastric bypass surgery and compare the values with those of normal weight (control) patients. Results  LPL activity was significantly higher in MO (SAT = 32.9 ± 1.0 vs VAT = 36.4 ± 3.3 mU/g tissue; p < 0.001) than in control subjects (SAT = 8.2 ± 1.4 vs VAT = 6.8 ± 1.0 mU/g tissue) in both adipose depots. HSL activity had similar values in both types of tissue (SAT = 32.8 ± 1.6 and VAT = 32.9 ± 1.6 mU/g) of MO. In the control group, we found similar results but with lower values (SAT = 11.9 ± 1.4 vs VAT = 12.1 ± 1.4 mU/g tissue). Twelve months after surgery, SAT LPL activity diminished (9.8 ± 1.4 mU/g tissue, p < 0.001 vs morbidly obese), while HSL (46.6 ± 3.7 mU/g tissue) remained high. All lipids in tissue and plasma diminished after bariatric surgery except plasma nonesterified fatty acids, which maintained higher levels than controls (16 ± 3 vs 9 ± 0 mg/dL; p < 0.001, respectively). Conclusions  When obese patients lose weight, they lose not only part of the lipid content of the cells but also the capacity to store triacylglycerides in SAT depots. E. Pardina and A. Lecube contributed equally to this study. J.A. Baena-Fustegueras and J. Peinado-Onsurbe share senior authorship.     

Serum C-Reactive Protein and White Blood Cell Count in Morbidly Obese Surgical Patients

Background  Obesity has been widely recognized as a chronic inflammatory condition and associated with elevated inflammatory indicators including C-reactive protein (CRP) and white blood cell count (WBC). Recent studies have shown elevated CRP or WBC is a significant risk factor for cardiac events and stroke but the clinical significance of CRP and WBC has not been clearly studied in morbidly obese patients. This study is aimed at the clinical significance of WBC and CRP in morbidly obese patients and the change after bariatric surgery. Methods  The study was a prospectively controlled clinical study. From December 1, 2001 to January 31, 2006, of 640 (442 females and 198 males) consecutive morbid obese patients enrolled in a surgically supervised weight loss program with at least 1 year’s follow-up were examined. Results  Of the patients, 476 (74.4%) had elevated CRP and 100 (15.6%) had elevated WBC at preoperative study. CRP and WBC were significantly related and both increased with increasing body mass index (BMI). CRP is also increased with increasing waist, glucose level, hemoglobin, albumin, Ca, insulin, C-peptide, and metabolic syndrome while WBC is increased with metabolic syndrome but decreased with increasing age. Multivariate analysis confirmed fasting glucose level and hemoglobin are independent predictors of the elevation of CRP while age is the only independent predictor for elevated WBC. Both WBC and CRP levels decreased rapidly after obesity surgery. These improvements resulted in a 69.8% reduction of CRP and 26.4% reduction of WBC 1 year after surgery. Although individuals who underwent laparoscopic gastric bypass lost significantly more weight (36.8 ± 11.7 kg vs. 17.3 ± 10.8 kg; p = 0.000) and achieved a lower BMI (27.8 ± 4.6 vs. 35.0 ± 5.5; p = 0.000) than individuals who underwent laparoscopic gastric banding, there was no difference in the resolution of elevated CRP 1 year after surgery (95.9% vs. 84.5%; p = 0.169) and WBC (99.4% vs. 98.3%; p = 0.323). Conclusions  Both baseline WBC and CRP are elevated in morbid obese patients but CRP has a better clinical significance. Significant weight reduction 1 year after surgery markedly reduced CRP and WBC with a resolution rate of 93.9% and 98.2% separately. Obesity surgery performed by laparoscopic surgery is recommended for obese patients with elevated CRP or WBC.     

Sleeve Gastrectomy — A Restrictive Procedure?

Background Diet and surgically-induced weight loss have been shown to lead to alterations in motor and sensory function of the stomach.We investigated the clinical outcome and gastric emptying of solid foods in morbidly obese (MO) patients following sleeve gastrectomy (SG). Methods We studied 23 MO patients [(7 males, 16 females), mean age 38.9 ± 11.0 years (range 20–64 years), mean weight 135.1 ± 19.0 kg (range 97–167 kg), mean BMI 47.2 ± 4.8 kg/m2 (range 39.6–56.0 kg/m2)] who each underwent a sleeve gastrectomy (SG) for weight reduction. At the monthly follow-up visits, variations in weight and BMI changes, postoperative meal size and frequency, and presence of gastrointestinal symptoms were recorded. 11 patients underwent scintigraphic measurement of the gastric emptying of a solid meal pre- and 6 months postoperatively. Results A significant reduction in patients’ weight was evidenced at 6 and 12 months postoperatively [98.6 ± 11.8 kg and 87.0 ± 10.7 kg respectively (P = 0.001)]. BMI decreased to 35.2 ± 4.3 kg/m² at 6 months and to 31.1 ± 4.5 kg/m² at 12 months, respectively (P = 0.001). Although meal size was drastically reduced, meal frequency increased postoperatively in 12 patients (52.2%). Only 5 patients (21.8%) reported occasional vomiting after meals following SG. The gastric emptying half-time (T1/2) accelerated (47.6 ± 23.2 vs. 94.3 ± 15.4, P < 0.01) and the T-lag phase duration decreased (9.5 ± 2 min vs. 19.2 ± 2 min, P < 0.05) postoperatively. The percentage of the meal emptied from the stomach 90 min after consumption increased significantly after SG (75.4 ± 14.9% vs. 49.2 ± 8.7%, P < 0.01). Conclusions This study indicates that following SG, the stomach empties its contents rapidly into the small intestine and symptoms of vomiting after eating (characteristic of restrictive procedures) are either absent or very mild. Therefore, the term ‘restrictive’ is possibly ill-advised for this new bariatric operation. It remains for other mechanisms of energy intake reduction, such as intestinal distension and satiety signals through gut hormones to be investigated, to comprehensively explain precisely how this ‘food limiting’ procedure results in weight loss.     

Boussignac CPAP in the Postoperative Period in Morbidly Obese Patients

Background In the postoperative period hypoventilation and hypoxia with hypercarbia may occur in morbidly obese patients due to the residual influence of general anesthesia drugs, postoperative atelectasis and postoperative pain. Non-Invasive Ventilation (NIV) is a method of improvement of respiratory efficiency in patients not requiring mechanical ventilation. The aim of the study was to compare NIV (Boussignac) CPAP and traditional oxygen delivery via nasal catheter in the postoperative acute care unit (PACU) in morbidly obese patients after open Roux-en-Y gastric bypass (RYGBP). Methods 19 morbidly obese patients scheduled for elective open RYGBP, were randomly divided into 2 groups: CPAP (10 patients) or control (nasal catheter – 9 patients). Patients consisted of: 8 male and 11 female, mean weight 127.76 ± 18.5 kg, height 173.41 ± 9.41 cm, BMI 42.43 ± 3.3 kg/m2, age 35.84 ± 9.05 years. In the PACU, capillary blood gas measurements were taken at 3 Time Points: T1 – 30 min, T2 – 4 hours and T3 – 8 hours after admission. Sample T0 was taken before surgery. For management of postoperative pain, patients received morphine 2 mg/h intravenously and tramadol 100 mg. Results Mean blood gas measurements of all postoperative time points were: pO₂ 81.0 ± 16.0 (range 78.1–85.7) mmHg vs 65.9 ± 4.9 (range 63.8–68.1) mmHg (P < 0.05); pCO₂ 40.6 ± 2.4 (range 39.4–41.8) mmHg vs 41.5 ± 4.0 (range 39.6–43.4) mmHg (P > 0.05), in the CPAP and control groups respectively. In every case, pulse-oxymetry oxygenation was >94%. Conclusion Boussignac CPAP improved blood oxygenation compared to passive oxygenation with a nasal catheter but had no influence on CO₂ elimination in non-CO₂ retaining morbidly obese patients.     

High Prevalence of Small Intestinal Bacterial Overgrowth in Patients with Morbid Obesity: A Contributor to Severe Hepatic Steatosis

Background With the increasing prevalence of obesity, non-alcoholic fatty liver disease (NAFLD) has become a major cause of liver diseases. Small intestinal bacterial overgrowth (SIBO) could be related to NAFLD. Our aim was to determine the prevalence of SIBO and its relationship with liver lesions in morbidly obese patients. Methods A glucose hydrogen (H₂) breath test (positive if fasting breath H₂ concentration > 20 ppm and/or an increase of > 10 ppm over baseline within the first 2 h) was performed in obese patients referred for bariatric surgery (body mass index [BMI] >  40 kg/m² or >  35 in association with comorbidities) and in healthy non-obese subjects. In obese patients, a surgical liver biopsy was performed. Results One hundred and forty-six patients (129 women, age [mean±SE]: 40.7 ± 11.4 years) were prospectively included in the study. The mean BMI was 46.1±6.4 kg/m². A liver biopsy was available in 137 patients and a breath test in 136. The frequency of positive breath tests was higher in obese patients (24/136, 17.1%) than in healthy subjects (1/40, 2.5%; P=0.031). In the univariate analysis, SIBO was not associated with clinical variables, but tended to be associated with more frequent severe hepatic steatosis (26.3 vs. 10.3%, P=0.127), whereas the frequency of sinusoidal or portal fibrosis, lobular necrosis and non-alcoholic steatohepatitis (NASH) were not different. In the multivariate analysis, SIBO (P=0.005) and the presence of a metabolic syndrome (P=0.006) were independent factors of severe hepatic steatosis. Conclusion In morbidly obese patients, bacterial overgrowth prevalence is higher than in healthy subjects and is associated with severe hepatic steatosis.     

Plasma Adhesion and Inflammation Markers: Asymmetrical Dimethyl-L-Arginine and Secretory Phospholipase A<Subscript>2</Subscript> Concentrations before and after Laparoscopic Gastric Banding in Morbidly Obese Patients

Background The aim of this study was to examine the relationship between subclinical inflammation and weight loss by laparoscopic adjustable gastric banding (LAGB). Methods Plasma concentrations of intercellular adhesion molecule-1 (ICAM-1), vascular adhesion molecule-1 (VCAM-1), sensitive C-Reactive Protein (sCRP), asymmetrical dimethyl-L-arginine (ADMA), Secretory Phospholipase A2 (sPLA2), and metabolic markers, such as homeostatic model assessment – insulin resistance (HOMA-IR) and body mass index (BMI) were determined in morbidly obese patients (n = 18, BMI 48.6 ± 1.7 kg/m²) at baseline and 1 month after operations. Baseline levels in patients were also compared with age-matched controls (n = 20, BMI 21.3 ± 1.8 kg/m²). Plasma ICAM-1,VCAM, sCRP and ADMA, and sPLA₂ concentrations were determined by enzyme-linked immunoassay methods and colorimetric method, respectively. Results Plasma sCRP, ICAM-1, ADMA and sPLA₂ concentrations and HOMA-IR were significantly higher in morbidly obese patients than in controls (for each, P < 0.01). Plasma VCAM-1 concentration was not changed in obese patients. HOMA-IR was significantly correlated with ICAM-1, ADMA and sPLA₂ in the obese group at baseline (for each, P < 0.01). There was a significant correlation between plasma sCRP and plasma glucose,VCAM-1, ICAM-1, ADMA and sPLA₂ concentrations (for each, P < 0.01). 1 month after LAGB, mean body weight loss was 13.2 ± 6.3 kg, and plasma sCRP and ADMA concentrations and HOMA-IR and BMI were significantly decreased (for each, P < 0.01). However, these levels cannot be decreased to the levels of the controls. Conclusion Obesity and insulin resistance appear to be associated with low-grade inflammation and endothelial dysfunction. Insulin resistance and endothelial dysfunction were improved by weight loss after LAGB.     

Mineral Metabolism in Obese Patients Following Vertical Banded Gastroplasty

Background Bone disease has been described in patients after surgical treatment for obesity, but few studies have dealt with the impact of vertical banded gastroplasty on mineral metabolism. We have examined bone mineral metabolism in morbidly obese patients before and after 3 months after vertical banded gastroplasty without vitamin D supplementation. Methods Sixteen morbidly obese patients (14 women, 2 men) with a mean (±SD) age of 38 ± 9 years and a body mass index (BMI) of 47.1 ± 8.1 kg/m² were studied. No vitamin D supplementation was given. Body weight, fat mass, calcium, 25OHD, iPTH, bone remodeling markers, and leptin levels were measured at baseline and after weight loss. Results Mean weight loss was 28 ± 11 kg; BMI and body fat mass decreased by 20 and 35%, respectively. Bone resorption markers and albumin-corrected serum calcium increased after operation, whereas iPTH fell. Serum 25OHD levels rose. Leptin levels decreased. Serum iPTH was positively correlated with weight, BMI, and fat mass before operation (p < 0.05), and its decline after weight reduction was negatively associated with the increase in bone resorption markers (p < 0.01). Leptin concentration was correlated with BMI and body fat mass (p < 0.05) both before and after surgery. Conclusions Weight reduction obtained in morbidly obese subjects 3 months after vertical banded gastroplasty increases bone turnover markers and decreases PTH secretion. Serum 25OHD levels rose. Therefore, no reasons for a metabolic bone disease related to hypovitaminosis D were readily apparent. However, an increase in bone turnover, which is generally regarded as a potential risk factor for osteoporosis, was observed. Further work is needed to clarify the importance of this turnover increase in the long run.     

Plasma Protein Carbonyl and Thiol Stress Before and After Laparoscopic Gastric Banding in Morbidly Obese Patients

Background The aim of this study is to examine the relationship between oxidative plasma protein and thiol stress and weight loss after laparoscopic adjustable gastric banding (LAGB). Methods Plasma protein carbonyl (PCO) concentration as a marker of protein oxidation, plasma thiol (PSH) and erythrocyte glutathione concentration (GSH, major intracellular thiol), as an antioxidant and metabolic markers, such as Homeostatic Model Assessment – Insulin resistance (HOMA-IR), BMI and plasma lipids were determined in morbidly obese patients (n 22, mean age 34.7 ± 11 years, BMI 48.4 ± 6.4 kg/m²) at baseline and 1 and 6 months after operation. Baseline levels in patients were also compared with the levels in agematched controls (n 20, BMI 21.3 ± 1.8 kg/m²). Plasma PCO and thiols and erythrocyte GSH concentrations were determined spectrophotometrically. Results Plasma PCO were significantly higher and plasma and erythrocyte thiol concentrations were significantly lower in morbidly obese patients than in controls (for each comparison, P < 0.01). BMI, plasma triglycerides and HOMA-IR were positively correlated with plasma PCO and negatively correlated with plasma P-SH and erythrocyte GSH (for each comparison, P < 0.01). Plasma HDL-cholesterol levels were positively correlated with plasma erythrocyte GSH (r = 0.405, P < 0.01) and negative correlated with plasma PCO (r = −0.273, P < 0.01). One and 6 months after the LAGB operation, total weight loss was 13.2 ± 6.3 and 35.5 ± 7.5 kg, respectively. Plasma PCO concentrations were decreased and P-SH and erythrocyte GSH concentrations were elevated following weight loss (for each, P < 0.01). Only plasma P-SH levels were restored to the control levels 6 months after LAGB. Conclusions Obesity and insulin resistance appear to be associated with plasma protein oxidation and thiol concentrations. Protein and thiol oxidative stress was improved by weight loss after LAGB in the short-term.     

Prevalence and Severity of Sleep Apnea in a Group of Morbidly Obese Patients

Background Obesity is the most important risk factor for obstructive sleep apnea. It is estimated that 70% of sleep apnea patients are obese. In the morbidly obese, the prevalence may reach 80% in men and 50% in women. The aim of this study was to determine the prevalence and severity of sleep apnea in a group of morbidly obese patients, leading to bariatric surgery. Methods In a cross-sectional study developed in Bahia, northeastern Brazil. 108 patients (78 women and 30 men) from the Obesity Treatment and Surgery Center - “Núcleo de Tratamento e Cirurgia da Obesidade” underwent standard polysomnography. Patients with an apnea-hypopnea index (AHI) ≥ 5 events/hour were considered apneic. Results Mean ± SD for age and BMI were 37.1 ± 10.2 years and 45.2 ± 5.4 kg/m2, respectively. The calculated AHI ranged widely from 2.5 to 128.9 events/hour. Sleep apnea was detected in 93.6% of the sample, wherein 35.2% had mild, 30.6% moderate and 27.8% severe apnea. Oxyhemoglobin desaturation was directly related to the AHI and was more severe in men. Conclusion There was a high frequency of sleep apnea in this group of morbidly obese patients, for whom it was very important to request polysomnography, thus enabling therapeutic management and prognostication.     

Outcome of laparoscopic Nissen fundoplication in patients with body mass index ≥35

Background To date, few studies have examined the effect of morbid obesity on the outcome of laparoscopic antireflux surgery and results have been conflicting. The aim of this work was to study the outcome of laparoscopic Nissen fundoplication (LNF) in patients with body mass index (BMI) ≥ 35. Methods We prospectively followed 70 patients (15 men, 55 women) with a proven diagnosis of gastroesophageal reflux disease (GERD) and a mean BMI of 38.4 ± 0.5 (range, 35–51) who underwent LNF. All patients underwent 24-h pH study, esophageal manometry, upper gastrointestinal (GI) endoscopy, and GERD symptom score before and 6 months after LNF. Surgical outcomes were compared to those of 70 sequential nonobese patients (BMI < 30) who also underwent LNF. Results LNF was completed laparoscopically in 69 of 70 patients in the morbidly obese (MO) group and in all 70 patients in the normal-weight (NW) group. The mean operative time for the MO group was not significantly longer than that for the NW group (55.9 ± 2.3 min vs 50.0 ± 2.1 min), but the mean length of stay was significantly longer (3.17 ± 0.2 days vs 2.2 ± 0.1 days, p < 0.0001) in the MO group. There was one postoperative complication (a transhiatal herniation of the stomach) in the morbidly obese group. In both patient groups, LNF resulted in a significant increase in lower esophageal sphincter (LES) pressures. This was associated with a significant decrease in percent acid reflux in 24-h testing and a significant improvement in GERD symptom score in both groups, although patients in the MO group had a significantly higher mean reflux symptom score after surgery than did those in the NW group. After a mean follow-up of 41.6 ± 2.9 months, one patient in the MO group required reoperation and one proton pump inhibitor therapy (PRN PPI), as required. Conclusions Morbid obesity does not adversely affect the outcome of LNF. The conversion rate is low when performed by an experienced surgeon. Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Los Angeles, CA, USA, 12–15 March 2003     

Changes in Depression Following Gastric Banding: A 5- to 7-year Prospective Study

Background Long-term outcomes of gastric banding regarding depression and predictors of change in depression are still unclear. This prospective, controlled study investigated depression and self-acceptance in morbidly obese patients before and after gastric banding. Methods A total of 248 morbidly obese patients (mean body mass index [BMI] = 46.4, SD = 6.9) seeking gastric banding completed questionnaires for symptoms of depression (Beck Depression Inventory) and self-acceptance. One hundred twenty-eight patients were treated with gastric banding and 120 patients were not. After 5 to 7 years, patients who either had (n = 40) or had not (n = 42) received gastric banding were reassessed. Results In the preoperative assessment, 35% of all obese patients suffered from clinically relevant depressive symptoms (BDI score ≥18). The mean depression score was higher and the mean self-acceptance score was lower than those of the normal population. Higher preoperative depression scores were observed among patients living alone and who had obtained low levels of education. After 5 to 7 years, patients with gastric banding had lost significantly more weight than patients without gastric banding (mean BMI loss 10.0 vs. 3.3). Gastric banding patients improved significantly in depression and self-acceptance, whereas no change was found in patients without gastric banding. Symptoms of depression were more reduced in patients who lost more weight, lived together with a partner, and had a high preoperative depression score. Conclusion Morbid obesity is associated with depressive symptoms and low self-acceptance. Gastric banding results in both long-term weight loss and improvement in depression and self-acceptance.     

Short-term Overfeeding Induces Insulin Resistance in Weight-stable Patients After Bariatric Surgery

Background Short time overfeeding of rats rapidly leads to insulin resistance (IR). A study with healthy human volunteers, which we suggest are less susceptible for developing IR after short time overfeeding, did not show these effects on IR. Therefore a study population of weight-stable, former morbidly obese subjects (BMI 31.3 kg/m²), which were treated with bariatric surgery approximately 3 years ago was selected. Methods Eleven subjects were submitted to a 7-day overfeeding study, resulting in a 53% increase in caloric intake (1,227 ± 394.4 to 1,879.2 ± 298.4 kcal/day). During normal diet and after overfeeding, insulin sensitivity was measured using steady state plasma glucose (SSPG) levels. At these time points, BMI and waist/hip ratio together with plasma levels of inflammatory markers (CRP, AGP, LBP, and TNF-α receptors) and plasma leptin values were also measured. Results SSPG levels after overfeeding increased from 8.2 ± 3.2 to 10.6 ± 2.6 mmol/l (P < 0.05), indicating decreased insulin sensitivity after overfeeding. Fasting plasma insulin, glucose, circulating levels of inflammatory markers, BMI, and waist/hip ratio remained unchanged. Conclusions This study shows that overfeeding in a group of weight-stable, former morbidly obese subjects 3 years after bariatric surgery results in decreased insulin sensitivity. The mechanisms behind decreased insulin sensitivity induced by overfeeding are poorly understood, but the present results reveal that a unique human model is available to study these mechanisms, leading to a better understanding of the pathophysiology of IR.     

Metabolic Syndrome after Laparoscopic Bariatric Surgery

Background  Metabolic syndrome (MS) is common among morbidly obese patients undergoing bariatric surgery. The aim of this study was to assess the impact and predictors of bariatric surgery on the resolution of MS. Methods  Subjects included 286 patients [age 44.0 ± 11.5, female 78.2%, BMI 48.7 ± 9.4, waist circumference 139 ± 20 cm, AST 23.5 ± 14.9, ALT 30.0 ± 20.1, type 2 diabetes mellitus (DM) 30.1% and MS 39.2%] who underwent bariatric surgery. Results  Of the entire cohort, 27.3% underwent malabsorptive surgery, 55.9% underwent restrictive surgery, and 16.8% had combination restrictive–malabsorptive surgery. Mean weight loss was 33.7 ± 20.1 kg after restrictive surgery (follow up period 298 ± 271 days), 39.4 ± 22.9 kg after malabsorptive surgery (follow-up period 306 ± 290 days), and 28.3 ± 14.1 kg after combination surgery (follow-up period 281 ± 239 days). Regardless of the type of bariatric surgery, significant improvements were noted in MS (p values from <0.0001–0.01) as well as its components such as DM (p values from <0.0001–0.0005), waist circumference (p values <0.0001), BMI (p values <0.0001), fasting serum triglycerides (p values <0.0001 to 0.001), and fasting serum glucose (p values <0.0001). Additionally, a significant improvement in AST/ALT ratio (p value = 0.0002) was noted in those undergoing restrictive surgery. Multivariate analysis showed that patients who underwent malabsorptive bariatric procedures experienced a significantly greater percent excess weight loss than patients who underwent restrictive procedures (p value = 0.0451). Percent excess weight loss increased with longer postoperative follow-up (p value <0.0001). Conclusions  Weight loss after bariatric surgery is associated with a significant improvement in MS and other metabolic factors.     

Prevalence of Obesity Among Children and/or Grandchildren of Adult Bariatric Surgery Patients

Background  Clinical experience suggests that some adults who undergo bariatric surgery have children who are obese. Childhood obesity is associated with increased morbidity and mortality in later life. This study examined the prevalence of obesity among children and grandchildren (≤12 years of age) of adult bariatric surgery patients. Methods  Patients in a prospective database of morbidly obese patients who underwent bariatric surgery between January 2004 and May 2007 were recruited by phone and in clinic. Patient demographics, body mass index (BMI) at surgery, and survey data were collected. The survey included questions regarding their child/grandchild's body habitus, weight, and height. Child obesity was defined as BMI percentile ≥95. Statistical significance was set at p < 0.05. Results  One hundred twenty-two patients were enrolled in this study (77% women, mean BMI 49 kg/m²). One hundred thirty-four out of 233 children/grandchildren identified had complete data; 41% had a BMI percentile ≥95. Only 29% of these obese children were so identified by the adult respondents. Significantly more biological children/grandchildren were obese than nonbiological (p = 0.013), and significantly more biological children were obese than biological grandchildren (p = 0.027). Conclusions  This sample of bariatric surgery patients had a high proportion of obese preteen children/grandchildren. Obesity was most prevalent among biological children (vs. biological grandchildren and nonbiological children). Patients often did not recognize the degree of overweight in their children/grandchildren. Because families of bariatric surgery patients often include obese children, interventions aimed at all family members merit consideration.