Bariatric surgery for morbidly obese adolescents: Is there a rationale for early intervention?

Obesity is one of the most common metabolic disorders affecting the US population: 31% of adults and 16% of adolescents now meet the criteria for obesity. Similar to the rising prevalence of morbid obesity in adults, the prevalence of more severe obesity is also increasing in pediatric patients. The most effective treatment for morbid obesity is bariatric surgery, a procedure most commonly performed in the fifth and sixth decades of life. Although it is clear that rapid, profound weight loss can significantly improve multiple comorbid conditions in adults, including disordered carbohydrate metabolism, obstructive sleep apnea, and cardiovascular risk factors, it is not clear to what degree similar comorbidities are affected in adolescents undergoing surgical weight loss. In this paper, the indications, contraindications, and early surgical outcomes of gastric bypass surgery for morbidly obese adolescents are reviewed, and important directions for future research are discussed.     

Cardiovascular benefits of bariatric surgery in morbidly obese patients

Morbid obesity is associated with increased morbidity and represents a major healthcare problem with increasing incidence worldwide. Bariatric surgery is considered an effective option for the management of morbid obesity. We searched MEDLINE, Current Contents and the Cochrane Library for papers published on bariatric surgery in English from 1 January 1990 to 20 July 2010. We also manually checked the references of retrieved articles for any pertinent material. Bariatric surgery results in resolution of major comorbidities including type 2 diabetes mellitus, hypertension, dyslipidemia, metabolic syndrome, non‐alcoholic fatty liver disease, nephropathy, left ventricular hypertrophy and obstructive sleep apnea in the majority of morbidly obese patients. Through these effects and possibly other independent mechanisms bariatric surgery appears to reduce cardiovascular morbidity and mortality. Laparoscopic Roux‐en‐Y gastric bypass (LRYGB) appears to be more effective than laparoscopic adjustable gastric banding (LAGB) in terms of weight loss and resolution of comorbidities. Operation‐associated mortality rates after bariatric surgery are low and LAGB is safer than LRYGB. In morbidly obese patients bariatric surgery is safe and appears to reduce cardiovascular morbidity and mortality.     

Criteria for selection of patients for bariatric surgery

International criteria for bariatric surgery and bariatric surgeons have been well-defined in terms of the current state of the art and are presented together with weight tables and a list of co-morbidities of morbid obesity. The bariatric surgeon should make the primary judgement concerning bariatric surgery using these criteria as guidelines only, not strict rules; others who use these criteria should govern themselves in a like, fair-minded, fashion. Medical insurers' and their agents' criteria, if excessively restrictive relative to the guidelines, may reflect an ingrained prejudice against the morbidly obese, manifesting itself in an unfair, unethical and immoral bias. It is the essence of humane and equitable behaviour on the part of all concerned that the morbidly obese receive non-discriminatory, appropriate treatment, care and medical insurer coverage for their disease and its comorbidities.     

Effects of changes in body weight and insulin resistance on inflammation and endothelial function in morbid obesity after bariatric surgery

Metabolic alterations such as insulin resistance are thought to underlie the endothelial dysfunction and low grade inflammation found in morbid obesity. Twenty-six morbidly obese patients, aged 39.0 +/- 10.0 (mean +/- sd), were evaluated before and 4.2 +/- 0.8 months after bariatric surgery. A marked increment in the insulin sensitivity index (S(I)) and the endothelium-dependent vasodilatory response in a dorsal hand vein was observed after weight loss following bariatric surgery. Circulating levels of E-selectin, P-selectin, plasminogen activator inhibitor-1, and von Willebrand factor, which were higher than those in the control group, decreased significantly after surgery. Plasma vascular cell adhesion molecule-1, angiotensin-converting enzyme, intercellular adhesion molecule-1, thrombomodulin, and plasma and intraplatelet cGMP levels did not change after weight loss. All inflammatory markers were higher in morbidly obese patients. After surgery, C- reactive protein and sialic acid diminished, whereas circulating levels of IL-6, TNF-alpha, and its soluble receptors did not. Positive correlations were found between changes in adiposity and S(I) and changes in C-reactive protein and between changes in sialic acid and changes in endothelial function. In conclusion, a marked improvement in S(I), endothelial function, and low grade inflammation was observed in the weight-losing, morbidly obese patients after bariatric surgery. S(I) and adiposity appear to play roles in obesity-related, low grade inflammation that contribute to the endothelial dysfunction observed in morbid obesity.     

Intragastric balloon: another option for treatment of obesity and morbid obesity

BACKGROUND/AIMS: The BioEnterics Intragrastric Balloon (BIB, BioEnterics, Santa Barbara, CA) in association with restricted diet has been used for the treatment of obesity and morbid obesity. METHODOLOGY: Since March 1998, 349 BIB were placed in 303 obese and morbidly obese patients; 95 patients were male and 208 female; mean age was 41.5 years (19-70); mean weight was 118.8 Kg (67-229); mean BMI was 42 Kg/m2, % excess weight was 62.3% (4.6-216.3). The balloon was inserted and removed endoscopically under general anesthesia. Patients were given a balanced diet of 1000 Kcal/day. RESULTS: After 4 months of balloon treatment, the mean weight loss was 13.9 Kg and the mean reduction in BMI was 4.8 Kg/m2. Weight loss was greater in male patients. Weight loss was accompanied by an improvement of the diseases associated with obesity, in particular diabetes. CONCLUSIONS: The best indications for BIB were: morbidly obese (BMI >40) and super-obese patients (BMI >50) in preparation for bariatric operations; obese patients with BMI 35-40 with co-morbidity in preparation for bariatric surgery; obese patients with BMI 30-35 with a chronic disease otherwise unresolved; patients with BMI <30 only in a multidisciplinary approach.     

Laparoscopic sleeve gastrectomy for morbid obesity

The incidence of obesity is steadily rising, and it has been estimated that 40% of the US population will be obese by the year 2025 if the current trend continues. In recent years there has been renewed interest in the surgical treatment of morbid obesity in concomitance with the epidemic of obesity. Bariatric surgery proved effective in providing weight loss of large magnitude, correction of comorbidities and excellent short-term and long-term outcomes, decreasing overall mortality and providing a marked survival advantage. The Laparoscopic Sleeve Gastrectomy （LSG） has increased in popularity and is currently very ＂trendy＂ among laparoscopic surgeons involved in bariatric surgery. As LSG proved to be effective in achieving considerable weight loss in the short-term, it has been proposed by some as a sole bariatric procedure. This editorial focuses on the particular advantages of LSG in the treatment of morbid obesity.     

Results of obesity surgery

Assessment of the outcome of obesity operations is exceedingly complex. Currently there is no consensus among bariatric surgeons as to what constitutes successful weight loss. Furthermore, weight loss data must be regularly reevaluated to account for later regaining of lost weight. There is no question that surgically-induced weight loss results in improvement or resolution of obesity-related medical problems in most patients. Yet it is not known whether sustained long-term weight loss will result in extended amelioration of these medical problems. Analysis of outcome is further complicated by difficulties in maintaining consistent long-term follow-up in such a way that the benefits of weight loss can be objectively evaluated. The next decade should provide improvements in a number of these problem areas. The new computer registry of the American Society of Bariatric Surgery has access to thousands of bariatric surgical patients. This registry will hopefully provide for some standardization in analysis and reporting of results of bariatric operations. The registry may eventually be able to provide the type of actuarial analysis of long-term results necessary to assess the true impact of bariatric operations on the morbidity and mortality risks associated with morbid obesity. It is also probable that more sophisticated patient selection methods will improve the likelihood of successful weight loss both by excluding patients who are prone to failure and by identification of patient profiles that are better suited for treatment by one type of operation over another. In the final analysis, there is no question that morbid obesity poses an increased risk to health and longevity. Thus it is only logical that substantial weight loss in this group of patients could be expected to improve both longevity and quality of life, provided that the treatment methods employed are free of serious side-effects. At present, surgery offers the only realistic hope for successful weight loss in the morbidly obese.     

Severe hypoglycemia after gastric bypass surgery for morbid obesity

Recently, hypoglycemia with endogenous hyperinsulinemia has been described after undergoing bariatric surgery because of morbid obesity. It has been theorized that after a gastric bypass surgery, some trophic factors affecting pancreatic beta cells could emerge. The authors present a case of morbidly obese patient with severe hypoglycemia 3 months after bariatric surgery. An abdominal helicoidally computed tomography scan showed a 1.7 cm tumor in the tail of the pancreas. Histopathology revealed an insulinoma with well-defined contours surrounded by pancreatic tissue with atrophic signs and with hyperplasia and hypertrophic phenomena compatible with nesidioblastosis in adjacent islets of the pancreatic duct. Authors hypothesize that maintenance of the stimulus produces hyperplasia/hypertrophy of the pancreatic islets and reemphasizes the dynamic qualities of pancreatic beta cells and the possibility of producing hyperplasia from the extreme resistance to insulin present in morbidly obese patients.     

Critical assessment of the current guidelines for the management and treatment of morbidly obese patients

An interdisciplinary panel of specialists met in Mallorca in the first European Symposium on Morbid Obesity entitled; "Morbid Obesity, an Interdisciplinary Approach". During the two and half days of the meeting, the participants discussed several aspects related to pathogenesis, evaluation, and treatment of morbid obesity. The expert panel included basic research scientists, dietitians and nutritionists, exercise physiologists, endocrinologists, psychiatrists, cardiologists, pneumonologists, anesthesiologists, and bariatric surgeons with expertise in the different weight loss surgeries. The symposium was sponsored by the Balearic Islands Health Department; however, this statement is an independent report of the panel and is not a policy statement of any of the sponsors or endorsers of the Symposium. The prevalence of morbid obesity, the most severe state of the disease, has become epidemic. The current recommendations for the therapy of the morbidly obese comes as a result of a National Institutes of Health (NIH) Consensus Conference held in 1991 and subsequently reviewed in 2004 by the American Society for Bariatric Surgery. This document reviews the work-up evaluation of the morbidly obese patient, the current status of the indications for bariatric surgery and which type of procedure should be recommended; it also brings up for discussion some important real-life clinical practice issues, which should be taken into consideration when evaluating and treating morbidly obese patients. Finally, it also goes through current scientific evidence supporting the potential effectiveness of medical therapy as treatment of patients with morbid obesity.     

减肥手术对骨骼健康的影响及其机制

肥胖症发病率的显著提高已成为严重的公众健康问题。胃减容或旁路手术是治疗重度肥胖症切实有效的方法。新近研究发现减肥手术不仅可能引起骨密度降低,而且远期可能导致骨折率上升。本文就减肥手术对骨骼的影响、机制及防治措施进行综述。     

Gastric food bezoar as a complication of bariatric surgery. Case report and review of the literature

In the last few years bariatric surgery has become an excellent therapeutic alternative for the treatment of morbid obesity. Food bezoar as a cause for obstruction seems to be a very infrequent postoperative complication. It has only been published as anecdotal case reports. We describe a female patient with morbid obesity (weight, 131 kg; body mass index, 45) who underwent laparoscopic bariatric surgery (subtotal 95% gastrectomy with gastroyeyunoanastomosis in Roux-Y) obtaining a significant weight reduction (51 kg) in the next few months post surgery. She developed a food bezoar in the gastric remnant as a late complication of surgery (13 months after bariatric surgery) and presented as a gastric outlet acute obstruction with persistent vomiting and satiety. The diagnosis and treatment was performed through an upper GI endoscopy. It is important to consider this complication in patients with persisting vomiting after this kind of surgery. In the near future we will probably have a significant amount of patients operated due to morbid obesity and we may see this kind of complication more frequently.     

Successful weight loss following obesity surgery and the perceived liability of morbid obesity.

Patients (n = 47) who lost 45 kg (100 lb) or more and who successfully maintained weight loss for at least three years following gastric restrictive surgery for morbid obesity viewed their previous morbidly obese state as having been extremely distressful. In spite of the strong proclivity for people to evaluate their own worst handicap as less disabling than other handicaps, patients said they would prefer to be normal weight with a major handicap (deaf, dyslexic, diabetic, legally blind, very bad acne, heart disease, one leg amputated) than to be morbidly obese. All patients said they would rather be normal weight than a morbidly obese multi-millionaire.     

Current status of bariatric surgery in the treatment of type 2 diabetes

Bariatric surgery (from the Greek words baros meaning ‘weight’ and iatrikos‘the art of healing’) is a rapidly evolving branch of surgical science. The aim is to induce major weight loss in those whose obesity places them at high risk of serious health problems. In an attempt to balance the risks of surgery against the benefits of weight loss, bariatric operations are currently performed only in the morbidly obese, or those with a body mass index (BMI) > 35 kgm^?2 who already have developed comorbidity such as type 2 diabetes. Although weight loss is beneficial for obese patients with diabetes, current medical treatment for obesity is difficult. In contrast, observational studies show a major impact of bariatric surgery on diabetes, raising the question whether this approach should be used more widely to treat diabetes in obese patients? If bariatric surgery were shown to be the best way to treat diabetes in obese subjects the implications for health services would be wide‐ranging. Bariatric surgery leads to withdrawal of diabetic treatment in about 60% or more of patients, and reductions of therapy for many others. Although data on bariatric surgery in subjects with diabetes are provocative, most studies have been uncontrolled or flawed in other ways. Most importantly, bariatric surgery has not yet been compared against standard medical treatment for diabetes in randomized controlled trials with diabetes‐specific endpoints in all relevant patient groups. Potential indications for bariatric surgery are discussed, and the unanswered questions that need to be addressed by clinical trials are summarized. Although small numbers of patients may be interested in bariatric surgery for type 2 diabetes, current data are insufficient to endorse its wide scale use for this indication. Until essential studies are undertaken the role and economics of bariatric surgery in the diabetic clinic will remain uncertain.     

Complications of antiobesity surgery

Bariatric surgery is an effective long-term treatment for patients who suffer from morbid obesity, the incidence of which is increasing in North America. Laparoscopic gastric bypass and laparoscopic adjustable gastric band placement are the two commonly performed bariatric procedures. This article discusses the indications for bariatric surgery and the early and late complications associated with these two procedures. Laparoscopic biliopancreatic diversion and laparoscopic sleeve gastrectomy are also briefly discussed.     

Endoscopic bariatric procedures: Assessment of postintervention safety and success

Morbid obesity has become one of the largest health care crises facing modern medicine. Medical intervention alone has proven inadequate in addressing this issue. Although bariatric surgery has been proven to be the most effective treatment for the medical comorbidities associated with morbid obesity, only a fraction of obese patients will undergo bariatric surgery owing to fear, financial restraint, and limited access to surgical expertise. There exists a void for which endoscopic therapies can provide substantial improvements in the care of the morbidly obese patient. Compared to traditional surgical therapies, endoscopic approaches may potentially speed recovery with decreased pain, incisional hernia development, and surgical site infections. Primary endoscopic bariatric procedures can be classified as space-occupying, restrictive, or bypass. These procedures, as well as foresight into endoscopic bridges to surgery and revisional approaches, are discussed herein.     

Morbid obesity and type 2 diabetes alter intestinal fatty acid uptake and blood flow

Aims

Bariatric surgery is the most effective treatment to tackle morbid obesity and type 2 diabetes, but the mechanisms of action are still unclear. The objective of this study was to investigate the effects of bariatric surgery on intestinal fatty acid (FA) uptake and blood flow.

Materials and Methods

We recruited 27 morbidly obese subjects, of whom 10 had type 2 diabetes and 15 were healthy age‐matched controls. Intestinal blood flow and fatty acid uptake from circulation were measured during fasting state using positron emission tomography (PET). Obese subjects were re‐studied 6 months after bariatric surgery. The mucosal location of intestinal FA retention was verified in insulin resistant mice with autoradiography.

Results

Compared to lean subjects, morbidly obese subjects had higher duodenal and jejunal FA uptake (P < .001) but similar intestinal blood flow (NS). Within 6 months after bariatric surgery, obese subjects had lost 24% of their weight and 7/10 diabetic subjects were in remission. Jejunal FA uptake was further increased (P < .03). Conversely, bariatric surgery provoked a decrease in jejunal blood flow (P < .05) while duodenal blood flow was preserved. Animal studies showed that FAs were taken up into enterocytes, for the most part, but were also transferred, in part, into the lumen.

Conclusions

In the obese, the small intestine actively takes up FAs from circulation and FA uptake remains higher than in controls post‐operatively. Intestinal blood flow was not enhanced before or after bariatric surgery, suggesting that enhanced intestinal FA metabolism is not driven by intestinal perfusion.     

A case of obstructive sleep apnea syndrome remarkably improved by gastric restriction surgery

A 23-year-man with morbid obesity and obstructive sleep apnea syndrome (OSAS) was admitted. He was 170 cm in height and 170 kg in weight. He underwent dietary treatment several times, but his weight returned to its original level, or even higher, within a short period. A diagnosis of OSAS was made by nocturnal polysomnography. In this morbidly obese patient with OSAS a nocturnal sleep apnea study was performed before and after weight reduction surgery (gastric restriction). The postoperative findings revealed a dramatic body weight reduction. At the same time, the results of apnea and oxygen desaturation were remarkably improved too. These results indicate that weight reduction surgery is a definitely effective treatment for morbid obesity associated with OSAS.     

Reduction in predicted coronary heart disease risk after substantial weight reduction after bariatric surgery

In recent years, bariatric surgery has become an increasingly used therapeutic option for morbid obesity. The effect of weight loss after bariatric surgery on the predicted risk of coronary heart disease (CHD) has not previously been studied. We evaluated baseline (preoperative) and follow-up (postoperative) body mass index, CHD risk factors, and Framingham risk scores (FRSs) for 109 consecutive patients with morbid obesity who lost weight after laparoscopic Roux-en-Y gastric bypass surgery. Charts were abstracted using a case-report form by a reviewer blinded to the FRS results. The study included 82 women (75%) and 27 men (25%) (mean age 46 +/- 10 years). Mean body mass index values at baseline and follow-up were 49 +/- 8 and 36 +/- 8 kg/m(2), respectively (p <0.0001). During an average follow-up of 17 months, diabetes, hypertension, and dyslipidemia resolved or improved after weight loss. Thus, the risks of CHD as predicted by FRS decreased by 39% in men and 25% in women. The predicted 10-year CHD risks at baseline and follow-up were 6 +/- 5% and 4 +/- 3%, respectively (p < or =0.0001). For those without CHD, men compared favorably with the age-matched general population, with a final 10-year risk of 5 +/- 4% versus an expected risk of 11 +/- 6% (p <0.0001). Likewise, women achieved a level below the age-adjusted expected 10-year risk of the general population, with a final risk of 3 +/- 3% versus 6 +/- 4% (p <0.0001). In conclusion, weight loss results in a significant decrease in FRS 10-year predicted CHD risk. Bariatric surgery decreases CHD risk to rates lower than the age- and gender-adjusted estimates for the general population. These data suggest substantial and sustained weight loss after bariatric surgery may be a powerful intervention to decrease future rates of myocardial infarction and death in the morbidly obese.