Psychosocial Effects of Bariatric Surgery

Introduction: Total mesorectal excision (TME) is the accepted standard for rectal cancer treatment. However, there is an increased risk of symptomatic anastomotic leakage associated with TME as TME potentially endangers the blood supply of the remaining rectum. On top of this, many patients will receive neo-adjuvant radio-chemotherapy. A defunctioning stoma helps in avoiding severe complications of anastomotic failure.

Material and mehods: We prospectively collected data of all patients with a rectal carcinoma within reach of the palpating finger, operated on in our department between December 2000 and January 2005. There were 70 patients (42 men and 28 women, median age 70 (range 32–95)).

Results: In 40 patients (40/70 = 57%) a sphincter-saving procedure was performed. Eleven patients were diagnosed with anastomotic leakage or failure. Seven patients had neo-adjuvant radio-chemotherapy, 4 had no neo-adjuvant therapy. In 4 patients signs of anastomotic leakage were seen on the barium-enema that is routinely performed before closing the defunctioning stoma. Seven patients (7/40 = 17,5%) had clinical signs of anastomotic leakage. Three of them could be treated conservatively with antibiotics and parenteral nutrition. Two of these patients did not have a defunc-tioning stoma. Four patients needed re-intervention and were treated in intensive care for several days. Three of these patients did not have a defunctioning stoma.

Conclusion: Neo-adjuvant radio-chemotherapy and TME resection are two factors in the treatment of rectal cancer that might interfere with anastomotic healing in the case of a sphincter-saving procedure. The construction of a defunctioning stoma helps in limiting the complications of anastomotic leakage or failure.     

A New Questionnaire for Quick Assessment of Food Tolerance after Bariatric Surgery

Background Bariatric surgery is often associated with reduced food tolerance and sometimes frequent vomiting, which influence quality of life, but are not included in the overall evaluation of these procedures, notably the BAROS. Our aim was to develop a simple questionnaire to evaluate food tolerance during follow-up visits. Methods A one-page questionnaire including questions about overall satisfaction regarding quality of alimentation, timing of eating over the day, tolerance to several types of food, and frequency of vomiting/ regurgitation was developed. A composite score was derived from this questionnaire, giving a score of 1 to 27.Validation was performed with a group of nonobese adults and a group of morbidly obese nonoperated patients. Patients were administered the questionnaire at follow-up visits since January 1999. Data were collected prospectively. Results It takes 1–2 minutes to fill out the questionnaire. Food tolerance is worse in the morbidly obese population compared with non-obese adults (24.2 vs 25.2, P = 0.004). Following Roux-en-Y gastric bypass, food tolerance is reduced after 3 months (21.2), but becomes comparable to that of the normal population and remains so at 1 year postoperatively. Following gastric banding, food tolerance is already significantly reduced after 3 months (22.3), and worsens continuously over time (19.03 after 7 years). In the gastric banding population, the decision to adjust the band is based at least partially on food tolerance, and the questionnaire proved helpful in that respect. Conclusion Our new questionnaire proved very easy to use, and helpful in day-to-day practice, especially after gastric banding. It was also helpful in comparing food tolerance over time after surgery, and in comparing food tolerance between procedures. Evaluation of food tolerance should be part of the overall evaluation of the results after bariatric surgery.     

Psychological Outcome Two Years after Restrictive Bariatric Surgery

Background An essential outcome criterion of obesity surgery besides weight loss is the improvement of medical and psychological health status. Both dimensions influence quality of life. This study evaluates depressive symptoms, self-esteem and health-related quality of life 2 years after bariatric surgery. Methods 149 patients (47 males (32%), 102 females (68%), mean age 38.8 ± 10.3 years) were assessed by standardized questionnaires before and 1 and 2 years after gastric restrictive surgery. Results Mean BMI pre-surgery was 51.3 ± 8.4 kg/m2. BMI decreased significantly to 38.6 ± 6.8 kg/m2 at 1 year and to 37.9 ± 7.4 kg/m2 at 2 years after surgery. Statistical analyses revealed a significant decrease in depressive symptoms and a significant improvement in selfesteem and the physical dimension of health-related quality of life. Pre-surgery, 40.5% (n = 62) of the patients suffered from depressive symptoms of clinical relevance. These depressive symptoms persisted in 17.7% (n = 27) 1 year and in 16.4% (n = 25) 2 years after surgery. Conclusion Parallel with a considerable weight loss after bariatric surgery, important aspects of mental health such as depressive symptoms and selfesteem improved significantly. These effects appear 1 year after surgery, but do not seem to change considerably afterwards.     

Nature versus Nurture: Identical Twins and Bariatric Surgery

Background Genetics and environment both play a role in weight maintenance. Twin studies may help clarify the influence of nature vs nurture in weight loss. We present the largest U.S. experience with monozygotic (MZ) twins undergoing bariatric surgery. Methods We retrospectively reviewed the charts of four sets of MZ twins who underwent Roux-en-Y gastric bypass (RYGBP) surgery and laparoscopic adjustable gastric band (LAGB) placement at three different institutions. BMI and co-morbidities were examined pre- and postoperatively, and laboratory values were recorded. Results All four sets of twins are female, live together, and have similar professions. Twin cohort 1 had near identical weight loss patterns after open RYGBP surgery in 1996 (preop 146/142 kg; 2 years 82/82; and 10 years 108/107). Twin cohort 1 also both underwent cholecystectomies within the first year postoperatively. Twin cohort 2 underwent laparoscopic RYGBP surgery and also required cholecystectomies in the first postoperative year. Cohort 2 also experienced nearly identical weight loss at 1 year (36.7% vs 37.0% BMI loss). Twin cohort 3 underwent LAGB placement with two different surgeons with differing amounts of weight loss at 6 months (6.5% vs 15.7% BMI loss). Finally, twin cohort 4 underwent laparoscopic RYGBP with 2-year BMI loss of 39% vs 34%. In twin cohort 4, the twin who lost less weight lived apart from her twin and extended family, and her weight loss was less than the twin living with her family. Conclusion Two sets of MZ twins had identical responses to bariatric surgery. The other two sets of identical twins had differential weight loss results, possibly due to differences in surgical approach and social support. While genetics do exert a strong influence on weight loss and maintenance, this case series demonstrates the potential effect of social support and postoperative management upon postoperative weight loss in the presence of identical genetics.     

A Nationwide Survey on Bariatric Surgery in France: Two Years Prospective Follow-up

Background Most studies on bariatric surgery outcomes have been performed in clinical trials (eg. the SOS) or reflect the clinical experience and practice of specific and experienced centers. Little is known about the current practice at a nationwide level. Methods This is a systematic nationwide study on the 2-year outcome of all consecutive 1,236 bariatric operations performed in France. Data on mortality, weight loss, complications, and patient satisfaction were collected independently from the medical and surgical team involved in the patients’ care. Results 87.3% of the patients underwent an adjustable gastric banding (ABG), 8.6% a vertical banded gastroplasty (VBG), 3.8% a Roux-en-Y gastric bypass (RYGBP) and 0.3% a biliopancreatic diversion (BPD). Loss of follow-up was 12% at year 1 and 18% at year 2. The rate of laparoscopic procedures was 98% for ABG and 73% for RYGBP. Mortality rate was 0.16% in the operative period and 0.27% during follow-up. Excess weight loss ranged from 43% (AGB) to 66% (RYGBP). Co-morbidities improved in more than 70% of patients. Conclusion Outcomes of bariatric surgery in routine practice (mortality, weight loss, course of co-morbidities, and quality of life) are similar to the results published in clinical trials.     

Rhabdomyolysis after Laparoscopic Bariatric Surgery

Background: Postoperative rhabdomyolysis is an uncommon event. The aim of this study was to determine the incidence of rhabdomyolysis following laparoscopic obesity surgery. Methods: Rhabdomyolysis was studied prospectively. Over a 6-month period, 66 consecutive patients underwent bariatric surgery (gastric banding (n=50) and gastric bypass (n=16)). All patients underwent laparoscopic procedures. A range of blood tests, including serum creatine phosphokinase (CPK) level and serum creatinine, were systematically performed before surgery, and on the first and third day postoperatively. Rhabdomyolysis was defined as a postoperative CPK level >1,050 IU/L. Results: Serum CPK was noted to increase significantly postoperatively to >1,050 units in 3 patients (6%) in the adjustable banding group and 12 patients (75%) in the gastric bypass group (P <0.01). In the bypass group, 4 patients (25%) had a serum CPK level >10,000 IU/L, but there were none in the gastric banding group. All patients with CPK level >10,000 IU/L had BMI >60 kg/m². No patients experienced acute renal failure. Conclusion: Rhabdomyolysis occurred in 22.7 % of 66 consecutive patients undergoing laparoscopic bariatric surgery. Risk factors were identified: massive obesity and long duration of the operation. Early diagnosis may have significant impact on outcome by preventing or reducing the severity of complications from rhabdomyolysis. CPK level should be performed systematically after obesity surgery.     

Analysis of the Incidence and Risk Factors for Wound Infections in Open Bariatric Surgery

Background: Our clinical impression derived from >95% follow-up of patients was that our wound infection rate was higher than the 1-10% reported in the literature. The purpose of this study was to determine the incidence and risk factors for wound infection in open bariatric surgery. Methods: We queried our prospectively acquired bariatric surgery outcomes database, and retrospectively audited the charts of patients operated from April 1 to March 31, 2003. Risk categories were obtained using the National Nosocomial Infection Surveillance (NNIS) definitions and stratification. Expected site-specific rates were adjusted for duration of operation, degree of wound contamination, and underlying disease condition. Results: 269 patients undergoing a standardized open Roux-en-Y gastric bypass were studied. The mean age (SD) was 39.5 (10.5) years and the mean BMI was 54.3 (9.9). Operating time averaged 63 (17) minutes, and length of stay was 4.1 (1.3) days. Based on NNIS categories 10.9 wound infections were expected, but 54 were observed, for a rate of 20%. Bacterial isolates included S. aureus (39%), α-hemolytic strep (26%), Enterococcus (16%), P.mirabilis (9%), and multiple other bacteria at 10%. Epidural analgesia and delayed antibiotic prophylaxis administration (after the incision was made) increased the odds of developing a wound infection, whereas gender, age, BMI, duration of surgery, and incidence of diabetes had no effect.There was a high correlation between wound infection and subsequent incisional hernia formation. Conclusion: The incidence of wound infections following open bariatric surgery is high, and the current recommendations for antibiotic prophylaxis are ineffective. As these infections carry significant morbidity, effective methods to prevent them are needed.     

Gastric Banding for Treatment of Morbid Obesity: Preliminary Results

Background: gastric banding (GB) has been used for treatment of morbid obesity. Methods: a banding device, introduced by Broadbent and consisting of a self-blocking nylon strip covered with a silicone tube, was used in 13 patients who have completed 1-year follow-up. This device was used for its mechanical properties, biocompatibility, ease of insertion and low cost. Results: at 1 year, mean excess weight loss was 51.6%, with all but one patient losing more than 25% of excess weight. Associated illnesses resolved. There were two complications (15%): one patient required band removal for self-induced vomiting and one patient required repair of an incisional hernia. Conclusions: GB has had good results thus far. Reported differences depend on materials, stoma diameter, pouch size, and developing techniques.     

Laparoscopic Roux-en-Y Gastric Bypass as a Revision Procedure after Restrictive Bariatric Surgery

Background  Adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG) have been extensively used to treat morbid obesity. Patients with insufficient weight loss or complications may require surgical revision. The laparoscopic Roux-en-Y gastric bypass (LRYGBP) is one of the most common procedures currently used for revision. The aim of the study was to analyze surgical outcomes of 30 consecutive patients who underwent revision to LRYGBP in a 2-year period. Methods  The prospectively constructed database and the medical records of all patients undergoing revision to LRYGBP were reviewed. Demographics, surgical details, results, and complications were analyzed. Results  There were 23 women and seven men with a mean age of 41.1 ± 9.7 years (r = 25–61). Mean body mass index (BMI) was 40.0 ± 7.5 kg/m² (r = 27.2–65.2). Initial operation was AGB in 24, VBG in five, and both in one patient. In ten patients, the band had been removed before revision, in 13 cases, band removal and LRYGBP were performed in one surgical intervention, and in two patients, it was performed in a two-step surgery. There were two conversions to open surgery. Five patients presented major surgical complications. Hospital stay averaged 5.1 days (r = 3–25). Mean percent excess body weight loss at 6 and 12 months was 61.7 ± 27.5 and 81.2 ± 20.5 kg/m², respectively. Mean percent low body mass index at 6 and 12 months was 22.5 ± 9.1 and 29.1 ± 11.4 kg/m², respectively. Conclusions  LRYGBP as a revision procedure is feasible in most patients. Surgical complications are more frequent.     

减重外科进展

减重手术在欧美、澳洲已是常见手术,在我国还处于起步阶段。目前世界范围内腹腔镜胃绕道术和可调节胃束带术是主要术式。腹腔镜可调节胃束带术是现在最新、最简单、最安全、效果较好的术式。     

Insulinoma Misdiagnosed as Dumping Syndrome after Bariatric Surgery

Background: Late dumping syndrome is a possible side-effect of gastric bypass. Hypoglycemic symptoms may develop 3-4 hours after certain types of foods.There may exist patients, however, who present hypoglycemia in the absence of dumping syndrome. The presence of only mild symptoms of hypoglycemia may make the evaluation of these patients difficult and delay the identification of other possible sources of hyperinsulinemia, including an insulinoma. Case Report: A 65-year-old woman underwent gastric bypass for continued weight gain and morbid obesity. After surgery, the patient had repeated episodes of hypoglycemia, diagnosed at follow-up as late dumping syndrome. The persistence of hypoglycemic episodes after nutritional counseling and modifications in the feeding pattern led to consideration of an autonomous source of hyperinsulinemia, and MRI and CT identified insulinoma. After a laparotomy and pancreatic tumor resection, she remains free of symptoms. Conclusion: Hypoglycemic episodes after obesity surgery are not always related to dumping syndrome. The persistence of hypoglycemia in spite of nutritional counseling should raise the possibility that there may exist other causes. Insulinoma, the most common cause of endogenous hyperinsulinemia, should be investigated in these patients, since it is a tumor that can be cured.     

Sexual Abuse Survivors and Psychiatric Hospitalization after Bariatric Surgery

Background Some investigators have postulated that a history of being the victim of childhood sexual abuse may impact outcome of bariatric surgery. Methods In this retrospective chart review, we examined the electronic medical records of 152 adults with morbid obesity who underwent Roux-en-Y gastric bypass and who had a weight recorded in their medical record or reported in a follow-up surgery at 2 years after the RYGBP. The purpose of this retrospective chart review was to examine the relationship between psychosocial factors assessed preoperatively and the percent of excess weight lost (%EWL) at 2 years after bariatric surgery. Results We found a high prevalence of being the victim of childhood sexual abuse (27%), adult sexual trauma (9%), and/or physical abuse (19%) at the initial evaluation. There was no association between these factors and %EWL at 2 years. However, when we examined participants’ medical records for post-operative psychiatric hospitalizations at our medical center, 8 of 11 hospitalized patients reported a history of childhood sexual abuse (73%). Conclusions History of being the victim of childhood sexual abuse is reported frequently by patients seeking bariatric surgery. Our finding that having been the victim of childhood sexual abuse may be associated with increased risk of psychiatric hospitalization after RYGBP has several clinical implications. First, we recommend that clinicians assess carefully for a history of sexual or physical abuse, and secondly, abuse survivors may need to be told that there is an increased risk of psychiatric morbidity after bariatric surgery. Finally, perhaps close monitoring of these patients may prevent psychiatric difficulties after surgery. Further research to verify these preliminary findings is clearly needed.     

Evidence Supporting Routine Polysomnography Before Bariatric Surgery

Background: Obstructive sleep apnea (OSA) is common in morbidly obese patients, with a reported prevalence from 12 to 40%. Preoperative diagnosis of OSA is important for both perioperative airway management and the prevention of postoperative pulmonary complications. BMI has been reported to be an independent risk factor, and has been used recently in scoring systems to help predict OSA. Our hypothesis was that OSA is highly prevalent in patients presenting for bariatric surgery, and that BMI alone is not a good predictor of the presence or absence of sleep apnea. Methods: A cross-sectional study was undertaken of the last 170 consecutive patients presenting for bariatric surgery in a single surgeon's practice. Clinical and demographic data were available from our prospective database, and polysomnography results were reviewed retrospectively. Sleep apnea was noted as present or absent, and graded from mild to severe. The patient population was stratified by BMI into severely obese (BMI 35-39.9), morbidly obese (BMI 40-49.9), super-obese (BMI 50-59.9), and super-super-obese (BMI ≥ 60). Results: OSA had been diagnosed before surgical consultation in 26 of the 170 patients (15.3%). Sleep studies were not available in 7 patients (4.1%). The remaining 137 patients (80.6%) had sleep data available, and 105 (76.6%) had sleep apnea (based on American Board of Sleep Medicine criteria).There was no correlation of sleep apnea with BMI. The overall prevalence of OSA in this cohort was 77% (131/170). Conclusions: In this large patient cohort, sleep apnea was prevalent (77%) independent of BMI, and most cases were not diagnosed before bariatric surgical consultation.These data support the use of routine screening polysomnography before bariatric surgery.     

Obesity and Obstructive Sleep Apnea-Hypopnea Syndrome: the Impact of Bariatric Surgery

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is characterized by successive episodes of cessation or decrease in respiratory airflow, in which obesity is an important risk factor. The prevalence of the disease in morbidly obese patients is ∼70%. Treatment is based on the use of continuous positive airway pressure (CPAP) and weight loss in obese patients.Weight loss by dieting often produces unsatisfactory results, and the use of CPAP does not show good adherence because of being long-term and uncomfortable. Bariatric surgery has emerged as the treatment for morbid obesity and various associated co-morbidities. This article reviews the principal studies that evaluate the modifications in obstructive sleep apnea after bariatric surgery, showing that surgery is an effective treatment for the management of OSAHS in morbidly obese patients.     

Outcome Following Bariatric Surgery in Super versus Morbidly Obese Patients: Does Weight Matter?

Background: Numerous investigators have attempted to identify prognostic indicators for successful outcome following bariatric surgery. The purpose of this study was to determine whether degree of obesity affects outcome in super obese [>225% ideal body weight (IBW)] versus morbidly obese patients (160-225% IBW) undergoing gastric restrictive/bypass procedures. Methods: Since 1984, 157 patients underwent either gastric bypass or vertical banded gastroplasty. Super obese (78) and morbidly obese (79) patients were followed prospectively, documenting outcome and complications. Results: Super obese patients reached maximum weight loss 3 years following bariatric surgery, exhibiting a decrease in body mass index (BMI) from 61 to 39 kg/m² and an average loss of 42% excess body weight (EBW). Morbidly obese patients had a decrease in BMI from 44 to 31 kg/m² and carried 39% EBW at 1 year. After their respective nadirs, each group began to regain the lost weight with the super obese exhibiting a current BMI of 45 kg/m² (61% EBW) versus 34 kg/m² (52% EBW) in the morbidly obese at 72 months cumulative follow-up. Currently, loss of 50% or more of EBW occurred in 53% of super obese patients versus 72% of morbidly obese (P < 0.01). Twenty-six percent of super obese patients returned to within 50% of ideal body weight (IBW) while 71% of morbidly obese were able to reach this goal (P < 0.01). Co-morbidities and complications related to surgery were similar in each group. Conclusions: Super obese patients have a greater absolute weight loss after bariatric surgery than do morbidly obese patients. Using commonly utilized measures of success based on weight, morbidly obese patients tend to have better outcomes following bariatric surgery.     

Gastric Pouch Adenocarcinoma and Tubular Adenoma of the Pylorus: A Field Effect of Dysplasia following Bariatric Surgery

There are reports of gastric carcinoma following bariatric surgery, but it is unclear if these procedures predispose to malignancy.We present a case of a 60-year-old man who, 15 years after vertical banded gastroplasty (VBG), had a massive upper GI bleed. Endoscopy revealed a large tumor of the gastric pouch. Histology confirmed an intestinal type of gastric adenocarcinoma arising in a background of H. pylori-negative gastritis with atrophy, foveolar hyperplasia and intestinal metaplasia. An incidental tubular adenoma at the pylorus was also identified. The pathogenesis of gastric pouch carcinoma is discussed. The present example of neoplastic change in both the pouch and pylorus may indicate that a field effect for dysplasia develops subsequent to VBG.     

Experience with Laparoscopic Adjustable Gastric Banding (La-Band System) up to 8 Years

Morbid obesity occurs in 2-5% of the population in Western countries.

Laparoscopic adjustable silicone gastric banding is a minimally invasive, adjustable and reversible procedure for the treatment of morbid obesity.

The lap-band system was evaluated retrospectively in a series of 222 patients. Postoperative outcome and weight loss patterns at up to 8 years follow-up are presented. The most frequent late complications were a leak between the port and the catheter, which occurred in 21 patients (9,4%) and total and irreversible food intolerance due to pouch dilation and/or slippage, which occurred in 13 patients (5,8%). The postoperative BMI reductions are successful and stable after a follow-up of up to 96 months. The lap-band system seems an effective procedure for achieving appreciable and stable weight loss up to 8 years of follow-up and the complications and re-operation rates are acceptable. In 81% of the cases also, the patient is very satisfied with the results of the operation. From the 47,3% who found their quality of life before the operation bad or even devastating, 93% envoy life after the operation like never before.     

Evaluation of the Clinical Pathway for Laparoscopic Bariatric Surgery

Background Clinical pathways (CP) are comprehensive systematized patient care plans for specific procedures. The CP for morbid obesity was implemented in our department in September 2005. The aim of this study is to evaluate the clinical pathway for this procedure 1 year after implementation. Methods A study was conducted on all the patients included in the CP since its implementation. The assessment criteria include degree of compliance, indicators of clinical care effectiveness, financial impact, and survey-based indicators of satisfaction. The results are compared to a series of patients undergoing surgery the year before the implementation of the CP. We analyzed the mean cost per procedure before and after CP implementation. Results Evaluation was made of a series of 49 consecutive patients who underwent surgery over the period of 1 year before the development of the CP and met the accepted inclusion criteria. The mean length of hospital stay was 7.95 days, and the mean cost per procedure before pathway implementation was 5,270.37 (±2,251.19) euros. One year after the implementation of the pathway, 70 patients were included. The mean length of hospital stay of the patients included in the CP was 5.1 days. The degree of compliance with stays was 71.4%. The most frequent reason for noncompliance was patient-dependent causes. The mean cost in the series of patients included in the CP was 4,532 (±1,753) euros. Conclusion The CP for morbid obesity reduced both variability in professional care patterns and hospital costs; justifying the work involved in its development and implementation.