减重手术与妊娠：影响、利弊与时机选择

肥胖不但影响育龄期女性生殖健康,同时也会增加母亲和胎儿发生并发症的可能性;减重手术改善了肥胖相关的生育能力低下。运动、饮食以及药物等传统的治疗方法都有其局限性,减重手术是目前最为有效、持久的对于肥胖的治疗方式,在达到减轻体质量的同时能够显著改善肥胖相关合并症。随着接受减重手术的肥胖育龄期女性越来越多,减重手术后妊娠也受到学界更多的关注。然而,目前仅有少数研究评估了减重手术对妊娠相关结局的影响,国内相关的文献更是匮乏。笔者就减重手术对妊娠相关结局的影响以及术后合理的妊娠时机进行总结,以期更好地指导减重手术前后妊娠相关事件的处理,获得最佳的妊娠结局。     

减重手术后妊娠风险和时机的临床研究进展

目前在世界范围内,超重和肥胖的育龄女性逐年增加。除了合并糖尿病、高血压等慢性疾病外,他们还可出现性激素的代谢紊乱,表现为月经不规律、不孕症以及产科并发症等。减重手术是减轻体重和纠正肥胖相关并发症的有效方法。肥胖育龄女性在接受减重手术后,生育能力显著改善,妊娠几率提升。另一方面,肥胖女性在减重术后受孕的时机,对减重手术效果、妊娠并发症、分娩结局及母子近远期结局的影响值得探讨。本文就育龄肥胖女性施行减重手术后受孕时机和减重效果及妊娠风险与结局的临床研究进展做一综述。     

Pregnancy outcomes after gastric-bypass surgery

BACKGROUND: The purpose of this study is to compare outcomes of patients who become pregnant within the first year after surgery and those who delayed pregnancy until after 1 year after surgery. METHODS: A retrospective review was performed to identify patients who became pregnant after their gastric-bypass surgery from 2001 to 2004. Endpoints included pregnancy complications, fetal birth weight and outcome, delivery method, weight change during pregnancy, and nutrition. RESULTS: Of 2,423 patients who had undergone bariatric surgery from 2001 to 2004, 21 patients became pregnant within the first year after surgery and 13 became pregnant after 1 year. Similar outcomes were seen between the 2 groups regarding fetal weight, term pregnancy, and complications. CONCLUSIONS: Pregnancy outcomes within the first year after weight-loss surgery revealed no significant episodes of malnutrition, adverse fetal outcomes, or pregnancy complications. Anxiety over poor outcomes of pregnancy during the first year after bariatric surgery can be allayed.     

The Potential Role of Intragastric Balloon in the Treatment of Obese-Related Infertility: Personal Experience

The prevalence of people who are overweight or obese has increased dramatically in high-income countries over the past 20 years. There is a strong association between obesity and infertility, and weight loss can result in increased fecundity in obese women. The aim of this study is to demonstrate the potential role of intragastric balloon in the treatment of obese-related infertility. This is a retrospective study. A chart review of 27 obese women seen between September 2003 and July 2008 was performed. They all presented with the diagnosis of infertility and had undergone endoscopic intragastric balloon positioning. Among these women who tried unsuccessfully to become pregnant before weight loss, 15 became pregnant afterward. The pregnancies proceeded without complications and ended with live births. An improvement in the fertility status after weight loss has been described, although data on fertility after weight loss following bariatric surgery are still limited. The results obtained in our experience are not different from data reported in literature for bariatric surgery. Therefore, balloon treatment might be effective in young infertile obese women who wish to become pregnant.     

Outcome of Pregnancies after Biliopancreatic Diversion

Background: Severe obesity has deleterious effects on fertility and pregnancy outcomes. Although surgery is the best long-term treatment for severe obesity, there is a risk of gestational undernutrition in operated mothers because bariatric surgery reduces nutrient availability. This is a follow-up report of our initial findings regarding pregnancy and neonatal outcomes in biliopancreatic diversion (BPD) patients, with addition of a new cohort of children born to mothers after BPD. Methods: All women (n = 916) who had successfully undergone BPD in our hospital were mailed a questionnaire containing multiple-choice and essay questions concerning gynecologic and obstetric history, and pregnancy and neonatal outcomes in both preoperative and postoperative pregnancies. Patients operated between 1984 and 1995 (n = 568) were mailed an additional questionnaire regarding children's weight and height progress, and school performance. Perinatal records from our patients' obstetric clinics were also reviewed. Results: The questionnaire was completed by 783 women (85.5%). 251 postoperative pregnancies in 132 women resulted in 166 infants by 109 mothers. 47.0% of patients who were unable to become pregnant preoperatively were successful postoperatively. 90 out of 109 women (82.6%) reported an appropriate weight gain (9.1 ± 5.9 kg) during postoperative pregnancies. The incidence of fetal macrosomia decreased from 34.8 to 7.7%, with a concomitant increase in normalweight babies from 62.1 to 82.7%. The elevated miscarriage rate (26.0%) in these obese women persisted after surgery. Conclusion: Major weight loss following BPD improves the reproductive function of severely obese women. BPD provides major beneficial effects for both mother and child, including normalization of gestational weight changes, reduction of fetal macrosomia, and normalization of the infant's birth-weight. Our results speak in favor of delaying pregnancy in obese women until after the substantial surgical weight loss has occurred.     

Pregnancy after laparoscopic bariatric surgery: comparative study of adjustable gastric banding and Roux-en-Y gastric bypass

BackgroundApproximately 80% of patients undergoing bariatric surgery are women, and about one half of these are of reproductive age. The purpose of the present study was to compare laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in a series of morbidly obese women with respect to maternal and neonatal outcomes at a university hospital in France.MethodsFrom January 2004 to December 2008, the data from women who had undergone LAGB or LRYGB at our center and were pregnant were collected, including age, parity, gravidity, weight, body mass index (BMI) before surgery and at scheduled intervals after surgery (1, 3, 6, 12, and 18 mo and yearly thereafter), interval from surgery to conception, weight and BMI at conception, weight and weight gain during pregnancy, weight and BMI at 2 weeks after pregnancy, complications during pregnancy, gestational age, method of delivery, fetal birth weight, and fetal outcome.ResultsThere were 42 pregnancies in 36 women, 22 in women who had undergone LAGB and 20 who had undergone LRYGB. The LAGB and LRYGB groups were comparable for all analyzed variables, except that the preoperative weight and BMI were greater in the LRYGB group. No differences in weight or BMI were found at conception or after pregnancy. No difference was found between the 2 groups in terms of obstetric complications or neonatal outcomes. A high frequency of cesarean deliveries was necessary in both groups.ConclusionsThe results of the present study have shown that no significant difference exists in the obstetric and birth outcomes between women who have undergone LRYGB and those who have undergone LAGB.     

Becoming pregnant within the first year after bariatric surgery adversely affects postoperative weight loss

BackgroundApproximately 80% of the patients undergoing bariatric surgery are female, with half of them undergoing surgery during their reproductive years. Most guidelines recommend that women wait at least 12 months after surgery before becoming pregnant. No previous studies have investigated whether becoming pregnant in the first or second year after surgery affects weight loss.ObjectivesThe aim of this study was to assess whether pregnancy within the first or second year after bariatric surgery affects weight loss up to 5 years after surgery.SettingA single institution.MethodsThis study is a retrospective study of women who underwent primary bariatric surgery between 2012 and 2016. Weight outcomes were measured until 5 years after surgery. A linear mixed model was used to assess the effect of the time between surgery and conception in groups on the basis of percentage total weight loss.ResultsA total of 55 patients undergoing a primary bariatric procedure were included. Forty-seven women underwent a laparoscopic Roux-en-Y gastric bypass (85.5%), and 8 underwent a sleeve gastrectomy (14.5%). The median time between surgery and estimated conception was 22 months (range: 0–51 months). Women who became pregnant between 12 and 24 months after bariatric surgery (n = 18) and women who became pregnant after 24 months (n = 24) had significantly more weight (β = 3.95, P = .020, and β = 4.09, P =.024, respectively) than women who became pregnant within 12 months after bariatric surgery (n = 12).ConclusionOur results suggest that pregnancy within 12 months after bariatric surgery negatively affects the long-term weight loss after bariatric surgery.     

Bariatric Surgery, Safety and Type 2 Diabetes

Obesity and type 2 diabetes (T2D) represent major health concerns in the USA. Weight loss is the most important aspect in T2D management, as it reduces both morbidity and mortality. Available lifestyle, behavioral, and pharmacological strategies provide just mild to moderate weight loss. The greatest degree of T2D prevention or T2D amelioration in obese subjects has been reported in subjects who underwent bariatric surgery. In the current review, we will describe various types of bariatric surgery, related safety profiles, and their effect on T2D, as well as the potential mechanisms involved in the remission of T2D. Finally, we hereby examine whether bariatric surgery may be considered a treatment for T2D in pregnant women, children, adolescents and subjects at least 65 years old.     

Impact of bariatric surgery on breastfeeding: a systematic review

Metabolic and bariatric surgery helps women achieve a healthier weight, reduce co-morbid conditions, increase fertility rates, and improve pregnancy outcomes compared with counterparts who are obese. Breastfeeding is known to provide both infant and maternal health benefits as well. Less is known about the impact of bariatric surgery on breastfeeding. The objective of this study was to review the impact of bariatric surgery on breastfeeding following the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. PubMed and Medline databases were searched using terms such as “bariatric surgery,” “postnatal care,” “lactation,” and “breastfeeding.” Reference lists were also used to find relevant articles. A total of 49 records were identified. Abstracts were screened, and 11 observational studies were identified after meeting inclusion criteria, which included the use of original research on breastfeeding and women who have had bariatric surgery. The available research shows that breast milk after bariatric surgery is adequate in nutrients and that no long-term effects were reported in cases studies when nutrient deficiencies were corrected. Limitations include observational study design and small sample sizes. This systematic review suggests that breastfeeding after bariatric surgery should be recommended along with monitoring and micronutrient supplementation. However, additional research and increased sample sizes are needed to further examine the relationship, and such studies should be conducted to strengthen the evidence and explore ways to improve breastfeeding rates in this population.     

Knowledge,attitudes, and behaviors of women during pregnancy after bariatric surgery

BackgroundWomen of childbearing age constitute a substantial proportion of the patients who undergo weight loss procedures. However, little is known regarding attitudes and behaviors of women during pregnancy after bariatric surgery (BS).ObjectivesWe explored women’s experience and behavior during pregnancy after BS.SettingUniversity hospital.MethodsA cross-sectional survey study was performed among women who underwent sleeve gastrectomy and delivered at our center.ResultsOverall, 111 women completed the questionnaire (response rate 88.1%). The median surgery-to-conception interval was 34 (25–50) months. For 28 (25.2%) women, future pregnancy was a motivation for undergoing the weight loss procedure. Only 10 (9.0%) received contraceptive advice perioperatively. Oral contraception was the most commonly used method after surgery (n = 47, 42.3%). Pregnancy was reported as unintended by 37 (33.3%) women. Only 14 (12.6%) women stated receiving an explanation regarding the implications of BS on pregnancy outcomes. Rates of follow-up with maternal-fetal medicine specialists, bariatric surgeons, and dieticians during pregnancy were 36.0%, 9.0%, and 23.4%, respectively. Forty-four women (39.6%) felt follow-up throughout gestation was inadequate. Satisfaction from BS improved after pregnancy in 23 (20.7%) women, and 75 (67.6%) stated that they would recommend BS to a friend with obesity who plans to conceive in the future.ConclusionsWomen reported insufficient knowledge regarding the expected outcomes of pregnancy after surgery, with low rates of medical and nutritional follow-up. Only a minority of respondents received contraceptive advice after surgery, and unintended pregnancies were common. These observations represent areas of improvement for following women of childbearing age who undergo weight loss procedures.     

The surgical management of obesity in young women: consideration of the mother’s and baby’s health before, during, and after pregnancy

Background  Maternal obesity has a substantial associated morbidity and mortality affecting both mother and child. This has a major impact on provision of care due to increased requirements for both medical and surgical management of the consequences that follow obesity in pregnancy. Methods  A review examined the English language literature on Medline databases describing the effect of obesity on pregnancy and outcomes of pregnancy after bariatric surgery. Guidelines from the National Institute for Clinical Excellence yielded information on selection criteria for fertility treatment and bariatric surgery. The World Health Organization definitions of overweight and obesity were adhered to throughout this review. Results  The level of clinical and morbid obesity has shown a dramatic increase in women of childbearing age, with far-reaching consequences for both their own health and that of their offspring. Obese women require a substantial amount of additional clinical care beyond that offered to women of normal weight due to the wide range of medical and obstetric complications they experience. Recent evidence suggests that obesity may be implicated in approximately one-third of maternal deaths. The consensus of the literature is that the best way to reduce obesity-associated morbidity is by weight reduction before pregnancy. Where behavioral and medical interventions fail, the most successful method is bariatric surgery. The effect of surgery on the outcome of subsequent pregnancies indicate improved chances of normal pregnancy, delivery, and healthy babies. Conclusions  Bariatric surgery is a safe and effective method of weight loss for morbidly obese women of childbearing age, with favorable outcomes for pregnancies after surgery.     

Patient Satisfaction and Results of Vertical Banded Gastroplasty and Gastric Bypass

Background: Morbid obesity contributes to many health risks, including physical, emotional, and social problems. Various surgical treatments for morbid obesity have developed and have so far met with good results. This study compares vertical banded gastroplasty (VBG) with gastric bypass (GBP) and the patients' satisfaction with either procedure. Methods: Between April 1993 and July 1997, 63 bariatric surgical procedures were performed at Eisenhower Army Medical Center. Of those, complete follow-up was obtained for 29 patients. The parameters evaluated included age, preoperative and postoperative weights, body mass index (BMI), type of surgery, complications, and the patient's level of satisfaction. Results: The study group consisted of 27 women and 2 men. The average preoperative weight was 135 kg, and the average preoperative BMI was 48.3 kg/m². There were 17 VBGs and 12 GBPs performed. The average total weight loss was 45.1 kg. The average postoperative BMI was 33.2 kg/m². There were no statistically significant differences in weight loss between VBG and GBP. Four of 17 patients had complications after VBG, and three of 12 patients had complications after GBP. After VBG, 94.1% of patients were satisfied, and after GBP, 100% were satisfied. Twenty-seven of 28 patients stated that they would have the surgery again. Conclusion: There were no statistically significant differences in weight loss or complications after VBG or GBP. Patient satisfaction was high after both procedures. Therefore, bariatric surgery is important in the treatment of appropriately selected, morbidly obese patients.     

Bariatric surgery in adolescents: a long-term follow-up study

BACKGROUND: The benefits of bariatric surgery in adult obese patients are well known, but data are lacking regarding the outcome of the surgery in adolescents. The aim of this study was to retrospectively assess the operative morbidity and mortality, percentage of loss of initial excess weight, and the incidence of long-term complications and reoperations in a cohort of obese patients who underwent biliopancreatic diversion (BPD) before their 18th birthday. METHODS: A total of 76 adolescent subjects underwent BPD between 1976 and 2005. Of these 78 patients, 7 had Prader-Willi syndrome and 1 had Turner syndrome and were excluded from the study. RESULTS: The patient population comprised 52 girls and 16 boys. Their mean age was 16.8 years, mean body weight at operation was 125 kg (mean body mass index 46 kg/m2). Operative mortality was nil. The mean follow-up was 11 years (range 2-23). The mean percentage of loss of initial excess weight at each patient's longest follow-up was 78%. Before surgery, 33 patients were hypertensive (49%), 11 were dyslipidemic (16%), 3 were hyperglycemic, and 2 had type 2 diabetes. At the longest follow-up period after surgery, only 6 patients were hypertensive, and none were dyslipidemic or diabetic. A total of 19 reoperations were performed in 14 patients (20%), including 7 revisions. Eleven patients developed protein malnutrition 1-10 years after BPD. The long-term mortality rate was 4%. At 4 to 23 years after BPD, 18 of the women had given birth to 28 healthy babies. Three women had had a complicated pregnancy. CONCLUSION: Adolescents can undergo malabsorptive bariatric surgery with excellent long-term weight loss results and an incidence of long-term complications similar to that observed during the 30-year evolution of BPD in our experience.     

Effect of postbariatric maternal weight loss and surgery to conception interval on perinatal outcomes of nulliparous women

BackgroundBariatric surgery is associated with an increased risk of delivering a small neonate. The role of maternal weight loss and surgery to conception interval is unclear.ObjectivesTo investigate the effect of maternal weight loss, as a result of bariatric surgery, and surgery to conception interval on fetal growth and birthweight (BW).SettingInner London Teaching HospitalMethodsWe studied prospectively nulliparous women with previous bariatric surgery. Information on type, time, and presurgery weight was obtained. Surgery-to-conception interval was calculated as the time between surgery and conception, defined as the fourteenth day of the pregnancy dated by first trimester ultrasound scan. In the first trimester, maternal weight was measured. Assessment of maternal weight change between presurgery and first trimester of pregnancy was defined as total weight loss (TWL) (%). Fetal ultrasound scans were performed twice; 30–32 and 35–37 weeks’ gestation and estimated fetal weight (EFW) was calculated. Fetal growth rate was calculated as the ratio of EFW increase (in grams) between 30–32 and 35–37 weeks divided by the time interval (in days) between the 2 examinations. BW was recorded.ResultsThe study included 54 pregnant women, 26 with a restrictive procedure (gastric band or vertical sleeve gastrectomy) and 28 with a gastric bypass. Surgery to conception interval was not a significant predictor of the offspring’s growth. Maternal TWL was a significant predictor of fetal growth rate (P = .04) and predictor of BW (P = .005), even after adjustment for confounders.ConclusionsMaternal weight loss, as a result of bariatric surgery, has an inverse correlation with fetal growth rate and BW.     

Treatment of liver failure post one anastomosis gastric bypass by revising to normal anatomy: A case report

IntroductionObesity and the associated metabolic syndrome are global health problems. Significant weight loss after bariatric surgery can cause a substantial difference in those comorbidities in obese patients. In this case, we described a rare complication of a patient who developed acute liver failure after an uneventful one anastomosis gastric bypass treated conservatively and revision of the one anastomosis gastric bypass to normal anatomy.Case presentationWe present a 52-year-old female known to have hypothyroidism and morbid obesity with a BMI of 45. For that, she underwent uneventful one anastomosis gastric bypass. Later, she developed liver failure and hepatic encephalopathy, which was managed conservatively and revision surgery to normal anatomy.DiscussionBariatric surgery plays an integral role in treating obese patients for its associated impacts, like facilitating weight loss and related metabolic syndrome improvement. The effects of bariatric surgery on liver functioning are controversial. Some malabsorptive procedures are linked to postoperative hepatic complications. However, it is uncommon in a recent new technique in bariatric surgery. Liver transplant and revision of the bariatric surgery have been described as management. However, optimal nutrition support without a liver transplant along with revision surgery is possible in experienced hands.ConclusionEarly detection of liver impairment and early intervention by a revision to normal anatomy by an experienced surgeon is considered the safest and most effective procedure for such patients. However, late detection where liver failure occurs, liver transplantation is the only effective treatment for preventing fatal outcomes.     

Effect of Revisional Bariatric Surgery on Weight Loss and Frequency of Complications

Background: The relative risks and effectiveness of primary and revision operations done to produce weight loss are of interest both from a patient care and an economic perspective. The possibility that patients requiring revision surgery comprise a treatment resistant subgroup who are more likely to have post-operative complications is a valid concern. Methods: The records of all patients having bariatric procedures since January of 1970 were evaluated for weight loss and complications. Results: Most revisions were from jejunoileal bypass or a gastric restrictive procedure. Early complications were significantly more common following revision surgery (19%) than after primary procedures (6%), although late and combined early and late complication rates were similar. Operative mortality was lower following primary procedures (2/382) than revisions (1/75). Cholecystectomy was a common sequela following primary procedures but did not occur after revision procedures. Regardless of surgical category, weight loss after revision was equivalent to weight loss after primary procedures. Conclusions: Weight loss following revisional bariatric surgery is equivalent to weight loss following a primary operation of the same type. Although mortality and early complications are more common after revisional bariatric surgery, the frequency of late complications is not different. In all groups wound infections and hernias were relatively common complications and cholecystectomies are rare after revisional bariatric operations.     

Pregnancy Following Gastric Bypass for Morbid Obesity

Background: Women who suffer from morbid obesity are often infertile. If these women are able to become pregnant, they are considered high risk because of the hypertension, diabetes and other associated risk factors. Following the pregnancy is difficult due to limitations of the physical examinations. More costly ultrasound examinations are needed at a higher frequency. Bariatric surgery reduces the woman's weight and the incidence of obesity related co-morbidities. The number of pregnancies and rate of complications during those pregnancies in our post-bariatirc surgical patients were evaluated. Method: Our group has been doing bariatric surgery since the early 1980s. We have over 2000 active patients on our current newsletter mailing list. The patients also have a series of networks through support groups. The patients are informed to contact us when they become pregnant so we may assist the obstetrician with their care. Through these various means, we have been able to identify 41 women in our patient population who have become pregnant. Using personal interview, questionnaire, and review of perinatal records, pregnancy-related risks and complications were studied. Results: With over a 95% follow-up rate on the patients identified as having been pregnant following surgery, we found less risk of gestational diabetes, macrosomia, and cesarean section than associated with obesity. There were no patients with clinically significant anemia. Conclusion: Since the patients had an operation that restricts their food intake, some basic precautions should be taken when they become pregnant. With this in mind, our patients have done well with their pregnancies. The post-surgical group had fewer pregnancy-related complications than did an internally controlled group that were morbidly obese during their previous pregnancies.     

Impact of Sustained Weight Loss Achieved through Roux-en-Y Gastric Bypass or a Lifestyle Intervention on Ghrelin,Obestatin, and Ghrelin/Obestatin Ratio in Morbidly Obese Patients

Background  

Appetite-regulating hormones seem to play an important role in weight loss after bariatric surgery. Less is known regarding long-term weight loss maintenance. The objective of the study was to evaluate ghrelin and obestatin levels following long-term weight loss achieved through bariatric surgery or a lifestyle intervention in morbidly obese patients.     

A Review of Unmet Needs in Obesity Management

The prevalence of obesity continues to escalate in the USA; however, there is no consensus regarding the optimal therapy for obesity. For the vast majority of severely obese patients, conventional medical therapies (i.e., diet, exercise, behavioral counseling) often fail over the long term. Existing pharmacotherapy adjunctive to behavioral therapy has limited effectiveness and an imperfect safety record. In contrast, bariatric surgery has a high degree of weight loss efficacy, yet only a small fraction of the qualifying obese population undergoes these procedures because of the associated perioperative risks and potential late complications. In addition, the role of bariatric surgery is unclear in certain patient populations, such as patients with lower body mass index (BMI, 30-35 kg/m(2)), the high-risk super-super obese patients (BMI > 60), the morbidly obese adolescent, and obese patients requiring weight reduction in preparation for other procedures, such as orthopedic, transplant, or vascular surgeries. In these circumstances, there is a need for an effective but less invasive treatment to bridge the gap between medical and surgical therapy. This review examines current treatment outcomes, identifies prominent areas of unmet clinical needs, and provides an overview of two minimally invasive "temporary procedures for weight loss" that may eventually address some of the unmet needs in obesity management.