Roux-en-Y gastric bypass ameliorates polycystic ovary syndrome and dramatically improves conception rates: a 9-year analysis

BackgroundPolycystic ovary syndrome (PCOS) is a common cause of infertility, especially in the morbidly obese. We evaluated the long-term effects of Roux-en-Y gastric bypass on PCOS and infertility.MethodsA total of 566 morbidly obese women underwent Roux-en-Y gastric bypass from 2000 to 2009. A total of 31 patients (5.5%) had a history of PCOS. Of the 31 patients, 6 were postmenopausal and 5 lost to follow-up and were excluded. Telephone interviews were conducted with the 20 eligible patients.ResultsThe mean age and body mass index was 32 ± 5.8 years (range 22–42) and 52.8 ± 9.08 kg/m² (range 37–76) before surgery. All 20 patients had ≥2 of 3 diagnostic criteria for PCOS, including clinical or biochemical evidence of hyperandrogenism, anovulation, or polycystic ovaries. Of these, 85% had oligomenorrhea, 70% had hirsutism, and 45% had type 2 diabetes mellitus with medication. Before surgery, 8 patients conceived with or without hormonal treatment, 2 did not desire pregnancy, and 10 did not conceive. The mean follow-up was 46.7 months. After surgical weight loss, menstruation was corrected in 82%, hirsutism had resolved in 29%, and 77.8% of those with diabetes had complete remission. Of the 10 patients who did not conceive before surgery, 4 no longer desired pregnancy, and the remaining 6 patients had become pregnant within 3 years of surgery—5 without any hormonal treatment and 1 with in utero insemination.ConclusionSurgical weight loss after Roux-en-Y gastric bypass achieves excellent amelioration of PCOS manifestations and the postoperative conception rate in infertile PCOS subjects desiring pregnancy was 100%.     

Changes in hormones and biomarkers in polycystic ovarian syndrome treated with gastric bypass

BackgroundSmall retrospective studies have demonstrated reduction in weight and co-morbid hirsutism and diabetes in women with polycystic ovary syndrome (PCOS) treated with Roux-en-Y gastric bypass. The objective of this study was to prospectively determine clinical improvements in obese women with PCOS treated with gastric bypass and identify postoperative biomarker changes.MethodsData were collected on obese women with PCOS undergoing Roux-en-Y gastric bypass over 1 year. Testosterone, follicle stimulating hormone, lutenizing hormone, insulin, fasting glucose, and lipid levels were obtained preoperatively at baseline, and 6 and 12 months after surgery. Testosterone was used as the primary hormonal biomarker. A physical examination for body mass index (BMI) and hirsutism, and information on menstrual pattern were collected at baseline and 3, 6, and 12 months after surgery.ResultsData were available for 14 women. Mean BMI decreased from 44.8±5.9 kg/m² at baseline to 29.2±5.9 kg/m² at 12 months postoperatively. Significant improvements were seen in testosterone, fasting glucose, insulin, cholesterol, and triglyceride at 12 months (P<.05). At baseline, irregular menses were reported in 10 patients; all patients were experiencing regular menses 6 and 12 months after surgery. Hirsutism was present in 11 patients at baseline and only 7 patients at 12 months. Improvements in biomarkers, menstrual cycling, and hirsutism was not correlated with degree of weight change.ConclusionGastric bypass achieved significant reductions in BMI, testosterone, and markers of glucose and lipid metabolism. These data confirm reports of previous retrospective studies showing weight reduction and health improvement in women with PCOS treated with gastric bypass.     

Bariatric surgery improves urinary incontinence in morbidly obese individuals

BACKGROUND: Urinary incontinence is common in obese individuals. We report on the prevalence of urinary incontinence in patients undergoing bariatric surgery and the effect of surgically induced weight loss on urinary incontinence. METHODS: The prospectively collected data from 201 consecutive candidates for bariatric surgery were evaluated. The patients were surveyed using a questionnaire regarding the duration of incontinence, stress/urge incontinence symptoms, and incontinence severity before and after undergoing bariatric surgery. Severity was quantified using a validated index developed Data are presented as the mean +/- standard deviation. RESULTS: Of 201 patients, 65 (32%) reported urinary incontinence. Of the 65 patients, 44 women and 1 man (age 49 +/- 11 years, body mass index 48 +/- 7 kg/m(2)) underwent Roux-en-Y gastric bypass (n = 42) or laparoscopic-assisted gastric banding (n = 3). Of the 38 patients who reported mild (2%), moderate (48%), and severe (50%) urinary incontinence preoperatively who had complete follow-up at > or = 6 months postoperatively, 19 (50%) had demonstrated resolution of urinary incontinence and 19 had reported residual slight-moderate (37%) or severe (13%) urinary incontinence. The overall severity score improved from 5.4 +/- 2.3 to 2.3 +/- 2.8 postoperatively (P <.001); the percentage of excess body weight loss was 61% +/- 19%. The patients reported subjective improvement within 4 months postoperatively or after a 50-lb weight loss. CONCLUSION: Urinary incontinence is prevalent in bariatric surgery patients. Surgically induced weight loss results in improvement or resolution of urinary incontinence in 82% of patients. The findings from this large cohort warrant additional investigation with urodynamic studies.     

Improvement of Insulin Resistance After Obesity Surgery: A Comparison of Gastric Banding and Bypass Procedures

BACKGROUND: Obesity is a major risk factor for the development of type 2 diabetes mellitus (T2DM). Insulin resistance (IR) is considered the pathologic link between T2DM and obesity. The mechanism in improving T2DM after bariatric surgery remains speculative. This trial assessed the effect of duodenal jejunal exclusion on the resolution of IR in gastric banding and gastric bypass procedures. METHODS: 660 patients with complete biochemical and clinical data at baseline and at 3 years were selected for analysis. There were 197 males and 463 females. The mean age was 31.5 years (18-64) and mean BMI was 41.4 (32-77). There were 544 patients who received laparoscopic gastric bypass, and 116 patients received laparoscopic gastric banding. IR was measured by homeostatic model assessment (HOMA) index (HI), that can be calculated as HI = plasma glucose (mmol/l) x insulin (UI/ml)/22.5. HI was measured before surgery and 1, 3, 6, 12, 24, and 36 months after surgery. RESULTS: Of the 660 individuals, 517 (78.4%) had IR. The mean HI was 7.62 +/- 13.13. The HI was correlated with BMI, waist circumference, insulin resistance, hyperlipidemia, inflammatory indicators, and abnormal liver enzymes. Before surgery, the HI was 7.92 +/- 14.18 for the bypass group and 6.27 +/- 6.47 for the banding group. After surgery, the HI began to lower in both groups, and this reduction was maintained during follow-up. At 36 months after surgery, mean percentage of excess weight loss (%EWL) was 70.5% for the bypass group and 41.9% for the banding group. The HI was 1.00 +/- 0.79 for bypass and 1.51 +/- 1.25 for banding. The bypass patients had a better and faster weight reduction, but the HI was similar between the two groups at the same weight reduction percentage. CONCLUSION: IR is common in morbidly obese patients. Both gastric banding and gastric bypass are effective for the reverse of IR in these patients. It seems that the effect is related to the absolute weight loss rather than different surgical procedures. There is no duodenal jejunal exclusion effect on IR resolution was observed in this study.     

Clinical diagnosis of polycystic ovarian syndrome and response to metformin therapy

Objective: To determine the accuracy of diagnosing polycystic ovarian syndrome (PCOS) predominantly on clinical features and the response to metformin therapy. Study Design: Quasi experimental study. Place and Duration of Study: Shifa College of medicine and Shifa International Hospital, Islamabad from January 2003 to July 2006. Patients and Methods: Women fulfilling the inclusion criteria (oligo/hypomenorrhea, infertility, weight gain, hyperandrogenism) were enrolled. Ultrasound pelvis was obtained in all women. Presence of eight or more multiple follicles in both or one ovary without presence of mature follicle was the cutoff number for positive ultrasound. Thyroid stimulating hormone levels were performed in all patients, and patients with abnormal levels were excluded from the study. Metformin was adjusted to 500 mg thrice daily. Six months later patients were again evaluated for response to metformin therapy and those who failed to conceive were given clomiphene citrate along with metformin. Fertility was re-evaluated at the end of one year. Results: At the start of the study, 81% women had menstrual irregularity and 84% had infertility. Hirsutism was seen in 72% while history of weight gain was present in 62% of patients. Ultrasound evidence of polycystic ovaries was seen in 93% of women. After 6 months of metformin therapy, 80% patients had achieved correction in their menstrual irregularity. After 6 months on metformin alone, 51% patients conceived while an additional 20% conceived on both metformin and clomiphene citrate during next 6 months. Overall fertility rate was 71% at the end of one year. There was statistically significant change in pre-treatment and posttreatment BMI. Conclusion: Combination of three or more of the clinical features (irregular cycles, history of weight gain, infertility and hirsutism) provide an appropriate basis for the diagnosis of PCOS. Metformin alone was an effective treatment for PCOS in this series.     

Preoperative Weight Loss as a Predictor of Long-term Success Following Roux-en-Y Gastric Bypass

BACKGROUND: All patients undergoing gastric bypass surgery at this institution are recommended to achieve a goal of 10% total body weight (TBW) loss prior to surgery. The objective of this study was to determine whether preoperative TBW correlated with 3- and 4-year weight loss outcome. METHODS: This study was conducted prospectively at a large teaching hospital. All adult patients with 3- and 4-year follow-up data since the start of the study in 1998 to September 2007 were included. All data are expressed as mean +/- SD. Pairwise correlation and ordinary least squares regression analysis was used to determine the strength of association between preoperative TBW loss and weight loss at 3 and 4 years. RESULTS: One hundred fifty patients (120 females), age 45.3 +/- 8.9 years, were included. Their body mass indexes (BMIs), preoperatively and after 3 years, were 52.2 +/- 9.8 and 35.4 +/- 8.2 kg/m(2), respectively. There was a significant correlation between preoperative and 3-year TBW lost (9.5 +/- 6.8% vs 31.9 +/- 11.7%, r = 0.302, p = 0.0002) and between excess body weight (EBW) lost preoperatively and after 3 years (16.1 +/- 11.3% vs 55.1 +/- 20.2%, r = 0.225, p = 0.006). Ninety five patients had follow-up data available at 4 years. Their mean preoperative BMI was 52.6 +/- 9.7 kg/m(2) and decreased to 37.5 +/- 9.0 kg/m(2). The TBW loss prior to and after surgery (10.0 +/- 6.5% vs 29.4 +/- 11.5%) was significantly correlated (r = 0.247, p = 0.015). The EBW loss preoperatively and after 4 years correlated positively (17.1 +/- 11.1% vs 50.8 +/- 19.8%, r = 0.205, p = 0.046). CONCLUSION: There is a significant correlation between weight loss attained preoperatively and sustained weight loss at 3 and 4 years.     

Initial outcomes of laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents

BACKGROUND: Adolescent obesity is an epidemic in the United States, leading to significant morbidity. Because the impact of laparoscopic bariatric surgery in this population is not as well delineated as in adults, we examined the short-term outcome of adolescents undergoing laparoscopic Roux-en-Y gastric bypass at our institution. METHODS: The medical records of patients < or =18 years of age who had undergone laparoscopic Roux-en-Y gastric bypass for morbid obesity from 1999 to June 2005 were reviewed. The outcome variables examined included preoperative body mass index, percent of excess weight lost for those with at least 3 months of follow-up, length of hospital stay, postoperative morbidity and mortality, changes in comorbid conditions, and effects of surgical weight loss on quality of life. Data are presented as the mean +/- standard error of the mean. RESULTS: Eleven patients (seven girls and four boys) had undergone laparoscopic Roux-en-Y gastric bypass. The mean follow-up was 11.5 +/- 2.8 months (range 3-32). The average patient age was 16.5 +/- 0.2 years, and the average body mass index was 50.5 +/- 2.0 kg/m(2). The average number of comorbidities was 5.3, 70% of which improved or resolved postoperatively. No mortalities resulted. Of the 11 patients, 1 had early postoperative bleeding and 2 developed a marginal ulcer. The quality-of-life surveys obtained from 9 patients reflected an overall improvement in self-esteem, social functioning, and productivity in school or the workplace. CONCLUSIONS: The initial data suggest that laparoscopic gastric bypass is an effective weight loss treatment for morbidly obese adolescents.     

Bariatric surgery improves cardiac function in morbidly obese patients with severe cardiomyopathy.

BACKGROUND: Longstanding morbid obesity can be associated with severe cardiomyopathy. However, the safety and efficacy of bariatric surgery in patients with severe cardiomyopathy has not been studied, and the effect of surgical weight loss on postoperative cardiac function is also unknown. In addition, morbidly obese patients have significantly increased mortality associated with cardiac transplantation, often precluding them from becoming recipients. METHODS: A retrospective study of patients with a left ventricular ejection fraction < or =35% who underwent bariatric surgery (1998-2005) was performed. Short-term morbidity/mortality, length of stay, excess weight loss, pre- and postoperative left ventricular ejection fraction, and New York Heart Association (NYHA) functional class were assessed. RESULTS: A total of 14 patients (10 men and 4 women) with a mean preoperative body mass index of 50.8 +/- 2.04 kg/m(2) underwent bariatric surgery (10 underwent laparoscopic Roux-en-Y gastric bypass, 1 open Roux-en-Y gastric bypass, 2 sleeve gastrectomy, and 1 laparoscopic gastric banding). The complications were pulmonary edema in 1, hypotension in 1, and transient renal insufficiency in 2. The median length of stay was 3.0 days (range 2-9). The mean excess weight loss at 6 months was 50.4%, with a decrease in the mean body mass index from 50.8 +/- 2.04 kg/m(2) to 36.8 +/- 1.72 kg/m(2). The mean left ventricular ejection fraction at 6 months had significantly improved from 23% +/- 2% to 32% +/- 4% (P = .04), correlating with improved functional capacity, as measured by the NYHA classification. Preoperatively, 2 patients (14%) had an NYHA classification of IV, 6 (43%) a classification of III, and 6 (43%) a classification of II. At 6 months postoperatively, no patient had an NYHA classification of IV, 2 (14%) had a classification of III, and 12 (86%) an NYHA classification of II. Two patients had undergone cardiac transplant evaluations preoperatively and underwent successful transplantation after weight loss. CONCLUSION: The results of our study have shown that bariatric surgery for patients with cardiomyopathy is feasible and effective. Surgically induced weight loss results in both subjective and objective improvement in cardiac function. In addition, surgical weight loss can provide a bridge to transplantation in patients who were prohibited secondary to their morbid obesity.     

Weight loss and metabolic outcomes in women with or without polycystic ovarian syndrome after Roux-en-Y gastric bypass: A case-matched study

Background and objectivesWeight loss is the mainstay of management for women with polycystic ovarian syndrome (PCOS). However, lifestyle and dietary modifications, and gastric banding have generally poor long-term efficacy. We aimed to investigate whether gastric bypass is equally efficacious in women with or without PCOS.MethodsWe performed a matched case–control study of primary Roux-en-Y gastric bypass surgery in women with PCOS (cases, n = 30) compared to women without PCOS (controls, n = 60) matched for baseline age, body mass index (BMI) and presence or absence of type 2 diabetes (T2D). Data shown represent mean values.ResultsAt 24 months after surgery the 90 participants (age 36.1 years) experienced significant reductions in BMI (53.4 vs. 34.9 kg/m², p < 0.0001), glycated haemoglobin (HbA1c) in 21 women with T2D (68.2 vs. 38.7 mmol/mol, p < 0.0001) and blood pressure (BP) in 29 women with hypertension (144/91 vs. 129/83 mmHg, p < 0.01), while obstructive sleep apnoea (OSA) resolved in 88.0% of the 25 affected patients. Women with PCOS compared to women without PCOS achieved equivalent reductions in percentage total weight loss (32.6% vs. 32.6% at 12 months and 34.8% vs. 36.1% at 24 months) and HbA1c (T2D subgroup; 38.3 vs. 41.6 mmol/mol at 12 months and 37.0 vs. 39.6 mmol/mol at 24 months) and comparable improvement in BP (hypertension subgroup) and resolution of OSA (87.5% vs. 88.2% at 24 months).ConclusionIn women with PCOS with morbid obesity, gastric bypass resulted in significant weight loss and metabolic outcomes similar to women without PCOS.     

Durability of antegrade synthetic aortomesenteric bypass for chronic mesenteric ischemia

OBJECTIVE: The optimal treatment (endovascular/open repair, conduit, configuration) for chronic mesenteric ischemia (CMI) remains unresolved. This study was designed to review the outcome of patients with CMI treated with antegrade synthetic aortomesenteric bypass. METHODS: The study was designed as a retrospective review in an academic tertiary care medical center. Patients with CMI who underwent antegrade synthetic aortomesenteric bypass were identified from a computerized vascular registry (from January 1987 to January 2001) with antegrade synthetic aortomesenteric bypass as intervention. Outcome measures were functional outcome (symptom relief, weight gain) and both graft patency (duplex ultrasound/angiography) and survival rates as determined with life-table analysis. RESULTS: Forty-seven patients (female, 70%; age, 62 +/- 12 years) underwent aortomesenteric bypass (aortoceliac/aortosuperior mesenteric, n = 45; aortosuperior mesenteric, n = 2) for CMI (abdominal pain, 98%; weight loss, 83%). In-hospital mortality rate was 11% (four multiple organ dysfunction, one bowel infarction), mean length of stay was 32 +/- 30 days, three patients (6%) were discharged to a nursing home, and one (2%) was discharged home on parenteral nutrition (duration 4 months). At a mean follow-up period of 31 +/- 27 months, all patients had relief of abdominal pain and 86% had gained weight (at > or =1 year follow-up: mean ideal body weight 103 +/- 22%; versus before surgery: 87 +/- 17%; P <.001). Fourteen patients (34%) had diarrhea at discharge that persisted more than 6 months in 10. One patient had acute mesenteric ischemia develop from a failed graft (at 20 months), two patients had recurrent CMI develop from failing grafts (at 46 months and 49 months), and one asymptomatic patient was found to have a failing graft with duplex ultrasound scan (at 17 months); all grafts were revised. Primary, primary assisted, and secondary 5-year graft patency rates with life-table analysis were 69% (standard error [SE], 17%), 94% (SE, 7%), and 100%, respectively, and the 5-year survival rate was 74% (SE, 12%). CONCLUSION: Antegrade synthetic aortomesenteric bypass for CMI is associated with good functional outcome and long-term graft patency.     

Prospective randomized trial of banded versus nonbanded gastric bypass for the super obese: early results

BACKGROUND: Banded gastric bypass has been reported to result in superior weight loss compared with standard nonbanded gastric bypass. However, an adequate comparison of these procedures has not yet been reported. METHODS: A total of 90 patients were enrolled in this prospective randomized double-blind trial comparing banded and nonbanded open gastric bypass for the treatment of super obesity. The banding technique involved placement of a 1.5 x 5.5-cm polypropylene band around the proximal gastric pouch of a standard gastric bypass procedure using the technique of Capella. Chi-square testing and analysis of variance were performed to find any differences in patient characteristics (gender, age, and initial body mass index), percentage of excess weight lost at 6, 12, 24, and 36 months postoperatively, improvement or resolution of co-morbidities, and complications in the banded versus nonbanded gastric bypass groups. RESULTS: As expected, no differences were present in the patient characteristics or incidence of co-morbidities between the banded (n = 46) and nonbanded (n = 44) groups. The body mass index, percentage of women, and mean age was 59.5 and 56.5 kg/m2, 64% and 73.8% (P = .09), and 40.6 +/- 7.4 and 42.6 +/- 7.2 years for the banded and nonbanded groups, respectively; all differences were nonsignificant. No significant differences were found in the resolution of co-morbidities. No significant difference was present in the percentage of excess weight loss at 6, 12, and 24 months (43.1% versus 24.7%, 64.0% versus 57.4%, and 64.2% versus 57.2%, respectively) postoperatively; however, the banded patients had achieved a significantly greater percentage of excess weight loss at 36 months (73.4% versus 57.7%; P <.05). The incidence of intolerance to meat and bread was greater in the banded patients. The overall number of complications was 12 (26%) in the banded and 13 (29.5%) in the nonbanded group, a nonsignficant difference. No band erosions had occurred at the last follow-up visit, and no patients in either group died. CONCLUSION: These results suggest that although the initial weight loss was not significantly different between the 2 groups, the banded patients continued to lose weight for < or = 3 years. The polypropylene band appeared to be well tolerated. We plan longer follow-up to confirm the possibility of additional weight loss and the prevention of weight regain in the banded group, as well as to document any long-term band complications.     

Effects of obesity surgery on the metabolic syndrome

HYPOTHESIS: Individuals with the metabolic syndrome (MS), a clustering of risk factors (high levels of triglycerides and serum glucose, low level of high-density-lipoprotein cholesterol, high blood pressure, abdominal obesity) defined by the Third Report of the National Cholesterol Education Program Expert Panel of Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (ATPIII), are at high risk of developing coronary heart disease and type 2 diabetes mellitus and may benefit from surgically induced weight loss. DESIGN: Prospectively controlled clinical study. SETTING: A tertiary referral center. PATIENTS: From December 1, 1999, to March 31, 2002, 645 consecutive morbidly obese patients were enrolled in a surgically supervised weight loss program, and the efficacy of weight loss 1 year after surgery was examined. INTERVENTION: Laparoscopic weight reduction surgery. MAIN OUTCOME MEASURES: Prevalence of the MS as defined by the ATPIII (>3 of the following): waist circumference greater than 102 cm in men and 88 cm in women; serum triglyceride level of at least 150 mg/dL (1.70 mmol/L); high-density lipoprotein cholesterol level less than 40 mg/dL (1.04 mmol/L) in men and 50 mg/dL (1.30 mmol/L) in women; blood pressure of at least 130/85 mm Hg; and serum glucose level of at least 110 mg/dL (6.11 mmol/L). RESULTS: Of 645 individuals, 337 (52.2%) met the ATPIII definition of the MS. Individuals with the MS had significant differences in age (31.5 years vs 28.1 years), sex (127 [37.7%] of 337 men vs 81 [26.3%] of 308 women), and many metabolic abnormalities compared with patients without the MS. Laparoscopic vertical banded gastroplasty was performed in 528 patients (81.9%) and laparoscopic gastric bypass in 117 (18.1%). A significant decrease in weight was found in both groups, but individuals who underwent laparoscopic gastric bypass lost significantly more weight (mean +/- SD, 38.4 +/- 14.4 kg vs 35.1 +/- 16.8 kg) and achieved a lower body mass index (29.3 +/- 4.8 vs 32.0 +/- 5.4) than individuals who underwent laparoscopic vertical banded gastroplasty. Substantial mean weight reduction (31.9%) of patients with the MS resulted in a substantial reduction of systolic (11.0 mm Hg) and diastolic (11.4 mm Hg) blood pressure and levels of glucose (46.1 mg/dL [2.56 mmol/L]), triglycerides (196.6 mg/dL [2.22 mmol/L]), and total cholesterol (33.7 mg/dL [0.88 mmol/L]) 1 year after surgery. These improvements resulted in a 95.6% resolution of the MS 1 year after surgery. There was no difference between operations (laparoscopic vertical banded gastroplasty or laparoscopic gastric bypass) in the resolution rate of the MS 1 year after surgery (95.0% vs 98.4%, respectively). CONCLUSION: The MS is prevalent in 52.2% of morbidly obese individuals enrolling in an obesity surgery program. Significant weight reduction 1 year after surgery markedly improved all aspects of the MS and resulted in a cure rate of 95.6%. Obesity surgery performed by laparoscopic surgery is recommended for obese patients with the MS.     

Association between support group attendance and weight loss after Roux-en-Y gastric bypass

BACKGROUND: Attending support group meetings has been linked to increased weight loss after gastric bypass surgery. However, the degree to which support group attendance influences weight loss is still unclear. This study quantitatively described the association between support group attendance and weight loss after Roux-en-Y gastric bypass. METHODS: The weight loss data and support group attendance of 78 consecutive Roux-en-Y gastric bypass patients were studied retrospectively. The patients were analyzed in 2 groups: those who attended >5 monthly support group meetings (group A) compared with those who went to < or =5 support group meetings (group B). The data from the first 12 months after surgery were analyzed. RESULTS: Group A achieved a mean percentage of excess weight loss of 10.5% at 2 weeks after surgery, 21.4% at 6 weeks, 30.9% at 3 months, 45.4% at 6 months, 53.6% at 9 months, and 55.5% at 12 months. Group B achieved a mean percentage of excess weight loss of 11.3% at 2 weeks, 21.8% at 6 weeks, 31.8% at 3 months, 41.3% at 6 months, 45.2% at 9 months, and 47.1% at 12 months. The differences between the 2 groups were significant at P <0.05 at 9 and 12 months. The weight loss was nonlinear and slowed as patients approached 1 year after surgery. CONCLUSION: Support groups are important for maintaining weight loss throughout the first year after surgery, especially after 6 months when the rate of weight loss from surgery begins to naturally decline. The amount of postoperative weight loss was greater than, or comparable to, the published data. Implementing regular support groups within the postoperative follow-up care may provide patients with the best chances of achieving maximal weight loss.     

The effect of a low-carbohydrate, high-protein diet on post laparoscopic gastric bypass weight loss: a prospective randomized trial

BACKGROUND: Laparoscopic gastric bypass has become the standard surgical treatment for severe obesity in the United States. Less clear is what diet should be followed by these patients after surgery to maximize their weight loss. METHODS: Patients undergoing laparoscopic gastric bypass procedures for morbid obesity were randomly assigned to either a low-fat control diet based on American Heart Association recommendations or a low-carbohydrate, high-protein diet based on the South Beach Diet. One-on-one diet counseling with a bariatric nutritionist was provided preoperatively, postoperatively while in the hospital, and at postoperative clinic visits during the 12-month follow-up period. Investigators were blinded to diet assignment. Body composition including Body Mass Index (BMI) was recorded preoperatively and during postoperative visits at 3, 6, and 12 months. RESULTS: Thirty-two patients were included in the analysis with 13 control and 19 low-carbohydrate, high-protein subjects. No demographic or clinical preoperative variables, including preoperative BMI, showed statistical differences between the two groups. Both groups demonstrated significant yet similar weight loss both by reduction in BMI (at 12 months, low fat diet, -14.0 +/- 5.5% versus low carbohydrate, -17.0 +/- 4.5%; P = 0.15) and excess body weight lost (at 12 months, low-fat diet, -60.3 +/- 15.3% versus low carbohydrate, -59.6 +/- 13.0%; P = 0.96). CONCLUSIONS: Based on this limited prospective study, no weight loss advantage is observed in substituting a low-carbohydrate, high-protein diet in place of a standard low-fat diet in patients who have undergone laparoscopic gastric bypass surgery.     

Preliminary results of subintimal angioplasty for limb salvage in lower extremities with severe chronic ischemia and limb-threatening ischemia

OBJECTIVE: This study examined the hypothesis that superficial femoral artery (SFA) subintimal angioplasty (SI-PTA) can maintain limb salvage with minimal complications in patients with symptomatic occlusive arterial disease. METHODS: From March 1, 2004, until April 28, 2006, 78 patients with rest pain (62.2%), gangrene (25.6%), or severe progressive claudication (12.2%) were treated consecutively with 82 SFA SI-PTAs (4 bilateral). The mean age was 59 +/- 1.2 years, and 21 (27%) of the patients were female. All patients were treated in the operating room under local anesthesia by using fluoroscopic guidance, and the percentage SFA that was occluded was measured during the diagnostic portion of the procedure. Selective stent placement was performed after successful recanalization of the occluded arterial segments. Patients were treated with chronic aspirin and clopidogrel bisulfate for 3 months and followed up at 30 days and then every 3 months with physical examination and arterial duplex scan. RESULTS: Of the 82 SFA SI-PTA attempts, 76 (92%) were initially successful, with an increase in the ankle-brachial index from 0.46 +/- 0.02 to 0.88 +/- 0.01 (P < .001). Five of the six patients with a failed SFA SI-PTA were female, two of the six had had previous bypass attempts, and one of the six had had a previous SFA SI-PTA attempt by another physician. Forty-nine (64%) of the 76 initially successful SFA SI-PTAs required placement of a stent, and 43 (56.5%) of the successful 76 SFA SI-PTAs required additional PTA of 1 or more arterial segments. The group treated with a successful SFA SI-PTA had 42.5% +/- 3.5% SFA occlusion, compared with 82% +/- 10% (P < .05) in the group with a failed attempt at SFA SI-PTA. Two of the six patients with initial SI-PTA failure underwent leg amputation within 30 days, three were treated with successful leg bypass surgery, and one was lost to follow-up. Of the 76 successful SFA SI-PTAs, 5 (6.5%) failed within 90 days, and the patients were treated successfully with leg bypass surgery. Of the 71 limbs with patent SI-PTAs at 90 days, 68 have remained patent with a mean follow-up 10.4 +/- 0.7 months (range, 2-24 months). Three of the 71 SFA SI-PTAs failed between 4 and 7 months (mean, 5 +/- 0.7 months): 1 patient was treated with successful bypass surgery, 1 patient is currently considering further intervention, and 1 patient was treated with amputation. Ten (14%) of the 71 successful SFA SI-PTAs required limited PTA for asymptomatic restenosis, as identified by the arterial duplex scan (7.4 +/- 1.4 months; range, 2-16 months). There were no perioperative deaths, and three patients have died during follow-up with patent SFA SI-PTAs (9.3 +/- 1.4 months). CONCLUSIONS: These data suggest that SFA SI-PTA can be successfully used for limb salvage with minimal morbidity and mortality in a group of patients with severe lower extremity occlusive vascular disease.     

Laparoscopic adjustable gastric banding versus Roux-en-Y gastric bypass: 5-year results of a prospective randomized trial.

BACKGROUND: To perform a prospective, randomized comparison of laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB). METHODS: LAGB, using the pars flaccida technique, and standard LRYGB were performed. From January 2000 to November 2000, 51 patients (mean age 34.0 +/- 8.9 years, range 20-49) were randomly allocated to undergo either LAGB (n = 27, 5 men and 22 women, mean age 33.3 years, mean weight 120 kg, mean body mass index [BMI] 43.4 kg/m(2); percentage of excess weight loss 83.8%) or LRYGB (n = 24, 4 men and 20 women, mean age 34.7, mean weight 120 kg, mean BMI 43.8 kg/m(2), percentage of excess weight loss 83.3). Data on the operative time, complications, reoperations with hospital stay, weight, BMI, percentage of excess weight loss, and co-morbidities were collected yearly. Failure was considered a BMI of >35 at 5 years postoperatively. The data were analyzed using Student's t test and Fisher's exact test, with P <.05 considered significant. RESULTS: The mean operative time was 60 +/- 20 minutes for the LAGB group and 220 +/- 100 minutes for the LRYGB group (P <.001). One patient in the LAGB group was lost to follow-up. No patient died. Conversion to laparotomy was performed in 1 (4.2%) of 24 LRYGB patients because of a posterior leak of the gastrojejunal anastomosis. Reoperations were required in 4 (15.2%) of 26 LAGB patients, 2 because of gastric pouch dilation and 2 because of unsatisfactory weight loss. One of these patients required conversion to biliopancreatic diversion; the remaining 3 patients were on the waiting list for LRYGB. Reoperations were required in 3 (12.5%) of the 24 LRYGB patients, and each was because of a potentially lethal complication. No LAGB patient required reoperation because of an early complication. Of the 27 LAGB patients, 3 had hypertension and 1 had sleep apnea. Of the 24 LRYGB patients, 2 had hyperlipemia, 1 had hypertension, and 1 had type 2 diabetes. Five years after surgery, the diabetes, sleep apnea, and hyperlipemia had resolved. At the 5-year (range 60-66 months) follow-up visit, the LRYGB patients had significantly lower weight and BMI and a greater percentage of excess weight loss than did the LAGB patients. Weight loss failure (BMI >35 kg/m(2) at 5 yr) was observed in 9 (34.6%) of 26 LAGB patients and in 1 (4.2%) of 24 LRYGB patients (P <.001). Of the 26 patients in the LAGB group and 24 in the LRYGB group, 3 (11.5%) and 15 (62.5%) had a BMI of <30 kg/m(2), respectively (P <.001). CONCLUSION: The results of our study have shown that LRYGB results in better weight loss and a reduced number of failures compared with LAGB, despite the significantly longer operative time and life-threatening complications.     

Outcomes of bariatric surgery in patients > or =65 years.

BACKGROUND: Although the Medicare Coverage Advisory Committee found that significant evidence supports the safety and effectiveness of bariatric surgery, few data are available on the outcomes of bariatric procedures in patients > or =65 years. The aim of this study was to report on contemporary outcomes of Roux-en-Y gastric bypass (RYGB) in patients > or =65 years. METHODS: We reviewed prospectively collected data from all patients > or =65 years who underwent RYGB at two Florida university-based programs from 1999 to 2005. Similarly, the Florida Discharge Database was queried for patients> or =65 years who had undergone RYGB from 1999 to 2005. The data are presented as the mean +/- SEM. RESULTS: A total of 25 patients > or =65 years had undergone RYGB at our institutions (age 68 +/- 1 years, body mass index 50 +/- 3 kg/m(2)). The overall complication rate was 20%, and the length of stay was 7 +/- 3 days. One patient (4%) died 5 weeks postoperatively of septic complications. For the 13 patients with a median follow-up of 21 months (range 9-61), the percentage of excess body weight loss was 51% +/- 7%; medication use for co-morbidities decreased from 9 +/- 1 to 4 +/- 1 medications/day (P <.01). The Florida Discharge Database reported 231 patients > or =65 years who had undergone RYGB. In that group of patients, the mean age was 67 +/- 0.2 years, the length of stay was 6 +/- 1 days, in-hospital mortality rate was 1.3%, and the overall complication rate was 15%. CONCLUSION: In a small cohort of patients > or =65 years, RYGB resulted in significant weight loss and resolution of obesity-related co-morbidities. The findings from the mandatory reported Florida Discharge Database strongly confirmed the safety of RYGB in patients > or =65 years.     

Metabolic,Behavioral, and Reproductive Effects of Vertical Sleeve Gastrectomy in an Obese Rat Model of Polycystic Ovary Syndrome

Background

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting women of reproductive age. Its clinical expression is diverse, including metabolic, behavioral, and reproductive effects, with many affected by obesity and decreased quality of life. Women with PCOS who have undergone surgically induced weight loss have reported tremendous benefit, not only with weight loss, but also improvement of hyperandrogenism and menstrual cyclicity.

Methods

In a rat model of PCOS achieved via chronic administration of dihydrotestosterone (DHT) exposure, we investigated the ability of bariatric surgery, specifically vertical sleeve gastrectomy (VSG), to ameliorate the metabolic, behavioral, and reproductive abnormalities invoked by this PCOS model.

Results

We found that DHT treatment combined with exposure to a high-fat diet resulted in increased body weight and body fat, impaired fasting glucose, hirsutism, anxiety, and irregular cycles. VSG resulted in reduced food intake, body weight, and adiposity with improved fasting glucose and triglycerides. VSG induced lower basal corticosterone levels and attenuated stress responsivity. Once the DHT levels decreased to normal, regular estrous cyclicity was also restored.

Conclusions

VSG, therefore, improved PCOS manifestations in a comprehensive manner and may represent a potential therapeutic approach for specific aspects of PCOS.     

Frequency distribution of weight loss percentage after gastric bypass and adjustable gastric banding

BACKGROUND: The results of surgical procedures for weight loss are often described in terms of the percentage of excess weight lost. Expressing outcomes using the mean and standard deviation might not adequately describe the clinical experience. This could in part be because the use of the mean +/- standard deviation assumes a normal or random distribution of outcomes. It has been our perception that the weight loss results after gastric bypass are relatively normally and tightly distributed around the mean, making it relatively predictable. However, we have found that the results after adjustable gastric banding are more highly variable. In fact, there appears to be 2 groups of patients after this restrictive operation. One group, that is able to work well and does not struggle much against the restriction, accepts the limits that it imposes, and another group, that does not easily learn to deal with the restriction and hence mal-adapts. METHODS: To evaluate the validity of our clinical perception, we undertook an analysis of the distribution of weight loss by the percentiles of excess weight lost. All patients with follow-up of > or =1 years after gastric bypass or adjustable banding were evaluated for this analysis. The demographics and percentage of excess weight loss were evaluated. The distribution of the percentage of excess weight loss in 10% increments was evaluated. RESULTS: Both groups were similar with respect to the mean patient age. However, the patients in the gastric bypass group had had a significantly greater mean preoperative body mass index and were more likely to be women. As expected, the weight loss of the gastric bypass patients fell in a normal single-peak distribution for < or =5 years of follow-up. The data from the adjustable gastric band patients at 1 year demonstrated a normal single-peak distribution, with a longer rightward tail. At 2 and 3 years postoperatively, the data from the band patients had a 2-peaked curve. CONCLUSION: The initial weight loss results after gastric banding are less predictable than those after gastric bypass. A similar analysis of long-term outcomes might be enlightening and assist in making clinical decisions.     

Mid-term results of combined transmyocardial laser revascularization and coronary artery bypass

BACKGROUND: Transmyocardial laser revascularization is increasingly used to treat intractable angina in the absence of graftable vessels; however, its role in combination with coronary artery bypass grafting remains undefined. The aim of this pilot study was to investigate the outcome of the combination therapy at mid-term follow-up. METHODS: Patients (n = 20) who had elective coronary artery bypass with one or more nongraftable coronary arteries were prospectively randomized to have either coronary artery bypass grafting alone or combination coronary artery bypass grafting plus transmyocardial laser revascularization with a holmium:YAG (yttrium-aluminum-garnet) laser to nongraftable areas. All patients had an exercise tolerance test preoperatively and at 6, 18, and 36 months follow-up. Stress echocardiography was performed on 17 patients at 18 months postoperatively, and regional wall motion score index was calculated in lased and nonlased nonrevascularizable myocardium of the left ventricle at rest and with dobutamine stress. RESULTS: Both groups of patients were similar in preoperative demographics and operative data. There was no perioperative death. There was no difference between the two groups in angina scoring at 6, 18, and 36 months follow-up. Exercise tolerance improved by a mean of 46.8 +/- 20.0 seconds in the coronary artery bypass grafting group versus 199.2 +/- 66.5 seconds per patient in the coronary artery bypass grafting plus transmyocardial laser revascularization group (p = 1.8 x10(-6)) at 6 months; this benefit was maintained at 18 months (157 +/- 46.3 versus 61 +/- 39.2 seconds; p = 4 x10(-4)) but was lost at 36 months (57.2. +/- 42.1 versus 68.1 +/- 46.7 seconds; p = 0.70). The mean values for wall motion score index in the lased and nonlased regions at each stage of dobutamine stress at 18 months after surgery were not statistically significant. CONCLUSIONS: The combination of coronary artery bypass and transmyocardial laser revascularization improved exercise tolerance in patients in whom complete revascularization could not be achieved by bypass grafting alone in the short term, but this benefit was lost by 36 months postoperatively. The transient improvement in exercise tolerance cannot be explained by changes in contractility in the lased areas.