Patients Who are Delayed from Undergoing Bariatric Surgery Do Not have Improved Weight Loss

Background Many patients have a prolonged wait time between initial surgeon visit and actual surgery day. Whereas there are various reasons for this, few have examined if patient wait time for bariatric surgery has any affect on weight loss. This investigation studies the hypothesis that patients who wait longer for bariatric surgery do not have improved weight loss over those with shorter wait times. Methods All patients in a private academic practice who underwent laparoscopic gastric bypass over a 6-month period were included in this study. The time from initial office visit to actual surgery date was calculated to be wait time (WT). Reasons for short or long WT were not investigated. The relationship between WT and percentage excess body weight loss (%EBWL) was examined. In addition, patients whose WT was greater than 6 months (WT > 6) were compared to those less than 6 months (WT < 6). Pearson’s correlation coefficients and two-tailed Mann–Whitney tests were used as appropriate. Results There were 104 patients with 99 patients who had a >1 year follow-up. WT did not correlate with %EBWL (r = 0.09, p = 0.37). There was no difference in %EBWL in the WT > 6 group versus the WT < 6 group (73 vs. 70%; p = NS). Patients who had <50% EBWL waited an average of 281 versus 254 days for those who have >50% EBWL (p = NS). Conclusions Patients who wait longer before having bariatric surgery do not show improved weight loss. Weight loss success was not related to wait time. These results suggest that prolonged mandatory weight times are not an effective method for improving bariatric surgery weight loss outcomes. Mandatory delays for bariatric surgery should not be required, as they have no scientific merit. Presented at the World Congress of the International Federation for the Surgery of Obesity, Sydney, Australia, September 1, 2006.     

Obesity,Bariatric Surgery,and Vitamin D

The high prevalence of obesity is a worldwide problem associated with multiple comorbidities, including cardiovascular diseases. Vitamin D deficiency with secondary hyperparathyroidism is common in obese individuals and can be aggravated after bariatric surgery. Moreover, there is no consensus on the optimal supplementation dose of vitamin D in postbariatric surgical patients. We present new data on the variability of 25(OH)D response to supplementation in postmenopausal obese women. It is important to recognize and treat vitamin D deficiency before bariatric surgery to avoid postoperative complications, such as metabolic bone disease with associated high fracture risk. The objective of this article is to discuss the bone metabolism consequences of vitamin D deficiency after bariatric surgery.     

Results of Bariatric Surgery for Morbid Obesity in Patients Older than 50 Years

Background: Surgery is increasingly used for weight loss in morbidly obese patients. The authors evaluated the safety and efficacy of bariatric surgery in patients older than 50 years. Methods: Prospective data on 62 consecutive patients (Male = 13, Female = 49) undergoing bariatric procedures between 1985-1994 were reviewed. Mean followup was 30 ± 2 months (3-48 months). All data are mean ± sem. Results: Age was 57 ± 1 year (range 50-71 years). Patients had a mean preoperative weight of 125 ± 4 kg (275 ± 9 lb) and 119 ± 6% excess body weight. A total of 68 procedures were performed: vertical banded gastroplasty (VBG = 23), Roux-en-Y gastric bypass (RYGB = 43), and biliopancreatic diversion (BPD = 2). Six patients were converted to RYGB (5) and BPD (1) after failed VBG. Hospital mortality was nil. Complications were wound infection (5), pulmonary (4), gastric leak (2), abscess (1) and others (4). Mean weight loss at 3 years was 55 ± 7 and 33 ± 6% of percent excess body weight for RYGB and VBG, respectively. Postoperative use of medications for arthritis, diabetes mellitus and asthma was reduced by 23%, 62% and 100%, respectively. Satisfaction with the outcome of treatment and weight loss was reported by 81% of patients. Six patients that were converted from jejunoileal bypass (metabolic complications) to VBG gained weight. Conclusions: Bariatric surgery is safe and well tolerated in morbidly obese patients older than 50 years. Weight loss parallels that of younger populations and is greater in patients treated with RYGB in this subgroup. Age should not be a contraindication to bariatric surgery provided the patient has obesity-related medical morbidity. Control of obesity-related co-morbid conditions is improved by weight loss.     

Prevalence of Thrombophilias in Patients Presenting for Bariatric Surgery

Background  The rise in bariatric surgery has driven an increased number of complications from venous thromboembolism (VTE). Evidence supports obesity as an independent risk factor for VTE, but the specific derangements underlying the hypercoagulability of obesity are not well defined. To better characterize VTE risk for the purpose of tailoring prophylactic strategies, we developed a protocol for thrombophilia screening in patients presenting for bariatric surgery at our institution. Methods  Between April 2004 and April 2006, 180 bariatric surgery candidates underwent serologic screening for inherited thrombophilias (Factor V-Leiden mutation, low Protein C activity, low Protein S activity, Free Protein S deficiency) and acquired thrombophilias (D-Dimer elevation, Fibrinogen elevation, elevation of coagulation factors VIII, IX, and XI, elevation of Lupus anticoagulants and homocysteine level, and Antithrombin III deficiency). Prevalence rate of each thrombophilia in the subject group was compared to the actual prevalence rate of the general population. Results  Most plasma markers of both inherited and acquired thrombophilias were identified in higher than expected proportions, including D-Dimer elevation in 31%, Fibrinogen elevation in 40%, Factor VIII elevation in 50%, Factor IX elevation in 64%, Factor XI elevation in 50%, and Lupus anticoagulant in 13%. Conclusions  Obesity is a well-described demographic risk factor for VTE. In bariatric surgery candidates routinely screened for serologic markers, both inherited and acquired thrombophilias occurred more frequently than in the general population, and may therefore prove to be useful for individualized VTE risk assessment and prophylaxis.     

Meralgia Paresthetica Following Bariatric Surgery

Background: Two papers in the literature have described meralgia paresthetica following bariatric surgery. One author ascribed the cause of the condition to pressure from an abdominal retractor. We encountered 11 similar cases in our bariatric surgery practice, but do not use the retractor previously invoked as the cause of the problem. It seems likely that some other factor is involved. Methods: Retrospective chart review. Results: 11 patients were identified whose symptoms and clinical findings were consistent with meralgia paresthetica. There were 6 men and 5 women. Symptoms developed immediately following surgery in 8 cases, and resolved spontaneously within 3 months in 6 of these. Conclusions: Multiple causes have been described for meralgia paresthetica. It appears to be more common in obese patients. While extrinsic pressure from an abdominal retractor may play a role in some cases, other factors are clearly involved in the cases reported here.     

Anti-Xa Levels in Bariatric Surgery Patients Receiving Prophylactic Enoxaparin

Background Limited data exist regarding efficacy and dosing of low-molecular-weight heparins, including enoxaparin, for morbidly obese patients. Prophylactic doses of 30 to 60 mg every 12 h have been described in bariatric surgery patients with appropriate anti-Xa levels reported between 0.18 and 0.6 units/mL. Methods Fifty-two laparoscopic gastric bypass or banding patients were enrolled. Patients were divided into two groups by the dose of enoxaparin that was given: Group 1—enoxaparin 30 mg every 12 hours—and Group 2—enoxaparin 40 mg every 12 h. Anti-Xa levels were obtained 4 h after the first and third doses. Levels between 0.18–0.44 units/mL were considered appropriate. Results There were 19 patients (74% female, mean body mass index [BMI] 48.4 kg/m²) in Group 1 and 33 patients (82% female, mean BMI 48.5 kg/m²) in Group 2. In Group 1, anti-Xa levels were 0.06 and 0.08 units/mL after the first and third doses, respectively. In Group 2, anti-Xa levels were 0.14 and 0.15 units/mL after first and third doses, respectively (p = NS). There was a statistically significant difference in anti-Xa levels between Group 1 first dose and Group 2 first dose (p < 0.05) and between Group 1 third dose and Group 2 third dose (p < 0.05). Percentage of appropriate anti-Xa levels at first dose differed 0% vs. 30.8% (Group 1 vs. Group 2; p = 0.01) and at third dose 9.1% vs. 41.7% (Group 1 vs. Group 2; p = 0.155). Conclusion When prophylactic dose enoxaparin of 30 mg every 12 h was changed to 40 mg every 12 h in bariatric surgery patients, anti-Xa levels significantly increased with prophylactic dose enoxaparin in bariatric surgery patients. The percentage of appropriate levels also increased; however, more than half of the patients receiving 40 mg every 12 hours failed to reach therapeutic levels. No levels were supratherapeutic. Dosage of 40 mg every 12 h may not be sufficient for bariatric surgery patients. Presented at the Society of American Gastrointestinal Endoscopic Surgeons annual meeting; April 18–22, 2007; Las Vegas, NV.     

Metabolic Syndrome after Laparoscopic Bariatric Surgery

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

An Occasional Review of Bariatric Surgery on the Internet

This is a brief evaluation of web sites available on the Internet. Particular emphasis has been placed on those which provide information concerning the indications, benefits, risks and outcome of surgery for obesity. These web sites are suitable for use as informational sources for potential candidates for surgery for obesity.     

The SAGES Bariatric Surgery Outcome Initiative

Background The recent initiative for identifying centers of excellence in bariatric surgery calls for documentation of surgical outcomes. The SAGES Outcomes Initiative is a national database introduced in 1999 as a method for surgeons to accumulate and compare their data with summary national data. A bariatric-specific dataset was established later in 2001. The aim of this study was to compare the outcomes of bariatric surgery from the Society of American Gastrointestinal Endoscopic Surgeons’ (SAGES) bariatric database with data derived from a national administrative database of academic centers. Methods Between 2001 and 2004, 24 surgeons with 1,954 patients participated in the SAGES Bariatric Outcome Initiative, and 97 institutions with 42,847 patients participated in the University HealthSystem Consortium (UHC) database. Only 7 of the 24 surgeons participating in the SAGES Bariatric Outcome Initiative submitted more than 50 cases. The main outcome measures included demographics, comorbidities, type of bariatric procedure, operative time, length of hospital stay, short- and long-term complications, mortality, and weight loss. Results Both datasets were comparable for gender. Roux-en-Y gastric bypass had been performed for 88% of the patients in the SAGES database and 96% of the patients in the UHC database. Associated comorbidities were similar between the two groups except for a higher rate of hyperlipidemia for the patients in the SAGES database. The SAGES database contains more bariatric-specific information such as body mass index, operative time, blood loss, bariatric-specific complications, long-term complications, and weight loss data than the UHC database. According to the available data, no statistically significant differences exist between the two datasets in terms of perioperative complications and mortality. Conclusions The SAGES Bariatric Outcome Initiative provides valuable bariatric-specific data not currently available in an administrative database that may be useful for benchmarking purposes. However, this database is currently underutilized. Presented at the Annual 2005 Meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Hollywood, FL, USA, 14 April 2005     

Potential Applications of Global Protein Expression Analysis (Proteomics) in Morbid Obesity and Bariatric Surgery

Global protein expression analysis, known as proteomics, has emerged as a novel scientific technology currently successfully applied to several fields of medicine including cancer and transplantation. Thereby, a thorough exploration of the pathogenic mechanisms and a better understanding of the pathophysiology of diseases as well as identification of diagnostic biomarkers have been achieved. In this paper, we outline the basic principles and potential applications of this promising tool in bariatric surgery where proteomics might hold great potential for new insights into diagnostic and therapeutic decision making based on improved knowledge of metabolic regulations pre- and postsurgical interventions in morbidly obese patients.     

Selected Topics in Malpractice Reduction in Bariatric and Other Surgery

On the basis of an extensive legal experience, the sound strategies that prevent or reduce malpractice litigation in bariatric or other surgery are presented.     

Transthoracic Dobutamine Stress Echocardiography in Patients Undergoing Bariatric Surgery

BACKGROUND: The feasibility and value of transthoracic dobutamine stress echocardiography (DSE) in patients scheduled for bariatric surgery has not been investigated. METHODS: We evaluated 611 patients (86.6% female, 42 +/- 10 years, 136 +/- 18 kg, BMI 48.0 +/- 6.1 kg/m2) referred for DSE prior to surgery between February 2000 and July 2005. Mortality and major cardiovascular events (cardiac death, acute coronary syndrome, and urgent revascularization) were recorded 30-days postoperatively and at 6 months. RESULTS: Adequate baseline imaging quality was achieved in 590 patients (96.6%), with use of echocardiographic contrast agents in 426 patients (72.2%); the remaining 21 patients (3.4%) were referred for alternative preoperative testing. There were no serious adverse events during DSE, which was negative in 545 patients (92.4%). The test was inconclusive in 38 patients (6.4%), requiring alternative investigations, and positive in 7 patients (1.2%). Eventually, 595 patients proceeded to surgery: 539 with DSE-based risk stratification and 56 with risk stratification based on alternative testing. Laparoscopic procedures were employed in 77.0% of patients. There were 3 perioperative deaths, all attributed to sepsis (perioperative mortality 0.50%), but no major cardiovascular events at 30-days. One patient (evaluated prior to surgery with alternative testing) experienced an acute coronary syndrome during the following 6 months (event rate 0.17%). CONCLUSION: Transthoracic DSE is feasible and safe in morbidly obese patients undergoing bariatric surgery; implementation of echocardiographic contrast agents allows for adequate imaging quality in the majority of these patients. However, the very low risk of contemporary bariatric procedures questions the need for routine preoperative stress testing in asymptomatic patients.     

Bariatric Surgery and Bariatric Psychology: Evolution of the Dutch Approach

Background Success of bariatric surgery is largely dependent on patients’ abilities to change their lifestyle and underlying psychosocial and behavioral factors; these factors should be carefully scrutinized. However, no consensus or guidelines exist for these evaluations. Materials and Methods To get a better understanding of the practice of bariatric surgery and bariatric psychology in The Netherlands and its evolution, a survey of bariatric surgery programs was conducted. Results Between 2000 and 2005, performance of bariatric surgery in The Netherlands has increased from 564 to more than 2,000 annually, mostly adjustable gastric banding. Most hospitals have a multidisciplinary selection process, and in 89% of the cases, a mental health specialist was involved. Conclusion Bariatric surgery in The Netherlands has increased tremendously; however, it is mostly limited to restrictive procedures, and there is no consensus regarding the psychological evaluation of patients.