The Impact of Bariatric Surgery on Menstrual Patterns

Background: Obesity and anovulation are common medical problems in the United States. Anovulation in obese patients primarily manifests with irregular, sporadic or absent menstrual bleeding. Weight loss of at least 5% has been shown to reverse obesity-related anovulation. The aim of this study was to assess the impact of bariatric surgery on infertility in morbidly obese women and to identify factors associated with return of normal menses following bariatric surgery. Methods: A survey of patients was collected from the bariatric surgery data-base at the Hospital of the University of Pennsylvania. 410 women under the age of 40 were sent questionnaires. 195 patients completed the questionnaire, and 29 patients had incorrect addresses without a forwarding address, resulting in a 51.2% response rate. Patients who reported menstrual cycle lengths >35 days were considered abnormal. 92 of the 195 responders were considered anovulatory preoperatively, based on menstrual history. Results: There was no significant difference in postoperative BMI, BMI decrease or age at surgery between the survey responders and non-responders. There was a significant difference between these 2 groups in time since surgery (P=.01). Both groups had a decrease in BMI of >18 kg/m². The mean menstrual cycle length preoperatively among those categorized as ovulatory and anovulatory was 27.3 and 127.5 days, respectively. Of the 98 patients who were anovulatory preoperatively, 70 patients (71.4%) regained normal menstrual cycles after surgery. Those patients who regained ovulation had greater weight loss than those who remained anovulatory (61.4 kg vs 49.9 kg, P=0.02). Conclusions: Anovulation resulting in abnormal menses is a common problem in morbidly obese premenopausal women. The menstrual cycle disorders may completely resolve after bariatric surgery. Thus, infertility due to anovulation among morbidly obese women could potentially be viewed as an additional indication for bariatric surgery.     

Positive Psychological Impact of Bariatric Surgery

Background Psychological impact of bariatric surgery has been described mostly in terms of reduction of psychopathology. This exploratory study examines the impact of bariatric surgery in terms of positive psychological growth and development. Methods 57 patients who underwent LAGB were recruited to this study; 31 patients (54.4%) completed a questionnaire battery 1 year or more following surgery. Positive impact was assessed using the posttraumatic growth questionnaire. Mental and physical health were assessed using the SF-36. Family support was assessed using the perceived family support questionnaire and weight loss measure was assessed using measured weight differences prior to and 1 year after surgery. Results Positive impact was apparent in all dimensions including greater appreciation of life, increased sense of personal strength and improvement in relating to others. Positive impact appears to be independent of physical and mental health as well as of family social support. Conclusion Positive impact of bariatric surgery is a substantial outcome and should be examined further. Positive impact of bariatric surgery should be taken into account as a therapeutic tool in positive oriented psychological interventions following bariatric surgery.     

Impact of Obesity and Bariatric Surgery on Survival

Bariatric surgery is the only reliable treatment that offers sustained, long-term weight loss. This results in cure or improvement in almost all of the obesity-associated diseases and translates into reduction in the relative risk of death or increased longevity of the operated morbidly obese population. Since the treatment of obesity-associated conditions is very costly, bariatric surgery also results in significant reductions in healthcare costs with a return on investment of 3 years. It is not just weight loss, it is health gain.     

Night Eating Syndrome: Impact on Bariatric Surgery

Individuals with night eating syndrome (NES) display a time-delayed pattern of food intake, outside the natural circadian rhythm. High prevalence estimates have been reported among bariatric surgery candidates, and some evidence suggests that NES is positively associated with obesity, negatively associated with weight loss efficacy, and follows a chronic course. In order to evaluate current NES theory, and the association between NES and bariatric surgery, literature searches were conducted to identify relevant literature published in English up to 2005. Because of inconsistencies in NES characterization, and significant heterogeneity in study design and methods, a qualitative assessment of NES and its relation to bariatric surgery was then undertaken. Within the literature, variable NES definitions highlight the distinct lack of clarity as to which behavioral features constitute a clinically meaningful entity. Prevalence estimates appear high among persons seeking bariatric surgery; however, no consistent pre- or postoperative demographic, clinical, or psychological factors reliably differentiate NES from non-NES. Further examination of the clinical significance, correlates, and course of NES in general and surgical samples is important, given the link with obesity. The ways in which NES departs from "normal" eating behavior must be clarified. Behavioral and psychological traits of NES need elucidation, and the establishment of agreed diagnostic criteria is essential for research to move forward. Therapy options should focus on aspects of the syndrome that cause greatest impairment, distress, or health risk.     

The Future of Bariatric Surgery

Scientific evidence is pointing more and more strongly to the fact that serious, or morbid, obesity is not a moral issue. Serious obesity is a consequence of a genetically-related, powerful biophysiological drive to consume more calories than are burned. This concept must eventually become incorporated into lay and medical paradigms of obesity. It will result in an increased understanding and sympathy for the suffering of the seriously obese and, as a consequence, stronger support for definitive treatment of serious obesity such as bariatric surgery. Reoperative bariatric surgery principles, currently limited by individual exposure and experience, will develop and evolve. Laparoscopic bariatric surgery may, in time, be developed and prove itself to be of value. Bariatric surgeons should also find it useful to enhance their teams' skills for nutritional, behavioral and psychological management, as well as broaden their operative base into other, related surgical areas such as partial ileal bypass procedures for hyperlipidemia management. As fields mature, organizational maturation is a natural and necessary accompaniment. An International Federation for Bariatric Surgery, or similar entity, will be founded to constructively unite national bariatric surgery and related organizations together. The international bariatric surgery journal, Obesity Surgery, will become more and more accepted as the truly professional and essential vehicle of communication concerning bariatric surgery that it has been since its first issue. Medical management simulating the effects of surgery will be employed successfully; it may arise out of the current genetic work. It may ultimately, in the next 25 years or so, replace the surgical treatment of serious obesity.     

The Impact of Hospital and Surgeon Volume on Clinical Outcome Following Bariatric Surgery

The dramatic rise in the prevalence of obesity worldwide has led to the rapid growth of bariatric surgery. The aim of this pooled analysis is to evaluate the relationship between institutional and surgeon volume and outcomes following bariatric surgery. Medical, Embase, trial registries, conference proceedings and reference lists were searched for trials comparing clinical outcome following bariatric surgery at high and low volume hospitals and by high and low volume surgeons. Outcomes analysed were mortality, morbidity and length of hospital stay. Fifteen publications were included in this analysis. In total, 289,732 bariatric procedures were included in the institutional volume analysis, and 32,920 bariatric operations were included in the surgeon volume analysis. Mortality was reduced following surgery at high volume institutions (0.24 vs. 2.18 %; pooled odds ratio = 0.26; P = 0.004) and by high volume surgeons (0.41 vs. 2.77 %; pooled odds ratio = 0.21; P < 0.001). Similarly, morbidity was reduced in high volume institutions (7.84 vs. 8.85 %; pooled odds ratio = 0.52; P < 0.001) and with high volume surgeons (6.92 vs. 7.29 %; pooled odds ratio = 0.47; P < 0.001). There were insufficient data for conclusive statistical analysis of length of hospital stay. This pooled analysis does suggest a benefit in the centralisation of bariatric surgery to high volume institutions and surgeons with respect to mortality and morbidity. Future high-powered studies with adjustment for procedural and patient case mix are required to further define the volume-outcome relationship in bariatric surgery.     

The Impact of Bariatric Surgery on Obstructive Sleep Apnea: A Systematic Review

There is a strong relationship between obesity and the development of obstructive sleep apnea (OSA). Respectively, bariatric surgery is often touted as the most effective option for treating obesity and its comorbidities, including OSA. Nevertheless, there remains paucity of data in the literature of the comparison of all the specific types of bariatric surgery themselves. In an effort to answer this question, a systematic review was performed, to determine, of the available bariatric procedures [Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, or biliopancreatic diversion (BPD)], which procedures were the most efficacious in the treatment of OSA. A total of 69 studies with 13,900 patients were included. All the procedures achieved profound effects on OSA, as over 75 % of patients saw at least an improvement in their sleep apnea. BPD was the most successful procedure in improving or resolving OSA, with laparoscopic adjustable gastric banding being the least. In conclusion, bariatric surgery is a definitive treatment for obstructive sleep apnea, regardless of the specific type.     

Obesity and Diabetes: The Impact of Bariatric Surgery on Type-2 Diabetes

Weight gain and obesity are driving the global epidemic of type-2 diabetes through metabolic and inflammatory pathways that cause insulin resistance and impair pancreatic β-cell function, the two important factors that are directly responsible for the development of this disease in susceptible populations. Lifestyle methods and modest weight loss are powerful at preventing and managing type-2 diabetes, but sustaining substantial weight loss is problematic. Bariatric surgery provides exceptional sustained weight loss and remission of type-2 diabetes in 50–85% of subjects, especially if treated early before irreparable β-cell damage has occurred. In addition, there is substantial evidence that bariatric surgery provides additional comorbidity and quality-of-life improvements and reduces mortality in patients with type-2 diabetes. There is an association between the extent of weight loss and remission of type-2 diabetes. Diversionary bariatric procedures such as gastric bypass and biliopancreatic diversion induce a rapid non-weight-loss-associated improvement in glycemic control. Several mechanisms have been proposed for this exciting and novel effect that may provide key insights into the pathogenesis of type-2 diabetes. A range of novel surgical, endoluminal procedures/devices, and pharmacologic therapies are likely to evolve when we better understand how bariatric surgery enables long-term changes in energy balance and non-weight-related metabolic improvements. Bariatric surgery should be considered for adults with BMI ≥ 35 kg/m² and type-2 diabetes, especially if the diabetes is difficult to control with lifestyle and pharmacologic therapy. Although all bariatric procedures produce exceptional results in the management of type-2 diabetes, choice of procedure requires a careful risk–benefit analysis for the individual patient.     

Impact of Patient Follow-Up on Weight Loss after Bariatric Surgery

Background: Postoperative follow-up after bariatric surgery is important. Because of the need for adjustments, follow-up after gastric banding may have a greater impact on weight loss than after Roux-en-Y gastric bypass.We reviewed all patients at 1 year after these two operations. Methods: During the first year after surgery, laparoscopic adjustable gastric banding (LAGB) patients were followed every 4 weeks and Roux-en-Y gastric bypass (RYGBP) patients were followed at 3 weeks postoperatively and then every 3 months.The number of follow-up visits for each patient was calculated, and 50% compliance for follow-up and weight loss was compared. Results: Between October 2000 and September 2002, 216 LAGB and 139 RYGBP operations were performed. Of these patients, 186 LAGB patients and 115 RYGBP patients were available for 1-year follow-up. Age and BMI were similar for each group. Overall excess weight loss (EWL) after LAGB was 44.5%. 130 (70%) returned 6 or less times in the first year and achieved 42% EWL. 56 patients (30%) returned more than 6 times and had 50% EWL (P=0.005). Overall %EWL after RYGBP was 66.1%. 53 patients (46%) returned 3 or less times in the first year, achieving 66.1% EWL. 62 patients (54%) returned more than 3 times after surgery and achieved 67.6% EWL (P=NS). Conclusion: Patient follow-up plays a significant role in the amount of weight lost after LAGB, but not after RYGBP. Patient motivation and surgeon commitment for long-term follow-up is critical for successful weight loss after LAGB surgery.     

The Impact of Bariatric Surgery on Comorbidities and Medication Use Among Obese Patients

Background  

The risks and benefits of bariatric surgery have rarely been evaluated in large multiyear patient samples. This study identifies the short- and long-term impact of bariatric surgery on comorbidities and medication use among obese patients.     

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     

Revisional Bariatric Surgery

Background  Revisional surgery is required in a significant number of patients because of failure to lose weight, loss of quality of life, weight regain, or complications of the previous procedure. It has traditionally been associated with higher complication rates, and there appears to be no standardized surgical approach to revisional surgery. The aim of the study was to review the revisional procedures performed at St George Private Hospital and analyze the outcomes of the different types of revisional surgery. Methods   We performed a retrospective review of 75 patients who underwent revisional surgery between December 2003 and October 2007. Demographic, anthropometric, perioperative, and clinical follow-up data were collected, and statistical analyses were performed using SPSS version 14.0. Results  Sixty-six of the 75 patients were female. The mean age at the time of revision was 46.32 (22–68) years. Mean initial weight was 119.08 kg, and body mass index (BMI) was 43.42 kg/m². The lowest BMI and excess weight loss (EWL) recorded after primary surgery was 36.9% and 53.5%, respectively. At the time of revision, the mean EWL was 24.79. The EWL at 3 months and 6 months were 41.7% and 47.8%, respectively. Revision was performed laparoscopically in 51 patients and via laparotomy in 24 patients. There was no mortality in the cohort, but there were 17.3% minor and 4.0% major perioperative morbidities. Conclusion  Our study suggests that revision can be performed safely. Weight loss is satisfactory, and complications of the previous operations were all reversed. Furthermore, revisions may be done laparoscopically, including those who had previous open procedures.