Clinical Significance of Central Obesity in Laparoscopic Bariatric Surgery

Background: Laparoscopic surgery had increased the interest and growth of bariatric surgery. Whether central obesity has any adverse effect in laparoscopic bariatric surgery is not clear. Methods: 612 morbidly obese patients received laparoscopic bariatric surgery,in a prospectively controlled clinical trial of the outcome of the bariatric surgery. For comparison, subjects were dichotomized into either a central obesity group or peripheral obesity group, based on waist/hip ratio (WHR). Various biochemistry and blood count variables, and perioperative and postoperative results were measured. Results: There were more female (458) than male patients (154). Male patients had higher BMI, and female patients were younger. 56 of 154 male patients (36.4%) belonged to the central obesity (WHR >1.0), and 321 of 458 female patients (70.1%) had central obesity (WHR >0.85). Central obesity was associated with age but not with BMI in males. In females, central obesity was associated with increased BMI. Central obesity predicted increased hyperglycemia and triglyceride levels in both male and female patients. Male patients with central obesity had higher WBC counts than the other patients. Although central obesity was associated with more intra-operative blood loss and prolonged recovery in female patients, there was no increase in complication rate or difference in postoperative weight loss. Conclusion: Central obesity is associated with a higher degree of hyperglycemia, hyperlipidemia and leukocytosis in morbidly obese patients who undergo bariatric surgery. Although there is increased technical difficulty in patients with severe central obesity, laparoscopic bariatric surgery is safe and effective in producing weight loss.     

Histological Behavior of Hepatic Steatosis in Morbidly Obese Patients after Weight Loss Induced by Bariatric Surgery

Background: Hepatic steatosis has a high prevalence among morbidly obese patients. Its relation to steatohepatitis and cirrhosis has been extensively studied among these patients. The aim of this study was to evaluate the behavior of hepatic steatosis with weight loss 1 year after bariatric surgery. Methods: This study is a historical cohort that compared liver biopsies obtained from morbidly obese patients during the bariatric operation, with percutaneous biopsies taken from the same patient 1 year after surgery. The results were compared with weight loss, patients' profile (gender, age, body mass index (BMI) and waist/hip ratio), and with the presence of co-morbidities such as diabetes, hypertension, and dyslipidemia. Results: 90 patients who had liver biopsies taken at the operation and postoperative period for bariatric surgery were included. The prevalence of hepatic steatosis was 87.6%. The average percent of excess weight loss was 81.4%. On the second biopsy, 16 patients (17.8%) of the total had the same degree of steatosis, 25 (27.8%) improved their steatosis pattern and 49 (54.4%) had normal hepatic tissue. There was no statistical difference regarding age, BMI, waist/hip ratio, and co-morbidities (P>0.05), but there was a difference in gender (P=0.044). Conclusion: Significant improvement in the hepatic histology of steatosis was observed after weight loss induced by bariatric surgery in most patients. There was no patient with a worsening in the histology.     

Development of Acute Gouty Attack in the Morbidly Obese Population after Bariatric Surgery

Background: Gout is associated with increased body weight. We evaluated the prevalence of gout and acute gouty attacks in the morbidly obese population who underwent bariatric surgery. Methods: The medical records and operative reports of 1,240 patients who underwent bariatric surgery were reviewed retrospectively for weight parameters, BMI, weight loss, medical history of gout, and onset of acute gouty attacks. Results: Of the 1,240 patients, 5 (0.4%) had been previously diagnosed with gout. 2 of these 5 had acute attacks during the postoperative period, and responded succesfully to intravenous colchicine. Conclusion: Although rare, gout must be considered a co-morbid illness in obese and morbidly obese patients. Surgeons should be familiar with the signs and symptoms of attacks in the postoperative period, and be knowledgeable in the management.     

The Intragastric Balloon – Smoothing the Path to Bariatric Surgery

Background: Intragastric balloon placement in association with diet for weight reduction is steadily gaining popularity. However, long-term follow-up studies on the effect of this method in maintaining weight loss are lacking. This study evaluated the long-term outcome following balloon removal in morbidly obese patients who had selected this method for weight loss. Methods: 140 morbidly obese patients who refused bariatric surgery because of fear of complications and mortality, underwent intragastric balloon placement and were followed over a 6- to 30-month period (mean 18.3 months) after balloon extraction. The 34 males and 106 females, with median age 38 years (range 16-62), median weight 122 kg (range 85-203), median BMI 42.3 kg/m² (range 35-61.3) and median excess weight (EW) 59 kg (range 29-132), received a Bioenterics Intragastric Balloon (BIB). Excess weight loss (EWL) ≥25% when the BIB was removed was considered a success. Weight fluctuations and any further interventional therapy requested by the patients after balloon removal were recorded. Results: 100 patients (71.4%) lost ≥25% of their EW on balloon extraction and were categorized as successes, while 40 patients (28.6%) did not achieve that weight loss and were categorized as failures of the method. During the follow-up period, 44 of the originally successful patients (31.4%) regained weight and were categorized as recurrences, while the remaining 56 patients (40%) maintained their EWL of ≥25% and were considered long-term successes. During follow-up, 45 patients (32.1%) requested and underwent bariatric surgery for their morbid obesity (21 Adjustable Gastric Band, 11 Laparoscopic Sleeve Gastrectomy, 13 Laparoscopic Gastric Bypass). Of these, 13 (32.5%) were from the group of 40 patients categorized as failures on BIB removal, 28 (63.6%) were from the group of 44 patients whose obesity recurred, and 4 (7.1%) were from the 56 patents who although they maintained successful weight loss requested further weight reduction. Conclusions: The BIB served as a first step and a smooth introduction to bariatric surgery for morbidly obese patients who initially refused surgical intervention. The incidence of surgical intervention was double in patients who initially experienced the benefits of weight loss and then had obesity recurrence, compared with patients in whom the method failed. Indeed, a significant number of patients were assisted in their efforts to lose and maintain an acceptable weight loss over a 6- to 30-month follow-up period.     

Treatment of morbid obesity with intragastric balloon in association with diet

Background: The BioEnterics Intragastric Balloon (BIB?, BioEnterics, Santa Barbara, CA) in association with restricted diet has been used for the treatment of obesity and morbid obesity. Methods: Since March 1998, 322 BIB were placed in 281 obese and morbidly obese patients; 73 patients were male and 208 female; mean age was 41.6 years (21-70); mean weight was 117.4 kg (67- 229); mean BMI was 41.8 kg/m² (29-81); % excess weight was 62% (10-216). The balloon was inserted and removed endoscopically under general anesthesia. Patients were given a balanced diet of 1000 kcal/day.Also, for 18 months we compared 42 obese patients treated only with 1000 kcal/day diet (group A) with 31 obese patients subjected to BIB for 4 months + 1000 kcal/day diet (group B). Results: After 4 months of balloon treatment, the mean weight loss was 13.9 kg and the mean reduction in BMI was 4.8. Weight loss was greater in male patients. Weight loss was accompanied by an improvement of the diseases associated with obesity, in particular diabetes. In the diet vs BIB+diet study, BIB with diet produced a greater weight loss in a shorter time than diet alone. Conclusion: The best indications for BIB were: morbidly obese opatients (BMI>40) and super-obese patients (BMI>50) in preparation for bariatric operations; obese patients with BMI 35-40 with co-morbilities in preparation for bariatric surgery; obese patients with BMI 30-35 with a chronic disease otherwise unresolved; patients with BMI <30 only in a multidisciplinary approach.     

Ghrelin,Leptin and Insulin Levels after Restrictive Surgery: a 2-Year Follow-up Study

Background: Ghrelin is a recently discovered orexigenic gastric hormone, whose production is induced by lack of food in the stomach. In morbidly obese individuals, ghrelin levels are low compared to lean persons. During dieting, plasma ghrelin levels increase, leading to an orexigenic signal, which could explain the lack of success of dieting in morbidly obese individuals. Morbid obesity is best treated with bariatric surgery, in which gastric bypass is reported to be more effective than restrictive surgery. A possible explanation could be the difference in plasma ghrelin levels after both operations for bariatric surgery. In this study, plasma ghrelin levels were investigated during a 2-year follow-up. Methods: 17 morbidly obese patients received gastric restrictive surgery. Plasma ghrelin, leptin and insulin levels were evaluated preoperatively and 1 year and 2 years postoperatively. Results: BMI decreased from 47.5 ± 6.2 kg/m² to 33.2 ± 5.8 kg/m² (P <0.001). Plasma ghrelin levels were significantly increased 1 year (P <0.05) and 2 years (P <0.02) postoperatively. Fasting plasma leptin and insulin levels were significantly lower at 2 years after surgery (P <0.001). Conclusion: After gastric restrictive surgery, ghrelin levels increased, in contrast to the reported fall in ghrelin levels after gastric bypass. This difference in ghrelin levels between these operations may be the k ey to understanding the superiority of gastric bypass in sustaining weight loss compared with restrictive surgery.     

Biliopancreatic Diversion with Duodenal Switch Combined with Laparoscopic Adjustable Gastric Banding

Background: The authors investigated the usefulness of an approach combining biliopancreatic diversion (BPD) with duodenal switch (DS) and laparoscopic adjustable gastric banding (LAGB) in morbidly obese patients. Methods: 258 morbidly obese patients underwent bariatric surgery. 80 underwent gastric bypass (GBP), with an 80-ml pouch, a 120-150-cm common channel and a 350-cm alimentary limb (Group 1). 178 underwent BPD combined with DS-LAGB (Group 2): an 80cm common channel and a 200-cm alimentary limb were created in 68 patients (Subgroup 2a); a 120-cm common channel and a 300-cm alimentary limb were created in 110 patients (Subgroup 2b). Quality of life was assessed using the Moorehead-Ardelt Quality of Life Questionnaire (MA-QLQ). Results: At 2 years, mean BMI and %EWL were 27.8 kg/m² and 77.4 (Group 1), 25.2 kg/m² and 99.6 (Subgroup 2a), and 27.6 kg/m² and 79.3 (Subgroup 2b), respectively. 4 GBP patients regained their weight 2 years after surgery. There was 1 death, not related to surgery in Subgroup 2b. Preoperative MA-QLQ scores were similar between groups; at 2 years, MA-QLQ scores were higher in Subgroups 2a and 2b compared to Group 1 (+2.49 and +2.59 vs +0.98, respectively). Conclusion: Combination bariatric surgery is a safe, effective and durable weight loss option for the treatment of morbid obesity.     

Anesthetic Management of Morbidly Obese and Super-Morbidly Obese Patients Undergoing Bariatric Operations: Hospital Course and Outcomes

Background: Although the implications for the anesthetic and perioperative care of severely obese patients undergoing weight loss operations are considerable, current anesthetic management of super-obese (SO) patients (BMI ≥50 kg/m²), including super-super-obese (BMI ≥60) derives from experience with morbidly obese (MO) patients (BMI 40-49.9 kg/m²). We compared anesthetic and perioperative data of SO patients and MO patients undergoing weight loss operations to evaluate if anesthetic management influenced outcome. Methods: A retrospective analysis was performed on data from 150 consecutive patients (119 MO, 31 SO) undergoing bariatric surgery between May 2000 and March 2005. Data analyzed included preoperative anesthetic assessment, anesthetic management, postoperative care, and intra- or postoperative complications. Results: There were no differences in anesthetic management or in postoperative course or outcome between MO and SO patients. Intraoperative surgical complications occurred in 26% (n=8) in the SO group and 14% (n=15) in the MO group (P<0.01). Conclusions: No differences in outcome occurred between MO and SO patients undergoing bariatric operations under similar anesthetic management. Anesthesia for weight loss surgery can be safely performed on SO patients with the understanding that these patients are not at risk per se due to their higher BMI. The degree of obesity influenced only the incidence of intraoperative surgical complications.     

The Role of Ultrasound in the Diagnosis of Hepatic Steatosis in Morbidly Obese Patients

Background: Hepatic steatosis is prevalent in obese patients. Although it requires histology for diagnosis, ultrasound may indicate its presence. We evaluated the importance of ultrasound in the diagnosis of steatosis in morbidly obese patients, and considered its clinical relevance for patients with BMI of 35-40 kg/m² without co-morbidities. Methods: 187 morbidly obese patients submitted to bariatric surgery were prospectively studied. All patients had ultrasound before the operation, and hepatic biopsies during the operation, which were compared. Results: The prevalence of steatosis histologically was 91.4%. The sensitivity and specificity of ultrasound in diagnosing steatosis was 49.1% and 75%, respectively,with a positive predictive value of 95.4%. Conclusion: The biopsies found a very high prevalence of steatosis in the studied population. The ultrasound results yielded a high positive predictive value (95.4%), suggesting its use as a diagnostic tool for this co-morbidity in morbidly obese patients.The low sensitivity of the method could be related to the lack of objective criteria for the ultrasound diagnosis of steatosis, and probably, technical problems in performing ultrasound in such patients. We believe that in patients with a BMI of 35-40 kg/m² without other comorbidities, the ultrasound finding of steatosis could be of value as an indication for bariatric surgery.     

Preoperative Evaluation for Bariatric Surgery using Transesophageal Dobutamine Stress Echocardiography

Background: Bariatric surgery is an effective option for weight control in morbid obesity. The goal of this study was to assess cardiac risk prior to bariatric surgery using transesophageal-dobutamine stress echocardiography (TE-DSE). Methods: 7 morbidly obese patients (mean BMI 67.7 ± 15.6) were prospectively evaluated by TE-DSE prior to bariatric surgery. Results: All patients underwent TE-DSE without complications. 6 of 7 patients had no evidence of ischemia on TE-DSE. One patient had abnormal TE-DSE showing inferior ischemia and was treated with beta-blockers and nitrates prior to surgery and had no complications. All patients underwent surgery without cardiac complications. 1 patient died at 18 days of sepsis. Over a mean follow-up period of 11 months, the 6 surviving patients have not experienced any cardiac events. Their average weight loss is 58.2 kg. Conclusion: TE-DSE is a valuable noninvasive technique for predicting cardiac risk in morbidly obese patients undergoing bariatric surgery.     

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

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

Outcome of Portal Injuries Following Bariatric Operations

Background: Portal vein thrombosis is rare following Roux-en-Y gastric bypass (RYGBP). Its natural history is dependent on the etiology of the thrombosis. Iatrogenic injuries at bariatric operations resulting in portal vein thrombosis are lethal complications typically necessitating a liver transplant, whereas postoperative portal vein thrombosis without an injury to the portal vein has a benign course. There are currently no data on management or prognostic factors of portal vein thrombosis after bariatric operations. Methods: 3 patients referred for liver transplantation secondary to portal vein injury following bariatric surgery between 2000 and 2003 are presented. Results: 2 super-obese (BMI ≥50 kg/m²) and 1 morbidly obese (BMI 44 kg/m²) patients sustained portal vein injuries during bariatric surgery (RYGBP 2, VBG 1) by experienced bariatric surgeons. In each case, the portal injury was identified and repaired. Thrombosis followed reconstruction in all 3 patients. All 3 underwent emergency liver transplantation, but died of sepsis and multi-organ failure following transplantation. Review of the literature found no cases of traumatic portal vein injuries following bariatric operations and 2 cases of postoperative portal vein thrombosis: 1 following LRYGBP (BMI 46) and one after a Lap-Band (BMI 41). Conclusion: Injury to the portal vein resulting from difficulty in discerning the anatomy of the intra-abdominal structures in the morbidly obese, is a lethal complication of bariatric surgery. Super-obese patients submitting to bariatic surgery should lose weight, undergo a two-stage bariatric procedure, or undergo laparoscopic RYGBP to minimize the risk of portal injury. Postoperative portal vein thrombosis has a benign course and can be managed conservatively.     

Comparison of IL-8, IL-6 and PGE2 Formation by Visceral (Omental) Adipose Tissue of Obese Caucasian Compared to African-American Women

Background: One of the key consequences of obesity is an enhanced release of cytokines such as IL-8 and IL-6 by adipose tissue. There may be differences in adiposity, inflammatory markers, and medical co-morbidity between morbidly obese African-American (AA) and Caucasian (CA) women. We hypothesized that there are ethnic differences in inflammatory markers and medical co-morbidities. Methods: We compared the mRNA content in omental fat and the release of IL-8, IL-6 and PGE₂ after a 4-hour incubation of explants of adipose tissue in women undergoing bariatric surgery. In addition, medical co-morbidities and fat measurements were examined and compared. Results: Medication usage differed, with CA women being three times more likely to report taking medication for depression compared to AA women (P≤0.001). IL-8 and PGE₂ release over 4 hours by omental fat in vitro was the same in CA and AA women. Similar results were seen with respect to the COX-2 mRNA and IL-8 mRNA values at the start and at the end of the incubation. In CA and AA women, the IL-6 mRNA content in fat immediately after removal from the patients was the same. Conclusions: In morbidly obese women seeking bariatric surgery, there are little ethnic differences between cytokine release by omental adipose tissue explants in vitro, or the mRNA content in omental adipose tissue of IL-6, IL-8 or COX-2. The only noted difference between AA and CA morbidly obese women was the greater use of antidepressants by CA women.     

Prevalence of Obesity Among Children and/or Grandchildren of Adult Bariatric Surgery Patients

Background  Clinical experience suggests that some adults who undergo bariatric surgery have children who are obese. Childhood obesity is associated with increased morbidity and mortality in later life. This study examined the prevalence of obesity among children and grandchildren (≤12 years of age) of adult bariatric surgery patients. Methods  Patients in a prospective database of morbidly obese patients who underwent bariatric surgery between January 2004 and May 2007 were recruited by phone and in clinic. Patient demographics, body mass index (BMI) at surgery, and survey data were collected. The survey included questions regarding their child/grandchild's body habitus, weight, and height. Child obesity was defined as BMI percentile ≥95. Statistical significance was set at p < 0.05. Results  One hundred twenty-two patients were enrolled in this study (77% women, mean BMI 49 kg/m²). One hundred thirty-four out of 233 children/grandchildren identified had complete data; 41% had a BMI percentile ≥95. Only 29% of these obese children were so identified by the adult respondents. Significantly more biological children/grandchildren were obese than nonbiological (p = 0.013), and significantly more biological children were obese than biological grandchildren (p = 0.027). Conclusions  This sample of bariatric surgery patients had a high proportion of obese preteen children/grandchildren. Obesity was most prevalent among biological children (vs. biological grandchildren and nonbiological children). Patients often did not recognize the degree of overweight in their children/grandchildren. Because families of bariatric surgery patients often include obese children, interventions aimed at all family members merit consideration.     

Surgical Treatment of Morbid Obesity in Schizophrenic Patients

Background: Newer antipsychotic medications have greatly improved the treatment of schizophrenia, but they are known to be associated with serious weight gain. Little is known about treatment of morbid obesity in this population. Methods: 5 patients with schizophrenia and morbid obesity were studied.Weight loss was compared with that achieved by 165 non-psychotic patients who also underwent bariatric surgery during a 1-year period. Results: 5 morbidly obese patients with schizophrenia underwent bariatric surgery between February 1999 and April 2003. All patients were well controlled on antipsychotics. The median BMI was 54 (51-70) and all had obesity-related co-morbities. All patients had been previously treated unsuccessfully with conservative methods of weight reduction. 3 patients had a duodenal switch operation, 1 patient had a sleeve gastrectomy, and 1 had conversion of a silastic ring gastroplasty to biliopancreatic diversion. All patients were maintained on their antipsychotic medications until 24 hours before surgery. Median percent excess weight loss at 6 months was comparable to that achieved in the control group. Conclusions: Good control of schizophrenia may be achieved by newer therapies but at the risk of weight gain. The results of bariatric surgery in such patients are comparable to those of non-psychotic morbidly obese patients. Further follow-up is needed, but the results are encouraging.     

Low-Back Pain in Morbidly Obese Patients and the Effect of Weight Loss Following Surgery

Background: Although low-back pain (LBP) is a common health problem and a source of significant discomfort, disability and work absences, its incidence, severity and outcome have not been extensively investigated in morbidly obese patients undergoing bariatric surgery. Methods: 50 morbidly obese candidates for vertical banded gastroplasty (VBG) were asked to fill in a questionnaire, to assess the incidence and severity of any existing LBP symptoms. 50 non-obese patients, admitted to our surgical unit for management of several benign conditions, were also asked to fill in the same questionnaire and served as controls. 24 months after VBG, the morbidly obese patients were again evaluated for their LBP symptoms. Results: LBP was identified in 29 morbidly obese patients (58%) preoperatively and in only 12 (24%) of the lean controls (P<0.01). 2 years after VBG, with a significant excess weight loss (P<0.0001), only 10 patients continued to have LBP but less frequently and requiring reduced doses of medications compared with the preoperative condition. In the remaining 19 patients with preoperative positive LBP history, the postoperative weight loss was associated with complete resolution of the symptoms. Conclusion: The frequency of LBP is significantly higher in morbidly obese patients than in lean subjects. Surgical weight reduction results in significant improvement and even disappearance of this obesity co-morbidity.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Prevalence of Cancer in Italian Obese Patients Referred for Bariatric Surgery

Background: An association between obesity and cancer has been shown in large epidemiological studies. The aim of this study was to evaluate the prevalence and types of malignancies in an Italian cohort of obese patients referred to a bariatric center. Methods: A retrospective, observational study was conducted. Between Jan 1996 and Dec 2004, 1,333 obese patients (M=369, F=964) were seen in the center for minimally invasive treatment of morbid obesity. Morbid obesity were considered as BMI >40 kg/m² or BMI >35 kg/m² with at least one co-morbidity. Obese and morbidly obese patients who suffered any form of cancer were reviewed. Results: 43 patients (3.2%) presented various malignancies, with 88.3% in females. The prevalence of cancer in the younger group (21-46 years) was higher than in the older group (47-70 years), 2.1% vs 1.1%. 26 obese patients out of the 43 (60.5%) (age 41±7.9 years, BMI 38.2±9.9) presented hormone-related tumors. The most frequent site of cancer was breast (20.9%), followed closely by thyroid. Conclusion: This is the first Italian report on prevalence of cancer in a homogeneous obese population attending an academic bariatric center. The morbidly obese patients appear to have a higher risk of developing cancer, with a higher prevalence of hormone-related tumors. The predominant gender affected by both obesity and cancer was female. Thus, a preoperative work-up for cancer screening is indicated in this group of patients.     

Clinical Predictors of Sleep Apnea in Patients Undergoing Bariatric Surgery

Background: Sleep apnea is a frequent and unappreciated condition of morbidly obese patients. If unrecognized it could lead to significant postoperative complications. A clinical tool to assess the severity of sleep apnea is not available.We prospectively determined whether the Epworth Sleepiness Scale (ESS) or body mass index (BMI) predict the severity of sleep apnea in morbidly obese patients. Methods: 66 consecutive patients evaluated for bariatric surgery from June to November 1999 were examined and prospectively administered a health questionnaire including the ESS. Patients with an ESS ≥ 6 were referred for polysomnography with calculation of Respiratory Disturbance Index (RDI). Sleep apnea was graded as mild (RDI 6-20), moderate (RDI 21-40) and severe (RDI>40). Clinical variables such as BMI and ESS score were compared using regression analysis. Data are mean ± SEM. Results: 4 men and 23 women (27/66) who scored >6 on the ESS completed a sleep study. Mean ESS was 13 ± 4.5. Sleep apnea was mild in 13 patients, moderate in 7, severe in 6, and absent in 1. Mean age was 43 ± 9.5 years. BMI was 52 ± 10 kg/m². Linear regression analysis did not demonstrate correlation between ESS score and severity of sleep apnea (r²=0.03, p>0.05). Multiple regression analysis demonstrated no correlation between BMI, patient snoring, and RDI score. Conclusions: Sleep apnea is frequent in candidates screened for bariatric surgery. ESS is a useful tool to investigate daytime sleepiness and other manifestations of sleep apnea. However, the ESS does not predict the severity of sleep apnea. Clinical suspicion of sleep apnea should prompt polysomnography.     

Impact of Psychosocial Stress and Symptoms on Indication for Bariatric Surgery and Outcome in Morbidly Obese Patients

Background: Obese patients often suffer from physical and psychiatric co-morbidity. Bariatric surgery has been widely used to treat morbid obesity. The present study addresses the issues of the impact of psychosocial stress and symptoms on indication for and outcome of bariatric surgery. Methods: A sample of 131 morbidly obese patients applying for bariatric surgery underwent assessment via the Psychosocial Stress and Symptom Questionnaire (PSSQ). Patients were categorized as under little/no (below cut-off) or great (above cut-off) psychosocial stress. 2 years after their first assessment and 1 year after potential bariatric surgery, 119 patients (90.8% participation rate), 69 of whom were treated surgically, were followed up by a telephone interview asking for outcome variables such as BMI, employability, medication, doctor consultations, and physical/psychological well-being. Results: 86 patients (72.3%) scored above the cutoff in the PSSQ.There was no correlation between the result of the PSSQ and the surgeons' indication for bariatric surgery. 69 patients (58.0%) underwent bariatric surgery, of whom 48 had PSSQ scores above the cut-off. Individuals under great psychosocial stress experienced the same positive physical and psychological well-being after surgery as subjects under little or no stress. Psychosocially stressed patients (n = 38) who did not undergo surgery showed the worst outcome. Conclusion: Great psychosocial stress in morbidly obese subjects should not be a contraindication for bariatric surgery. However, those patients should receive pre- and post-surgical counseling, to reduce anxiety before surgery and increase compliance after surgery.