Relationship between Obstructive Sleep Apnea and Liver Abnormalities in Morbidly Obese Patients: A Prospective Study

Background Morbid obesity is a risk factor of nonalcoholic steatohepatitis (NASH). Obstructive sleep apnea (OSA) could also be an independent risk factor for elevated liver enzymes and NASH. The relationships between liver injuries and OSA in morbidly obese patients requiring bariatric surgery were studied prospectively. Methods Every consecutive morbidly obese patient (BMI ≥40 kg/m² or ≥35 kg/m² with severe comorbidities) requiring bariatric surgery was included between January 2003 and October 2004. Polygraphic recording, serum aminotransferases (ALT, AST), γ-glutamyltransferase (GGT) and liver biopsy were systematically performed. OSA was present when the apnea–hypopnea index (AHI) was >10/h. Results 62 patients (54 F; age 38.5 ± 11.0 (SD) yrs; BMI 47.8 ± 8.4 kg/m²) were included. Liver enzymes (AST, ALT or GGT) were increased in 46.6%. NASH was present in 34.4% and OSA in 84.7%. Patients with OSA were significantly older (P = 0.015) and had a higher BMI (P = 0.003). In multivariate analysis, risk factors for elevated liver enzymes were the presence of OSA and male sex.The presence of NASH was similar in patients with or without OSA (32.7% vs 44.4% of patients, P = 0.76). Conclusion In this cohort of morbidly obese patients requiring bariatric surgery, one-third of patients had NASH, a prevalence similar to previous studies. OSA was found to be a risk factor for elevated liver enzymes but not for NASH.     

High Prevalence of Asymptomatic Esophageal Motility Disorders among Morbidly Obese Patients

Background: Morbid obesity is becoming more prevalent in the industrialized world. Few data exist regarding the resting lower esophageal sphincter pressure (LESP) and esophageal motility in relationship to body mass index (BMI). Methods: During a 3-year period, 111 of 152 morbidly obese patients seeking bariatric surgery completed esophageal manometric testing and questionnaire regarding esophageal symptoms. Manometric parameters included wave amplitude and duration of esophageal contractions, percentage of peristaltic function, and resting LESP. Questionnaire data included age, sex, medications, prior medical conditions, and esophageal symptoms. Results: 88 (79%) of the patients were female; 23 (21%) were male. The mean age was 39.8 years (± 9.9), the mean BMI was 50.7 kg/m2 (± 9.4). There was a lack of correlation between BMI and LESP (r = 0.04). Abnormal manometric findings were observed in 68/111 (61%) patients: 28 (25%) had only hypotensive lower esophageal sphincter (LESP < 10 mm Hg); 16 (14%) had nutcracker esophagus (amplitude >180 mm Hg), 15 (14%) had nonspecific esophageal motility disorders, 8 (7%) had diffuse esophageal spasm (DES), and 1 (1%) had achalasia. Patients with DES had a significantly higher BMI than those with other motility disorders (P < 0.05). Dysphagia was reported in 7 (6%) patients and chest pain in 1 patient. Heartburn and/or regurgitation (gastroesophageal reflux disease, GERD) was noted in 35 patients (32%), of whom 18 (51%) had a hypotensive resting LES. 40 of 68 patients (59%) with abnormal motility tracings did not report any esophageal symptoms. Conclusion: Morbid obesity per se does not imply an abnormality of LESP. In addition, a majority of morbidly obese patients who were considering bariatric surgery had no esophageal symptoms but were found to have abnormal esophageal manometric patterns. These findings add support to the suggestion that morbidly obese patients may have abnormal visceral sensation.     

Hemodynamic Changes During Laparoscopic Gastroplasty in Morbidly Obese Patients

Background: In nonobese patients, peritoneal insufflation has consistently been shown to influence parameters of preload and afterload as well as cardiac output. Obese patients have an abnormal and particular cardiovascular status. The aim of this study was to investigate the hemodynamic changes induced by an increase of intra-abdominal pressure in morbidly obese patients (MOP). Methods: Standard general anesthetia was administered to 15 informed MOP (body mass index > 40 kg/m²) scheduled for laparoscopic gastroplasty. Hemodynamic parameters were measured by thermodilution through a pulmonary artery catheter and through invasive blood pressure monitoring. Results: CO₂ insufflation with an intra-abdominal pressure of 17 mmHg caused a significant increase of mean arterial pressure (MAP) (33%, P = 0.005), mean pulmonary arterial pressure (MPAP) (40%, P = 0.001), pulmonary capillary wedge pressure (PCWP) (41%, P = 0.001), and central venous pressure (CVP) (55%, P = 0.001). The increase in diastolic filling pressures could be due to an increase in the filling volume or to a decrease in diastolic compliance. Ventricular volumes were not measured but we speculate that the rise in CVP, PCWP and MPAP is due to an increase in intrathoracic pressure as judged by the increase of pulmonary airway pressure. Stroke volume fell slightly (11%, P = 0.008), because of a reduction in transmural pressure and a fall ineffective preload. Cardiac output rose slightly (16%, P = 0.005) because of an increase in heart rate (15%, P = 0.014) probably induced by sympathetic stimulation, which only became fully operative after 15 minutes. Conclusions: When compared to nonobese patients our obese patients tolerated the pneumoperitoneum surprisingly well, without experiencing fall in cardiac output. The hemodynamic consequences of peritoneal insufflation seem to be different in obese and nonobese patients.     

Resolution of Diabetes Following Vertical Gastroplasty in Morbidly Obese Patients

Case reports are presented on three patients treated for morbid obesity by vertical gastroplasty. Prior to surgery the patients had diabetes which required insulin, up to 200 units per day, or oral hypoglycaemics for its control. Six months after surgery the diabetes had been resolved in all three patients, and they were no longer dependent on medication. Subjective reports from the patients suggests that their quality of life improved significantly.     

Bariatric Surgery in Morbidly Obese Patients in Wheelchairs

Two morbidly obese patients are presented. The first patient is a 38-year-old superobese female with BMI 56.2 in a wheelchair secondary to multiple sclerosis. The second patient is a 49-year-old female with BMI 47.7 confined to a wheelchair secondary to spinal cord transection due to a motor vehicle accident. Both patients underwent an open duodenal switch procedure, which provided significant weight loss and improved quality of life primarily for mobility with a wheelchair, as well as controlling comorbidities.     

Attitudes of Morbidly Obese Patients to Weight Loss and Body Image following Bariatric Surgery and Body Contouring

Background The authors evaluated body image attitudes in post-obese persons following bariatric surgery who require cosmetic and body contouring operations. Methods We studied 20 morbidly obese women prior to biliopancreatic diversion (BPD) (OB group), 20 post-obese women at >2 years following BPD (POST group), 10 post-obese women following BPD who required cosmetic procedures (POST-A group), 10 post-obese women after BPD and subsequent cosmetic surgery (POST-B group), and 20 healthy lean controls. Attitudes to weight and shape were evaluated by means of the Body Uneasiness Test (BUT). Results In comparison with the obese patients in the POST group, lower BUT scores were observed, while in the POST-A group the values were very similar to those observed in the non-operated obese individuals. In the individuals having received cosmetic surgery, the BUT findings were similar to those recorded in the POST group patients, the values approaching data found in the controls. Conclusion Despite a fully satisfactory weight loss and maintenance, the post-BPD individuals requiring aesthetic surgery showed some disparagement of body image; in these subjects, cosmetic and body contouring procedures may actually improve body weight and shape attitudes towards normality.     

Myocardial Mass in Morbidly Obese Patients and Changes with Weight Reduction

Cardiac weight was determined at autopsy in 27 morbidly obese, but otherwise healthy men (mean weight 168 kg) and women (mean weight 138 kg) who died suddenly, prior to, or shortly after gastric restriction operations for relief of obesity. They had lost no weight. Post-mortem examination revealed no cardiac or other pathology explaining the cause of death. Cardiac weight was also measured in 25 men and women of equivalent baseline weight and body mass index who, after operation, subsisted on a hypocaloric diet for 3-4 months after operation, but then died suddenly. Mean weight losses of this latter group were 45.8 kg in men and 32.9 kg in women. No cardiac abnormalities and no organic causes of death were found at autopsy. Decreases in heart weight were calculated. The baseline measurements demonstrated that cardiac weight in the healthy obese rose with increasingly severe obesity in both sexes, but the increase tended to lessen with more extreme obesity. The generally quoted figures of cardiac weight as a fraction of body weight are 0.043 and 0.040% for men and women, respectively. In the group of morbidly obese men, cardiac weight was 0.035% of body weight or 16% lower than predicted. In morbidly obese women, cardiac weight was 0.030% of body weight or 25% lower than predicted. In men, a 28% body weight reduction due to dietary restriction resulted in a proportionately similar 20% decrease in cardiac weight. In contrast, in women after a 27% loss of body weight, cardiac weight decreased only 5%. Severe dietary restriction with a drastic body weight loss did not result in a disproportionate decrease of cardiac weight in either sex, when final body weight had remained above or in the normal range.     

Influence of a Forced Air Warming System on Morbidly Obese Patients Undergoing Roux-en-Y Gastric Bypass

Background: Hypothermia during and after major abdominal surgery decreases host defenses, increases the incidence of coagulopathy and may alter blood pressure, cardiac contractility and myocardial stability. Methods: We designed a prospective randomized study to compare the benefits of a forced air warming system with warm blanket treatments in minimizing the effects of hypothermia on 64 morbidly obese patients undergoing Roux-en-Y gastric bypass. Results: Patients in the forced air warming group (n = 32) had significantly higher perioperative body core temperature, lower central venous pressure and blood pressure readings, lower incidence of shivering, less blood loss intraoperatively and achieved a higher post anesthesia Aldrete Score than those patients in the warmed blanket group (n = 32). Conclusion: The forced air warming system is safe, cost effective and beneficial in minimizing the undesirable consequences of hypothermia in morbidly obese patients undergoing Roux-en-Y gastric bypass.     

Relationship between the Upper Airway and Obstructive Sleep Apnea-Hypopnea Syndrome in Morbidly Obese Women

Background The authors studied changes in the upper airway in morbidly obese women and the relationship to sleep apnea-hypopnea syndrome (OSAS). Methods Patients underwent a cardiorespiratory polygraphic study, respiratory function test (spirometry, plethysmography, maximum inspiratory pressures and arterial blood gas analysis), and computed tomographic studies of the upper airway. Results 40 morbidly obese women being evaluated for bariatric surgery (mean age 39.6 ± 9.6 years old, BMI 48.7 ± 5.6 kg/m²) were studied. 37 women had OSAS, and 14 had severe OSAS. Results on respiratory function tests were normal. BMI and weight had a positive correlation with apnea-hypopnea index (AHI), apnea index (AI), desaturation index (DI), lowest oxygen saturation and CT90. Uvula diameter had a negative correlation with FEV₁, FVC, VC IN and a positive correlation with TLC. Retropharynx soft tissue at the retropalatal level had a negative correlation with FEV₁, FVC and VC IN. The oropharynx area at maximal inspiration (total lung capacity) obtained a negative correlation with the AHI (r = −0.423, P = 0.044), AI (r = −0.484, P = 0.042) and DI (r = −0.484, P = 0.019). Conclusions Prevalence of OSAS in morbidly obese women is very high. Our results show the significant correlation between BMI and AHI in morbidly obese women. Uvula diameter and retropharynx soft tissue are the upper airway parameters with higher relationship with pulmonary function. A reduction in the cross-sectional area of the airway at the level of the oropharynx could be related to the severity of OSAS in morbidly obese women.     

Changes in Body Image Disturbance in Morbidly Obese Patients 1 Year after Laparoscopic Adjustable Gastric Banding

Background The effectiveness of post-surgical weight loss in improving body image disturbance (BID) in morbidly obese patients is still unclear. Providing multidimensional measures of BID and controlling for the effect of co-morbid eating psychopathology may help to clarify this issue. This preliminary study explores whether 1) BID improves 1 year after laparoscopic adjustable gastric banding (LAGB), and whether 2) such improvement is related to post-surgical BMI and/or eating disorder reduction. BID was multidimensionally assessed by means of the Body Uneasiness Test(BUT). Methods 35 obese subjects (mean BMI 45.5) were evaluated prior to and 1 year after LAGB using the BUT, and a standardized interview and questionnaire to assess eating psychopathology. BID and eating habit changes during follow-up were also investigated. Postoperative BUT values were entered as outcome measures (dependent variables) in a series of stepwise multiple regression analyses; BMI and binge eating reduction, baseline BUT scores, gender, age, and age of onset of obesity were tested as independent variables. Results Some aspects of BID (body image overconcern and related avoidance behaviors, compulsive self-monitoring, and overall severity of BID) improved following LAGB, while others (weight phobia, depersonalization, and uneasiness toward body parts) did not. The post-surgical lower levels of the former were predicted by the overall decrease in binge eating symptoms, irrespective of BMI reduction, age, gender, and age of onset of obesity. Conclusions LAGB may ameliorate some BID aspects in morbidly obese patients, and an improvement in eating behaviors may contribute to this effect.     

Effect of Surgically Induced Weight Loss on Asthma in the Morbidly Obese

Forty morbidly obese asthmatic patients who underwent gastric restrictive surgery more than 2 years earlier were evaluated to determine the influence of weight loss on asthma outcome. Mean percentage excess weight loss in this group was 68% and body mass index (BMI) fell from a mean of 46 to 30. Following surgery, 90% showed improvement in asthma symptoms. Complete remission of asthma occurred in 48% and a further 12.5% became asthma free on reduced medications dosage. Of those taking daily medications for asthma before surgery, 42% were completely off medication following weight loss surgery, and another 18.5% experienced fewer asthma attacks on reduced medication dosage. Of the 22 patients with severe asthma (> 10 attacks per year) on routine daily medications for asthma preoperatively, 8(36%) required no medication after surgery, 7(32%) used medication only on an ‘as-needed’ basis, and 7(32%) controlled their asthma on reduced medication dosage. Five patients gained weight during the follow-up period. All developed an increased incidence of asthma attacks, which again abated after successfully losing weight following revisional surgery. Coexistent factors of smoking and clinically apparent esophageal reflux were evaluated, but no statistically significant correlation was shown with either smoking or reflux and improvement in asthma. Possible etiologies of the improvement in asthma with weight loss are discussed.     

Laparoscopic Cholecystectomy in Obese and Nonobese Patients

Background: From November 1997 to November 1998, 145 cases of laparoscopic cholecystectomy (LC) have been attempted at the District General Hospital of Corfu. Methods: 23 (15.8%) were obese (Group I, BMI >30) and 122 (84.2%) were nonobese patients (Group II, BMI ≤30). One-fifth of these patients suffered from acute cholecystitis. Results: Operative time averaged 95 minutes in Group 1 and 78 minutes in Group II. There were no deaths. There were no significant differences between the obese and nonobese groups in conversion to open procedure (Group1: 0%, Group II: 2.4%), intraoperative and postoperative complications (Group I: 4.3%, Group II: 4.0%), operating time, and length of postoperative hospitalization. Conclusion: LC was a safe and effective treatment for obese patients with symptomatic cholelithiasis.     

Abdominoplasty after Weight Loss in Morbidly Obese Patients: A 4-Year Clinical Experience

Background Morbid obesity is associated with various co-morbidities. With the significant weight loss, new dysfunctions arise, and prior body contour disorders start to severely affect the patient’s quality of life. The abdominal apron is generally the greater and the first disturbance faced by the post-bariatric patient. Methods The authors retrospectively reviewed their clinical experience in the treatment of those disorders through abdominoplasty. The benefits in terms of relief of said disorders and drawbacks in terms of surgical complications are described. Results 117 abdominoplasties were performed from January 2002 to December 2005 on patients who had lost significant weight.The tissue removed ranged from 400 g to 10,500 g of adipose-cutaneous tissue (mean 2,276.5 g). Mean duration of the procedure was 4 hours and 25 minutes, with a maximum of 7 and a minimum of 2 and 40. Complication rate was 50.43%. Conclusion Abdominoplasty in the post-obese patient is an apparently simple procedure, which in fact causes a high rate of surgical complications. The complication rate is higher than that of cosmetic abdominoplasties. Nevertheless, the improvement in quality of life following such a procedure renders it a fundamental step in the rehabilitation of the formerly obese patient.     

Relationship among Adiponectin, Adiponectin Gene Expression and Fatty Acids Composition in Morbidly Obese Patients

Background he aim of this study was to examine the relationship between adiponectin plasma circulating levels and its gene expression in two abdominal fat depots (subcutaneous and visceral) with the fatty acid composition of plasma and adipose tissue in morbidly obese subjects. Methods 20 patients (10 women and 10 men) were selected. All were morbidly obese (BMI ≥40 kg/m²) and admitted for gastric surgery. Plasma samples and adipose tissue from both subcutaneous and visceral regions were obtained. Plasma adiponectin and adipose adiponectin expression were analyzed. Results Adiponectin mRNA expression in the subcutaneous tissue was significantly higher (P = 0.048) than in visceral tissue. Circulating adiponectin values, were positively associated with the proportion of n-3 polyunsaturated fatty acids in plasma (r = 0.62, P = 0.002). The visceral depot showed greater statistical associations between adiponectin gene expression and fatty acids profile, being saturated fatty acids associated with a decrease (r = −0.68, P = 0.015), whereas monounsaturated were related to an increase in this adipose region (r = 0.67, P = 0.017). Conclusions e demonstrated significant associations between adipose tissue adiponectin gene expression and fatty acid composition. These associations were more evident in relation to the visceral depot, an adipose tissue region highly implicated in the metabolic syndrome.     

The Use of the Biliopancreatic Diversion as a Treatment for Failed Gastric Partitioning in the Morbidly Obese

The dilemma with which every bariatric surgeon is confronted is: What to do with the inevitable failures? In vertical gastric partitioning, revising the gastroplasty results in a high second failure rate. In an effort to improve the Success rate in failed gastroplasty patients who request revisionary surgery, the biliopancreatic bypass (classic Scopinaro procedure) was carried out on 57 patients. They have been followed for up to 10 years. The long-term weight loss has averaged 69.4 lb, which is 87% of the pregastroplasty excess weight. The price paid by these patients, in terms of complications, has been significant. Twenty-two Percent have developed hypoalbuminemia with its accompanying peripheral edema; 24% have required i.v. hyperalimintation because Of malnutrition. Sixteen percent of the patients developed a late post-op bowel obstruction, one resulting in death. Osteomalacia, spontaneous fractures have occurred. The biliopancreatic diversion procedure (BPD) is an effective weight-loss operation in the failed gastroplasty patients, but a significant price must be paid in terms of careful follow-up, nutritional deficiencies, and rehospitalizations.     

Post-surgery Adherence to Scheduled Visits and Compliance,More than Personality Disorders,Predict Outcome of Bariatric Restrictive Surgery in Morbidly Obese Patients

BACKGROUND: With bariatric restrictive procedures a major issue is predictors of clinical outcome; non-surgical (compliance) and psychological factors might play a role in long term-results of bariatric surgery. We evaluated a set of predictors of short-term and long-term clinical outcome including psychiatric and psychological variables, as well as measures of post-surgery compliance. METHODS: 172 consecutive patients undergoing laparoscopic adjustable gastric banding (LAGB) with a minimum of 12 months follow-up, were studied; before surgery they were administered the NIMH Diagnostic Interview Schedule (Version III-R, DIS III-R) and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (Version 2.0, SCID-II). After surgery, patients were scheduled for visits at 2-week intervals for the first 2 months, at monthly intervals up to 1 year and 3-monthly intervals for 2 years; compliance with diet, rules, physical exercise, plus integrated compliance (sum of scores), and percentage of attendance at scheduled visits were recorded. Patients were contacted again at 36 and at 48 months. RESULTS: BMI, compliance, percentage of attendance at scheduled visits (positively), and narcissistic personality (negatively) were all associated with weight loss at 12, 24 (and 36 months). Percentage of attendance was also associated at 48 months. At stepwise regression analysis, BMI and integrated compliance predicted weight loss at 12, 24, and 36 months, while percentage of attendance at scheduled visits predicted weight loss at 48 months. Narcissistic personality predicted weight loss only at 12 months. CONCLUSION: Adherence to scheduled visits and compliance to recommended rules, more than personality disorders, predict success of LAGB, at least during the first 4 years.     

Aorta and Iliac Arterial Sizes in Pre-operative Morbidly Obese Patients: a preliminary report

Central blood flow and cardiac output are increased in most morbidly obese patients. This may be reflected in abnormal vessel sizes. Other influences such as smoking, age, weight, vertebral size, hypertension and age at onset of obesity may also be operative. Abdominal aorta and common iliac artery diameters were retrospectively measured on abdominal computer-assisted axial tomography scans of 44 morbidly obese, vascular disease-free females prior to their bariatric surgery. They were compared at standardized aortic and illiac levels with normal weight, similar age, control patients. There was no correlation between patient body weight, body mass index, per cent excess body weight or age at onset of obesity versus any of the aortic or iliac diameters. Pearson's correlation analysis of smoking, age and hypertension each showed a significant positive relationship with aorto-iliac diameters (p<0.05). Vertebral coronal body widths revealed a significant correlation with age (p<0.05) but not with body weight, aortic or iliac diameters at any level. We conclude that the aortic and iliac arterial diameters of morbidly obese patients are significantly enlarged relative to normal weight controls. Smoking, age and hypertension also appear to have some degree of influence on aorto-iliac diameters in morbidly obese middle-aged women.     

Psychosocial Correlates of Psychopathology in a National Sample of the Morbidly Obese

Background: Although several studies have documented the existence of psychopathology in the morbidly obese, there is disagreement as to its extent and nature. The disagreement has been difficult to resolve because earlier studies have tended to use small, regional samples, and diverse, unstandardized approaches to measuring psychopathology. Methods: To add clarity, the present study utilized an unusually large, national sample, all subjects of which were administered a standardized, comprehensive test of psychopathology (the MMPI-2), an intensive interview concerning psychosocial history, and a medical examination. Subjects' scores on the MMPI-2 were compared to available norms. The psychosocial interview yielded information about families of both origin and reference. Information about comorbidities, medications, and body mass index (BMI) were available from the medical examinations. Multiple regression analyses were performed to determine the variables that best predicted psychopathology and BMI. Results: The percentage of subjects whose MMPI-2 scores exceeded and approached psychopathological levels was in excess of normative expectations. The 1,3,2 pattern of scale scores on this test expresses depressive disorder, with anxiety and somatization features. Regression analyses showed that abuse of the subject and of substances in the family of origin positively predicted, while education and number of children negatively predicted both psychopathology and BMI. Conclusions: Dysfunctionality in the family of origin may lead to obesity through such regressive coping styles as stress eating, but this can be offset by personal development and nurturance responsibilities.