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.     

Laparoscopic bariatric surgery for those with body mass index of 70–125 kg/m2

BackgroundData on laparoscopic bariatric surgery in the extremely obese are limited. Technical difficulties, in addition to the patients' severe weight-related co-morbidities, can compromise the safety of bariatric surgery in these patients. Our objectives were to assess the safety and feasibility of laparoscopic bariatric surgery in extremely obese patients and to compare the outcomes of different surgical approaches at a bariatric surgery center of excellence in an academic medical center.MethodsWe reviewed our prospectively collected database and identified all patients with a body mass index (BMI) of ≥70 kg/m² who had undergone bariatric surgery. The data on patient demographics, baseline characteristics, and outcomes of bariatric surgery were retrieved.ResultsA total of 49 patients with a mean BMI of 80.7 kg/m² (range 70–125) underwent 61 bariatric procedures. Of the 49 patients, 26 underwent sleeve gastrectomy, 11 gastric bypass, and 12 underwent a 2-stage procedure (sleeve gastrectomy followed by gastric bypass). At a mean follow-up of 17.4 months, the average BMI had decreased to 60.9 kg/m² (36% excess weight loss). Overall, the patients who underwent a 2-stage procedure achieved greater percentage of excess weight loss (54.5%) than did those who underwent either single-stage sleeve gastrectomy or gastric bypass (25.4%, P = .002 and 43.8%, P = .519, respectively). Of the 61 cases, 60 (98.4%) were completed laparoscopically. The early complication rate was 16.4% overall; most were minor complications. The late complication rate was 14.8%. A single late mortality occurred in this series.ConclusionLaparoscopic bariatric surgery can be performed safely on patients with a BMI of ≥70 kg/m². A staged approach might offer better weight loss results.     

Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index

BackgroundThe current National Institutes of Health guidelines have recommended bariatric surgery for patients with a body mass index (BMI) >40 kg/m² or BMI >35 kg/m² with significant co-morbidities. However, some preliminary studies have shown that patients with a BMI that does not meet these criteria could also experience similar weight loss and the benefits associated with it.MethodsAn institutional review board-approved protocol was obtained to study the effectiveness of laparoscopic adjustable gastric banding in patients with a low BMI. A total of 66 patients with a BMI of 30–35 kg/m² and co-morbidities (n = 22) or a BMI of 35–40 kg/m² without co-morbidities (n = 44) underwent laparoscopic adjustable gastric banding. These patients were compared with 438 standard patients who had undergone laparoscopic adjustable gastric banding who met the National Institutes of Health criteria for bariatric surgery. The excess weight loss at 3, 6, 12, and 18 months and the status of their co-morbidities were compared between the 2 groups.ResultsThe average BMI for the study group was 36.1 ± 2.6 kg/m² compared with 46.0 ± 7.3 kg/m² for the control group. Both groups had significant co-morbidities, including hypertension, diabetes, hyperlipidemia, arthritis, gastroesophageal reflux disease, stress incontinence, and obstructive sleep apnea. The mean percentage of excess weight loss was 20.3% ± 9.0%, 28.5% ± 14.0%, 44.7% ± 19.3%, and 42.2% ± 33.7% at 3, 6, 12, and 18 months, respectively. This was not significantly different from the excess weight loss in the control group, except for at 12 months. Both groups showed similar improvement of most co-morbidities.ConclusionModerately obese patients whose BMI is less than the current guidelines for bariatric surgery will have similar weight loss and associated benefits. Laparoscopic adjustable gastric banding is a safe and effective treatment for patients with a BMI of 30–35 kg/m².     

Bariatric Surgery for Morbid Obesity

Background: Bariatric surgery is a treatment for severely obese patients.We examined the efficacy of bariatric surgery, addressing three questions: 1) "What is the overall weight reduction following bariatric surgery?" 2) "What complications are associated with bariatric surgery?" 3) "What impact does weight loss have on obesity-related comorbidity?" Methods: Fixed and random effects meta-analyses were used to determine the amount of weight reduction following bariatric surgery. The influence of a variety of co-variates that could affect study results was examined. Information from evidencebased sources was used to explore the impact of weight loss on comorbidities. Results: Meta-analyses results were affected by loss to follow-up, and within-study heterogeneity of variance. Therefore, results were pooled from studies with complete patient follow-up. Meta-analysis of six studies reporting weight loss at 1 year and four studies with mean follow-up of 9 months to 7 years demonstrated BMI reductions of 16.4 kg/m² and 13.3 kg/m², respectively. Weight reduction following bariatric surgery may be associated with improvements in risk factors for cardiac disease including hypertension, type 2 diabetes and lipid abnormalities, and may decrease the severity of obstructive sleep apnea. Conclusion: Bariatric surgery is appropriate for obese patients (BMI>40 kg/m² or ≥35 kg/m² with obesity-related comorbidity) in whom non-surgical treatment options were unsuccessful. Additional research is needed to examine the long-term benefits of weight loss following bariatric surgery, particularly with respect to obesity-related comorbidities.     

Singapore Experience in Obesity Surgery

Background: The outcome of bariatric surgery has been well documented in large series in the West. In Asia, where obesity has been less rampant, such surgery has been correspondingly less frequent, and there is a dearth of information on bariatric surgery on Asians. Method: The outcome of a personal series of 40 patients who underwent "gastric stapling" and banding from 1987 to 2003 in Singapore is analyzed. Results: From 1987 to 1997, 26 patients underwent open bariatric surgery (Roux-en-Y gastric bypass 4, vertical banded gastroplasty 22). Initial mean BMI was 43.3 kg/m². At 0.6, 1, 2, 4 and 8 years after surgery, mean BMI was 35.2, 31.9, 31.2, 31.1 and 34.1 kg/m². Mean initial weight was 127.2 kg. %EWL was 42.2, 56.2, 56.9, 56.3 and 48.3%. From 1999 to 2003, 14 patients underwent adjustable gastric banding, 11 by laparoscopy. Initial mean BMI was 42.9 kg/m². At 0.6, 1 and 2 years, mean BMI was 38.9, 36.6, and 32.6 kg/m². Mean initial weight was 122.6 kg. %EWL was 26.6, 38.8 and 59.2%. One patient, following perigastric insertion of Lap-Band^? developed band slippage and gastric prolapse requiring removal. Since adopting the newer technique of combined pars flaccida and perigastric dissection in the last 6 patients, no band slippage has occurred. Conclusion: Our results of safety and low operative morbidity as well as the pattern and magnitude of weight loss following gastric stapling and banding for morbidly obese patients in Singapore appears to be similar to the Western experience.     

The Influence of Eating Behavior and Eating Pathology on Weight Loss after Gastric Restriction Operations

Background: Eating behavior before surgery is considered to have great predictive value for the course of weight after surgery. The present study investigates the predictive value of three dimensions of eating behavior and disturbed eating on weight loss after gastric restriction surgery. Methods: 149 patients consisting of 47 males (32%), 102 females (68%), with mean age 38.8+10.3 years, were investigated by means of a structured interview and the Three Factor Eating Questionnaire (TFEQ) before (T1) and at least 12 months after (T2) (14.0+1.5 months) gastric restriction surgery. Results: Mean BMI before surgery was 50.9±8.1 kg/m²; postoperatively, the BMI decreased on average by 12.8 kg/m² to 38.6±6.8 kg/m² (t=22.7, P=0.000) at T2. Point-prevalence of Binge Eating Disorder (BED) according to DSM-IV was 2.0%, and lifetime-prevalence 7.4%, respectively. Of our sample, 20.1% reported current binge episodes without fulfilling all criteria for BED. An eating pathology consisting of continual eating ("grazing") was reported in 19.5% of the patients. At T2, patients with a weight loss of at least 25% of their pre-surgery weight indicated significantly less hunger and disinhibition compared with patients with less weight loss. Patients with a distinct craving for sweets after surgery lost significantly less weight. Patients with binge episodes or "grazing" before surgery did not differ in average weight loss from patients without binge episodes or "grazing". Conclusion: Postoperative but not preoperative eating behavior is of predictive value for the extent of weight loss after gastric restriction surgery.     

The relationship between weight loss and psychosocial functioning among bariatric surgery patients

Background

Success after bariatric surgery should also reflect improvement in psychosocial functioning. The objective of this study was to assess the relationships between both mental health and eating disorders and weight loss in morbidly obese patients 2 years after gastric bypass.

Methods

Forty-three obese women (mean age, 39.3 ± 1.4 years; mean body mass index, 44.7 ± 0.4 kg/m²) were evaluated before and 1 and 2 years after gastric bypass. The Beck Depression Inventory and the Hospital Anxiety and Depression Scale were used for depression and anxiety evaluation and the Eating Disorder Inventory for eating disorder assessment.

Results

Decreases in depression (P <.01), anxiety (P <.05), and eating disorder (P <.01) scores were measured 2 years after surgery. Both excess weight loss and change in body mass index were associated with improvements in all measured psychologic outcomes 2 years after surgery.

Conclusions

The importance of weight loss is in relation to mental health 2 years after bariatric surgery. Psychologic outcomes and eating disorders did not predict weight loss 2 years after gastric bypass. However, these factors improved significantly after weight loss.     

Nutritional Behavior as a Predictor of Early Success after Vertical Gastroplasty

Background: Patients' nutritional habits are seldom taken in account in planning surgery for clinically severe obesity. Our proposed hypothesis is that the patient's nutritional behavior may influence the outcome of bariatric surgery. Methods: The impact of nutritional behavior on the postoperative weight-loss was evaluated before and after bariatric surgery. A 6-month prospective consecutive case study was carried out on patients undergoing a Silastic ring vertical gastroplasty (SRVG). Patients were interviewed and examined before and at 1, 3 and 6 months after surgery. Demographic and clinical data were collected from the patients' medical charts. Nutritional data collected from a self-filled questionnaire included information on hunger and satiety perception, nutritional behavior (intake, eating habits and maximum consistency of consumed food) and concomitant symptoms. Results: The sample included 69 patients: 56 were women (81%); average age was 32 years (range 18 50). Average preoperative BMI was 43.4 ± 5.3 kg/m² (range 35-58). 6 months after surgery, BMI was 30.3 ± 3.8 kg/m² (range 21-42). Weight loss forecast models showed a statistically significant role of factors related to: anthropometrical preoperative data, hunger perception, prevalence of oral mucosal sore, and nutritional behavior. Conclusion: The short nutrition outcomes after gastric restrictive surgery were looked at, with their impact on weight-loss success. The Eating Status concept should be part of a systematic profiling of morbidly obese patients for preoperative nutritional behavior and postoperative nutritional education, to achieve the best comprehensive treatment in regard to weight loss and quality of life.     

Relationship of psychiatric disorders to 6-month outcomes after gastric bypass

BACKGROUND: Although most bariatric surgery patients undergo a preoperative psychological evaluation, the potential effect of psychiatric disorders on weight loss is not well understood. We sought to document the relationship of preoperative psychiatric disorders to the 6-month outcomes after gastric bypass. METHODS: The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was used to assess current and lifetime Axis I clinical disorders, as well as Axis II personality disorders, before surgery. We used linear regression models to examine the relationship of psychiatric disorders to postoperative weight-related outcomes. RESULTS: The sample (n = 207) was 83.1% female and 92.7% white. The preoperative body mass index (BMI) was 51.4 +/- 9.6 kg/m(2) and age was 45.8 +/- 9.5 years. After adjusting for the initial BMI, gender, race, and age, a lifetime Axis I disorder was associated with a smaller decrease in BMI (t = -3.7, df = 205, P <.001) at 6 months after surgery. The results of separate models for each class of disorder indicated that lifetime mood disorder was associated with a smaller decrease in BMI (t = -3.7, df = 205, P <.001), as was lifetime anxiety disorder (t = -2.6, df = 205, P = 0.009), but substance and eating disorders were not. In this sample, current Axis I clinical disorders and Axis II personality disorders were unrelated to outcomes at 6 months. Similar overall results were found when the percentage of weight loss and excess weight loss were predicted. CONCLUSION: The results of our study have shown that patients who have ever had an Axis I clinical disorder, especially mood or anxiety, exhibit poorer weight outcomes 6 months after gastric bypass than those who have never had an Axis I disorder. Additional research with larger samples is needed to replicate these findings and examine more fully the effect of current clinical disorders and personality disorders on weight loss. Nevertheless, our results suggest that patients with current or past disorders might benefit from close monitoring or psychosocial intervention to improve their short-term outcomes. However, a greater duration of follow-up is needed to identify predictors of longer-term weight control.     

Bariatric surgery for severely obese adolescents

A 1991 National Institutes of Health Consensus Conference concluded that severely obese adults could be eligible for bariatric surgery if they had a body mass index (BMI) ≥35 kg/m² with or ≥40 kg/m² without obesity comorbidity. It was thought at that time that there were inadequate data to support bariatric surgery in severely obese adolescents. An estimated 25% of children in the United States are obese, a number that has doubled over a 30-year period. Very little information has been published on the subject of obesity surgery in adolescents. Therefore we reviewed our 20-year database on bariatric surgery in adolescents. Severely obese adolescents, ranging from 12 to less than 18 years of age, were considered eligible for bariatric surgery according to the National Institutes of Health adult criteria. Gastroplasty was the procedure of choice in the initial 3 years of the study followed by gastric bypass, which was found to be significantly more effective for weight loss in adults. Distal gastric bypass (D-GBP) was used in extremely obese patients (BMI ≥60 kg/m²) before 1992 and long-limb gastric bypass (LL-GBP) was used for super-obese patients (BMI ≥50 kg/m²) after 1992. Laparoscopic gastric bypass was used after 2000. Thirty-three adolescents (27 white, 6 black; 19 females, 14 males) underwent the following bariatric operations between 1981 and June 2001: horizontal gastroplasty in one, vertical banded gastroplasty in two, standard gastric bypass in 17 (2 laparoscopic), LL-GBP in 10, and D-GBP in three. Mean BMI was 52 ±11 kg/m² (range 38 to 91 kg/m²), and mean age was 16 ± 1 years (range 12.4 to 17.9 years). Preoperative comorbid conditions included the following: type II diabetes mellitus in two patients, hypertension in 11, pseudotumor cerebri in three, gastroesophageal reflux in five, sleep apnea in six, urinary incontinence in two, polycystic ovary syndrome in one, asthma in one, and degenerative joint disease in 11. There were no operative deaths or anastomotic leaks. Early complications included pulmonary embolism in one patient, major wound infection in one, minor wound infections in four, stomal stenoses (endoscopically dilated) in three, and marginal ulcers (medically treated) in four. Late complications included small bowel obstruction in one and incisional hernias in six patients. There were two late sudden deaths (2 years and 6 years postop-eratively), but these were unlikely to have been caused by the bariatric surgical procedure. Revision procedures included one D-GBP to gastric bypass for malnutrition and one gastric bypass to LL-GBP for inadequate weight loss. Regain of most or all of the lost weight was seen in five patients at 5 to 10 years after surgery; however, significant weight loss was maintained in the remaining patients for up to 14 years after surgery. Comorbid conditions resolved at 1 year with the exception of hypertension in two patients, gastroesophageal reflux in two, and degenerative joint disease in seven. Self-image was greatly enhanced; eight patients have married and have children, five patients have completed college, and one patient is currently in college. Severe obesity is increasing rapidly in adolescents and is associated with significant comorbidity and social stigmatization. Bariatric surgery in adolescents is safe and is associated with significant weight loss, correction of obesity comorbidity, and improved self-image and socialization. These data strongly support obesity surgery for those unfortunate individuals who may have difficulty obtaining insurance coverage based on the 1991 National Institutes of Health Consensus Conference statement. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation).     

Laparoscopic Reoperative Bariatric Surgery: Experience from 27 Consecutive Patients

Background: 10 to 25% of patients undergoing bariatric surgery will require a revision, either for unsatisfactory weight loss or for complications. Reoperation is associated with a higher morbidity and has traditionally been done in open fashion.The purpose of this study was to determine the safety and efficacy of reoperative surgery using a laparoscopic approach. Methods: A retrospective review of medical records over a 22-month period was conducted. 27 consecutive obesity surgery patients, who had undergone a laparoscopic revision, were identified. 26 of the 27 patients were women. The average age was 40.3 years (range 20 to 58 years) and average original preoperative body mass index (BMI) was 51.6 kg/m2 (range 42 to 66.5).The 27 primary bariatric operations consisted of vertical banded gastroplasty (12), gastric band placement (9) and gastric bypass (6). 17 of them were open procedures. After the primary surgery, the lowest average BMI was 37.6 kg/m² (range 21 to 52), which increased to 42.7 kg/m² (range 29 to 56) before reoperation. 24 of the 27 reoperations were indicated for insufficient weight loss. On average, revision was undertaken 52 months after the primary procedure (range 12 to 240 months). Results: 24 of the 27 laparoscopic reoperations were conversions to a gastric bypass. A second reoperation was indicated for insufficient weight loss on four occasions. In one case, conversion to open surgery was required. The average operative time was 232 ± 18.5 minutes (range 120 to 480) and length of hospital stay was 3.7 days (range 1 to 9). 22% percent of patients (6) experienced complications, including pneumothorax, gastric remnant dilation, gastrojejunostomy stenosis, port-site hernia and protein malnutrition. There was no mortality in the study.The average BMI was 35.9 kg/m² (range 27 to 45.5) 8 months after surgery (range 1 to 22 months). Compared with a preoperative BMI of 42.7 kg/m², the weight loss was statistically significant (p<0.001). Conclusion: Our results compare favorably with those reported for open reoperative bariatric surgery. A laparoscopic approach may be considered a feasible and safe alternative to an open operation.     

Quality of Life in Morbidly Obese Patients after Surgical Weight Loss

Background Laparoscopic adjustable gastric banding (LAGB) is seen as a safe surgical procedure in individuals with morbid obesity, with satisfactory weight loss and significant postoperative improvement in quality of life (QoL). The present study investigates the predictive value of various parameters such as age, gender, weight loss, and preoperative psychiatric disorders with regard to QoL after LAGB. Methods 300 obesity surgery patients were sent questionnaires to assess a variety of personal parameters. QoL was assessed using the Ardelt-Moorehead Quality of Life Questionnaire. Questionnaires were completed by 140 (63%) female patients and 36 (45%) male patients. Results Average weight loss in both sexes was 14.7 kg/m²; however, not all patients successfully lost weight. No difference was seen in satisfaction with weight loss among the age groups. Some correlations were seen between the amount of weight loss and QoL scores in females, but not in males. Greater weight loss showed a statistically significant positive correlation to self-esteem, physical activity, social relationships, sexuality, and eating pattern. Obese females with no preoperative psychiatric diagnosis had better self-esteem, more physical activity, and more satisfying social and sexual relationships than those with psychiatric diagnoses at follow-up. Conclusion A majority of morbidly obese patients show psychological and interpersonal improvement after surgery. However, some obese patients, particularly those having a preoperative psychiatric or personality disorder, need more individual strategies for psychosocial intervention than do obese individuals with no psychiatric disorder.     

Laparoscopic Gastric Banding in Morbidly Obese Adolescents

Background: 4% of adolescents in the U.S.A. are obese, 80% of whom will become obese adults. Obesity in adolescence is associated with increased mortality and morbidity in adulthood. Is laparoscopic adjustable silicone gastric banding a safe and effective method of weight loss in morbidly obese adolescents? Methods: Since 1996, data has been prospectively collected on all patients undergoing laparoscopic adjustable gastric banding (LAGB) by a single surgeon. Patients are reviewed at 6 and 12 weeks following surgery,then at 3 monthly intervals.Weight loss is measured in absolute terms, reduction in body mass index (BMI) and as percentage of excess weight loss. Results: 17 patients with a median age of 17 (12 to 19) years underwent LAGB. Median follow-up was 25 (12 to 46) months. 2 complications occurred, 1 slipped band and 1 leaking port. BMI fell from a preoperative median of 44.7 to 30.2 kg/m² at 24 months following surgery, corresponding to a median loss of 35.6 kg or 59.3% of excess weight. 13 of 17 patients (76.5%) lost at least 50% of their excess weight, and 9 of 11 patients (81.8%) had a BMI <35 kg/m² at 24 months following surgery. Conclusion: LAGB is a safe and effective method of weight loss in morbidly obese adolescents, at least in the medium term. Its role in preventing obesity and obesity-related disease in adulthood remains to be determined as part of our long-term study.     

Massive Weight Loss Without Surgery in a Super Obese Patient

Large weight losses are rarely achieved through non-surgical procedures, but are also possible without professional help. A massive weight loss may be complicated by the development of an eating disorder psychopathology, followed by weight regain. We report the case of a male patient with super obesity (BMI, 86.2 kg/m²), who achieved a massive weight loss (170 kg in 2 years) largely without professional help and without surgery. The final body weight (∼100 kg; BMI, 32.6) has now been maintained for nearly 2 years. After weight loss, the patient had massive skin redundancy in several areas including the breasts, arms, abdomen, back, and thighs and a true body weight probably in the normal range. All laboratory tests were normal, with the exception of low free testosterone. Sonographic examination showed gall bladder microlithiasis. No eating disorders and other axis I and axis II psychiatric disorders were present. The case illustrates how much weight loss and weight-loss maintenance can be exceptionally achieved without surgery and without developing an eating disorder of clinical severity or other psychiatric disorders.     

Gastric Bypass in a Japanese Man with Prader-Willi Syndrome and Morbid Obesity

Background: In Prader-Willi syndrome (PrWS), marked obesity is the most serious and common complication, contributing significantly to morbidity and mortality. Because of the associated psychosocial difficulties, bariatric surgery appears to be the only effective treatment. Case Report: A 30-year-old man with PrWS weighing 108 kg (BMI 50 kg/m²), underwent Roux-en-Y gastric bypass (RYGBP). 3 months before the RYGBP, he weighed 146 kg (BMI 68.5), partly because of heart failure. 18 months after RYGBP, he weighed 92.4 kg (BMI 43.3), with no postoperative complications. Moreover, he showed considerable increase in serum HDL-cholesterol levels with reciprocal reduction in LDL-cholesterol after the surgery. Conclusion: RYGBP resulted in satisfactory weight loss and improvement in serum lipid profile in a Japanese morbidly obese patient with PrWS.     

Changes in Metabolic Profile and Adipoinsular Axis in Morbidly Obese Premenopausal Females Treated with Restrictive Bariatric Surgery

Background

The aim of the present study was to evaluate the effects of surgically induced weight loss on the metabolic profile and adipocytokine levels in premenopausal morbidly obese females.

Methods

Twenty premenopausal morbidly obese (MO) women with a median age of 34?years (range: 24?C48?years) and a median body mass index (BMI) of 41.47?kg/m² (range: 38.0?C56.73?kg/m²) were studied (13 women underwent gastric banding and 7 women underwent sleeve gastrectomy). In addition, 20 lean premenopausal women with a median age of 32?years (range: 22?C44?years) and a median BMI of 20.0?kg/m² (range: 18.5?C24.7?kg/m²) were also studied. Anthropometric measurements and metabolic parameters were analyzed in each patient, along with changes in leptin, adiponectin, resistin, and interleukin-6 (IL-6) before surgery, 6?months after surgery, and 12?months after surgery. Comparisons with the reference normal-weight subjects were also performed.

Results

Both weight and BMI were found to be significantly decreased postoperatively. A 54.5% loss of excess BMI was observed 12?months after surgery, and was associated with significant improvement in all anthropometric and metabolic parameters. Twelve months after surgery we also observed decreased levels of serum leptin, resistin, and IL-6; increased levels of serum adiponectin; and a remarkable improvement in metabolic syndrome markers. Furthermore, postoperative serum resistin and IL-6 levels were found to reach those of normal-weight volunteers.

Conclusions

The results of this study suggest that weight loss through restrictive bariatric surgery results in a significant reduction in leptin, resistin, and IL-6 levels, and an increase in adiponectin levels, in addition to improving insulin sensitivity and glucose and lipid homeostasis in young morbidly obese female patients. These changes were significantly correlated with the magnitude of weight loss.     

A Prospective Multicenter Study of 163 Sleeve Gastrectomies: Results at 1 and 2 Years

Background Good results obtained after laparoscopic sleeve gastrectomy (LSG), in terms of weight loss and morbidity, have been reported in few recent studies. Our team has designed a multicenter prospective study for the evaluation of the effectiveness and feasibility of this operation as a restrictive procedure. Methods From January 2003 to September 2006, 163 patients (68% women) with an average age of 41.57 years, were operated on with a LSG. Indications for this procedure were morbid obese [body mass index (BMI) > 40 kg/m²] or severe obese patients (BMI > 35 kg/m²) with severe comorbidities (diabetes, sleep apnea, hypertension…) with high-volume eating disorders and superobese patients (BMI > 50 kg/m²). Results The average BMI was 45.9 kg/m². Forty-four patients (26.99%) were superobese, 84 (51.53%) presented with morbid obesity, and 35 (21.47%) were severe obese patients. Prospective evaluations of excess weight loss, mortality, and morbidity have been analyzed. Laparoscopy was performed in 162 cases (99.39%). No conversion to laparotomy had to be performed. There was no operative mortality. Perioperative complications occurred in 12 cases (7.36%). The reoperation rate was 4.90% and the postoperative morbidity was 6.74% due to six gastric fistulas (3.66%), in which four patients (2.44%) had a previous laparoscopic adjustable gastric banding. Long-term morbidity was caused by esophageal reflux symptoms (11.80%). The percentage of loss in excessive body weight was 48.97% at 6 months, 59.45% at 1 year (120 patients), 62.02% at 18 months, and 61.52% at 2 years (98 patients). No statistical difference was noticed in weight loss between obese and extreme obese patients. Conclusions The sleeve gastrectomy seems to be a safe and effective restrictive bariatric procedure to treat morbid obesity in selected patients. LSG may be proposed for volume-eater patients or to prepare superobese patients for laparoscopic gastric bypass or laparoscopic duodenal switch. However, weight regained, quality of life, and evolution of morbidities due to obesity need to be evaluated in a long-term follow up.     

Weight loss after bariatric surgery in obese adolescents: a systematic review and meta-analysis

Of adolescents in the United States, 20% have obesity and current treatment options prioritize intensive lifestyle interventions that are largely ineffective. Bariatric surgery is increasingly being offered to obese adolescent patients; however, large-scale effectiveness data is lacking. We used MEDLINE, Embase, and Cochrane databases, and a manual search of references to conduct a systematic review and meta-analysis on overall weight loss after gastric band, gastric sleeve, and gastric bypass in obese adolescent patients (age ≤19) and young adults (age ≤21) in separate analyses. We provided estimates of absolute change in body mass index (BMI, kg/m²) and percent excess weight loss across 4 postoperative time points (6, 12, 24, and 36 mo) for each surgical subgroup. Study quality was assessed using a 10 category scoring system. Data were extracted from 24 studies with 4 having multiple surgical subgroups (1 with 3, and 3 with 2 subgroups), totaling 29 surgical subgroup populations (gastric band: 16, gastric sleeve: 5, gastric bypass: 8), and 1928 patients (gastric band: 1010, gastric sleeve: 139, gastric bypass: 779). Mean preoperative BMI (kg/m²) was 45.5 (95% confidence interval [CI]: 44.7, 46.3) in gastric band, 48.8 (95%CI: 44.9, 52.8) in gastric sleeve, and 53.3 (95%CI: 50.2, 56.4) in gastric bypass patients. The short-term weight loss, measured as mean (95%CI) absolute change in BMI (kg/m²) at 6 months, was –5.4 (?3.0, ?7.8) after gastric band, ?11.5 (?8.8, ?14.2) after gastric sleeve, and ?18.8 (?10.9, ?26.6) after gastric bypass. Weight loss at 36 months, measured as mean (95%CI) absolute change in BMI (kg/m²) was ?10.3 (?7.0, ?13.7) after gastric band, ?13.0 (?11.0, ?15.0) after gastric sleeve, and ?15.0 (?13.5, ?16.5) after gastric bypass. Bariatric surgery in obese adolescent patients is effective in achieving short-term and sustained weight loss at 36 months; however, long-term data remains necessary to better understand its long-term efficacy.     

Preparation of Extremely Obese Patients for Laparoscopic Gastric Banding by Gastric Balloon Therapy

Background: In super, super obese patients (body mass index [BMI] >60), especially those with extreme intra-abdominal fat deposition, the technical difficulties in laparoscopic procedures increase. The purpose of this study was to evaluate whether gastric balloon therapy (GBT) can improve the operative conditions for laparoscopic adjustable gastric banding (LAGB) in extremely obese patients. Materials and Methods: From April 1995 to August 1998, 196 LAGBs were performed. In 15 patients (7 female and 8 male), median age 38.8 years (range 17-54), who had been selected as suitable candidates for bariatric surgery, preoperative GBT was studied. Fourteen patients were extremely obese (BMI 60.2 kg/m² [range 58-72]). One 17-year-old boy with BMI 46.6 kg/m² was also treated. The Bioenterics Intragastric Balloon (BIB) was used. The placement, the volume modification, and the removal of the BIB were performed endoscopically. Close follow-up was possible in 14 patients. After balloon removal, 13 patients underwent LAGB. Results: In 14 of 15 cases, GBT was successful. There was only one ballon dysfunction. The mean weight loss was 18.1 kg, and the median duration of balloon therapy was 16.8 weeks. After balloon removal, body weight started to increase. Conclusions: In our experience, the gastric balloon can improve the conditions for laparoscopic surgery in super and in super, super obese patients. There was no conversion to open surgery. The effect of weight loss is much less than immediately after LAGB. However, after failure of all conservative treatments to reduce the preoperative body weight, the GBT seems to be the last possibility.     

Bariatric Surgery to Target Obesity in the Renal Transplant Population: Preliminary Experience in a Single Center

During the last century, obesity has become a global epidemic. The effect of obesity on renal transplantation may occur in perioperative complications and impairment of organ function. Obese patients have metabolic derangements that can be exacerbated after transplantation and obesity directly impacts most transplantation outcomes. These recipients are more likely to develop adverse graft events, such as delayed graft function and early graft loss. Furthermore, obesity is synergic to some immunosuppressive agents in triggering diabetes and hypertension. As behavioral weight loss programs show disappointing results in these patients, bariatric surgery has been considered as a means to achieve rapid and long-term weight loss.Up-to-date literature shows laparoscopic bariatric surgery is feasible and safe in transplantation candidates and increases the rate of transplantation eligibility in obese patients with end-stage organ disease. There is no evidence that restrictive procedures modify the absorption of immunosuppressive medications. From 2013 to 2016 we performed six bariatric procedures (sleeve gastrectomy) on obese patients with renal transplantation; mean preoperative body mass index (BMI) was 39.8 kg/m². No postoperative complication was observed and no change in the immunosuppressive medications regimen was needed. Mean observed estimated weight loss was 27.6%, 44.1%, 74.2%, and 75.9% at 1, 3, 6, and 12 months follow-up, respectively. Our recommendation is to consider patients with BMI >30 kg/m² as temporarily ineligible for transplantation and as candidates to bariatric surgery if BMI >35 kg/m². We consider laparoscopic sleeve gastrectomy as a feasible, first-choice procedure in this specific population.