Bone Metabolism After Bariatric Surgery

Bariatric surgery is a popular and effective treatment for severe obesity but may have negative effects on the skeleton. This review summarizes changes in bone density and bone metabolism from animal and clinical studies of bariatric surgery, with specific attention to Roux‐en‐Y gastric bypass (RYGB), adjustable gastric banding (AGB), and sleeve gastrectomy (SG). Skeletal imaging artifacts from obesity and weight loss are also considered. Despite challenges in bone density imaging, the preponderance of evidence suggests that bariatric surgery procedures have negative skeletal effects that persist beyond the first year of surgery, and that these effects vary by surgical type. The long‐term clinical implications and current clinical recommendations are presented. Further study is required to determine mechanisms of bone loss after bariatric surgery. Although early studies focused on calcium/vitamin D metabolism and mechanical unloading of the skeleton, it seems likely that surgically induced changes in the hormonal and metabolic profile may be responsible for the skeletal phenotypes observed after bariatric surgery. © 2014 American Society for Bone and Mineral Research.     

A review of studies comparing three laparoscopic procedures in bariatric surgery: sleeve gastrectomy, Roux-en-Y gastric bypass and adjustable gastric banding

Obesity is a major worldwide problem in public health, reaching epidemic proportions in many countries, especially in urbanized regions. Bariatric procedures have been shown to be more effective in the management of morbid obesity, compared to medical treatments in terms of weight loss and its sustainability. The two most commonly performed procedures are laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic adjustable gastric banding (LAGB), and the novel laparoscopic sleeve gastrectomy (LSG). The MEDLINE database (cutoff date September 2010), LILACS, and the Cochrane Library were searched using the key words “gastric bypass,” “sleeve gastrectomy,” and “gastric banding.” Only studies that compared at least two of the laparoscopic procedures were included. Reviews and meta-analysis, editorial letters or comments, case reports, animal or in vitro studies, comparisons with medical treatment, comparisons with open (non-laparoscopic) procedures were excluded. Most studies indicated that LRYGB and LSG could be more effective achieving weight loss than LAGB. However, LAGB seems to be a safer procedure with frequent, but less severe, long-term complications. Although not uniformly reported, a resolution of obesity-related comorbidities was achieved with most bariatric procedures. The three procedures have acceptable efficacy and safety. We believe that patients should be informed in detail on the advantages and disadvantages of each available procedure, possibly in several interviews and always accompanied by a specialized interdisciplinary team, warranting long-term follow-up.     

Bone Health Following Bariatric Surgery: An Update

Obesity rates are increasing rapidly, and bariatric surgery is currently the most effective tool for weight loss. Recently, bariatric surgery induced bone loss has gained attention. Such detrimental effect on bone is multifactorial and causes may include nutrient deficiencies, gut and gonadal hormonal changes, mechanical unloading, loss of lean mass, increased bone marrow fat, and increased risk of fall. This review describes the available evidence on bone loss and fracture risk following bariatric surgery and summarizes the guidelines on the topic. Increased bone resorption starts early postsurgery, and bone markers peak at 1–2 yr. Across studies, the drop in areal bone mineral density is inconsistent at the lumbar spine, while a 2%–5% drop at 6 mo and a 6%–10.5% at 9–12 mo are observed at the total hip. Conversely, studies using quantitative CT showed a 6%–7% decrease in volumetric bone mineral density at the lumbar spine at 6-12 mo postsurgery. These studies also report significant bone loss at the radius and tibia, in addition to alteration in bone microarchitecture. Fracture risk increases 2 yr after surgery, more so following malabsorptive procedures. Fractures were reported at axial, weight bearing sites and at appendicular sites. The available evidence is very heterogeneous, and mostly derived from studies on Roux-en-y gastric bypass in premenopausal women. Data on restrictive procedures is scarce. Our findings suggest that the early postoperative phase represents the “golden window” to intervene and promote bone health. More research is needed to determine the effect of different bariatric procedures on bone, to identify optimal interventions to prevent bone loss and to characterize high risk individuals who should be targeted.     

Successful Multi-Intervention Treatment of Severe Obesity: A 7-year Prospective Study with 96% Follow-up

Background  No long-term, high participation study of the outcome of bariatric surgery has examined how a multi-intervention approach to the treatment of severe obesity can achieve and sustain weight loss after an initial bariatric procedure. Methods  We employed a multi-intervention treatment that combines adjustable gastric banding with intensive follow-up to support patient life-style change and use of an algorithm allowing reoperation—to bypass, if necessary—in the event of complications. Four hundred four severely obese patients with an average BMI = 42.6 at the outset had initial AGB surgery and were followed with a high rate of face-to-face consultations for 7 years. Seventy-five percent of the patients retained a gastric band throughout the study. Weight loss, complications, and comorbidities were studied, and quality of life was assessed using Bariatric Analysis and Reporting Outcome System (BAROS). Results  Three hundred eighty-eight (96%) patients completed the 7-year follow-up. Average BMI reduction at 5 years was 28% and remained stable through year 7, at which the mean excess weight loss was 61%. The preoperative prevalence of metabolic syndrome, 59.7%, decreased to 13.3% at 7 years and was abolished for patients with more than 40% loss of initial BMI. Similar changes were seen for all components of metabolic syndrome. More than 60% of patients had a “good” or higher BAROS score; 10.1% were considered failures. Patients converted to gastric bypass, and those retaining gastric bands throughout the study had very similar outcomes. Conclusions  Long-term, multi-intervention treatment of severe obesity can achieve and preserve weight loss and thus improved quality of life and sustained reduction or disappearance of all components of metabolic syndrome, for a high proportion of severely obese patients with preoperative BMI between 35 and 55.     

Laparoscopic Surgery for Morbid Obesity: 1,001 Consecutive Bariatric Operations Performed at the Bariatric Institute, Cleveland Clinic Florida

Background: Morbid obesity is an epidemic in America. This series evaluates the safety and efficacy in the first 1,001 laparoscopic bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida. Methods: A retrospective review was conducted examining all patients undergoing a primary bariatric procedure (either laparoscopic gastric bypass or laparoscopic gastric banding) from July 2000 to December 2003. Results: 2 surgeons performed 1,001 laparoscopic bariatric operatons. Average age was 47 (19-75) years, average BMI was 55.6 (35-97) kg/m², and average ASA class was III. Excess weight loss was 51% at 6 months, 73.4% at 1 year for the gastric bypass group and 54% at 1 year for the laparoscopic banding group. The overall complication rate was 31.8% (12.4% major and 19.4% minor) in the gastric bypass group and 13% in the laparoscopic banding group. There was no postoperative mortality. Conclusion: Laparoscopic bariatric surgery is feasible and safe for weight loss. Results obtained have been comparable to those reported for the open approach for weight loss, with a similar major morbidity rate and an improved mortality rate.     

Influence of Reoperations on Long-Term Quality of Life After Restrictive Procedures: A Prospective Study

Quality of life improves after bariatric surgery. However, long-term results and the influence of reoperations are not well known. A prospective quality of life assessment before, 1 and 7 years after laparoscopic adjustable gastric banding (LAGB) and vertical banded gastroplasty (VBG) was performed in order to determine the influence of reoperations during follow-up. One hundred patients were included in the study. Fifty patients underwent VBG and 50 LAGB. Patients completed the quality of life questionnaires prior to surgery and two times during follow-up. Health-related quality of life (HRQoL) questionnaires included the Nottingham Health Profile I and II and the Sickness Impact Profile 68. Follow-up was 84% with a mean duration of 84 months (7 years). During follow-up, 65% of VBG patients underwent conversion to Roux-en-Y gastric bypass while 44% of LAGB patients underwent a reoperation or conversion. One year after the procedure, nearly all quality-of-life parameters significantly improved. After 7 years, the Nottingham Health Profile (NHP)-I domain “physical ability”, the NHP-II and the SIP-68 domains “mobility control”, “social behavior”, and “mobility range” were still significantly improved in both groups. The domains “emotional reaction”, “social isolation” (NHP-I), and “emotional stability” (SIP-68) remained significantly improved in the VBG group while this was true for the domain “energy level” (NHP-I) in the LAGB group. Both the type of procedure and reoperations during follow-up were not of significant influence on the HRQoL results. Weight loss and decrease in comorbidities were the only significant factors influencing quality of life. Restrictive bariatric surgery improves quality of life. Although results are most impressive 1 year after surgery, the improvement remains significant after long-term follow-up. Postoperative quality of life is mainly dependent on weight loss and decrease in comorbidities and not on the type of procedure or surgical complications.     

Evolution of operative procedures for the management of morbid obesity 1950-2000

Background: At the turn of the 21st century, obesity is the epidemic with the greatest prevalence in the United States. Fifteen million people, 1 out of 20, in this country have a body mass index (BMI) ≥35 kgm². Obesity is not only a medical problem, but also a social, psychological, and economic problem. At present, the morbidly obese are refractory to diet and drug therapy, but have a substantial, sustained weight loss after bariatric surgery. Methods: This chronology of the landmark operations in bariatric surgery is based on a review of the medical literature. Results: Bariatric surgery can be classified into 4 categories: malabsorptive procedures, malabsorptive/restrictive procedures, restrictive procedures, and other, experimental procedures. The prototype of malabsorptive procedures and the first operation performed specifically to induce weight loss was the jejunoileal bypass. The problems associated with this operation caused its demise. Today's popular malabsorptive procedures are the biliopancreatic diversion and the duodenal switch. Malabsorptive /restrictive surgery currently is predicated on the Roux-en-Y gastric bypass, both the traditional short-limb, and the long-limb for the super obese. Restrictive procedures are represented by the banded and ringed vertical gastroplasty, as well as gastric banding. Experimental procedures include gastric pacing. All of these operations can be performed by open surgery and laparoscopically. Conclusions: Since bariatric surgery is the only broadly successful treatment for morbid obesity,it is incumbent on all physicians to be familiar with current bariatric operations, and to understand the evolution of bariatric surgery.     

The Gastric Band: First-Choice Procedure for Obesity Surgery

The advent of laparoscopic adjustable gastric banding (LAGB) during the latter part of the 20th century represents a watershed in the management of chronic obesity. In this paper we provide an overview of LAGB with respect to its development, clinical outcomes, and future role. We also address current controversies, including a comparison of LAGB with Roux-en-Y gastric bypass (RYGBP). At present LAGB seems to be increasing in popularity in the United States, whereas in Europe there seems to be a trend away from gastric banding toward RYGBP. Optimal outcomes after LAGB are a function of correct laparoscopic technique, an experienced surgical team, a well-engineered device, and intensive long-term follow-up. The majority of studies show that LAGB is an extremely safe and effective procedure, with an operative mortality of 0–0.1% and excess weight loss (%EWL) of 50–60%. Commensurate with this degree of weight loss, almost all studies show substantial improvements in obesity-related co-morbidities, such as hypertension, type II diabetes, and dyslipidemia. In addition, LAGB has been shown to be both safe and effective in the super-obese, in adolescents, and in older patients and can be delivered as an ambulatory procedure. Operative mortality and early complication rates are significantly higher for RYGBP and, whilst gastric bypass results in greater weight loss than LAGB in the first 2 years, at 3 years and beyond the difference appears to be less marked. Overall, LAGB provides a safe, effective intervention for obese patients and remains our first-choice procedure for bariatric surgery.     

Bone and mineral metabolism in patients undergoing Roux-en-Y gastric bypass

Summary

Despite effective weight reduction, the impact of bariatric surgery on bone is a major concern. Mechanisms include decreased mechanical loading, calcium and vitamin D malabsorption, deficiency in other nutrients, and alterations in fat- and gut-derived hormones. The evidence to support clinical care pathways to prevent bone loss and fractures is at this point weak.

Introduction

There is a growing concern regarding the potential deleterious impact of bariatric surgery on bone metabolism. This comprehensive review addresses this controversial topic.

Methods

We reviewed and analyzed articles evaluating bone metabolism and mechanisms for the ensuing putative bone loss in adult patients exclusively undergoing Roux-en-Y gastric bypass (RYGB) surgery, for the period spanning 1942 till September 2012.

Results

Mechanisms identified to contribute to alterations in bone metabolism after bypass surgery include: decreased mechanical loading, calcium and vitamin D malabsorption with secondary hyperparathyroidism, deficiency in other nutrients, in addition to alterations in adipokines, gonadal steroids, and gut-derived hormones favoring bone loss, with the exception of serotonin and glucagon-like peptide-1. The relative contribution of each of these hormones to changes in bone homeostasis after bypass surgery remains undefined. Bone loss reflected by a decline in bone mineral density (BMD) and an increase in bone turnover markers have been reported in many studies, limited for the most part by the exclusive use of dual energy X-ray absorptiometry. Well-designed long-term prospective trials with fractures as an outcome, and studies investigating the magnitude, reversibility, and impact of the observed metabolic changes on fracture outcomes are lacking.

Conclusion

Robust conclusions regarding bone loss and fracture outcome after RYGB surgery cannot be drawn at this time. Although not evidence based, baseline evaluation and sequential monitoring with measurement of BMD and calciotropic hormones seem appropriate, with adequate calcium and vitamin D replacement. Beneficial interventions remain unclear.     

Reduced Cardiovascular Risk Following Bariatric Surgeries is Related to a Partial Recovery from “Adiposopathy”

Background  

Altered cytokine secretion from dysfunctional adipose tissue or “adiposopathy” is implicated in obesity related inflammation and may mediate reduced cardiovascular disease (CVD) risk in response to weight loss after bariatric surgery. We hypothesized that bariatric surgery reduces CVD risk by favorably altering the pro-inflammatory profile of adipose tissue as a result of weight loss.     

Clinical Characteristics and Outcome of Morbidly Obese Bariatric Patients with Concurrent Hepatitis B Viral Infection

Background Bariatric surgery is the only effective and long-lasting treatment of morbidly obese patients. However, the safety and efficacy of bariatric surgery in patients with hepatitis B viral (HBV) infection is not clear. The aim of the present study is to investigate weather HBV infection influences clinic features and outcomes of bariatric surgery. Methods The preoperative seropositivity of HBV surface antigen (HBsAg) using radioimmunoassay was determined in 592 patients (481 female, 111 male: mean age 30.5 ± 8.1 years; mean body mass index [BMI] 43.1 ± 6.0) who had undergone bariatric surgery (209 banding and 383 gastric bypass) for their morbid obesity in the past 5 years. All the clinical data were prospectively collected and stored. Results The overall seroprevalence of HbsAg was 18.8%. Morbidly obese patients positive for HBV infection were associated with older age and higher diastolic blood pressure, but not with sex, BMI, liver enzyme, blood lipid, and glucose levels. Although minigastric bypass (MGB) had a better weight reduction than gastric banding, there was no difference in weight reduction between patients who were positive and negative for HBV infection. The weight loss curves and resolution of obesity-related comorbidities were similar between the two groups except the postoperative aspartate transaminase (AST) and alanine transaminase (ALT) were significantly higher in patients who were positive for HBV infection. During follow-up, two patients developed fulminating hepatitis after MGB with one mortality. Conclusion Morbidly obese patients with the existence of HBV infection do not influence the outcome of bariatric surgery, but continuing monitor of the liver function is indicated.     

The state of the art in bariatric surgery for weight loss in the morbidly obese patient

Bariatric surgery is a safe and effective method for achieving durable weight loss for patients with morbid obesity. Gastric restrictive procedures include vertical banded gastroplasty and gastric banding. Malabsorptive procedures include long-limb gastric bypass, biliopancreatic diversion, and biliopancreatic diversion with duodenal switch. The gastric bypass has features of both restriction and malabsorption. The laparoscopic approach to bariatric surgery has substantially improved postoperative recovery. Careful patient selection and preoperative work-up are extremely important. A number of medical comorbidities are improved after surgically-induced weight loss.     

Markers of Bone and Calcium Metabolism Following Gastric Bypass and Laparoscopic Adjustable Gastric Banding

BACKGROUND: Several studies have suggested that morbid obesity is associated with vitamin D deficiency and elevated parathyroid hormone (PTH). Studies have also suggested that there is an increase in vitamin D deficiency, bone resorption, and elevated PTH after gastric bypass surgery. Few studies have evaluated markers of bone and calcium metabolism after laparoscopic adjustable gastric banding or compared these results to those after gastric bypass. METHODS: Data on all patients undergoing primary gastric bypass (GBP; n = 979) and laparoscopic adjustable gastric banding (LAGB; n = 269) procedures at a tertiary-referral center from June 1996 through March 2005 were reviewed from a prospective database. Only patients with 25OH vitamin D levels available were included in this study (n = 534; GBP = 403, LAGB = 131). All patients were advised to take at least 1,200 mg calcium and 800-1,200 IU of vitamin D daily before and subsequent to their operation. Markers for bone metabolism [25OH Vitamin D, corrected serum calcium, alkaline phosphatase (AP), and PTH] were evaluated preoperatively and 3, 6, 12, and 24 months postoperatively. An analysis of variance and chi-square were performed to determine differences between the operative groups. Linear regression analysis was performed to evaluate the relationship between preoperative body mass index (BMI) and 25OH vitamin D and PTH levels and between percent excess weight loss and 25OH vitamin D and PTH after surgery. RESULTS: Sixty-four percent of all patients presented with vitamin D deficiency (<20 ng/ml) and 14% presented with elevated PTH preoperatively. Mean 25OH vitamin D levels and AP levels increased significantly after GBP surgery (vitamin D, 17 to 25 ng/ml 12 months post-op; AP, 80 to 90 IU/L 24 months post-op). Corrected calcium levels remained within normal limits and showed no change over time after both procedures. AP levels significantly increased from 76 IU/l preoperatively to 82 IU/l 6 months after LAGB surgery and then decreased to 59 IU/l 24 months after LAGB surgery. Linear regression analysis of preoperative vitamin D, PTH, and BMI values showed a significant positive relationship between initial BMI and PTH (r = 0.29) and a significant negative relationship between vitamin D and initial BMI (r = -0.19). A significant positive linear relationship between vitamin D and percent excess weight loss was evident 12 and 24 months after GBP surgery (r = 0.39 and 0.57, respectively). A negative relationship was evident between PTH and vitamin D 6 months after GBP surgery (r = -0.35) and 12 months after LAGB surgery (r = -0.61). CONCLUSIONS: These findings suggest that morbid obesity is associated with vitamin D deficiency, and elevated PTH and with adequate supplementation, GBP, and particularly LAGB, patients can improve their bone metabolism abnormalities related to obesity. Furthermore, adequate supplementation for GBP patients may attenuate the increased risk for bone loss associated with malabsorption from the bypass.     

Bariatric Surgery for the Treatment of Morbid Obesity: A Meta-analysis of Weight Loss Outcomes for Laparoscopic Adjustable Gastric Banding and Laparoscopic Gastric Bypass

Bariatric surgery has emerged as an important tool in the fight against morbid obesity. However, reviewers have noted that there is a scarcity of long-term clinical surveillance data for bariatric surgery beyond 1-year follow-up and that a high percentage of patients are lost to follow-up, raising questions regarding the accuracy of current outcomes estimates. A meta-analysis of clinical reports providing bariatric surgery weight loss outcomes for morbidly obese patients was conducted over the period 2003–2007. Studies included were randomized controlled trials, nonrandomized controlled trials, and consecutive case series involving patients receiving either laparoscopic adjustable gastric banding (LAGB) or laparoscopic gastric bypass (LGB) surgery. Included studies involved n = 7,383 patients and were largely academic hospital-based (78.6%) and retrospective in design (71.4%). Weight loss outcome was defined by percent excess weight loss (%EWL). Composite estimates showed a significantly greater %EWL for LGB surgery (62.6%) compared to LAGB (49.4%). The superiority of LGB persisted at all three postsurgical time points examined (1, 2, and >3 years). Problems were identified regarding incomplete or suboptimal data reporting in many studies reviewed, and high patient attrition was evident at 2-year (49.8% LAGB, 75.2% LGB) and >3-year (82.6% LAGB, 89% LGB) end points. This meta-analysis confirms the superiority of LGB to LAGB in %EWL found in earlier studies. Although problems in study quality raised significant concerns regarding the validity of current weight loss estimates in this area, there was no evidence of publication bias.     

Discrepancy Between Ideal and Realistic Goal Weights in Three Bariatric Procedures: Who Is Likely to Be Unrealistic?

Background  

Patients choose to undergo bariatric surgery for a variety of medical and psychosocial reasons. However, the majority of bariatric surgery candidates have unrealistic weight loss goals, and certain subgroups within this population may be more likely to endorse such beliefs. This study examines weight loss expectations in patients undergoing three different weight loss procedures (laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, or laparoscopic sleeve gastrectomy).     

Differential Changes in Dietary Habits after Gastric Bypass Versus Gastric Banding Operations

Background  Reduction of food intake is an important mechanism by which bariatric procedures reduce body weight. However, only few studies have systematically assessed what patients actually eat after different types of bariatric operations. Methods  Dietary habits were assessed by a food frequency questionnaire in 121 bariatric patients (48 gastric bypass patients, 73 gastric banding patients) during follow-up visits in our interdisciplinary obesity center as well as in 45 severely obese (body mass index (BMI) > 35 kg/m²) and 45 nonobese (BMI < 27 kg/m²) control subjects. Results  As compared with nonobese control subjects, obese control subjects consumed more meat, white bread, and diet soft drinks. Gastric bypass patients showed an enhanced consumption of foods rich in protein such as poultry, fish, and eggs as well as of cooked vegetables, while the consumption of fatty sweets like chocolate, cake, biscuits, and cookies was found to be distinctly reduced in this patient group. In contrast, gastric banding patients reported on a reduced intake of pasta, white bread, and fresh fruits and, just like gastric bypass patients, also on an enhanced intake of poultry and fish. Direct comparison of dietary habits between the two bariatric patient groups revealed that gastric bypass patients consumed more frequently fresh fruits, eggs, and diet soft drinks but strikingly less chocolate than gastric banding patients. Conclusion  Collectively, data clearly point to distinct changes in dietary habits after bariatric operations which markedly differ between gastric bypass and gastric banding patients. Overall, it is tempting to conclude that gastric bypass operations lead to a healthier and a more balanced diet than gastric band implantations. The authors have no commercial interest to disclose. The study was financially supported by a grant from Johnson & Johnson. The funder had no role in the study design, analysis, and publication of the data.     

Impact of Preoperative Teaching on Surgical Option of Patients Qualifying for Bariatric Surgery

Background: During the last 5 years, the performance of bariatric operations has doubled via our outpatient obesity clinic. Currently, 52% of the patients presenting for weight loss are interested in bariatric surgery. Gastric banding and Roux-en-Y gastric bypass are the two laparoscopic procedures proposed. The aim of this study was to evaluate the impact of preoperative teaching on the patients' surgical option. Methods: All the candidates for bariatric surgery were submitted to preoperative teaching and those between February 2001 and December 2002 are the subject of this study. The teaching consisted of 3 weekly interactive 2-hour sessions. During the first session, the patients were asked about the type of operation that they had in mind: gastric banding, gastric bypass, or not yet decided. The same questions were repeated at the end of the third session, with an additional possible answer: no surgery. Results: 297 consecutive patients with a BMI >35 kg/m² with at least one severe co-morbidity, were submitted to preoperative teaching. 80% of the patients were women. Median age was 41 years. Before teaching, 68 patients (23%) were uncertain, 100 (34%) favored gastric banding, and 129 (43%) wanted a gastric bypass. After education, only 3 patients (1%) remained uncertain, 45 (15%) changed their surgical option, and 27 (9%) declined surgery. The proportion of patients opting for gastric banding decreased from 34% to 20%, whereas those electing bypass increased from 43% to 70%. Conclusions: Preoperative training provides an informed and better patient selection for bariatric surgery. It helps the patients understand the various surgical options, and makes their decision easier.     

Surgery for Obesity: A Review of the Current State of the Art and Future Directions

The number of patients undergoing surgery for the treatment of obesity, and the proportion of the health care budget dedicated to this health problem, is growing exponentially. There are several competing surgical approaches for the management of morbid obesity. We review the literature relating to four of these: gastric bypass, biliopancreatic diversion, gastric banding, and gastric pacing. Our review finds that while enhancing the malabsorptive activity of these procedures may induce an incremental increase in excess body weight loss, the proportion of patients who fail to lose more than 50% of their excess body weight is similar no matter how radical is the surgery performed. There is little guidance from the literature as to appropriate patient selection for the varying procedures, and anonymously reported registries have yet to show that patients who undergo bariatric surgery have enhanced longevity. To date, the bariatric surgical community has not conducted adequately powered randomized prospective trials to elucidate key elements of the surgical procedure such as optimal bypass length, to determine whether mixed operations are superior to those that offer intake restriction only, and to define what constitutes success after bariatric surgery. As a public health measure, bariatric surgery in the United States is being pursued in an irrational manner, being concentrated in areas where there are fewer morbidly obese patients, and used disproportionately among the population of white obese females.     

Does patient compliance with preoperative bariatric office visits affect postoperative excess weight loss?

BackgroundThe amount of excess weight loss (EWL) achieved after bariatric surgery has varied considerably. Reliable preoperative predictors of the postoperative %EWL do not exist. Patient compliance with the physician recommendations has generally been believed to be important for long-term success after bariatric surgery, especially after gastric banding. We hypothesized that poor preoperative patient compliance with office visits, a likely indicator of overall compliance, would be associated with lower %EWL after bariatric surgery at a teaching hospital in the United States.MethodsWe performed an institutional review board-approved review of prospectively collected data from all patients undergoing bariatric surgery from 2007 to 2009. The patients were categorized into 2 groups: those who had missed <25% of all preoperative appointments at our bariatric center and those who had missed >25%. The average %EWL at 12 months between the 2 groups was compared using the unpaired t test separately for the gastric bypass and gastric banding patients.ResultsThe gastric band patients with >25% missed appointments had lost 23% EWL at 12 months compared with 32% EWL for the gastric band patients who had missed <25% of their appointments (P = .01). No difference was found in the %EWL for the gastric bypass patients according to the missed preoperative appointments. The postoperative compliance was significantly poorer than preoperatively.ConclusionThe patients with a greater percentage of missed preoperative appointments had a lower postoperative %EWL at 1 year after gastric banding but not after gastric bypass. This information could prove useful during patient selection or when counseling patients about the type of bariatric surgery to pursue.     

Evolution and Outcomes of a Canadian Pediatric Bariatric Surgery Program

PurposeAn interdisciplinary obesity management program was established in 2007 at our quaternary hospital, including bariatric surgery for selected adolescent patients. We report the evolution of surgical management within the program and outcomes following bariatric surgery.MethodsThis was a retrospective review of adolescents who underwent bariatric surgery between 2007 and 2017. All cases were performed by a pediatric surgeon and an adult bariatric surgeon. Baseline demographics, BMI, co-morbidities, and post-operative outcomes were recorded.ResultsThirty-eight patients underwent bariatric surgery. Median age at entrance into the program was 16.5 (range, 12.1–17.4) years and at time of surgery was 17.4 (range, 13.6–18.8) years. Eight patients had laparoscopic adjustable gastric banding (LAGB) from 2007 to 10. Between 2011 and 2017, 18 had laparoscopic sleeve gastrectomy (LSG), and 12 had laparoscopic Roux-en-Y gastric bypass (RYGB). There were no intraoperative complications or conversions. Postoperative complications included wound infection, bleeding requiring transfusion and re-exploration, and internal hernia. Of patients who had LAGB, 2 required surgical revision, and 3 underwent subsequent removal.ConclusionsAdolescent bariatric surgery in the context of a multidisciplinary obesity management program is safe and effective. RYGB and sleeve gastrectomy are associated with superior weight loss in the immediate post-operative period and at most recent follow-up and lower reoperation rates than gastric banding.Level of EvidenceIII.