Psychological Gender Differences in Bariatric Surgery Candidates

Background Over 177,000 bariatric surgeries were performed in 2006. Most patients are required to receive presurgical psychological clearance, although there are no empirically validated psycho-surgical risk factors. In an effort to establish normative data on suspected risk factors, the present study was conducted to determine if males and females differ on psycho-surgical risk factors. Methods Subjects consisted of 361 consecutive bariatric surgery candidates undergoing a psychological evaluation in a private practice setting. They were administered the PsyBari, a test that detects and measures psycho-surgical risk factors, and the Beck Depression Inventory (BDI-2). Results The results indicate that males have significantly higher BMIs than females (p = 0.035). Females have tried significantly more diets than males (p < 0.000). Females are significantly more likely to report a history of depression than males (p < 0.000). Females received significantly higher scores on the PsyBari Depression Index than males (p < 0.000.). Females received significantly higher BDI-2 scores than males (p < 0.001). Females are significantly more likely to report a history of anxiety than males (p = 0.004). Females received significantly higher scores on the PsyBari Social Anxiety Index than males (p = 0.038). Conclusion The results indicate that males and females differ significantly on suspected psycho-surgical risk factors. Assessments of bariatric surgery candidates should recognize that males and females have different baselines for psycho-surgical risk factors. Further research on bariatric surgery candidates should report results separated by gender.     

Psychosocial Status in Adolescents Undergoing Bariatric Surgery

Background Little is known about the psychosocial status of adolescents who undergo bariatric surgery. Our objective was to describe the psychological and behavioral characteristics of patients in this age group who underwent bariatric surgery at our institution. Methods A review of clinical charts of patients aged 14–21 years who had bariatric surgery at our institution between 2000 and 2005 was conducted. Abstracted data included clinical information and the results of a psychosocial evaluation consisting of a clinical interview with a psychologist and self-reported data from the Weight and Lifestyle Inventory and the Beck Depression Inventory-II. Results Twenty-five patient records were reviewed. Nineteen patients (76%) were female. The mean (±SD) age was 18.7 ± 1.6 years, and mean body mass index was 50.6 ± 7.9 kg/m². Depression was the most common psychiatric comorbidity (68%). Abnormal eating behaviors were frequent and included binge eating (48%), rapid eating (44%), having guilt associated with eating (36%), eating until uncomfortably full (36%), loss of control (24%), eating without hunger (24%), and eating alone (20%). Sixteen patients were judged to be appropriate for surgery by the bariatric surgery team; surgery was delayed for nine patients primarily because of concerns about ability to adhere to the postoperative diet. These patients were recommended for additional dietary counseling and/or psychotherapeutic treatment prior to surgery. Conclusions Among adolescent bariatric surgery candidates, depression and aberrant eating behaviors were very common. Early identification and management of these conditions may enable most of these patients to undergo bariatric surgery and optimize the likelihood for a successful outcome.     

Prophylaxis of Thromboembolism in Bariatric Surgery with Parnaparin

Background There are limited data on appropriate dosing of low-molecular-weight heparins (LMWHs) for venous thromboembolism (VTE) prophylaxis in bariatric surgery. The primary objective of this preliminary study was to evaluate the preoperative effects of increasing doses of the LMWH parnaparin on coagulation in severely obese patients undergoing bariatric surgery. Methods Severely obese patients (BMI > 50 kg/m²) were administered three increasing single doses of parnaparin (3200, 4250, and 6400 IU) on the three consecutive days leading up to biliointestinal bypass surgery. Activated partial thromboplastin time (APTT), anti-factor IIa and anti-factor Xa levels were measured 1 h before and 4 h after dosing. The highest dose (6400 IU/day) was continued from the day of surgery until day 30 (recovery period). Intermittent pneumatic compression and stockings were applied during surgery and the recovery period, respectively. Lower limb echoDoppler and phleboscintigraphy, and pulmonary scintigraphy were used for VTE detection. Results Ten patients (mean BMI 52.4 kg/m²) were recruited into this study. During the preoperative dosing phase, parnaparin dose-dependently prolonged APTT, with the 6400 IU dose significantly prolonging APTT versus the lower doses. Meanwhile, anti-factor Xa and anti-factor IIa activity was increased by the 4250 and 6400 IU doses. After surgery, one patient with heparin resistance experienced pulmonary embolization. No bleeding complications were observed. Conclusion The dose–response data reported in this preliminary study suggest that parnaparin doses of 4250 and 6400 IU may provide effective prophylaxis for VTE in patients undergoing bariatric surgery. However, given the small number of patients, larger, well-controlled trials are required to confirm these findings.     

Patient Motivations and Goals for Bariatric Surgery: A Mixed Methods Study

BackgroundExisting research has primarily focused on weight as the outcome of interest for bariatric surgery; however, patients frequently report other lifestyle and interpersonal surgery motivations and goals. Understanding the spectrum of bariatric surgery goals and motivations has important implications for enhancing patient-centered care and surgery outcomes.ObjectivesThe current study characterized the nature of bariatric patient motivations and goals for surgery, described the extent to which motivations matched goals, and examined whether men and women differed in the specific motivations/goals described.SettingTeaching hospital, United StatesMethodsData were obtained via retrospective chart review of bariatric patient responses to the clinic’s standard open-ended questions about motivations and goals for bariatric surgery. A mixed method approach was used, including content analysis, to identify themes and χ²/t test analyses to test gender differences.ResultsSurgery motivations and outcome goals were reflected by 8 overarching and overlapping themes. The most common motivations were related to general health and quality of life. The most common goals were to improve health/longevity and mobility. Over a quarter of patients showed no overlap between motivations and goals. Few gender differences were observed.ConclusionFindings underscore the importance of goals beyond weight loss, as well as the utility of helping patients shape their goals in accordance with goal-setting theories.     

Bariatric Surgery: A History of Empiricism, a Future in Science

Background  The observation that obesity can be successfully treated by gastrointestinal surgery is a tribute to the innovative efforts by determined surgeons and the ever improving safety of general anesthesia. Yet as the body of knowledge and discovery on the root causes of human obesity accumulate, surgical approaches to treat morbid obesity are likely to change dramatically. While there is little doubt that dramatic weight loss can be achieved by surgically creating volume and absorption limitation to the reservoir and digestive functions of the gastrointestinal tract, human progress to more processed foods, less physical activity, and the pervasive public opinion that obesity is self-imposed are major obstacles to more widespread application of this approach. Discussion  Here we provide a mechanico-physiologic analysis of current operations, their rationale and limitations, as well as a glimpse of how future interventions might develop as a result of current knowledge in the field. The future of bariatric surgery is discussed in the context of these emerging technologies and in the context of the politics of obesity.     

Hemorrhagic and Thromboembolic Complications after Bariatric Surgery in Patients Receiving Chronic Anticoagulation Therapy

Background Perioperative management of bariatric surgical patients receiving chronic anticoagulation requires an understanding of potential hemorrhagic and thromboembolic risks. The aim of this study is to evaluate hemorrhagic and thromboembolic complications in morbidly obese patients who are on oral anticoagulation treatment and subsequently undergo laparoscopic bariatric surgery. Methods The medical records of all laparoscopic Roux-en-Y gastric bypass (LRYGB) patients from June 2001 to March 2006 were retrospectively reviewed. In addition, data of patients who received chronic anticoagulation therapy with Coumadin and underwent laparoscopic Roux-en-Y gastric bypass was analyzed. Clinical parameters included length of hospitalization, hemorrhagic complications, thromboembolic complications, conversion rate, reoperation, and blood transfusion. Results During the study period, 1,700 consecutive patients underwent bariatric surgery for the treatment of morbid obesity. Of these, 21 patients were treated with chronic oral anticoagulation; 3 of the 21 (14%) had hemorrhagic complications: one patient had intraluminal hemorrhage and two patients had intraabdominal hemorrhage. Two patients required blood transfusion, and one patient underwent surgical reintervention. None of the 21 laparoscopic operations were converted to open procedures. There were no postoperative mortalities, and there were no thromboembolic events in this series. Conclusions Laparoscopic bariatric surgery can be performed relatively safely in morbidly obese patients who are treated with chronic oral anticoagulation. Even in the presence of bleeding, patients can be successfully treated without the need for reoperation.     

Bariatric Surgery Improves Atherogenic LDL Profile by Triglyceride Reduction

Background  Small dense low-density lipoprotein (LDL) are atherogenic particles frequently observed in obese patients. Fatty acids modulate LDL. Objective of this study was to determine the relations between plasma phospholipid fatty acid composition and the presence of small dense LDL particles in morbidly obese patients treated with laparoscopic gastric banding (LAGB). Methods  Small dense LDL, plasma lipids, lipoproteins, apoproteins, and phospholipid fatty acid composition (a marker of dietary fatty acid intake) were quantified before and 12 months after surgery in four men and 11 women who were morbidly obese and (BMI > 40 kg/m²) eligible for surgery, consecutively treated with LAGB at the Department of Medical and Surgical Sciences of the University of Padova. Results  BMI was 48.3 ± 4.8 kg/m² before and 36.1 ± 5.5 kg/m² after LAGB. Plasma triglycerides and apoprotein E levels significantly decreased, while HDL cholesterol significantly increased after LAGB. A reduction of small dense LDL with an increase of LDL relative flotation (0.34 ± 0.04 before vs 0.38 ± 0.03 after LAGB, p < 0.001) was also observed. These modifications were neither related to weight reduction nor to changes in phospholipid fatty acid composition, but they were associated to triglyceride reduction, which explained 76.7% of the LDL relative flotation variation. Conclusion  Weight loss obtained by LAGB in morbidly obese subjects was accompanied by triglyceride reduction, high-density lipoprotein increase, and an improvement of the atherogenic LDL profile. Triglyceride reduction, but not the extent of weight loss or dietary fatty acid modifications, is the determinant of modifications of LDL physical properties in these patients.     

术前饮食行为对减重手术效果的影响

目的: 探讨术前饮食行为对减重手术效果的影响,为预测减重手术效果提供参考。方法: 采用荷兰饮食行为问卷（Dutch Eating Behavior Questionnaire, DEBQ）及相关评分标准,对85例肥胖症行腹腔镜胃袖状切除的减重手术病人进行分组,分为限制性饮食组44例和非限制性饮食组41例,其中限制性饮食组再分为成功限制亚组27例与失败限制亚组17例。分别比较术前不同饮食行为组及亚组之间术后6、12个月的体重、体质量指数（body mass index, BMI）及多余体重减少率（excess weight loss, %EWL）改变。结果: 85例病人均成功接受减重手术。限制饮食组术后6、12个月体重和BMI显著高于非限制组,%EWL显著低于非限制组。限制饮食组中,成功限制亚组术后6、12个月体重和BMI显著高于失败限制亚组,%EWL显著低于失败限制亚组。结论: 术前饮食行为显著影响减重手术结果,可作为预测减重手术效果的参考。     

Childhood Maltreatment and Psychiatric Morbidity in Bariatric Surgery Candidates

Background This study used standardized assessments to evaluate the association between childhood maltreatment (i.e., emotional, physical, and sexual abuse and emotional and physical neglect) and Axis I and II psychiatric disorders in patients presenting for bariatric surgery. Methods Participants (N = 230) provided demographic information and completed the Childhood Trauma Questionnaire, short form. The Structured Clinical Interview for the DSM-IV was used to assess Axis I clinical disorders and Axis II personality disorders. Results Approximately 66% of participants had a history of childhood maltreatment. Individuals reporting childhood maltreatment had a greater number of lifetime Axis I diagnoses than did those without, although the effect for physical neglect was no longer significant after controlling for multiple comparisons. With respect to specific Axis I diagnoses, a history of emotional or sexual abuse was associated with increased rates of lifetime mood and anxiety disorder diagnoses. Emotional neglect also was associated with increased rates of mood disorder diagnoses, and physical abuse was associated with increased rates of substance use disorders. There was no significant association between childhood maltreatment and personality psychopathology. Conclusion This study confirms high rates of childhood maltreatment in patients presenting for bariatric surgery that are associated with increased prevalence of lifetime mood, anxiety, and substance use disorders. Future prospective studies should include evaluation of a broad range of mental health and childhood experiences to tease apart the nature of the relationships between these factors and their potential impact on post-surgical outcomes.