Pregnancy outcomes after bariatric surgery: maternal, fetal, and infant implications.

Obese women who become pregnant face many health risks, including gestational diabetes, pregnancy-induced hypertension, and pre-eclampsia. These women also have a greater incidence of preterm labor, cesarean sections, and perioperative morbidity. Infants born to obese women have increased rates of macrosomia and congenital anomalies, as well as life-long complications such as obesity and its associated morbidities. With the increase in numbers of weight loss operations being performed in women of child-bearing age, physicians will have to address patient concerns regarding the safety of pregnancy after surgery. Many of the proposed health benefits of weight loss after surgery could translate to decreased rates of complications experienced by obese pregnant women. Case reports and small series have emerged documenting pregnancy courses after bariatric surgery. We reviewed the studies that reported pregnancy outcomes compiled from PubMed and Ovid databases to help draw conclusions regarding the maternal, fetal, and infant safety in women after bariatric surgery. The observations from these studies have shown that the health risks experienced by obese women during pregnancy are reduced after weight loss surgery. Additionally, there does not appear to be any increased risk regarding fetal or infant outcome.     

Pregnancies after Adjustable Gastric Banding

Background: We evaluated outcome of pregnancies of morbidly obese women who are within the first 2 years after laparoscopic adjustable gastric banding. Methods: 215 morbidly obese women of reproductive potential (age 18-45 years), who had agreed to remain on reliable contraceptives for 2 years after surgery, were retrospectively analyzed following bariatric surgery. Results: 7 unexpected pregnancies were observed. 5 pregnancies were full-term (3 vaginal and 2 cesarean deliveries). The birth weights ranged from 2110 g to 3860 g. 2 women had first trimester miscarriages. All gastric bands were completely decompressed due to nausea and vomiting, resulting in further weight gain. 2 serious band complications were observed (1 intragastric band migration and 1 balloon defect), which required re-operation. Conclusions: Pregnancy in morbidly obese women soon after adjustable gastric banding may occur unexpectedly during a period of weight loss. Prophylactic fluid removal from the band eliminates the efficacy of the obesity treatment. Moreover, this cohort shows an increased incidence of spontaneous abortions and band-related complications.     

Gastric Perforation as a complication of intragastric balloon

Obesity is considered the most common nutritional disorder in Western countries and is related to multiple morbidity and mortality. There are different options for obesity treatment, including diet, behavioral therapy, medications, and surgery. If patients do not meet the criteria for bariatric surgery, intragastric balloons may be used to achieve weight reduction. Currently, the intragastric balloon is one of the most common bariatric procedures in obese patients in Europe. Gastric perforation associated with intragastric balloon is a rare but dangerous complication. We report a case of a 42-year-old female patient who presented to the emergency department with acute abdomen. Chest x-ray in an erect posture indicated free gas under the diaphragm. She had undergone placement of an intragastric adjustable balloon device 13 months earlier and was overdue for removal of the balloon. In the emergency theater, a large perforated ulcer was found in the posterior wall of the stomach, which was repaired laparoscopically. Her postoperative course was uneventful. We also review the literature on intragastric balloon–induced gastric perforation. Our case is a very rare report of late gastric perforation after adjustable intragastric balloon placement. We recommend regular follow-up and removal in proper time after insertion of the gastric balloon.     

The Impact of Bariatric Surgery on Menstrual Patterns

Background: Obesity and anovulation are common medical problems in the United States. Anovulation in obese patients primarily manifests with irregular, sporadic or absent menstrual bleeding. Weight loss of at least 5% has been shown to reverse obesity-related anovulation. The aim of this study was to assess the impact of bariatric surgery on infertility in morbidly obese women and to identify factors associated with return of normal menses following bariatric surgery. Methods: A survey of patients was collected from the bariatric surgery data-base at the Hospital of the University of Pennsylvania. 410 women under the age of 40 were sent questionnaires. 195 patients completed the questionnaire, and 29 patients had incorrect addresses without a forwarding address, resulting in a 51.2% response rate. Patients who reported menstrual cycle lengths >35 days were considered abnormal. 92 of the 195 responders were considered anovulatory preoperatively, based on menstrual history. Results: There was no significant difference in postoperative BMI, BMI decrease or age at surgery between the survey responders and non-responders. There was a significant difference between these 2 groups in time since surgery (P=.01). Both groups had a decrease in BMI of >18 kg/m². The mean menstrual cycle length preoperatively among those categorized as ovulatory and anovulatory was 27.3 and 127.5 days, respectively. Of the 98 patients who were anovulatory preoperatively, 70 patients (71.4%) regained normal menstrual cycles after surgery. Those patients who regained ovulation had greater weight loss than those who remained anovulatory (61.4 kg vs 49.9 kg, P=0.02). Conclusions: Anovulation resulting in abnormal menses is a common problem in morbidly obese premenopausal women. The menstrual cycle disorders may completely resolve after bariatric surgery. Thus, infertility due to anovulation among morbidly obese women could potentially be viewed as an additional indication for bariatric surgery.     

Becoming pregnant within the first year after bariatric surgery adversely affects postoperative weight loss

BackgroundApproximately 80% of the patients undergoing bariatric surgery are female, with half of them undergoing surgery during their reproductive years. Most guidelines recommend that women wait at least 12 months after surgery before becoming pregnant. No previous studies have investigated whether becoming pregnant in the first or second year after surgery affects weight loss.ObjectivesThe aim of this study was to assess whether pregnancy within the first or second year after bariatric surgery affects weight loss up to 5 years after surgery.SettingA single institution.MethodsThis study is a retrospective study of women who underwent primary bariatric surgery between 2012 and 2016. Weight outcomes were measured until 5 years after surgery. A linear mixed model was used to assess the effect of the time between surgery and conception in groups on the basis of percentage total weight loss.ResultsA total of 55 patients undergoing a primary bariatric procedure were included. Forty-seven women underwent a laparoscopic Roux-en-Y gastric bypass (85.5%), and 8 underwent a sleeve gastrectomy (14.5%). The median time between surgery and estimated conception was 22 months (range: 0–51 months). Women who became pregnant between 12 and 24 months after bariatric surgery (n = 18) and women who became pregnant after 24 months (n = 24) had significantly more weight (β = 3.95, P = .020, and β = 4.09, P =.024, respectively) than women who became pregnant within 12 months after bariatric surgery (n = 12).ConclusionOur results suggest that pregnancy within 12 months after bariatric surgery negatively affects the long-term weight loss after bariatric surgery.     

Outcome of Pregnancies after Biliopancreatic Diversion

Background: Severe obesity has deleterious effects on fertility and pregnancy outcomes. Although surgery is the best long-term treatment for severe obesity, there is a risk of gestational undernutrition in operated mothers because bariatric surgery reduces nutrient availability. This is a follow-up report of our initial findings regarding pregnancy and neonatal outcomes in biliopancreatic diversion (BPD) patients, with addition of a new cohort of children born to mothers after BPD. Methods: All women (n = 916) who had successfully undergone BPD in our hospital were mailed a questionnaire containing multiple-choice and essay questions concerning gynecologic and obstetric history, and pregnancy and neonatal outcomes in both preoperative and postoperative pregnancies. Patients operated between 1984 and 1995 (n = 568) were mailed an additional questionnaire regarding children's weight and height progress, and school performance. Perinatal records from our patients' obstetric clinics were also reviewed. Results: The questionnaire was completed by 783 women (85.5%). 251 postoperative pregnancies in 132 women resulted in 166 infants by 109 mothers. 47.0% of patients who were unable to become pregnant preoperatively were successful postoperatively. 90 out of 109 women (82.6%) reported an appropriate weight gain (9.1 ± 5.9 kg) during postoperative pregnancies. The incidence of fetal macrosomia decreased from 34.8 to 7.7%, with a concomitant increase in normalweight babies from 62.1 to 82.7%. The elevated miscarriage rate (26.0%) in these obese women persisted after surgery. Conclusion: Major weight loss following BPD improves the reproductive function of severely obese women. BPD provides major beneficial effects for both mother and child, including normalization of gestational weight changes, reduction of fetal macrosomia, and normalization of the infant's birth-weight. Our results speak in favor of delaying pregnancy in obese women until after the substantial surgical weight loss has occurred.     

Intragastric Balloon Treatment for Obesity: Results of a Large Single Center Prospective Study

Background  

The intragastric balloon is a widely used method in the treatment of obesity indicated for those patients who have failed to achieve and maintain the weight loss with conventional measures or for preparation of patients who are candidates for bariatric surgery.     

Intragastric Balloon (BIB system) in the treatment of obesity and preparation of patients for surgery - own experience and literature review

Despite the recognition of bariatric surgery as the only effective method of weight reduction, we remain in search of minimally invasive methods, both for the treatment of obesity and preparation of patients for surgical procedures. The aim of the study was to determine intragastric balloon (Allergan) implantation results as the only method of treating obesity, and patient preparation for further stages of abdominal hernia operations, as well as other surgical procedures. MATERIAL AND METHODS: The study presented own results considering the use of Bioenteric Intragastric Balloons (BIB system) in the treatment of pathological obesity, and preparation of patients for bariatric surgery and abdominal hernia operations. The study group comprised 18 female and 7 male patients. Average patient age amounted to 50.6 and 54 years, respectively. Indications for intragastric balloon insertion were as follows: preparation for hernia (10 cases) and bariatric (5 patients) operations, and weight reduction management (8 patients). In two cases the implantation of the intragastric balloon served the preparation for gynecological and orthopedic (vertebral column) operations. One female patient was prepared for both bariatric and hernial surgery. The procedure was performed under general anesthesia. Statistical analysis considered 22 patients (one female patient was excluded from analysis, due to death, two other were excluded because of lack of sufficient data).Results. In case of two patients the intragastric balloon system was removed before 6 months had elapsed because of intolerance. One female patient died during the observation period for reasons not related to the procedure. The obtained BMI reduction ranged between 2 and 6 kg/m2, which amounted to a maximum weight loss of 24 kg. In one patient a weight gain of 2 kg was observed. Considering patients prepared for abdominal hernia operations weight reduction was greater and better maintained after the removal of the BIB system. CONCLUSIONS: According to the authors of the presented study the intragastric balloon serves its role as a bridge to bariatric procedures and weight reduction, before planned extensive postoperative hernia operations. The use of the intragastric balloon only to reduce weight has no medical and economic justification.     

The Intragastric Balloon – Smoothing the Path to Bariatric Surgery

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

Intragastric balloon outcomes in super-obesity: a 16-year city center hospital series

Background

Intragastric balloons represent an endoscopic therapy aimed at achieving weight loss by mechanical induction of satiety. Their exact role within the bariatric armamentarium remains uncertain.

Short- and Long-Term Efficacy of Intragastric Air-Filled Balloon (Heliosphere? BAG) Among Obese Patients

Background

Obesity is an increasing health problem worldwide. The intragastric balloon as a temporary endoscopic treatment of obesity can play an important role among the aforementioned group of obese individuals. It can also be used as a preoperative test before subjecting patients to restrictive bariatric surgery. Furthermore, the intragastric device may be applied to patients affected by severe obesity as a ??bridge treatment?? before they undergo major surgery in order to reduce chances of operation-related risks. To date, there are insufficient data in the literature on the long-term results of the intragastric balloon.

Methods

Our study includes an analysis of our experience with Heliosphere? BAG from 2006 through to 2010, concerning early weight loss and weight loss maintenance over at least 18?months since the device??s removal. The 32 patients who completed the 6-month treatment had recorded a mean weight loss of 12.66?kg and a mean overweight loss of 24.37?% (SD, 12.74).

Results

A total of 16 patients are subjected to an 18-month follow-up. Their pretreatment and long-term body mass index (BMI) were calculated: 6?months later, when devices were removed, they showed a mean weight of 99.75?kg (SD, 17.90; p?<?0.001) and a mean weight loss of 13.62?kg and 26.14?% (SD, 12.79). 18?months after removing Heliosphere? BAG, the 16 patients?? mean BMI was 37.28?kg/m2 (SD, 5.41; p?=?0.004), with a mean weight of 103.56?kg (SD 17.25; p?=?0.0125), and a mean weight loss of 9.8?kg or 18.2?% (SD, 12.07).

Conclusions

Heliosphere? BAG enables modest short-term weight loss with little side effects, although mid/long-term follow-up may entail partial weight gain. We believe it can be considered a useful bridge treatment in bariatric surgery in order to reduce chances of preoperative risks.     

Obesity： modern man＇s fertility nemesis

The obesity pandemic has grown to concerning proportions in recent years, not only in the Western World, but in developing countries as well. The corresponding decrease in male fertility and fecundity may be explained in parallel to obesity, and obesity should be considered as an etiology of male fertility. Studies show that obesity contributes to infertility by reducing semen quality, changing sperm proteomes, contributing to erectile dysfunction, and inducing other physical problems related to obesity. Mechanisms for explaining the effect of obesity on male infertility include abnormal reproductive hormone levels, an increased release of adipose-derived hormones and adipokines associated with obesity, and other physical problems including sleep apnea and increased scrotal temperatures. Recently, genetic factors and markers for an obesity-related infertility have been discovered and may explain the difference between fertile obese and infertile obese men. Treatments are available for not only infertility related to obesity, but also as a treatment for the other comorbidities arising from obesity. Natural weight loss, as well as bariatric surgery are options for obese patients and have shown promising results in restoring fertility and normal hormonal profiles. Therapeutic interventions including aromatase inhibitors, exogenous testosterone replacement therapy and maintenance and regulation of adipose-derived hormones, particularly leptin, may also be able to restore fertility in obese males. Because of the relative unawareness and lack of research in this area, controlled studies should be undertaken and more focus should be given to obesity as an etiolgy of male infertility.     

减重手术与妊娠：影响、利弊与时机选择

肥胖不但影响育龄期女性生殖健康,同时也会增加母亲和胎儿发生并发症的可能性;减重手术改善了肥胖相关的生育能力低下。运动、饮食以及药物等传统的治疗方法都有其局限性,减重手术是目前最为有效、持久的对于肥胖的治疗方式,在达到减轻体质量的同时能够显著改善肥胖相关合并症。随着接受减重手术的肥胖育龄期女性越来越多,减重手术后妊娠也受到学界更多的关注。然而,目前仅有少数研究评估了减重手术对妊娠相关结局的影响,国内相关的文献更是匮乏。笔者就减重手术对妊娠相关结局的影响以及术后合理的妊娠时机进行总结,以期更好地指导减重手术前后妊娠相关事件的处理,获得最佳的妊娠结局。     

Intragastric balloons for morbid obesity: results, patient tolerance and balloon life span

Sixty morbidly obese patients were treated with 88 intragastric balloons. An air-filled intragastric balloon was used, which was permanently connected to an inflation catheter exiting through the nose. Patients were evaluated for loss of body weight and tolerance of the balloon; the balloon was inspected for efficacy and safety. A mean total loss of body weight of 21 kg was obtained after a mean of 39 weeks in 15 men (mean age 37.7 years) and 45 women (mean age 36.2 years), with a mean initial weight of 127.9 kg. The maximum rate of weight loss occurred in the first 6 months, with a steady decrease of 1 kg per week; thereafter the rate declined. Subjective complaints were infrequent and consisted of nasal discomfort or abdominal symptoms. Intolerance in 12 per cent of patients was due to enhanced hunger (one patient), nasal pulling sensation (four patients) and symptomatic ulcer (two patients). Fifteen patients asked for removal of the well functioning balloon after a mean of 169 days; 14 of the 15 balloons were still airtight. Forty balloons failed prematurely. Nine were retrieved orally and 31 were passed per anum, of which 28 passed with mild abdominal cramping, two patients required transabdominal puncture and one needed laparotomy. Even the 40 prematurely removed balloons remained in situ for a mean of 108 days; only one-third showed leakage. As yet, 33 well functioning balloons have been in situ for a mean of 167 days. Well functioning balloons deflated at a rate of 2.3 ml per day. Malfunctioning of the balloon was due to leakage in 12 cases and to clogging of the inflation catheter in three cases. Major complications (8 per cent) included two gastric ulcers and three cases of mild ileus. One ileus patient required surgery (2 per cent). The reported intragastric balloon model is effective and safe. We recommended this type of balloon as a weight reducing adjuvant therapy before bariatric surgery.     

Gastric Perforation as a Complication after BioEnterics Intragastric Balloon Bariatric Treatment in Obese Patients—Synergy of Endoscopy and Videosurgery

The BioEnterics intragastric balloon (BIB) is one of the most common bariatric procedures in obese patients in Europe. Associated gastric perforation is a rare, yet very dangerous, complication. We report a case of such a complication after BioEnterics intragastric balloon insertion in a 60-year-old female patient and subsequent cooperation between an endoscopist and bariatric videosurgeon in her treatment.     

减重手术后妊娠风险和时机的临床研究进展

目前在世界范围内,超重和肥胖的育龄女性逐年增加。除了合并糖尿病、高血压等慢性疾病外,他们还可出现性激素的代谢紊乱,表现为月经不规律、不孕症以及产科并发症等。减重手术是减轻体重和纠正肥胖相关并发症的有效方法。肥胖育龄女性在接受减重手术后,生育能力显著改善,妊娠几率提升。另一方面,肥胖女性在减重术后受孕的时机,对减重手术效果、妊娠并发症、分娩结局及母子近远期结局的影响值得探讨。本文就育龄肥胖女性施行减重手术后受孕时机和减重效果及妊娠风险与结局的临床研究进展做一综述。     

Successful pregnancy in morbidly obese lady with polycystic ovary syndrome after bariatric surgery: A case report

IntroductionObesity has been proven to have adverse effects on fertility and is one of the predisposing factors for delay in pregnancy even with the use of assisted reproductive technique. There are many pathways in which obesity can affect fertility such as anovulation, poor implantation and low-quality oocyte.Case presentationWe report a case of a 40-year-old lady with primary infertility for six years with underlying polycystic ovary syndrome (PCOS) and BMI 45.7 whom was successfully conceived twice following bariatric surgery procedure in which reduction of 70% of her BMI prior to bariatric surgery lead to her spontaneous conception without fertility intervention and successful live birth.Clinical discussionObese PCOS needs multidisciplinary approaches which include weight loss program such as dietary advice, exercise intervention as part of preliminary treatment prior to ovulation induction and counselling.ConclusionBariatric surgery has been a mainstay treatment in patients with morbid obesity and those with BMI more than 35 associated with obesity related problems such as joint pain, hypertension or diabetes mellitus. Bariatric surgery such as laparoscopic sleeve gastrectomy should be considered more often in contrast to lifestyle modification for morbidly obese lady with PCOS and infertility prior to the use of standard ovulation induction regime for treating infertility.     

Bariatric Surgery, Safety and Type 2 Diabetes

Obesity and type 2 diabetes (T2D) represent major health concerns in the USA. Weight loss is the most important aspect in T2D management, as it reduces both morbidity and mortality. Available lifestyle, behavioral, and pharmacological strategies provide just mild to moderate weight loss. The greatest degree of T2D prevention or T2D amelioration in obese subjects has been reported in subjects who underwent bariatric surgery. In the current review, we will describe various types of bariatric surgery, related safety profiles, and their effect on T2D, as well as the potential mechanisms involved in the remission of T2D. Finally, we hereby examine whether bariatric surgery may be considered a treatment for T2D in pregnant women, children, adolescents and subjects at least 65 years old.     

Psychosocial aspects of obesity and obesity surgery

There is a growing consensus that bariatric surgery is the treatment of choice for extremely obese individuals who have failed to reduce their weight satisfactorily using behavioral or pharmacologic interventions. The gastric bypass in particular is associated with excellent long-term weight loss. Although most extremely obese individuals will have essentially normal psychological functioning, a significant minority suffer from depression, binge eating, trauma, or other emotional complications that may require treatment before or after bariatric surgery. A structured behavioral assessment, conducted by a mental-health professional and a registered dietitian, can readily identify those who are most likely to require adjunct counseling.     

Maternal nutritional status and related pregnancy outcomes following bariatric surgery: A systematic review

Up to 80% of patients who undergo bariatric surgery are women of childbearing age. Coupled with improved fertility in women with obesity after bariatric surgery, pregnancy postbariatric surgery has become increasingly more common. Although numerous studies have evaluated associations of bariatric surgery with pregnancy outcomes, the effect of maternal nutritional status on maternal and perinatal outcomes is not well established. We used Medline and Embase databases and a manual search of references for articles published until June 2018 to conduct a systematic review on nutritional status after bariatric surgery and its association with maternal and perinatal outcomes. Of the 306 initially identified articles, 27 met the study inclusion criteria, comprising 2056 women with pregnancies after bariatric surgery. Deficiencies were reported in maternal concentrations of vitamins A, B1, B6, B12, C, D, K, iron, calcium, selenium, and phosphorous. The only adverse events documented for these deficiencies encountered during pregnancy were anemia (vitamin B12, iron), night blindness (vitamin A), and urinary tract infections (vitamin A, D). This systematic review suggests that various micronutrient deficiencies are common among pregnant postbariatric surgery patients. Nevertheless, despite the concern that these deficiencies could adversely affect pregnancy outcomes (e.g., lower neonatal birth weight), evidence of such is lacking. Further prospective studies are warranted to confirm our findings and better delineate the optimal supplementation regimen during pregnancy after bariatric surgery.