Results of Biliopancreatic Diversion in Two Patients with Prader-Willi Syndrome

Prader-Willi Syndrome (PWS) is a genetic disorder characterized by hypotonia, mental retardation or learning disability, hyperphagia and compulsive eating due to hypothalamic dysfunction. Obesity is a major cause of increased morbidity and mortality among patients with PWS. Gastric restrictive surgery has been associated with partial breakdown of the staple-line in PWS. We report two patients with PWS associated with morbid obesity and obstructive sleep apnea who underwent biliopancreatic diversion (BPD). A 27-year-old male with BMI 52 kg/m² and a 20year-old female with BMI 64 kg/m² underwent BPD. No perioperative complications were observed. After BPD, the male's BMI was 36.7 kg/m² at 12 months and the female's BMI was 48.4 kg/m² at 28 months, with excess weight loss 58% and 48%, respectively. They developed loose stools associated with eating. These patients have shown a considerable improvement in hypersomnia and respiratory difficulties. BPD proved to be an effective approach to weight loss in PWS, resulting in improvement of sleep apnea, behavior problems and quality of life.     

Combining Laparoscopic Adjustable Gastric Banding and Biliopancreatic Diversion after Failed Bariatric Surgery

Background: A percentage of all types of bariatric surgery will fail. Our experience with failed biliopancreatic diversion (BPD) as a primary operation or revision operation for failed laparoscopic adjustable gastric banding (LAGB) convinced us that uncontrolled hunger is often the underlying cause. To control hunger after failed bariatric surgery,a novel approach combining LAGB with BPD-duodenal switch (DS) has been tried. Methods: Patients who had failed to lose weight after BPD or LAGB were considered in 2 groups. Group 1: patients who had failed LAGB underwent laparoscopic BPD-DS without sleeve gastrectomy, with the LAGB left in-situ. Group 2: patients who had failed primary (subgroup 2a) or revision (subgroup 2b) BPD had a LAGB placed with no other revision of their surgery. Results: 11 patients have undergone this form of revision surgery with little morbidity. Mean age at the original operation was 45 years, mean (range) BMI was 45.3 (38-62) kg/m². After the reoperation, at 3 months (9 patients) mean BMI was 30 kg/m² and at 6 months (4 patients) mean BMI was 27 kg/m². Conclusion: In this small study, combination surgery was safe and effective for failed BPD or LAGB. LAGB failure may be best managed with DS malabsorption without gastric resection.     

Laparoscopic Reoperative Sleeve Gastrectomy for Poor Weight Loss after Biliopancreatic Diversion with Duodenal Switch

Background: The revisional surgery for patients with inadequate weight loss after biliopancreatic diversion with duodenal switch (BPD/DS) is controversial. It has not yet been determined whether a common channel should be shortened or gastric pouch volume reduced. Since the revision of the distal anastomosis remains technically difficult and associated with possible complications, we turned our attention to the reduction of gastric sleeve volume. This operation is more feasible and potential complications are less probable. Patient and Method: We present the case of a 47-year-old women with a life-long history of morbid obesity. She was operated on in January 2000 with a laparoscopic BPD/DS with 100 ml gastric pouch, 150 cm of alimentary limb and 100 cm of common channel. Before this operation, her weight was 170 kg, with BMI 64 kg/m². She lost most of her excess weight within 17 months after surgery and was regaining weight at 77 kg and BMI 29 kg/m². Upper GI series showed a markedly dilated gastric pouch. Her second surgery consisted of a laparoscopic sleeve partial gastrectomy along the greater curvature using endo GIA staplers with bovine pericardium for reinforcement of the stapler line. Results: No postoperative complications occurred. The patient was discharged on the first postoperative day. Significant further weight reduction was noted, and at 10 months after surgery, her weight is 61 kg with BMI 22. Conclusion: A repeat laparoscopic gastric sleeve resection was performed for inadequate weight loss after BPD/DS, and resulted in further weight reduction.     

Results of Biliopancreatic Diversion after Five Years

Background: Gastric restrictive procedures, currently the most popular surgical operations for morbid obesity, have proved to be effective in initiating weight loss, but questions regarding their long-term efficacy in weight maintenance have arisen. Biliopancreatic diversion (BPD) is a mixed and complex technique that has shown good long-term results. There are no series with long-term follow-up of BPD in Spain. We present >5 year results (average 67.9 ± 15 SD mons, range 48-96), evaluating weight loss, morbidity and mortality after BPD. Methods: 74 patients who underwent BPD and completed 5 or more years of follow-up were studied. The results have been analyzed in terms of weight loss (classification of Reinhold), improvement in morbidity, and improvement in quality of life (BAROS). Results: 78.6% were women. Mean age was 38 ± 11 years (18-61). Mean preoperative body mass index (BMI) was 54 ± 8 kg/m². Progression of BMI: 1 year 34 ± 6, 2 years 31 ± 6, 5 years 33 ± 7 and 7 years 31 ± 3 kg/m² . Excess weight loss at 1 year follow-up was 67%, at 2 years 75%, at 5 years 70% and at 7 years 71%. There were significant differences between morbidly obese (BMI <50 kg/m²) and super-obese (BMI >50 kg/m² ), with better results in the morbidly obese group. Conclusion: BPD shows long-term effectiveness in weight loss, co-morbidity improvement and quality of life. Protein, vitamin and oligoelement deficits may appear in the long-term, so that strict follow-up and supplementation of deficiencies are necessary.     

Impact of Surgically-Induced Weight Loss on Respiratory Function: A Prospective Analysis

Background: Morbid obesity (MO) causes several degrees of respiratory impairment that may resolve after weight reduction. The aims of the present study were to investigate the frequency of respiratory impairment in a selected cohort of morbidly obese patients with BMI 40-50 kg/m² with no respiratory symptoms and to evaluate the impact of surgically-induced weight loss on respiratory function. Methods: Prospective analysis of respiratory impairment was conducted before surgery and 1 year after surgery in a cohort of patients with MO who underwent vertical banded gastroplasty (VBG). 30 consecutive patients with MO who underwent VBG (14 open and 16 laparoscopic) in a 1-year period were studied. Respiratory function tests, arterial blood gases and hemoglobin were obtained in all patients before and 1 year after VBG. Results: Results were analyzed using the Wilcoxon signed-rank test and Spearman for variables without normal distribution. Mean age was 35±8 years; there were 3 males and 27 females. BMI was 44±4 kg/m² before surgery and 32±4 kg/m² at 1-year follow-up. By respiratory function tests, the diagnosis of obstructive disease was made before surgery in 4 patients and a restrictive disorder was identified in 4 additional patients. Evidence of pulmonary disease was absent in all patients 1 year after surgery. Forced vital capacity, inspiratory and expiratory forces, tidal volume, SaO₂, and PaCO₂ significantly improved after weight reduction. Conclusion: Surgically-induced weight loss significantly improves pulmonary function.     

Laparoscopic Adjustable Gastric Banding with Duodenal Switch for Morbid Obesity: Technique and Preliminary Results

Background: The procedure of choice for morbid obesity remains controversial. One of the most effective treatments is the biliopancreatic diversion with duodenal switch (BPD/DS), which is, however, associated with a significant morbidity rate. Adjustable gastric banding (AGB) by the laparoscopic approach is an easier procedure with the intent to reduce complication rates. It replaced the sleeve gastrectomy in this study. The objective was to assess the feasibility and safety of this new laparoscopic treatment. Methods: AGB with duodenal switch (DS) was performed laparoscopically with 7 trocars. A gastric band was appropriately placed below the gastroesophageal junction, followed by BPD/DS with a 250-cm alimentary channel and a 100-cm common channel. Results: All 5 patients were women, with mean preoperative BMI 52.2 kg/m² (40.6 to 64.4). The operations were performed via laparoscopy in a mean of 206 ± 35 minutes. There was no postoperative complication, infection or conversion. Mean hospital stay was 8.8 days (8-11). At 12 months, mean BMI is 35.8 kg/m² (26.1-46.0), with continuing weight loss and no hypoalbuminemia. Conclusions: These data suggest that laparoscopic AGB/DS is feasible, with a low morbidity rate. This technique could combine the long-term weight loss of malabsorptive procedures, with a low-morbidity, adjustable, restrictive procedure. This technique could be used in selected patients, but requires a larger study with longer follow-up.     

Anesthetic Management of Morbidly Obese and Super-Morbidly Obese Patients Undergoing Bariatric Operations: Hospital Course and Outcomes

Background: Although the implications for the anesthetic and perioperative care of severely obese patients undergoing weight loss operations are considerable, current anesthetic management of super-obese (SO) patients (BMI ≥50 kg/m²), including super-super-obese (BMI ≥60) derives from experience with morbidly obese (MO) patients (BMI 40-49.9 kg/m²). We compared anesthetic and perioperative data of SO patients and MO patients undergoing weight loss operations to evaluate if anesthetic management influenced outcome. Methods: A retrospective analysis was performed on data from 150 consecutive patients (119 MO, 31 SO) undergoing bariatric surgery between May 2000 and March 2005. Data analyzed included preoperative anesthetic assessment, anesthetic management, postoperative care, and intra- or postoperative complications. Results: There were no differences in anesthetic management or in postoperative course or outcome between MO and SO patients. Intraoperative surgical complications occurred in 26% (n=8) in the SO group and 14% (n=15) in the MO group (P<0.01). Conclusions: No differences in outcome occurred between MO and SO patients undergoing bariatric operations under similar anesthetic management. Anesthesia for weight loss surgery can be safely performed on SO patients with the understanding that these patients are not at risk per se due to their higher BMI. The degree of obesity influenced only the incidence of intraoperative surgical complications.     

Duodenal Switch Without Gastric Resection after Failed Gastric Restrictive Surgery for Morbid Obesity

Background: Several surgical treatments have been proposed for patients in whom gastric restrictive operations have failed. The aim of this study was to analyze the effectiveness and safety of duodenal switch (DS) with restoration of normal gastric capacity in such patients. Methods: Between May 2001 and May 2003, 11 DS with restoration of normal gastric capacity were performed without other gastric procedures in patients who had had previous gastric restrictive operations which had failed because of inadequate weight loss or weight regain. Data were collected and follow-up was 2 years for all patients. Results: At the original operation, mean BMI was 47.3 (range 38-53) kg/m², and mean age was 42 years. 7 of the 11 patients (63.6%) had previous vertical banded gastroplasty, and 4 of the 11 (36.4%) had previous laparoscopic adjustable gastric banding. Mean percentage weight regain and mean BMI at the time of DS were 92.1% and 44.6 (range 35-53) kg/m² respectively. After the second operation, mean BMI at 6 months was 35.4 kg/m², at 12 months 31.7 kg/m² and at 24 months 28.6 kg/m². The % excess weight loss was 41.1 after 6 months, 56.6 after 12 months and 69.6 after 2 years. There was minor morbidity and no mortality. Conclusion: After this experience, we suggest that patients with failed gastric restrictive operations (weight regain or inadequate weight loss) may undergo DS with restoration of normal gastric capacity. This second operation proved to be safe and effective.     

Intragastric Balloon for Preoperative Weight Reduction in Candidates for Laparoscopic Gastric Bypass with Massive Obesity

Background: Laparoscopic bariatric operations can be technically challenging in massively obese patients. The potential of the intragastric balloon for preoperative weight reduction was evaluated in candidates for laparoscopic Roux-en-Y gastric bypass (LRYGBP) with super obesity. Methods: From January 2004 to March 2005, 10 patients with super obesity who were potential candidates for LRYGBP were included in a prospective observational study. An intragastric balloon was placed endoscopically under general anesthesia. Patients were then followed by a multidisciplinary team until removal of the balloon after 6 months. Weight, BMI, and percent excess weight lost (%EWL) were monitored after 1, 3 and 6 months. Results: The 10 patients were all female with mean ± SD age of 33±11 years (range 17-51). Initial weight was 175±25 kg (range 135-223) and initial BMI was 64±7 kg/m² (range 59-78). After completion of 1, 3 and 6 months, weight, BMI, and %EWL reached respectively: 166±27 kg*, 165±27 kg*, and 169±26 kg*; 61.1±7.6 kg/m²*, 60.8±8.4 kg/m²*, and 61±8.2 kg/m²*; 9±5%, 10±7%, 7±6%. (*=P<0.01 vs preop). Conclusion: In potential candidates for LRYGBP with super obesity, preoperative placement of an intragastric balloon can reduce the excess weight by 10% within 3 months. Extending this period failed to improve these results further.     

Intragastric Balloons for Preoperative Weight Reduction

Background: If medical treatment of obesity fails and if surgical gastroplasty is not indicated, insertion of an intragastric balloon may represent an intermediate modality. Methods: Two patients are reported in whom a balloon was placed for weight reduction before elective surgery: 1) A 53-year-old woman with a BMI of 41.3 kg/m² lost 18 kg in 6 months and then underwent surgical repair of a huge incisional hernia; 2) A 58- year-old woman with a BMI of 35.8 kg/m² had total hip arthroplasty after losing 15.5 kg in 5 months. Results: The uneventful postoperative recovery in both patients was thought to be positively influenced by their preoperative weight loss. Conclusion: In morbidly obese patients, intragastric balloon placement may contribute to preoperative weight reduction before elective surgery.     

Biliopancreatic Diversion for Treatment of Morbid Obesity: Experience in 50 Cases

Background: Biliopancreatic diversion (BPD) by Scopinaro's method is an operation advocated by some surgeons as an effective treatment for morbid obesity. Methods: Between February 1995 and April 1997 we performed BPD by Scopinaro's method on 50 patients with morbid obesity (23 males), average age 41.4 years (range 20-63 years), average body weight 135.08 kg (range 89-256 kg), mean body mass index (BMI) 50.65 kg/m² (range 37.01-81.56 kg/m²). Results: In all cases a gradual decrease in weight was obtained [mean BMI at 1 month: 44.8 kg/m², at 6 months (31 patients): 35.09 kg/m², at 1 year (23 patients): 31.36 kg/m², at 18 months (14 patients): 29.89 kg/m² and at 2 years (5 patients): 29.27 kg/m²]. At the same time a significant improvement in the pathological conditions associated with morbid obesity was observed. The patients were able to suspend oral antihypertensive and antidiabetic therapy as these parameters spontaneously returned to normal values by the sixth postoperative month; all cases showed a marked reduction in hypercholesterolemia and hypertriglyceridemia. Postoperative complications were: one death (2%) on the third day due to heart failure; two late intestinal occlusions (4%); one acute dilatation of the stomach (2%); one peritonitis caused by early dehiscence of the anastomosis (2%); five anastomotic ulcers (10%); two cases of protein malnutrition (4%). Conclusions: BPD by Scopinaro's method is a bariatric procedure which is technically complex. However is it safe and reproducible and it induces a substantial weight loss.     

Duodenal Switch without Gastric Resection: Results and Observations after 6 Years

Background: The results on metabolic effects of the classical biliopancreatic diversion (BPD) have led us to investigate the operation without gastric resection, thus preserving stomach and pylorus, in patients who are not seriously obese but suffer from hypercholesterolemia, often associated with type 2 diabetes and hypertriglyceridemia. Methods: Between 1996 and 1999, we performed the duodenal switch (DS) without gastric resection on 24 mildly obese patients. Mean preoperative BMI was 36.2 kg/m². 17 patients (70.8%) suffered from type 1 diabetes, 4 (16.6%) had impaired glucose tolerance, while the remainder had fasting hyperglycemia. In 20 patients (83.3%), hypercholesterolemia and alterations in lipid profile were present. Another 20 patients were taking drugs for arterial hypertension. The pluri-metabolic syndrome was present in 41.6% of patients. Results: Mean follow-up was 4 years. BMI reduction and weight loss were not large. 2 patients who had severe longstanding diabetes type 2 needed a second operation of the classical BPD because of failure in improving diabetes. Another 2 patients were changed to classical BPD because of a relapsing chronic duodeno-ileal ulcer. The incidence of ileal ulcer was 29.1%. Regarding hypercholesterolemia, hypertrigliceri-demia, and type 2 diabetes when there is a good pancreatic "reservoir", the operation seems effective in the long-term. Protein absorption is better than that obtained with the classical BPD. Conclusions: Our long-term results suggest that in carefully selected patients suffering from serious hypercholesterolemia or type 2 diabetes with insulin reserves still at an acceptable level, and with BMI 30-40, DS without gastric resection can be proposed as a surgical treatment for metabolic diseases but not for obesity.     

Biliopancreatic Diversion with Duodenal Switch Combined with Laparoscopic Adjustable Gastric Banding

Background: The authors investigated the usefulness of an approach combining biliopancreatic diversion (BPD) with duodenal switch (DS) and laparoscopic adjustable gastric banding (LAGB) in morbidly obese patients. Methods: 258 morbidly obese patients underwent bariatric surgery. 80 underwent gastric bypass (GBP), with an 80-ml pouch, a 120-150-cm common channel and a 350-cm alimentary limb (Group 1). 178 underwent BPD combined with DS-LAGB (Group 2): an 80cm common channel and a 200-cm alimentary limb were created in 68 patients (Subgroup 2a); a 120-cm common channel and a 300-cm alimentary limb were created in 110 patients (Subgroup 2b). Quality of life was assessed using the Moorehead-Ardelt Quality of Life Questionnaire (MA-QLQ). Results: At 2 years, mean BMI and %EWL were 27.8 kg/m² and 77.4 (Group 1), 25.2 kg/m² and 99.6 (Subgroup 2a), and 27.6 kg/m² and 79.3 (Subgroup 2b), respectively. 4 GBP patients regained their weight 2 years after surgery. There was 1 death, not related to surgery in Subgroup 2b. Preoperative MA-QLQ scores were similar between groups; at 2 years, MA-QLQ scores were higher in Subgroups 2a and 2b compared to Group 1 (+2.49 and +2.59 vs +0.98, respectively). Conclusion: Combination bariatric surgery is a safe, effective and durable weight loss option for the treatment of morbid obesity.     

Treatment of morbid obesity with intragastric balloon in association with diet

Background: The BioEnterics Intragastric Balloon (BIB?, BioEnterics, Santa Barbara, CA) in association with restricted diet has been used for the treatment of obesity and morbid obesity. Methods: Since March 1998, 322 BIB were placed in 281 obese and morbidly obese patients; 73 patients were male and 208 female; mean age was 41.6 years (21-70); mean weight was 117.4 kg (67- 229); mean BMI was 41.8 kg/m² (29-81); % excess weight was 62% (10-216). The balloon was inserted and removed endoscopically under general anesthesia. Patients were given a balanced diet of 1000 kcal/day.Also, for 18 months we compared 42 obese patients treated only with 1000 kcal/day diet (group A) with 31 obese patients subjected to BIB for 4 months + 1000 kcal/day diet (group B). Results: After 4 months of balloon treatment, the mean weight loss was 13.9 kg and the mean reduction in BMI was 4.8. Weight loss was greater in male patients. Weight loss was accompanied by an improvement of the diseases associated with obesity, in particular diabetes. In the diet vs BIB+diet study, BIB with diet produced a greater weight loss in a shorter time than diet alone. Conclusion: The best indications for BIB were: morbidly obese opatients (BMI>40) and super-obese patients (BMI>50) in preparation for bariatric operations; obese patients with BMI 35-40 with co-morbilities in preparation for bariatric surgery; obese patients with BMI 30-35 with a chronic disease otherwise unresolved; patients with BMI <30 only in a multidisciplinary approach.     

Biliopancreatic Diversion for Treatment of Morbid Obesity: Experience in 180 Consecutive Cases

Background: Biliopancreatic diversion (BPD) by Scopinaro's method is used by many as a surgical treatment for morbid obesity. The authors present their results in 180 consecutive cases. Method: Between June 1995 and May 1998, the authors performed BPD by Scopinaro's method on 180 patients (36 men) with morbid obesity, mean age 35.8 years (range 18-58 years), mean body mass index (BMI) 48.8 kg/m² (range 35-66 kg/m²). Results: In all cases, a gradual decrease in weight was obtained: the mean BMI at 1 month was 40.3 kg/m², at 6 months 34 kg/m², at 1 years 32 kg/m², at 18 months 30.2 kg/m², and at 36 months 28.8 kg/m². At the same time a significant improvement in the pathologic conditions associated with morbid obesity was observed. Postoperative complications were two duodenum blowout syndromes requiring prolonged intensive care, and an 18% rate of incisional hernias. Conversion to normal small bowel continuity was necessary in three cases. Protein malnutrition developed in 2 patients (1.1%), in 1 patient coinciding with addiction to cocaine. One patient could not psychologically accept the physical changes and requested conversion. Anastomotic ulceration was seen in 11% of the patients. Operation for late obstruction occurred in 2 patients. There was no mortality. Conclusions: Although BPD by Scopinaro's method is technically complex, it is safe and effective.     

Weight reduction by means of intragastric device: experience with the bioenterics intragastric balloon

Background: A new intragastric balloon is available for weight reduction. Methods: Patients consulting for a weight reduction plan and refusing any kind of actual surgery, or suffering from obesity but not meeting the IFSO standards for surgery, were offered the possibility of weight reduction by the BioEnterics intragastric balloon (BIB). A preoperative questionnaire was completed by all patients, inquiring about medical history, co-morbidity factors, dietary habits, previous treatments for weight and social, psychological, relational and economic impact of the obesity. BIB placement was done on an inpatient basis, under general anesthesia.Inflation was standardized at 500 ml saline. Intravenous antiemetic and spasmolytic drugs were given to control post-insertion nausea for 24 hours, and oral medication was administered on the patient's discharge. A standard 800 calorie diet was prescribed after dietitian's consultation. Extraction of the balloon was left to the patient's discretion at 3 or maximum 6 months after placement. Patients choosing for the maximal period received a formal invitation to extract the balloon. Evaluation of weight reduction was done at extraction and by questionnaire. Results: 126 patients (5M, 121 F) with mean age of 35.6 years (20-62) were included after preoperative evaluation. Mean preoperative BMI was 37.7 kg/m² (26.7-57.7 kg/m²), with a mean initial excessive weight of 35.3 kg (8.8-96.4 kg) and mean initial % excess weight of 32.2 (6.3-102). 69 patients were eligible for review; mean excess weight loss after 3 months was 48.6% and after 6 months 50.8%. Mean weight loss was 15.4 kg (0-35 kg). 76.8% of the patients (41/69) complained of severe nausea and vomiting lasting an average of 1 week (1 day - 6 months), resulting in 3 patients in early removal of the balloon (at 1 day, 1 week, 1 month after placement respectively). 2 patients suffered gastric perforation presenting as acute peritonitis 3 and 4 months after placement and were operated. Extraction of the balloon was performed in 3 patients after 3 months and in 66 patients after 6 months. In 11 patients (22%), esophagitis was present (8 grade I, 2 grade II, 1 grade III), and one patient showed diffuse gastric erosion. One patient required removal of the balloon by rigid esphagoscopy following technical failure of the endoscopic extraction device. 45 patients replied to the mailed questionnaire; 15% (7/45) were very satisfied, 13% (6/45) satisfied, 22% (10/45) reasonably satisfied, 8.8% (4/45) unsatisfied and 40% very unsatisfied. Degree of satisfaction correlated poorly with weight loss. Results may be better with close continuous guidance by a counselor. Conclusion: BIB as a means of weight reduction in the obese patient led to a 50.8% loss of excess weight after 6 months. Although severe morbidity can occur, the BIB provides a means for short-term weight reduction in conjunction with dietary measures.     

Comparative Analysis of Vertical Banded Gastroplasty and Duodenal Switch at Five Years Follow-Up

Background: Bariatric surgery is the only effective long-term treatment for morbid obesity. We compared long-term results of the vertical banded gastroplasty (VBG) and biliopancreatic diversion with duodenal switch (DS). Quality of life (QoL), weight loss (WL), and reoperation were evaluated. Methods: This is a retrospective study of 85 of 129 patients with VBG and 49 of 743 patients with DS, with follow-up >5 years. Mean preoperative BMI of the VBG patients was 48.8 kg/m² and for the DS patients was 50.3 kg/m². Results: Percent excess weight loss (%EWL) at 5 years for VBG patients was 56.4% and for DS patients 70.6% (P<0.0001). 8 VBG patients (9.4%) and 1 DS patient (2.0%) required re-operation due to failure of the technique. None of the VBG patients could eat a normal diet, while 80% of the DS had no restriction in the quality of their intake. Conclusions: At 60 months follow-up, only the DS patients fullfilled the ASBS requirements of %EWL >50 in over 75% of the patients.     

Plasma Antioxidant Capacity in Morbidly Obese Patients Before and After Weight Loss

Background: Oxidative stress may play a critical role in the pathogenesis and development of obesity-associated co-morbidities. Reactive oxygen and nitrogen species are produced as a consequence of normal aerobic metabolism and removed and/or inactivated in vivo by both endogenous (uric acid, bilirubin, thiols) and diet-derived (exogenous) antioxidants. The purpose of this study is to measure the total plasma antioxidant capacity (TAC), as well as the corrected TAC (cTAC, an index of exogenous provided antioxidants) in morbidly obese patients before and after surgical weight reduction. Methods: 16 morbidly obese (5 male and 11 female) candidates for surgical intervention, median age 34 (range 22-56) years, median weight 128 (range 96-186) kg, median excess weight 62 (range 28-115) kg and median BMI 44.4 (range 33.7-60.1) kg/m² were evaluated before and 6 months after implantation of an intragastric balloon. 15 healthy blood donors (4 male and 11 female) on a normal diet, median age 35 (range 21-52) years, median weight 64.3 (range 46-78) kg and median BMI 24.2 (range 23.7-25.2) kg/m² were also evaluated. Blood samples for routine clinical chemistry, TAC and cTAC determination were drawn, and weight and BMI calculation were performed once in the control group, and in the morbidly obese patients (MO) before and 6 months after the balloon implantation. Results: 6 months after balloon placement, weight and BMI of the MO patients were statistically significantly reduced from the preoperative values (P<0.001). Plasma TAC and cTAC values in the MO group were significantly lower preoperatively, compared to the control group (P<0.05 and P<0.001 respectively). cTAC values in the MO patients increased significantly following weight loss (P<0.001) and were restored to normal. However, the postoperative TAC values in the MO group did not change significantly and remained lower than in the normal controls. A significant decrease (P<0.001) in uric acid values was also noticed in the MO group after weight loss. Conclusion: Plasma TAC and cTAC values are impaired in morbidly obese patients. Weight loss from an intragastric balloon is associated with significant increase in plasma cTAC values. Plasma TAC values, after the weight loss remain unchanged, possibly due to a decrease in uric acid, an important endogenous antioxidant.     

Distal Gastric Bypass/Duodenal Switch Procedure, Roux-en-Y Gastric Bypass and Biliopancreatic Diversion in a Community Practice

Background: Hybrid procedures combining purely restrictive and purely malabsorptive components to achieve stable long-term weight reduction have evolved since the 1970s. In a solo surgical community-based practice over the period 1984-1997, three different hybrid procedures were utilized as primary operations in patients who had not had prior bariatric surgery. Methods: Restrospective comparison of 32 patients who underwent biliopancreatic diversion (BPD), 138 patients who underwent distal gastric bypass Roux-en-Y (RGB) and 105 patients undergoing distal gastric bypass/duodenal switch procedure (DS) with 2-4 year follow-up in 37 DS patients. Results: Height, initial weight and initial body mass index (BMI) were similar in the three groups. The DS patients were older. Mean BMI at 2 years fell from 49 to 29 kg/m² in both DS and RGB. Mean percentage maximum preoperative weight lost was 40% in both the DS and RGB groups. Two-year mean percentage excess weight lost in DS was 78%, compared to 74% in RGB. There were no operative deaths and no ulcers in the DS group. Conclusion: DS is an important new option for primary treatment of morbid obesity. It can be performed safely, with up to 4 year follow-up showing stable weight loss.     

Endothelial Function and Weight Loss in Obese Humans

Background: Obesity is a major risk factor for the development of endothelial dysfunction. We explored the effect of different degrees of body mass on endothelial function, lipids, systemic inflammation and glucose homeostasis and the effect of surgically-induced weight loss on endothelial function in severely obese humans. Methods: A cross-sectional study of healthy subjects across a wide range of body fatness was performed to characterize the effect of obesity on flow-mediated dilatation (FMD), systemic inflammation, blood pressure and insulin sensitivity. A longitudinal study was performed to assess the effect of bariatric surgery induced weight loss on these parameters. 73 healthy subjects across a wide range of body mass were recruited; of these, 8 underwent bariatric surgery (median BMI 52.2 kg/m², interquartile range 50.355.9). Endothelial dependent vasodilatation was measured using the brachial artery vasodilatory response to forearm hyperemia assessed using highresolution ultrasonography. Results: Obese subjects were characterised by a complex collection of abnormalities, with hypertension, impaired glucose homeostasis, systemic inflammation and reduced FMD. BMI ≤25 kg/m² (median FMD 9.7%, interquartile range 6.8-12.2), BMI >30 kg/m² (median FMD 6.7% 4.8-7.5), P=0.01 comparing FMD in lean and obese subjects. A mean reduction in weight of 23.4 (4.6) kg produced an improvement in FMD from 5.3% (3.87.0) to 10.2% (7.6-13.3), P=0.01. Conclusions: Even moderate obesity leads to endothelial dysfunction. In severely obese subjects, FMD is normalized by weight loss. This improvement in FMD is associated with a decline in inflammatory markers, blood pressure and insulin. The improvement in FMD occurred despite patients remaining significantly obese. These results suggest that an integrated approach to improving endothelial function in obese humans may be necessary.