Gastric Bypass in Patients with BMI <40 but >32 Without Life-threatening Co-morbidities: Preliminary Report

Background: Surgical intervention is currently indicated for patients with BMI >40 or >35 with life-threatening comorbidities. Patients with BMI 32-40 without these comorbidities not only have the increased propensity to develop them but also suffer from similar psychosocioeconomic consequences. These patients may not respond to non-surgical treatment of obesity any better than those with BMI>40. The question has been raised whether to offer them surgical intervention. Methods: A study was carried out to determine outcome of surgery on patients with BMI >32 but <40 without life-threatening comorbidities but with either psychological, economic or social impairments affecting their quality of life. The approval of our Hospital Internal Review Board was obtained. In addition to routine evaluation for surgical intervention, these patients were required to have the approval of their primary care physician, be seen pre-operatively by a psychiatrist, and have a member of the family or a very close friend present at the time of discussion of operative risks and follow-up requirements. Patients committed to at least a 5-year follow-up. They were to be self-paying patients. The transected silastic ring vertical gastric bypass with a temporary gastrostomy was used. Results: 50 patients, 49 women and one man, were entered into the study between May 1, 1999 and April 30, 2000. 50% were self-pay, and the other 50% were able to obtain coverage through their insurance companies. There were few peri-operative complica tions and no deaths. The late complications include incisional hernias, dumping and transient alopecia. Hospital stay averaged 3.7 days. Follow-up has been 18-27 months. Weight loss has been excellent. Conclusion: Preliminary results of surgical intervention extended to patients with BMI 32-40 without life-threatening comorbidities but with psychosocioeconomic ramifications are very promising. Long term follow-up and comparison with other bariatric patients are planned.     

“徐而疾则实,疾而徐则虚”释义

目前通常此言作为两种徐疾补泻的方法来解释，笔者认为是指脉象，是通过针刺治疗前后对脉象的徐疾诊察，来预测和判断疾病的虚实转归。     

Patient Motivation for Bariatric Surgery: Characteristics and Impact on Outcomes

Background: Motivation for seeking obesity surgery has not been studied. The authors explored the patient's motivation for selecting surgery and examined for a relationship between primary motivating factors and weight outcomes. Methods: 208 (177F: 31M) unselected participants followed at least 1 year after Lap-Band? placement completed a short questionnaire. 6 statements were scored 1-6 from the most important through to the least important. Statements included appearance, embarrassment, medical conditions, health concerns, physical fitness and physical limitation. Any additional factors were also sought. Results: Mean age, weight and BMI before surgery were 41±10 years, 129±16 kg and 46±8 kg/m² respectively. Responses to appearance and embarrassment correlated strongly and were grouped together. Medical conditions and health concerns account for 52%, appearance and embarrassment for 32%, and poor physical fitness and physical limitation for 16% of first choices. Those who scored 1 for appearance or embarrassment (n=67) had a lower presenting BMI (44 kg/m², P=0.03) and all but 1 were female (P<0.001). This group reported more depressive symptoms, poorer mental quality of life and poorer body image preoperatively. Men were more likely than women to be motivated by medical problems (P=0.007). Subjects motivated by a medical condition were more likely to have hypertension or diabetes and less likely to smoke. This group tended to be older. Weight history did not influence motivation. The first choice of motivating factor was not associated with weight outcomes at 1-3 years following surgery. Conclusion: Health issues dominate the motivation for seeking surgery. Weight outcomes do not appear to be affected by the patient's primary motivating factor.     

Is Laparoscopic Adjustable Gastric Banding a Day Surgery Procedure?

Background: Laparoscopic adjustable gastric banding is the least invasive bariatric operation. However, just isolated attempts to perform this procedure as a Day Case have been published. This study highlights some aspects that might contribute to safe patient discharge within 23 hours after LAGB. Methods: Prospective evaluation of 20 consecutive patients was carried out. Patients were indicated for laparoscopic Swedish adjustable gastric banding (SAGB, Obtech, Ethicon Endo-Surgery) in a private Bariatric center in the first 6 months of 2003. The effect of extensive pre- and immediate postoperative education and psychological support, and information on postoperative health consequences delivered through a multi-disciplinary bariatric team effort, was evaluated, regarding the influence of these facilitators in shortening the length of hospital stay. Results: Mean preoperative BMI of the 20 patients entering the study was 42.3. Mean operating-time was 91 minutes (58-112 min). Time spent on information and education of each patient was 60 minutes in total during the preoperative period. Average postoperative hospitalization was 21 hours. There were no intraoperative or early postoperative complications. Excess weight loss was 44% at 12 months after surgery. Conclusion: SAGB performed on a Day Case basis in selected patients who are subjected to intensive pre- and immediate postoperative dedicated education appears to be a feasible alternative.     

Minimally Invasive Gastric Bypass in a Morbidly Obese Patient with Myasthenia Gravis

Associated or rare diseases, such as myasthenia gravis, introduce a challenge to the perioperative management of severely obese patients undergoing bariatric surgery. We report the surgical management and unique anesthetic approach to a 55-year-old morbidly obese woman with a complex past medical history that included myasthenia gravis, who underwent laparoscopic gastric bypass. Her myasthenia was controlled on pyridostigmine and her greatest concern was the potential need for postoperative mechanical ventilation. While the laparoscopic surgical approach was ideal to reduce pain and the adverse effects on ventilatory mechanics associated with open upper abdominal surgery, a combined inhalational and intravenous anesthetic without muscle relaxants resulted in satisfactory surgical conditions, and allowed for immediate postoperative extubation followed by an uneventful postoperative course. Continued perioperative anticholinesterase administration may have facilitated this successful outcome. We conclude that a diagnosis of myasthenia gravis does not mandate postoperative mechanical ventilation following laparoscopic gastric bypass.     

Effect of Abdominal Obesity on Insulin Resistance and the Components of the Metabolic Syndrome: Evidence Supporting Obesity as the Central Feature

Background: Metabolic syndrome includes abdominal obesity, diabetes type 2, hypertension, dyslipidemia, derangements of fibrinolysis, and atherosclerosis. Since abdominal obesity is one of the major components of the insulin resistance syndrome (IRS), an attempt was made to evaluate the interrelationships between the magnitude of obesity and the components of the syndrome. Methods: A cross-sectional study of 123 subjects with type 2 diabetes, of whom 31 were normal body weight and 92 had varying degrees of obesity was conducted. The participants were investigated in terms of clinical and laboratory findings of IRS. Fasting and 30-min (early) plasma glucose and serum insulin excursions in response to oral glucose challenge (75 g) were determined. The peripheral and hepatic insulin resistance (insensitivity) was calculated by homeostasis model assessment (HOMA). Results: Clinical and biochemical findings were compared with the components of the IRS, and demonstrated that a rise in fasting as well as 30-min insulin secretion increases as abdominal body fat (obesity) increases. There was also a significant and proportional correlation between the magnitude of abdominal obesity and the components of metabolic syndrome. Conclusion: Abdominal adiposity appears to have a pivotal role in the development of IRS.     

Psychosocial Functioning Before and After Laparoscopic Adjustable Gastric Banding: a Cross-Sectional Study

Background: The aim of this cross-sectional study was to examine short and long-term physical, mental and, particularly, social quality of life (QoL) of patients with severe obesity after laparoscopic adjustable gastric banding (LAGB). Methods: 250 patients (221 female, 29 male, mean age 39.6 years, age range 22-61) filled out questionnaires to evaluate several aspects of QoL: 93 patients before LAGB, 48 with a follow-up duration of 8 through 24 months, and 109 patients 25 through 68 months after LAGB. Results: Compared with patients before surgery, patients after surgery, in both follow-up groups, had lower weight and co-morbidity, felt and functioned better on physical and psychological dimensions of QoL, and on most aspects of social QoL. No significant differences emerged between the two postoperative groups. On average, the postoperative QoL was still lower than the age norm group. Mutual correlations between QoL and weight outcome were very low up to 2 years after surgery, but more strongly associated >2 years after surgery. Conclusion: LAGB could be a long-term solution to morbid obesity with regard to both weight and QoL outcome. The findings of our study emphasize the importance of including social QoL variables in outcome research. They further suggest that when the follow-up duration increases, especially in patients who are single, intervention and consultation should be simultaneously directed at weight and psychosocial variables.     

Single-Stage Abdominoplasty and Mastopexy after Weight Loss following Gastric Banding

Background: With the increasing number of massively obese patients who undergo the implant of a gastric band, there is also a growing demand for a plastic-reconstructive operation of the overstretched skin, now lax after the enormous weight reduction. Methods: From May 2000 to March 2002, 12 abdominoplasties and 12 mastopexies were performed in patients with an average age of 37.3 years (range 33-44 years) as single-stage procedures after an average weight-loss of 67 kg (range 43-111 kg) after gastric banding. A follow-up examination of all patients was carried out an average of 8.4 months (range 1-23 months) after the operation, to review the duration of hospital stay and assess the period of work disablement as well as the patients' satisfaction, which was judged on a scale from 1 (very dissatisfied) to 7 (very satisfied), based on a written questionnaire. Results: The average duration of hospital stay was 7.4 days. There were 5 complications that healed under conservative management. 8 patients suffered an average work disability of 5.4 weeks. 4 patients who were housewives suffered no impairments that affected their ability to carry on with their household duties. The patients' postoperative satisfaction in regard to psyche, appearance, self-confidence and vitality was strongly improved in each case. Conclusions: In comparison to multi-stage procedures, single-stage operations resulted in a reduced duration of hospital stay by 4.1 days and thus in diminished medical costs and in a reduction of work disablement by 3.5 weeks. Patients who underwent single-stage operations were postoperatively more satisfied than those with multi-stage operations.     

Quality of Life after Obesity Surgery, an Evidence-Based Medicine Literature Review: How to Improve Systematic Searches for Enhanced Decision-Making and Clinical Outcomes

Background: Research attests to the exponential sweep of clinical obesity in America. Obesity has become one of the most profound public health concerns, closely linked to increased morbidity, mortality, and social, occupational, and psychological discrimination. It is incumbent for specialists to design treatment and outcome analysis based accurately upon systematic research. Regulators, payors, and most notably, patients, need reliable and effective treatment to determine practical standards, manage cost of care, and protocols. Methods: A comprehensive evidence-based medicine (EBM) review was done of relevant research on quality-of-life (QoL) outcomes after obesity surgery. The Cochrane Collaboration was the EBM searching resource utilized for this project, accessed via the Internet. A systematic EBM search design was implemented. Results: In the search, QoL reported 3,234 hits, "obesity surgery" reported 33 hits, QoL and obesity surgery" reported 6 hits, and QoL and hypertension reported 288 hits. Conclusion: We found that a thorough EBM search can be achieved using the Cochrane Collaboration, which provides an efficient, effective and ethical means to enhance evidence-based clinical decision-making in treating severely obese surgery patients.     

Comparison of Ultrasound-Secretin Test and Sphincter of Oddi Manometry in Patients with Recurrent Acute Pancreatitis

Manometry is considered the gold standard forevaluating sphincter of Oddi dysfunction. It hasrecently been demonstrated that the ultrasound (US)secretin test proposed a few years ago as a noninvasive test for the study of sphincter of Oddidysfunction yields a substantial percentage ofpathological findings in patients with acute recurrentpancreatitis. The aim of this study was to compare theresults of the US secretin test with sphincter of Oddimanometry findings in a consecutive series of patientswith recurrent acute pancreatitis. Forty-seven patientsadmitted to our gastrointestinal unit suffering from recurrent acute pancreatitis underwentultrasonographic measurement of the main pancreatic ductat baseline and for 60 min after maximal stimulationwith secretin at 1 IU/kg. According to the US secretin test findings in 35 healthy control subjects,the test results were considered to indicate pathologywhen the duct was still dilated after 20 min. Withinthree to seven days the same patients underwent perendoscopic manometry. Thirty-six patients(17 men, 19 women; mean age 41 ± 15 years) had asuccessful US secretin test and sphincter of Oddimanometry. Eleven patients (30.6%) presented normalmanometric findings. Two of these had an abnormal USsecretin test. Twenty-five patients had abnormalmanometry findings, revealing stenosis in 19 (52.7%) (17with abnormal US secretin test) and dyskinesia in six (five with an abnormal US secretin test).Compared to manometry findings, the US secretin testsensitivity and specificity for sphincter of Oddidysfunction were 88% and 82%, respectively. Inconclusion, most patients with recurrent acute pancreatitishave sphincter of Oddi dysfunction documented by both atthe US secretin test and sphincter of Oddi manometry;results of the US secretin test are reliable compared to sphincter of Oddi manometry, andtherefore the US secretin test may offer a validalternative to the more expensive and invasivemanometric procedure for assessing sphincter of Oddidysfunction in patients with recurrent acutepancreatitis.