Pay Status as a Predictor of Outcome in Surgical Treatment of Obesity

Background: Higher complication rates and lower success in surgery for severe obesity have been reported for patients with government pay status. We examined the effect of pay status upon outcome in surgical treatment of obesity. Methods: This was an observational study from an aggregate data set of individual patient information. Government pay status (G) was defined as full or partial medical care payment through Medicare, Medicaid, or Veterans Administration. Payment entirely by private insurance was defined as private (P). Operations were classified as either simple (S, gastric restriction) or complex (C, gastric restriction with small bowel bypass). Two measures of outcome, perioperative complication rate and weight loss success (≤50% excess weight), were examined to determine pay status effect. Results: More G than P patients were treated with simple procedures (79% vs 51%, p < 0.05). Perioperative complication rates were more common for G than P patients (14.4% vs 9.1%, p < 0.05). One-year weight loss success was higher for P than G, regardless of operation type. Conclusion: Pay status should be included in characterization of patient groups and in the analysis of results when effectiveness of surgical treatment for severe obesity is reported.     

The Patient Factor

Long-term results of bariatric surgery are reviewed. The weight criteria for patient acceptance for bariatric surgery and their variation are presented graphically and discussed. Factors affecting patient selection in an attempt to improve outcome results in the small group of patients who currently achieve less weight loss than anticipated are defined. An attempt is made to define pre-operative criteria for selection of pure restrictive versus combined restrictive and malabsorptive procedures. Aspects of motivation, co-morbidity, age and pre-operative weight are discussed and the position statement of the ASBS in regard to laparoscopic bariatric surgery is defined.     

Inhibition of dopamine release in the cat caudate nucleus by nigral application of glycine

"Encéphale isolé" cats were implanted with two push-pull cannulae, one in the left caudate nucleus and the other in the ipsilateral substantia nigra. L-3,5(-3)H-Tyrosine was introduced continuously into the caudate nucleus to study the release of 3H-DA. Glycine (10(-5)M) added to the superfusing medium of the push-pull cannula inserted into the substantia nigra reduced (25%) the spontaneous release of 3H-DA. Conversely, strychnine (10(-5)M) slightly stimulated the 3H-transmitter release. The inhibiting effect of glycine (10(-5)M) on 3H-DA release was no longer seen in the presence of strychnine (10(-5) M). The results support the hypothesis of a tonic glycinergic inhibitory control of the activity of the nigrostriatal dopaminergic neurons.     

Withdrawal-like behaviour induced by inhibitors of biogenic amine reuptake in rats treated chronically with Δ 9-tetrahydrocannabinol

The effects of the biogenic amine reuptake inhibitors fluoxetine, clomipramine and imipramine on the behaviour of rats after chronic treatment with ⁹ tetrahydrocannabinol ( ⁹-THC) for 5 and 10 days were examined. Rats with permanently in-dwelling IV cannulae were injected twice daily with doses of ⁹-THC (2–6 mg/kg). ⁹-THC treatment reduced the rate of body weight gain and induced the typical biphasic modifications of behaviour. Tolerance developed to both of these effects. On days 6 and 11 of the experiment, rats were injected IP with 15 mg/kg imipramine HCl, clomipramine HCl or fluoxetine HCl, and behaviour, consisting of writhes, backward kicks, jumps and wet shakes, was observed for the next 30 min. Each of the amine reuptake inhibitors induced changes in behaviour, the severity of which appeared to correlate with their ability to inhibit the reuptake of 5-hydroxytryptamine (5-HT). It is suggested that tryptaminergic mechanisms are involved in the production of a withdrawal-like behaviour after chronic ⁹-THC treatment.     

Effects of gamma-vinyl GABA (vigabatrin) on blood pressure and body weight of hypertensive and normotensive rats

Summary Inactivation of GABA was inhibited by -vinyl GABA (GVG) and the effects of the increased GABA level in the brain on blood pressure and body weight of spontaneously hypertensive rats (SHR) and normotensive rats (WKY) were investigated.When started at the age of 8 weeks or 5 weeks, treatment of SHR and WKY with GVG (150 mg/kg, s.c.) for several weeks did not influence systolic blood pressure. In 1-week old SHR, treatment with GVG (up to 150 mg/kg, s.c.) abolished the rise in blood pressure until animals were 8 weeks old. Thereafter, arterial blood pressure started to increase but it remained distinctly lower than that in untreated animals. When started at the age of 1 week, treatment with GVG for 7 weeks did not influence arterial blood pressure in WKY. GVG delayed increase in body weight in SHR and WKY, irrespective of their age. GVG greatly increased GABA levels in the hypothalamus, frontal cortex, brainstem and rest of the brain in both WKY and SHR.It is concluded that an increase in the GABA level in the brain leads to a delay in the development of hypertension in young SHR. Hence, development of genetic hypertension seems to be susceptible to activation of the GABAergic system in a very early critical phase only. Send offprint requests to N. Singewald at the above addressThis work was supported by the Fonds zur Förderung der wissenschaftlichen Forschung     

The Rationale and Results of Gastroplasty/Distal Gastric Bypass

A recent review of the results of gastroplasties done at the University of Alberta Hospital showed that there was a high incidence of late weight loss failure. Therefore a new operation, gastroplasty/distal gastric bypass, has been performed on 263 patients. This operation results in a profound (mean greatest percentage excess weight loss of 87% at approximately 2 years) and lasting weight loss (mean final percentage excess weight loss of 78%) at 4 years, range 2-7.5 years post-operatively. Only 0.9% of patients failed to maintain at least a 40% excess weight loss. The operation achieves its effect through a moderate restriction that permits patients to eat normal table food from the time of discharge and with a mild malabsorption that is not ordinarily associated with diarrhea or notable deficiencies. Certain patients required debanding of the stoma and others developed staple-line eventration. Neither of these events after long-term follow-up resulted in weight loss failure nor in other serious side-effects. It is concluded that moderate failure of the gastroplasty stoma and staple line does not necessarily result in weight loss failure, because the malabsorptive portion of the operation remains intact. Low hemoglobin occurred in 16% of cases and deficiency of serum iron in 34%; a much smaller number of patients had chronic or intermittent deficiencies of these entities. Correction was easily achieved with oral replacement. Deficiencies in albumin, calcium, phosphorus and folate were rarely seen and minimal elevation of serum AST values occurred in just over 1% of patients. Chronic deficiencies or elevations were not seen in these patients. Stomal ulcer occurred in 6% of patients and bleeding associated with stomal ulcer in 1%. Half the patients with ulcer were managed with H₂ blockers, the other half with vagotomy. Both forms of treatment when individualized effectively prevent re-ulceration.     

Changes in Sexual Patterns Following Vertical Banded Gastroplasty and Weight Loss

Weight loss following vertical banded gastroplasty (VBG) is well established. Herein the effect of weight loss on sexuality was examined. Twenty-seven females and seven males (mean age 39 years) underwent VBG and returned completed questionnaires regarding preoperative and postoperative sexuality. There was a mean interval follow-up of 33 months, with a mean weight loss of 48.6 kg. In general, there was an overall increase in frequency, quality, and enjoyment of sex. Similarly, an improvement in body image, an increase in initiating sexual intercourse, and an increase in the number of sexual partners was found. A small number of patients developed psychosocial problems that limited sexual enjoyment. In conclusion, weight loss after VBG improves sexual life, though not uniformly, as new sexual problems can occur. Decreased sexual inhibition, increased sexual enjoyment and frequency, and increased frequency of orgasm characterizes many of the changes occurring after VBG with resultant weight loss. To help provide a holistic approach to the care of morbidly obese patients after VBG, the potential alterations in their sexual lives should be considered.     

Revisional Surgery for Severe Obesity with Fascia Banded Stoma Roux-en-Y Gastric Bypass

The fascia banded stoma Roux-en-Y gastric bypass (RYGBP) has been effective both as a primary and revision operation for severe obesity or failure of another operation. Since May 1984, 361 primary and 100 revisional fascia banded RYGBP operations have been reported. Weight loss achieved a mean body mass index of 30 for primary and 31 for revision patients at most recent follow-up of 3-6 years (mean 4.3 years) postoperatively. Mean overweight was 28% for primary, and 34% for revision patients. Eighty percent of primary and 79% of revision patients were within 50% of ideal weight. Revision rates for these patients were 0 for primary and 1% for revision patients. Operative mortality was 0 for primary and 1% for revision patients. Since morbidity and mortality, although low, are higher for revision than primary surgery, it is important to use an effective primary operation.     

The Effect of Gastric Bypass on Cholesterol,HDL, and the Risk of Coronary Heart Disease

A review of 150 charts revealed that 36 patients had pre-operative serum cholesterol greater than 200 mg% prior to Roux-Y gastric bypass. The average pre-operative weight was 266 lb (121 kg) and at 1 year post-operative 166 lb (75 kg), or 100 lb (45 kg) lost (77% excess weight loss). We compared the following pre- and post- operative data and found that: (1) cholesterol was decreased by 24% and triglycerides decreased by 40%; (2) post-operative cholesterol/HDL-C ratio of 3.31 put our patients in the half of average risk category for a clinical pathological coronary event according to the SmithKline Beecham Laboratories risk ratio chart. We conclude that Roux-Y gastric bypass and its ability to produce a significant weight loss and markedly affect cholesterol and triglyceride metabolism will also reduce a patient's risk of myocardial infarction.