No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient - 2013 Update: Cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery
... • For patients at risk for metabolic bone disease, screen vitamin D and parathyroid hormone levels. 266 ...
... 412 • Calcium citrate supplementation, increased hydration, limiting dietary oxalate, and adhering to a lowfat diet are recommended basic therapeutic strategies to manage hyperoxaluria. 266,409 • If basic strategies are insufficient, gastrointestinal oxalate absorption may be reduced further by administering certain probiotics (Lactobacillus alone or in combination with Streptococcus thermophilus and Bifidobacterium). 413,414 • Patients should strictly adhere to their prescribed vitamin B6 supplementation to avoid deficiency, which may contribute to the formation of kidney stones. ...
... Clinical Obesity. 2020.5.2 Indications for bariatric surgeryBariatric surgery is indicated in patients above 18 yrs of age with EITHER[265][266][267] ...
Oman national obesity guidelines
... La CBM, asociada a intervenciones conductuales y del estilo de vida, representa la herramienta terapéutica más eficaz y duradera de la obesidad, en referencia a la pérdida de peso y mejoría de enfermedades crónicas asociadas, como DM2, HTA, dislipidemia y SAHOS, entre otras 241,242 . ...
... Los pacientes que no evidencien capacidad para adherir al seguimiento a largo plazo podrían ser considerados candidatos inapropiados por el riesgo de complicaciones a mediano y largo plazo 242,243 . ...
... Los pacientes que buscan cirugía bariátrica deben ser evaluados por nutricionistas, psicólogos y médicos especializados en obesidad. La evaluación debe incluir un historial de peso, revisión de conductas alimentarias, revisión de medicamentos, examen físico y evaluación de micronutrientes con el fin de apoyar al paciente antes y después de la cirugía 242,243,247,248 . ...
La obesidad es una enfermedad crónica que genera altos costos en salud, cuyo tratamiento, en ocasiones, no se aborda o se lo hace de forma inadecuada, y muchas veces no se basa en la evidencia disponible. Es por ello que, a partir de una iniciativa de la Sociedad Argentina de Nutrición, diferentes sociedades científicas se reunieron con el objetivo de construir un documento actualizado, basado en una metodología científica, que aporte al mejor tratamiento de las personas que viven con obesidad en Argentina. Este es el primer Consenso Intersocietario para el tratamiento de la Obesidad en adultos en Argentina a partir del cual se obtuvieron recomendaciones para la práctica clínica basadas en la evidencia científica. Es una necesidad primordial contar con herramientas, adecuadas a la realidad local y consensuadas por expertos de distintas disciplinas.
... Patients eligible for DS must undergo a thorough preoperative evaluation conducted by a multidisciplinary team. This team comprises a bariatric surgeon, an endocrinologist, a psychologist, a registered dietitian, and other specialized healthcare providers (12,13). Apart from a comprehensive medical history and physical examination, a range of metabolic tests is essential to identify and address obesity-related medical conditions. ...
... An esophagogastroduodenoscopy (EGD) is typically performed preoperatively as part of the investigation for concomitant esophageal or gastric disease. Lastly, it is also recommended to conduct psychological and compliance assessments prior to DS (12,13). ...
... Following bariatric surgery, vitamin D deficiency is frequently observed in obese individuals, necessitating significant supplementation to attain adequate levels (8) . It is recommended to receive post-operative vitamin D supplements (at least 3000 IU/day) after sleeve gastrectomy until serum 25(OH) vitamin D level reaches > 70 nmol/L (9) . ...
... The European Association for Endoscopic Surgery (EAES) recommendations include 3-8 patient visits in the 1 st postoperative year, 1-4 visits in the 2 nd year, and once or twice the year after. The American Society for Metabolic and Bariatric Surgery stated that a vitamin D supplement of 3000 IU/day at least and a calcium supplement of 1200 mg/day at least are essential after bariatric surgery (9) . ...
... Клиническую оценку больного с ожирением, подлежащего хирургическому лечению рекомендуется проводить мультидисциплинарной группой, включающей в себя следующих специалистов, имеющих опыт работы в бариатрической хирургии: эндокринолог, хирург, терапевт/кардиолог, диетолог, психиатр, при необходимости -другие специалисты [5;35]. Пациентам с морбидным ожирением назначается стандартное предоперационное обследование, с уделением особого внимания показателям основного обмена [35] Консервативное лечение больных с морбидным ожирением направлена для снижения массы тела на 5-10% за 3-6 месяцев терапии и удержание результата в течение года, что позволяет уменьшить риски для здоровья, улучшить течения заболеваний, ассоциированных с ожирением. Снижение массы тела показано всем пациентам, имеющим ожирение, а также пациентам с избыточной массой тела и наличием одного и более факторов риска ССЗ или с наличием сопутствующих заболеваний, течение которых ассоциировано с ожирением [4;37]. ...
... Хирургическое лечение рекомендуется пациентам с морбидным ожирением в возрасте 18-60 лет при неэффективности ранее проводимых консервативных мероприятий при ИМТ> 40 кг/м2 (независимо от наличия сопутствующих заболеваний), а также при ИМТ> 35 По данным регистра Международной федерации хирургии ожирения и метаболических нарушений, в 2018 г. в 50 странах мира было выполнено почти 400 тысяч хирургических вмешательств данной направленности [27]. Однако, число проводимых бариатрических оперативных вмешательств намного превышают представленные данные. ...
В данном литературном обзоре авторы отмечают, что во всем мире наметилась отчетливая тенденция к неуклонному росту ожирения, и в том числе морбидного ожирения. Данной проблемы посвящены ряд исследований, где изучаются вопросы этиопатогенеза, методов консервативного и хирургического лечения. Однако, не смотря на достигнутые успехи, в 90-95% случаев консервативная терапия безуспешна, а при хирургическом лечении в 60% случаев отмечаются осложнения в отдаленные сроки, которые требуют повторного оперативного лечения в 25% случаев. Данное обстоятельство, на наш взгляд, связано с отсутствием конкретизированных лечебно-диагностических алгоритмов, а также не достаточным уделением внимания сочетанной патологии, требующих симультанной операции, что вызывает настоятельную необходимость проведения дальнейших исследований.
... Patients who are scheduled for bariatric surgery should be thoroughly educated about the significant lifestyle changes that come with the procedure. A preoperative educational program is frequently advised to establish accurate expectations, minimize anxiety, lower the risk of wound complications, alleviate postoperative pain, and reduce the length of hospital stay [24]. In a meta-analysis that encompassed patients undergoing cancer surgery, it was observed that education not only decreased anxiety and healthcare expenses but also enhanced patients' knowledge and satisfaction [25]. ...
... Mechanick et al. [24] 2013 USA A preoperative education program minimizes anxiety. ...
Enhanced recovery after surgery (ERAS) has emerged as a paradigm-shifting approach in perioperative care, aimed at optimizing patient outcomes, accelerating recovery, and minimizing hospital stays. This review delves into the latest advances and strategies within the field of ERAS, encompassing a comprehensive examination of preoperative, intraoperative, and postoperative interventions. By analyzing an array of clinical studies, meta-analyses, and implementation experiences, this review highlights the multifaceted elements contributing to the success of ERAS programs. Key components such as preoperative patient education, minimally invasive surgical techniques, tailored anesthesia protocols, judicious fluid management, optimized pain control, early ambulation, and structured nutritional support are thoroughly explored. Furthermore, the review delves into the intricacies of ERAS implementation across diverse surgical specialties, emphasizing the significance of multidisciplinary collaboration, protocol customization, and sustained quality improvement initiatives. The analysis not only showcases the tangible benefits of ERAS, including reduced complication rates, shortened hospital stays, and enhanced patient satisfaction, but also underscores the challenges and barriers that medical professionals encounter during program adoption. By synthesizing the current state of ERAS research and practice, this review provides clinicians, administrators, and researchers with valuable insights into the evolving landscape of perioperative care, fostering a deeper understanding of ERAS as a holistic approach that transcends traditional surgical pathways.
... Elevated NLR is a systemic marker that reflects an imbalance between neutrophils and lymphocytes, often associated with an inflammatory response. Adipose tissue exhibits chronic lowgrade inflammation, which can disrupt metabolic processes, including lipolysis, leading to suboptimal clinical response and recurrent weight regain after bariatric surgery [4][5][6]. Thus, this leads us to conclude that monitoring inflammatory markers like NLR post-operatively can identify patients at high risk of suboptimal outcomes. ...
... The recommendations of this position statement are based on current clinical knowledge, expert opinion, and published peerreviewed scientific evidence. [25][26][27][28] ...
... Different surgical procedures may affect zinc absorption due to altered gastrointestinal outcomes. Although both the British Obesity and Metabolic Surgery Society (BOMSS) [6] and the American Society for Metabolic & Bariatric Surgery (ASMBS) [7] recommend routine zinc supplementation after BS, there is currently no consensus on the optimal postoperative zinc supplementation dosage and monitoring protocol. In fact, there are even conflicting recommendations from some sources. ...
Bariatric surgery has become an effective method for treating severe obesity and its related complications. While the effectiveness and safety of BS have been widely confirmed, micronutrient deficiency has emerged as a long-term complication after surgery. Literature was collected through online searches of PubMed, Cochrane Library, Web of Science, and Embase databases, as well as manual searches. A total of 15 studies, with a sample size of 2993 cases, were included. The studies found that the risk of zinc deficiency increased gradually at 6 months, 1 year, and 2 years after surgery compared to pre-surgery levels. Subgroup analysis revealed that serum zinc levels decreased by 9.40% (95% CI − 16.44%, − 2.36%) at 1 year after laparoscopic sleeve gastrectomy, 9.33% (95% CI − 10.73%, − 7.92%) after Roux-en-Y gastric bypass and one-anastomosis gastric bypass, and 22.30% (95% CI − 30.14%, − 14.46%) after biliopancreatic diversion/duodenal switch. Meanwhile, the total prevalence of zinc deficiency at 1 year after surgery was 26.1%. In conclusion, zinc deficiency worsens and serum zinc levels decrease after bariatric surgery. It is recommended that patients undergoing weight loss surgery undergo regular monitoring of serum zinc levels and receive timely zinc supplementation therapy.
... In SG, which is one of the minimally invasive BS methods, the stomach volume is significantly reduced. In RYGB, the stomach is divided into two sections, allowing food to bypass a portion of the digestive tract [9]. OAGB is similar to RYGB but creates a smaller stomach pouch and connects a segment of the small intestine to it, reducing nutrient absorption and potentially leading to malabsorption-related complications, such as iron and vitamin B12 deficiencies [10]. ...
Objective
This study aims to investigate trends in anemia severity among patients with pre-existing anemia who underwent bariatric surgery due to obesity. It also examines how different bariatric surgery techniques impact anemia outcomes.
Methods
This prospective study included 280 patients aged 18 to 65 with obesity who underwent bariatric surgery. The patients were categorized into three groups based on the type of surgery: sleeve gastrectomy, one-anastomosis gastric bypass, and Roux-en-Y gastric bypass. Anemia severity was evaluated over a 12-month follow-up period. Chi-square tests were used to assess the homogeneity of baseline factors among the groups, and McNemar tests along with generalized estimating equations were used to compare anemia outcomes.
Results
Before surgery, the rates of moderate anemia across the three surgical groups ranged from 18.2% to 22.4%, with no cases of severe anemia observed. There was no significant difference among the groups (p=0.949). During the 12-month follow-up, the odds ratio for reducing anemia severity in the sleeve gastrectomy and Roux-en-Y gastric bypass groups were 2.13 and 1.91, respectively, compared to the one-anastomosis gastric bypass group. Additionally, the odds ratio for reducing anemia severity in patients with hypothyroidism was 1.84 compared to those without hypothyroidism.
Conclusion
The choice of bariatric surgery technique significantly affects anemia outcomes, with sleeve gastrectomy showing a higher success rate in reducing anemia severity. The role of hypothyroidism in anemia management also appears to be significant.
... Within a few months of the COVID-19 outbreak, MBS was postponed at the recommendation of global experts [6]. This resulted in a significant fall in the number of MBS and restricted follow-up access to MBS care providers such as mental health professionals, dietitians, and surgeons, ultimately this limitation in access threatened optimal outcomes of MBS [7][8][9]. Virtual appointments were therefore utilized as a tool to adequately manage and support patients before and after MBS. ...
Background
The COVID-19 pandemic saw an acceleration in virtual-visits (VV) for healthcare delivery. However, the impact of virtual care in metabolic/bariatric surgery (MBS) programs is not well described.
Methods
Appointment data from three time-points: pre-pandemic (1/1/19–3/15/20, n = 19,290), pandemic (3/16/20–10/31/21, n = 29,459) and current-state (11/1/21–12/31/2022, n = 24,270) was retrieved in our multi-hospital ambulatory MBS program. Appointments were grouped by health care provider (HCP) (MD, dietician, and psychologist) and type (VV and in-person). Surveys assessing patient satisfaction were distributed electronically. All pre-op and post-op appointment data was analyzed for the time-points above. Appointment completion rates and patient reported preferences were described.
Results
Our data showed an increase in scheduled VV from 0.5% for all HCP visits to 81% during the pandemic and a current VV visit of 77%. The number of completed VV increased for all HCPs, most prominently for dieticians. Parallel to this, the percentage of no-show visits also improved for all HCP, with MDs having the lowest no-show rate currently. Survey data revealed 89% of patients experience added benefits with VV and > 90% reported their VV experience as very good. VV were preferred over in-person visits for psychologists and dietitians (> 61%), but the majority preferred to see MDs in-person (70%).
Conclusions
Our findings reveal significant changes in healthcare utilization trends since the transition to virtual care. While overall satisfaction with virtual care is high, most patients prefer in-person visits with MDs. Thus, multi-disciplinary MBS care can be performed effectively using a hybrid model to ensure efficient distribution of resources.
Graphical Abstract
... After BS, CG received standard care [27], which includes multivitamins (e.g., Centrum®), protein supplements (e.g., Protifar®, Fantomalt®), and verbal advice to increase physical activity; however, no structured exercise prescriptions were given. The EG, alongside standard care, underwent a 3-session/ week, 75-min/session MEP for 11-month post-BS, as previously published [25,26]. ...
Purpose
This study examined the benefits of an 11-months multicomponent exercise program (MEP) on muscular strength (MS) after bariatric surgery.
Methods
Of the 84 randomized patients, 41 participants from the exercise group (EG) and 20 participants from the control group (CG) were included in the analysis. The EG received supervised MEP for 11 months, starting 1-month post-bariatric surgery (BS) in addition to standard medical care, while the CG received medical care recommendations only. Knee and trunk MS was assessed by isokinetic dynamometry pre-surgery, 1-, 6-, and 12-month post-surgery, while body composition was assessed by dual-energy X-ray absorptiometry.
Results
The MEP did not significantly impact absolute MS in the dominant knee and trunk regions at 6- and 12-month post-BS. However, relative MS showed significant improvements. At 6-month post-BS, knee flexion at 60°/s relative to body weight (BW) increased significantly (p = 0.047), as did knee extension at 180°/s relative to BW (p = 0.009), and knee extension at 60°/s relative to total lean mass (p=0.040). At 12-month post-BS, knee flexion at 60°/s relative to BW also significantly improved (p=0.038).
Conclusion
While absolute MS was not significantly improved with MEP, this study found significant enhancements in relative MS, particularly in dominant knee flexion post-MEP participation. Further research should explore different exercise intensities and frequencies to optimize postoperative MS recovery post-BS.
Clinical Trial Registration
ClinicalTrials.gov (NCT02843048)
Graphical Abstract
... Geralmente, é recomendada para pacientes com um IMC superior a 40 kg/m² ou um IMC superior a 35 kg/m² com comorbidades associadas, como diabetes tipo 2, hipertensão arterial, apneia do sono e doença cardiovascular (American Society for Metabolic and Bariatric Surgery, 2018). A decisão de submeter-se à cirurgia deve ser cuidadosamente avaliada por uma equipe multidisciplinar, incluindo endocrinologistas, cirurgiões bariátricos, psicólogos e nutricionistas, levando em consideração os riscos e benefícios do procedimento para cada paciente (Mechanick et al., 2013). ...
A cirurgia bariátrica é um procedimento eficaz para o tratamento da obesidade grave, resultando em significativa perda de peso e melhora das comorbidades associadas. No entanto, alguns pacientes podem desenvolver transtornos psicológicos após a cirurgia, como depressão, ansiedade e distúrbios alimentares. Esses transtornos podem surgir como uma resposta disfuncional ao processo de perda de peso e às mudanças no estilo de vida pós-operatório. O manejo adequado desses transtornos requer uma abordagem multidisciplinar, envolvendo acompanhamento psicológico regular, terapia cognitivo-comportamental e, em alguns casos, o uso de medicamentos psicotrópicos. É fundamental uma avaliação cuidadosa e individualizada de cada paciente para identificar e tratar precocemente quaisquer problemas psicológicos que possam surgir após a cirurgia bariátrica, visando promover uma recuperação bem-sucedida e melhorar a qualidade de vida a longo prazo.
... The age demographics of those subjected to WRS were in the reproductive age (the youngest population compared to other countries), and more than 70% of patients were female gender [14]. There is no conclusive data on the optimal timing of pregnancy after WRS in the literature, especially in Saudi women, and what is available only provides low-level evidence of recommendations [15]. To our knowledge, this is the first study assessing pregnancy following laparoscopic sleeve gastrectomy (LSG) in Saudi Arabia. ...
Background
Controversy regarding the timing of pregnancy and its implications is present in the literature.
Objective
To evaluate the midterm outcome of weight loss in women who have undergone laparoscopic sleeve gastrectomy (LSG) followed by pregnancy at two different times.
Methods
We retrospectively reviewed 53 women who matched the inclusion criteria and included them in the analysis. Demographics and anthropometric measurements were collected. Women who conceived within 12 months of LSG were labeled as early group (EG), and who conceived after 12 months were noted as late group (LG).
Results
There were no differences between the groups regarding obesity-associated disease and number of pregnancies before. EG had higher weight (P = 0.0001) and body mass index (BMI) (P = 0.002) at LSG. The mean interval time for EG was 6.7 ± 3.2 months, and LG was 20 ± 5.2 months. Gestational weight gain (GWG) was lower in the EG (P = 0.001). There were no differences in the number of small for gestational age (SGA) births or gestational weight. In the first 2 years after LSG, LG had a higher percentage of total weight loss (%TWL) and percentage of body mass index loss (%EBMIL) (P < 0.0001). After 5 years of follow-up, %TWL (P = 0.4) and %EBMIL (P = 0.1) were not statistically significant between both groups.
Conclusion
Conception within 12 months from LSG might hinder the weight loss process in the short term but have no significant effect over 5 years of follow-up.
Graphical Abstract
... The recommended amount of time to delay pregnancy following a bariatric procedure differs based on referenced society, with the CDC, American Association of Clinical Endocrinology (AACE), The Obesity Society (TOS), and the ASMBS recommending 12-18 months, while the American College of Obstetricians and Gynecologists (ACOG) recommends 12-24 months. While the specific timeframe does vary, the agreed recommendation to delay pregnancy highlights the importance of access to contraception [1][2][3]. Extensive literature review yielded six studies that assessed knowledge, comfort, and behavior of bariatric providers regarding counseling on delaying pregnancy and using contraception. Most of the surveyed providers agreed contraceptive counseling was important. ...
Bariatric surgery is a common treatment for obesity, and about half of patients undergoing these procedures are patients of reproductive age. Following bariatric procedures, rapid weight loss and an increase in fertility occur. Guidelines recommend pregnancy delay for 12–24 months postoperatively. It is important that patients capable of pregnancy undergoing bariatric procedures receive preoperative contraceptive counseling. Studies surveying bariatric providers demonstrate that most providers understand the importance of delaying pregnancy and contraceptive counseling. However, deficiencies in bariatric provider knowledge, comfort, and practice with contraceptive counseling were identified. These gaps highlight opportunities for improvement in preoperative care to ensure patients are receiving appropriate contraception.
... The number of adults living with obesity has tripled worldwide since 1975, and continues to rise in the western world( 1 ). Abdominal adiposity and hepatosteatosis can hinder port placement, operative exposure, and increase technical difficulty of gynaecological and general surgical procedures ( 2,3 ). This can increase the length of procedures and complication risk, attributing major costs to surgical care( 4 ). ...
Obesity can increase risk of postoperative complications. Despite increased demand for patients living with obesity to lose weight prior to common surgical procedures, the impact of intentional weightloss on surgical outcomes is largely unknown. We aimed to conduct a pilot study to assess the feasibility of a full-scale randomised controlled trial to examine the effect of preoperative dietitian-led Very Low Calorie Diet (VLCD) Clinic on surgical outcomes in gynaecology and general surgeries.
Between August 2021 and January 2023, a convenience sample of adults living with obesity (BMI≥30kg/m ² ) awaiting gynaecology, laparoscopic cholecystectomy, and ventral hernia repair procedures were randomised to dietitian-led VLCD (800-1000kcal using meal replacements and allowed foods), or control (no dietary intervention), 2-12 weeks preoperatively. Primary outcome was feasibility (recruitment, adherence, safety, attendance, acceptability, and quality-of-life). Secondary outcomes were anthropometry and 30-day postoperative outcomes. Outcomes were analysed as intention-to-treat. 51 participants were recruited (n=23 VLCD, n=28 control), mean 48(SD13) years, 86%female, mean BMI 35.8(SD4.6) kg/m ² . Recruitment was disrupted by COVID-19, but other thresholds for feasibility were met for VLCD group: high adherence without unfavourable body composition change, high acceptability, improved pre/post quality-of-life (22.1±15 points, <0.001), with greater reductions in weight (-5.5kg VLCD vs -0.9kg control, p <0.05) waist circumference (-6.6cm VLCD vs +0.6 control, p <0.05), and fewer 30-day complications (n=4/21) than controls (n=8/22) ( p >0.05). The RCT study design was deemed feasible in a public hospital setting. The dietitian-led VLCD resulted in significant weightloss and waist circumference reduction compared to a control group, without unfavourable body composition change, and improved quality-of-life.
... Morbid obesity is a serious medical and social problem associated with a decrease in the quality of life and its duration. According to WHO data, among adults, 1.6-1.9 billion people are overweight [17,30]. ...
Goals: To study the evaluation of lipid metabolism after the operation of sleeve resection in patients with morbid obesity. Materials and Methods: From 2019 to 2022, 277 bariatric and metabolic surgeries were performed in our clinical sites, including 125 MGSH and 152 PRG. Results: In our clinic, we studied the effect of sleeve resection practice on lipid metabolism before surgery and in the long term 6 months after surgery. The frequency of occurrence of the studied types of dyslipidemia depended on the degree of obesity. The frequency of the studied types of dyslipidemia depended on the degree of obesity. Hypercholesterolemia persisted in 4 (8.9%) patients after traditional sleeve resection, and after the proposed method of sleeve resection, this indicator in all patients did not differ from the normative indicators. The proposed surgical procedure leads to a decrease in the coefficient of atherogenicity and prevents dyslipoproteinemia. Conclusion: After 6 months of bariatric surgery, a statistically significant decrease in the level of UAG in serum blood was observed in the primary and control group of patients, which testifies to the greater effectiveness of the proposed operative intervention compared to the control group and the ratio of complete liquidation of hypertriglyceridemia.
... The classic criteria in order for a patient to be a candidate for any bariatric surgery is a BMI score greater than or equal to 40 kg/m 2 or a BMI of 35-40 kg/m 2 with at least one obesity-related comorbid condition, such as hypertension, diabetes mellitus, or severely limiting musculoskeletal issues (near unsuccessful nonoperative weight loss attempts, mental health clearance, no medical contraindication to surgery). Recent updates now include patients with a BMI of 30-35 kg/m 2 with uncontrollable Type 2 diabetes or metabolic syndrome as an indication for a laparoscopic sleeve gastrectomy [20,21]. ...
(1) Background and Objectives: Morbid obesity significantly increases the prevalence of comorbidities, such as heart disease, restrictive lung disease, stroke, diabetes mellitus and more. (2) Methods: Patients undergoing gastric sleeve surgery were divided into three groups with BMI between 30–34.9 kg/m2 (Group I), 35–39.9 kg/m2 (Group II), and over 40 kg/m2 (Group III). Preoperative examinations included cardiac ultrasound, respiratory function and laboratory tests, and preoperative comorbidities were also recorded. Following a one-year follow-up, we compared the rate of weight loss in the three groups at six months and one year following surgery, specifically, the effect of surgery on preoperative comorbidities at one year. (3) Results: The weight loss surgeries performed were successful in all three groups. Preoperative laboratory examinations, an echocardiogram and respiratory function results showed no clinically significant difference, except moderate elevations in blood lipid levels. Hypertension was the most common comorbidity. (4) Conclusions: In our patient population, hypertension and diabetes were the only comorbidities with a high prevalence. It can be explained by the relatively younger age among the patients (mean age 44.5 years) and the fact that they had not yet developed the pathological consequences of severe obesity. Consequently, while performing the surgery at a relatively younger age, it seems far more likely that the patient will return to a more active and productive life and enjoy a better quality of life. Additionally, the perioperative risk is lower, and the burden upon health systems and health expenditure is reduced by preventing comorbidities, in particular, multimorbidity. On this basis, it may be advisable to direct patients who do not exhaust the classical indications for bariatric surgery toward the surgical solution at a younger age. Our results suggest it is not worth waiting for comorbidities, especially multimorbidity, to appear.
... Pre-operative nutritional status was only reported in 59 (13.2%) patients in this review. Of note, as per clinical guidelines cosponsored by the American Association of Clinical Endocrinologists, The Obesity Society, and American Society of Metabolic and Bariatric Surgery, assessment of preoperative nutritional status is imperative in patients undergoing MBS, and a thorough checklist is recommended [30]. The BPL length was not mentioned in almost twothirds of patients who received treatment for severe malnutrition. ...
Severe malnutrition following one-anastomosis gastric bypass (OAGB) remains a concern. Fifty studies involving 49,991 patients were included in this review. In-hospital treatment for severe malnutrition was needed for 0.9% (n = 446) of patients. Biliopancreatic limb (BPL) length was 150 cm in five (1.1%) patients, > 150 cm in 151 (33.9%), and not reported in 290 (65%) patients. OAGB was revised to normal anatomy in 126 (28.2%), sleeve gastrectomy in 46 (10.3%), Roux-en-Y gastric bypass in 41 (9.2%), and shortening of BPL length in 17 (3.8%) patients. One hundred fifty-one (33.8%) patients responded to treatment; ten (2.2%) did not respond and was not reported in 285 (63.9%) patients. Eight (0.02%) deaths were reported. Standardisation of the OAGB technique along with robust prospective data collection is required to understand this serious problem.
... In addition, these medications are associated with side effects and in many cases even contraindicated 9 . Invasie surgical procedures are associated with significant risk 10 . Most importantly, maintenance of weight loss regardless of the method used is difficult for most patients in long term 8 . ...
Reduction in visceral adipose tissue (VAT) mass reduces body weight and metabolic disease risk in obese patients. However surgical removal of VAT is highly invasive and thus not clinically feasible. We developed an injectable ice slurry for selective reduction of adipose tissue through cryolipolysis. The aim of this study was to investigate safety, feasibility and mechanism of ice slurry-induced cryolipolysis of VAT. Perigonadal VAT in diet-induced obese mice and rats was subjected to slurry or sham treatment. Body weight and blood chemistry were monitored for 56 days post-treatment. Histological analysis and molecular studies were performed to elucidate mechanisms of fat reduction. Treatment of VAT was well tolerated in all animals. Slurry induced adipocyte cell death via selective cryolipolysis; significant weight loss was noted at day 21 post-treatment. RNA sequencing from treated VAT samples showed increased expression of genes involved in inflammation, immune response, collagen biosynthesis and wound healing, and decreased expression of adipokines. This study demonstrates that slurry treatment is safe and effective in inducing cryolipolysis of VAT and subsequent weight loss in mice. Ice slurry is promising as a minimally-invasive treatment to reduce visceral adipose tissue.
... The American Society for Metabolic and Bariatric Surgery (ASMBS) has recognized the significant impact of LSG, and utilizing long-term outcome data from large studies, has officially classified it as a primary bariatric operation for the management of morbid obesity [4]. Indications to undergo sleeve gastrectomy remain the same as with other types of bariatric surgery and include BMI equal or greater than 35 kg/m 2 , BMI of 30 to 35 kg/m 2 with the presence of serious metabolic disease as a comorbidity, especially regarding poorly controlled diabetes mellitus or metabolic syndrome [5][6][7]. ...
Sleeve gastrectomy (SG) has gained ever-increasing popularity among laparoscopic surgeons involved in bariatric surgery. This single-institution, retrospective cohort study aims to evaluate the prevalence of postoperative staple line leakage (PSLL) after LSG and identify risk factors for its development. We included patient data that underwent LSG at our institution for a span of 17 years—starting in January 2005 and ending in December 2022. We set the investigation of correlations of patient-related factors (age, weight, BMI, smoking status, presence of diabetes mellitus) with the occurrence of postoperative leaks. A total of 402 patients were included in our study. Of them, 26 (6.46%) developed PSLL. In total, 19 (73%) patients underwent percutaneous drainage and 14 patients (53.8%) were treated with intraluminal endoscopic stenting. Finally, five patients (19.2%) were treated with endoscopic clipping of the defect. Operative management was required in only one patient. There were no statistically significant differences in patient age, mean weight at the time of operation, and mean BMI. Abnormal drain amylase levels were associated with earlier detection of PSLL. More consideration needs to be given to producing a consensus regarding the management of PSLL, prioritizing nonoperative management with the combination of percutaneous drainage and endoscopic stenting as the safest and most efficient approach.
... A prophylactic dose of subcutaneous low molecular weight heparin was routinely administered to all patients based on their weight the night before the operation. Proper thromboembolic prophylaxis was administered for patients with a history of thromboembolic diseases [13]. Patients who had OSAS were prepared by continuous positive airway pressure under the supervision of a pulmonologist. ...
... While most people with obesity will achieve weight reduction through lifestyle and dietary modifications, a percentage of those classified as morbidly obese (BMI ≥ 40 kg/m 2 ) will eventually require surgical intervention to minimize their mortality risk. In 2017, approximately 228,000 bariatric operations were performed in the U.S., with the estimated prevalence constantly on the rise [1][2][3]. ...
Introduction:
Morbid obesity is a well-defined chronic disease, the incidence of which is constantly rising. Surgical treatment of morbid obesity has produced superior outcomes compared to conventional weight loss measures. Currently, there is a gap in the literature regarding long-term outcomes. Our single-institution, retrospective cohort study aims to evaluate weight loss outcomes, comorbidity reduction, and adverse effects at 10 years following Roux-en-Y Gastric Bypass (RYGB), Biliopancreatic Diversion (BPD), and Sleeve Gastrectomy (SG).
Materials and methods:
We included all consecutive patients with 10-year follow-up records operated on within our institution. The comparison was carried out on the average percentage of weight and BMI loss. Nausea and vomiting were evaluated through self-reporting Likert scales. Diabetes resolution and nutritional deficiencies were also evaluated.
Results:
A total of 490 patients from 1995 up to 2011 were included in our study. Of these, 322 underwent RYGB, 58 underwent long-limb BPD, 34 underwent laparoscopic RYGB with fundus excision, 47 underwent laparoscopic SG, and 29 underwent laparoscopic RYGB as a revision of prior SG. RYGB and BPD were significantly associated with higher percentages of weight loss (37.6% and 37.5%), but were not found to be independent predictors of weight loss. Nausea and vomiting were associated with SG and laparoscopic RYGB with fundus excision, more so than the other operations. No differences were observed regarding diabetes resolution and nutritional deficiencies.
Conclusions:
Longer follow-up reports are important for the comparison of outcomes between different types of bariatric operations. BPD and RYGB resulted in superior weight loss, with no observed differences in diabetes resolution and adverse outcomes.
La cirugía bariátrica (CB) ha demostrado su eficacia y eficiencia, pero solo el 1% de los pacientes seleccionados llegará a recibirla.
En comparación con el tratamiento médico de la obesidad, la CB, ha demostrado una mayor pérdida ponderal mantenida a largo plazo, una reducción de la mortalidad tanto total como cardiovascular (CV), mejoría o remisión de los factores de riesgo CV y de otras comorbilidades asociadas a la obesidad, así como mejor movilidad y calidad de vida.
Presenta riesgos similares a otras intervenciones quirúrgicas abdominales, con la obesidad como factor de riesgo añadido. No obstante, la mortalidad después de este tipo de cirugía es menor al 1%, siendo en centros especializados incluso inferior al 0,3%, con una morbilidad menor al 7%.
Los procedimientos quirúrgicos más comúnmente realizados en el momento actual son la gastrectomía vertical (GV) y el bypass gástrico en Y de Roux (BGYR), preferiblemente mediante abordaje laparoscópico.
Objectives: Sleeve gastrectomy (SG) is one of the most commonly performed weight loss (WL) bariatric procedures. The main goal of WL is reducing total body weight (TBW) and fat mass (FM). However, TBW loss is systematically accompanied by a decline in fat-free mass (FFM), predominantly in the first post-surgical month, despite protein supplementation. Branched-chain amino acids (BCAAs) and vitamin D seem to attenuate loss of FFM and, thus, reduce the decline in muscle strength (MS). However, data on the role of an integrated supplementation with whey protein plus BCAAs plus vitamin D (P+BCAAs+Vit.D) vs. protein alone on total weight loss (TWL), fat mass (FM), fat-free mass (FFM), and (MS) in the first month after SG are lacking. Therefore, the present study aims to evaluate the impact of P+BCAAs+Vit.D vs. protein alone supplementation on TWL, FM, FFM, and MS in the first month after SG. Materials and Methods: Before SG and at 1 month afterward, we prospectively measured and compared TBW, FM, FFM, and MS in 57 patients who received either a supplementation with P+BCAAs+Vit.D (n = 31) or protein alone (n = 26). The impact of P+BCAAs+Vit.D and protein alone supplementation on clinical status was also evaluated. Results: Despite non-significant variation in TBW, FM decreased more significantly (18.5% vs. 13.2%, p = 0.023) with the P+BCAA+Vit.D supplementation compared to protein alone. Furthermore, the P+BCAA+Vit.D group showed a significantly lower decrease in FFM (4.1% vs. 11.4%, p < 0.001) and MS (3.8% vs. 18.5%, p < 0.001) compared to the protein alone group. No significant alterations in clinical status were seen in either group. Conclusion: P+BCAA+Vit.D supplementation is more effective than protein alone in determining FM loss and is associated with a lower decrease in FFM and MS, without interfering with clinical status in patients 1 month after SG.
The frequency of transgender individuals seeking gender affirming care is increasing over the last decade. Transgender patients suffer from obesity and psychiatric illness at elevated levels compared with the general population. A 54-year-old male-to-female transition patient presented with morbid obesity, hyperlipidaemia, and weight gain 2 years after their gender-transition and hormonal therapy. She received a Roux-en-Y gastric bypass (RYGB). At 7 months postoperatively, the patient has experienced 49% excess body weight loss, her body dissatisfaction had resolved and has completed further plastic surgery. The RYGB is an effective method for weight loss as well as benefits from cardiovascular disease, cancer, metabolic related conditions, and psychosocial wellbeing. Holistic treatment in conjunction with dietetic and psychology services can help maintain long-term weight management. Bariatric surgery combined with a multidisciplinary care team addressing medical and psychiatric concerns is integral to achieving and maintaining weight loss and gender identity.
The increasing prevalence of worldwide obesity calls for a comprehensive understanding of available treatment options. Bariatric surgery remains a very effective obesity treatment, showing substantial effects on obesity-related complications, including type 2 diabetes mellitus and cardiovascular disease, mainly related to significant long-term weight loss. Besides the benefits, weight loss can lead to some deleterious consequences, such as gallstones, constipation, muscle mass loss, bone fractures, vitamin deficiencies, peripheral neural palsy, suicide, eating disorders, alcohol dependency syndrome, and increased divorce. Those consequences may also be seen after long-term effective pharmacotherapy for obesity. Understanding these risks will lead to improved awareness and successful treatment with both surgical and nonsurgical treatments.
Background
Conversional surgery is common after laparoscopic sleeve gastrectomy (LSG) because of suboptimal weight loss (SWL) or poor responders and gastroesophageal reflux disease (GERD). Roux-en-Y gastric bypass (RYGB) is the most common conversional procedure after LSG.
Methods
A retrospective cohort study analyzed patients who underwent primary RYGB (PRYGB) or conversional RYGB (CRYGB) at three specialized bariatric centers between 2008 and 2019 and tested for weight loss, resolution of GERD, food tolerance (FT), early and late complications, and the resolution of associated medical problems. This was analyzed by propensity score matching (PSM).
Results
In total, 558 (PRYGB) and 155 (CRYGB) completed at least 2 years of follow-up. After PSM, both cohorts significantly decreased BMI from baseline (p < 0.001). The CRYGB group had an initially more significant mean BMI decrease of 6.095 kg/m² at 6 months of follow-up (p < 0.001), while the PRYGB group had a more significant mean BMI decrease of 5.890 kg/m² and 8.626 kg/m² at 1 and 2 years, respectively (p < 0.001). Food tolerance (FT) improved significantly in the CRYGB group (p < 0.001), while CRYGB had better FT than PRYGB at 2 years (p < 0.001). A GERD resolution rate of 92.6% was recorded in the CRYGB (p < 0.001). Both cohorts had comparable rates of early complications (p = 0.584), late complications (p = 0.495), and reoperations (p = 0.398). Associated medical problems at 2 years significantly improved in both cohorts (p < 0.001).
Conclusions
CRYGB is a safe and efficient option in non- or poor responders after LSG, with significant weight loss and improvement in GERD. Moreover, PRYGB and CRYGB had comparable complications, reoperations, and associated medical problem resolution rates.
The prevalence of obesity is significantly increasing in the U.S. population and is associated with both increased incidence of total hip arthroplasty (THA) and potentially worsened postoperative outcomes. Current guidelines strongly encourage exercise-based weight loss in morbidly obese THA candidates to decrease patient risk profiles, but data on the impact of receiving bariatric surgery (BS) for weight loss prior to THA are limited and controversial. The purpose of this study was to clarify the impact of BS on postoperative complications and outcomes following THA. Using Current Procedural Terminology, International Classification of Diseases (ICD)-9, and ICD-10 codes, patients undergoing primary THA from 2010 to 2018 were retrospectively collected from PearlDiver's Mariner dataset. Patients were divided into three cohorts who underwent primary THA: nonmorbidly obese patients, morbidly obese patients, and morbidly obese patients who underwent THA within 2 years of BS. Patients were subsequently matched based on age, Charlson Comorbidity Index, gender, and tobacco use. The primary outcome of this study was the frequency of 90-day and 2-year postoperative complications following primary THA. Compared with morbidly obese non-BS patients, morbidly obese patients who underwent BS prior to receiving a primary THA were less likely to have blood transfusion (4.24 vs. 7.44%, p < 0.05), cellulitis (2.92 vs. 6.11%, p < 0.05), myocardial infarction (2.39 vs. 4.91%, p < 0.05), and deep venous thrombosis (1.06 vs. 3.05%, p < 0.05) at 90-day follow-up. The remaining 90-day postoperative outcomes were not found to be statistically different between cohorts. There were no significant differences in 2-year surgical complications between the morbidly obese non-BS cohort and morbidly obese BS cohort. In this study, we found that morbidly obese patients who underwent BS prior to THA had fewer 90-day medical complications and no significant differences in 2-year surgical complications compared with those who did not undergo BS prior to THA.
Objective
Adherence to lifestyle changes after bariatric surgery is associated with better health outcomes; however, research suggests that patients struggle to follow post‐operative recommendations. This systematic review aimed to examine psychological factors associated with adherence after bariatric surgery.
Methods
PubMed, PsycInfo, and Embase were searched (from earliest searchable to August 2022) to identify studies that reported on clinically modifiable psychological factors related to adherence after bariatric surgery. Retrieved abstracts ( n = 891) were screened and coded by two raters.
Results
A total of 32 studies met the inclusion criteria and were included in the narrative synthesis. Appointment attendance and dietary recommendations were the most frequently studied post‐operative instructions. Higher self‐efficacy was consistently predictive of better post‐operative adherence to diet and physical activity, while pre‐operative depressive symptoms were commonly associated with poorer adherence to appointments, diet, and physical activity. Findings were less inconsistent for anxiety and other psychiatric conditions.
Conclusions
This systematic review identified that psychological factors such as mood disorders and patients' beliefs/attitudes are associated with adherence to lifestyle changes after bariatric surgery. These factors can be addressed with psychological interventions; therefore, they are important to consider in patient care after bariatric surgery. Future research should further examine psychological predictors of adherence with the aim of informing interventions to support recommended lifestyle changes.
Background: There is a paucity of research exploring postoperative psychosocial interventions for bariatric surgery patients exceeding 2 years, and therefore, an interdisciplinary postoperative approach is warranted. This qualitative study explored the psychosocial support that bariatric surgery patients feel they need to sustain long-term weight loss and their psychological wellbeing. Methods: Fifteen postoperative patients participated in recorded semi-structured online interviews that were transcribed verbatim and analysed using a reflexive thematic analysis approach. Results: Three themes and six subthemes emerged. Theme 1, Journey to surgery, has two subthemes: Deep roots and Breaking point. Theme 2, The precipice of change, has two sub-themes: Continuity of care and Can’t cut the problem out. Theme 3, Bridging the Gap, has two subthemes: Doing it together and Taking back the reigns. The inconsistencies participants experienced in their pre- and postoperative care led to dissonance, and they felt unprepared for the demands of life postoperatively. Conclusions: Bariatric surgery is a catalyst for physical change, but surgery alone is insufficient to ensure sustained change. Surgical and psychosocial interventions are interdependent rather than mutually exclusive. Patients favour an integrative, personalised, stepped-care approach pre- and postoperatively, with active participation fostering autonomy and access to ongoing support extending into the long-term.
Background
Psychological Clearance level (PCL) for patients undergoing metabolic and bariatric surgery (MBS) is a critical step for successful postoperative outcomes. This study aims to assess the relationship between the level of psychologic fitness and postoperative outcomes in patients undergoing MBS.
Methods
We retrospectively analyzed the data of patients who underwent MBS (laparoscopic sleeve gastrectomy [LSG] and laparoscopic Roux-en-Y Gastric Bypass [LRYGB]) and completed two years follow-up, between 2012 and 2019, in a single medical center. The patients were divided into four groups based on PCL, suggesting level of readiness for surgery: Group A (PCL-0: guarded), group B (PCL-1: Fair/reasonable), group C (PCL-2: Good/appropriate), and group D (PCL-3: Strong/excellent). Primary outcome was the percent of total body weight loss (%TWL), and the absolute change in BMI units. Secondary outcomes were missed postoperative visits and patient compliance. Differences between the groups were analyzed using a generalized linear model (GLM), chi-squared and exact Fisher tests, as appropriate.
Results
Of 1411 total patients, 607 (43.20%) had complete data at two years follow-up. 512 (84.34%) were females. LSG was performed in 361 (59.5%). No difference was found in %TWL between the four groups (22.14% vs. 28.0% vs. 26.0% vs. 24.8%, p = 0.118). We found a small difference in the mean (SD) of absolute change in BMI between the groups, and on post-hoc analysis it was found between groups B (PCL-1) and D (PCL-3). Overall, no difference between the groups in number of follow-up visits, or compliance issues. However, patients who attended more follow-up visits had less compliance issues (p < 0.001). PCL is inversely correlated with number of psychologic diagnoses (r = − 0.41, p < 0.001) and medical comorbidities (r = − 0.20, p < 0.001).
Conclusion
We found no difference in the percent of TWL in patients who underwent MBS based on PCL at two -years follow-up. Medical comorbidities and psychiatric diagnoses impact the PCL.
Graphical abstract
Aim: This study aimed to review the technical and clinical results of cone-beam computed tomography (CBCT) fluoroscopy-guided drainage of anastomosis or staple line leakage, which is the most important complication after laparoscopic sleeve gastrectomy due to obesity. Methods: A retrospective analysis was performed of the demographic findings, clinical manifestations, leakage location, and medical data of 30 cases who underwent CBCT fluoroscopy-guided percutaneous drainage due to anastomosis or staple line leakage after sleeve gastrectomy due to obesity in the interventional unit of our hospital between February 2015 and September 2020. Results: A total of 48 drainage catheters were inserted in 30 patients (8 females and 22 males), aged 19–71 years (mean 51.24), under the guidance of CBCT fluoroscopy. Drainage was completed in a single session with one catheter in 13 (43.3%) patients. In 17 (56.7%) patients, the procedure was completed with two or more catheterizations in more than one session due to different leakage locations and subsequent occlusion or dislocation of the catheter. Inflammatory parameters and symptoms related to leakage regressed in 29 (94%) patients within 48–72 hours with clinical improvement. The success rate of percutaneous drainage was 100% without any complications. Conclusion: Anastomosis, or staple line leakage, is one of the most serious life-threatening complications that can be seen following laparoscopic sleeve gastrectomy. CBCT fluoroscopy-guided drainage is a safe, highly effective, and minimally invasive treatment option that has a low risk of complications. This technique can facilitate the treatment of postoperative collections with alternative treatment methods.
Nonsteroidal anti‐inflammatory drugs (NSAIDs) are a valuable class of medications for orthopedic surgeons and often play a pivotal role in pain control. However, there are many common stipulations resulting in avoidance of its use in the treatment of musculoskeletal disease. This review summarizes the mechanism of action of NSAIDs as well as provides an overview of commonly used NSAIDs and the differences between them. It provides a concise summary on the osseous effects of NSAIDs with regard to bone healing and heterotopic ossification. Most of all, it serves as a guide or reference for orthopedic providers when counseling patients on the risks and benefits of NSAID use, as it addresses the common stipulations encountered: “It irritates my stomach,” “I have a history of bariatric surgery,” “I'm already on a blood thinner,” “I've had a heart attack,” and “I've got kidney problems” and synthesizes both current research and society recommendations regarding safe use and avoidance of NSAIDs.
The dual burden of malnutrition is characterised by the coexistence of undernutrition alongside overweight/obesity and diet-related noncommunicable diseases. It is a paradox which disproportionately affects women and is applicable to those who become pregnant after weight loss surgery. Obesity before and during pregnancy is associated with increased risk of adverse perinatal outcomes in both mother and child. Overall lifestyle interventions targeting weight loss in the preconception period have not proven effective, with people, and women in particular, increasingly seeking weight loss surgery. In women with severe obesity, surgery may normalise hormonal abnormalities and improve fertility. In those who become pregnant after surgery, evidence suggests a better overall obstetric outcome compared to those with severe obesity managed conservatively, however there is heightened risk of maternal nutritional deficiencies and infants born small for gestational age. Specifically, pregnancy soon after surgery, in the catabolic phase when rapid weight loss is occurring, has the potential for poor outcomes. Lifelong micronutrient supplementation is required and there is considerable risk of malnutrition if nutritional aftercare guidelines are not adhered to. It is therefore recommended that pregnancy is delayed until a stable weight is achieved and is supported by individualised advice from a multidisciplinary team. Further research is required to better understand how weight loss surgery affects the chances of having a healthy pregnancy and to ultimately improve nutritional management and patient care. In this review we aim to summarise the evidence and guidance around nutrition during pregnancy after weight loss surgery.
We report a case of a 72-year-old woman who developed recurrent abdominal laparotomy wound dehiscence and infection following a hepatico-jejunostomy. Her surgical history included a Roux-en-Y gastric bypass (RYGB) that was carried out 11 years ago. Upon further assessment in the current admission, she was found to be deficient in both selenium and zinc. Daily multivitamin and mineral tablets and a nutritional supplement drink were prescribed to address her deficiencies. After 2 months of supplementation, the laparotomy wound had made significant healing progress and no further surgical input was required. This case illustrates the importance of assessing micronutrient levels in patients with a history of bariatric surgery who present with poor wound healing and infection. Bariatric patients should also be educated about the risks of nutritional deficiencies and encouraged to adhere to prescribed dietary and lifestyle changes. Importantly, family medicine and primary care physicians need to consider an adequate level of supplementation of micronutrients in all patients with RYGB surgery.
A lack of or insufficient supplementation makes a deficiency of vitamins and minerals very likely. But even with sufficient supplementation, deficiencies can occur. Therefore, it is important to diagnose them in time and to interpret symptoms correctly, in order to perform an additive substitution early and to avoid severe nutritional complications.
Bone metabolism is a dynamic process and is continuously adapted to the functional needs of the human body. Osteogenesis (bone formation) and osteolysis (bone resorption) are the basic activities of the bone tissue. A change in food intake or nutritional status and significant weight loss affect the metabolically active bone metabolism and can result in a reduction of bone density. Bone metabolism and bone density must therefore be regularly monitored after bariatric and metabolic surgery. The risk of developing postoperative secondary hyperparathyroidism and postoperative osteoporosis must be minimized by physical exercise and by regular supplementation of calcium and vitamin D.
Son yıllarda tıbbi gelişmelerle birlikte ameliyat öncesi- sırası- sonrası süreçlerinde hasta bakımı kanıta dayalı uygulamalara göre yapılmaktadır. Cerrahi Sonrası Hızlandırılmış İyileşme (Enhanced Recovery After Surgery; ERAS) protokolü kanıta dayalı uygulamalar arasında yer almaktadır. Bu protokoller her alanda özelleştirilmiştir. Bu alanlardan biri ise bariatrik cerrahi sonrası hızlandırılmış iyileştirme protokolleridir. Cerrahi hemşiresi ameliyat öncesi- sırası- sonrası olmak üzere cerrahi sürecin her noktasında aktif rol almaktadır. Bu çalışmada, hemşirelerin bariatrik cerrahi için hastaneye başvuran hastalara verecekleri bakımda kanıta dayalı uygulamalardan yararlanması, ayrıca hemşirelik alanına yeni ve kanıta dayalı bir bakış açısı kazandırması hedeflenmektedir.
Obesity is highly prevalent in patients with chronic kidney disease (CKD), as it contributes to or accelerates the progression of kidney disease in this at-risk population and is frequently a barrier to kidney transplantation. Patients with renal failure have unique dietary needs due to various metabolic disturbances resulting from altered processing and clearance of nutrients. They also frequently present with physical disability, resulting in difficulty achieving adequate weight loss through lifestyle modifications. Therefore, kidney transplant candidates may benefit from bariatric surgery, particularly sleeve gastrectomy (SG) as the safest, most effective, and long-lasting weight loss option, to improve comorbidities and access to transplantation. However, concerns regarding nutritional risks post-bariatric surgery prevent broader dissemination of SG in this population. No specific guidelines tailored to the nutritional needs of patients with CKD undergoing SG have been developed. Moreover, appropriate monitoring strategies and interventions for muscle loss and functional status preservation, a major concern in this at-risk population, are unknown. We aimed to summarize the available literature on the nutritional requirements of patients with kidney failure seeking SG as a bridge to transplantation. We also provide insight and guidance into the nutritional management pre- and post-SG.
Background
Percentage excess weight loss (%EWL) and percentage total weight loss (%TWL) are used for reporting outcomes after bariatric surgery. However, they are not ideal for comparing outcomes on populations of varied initial body mass index (BMI). This study aimed to validate a recently introduced metric - percentage alterable weight loss (%AWL), after laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (LRYGB).
Methods
Analysis of weight data of all patients who had undergone LSG and LRYGB until the end of the year 2021. Outcomes for both procedures were analyzed separately. The patients were divided into quartile subgroups Q1 (lowest BMI) to Q4 (highest BMI) and weight loss up to 5 years postoperatively was compared using %EWL, %TWL and %AWL metrics. An intermediary metric was also tested for its effect on the weight loss patterns for both procedures.
Results
The cohort included 1020 LSG and 322 LRYGB patients, with initial mean BMI of 43.5 ± 7.5 and 41.9 ± 8.3 kg/m², respectively. %EWL significantly favors lower BMI subgroups for both procedures. %TWL is ideal for comparing weight loss during the first 6 months but it then favors higher BMI subgroups beyond 6 months. %AWL with reference BMI of 13 kg/m² seems the best metric for medium-term comparison of weight loss for LRYGB and an intermediary metric based on BMI 8 kg/m² provides the best fit for medium-term comparison for LSG.
Conclusions
%TWL is least influenced by initial BMI during short-term follow-up after LSG and LRYGB. For medium-term comparison, %AWL is best suited for LRYGB while an intermediary metric is found to provide the best fit for LSG.
There is growing evidence that excess body weight increases the risk of cancer at several sites, including kidney, endometrium, colon, prostate, gallbladder and breast in post‐menopausal women. The proportion of all cancers attributable to overweight has, however, never been systematically estimated. We reviewed the epidemiological literature and quantitatively summarised, by meta‐analysis, the relationship between excess weight and the risk of developing cancer at the 6 sites listed above. Estimates were then combined with sex‐specific estimates of the prevalence of overweight [body mass index (BMI) 25–29 kg/m²] and obesity (BMI ≥30 kg/m²) in each country in the European Union to obtain the proportion of cancers attributable to excess weight. Overall, excess body mass accounts for 5% of all cancers in the European Union, 3% in men and 6% in women, corresponding to 27,000 male and 45,000 female cancer cases yearly. The attributable proportion varied, in men, between 2.1% for Greece and 4.9% for Germany and, in women, between 3.9% for Denmark and 8.8% for Spain. The highest attributable proportions were obtained for cancers of the endometrium (39%), kidney (25% in both sexes) and gallbladder (25% in men and 24% in women). The largest number of attributable cases was for colon cancer (21,500 annual cases), followed by endometrium (14,000 cases) and breast (12,800 cases). Some 36,000 cases could be avoided by halving the prevalence of overweight and obese people in Europe. © 2001 Wiley‐Liss, Inc.
Background
Previously published cohort studies in clinical populations have suggested that obstructive sleep apnea (OSA) is a risk factor for mortality associated with cardiovascular disease. However, it is unknown whether sleep apnea is an independent risk factor for all-cause mortality in a community-based sample free from clinical referral bias.
Methods
Residents of the Western Australian town of Busselton underwent investigation with a home sleep apnea monitoring device (MESAM IV). OSA was quantified via the respiratory disturbance index (RDI). Mortality status was determined in 397/400 participants (99.3%) after up to 14 years (mean follow-up 13.4 years) by data matching with the Australian National Death Index and the Western Australian Death Register. Univariate analyses and multivariate Cox proportional hazards modelling were used to ascertain the association between sleep apnea and mortality after adjustment for age, gender, body mass index, mean arterial pressure, total cholesterol, high-density lipoprotein cholesterol, diabetes, and medically diagnosed angina in those free from heart attack or stroke at baseline (n = 380).
Results
Among the 380 participants, 18 had moderate-severe OSA (RDI ≥15/hr, 6 deaths) and 77 had mild OSA (RDI 5 to <15/hr, 5 deaths). Moderate-to-severe OSA was independently associated with greater risk of all-cause mortality (fully adjusted hazard ratio [HR] = 6.24, 95% CL 2.01, 19.39) than non-OSA (n = 285, 22 deaths). Mild OSA (RDI 5 to <15/hr) was not an independent risk factor for higher mortality (HR = 0.47, 95% CL 0.17, 1.29).
Conclusions
Moderate-to-severe sleep apnea is independently associated with a large increased risk of all-cause mortality in this community-based sample.
Background:
Gastric bypass has profound effects on glycemic control in adults with type 2 diabetes mellitus. The goal of this study was to examine the long-term rates and clinical predictors of diabetes remission and relapse among patients undergoing gastric bypass.
Methods:
We conducted a retrospective cohort study of adults with uncontrolled or medication-controlled type 2 diabetes who underwent gastric bypass from 1995 to 2008 in three integrated health care delivery systems in the USA. Remission and relapse events were defined by diabetes medication use and clinical laboratory measures of glycemic control. We identified 4,434 adults with uncontrolled or medication-controlled type 2 diabetes who had gastric bypass.
Results:
Overall, 68.2 % (95 % confidence interval [CI], 66 and 70 %) experienced an initial complete diabetes remission within 5 years after surgery. Among these, 35.1 % (95 % CI, 32 and 38 %) redeveloped diabetes within 5 years. The median duration of remission was 8.3 years. Significant predictors of complete remission and relapse were poor preoperative glycemic control, insulin use, and longer diabetes duration. Weight trajectories after surgery were significantly different for never remitters, relapsers, and durable remitters (p = 0.03).
Conclusions:
Gastric bypass surgery is associated with durable remission of type 2 diabetes in many but not all severely obese diabetic adults, and about one third experience a relapse within 5 years of initial remission. More research is needed to understand the mechanisms of diabetes relapse, the optimal timing of surgery in effecting a durable remission, and the relationship between remission duration and incident microvascular and macrovascular events.
A. The American Association of Clinical Endocrinologists (AACE) views obesity as a disease. This position reflects the analysis done by the American Medical Association of the criteria for a disease and the fact that obesity fits these criteria. The criteria are: 1. An impairment of the normal functioning of some aspect of the body; 2. Characteristic signs or symptoms; and 3. Harm or morbidity. The conclusion that obesity is a disease with multiple pathophysiological aspects, including genetic, environmental, physiological, and psychological factors, sets the framework for future efforts from many stakeholders to advance its treatment and prevention. B. AACE plans to establish several strategies to meet a need for additional training for endocrinologists in obesity management; C. AACE plans to develop a certifying procedure for endocrinologists who have successfully completed additional training programs; and D. AACE plans to work with other organizations to develop additional efforts to combat obesity as a Disease.
Extreme obesity is associated with health and cardiovascular disease risks. Although gastric bypass surgery induces rapid weight loss and ameliorates many of these risks in the short term, long-term outcomes are uncertain.
To examine the association of Roux-en-Y gastric bypass (RYGB) surgery with weight loss, diabetes mellitus, and other health risks 6 years after surgery.
A prospective Utah-based study conducted between July 2000 and June 2011 of 1156 severely obese (body mass index [BMI] ≥ 35) participants aged 18 to 72 years (82% women; mean BMI, 45.9; 95% CI, 31.2-60.6) who sought and received RYGB surgery (n = 418), sought but did not have surgery (n = 417; control group 1), or who were randomly selected from a population-based sample not seeking weight loss surgery (n = 321; control group 2).
Weight loss, diabetes, hypertension, dyslipidemia, and health-related quality of life were compared between participants having RYGB surgery and control participants using propensity score adjustment.
Six years after surgery, patients who received RYGB surgery (with 92.6% follow-up) lost 27.7% (95% CI, 26.6%-28.9%) of their initial body weight compared with 0.2% (95% CI, -1.1% to 1.4%) gain in control group 1 and 0% (95% CI, -1.2% to 1.2%) in control group 2. Weight loss maintenance was superior in patients who received RYGB surgery, with 94% (95% CI, 92%-96%) and 76% (95% CI, 72%-81%) of patients receiving RYGB surgery maintaining at least 20% weight loss 2 and 6 years after surgery, respectively. Diabetes remission rates 6 years after surgery were 62% (95% CI, 49%-75%) in the RYGB surgery group, 8% (95% CI, 0%-16%) in control group 1, and 6% (95% CI, 0%-13%) in control group 2, with remission odds ratios (ORs) of 16.5 (95% CI, 4.7-57.6; P < .001) vs control group 1 and 21.5 (95% CI, 5.4-85.6; P < .001) vs control group 2. The incidence of diabetes throughout the course of the study was reduced after RYGB surgery (2%; 95% CI, 0%-4%; vs 17%; 95% CI, 10%-24%; OR, 0.11; 95% CI, 0.04-0.34 compared with control group 1 and 15%; 95% CI, 9%-21%; OR, 0.21; 95% CI, 0.06-0.67 compared with control group 2; both P < .001). The numbers of participants with bariatric surgery-related hospitalizations were 33 (7.9%), 13 (3.9%), and 6 (2.0%) for the RYGB surgery group and 2 control groups, respectively.
Among severely obese patients, compared with nonsurgical control patients, the use of RYGB surgery was associated with higher rates of diabetes remission and lower risk of cardiovascular and other health outcomes over 6 years.
Weight loss protects against type 2 diabetes but is hard to maintain with behavioral modification alone. In an analysis of data from a nonrandomized, prospective, controlled study, we examined the effects of bariatric surgery on the prevention of type 2 diabetes.
In this analysis, we included 1658 patients who underwent bariatric surgery and 1771 obese matched controls (with matching performed on a group, rather than individual, level). None of the participants had diabetes at baseline. Patients in the bariatric-surgery cohort underwent banding (19%), vertical banded gastroplasty (69%), or gastric bypass (12%); nonrandomized, matched, prospective controls received usual care. Participants were 37 to 60 years of age, and the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) was 34 or more in men and 38 or more in women. This analysis focused on the rate of incident type 2 diabetes, which was a prespecified secondary end point in the main study. At the time of this analysis (January 1, 2012), participants had been followed for up to 15 years. Despite matching, some baseline characteristics differed significantly between the groups; the baseline body weight was higher and risk factors were more pronounced in the bariatric-surgery group than in the control group. At 15 years, 36.2% of the original participants had dropped out of the study, and 30.9% had not yet reached the time for their 15-year follow-up examination.
During the follow-up period, type 2 diabetes developed in 392 participants in the control group and in 110 in the bariatric-surgery group, corresponding to incidence rates of 28.4 cases per 1000 person-years and 6.8 cases per 1000 person-years, respectively (adjusted hazard ratio with bariatric surgery, 0.17; 95% confidence interval, 0.13 to 0.21; P<0.001). The effect of bariatric surgery was influenced by the presence or absence of impaired fasting glucose (P=0.002 for the interaction) but not by BMI (P=0.54). Sensitivity analyses, including end-point imputations, did not change the overall conclusions. The postoperative mortality was 0.2%, and 2.8% of patients who underwent bariatric surgery required reoperation within 90 days owing to complications.
Bariatric surgery appears to be markedly more efficient than usual care in the prevention of type 2 diabetes in obese persons. (Funded by the Swedish Research Council and others; ClinicalTrials.gov number, NCT01479452.).
Roux-en-Y gastric bypass (RYGB) ameliorates type 2 diabetes in severely obese patients through mechanisms beyond just weight loss, and it may benefit less obese diabetic patients. We determined the long-term impact of RYGB on patients with diabetes and only class I obesity.
Sixty-six consecutively selected diabetic patients with BMI 30-35 kg/m(2) underwent RYGB in a tertiary-care hospital and were prospectively studied for up to 6 years (median 5 years [range 1-6]), with 100% follow-up. Main outcome measures were safety and the percentage of patients experiencing diabetes remission (HbA(1c) <6.5% without diabetes medication).
Participants had severe, longstanding diabetes, with disease duration 12.5 ± 7.4 years and HbA(1c) 9.7 ± 1.5%, despite insulin and/or oral diabetes medication usage in everyone. For up to 6 years following RYGB, durable diabetes remission occurred in 88% of cases, with glycemic improvement in 11%. Mean HbA(1c) fell from 9.7 ± 1.5 to 5.9 ± 0.1% (P < 0.001), despite diabetes medication cessation in the majority. Weight loss failed to correlate with several measures of improved glucose homeostasis, consistent with weight-independent antidiabetes mechanisms of RYGB. C-peptide responses to glucose increased substantially, suggesting improved β-cell function. There was no mortality, major surgical morbidity, or excessive weight loss. Hypertension and dyslipidemia also improved, yielding 50-84% reductions in predicted 10-year cardiovascular disease risks of fatal and nonfatal coronary heart disease and stroke.
This is the largest, longest-term study examining RYGB for diabetic patients without severe obesity. RYGB safely and effectively ameliorated diabetes and associated comorbidities, reducing cardiovascular risk, in patients with a BMI of only 30-35 kg/m(2).
Anecdotal reports suggest bariatric surgery may increase the risk of alcohol use disorder (AUD), but prospective data are lacking.
To determine the prevalence of preoperative and postoperative AUD, and independent predictors of postoperative AUD.
A prospective cohort study (Longitudinal Assessment of Bariatric Surgery-2) of adults who underwent bariatric surgery at 10 US hospitals. Of 2458 participants, 1945 (78.8% female; 87.0% white; median age, 47 years; median body mass index, 45.8) completed preoperative and postoperative (at 1 year and/or 2 years) assessments between 2006 and 2011.
Past year AUD symptoms determined with the Alcohol Use Disorders Identification Test (indication of alcohol-related harm, alcohol dependence symptoms, or score ≥8).
The prevalence of AUD symptoms did not significantly differ from 1 year before to 1 year after bariatric surgery (7.6% vs 7.3%; P = .98), but was significantly higher in the second postoperative year (9.6%; P = .01). The following preoperative variables were independently related to an increased odds of AUD after bariatric surgery: male sex (adjusted odds ratio [AOR], 2.14 [95% CI, 1.51-3.01]; P < .001), younger age (age per 10 years younger with preoperative AUD: AOR, 1.31 [95% CI, 1.03-1.68], P = .03; age per 10 years younger without preoperative AUD: AOR, 1.95 [95% CI, 1.65-2.30], P < .001), smoking (AOR, 2.58 [95% CI, 1.19-5.58]; P = .02), regular alcohol consumption (≥ 2 drinks/week: AOR, 6.37 [95% CI, 4.17-9.72]; P < .001), AUD (eg, at age 45, AOR, 11.14 [95% CI, 7.71-16.10]; P < .001), recreational drug use (AOR, 2.38 [95% CI, 1.37-4.14]; P = .01), lower sense of belonging (12-item Interpersonal Support Evaluation List score per 1 point lower: AOR, 1.09 [95% CI, 1.04-1.15]; P = .01), and undergoing a Roux-en-Y gastric bypass procedure (AOR, 2.07 [95% CI, 1.40-3.08]; P < .001; reference category: laparoscopic adjustable gastric band procedure).
In this cohort, the prevalence of AUD was greater in the second postoperative year than the year prior to surgery or in the first postoperative year and was associated with male sex and younger age, numerous preoperative variables (smoking, regular alcohol consumption, AUD, recreational drug use, and lower interpersonal support) and undergoing a Roux-en-Y gastric bypass procedure.
Background:
The mechanisms by which increased body weight influence bone mass density (BMD) are still unknown. The aim of our study was to analyze the relationship between anthropometric and body composition variables, insulin growth factor-I (IGF-I), adiponectin and soluble tumor necrosis factor-alpha receptors (sTNFR) 1 and 2 with BMD in two cohorts of morbid obese patients, before and after bypass surgery.
Methods:
The first cohort included 25 women aged 48+/-7.6 years studied before bypass surgery. The second included 41 women aged 46+/-9.2 years, 12 months after surgery. We studied anthropometric variables obtained from whole body DEXA composition analysis. Serum IGF-I, intact serum parathyroid hormone, 25-hydroxivitamin D3, plasma adiponectin concentrations, sTNFR1, sTNFR2 concentrations were measured.
Results:
In the first cohort, the BMI was 44.5+/-3.6 kg/m2, parathyroid hormone, IGF-I, and adiponectin concentrations were lower, and sTNFR1 concentrations were higher than in the second cohort. In the multiple regression analysis, BMD remained significantly associated with body fat percentage (beta -0.154, p=0.01), lean mass (beta 0.057, p=0.016) and phosphate concentration (beta 0.225, p=0.05). In the second cohort, BMI was 31+/-5.1 kg/m2. In the multiple regression analysis, BMD remained significantly associated with lean mass (beta 0.006, p=0.03).
Conclusion:
The inverse correlation found between body fat and BMD in the first cohort indicates morbid obesity increases the risk of osteoporosis and we found a positive correlation with lean and fat mass before bariatric surgery and with lean mass after bypass surgery.
Background
Surgical treatment has proved to be effective for weight loss, improving the quality of life of obese individuals. However, metabolic and nutritional deficiencies may occur during the late postoperative period. The objective of the present study was to assess the metabolic and nutritional profile of grade III obese individuals for 12 months after Roux-en-Y gastric bypass (RYGBP).
Methods
Forty-eight patients with mean body mass index (BMI) of 51.9 ± 7.8 kg/m2 were submitted to RYGBP. Anthropometric, food intake, and biochemical data were obtained before and for 12 months after surgery.
Results
There was an average weight and body fat reduction of 35% and 46%, respectively. Calorie intake was reduced, ranging from 773 ± 206 to 1035 ± 345 kcal during the study. Protein intake remained below recommended values throughout follow-up, corresponding to 0.5 ± 0.3 g/kg/current body weight/day during the 12th month. Iron and fiber intake was significantly reduced, remaining below recommended levels throughout the study. Serum cholesterol, low-density lipoprotein cholesterol, and glycemia were reduced. Albumin deficiency was present in 15.6% of subjects at the beginning of the study vs 8.9% at the end, calcium deficiency was present in 3.4% vs 16.7%, and iron deficiency was present in 12.2% vs 14.6%.
Conclusions
RYGBP was effective for weight loss and for the reduction of obesity rates and risk factors for comorbidities. The diet of these patients, who frequently present inadequate intake of macronutrients and micronutrients, should receive special attention. Patient follow-up and assessment at short intervals are necessary for an early correction of nutritional deficiencies.
It has been suggested that a higher calcium intake might favourably modify cardiovascular risk factors. However, findings of an ultimately decreased risk of cardiovascular disease (CVD) are limited. Instead, recent evidence warns that taking calcium supplements might increase myocardial infarction (MI) risk.
To prospectively evaluate the associations of dietary calcium intake and calcium supplementation with MI and stroke risk and overall CVD mortality.
Data from 23 980 Heidelberg cohort participants of the European Prospective Investigation into Cancer and Nutrition study, aged 35-64 years and free of major CVD events at recruitment, were analysed. Multivariate Cox regression models were used to estimate HRs and 95% CIs.
After an average follow-up time of 11 years, 354 MI and 260 stroke cases and 267 CVD deaths were documented. Compared with the lowest quartile, the third quartile of total dietary and dairy calcium intake had a significantly reduced MI risk, with a HR of 0.69 (95% CI 0.50 to 0.94) and 0.68 (95% CI 0.50 to 0.93), respectively. Associations for stroke risk and CVD mortality were overall null. In comparison with non-users of any supplements, users of calcium supplements had a statistically significantly increased MI risk (HR=1.86; 95% CI 1.17 to 2.96), which was more pronounced for calcium supplement only users (HR=2.39; 95% CI 1.12 to 5.12).
Increasing calcium intake from diet might not confer significant cardiovascular benefits, while calcium supplements, which might raise MI risk, should be taken with caution.
The most recent national data on obesity prevalence among U.S. adults, adolescents, and children show that more than one-third of adults and almost 17% of children and adolescents were obese in 2009–2010. Differences in prevalence between men and women diminished between 1999–2000 and 2009–2010, with the prevalence of obesity among men reaching the same level as that among women. Age differences in obesity prevalence varied between men and women. The prevalence of obesity was higher among older women compared with younger women, but there was no difference by age in obesity prevalence among men. Among children and adolescents, the prevalence of obesity was higher among adolescents than among preschool-aged children. There has been no change in obesity prevalence in recent years; however, over the last decade there has been a significant increase in obesity prevalence among men and boys but not among women and girls overall. The Healthy People 2010 goals of 15% obesity among adults and 5% obesity among children were not met (6).
Obesity is becoming an epidemic health problem and is associated with concomitant diseases, such as sleep apnea syndrome and gastroesophageal reflux disease (GERD). There is no standardized diagnostic workup for the upper gastrointestinal tract in obese patients; many patients have no upper gastrointestinal symptoms, and few data are available on safety of endoscopy in morbidly obese patients.
Sixty-nine consecutive diagnostic upper gastrointestinal endoscopies in morbidly obese patients (26 men, 43 women; mean age 43.4 +/- 10.9 years) were prospectively evaluated from January to December 2008 in an outpatient setting before bariatric procedures. Sedation was administered with propofol. Data on sedation, critical events, and examination times were recorded, as well as pathological findings.
The patients' mean body mass index was 47.6 +/- 7.9 (range, 35.1-73.3) kg/m(2); 17.4% reported GERD symptoms. The mean duration of the endoscopy procedure (including sedation) was 20.3 +/- 9.3 (range, 5-50) min, and the whole procedure (including preparation and postprocessing) took 58.2 +/- 19 (range, 20-120) min. The mean propofol dosage was 380 +/- 150 (range, 80-900) mg. Two patients had critical events that required bronchoscopic intratracheal O(2) insufflation due to severe hypoxemia (<60% SaO: (2)). Nearly 80% of patients had pathological findings in the upper gastrointestinal tract. Only 20% reported upper gastrointestinal symptoms. Pathologic conditions were found in the esophagus in 23.2% of the patients, in the stomach in 78.2%, and in the duodenum in 11.6%. The prevalence of Helicobacter pylori infection was 8.7%.
Upper gastrointestinal endoscopy can be performed safely. However, careful monitoring and anesthesiological support are required for patients with concomitant diseases and those receiving sedation. Because 80% of the patients with pathological findings were asymptomatic, every morbidly obese patient should undergo endoscopy before bariatric surgery because there may be findings that might change the surgical strategy.
Observational studies have shown improvement in patients with type 2 diabetes mellitus after bariatric surgery.
In this randomized, nonblinded, single-center trial, we evaluated the efficacy of intensive medical therapy alone versus medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy in 150 obese patients with uncontrolled type 2 diabetes. The mean (±SD) age of the patients was 49±8 years, and 66% were women. The average glycated hemoglobin level was 9.2±1.5%. The primary end point was the proportion of patients with a glycated hemoglobin level of 6.0% or less 12 months after treatment.
Of the 150 patients, 93% completed 12 months of follow-up. The proportion of patients with the primary end point was 12% (5 of 41 patients) in the medical-therapy group versus 42% (21 of 50 patients) in the gastric-bypass group (P=0.002) and 37% (18 of 49 patients) in the sleeve-gastrectomy group (P=0.008). Glycemic control improved in all three groups, with a mean glycated hemoglobin level of 7.5±1.8% in the medical-therapy group, 6.4±0.9% in the gastric-bypass group (P<0.001), and 6.6±1.0% in the sleeve-gastrectomy group (P=0.003). Weight loss was greater in the gastric-bypass group and sleeve-gastrectomy group (-29.4±9.0 kg and -25.1±8.5 kg, respectively) than in the medical-therapy group (-5.4±8.0 kg) (P<0.001 for both comparisons). The use of drugs to lower glucose, lipid, and blood-pressure levels decreased significantly after both surgical procedures but increased in patients receiving medical therapy only. The index for homeostasis model assessment of insulin resistance (HOMA-IR) improved significantly after bariatric surgery. Four patients underwent reoperation. There were no deaths or life-threatening complications.
In obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone. Further study will be necessary to assess the durability of these results. (Funded by Ethicon Endo-Surgery and others; ClinicalTrials.gov number, NCT00432809.).
Roux-en-Y gastric bypass and biliopancreatic diversion can markedly ameliorate diabetes in morbidly obese patients, often resulting in disease remission. Prospective, randomized trials comparing these procedures with medical therapy for the treatment of diabetes are needed.
In this single-center, nonblinded, randomized, controlled trial, 60 patients between the ages of 30 and 60 years with a body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) of 35 or more, a history of at least 5 years of diabetes, and a glycated hemoglobin level of 7.0% or more were randomly assigned to receive conventional medical therapy or undergo either gastric bypass or biliopancreatic diversion. The primary end point was the rate of diabetes remission at 2 years (defined as a fasting glucose level of <100 mg per deciliter [5.6 mmol per liter] and a glycated hemoglobin level of <6.5% in the absence of pharmacologic therapy).
At 2 years, diabetes remission had occurred in no patients in the medical-therapy group versus 75% in the gastric-bypass group and 95% in the biliopancreatic-diversion group (P<0.001 for both comparisons). Age, sex, baseline BMI, duration of diabetes, and weight changes were not significant predictors of diabetes remission at 2 years or of improvement in glycemia at 1 and 3 months. At 2 years, the average baseline glycated hemoglobin level (8.65±1.45%) had decreased in all groups, but patients in the two surgical groups had the greatest degree of improvement (average glycated hemoglobin levels, 7.69±0.57% in the medical-therapy group, 6.35±1.42% in the gastric-bypass group, and 4.95±0.49% in the biliopancreatic-diversion group).
In severely obese patients with type 2 diabetes, bariatric surgery resulted in better glucose control than did medical therapy. Preoperative BMI and weight loss did not predict the improvement in hyperglycemia after these procedures. (Funded by Catholic University of Rome; ClinicalTrials.gov number, NCT00888836.).
The following position statement is issued by the American Society for Metabolic and Bariatric Surgery in response to numerous inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others, regarding the complication of gastrointestinal leak after gastrointestinal bariatric procedures. In this statement, available data regarding leak are summarized and suggestions made regarding reasonable approaches to the prevention and postoperative detection based on current knowledge, expert opinion, and published peer-reviewed scientific evidence available at this time. The intent of issuing such a statement is to provide objective information about the complication of leak. The statement is not intended as, and should not be construed as, stating or establishing a local, regional, or national standard of care. The statement will be revised in the future as additional evidence becomes available.
Background: Obesity is a major, growing health problem. Observational studies suggest that bariatric surgery is more effective than nonsurgical therapy, but no randomized, controlled trials have confirmed this. Objective: To ascertain whether surgical therapy for obesity achieves better weight loss, health, and quality of life than nonsurgical therapy. Design: Randomized, controlled trial. Setting: University departments of medicine and surgery and an affiliated private hospital. Patients: 80 adults with mild to moderate obesity (body mass index, 30 kg/m 2 to 35 kg/m 2 ) from the general community. Interventions: Patients were assigned to a program of very-low-calorie diets, pharmacotherapy, and lifestyle change for 24 months (nonsurgical group) or to placement of a laparoscopic adjustable gastric band (LAP-BAND System, INAMED Health, Santa Barbara, California) (surgical group). Measurements: Outcome measures were weight change, presence of the metabolic syndrome, and change in quality of life at 2 years. Results: At 2 years, the surgical group had greater weight loss, with a mean of 21.6% (95% Cl, 19.3% to 23.9%) of initial weight lost and 87.2% (Cl, 77.7% to 96.6%) of excess weight lost, while the nonsurgical group had a loss of 5.5% (Cl, 3.2% to 7.9%) of initial weight and 21.8% (Cl, 11.9% to 31.6%) of excess weight (P< 0.001). The metabolic syndrome was initially present in 15 (38%) patients in each group and was present in 8 (24%) nonsurgical patients and 1 (3%) surgical patient at the completion of the study (P < 0.002). Quality of life improved statistically significantly more in the surgical group (8 of 8 subscores of Short Form-36) than in the nonsurgical group (3 of 8 subscores). Limitations: The study included mildly and moderately obese participants, was not powered for comparison of adverse events, and examined outcomes only for 24 months. Conclusions: Surgical treatment using laparoscopic adjustable gastric banding was statistically significantly more effective than nonsurgical therapy in reducing weight, resolving the metabolic syndrome, and improving quality of life during a 24-month treatment program.
Background
Obstructive sleep apnea (OSA) is common in severely obese subjects (body mass index [BMI] > 35). Overnight polysomnography (OPS) is the “gold standard” method of evaluating this condition; however, it is time-consuming, inconvenient, and expensive. Selection of patients for OPS would be enhanced if we could better predict those likely to have clinically significant OSA.
Study objective
To look for clinical and biochemical predictors of OSA in symptomatic patients presenting for obesity surgery.
Design and patients
Symptoms suggestive of OSA were sought in a structured interview. We report OPS results of 99 consecutive subjects in whom OSA was clinically suspected. Predictors of apnea-hypopnea index (AHI) were sought from an extensive preoperative data collection. Multivariate linear and logistic analysis was used to identify independent predictors of AHI.
Results
Symptoms were poor predictors of AHI, with observed sleep apnea the only positive predictor. Four clinical and two biochemical factors independently predicted AHI: observed sleep apnea, male sex, higher BMI, age, fasting insulin, and glycosylated hemoglobin AIc (r² = 0.42). Neck circumference (the best single measure) could replace BMI and sex in the analysis (r² = 0.43). With cutoffs selected, a simple scoring system using these six factors provides a method of predicting those with moderate or severe OSA. A score ≥ 3 provides a sensitivity and specificity of 89% and 81%, and 96% and 71% for AHIs of ≥ 15 and ≥ 30, respectively. None of the 31 subjects with scores of 0 or 1 were found to have an AHI ≥ 15.
Conclusion
We explore sleep disturbance and report a simple method of predicting OSA in severely obese symptomatic subjects. This should assist in limiting the use of OPS to those with greater risk and provide a method of assessing risk in those not presenting primarily with a sleep problem.
Background Existing evidence has suggested that bariatric surgery produces sustainable weight loss and remission or cure of type 2 diabetes mellitus (DM). Laparoscopic sleeve gastrectomy (LSG) has garnered considerable interest as a low morbidity bariatric surgical procedure that leads to effective weight loss and control of co-morbid disease. The objective of the present study was to systematically review the effect of LSG on type 2 DM. Methods An electronic data search of MEDLINE, PubMed, Embase, Scopus, Dare, Clinical Evidence, TRIP, Health Technology Database, Conference abstracts, clinical trials, and the Cochrane Library database was completed. The search terms used included LSG, vertical gastrectomy, bariatric surgery, metabolic surgery, and diabetes (DM), type 2 DM, or co-morbidities. All human studies, not limited to those in the English language, that had been reported from 2000 to April 2010 were included. Results After an initial screen of 3621 titles, 289 abstracts were reviewed, and 28 studies met the inclusion criteria and the full report was assessed. One study was excluded after a careful assessment because the investigators had combined LSG with ileal interposition. A total of 27 studies and 673 patients were analyzed. The baseline mean body mass index for the 673 patients was 47.4 kg/m 2 (range 31.053.5). The mean percentage of excess weight loss was 47.3% (range 6.374.6%), with a mean follow-up of 13.1 months (range 336). DM had resolved in 66.2% of the patients, improved in 26.9%, and remained stable in 13.1%. The mean decrease in blood glucose and hemoglobin A1c after sleeve gastrectomy was -88.2 mg/dL and -1.7%, respectively. Conclusion Most patients with type 2 DM experienced resolution or improvement in DM markers after LSG. LSG might play an important role as a metabolic therapy for patients with type 2 DM.
The Swedish Obese Subjects Study is a prospective investigation involving obese subjects who underwent bariatric surgery or conventional treatment for obesity. This report documents follow-up data for subjects (mean age, 48 years; mean body mass index, 41 kg/m²) who were enrolled in the study for at least 2 years (4047 subjects) or 10 years (1703 subjects). The follow-up rate for laboratory examinations was 86.6% at 2 years and 74.5% at 10 years.
IntroductionBariatric surgery using the technique of duodenal switch is considered as one of the most effective treatments to lose weight and decrease comorbidity in morbidly obese patients. However, we have to be familiar with and adequately manage the various nutritional deficiencies that may occur as a consequence of its practice.
Objective: The prognostic significance of binge eating for extremely obese patients who undergo bariatric surgery is uncertain. We examined the relation of preoperative binge eating to preoperative presentation and 12-month postoperative outcomes.
Methods: 139 extremely obese gastric bypass surgery patients completed assessments of binge eating and eating disorders (Eating Disorder Examination-Questionnaire version), body dissatisfaction (Body Shape Questionnaire), depression (Beck Depression Inventory), and self-esteem (Rosenberg Self-Esteem Scale) before surgery and again 12 months postsurgery.
Results: At baseline, 60% of patients denied binge eating, 16% reported binge eating infrequently (less than once weekly), and 24% reported binge eating at least weekly. At 12 months postsurgery, 8.8% reported infrequent binge eating and only 0.7% reported binge eating weekly. At baseline, infrequent binge eaters and regular binge eaters differed little from each other but had significantly elevated eating and psychosocial problems relative to non-binge eaters. Statistically significant and clinically robust improvements in weight and in all measures of functioning were observed at 12 months postsurgery across all groups. At 12-month follow-up, patients who reported regular binge eating at baseline had significantly higher levels of eating-specific concerns (but not psychosocial concerns) than the infrequent binge eaters and non-binge eaters; the infrequent and non-binge eaters did not differ from each other. Significant time-by-binge eating interactions indicated that the regular versus infrequent binge-eating groups improved differently over time; infrequent binge eaters had sharper improvements than regular binge eaters and non-binge eaters.
Conclusion: Binge eating is common in extremely obese bariatric surgery candidates and is associated with heightened eating and psychological problems. Regular binge eating preoperatively, however, does not appear to be a potent negative prognostic indicator for gastric bypass surgery. Our findings, which are limited to 12 months postsurgery, highlight substantial improvements in weight and psychosocial functioning, and these robust improvements differ little by binge-eating status.
Objective
Hypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-based clinical guidelines for the clinical management of hypothyroidism in ambulatory patients.
Methods
The development of these guidelines was commissioned by the American Association of Clinical Endocrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assem bled a task force of expert clinicians who authored this article. The authors examined relevant literature and took an evidence-based medicine approach that incor porated their knowledge and experience to develop a series of specific recommendations and the rationale for these recommendations. The strength of the recommen dations and the quality of evidence supporting each was rated according to the approach outlined in the American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Guidelines—2010 update.
Results
Topics addressed include the etiology, epide miology, clinical and laboratory evaluation, management, and consequences of hypothyroidism. Screening, treatment of subclinical hypothyroidism, pregnancy, and areas for future research are also covered.
Conclusions
Fifty-two evidence-based recommenda tions and subrecommendations were developed to aid in the care of patients with hypothyroidism and to share what the authors believe is current, rational, and optimal medi cal practice for the diagnosis and care of hypothyroidism. A serum thyrotropin is the single best screening test for primary thyroid dysfunction for the vast majority of outpa tient clinical situations. The standard treatment is replace ment with L-thyroxine. The decision to treat subclinical hypothyroidism when the serum thyrotropin is less than 10 mIU/L should be tailored to the individual patient.
To reevaluate and update evidence-based best practice recommendations published in 2004 for anesthetic perioperative care and pain management in weight loss surgery (WLS), we performed a systematic search of English-language literature on anesthetic perioperative care and pain management in WLS published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. We identified relevant abstracts by using key words, retrieved full text articles, and stratified the resulting evidence according to systems used in established evidence-based models. We updated prior evidence-based best practice recommendations based upon interim literature. In instances of controversial or inadequate scientific evidence, the task force reached consensus recommendations following evaluation of the best available information and expert opinion. The search yielded 1,788 abstracts, with 162 potentially relevant titles; 45 were reviewed in detail. Despite more information on perioperative management of patients with obstructive sleep apnea (OSA), evidence to support preoperative testing and treatment or to guide perioperative monitoring is scarce. New evidence on appropriate intraoperative dosing of muscle relaxants allows for greater precision in their use during WLS. A novel application of -2 agonists for perioperative anesthetic care is emerging. Key elements that may enhance patient safety include integration of the latest evidence on WLS, obesity, and collaborative multidisciplinary care into clinical care. However, large gaps remain in the evidence base.
Background: We report a long-term (13-15 year) follow-up of a cohort of 100 patients who underwent gastric bypass for morbid
obesity. Methods: Sources of information include baseline data collected before surgery and information obtained at follow-up
interview including data on weight history, psychosocial functioning, and medical complications. Results: Mean age at follow-up
was 56.8 years. The mean weight loss at long-term follow-up was 29.5 kg (range-13.6 to 93.6 kg). Three subjects weighed more
at long-term follow-up than before the operation. Overall, 74% of those interviewed indicated that the gastric bypass had
benefited them in terms of their physical health. However, 68.8% reported continued problems with vomiting and 42.7% with
"plugging". Eight had died. Conclusion: The findings in this study suggest that at long-term follow-up the majority of individuals
who have undergone gastric bypass feel that the procedure benefited them, although some complications including difficulties
with "plugging" and vomiting were present at long-term follow-up.
Bariatric surgery is a powerful treatment of severe obesity. During the past several years, a greater appreciation for the need for multidisciplinary care to optimize outcomes has developed, and a number of studies have been started to examine the role of postoperative interventions used in combination with surgery. The purpose of the present study was to investigate the hypothesis that the provision of postoperative dietary counseling, delivered by a registered dietitian, would lead to greater weight loss and more positive improvements in dietary intake and eating behavior compared with standard postoperative care. The study was performed at an academic medical center.
Eighty-four individuals who underwent bariatric surgery were randomly assigned to receive either dietary counseling or standard postoperative care for the first 4 months after surgery. The participants completed measures of macronutrient intake and eating behavior at baseline and 2, 4, 6, 12, 18, and 24 months after surgery.
The patients who received dietary counseling achieved greater weight loss than those who received standard postoperative care that did not involve this counseling, although this difference did not reach statistical significance. Patients in the dietary counseling arm did report significant changes in several eating behaviors believed to be important to successful long-term weight maintenance.
The results of our pilot study provide some support for the efficacy of early postoperative dietary counseling to improve outcomes after bariatric surgery.
The aim of the present study was to evaluate whether serum C-reactive protein (CRP) is a useful predictor of early post-operative complications, particularly of intestinal leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery.
The present study was a retrospective analysis of a prospectively maintained database with 809 patients who underwent LRYGB from 2002 until 2011. For 410 of these patients, at least one CRP measurement within the first seven post-operative days was available. The diagnostic value was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve.
Forty-nine of 410 patients (12.0 %; 95 % confidence intervals [95 % CI], 9.2-15.5 %) developed surgery-related complications. Leaks occurred in 17 patients (4.1 %; 95 % CI, 2.6-6.5 %) at a median of 5 days after surgery. CRP levels 2 days after surgery showed the highest diagnostic value for post-operative complications (AUC, 0.74; 95 % CI, 0.60-0.89). Sensitivity was 0.53 (95 % CI, 0.31-0.74) and specificity was 0.91 (95 % CI, 0.79-0.96) on day 2 (cutoff level, 229 mg/l). The sensitivity for intestinal leaks was 1.00 (95 % CI, 0.51-1.00).
CRP on post-operative day 2 is a valuable predictor of post-operative complications, in particular intestinal leaks. Radiological imaging studies for intestinal leaks could be restricted to patients with CRP values exceeding 229 mg/l.
Background:
Laparoscopic adjustable gastric banding is a popular and effective restrictive bariatric procedure. However, with longer follow-up, it has become clear that a considerable number of patients require revisional surgery, of which Roux-en-Y gastric bypass (RYGB) is the most commonly performed procedure. Studies that compared the outcomes of primary RYGB and revisional RYGB have not been conclusive. Our objective was to determine whether significant differences exist in the 1-year outcomes between primary RYGB (prim-RYGB) and revisional RYGB after laparoscopic adjustable gastric banding (rev-RYGB) at a major training hospital in The Netherlands.
Methods:
All prim-RYGB and rev-RYGB procedures performed from 2007 to 2009 were analyzed. Data were collected regarding weight loss, hospitalization, operative time, postoperative complications, and co-morbidities.
Results:
A total of 292 RYGB procedures were performed: 66 rev-RYGB and 226 prim-RYGB procedures. The operative time was significantly shorter in the prim-RYGB group (136.6±37.5 versus 167.5±40.6 min; P<.0001). No significant differences were found in hospitalization time (4.4±1.7 versus 4.9±2.4 d; P= .063) or complication rate (14.7% versus 15.2%; P=.962). No deaths occurred in either group. The number of patients with resolved diabetes and hypertension did not differ between the 2 groups (50.1% versus 23.1%; P=.116; and 40.7% versus 25.0%; P=.384, respectively). Weight loss was significantly greater in the prim-RYGB group in terms of excess weight loss (71.6%±20.8% versus 48.4%±26.8%; P<.0001), body mass index reduction (13.0±3.8 versus 10.2±5.6 kg/m(2); P<.0001), absolute weight loss (37.4±11.5 versus 29.3±17.2 kg; P=.001), and percentage of weight loss (29.7%±8% versus 21.7%±11.5%; P<.0001).
Conclusion:
rev-RYGB is a safe procedure with outcomes similar to those of prim-RYGB in terms of complication rate, hospitalization time, and effect on co-morbidity. Weight loss, however, was significantly less after rev-RYGB than after prim-RYGB.