Gastric Restrictive Surgery Research Articles

Gastroplasty for Morbid Obesity after Cardiac and Renal Transplantation.

The success of vertical banded gastroplasty (VBG) in the obese transplanted population is measured by a low operative morbidity and mortality in the context of a good record of permanent weight loss and an enhanced quality of life. Selection of transplanted patients for gastroplasty should be guided by the prevailing standards for the general population. VBG is the procedure of choice because of proven efficacy and has the benefit over gastric bypass of not producing malabsorption. The operation causes early satiety while allowing consistent absorption of immunosuppressive medication from the upper gastrointestinal tract, essential in these patients. This risk of hypertension, diabetes mellitus, hyperlipidemia, and immunosuppressive medication toxicity may be decreased by substantial long-term weight loss afforded morbidly obese transplant patients by gastric restrictive surgery. Cardiac risk factors associated with morbid obesity and immunosuppressive therapy are lessened with sustained weight reduction.

Social and Economic Effects of Bariatric Surgery.

One to 5 years after gastric restrictive surgery and subsequent weight loss, 79 bariatric surgery patients were compared with a similar group of 54 non-operated patients. The operated group had a significantly higher proportion of employment, more working hours, and a higher income. They were also more active in different physical and social activities and had a better sexual life. They required less medical care, had fewer days of sick leave or sick pension, and gave a much higher score in assessment of their general health. The results indicate that obesity surgery is highly cost-effective.

Folate Status Following Gastric Bypass Surgery (The Great Folate Mystery).

Several previous investigators have reported an incidence of folic acid deficiency following gastric bypass surgery of up to 38%. Failure to encounter any folic acid deficiencies in our postoperative patients led us to discontinue follow-up folate studies for several years. However, due to repeated references to this deficiency in the literature, we re-instituted folate studies as part of the routine follow-up of our patients. Preoperative serum folate levels were obtained in 1,067 patients and preexisting deficiencies found in 63, an incidence of 6%. Of the 588 folate levels determined 1 to 10 years following gastric bypass, only six were less than 3.0 ng/di, an incidence of 1%. All patients were instructed preoperatively and postoperatively to take multivitamin/mineral supplements after gastric restrictive surgery, and were continually educated on their importance. In a bariatric surgery practice in which patients are instructed, reminded, encouraged and even badgered into taking postoperative vitamin/mineral supplements, folate deficiency should be a rarity. In such circumstances, folate deficiency may well act as a sensitive marker of non-compliance.

ASSESSMENT OF NUTRIENT INTAKE IN ASSOCIATION WITH WEIGHT LOSS AFTER GASTRIC RESTRICTIVE PROCEDURES FOR MORBID OBESITY

Postoperative nutrient intakes were examined in patients who were losing weight in an early period following gastric restrictive surgery for morbid obesity (3 to 6 months post-surgery), and patients whose reduced weight was relatively stable at 1 to 2 years post-surgery. In association with weight loss, patients showed increased physical activity and reduced energy intakes which were frequently less than the Recommended Daily Intakes (RDI), particularly in the early period. Protein intake was also below recommended levels in the two post-operative phases. The intakes of iron, folate and calcium were below the recommended levels in the early postoperative phase. The intakes of iron and folate were also below recommended levels in the late postoperative phase. The study indicates the potential for deficiencies of iron, folate and calcium after gastric restrictive surgery and supports the importance of careful and prolonged follow-up of these patients, with particular attention to nutritional status.

Gallbladder Disease in the Morbidly Obese Patient.

Obesity alone and rapid weight loss induced by bariatric surgical procedures are both recognized risk factors for the development of cholelithiasis. The advisability of performing routine concomitant cholecystectomy with bariatric surgery has been controversial. This prospective clinical study was performed to determine if preoperative ultrasonography, preoperative cholescintigraphy and intraoperative surgical findings could help determine which patients would benefit from concomitant cholecystectomy. Eighteen morbidly obese patients undergoing bariatric surgery were studied preoperatively with gallbladder ultrasonography and cholescintigraphy. All patients had a description of intraoperative findings. Gallbladders were removed routinely and examined pathologically. Sixty percent of patients in this study had abnormal gallbladder pathology. Preoperative ultrasonography and/or cholescintigraphy was inaccurate at predicting reliably those patients who would benefit from cholecystectomy concomitant with gastric-restrictive surgery. lntraoperative findings other than palpable gallstones were also unreliable.

Age, Obesity Surgery, and Weight Loss.

Some centers consider an age over 50 to be a contraindication for obesity surgery. This study was conducted to examine the relationship between age and one-year postoperative weight of patients receiving gastric restrictive surgery (n = 616) for morbid obesity. Patients were divided into four age groups (18-29, 30-39, 40-49, 50-65 years) matched for preoperative obesity. At one year there were no statistically significant differences in weight loss or postoperative obesity. There were four (0.6%) surgically-related deaths. The mortality of patients aged 50 or older (1.1%) was not significantly higher than that of younger patients (0.6%). It was concluded that older age per se need not be a contraindication for surgery.

Pathologic Changes in the Stomach at the Site of Silicone Gastric Banding.

Silicone gastric banding procedures for severe obesity have been done on 303 patients; 214 as primary operations and 89 as revisions of different types of gastric restriction operations. Twenty-five bands were removed, and in 16 of these cases full thickness gastric wall biopsies were done at the banding site. The pathologic changes at the banding site in these 16 patients consisted of variable local tissue responses consistent with constriction due to the banding process. The most significant finding, seen in only one patient, was full thickness fibrous replacement of the muscular wall. Ten patients had only serosal fibrosis at the banding site and four had both serosal fibrosis and patchy fibrous replacement of the muscularis propria. One biopsy specimen showed no pathologic changes. Notably absent in all cases were evidence of ischemia and evidence of penetration of the gastric wall by the band.

Morbid Obesity: Effects on the Marital System of Weight Loss after Gastric Restriction

Eighty morbidly obese married women and 69 of their husbands completed a self-report measure of personal and marital adjustment before the women proceeded to gastric restriction surgery. Fifty-five women and 41 husbands repeated the measure 12 months after surgery, at which time the women had lost a mean of 35.4 kg. Women rated themselves as significantly more attractive and sociable, and rated their husbands as significantly less sociable and interesting, than before surgery. Husbands rated their wives as excessively sociable after surgery, the reverse of their previous view. The data offered some support for a family systems view of morbid obesity, but the systemic effect appeared weak, and is probably not a major contributor to wives' morbid obesity in most cases.

PSYCHOSOCIAL AND PHYSICAL ACTIVITY CHANGES AFTER GASTRIC RESTRICTIVE PROCEDURES FOR MORBID OBESITY

Gastric restrictive procedures for morbid obesity are frequently performed to reduce problems arising from the physical limitations and social isolation of massive obesity. Numerous reports have described changes in weight after gastric restrictive operations, yet few studies have documented changes in the secondary effects of obesity. This report deals with changes in psychosocial status and physical activity occurring in 240 patients who remained in the study 3 years after surgery. These patients were members of a group of 310 patients who were entered into a prospective randomized trial to assess the relative benefits of three forms of gastric restrictive procedure. Prior to operation, and at yearly intervals after operation, the physical activities and psychosocial status of each patient was assessed by a standardized semi-structured interview. At the time of the three-year interview the median weight loss for these patients was 29.5 kg which represents 53% of excess weight lost. This weight loss was associated with a marked reduction in the amount of food eaten. There was a significant increase in the number of patients smoking more than 20 cigarettes a day and a mild increase in alcohol intake. There were significant improvements in the level of self-image and state of happiness. The social lives and sex lives of the majority of patients were improved and a significantly greater number of patients reported being in a stable emotional relationship at 3 years after operation than did so pre-operatively. There was a marked increase in the number of patients in full-time or part-time employment from 38% prior to surgery to 60% at 3 years after operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Cure of arthritis-dermatitis syndrome due to intestinal bypass by resection of nonfunctional segment of blind loop

Many complications that followed jejunoileal bypass operations performed for the relief of morbid obesity were caused by bacterial overgrowth in the excluded blind loop. The arthritis-dermatitis syndrome was one of the common distressing disorders. The pathogenetic mechanism was thought to be an immune-complex-mediated process related to bypass enteritis. Antiarthritic medication was ineffective in most instances, and the skin lesions were refractory to treatment. A 45-year-old woman was suffering from the disorder as described above. She also had diarrhea, a low hematocrit, an elevated white blood cell count, and an increased sedimentation rate. Her nutritional status was satisfactory, presumably because of adaptive hypertrophy of the short functioning small intestinal segment. The patient adamantly refused dismantling of the bypass or any gastric restriction operations. Therefore, the blind loop, the source of her disease, was excised with immediate relief of all ill effects and restoration of normal laboratory findings. The patient has been entirely well since, and her weight has remained stable for one year.

Gastric Surgery for Morbid Obesity

The efficacy of three gastric restriction operations were compared in a prospective randomized study of 310 morbidly obese subjects. The median patient age was 34 years (range, 18 to 62 years). They were predominantly female (13:1) and had a median pre-operative weight that was 198% of their ideal weight (range, 160% to 318%). There was an equitable dispersion of perceived risk factors between the groups under study and there were no deaths during the perioperative period. Compliance with follow-up at 3 years was 91%. When success was defined as a loss of more than 50% of excess weight or a current pregnancy, the success rates at 3 years were 17% for gastrogastrostomy, 48% for vertical gastroplasty, and 67% for Roux-en-Y gastric bypass (p less than 0.001). Although the gastric bypass operation took longer to perform, there were similar outcome patterns for the three groups during the postoperative period. We conclude that the Roux-en-Y gastric bypass is the preferred procedure for the surgical treatment of morbid obesity.

Gastric restrictive surgery

Gastric restrictive surgery

Gastric Restrictive Surgery

<h3>To the Editor. —</h3> This letter pertains to the DATTA survey on gastric restrictive surgery for morbid obesity published in the March 10 issue of<i>JAMA</i>.¹I think the editors are to be commended for publishing this survey in a journal that has a predominantly nonsurgical readership. The discussion of the subject of surgical treatment for morbid obesity that followed the results of the survey was succinct, up-to-date, and accurate. However, as a surgeon who has performed gastric restriction operations for more than 8 years, I was distressed by the fact that such a large minority of the respondents thought gastric bypass and vertical banded gastroplasty to be investigational. These two operations have been used in the treatment of morbid obesity for nearly a decade. It has been estimated that more than 25 000 gastric restriction operations are performed annually in the United States for treatment of morbid obesity.

Diagnostic and therapeutic technology assessment. Gastric restrictive surgery

Diagnostic and therapeutic technology assessment. Gastric restrictive surgery

Gastric restrictive operations for morbid obesity

Gastric restrictive surgery has evolved over the past decade as the treatment of choice for morbid obesity. We reviewed our experience with 289 patients who underwent gastric surgery for morbid obesity. Comorbid diseases included respiratory insufficiency in 19 percent of the patients, hypertension in 36 percent, diabetes in 15 percent, arthritis in 30 percent, and heart disease in 6 percent. Operative mortality was 0. The follow-up rate was 93 percent. Overall mortality was 1 percent, with no death directly attributed to the operative procedure. Weight loss was studied over the 6-year study period. Four to 6 years postoperatively, overall weight loss was 50 to 64 percent of excess weight. The treatment failure rate 12 to 18 months postoperatively was 5 percent. The experience with gastric restrictive surgery in 12 centers involving 5,178 patients was reviewed and compared with our results. Overall operative and late mortality rates were quite similar to observed death rates for nonobese men and women between 25 and 64 years of age. These data suggest that gastric surgery for morbid obesity results in a significant reduction in health risk.

Hepatobiliary effects of obesity and weight-reducing surgery.

Obesity clearly increases the risk of gallstone formation. The role of nucleating factors may be most decisive in transforming merely saturated bile into a gallstone-forming solution. Weight loss in the short run may promote stone formation but in the long run may be beneficial if it is maintained. UDCA appears to be a promising prophylactic agent against gallstone formation during weight loss regardless of whether it is achieved by diet alone, by jejunoileal bypass, or by gastric restriction surgery.

Gastric balloons: A plea for sanity in the midst of balloonacy

Intragastric balloons have been suggested as a treatment for severe obesity, a degree of obesity associated with a relatively greater eating disorder or lack of control of energy balance. The premises that 250–500-ml balloons are able to simulate “satiety” in a 1700-ml stomach sufficiently to cause weight loss, that the stomach will not stretch to accommodate such a besoar (with or without ulcerating), and that behavioral modification is cost-effective in weight control in this population have not been corroborated. Experience from gastric restrictive surgery has demonstrated the conceptual failure of gastric satiety as a means of achieving and sustaining weight loss in a substantial percentage of morbidly obese patients. Other methods are needed to reduce the increased morbidity and mortality of severe obesity.

Brain computed tomography in morbid obesity before and after gastric restriction surgery: a prospective quantitative study.

Linear brain parameters were measured by CT in 19 patients with morbid obesity (mean weight 126.4 +/- 20.5 kg) and 20 age and sex matched normal weight subjects (mean weight 62.6 +/- 14.9 kg). Ventricular parameters were slightly smaller and cortical parameters were slightly larger in the preoperative obese than in control subjects. However, only the four cortical sulci ratio was significantly different in the two groups (P = 0.02). After gastric restriction surgery and drastic weight loss (mean postoperative weight 82.9 +/- 27.4 kg), all the ventricular and cortical parameters increased, with significant change in the frontal interhemispheric fissure ratio (P less than 0.05). Obese patients followed for 23 months after surgery had less striking changes than those followed for 6 months. Morbidly obese subjects have altered brain CT dimensions which are partly reversible after weight correction.

The Use of Endoscopy After Gastric Partitioning for Morbid Obesity

Fiberoptic endoscopy is an important diagnostic modality for evaluating the patient with upper gastrointestinal tract symptoms following gastric restrictive operations. The specific indications for endoscopy after obesity surgery include stoma evaluation in patients who fail to lose adequate weight; stomal stenosis; esophagitis; surveillance of the excluded pouch; and suspicion of a marginal ulcer after gastric bypass.

Radiology of Obesity Surgery

Modern imaging modalities are the key to prompt evaluation of the efficacy and complications of obesity surgery. These are divided into the early and late complications of gastric restrictive surgery and intestinal bypass surgery.