Improvement Of Comorbid Conditions Research Articles

Bariatric surgery in University Clinical Centre Tuzla and Bosnia and Herzegovina: where we are and where we want to be

<p>Bariatric surgery has emerged as the most effective treatment for morbid obesity, offering substantial and sustained weight loss and improvement in comorbid conditions. This paper reviews the development, implementation, and outcomes of bariatric surgery at the University and Clinical Centre Tuzla based on a retrospective analysis of patients who underwent bariatric surgery over a three-year period. A significant weight loss was observed, postoperative complications were minimal, with no in-hospital mortality. The bariatric surgery program demonstrates a significant progress in treating morbid obesity in Bosnia and Herzegovina.</p>

Perioperative considerations in anesthesia for pediatric bariatric procedures

Obesity is a global epidemic affecting a broad range of individuals, regardless of economic and social strata. In 2022, the World Health Organization (WHO) reported that 16 % of adults and 160 million children were living with this condition. The economic impact is significant, with a recent Milken report estimating the annual cost of obesity in the US at 1.4 trillion dollars, accounting for almost 7 % of the United States gross domestic product. It is widely recognized that the most severe forms of pediatric obesity (120 % of the 95th percentile for age and sex) represent an epidemic within an epidemic, given their potential for diminished long-term health and shortened lifespan. The treatment paradigm for obesity covers a range of approaches, with the American Academy of Pediatrics (AAP) recommending behavior and lifestyle modification as initial components of care. Since 2004, bariatric surgery has increasingly been utilized as an additional option for treating adolescent obesity, as long-term findings have shown sustained reductions in BMI and improvements in comorbid conditions. For anesthesiologists, these patients present specific challenges that require review.

Metabolic and Bariatric Surgery in Children: Current Practices and Outcomes.

This review will examine the most current evidence for Metabolic and Bariatric Surgery (MBS) in the pediatric population, specifically in terms of weight loss outcomes and improvement in comorbid conditions and complications. Additionally, we compare surgical and non-surgical interventions, review current guidelines, and propose a stepwise evidence-based approach to the management of obesity in children. MBS is a safe option for appropriately selected pediatric patients which leads to significant and sustained weight loss. This weight loss is associated with improvement of related comorbid conditions. Laparoscopic sleeve gastrectomy (LSG) has emerged as the procedure of choice with a better safety profile. Despite the evidence, very few adolescents undergo MBS. New pharmacologic agents specifically the GLP-1/GIP agents have shown early promise especially in patients under body mass index 40, but the long-term effects are unknown. MBS is an effective tool in the management of pediatric obesity, and its use has been recommended by professional societies. Early referral to a multidisciplinary obesity team can help identify appropriate patients.

Sleeve Gastrectomy Performed with Single Staple Height and Bioabsorbable Reinforcement in a Single Surgeon > 2500 Consecutive Case Series: Is Smart Technology Necessary?

Laparoscopic sleeve gastrectomy (LSG) is shown to have durable and sustained weight reduction outcomes and improvement in comorbid conditions in patients with severe clinical obesity. Discussions regarding "proper" staple height for various gastric locations continue. We propose a standard approach of consistent use of single staple load height and bioabsorbable staple line reinforcement during the LSG to reduce variability. A retrospective chart review of 2556 consecutive cases of adult patients who underwent LSG evaluated perioperative complications, postoperative leaks or bleeding, and average weight and body mass index (BMI) change and excess weight loss (EWL) at 6, 12, and 24months. The same green staple load (2.0mm) and staple line reinforcement were used in all cases for all staple firings, regardless of patient size or gastric location. Patients were a mean age of 42years, 87.3% were female, and the mean preoperative weight was 134.2kg and BMI was 48.2kg/m2. No staple line leak was detected. Three bleeding events occurred but did not require readmission or rehospitalization. Mean EWL and BMI, respectively, were 49.0% and 35.5kg/m2 at 6months, 69.8% and 29.6kg/m2 at 12months, and 70.0% and 29.5kg/m2 at 24months. In this case series of 2556 consecutive LSG performed by a single surgeon, clinically meaningful EWL and decreased BMI were achieved. Streamlining the LSG procedure by utilizing the same staple height and a bioabsorbable staple line reinforcement proved safe with minimal complications.

Complications Requiring Intensive Nutritional Care After Bariatric Surgery Result in More Long-Term Weight Loss but Has No Impact on Nutritional Deficiencies and Depression-Anxiety Scores.

Bariatric surgery is associated with significant weight loss and improvement in comorbid conditions but in rare cases can expose to complications requiring intensive nutritional care (INC). INC in this context is poorly described and no data are available concerning long-term impact. We retrospectively reviewed charts of bariatric patients who were hospitalized in our institution between 2013 and 2018. We identified patients with a postoperative complication requiring INC and we described their nutritional management (INC group). These patients were compared with controls matched to age, gender, preoperative BMI, and type of surgery selected from our database (control group). The primary endpoint was the percentage of total weight loss (%TWL) at 2.5 years. Secondary endpoints were improvement of co-morbidities, vitamin deficiencies, and depression/anxiety scores. The INC group consisted of 18 patients among which 77.8% had sleeve gastrectomy (SG). Half of these patients underwent revisional surgery. The most common complication was fistula formation (66.7%). Patients in the INC group, compared to the control group, showed a significantly higher %TWL at 2.5 years (33.6% vs 26.1%, P = 0.03). There was no significant difference in either reduction of preoperative comorbidities or depression/anxiety scores between the two groups. The number of patients with more than three nutritional deficiencies was similar in both groups. Thiamine deficiency was only observed in the INC group. Complications requiring INC after bariatric surgery occur mainly after revisional surgery and may increase long-term %TWL but have no impact on nutritional deficiencies or symptoms of anxiety/depression.

Safety and Feasibility of a Novel Endoscopic Suturing Device (EndoZip TM) for Treatment of Obesity: First-in-Human Study.

Endoscopic gastroplasty and gastric volume reduction techniques have been shown to achieve significant weight loss and improvement in comorbid conditions. The objective of this study is to assess the feasibility and safety of a novel fully automated, operator-independent endoscopic suturing system (EndoZip™) for minimally invasive treatment of obesity. Single-center pilot feasibility study. Eleven patients with a body mass index (BMI) of 30 to 40kg/m2 with or without obesity-associated comorbidity. Gastric volume reduction with EndoZip™ system. Primary outcome was to assess the technical feasibility and safety. The secondary outcome was to determine %total body weight loss (TBWL) and %excess weight loss (EWL) at 6months. The mean ± SD age was 42.7 ± 5.6years, and the mean ± SD BMI was 36.9 ± 2.8kg/m2. A majority (64%) were men. The procedure was technically successful (100%) in all patients. A median of 3 (range, 2-4) full-thickness sutures were placed, and the mean procedure time was 54.6 ± 23.9 (23-100) min. No immediate complications occurred, and all were discharged in 24h. One patient developed respiratory infection 3days after the procedure and required hospitalization. The infection was mild and resolved with antibiotic treatment. At 6-month follow-up, the mean ± SD TBWL, %TBWL, and %EWL were 17.8 ± 6.7kg, 16.2 ± 6.0%, and 54.3 ± 28.4%, respectively (p < 0.001). Limited number of patients. Our first-in-human study showed that the Endozip™ device could be safely used for the treatment of obesity. The early weight loss results are promising. An extended feasibility study on a larger sample size is being planned (Clinicaltrials.gov. NCT03472196).

A call to action to inform patient-centred approaches to obesity management: Development of a disease-illness model.

Patient‐centred care is an essential component of high‐quality health care, shown to improve clinical outcomes and patient satisfaction, and reduce costs. While there are several authoritative models of obesity pathophysiology and treatment algorithms, a truly patient‐centred model is lacking. We describe the development of a patient‐centric obesity model. A disease‐illness framework was selected because it emphasizes each patient's unique experience while capturing biomedical aspects of the disease. Model input was obtained from an accumulation of research including contributions from experts in obesity and patient‐reported outcomes, qualitative research with adults living in the United States, and two targeted literature searches. The model places the patient with obesity at its core and links pathologic imbalances of energy intake and expenditure to environmental, sociodemographic, psychological, behavioural, physiological and medical health determinants. It highlights relationships between obesity signs and symptoms, comorbid conditions, impacts on health‐related quality of life, and some barriers to obesity management that must be considered to attain better outcomes. Providers need to evaluate patients holistically, understand what changes each patient is motivated to make, and recognize what challenges might impede weight reduction, improvements in comorbid conditions, signs and symptoms, and health‐related quality of life before pursuing individualized treatment goals. Patients living with obesity who do lose weight perceive benefits beyond weight loss. Ideally, this model will increase awareness of the complex, heterogeneous impacts of obesity on patients' well‐being and recognition of obesity as a chronic disease, and prompt a call to action among stakeholders to improve quality of care.

Obesity in Adolescents and Youth: The Case for and against Bariatric Surgery

Obesity in Adolescents and Youth: The Case for and against Bariatric Surgery

Complications and Nutrient Deficiencies after Bariatric Surgery: A general review

Obesity is a major public health problem worldwide; approximately 600 million adults over 18 years old are obese. Changes in the lifestyle including diet and physical activity are main causes of overweight and obesity. Use of management methods including diet, physical activity and behavioral modifications has been found to be disappointing in the excessively obese population with weight regain problem. Hence, surgery, mainly bariatric surgery, is a choice in case of morbid obesity (where BMI is more than 40 or in case of diabetic patients with BMI of 35 or more). However, the substantial weight loss and improvements in co morbid conditions observed after bariatric surgery are not without health and nutritional risks. Bariatric procedures produce changes in the gastrointestinal anatomy and physiology, leading to changes in the quantity and quality of diet, which may result in nutrient deficiencies. The most common nutritional concerns following bariatric surgery are deficiencies of iron, vitamin B12, folic acid, vitamin D, calcium, and in some patients thiamin, vitamin A, zinc and selenium. In this review nutrient deficiencies after bariatric surgery are discussed.

Pilot Study of a New Model of Bariatric Surgery: Laparoscopic Intestinal Bipartition-Safety and Efficacy Against Metabolic Disorders.

Despite the availability of many gastric surgery techniques to reduce obesity and its associated comorbidities, most of these procedures can result in life-threatening conditions including lifetime chronic illnesses and death. Vertical sleeve gastrectomy and Roux-en-Y gastric bypass have been reported to improve obesity-related comorbidities such as T2DM, but the long-term efficacy of these two procedures is unknown, and their significant impact on long-term weight loss was diminished by complications as reported in previous studies. Recently, laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) was developed to achieve sustained weight loss (Buchwald et al. Am J Med. 122:248-56, 2009; Sjöström et al. N Engl J Med. 351:2683-93, 2004) as well as an improvement in comorbid conditions, such as T2DM and hypertension (Buchwald et al. in Am J Med. 122:248-56, 2009; Dorman et al. Surgery. 152:758-65, 2012). The malabsorptive strategy of bypassing portions of the small intestine and delivering nutrients directly to the ileum may promote weight loss by enhanced activation of a negative feedback mechanism known as the "ileal brake" (Näslund et al. J Gastrointest Surg. 5:556-67, 2001). The purpose of this pilot study was to evaluate the safety, reproducibility, and efficiency of a new surgical bariatric model of laparoscopic intestinal bipartition (LIB) in patients with a BMI between 35 and 40kg/m2. The setting was in university hospitals. Between January 2011 and September 2012, seven patients were enrolled in the study and underwent the LIB procedure. One patient was operated by LIB for morbid obesity with comorbidities, especially T2DM, without any previous bariatric or gastric surgery. Six patients underwent the surgery after a sleeve gastrectomy for ≥ 4years with a recurrence of obesity and diabetes. The comorbidity factors decreased to the normal values in all patients at 6months, 1year, and 5years postoperatively. The percentage of total weight loss was 21.1% at 6months, 22.6% at 1year, and 15.6% at 5years. Weight excess was significantly lower at 6-month, 1-year, and 5-year postoperatively compared with baseline (p < 0.001). Comparison of comorbidity values at 6months, 1year, and 5years did not show any significant differences. Laparoscopic intestinal bipartition produced a total recovery from obesity-related comorbidities, especially T2DM and EWL without any signs of nutritional deficiency, although the 5-year follow-up is ongoing in order to demonstrate the efficacy and long-term durability of this procedure.

A comparative study of weight loss and co morbidity benefits between Laparoscopic Sleeve Gastrectomy and Laparoscopic Gastric Imbrication/Plication in morbid obesity

Background: Laparoscopic sleeve gastrectomy (LSG) involves resection of a portion of the greater curvature of stomach. Laparoscopic greater curvature plication /imbrication (LGCP) involves plicating/imbricating the greater curvature without gastric resection. Materials and Methods: 30 patients who fulfilled the NIH criteria were randomized for either LSG (n = 15) [12 women and 3 men; mean age 38. 3 years (28–50 years) and mean BMI 43 kg/m2 or LGCP (n = 15) [10 women and 5 men; mean age 36.8 years (19–48years) and mean BMI 41 kg/m2. Patients were studied in terms of postoperative weight loss, changes in hypertension (systolic and diastolic blood pressure), FBS level and total cholesterol level. Follow-up period was 6 months. The mean hospital stay was 4 days for both groups. There were no intraoperative complications. All patients experienced postoperative excess weight loss and improvement in co morbid conditions. The improvement was significantly better in the LSG group in terms of excess weight loss (52.2% in LSG and 43.7% in LGCP) and change in FBS and Hypertension was not statistically significant (t test). Conclusion: LGCP is feasible, safe, and effective, but has an inferior weight-loss effect as compared to LSG for morbidly obese patients with BMI above 40 kg/m2 and 35kg/m2 with co morbid conditions.

Role of mindfulness in dissociative disorders among adolescents.

Context:Dissociation is understood as maladaptive coping and is common in children and adolescents. Treatment outcome studies show improvement in comorbid conditions suggesting the need to implement programs that target dissociative pathology.Aim:To study the effect of practicing mindfulness among adolescents diagnosed with dissociative disorders.Settings and Design:It was a hospital-based repeated measures design.Materials and Methods:7 adolescents participated in a mindfulness-based therapeutic program for 6 weeks.Statistical Analysis:Scores were expressed as mean ± standard deviation. Friedman test was used to assess significance of the difference in scores at various assessment phases. Wilcoxon signed rank test was used for post hoc analysis.Results:Participants were mostly female adolescents from rural, Eastern India. There was a significant reduction in dissociative experiences and significant improvement in mindfulness.Conclusions:Incorporating mindfulness in clinical practice may prove effective in reducing dissociation and promoting adaptive functioning.

Outcomes of Laparoscopic Sleeve Gastrectomy and Roux-en-Y Gastric Bypass in Patients Older than 60.

The proportion of population older than 60 years is rapidly increasing. The majority of this older population suffers from multiple comorbid conditions including obesity. Non-surgical means of weight loss do not offer a predictable solution. Surgical interventions seem to be the most promising solution for the obesity problem, but there is a relative lack of data in literature regarding bariatric procedures in older populations. Our study aims to evaluate the safety and efficacy of bariatric surgery in patients older than 60 years of age, to determine the weight loss, rate of operation-related complications, and impacts of surgery on comorbid conditions, and to compare the effectiveness of bariatric surgery in older patients to the effectiveness of bariatric surgery for the general population at Montefiore Medical Center. A retrospective review of patients' medical records were used to collect data to create databases to identify patients older than 60 years age who underwent bariatric surgery procedures spanning a 4-year period between January 2009 and October 2013. Data reviewed included age, sex, height, pre-operative weight, and body mass index (BMI), presence of obesity-related comorbid conditions, procedures performed, mortality, immediate or delayed complications, length of follow-up, excess weight lost, BMI points lost, percent of excess weight loss (%EWL), hemoglobin Alc (HgbA1c), and effects on obesity-related comorbid conditions. The percent of excess weight loss and number of complications within the older patient group were compared to the general population, which consists of patients between the ages of 22 and 59. Ninety-eight patients were identified. Seven patients did not follow up at any time period, and the eight patients who had laparoscopic adjustable gastric band (LAGB) were also excluded due to insufficient data. Overall, 83 patients who were above the age of 60 were examined; 30 patients had laparoscopic sleeve gastrectomy (LSG), and 53 patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB). The average patient age was 63.4 years, the average pre-operative weight was 122.3 kg, and the average excess body weight was 54.8 kg. The pre-existing comorbid conditions included 90.4 % hypertension (HTN), 63.9 % diabetes mellitus (DM), 50.6 % hyperlipidemia (HL), 34.9 % obstructive sleep apnea (OSA), and 30.1 % asthma. The average %EWL at 3 months, 6 months, and 12 months was 37.0, 51.3, and 65.2 %, respectively. A significant proportion of patients reported resolution or improvement in comorbid conditions. When results were compared to the general, population there was no significant difference in the number of complications that occurred within each of the two groups. The difference in %EWL at the 12-month follow-up was not statistically significant between the general population and the older patients, which suggests that both groups lost a similar amount of weight and that bariatric surgery on patients who are above the age of 60 is effective. Bariatric surgery can be safe and effective for patients older than 60 years of age with a low morbidity and mortality; the weight loss and improvement in comorbidities in older patients were clinically significant. When compared to the general population, there was no statistically significant difference in the average %EWL at 12 months or the number of complications due to surgery. Long-term effects of such interventions will need further studies and investigations.

Nutritional Implications of Bariatric Surgery and the Role of Registered Dietitians

A S THE NUMBER OF INDIVIDUALS WITH OBESITY continues to increase, so has the prevalence of bariatric surgery in the United States and worldwide. Bariatric surgery is currently the only knownmethod that offers both considerable and long-termweight loss. Depending on the surgical procedure, patients can expect to lose between 29% and 87% of excess bodyweight 1 to 2 years postsurgery. Despite the substantial weight loss and improvements in comorbid conditions observed after bariatric surgery, these procedures are notwithout nutritional risk, which underscores the importance of registered dietitians (RDs) to the bariatric surgical care team. Nutritional deficiencies after bariatric surgery can arise from a variety of factors, including surgical modifications of the gastrointestinal tract that reduce dietary intake and/or promote malabsorption, or because of poor patient compliance with treatment recommendations (eg, diet and multivitamin supplementation). In this issue, MoizE and colleagues prospectively evaluated long-term nutritional deficiencies and dietary patterns after both sleeve gastrectomy and Rouxen-Y gastric bypass (RYGB). They demonstrated that nutritional deficiencies anddietary intake patternswere similar up to 5 years after sleeve gastrectomy and RYGB. Insufficient or deficient 25-hydroxyvitamin D appeared to be the most common problem before and up to 5 years after both surgeries, despite implementing a vitamin D supplementation protocol and living in aMediterranean climate (insufficiency defined by MoizE and colleges as 10 to 29 ng/mL [25 to 72 nmol/L] and deficiency defined as 10 ng/mL [ 25 mmol/L]). Considering that amajority of patients in theMoizE and colleagues studywere either insufficient or deficient before surgery suggests that routine supplementation of vitamin D should occur preoperatively. Moreover, the results from MoizE and colleagues and others highlight the importance of vitamin D supplementation in the bariatric surgery patient population and suggest that the frequently recARTICLE INFORMATION

Safety and efficacy of pregabalin in patients with central post-stroke pain

Pregabalin has demonstrated efficacy in several forms of neuropathic pain, but its long-term efficacy in central post-stroke pain (CPSP) is unproven. We evaluated the efficacy and safety of pregabalin versus placebo in patients with CPSP. A 13-week, randomized, double-blind, multicenter, placebo-controlled, parallel group study of 150 to 600 mg/day pregabalin was conducted in patients aged ⩾18 years with CPSP. The primary efficacy endpoint was the mean pain score on the Daily Pain Rating Scale over the last 7 days on study drug up to week 12 or early termination visit. Secondary endpoints included other pain parameters and patient-reported sleep and health-related quality-of-life measures. A total of 219 patients were treated (pregabalin n = 110; placebo n = 109). A mean pain score at baseline of 6.5 in the pregabalin group and 6.3 in the placebo group reduced at endpoint to 4.9 in the pregabalin group and 5.0 in the placebo group (LS mean difference = –0.2; 95% CI = –0.7, 0.4; P = 0.578). Treatment with pregabalin resulted in significant improvements, compared with placebo, on secondary endpoints including MOS-sleep, HADS-A anxiety, and clinician global impression of change (CGIC) P < 0.05. Adverse events were more frequent with pregabalin than with placebo and caused discontinuation in 9 (8.2%) of pregabalin patients versus 4 (3.7%) of placebo patients. Although pain reductions at endpoint did not differ significantly between pregabalin and placebo, improvements in sleep, anxiety, and CGIC suggest some utility of pregabalin in the management of CPSP. Pain reductions at endpoint did not differ significantly between pregabalin and placebo, but improvements in comorbid conditions suggest some utility of pregabalin in central post-stroke pain management.

Effectiveness and cost-effectiveness of paediatric bariatric surgery: a systematic review.

Strong evidence for successful and cost-effective obesity management strategies is still generally lacking, leading the medical profession to rely increasingly on surgical options to treat obesity in children and adolescents. We performed a systematic review to examine the effectiveness of surgical interventions to treat obese children and adolescents, and whether they are cost-effective. We searched PubMed, ISI Web of Science, Embase and the Cochrane Library to 6 September 2010, and hand-searched bibliographies. We included articles with English abstracts if they examined subjects ≤19 years of age, reported at least one postoperative weight loss measure and at least 1 year of postoperative follow-up. Thirty-seven relevant papers on bariatric surgery effectiveness in 831 children or adolescents were included, spanning 36 years. Thirteen studies examined gastric banding, with mean body mass index (BMI) reductions ranging from 8.5 to 43 kg m(-2) . Weight gain was reported in one case study. Eight papers examined Roux-en-Y gastric bypass, with mean BMI reductions ranging from 9 to 25 kg m(-2) . Fourteen publications studied other forms of bariatric surgery: sleeve gastrectomies, vertical banded gastroplasty, biliopancreatic diversion or a combination of procedures. Mean BMI reductions ranged from 9 to 24 kg m(-2) . Three surgery-related mortalities were reported, as was weight regain in several cases. The majority of studies reported resolution or improvement of comorbid conditions. A range of postoperative complications were identified across surgery types, including: ulcers, intestinal leakage, wound infection, anastomotic stricture, nutritional deficiencies, bowel obstruction, pulmonary embolism, disrupted staple lines, band slippage, psychological intolerance and repeated vomiting. Evidence on cost-effectiveness was limited to one Australian modelling project, which deemed laparoscopic adjustable gastric banding cost-effective for adolescents. Existing evidence - although based generally on underpowered, retrospective studies - suggests that bariatric surgery in older children results in significant weight loss and improvements in comorbidities and quality of life. However, postoperative complications, compliance and follow-up may be more problematic in adolescents than adults, and availability of long-term data on safety, effectiveness and cost-effectiveness remains largely unknown. Pending an improvement in the quality of available evidence, a cautious approach to child and adolescent bariatric surgery is warranted, and reversible techniques are advisable compared to approaches that permanently alter anatomy.

Chronic Insomnia

Chronic insomnia afflicts millions of people in the United States. It is associated with decreased quality of life, accidents, several comorbid conditions, increased morbidity, and substantial direct and indirect costs. Chronic insomnia is a multifactorial and individualized disorder. Its etiology may be cognitive or physiologic in nature (or both), and is more often than not associated with a comorbid condition, complicating its recognition, evaluation, and treatment. Effective nonpharmacotherapeutic (cognitive-behavioral therapy for insomnia) and pharmacotherapeutic (hypnotic medications) treatment modalities are available. Treatment of chronic insomnia can make a significant improvement in quality of life, and may also be associated with an improvement in comorbid conditions.

Open Label Aripiprazole in the Treatment of Youth with Tic Disorders

Primarily safe and efficacious treatments for chronic tic disorders are needed. Also needed are such treatments that target co-morbid conditions. Aripiprazole, a dopaminergic/serotonergic agent with partial agonist properties at the D2 dopamine receptor and 5-hydrdoxytryptamine 1A (5-HT(1A)) receptor and antagonist properties at the 5-HT(2A) receptor, holds promise in both regards. This was an open-label, flexible-dose study to evaluate the safety of aripiprazole in children and adolescents with a primary diagnosis of a chronic tic disorder with/without co-morbid disorder(s). Sixteen children (15 males) aged 8-17 years participated in the 6-week trial. Ratings for tic, obsessive compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD), and side effects were administered weekly. Baseline and exit laboratory measures, electrocardiograms (ECGs), weight, and height were obtained. The average daily aripiprazole dose was 3.3 mg (range 1.25-7.5 mg). Significant pre-and posttreatment differences were ascertained for the Yale Global Tic Severity Scale motor (p < or = 0.0001), phonic (p < or = 0.0001), and total tic (p < or = 0.0001) scores. Results of other rating scales suggested significant improvements in co-morbid disorders as well, including OCD, ADHD, and depressive disorders. Although aripiprazole was well tolerated, increases in weight were found. In this preliminary open-label trial, aripiprazole was a well-tolerated treatment for tics and co-morbid OCD and ADHD symptoms. Improvements in co-morbid conditions may be secondary to tic reduction or to specific to aripiprazole therapy; however, further study is warranted.

Clinical application of laparoscopic bariatric surgery: an evidence-based review

Approximately one-third of U.S. adults are obese. Current evidence suggests that surgical therapies offer the morbidly obese the best hope for substantial and sustainable weight loss, with a resultant reduction in morbidity and mortality. Minimally invasive methods have altered the demand for bariatric procedures. However, no evidence-based clinical reviews yet exist to guide patients and surgeons in selecting the bariatric operation most applicable to a given situation. This evidenced-based review is presented in conjunction with a clinical practice guideline developed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). References were reviewed by the authors and graded as to the level of evidence. Recommendations were developed and qualified by the level of supporting evidence available at the time of the associated SAGES guideline publication. The guideline also was reviewed and co-endorsed by the American Society for Metabolic and Bariatric Surgery. Bariatric surgery is the most effective treatment for severe obesity, producing durable weight loss, improvement of comorbid conditions, and longer life. Patient selection algorithms should favor individual risk-benefit considerations over traditional anthropometric and demographic limits. Bariatric care should be delivered within credentialed multidisciplinary systems. Roux-en-Y gastric bypass (RGB), adjustable gastric banding (AGB), and biliopancreatic diversion with duodenal switch (BPD + DS) are validated procedures that may be performed laparoscopically. Laparoscopic sleeve gastrectomy (LSG) also is a promising procedure. Comparative data find that procedures with more dramatic clinical benefits carry greater risks, and those offering greater safety and flexibility are associated with less reliable efficacy. Laparoscopic RGB, AGB, BPD + DS, and primary LSG have been proved effective. Currently, the choice of operation should be driven by patient and surgeon preferences, as well as by considerations regarding the relative importance placed on discrete outcomes.

Roux-en-Y Near Esophagojejunostomy for Intractable Gastroesophageal Reflux After Antireflux Surgery

Intractable gastroesophageal reflux disease (GERD) after prior antireflux operation presents a difficult challenge. Our objective was to investigate the role of Roux-en-Y near esophagojejunostomy (RNYNEJ) in the management of intractable reflux symptoms after prior antireflux surgery. Between June 2000 and October 2005, 25 patients with GERD after antireflux surgery underwent RNYNEJ. The endpoints evaluated were improvement in GERD symptoms using the GERD-Health Related Quality of Life (HRQL) scale, overall patient satisfaction, overall patient weight loss, and improvement of comorbid conditions. There were 4 men and 21 women (mean age 51 years; range, 35 to 74). Seventy two percent had a body mass index (BMI) greater than 30. Forty-four percent had more than one antireflux surgery and 40% had a previous Collis gastroplasty. The perioperative mortality was 0%. Six patients (24%) developed major postoperative complications, including anastomotic leak (n = 2) and Roux-limb obstruction (n = 1). The median length of stay was 6 days. Eighty percent of the patients reported satisfaction at mean follow-up time of 16.5 months. Their BMI reduced from 35.8 to 27.7 (p < 0.001). Seventy three percent of comorbid conditions were improved and the GERD HRQL score improved from 29.9 to 7.3 (p < 0.001). The RNYNEJ for persistent GERD after prior antireflux surgery is technically challenging with significant morbidity. However, the majority of the patients reported satisfaction with significant improvement in symptoms. Many patients had associated benefits of weight loss and improvement in comorbid conditions. Roux-en-Y near esophagojejunostomy should be considered as an important option for the treatment of intractable GERD after prior antireflux surgery, particularly in the obese.