Resolution Of Obesity-related Comorbidities Research Articles

Laparoscopic Sleeve Gastrectomy: Co-morbidity Profiles and Intermediate-Term Outcomes.

Bariatric surgery is effective at achieving sustained weight loss and improving the control and resolution of obesity-related co-morbidities. Most studies that have demonstrated co-morbidity resolution in patients undergoing laparoscopic sleeve gastrectomy (LSG) only follow patients for the short term (less than 1year) or follow a relatively small cohort (<100 patients) for the intermediate or long term (more than 5years). We report our experience following a large cohort of morbidly obese patients who underwent LSG with intermediate-term follow-up. We retrospectively reviewed 435 consecutive patients who underwent LSG from January 2004 to November 2013. Co-morbidities investigated included diabetes mellitus (DM), hypertension (HTN), and hyperlipidemia (HL). A co-morbidity was determined to be resolved if the patient was no longer taking any medication to treat that specific co-morbidity. Mean follow-up was 26 ± 25months (range = 1-112). Mean postoperative total weight loss (%TWL) at 6, 12, 24, 36, 48, 60, and 72months were 23.6, 29.9, 29.5, 25.2, 26.7, 25.4, and 24.3%, respectively. The incidence of all three co-morbidities was found to be significantly lower at the last patient follow-up. The resolution rates for DM, HTN, and HL were 59, 31, and 50%, respectively. In patients who continued to have co-morbidities, the mean numbers of medications for DM (1.2 ± 0.7 vs. 0.5 ± 0.7, p < 0.0001), HTN (1.8 ± 1.1 vs. 1.3 ± 1.2, p < 0.0001), and HL (0.9 ± 0.7 vs. 0.6 ± 0.6, p < 0.0001) postoperatively were all significantly less. LSG is effective at achieving significant and sustained weight loss, improvement in co-morbidity profiles, and a reduction in poly-pharmacy for these conditions over intermediate-term follow-up.

The Swedish laparoscopic duodenal switch—from omega-loop to Roux-en-Y

The biliopancreatic diversion with duodenal switch (BPDDS) is considered to be the most effective bariatric procedure for introduction and maintenance of weight loss and resolution of obesity-related co-morbidities [1]. Scopinaro described the biliopancreatic diversion (BPD) in 1979 with a partial distal gastrectomy, closure of the duodenal stump, a Roux-en-Y gastroenterostomy, and an anastomosis between the biliary and the alimentary limb 50 cm proximal to ileocecal valve [2]. To gain control of complications related to Scopinaro’s procedure, the common channel was lengthened and the duodenal switch (DS) was added. The latter comprises a vertical sleeve gastrectomy with preservation of the pylorus and a duodenoileostomy [3]. In 1999 a laparoscopic approach for the DS procedure was introduced [4]. Study results concerning postoperative complication rates comparing open and laparoscopic DS are inconsistent [5,6]. This might be a result of the complexity of the surgery and the relatively small number of procedures performed worldwide. Internal herniation (IH) is a common complication after bariatric surgery. It has been shown that the closure of the mesenteric defects reduces the risk of IH and ileus. Closure of the mesenteric defects is technically challenging during standard laparoscopic DS with the entero-entero-anastomosis (EA) in the lower part of the abdomen. For successful advancement of the laparoscopic DS, the following 3 aims were defined that the novel procedure had to fulfill: (1) enhancement of the surgical workflow, (2) better overview of the correct positioning of the different limbs, and (3) facilitation of the closure of the mesenteric defects. The presented procedure accomplishes these targets.

A5204 - Switching Biliopancreatic diversion to Roux-Y bypass treats complications and failure to lose weight

Introduction: Bariatric surgery is an effective method of treatment for morbid obesity as it provides not only weight loss but also resolution of obesity-related co-morbidities. The aim of this study was to evaluate the clinical efficacy of malabsorptive procedures (Laparoscopic Gastric Bypass-LGBP & Duodenal Switch-DS) versus restrictive procedures (Laparoscopic Sleeve Gastrectomy-LSG) as it relates to percentage excess weight loss, postoperative complications & resolution of comorbidities. Methods: A systematic review was conducted identifying all relevant studies from 2005 – 2015 with comparative data on malabsorptive and restrictive procedures. The primary outcome was percentage excess weight loss and postoperative complications (leaks, bleeding, strictures etc.).The secondary outcome was resolution of comorbidities (Diabetes Mellitus-DM, Hyperlipidemia-HLP, Gastroesophageal Reflux Disease-GERD & Hypertension-HTN). The results were analyzed as standard difference in means with standard error. Statistical analysis was done using random-effects meta-analysis to compare the mean value of the two groups (Comprehensive Meta-Analysis Version 3.3.070 software; Biostat Inc., Englewood, NJ). Results: Thirteen studies were quantitatively assessed and included for meta-analysis including one double-blind randomized controlled trial, two randomized controlled trials, three prospective studies and seven retrospective studies. There were a total of 3,035 LGBP patients, 155 DS patients, and 2006 LSG patients. Malabsorptive procedures were associated with greater %EWL (-0.070 0.03; p1⁄40.02) and postoperative complications (2.03 0.07; po 0.001) when compared to restrictive procedures. GERD demonstrated greater postoperative occurrence in restrictive procedures compared to malabsorptive procedures (-2.05 0.07; po 0.001). Malabsorptive procedures were associated with greater resolution of comorbidities in terms of DM (0.87 0.07; po 0.001), HLP (1.03 0.09; po 0.001) & HTN (-0.48 0.65; po 0.001). CONCLUSIONS Malabsorptive bariatric procedures yielded significantly higher percentage excess weight loss, rate of postoperative complications and resolution of comorbidities than restrictive procedures.

The effect of laparoscopic sleeve gastrectomy on morbid obesity and obesity-related comorbidities: A cohort study.

Bariatric surgery with multidisciplinary management is a more effective method to treat morbid obesity and obesity-related comorbidities compared with nonsurgical treatments. Laparoscopic sleeve gastrectomy (LSG) was initially performed as the first stage of biliopancreatic diversion with duodenal switch in the super-obese population. In the past few years, however, LSG has been performed as a definitive procedure because of its promising early and midterm results. The aim of this study is to evaluate the efficacy of our initial LSG series of 73 patients on excess weight loss (EWL) and resolution of obesity-related comorbidities in short-term follow-up. From March 2013 to May 2014, 78 morbid obese patients with an average body mass index (BMI) of 46.3 kg/m(2) underwent LSG. There is a 9-month follow-up period on average. Five patients were excluded from the study, because they could not be contacted. Comorbidities, preintervention BMI, glucose, HbA1c, and lipid profiles were recorded at 1, 6, and 12 months postintervention. After the surgery, the percent EWL was 58%. The mean serum glucose level, HbA1c level, LDL-cholesterol level, triglyceride level, insulin, and insulin resistance decreased significantly and the mean HDL-cholesterol level increased. For the resolution of comorbidities, LSG may be used as an effective bariatric and metabolic surgery.

Vėlyvieji laparoskopinės vertikalios skrandžio rezekcijos gydymo rezultatai

Darbo tikslasRemiantis literatūros duomenimis išanalizuoti vėlyvuosius (≥5 metų) laparoskopinės vertikalios skrandžio rezekcijos rezultatus gydant morbidinį nutukimą.Tiriamoji medžiaga ir metodaiPublikacijų paieška atlikta „Medline“, „Current Contents“ ir „Cochrane Library“ duomenų bazėse. Apžvelgtos visos laparoskopinės vertikalios skrandžio rezekcijos 5 metų ir vėlesnius rezultatus pateikiančios publikacijos, paskelbtos iki 2015 m. sausio 1 dienos.RezultataiAtlikus literatūros šaltinių paiešką, rasta 20 publikacijų, pateikiančių 5 metų ir vėlesnius vertikalios skrandžio rezekcijos rezultatus. Įtrauktose studijose tirti 4354 ligoniai, iš kurių 1536 buvo stebėti 5 metus ir ilgiau. Tiriamųjų amžiaus vidurkis buvo 37,9 metai. Vidutinis priešoperacinis KMI buvo 46,3 kg/m2. Vidutinis procentinis perteklinės kūno masės netekimas po 5, 6, 7 ir 8 metų atitinkamai buvo 59,9 %, 58,5 %, 56,6 % ir 56,4 %. Bendras komplikacijų dažnis – 6,47 %, o pooperacinis 30 dienų mirštamumas – 0,19 %. Po 5 metų nustatyta gretutinių ligų remisija ar pagerėjimas: antro tipo cukrinio diabeto – 71,4 %, arterinės hipertenzijos – 61,4 %, dislipidemijos – 50,1 %, miego apnėjos – 86,9 %, gastroezofaginio refliukso ligos – 41,8 %, degeneracinių sąnarių ligų – 83,9 % ligonių. Vidutinis BAROS skalės balų skaičius praėjus 5 metams po vertikalios skrandžio rezekcijos buvo 6, tai atitinka labai gerus rezultatus.IšvadosLaparoskopinė vertikali skrandžio rezekcija yra efektyvi ir saugi nutukimo gydymo operacija, pasižyminti gera pooperacinegyvenimo kokybe ir gretutinių ligų kontrole, o perteklinės masės netekimas 5 metų laikotarpiu yra ženklus ir stabilus.

Comparison of short-term outcome of laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: A prospective randomized controlled multicenter SLEEVEPASS study with 6-month follow-up

The long-term efficacy of laparoscopic Roux-en-Y gastric bypass in the treatment of morbid obesity has already been demonstrated. Laparoscopic sleeve gastrectomy has shown promising short-term results, but the long-term efficacy is still unclear. The aim of this prospective randomized multicenter study is to compare the results of Roux-en-Y gastric bypass and sleeve gastrectomy. A total of 240 morbidly obese patients were randomized to undergo either Roux-en-Y gastric bypass or sleeve gastrectomy. The primary end point of study was weight loss, and the secondary end points were resolution of comorbidities and morbidity. The short-term results at 6 months were analyzed. The mean excess weight loss at 6 months was 49.2% in the sleeve gastrectomy group and 52.9% in the Roux-en-Y gastric bypass group (p = 0.086). Type 2 diabetes was resolved or improved in 84.3% of patients in the sleeve gastrectomy group and 93.3% in the Roux-en-Y gastric bypass group (p = 0.585). The corresponding results for arterial hypertension were 76.8% and 81.9% (p = 0.707) and for hypercholesterolemia 64.1% and 69.0% (p = 0.485). There was no mortality at 6 months. There was one major complication following sleeve gastrectomy and two after Roux-en-Y gastric bypass (p = 0.531). Eight sleeve gastrectomy patients and 11 Roux-en-Y gastric bypass patients had minor complications (p = 0.403). The short-term results of sleeve gastrectomy and Roux-en-Y gastric bypass regarding weight loss, resolution of obesity-related comorbidities and complications were not different at 6 months.

Comparison of the Long-term Results of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy for Morbid Obesity

Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are 2 of the most widely used bariatric procedures today, in this meta-analysis, both techniques were compared for evaluating the efficacy and safety of the treatment of morbid obesity. Systematic literature search of Cochrane Controlled Trials Register Databases, Medline, Embase, ISI databases, and Chinese Biomedical Literature Database was performed. Statistical analyses were carried out using RevMan software. Thirty-two recent studies including 6526 patients in total were included in this meta-analysis. Compared with SG, RYGB had significantly better effect in resolving type 2 diabetes mellitus, hypertension, hypercholesterolemia, gastroesophageal reflux disease, and arthritis. However, RYGB had higher incidence of complications and reoperation, and longer operation time than SG. RYGB was more effective than SG in the resolution of obesity-related comorbidities, SG was a safer procedure with a reduced rate of complications and reoperation.

Outcomes of Laparoscopic Sleeve Gastrectomy in Patients Older than 60 Years

Morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) occur at acceptable rates, but its safety and efficacy in the elderly are unknown. A retrospective review was performed of all patients aged >60 years who underwent LSG from 2008 to 2012. These patients were 1:2 matched, by gender and body mass index (BMI) to young patients, 18 < age < 50. Data analyzed included demographics, preoperative and postoperative BMI, postoperative complications, and improvement or resolution of obesity-related comorbidities. Fifty-two morbid obese patients older than 60 years underwent LSG (mean age, 62.9 ± 0.3 years). These were matched to 104 young patients, age 18-50 years (mean age, 35.7 ± 0.8 years). Groups did not differ in male gender (44 vs. 43%, p = 0.9), preoperative BMI (42.6 ± 0.7 vs. 42.6 ± 0.6, p = 0.97), and length of follow-up (17 ± 2 vs. 22 ± 1.4 months, p = 0.06). Obesity-related comorbidities were significantly higher in the older group (96 vs. 65%, p < 0.001). Excess weight loss (EWL) was higher in the younger group (75 ± 2.4 vs. 62 ± 3%, p = 0.001). Older patients had a significantly higher rate of a concurrent hiatal hernia repair (23 vs. 1.9%, p < 0.001). Overall postoperative minor complication rate was higher in the older group (25 vs. 4.8%, p < 0.001). This included atrial fibrillation (9.5%), urinary tract infection (7%), trocar site hernia (4%), dysphagia, surgical site infection, bleeding, bowel obstruction, colitis, and nutritional deficiency (2%, each). No perioperative mortality occurred. Comorbidity resolution or improvement was comparable between groups (88 vs. 80%, p = 0.13). LSG is safe and very efficient in patients aged >60, despite higher rates of perioperative comorbidities.

Clinical experience of weight loss surgery in morbidly obese Korean adolescents.

PurposeComprehensive multidisciplinary weight management programs encompassing various conservative measures have shown only modest weight loss results in obese children and adolescents; therefore, bariatric surgery for this population has become a matter of discussion. This study aimed to present our experience with and outcomes for laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in morbidly obese Korean adolescents.Materials and MethodsThe prospectively established database of all patients undergoing bariatric surgery at Soonchunhyang University Seoul Hospital, Korea between January 2011 and January 2013 was retrospectively reviewed. Adolescents aged 14 to 20 years were included in the present analyses.ResultsTwenty-two adolescents underwent bariatric surgery during the study period; 14 underwent LSG and 8, LRYGB. Of these, 17 were female and 5 were male. The mean age was 19 years. Their mean body weight and body mass index (BMI) before surgery were 115 kg and 40.1 kg/m2. The only postoperative complication was intraluminal bleeding in 1 patient, which was managed conservatively. The mean BMI decreased to 29.1 kg/m2 after a mean follow-up of 10 months. The percent excess weight loss (%EWL) at 1, 3, 6, and 12 months postoperatively were 19.6, 39.9, 52.6, and 74.2%, respectively. Only 1 patient showed %EWL less than 30% at 12 months after surgery. All patients with diabetes and sleep apnea were cured of their disease, and other comorbidities also improved or resolved after surgery.ConclusionBariatric surgery leads to significant short-term weight loss along with resolution of obesity-related comorbidities in obese children and adolescents.

Early Outcomes of Roux-en-Y Gastric Bypass in a Publically Funded Obesity Program.

Background. There is limited literature assessing the outcomes of bariatric surgery in a publically funded, North American, multidisciplinary bariatric program. Our objective was to assess outcomes of roux-en-Y gastric bypass (RYGB) in a publically funded bariatric program through a retrospective review of patient records. Methods. 293 patients spent a median of 13 months attending a multidisciplinary obesity clinic prior to undergoing laparoscopic RYGB surgery. The hospital was a Canadian, publically funded, level 2 trauma center with university teaching services. Results. 79% of the patients were female and the average BMI at first visit to clinic was 55.3 kg/m2. The average decrease in BMI was 19.2 ± 0.9 kg/m2. This was an average absolute weight loss of 56.1 kg or 35.5% of initial weight. The average excess weight loss was 63.4 ± 20.4%. Improvement or resolution of obesity related comorbidities occurred in 65.9% of type 2 diabetics and in 50% of hypertensive patients. Conclusion. Despite this being an unconventional setting of a publically funded program in a large Canadian teaching hospital, early outcomes following RYGB were appropriate in severely obese patients. Ongoing work will identify areas of improvement for enhanced efficiencies within this system.

Reduction in obesity-related comorbidities: is gastric bypass better than sleeve gastrectomy?

Bariatric surgery is currently the most effective treatment for morbid obesity. It provides not only substantial weight loss, but also resolution of obesity-related comorbidities. Laparoscopic sleeve gastrectomy (LSG) has rapidly been gaining in popularity. However, there are limited data on the reduction of obesity-related comorbidities for LSG compared to laparoscopic Roux-en-Y gastric bypass (LRYGB). The aim of this study was to assess the effectiveness of laparoscopic LSG versus LRYGB for the treatment of obesity-related comorbidities. A total of 558 patients who underwent either LSG or LRYGB for morbid obesity at the Westchester Medical Center between April 2008 and September 2010 were included. Data were collected prospectively into a computerized database and reviewed for this study. Fisher's exact test analyses compared 30-day, 6-month, and 1-year outcomes of obesity-related comorbidities. A total of 558 patients were included in the analysis of obesity-related comorbidity resolution; 200 underwent LSG and 358 underwent LRYGB. After 1 year, 86.2 % of the LSG patients had one or more comorbidities in remission compared to 83.1 % LRYGB patients (P = 0.688). With the exception of GERD (-0.09 vs. 50 %; P < 0.001), similar comorbidity remission rates were observed between LSG and LRYGB for sleep apnea (91.2 vs. 82.8 %; P = 0.338), hyperlipidemia (63 vs. 55.8 %; P = 0.633), hypertension (38.8 vs. 52.9 %; P = 0.062), diabetes (58.6 vs. 65.5 %; P = 0.638), and musculoskeletal disease (66.7 vs. 79.4 %; P = 0.472). Laparoscopic sleeve gastrectomy markedly improves most obesity-related comorbidities. Compared to LRYGB, LSG may have equal in reducing sleep apnea, hyperlipidemia, hypertension, diabetes, and musculoskeletal disease. LRYGB appears to be more effective at GERD resolution than LSG.

Comorbidities Remission After Roux-en-Y Gastric Bypass for Morbid Obesity is Sustained in a Long-Term Follow-up and Correlates with Weight Regain

Obesity-related comorbidities are treated by Roux-en-Y gastric bypass (RYGB) due to weight loss and intestinal hormone changes. Few studies report the evolution of these comorbidities in a long-term follow-up, especially if weight regain is present. This study aims to analyze: (1) the resolution of obesity-related comorbidities after RYGB in a long-term follow-up and (2) its relationship to weight regain. A retrospective study was conducted on 140 patients submitted to RYGB for morbid obesity for at least 5years (mean follow-up 90months). Mean body mass index (BMI) before operation was 52kg/m(2), at nadir weight 29kg/m(2), and at last follow-up 33kg/m(2). The comorbidities diabetes, cardiovascular disease, arterial hypertension, dyslipidemia, sleep apnea, arthropathy, and infertility were classified as resolved, improved, unchanged, and worsened at nadir weight that happened between the first and second year and after five or more years of surgery. For each comorbidity, we compared the changes in the distribution of patients in the categories and the correlation of it with weight loss at the nadir and final weight. BMI was significantly different in the three periods. Comorbidities resolution was sustained in a long-term follow-up for diabetes, hypertension, cardiovascular disease, and infertility. Comorbidities status was directly related to the weight loss for all comorbidities except infertility. Our results show that comorbidities remission after RYGB is sustained in a long-term follow-up. Weight regain is linked to worse results for all comorbidities except infertility.

SLEEVEPASS: A randomized prospective multicenter study comparing laparoscopic sleeve gastrectomy and gastric bypass in the treatment of morbid obesity: preliminary results

The long-term efficacy of laparoscopic Roux-en-Y gastric bypass (RYGB) in the treatment of morbid obesity has been demonstrated. Laparoscopic sleeve gastrectomy (SG) as a single procedure has shown promising short-term results, but the long-term efficacy of SG has not yet been demonstrated. The aim of this study was to determine the preliminary 30-day morbidity and mortality of RYGB and SG in a prospective multicenter randomized setting. A total of 240 morbidly obese (BMI = 35-66 kg/m²) patients evaluated by a multidisciplinary team were randomized to undergo either RYGB or SG. There were 117 patients in the RYGB group and 121 in the SG group; two patients had to be excluded after randomization. Both study groups were comparable regarding age, gender, BMI, and comorbidities. There was no 30-day mortality. The median operating time was significantly shorter in the SG group (66 min vs. 94 min, p < 0.001). All complications were recorded thoroughly. There were 7 (5.8 %) major complications following SG and 11 (9.4 %) after RYGB (p = 0.292). Nine (7.4 %) SG patients and 20 (17.1 %) RYGB patients had minor complications (p = 0.023). The overall morbidity was 13.2 % after SG and 26.5 % after RYGB (p = 0.010). There were three (2.5 %) early reoperations after SG and four (3.3 %) after RYGB (p = 0.719). At 30-day analysis SG is associated with a shorter operating time and fewer early minor complications compared to RYGB. There were no significant differences in major complications or early reoperations. Long-term follow-up is required to determine the effect on weight loss, resolution of obesity-related comorbidities, and improvement of quality of life.

Efficacy of sleeve gastrectomy as sole procedure in patients with clinically severe obesity (BMI ≤50 kg/m2)

BackgroundSleeve gastrectomy (SG) is increasingly indicated as a stand-alone procedure for the treatment of clinically severe obesity. Our objective was to present the outcomes of SG in relation to weight loss, resolution of co-morbidities, and procedural morbidity/mortality for ≤5 years postoperatively. The study was conducted at a university hospital, bariatric referral center. MethodsFrom January 2005 to December 2010, 208 patients underwent SG at our institution. Per standard protocol, SG was the sole surgery indicated for weight reduction in patients with a body mass index of ≤50 kg/m2 who were not “sweet-eaters” and had no symptoms of gastroesophageal reflux disease. The study endpoints were weight loss, perioperative and late morbidity/mortality, and clinical improvement in co-morbidities and consequential nutritional deficiencies. ResultsSG was performed laparoscopically in 203 of the patients. The mean age and body mass index was 34.3 ± 10.3 years and 43.2 ± 2.8 kg/m2, respectively. No deaths were recorded. Early morbidity (≤30 d) was 9.6%, chiefly owing to staple line closure leaks, and late morbidity was 4.8%. A mean excess weight loss of 71.1% was documented in 90 (89.4%) of 106 patients, available for follow-up after 3 years. The excess weight loss slowly declined to 57.6% in 21 (77.7%) of 27 patients at 5 years of follow-up. No major metabolic deficiencies were apparent. Statistically significant improvements in pre-existing hypertension, diabetes mellitus, and dyslipidemia were achieved. After laparoscopic SG, gastroesophageal reflux disease symptoms developed in 9.8% of patients within the first postoperative year but lessened over time to 7.4% at the 5-year mark. ConclusionsSG is a reproducible procedure associated with significant weight reduction, resolution of obesity-related co-morbidities, and minor nutritional deficits at 5 years of follow-up. Laparoscopic SG can thus be safely used as the sole surgical treatment of clinically severe obesity (body mass index ≤50 kg/m2). The chief complication of postoperative leakage can be managed nonoperatively in most patients.

A 5-Year Prospective Quality of Life Analysis Following Laparoscopic Adjustable Gastric Banding for Morbid Obesity

In addition to actual weight loss and the possible resolution of obesity-related co-morbidities following bariatric surgery, another widely recognized important outcome measure is the improvement of quality of life (QOL). Disease-specific quality of life (DSQOL) and general health-related quality of life (HRQOL) were measured preoperatively and at 1 and 5years postoperatively following laparoscopic adjustable gastric banding (LAGB) for morbid obesity. The Moorehead-Ardelt questionnaire was used for DSQOL assessments and a generic 15-dimensional questionnaire (15D) was used for HRQOL measurements. In addition, HRQOL was compared with that of the age- and gender-standardized general population. DSQOL scores were significantly improved on all domains after 1year from the operation and this improvement was maintained at 5years. This improvement was also seen in the total HRQOL scores. Despite this improvement, the HRQOL after LAGB remained worse compared to the age- and gender-standardized general population. DSQOL and HRQOL improve both significantly after LAGB. This QOL improvement is maintained at 5-year follow-up although QOL does not reach the level of the general population.

A Review of Studies Comparing Three Laparoscopic Procedures in Bariatric Surgery: Sleeve Gastrectomy, Roux-en-Y Gastric Bypass and Adjustable Gastric Banding

Obesity is a major worldwide problem in public health, reaching epidemic proportions in many countries, especially in urbanized regions. Bariatric procedures have been shown to be more effective in the management of morbid obesity, compared to medical treatments in terms of weight loss and its sustainability. The two most commonly performed procedures are laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic adjustable gastric banding (LAGB), and the novel laparoscopic sleeve gastrectomy (LSG). The MEDLINE database (cutoff date September 2010), LILACS, and the Cochrane Library were searched using the key words "gastric bypass," "sleeve gastrectomy," and "gastric banding." Only studies that compared at least two of the laparoscopic procedures were included. Reviews and meta-analysis, editorial letters or comments, case reports, animal or in vitro studies, comparisons with medical treatment, comparisons with open (non-laparoscopic) procedures were excluded. Most studies indicated that LRYGB and LSG could be more effective achieving weight loss than LAGB. However, LAGB seems to be a safer procedure with frequent, but less severe, long-term complications. Although not uniformly reported, a resolution of obesity-related comorbidities was achieved with most bariatric procedures. The three procedures have acceptable efficacy and safety. We believe that patients should be informed in detail on the advantages and disadvantages of each available procedure, possibly in several interviews and always accompanied by a specialized interdisciplinary team, warranting long-term follow-up.

The Role of Physical Activity Participation in Weight Loss Outcomes Following Weight Loss Surgery

Weight loss surgery (WLS) is an effective intervention for the reduction of body mass and the resolution of obesity-related comorbidities. Excess weight loss following WLS has been reported in the range of 40% to 78% depending on the surgery type and the follow-up time period. Initial weight loss outcomes and weight loss maintenance have been shown to depend on several factors, including the type of surgical procedure, preexisting comorbidities, and compliance with postoperative medical, nutritional, and behavioral recommendations. One factor that has received limited attention in the scientific literature is the role of physical activity in initial weight loss and maintenance following WLS. Physical activity participation of sufficient frequency, intensity, and duration during both the pre- and postoperative time periods has the potential to reduce surgical complications, enhance weight loss outcomes, and improve physical fitness and overall health following WLS. In addition, physical activity has the potential to improve the quality of postoperative weight loss by enhancing fat mass loss while preserving fat-free mass, thereby minimizing the impact of massive weight loss on metabolic rate. In light of these potential benefits, appropriate interventions should be employed to promote physical activity participation of appropriate frequency, intensity, and duration both before and after WLS.

Early Experience with Laparoscopic Sleeve Gastrectomy as a Single-Stage Bariatric Procedure

Laparoscopic sleeve gastrectomy (LSG) as a single-stage restrictive bariatric procedure is becoming increasingly popular, especially in patients who are high risk and/or superobese. Between November 21, 2006, and September 30, 2008, 42 patients underwent LSG at our institution. Average age was 47 +/- 11 years, average body mass index was 54 +/- 10 kg/m2, and 62 per cent were female. Preoperative indications for LSG included contraindication to laparoscopic Roux-en-Y gastric bypass (n = 11), severe coronary artery disease and/or congestive heart failure (n = 3), significant liver disease (n = 3), and patient preference (n = 4). Intraoperative indications for LSG included a foreshortened mesentery with inability to create a gastrojejunostomy (n = 13), extensive adhesions (n = 5), and intraoperative findings concerning for cirrhosis (n = 3). Twelve complications occurred in six patients: laparoscopic to open conversion (n = 1), reoperation (n = 3), nosocomial pneumonia (n = 1), wound infection (n = 1), bleeding (n = 1), pulmonary embolus (n = 1), readmission (n = 3), and superior splenic pole infarction. There was one death resulting from pulmonary embolism that occurred 2 weeks postoperatively. Preliminary excess body weight loss at 3, 6, 9, and 12 months was 29, 32 t, 38, and 30 per cent, respectively, and many patients had improvement or resolution of obesity-related comorbidities. Early review of our experience demonstrates that LSG may be an effective single-stage bariatric procedure. Additional follow up will be necessary to better define its long-term safety and efficacy.

Gastric Banding or Bypass? A Systematic Review Comparing the Two Most Popular Bariatric Procedures

Objective Bariatric surgical procedures have increased exponentially in the United States. Laparoscopic adjustable gastric banding is now promoted as a safer, potentially reversible and effective alternative to Roux-en-Y gastric bypass, the current standard of care. This study evaluated the balance of patient-oriented clinical outcomes for laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass. Methods The MEDLINE database (1966 to January 2007), Cochrane clinical trials database, Cochrane reviews database, and Database of Abstracts of Reviews of Effects were searched using the key terms gastroplasty, gastric bypass, laparoscopy, Swedish band, and gastric banding. Studies with at least 1 year of follow-up that directly compared laparoscopic adjustable gastric banding with Roux-en-Y gastric bypass were included. Resolution of obesity-related comorbidities, percentage of excess body weight loss, quality of life, perioperative complications, and long-term adverse events were the abstracted outcomes. Results The search identified 14 comparative studies (1 randomized trial). Few studies reported outcomes beyond 1 year. Excess body weight loss at 1 year was consistently greater for Roux-en-Y gastric bypass than laparoscopic adjustable gastric banding (median difference, 26%; range, 19%-34%; P < .001). Resolution of comorbidities was greater after Roux-en-Y gastric bypass. In the highest-quality study, excess body weight loss was 76% with Roux-en-Y gastric bypass versus 48% with laparoscopic adjustable gastric banding, and diabetes resolved in 78% versus 50% of cases, respectively. Both operating room time and length of hospitalization were shorter for those undergoing laparoscopic adjustable gastric banding. Adverse events were inconsistently reported. Operative mortality was less than 0.5% for both procedures. Perioperative complications were more common with Roux-en-Y gastric bypass (9% vs 5%), whereas long-term reoperation rates were lower after Roux-en-Y gastric bypass (16% vs 24%). Patient satisfaction favored Roux-en-Y gastric bypass ( P = .006). Conclusion Weight loss outcomes strongly favored Roux-en-Y gastric bypass over laparoscopic adjustable gastric banding. Patients treated with laparoscopic adjustable gastric banding had lower short-term morbidity than those treated with Roux-en-Y gastric bypass, but reoperation rates were higher among patients who received laparoscopic adjustable gastric banding. Gastric bypass should remain the primary bariatric procedure used to treat obesity in the United States.

PL-17: How much EWL is enough? A Bayesian analysis to determine minimal EWL to deliver improvement/resolution of comorbidities after laparoscopic adjustable gastric banding in patients with BMI 30-40

Background: Many mild-to-moderately obese individuals (BMI 40) suffer from serious diseases related to their obesity. Surgery has proven effective in this population, but little is known about the quantitative relationship between the percent excess weight loss (%EWL) and the resolution of co-morbidities. Methods: Between 2004 and 2006, 50 patients with BMI 30-40 underwent laparoscopic adjustable gastric banding (LAGB). Data on all patients were collected prospectively and entered into an electronic registry. Dynamic Bayesian Analysis was performed (using the software at http://www.minituba.org), to yield a conditional probability table for %EWL and co-morbidity status (which was recorded as a binary, either ‘improved/resolved’ or ‘unchanged/aggravated’). Results: Mean preop age was 46.1 years (23-66) and mean preop BMI was 35.2 kg/m2 (32.6-37.7). All of the patients suffered from at least one obesity-related comorbidity. Mean %EWL was 41.4 16.0, 59.1 19.4, and 61.4 25.2, at 0.5, 1, and 2 years, respectively. Our defined end-point for the Bayesian Analysis was the minimum %EWL (as an interval of 5 units) required to achieve the maximum probability of resolving or improving the comorbidity. As such, for diabetes, a %EWL of 20-25 yielded the maximum of 83.3% resolution-or-improvement rate. For dyslipidemia, a %EWL of 30-35 yielded the maximum of 70% resolution rate. For HTN, a %EWL of 25-30 yielded the maximum of 75%, and for obstructive sleep apnea, a %EWL of 30-35 yielded the maximum of 75%. Conclusion: %EWL 50 (and as little as 20%) is sufficient to deliver substantial improvement or even resolution of obesityrelated comorbidities.