Surgical Treatment Of Severe Obesity Research Articles

Sleeve gastrectomy - still popular bariatric method.

Obesity is currently the most common multifactorial disease affecting almost all social strata of the population. Conservative therapy of obesity usually succeeds in reducing excess weight by an average of 10-15%. After surgical treatment of severe obesity (bariatric surgery), the average decrease in excess weight is several times greater and, in most cases, has a long-term positive effect on the overall clinical condition of the patients. Sleeve gastrectomy (SG) is the most used bariatric method of treating severe obesity today. The principle of SG is a vertical resection of a major portion of the gastric greater curvature. After the resection, the residual stomach has the shape of a sleeve with a remaining volume of about 120-150 ml. The effect of the method is both restrictive and hormonal, because after SG, the plasma level of active ghrelin decreases in the long term, among other things. Obesity is considered one of the most serious global health problems today. In 2018 a total of 696,191 bariatric procedures were performed worldwide. Sleeve gastrectomy was originally used in high-risk severely obese patients as the first stage of a duodenal switch (DS) or gastric bypass. Since 2003, this method has been used independently because for most of the patients, SG had a sufficient effect on weight reduction and improvement of comorbidities, and that is why since 2015, SG has become the most frequently used bariatric method.

Single anastomosis sleeve ileal bypass a single anastomosis sleeve jejunal bypass in the surgical treatment of severe obesity.

Bariatric surgery has been proven to be an effective method in the treatement of morbid obesity. The ideal bariatric procedure should be effective, easy to perform and safe. Sleeve gastrectomy and RYGB currently represent the most frequently used bariatric/metabolic procedures. However, they have a certain percentage of complications and post-operative morbidity and also they fail in some patients. These facts lead to the development of new surgical procedures, which also include single anastomosis sleeve ileal bypass (SASI) and single anastomosis sleeve jejunal bypass (SASJ). These procedures combines the advantages of restrictive and malabsorptive operations at the same time reducing the risk of nutrient deficiencies by maintaining passage through all the alimentary tract. The results so far are encouraging, further research and especially longer-term results are necessary.

Resting-state network functional connectivity before and after bariatric surgery.

Bariatric surgery is an increasingly popular treatment for patients with severe obesity and related health issues (e.g., diabetes, cardiovascular disease). Studies have identified alterations in functional connectivity both in obesity and following surgical treatment for severe obesity. This study aimed to assess brain function via resting-state within-network connectivity in bariatric surgery patients with severe obesity. University hospital. Thirty-four bariatric surgery patients completed functional neuroimaging at baseline and postoperatively (goal, 12 weeks; actual, 16 weeks, on average). They also self-reported health information. Baseline resting-state functional connectivity (RSFC) was predicted by baseline age, body mass index (BMI), continuous positive airway pressure use, and reported history of rheumatoid arthritis and type 2 diabetes. Change in RSFC was assessed using the same predictors. This model was run with and without controlling for baseline RSFC. Higher baseline BMI predicted lower baseline RSFC in 3 networks. Lower baseline RSFC also was related to rheumatoid arthritis and type 2 diabetes. Difference between baseline and follow-up RSFC was strongly negatively associated with baseline RSFC. Controlling for baseline RSFC, type 2 diabetes negatively predicted RSFC difference. RSFC may reflect brain dysfunction in patients with obesity and related diseases. Thatless connectivity at baseline predicted greater positive change suggests that RSFC may be a biomarker of neurocognitive improvement following bariatric surgery. Diseases more prevalent in patients with obesity (e.g., rheumatoid arthritis and type 2 diabetes) along with elevated BMI negatively affect RSFC likely through inflammatory pathways.

Interpretation for indications of metabolic and bariatric surgery released by ASMBS and IFSO in 2022

With the increasing number of obese patients worldwide, metabolic and bariatric surgery (MBS) has quickly become an effective way to treat obesity and related metabolic diseases such as type 2 diabetes, hypertension, lipid abnormalities, etc. Although MBS has become an important part of general surgery, there is still controversy regarding the indications for MBS. In 1991, the National Institutes of Health (NIH) issued a statement on the surgical treatment of severe obesity and other related issues, which continues to be the standard for insurance companies, health care systems, and hospital selection of patients. The standard no longer reflects the best practice data and lacks relevance to today's modern surgeries and patient populations. After 31 years, in October 2022, the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), the world's leading authorities on weight loss and metabolic surgery, jointly released new guidelines for MBS indications, based on increasing awareness of obesity and its comorbidities and the accumulation of evidence of obesity metabolic diseases. In a series of recommendations, the eligibility of patients for bariatric surgery has been expanded. Specific key updates include the following: (1) MBS is recommended for individuals with BMI≥35 kg/m2, regardless of the presence, absence, or severity of co-morbidities; (2) MBS should be considered for individuals with metabolic diseases and BMI 30.0-34.9 kg/m2; (3) the BMI threshold should be adjusted for the Asian population:: BMI≥25 kg/m2 suggest clinical obesity, and BMI ≥ 27.5 kg/m2 population should consider MBS; (4) Appropriately selected children and adolescents should be considered for MBS.

Remission of Food Addiction Does Not Induce Cross-Addiction after Sleeve Gastrectomy and Gastric Bypass: A Prospective Cohort Study

Background: The hypothesis of “cross-addiction” has never been validated, and numerous aspects speak against it. Objectives: To compare the differences between sleeve gastrectomy (SG) and gastric bypass (GB) procedures concerning cross-addiction. Setting: Center for maximum care in Germany. Methods: We performed a prospective analysis of patients undergoing SG or GB as the first surgical treatment for severe obesity. All patients completed validated questionnaires to evaluate food intake (Yale Food Addiction Scale, YFAS), alcohol intake (Alcohol Use Disorders Identification Test), nicotine use (Fagerstrom Test for Nicotine Dependence), exercise (Exercise Addiction Inventory), drug addiction (20-item Drug Abuse Screening Test), and Internet use disorder (Internet Addiction Test) before the operation (T0) and 6 (T6) and 24 (T24) months postoperatively (ClinicalTrials.gov identifier: NCT02757716). Results: One hundred thirteen patients underwent SG (n = 68) or GB (n = 45). At the follow-up, 61% completed the questionnaires at T6 and 44% at T24. In the YFAS, the percentage of patients diagnosed with food addiction decreased from 69 to 10%, and the mean symptom count decreased from 3.52 ± 1.95 to 1.26 ± 0.99 at T24 (p < 0.0001); these values did not differ between the surgical groups (p = 0.784). No significant evidence of cross-addiction was observed for use of alcohol, nicotine, drugs, the Internet, or exercise in either surgical group. The percentage of patients with moderate nicotine dependence increased in the SG group (+8.9%) at T24, but this was not significant. Conclusion: In this single-center cohort study, surgery for obesity caused significant addiction remission regarding food but without inducing cross-addiction after 2 years. Importantly, no significant differences were seen between the SG and GB procedures.

Estimated Costs of Clinical and Surgical Treatment of Severe Obesity in the Brazilian Public Health System.

Obesity is a major global epidemic and a burden to society and health systems. This study aimed to estimate and compare the anual costs of clinical and surgical treatment of severe obesity from the perspective of the Brazilian Public Health System. An observational and cross-sectional study was performed in three reference centers. Data collection on health resources utilization and productivity loss was carried out through an online questionnaire. Participants were divided in clinical (waiting list for a bariatric surgery) and surgical groups (open Roux-en-Y gastric bypass), and then allocated by the time of surgery (up to 1year; 1-2years; 2-3years; and >3years). Costs of visits, medications, exams, and surgeries were obtained from government sources. Data on non-medical costs, such as transportation, special diets, and caregivers, were also colleted. Productivity loss was estimated using self-reported income. Costs in local currency (Real) were converted to international dollars (Int$ 2015). Two hundred and seventy-four patients, 140 in surgical group and 134 in clinical group were included. In first postoperative year, the surgical group had higher costs than clinical group (Int$6005.47 [5000.18-8262.36] versus 2148.14 [1412.2-3506.8]; p=0.0002); however, from the second year, the costs decreased progressively. In the same way, indirect costs decreased significantly after surgery (259.08 [163.63-662.72] versus 368.17 [163.62-687.27]; p=0.06). Total costs were higher in the surgical group in the first 2years after surgery. However, from the third year on, the costs were lower than in the clinical group.

Complications in bariatric surgery

Bariatric surgery is one of the fastest growing hospital procedures performed in the world and also is an important option for patients with extreme obesity and co-morbidities. Bariatric surgery, however, has risks and complications involved. Complications following surgical treatment of severe obesity vary based upon the procedure performed and can be as high as 40 percent. Due to the high surgical volume, improving the safety of these operations has become a high priority, leading to the development of strict criteria for center accreditation, guidelines for safe and effective bariatric surgery, and careful monitoring of surgical outcomes. This topic will review the major complications of bariatric surgery.

Financial costs and patients' perceptions of medical tourism in bariatric surgery.

Many Canadians pursue surgical treatment for severe obesity outside of their province or country - so-called "medical tourism." We have managed many complications related to this evolving phenomenon. The costs associated with this care seem substantial but have not been previously quantified. We surveyed Alberta general surgeons and postoperative medical tourists to estimate costs of treating complications related to medical tourism in bariatric surgery and to understand patients' motivations for pursuing medical tourism. Our analysis suggests more than $560 000 was spent treating 59 bariatric medical tourists by 25 surgeons between 2012 and 2013. Responses from medical tourists suggest that they believe their surgeries were successful despite some having postoperative complications and lacking support from medical or surgical teams. We believe that the financial cost of treating complications related to medical tourism in Alberta is substantial and impacts existing limited resources.

Is Physical Activity a Worthwhile Option for the Management of Severe Obesity?

Physical activity is recommended by experts in the medical and surgical management of severe obesity. However, there is no specific physical activity recommendation for this population. Yet, individuals with severe obesity need to be considered specifically because of higher prevalence of comorbidities, poorer quality of life and physical fitness compared to people with less severe obesity. In addition, they have several weight related or unrelated barriers that can prevent them from reaching recommended level of physical activity. Weight loss is an important outcome for obese patients. However, physical activity is associated with no or moderate weight loss, and there is a large weight loss variability between individuals. More and more evidence confirms that physical activity interventions are feasible and effective to maintain weight loss and improve health of individuals with severe obesity beyond weight loss. Thus, to avoid frustration and disappointment, no focus on weight loss should be done during physical activity intervention. Overall, more high quality studies are now required to improve the level of evidence and provide information on the optimal physical activity support, modes of delivery, timing and dose in individuals with severe obesity. In addition, the assessment of implementation outcomes (compliance, adverse outcomes and satisfaction) and cost-effectiveness analyses are required to support that physical activity intervention is a worthwhile option in the medical and surgical treatment of severe obesity.

Preoperative assessment of gut hormones does not correlate to weight loss after Roux-en-Y gastric bypass surgery

BackgroundRoux-en-Y gastric bypass (RYGB) surgery is an effective and frequently used surgical treatment for severe obesity. Postoperative weight loss varies markedly, but biomarkers to predict weight loss outcomes remain elusive. Levels of the satiety gut hormones glucagon like peptide-1 (GLP-1) and peptide YY (PYY) are attenuated in obese patients but elevated after RYGB surgery. We aimed to evaluate the preoperative responses of GLP-1 and PYY to a standard meal as a predictor of weight loss after RYGB surgery. We hypothesized that weak satiety gut hormone responses preoperatively, would predict poor weight loss after RYGB surgery. MethodsPreoperatively 43 patients (F = 25/M = 18) had GLP-1 and PYY measured in the fasting state and at 30-minute intervals over 180 minutes after a standard 400 kcal mixed meal. Weight loss was assessed at weight stability after surgery (mean 16.2 mo [CI 15.516.9]). ResultsBody mass index decreased from 44.0 kg/m2 (CI 42.2–45.7) before surgery to 30.3 kg/m2 (CI 28.4–32.2) after surgery (P<.001). Preoperative GLP-1 and PYY responses to food intake; as delta value between fasting and maximum as well as total responses during 180 minutes did not correlate to total weight loss (GLP-1; rho = .060 and rho = −.089, PYY; rho = −.03 and rho = −.022, respectively) or to excess weight loss % (GLP-1; rho = .051 and rho = −.064, PYY; rho = −.1 and rho = −.088, respectively). ConclusionPreoperative responses of GLP-1 and PYY to a 400 kcal mixed meal do not correlate to postoperative weight loss after RYGB surgery for morbid obesity.

Outcomes of revision laparoscopic gastric banding: a retrospective study

Obesity is a health problem approaching pandemic proportions. Laparoscopic adjustable gastric banding (LAGB) is the bariatric procedure of choice in Australia for effective surgical treatment of severe obesity. Complications of LAGB lead to a high proportion of patients requiring revision surgery. However, literature regarding outcomes and failure rates of revision bariatric surgery is scarce, such that the choice of procedure at reoperation remains controversial. This paper aims to present outcomes of revision laparoscopic gastric banding. One hundred eighty-three consecutive revision LAGB procedures were performed in 163 patients between March 1998 and July 2009. Patients were followed up for a median period of 36 months. Weight change in terms of body mass index (BMI) and percentage excess weight loss (%EWL), morbidity and patient tolerance were examined. The average reduction in BMI from the primary LAGB procedure was 8.45 kg/m(2) , equivalent to a %EWL of 50.55. BMI of patients who underwent revision LAGB appears to remain stable, with mean change of +0.25 kg/m(2) (%EWL 45.76, P = 0.5) at 3 years and -1.59 (%EWL 51.52, P = 0.12) at 5 years. The overall complication rate of revision LAGB was 13.7%, most commonly recurrent gastric pouch dilatation. Revision LAGB is reasonably well tolerated by most patients. Preliminary outcome data indicate that revision gastric banding does not result in further weight loss in patients who have lost weight from primary banding, but does maintain the weight loss achieved.

Laparoscopic Sleeve Gastrectomy for Super Obese Patients

In this study, we report long-term outcomes of high-risk, high-BMI (body mass index) patients who underwent laparoscopic sleeve gastrectomy (LSG). Short- and medium-term data appear to support the effectiveness of LSG, but long-term data to support its durability are sparse. A prospective database was reviewed on all high-risk patients who underwent LSG as part of a staged approach for surgical treatment of severe obesity between January 2002 and February 2004. We included only patients who did not proceed to second-stage surgery (gastric bypass). Analyzed data included demographics, BMI, comorbidities, and surgical outcomes. All partial gastrectomies were performed using a 50F bougie. Seventy-four patients underwent LSG, and follow-up data were available on 69 of 74 patients (93%). The mean age was 50 years (25-78) and the mean number of co-morbidities was 9.6. Perioperative mortality (<30 days) was zero, and the incidence of short- and long-term postoperative complications was 15%. The mean overall follow-up time period was 73 months (38-95). Mean excess weight loss (EWL) at 72, 84, and 96 months after LSG was 52%, 43%, and 46%, respectively, with an overall EWL of 48%. The mean BMI decreased from 66 kg/m(2) (43-90) to 46 kg/m(2) (22-73). Seventy-seven percent of the diabetic patients showed improvement or remission of the disease. This study reports the longest follow-up of LSG patients thus far and supports the effectiveness, safety, and durability of laparoscopic sleeve gastrectomy as a definitive therapeutic option for severe obesity, even in high-risk, high-BMI patients.

Depletion of Serum Carotenoid and Other Fat-Soluble Vitamin Concentrations following Obesity Surgery

Obesity constitutes a growing health problem, and surgical treatment of severe obesity is increasingly used. Nutrient deficiencies are common following bariatric surgery and the evidence indicates a progressive increase in the incidence and severity of the deficiency of certain vitamins and related clinical conditions. Because of the potential role of carotenoids in disease prevention, our aim was to assess the carotenoid status in candidates for obesity surgery and the time-course changes following two bariatric procedures. Seventy-five candidates for bariatric surgery (17 men, 58 women; age 43 ± 10years) and a total of 362 serum samples after obesity surgery (i.e., Roux-en-Y gastric bypass (n = 187) and biliopancreatic diversion (n = 175)) were consecutively collected and assessed. Retinol, α- and γ-tocopherol, 25-OH-vitamin D3, lutein, zeaxanthin, α- and β-cryptoxanthin, lycopene (trans and cis), α- and β-carotene (trans and cis) were analyzed by high-performance liquid chromatography. Mean serum levels of carotenoids in candidates for obesity surgery were within the reference values reported in controls and seasonal variations were present in several analytes. After surgery, and regardless of the type of intervention, all serum carotenoids dropped following first-order kinetics. Cis/trans ratio of lycopene and β-carotene did not change after surgery, over the time or between surgical procedures. On a long-term, serum carotenoids were at or below fifth percentile of reference groups. The chronic low levels of carotenoids in these patients compromise their availability to tissues, constituting an additional risk factor for other clinical conditions. Dietary advice on carotenoid-rich, fortified foods or supplements should be also evaluated in these patients.

P120: Hybrid notes sleeve gastrectomy in an animal model

Sleeve gastrectomy is being increasingly used for surgical treatment of severe obesity. Natural Orifice Translumenal Endoscopic Surgery (NOTES) is an emerging minimally invasive technique that holds the promise of scarless, pain free surgery. We report on performance of two cases of hybrid natural orifice sleeve gastrectomy in a canine model.

The Effect of a Low-Carbohydrate, High-Protein Diet on Post Laparoscopic Gastric Bypass Weight Loss: A Prospective Randomized Trial

Laparoscopic gastric bypass has become the standard surgical treatment for severe obesity in the United States. Less clear is what diet should be followed by these patients after surgery to maximize their weight loss. Patients undergoing laparoscopic gastric bypass procedures for morbid obesity were randomly assigned to either a low-fat control diet based on American Heart Association recommendations or a low-carbohydrate, high-protein diet based on the South Beach Diet. One-on-one diet counseling with a bariatric nutritionist was provided preoperatively, postoperatively while in the hospital, and at postoperative clinic visits during the 12-month follow-up period. Investigators were blinded to diet assignment. Body composition including Body Mass Index (BMI) was recorded preoperatively and during postoperative visits at 3, 6, and 12 months. Thirty-two patients were included in the analysis with 13 control and 19 low-carbohydrate, high-protein subjects. No demographic or clinical preoperative variables, including preoperative BMI, showed statistical differences between the two groups. Both groups demonstrated significant yet similar weight loss both by reduction in BMI (at 12 months, low fat diet, -14.0 +/- 5.5% versus low carbohydrate, -17.0 +/- 4.5%; P = 0.15) and excess body weight lost (at 12 months, low-fat diet, -60.3 +/- 15.3% versus low carbohydrate, -59.6 +/- 13.0%; P = 0.96). Based on this limited prospective study, no weight loss advantage is observed in substituting a low-carbohydrate, high-protein diet in place of a standard low-fat diet in patients who have undergone laparoscopic gastric bypass surgery.

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There are procedures for the surgical treatment of severe obesity, one of which is the biliopancreatic diversion/duodenal switch (BPD/DS), a highly effective weight loss operation performed either open or laparoscopically. This is considered to be a very complex laparoscopic procedure. We have used a simplified laparoscopic gastric bypass procedure (2005 ASBS video) in > 2,000 cases, which has been reproduced in Latin America, Europe and Asia with similar results. As the BPD/DS may be more effective for super-obese patients, we have also developed a simplified and reproducible approach for this operation.

P194: The effect of a low-carbohydrate, high-protein diet on post laparoscopic gastric bypass weight loss: A prospective randomized trial

IntroductionLaparoscopic gastric bypass (LGB) has become the standard surgical treatment for severe obesity in the United States. Less clear is what diet should be followed by these patients after surgery to maximize their weight loss. Recently low-carbohydrate, high-protein diets have become popular and widely employed by the general public. In non-surgical patients many studies have compared diet compositions with mixed results. No clear data exist to describe the ideal diet after LGB surgery.

Insurance-mandated preoperative dietary counseling does not improve outcome and increases dropout rates in patients considering gastric bypass surgery for morbid obesity

Background Preoperative dietary counseling (PDC) before bariatric surgery is mandated by a growing number of insurance payers. Their claim is that PDC improves outcomes and postoperative compliance. We compared outcomes of GBP patients undergoing a mandatory 13 weeks of PDC (n = 72) to a contemporaneous group of patients with no such requirement (no-PDC; n = 252) who underwent operation between January 2000 and December 2002. Methods The PDC and no-PDC groups were characterized by similar male:female ratios (1:4 vs 1:4.6), mean age (42 years), mean body weight (324 lb vs 309 lb), and mean body mass index (BMI) (52 kg/m 2 vs 50 kg/m 2). The PDC group had a higher incidence of obstructive sleep apnea compared with the no-PDC group (41% vs 28%; P < .04) but otherwise the two groups had similar incidences of obesity-related comorbidities. The presurgery dropout rate was 50% higher in the PDC group than in the no-PDC group (28% vs 19%; P < .05). Results At 1 year follow-up, the no-PDC patients had a statistically greater percentage excess weight loss (67% vs 60%; P < .0001), lower BMI (32 vs 35; P < .015), and lower body weight (197 vs 218; P < .01). Resolution of major comorbidities, complication rates, 30-day postoperative mortality, and postoperative compliance with follow-up were similar in the two groups. Conclusions The data demonstrate that insurance-mandated PDC is an obstacle to patient access for surgical treatment of severe obesity and has no impact on weight loss outcome or postsurgical compliance. PDC should be abandoned by the insurance industry.

Perioperative outcomes and risk factors in gastric surgery for morbid obesity: A 9-year experience

Surgical treatment of severe obesity is the most rapidly growing specialty area of surgery. The rapid expansion of bariatric surgery has raised questions and concerns regarding possible increased surgical mortality and morbidity rates in both academic and community settings. The purpose of this study was to evaluate postoperative outcomes and risk factors for bariatric gastric surgery for severe obesity. A community experience of 1009 consecutive patients who underwent open surgical treatment of morbid obesity during a 9-year period was reviewed from a prospective database. The series included 858 primary gastric bypass operations and 151 revision operations. Perioperative outcomes, late complications, and weight loss results were recorded. Morbidity and mortality rates were analyzed according to patient age, body mass index (BMI), and gender. The mortality rate in the series was 0.6%, and the morbidity rate was 20%. The major complication rate was 6.6%. There were no deaths in the 151 revision patients. The gastrointestinal leak rate was 0.8%, and the thromboembolism rate was 1%. Statistical analysis indicates that BMI is a risk factor for surgical complications. Open gastric surgery for morbid obesity can be carried out in the community setting with low mortality and morbidity rates. BMI is a proven surgical risk factor.

Preoperative dietary counseling does not improve outcome and increases drop-out rates in patients considering gastric bypass surgery for morbid obesity

Purpose: Preoperative dietary counseling (PDC) before bariatric surgery is mandated by a growing number of insurance payers. Their claim is that PDC improves the outcomes and postoperative compliance. Methods: We compared the outcomes of gastric bypass (GB) patients undergoing a mandatory 6 months of PDC (n 72) with a contemporaneous group of patients with no such requirements (No-PDC, n 252) who underwent surgery between January 2000 and December 2002. Results: The PDC and No-PDC groups were characterized by a similar male/female ratio (1:4 vs. 1:4.6), age (mean 42 years), mean body weight (324 vs. 309 lb), and body mass index (52 vs. 50 kg/m). The PDC group had a greater incidence of obstructive sleep apnea compared with the No-PDC group (41% vs. 28%, p 0.04) but otherwise had a similar incidence of obesityrelated comorbidities. The preoperative drop-out rate was 50% greater in the PDC group than in No-PDC group (26% vs. 17%, p 0.05). At 1 year of follow-up, the No-PDC group had a statistically greater percentage of excess weight loss (67% vs. 60%, p 0.0001), lower BMI (32 vs. 35 kg/m, p 0.015), and lower body weight (197 vs. 218 lb, p 0.01). Resolution of major comorbidities, complication rates, 30-day postoperative mortality, and postoperative compliance with follow-up were similar in both groups. Conclusions: These data have demonstrated that mandatory PDC is an obstacle to patient access for surgical treatment of severe obesity that demonstrates no impact on weight loss outcome or postoperative compliance. PDC should be abandoned by the insurance industry. PII: S1550-7289(05)00125-5