Surgical Treatment Of Severe Obesity Research Articles

Growth hormone secretion and leptin in morbid obesity before and after biliopancreatic diversion: relationships with insulin and body composition.

Obesity is characterized by increased leptin levels and insulin resistance, whereas blunted GH secretion is paired with normal, low, or high plasma IGF-I levels. To investigate body composition in human obesity and the interactions among the GH-IGF-I axis, leptin, and insulin resistance [measured with the homeostasis model assessment (HOMA) score], we studied 15 obese females, aged 23-54 yr (mean age, 42.7 +/- 2.6), with a body mass index (BMI) of 44.02 +/- 1.45 kg/m(2), who underwent treatment by biliopancreatic diversion (BPD), before and after surgery (16-24 months; BMI, 28.29 +/- 0.89 kg/m(2)). Our controls were 15 normal females, aged 28-54 yr (mean age, 40.8 +/- 2.3 yr), with a BMI of 27.52 +/- 0.53 kg/m(2). Insulin and leptin levels and HOMA scores were higher pre-BPD than in the controls. The GH response to GHRH was blunted, with a GH peak and GH area under the curve (AUC) significantly lower than those in controls. IGF-I and IGF-binding protein-3 (IGFBP-3) were also lower than control values. After surgery, BMI, fat mass, lean body mass, HOMA, insulin, and leptin significantly decreased. Furthermore, the GH response to GHRH severely increased; IGF-I and IGFBP-3 levels did not significantly vary. Considering all subjects, correlation analysis showed a strong positive correlation between insulin and leptin, and a negative correlation between insulin and GH peak and between insulin and GH AUC. Regression analysis performed grouping pre- and post-BPD indicated that leptin and GH peak or AUC could best be predicted from insulin levels. The surgical treatment of severe obesity after stabilization of body weight decreases BMI and fat mass while preserving normal lean body mass as well as positively influencing insulin sensitivity and thus aiding the normalization of leptin levels. The insulin reduction may be mainly involved in the increase in the GH response to GHRH through various possible central and peripheral mechanisms while decreasing the peripheral sensitivity to GH itself, as shown by the stable nature of the IGF-I and IGFBP-3 values. Our findings suggest that the changes in insulin levels are the starting point for changes in both leptin levels and the somatotrope axis after BPD.

Bariatric surgery and long-term control of morbid obesity.

OBESITY, DEFINED AS 20% OR more than the ideal weight or body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of 30 or more, has reached epidemic levels in the United States, affecting more than 30% of adults. Annual direct costs for treating obesityrelated medical illnesses have been estimated at nearly $51.6 billion; the annual US expenditure on weight reduction exceeds $30 billion. It was recently estimated that the prevalence of obesity in US adults increased by 8% during the past decade. In the 21st century, obesity may be the number 1 US public health problem (http://www .surgeongeneral.gov/topics/obesity/). Morbid or severe obesity was traditionally defined as a weight of 45 kg or more or 100% over ideal body weight defined by standard life insurance tables. More recent classification systems define morbid obesity as a BMI of 40 or more or a BMI of 35 or more in the presence of comorbidities. The prevalence of severe obesity based on US 19992000 population data was estimated to be 3.1% in men and 6.7% in women. Inapublishedreportofmortalityrates in patients who were morbidly obese, mortality was 12 times higher in men aged 25 to 34 years and 6 times higher in men aged 35 to 44 years vs men with healthy weight of the same age. Because even modest weight loss (10%-15% of initialweight)usuallyresults inimprovement or resolution of multiple medical comorbidities, surgical treatment of severe obesity appears to be cost-effective by eliminating use of medications and absenteeism from work in patients who were previously morbidly obese. Gastric Restrictive Operations There are 3 types of gastric restrictive operations: stapled gastroplasty, gastric banding, and conventional Rouxen-Y gastric bypass. In stapled gastroplasty, the stomach is partitioned close to the gastroesophageal junction creating a small-capacity upper gastric pouch with a small calibrated outlet leading from the upper pouch to the remainder of the digestive tract (FIGURE, A). Early weight loss results after banded gastroplasty have been acceptable with a mean excess weight (difference between preoperative and ideal weight) loss reported in the range of 60% (or approximately 30% of initial preoperative weight lost). The early morbidity rate (within the first 30 days) for banded gastroplasty is less than 10% and the perioperative mortality rate is less than 1.0%. However, many patients regain a substantial portion of their lost weight between 3 and 5 years, postoperatively. Vertical-banded gastroplasty has been shown to adversely alter postoperative eating behavior toward sweets and ice cream, which, in part, explain inferior weight loss results in comparison with Roux-en-Y gastric bypass; a nearly 80% failure rate has been reported 10 years following vertical-banded gastroplasty. Gastroplasty has recently fallen into disfavor due to poor weight loss maintenance and a 15% to 20% rate of reoperation for either stomal outlet stenosis or severe gastroesophageal reflux. Gastric banding uses a premeasured prosthetic device to restrict oral intake (Figure, B). The circumference of the band is generally in the range of 5.0 cm, similar to the measurement used for gastroplasty. Kuzmak introduced an inflatable band in which the diameter of the band can be adjusted by infusion of saline through a subcutaneous reservoir. Complication rates with the early techniques of gastric banding were relatively high due to stenosis, erosion, or both of the band, frequently requiring reoperation. Weight loss results and complication rates with the inflatable bands are better than those observed after the earlier banding techniques. Although erosion of the inflatable bands is relatively uncommon, usability of the subcutaneous reservoir deteriorates over time. Weight loss with gastric banding has been less consistent than weight loss reported after banded gastroplasty and gastric bypass. Gastric bypass combines gastric restriction with a small amount of subclinical malabsorption. Although absorption of iron and vitamin B12 is decreased after gastric bypass, malabsorption of protein, carbohydrate, and fat has not been reported after gastric bypass performed with short Roux limb lengths. In gastric bypass, the upper stomach is completely closed off, thereby excluding more than 95% of the stomach, all of the duodenum, and 15 to 20 cm of proximal jejunum from digestive continuity. The Roux-en-Y technique (Figure, C) is currently the preferred method of gastric bypass. Weight loss results with the Rouxen-Y technique have been superior to thoseobservedafterothergastric restrictive operations in multiple clinical comparisons. Mean excess weight loss in gastric bypass patients typically ranges from 65% to 75%, which corresponds to loss of approximately 35% of initial weight. However, there is some degree of recidivism between 3 and 5

Anesthetic Considerations for Bariatric Surgery

According to the National Institutes of Health, obesity is a major health problem with clearly established health implications, including an increased risk for coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, gallbladder disease, degenerative joint disease, obstructive sleep apnea, and socioeconomic and psychosocial impairment (1). The risk of developing one or more of these obesityrelated conditions is based on body mass index (BMI), with 25–30 kg/m 2 being low risk and 40 kg/m 2 being very high risk (2). The prevalence of obesity in the 18- to 29-yr-old group increased from 12% in 1991 to 18.9% in 1999 (3). Bariatric surgery encompasses a variety of surgical weight loss procedures used to treat morbid obesity. Obesity is clinically expressed in terms of BMI or Quetelet’s index (4), which is derived by dividing weight by the square of height to estimate the degree of obesity. Thus, BMI body weight (kg)/height 2 (m 2 ). Morbid obesity is a BMI more than 35 kg/m 2 , and super morbid obesity is BMI more than 55 kg/m 2 . The indications for surgical treatment of severe obesity, as outlined in the 1991 National Institutes of Health Consensus Development Conference Panel, include an absolute BMI more than 40 kg/m 2 or BMI more than 35 kg/m 2 in combination with lifethreatening cardiopulmonary problems or severe diabetes mellitus (1). Patients seeking surgical weight loss must have proven attempts at medically supervised weight loss. Documentation of loss of 5% to 10% excess body weight or weight gain after at least 6 mo of diet modification, exercise, and medical therapy or nonimprovement in comorbid conditions during this period indicates failure. Studies have shown that weight loss of 5%–10% of initial body weight improves glucose intolerance and Type II diabetes, hypertension, and dyslipidemia (5–7). The average expenditure is approximately $7000 per year per patient on weight loss programs and equipment. Unfortunately, long-term weight loss is the exception, and most patients regain weight, sometimes more than they initially lost.

The Epidemic of Severe Obesity: The Value of Surgical Treatment

The Epidemic of Severe Obesity: The Value of Surgical Treatment

Techniques and Procedures: Surgical Treatment for Severe Obesity: The State‐of‐the‐Art for the New Millennium

Obesity is becoming an ever‐increasing health concern for the Western world. As the incidence rises, so do the health care costs. For patients with extreme obesity, surgical treatments have evolved into safe and effective options. The current procedures have grown from the experience obtained over 30 years of evolution. This accumulated knowledge, along with the introduction of minimally invasive techniques, may further improve the safety of these procedures. As we enter the new millennium, the current surgical techniques, in conjunction with the many aspects of a multidisciplinary approach to patient screening, preparation, and aftercare, offer the best treatment option for these patients. A thorough understanding of the procedures, including the potential long‐term considerations, is also critical to minimize problems and maximize success.

An interval report on prospective investigation of adjustable silicone gastric banding devices for the treatment of severe obesity.

A review and updated report of an ongoing prospective investigation of two different adjustable silicone gastric banding devices is presented. One cohort of this study includes 40 subjects who have had a band placed by laparotomy. A second cohort includes 22 subjects who have had a newly designed adjustable silicone gastric band (ASGB) placed by laparoscopic or open technique. The goal of this investigation is to evaluate the achievement of sustained weight loss without the need for re-operation. Because of the frequent need for re-operation to correct life-threatening complications or ineffectiveness of ASGB devices, present clinical data indicate that improvements to the implantable system and the operative technique need to be made and verified by long-term study. At this point in development, ASGB remains an investigative procedure that has not fulfilled the scientific requirements of an accepted surgical treatment for severe obesity.

Past, present, and future of obesity surgery.

At the meeting 1 year ago, Mary Lou Walen asked the author to provide a brief luncheon talk about the past, present, and future of obesity surgery for the Allied Health Sciences members who meet in conjunction with the annual meeting of the American Society for Bariatric Surgery. This led the author to examine the surgical treatment of severe obesity as it relates to our times and society. Edward O. Wilson has recommended that bariatric surgeons enlarge their view of the work they are engaged in, to include a more universal perspective. From this review, the following talk was presented.

Prospective investigation of complications, reoperations, and sustained weight loss with an adjustable gastric banding device for treatment of morbid obesity

The purpose of this study was to determine prospectively the safety and efficacy of an adjustable silicone gastric band and reservoir system for the treatment of morbid obesity. Between 1992 and 1995, forty primary procedures were performed. Twenty-six females and 14 males entered the study. The mean age of the subjects was 34 years (range 19 to 51 years). Mean body mass index was 50 kg/m 2 (range 39 to 75 kg/m 2). There were no deaths. Mean body mass index (in kg/m 2) at follow-up visits was 38.4 at 1 year, 38.0 at 2 years, 40.2 at 3 years, and 40.4 at 4 years. These decreases were significant at P <0.001. Thirty-two reoperations (12 intra-abdominal procedures and 20 abdominal wall procedures) have been necessary to maintain efficacy or correct complications. At the four-year interval, the reoperation rate of 80% was unsatisfactory. The excess weight loss has been 41% for those subjects who have an intact gastric band system and continue in the study. Improvements to the implantable band and/or operative technique must be implemented and studied long term if this procedure is to become an accepted surgical treatment for severe obesity.

A decade of change in obesity surgery. National Bariatric Surgery Registry (NBSR) Contributors.

The International (formerly National) Bariatric Surgery Registry began collecting data in January 1986. The aim of this study was to examine changes in the practice of surgical treatment of severe obesity that occurred during the decade of 1986 through 1995, as observed in the IBSR data. All data submitted to the IBSR during the decade were transferred to the IBM mainframe computer for analysis. Characteristics of operative type populations were compared over time using analysis of variance (ANOVA) for age, body mass index (BMI), operative weight and Chi-square (chi2) test for gender. There has been a steady increase over the decade in mean patient weight. The operations used have changed from predominantly 'simple' operations to more frequent use of 'complex' operations. Within the categories of 'simple' and 'complex', an increase in the variety of operations occurred. As a group, patients with 'simple' operations have been heavier, more often male and public pay patients than those who have undergone 'complex' operations. One year weight loss was greater for Roux-en-Y gastric bypass (RGB) than vertical banded gastroplasty (VBG), but follow-up rates were too low to study the relative merits of the operations used. The reported incidence of operative mortality and serious complications (leak with peritonitis, abscess and pulmonary embolism) remained low. These observations and their implications can be summarized in three statements which relate to action for improved patient care in the beginning of the new century: (1) increasing weight of candidates for surgical treatment during this decade indicates the need for earlier use of operative treatment before irreversible complications of obesity can develop; (2) low risk of obesity surgery, decreasing postoperative hospital stay, and early weight control support the continued and increased use of surgical treatment; (3) continued widespread use of both 'simple' and 'complex' operations with increased modifications of standard RGB and VBG procedures emphasizes the need for standardized long-term data and analyses regarding both weight control and postoperative side-effects.

Pregnancy following gastric bypass surgery for morbid obesity

Surgical treatment for severe obesity is sometimes recommended. Many long-term risks, particularly to adolescents and to subsequent pregnancies, are still being determined. A 23-year-old woman, gravida 6, para 2, treated for morbid obesity during adolescence with gastric bypass surgery, presented at 6 weeks' gestation with severe microcytic anemia. Significant iron and cobalamin deficiencies were found. Although the vitamin B12 deficiency responded to parenteral treatment, the iron deficiency was refractory to oral supplementation because of malabsorption. By 30 weeks' gestation, the patient required blood transfusions to correct the progressive anemia. Subsequently, she delivered a healthy male infant at term. Severe iron deficiency anemia resulting from malabsorption can complicate pregnancy following gastric bypass surgery for morbid obesity. For women of childbearing age, this potential adverse effect must be considered.

Pay Status as a Predictor of Outcome in Surgical Treatment of Obesity.

BACKGROUND: Higher complication rates and lower success in surgery for severe obesity have been reported for patients with government pay status. We examined the effect of pay status upon outcome in surgical treatment of obesity. METHODS: This was an observational study from an aggregate data set of individual patient information. Government pay status (G) was defined as full or partial medical care payment through Medicare, Medicaid, or Veterans Administration. Payment entirely by private insurance was defined as private (P). Operations were classified as either simple (S, gastric restriction) or complex (C, gastric restriction with small bowel bypass). Two measures of outcome, perioperative complication rate and weight loss success (</= 50% excess weight), were examined to determine pay status effect. RESULTS: More G than P patients were treated with simple procedures (79% vs 51%, p < 0.05). Perioperative complication rates were more common for G than P patients (14.4% vs 9.1%, p < 0.05). One-year weight loss success was higher for P than G, regardless of operation type. CONCLUSION: Pay status should be included in characterization of patient groups and in the analysis of results when effectiveness of surgical treatment for severe obesity is reported.

Rationale for the Surgical Treatment of Severe Obesity.

Rationale for the Surgical Treatment of Severe Obesity.

Obesity: The Role of Gastric Surgery

To the Editor. —The Grand Rounds at the Clinical Center of the National Institutes of Health (NIH) by Dr Wilber entitled Neural peptides, appetite regulation, and human obesity1 that appeared inJAMAfailed to describe gastric surgery for the management of severe obesity in the treatment section. This topic was recently discussed at a Consensus Panel on the Surgical Treatment of Severe Obesity at the NIH at which it was concluded that gastric surgery is appropriate for patients who have a body mass index of less than 40 without comorbidity and that patients who have significant comorbidity and a body mass index of 35 to 40 should be considered as candidates for the procedure. Clearly, this has had the most effective long-term efficacy in the management of severe obesity with the data now showing the average loss of excess weight between 50% to 60% for as long as 10 years

Regional fat aspiration for body contouring.

Our experience with the original suction lipectomy is presented. The fat removal, done with a specially designed suction tube, is performed layerwise, creating a continuous, regular cavity that is transformed into a virtual space by compressive dressings. The main indication being excessive peritrochanteric fat pads, the operation is done under either epidural or general anesthesia. No antibiotics or anticoagulants are administered, and the patients are mobilized as soon as fully awake. Practicing suction-assisted lipectomy for more than seven years, we have never observed an infection, thrombosis, or fat embolism. In experienced hands, good results can be expected in about 80 percent of patients. Complications are almost always of an aesthetic nature as a result of bad indications. The method is not a surgical treatment for severe obesity.