Treatment Of Extreme Obesity Research Articles

Economic Evaluation of Surgical Treatment of Obesity

IntroductionObesity surgery is the best treatment for extreme obesity, with demonstrated long-term positive outcomes. The potential cost-savings generated by the improvement of comorbidities after surgery can justify the allocation of more resources in the surgical treatment of obesity. MethodsThis was an observational, descriptive, longitudinal and retrospective study. Eligible patients underwent Roux-en-Y gastric bypass surgery at the Hospital Universitario Central de Asturias between 2003 and 2012. The established minimum follow-up period was two years. We calculated the individualized cost per patient treated (bottom-up) as well as per Diagnosis-Related Group (DRG) codes (top-down). ResultsOur study included 307 patients. The average cost per hospitalization calculated by DRG codes was €6545.90, and the average cost per patient was €10572.20. DRG 288 represented 91% of the series, with a value of €4631. The number of medications also decreased during this period, from 2.86 to 0.78 per medically treated patient, representing a cost reduction of €4433 per patient with all the obesity-related comorbidities analyzed. ConclusionsTwo years after Roux-en-Y gastric bypass conducted at Hospital Universitario Central de Asturias, the savings in drug costs for patients with multiple pathologies would compensate the inherent costs of the surgical treatment itself. Our results showed that DRG-related costs were insufficient to make a correct economic evaluation, so we recommend an individualized cost calculating method.

Evaluación económica del tratamiento quirúrgico de la obesidad

IntroductionObesity surgery is the best treatment for extreme obesity, with demonstrated long-term positive outcomes. The potential cost-savings generated by the improvement of comorbidities after surgery can justify the allocation of more resources in the surgical treatment of obesity. MethodsThis was an observational, descriptive, longitudinal and retrospective study. Eligible patients underwent Roux-en-Y gastric bypass surgery at the Hospital Universitario Central de Asturias between 2003 and 2012. The established minimum follow-up period was two years. We calculated the individualized cost per patient treated (bottom-up) as well as per Diagnosis-Related Group (DRG) codes (top-down). ResultsOur study included 307 patients. The average cost per hospitalization calculated by DRG codes was €6,545.90, and the average cost per patient was €10,572.20. DRG 288 represented 91% of the series, with a value of €4,631. The number of medications also decreased during this period, from 2.86 to 0.78 per medically treated patient, representing a cost reduction of €4,433 per patient with all the obesity-related comorbidities analyzed. ConclusionsTwo years after Roux-en-Y gastric bypass conducted at Hospital Universitario Central de Asturias, the savings in drug costs for patients with multiple pathologies would compensate the inherent costs of the surgical treatment itself. Our results showed that DRG-related costs was insufficient to make a correct economic evaluation, so we recommend an individualized cost calculating method.

Changes in weight, physical activity and its theory-based psychosocial correlates within an adolescent bariatric clinic: contrasts with adults with extreme obesity.

Albeit their practical implications, psychosocial correlates of physical activity and related weight loss in the treatment of extreme obesity have been only sparsely addressed in adults; and even more minimally focused upon in adolescents. This research contrasted results of a 6-month social cognitive theory-based physical activity-support protocol along with standard nutrition counseling in groups of adolescents (n = 19; agemean = 15.4 years) and adults (n = 26, agemean = 44.7 years) with class 3 (extreme) obesity [overall body mass index (BMI)mean = 53.4 kg/m2, standard deviation (SD) = 8.2]. Although baseline total mood disturbance scores were significantly greater in both groups when contrasted with age-corresponding normative values, between-group scores did not significantly differ. BMI and physical activity changes over 3 and 6 months were significantly more favorable in the adult group. There were significant overall improvements in exercise self-efficacy, physical activity self-regulation and total mood disturbance scores, however, the self-efficacy and self-regulation increases were significant in only the adult group. Inverse relationships between changes in physical activity and BMI were stronger in the adult group. Regardless of group, simultaneous entry of changes in exercise self-efficacy, physical activity self-regulation and total mood disturbance scores, over both 3 and 6 months, significantly predicted physical activity changes (R2-values = 0.45-0.75, p-values < 0.001). In each model, self-regulation change was the most salient of those three psychosocial predictors. Although findings suggested that psychosocial correlates of physical activity, leading to weight change, are similar in adolescents and adults with extreme obesity, facilitation of larger effect sizes and/or foci on additional theory-based determinants may be required for clinically meaningful treatment outcomes in adolescents.

A rare case of gastric outlet syndrome: internal incarceration after removal of gastric banding

The laparoscopically administrated adjustable gastric banding used to be widely practiced as treatment of extreme obesity. As lots of complaints and complications arose sooner or later after this procedure, they had to be removed quite often. Half year after such a removal we observed a 37-year-old female patient with complete gastric outlet obstruction. The patient was operated and cured completely. The cause of gastric obstruction was an internal incarceration of the pyloric region between the plication made at the time of the ring removal and the gastric body. We found no similar case of gastric outlet obstruction in the corresponding literature.

Perioperative Safety in the Longitudinal Assessment of Bariatric Surgery

To improve decision making in the treatment of extreme obesity, the risks of bariatric surgical procedures require further characterization. We performed a prospective, multicenter, observational study of 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical sites in the United States from 2005 through 2007. A composite end point of 30-day major adverse outcomes (including death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; and failure to be discharged from the hospital) was evaluated among patients undergoing first-time bariatric surgery. There were 4776 patients who had a first-time bariatric procedure (mean age, 44.5 years; 21.1% men; 10.9% nonwhite; median body-mass index [the weight in kilograms divided by the square of the height in meters], 46.5). More than half had at least two coexisting conditions. A Roux-en-Y gastric bypass was performed in 3412 patients (with 87.2% of the procedures performed laparoscopically), and laparoscopic adjustable gastric banding was performed in 1198 patients; 166 patients underwent other procedures and were not included in the analysis. The 30-day rate of death among patients who underwent a Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding was 0.3%; a total of 4.3% of patients had at least one major adverse outcome. A history of deep-vein thrombosis or pulmonary embolus, a diagnosis of obstructive sleep apnea, and impaired functional status were each independently associated with an increased risk of the composite end point. Extreme values of body-mass index were significantly associated with an increased risk of the composite end point, whereas age, sex, race, ethnic group, and other coexisting conditions were not. The overall risk of death and other adverse outcomes after bariatric surgery was low and varied considerably according to patient characteristics. In helping patients make appropriate choices, short-term safety should be considered in conjunction with both the long-term effects of bariatric surgery and the risks associated with being extremely obese. (ClinicalTrials.gov number, NCT00433810.)

Message from Griffin P. Rodgers, M.D., M.A.C.P., Director, NIDDK, on the Institute’s Obesity Research

Message from Griffin P. Rodgers, M.D., M.A.C.P., Director, NIDDK, on the Institute’s Obesity Research

Mayo Clinic Proceedings 2007: Enriching Our Service to Authors and Readers

Mayo Clinic Proceedings 2007: Enriching Our Service to Authors and Readers

Bariatric surgery for pediatric extreme obesity: now or later?

Obesity is a multifactorial disease of epidemic and global proportions that poses the most significant threat to the health of our younger generations. Those who are the most extremely affected bear the largest burden of health problems. In the US, extreme obesity affects approximately 9 million adults and 2 million children, and is associated with both immediate health problems and later health risk, including premature mortality. Present medical and behavioral interventions for extreme obesity in adults and children rarely result in the significant, durable weight loss necessary to improve health outcomes, prompting a search for more aggressive measures. Weight loss (bariatric) surgery has been advocated as an intervention for those with extreme obesity. In adults, bariatric surgery results in prolonged weight control and improvement in serious obesity comorbidities, namely type 2 diabetes, dyslipidemias, hypertension and obstructive sleep apnea syndrome. A surge in weight loss operations for adolescents has been observed recently, with a threefold increase in case volumes nationwide from 2000 to 2003. Current evidence suggests that after bariatric surgery, adolescents lose significant weight and serious obesity-related medical conditions and psychosocial status are improved. Thus it is reasonable to propose that bariatric surgery performed in the adolescent period may be more effective treatment for childhood-onset extreme obesity than delaying surgery for extremely obese youth until adulthood. This position has been echoed by a number of groups and an independent systematic review. Finally, it is conceivable that bariatric surgery performed in adulthood for childhood onset extreme obesity may not be as effective for comorbidity treatment as surgery performed earlier during adolescence. The purpose of this review is to examine the evidence, which supports early rather than later use of bariatric surgery in the treatment of extreme obesity, and to present this information in light of the medical and surgical risks of bariatric surgery.

Perioperative Care of Patients Undergoing Bariatric Surgery

The epidemic of obesity in developed countries has resulted in patients with extreme (class III) obesity undergoing the full breadth of medical and surgical procedures. The popularity of bariatric surgery in the treatment of extreme obesity has raised awareness of the unique considerations in the care of this patient population. Minimizing the risk of perioperative complications that contribute to morbidity and mortality requires input from several clinical disciplines and begins with the preoperative assessment of the patient. Airway management, intravenous fluid administration, physiologic responses to pneumoperitoneum during laparoscopic procedures, and the risk of thrombotic complications and peripheral nerve injuries in extremely obese patients are among the factors that present special intraoperative challenges that affect postoperative recovery of the bariatric patient. Early recognition of perioperative complications and education of the patient regarding postoperative issues, including nutrition and vitamin supplementation therapy, can improve patient outcomes. A suitable physical environment and appropriate nursing and dietetic support provide a safe and dignified hospital experience. This article reviews the multidisciplinary management of extremely obese patients who undergo bariatric surgery at the Mayo Clinic.

Surgical treatmentof extreme obesity

The Surgeon General has identified obesity as a leading threat to public health in the United States. It is associated with a wide variety of chronic diseases, which are exacerbated by increasing degrees of overweight. Starting points for treatment of obesity include diet, exercise, and behavioral therapy. Medication can be added to help effect weight loss. However, there is a growing consensus that weight reducing (bariatric) surgery is the treatment of choice for extremely obese individuals who have failed to reduce their weight through dietary, behavioral, and pharmacologic interventions. The two operations that have been most widely used in the United States are vertical banding gastroplasty and Roux-en-Y gastric bypass. Between these, gastric bypass appears to have better long-term effectiveness in reducing weight and managing comorbidities related to obesity. More important than enabling the patient to reach an ideal body weight, bariatric surgery can be very effective in ameliorating, or even resolving, obesity-related diseases.

Surgical Treatment for Extreme Obesity: Evolution of a Rapidly Growing Field

Surgical Treatment for Extreme Obesity: Evolution of a Rapidly Growing Field

S‐Tryptophan Concentrations after Intestinal Bypass in extreme Obesity

Treatment of extreme obesity with jejunoileostomy was followed by a decreased level of S-tryptophan; permanently low concentrations were recorded postoperatively in 29 out of 52 patients. Patients in the low tryptophan group had a higher rate of weight loss and a hgiehr incidecnce of electrolyte disturbances and signs of liver injury. Symptoms of depression and anxiety were slightly more common in patients with low S-tryptophan. The influence of a decreased S-albumin and a deranged amino acid pattern on the non-protein-bound fraction of S-tryptophan needs further investigation. Serum levels of tryptophan rose significantly after rwo weeks' oral supplementation with 1.2 g L-tryptophan daily; this dosage was insufficient to normalize a low S-tryptophan level in patients who have undergone jejunoileostomy.