Treatment Of Severe Obesity Research Articles

Perioperative Outcomes of Laparoscopic Adjustable Gastric Banding in Mildly Obese (BMI < 35 kg/m2) Compared to Severely Obese

Laparoscopic adjustable gastric banding (LAGB) has become a standard restrictive procedure in the USA for the treatment of severe obesity (body mass index, BMI > 35 kg/m(2)). Mildly obese individuals (BMI < 35 kg/m(2)) are also at increased risk from obesity-related conditions. Recently, an FDA panel supported its use in this subgroup. We compared the perioperative outcomes of LAGB in mildly and severely obese. Thirty consecutive patients (mildly obese n=10; severely obese n=20) that underwent preoperative medical weight loss followed by LAGB procedures were prospectively evaluated. Outcome variables included: operative room (OR) time, intraoperative estimated blood loss (EBL), length of hospital (LOS), and intensive care unit (ICU) stay, reoperations, readmissions, 30-day morbidity and mortality. Demographic data was comparable between groups. BMI was significantly higher in the severely obese compared to mildly obese (44.0 ± 5 vs. 33.6 ± 1 kg/m(2)). OR time, EBL, LOS, and ICU admissions were similar between BMI groups. There were no reoperations or 30-day mortality in either group. Minor morbidity was only observed in the severely obese group. BMI correlated with OR time and EBL. In mildly obese, LAGB is as safe as in the severely obese with no perioperative morbidity. The perioperative outcomes and hospital resource utilization are comparable between BMI groups. Lower BMI is associated with lower operative times and blood loss.

Effectiveness of surgical weight loss on the remission of type 2 diabetes mellitus: A systematic review

Effectiveness of surgical weight loss on the remission of type 2 diabetes mellitus: A systematic review

Reversible Gastric Restriction Implant: Safety and Efficacy in a Canine Model

Gastric restrictive procedures are considered effective weight loss treatment for severe obesity. The aim of the study was to evaluate the efficacy and safety of a reversible implant that renders a partial restriction of stomach in a canine model. The device was comprised of two longitudinal parallel non-compressive plates with two C-rings to create a small gastric pouch that opposed gastric distension. Three groups of non-obese mongrel dogs were included: group I (n = 6) underwent surgical implant for 6 weeks, group II (n = 6) underwent surgical implant for 6 weeks, followed by surgical removal of the implant and additional monitoring for 5 weeks, and group III (n = 5) served as sham-operated controls for groups I and II. Food intake and body weight were monitored, and the stomachs were examined histologically postmortem. The average food intake was significantly decreased by 38.2% in group I as compared to group III throughout the 6 weeks of surgical implant (P < 0.05). The implanted dogs showed a progressive weight loss as compared to sham, which reached 21% by the end of 6 weeks. In group II, after 5 weeks of implant removal, the body weights recovered to approximately 96% of baseline. Histological evidence of the implant site at the gastric walls revealed no significant structural changes, tissue ischemia, hemorrhage, or necrosis. Our results validate the feasibility of a reversible gastric restriction implant in a non-obese canine model, with the potential for achieving significant weight loss within 6 weeks and with no injury to the gastric wall.

PL-218: Laparoscopic gastric plication for the treatment of severe obesity

PL-218: Laparoscopic gastric plication for the treatment of severe obesity

Glucose Tolerance in the Proximal Versus the Distal Small Bowel in Wistar Rats

Type 2 diabetes is an epidemic and insulin resistance is the central etiology of this disease. Obesity increases insulin resistance and glucose intolerance and also exacerbates metabolic abnormalities present in type 2 diabetes. Bariatric surgery is the most effective treatment for severe obesity. Most reported series show that return to euglycemia and normal insulin levels occur days after gastric bypass and biliopancreatic diversion, long before major weight loss has taken place. The mechanisms underlying this dramatic reversal of type 2 diabetes following these bariatric procedures are not well understood. Twelve Wistar rats were fed with a palatable hyperlipidic diet for 12 weeks. Body weight, glucose, and intraperitoneal glucose tolerance test were measured regularly. On day 91, they were randomized in two groups (hindgut and controls) and operated. Twenty-one days later, the tests were done again and the hindgut group re-operated. A duodenal exclusion was done. The results of an intraperitoneal glucose tolerance test were compared after the procedures. Body weight increased regularly in all the rats. Some rats developed hyperglycemia 28 days after beginning hyperlipidic diet, but these levels returned to baseline on days 56 and 84. The glucose tolerance test showed an improvement in glycemic levels in the hindgut group 21 days after the first operation (151 +/- 21mg/dl). After the second operation, despite weight loss, the glucose tolerance test of the foregut group worsened again (267 +/- 53 mg/dl) (p < 0.01). Comparing the "hindgut hypothesis" and the "foregut hypothesis", our data show an improvement in the 30 min glucose tolerance test in the hindgut group.

Sleeve Gastrectomy as Treatment for Severe Obesity after Orthotopic Liver Transplantation

Obesity is highly prevalent in both liver transplant candidates and recipients, and can have a significant impact on perioperative morbidity and mortality and the overall cost of transplantation. Herein, we describe an obese patient who was managed sequentially with an intragastric balloon in the pre-transplant setting and a gastric sleeve following transplantation, with good long-term results. Sleeve gastrectomy is a non-malabsorptive bariatric procedure with potential benefit for liver transplant patients due to its lack of influence on the absorption of immunosuppressive agents.

One hundred–pound weight losses with an intensive behavioral program: changes in risk factors in 118 patients with long-term follow-up"

Background: Treatment of severe obesity is difficult; in the past, lifestyle measures did not prove effective. Recently, however, intensive behavioral interventions using meal replacements and low-energy diets have enabled some severely obese persons to achieve nonobese weights.Objective: We assessed rates of weight loss, changes in risk factors and medication requirements, and long-term weight maintenance in patients who lost ≥100 pounds (45.5 kg).Design: Over a 9-y period, we prospectively identified patients who lost ≥100 pounds (45.5 kg) and actively recorded follow-up weights. Charts were systematically reviewed to assess outcome measures and side effects. The intervention included meal replacements (shakes and entrées), low-energy diets, weekly classes, and training in record keeping and physical activity. Assessments included weekly weights, laboratory studies, medication use, lifestyle behaviors, side effects, and follow-up weights.Results: Sixty-three men and 55 women lost ≥100 pounds. At baseline, the subjects' average weight was 160 kg, 97% had ≥1 obesity-related comorbidity, and 74% were taking medications for comorbidities. Weight losses averaged 61 kg in 44 wk. Medications were discontinued in 66% of patients with a cost savings of $100/mo. Despite medication discontinuation, significant decreases in LDL cholesterol (20%), triacylglycerol (36%), glucose (17%), and systolic (13%) and diastolic (15%) blood pressure values were seen. Side effects were mild, and only 2 patients had severe or serious adverse events. At an average of 5 y of follow-up, patients were maintaining an average weight loss of 30 kg.Conclusion: Intensive behavioral intervention can be very effective with minimal risk for certain severely obese persons.

Perioperative management of the bariatric surgery patient: focus on cardiac and anesthesia considerations.

Obesity is a major public health problem in developed nations worldwide. Currently, the only treatment for severe obesity (BMI > or = 35 kg/m2 with comorbidity) that provides long-term weight loss is bariatric surgery. Restrictive, malabsorptive, and combination procedures have been developed. Each type of procedure has its merits and unique set of risks and complications. Weight loss after bariatric surgery is accompanied by predictable improvement or resolution of obesity-related comorbidities and improved quality of life and life expectancy. Candidates for bariatric surgery are often at high risk for complications because of obesity-related comorbidities. Therefore, careful patient selection for bariatric surgery, together with well-designed strategies for preventing and managing complications, are keys to success. Close monitoring for nutritional deficiencies and short- and long-term complications is required to completely assess outcomes of these procedures.

Quality Control of Bariatric Surgery

Bariatric surgery is the only effective treatment for severe obesity and the associated comorbidities, an increasingly common syndrome that afflicts eight million Americans who have a body mass index (BMI) >40. Currently less than one percent of these individuals have access to the surgery that could free them of diabetes, sleep apnea, cardiopulmonary failure, pseudotumor cerebri, and sharply improve their crippling arthritis. There are a number of reasons for this failure to deliver the care to those who need it, but one is that the quality of bariatric surgery is uneven. To improve the delivery of bariatric surgery with efficacy, efficiency, and safety, the American Society for Bariatric Surgery founded the Surgical Review Corporation as an independent non-profit organization to recognize Centers of Excellence based on their outcomes. The results of this initiative have been impressive, with the delivery of bariatric surgery to 33,117 patients with a mortality rate of 0.3% and a readmission rate of 4.5%...

A Rat Model of Restrictive Bariatric Surgery with Gastric Banding

Gastric banding is a well established weight reduction operation that is effective in the treatment of severe obesity. Its metabolic and endocrine mechanisms of action, however, remain unclear. The aim of this study was to establish a rat model of gastric banding that would replicate the procedure performed in human obese patients. Male Wistar rats were submitted either to gastric banding (n=5) or sham gastric banding (n=4), and were followed for 21 days. Detailed description on how to perform gastric banding in rats are herein described. The Wistar rats submitted to gastric banding showed a decrease in weight gain and food intake when compared to sham-operated rats. The cumulative weight gain during the 21 days after the surgical procedure was 143+/-2.58 g for the gastric banded rats and 162+/-2.48 g for the sham-operated animals (P=0.001). The cumulative food intake was 329+/-0.53 g for the gastric banded rats and 380+/-15.22 g for the sham-operated animals, also statistically significant (P=0.025). A rat model to study gastric banding is described. This model can now be used for experimental investigation of biochemical and molecular mechanisms of weight loss resulting from this type of surgery.

What Plastic Surgeons Should Know about Bariatric Surgery

Bariatric surgery is the current standard treatment for severe obesity. A variety of procedures are currently performed, which provide durable and rapid weight loss through malabsorption, restriction, or a combination of the two. The significant amelioration of obesity-associated comorbidities has been demonstrated. Laparoscopic techniques in bariatric surgery provide patients with decreased morbidity and faster recovery, with an equivalent amount of weight loss. Weight loss is dramatic and progressive until a plateau is reached. Patients often seek the services of a plastic surgeon to remove the excess lax skin and improve the ptosis associated with such massive weight loss.

Bariatric surgery in the field of gynecological oncology

Obesity has become a foremost health problem. More than half of US adults are overweight or obese. This has been due to sedentary lifestyles, increased intake of refined carbohydrates, and fat-rich diets. Obese women are particularly susceptible to a variety of health risks including cancer, especially cancers of the breast, endometrium, and colon. Bariatric surgery appears to be a viable option for the treatment of severe obesity. As the role of surgery in the management of this condition becomes increasingly frequent, it is important for gynecological oncologists to recognize the potential for gynecological malignancies in this patient population.

The Application of Laparoscopic Bariatric Surgery for Treatment of Severe Obesity in Adolescents Using a Multidisciplinary Adolescent Bariatric Program

The evolution of laparoscopic surgery has made bariatric surgery acceptable for weight loss; however, much controversy exists about its appropriateness for adolescents. Despite the controversial issues, the growing epidemic in adolescent obesity has resulted in rising numbers of applications for bariatric surgery. There are few bariatric surgical programs designed for adolescents. Pediatric settings face high start-up costs and poor reimbursement and lack established bariatric surgeons. Even so, bariatric surgery is increasingly being performed on adolescents in alarming numbers. To avoid adverse physical and psychosocial outcomes, the application of the principles of growth and development is essential. The program should be established as a multidisciplinary approach to management of adolescents and should be in institutions capable of meeting the guidelines for surgical treatment outlined by the American Society of Bariatric Surgery. To prevent postoperative complication, a multidisciplinary team of experienced medical and surgical specialists is needed for optimal preoperative decision making and postoperative management and long-term follow-up. Laparoscopic Roux-en-Y gastric bypass is a safe procedure and an effective means to treat obesity-related morbidity in the adolescent. Results have been excellent and justify a clinical trial to confirm the safety and efficacy of bariatric surgery in the adolescent population.

Effectiveness and cost-effectiveness of Swedish adjustable gastric banding versus conservative therapy in treatment of severe obesity

Effectiveness and cost-effectiveness of Swedish adjustable gastric banding versus conservative therapy in treatment of severe obesity

Surgery for Weight Loss: Effects on the Reproductive Health of Women

Clinicians are being faced with increasing numbers of women undergoing surgical procedures for the treatment of severe obesity. Patients who are

The cost-effectiveness of bariatric surgery.

The purpose of the study was to estimate the cost-effectiveness of gastric bypass in the treatment of severe obesity (body mass index > 40). A deterministic decision analysis that compared the lifetime expected costs and outcomes between open gastric bypass and no treatment of severe obesity from the payer perspective was performed. Men and women between the ages of 35 and 55 yr, with body mass index between 40 and 50 kg/m(2), who did not have cardiac disease and who failed conservative treatment, including pharmacotherapy, were included. Cost-effectiveness ratio of the base case conditions was made with parameter estimates from the literature and expert discussion and expressed as cost per quality-adjusted life-years (QALY). One- and two-way sensitivity analyses were performed on selected variables. Gastric bypass was not cost-saving, because the reduction in lifetime medical costs was less than the cost of treatment in any subgroup. The base case cost-effectiveness ratios ranged from 5,400 US dollars to 16,100 US dollars for women and from 10,700 US dollars to 35,600 US dollars per QALY for men. Sensitivity analysis demonstrated that in older, less obese men, the cost effectiveness ratio was responsive to the amount of weight lost, obesity-related quality of life, and complication rates. Parameter variation did not significantly affect cost-effectiveness ratios in the remaining patients. The authors concluded that gastric bypass is a cost-effective alternative to no treatment in the severely obese, at less than 50,000 US dollars per QALY.

The cost-effectiveness of bariatric surgery: Craig BM, Tseng DS. Cost-Effectiveness of Gastric Bypass for Severe Obesity, Am J Intern Med 2002;113:491–8

The purpose of the study was to estimate the cost-effectiveness of gastric bypass in the treatment of severe obesity (body mass index > 40). A deterministic decision analysis that compared the lifetime expected costs and outcomes between open gastric bypass and no treatment of severe obesity from the payer perspective was performed. Men and women between the ages of 35 and 55 yr, with body mass index between 40 and 50 kg/m 2, who did not have cardiac disease and who failed conservative treatment, including pharmacotherapy, were included. Cost-effectiveness ratio of the base case conditions was made with parameter estimates from the literature and expert discussion and expressed as cost per quality-adjusted life-years (QALY). One- and two-way sensitivity analyses were performed on selected variables. Gastric bypass was not cost-saving, because the reduction in lifetime medical costs was less than the cost of treatment in any subgroup. The base case cost-effectiveness ratios ranged from $5,400 to $16,100 for women and from $10,700 to $35,600 per QALY for men. Sensitivity analysis demonstrated that in older, less obese men, the cost effectiveness ratio was responsive to the amount of weight lost, obesity-related quality of life, and complication rates. Parameter variation did not significantly affect cost-effectiveness ratios in the remaining patients. The authors concluded that gastric bypass is a cost-effective alternative to no treatment in the severely obese, at less than $50,000 per QALY.

Cognitive behavioral interventions in the management of severe pediatric obesity

The prevalence of pediatric obesity has increased significantly, and the greatest increase in prevalence has occurred among the heaviest children. Severe pediatric obesity is associated with higher rates of medical and psychosocial morbidity than is milder obesity. Although the efficacy of family-based behavioral weight control programs in the treatment of moderate pediatric obesity is well established, there is little information on the treatment of severe obesity. We believe that family-based cognitive behavioral interventions, which focus on increasing healthy eating behaviors and physical activity and decreasing unhealthy eating and sedentary behaviors, are critical for these children. Treatment adaptations that address inappropriate eating among children, peer teasing, and poor body image also are useful in managing this high-risk population.

Medical and surgical options in the treatment of severe obesity

Weight loss programs, diets, and drug therapy have not shown long-term effectiveness in treating morbid obesity. A 1992 statement from the National Institutes of Health Consensus Development Conference affirmed the superiority of surgical over nonsurgical approaches to this condition. Bariatric surgical procedures work in 1 of 2 ways: by restricting a patient’s ability to eat ( restrictive procedures) or by interfering with ingested nutrient absorption ( malabsorptive procedures). Many of these procedures can be performed by a laparoscopic approach, which has been shown to reduce operative morbidity. In the United States, the primary operative choice for morbidly obese patients has recently shifted from vertical banded gastroplasty (VBG) to the Roux-en-Y gastric bypass (RYGBP). VBG, a purely restrictive procedure, has fallen into disfavor because of inadequate long-term weight loss. RYGBP combines restriction and malabsorption principles, and has been shown to induce greater weight loss than VBG. Other procedures currently being offered include laparoscopic adjustable gastric banding; biliopancreatic diversion (BPD), including the duodenal switch (BPD-DS) variation; and distal gastric bypass (DGBP). Laparoscopic adjustable gastric banding with the LAP-BAND system (INAMED Health, Santa Barbara, CA), a restrictive procedure involving placement of a silicone band around the upper stomach, was introduced in the early 1990s and approved by the US Food and Drug Administration for use in the United States in June 2001. Outside the United States, LAP-BAND surgery is the most commonly performed operation for severe obesity. The BPD, BPD-DS, and DGBP are all malabsorptive procedures offered primarily by laparotomy. They have been shown to induce good long-term weight loss but have a higher rate of adverse nutritional complications. Many safe and effective surgical options for severe obesity are available. More scientific appraisals comparing different procedures and open and laparoscopic approaches are needed.

Cost-effectiveness of gastric bypass for severe obesity

Purpose To estimate the cost-effectiveness of gastric bypass in the treatment of severe obesity. Subjects and methods We performed a cost-effectiveness analysis of gastric bypass versus no treatment from the payer perspective. We discounted quality-adjusted life-years (QALYs), life-years, and cost during the patient’s lifetime. Our target group comprised women and men aged 35 to 55 years with a body mass index between 40 and 50 kg/m 2, and who did not have cardiovascular disease and in whom conservative bariatric therapies had been unsuccessful. Results The base case cost-effectiveness ratios ranged from $5000 to $16,100 per QALY for women and from $10,000 to $35,600 per QALY for men, depending on age and initial body mass index. In a few subgroups of older, less obese men, variation in parameters such as loss of excess weight, obesity-related quality of life, complication rates, and perioperative mortality affected the cost-effectiveness ratios. Parameter variation did not result in meaningful changes in the remaining patients. Conclusion Gastric bypass is a cost-effective alternative to no treatment, providing substantial lifetime benefits in patients who are severely obese.