Undergoing Weight Loss Surgery Research Articles

Reductions in cardiovascular risk after bariatric surgery

Obesity is commonly associated with multiple conditions imparting adverse cardiovascular risk, including hypertension, dyslipidemia, and insulin resistance or diabetes. In addition, sleep disordered breathing, inflammation, left ventricular hypertrophy, left atrial enlargement, and subclinical left ventricular systolic and diastolic dysfunction may collectively contribute to increased cardiovascular morbidity and mortality. This review will describe improvements in cardiovascular risk factors after bariatric surgery. All of the cardiovascular risk factors listed above are improved or even resolved after bariatric surgery. Cardiac structure and function also have shown consistent improvement after surgically induced weight loss. The amount of improvement in cardiac risk factors is generally proportional to the amount of weight lost. The degree of weight loss varies with different bariatric procedures. On the basis of the improvement in risk profiles, it has been predicted that progression of atherosclerosis could be slowed and the 10-year risk of cardiac events would decline by ~50% in patients undergoing weight loss surgery. In keeping with these predictions, two studies have demonstrated reductions in 10-year total and cardiovascular mortality of approximately 50% in patients who had bariatric surgery. These encouraging data support the continued, and perhaps expanded, use of surgical procedures to induce weight loss in severely obese patients.

Perioperative Management of Morbid Obesity

Data from the NHS Information Centre reveals that more than one in three adults (36.9%) is overweight. In addition, almost a quarter of adults (24% of men and 25% of women aged 16 or over) are obese, with their need for treatment placing a growing burden on the NHS (The NHS Information Centre 2010). Given these proportions, and that an increasing number of morbidly obese patients are undergoing weight loss surgery and procedures related to obesity, it is an opportune time to review the perioperative care of morbidly obese patients.

Postoperative epidural analgesia in patients undergoing weight loss surgery: Does the addition of morphine to low (0.1%) or high dose (0.2%) levo-bupivacaine improve ambulation and bowel function?

s and Programme: EUROANAESTHESIA 2011: The European Anaesthesiology Congress: Intensive Care Medicine

Effect of Weight Loss After Weight Loss Surgery on Plasma N-Terminal Pro-B-Type Natriuretic Peptide Levels

Natriuretic peptides have multiple beneficial cardiovascular effects. Previous cross-sectional studies have indicated that obese subjects have lower natriuretic peptide concentrations than those of normal weight. It is not known whether this relative natriuretic peptide deficiency is reversible with weight loss. We studied 132 obese subjects undergoing weight loss surgery with serial measurement of plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations at preoperative, early (1 to 2 months), and late postoperative (6 months) points. In addition, 20 subjects also underwent echocardiography at baseline and 6 months after surgery. Significant weight loss was observed after surgery (median body mass index 45.1, 41.0, and 32.9 kg/m(2) for the 3 corresponding points, analysis of variance p <0.001). The median NT-proBNP levels increased substantially (31.6, 66.9, and 84.9 pg/ml; p <0.001). The average intrasubject increase in NT-proBNP at the 2 postoperative points was 3.4 and 5.0 times the preoperative level (p <0.001 for both points vs preoperatively). In the multivariate regression models adjusted for clinical characteristics and insulin resistance, the strongest predictor of the change in NT-proBNP level 6 months after weight loss surgery was the change in weight (p = 0.03). Echocardiography showed a mean intrasubject reduction in left ventricular mass index of 18% (p <0.001) and mild improvements in diastolic function, with no change in ejection fraction. In conclusion, we have demonstrated that weight loss is associated with early and sustained increases in NT-proBNP concentrations, despite evidence of preserved systolic and improved diastolic function. These findings suggest a direct, reversible relation between obesity and reduced natriuretic peptide levels.

Bariatric Surgery Outcomes in Patients Aged 65 Years and Older at an American Society for Metabolic and Bariatric Surgery Center of Excellence

Although morbid obesity rates in patients >or=65 years of age are increasing, few centers have reported weight loss surgery outcomes in elderly patients, resulting in a paucity of literature on perioperative mortality and morbidity. A retrospective analysis was performed on 197 consecutive patients >or=65 years old who underwent weight loss surgery from January 2000 to December 2007. Primary data points included 30-day and 1-year mortality rates, length of stay (LOS), percent excess weight loss (EWL), change in daily medication use, and quality of life (QOL). The average patient's age was 67.3 years with 72.1% being female. Average preoperative weight and BMI were 131.9 kg and 48.1 kg/m(2), respectively. Average preoperative daily medication use was 8.04 +/- 3.67. Procedure types included Roux-en-Y gastric bypass (79.3%), adjustable gastric banding (17.2%), and vertical sleeve gastrectomy (3%). Ninety-seven percent of procedures were performed laparoscopically. Average LOS was 2.0 +/- 2.1 days. Average weight, BMI, and daily medication use were significantly reduced at 6 months and 1 year (p < 0.001), with patients achieving an average EWL of 44.5% and 55.3% at 6 months and 1 year, respectively. QOL scores improved at 6 months (p < 0.001) and 1 year (p = 0.049). In all patients, the 30-day mortality rate was 0%. The 1-year mortality rate for RYGB patients was 1.3%. Complication rates were acceptable, with 7% of RYGB patients experiencing a major postoperative complication. Weight loss surgery is effective in patients >or=65 years of age, producing significant EWL, reduction in daily medication use, and improvement in QOL. Surgery is also associated with a low mortality rate and an acceptable morbidity profile.

Tumor growth factor expression in obesity and changes in expression with weight loss: another cause of increased virulence and incidence of cancer in obesity

Background Obesity is associated with increased tumerogenesis. Previously, we demonstrated that inflammation in obesity caused cancer fighting cells to display greater surface receptor levels, predisposing them to early cell death. We measured the inflammatory tumor growth factor levels to determine whether inflammation in obesity increases expression of these factors, potentially predisposing these patients to greater rates of neoplasia. Methods A total of 24 patients undergoing weight loss surgery had samples collected preoperatively and at 6 and 12 months after surgery. The growth factors analyzed included tumor necrosis factor (TNF)-α, granulocyte-macrophage colony-stimulating factor, interferon-γ, interleukin (IL)-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, vascular endothelial growth factor, hepatocyte growth factor, TNF-receptor I (TNF-RI), TNF-RII, death receptor 5, leptin, and adiponectin. Control samples were obtained from 10 healthy, normal weight volunteers. Results The tumor growth factors TNF-α, TNF-RI, TNF-RII, vascular endothelial growth factor, hepatocyte growth factor, interferon-γ, IL-2, IL-5, and IL-6 all decreased significantly ( P <.05) compared with the preoperative values. The IL-4, IL-8, leptin, death receptor 5, adiponectin, and granulocyte-macrophage colony-stimulating factor levels did not change significantly over time. The IL-1b and IL-10 levels were less than the detection limit at all points. When obese patient serum was compared with healthy volunteer pooled serum, we found that the leptin, death receptor 5, hepatocyte growth factor, vascular endothelial growth factor, TNF-RI, TNF-RII, TNF-α, IFN-γ, granulocyte-macrophage colony-stimulating factor, IL-4, IL-5, IL-6, and IL-8 levels were all 2–37 times greater than the levels in the controls at baseline. The concentrations of these same growth factors had decreased levels only 1–3.5 times greater than those of the controls at 12 months postoperatively. Conclusion Many inflammatory tumor growth factors are present in greater concentrations in obese individuals. This could explain the greater prevalence of neoplasia in the morbidly obese population.

History of substance abuse relates to improved postbariatric body mass index outcomes

BackgroundRecent clinical guidelines have identified current alcohol or substance abuse as contraindications for weight loss surgery. Past research has indicated that a lifetime history of any substance use disorder is significantly greater in those seeking weight loss surgery than the population base rate. However, current substance abuse has been reported to be remarkably low (<1%). The objective was to examine whether a history of substance abuse/dependence is associated with differing weight loss outcomes after bariatric surgery. MethodsA total of 413 patients who had undergone weight loss surgery (75.8% women, 77.7% white, mean age 47.72 years, mean body mass index 50.27 kg/m2) at the Cleveland Clinic Bariatric and Metabolic Institute completed a psychological evaluation before surgery, and a history of substance abuse and/or dependence was determined. ResultsA series of analyses of covariance examining group differences in the percentage of excess weight loss (%EWL) at 1, 3, 6 , 9, and 12 months after surgery were conducted comparing a history of substance abuse/dependence (SA+; n = 45) with the absence of a substance abuse/dependence history (SA−; n = 368), controlling for the baseline body mass index. The groups did not differ in the type of surgery or %EWL at 1 and 3 months of follow-up. However, after adjusting for the baseline body mass index, the patients with a substance abuse history had a significantly greater %EWL at 6 and 9 months postoperatively, with a trend toward significance at the 12-month follow-up visit. ConclusionPatients with a substance abuse/dependence history had a greater %EWL from 6 months postoperatively onward. Future research should examine longer term outcomes among SA+ patients and the possible explanations for their short-term improved outcomes compared with SA− patients.

“My quality of life is worse compared to my earlier life”

Weight loss surgery is commonly regarded as improving individuals’ health and social life, and resulting in a happier and more active life for those defined as “morbidly obese.” However, some researchers have started to doubt whether these positive outcomes apply to everyone and this article explores this doubt further. More specifically, we focus on the experiences of women whose life situation became worse after weight loss surgery. The material draws on qualitative interviews of five Norwegian women undergoing the irreversible gastric bypass procedure. Our findings illustrate that the women lived seemingly “normal” lives prior to the surgery with few signs of illness. Worries about future illness as well as social stigma because of their body shape motivated them to undergo weight loss surgery. After the surgery, however, their situation was profoundly changed and their lives were dramatically restricted. Chronic pain, loss of energy, as well as feelings of shame and failure for having these problems not only limited their social lives but it also made them less physically active. In addition, they had difficulties taking care of their children, and functioning satisfactorily at work. Accordingly, the women gradually felt more “disabled,” regarding themselves as “outsiders” whose problems needed to be kept private. The results highlight some “subtle” consequences of weight loss surgery, particularly the shame and stigma experienced by those whose lives became dramatically worse. Living in a society where negative impacts of weight loss surgery are more or less neglected in research as well as in the public debate the women seemed to suffer in silence. Their problems were clearly present and felt in the body but not talked about and shared with others.

Discrepancy Between Ideal and Realistic Goal Weights in Three Bariatric Procedures: Who Is Likely to Be Unrealistic?

Patients choose to undergo bariatric surgery for a variety of medical and psychosocial reasons. However, the majority of bariatric surgery candidates have unrealistic weight loss goals, and certain subgroups within this population may be more likely to endorse such beliefs. This study examines weight loss expectations in patients undergoing three different weight loss procedures (laparoscopic Roux-en-Y gastric bypass, laparoscopic adjustable gastric banding, or laparoscopic sleeve gastrectomy). Between October 2007 and June 2008, 114 patients (81.6% female) underwent weight loss surgery. At entry into the program, patients identified their postsurgical goal weights. "Realistic" weights were calculated based on patients' presurgical excess weights and expected loss based upon their surgical procedure. Patient [mean preoperative body mass index (BMI) = 48.89] weight loss discrepancies were quite variable with "realistic" versus "dream" weight discrepancies ranging from 0.34 to 71.11 kg (M = 28.79 kg; SD = 13.21 kg). The mean was equivalent to losing 106% (SD = 0.15%) of excess body weight. Baseline BMI, female gender, younger age, and Caucasian ethnicity accounted for up to 62% of the variance in discrepancy scores. After controlling for initial BMI, there were no differences in discrepancies based upon type of surgery. Across all three surgery types, women, Caucasians, younger patients, and those with higher initial BMIs were more likely to have unrealistic goals. Informed consent procedures should help patients, particularly those most likely to be unrealistic, understand likely outcomes as part of education on risks and benefits of weight loss surgery.

Preinductive use of clonidine and ketamine improves recovery and reduces postoperative pain after bariatric surgery

Background In obese patients, concomitant use of clonidine and ketamine might be suitable to reduce the doses and minimize the undesired side effects of anesthetic and analgesic drugs. In this study, we evaluated the perioperative effects of administration of clonidine and ketamine in morbidly obese patients undergoing weight loss surgery at a university hospital in Rome, Italy. Methods A total of 50 morbidly obese patients undergoing open biliopancreatic diversion for weight loss surgery were enrolled. The patients were randomly allocated into a study group (n = 23) receiving a slow infusion of ketamine-clonidine before anesthesia induction and a control group (n = 27) who received standard anesthesia. The hemodynamic profile, intraoperative end-tidal sevoflurane and opioid consumption, tracheal extubation time, Aldrete score, postoperative pain assessment by visual analog scale, and analgesic requirements were recorded. Results The patients in the study group required less end-tidal sevoflurane, lower total doses of fentanyl (3.8 ± 0.3 γ/kg actual body weight versus 5.0 ± 0.2 γ/kg actual body weight, respectively; P <.05) and had a shorter time to extubation (15.1 ± 5 min versus 28.2 ± 6 min, P <.05). The Aldrete score was significantly better in the postanesthesia care unit in the study group. The study group consumed less tramadol than did the control group (138 ± 57 mg versus 252 ± 78 mg, P <.05) and had a lower visual analog scale score postoperatively during the first 6 hours. Conclusion The preoperative administration of low doses of ketamine and clonidine at induction appears to provide early extubation and diminished postoperative analgesic requirements in morbidly obese patients undergoing open bariatric surgery.

PL-43: Effect of immunosuppression on patients undergoing weight loss surgery

PL-43: Effect of immunosuppression on patients undergoing weight loss surgery

Bariatric Surgery: Low Mortality at a High-Volume Center

The American Society of Bariatric Surgery has initiated a Bariatric Surgery Center of Excellence Program and the American College of Surgeons has followed with their Bariatric Surgery Center Network Accreditation Program. These programs postulate that concentration of weight loss operations in high-volume centers will decrease surgical mortality and improve outcomes. The purpose of this study was to calculate the in-hospital mortality for bariatric operations accomplished at the highest volume bariatric surgery center in the state of New Jersey. After receiving Institutional Revew Board approval, the revised surgical schedule was used to identify all patients undergoing weight loss surgery (WLS) at Hackensack University Medical Center from 1998 through June, 2006. Data for these patients were then harvested from the hospital's electronic medical record. Step-wise and univariate logistic regression analysis tested the impact of various factors on hospital length of stay and in-hospital mortality. Between 1998 and June, 2006, 5,365 patients underwent WLS surgery: 2,099 open vertical banded gastroplasty-Roux en Y gastric bypass (VBG-RYGB); 2,177 laparoscopic Roux en Y gastric bypass (LRYGB); and 1,089 laparoscopic adjustable gastric banding (LAGB). 75.5% of patients were women. Median age was 41 years old (13-79), median weight 128 kg (81.2-290.3), and median body mass index 46.1 kg/m2 (35.0-92.6). Median total operating room time for VBG-RYGB was 115 min (33-328); LRYGB 155 min (53-493), and LAGB 92 min (33-274). Median length of stay for VBG-RYGB was 3 days (1-39 days), LRYGB 2 days (1-46 days), and LAGB 1 day (1-20). Seven patients died in hospital after the 5,365 WLS operations (0.13%): four after VBG-RYGB (0.19%); three after LRYGB (0.14%); and none after LAGB (0%). The characteristics of the patients who died did not significantly differ from the group as a whole. Surgeons at Hackensack University Medical Center, a high volume, accredited 1A American College of Surgeons Bariatric Surgery Center, achieved a 0.13% mortality among 5,365 patients undergoing weight loss operations between 1998 and June, 2006. This study supports the concept that high-volume centers perform bariatric operations with low mortalities.

Short-term outcomes for super-super obese (BMI ≥60 kg/m2) patients undergoing weight loss surgery at a high-volume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass

We previously reported significantly longer operating room times and a trend toward increased complications and mortality in the super-super obese (body mass index [BMI] > or =60 kg/m(2)) early in our experience with laparoscopic Roux-en-Y gastric bypass. The goal of this study was to re-examine the short-term outcomes for super-super obese patients undergoing weight loss surgery at our high-volume bariatric surgery center well beyond our learning curve. The records for all patients who had undergone weight loss surgery at Hackensack University Medical Center from 2002 to June 2006 were harvested from the hospital's electronic medical database. This population was analyzed as 2 groups (those with a BMI <60 kg/m(2) and those with a BMI > or =60 kg/m(2)), as well as by type of operation. Step-wise and univariate logistic regression analyses assessed the effect of BMI on the outcome variables, including mortality, length of surgery, length of hospital stay, and disposition at discharge. A total of 3692 patients were studied. Of these patients, 3401 had a BMI <60 kg/m(2) and 291 had a BMI > or =60 kg/m(2). Of the 291 super-super obese patients, 130 underwent vertical banded gastroplasty-Roux-en-Y gastric bypass, 116 laparoscopic Roux-en-Y gastric bypass, and 45 laparoscopic adjustable gastric banding. The proportion of male patients, black patients, and patients with sleep apnea was increased in the BMI > or =60 kg/m(2) group. The number of co-morbid diseases per patient correlated with age but not BMI. The BMI > or =60 kg/m(2) group required a significantly longer total operating room time (136 versus 120 min). Hospital length of stay was significantly longer only in the laparoscopic Roux-en-Y gastric bypass patients (3 d for the BMI > or =60 kg/m(2) group versus 2 d for the BMI <60 kg/m(2) group). A significantly greater percentage of patients in the super-super obese group were discharged to chronic care facilities. The overall in-hospital mortality rate was 0.15% (5 of 3692) but did not significantly differ between the 2 groups: BMI <60 kg/m(2), rate of 0.12% (4 of 3401 patients), and BMI > or =60 kg/m(2), rate of 0.34% (1 of 291 patients). The type of operation did not significantly affect the disposition at discharge or in-hospital mortality. Super-super obese patients required longer total operating room times, a longer hospital length of stay, and were more likely to be discharged to chronic care facilities than were patients with a BMI <60 kg/m(2); however, the in-hospital mortality was similar for both groups.

Complications of Laparoscopic Gastric Banding in Renal Transplant Recipients: A Case Study

As bariatric surgery becomes more popular, the number of renal transplant recipients who undergo weight loss surgery will continue to grow. This population presents unique challenges because of increased infection risks, tendency to posttransplant weight gain, and inferior tissue-healing properties. We present two cases of renal transplant recipients who experienced the complications of band erosion and band migration after laparoscopic gastric banding, and we discuss the special considerations that apply to this patient population.

Gallbladder disease in patients undergoing laparoscopic adjustable gastric banding

Background Patients undergoing weight loss surgery may have an increased incidence of subsequent gallbladder disease. Management options include treatment of symptomatic disease only, preoperative ultrasonography and concurrent cholecystectomy in presence of stones, routine concurrent cholecystectomy, and choleretic therapy postoperatively. Here we report our approach to patients undergoing laparoscopic adjustable gastric banding (LAGB) and subsequent outcomes. Methods A retrospective review of all consecutive patients undergoing LAGB at our institution was performed. Only symptomatic patients were preoperatively evaluated for cholelithiasis and underwent concurrent cholecystectomy. No choleretics were used postoperatively. Weight loss data were collected when patients returned for band adjustments. All band adjustments were patient-driven and performed under fluoroscopic guidance. Results Between November 2001 and July 2004, 324 patients underwent LAGB. Mean starting weight was 143.6 kg (range, 92.3 to 250.5 kg), and mean body mass index was 50.5 kg/m 2 (range, 35.6 to 80 kg/m 2). Fifty-six patients had undergone previous cholecystectomy, and 7 other patients underwent concurrent cholecystectomy. Average follow-up was 12.5 months (range, 1.3 to 31 months). Absolute weight loss for all patients ranged from − 2.7 to 102.3 kg. Of the remaining patients, 3 underwent subsequent uneventful laparoscopic cholecystectomy for symptomatic cholelithiasis. No independent predictors for post-LAGB gallbladder disease were identified. Conclusion Despite significant weight loss, few patients require cholecystectomy after LAGB. Routine preoperative ultrasonography, empiric cholecystectomy, and choleretic therapy are of questionable value in LAGB patients. Considering the magnitude of weight loss in our patients, empiric cholecystectomy for all bariatric procedures may merit further investigation.

Presentation and Management of Common Post–Weight Loss Surgery Problems in the Emergency Department

Morbid obesity is an epidemic in this country. An increasing number of patients are undergoing weight loss surgery in an effort to combat the negative physical and psychological impact of morbid obesity. Fueling the increasing interest in surgical treatment of morbid obesity has been the development of new laparoscopic techniques. There are several surgical approaches to morbid obesity, and each has its own unique set of risks and potential complications. As more patients have weight loss surgery, clinicians working in the emergency department will frequently encounter complications of these procedures. To ensure timely diagnosis and optimal care, clinicians should be familiar with the standard weight loss approaches and the potential complications of these interventions.

The Optimal Surgical Management of the Super Obese Patient: The Debate

Optimal management of the super-obese patient (body mass index>50 kg/m2) undergoing weight loss surgery in the new era of laparoscopic treatment is more controversial than ever before. Newer laparoscopic options for treatment of the super obese, including laparoscopic adjustable gastric banding, sleeve gastrectomy, and staging of gastric bypass, are technically easier and may be safer. Concerns that weight loss may be suboptimal or that the procedures will require revision, or both, make these choices controversial. Open access/conversion for established procedures such as long-limb gastric bypass and biliopancreatic diversion with or without duodenal switch are the traditional alternatives when laparoscopic access fails or is deemed too difficult to undertake. The following debate was presented by invited experts in laparoscopic and open bariatric surgery at the 2005 Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons in Florida. The presenters put forth arguments for the various modern options for treatment of the super obese, which are presented in written form. Interactive audience response technology provided a mechanism for polling the audience before and after the presentations. A review of the audience's responses provides insight into the decision-making considerations of a population of laparoscopically oriented bariatric surgeons.

Effective treatment of polycystic ovarian syndrome with Roux-en- Y gastric bypass

Purpose Many women with polycystic ovarian syndrome (PCOS) are overweight. This study investigated the impact of weight loss surgery on the clinical manifestations of this disorder in morbidly obese women with PCOS—a major risk factor for the development of heart disease, stroke, and type II diabetes. Methods We reviewed the outcomes of women diagnosed with PCOS who had undergone weight loss surgery at the University of Pittsburgh between July 1997 and November 2001. We evaluated the changes in menstrual cycles, hirsutism, infertility, and type II diabetes. Results A total of 24 women with PCOS were included in the study. Their mean age was 34 ± 9.7 years. The mean preoperative body weight was 306 ± 44 lb, with a body mass index of 50 ± 7.5. All patients were oligomenorrheic. Of the 24 patients, 23 were hirsute. All women underwent elective laparoscopic gastric bypass surgery. The mean follow-up period was 27.5 ± 16 months. The mean excess weight loss at 1 year of follow-up was 56.7% ± 21.2%. All women resumed normal menstrual cycles after a mean of 3.4 ± 2.1 months postoperatively. Of the 23 women with hirsutism, 12 (52%) had complete resolution at a mean follow-up of 8 ± 2.3 months, 6 (25%) had moderate resolution at a mean of 21 ± 18 months, and 3 had minimal resolution at 34 ± 14 months. Two women reported no change in their hirsutism at 32 ± 7 months. Five women were able to conceive after surgery without the use of clomiphene. Conclusion Gastric bypass surgery and its consequent weight loss results in significant improvement of multiple clinical problems related to PCOS.

Criteria for Patient Selection and Multidisciplinary Evaluation and Treatment of the Weight Loss Surgery Patient

To provide evidence-based guidelines for patient selection and to recommend the medical and nutritional aspects of multidisciplinary care required to minimize perioperative and postoperative risks in patients with severe obesity who undergo weight loss surgery (WLS). Members of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS in general and medical and nutritional care in particular. Pertinent abstracts and literature were reviewed for references. Multiple searches were carried out for various aspects of multidisciplinary care published between 1980 and 2004. A total of 3000 abstracts were identified; 242 were reviewed in detail. We recommended multidisciplinary screening of WLS patients to ensure appropriate selection; preoperative assessment for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity-related diseases associated with increased risk for complications or mortality; preoperative weight loss and cessation of smoking; perioperative prophylaxis for deep vein thrombosis and pulmonary embolism (PE); preoperative and postoperative education and counseling by a registered dietitian; and a well-defined postsurgical diet progression. Obesity-related diseases are often undiagnosed before WLS, putting patients at increased risk for complications and/or early mortality. Multidisciplinary assessment and care to minimize short- and long-term risks include: comprehensive medical screening; appropriate pre-, peri-, and postoperative preparation; collaboration with multiple patient care disciplines (e.g., anesthesiology, pulmonary medicine, cardiology, and psychology); and long-term nutrition education/counseling.

Message from the Editor‐in‐Chief

Happy New Year, and welcome to another exciting year at Obesity Research. We anticipate continued publication of top-notch and seminal research, plus some exciting and novel contributions. Coming in February is a series of evidence-based reports on recommendations for best practice in weight loss surgery. These reports evolved from a request to convene an expert panel to study weight-loss surgical programs and procedures as they relate to patient safety. The request was from the Massachusetts Commissioner of Public Health's Betsy Lehman Center for Patient Safety and Medical Error Reduction. The report includes recommendations for improving the safety and well-being of patients who undergo weight loss surgery in Massachusetts. These unique reports are expected to have far-reaching impact to inform health care core policy and clinical practice. New this year will be a series of invited “Perspectives” on the relationship among the food industry, health and environmental policies, and obesity. These “Perspectives” will be written by leading policy experts. As always, we welcome suggestions for additional perspectives or reviews. I would like to thank all contributors and reviewers for their part in increasing our submissions, impact, and membership during the past year. We encourage your continued support of Obesity Research as there can be no growth or improvement in our impact without your participation. We apologize for any delays you may have encountered with our review process during the past year. We are trying to eliminate this problem and, toward that end, expect the review process (as well as the submission process) to be going online soon. We particularly want to encourage those who submit articles to the journal to help with the review process by recommending at least five reviewers for their own articles and agreeing to review articles by others. In order to show our appreciation to excellent reviewers, we will begin a new annual process to acknowledge our premier reviewers at the annual meeting. This honor will be based on the number of articles reviewed and the rapidity of review. In the same spirit, in the past year we instituted an annual monetary award for the best authors of basic, clinical, or population articles that appeared in the journal. The 2004 winners, Thomas A. Wadden and Jacqueline Stephens, were selected by a vote of the Associate Editors. Considerations included the article itself, its impact on the field, and other contributions by the author. This award will continue to be given annually. A special thank-you is also due to the Managing and Associate Editors and the NAASO staff for their hard work, commitment, and support.