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Background: The lack of standardized objective assessment of esophageal physiology and anatomy contributes to controversies regarding the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on gastroesophageal reflux disease. This study aimed to investigate esophageal acid exposure, esophageal motility, and endoscopic findings before and after SG and RYGB., Methods: This was a systematic review and meta-analysis of studies reporting at least 1 objective measure of esophageal physiology and/or esophagogastroduodenoscopy (EGD) at baseline and after SG or RYGB. The changes in pH test, manometry, and EGD parameters were summarized., Results: Acid exposure time (AET) and DeMeester score (DMS) significantly increased after SG (mean difference [MD]: 2.1 [95% CI, 0.3-3.9] and 8.6 [95% CI, 2.0-15.2], respectively). After RYGB, both AET and DMS significantly decreased (MD: -4.2 [95% CI, -6.1 to -2.3] and -16.6 [95% CI, -25.4 to -7.8], respectively). Lower esophageal sphincter resting pressure and length significantly decreased after SG (MD: -2.8 [95% CI, -4.6 to -1.1] and -0.1 [95% CI, -0.2 to -0.02], respectively). There were no significant changes in esophageal manometry after RYGB. The relative risks of erosive esophagitis were 2.3 (95% CI, 1.5-3.5) after SG and 0.4 (95% CI, 0.2-0.8) after RYGB. The prevalence rates of Barrett esophagus changed from 0% to 3.6% after SG and from 2.7% to 1.4% after RYGB., Conclusion: SG resulted in the worsening of all objective parameters, whereas RYGB resulted in the improvement in AET, DMS, and EGD findings. Determining the risk factors associated with these outcomes can help in surgical choice., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

This study sought to evaluate the impact of severe obesity on image quality and ventricular function assessment in cardiovascular magnetic resonance (MRI) and trans-thoracic echocardiography (TTE). We studied 100 consecutive patients who underwent clinically indicated cardiac MRI and TTE studies within 12 months between July 2017 and December 2020; 50 (28 females and 22 males; 54.5 ± 18.7 years) with normal body mass index (BMI) (18.5-25 kg/m 2 ) and 50 (21 females and 29 males; 47.2 ± 13.3 years) with severe obesity (BMI ≥ 40 kg/m 2 ). MRI and TTE image quality scores were compared within and across cohorts using a linear mixed model. Categorical left (LVF) and right (RVF) ventricular function were compared using Cohens Kappa statistic. Mean BMI for normal weight and obese cohorts were 22.2 ± 1.7 kg/m 2 and 50.3 ± 5.9 kg/m 2 , respectively. Out of a possible 93 points, mean MRI image quality score was 91.5 ± 2.5 for patients with normal BMI, and 88.4 ± 5.5 for patients with severe obesity; least square (LS) mean difference 3.1, p = 0.460. TTE scores were 64.2 ± 13.6 for patients with normal BMI and 46.0 ± 12.9 for patients with severe obesity, LS mean difference 18.2, p < 0.001. Ventricular function agreement between modalities was worse in the obese cohort for both LVF (72% vs 80% agreement; kappa 0.53 vs 0.70, obese vs. normal BMI), and RVF (58% vs 72% agreement, kappa 0.18 vs 0.34, obese vs. normal BMI). Severe obesity had limited impact on cardiac MRI image quality, while obesity significantly degraded TTE image quality and ventricular function agreement with MRI., (© 2024. The Author(s).)

Purpose: Bariatric surgery (BS) has been recognized as an effective treatment for most patients with morbid obesity, but a variable range of patients failed to achieve a successful weight-loss. Controversial data are available about predictors of unsuccess. We aimed to retrospectively assess whether clinical baseline characteristics of patients submitted to sleeve gastrectomy (SL) or gastric bypass (GBP) were associated with unsuccessful weight-loss after 12 and 24-month follow-up., Methods: Three hundred patients who underwent BS from the 1st January 2016, with at least 24-months follow-up, were enrolled. Patients were divided according to their percentage of excess weight-loss (%EWL) either < 50% or ≥ 50% after 12 and 24-month follow-up., Results: None of the patients was lost at follow-up; 56 (18.7%) patients showed a %EWL < 50% at 24 months. Age, neck circumference, obstructive sleep apnea (OSA) were significantly higher, while total cholesterol and %EWL 6-months lower in those with %EWL < 50% at 12-months. Age, neck circumference, male and OSA rates were increased, while %EWL at 6-months lower in patients with %EWL < 50% at 24-months. In a multiple regression model, age (OR = 1.076; 95% CI 1.029-1.125; p = 0.001; OR = 1.066; 1.027-1.107; p < 0.001) and %EWL at 6-months (OR = 0.876; 0.840-0.913; p < 0.001; OR = 0.950; 0.928-0.972; p < 0.001) were associated with %EWL < 50% both at 12- and 24-months, respectively, and neck circumference (OR = 1.142; 1.011-1.289; p = 0.032) with %EWL < 50% at 24-months., Conclusion: Older age, larger neck circumference, and %EWL at 6-months were significantly associated with BS unsuccess, showing almost 90% of those patients an unsuccessful weight-loss early after surgery. Further larger studies with longer follow-up are needed to confirm these results.

Background: Sexual difficulties are common among obese patients, but only a few research studies have examined the relationship between obesity and sexual quality of life (QoL). The aim of this study is to investigate the efficacy of bariatric surgery to improve sexual function and related quality of life in obese men., Methods: Prospective study including consecutive male patients undergoing bariatric surgery procedures, both sleeve gastrectomy and Roux en Y gastric bypass, between 2013 and 2017. Anthropometric parameters, biochemical and hormonal assessment and QoL questionnaires [International Index of Erectile Function (IIEF), Sexual Desire Inventory (SDI), Short Form-36 (SF-36) health survey questionnaire] were collected before and 12 months after surgery., Results: 44 male patients were recruited in the study. 40/44 (90.91%) underwent a SG and 4/44 a RYGB (9.09%). Median age was 43.45 years. Waist Circumference, Hip Circumference, body weight and body mass index significantly decreased 12 months after surgery, with a median weight loss of 49 kg and a median BMI difference of 14.28 kg/m 2 12 months after surgery. Basal glycaemia, HbA1c, basal insulin, triglycerides, HDL cholesterol and CRP levels significantly decreased, while FSH, total testosterone and SHBG levels significantly increased. IEEF total score was significantly higher 12 months after surgery. Univariate analysis identified SHBG, estradiol and inhibin B levels, IIEF erectile function, IIEF intercourse satisfaction, IIEF total and SF-36 physical functioning scores as significant negative predictive factors of sexual improvement. None of them reached the statistical significance in the multivariate analysis., Conclusions: Sexual impairment in morbidly obese men represents an underestimated problem, with a high prevalence in the IIEF domains in our series. Bariatric surgery represents the most effective therapy of morbid obesity, having a tremendous impact on metabolic profile, sexual function and self-perceived QoL.

Background: Sleeve gastrectomy (SG) has become a frequent bariatric procedure. Single-port sleeve gastrectomy (SPSG) could reduce parietal aggression however its development has been restrained due to fear of a complex procedure leading to increased morbidity and suboptimal sleeve construction. The aim of this study was to compare the short-term outcomes of SPSG versus conventional laparoscopic sleeve gastrectomy (CLSG) with regards to morbidity, weight loss, and co-morbidity resolution., Methods: Between January 2015 and December 2016, data from all consecutive patients that underwent SPSG and CLSG in two institutions performing exclusively one or the other approach were retrospectively analyzed. Propensity score adjustment was performed on the factors known to influence the choice of approach., Results: During the study period, 1122 patients underwent SG in both institutions (610 SPSG and 512 CLSG). From each group, 314 patients were successfully matched. A 15-min increase in operative time was observed during SPSG (P < 0.001). Postoperative morbidity was similar with a minor increase after SPSG (8.6 vs. 6.7%, P = 0.453). No differences in incisional hernia rates were observed (1.6 (SPSG) vs. 0.3% (CLSG), P = 0.216). Percentage of total weight loss was 31.1% and 28.2% in the CLSG and SPSG 12 months after surgery, respectively (P = 0.321). Co-morbidities resolution 12 months following the procedure was similar., Conclusions: SPSG can be performed safely with similar intraoperative and postoperative morbidity compared to CLSG. Weight loss and co-morbidities resolution at 1 year are equivalent. A 15-min longer operative time was the only negative side of SPSG.

Background: Arterial hypertension (HTN) is one of the most important risk factors for the development and progression of chronic kidney disease (CKD). Rapid weight loss after bariatric interventions has a positive impact on blood pressure levels of hypertensive patients. The aim of our study is to assess the prevalence of HTN in patients with CKD after bariatric surgery (BS)., Methods: We retrospectively reviewed severely obese patients who underwent BS from 2010 to 2017. We used guidelines of the American College of Cardiology to define HTN. Only patients meeting ACC criteria and the calculation of estimated glomerular filtration rate (eGFR) using CKD epidemiology collaboration study equation preoperatively and at 12-month follow-up were included in the analysis., Results: From a total of 2900 patients, 29.13% (845) met the required criteria and had variables for the calculation of eGFR recorded preoperatively. 36.92% (312) had preoperative HTN and s classified as CKD stage ≥ 2. We observed a predominantly female population 63.83% (203) with mean age of 54.10 ± 11.58. Patients preoperatively classified in CKD 2, 3a, and 3b exhibited the greatest prevalence reduction of HTN at 12-month follow-up (68.59%, n = 214 vs. 36.59%, n = 114; 16.67%, n = 52 vs. 6.41%, n = 20; 7.69%, n = 24 vs. 1.28%, n = 4; p < 0.0001). A marked improvement in CKD was also observed along with improvement in HTN. The greatest benefit corresponded to patients classified preoperatively in CKD 2, 3a and 3b. A total of n = 70 (62.5%) patients with HTN were classified as CKD 2 preoperatively compared to n = 55 (49.11%) at 12-month follow-up (p = 0.0436). Similarly, n = 22 (19.64%) patients with HTN were classified preoperatively as CKD 3a compared to n = 7 (6.25%) and n = 12 (10.71%) patients as CKD 3b compared to n = 4 (3.57%) during the same time period (p = 0.0028, p = 0.0379, respectively)., Conclusions: Rapid weight loss after BS significantly reduces prevalence of HTN in all stages of CKD at 12-month follow-up. Additionally, there was a positive impact on classification of CKD at 12-month follow-up.

Purpose: Obstructive sleep apnea (OSA) is very common occurrence among morbidly obese patients. Our main objectives were to validate the No-Apnea, a 2-item screening tool, in morbidly obese patients and compare its performance with three other instruments: STOP-Bang questionnaire, NoSAS score, and Epworth Sleepiness Scale (ESS)., Methods: A cross-sectional analysis of morbidly obese patients (body mass index [BMI] ≥ 35.0 kg/m 2 ) grouped into two independent samples: bariatric surgery patients (BS) and non-bariatric surgery patients (NBS). All patients underwent overnight polysomnography. Discriminatory ability was assessed by area under the curve (AUC). OSA severity was defined by apnea/hypopnea index cut-off points: ≥ 5.0/h (OSA ≥5 ), ≥ 15.0/h (OSA ≥15 ), and ≥ 30.0/h (OSA ≥30 )., Results: A total of 1017 subjects (40.4% in BS cohort and 59.6% in NBS cohort) were evaluated. In the BS cohort, No-Apnea had similar discrimination to STOP-Bang and NoSAS for predicting OSA ≥5 (p = 0.979 and p = 0.358, respectively), OSA ≥15 (p = 0.158 and p = 0.399, respectively), and OSA ≥30 (p = 0.388 and p = 0.903, respectively). In the NBS cohort, No-Apnea had similar discrimination to STOP-Bang and NoSAS for predicting OSA ≥5 (p = 0.528 and p = 0.428, respectively), OSA ≥15 (p = 0.825 and p = 0.108, respectively), and OSA ≥30 (p = 0.458 and p = 0.186, respectively). Moreover, No-Apnea performed significantly better than ESS in both BS and NBS cohorts (p < 0.001)., Conclusions: No-Apnea is a useful and practical tool for screening of OSA in morbidly obese patients, with non-inferior performance to STOP-Bang questionnaire and NoSAS score.

Introduction: New persistent opioid use following surgery is a common iatrogenic complication, developing in roughly 6% of patients after elective surgery. Despite increased awareness of misuse and associated morbidity, opioids remain the cornerstone of pain management in bariatric surgery. The potential impact of new persistent opioid use on long-term postoperative outcomes is unknown. We sought to determine the relationship between new persistent opioid use and 1-year postoperative outcomes for patients undergoing bariatric surgery., Methods: Using data from the MBSC registry, we identified patients undergoing primary bariatric surgery between 2006 and 2016. Using previously validated patient-reported survey methodology, we evaluated patient opioid use preoperatively and at 1 year following surgery. New persistent use was defined as a previously opioid-naïve patient who self-reported opioid use 1 year after surgery. We used multivariable logistic regression models to evaluate the association between new persistent opioid use, risk-adjusted weight loss, and psychologic outcomes (psychological wellbeing, body image, and depression)., Results: 27,799 patients underwent primary bariatric surgery between 2006 and 2016. Among opioid-naïve patients, the rate of new persistent opioid use was 6.3%. At 1-year after surgery, patients with new persistent opioid user lost significantly less excess body weight compared to those without new persistent use (57.6% vs. 60.3%; p < 0.0001). Patients with new persistent opioid use had significantly worse psychological wellbeing (35.0 vs. 33.1; p < 0.0001), body image (19.9 vs. 18.0; p < 0.0001), and depression scores (2.4 vs. 5.0; p < 0.0001). New persistent opioid users also reported less overall satisfaction with their bariatric surgery (75.1% vs. 85.7%; p < 0.0001)., Conclusions: New persistent opioid use is common following bariatric surgery and associated with significantly worse physiologic and psychologic outcomes. More effective screening and postoperative surveillance tools are needed to identify these patients, who likely require more aggressive counseling and treatment to maximize the benefits of bariatric surgery.

The worldwide obesity epidemic continues unabated, adversely impacting upon global health and economies. People with severe obesity suffer the greatest adverse health consequences with reduced life expectancy. Currently, bariatric surgery is the most effective treatment for people with severe obesity, resulting in marked sustained weight loss, improved obesity-associated comorbidities and reduced mortality. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), the most common bariatric procedures undertaken globally, engender weight loss and metabolic improvements by mechanisms other than restriction and malabsorption. It is now clear that a plethora of gastrointestinal (GI) tract-derived signals plays a critical role in energy and glucose regulation. SG and RYGB, which alter GI anatomy and nutrient flow, impact upon these GI signals ultimately leading to weight loss and metabolic improvements. However, whilst highly effective overall, at individual level, post-operative outcomes are highly variable, with a proportion of patients experiencing poor long-term weight loss outcome and gaining little health benefit. RYGB and SG are markedly different anatomically and thus differentially impact upon GI signalling and bodyweight regulation. Here, we review the mechanisms proposed to cause weight loss following RYGB and SG. We highlight similarities and differences between these two procedures with a focus on gut hormones, bile acids and gut microbiota. A greater understanding of these procedure-related mechanisms will allow surgical procedure choice to be tailored to the individual to maximise post-surgery health outcomes and will facilitate the discovery of non-surgical treatments for people with obesity.

Background: Mental health disorders are highly prevalent among bariatric surgery patients. Bariatric surgery induces weight loss with continuous health improvements. However, long-term follow-up data on weight loss and quality of life data of patients who have a mental illness after bariatric surgery are scarce, and it is not clear whether mental illness is associated with more pronounced weight regain. The aim was to investigate the impact of preoperative mental illness on the course of long-term weight changes after bariatric surgery., Methods: Patients with sleeve gastrectomy (SG) or Roux-en-Y gastric bypass surgery (RYGB) between 2005 and 2013 with a follow-up of at least 3 years were included. The study population was divided into two groups: patients with mental illness (MI) and patients without (No-MI). Weight loss outcomes over time were compared using mixed models up to 4 years after surgery., Results: In total, 254 patients (RYGB 61.0%, SG 39%) were included. The distribution of baseline characteristics was similar between the MI (n = 108) and No-MI groups (n = 146). The most prevalent mental illness was depressive disorder (63.9%). In the MI group, the percent of total weight loss (%TWL) was significantly smaller over the study period. After 36 months, the predicted mean group-difference of %TWL was 4.6% (95% CI 1.9, 7.2; p = 0.001), and the predicted odds ratio for weight regain was 4.9 (95% CI 1.6, 15.1) for patients in the MI group., Conclusion: Preoperative mental illness leads to lower long-term weight loss and an increased risk of weight regain after bariatric surgery.

Purpose: Laparoscopic sleeve gastrectomy (LSG) is one of the most frequently performed bariatric surgery interventions because of its safety and efficacy. Nevertheless, concerns have been raised on its detrimental effect on patient nutritional state that can ultimately lead to the loss of fat-free mass (FFM). There is interest in identifying predictors for the early identification of patients at risk of this highly unwanted adverse because they could benefit of nutritional preventive interventions. Therefore, we investigated whether anthropometric parameters, body composition or resting energy expenditure (REE) measured before surgery could predict FFM loss 1 year after LSG., Methods: Study design was retrospective observational. We retrieved data on body weight, BMI, body composition and REE before and 1 year after LSG from the medical files of 36 patients operated on by LSG at our institutions. Simple regression, the Oldham's method and multilevel analysis were used to identify predictors of FFM loss., Results: Averaged percentage FFM loss 1 year after LSG was 17.0 ± 7.7% with significant differences between sexes (20.8 ± 6.6 in males and 12.2 ± 6.1% in females, p < 0.001). FFM loss was strongly predicted by pre-surgery FFM and this effect persisted also after correcting for the contribution of sex., Conclusions: High FFM values before surgery predict a more severe FFM loss after LSG. This factor could also account for the higher FFM loss in men than in women. Our finding could help in the early identification of patient requiring a nutritional support after LSG.

Introduction: Although bariatric surgery seems to increase spontaneous fertility by improving ovulatory function in young women, its impact on ovarian reserve remains largely unknown., Objective: To evaluate changes in serum anti-Mullerian hormone (AMH) levels in reproductive-age severely obese women after bariatric surgery (BS)., Methods: AMH levels were measured retrospectively in 39 women (mean age 34.6 ± 1.1 years, range 18-45) that underwent a sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) at baseline, and 6 and 12 months after BS. Metabolic and micronutrient status, including fasting plasma insulin and glucose, HOMA-IR, leptin, adiponectin, calcium, albumin, transthyretin, ferritin, vitamins (B9, B12, B1, A, E, D), zinc, and selenium, were assessed in all patients before and 1 year after BS., Results: Of the patients, 79% had class-3 obesity. At 6 and 12 months, mean total weight losses (TWL) were 26 and 30%; mean excess weight losses (EWL) were 61.7 and 70.2%. Compared to baseline, AMH levels significantly decreased by 18% at 6 months, and 32% at 12 months post-operatively (p = 0.010 and p = 0.001, respectively). There was no correlation between AMH variation and changes in metabolic parameters or micronutrient levels. Remarkably, changes in AMH levels did not differ between sleeve and RYGB patients and were not correlated with EWL., Conclusion: This pilot study shows a drastic reduction in AMH levels at 1 year after BS in reproductive-age severely obese women, which was not related to weight loss: this suggests a negative impact of BS on ovarian reserve, at least in the short term.

Background: Laparoscopic sleeve gastrectomy (LSG) has increased in popularity in recent years as a definitive bariatric procedure. Despite its growing popularity worldwide, the surgical technique is not well standardized. There is a lack of evidence on the matter of the antrum size and its relation to gastric emptying and weight-loss outcomes. The aim of the study is to evaluate the influence of antrum size over gastric emptying and weight-loss outcomes., Methods: Twenty-five patients were prospectively randomized according to the distance between the first firing and the pylorus: AR group (antrum resection-2 cm from the pylorus) and AP group (antrum preservation-5 cm from the pylorus). Gastric emptying (%GE) was evaluated by a gastric emptying scintigraphy before surgery, 2 months and 1 year after LSG. Antrum volume was measured using a MultiSlice CT Scan performed 2 months and 1 year after surgery. The percent of excess weight loss (%EWL) was calculated after 1 year follow-up., Results: At 2 months after LSG the mean %GE was 69.7 ± 18 in the AR group and 72.8 ± 20 in the AP group (p = 0.69). At 1 year it was 66.5 ± 21 and 74.2 ± 16 in the AR and AP groups, respectively (p = 0.30). A significant accelerated gastric emptying was observed at 2 months (p = 0.025) and at 1 year (p = 0.013) in the AP group. Meanwhile in the AR group this increase was not significant (p = 0.12 at 2 months and p = 0.21 at 1 year). Differences regarding the %EWL between groups were no statistically significant (p = 0.74)., Conclusions: After LSG there is a global tendency to an accelerated gastric emptying, although only significant in the antrum preservation group; however, no differences were observed regarding the %EWL between groups after 1 year follow-up.

Objective: Synoptic reporting (SR) is one solution to improve the quality of operative reports. However, SR has not been investigated in bariatric surgery despite an identified need by bariatric surgeons. SR for RYGB was developed using quality indicators (QIs) established by a national Delphi process. The objective of this study is to assess the completeness, accuracy, reliability, and efficiency of synoptic versus narrative operative reports (NR) in Roux-en-Y gastric bypass (RYGB)., Methods: A NR and SR were completed on 104 consecutive RYGBs. Two evaluators independently compared the reports to QIs. Completeness and accuracy measures were determined. Reliability was calculated using Bland-Altman plots and 95% limits of agreement (LOA). Time to complete SR and NR was also compared., Results: The mean completion rate of SR was 99.8% (±SD 0.98%) compared to 64.0% (±SD 6.15%) for NR (t = 57.9, p < 0.001). All subsections of SR were >99% complete. This was significantly higher than for NR (p < 0.001) except for small bowel division details (p = 0.530). Accuracy was significantly higher for SR than NR (94.2% ± SD 4.31% vs. 53.6% ± SD 9.82%, respectively, p < 0.001). Rater agreement was excellent for both SR (0.11, 95% LOA -0.53 to 0.75) and NR (-0.26, 95% LOA -4.85 to 4.33) (p = 0.242), where 0 denotes perfect agreement. SR completion times were significantly shorter than NR (3:55 min ± SD 1:26 min and 4:50 min ± SD 0:50 min, respectively, p = 0.007)., Conclusion: The RYGB SR is superior to NR for completeness and accuracy. This platform is also both reliable and efficient. This SR should be incorporated into clinical practice.

Introduction: Nonalcoholic fatty liver disease (NAFLD) is an epidemic in the obese population. Bariatric surgery is known to reverse multiple metabolic complications of obesity such as diabetes, dyslipidemia, and NAFLD, but the timing of liver changes has not been well described., Materials and Methods: This was an IRB-approved, two-institutional prospective study. Bariatric patients received MRIs at baseline and after a pre-operative liquid diet. Liver biopsies were performed during surgery and if NAFLD positive, the patients received MRIs at 1, 3, and 6 months. Liver volumes and proton-density fat fraction (PDFF) were calculated from offline MRI images. Primary outcomes were changes in weight, body mass index (BMI), percent excess weight loss (EWL%), liver volume, and PDFF. Resolution of steatosis, as defined as PDFF < 6.4% based on previously published cutoffs, was assessed. Secondarily, outcomes were compared between patients who underwent laparoscopic sleeve gastrectomy (LSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB)., Results: From October 2010 to June 2015, 124 patients were recruited. 49 patients (39.5%) completed all five scans. EWL% at 6 months was 55.6 ± 19.0%. BMI decreased from 45.3 ± 5.9 to 34.4 ± 5.1 kg/m 2 and mean liver volume decreased from 2464.6 ± 619.4 to 1874.3 ± 387.8 cm 3 with a volume change of 21.4 ± 11.4%. PDFF decreased from 16.6 ± 7.8 to 4.4 ± 3.4%. At 6 months, 83.7% patients had resolution of steatosis. Liver volume plateaued at 1 month, but PDFF and BMI continued to decrease. There were no statistically significant differences in liver volume or PDFF reduction from baseline to 6 months between the LSG versus LRYGB subgroups., Conclusion: Patients with NAFLD undergoing bariatric surgery can expect significant decreases in liver volume and hepatic steatosis at 6 months, with 83.7% of patients achieving resolution of steatosis. Liver volume reduction plateaus 1-month post-bariatric surgery, but PDFF continues to decrease. LSG and LRYGB did not differ in efficacy for inducing regression of hepatosteatosis.

Introduction: The impact of Roux-en-Y gastric bypass (RYGB) on weight loss and co-morbid disease resolution is well established. However, the mechanisms underlying the procedure remain incompletely understood. Intestinal remodeling involving glucose transporters (GLUTs) may play a crucial role. Rat studies have demonstrated morphological adaptation of GLUTs within adipose and intestinal cells in association with the reprogramming of glucose metabolism. There is a limited understanding of the variations in expression amongst GLUT family receptors in the human intestine. The aim of this study was to evaluate and describe jejunal GLUT expression patterns in the obese versus non-obese., Methods: Tissue samples were collected from 19 adults (age ≥18) patients with morbid obesity undergoing elective RYGB. Specimens were obtained from excess jejunum removed during the stapled jejuno-jejunal anastomosis. All subjects met National Institutes of Health criteria for bariatric surgery (body mass index or BMI ≥40 or ≥35 with obesity-related comorbidities). Exclusion criteria included age less than 18, age greater than 65, patients undergoing a revision procedure, and the presence of a seizure disorder (possible association with GLUT-1 deficiency syndrome). Five samples were obtained from non-obese subjects (average BMI 26.7) without diabetes who were consenting organ donors after brain death. Samples of jejunum from non-obese individuals were obtained at the time of organ procurement. Institutional Review Board and Gift of Hope approval was obtained. Specimens underwent quantitative real-time PCR and Western blotting. Western blot densitometry was performed using Image J software. Student T test was performed using SPSS statistics software., Results: GLUT-1 and GLUT-7 expression were not detected in the jejunum of either group. No difference in expression pattern was observed for GLUT-2, GLUT-4, and GLUT-9 between the groups. Western blot band density of GLUT-5 to loading control (GADPH) mean ratio was 0.21 (SD = 0.20) in obese specimens compared to 0.56 (SD = 0.17) in non-obese. Densitometry revealed GLUT-5 levels in the jejunum of the obese were significantly lower than non-obese specimens (P < 0.05)., Conclusion: The absence of GLUT-1 expression in both the obese and non-obese groups is consistent with the established view of GLUT-1 being abundantly present in fetal intestine but diminished to negligible levels by adulthood. Decreased GLUT-5 expression in samples from subjects with obesity compared to non-obese samples may represent a down-regulation of gene expression amongst the obese. The differential expression of GLUT-5 suggests a possible role in obesity. Studies of GLUT family expression will aid in understanding the impact of intestinal remodeling on obesity.

Introduction: Weight loss after bariatric surgery improves both blood pressure and glycemic control following surgery. The effect of bariatric surgery on renal function is not well characterized. In this study, we sought to quantify the change in renal function over time following surgery., Methods: We retrospectively reviewed all patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between 2012 and 2014 at our institution. The glomerular filtration rate (GFR, mL/min) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Body mass index (BMI, kg/m 2 ) and percent weight loss (%WL) were calculated following the surgery., Results: A total of 149 patients who underwent bariatric surgery were included in this study: LRYGB (n = 86 and LSG (n = 63). In LRYGB group, baseline BMI (kg/m 2 , ±SD) and GFR (mL/min, ±SD) were 48.5 ± 6.8 and 94.7 ± 23.8, respectively. In comparison, BMI and GFR were 49.1 ± 11.9 kg/m 2 and 93.1 ± 28.0 mL/min in the LSG group, respectively. Over the follow-up period (19.89 ± 10.93 months), the patients who underwent LRGYB lost a larger percentage of weight as compared to those in the LSG group (29.9 ± 11.7% vs 22.3 ± 10.7%; p = <0.0001). Overall, GFR improved in both LRYGB (101.0 ± 25.8 mL/min) and LSG groups (97.9 ± 25.8 mL/min) and was not significantly different between the two groups. Of patients with a GFR < 90 mL/min prior to weight loss surgery (n = 62), 42% had improvement of their GFR to > 90 mL/min postoperatively (p < 0.001). There was no relationship between weight loss percentage and GFR improvement (p = 0.8703)., Conclusions: Bariatric surgery was associated with improvement in postoperative renal function at almost two years following surgery but was not different for LRYGB versus LSG. The gain in GFR was independent of percentage of weight lost suggesting an alternate mechanism in the improvement of renal function other than weight loss alone.

Background: Despite accumulating evidence of the important health benefits of bariatric surgery in morbidly obese patients in general, bariatric surgery outcomes are less clear in higher-risk, high-priority populations of patients with BMI ≥ 50 kg/m 2 . To help the Department of Veterans Affairs (VA) Health Services Research & Development Service (HSR&D) develop a research agenda, we conducted a rapid evidence review to better understand bariatric surgery outcomes in adults with BMI ≥ 50 kg/m 2 ., Methods: We searched MEDLINE ® , the Cochrane Database of Systematic Reviews, the Cochrane Central Registry of Controlled Trials, and ClinicalTrials.gov through June 2016. We included trials and observational studies. We used pre-specified criteria to select studies, abstract data, and rate internal validity and strength of the evidence (PROSPERO registration number CRD42015025348). All decisions were completed by one reviewer and checked by another., Results: Among 1892 citations, we included 23 studies in this rapid review. Compared with usual care, one large retrospective VA study provided limited evidence that bariatric surgery can lead to increased mortality in the first year, but decreased mortality long-term among super obese veterans. Studies that compared different bariatric surgical approaches suggested some differences in weight loss and complications. Laparoscopic gastric bypass generally resulted in greater short-term proportion of excess weight loss than did other procedures. Duodenal switch led to greater long-term weight loss than did gastric bypass, but with more complications., Conclusions: The published literature that separates the super obese is insufficient for determining the precise balance of benefits and harms of bariatric surgery in this high-risk subgroup. Future studies should evaluate a more complete set of key outcomes with longer follow-up in larger samples of more broadly representative adults.

To determine impact of obesity on recovery parameters and pulmonary functions of women undergoing major abdominal gynecological surgeries. Eighty women undergoing major gynecological surgeries were included in this study. Anesthesia was induced by remifentanil bolus, followed by propofol and cisatracurium to facilitate oro-tracheal intubation and was maintained by balanced anesthesia of remifentanil intravenous infusion and sevoflurane in oxygen and air. Time from discontinuation of maintenance anesthesia to fully awake were recorded at 1-min intervals and time from discontinuation of anesthesia until patient was transferred to post-anesthesia care unit (PACU) and discharged from PACU was also recorded. Pulmonary function tests were performed before surgery and repeated 4 h, days 1, 2 and 3 post-operative for evaluation of forced vital capacity, forced expiratory volume in 1 s and peak expiratory flow rate. Occurrence of post-operative complications, re-admission to ICU, hospital stay and morbidities were also recorded. Induction of anesthesia using remifentanil bolus injection resulted in significant decrease of heart rate and arterial pressures compared to pre-operative and pre-induction values. Recovery times were significantly shorter in obese compared to morbidly obese women. Post-operative pulmonary function tests showed significant deterioration compared to pre-operative measures but showed progressive improvement through first 3 post-operative days. Hospital stay was significantly shorter for obese compared to morbid obese women. Obesity delays recovery from general anesthesia, adversely affects pulmonary functions and increases post-operative complications. Remifentanil infusion and sevoflurane could be appropriate combination for obese and morbidly obese women undergoing major surgeries.

Introduction: Among morbidly obese adult patients (BMI >40 kg/m(2)), those who are super-super obese (BMI >60 kg/m(2)) present particular challenges for bariatric surgeons. Surgical management of super-super obese (SSO) patients has been associated with higher morbidity and mortality and increased surgical risk. The optimal surgical management of these patients is controversial. The aim of this study was to compare perioperative outcomes, percent excess weight loss (%EWL), and percent weight loss (%WL) in super-super obese patients who underwent either SG or RYGB., Materials and Methods: This study was a nonrandomized, controlled, retrospective review of 89 SSO patients who underwent SG or RYGB at the University of Illinois Hospital and Health Sciences System from January 2008 to June 2014. Patient demographics, pre-surgical comorbidities, perioperative parameters, post-operative complications (leak, conversion to open surgery, and 30-day mortality), and post-operative outcome months were examined., Results: Seventy-seven patients underwent SG (nine robotic sleeve and 68 laparoscopic sleeve gastrectomy), and 12 underwent RYGB. The mean pre-operative BMI was 63.4 kg/m(2) (SD = 3.7 kg/m(2)). The mean operative time was 88.4 min (SD = 31.7) for the SG patients and 219.2 min (SD = 80.2) for the RYGB patients. There were no significant differences in complications or length of hospitalization between the groups. There were significant differences in %EWL and %WL at 12- and 24-month follow-up between groups (p's < 0.05)., Conclusions: Based on the results from this sample of patients, SG and RYGB appear to be viable procedures for the surgical management of super-super obese patients. RYGB, however, provides a significantly higher %EWL and %WL at 12 and 24 months compared to SG, which in turn, yields acceptable but lower %EWL and %WL.

Purpose: The pressures delivered by autotitrating continuous positive airways pressure (CPAP) devices not only treat obstructive sleep apnoea (OSA) effectively but also give potentially interesting physiological information about the forces impinging on the pharynx. In earlier work from this unit, we used correlations between autoCPAP pressure and both OSA severity and obesity, to construct an algorithm to estimate the fixed CPAP pressure a patient required for subsequent clinical use. We wished to discover if these relationships could be reliably extended to a much more obese group., Methods: We performed a prospective cohort study in an obese population. Measurements of obesity were made, OSA severity was recorded, and the 95th centile autoCPAP pressure was recorded during 1 week of autoCPAP. Spearman's rank correlation was performed between measurements of obesity and autoCPAP pressure, and between OSA severity and autoCPAP pressure., Results: Fifty-four obese individuals (median body mass index (BMI) 43.0 kg/m(2)), 52 % of whom had OSA (apnoea-hypopnoea index (AHI) ≥ 15), had a median 95th centile autoCPAP pressure of 11.8 cmH2O. We found no significant correlation between autoCPAP pressure and neck circumference, waist circumference or BMI. There was a moderate correlation between autoCPAP pressure and OSA severity (AHI r = 0.34, p = 0.02; oxygen desaturation index (ODI) r = 0.48, p < 0.001)., Conclusions: In this population, neither BMI nor neck circumference nor waist circumference is predictive of autoCPAP pressure. Therefore, the previously derived algorithm does not adequately predict the fixed CPAP pressure for subsequent clinical use in these obese individuals. In addition, some subjects without OSA generated high autoCPAP pressures, and thus, the correlation between OSA severity and autoCPAP pressure was only moderate.

Introduction: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the gold standard for surgical weight loss. The success of LRYGB may be measured by excess body mass index loss (%EBMIL) over 25 kg/m(2), which is partially determined by multiple patient factors. In this study, artificial neural network (ANN) modeling was used to derive a reasonable estimate of expected postoperative weight loss using only known preoperative patient variables. Additionally, ANN modeling allowed for the discriminant prediction of achievement of benchmark 50% EBMIL at 1 year postoperatively., Methods: Six hundred and forty-seven LRYGB included patients were retrospectively reviewed for preoperative factors independently associated with EBMIL at 180 and 365 days postoperatively (EBMIL180 and EBMIL365, respectively). Previously validated factors were selectively analyzed, including age; race; gender; preoperative BMI (BMI0); hemoglobin; and diagnoses of hypertension (HTN), diabetes mellitus (DM), and depression or anxiety disorder. Variables significant upon multivariate analysis (P < .05) were modeled by "traditional" multiple linear regression and an ANN, to predict %EBMIL180 and %EBMIL365., Results: The mean EBMIL180 and EBMIL365 were 56.4 ± 16.5 % and 73.5 ± 21.5%, corresponding to total body weight losses of 25.7 ± 5.9% and 33.6 ± 8.0%, respectively. Upon multivariate analysis, independent factors associated with EBMIL180 included black race (B = -6.3%, P < .001), BMI0 (B = -1.1%/unit BMI, P < .001), and DM (B = -3.2%, P < .004). For EBMIL365, independently associated factors were female gender (B = 6.4%, P < .001), black race (B = -6.7%, P < .001), BMI0 (B = -1.2%/unit BMI, P < .001), HTN (B = -3.7%, P = .03), and DM (B = -6.0%, P < .001). Pearson r(2) values for the multiple linear regression and ANN models were 0.38 (EBMIL180) and 0.35 (EBMIL365), and 0.42 (EBMIL180) and 0.38 (EBMIL365), respectively. ANN prediction of benchmark 50% EBMIL at 365 days generated an area under the curve of 0.78 ± 0.03 in the training set (n = 518) and 0.83 ± 0.04 (n = 129) in the validation set., Conclusions: Available at https://redcap.vanderbilt.edu/surveys/?s=3HCR43AKXR, this or other ANN models may be used to provide an optimized estimate of postoperative EBMIL following LRYGB.

Background: Obstructive sleep apnoea (OSA) may independently increase cardiovascular risk in obesity. Although there is evidence that arterial stiffness is altered in OSA, knowledge of these effects with continuous positive airway pressure (CPAP) in severe obesity (body mass index (BMI) ≥ 35 kg/m(2)) is limited. This study aimed to explore how arterial stiffness, as measured by the augmentation index (Aix), changed in severely obese patients with OSA who were treated with CPAP and in patients without OSA., Methods: Forty-two patients with severe obesity-22 with OSA, 20 without OSA-were recruited at baseline and followed-up after a median of 13.5 months. Pulse wave analysis (PWA) was performed using applanation tonometry at the radial artery to measure augmentation index (Aix), augmentation pressure (AP) and subendocardial viability ratio (SEVR). Cardiovascular parameters and body composition were also measured., Results: There were significant improvements in Aix, AP (both P < 0.001) and SEVR (P = 0.021) in OSA patients on CPAP compared with subjects without OSA. Epworth scores (P < 0.001), systolic (P < 0.001) and mean arterial pressures (P = 0.002) improved with CPAP. Regression showed that CPAP was significantly associated with change in arterial stiffness from baseline. However, patients with OSA on CPAP continued to have increased arterial stiffness (Aix) (P < 0.001), AP (P = 0.028) and reduced SEVR (P = 0.002) relative to non-OSA patients., Conclusion: Although sleepiness and blood pressure improve with CPAP in severe obesity, CPAP alone is not sufficient to modify PWA measures to levels comparable with non-OSA patients. This supports a need for a multifaceted approach when managing cardiovascular risk in patients with severe obesity and obstructive sleep apnoea receiving CPAP therapy.

Background: Previous studies show that 'poor responders' to Roux-en-Y gastric bypass (RYGBP) may be identified on the basis of early postoperative weight loss. Early identification of poor responders could allow earlier provision of postoperative behavioural and/or intensive lifestyle interventions and enhance their maximal weight loss. Our aim was to investigate whether early postoperative weight loss predicts the maximal weight loss response after RYGBP and sleeve gastrectomy (SG)., Methods: We undertook a retrospective cross-sectional study of 1,456 adults who underwent either RYGBP (n = 918) or SG (n = 538) as a primary procedure in one of two European centres. Postoperative weight loss was expressed as weight loss velocity (WLV) and percentage weight loss. Linear regression analyses were performed to determine the association of early postoperative weight loss with maximal %WL, including adjustment for baseline variables., Results: There was marked variability in maximal %WL following both RYGBP (mean 32.9 %, range 4.1-60.9 %) and SG (mean 26.2 %, range 1.1-58.3 %). WLV 3-6 months postoperatively was more strongly associated with maximal %WL (r (2) = 0.32 for RYGBP and r (2) = 0.26 for SG, P < 0.001 for both) than either WLV 0-6 weeks or 6 weeks to 3 months postoperatively (r (2) = 0.14 and 0.10 for RYGBP, respectively; r (2) = 0.18 and 0.21 for SG, respectively; P < 0.001 for all). Multiple linear regression analysis, including baseline variables of age, sex, preoperative BMI, type 2 diabetes, ethnicity, and bariatric centre, revealed that 3-6 month WLV was an independent predictor of maximal %WL in both SG and RYGBP groups (standardised β-coefficients 0.51 and 0.52, respectively; P < 0.001 for both)., Conclusions: There is a marked variability in weight loss response following RYGBP and SG. Early postoperative weight loss can be used to identify patients whose predicted weight loss trajectories are suboptimal. Early targeting of poor responders with more intensive postoperative lifestyle and behavioural support could potentially enhance their weight loss response.

Bariatric surgery is an effective and enduring treatment for obesity; however, variation in weight loss may occur following surgery. Many factors beyond technical considerations may influence postoperative outcomes. A better understanding of the influence of adverse childhood experiences (ACE) on surgical weight loss may improve preoperative care. Demographic and preoperative and postoperative data were prospectively obtained for 223 patients undergoing bariatric surgery. All cases were completed laparoscopically without serious complication. Patients completed the ACE questionnaire, which assesses childhood maltreatment. Patients had an average age of 48 years and 77 % were female. There was a significant reduction from preoperative to 12-month postoperative BMI (45 to 31 kg/m(2), p ≤ 0.01). The average ACE score was 2.9 and these patients were more likely than population norms to have an ACE score ≥4 (35.9 vs. 12.5 %, p < 0.001). There was a positive correlation between the number of preoperative comorbidities and preoperative ACE score (R = 0.112, p = 0.09). Patients with a high ACE score (≥6) vs. patients low ACE scores had a higher postoperative BMI at 6-months (36.9 vs. 33.4 kg/m(2), p = 0.03) and 12-months postoperatively (34.5 vs. 30.5 kg/m(2), p = 0.07). High ACE patients had higher total cholesterol (191 vs. 169 mg/dL, p = 0.02) and LDL cholesterol (116 vs. 94 mg/dL, p = 0.02) than low ACE patients 12-months postoperatively. A high preoperative ACE score decreases weight loss following bariatric surgery and may warrant an increased preoperative counseling.

The aim of this report is to perform a systematic review and qualitative synthesis of the literature to address whether, and to what extent, diet modulates the effects of the Pro12Ala polymorphism of peroxisome proliferator-activated receptor gamma 2 (PPARγ2) on body weight and other measures of adiposity. A systematic search of the literature was conducted, wherein both observational and experimental studies of adults were reviewed. Overall, the results of the observational studies show little consistency. Methodological differences in their design, conduct and analysis may largely account for the apparently discrepant findings. This notwithstanding, the main picture that emerges is that the energy content and composition of the diet may affect BMI, body composition and metabolic parameters in Ala allele carriers more than in Pro/Pro homozygotes. In most studies, carriers of the Ala allele with an obesogenic lifestyle (i.e. high-energy, high-carbohydrate and, to some extent, high-fat diets) are more obese than Pro homozygotes. Well-designed intervention studies with a sufficiently large sample size consistently show that carriers of the Ala allele are more prone to weight loss when exposed to a healthy lifestyle; however, these individuals do not seem to retain these benefits when returning to a sedentary lifestyle and inadequate dieting behaviours. Some key questions in this area of research have emerged. Carefully designed and adequately powered studies are needed, particularly involving the development and validation of standardized tools for the assessment of dietary exposure, including the use of biomarkers, to move the field forward.

Background: Sleeve gastrectomy (SG) is being performed as a conversion after adjustable gastric banding (AGB), often in a single stage. However, some argue that it should be performed in 2 stages to improve safety. Few studies compare complications between 1-stage and 2-stage procedures. Our aim is to compare the 30-day complication rates among these two groups., Methods: We retrospectively reviewed patients converted from AGB to SG between 8/2008 and 10/2013 and compared patients undergoing 1-stage and 2-stage techniques. Primary outcome was overall 30-day adverse event rate (postoperative complication, readmission, or reoperation). Secondary outcomes included operating room (OR) time, length of stay (LOS), leak, infection, and bleeding rates, as well as mortality., Results: A total of 83 patients underwent SG after band removal; three were excluded due to short follow-up, leaving 60 1-stage and 20 2-stage. Mean time from band removal to SG for 2-stage was 438 days. Demographics, intraoperative technique (bougie size, staple reinforcement, oversewing staple line, and leak test), and mean follow-up were not statistically different. Mean OR time (132.1 min 1-stage vs. 127.8 min 2-stage, p = 0.702) and LOS (3.1 vs. 2.4 days, p = 0.676) were similar. Overall 30-day adverse event rate was 12 % for 1-stage versus 15 % for 2-stage procedures (p = 0.705). Differences in 30-day readmission (8 vs. 5 %) and reoperation (5 vs. 0 %) were not statistically significant (p = 0.999 and 0.569, respectively). Leak (3 vs. 0 %, p = 0.999), abscess (2 vs. 5 %, p = 0.440), and bleeding rates (2 vs. 0 %, p = 0.999) were not different. There were no deaths., Conclusions: SG performed as a conversion after AGB is safe and feasible. Our findings indicate no statistical difference in 30-day outcomes when performed in 1 or 2 stages. Future studies with larger sample sizes are necessary to further investigate these differences.

Introduction: Conversion to laparoscopic gastric bypass (LRYGB) appears to be the treatment of choice after failed LAGB. To reduce the risk of postoperative complications, some surgeons routinely adopt a two-stage strategy. The purpose of this study was to analyze our institution's experience with the two-stage procedure for LAGB conversion to LRYGB MATERIALS AND METHODS: The bariatric database of our institution was reviewed to identify patients who had undergone conversion of LAGB to LRYGB from November 2007 to June 2012., Results: One hundred patients were included. Of these, 62 (62%) required conversion to LRYGB for inadequate weight loss or weight regain and 38 for band-related complications. All the procedures were performed in two stages and laparoscopically. The average time between band removal and LRYGB was 17.3 months. The mean follow-up after LRYGB was 31 ± 18.7 months. The mean BMI prior to LRYGB conversion was 45.3 ± 5.2. Early complications occurred in 15 patients (15%), while late complications occurred in only 3 patients (3%). The average %EWL at 24 months and 48 months after conversion was 70.1 and 69.4%, respectively., Conclusion: Although a two-stage conversion strategy increases the number of operations and hospital stay without decreasing the rate of early complications compared to one-stage conversion; it has shown to be associated with low rates of GJA stenosis and excellent %EWL.

Background: Non-alcoholic fatty liver disease (NAFLD) is an independent predictor of type 2 diabetes mellitus (T2DM). Insulin resistance and beta-cell dysfunction are involved in the pathogenesis of T2DM. Insulin resistance is associated with NAFLD but little is known about beta-cell dysfunction and NAFLD., Aim: We tested whether NAFLD severity is associated with insulin sensitivity and beta-cell function in morbidly obese women., Subjects and Methods: We studied 61 Caucasian women aged 18-60 years without T2DM and with a body mass index ranging from 35.3 to 48.8 kg/m². The insulin sensitivity index (ISI) and the disposition index (DI) from oral glucose tolerance testing were used as measures of insulin sensitivity and beta-cell function, respectively. Fat was measured by dual-energy X-ray absorptiometry. Fatty liver was diagnosed by ultrasonography and ordinally coded as 0 = none, 1 = light, 2 = moderate, 3 = severe. Proportional-odds logistic regression was used to evaluate the association of NAFLD severity with log(e)ISI and log(e)DI with and without correction for total and truncal fat., Results: The odds of more severe vs. less severe NAFLD decreased for increasing log(e)ISI [odds ratio (OR) 0.40, 95 % CI 0.19-0.84, p < 0.05] and log(e)DI (OR 0.80, 95 % CI 0.69-0.92, p < 0.01). Neither total nor truncal fat had any effect on these associations., Conclusion: In morbidly obese women, NAFLD severity is inversely associated with insulin sensitivity and beta-cell function. The association of NAFLD severity with beta-cell dysfunction is stronger than that with insulin resistance.

Background: The aim of this study was to evaluate the impact of age on weight loss and on related glycolipid profile changes at 2-year follow-up after laparoscopic sleeve gastrectomy (LSG)., Methods: From 2005 to 2010, a total of 308 consecutive patients undergoing LSG were enrolled. Mean age was 39.7 ± 10.7 years, mean weight was 127.9 ± 24.5 kg, and mean body mass index (BMI) was 45.9 ± 6.8 kg/m(2). Patients were divided into three age groups: young (18-29 years, n = 64), intermediate (30-49 years, n = 183), and senior (50-68 years, n = 61). BMI, excess weight loss (%EWL), and several biochemical examinations for the evaluation of glycolipid profile transition, including homeostasis model assessment for insulin resistance (HOMA-IR), were assessed at 6, 12, and 24 months (M6, M12, and M24) after LSG., Results: All three groups had a significant BMI reduction and %EWL at 2 years' follow-up. The young group obtained significantly better %EWL at M6, M12, and M24 (62.6 ± 14.4, 73.4 ± 17.1, and 72.5 ± 18.9 %) compared to intermediate (53.2 ± 18.0, 64.8 ± 19.9, and 66.8 ± 23.0 %) and senior group (48.0 ± 15.5, 54.6 ± 15.3, and 54.4 ± 15.4 %). Fasting serum glucose levels improved significantly in all three groups at all follow-up assessment points (M6, M12, and M24). A significant improvement in HbA1c was also observed in the three groups at M6 and M12, while at M24 only patients in the young and intermediate groups still presented a significantly improved glycemic control. A significantly lower HOMA-IR improvement was observed at M6 in the senior group (2.83 ± 1.86) compared to both young (1.30 ± 0.54) and intermediate (1.43 ± 0.82) groups of patients. Total and low-density lipoprotein cholesterol level was significantly improved only in the young group., Conclusions: An age-dependent trend toward better %EWL and glycolipid profile improvement was observed in young patients after LSG.

Background: Mechanical overload and poor quality of contractile elements related to metabolic abnormalities concur to motor disability of obesity. The independent contribution of these factors to motor dysfunction in obese individuals is scarcely defined., Aim: Aim of the study is to test the hypothesis that metabolic factors may independently affect motor function in obesity., Methods: Leg maximum power output per unit body mass (W Mb), per unit fat-free mas (W FFM) and fatigue in daily functioning were assessed in 635 obese [body mass index (BMI)≥ 35 kg/m(2)] individuals (286 men, 349 women) aged 19-78 yr. The independent effects of age, BMI, insulin resistance and the five components of the metabolic syndrome on W Mb, W FFM and fatigue were evaluated by multivariate analysis., Results: A multiple regression analysis revealed that in both genders W Mb (denoting the individual's performance capability during anaerobic tasks) was independently reduced by age (p<0.001), BMI (p<0.05-0.001) and abnormalities of glucose metabolism (p<0.06-0.01), while W FFM (representing the muscle intrinsic anaerobic capability) was affected only by age (p<0.001) and glucose metabolism impairment (p<0.06-0.01). In both genders fatigue was increased by age (p<0.001) and BMI (p<0.05-0.01), but augmented by low levels of HDL-cholesterol in men only (p<0.05)., Conclusions: Besides depending on mechanical overload and age, low muscle power output in obese individuals was independently associated also with metabolic abnormalities related to impaired glucose homeostasis. Fatigue and performance, although similarly influenced by age and body mass excess, are affected by different metabolic factors.

Background: Obesity is associated with various changes in cardiac geometry and this process involves both hemodynamic and non-hemodynamic factors, among which adipocitokines and growth factors may play an important role. The aim of this study was to identify the extent and pattern of cardiac remodeling in a group of severely obese patients and analyze the relationship between adiponectin, IGFI and cardiac parameters reflecting obesity-associated structural changes., Subjects and Methods: Our study included 344 patients (104 men) with severe obesity [mean body mass index (BMI)= 45.7 ± 8.5 kg/m(2)], extensively evaluated clinically and biologically (complete metabolic tests, serum adiponectin, and IGF-I measurements). Left ventricular (LV) mass index (LVMI), left atrium (LA) size, and LV geometry were determined by means of cardiac ultrasound., Results: The most prevalent pattern of LV geometry was eccentric hypertrophy (28.7% of patients). In a gender-, age-, BMI-, diabetes- and hypertension-adjusted general linear model, patients with concentric or eccentric hypertrophy had significantly lower values of adiponectin than those with normal geometry (6.75 ± 0.41, 6.96 ± 0.53, vs 9.04 ± 0.42 mg/l, p<0.05). In multivariate analysis, independent determinants for LVMI were BMI (β=0.364, p<0.001), systolic blood pressure (BP) (β=0.187, p=0.004), age (β=0.246, p<0.001), adiponectin (β=-0.151, p=0.012), and IGF-I z-score (β=0.134, p=0.025) while factors independently related to LA size were systolic BP (β=0.218, p<0.001), BMI (β=0.194, p<0.001), age (β=0.273, p<0.001), gender (β=-0.195, p<0.001), and adiponectin (β=-0.180, p=0.005)., Conclusions: In patients with severe obesity, IGF-I z score and adiponectin correlate with parameters of cardiac remodeling independently of anthropometric, hemodynamic or metabolic factors.

Background: The relative contribution of anthropometric, hormonal, and metabolic changes after bariatric surgery (BS) on sexual function (SF) in severely obese subjects is not well established., Methods: Prospective observational case series study of 39 men undergoing BS. SF was assessed by means of the international index of erectile function (IIEF) before and at 1 year after surgery. At the same time points, anthropometric (body mass index, waist circumference), hormonal (testosterone, sex hormone binding globulin, estradiol, gonadotropins, inhibin B, prolactin, leptin), and metabolic parameters (insulin sensitivity, C-reactive protein, lipid profile, hemoglobin A1c, presence of hypertension or sleep apnea) were assessed., Results: BS was associated with marked weight loss (77.18% excess weight loss), improved IIEF score (baseline: 54.85 ± 16.59, 1 year: 61.21 ± 14.10; p < 0.01), gonadal function (testosterone: baseline 256.36 ± 120.98, 1 year: 508.01 ± 161.90; p < 0.001), and improved metabolic profile. However, on multivariate regression analysis whereas changes in body mass index (beta: -0.677, p = 0.001), and baseline IIEF score (beta: -0.397, p = 0.023), were independent predictors of the changes in the IIEF score at 1 year after surgery, changes in hormonal and metabolic factors were not. Variables in the model accounted for 66% of the postsurgical variation in the IIEF score. Similar results were found when the different IIEF-sexual domains were evaluated, except for intercourse satisfaction for which no independent predictor was identified., Conclusions: Weight loss's beneficial effects on SF occurring after BS are beyond the parallel improvement in gonadal and metabolic profiles.

Background: Few longitudinal studies have examined associations between body mass index (BMI) changes in adults with diabetes and the development of disability., Objective: To investigate association patterns between BMI and disability in middle-aged adults with diabetes., Design and Setting: Retrospective cohort design with data from the 1992-2006 Health and Retirement Study (HRS). A group-based joint trajectory method identified distinct BMI change trajectories and their link to subsequent disability trajectories., Participants: U.S. nationally representative adults aged 51-61 who reported a diagnosis of diabetes in the 1992 HRS (N = 1,064)., Measurements: BMI and self-reported disability score were the main variables. Sociodemographic, clinical, behavioral, and diabetes-related factors were also examined., Results: Four distinct weight trajectories (stable normal weight, 28.7 %; stable overweight, 46.2 %; loss and regain obese, 18.0 %; weight cumulating morbidly obese, 7.1 %) and three disability trajectories (little or low increase, 34.4 %; moderate increase, 45.4 %; chronic high increase, 20.2 %) best characterized the long-term patterns of BMI and disability change in middle-aged adults with diabetes. Adults in stable normal weight had the highest probability of being in the little/low increase disability group; however, one in five adults in that group progressed into chronic high disability, a higher proportion compared to the stable overweight group., Conclusions: Although there were various ways in which the two trajectories were linked, the beneficial impacts of optimizing weight in adults with diabetes were supported. In addition, the complexity of diabetes control in those with relatively normal weight was highlighted from this study.

Background: Roux-en-Y gastric bypass is the most commonly performed operation for the treatment of morbid obesity in the US. Dumping syndrome is an expected and desired part of the behavior modification caused by gastric bypass surgery; it can deter patients from consuming energy-dense food. In this study we assessed the role dumping has in weight loss and its relationship with the patient's eating behavior., Methods: Fifty patients who underwent gastric bypass between January 2008 and June 2008 were enrolled. Two questionnaires, the dumping syndrome questionnaire and the Three-Factor Eating Questionnaire (TFEQ), were used to record the patients' responses. The diagnosis of dumping syndrome was based on the Sigstad scoring system, where a score of 7 and above was considered positive. TFEQ evaluated the patients' eating behavior under three scales: cognitive restraint, uncontrolled eating, and emotional eating. The results were analyzed with descriptive and parametric statistics where applicable., Results: The prevalence of dumping syndrome was 42 %, with 66.7 % of the subjects being women. The nondumpers were observed to have a greater mean decrease in body mass index than the dumpers at 1 and 2 years (18.5 and 17.8 vs. 14.4 and 13.7 respectively). There was no definite relationship between the presence of dumping syndrome and the eating behavior of the patient. However, the cognitive restraint scores, greater than 80 %, were associated with an average decrease in BMI of 19 and 20.8 at 1 and 2 years compared with 14.6 and 12.4 in those with scores less than 80 % (p = 0.01 and p = 0.03, respectively)., Conclusion: The presence of dumping syndrome after gastric bypass does not influence weight loss, though eating behaviors may directly influence it.

Bariatric surgery is nowadays an effective therapeutic option for morbid obesity. Endocrinologists may thus have a growing opportunity to diagnose and treat obese patients eligible for surgery in pre- and post-operative phase. This requires a better understanding of endocrine changes caused by either obesity or weight loss surgery. Despite the large number of studies available in literature, only limited well-designed clinical trials have been performed so far to investigate changes of endocrine axes following bariatric procedures. There are still areas of unclear results such as female and male fertility, however, weight loss after bariatric surgery is considered to be associated with favorable effects on most endocrine axes. The aim of this clinical review is to overview the available literature on the effects of weight loss after bariatric surgery on the endocrine systems to suggest the most appropriate pre- and post-operative management of obese patients undergoing bariatric surgery in terms of "endocrine" health.

Background: Leaks occurring after weight loss operations constitute a therapeutic challenge. There is no consensus as to what comprises state-of-the-art management of leaks after bariatric surgery. We sought to determine the efficacy and possible adverse effects of endoluminal stenting for leaks after bariatric surgery., Methods: We report our experience with the stent treatment of consecutive bariatric patients with a leak (retrospective cohort study). Between October 2005 and July 2010, 47 patients presented an acute leak after a bariatric procedure (61 % primary procedures, 39 % revisions). Fifteen patients were initially approached laparoscopically, and 32 were treated by nonoperative techniques. After adequate drainage and resuscitation, all 47 patients were treated by the endoscopic placement of a partially covered metallic stent, and later of a plastic stent inside the metallic prosthesis to facilitate removal. Both stents were then ablated 1 week later. Primary outcome measurement concerned healing of the fistula, as evidenced by radiographic imaging. Secondary outcomes were length of hospital stay and occurrence of peri- and postprocedural complications., Results: There was no mortality. 41 patients (87.23 %) healed with stent treatment alone; 5 of the 6 persisting leaks healed with laparoscopic intervention (intention-to-treat success rate 96 %). Complication rate was 28.7 %. Length of hospital stay was mean ± standard deviation 22.4 ± 19.38 days for the patients treated by stent alone, and 23.4 ± 18.4 days for the patients requiring additional surgery (P = NS). One patient developed a stricture and required endoscopic dilation, and one is still awaiting surgical treatment., Conclusions: Leaks after bariatric surgery can be treated safely and effectively by endoscopic stents. In cases of persisting leaks, laparoscopic intervention is successful in a majority of cases. Late strictures seldom occur.

Background: Glomerular hyperfiltration commonly associated with obesity is expected to improve postbariatric surgery. However, formula-based glomerular filtration rate (GFR) estimation in these patients is limited by body size confounders necessitating use of modified equations, the reliability of which remains uncertain., Methods: In this study, various GFR-estimating formulae were compared in morbidly obese patients at baseline and postbariatric surgery. Through a retrospective chart review, we identified 220 patients who had undergone this procedure, with over 6-month follow-up, during which major weight reduction was achieved., Results: A significant decrease in BP and glomerular hyperfiltration was observed, though there was large variability in GFR estimation using the different formulae. Gross over and underestimation was observed which improved with correction for body size confounders especially lean body weight (LBW). Postoperatively, significant attenuation in estimated GFR was demonstrated when LBW or body surface area-adjusted versions were used. In a subgroup of patients with chronic kidney disease, a significant improvement in GFR was seen postoperatively with the LBW-modified formula but there were again inconsistencies when using other equations., Conclusion: Though clinicians must be critical in the application of GFR estimates to patient care, LBW adjustment appears to be the most practical solution to its estimation in the obese patients. This is particularly true for patients with normal renal function but appears to be also applicable to those with compromised kidney function. Future studies are needed to compare these equations with a gold standard GFR measure as well as to explore whether the renal benefits from bariatric surgery are sustained or seen in more advanced CKD stages.

Purpose: Positive impact of weight loss on sexual function and hormones has been demonstrated, and male fertility in this scenario is to be better defined. We evaluated the impact of lifestyle modifications and gastric bypass on sperm quality., Methods: We prospectively studied 20 morbidly obese men during 24 months, randomized for intervention: lifestyle modifications (exercise and diet) for 4 months and subsequently gastric bypass (n = 10); and control: follow-up (n = 10). All patients underwent International Index of Erectile Function (IIEF-5) questionnaire, serum estradiol, prolactin (PRL), luteinizing and follicle-stimulating hormones (LH and FSH), free and total testosterones (FT and TT) and semen analysis at baseline (time 0), surgery 4 months later baseline (time 1) and final evaluation 24 months (time 2)., Results: Intervention group presented significant reduction in body mass index (BMI) at times 1 and 2, compared to control. There were no significant differences among sperm parameters between groups at times 0, 1, and 2 and among times 0, 1, and 2 in each group. Increases in IIEF-5 score (P = .0469), TT (P = .0349), and FSH (P = .0025) and reduction in PRL (P < .0001) were observed in the intervention group from times 0 to 2 and 1 to 2. Comparing groups at time 2, IIEF-5, TT, and FT increased significantly in the intervention group (P = .0224, P = .0043, and P = .0149, respectively)., Conclusions: Surgery-induced massive weight loss does not interfere with sperm quality, while it increased the quality of sexual function, TT, FT and FSH and reduced PRL. Lifestyle modifications impacted merely the BMI. New studies are warranted, mostly considering birth rate as primary end point and including infertile men.

Purpose: We aimed to determine the impact of insulin resistance and hyperandrogenemia on polysomnographic variables in obese adolescents with polycystic ovarian syndrome (PCOS), as studies in adults with PCOS suggest that parameters of glucose metabolism and serum androgens are related to respiratory polysomnographic variables (RPV), and the symptoms of PCOS usually begin around menarche., Methods: We divided our study group of obese adolescents with PCOS according to HOMA-index and in a second analysis according to free androgen index (FAI). Study group A consisted of 14 girls with HOMA-index <4, study group B of 17 girls with HOMA-index >4. Study group C consisted of 19 girls with FAI <10, and study group D of 18 girls with FAI >10. The control group for both analyses consisted of 19 healthy obese adolescents without PCOS. All girls underwent overnight 12-channel polysomnography., Results: In both analyses, we found no differences between the groups concerning the RPV. Study group B demonstrated a significantly lower percentage of REM-sleep than the control group (p = 0.02). Study group D demonstrated a significantly lower percentage sleep stages 3 and 4 of non-REM-sleep than study group C and the controls (p = 0.008). Study group D demonstrated significantly lower sleep efficiency than the controls (p = 0.03)., Conclusions: Insulin resistance and hyperandrogenemia do not seem to have a significant impact on RPV in obese adolescents with PCOS. Differences in sleep architecture found between patients with PCOS and controls, however, are possibly influenced by insulin resistance and/or serum androgens.

Background: The prevalence of obesity is increasing worldwide and has lately reached epidemic proportions in western countries. Several epidemiological studies have consistently shown that both overweight and obesity are important risk factors for the development of various functional defaecatory disorders (DDs), including faecal incontinence and constipation. However, data on their prevalence as well as effectiveness of bariatric surgery on their correction are scant. The primary objective of this study was to estimate the effect of morbid obesity on DDs in a cohort of patients listed for bariatric surgery. We also evaluated preliminary results of the effects of sleeve gastrectomy on these disorders., Patients and Methods: A questionnaire-based study was proposed to morbidly obese patients having bariatric surgery. Data included demographics, past medical, surgical and obstetrics histories, as well as obesity related co-morbidities. Wexner Constipation Score (WCS) and the Faecal Incontinence Severity Index (FISI) questionnaires were used to evaluate constipation and incontinence. For the purpose of this study, we considered clinically relevant a WCS ≥5 and a FISI score ≥10. The same questionnaires were completed at 3 and 6 months follow-up after surgery., Results: A total of 139 patients accepted the study and 68 underwent sleeve gastrectomy and fully satisfied our inclusion criteria with a minimum follow-up of 6 months. Overall, mean body mass index (BMI) at listing was 47 ± 7 kg/m(2) (range 35-67 kg/m(2)). Mean WCS was 4.1 ± 4 (range 0-17), while mean FISI score (expressed as mean±standard deviation) was 9.5 ± 9 (range 0-38). Overall, 58.9% of the patients reported DDs according to the above-mentioned scores. Twenty-eight patients (20%) had WCS ≥5. Thirty-five patients (25%) had a FISI ≥10 while 19 patients (13.7%) reported combined abnormal scores. Overall, DDs were more evident with the increase of obesity grade: Mean BMI decreased significantly from 47 ± 7 to 36 ± 6 and to 29 ± 4 kg/m(2) respectively at 3 and 6 months after surgery (p < 0.0001). According to the BMI decrease, the mean WCS decreased from 3.7 ± 3 to 3.1 ± 4 and to 1.6 ± 3 respectively at 3 and 6 months (p = 0.02). Similarly, the FISI score decreased from 10 ± 8 to 3 ± 4 and to 1 ± 2 respectively at 3 and 6 months (p = 0.0001)., Conclusions: Defaecatory disorders are common in morbidly obese patients. The risk of DDs increases with BMI. Bariatric surgery reduces DDs, mainly faecal incontinence, and these findings correlated with BMI reduction.

Context: Use of bariatric surgery for severe obesity has increased dramatically., Objective: To systematically review 1. the clinical efficacy and safety, 2. cost-effectiveness of bariatric surgery, and 3. the association between number of surgeries performed (surgical volume) and outcomes., Data Sources: MEDLINE (from 1950), EMBASE (from 1980), CENTRAL, EconLit, EURON EED, Harvard Center for Risk Analysis, trial registries and HTA websites were searched to January 2011., Study Selection: 1. Randomized controlled trials (RCTs) and 2. cost-utility and cost-minimisation studies comparing a contemporary bariatric surgery (i.e., adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy) to another contemporary surgical comparator or a non-surgical treatment or 3. Any study reporting the association between surgical volume and outcome., Data Extraction: Outcomes included changes in weight and obesity-related comorbidity, quality of life and mortality, surgical complications, resource utilization, and incremental cost-utility., Results: RCT data evaluating mortality and obesity-related comorbidity endpoints were lacking. A small RCT of 16 patients reported that adjustable gastric banding reduced weight by 27% (p < 0.01) compared to diet-treated controls over 40 weeks. Six small RCTs reported comparisons of commonly used, contemporary procedures. Gastric banding reduced weight to a lower extent than gastric bypass and sleeve gastrectomy and resulted in shorter operating times, fewer serious complications, lower weight loss efficacy, and more frequent reoperations compared to gastric bypass. Sleeve gastrectomy and gastric bypass reduced weight to a similar extent. A 2-year RCT in 50 adolescents reported that gastric banding substantially reduced weight compared to lifestyle modification (35 kg vs. 3 kg; p <0.001). Based on findings of 14 observational studies, higher volume centers and surgeons had lower mortality and complication rates. Surgery resulted in long-term incremental cost-utility ratios of $ <1.000-$40,000 (2009 USD) per quality-adjusted-life-year compared with non-surgical treatment., Conclusions: Contemporary bariatric surgery appears to result in sustained weight reduction with acceptable costs but rigorous, longer-term (≥5 year) data are needed and a paucity of RCT data on mortality and obesity related comorbidity is evident. Procedure-specific variations in efficacy and risks exist and require further study to clarify the specific indications for and advantages of different procedures.

Background: Obesity is associated with a chronic low-grade inflammatory state, insulin resistance, and endothelial dysfunction, all of which contribute to increased risk of cardiovascular disease. We hypothesized that gastric bypass would produce rapid improvements in endothelial function, reduce inflammation, and lead to a decrease in cardiovascular risk., Methods: We performed a prospective study of morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGB). Clinical data, biochemical markers of inflammation, and parameters indicative of cardiovascular risk were collected preoperatively and at 3 and 6 months postoperatively. Metabolic and inflammatory mediators that were quantified included C-reactive protein, fibrinogen, PAI-1, IL-6, IL-10, IL-1Ra, adiponectin, leptin, triglycerides, total cholesterol, HDL, LDL, glucose, insulin, and HbA1c. Brachial artery reactivity testing (BART) was performed to assess peripheral arterial endothelial function, and Framingham cardiovascular risk score (FRS) was calculated on all study participants pre- and postoperatively., Results: Fifteen patients (11 female) were enrolled (age = 49.2 ± 10.4 years; BMI = 48.1 ± 5.3 kg/m(2)). Six months post RYGB, mean BMI decreased to 35.4 ± 4.5, corresponding to 51.7% excess weight loss (P < 0.001). Mean waist circumference decreased significantly from 132 cm at baseline to 110 cm at 3 months (P = 0.003) and 107 cm at 6 months (P < 0.001). Six months after RYGB, weight loss led to significant improvements in clinical parameters indicative of cardiovascular disease or risk, including brachial artery diameter, endothelial independent vasodilation, and FRS. Favorable improvements in the proinflammatory markers CRP (P = 0.01) and leptin (P = 0.005), the anti-inflammatory mediator adiponectin (P = 0.002), and insulin sensitivity (HOMA-IR, P = 0.007) were evident at 3 months. At 6 months, improvements in CRP, leptin, and fasting insulin were maintained and fibrinogen levels also decreased (P = 0.047). Adiponectin continued to increase at 6 months (P = 0.004)., Conclusion: Gastric bypass is associated with early reversal of endothelial dysfunction, a more favorable inflammatory milieu, and, most importantly, a reduction in cardiovascular risk.

Background: This report describes the laparoscopic conversion of a Roux-en-Y gastric bypass (RYGBP) to biliopancreatic diversion (BPD)., Case Report: In January 1995, a 47-year-old woman with a body mass index (BMI) of 54 kg/m(2) benefited from a silicon ring vertical banded gastroplasty (SRVBG) for morbid obesity. She showed significant weight loss and reached a BMI of 30 kg/m(2). After 7 years, she experienced weight regain (BMI, 34.5 kg/m(2)), so a laparoscopic conversion to RYGBP was proposed. The patient again had a successful weight loss (BMI, 26 kg/m(2)), but 6 years later, she mentioned a weight regain (BMI, 33 kg/m(2)) with invalidating retrosternal pain. The nutritionist's analysis of the patient showed a certain modification of the alimentary character with frequent meals (grazing/polyphagia), and the psychologist's consultation identified an important binge-eating disorder. A laparoscopic conversion of RYGBP to BPD was proposed. The procedure consisted of (1) adhesiolysis and reduction of a hiatal hernia, (2) sectioning of the gastric pouch proximally to the gastrojejunostomy, (3) resection of the fundus of the gastric remnant excluded by the previous SRVBG, (4) restoration of the continuity of the stomach between the gastric pouch and the gastric remnant, (5) resection of the gastric antrum and pylorus, (6) deconstruction of the previous jejunojejunostomy, (7) restoration of the continuity of the small bowel, (8) measurement of the new common and alimentary limbs and construction of the jejunoileostomy, (9) closure of the mesenteric defect, (10) construction of the gastroileostomy, (11) closure of Petersen's space, and (12) repair of the hiatal hernia followed by a leak test., Results: The operative time was 320 min, and the blood loss was 380 ml. The patient had an uneventful recovery and was discharged on postoperative day 5. Her BMI was 30.5 kg/m(2) after 3 months and 26 kg/m(2) after 6 months. The barium swallow showed good transit through the gastrointestinal tract., Conclusions: The laparoscopic conversion of RYGBP to BPD is technically feasible and effective during the short term for cases of repeated weight regain.

Background: Optimal results of bariatric surgery are achieved when it is performed within a multidisciplinary team. Within this team, the dietician plays a key role before and after surgery in patient education and behaviour change. With long-term follow-up, the number of patients per surgeon increases exponentially. This study evaluated the outcomes of a dietician-only led management program for patients who underwent laparoscopic gastric banding in our unit., Methods: Between April 2003 and November 2007, 1,335 patients underwent laparoscopic gastric banding in two hospitals by the same surgical team. Weight loss outcomes were compared for patients in a dietician-led management program against a surgeon/nurse specialist follow-up program with more frequent patient visits. For the dietician-led group, a standard protocol of six postoperative visits and two to three fluoroscopic adjustments was developed from referral until 2 years after surgery., Results: There were 316 patients followed up in a dietician-led program. They were compared with the remaining patients who were followed up in a surgeon/ nurse specialist led program. The mean preoperative weight and body mass index (BMI) for the dietetic-led subset was significantly higher (weight: 147.4 +/- 30.2; BMI: 52.8 +/- 8.9) compared with the remaining group (weight: 113.8 +/- 18.7; BMI: 41.6 +/- 5.2; p < 0.001: Mann-Whitney test). Percent BMI loss was initially lower in the dietician-led group, but this difference disappeared at the end of 24 months (p = 0.056)., Conclusions: A patient management program led by specialist dieticians is an effective way to manage large numbers of patients after laparoscopic gastric banding while maintaining comparable weight loss to surgeon/nurse-led series.

Background: Morbid obesity (MO) is associated with increased renal plasma flow (RPL) and glomerular filtration rate (GFR). This type of obesity usually does not respond to medical treatment, with bariatric surgery being the current treatment of choice. The present study aimed to evaluate whether weight loss may reverse the glomerular hyperfiltration of MO patients., Methods: This was a retrospective study of 140 patients submitted to Roux-en-Y gastric bypass (31.5% men, mean body mass index 46.17 +/- 5). Renal glomerular function and anthropometric and biochemical parameters were studied in patients before and 8 months after the surgery. GFR was determined by 24-hour urine samples., Results: In the obese group, GFR before surgery was 148.7 +/- 35.2 ml/min. After the weight loss, GFR decreased to 113.8 +/- 31.7 ml/min (p<0.0001). Homeostasis model assessment-insulin resistance and glycosylated hemoglobin values were higher in MO with hyperfiltration. Weight loss was associated with reduction in blood pressure and GFR. It was found that the variation in systolic and diastolic blood pressure was a predictor of change in GFR., Conclusion: This study shows that obesity-related glomerular hyperfiltration ameliorates after weight loss. The improvement in hyperfiltration may prevent the development.

Objective: To present a technique of revisional RY gastric bypass in patients with unsatisfactory weight loss after primary gastric bariatric operations., Methods: The Roux limb was lengthened by creating a 75-100 cm common channel below the enteroenterostomy with concomitant revision of the gastrojejunostomy., Results: Fifty-four patients had this distal modification of RYGB including 47 patients who had primary gastric bypass and 7 patients who failed pure restrictive operations. Mean excess weight loss was 47.9% in patients followed for > or = 1 year., Conclusions: This distal modification of RYGB resulted in satisfactory weight loss for nearly half of the 54 patients in this series.

The objectives of the present study were to develop and cross-validate new equations for predicting resting energy expenditure (PREE) in severely obese Italian males, and to compare their accuracy with those of the Harris-Benedict, WHO/ FAO/UNU, Huang, Owen, Mifflin, Livingston, Nelson, Bernstein, and Cunnimgham equations in order to predict resting energy expenditure (REE), using the Bland-Altman method. One hundred and sixty-four severely obese males [mean body mass index (BMI): 45.4 kg/m2; 50.2% fat mass), aged 20 to 65 yr participated in this study. REE was measured by indirect calorimetry and body composition by bioelectrical analysis. Equations were derived by stepwise multiple regression analysis using a calibration group and tested against the validation group. Two new specific equations, based on anthropometric [REE=Weight x 0.048 + Height x 4.655 - age x 0.020 - 3.605 (R2=0.68, SE=1.14 MJ/d)] or body composition parameters [REE=fat free mass (FFM) x 0.081 + fat mass (FM) x 0.049 - age x 0.019 - 2.194 (R2=0.65, SE=1.15 MJ/d)], were generated. Mean PREE were not different from the mean measured REE (MREE) (<1%, p<0.001), REE being predicted accurately (95-105% of MREE) in 66 and 62% of subjects, respectively. The Harris-Benedict, WHO/FAO/UNU, Huang and Owen equations showed mean differences lower than 5% and PREE was accurate in less than 30% of subjects. The Mifflin, Livingston, and Nelson equations showed a mean PREE underestimation >7% (p<0.001) and PREE was accurate in less than 25% of subjects. The Bernstein and Cunningham equations showed a greater PREE underestimation (>22%, p<0.001) in more than 85% of subjects. The new prediction equations allow an accurate estimation of REE in groups of severely obese males and result in lower mean differences and lower limits of agreement between PREE and MREE than the commonly used equations.

Introduction: Obese individuals may have normal insulin-glucose homeostasis, insulin resistance, or diabetes mellitus. Whereas gastric bypass cures insulin resistance and diabetes mellitus, its effects on normal physiology have not been described. We studied insulin resistance and beta-cell function for patients undergoing gastric bypass., Methods: One hundred thirty-eight patients undergoing gastric bypass had fasting insulin and glucose levels drawn on days 0, 12, 40, 180, and 365. Thirty-one (22%) patients with diabetes mellitus were excluded from this analysis. Homeostatic model of assessment was used to estimate insulin resistance, insulin sensitivity, and beta-cell function. Based on this model, patients were categorized as high insulin resistance if their insulin resistance was >2.3., Results: Body mass index did not correlate with insulin resistance. Forty-seven (34%) patients were categorized as high insulin resistance. Correction of insulin resistance for this group occurred by 12 days postoperatively. Sixty (43%) patients were categorized as low insulin resistance. They demonstrated an increase of beta-cell function by 12 days postoperatively, which returned to baseline by 6 months. At 1 year postoperatively, the low insulin resistance group had significantly higher beta-cell function per degree of insulin sensitivity., Conclusions: Adipose mass alone cannot explain insulin resistance. Severely obese individuals can be categorized by degree of insulin resistance, and the effect of gastric bypass depends upon this preoperative physiology.

Background: While the majority of patients achieve good outcomes with the LAP-BAND, there is a subset of patients who experience complications or fail to lose sufficient weight after the banding procedure. This study examines the feasibility and outcome of performing laparoscopic Roux-en-Y gastric bypass (RYGBP) as a single-step revision surgery after a failed LAP-BAND procedure., Methods: In the past five years we have performed more than 1400 LAP-BAND procedures. We laparoscopically converted 33 (30 females) of these patients (mean age = 43.8 years) from LAP-BAND to RYGBP because of inadequate weight loss and/or complications. Key steps in the revision procedures were (1) identification and release of the band capsule; (2) careful dissection of the gastrogastric sutures; (3) creation of a small gastric pouch; and (4) Roux-en-Y anterior colic anterior gastric pouch-jejunum anastomosis. Revisions took place at a mean 28.2 months (range = 11-46; SD = 11.3) after the original gastric banding. Change in body mass index (BMI) between pre- and postrevision was evaluated with paired t tests., Results: Among the 33 patients who would undergo revision surgery, the mean BMI before the LAP-BAND procedure was 45.7 kg/m2 (range = 39.9-53.0; SD = 3.4) and the mean weight was 126 kg (range = 99-155; SD = 17). The lowest BMI achieved by this group with the LAP-BAND before revision was 39.7 kg/m2 (range = 30-49.2; SD = 4.9); however, the mean BMI at the time of revision was 42.8 kg/m2 (range = 33.1-50; SD = 4.8). The mean revision operative time was 105 min (range = 85-175), and the mean hospital stay was 2.8 days (range = 1-10). Complications included one patient who underwent open reoperation and splenectomy for a bleeding spleen and one patient who required repair of an internal hernia. After conversion to RYGBP, mean BMI decreased to 33.9 kg/m2 at 6 months (p < 0.001) and 30.7 kg/m2 (range = 22-39.6; SD = 5.3) at 12 months or more of followup (average = 15.7 months; p < 0.0001)., Conclusions: Laparoscopic conversion from LAP-BAND to RYGBP is safe and can be an alternative for patients who failed the LAP-BAND procedure. However, revision surgery is technically challenging and should be performed only by surgeons who have completed the learning curve for laparoscopic RYGBP.