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Obesity increases the risk of developing type 2 diabetes, hypertension, and hyperlipidemia. We sought to determine the impact of obesity maintenance, weight regain, weight loss maintenance, and magnitudes of weight loss on future risk and time to developing these cardiometabolic conditions. This was a retrospective cohort study of adults receiving primary care at Geisinger Health System between 2001 and 2017. Using electronic health records, patients with ≥3-weight measurements over a 2-year index period were identified and categorized. Obesity maintainers (OM) had obesity (body mass index ≥30 kg/m²) and maintained their weight within ±3% from baseline (reference group). Both weight loss rebounders (WLR) and weight loss maintainers (WLM) had obesity at baseline and lost5% body weight in year 1; WLR regained ≥20% of weight loss by end of year 2 and WLM maintained ≥80% of weight loss. Incident type 2 diabetes, hypertension, and hyperlipidemia, and time-to-outcome were determined for each study group and by weight loss category for WLM. Of the 63,567 patients included, 67% were OM, 19% were WLR, and 14% were WLM. The mean duration of follow-up was 6.6 years (SD, 3.9). Time until the development of electronic health record-documented type 2 diabetes, hypertension, and hyperlipidemia was longest for WLM and shortest for OM (log-rank test p0.0001). WLM had the lowest incident type 2 diabetes (adjusted hazard ratio [HR] 0.676 [95% confidence interval [CI] 0.617 to 0.740]; p0.0001), hypertension (adjusted HR 0.723 [95% CI 0.655 to 0.799]; p0.0001), and hyperlipidemia (adjusted HR 0.864 [95% CI 0.803 to 0.929]; p0.0001). WLM with the greatest weight loss (15%) had a longer time to develop any of the outcomes compared with those with the least amount of weight loss (7%) (p0.0001). In an integrated delivery network population, sustained weight loss was associated with a delayed onset of cardiometabolic diseases, particularly with a greater magnitude of weight loss.

The presence of chronic low-grade inflammation, commonly identified in patients with severe obesity, alters iron homeostasis and indicators of iron status, fostering the development of updated guidelines for the diagnosis of iron deficiency (ID). Current recommended diagnostic thresholds for ID in obesity derived from expert opinion include a ferritin level of30 ng/mL and/or transferrin saturation (TSAT)20%. Earlier studies of ID among candidates for metabolic surgery using low levels of ferritin or iron as diagnostic thresholds demonstrated a prevalence of 5%-20%.Using the current recommended diagnostic thresholds for ID, this study measures the prevalence of ID in a large cohort of surgical candidates and its relationship to surgical outcomes.Geisinger Medical Center, Danville, Pennsylvania.The study cohort included 3,723 patients who underwent pre- operative nutritional assessment which included markers of iron nutrition over the period 2004-2018.The cohort included 2,988 women (80.3%) and 735 men (19.7%); body mass index: 49.4 ± 9 kg/mThe prevalence of ID among surgical candidates (45.4%) is more than twice that identified as ID in earlier studies. ID was commonly identified in the absence of anemia. The most severe ID was found in those with a serum ferritin level30 ng/mL and TSAT20%. ID in the presence of inflammation is often unrecognized and has implications regarding surgical outcomes after metabolic surgery.

Obesity and diabetes are associated with chronic inflammation. Specialized pro-resolving lipid mediators (SPMs)—resolvins (Rv), protectins (PD) and maresins (MaR)—actively resolve inflammation. Bariatric surgery achieves remission of diabetes, but mechanisms are unclear. We measured SPMs and proinflammatory eicosanoid levels using liquid chromatography-tandem mass spectrometry in 29 morbidly obese subjects (13 with diabetes) and 15 nondiabetic, mildly obese subjects. Compared to the mildly obese, the morbidly obese had higher levels of SPMs—RvD3, RvD4 and PD1—and white blood cells (WBC) and platelets. Post-surgery, SPM and platelet levels decreased in morbidly obese nondiabetic subjects but not in diabetic subjects, suggesting continued inflammation. Despite similar weight reductions 1 year after surgery (44.6% vs. 46.6%), 8 diabetes remitters had significant reductions in WBC and platelet counts whereas five non-remitters did not. Remitters had a 58.2% decrease (p = 0.03) in 14-HDHA, a maresin pathway marker; non-remitters had an 875.7% increase in 14-HDHA but a 36.9% decrease in MaR1 to a median of 0. In conclusion, higher levels of RvD3, PD1 and their pathway marker, 17-HDHA, are markers of leukocyte activation and inflammation in morbid obesity and diabetes and diminish with weight loss in nondiabetic but not diabetic subjects, possibly representing sustained inflammation in the latter. Lack of diabetes remission after surgically-induced weight loss may be associated with reduced ability to produce MaR1 and sustained inflammation.

The near universal presence of chronic low-grade systemic inflammation among patients with severe obesity disrupts iron homeostasis and underlies the association between obesity and iron deficiency. Immune activation and inflammation results in a reduction in circulating iron and diminished iron bioavailability for erythropoiesis. Inflammation also alters blood levels of commonly measured markers of iron nutrition status, which makes the diagnosis of iron deficiency difficult and has led to new recommendations regarding laboratory markers for the diagnosis. Recent evidence utilizing these newly recommended laboratory markers which include levels of ferritin, C Reactive Protein, and Transferrin Saturation suggests that the actual prevalence of iron deficiency among candidates for metabolic surgery may be double or triple the prevalence identified by low levels of ferritin alone. Thus, large numbers of surgical candidates have iron deficiency which has been heretofore largely unrecognized and inadequately treated. The assessment of iron status utilizing the currently recommended markers in the presence of chronic inflammatory diseases, and repletion of depleted stores for surgical candidates with deficiency during the pre-operative period presents an important opportunity for mitigating this condition in post-operative patients.

The current popularity of metabolic surgery has led to increasing attention to long-term nutritional complications.The purpose of this retrospective study is to accurately define the long-term incidence of clinically significant anemia after Roux-en-Y gastric bypass (RYGB) and to identify factors that contribute to increased risk.The study cohort consisted of 2116 patients who underwent RYGB with necessary laboratory information available, and with longitudinal follow-up available (mean 5.3 ± 3.3 yr). A concurrent cohort of nonoperated patients matched for age, sex, body mass index, and baseline hemoglobin was identified (N = 1126). The RYGB and control cohorts were followed longitudinally to estimate the percent that develop mild, moderate, or severe anemia using Kaplan-Meier analysis. Predictors of severe anemia within the RYGB cohort were identified using Cox regression.The percent developing postRYGB mild, moderate, and severe anemia was 27%, 9%, and 2% at 1 year postRYGB and increased to 68%, 33%, and 11% at 5 years postRYGB. As compared with the nonoperated control cohort, the RYGB cohort was more likely to develop mild anemia (hazard ratio [HR] = 1.36, P.001), moderate anemia (HR = 1.75, P.001), and severe anemia (HR = 1.87, P.001). Severity of anemia was associated with an increasing percentage of microcytosis (P.0001). Clinical factors independently associated with an increased risk of severe anemia within the RYGB cohort included females and males40 years of age (HR = 2.97, 95% confidence interval [CI] = 1.14, 7.75, P = .026), preoperative anemia (HR = 1.65, 95% CI = 1.19, 2.29, P = .0029), preoperative low ferritin level (HR = 2.28, 95% CI = 1.39, 3.74, P = .0029), and a rapid 6-month weight loss trajectory (HR = 1.71, 95% CI = 1.22, 2.38, P = .0018).The long-term incidence of clinically significant anemia after RYGB is alarmingly high and warrants more detailed study.

Total Knee Arthroplasty (TKA, also known as total knee replacement) is a highly effective surgical intervention for the restoration of physical function and improving quality of life in patients with disabling knee osteoarthritis. Recent data suggest that obesity is a major risk factor in the pathogenesis and progression of knee osteoarthritis, with increases in body mass index (BMI, kg/m2) directly correlating with the prevalence of knee osteoarthritis. However, recent data also suggest that there are increased risks associated with TKAs when performed in patients with morbid obesity (BMI > 40 kg/m2). Patients with morbid obesity are routinely referred for weight management prior to surgery. Many of these patients fail to meet the recommended weight loss goals prior to TKA, potentially making them ineligible for surgery or placing them at increased risk for sub-optimal outcomes. Thus, the purpose of this study is to examine the potential therapeutic impact and long-term outcomes of surgically induced weight loss on TKA outcomes. Specifically, these outcomes will include measures of physical function, mobility, and indices of joint function at 1 and 2 years post-TKA compared between extremely obese patients who undergo TKA (Control group, n = 150) and those with TKA performed ~1 year after bariatric surgery (Test group, n = 150). An additional primary endpoint will be the percent of bariatric patients that negate or delay the need for TKA. Secondary endpoints include perioperative outcomes after TKA.

Angiopoietin-like 4 (ANGPTL4) is an endogenous inhibitor of lipoprotein lipase that modulates lipid levels, coronary atherosclerosis risk, and nutrient partitioning. We hypothesize that loss of ANGPTL4 function might improve glucose homeostasis and decrease risk of type 2 diabetes (T2D). We investigate protein-altering variants in ANGPTL4 among 58,124 participants in the DiscovEHR human genetics study, with follow-up studies in 82,766 T2D cases and 498,761 controls. Carriers of p.E40K, a variant that abolishes ANGPTL4 ability to inhibit lipoprotein lipase, have lower odds of T2D (odds ratio 0.89, 95% confidence interval 0.85–0.92, p = 6.3 × 10−10), lower fasting glucose, and greater insulin sensitivity. Predicted loss-of-function variants are associated with lower odds of T2D among 32,015 cases and 84,006 controls (odds ratio 0.71, 95% confidence interval 0.49–0.99, p = 0.041). Functional studies in Angptl4-deficient mice confirm improved insulin sensitivity and glucose homeostasis. In conclusion, genetic inactivation of ANGPTL4 is associated with improved glucose homeostasis and reduced risk of T2D., Genetic variation in ANGPTL4 is associated with lipid traits. Here, the authors find that predicted loss-of-function variants in ANGPTL4 are associated with glucose homeostasis and reduced risk of type 2 diabetes and that Angptl4−/− mice on a high-fat diet show improved insulin sensitivity.

Objective Determine the impact of long-term non-surgical weight loss maintenance on clinical relevance for osteoarthritis, cancer, opioid use, and depression/anxiety and healthcare resource utilization. Methods A cohort of adults receiving primary care within Geisinger Health System between 2001–2017 was retrospectively studied. Patients with ≥3 weight measurements in the two-year index period and obesity at baseline (BMI ≥30 kg/m2) were categorized: Obesity Maintainers (reference group) maintained weight within +/-3%; Weight Loss Rebounders lost ≥5% body weight in year one, regaining ≥20% of weight loss in year two; Weight Loss Maintainers lost ≥5% body weight in year one, maintaining ≥80% of weight loss. Association with development of osteoarthritis, cancer, opioid use, and depression/anxiety, was assessed; healthcare resource utilization was quantified. Magnitude of weight loss among maintainers was evaluated for impact on health outcomes. Results In total, 63,567 patients were analyzed including 67% Obesity Maintainers, 19% Weight Loss Rebounders, and 14% Weight Loss Maintainers; median follow-up was 9.7 years. Time until osteoarthritis onset was delayed for Weight Loss Maintainers compared to Obesity Maintainers (Logrank test p 15% weight loss was associated with the greatest decrease in incident osteoarthritis. Healthcare resource utilization was significantly higher for Weight Loss Rebounders and Maintainers compared to Obesity Maintainers. Increased weight loss among Weight Loss Maintainers trended with lower overall healthcare resource utilization, except for hospitalizations. Conclusions In people with obesity, sustained weight loss was associated with greater clinical benefits than regained short-term weight loss and obesity maintenance. Higher weight loss magnitudes were associated with delayed onset of osteoarthritis and led to decreased healthcare utilization.

The objective of this study was to determine whether the DiaRem, a score that predicts type 2 diabetes (T2D) remission following roux-en-y gastric bariatric surgery (RYGB), also predicts remission following laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) in white and Hispanic patients.While bariatric surgery is highly effective in reversing insulin resistance, there are patients for whom surgery will not lead to remission. To date, there is no score for predicting remission following LAGB or LSG surgery. Additionally, there is little known about how to predict whether Hispanic patients will experience remission.We conducted a retrospective cohort study of white and Hispanic patients with T2D who received bariatric surgery. There were 361 white and 130 Hispanic patients among whom 328 had RYGB surgery, 107 had LSG surgery, and 56 had LAGB surgery. We used age, diabetes treatment, and hemoglobin A1c to calculate DiaRem scores. Mann-Whitney U test was used to determine the association between DiaRem scores and remission. Area under the receiver operant curve (AUC) was used to assess the ability of the DiaRem to discriminate between patients who did and did not remit.The DiaRem was associated with partial remission in all surgery types for white and Hispanic patients (Mann-Whitney, p 0.001). The DiaRem had moderate to high discriminant ability (AUC 0.70) for all surgical and racial/ethnic groups.The DiaRem distinguishes between patients likely and unlikely to experience remission, informing expectations of patients making T2D treatment decisions.

OBJECTIVE: We sought to validate an algorithm designed to identify patients with post-gastric bypass hypoglycemia (PGBH) using clinician chart review. METHODS: We conducted a chart review study of nondiabetic patients who underwent Roux-en-Y gastric bypass (RYGB) at our institution from 2004 to 2013. The EMR algorithm was based on any post-operative glucose

Increased inflammation and oxidative stress associated with obesity can accelerate aging. Telomere length (TL) has the capacity to serve as an aging indicator at the cellular level. Obesity has a known association with shorter TL. This study evaluated TL of immune cells in a population of obese individuals who underwent gastric bypass surgery. Pre- and post-operative DNA samples were available for 50 subjects who had gastric bypass surgery. DNA was analyzed via quantitative polymerase chain reaction to determine TL. Changes in TL were evaluated by comparing TL at baseline to TL at 3-5 years post gastric bypass surgery. Sixty percent of the individuals in the study observed an increase in TL. Significant lengthening was observed for those with the shortest baseline TL (P=0.0011), but not for those with intermediate baseline TL (P=0.411) or longest baseline TL (P=0.207). Change in TL was negatively correlated with age and triglycerides but not correlated with weight loss induced by bariatric surgery. This study confirms that TL lengthening is observed post bariatric surgery and is the first to detect TL lengthening 3-5 years after surgery.

Background DiaRem is a validated tool for predicting the likelihood of type 2 diabetes (T2D) remission after Roux-en-Y gastric bypass (RYGB) surgery. Objectives The objective of this study was to determine if the addition of duration of T2D to DiaRem improves its ability to discriminate between patients with or without T2D remission and/or to reclassify presurgery patients into accurate risk groups. Setting Academic Medical Center. Methods This study included patients consented into a prospective registry of Roux-en-Y gastric bypass between July 2009 and November 2015 with known duration of T2D (n = 307). Electronic health record–derived duration of T2D was compared with patient reported duration of T2D in a subset of patients (n = 48). DiaRem2 was created using clinical variables from DiaRem and duration of T2D. Area under the curve and the net reclassification index were used to assess increased performance of DiaRem2. Results Self-reported duration of T2D was highly concordant with electronic health record–derived T2D duration (96% agreement). Early T2D remission occurred in 44% of patients. DiaRem2 included age, hemoglobin A1C, insulin medication use, and duration of T2D. DiaRem2 had a higher area under the curve than DiaRem (.876 versus .850, P = .026), reduced the number of remission risk groups from 5 down to 3, and reclassified patients from intermediate to either high or low remission groups (net reclassification index, P Conclusions DiaRem2 simplifies and improves the accuracy of assessing probability of T2M remission after Roux-en-Y gastric bypass. Self-reported duration of T2D is an acceptable surrogate for T2D duration derived from clinical data.

Iron deficiency and anaemia after metabolic surgery, potentially modifiable nutritional complications, are becoming an increasing cause for concern as prevalence increases with time and there is limited evidence supporting the effectiveness of the current guidelines for prophylactic oral iron supplementation and treatment for deficiency. Abnormalities in iron nutrition predisposing to deficiency are common in severely obese patients, and the low-grade systemic inflammation, also common to these patients, reduces the effectiveness of oral iron supplementation. The surgical procedures result in alterations of foregut anatomy and physiology, which limit iron absorptive capacity and daily food intake. These alterations and the limited effects of oral iron supplementation explain the high prevalence of postoperative iron deficiency and anaemia. This review outlines current mechanisms concerning the pathogenesis of disordered iron nutrition in patients with severe obesity, current gaps in knowledge, and opportunities for quality improvement.

PURPOSE: The objective of this descriptive study was to identify clinical characteristics of Roux-en-Y Gastric Bypass (RYGB) patients who died from intentional self-harm or accidental overdose postoperatively. MATERIALS AND METHODS: This retrospective, descriptive study included RYGB patients from a large rural medical center that completed surgery between January 2004 and December 2014 and died from intentional self-harm or accidental overdose through December 2015. Specific causes of death were obtained from the National Death Index and clinical data from electronic health records. Clinical characteristics explored were age, sex, time to surgery, weight loss expectations, postoperative weight loss, medication, diagnoses, psychiatric histories (diagnoses, self-harm, suicidal ideation and behaviors, medications, substance use, preoperative Beck Depression Inventory-II scores), pain, social support and reported life stressors. RESULTS: Overall, twenty-two patients of 146 total deceased patients died from intention self-harm (n = 6) or accidental overdose (n = 16) over the study period (77.3% female, mean age at time of surgery = 38.4±9.1 years). Younger age (< 40 years), history of self-harm or depression, preoperative pain and use of opioids at the time of surgery emerged as common characteristics in weight-loss surgery patients who died from intentional self-harm or accidental overdose. No trends regarding social support, life stressors, or actual or expected weight loss were identified. CONCLUSION: Certain weight-loss surgery patients may be at risk for death from self-harm or overdose and may benefit from greater surveillance postoperatively.

Background Nonalcoholic fatty liver disease (NAFLD) is a prevalent complication of extreme obesity. Loading of the liver with fat can progress to inflammation and fibrosis including cirrhosis. The molecular factors involved in the progression from simple steatosis to fibrosis remain poorly understood. Methods Gene expression profiling using microarray, PCR array, and RNA sequencing was performed on RNA from liver biopsy tissue from patients with extreme obesity. Patients were grouped based on histological findings including normal liver histology with no steatosis, lobular inflammation, or fibrosis, and grades 1, 2, 3, and 4 fibrosis with coexistent steatosis and lobular inflammation. Validation of expression was conducted using quantitative PCR. Serum analysis was performed using ELISA. Expression analysis of hepatocytes and hepatic stellate cells in response to lipid loading were conducted in vitro using quantitative PCR and ELISA. Results Three orthogonal methods to profile human liver biopsy RNA each identified the chemokine CCL20 (CC chemokine ligand 20 or MIP-3 alpha) gene as one of the most up-regulated transcripts in NAFLD fibrosis relative to normal histology, validated in a replication group. CCL20 protein levels in serum measured in 224 NAFLD patients were increased in severe fibrosis (p

This study assessed all-cause and specific-cause mortality after Roux-en-Y gastric bypass (RYGB) and in matched control subjects, stratified by diabetes status.RYGB patients were matched by age, BMI, sex, and diabetes status at time of surgery to nonsurgical control subjects using data from the electronic health record. Kaplan-Meier curves and Cox regression were used to assess differences in all-cause and specific-cause mortality between RYGB patients and control subjects with and without diabetes.Of the 3,242 eligible RYGB patients enrolled from January 2004 to December 2015, control subjects were identified for 2,428 (All-cause mortality benefits of RYGB are driven predominantly by patients with diabetes at the time of surgery. RYGB patients with diabetes were less likely to die of cardiovascular diseases, diabetes, and respiratory conditions than their counterparts without RYGB.

Background Obesity and its association with reduced life expectancy are well established, with cardiovascular disease as one of the major causes of fatality. Metabolic surgery is a powerful intervention for severe obesity, resulting in improvement in comorbid diseases and in cardiovascular risk factors. This study investigates the relationship between metabolic surgery and long‐term cardiovascular events. Methods and Results A cohort of Roux‐en‐Y gastric bypass surgery ( RYGB ) patients was tightly matched by age, body mass index, sex, Framingham Risk Score, smoking history, use of antihypertension medication, diabetes mellitus status, and calendar year with a concurrent cohort of nonoperated control patients. The primary study end points of major cardiovascular events (myocardial infarction, stroke, and congestive heart failure) were evaluated using Cox regression. Secondary end points of longitudinal cardiovascular risk factors were evaluated using repeated‐measures regression. The RYGB and matched controls (N=1724 in each cohort) were followed for up to 12 years after surgery (overall median of 6.3 years). Kaplan–Meier analysis revealed a statistically significant reduction in incident major composite cardiovascular events ( P =0.017) and congestive heart failure (0.0077) for the RYGB cohort. Adjusted Cox regression models confirmed the reductions in severe composite cardiovascular events in the RYGB cohort (hazard ratio=0.58, 95% CI =0.42–0.82). Improvements of cardiovascular risk factors (eg, 10‐year cardiovascular risk score, total cholesterol, high‐density lipoprotein, systolic blood pressure, and diabetes mellitus) were observed within the RYGB cohort after surgery. Conclusions Gastric bypass is associated with a reduced risk of major cardiovascular events and the development of congestive heart failure.

Non-alcoholic fatty liver disease (NAFLD) represents a spectrum of conditions that include steatohepatitis and fibrosis that are thought to emanate from hepatic steatosis. Few robust biomarkers or diagnostic tests have been developed for hepatic steatosis in the setting of obesity. We have developed a multi-component classifier for hepatic steatosis comprised of phenotypic, genomic, and proteomic variables using data from 576 adults with extreme obesity who underwent bariatric surgery and intra-operative liver biopsy. Using a 443 patient training set, protein biomarker discovery was performed using the highly multiplexed SOMAscan® proteomic assay, a set of 19 clinical variables, and the steatosis predisposing PNPLA3 rs738409 single nucleotide polymorphism genotype status. The most stable markers were selected using a stability selection algorithm with a L1-regularized logistic regression kernel and were then fitted with logistic regression models to classify steatosis, that were then tested against a 133 sample blinded verification set. The highest area under the ROC curve (AUC) for steatosis of PNPLA3 rs738409 genotype, 8 proteins, or 19 phenotypic variables was 0.913, whereas the final classifier that included variables from all three domains had an AUC of 0.935. These data indicate that multi-domain modeling has better predictive power than comprehensive analysis of variables from a single domain.

OBJECTIVE Gastric bypass surgery is an effective therapy for extreme obesity. However, substantial variability in weight loss outcomes exists that remains largely unexplained. Our objective was to determine whether any commonly collected pre-operative clinical variables were associated with weight loss following Roux-en-Y gastric bypass surgery. DESIGN The analysis was based on a prospectively recruited observational cohort of 2365 patients who underwent Roux-en-Y gastric bypass surgery from 2004-2009. Weight loss was stratified into three major phases, early (0-6 months), nadir, and long-term (>36 months). Multivariate regression models were constructed using a database of over 350 variables. RESULTS A total of 12-14 pre-operative variables were independently associated (p50 years, and the presence of fibrosis on liver biopsy. CONCLUSIONS Several variables previously associated with poorer weight loss after RYGB surgery including age, baseline BMI, and type 2 diabetes were replicated. Several others suggest possible clinical interventions for post-operative management of RYGB patients to improve weight loss outcomes.

Objectives. The accumulation of lipids stored as excess triglycerides in the liver (steatosis) is highly prevalent in obesity and has been associated with several clinical characteristics, but most studies have been based on relatively small sample sizes using a limited set of variables. We sought to identify clinical factors associated with liver fat accumulation in a large cohort of patients with extreme obesity.Methods. We analyzed 2929 patients undergoing intraoperative liver biopsy during a primary bariatric surgery. Univariate and multivariate regression modeling was used to identify associations with over 200 clinical variables with the presence of any fat in the liver and with moderate to severe versus mild fat accumulation.Results. A total of 19 data elements were associated with the presence of liver fat and 11 with severity of liver fat including ALT and AST, plasma lipid, glucose, and iron metabolism variables, several medications and laboratory measures, and sleep apnea. The accuracy of a multiple logistic regression model for presence of liver fat was 81% and for severity of liver fat accumulation was 77%.Conclusions. A limited set of clinical factors can be used to model hepatic fat accumulation with moderate accuracy and may provide potential mechanistic insights in the setting of extreme obesity.

We sought to identify the major risk factors associated with mortality in Roux-en-Y gastric bypass (RYGB) surgery.Bariatric surgery has become an established treatment for extreme obesity. Bariatric surgery mortality has steadily declined with current rates of less than 0.5%. However, significant variation in the mortality rates has been reported for specific patient cohorts and among bariatric centers.Clinical outcome data from 185,315 bariatric surgery patients from the Bariatric Outcome Longitudinal Database were reviewed. Of these, 157,559 patients had either documented 30 or more day follow-up data, including mortality. Multiple demographic, socioeconomic, and clinical factors were analyzed by univariate analysis for their association with 30-day mortality after gastric bypass. Variables found to be significant were entered into a multiple logistic regression model to identify factors independently associated with 30-day mortality. On the basis of these results, a RYGB mortality risk score was developed.The overall 30-day mortality rate for the entire bariatric surgery cohort was 0.1%. Of the 81,751 RYGB patients, the mortality rate was 0.15%. Factors significantly associated with 30-day gastric bypass mortality included increasing body mass index (BMI) (P0.0001), increasing age (P0.005), male gender (P0.001), pulmonary hypertension (P0.0001), congestive heart failure (P=0.0008), and liver disease (P=0.038). When the RYGB risk score was applied, a significant trend (P0.0001) between increasing risk score and mortality rate is found.Increasing BMI, increasing age, male gender, pulmonary hypertension, congestive heart failure, and liver disease are risk factors for 30-day mortality after RYGB. The RYGB risk score can be used to determine patients at greater risk for mortality after RYGB surgery.

Objective The goal of the present study was to identify differences in gene expression between SAT, VAT, and EAT depots in Class III severely obese individuals. Design Human subcutaneous (SAT) and visceral (VAT) adipose tissues exhibit differential gene expression profiles. There is little information, however, about the other proximal white adipose tissue, epigastric (EAT) in terms of its function and contribution to metabolism. Subjects and Methods Using RNA from adipose biospecimens obtained from Class III severely obese patients undergoing open Roux-en-Y gastric bypass surgery, we compared gene expression profiles between SAT, VAT, and EAT, using microarrays validated by real time quantitative PCR. Results The three depots were found to share 1,907 genes. VAT had the greatest number of genes [66] expressed exclusively in this depot, followed by SAT [23], and then EAT [14]. Moreover, VAT shared more genes with EAT [65] than with SAT [38]. Further analyses using ratios of SAT/EAT, VAT/EAT, and SAT/VAT, identified specific as well as overlapping networks and pathways of genes representing dermatological diseases, inflammation, cell cycle and growth, cancer, and development. Targeted analysis of genes playing a role in adipose tissue development and function, revealed that Peroxisome proliferator-activated receptor Gamma Coactivator 1-alpha (PGC1-α) that regulates the precursor of the hormone Irisin (FNCD5), were abundantly expressed in all three fat depots, along with fibroblast growth factors (FGF) FGF1, FGF7, and FGF10, whereas, FGF19 and FGF21 were undetectable. Conclusions These data indicate that EAT has more in common with VAT suggesting similar metabolic potential. The human epigastric adipose depot could play a significant functional role in metabolic diseases and should be further investigated.

Objectives: Genome-wide association studies (GWAS) have led to the identification of single nucleotide polymorphisms in or near several loci that are associated with the risk of obesity and nonalcoholic fatty liver disease (NAFLD). We hypothesized that missense variants in GWAS and related candidate genes may underlie cases of extreme obesity and NAFLD-related cirrhosis, an extreme manifestation of NAFLD. Methods: We performed whole-exome sequencing on 6 Caucasian patients with extreme obesity [mean body mass index (BMI) 84.4] and 4 obese Caucasian patients (mean BMI 57.0) with NAFLD-related cirrhosis. Results: Sequence analysis was performed on 24 replicated GWAS and selected candidate obesity genes and 5 loci associated with NAFLD. No missense variants were identified in 19 of the 29 genes analyzed, although all patients carried at least 2 missense variants in the remaining genes without excess homozygosity. One patient with extreme obesity carried 2 novel damaging mutations in BBS1 and was homozygous for benign and damaging MC3R variants. In addition, 1 patient with NAFLD-related cirrhosis was compound heterozygous for rare damaging mutations in PNPLA3. Conclusions: These results indicate that analyzing candidate loci previously identified by GWAS analyses using whole-exome sequencing is an effective strategy to identify potentially causative missense variants underlying extreme obesity and NAFLD-related cirrhosis.

This study evaluated the social environment of bariatric surgery patients in the preoperative period. Forty bariatric surgery patients (mean = 46.2 ± 11.2 years), 35 adult cohabitating family members (mean = 45.2 ± 12.7 years), and 15 cohabitating children (mean = 11.5 ± 3.6 years) were recruited from a large rural medical center. Adult participants (patients and family members) completed height, weight, body composition, blood draws, and physical activity assessments (accelerometry), as well as eating behavior and social support inventories before the patient underwent bariatric surgery. Child participants completed demographic, height, and weight assessment only. Over 90 % of adult family members were overweight or obese (body mass index (BMI) ≥ 25 kg/m2, as were 50 % of children (BMI percentile ≥ 85 %). More than one third (37.1 %) of family members met the criteria for moderate to severe insulin resistance. Physical activity measured by accelerometry was moderately correlated between the patient and adult family members (r = 0.46, p = 0.023). Bariatric surgery patients reported high levels of social support from their family members on multiple social support measures. Many family members of bariatric surgery patients also lived with obesity and related comorbidities, and demonstrate high sedentary behavior. However, patients reported high levels of support from family members, including support in following a healthy diet and engaging in physical activity. Engaging families in behavior change may help bariatric surgery patients and their families to become healthier.

Genome-wide association and linkage studies have identified multiple susceptibility loci for obesity. We hypothesized that such loci may affect weight loss outcomes following dietary or surgical weight loss interventions. A total of 1,001 white individuals with extreme obesity (BMI >35 kg/m(2)) who underwent a preoperative diet/behavioral weight loss intervention and Roux-en-Y gastric bypass surgery were genotyped for single-nucleotide polymorphisms (SNPs) in or near the fat mass and obesity-associated (FTO), insulin induced gene 2 (INSIG2), melanocortin 4 receptor (MC4R), and proprotein convertase subtilisin/kexin type 1 (PCSK1) obesity genes. Association analysis was performed using recessive and additive models with pre- and postoperative weight loss data. An increasing number of obesity SNP alleles or homozygous SNP genotypes was associated with increased BMI (P < 0.0006) and excess body weight (P < 0.0004). No association between the amounts of weight lost from a short-term dietary intervention and any individual obesity SNP or cumulative number of obesity SNP alleles or homozygous SNP genotypes was observed. Linear mixed regression analysis revealed significant differences in postoperative weight loss trajectories across groups with low, intermediate, and high numbers of obesity SNP alleles or numbers of homozygous SNP genotypes (P < 0.0001). Initial BMI interacted with genotype to influence weight loss with initial BMI

Critically ill obese patients require timely nutrition in the intensive care unit. Hypocaloric, high protein nutritional feeding might have a role in critically ill obese patients. Although critically ill obese patients need special medical and nutritional care as do nonobese patients in the ICU, there are some differences in the literature about the initiation, routes, and nature of nutritional support. This article reviews the norms of nutritional care among critically ill obese patients and the differences between these patients and those with a normal BMI.

Nonalcoholic fatty liver disease (NAFLD) is common in adults with extreme obesity and can impact long-term health and survival. Liver biopsy is the only accurate test for diagnosis and staging, but is invasive and costly. Non-invasive testing offers an attractive alternate, but the overall accuracy remains a significant issue. This study was conducted to determine the accuracy and clinical utility of pre-operative ultrasound and liver transaminase levels, as well as intra-operative hepatic visual inspection, for assessing presence of NAFLD as confirmed by hepatic histology.Data was collected prospectively from 580 morbidly obese adult patients who underwent Roux-en-Y gastric bypass surgery with intraoperative wedge biopsy between January 2004 and February 2009. Complete data for ultrasound, ALT and AST levels, and documented visual inspection was available for 513 patients.The prevalence of NAFLD was 69 % and that of NASH was 32 %. The individual non-invasive clinical assessments demonstrated low sensitivity, specificity, and accuracy for detecting the presence of steatosis, steatohepatitis, or fibrosis. The combination of normal or abnormal results for all tests improved predictive utility. Abnormal tests with all three assessments had a sensitivity of 95-98 % and a specificity of 28-48 % for major histologic findings in NAFLD/NASH. Normal tests with all three assessments had a sensitivity of 12-22 % and a specificity of 89-97 % for major histologic findings in NAFLD/NASH.Although individual clinical tests for NAFLD have limited accuracy, the use of combined clinical tests may prove useful.

Type 2 diabetes mellitus (“T2D” or “diabetes,” herein) has significant medical and socioeconomic implications.1 Roux-en-Y gastric bypass (RYGB) surgery is an effective intervention in humans that remits T2D,2 with approximately 60% of patients achieving temporary resolution or durable T2D remission.3,4 RYGB has also been proposed as a therapy for T2D resolution even in cases where weight loss may not be the primary objective5 and particularly for cases with low body mass index (BMI) ranging from 25 to 35 kg/m2.6 Durable T2D remission has been associated with early-stage diabetes7 and significant percent excess body weight loss,8 whereas inability to achieve long-term remission has been associated with inadequate weight loss.9 Glycemic response to gastric bypass has also been correlated with BMI, duration of diabetes, fasting C peptide, and weight loss.10 Young age and low BMI (25–35 kg/m2) have also been associated with long-term T2D remission,6 whereas use of insulin, high HbA1c, and low percent excess body weight loss have been associated with decreased rate of remission after RYGB surgery.11 In the Swedish obese subjects study, 72% of patients experience remission of diabetes within 2 years after surgery but only 36% remained in remission after 10 years.12 In a recent study, patients not taking insulin before RYGB surgery had significantly higher remission rates than patients using insulin (53.8% vs 13.5%).3 Elsewhere, approximately 70% of patients using insulin did not remit diabetes 2 years after RYGB surgery, whereas among noninsulin users only approximately 15% of patients did not remit.13 In general, preoperative use of insulin is associated with low remission rates after RYGB surgery over 5 years.3,13 Here, we show that preoperative addition of incretins could significantly improve remission rates for this group of patients.

Fibroblast growth factors 19 and 21 (FGF19 and FGF21) have been implicated, independently, in type 2 diabetes (T2D) but it is not known if their circulating levels correlate with each other or whether the associated hepatic signaling mechanisms that play a role in glucose metabolism are dysregulated in diabetes. We used a cross-sectional, case/control, experimental design involving Class III obese patients undergoing Roux-en-Y bariatric surgery (RYGB), and measured FGF19 and FGF21 serum levels and hepatic gene expression (mRNA) in perioperative liver wedge biopsies. We found that T2D patients had lower FGF19 and higher FGF21 serum levels. The latter was corroborated transcriptionally, whereby, FGF21, as well as CYP7A1, β-Klotho, FGFR4, HNF4α, and glycogen synthase, but not of SHP or FXR mRNA levels in liver biopsies were higher in T2D patients that did not remit diabetes after RYGB surgery, compared to T2D patients that remitted diabetes after RYGB surgery or did not have diabetes. In a Phenome-wide association analysis using 205 clinical variables, higher FGF21 serum levels were associated with higher glucose levels and various cardiometabolic disease phenotypes. When serum levels of FGF19 were < 200 mg/mL and FGF21 > 500 mg/mL, 91% of patients had diabetes. These data suggest that FGF19/FGF21 circulating levels and hepatic gene expression of the associated signaling pathway are significantly dysregulated in type 2 diabetes.

Background: Laparoscopic bariatric surgery has experienced a rapid expansion of interest over the past 5 years, with a 470% increase. This rapid expansion has markedly increased overall cost, reducing surgical access. Many surgeons believe that the traditional open approach is a cheaper, safer, equally effective alternative. Methods: 16 highly experienced "open" bariatric surgeons with a combined total of 25,759 cases representing >200 surgeon years of experience, pooled their open Roux-en-Y gastric bypass (ORYGBP) data, and compared their results to the leading laparoscopic (LRYGBP) papers in the literature. Results: In the overall series, the incisional hernia rate was 6.4% using the standard midline incision. Utilizing the left subcostal incision (LSI), it was only 0.3%. Return to surgery in

Objective Surgical treatment of severe obesity is the most rapidly growing specialty area of surgery. The rapid expansion of bariatric surgery has raised questions and concerns regarding possible increased surgical mortality and morbidity rates in both academic and community settings. The purpose of this study was to evaluate postoperative outcomes and risk factors for bariatric gastric surgery for severe obesity. Methods A community experience of 1009 consecutive patients who underwent open surgical treatment of morbid obesity during a 9-year period was reviewed from a prospective database. The series included 858 primary gastric bypass operations and 151 revision operations. Perioperative outcomes, late complications, and weight loss results were recorded. Morbidity and mortality rates were analyzed according to patient age, body mass index (BMI), and gender. Results The mortality rate in the series was 0.6%, and the morbidity rate was 20%. The major complication rate was 6.6%. There were no deaths in the 151 revision patients. The gastrointestinal leak rate was 0.8%, and the thromboembolism rate was 1%. Statistical analysis indicates that BMI is a risk factor for surgical complications. Conclusion Open gastric surgery for morbid obesity can be carried out in the community setting with low mortality and morbidity rates. BMI is a proven surgical risk factor.

The severely obese patient has varying degrees of intrinsic reduction of expiratory flow rates and lung volumes. Thus, the severely obese patient is predisposed to postoperative atelectasis, ineffective clearing of respiratory secretions, and other pulmonary complications. This study evaluated the effect of bi-level positive airway pressure (BiPAP) on pulmonary function in obese patients following open gastric bypass surgery. Patients with a body mass index (BMI) of at least 40 kg/m 2 who were undergoing elective gastric bypass were eligible to be randomized to receive either BiPAP during the first 24 h postoperatively or conventional postoperative care. Patients with significant cardiovascular and pulmonary diseases were excluded from the study. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV 1.0 ), peak expiratory flow rate (PEFR), and percent hemoglobin oxygen saturation ( S pO 2 ) were measured preoperatively, and on postoperative days 1, 2, and 3. Twenty-seven patients were entered in the study, 14 received BiPAP and 13 received conventional postoperative care. There was no significant difference preoperatively between the study and control groups in regards to age, BMI, FVC, FEV 1.0 . PEFR or S pO 2 . Postoperatively, expiratory flow was decreased in both groups. However, the FVC and FEV 1.0 were significantly higher on each of the three consecutive postoperative days in the patients who received BiPAP therapy. The S pO 2 was significantly decreased in the control group over the same time period. Prophylactic BiPAP during the first 12–24 h postoperatively resulted in significantly higher measures of pulmonary function in severely obese patients who had undergone elective gastric bypass surgery. These improved measures of pulmonary function, however, did not translate into fewer hospital days or a lower complication rate in our study population of otherwise healthy obese patients. Further study is necessary to determine if BiPAP therapy in the first 24 postoperative hours would be of benefit in severely obese patients with comorbid illnesses who have undergone elective gastric bypass.

Health care in the United States is expensive and quality is variable. The aim of this study was to investigate whether our integrated health system, composed of academic hospitals, a practice plan, and a managed care payer, could reliably implement an evidence-based program for gastric bypass surgery. A secondary aim was to evaluate the impact of the program on clinical outcomes.A standardized program for delivery of clinical best-practice elements for patients undergoing initial open or laparoscopic Roux-en-Y gastric bypass was implemented in 2008. Best-practice elements were embedded into the workflow. The best-practice elements were refined after reviewing failures observed during the early implementation period. The study period was divided into 3 groups: group α = year preceding program implementation (control), group β = first year of implementation (unreliable), and group Ω = 2nd to 4th years of implementation (reliable). Outcomes data were collected for all patients who had undergone Roux-en-Y gastric bypass between May 2008 and April 2012 and were compared with a control group from the preceding year using multiple logistic regression analysis.Two thousand and sixty-one patients were studied, with no significant demographic differences between study groups. Best-practice elements delivery was 40% in group β, but was90% for group Ω (p0.001). Length of stay for group α was 3.5 days and improved to 2.2 days (p0.001) for group Ω. Complications and readmission rates improved considerably with reliable delivery of best-practice elements.Standardization of evidence-based care delivery for Roux-en-Y gastric bypass was feasible and reliable delivery of this pathway improved clinical outcomes.

Challenges of specimen extraction during laparoscopic sleeve gastrectomy and other resectional laparoscopic procedures can often be proven to be time consuming and frustrating, and the risk of wound infection and port site tumor implantation increases. In this paper, we discuss our experience with an efficient approach to specimen extraction utilizing a novel technique for deployment of a very small self-expanding wound protector through a 12- or 15-mm port. We also report our observations with regard to the learning curve of this technique and the influence of BMI to retractor insertion times and specimen extraction times during laparoscopic sleeve gastrectomy.

Background. Current patient education and informed consent regarding weight loss expectations for bariatric surgery candidates are largely based on averages from large patient cohorts. The variation in weight loss outcomes illustrates the need for establishing more realistic weight loss goals for individual patients. This study was designed to develop a simple web-based tool which provides patient-specific weight loss expectations.Methods. Postoperative weight measurements after Roux-en-Y gastric bypass (RYGB) were collected and analyzed with patient characteristics known to influence weight loss outcomes. Quantile regression was used to create expected weight loss curves (25th, 50th, and 75th %tile) for the 24 months after RYGB. The resulting equations were validated and used to develop web-based tool for predicting weight loss outcomes.Results. Weight loss data from 2986 patients (2608 in the primary cohort and 378 in the validation cohort) were included. Preoperative body mass index (BMI) and age were found to have a high correlation with weight loss accomplishment (P<0.0001for each). An electronic tool was created that provides easy access to patient-specific, 24-month weight loss trajectories based on initial BMI and age.Conclusions. This validated, patient-centered electronic tool will assist patients and providers in patient teaching, informed consent, and postoperative weight loss management.

Objective Severe obesity (ie, at least 100% overweight or body mass index > or =40 kg/m2) is associated with significant morbidity and increased mortality. It is apparently becoming more common in this country. Conventional weight-loss treatments are usually ineffective for severe obesity and bariatric surgery is recommended as a treatment option. However, longitudinal data on the long-term outcome of bariatric surgery are sparse. Available data indicate that the outcome of bariatric surgery, although usually favorable in the short term, is variable and weight regain sometimes occurs at 2 years after surgery. The objective of this study is to present a review of the outcome of bariatric surgery in three areas: weight loss and improvement in health status, changes in eating behavior, and psychosocial adjustment. The study will also review how eating behavior, energy metabolism, and psychosocial functioning may affect the outcome of bariatric surgery. Suggestions for additional research in these areas are made. Method Literature review. Results On average, most patients lose 60% of excess weight after gastric bypass and 40% after vertical banded gastroplasty. In about 30% of patients, weight regain occurs at 18 months to 2 years after surgery. Binge eating behavior, which is common among the morbidly obese, may recur after surgery and is associated with weight regain. Energy metabolism may affect the outcome of bariatric surgery, but it has not been systematically studied in this population. Presurgery psychosocial functioning does not seem to affect the outcome of surgery, and psychosocial outcome is generally encouraging over the short term, but there are reports of poor adjustment after weight loss, including alcohol abuse and suicide. Conclusions Factors leading to poor outcome of bariatric surgery, such as binge eating and lowered energy metabolism, should be studied to improve patient selection and outcome. Long-term outcome data on psychosocial functioning are lacking. Longitudinal studies to examine the long-term outcome of bariatric surgery and the prognostic indicators are needed.

Importance Weight loss after bariatric surgery varies, yet preoperative clinical factors associated with long-term suboptimal outcomes are not well understood. Objective To evaluate the association between preoperative clinical factors and long-term weight loss after Roux-en-Y gastric bypass (RYGB). Design, Setting, and Participants From June 2001 to September 2007, this retrospective cohort study followed up RYGB patients before surgery to 7 to 12 years after surgery. The setting was a large rural integrated health system. Of 1033 eligible RYGB patients who consented to participate in longitudinal research and completed surgery before October 2007, a total of 726 (70.3%) had a weight entered in the electronic medical record 7 or more years after surgery and were included in the analyses after exclusions for pregnancy and mortality. Date of the long-term weight measurement was recorded between August 2010 and January 2016. Main Outcomes and Measures The primary outcome was percentage weight loss (%WL) at 7 to 12 years after surgery. Preoperative clinical factors (>200) extracted from the electronic medical record included medications, comorbidities, laboratory test results, and demographics, among others. Results Among the 726 study participants, 83.1% (n = 603) were female and 97.4% (n = 707) were of white race, with a mean (SD) preoperative body mass index (calculated as weight in kilograms divided by height in meters squared) of 47.5 (7.4) . From the time of surgery to long-term follow-up (median, 9.3 postoperative years), the mean (SD) %WL was 22.5% (13.1%). Preoperative insulin use, history of smoking, and use of 12 or more medications before surgery were associated with greater long-term postoperative %WL (6.8%, 2.8%, and 3.1%, respectively). Preoperative hyperlipidemia, older age, and higher body mass index were associated with poorer long-term postoperative %WL (−2.8%, −8.8%, and −4.1%, respectively). Conclusions and Relevance Few preoperative clinical factors associated with long-term weight loss after RYGB were identified. Preoperative insulin use was strongly associated with better long-term %WL, while preoperative hyperlipidemia, higher body mass index, and older age were associated with poorer %WL. Our findings provide additional insight into preoperative identification of RYGB patients at higher risk for long-term suboptimal outcomes.

Severe obesity affects the health and quality of life of 4 million Americans. The major cost of treating severe obesity and its associated comorbidities of hypertension, diabetes, cardiovascular disease, pulmonary insufficiency, cancer, and degenerative arthritis as well as the poor long-term results of medical, drug, and behavioral therapy has increased the numbers of patients being referred for surgical treatment. Gastric bypass and vertical banded gastroplasty are the two procedures recommended for severely obese patients. These operations currently have low morbidity and mortality. Surgery should be considered adjuvant therapy and must be part of a multidisciplinary approach. The significant long-term weight control resulting from the surgical therapy is associated with improvement and, often, resolution of comorbidities, including diabetes, hypertension, hyperlipidemia, and pulmonary insufficiency.

Background The effectiveness of weight loss therapies is commonly measured using body mass index and other obesity-related variables. Although these data are often stored in electronic health records (EHRs) and potentially very accessible, few studies on obesity and weight loss have used data derived from EHRs. We developed processes for obtaining data from the EHR in order to construct a database on patients undergoing Roux-en-Y gastric bypass (RYGB) surgery. Methods Clinical data obtained as part of standard of care in a bariatric surgery program at an integrated health delivery system were extracted from the EHR and deposited into a data warehouse. Data files were extracted, cleaned, and stored in research datasets. To illustrate the utility of the data, Kaplan-Meier analysis was used to estimate length of post-operative follow-up. Results Demographic, laboratory, medication, co-morbidity, and survey data were obtained from 2028 patients who had undergone RYGB at the same institution since 2004. Pre-and post-operative diagnostic and prescribing information were available on all patients, while survey laboratory data were available on a majority of patients. The number of patients with post-operative laboratory test results varied by test. Based on Kaplan-Meier estimates, over 74% of patients had post-operative weight data available at 4 years. Conclusion A variety of EHR-derived data related to obesity can be efficiently obtained and used to study important outcomes following RYGB.

Hypertension is a major health risk factor in patients who are morbidly obese. Two hundred eighty-nine morbidly obese patients undergoing gastric restrictive surgery were evaluated for the presence of hypertension (blood pressure greater than or equal to 160/90 mm Hg or currently undergoing antihypertensive therapy) pre- and postoperatively. Of 74 (26%) preoperatively hypertensive patients, 67 (91%) were available for follow-up. Preoperative hypertension resolved in 66% (44 of 67) of patients following gastric restrictive surgery. Superobese and morbidly obese patients had similar reductions in hypertension after surgery (69% versus 63%). Patients not receiving antihypertensives preoperatively had a greater reduction of hypertension than those medically treated preoperatively (78% versus 58%). The amount of weight loss significantly predicted the reduction of hypertension, whereas follow-up weight achieved did not. The amounts of weight loss for patients with resolved and persistent hypertension were 89.3 +/- 5.6 lbs (mean +/- standard error of the mean +ADSEM+BD) and 66.0 +/- 8.3 lbs, respectively (p less than 0.02). For patients with resolved hypertension, follow-up weights for the morbidly obese and superobese were 162.0 +/- 10.8 lbs (133% +/- 4% ideal body weight +ADIBW+BD) and 220.4 +/- 9.5 lbs (170% +/- 7% IBW). Gastric restrictive surgery is effective therapy for hypertension in morbidly obese patients. Patients need not achieve weights approaching IBW to enjoy the benefits of gastric restrictive surgery on hypertension.

Severe obesity is associated with abnormalities of cardiac structure and function. These include an increased cardiac workload and ventricular hypertrophy. Hypertension in combination with severe obesity seriously burdens the heart because the increased preload and afterload compound cardiac work. Weight reduction induced by gastric operations for severe obesity is associated with resolution of hypertension, reduction in ventricular wall thickness and cardiac chamber size, as well as improved systolic function. Additional data are needed to predict when in the course of development of obese cardiomyopathy the changes in contractile function become irreversible. Additionally, the impact of coronary artery disease on the progression of obese cardiomyopathy and the effects of surgical weight reduction on cardiac structure and function need to be further clarified. Studies of the association between obesity, its treatment, and modification of cardiovascular risk are a major focus of preventive cardiology today.

Preoperative weight loss reduces the frequency of surgical complications in patients undergoing bariatric surgery.Review of records of patients undergoing open or laparoscopic gastric bypass.A comprehensive, multidisciplinary obesity treatment center at a tertiary referral center that serves central Pennsylvania.A total of 881 patients undergoing open or laparoscopic gastric bypass from May 31, 2002, through February 24, 2006.All preoperative patients completed a 6-month multidisciplinary program that encouraged a 10% preoperative weight loss.Loss of excess body weight (EBW) and total and major complication rates.Of the 881 patients, 592 (67.2%) lost 5% or more EBW and 423 (48.0%) lost more than 10% EBW. Patients referred for open gastric bypass (n = 466) were generally older (P.001), had a higher body mass index (P.001), and were more often men (P.001) than those undergoing laparoscopic gastric bypass (n = 415). Total and major complication rates were higher in patients undergoing open gastric bypass (P.001 and P = .03, respectively). Univariate analysis revealed that increasing preoperative weight loss is associated with reduced complication frequencies for the entire group for total complications (P =.004) and most likely for major complications (P = .06). Controlling for age, sex, baseline body mass index, and type of surgery in a multiple logistic regression model, increased preoperative weight loss was a predictor of reduced complications for any (P =.004) and major (P = .03) complications.Preoperative weight loss is associated with fewer complications after gastric bypass surgery.

Laparoscopic sleeve gastrectomy has recently become a feasible option in the management of morbid obesity. One of the most feared complications of this procedure is staple line disruption and leakage. There are, to our knowledge, few literature reports that try to explain the reasons and management of this rare but serious complication. We report a case of staple line disruption that was managed using a T-tube gastrostomy. A 50-year-old female, 2 weeks status post-sleeve gastrectomy in an outside facility, was admitted to the emergency room at Cleveland Clinic Florida with new onset of fever, abdominal pain, jaundice, hematemesis, and melena. A computed tomography scan of the abdomen revealed a large extravasation of contrast material parallel to the gastric sleeve. A diagnostic laparoscopy was performed that showed a distal and proximal disruption of the staple line. A T-tube gastrostomy with a large proximal and distal limb was placed into the most distal area of disruption. After thorough over sewing and drainage of the proximal site and T-tube, a feeding jejunostomy was placed. The T-tube permitted to control the leak and to have a controlled fistula. Four weeks postoperatively, the T-tube was removed after the patient had a negative Gastrografin study and tolerated oral fluids with a clamped T-tube. The long-term recovery and follow-up were uneventful. T-tube gastrostomy appears to be a safe and feasible treatment option for staple line disruption after vertical sleeve gastrectomy. Early detection and drainage remain the most important principles to manage this type of complication.

After a decade of intense fiscal scrutiny, appropriate utilization of intensive care resources remains controversial. In particular, the financial impact of patients transferred to a tertiary surgical intensive care unit (SICU) from a community hospital (interhospital) is unknown, especially when compared with elective (intrahospital) SICU admissions admitted from the tertiary center itself. We prospectively studied outcome and costs in 82 consecutive tertiary SICU admissions. Half were transferred acutely from community hospitals and half were transferred from within the hospital or postoperatively. Severity of illness (APACHE II) was scored on day 1, at the same time of the day (9:00-10:00 AM) and by one attending surgeon (BCB). Acute transfer patients had a significantly elevated mortality (36%) when compared with elective admissions (12%) (p less than 0.05). When stratified by APACHE II score, acute transfers had twice the mortality for equivalent APACHE II scores (p less than 0.05). Acute transfer patients with APACHE II scores greater than 19 had an 89% mortality; those nonsurvivors cost $128,652 each. From these results we conclude the following: (1) Acute transfer patients have a significantly elevated mortality when compared with elective intrahospital admissions with equivalent APACHE II day-1 scores; (2) patients transferred acutely to tertiary SICUs are significantly more costly, irrespective of outcome; (3) admission source (elective vs. acute transfer) should be seriously considered when evaluating patient outcome and cost in a SICU.

Patients with a recent myocardial infarction, congestive heart failure, sever angina, or uncorrected multivessel coronary artery disease are at increased risk of cardiac complications after major noncardiac surgery. Although invasive hemodynamic monitoring and preoperative optimization of cardiac status may lead to some reduction in the rate of perioperative cardiac events, the mortality from such events remains high. We report our experience with the use of perioperative intra-aortic balloon counterpulsation in eight patients with unstable coronary syndromes or severe coronary artery disease who underwent urgent noncardiac surgery. There were no perioperative cardiac events while the intra-aortic balloon pump (IABP) was in place. There were two postoperative cardiac events (non-fatal myocardial infarction, congestive heart failure) in the first postoperative week after the IABP was removed. One patient required emergent femoral thrombectomy as a result of intra-aortic balloon counterpulsation and subsequently died of a gastrointestinal hemorrhage. Intra-aortic balloon counterpulsation should be considered as an adjunct to maintain hemodynamic stability for the high-risk cardiac patient about to undergo urgent or emergent noncardiac surgery.

Objective To determine whether 2 single nucleotide polymorphisms (SNPs) in the obesity genes the fat mass and obesity associated gene (FTO) and the insulin induced gene 2 (INSIG2) are associated with class III, or morbid, obesity in patients undergoing bariatric weight loss operations. Design Retrospective analysis of genotype and clinical data. Setting Large rural tertiary care health system. Patients A total of 707 adult patients with a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of at least 40 undergoing open or laparoscopic Roux-en-Y gastric bypass operations for morbid obesity or its comorbid medical problems at Geisinger Medical Center, Danville, Pennsylvania. Results The mean BMI in the predominantly white female cohort was 51.2. Approximately 21% of patients were homozygous for theFTO obesity SNP variant, 13% were homozygous for theINSIG2obesity SNP variant, and 3.4% were homozygous for both. Mean BMIs in the groups homozygous for each of these genes were not significantly different from nonhomozygotes. However,FTO/INSIG2double homozygotes and homozygote/heterozygote pairs had significantly higher BMIs than the other groups. Conclusion Increased BMI in morbid obesity is associated with a combination ofFTOandINSIG2SNPs.

Liposuction, the most common aesthetic procedure performed in the United States, is not without risk, but the overall complication rate in the literature varies from less than 1% to 9.3%. A 55-year-old woman who had undergone abdominal liposuction with bilateral breast augmentation was hospitalized in a state of profound septic shock. A diagnosis of necrotizing fasciitis was made on the basis of findings that included abdominal skin discoloration, subcutaneous emphysema, and air in the subcutaneous plane seen on abdominal computed tomography (CT) scan. During the operative procedure for abdominal wall debridement, extensive necrosis of abdominal wall fascia with leakage of bilious fluid from defects in the rectus sheath was found. Subsequent peritoneal cavity exploration showed two perforations in the mid ileum with gross peritoneal cavity contamination.

Background The rapid national expansion in bariatric surgical procedures has been accompanied by recent reports of significant complication rates. This has resulted in increased public scrutiny of bariatric surgery outcomes, restrictions on patient eligibility criteria by payors, and credentialing requirements for providers. This focus on outcomes has resulted in interest in bariatric risk analysis. Methods During an 8-year period, 1210 patients were evaluated for bariatric surgery. Clinical information was recorded prospectively. Co-morbid medical conditions were analyzed according to proven surgical risk factors: age, body mass index (BMI), and male gender. Results The prevalence of many co-morbid conditions and the total number of co-morbid conditions correlate highly with increasing age, increasing BMI, and male gender. Conclusion The established surgical risk factors, age, BMI, and male gender, are markers for a sicker patient population, as evidenced by a greater obesity disease burden.

A National Institutes of Health Consensus Conference in 1991 established gastric surgery as accepted therapy for the treatment of severe obesity. The increasing prevalence of obesity in the United States, and the increasing numbers of patients undergoing gastric surgery for severe obesity, result in substantial numbers of patients being considered for revisional surgery. The indications and efficacy of revisional surgery remain controversial.Sixty-three patients were followed prospectively after undergoing revisional surgery for obesity between 1981 and 1994. All patients had previously undergone obesity operations. Weight data were recorded at the time of original obesity surgery, at revisional surgery, and at most current follow-up. Complications following revisional surgery were monitored.The follow-up in the group is 98%. Revisional surgery after obesity surgery was associated with a 0% mortality rate and a serious complication rate of 16%. Body mass index (BMI) at the time of original surgery was 50 +/- 10 kg/m2, at revisional surgery 39 + 9 kg/m2, and at recent follow-up 34 +/- 10 kg/m2 (P0.001 vs original BMI). Those patients whose original BMI was50 kg/m2 lost significantly more weight (P0.0001) than those with an original BMI50 kg/m2.Revisional gastric surgery is safe and does provide patients with the opportunity to achieve long-term weight control.