The pathophysiology of severe obesity and the effects of surgically induced weight loss

Integrated Approach to Upper Body Shaping: Long Time Results

BACKGROUND

As the frequency of bariatric procedures rises, so does the demand for breast contouring operations. Massive weight loss results in ptotic breasts that are challenging to shape. However, concentrating solely on the breasts in the upper body leads to a state of imbalance. In this study, we aimed to add additional volume to the breast tissue by utilizing the lateral chest folds/back folds with combined upper body lifting procedures and show the long-term results.

METHODS

Between January 2018 and June 2024, 24 patients presented to our clinic with a complaint of breast deformity due to massive weight loss. They were evaluated as a whole. Upper body lift and autoaugmentation mastopexy with a lateral thoracic region perforators-based flap were planned in a single stage. Dorsal soft tissue was also utilized for autoaugmentation in selected patients. The viability of the extended dorsal flaps was examined with the intraoperative indocyanine green angiography.

RESULTS

The body contouring surgery was performed an average of 2.2 years after bariatric surgery. Autoaugmentation with extended fasciocutaneous flap procedures was performed in combination with other upper body lifting procedures according to the patient's needs. The postoperative follow-up period was 1 month to 5 years.

CONCLUSIONS

In postbariatric patients, focusing only on the breast leads to aesthetic disharmony in the upper body. Using subcutaneous tissue in the autologous augmentation method eliminates sagging in the upper body and provides the desired volume to ptotic breasts. The five-year follow-up results demonstrate that this method provides long-lasting, satisfying results with minimal complications.

LEVEL OF EVIDENCE IV

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Bariatric Surgery is Associated with a Reduced Risk of Mortality in Morbidly Obese Patients with a History of Major Cardiovascular Events

Although the safety of bariatric surgery in patients with established cardiovascular disease has been demonstrated, little is known about the mid- to long-term survival of these patients after surgery. We conducted a retrospective cohort study of bariatric surgical patients (n = 349) compared with morbidly obese surgical controls (n = 903). Data were obtained on all patients 40 to 79 years of age, from 1996 to 2008, with a diagnosis code of morbid obesity, a primary surgical procedure of interest, and a cardiovascular event history. Data sources were the statewide South Carolina UB92 inpatient hospitalization database and death records. The primary outcome was all-cause mortality. A total of 349 bariatric and 903 control patients with cardiovascular event histories were identified. Among bariatric patients, 19 deaths occurred in 986 person-years of follow-up versus 150 deaths among controls in 3138 person-years of follow-up. Unadjusted all-cause mortality was estimated at 7 ± 2 per cent at 5 years in bariatric patients compared with 19 ± 2 per cent ( P < 0.001) in controls. Adjusting for age, comorbidities, and event history, the relative risk of mortality was reduced by 40 per cent in bariatric patients compared with controls [hazard ratios (95% confidence interval): 0.60 (0.36, 0.99)]. In patients with a history of cardiovascular events, bariatric surgery is associated with a significantly decreased risk of all-cause mortality.

Surgical approaches to the treatment of obesity: bariatric surgery

As the obesity epidemic continues to grow in the Unites States, so does the search for the ideal nonsurgical or surgical solution. Bariatric surgery continues to be the most sustainable form of weight loss available to morbidly obese patients. In addition, bariatric surgery has established an acceptable safety profile with respect to morbidity and mortality. With the number of elective bariatric cases growing in recent years, it is unsurprising that results have improved and better data are emerging regarding improvement of obesity-related comorbid conditions. Additionally, ample evidence suggests that bariatric surgery may increase longevity, particularly through reducing cardiovascular deaths. Although the specific mechanisms involved in the remission of these medical conditions remain to be fully elucidated, it has become clear that bariatric surgery has established a significant and firm role in the treatment of medical comorbidities that result directly from obesity. However, until commercial insurance carriers provide improved coverage for bariatric surgery, patient access to these treatments will remain limited.

Usefulness of an accelerated transoesophageal stress echocardiography in the preoperative evaluation of high risk severely obese subjects awaiting bariatric surgery

Background

Severe obesity is associated with an increased risk of coronary artery disease (CAD). Bariatric surgery is an effective procedure for long term weight management as well as reduction of comorbidities. Preoperative evaluation of cardiac operative risk may often be necessary but unfortunately standard imaging techniques are often suboptimal in these subjects. The purpose of this study was to demonstrate the feasibility, safety and utility of transesophageal dobutamine stress echocardiography (TE-DSE) using an adapted accelerated dobutamine infusion protocol in severely obese subjects with comorbidities being evaluated for bariatric surgery for assessing the presence of myocardial ischemia.

Methods

Subjects with severe obesity [body mass index (BMI) >40 kg/m²] with known or suspected CAD and being evaluated for bariatric surgery were recruited.

Results

Twenty subjects (9M/11F), aged 50 ± 8 years (mean ± SD), weighing 141 ± 21 kg and with a BMI of 50 ± 5 kg/m² were enrolled in the study and underwent a TE-DSE. The accelerated dobutamine infusion protocol used was well tolerated. Eighteen (90%) subjects reached their target heart rate with a mean intubation time of 13 ± 4 minutes. Mean dobutamine dose was 31.5 ± 9.9 ug/kg/min while mean atropine dose was 0.5 ± 0.3 mg. TE-DSE was well tolerated by all subjects without complications including no significant arrhythmia, hypotension or reduction in blood arterial saturation. Two subjects had abnormal TE-DSE suggestive of myocardial ischemia. All patients underwent bariatric surgery with no documented cardiovascular complications.

Conclusions

TE-DSE using an accelerated infusion protocol is a safe and well tolerated imaging technique for the evaluation of suspected myocardial ischemia and cardiac operative risk in severely obese patients awaiting bariatric surgery. Moreover, the absence of myocardial ischemia on TE-DSE correlates well with a low operative risk of cardiac event.

Surgical approaches to the treatment of obesity: bariatric surgery

As bariatric surgery for the treatment of morbid obesity enters its sixth decade, much has been and continues to be learned from the results of several key bariatric operations, particularly the Roux-en-Y gastric bypass. Because of the obesity epidemic and development of the laparoscopic approach, bariatric procedures have increased exponentially in the past decade and are now among the more commonly performed gastrointestinal operations. Emerging data support the role of bariatric surgery as an effective treatment for improvement or remission of type 2 diabetes, hypertension, dyslipidemia, and multiple other comorbid conditions that accompany obesity. The mechanisms involved in the remission of these conditions, however, remain poorly understood and constitute an exciting area of research. This article delineates the current types of bariatric surgery, their respective outcomes, and their impact on obesity-related medical comorbidities.

Gut-brain communication: how does it stand after bariatric surgery?

PURPOSE OF REVIEW

This article aims to critically review the literature, describing the possible implications of different bariatric surgery techniques in gastrointestinal peptides and their relation with the neural paths involved in the central regulation of appetite and satiety: the gut-brain axis.

RECENT FINDINGS

Bariatric surgery operations change orexigenic and anorexigenic gastrointestinal peptide levels. Forty-one studies were analyzed in order to understand the effects of different operations on the behavior of gut peptides (ghrelin, cholecystokinin, peptide YY, glucagon-like peptide-1, gastric inhibitory polypeptide, pancreatic polypeptide). The authors have tried to correlate these findings with weight loss/maintenance via different surgical techniques.

SUMMARY

The present line of research is recent and there is a lack of comparability between studies. There are different design approaches and study protocols, different laboratorial exams. Prospective long-term studies with larger samples are needed to clarify the effects of bariatric operations on the gut-brain axis.