Experience with the Roux-en-Y gastric bypass, and commentary on current trends

Long-term outcomes following laparoscopic Roux-en-Y gastric bypass: weight loss and resolution of comorbidities at 15 years and beyond

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold-standard bariatric procedure with proven efficacy in morbidly obese populations. While the short-term benefits of LRYGB have been well-documented, durable weight loss and long-term resolution of obesity-related comorbidities have been less clearly described.

METHODS

This single-center study prospectively reports weight loss and comorbidity resolution in patients undergoing LRYGB between August 2001 and September 2007 with at least 15-year follow-up. Data were collected at the time of surgery; 1, 3, 6, and 12 months postoperatively; and then annually thereafter.

RESULTS

A total of 486 patients were included in this analysis. Patients were predominantly female (88.7%), and the median age was 36.0 [IQR 29.0-45.0] years. Patients were ethnically diverse, including Black/African American (43.6%), White/Caucasian (35.0%), Hispanic (18.3%), and other backgrounds (3.1%). Mean preoperative weight and body mass index were 133.0 ± 21.9 kg and 48.4 ± 6.5 kg/m2, and the median number of comorbidities was 6.0 [IQR 4.0-7.0]. Follow-up rates at 1, 5, 10, and 15 years were 75.3%, 37.2%, 35.2%, and 18.9%, respectively. On average, maximum percentage total weight loss (%TWL) occurred 2 years postoperatively (- 36.2 ± 9.5%), and ≥ 25% TWL was consistently achieved at 1, 5, 10, and 15-year time intervals (- 28.0 ± 13.0% at 15 years). Patients with comorbidities experienced improvement or resolution of their conditions within 1 year, including type 2 diabetes mellitus (83/84, 98.8%), obstructive sleep apnea (112/116, 96.6%), hypertension (142/150, 94.7%), and gastroesophageal reflux disease (217/223, 97.3%). Rates of improved/resolved comorbidities remained consistently high through at least 10 years after surgery.

CONCLUSIONS

LRYGB provides durable weight loss for at least 15 years after surgery, with stable average relative weight loss of approximately 25% from baseline. This outcome corresponds with sustainable resolution of obesity-related comorbidities for at least 10 years after the initial operation.

Predictors for weight loss after Roux-en-Y gastric bypass: the trend and associated factors for weight loss

BACKGROUND

Historically, Roux-en-Y gastric bypass (RYGB) has been considered the gold standard of bariatric surgery (BS). This procedure acts as a mixed restrictive and malabsorptive operation.

METHODS

 This retrospective cohort study included 410 morbidly obese patients (BMI > 40 kg/m2 or BMI > 35 kg/m2 along with at least one major comorbidity) who underwent primary laparoscopic RYGB surgery from 2009 to 2015 by a single surgery team. The patients were 18 years and older with at least 12 months of follow-up. Total weight loss (%TWL) and comorbidity resolution were compared in short-term (12 months) and mid-term (12-60 months) follow-ups. The primary and secondary outcomes were evaluating the effect of Roux-en-Y on weight loss and control of comorbidities, respectively.

RESULTS

 The mean ± SD age, weight, and BMI at surgery were 40.1 ± 10.58 years, 123.32 ± 19.88 kg, and 45.78 ± 5.54 kg/m2, respectively, and 329 (80%) were female, and 62 (15%) had T2DM. %TWL was significantly higher in T2DM patients 9 months postoperatively and after that. Patients with lower BMI (< 50 kg/m2) at surgery and non-diabetic patients had a significantly lower %TWL over a short- and long-term follow-up (P < 0.001).

CONCLUSIONS

BS remains the most efficacious and durable weight loss treatment. However, a proportion of patients will experience insufficient weight loss following BS.

How Sustained is Roux-en-Y Gastric Bypass Long-term Efficacy? : Roux-en-Y Gastric Bypass efficacy

Purpose

The rate of weight regain after Roux-en-Y Gastric Bypass (RYGB) can hamper the procedure long-term efficacy for obesity treatment and related comorbidities. To evaluate the rate of weight loss and comorbidity remission failure 10 years or more after RYGB surgery.

Materials and methods

Retrospective observational cohort study. Patients submitted to RYGB for obesity treatment at a single centre with 10 years or more after surgery underwent a clinical reassessment.

Results

Among the subjects invited for clinical revaluation (n = 585), only those who performed RYGB and attended the hospital visit were included in the study (n = 281). The pre-operative mean body mass index (BMI) was 44.4 ± 6.1 kg/m². Mean post-operative time was 12.2 ± 1.1 years. After surgery, mean BMI was significantly lower 33.4 ± 5.8 kg/m² (p < 0.0001), 29.5% with a BMI < 30 kg/m². Mean Total Weight Lost (%TWL) was 24.3 ± 11.4%, reaching a %TWL ≥ 20% in 70.1% with a mean %TWL of 30.0 ± 7.0%. Co-morbidities remission rate was 54.2% for type 2 diabetes, 34.1% for hypertension, 52.4% for hyperlipidemia and 50% for obstructive sleep apnea. Early complications rate was 13.2% and revision surgery occurred in 2.8% of patients. Four patients died of RYGB complications within the first 90 days after surgery.

Conclusion

RYGB has a high rate of long-term successful weight loss and obesity-associated comorbidity improvement. Weight loss failure requiring revision surgery occurs in a small proportion of patients. Our data confirms the long-term effectiveness of RYGB as primary bariatric intervention.

Graphical abstract

Weight loss dynamics following laparoscopic Roux-en-Y gastric bypass. An analysis of 10-year follow-up data

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) still remains the gold-standard bariatric procedure. Short-term weight loss and improvement of type 2 diabetes mellitus (DM2) after LRYGB are well-documented. Little data are available on long-term weight loss and continued remission of DM2 in these patients.

METHODS

This study reports on weight loss and remission of DM2 in 576 consecutive patients who underwent primary LRYGB between August 2001 and August 2009 with at least 10-year follow up. All patients were treated at a single institution by a single surgeon. All data were collected and entered into the database prospectively.

RESULTS

A total of 576 patients were included in the study. Patients' mean age was 38.2 ± 10.9 years and females represented 88.2% of patients. Patients' ethnicity was diverse, including African Americans (44.4%), Caucasians (34.0%), Hispanics (18.1%), and 3.5% from other backgrounds. On average, there were 6.9 ± 2.7 comorbidities per patient and DM2 was initially present in 150/576 patients (26.0%). Mean preoperative weight and BMI were 132.4 ± 22.0 kg and 48.3 ± 6.7 kg/m², respectively. Ten-year follow-up reporting rate was 145/576 (25.2%). Maximum weight loss occurred at 18 months (mean weight 83.4 ± 16.5 kg, mean BMI 30.5 ± kg/m²). At 10 years, mean weight was maintained at 94.8 ± 20.5 kg and mean BMI was 34.3 ± 6.8 kg/m². The average weight regain between one and ten years was 8.27 kg. Among patients with preoperative DM2, continued remission of DM2 at 10 years occurred in 19/32 (59.4%) patients.

CONCLUSIONS

LRYGB provides durable long-term weight loss, as well as successful remission of DM2 at 10 years. More long-term follow-up studies evaluating weight loss and comorbidities extending beyond the initial 10-year period are needed. Such studies are essential for projecting late outcomes of LRYGB, particularly in younger patients with life expectancy exceeding several decades.

Functional and systemic effects of whole body electrical stimulation post bariatric surgery: study protocol for a randomized controlled trial

Background

Obesity represents a major public health problem and is the fifth leading risk factor for mortality. Morbid obesity is associated with chronic systemic inflammation which increases the risk of comorbidities. Bariatric surgery (BS) is considered an effective intervention for obese patients. However, BS is associated with dietary restriction, potentially limiting physical activity. Whole-body neuromuscular electrical stimulation (WBS) could represent an innovative option for the rehabilitation of BS patients, especially during the early postoperative phase when other conventional techniques are contraindicated. WBS is a safe and effective tool to combat sarcopenia and metabolic risk as well as increasing muscle mass, producing greater glucose uptake, and reducing the proinflammatory state. Therefore, the objective of this study is to evaluate the effects of WBS on body composition, functional capacity, muscle strength and endurance, insulin resistance, and pro- and anti-inflammatory circulating markers in obese patients undergoing BS.

Methods/design

The present study is a randomized, double-blind, placebo-controlled, parallel groups clinical trial approved by the Ethics Committee of our Institution. Thirty-six volunteers (body mass index (BMI) > 35 kg/m²) between 18 and 45 years of age will be randomized to the WBS group (WBSG) or control (Sham) group (ShamG) after being submitted to BS. Preoperative assessments will include maximal and submaximal exercise testing, body composition, blood inflammatory markers, and quadriceps strength and endurance. The second day after discharge, body composition will be evaluated and a 6-min walk test (6MWT) will be performed. The WBS or Sham protocol will consist of 30 daily sessions for 6 consecutive weeks. Afterwards, the same assessments that were performed in the preoperative period will be repeated.

Discussion

Considering the important role of WBS in skeletal muscle conditioning and its value as an aid in exercise performance, the proposed study will investigate this technique as a tool to promote early rehabilitation in these patients, and as a strategy to enhance exercise capacity, weight loss, and peripheral muscle strength with positive systemic effects. The present study is still ongoing, and data will be published after its conclusion.

Trial registration

REBEC, RBR-99qw5h. Registered on 20 February 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2844-8) contains supplementary material, which is available to authorized users.

Life Expectancy Benefits of Gastric Bypass Surgery

Bariatric surgery is the most effective treatment for achieving sustained weight loss in morbidly obese patients. Although the use of gastric bypass is growing rapidly, the potential life expectancy benefits of the procedure are unknown. We created a Markov decision analysis model to examine the effect of gastric bypass surgery on life expectancy in morbidly obese patients (body mass index [BMI] = 40 kg/m2). Input assumptions for the model were obtained from published life tables (baseline mortality risks), epidemiologic studies (obesity-related excess mortality), and large case series (surgical outcomes). In our baseline analysis, a 40-year-old woman (BMI = 40 kg/m2) would gain 2.6 years of life expectancy by undergoing gastric bypass (38.7 years versus 36.2 years without surgery). In sensitivity analysis, life-years gained with surgery remained substantial when assumptions were varied across reasonable ranges for surgical mortality risk (1.0-3.0 years) and effectiveness (0.9-4.4 years). Life-years gained with gastric bypass surgery did not vary considerably by age and sex subgroups. Relative to other major surgical procedures, gastric bypass for morbid obesity is associated with substantial gains in life expectancy. Long- term data from prospective studies are needed to confirm this finding.

Vitamin D status 10 years after primary gastric bypass: gravely high prevalence of hypovitaminosis D and raised PTH levels

BACKGROUND

The primary aim of this study was to evaluate the prevalence of vitamin D deficiency and secondary hyperparathyroidism after Roux-en-Y gastric bypass. Secondly, we have tried to assess predictors for vitamin D deficiency.

METHODS

Five hundred thirty-seven patients who underwent primary Roux-en-Y gastric bypass surgery between 1993 and 2003 at the Örebro University Hospital and Uppsala University Hospital were eligible for the study. Patients were asked to provide a blood sample between November 2009 and June 2010 and to complete a questionnaire about their postoperative health status. Serum values of 25-OH vitamin D, parathyroid hormone (PTH), alkaline phosphatase (ALP) and calcium were determined.

RESULTS

Follow-up was completed in 293 patients, of which 83 % were female, with an age of 49 ± 9.9 years after a median time of 11 ± 2.8 years. Vitamin D, PTH and albumin-corrected calcium values were 42 ± 20.4 nmol/L, 89.1 ± 52.7 ng/L and 2.3 ± 0.1 mmol/L, respectively. Of all patients, 65 % were vitamin D deficient, i.e. 25-OH vitamin D <50 nmol/L, and 69 % had PTH above the upper normal reference range, i.e. >73 ng/L. Vitamin D was inversely correlated with PTH levels (p < 0.001) and positively correlated with calcium (p = 0.016). Vitamin D did not correlate with ALP. The only factor found to predict vitamin D deficiency was high preoperative body mass index (BMI) (p = 0.008), whereas gender, age, time after surgery and BMI at follow-up did not.

CONCLUSIONS

Vitamin D deficiency and secondary hyperparathyroidism after Roux-en-Y gastric bypass (RYGB) were confirmed in our study because 65 % of patients had vitamin D deficiency, and 69 % had increased PTH levels more than 10 years after surgery. These data are alarming and highlight the need for improved long-term follow-up. Vitamin D deficiency does not seem to progress with time after surgery, possibly due to weight loss. Only preoperative BMI, cutoff point 43 kg/m(2), was a predictor of vitamin D deficiency at follow-up. Improved long-term follow-up of patients that undergo RYGB is needed.

Optimal diabetes management during medical weight loss for cardiovascular risk reduction

Obesity has long been recognized as a significant risk factor for type 2 diabetes. Both obesity and type 2 diabetes are associated with an increase in cardiovascular risk. As cardiovascular disease continues to be the number one killer in the USA and western adult populations, the rise in prevalence of obesity and type 2 diabetes is alarming. This is especially disturbing in the tripling of overweight children and adolescents, accompanied by the increase in prevalence of pediatric type 2 diabetes. Optimal strategies for long-term diabetes management aim at effectively controlling, reducing and ultimately preventing obesity. This review explores the clinical recommendations in place, new clinical investigations, diet therapy, medical nutrition therapy, meal replacements, behavior therapy, exercise therapy, pharmacotherapy and surgical therapy as strategies to achieve weight-loss success in diabetic patients and ultimately reduce cardiovascular disease.

Obesity, adiposity, and dyslipidemia: a consensus statement from the National Lipid Association

The term "fat" may refer to lipids as well as the cells and tissue that store lipid (ie, adipocytes and adipose tissue). "Lipid" is derived from "lipos," which refers to animal fat or vegetable oil. Adiposity refers to body fat and is derived from "adipo," referring to fat. Adipocytes and adipose tissue store the greatest amount of body lipids, including triglycerides and free cholesterol. Adipocytes and adipose tissue are active from an endocrine and immune standpoint. Adipocyte hypertrophy and excessive adipose tissue accumulation can promote pathogenic adipocyte and adipose tissue effects (adiposopathy), resulting in abnormal levels of circulating lipids, with dyslipidemia being a major atherosclerotic coronary heart disease risk factor. It is therefore incumbent upon lipidologists to be among the most knowledgeable in the understanding of the relationship between excessive body fat and dyslipidemia. On September 16, 2012, the National Lipid Association held a Consensus Conference with the goal of better defining the effect of adiposity on lipoproteins, how the pathos of excessive body fat (adiposopathy) contributes to dyslipidemia, and how therapies such as appropriate nutrition, increased physical activity, weight-management drugs, and bariatric surgery might be expected to impact dyslipidemia. It is hoped that the information derived from these proceedings will promote a greater appreciation among clinicians of the impact of excess adiposity and its treatment on dyslipidemia and prompt more research on the effects of interventions for improving dyslipidemia and reducing cardiovascular disease risk in overweight and obese patients.

A review of evidence-based strategies to treat obesity in adults

Obesity, with its comorbidities, is a major public health problem. Population-based surveys estimate 2 of every 3 U.S. adults are overweight or obese. Despite billions of dollars spent annually on weight loss attempts, recidivism is high and long-term results are disappointing. In simplest terms, weight loss and maintenance depend on energy balance, and a combination of increased energy expenditure by exercise and decreased energy intake through caloric restriction is the mainstay of behavioral interventions. Many individuals successfully lose 5%-10% of body weight through behavioral approaches and thereby significantly improve health. Similar success occurs with some weight loss prescriptions, although evidence for successful weight loss with over-the-counter medications and supplements is weak. Commercial weight loss programs have helped many individuals achieve their goals, although few programs have been carefully evaluated and compared, limiting recommendations of one program over another. For the very obese, bariatric surgery is an option that leads to significant weight loss and improved health, although risks must be carefully weighed. Lifestyle changes, including regular physical activity, healthy food choices, and portion control, must be adopted, regardless of the weight loss approach, which requires ongoing support. Patients can best decide the appropriate approach working with a multidisciplinary team, including their health care provider and experts in nutrition, exercise, and behavioral intervention.

Long-term results 11 years after primary gastric bypass in 384 patients

BACKGROUND

Roux-en-Y gastric bypass surgery (RYGB) as treatment of morbid obesity results in substantial weight loss. Most published long-term studies have included few patients at the last follow-up point. The aim of the present study was to explore long-term results in a large cohort of patients 7-17 years after gastric bypass.

METHODS

All 539 patients who had undergone primary RYGB from 1993 to 2003 at Uppsala and Örebro University Hospitals received a questionnaire regarding their postoperative status. Blood samples were obtained and the medical charts studied.

RESULTS

Of the 539 patients, 384 responded (71.2% response rate, mean age 37.9 yr, body mass index 44.5 kg/m(2) at surgery, 317 women, and 67 men). At a mean follow-up of 11.4 years (range 7-17), the body mass index had decreased to 32.5 kg/m(2), corresponding to an excess body mass index loss of 63.3%. Similar weight loss was observed, regardless of the length of follow-up. Orally treated diabetes resolved in 72% and sleep apnea and hyperlipidemia were improved. Revisional bariatric surgery had been performed in 2.1% and abdominoplasty in 40.2%. The gastrointestinal symptoms were considered tolerable. The overall result was satisfactory for 79% of the patients and 92% would recommend Roux-en-Y gastric bypass to a friend. Attendance to the annual checkups was 37%. Vitamin B12 supplements were taken by 72% and multivitamins by 24%.

CONCLUSION

At 11 years, substantial weight loss was maintained and revisional surgery was rare. Surprisingly few patients were compliant with the recommendation of lifelong supplements and yearly evaluations; however, patient satisfaction was high.

Laparoscopic reconversion of Roux-en-Y gastric bypass to original anatomy: technique and preliminary outcomes

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures performed. Dumping syndrome, intolerance to RYGB-induced restriction, and weight loss issues are possible problems bariatric surgeons are confronted with. This study reports the feasibility, safety, and outcomes of laparoscopic reconversion of RYGB to original anatomy (OA) as treatment of these complications.

METHODS

Between January 2005 and April 2008, eight patients benefited from laparoscopic reconversion of RYGB to OA. Reason was dumping syndrome without postprandial hypoglycemia (three), intolerance to RYGB-induced restriction (three), too much (one) and too little weight loss (one). Mean weight and body mass index (BMI) at RYGB were 104.7±19.3 kg and 38.7±6 kg/m(2), respectively. Four patients suffered of obesity co-morbidities. Mean time between RYGB and reconversion was 21±18.8 months. Mean weight, BMI, and % excess weight loss at reconversion was 66.8±21.7 kg, 20.1±7 kg/m(2), and 23.7±55%, respectively. The procedure involved dismantling both gastrojejunostomy and jejunojejunostomy, reanastomosing gastric pouch to gastric remnant, and proximal alimentary limb end to distal biliary limb end.

RESULTS

Mean operative time was 132.2±29.5 min. There were no conversions to open surgery and no early complications. Gastrogastrostomy was performed manually (four) and by linear stapler (four), and jejunojejunostomy by linear stapler (eight). Mean hospital stay was 7.7±3.5 days. After a mean follow-up of 18.3±9.2 months, two patients continued to further lose weight, two patients maintained the same weight, and four patients presented weight regain. Gastroesophageal reflux disease appeared in three patients.

CONCLUSIONS

Laparoscopic reconversion of RYGB to OA is feasible and safe. Dumping syndrome and intolerance to RYGB-induced restriction are resolved. The anatomy remains one of the aspects besides nutritional and psychological factors in cases of reconversion for weight issues.

Impact of aerobic exercise training on heart rate variability and functional capacity in obese women after gastric bypass surgery

BACKGROUND

Obesity is a major public health concern on a global scale. Bariatric surgery is among the treatment options, resulting in significant and sustainable weight loss as well as amelioration of comorbidities. The purpose of this study was to evaluate whether a 12-week aerobic exercise program positively impacts heart rate variability (HRV) and functional capacity after gastric bypass surgery (GBS) in a female cohort.

METHODS

Of the 52 patients initially recruited, 21 were randomized to a training group (TG) or control group and successfully completed the study. Patients were tested on two occasions: 1 week before GBS and 4 months after GBS. Anthropometric variables, body composition, record of heart rate and R-R intervals, and 6-min walk test (6MWT) were assessed at both time points. The TG underwent an aerobic exercise training program on a treadmill (1-h session, totaling 36 sessions over 12 weeks).

RESULTS

The main findings from this study were: (1) only the TG demonstrated a significant increase (p < 0.05) in all indexes of heart rate variability (HRV) after 12 weeks of aerobic exercise training and (2) only the TG demonstrated a significant increase (p < 0.05) in 6MWT distance and decrease in diastolic blood pressure after aerobic exercise training.

CONCLUSIONS

We conclude that 12 weeks of aerobic exercise training improves cardiac autonomic modulation and functional capacity 4 months after GBS.

Long-term outcomes of laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass in the United States

BACKGROUND

Although laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the most common bariatric procedures performed in the past decade, little is known about their long-term (>5 years) outcomes.

METHODS

A retrospective outcome study investigated 148 consecutive patients from a single practice who underwent LAGB from November 2000 to March 2002. The group was matched with 175 consecutive patients who underwent LRYGB from June 2000 to March 2005. Follow-up data for 5 years or longer was available for 127 LAGB patients (86%) and 105 LRYGB patients (60%).

RESULTS

After an initial 4 years of progressive weight loss, body mass index (BMI) loss stabilized at 5-7 years at approximately 15 kg/m(2) for the LRYGB patients and at about 9 kg/m(2) for the LAGB patients with band in place (P < 0.01). At 7 years, the excess weight loss (EWL) was 58.6% for LRYGB and 46.3% for LAGB with band in place (P < 0.01). By 7 years, 19 LAGB patients (15%) had had their bands removed, bringing the failure rate for LAGB (including patients with less than 25% EWL) to 48.3% versus 10.7% for LRYGB (P < 0.01). By 10 years, 29 (22.8%) of the bands had been removed, bringing the total LAGB failure rate to 51.1%. In 10 years, 67 LAGB (52.8%) and 43 LRYGB (41%) adverse events had occurred. However, over time, the LRYGB group experienced 9 (8.6%) serious, potentially life-threatening complications, whereas the LAGB group had none (P < 0.001). One procedure-related death occurred in the LRYGB group.

CONCLUSIONS

Over the long term, LRYGB had an approximate reduction of 15 kg/m(2) BMI and 60% EWL, a significantly better outcome than LAGB patients experienced with band intact. The main issue with LAGB was its 50% failure rate in the long term, as defined by poor weight loss and percentage of band removal. Nevertheless, LAGB had a remarkably safe course, and it may therefore be considered for motivated and informed patients.

Laparoscopic conversion of Roux-en-Y gastric bypass to distal gastric bypass for weight regain

BACKGROUND

Weight regain after Roux-en-Y gastric bypass (RYGB) is one of the possible complications bariatric surgeons are confronted with. An option for enhancing weight loss is the conversion of RYGB into distal RYGB (DRYGB), which is a malabsorptive procedure. We report the technical strategy and the preliminary outcomes of conversion of RYGB to DRYGB by laparoscopy.

PATIENTS AND METHODS

Between April 2005 and November 2009, 7 patients benefited from laparoscopic conversion of RYGB to DRYGB for weight regain mainly due to a new dietary behavior, namely, polyphagia (eating too frequent meals). At the time of RYGB, the mean weight and BMI was 120.5 ± 26.4 kg and 43.2 ± 6.7 kg/m(2), respectively. Five patients suffered of obesity-related comorbidities. Mean interval time between RYGB and conversion was 41 ± 15.9 months. At the time of conversion, the mean weight, BMI, % excess weight loss were 100.7 ± 19.8 kg, 36.1 ± 4.8 kg/m(2), and 33.7% ± 12.1%, respectively. Obesity-related comorbidities at that time affected 4 patients.

RESULTS

Mean operative time was 122.1 ± 34 minutes. There were no conversions to open surgery and no mortality. Postoperatively, 1 patient suffered of a bleeding. Mean hospital stay was 4.7 ± 2.5 days. After a mean follow-up of 19 ± 23.7 months, the mean weight, BMI, and % excess weight loss was 82.5 ± 19.7 kg, 29.5 ± 5.3 kg/m(2), and 57.6% ± 8.1%, respectively. Obesity-related comorbidities remained unchanged after the conversion in the 4 patients. One patient required a surgical reoperation for internal hernia.

CONCLUSION

Conversion of RYGB to DRYGB for weight regain can safely be performed by laparoscopy, with satisfactory early results.

Laparoscopic Roux-en-Y gastric bypass: 10-year follow-up

BACKGROUND

The short-term benefits of bariatric surgery are well documented; however, few reports with data beyond 10 years exist. Those that have been published have described only open procedures. We present our 10-year follow-up results with laparoscopic Roux-en-Y gastric bypass with hand-sewn gastrojejunal anastomosis in a group private practice.

METHODS

We performed an institutional review board-approved retrospective review of a prospectively maintained database, combined with office visits and telephone questionnaires, for patients who underwent laparoscopic Roux-en-Y gastric bypass between February 1998 and April 1999.

RESULTS

A total of 242 patients underwent surgery from February 1998 to April 1999. The office follow-up rate was 33% at 2 years and 7% at 10 years. An additional 19% had telephone follow-up at 10 years. The mean excess weight loss was 57% at 10 years. Of the 242 patients, 65 (33.2%) failed to achieve an excess weight loss of >50%; 86 (35%) had ≥1 complication during follow-up. However, 83%, 87%, 67%, and 76% of patients with diabetes, hypertension, dyslipidemia, and obstructive sleep apnea, respectively, experienced improvement or resolution. The internal hernia rate was 16%, and the gastrojejunal stenosis rate was 4.9%. No surgery-related deaths occurred. Of the 242 patients, 136 (51%) had nutritional testing at least once after postoperative year 1. Of these 136 patients, only 24 (18%) had remained nutritionally intact during follow-up.

CONCLUSION

The obstacles to follow-up have continued to impede the collection of accurate long-term data. Of the 26% of patients with data, laparoscopic Roux-en-Y gastric bypass provided sustainable weight loss and resolution of co-morbidities. However, nutritional deficiencies presented sporadically over time and underscore the importance of routine testing.

Nonalcoholic fatty liver disease in children living in the obeseogenic society

BACKGROUND

The problem of obesity in children has grown considerably in recent years in the United States as well as the rest of the world. This has resulted in a marked increase in the prevalence of nonalcoholic liver disease in the pediatric age group. Nonalcoholic fatty liver disease (NAFLD) is currently the most common hepatic disorder seen in pediatric hepatology practice.

DATA SOURCES

We have reviewed the most recent literature regarding the prevalence, pathogenesis as well as the most recent advances in the diagnostic and therapeutic modalities of NAFLD in children.

RESULTS

NAFLD affects a substantial portion of the population including children.

CONCLUSIONS

The rising incidence of NAFLD, nonalcoholic steatohepatitis (NASH) and cirrhosis emphasizes the need for effective treatment options. The lack of complete understanding of the pathogenesis of NAFLD still limits our ability to develop novel therapeutic modalities that can target the metabolic derangements implicated in the development of the disorder.

The surgical approach to management of pediatric obesity: when to refer and what to expect

Weight loss surgery is recommended for adult patients with morbid obesity and has been used on a case by case basis in the pediatric population. Surgery, however,is just a tool added to the two mainstays of therapy for obesity: 1.) controlled dietary intake and 2.) increases inactivity and exercise behaviors. For the pediatric population,the health consequences of obesity are profound with increased cardiovascular risk during adolescence and increased mortality in adulthood. Currently accepted guidelines for weight loss surgery referral use BMI cut points that are the same as for adults: BMI > or = 35 kg/m(2) and serious comorbidities of obesity or BMI > or = 40 kg/m(2) with minor comorbidities of obesity. A multidisciplinary approach to weight management must be utilized, and a lifetime of follow-up must be addressed. The most commonly performed operations for obesity are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB). LAGB is safer and does not permanently alter gastrointestinal continuity; however, LAGB is not currently approved for implantation in adolescent patients. LRYGB involves a complex, permanent altering of the gastrointestinal anatomy and is associated with more complications around the time of surgery and is not subject to FDA approval because there is no associated implant. In each operation, appetite is suppressed by construction of a virtual (LAGB) or real(LRYGB) pouch. The dynamics and speed of appetite suppression and, consequently, weight loss are typically different for each operation though longer-term outcomes may be similar. Short- and long-term risks of surgery must be carefully weighed against the benefits of the associated weight loss for each patient. The patient must be empowered to understand the importance of lifestyle and behavior in achieving long-term health.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Laparoscopic placement of non-adjustable silicone ring for weight regain after Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) is presently one of the most popular surgical procedures for obesity. One of the possible long-term problems is weight regain, usually after a period of successful weight loss. Weight regain after RYGBP can be due to new eating habits, like sweet-eating or grazing, or volume eating because of impaired restriction. This paper reports our experience in patients who presented weight regain after laparoscopic RYGBP, because of new appearance of volume eating or hyperphagia, treated by the laparoscopic placement of a non-adjustable silicone ring around the gastric pouch.

METHODS

From July 2004 to November 2007, six patients affected by weight regain due to hyperphagic behavior, benefited from revision of RYGBP consisting of the placement of a non-adjustable silicone ring loosely encircling the stomach part. Mean weight and body mass index (BMI) at the time of RYGBP were 105.0 kg +/- 12.3 and 36.3 +/- 3.0 kg/m(2), respectively, and all patients suffered from obesity-related co-morbidities. After a mean time from RYGBP of 26.0 +/- 14.2 months, patients presented a weight regain of 4.7 +/- 3.4 kg compared with their minimal weight, with a final mean weight, BMI, and percentage of excess weight loss (%EWL) at the time of the silicone ring of 86.0 +/- 13.1 kg, 29.5 +/- 3.9 kg/m(2), and 47.0 +/- 24.7%, respectively. Preoperative evaluation for each patient included history and physical examination, nutritional and psychiatric evaluation, laboratory tests, and barium swallow check. Outcome measures included evaluation of the Roux-en-Y construction, operative time, postoperative morbidity and mortality, and weight loss in terms of absolute weight loss, BMI, and %EWL.

RESULTS

Any modification of the digestive circuit was evidenced. Mean operative time was 82.5 +/- 18.3 min. No operative mortality and no conversion to open surgery were achieved. No postoperative complications were achieved. Mean hospital stay was 2.6 +/- 1.5 days. After a mean follow-up of 14.0 +/- 9.2 months, the six patients presented a mean weight loss of 9.1 +/- 2.4 kg, with a final mean weight, BMI, and %EWL of 76.8 +/- 13.7 kg, 26.4 +/- 4.2 kg/m(2), and 70.4 +/- 30.4%, respectively. Difference in term of %EWL before and after revision (23.4 +/- 5.7) is statistically significant (p < 0.05). There have been no erosions or slippage of the ring during this follow-up.

CONCLUSION

One of the possible causes of weight regain after RYGBP is the new eating behavior of the patient, one of which is hyperphagia. Treatment of this condition can be the placement of a non-adjustable silicone ring loosely fitted around the gastric pouch which contributes to improved weight loss.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Relation between degree of weight loss after bariatric surgery and reduction in albuminuria and C-reactive protein

BACKGROUND

Bariatric surgery achieves long-term weight loss in obese adults with amelioration of diabetes and hypertension. Improvement in albuminuria and high-sensitivity C-reactive protein (hs-CRP) has also been reported. We investigated, at a weight control center in a community hospital setting, the relation between degree of surgical weight loss and reduction in the cardiovascular risk markers, albuminuria and hs-CRP.

METHODS

We performed a retrospective study of 62 obese adults who had undergone Roux-en-Y gastric bypass surgery and had a median follow-up of 15 months.

RESULTS

The baseline (preoperative) mean age was 46 years, 82% were women, 26 had a blood pressure of > or =140/90 mm Hg, and 25 had type 2 diabetes. During follow-up (postoperative), a decrease occurred in the body mass index (mean +/- standard deviation 49.2 +/- 8.7 kg/m(2) to 34.1 +/- 8.1 kg/m(2); P <.0001), excess body weight (mean +/- SD 76.1 +/- 23.6 kg to 34.9 +/- 21.7 kg; P <.0001), hemoglobin A1c (mean +/- SD 6.5% +/- 1.3% to 5.6% +/- 0.8%; P <.0001), systolic blood pressure (mean +/- SD 133.7 +/- 14.3 mm Hg to 112.9 +/- 14.6 mm Hg; P < .0001), urine albumin creatinine ratio (from a median of 8.0 mg/g [interquartile range 5.0-29.3] to a median of 6.0 mg/g [interquartile range 3.3-11.5]; P <.0001), and hs-CRP (mean +/- SD 11.2 +/- 9.8 mg/L to 4.7 +/- 5.9 mg/L; P <.0001). The study sample was divided into tertiles of the percentage of excess body weight loss; the mean percentage of excess body weight loss was -37.1% +/- 5.5% in the first tertile, -54.3% +/- 6.8% in the second tertile, and -75.8% +/- 10.9% in the third tertile. The median percentage of change in albuminuria was greatest (median -52.8%, interquartile range -79.1% to -17.5%) in the third tertile, intermediate (median -45.5%, interquartile range -72.4% to 0%) in the second tertile, and lowest (-42.6%, interquartile range -80.5% to 16.7%) in the first tertile (P = .953). The mean percentage of change in hs-CRP was greatest (-72.4% +/- 30.4%) in the third tertile, intermediate (-55.4% +/- 31.9%) in the second tertile, and lowest (-44.8% +/- 30.6%) in the first tertile (P = .037).

CONCLUSION

The results of our study have shown that obese adults experience a reduction in albuminuria and hs-CRP after bariatric surgery, with a greater reduction in hs-CRP observed with more surgical weight loss.

[Can bariatric surgery cure metabolic syndrome?]

OBJECTIVES

To evaluate the impact of bariatric surgery on the metabolic syndrome (MS) and what are the criteria that contribute the most for its exclusion after surgery. The progress of leucometry was also analyzed.

METHODS AND PROCEDURES

47 obese women with MS were evaluated. All patients were operated with the Roux-en-Y vertical gastric bypass technique, with the insertion of a contention ring on the gastro-jejune anastomosis (Fobi-Capella). Patients were evaluated before and on the first year post-surgery.

RESULTS

Fasting glucose presented a relevant decrease at 3 months after surgery. After 12 months, all 20 patients who had DM2 or altered fasting glucose presented normal levels of fasting glucose and glicated hemoglobin, and none of them was using any anti-diabetic drug. Triglycerides levels were reduced by 49.2%, whereas HDL-cholesterol increased by 27.2%. Systolic and diastolic blood pressures were reduced by an average of 28.7 and 20.8 mmHg, respectively. Leucocytes counting fell from 7671/microL to 6156/microL. Fasting glucose, triglycerides, DBP, SBP and HDL-cholesterol were the variables that contributed most for the reduction of MS. At the end of the first year, elimination of MS occurred in 80.9% of the patients.

DISCUSSION

Bariatric surgery reduces resistance to insulin and consequently the cardiovascular risk factors.

Severe recurrent hypoglycemia after gastric bypass surgery

BACKGROUND

Bariatric surgery is, at present, the most effective method to achieve major, long-term weight loss in severely obese patients. Recently, severe recurrent symptomatic hyperinsulinemic hypoglycemia was described as a consequence of gastric bypass surgery (GBS) in a small series of patients with severe obesity. Pancreatic nesidioblastosis, a hyperplasia of islet cells, was postulated to be the cause, and subtotal or total pancreatectomy was the suggested treatment.

METHODS

We observed that severe, disabling hypoglycemia after GBS occurred only in patients with loss of restriction. Whether restoration of gastric restriction might treat severe, recurrent hypoglycemia after GBS is unknown.

RESULTS

Therefore, gastric restriction was restored by surgical placement of a silastic ring (n = 8, first two patients with additional distal pancreatectomy) or an adjustable gastric band (n = 4) around the pouch in 12 consecutive patients presenting with severe hypoglycemia (blood glucose below 2.2 mM). At follow-up after restoration of gastric restriction (median follow-up 7 months, range 5 to 19 months), 11 patients demonstrated no hypoglycemic episodes, while one had recurrence of hypoglycemia and underwent distal pancreatectomy. Procedural mortality was 0% and morbidity 8.3%.

CONCLUSION

Patients suffering from severe recurrent hypoglycemia after GBS can be treated, in most cases, just by restoration of gastric restriction. Distal pancreatectomy should be considered a second-line treatment.

Pathophysiology of obesity: why surgery remains the most effective treatment

Obesity is a rapidly increasing, worldwide epidemic. Despite recent scientific advances, no currently recommended dietary program or medication results in long-term weight loss of more than 10% of body weight for the vast majority of people who attempt these interventions. Hence, surgical intervention is recommended for patients with a BMI > or =40 kg/m2. Although surgery is an effective, sustainable treatment of obesity, it can be associated with potentially significant perioperative risks and long-term complications. Current research is focused on developing a medical therapy, which produces more effective and sustainable weight loss, yet avoids the risks inherent in major surgery. With a reduced risk profile, such therapy could also be appropriately offered to those who are less obese and, in theory, help those who have BMIs as low as 27 kg/m2. Toward that end, numerous scientists are working to both unravel the pathophysiology of obesity and to determine why surgical intervention is so effective. This review briefly examines the current status of obesity pathophysiology and management, the reasons for failure of conventional medical treatments, and the success of surgical intervention. Finally, future areas of research are discussed.

Implications of altered gastrointestinal motility in obesity

The onset of obesity occurs as a result of an imbalance between nutrient consumption/absorption and energy expenditure. Gastrointestinal (GI) motility plays a critical role in the rate of consumption of foods, digestion, and absorption of nutrients. Various segments of the GI tract coordinate in a complex yet precise way, to control the process of food consumption, digestion, and absorption of nutrients. GI motility not only regulates the rates at which nutrients are processed and absorbed in the gut, but also, via mechanical and neurohormonal methods, participates in the control of appetite and satiety. Altered GI motility has frequently been observed in obese patients, the significance of which is incompletely understood. However, these alterations can be considered as potential contributing factors in the development and maintenance of obesity and changed eating behavior. Therapies aimed at regulating or counteracting the observed changes in GI motility are being actively explored and applied clinically in the management of obese patients.

Cost-effectiveness analysis of laparoscopic gastric bypass, adjustable gastric banding, and nonoperative weight loss interventions

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are the two most commonly performed bariatric procedures. Although both procedures likely reduce healthcare expenditures related to the resolution of co-morbid conditions, they have different rates of perioperative risks and different rates of associated weight loss. We designed a model to evaluate the incremental cost-effectiveness of these procedures compared with nonoperative weight loss interventions and with each other.

METHODS

We used a deterministic, payer-perspective model comparing the lifetime expected costs and outcomes of LAGB, LRYGB, and nonoperative treatment. The major endpoints were survival, health-related quality of life, and weight loss. Life expectancy and lifetime medical costs were calculated across age, gender, and body mass index (BMI) strata using previously published data.

RESULTS

For both men and women, LRYGB and LAGB were cost-effective at <$25,000/quality-adjusted life-year (QALY) even when evaluating the full range of baseline BMI and estimates of adverse outcomes, weight loss, and costs. For base-case scenarios in men (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $11,604/QALY for LAGB compared with $18,543/QALY for LRYGB. For base-case scenarios in women (age 35 y, BMI 40 kg/m(2)), the incremental cost-effectiveness was $8878/QALY for LAGB compared with $14,680/QALY for LRYGB.

CONCLUSION

The modeled cost-effectiveness analysis showed that both operative interventions for morbid obesity, LAGB and RYGB, were cost-effective at <$25,000 and that LAGB was more cost-effective than RYGB for all base-case scenarios.

Bariatric surgery for morbid obesity: risks and benefits in chronic kidney disease patients

Obesity is one of the most preventable causes of morbidity and mortality of the 21st century. Chronic kidney disease (CKD) has been a largely overlooked consequence of obesity; however, accumulating evidence elucidates the association. Obesity is at the core, promoting a cascade of secondary pathologies including diabetes, dyslipidemia, inflammation, hypertension, and the metabolic syndrome; these comorbidities constitute great risk for CKD. With the diagnosis of CKD, there is an increased threat of cardiovascular disease and the attendant increase in morbidity and mortality rates. Substantial weight loss in the obese population can be effectively achieved and maintained through bariatric surgery, which confers major health benefits by producing resolution or improvement of obesity-related comorbidities. This surgical procedure presents an early hazard of acute on chronic kidney failure, which is offset by a potential improvement in the risk of CKD progression with anticipated improvement in hypertension, diabetes, and CKD risk factors. Future research is needed to describe the clinical course and risks and benefits of bariatric surgery in the CKD population.

Best practice recommendations for surgical care in weight loss surgery

OBJECTIVE

To establish evidence-based guidelines for best practices for surgical care in weight loss surgery (WLS).

RESEARCH METHODS AND PROCEDURES

We carried out a systematic search of English-language literature on WLS in MEDLINE and the Cochrane Library. Key words were used to narrow the field for a selective review of abstracts. Data extraction was performed, and evidence categories were assigned according to a grading system based on established evidence-based models.

RESULTS

We assessed types of WLS, recommended guidelines for appropriateness, developed strategies for medical error reduction, established criteria for credentialing of systems and practitioners, and specified research needed for the future.

DISCUSSION

Surgeon training, credentialing, and type of surgery performed were identified as key factors in patient safety. Other important issues in the delivery of best practice care included appropriate patient selection; use of a multidisciplinary treatment team; facility staffing, equipment, and administrative support; and early recognition and proper management of complications.

The effect of insulin on cardiac autonomic balance predicts weight reduction after gastric bypass

AIMS/HYPOTHESIS

The aim of this study was to assess the predictive role of autonomic reactivity in body weight loss induced by gastric bypass.

METHODS

A group of 22 morbidly obese subjects, who were due to undergo a gastric bypass, were submitted, before surgery, to a euglycaemic-hyperinsulinaemic clamp, during which a continuous recording of the ECG was performed. The effect of insulin on cardiac autonomic balance was evaluated by performing power spectral analysis of heart rate variability. The low-to-high frequency ratio was calculated before and during the clamp and its modifications were expressed as % delta low-to-high frequency ratio (%Delta L: H).

RESULTS

Preoperative %Delta L: H showed a significant (p=0.0009, r2=0.43), positive relationship to the reduction of body weight, measured 1 year after surgery and expressed as % excess weight loss (% EWL). Preoperative BMI was also significantly (p=0.0009, r2=0.43) negatively related to the 12-month % EWL. In a multiple regression analysis, %Delta L: H remained a significant (p=0.003), independent predictor of body weight loss, even when preoperative BMI or age, % fat mass, insulinaemia and glucose disposal were taken into account.

CONCLUSIONS/INTERPRETATION

The best correction of excess body weight was achieved by those obese subjects who had a preserved capacity to shift their cardiac autonomic balance towards a sympathetic prevalence in response to an euglycaemic-hyperinsulinaemic clamp. Further studies are needed to elucidate the mechanisms through which the autonomic nervous system influences weight reduction.

Open Roux-en-Y gastric bypass in 925 patients without mortality

BACKGROUND

Open Roux-en-Y gastric bypass has become the gold standard for bariatric surgery. Safety has always been a concern with this elective surgery, especially among the general public. With increasing numbers of bariatric surgeries being performed, the public eye is once again focused on safety and outcomes for these patients.

METHODS

Nine hundred twenty-five consecutive open Roux-en-Y gastric bypass patients were reviewed. Charts were retrospectively reviewed for early complications, late complications, and resolution of medical comorbidities.

RESULTS

There were no deaths in this study group. The average body mass index (BMI) was 51. Eight leaks at the anastomosis occurred with no reoperations. Hypertension resolved in 70% and diabetes mellitus resolved in 58% of patients.

CONCLUSIONS

Open Roux-en-Y gastric bypass is a safe operation, even with increasing numbers of surgeries being performed. Major complications are low and improvement of medical comorbidities is significant. A multidisciplinary team approach helps to improve care and clinical outcomes.

National trends in utilization and outcomes of bariatric surgery

BACKGROUND

Because of the growing interest in surgery to treat morbid obesity, this study examined changes in the utilization and in-hospital outcomes of bariatric surgery in the United States over a 10-year period.

METHODS

Data were obtained from the Nationwide Inpatient Sample, the largest all-payer discharge database in the United States. International Classification of Disease (ICD-9) codes were used to identify all bariatric procedures performed for adults from 1990 to 2000. Population-based rates of surgery for each year were calculated by applying sampling weights and U.S. Census data. Secular trends in annual rates of surgery, changes in patient characteristics, and in-hospital mortality and complications were analyzed.

RESULTS

From 1990 to 2000, the national annual rate of bariatric surgery increased nearly six fold, from 2.4 to 14.1 per 100,000 adults (p = 0.001). There has been more than a ninefold increase in the use of gastric bypass procedures (1.4 to 13.1 per 100,000; p < 0.001). This represents an increase from 55% of all bariatric procedures in 1990 to 93% of such procedures in 2000 (p < 0.001). The rates of in-hospital mortality were low (0.4% overall), but increased slightly over time (0.2% in 1990 to 0.5% in 2000; p = 0.009). There is no significant difference in adjusted mortality for the past 8 years, but a slight rise did occur over the full 10-year period. The rates for reoperation (1.3%) and pulmonary emboli (0.3%) remained stable. The rates for respiratory failure associated with bariatric surgery declined from 7.7% in 1990 to 4.5% in 2000 (p < 0.001). Over this time, the mean length of hospital stay declined from 6.0 to 4.1 days (p < 0.001).

CONCLUSIONS

The annual rate of bariatric surgery in the United States increased nearly six fold between 1990 and 2000, with little change in in-hospital morbidity and mortality. This appears to be driven largely by the increasing popularity of gastric bypass procedures.

Impact of gastric bypass operation on survival: a population-based analysis

BACKGROUND

Bariatric procedures are increasingly performed but their impact on survival is unknown.

STUDY DESIGN

We evaluated short- and longterm mortality rates of patients undergoing gastric bypass on a population level compared with a nonoperated cohort of patients with morbid obesity in a retrospective study, using the Washington State Comprehensive Hospital Abstract Reporting System database and the Vital Statistics database. The study included all patients (age 18 to 65 years) from 1987 to 2001 who underwent gastric bypass with ICD-9 diagnostic codes for obesity. The comparator group included patients of similar age with a diagnosis of obesity or morbid obesity who did not have a bariatric procedure. Survival analysis was used to determine the association of surgeon experience on 30-day mortality and of the procedure on survival while controlling for age, gender, and comorbidity index.

RESULTS

Of the 66,109 obese patients we evaluated, 3,328 had a bariatric procedure. Incidence of the procedure increased from 0.7 to 10.6 per 100,000 from 1987 to 2001, with a 2.5-fold increase in incidence rate of the procedure in the years after 1996 (incidence rate ratio, 2.5; 95% CI, 2.4 to 2.7). Thirty-day mortality was 1.9% and was associated with surgical inexperience. Within the surgeon's first 19 procedures the odds of death within 30 days were 4.7 times higher (95% CI, 1.2 to 18.2) than at later points in a surgeon's case order. At 15 years followup, 16.3% of nonoperated patients had died as compared with 11.8% of patients who had the bariatric procedure. When survival was compared beginning 1 year after the procedure, the adjusted hazard for death was 33% lower than that of nonoperated patients (hazard ratio 0.67; 95% CI, 0.54 to 0.85).

CONCLUSIONS

Thirty-day mortality after gastric bypass is higher than previously reported and closely linked to surgeon inexperience. A modest overall survival benefit was associated with the procedure but a marked survival advantage was noted for patients who survive to the first postoperative year.

Management of nonalcoholic fatty liver disease: weight control

With obesity reaching epidemic proportions in the United States, it is imperative that hepatologists have an understanding of the medical ramifications and methods of treatment. Evaluation of nonalcoholic fatty liver disease may get the patient into the office,but weight reduction may provide a therapeutic hurdle. This article provides an overview of current obesity treatment.

Obesity and type 2 diabetes

The increasing prevalence of obesity is accompanied by an increasing prevalence of type 2 diabetes. Obesity not only increases the risk of developing type 2 diabetes but also compounds its health risks and complicates its management. The health benefits of weight loss and the efficacy of current weight loss strategies in obese persons with type 2 diabetes are evaluated. In addition, the article reviews the results of lifestyle intervention trials designed to reduce conversion to type 2 diabetes in at-risk individuals.