Bariatric Surgery

BACKGROUND Obstructive sleep apnea (OSA) is strongly associated with metabolic syndrome. Bariatric surgery is an effective available treatment for OSA; however, limited research predicts which patients undergoing bariatric surgery will undergo OSA resolution. OBJECTIVES To determine perioperative predictors for OSA resolution following bariatric surgery using a national database. SETTING United Kingdom national bariatric surgery database. METHODS The UK National Bariatric Surgery Registry (NBSR) was interrogated to identify all patients with OSA that underwent primary bariatric surgery between January 2009 and June 2017. Those with at least 1 follow-up recording postoperative OSA status were selected for further analysis. Demographic, pre- and postoperative outcomes were collected and analyzed. Poisson multivariate regression was conducted to identify predictors of OSA remission. RESULTS A total of 4015 bariatric cases were eligible for inclusion: 2482 (61.8%) patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB), 1196 (29.8%) sleeve gastrectomy (LSG), and 337 (8.4%) adjustable gastric banding (LAGB). Overall, the mean excess weight loss (EWL) % for the whole group was 61.2 (SD ± 27.2). OSA resolution was recorded in 2377 (59.2%) patients. Following Poisson regression, LRYGB (risk ratio [RR], 1.49 confidence interval [CI] 1.25-1.78) and LSG (RR, 1.46 [CI 1.22-1.75] were associated with approximately 50% increased likelihood of OSA remission compared with LAGB. Greater weight loss following intervention was associated with greater likelihood of OSA remission, while both greater age and greater preoperative body mass index (BMI) were associated with reduced likelihood of OSA remission (P < .001). CONCLUSION This study demonstrated that metabolic surgery results in OSA remission in the majority of patients with obesity. Younger age, lower BMI preprocedure, greater %EWL and the use of LSG or LRYGB positively predicted OSA remission.

The prevalence of obesity and overweight is growing in adults and children worldwide. With the failure of diets and lifestyle factors, more people are looking to bariatric surgery to address this significant medical problem. Severe obesity may be associated with significant perioperative respiratory complications. This article reviews potential respiratory and sleep complications, screening, and management of these problems.

The following case report illustrates a 24-year-old male who presented with massive pleural effusion caused by Tuberculosis (TB), which required drainage of nearly 2 liters of pleural fluid. This is a unique presentation as pleural effusion in TB are typically small to moderate in size, occupying less than one-third of the hemithorax in 80% of cases [1]. Studies show approximately only 5% of patients with TB will develop extrapulmonary TB of which greater incidence of pleural effusion are found in patients who are tested positive for human immunodeficiency virus (HIV) [2 ]. This patient was negative for HIV and he had no prior medical conditions, which places him under a very low risk of developing this condition.

The prevalence of obesity in both the United States and worldwide has grown significantly over the last several decades. With this growing pandemic, more patients are seeking surgical alternatives to achieve weight loss goals. Bariatric surgery has multiple proven health benefits, including weight loss and resolution of several co-morbidities, including diabetes. Advances in surgical techniques, including laparoscopy, have allowed bariatric surgery to increase in popularity among obese patients. However, bariatric surgery is not without complications. Key to successful weight loss surgery includes appropriate pre-operative laboratory workup, a multidisciplinary approach with other health care providers, proper peri-operative techniques as well as close post-operative follow up. This article will highlight several important criteria bariatric surgeons should bear in mind when evaluating patients in pre-operative, peri-operative and post-operative states to help prevent common complications seen in weight loss surgery.

Bariatric surgery results in decreased food intake and a variable degree of malabsorption. Without adequate supplementation, the most common complications of this surgery are nutritional disorders. Pregnancy following surgery for obesity is a particular condition requiring strict monitoring of nutrient intake necessary for fetal development and a favourable neonatal prognosis. Malnutrition in pregnancy and congenital neural malformations are reported in three women who had previously undergone bariatric surgery (1, 5 and 18 years before pregnancy, respectively). Two patients underwent the Roux en Y bypass and one bilio-pancreatic diversion with gastroplasty. None of the three received pre-conceptional nutritional counselling. Patients 1 and 2 did not undergo postoperative nutritional surveillance; nutrient supplementation was started at 22 and 20 weeks gestation, respectively. In patient 3, supplementation was stopped at six weeks gestation. Newborns 1 and 2 presented with dorsal my...

Situs inversus totalis is a rare defect which can present difficulties in the management in laparoscopic surgery due to the mirror-image anatomy. Herein, we report a patient with situs inversus totalis and super-super-obesity (BMI 76 kg/m2). We performed successful laparoscopic sleeve gastrectomy. Technical details of this operation, with situs inversus totalis, are presented. There were no major difficulties compared to patients with usual anatomy. There are potential diseases associated with situs inversus and obesity; therefore, a careful investigation, including a chest x-ray and cardiac and abdominal ultrasounds should be performed before surgery. Sleeve gastrectomy is an adequate procedure in super-super-obese patients with situs inversus totalis.

Thirty-five morbidly obese patients underwent Roux-en-Y gastric bypass surgery (RYGB). In addition to weight loss, these patients showed significant improvement of insulin resistance and a reduction of hepatic fat content. Three months after surgery, the serum bile salts were slightly but significantly elevated, and the levels of the endocrine-acting fibroblast growth factor 19 (FGF19) and FGF21 were increased. FGF19 and FGF21 play a role as regulators of hepatic lipid and glucose metabolism. These results show that RYGB surgery improves metabolism and that this improvement is still apparent 3 months after surgery. Bile salts may play a key role in the improvement of metabolism after RYGB. Why serum bile salt concentrations are elevated after RYGB needs to be investigated.

Obesity-related hypogonadotrophic hypogonadism (OrHH) occurs in over 40% of morbidly obese men. Obesity-related hypogonadotrophic hypogonadism may reduce the beneficial effects of bariatric surgery. To assess the impact of OrHH on the outcome of bariatric surgery in men. Observational study with measurement of serum gonadal hormones, and assessment of body composition, glucose, lipid and bone metabolism during the first year after bariatric surgery in 13 men with OrHH (free testosterone (free T) <225 pmol/l) and 11 age-matched eugonadal morbidly obese men (free T > 225 pmol/l). Serum free T was inversely related to body weight (R = -0·65, P < 0·0001) and rose gradually after bariatric surgery, in eugonadal as well as in OrHH men, by 30 pmol/l for every 10 kg loss of weight. In three patients, serum free T remained within the hypogonadal range despite substantial weight loss. Gonadal hormone status prior to surgery did not affect the 1-year outcome of surgery. Obesity-related hypogonadotrophic hypogonadism is a reversible condition in the majority of obese men. It does not reduce the efficacy of bariatric surgery. Preoperative weight-adjusted normal values are recommended to avoid an incorrect diagnosis of hypogonadism in obese men.

Changes in liver fatty acid metabolism are important in understanding the mechanisms of diabetes remission and metabolic changes after bariatric surgery. Liver fatty acid uptake (LFU), blood flow, and fat content (LFC) were measured in 25 obese subjects before bariatric surgery and 6 months after using positron emission tomography/computed tomography and MRS; 14 lean individuals served as the control subjects. The increased LFU in obese subjects was associated with body adiposity. LFU was reduced postoperatively but was still high compared with the control subjects. LFC was normalized. Liver blood flow (per unit volume) was higher in obese subjects than in the control subjects at baseline and was further increased postoperatively; however, the total organ blood flow was unchanged as the liver volume decreased. The findings suggest that in a postoperative state, intrahepatic fatty acids are not stored in the liver but are used for oxidation to provide energy. Changes in perfusion may...

Obesity has long been associated with an increased risk of cardiovascular disease (CVD). The aim of this study was to evaluate the impact of substantial weight loss induced by bariatric surgery on carotid intima media thickness (C-IMT) (surrogate marker of early atherosclerosis) and classic factors of cardiovascular risk (CVRFs). thirty-one obesity patients were evaluated for bariatric surgery. Twenty-seven were undergone surgery, 14 Roux-en-Y gastric bypass surgery (GBS) and 13 sleeve gastrectomy. The four obese patients who did not undergo surgery, were performed the same evaluations. Body weight, BMI, blood pressure, total cholesterol, TC levels, LDL-C, HDL-C, TG, fasting plasma glucose and insulin, HOMA IR, and US B-mode C-IMT was measured. After 354 ± 92 days follow up, 27 patients that underwent bariatric surgery evidenced a mean body mass index decrease from 38 to 27 k/m² (p < 0.001), simultaneously was observed improvement in CVRFs, 10 years Framingham risk and a signific...

Background: There is disagreement regarding hospital and physician reimbursement fees when DRG codes are used. We have found that physicians and hospitals are rewarded differently depending on the type of insurance coverage - per diem HMO (Health Maintenance Organization) vs public. Methods: 133 patients were retrospectively analyzed in a single institution. There were 59 privately-insured and 74 publicly-insured patients. Using DRG 288, hospital and surgeon reimbursement rates, complications, length of stay, blood loss and basic demographics were evaluated on all patients. Reimbursement rates were then compared to inpatient hospital costs per case for both open and laparoscopic Roux-en-Y gastric bypass (RYGBP). Statistical analysis used Student's t-test and standard deviation. Results: The 2 groups were similar in terms of age, sex and BMI. There was a large difference in physician reimbursement when comparing public to private insurance ($931±73 vs $2356±822, PP

Scholars have problematized popular culture and media (re)presentations of obesity/overweight. However, few have considered the ways bariatric surgery, a rapidly growing treatment for morbid obesity, fits within the discussion. In this article, we explore news media (re)presentations of bariatric surgery using an eclectic approach to critical discourse analysis. Our findings reveal dominant discourses about bariatric surgery and the surgical population, providing an understanding of media (re)presentations as possible contributors to bias, stigmatization, and discrimination. Novel in our findings was our identification of subject positions in the dominant discourses (which were biomedical and benevolent government). We argue that existing (re)presentations of bariatric surgery are highly problematic because they reinforce oversimplistic and binary understandings of weight-loss surgery and obesity, weaving a highly gendered fairy-tale narrative and ultimately promoting weight-based s...

The rate of surgical complications from bariatric procedures remains low despite an increase in volume. When serious complications occur, they are associated with an increased risk of mortality. The aim of this study is to determine if frail bariatric patients have an increased rate of Clavien level 4 and 5 complications. This study was conducted in participating hospitals in the National Surgical Quality Improvement Program (NSQIP). The NSQIP participant use files were used to identify 104,952 patients undergoing elective bariatric procedures from 2005 to 2012. A previously described modified frailty index (mFI) was calculated based on available NSQIP variables, with a higher index suggesting more frail patients. Postoperative adverse events were stratified to Clavien levels 4 and 5 utilizing a pre-existing mapping scheme. Overall, 1 % of patients undergoing elective bariatric surgery experienced Clavien level 4 complications, and 0.2 % experienced a Clavien level 5 complication (mortality). Univariate analysis demonstrated that frailty was significant for both Clavien level 4 and 5 complications (p < 0.001). The mean mFI for those with Clavien level 4 complications, 0.15, was significantly higher than those without Clavien 4 complications, 0.09 (p < 0.001). Those experiencing mortality had a mean mFI of 0.17 compared to a mean mFI of 0.09 in those without mortality (p < 0.001). Frailty retained the highest odds ratio for both Clavien 4 and 5 complications in multivariate analysis compared to American Society of Anesthesiologist (ASA) class, age, sex, body mass index (BMI), and procedure type. Frailty may be used during patient selection to stratify bariatric surgery patients at high risk for critical care level complications.

Obesity has serious implications on a woman's quality of life and body image. We propose a qualitative investigation aimed at understanding the postoperative significance of bariatric surgery for women suffering from morbid obesity and how these factors influence the outcomes, with an emphasis on body image and on the possible psychological complications that may jeopardize the operation's success. This study uses a clinical qualitative method, through a semidirected interview with open-ended questions in an intentional sample, closed by saturation, with seven women operated in a period of 1.5-3 years, following the definition of emergent categories and qualitative content analysis. Bariatric surgery is a procedure that brings about rapid physical, social, and emotional changes, and it is seen by patients as a possibility of being reinstated and accepted socially. The reencounter with the feminine body after surgery is experienced as a means of reinstatement but also with a feeling of defenselessness, which may lead to the development of phobic symptoms. Imbalance in family and conjugal relationships may be factors that discourage the continuation of the treatment. The patient sees the skin folds, flaccidity, and the scars as therapeutic failures, which can lead to a constant quest for plastic surgery. We observe the necessity of studies that allow the health team to identify those aspects of a patient's psychological makeup which would be expected to improve or worsen their prognosis and to provide the necessary preoperative and postoperative psychosocial interventions.

Obesity is a very serious problem at the 21st Century essentially affecting developed countries. It may be considered a pandemicity. Among predisposing factors for obesity here are, on the one hand, the new feeding habits with fat-and carbohydrate-rich pre-cooked foods, and in the other hand sedentary lifestyle due to occidental society lifestyles. Although obesity is considered a chronic disease, it would really represent a normal and physiologic adaptation mechanism to an "obesogenic" environment. Bariatric surgery represents a solution for morbid obesity when all the other conservative measures have failed, achieving the modification of nutritional habits and nutrients absorption. However, it is paramount to modify lifestyle concerning sedentary lifestyle. Individualized exercise monitoring offers the advantage of motivating and rejection to exercise. It is necessary to study and assess the efficacy of aerobic and anaerobic physical activity at both pre-surgical prepara...

Background : Due to the increased prevalence of obesity in many countries, the number of bariatric surgeries is increasing. They are considered the most effective treatment for obesity. In the postoperative there may be difficulties with the quality of alimentation, tolerance to various types of food, as well as vomiting and regurgitation. Few surveys are available to assess these difficulties in the postoperative. Aim : To perform a systematic literature review about food tolerance in patients undergoing bariatric surgery using the questionnaire "Quality of Alimentation", and compare the results between different techniques. Method : A descriptive-exploratory study where the portals Medline and Scielo were used. The following headings were used in english, spanish and portuguese: quality of alimentation, bariatric surgery and food tolerance. A total of 88 references were found, 14 used the questionnaire "Quality of Alimentation" and were selected. Results : In t...

Obesity and metabolic syndrome are considered as responsible for a condition known as the non-alcoholic fatty liver disease that goes from simple accumulation of triglycerides to hepatic inflammation and may progress to cirrhosis. Patients with obesity also have an increased risk of primary liver malignancies and increased body mass index is a predictor of decompensation of liver cirrhosis. Sarcopenic obesity confers a risk of physical impairment and disability that is significantly higher than the risk induced by each of the two conditions alone as it has been shown to be an independent risk factor for chronic liver disease in patients with obesity and a prognostic negative marker for the evolution of liver cirrhosis and the results of liver transplantation. Cirrhotic patients with obesity are at high risk for depletion of various fat-soluble, water-soluble vitamins and trace elements and should be supplemented appropriately. Diet, physical activity and protein intake should be car...

Context: Postprandial hypoglycemia (PPHG) is a recognized complication of Roux-en-Y gastric bypass (RYGB) surgery. Data on PPHG after laparoscopic sleeve gastrectomy (LSG) are scant. Objective: The objective of the study was to identify preoperative predictors of PPHG in subjects spontaneously self-reporting PPHG after RYGB or LSG. Patients, Setting, and Intervention: Nondiabetic patients spontaneously self-reporting symptoms/signs of PPHG (PPHG group, 21 RYGB and 11 LSG) were compared in a case-control design with subjects who never experienced spontaneous or oral glucose tolerance test (OGTT)-induced hypoglycemia over 24 months after surgery (No-PPHG group, 13 RYGB and 40 LSG). Paired pre- and postoperative 3-hour OGTTs were analyzed in all participants. Main Outcome Measures: Insulin sensitivity was assessed by the oral glucose insulin sensitivity index and β-cell function by mathematical modeling of the C-peptide response to glucose. Results: Before surgery, the body mass index ...

BackgroundMesenteric internal hernia (MIH) is the most common cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass. Because MIH is a potentially life-threatening complication, we hypothesized that elective repair of MIH before developing acute SBO could decrease morbidity in this population.

BACKGROUND: Obesity is associated with numerous comorbidities and affects various aspects of life, including quality of life (QOL) and sexual function (SF). Bariatric surgery (BS) is an effective treatment for obese people. Also QOL and SF after BS in the people are not well known. AIMS: To provide insight in the available prospective evidence regarding the short and long-term effects of BS on QOL and SF. MATERIALS AND METHODS: A systematic multi-database search was conducted for quality of life, Sexual function and Bariatric surgery. Only prospective studies with QOL or SF before and after BS were included. The quality assessment tool for beforeafter studies with no control group was used to assess the methodological quality. RESULTS: Twenty-four studies met the inclusion criteria. Most studies were assessed to be of fair to good methodological quality. Seven different questionnaires were used to measure both QOL and SF. A significant increase in QOL after BS and light increase in ...

Background: Rhabdomyolysis (RML) is a clinical and biochemical syndrome caused by skeletal muscle necrosis that results in extravasation of toxic intra-cellular contents from the myocytes into the circula-tory system. Postoperative RML in bariatric surgery occurs with various ...

The gut microbiota is recognized to have an important role in energy storage and the subsequent development of obesity. To date, bariatric surgery (indicated for severe obesity) represents the only treatment that enables substantial and sustained weight loss. Bariatric surgery is also a good model to study not only the pathophysiology of obesity and its related diseases but also the mechanisms involved in their improvement after weight reduction. Scarce data from humans and animal models have demonstrated that gut microbiota composition is modified after Roux-en-Y gastric bypass (RYGB), suggesting that weight reduction could affect gut microbiota composition. However, weight loss might not be the only factor responsible for those modifications. Indeed, bariatric surgery not only improves hormonal and inflammatory status, but also induces numerous changes in the digestive tract that might account for the observed modifications of microbiota ecology. In future bariatric surgery studie...

Multiple interventions are available to reduce excess body weight in children. We appraised the quality of evidence supporting each intervention and assessed the effectiveness on different obesity-related outcomes. We conducted a systematic search for systematic reviews of randomized controlled trials evaluating pediatric obesity interventions applied for ≥6 months. We assessed the quality of evidence for each intervention using GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) approach. From 16 systematic reviews, we identified 133 eligible randomized controlled trials. Physical activity interventions reduced systolic blood pressure and fasting glucose (low to moderate quality of evidence). Dietary interventions with low-carbohydrate diets had a similar effect to low-fat diets in terms of body mass index (BMI) reduction (moderate quality of evidence). Educational interventions reduced waist circumference, BMI, and diastolic blood pressure (low quality of ev...

Type Two Diabetes Mellitus (T2DM), formerly known as adult-onset diabetes, is a disease caused by impaired pancreatic insulin production and the ineffective use of insulin (insulin resistance) in the liver and periphery. It is believed that today, up to 5000 children are being diagnosed with Type Two Diabetes Mellitus per year, with the incidence of T2DM tripling between the ages of 10-14 and 15-18, especially among racial minorities. A high-yield symptom for those suffering from T2DM is weight gain, however, T2DM can also be linked to other co-morbidities including hypertension, dyslipidaemia, diabetic retinopathy, nephropathy, and neuropathy. This is why the American Diabetes Association introduced bariatric surgery as a form of diabetic treatment in 2009. Since its approval, bariatric surgical procedures such as Gastric Banding (GB), Roux-en-Y Gastric Bypass (RYGB), Biliopancreatic Diversion (BPD), and Sleeve Gastrectomy (SG) have elicited several positive results in adult patients. However, its use on children has been put into question due to safety concerns. For that reason, we searched databases such as PubMed, ScienceDirect, Cochrane Library, Embase, and Google Scholar to conduct a systematic review containing 34528 patients from 20 different studies to determine the effectiveness of bariatric surgery as a treatment option for obese pediatric patients with Type Two Diabetes Mellitus. For this systematic review, we only included patients <18 years of age with a BMI >35 along with papers that measured their patients' change in Body Mass Index (BMI), estimated weight loss (EWL), or total weight loss (TWL). Upon completion of the investigation, it was concluded that bariatric surgery is an effective treatment for obese adolescents with Type Two Diabetes Mellitus.