2013 AHA/ACC/TOS Guideline for the Management of Overweight

BackgroundLong-term results from randomized, controlled trials that compare medical therapy with surgical therapy in patients with type 2 diabetes are limited. MethodsWe assessed outcomes 5 years after 150 patients who had type 2 diabetes and a body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) of 27 to 43 were randomly assigned to receive intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy. The primary outcome was a glycated hemoglobin level of 6.0% or less with or without the use of diabetes medications. ResultsOf the 150 patients who underwent randomization, 1 patient died during the 5-year follow-up period; 134 of the remaining 149 patients (90%) completed 5 years of follow-up. At baseline, the mean (±SD) age of the 134 patients was 49±8 years, 66% were women, the mean glycated hemoglobin level was 9.2±1.5%, and the mean BMI was 37±3.5. At 5 years, the criterion for the primary end point was met by 2...

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Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 5-Year Outcomes

This meta-analysis on surgical treatment of obesity supports the American College of Physicians' clinical guideline in this issue. Surgery is more effective than nonsurgical treatment for weight lo...

http://www.paxysarkia.net/Download/Article_metaanalysis_surgical%20treatment%20of%20obesity.pdf

Meta-analysis: surgical treatment of obesity.

Objective To evaluate the short-term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with a follow-up of 1 to 31 months. Background Data The Roux-en-Y gastric bypass is a highly successful approach to morbid obesity but results in significant perioperative complications. A laparoscopic approach has significant potential to reduce perioperative complications and recovery time. Methods Consecutive patients (n = 275) who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass between July 1997 and March 2000. A 15-mL gastric pouch and a 75-cm Roux limb (150 cm for superobese) was created using five or six trocar incisions. Results The conversion rate to open gastric bypass was 1%. The start of an oral diet began a mean of 1.58 days after surgery, with a median hospital stay of 2 days and return to work at 21 days. The incidence of early major and minor complications was 3.3% and 27%, respectively. One death occurred related to a pulmonary embolus (0.4%). The hernia rate was 0.7%, and wound infections requiring outpatient drainage only were uncommon (5%). Excess weight loss at 24 and 30 months was 83% and 77%, respectively. In patients with more than 1 year of follow-up, most of the comorbidities were improved or resolved, and 95% reported significant improvement in quality of life. Conclusion Laparoscopic Roux-en-Y gastric bypass is effective in achieving weight loss and in improving comorbidities and quality of life while reducing recovery time and perioperative complications.

Outcomes After Laparoscopic Roux-en-Y Gastric Bypass for Morbid Obesity

Objective: This study tested the hypothesis that weight-reduction (bariatric) surgery reduces long-term mortality in morbidly obese patients. Background: Obesity is a significant cause of morbidity and mortality. The impact of surgically induced, long-term weight loss on this mortality is unknown. Methods: We used an observational 2-cohort study. The treatment cohort (n = 1035) included patients having undergone bariatric surgery at the McGill University Health Centre between 1986 and 2002. The control group (n = 5746) included age- and gender-matched severely obese patients who had not undergone weight-reduction surgery identified from the Quebec provincial health insurance database. Subjects with medical conditions (other then morbid obesity) at cohort-inception into the study were excluded. The cohorts were followed for a maximum of 5 years from inception. Results: The cohorts were well matched for age, gender, and duration of follow-up. Bariatric surgery resulted in significant reduction in mean percent excess weight loss (67.1%, P < 0.001). Bariatric surgery patients had significant risk reductions for developing cardiovascular, cancer, endocrine, infectious, psychiatric, and mental disorders compared with controls, with the exception of hematologic (no difference) and digestive diseases (increased rates in the bariatric cohort). The mortality rate in the bariatric surgery cohort was 0.68% compared with 6.17% in controls (relative risk 0.11, 95% confidence interval 0.04-0.27), which translates to a reduction in the relative risk of death by 89%. Conclusions: This study shows that weight-loss surgery significantly decreases overall mortality as well as the development of new health-related conditions in morbidly obese patients.

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Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients.

Background:The authors have performed the laparoscopic gastric bypass since 1993 and perform about one-half of bariatric cases laparoscopically. Since our initial report, several groups throughout the world have preformed the gastric bypass laparoscopically, with various modifications. Method: Prospectively, we followed and recorded the results of our laparoscopic patients. A detailed pre- and post-operative analysis of the patient's co-morbidities is performed as well as complete weight and laboratory data evaluation. Results:With > 80% follow-up, we found an excess weight loss of about 80% by the first year. This degree of loss is well sustained. Over 95% of the significant pre-operative co-morbidities are controlled. Conclusion: The laparoscopic gastric bypass has been refined over 5 years of use. Though we have not changed the basic operation as we originally described, others have modified the various anastomotic techniques. The weight loss results are very good to excellent, with patients now out to "long-term" follow-up. Resolution of the co-morbidities is documented. The operation has an adequate track record to show effectiveness, and training programs should be established to maximize safety.

Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3-60 month follow-up.

Background: Women who suffer from morbid obesity are often infertile. If these women are able to become pregnant, they are considered high risk because of the hypertension, diabetes and other associated risk factors. Following the pregnancy is difficult due to limitations of the physical examinations. More costly ultrasound examinations are needed at a higher frequency. Bariatric surgery reduces the woman's weight and the incidence of obesity related co-morbidities. The number of pregnancies and rate of complications during those pregnancies in our post-bariatirc surgical patients were evaluated. Method: Our group has been doing bariatric surgery since the early 1980s. We have over 2000 active patients on our current newsletter mailing list. The patients also have a series of networks through support groups. The patients are informed to contact us when they become pregnant so we may assist the obstetrician with their care. Through these various means, we have been able to identify 41 women in our patient population who have become pregnant. Using personal interview, questionnaire, and review of perinatal records, pregnancy-related risks and complications were studied. Results: With over a 95% follow-up rate on the patients identified as having been pregnant following surgery, we found less risk of gestational diabetes, macrosomia, and cesarean section than associated with obesity. There were no patients with clinically significant anemia. Conclusion: Since the patients had an operation that restricts their food intake, some basic precautions should be taken when they become pregnant. With this in mind, our patients have done well with their pregnancies. The post-surgical group had fewer pregnancy-related complications than did an internally controlled group that were morbidly obese during their previous pregnancies.

Pregnancy following gastric bypass for morbid obesity.

Background: Laparoscopic Roux en-Y Gastric Bypass (RYGB) has been performed in 100 patients, in our series Methods: The results of surgery, including 3-30-months follow-up, are described with 100% follow-up, for the first 75 patients Weight loss, operative morbidity and relief of co-morbidities have been thoroughly studied in a prospective fashion Results: Diabetes mellitus was normalized in 22 of 24 patients and gastroesophageal reflux was relieved in all patients Length of stay, recovery time and cosmetic results are superior to the ‘open’ technique, and the operative times are competitive Conclusion: Laparoscopic RYGB deserves a place in the operative repertoir of bariatric surgeons

Laparoscopic Gastric Bypass, Roux en-Y: Technique and Results in 75 Patients With 3-30 Months Follow-up

Adiponectin is an insulin sensitizing fat cell (FC) hormone whose levels are related to adipose tissue (AT) mass and depot distribution. We hypothesized that the nature of AT expansion (hypertrophy...

https://www.tandfonline.com/doi/pdf/10.4161/adip.24953

Adipose tissue depot and cell size dependency of adiponectin synthesis and secretion in human obesity

Bariatric surgery has not been routinely presented as an option for patients over 60 years of age. Part of the reason is the long-standing perception that there is additional risk. Additionally, until its recent ruling, Medicare was inconsistent in its coverage, thus making it difficult for some beneficiaries to gain access to the procedures. The aim of this study was to evaluate the perioperative morbidity in our patients who were 60 years of age or older who underwent a laparoscopic gastric bypass Roux-en-Y (LGBRY). We also report the impact of surgery on five objectively graded comorbidities in the early postoperative period. Our prospectively maintained database was used to identify and report on all patients operated on at our program from January 2002 through January 2007. One hundred twenty patients were identified with 100% follow-up through the perioperative phase and 85% follow-up at 12 months. The mean age was 62 years (range 60–74) with a mean body mass index of 43 kg/m2 (range 34–70). All patients underwent an LGBRY. There was no 30-day mortality. Perioperative complications included: 13 strictures, one abscess, two wound infections, three ulcers, two small bowel obstructions, three bleeding episodes in patients who required coumadin, and atrial fibrillation in two patients. The five graded/measurable comorbid conditions (preop/postop) were diabetes mellitus type II (68/17), hypertension (86/10), obstructive sleep apnea requiring continuous positive airway pressure (CPAP; 48/3), hypercholesterolemia (106/18), and hypertriglyceridemia (60/5). LGBRY can be done safely in patients over 60 years of age in an experienced bariatric program, even in patients with relatively high risk based on their comorbid conditions preoperatively. Resolution of associated comorbidities far exceeds that found with any other treatment modality.

Alan C Wittgrove

Papers

Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3-60 month follow-up.

Pregnancy following gastric bypass for morbid obesity.

Laparoscopic Gastric Bypass, Roux en-Y: Technique and Results in 75 Patients With 3-30 Months Follow-up

Adipose tissue depot and cell size dependency of adiponectin synthesis and secretion in human obesity

Laparoscopic gastric bypass in patients 60 years and older: early postoperative morbidity and resolution of comorbidities.