Early experience with two-stage laparoscopic Roux-en-Y gastric bypass as an alternative in the super-super obese patient.

BACKGROUND: Surgical management of the supersuper obese patient (BMI >60 kg/m2) has been a challenging problem associated with higher morbidity, mortality, and long-term weight loss failure. Current limited experience exists with a two-stage biliopancreatic diversion and duodenal switch in the supersuper obese patient, and we now present our early experience with a two-stage gastric bypass for these patients. METHODS: We completed a retrospective bariatric database and chart review of super-super obese patients who underwent laparoscopic sleeve gastrectomy as a first-stage procedure followed by laparoscopic Roux-en-Y gastric bypass as a second-stage for more definitive treatment of obesity. RESULTS: During a two-year period, 7 patients with BMI 58-71 kg/m2 underwent a two-stage laparoscopic Roux-en-Y gastric bypass by two surgeons at the Mount Sinai Medical Center. 3 patients were female, 4 patients were male, and the average age was 43. Prior to the sleeve gastrectomy, the mean weight was 181 kg with a BMI of 63. Average time between procedures was 11 months. Prior to the second-stage procedure, the mean weight was 145 kg with a BMI of 50 and average excess weight loss of 37 kg (33% EWL). Six patients have had follow-up after the second-stage procedure with an average of 2.5 months. At follow-up the mean weight was 126 kg with a BMI of 44 and average excess weight loss of 51 kg (46% EWL). The mean operative times for the two procedures were 124 and 158 minutes respectively. The average length of stay for all procedures was 2.7 days. 4 patients had 5 complications, which included splenic injury, proximal anastomotic stricture, left arm nerve praxia, trocar site hernia, and urinary tract infection.There were no mortalities in the series. CONCLUSIONS: Laparoscopic sleeve gastrectomy with second-stage Roux-en-Y gastric bypass are feasible and effective procedures based on short-term results. This two-stage approach is a reasonable alternative for surgical treatment of the high-risk supersuper obese patient.

Skeletal muscle metabolism in overweight and post-overweight women: an isometric exercise study using (31)P magnetic resonance spectroscopy.

OBJECTIVE: To investigate whether skeletal muscle anaerobic metabolism, oxidative metabolism or metabolic economy during controlled sub-maximal and near-maximal exercises is altered in overweight women after diet-induced weight reduction, and whether these parameters are different between normal-weight, obesity-prone and normal-weight obesity-resistant women with similar physical fitness levels. DESIGN: A prospective weight loss study of overweight women and their comparison with never overweight controls. SUBJECTS: Thirty overweight, nondiabetic, premenopausal women and 28 never overweight controls were included in this analysis. All were participating in a longitudinal investigation of the role of energy metabolism in the etiology of obesity.The overweight women were recruited specifically to have a positive family history of obesity and have a body mass index (BMI) between 27 and 30 kg/m(2) and were studied in the overweight state and after reduction to a normal weight. The never-overweight controls were recruited specifically to have no personal and family history of obesity and were group matched with the weight-reduced post-overweight subjects in terms of premenopausal status, age, BMI, race and sedentary lifestyle. MEASUREMENTS: All testing was performed following one month of weight maintenance and during the follicular phase of the menstrual cycle. Hydrostatic weighing was performed to measure body composition and a whole-body maximal oxygen uptake (VO(2max)) test was done to measure aerobic fitness. (31)P MRS was used to determine ATP production from oxidative phosphorylation (OxPhos), 'anaerobic' glycolysis (AnGly), and creatine kinase (CK), as well as muscle metabolic economy. The time constant of ADP (TC(ADP)), V(PCr) (ie the initial rate of PCr resynthesis following exercise), and Q(max) (ie the apparent maximal oxidative ATP production rate) were also calculated as additional markers of mitochondrial function. RESULTS: Diet-induced weight loss did not have any effects on the anaerobic metabolism markers (AnGly and CK). The aerobic metabolism markers calculated from the initial recovery data (OxPhos and V(PCr)) were unaffected by diet-induced weight loss. However, diet-induced weight loss resulted in improvements in the TC(ADP) and Q(max) in the post-overweight state as compared to their overweight state. There were no differences in any of the anaerobic (AnGly and CK) or oxidative metabolism markers (OxPhos, V(PCr), Q(max) and TC(ADP)) between the post-overweight and control groups. CONCLUSIONS: Once the overweight women were reduced to a normal-weight state, their skeletal muscle energy metabolism and economy was similar to the never overweight control women. In overweight women, oxidative metabolism or mitochondrial function may be limited by blood flow to the muscle following the cessation of exercise.

The importance of histopathological and clinical variables in predicting the evolution of colon cancer.

It has been a consensus that prognostic factors should always be taken into account before planning treatment in colorectal cancer. AIM: A 5 year prospective study was conducted, in order to assess the importance of several histopathological and clinical prognostic variables in the prediction of evolution in colon cancer. Some of the factors included in the analysis are still subject to dispute by different authors. METHODS: 46 of 53 screened patients qualified to enter the study and underwent a potentially curative resection of the tumor, followed, when necessary, by adjuvant chemotherapy. Univariate and multivariate analyses were carried out in order to identify independent prognostic indicators. The endpoint of the study was considered the recurrence of the tumor or the detection of metastases. RESULTS: 65.2% of the patients had a good evolution during the follow up period. Multivariate survival analysis performed by Cox proportional hazard model identified 3 independent prognostic factors: Dukes stage (p = 0.00002), the grade of differentiation (p = 0.0009) and the weight loss index, representing the weight loss of the patient divided by the number of months when it was actually lost (p = 0.02). Age under 40 years, sex, microscopic aspect of the tumor, tumor location, anemia degree were not identified by our analysis as having prognostic importance. CONCLUSIONS: Histopathological factors continue to be the most valuable source of information regarding the possible evolution of patients with colorectal cancer. Individual clinical symptoms or biological parameters such as erytrocyte sedimentation rate or hemoglobin level are of little or no prognostic value. More research is required relating to the impact of a performance status index (which could include also weight loss index) as another reliable prognostic variable.

The national cholesterol education program diet vs a diet lower in carbohydrates and higher in protein and monounsaturated fat: a randomized trial.

BACKGROUND: In the United States, obesity is a major clinical and public health problem causing diabetes, dyslipidemia, and hypertension, as well as increasing cardiovascular and total mortality. Dietary restrictions of calories and saturated fat are beneficial. However, it remains unclear whether replacement of saturated fat with carbohydrates (as in the US National Cholesterol Education Program [NCEP] diet) or protein and monounsaturated fat (as in our isocaloric modified low-carbohydrate [MLC] diet, which is lower in total carbohydrates but higher in protein, monounsaturated fat, and complex carbohydrates) is optimal. METHODS: We randomized 60 participants (29 women and 31 men) to the NCEP or the MLC diet and evaluated them every 2 weeks for 12 weeks. They were aged 28 to 71 years (mean age, 44 years in the NCEP and 46 years in the MLC group). A total of 36% of participants from the NCEP group and 35% from the MLC group had a body mass index (calculated as weight in kilograms divided by the square of height in meters) greater than 27. The primary end point was weight loss, and secondary end points were blood lipid levels and waist-to-hip ratio. RESULTS: weight loss was significantly greater in the MLC (13.6 lb) than in the NCEP group (7.5 lb), a difference of 6.1 lb (P = .02). There were no significant differences between the groups for total, low density, and high-density lipoprotein cholesterol, triglycerides, or the proportion of small, dense low-density lipoprotein particles. There were significantly favorable changes in all lipid levels within the MLC but not within the NCEP group. Waist-to-hip ratio was not significantly reduced between the groups (P = .27), but it significantly decreased within the MLC group (P = .009). CONCLUSIONS: Compared with the NCEP diet, the MLC diet, which is lower in total carbohydrates but higher in complex carbohydrates, protein, and monounsaturated fat, caused significantly greater weight loss over 12 weeks. There were no significant differences between the groups in blood lipid levels, but favorable changes were observed within the MLC diet group.

Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain.

weight loss is difficult to achieve and maintaining the weight loss is an even greater challenge. The identification of factors associated with weight loss maintenance can enhance our understanding for the behaviours and prerequisites that are crucial in sustaining a lowered body weight. In this paper we have reviewed the literature on factors associated with weight loss maintenance and weight regain. We have used a definition of weight maintenance implying intentional weight loss that has subsequently been maintained for at least 6 months. According to our review, successful weight maintenance is associated with more initial weight loss, reaching a self-determined goal weight, having a physically active lifestyle, a regular meal rhythm including breakfast and healthier eating, control of over-eating and self-monitoring of behaviours. Weight maintenance is further associated with an internal motivation to lose weight, social support, better coping strategies and ability to handle life stress, self-efficacy, autonomy, assuming responsibility in life, and overall more psychological strength and stability. Factors that may pose a risk for weight regain include a history of weight cycling, disinhibited eating, binge eating, more hunger, eating in response to negative emotions and stress, and more passive reactions to problems.

Long-term changes in energy expenditure and body composition after massive weight loss induced by gastric bypass surgery.

BACKGROUND: Little is known about the determinants of individual variability in body weight and fat loss after gastric bypass surgery or about the effects of massive weight loss induced by this surgery on energy requirements. OBJECTIVES: The objectives were to determine changes in energy expenditure and body composition with weight loss induced by gastric bypass surgery and to identify presurgery predictors of weight loss. DESIGN: Thirty extremely obese women and men with a mean (+/- SD) age of 39.0 +/- 9.6 y and a body mass index (BMI; in kg/m(2)) of 50.1 +/- 9.3 were tested longitudinally under weight-stable conditions before surgery and after weight loss and stabilization (14 +/- 2 mo). Total energy expenditure (TEE), resting energy expenditure (REE), body composition, and fasting leptin were measured. RESULTS: Subjects lost 53.2 +/- 22.2 kg body weight and had significant decreases in REE (-2.4 +/- 1.0 MJ/d; P < 0.001) and TEE (-3.6 +/- 2.5 MJ/d; P < 0.001). Changes in REE were predicted by changes in fat-free mass and fat mass. The average physical activity level (TEE/REE) was 1.61 at both baseline and follow-up (P = 0.98). weight loss was predicted by baseline fat mass and BMI but not by any energy expenditure variable or leptin. Measured REE at follow-up was not significantly different from predicted REE. CONCLUSIONS: TEE and REE decreased by 25% on average after massive weight loss induced by gastric bypass surgery. REE changes were predicted by loss of body tissue; thus, there was no significant long-term change in energy efficiency that would independently promote weight regain.

Lap-band: outcomes and results.

INTRODUCTION: Laparoscopic adjustable gastric banding was first introduced in the early 1990s as a potentially safe, controllable, and reversible method for achieving significant weight loss in the severely obese. The Bioenterics Lap-Band system (Inamed Health, Santa Barbara, California) is the device most commonly used. After 10 years of experience in treating more than 100000 patients with the Lap-Band, it is timely for us to review the outcomes. METHODS: Data for the review are derived from the experience of our unit in the treatment of 1250 patients to date, from an independent systematic review of the published literature up to September 2001, and from major studies published after the date of closure of the systematic review. RESULTS: Lap-Band placement has proved to be a very safe procedure with a mortality rate in the published reports of 1 in 2000, only 10% of the published mortality rate of gastric bypass. The early complication rate has been very low, but late complications of prolapse or erosions have been more frequent, particularly during the early experience. Weight is lost during the first 2 to 3 years after surgery. The systematic review reports 56% excess weight loss (EWL) at 5 years (three reports). In comparison, Roux-en-Y gastric bypass (RYGB) is reported to have achieved 59% EWL at 5 years (four reports). Major improvements in comorbid conditions have been reported in association with weight loss after Lap-Band placement. Most importantly, type 2 diabetes is usually cured, and insulin resistance and reduced pancreatic beta-cell function are reversed. Gastroesophageal reflux, obstructive sleep apnea, and depression are other diseases in which marked improvement is noted. Quality-of-life scores return to normal values. CONCLUSIONS: Lap-Band placement is proving to be safe and effective. In view of the attributes of adjustability, safe laparoscopic placement, and reversibility, it should be considered the optimal initial approach for the control of obesity and its comorbid conditions.

Effect of weight loss on bone metabolism: comparison of vertical banded gastroplasty and medical intervention.

BACKGROUND: We studied the effects of weight loss on bone metabolism. METHODS: 16 consecutive surgically-treated (14 female, 2 male) morbidly obese patients and 65 obese (53 male, 12 female) medically-treated patients were enrolled in an observational study. Surgical treatment for morbidly obese patients was vertical banded gastroplasty (VBG). Studies were performed prior to and 12 months after the start of treatment. Bone mineral density (BMD), bone turnover markers, sex steroids, calcium excretion and parathyroid hormone measurements were done at each visit. RESULTS: weight loss was more prominent with surgical than with medical treatments. Bone loss was also pronounced in the surgical treatment group, and occurred at the hip level only (P<0.05). Compared to previously reported studies, where the effects of malabsorptive treatments for obesity on bone metabolism were studied, calcium excretion and parathyroid hormone levels did not change after VBG or medical therapy. For both groups, bone markers indicated an increased bone turnover, evidenced by increased urinary excretion of deoxypyridinoline and serum levels of osteocalcin (P<0.05). Sex steroid measurements revealed a decrease in estradiol levels in the surgical treatment group, but not in medical treatment group. This finding was thought to be secondary to less weight loss in the medical group. CONCLUSION: Our data indicate that weight loss causes bone loss. The bone loss is independent of the method of weight reduction. However, the mechanism of the bone loss is not clear. It may be explained partly by reduced estradiol levels in female patients. Because the mechanisms of bone disease after weight loss remain unclear, it is difficult to determine the most effective treatment. It is important to detect osteopenia early, before fractures occur. Measuring BMD appears to be the only reliable method for screening.