Effect of the learning curve on the early outcomes of laparoscopic Roux-en-Y gastric bypass.

Open gastric bypass has been demonstrated to provide durable weight loss in morbidly obese patients. As laparoscopic techniques have evolved surgeons are offering patients such an approach for performance of gastric bypass. The purpose of this study was to evaluate the relationship between increasing experience and outcome for this technically challenging operation. A retrospective analysis was performed on the initial 160 consecutive patients undergoing laparoscopic gastric bypass by a single surgeon over a 24-month period. Patients were divided into quartiles for data analysis. Duration of surgery decreased significantly between quartiles: 324 +/- 124, 225 +/- 70, 190 +/- 47, and 168 +/- 40 minutes, respectively (P < 0.01). However, the conversion rate (3.1%) and mean hospital length of stay (2.1 +/- 2.4 days) were unaffected by surgeon experience. The early and late postoperative complication rates were 9.4 and 3.1 per cent, respectively. Early complications included: leak (1.3%), bleeding (3.8%), obstruction (1.9%), acute gastric distention (0.6%), subphrenic abscess (0.6%), and wound infection (0.6%). Late complications include: obstruction (1.3%), anastomotic stricture (1.3%), and marginal ulcer (0.6%). The complication rates did not change statistically between quartiles. The excess weight loss at one year was 77.4 +/- 16.7 per cent. These data suggest that throughout the learning curve laparoscopic gastric bypass can be accomplished with acceptable complication rates, conversion rates, and hospital length of stay. Duration of surgery improves with experience. Early weight loss results compare favorably with those of open gastric bypass.

Modest weight loss and reduction in waist circumference after medical treatment are associated with favorable changes in serum adipocytokines.

Modest weight loss if maintained is associated with significant metabolic benefits and reduction in cardiovascular risk. Adipose tissue secretes cytokines believed to contribute to the pathogenesis of insulin resistance and cardiovascular risk. We therefore observed the effect of modest weight loss on serum adipocytokines and their relationship with changes in anthropometric and metabolic parameters within a period of 6 months in the setting of a routine obesity hospital clinic after various medical treatments. In this prospective, nonrandomized, nonblinded observational study, patients were first given treatment (Sibutramine ( Meridia ) or Orlistat ( Xenical )) as decided by the treating clinician and then allocated into 1 of 2 groups according to the treatment prescribed. The first group included 21 Caucasian nondiabetic female subjects, with a mean (+/-SD) age of 43 +/- 11 years and a mean body mass index (BMI) of 46 +/- 8.6 kg/m(2); subjects were treated with Sibutramine ( Meridia ) 10 or 15 mg/d for weight loss. The second group included 20 Caucasian nondiabetic female subjects, mean age 42 +/- 9 years and mean BMI 45.2 +/- 5.2 kg/m(2); Orlistat ( Xenical ) was introduced after 1 month on a low-fat (</=30%) diet in this group. Blood pressure and anthropometric measurements were performed before and after weight loss by a single observer. Serum glucose, insulin, lipid profile, C-reactive protein (CRP), resistin, leptin, and adiponectin were measured before and after weight loss on a fasting sample. After 6 months, the Sibutramine ( Meridia ) group had a modest mean weight loss of 5.4% (P =.0001), and waist circumference was reduced by 4.5 +/- 1.4 cm. There was a decrease in serum resistin, leptin, and CRP levels, and a rise in serum adiponectin (P <.05). Change (%) (Delta) in BMI (DeltaBMI%) was associated with Deltainsulin(%) (P =.02, r = 0.53) and Deltaleptin(%) (P =.01, r = 0.58). Change in waist was associated with Deltainsulin(%) (P =.005, r = 0.75) and Deltaresistin(%) (P =.03, r = -0.55). The Orlistat ( Xenical )-treated group had a mean weight loss of 2.5%. Although this group did not show significant change in metabolic parameters, surprisingly there was a greater decrease of resistin (P =.02) associated with comparable (%) increase in adiponectin and (%) reduction of waist circumference and CRP. We conclude that modest weight loss (>5%) after medical treatment in a routine obesity hospital clinic is associated with improvements in insulin sensitivity and lipid profile. Modest weight loss is also associated with potentially favourably changes in serum adipocytokines, particularly in a rise of serum adiponectin. Reduction of waist circumference is associated with a change in serum resistin.

Weight Loss reduces interleukin-18 levels in obese women.

Obesity is associated with an increased risk of developing atherosclerosis, which may be mediated, at least in part, by increased secretion of proinflammatory cytokines by adipose tissue. We examined the hypothesis that circulating levels of IL-18 were elevated in obese women and would be reduced by weight loss. In a sample of 40 obese (body mass index, 36.4 +/- 3.1 kg/m(2)) women we found that plasma IL-18 levels were higher than in 40 normal weight control women (P < 0.01) and were positively associated with body weight (r = 0.46; P < 0.01) and visceral fat (waist to hip ratio; r = 0.39; P < 0.01). Caloric restriction-induced weight loss (> or = 10% of original weight) over 1 yr reduced IL-18 levels from 247 (204/309) to 147 (111/210) pg/ml (medians and 25%/75%; P < 0.01), positively associated with changes in body mass index and waist to hip ratio. In obese women, IL-18 levels are associated with body weight and abdominal fat deposition; weight loss is an important intervention to reduce IL-18 levels. IL-18 may be a novel cytokine operating in human obesity.

National institute for clinical excellence (NICE) guidance for anti-obesity medication: is it being followed?

Background: anti-obesity medication is being used increasingly by some general practitioners (GP) for obesity management (Lawrence, 2002). The aim of this audit was to identify whether the anti-obesity medication prescribed by GPs was in accordance with the NICE guidance (NICE, 2001a,b). Method: The medical notes and electronic patient records of 154 patients prescribed either Orlistat ( Xenical ) or Sibutramine ( Meridia ) between September 2002 and April 2003, were examined. Information about patients' weight, previous weight loss, previous dietary and physical activity advice, behaviour modification, time on medication, weight loss achieved and blood pressure were recorded and comparisons made with the NICE guidance. Results: NICE guidanceOrlistat ( Xenical ) (n = 103)Sibutramine ( Meridia ) (n = 51)Only for individuals who have lost at least 2.5 kg in the preceding month20% achieved this weight loss56% attempted to lose weightBMI calculated66% calculated 71% calculatedDietary advice given 80% received advice49% received advicePhysical activity discussed36% physical activity discussed26% physical activity discussedBehavioural modification10% documented0% documentedweight loss after starting drug 4 weeksNone required by NICE22% lost at least 2 kg weight 3 months17% patients lost >5% of initial body weight16% patients lost >5% of initial body weight 6 months3% lost >10% of initial body weight8% lost >10% initial body weightBlood pressure /pulse rate monitoringNone required74% BP initially checked; 20% BP >145/90 mm Hg; 9% pulse rate checkedNo more than 12 months on medication8% patients prescribed for >12 months4% patients prescribed for >12 monthsBMI, body mass index; BP, blood pressure. Conclusion: The results show that the majority of patients prescribed with Orlistat ( Xenical ) and Sibutramine ( Meridia ) are not treated in accordance with the NICE guidance. The recommendation is that GPs are given further training about the optimum treatment associated with the prescription of anti-obesity medication. References: Lawrence, G. (2002) Prescribing Advisor. Personal communication. NICE (2001a) NHS National Institute for Clinical ExcellenceGuidance. Technology Appraisal Guidance No 22. Guidance on the use of Orlistat ( Xenical ) for the treatment of obesity. NICE (2001b) NHS National Institute for Clinical Excellence Guidance. Technology Appraisal Guidance No 31. Guidance on the use of Sibutramine ( Meridia ) for the treatment of obesity.