Barry L. Fisher

Medical and surgical options in the treatment of severe obesity.

Weight loss programs, diets, and drug therapy have not shown long-term effectiveness in treating morbid obesity. A 1992 statement from the National Institutes of Health Consensus Development Conference affirmed the superiority of surgical over nonsurgical approaches to this condition. Bariatric surgical procedures work in 1 of 2 ways: by restricting a patients ability to eat (restrictive procedures) or by interfering with ingested nutrient absorption (malabsorptive procedures). Many of these procedures can be performed by a laparoscopic approach, which has been shown to reduce operative morbidity. In the United States, the primary operative choice for morbidly obese patients has recently shifted from vertical banded gastroplasty (VBG) to the Roux-en-Y gastric bypass (RYGBP). VBG, a purely restrictive procedure, has fallen into disfavor because of inadequate long-term weight loss. RYGBP combines restriction and malabsorption principles, and has been shown to induce greater weight loss than VBG. Other procedures currently being offered include laparoscopic adjustable gastric banding; biliopancreatic diversion (BPD), including the duodenal switch (BPD-DS) variation; and distal gastric bypass (DGBP). Laparoscopic adjustable gastric banding with the LAP-BAND system (INAMED Health, Santa Barbara, CA), a restrictive procedure involving placement of a silicone band around the upper stomach, was introduced in the early 1990s and approved by the US Food and Drug Administration for use in the United States in June 2001. Outside the United States, LAP-BAND surgery is the most commonly performed operation for severe obesity. The BPD, BPD-DS, and DGBP are all malabsorptive procedures offered primarily by laparotomy. They have been shown to induce good long-term weight loss but have a higher rate of adverse nutritional complications. Many safe and effective surgical options for severe obesity are available. More scientific appraisals comparing different procedures and open and laparoscopic approaches are needed.

A review of psychosocial outcomes of surgery for morbid obesity.

There is consistent evidence to support the notion that morbid obesity poses serious risks to physical health and has a substantial impact on psychosocial well-being. Researchers agree that bariatric surgery is currently the most viable option for successful weight loss and maintenance in the morbidly obese individual. The drastic, major weight loss and alleviation of medical risks that patients typically experience post-surgically are accompanied by psychosocial changes that appear to be equally remarkable. These psychosocial changes have yet to be studied as systematically or diligently as the physical changes and therefore remain to be fully understood. This paper (1) reviews the literature of psychosocial outcomes of obesity surgery for the past 36 years; (2) provides a critical assessment of the methodology utilized; and (3) suggests future research directions.

Obesity correlates with gastroesophageal reflux.

Thirty morbidly obese patients presenting forbariatric surgery were evaluated for symptomatic andobjective evidence of gastroesophageal reflux. Sixteenpatients had heartburn while 14 were asymptomatic. All underwent esophageal function testing;manometry was performed in all patients, pH monitoringin 28. Patients with esophageal pH < 4 for more than5% of observed time weighed more than those with normal acid exposure, 165.2 vs 129.8 kg (P <0.01), and had significantly higher body mass indices,56.5 vs 48.3 kg/m2 (P < 0.05). Similarly,morbidly obese patients with abnormal reflux scores weighed significantly more and hadgreater body mass indices than patients with normalscores (P < 0.05). Lower esophageal sphincterpressure was higher in patients with normal esophagealacid exposure than in those with abnormal findings,15.5 vs 12.5 mm Hg (P < 0.05). This studydemonstrates a correlation between both weight and bodymass index with gastroesophageal reflux.

A case-controlled matched-pair cohort study of laparoscopic Roux-en-Y gastric bypass and Lap-Band patients in a single US center with three-year follow-up.

Background: Open or laparoscopic Roux-en-Y gastric bypass (RYGBP) is the most common operation for treatment of morbid obesity in USA. The laparoscopic adjustable gastric band (LAGB) has been the most common bariatric operation performed worldwide. The LapBand® was approved for use in USA in July 2001. Since then, several US surgeons have adopted one procedure preferentially over the other, and several have reported patient outcomes. We added the option of the LAGB to the RYGBP in our practice in July 2001. We hypothesized that both procedures will provide similar weight loss and co-morbidity reduction if followed for a sufficient length of time. To enhance weight loss, we adopted a patient behavioral program that is easy to remember, in an attempt to ensure a reduction in caloric intake and reduce hunger regardless of the operation performed. Methods: A case-controlled matched-pair cohort study was conducted. All patients who presented to the Surgical Weight Control Center of Las Vegas between Aug 2001 and Aug 2004 for LAGB were placed into one group, and a matched-pair RYGBP cohort group was created. Patients in the RYGBP cohort were matched for age, sex, date of surgery, and BMI. All patients were evaluated on an intention to treat basis. Data were collected prospectively and analyzed retrospectively. All patients were subjected to the same preoperative education regarding calorie reduction behaviors and diet change, and received the same postoperative counseling regarding long-term eating behavior and food choices. Results: During this period, 208 patients underwent LAGB and 600 underwent RYGBP. Of the 208 LAGB patients, 181 had suitable open or laparoscopic RYGBP matches. The two groups were similar in terms of age, sex, BMI, and co-morbidities. There were no deaths in either group. Resolution of co-morbidities statistically favored RYGBP as did the weight loss, over the study period. Conclusion: When patients are matched with 3-year follow-up according to time of surgery, age, sex and BMI, LRYGBP provides superior weight and co-morbidity reduction and can be done without severe complications. However, the LAGB is an effective weight loss tool and not every patient wishes to have the LRYGBP.

Sensitivity and Specificity of Postoperative Upper GI Series Following Gastric Bypass

Background: Routine postoperative GI series has been common before discharging gastric bypass patients. 78,000 operations were performed in the USA in 2002. At

Efficacy of Venous Thromboembolism Prophylaxis in Morbidly Obese Patients Undergoing Gastric Bypass Surgery

75 each, the total annual expenditure for the upper GI series approaches 6 million dollars. This study examines the value of performing routine upper GI series. Materials and Methods: From 1996 to 2000, 396 open gastric bypass procedures were performed by one surgeon at the University Medical Center. 242 randomly selected charts were retrospectively reviewed for signs and symptoms possibly related to leak or obstruction. Radiology reports were compared with clinical findings. Results: 82% of patients (192/242) were discharged following unremarkable postoperative courses and normal x-rays. 18% (44/242) exhibited one or more clinical signs suspicious of leak or obstruction. These included fever, tachycardia, tachypnea, inordinate pain, elevated white cell count or GI hemorrhage. Leak was reported in 5, and obstruction in 5. 4 patients with reported leaks were re-operated: 2 were positive for unconfined leak requiring surgical treatment; 2 had negative laparotomies. The 2 patients (0.82%) with free leakage had dramatic clinical deterioration, and x-rays were confirmatory rather than diagnostic. 1 patient with a minimal confined leak was treated non-operatively. 8 films were misread as showing a leak when none was present: 2 underwent negative laparotomy, the others being correctly interpreted after review. 8 of 10 initial interpretations were falsely positive. Conclusion: Routine postoperative GI series following gastric bypass is not beneficial. All true leaks are demonstrated when x-rays are indicated. We recommend GI series only when clinically indicated. GI series had low positive predictive value for leak.

Gastric Bypass for Morbid Obesity: a Standard Surgical Technique by Consensus

Background: Patients undergoing gastric bypass are at risk of developing venous thromboembolism (VTE) due to multiple risk factors including obesity and abdominal surgery. The purpose of this study is to evaluate the effectiveness of inpatient VTE prophylaxis in morbidly obese patients undergoing gastric bypass and the incidence of symptomatic VTE following discharge. Methods: A retrospective chart review of patients undergoing gastric bypass from August 2000 to August 2001 was performed. Inpatient charts from medical records and physician outpatient office charts were reviewed. Evaluation consisted of: VTE prophylaxis utilized, acquired risk factors for VTE, BMI, development of deep venous thrombosis (DVT) or pulmonary embolism (PE) during hospitalization, outpatient office visits following discharge, and VTE after discharge. Results: 107 patient charts were reviewed. There were no incidences of VTE documented during hospitalization, and only one patient developed a symptomatic DVT after discharge. During hospitalization, all patients received DVT prophylaxis consisting of medical management, external compression devices, and ambulation orders. At the time of surgery, patients had a mean age of 40 years (23-69 years) and a BMI of 51.3 kg/m2 (37-82). Surgery lasted a mean of 108.9 minutes (65-305), patients were hospitalized for a mean of 4.3 days (3-7), and had a mean of 3.4 risk factors (2-7 risk factors) for the development of VTE. After hospital discharge, 101 patients were followed for the development of VTE. Conclusion: Combination of medical management, early ambulation, and external compression devices adequately prevented the development of VTE in patients after gastric bypass.

The Elite II™ Bariatric Surgery Retractor System: A Recent Addition to the Bariatric Surgeon's Tool Chest

Background: The gastric bypass operation has evolved since 1966 when it was first introduced. The purpose of this study was to determine the present state of gastric bypass by consensus among the members of the American Society for Bariatric Surgery (ASBS). Method: A questionnaire was sent to all members of the ASBS. Forty-three percent responded reporting over 41,200 cases. Results: Results were analyzed by using χ2 tests with a null hypothesis. Surgeons agreed on several technical aspects, preferring a vertical to a horizontal stapleline; estimating, rather than measuring, the pouch volume at an average of 22 cc. Few surgeons divide the short gastric vessels, and only 25% of surgeons polled use a restrictive ring or band proximal to the gastroenterostomy. Most surgeons calibrate the gastroenterostomy, reporting a preferred average diameter of 12.3 cm. There was no consensus regarding forming the gastroenterostomy, 58% preferring hand-sewn and 42% stapled anastomoses. There was no consensus regarding dividing the gastric pouch from the bypassed stomach: Conclusion: The preferred gastric bypass is vertical, with the pouch estimated at 20-25 cc, and the gastroenterostomy calibrated at 12 mm diameter. The short gastric vessels need not be divided, and restrictive bands or rings are not preferred. This technique of gastric bypass should be used as the control procedure when modifications are tested in future trials. Randomized prospective studies are suggested to probe the benefits of division of the stomach pouch from the bypassed stomach.

Tumor growth factor expression in obesity and changes in expression with weight loss: another cause of increased virulence and incidence of cancer in obesity

Background: A good surgical retractor is essential for facilitating bariatric surgery. Recently,Thompson Surgical Instruments designed a new system specifically for bariatric surgical procedures. Methods: The Elite II™ Bariatric Retractor system was evaluated in 50 successive bariatric surgical patients. We had the opportunity to modify and improve several major components. We report our experience with this modified retractor system. Results: This system proved to be safe, easy to use, durable, and useful in patients of all BMIs, following modifications and improvements to standard parts. Conclusion: This new bariatric retractor system is an improvement over prior bariatric retractor systems being used.

Erosive Esophagitis following Horizontal Gastroplasty for Morbid Obesity: Treatment by Gastric Bypass

BACKGROUND Obesity is associated with increased tumorigenesis. Previously, we demonstrated that inflammation in obesity caused cancer fighting cells to display greater surface receptor levels, predisposing them to early cell death. We measured the inflammatory tumor growth factor levels to determine whether inflammation in obesity increases expression of these factors, potentially predisposing these patients to greater rates of neoplasia. METHODS A total of 24 patients undergoing weight loss surgery had samples collected preoperatively and at 6 and 12 months after surgery. The growth factors analyzed included tumor necrosis factor (TNF)-α, granulocyte-macrophage colony-stimulating factor, interferon-γ, interleukin (IL)-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, vascular endothelial growth factor, hepatocyte growth factor, TNF-receptor I (TNF-RI), TNF-RII, death receptor 5, leptin, and adiponectin. Control samples were obtained from 10 healthy, normal weight volunteers. RESULTS The tumor growth factors TNF-α, TNF-RI, TNF-RII, vascular endothelial growth factor, hepatocyte growth factor, interferon-γ, IL-2, IL-5, and IL-6 all decreased significantly (P <.05) compared with the preoperative values. The IL-4, IL-8, leptin, death receptor 5, adiponectin, and granulocyte-macrophage colony-stimulating factor levels did not change significantly over time. The IL-1b and IL-10 levels were less than the detection limit at all points. When obese patient serum was compared with healthy volunteer pooled serum, we found that the leptin, death receptor 5, hepatocyte growth factor, vascular endothelial growth factor, TNF-RI, TNF-RII, TNF-α, IFN-γ, granulocyte-macrophage colony-stimulating factor, IL-4, IL-5, IL-6, and IL-8 levels were all 2-37 times greater than the levels in the controls at baseline. The concentrations of these same growth factors had decreased levels only 1-3.5 times greater than those of the controls at 12 months postoperatively. CONCLUSION Many inflammatory tumor growth factors are present in greater concentrations in obese individuals. This could explain the greater prevalence of neoplasia in the morbidly obese population.