Christopher de Gara

Weight Recidivism Post-Bariatric Surgery: A Systematic Review

Obesity is considered a worldwide health problem of epidemic proportions. Bariatric surgery remains the most effective treatment for patients with severe obesity, resulting in improved obesity-related co-morbidities and increased overall life expectancy. However, weight recidivism has been observed in a subset of patients post-bariatric surgery. Weight recidivism has significant medical, societal and economic ramifications. Unfortunately, there is a very limited understanding of how to predict which bariatric surgical patients are more likely to regain weight following surgery and how to appropriately treat patients who have regained weight. The objective of this paper is to systematically review the existing literature to assess the incidence and causative factors associated with weight regain following bariatric surgery. An electronic literature search was performed of the Medline, Embase and Cochrane library databases along with the PubMed US national library from January 1950 to December 2012 to identify relevant articles. Following an initial screen of 2,204 titles, 1,437 abstracts were reviewed and 1,421 met exclusion criteria. Sixteen studies were included in this analysis: seven case series, five surveys and four non-randomized controlled trials, with a total of 4,864 patients for analysis. Weight regain in these patients appeared to be multi-factorial and overlapping. Aetiologies were categorized as patient specific (psychiatric, physical inactivity, endocrinopathies/metabolic and dietary non-compliance) and operation specific. Weight regain following bariatric surgery varies according to duration of follow-up and the bariatric surgical procedure performed. The underlying causes leading to weight regain are multi-factorial and related to patient- and procedure-specific factors. Addressing post-surgical weight regain requires a systematic approach to patient assessment focusing on contributory dietary, psychologic, medical and surgical factors.

Surgical interventions for obesity and metabolic disease.

Obesity continues to be a growing problem in both the developed and the developing world. Its strong link with co-morbid conditions such as type 2 diabetes, hypertension, obstructive sleep apnea, and depression presents an increasing strain on health care systems around the world. Diet and exercise alone has been shown to be largely ineffective at managing obesity. Surgery is the only evidence-based method of allowing morbidly obese patients to lose weight and to maintain this weight loss. Weight-reduction in obese individuals from bariatric surgery has also been found to markedly improve obesity-related co-morbid conditions, particularly, type 2-diabetes. Diabetic remission from bariatric surgery has resulted in the inclusion of bariatric surgery, by the International Diabetes Taskforce, as a treatment modality for type-2 diabetes. This consensus statement named four surgical options that have been found to be effective in both weight-loss and in inducing diabetes remission. These four surgical procedures lead to weight-loss through restrictive and malabsorptive mechanisms. Each specific operation has a different level of efficacy in inducing weight-loss and diabetic remission, as well as distinct types and rates of complications. This article reviews the best evidence that exists for the effectiveness and complications of these four operations.

Gastric Band Removal in Revisional Bariatric Surgery, One-Step Versus Two-Step: a Systematic Review and Meta-analysis

We aimed to systematically review the literature comparing the safety of one-step versus two-step revisional bariatric surgery from laparoscopic adjustable gastric banding (LAGB) to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). There is debate on the safety of removing the gastric band and performing revisional surgery immediately or in a delayed, two-step fashion due to potential higher complications in one-step revisions. A systematic and comprehensive search of the literature was conducted. Included studies directly compared one-step and two-step revisional surgery. Eleven studies were included with 1370 patients. Meta-analysis found comparable rates of complications, morbidity, and mortality between one-step and two-step revisions for both RYGB and SG groups. This suggests that immediate or delayed revisional bariatric surgeries are both safe options for LAGB revisions.

The Economic Impact of Weight Regain

Background. Obesity is well known for being associated with significant economic repercussions. Bariatric surgery is the only evidence-based solution to this problem as well as a cost-effective method of addressing the concern. Numerous authors have calculated the cost effectiveness and cost savings of bariatric surgery; however, to date the economic impact of weight regain as a component of overall cost has not been addressed. Methods. The literature search was conducted to elucidate the direct costs of obesity and primary bariatric surgery, the rate of weight recidivism and surgical revision, and any costs therein. Results. The quoted cost of obesity in Canada was

Ageism in rectal carcinoma? Treatment and outcome variations.

2.0 billion–

Biliopancreatic Diversion: The Effectiveness of Duodenal Switch and Its Limitations

6.7 billion in 2013 CAD. The median percentage of bariatric procedures that fail due to weight gain or insufficient weight loss is 20% (average: 21.1% ± 10.1%, range: 5.2–39, n = 10). Revision of primary surgeries on average ranges from 2.5% to 18.4%, and depending on the procedure accounts for an additional cost between

Perceptions of conflict of interest: surgeons, internists, and learners compared

14,000 and

Mentorship for the physician recruited from abroad to Canada for rural practice

50,000 USD per patient. Discussion. There was a significant deficit of the literature pertaining to the cost of revision surgery as compared with primary bariatric surgery. As such, the cycle of weight recidivism and bariatric revisions has not as of yet been introduced into any previous cost analysis of bariatric surgery.

A comparison of revisional and primary bariatric surgery

Background. Rectal cancer adjuvant and neo-adjuvant therapies are associated with improved survival and local control rates. Concerns regarding adverse treatment effects tend to reduce administration in the elderly—the very population this disease affects.Purpose. To determine the extent to which age alters rectal cancer treatment and its outcome.Methods and Materials. Using the population based provincial cancer registry, patients with adenocarcinoma of the rectum diagnosed between 1991 and 1998 were identified. From this cohort, a random subsample of patients seen at the regional cancer center were selected for detailed analysis. Demographic and clinical data between the provincial cohort and the subsample were compared for homogeneity. Log rank tests and Kaplan-Meier survival estimates were carried out on the subsample.Results. The population cohort (n=1979) and the subsample (n = 259) were similar in age, sex, and treatment distributions. Elderly patients (≥ 75 yr) made up 23% of the rectal cancer population in Alberta. Age had a highly significant (p=0.001) impact on whether patients received surgery alone or had surgery plus chemoradiotherapy. This corresponded to a considerable survival advantage for those elderly patients who did receive multimodality therapy (p=0.008).Conclusion. The advantage of multimodality therapy in rectal cancer is confirmed in this population-based study. Although a significant number of elderly patients are fit enough to tolerate major surgery they are being denied adjuvant therapies, presumably on the basis of potentially high treatment-related complication rates, with a subsequent reduction in survival. Strategies must be developed to ensure that maximum treatment benefit is obtained without increased harm in the elderly rectal cancer patient.

A Systematic Review and Meta-Analysis of Outcomes for Type 1 Diabetes after Bariatric Surgery.

The prevalence of morbidly obese individuals is rising rapidly. Being overweight predisposes patients to multiple serious medical comorbidities including type two diabetes (T2DM), hypertension, dyslipidemia, and obstructive sleep apnea. Lifestyle modifications including diet and exercise produce modest weight reduction and bariatric surgery is the only evidence-based intervention with sustainable results. Biliopancreatic diversion (BPD) produces the most significant weight loss with amelioration of many obesity-related comorbidities compared to other bariatric surgeries; however perioperative morbidity and mortality associated with this surgery are not insignificant; additionally long-term complications including undesirable gastrointestinal side effects and metabolic derangements cannot be ignored. The overall quality of evidence in the literature is low with a lack of randomized control trials, a preponderance of uncontrolled series, and small sample sizes in the studies available. Additionally, when assessing remission of comorbidities, definitions are unclear and variable. In this review we explore the pros and cons of BPD, a less well known and perhaps underutilized bariatric procedure.