Daniel R. Cottam

Laparoscopic sleeve gastrectomy as an initial weight-loss procedure for high-risk patients with morbid obesity

BackgroundThe surgical treatment of obesity in the high-risk, high-body-mass-index (BMI) (>60) patient remains a challenge. Major morbidity and mortality in these patients can approach 38% and 6%, respectively. In an effort to achieve more favorable outcomes, we have employed a two-stage approach to such high-risk patients. This study evaluates our initial outcomes with this technique.MethodsIn this study, patients underwent laparoscopic sleeve gastrectomy (LSG) as a first stage during the period January 2002–February 2004. After achieving significant weight loss and reduction in co-morbidities, these patients then proceeded with the second stage, laparoscopic Roux-en-Y gastric bypass (LRYGBP).ResultsDuring this time, 126 patients underwent LSG (53% female). The mean age was 49.5 ± 0.9 years, and the mean BMI was 65.3 ± 0.8 (range 45–91). Operative risk assessment determined that 42% were American Society of Anesthesiologists physical status score (ASA) III and 52% were ASA IV. The mean number of co-morbid conditions per patient was 9.3 ± 0.3 with a median of 10 (range 3–17). There was one distant mortality and the incidence of major complications was 13%. Mean excess weight after LSG at 1 year was 46%. Thirty-six patients with a mean BMI of 49.1 ± 1.3 (excess weight loss, EWL, 38%) had the second-stage LRYGBP. The mean number of co-morbidities in this group was 6.4 ± 0.1 (reduced from 9). The ASA class of the majority of patients had been downstaged at the time of LRYGB. The mean time interval between the first and second stages was 12.6 ± 0.8 months. The mean and median hospital stays were 3 ± 1.7 and 2.5 (range 2–7) days, respectively. There were no deaths, and the incidence of major complications was 8%.ConclusionThe staging concept of LSG followed by LRYGBP is a safe and effective surgical approach for high-risk patients seeking bariatric surgery.

The Chronic Inflammatory Hypothesis for the Morbidity Associated with Morbid Obesity: Implications and Effects of Weight Loss

Background: Obesity is a worldwide pandemic that causes a multitude of co-morbid conditions.However, there has been slow progress in understanding the basic pathophysiology that underlies co-morbid conditions associated with obesity. Recently, there has been intense interest in the role of inflammation in obesity. Using the inflammatory hypothesis, many of the mechanisms by which co-morbid conditions are associated with obesity are being elucidated. Methods: We searched the literature and reviewed all relevant articles. We focused on hormones and cytokines that have been associated with other inflammatory conditions such as sepsis and systemic inflammatory response syndrome. Findings: Angiotensinogen (AGT), transforming growth factor beta (TGFβ), tumor necrosis factor alpha (TNFα), and interleukin six (IL-6) are all elevated in obesity and correlate with several markers of adipocyte mass. These mediators have detrimental effects on hypertension, diabetes, dyslipidemia, thromboembolic phenomena, infections, and cancer. Weight loss results in a reduction of inflammatory mediators and a diminution of the associated co-morbid conditions. Conclusions: The success of weight loss surgery in treating the complications associated with obesity is most probably related to the reduction of inflammatory mediators. While some aspects of bariatric physiology remain unclear, there appears to be a strong association between obesity and inflammation, thereby rendering obesity a chronic inflammatory state. A clearer understanding of the physiology of obesity will allow physicians who treat the obese to develop better strategies to promote weight loss and improve the well-being of millions of individuals.

Results of Laparoscopic Gastric Bypass in Patients with Cirrhosis

Background: The safety and efficacy of bariatric surgery in patients with cirrhosis has not been well studied. Methods: A retrospective review was conducted of patients with cirrhosis who underwent weight-loss surgery at a single institution. Results: Out of a total of 2,119 patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP), 30 patients (1.4%) with cirrhosis were identified.When compared with the entire cohort, patients with cirrhosis were significantly more prone to be heavier (BMI 53 vs 48), older in years (age 50 vs 45), more likely to be male (RR=1.3), and have a higher incidence of diabetes (70% vs 21%) and hypertension (67% vs 21%), P<0.05. The diagnosis of cirrhosis was made intra-operatively in 90% of patients. There were no perioperative deaths, conversions to laparotomy, or liver-related complications. Early complications occurred in 9 patients and included anastomotic leak (1), acute tubular necrosis (4), prolonged intubation (2), ileus (1), and blood transfusion (2). Mean length of hospital stay was 4 days (2-18). There was one late unrelated death and one patient with prolonged nausea and protein malnutrition. The average follow-up time was 16 months (1-48). For patients >12 months postoperatively (n=15), the average percent excess weight loss was 63±15%. Conclusion: Laparoscopic RYGBP in the cirrhotic patient has an acceptable complication rate and achieves satisfactory early weight loss. Patients tend to be heavier, older, male and more likely to have diabetes and hypertension. Long-term studies are necessary to examine how weight loss impacts established cirrhosis.

Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred

Background: There is no consensus regarding the optimal treatment of ventral hernias in patients who present for weight loss surgery. Methods: Medical records of consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y (LRYGB) gastric bypass with a secondary diagnosis of ventral hernia were reviewed. Only patients who were beyond 6 months of follow-up were included. Results: The study population was 85 patients. There were three groups of patients according to the method of repair: primary repair (59), small intestine submucosa (SIS) (12), and deferred treatment (14). Average follow-up was 26 months. There was a 22% recurrence in the primary repair group. There were no recurrences in the SIS group. Five of the patients in the deferred treatment group (37.5%) presented with small bowel obstruction due to incarceration. Conclusion: Biomaterial mesh (SIS) repair of ventral hernias concomitant with LRYGB resulted in the most favorable outcome albeit having short follow-up. Concomitant primary repair is associated with a high rate of recurrence. All incarcerated ventral hernias should be repaired concomitant with LRYGB, as deferment may result in small bowel obstruction.

Is Ghrelin the Culprit for Weight Loss after Gastric Bypass Surgery? A Negative Answer

Background: Ghrelin is a potent appetite stimulator, mainly synthesized in the stomach. Paradoxically, obese subjects have lower plasma ghrelin than lean subjects and increase their weight in spite of low ghrelin levels. The role of ghrelin in weight regulation after bariatric surgery is still controversial. The aim of this study was to evaluate whether rapid weight loss after laparoscopic Roux-en-Y gastric bypass surgery (LRYGBP), was associated with changes in plasma ghrelin levels. In addition, we determined the acute impact of LRYGBP on insulin resistance and adiponectin levels. Methods: 49 morbidly obese subjects who underwent LRYGBP were studied. 19 subjects who underwent other laparoscopic gastrointestinal surgeries acted as the control group. Fasting plasma levels of ghrelin, insulin and adiponectin were determined preoperatively and 2 hours, 10 days and 6 months postoperatively. Results: At 2 hours after LRYGBP, there was a significant reduction in ghrelin and adiponectin levels, which coincided with elevated plasma glucose and insulin levels. Interestingly, once glucose and insulin levels normalized at 6 months after surgery, ghrelin also normalized. Adiponectin reached pre-surgical levels at 10 days after LRYGBP and continued to significantly rise until 6 months postoperatively. Conclusion: Weight loss after LRYGBP occurs in spite of the absence of significant changes in plasma ghrelin levels. Improvement of insulin resistance occurred within 10 days after surgery, and could be related to the normalization of adiponectin levels. This data questions the role of peripheral ghrelin as a cause of weight loss in obese humans after LRYGBP.

The impact of laparoscopy on bariatric surgery

The rising popularity of bariatric surgery over the past several years is attributable in part to the development of laparoscopic bariatric surgery. Morbidly obese patients have associated comorbid conditions that may predispose them to postoperative morbidity. The laparoscopic approach to bariatric surgery offers a minimally invasive option that reduces the physiologic stress and provides clinical benefits, as compared with the open approach. This review summarizes the impact of laparoscopic surgery on bariatric surgery, the various risk factors that could potentially predispose morbidly obese patients to postoperative morbidity, the fundamental differences between laparoscopic and open bariatric surgery, and the physiology of reduced tissue injury associated with laparoscopic bariatric surgery.

The impact of laparoscopic bariatric workshops on the practice patterns of surgeons

BackgroundThis study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons.MethodsFrom October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants.ResultsResponses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10–150 cases) are needed for a claim of proficiency.ConclusionLaparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery.

Potential role of hypothalamic ghrelin in the pathogenesis of human obesity.

Ghrelin is a potent appetite stimulator, mainly synthesized in the stomach but also made in the brain. Paradoxically, obese subjects have lower plasma ghrelin than lean subjects and increase their weight in spite of low ghrelin levels. We hypothesize that central, and not peripheral ghrelin, is primarily responsible for overeating in humans. The aim of this study was to determine hypothalamic ghrelin levels in lean vs obese subjects. We collected anterior hypothalamus from lean and obese patients at the time of autopsy, and Western blots and semiquantitative RT-PCR for ghrelin and neuropeptide Y (NPY) were carried out. Our results showed that ghrelin expression was significantly higher in the hypothalamus of obese subjects compared to lean ones. This finding correlates with similar increases in NPY in the obese group. Ghrelin and NPY mRNA levels followed the same trend and were significantly higher in the hypothalamus in obese compared to lean subjects, suggesting a central origin for the increased protein content in the obese subjects. In conclusion, obesity in humans is associated with elevated central ghrelin. This data questions the significance of the role of peripheral ghrelin in the regulation of appetite in humans and suggests an important role for central ghrelin in the pathogenesis of obesity in humans.

Nongynecologic advances in minimally invasive surgery

In the past 10 years an explosion of technology has allowed surgeons of all types to perform minimally invasive operations that were only a dream a mere decade ago. This has enabled surgeons and patients to reap the benefits of decreased postoperative pain, earlier return of bowel function, better postoperative pulmonary function, decreased blood loss, better cosmesis, fewer incisional hernias, less inflammatory reaction, fewer wound infections, shorter hospital stays, and earlier return to full activity. Despite these obvious benefits that extend to most operations performed laparoscopically, practicing surgeons have not universally adopted laparoscopic approaches. This has been attributed to the lack of evidence of clear benefit in cases of oncologic surgery and the steep procedure-specific learning curves associated with all forms of laparoscopic surgery. These obstacles are only now being overcome with education, mentoring, and outcome-based randomized studies. Although we cannot chronicle every advance in nongynecologic laparoscopic surgery, we hope to enlighten the reader on advances in laparoscopic surgery over the past decade.

It is the surgical center and not the procedure that matters: A matched-pair cohort study with 3-years’ follow-up of laparoscopic Roux-en-Y gastric bypass and lap-band in a single US center

Purpose: Worldwide, the laparoscopic adjustable gastric band (LAGB) is the most common procedure performed, but in the United States, the most common procedure is the laparoscopic Roux-en-Y gastric bypass (LRYGBP). To date, no single institution with large numbers of both procedures has published their results. We hypothesized that both procedures will provide similar weight loss and comorbidy reduction if followed for a sufficient length of time. Methods: A matched-pair bariatric cohort study was performed. All patients who presented to the Weight Control Center between August 1, 2001 and August 2004 for LAGB were placed into one group and a matched pair LRYGBP cohort group was created. Patients were matched according to the time since surgery and body mass index (BMI). All data were collected prospectively using our database manager, Remedy M.D., and analyzed retrospectively. Results: During this time, 210 patients underwent LAGB and 861 underwent LRYGBP. For 210 LAGB patients, 186 suitable RYGBP patients were found. The RYGBP group was similar to the LAGB group in terms of age (42.1 vs. 42.8 years), BMI (47.2 vs. 47.2 kg/m), weight (287 vs. 293 kg), and sex (149 vs. 164 women). Weight loss was significantly different from 1 to 24 months (p 0.001) favoring RYGBP. However, at 36 months, no significant difference was found between the groups (BMI 25 4 kg/m for the RYGBP and BMI 31 5 kg/m for the LAGB group; p 0.069). Conclusions: A single institution specializing in both LRYGBP and LAGB can produce results equal to centers that specialize in only one surgical procedure. When bariatric patients were matched according to the time since surgery and BMI, their weight loss and comorbidity reduction were similar at 3 years. PII: S1550-7289(05)00150-4 21.