Mervyn Deitel

Overweight and Obesity Worldwide now Estimated to Involve 1.7 Billion People

Prof. Philip James,1 Chair of the International Obesity TaskForce (IOTF) – a collaborative program of the International Association for the Study of Obesity (IASO) and the World Health Organization (WHO), announced the new 1.7 billion overweight/obesity estimate. Previous studies, using WHO classic definitions (BMI 325 = overweight, BMI 330 = obese) estimated that 1.1 billion people globally were overweight or obese. This may indicate that most governments have been ignoring one of the most major risks to health affecting the world’s population. Among the recommendations are improvements in long-term diet, increased activity levels, early education, and treatment which may include behavior, lifestyle and drugs. This new estimate by the WHO expert group results from the finding that obesity-related healthrisks increase among Asians from a lower BMI threshold. Asians have been found to be particularly vulnerable to obesity-related diseases, with rising rates of co-morbidities from BMI 23. Thus, the WHO has recommended that the optimal BMI for Asian populations be narrowed to 18.5-23 kg/m. Compared with western populations, the percentage of body fat and the risk factors for cardiovascular disease, diabetes and hypertension at a given BMI are higher among Asian populations. The IOTF estimates that a significant proportion of the 3.6 billion Asian population already has BMI 323. The prevalence of the serious sequelae, eg. type 2 diabetes, heart disease, hypertension, stroke, arthritis of weight-bearing joints, many forms of cancer, poor quality of life, depression, premature death, etc. are prevented or reduced by weight loss – even by modest weight loss. The burden of the medical complications of “globesity” threatens to overwhelm health services, and the impact on health may soon overtake that of tobacco.1 In the USA, adult obesity rates rose from 14.25% in 1978 to 31% in 2000. In the UK, adult obesity rates rose from 6% of men and 8% of women in 1980, to 21% of men and 23.5% of women in 2001. The World Health Report 2002 estimated that worldwide >2.5 million deaths per year are weightrelated – 220,000 per year in Europe and >300,000 per year in USA. The extreme forms of obesity are rising even faster than the overall epidemic. In the USA, the percent of black women with BMI 340 has doubled in less than a decade to 15%. Overall, 6.3% of US women (1 in 16) are morbidly obese. Morbid obesity has also increased rapidly in Europe; in the UK, 1 in 40 are morbidly obese, with a threefold rise in the past decade. Obesity is prevalent in both developed and developing countries, and is now affecting children. The epidemic reflects changes in behavioral patterns, including decreased physical activity and over-consumption of high-fat, energy-dense foods. Furthermore, many individuals become obese because of a biological predisposition to gain weight readily when they are exposed to an unfavorable environment. In the World Health Report April 25, 2003, the WHO identifies the main global risks affecting today’s disease, disability and death rates (Figure 1).11 The top 10 risks account for 40% of global Editorials

The First International Consensus Summit for Sleeve Gastrectomy (SG), New York City, October 25–27, 2007

Sleeve gastrectomy is a rapid and less traumatic operation, which thus far is showing good resolution of comorbidities and good weight loss if a narrower channel is constructed than for the duodenal switch. There are potential intraoperative complications, which must be recognized and treated promptly. Like other bariatric operations, there are variations in the technique used. The laparoscopic sleeve gastrectomy (LSG) is being performed for superobese and high-risk patients, but its indications have been increasing. A second-stage bariatric operation may be performed if necessary, with increased safety. Long-term results of LSG and further networking are anxiously awaited.

The Second International Consensus Summit for Sleeve Gastrectomy, March 19–21, 2009

BACKGROUND Sleeve gastrectomy (SG) is a rapid and comparatively simple bariatric operation, which thus far shows good resolution of co-morbidities and good weight loss. The potential peri-operative complications must be recognized and treated promptly. Like other bariatric operations, there are variations in technique. Laparoscopic SG was initially performed for high-risk patients to increase the safety of a second operation. However, indications for SG have been increasing. Interaction among those performing this procedure is necessary, and the Second International Consensus Summit for SG (ICSSG) was held to evaluate techniques and results. METHODS A questionnaire was filled out by attendees at the Second ICSSG, held March 19-22, 2009, in Miami Beach, and rapid responses were recorded during the consensus part. RESULTS Findings are based on 106 questionnaires representing a total of 14,776 SGs. In 86.3%, SG was intended as the sole operation. A total of 81.9% of the surgeons reported no conversions from a laparoscopic to an open SG. Mean +/- SD percent excess weight loss was as follows: 1 year, 60.7 +/- 15.6; 2 years, 64.7 +/- 12.9; 3 years, 61.7 +/- 11.4; 4 years 64.6 +/- 10.5; >4 years, 48.5 +/- 8.7. Bougie size was 35.6F +/- 4.9F (median 34.0F, range 16F-60F). The dissection commenced 5.0 +/- 1.4 cm (median 5.0 cm, range 1-10 cm) proximal to the pylorus. Staple-line was reinforced by 65.1% of the responders; of these, 50.9% over-sew, 42.1% buttress, and 7% do both. Estimated percent of fundus removed was 95.8 +/- 12%; many expressed caution to avoid involving the esophagus. Post-operatively, a high leak occurred in 1.5%, a lower leak in 0.5%, hemorrhage in 1.1%, splenic injury in 0.1%, and later stenosis in 0.9%. Post-operative gastroesophageal reflux ( approximately 3 mo) was reported in 6.5% (range 0-83%). Mortality was 0.2 +/- 0.9% (total 30 deaths in 14,776 patients). During the consensus part, the audience responded that there was enough evidence published to support the use of SG as a primary procedure to treat morbid obesity and indicated that it is on par with adjustable gastric banding and Roux-en-Y gastric bypass, with a yes vote at 77%. CONCLUSION SG for morbid obesity is very promising as a primary operation.

Effect of Nutritional Support on Weaning Patients Off Mechanical Ventilators

The provision of adequate nutritional support to ventilator patients (VP), although important, is still overlooked in many hospitals. All VP in our intensive care unit from July 1977 to June 1979 were reviewed; only those who were on ventilators for 3 or more days (range 3-25) were included, but those ventilated after cardiac arrest with possible brainstem damage were excluded. Group A included 33 VP (22 surgical, 11 medical) who received a protein-free, energy-deficient routine IV diet (1650 kJ/day as dextrose in water or electrolyte solution); group B had 14 VP who received nutritional support as TPN or nasogastric tube feeding (8300-12600 kJ/day with optimum nitrogen). In group A, 18 (54.5%) of the 33 VP were able to be weaned off the ventilator compared to 13 (92.8%) of the 14 VP in group B (p less than 0.05). Of medical VP, 10 (90.9%) of 11 in group A were weaned compared with 3 (100%) of 3 in group B (not significant). However, of surgical VP, only 8 (36.3%) of 22 in group A were able to be weaned off mechanical ventilation compared with 10 (90.9%) of 11 in group b (p less tha 0.01); this was likely highly significant in surgical patients because of greater metabolic demand for wound healing and more severe sepsis.

Vertical banded gastroplasty as an antireflux procedure

Vertical banded gastroplasty creates a channel by two applications of the TA-90 stapler from an end-to-end anastomosis window above the crows foot to the angle of His, against a 32 F. tube along the lesser curvature. The caudad end of the channel is restricted by a 5 cm collar. Thirty-one obese patients more than 45 kg overweight were studied by interview, barium swallow, endoscopy, and manometry. These procedures were repeated 13 +/- 5.5 weeks postoperatively, after resolution of operative edema and before extensive weight loss. Preoperative symptoms included heartburn in 24 patients, regurgitation in 17 patients, and aspiration in 2 patients, and barium swallow demonstrated hiatal hernia in 7 patients and reflux in 7 patients (5 with hiatal hernia). In addition, endoscopy detected mild esophagitis in 3 patients, and hiatal hernia in 11 patients. Postoperatively, the incidence of heartburn decreased in all patients, barium swallow showed slow channel emptying but no hiatal hernia or reflux, and endoscopy did not identify any esophagitis. Preoperative lower esophageal sphincter pressure was 14.5 +/- 7.2 mm Hg. Postoperatively, the vertical banded gastroplasty channel had an initial peak (collar) pressure of 19.2 +/- 7.8 mm Hg (p less than 0.01 compared with preoperative lower esophageal sphincter pressure), a channel pressure of 9.5 +/- 6 mm Hg, a lower esophageal sphincter pressure of 20.1 +/- 7.7 mm Hg (p less than 0.005), and a channel length of 6.8 +/- 1.4 cm. Vertical banded gastroplasty creates a high pressure channel, inhibiting reflux of gastric juice without the need for any additional procedure.

Overview of Operations for Morbid Obesity

Abstract. Massive obesity is prevalent and associated with serious co-morbidities. For patients who cannot sustain weight loss, malabsorption and gastric reduction operations have been developed. Patients with the former operation require surveillance for protein malnutrition and other sequelae; those with gastric reduction require a permanent tiny reservoir and stoma. Long-term follow-up surveillance is necessary. Postoperatively, 15% to 40% of patients, depending on the operative procedure performed, fail to maintain adequate weight loss. Successful weight loss in most of these patients makes this challenging surgery worthwhile, with alleviation of devastating disease and marked improvement in quality of life.

Long-term Outcome in a Series of Jejunoileal Bypass Patients.

In 65 jejunoileal (JI) bypasses done from 1973-1979, there were nine Scott and 56 Payne (with Y-shaped anastomosis). Preoperative excess body weight (EBW) translated to the 1983 Metropolitan Tables was 112 ± 30%. Eight patients are lost to follow-up. We reversed seven patients for renal stones (12%) accompanied by a vertical banded gastroplasty (VBG) and one because she demanded a VBG. Five patients were reversed by surgeons elsewhere for minor problems (three with an accompanying gastric reduction operation), and all five regained and requested a JI bypass again, which we now refused to undertake. This leaves 44 JI bypass patients being followed: loss of EBW is 71 ± 22% at 12-18 years. The eight reversed by us accompanied by a VBG regained some weight (loss of EBW from initial weight is 56 ± 18%). Liver biopsies were done for 5 years in 31 patients, and showed improvement by 36 months. Patients took predigested collagen capsules plus high protein and multivitamins. Injections of B12 are indicated in 18 patients, given every 3 months. Liver dysfunction has not occurred in the long-term. Low serum carotene levels persist. Migratory arthralglas were controlled by oral metronidazole and did not occur after the fifth year. Oxalate crystals remain on urinalysis. Potassium and magnesium replacement is not required now, and a mean of 2.5 stools per day is not a problem, with infrequent diarrhea after greasy foods. Metronidazole is continued in 33 patients to prevent foul flatus. One patient developed a brain tumor, one myxedema, and one primary hyperparathyroidism, thought to be complications of the bypass until diagnosed. Most patients appear to be doing well.

Endoscopic Threaded Imaging Port (EndoTIP) for Laparoscopy: Experience with Different Body Weights

Background: A laparoscopic access system was developed for primary port insertion. The cannula requires no trocar and no axial penetration force during insertion. It provides magnified visualization through the scope on the monitor during access and exit. The device has a proximal valve section and a distal cannula section with a single thread winding around its outer surface, ending in a blunt tip. After umbilical incision and Veress insufflation, a 0° laparoscope is mounted in the cannula. The tip of the cannula is inserted into a tiny fascial incision and rotated clockwise. The fascia and then the muscle fibers spread radially and are transposed onto the cannulas outer thread. The thin peritoneum transilluminates; bowel, vessels, and/or adhesions are visualized before entry into the peritoneum. Methods: The cannula was used in 234 consecutive patients: 8.1% were markedly obese, with a body mass index (BMI) ≥35, 14.8% were moderately obese (BMI 30 to <35), and 77.1% were mildly obese or normal (BMI <30). Results: There were no instrument-related or insertion-related complications. No insertion failed. Insertion time was slightly longer in the morbidly obese patients who had had previous umbilical surgical incisions. No port-site hernias have been found thus far (follow-up 6-48 months). Conclusion: This reusable cannula was found to be safe for any body weight.

Update: Why Diabetes Does Not Resolve in Some Patients after Bariatric Surgery

Bariatric surgery provides resolution of co-morbidities of morbid obesity—importantly diabetes type 2. This is initiated by immediate postoperative decrease in intake or assimilation of glucose and is continued by the substantial loss of adipose tissue. Greater weight loss and greater resolution of type 2 diabetes occur after operations that provide rapid passage of nutrients to the hindgut, which likely results in beta-cell stimulation by incretins. Failure of resolution of the diabetes can result from lack of patient compliance, inadequate weight loss, longstanding uncontrolled diabetes, or when the diabetes is actually a type 1.

An Outbreak of Staphylococcus Epidermidis Septicemia

During 45 wk from August 1980 to June 1981, the catheter sepsis rate increased from a prior 2 to 34% (23 of 68 patients on intravenous hyperalimentation). The causative organism was Staphylococcus epidermidis, grown on blood cultures in 21 of the 23 patients and on the catheter-tips of all 23. Routine cultures of the catheter-tips of the 45 patients who received intravenous hyperalimentation during this period with no evidence of catheter sepsis grew S. epidermidis on three catheter-tips (6.7%), possibly contamination during catheter removal. Sepsis resolved within 24 hr after catheter removal, with no antibiotics given for the sepsis. The organism had identical antibiograms on the blood and catheter-tip cultures in each patient, but antibiograms varied between patients. In these complex patients undergoing multiple medical events, the intravenous hyperalimentation nurse recorded that iv tubing in septic patients had leaked solution at the attachment to the catheter hub, and a review of nursing notes on charts of patients who had been on intravenous hyperalimentation revealed that a leak had been noted in the patients who subsequently had catheter sepsis. The leak was due to a manufacturing defect resulting in a decrease in diameter of the plastic connection of the iv tubing, which produced a loose attachment to the hub. The problem was remedied by switching to a Luer-lok attachment. However, in July 1982, two patients had separation of the Luer due to a manufacturing defect in the threads, followed by a catheter sepsis. Sepsis from the local contamination was not manifest until 5.4 +/- 2.7 days later. Quality control by manufacturers is emphasized.