Noel N. Williams

Preoperative eating behavior, postoperative dietary adherence, and weight loss after gastric bypass surgery

BACKGROUND To investigate the relationship between preoperative eating behavior, postoperative dietary adherence and weight loss after gastric bypass surgery in a major, urban medical center with a comprehensive bariatric surgery program. Despite the significant weight loss and dramatic improvements in co-morbidities associated with bariatric surgery, a significant minority of patients appear to experience suboptimal weight loss. The reasons for this are not well understood, but the suboptimal weight loss is often attributed to preoperative psychosocial characteristics and/or eating behaviors, as well as poor adherence to the recommended postoperative diet. METHODS A prospective investigation was performed of 200 female and male patients who were studied both preoperatively and 20, 40, 66, and 92 weeks postoperatively. All patients underwent either open or laparoscopic Roux-en-Y gastric bypass surgery. The measures were the percentage of weight loss, macronutrient intake, dietary adherence, and eating behavior. RESULTS Gender, baseline cognitive restraint, and self-reported adherence to the postoperative diet at postoperative week 20 were associated with the percentage of weight loss at postoperative week 92. Those high in dietary adherence had lost 4.5% more weight at postoperative week 92 than those low in dietary adherence. CONCLUSION Baseline cognitive restraint and adherence to the recommended postoperative diet were associated with the percentage of weight loss after gastric bypass surgery. These results suggest the potential utility of pre- and/or postoperative dietary counseling interventions to improve the postoperative outcomes.

Night Eating Syndrome and Binge Eating Disorder among Persons Seeking Bariatric Surgery: Prevalence and Related Features

Objective: To assess the prevalence of night eating syndrome (NES) and binge eating disorder (BED) and their related behavioral and psychological correlates in persons who sought bariatric surgery.

Changes in quality of life and body image after gastric bypass surgery

BACKGROUND Improvements in psychosocial status are an important aspect of successful outcomes after bariatric surgery. Relatively few studies have investigated the changes in psychosocial functioning at a number of points in the first few postoperative years. The present study was undertaken to assess the changes in quality of life and body image after gastric bypass surgery. The present study was performed at an academic medical center. METHODS A total of 200 men and women were enrolled in the study and completed psychometric measures of quality of life and body image before surgery and again 20, 40, and 92 weeks postoperatively. RESULTS The participants reported significant improvements in several domains of health- and weight-related quality of life, as well as changes in body image, after surgery. These changes were correlated with the percentage of weight loss. CONCLUSION Those who undergo gastric bypass surgery experienced significant improvements in quality of life and body image within the first few months after surgery. These changes were, with few exceptions, maintained into the second postoperative year.

Comparison of Psychosocial Status in Treatment-Seeking Women with Class III vs. Class I–II Obesity

Objective: This study compared the psychosocial status and weight loss expectations of women with extreme (class III) obesity who sought bariatric surgery with those of women with class I–II obesity who enrolled in a research study on behavioral weight control.

The Impact of Bariatric Surgery on Menstrual Patterns

Background: Obesity and anovulation are common medical problems in the United States. Anovulation in obese patients primarily manifests with irregular, sporadic or absent menstrual bleeding. Weight loss of at least 5% has been shown to reverse obesity-related anovulation. The aim of this study was to assess the impact of bariatric surgery on infertility in morbidly obese women and to identify factors associated with return of normal menses following bariatric surgery. Methods: A survey of patients was collected from the bariatric surgery data-base at the Hospital of the University of Pennsylvania. 410 women under the age of 40 were sent questionnaires. 195 patients completed the questionnaire, and 29 patients had incorrect addresses without a forwarding address, resulting in a 51.2% response rate. Patients who reported menstrual cycle lengths >35 days were considered abnormal. 92 of the 195 responders were considered anovulatory preoperatively, based on menstrual history. Results: There was no significant difference in postoperative BMI, BMI decrease or age at surgery between the survey responders and non-responders. There was a significant difference between these 2 groups in time since surgery (P=.01). Both groups had a decrease in BMI of >18 kg/m2. The mean menstrual cycle length preoperatively among those categorized as ovulatory and anovulatory was 27.3 and 127.5 days, respectively. Of the 98 patients who were anovulatory preoperatively, 70 patients (71.4%) regained normal menstrual cycles after surgery. Those patients who regained ovulation had greater weight loss than those who remained anovulatory (61.4 kg vs 49.9 kg, P=0.02). Conclusions: Anovulation resulting in abnormal menses is a common problem in morbidly obese premenopausal women. The menstrual cycle disorders may completely resolve after bariatric surgery. Thus, infertility due to anovulation among morbidly obese women could potentially be viewed as an additional indication for bariatric surgery.

The Tumor Suppressor Gene WWOX at FRA16D Is Involved in Pancreatic Carcinogenesis

Purpose: WWOX (WW domain containing oxidoreductase) is a tumor suppressor gene that maps to the common fragile site FRA16D. We showed previously that WWOX is frequently altered in human lung and esophageal cancers. The purpose of this study was to delineate more precisely the role of WWOX in pancreatic carcinogenesis. Experimental Design: We analyzed 15 paired pancreatic adenocarcinoma samples and 9 pancreatic cancer cell lines for WWOX alterations. Colony assay and cell cycle analysis were also performed to evaluate the role of the WWOX as a tumor suppressor gene. Results: Loss of heterozygosity at the WWOX locus was observed in 4 primary tumors (27%). Methylation analysis showed that site-specific promoter hypermethylation was detected in 2 cell lines (22%) and treatment with the demethylating agent 5-aza-2′-deoxycytidine demonstrated an increase in the expression of WWOX. In addition, 2 primary tumor samples (13%) showed promoter hypermethylation including the position of site-specific methylation. Transcripts missing WWOX exons were detected in 4 cell lines (44%) and in 2 tumor samples (13%). Real-time reverse transcription PCR revealed a significant reduction of WWOX expression in all of the cell lines and in 6 primary tumors (40%). Western blot analysis showed a significant reduction of the WWOX protein in all of the cell lines. Furthermore, transfection with WWOX inhibited colony formation of pancreatic cancer cell lines by triggering apoptosis. Conclusion: These results indicate that the WWOX gene may play an important role in pancreatic tumor development.

An objective scoring system for laparoscopic cholecystectomy

BACKGROUND Direct observation with structured criteria for performance is the most reliable and valid method of assessing technical skill during operative procedures. We developed such a system to evaluate technical performance during a laparoscopic cholecystectomy. The reliability and validity of the system were tested by analyzing the correlation among three observers in a multicenter study and comparing performance with years of surgical experience. STUDY DESIGN Thirty consecutive cases of laparoscopic cholecystectomy were recorded on videotape, 10 from each of 3 institutions. Independent scores were generated by three observers examining each of the videotapes, providing a total of 90 scores. Points were awarded for successful completion of each of 23 different steps required to perform a laparoscopic cholecystectomy. Error points were tabulated based on the frequency and relative severity of each of 21 potential technical mistakes during the operation. The final score was assumed to be a relative measure of technical skill and was derived by subtracting error points from points awarded for completion of each step of the procedure. Pearson correlation coefficients were used to assess agreement among examiners and correlation with year of surgical experience. RESULTS Agreement in final scores among the three observers was excellent (r = 0.74-0.96) despite the fact that one observer assigned significantly fewer error points. Correlation between year of experience and two-handed technique scoring was good (r = 0.5, p = 0.057), but the correlation between experience and one-handed technique scores was poor (r = 0.02). CONCLUSIONS The technical skills required to perform laparoscopic cholecystectomy can reliably be measured using this tool. This method can be used to track the learning curve of surgeons in training, evaluate the efficacy of alternative training tools, and provide a means of self-assessment for the trainee.

Continuous Positive Airway Pressure via the Boussignac System Immediately after Extubation Improves Lung Function in Morbidly Obese Patients with Obstructive Sleep Apnea Undergoing Laparoscopic Bariatric Surgery

Background:Morbidly obese patients are at elevated risk of perioperative pulmonary complications, including airway obstruction and atelectasis. Continuous positive airway pressure may improve postoperative lung mechanics and reduce postoperative complications in patients undergoing abdominal surgery. Methods:Forty morbidly obese patients with known obstructive sleep apnea undergoing laproscopic bariatric surgery with standardized anesthesia care were randomly assigned to receive continuous positive airway pressure via the Boussignac system immediately after extubation (Boussignac group) or supplemental oxygen (standard care group). All subjects had continuous positive airway pressure initiated 30 min after extubation in the postanesthesia care unit via identical noninvasive ventilators. The primary outcome was the relative reduction in forced vital capacity from baseline to 24 h after extubation. Results:Forty patients were enrolled into the study, 20 into each group. There were no significant differences in baseline characteristics between the groups. The intervention predicted less reduction in all measured lung functions: forced expiratory volume in 1 s (coefficient 0.37, SE 0.13, P = 0.003, CI 0.13–0.62), forced vital capacity (coefficient 0.39, SE 0.14, P = 0.006, CI 0.11–0.66), and peak expiratory flow rate (coefficient 0.82, SE 0.31, P = 0.008, CI 0.21–0.1.4). Conclusions:Administration of continuous positive airway pressure immediately after extubation maintains spirometric lung function at 24 h after laparoscopic bariatric surgery better than continuous positive airway pressure started in the postanesthesia care unit.

Long term survival after pancreatic resection for pancreatic adenocarcinoma

OBJECTIVE:The aim of this study was to determine the long term survival of patients with pancreatic adenocarcinoma who underwent surgical resection and to assess the association of clinical, pathological, and treatment features with survival.METHODS:Between January, 1990, and December, 1998, 125 patients underwent a pancreaticoduodenal or partial pancreatic resection for pancreatic ductal adenocarcinoma at our institution. The records of these patients were reviewed for demographics, tumor characteristics including size, histological grade, margin status, lymph node status, surgical TNM staging, and postoperative adjuvant therapy. The primary outcome variable analyzed was survival.RESULTS:A total of 116 patients had complete follow-up and were included in the final analysis. The median survival after surgery was 16 months. The 1-, 3-, 5-, and 7-yr survival rates for all 116 patients were 60%, 23%, 19%, and 11%, respectively. The 1-, 3-, 5-, and 7-yr survival rates for patients who received adjuvant therapy were 69%, 28%, 23%, and 18% compared with 20% and 0% in patients who did not receive adjuvant therapy (p < 0.0001). The 1-, 3-, 5-, and 7-yr survival rates for patients with negative lymph nodes were 73%, 38%, 26%, and 22% compared with survival rates of 52%, 14%, 14%, and 9% in patients with positive lymph nodes (p = 0.01). In multivariate analyses, adjuvant therapy was the only feature found to be strongly associated with survival (hazards ratio = 0.26, 95% CI = 0.15–0.44).CONCLUSIONS:The overall 5- and 7-yr survival rates of 19% and 11% in our study further validate that surgical resection in patients with pancreatic adenocarcinoma can result in long term survival, particularly when performed in association with adjuvant chemoradiation.

Binge Eating Disorder and the Outcome of Bariatric Surgery at One Year: A Prospective, Observational Study

Previous studies have suggested that binge eating disorder (BED) impairs weight loss following bariatric surgery, leading some investigators to recommend that patients receive behavioral treatment for this condition before surgery. However, many of these investigations had significant methodological limitations. The present observational study used a modified intention‐to‐treat (ITT) population to compare 1‐year changes in weight in 59 surgically treated participants, determined preoperatively to be free of a current eating disorder, with changes in 36 individuals judged to have BED. Changes in weight and binge eating in the latter group were compared with those in 49 obese individuals with BED who sought lifestyle modification for weight loss. BED was assessed using criteria proposed for the Diagnostic and Statistical Manual (DSM) 5. At 1 year, surgically treated participants without BED lost 24.2% of initial weight, compared with 22.1% for those with BED (P > 0.309). Both groups achieved clinically significant improvements in several cardiovascular disease (CVD) risk factors. Participants with BED who received lifestyle modification lost 10.3% at 1 year, significantly (P < 0.001) less than surgically treated BED participants. The mean number of binge eating days (in the prior 28 days) fell sharply in both BED groups at 1 year. These two groups did not differ significantly in BED remission rates or in improvements in CVD risk factors. The present results, obtained in carefully studied participants, indicate that the preoperative presence of BED does not attenuate weight loss or improvements in CVD risk factors at 1 year in surgically treated patients. Longer follow‐up of participants is required.