Ramesh C. Ramanathan

Safety and Efficacy of Bariatric Surgery in Morbidly Obese Patients with Severe Systolic Heart Failure

Morbid obesity (MO) is a risk factor for congestive heart failure (CHF). The presence of MO impairs functional status and disqualifies patients for cardiac transplantation. Bariatric surgery (BAS) is a frontline, durable treatment for MO; however, the safety and efficacy of BAS in advanced CHF is unknown.

Bariatric surgery: A safe and effective conduit to cardiac transplantation

BACKGROUND Obesity and obesity-related co-morbidities, including advanced heart failure, are epidemic. Some of these patients will progress to require cardiac allografts as the only means of long-term survival. Unfortunately, without adequate weight loss, they may never be deemed acceptable transplant candidates. Often surgical weight loss may be the only effective and durable option for these complex patients. The objective of this study was to assess whether bariatric surgery is feasible and safe in patients with severe heart failure, which in turn, after adequate weight loss, would allow these patients to be listed for a heart transplant. METHODS Four patients who underwent bariatric procedures, such as laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (SG), for the purpose of attaining adequate weight loss with the goal to improve their eligibility for orthotopic heart transplants are presented. RESULTS All patients did well around the time of surgery, and 3 of the 4 progressed to receiving a heart transplant. The fourth patient will be listed pending attaining adequate weight loss. CONCLUSION Bariatric surgery may be an important bridge to transplantation for morbidly obese patients with severe heart failure. With the appropriate infrastructure, bariatric surgery is a feasible and effective weight loss method in this population.

Dramatic Functional Improvement Following Bariatric Surgery in a Patient With Pulmonary Arterial Hypertension and Morbid Obesity

Pulmonary arterial hypertension (PAH) and morbid obesity both dramatically impair functional capacity. New therapies have emerged for both conditions, including pharmaceutical agents for the former and bariatric surgery for the latter. The presence of both conditions simultaneously, however, may limit the applicability and effectiveness of these therapies. We report a case of a morbidly obese patient with severe PAH and functional impairment. A three-drug combination regimen consisting of oral bosentan and sildenafil, and inhaled iloprost produced sufficient hemodynamic improvement to allow for the performance of bariatric surgery. Over the subsequent 7 months, body weight, oxygen requirement, functional class, and 6-min walk distance all improved dramatically despite the persistence of PAH. While such surgery is typically denied to patients with PAH, we suggest that aggressive medical therapy for patients with PAH may allow for its safe performance, and that the clinical improvement resulting from the subsequent weight loss may be quite dramatic.

Changes in inflammatory endometrial cancer risk biomarkers in individuals undergoing surgical weight loss

OBJECTIVE Obesity has been strongly linked to endometrial cancer (EC) risk. A number of potential EC risk biomarkers have been proposed, including heightened pro-inflammatory cytokines and adipokines. To evaluate if bariatric surgery can serve as a means for altering levels of such EC risk biomarkers, we investigated changes in these biomarkers after weight loss. METHODS Blood samples were collected pre-operatively and 6months post-operatively in 107 female bariatric surgery patients aged 18-72years. Wilcoxon signed-rank tests were used to compare biomarker levels (measured using xMAP immunoassays) pre- and post-surgery. Normative comparisons were implemented to contrast 6-month post-surgery biomarker levels to levels in a sample of 74 age-matched non-obese women. Linear regression was used to evaluate the relationship between biomarker expression at baseline and 6months post-surgery and the relationship between race and biomarker levels. RESULTS On average, participants lost 30.15kg (SD: 12.26) after the bariatric intervention. Levels of C-peptide, insulin, CRP, leptin, IL-1Rα, and IL-6 significantly decreased, while levels of SHBG, IGFBP1, and adiponectin significantly increased with weight loss. Normative comparisons showed the levels of SHBG, C-peptide, insulin, IGFBP1, adiponectin, CRP, and TNFα after bariatric intervention approached the level of markers in comparison group. Multiple regression analyses revealed significant relationships between changes in BMI and changes in biomarker levels. The changes in IL-1Rα were significantly associated with race. CONCLUSIONS Our findings demonstrate that normalization of EC risk biomarkers can be achieved with bariatric surgery. Improved understanding of biological mechanisms associated with weight loss may inform preventive strategies for EC.

Endometrial cancer associated biomarkers in bariatric surgery candidates: exploration of racial differences

BACKGROUND Obesity is the main risk factor for endometrial cancer (EC), the most common gynecologic malignancy in the United States. A number of potential risk biomarkers have been associated with EC development, including altered proinflammatory cytokines, chemokines, and adipokines. OBJECTIVES The overarching aim of this research is to investigate racial differences in the expression of EC-associated biomarkers among bariatric surgery candidates. SETTING Tertiary academic medical center METHODS: Blood samples were collected from 175 women aged 18 to 72 (mean age: 42.93; standard deviation 11.66), before bariatric surgery. Levels of biomarkers associated with obesity and EC risk were measured using xMAP immunoassays. Wilcoxon rank sum and Fishers exact tests were utilized to compare biomarker and demographic variables between African American and European American women. Linear regression models, adjusted for menopause status and diabetes, were utilized to identify factors associated with biomarker levels. RESULTS When the biomarker levels were compared by race, insulin-like growth factor-binding protein 1 and adiponectin were significantly lower in African American women (P<.05), whereas estradiol was significantly higher in African American women (P<.05). Linear regression models found that race significantly predicted insulin-like growth factor binding protein 1, adiponectin, resistin, and interleukin-1 receptor alpha expression levels, menopause status and diabetes status were significantly associated with adiponectin and leptin levels, whereas body mass index was significantly associated with leptin, adiponectin, interleukin-1 receptor alpha, and interleukin-6 levels. CONCLUSION As one of the first efforts to explore racial differences in EC-associated biomarkers in a cohort of women with severe obesity, this study found several significant differences that should be further explored in large-scale studies.

Operating Room Positioning, Equipment, and Instrumentation for Laparoscopic Bariatric Surgery

Since 1995, the number of laparoscopic bariatric surgical procedures has dramatically increased both in the United States and in other countries. These advanced laparoscopic operations offer the advantage of more rapid recovery and dramatically reduced wound complication with established efficacy. For optimal efficiency and outcomes, laparoscopic procedures on obese patients require specialized laparoscopic equipment and instrumentation, including staplers and hand instruments, which are used with individual skill and coordinated teamwork to facilitate patient positioning, laparoscopic access, insufflation, visualization by camera, energy sources for transection and coagulation, flexible endoscopy, and voice activation and robotics, and to provide a fully integrated operating room layout.