S G Frederiksen

Management of suspected anastomotic leak after bariatric laparoscopic Roux-en-y gastric bypass

Anastomotic leak is one of the most serious complications following bariatric laparoscopic Roux‐en‐Y gastric bypass (LRYGB), and associated with high morbidity rates and prolonged hospital stay. Timely management is of utmost importance for the clinical outcome. This study evaluated the approach to suspected leakage in a high‐volume bariatric surgery unit.

Weight Loss After Vertical Banded Gastroplasty Can Be Predicted: A Prospective Psychological Study

Background: Although treatment failure after Vertical Banded Gastroplasty (VBG) is not uncommon, the safety of the procedure makes it the most widely used form of bariatric surgery. The reasons for failure may be either technical, such as staple-line dehiscence, or psychological inability on the part of the patient to adjust to the small stomach pouch and to its consequences. Methods: We carried out prospective testing of a cohort of consecutive VBG candidates, using a battery of psychological tests consisting of the ‘Three Factor Eating Questionnaire’, ‘Hopkins Symptom Check List (HSCL)’, ‘Mood Adjective Check List (MACL)’, ‘Karolinska Scales of Personality (KSP)’, and two projective tests, the ‘Meta-Contrast Technique (MCT)’ and the ‘Perceptgenetic Object Relation Test (PORT)’. The patients had been scheduled for surgery on clinical considerations only, and the results of the psychological testing were not disclosed to the surgeons until after the follow-up. Results: Mean preoperative Body Mass Index (BMI) was 42.0 (sd 9.9). Patients were extensively tested during the 3 weeks prior to surgery. There were no operative complications. Patients were tested psychologically again after 3 years. Their mean BMI then was 32.3 (sd 5.6). Thirteen patients had lost more than 50% of their overweight (BMI mean 29.6; sd 1.1), seven patients had lost less than 50% (BMI mean 37.0; sd 1.6; p = 0.0043). These two groups were compared. The single factor that correlated consistently with an unsatisfactory weight loss was preoperative signs of depression (p = 0.04). Stepwise discriminant analysis using three preoperative factors(Hunger, Verbal aggression and Socialization) correctly classified 90% of the patients who had lost <50% of their overweight. Other variables (Impulsivity, Emotional detachment and Maladaptive psychological defence) identified patients who were later to suffer from dysphoric mood (n = 5) or disturbed eating behaviour (n = 11). These factors may compromise a sustained ability to tolerate food restriction. Despite the operations disadvantages, all patients considered it worthwhile and displayed improved psychosocial adaptation postoperatively. Conclusion: We conclude that extensive psychological testing can accurately predict the intermediate-term weight outcome following VBG and that even patients who show little weight loss benefit from the procedure.

Bariatric surgery in a national cohort of women: sociodemographics and obstetric outcomes

OBJECTIVE In a large, prospective Swedish national cohort, we investigated individual birth characteristics for women who had undergone bariatric surgery and their obstetric outcome and made comparisons with all other women during the same period. STUDY DESIGN The cohort consisted of 494,692 women born 1973-1983 of which 681 women who had undergone bariatric surgery constituted the index group. RESULTS The index women more often have parents with lower sociodemographic status and are more often born large for gestational age. The women surgically treated before their first child had a shorter gestational length, their children had lower birthweight, and were more often born small for gestational age compared with the children born to the reference mothers. Women whose child was born before their bariatric surgery more often had a cesarean section, and their children were more often large for gestational age. CONCLUSION Preconception bariatric surgery in obese women may be associated with improved obstetric outcomes.

Neither low-calorie diet nor vertical banded gastroplasty influence gastro-oesophageal reflux in morbidly obese patients.

OBJECTIVE Investigate the effect of a liquid diet, and of vertical banded gastroplasty, on gastro-oesophageal reflux in morbidly obese patients. DESIGN Prospective study, patients being their own controls. SETTING University hospital, Sweden. SUBJECTS 25 morbidly obese patients, listed for vertical banded gastroplasty. INTERVENTIONS 24 hour ambulatory intra-oesophageal pH-monitoring three weeks before operation and repeated after 10-14 days on a liquid very low calorie diet, and finally three weeks after operation, while still on a liquid very low calorie diet. MAIN OUTCOME MEASURES Percentage of time that pH in the oesophagus was < or =4. RESULTS There were no changes in the amount of reflux, either after a liquid diet or after vertical banded gastroplasty. CONCLUSIONS Neither the liquid diet nor vertical banded gastroplasty alone had any appreciable effect on gastro-oesophageal reflux.

Alterations in cyclic nucleotide phosphodiesterase activities in omental and subcutaneous adipose tissues in human obesity

Objective:To elucidate the activity and expression of cyclic nucleotide phosphodiesterase (PDE) families in omental (OM) and subcutaneous (SC) adipose tissue and adipocytes, and to study alterations in their activity in human obesity.Design:Cross-sectional, translational research study.Patients:In total, 25 obese and 9 non-obese subjects undergoing gastrointestinal surgery participated in the study.Results:Inverse correlations between PDE activities and body mass index (BMI) were seen in both SC and OM adipose tissue. Inverse correlations between total PDE and PDE3 activity and BMI were seen in OM adipocytes but not in SC adipocytes. In both SC and OM adipose tissue of obese patients, total PDE and PDE3 activities were decreased compared with the controls. In SC adipose tissue of Type 2 diabetes (T2D) patients, the PDE activity not inhibitable by PDE3 or PDE4 inhibitors (PDEn) was increased compared with obese non-diabetic patients. In addition to PDE3 and 4 isoforms, PDE7B, PDE9A and PDE10A proteins were also detected in adipose tissue or adipocytes.Conclusions:Multiple PDE families are present in human adipose tissue and their activities are differentially affected by obesity and T2D.

Preoperative Intermaxillary Fixation has no Influence on Weight Loss Induced by Vertical Banded Gastroplasty

Surgery is the only therapeutic modality that has shown lasting results in the treatment of morbid obesity. Ability to lose weight by voluntary dieting has been associated with unsatisfactory weight loss after gastroplasty. This report examines the effect of preoperative inter-maxillary fixation (IMF) on weight reduction induced by vertical banded gastroplasty (VBG). Twenty-four patients entered the study and were randomly assigned to either 10 weeks of IMF or 10 weeks on the waiting-list. Patient groups were similar in respect to age, gender and Body Mass Index (BMI). All patients were urged to lose weight preoperatively. Patients in the IMF group lost 18 kg (−12 to −36; median, range) and the waiting list group lost 3 kg (+3 to −30) during the 10 weeks prior to surgery. Total weight loss from time of inclusion to 24 months postoperatively was the same in both groups. Our results suggest that weight loss up to 2 years after VBG is not influenced by short-term preoperative IMF. Although we found no obvious advantage in having patients pre-treated by IMF, our findings indicate that jaw wiring can be used for patients in whom moderate preoperative weight loss is desired without endangering the effect of VBG on body weight development.

Mesenteric Torsion as a Cause of Late Abdominal Pain after Gastric Bypass Surgery

Gastric bypass (GBP) has been the most common surgical way to treat obesity and its comorbidities. Late abdominal pain may occur by gastro-jejunal ulcers, gallstones, internal herniation or, rarely, intussusception. In an area with more than 1000 GBPs performed yearly, three patients with primary small bowel volvulus causing abdominal pain and requiring emergency or semi-urgent surgery were identified. Patients’ histories, radiology, and surgery performed are presented. Weight loss followed by mesenteric narrowing of the root and thus relative elongation may make rotation of the small bowel mesentery possible. Such a torsion might be an overlooked differential diagnosis in obscure abdominal pain after GBP.

Low-Molecular-Weight-Heparin as Thromboprophylaxis: a Dosage Problem in Obese Patients

Background: Prophylaxis with fixed doses of low-molecular-weight heparin (LMWH) is standard procedure to reduce the risk of venous thromboembolism after surgery. Patient studies have rarely been stratified for body weight. There is evidence to suggest that lack of sufficient levels of anti-factor X a-activity (anti-Xa) in morbidly obese patients on LMWH. Anti-Xa is used as a measurement of antithrombotic activity. The objective of the present study was to see, for obese patients, whether body weight-adjusted dosing of enoxaparin results in anti-Xa levels comparable to those of a standard fixed dose of normal weight patients. Material and Methods: Subcutaneous injections of enoxaparin 0.3 mg/kg and 0.6 mg/kg were administered to 10 morbidly obese volunteers (median body weight 127 kg). Plasma anti-Xa was measured at defined intervals for 10 hours after injection. Reference values for anti-Xa were obtained from a former study where a fixed dose of 40 mg enoxaparin was given to subjects with different body weights. Results: Body weight dosing with 0.6 mg/kg enoxaparin yields levels of anti-Xa in the same range as in normal weight patients who receive the recommended fixed dose of 40 mg. Conclusion: Body weight-adjusted dosing may be considered in perioperative thromboprophylaxis with LMWH in obese patients.