Simon Marceau

Large maternal weight loss from obesity surgery prevents transmission of obesity to children who were followed for 2 to 18 years.

OBJECTIVE. Our aim was to compare the prevalence of obesity in 172 children who were aged 2 to 18 years and born to 113 obese mothers (BMI: 31 ± 9 kg/m2) with substantial weight loss after biliopancreatic bypass surgery with 45 same-age siblings who were born before maternal surgery (mothers’ BMI: 48 ± 8 kg/m2) and with current population standards. METHODS. In this case series, with >88% follow-up in a tertiary referral center, crosssectional office chart and telephone data on childhood and adolescent weights were transformed to z scores. RESULTS. After maternal surgery, the prevalence of obesity in the offspring decreased by 52% and severe obesity by 45.1%, with no increase in the prevalence of underweight. The z score reduction in obesity was gender specific, with boys reducing from 1.4 ± 1.3 before to 0.57 ± 1.7 after maternal surgery, corrected for birth order. The difference was not significant in girls (0.8 ± 1.3 vs 0.8 ± 1.2). Among children of both genders who were aged 6 to 18 years of age and born after maternal surgery, the prevalence of overweight was reduced to population levels. CONCLUSIONS. Contrary to outcomes after intrauterine under- and overnutrition, the prevalence of overweight and obesity in children of mothers with large voluntary postsurgical weight loss was similar to that in the general population, with no increase in underweight. The results demonstrate the importance of potentially modifiable epigenetic factors in the cause of obesity.

Reducing weight increases postural stability in obese and morbid obese men

Objective:To investigate the effect of weight loss on balance control in obese and morbid obese men.Methods:In a longitudinal and clinical intervention study, postural stability was measured with a force platform before and after weight loss in men. Weight loss was obtained in obese men (mean body mass index (BMI)=33.0 kg/m2) by hypocaloric diet until resistance and in morbid obese men (mean BMI=50.5 kg/m2) by bariatric surgery. Morbid obese men were tested before surgery, and 3 and 12 months after surgery when they had lost 20 and nearly 50% of initial body weight, respectively. Normal weight individuals (mean BMI=22.7 kg/m2) were tested twice within a 6- to 12-month period to serve as control. Body fatness and fat distribution measures, and posturographic parameters of the center of foot pressure (CP) along the antero-posterior and medio-lateral axes for conditions with and without vision were performed in all subjects.Results:Weight loss averaged 12.3 kg after dieting and 71.3 kg after surgery. Body weight remained unchanged in the control group. After weight loss, nearly all measures of postural stability were improved with and without vision (i.e., CP speed and range in antero-posterior and medio-lateral axes). A strong linear relationship was observed between weight loss and improvement in balance control measured from CP speed (adjusted R 2=0.65, P<0.001).Conclusion:Weight loss improves balance control in obese men and the extent of the improvement is directly related to the amount of weight loss. This should decrease the habitual greater risk of falling observed in obese individuals.

MALABSORPTIVE OBESITY SURGERY

Biliopancreatic diversion is the only valuable surgical approach for changing intestinal absorption. It is efficient in producing appropriate permanent weight loss and has a considerable psychological advantage because it does not impose abnormal food restriction. It not only decreases caloric absorption, but it also directly improves insulin and lipid metabolism. The ideal technique for the construction of BPD is not yet established, but our current preference is for the duodenal switch type. BPD must be seen as a means to change an intolerable and untreatable disease to a tolerable and treatable one, with substantial improvement in quality of life.

Biliopancreatic Diversion with a New Type of Gastrectomy: Some Previous Conclusions Revisited.

Background: In 1990, we modified Scopinaros biliopancreatic diversion (BPD); instead of a distal gastrectomy and gastroileal anastomosis, a parietal gastrectomy was performed with nutrients diverted through a duodenal switch. Also, the length of the common channel (50 cm) was doubled to 100 cm, while the nutrient limb remained 250 cm. In 1991, we reported initial results after 16 months: weight loss was as expected following BPD, but patients reported fewer side-effects and the prevalence of excessive malabsorption was less. This cohort of patients had their duodenum stapled shut to construct the duodenal switch. This staple-line failed insidiously in some patients, allowing the duodenum to recanalize partially or completely. This resulted in an incomplete BPD. Methods: Since 1992, the duodenal switch has been constructed with a complete transection of the duodenum to prevent recanalization. We report here on the first 61 patients who underwent this definitive procedure. Results: At 16 months, we observed a mean weight loss of 84% of initial excess weight, the number of daily stools at 2.9 ± 1.6 and the prevalence of diarrhea at 10%. Twenty per cent of patients experienced mild anaemia, hypocalcemia, or hypoalbuminemia, which required added supplements. Conclusions: BPD with parietal gastrectomy, duodenal switch and longer common channel improved weight loss and decreased gastrointestinal side-effects without an increased prevalence of excessive malabsorption. The parietal gastrectomy may contribute to weight loss by increasing satiety, and decreasing side-effects by regulating gastric emptying.

Does bone change after biliopancreatic diversion

This prospective study evaluated bone changes after biliopancreatic diversion (BPD) consisting of a distal gastrectomy, a 250 cm alimentary channel, and a 50 cm common channel. Thirty-three consecutive patients had clinical, biochemical, and bone mineral density analysis before surgery and 4 and 10 years after surgery. Iliac crest bone biopsies and special tests including parathyroid hormone (PTH), 25-hydroxyvitamin D (25-OH-D), 1,25-dihydroxyvitamin D (1,25-OH2-D), bone-specific alkaline phosphatase (BAP), and osteocalcin were obtained at surgery and 4 years postoperatively. Over the years, with close metabolic surveillance, additional calcium and vitamin D were given as indicated. After BPD, serum levels of calcium and vitamin D were decreased and serum levels of PTH, BAP, and osteocalcin were increased. Bone turnover and mineralization were both increased. Mean osteoid volume (P < 0.0007) and bone formation rate in relation to bone volume (P < 0.02) were increased. Static measures of bone were altered as follows: cortical thickness decreased (P < 0.01) and trabecular bone volume increased (P < 0.01). Ten years after surgery, overall bone mineral density was unchanged at the hip and was decreased by 4% at the lumbar spine. Overall fracture risk, based on the Z score, was unchanged. Preoperative factors predicting bone loss included menopause, smoking, and preexisting osteopenia. An elevated level of 1,25-OH2-D was also found to be a predictor of future bone loss (r = 0.40; P < 0.002). After surgery, a greater increase in bone markers and bone turnover was associated with an increased risk of bone loss. Although elevated osteocalcin levels were associated with overall bone loss (r = 0.52; P < 0.002), lower albumin levels were associated only with bone loss at hip level (r = 0.44; P < 0.02), whereas lower calcium levels were associated only with the loss at the lumbar spine (r = 0.39; P < 0.02). Ten years after surgery, bone loss at the hip continued to depend on albumin levels (r = 0.37; P < 0.03). We concluded that bone was relatively tolerant to the metabolic changes due to BPD. Provided that there is close surveillance for metabolic disturbances, the use of appropriate supplements, and the avoidance of malnutrition, the beneficial effects of surgery far outweigh the risk of postoperative bone disease.

Asthma and sleep apnea in patients with morbid obesity: outcome after bariatric surgery.

Background: Asthma and sleep apnea syndrome (SAS) are frequently reported in obese patients. The authors determined the prevalence of asthma and SAS in morbidly obese patients and the effect of biliopancreatic diversion with duodenal switch (BPD-DS) on these conditions. Methods: 398 patients were evaluated for bariatric surgery in a university-affiliated tertiary care center. All patients completed a written questionnaire on asthma and SAS before BPD-DS. In addition, 139 patients also completed a questionnaire on their general health status, including asthma and SAS, 2 years after the procedure. Results: For the cohort of 398 patients, the prevalence of self-reported asthma was 30.4% and that of SAS, 32.2%. No significant association was found between asthma and SAS diagnosis (P =0.10). Significant relationships were observed between the diagnosis of asthma and age, hip circumference, waist/hip ratio, weight and BMI of the patients as well as between a diagnosis of SAS and gender, waist circumference, hip circumference, waist/hip ratio, weight and BMI. 2 years after surgery (mean BMI was reduced from 51.4 to 30.5 kg/m2), asthma was reported improved in 79.3% of patients and SAS was improved in all but one with this condition; among 29 SAS patients using CPAP before surgery, only 4 were still using this treatment after 2 years. Conclusion: The prevalence of asthma and SAS is high in the morbidly obese population and is associated with markers of obesity. We found no association between the diagnosis of asthma and SAS diagnosis in this population. BPD-DS improved self-reported severity of asthma and SAS symptoms.

Biliopancreatic Diversion, with Distal Gastrectomy, 250 cm and 50 cm Limbs: Long-term Results

Background: Since 1984, biliopancreatic diversion (BPD) has been our procedure of choice in the treatment of morbid obesity. Better understanding of long-term outcome following BPD is needed. Methods: We report the results of our first consecutive 92 patients who underwent BPD more than 5 years ago. Of these 92, only 82 were available for a recent formal evaluation after a mean of 79 months. Results: Weight loss was maintained over the years at 62% of initial excess weight; the success rate for losing more than 50% of initial excess weight was 72%. The gastrointestinal side-effects decreased with time, but diarrhea was still present in 13%. The average number of daily stools was 3 ± 1.0. Of the patients, 76% were free from any gastrointestinal side-effects, taking normal diet and having normal stools. Malabsorption, however, was still present. A third of patients had laboratory values slightly below normal levels for haemoglobin, albumin and calcium. These values were mostly without clinical manifestation and were well tolerated by the patients. Regarding associated diseases, 75% were cured or improved following BPD. In 14 patients, reoperation was required to improve diarrhea or serum albumin. In these patients, the common channel was lengthened from 50 to 100 cm. The revision was successful in 11 and did not cause significant weight gain. Conclusion: BPD, as proposed by Scopinaro, was an efficient surgical treatment of morbid obesity that allowed normal eating habits and despite malabsorption was well tolerated by the great majority of patients.

Increased Plasma Levels of Toxic Pollutants Accompanying Weight Loss Induced by Hypocaloric Diet or by Bariatric Surgery

Background: Weight loss reduces the risk of several diseases. Increases of plasma organochlorine and pesticide compounds, however, have been observed with weight loss induced by a dietary intervention and by a gastroplasty. This increased concentration of toxic pollutants could be a side-effect of weight loss and a risk for health problems. The aim of this study was: 1) to observe if there is a relationship between the plasma concentration of organochlorines and BMI at steady state weight, and 2) to determine, after a bariatric surgical intervention, if the magnitude of the weight loss has a direct effect on this concentration. Methods: Weight loss was obtained in obese individuals by a hypocaloric diet program until resistance and in morbidly obese individuals by a bariatric operation (biliopancreatic diversion - duodenal switch [BPD-DS]). Normal-weight individuals were tested to serve as controls. Blood samples were analyzed for organochlorine and pesticide compounds at baseline in all groups, after resistance to weight loss in obese individuals, and at 3 months and 1 year after surgery in morbidly obese individuals. Results: At steady state weight, organochlorine and pesticide compounds were found in all groups, and the sum of all organochlorine compounds correlated with age and not BMI. Weight loss averaged 12.1% of the initial body weight after dieting and 20.9% at 3 months after surgery, respectively. This weight loss yielded significant increases in total plasma organochlorine concentration (increase of 23.8% for obese and 51.8% for morbidly obese individuals). For morbidly obese individuals, the weight loss at 1 year after surgery (46.3%) yielded a 388.2% increase in total plasma organochlorine concentration. Conclusion: Plasma organochlorine concentration increases with weight loss and is related to the magnitude. Future research will have to determine if: 1) this pollutant concentration remains elevated over time and 2) there are long-term effects of this high concentration on health.

Duodenal switch improved standard biliopancreatic diversion: a retrospective study.

BACKGROUND This was a retrospective study, performed 10 years after surgery, to compare the results between biliopancreatic diversion (BPD) with distal gastrectomy (DG) versus BPD with duodenal switch (DS). METHODS Complete follow-up data were available for 96% of patients, allowing a comparison of weight loss, revision, side effects, and complications at 10 years. RESULTS After BPD-DS, weight loss was 25% greater than after BPD-DG (46.8 +/- 21.7 kg versus 37.5 +/- 22 kg, respectively; P <.0001). The need for revision decreased from 18.5% to 2.7% (P <.0001), and the prevalence of vomiting during the previous month was 50% less (23.7-50.6%, P <.0001) after BPD-DS compared with after BPD-DG. Late complications were the same for both procedures. Blood analysis showed that, after BPD-DS, the levels of calcium, iron, and hemoglobin were significantly greater and the parathyroid hormone level was lower than after BPD-DG (71.3 +/- 44.2 versus 103.0 +/- 64.0 ng/L, respectively; P <.0001). CONCLUSION The DS greatly improved the BPD, as it was initially proposed. The use of the DS increased weight loss, decreased the need for revision, resulted in fewer side effects, and improved the absorption of nutrients.

Weight loss and muscular strength affect static balance control

Objective:Overweight individuals sway more than normal weight individuals. Major weight loss improves their balance control despite a related decrease in muscle strength. Presumably, muscular strength is an important factor for balance control. This study investigated the effect that a change in body mass has on relative strength and balance control.Methodology:Force (isometric knee extension) and balance control (center of pressure speed and range) were studied in three groups; normal weight (BMI <25 kg m−2), obese (30 kg m−2 <BMI< 40 kg m−2) and excess obese (BMI >40 kg m−2) Caucasian male individuals.Results:The excess obese individuals who underwent bariatric surgery as a weight loss strategy were studied before, 3 and 12 months after losing on average, 66.9 kg (±95% CI 55.8, 77.9 kg; on average, 45% of their weight). The obese individuals who underwent diet modifications were studied before dieting and when resistance to weight loss occurred after losing on average 11.7 kg (±95% CI 9.3, 14.2 kg; on average, 12% of their weight). The control group was studied twice, 50 weeks apart. In obese and excess obese individuals, losing weight reduced absolute knee muscular strength on average, by 8.2 kg (±95% CI 3.9, 12.5 kg; on average, 10% of their strength) and 23.9 kg (±95% CI 12.1, 35.8 kg; on average, 33% of their strength). However, it also increased balance control measured with speed of the center of foot pressure, on average, by 0.10 cm s–1 (±95% CI 0.05, 0.14 cm s–1; or increased of 12%) and 0.28 cm s–1 (±95% CI 0.07, 0.47 cm s–1; increased of 27%), respectively. Relative strength increased approximately by 22% for only the excess obese group 12 months post surgery.Conclusion:This suggests, in overweight individuals, weight loss is more efficient at improving balance control than increasing, or even maintaining muscle strength. In these individuals, training programs aimed at improving balance control should primarily target weight loss.