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Bariatric Surgery and Cardiovascular Risk Factors A Scientific Statement From the American Heart Association
Abstract
The rate of obesity is rising logarithmically, especially in those with severe obesity (body mass index [BMI] >40 kg/m2). Cardiologists, endocrinologists, internists, family practitioners, and most healthcare professionals are increasingly confronted with the severely obese patient and with postoperative bariatric patients because obesity is associated with significant morbidity and increased mortality. In addition, more adolescents these days are severely obese. Substantial long-term successes of lifestyle modifications and drug therapy have been disappointing in this population. The National Institutes of Health has suggested that surgical therapy be proposed to those patients with BMI >40 kg/m2 or >35 kg/m2 with serious obesity-related comorbidities such as systemic hypertension, type 2 diabetes mellitus, and obstructive sleep apnea. When indicated, surgical intervention leads to significant improvements in decreasing excess weight and comorbidities that can be maintained over time. These include diabetes mellitus, dyslipidemia, liver disease, systemic hypertension, obstructive sleep apnea, and cardiovascular dysfunction. Recent prospective, nonrandomized, observational, or case-control population studies have also shown bariatric surgery to prolong survival in the severely obese. Different types of bariatric procedures are being performed. Historically, operative mortality was between 0.1% and 2.0% with more recent data not exceeding 1%. Early complications include pulmonary embolus (0.5%), anastomotic leaks (1.0% to 2.5%), and bleeding (1.0%). Late complications include anastomotic stricture, anastomotic ulcers, hernias, band slippage, and behavioral maladaptation. The number of bariatric operations being performed is increasing tremendously as a result of increasing medical need and the evolution of safer surgical techniques and guidelines. Currently, bariatric surgery should be reserved for patients who have severe obesity in whom efforts at medical therapy have failed and an acceptable operative risk is present.
The terms overweight, obese, and severe obesity refer to a clinical continuum. Excess adiposity should be considered a chronic disease that has serious health consequences. An …
... 11 Besides, to optimize the results of bariatric surgery and reduce perioperative morbidity, experts recommend adapting to a healthy lifestyle intervention before and after surgery. [12][13][14] Thus, exercise is strongly recommended in multidisciplinary medical and surgical management for people with morbid obesity. The literature highlights that individuals who practice exercise before and after surgery achieve better weight loss and maintenance. ...
... 36 Comorbid diseases in morbid obesity increase the risk of developing complications and negatively affect treatment. 13 As a result of the research, we found that vital signs, respiratory functions, and biochemical analysis were investigated in some studies. 26,29,31,[33][34][35] In this population accompanied by chronic diseases, the evaluation of these parameters can direct the treatment and its results. ...
... PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses. 4 TOKGOZ AND ARMAN the presurgical period. 13 Examples of interventions that increase the physical activity level of SMOABS are individual exercises and group exercises. 14 In the literature, aerobic, strengthening, flexibility and balance-proprioceptive exercises, dance, and underwater exercises are recommended to treat obesity. ...
... The increasing prevalence of obesity in modern society makes it one of the main public health concerns [1]. Obesity is a major risk factor for several other medical conditions and particularly for non-communicable diseases [2][3][4]. Bariatric surgery is the most effective treatment for severe obesity and its associated co-morbidities, since it has proven to successfully achieve a significant and sustained body mass index (BMI) decrease, besides improving several obesity related diseases, such as type 2 diabetes (T2D) [4]. ...
... Obesity is a major risk factor for several other medical conditions and particularly for non-communicable diseases [2][3][4]. Bariatric surgery is the most effective treatment for severe obesity and its associated co-morbidities, since it has proven to successfully achieve a significant and sustained body mass index (BMI) decrease, besides improving several obesity related diseases, such as type 2 diabetes (T2D) [4]. ...
Metabolomics emerged as an important tool to gain insights on how the body responds to therapeutic interventions. Bariatric surgery is the most effective treatment for severe obesity and obesity-related co-morbidities. Our aim was to conduct a systematic review of the available data on metabolomics profiles that characterize patients submitted to different bariatric surgery procedures, which could be useful to predict clinical outcomes including weight loss and type 2 diabetes remission. For that, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - PRISMA guidelines were followed. Data from forty-seven original study reports addressing metabolomics profiles induced by bariatric surgery that met eligibility criteria were compiled and summarized. Amino acids, lipids, energy-related and gut microbiota-related were the metabolite classes most influenced by bariatric surgery. Among these, higher pre-operative levels of specific lipids including phospholipids, long-chain fatty acids and bile acids were associated with post-operative T2D remission. As conclusion, metabolite profiling could become a useful tool to predict long term response to different bariatric surgery procedures, allowing more personalized interventions and improved healthcare resources allocation.
... Desde hace más o menos cinco años la cirugía bariátrica se empezó a reconocer como metabólica 20,21 , mostrando que mejora o soluciona más de 30 diferentes condiciones relacionadas con la obesidad 22 . La American Heart Association (AHA), en su declaración científica de marzo de 2011, menciona que dicha cirugía puede resultar en una pérdida de peso a largo plazo y consecuentemente genera una reducción de diferentes factores de riesgo, entre ellos los cardiacos; por lo tanto, resalta que la relación riesgo/beneficio de la cirugía bariátrica favorece la práctica del procedimiento quirúrgico en los pacientes gravemente obesos 23 . A su vez, en las guías del 2009 de la American Diabetes Association (ADA), se recomienda considerar la cirugía bariátrica cuando el IMC es de 35 kg/m 2 o mayor, especialmente si son pacientes difíciles de controlar mediante las modificaciones en el estilo de vida y el tratamiento farmacológico 24 . ...
La cirugía bariátrica es hasta el momento la mejor solución para el problema de obesidad y la diabetes, e incluso, influye en la mejoría de las enfermedades no transmisibles relacionadas con la nutrición. Sin embargo, no está exenta de complicaciones, entre las cuales son frecuentes las metabólicas y nutricionales que, afortunadamente, son predecibles, prevenibles y tratables. Es necesario que el médico, el equipo de salud y el paciente se encuentren conscientes de la importancia de la nutrición, no solamente antes de la cirugía e inmediatamente después de ella, sino el resto de la vida. Es fundamental cumplir diariamente con las necesidades de proteína del paciente, la cual debe seleccionarse en la forma más tolerable y absorbible, con el objeto de prevenir deficiencias nutricionales importantes que muchas veces se atribuyen equivocadamente a déficits de otros nutrientes. Finalmente, el cambio de estilo de vida debe incorporarse al tratamiento, para prevenir de esta manera la nueva ganancia de peso y las implicaciones que esto conlleva.
... Faced with this problematic scenario, metabolic and bariatric surgery (MBS) is increasingly performed worldwide [8]. Patients considered eligible for MBS have a body mass index (BMI) equal to or greater than 40 kg/m 2 without comorbidities or a BMI equal to or greater than 35 kg/m 2 with comorbidities [9][10][11]. MBS is common in adult treatment, but in young people with severe obesity, treatment has similar effects on weight loss and comorbidity improvement [12]. ...
Obesity is a worldwide epidemic, and bariatric surgery has become increasingly popular due to its effectiveness in treating it. Therefore, understanding this area is of paramount importance. This article aims to provide an understanding of the development of the topic related to procedures, content, data, and status. To achieve this objective, a literature review and a bibliometric analysis were conducted. The methods provided insight into the current state and relevant topics over time. In conclusion, the article provided the identification of the transformation of the research field, initially focused only on physical aspects, to a more complex approach, which also incorporates psychological and social aspects and the correlation between obesity, bariatric surgery, and quality of life.
Graphical abstract
... The efficacy and safety of bariatric surgery have been well documented in numerous clinical studies and systematic reviews [6][7][8][9][10]. Over the past two decades, the efficacy of bariatric surgery for weight reduction has been widely documented for patients with cardiovascular disease, as evidenced by several cohort and randomized controlled trials (RCTs) studies [11][12][13][14][15]. However, limited research has explored the impact of bariatric surgery on cardiovascular-related medication utilization [16][17][18][19][20]. ...
Background
Bariatric surgery has been shown to improve hyperlipidemia, decreasing the need for statin medications. Although maintaining statin therapy post-surgery for those with a history of atherosclerotic cardiovascular disease (ASCVD) is advised, it is uncertain if discontinuation risks differ between those with and without ASCVD history.
Aim
The study aims to analyze the rate and reasons for statin cessation post-bariatric surgery in the US using real-world data.
Methods
Using the TriNetX electronic medical records network from 2012 to 2021, the study involved patients aged 18 or older on statins at the time of bariatric surgery. They were categorized into primary and secondary prevention groups based on prior ASCVD. Statin discontinuation was defined as a 90-day gap post the last statin dosage. The Cox model assessed factors influencing statin cessation.
Results
Seven hundred and thirty-three statin users undergoing bariatric surgery were identified, with 564 (77%) in primary prevention. Six months post-surgery, 48% of primary prevention patients and 34.5% of secondary ones stopped statins. Primary prevention patients had a 30% higher likelihood of cessation compared to secondary prevention (hazard ratio, 1.30; 95% CI, 1.06–1.60) as shown by multivariable analysis.
Conclusions
Post-bariatric surgery, primary prevention patients are more likely to discontinue statins than secondary prevention patients.
Graphical Abstract
... Although there is no specific guideline for physical activity in bariatric surgery in the literature, it is recommended to start physical activity in the preoperative period (11)(12)(13). A combination of 20 min of aerobic exercise and resistance training 3 or 4 d a week, together with dietary restriction before bariatric surgery, will reduce the risk of surgical complications, accelerate recovery and increase cardiorespiratory fitness (11,13,14). The American Society for Metabolic and Bariatric Surgery (ASMBS) recommends an average of 30 min of moderate-intensity exercise daily after surgery and making it a routine of daily life. ...
Background
We aimed to analyze the relationship between physical activity and the factors related to the weight management of bariatric surgery patients.
Methods
This descriptive-correlational study was conducted on 87 participants, who underwent bariatric surgery in Cyprus between May and Oct 2020. The International Physical Activity Questionnaire and a questionnaire on socio-demographic and obesity characteristics were used to collect data.
Results
Mean age of the participants was 34.7±8.43 and 65.5% were female. A statistically significant difference was found between physical activity levels and weight loss (P=0.021). Post-bariatric surgery physical activity level was low active for 65.5% of the participants. There was a statistically significant difference between the MET scores of the participants according to their gender, and the scores of men were higher than women (2256.9; 1110.9 respectively). Although most of the participants in the study were females, women lost less weight than males (45.5; 54.2 respectively).
Conclusion
Being female, married, and having chronic diseases caused less weight loss after bariatric surgery. As the physical activity levels of the patients increased, their weight loss increased. In line with these results, people undergone bariatric surgery and are at risk of regaining weight should be followed closely after surgery and appropriate physical activities should be planned.
... In the current study, 46.3% of patients had at least one comorbid condition, which is consistent with earlier studies that found a high prevalence of comorbidities among obese people receiving bariatric surgery [9][10][11]. The current study's high prevalence of diabetes mellitus and hypertension is also in line with earlier studies [12][13][14], emphasizing the significance of managing these comorbidities in the management of obesity. ...
Background: Gallstone is a significant health issue in the KSA and other developing countries. Multiple important risk factors have been identified as being associated with gallstones. Obesity is one of the risk factors for gallstone formation. Therefore, this study intends to determine the incidence of asymptomatic gallstone disease among the obese population in the Qassim region. The purpose of this study is to determine the incidence of asymptomatic gallstone in obese patients and the risk factors that contribute to its development in the Qassim region. As well as to compare the prevalence of gallstone disease between age groups and genders.
Methodology: A retrospective study of all patients who underwent bariatric surgery and had gallstones between January 2018 and January 2022 at King Fahad Specialist Hospital in Qassim Region, Saudi Arabia. The data, including age, gender, body mass index (BMI), and co-morbidities, will be collected from their charts.
Results: The current study included 295 patients with a mean age of 34.83 years (SD = 11.7) and 126 (42.7%) male participants. The most common comorbidity was diabetes mellitus, which was present in 54 (18.4%) participants, followed by hypertension in 42 (14.3%) participants. Of the 295 participants, 232 (78.6%) had asymptomatic gallstones, while 63 (14.3%) patients were symptomatic. The results showed that younger people (16-25 years) had the highest odds ratio of having asymptomatic gallstones compared to the reference group (>55 years). Gender was also significantly associated with asymptomatic gallstones, with males having higher odds of having asymptomatic gallstones than females. Participants with comorbidities other than diabetes mellitus had lower odds of having asymptomatic gallstones.
Conclusion: The present study's main finding is that obese patients receiving bariatric surgery had a significant prevalence of comorbidities and asymptomatic gallstones. According to the results, diabetes mellitus, male gender, and younger age may all be risk factors for the occurrence of asymptomatic gallstones in this population.
... Some studies even suggest that same-day discharge after Roux-en-Y gastric bypass (RYGB) is safe [8]. This small window presents a challenge to observe major complications, especially in patients with severe obesity who are more at risk for complications such as hemorrhage, anastomotic leaks, stenosis, and thrombosis [9,10]. ...
Introduction:
In fast-track metabolic surgery, the window to identify complications is narrow. Postoperative checklists can be useful tools in the decision-making of safe early discharge. The aim of this study was to evaluate the predictive value of a checklist used in metabolic surgery.
Methods:
Retrospective data from June 2018 to January 2021 was collected on all patients that underwent metabolic surgery in a high-volume bariatric hospital in the Netherlands. Patients without an available checklist were excluded. The primary outcome was major complications and the secondary outcomes were minor complications, readmission, and unplanned hospital visits within 30 days postoperatively.
Results:
Major complications within 30 days postoperatively occurred in 62/1589 (3.9%) of the total included patients. An advise against early discharge was significantly more seen in patients with major complications compared to those without major complications (90.3% versus 48.1%, P < 0.001, respectively), and a negative checklist (advice for discharge) had a negative predictive value of 99.2%. The area under the curve for the total checklist was 0.80 (P < 0.001). Using a cut-off value of ≥3 positive points, the sensitivity and specificity were 65% and 82%, respectively. Individual parameters from the checklist: oral intake, mobilization, calf pain, willingness for discharge, heart rate, drain (>30 ml/24 h), hemoglobin, and leukocytes count were also significantly different between groups.
Conclusion:
This checklist is a valuable tool to decide whether patients can be safely discharged early. Heart rate appeared to be the most predictive parameter for the development of major complications. Future studies should conduct prediction models to identify patients at risk for major complications.
... kg/m 2 , and class V as a BMI ≥60 kg/m 2 . 1 The prevalence of super obesity (Class IV) and super super obese (Class V) is increasing. 2,3 Patients with class IV and class V obesity suffer greatly from associated comorbidities (e.g., type 2 diabetes, hypertension, hyperlipidemia, obstructive sleep apnea). ...
Background: Recent studies have reported higher postoperative complication rates in patients with severe obesity who undergo bariatric surgery. The extremely obese patient deserves special consideration: significant comorbidities, technical difficulties, and increased postoperative morbidity and mortality are all expected in this patient population. Current data are limited and discrepant on the relationship between patients with class IV obesity (body mass index (BMI) ≥50-59.9 kg/m2), and class V obesity (BMI ≥60 kg/m2). This study compared early postoperative complications (≤30-day) following one-anastomosis gastric bypass (OAGB) morbidity in patients with class III, IV, and V obesity. Methods: Retrospective analysis of perioperative OAGB outcomes in three BMI groups at a high-volume hospital. Operative time, length of stay (LOS), and overall early postoperative complication rates were studied. Complications were ranked by Clavien-Dindo classification (CDC). Results: Between January 2017-December 2021, consecutive patients with obesity class III (n= 2,950), IV (n= 256), and V (n= 23) underwent OAGB. BMI groups were comparable in gender, age, and associated comorbidities. Mean operative time was significantly longer in the higher BMI groups: class III (66.5±25.6 min), IV (70.5±28.7 min), and V (80.0±34.7 min), respectively (p= 0.018); no difference in LOS. In respective BMI classes, ≤30-day complication rates were 3.2%, 3.5%, and 4.3% (p= 0.926). The respective number of patients with CDC grades of 1-2 were 45 (1.5%), 6 (2.3%), and 1 (4.3%), p= 0.500; and in grade ≥3a, 25 (0.8%), 1 (0.4%), 0 (0.0%), p= 0.669. No significant differences in rates of early complications, reoperations, and readmissions were found in revisional patients across BMI groups. There was 0.06% mortality (n= 2 in 3,229), both in BMI class III. Conclusion: OAGB is a safe metabolic bariatric surgery procedure in patients with class III, IV, and V obesity in the perioperative term with comparable ≤30-day morbidity in the three BMI groups.
... Changes in the pharmacokinetics of many medications are caused by increased fat tissue and muscle mass [18] . Also, diseases that are linked to obesity reduce this population's physiological reserves [19] . Even though magnesium sulfate is helpful in many areas of medicine, it has side effects like pulmonary edema, so it is essential to assess the effect of obesity on the achieved therapeutic dose of magnesium sulfate and its effect on the primary outcome of delayed delivery >48 h from first bleeding. ...
... Presently, the most common surgical techniques are sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). These interventions result in a sustainable weight reduction and remission of comorbidities in most of patients with common obesity (78,79). Bariatric surgery has regularly been undertaken for syndromic and monogenic obesity due to their severity, as the most effective treatment for patients with complicated severe obesity (80). ...
Obesity derives from impaired central control of body weight, implying interaction between environment and an individual genetic predisposition. Genetic obesities including monogenic and syndromic obesities are rare and complex neuro-endocrine pathologies where the genetic contribution is predominant. Severe and early-onset obesity with eating disorders associated with frequent comorbidities make these diseases challenging. Their current estimated prevalence of 5-10% in severely obese children is probably underestimated due to the limited access to genetic diagnosis. A central alteration of the hypothalamic regulation of weight implying the leptin-melanocortin pathway is responsible for the symptoms. The management of genetic obesity has so far been only based, above all, on lifestyle intervention especially regarding nutrition and physical activity. New therapeutics options have emerged in the last years for these patients, raising great hope to manage their complex situation and improve quality of life. Implementation of genetic diagnosis in clinical practice is thus of paramount importance to allow individualized care. This review describes the current clinical management of genetic obesity and the evidence on which it is based. Some insights will also be provided into new therapies under evaluation.
... Obesity is associated with dyslipidaemia, hypertension, diabetes mellitus, and cardiovascular diseases [2]. Surgical treatment of obesity is an effective therapy, especially for severe obesity [3], which induces the sustained loss of weight and reduction of comorbidities [4][5][6][7]. Robot-assisted surgery brings the benefits of minimally invasive surgery to the weight-loss surgery [8]. The da Vinci operating robot was approved by FDA in 2000, and currently is widely applied in bariatric surgery [9][10][11][12]. ...
Objective
To analyze the effect of a new type of tension-reduced suture named “double W tension-reduced suture technique” on the abdominal scars following the da Vinci robot-assisted gastrectomy for severely obese patients.
Methods
40 abdominal incisions following the da Vinci robot-assisted gastrectomy on severely obese patients from September 1st, 2021 to March 1st, 2022 were comprised in the study. 20 incisions were closed by the conventional full-thickness surgical suture as the control group, and 20 incisions were sewn up by double W tension-reduced suture as the double W group. The scars were assessed at the 1-month follow-up visit using the Vancouver scar scale (VSS), ultrasound and patient satisfaction. Meanwhile, digital photographs of scars were taken as well.
Results
The VSS score was 6.80 ± 2.16 in the control group, while that of the double W group was 2.60 ± 1.89. The difference between groups was significant. Digital photographs showed that the scar color was not only light and close to the skin color, but also flat and soft in the double W group. Ultrasound showed that the fibers of subcutaneous tissue in the double W group were arranged neatly, the ultrasonic signal intensity was relatively uniform, and the tunnel was small without obvious lacunae. More patients were satisfied and very satisfied with scars in the double W group.
Conclusion
Double W tension-reduced suture technique could significantly improve the appearance and reduce comorbidities of scars following the da Vinci robot-assisted gastrectomy for severely obese patients.
... Drug resources cannot completely resolve the disorders associated with higher body mass index (BMI) values [2]. In this case, bariatric surgery can be an effective intervention for the prevention and remission of associated disorders [3]. However, vitamin and mineral deficiencies are common conditions after surgical procedures that use disabsorptive, restrictive, and mixed techniques [4]. ...
Vitamin D status affects the clinical and corporal outcomes of postoperative patients who undergo a Roux-en-Y gastric bypass (RYGB). The aim of this study was to evaluate the effect of adequate vitamin D serum concentrations on thyroid hormones, body weight, blood cell count, and inflammation after an RYGB. A prospective observational study was conducted with eighty-eight patients from whom we collected blood samples before and 6 months after surgery to evaluate their levels of 25-hydroxyvitamin D 25(OH)D, thyroid hormones, and their blood cell count. Their body weight, body mass index (BMI), total weight loss, and excess weight loss were also evaluated 6 and 12 months after surgery. After 6 months, 58% of the patients achieved an adequate vitamin D nutritional status. Patients in the adequate group showed a decrease in the concentration of thyroid-stimulating hormone (TSH) (3.01 vs. 2.22 µUI/mL, p = 0.017) with lower concentrations than the inadequate group at 6 months (2.22 vs. 2.84 µUI/mL, p = 0.020). Six months after surgery, the group with vitamin D adequacy showed a significantly lower BMI compared with the inadequate group at 12 months (31.51 vs. 35.04 kg/m2, p = 0.018). An adequate vitamin D nutritional status seems to favor a significant improvement in one’s thyroid hormone levels, immune inflammatory profile, and weight loss performance after an RYGB.
... Bariatric surgery proven to be safe and effective in the treatment of obesity, eliciting durable weight loss 9-11 , promoting comorbidities improvement/resolution 4,12,13 and significantly improving life-expectancy and quality of life [14][15][16][17][18][19] . The stomach is one of the main target organs of bariatric surgery, as it is involved in most surgical interventions. ...
Objective:
Preoperative upper gastrointestinal endoscopy (UGIE) and postoperative histopathological examination (HPE) of resected specimens are still controversial issues in bariatric surgery.
Methods:
A retrospective review of prospectively collected laparoscopic sleeve gastrectomies (SG) performed at our institution for morbid obesity was carried out. All patients underwent pre-operative UGIE with biopsy, post-operative HPE and conventional post-operative follow-up.
Results:
From January 2019 through January 2021 we performed a total of 501 laparoscopic SG. A total of 12 (2.4%) neoplasms were found, 2 evident at preoperative UGIE, 4 detected during operation, and 6 at HPE. Eight of these 12 cases had some malignant potential and 5 would not have been detected without HPE of the specimen. The most significant unexpected case was a fundic gland type adenocarcinoma in a 64-year-old female with severe obesity.
Conclusion:
On the basis of our clinical experience, we recommend both preoperative endoscopic assessment and postoperative HPE of the specimen to provide the best available treatment to these patients.
... Current management strategies for patients with CKD emphasize the importance of delaying kidney function decline and managing its complications and comorbidities. As such, bariatric surgery, which has been shown to facilitate weight loss and improve cardiac risk factors such as dyslipidemia, hypertension, and type-2 diabetes mellitus, presents a potential treatment option for this patient population [7][8][9]. In addition, a recent systematic review and meta-analysis demonstrated that bariatric surgery has been shown to improve kidney function in patients with CKD and mitigate important cardiometabolic risk factors [7]. ...
Background
As chronic kidney disease (CKD) has a higher prevalence in patients with obesity, there is an increasing need to understand the safety of bariatric surgery for patients with advanced CKD. This study determined if short-term bariatric surgical outcomes and healthcare utilization differ in patients with advanced CKD.
Methods
A retrospective analysis of the Healthcare Cost and Utilization Project National Inpatient Sample (NIS) was performed. Patients with obesity who underwent bariatric surgery from 2015 to 2019 were included. Patients without CKD, with CKD, and end-stage kidney disease (ESKD) were compared for outcome differences. Univariate and multivariable regression was used to determine the association between perioperative outcomes to CKD status.
Results
The unadjusted analysis found significantly higher mortality and overall complication rate in CKD and ESKD patients, however, after adjustment for confounders, only the ICU admission rate remained significantly higher for patients CKD compared to non-CKD patients (odds ratio 4.21, 95% CI [3.29–5.39]). Length of stay was longer for patients with CKD (mean difference (MD) 0.14 days, 95% CI, [0.04, 0.23]) and patients with ESKD (MD 0.27 days, 95% CI, [0.10, 0.43]) compared to non-CKD patients. Patients with ESKD had higher admission costs compared to non-CKD patients (MD $1982.65).
Conclusion
Patients with CKD and ESKD have increased healthcare utilization and higher rates of ICU admission after bariatric surgery compared to non-CKD patients. Otherwise, there is no significant difference in other post-operative complications and mortality. Bariatric surgery may therefore be safely offered to this patient population in hospitals with on-site ICU capacity.
Graphical Abstract
... [127] A similar preoperative exercise recommendations, of low-to moderate-intensity physical activity for at least 20 minutes per day for 3 to 4 days per week, was also endorsed by the American Heart Association. [128] In addition, the joint guidelines from the ASMBS, the Obesity Society, and the American Association of Clinical Endocrinologists recommend that all postoperative patients should follow the general recommendations for health-enhancing daily PA of at least 30 minutes per day. [95] However, evidence-based PA recommendations for overweight or obese adults indicate that the amount of exercise that is needed for weight loss and long term maintenance in adults seems to be much higher than the previous guidelines, as the American College of Sports Medicine position stand has recommended a moderate intensity PA above 250 minutes per week in order to induce clinically substantial weight loss. ...
... suggested that surgical therapy be proposed as a treatment option to patients with BMI >35 kg/m 2 and diabetes [26]. This is 34.4% of the population we studied in 2015-2020, up from 24.4% in 1999-2002. ...
Objective:
Trends in obesity prevalence and trends in control of cardiometabolic risk factors among National Health and Nutrition Examination Survey participants with diabetes from 1999 through 2020 were analyzed.
Methods:
Adults who were 20 years or older and who reported having received a diagnosis of diabetes from a physician were included.
Results:
The prevalence of overall obesity, obesity class II, and obesity class III increased from 46.9%, 14.1%, and 10.3% in 1999 to 2002 to 58.1%, 16.6%, and 14.8% in 2015 to 2020, respectively. The prevalence of participants who achieved glycemic control (HbA1c <7%) increased from 42.5% in 1999 to 2002 to 51.8% in 2007 to 2010, then decreased to 48.0% in 2015 to 2020. The prevalence of participants who achieved blood pressure control (<140/90 mmHg) or achieved non-high-density lipoprotein cholesterol control (<130 mg/dL) increased throughout the study periods. The prevalence of participants who met all three risk factor goals increased from 8.3% in 1999 to 2002 to 21.2% in 2011 to 2014 and then decreased to 18.5 in 2015 to 2020. Participants with obesity showed worsening glycemic control and lipid control than participants with normal weight.
Conclusions:
There were increasing trends in prevalence of obesity, blood pressure control, and lipid control from 1999 to 2002 to 2015 to 2020. Participants with obesity showed worsening glycemic control and lipid control than normal-weight participants.
... Therefore, weight loss of at least 5% is recommended in patients with NAFLD for hepatic and cardiac benefits [140,141]. Weight reduction via diet or bariatric surgery was shown to have these benefits [328][329][330][331]. Another benefit of bariatric surgery is that it may be used as a bridge for weight loss in morbidly obese patients ineligible for cardiac transplantation [332]. ...
Nonalcoholic Fatty Liver Disease (NAFLD) is a growing global phenomenon, and its damaging effects in terms of cardiovascular disease (CVD) risk are becoming more apparent. NAFLD is estimated to affect around one quarter of the world population and is often comorbid with other metabolic disorders including diabetes mellitus, hypertension, coronary artery disease, and metabolic syndrome. In this review, we examine the current evidence describing the many ways that NAFLD itself increases CVD risk. We also discuss the emerging and complex biochemical relationship between NAFLD and its common comorbid conditions, and how they coalesce to increase CVD risk. With NAFLD's rising prevalence and deleterious effects on the cardiovascular system, a complete understanding of the disease must be undertaken, as well as effective strategies to prevent and treat its common comorbid conditions.
... In the United States of America from 1999 to 2018 the prevalence of obesity increased from 30.5 to 42.4%, and the prevalence of severe obesity increased from 4.7 to 9.2% [1]; in Europe, in 2014, its average prevalence reached 15.9% with associated increased morbidity and mortality [2]. As compared with conventional therapy, bariatric surgery has proven to be effective for the treatment of clinically severe obesity, reducing the overall mortality [3,4] with improvement or resolution of associated comorbidities and quality of life [5][6][7][8][9]. ...
Background:
The role of preoperative upper gastrointestinal endoscopy before bariatric surgery is still debated, and a consensus among the international scientific community is lacking. The aims of this study, conducted in three different geographic areas, were to analyze data regarding the pathological endoscopic findings and report their impact on the decision-making process and surgical management, in terms of delay in surgical operation, modification of the intended bariatric procedure, or contraindication to surgery.
Methods:
This is a multicenter cross-sectional study using data obtained from three prospective databases. The preoperative endoscopic reports, patient demographics, Body Mass Index, type of surgery, and Helicobacter pylori status were collected. Endoscopic findings were categorized into four groups: (1) normal endoscopy, (2) abnormal findings not requiring a change in the surgical approach, (3) clinically important lesions that required a change in surgical management or further investigations or therapy prior to surgery, and (4) findings that contraindicated surgery.
Results:
Between 2006 and 2020, data on 643 patients were analyzed. In all of the enrolled bariatric institutions, preoperative endoscopy was performed routinely. A total of 76.2% patients had normal and/or abnormal findings that did not required a change in surgical management; in 23.8% cases a change or a delay in surgical approach occurred. Helicobacter pylori infection was detected in 15.2% patients. No patient had an endoscopic finding contraindicating surgery.
Conclusions:
The role of preoperative UGE is to identify a wide range of pathological findings in patients with obesity that could influence the therapeutic approach, including the choice of the proper bariatric procedure. Considering the anatomical modifications, the incidence of asymptomatic pathologies, and the risk of malignancy, we support the decision of performing preoperative endoscopy for all patients eligible for bariatric operation.
... The NIH guidelines from 1991 advocated for bariatric surgery based on BMI and medical comorbidities. Patients suffering from obesity with a body mass index (BMI) > 40 kg/m 2 or a BMI > 35 kg/m 2 are recommended for bariatric surgery [2]. In recent years, the relationship between bariatric surgery and cerebrovascular events has received widespread attention. ...
Purpose
To perform a meta-analysis of the literature to evaluate the prevalence of cerebrovascular comorbidities between patients undergoing bariatric surgery and those not undergoing bariatric surgery.
Materials and Methods
Studies about the risk of cerebrovascular disease both before and after bariatric surgery were systematically explored in multiple electronic databases, including PubMed, Web of Science, Cochrane Library, and Embase, from the time of database construction to May 2022.
Results
Seventeen studies with 3,124,063 patients were finally included in the meta-analysis. There was a statistically significant reduction in cerebrovascular event risk following bariatric surgery (OR 0.68; 95% CI 0.58 to 0.78; I² = 87.9%). The results of our meta-analysis showed that bariatric surgery was associated with decreased cerebrovascular event risk in the USA, Sweden, the UK, and Germany but not in China or Finland. There was no significant difference in the incidence of cerebrovascular events among bariatric surgery patients compared to non-surgical patients for greater than or equal to 5 years, but the incidence of cerebrovascular events less than 5 years after bariatric surgery was significantly lower in the surgical patients compared to non-surgical patients in the USA population.
Conclusion
Our meta-analysis suggested that bariatric surgery for severe obesity was associated with a reduced risk of cerebrovascular events in the USA, Sweden, the UK, and Germany. Bariatric surgery significantly reduced the risk of cerebrovascular events within 5 years, but there was no significant difference in the risk of cerebrovascular events for 5 or more years after bariatric surgery in the USA.
Graphical abstract
... For this reason, a thorough evaluation for coronary artery disease, as well as valvular disease and heart failure, should be completed in any potential EBT patient, but even more importantly for the subset of elderly patients. Preoperative cardiovascular risk stratification is supported in the bariatric surgery literature [14,15]. The ASGE recommends screening for obesity-related diseases with additional cardiovascular evaluation dependent on initial pre-procedure evaluation prior to EBT. ...
Purpose of review
Obesity is an increasingly prevalent disease among patients greater than age 65. Bariatric procedures offer a promising route to treat obesity in this population. Endoscopic bariatric therapy (EBT) is a promising technique with less risk than surgery. Minimal data exist on the role of EBT in the elderly population. We aim to summarize available literature to make recommendations on procedural considerations and discuss areas for further development.
Recent findings
Existing EBT has largely been studied in a middle-aged population with very few patients above age 65 in pivotal trials. There are several comorbidities frequently encountered in the population evaluated for these procedures, and such conditions warrant a multidisciplinary approach to planning. Specific pre-, intra-, and post-procedure considerations should be given to the elderly population undergoing EBT to optimize the results of the procedure.
Summary
EBT in the elderly population requires more considerations and interdisciplinary planning than procedures in younger counterparts. Given the burden of obesity in this population, there is room for the development of this field, which has the potential to offer life-altering treatment for many.
... 8 Restrictive operations have a lower mortality risk than malabsorptive operations; however, both interventions have many serious complications. 9 As a result, there is a pressing demand for noninvasive body contouring procedures that are safer, have a shorter recovery period, and have less adverse effects. 10 Several studies demonstrated the scientific systemic effect of many noninvasive lipolysis techniques, such as ultrasound cavitation, radiofrequency, and cryolipolysis, without side effects or hazards. ...
Background and objective:
To investigate the efficacy of adding ultrasound cavitation and radiofrequency versus cryolipolysis to weight reduction program on leptin, insulin, waist circumference, skinfold, body weight in central obese subjects.
Material and methods:
Sixty centrally obese participants were randomly allocated into three equal groups. Subjects in the study group (I) received cavitation and radiofrequency plus dietary regimen, subjects in the second study group (II) received cryolipolysis in conjunction with the same diet program, and subjects in the control group (III) received the same dietary regimen only. Leptin, insulin level, waist circumference, skinfold, body weight, and body mass index were measured shortly before intervention techniques and 3 months afterward.
Results:
There were no statistically significant differences between cavitation plus radiofrequency and cryolipolysis on leptin and insulin levels after 3 months of intervention. However, statistically significant differences were found in waist circumference, skinfold, weight reduction, and body mass index in favor of the cavitation group (p < 0.05). In addition, both cavitation-radiofrequency and cryolipolysis were statistically significantly different than the diet alone in favor of the study groups (p < 0.05) in all the outcome measures. Furthermore, there were statistically significant differences in all outcome measures (p < 0.05) when comparing the baseline and postintervention results in each group except for leptin level in the diet group (p = 0.14).
Conclusion:
Subjects who underwent cavitation plus radiofrequency had better improvement on waist circumference, skinfold, and body mass index than subjects who received cryolipolysis. However, no differences were found between cavitation plus radiofrequency and cryolipolysis on leptin and insulin levels.
... Following bariatric surgery, the body undergoes a multilevel metabolic alteration which in turn impacts the cardiovascular system [38]. A complete mechanism of these variabilities is not fully understood [39]; however, numerous researches have postulated answers to this concern. One study states that this alteration primarily begins with an early transfer of nutrients, modifications in nutrient absorption in the gut, change in bile flow, and variations in the microbiota profile [40]. ...
Obesity and its complications are increasing in today's era, with cardiovascular health being one of the most significant obesity-related comorbidities. Hypertension in obesity is considered one of the major causes of death and disability due to their negative repercussions on cardiovascular health. Bariatric surgery is an approved therapeutic modality for obese people in classes II and III who have a body mass index (BMI) of more than 35 kg/m2 and 40 kg/m2, respectively. These weight loss surgeries are procedures that alter metabolism by causing weight reduction and altering gastrointestinal physiology, thereby considerably decreasing cardiometabolic risk factors that have been poorly understood to date. The purpose of this review is to explore the impact of bariatric surgery on reducing cardiac risk factors, in turn protecting the heart from succumbing to premature death. A literature search was done in the following databases: PubMed, Google Scholar, and PubMed Central (PMC). The studies taken into account for this review were observational studies published between 2016 and 2021 in the English language, where the quality was assessed using relevant quality appraisal methodologies. Finally, 10 reports were selected as definitive studies. Upon extensive evaluation of the final studies, it can be concluded that bariatric surgery results in significant weight loss, which lowers metabolic syndrome prevalence, cardiovascular risk factors, and major adverse cardiovascular events, particularly acute coronary events, and a favorable improvement in cardiac structure and function, altogether steering to reduced mortality due to cardiovascular diseases in obese patients. It is also worth noting that, while metabolic surgery can help patients with various metabolic comorbidities, the impact on individuals with hypertension is still debatable. Although the studies show significant effects on the cardiovascular system, these were only observational studies in geographically dispersed locations where each patient's lifestyle patterns and motivational levels could vary. Since real-world data are not fully explored due to the limited randomized controlled trials, it is suggested that further human trials on a larger scale be conducted to provide an even more factual conclusion.
... We highlighted that this result corroborates other scientific studies, which identified positive results that significantly reduced BMI only 6 months after gastroplasty 23,24 . Meanwhile, other studies only identified such results at the end of the first year 17,20 . ...
RESUMO - RACIONAL: A obesidade é caracterizada pelo acúmulo excessivo de gordura corporal prejudicial à saúde e nos últimos anos tem crescido significativamente na maioria dos países. A cirurgia bariátrica deverá ser recomendada para pacientes obesos que não obtiveram êxito no tratamento clínico e após análise da equipe multiprofissional. Objetivo: comparar os resultados metabólicos, perda ponderal e parâmetros associados à obesidade no pré e pós-operatório dos pacientes submetidos à cirurgia bariátrica. Métodos: estudo retrospectivo, descritivo, transversal, de abordagem quantitativa através da consulta a prontuários. Os dados foram coletados no período de maio a setembro de 2020, de indivíduos submetidos à cirurgia bariátrica no período de 15 anos (2003 a 2018). Foi realizada análise estatística comparativa e descritiva das variáveis antropométricas, metabólicas, bioquímicas e morbidades associadas. Resultados: a maioria era do sexo feminino (68,50%). Em ambos os sexos a maior prevalência se encontravam na faixa etária de 30 a 39 anos e mais da metade tinha obesidade grau III. A técnica cirúrgica utilizada foi o gastroplastia em Y de Roux. Após 4 meses houve uma redução significativa do perfil lipídico, dos parâmetros antropométricos e enzimas hepáticas em ambos os sexos, os quais permaneceram em declínio no final do primeiro ano, com melhora acentuada da síndrome metabólica. Conclusões: O impacto positivo determinado pela gastroplastia na perda de peso, na redução do IMC e perfil lipídico é bastante relevante já após quatro meses, e se mantém após um ano da realização do procedimento, demonstrando benefícios na redução dos fatores de risco da síndrome metabólica.
... Bariatric surgeries have gained immense popularity over the last few decades, especially with long-term studies proving sustained weight loss and resolution of comorbidities as well as decreased mortality and increased life expectancy [13,14]. After 5 decades of the first described weight loss surgery, several procedures have emerged while some have vanished. ...
Data comparing the occurrence of gastroesophageal cancer after gastric bypass procedures are lacking and are only available in the form of case reports. We perform in this study a systematic review and a meta-analysis of all the reported cases of gastroesophageal cancer following Roux-en-Y gastric bypass (RYGB) and loop gastric bypass-one anastomosis gastric bypass/mini gastric bypass (LGB-OAGB/MGB). We conducted a systematic review of all the reported cases in articles referenced in PubMed/Medline, Cochrane, and Scholar Google. Only cases of gastro-esophageal adenocarcinoma following RYGB or LGB-OAGB/MGB are included. Statistical analysis was done accordingly. Fifty cases were identified, along with 2 reported in this paper. Sixty-one percent (27/44) of the cancers after RYGB were in the gastric tube compared to 37.5% (3/8) after LGB-OAGB/MGB. This resulted in an odds ratio of 0.38 (p-value = 0.26), which failed to prove an increase in cancer occurrence in the gastric tube after LGB-MGB/OAGB compared to RYGB. The most common symptoms were dysphagia for cancers occurring in the gastric tube (15/30) and abdominal pain for those occurring in the excluded stomach (10/22). Twenty-nine/thirty of the cancers in the gastric tube were diagnosed by gastroscopy and 13/22 of the cancers in the excluded stomach were diagnosed by CT scan. Gastroesophageal cancers after gastric bypass procedures occur commonly in the excluded stomach where many are not identified by conventional means. Physician awareness and patient education as well as lifelong follow-up are essential for maintaining bypass surgeries on the beneficial side.
... Die bariatrische Chirurgie ist eine sehr wirksame Methode zur Gewichtsreduktion bei Patient*innen mit polygener Adipositas [62]. Ihre Effektivität bei Patient*innen mit angeborener Adipositas wurde bisher hauptsächlich in Fallberichten/-serien untersucht [63]. ...
Zusammenfassung
Etwa 5 % der Fälle schwerer Adipositas sind auf eine Mutation in einem einzigen Gen zurückzuführen. Diese genetischen Adipositasformen werden in monogene und syndromische Adipositas eingeteilt. Monogene Adipositas wird häufig durch Mutationen im Leptin-Melanocortin-Signalweg, der den Appetit reguliert, verursacht und ist durch frühkindlich auftretendes schweres Übergewicht gekennzeichnet. Bei syndromischer Adipositas (z. B. Prader-Willi‑, Bardet-Biedl- und Alström-Syndrom) liegen neben dem Übergewicht häufig auch Entwicklungsstörungen, dysmorphe Merkmale und Organanomalien vor. Die richtige Diagnose ist von Bedeutung, da es bereits medikamentöse Therapiemöglichkeiten gibt und eine Indikation zur bariatrischen Chirurgie nur mit großer Vorsicht getroffen werden sollte. Demzufolge sollte man in ausgewählten Fällen ein genetisches Screening anfordern. Warnsignale für eine genetische Ursache sind frühkindliche, ausgeprägte Adipositas, schwere Hyperphagie, normaler BMI der Eltern und Angehörigkeit zu Ethnien mit höherer Prävalenz von Konsanguinität (z. B. Pakistan, Türkei). Das genetische Screening sollte in erfahrenen Zentren mittels Gen-Panel erfolgen. Akkreditierte medizinisch-genetische Labore werden in den Datenbanken von Orphanet und Genetic Testing Registry (GTR) aufgelistet. In der EU liegt die klinische Zulassung für das Medikament Metreleptin bei LEP- Mutationen, so wie für das MC4R-Agonisten Setmelanotid bei LEPR -, POMC- und PCSK1 -Mutationen vor. Bei MC4R -Mutationen, der häufigsten Ursache monogener Adipositas, scheint Liraglutid wirksam zu sein. Verschiedenste Medikamente für Prader-Willi‑, Bardet-Biedl- und Alström-Syndrom werden gerade in klinischen Studien untersucht.
... Furthermore, given the cardiovascular risk associated with CKD [12] and the increased mortality associated with traditional cardiovascular risk factors [13] in this patient population, cardiovascular risk reduction, including weight loss in patients with obesity, is strongly recommended [1]. Bariatric surgery has been shown to not only facilitate sustained weight loss in patients with obesity, but also independently improve cardiac risk factors such as dyslipidemia, hypertension, and type 2 diabetes mellitus [14,15]. It has also been shown to reverse glomerular hyperfiltration and lower proteinuria in patients with obesity and normal kidney function [16], and improve access to kidney transplantation in patients with ESRD [17]. ...
The general management for chronic kidney disease (CKD) includes treating reversible causes, including obesity, which may be both a driver and comorbidity for CKD. Bariatric surgery has been shown to reduce the likelihood of CKD progression and improve kidney function in observational studies. We performed a systematic review and meta‐analysis of patients with at least stage 3 CKD and obesity receiving bariatric surgery. We searched Embase, MEDLINE, CENTRAL and identified eligible studies reporting on kidney function outcomes in included patients before and after bariatric surgery with comparison to a medical intervention control if available. Risk of bias was assessed with the Newcastle‐Ottawa Risk of Bias score. Nineteen studies were included for synthesis. Bariatric surgery showed improved eGFR with a mean difference (MD) of 11.64 (95%CI: 5.84 to 17.45, I2 = 66%) mL/min/1.73m2 and reduced SCr with MD of −0.24 (95%CI ‐0.21 to −0.39, I2 = 0%) mg/dL after bariatric surgery. There was no significant difference in the relative risk (RR) of having CKD stage 3 after bariatric surgery, with a RR of −1.13 (95%CI: −0.83 to −2.07, I2 = 13%), but there was reduced likelihood of having uACR >30 mg/g or above with a RR of −3.03 (95%CI: −1.44 to −6.40, I2 = 91%). Bariatric surgery may be associated with improved kidney function with the reduction of BMI and may be a safe treatment option for patients with CKD. Future studies with more robust reporting are required to determine the feasibility of bariatric surgery for the treatment of CKD. This article is protected by copyright. All rights reserved.
... ИМТ признан ВОЗ как наиболее эффективный и простой критерий ожирения [7]. Кроме того, американская кардиологическая ассоциация предложила дополнительные подгруппы ожирения, чтобы принять во внимание быстро растущую когорту пациентов с массивным ожирением, и ввела ожирение 4-й степени, соответствующее ИМТ ≥50 кг/м 2 , и 5-й степени с ИМТ ≥60 кг/м 2 [8]. ...
Adipose tissue is currently regarded as a key organ for excess dietary lipids, which determine whether the body will maintain normal homeostasis or whether inflammation and insulin resistance will develop. In recent years, there is more information about novel prognostic models — the visceral adiposity index and the lipid accumulation product. The aim of this review was to analyze the results of studies examining the relationship between various indices of obesity and cardiometabolic risk. We analyzed 105 literature sources, 53 of which were ruled out, becausethe processes of interest were not described in detail or included anassessment of the relationship of various obesity indices with metabolic parameters. The results obtained indicate the advisability of using novel obesity indices, which have a good predictive ability and are simple and convenient to use. It is necessary to use additional methods of anthropometric and clinical examination in order to assess the metabolic phenotype of obesity, which will make it possible to stratify patients by the level of cardiometabolic risk.
Background
The extremely obese patient deserves special consideration: significant comorbidities, technical difficulties, and increased postoperative morbidity and mortality are all expected in this patient population. The study compared early postoperative complications (≤30‐day) following one‐anastomosis gastric bypass (OAGB) morbidity in patients with morbid obesity class IV obesity, body mass index (BMI) ≥50–59.9 kg/m ² , and class V obesity, BMI ≥60 patients.
Methods
We retrospectively reviewed perioperative OAGB outcomes in three BMI groups. Operative time, length of stay (LOS), and overall early postoperative complication rates were studied. Patient‐reported complications were ranked by Clavien–Dindo Classification (CDC).
Results
Between January 2017–December 2021, consecutive patients with obesity class III ( n = 2950), IV ( n = 256), and V ( n = 23) underwent OAGB. BMI groups were comparable in sex, age, and associated comorbidities. Mean operative time was significantly longer in the higher BMI groups: class III (66.5 ± 25.6 min), IV (70.5 ± 28.7 min), and V (80.0 ± 34.7 min), respectively ( p = 0.018); no difference in LOS. In respective BMI classes, ≤30‐day complication rates were 3.2%, 3.5%, and 4.3% ( p = 0.926). The respective number of patients with CDC grades of one to two were 45 (1.5%), 6 (2.3%), and 1 (4.3%), p = 0.500; and in grade ≥3a, 25 (0.8%), 1 (0.4%), 0 (0.0%), p = 0.669. There was 0.06% mortality ( n = 2 in 3229), both in BMI class III.
Conclusions
OAGB is a safe BS procedure in patients with class III, IV, and V obesity in the perioperative term with comparable ≤30‐day morbidity in the three BMI groups.
Background
This joint expert review by the Obesity Medicine Association (OMA) and National Lipid Association (NLA) provides clinicians an overview of the pathophysiologic and clinical considerations regarding obesity, dyslipidemia, and cardiovascular disease (CVD) risk.
Methods
This joint expert review is based upon scientific evidence, clinical perspectives of the authors, and peer review by the OMA and NLA leadership.
Results
Among individuals with obesity, adipose tissue may store over 50% of the total body free cholesterol. Triglycerides may represent up to 99% of lipid species in adipose tissue. The potential for adipose tissue expansion accounts for the greatest weight variance among most individuals, with percent body fat ranging from less than 5% to over 60%. While population studies suggest a modest increase in blood low-density lipoprotein cholesterol (LDL-C) levels with excess adiposity, the adiposopathic dyslipidemia pattern most often described with an increase in adiposity includes elevated triglycerides, reduced high density lipoprotein cholesterol (HDL-C), increased non-HDL-C, elevated apolipoprotein B, increased LDL particle concentration, and increased small, dense LDL particles.
Conclusions
Obesity increases CVD risk, at least partially due to promotion of an adiposopathic, atherogenic lipid profile. Obesity also worsens other cardiometabolic risk factors. Among patients with obesity, interventions that reduce body weight and improve CVD outcomes are generally associated with improved lipid levels. Given the modest improvement in blood LDL-C with weight reduction in patients with overweight or obesity, early interventions to treat both excess adiposity and elevated atherogenic cholesterol (LDL-C and/or non-HDL-C) levels represent priorities in reducing the risk of CVD.
Obesity is a major global public health issue involving dyslipidemia, oxidative stress, inflammation, and increased risk of CVD. Weight loss reduces this risk, but the biochemical underpinnings are unclear. We explored how obesity and weight loss after bariatric surgery influence LDL interactions that trigger proatherogenic versus antiatherogenic processes. LDL was isolated from plasma of six patients with severe obesity before (basal) and 6–12 months after bariatric surgery (basal BMI = 42.7 kg/m²; 6-months and 12-months postoperative BMI = 34.1 and 30 kg/m²). Control LDL were from six healthy subjects (BMI = 22.6 kg/m²). LDL binding was quantified by ELISA; LDL size and charge were assessed by chromatography; LDL biochemical composition was determined. Compared to controls, basal LDL showed decreased nonatherogenic binding to LDL receptor, which improved postoperatively. Conversely, basal LDL showed increased binding to scavenger receptors LOX1 and CD36 and to glycosaminoglycans, fibronectin and collagen, which is proatherogenic. One year postoperatively, this binding decreased but remained elevated, consistent with elevated lipid peroxidation. Serum amyloid A and nonesterified fatty acids were elevated in basal and postoperative LDL, indicating obesity-associated inflammation. Aggregated and electronegative LDL remained elevated, suggesting proatherogenic processes. These results suggest that obesity-induced inflammation contributes to harmful LDL alterations that probably increase the risk of CVD. We conclude that in obesity, LDL interactions with cell receptors and extracellular matrix shift in a proatherogenic manner but are partially reversed upon postoperative weight loss. These results help explain why the risk of CVD increases in obesity but decreases upon weight loss.
In recent years, a growing body of research has demonstrated that an individual’s fitness level is a strong and independent marker of risk for cardiovascular and all-cause mortality. In addition, modest improvements in fitness through exercise intervention have been associated with considerable health outcome benefits. These studies have generally assessed fitness as a baseline marker in traditional epidemiological cohorts. However, there has been a recent recognition that fitness powerfully predicts outcomes associated with a wide range of surgical interventions. The concept of "prehabilitation" is based on the principle that patients with higher functional capability will better tolerate a surgical intervention, and studies have shown that patients with higher fitness have reduced postoperative complications and demonstrate better functional, psychosocial, and surgery-related outcomes. This review focuses on the impact of fitness on surgical outcomes and provides a rationale in support of routine application of prehabilitation in the management of patients undergoing surgery.
Obesity in combination with type 2 diabetes mellitus (T2DM) is associated with excess cardiovascular (CV) morbidity and mortality, which adds to worsening of renal function. Weight loss of more than 15% has the potential to attenuate this phenomenon. Bariatric surgery effectively induces significant and sustained weight loss in patients with obesity and T2DM. In addition, bariatric surgery can produce improvements in, as well as remission of T2DM, hypertension, dyslipidemia, inflammation, and chronic kidney disease. Improvement in cardiorenal risk factors following bariatric surgery reduces the incidence of fatal and nonfatal CV events, with reduction of incidence or reversal of chronic kidney disease (CKD). This chapter will outline the differential effects of each of the current most common bariatric procedures on cardiorenal risk factors.
Obesity is a growing global disease that results in serious health risks. Obesity is a known cause of arterial hypertension, and it is also responsible for structural and functional changes in the heart, arterial vessels and kidneys, among others. Thus, obese people have a higher prevalence of left ventricle hypertrophy and heart failure, as well as arterial stiffness. In kidneys, obesity is responsible for glomerular hyperfiltration and proteinuria, which could lastly produce focal and segmentary glomerulosclerosis and renal function decline. On the other hand, the adipocyte dysfunction observed in obesity causes an abnormal activation of cytokines and pro-inflammatory factors, insulin resistance, and the renin angiotensin system (RAS) upregulation. Adipose tissue has the RAS peptides necessary for the local production of angiotensin II, in addition to the systemic RAS. The over-activity of the RAS in obese individuals leads to an increase in blood pressure levels and to structural and functional changes in several organs, such as the heart, arterial vessels or the kidneys. Normalization of both elevated blood pressure and these pathological obesity-related organ changes observed after weighting loss by bariatric surgery appears to be mainly mediated by the RAS system. In this chapter, the relationships between the RAS and obesity-derived organ damage and hypertension and their modifications after BS are explored.KeywordsRenin angiotensin systemAldosteroneAngiotensin IIObesityBariatric surgeryOrgan damage
Background:
Evidence about the associations between obesity severity, metabolic status and risk of incident cardiovascular disease (CVD) in adults with obesity remains limited.
Methods:
The study included 109,301 adults with obesity free of prior CVD based on the UK Biobank cohort. Metabolic status was categorized into metabolically healthy obesity (MHO; free of hypertension, hypercholesterolemia, and diabetes) and metabolically unhealthy obesity (MUO). Obesity severity was classified into three levels: class I (body mass index of 30.0 - 34.9 kg/m2 ), II (35.0 - 39.9) and III (≥ 40.0). Cox proportional hazards models were used for analyses.
Results:
There were 8,059 incident CVD events during a median follow up of 8.1 years. MUO was significantly associated with a 74% increased CVD risk compared with MHO (HR = 1.74, 95% CI: 1.62 - 1.83). There was a significant interaction between obesity severity and metabolic status on an additive scale regarding CVD risk. When taking class I obesity as reference, class II was non-significantly associated with an increased risk of CVD in the MHO group (HR = 1.07, 95% CI: 0.90 - 1.27), while class III was significantly related to increased risks of CVD (HR = 1.48, 95% CI: 1.12 - 1.96). In the MUO group both classes II and III were significantly related with increased risks of CVD. Significant subgroup effects of age (P = 0.009) and sex (P = 0.047) were observed among participants with MUO, but not in the MHO group.
Conclusions:
Both elevated obesity severity and MUO were significantly associated with increased risks of CVD in adults with obesity, while metabolic status could modify the relationship between obesity severity and CVD risk. More research is needed to further clarify the relationship.
Background:
Magnesium sulfate has analgesic properties during the postoperative period. However, there is a knowledge gap in pharmacology related to the use of the real, ideal, or corrected ideal body weight to calculate its dose in obese patients. This trial compared postoperative analgesia using actual and corrected ideal body weight.
Methods:
Seventy-five obese patients scheduled to undergo laparoscopic gastroplasty or cholecystectomy under general anesthesia were randomly assigned to three groups. The patients in the control group did not receive magnesium sulfate; the other two groups received magnesium sulfate at 40 mg·kg-1 of actual body weight or corrected ideal body weight.
Results:
In patients with body mass index >30 mg·kg-2 (mean body mass index ranging from 32.964 kg·m-2 to 33.985 kg·m-2, according to the groups) scheduled for video laparoscopic cholecystectomy, there were no differences in the blood magnesium concentrations in the groups receiving magnesium sulfate throughout the study, regardless of whether the strategy to calculate its dose was based on total or corrected ideal body weight. Patients in the groups receiving magnesium sulfate showed a significant reduction in morphine consumption (p ≤ 0.001) and pain scores (p=0.006) in the postoperative period compared to those in the control group. There were no significant differences in morphine consumption (p=0.323) or pain scores (p=0.082) between the two groups receiving magnesium sulfate. There were no differences in the total duration of neuromuscular block induced by cisatracurium among the three groups (p=0.181).
Conclusions:
Magnesium sulfate decreased postoperative pain and morphine consumption without affecting the recovery time of cisatracurium in obese patients undergoing laparoscopic cholecystectomy. Strategies to calculate the dose based on the actual or corrected ideal body weight had similar outcomes related to analgesia and the resulting blood magnesium concentration. However, as the sample in this trial presented body mass indices ranging from 30.11 kg·m-2 to 47.11 kg/m-2, further studies are needed to confirm these findings in more obese patients, easily found in centers specialized.
Aim: Obesity and co-existing metabolic comorbidities are associated with increased cardiovascular (CV) morbidity and mortality risks, generally clustered to risk factors such as dyslipidemia. The aim of this study was to evaluate the lipid profile changes in subjects with severe obesity undergoing different procedures of bariatric and metabolic surgery (BMS), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB) in a real-world, clinical setting.
Methods: A single-center, retrospective, observational clinical study was performed enrolling patients undergoing BMS. The primary outcome was the change in total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL) cholesterol, and triglycerides.
Results: In total, 123 patients were enrolled (males 25.2% and females 74.8%) with a mean age of 48.2 ± 7.9 years and a mean BMI of 47.0 ± 9.1 kg/m². All patients were evaluated until 16.9 ± 8.1 months after surgery. Total and HDL cholesterol did not change after surgery, while a significant reduction in triglyceride levels was recorded. Moreover, a rapid decline of both LDL and non-HDL cholesterol among follow-up visits was observed. In particular, significant inverse correlations were found between total cholesterol, LDL cholesterol, non-HDL cholesterol, and triglycerides and the number of months elapsed after bariatric surgery. Similarly, a direct correlation was found considering HDL cholesterol. Moreover, total cholesterol, LDL cholesterol, non-HDL cholesterol, and triglycerides significantly changed among visits after RYGB, while no changes were observed in the SG group. Finally, considering lipid-lowering therapies, the improvement in lipid asset was detected only in non-treated patients.
Conclusion: This study corroborates the knowledge of the improvement in lipid profile with BMS in clinical practice. Together with sustained weight loss, the BMS approach efficiently corrects dyslipidemia, contributing to decreasing the CV risk.
Heart transplantation is recommended for patients with advanced heart failure refractory to medical and device therapy and who do not have absolute contraindications. When patients become eligible for heart transplantation, they undergo comprehensive evaluation and preparation to optimize their post-transplantation outcomes. This review provides an overview of the processes that are employed to enable the candidates transplant-ready when donor hearts are available.
Background
Cardiomyopathies are a group of diseases of the heart that can lead to heart failure, cardiac arrhythmia, and sudden death. They typically manifest as an enlarged heart or a normal heart with microscopic anomalies [fibrosis, inflammation, etc.]. The aim of the study is to investigate the prevalence of deaths due to cardiomyopathies of unknown etiology in young subjects in a forensic pathology setting.
Materials and Methods
Deaths due to cardiomyopathy in decedents less than 40 years old evaluated at the Cook County Medical Examiner’s Office in Chicago from January 2013 to June 2018 were studied.
Results and Conclusions
In total, 140 cases of cardiomyopathies were identified in the study period: among these, in 20 cases [14%] no underlying etiology could be found through medical history and autopsy investigation. The demographics and the macroscopic and microscopic findings of these cases are described, highlighting the importance of medical history review and adequate histological sampling of hearts in cases of sudden, unexpected death in children and young adults.
Branched-chain amino acids (BCAAs) include leucine, isoleucine, and valine. Mammalians cannot synthesize these amino acids de novo and must acquire them through their diet. High levels of BCAAs are associated with insulin resistance; type 2 diabetes; obesity; and non-metabolic diseases, including several forms of cancer. BCAAs—in particular leucine—activate the rapamycin complex1 mTORC1, which regulates cell growth and metabolism, glucose metabolism and several more essential physiological processes. Diets rich in BCAAs are associated with metabolic diseases (listed above), while diets low in BCAAs are generally reported to promote metabolic health. As for the dysregulation of the metabolism caused by high levels of BCAAs, recent studies propose that the accumulation of acyl-carnitine and diacyl-CoA in muscles alters lipid metabolism. However, this suggestion is not broadly accepted. On clinical grounds, pre- and post-operative metabolic profiles of candidate patients for bariatric surgery are being used to select the optimal procedure for each individual patient.
Objective:
This study aimed to evaluate microRNAs (miRNAs) as predictive biomarkers for type 2 diabetes (T2D) remission 12 months after sleeve gastrectomy (SG).
Methods:
A total of 179 serum miRNAs were profiled, and 26 clinical variables were collected from 46 patients. Two patients were later excluded because of hemolysis, and six patients with unclear remission status were set aside to evaluate the prediction models. The remaining 38 patients were included for model building. Variable selection was done using different approaches, including Least Absolute Shrinkage and Selection Operator (LASSO). Prediction models were then developed using LASSO and assessed in the validation set.
Results:
A total of 26 out of 38 patients achieved T2D remission 12 months after SG. The prediction model with only clinical variables misclassified two patients, which were correctly classified using miRNAs. Two miRNA-only models achieved an accuracy of one but performed poorly for the validation set. The best miRNA model was a mixed model (accuracy: 0.974) containing four miRNAs (hsa-miR-32-5p, hsa-miR-382-5p, hsa-miR-1-3p, and hsa-miR-21-5p) and four clinical variables (T2D medication, sex, age, and fasting blood glucose). These miRNAs are involved in pathways related to obesity and insulin resistance.
Conclusions:
This study suggests that four serum miRNAs might be predictive biomarkers for T2D remission 12 months after SG, but further validation studies are needed.
The worldwide prevalence of type 2 diabetes (T2D) is steadily increasing, and it remains a challenging public health problem for populations in both developing and developed countries around the world. Despite the recent advances in novel antidiabetic agents, diabetic kidney disease and cardiovascular disease remain the leading causes of morbidity and mortality in T2D. Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs), incretin hormones that stimulate postprandial insulin secretion, serve as a promising avenue for treatment of T2D as they result in a variety of antihyperglycemic effects including increased endogenous insulin secretion, decreased gluconeogenesis, inhibition of pancreatic α-cell glucagon production, decreased pancreatic β-cell apoptosis, and increased β-cell proliferation. GLP-1RAs have also been found to delay gastric emptying, promote weight loss, increase satiety, decrease hypertension, improve dyslipidemia, reduce inflammation, improve albuminuria, induce natriuresis, improve cardiovascular function, and prevent thrombogenesis. In this review, we will present risk factors for the development of cardiac and kidney disease in individuals with T2D and discuss possible mechanisms for the cardiorenal protective effects seen with GLP-1RAs. We will also present the possibility of dual- and tri-receptor agonist therapies with GLP-1, gastric inhibitory peptide, and glucagon RAs as an area of possible mechanistic synergy in the treatment of T2D and the prevention of cardiorenal complications.
Insulin resistance and type 2 diabetes, driven largely by obesity, are characterized by an increase in triglyceride-rich lipoproteins (TRLs) due to both reduced TRL clearance from the circulation and increased production by the liver (apoB-100 containing VLDLs) and intestine (apoB-48 containing chylomicrons). Bariatric surgery is the only treatment currently that leads to marked, sustained weight loss. Here, we will review the effects of bariatric surgery on circulating triglyceride/TRL Bariatric surgery leads to a marked reduction in fasting and postprandial plasma triglyceride Available data suggest that bariatric surgery reduces triglyceride and intestinal and hepatic TRL production with increased clearance of hepatic TRL particles. Some bariatric surgery studies have reported no/weak correlation between weight loss and improvements in triglyceride/TRL, suggesting that as factors like GLP-1 beyond weight loss may contribute to the marked changes in TRL that occur postbariatric surgery.Further studies are also needed to compare the effects of various bariatric surgery procedures on TRL kinetics and to elucidate underlying mechanisms.
Background
Bariatric surgery has emerged as a promising treatment for improving adipose tissue dysfunction in obesity, but the mechanisms for such amelioration are still not known. This study comprehensively explores a panel of adipo-cytokines in individuals with obesity undergoing bariatric surgery, in conjunction with markers of insulin resistance, at three time points i.e., pre-op, immediate post-op and 6 months post-surgery.
Methods
It is a case-control prospective study among obese individuals undergoing bariatric surgery (BMI ≥35 kg/m2, n=30) and non-obese subjects (BMI <25 kg/m2, n=30), comparing the levels of serum adiponectin, resistin, C-Reactive Protein (CRP), Interleukin (IL)-6 and 8, Monocyte chemoattractant protein (MCP)-1 and Tumor necrosis factor (TNF)-α between them. The same were followed at immediate and 6-month post-op periods in the former group. The serum markers were correlated with the markers of Insulin resistance like HOMA-IR, HOMA-β and QUICKI.
Results
A significant increase in adiponectin was seen after weight loss in obese group (17.54 ± 1.31 μg/mL at baseline vs 68.76 ± 1.84 μg/mL at 6- month post-surgery). CRP being an acute phase protein showed significant higher levels at immediate post-op period but declined even below its baseline at 6 months after surgery (33.34 ± 16.85 μg/mL at baseline vs 59.85 ± 23.12 μg/mL at immediate post-op vs 9.66 ± 1.84 μg/mL at 6 months post-operatively). Few inconsistencies were observed in the trajectories of IL-6 and TNF-α, while other pro-inflammatory markers indicated resolution after surgery.
Conclusion
Bariatric surgery alleviated the systemic inflammation, correlating with improved insulin resistance in individuals with obesity.
Obesity-related metabolic dysregulation causes mild cognitive impairment and increased risk for dementia. We used an LDLR-deficient C57BL/6 J mouse model (LDLRKO) to investigate whether adropin, a neuropeptide linked to neurodegenerative diseases, improves cognitive function in situations of metabolic dysregulation. Adropin transgenic mice (AdrTG) were crossed with LDLRKO; male and female progeny were fed a high fat diet for 3-months. Male chow-fed wild type (WT) mice were used as controls. Diet-induced obesity and LDLR-deficiency caused severe dyslipidemia, irrespective of sex. The AdrTG prevented reduced adropin protein levels in LDLRKO cortex. In males, metabolic dysregulation and AdrTG genotype significantly and bi-directionally affected performance in the novel object recognition (NOR) test, a declarative hippocampal memory task (discrimination index mean ± SE for WT, 0.02 ± 0.088; LDLRKO, -0.115 ± 0.077; AdrTG;LDLRKO, 0.265 ± 0.078; genotype effect, p = 0.009; LDLRKO vs. AdrTG;LDLRKO, P < 0.05). A 2-way ANOVA (fixed variables: sex, AdrTG genotype) indicated a highly significant effect of AdrTG (P = 0.003). The impact of the diet-genotype interaction on the male mouse brain was investigated using RNA-seq. Gene-ontology analysis of transcripts showing fold-changes of >1.3 or <-1.3 (P < 0.05) indicated metabolic dysregulation affected gene networks involved in intercellular/neuronal signaling, immune processes, angiogenesis, and extracellular matrix organization. The AdrTG selectively attenuated the impact of metabolic dysregulation on intercellular/neuronal signaling pathways. Intercellular/neuronal signaling pathways were also the predominant processes overrepresented when directly comparing AdrTG;LDLRKO with LDRKO. In summary, adropin overexpression improves cognitive function in severe metabolic dysregulation through pathways related to cell-cell communication and neuronal processes, and independently of preventing inflammatory responses.
Objective
This report estimates the percent of medically eligible adolescents who are referred for metabolic and bariatric surgery (MBS) evaluation or factors associated with referral.
Methods
This cross-sectional retrospective review evaluated patients aged 13 to 18 years seen between 2017 and 2019 for demographics, insurance status, body mass index (BMI), obesity-related comorbidities, and compared these data to patients whom had been referred and received MBS.
Results
Half of the patients (86 411/163137, 53%) between ages of 13 and 18 years identified had BMI documented, of which, 1974 (2.3%) were medically eligible for MBS, 238 (12%) were referred for MBS and 52 (22%) underwent MBS. Females had similar odds of being eligible for MBS [odds ratio (OR) = 1.01, 95% confidence interval (CI) 0.92-1.11, P = .9], but greater odds of referral (OR = 1.58, 95% CI 1.13-2.23, P = .009). Independently, miniorities and patients with public insurance had higher odds of being eligible for MBS, but similar odds of being referred as non-Hispanic white patients. Black patients with public insurance had greater odds of being referred for MBS (OR = 12.22, 95% CI 2.08-235.15, P = .022). Patients' multiple comorbidities had greater odds of being referred for MBS (OR = 2.16, 95% CI 1.29-3.68, P = .004).
Conclusions
Referral is barrier for patients medically eligible for MBS; however, this barrier is not uniformly faced by all patients.
Objective: The sustainability of surgically induced weight-loss implies that energy homeostasis is favorably altered. We investigated the hypothesis that laparoscopic adjustable gastric banding (LAGB) induces prolonged satiety and that plasma ghrelin is involved. Methods: 17 weight-stable subjects who had achieved LAGB induced weight-loss attended blind crossover breakfast tests; one with optimal band restriction and one with reduced restriction. Standardized meals were consumed (0900 h) after 14 h fasting. Satiety Visual Analog Scales were completed hourly (0700 h to 1100 h) and after feeding. Blood glucose, and plasma insulin, ghrelin and leptin levels were measured. 17 BMI matched controls were tested. Results: Optimal restriction was associated with significantly greater fasting and post-prandial satiety levels than reduced restriction (P < 0.01). Glucose, insulin, ghrelin and leptin levels did not alter between optimal and reduced restriction. LAGB subjects displayed higher ghrelin (+12%, P = 0.13) and lower glucose (-17%, P = 0.018), insulin (-33%, P = 0.016), and leptin (-32%, P = 0.05) 4hrAUC levels than controls. Conclusions: Optimal LAGB restriction increased fasting and post-prandial satiety levels. This supports the hypothesis that LAGB provides prolonged satiety, present even during fasting, favorably influencing energy homeostasis. Plasma insulin, leptin and ghrelin appeared unrelated to the satiety effect and displayed orexigenic compensatory changes. Identifying the mechanisms underlying LAGB induced satiety may assist the understanding of human energy homeostasis and obesity.
To examine the factors associated with liver steatosis in severely obese subjects and to test the potential reversibility of fatty liver after weight loss.
Retrospective clinical study.
528 obese patients before bariatric surgery and 69 obese subjects of the initial cohort evaluated before and 27+/-15 months after gastroplasty.
Fatty deposition (scored as mild, moderate or severe) and inflammatory changes were evaluated in liver biopsies; clinical (body mass index (BMI), age, gender, duration of obesity) and biological (glucose, triglycerides, liver enzymes) parameters were related to histological findings.
74% of the 528 biopsies showed fatty change, estimated as mild in 41% of cases, moderate in 32% and severe in 27%. The prevalence of steatosis was significantly higher in men than in women (91% vs 70%, P = 0.001) and in patients with impaired glucose tolerance or type 2 diabetes compared with nondiabetics (89% vs 69% P = 0.001). The severity of the steatosis was associated with BMI (P = 0.002) but not with the duration of obesity or the age of the patient. When compared with patients without fatty change, those with liver steatosis had significantly higher fasting plasma glucose (5.5 mmol/l vs 5.1 mmol/l, P = 0.007) and triglycerides (1.8 mmol/l vs 1.3 mmol/l, P = 0.002). Mean serum liver enzyme activities (alkaline phosphatase, aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyl-transpeptidase (gammaGT) were significantly (P < 0.001) increased in patients with fatty change but remained within laboratory reference values. In the 69 patients who have been evaluated after a marked weight reduction (-32+/-19kg), 45% of the biopsies were considered as normal (vs 13% before, P < 0.001) while pure fatty change was still observed in 38% of the patients (vs 83% before, P = 0.001). However, the severity of the steatosis was significantly (P < 0.001) reduced (mild: 62% vs 21%; moderate: 23% vs 37%; severe: 15% vs 42%). In addition, a significant increase of hepatitis was observed in 26% of the biopsies (vs 14% before, P < 0.05).
Liver steatosis in obese subjects is associated with men, diabetic status, BMI, higher fasting glucose and hypertriglyceridaemia. Postgastroplasty weight loss reduces liver steatosis, but seems to increase the incidence of inflammatory lobular hepatitis.
Severe obesity is associated with an increased risk of coronary artery disease (CAD). Bariatric surgery is an effective procedure for long term weight management as well as reduction of comorbidities. Preoperative evaluation of cardiac operative risk may often be necessary but unfortunately standard imaging techniques are often suboptimal in these subjects. The purpose of this study was to demonstrate the feasibility, safety and utility of transesophageal dobutamine stress echocardiography (TE-DSE) using an adapted accelerated dobutamine infusion protocol in severely obese subjects with comorbidities being evaluated for bariatric surgery for assessing the presence of myocardial ischemia.
Subjects with severe obesity [body mass index (BMI) >40 kg/m2] with known or suspected CAD and being evaluated for bariatric surgery were recruited.
Twenty subjects (9M/11F), aged 50 +/- 8 years (mean +/- SD), weighing 141 +/- 21 kg and with a BMI of 50 +/- 5 kg/m2 were enrolled in the study and underwent a TE-DSE. The accelerated dobutamine infusion protocol used was well tolerated. Eighteen (90%) subjects reached their target heart rate with a mean intubation time of 13 +/- 4 minutes. Mean dobutamine dose was 31.5 +/- 9.9 ug/kg/min while mean atropine dose was 0.5 +/- 0.3 mg. TE-DSE was well tolerated by all subjects without complications including no significant arrhythmia, hypotension or reduction in blood arterial saturation. Two subjects had abnormal TE-DSE suggestive of myocardial ischemia. All patients underwent bariatric surgery with no documented cardiovascular complications.
TE-DSE using an accelerated infusion protocol is a safe and well tolerated imaging technique for the evaluation of suspected myocardial ischemia and cardiac operative risk in severely obese patients awaiting bariatric surgery. Moreover, the absence of myocardial ischemia on TE-DSE correlates well with a low operative risk of cardiac event.
Many of the metabolic benefits of Roux-en-Y gastric bypass (RYGB) occur before weight loss. In this study we investigated the influence of caloric restriction on the improvements in the metabolic responses that occur within the 1st week after RYGB. RESEARCH METHODS AND DESIGN: A mixed meal was administered to nine subjects before and after RYGB (average 4 +/- 0.5 days) and to nine matched, obese subjects before and after 4 days of the post-RYGB diet.
Weight loss in both groups was minimal; the RYGB subjects lost 1.4 +/- 5.3 kg (P = 0.46) vs. 2.2 +/- 1.0 kg (P = 0.004) in the calorically restricted group. Insulin resistance (homeostasis model assessment of insulin resistance) improved with both RYGB (5.0 +/- 3.1 to 3.3 +/- 2.1; P = 0.03) and caloric restriction (4.8 +/- 4.1 to 3.6 +/- 4.1; P = 0.004). The insulin response to a mixed meal was blunted in both the RYGB and caloric restriction groups (113 +/- 67 to 65 +/- 33 and 85 +/- 59 to 65 +/- 56 nmol x l(-1) x min(-1), respectively; P < 0.05) without a change in the glucose response. Glucagon-like peptide 1 levels increased (9.2 +/- 8.6 to 12.2 +/- 5.5 pg x l(-1) x min(-1); P = 0.04) and peaked higher (45.2 +/- 37.3 to 84.8 +/- 33.0 pg/ml; P = 0.01) in response to a mixed meal after RYGB, but incretin responses were not altered after caloric restriction.
These data suggest that an improvement in insulin resistance in the 1st week after RYGB is primarily due to caloric restriction, and the enhanced incretin response after RYGB does not improve postprandial glucose homeostasis during this time.
Bariatric surgery has emerged as an important tool in the fight against morbid obesity. However, reviewers have noted that there is a scarcity of long-term clinical surveillance data for bariatric surgery beyond 1-year follow-up and that a high percentage of patients are lost to follow-up, raising questions regarding the accuracy of current outcomes estimates. A meta-analysis of clinical reports providing bariatric surgery weight loss outcomes for morbidly obese patients was conducted over the period 2003-2007. Studies included were randomized controlled trials, nonrandomized controlled trials, and consecutive case series involving patients receiving either laparoscopic adjustable gastric banding (LAGB) or laparoscopic gastric bypass (LGB) surgery. Included studies involved n = 7,383 patients and were largely academic hospital-based (78.6%) and retrospective in design (71.4%). Weight loss outcome was defined by percent excess weight loss (%EWL). Composite estimates showed a significantly greater %EWL for LGB surgery (62.6%) compared to LAGB (49.4%). The superiority of LGB persisted at all three postsurgical time points examined (1, 2, and >3 years). Problems were identified regarding incomplete or suboptimal data reporting in many studies reviewed, and high patient attrition was evident at 2-year (49.8% LAGB, 75.2% LGB) and >3-year (82.6% LAGB, 89% LGB) end points. This meta-analysis confirms the superiority of LGB to LAGB in %EWL found in earlier studies. Although problems in study quality raised significant concerns regarding the validity of current weight loss estimates in this area, there was no evidence of publication bias.
To improve decision making in the treatment of extreme obesity, the risks of bariatric surgical procedures require further characterization.
We performed a prospective, multicenter, observational study of 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical sites in the United States from 2005 through 2007. A composite end point of 30-day major adverse outcomes (including death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; and failure to be discharged from the hospital) was evaluated among patients undergoing first-time bariatric surgery.
There were 4776 patients who had a first-time bariatric procedure (mean age, 44.5 years; 21.1% men; 10.9% nonwhite; median body-mass index [the weight in kilograms divided by the square of the height in meters], 46.5). More than half had at least two coexisting conditions. A Roux-en-Y gastric bypass was performed in 3412 patients (with 87.2% of the procedures performed laparoscopically), and laparoscopic adjustable gastric banding was performed in 1198 patients; 166 patients underwent other procedures and were not included in the analysis. The 30-day rate of death among patients who underwent a Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding was 0.3%; a total of 4.3% of patients had at least one major adverse outcome. A history of deep-vein thrombosis or pulmonary embolus, a diagnosis of obstructive sleep apnea, and impaired functional status were each independently associated with an increased risk of the composite end point. Extreme values of body-mass index were significantly associated with an increased risk of the composite end point, whereas age, sex, race, ethnic group, and other coexisting conditions were not.
The overall risk of death and other adverse outcomes after bariatric surgery was low and varied considerably according to patient characteristics. In helping patients make appropriate choices, short-term safety should be considered in conjunction with both the long-term effects of bariatric surgery and the risks associated with being extremely obese. (ClinicalTrials.gov number, NCT00433810.)
Introduction
Inflammation contributes to cardiovascular disease and is exacerbated with increased adiposity, particularly omental adiposity; however, the role of epicardial fat is poorly understood.
Methods
For these studies the expression of inflammatory markers was assessed in epicardial fat biopsies from coronary artery bypass grafting (CABG) patients using quantitative RT-PCR. Further, the effects of chronic medications, including statins, as well as peri-operative glucose, insulin and potassium infusion, on gene expression were also assessed. Circulating resistin, CRP, adiponectin and leptin levels were determined to assess inflammation.
Results
The expression of adiponectin, resistin and other adipocytokine mRNAs were comparable to that in omental fat. Epicardial CD45 expression was significantly higher than control depots (p < 0.01) indicating significant infiltration of macrophages. Statin treated patients showed significantly lower epicardial expression of IL-6 mRNA, in comparison with the control abdominal depots (p < 0.001). The serum profile of CABG patients showed significantly higher levels of both CRP (control: 1.28 ± 1.57 μg/mL vs CABG: 9.11 ± 15.7 μg/mL; p < 0.001) and resistin (control: 10.53 ± 0.81 ng/mL vs CABG: 16.8 ± 1.69 ng/mL; p < 0.01) and significantly lower levels of adiponectin (control: 29.1 ± 14.8 μg/mL vs CABG: 11.9 ± 6.0 μg/mL; p < 0.05) when compared to BMI matched controls.
Conclusion
Epicardial and omental fat exhibit a broadly comparable pathogenic mRNA profile, this may arise in part from macrophage infiltration into the epicardial fat. This study highlights that chronic inflammation occurs locally as well as systemically potentially contributing further to the pathogenesis of coronary artery disease.
Type 2 diabetes mellitus is associated with obesity, dyslipidemia, and hypertension, all well-known risk factors for cardiovascular disease. Surgical weight loss has resulted in a marked reduction of these risk factors in adults. We hypothesized that gastric bypass would improve parameters of metabolic dysfunction and cardiovascular risk in adolescents with type 2 diabetes mellitus.
Eleven adolescents who underwent Roux-en-Y gastric bypass at 5 centers were included. Anthropometric, hemodynamic, and biochemical measures and surgical complications were analyzed. Similar measures from 67 adolescents with type 2 diabetes mellitus who were treated medically for 1 year were also analyzed.
Adolescents who underwent Roux-en-Y gastric bypass were extremely obese (mean BMI of 50 +/- 5.9 kg/m(2)) with numerous cardiovascular risk factors. After surgery there was evidence of remission of type 2 diabetes mellitus in all but 1 patient. Significant improvements in BMI (-34%), fasting blood glucose (-41%), fasting insulin concentrations (-81%), hemoglobin A1c levels (7.3%-5.6%), and insulin sensitivity were also seen. There were significant improvements in serum lipid levels and blood pressure. In comparison, adolescents with type 2 diabetes mellitus who were followed during 1 year of medical treatment demonstrated stable body weight (baseline BMI: 35 +/- 7.3 kg/m(2); 1-year BMI: 34.9 +/- 7.2 kg/m(2)) and no significant change in blood pressure or in diabetic medication use. Medically managed patients had significantly improved hemoglobin A1c levels over 1 year (baseline: 7.85% +/- 2.3%; 1 year: 7.1% +/- 2%).
Extremely obese diabetic adolescents experience significant weight loss and remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass. Improvements in insulin resistance, beta-cell function, and cardiovascular risk factors support Roux-en-Y gastric bypass as an intervention that improves the health of these adolescents. Although the long-term efficacy of Roux-en-Y gastric bypass is not known, these findings suggest that Roux-en-Y gastric bypass is an effective option for the treatment of extremely obese adolescents with type 2 diabetes mellitus.
Context.—It has become increasingly evident that adipose tissue is a multifunctional organ that produces and secretes multiple paracrine and endocrine factors. Research into obesity, insulin resistance, and diabetes has identified a proinflammatory state associated with obesity. Substantial differences between subcutaneous and omental fat have been noted, including the fact that omental fat produces relatively more inflammatory cytokines. Periadventitial fat, as a specific adipose tissue subset, has been overlooked in the field of atherosclerosis despite its potential diagnostic and therapeutic implications.
Objective.—To review (1) evidence for the role of adventitial and periadventitial fat in vessel remodeling after injury, (2) the relationship between adventitial inflammation and atherosclerosis, (3) the association between periadventitial fat and plaque inflammation, and (4) the diagnostic and therapeutic implications of these roles and relationships for the progression of atherosclerosis.
Data Sources.—We present new data showing greater uptake of iron, administered in the form of superparamagnetic iron oxide, in the periadventitial fat of atherosclerotic mice than in control mice. In addition, macrophage density in the periadventitial fat of lipid-rich plaques is increased compared with fibrocalcific plaques.
Conclusions.—There is a striking paucity of data on the relationship between the periadventitial fat of coronary arteries and atherosclerosis. Greater insight into this relationship might be instrumental in making strides into the pathophysiology, diagnosis, and treatment of coronary artery disease.
The Medicare Coverage Advisory Committee recently concluded that evidence supports the safety and effectiveness of bariatric surgery in the general adult population. However, more information is needed on the role of bariatric surgery in the elderly. The aim of this study was to examine the outcome of bariatric surgery in the elderly performed at academic centers. Using International Classification of Diseases, 9th Revision diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all elderly (>60 years) and nonelderly (19–60 years) patients who underwent bariatric surgery for the treatment of morbid obesity between 1999 and 2005. Outcome measures, including patient characteristics, length of stay, 30-day readmission, morbidity, and observed and expected (risk-adjusted) mortality, were compared between groups. Bariatric surgery in the elderly represents 2.7 per cent (n = 1,339) of all bariatric operations being performed at academic centers. Of the 99 University HealthSystem Consortium centers performing bariatric surgery, 78 centers (79%) perform bariatric surgery in the elderly. Compared with nonelderly patients, elderly patients who underwent bariatric surgery had more comorbidities, longer lengths of stay (4.9 days vs 3.8 days, P < 0.01), more overall complications (18.9% vs 10.9%, P < 0.01), pulmonary complications (4.3% vs 2.3%, P < 0.01), hemorrhagic complications (2.5% vs 1.5%, P < 0.01), and wound complications (1.7% vs 1.0%). The in-hospital mortality rate was also higher in the elderly group (0.7% vs 0.3%, P = 0.03). When risk adjusted, the observed-to-expected mortality ratio for the elderly group was 0.9. In a subset of elderly patients with a pre-existing cardiac condition (n = 236), the in-hospital mortality was 4.7 per cent. Bariatric surgery in the elderly represents only a small fraction of the number of bariatric operations performed at academic centers. Although the morbidity and mortality is higher in the elderly, bariatric surgery in the elderly is considered as safe as other gastrointestinal procedures because the observed mortality is better than the expected (risk-adjusted) mortality.
The Medicare Coverage Advisory Committee recently concluded that evidence supports the safety and effectiveness of bariatric surgery in the general adult population. However, more information is needed on the role of bariatric surgery in the elderly. The aim of this study was to examine the outcome of bariatric surgery in the elderly performed at academic centers. Using International Classification of Diseases, 9th Revision diagnosis and procedure codes, we obtained data from the University HealthSystem Consortium Clinical Data Base for all elderly (> 60 years) and nonelderly (19-60 years) patients who underwent bariatric surgery for the treatment of morbid obesity between 1999 and 2005. Outcome measures, including patient characteristics, length of stay, 30-day readmission, morbidity, and observed and expected (risk-adjusted) mortality, were compared between groups. Bariatric surgery in the elderly represents 2.7 per cent (n = 1,339) of all bariatric operations being performed at academic centers. Of the 99 University HealthSystem Consortium centers performing bariatric surgery, 78 centers (79%) perform bariatric surgery in the elderly. Compared with nonelderly patients, elderly patients who underwent bariatric surgery had more comorbidities, longer lengths of stay (4.9 days vs 3.8 days, P < 0.01), more overall complications (18.9% vs 10.9%, P < 0.01), pulmonary complications (4.3% vs 2.3%, P < 0.01), hemorrhagic complications (2.5% vs 1.5%, P < 0.01), and wound complications (1.7% vs 1.0%). The in-hospital mortality rate was also higher in the elderly group (0.7% vs 0.3%, P = 0.03). When risk adjusted, the observed-to-expected mortality ratio for the elderly group was 0.9. In a subset of elderly patients with a pre-existing cardiac condition (n = 236), the in-hospital mortality was 4.7 per cent. Bariatric surgery in the elderly represents only a small fraction of the number of bariatric operations performed at academic centers. Although the morbidity and mortality is higher in the elderly, bariatric surgery in the elderly is considered as safe as other gastrointestinal procedures because the observed mortality is better than the expected (risk-adjusted) mortality.
Background: Obesity is a major, growing health problem. Observational studies suggest that bariatric surgery is more effective than nonsurgical therapy, but no randomized, controlled trials have confirmed this. Objective: To ascertain whether surgical therapy for obesity achieves better weight loss, health, and quality of life than nonsurgical therapy. Design: Randomized, controlled trial. Setting: University departments of medicine and surgery and an affiliated private hospital. Patients: 80 adults with mild to moderate obesity (body mass index, 30 kg/m 2 to 35 kg/m 2 ) from the general community. Interventions: Patients were assigned to a program of very-low-calorie diets, pharmacotherapy, and lifestyle change for 24 months (nonsurgical group) or to placement of a laparoscopic adjustable gastric band (LAP-BAND System, INAMED Health, Santa Barbara, California) (surgical group). Measurements: Outcome measures were weight change, presence of the metabolic syndrome, and change in quality of life at 2 years. Results: At 2 years, the surgical group had greater weight loss, with a mean of 21.6% (95% Cl, 19.3% to 23.9%) of initial weight lost and 87.2% (Cl, 77.7% to 96.6%) of excess weight lost, while the nonsurgical group had a loss of 5.5% (Cl, 3.2% to 7.9%) of initial weight and 21.8% (Cl, 11.9% to 31.6%) of excess weight (P< 0.001). The metabolic syndrome was initially present in 15 (38%) patients in each group and was present in 8 (24%) nonsurgical patients and 1 (3%) surgical patient at the completion of the study (P < 0.002). Quality of life improved statistically significantly more in the surgical group (8 of 8 subscores of Short Form-36) than in the nonsurgical group (3 of 8 subscores). Limitations: The study included mildly and moderately obese participants, was not powered for comparison of adverse events, and examined outcomes only for 24 months. Conclusions: Surgical treatment using laparoscopic adjustable gastric banding was statistically significantly more effective than nonsurgical therapy in reducing weight, resolving the metabolic syndrome, and improving quality of life during a 24-month treatment program.
Obesity produces an increase in total blood volume and cardiac output because of the high metabolic activity of excessive fat. In moderate to severe cases of obesity, this may lead to left ventricular dilation, increased left ventricular wall stress, compensatory (eccentric) left ventricular hypertrophy, and left ventricular diastolic dysfunction. Left ventricular systolic dysfunction may occur if wall stress remains high because of inadequate hypertrophy. Right ventricular structure and function may be similarly affected by the aforementioned morphologic and hemodynamic alterations and by pulmonary hypertension related to the sleep apnea/obesity hypoventilation syndrome. The term obesity cardiomyopathy is applied when these cardiac structural and hemodynamic changes result in congestive heart failure. Obesity cardiomyopathy typically occurs in persons with severe and long-standing obesity. The predominant causes of death in those with obesity cardiomyopathy are progressive congestive heart failure and sudden cardiac death.
▪ Surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists, and other health care professionals, as well as members of the public convened to address nonsurgical treatments for severe obesity, surgical treatments for severe obesity, and criteria for selection, the efficacy, and risks of surgical treatments for severe obesity, and the need for future research on and epidemiologic evaluation of these therapies.
The National Institutes of Health Consensus Development Panel recommended that patients seeking therapy for severe obesity for the first time should be considered for treatment in a nonsurgical program that integrates a dietary regimen, appropriate exercise, behavior modification, and psychological support; that gastric restrictive or bypass procedures could be considered for well-informed and motivated patients in whom the operative risks were acceptable; that patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise; that surgery be done by a surgeon who has substantial experience in the particular procedure and who works in a clinical setting with adequate support for all aspects of management and assessment; and that patients undergo lifelong medical surveillance after surgery.
ACSM Position Stand on the Appropriate Intervention Strategies for Weight Loss and Prevention of Weight Regain for Adults. Med. Sci. Sports Exerc., Vol. 33, No. 12, 2001, pp. 2145–2156. In excess of 55% of adults in the United States are classified as either overweight (body mass index = 25–29.9 kg·m−2) or obese (body mass index ≥ 30 kg·m−2). To address this significant public health problem, the American College of Sports Medicine recommends that the combination of reductions in energy intake and increases in energy expenditure, through structured exercise and other forms of physical activity, be a component of weight loss intervention programs. An energy deficit of 500–1000 kcal·d−1 achieved through reductions in total energy intake is recommended. Moreover, it appears that reducing dietary fat intake to <30% of total energy intake may facilitate weight loss by reducing total energy intake. Although there may be advantages to modifying protein and carbohydrate intake, the optimal doses of these macronutritents for weight loss have not been determined. Significant health benefits can be recognized with participation in a minimum of 150 min (2.5 h) of moderate intensity exercise per week, and overweight and obese adults should progressively increase to this initial exercise goal. However, there may be advantages to progressively increasing exercise to 200–300 min (3.3–5 h) of exercise per week, as recent scientific evidence indicates that this level of exercise facilitates the long-term maintenance of weight loss. The addition of resistance exercise to a weight loss intervention will increase strength and function but may not attenuate the loss of fat-free mass typically observed with reductions in total energy intake and loss of body weight. When medically indicated, pharmacotherapy may be used for weight loss, but pharmacotherapy appears to be most effective when used in combination with modifications of both eating and exercise behaviors. The American College of Sports Medicine recommends that the strategies outlined in this position paper be incorporated into interventions targeting weight loss and the prevention of weight regain for adults.
The diagnosis of fatty heart was frequently made by clinicians in the past generation, but in recent years investigators have, to a large extent, avoided the problem. Considerable confusion has arisen from the use of such terms as fatty degeneration, fatty infiltration, fatty metamorphosis, adiposity of the heart (cor adiposum or adipositas cordis) and obesity of the heart.In the past, two distinct conditions have commonly been confused, and both have been alluded to as fatty heart. These are (1) the state in which there is an abnormal increase in the amount of fat in the subepicardial connective tissue and in which penetration or infiltration of fat into the connective tissue lying between the muscle bundles and the muscle fibers takes place and (2) the state in which fatty changes take place within the cell (cytoplasm) and which most pathologists1 believe to be the result of a diminished utilization
The term myocardial bridge (MB) describes the surprisingly common situation in which part of the left anterior descending coronary artery (LAD), running in epicardial adipose tissue, is covered by a bridge of myocardial tissue. The presence of an MB may influence arterial tissue through the alteration of haemodynamic forces by the myocardial contraction of the bridge itself. Histopathologically and ultrastructurally, any manifestations of atherosclerosis elsewhere in the LAD are suppressed in the intima beneath the MB. By scanning electron microscopy, abrupt changes in endothelial cell morphology indicate that the intima beneath the bridge is protected by haemodynamic factors. Furthermore, the closer the bridge to the left coronary ostium, the greater the extent of proximal intimal thickening. In parallel with this, considering the occurrence of myocardial infarction in cases of proximal MB together with previous reports on relationships between MB and coronary ischaemia, it appears that anatomical characteristics such as the location, length, and thickness of the MB have a bearing on the effects of this abnormality. When the pathologist examines the heart at autopsy, this quite common condition should be borne in mind, in view of its potential but complex relationship to atherosclerosis and ischaemic heart disease. © 1998 John Wiley & Sons, Ltd.
ABSTRACT Electrocardiograms, serum electrolytes, plasma concentrations of pre-albumin and retinol-binding globulin, and dietary intakes were analyzed in 22 women during weight loss after gastroplasty surgery for morbid obesity. QT interval corrected for heart rate (QTc) was prolonged (>0.44 sec) in 32% (95% confidence limits 14–55%) on one or more occasions. No clinical or electrocardiographic complications were seen. Occurrence of QTc prolongation was significantly (p<0.05) associated with protein intake below recommendation and with low plasma pre-albumin concentrations. QTc prolongation was not associated with mineral intake and occurred in spite of normal serum levels of calcium (uncorrected and albumin-corrected), magnesium, potassium and sodium. Because QTc prolongation may precede fatal arrhythmias, adequate protein intake is mandatory during weight reduction.
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.
In an attempt to improve the results of biliopancreatic diversion in the treatment of morbid obesity, two aspects of the procedure
performed at Laval Hospital were modified to reduce adverse physiological consequences. The distal gastrectomy was replaced
by a parietal gastrectomy which preserves vagal continuity along with the lesser curvature, and leaves intact the antro-pyloro-duodenal
pump. The duodenum was stapled shut and nutrients were diverted through a duodeno-ileal anastomosis. The biliopancreatic diverting
intestinal limb was anastomosed to the nutrient ileal limb 100 cm proximal to the ileocaecal valve instead of 50 cm proximal
to it, thus doubling the length of the common ileal absorptive segment. Weight loss after either operation was greater than
70% of initial excess weight. Following the new operation, there was a lesser prevalence of side-effects, especially loose
stools and malodorous gas, a lesser degree of hypocalcemia and no hypoalbuminemia. The duodenum recanalized at the staple
line in 20% of the patients who had the new operation. When data from these patients were excluded, weight loss following
the new operation was greater than that seen after the old one. The prevalence of side-effects and the degree of calcium and
protein malabsorption remained significantly lower. Weight loss remained satisfactory with a common limb measuring 100 cm.
The parietal gastrectomy was not restrictive as shown by the failure to lose further weight when the duodenal stapled diversion
failed. Weight loss was thus mainly a function of biliopancreatic diversion, but increased weight loss in the new procedure
despite a doubling of the common ileal limb suggests that parietal gastrectomy contributed to weight loss. Because duodenal
recanalization can be corrected surgically and now prevented, the modified biliopancreatic bypass is preferred.
p
< 0.01) and systemic blood pressure (
p
< 0.05). Weight loss with GBP was also associated with significant reductions in the apoprotein B-containing lipoproteins
and the triglyceride and cholesterol composition of these particles. There was a trend (
p
< 0.10) toward increased serum levels of high density lipoprotein (HDL)-cholesterol following GBP, and significant (
p
< 0.05) improvement in HDL subfraction distribution and composition. These findings demonstrate the effectiveness of GBP
in inducing metabolic changes in the MO population, which may reduce the risk of coronary artery disease, diabetes, and hypertension.
Of 232 morbidly obese patients with non-insulin-dependent diabetes mellitus referred to East Carolina University between March
5, 1979, and January 1, 1994, 154 had a Roux-en-Y gastric bypass operation and 78 did not undergo surgery because of personal
preference or their insurance company's refusal to pay for the procedure. The surgical and the nonoperative (control) groups
were comparable in terms of age, weight, body mass index, sex, and percentage with hypertension. The two groups were compared
retrospectively to determine differences in survival and the need for medical management of their diabetes. Mean length of
follow-up was 9 years in the surgical group and 6.2 years in the control group. The mean glucose levels in the surgical group
fell from 187 mg/dl preoperatively and remained less than 140 mg/dl for up to 10 years of follow-up. The percentage of control
subjects being treated with oral hypoglycemics or insulin increased from 56.4% at initial contact to 87.5% at last contact,
(P=0.0003), whereas the percentage of surgical patients requiring medical management fell from 31.8% preoperatively to 8.6%
at last contact (P=0.0001). The mortality rate in the control group was 28% compared to 9% in the surgical group (including perioperative deaths).
For every year of follow-up, patients in the control group had a 4.5% chance of dying vs. a 1.0% chance for those in the surgical
group. The improvement in the mortality rate in the surgical group was primarily due to a decrease in the number of cardiovascular
deaths.
Over 23 million Americans are afflicted with severe obesity, i.e. their body mass index (in kilograms per square meter) values exceed 35. Of even greater concern is the association of the adiposity with comorbidities such as diabetes, hypertension, cardiopulmonary failure, asthma, pseudotumor cerebri, infertility, and crippling arthritis.
Diets, exercise, behavioral modification, and drugs are not effective in these individuals. This article examines the effect of surgery on the control of the weight and the comorbidities, as well as the safety of these operations.
Although the article focuses on the outcomes of the three most commonly performed operations, i.e. adjustable gastric banding, the gastric bypass, and the biliopancreatic bypass with duodenal switch, it aims for perspective with the inclusion of abandoned and current investigational procedures, a review of the complications, and an emphasis on the appropriate selection of patients. POSITIONS: Ample evidence, including controlled randomized studies, now document that bariatric surgery produces durable weight loss exceeding 100 lb (46 kg), full and long-term remission of type 2 diabetes in over 80% with salutary effects on the other comorbidities as well with significant reductions in all-cause mortality. Although the severely obese present with serious surgical risks, bariatric surgery is performed safely with a 0.35% 90-d mortality in Centers of Excellence throughout the United States-similar to the complication rates after cholecystectomy.
Until better approaches become available, bariatric surgery is the therapy of choice for patients with severe obesity.
Previously we showed that peripheral neuropathy occurs after bariatric surgery and was associated with malnutrition (mainly sensory polyneuropathy). This study asks whether a multidisciplinary approach to bariatric surgery lowers risk for developing peripheral neuropathy. We performed a retrospective cohort study of all patients with bariatric surgery at the Mayo Clinic between 1985 and 2002. Patients underwent intensive nutritional management before and after surgery. Potential risk factors were analyzed using life-table methods (Cox regression). Univariate analysis showed the following risk factors: increased serum glycosylated hemoglobin and triglycerides, prolonged hospitalization, postoperative gastrointestinal symptoms, and nausea and vomiting. Peripheral neuropathy occurred less frequently (7% vs. 13%, P < 0.01) and specifically the sensory polyneuropathy subtype (1% vs. 7%, P < 0.0001) than in our prior cohort. A systematic, multidisciplinary approach of intensive nutritional management before and after surgery with frequent follow-up greatly decreased development of peripheral neuropathy (especially sensory polyneuropathy) in patients receiving bariatric surgery.
Bariatric surgery has become a common treatment for morbid obesity. The relative changes in body tissue that comprise the substantial weight loss over time are not completely understood.
We evaluated the differential rates of fat and lean tissue losses in morbidly obese patients who underwent Roux-en-Y gastric bypass surgery. Body composition was assessed using whole-body dual energy X-ray absorptiometry (DXA) performed at two timepoints in the postoperative period. Patients were stratified by the tertile of rapidity of weight loss expressed as percent reduction in body mass index per month.
Thirty two patients (25 women, 7 men) with a mean age of 46.7 +/- 10.4 years and an average initial body weight of 141.4 +/- 29.4 kg experienced a 52.3 +/- 16.6 kg (36.5 +/- 5.5%) weight loss over 13.9 +/- 6.0 months. The incremental rates of lean body mass loss by tertiles were 0.3 +/- 0.6, 0.5 +/- 0.2, and 1.0 +/- 0.8 kg/month (P = 0.02), whereas the rates of fat loss were 1.2 +/- 0.9, 1.8 +/- 0.4, and 2.9 +/- 1.0 kg/month (P = 0.0001). The ratios for lean to fat loss among the respective tertiles were 1:4.0, 1:3.6, and 1:3.0. The correlation between rates of lean and fat mass loss was r = 0.37 (P = 0.04). Only three of the 32 patients (9.4%) patients maintained or gained lean mass following Roux-en-Y gastric bypass surgery.
After bariatric surgery, those patients losing weight at the greatest rate appear to have accelerated losses of both lean and fat mass. Few patients maintain lean body mass after bariatric surgery, despite self-reported participation in conventional exercise programs. These data suggest the need for more aggressive interventions to preserve lean body mass during the weight loss phase after Roux-en-Y gastric bypass surgery.
‘Traditional’ risk factors such as hypertension, elevated cholesterol, smoking, and diabetes have long been linked to cardiovascular disease (CVD). However, although remarkable progress has been made in the management of these classical CVD risk factors, obesity, the metabolic syndrome, and type 2 diabetes have reached such epidemic proportions that CVD remains a major cause of morbidity and mortality worldwide. As obesity rates soar, more and more patients are developing additional metabolic abnormalities that raise their CVD risk. Though obesity’s health hazards are well documented, physicians are sometimes perplexed by the absence of complications in some very obese patients. Equally perplexing is the fact that some moderately overweight individuals are characterized by a whole cluster of atherogenic and diabetogenic metabolic abnormalities. Because body mass index (BMI) provides little information about the location of body fat, calculating BMI as the ratio of weight over height-squared is therefore only useful as an initial step towards crudely classifying patients based on their relative weight. In this regard, numerous studies in the last two decades have confirmed that a high amount of abdominal fat, intra-abdominal (or visceral) adipose tissue in particular, is linked to a cluster of emerging metabolic risk factors/markers that may increase the risk of type 2 diabetes, CVD, and related mortality beyond excess body weight. The scientific and medical community’s recent recognition of abdominal obesity (especially the form characterized by excess visceral/ectopic fat) as the most prevalent form of the clustering atherothrombotic-inflammatory abnormalities associated with insulin resistance is an important conceptual advance with very significant clinical and public health implications. However, yet to be resolved is the extent to which the specific clustering abnormalities of visceral obesity increase overall CVD and type 2 diabetes risk estimated by traditional risk factors. There is evidence to suggest that current risk assessment algorithms may not accurately estimate the global CVD risk in patients with visceral obesity. In light of this, better methods are needed to assess the global risk of CVD and type 2 diabetes in the presence of traditional risk factors and emerging markers found in individuals with excess intra-abdominal adiposity and a ‘dysfunctional’ adipose tissue phenotype. This global risk is defined as cardiometabolic risk.
Obesity is associated with comorbidities that may lead to disability and death. During the past 20 years, the number of individuals with a body mass index >30, 40, and 50 kg/m(2), respectively, has doubled, quadrupled, and quintupled in the United States. The risk of developing comorbid conditions rises with increasing body mass index. Possible cardiac symptoms such as exertional dyspnea and lower-extremity edema occur commonly and are nonspecific in obesity. The physical examination and electrocardiogram often underestimate cardiac dysfunction in obese patients. The risk of an adverse perioperative cardiac event in obese patients is related to the nature and severity of their underlying heart disease, associated comorbidities, and the type of surgery. Severe obesity has not been associated with increased mortality in patients undergoing cardiac surgery but has been associated with an increased length of hospital stay and with a greater likelihood of renal failure and prolonged assisted ventilation. Comorbidities that influence the preoperative cardiac risk assessment of severely obese patients include the presence of atherosclerotic cardiovascular disease, heart failure, systemic hypertension, pulmonary hypertension related to sleep apnea and hypoventilation, cardiac arrhythmias (primarily atrial fibrillation), and deep vein thrombosis. When preoperatively evaluating risk for surgery, the clinician should consider age, gender, cardiorespiratory fitness, electrolyte disorders, and heart failure as independent predictors for surgical morbidity and mortality. An obesity surgery mortality score for gastric bypass has also been proposed. Given the high prevalence of severely obese patients, this scientific advisory was developed to provide cardiologists, surgeons, anesthesiologists, and other healthcare professionals with recommendations for the preoperative cardiovascular evaluation, intraoperative and perioperative management, and postoperative cardiovascular care of this increasingly prevalent patient population.
Limited evidence suggests bariatric surgery can result in high cure rates for obstructive sleep apnea (OSA) in the morbidly obese. We performed a systematic review and meta-analysis to identify the effects of surgical weight loss on the apnea-hypopnea index.
Relevant studies were identified by computerized searches of MEDLINE and EMBASE (from inception to March 17, 2008), and review of bibliographies of selected articles. Included studies reported results of polysomnographies performed before and at least 3 months after bariatric surgery. Data abstracted from each article included patient characteristics, sample size who underwent both preoperative and postoperative polysomnograms, types of bariatric surgery performed, results of preoperative and postoperative measures of OSA and body mass index, publication year, country of origin, trial perspective (prospective vs retrospective), and study quality.
Twelve studies representing 342 patients were identified. The pooled mean body mass index was reduced by 17.9 kg/m(2) (95% confidence interval [CI], 16.5-19.3) from 55.3 kg/m(2) (95% CI, 53.5-57.1) to 37.7 kg/m(2) (95% CI, 36.6-38.9). The random-effects pooled baseline apnea hypopnea index of 54.7 events/hour (95% CI, 49.0-60.3) was reduced by 38.2 events/hour (95% CI, 31.9-44.4) to a final value of 15.8 events/hour (95% CI, 12.6-19.0).
Bariatric surgery significantly reduces the apnea hypopnea index. However, the mean apnea hypopnea index after surgical weight loss was consistent with moderately severe OSA. Our data suggest that patients undergoing bariatric surgery should not expect a cure of OSA after surgical weight loss. These patients will likely need continued treatment for OSA to minimize its complications.
The objective of this study is to update evidence-based best practice guidelines for multidisciplinary care of weight loss surgery (WLS) patients. We performed systematic search of English-language literature on WLS, patient selection, and medical, multidisciplinary, and nutritional care published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. Key words were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. A total of 150 papers were retrieved from the literature search and 112 were reviewed in detail. We made evidence-based best practice recommendations from the most recent literature on multidisciplinary care of WLS patients. New recommendations were developed in the areas of patient selection, medical evaluation, and treatment. Regular updates of evidence-based recommendations for best practices in multidisciplinary care are required to address changes in patient demographics and levels of obesity. Key factors in patient safety include comprehensive preoperative medical evaluation, patient education, appropriate perioperative care, and long-term follow-up.
To compare outcomes of patients undergoing bariatric procedures in hospitals designated as centers of excellence compared with nondesignated hospitals.
The 2005 National Inpatient Survey was used to compare outcomes at designated vs nondesignated hospitals. In addition to conventional null-hypothesis statistical testing to assess differences, effect sizes were calculated to estimate the clinical significance for observed differences.
Centers of excellence performed substantially more operations than nondesignated centers. Despite this, outcomes were equivalent at centers of excellence and hospitals without this designation. Volume-outcome modeling attempting to identify the optimal number for a minimum volume threshold for bariatric operations revealed that annual procedure volume has a weak effect on outcomes. Similarly, many variables that were statistically significantly different between centers and noncenters proved to be clinically unimportant by effect size analysis. Risk adjustment was effectively achieved by using the Agency for Healthcare Research and Quality-supplied variables all-payer severity-adjusted diagnostic related group expected charges and deaths.
Designation as a bariatric surgery center of excellence does not ensure better outcomes. Neither does high annual procedure volume. Extra expenses associated with center of excellence designation may not be warranted.
Sedentary lifestyles and poor physical fitness are major contributors to the current obesity and cardiovascular disease pandemic.
Daily physical activity and cardiorespiratory fitness are correlated in morbidly obese individuals in their free-living environment.
Ten morbidly obese participants continuously wore an activity sensor that measured caloric expenditure, minute-by-minute physical activity, and steps/day over a 72-h period. Following collection of the device data, structured cardiorespiratory fitness testing was performed on each subject.
Mean caloric expenditure for all individuals was 2,668+/-481 kcal/d. On average, subjects took 3,763+/-2,223 steps. On average 23 h and 51.6 min per d were spent sleeping or engaged in sedentary activity (<3 metabolic equivalents [METs]) and the remaining 8.4 min were spent in moderate activity (3-6 METs). Average peak VO2 was 16.8+/-4.7 mL/kg/min. Higher peak VO2 correlated with higher total caloric expenditure (TCE; r=0.628, p=0.05) and trended with higher steps/day (r=0.591, p=0.07).
Most morbidly obese participants in this study were markedly sedentary. These study results may provide important links between obesity, poor fitness, and cardiovascular disease.
Although Roux-en-Y gastric bypass (RYGBP) is one of the preferred bariatric procedures in obese individuals, the efficacy of this procedure in the setting of super-obesity [body mass index (BMI) >/=50] is unclear. The aim of this study was to compare the efficacy of laparoscopic (L) RYGBP to reverse metabolic syndrome, inflammation, and insulin resistance in super-obese women compared to morbidly obese women.
Seventy-three consecutive women were enrolled in this prospective study. Anthropometric, metabolic, and inflammatory biological parameters were assessed in 18 super-obese and 55 morbidly obese women before LRYGBP and 1 year after surgery. Metabolic syndrome was diagnosed according to the International Diabetes Federation definition.
Before surgery, super-obese women had a higher BMI, fat mass, blood insulin, and HOMA1-IR than morbidly obese women. Both groups had similar serum levels of C-reactive protein and orosomucoid. The incidence of metabolic syndrome, type 2 diabetes, and increased liver enzymes was comparable in the two groups. One year after LRYGBP, metabolic syndrome, type 2 diabetes, metabolic and inflammatory biological parameters were improved in the whole study population. A similar degree of improvement was observed in super-obese and morbidly obese women, although BMI and fat mass were persistently higher in super-obese patients.
One year after surgery, LRYGBP was equally effective at reversing metabolic syndrome, inflammation, and insulin resistance in morbidly obese and super-obese women.
Epidemiological evidence suggests that obesity has become a global pandemic with significant implications to public health. First, it affects virtually all ages and socioeconomic groups; second, it has become a major contributor to the international burden of chronic illness, including diseases of the cardiovascular system. According to the World Health Organization, an estimated 1.6 billion adults globally were overweight (body mass index [BMI] >25 kg/m2) and at least 400 million were obese (BMI >30 kg/m2) in 2005. Statistical projections indicate that these figures will continue to rise, so that by 2015 ≈2.3 billion adults will be overweight and >700 million will be obese.1
Traditional treatments to achieve weight loss such as diet, lifestyle, and behavioral therapy have proven relatively ineffective in treating obesity and associated cardiovascular risk factors in the long term, especially when used in isolation, but have demonstrated some metabolic and cardiovascular benefits when they are used together as combination strategies.2 It is important to note that these treatments have been specifically ineffective on the morbidly obese subgroup of patients (BMI >40 kg/m2) and have led to development of operations in the form of “bariatric surgery” to treat obesity and its comorbidities. Surgery for the treatment of morbid obesity can be offered according to guidelines established by the National Institutes of Health (United States) and the National Institute for Clinical Excellence (United Kingdom). Herein, we explore the potential role of bariatric surgery in the treatment and prevention of obesity-related cardiac disease, examining the associations and potential pathophysiological mechanisms through which both obesity and cardiac disease can be modified by bariatric operations.
The term bariatric surgery refers to all surgical procedures utilized to achieve reduction of excess weight. The most widely accepted indication for bariatric operations currently includes patients seen in a multidisciplinary specialist …
The purpose of this study was to determine whether pre- to postoperative increases in physical activity (PA) are associated with weight loss and health-related quality of life (HRQoL) following bariatric surgery. Participants were 199 Roux-en-Y gastric bypass (RYGB) surgery patients. The International Physical Activity Questionnaire (IPAQ) was used to categorize participants into three groups according to their preoperative and /1-year postoperative PA level: (i) Inactive/Active (<200-min/week/>or=200-min/week), (ii) Active/Active (>or=200-min/week/>or=200-min/week) and (iii) Inactive/Inactive (<200-min/week/<200-min/week). The Medical Outcomes Study Short Form-36 (SF-36) was used to assess HRQoL. Analyses of covariance were conducted to examine the effects of PA group on weight and HRQoL changes. Inactive/Active participants, compared with Inactive/Inactive individuals, had greater reductions in weight (52.5 +/- 15.4 vs. 46.4 +/- 12.8 kg) and BMI (18.9 +/- 4.6 vs. 16.9 +/- 4.2 kg/m(2)). Weight loss outcomes in the Inactive/Active and Active/Active groups were similar to each other. Inactive/Active and Active/Active participants reported greater improvements than Inactive/Inactive participants on the mental component summary (MCS) score and the general health, vitality and mental health domains (P < 0.01). Although the direction of causation is not clear, these findings suggest that RYGB patients who become active postoperatively achieve weight losses and HRQoL improvements that are greater than those experienced by patients who remain inactive and comparable to those attained by patients who stay active. Future randomized controlled trials should examine whether assisting patients who are inactive preoperatively to increase their PA postoperatively contributes to optimization of weight loss and HRQoL outcomes.
Despite its overall excellent outcomes, weight loss after Roux-en-Y gastric bypass (RYGB) is highly variable. We conducted this study to identify clinical predictors of weight loss after RYGB. We reviewed charts from 300 consecutive patients who underwent RYGB from August 1999 to November 2002. Data collected included patient demographics, medical comorbidities, and diet history. Of the 20 variables selected for univariate analysis, 9 with univariate P values <or= 0.15 were entered into a multivariable regression analysis. Using backward selection, covariates with P < 0.05 were retained. Potential confounders were added back into the model and assessed for effect on all model variables. Complete records were available for 246 of the 300 patients (82%). The patient characteristics were 75% female, 93% white, mean age of 45 years, and mean initial BMI of 52.3 kg/m(2). One year after surgery, patients lost an average of 64.8% of their excess weight (s.d. = 20.5%). The multivariable regression analysis revealed that limited physical activity, higher initial BMI, lower educational level, diabetes, and decreased attendance at postoperative appointments had an adverse effect on weight loss after RYGB. A model including these five factors accounts for 41% of the observed variability in weight loss (adjusted r(2) = 0.41). In this cohort, higher initial BMI and limited physical activity were the strongest predictors of decreased excess weight loss following RYGB. Limited physical activity may be particularly important because it represents an opportunity for potentially meaningful pre- and postsurgical intervention to maximize weight loss following RYGB.
Bariatric surgery achieves long-term weight loss in obese adults with amelioration of diabetes and hypertension. Improvement in albuminuria and high-sensitivity C-reactive protein (hs-CRP) has also been reported. We investigated, at a weight control center in a community hospital setting, the relation between degree of surgical weight loss and reduction in the cardiovascular risk markers, albuminuria and hs-CRP.
We performed a retrospective study of 62 obese adults who had undergone Roux-en-Y gastric bypass surgery and had a median follow-up of 15 months.
The baseline (preoperative) mean age was 46 years, 82% were women, 26 had a blood pressure of > or =140/90 mm Hg, and 25 had type 2 diabetes. During follow-up (postoperative), a decrease occurred in the body mass index (mean +/- standard deviation 49.2 +/- 8.7 kg/m(2) to 34.1 +/- 8.1 kg/m(2); P <.0001), excess body weight (mean +/- SD 76.1 +/- 23.6 kg to 34.9 +/- 21.7 kg; P <.0001), hemoglobin A1c (mean +/- SD 6.5% +/- 1.3% to 5.6% +/- 0.8%; P <.0001), systolic blood pressure (mean +/- SD 133.7 +/- 14.3 mm Hg to 112.9 +/- 14.6 mm Hg; P < .0001), urine albumin creatinine ratio (from a median of 8.0 mg/g [interquartile range 5.0-29.3] to a median of 6.0 mg/g [interquartile range 3.3-11.5]; P <.0001), and hs-CRP (mean +/- SD 11.2 +/- 9.8 mg/L to 4.7 +/- 5.9 mg/L; P <.0001). The study sample was divided into tertiles of the percentage of excess body weight loss; the mean percentage of excess body weight loss was -37.1% +/- 5.5% in the first tertile, -54.3% +/- 6.8% in the second tertile, and -75.8% +/- 10.9% in the third tertile. The median percentage of change in albuminuria was greatest (median -52.8%, interquartile range -79.1% to -17.5%) in the third tertile, intermediate (median -45.5%, interquartile range -72.4% to 0%) in the second tertile, and lowest (-42.6%, interquartile range -80.5% to 16.7%) in the first tertile (P = .953). The mean percentage of change in hs-CRP was greatest (-72.4% +/- 30.4%) in the third tertile, intermediate (-55.4% +/- 31.9%) in the second tertile, and lowest (-44.8% +/- 30.6%) in the first tertile (P = .037).
The results of our study have shown that obese adults experience a reduction in albuminuria and hs-CRP after bariatric surgery, with a greater reduction in hs-CRP observed with more surgical weight loss.