Randomized sham-controlled trial of the 6-month swallowable gas-filled intragastric balloon system for weight loss.

BACKGROUND: Obesity is a significant health problem and additional therapies are needed to improve obesity treatment. OBJECTIVE: Determine the efficacy and safety of a 6-month swallowable gas-filled intragastric balloon system for weight loss. SETTING: Fifteen academic and private practice centers in the United States. METHODS: This was a double-blind, randomized sham-controlled trial of the swallowable gas-filled intragastric balloon system plus lifestyle therapy compared with lifestyle therapy alone for weight loss at 6 months in participants aged 22 to 60 years with body mass index 30 to 40 kg/m2, across 15 sites in the United States. The following endpoints were included: difference in percent total weight loss in treatment group versus control group was >2.1%, and a responder rate of >35% in the treatment group. RESULTS: Three hundred eighty-seven patients swallowed at least 1 capsule. Of participants, 93.3% completed all 24 weeks of blinded study testing. Nonserious adverse events occurred in 91.1% of patients, but only .4% were severe. One bleeding ulcer and 1 balloon deflation occurred. In analysis of patients who completed treatment, the treatment and control groups achieved 7.1 ± 5.0% and 3.6 ± 5.1% total weight loss, respectively, and a mean difference of 3.5% (P = .0085). Total weight loss in treatment and control groups were 7.1 ± 5.3 and 3.6 ± 5.1 kg (P < .0001), and body mass index change in the treatment and control groups were 2.5 ± 1.8 and 1.3 ± 1.8 kg/m2 (P < .0001), respectively. The responder rate in the treatment group was 66.7% (P < .0001). Weight loss maintenance in the treatment group was 88.5% at 48 weeks. CONCLUSIONS: Treatment with lifestyle therapy and the 6-month swallowable gas-filled intragastric balloon system was safe and resulted in twice as much weight loss compared with a sham control, with high weight loss maintenance at 48 weeks.

Primary care provider management of patients with obesity at an integrated health network: A survey of practices, views, and knowledge.

BACKGROUND: Obesity is a serious health problem that affects a wide range of patients and disease processes. OBJECTIVE: The purpose of this study is to evaluate perceptions, knowledge, and practice habits of primary care providers (PCPs) regarding the care of patients with obesity, including barriers to effective care and their experience with bariatric surgery in our integrated health network. SETTING: Integrated health network. METHODS: A 16-question survey was distributed electronically to 160 PCPs at our integrated health network. Results were analyzed to identify attitudes, knowledge, practice habits, and bariatric surgery referral patterns while treating patients with obesity. RESULTS: Among 160 PCPs, 45 (28.1%) responded. Specialty, sex, patient population, insurance accepted, and practice years of PCPs were reported. Most PCPs reported "always" calculating patient body mass index (88.9%) with only 13.3% "always" discussing the body mass index results. Respondents most frequently prescribed diet and exercise to patients with obesity and rarely prescribed medications, with bariatric surgery referrals falling between the two. PCPs viewed management of obesity as the responsibility of the patient (97.6%) and the PCP (100%). Ninety-three percent felt obesity is a common diagnosis in their practice, but no one correctly identified the prevalence of obesity in our region. Respondents demonstrated adequate knowledge regarding medical consequences of obesity. A majority was able to identify the correct eligibility criteria for bariatric surgery, as well specific medical problems that can improve or be eliminated postoperatively. While 61.9% of respondents were aware of free weight loss and bariatric informational sessions offered, 28.6% reported that they were unfamiliar with existing bariatric surgeons. One respondent was not aware of any bariatric surgery performed. Some PCPs reported prior negative experiences with post-bariatric surgery patients, and thus were hesitant to refer additional patients. CONCLUSIONS: PCPs report discussing an obesity diagnosis with patients but are not always using body mass index in that discussion. They most often prescribe lifestyle modification as treatment for patients, which they believe to be most effective to treat obesity. However, they report only one third of their patients are motivated to lose weight. Additionally, they demonstrate appropriate knowledge of indications and benefits of bariatric surgery. A majority of the PCPs is aware of weight loss informational sessions and bariatric services provided within our integrated health network, but almost one third were unable to identify a surgeon, a possible target for improved relationships. Barriers to care include patient motivation and insurance coverage.

Sleeve gastrectomy revision by endoluminal sleeve plication gastroplasty: a small pilot case series.

BACKGROUND: The necessity for reoperation due to insufficient weight loss after bariatric surgery has led to a novel endoluminal plication of the gastric sleeve using a endoscopic suturing device. Advances in endoluminal endoscopy and other minimally invasive bariatric surgeries have inspired innovative techniques and have produced reliable suturing tools for gastric volume reduction. METHODS: Retrospective pilot case series of 5 patients with an enlarged gastric sleeve. RESULTS: The data show a sustained weight loss for all patients ranging from 19 to 36 lbs at 1 year, with the greatest average weight loss (27 lbs) observed at 6 months. At 1 year post-op, the mean body mass index was 33 kg/m2. Four of the patients were considered successful, with a excess weight loss (EWL) sustained at 1 year post-procedure, ranging from 21 to 61% with a mean of 38%. One patient experienced a EWL of only 13%, which was attributed to failed lifestyle modification. The mean EWL of the series is 33%. The percent total weight loss (%WL) ranged from 6.7 to 17.2%. CONCLUSIONS: The endoluminal approach with an endoscopic suturing device for sleeve revision by plication is showing early promising results and expands the management of weight gain following laparoscopic sleeve gastrectomy. This simple approach may offer a significant option for these patients as an interventional strategy in the early phases of weight regain, and prior to reaching a BMI of 40 kg/m2, such as the traditional surgical approach.

Laparoscopic Sleeve Gastrectomy: Surgical Technique and Perioperative Care.

Laparoscopic sleeve gastrectomy is a bariatric surgical procedure created for long-term weight loss and improvement of metabolic syndrome abnormalities in morbidly obese patients. It has been shown to demonstrate durable results compared with other bariatric procedures. This article aims to describe the surgical technique and perioperative care for patients undergoing laparoscopic sleeve gastrectomy based on current scientific literature and best standard practices.

Management of Refractory Noninsulinoma Pancreatogenous Hypoglycemia Syndrome with Gastric Bypass Reversal: A Case Report and Review of the Literature.

Background. Roux-en-Y gastric bypass (RYGB) is a commonly performed, effective bariatric procedure; however, rarely, complications such as postprandial hypoglycemia due to noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) may ensue. Management of refractory NIPHS is challenging. We report a case that was successfully treated with RYGB reversal. Case Report. A 58-year-old male with history of RYGB nine months earlier for morbid obesity presented for evaluation of postprandial, hypoglycemic seizures. Testing for insulin level, insulin antibodies, oral hypoglycemic agents, pituitary axis hormone levels, and cortisol stimulation was unrevealing. Computed tomography (CT) scan of the abdomen was unremarkable. A 72-hour fast was completed without hypoglycemia. Mixed meal testing demonstrated endogenous hyperinsulinemic hypoglycemia (EHH) and selective arterial calcium stimulation testing (SACST) was positive. Strict dietary modifications, maximal medical therapy, gastrostomy tube feeding, and stomal reduction failed to alleviate symptoms. Ultimately, he underwent laparoscopic reversal of RYGB. Now, 9 months after reversal, he has markedly reduced hypoglycemia burden. Discussion. Hyperfunctioning islets secondary to exaggerated incretin response and altered intestinal nutrient delivery are hypothesized to be causative in NIPHS. For refractory cases, there is increasing skepticism about the safety and efficacy of pancreatic resection. RYGB reversal may be successful.

Emerging technologies and procedures: results of an online survey and real-time poll.

BACKGROUND: Many new techniques and bariatric endoluminal procedures are being developed and used for the treatment of obesity. Clear guidelines or opinions of the new techniques are not readily available. The aim of this study was to gauge the level of interest and opinions of bariatric surgeons regarding these new techniques, using online and real poll surveys. METHODS: The American Society for Metabolic and Bariatric Surgery (ASMBS) Emerging Technologies committee developed a questionnaire that was distributed among the membership and conducted a live poll of attendees at Obesity Week 2013. Opinions of new technologies and techniques by practitioners were assessed. RESULTS: A total of 134 responses to the questionnaire were returned. Most responses (79%) expressed the belief that new bariatric techniques are needed to improve the practice of bariatric and metabolic surgery. The responses describing the effects of new procedures and technology as beneficial were (1) increased interest from patients or referring physicians (94%), (2) expanded indications for intervention (93%), and (3) lower risk intervention (96%). Nearly all respondents (90.2%) identified value in informational guidelines on new technologies and procedures, and most (88.7%) agreed that the ASMBS should coordinate clinical trials or registries to evaluate these therapies. CONCLUSION: Although most bariatric and metabolic surgeons agree that new endoluminal surgical techniques are beneficial, most also are unable to offer the procedures to their patients without more clinical evidence and clear guidelines from the society.

Association between bariatric surgery and long-term survival.

IMPORTANCE: Accumulating evidence suggests that bariatric surgery improves survival among patients with severe obesity, but research among veterans has shown no evidence of benefit. OBJECTIVE: To examine long-term survival in a large multisite cohort of patients who underwent bariatric surgery compared with matched control patients. DESIGN, SETTING, AND PARTICIPANTS: In a retrospective cohort study, we identified 2500 patients (74% men) who underwent bariatric surgery in Veterans Affairs (VA) bariatric centers from 2000-2011 and matched them to 7462 control patients using sequential stratification and an algorithm that included age, sex, geographic region, body mass index, diabetes, and Diagnostic Cost Group. Survival was compared across patients who underwent bariatric surgery and matched controls using Kaplan-Meier estimators and stratified, adjusted Cox regression analyses. EXPOSURES: Bariatric procedures, which included 74% gastric bypass, 15% sleeve gastrectomy, 10% adjustable gastric banding, and 1% other. MAIN OUTCOMES AND MEASURES: All-cause mortality through December 2013. RESULTS: Surgical patients (n = 2500) had a mean age of 52 years and a mean BMI of 47. Matched control patients (n = 7462) had a mean age of 53 years and a mean BMI of 46. At the end of the 14-year study period, there were a total of 263 deaths in the surgical group (mean follow-up, 6.9 years) and 1277 deaths in the matched control group (mean follow-up, 6.6 years). Kaplan-Meier estimated mortality rates were 2.4% at 1 year, 6.4% at 5 years, and 13.8% at 10 years for surgical patients; for matched control patients, 1.7% at 1 year, 10.4% at 5 years, and 23.9% at 10 years. Adjusted analysis showed no significant association between bariatric surgery and all-cause mortality in the first year of follow-up (adjusted hazard ratio [HR], 1.28 [95% CI, 0.98-1.68]), but significantly lower mortality after 1 to 5 years (HR, 0.45 [95% CI, 0.36-0.56]) and 5 to 14 years (HR, 0.47 [95% CI, 0.39-0.58]). The midterm (>1-5 years) and long-term (>5 years) relationships between surgery and survival were not significantly different across subgroups defined by diabetes diagnosis, sex, and period of surgery. CONCLUSIONS AND RELEVANCE: Among obese patients receiving care in the VA health system, those who underwent bariatric surgery compared with matched control patients who did not have surgery had lower all-cause mortality at 5 years and up to 10 years following the procedure. These results provide further evidence for the beneficial relationship between surgery and survival that has been demonstrated in younger, predominantly female populations.

Groin defects seen at extra-peritoneal laparoscopic dissection during surgical treatment of athletic pubalgia.

BACKGROUND: Recently new disease process, often referred to as athletic pubalgia (AP), has been acknowledged by the medical community. The patients suffering from this ailment present with unilateral or bilateral chronic groin pain associated with physical activity without a clear diagnosis of a groin hernia. Though physical therapy and medical treatments are considered first line remedies, some believe that surgical treatment may have better, quicker, and more durable outcomes and procedures aimed at groin reinforcement seem to relieve most of symptoms in the majority of the patients. Despite many surgeons consistently noting rectus insertion or adductor thinning, multiple hernia defects are often seen during dissections and the clinical significance of these findings is still not known. MATERIALS AND METHODS: Between 2007 and 2011, 40 patients underwent an extra-peritoneal laparoscopic reinforcement of rectus abdominals and insertion of adductor muscles for AP. All patients underwent wide and bilateral groin dissection and the findings were cataloged. RESULTS: All of the patients presented with groin defects upon wide dissection. Thirty-four patients (85%) presented with small bilateral indirect inguinal defects and 28 (70%) of these patients did not have any additional defects. Five patients (12.5%) were found to have only unilateral inguinal hernia defects. One patient presented with a small direct defect. In addition to these defects, five patients (12.5%) had additional unilateral femoral hernias, whereas no patient had solitary femoral hernia defects. CONCLUSION: AP is a new diagnostic entity with poorly understood etiology. It mostly affects young active adults, often involved in competitive sports and surgical methods may be most effective at achieving the cure. In our experience all of the patients presented with groin defects, though not all were the same. It is our belief that these defects, although likely not the only component, play a significant role in the pathophysiology of AP.

Clinical trial demonstrates exercise following bariatric surgery improves insulin sensitivity.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) surgery causes profound weight loss and improves insulin sensitivity (S(I)) in obese patients. Regular exercise can also improve S(I) in obese individuals; however, it is unknown whether exercise and RYGB surgery-induced weight loss would additively improve S(I) and other cardiometabolic factors. METHODS: We conducted a single-blind, prospective, randomized trial with 128 men and women who recently underwent RYGB surgery (within 1-3 months). Participants were randomized to either a 6-month semi-supervised moderate exercise protocol (EX, n = 66) or a health education control (CON; n = 62) intervention. Main outcomes measured included S(I) and glucose effectiveness (S(G)), which were determined from an intravenous glucose tolerance test and minimal modeling. Secondary outcomes measured were cardiorespiratory fitness (VO2 peak) and body composition. Data were analyzed using an intention-to-treat (ITT) and per-protocol (PP) approach to assess the efficacy of the exercise intervention (>120 min of exercise/week). RESULTS: 119 (93%) participants completed the interventions, 95% for CON and 91% for EX. There was a significant decrease in body weight and fat mass for both groups (P < 0.001 for time effect). S(I) improved in both groups following the intervention (ITT: CON vs. EX; +1.64 vs. +2.24 min⁻¹/µU/ml, P = 0.18 for Δ, P < 0.001 for time effect). A PP analysis revealed that exercise produced an additive S(I) improvement (PP: CON vs. EX; +1.57 vs. +2.69 min⁻¹/µU/ml, P = 0.019) above that of surgery. Exercise also improved S(G) (ITT: CON vs. EX; +0.0023 vs. +0.0063 min⁻¹, P = 0.009) compared with the CON group. Exercise improved cardiorespiratory fitness (VO2 peak) compared with the CON group. CONCLUSION: Moderate exercise following RYGB surgery provides additional improvements in S(I), S(G), and cardiorespiratory fitness compared with a sedentary lifestyle during similar weight loss. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT00692367. FUNDING: This study was funded by the NIH/National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK078192) and an NIH/National Center for Research Resources/Clinical and Translational Science Award (UL1 RR024153).

Changes in hormones and biomarkers in polycystic ovarian syndrome treated with gastric bypass.

BACKGROUND: Small retrospective studies have demonstrated reduction in weight and co-morbid hirsutism and diabetes in women with polycystic ovary syndrome (PCOS) treated with Roux-en-Y gastric bypass. The objective of this study was to prospectively determine clinical improvements in obese women with PCOS treated with gastric bypass and identify postoperative biomarker changes. METHODS: Data were collected on obese women with PCOS undergoing Roux-en-Y gastric bypass over 1 year. Testosterone, follicle stimulating hormone, lutenizing hormone, insulin, fasting glucose, and lipid levels were obtained preoperatively at baseline, and 6 and 12 months after surgery. Testosterone was used as the primary hormonal biomarker. A physical examination for body mass index (BMI) and hirsutism, and information on menstrual pattern were collected at baseline and 3, 6, and 12 months after surgery. RESULTS: Data were available for 14 women. Mean BMI decreased from 44.8±5.9 kg/m(2) at baseline to 29.2±5.9 kg/m(2) at 12 months postoperatively. Significant improvements were seen in testosterone, fasting glucose, insulin, cholesterol, and triglyceride at 12 months (P<.05). At baseline, irregular menses were reported in 10 patients; all patients were experiencing regular menses 6 and 12 months after surgery. Hirsutism was present in 11 patients at baseline and only 7 patients at 12 months. Improvements in biomarkers, menstrual cycling, and hirsutism was not correlated with degree of weight change. CONCLUSION: Gastric bypass achieved significant reductions in BMI, testosterone, and markers of glucose and lipid metabolism. These data confirm reports of previous retrospective studies showing weight reduction and health improvement in women with PCOS treated with gastric bypass.

Bariatric surgery interest around the world: what Google Trends can teach us.

BACKGROUND: Bariatric surgery may prove an effective weight loss option for those struggling with severe obesity, but it is difficult to determine levels of interest in such procedures at the population level through traditional approaches. Analysis of Google Trend information may give providers and healthcare systems useful information regarding Internet users' interest in bariatric procedures. The objective of this study was to gather Google Trend information on worldwide Internet searches for "bariatric surgery", "gastric bypass", "gastric sleeve", "gastric plication", and "lap band" from 2004-2012 and to explore temporal relationships with relevant media events, economic variations, and policy modifications. METHODS: Data were collected using Google Trends. Trend analyses were performed using Microsoft Excel Version 14.3.5 and Minitab V.16.0. RESULTS: Trend analyses showed that total search volume for the term "bariatric surgery" has declined roughly 25% since January 2004, although interest increased approximately 5% from 2011 to 2012. Interest in lap band procedures declined 30% over the past 5 years, while "gastric sleeve" has increased 15%. Spikes in search numbers show an association with events such as changing policy and insurance guidelines and media coverage for bariatric procedures. CONCLUSION: This report illustrates that variations in Internet search volume for terms related to bariatric surgery are multifactorial in origin. Although it is impossible to ascertain if reported Internet search volume is based on interest in potentially undergoing bariatric surgery or simply general interest, this analysis reveals that search volume appears to mirror real world events. Therefore, Google Trends could be a way to supplement understanding about interest in bariatric procedures.

StomaphyX vs a sham procedure for revisional surgery to reduce regained weight in Roux-en-Y gastric bypass patients : a randomized clinical trial.

IMPORTANCE: Revisional laparoscopic surgery after Roux-en-Y gastric bypass (RYGB) has been linked to substantial complications and morbidity. OBJECTIVE: To investigate the safety and effectiveness of endoscopic gastric plication with the StomaphyX device vs a sham procedure for revisional surgery in RYGB patients to reduce regained weight. DESIGN, SETTING, AND PARTICIPANTS: A prospective, single-center, randomized, single-blinded study from July 2009 through February 2011, evaluating revisional surgery using StomaphyX was conducted in patients with initial weight loss after RYGB performed at least 2 years earlier. We planned for 120 patients to be randomized 2:1 to multiple full-thickness plications within the gastric pouch and stoma using the StomaphyX device with SerosFuse fasteners or a sham endoscopic procedure and followed up for 1 year. The primary efficacy end point was reduction in pre-RYGB excess weight by 15% or more excess body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) loss and BMI less than 35 at 12 months after the procedure. Adverse events were recorded. RESULTS: Enrollment was closed prematurely because preliminary results indicated failure to achieve the primary efficacy end point in at least 50% of StomaphyX-treated patients. One-year follow-up was completed by 45 patients treated with StomaphyX and 29 patients in the sham treatment group. Primary efficacy outcome was achieved by 22.2% (10) with StomaphyX vs 3.4% (1) with the sham procedure (P < .01). Patients undergoing StomaphyX treatment experienced significantly greater reduction in weight and BMI at 3, 6, and 12 months (P ≤ .05). There was one causally related adverse event with StomaphyX, that required laparoscopic exploration and repair. CONCLUSIONS AND RELEVANCE: StomaphyX treatment failed to achieve the primary efficacy target and resulted in early termination of the study. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00939055.

Endoluminal revision of gastric bypass for weight regain--a systematic review.

BACKGROUND: Weight recidivism after Roux-en-Y gastric bypass (RYGB) is a challenging problem for patients and bariatric surgeons alike. Traditional operative strategies to combat weight regain are technically challenging and associated with a high morbidity rate. Endoluminal interventions are thus an attractive alternative that may offer a good combination of results coupled with lower periprocedure risk that might one day provide a solution to this increasingly prevalent problem. The purpose of this article is to systematically review the available literature on endoluminal procedures used to address weight regain after RYGB, with specific attention to the safety profile, efficacy, cost, and current availability. This review focuses only on endoluminal procedures that are performed for weight regain after RYGB, as opposed to primary endoluminal obesity procedures. METHODS: This study was a retrospective review. RESULTS: Several methods of endoluminal intervention for weight regain are reviewed, ranging from injection of inert substances to suturing and clipping devices. The literature review shows the procedures on the whole to be well tolerated with limited efficacy. The majority of the literature is limited to small case series. Most of the reviewed devices are no longer commercially available. CONCLUSIONS: Endoluminal therapy represents an intriguing strategy for weight regain after RYGB. However, the current and future technologies must be rigorously studied and improved such that they offer durable, repeatable, cost-effective solutions.

Ventral hernias in morbidly obese patients: a suggested algorithm for operative repair.

With the rise in prevalence of obesity, most general surgeons will have to face the problem of the obese patient with an abdominal wall defect. Treatment of these bariatric patients raises unique challenges, and at this time there is still no consensus on the best treatment option. This study was performed in a high-volume bariatric and minimally invasive surgery center at a tertiary care facility in the USA. Twenty-eight morbidly obese patients treated at our facility between 2003 and 2008 were separated into four groups according to anatomic features and symptoms. Patients with the following characteristics were classified as having a favorable anatomy: body mass index not exceeding 50 kg/m(2), gynecoid body habitus, reducible hernias found in a central location, abdominal wall thickness less than 4 cm, and the defect's largest diameter not exceeding 8 cm. All other patients were classified as having an unfavorable anatomy. In this study, we report a systematic treatment approach for the morbidly obese patient presenting with a ventral hernia based on whether the hernia is symptomatic or asymptomatic, as well as the distinct characteristics of the hernia and body habitus features. We followed up on these patients postoperatively for at least 2 years, with a mean follow-up period of 30 months. Only a total of three hernia recurrences were observed. Successful treatment of ventral hernias in morbidly obese patients should be individualized based on the patient's symptoms and defined hernia characteristics.

Laparoscopic sleeve gastrectomy for super obese patients: forty-eight percent excess weight loss after 6 to 8 years with 93% follow-up.

OBJECTIVES: In this study, we report long-term outcomes of high-risk, high-BMI (body mass index) patients who underwent laparoscopic sleeve gastrectomy (LSG). BACKGROUND: Short- and medium-term data appear to support the effectiveness of LSG, but long-term data to support its durability are sparse. METHODS: A prospective database was reviewed on all high-risk patients who underwent LSG as part of a staged approach for surgical treatment of severe obesity between January 2002 and February 2004. We included only patients who did not proceed to second-stage surgery (gastric bypass). Analyzed data included demographics, BMI, comorbidities, and surgical outcomes. All partial gastrectomies were performed using a 50F bougie. RESULTS: Seventy-four patients underwent LSG, and follow-up data were available on 69 of 74 patients (93%). The mean age was 50 years (25-78) and the mean number of co-morbidities was 9.6. Perioperative mortality (<30 days) was zero, and the incidence of short- and long-term postoperative complications was 15%. The mean overall follow-up time period was 73 months (38-95). Mean excess weight loss (EWL) at 72, 84, and 96 months after LSG was 52%, 43%, and 46%, respectively, with an overall EWL of 48%. The mean BMI decreased from 66 kg/m(2) (43-90) to 46 kg/m(2) (22-73). Seventy-seven percent of the diabetic patients showed improvement or remission of the disease. CONCLUSIONS: This study reports the longest follow-up of LSG patients thus far and supports the effectiveness, safety, and durability of laparoscopic sleeve gastrectomy as a definitive therapeutic option for severe obesity, even in high-risk, high-BMI patients.

Walking capacity of bariatric surgery candidates.

BACKGROUND: This study characterizes the walking limitations of bariatric surgery candidates by age and body mass index (BMI) and determines factors independently associated with walking capacity. The setting was multi-institutional at research university hospitals in the United States. METHODS: Participants of the Longitudinal Assessment of Bariatric Surgery study (n=2458; age 18-78 yr, BMI 33-94 kg/m(2)) attended a preoperative research visit. Their walking capacity was measured by self-report and the 400 m Long Distance Corridor Walk (LDCW). RESULTS: Almost two thirds (64%) of subjects reported limitations with walking several blocks, 48% had an objectively defined mobility deficit, and 16% reported at least some walking aid use. In multivariate analysis, BMI, older age, lower income, and greater bodily pain were independently associated (P < .05) with walking aid use, physical discomfort during the LDCW, an inability to complete the LDCW, and a slower time to complete the LDCW. Female gender, Hispanic ethnicity (but not race), greater heart rate at rest, a history of smoking, several co-morbidities (history of stroke, ischemic heart disease, diabetes, asthma, sleep apnea, venous edema with ulcerations), and depressive symptoms were also independently related (P < .05) to at least one measure of reduced walking capacity. CONCLUSIONS: Walking limitations are common in bariatric surgery candidates, even among the least severely obese and youngest patients. Physical activity counseling must be tailored to individuals' abilities. Although several factors identified in the present study (eg, BMI, age, pain, co-morbidities) should be considered, directly assessing the patient's walking capacity will facilitate appropriate goal setting.

Pre- to postoperative changes in physical activity: report from the longitudinal assessment of bariatric surgery-2 (LABS-2).

BACKGROUND: Numerous studies have reported that bariatric surgery patients report more physical activity (PA) after surgery than before; however, the quality of the PA assessment has been questionable. METHODS: The longitudinal assessment of bariatric surgery-2 is a 10-center longitudinal study of adults undergoing bariatric surgery. Of 2458 participants, 455 were given an activity monitor, which records the steps per minute, and an exercise diary before and 1 year after surgery. The mean number of steps/d, active min/d, and high-cadence min/wk were calculated for 310 participants who wore the monitor ≥10 hr/d for ≥3 days at both evaluations. Pre- and postoperative PA were compared for differences using the Wilcoxon signed-rank test. Generalized estimating equations were used to identify independent preoperative predictors of postoperative PA. RESULTS: PA increased significantly (P < .0001) from before to after surgery for all PA measures. The median values before and after surgery were 7563 and 8788 steps/d, 309 and 340 active min/d, and 72 and 112 high-cadence min/wk, respectively. However, depending on the PA measure, 24-29% of participants were ≥5% less active postoperatively than preoperatively. Controlling for surgical procedure, gender, age, and body mass index, more PA preoperatively independently predicted for more PA postoperatively (P < .0001, for all PA measures). Less pain, not having asthma, and the self-report of increasing PA as a weight loss strategy preoperatively also independently predicted for more high-cadence min/wk postoperatively (P < .05). CONCLUSIONS: The majority of adults increase their PA level after bariatric surgery. However, most remain insufficiently active, and some become less active. Increasing PA, addressing pain, and treating asthma before surgery might have a positive effect on postoperative PA.