Roux-en-Y gastric bypass vs intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: the Diabetes Surgery Study randomized clinical trial.

IMPORTANCE: Controlling glycemia, blood pressure, and cholesterol is important for patients with diabetes. How best to achieve this goal is unknown. OBJECTIVE: To compare Roux-en-Y gastric bypass with lifestyle and intensive medical management to achieve control of comorbid risk factors. DESIGN, SETTING, AND PARTICIPANTS: A 12-month, 2-group unblinded randomized trial at 4 teaching hospitals in the United States and Taiwan involving 120 participants who had a hemoglobin A1c (HbA1c) level of 8.0% or higher, body mass index (BMI) between 30.0 and 39.9, C peptide level of more than 1.0 ng/mL, and type 2 diabetes for at least 6 months. The study began in April 2008. INTERVENTIONS: Lifestyle-intensive medical management intervention and Roux-en-Y gastric bypass surgery. Medications for hyperglycemia, hypertension, and dyslipidemia were prescribed according to protocol and surgical techniques that were standardized. MAIN OUTCOMES AND MEASURES: Composite goal of HbA1c less than 7.0%, low-density lipoprotein cholesterol less than 100 mg/dL, and systolic blood pressure less than 130 mm Hg. RESULTS: All 120 patients received the intensive lifestyle-medical management protocol and 60 were randomly assigned to undergo Roux-en-Y gastric bypass. After 12-months, 28 participants (49%; 95% CI, 36%-63%) in the gastric bypass group and 11 (19%; 95% CI, 10%-32%) in the lifestyle-medical management group achieved the primary end points (odds ratio [OR], 4.8; 95% CI, 1.9-11.7). Participants in the gastric bypass group required 3.0 fewer medications (mean, 1.7 vs 4.8; 95% CI for the difference, 2.3-3.6) and lost 26.1% vs 7.9% of their initial body weigh compared with the lifestyle-medical management group (difference, 17.5%; 95% CI, 14.2%-20.7%). Regression analyses indicated that achieving the composite end point was primarily attributable to weight loss. There were 22 serious adverse events in the gastric bypass group, including 1 cardiovascular event, and 15 in the lifestyle-medical management group. There were 4 perioperative complications and 6 late postoperative complications. The gastric bypass group experienced more nutritional deficiency than the lifestyle-medical management group. CONCLUSIONS AND RELEVANCE: In mild to moderately obese patients with type 2 diabetes, adding gastric bypass surgery to lifestyle and medical management was associated with a greater likelihood of achieving the composite goal. Potential benefits of adding gastric bypass surgery to the best lifestyle and medical management strategies of diabetes must be weighed against the risk of serious adverse events. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00641251.

Adolescent bariatric surgery.

Overall it is clear that bariatric surgical intervention in appropriately selected adolescents is effective at both adequate weight loss and resolution of weight related co-morbidities in the short and medium term. Long-term results are being conducted currently to assess durability of bariatric surgical interventions. We believe that adolescents undergoing bariatric evaluation have unique needs and until more long-term data are available, the indications for surgery should be stricter than those used in adults. All of the bariatric procedures discussed must be performed in the background of positive behavioral modifications over a period of time. If lifestyle modification fails, these adolescents can gain weight by overcoming the physiologic effects of the surgery as they eat high calorie foods at very frequent intervals. Finally, close postoperative follow-up is required with active management of weight loss/gain, co-morbidities, and postoperative complications should they occur.

Adipocyte Proteins and Storage of Endogenous Fatty Acids in Visceral and Subcutaneous Adipose Tissue in Severe Obesity.

OBJECTIVE: This study tested whether substrate concentrations or fatty acid storage proteins predict storage of endogenous lipids in visceral adipose tissue (VAT) and upper body subcutaneous adipose tissue (UBSQ) fat. METHODS: The day prior to surgery, 25 patients undergoing bariatric procedures received an infusion of autologous [1-14 C]triolein-labeled very low-density lipoprotein (VLDL) particles, and during surgery, they received a continuous [U-13 C]palmitate infusion/bolus [9,10-3 H]palmitate tracer. VAT and UBSQ fat were collected to measure VLDL-triglyceride (TG) storage, direct free fatty acid (FFA) storage rates, CD36 content, lipoprotein lipase (LPL), acyl-CoA synthetase, diacylglycerol acetyl-transferase, and glycerol-3-phosphate acyltransferase activities. RESULTS: Storage of VLDL-TG and FFA-palmitate in UBSQ and VAT was not different. Plasma palmitate concentrations correlated with palmitate storage rates in UBSQ and VAT (r = 0.46, P = 0.02 and r = 0.46, P = 0.02, respectively). In VAT, VLDL-TG storage was correlated with VLDL concentrations (r = 0.53, P < 0.009) and LPL (r = 0.42, P < 0.05). In UBSQ, VLDL-TG storage was correlated with LPL (r = 0.42, P < 0.05). CD36, acyl-CoA synthetase, glycerol-3-phosphate acyltransferase, and diacylglycerol acetyl-transferase were not correlated with VLDL-TG or palmitate storage. CONCLUSIONS: Adipose storage of VLDL-TG is predicted by VLDL-TG concentrations and LPL; FFA concentrations predict direct adipose tissue FFA storage rates.

Laparoscopic duodenojejunostomy for superior mesenteric artery syndrome.

BACKGROUND: Superior mesenteric artery (SMA) syndrome, also called Wilkie's syndrome, is a rare clinical phenomenon believed to be caused by compression of the third portion of the duodenum by the overlying superior mesenteric artery. We present the case of a 32-year-old female who presented with epigastric pain, weight loss, and vomiting. METHODS: Her workup included a normal upper endoscopy as well as an abdominal CT scan and upper GI contrast study that confirmed the diagnosis of superior mesenteric artery syndrome. The patient was taken to the operating room and underwent successful treatment with laparoscopic duodenojejunostomy. RESULTS: The patient achieved complete relief of her symptoms and is able to eat a regular diet without difficulty. SMA syndrome is a real anatomic clinical pathology resulting in chronic, consistent obstructive symptoms. An upper GI series and CT scan with contrast can confirm the diagnosis. CONCLUSION: Laparoscopic duodenojejunostomy should be considered the treatment of choice for these patients, because it offers a high likelihood of excellent outcome based on the current literature.

Hepatic Fatty Acid Balance and Hepatic Fat Content in Humans With Severe Obesity.

OBJECTIVE: Nonalcoholic fatty liver disease can lead to hepatic inflammation/damage. Understanding the physiological mechanisms that contribute to excess hepatic lipid accumulation may help identify effective treatments. DESIGN: We recruited 25 nondiabetic patients with severe obesity scheduled for bariatric surgery. To evaluate liver export of triglyceride fatty acids, we measured very-low-density lipoprotein (VLDL)-triglyceride secretion rates the day prior to surgery using an infusion of autologous [1-14C]triolein-labeled VLDL particles. Ketone body response to fasting and intrahepatic long-chain acylcarnitine concentrations were used as indices of hepatic fatty acid oxidation. We measured intraoperative hepatic uptake rates of plasma free fatty acids using a continuous infusion of [U-13C]palmitate, combined with a bolus dose of [9,10-3H]palmitate and carefully timed liver biopsies. Total intrahepatic lipids were measured in liver biopsy samples to determine fatty liver status. The hepatic concentrations and enrichment from [U-13C]palmitate in diacylglycerols, sphingolipids, and acyl-carnitines were measured using liquid chromatography/tandem mass spectrometry. RESULTS: Among study participants with fatty liver disease, intrahepatic lipid was negatively correlated with VLDL-triglyceride secretion rates (r = -0.92, P = 0.01) but unrelated to hepatic free fatty acid uptake or indices of hepatic fatty acid oxidation. VLDL-triglyceride secretion rates were positively correlated with hepatic concentrations of saturated diacylglycerol (r = 0.46, P = 0.02) and sphingosine-1-phosphate (r = 0.44, P = 0.03). CONCLUSION: We conclude that in nondiabetic humans with severe obesity, excess intrahepatic lipid is associated with limited export of triglyceride in VLDL particles rather than increased uptake of systemic free fatty acids.

Nausea, bloating and abdominal pain in the Roux-en-Y gastric bypass patient: more questions than answers.

Bariatric surgery is the most effective treatment for severe obesity. After surgery, patients may complain of gastrointestinal symptoms but their altered anatomy can make investigations difficult to perform or interpret. In particular, the Roux-en-Y gastric bypass (RYGBP) creates an excluded segment that is not easily accessible. We present a case illustrating some of the difficulties encountered when investigating the RYGBP patient complaining of nonspecific GI symptoms. Options are discussed for examining the excluded segment, and the diagnosis and significance of small intestine bacterial overgrowth in the RYGBP patient is reviewed.

Randomized sham-controlled trial evaluating efficacy and safety of endoscopic gastric plication for primary obesity: The ESSENTIAL trial.

OBJECTIVE: Evaluate safety and efficacy of the pose™ procedure for obesity treatment. METHODS: Subjects with Class I to II obesity were randomized (2:1) to receive active or sham procedure, after each investigator performed unblinded lead-in cases. All subjects were provided low-intensity lifestyle therapy. Efficacy end points were the mean difference in percent total body weight loss (%TBWL) at 12 months between randomized groups, and responder rate achieving ≥5% TBWL. The primary safety end point was incidence of reported adverse events. RESULTS: Three hundred thirty-two subjects were randomized (active, n = 221; sham, n = 111); thirty-four subjects were included in the unblinded lead-in cohort. Twelve-month results were mean TBWL 7.0 ± 7.4% in lead-in, 4.95 ± 7.04% in active, and 1.38 ± 5.58% in sham groups, respectively. Responder rate was 41.55% in active and 22.11% in sham groups, respectively (P < 0.0001); mean responder result was 11.5% TBWL. The differences observed between active and sham groups for co-primary end points were statistically significant (P < 0.0001); however, super superiority margin as set forth in the study design was not met. No unanticipated adverse events or deaths occurred. Procedure-related serious adverse event rates were 5.0% (active) and 0.9% (sham), P = 0.068. CONCLUSIONS: The pose procedure was safe and resulted in statistically significant and clinically meaningful weight loss over sham through 1 year.

Safety of laparoscopic ventral hernia repair in older adults.

The published recurrence rate after laparoscopic ventral hernia repair is much less than the rate of recurrence via the open approach. Studies have demonstrated the safety and efficacy of this procedure but have had relatively young patient populations. We present our experience in a significantly older population. A retrospective chart review of all patients undergoing a laparoscopic ventral hernia repair at our institution from May 2000 to September 2004 was performed. Data extracted from charts included demographics, number and type of previous abdominal operations, number of previous hernia repairs, defect and mesh size, postoperative complications, and follow-up. Ninety-seven patients underwent laparoscopic ventral hernia repair (50 men and 47 women). The mean age was 68.5 years (37-85 years) with 78% of patients over the age of 60. Patients had undergone a mean of 2.1 prior abdominal operations. Thirty-five (36%) patients had undergone a mean of 1.8 previous open hernia repairs; 54% with mesh. The mean length of stay was 3.4 days (0-31 days). Thirty-three minor complications occurred in 27 patients. Six major complications occurred in five patients. Three patients required reoperation. Thirty-one percent of patients complained of pain at a transabdominal suture site 6 weeks after surgery. Nine percent of patients had seromas lasting longer than 6 weeks. Two recurrences occurred during follow-up and two patients required mesh removal. There were no deaths. Laparoscopic ventral hernia repair can be performed safely in patients regardless of age. Length of stay and overall complications are not affected by age. Long-term follow-up is necessary to evaluate the effectiveness of LVHR in this patient population.

Outcomes, health status, and medical resource utilization after bariatric surgery.

Surgical results, economic consequences, and shortterm health of obese patients were evaluated before and after bariatric surgery. Of 35 patients in Mayo Health Plan Arizona eligible for bariatric surgery and scheduled for gastric restriction with Roux-en-Y gastrojejunostomy, 22 (7 men, 15 women) completed pre- and postoperative (6- and 12-mo) short form (SF)-12 Health Surveys. Nineteen patients had open bariatric procedures and 3 had laparoscopic procedures. Comorbid conditions, hospital course, weight loss, and complications were examined. Health care utilization (actual dollars paid by plan) for the preceding year and at 1- and 2-yr follow-up were compared. Major comorbid conditions included diabetes mellitus or impaired fasting glucose, hyperlipidemia, sleep apnea, and hypertension. Mean length of hospital stay was 4.8 d after open procedures and 2 d after laparoscopic procedures. No serious operative or postoperative complications occurred. From a baseline average body mass index (BMI) of 51.9, the 6- and 12-mo BMI averages were 39.6 (23.7% decrease) and 35.3 (32% decrease), respectively. Both physical and mental status improved. From baseline, physical health changed 18 and 21.2 points at 6 and 12 mo, respectively (p < 0.001), and mental health changed 9.3 points at each interval (p =0.003). Each postoperative year, resource utilization decreased (mean= $1300 per patient). Our findings of good surgical outcomes, significant weight loss, improved health status, and potential financial savings in this small sample may help patients, insurers, and self-funded employer groups evaluate the appropriateness of bariatric procedures.

Impact of advanced age on weight loss and health benefits after laparoscopic gastric bypass.

BACKGROUND: Advanced age is considered a relative contraindication to primary bariatric surgery at some institutions. As life expectancy is steadily increasing and quality of life is improving in our elderly population, we may need to reconsider the health benefits that obese elderly patients can obtain from bariatric surgery. Therefore, we examine the operative outcomes, weight loss, reduction of comorbidities, and medication requirements in patients older than 60 years compared with those younger than 60 years undergoing laparoscopic Roux-en-Y gastric bypass. HYPOTHESIS: The null hypothesis tested in this study is that patients older than 60 years who undergo laparoscopic Roux-en-Y gastric bypass experience a medical benefit not significantly different from that experienced by younger patients in terms of the number of medications and comorbid conditions. METHODS: The number of preoperative and postoperative comorbid conditions and the medications required for those conditions were compared between consecutive patients older than 60 years and those younger than 60 years who underwent Roux-en-Y laparoscopic gastric bypass. Early operative outcomes were also assessed. RESULTS: Analysis of 110 patients younger than 60 years compared with 20 patients older than 60 years revealed no difference in complication rate or length of hospital stay. Younger patients lost more weight and had a significantly greater reduction in body mass index. Younger patients also demonstrated more complete resolution of comorbid conditions, although this difference was not significant. Older patients, who had more comorbid conditions requiring more medication at the time of surgery, experienced a greater medication reduction during follow-up, although this was not statistically significant. CONCLUSIONS: Patients of advanced age can safely undergo laparoscopic Roux-en-Y gastric bypass. Younger patients can be expected to demonstrate greater weight loss and experience more complete resolution of their comorbid conditions. Older patients demonstrated greater overall reduction in medication requirements. Therefore, patients older than 60 years can be considered good candidates for obesity surgery and can be expected to enjoy substantial health benefits similar to those experienced by younger patients.

Small-bowel diaphragm disease: seven surgical cases.

HYPOTHESIS: Small-bowel diaphragm disease is an important source of gastrointestinal tract bleeding and subacute intestinal obstruction that may require surgical intervention. DESIGN: Case series. SETTING: Tertiary-care academic medical center. PATIENTS: Seven consecutive patients with histologically confirmed enteropathy induced by use of nonsteroidal anti-inflammatory drugs received treatment at our institution from February 2001 to February 2004. INTERVENTIONS: Laparotomy with small-bowel resection. MAIN OUTCOME MEASURES: Initial symptoms and signs, findings at diagnostic workup, type of medication and duration of use, operation performed, and intraoperative findings were evaluated. RESULTS: Patients were identified who had symptoms of subacute intestinal obstruction or signs of gastrointestinal tract bleeding and were determined to have used nonsteroidal anti-inflammatory drugs for differing periods. All 7 patients underwent extensive nondiagnostic radiologic and endoscopic examinations. The diagnosis of diaphragm disease was ultimately made at either video capsule endoscopy or laparotomy. Randomly distributed diaphragms throughout the jejunum and ileum necessitated resection in all cases. No patient has had a documented recurrence, although follow-up is short (range, 0-20 months). CONCLUSIONS: Nonsteroidal anti-inflammatory drugs are clearly linked to pathologic findings of diaphragm disease in both the upper and lower gastrointestinal tracts. Although rarely reported in the surgical literature, small-bowel diaphragm disease may be more common than thought and can manifest as gastrointestinal tract bleeding or obstruction. Diagnosis is difficult and may require laparotomy and small-bowel resection.

Is Roux-en-Y gastric bypass safe after previous antireflux surgery? Technical feasibility and postoperative symptom assessment.

BACKGROUND: Clinically significant morbid obesity is associated with an increased risk of gastroesophageal reflux disease. Vertical Roux-en-Y gastric bypass (RYGBP) is known to eliminate acid (and bile) in the pouch of cardia, which would provide control of reflux symptoms. The aim of our study was to assess the technical considerations, morbidity, and safety of RYGBP after previous antireflux surgery and evaluate postoperative reflux symptoms. METHODS: Retrospective review of all patients undergoing RYGBP after previous antireflux surgery from three institutions. Follow-up (mean 18 months) data were obtained from medical records and by questionnaire. RESULTS: A total of 19 patients (18 women and 1 man) underwent standard (n = 18) or distal (n = 1) RYGBP 8 +/- 1 years after Nissen (n = 18) or Toupet (n = 1) fundoplication. Open RYGBP was undertaken in 17 of 19 patients. No postoperative deaths occurred. Substantive complications occurred in 4 patients (21%) and included hemorrhage requiring transfusion, concomitant splenectomy, and reoperation for suspected leak in 2. Of the 19 patients, 16 returned the questionnaire, 15 of whom reported subjective improvement in reflux symptoms after RYGBP compared with after antireflux surgery. No patient in this series required medical therapy for reflux symptoms at the last follow-up visit. The body mass index decreased from 42 +/- 2 kg/m(2) to 32 +/- 2 kg/m(2) (mean +/- SEM); all patients with >or=1 year of follow-up had a body mass index of

Stop regain: a pilot psychological intervention for bariatric patients experiencing weight regain.

BACKGROUND: A subset of bariatric patients fails to achieve or maintain long-term successful weight loss. Psychological and behavioral factors contributing to poor long-term outcomes include decreased adherence to surgical eating guidelines, life stressors that derail weight maintenance, unhealthy eating patterns, and substance use. OBJECTIVES: A 6-week pilot group behavioral intervention utilizing techniques of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) was developed to treat bariatric patients experiencing weight regain. SETTING: Patients were treated at a large Midwestern academic medical center. METHODS: Twenty-eight patients (93% female, 100% Caucasian) with a mean age of 53 and a mean BMI of 35.6 had regained an average of 17 kg or 37% of the weight lost after initially successful Roux-en-Y gastric bypass (RYGB). All patients completed the Structured Clinical Interview for DSM-IV-TR (SCID I) modules assessing mood and substance dependence, and completed a series of questionnaires before and after group treatment, with weekly assessment of depressive symptoms, binge eating, and alcohol use. Results were analyzed utilizing repeated measures ANOVA. RESULTS: Weight decreased during the intervention by an average of 1.6 ± 2.38 kg (p ≤ 0.01). Level of depressive symptoms improved for treatment completers (p ≤ 0.01). Food records indicated that grazing patterns decreased (p ≤ 0.01) and subjective binge eating episodes decreased (p ≤ 0.03). CONCLUSIONS: A 6-week pilot group behavioral intervention demonstrated an ability to help patients reverse their pattern of weight regain. Tailored behavioral interventions may be a useful treatment to enhance maintenance of long-term weight loss.

Primary care perspective on bariatric surgery.

The role of primary care physicians in identifying potential candidates for bariatric surgery and providing them with long-term postoperative care is gaining rapidly in importance. With the increased use of surgical procedures as treatment options for obesity, a knowledge of bariatric surgery is essential for providing optimal care. During the past decade, the number of bariatric procedures has increased, and refinements of these procedures have made them safer and more effective. Primary care physicians should know how to Identify appropriate surgical candidates and be familiar with available procedures, aware of potential complications and benefits, and able to provide lifelong monitoring and follow-up care. Thus, the primary care physician must be informed about surgical criteria, types of procedures, outcomes, complications, and the long-term monitoring needs of these patients.

Evaluation of vagus nerve function before and after antireflux surgery.

We sought to evaluate vagus nerve integrity before and after antireflux surgery and to compare it with symptomatic outcome. Antireflux surgery patients were recruited. Patients with disorders associated with vagus dysfunction or who took medications with anticholinergic effects were excluded. Each patient underwent a sham-feeding-stimulated pancreatic polypeptide (PP) test before and after surgery. A symptom survey was also administered. Twenty patients completed preoperative testing; their mean age was 57 years, and postoperative testing results were available for 16 of them. Of the 20, 14 (70%) had an appropriate increase in PP level with sham-meal preoperatively. All 4 patients with an abnormal preoperative test remained abnormal, and 5 of 12 (42%) with a normal preoperative test had an abnormal postoperative result; thus 9 of 16 (56%) had an abnormal postoperative PP test. In 15 patients, assessments of bowel function were obtained before and after surgery. Six of 15 (40%) patients developed new or worse symptoms (diarrhea in 4, flatus in 2). The symptoms did not correlate with PP results. This suggests that some patients referred for antireflux surgery have evidence of abnormal vagus function that persists after surgery. Many patients (42%) with normal testing before surgery develop an abnormal test after surgery. There was no correlation between PP tests and the development or worsening of bowel symptoms.

Achalasia: a comprehensive review.

Achalasia is a rare neurologic deficit of the esophagus, producing a syndrome of impaired relaxation of the lower esophageal sphincter and decreased motility of the esophageal body for which the cause is unknown. The resultant chronic esophageal stasis produces discomforting symptoms that can be managed with medication, chemical paralysis of the lower esophageal sphincter, mechanical dilation, or surgical esophagomyotomy. Chemical paralysis by injection of the esophagus with botulinum toxin and dilation with an inflatable balloon offers good short-term relief of symptoms; however, the best long-term results are produced by surgery, and advancing minimally invasive techniques continually reduce the morbidity of these operations. The type of surgical procedure, the necessity for fundoplication, and the order of treatment continue to be unresolved issues, but prospective evaluation with objective followup should allow us to provide the optimal treatment regimen to our patients.

Adipocyte mitochondrial function is reduced in human obesity independent of fat cell size.

CONTEXT: It has been suggested that mitochondrial dysfunction in adipocytes contributes to obesity-related metabolic complications. However, obesity results in adipocyte hypertrophy, and large and small adipocytes from the same depot have different characteristics, raising the possibility that obesity-related mitochondrial defects are an inherent function of large adipocytes. OBJECTIVE: Our goal was to examine whether obesity, independent of fat cell size and fat depot, is associated with mitochondria dysfunction. DESIGN: We compared adipocyte mitochondrial function using a cross-sectional comparison study design. SETTING: The studies were performed at Mayo Clinic, an academic medical center. PATIENTS OR OTHER PARTICIPANTS: Omental and/or abdominal subcutaneous adipose samples were collected from 20 age-matched obese and nonobese nondiabetic men and women undergoing either elective abdominal surgery or research needle biopsy. INTERVENTION: Interventions were not conducted as part of these studies. MAIN OUTCOME MEASURES: We measured mitochondrial DNA abundance, oxygen consumption rates, and citrate synthase activity from populations of large and small adipocytes (separated with differential floatation). RESULTS: For both omental and subcutaneous adipocytes, at the cell and organelle level, oxygen consumption rates and citrate synthase activity were significantly reduced in cells from obese compared with nonobese volunteers, even when matched for cell size by comparing large adipocytes from nonobese and small adipocytes from obese. Adipocyte mitochondrial content was not significantly different between obese and nonobese volunteers. Mitochondrial function and content parameters were not different between small and large cells, omental, and subcutaneous adipocytes from the same person. CONCLUSION: Adipocyte mitochondrial oxidative capacity is reduced in obese compared with nonobese adults and this difference is not due to cell size differences. Adipocyte mitochondrial dysfunction in obesity is therefore related to overall adiposity rather than adipocyte hypertrophy.

The effect of vagal nerve blockade using electrical impulses on glucose metabolism in nondiabetic subjects.

PURPOSE: Vagal interruption causes weight loss in humans and decreases endogenous glucose production in animals. However, it is unknown if this is due to a direct effect on glucose metabolism. We sought to determine if vagal blockade using electrical impulses alters glucose metabolism in humans. PATIENTS AND METHODS: We utilized a randomized, cross-over study design where participants were studied after 2 weeks of activation or inactivation of vagal nerve blockade (VNB). Seven obese subjects with impaired fasting glucose previously enrolled in a long-term study to examine the effect of VNB on weight took part. We used a standardized triple-tracer mixed meal to enable measurement of the rate of meal appearance, endogenous glucose production, and glucose disappearance. The 550 kcal meal was also labeled with (111)In-diethylene triamine pentaacetic acid (DTPA) to measure gastrointestinal transit. Insulin action and ß-cell responsivity indices were estimated using the minimal model. RESULTS: Integrated glucose, insulin, and glucagon concentrations did not differ between study days. This was also reflected in a lack of effect on ß-cell responsivity and insulin action. Furthermore, fasting and postprandial endogenous glucose production, integrated meal appearance, and glucose disposal did not differ in the presence or absence of VNB. Similarly, gastric emptying and colonic transit were unchanged by VNB. CONCLUSION: In this pilot study in nondiabetic humans, electrical vagal blockade had no acute effects on glucose metabolism, insulin secretion and action, or gastric emptying. It remains to be determined if more pronounced effects would be observed in diabetic subjects.

All strictures are not alike: laparoscopic removal of nonadjustable Silastic bands after banded Roux-en-Y gastric bypass.

BACKGROUND: The concept of a nonadjustable Silastic band (NASB) has been used to promote surgically induced weight loss for >30 years. Vertical banded Roux-en-Y gastric bypass is an example. Some patients develop serious, band-related complications requiring treatment. Narrowing at the NASB will lead to refractory nausea, vomiting, regurgitation, and, even, malnutrition, requiring revision of their bariatric operation. We report on the evaluation, diagnosis, and laparoscopic treatment of proximal obstructive symptoms secondary to a NASB. METHODS: From February 2005 to January 2009, we retrospectively reviewed the preoperative and perioperative data for 6 patients who had presented with proximal obstructive symptoms after undergoing banded Roux-en-Y gastric bypass. RESULTS: The mean interval from primary NASB placement to surgery was 58 months (range 25-110). The mean duration of symptoms was 29 months (range 8-70). All patients presented with multiple symptoms, but all had nausea, vomiting, regurgitation, and dysphagia to liquids and solids. The patients had undergone multiple upper endoscopies (mean 4, range 3-6) and dilations (mean 1.3, range 1-2) without relief of their symptoms. All patients underwent successful laparoscopic removal of the NASB. Their mean hospital stay was 1 day (range 0-2). No operative or postoperative complications occurred. The reflux and obstructive symptoms had resolved immediately postoperatively in all patients. CONCLUSION: Patients with a NASB in place can experience proximal obstructive symptoms. Endoscopy is deceptive in judging the stomal size, because the endoscope can be pushed through the band area. Moreover, endoscopic dilation will offer no benefit in most patients with symptomatic banded Roux-en-Y gastric bypass. Laparoscopic removal of the NASB is safe, relieves the symptoms immediately, and can be applied to patients who have undergone both open and laparoscopic Silastic banded bariatric procedures.

Combined group and individual model for postbariatric surgery follow-up care.

BACKGROUND: The prevalence of bariatric surgery in the United States has increased significantly during the past decade, increasing the number of patients requiring postbariatric surgery follow-up care. Our objective was to develop and implement an efficient, financially viable, postbariatric surgery practice model that would be acceptable to patients. The setting was the Mayo Clinic (Rochester, MN). METHODS: By monitoring the attendance rates and using patient surveys, we tested patient acceptance of a new, shared medical appointment practice model in the care of postbariatric surgery patients. Efficiency was assessed by comparing differences in time per patient and total provider time required between the former and new care models. Individual-only patient/provider visits were replaced by combined group and individual visits (CGV). RESULTS: Our CGV model was well-attended and accepted. The patient attendance rate was >90% at all postoperative follow-up points. Furthermore, 83%, 85.2%, and 75.7% of the 3-, 6-, and 12-month postbariatric surgery patients, respectively, responded that they would not prefer to have only individual visits with their healthcare providers. The CGV model also resulted in greater time efficiency and cost reduction. On average, 5 patients were seen within 4.9 provider hours compared with 10.4 provider hours with the individual-only patient/provider visit model. Furthermore, the average billable charge for the CGV model's group medical nutrition therapy was 50-64% less than the equivalent individual medical nutrition therapy used in the individual-only patient/provider visit model. CONCLUSION: Shared medical appointments have a valuable role in the care of the postbariatric surgery population, offering a time- and cost-effective model for healthcare provision that is well-accepted by patients.