Rising role of obesity surgery caused by increase of morbid obesity, failure of conventional treatments and unrealistic expectations: trends from 1997 to 2001.

BACKGROUND: The authors analyzed the trends in anthropometric and behavioral characteristics among patients seeking weight loss and the trends in choice of treatments, between 1997 and 2001 in an outpatient obesity clinic. PATIENTS AND METHODS: 138 and 128 consecutive patients attending the out-patient obesity clinic at University Hospital of Lausanne were screened in 1997 and in 2001 respectively. Eating habits, body composition and treatment used were assessed. RESULTS: Median BMI was 35 kg/m2 in 1997 and 38 kg/m2 in 2001 (P <0.001) and waist circumference was 99 cm and 111 cm respectively (P <0.001). This increase in the average body weight involved especially patients <30 years old (P <0.01). Morbid obesity increased by 16% (P <0.01), and prevalence of abdominal obesity by 13% (P < 0.05). The median desired weight loss increased significantly from 25% to 29% (P <0.05). 64% of the patients in 1997 and 83% in 2001 (P <0.01) hoped for a weight loss of 20% of their baseline weight. Motivation to lose weight for esthetic reasons was found in 81% of the women and 55% of the men in 1997 (P <0.01), while in 2001 the percentage was 89 and 43 respectively (P <0.001). CONCLUSION: In spite of the increasing access to weight loss programs, we found that the patients are more severely obese, especially those <30 years old, and have more unrealistic expectations of weight loss. This may explain the doubling of the patients treated by surgery.

Effects of laparoscopic gastric banding on body composition, metabolic profile and nutritional status of obese women: 12-months follow-up.

BACKGROUND: Obesity is frequently associated with metabolic and cardiovascular co-morbidities and high mortality rates. Besides, because of the increasingly recognized fact that conservative therapy for morbid obesity is associated with an almost 90-95% failure rate in the long term, and probably because of the development of laparoscopic surgery,the demand for bariatric surgery is increasing rapidly. The significant weight loss observed during the first 6-12 months after gastric banding is related to the severe food restriction, related hypercatabolism, and has a potential risk of mineral and vitamin deficiencies. The aim of this study was to evaluate the effects of gastric banding on total body composition, metabolic profile and nutritional status. METHODS: 31 women were studied with median age 36 years (range 25-52), body weight 118.6 kg (range 98-156), BMI 43.6 kg/m(2) (range 36-56 kg/m(2)), percentage of excess body weight (%EW) of 107% (range 72- 166%), waist 115 cm (range 98-132) and hip 138 cm (range 119-155). Total body composition was measured before, 6 and 12 months after laparoscopic gastric banding, using dual-energy x-ray absorptiometry. Metabolic and nutritional profile were evaluated before and 1, 3, 6, 9 and 12 months postoperatively. RESULTS: There was a 23.3% reduction of total body weight and 36.8% reduction of body fat. Unfortunately we also observed a reduction of Fat Free Mass (FFM) of 9.6%. In addition, the major determinants of weight loss were the initial body weight and abdominal distribution of fat mass. Reduction of FFM was positively correlated with the rapidity of weight loss. A significant improvement of glucidic profile was observed, with disappearance of impaired fasting glucose, and normalization of the values of triglycerides in all patients. The prevalence of the metabolic syndrome decreased from 89% in preoperative conditions to 15% 1 year after gastric banding. No major nutritional deficiencies was found following gastric banding. CONCLUSIONS: This prospective study suggests that the first 6 months postoperatively are crucial for weight loss and changes in body composition. Furthermore, the significant reduction of body weight is accompanied by an important improvement of biological abnormalities.

Early results of laparoscopic gastric banding compared with open vertical banded gastroplasty.

BACKGROUND: The introduction of laparoscopy and the increasing awareness that surgery is the only efficient long-term treatment for morbid obesity have been followed by an enormous increase in the demand for bariatric surgery. We introduced laparoscopic gastric banding (GB) in 1995, after a 15-year experience with vertical banded gastroplasty (VBG). The aim of this article is to compare the early results of this new technique with those of VBG. METHODS: The charts of all the patients who underwent VBG (group A) between 1981 and 1995 were reviewed. The data for the patients who underwent laparoscopic GB (group B) between December 1995 and March 1998 were collected prospectively. Weight loss was compared between groups. All the complications arising during follow-up in the laparoscopy group were considered for analysis. In the VBG group, the complications during the first 18 postoperative months were taken into consideration. RESULTS: There were 197 patients in group A and 76 patients in group B. The ages and risk factors were similar in both groups, but the mean body weight (116 kg vs. 121 kg, P < 0.01) and the mean body mass index (BMI) (42.7 versus 45.5, P < 0.001) were significantly higher in the laparoscopy group. If the first 30 patients of group B are excluded, duration of surgery was not different between groups. Mortality was similar, but the postoperative morbidity was higher in the VBG group (23.8% vs. 8.0%, P < 0.005). The hospital stay was much shorter in group B. Weight loss was less after 6 and 12 months in group B but was similar after 18-24 months in both groups. During early follow-up as defined in the Methods section, overall morbidity and the need for reoperation were not different between groups. Most complications were noted among the first 30 patients operated on. CONCLUSIONS: Laparoscopic GB takes no longer to perform than VBG once the learning curve is over. It is associated with less postoperative morbidity and a much shorter hospital stay. Weight loss is slower after laparoscopic GB but is similar to that achieved after 18-24 months by VBG. With proper surgical technique, laparoscopic GB can be performed adequately with a very low rate of postoperative and long-term complications. Considering the high incidence of long-term complications after VBG, it is probable that laparoscopic GB will eventually replace VBG as the restrictive procedure of choice for morbid obesity.

Impact of preoperative teaching on surgical option of patients qualifying for bariatric surgery.

BACKGROUND: During the last 5 years, the performance of bariatric operations has doubled via our outpatient obesity clinic. Currently, 52% of the patients presenting for weight loss are interested in bariatric surgery. Gastric banding and Roux-en-Y gastric bypass are the two laparoscopic procedures proposed. The aim of this study was to evaluate the impact of preoperative teaching on the patients' surgical option. METHODS: All the candidates for bariatric surgery were submitted to preoperative teaching and those between February 2001 and December 2002 are the subject of this study. The teaching consisted of 3 weekly interactive 2-hour sessions. During the first session, the patients were asked about the type of operation that they had in mind: gastric banding, gastric bypass, or not yet decided. The same questions were repeated at the end of the third session, with an additional possible answer: no surgery. RESULTS: 297 consecutive patients with a BMI >35 kg/m(2) with at least one severe co-morbidity, were submitted to preoperative teaching. 80% of the patients were women. Median age was 41 years. Before teaching, 68 patients (23%) were uncertain, 100 (34%) favored gastric banding, and 129 (43%) wanted a gastric bypass. After education, only 3 patients (1%) remained uncertain, 45 (15%) changed their surgical option, and 27 (9%) declined surgery. The proportion of patients opting for gastric banding decreased from 34% to 20%, whereas those electing bypass increased from 43% to 70%. CONCLUSIONS: Preoperative training provides an informed and better patient selection for bariatric surgery. It helps the patients understand the various surgical options, and makes their decision easier.

Laparoscopic Roux-en-Y gastric bypass: initial 2-year experience.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP)-essentially a restrictive bariatric procedure-is currently considered the gold standard for the surgical treatment of morbid obesity. Open surgery in obese patients is associated with a high risk of cardiopulmonary complications, wound infection, and late incisional hernia. Laparoscopic surgery has been shown to reduce perioperative morbidity and to improve postoperative recovery for various procedures. Herein we present our results with laparoscopic RYGBP after an initial 2-year experience. METHODS: A prospective database was created in our department beginning without the first laparoscopic bariatric procedure. To provide a complete follow-up of 6 months, the results of all patients operated on between June 1999 and August 2001 were reviewed. Early surgical results, weight loss, correction of comorbidities, and improvement of quality of life were evaluated. RESULTS: A total of 107 patients were included. There were 82 women and 25 men, with a mean age of 39.7 years (range, 19-58). RYGBP was a primary procedure in 80 cases (49 morbidly obese and 31 superobese patients) and a reoperation after failure or complication of another bariatric operation in 27 cases. Mean duration of surgery was 168 min for morbidly obese patients, 196 min for surperobese patients, and 205 min for reoperated patients (p <0.01). Conversion to open surgery was necessary in two cases. A total of 22 patients (20.5%) developed complication. Nine of them (8.4%) required reoperation for leak (five cases, or 4.6%), bowel occlusion (three cases, or 2.8%), or subphrenic abscess (one case, or 0.9%). mortality was 0.9%. Major morbidity decreased over time (first two-thirds, 12.5%, last third, 2.7%). major morbidity decreased over time (first two-thirds, 12.5%; last third, 2.7%). Excess weight loss of -50% was achieved in >80% of the patients, corresponding to a loss of 15 body mass index (BMI) units in morbidly obese patients and 20 BMI units in superobese patients. In the vast majority of patients, comorbidities improved or disappeared over time and quality of life improved. CONCLUSIONS: Laparoscopic Roux-en-Y gastric bypass is feasible, but it is a very complex operation. Indeed, it is associated with a long and steep learning curve, as reflected in the high number of major complications among our first 70 patients. The learning curve probably includes between 100 and 150 patients. With increasing experience, the morbidity rate becomes more acceptable and comparable to that of open RYGBP. The results in terms of weight loss and correction of comorbidities are similar to those obtained after open surgery, at least in the short term. However, only surgeons with extensive experience in advanced laparoscopic as well as bariatric surgery should attempt this procedure.

Laparoscopic gastric banding.

INTRODUCTION: Laparoscopic gastric banding (LGB) is currently the most popular purely restrictive bariatric operation in Europe and many other countries. It has a low operative morbidity, but is associated with a substantial late complication rate. Many late complications have been attributed to technical errors or to the learning curve. The aim of this paper is to present our results with gastric banding after the learning curve in order to disclose the true incidence of long-term complications. METHODS: LGB was introduced in our department in December 1995. Thirty patients were operated on until June 1997 using the early banding technique (band within the lesser sac), at which time the surgical technique was slightly modified in order to place the band above the lesser sac. Then another 300 patients underwent LGB using either the Lapband or the SAGB system. This report focuses on the latter patients. All the data were collected prospectively. RESULTS: The series includes 300 patients (257 women and 43 men) with a mean age of 38.3 years (19-64). The mean initial weight was 119.2 kg (57-179), initial body mass index (BMI) was 43.3 kg/m2 (21-64), and initial excess weight was 96.5% (0-191). The mean duration of surgery was 90 min, decreasing over time to a mean of 75 min for the last 50 cases. Early overall morbidity was 6.6%. Major complications occurred in 7 patients (2.3%). Excess weight loss (EWL) was at least 50% in 66% of the patients after 2 years, averaging 60%, with no substantial change until 4 years, and the BMI stabilized between 30 and 31 kg/m2. Forty-nine patients developed a total of 52 long-term complications, of which 23 (7.6%) were related only to the port or catheter. Band erosion occurred in 17 (5.6%), pouch dilatation with slippage in 8 (2.6%), and infection in 4 (1.3%) patients. Fifty-five reoperations were necessary. Twenty-five of these were related only to the port. The band was removed from 26 (9%) patients, of whom 17 were converted to Roux-en-Y gastric bypass. CONCLUSIONS: LGB gives satisfactory results in terms of weight loss in about two-thirds of the patients. Even beyond the learning curve, the long-term morbidity is not negligible, but is acceptable compared to other procedures such as vertical banded gastroplasty. Conversion to gastric bypass is possible when complications occur and can be performed when the band is removed in most cases.

[The contribution of epidemiology to the definition of obesity and its risk factors]. / Les contributions de l'épidémiologie dans la définition de l'obésité et de ses facteurs de risque.

Whereas up to the end of the last century overweight reflected the privilege of the high society and her relative good health, the recent epidemiological studies have assessed the relations between body weight and general or cause specific morbidity and mortality. The major diseases associated with obesity are hypertension, atherosclerosis and diabetes, as well as certain types of cancer. Less well known complications include hepatic steatosis, gallbladder diseases, pulmonary function impairment, endocrine abnormalities, obstetric complications, trauma to the weight bearing joints, gout, cutaneous diseases, proteinuria, increased hemoglobin concentration and possibly immunologic impairments. From these wide epidemiological studies arise the definition of obesity: with an excess of 20% beyond the desirable weight, the complications bound to the overweight become statistically more frequent. Over there a U or J shaped curve illustrates the relation between the overweight and the degree of these various complications. An excess of 45 kg or more represents the critical level which defined "morbid obesity" with its own complications, the most important are sudden unexplained death, ventilatory disorders, circulatory congestion and functional limitations in activities of daily living and of course psychological consequences. When for certain complications, such as diabetes, the relationship with the overweight is evident, discrepancies between certain studies, especially for the cardiovascular diseases, had focused the attention on the regional patterns of fat distribution. Cross-sectional studies have shown abdominal obesity to be strongly associated with risk factors for cardiovascular disease, stroke and death independent of the total degree of obesity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Drug treatment of obesity]. / Le traitement médicamenteux de l'obésité.

Anorectic agents constitute the most widely used supportive drug treatment in obesity as well as that most often prescribed. A large number of substances have been proposed for this purpose, and some have been found to be reasonably effective, while others exhibiting side effects which forbid their use, as thyroid hormones and diuretic agents. There are other substances with properties that might justify their use, such as ballast preparations, some antidepressive agents, and a few compounds acting principally on the gastrointestinal tract. Of current interest are substances furthering thermogenesis, but for the time being these remain in the realm of pure research. The anorectic agents usually available bring about a weight loss of about 0.5 lb (0.230 kg) per week more than prescription of a placebo, though only over a limited period of time. Once the drug is discontinued, weight regain is the rule and it appears even that association of an anorectic agent to behavioural therapy might have an unfavourable effect on maintenance of the weight loss. Their use is therefore difficult to justify except in the rare cases where a short-term reduction in weight is desired or in patients suffering from an illness linked to their overweight. Differences in eating habits observed with amphetamines compared with fenfluramine and its dextrorotatory isomer dexfenfluramine suggest that these compounds could play a supportive role in the management of obese patients along with the dietetic training and changes in eating habits which are still fundamental to the medical treatment of obesity.

[The intragastric balloon: a logical and attractive idea, but probably ineffective]. / Le ballon intragastrique: une idée logique et séduisante, mais probablement inefficace.

Loss of post prandial satiety is often of limiting value in the success of a slimming training. Thus, the idea to introduce a balloon filled partially with air to occupy the stomach seems to be logic. A technic easy to handle had contributed to a large diffusion of this method before people asked about its real efficacy. Several short term (10 days) or medium term (6-10 months) studies show a significant weight loss, but there have been no controlled trials to determine the relative contribution to weight loss of the gastric balloon vs dietary and behaviour modifications. Furthermore, a great variability in the weight loss, some subjects even gaining weight, suggest that the compliance of the patients may be the most relevant factor. Adverse effects are effectively low and principally concern local gastric irritation (2-5%) and intestinal occlusion in some rare cases requiring surgical removal of the partially deflected balloon. Thus, if the implantation of a gastric balloon is relatively safe, it is difficult to recommend its use to the treatment of obesity in regard of the actual published results, even if most of the treated patients suffered of refractory obesity, difficult to modify with non surgical treatment.

Gastric banding induces negative bone remodelling in the absence of secondary hyperparathyroidism: potential role of serum C telopeptides for follow-up.

OBJECTIVE: Data about the consequences of laparoscopic adjustable gastric banding (LAGB) on phospho-calcic and bone metabolism remain scarce. SUBJECTS: We studied a group of 37 obese premenopausal women (age: 24-52 y; mean BMI = 43.7 kg/m2) who underwent LAGB. METHODS: Serum calcium, phosphate, alkaline phosphatase, parathormone (PTH), vitamin D3, serum C-telopeptides, IGFBP-3 and IGF-1 were measured at baseline, 6, 12, 18 and 24 months after surgery. Body composition, bone mineral content (BMC) and density (BMD) were measured using dual-X-ray absorptiometry (DXA) at baseline, 6, 12 and 24 months after surgery. RESULTS: There was no clinically significant decrease of calcemia; PTH remained stable. Serum telopeptides increased by 100% (P < 0.001) and serum IGFBP-3 decreased by 16% (P < 0.001) during the first 6 months, and then stabilized, whereas IGF-1 remained stable over the 2 y. BMC and BMD decreased, especially at the femoral neck; this decrease was significantly correlated with the decrease of waist and hip circumference. CONCLUSIONS: We concluded that there was no evidence of secondary hyperparathyroidism 24 months after LAGB. The observed bone resorption could be linked to the decrease of IGFBP-3, although this decrease could be attributable to other confounding factors. Serum telopeptides seem to be a reliable marker of bone metabolism after gastric banding. DXA must be interpreted cautiously during major weight loss, because of the artefacts caused by the important variation of fat tissue after LAGB.

[Tolerance and acceptability of dexfenfluramine in the long-term treatment of obesity in private practice. ESIM Group]. / Tolérance et acceptabilité de la dexfenfluramine dans le traitement à long terme de l'obésité en pratique privée. Groupe ESIM.

OBJECTIVE: The value of a one year prescription of dexfenfluramine (dF) was demonstrated by a large multicentric study performed in centres specialised in the treatment of obesity (Guy-Grand 1989). We tried to evaluate the safety and acceptability of this treatment prescribed in routine practice. METHOD: 27 internal physicians or general practitioners recruited 58 overweight patients who received 15 mg of dF twice a day in association with a balanced hypocaloric diet and were followed for one year with two-monthly visits, plus a visit after the first month of treatment. At each visit, the patients were weighed and completed a questionnaire concerning hunger sensations, appetite, preference for sweet foods and the number of meals per day. RESULTS: 32 of the 58 patients (55%) followed the proposed treatment for 12 months. The dietary survey showed a significant reduction until the sixth month, then a maintenance until the twelfth month for the number of meals per day, the urge to eat, as well as the desire for foods prohibited by the diet. The course of the desire to eat sweet foods was similar but non-significant as compliance with diet deteriorated regularly with time from the second month of treatment onwards. Drug consumption, evaluated by the doctor, was regular for 79% of patients after 6 months and for 77% of patients at the end of the study. Acceptability was considered to be good or very good for 92% of patients after 6 months and for 97% after 12 months. The mean weight loss for the 32 patients who complied with treatment for twelve months was 8.8 kg, close to 10% of their initial weight. DISCUSSION: The long-term addition of dF to a moderate low calorie diet was well tolerated and perceived as an aid by the majority of patients. The weight loss achieved by general practice management, as well as the proportion of patients who completed 12 months of treatment, was close to that observed by Guy-Grand and should encourage general practitioners to undertake the outpatient treatment of obesity.

[Therapeutic strategy in obesity]. / Stratégie thérapeutique dans l'obésité.

Therapeutic strategy in obesity depends on the patient. No diet is more effective or better than another; in fact a diet is more successful because the doctor's choice is adapted to his patient. Although the choice is relatively restrictive, the therapeutic options are variable enough to include a range from behavioral therapies to surgery. The different approaches to treatment are evaluated according to the degree of overweight, but perhaps above all to the personality and motivation of the obese patient, suggested by his dietary habits and the prior evolution of his body weight. As a complement, clinical examination may detect possible endocrinopathies and laboratory results are restricted to making certain that the patient is in good health and/or to confirming the expected metabolic complications of obesity.

Short and long term results of a progressive reintroduction of carbohydrates (PRCH) after a protein-sparing modified fast (PSMF).

Most studies report on a more than 50 percent weight regain 2-3 years after PSMF. We studied the effect of a progressive reintroduction of carbohydrates (PRCH) after a PSMF diet based on natural foods which delivered 800-1200 kcal, 1.2-1.4 g protein/kg of ideal weight, less than 40 g CHO/day. Among 1270 outpatients between 1981-1985, 87 (18M, 69F, age 41.3 +/- 13.8, BMI 32.9 +/- 5.1) followed both PSMF and PRCH. Follow-up was obtained for 57 patients, 1/3 by direct examination, 2/3 by letter. Weight remained stable during PRCH, in opposition to other reports. Best results during PRCH were found in patients with optimal compliance to PSMF, as measured by rate of weight loss (r = 0.284). Only about 40 percent of the obtained weight loss was regained 39.5 months after the treatment. Progressive reintroduction of carbohydrates prevents the expected weight regain after PSMF and even seems to have a positive effect on long term weight maintenance.

Predictive factors of binge eating disorder in women searching to lose weight.

METHODS: The aim of this study was to detect predictive factors of binge eating disorder (BED) in an out-patient obesity clinic. Eating behaviour, weight history and body composition were assessed in 138 consecutive patients. BED was diagnosed according to the criteria of appendix B of the Diagnostic and Statistical Manual of Mental Disorders. RESULTS: The body mass index (BMI; p < 0.005) and the waist circumference (p < 0.05) were significantly higher in binge patients than in patients without eating disorders. Similar differences were observed between patients who regularly went through weight loss programmes and patients who consulted for the first time. The prevalence of BED increases with the degree of obesity and especially with the number of previous intentional weight loss programmes. A positive and significant correlation was found between the weight cycling syndrome and BMI (p < 0.0001), waist circumference (p < 0.0001) and body fat (p < 0.001). DISCUSSION: The patients with BED present a specific anthropometric profile and a typical behavioural pattern characterized by a higher degree of central obesity and a weight history with a higher number of attempts of weight loss.

[Ten questions on the causes and consequences of obesity: stress hormones]. / Dix questions sur les causes et les conséquences de l'obésité: des hormones aux stress.

In Switzerland, 6% of men and 5% of women are obese (BMI > 30); 33% of men and 17% of women are overweight (BMI 25-30). Both genetic and environmental factors are responsible for obesity. There is an increased risk of C-V disease, diabetes and steato-hepatitis in abdominal obesity (abdominal circumference > 102 cm for men and > 88 cm for women). There is also an increased level of cortisol, which could be due to a difficulty to cope with psycho-social stress. Leptine and different hormones play a role in fat storage. Menopause and pregnancy are moderate risk factors for obesity. Weight gain may also result from different drugs, smoking cessation and stress. Eating disorders such as boulimia and binge eating must be diagnosed and treated. Beneficial health effect of weight loss is analysed.

[Ten questions on the treatment of obesity: from dieting to surgery]. / Dix questions sur les traitements de l'obésité: des régimes à la chirurgie.

Advantages and risk of weight reduction achieved by combining diets or unbalanced diets with restriction of carbohydrates or fat are discussed. Nutriments differ according to their density, their flavour, their satiating, and their thermogenic effect. Food is also a source of pleasure and a remedy to frustration. One of the problems of dieting is that most patients regain the weight they have lost due to a hypometabolism secondary to caloric restriction. Only physical exercise together with behavior therapy are able to slow down this weight regain. The indication of drug treatment with orlistat, sibutramine and fluoxetin and the indication to bariatric surgery are presented. The importance of the prevention of obesity by nutrition teaching in schools as well as the necessity of a long term treatment as in type II diabetes are underlined.

[Effect of eating habits on morbidity in 645 patients at a specialized clinic]. / Influence des habitudes alimentaires sur la morbidité chez 645 patients obèses d'une consultation spécialisée.

Among 645 obese patients examined at an out-patient clinic for obese patients by physical examination and a computerized questionnaire, two subgroups of patients could be identified according to their nutritional preferences: 177 patients preferred carbohydrates exclusively (group A) and 73 patients fat exclusively (group B). No definite preferences were formulated by the other patients. Among patients under 25 years, only 3 belonged to group B and 49 to group A, while in older patients no significant differences were found. Among patients with BMI less than 30, there were significantly fewer patients from group B than from group A (p = 0.006), while in patients with BMI greater than 30 no significant difference was observed. There were significantly more men in group B than in group A. 57% of the patients of group B complained of physical symptoms related to their obesity, compared to 37% in group A (p = 0.006). 26% of group B suffered from joints and muscles compared to 13% of group A (p = 0.003). Hyperglycemia (greater than 5,6 mmol/l) was found in 21% of group A and in 40% of group B (p less than 0.005). Hypercholesterolemia (greater than 6.5 mmol/l) was found in 20% of group A and in 32% of group B (p less than 0.05). In conclusion, obese patients who prefer fat have more general symptoms related to obesity, more abnormal physical signs, and more frequently have hyperglycemia and hypercholesterolemia than patients who prefer carbohydrates.