The surgical management of obesity in young women: consideration of the mother's and baby's health before, during, and after pregnancy.

BACKGROUND: Maternal obesity has a substantial associated morbidity and mortality affecting both mother and child. This has a major impact on provision of care due to increased requirements for both medical and surgical management of the consequences that follow obesity in pregnancy. METHODS: A review examined the English language literature on Medline databases describing the effect of obesity on pregnancy and outcomes of pregnancy after bariatric surgery. Guidelines from the National Institute for Clinical Excellence yielded information on selection criteria for fertility treatment and bariatric surgery. The World Health Organization definitions of overweight and obesity were adhered to throughout this review. RESULTS: The level of clinical and morbid obesity has shown a dramatic increase in women of childbearing age, with far-reaching consequences for both their own health and that of their offspring. Obese women require a substantial amount of additional clinical care beyond that offered to women of normal weight due to the wide range of medical and obstetric complications they experience. Recent evidence suggests that obesity may be implicated in approximately one-third of maternal deaths. The consensus of the literature is that the best way to reduce obesity-associated morbidity is by weight reduction before pregnancy. Where behavioral and medical interventions fail, the most successful method is bariatric surgery. The effect of surgery on the outcome of subsequent pregnancies indicate improved chances of normal pregnancy, delivery, and healthy babies. CONCLUSIONS: Bariatric surgery is a safe and effective method of weight loss for morbidly obese women of childbearing age, with favorable outcomes for pregnancies after surgery.

Vascular emergencies in cholelithiasis and cholecystectomy: our experience with two cases and literature review.

BACKGROUND: Complications from gallstones and laparoscopic cholecystectomy can be serious and fatal if there is a delay in recognition and treatment. We aim to present two unusual, life threatening vascular complications as a result of gallstones and laparoscopic cholecystectomy. Their management is highlighted with a brief review of literature. METHODS: Data for the article were gathered from clinical case note review. Radiology database was used for images. A brief literature review was undertaken using Pubmed search. The keywords used included hemobilia, pseudoaneurysm, arterio-biliary fistula and laparoscopic cholecystectomy. RESULTS: The article highlights two individual case reports. The first case constitutes an 81-year woman who had cystic arterial erosion causing hematemesis, while the second patient was a 57-year man who presented with hemobilia from a pseudoaneurysm of right hepatic artery (RHA) following laparoscopic cholecystectomy. Cystic arterial erosion was treated with subtotal cholecystectomy with duodenal defect closure while the pseudoaneurysm underwent radiological intervention. CONCLUSIONS: Cystic artery erosion and pseudoaneurysm causing arteriobiliary fistula are rare vascular complications related to the biliary tree. A high index of suspicion and timely intervention is important. Trauma to arteries should be avoided during laparoscopic cholecystectomy.

Biomarkers of Colorectal Cancer Risk Decrease 6 months After Roux-en-Y Gastric Bypass Surgery.

PURPOSE: The impact of weight loss on obesity-related colorectal cancer (CRC) risk is not well defined. Previous studies have suggested that Roux-en-Y gastric bypass (RYGB) surgery may have an unexpected adverse impact on CRC risk. This study aimed to investigate the impact of RYGB on biomarkers of CRC risk. MATERIALS AND METHODS: Rectal mucosal biopsies and blood were obtained from patients undergoing RYGB (n = 22) and non-obese control participants (n = 20) at baseline and at a median of 6.5 months after surgery. Markers of systemic inflammation and glucose homeostasis were measured. Expression of pro-inflammatory genes and proto-oncogenes in the rectal mucosa was quantified using qPCR. Crypt cell proliferation state of the rectal mucosa was assessed by counting mitotic figures in whole micro-dissected crypts. RESULTS: At 6.5 months post-surgery, participants had lost 29 kg body mass and showed improvements in markers of glucose homeostasis and in systemic inflammation. Expression of pro-inflammatory genes in the rectal mucosa did not increase and COX-1 expression fell significantly (P = 0.019). The mean number of mitoses per crypt decreased from 6.5 to 4.3 (P = 0.028) after RYGB. CONCLUSION: RYGB in obese adults led to lower rectal crypt cell proliferation, reduced systemic and mucosal markers of inflammation and improvements in glucose regulation. These consistent findings of reduced markers of tumourigenic potential suggest that surgically induced weight loss may lower CRC risk.

Changes in physical activity after bariatric surgery: using objective and self-reported measures.

BACKGROUND: Many studies using self-reported physical activity (PA) assessment tools have suggested there is an increase in PA after bariatric surgery. OBJECTIVES: Our aim was to assess PA and sedentary behavior before bariatric surgery and at 6 months after, using subjective and objective tools. SETTING: Bariatric surgery candidates were recruited from a single center. METHODS: Demographic data, medical history, current medications, and anthropometric measurements were recorded. Participants were asked to complete a PA and lifestyle questionnaire and to wear an accelerometer on their nondominant wrist. Data were collected before and at 6 months after surgery. RESULTS: Twenty-two participants were included (17 gastric bypass; 4 sleeve gastrectomy; 1 intragastric balloon). Mean age was 46 years and the majority were female (72%). At a median of 6.3 months follow-up, there were significant reductions in measures of body fatness with a mean reduction of 27 kg in weight. The majority of daytime (12.5±1.1 out of 16 h) was spent in sedentary behavior presurgery with little change postsurgery (12.2±1.2; P = .186). Objectively measured mean moderate-vigorous PA did not change significantly from pre- to postsurgery (mean 11.5±13.9 and 11.6±13.1 min/d, respectively; P = .971). Self-reported total nonoccupational PA did not change significantly (P = .390). CONCLUSIONS: The majority of bariatric surgery candidates were physically inactive presurgery, and there was no significant change in either subjectively or objectively measured PA at follow-up. This patient group may benefit from objective PA assessment and interventions aimed at increasing PA.

Ascertaining the Place of Social Media and Technology for Bariatric Patient Support: What Do Allied Health Practitioners Think?

BACKGROUND: There is an increasing presence of patient-led social media, mobile apps and patient support technology, but little is known about the role of these in the support of bariatric surgery patients in the UK. This study aimed to seek the views of allied health professionals (AHPs) working in bariatric surgical teams to understand their current perceptions of the role of social media, mobile apps and patient-support technology within bariatric surgery in the UK. METHODS: A confidential, printed survey was distributed to the AHPs at the British Obesity and Metabolic Surgery Society (BOMSS) 7th Annual Scientific Conference in January 2016. An email to AHPs who did not attend the conference was sent requesting voluntary participation in the same survey online through Survey Monkey® within 2 weeks of the conference. RESULTS: A total of 95 responses were received, which was a 71% response rate (n = 134). Responses were from nurses (34%, n = 46), dietitians (32%, n = 32), psychologists (16%, n = 12) and 1 nutritionist, 1 physiotherapist, 1 patient advocate, 1 surgeon and 9 respondents did not fill in their title. CONCLUSION: The use of social media and mobile apps by patients is increasing, with AHPs concerned about misinformation; advice may differ from what is given in clinic. Technologies, e.g. telehealth and videoconferencing are not widely used in bariatric surgery in the UK. AHPs are unclear about the role of technologies for bariatric surgical patient support. Further discussions are needed to understand the potential of technology with AHPs supporting/facilitating patients as this becomes more commonplace.

The Effects of Bariatric Procedures on Bowel Habit.

BACKGROUND: Bariatric procedures are increasingly being used to combat the rising obesity epidemic. The aim of this study was to assess the effect of these interventions on bowel habit. METHODS: We recruited obese adults listed for a bariatric procedure. Demographic data, medical history, medications and anthropometric measurements were recorded. Bowel habit was characterized using a 7-day Bristol Stool Form Scale (BSFS) diary. A validated food frequency questionnaire (FFQ) was used to assess diet. RESULTS: Twenty-six patients were assessed pre-operatively and at a median of 6.4 months post-operatively. Nineteen had a Roux-en-Y gastric bypass (RYGB), five had a sleeve gastrectomy (SG) and two had an intra-gastric balloon (IGB) with median percentage excess weight loss (% EWL) of 67.9, 52.4 and 31.3 %, respectively. Dietary fibre intake decreased from 24.4 (±12.1) g/day pre-operatively to 17.5 (±7.3) g/day post-operatively (P = 0.008). Frequency of bowel motions decreased from 8.6 (±3.5) to 5.7 (±3.5) motions/week (P = 0.001). Mean usual BSFS score decreased (towards firmer stool) from 4.1 (±1.3) pre-operatively to 3.1 (±1.9) post-operatively (P = 0.016). Constipation increased from 8 to 27 %, but this did not reach statistical significance (P = 0.125). CONCLUSIONS: Constipation is a common problem after bariatric surgery. The decrease in bowel motion frequency and change towards firmer stools suggest prolonged intestinal transit time after bariatric procedures. Reduction in dietary fibre intake is likely to be a contributory factor.

Weight Loss Decreases Excess Pancreatic Triacylglycerol Specifically in Type 2 Diabetes.

OBJECTIVE: This study determined whether the decrease in pancreatic triacylglycerol during weight loss in type 2 diabetes mellitus (T2DM) is simply reflective of whole-body fat or specific to diabetes and associated with the simultaneous recovery of insulin secretory function. RESEARCH DESIGN AND METHODS: Individuals listed for gastric bypass surgery who had T2DM or normal glucose tolerance (NGT) matched for age, weight, and sex were studied before and 8 weeks after surgery. Pancreas and liver triacylglycerol were quantified using in-phase, out-of-phase MRI. Also measured were the first-phase insulin response to a stepped intravenous glucose infusion, hepatic insulin sensitivity, and glycemic and incretin responses to a semisolid test meal. RESULTS: Weight loss after surgery was similar (NGT: 12.8 ± 0.8% and T2DM: 13.6 ± 0.7%) as was the change in fat mass (56.7 ± 3.3 to 45.4 ± 2.3 vs. 56.6 ± 2.4 to 43.0 ± 2.4 kg). Pancreatic triacylglycerol did not change in NGT (5.1 ± 0.2 to 5.5 ± 0.4%) but decreased in the group with T2DM (6.6 ± 0.5 to 5.4 ± 0.4%; P = 0.007). First-phase insulin response to a stepped intravenous glucose infusion did not change in NGT (0.24 [0.13-0.46] to 0.23 [0.19-0.37] nmol ⋅ min(-1) ⋅ m(-2)) but normalized in T2DM (0.08 [-0.01 to -0.10] to 0.22 [0.07-0.30]) nmol ⋅ min(-1) ⋅ m(-2) at week 8 (P = 0.005). No differential effect of incretin secretion was observed after gastric bypass, with more rapid glucose absorption bringing about equivalently enhanced glucagon-like peptide 1 secretion in the two groups. CONCLUSIONS: The fall in intrapancreatic triacylglycerol in T2DM, which occurs during weight loss, is associated with the condition itself rather than decreased total body fat.

Guidelines for the follow-up of patients undergoing bariatric surgery.

Bariatric surgery can facilitate weight loss and improvement in medical comorbidities. It has a profound impact on nutrition, and patients need access to follow-up and aftercare. NICE CG189 Obesity emphasized the importance of a minimum of 2 years follow-up in the bariatric surgical service and recommended that following discharge from the surgical service, there should be annual monitoring as part of a shared care model of chronic disease management. NHS England Obesity Clinical Reference Group commissioned a multi-professional subgroup, which included patient representatives, to develop bariatric surgery follow-up guidelines. Terms of reference and scope were agreed upon. The group members took responsibility for different sections of the guidelines depending on their areas of expertise and experience. The quality of the evidence was rated and strength graded. Four different shared care models were proposed, taking into account the variation in access to bariatric surgical services and specialist teams across the country. The common features include annual review, ability for a GP to refer back to specialist centre, submission of follow-up data to the national data base to NBSR. Clinical commissioning groups need to ensure that a shared care model is implemented as patient safety and long-term follow-up are important.

The effects of bariatric surgery on colorectal cancer risk: systematic review and meta-analysis.

Obesity is an established risk factor for colorectal cancer (CRC) but the effects of bariatric surgery on CRC incidence are uncertain. A systematic review of six electronic databases identified 3691 articles. Four observational studies met our inclusion criteria and results were pooled using a random effects model. Meta-analysis of these four studies revealed that bariatric surgery was associated with a significantly (p = 0.004) lower CRC incidence (RR = 0.73, 95 % confidence interval, 0.58 - 0.90) when compared with obese non-operated individuals, i.e., bariatric surgery is associated with a 27 % lower CRC risk. However the evidence base is limited and these findings should be confirmed by future studies with improved designs.

Risk factors in laparoscopic cholecystectomy: a multivariate analysis.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the operation of choice in the treatment of symptomatic gallstone disease. The aim of this study is to identify risk factors for LC, outcomes include operating time, length of stay, conversion rate, morbidity and mortality. METHODS: All patients undergoing LC between 1998 and 2007 in a single district general hospital. Risk factors were examined using uni- and multivariate analysis. RESULTS: 2117 patients underwent LC, with 1706 (80.6%) patients operated on electively. Male patients were older, had more co-morbidity and more emergency surgery than females. The median post-operative hospital stay was one day, and was positively correlated with the complexity of surgery. Conversion rates were higher in male patients (OR 1.47, p = 0.047) than in females, and increased with co-morbidity. Emergency surgery (OR 1.75, p = 0.005), male gender (OR 1.68, p = 0.005), increasing co-morbidity and complexity of surgery were all positively associated with the incidence of complications (153/2117 [7.2%]), whereas only male gender was significantly associated with mortality (OR 5.71, p = 0.025). CONCLUSION: Adverse outcome from LC is particularly associated with male gender, but also the patient's co-morbidity, complexity and urgency of surgery. Risk-adjusted outcome analysis is desirable to ensure an informed consent process.

Quality of life following laparoscopic anterior 90 degrees versus Nissen fundoplication: results from a multicenter randomized trial.

BACKGROUND: The short-term clinical outcomes from a multicenter prospective randomized trial of laparoscopic Nissen versus anterior 90 degrees partial fundoplication have been reported previously. These demonstrated a high level of satisfaction with the overall outcome following anterior 90 degrees fundoplication. However, the results of postoperative objective tests and specific clinical symptoms are not always consistent with an individual patient's functional status and general well being following surgery, and quality of life (QOL) is also an important outcome to consider following surgery for reflux. Hence, QOL information was collected in this trial to investigate the hypothesis: improvements in QOL following laparoscopic antireflux surgery are greater after anterior 90 degrees partial fundoplication than after Nissen fundoplication. METHODS: Patients undergoing a laparoscopic fundoplication for gastro-esophageal reflux at one of nine university teaching hospitals in six major cities in Australia and New Zealand were randomized to undergo either laparoscopic Nissen or anterior 90 degrees partial fundoplication. Quality of life before and after surgery was assessed using validated questionnaires - the Short Form 36 general health questionnaire (SF36) and an Illness Behavior Questionnaire (IBQ). Patients were asked to complete these questionnaires preoperatively and at 3, 6, 12 and 24 months postoperatively. RESULTS: One hundred and twelve patients were randomized to undergo a Nissen fundoplication (52) or a 90 degrees anterior fundoplication (60). Patients who underwent anterior fundoplication reported significant improvements in eight of the nine SF36 scales compared to four of the nine following a Nissen fundoplication. The majority of these improvements occurred early in the postoperative period. With respect to the illness behavior data, there were no significant differences between the two procedures. Both groups had a significant improvement in disease conviction scores at all time points compared to their preoperative scores. CONCLUSIONS: Patients undergoing laparoscopic anterior 90 degrees partial fundoplication reported more QOL improvements in the early postoperative period than patients undergoing a Nissen fundoplication. However, the QOL outcome for both procedures was similar at later follow-up.

Functional activity of natural antibody is altered in Cr2-deficient mice.

The major source of natural IgM Abs are B-1 cells, which differ from conventional B cells in their anatomic location, cell surface phenotype, restricted usage of particular V(H) genes and limited use of N-region addition during V-D-J rearrangement. The origin of B-1 cells is unclear. However, they are capable of self-renewal and their development is sensitive to signaling via the B cell receptor, as genetic defects that impair the strength of the signal often result in limited development. These findings suggest that B-1 cells require either an intrinsic signal, or contact with Ag, for positive selection and expansion and/or maintenance in the periphery. In support of interaction with cognate Ag, deficiency in the complement receptors CD21/CD35 results in a 30-40% decrease in the CD5(+) B-1 population. To determine whether this reduction reflects a loss of certain specificities or simply a proportional decline in the repertoire, we examined peritoneal B cells isolated from Cr2(+) and Cr2(def) mice for recognition of a B-1 cell Ag, i.e., phosphatidylcholine, and assayed for injury in an IgM natural Ab-dependent model of reperfusion injury. We found a similar frequency of phosphatidylcholine-specific CD5(+) B-1 cells in the two strains of mice. By contrast, the Cr2(def) mice have reduced injury in the IgM-dependent model of reperfusion injury. Reconstitution of the deficient mice with pooled IgM or adoptive transfer of Cr2(+) peritoneal B cells restored injury. These results suggest that complement receptors CD21/CD35 are important in maintenance of the B-1 cell repertoire to some, but not all, specificities.