Long-term impact of weight loss for people with overweight but not obesity, and with type 2 diabetes: 10-year outcomes of a randomized trial of gastric band surgery.

AIM: Randomized trials reporting 5-year outcomes have shown bariatric surgery  to induce diabetes remission and improve cardiovascular risk. However, the longer-term effects of surgery are uncertain, with only one randomized trial reporting 10-year diabetes outcomes in people with obesity. We aimed to compare 10-year diabetes outcomes of people who are overweight but not obese, randomly assigned to receive either multidisciplinary diabetes care, or multidisciplinary diabetes care combined with gastric band (GB) surgery. METHODS: Between 2009 and 2011, 51 adults were randomized. After 5 years, they were discharged to receive community care and reassessed after 10 years. The primary outcome was diabetes remission, defined as glycated haemoglobin (HbA1c) <6.5% (48 mmol/mol) without glucose-lowering medication. RESULTS: Forty-one participants (20 medical and 21 GB) completed the 10-year assessment. The median (Q1, Q3) weight loss in the GB group was 9.8 (6.7, 16.3)% at 10 years compared with 5.6 (3.4, 7.6)% in the medical group (median difference 4.2%; p = .008). Diabetes remission occurred in five GB participants and no medical participants (relative risk 0.76, 95% CI: 0.55-0.93, p = .048). GB participants used fewer glucose-lowering medications at 10 years but HbA1c, fasting glucose, calculated cardiovascular risk, quality-of-life and incident diabetes complications did not differ significantly between the groups. CONCLUSION: When compared with medical care, GB surgery achieved greater weight loss and modestly increased the likelihood of diabetes remission. However, it did not improve HbA1c, cardiovascular risk or quality of life.

Integrated phenotypic and activity-based profiling links Ces3 to obesity and diabetes.

Phenotypic screening is making a comeback in drug discovery as the maturation of chemical proteomics methods has facilitated target identification for bioactive small molecules. A limitation of these approaches is that time-consuming genetic methods or other means are often required to determine the biologically relevant target (or targets) from among multiple protein-compound interactions that are typically detected. Here, we have combined phenotypic screening of a directed small-molecule library with competitive activity-based protein profiling to map and functionally characterize the targets of screening hits. Using this approach, we identify carboxylesterase 3 (Ces3, also known as Ces1d) as a primary molecular target of bioactive compounds that promote lipid storage in adipocytes. We further show that Ces3 activity is markedly elevated during adipocyte differentiation. Treatment of two mouse models of obesity-diabetes with a Ces3 inhibitor ameliorates multiple features of metabolic syndrome, illustrating the power of the described strategy to accelerate the identification and pharmacologic validation of new therapeutic targets.

Laparoscopic adjustable gastric banding and progression from impaired fasting glucose to diabetes.

AIMS/HYPOTHESIS: Obesity and dysglycaemia are major risk factors for type 2 diabetes. We determined if obese people undergoing laparoscopic adjustable gastric banding (LAGB) had a reduced risk of progressing from impaired fasting glucose (IFG) to diabetes. METHODS: This was a retrospective cohort study of obese people with IFG who underwent LAGB. Weight and diabetes outcomes after a minimum follow-up period of 4 years (mean ± SD 6.1 ± 1.7 years) were compared with those of Australian adults with IFG from a population-based study (AusDiab). RESULTS: We identified 281 LAGB patients with baseline IFG. Their mean ± SD age and BMI were 46 ± 9 years and 46 ± 9 kg/m(2), respectively. The diabetes incidence for patients in the lowest, middle and highest weight loss tertile were 19.1, 3.4 and 1.8 cases/1,000 person-years, respectively. The AusDiab cohort had a lower BMI (28 ± 5 kg/m(2)) and a diabetes incidence of 12.5 cases/1,000 person-years. This increased to 20.5 cases/1,000 person-years when analysis was restricted to the 322 obese AusDiab participants, which was higher than the overall rate of 8.2 cases/1,000 person-years seen in the LAGB group (p = 0.02). Multivariable analysis of the combined LAGB and AusDiab data suggested that LAGB was associated with ∼75% lower risk of diabetes (OR 0.24 [95% CI 0.10, 0.57], p = 0.004). CONCLUSIONS/INTERPRETATION: In obese people with IFG, weight loss after LAGB is associated with a substantially reduced risk of progressing to diabetes over ≥4 years. Bariatric surgery may be an effective diabetes prevention strategy in this population.

Long-term outcomes after bariatric surgery: fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature.

OBJECTIVE: To describe the long-term outcomes after laparoscopic adjustable gastric banding (LAGB) and compare these with the published literature on bariatric surgery. BACKGROUND: Because obesity is a chronic disease, any proposed obesity treatment should be expected to demonstrate long-term durability to be considered effective. Yet for bariatric surgery, few long-term weight loss data are available. We report our 15-year follow-up data after LAGB and provide a systematic review of the peer-reviewed literature for weight loss at 10 years or more after bariatric surgical procedures. METHODS: We performed a prospective longitudinal cohort study of LAGB patients using an electronic database system (LapBase) to track progress, measure weight changes, and document revisional procedures. The evolution of the LAGB procedure was recognized, and revisional rates for 3 separate periods between September 1994 and December 2011 were described. In addition, we performed a systematic review of the peer-reviewed published literature collecting all reports that included weight loss data at or beyond 10 years. RESULTS: A total of 3227 patients, with a mean age of 47 years and a mean body mass index of 43.8 kg/m, were treated by laparoscopic adjustable gastric band placement between September 1994 and December 2011. Seven hundred fourteen patients had completed at least 10 years of follow-up. Follow-up was intact in 81% of patients overall and 78% of those beyond 10 years. There was no perioperative mortality for the primary placement or for any revisional procedures. There was 47.1% of excess weight loss (% EWL) at 15 years [n = 54; 95% confidence interval (CI) = 8.3] and 62% EWL at 16 years (n = 14; 95% CI = 13.6). There was a mean of 47.0% EWL (n = 714; 95% CI = 1.3) for all patients who were at or beyond 10 years follow-up. Revisional procedures were performed for proximal enlargement (26%), erosion (3.4%), and port and tubing problems (21%). The band was explanted in 5.6%. The need for revision decreased as the technique evolved, with 40% revision rate for proximal gastric enlargements in the first 10 years, reducing to 6.4% in the past 5 years. The revision group showed a similar weight loss to the overall group beyond 10 years. The systematic review of all bariatric procedures with 10 or more years of follow-up showed greater than 50% EWL for all current procedures. The weighted mean at maximum follow-up for LAGB was 54.2% EWL and for Roux-en-Y gastric bypass was 54.0% EWL. CONCLUSIONS: The LAGB study from 1 center demonstrates a durable weight loss with 47% EWL maintained to 15 years. This weight loss occurred regardless of whether any revisional procedures were needed. A systematic review shows substantial and similar long-term weight losses for LAGB and other bariatric procedures.

Heterogeneity of fibrosis patterns in non-alcoholic fatty liver disease supports the presence of multiple fibrogenic pathways.

BACKGROUND: Adult non-alcoholic fatty liver disease (NAFLD) involves lobular necroinflammatory activity and fibrosis is typically centrilobular, whereas paediatric NAFLD has predominantly portal fibrosis. The reasons for these differences are unclear. We aimed to determine (a) how centrilobular and portal fibrosis in children relate to histological parameters; and (b) whether atypical fibrosis patterns exist in adults that are unexplained by current fibrogenesis models. METHODS: Histological features of paediatric (n = 38) and adult (n = 56) NAFLD were assessed using conventional scoring systems. Keratin-7 immunostaining was used to assess hepatic progenitor cell numbers and the ductular reaction. Centrilobular and portal components of fibrosis were independently scored and fibrosis patterns were classified according to accepted types. Post-treatment (rosiglitazone/gastric banding) biopsies were also examined in adults. RESULTS: Twenty-six children (68.4%) had portal-predominant fibrosis, although the typical "adult" pattern was seen in 11 (28.9%). Portal fibrosis was associated with a ductular reaction (P = 0.021) and hepatic progenitor cell expansion (P < 0.001), whereas centrilobular fibrosis was associated with lobular inflammation (P = 0.026) and ballooning (P = 0.001). Before intervention, six adults (10.7%) had atypical fibrosis including 3 (5.4%) with a previously unrecognized pattern of very fine, non-zonal sinusoidal fibrosis. Despite improvements in steatosis and inflammation, more patients developed this unusual pattern after intervention with most having had surgery (9 of 10 adults; P < 0.001). CONCLUSION: Differing associations with portal and centrilobular fibrosis in children and atypical fibrosis patterns in adults suggest that multiple fibrogenic pathways exist in NAFLD. This has implications for therapy and understanding pathogenesis.

Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial.

CONTEXT: Obstructive sleep apnea (OSA) is strongly related to obesity. Weight loss is recommended as part of the overall management plan for obese patients diagnosed with OSA. OBJECTIVE: To determine whether surgically induced weight loss is more effective than conventional weight loss therapy in the management of OSA. DESIGN, SETTING, AND PATIENTS: A randomized controlled trial of 60 obese patients (body mass index: >35 and <55) with recently diagnosed (<6 months) OSA and an apnea-hypopnea index (AHI) of 20 events/hour or more. These patients had been prescribed continuous positive airway pressure (CPAP) therapy to manage OSA and were identified via accredited community sleep clinics. The trial was conducted between September 2006 and March 2009 by university- and teaching hospital-based clinical researchers in Melbourne, Australia. Patients with obesity hypoventilation syndrome, previous bariatric surgery, contraindications to bariatric surgery, or significant cardiopulmonary, neurological, vascular, gastrointestinal, or neoplastic disease were excluded. INTERVENTIONS: Patients were randomized to a conventional weight loss program that included regular consultations with a dietitian and physician, and the use of very low-calorie diets as necessary (n = 30) or to bariatric surgery (laparoscopic adjustable gastric banding; n = 30). MAIN OUTCOME MEASURES: The primary outcome was baseline to 2-year change in AHI on diagnostic polysomnography scored by staff blinded to randomization. Secondary outcomes were changes in weight, CPAP adherence, and functional status. RESULTS: Patients lost a mean of 5.1 kg (95% CI, 0.8 to 9.3 kg) in the conventional weight loss program compared with 27.8 kg (95% CI, 20.9 to 34.7 kg) in the bariatric surgery group (P < .001). The AHI decreased by 14.0 events/hour (95% CI, 3.3 to 24.6 events/hour) in the conventional weight loss group and by 25.5 events/hour (95% CI, 14.2 to 36.7 events/hour) in the bariatric surgery group. The between-group difference was -11.5 events/hour (95% CI, -28.3 to 5.3 events/hour; P = .18). CPAP adherence did not differ between the groups. The bariatric surgery group had greater improvement in the Short Form 36 physical component summary score (mean, 9.3 [95% CI, 0.5 to 18.0]; P = .04). CONCLUSION: Among a group of obese patients with OSA, the use of bariatric surgery compared with conventional weight loss therapy did not result in a statistically greater reduction in AHI despite major differences in weight loss. TRIAL REGISTRATION: anzctr.org Identifier: 12605000161628.

Bariatric surgery: mechanisms, indications and outcomes.

The rising problem of obesity is causing major health problems, reduced quality of life and reduced life expectancy. It now generates approximately 10% of all health costs. The progression of the problem indicates preventive measures have been unsuccessful so far. Only bariatric surgical treatments have been able to achieve substantial and durable weight loss. Gastric banding and gastric bypass are used in more than 90% of bariatric operations. The proportion of each varies from greater than 95% bands in Australia, about 50/50 in Europe and USA and nearly 100% bypass in South America. The availability of follow up is a prime determinant of choice. Understanding the mechanisms of effect for the bariatric procedures is central to optimizing their effect. The traditional narrow concepts of restrictive (blocking the transit of food) and malabsorptive (preventing the absorption of food) should be discarded and the importance of induction of satiety, change of taste, diversion of chyme, neural and hormonal mediation and the effects of aversion need to be included. The primary mechanism of effect for gastric banding is the generation of a background of satiety and early post-prandial satiation via specifically structured vagal afferents at the level of the band. At five years after banding or bypass, there is typically a loss of 30-35 kg representing 50-60% of excess weight. This weight loss has been shown to be associated with major improvement or complete resolution of multiple common and serious health problems plus improvement in quality of life and in survival. Level 1 evidence supports the use of the gastric band over optimal lifestyle therapy. Randomized controlled trials has shown gastric banding to achieve better weight loss, health and quality of life than optimal lifestyle therapies for adults above a BMI of 30 and adolescents above a BMI of 35. In adults with mild to severe obesity and type 2 diabetes gastric banding leads to remission in three out of four individuals. Perioperative risk is significant with gastric bypass and late revisional procedures can be required after both procedures. Gastric banding is indicated in any adult who has a BMI over 30, has problems with their obesity and has made substantial effort to reduce their weight by lifestyle methods. Gastric bypass or biliopancreatic diversion should be considered in those with BMI greater than 35 if banding is contraindicated or has been unsuccessful.

Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial.

CONTEXT: Adolescent obesity is a common and serious health problem affecting more than 5 million young people in the United States alone. Bariatric surgery is being evaluated as a possible treatment option. Laparoscopic adjustable gastric banding (gastric banding) has the potential to provide a safe and effective treatment. OBJECTIVE: To compare the outcomes of gastric banding with an optimal lifestyle program on adolescent obesity. DESIGN, SETTING, AND PATIENTS: A prospective, randomized controlled trial of 50 adolescents between 14 and 18 years with a body mass index (BMI) higher than 35, recruited from the Melbourne, Australia, community, assigned either to a supervised lifestyle intervention or to undergo gastric banding, and followed up for 2 years. The study was performed between May 2005 and September 2008. MAIN OUTCOME MEASURES: Weight loss. Secondary outcomes included change in metabolic syndrome, insulin resistance, quality of life, and adverse outcomes. RESULTS: Twenty-four of 25 patients in the gastric banding group and 18 of 25 in lifestyle group completed the study. Twenty-one (84%) in the gastric banding and 3 (12%) in the lifestyle groups lost more than 50% of excess weight, corrected for age. Overall, the mean changes in the gastric banding group were a weight loss of 34.6 kg (95% CI, 30.2-39.0), representing an excess weight loss of 78.8% (95% CI, 66.6%-91.0%), 12.7 BMI units (95% CI, 11.3-14.2), and a BMI z score change from 2.39 (95% CI, 2.05-2.73) to 1.32 (95% CI, 0.98-1.66). The mean losses in the lifestyle group were 3.0 kg (95% CI, 2.1-8.1), representing excess weight loss of 13.2% (95% CI, 2.6%-21.0%), 1.3 BMI units (95% CI, 0.4-2.9), and a BMI z score change from 2.41 (95% CI, 2.21-2.66) to 2.26 (95% CI, 1.91-2.43). At entry, 9 participants (36%) in the gastric banding group and 10 (40%) in the lifestyle group had the metabolic syndrome. At 24 months, none of the gastric banding group had the metabolic syndrome (P = .008; McNemar chi(2)) compared with 4 of the 18 completers (22%) in the lifestyle group (P = .13). The gastric banding group experienced improved quality of life with no perioperative adverse events. However, 8 operations (33%) were required in 7 patients for revisional procedures either for proximal pouch dilatation or tubing injury during follow-up. CONCLUSIONS: Among obese adolescent participants, use of gastric banding compared with lifestyle intervention resulted in a greater percentage achieving a loss of 50% of excess weight, corrected for age. There were associated benefits to health and quality of life. TRIAL REGISTRATION: ANZCTR Identifier: 12605000160639.

Pre-operative Restraint and Post-operative Hunger, Disinhibition and Emotional Eating Predict Weight Loss at 2 Years Post-laparoscopic Adjustable Gastric Banding.

INTRODUCTION: A principal mechanism of action in bariatric surgery is reduction in calorie consumption due to decreased hunger and increased satiety. Patients' ability to perceive post-operative changes to their hunger is therefore central to optimal results. This study examined factors that may impact how patients perceive post-operative hunger and how perception of hunger impacts eating and subsequent weight loss after laparoscopic adjustable gastric banding (LAGB). METHODS: Patients undertaking LAGB (n = 147) provided pre-surgery and 2-year weight loss data and pre-surgery and 12-month psychological data (perception of hunger, disinhibition related to eating, emotional eating). RESULTS: Path analysis demonstrated that patients with lower levels of pre-surgery cognitive restraint over eating experienced significantly greater reduction in perception of hunger at 12 months post-surgery. Perceived reduction in hunger was significantly associated with lower levels of both emotional eating and disinhibited eating. Finally, reduced emotional eating at 12 months significantly predicted 9% of the variance in percentage of total weight loss (%TWL) at 2 years after surgery. CONCLUSION: These initial findings suggest that preparation for bariatric surgery may be enhanced by psychoeducation regarding cognitive restraint over eating and its effect on hunger perception. In addition, psychological treatment that focuses on identifying and responding to changes in hunger may contribute to improved outcomes for those who have difficulty adjusting to post-operative eating behaviours.

The effect of laparoscopic adjustable gastric bands on esophageal motility and the gastroesophageal junction: analysis using high-resolution video manometry.

BACKGROUND: Laparoscopic adjustable gastric bands (LAGB) are a safe and effective treatment for obesity. Conflicting data exist concerning their effect on the esophagus, gastroesophageal junction, and mechanism of action. These patients will increasingly require accurate assessment of their esophageal function. METHODS: Twenty LAGB patients underwent high-resolution video manometry with the LAGB empty, 20% under, 20% over, and at their optimal volume. Twenty obese controls were also studied. Effects on esophageal motility, the lower esophageal sphincter (LES), and the gastroesophageal junction were measured. Transit during liquid and semisolid swallows was assessed. RESULTS: The intraluminal pressure at the level of LAGB was a mean of 26.9 (19.8) mm Hg. This pressure varied depending on the volume within the LAGB and was separate to and distal to the lower esophageal sphincter LES. The LES was attenuated compared to controls (10 vs 18 mm Hg; p < 0.01) although relaxed normally. Esophageal motility was well preserved at optimal volume compared to 20% overfilled, with 77% normal swallows vs 51%, p = 0.008. Repetitive esophageal contractions were observed in 40% of swallows at optimal volume compared to 16% in controls, p = 0.024. In comparison to controls, the transit of liquid, 21 vs 8 s (p < 0.001), and semisolids, 50 vs 16 s (p < 0.001), was delayed. CONCLUSIONS: In LAGB patients, the LES is attenuated, although relaxes normally. Esophageal motility is preserved, although disrupted by overfilling the band. In the optimally adjusted LAGB, a delay in transit of liquids and semisolids through the esophagus and band is produced, along with an increase in repeated esophageal contractions.

Laparoscopic adjustable gastric banding.

BACKGROUND: The laparoscopic adjustable gastric band is a useful tool in the treatment of severe obesity. It is a safe and durably effective procedure, however, optimal results depend upon the patient participating in a process of lifelong care. OBJECTIVE: This article discusses the procedure, follow up, and late complications for laparoscopic adjustable gastric banding. It also provides the general practitioner with 'alert' symptoms and signs of when to contact the treating surgeon. DISCUSSION: Lifelong care involves counselling about food choices and eating patterns, as well as adjustment of the device. The delivery of this care usually involves a multidisciplinary team. Patients should not be offered surgery unless a process for continuing care is in place. Late complications of laparoscopic adjustable gastric banding are relatively common; however, they can be readily treated in most cases, with weight loss continuing. Symptoms of volume reflux, nocturnal aspiration, dysphagia, regular regurgitation and vomiting may alert the primary care GP to complications. Abdominal pain along with any of these symptoms may suggest an acute complication, but other causes of abdominal pain should also be considered, depending on the clinical scenario.

Long-Term Outcomes After Bariatric Surgery: a Systematic Review and Meta-analysis of Weight Loss at 10 or More Years for All Bariatric Procedures and a Single-Centre Review of 20-Year Outcomes After Adjustable Gastric Banding.

INTRODUCTION: Durability is a key requirement for the broad acceptance of bariatric surgery. We report on durability at and beyond 10 years with a systematic review and meta-analysis of all reports providing data at 10 or more years and a single-centre study of laparoscopic adjustable gastric banding (LAGB) with 20 years of follow-up. METHODS: Systematic review with meta-analysis was performed on all eligble reports containing 10 or more years of follow-up data on weight loss after bariatric surgery. In addition, a prospective cohort study of LAGB patients measuring weight loss and reoperation at up to 20 years is presented. RESULTS: Systematic review identified 57 datasets of which 33 were eligible for meta-analysis. Weighted means of the percentage of excess weight loss (%EWL) were calculated for all papers included in the systematic review. Eighteen reports of gastric bypass showed a weighted mean of 56.7%EWL, 17 reports of LAGB showed 45.9%EWL, 9 reports of biliopancreatic bypass +/- duodenal switch showed 74.1%EWL and 2 reports of sleeve gastrectomy showed 58.3%EWL. Meta-analyses of eligible studies demonstrated comparable results. Reoperations were common in all groups. At a single centre, 8378 LAGB patients were followed for up to 20 years with an overall follow-up rate of 54%. No surgical deaths occurred. Weight loss at 20 years (N = 35) was 30.1 kg, 48.9%EWL and 22.2% total weight loss (%TWL). Reoperation rate was initially high but reduced markedly with improved band and surgical and aftercare techniques. CONCLUSION: All current procedures are associated with substantial and durable weight loss. More long-term data are needed for one-anastomosis gastric bypass and sleeve gastrectomy. Reoperation is likely to remain common across all procedures.

Identification of Metabolically Distinct Adipocyte Progenitor Cells in Human Adipose Tissues.

Adipocyte progenitor cells (APCs) provide the reservoir of regenerative cells to produce new adipocytes, although their identity in humans remains elusive. Using FACS analysis, gene expression profiling, and metabolic and proteomic analyses, we identified three APC subtypes in human white adipose tissues. The APC subtypes are molecularly distinct but possess similar proliferative and adipogenic capacities. Adipocytes derived from APCs with high CD34 expression exhibit exceedingly high rates of lipid flux compared with APCs with low or no CD34 expression, while adipocytes produced from CD34- APCs display beige-like adipocyte properties and a unique endocrine profile. APCs were more abundant in gluteofemoral compared with abdominal subcutaneous and omental adipose tissues, and the distribution of APC subtypes varies between depots and in patients with type 2 diabetes. These findings provide a mechanistic explanation for the heterogeneity of human white adipose tissue and a potential basis for dysregulated adipocyte function in type 2 diabetes.

Inhibition of mTOR Signaling and Clinical Activity of Rapamycin in Head and Neck Cancer in a Window of Opportunity Trial.

PURPOSE: We studied the impact of mTOR signaling inhibition with rapamycin in head and neck squamous cell carcinoma (HNSCC) in the neoadjuvant setting. The goals were to evaluate the mTOR pathway as a therapeutic target for patients with advanced HNSCC, and the clinical safety, antitumor, and molecular activity of rapamycin administration on HNSCC. PATIENTS AND METHODS: Patients with untreated stage II-IVA HNSCC received rapamycin for 21 days (day 1, 15 mg; days 2-12, 5 mg) prior to definitive treatment with surgery or chemoradiation. Treatment responses were assessed clinically and radiographically with CT and FDG-PET. Pre- and posttreatment biopsies and blood were obtained for toxicity, immune monitoring, and IHC assessment of mTOR signaling, as well as exome sequencing. RESULTS: Sixteen patients (eight oral cavity, eight oropharyngeal) completed rapamycin and definitive treatment. Half of patients were p16 positive. One patient had a pathologic complete response and four (25%) patients met RECIST criteria for response (1 CR, 3 PR, 12 SD). Treatment was well tolerated with no grade 4 or unexpected toxicities. No significant immune suppression was observed. Downstream mTOR signaling was downregulated in tumor tissues as measured by phosphorylation of S6 (P < 0.0001), AKT (P < 0.0001), and 4EBP (P = 0.0361), with a significant compensatory increase in phosphorylated ERK in most patients (P < 0.001). Ki67 was reduced in tumor biopsies in all patients (P = 0.013). CONCLUSIONS: Rapamycin treatment was well tolerated, reduced mTOR signaling and tumor growth, and resulted in significant clinical responses despite the brief treatment duration, thus supporting the potential role of mTOR inhibitors in treatment regimens for HNSCC.

Hunger control and regular physical activity facilitate weight loss after laparoscopic adjustable gastric banding.

BACKGROUND: Bariatric surgery facilitates substantial and durable weight loss; however, outcomes vary. In addition to physiological and technical factors, weight loss efficacy is dependent on modification of behavior to maintain a long-term change in energy balance. This study aimed to assess the extent and nature of change in energy intake and physical activity and identify factors associated with percentage weight loss (%WL) 12 months after laparoscopic adjustable gastric banding (LAGB). METHODS: 129 bariatric surgery candidates (26 men/103 women, mean age 45.2 +/- 11.5, mean body mass index [BMI] 44.3 +/- 6.8, range 31.9 to 66.7) completed the study. Data were collected at baseline and 12 months. Validated questionnaires included the Cancer Council Victoria Food Frequency Questionnaire, Three Factor Eating Questionnaire, Short Form-36, Baecke Physical Activity Questionnaire, and Beck Depression Inventory. Symptoms of "non-hungry eating," "emotional eating," and "grazing" were assessed. RESULTS: Mean %WL was 20.8 +/- 8.5%, and excess weight loss was 50.0 +/- 20.7 (p < 0.001). Mean total energy intake reduced from 9,991 +/- 3,986 kj to 4,077 +/- 1,493 kj (p < 0.001). Average leisure time and sport-related physical activity scores increased (both p < 0.001). Regression analysis identified baseline BMI (beta = 0.241; p = 0.002), subjective hunger (beta = -0.275; p = 0.001), physical function (beta = 0.309; p < 0.001), and leisure time physical activity (beta = 0.213; p = 0.010) as independent predictors of %WL, total R (2) 0.34%. "Non-hungry eating" and symptoms of depression were also related to poorer %WL. CONCLUSION: LAGB affects marked behavior change and facilitates substantial weight loss in the first 12 months. However, variations in adopted behaviors can affect energy balance and weight loss success. Achievement and maintenance of favorable behaviors should be an important consideration during on-going postsurgical review and counseling. Management should include adequate band adjustment to control physical hunger, optimization of physical function and activity, and reinforcement of strategies to reduce energy intake.

Symmetrical pouch dilatation after laparoscopic adjustable gastric banding: incidence and management.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) has commonly been complicated by the problem of band slippage or prolapse. Since popularization of the pars flaccida approach and improved anterior fixation, it is our impression that the problem of symmetrical dilatation of the proximal gastric pouch has become more important. METHODS: We have reviewed the results of a series of 425 LAGB all performed by the pars flaccida approach from June 2003 to October 2007 to analyze the incidence and implications of this new pattern. RESULTS: There were no posterior prolapses, 2 anterior prolapses, and 17 cases of symmetrical pouch dilatation (SPD) (revision rate 4.4%). Teenage patients had a 22% revision rate for SPD. All revisions were completed laparoscopically with no mortality, no significant complications, and a median hospital stay of 1 day. The median weight loss following revisional surgery was not significantly different from the background cohort. CONCLUSION: SPD is the most common reason for revision of LAGB in this series. We postulate that SPD is caused by excessive pressure in the proximal gastric pouch. This may be generated either by eating too quickly or too large a volume or excessive tightening of the band. The radial forces in the pouch may ultimately cause pressure on the phrenoesophageal ligament and a secondary hiatal hernia.

Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial.

CONTEXT: Observational studies suggest that surgically induced loss of weight may be effective therapy for type 2 diabetes. OBJECTIVE: To determine if surgically induced weight loss results in better glycemic control and less need for diabetes medications than conventional approaches to weight loss and diabetes control. DESIGN, SETTING, AND PARTICIPANTS: Unblinded randomized controlled trial conducted from December 2002 through December 2006 at the University Obesity Research Center in Australia, with general community recruitment to established treatment programs. Participants were 60 obese patients (BMI >30 and <40) with recently diagnosed (<2 years) type 2 diabetes. INTERVENTIONS: Conventional diabetes therapy with a focus on weight loss by lifestyle change vs laparoscopic adjustable gastric banding with conventional diabetes care. MAIN OUTCOME MEASURES: Remission of type 2 diabetes (fasting glucose level <126 mg/dL [7.0 mmol/L] and glycated hemoglobin [HbA1c] value <6.2% while taking no glycemic therapy). Secondary measures included weight and components of the metabolic syndrome. Analysis was by intention-to-treat. RESULTS: Of the 60 patients enrolled, 55 (92%) completed the 2-year follow-up. Remission of type 2 diabetes was achieved by 22 (73%) in the surgical group and 4 (13%) in the conventional-therapy group. Relative risk of remission for the surgical group was 5.5 (95% confidence interval, 2.2-14.0). Surgical and conventional-therapy groups lost a mean (SD) of 20.7% (8.6%) and 1.7% (5.2%) of weight, respectively, at 2 years (P < .001). Remission of type 2 diabetes was related to weight loss (R2 = 0.46, P < .001) and lower baseline HbA1c levels (combined R2 = 0.52, P < .001). There were no serious complications in either group. CONCLUSIONS: Participants randomized to surgical therapy were more likely to achieve remission of type 2 diabetes through greater weight loss. These results need to be confirmed in a larger, more diverse population and have long-term efficacy assessed. TRIAL REGISTRATION: actr.org Identifier: ACTRN012605000159651.

Diabetes Outcomes More than a Decade Following Sustained Weight Loss After Laparoscopic Adjustable Gastric Band Surgery.

BACKGROUND: Long-term outcome data are needed to define the role of bariatric surgery in type 2 diabetes (T2D). To address this, we collated diabetes outcomes more than a decade after laparoscopic adjustable gastric band (LAGB) surgery. METHOD: Clinical and biochemical measures from 113 obese T2D patients who underwent LAGB surgery in 2003 and 2004 were analyzed. Diabetes remission was defined as HbA1c < 6.2% (44 mmol/mol) and fasting glucose < 7.0 mmol/L. RESULTS: Seventy-nine patients had weight data at 10 years and attained a median [Q1, Q3] weight loss of 16 [10, 21] percent. Sixty patients attended a follow-up assessment. Their baseline HbA1c of 7.8 [7.1, 9.3] percentage units (62 [54, 78] mmol/mol) had decreased to 6.6 [6.1, 8.4] (49 [43, 68] mmol/mol) despite no significant change in glucose-lowering therapy. Eleven patients (18%) were in diabetes remission and another 18 had HbA1c ≤ 6.5%. Significant improvements in physical measures of quality of life, blood pressure, and lipid profile were also observed but there was no change in the proportion of patients with albuminuria and a significant decline in estimated glomerular filtration rate. Twelve patients in the follow-up cohort (20%) required anti-reflux medication after surgery and 26 (43%) underwent gastric band revision surgery. CONCLUSION: Weight loss for over 10 years after LAGB surgery delivers clinically meaningful improvements in HbA1c, blood pressure, lipids, and quality of life at the cost of a high rate of revision surgery and increased use of anti-reflux medication. These findings support the use of bariatric surgery as a long-term treatment for weight loss and wellbeing in patients with T2D. STUDY REGISTRATION: Registered with the Australian Clinical trials registry as ACTRN12615000089538.

Detailed Description of Change in Serum Cholesterol Profile with Incremental Weight Loss After Restrictive Bariatric Surgery.

INTRODUCTION: Dyslipidemia affects up to 75% of morbidly obese individuals and is a key driver of cardiovascular disease. Weight loss is an established strategy to improve metabolic risk, including dyslipidemia. We aimed to determine weight loss goals for resolution of serum lipid abnormalities, by measuring improvements during progressive weight loss in obese individuals. METHODS: We performed a prospective cohort study of obese individuals with the metabolic syndrome undergoing adjustable gastric banding. Lipid levels were monitored monthly for 9 months, then three monthly until 24 months. RESULTS: There were 101 participants included, age 47.4 ± 10.9 years with body mass index 42.6 ± 5.9 kg/m2. At 24 months, total body weight loss (TBWL) was 18.3 ± 7.9%. This was associated with significant improvements in high-density lipoprotein (HDL) (1.18 vs 1.47, p < 0.001), triglyceride (2.0 vs 1.4, p < 0.001), and total cholesterol to HDL ratio (TC:HDL) (4.6 vs 3.6, p < 0.001). Over this time, progressive and linear improvements in HDL, triglycerides, and TC:HDL were seen with incremental weight loss (observed at 2.5% TBWL intervals). Significant improvements occurred after a threshold weight loss of 7.5-12.5% TBWL was achieved, with odds ratio (OR) 1.48-2.50 for normalization. These odds improved significantly with increasing weight loss (OR 18.2-30.4 with > 25% TBWL). Despite significant weight loss, there was no significant change in low-density lipoprotein (LDL). CONCLUSION: Significant improvements in triglycerides, HDL, and TC:HDL occur after 7.5-12.5% TBWL, with ongoing benefit after greater weight loss. LDL needs to be addressed independently, as this was not observed to respond to weight loss alone. TRIAL REGISTRATION NUMBER: Australian Clinical Trials Registry (ACTRN12610000049077).