Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensus.

Metabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.

Current state of the definition and terminology related to weight recurrence after metabolic surgery: review by the POWER Task Force of the American Society for Metabolic and Bariatric Surgery.

Bariatric surgery continues to be the most reliable treatment for the disease of obesity. Despite excellent results, some patients experience weight recurrence with or without concomitant recurrence of co-morbidities. There is currently no standard definition for clinically significant weight recurrence after bariatric surgery so that patients and clinicians have a platform from which to plan treatment. The Post-Operative Weight Recurrence (POWER) Task Force was formed by the American Society for Metabolic and Bariatric Surgery to address this aspect of the disease of obesity. This article reviews the literature of existing definitions for weight recurrence and their limitations. Furthermore, the term weight recurrence is introduced to replace weight regain or recidivism, and the term nonresponder is introduced to replace inadequate weight loss after surgery.

Cancer in obese women: potential protective impact of bariatric surgery.

BACKGROUND: The use of bariatric surgery has been increasing over the last several years in response to the obesity epidemic, and the objective of this study was to report on the types of cancer in morbidly obese women undergoing bariatric surgery and compare these with types of cancer in obese women without surgery. STUDY DESIGN: A retrospective, observational study was conducted. The bariatric surgery database identified women who underwent operations between 1990 and 2006 at the University of Virginia. Medical records and the institution's and state's cancer registries were searched for demographics and cancer data. Morbidly obese patients not undergoing bariatric surgery were used for comparison. RESULTS: There were 1,482 women who had bariatric surgery, and 53 of these (3.6%) were diagnosed with cancer. The most common cancer site was the breast (n = 15, 28.3%) followed by the endometrium (n = 9, 17%) and the cervix (n = 6, 11.3%). The mean age at cancer diagnosis was 39.4 years. Most cancers (n = 34, 64.1%) were diagnosed before the bariatric surgery. Bariatric surgery patients with cancer were older than noncancer patients at time of surgery (mean age 44.7 versus 41.6 years; p=0.019), but otherwise did not differ significantly with regard to race, body mass index, or comorbid conditions. Compared with a control group of 3,495 morbidly obese women who had not undergone bariatric surgery, the surgery patients had fewer cancers (3.6% versus 5.8%, p=0.002), were younger (41.7 versus 46.9 years, p < 0.001), and were younger at cancer diagnosis (45.0 versus 56.8 years, p < 0.001). The most frequent cancers in the control obese women were endometrial, ovarian, and breast cancer. Both groups of obese women with endometrial, breast, ovarian, and colorectal cancers were younger at diagnosis compared with Virginia Cancer Registry means. CONCLUSIONS: Breast and endometrial cancers remain the most common types in obese women and may occur at young ages; bariatric surgery may decrease cancer development in obese women.

Incidentally identified adrenal lipoma: case report and review of related literature.

OBJECTIVE: To report a case of an incidentally identified adrenal lipoma in a 68-year-old man with flank pain and hypertension. METHODS: The clinical, computed tomographic, and magnetic resonance imaging findings in this patient are described, and the pathologic features of the tumor are characterized. Moreover, the related literature is reviewed and summarized. RESULTS: The patient had undergone coronary artery bypass grafting, had a prosthetic heart valve, and required systemic anticoagulation. Computed tomography showed a well-circumscribed left adrenal lesion with evidence of scattered foci of macroscopic fat; these findings were confirmed on magnetic resonance imaging. After laparoscopic left adrenalectomy, pathologic examination revealed a well-circumscribed, fatty, 7-cm adrenocortical-based tumor, which weighed 135 g. Histologic sampling disclosed mature adipose tissue without evidence of myeloid heterotopy or features of malignant involvement, and adrenal lipoma was diagnosed. On the basis of our review of the English-language literature, this tumor is the 11th reported case of adrenal lipoma. The vast majority of these tumors have been asymptomatic and identified incidentally on imaging or at autopsy. A minority of patients have had a history of hypertension. CONCLUSION: With the increased utilization and sensitivity of abdominal imaging techniques, identification of nonfunctional adrenal tumors has become more frequent. Adrenal lipoma should be included in the differential diagnosis of lipomatous adrenal tumors.

Quality of life and resolution of co-morbidities in super-obese patients remaining morbidly obese after Roux-en-Y gastric bypass.

BACKGROUND: Not all patients undergoing Roux-en-Y gastric bypass with an initial body mass index (BMI) >50 kg/m(2) attain a BMI of <35 kg/m(2) postoperatively. We hypothesized that even though many of these patients remain morbidly obese after surgery, they still realize an improvement in co-morbidities and quality of life. METHODS: Patients who had undergone Roux-en-Y gastric bypass and who had a preoperative BMI >50 kg/m(2) and postoperative BMI >35 kg/m(2) were identified. The records of 120 patients were reviewed for the presence of diabetes, hypertension, hyperlipidemia, and gastroesophageal reflux disease. Patients were queried about their use of medications, medical problems, and quality of life. RESULTS: The average preoperative and postoperative BMI was 63.2 and 43.7 kg/m(2). Of the 120 patients, 77 responded to the survey. In the preoperative group, the rate of diabetes, hypertension, hyperlipidemia, and gastroesophageal reflux disease was 35%, 50.8%, 15%, and 34.2%, respectively. Postoperatively, 73.8%, 62.3%, 38.9%, and 87.8% of patients had been cured of these co-morbidities. The change in the incidence of diabetes, hypertension, and gastroesophageal reflux disease was significant at P = 0.0014, P = 0.037, and P <0.0001, respectively. More than 90% of patients considered themselves to be better postoperatively in the areas of overall health and ability to move about; 80-90% had improved ability to exercise, greater energy levels, more self esteem, and an improved physical appearance; 70-80% saw their ability to work and their social relationships as improved; and 56% believed their sexual relationships had improved. CONCLUSION: Super-obese patients experience significant improvements in co-morbidities and quality of life after Roux-en-Y gastric bypass even if their BMI remains >35 kg/m(2).