Primary care provider management of patients with obesity at an integrated health network: A survey of practices, views, and knowledge.

BACKGROUND: Obesity is a serious health problem that affects a wide range of patients and disease processes. OBJECTIVE: The purpose of this study is to evaluate perceptions, knowledge, and practice habits of primary care providers (PCPs) regarding the care of patients with obesity, including barriers to effective care and their experience with bariatric surgery in our integrated health network. SETTING: Integrated health network. METHODS: A 16-question survey was distributed electronically to 160 PCPs at our integrated health network. Results were analyzed to identify attitudes, knowledge, practice habits, and bariatric surgery referral patterns while treating patients with obesity. RESULTS: Among 160 PCPs, 45 (28.1%) responded. Specialty, sex, patient population, insurance accepted, and practice years of PCPs were reported. Most PCPs reported "always" calculating patient body mass index (88.9%) with only 13.3% "always" discussing the body mass index results. Respondents most frequently prescribed diet and exercise to patients with obesity and rarely prescribed medications, with bariatric surgery referrals falling between the two. PCPs viewed management of obesity as the responsibility of the patient (97.6%) and the PCP (100%). Ninety-three percent felt obesity is a common diagnosis in their practice, but no one correctly identified the prevalence of obesity in our region. Respondents demonstrated adequate knowledge regarding medical consequences of obesity. A majority was able to identify the correct eligibility criteria for bariatric surgery, as well specific medical problems that can improve or be eliminated postoperatively. While 61.9% of respondents were aware of free weight loss and bariatric informational sessions offered, 28.6% reported that they were unfamiliar with existing bariatric surgeons. One respondent was not aware of any bariatric surgery performed. Some PCPs reported prior negative experiences with post-bariatric surgery patients, and thus were hesitant to refer additional patients. CONCLUSIONS: PCPs report discussing an obesity diagnosis with patients but are not always using body mass index in that discussion. They most often prescribe lifestyle modification as treatment for patients, which they believe to be most effective to treat obesity. However, they report only one third of their patients are motivated to lose weight. Additionally, they demonstrate appropriate knowledge of indications and benefits of bariatric surgery. A majority of the PCPs is aware of weight loss informational sessions and bariatric services provided within our integrated health network, but almost one third were unable to identify a surgeon, a possible target for improved relationships. Barriers to care include patient motivation and insurance coverage.

Groin defects seen at extra-peritoneal laparoscopic dissection during surgical treatment of athletic pubalgia.

BACKGROUND: Recently new disease process, often referred to as athletic pubalgia (AP), has been acknowledged by the medical community. The patients suffering from this ailment present with unilateral or bilateral chronic groin pain associated with physical activity without a clear diagnosis of a groin hernia. Though physical therapy and medical treatments are considered first line remedies, some believe that surgical treatment may have better, quicker, and more durable outcomes and procedures aimed at groin reinforcement seem to relieve most of symptoms in the majority of the patients. Despite many surgeons consistently noting rectus insertion or adductor thinning, multiple hernia defects are often seen during dissections and the clinical significance of these findings is still not known. MATERIALS AND METHODS: Between 2007 and 2011, 40 patients underwent an extra-peritoneal laparoscopic reinforcement of rectus abdominals and insertion of adductor muscles for AP. All patients underwent wide and bilateral groin dissection and the findings were cataloged. RESULTS: All of the patients presented with groin defects upon wide dissection. Thirty-four patients (85%) presented with small bilateral indirect inguinal defects and 28 (70%) of these patients did not have any additional defects. Five patients (12.5%) were found to have only unilateral inguinal hernia defects. One patient presented with a small direct defect. In addition to these defects, five patients (12.5%) had additional unilateral femoral hernias, whereas no patient had solitary femoral hernia defects. CONCLUSION: AP is a new diagnostic entity with poorly understood etiology. It mostly affects young active adults, often involved in competitive sports and surgical methods may be most effective at achieving the cure. In our experience all of the patients presented with groin defects, though not all were the same. It is our belief that these defects, although likely not the only component, play a significant role in the pathophysiology of AP.

Clinical trial demonstrates exercise following bariatric surgery improves insulin sensitivity.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) surgery causes profound weight loss and improves insulin sensitivity (S(I)) in obese patients. Regular exercise can also improve S(I) in obese individuals; however, it is unknown whether exercise and RYGB surgery-induced weight loss would additively improve S(I) and other cardiometabolic factors. METHODS: We conducted a single-blind, prospective, randomized trial with 128 men and women who recently underwent RYGB surgery (within 1-3 months). Participants were randomized to either a 6-month semi-supervised moderate exercise protocol (EX, n = 66) or a health education control (CON; n = 62) intervention. Main outcomes measured included S(I) and glucose effectiveness (S(G)), which were determined from an intravenous glucose tolerance test and minimal modeling. Secondary outcomes measured were cardiorespiratory fitness (VO2 peak) and body composition. Data were analyzed using an intention-to-treat (ITT) and per-protocol (PP) approach to assess the efficacy of the exercise intervention (>120 min of exercise/week). RESULTS: 119 (93%) participants completed the interventions, 95% for CON and 91% for EX. There was a significant decrease in body weight and fat mass for both groups (P < 0.001 for time effect). S(I) improved in both groups following the intervention (ITT: CON vs. EX; +1.64 vs. +2.24 min⁻¹/µU/ml, P = 0.18 for Δ, P < 0.001 for time effect). A PP analysis revealed that exercise produced an additive S(I) improvement (PP: CON vs. EX; +1.57 vs. +2.69 min⁻¹/µU/ml, P = 0.019) above that of surgery. Exercise also improved S(G) (ITT: CON vs. EX; +0.0023 vs. +0.0063 min⁻¹, P = 0.009) compared with the CON group. Exercise improved cardiorespiratory fitness (VO2 peak) compared with the CON group. CONCLUSION: Moderate exercise following RYGB surgery provides additional improvements in S(I), S(G), and cardiorespiratory fitness compared with a sedentary lifestyle during similar weight loss. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT00692367. FUNDING: This study was funded by the NIH/National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK078192) and an NIH/National Center for Research Resources/Clinical and Translational Science Award (UL1 RR024153).

Changes in hormones and biomarkers in polycystic ovarian syndrome treated with gastric bypass.

BACKGROUND: Small retrospective studies have demonstrated reduction in weight and co-morbid hirsutism and diabetes in women with polycystic ovary syndrome (PCOS) treated with Roux-en-Y gastric bypass. The objective of this study was to prospectively determine clinical improvements in obese women with PCOS treated with gastric bypass and identify postoperative biomarker changes. METHODS: Data were collected on obese women with PCOS undergoing Roux-en-Y gastric bypass over 1 year. Testosterone, follicle stimulating hormone, lutenizing hormone, insulin, fasting glucose, and lipid levels were obtained preoperatively at baseline, and 6 and 12 months after surgery. Testosterone was used as the primary hormonal biomarker. A physical examination for body mass index (BMI) and hirsutism, and information on menstrual pattern were collected at baseline and 3, 6, and 12 months after surgery. RESULTS: Data were available for 14 women. Mean BMI decreased from 44.8±5.9 kg/m(2) at baseline to 29.2±5.9 kg/m(2) at 12 months postoperatively. Significant improvements were seen in testosterone, fasting glucose, insulin, cholesterol, and triglyceride at 12 months (P<.05). At baseline, irregular menses were reported in 10 patients; all patients were experiencing regular menses 6 and 12 months after surgery. Hirsutism was present in 11 patients at baseline and only 7 patients at 12 months. Improvements in biomarkers, menstrual cycling, and hirsutism was not correlated with degree of weight change. CONCLUSION: Gastric bypass achieved significant reductions in BMI, testosterone, and markers of glucose and lipid metabolism. These data confirm reports of previous retrospective studies showing weight reduction and health improvement in women with PCOS treated with gastric bypass.

StomaphyX vs a sham procedure for revisional surgery to reduce regained weight in Roux-en-Y gastric bypass patients : a randomized clinical trial.

IMPORTANCE: Revisional laparoscopic surgery after Roux-en-Y gastric bypass (RYGB) has been linked to substantial complications and morbidity. OBJECTIVE: To investigate the safety and effectiveness of endoscopic gastric plication with the StomaphyX device vs a sham procedure for revisional surgery in RYGB patients to reduce regained weight. DESIGN, SETTING, AND PARTICIPANTS: A prospective, single-center, randomized, single-blinded study from July 2009 through February 2011, evaluating revisional surgery using StomaphyX was conducted in patients with initial weight loss after RYGB performed at least 2 years earlier. We planned for 120 patients to be randomized 2:1 to multiple full-thickness plications within the gastric pouch and stoma using the StomaphyX device with SerosFuse fasteners or a sham endoscopic procedure and followed up for 1 year. The primary efficacy end point was reduction in pre-RYGB excess weight by 15% or more excess body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) loss and BMI less than 35 at 12 months after the procedure. Adverse events were recorded. RESULTS: Enrollment was closed prematurely because preliminary results indicated failure to achieve the primary efficacy end point in at least 50% of StomaphyX-treated patients. One-year follow-up was completed by 45 patients treated with StomaphyX and 29 patients in the sham treatment group. Primary efficacy outcome was achieved by 22.2% (10) with StomaphyX vs 3.4% (1) with the sham procedure (P < .01). Patients undergoing StomaphyX treatment experienced significantly greater reduction in weight and BMI at 3, 6, and 12 months (P ≤ .05). There was one causally related adverse event with StomaphyX, that required laparoscopic exploration and repair. CONCLUSIONS AND RELEVANCE: StomaphyX treatment failed to achieve the primary efficacy target and resulted in early termination of the study. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00939055.

Ventral hernias in morbidly obese patients: a suggested algorithm for operative repair.

With the rise in prevalence of obesity, most general surgeons will have to face the problem of the obese patient with an abdominal wall defect. Treatment of these bariatric patients raises unique challenges, and at this time there is still no consensus on the best treatment option. This study was performed in a high-volume bariatric and minimally invasive surgery center at a tertiary care facility in the USA. Twenty-eight morbidly obese patients treated at our facility between 2003 and 2008 were separated into four groups according to anatomic features and symptoms. Patients with the following characteristics were classified as having a favorable anatomy: body mass index not exceeding 50 kg/m(2), gynecoid body habitus, reducible hernias found in a central location, abdominal wall thickness less than 4 cm, and the defect's largest diameter not exceeding 8 cm. All other patients were classified as having an unfavorable anatomy. In this study, we report a systematic treatment approach for the morbidly obese patient presenting with a ventral hernia based on whether the hernia is symptomatic or asymptomatic, as well as the distinct characteristics of the hernia and body habitus features. We followed up on these patients postoperatively for at least 2 years, with a mean follow-up period of 30 months. Only a total of three hernia recurrences were observed. Successful treatment of ventral hernias in morbidly obese patients should be individualized based on the patient's symptoms and defined hernia characteristics.

Laparoscopic sleeve gastrectomy for super obese patients: forty-eight percent excess weight loss after 6 to 8 years with 93% follow-up.

OBJECTIVES: In this study, we report long-term outcomes of high-risk, high-BMI (body mass index) patients who underwent laparoscopic sleeve gastrectomy (LSG). BACKGROUND: Short- and medium-term data appear to support the effectiveness of LSG, but long-term data to support its durability are sparse. METHODS: A prospective database was reviewed on all high-risk patients who underwent LSG as part of a staged approach for surgical treatment of severe obesity between January 2002 and February 2004. We included only patients who did not proceed to second-stage surgery (gastric bypass). Analyzed data included demographics, BMI, comorbidities, and surgical outcomes. All partial gastrectomies were performed using a 50F bougie. RESULTS: Seventy-four patients underwent LSG, and follow-up data were available on 69 of 74 patients (93%). The mean age was 50 years (25-78) and the mean number of co-morbidities was 9.6. Perioperative mortality (<30 days) was zero, and the incidence of short- and long-term postoperative complications was 15%. The mean overall follow-up time period was 73 months (38-95). Mean excess weight loss (EWL) at 72, 84, and 96 months after LSG was 52%, 43%, and 46%, respectively, with an overall EWL of 48%. The mean BMI decreased from 66 kg/m(2) (43-90) to 46 kg/m(2) (22-73). Seventy-seven percent of the diabetic patients showed improvement or remission of the disease. CONCLUSIONS: This study reports the longest follow-up of LSG patients thus far and supports the effectiveness, safety, and durability of laparoscopic sleeve gastrectomy as a definitive therapeutic option for severe obesity, even in high-risk, high-BMI patients.

Walking capacity of bariatric surgery candidates.

BACKGROUND: This study characterizes the walking limitations of bariatric surgery candidates by age and body mass index (BMI) and determines factors independently associated with walking capacity. The setting was multi-institutional at research university hospitals in the United States. METHODS: Participants of the Longitudinal Assessment of Bariatric Surgery study (n=2458; age 18-78 yr, BMI 33-94 kg/m(2)) attended a preoperative research visit. Their walking capacity was measured by self-report and the 400 m Long Distance Corridor Walk (LDCW). RESULTS: Almost two thirds (64%) of subjects reported limitations with walking several blocks, 48% had an objectively defined mobility deficit, and 16% reported at least some walking aid use. In multivariate analysis, BMI, older age, lower income, and greater bodily pain were independently associated (P < .05) with walking aid use, physical discomfort during the LDCW, an inability to complete the LDCW, and a slower time to complete the LDCW. Female gender, Hispanic ethnicity (but not race), greater heart rate at rest, a history of smoking, several co-morbidities (history of stroke, ischemic heart disease, diabetes, asthma, sleep apnea, venous edema with ulcerations), and depressive symptoms were also independently related (P < .05) to at least one measure of reduced walking capacity. CONCLUSIONS: Walking limitations are common in bariatric surgery candidates, even among the least severely obese and youngest patients. Physical activity counseling must be tailored to individuals' abilities. Although several factors identified in the present study (eg, BMI, age, pain, co-morbidities) should be considered, directly assessing the patient's walking capacity will facilitate appropriate goal setting.

Pre- to postoperative changes in physical activity: report from the longitudinal assessment of bariatric surgery-2 (LABS-2).

BACKGROUND: Numerous studies have reported that bariatric surgery patients report more physical activity (PA) after surgery than before; however, the quality of the PA assessment has been questionable. METHODS: The longitudinal assessment of bariatric surgery-2 is a 10-center longitudinal study of adults undergoing bariatric surgery. Of 2458 participants, 455 were given an activity monitor, which records the steps per minute, and an exercise diary before and 1 year after surgery. The mean number of steps/d, active min/d, and high-cadence min/wk were calculated for 310 participants who wore the monitor ≥10 hr/d for ≥3 days at both evaluations. Pre- and postoperative PA were compared for differences using the Wilcoxon signed-rank test. Generalized estimating equations were used to identify independent preoperative predictors of postoperative PA. RESULTS: PA increased significantly (P < .0001) from before to after surgery for all PA measures. The median values before and after surgery were 7563 and 8788 steps/d, 309 and 340 active min/d, and 72 and 112 high-cadence min/wk, respectively. However, depending on the PA measure, 24-29% of participants were ≥5% less active postoperatively than preoperatively. Controlling for surgical procedure, gender, age, and body mass index, more PA preoperatively independently predicted for more PA postoperatively (P < .0001, for all PA measures). Less pain, not having asthma, and the self-report of increasing PA as a weight loss strategy preoperatively also independently predicted for more high-cadence min/wk postoperatively (P < .05). CONCLUSIONS: The majority of adults increase their PA level after bariatric surgery. However, most remain insufficiently active, and some become less active. Increasing PA, addressing pain, and treating asthma before surgery might have a positive effect on postoperative PA.

Long-term outcomes of laparoscopic Roux-en-Y gastric bypass in US veterans.

BACKGROUND: The objective of this study is to evaluate the long-term outcomes following laparoscopic Roux-en-Y gastric bypass (LREYGB) in veteran patients. The VA bariatric population differs from its counterpart in the private sector by the predominance of a male population, a higher percentage of patients from a lower socioeconomic background, a higher mean age, and a higher rate of obesity-related comorbidities. METHODS: A retrospective review with prospectively collected data was used to analyze postoperative changes of comorbidities and percent of excess weight loss (% EWL) in consecutive patients who underwent LREYGB between August 2003 and September 2006. RESULTS: Among 70 patients, 73% were men with a mean age of 52 years (29-66 years). Average preoperative weight and body mass index were 310 lbs (224-397 lbs) and 46 kg/m(2) (36-60 kg/m(2)), respectively. The incidence of major and minor complications was 1.4% and 15.7%, respectively. There were no mortalities. Follow-up (f/u) was possible in all patients. At a mean f/u rate of 39 months, % EWL was 56%. At 1, 3, and 5 years, % EWL was 61%, 53%, and 59%, respectively. Thirty-five patients (50%) had type 2 diabetes mellitus (T2DM). Glycosylated hemoglobin concentrations returned to normal levels in 91% of patients and improved in an additional 6% of T2DM cases. Only 7% of patients are still maintained on antidiabetic medications. In patients with more than 1 year f/u, most other comorbidities were improved or resolved. CONCLUSIONS: Long-term f/u of LREYGB in veteran patients demonstrated significant and durable weight loss (56% EWL) with marked improvements in comorbidities especially T2DM.

Physical activity and physical function changes in obese individuals after gastric bypass surgery.

BACKGROUND: Little is known about the effects of gastric bypass surgery (GBS) on physical activity and physical function. We examined the physical activity, physical function, psychosocial correlates to physical activity participation, and health-related quality of life of patients before and after GBS. METHODS: A total of 20 patients were assessed before and 3 months after GBS. Physical activity was assessed using the 7-day physical activity recall questionnaire and a pedometer worn for 7 days. Physical function was assessed using the 6-minute walk test, Short Physical Performance Battery, and the physical function subscale of the Medical Outcomes Short Form-36 (SF-36). The Physical Activity Self-Efficacy questionnaire, the Physical Activity Barriers and Outcome Expectations questionnaire, the SF-36, and the Numeric Pain Rating Scale were also administered. RESULTS: Physical activity did not significantly increase from before (191.1 +/- 228.23 min/wk) to after (231.7 +/- 230.04 min/wk) GBS (n = 18); however, the average daily steps did significantly increase (from 4621 +/- 3701 to 7370 +/- 4240 steps/d; n = 11). The scores for the 6-minute walk test (393 +/- 62.08 m to 446 +/- 41.39 m; n = 17), Short Physical Performance Battery (11.2 +/- 1.22 to 11.7 +/- .57; n = 18), physical function subscale of the SF-36 (65 +/- 18.5 to 84.1 +/- 19.9), and the total SF-36 (38.2 +/- 23.58 to 89.7 +/- 15.5; n = 17) increased significantly. The Numeric Pain Rating Scale score decreased significantly for low back (3.5 +/- 1.8 to 1.7 +/- 2.63), knee (2.4 +/- 2.51 to 1.0 +/- 1.43), and foot/ankle (2.3 +/- 2.8 to 0.9 +/- 2.05) pain. No significant changes were found in the Physical Activity Self-Efficacy questionnaire or the Physical Activity Barriers and Outcome Expectations questionnaire. CONCLUSION: GBS improves physical function, health-related quality of life, and self-reported pain and results in a modest improvement in physical activity. These are important clinical benefits of surgical weight loss. Long-term follow-up is needed to quantify the ability to sustain or further improve these important clinical outcomes.

Transoral endoscopic inner layer esophagectomy: management of high-grade dysplasia and superficial cancer with organ preservation.

INTRODUCTION: Limitations of endoscopic therapies for Barrett's esophagus and superficial cancer include a compromised histological assessment, the need for surveillance, subsequent procedures, and stricture formation. Circumferential en bloc resection of the mucosa-submucosa complex followed by deployment of a biologic scaffold onto the remaining muscularis propria may address these concerns. The objective of this study was to determine technical feasibility of transoral resection of the esophageal lining. MATERIALS AND METHODS: Transoral endoscopic inner layer esophagectomy was performed in ten swine. Endpoints included procedure duration, hemorrhage, number of perforations, and adequacy of resection length and depth. RESULTS: Procedures were successfully completed in all animals without perioperative mortality. Procedure times averaged 179 min (range 125-320). No perforations were found, and a mean of 1.7 (0-4) interventions for hemorrhage was required. Complete longitudinal resection was achieved in nine of ten animals. Resection depth included all mucosal layers in 100% of tissue sections, the submucosal layers, SM1 in 100%, and SM2 in 96%. A portion of SM3 was adherent to the muscularis propria in 70%. CONCLUSION: Transoral endoscopic resection of the inner esophageal layers was feasible and reproducible. This technique may facilitate a single-step definitive treatment and staging tool for early neoplastic lesions, obviating the need for esophagectomy.

Physical activity levels of patients undergoing bariatric surgery in the Longitudinal Assessment of Bariatric Surgery study.

BACKGROUND: Bariatric surgery candidates' physical activity (PA) level might contribute to the variability of weight loss and body composition changes following bariatric surgery. However, there is little research describing the PA of patients undergoing bariatric surgery to inform PA recommendations in preparation for, and following, surgery. We describe the PA assessment in the Longitudinal Assessment of Bariatric Surgery-2 study at 6 sites in the United States and report preoperative PA level. We also examined the relationships between objectively determined PA level and the patient's body mass index and self-reported purposeful exercise. METHODS: The participants wore an accelerometer and completed a PA diary. Standardized measures of height and weight were obtained. RESULTS: Of the 757 participants, 20% were sedentary (<5000 steps/d), 34% had low activity (5000-7499 steps/d), 27% were somewhat active (7500-9999 steps/d), 14% were active (10,000-12,499 steps/d), and 6% were highly active (>or=12,500 steps/d). Body mass index was inversely related to the mean number of steps daily and the mean number of steps each minute during the most active 30 minutes of each day. The most commonly reported activities were walking (44%), gardening (11%), playing with children (10%), and stretching (7%). The self-reported minutes of exercise accounted for 2% of the variance in the objectively determined steps. CONCLUSION: Patients present for bariatric surgery with a wide range of PA levels, with almost one half categorized as somewhat active or active. Body mass index was inversely related to the total amount and intensity of PA. Few patients reported a regular preoperative exercise regimen, suggesting most PA is accumulated from activities of daily living. Patients' report of daily minutes of walking or exercise might not be a reliable indication of their PA level.

Laparoscopic colorectal surgery is safe in the high-risk patient: a NSQIP risk-adjusted analysis.

BACKGROUND: Laparoscopic colectomy was considered initially to be contraindicated in patients at high risk for operative morbidity and mortality. We hypothesized that this procedure is safe to perform in high-risk patients, stratifying this risk using National VA Surgical Quality Improvement Program (NSQIP) algorithms. METHODS: A case-matched, comparative study was performed for high-risk veteran patients who underwent colectomy during the period October 2002-September 2004. Consecutive patients undergoing laparoscopic colectomy were matched to patients who underwent open colectomy during the same period for age, body mass index (BMI), procedure, and NSQIP-predicted risk. The groups were compared for risk-stratified, 30-day morbidity/mortality, length of stay (LOS), and operating time. RESULTS: Forty-five patients (23 laparoscopic and 22 open cases) were defined as at high risk for complications (predicted complication >0.15). The rate of major complications was significantly less in the laparoscopic group. There were 4 (18%) cases of postoperative respiratory failure in the open group and none in the laparoscopic group. There was no surgically related mortality in the laparoscopic group, compared with 2 deaths in the open group (P = .5). Median LOS was less in the laparoscopic group (5 days) compared with open (8 days) (P = .001). There were no significant differences in operating time or the number of minor complications. CONCLUSIONS: Our results suggest that the laparoscopic approach to colorectal diseases is safe in the population of patients at high risk for operative morbidity and mortality. Rather, this approach may represent a safer alternative to open access.

Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass.

OBJECTIVES: A precipitating factor for marginal ulcer formation after Roux-en-Y gastric bypass may be the prolonged irritation by foreign material, such as nonabsorbable suture at the gastrojejunostomy. This study examines the incidence of marginal ulcers before and after a change was made from using nonabsorbable suture to using absorbable suture for the inner layer of the anastomosis. METHODS: A total of 3285 laparoscopic Roux-en-Y gastric bypass operations were performed during a 5-year period. The gastrojejunostomy technique was modified in August 2002. Those patients who developed a marginal ulcer postoperatively were identified, and their charts were retrospectively analyzed for the operative technique, patient age, history of previous gastric surgery, presence of preoperative diabetes, coronary artery disease, or peptic ulcer disease, and use of nonsteroidal anti-inflammatory medications or tobacco. RESULTS: The incidence of marginal ulceration after Roux-en-Y gastric bypass decreased significantly from 2.6% (28/1095) with the use of nonabsorbable suture to 1.3% (29/2190) after the change to absorbable suture for the inner layer of the gastrojejunal anastomosis (P < .001). The incidence of visible suture adjacent to the ulcer on endoscopy was also significantly reduced (64.3% vs 3.4%; P < .001). When the results were corrected for length of follow-up, the difference in the incidence of ulcers occurring within 1 year of surgery remained significant between the two groups (P = .002). There were no other significant differences in the factors analyzed. CONCLUSIONS: The use of nonabsorbable sutures for the inner layer of the gastrojejunal anastomosis is associated with an increased incidence of marginal ulcers, and the adoption of absorbable suture material has reduced this incidence.

Laparoscopic repair of umbilical hernias in conjunction with other laparoscopic procedures.

BACKGROUND: This study evaluates the feasibility of laparoscopic transfascial suture repair of umbilical hernias when combined with another laparoscopic procedure that potentially contaminates the peritoneal cavity. METHOD: From August 1997 to November 2001, 32 patients underwent laparoscopic umbilical suture repair in association with another laparoscopic procedure. The repair was performed with the Carter-Thomason suture passer. RESULTS: Of the 32, 26 patients with more than 1-year follow-up were included in the study. The mean diameter of the umbilical hernia defect was 1.67 cm (range, 0.5 to 3). At a mean follow-up of 34 months (range, 12 to 60), there were only 2 recurrences (7.7%) both of which happened in patients with hernia defects larger than 2 cm in diameter. Apart from 2 wound infections, no other complications occurred. CONCLUSION: Laparoscopic suture repair of umbilical hernias with the suture passer method is effective and durable even when combined with other laparoscopic procedures that potentially contaminate the peritoneal cavity with bile or enteric contents.

Surgically-induced weight loss significantly improves nonalcoholic fatty liver disease and the metabolic syndrome.

OBJECTIVE: To evaluate the effects of surgical weight loss on fatty liver disease in severely obese patients. SUMMARY BACKGROUND DATA: Nonalcoholic fatty liver disease (NAFLD), a spectrum that extends to liver fibrosis and cirrhosis, is rising at an alarming rate. This increase is occurring in conjunction with the rise of severe obesity and is probably mediated in part by metabolic syndrome (MS). Surgical weight loss operations, probably by reversing MS, have been shown to result in improvement in liver histology. METHODS: Patients who underwent laparoscopic surgical weight loss operations from March 1999 through August 2004, and who agreed to have an intraoperative liver biopsy followed by at least one postoperative liver biopsy, were included. RESULTS: There were 70 patients who were eligible. All patients underwent laparoscopic operations, the majority being laparoscopic Roux-en-Y gastric bypass. The mean excess body weight loss at time of second biopsy was 59% +/- 22% and the time interval between biopsies was 15 +/- 9 months. There was a reduction in prevalence of metabolic syndrome, from 70% to 14% (P < 0.001), and a marked improvement in liver steatosis (from 88% to 8%), inflammation (from 23% to 2%), and fibrosis (from 31% to 13%; all P < 0.001). Inflammation and fibrosis resolved in 37% and 20% of patients, respectively, corresponding to improvement of 82% (P < 0.001) in grade and 39% (P < 0.001) in stage of liver disease. CONCLUSION: Surgical weight loss results in significant improvement of liver morphology in severely obese patients. These beneficial changes may be associated with a significant reduction in the prevalence of the metabolic syndrome.