Bariatric surgery for obesity and metabolic disorders: state of the art.

Obesity is one of the most important public health conditions worldwide. Bariatric surgery for severe obesity is an effective treatment that results in the improvement and remission of many obesity-related comorbidities, as well as providing sustained weight loss and improvement in quality of life. Contemporary bariatric operations include Roux-en-Y gastric bypass, sleeve gastrectomy, adjustable gastric band and the duodenal switch. The vast majority of these procedures are now performed using laparoscopic technique, the main advantages of which include rapid recovery, the reduction of postoperative pain and the reduction of wound-related complications, compared with open surgery. Contemporary bariatric surgery is now safe, with a mortality of three in 1,000 patients; however, all bariatric operations are associated with their own unique short-term and long-term nutritional and procedural-related complications. Type 2 diabetes mellitus (T2DM) is the most studied metabolic disorder associated with obesity, with data demonstrating that improvement and remission of T2DM in patients with obesity is superior after bariatric surgery compared with conventional medical therapy. Bariatric surgery is now a part of some treatment algorithms for the medical management of patients with T2DM and severe obesity. New, minimally invasive and endoscopic devices for the treatment of obesity have now been approved in the USA, which will expand the treatment options for individuals with obesity.

Laparoscopic sleeve gastrectomy leads the U.S. utilization of bariatric surgery at academic medical centers.

BACKGROUND: Analysis of a recent single state bariatric surgery registry revealed that laparoscopic sleeve gastrectomy was the most common bariatric procedure starting in 2012. The objective of this study was to examine the trend in utilization of laparoscopic sleeve gastrectomy performed at academic medical centers in the United States. METHODS: Using ICD-9 diagnosis and procedure codes, clinical data obtained from the University HealthSystem Consortium database for all bariatric procedures performed for the treatment of severe obesity between October 1, 2011, and June 30, 2014. Quarterly trends in utilization for the 4 most commonly performed bariatric operations were examined, and comparisons between procedures were performed. RESULTS: A total of 54,953 bariatric procedures were performed. Utilization of laparoscopic sleeve gastrectomy increased from 23.7% of all bariatric procedures during the fourth quarter of 2011 to 60.7% during the second quarter of 2014 while laparoscopic gastric bypass decreased from 62.2% to 37.0%, respectively. Utilization of laparoscopic sleeve gastrectomy surpassed that of laparoscopic gastric bypass in the second quarter of 2013 (50.6% versus 45.8%). During the same time period, utilization of open gastric bypass fell from 6.6% to 1.5%, and the use of laparoscopic adjustable gastric banding decreased from 7.5% to .8%. CONCLUSIONS: Within the context of U.S. academic medical centers, there has been a significant increase in the utilization of laparoscopic sleeve gastrectomy, which has surpassed laparoscopic gastric bypass utilization since 2013. Laparoscopic sleeve gastrectomy is now the most commonly performed bariatric procedure at the national level within academic centers.

Matched weight loss induced by sleeve gastrectomy or gastric bypass similarly improves metabolic function in obese subjects.

OBJECTIVE: The effects of marked weight loss, induced by Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgeries, on insulin sensitivity, ß-cell function and the metabolic response to a mixed meal were evaluated. METHODS: Fourteen nondiabetic insulin-resistant patients who were scheduled to undergo SG (n = 7) or RYGB (n = 7) procedures completed a hyperinsulinemic-euglycemic clamp procedure and a mixed-meal tolerance test before surgery and after losing ∼20% of their initial body weight. RESULTS: Insulin sensitivity (insulin-stimulated glucose disposal during a clamp procedure), oral glucose tolerance (postprandial plasma glucose area under the curve), and ß-cell function (insulin secretion in relationship to insulin sensitivity) improved after weight loss, and were not different between surgical groups. The metabolic response to meal ingestion was similar after RYGB or SG, manifested by rapid delivery of ingested glucose into the systemic circulation and a large early postprandial increase in plasma glucose, insulin, and C-peptide concentrations in both groups. CONCLUSIONS: When matched on weight loss, RYGB and SG surgeries result in similar improvements in the two major factors involved in regulating plasma glucose homeostasis, insulin sensitivity and ß-cell function in obese people without diabetes.

The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003-2012.

IMPORTANCE: The prevalence of obesity and outcomes of bariatric surgery are well established. However, analyses of the surgery impact have not been updated and comprehensively investigated since 2003. OBJECTIVE: To examine the effectiveness and risks of bariatric surgery using up-to-date, comprehensive data and appropriate meta-analytic techniques. DATA SOURCES: Literature searches of Medline, Embase, Scopus, Current Contents, Cochrane Library, and Clinicaltrials.gov between 2003 and 2012 were performed. STUDY SELECTION: Exclusion criteria included publication of abstracts only, case reports, letters, comments, or reviews; animal studies; languages other than English; duplicate studies; no surgical intervention; and no population of interest. Inclusion criteria were a report of surgical procedure performed and at least 1 outcome of interest resulting from the studied surgery was reported: comorbidities, mortality, complications, reoperations, or weight loss. Of the 25,060 initially identified articles, 24,023 studies met the exclusion criteria, and 259 met the inclusion criteria. DATA EXTRACTION AND SYNTHESIS: A review protocol was followed throughout. Three reviewers independently reviewed studies, abstracted data, and resolved disagreements by consensus. Studies were evaluated for quality. MAIN OUTCOMES AND MEASURES: Mortality, complications, reoperations, weight loss, and remission of obesity-related diseases. RESULTS: A total of 164 studies were included (37 randomized clinical trials and 127 observational studies). Analyses included 161,756 patients with a mean age of 44.56 years and body mass index of 45.62. We conducted random-effects and fixed-effect meta-analyses and meta-regression. In randomized clinical trials, the mortality rate within 30 days was 0.08% (95% CI, 0.01%-0.24%); the mortality rate after 30 days was 0.31% (95% CI, 0.01%-0.75%). Body mass index loss at 5 years postsurgery was 12 to 17. The complication rate was 17% (95% CI, 11%-23%), and the reoperation rate was 7% (95% CI, 3%-12%). Gastric bypass was more effective in weight loss but associated with more complications. Adjustable gastric banding had lower mortality and complication rates; yet, the reoperation rate was higher and weight loss was less substantial than gastric bypass. Sleeve gastrectomy appeared to be more effective in weight loss than adjustable gastric banding and comparable with gastric bypass. CONCLUSIONS AND RELEVANCE: Bariatric surgery provides substantial and sustained effects on weight loss and ameliorates obesity-attributable comorbidities in the majority of bariatric patients, although risks of complication, reoperation, and death exist. Death rates were lower than those reported in previous meta-analyses.

Gastric bypass and banding equally improve insulin sensitivity and ß cell function.

Bariatric surgery in obese patients is a highly effective method of preventing or resolving type 2 diabetes mellitus (T2DM); however, the remission rate is not the same among different surgical procedures. We compared the effects of 20% weight loss induced by laparoscopic adjustable gastric banding (LAGB) or Roux-en-Y gastric bypass (RYGB) surgery on the metabolic response to a mixed meal, insulin sensitivity, and ß cell function in nondiabetic obese adults. The metabolic response to meal ingestion was markedly different after RYGB than after LAGB surgery, manifested by rapid delivery of ingested glucose into the systemic circulation, by an increase in the dynamic insulin secretion rate, and by large, early postprandial increases in plasma glucose, insulin, and glucagon-like peptide-1 concentrations in the RYGB group. However, the improvement in oral glucose tolerance, insulin sensitivity, and overall ß cell function after weight loss were not different between surgical groups. Additionally, both surgical procedures resulted in a similar decrease in adipose tissue markers of inflammation. We conclude that marked weight loss itself is primarily responsible for the therapeutic effects of RYGB and LAGB on insulin sensitivity, ß cell function, and oral glucose tolerance in nondiabetic obese adults.

2D versus 3D visualization: impact on laparoscopic proficiency using the fundamentals of laparoscopic surgery skill set.

INTRODUCTION: We compared the impact of two-dimensional (2D) versus three-dimensional (3D) visualization on both objective and subjective measures of laparoscopic performance using the validated Fundamentals of Laparoscopic Surgery (FLS) skill set. SUBJECTS AND METHODS: Thirty-three individuals with varying laparoscopic experience completed three essential drills from the FLS skill set (peg transfer, pattern cutting, and suturing/knot tying) in both 2D and 3D. Participants were randomized to begin all tasks in either 2D or 3D. Time to completion and number of attempts required to achieve proficiency were measured for each task. Errors were also noted. Participants completed questionnaires evaluating their experiences with both visual modalities. RESULTS: Across all tasks, greater speed was achieved in 3D versus 2D: peg transfer, 183.4 versus 245.6 seconds (P<.0001); pattern cutting, 167.7 versus 209.3 seconds (P=.004); and suturing/knot tying, 255.2 versus 329.5 seconds (P=.031). Fewer errors were committed in the peg transfer task in 3D versus 2D (P=.008). Fourteen participants required multiple attempts to achieve proficiency in one or more tasks in 2D, compared with 7 in 3D. Subjective measures of efficiency and accuracy also favored 3D visualization. The advantage of 3D vision persisted independent of participants' level of technical expertise (novice versus intermediate/expert). There were no differences in reported side effects between the two visual modalities. Overall, 87.9% of participants preferred 3D visualization. CONCLUSIONS: Three-dimensional vision appears to greatly enhance laparoscopic proficiency based on objective and subjective measures. In our experience, 3D visualization produced no more eye strain, headaches, or other side effects than 2D visualization. Participants overwhelmingly preferred 3D visualization.

Intrahepatic diacylglycerol content is associated with hepatic insulin resistance in obese subjects.

Data from studies in animal models indicate that certain lipid metabolites, particularly diacylglycerol, ceramide, and acylcarnitine, disrupt insulin action. We evaluated the relationship between the presence of these metabolites in the liver (assessed by mass spectrometry) and hepatic insulin sensitivity (assessed using a hyperinsulinemic-euglycemic clamp with stable isotope tracer infusion) in 16 obese adults (body mass index, 48 ± 9 kg/m²). There was a negative correlation between insulin-mediated suppression of hepatic glucose production and intrahepatic diacylglycerol (r = -0.609; P = .012), but not with intrahepatic ceramide or acylcarnitine. These data indicate that intrahepatic diacylglycerol is an important mediator of hepatic insulin resistance in obese people with nonalcoholic fatty liver disease.

Comparison of laparoscopic skills performance between single-site access (SSA) devices and an independent-port SSA approach.

BACKGROUND: This study compared the performance of validated laparoscopic tasks on four commercially available single-site-access (SSA) devices with the performance of those tasks on an independent-port (IP) SSA setup. METHODS: A prospective, randomized comparison of laparoscopic skills performance on four access devices (ADs) (GelPOINT, SILS Port, SSL Access System, TriPort) and one IP-SSA setup was conducted. A laparoscopic trainer box was used to train 18 (2nd- to 4th-year) medical students, four surgical residents, and five attending surgeons to proficiency in multiport laparoscopy using four laparoscopic drills (i.e., peg transfer, bean drop, pattern cutting, extracorporeal suturing). Drills then were performed in random order on each IP-SSA and AD-SSA setup using straight laparoscopic instruments. Repetitions were timed and errors recorded. Data are presented as mean ± standard deviation. Statistical analysis was performed by two-way analysis of variance (ANOVA) with Tukey HSD post hoc tests. RESULTS: The attending surgeons had significantly faster total task times than the residents or students (P < 0.001), but the difference between the residents and students was not significant. Pair-wise comparisons showed significantly faster total task times for the IP-SSA setup than for all four AD-SSAs within the student group only (P < 0.05). The total task times for the residents and attending surgeons showed a similar profile, but the differences were not significant. When the data for the three groups were combined, the total task time was less for the IP-SSA setup than for each of the four AD-SSA setups (P < 0.001). Similarly, the IP-SSA setup was significantly faster than three of the four AD-SSA setups for peg transfer, three of the four setups for pattern cutting, and two of the four setups for suturing. No significant differences in error rates between the IP-SSA and AD-SSA setups were detected. CONCLUSIONS: Compared with an IP-SSA laparoscopic setup, AD-SSAs are associated with longer task performance times in a trainer box model, independently of the level of training. Task performance was similar across the different SSA devices.

Bariatric surgery: a cure for diabetes?

PURPOSE OF REVIEW: To review the basic mechanisms of caloric intake reduction of bariatric surgery and its clinical and metabolic outcomes. To describe novel bariatric procedures, their effects on glucose homeostasis and insulin sensitivity and to explain the proposed mechanisms for type 2 diabetes mellitus (T2DM) resolution. RECENT FINDINGS: The effects of surgically induced weight loss on T2DM have elucidated in part the role of proximal and distal gastrointestinal bypass on insulin sensitivity. A dual mechanism for improvement in glucose homeostasis after bariatric surgery has been proposed that appears to be weight loss independent. SUMMARY: Bariatric surgery is the most effective therapy for obesity and obesity-related comorbidities today that provide high rates of resolution of T2DM with improvements in insulin resistance and ß-cell function. Novel bariatric procedures offer a unique opportunity to understand the pathophysiology of T2DM and to identify potential pharmacologic targets for effective T2DM treatments and a potential cure.

Perioperative outcomes of laparoscopic adjustable gastric banding in mildly obese (BMI < 35 kg/m2) compared to severely obese.

Laparoscopic adjustable gastric banding (LAGB) has become a standard restrictive procedure in the USA for the treatment of severe obesity (body mass index, BMI > 35 kg/m(2)). Mildly obese individuals (BMI < 35 kg/m(2)) are also at increased risk from obesity-related conditions. Recently, an FDA panel supported its use in this subgroup. We compared the perioperative outcomes of LAGB in mildly and severely obese. Thirty consecutive patients (mildly obese n=10; severely obese n=20) that underwent preoperative medical weight loss followed by LAGB procedures were prospectively evaluated. Outcome variables included: operative room (OR) time, intraoperative estimated blood loss (EBL), length of hospital (LOS), and intensive care unit (ICU) stay, reoperations, readmissions, 30-day morbidity and mortality. Demographic data was comparable between groups. BMI was significantly higher in the severely obese compared to mildly obese (44.0 ± 5 vs. 33.6 ± 1 kg/m(2)). OR time, EBL, LOS, and ICU admissions were similar between BMI groups. There were no reoperations or 30-day mortality in either group. Minor morbidity was only observed in the severely obese group. BMI correlated with OR time and EBL. In mildly obese, LAGB is as safe as in the severely obese with no perioperative morbidity. The perioperative outcomes and hospital resource utilization are comparable between BMI groups. Lower BMI is associated with lower operative times and blood loss.

Disparities in access to basic laparoscopic surgery at U.S. academic medical centers.

BACKGROUND: Laparoscopy is the standard approach used for basic gastrointestinal procedures such appendectomy and cholecystectomy. This study determined the disparities in access to laparoscopic surgery for these commonly performed procedures at U.S. academic medical centers. METHODS: Using appropriate International Classification of Diseases, 9th ed, Clinical Modification (ICD-9-CM) procedure and diagnosis codes, 112,540 basic gastrointestinal procedures were identified from the University HealthSystem Consortium database over a 4-year period (2005-2009). During this period, 82,062 laparoscopic (72.9%) and 30,478 open (27.1%) procedures were performed. The odds ratios (ORs) for laparoscopic versus open procedures were calculated and stratified for age, gender, race/ethnicity, admission status, severity of illness, and primary payer status. RESULTS: Univariate analysis showed that young age (OR, 1.33; 95% confidence interval [CI], 1.27-1.39), white race/ethnicity (OR, 1.07; 95% CI, 1.03-1.11), female gender (OR, 1.79; 95% CI, 1.75-1.84), minor severity of illness (OR, 1.49; 95% CI, 1.44-1.53), and commercial/private payer status (OR, 1.25; 95% CI, 1.21-1.29) increased the likelihood that a laparoscopic approach would be used for the procedures studied. CONCLUSION: A disparity in access to basic laparoscopic surgery exists at U.S. academic medical centers based on age, gender, race/ethnicity, severity of illness, and primary payer status.

Laparoscopic sleeve gastrectomy versus laparoscopic adjustable gastric banding for the treatment severe obesity in high risk patients.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has emerged as an alternative restrictive bariatric procedure to the most popular laparoscopic adjustable gastric banding (LAGB). We analyze and compare the clinical and weight loss outcomes of LSG versus LAGB for the treatment of severe obesity in high-risk patients. METHODS: Forty severely obese veterans (20/group) received either LSG or LAGB and were followed prospectively for 2 years. Outcome measures included operating room (OR) time, estimated blood loss (EBL), length of hospital stay (LOS), morbidity, mortality, reoperations, readmission rates, and weight loss over time. RESULTS: The cohort primarily comprised high-risk and older male veterans. Patient's baseline demographics were similar between groups. LSG was associated with prolonged OR time (116±31 vs. 94±28min), higher EBL (34±28 vs. 17±19mL), and LOS (2±.9 vs. 1±.4days) when compared with LAGB. Minor morbidity and readmissions were similar between groups, while no major morbidity, reoperations, or mortality occurred. Total weight and BMI decreased significantly after surgery in both groups (LSG: 302±52 to 237lbs and 45±5 to 36±5kg/m(2) vs. LAGB: 280±36 to 231±29lbs and 43±5 to 36±5kg/m(2), respectively). Total weight loss was superior in the LSG vs. LAGB group at 2 years (TWL=65±24 vs. 49±28 lbs (P=.03); %EWL=51±20 vs. 46±23%; %EBMI loss=48±22 vs. 45±23%, and %BWL=21±8 vs. 17±9%, respectively). CONCLUSION: In severely obese and high-risk patients, laparoscopic sleeve gastrectomy provides superior total weight loss at 2 years.

Video. Modified single-incision laparoscopic adjustable gastric band.

INTRODUCTION: This video describes a modified single-incision laparoscopic approach for adjustable gastric band placement. METHOD: The patient was a 28-year-old female with a BMI of 48.75 with no prior surgery but with numerous comorbidities. With the patient placed in a split-leg position and in steep reverse Trendelenburg, a 12-mm optical trocar is placed 12 cm distal to the xiphoid process in the left paramedian location. A Nathanson liver retractor is placed through a midepigastric 5-mm incision. Two 5-mm low-profile trocars are placed next to the 12-mm trocar through separate incisions (this maintains stability of each cannula) and a 5-mm 45 ° laparoscope is used. Using an automated suturing device, a stay suture is placed high on the fundus and externalized for retraction. An articulating band passer dissects the phrenogastric attachments at the angle of His. The 12-mm port is removed and the gastric band is inserted. The GE junction fat pad is excised and the Pars Flaccida membrane is divided using conventional instruments. A second traction suture is placed to retract the lesser curve fat and right crus fat pad. A peritoneal bite is also taken in the left lateral subcostal area such that when this suture is externalized, it acts as a pulley. An articulating 5-mm grasper is used to develop the retrogastric tunnel. Then the band is fed into position and its buckle is locked. Three interrupted sutures are placed to create an anterior gastric plication and a fourth antislippage suture is placed below the band along the lesser curve. The band tubing is externalized and the port is implanted by joining the three working trocar incisions into a single 4.5-cm incision. RESULTS: The patient did well postoperatively with no complications. CONCLUSIONS: A modified single incision approach for laparoscopic gastric band placement is feasible and provides patients with improved cosmesis.

Laparoscopic surgery significantly reduces surgical-site infections compared with open surgery.

BACKGROUND: Surgical-site infections (SSIs) are nosocomial infectious complications causing significant morbidity, mortality, and hospital costs. Recently, the US Department of Human Health Services and the Centers for Medicare and Medicare Services outlined measures intended to decrease and prevent hospital-acquired infections such as SSI. This study aimed to compare the incidence of SSI after laparoscopic and open surgery. METHODS: A retrospective analysis of a large administrative, clinical, and financial database (University Health System Consortium) of US Academic Medical Centers and affiliated community hospitals was conducted. Patients who underwent laparoscopic (n = 94,665) or open (n = 36,965) appendectomy, cholecystectomy, antireflux surgery, or gastric bypass between 2004 and 2008 were included in the analysis. The main outcome measure was inpatient diagnosis of SSI after laparoscopic and open surgery. RESULTS: During the 45-month study period, a total of 131,630 patients underwent one of four selected procedures. Overall, the incidence of SSI was significantly lower in laparoscopic (483 of 94,665, 0.5%) than in open (669 of 36,965, 1.8%) surgery (p < 0.01). Largely, laparoscopic techniques offered a protective effect against SSI (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.25-0.31). Patients treated with laparoscopy were 72% less likely to experience an SSI. This protective effect was shown to be sustained after stratification by severity of illness (minor: OR, 0.19; 95% CI, 0.14-0.26; moderate: OR, 0.30; 95% CI, 0.25-0.35; major/extreme: OR, 0.65; 95% CI, 0.54-0.79), admission status (elective: OR, 0.25; 95% CI, 0.20-0.31; urgent: OR, 0.38; 95% CI, 0.28-0.53; emergent: OR, 0.29; 95% CI, 0.25-0.34), and wound classification (dirty wounds: OR, 0.45; 95% CI, 0.37-0.54). CONCLUSIONS: In US academic medical centers, laparoscopy significantly reduces SSI. Patients treated with laparoscopic procedures are less likely to experience SSI. After stratification by severity of illness, admission status, and wound classification, laparoscopic techniques showed a protective effect against SSI.

Barrett's esophagus: a late complication of laparoscopic adjustable gastric banding.

Laparoscopic adjustable gastric banding has become a popular bariatric restrictive procedure in the USA. The increasing popularity of the laparoscopic adjustable gastric band procedure could, in part, be related to the lower cost and lower morbidity compared with laparoscopic gastric bypass. Although its placement is related to a lower number of perioperative complications compared with laparoscopic gastric bypass, its morbidity may be substantial. Barrett's esophagus or esophageal intestinal metaplasia is a known complication of chronic gastro-esophageal reflux disease that, in rare occasions, progresses to dysplasia and esophageal adenocarcinoma. Barrett's esophagus, after laparoscopic adjustable gastric banding placement, is a rare but not unexpected complication after gastric band placement. The incidence of Barrett's esophagus after adjustable gastric banding is not known. We present a case of Barrett's esophagus as a result of laparoscopic adjustable gastric banding placement due to a chronically and highly restrictive gastric band in a former morbidly obese patient.

Single-site laparoscopic sleeve gastrectomy: preclinical use of a novel multi-access port device.

INTRODUCTION: Single-site laparoscopy (SSL) has emerged as an alternative technique for sleeve gastrectomy. The author describes the preclinical technique of SSL sleeve gastrectomy through a novel multichannel port device in the porcine model. METHODS: Anesthetized swine underwent 3-cm longitudinal supra-umbilical incision. A multichannel port device was inserted. A gastric sleeve was created by multiple applications of a 60-mm stapler. The access device's channel housing was removed and the sleeve specimen exteriorized. RESULTS: The mean operative time was 60+/-10 minutes, and the mean estimated blood loss was 30+/-5 cc. The multichannel port device allowed induction and maintenance of pneumoperitoneum throughout the procedure (range 12-15 mm Hg) with efficient rotation and substantial abdominal wall torque and minimal instrument clashing. CONCLUSION: SSL sleeve gastrectomy in the porcine model was facilitated by the use of a novel multichannel port device. Clinical studies are warranted.

Correlations between intra-abdominal pressure and obesity-related co-morbidities.

BACKGROUND: Obesity is associated with chronic increases in intra-abdominal pressure (IAP). The aim of the present study was to examine the correlation between the IAP and the number of obesity-related co-morbidities. METHODS: A total of 63 morbidly obese patients who were undergoing bariatric surgery had their IAP measured intraoperatively while in a supine position and under general anesthesia. The IAP readings were obtained through an indwelling urinary bladder catheter. The correlation of obesity-related co-morbidities, including systemic hypertension, type 2 diabetes mellitus, gastroesophageal reflux disease, urinary stress incontinence, lower extremity edema, obstructive sleep apnea, and abdominal wall hernia, and the level of IAP were examined using a stepwise regression analysis model. RESULTS: Of the 62 patients, 57 were women. The mean age was 44 + or - 11 years, and the body mass index was 49 + or - 10 kg/m(2). Of the 62 patients, 48 (77%) had an elevated IAP (> or = 9 cm H(2)O). A significant and positive correlation was found between the IAP level and the number of obesity-related co-morbidities (Pearson's r = .8; P <.05). Stepwise logistic regression analysis revealed that systemic hypertension, American Society of Anesthesiologists score, and body mass index were predictors of elevated IAP. A normal IAP appeared to offer a protective effect against systemic hypertension. CONCLUSION: In this cohort of mainly obese women, the baseline IAP of morbidly obese patients was abnormally elevated. A greater IAP correlated with the presence of a greater number of obesity-related co-morbid conditions. Systemic hypertension was significantly associated with an elevated IAP. Chronic increases in IAP might, in part, be responsible for the pathogenesis of systemic hypertension in the morbidly obese.