A Randomized Clinical Trial of Fecal Microbiota Transplant for Alcohol Use Disorder.

BACKGROUND AND AIMS: Alcohol use disorder (AUD) is associated with microbial alterations that worsen with cirrhosis. Fecal microbiota transplant (FMT) could be a promising approach. APPROACH AND RESULTS: In this phase 1, double-blind, randomized clinical trial, patients with AUD-related cirrhosis with problem drinking (AUDIT-10 > 8) were randomized 1:1 into receiving one placebo or FMT enema from a donor enriched in Lachnospiraceae and Ruminococcaceae. Six-month safety was the primary outcome. Alcohol craving questionnaire, alcohol consumption (urinary ethylglucuronide/creatinine), quality of life, cognition, serum IL-6 and lipopolysaccharide-binding protein, plasma/stool short-chain fatty acids (SCFAs), and stool microbiota were tested at baseline and day 15. A 6-month follow-up with serious adverse event (SAE) analysis was performed. Twenty patients with AUD-related cirrhosis (65 ± 6.4 years, all men, Model for End-Stage Liver Disease 8.9 ± 2.7) with similar demographics, cirrhosis, and AUD severity were included. Craving reduced significantly in 90% of FMT versus 30% in placebo at day 15 (P = 0.02) with lower urinary ethylglucuronide/creatinine (P = 0.03) and improved cognition and psychosocial quality of life. There was reduction in serum IL-6 and lipopolysaccharide-binding protein and increased butyrate/isobutyrate compared with baseline in FMT but not placebo. Microbial diversity increased with higher Ruminococcaceae and other SCFAs, producing taxa following FMT but not placebo, which were linked with SCFA levels. At 6 months, patients with any SAEs (8 vs. 2, P = 0.02), AUD-related SAEs (7 vs. 1, P = 0.02), and SAEs/patient (median [interquartile range], 1.5 [1.25] vs. 0 [0.25] in FMT, P = 0.02) were higher in placebo versus FMT. CONCLUSIONS: This phase 1 trial shows that FMT is safe and associated with short-term reduction in alcohol craving and consumption with favorable microbial changes versus placebo in patients with alcohol-associated cirrhosis with alcohol misuse. There was also a reduction in AUD-related events over 6 months in patients assigned to FMT.

Bariatric surgery in Medicare patients: greater risks but substantial benefits.

BACKGROUND: Recent reports have documented greater mortality for bariatric surgery in Medicare (MC) patients compared with patients from other payors. METHODS: We reviewed our database for the mortality and outcomes of 282 MC and 3169 non-Medicare (NMC) patients undergoing bariatric surgery. RESULTS: Of the MC patients, 27 were >65 years of age, and 255 were receiving disability. The average age was 48.45 +/- 11.8 years, and the average BMI was 52.4 +/- 10.0 kg/m2. NMC patients had average age of 40.0 +/- 10.1 years and a BMI of 50.6 +/- 9.1 kg/m2. The co-morbidities were greater in the MC patients than in the NMC patients (hypertension 71.9% versus 48.4%, diabetes mellitus 39.72% versus 19.4%, obstructive sleep apnea 46.45% versus 28.46%, and obesity hypoventilation syndrome 9.93% versus 2.71%). The mortality rate was 2.48% in the MC patients and .76% in the NMC patients. Mortality was absent in MC patients >65 years old. The percentage of excess weight lost was less in the MC patients (60.8%) than in the NMC patients (66.5%, P <.0001). The resolution of diabetes mellitus also differed (64.86% for the MC patients and 77.18% for the NMC patients; P = .0329). The male MC patients had more prevalent co-morbidities than did the male NMC patients (hypertension 79.17% versus 58.85%; diabetes mellitus 36.11% versus 24.83%; obstructive sleep apnea 79.17% versus 54.51%; and obesity hypoventilation syndrome 26.39% versus 7.64%). The operative mortality rate was 5.6% for the male MC patients and 1.5% for the female MC patients. The weight loss was similar for the male MC and male NMC patients. The male MC patients had slightly better resolution of both hypertension (MC patients 54.8% versus NMC patients 26.7%, P = .0025) and diabetes mellitus (MC patients 30% versus NMC patients 22.5%, P = .745). When the patients were stratified into low-, intermediate-, and high-risk groups using a previously validated risk scale, patients with similar risk factors had similar mortality in both groups. CONCLUSION: The results of our study have shown that disabled MC patients have greater operative mortality than NMC patients that appears to be associated with more prevalent risk factors. However, the risk was counterbalanced by a substantial improvement in health.

Does diabetes affect weight loss after gastric bypass?

BACKGROUND: Weight loss in diabetics improves glycemic control. We investigated whether diabetes mellitus (DM) adversely affects postgastric bypass weight loss. METHODS: Our database was queried for the demographics and outcomes of patients with and without DM who had undergone gastric bypass surgery. DM was subdivided by severity: diet-controlled, oral hypoglycemic agents, and insulin. RESULTS: Of the 3193 patients, 655 (20%) had DM. The DM group was older (45.8 +/- 10.4 yr versus 39.1 +/- 9.9 yr, P <.0001), with more co-morbidities: hypertension (70.5% versus 44.2%, P <.0001), sleep apnea (36.7% versus 26.1%, P <.0001), and venous stasis (5.6% versus 2.6%, P <.0001). More men had DM (25.6% versus 19.3%, P = .0006). The age-adjusted, preoperative weight, and body mass index were equal. A direct relationship was found between DM severity and age, weight, and co-morbidities. At 1 year, the DM group had a lower percentage of excess weight loss (60.8% +/- 16.6% versus 67.6% +/- 16.7%, P <.0001) and greater body mass index (34.2 +/- 7.1 kg/m(2) versus 32.3 +/- 7.2 kg/m(2), P <.0001). The percentage of excess weight loss was 67.6% for those without DM, 63.5% for those with diet-controlled DM, 60.5% for those with DM controlled by oral hypoglycemic agents, and 57.5% for those requiring insulin. DM resolved in 89.8% of those with diet-controlled DM, 82.7% of those taking oral hypoglycemic medication, and 53.3% of those requiring insulin. Hypertension resolution was greatest in patients without DM (74.4% versus 63.5%, P <.0001). CONCLUSION: The results of our study have shown that those with DM typically have more co-morbidities, despite having no difference in preoperative weight compared with those without DM. Despite the lower weight loss, those with DM had significant resolution of their DM and hypertension and should not be deterred from undergoing gastric bypass surgery.

Participation in 150 min/wk of moderate or higher intensity physical activity yields greater weight loss after gastric bypass surgery.

BACKGROUND: The American College of Sports Medicine's position stand on weight loss and prevention of weight regain in adults has suggested that overweight adults should participate in a minimum of 150 min/wk of moderate intensity physical activity (PA). This study compared the 3-, 6-, and 12-month postoperative weight loss between gastric bypass surgery (GBS) patients who met or exceeded the recommended 150 min/wk of moderate or higher PA and those not meeting the recommendation. METHODS: The self-administered short version of the International Physical Activity Questionnaire was used to assess moderate or higher intensity PA participation at 3 (n = 178), 6 (n = 128), and 12 months (n = 209) after GBS. The patients' height and body weight were obtained to determine the kilograms of weight lost, percentage of excess weight loss, body mass index change, and total weight loss percentage. The weight loss differences were analyzed using analysis of covariance at each point, with age and preoperative body mass index as covariates. RESULTS: Patients reporting 150 min/wk of moderate or higher PA had significantly (P <.05) greater weight lost, percentage of excess weight loss, change in body mass index, and total weight loss percentage at 6 and 12 months postoperatively. The percentage of excess weight loss was 56.0% +/- 11.5% versus 50.5% +/- 11.6% and 67.4% +/- 14.3% versus 61.7% +/- 17.0% for the group meeting and not meeting the PA requirement at 6 and 12 months after GBS, respectively. No significant difference existed at 3 months after GBS. CONCLUSION: Participation in a minimum of 150 min/wk of moderate or higher intensity PA was associated with greater postoperative weight loss at 6 and 12 months postoperatively. Patients should be encouraged to meet or exceed this recommendation until prospective, randomized studies have definitively established a link between PA and greater postoperative weight loss and maintenance.

Selective, versus routine, upper gastrointestinal series leads to equal morbidity and reduced hospital stay in laparoscopic gastric bypass patients.

BACKGROUND: The use of routine upper gastrointestinal contrast radiology series (UGIS) after laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) can entail risk, expense, and patient discomfort. We have discontinued routine UGIS in favor of selective UGIS guided by patient symptoms and signs or elevations in the juxta-anastomotic drain amylase. We hypothesized that elimination of routine UGIS would not adversely affect morbidity or mortality. METHODS: We retrospectively reviewed the anastomotic leak, reoperation, and death rates and length of hospital stays for all patients who underwent LRYGB between two periods when either routine (November 2003 to December 2004) or selective (January 2005 to February 2006) postoperative UGIS were done. RESULTS: In group 1, were 267 patients who had undergone LRYGB with routine UGIS during November 2003 to December 2004. Group 2 consisted of 151 patients who had undergone LRYGB with selective UGIS during January 2005 to February 2006. The mean +/- standard error of the mean hospital stay for groups 1 and 2 was 4.3 +/- 0.3 and 3.3 +/- 0.2 days (P = .08), respectively. In group 1, 18 gastrojejunostomy leaks (6.7%) occurred compared with 6 (4.0%) in group 2 (P = .28). Also, 14 patients (5.2%) in group 1 required reoperation for anastomotic leak compared with 3 (2.0%) in group 2 (P = .13). Three patients (1.1%) in group 1 and no patients in group 2 died (P = .56). CONCLUSION: The elimination of routine UGIS did not adversely affect morbidity or mortality. The mean hospital stay in the group with selective UGIS decreased, although this decrease had not yet achieved statistical significance.

Wound wise: wounds in surgical patients who are obese.

The number of surgical patients who are obese in the United States is rising, a trend that's likely to continue. Such patients are at higher risk than nonobese patients are for surgical site infections and other complications such as dehiscence, pressure ulcers, deep tissue injury, and rhabdomyolysis. This article details the factors that can contribute to such complications, including a high number of comorbidities, and offers practical suggestions for preventing them. Nurses should understand that special equipment, precautions, and protocols may be needed at every stage of care, and that obese patients aren't anomalies but rather a part of a growing population with particular needs.

Physical activity and quality of life improvements before obesity surgery.

OBJECTIVE: To examine quality of life (QOL), physical activity (PA), and physical activity readiness (PAR) among gastric-bypass surgery (GBS) candidates. METHODS: The SF-36v2, International Physical Activity Questionnaire, and a stages-of-change measure assessed QOL, PA, and PAR respectively across 2 presurgical visits. RESULTS: Increases in mental QOL, PA, and PAR were observed across visits. Sufficiently physically active participants reported significantly higher physical QOL than did insufficiently physically active participants. CONCLUSIONS: Findings demonstrating positive presurgical changes in PA and PA readiness as well as the association between PA and QOL warrant increased efforts to promote PA adoption and maintenance among GBS candidates.

Insurance-mandated preoperative dietary counseling does not improve outcome and increases dropout rates in patients considering gastric bypass surgery for morbid obesity.

BACKGROUND: Preoperative dietary counseling (PDC) before bariatric surgery is mandated by a growing number of insurance payers. Their claim is that PDC improves outcomes and postoperative compliance. We compared outcomes of GBP patients undergoing a mandatory 13 weeks of PDC (n = 72) to a contemporaneous group of patients with no such requirement (no-PDC; n = 252) who underwent operation between January 2000 and December 2002. METHODS: The PDC and no-PDC groups were characterized by similar male:female ratios (1:4 vs 1:4.6), mean age (42 years), mean body weight (324 lb vs 309 lb), and mean body mass index (BMI) (52 kg/m2 vs 50 kg/m2). The PDC group had a higher incidence of obstructive sleep apnea compared with the no-PDC group (41% vs 28%; P < .04) but otherwise the two groups had similar incidences of obesity-related comorbidities. The presurgery dropout rate was 50% higher in the PDC group than in the no-PDC group (28% vs 19%; P < .05). RESULTS: At 1 year follow-up, the no-PDC patients had a statistically greater percentage excess weight loss (67% vs 60%; P < .0001), lower BMI (32 vs 35; P < .015), and lower body weight (197 vs 218; P < .01). Resolution of major comorbidities, complication rates, 30-day postoperative mortality, and postoperative compliance with follow-up were similar in the two groups. CONCLUSIONS: The data demonstrate that insurance-mandated PDC is an obstacle to patient access for surgical treatment of severe obesity and has no impact on weight loss outcome or postsurgical compliance. PDC should be abandoned by the insurance industry.

Physical activity stage of readiness predicts moderate-vigorous physical activity participation among morbidly obese gastric bypass surgery candidates.

BACKGROUND: Despite the ever-growing body of literature linking stage of physical activity readiness (PAR) with physical activity (PA) participation in overweight and obese populations, this relationship has not been examined among individuals seeking gastric bypass surgery (GBS). Furthermore, little is known about the specific intensity of activities undertaken by GBS candidates. Therefore, this study sought to determine whether greater PAR was associated with greater moderate-vigorous physical activity (MVPA) participation among GBS candidates. METHODS: The International Physical Activity Questionnaire (IPAQ), administered 2-weeks presurgery to 87 GBS candidates, determined MVPA participation using a formula based on metabolic equivalents (MET)-minutes/week. A stages-of-change measure categorized each candidate into one of five PAR stages: precontemplation, contemplation, preparation, action, or maintenance. RESULTS: The proportion of individuals in each PAR stage and the corresponding MVPA was as follows: contemplation (5.7%, 48.0 MET-minutes/week), preparation (46%, 394.0 MET-minutes/week), action (34.5%, 1614.0 MET-minutes/week), and maintenance (13.8%, 2056.7 MET-minutes/week). MVPA was significantly greater in candidates in the action or maintenance stages compared with those in contemplation (P =.008 and .025 for action and maintenance, respectively) or preparation (P < .0001 and .006 for action and maintenance, respectively). CONCLUSIONS: This study is the first to demonstrate a relationship between PAR and PA among GBS candidates, with 100% of the sample reporting either an intention to engage in PA or actual engagement in PA. This finding, coupled with the recent support for the importance of PA for weight loss/maintenance in GBS patients, warrants an investigation into the effectiveness of presurgical and postsurgical PA interventions matched to patients' PAR levels.

Impact of major co-morbidities on mortality and complications after gastric bypass.

BACKGROUND: We hypothesized that major co-morbidities affect survival and complications after gastric bypass. METHODS: A total of 1465 patients undergoing laparoscopic and open gastric bypass between 1995 and 2002 were studied. Patients with a body mass index >or= 35 kg/m(2) and major co-morbidities (group 1, n = 1045) were compared with patients with a body mass index >or= 40 kg/m(2) with minor/no co-morbidities (group 2, n = 420). RESULTS: Group 1 patients were older (43 versus 36 years, P < 0.001) and had a greater BMI (53 versus 50 kg/m(2), P < 0.001). Early postoperative complications were greater in group 1 than in group 2 and included leaks (4.1% versus 1.2%, P < 0.0032) and wound infections (3.9% versus 1.4%, P < 0.0133). Procedure-related mortality in the series was 1.7%. Mortality was 10-fold greater in group 1 (2.3% versus 0.2%, P < 0.0032). The incidence of small bowel obstruction, incisional hernia, and pulmonary embolism was similar in the two groups. Excess weight loss was significantly greater in group 2 (68% versus 62%, P < 0.001) at 1 year. Resolution of group 1 co-morbidities was great, including hypertension in 62%, diabetes in 75%, venous stasis disease in 96%, and pseudotumor cerebri in 98%. CONCLUSION: Outcomes analysis of obesity surgery requires risk stratification. The very low mortality rates in published studies are likely explained by surgical treatment of low-risk patients with minor co-morbidities, such as those seen in group 2. However, despite the increased perioperative risk, the group 1 patients (with major co-morbidities) demonstrated dramatic resolution of their co-morbid conditions, justifying the decision to go forward with surgery. The data support a radical change in treatment philosophy in which morbidly obese individuals should be offered bariatric surgery before major co-morbid conditions develop as a strategy to decrease the operative risk.

A conceptual application of health behavior theory in the design and implementation of a successful surgical weight loss program.

Obesity (BMI > or =30 kg/m(2)) is recognized as a primary risk factor in the pathogenesis of several leading causes of morbidity and mortality, most notably hypertension, diabetes, and coronary artery disease. Despite numerous preventive approaches, the number of Americans who are overweight and obese has reached pandemic proportions and continues to increase. Moreover, the "fat are becoming fatter" as evidenced by the increasing prevalence of morbidly obese individuals (BMI > or =40 kg/m(2)). For the morbidly obese individual with potentially life-threatening comorbidities, the support for and use of surgical treatment options as a corrective mechanism is growing. Weight reduction results for bariatric surgery average 30-80% of excess body weight, depending on the length of the follow-up and the surgical technique. The demonstrated effectiveness of surgical treatment as a weight-reduction method coupled with the increasing prevalence of severe obesity is certain to increase the popularity of surgical treatment options. With this increased popularity, comes a responsibility for health-care professionals to guard against patients' perception of surgical treatment as a panacea. To counter this possibility, three recommendations are presented as components of a treatment paradigm by a multidisciplinary team of health professionals, which incorporate surgical and non-surgical treatment components, increase patient responsibility, promote lifelong health behavior change and effect permanent weight loss.

Lap-band failures: conversion to gastric bypass and their preliminary outcomes.

BACKGROUND: The LAP-BAND is designed to be an adjustable laparoscopically placed gastric restriction device for the treatment of severe obesity. The purpose of this study was to assess the outcome in patients who had failed to effectively lose weight with this device and were converted to a gastric bypass. METHODS: A retrospective chart review was performed of all LAP-BANDS placed in patients at our institution from March 1996 to June 1998. RESULTS: 36 LAP-BANDS were placed. To date, 18 of 36 (50%) have been removed. Fourteen of 18 were simultaneously converted to a gastric bypass. Indications for conversion included: failed weight loss (5), failed weight loss with esophageal dilatation (5), failed weight loss with leaking band (2), and symptomatic esophageal dilatation (1). Median time to conversion after LAP-BAND placement was 38.2 months. Median follow-up after conversion to gastric bypass was 8.3 months. Nineteen percent excess weight loss occurred after LAP-BAND placement. Forty-three percent excess weight loss occurred after conversion to gastric bypass (P =.025). CONCLUSIONS: In our experience, the LAP-BAND is associated with a high frequency of inadequate weight loss. Conversion to gastric bypass in this subset of patients is technically challenging but results in superior weight loss in a shorter time period.

Impact of self-reported physical activity participation on proportion of excess weight loss and BMI among gastric bypass surgery patients.

Habitual physical activity is an important component of successful weight loss programs for morbidly obese individuals. This study examined self-reported physical activity (PA) participation in relation to excess weight loss and body mass index (BMI) reduction among gastric bypass surgery patients (GBS). PA participation was hypothesized to contribute to both greater excess weight loss (% EWL) and a greater reduction in BMI at 2 years postsurgery. PA participation was measured via self-report among 1585 GBS patients between 1988 and 2001. GBS patients were assigned to groups [PA (n = 1479)/no PA (n = 106)] and further stratified by presurgical BMI [35-49 kg/m2 (n = 897) and 50-70 kg/m2 (n = 688)]. Findings showed that GBS patients who reported PA participation were younger [P < 0.0001, PA (40.1 +/- 9.9) vs no PA (44.2 +/- 11.2)], had greater % EWL [P = 0.0081, PA (68.2 +/- 17.4%) vs no PA (63.9 +/- 19.5%)], and a greater decrease in BMI [P = 0.0011, PA (18.3 +/- 5.7 kg/m2) vs no PA (16.6 +/- 5.4 kg/m2)]. When stratified by presurgical BMI, only physically active patients with a BMI of 50-70 kg/m2 showed an increase in % EWL [P = 0.0444, PA (63.2 +/- 16.5) vs no PA (57.9 +/- 17.3)], whereas both BMI groups showed significant reductions in BMI at 2 years [BMI of 35-49 kg/m2 P = 0.0184, PA (16.0 +/- 4.0 kg/m2) vs no PA (14.4 +/- 4.0 kg/m2); and BMI of 50-70 kg/m2 P = 0.0221, PA (21.50 +/- 6.0 kg/m2) vs no PA (19.7 +/- 5.5 kg/m2)], respectively. PA had a favorable effect on % EWL and BMI among GBS patients at 2 years postsurgery, thus supporting the inclusion of habitual PA in a comprehensive GBS postsurgical weight maintenance program.

Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass.

BACKGROUND: Data on the durability of remission of type 2 diabetes mellitus (T2DM) after gastric bypass are limited. Our purpose was to identify the rate of long-term remission of T2DM and the factors associated with durable remission. METHODS: A total of 177 patients with T2DM who had undergone Roux-en-Y gastric bypass from 1993 to 2003 had 5-year follow-up data available. T2DM status was determined by interview and evaluation of the diabetic medications. Patients with complete remission or recurrence of T2DM were identified. RESULTS: Follow-up ranged from 5 to 16 years. Of the 177 patients, 157 (89%) had complete remission of T2DM with a decrease in their mean body mass index from baseline (50.2 +/- 8.2 kg/m(2)) to 31.3 +/- 7.2 kg/m(2) postoperatively (mean percentage of excess weight loss 70.0% +/- 18.6%). However, 20 patients (11.3%) did not have T2DM remission despite a mean percentage of excess weight loss of 58.2% +/- 12.3% (P <.0009). Of the 157 patients with initial remission of their T2DM, 68 (43%) subsequently developed T2DM recurrence. Remission of T2DM was durable in 56.9%. Durable (>5-year) resolution of T2DM was greatest in the patients who originally had either controlled their T2DM with diet (76%) or oral hypoglycemic agents (66%). The rate of T2DM remission was more likely to be durable in men (P = .00381). Weight regain was a statistically significant, but weak predictor, of T2DM recurrence. CONCLUSION: Early remission of T2DM occurred in 89% of patients after Roux-en-Y gastric bypass. T2DM recurred in 43.1%. Durable remission correlated most closely with an early disease stage at gastric bypass.

Drain amylase levels are an adjunct in detection of gastrojejunostomy leaks after Roux-en-Y gastric bypass.

BACKGROUND: Because anastomotic leaks after gastric bypass surgery can have devastating consequences for the patient, early detection is highly desirable. This and many other bariatric surgical centers have discontinued routine use of upper gastrointestinal contrast x-ray because of the lack of cost-effectiveness, discomfort to the patient, and the failure of the study to detect some leaks. We postulated that drain amylase levels from a juxta-anastomotic drain would detect the presence of salivary amylase and be a sensitive test for gastrojejunostomy leak. STUDY DESIGN: Routine measurement of amylase levels from a drain adjacent to the gastrojejunostomy was instituted in 2005. Leak was defined as anastomotic incompetence documented either by confirmatory upper gastrointestinal contrast x-rays, CT scans, or reoperation. RESULTS: On postoperative day 1, the drain amylase levels of 350 patients were tested. Seventeen patients had postoperative leaks (4.8%); 14 of the 17 had leaks at the gastrojejunal anastomosis (82%). The median peak value for patients without leak was 79.5 IU/L+/-1,436.2 SD; for patients with leak it was 6,307 IU/L+/-50,166 (p < 0.0001, Wilcoxon rank sum test). All patients but one with a leak had a drain amylase > 400 IU/L. A drain amylase value of 400 IU/L empirically defines gastrojejunostomy leaks with a sensitivity of 94.1% and a specificity of 90.0%. Negative predictive value of a drain amylase level < 400 IU/L in excluding leak was 99.6%. Positive predictive value of a drain amylase > 400 IU/L in predicting leak was 33.3%. Of the 17 leaks, 7 required reoperation at a median of 1 day (mean, 1.6+/-1.1 days). There was no perioperative mortality. CONCLUSIONS: Drain amylase levels are a simple, low-cost adjunct with high sensitivity and specificity that can help to identify patients who may have a leak after gastric bypass surgery.

Becoming physically active after bariatric surgery is associated with improved weight loss and health-related quality of life.

The purpose of this study was to determine whether pre- to postoperative increases in physical activity (PA) are associated with weight loss and health-related quality of life (HRQoL) following bariatric surgery. Participants were 199 Roux-en-Y gastric bypass (RYGB) surgery patients. The International Physical Activity Questionnaire (IPAQ) was used to categorize participants into three groups according to their preoperative and /1-year postoperative PA level: (i) Inactive/Active (<200-min/week/>or=200-min/week), (ii) Active/Active (>or=200-min/week/>or=200-min/week) and (iii) Inactive/Inactive (<200-min/week/<200-min/week). The Medical Outcomes Study Short Form-36 (SF-36) was used to assess HRQoL. Analyses of covariance were conducted to examine the effects of PA group on weight and HRQoL changes. Inactive/Active participants, compared with Inactive/Inactive individuals, had greater reductions in weight (52.5 +/- 15.4 vs. 46.4 +/- 12.8 kg) and BMI (18.9 +/- 4.6 vs. 16.9 +/- 4.2 kg/m(2)). Weight loss outcomes in the Inactive/Active and Active/Active groups were similar to each other. Inactive/Active and Active/Active participants reported greater improvements than Inactive/Inactive participants on the mental component summary (MCS) score and the general health, vitality and mental health domains (P < 0.01). Although the direction of causation is not clear, these findings suggest that RYGB patients who become active postoperatively achieve weight losses and HRQoL improvements that are greater than those experienced by patients who remain inactive and comparable to those attained by patients who stay active. Future randomized controlled trials should examine whether assisting patients who are inactive preoperatively to increase their PA postoperatively contributes to optimization of weight loss and HRQoL outcomes.

Four hundred fifty consecutive laparoscopic Roux-en-Y gastric bypasses with no mortality and declining leak rates and lengths of stay in a bariatric training program.

BACKGROUND: We reviewed our obesity surgery database for 2 experienced bariatric surgeons since their last patient death in October 2003 through July 2007. STUDY DESIGN: Data on all patients undergoing planned laparoscopic Roux-en-Y gastric bypass (L-GBP) by the two attending bariatric surgeons at the Medical College of Virginia Hospitals were reviewed. The operations were performed by fellows in minimally invasive surgery, assisted by the 2 attending physicians in more than 90% of patients. Surgical technique included a handsewn imbrication of a gastrojejejunostomy and jejunojejunostomy, each performed with a linear stapler. Routine sampling of a juxtaanastamotic drain for amylase levels was substituted for routine upper gastrointestinal contrast studies during the study period. RESULTS: All patients, except those who had earlier extensive upper abdominal surgery in that time period, were offered a laparoscopic approach (5.7% were converted to open procedures). The mean (+/- SD) age was 42.4+/-11 years; body mass index was 49.5+/-9 kg/m(2). Women represented 80.5% of patients. The leak rate declined from 9.7% in 2004 to 2.0% in 2006 (p < 0.05, chi-square test); there have been no leaks in any patient since July 2006, including the 40 patients in 2007. Hospital length of stay declined from 4.7+/-5.7 days in 2004 to 2.9+/-3.3 days in 2006 (p < 0.05, Wilcoxon rank test). At 1-year followup, 270 patients had lost 66.1%+/-17% of initial excess weight, which was similar to that in our open gastric bypasses. Comorbid conditions improved or resolved in 67.6% of patients with diabetes, 56.1% of those with hypertension, 75% of those with sleep apnea, 87.8% of those with urinary stress incontinence, 95.9% of those with gastroesophageal reflux disease, and in 100% of those with stasis ulcers. Overall complication rates of wound infection (1.5%), incisional hernia (1.7%), internal hernia (0.2%), and intestinal obstruction (1.7%) were low. CONCLUSIONS: Results for laparoscopic Roux-en-Y gastric bypass improve with experience and can be taught in an academic training program, with low morbidity and mortality. Routine postoperative upper gastrointestinal contrast studies are unnecessary and may lengthen hospital stay.

Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity.

OBJECTIVE: To determine the safety and efficacy of laparoscopic Roux-en-Y gastric bypass for the treatment of morbid obesity. SUMMARY BACKGROUND DATA: Laparoscopic Roux-en-Y gastric bypass is a new and technically challenging surgical procedure that requires careful study. METHODS: The authors attempted total laparoscopic Roux-en-Y gastric bypass in 281 consecutive patients. Procedures included 175 proximal bypasses, 12 long-limb bypasses, and 9 revisional procedures from previous bariatric operations. The gastrojejunostomy and jejunojejunostomy were primarily constructed using linear stapling techniques. RESULTS: Eight patients required conversion to an open procedure (2.8%). The mean age of the patients was 41.6 years (range 15-71) and 87% were female. The mean preoperative body mass index was 48.1 kg/m2. The operative time decreased significantly from 234 +/- 77 minutes in the first quartile to 162 +/- 42 minutes in the most recent quartile. Postoperative length of stay averaged 4 days (range 2-91), with 75% of patients discharged within 3 days. The median hospital stay was 2 days. No patient died after surgery. Complications included three (1.5%) major wound infections (each followed a reoperation for a complication or open conversion), incisional hernia in 5 patients (1.8%), and anastomotic leak with peritonitis in 14 patients (5.1%). Three gastrojejunal leaks were managed without surgery, four by laparoscopic repair/drainage, and three by open repair/drainage. Only three patients had anastomotic leaks in the most recent 164 procedures (1.8%) since the routine use of a two-layer anastomotic technique. Data at 1 year after surgery were available in 69 of 96 (72%) patients (excludes revisions). Weight loss at one year was 70 +/- 5% of excess weight. Most comorbid conditions resolved by 1 year after surgery; notably, 88% of patients with diabetes no longer required medications. CONCLUSIONS: Laparoscopic gastric bypass demonstrates excellent weight loss and resolution of comorbidities with a low complication rate. The learning curve is evident: operative time and leaks decreased with experience and improved techniques. The primary advantage is an extremely low risk of wound complications, including infection and hernia.

Effects of bariatric surgery in older patients.

OBJECTIVE: Evaluate the safety and efficacy of bariatric surgery in older patients. BACKGROUND: Because of an increased morbidity in older patients who may not be as active as younger individuals, there remain concerns that they may not tolerate the operation well or lose adequate amounts of weight. METHODS: The database of patients who had undergone bariatric surgery since 1980 and National Death Index were queried for patients <60 and >/= 60 years of age. GBP was the procedure of choice after 1985. Data evaluated at 1 and 5 years included weight lost, % weight lost (%WL), % excess weight loss (%EWL), % ideal body weight (%IBW), mortality, complications, and obesity comorbidity. RESULTS: Eighty patients underwent bariatric surgery: age 63 +/- 3 years, 78% women, 68 white, 132 +/- 22 kg, BMI 49 +/- 7 kg/m, 217 +/- 32%IBW. Preoperative comorbidity, was greater (P < 0.001) in patients >/= 60 years. There were no operative deaths but 11 late deaths. COMPLICATIONS: 4 major wound infections, 2 anastomotic leaks, 10 symptomatic marginal ulcers, 5 stomal stenoses, 3 bowel obstructions, 26 incisional hernias (nonlaparoscopic), and 1 pulmonary embolism. At 1 year after surgery (94% follow-up), patients lost 38 +/- 11 kg, 57%EWL, 30%WL, BMI 34.5 +/- 7 kg/m, %IBW 153 +/- 31. Comorbidities decreased (P < 0.001); however, %WL and %EWL and improvement in hypertension and orthopedic problems, although significant, were greater in younger patients. At 5 years after surgery (58% follow-up), they had lost 31 +/- 18 kg, 50%EWL, 26%WL, BMI 35 +/- 8 kg/m, and %IBW 156 +/- 36. CONCLUSIONS: Bariatric surgery was effective for older patients with a low morbidity and mortality. Older patients had more pre- and post-operative comorbidities and lost less weight than younger patients. However the weight loss and improvement in comorbidities in older patients were clinically significant.