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Ann Surg 2002 Nov;236(5):554-9 Potential of surgery for curing type 2 diabetes mellitus. Rubino F, Gagner M. IRCAD-European Institute of Telesurgery, Strasbourg, France. f.rubino@lycos.com OBJECTIVE: To review the effect of morbid obesity surgery on type 2 diabetes mellitus, and to analyze data that might explain the mechanisms of action of these surgeries and that could answer the question of whether surgery for morbid obesity can represent a cure for type 2 diabetes in nonobese patients as well. SUMMARY BACKGROUND DATA: Diabetes mellitus type 2 affects more than 150 million people worldwide. Although the incidence of complications of type 2 diabetes can be reduced with tight control of hyperglycemia, current therapies do not achieve a cure. Some operations for morbid obesity not only induce significant and lasting weight loss but also lead to improvements in or resolution of comorbid disease states, especially type 2 diabetes. METHODS: The authors reviewed data from the literature to address what is known about the effect of surgery for obesity on glucose metabolism and the endocrine changes that follow this surgery. RESULTS: Series with long-term follow-up show that gastric bypass and biliopancreatic diversion achieve durable normal levels of plasma glucose, plasma insulin, and glycosylated hemoglobin in 80% to 100% of severely obese diabetic patients, usually within days after surgery. Available data show a significant change in the pattern of secretion of gastrointestinal hormones. Case reports have also documented remission of type 2 diabetes in nonmorbidly obese individuals undergoing biliopancreatic diversion for other indications. CONCLUSIONS: Gastric bypass and biliopancreatic diversion seem to achieve control of diabetes as a primary and independent effect, not secondary to the treatment of overweight. Although controlled trials are needed to verify the effectiveness on nonobese individuals, gastric bypass surgery has the potential to change the current concepts of the pathophysiology of type 2 diabetes and, possibly, the management of this disease. Publication Types: Review Review, Academic
5: AORN J 2002 Oct;76(4):590, 593-604; quiz 606-8 Roux-en-Y gastric bypass for morbid obesity. Barrow CJ. Doylestown Hospital, Doylestown, PA, USA. Obesity among adults has increased 60% since 1991, and 25% of children are overweight or obese. Direct and indirect costs of obesity represent almost 17% of total health care costs. People who are morbidly obese are far more likely to develop diabetes, hypertension, sleep apnea, osteoarthritis, and some forms of cancer, as well as depression and anxiety disorders than people who are not obese. Medical treatment of obesity only has long-term success rates of approximately 5%. Studies have validated that bariatric surgery, on the other hand, has greater success rates for weight loss maintenance. Of current surgical options, Roux-en-Y gastric bypass offers the best results:complications ratio and is seen as the "gold standard" in bariatric surgery. Publication Types: Review Review, Tutorial
6: Arch Intern Med 2002 Oct 14;162(18):2061-9 Pharmaceutical costs in obese individuals: comparison with a randomly selected population sample and long-term changes after conventional and surgical treatment: the SOS intervention study. Narbro K, Agren G, Jonsson E, Naslund I, Sjostrom L, Peltonen M; Swedish Obese Subjects Intervention Study. SOS Secretariat, Department of Internal Medicine, Sahlgrenska University Hospital, SE-413 45 Goteborg, Sweden. kristina.narbro@medfak.gu.se BACKGROUND: Obesity is associated with increased morbidity rates and pharmaceutical costs. To what extent various medication costs are affected by intentional weight loss is unknown. METHODS: A cross-sectional comparison of the use of prescribed pharmaceuticals was conducted in 1286 obese individuals in the Swedish Obese Subjects (SOS) intervention study and 958 randomly selected reference individuals. Medication changes for 6 years after bariatric surgery were evaluated in 510 surgically and 455 conventionally treated SOS patients. RESULTS: Compared with the reference group, obese individuals were more often taking diabetes mellitus, cardiovascular disease, nonsteroidal anti-inflammatory and pain, and asthma medications (risk ratios ranging from 2.3-9.2). Average annual costs for all medications were 1400 Swedish kronor (SEK) (US $140) in obese individuals and 800 SEK (US $80) in the reference population (P<.001). Average yearly medication costs during follow-up were 1849 (US $185) in surgically treated patients (weight change -16%) and 1905 SEK (US $190) in weight-stable conventionally treated patients (P =.87). The surgical group had lower costs for diabetes mellitus (difference: -94 SEK/y (-US $9]) and cardiovascular disease medications (difference: -186 SEK/y (-US $19]) but higher costs for gastrointestinal tract disorder (difference: +135 SEK/y [US $13]) and anemia and vitamin deficiency medications (difference: +50 SEK/y [US $5]). CONCLUSIONS: Use and cost of medications are markedly increased in obese vs reference populations. Surgical obesity treatment lowers diabetes mellitus and cardiovascular disease medication costs but increases other medication costs, resulting in similar total costs for surgically and conventionally treated obese individuals for 6 years.
7: Arch Surg 2002 Oct;137(10):1109-17 Effects of obesity surgery on non-insulin-dependent diabetes mellitus. Greenway SE, Greenway FL 3rd, Klein S. Department of Surgery, Harbor-University of California, Los Angeles Medical Center, Torrance, CA 90509, USA. CONTEXT: Most individuals who have non-insulin-dependent diabetes mellitus are obese. The obese population has proved a frustrating entity regarding weight loss and diabetes control. Results of medical weight loss programs, medications, and behavior therapy have proved disappointing. HYPOTHESIS: Bariatric surgery is the most effective method of diabetes management and cure in the morbidly obese population. Surgical procedures to cause malabsorption provide a more dramatic effect on diabetes owing to the imparted bypass of the hormonally active foregut. DATA SOURCES: Pertinent journal articles spanning the last 40 years, as well as textbooks. CONCLUSIONS: Bariatric surgical procedures have proven a much more successful method of weight loss and diabetes control in the obese population than conservative methods. These surgical procedures have proven safe with reported mortality rates of 0% to 1.5%. Bariatric operations may be divided based on the method of weight loss and effect on diabetes. The first category is restrictive and includes vertical banded gastroplasty and adjustable silicone gastric banding. These operations improve diabetes by decreasing food intake and body weight with a slowing of gastric emptying. The second category not only contains restrictive components but also elements of malabsorption. This category includes the Roux-en-Y gastric bypass and biliary-pancreatic diversion, which bypass the foregut. Although all of the surgical procedures for obesity offer improved weight loss and diabetes control compared with conservative methods, the Roux-en-Y gastric bypass and biliary-pancreatic diversion offer superior weight loss and resolution of diabetes. The more dramatic effect seen in the surgical procedures to cause malabsorption is likely secondary to the bypass of the foregut resulting in increased weight loss and elevation of the enteroglucagon level. Publication Types: Review Review, Tutorial
9: Am J Surg 2002 Aug;184(2):103-13 Obesity and its surgical management. Livingston EH. VAMC Greater Los Angeles Health Care System, UCLA Bariatric Surgery Program, Box 95-6904, UCLA School of Medicine, 90095-6904, USA. elivingston@mednet.ucla.edu Obesity is increasing in epidemic proportions world-wide. Even mild degrees of obesity have adverse health effects and are associated with diminished longevity. For this reason aggressive dietary intervention is recommended. Patients with body mass indices exceeding 40 have medically significant obesity in which the risk of serious health consequences is substantial, with concomitant significant reductions in life expectancy. For these patients, sustained weight loss rarely occurs with dietary intervention. For the appropriately selected patients, surgery is beneficial. Various operations have been proposed for the treatment of obesity, many of which proved to have serious complications precluding their efficacy. A National Institutes of Health Consensus Panel reviewed the indications and types of operations, concluding that the banded gastroplasty and gastric bypass were acceptable operations for treating seriously obese patients. Surgical treatment is associated with sustained weight loss for seriously obese patients who uniformly fail nonsurgical treatment. Following weight loss there is a high cure rate for diabetes and sleep apnea, with significant improvement in other complications of obesity such as hypertension and osteoarthritis. Publication Types: Review Review, Tutorial PMID: 12169352 [PubMed - indexed for MEDLINE]
10: Obes Surg 2002 Jun;12(3):343-8 Insulin resistance in the severely obese and links with metabolic co-morbidities. Stubbs RS, Wickremesekera SK. Wakefield Gastroenterology Centre, Wakefield Hospital, Private Bag 7909, Wellington, New Zealand. rsstubbs.wakefield@clear.net.nz BACKGROUND: The association between insulin resistance (IR) and obesity and its causal relationship with type 2 diabetes is well recognized. The possibility of an association, causal or otherwise, with other obesity-related co-morbidities warrants consideration. METHODS: IR was calculated pre-operatively in 80 patients undergoing gastric bypass surgery for severe obesity, using the homeostasis model assessment (HOMA) method, and again in 70 patients on at least one occasion post-operatively within 12 months. Correlations with weight parameters and pre-existing co-morbidities including diabetes, hypertension, dyslipidemia and hepatic steatosis were made. RESULTS: 78/80 patients had IR pre-operatively which did not correlate with pre-operative weight or BMI. As expected, there were positive correlations between pre-operative IR and abnormal glucose tolerance and diabetes. A positive correlation was also found between IR and hepatic steatosis, but no correlation was noted between IR and hypertension or fasting levels of cholesterol, triglycerides or Chol/HDL cholesterol ratios. Improvement in IR was uniformly seen after gastric bypass, sooner than would be accounted for by weight loss alone. The degree of pre-operative IR was not a predictor of weight loss after gastric bypass in these patients. CONCLUSIONS: While IR is an almost universal accompaniment of severe obesity, it does not correlate with the degree of obesity in this group of patients. A number of important co-morbidities show a clear association with IR, and improvement in these after gastric bypass may well be related to striking and rapid changes in IR. PMID: 12082884 [PubMed - indexed for MEDLINE]
11: J Surg Res 2002 Jun 1;105(1):48-52 Assessing the relative contribution of individual risk factors on surgical outcome for gastric bypass surgery: a baseline probability analysis. Livingston EH, Ko CY. VAMC Greater Los Angeles Health Care System, California, USA. elivingston@mednet.ucla.edu BACKGROUND: Multiple regression is the best technique for the simultaneous analysis of the contributions of multiple risk factors to a surgical outcome. A probability analysis is used to determine the relative contribution of individual factors to the overall outcome being assessed. We used these techniques to determine which of the potential risk factors had the greatest impact on adverse outcomes following gastric bypass surgery. METHODS: Records from 1067 consecutive patients undergoing Roux-Y gastric bypass at the UCLA Medical Center from December 1993 until June 2000 were reviewed. Major complications were used as the dependent variable in a multivariate logistic regression analysis, and 10 risk factors served as the independent variables. Based on the analysis, an average (i.e., baseline) patient was defined. Variations in the preoperative risk factors were then analyzed individually and in various combinations and their effect on the predicted probability for complication development was assessed. RESULTS: The overall major complication rate in this series was 5.8%. The average patient was defined as a 334-pound woman who was 42.3 years of age. For this patient, the predicted complication rate by probability analysis was 3.9%. The greatest increase in the anticipated complication rate was attributable to revisional procedures that increased the rate to 6.5%. Many patients have a combination of risk factors; to this end, a 62-year-old, male patient with a 2SD increase in weight (i.e., 464 pounds) who was undergoing a revision operation and had a history of smoking, hypertension, diabetes, and sleep apnea had a predicted complication rate of 33.7%. CONCLUSION: Probability analysis is a useful tool for determining the relative contribution of individual and combinations of risk factors for predicting the outcomes for surgical procedures. The four most influential factors for predicting a complication after gastric bypass surgery were; (1) male gender, (2) revisional surgery, (3) increasing age, and (4) increasing weight. These factors increased the predicted complication rate by 56, 67, 28 and 28%, respectively. (c) 2002 Elsevier Science (USA). PMID: 12069501 [PubMed - indexed for MEDLINE]
12: Diabet Med 2002 Jun;19 Suppl 3:14-7 Is surgery the best treatment for Type 2 diabetes in the obese? Summers LK. Leeds General Infirmary, Leeds, UK. PMID: 12030863 [PubMed - indexed for MEDLINE]
13: Ann Endocrinol (Paris) 2002 Apr;63(2 Pt 1):163-70 Results of obesity treatment. Scheen AJ. Division of Diabetes, Nutrition and Metabolic Disorders, Department of Medicine, CHU Sart Tilman (B35), B-4000, Liege, Belgium. Obesity is a chronic disease so that results of obesity treatment should only be evaluated on a long-term basis. The present paper aims at analyzing the long-term (1 year or more) results of three anti-obesity approaches, i.e. lifestyle modifications, pharmacological treatments and surgical procedures. Dietary interventions include diets with moderate calorie restriction and very-low energy diets (VLED). Even if an initial greater weight loss is observed with VLED, no study has conclusively shown that the long-term approaches including VLED are better than non-VLED programmes. Physical activity is not the most efficient method of initial weight loss, but it appears to be more crucial for maintaining weight loss once it has occurred. In general, long-term results of lifestyle modifications are disappointing because of poor compliance. Several 1-2 year large-scale randomized placebo-controlled clinical trials with orlistat, an intestinal lipase inhibitor, and sibutramine, a central appetite regulator, have demonstrated that both drugs significantly, although modestly on average, increase weight reduction, almost double the number of responders (weight loss >=5 or 10% of initial body weight) and improve weight maintenance up to 2 years. Surgical procedures provide a much greater weight reduction than medical interventions in patients with morbid obesity, particularly after a follow-up of several years. Weight loss is greater with gastric bypass, inducing some malbsorption, than with gastroplasty, a pure gastric restriction technique. Associated risk factors such as markers of insulin resistance syndrome and type 2 diabetes are remarkably reduced, but no prospective study of morbidity or mortality is available yet. In all cases, the management of obesity requires a multidisciplinary approach to improve the success rate. Publication Types: Review Review, Tutorial PMID: 11994682 [PubMed - indexed for MEDLINE]
14: Ann Surg 2002 May;235(5):640-5; discussion 645-7 Results of 281 consecutive total laparoscopic Roux-en-Y gastric bypasses to treat morbid obesity. DeMaria EJ, Sugerman HJ, Kellum JM, Meador JG, Wolfe LG. Department of Surgery and the Center for Minimally Invasive Surgery, Medical College of Virginia Campus of Virginia Commonwealth University, Richmond, Virginia 23298, USA. edemaria@hsc.vcu.edu 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. PMID: 11981209 [PubMed - indexed for MEDLINE]
15: Obes Surg 2002 Apr;12(2):261-4 Outcome of gastric bypass patients. Holzwarth R, Huber D, Majkrzak A, Tareen B. University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND, USA. BACKGROUND: The authors analyzed previously studied outcomes of Roux-en-Y gastric bypass (RYGBP), examined pre-surgical factors of post-surgical outcomes, and examined some of the psychosocial benefits. METHODS: A retrospective chart review was conducted of 138 patients who underwent RYGBP between 1997 and 2000. Pre-surgical BMI, cholesterol, blood pressure, creatinine, number of antidepressant/glycemic drugs, and hemoglobin were recorded. Post-surgical follow-up was reviewed to examine changes. RESULTS: Statistically significant changes were found in BMI, hypertension, cholesterol and glycemic control. Surgery was found to reduce creatinine from a pre-surgery average of 1.14 to 1.01 (n = 11, p = .0015)). Patients with early post-operative complications (defined as length of stay > 6 days or re-hospitalization within 1 month following surgery) had an average BMI of 57.58 (n = 23) vs a BMI of 49.9 (n = 103) in those who did not experience any complications (p = 0.0004). There was a statistically significant decrease in the rate of anti-depressant use following surgery. 49 patients were on antidepressants before surgery vs 38 following surgery (p = .0016). CONCLUSION: RYGBP significantly improves hypertension, hyperlipidemia and type II diabetes, and may also improve kidney function. Patients with higher pre-surgical BMIs are at greater risk for post-surgical complications. Postoperative antidepressant use appears to decrease. PMID: 11975225 [PubMed - indexed for MEDLINE]
16: J Assoc Acad Minor Phys 2001 Jul;12(3):129-36 Bariatric surgery for severe obesity. Sugerman HJ. Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia 23298-0519, USA. hsugerma@hsc.vcu.edu Severe obesity is associated with multiple comorbidities and is refractory to dietary management with or without behavioral or drug therapies. There are a number of surgical procedures for the treatment of morbid obesity, including purely gastric restrictive, a combination of malabsorption and gastric restriction or primary malabsorption. The purely gastric restrictive procedures, including vertical banded gastroplasty and laparoscopic adjustable silicone gastric banding, do not provide adequate weight loss. African-American patients do especially poorly after the banding procedure with the loss of only 11% of excess weight in one study. Gastric bypass (GBP) is associated with the loss of 66% of excess weight at 1 to 2 years after surgery, 60% at 5 years and 50% at 10 years. For unknown reasons, African-American patients lose significantly less weight than Caucasians after GBP. There is a risk of micronutrient deficiencies after GBP, including iron deficiency anemia in menstruating women, vitamin B12, and calcium deficiencies. Prophylactic supplementation of these nutrients is necessary. Recurrent vomiting after bariatric surgery may be associated with a severe polyneuropathy and must be aggressively treated with endoscopic dilatation before this complication is allowed to develop. The malabsorptive procedures include the partial biliopancreatic bypass (BPD) and BPD with duodenal switch (BPD/DS). The BPD appears to cause severe protein-calorie malnutrition in American patients; the BPD/DS may be associated with less malnutrition. Weight loss failure after GBP does not respond to tightening a dilated gastrojejunal stoma or reducing the size of the gastric pouch. These patients may require conversion to a malabsorptive distal GBP, similar to the BPD. However, because of the risk of severe protein-calorie malnutrition and calcium deficiency BPD should be reserved for patients with severe obesity comorbidity. The risk of death following bariatric surgery is between 1% and 2% in most series but is significantly higher in patients with respiratory insufficiency of obesity. In most patients, surgically induced weight loss will correct hypertension, type II diabetes mellitus, sleep apnea, obesity hypoventilation syndrome, gastroesophageal reflux, venous stasis disease, urinary incontinence, female sexual hormone dysfunction, pseudotumor cerebri, degenerative joint disease pains, as well as improved self-image and employability. Publication Types: Review Review, Tutorial PMID: 11851201 [PubMed - indexed for MEDLINE]
17: Rev Med Liege 2001 Dec;56(12):816-22 [Clinical case of the month. Natural history of morbid obesity: towards insulin-requiring type 2 diabetes and reversal after bariatric surgery] [Article in French] De Flines J, Letiexhe MR, Desaive C, Scheen AJ. Morbid obesity is a crucial risk factor in the development of type 2 diabetes and is often associated with a metabolic syndrome closely linked to insulin resistance. This case report illustrates the natural history of morbid obesity, starting during the adolescence and ending with an extremely severe type 2 diabetes at the age of 40. Numerous attempts of weight loss with various medical approaches failed and diabetes mellitus rapidly became insulin-requiring in a context of extreme insulin resistance. Finally, the patient was submitted to a gastric bypass which resulted in a drastic weight loss over 50 kg during the year following surgery without any significant side-effects or complications. Type 2 diabetes almost disappeared and the classical markers of insulin resistance were markedly improved. This clinical case clearly demonstrates that successful management of obesity with bariatric surgery can reverse severe type 2 diabetes. PMID: 11820033 [PubMed - indexed for MEDLINE]
18: Obes Surg 2001 Dec;11(6):693-8 Serum leptin levels after bariatric surgery across a range of glucose tolerance from normal to diabetes. Geloneze B, Tambascia MA, Pareja JC, Repetto EM, Magna LA, Pereira SG. Endocrinology and Metabolism Service, State University of Campinas, Brazil. bgeloneze@aol.com BACKGROUND: A longitudinal, clinical intervention study with bariatric surgery was done to investigate the relationship between leptin levels, BMI, and insulin during weight loss across a range of glucose tolerance from normal to diabetes. METHODS: 43 morbidly obese patients (BMI: 42-75 kg/m2) undergoing vertical banded gastroplasty Roux-en-Y gastric bypass (VBG-RGB), were divided into 3 groups: 21 normal (NGT), 12 impaired glucose tolerance (IGT) and 10 type 2 diabetes (DM). Leptin, insulin, glucose, lipids and uric acid were measured at baseline and 2, 4, 6, and 12 months following surgery. RESULTS: BMI fell from 54.1 +/- 9.1 to 34.6 +/- 6.3 kg/m2, similarly in all groups. Leptin decreased from 73.9 +/- 8.7 to 16.9 +/- 10.2 ng/ml and was strongly correlated with BMI during 1-year follow-up (r = 0.78; p < 0.001). Linear univariate analysis for repeated evaluation showed a positive correlation between leptin and glucose, triglycerides, uric acid, and insulin. Multivariate regression analysis indicated that BMI was independently correlated with the decrease in leptin (p < 0.001), accounting for 66% of the variance in leptin levels during weight loss. These results were found in the NGT and IGT groups. In the DM group, a small additional influence in leptin levels was attributed to glucose decrease. CONCLUSIONS: A strong link between leptin and BMI was found after surgery. BMI was the main determinant of the decrease of leptin. In these patients submitted to bariatric surgery, ranging from normal glucose tolerance to diabetes, changes in insulin levels and metabolic parameters, except for glucose in the DM group, did not appear to be correlated with changes in leptin levels. PMID: 11775566 [PubMed - indexed for MEDLINE]
19: Obes Res 2001 Dec;9(12):763-9 The insulin tolerance test in morbidly obese patients undergoing bariatric surgery. Geloneze B, Tambascia MA, Pareja JC, Repetto EM, Magna LA. Endocrinology Service, Obesity Surgery Unit, Department of Surgery, University of Campinas, Sao Paulo, Brazil. Bgeloneze@aol.com OBJECTIVE: To assess the effect of massive weight loss in relation to insulin resistance and its correlation to changes in glycemic homeostasis and lipid profile in severely obese patients. RESEARCH METHODS AND PROCEDURES: A prospective clinical intervention study was carried out with 31 morbidly obese women (body mass index: 54.2 +/- 8.8 kg/m(2)) divided into three groups according to their glucose tolerance test: 14 normal, 8 impaired glucose tolerance, and 9 type 2 diabetes. All subjects underwent an insulin tolerance test with intravenous bolus of 0.1 U insulin/kg body weight before silastic ring vertical gastroplasty Roux-en-Y gastric bypass surgery, and again at 2, 4, 6, and 12 months postoperatively. Fasting plasma glucose, hemoglobin A1c, and lipid profile were also evaluated. RESULTS: A reduction of 68 +/- 15% in initial excess body weight was evident within 1 year. Along with weight loss, the following statistically significant changes were found: an increase in the insulin-sensitivity index (Kitt) and a decrease in fasting plasma glucose and hemoglobin A1c, most notably in the type 2 diabetes group. An overall improvement in lipid profile was observed in all three groups. DISCUSSION: Bariatric surgery was an effective therapeutic approach for these obese patients because it reduced both weight and insulin resistance, along with improving metabolic parameters. Significant correlations were found between insulin resistance and metabolic improvements. Weight loss after bariatric surgery induced an improvement in metabolic fitness, related to the reduction in insulin resistance over a range of glucose tolerance statuses from normal to diabetic. PMID: 11743060 [PubMed - indexed for MEDLINE]
20: World J Surg 2001 Apr;25(4):527-31 Etiology of type II diabetes mellitus: role of the foregut. Pories WJ, Albrecht RJ. Department of Surgery, East Carolina University School of Medicine, Greenville, North Carolina 27858, USA. The Greenville version of the gastric bypass induced long-term remission of type II diabetes mellitus in 121 of 146 (82.9%) morbidly obese patients. Similarly, the operation returned 150 of 152 (98.7%) morbidly obese patients with impaired glucose tolerance to euglycemia. These outcomes were not merely changes in glucose levels; the operation also reduced the mortality and morbidity of the disease. Diabetic patients submitted to surgery had a 1.0% chance of dying during a 10-year period of follow-up compared to a mortality rate of 4.5% in a matched group (p = 0.0003). These results, the best therapeutic outcomes for type II diabetes ever reported, suggest that the disease is not an untreatable, hopeless illness but one that can be treated successfully with better understanding of the pathophysiology of these surgical remissions. The mechanism of the improvement is not yet clear. The rapidity of the correction to euglycemia, usually a matter of days, suggests that the reason is not the loss of weight (i.e., reduction in fat mass) but, rather, the result of the exclusion of food and a secondary alteration in incretin signals from the antrum, duodenum, and proximal jejunum to the islets. PMID: 11344408 [PubMed - indexed for MEDLINE]
21: Lancet 2001 Apr 28;357(9265):1357-9 Comment in: Lancet. 2001 Aug 25;358(9282):668-9. Should surgeons treat diabetes in severely obese people? Pinkney JH, Sjostrom CD, Gale EA. Department of Medicine, University of Liverpool, Clinical Sciences Centre, University Hospital Aintree, L9 7AL, Liverpool, UK. jpinkney@liverpool.ac.uk Publication Types: Review Review, Tutorial PMID: 11343762 [PubMed - indexed for MEDLINE]
22: Gastroenterology 2001 Feb;120(3):669-81 Current status of medical and surgical therapy for obesity. Mun EC, Blackburn GL, Matthews JB. Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts 02215, USA. emun@caregroup.harvard.edu The incidence of obesity (especially childhood obesity) and its associated health-related problems have reached epidemic proportions in the United States. Recent investigations suggest that the causes of obesity involve a complex interplay of genetic, environmental, psychobehavioral, endocrine, metabolic, cultural, and socioeconomic factors. Several genes and their protein products, such as leptin, may be particularly important in appetite and metabolic control, although the genetics of human obesity appear to involve multiple genes and metabolic pathways that require further elucidation. Severe obesity is frequently associated with significant comorbid medical conditions, including coronary artery disease, hypertension, type II diabetes mellitus, gallstones, nonalcoholic steatohepatitis, pulmonary hypertension, and sleep apnea. Long-term reduction of significant excess weight in these patients may improve or resolve many of these obesity-related health problems, although convincing evidence of long-term benefit is lacking. Available treatments of obesity range from diet, exercise, behavioral modification, and pharmacotherapy to surgery, with varying risks and efficacy. Nonsurgical modalities, although less invasive, achieve only relatively short-term and limited weight loss in most patients. Currently, surgical therapy is the most effective modality in terms of extent and duration of weight reduction in selected patients with acceptable operative risks. The most widely performed surgical procedure, Roux-en-Y gastric bypass, achieves permanent (followed up for more than 14 years) and significant weight loss (more than 50% of excess body weight) in more than 90% of patients. Publication Types: Review Review, Tutorial PMID: 11179243 [PubMed - indexed for MEDLINE]
23: Obes Surg 2000 Aug;10(4):285 Comment on: Obes Surg. 2000 Aug;10(4):372-5. Diabetes and bariatric surgery. Deitel M. Publication Types: Comment Editorial PMID: 11109068 [PubMed - indexed for MEDLINE]
24: Obes Surg 2000 Oct;10(5):391-401 Bariatric surgery for morbid obesity. Monteforte MJ, Turkelson CM. ECRI Plymouth Meeting, Pennsylvania 19462-1298, USA. BACKGROUND: Bariatric surgery is a treatment for severely obese patients. We examined the efficacy of bariatric surgery, addressing three questions: 1) What is the overall weight reduction following bariatric surgery? 2) What complications are associated with bariatric surgery? 3) What impact does weight loss have on obesity-related comorbidity? METHODS: Fixed and random effects meta-analyses were used to determine the amount of weight reduction following bariatric surgery. The influence of a variety of co-variates that could affect study results was examined. Information from evidence-based sources was used to explore the impact of weight loss on comorbidities. RESULTS: Meta-analyses results were affected by loss to follow-up, and within-study heterogeneity of variance. Therefore, results were pooled from studies with complete patient follow-up. Meta-analysis of six studies reporting weight loss at 1 year and four studies with mean follow-up of 9 months to 7 years demonstrated BMI reductions of 16.4 kg/m(2) and 13.3 kg/m(2), respectively. Weight reduction following bariatric surgery may be associated with improvements in risk factors for cardiac disease including hypertension, type 2 diabetes and lipid abnormalities, and may decrease the severity of obstructive sleep apnea. CONCLUSION: Bariatric surgery is appropriate for obese patients (BMI >40 kg/m(2) or > or =35 kg/m(2) with obesity-related comorbidity) in whom non-surgical treatment options were unsuccessful. Additional research is needed to examine the long-term benefits of weight loss following bariatric surgery, particularly with respect to obesity-related comorbidities. Publication Types: Meta-Analysis PMID: 11054242 [PubMed - indexed for MEDLINE]
25: RN 2000 Feb;63(2):24hf8 Unconventional surgery yields dramatic results. PMID: 10745880 [PubMed - indexed for MEDLINE]
26: Obes Surg 1995 Nov;5(4):399-402 Results of Bariatric Surgery for Morbid Obesity in Patients Older than 50 Years. Murr MM, Siadati MR, Sarr MG. Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN, 55905, USA. BACKGROUND: Surgery is increasingly used for weight loss in morbidly obese patients. The authors evaluated the safety and efficacy of bariatric surgery in patients older than 50 years. METHODS: Prospective data on 62 consecutive patients (Male = 13, Female = 49) undergoing bariatric procedures between 1985-1994 were reviewed. Mean follow-up was 30 +/- 2 months (3-48 months). All data are mean +/- SEM. RESULTS: Age was 57 +/- 1 year (range 50-71 years). Patients had a mean preoperative weight of 125 + 4 kg (275 +/- 9 lb) and 119 +/- 6% excess body weight. A total of 68 procedures were performed: vertical banded gastroplasty (VBG = 23), Roux-en-Y gastric bypass (RYGB = 43), and billopancreatic diversion (BPD = 2). Six patients were converted to RYGB (5) and BPD (1) after failed VBG. Hospital mortality was nil. Complications were wound infection (5), pulmonary (4) gastric leak (2) abscess (1) and others (4). Mean weight loss at 3 year; was 55 +/- 7 and 33 +/- 6% of percent excess body weight for RYGB and VBG, respectively. Postoperative use of medications for arthritis, diabetes mellitus and asthma was reduced by 23%, 62% and 100%, respectively. Satisfaction with the outcome of treatment and weight loss was reported by 81 % of patients. Six patients that were converted from jejunoileal bypass (metabolic complications) to VBG gained weight. CONCLUSIONS: Bariatric surgery is safe and well tolerated in morbidly obese patients older than 50 years. Weight loss parallels that of younger populations and is greater in patients treated with RYGB in this subgroup. Age should not be a contraindication to bariatric surgery provided the patient has obesity-related medical morbidity. Control of obesity-related co-morbid conditions is improved by weight loss. PMID: 10733835 [PubMed - as supplied by publisher]
27: Obes Res 1999 Sep;7(5):477-84 Reduction in incidence of diabetes, hypertension and lipid disturbances after intentional weight loss induced by bariatric surgery: the SOS Intervention Study. Sjostrom CD, Lissner L, Wedel H, Sjostrom L. Department of Anesthesiology and Intensive Care, University of Goteborg, Sweden. OBJECTIVE: To examine the effect of a large, long standing and intentional weight reduction on the incidence of diabetes, hypertension and lipid disturbances in severely obese individuals as compared to weight-stable obese controls. RESEARCH METHODS AND PROCEDURES: The ongoing prospective SOS (Swedish Obese Subjects) intervention consists of a surgically treated group and a matched control group obtaining conventional obesity treatment. This report is based on 845 surgically treated patients and 845 controls (BMI 41.0+/-4.6 kg/m2 (mean+/-standard deviation [S])) followed for 2 years. RESULTS: Surgically treated patients lost 28+/-15 kg and controls 0.5+/-8.9 kg (p<0.0001). Two-year incidence of hypertension, diabetes, hyperinsulinemia, and lipid disturbances was compared in the two treatment groups. Adjusted odds ratios (95% CI) for the surgically treated group versus controls were 0.38 (0.22, 0.65) for hypertension, 0.02 (0.00, 0.16) for diabetes, 0.10 (0.03, 0.28) for hyperinsulinemia, 0. 10 (0.04, 0.25) for hypertriglyceridemia, 0.28 (0.16, 0.49) for low HDL-cholesterol and 1.24 (0.84, 1.8) for hypercholesterolemia. Compared to controls, the 2-year recovery rates from hypertension, diabetes, hypo-HDL, and hypertriglyceridemia were significantly higher in the surgically treated group. DISCUSSION: Intentional weight loss in the obese causes a marked reduction in the 2-year incidence of hypertension, diabetes and some lipid disturbances. The results suggest that severe obesity can and should be treated. PMID: 10509605 [PubMed - indexed for MEDLINE] |
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