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Summary People with excess weight and obesity compose 64.5% of the Ecuadorian population. The Allurion Intragastric Balloon (IGB) is a noninvasive weight loss alternative for patients ineligible for other bariatric procedures. The impact of the procedure on weight loss and body composition, along with insertion complications and secondary effects were investigated. This is a single‐centre retrospective study of patients who underwent Allurion IGB insertion from July 2020 to March 2021. This study followed 167 patients for 12 months after EIGB insertion. Our sample had a mean initial weight of 83.6 ± 13.8 kg and initial body mass index of 31.3 ± 3.6 kg/m2. Percentage total weight loss was 4.65% ± 0.56%, 8.5% ± 4%, 12.29% ± 4.65%, 15.68% ± 5.22%, 17.14% ± 6.05%, and 14.68% ± 18.02% for months 1, 2, 3, 4, 6 and 12, respectively. In the fourth month, 92 patients (56.4%) had lost ≥50% excess body weight; at month 6, 104 patients (67.5%) achieved this goal. Regarding body composition, body fat percentage started at 38.99% ± 7.92%, and at month 6 was 35.67% ± 6.84%, this was the only significance in the statistical analysis.This study aligns with the literature's safety and efficacy results for the Allurion IGB while illustrating the need for further research regarding weight behaviour after its expulsion. [ABSTRACT FROM AUTHOR]

Summary: Obesity is a grave concern within the United States, resulting in lost productivity, increased medical costs, and comorbidities with lifelong repercussions. The laparoscopic sleeve gastrectomy is a treatment option for obesity. The following meta‐analysis sought to combine adolescent and adult literature to determine the overall effect of the sleeve gastrectomy on weight loss, to evaluate the effect of age at the time of surgery on weight loss, and to describe and explore variation in weight loss by sample characteristics. Overall weight loss was assessed at proximal and distal points, a dichotomous moderator variable analysis was conducted with subjects ≤21 years of age and >21 years of age, and a meta‐regression assessing % male, % female, and baseline BMI was conducted to assess moderator variables. The laparoscopic sleeve gastrectomy was effective at facilitating weight loss with effect sizes varying from 0.916 to2.816. Age, biological sex, and baseline BMI were not found to have an impact on weight loss. The clinical consequences of prolonged obesity are evident and earlier intervention may be justified to counter the long‐term effects caused by obesity related comorbidities. Standardized reporting of comorbidities and the effect of bariatric surgery on comorbid conditions is essential to allow further analysis. [ABSTRACT FROM AUTHOR]

The rate of obesity is increasing in the Australian population, and this also includes patients with cancer. The safety and dignity of this cohort of patients is paramount as well as the timely acquisition of equipment required to assist patients with obesity to complete a course of radiation therapy (RT). The design and manufacture of equipment used in most RT departments is not suitable for the weight or BMI of all patients presenting for treatment. RT also operates under a unique set of circumstances that differs from the routine hospital environment which prompted the design of an RT bariatric protocol for use in our department. The protocol is based on the mapping of a patient's pathway from simulation and treatment. Treatment technique and equipment limitations as well as information relating to a patient with high BMI are used as trigger points that direct a patient pathway. The bariatric protocol provides the RT team with decision‐making support for appropriate resource utilisation ensuring safe and efficient treatment delivery for both the patient and staff. This paper will outline how the RT bariatric protocol was developed and implemented in our department, highlighting areas that required more attention due to the RT‐specific environment. [ABSTRACT FROM AUTHOR]

Metabolic and bariatric surgeries have been shown to be the most effective strategy to induce and maintain significant weight loss for people living with severe obesity. However, ongoing concerns regarding operative risks, irreversibility and excess costs limit their broader clinical use. Endoscopic bariatric therapies are pragmatic alternatives for patients who are not suitable for metabolic and bariatric surgeries or who are concerned regarding their long‐term safety. Endoscopic sleeve gastroplasty has emerged as a novel technique of endoscopic bariatric therapies, which have garnered significant interest and evidence in the past few years. Its safety, efficacy and cost‐effectiveness have been shown in various studies, while comparisons with sleeve gastrectomy have been widely made. This review brings together current evidence pertaining to the technicality of the procedure itself, current indications, safety and efficacy, cost‐effectiveness, as well as its future role and development. [ABSTRACT FROM AUTHOR]

Background: Bariatric surgery is a proven effective method of reducing obesity and reversing or preventing obesity‐related comorbidities. The aim of this study is to describe the development of a tool to assist with the prioritization of patients with obesity for bariatric surgery. The tool would meet the criteria for being evidence‐based, fair, implementable and transparent. Methods: The development of the tool involved a validated step‐by‐step process based on the consensus of clinical judgement of the New Zealand Ministry of Health working party. The process involved elicitation of criteria, clinical ranking of vignettes and creation of weightings using the 1000Minds® tool. The concurrent validity was tested by comparing tool rankings of vignettes to clinical judgement rankings. Results: Four major criteria (impact on life, likelihood of achieving maximum benefit with respect to control of diabetes, duration of benefit and surgical risk) are used to characterize the need and potential to benefit. The impact on life criterion has the largest weighting (up to 44.3%). There was good concurrent validity with a correlation coefficient r = 0.67. Conclusion: The tool as presented is evidence‐based, transparent and internally valid. The next step is to assess the predictive validity of the tool using real patient data to evaluate the effectiveness of the tool and determine what modifications may be required. [ABSTRACT FROM AUTHOR]

The article presents the discussion on management of youth with different types of diabetes undergoing surgery. Topics include young people with diabetes having a diabetes consultation prior to all types of surgery or anesthesia; and surgery being preferably scheduled as the first case of the day or on the surgical list.

Background: The DIAMOND antenatal clinic was established to provide multidisciplinary continuity of care to pregnant women living with morbid (body mass index (BMI) ≥40 kg/m2) or super‐obesity (BMI ≥50 kg/m2). Aim: The aim was to describe clinic processes, demographics, clinical outcomes and women's perceptions of the clinic. Methods: Women who received antenatal care in the clinic between 2016 and 2019 (n = 257) had routine data collected for retrospective analysis. A patient satisfaction survey was conducted for women who received care in 2019 (n = 89). Results: The median BMI was 49 kg/m2 (max = 81 kg/m2). The mean age was 32 years. The largest proportion of women (27.6%) resided in the most disadvantaged suburbs of the region. Primipara comprised 29.6%, and 4.7% of women identified as Aboriginal or Torres Strait Islander. Diabetes was present in 47.5%, and 9.3% developed pre‐eclampsia. Half (49.4%) had their labour induced (49.8% required cervical ripening), and 37% had an elective caesarean section. Almost a quarter (24.1%) of women underwent emergency caesarean section. One in six women had a measured blood loss of more than 1000 mL. The unadjusted stillbirth rate was 0.8%. Blood transfusions were required by 3.9%, and 1.9% of women required intensive care admission. Survey responses showed women valued the clinic for the enhanced surveillance, continuity, care coordination and respectful care. Improvements to waiting times were recommended. Conclusions: Establishing a dedicated clinic for women living with high BMI provides a well‐liked environment for a high‐risk cohort of women. Our review identified opportunities for improvement in clinic processes. We plan to assess overall impact on perinatal outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Occupational therapists are key members of the multidisciplinary team and regularly work with people of higher weight across age groups and practice settings. There is limited existing research regarding the occupational therapy role with this client group. The aim of this study was to explore occupational therapy practice and barriers to service provision for Australian occupational therapists working with clients of higher weight. Methods: A cross‐sectional study design using a self‐administered online survey was distributed to members of the national occupational therapy professional association. The survey was designed to identify common assessments and interventions used with clients of higher weight and explore occupational therapists' perspectives on their knowledge and confidence and the barriers to service delivery. Descriptive statistics were used to summarise rating scales, and open‐ended responses were analysed using thematic analysis. Results: Eighty Australian occupational therapists working in a range of settings and with varied experience levels participated in the study. Participants described the most common areas of occupational therapy assessment and intervention when working with clients of higher weight to be self‐care, equipment prescription, home modifications and pressure care. Respondents were least confident in interventions related to psychosocial, leisure and employment interventions. Barriers to service delivery included accessibility and cost of equipment, lack of training and weight stigma. Conclusion: Occupational therapy practice promotes and enables participation in everyday occupations with people of higher weight. This study highlights not only the occupational therapy skills and unique approach to the person, their environment and occupations but also the challenges faced by occupational therapists when working with people of higher weight. Occupational therapists could consider utilising the weight‐inclusive paradigm to broaden their contribution from self‐care to other important aspects of participation and well‐being. [ABSTRACT FROM AUTHOR]

Background: To determine whether a bariatric surgical procedure is associated with a reduction in healthcare utilisation among patients with obesity and high pre-procedural healthcare needs. Methods: Design: Retrospective cohort study. Setting: Tertiary Victorian public hospital. Participants: Twenty-nine adults who underwent publicly funded primary bariatric surgery between 2008 and 2018 at the Alfred Hospital, Melbourne and had high resource use over the year prior to surgery, defined as at least two of ≥3 hospital admissions, ≥7 inpatient bed days for obesity-related co-morbidities or inpatient hospital costs ≥$10 000. Main outcome measures: Change in inpatient and outpatient resource use. Results: After 1 year following bariatric surgery, total hospital bed days decreased from 663 to 80 and the median (Q1, Q3) per patient decreased from 7 (4.5, 15) to 5 (2.25, 9.75) (p = 0.001) and the total number of hospital admissions fell from 118 to 67 (p < 0.001). The median cost of inpatient care decreased from $11 405 ($4408, $22251) to $3974 ($0, $4325) per annum (p < 0.001). The total and median number of outpatient attendances did not significantly change 12 months after bariatric surgery, but the demand for outpatient services unrelated to bariatric surgery declined by a median of four visits per patient (p = 0.013). Conclusions: The evidence from this small pilot study suggests that Bariatric surgery has the potential to decrease resource use and inpatient hospital costs over a 1-year time frame for obese patients with high resource use. These data will be used to design a prospective randomised controlled trial to provide more definitive information on this important issue. [ABSTRACT FROM AUTHOR]

Introduction: Over the last 20 years, the number of individuals affected by obesity in Australia has increased by 56%. The impact of excessive weight gain results in a wide range of physical, psychological and social difficulties, with resultant changes to occupational performance and engagement. For some people within this population, a further consequence of this increasing weight gain contributes to additional difficulties, with the individual being considered to be "bariatric". For these people, resultant changes include decreased capacity to engage in self‐care activities, leisure occupations and productive roles, creating significant difficulties in undertaking important life roles. This phenomenological study aimed to understand the occupational engagement of individuals with bariatric needs, and to identify potential opportunities to support the engagement and participation of these individuals from the perspectives of Australian occupational therapists. Methods: Qualitative data were collected from 11 semi‐structured interviews with occupational therapists from a variety of practice settings. Results: Thematic analysis identified four central themes (a) Occupational engagement was significantly impacted by a lack of suitable resources and availability of daily living equipment; (b) Health and well‐being were impacted by a disruption in meaningful occupational engagement; (c) Occupational roles were limited due to poor occupational identity and perceptions of not belonging within the community; (d) Occupational therapists do have a varied role when working with individuals with bariatric needs. Conclusion: Occupational therapists engaged in this study indicated that people with bariatric needs were significantly impacted by many complex issues as a result of their health condition, often contributing to poor health and decreased well‐being. Occupational therapists are well‐placed to engage with individuals with bariatric needs across many care contexts and must take up potential opportunities to provide services targeted towards the increased engagement and participation of these individuals, with resultant improvements to health and well‐being. [ABSTRACT FROM AUTHOR]

Background: There are controversial data regarding the relationship between bariatric surgery and atrial fibrillation (AF). This meta‐analysis was performed to evaluate (i) the incidence and (ii) the risk of AF in patients following bariatric surgery. Aims: To explore the incidence and risk factors of AF in patients after bariatric surgery. Methods: A literature search was conducted utilising MEDLINE, EMBASE and Cochrane Database from inception through March 2019. We included studies that evaluated the (i) incidence and (ii) risk of AF in patients after bariatric surgery. Pooled incidence and odds ratios (OR) with 95% confidence interval (CI) were calculated using random effects meta‐analysis. Results: Seven cohort studies consisting of 7681 patients undergoing bariatric surgery were enrolled in this systematic review. The prevalence of AF in patients undergoing bariatric surgery ranged between 0% and 4.6%. Overall, the pooled estimated incidence of AF following bariatric surgery was 5.3% (95% CI: 1.9–13.8) at a median follow‐up time of 7.9 years (interquartile range (IQR) 4.1–15.0 years). Compared to controls, the pooled OR of AF among patients undergoing bariatric surgery was 0.42 (95% CI: 0.22–0.83) at a median follow‐up time of 7.9 years (IQR 7.2–19.0 years). Egger regression test demonstrated no significant publication bias in our meta‐analysis of AF incidence following bariatric surgery. Conclusion: The overall estimated incidence of AF following bariatric surgery was 5.3%. Our study demonstrates a significant beneficial association between bariatric surgery and AF, with a 0.42‐fold decreased risk of AF. Future large‐scale studies are needed to confirm the potential benefits of bariatric surgery on risk of AF. [ABSTRACT FROM AUTHOR]

Objective: Follistatin binds and inactivates activins, which are potent inhibitors of muscle growth and metabolism and are currently being developed for the treatment of obesity and type 2 diabetes (T2D). We have recently reported that follistatin is regulated by glucose (and not lipids) and can prospectively predict the metabolic improvements observed after bariatric surgery. We utilized novel assays herein to investigate whether activins are regulated by glucose or lipids, whether their circulating levels change after bariatric surgery and whether these changes are predictors of metabolic outcomes up to 12 months later.Design and Methods: Activin A, B, AB and their ratios to follistatin were measured in (a) healthy humans (n = 32) undergoing oral or intravenous lipid or glucose intake over 6 h, (b) morbidly obese individuals with or without type 2 diabetes undergoing three different types of bariatric surgery (gastric banding, Roux-en-Y bypass or sleeve gastrectomy) in two clinical studies (n = 14 for the first and n = 27 for the second study).Results: Glucose intake downregulates circulating activin A, B and AB, indicating the presence of a feedback loop. Activin A decreases (~30%), activin AB increases (~25%) and activin B does not change after bariatric surgery. The changes in activin AB and its ratio to follistatin 3 months after bariatric surgery can predict the BMI reduction and the improvement in insulin and HOMA-IR observed 6 months postoperatively.Conclusion: Activins are implicated in glucose regulation in humans as part of a feedback loop with glucose or insulin and predict metabolic outcomes prospectively after bariatric surgery. [ABSTRACT FROM AUTHOR]

Background and Aim: Endoscopic sleeve gastroplasty (ESG) is gaining acceptance as a non‐surgical option for the treatment of obesity. However, its role is still not consolidated for all populations and the ideal indications are yet to be determined. We aimed to study the efficacy and safety of ESG in Indian patients. Methods: We conducted a single‐center retrospective study of obese patients who underwent consecutive ESG at our tertiary care center. Data on weight loss and adverse events at 1, 3, 6, and 12 months were collected and analyzed. Results: Fifty‐three patients underwent ESG from March 2017 to October 2018. Eighty one percent of patients were female (43/53). Mean baseline age and body mass index were 40.54 ± 13.79 years and 34.78 ± 5.20 kg/m2, respectively. Mean duration of procedure was 68.96 ± 11.19 min. Immediate postoperative complications included mainly epigastric pain (45.2%) and nausea (22.6%) but there was no serious adverse event. Average percentage of total weight loss (%TWL) was 8.26%, 11.96%, 14.25%, and 19.94% at 1, 3, 6, and 12 months, respectively. Eighty‐eight percent of patients achieved >15% TWL at 12 months. Younger patients (<30 years old) and female patients had greater %TWL at 12 months (P = 0.01 and P = 0.021, respectively). Last 18 procedures were significantly faster than the first 35 cases (P = 0.01). Conclusions: Endoscopic sleeve gastroplasty is effective and safe at promoting weight loss in the Indian population. Young age and female gender are related to better outcomes. [ABSTRACT FROM AUTHOR]

Summary: Objective: Spouses are known to influence the outcomes of an individual's attempt at weight loss, but little is known about the broader influence of, and on, the family. The objectives were to explore: (a) the effects of an adult weight management program on the family and (b) family factors that help or hinder patient weight loss. Methods: A qualitative design was employed to explore triadic family members' experiences of patient participation in a weight management program. Semi‐structured interviews were conducted with patients, partners and children (ages 7‐18). Questions included support for patient participation and weight loss, dietary choices, meal preparation, physical activity routines, the home‐food environment, communication about health and family dynamics. Thematic analysis was used, where codes and categories of codes were then grouped together to create themes and subthemes. Results: Nineteen triadic interviews were conducted (57 total). Seven themes emerged, including four related to Outcomes (objective 1): (a) shift in family dynamics, (b) family behaviour change, (c) child observations of family change, (d) indirect benefit to partner; and three related to Process (objective 2): (e) level of accountability, (f) patient perception of support and (g) support is essential and flexible. Conclusions: Future research and clinical applications from these themes should seek to determine the positive behaviour change that was evident in the families that were interviewed, where the culmination of family interactions, expectations and concurrent partner weight loss indicates the potential longevity of weight management programs beyond patients' own participation. [ABSTRACT FROM AUTHOR]

Summary: This study compared the measurement properties of the Moorehead‐Ardelt quality of life questionnaire‐II (MAQOL‐II) and the BODY‐Q, to determine which was more suitable for measuring patient‐reported outcome (PRO) in Danish bariatric surgery (BS) and body contouring surgery (BC) patients. We examined content validity against the COSMIN guidelines and compared psychometric performance using Rasch measurement theory methods and criteria. MAQOL‐II data were obtained from the Danish Bariatric Surgery Database from September 2010 to November 2017, and BODY‐Q data were collected from June 2015 to March 2018. The MAQOL‐II failed to meet recommended standards for content validity, while all criteria were met for the BODY‐Q. A total of 16 965 MAQOL‐II and 2259 BODY‐Q assessments were obtained. A random sample was selected from the MAQOL‐II dataset to match the BODY‐Q sample. Psychometrically, the BODY‐Q performed better than the MAQOL‐II. For example, Cronbach's α was 0.82 for the MAQOL‐II vs ≥0.90 for all BODY‐Q scales. Fifty percent (3/6) of MAQOL‐II items had disordered thresholds, while all BODY‐Q items had ordered thresholds (123/123). Poor item fit was revealed for 17% (1/6) of MAQOL‐II and 8% (10/123) of BODY‐Q items. For scale reliability, person separation index was 0.79 for the MAQOL‐II and 0.88 (0.81‐0.93) for the BODY‐Q. In conclusion, the MAQOL‐II does not meet today's standards for a rigorously developed PRO measure. The BODY‐Q, on the other hand, gives substantial, accurate and interpretable measurement and should be recommended for use in PRO in BS and BC patients. [ABSTRACT FROM AUTHOR]

With the rise of obesity in adult populations in the western world there has been a concurrent rise in bariatric procedures to address this problem. Although the safety of bariatric procedures has improved significantly over the past 20 years, there are still a number of serious surgical complications that can occur in the postoperative period that emergency physicians need to be familiar with. These complications can have subtle presentations that if unrecognised can go on to cause morbidity and mortality. This review will cover the more common bariatric procedures that are being performed today. It will discuss the complications, clinical presentations and management of these patients that emergency physicians should be familiar with. [ABSTRACT FROM AUTHOR]

In the absence of dental related guidelines available in Australia specific to obesity and minimal awareness of the clinical implications on local dental practice, bariatric dental care can be perceived as a 'silent disability crisis'. This opinion piece and brief clinical note aims to question and raise awareness amongst dental professionals surrounding the current limited availability of bariatric dental chairs, difficulties in access, the safety of dental care delivery and ethical considerations for the dental management of people with obesity. [ABSTRACT FROM AUTHOR]

Background: In Australia, there is limited access to public revisional bariatric procedures. However, the need for such procedures is rising. We investigated the safety and efficacy of band‐to‐bypass procedures in our experience at a public teaching hospital over a period of 10 years. Methods: Using a prospectively maintained bariatric surgical database, we analysed 91 consecutive planned band‐to‐bypass procedures from 2007 to November 2016. All patients had prior laparoscopic adjustable gastric bands removed and formation of Roux‐en‐Y gastric bypass, in one or two stages. Primary outcomes were 30‐day complication rate and excess weight loss from 12 months. The impact of fellows as primary operators on these outcomes was assessed. Results: Eighty‐two patients met the inclusion criteria. Seventy‐one (84.5%) were females. Mean age was 48.8 years (SD: 8.85). Immediate post‐operative complications included six (7.3%) patients with gastrojejunostomy leak, three of whom required conversion to laparotomy, with one mortality (1.22%). Fifty‐two patients had follow‐up of 1 year or more (median: 2.36, range: 1–9.24). Mean excess weight loss at the end of follow‐up was 52.79% (SD: 46.46). Twenty‐eight (34.14%) cases were performed primarily by a fellow under the guidance of an experienced bariatric surgeon, with equivalent results. Conclusion: Revisional band‐to‐bypass in the public setting is an effective but complex procedure associated with morbidity. Some risk may be ameliorated by development of selection criteria to exclude certain high‐risk groups. We hope discussion amongst other bariatric groups will further refine this approach. [ABSTRACT FROM AUTHOR]

Abstract: Understanding the member population to which medical coverage policies apply is important for ensuring the relevance of a health insurer's policies. The medical policy unit of our company developed a registry and workflow to enhance our knowledge about the members who seek authorization for bariatric surgery. Data captured in the registry have allowed us to construct a descriptive profile of the entire population that seeks bariatric surgery (both members who are approved and members who are denied). In addition, we have examined characteristics associated with denied authorization requests, determined the proportion of requests originating from specific insurance products, and studied the relationship between results on a specific laboratory test and authorization decisions. Given the growing importance of data in the realm of health care management, this article is an important demonstration of how data can be used to understand populations of members who are affected by medical policies. [ABSTRACT FROM AUTHOR]

Background/aim: Home modifications maintain people's functional independence and safety. No literature exists to guide the prescription of home modifications for clients with bariatric care needs. With Australia's increasing obesity rate, more evidence is needed to support home modification prescribers. This study aimed to map Australian home modification prescribing practices for clients with bariatric care needs and to establish and evaluate a clinical resource for this prescription process. Methods: The study included two phases. Phase 1 conducted a cross‐sectional survey of therapists practicing in Australia, and Australian industry partners who prescribe or install home modifications for clients with bariatric care needs. Phase 2 included design, implementation and evaluation of a clinical resource. Data were analysed with means and frequencies; multivariable regression analysis was used to explore prescribing habits. Results: Therapists surveyed (n = 347) reported 11 different bariatric weight definitions. Less than 3% constantly or regularly prescribed home modifications for these clients; rails were most commonly prescribed. Many therapists (n = 171, 58%) ‘never’ or ‘rarely’ knew rail load capacity. Therapists’ knowledge of rail load capacity was associated with previous experience prescribing home modifications (P = 0.009); rail manufacturer's advice (P = 0.016) and not using advice from builders (P = 0.001). Clinical resources were used by 11% (n = 26) of therapists to support their prescription, and industry sporadically relied on therapists to specify modification design requirements (n = 5, 45%). Post‐implementation of a clinical resource increased consensus regarding understanding of the term bariatric and increased consultation with builders and manufacturers. Conclusion: There was a lack of consistency in bariatric terminology, uncertainty of rail load capacities and minimal use of clinical practice guidelines. Additional resources will assist with consistency in prescribing practices to maximise occupational performance for clients with bariatric care needs. [ABSTRACT FROM AUTHOR]

Short-term very-low-energy diets ( VLEDs) are used in clinical practice prior to bariatric surgery, but regimens vary and outcomes of a short intervention are unclear. We examined the effect of 2 VLEDs, a food-based diet ( FD) and a meal-replacement plan ( MRP; LighterLife UK Limited, Harlow, UK), over the course of 2 weeks in a randomized controlled trial. We collected clinical and anthropometric data, fasting blood samples, and dietary evaluation questionnaires. Surgeons took liver biopsies and made a visual assessment of the liver. We enrolled 60 participants of whom 54 completed the study ( FD, n = 26; MRP, n = 28). Baseline demographic features, reported energy intake, dietary evaluation and liver histology were similar in the 2 groups. Both diets induced significant weight loss. Perceived difficulty of surgery correlated significantly with the degree of steatosis on histology. There were reductions in the circulating inflammatory mediators C-reactive protein, fetuin- A and interleukin-6 between baseline (pre-diet) and post-diet. The diets achieved similar weight loss and reduction in inflammatory biomarkers. There were no significant differences in perceived operative difficulty or between patients' evaluation of diet satisfaction, ease of use or hunger frequency. Non-alcoholic fatty liver disease histology assessments post-diet were also not significantly different between diets. The results of this study show the effectiveness of short-term VLEDs and energy restriction, irrespective of macronutrient composition, although the small sample size precluded detection of subtle differences between interventions. [ABSTRACT FROM AUTHOR]

Background: Although most individuals experience successful weight loss following Roux-en-Y gastric bypass (RYGB), weight regain is a concern, the composition of which is not well documented. Our aim was to evaluate changes in body composition and handgrip strength as a measure of functional status in participants from a previous 1-year post-RYGB longitudinal study who had undergone RYGB approximately 9 years prior.Methods: Five women from an original larger cohort were monitored pre-RYGB and 1.5 months, 6 months, 1 year, and 9 years post-RYGB. Body composition was assessed at all time points using dual energy x-ray absorptiometry and multiple dilution. Handgrip strength was measured using a digital isokinetic hand dynamometer (Takei Scientific Instruments, Ltd, Tokyo, Japan).Results: Mean time to final follow-up was 8.7 years. Lean soft tissue (LST) loss over the ~9-year period was on average 11.9 ± 5.6 kg. Compared with 1-year post-RYGB, 9-year LST was 4.4 ± 3.0 kg lower ( P = .03). Fat-free mass decreased over the 9-year period by 12.6 ± 5.8 kg. Mean fat mass (FM) decreased from 75.4 ± 22.6 kg pre-RYGB to 35.5 ± 21.5 kg 1 year post-RYGB but then trended toward an increase of 8.6 ± 7.0 kg between 1 year and 9 years post-RYGB ( P = .053). Loss of LST was correlated with loss of handgrip strength ( r = 0.64, P = .0005).Conclusion: The continued loss of lean mass associated with decreased handgrip strength occurring with long-term trend toward FM regain post-RYGB is concerning. The loss of LST and functional strength carries particular implications for the aging bariatric population and should be investigated further. [ABSTRACT FROM AUTHOR]

Background Bariatric surgery has not been widely used in the Australian public health system. As obesity is strongly associated with socio-economic status, excluding its use from the public system will deny many of the most in-need access to a potentially very effective treatment. Alternatively, with rigorous follow-up and behavioural change requirements, highly successful outcomes in the private system may not translate to the public system. Methods The Alfred Hospital rapidly expanded bariatric surgery from 2007. A 6-year prospective follow-up study was conducted with annual review of weight, co-morbidities, retention in follow-up, serum HbA1 c, quality of life and patient satisfaction. Results There were 1453 patients. Procedures were predominantly laparoscopic-adjustable gastric bands ( n = 861). Patient details were age 49 ± 11 years, body mass index 50.7 ± 11.2 kg/m2 and weight 139.0 ± 30.2 kg. There was no mortality, and mean length of stay was 1.1 ± 1.2 days. Follow-up was 98% (1 year) and 85% (6 years). Weight loss was 22 ± 13.1 kg (32.8 ± 18% excess weight loss) at 1 and 30.1 ± 16.8 kg (60 ± 28%) at 6 years. The mean number of co-morbidities was 4.2 ± 1.1 with significant improvements observed. Patient satisfaction was 7.7 ± 2.3 out of 10. Mental and physical summary scores ( SF-36) improved from 41.02 ± 13.17 to 45.50 ± 13.27 ( P < 0.001) and 33.97 ± 10.53 to 44.79 ± 11.19 ( P < 0.001). Conclusions Patients were older, heavier and suffered more co-morbid disease than previously reported cohorts. For the first time, excellent outcomes across a range of key quality domains in a large patient cohort have been reported in the public system. High-volume bariatric surgery in the public system is viable. [ABSTRACT FROM AUTHOR]

This review paper will discuss the recent literature examining the relationship between obesity and neurocognitive outcomes, with a particular focus on cognitive changes after bariatric surgery. Obesity is now recognized as an independent risk factor for adverse neurocognitive outcomes, and severely obese persons appear to be at even greater risk. Bariatric surgery is associated with rapid improvements in cognitive function that persist for at least several years, although the mechanisms underlying these improvements are incompletely understood. Assessment of cognitive impairment in bariatric surgery patients is challenging, and improved methods are needed, as poorer performance on neuropsychological tests of memory and executive function leads to poorer clinical weight outcomes. In addition to its clinical importance, further study in this area will provide key insight into obesity-related cognitive dysfunction and clarify the possibility of an obesity paradox for neurological outcomes. Copyright © 2015 John Wiley & Sons, Ltd and Eating Disorders Association. [ABSTRACT FROM AUTHOR]

Background Optimal dosing of propofol to maintain appropriate anesthetic depth is challenging in severely obese ( SO) adolescents. We previously reported that total body weight ( TBW) is predictive of propofol clearance. This study was aimed at characterizing pharmacokinetics ( PK) and pharmacodynamics ( PD) of propofol in SO adolescents, using bispectral index ( BIS), and toward developing PK/ PD model-based dosing guidelines. Methods A prospective PK/ PD study was conducted in 26 SO children and adolescents aged 9-18 years (body mass index 31-69 kg·m−2), undergoing surgery with intravenous propofol anesthesia clinically titrated by providers blinded to BIS. BIS data and propofol infusion schemes were recorded. Venous blood samples collected during and after propofol infusion were assayed for propofol concentrations. A propofol PK/ PD model was developed using NONMEM and model-based simulations were performed to determine propofol dosing regimens targeting BIS of 50 ± 10. Results A three-compartment PK model linked to a sigmoidal inhibitory Emax PD model by a first-order rate constant, adequately described the propofol concentration ( n = 375) and BIS ( n = 3334) data. TBW was the most predictive covariate for propofol clearance [ CL (l·min−1) = 1.65 × ( TBW/70)0.75]. An effect-site propofol concentration of 3.19 μg·ml−1 was estimated for half-maximal effect, with no identifiable predictive covariates. The proposed maintenance dosing regimen targeted to a BIS of 50 ± 10, based on our PK/ PD model, was able to predict desired propofol concentrations and BIS in a representative obese teen when used in conjunction with accepted PK/ PD models for children/obese adults ( PK:Eleveld/ PD: Cortinez), further supporting evidence for the dosing based on TBW. Conclusion This is the first study to describe the PK/ PD of propofol in SO adolescents. The proposed maintenance dosing regimen for propofol uses TBW in an allometric function as a dosing scalar, with an exponent of 0.75. Our results suggest no relevant effect of obesity on the propofol concentration- BIS relationship. [ABSTRACT FROM AUTHOR]

Study Objective To evaluate the effect of therapeutic doses of intravenous acetaminophen (IV APAP) on postoperative opioid use following bariatric surgery. Design Retrospective review of medical records. Setting A 654-bed academic hospital. Patients Records for 104 patients who underwent laparoscopic sleeve gastrectomy ( LSG; 44 patients) or laparoscopic Roux-en-Y gastric bypass ( LRYGB; 60 patients) were reviewed. Patients received IV APAP 1 g every 6 hours postoperatively (22 LSG patients and 30 LRYGB patients) or no IV APAP (22 LSG patients and 30 LRYGB patients). Measurements and Main Results Baseline demographic features were similar for both groups. Patients receiving IV APAP required fewer intravenous morphine equivalents than patients treated with opioids alone. Reductions in morphine equivalents with IV APAP were 21 mg ( LSG), 33 mg ( LRYGB), and 28 mg (all patients) (p<0.001 for all comparisons). IV APAP was associated with a shorter hospital length of stay (LOS) for the LRYGB (mean difference 1.47 days; p =0.039) and combined groups (mean difference 0.95 days; p =0.025). Patients who received IV APAP had earlier return of bowel sounds and flatus. IV APAP did not reduce mean pain scores in any group. Conclusion Patients undergoing bariatric surgery who received IV APAP during the 24-hour postoperative period consumed fewer intravenous morphine equivalents and had similar pain scores as patients who were treated with opioids alone. Use of IV APAP reduced the hospital LOS and resulted in earlier return of bowel sounds and passage of flatus. [ABSTRACT FROM AUTHOR]

Many changes associated with bariatric surgery have the potential to affect warfarin dosing; yet current literature includes little data describing this phenomenon. Investigating this relationship may allow for determination of post-bariatric surgery warfarin dosing using stable pre-operative dosing levels. A retrospective chart review was completed for 10 patients stabilized on chronic warfarin therapy who underwent bariatric surgery. Data collection consisted of the following: warfarin requirement in mg/week, time in target range ( TTR), creatinine, liver function, diarrhoea, medication changes, diet, and signs of bleeding and/or thrombosis. Three study patients underwent laparoscopic adjustable gastric banding procedures and seven patients underwent Roux-en- Y gastric bypass. The average (standard deviation) weekly warfarin dose required in the immediate post-operative interval was 64% (25%) of baseline dosing, corresponding to a TTR of 48%. At 6 months, patients required 85% (19%) of baseline weekly dosing, with TTR of 53.4%. At 1 year, dosing was 90% (16%) of baseline with TTR of 63.5%. Patients underwent medication changes as well as transient bouts of diarrhoea. Two patients suffered unspecified haemorrhages of the gastrointestinal tract (international normalized ratio [ INR] = 2.3 and 9.8). This patient set demonstrated an initial drop in warfarin requirement, followed by escalating dosing trends that became more predictable as patients were farther out from procedure. [ABSTRACT FROM AUTHOR]

Laparoscopic Roux-en- Y gastric bypass is the most commonly performed surgical procedure for obesity and, consequently, post-operative patients are increasingly encountered by all specialties. This is a case of a patient presenting with abdominal pain, nausea and fever 9 months following gastric bypass surgery caused by diffuse large B-cell lymphoma ( DLBCL) in the bypassed stomach. It demonstrates well that symptoms that may normally be considered 'red-flags' may not be as obvious or specific following an operation. The case also indicates the importance of considering diagnoses unrelated to surgery presenting in the post-operative period (especially when conventional investigation methods are not feasible), and the potential danger of assuming they are due to the operation alone; had this occurred in this patient then a malignancy may have been missed. This is only the second reported case of DLBCL in the bypassed stomach, and the third for lymphoma of any type. [ABSTRACT FROM AUTHOR]

Obesity is the new epidemic and is associated with an increased risk of diastolic and systolic heart failure. Effective treatment options with drastic results such as bariatric surgery have raised interest in the possible reversal of some of the cardiovascular sequelae. Many studies have assessed individually the effect of weight loss on specific echocardiographic indices, mostly employing nonhomogeneous groups. The purpose of this narrative review is to summarise the effect of bariatric surgery on echocardiographic indices of biventricular function and to help in the understanding of the expected echocardiographic changes in bariatric patients after weight-loss surgery [ABSTRACT FROM AUTHOR]

The increasing prevalence of obesity in developed countries is reflected in the chronic kidney disease, dialysis, and transplant populations. The added risk factor of obesity increases the risk of vascular events, inflammation, insulin resistance, blood pressure, dyslipidemia, and mortality risk. Nephrology center policies may exclude obese people from transplantation programs resulting in many years of dialysis. The case of a 215-kg Australian male who has successfully dialyzed at home for more than 8 years will be used to illustrate the important considerations and clinical support that these people require for successful home dialysis treatment. The aim of this paper is to report on a program that has successfully trained 23 obese (body mass index >30) people who commenced on home hemodialysis between 2001 and 2009. Body weight ranged between 94.0 and 215 kg (mean 126, SD 26.19) and body mass index ranged between 34.9 and 71 (mean 43.38, SD 9.99) at the start of home training. During the 8.5 years of follow-up, average time on home dialysis was 43.7 months. Home hemodialysis is a feasible treatment for obese people to facilitate longer and more frequent dialysis, resulting in improved hemodynamic stability and improved quality of life. For obese people with end-stage kidney disease, home hemodialysis has shown to be cost-effective and can result in greater treatment efficacy than in-center hospital dialysis. [ABSTRACT FROM AUTHOR]

The increasing proportion of acutely ill hospital patient admissions presenting with a morbidly obese body mass index (BMI ≥ 40 kg m−2) as a comorbidity is an emerging clinical concern. Suboptimal food intake and malnutrition is prevalent in the acute care hospital setting. The energy requirements necessary to prevent malnutrition in acutely ill patients with morbid obesity remains unclear. The aim of this systematic review was to identify studies in the literature that have used indirect calorimetry to measure the resting energy expenditure of patients with morbid obesity to establish their minimum energy requirements and the implications for optimal feeding practices in acutely ill hospitalized patients. A total of 20 studies from PubMed, Cochrane Library and Embase met the inclusion criteria and were reviewed. All articles were graded using the Australian National Health and Medical Research Council levels of evidence and given a quality rating using the American Dietetic Association recommendations. Studies were categorized according to the mean BMI of its subjects. The most commonly measured resting energy expenditures for morbidly obese patients are between 2,000 and 3,000 kcal d−1 (8,400-12,600 kJ d−1). Activity and injury factors of acutely ill morbidly obese patients could result in significantly greater energy requirements for this patient group and are unlikely to be met by standard hospital menus. Establishing the minimum energy requirements for this population group will help inform adequate and accurate energy provision in the acute setting. Outcomes of underfeeding and overfeeding in morbidly obese patients warrant further research. [ABSTRACT FROM AUTHOR]

Metabolic surgery was developed through the application and experience gained from bariatric or weight loss procedures. Much of our knowledge from the procedures comes from the study of animal models, where they have revealed anatomic feasibility, systemic physiological elements and cellular metabolic effects. The first generation of operation included the jejunoileal bypass and partial ileal bypass that led to the development of the current procedures including Roux-en-Y gastric bypass, biliopancreatic diversion, adjustable gastric banding and sleeve gastrectomy. These operations carry significant metabolic benefits and can reduce the risk of diabetes, heart disease and cancer. Further insights from these animal models can reveal genetic, molecular and systemic effects that can enhance and develop the next generation of metabolic operations. [ABSTRACT FROM AUTHOR]

Worldwide, there is an epidemic of obesity and its associated diseases. The past decade of research has brought about a paradigm shift in our understanding of both the mechanisms underlying energy homeostasis and the multiple factors contributing to the pathophysiology of obesity. Metabolic surgery is currently far more effective than diet and exercise or pharmacotherapy in achieving durable weight loss. Moreover, the remarkable results of surgery in achieving a rapid remission of type 2 diabetes mellitus has sparked tremendous excitement and research into the mechanisms through which metabolic surgery has its dramatic effect. As opposed to the traditional understanding of 'restriction' and 'malabsorption,' current evidence suggests that metabolic surgery alters the expression of multiple hormones that affect both short-term and long-term signals of energy balance. We review the hormonal changes following the most common types of metabolic operations currently being performed. The profile of hormonal changes provides a guide to tailor the choice of operation for each individual patient toward achieving the desired metabolic result. In the future, individualized metabolic surgery alone or modulated by targeted pharmacological therapy may achieve the most reliable and effective results with the highest safety and lowest side effect profile. Mt Sinai J Med 77:446-465, © 2010 Mount Sinai School of Medicine [ABSTRACT FROM AUTHOR]

Obesity is a public health epidemic with medical, psychological and economic consequences. It continues to increase globally in prevalence and severity. Despite numerous behaviourally, medically or pharmacologically guided treatments, an effective non-surgical long-term treatment approach has not been identified. Bariatric surgery has surfaced as a viable option for a subset of individuals with medically complicated obesity who have failed non-surgical approaches. Pre-operative evaluation followed by post-operative, longitudinal follow-up by a multidisciplinary team specializing in surgery, medicine, psychiatry/psychology, exercise science and nutrition constitutes recognized and necessary standard of care for these complex patients. More information is needed regarding factors that interfere with successful outcomes and mechanisms of optimal follow-up for bariatric surgery patients to prevent and detect post-operative medical, psychological and social difficulties. We will review these issues with a focus on issues relevant to eating disorders professionals. Copyright © 2010 John Wiley & Sons, Ltd and Eating Disorders Association. [ABSTRACT FROM AUTHOR]

The increasing prevalence of obesity and the associated morbidity and mortality has resulted in a major research effort to identify mechanisms that regulate appetite. It is well established that the hypothalamus and brain stem are major sites in the central nervous system (CNS) that regulate appetite. Until recently the missing element has been how information regarding food intake and energy stores is communicated to the CNS. Gut hormones have recently been found to be an important element in this regulation, communicating information regarding food intake to the CNS. Several gut hormones have been found to exert anorectic effects. These include members of the Pancreatic Polypeptide (PP)-fold family, namely PP itself and also peptide tyrosine-tyrosine (PYY), the first gut hormone shown to have appetite-inhibiting properties. The other main class of anorectic gut hormones are those derived by proteolytic processing from proglucagon, most importantly glucagon-like peptide-1 (GLP-1) and oxyntomodulin. All of these are currently being investigated as the basis of treatments to prevent the development of obesity. So far the only gastrointestinal hormone demonstrated to stimulate appetite is ghrelin. Potential sites and mechanisms of action and therapeutic use of these gastrointestinal hormones are discussed. [ABSTRACT FROM AUTHOR]

Background: It is estimated that up to 80% of persons with diabetes mellitus type 2 are overweight and in these patients it is recognized that effective weight control can lead to improvement or even resolution of their diabetes (Colagiuri et al.). All currently carried out operations for morbid obesity have been shown to improve diabetes, but there appears to be a variable response to surgery depending on several surgical and patient factors. Methods: In this prospective review, we analysed the change in the diabetic status in 72 patients undergoing three different bariatric procedures in a single institution over 30 months. A review of the published work comparing the efficacy of the various procedures in achieving improvement or resolution of diabetes was also carried out and correlated to our findings. Results: At an average follow up of 13 months, 50% of patients who had placement of laparoscopic adjustable gastric band had an improvement or resolution of their diabetes, compared with 95% of patients who had had laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass. Two of 12 (17%) laparoscopic adjustable gastric band patients had normal blood glucose levels off all diabetic medications compared with 7 of 21 (33%) laparoscopic sleeve gastrectomy and 27 of 39 (69%) Roux-en-Y gastric bypass patients. There was no significant association between the amount of weight lost and the return to euglycaemia. Conclusion: Direct comparison has shown a significant difference in the effects of different forms of bariatric surgery on type 2 diabetes, this is in keeping with evidence that surgery can lead to improvement in diabetes additional to that obtained by weight loss alone. [ABSTRACT FROM AUTHOR]

Summary: Delphi methodology may be utilized to develop consensus opinion among a group of experts. The aim of our study was to use a modified Delphi process to determine the future research priorities among bariatric and metabolic healthcare professionals in the United Kingdom. Members of the Association of Upper Gastrointestinal Surgeons and the British Obesity and Metabolic Surgery Society were invited to submit individual research questions via an online survey (phase I). Two rounds of prioritization by multidisciplinary expert healthcare professionals (phase II and III) were completed to determine a final list of high‐priority research questions. Fifty‐one bariatric and metabolic surgery‐focused questions were identified in phase I. Thirty‐five questions were taken forward for prioritization in phase II. Eleven high‐priority questions were identified in phase III. The final list of high‐priority questions had an emphasis on the pathophysiology and long‐term sequelae of bariatric and metabolic surgery. A modified Delphi process has produced a list of 11 high‐priority research questions in bariatric and metabolic surgery. Future studies and awards from funding bodies should reflect this consensus list of prioritized questions in the interest of improving patient care and encouraging collaborative research across multiple centres. [ABSTRACT FROM AUTHOR]

Summary: Research teams have argued that some bariatric patients require psychological input pre‐ and post‐surgery and that weight loss surgery should only be undertaken by a multidisciplinary team (MDT) that can provide psychological support. To date, no guidelines exist for the provision of psychological support pre‐ and post‐bariatric surgery. The authors were approached by British Obesity Metabolic Surgery Society (BOMSS) in September 2017 to produce guidelines for the provision of psychological support for patients pre‐ and post‐bariatric surgery. These guidelines were developed using seven stages: (a) review of evidence base; (b) expert input; (c) feedback from BOMSS delegates; (d) feedback from the special interest group; (e) service user feedback; (f) presentation to BOMSS council; and (g) presentation to the Association for the Study of Obesity. The guidelines describe two stepped care service models for the delivery of psychological support pre‐surgery and 6 to 9 months post‐surgery involving online resources, group workshops and one‐to‐one with a clinical psychologist. They are founded upon the following principles: (a) a living document to be modified over time; (b) flexible and pragmatic; (c) advisory not prescriptive; (d) broad based content; (e) skills based delivery. These guidelines are feasible for use across all services and should minimize patient risk and maximize patient health outcomes. [ABSTRACT FROM AUTHOR]

Summary: Background: NHS England has recommended a multidisciplinary weight management services (MWMS—Tier 3 services) for patients requiring specialized management of obesity, including bariatric surgery, but clinical and measurable health‐related outcomes from these services remains fragmented. We therefore undertook a systematic review to explore the evidence base of effect on body weight loss and comorbidities outcomes of Tier 3 or UK pre‐bariatric MWMPs. Methods: AMED, CINAHL, EMBASE, HMIC, MEDLINE, PsycINFO, PubMed, HDAS search and Google Scholar were searched from January 2000 to September 2017 in a free‐text fashion and crossed‐references of included studies to identify potential illegibility. Inclusion criteria were as follows: (a) published Tier 3 original study abstracts/articles; (b) intervention studies with before and after data; (c) studies that included any sort of MWMPs conducted on British residents with obesity; and (d) studies included T2DM measurements in a MWMPs. Results: In total, 19 studies met the inclusion criteria. The total number of participants analysed was N = 11,735. Baseline accumulative average BMI was calculated at 42.54 kg/m2, weight 117.88 kg and waist circumference 126.9 cm. And at 6 months, 40.73 kg/m2, 112.17 kg and 120.3 cm, respectively. Secondary outcome variables were as improved with reduction in HbA1c, fasting blood sugars, insulin usage and blood pressure. Physical activity increased at 3 months then declined after 6 months with no significant changes in cholesterol levels. Conclusion: Tier 3 and MWMPs have a short to mid‐ranged positive effect on obese patients (BMI ≥30 kg/m2) living in the UK regarding accumulated reduction in weight, glycaemic control, blood pressure and with subtle improvements in physical activity. Although NHS England has recommended a multidisciplinary weight management services (MWMS ‐Tier 3 services) for patients requiring specialized management of obesity, including bariatric surgery, clinical and measurable health‐related outcomes from these services remains fragmented. This systematic review of services in the UK for the management of patients with morbid obesity prior to bariatric surgery involved 19 studies (N = 11 735 patients). We report that Tier 3 and MWMPs have a short to mid‐ranged positive effect on obese patients (BMI ≥30 kg/m2) living in the UK regarding accumulated reduction in weight, glycaemic control, BP and with subtle improvements in physical activity. [ABSTRACT FROM AUTHOR]

Unlabelled: What is already known about this subject •  There is a discrepancy between clinical and patient goals for weight loss. •  Evidence suggests that some bariatric patients highly value, and are willing to endure hardships for weight loss. •  Obesity is commonly framed as an easily reversed and individual problem, which in turn promotes weight discrimination. What this study adds •  Patient beliefs about weight loss are in accordance with social understandings of obesity but not with current treatment options. •  Patients may not be willing to endure hardships for weight loss. •  Weight discrimination may relate to how patients approach weight loss., Summary: Bariatric patients report weight loss goals, which are three times higher than weight loss recommended by clinicians. It is unclear which weight loss interventions patients feel are necessary to reach these goals or whether responses associate with perceptions of weight discrimination. One hundred fifteen patients (BMI = 40.0 ± 6.9 kg m(-2) , age = 47.2 ± 12.2 years, 85% female, 77% reporting weight discrimination) were surveyed from weight management clinics. Participants reported ideal weight losses of 37.6 ± 16.7 kg (33% of initial weight), and the majority felt weight loss could be achieved through lifestyle changes such as improved physical activity (80%) or diet (52%), with fewer reporting pharmacotherapy (8%), surgery (12%) or genetic modification (7%) as necessary for goal attainment. Participants selecting lifestyle changes or pharmacotherapy for weight loss reported ideal weight loss goals that would generally be achievable through surgical means (32% and 33%, respectively), and participants selecting surgical intervention reported ideal goals at the upper end of what is generally achievable with this intervention (38%). All participants selecting surgery or genetic modifications reported experiencing weight discrimination. These results indicate a disparity between weight loss goals and selected interventions, and suggest that weight discrimination is associated with the selection of potentially riskier weight loss interventions., (© 2011 The Authors. Clinical Obesity © 2011 International Association for the Study of Obesity.)

A variety of European, North American and, recently, Middle East and Australasian guidelines are now available for clinicians treating obese children and adolescents. This review aims to synthesize recommendations from recent guidance to provide direction to clinicians on the appropriate use of bariatric surgery in adolescents. A literature search for English-language guidelines endorsed by national governments or professional health associations or societies was conducted, and subject experts were consulted to identify the most recently released guidance. Fifteen sets of guidelines were found, released in the past 6 years, of which nearly all suggested that bariatric surgery is indicated for obese paediatric patients after previous failed attempts at weight loss. Guidance was broadly similar in terms of the categories addressed (patient selection criteria, requirements of the surgical team and institution, and suggested preoperative and postoperative protocols), although relatively little consensus was evident among the criteria specified within these categories. Recommendations differed regarding the appropriate age and degree of obesity at which to intervene. Fewer guidelines addressed preoperative and postoperative care requirements, and of those that did the emphasis varied between familial care and involvement, psychological state and patient motivation, and the importance of long term care. There is a lack of uniformity in the guidance in this area, indicative of the complex nature of obesity management for younger patients. While guidance is necessary to inform and update clinicians, obese paediatric patients require individualized assessment and care., (© 2011 IASO. Clinical Obesity © 2011 International Association for the Study of Obesity.)

Strong evidence for successful and cost-effective obesity management strategies is still generally lacking, leading the medical profession to rely increasingly on surgical options to treat obesity in children and adolescents. We performed a systematic review to examine the effectiveness of surgical interventions to treat obese children and adolescents, and whether they are cost-effective. We searched PubMed, ISI Web of Science, Embase and the Cochrane Library to 6 September 2010, and hand-searched bibliographies. We included articles with English abstracts if they examined subjects ≤19 years of age, reported at least one postoperative weight loss measure and at least 1 year of postoperative follow-up. Thirty-seven relevant papers on bariatric surgery effectiveness in 831 children or adolescents were included, spanning 36 years. Thirteen studies examined gastric banding, with mean body mass index (BMI) reductions ranging from 8.5 to 43 kg m(-2) . Weight gain was reported in one case study. Eight papers examined Roux-en-Y gastric bypass, with mean BMI reductions ranging from 9 to 25 kg m(-2) . Fourteen publications studied other forms of bariatric surgery: sleeve gastrectomies, vertical banded gastroplasty, biliopancreatic diversion or a combination of procedures. Mean BMI reductions ranged from 9 to 24 kg m(-2) . Three surgery-related mortalities were reported, as was weight regain in several cases. The majority of studies reported resolution or improvement of comorbid conditions. A range of postoperative complications were identified across surgery types, including: ulcers, intestinal leakage, wound infection, anastomotic stricture, nutritional deficiencies, bowel obstruction, pulmonary embolism, disrupted staple lines, band slippage, psychological intolerance and repeated vomiting. Evidence on cost-effectiveness was limited to one Australian modelling project, which deemed laparoscopic adjustable gastric banding cost-effective for adolescents. Existing evidence - although based generally on underpowered, retrospective studies - suggests that bariatric surgery in older children results in significant weight loss and improvements in comorbidities and quality of life. However, postoperative complications, compliance and follow-up may be more problematic in adolescents than adults, and availability of long-term data on safety, effectiveness and cost-effectiveness remains largely unknown. Pending an improvement in the quality of available evidence, a cautious approach to child and adolescent bariatric surgery is warranted, and reversible techniques are advisable compared to approaches that permanently alter anatomy., (© 2011 IASO. Clinical Obesity © 2011 International Association for the Study of Obesity.)