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The Centers for Disease Control and Prevention recently issued two statements that 1) maintain that obesity causes diabetes and other expressions of the metabolic syndrome and 2) that imply obesity is the victim's fault. Both statements are incorrect and potentially harmful., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Prior literature has demonstrated that bariatric surgery is a safe approach for patients with morbid obesity. However, the relationship between body mass index (BMI) and risk of mortality in these patients has not been fully elucidated. Primary objective of this study was to evaluate the relationship between BMI and risk of mortality using data obtained from a national database, with a special focus on patients with BMI ≥ 70.0 kg/m 2 ., Methods: A retrospective cohort study of patients with morbid obesity (BMI ≥ 40 kg/m 2 ) undergoing first-time bariatric surgery between 2015 and 2018 was performed using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Primary outcome was intra-operative death or death within 30 days post-operatively. Patients were categorized into quartiles according to BMI. Multivariable analysis was performed to evaluate the association of BMI with risk of mortality. Relative risk (RR) and 95% confidence interval (CI) are provided as measures of strength of association and precision, respectively., Results: A total of 463, 436 patients were included with a 30-day mortality rate of 0.11%. Mean BMI (SD) was 48.2 (7.3) kg/m 2 ; 1.5% of patients had BMI ≥ 70.0 kg/m 2 . On multivariable analysis, highest quartile patients had a significantly higher risk of mortality than lowest quartile patients. For patients with BMI ≥ 70.0 kg/m 2 , the risk of mortality was more pronounced with an eightfold increase compared to the lowest quartile. In patients with BMI ≥ 70.0 kg/m 2 , although sleeve gastrectomy (SG) was the most common procedure, the risk of mortality was significantly higher in patients undergoing Roux-en-Y gastric bypass (RYGB)., Conclusions: BMI is associated with increased risk of 30-day mortality. The effect of BMI is more pronounced in patients with BMI ≥ 70.0 kg/m 2 . In these patients, RYGB is associated with increased risk of mortality compared to SG., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Obesity impairs the gastrointestinal microbiome (GM) and may promote micronutrient deficiencies. Bariatric surgery (BS), the most efficacious treatment for severe obesity, produces sustained weight loss and improvements in obesity-related comorbidities, but might not fully restore microbial balance. Moreover, BS may result in deleterious consequences that affect weight loss and further intensify post-operative micronutrient deficiencies. To date, the use of probiotics appears to be associated with greater weight loss in bariatric patients, improved vitamin synthesis and availability, and decreased instances of small intestinal bacterial overgrowth. Thus, manipulation of the GM through probiotics represents a promising therapeutic approach in bariatric patients. This review aims to highlight the benefits of using probiotics in bariatric surgical patients by addressing the impact of probiotics on the GM, how BS impacts the microbial environment, associations between gastrointestinal dysbiosis and negative health outcomes, how BS contributes to dysbiosis, and how probiotics may prove efficacious in treating patients who undergo Roux-en-Y gastric bypass (RYGB). Based on currently available data, the role of microbial manipulation post-RYGB through probiotics has shown great potential, but a further clinical investigation is warranted to better understand their efficacy., (© 2022 The Authors. Clinical Obesity published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Purpose: Metabolic surgery dramatically improves type 2 diabetes mellitus (T2DM). In 2017, the American Diabetes Association (ADA) recommended metabolic surgery as the optimal treatment for patients with T2DM and Body Mass Index (BMI) > 40. We sought to evaluate whether or not that recommendation is being implemented. The purpose of this study was to evaluate the trend of bariatric surgery 2 years prior and 2 years following the ADA statement., Materials and Methods: A retrospective analysis of primary bariatric procedures on patients with class III obesity (BMI > 40 kg/m 2 ) and T2DM performed between 2015 and 2018, using the Metabolic and Bariatric Surgery Accreditation Quality and Improvement Project (MBSAQIP) database., Results: From 2015 to 2018, 164,535 patients with T2DM underwent bariatric surgery. The majority had a BMI > 40 kg/m 2 (n = 117,422, 71.4%) and most were not using insulin. Majority of the patients with T2D and class III obesity were female (72.1%), Caucasian (71.5%), and mean age (SD) 48.5 (11.5). Although the numbers of patients with T2DM and class III obesity increased during this time period, there was not a significant change in the overall percentage of patients who were treated with surgery: from 25.99% in 2015 to 24.96% in 2018. In addition, this group is associated with higher rates of complications and mortality compared to patients with BMI > 40 kg/m 2 without T2DM., Conclusion: Utilization of metabolic surgery in patients with obesity and T2DM has not improved following the updated 2017 ADA guidelines. There is a clear need for more awareness of these guidelines among providers, patients, and the public., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: The aim of this study is to evaluate the change in rate of increase of bariatric surgery performed compared to the growth of obesity and severe obesity in the United States (US)., Materials and Methods: The number of primary adult bariatric procedures performed in the US between 2015 and 2018 was obtained from the Metabolic and Bariatric Surgery Accreditation Quality and Improvement Project (MBSAQIP) database. The US Census database was used to derive age-adjusted obesity and severe obesity prevalence among adults. Prevalence of bariatric surgery, by year, was estimated as the ratio of the number of patients undergoing surgery and the projected number of eligible individuals for that year., Results: There were 627,386 bariatric procedures performed for body mass index (BMI) ≥ 30 kg/m 2 , of which 73.3% (n = 459,800) were performed for BMI ≥ 40 kg/m 2 . Although the rate of obesity increased by 3.32% per year during this period (RR = 1.0332 per year increase; 95% CI = 1.0313, 1.0352), the rate of surgery per eligible population increased by only 2.47% (RR = 1.0247 per year increase; 95% CI = 1.0065, 1.0432). The prevalence of severe obesity increased from 7.70% (n = 17,494,910) in 2015 to 9.95% (n = 23,135,039) in 2018 while the prevalence of surgery decreased from 0.588 per 100 eligible population in 2015 to 0.566 per 100 eligible population in 2018., Conclusion: The rate of utilization has not kept up with the rate of increase in this disease, our costliest illness. There is a strong need to educate the public, healthcare professionals, insurance carriers, and legislators., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Postbariatric hypoglycemia (PBH) can be a devastating complication for which current therapies are often incompletely effective. More information is needed regarding frequency, incidence, and risk factors for PBH., Objectives: To examine hypoglycemia symptoms following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) and baseline and in-study risk factors., Setting: Multicenter, at 10 US hospitals in 6 geographically diverse clinical centers., Methods: A prospective, longitudinal cohort study of adults undergoing RYGB or LAGB as part of clinical care between 2006 and 2009 were recruited and followed until January 31, 2015, with baseline and annual postoperative research assessments. We analyzed baseline prevalence and post-operative incidence and frequency of self-reported hypoglycemia symptoms as well as potential preoperative risk factors., Results: In all groups, postoperative prevalence of hypoglycemia symptoms was 38.5%. Symptom prevalence increased postoperatively from 2.8%-36.4% after RYGB in patients without preoperative diabetes (T2D), with similar patterns in prediabetes (4.9%-29.1%). Individuals with T2D had higher baseline hypoglycemia symptoms (28.9%), increasing after RYGB (57.9%). Hypoglycemia symptoms were lower after LAGB, with 39.1% reported hypoglycemia symptoms at only 1 postoperative visit with few (4.0%) having persistent symptoms at 6 or more annual visits. Timing of symptoms was not restricted to the postprandial state. Symptoms of severe hypoglycemia were reported in 2.6-3.6% after RYGB. The dominant risk factor for postoperative symptoms was preoperative symptoms; additionally, baseline selective serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitor use was also associated with increased risk in multivariable analysis. Weight loss and regain were not related to hypoglycemia symptom reporting., Conclusion: Hypoglycemia symptoms increase over time after RYGB, particularly in patients without diabetes. In a small percentage, symptoms can be persistent or severe and require hospitalization. Preoperative hypoglycemia symptoms and SSRI/SNRI use in RYGB patients without diabetes is associated with increased risk of symptoms., (Copyright © 2021. Published by Elsevier Inc.)

Bariatric surgery has been shown to improve cognition in patients with severe obesity. Bariatric surgery may improve mental function in patient populations with obesity and with cognitive impairment, including nonacquired, dementia, and traumatic brain injury, although studies have been limited. Bariatric surgery provides an opportunity to explore the effects of obesity, type 2 diabetes, dyslipidemias, and other expressions of metabolic syndrome on cognition. It offers the unusual opportunity to study patients with these chronic diseases and, later, those without them. This suggests the need for further studies into the effects of bariatric surgery on patient populations with obesity and with cognitive impairment to look at the effects of the continuing metabolic brain damage in people with severe obesity when earlier intervention could be considered., (© 2021 The Obesity Society.)

The broad effects of bariatric/metabolic surgery on virtually every tissue and organ system remain unexplained. Weight loss, although a major factor, does not fully account for the rapid, full, and durable remission of type 2 diabetes, return of islet function, reduction of the prevalence of cancers, increase in gray matter of the brain, and decrease in all-cause mortality. This review supports the thesis that the metabolic syndrome is not a group of separate diseases but rather multiple expressions of a shared defect in the utilization of carbohydrates and lipids. That error is probably caused by a dysmetabolic signal from the foregut, stimulated by food, that limits entry of 2-carbon fragments into the tricarboxylic acid cycle, the accumulation of lactate and, in turn, increases in glucose and insulin. Surgery limits that signal by reducing contact between food and foregut mucosa. Speciation of that signal(s) may offer a new pathway for drug development., (Copyright © 2021. Published by Elsevier Inc.)

Context: Few studies have examined the clinical characteristics that predict durable, long-term diabetes remission after bariatric surgery., Objective: To compare diabetes prevalence and remission rates during 7-year follow-up after Roux-en-Y gastric bypass (RYGB) and laparoscopic gastric banding (LAGB)., Design: An observational cohort of adults with severe obesity recruited between 2006 and 2009 who completed annual research assessments for up to 7 years after RYGB or LAGB., Setting: Ten US hospitals., Participants: A total sample of 2256 participants, 827 with known diabetes status at both baseline and at least 1 follow-up visit., Interventions: Roux-en-Y gastric bypass or LAGB., Main Outcome Measures: Diabetes rates and associations of patient characteristics with remission status., Results: Diabetes remission occurred in 57% (46% complete, 11% partial) after RYGB and 22.5% (16.9% complete, 5.6% partial) after LAGB. Following both procedures, remission was greater in younger participants and those with shorter diabetes duration, higher C-peptide levels, higher homeostatic model assessment of β-cell function (HOMA %B), and lower insulin usage at baseline, and with greater postsurgical weight loss. After LAGB, reduced HOMA insulin resistance (IR) was associated with a greater likelihood of diabetes remission, whereas increased HOMA-%B predicted remission after RYGB. Controlling for weight lost, diabetes remission remained nearly 4-fold higher compared with LAGB., Conclusions: Durable, long-term diabetes remission following bariatric surgery is more likely when performed soon after diagnosis when diabetes medication burden is low and beta-cell function is preserved. A greater weight-independent likelihood of diabetes remission after RYGB than LAGB suggests mechanisms beyond weight loss contribute to improved beta-cell function after RYGB.Trial Registration clinicaltrials.gov Identifier: NCT00465829., (© The Author(s) 2020. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Obesity is a common outcome of traumatic brain injury (TBI) that exacerbates principal TBI symptom domains identified as common areas of post-TBI long-term dysfunction. Obesity is also associated with increased risk of later-life dementia and Alzheimer's disease. Patients with obesity and chronic TBI may be more vulnerable to long-term mental abnormalities. This review explores the question of whether weight loss induced by bariatric surgery could delay or perhaps even reverse the progression of mental deterioration. Bariatric surgery, with its induction of weight loss, remission of type 2 diabetes, and other expressions of the metabolic syndrome, improves metabolic efficiency, leads to reversal of brain lesions seen on imaging studies, and improves function. These observations suggest that metabolic/bariatric surgery may be a most effective therapy for TBI.

Obesity is a common outcome of traumatic brain injury (TBI) that exacerbates principal TBI symptom domains identified as common areas of post-TBI long-term dysfunction. Obesity is also associated with increased risk of later-life dementia and Alzheimer's disease. Patients with obesity and chronic TBI may be more vulnerable to long-term mental abnormalities. This review explores the question of whether weight loss induced by bariatric surgery could delay or perhaps even reverse the progression of mental deterioration. Bariatric surgery, with its induction of weight loss, remission of type 2 diabetes, and other expressions of the metabolic syndrome, improves metabolic efficiency, leads to reversal of brain lesions seen on imaging studies, and improves function. These observations suggest that metabolic/bariatric surgery may be the most effective therapy for TBI.

Obesity is a common outcome of traumatic brain injury (TBI) that exacerbates principal TBI symptom domains identified as common areas of post-TBI long-term dysfunction. Obesity is also associated with increased risk of later-life dementia and Alzheimer's disease. Patients with obesity and chronic TBI may be more vulnerable to long-term mental abnormalities. This review explores the question of whether weight loss induced by bariatric surgery could delay or perhaps even reverse the progression of mental deterioration. Bariatric surgery, with its induction of weight loss, remission of type 2 diabetes, and other expressions of the metabolic syndrome, improves metabolic efficiency, leads to reversal of brain lesions seen on imaging studies, and improves function. These observations suggest that metabolic/bariatric surgery may be a most effective therapy for TBI.

Objective: This study aimed to examine whether pregnancy following bariatric surgery affects long-term maternal weight change and offspring birth weight., Methods: Using data from the Longitudinal Assessment of Bariatric Surgery (LABS)-2 study, linear regression was used to evaluate percent change in total body weight over a 5-year follow-up period among reproductive-aged women who underwent Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding as well as evaluate the association of bariatric procedure type and offspring birth weight., Results: Of 727 women with preoperative age of 36.1 (6.3) years (mean [SD]) and BMI of 46.9 (7.0) kg/m 2 , 80 (11%) reported at least one pregnancy. After adjusting for covariates, percent change in total body weight was not significantly different between women who became pregnant and those who did not during a 5-year follow-up period (β = 2.02; 95% CI: -1.03 to 5.07; P = 0.19). Additionally, mean birth weight was not significantly different between mothers who underwent Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding (P = 0.99)., Conclusions: Postoperative pregnancy did not diminish long-term weight loss in women in the LABS-2 study. The finding of comparable weight loss is relevant for providers counseling women of reproductive age on weight-loss expectations and family planning following bariatric surgery., (© 2020 The Obesity Society.)

On August 9-10, 2017, the American College of Surgeons hosted a symposium on metabolic surgery, with 12 follow-on papers published serially in the Bulletin of the College. The current synopsis outlines the varied contents of these papers, often in the original words of their authors, who are cited within their topic sections. Topics covered include the following: history and definition of metabolic surgery, bariatric surgery, international bariatric surgery, mechanisms of metabolic surgery, diabetes and the metabolic syndrome, frontiers of metabolic surgery, institutional collaborations, accreditations and quality initiatives, professional training, the role of the National Institutes of Health, and advocacy. Based on these insights, an enthusiastic affirmation for the future of metabolic surgery is warranted.

Objective: This study sought to examine weight change, postoperative adverse events, and related outcomes of interest among age-qualified (AQ) and disability-qualified (DQ) Medicare recipients compared with non-Medicare (NM) patients undergoing an initial bariatric procedure., Methods: The Longitudinal Assessment of Bariatric Surgery (LABS-2) is an observational cohort study of 2,458 adults who underwent Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) bariatric surgery. Weight, percentage body fat, functional status, and comorbidities, as well as postoperative adverse events, were assessed at baseline and annually for 5 years. The 1,943 participants who reported insurance type were categorized into the following groups: AQ, DQ, or NM., Results: The median preoperative BMI ranged from 45 to 48 kg/m 2 across groups. For RYGB, 5-year BMI loss was approximately 30% for all groups, and for LAGB, BMI loss was 12% to 15%. Diabetes remission after 5 years was also similar across groups within procedure types (RYGB: 33%-40%; LAGB: 13%-19%). The frequency of adverse events after RYGB ranged from 4.1% for NM participants to 6.7% for DQ participants. After LAGB, there were no adverse events for the AQ group, whereas 3% of DQ participants and 1.8% of NM participants had at least one adverse event., Conclusions: Medicare participants experienced substantial BMI loss and diabetes remission, with a frequency of adverse events similar to that of NM participants., (© 2019 The Obesity Society.)

Background: Fasting lactate is elevated in metabolic diseases and could possibly be predictive of the risk of developing the metabolic syndrome., Methods: Plasma samples were analyzed for fasting lactate to compare lean subjects, nondiabetic subjects with severe obesity, and metabolically impaired subjects. Subjects with severe obesity were studied 1 week before and 1 week to 9 months after gastric bypass surgery. Subjects with components of the metabolic syndrome were studied before and after 6 months of an exercise intervention., Results: Metabolically impaired subjects had higher fasting lactate concentrations (P < .0001) and respond to a glucose or insulin challenge with higher lactates than non-obese subjects (P < .004). Lactate was significantly reduced a week after gastric bypass surgery (P < .05) and further reduced 1 to 9 months after surgery (0.95 ± 0.04 mM in non-obese, 1.26 ± 0.12 mM in subjects with severe obesity, and 0.68 ± 0.03 mM 1-3 months after gastric bypass). Six months of chronic exercise resulted in a 16% reduction (P = .028) in fasting lactate., Conclusion: Fasting plasma lactate was elevated in obese subjects with the metabolic syndrome compared with healthy lean individuals. Lactate was reduced by exercise and bariatric surgery, interventions that improve metabolic health and risk for subsequent disease. The results of this study and those previously published by our research group suggest that elevated lactate may be caused by an impairment in aerobic metabolism and may offer a metric assessing the severity of the metabolic syndrome., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Several studies have demonstrated that minorities and Hispanic ethnicities have disproportionally greater burden of morbid obesity in the United States. However, the majority of bariatric procedures are performed in the non-Hispanic white population., Objectives: The objective of this study was to investigate the weight loss and remission of obesity-related co-morbidities based on race and ethnicity., Setting: The Longitudinal Assessment of Bariatric Surgery prospective, multicenter, observational study was used to collect patients from 10 different health centers across the United States., Methods: Retrospective analysis of a prospective, multicenter, observational study over a 5-year follow-up., Results: All patients who underwent primary gastric bypass and provided racial/ethnic information were included in the study (n = 1695). Regardless of race or ethnicity, total weight loss was maintained over a 5-year follow-up, which included 87% of the original cohort. However, whites had on average 1.94% higher adjusted total weight loss compared with blacks (P < .0001). After adjusting for confounders there were no significant differences in resolution of co-morbidities, including diabetes., Conclusion: All patients regardless of race or ethnicity have significant and sustained total weight loss and resolution of co-morbidities after gastric bypass at 5-year follow-up., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Some studies suggest that changes in weight or metabolic outcomes are affected by the lengths of the gastrointestinal limbs in the Roux-en-Y gastric bypass., Methods: Participants (N = 1,770) underwent primary Roux-en-Y gastric bypass and were followed ≤7 years in the Longitudinal Assessment of Bariatric Surgery-2, a multicenter US cohort study. Alimentary limb and biliopancreatic limb lengths were measured according to research protocol; common channel was measured in a subsample (N = 547). Aimentary limb, biliopancreatic limb, and common channel ratio to total small bowel length were calculated., Results: Median presurgery body mass index was 46 (25th-75th percentile: 43-51) kg/m 2 . Medians (25th-75th percentiles) for alimentary limb length were 125 cm (100-150), for biliopancreatic limb length were 50 cm (50-60), and common channel length were 410 cm (322-520). Statistics for ratios to the small bowel length were 0.23 (0.18-0.27) for alimentary limb, 0.09 (0.07-0.10) for biliopancreatic limb, and 0.69 (0.63-0.73) for common length. There were no significant associations between alimentary limb, biliopancreatic limb, common channel, alimentary limb ratio, biliopancreatic limb ratio or common channel ratio, and either weight loss or improvement in cardiometabolic outcomes., Conclusion: The common channel length in Roux-en-Y gastric bypass is highly variable between individuals. None of the limb lengths in this study, nor alimentary limb, biliopancreatic limb, or common channel ratios, seem to be related to weight loss or metabolic improvements >7 years., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background/objective: The partitioning of glucose toward glycolytic end products rather than glucose oxidation and glycogen storage is evident in skeletal muscle with severe obesity and type 2 diabetes. The purpose of the present study was to determine the possible mechanism by which severe obesity alters insulin-mediated glucose partitioning in human skeletal muscle., Subjects/methods: Primary human skeletal muscle cells (HSkMC) were isolated from lean (BMI = 23.6 ± 2.6 kg/m 2 , n = 9) and severely obese (BMI = 48.8 ± 1.9 kg/m 2 , n = 8) female subjects. Glucose oxidation, glycogen synthesis, non-oxidized glycolysis, pyruvate oxidation, and targeted TCA cycle metabolomics were examined in differentiated myotubes under basal and insulin-stimulated conditions., Results: Myotubes derived from severely obese subjects exhibited attenuated response of glycogen synthesis (20.3%; 95% CI [4.7, 28.8]; P = 0.017) and glucose oxidation (5.6%; 95% CI [0.3, 8.6]; P = 0.046) with a concomitant greater increase (23.8%; 95% CI [5.7, 47.8]; P = 0.004) in non-oxidized glycolytic end products with insulin stimulation in comparison to the lean group (34.2% [24.9, 45.1]; 13.1% [8.6, 16.4], and 2.9% [-4.1, 12.2], respectively). These obesity-related alterations in glucose partitioning appeared to be linked with reduced TCA cycle flux, as 2-[ 14 C]-pyruvate oxidation (358.4 pmol/mg protein/min [303.7, 432.9] vs. lean 439.2 pmol/mg protein/min [393.6, 463.1]; P = 0.013) along with several TCA cycle intermediates, were suppressed in the skeletal muscle of severely obese individuals., Conclusions: These data suggest that with severe obesity the partitioning of glucose toward anaerobic glycolysis in response to insulin is a resilient characteristic of human skeletal muscle. This altered glucose partitioning appeared to be due, at least in part, to a reduction in TCA cycle flux.

Background: Past research suggests self-harm/suicidality are more common among adults who have undergone bariatric surgery than the general population., Objectives: To compare prevalence of self-harm/suicidal ideation over time and identify presurgery risk factors for postsurgery self-harm/suicidal ideation., Setting: The Longitudinal Assessment of Bariatric Surgery-2 is a cohort study with presurgery and annual postsurgery assessments conducted at 10 U.S. hospitals., Methods: Adults with severe obesity undergoing bariatric surgery between March 2006 and April 2009 (n = 2458). Five-year follow-up is reported. Self-reported history of suicidality assessed retrospectively via the Suicide Behavior Questionnaire-Revised (SBQ-R) and self-reported self-harm/suicidal ideation assessed prospectively via the Beck Depression Inventory-Version 1 (BDI-1)., Results: The SBQ-R was completed by 1540 participants; 2217 completed the BDI-1 pre- and postsurgery. Over 75% of participants were female, with a median age of 46 years and body mass index of 45.9 kg/m 2 . Approximately one fourth of participants (395/1534) reported a presurgery history of suicidal thoughts or behavior (SBQ-R). The prevalence of self-harm/suicidal ideation (BDI-1) was 5.3% (95% confidence interval [CI], 3.7-6.8) presurgery and 3.8% (95% CI, 2.5-5.1) at year 1 postsurgery (P = .06). Prevalence increased over time postsurgery to 6.6% (95% CI, 4.6-8.6) at year 5 (P = .001) but was not significantly different than presurgery (P = .12)., Conclusions: A large cohort of adults with severe obesity who underwent bariatric surgery had a prevalence of self-harm/suicidal ideation that may have decreased in the first postoperative year but increased over time to presurgery levels, suggesting screening for self-harm/suicidality is warranted throughout long-term postoperative care. Several risk factors were identified that may help with enhanced monitoring., (Copyright © 2018 American Society for Bariatric Surgery. All rights reserved.)

Background: Bariatric surgery usually results in substantial weight loss and a reduction in medical comorbidities. Many patients, as a consequence of the weight loss, subsequently evidence loose, redundant skin., Objectives: This investigation seeks to examine the prevalence of body contouring surgery (BCS) by patients approximately 4 to 5 years after Roux-en-Y gastric bypass surgery. Demographics, change in BMI, and psychosocial variables were also used to predict body dissatisfaction, desire for BCS, and patients who reported obtaining BCS., Setting: The clinical sites involved in the Longitudinal Assessment of Bariatric Surgery project, which included 10 hospitals across the United States., Methods: The sample comprised 1159 patients who underwent Roux-en-Y gastric bypass and were enrolled in the Longitudinal Assessment of Bariatric Surgery-2 study. Participants were surveyed using the Excessive Skin Survey and other psychosocial measures at their 4- or 5-year postoperative outcome. The participants were predominately women (80.5%), Caucasian (88.3%), and middle-aged (mean = 46.1 yr, standard deviation = 11.11 yr)., Results: Participants reported modest degrees of being bothered by excessive skin, primarily in their waist/abdomen, thighs, and chest/breasts body areas. Only 11.2% of the sample had undergone any BCS procedure, and a majority of those participants paid "out of pocket" for BCS. Desire for BCS and body dissatisfaction 4 to 5 years postsurgery was associated with higher depression scores and poorer quality of life scores., Conclusions: Excessive skin is associated with poorer psychosocial functioning. Despite reporting modest levels of being bothered by excessive skin and body dissatisfaction, only a small fraction of participants underwent BCS. Cost of BCS was reported to be a primary barrier for not obtaining BCS. All rights reserved., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: More information is needed about the durability of weight loss and health improvements after bariatric surgical procedures., Objective: To examine long-term weight change and health status following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB)., Design, Setting, and Participants: The Longitudinal Assessment of Bariatric Surgery (LABS) study is a multicenter observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. Adults undergoing bariatric surgical procedures as part of clinical care between 2006 and 2009 were recruited and followed up until January 31, 2015. Participants completed presurgery, 6-month, and annual research assessments for up to 7 years., Main Outcome and Measures: Percentage of weight change from baseline, diabetes, dyslipidemia, and hypertension, determined by physical measures, laboratory testing, and medication use., Results: Of 2348 participants, 1738 underwent RYGB (74%) and 610 underwent LAGB (26%). For RYBG, the median age was 45 years (range, 19-75 years), the median body mass index (calculated as weight in kilograms divided by height in meters squared) was 47 (range, 34-81), 1389 participants (80%) were women, and 257 participants (15%) were nonwhite. For LAGB, the median age was 48 years (range, 18-78), the body mass index was 44 (range, 33-87), 465 participants (76%) were women, and 63 participants (10%) were nonwhite. Follow-up weights were obtained in 1300 of 1569 (83%) eligible for a year-7 visit. Seven years following RYGB, mean weight loss was 38.2 kg (95% CI, 36.9-39.5), or 28.4% (95% CI, 27.6-29.2) of baseline weight; between years 3 and 7 mean weight regain was 3.9% (95% CI, 3.4-4.4) of baseline weight. Seven years after LAGB, mean weight loss was 18.8 kg (95% CI, 16.3-21.3) or 14.9% (95% CI, 13.1-16.7), with 1.4% (95% CI, 0.4-2.4) regain. Six distinct weight change trajectory patterns for RYGB and 7 for LAGB were identified. Most participants followed trajectories in which weight regain from 3 to 7 years was small relative to year-3 weight loss, but patterns were variable. Compared with baseline, dyslipidemia prevalence was lower 7 years following both procedures; diabetes and hypertension prevalence were lower following RYGB only. Among those with diabetes at baseline (488 of 1723 with RYGB [28%]; 175 of 604 with LAGB [29%]), the proportion in remission at 1, 3, 5, and 7 years were 71.2% (95% CI, 67.0-75.4), 69.4% (95% CI, 65.0-73.8), 64.6% (95% CI, 60.0-69.2), and 60.2% (95% CI, 54.7-65.6), respectively, for RYGB and 30.7% (95% CI, 22.8-38.7), 29.3% (95% CI, 21.6-37.1), 29.2% (95% CI, 21.0-37.4), and 20.3% (95% CI, 9.7-30.9) for LAGB. The incidence of diabetes at all follow-up assessments was less than 1.5% for RYGB. Bariatric reoperations occurred in 14 RYGB and 160 LAGB participants., Conclusions and Relevance: Following bariatric surgery, different weight loss patterns were observed, but most participants maintained much of their weight loss with variable fluctuations over the long term. There was some decline in diabetes remission over time, but the incidence of new cases is low following RYGB., Trial Registration: clinicaltrials.gov Identifier: NCT00465829.

Background: The role of robotic assistance for gastric bypass remains controversial. Using a large nationwide cohort, we compared early outcomes after robotic Roux-en-Y gastric bypass (Robot-RYGB) with the laparoscopic technique (LRYGB)., Objective: This study aimed to use a bariatric-specific, large, nationwide cohort with several years of data to compare the early postoperative outcomes of the Robot-RYGB and LRYGB., Setting: Nationwide register-based cohort study., Methods: The Bariatric Outcomes Longitudinal Database from 2007 to 2012 was used to identify patients who underwent nonrevisional Robot-RYGB or LRYGB. Propensity matching was used to account for differences in age, body mass index, sex, American Society of Anesthesiologists classification, multiple preoperative co-morbidities, and procedural year. A second propensity score was calculated with adjustment of operative time in addition to the other adjusted variables., Results: We identified 137,455 patients who underwent Robot-RYGB (n = 2415) or LRYGB (n = 135,040) with a mean body mass index of 47.1 ± 8.4 kg/m 2 and age of 45.4 ± 11.7 years. In the propensity-matched cohorts, there were 30-day differences in operative time (150.2 ± 72.5 versus 111.8 ± 47.6, P<.001); 30-day rates of reoperation (4.8% versus 3.1%, P = .002); 90-day rates of reoperation (8.8% versus 5.3%, P<.001), complication (15.8% versus 12.5%, P = .001), readmission (8.5% versus 6.4%, P = .005), stricture (3.5% versus 2.0%, P = .001), ulceration (1.2% versus .6%, P = .034), nausea or emesis (6.4% versus 4.36%, P = .001), and anastomotic leak (1.6% versus .2%, P<.001) when comparing Robot-RYGB with LRYGB. After including operative time in propensity matching, there were no significant differences in rates of 30-day readmission or ulceration or 90-day readmission or ulceration; all other differences remained significant., Conclusions: Despite controlling for patient characteristics, patients undergoing Robot-RYGB developed higher rates of early morbidity compared with LRYGB, suggesting LRYGB may provide improved postoperative outcomes. Further studies are needed to definitively compare these 2 operative approaches., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Limited evidence suggests bariatric surgery may not reduce opioid analgesic use, despite improvements in pain., Objective: To determine if use of prescribed opioid analgesics changes in the short and long term after bariatric surgery and to identify factors associated with continued and postsurgery initiated use., Setting: Ten U.S. hospitals., Methods: The Longitudinal Assessment of Bariatric Surgery-2 is an observational cohort study. Assessments were conducted presurgery, 6 months postsurgery, and annually postsurgery for up to 7 years until January 2015. Opioid use was defined as self-reported daily, weekly, or "as needed" use of a prescribed medication classified as an opioid analgesic., Results: Of 2258 participants with baseline data, 2218 completed follow-up assessment(s) (78.7% were female, median body mass index: 46; 70.6% underwent Roux-en-Y gastric bypass). Prevalence of opioid use decreased after surgery from 14.7% (95% CI: 13.3-16.2) at baseline to 12.9% (95% CI: 11.5-14.4) at month 6 but then increased to 20.3%, above baseline levels, as time progressed (95% CI: 18.2-22.5) at year 7. Among participants without baseline opioid use (n = 1892), opioid use prevalence increased from 5.8% (95% CI: 4.7-6.9) at month 6 to 14.2% (95% CI: 12.2-16.3) at year 7. Public versus private health insurance, more pain presurgery, undergoing subsequent surgeries, worsening or less improvement in pain, and starting or continuing nonopioid analgesics postsurgery were significantly associated with higher risk of postsurgery initiated opioid use., Conclusion: After bariatric surgery, prevalence of prescribed opioid analgesic use initially decreased but then increased to surpass baseline prevalence, suggesting the need for alternative methods of pain management in this population., (Copyright © 2017 American Society for Bariatric Surgery. All rights reserved.)

Background: The disproportionate increase in the super obese (SO) is a hidden component of the current obesity pandemic. Data on the safety and efficacy of bariatric procedures in this specific patient population are limited. Our aim is to assess the comparative effectiveness of the two most common bariatric procedures in the SO., Methods: Using the Bariatric Outcomes Longitudinal Database from 2007 to 2012, we compared SO patients (BMI ≥ 50) undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Stepwise logistic regression modeling was used to calculate a propensity score to adjust for patient demographics and comorbidities., Results: We identified 50,987 SO patients who underwent RYGB (N = 42,119) or SG (N = 8868). There was no difference in adjusted overall 30-day complication rate comparing RYGB and SG patients (11.5 vs. 11.1 %, p = 0.250). RYGB patients had higher adjusted rates of 30-day mortality (0.3 vs. 0.2 %, p = 0.042), reoperation (4.0 vs. 2.4 %, p < 0.001), and readmission (6.9 vs. 5.5 %, p < 0.001) compared to SG patients. The percent of total weight loss (%TWL) was significantly higher for RYGB patients compared to SG at 3 months (14.1 vs. 13.1 %, p < 0.001), 6 months (25.2 vs. 22.4 %, p < 0.001), and 12 months (34.5 vs. 29.7 %, p < 0.001). RYGB patients had increased resolution of all measured comorbidities: diabetes mellitus (61.6 vs. 50.8 %, p < 0.001), hypertension (43.1 vs. 34.5 %, p < 0.001), gastroesophageal reflux disease (53.9 vs. 32.5 %, p < 0.001), hyperlipidemia (39.7 vs. 32.5 %, p < 0.001), and obstructive sleep apnea (42.8 vs. 40.6 %, p = 0.058) at 12 months compared to SG patients., Conclusions: There are significant differences in comorbidity improvement and resolution as well as weight loss between RYGB and SG in the SO population. There was no difference in overall 30-day complications, but more RYGB patients required readmission and reoperation. However, RYGB was considerably more effective in controlling obesity-related comorbidities. Our results favor performance of RYGB in SO patients of appropriate risk.

Background: Prior studies have shown a relationship between surgeon volume and patient outcomes in Roux-en-Y gastric bypass (RYGB) patients. Laparoscopic sleeve gastrectomy (SG) is now the most common bariatric procedure, but there is a little data on surgeon volume and outcomes after SG. We examined the relationship between annual surgeon bariatric volume and 30-day complication rate after SG., Methods: The Bariatric Outcomes Longitudinal Database for 2011 was used for this study. Using 50 annual cases as a cutoff point, surgeons were classified as low (LV-SG) or high volume SG (HV-SG) and low (LV-RYGB) or high volume RYGB (HV-RYGB) providers. Multivariable logistic regression models were used to examine the effect of surgeon volume on 30-day readmissions, reoperations, and complications following SG while controlling for patient demographics and comorbidities., Results: We identified 16,547 SG patients. After controlling for baseline characteristics, HV-SG surgeons had lower rates of 30-day complications (OR 0.80, 95 % CI 0.64-0.92), reoperation (OR 0.69, 95 % CI 0.52-0.90), and readmission (OR 0.73, 95 % CI 0.61-0.88) compared to LV-SG surgeons. HV-RYGB surgeons had lower 30-day complication rates (OR 0.80, 95 % CI 0.69-0.92), but were without differences in reoperation (OR 0.82, 95 % CI 0.61-1.10) or readmission (OR 1.06, 95 % CI 0.88-1.27) compared to LV-RYGB surgeons., Conclusions: High SG volume is associated with improved 30-day readmission, reoperation, and complication rates. Concurrent RYGB volume impacts the 30-day complication rate after SG, but does not affect the readmission or reoperation rate. Our findings suggest that SG-specific volume is important for optimal safety outcomes in SG patients.

Importance: The variability and durability of improvements in pain and physical function following Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) are not well described., Objectives: To report changes in pain and physical function in the first 3 years following bariatric surgery, and to identify factors associated with improvement., Design, Setting, and Participants: The Longitudinal Assessment of Bariatric Surgery-2 is an observational cohort study at 10 US hospitals. Adults with severe obesity undergoing bariatric surgery were recruited between February 2005 and February 2009. Research assessments were conducted prior to surgery and annually thereafter. Three-year follow-up through October 2012 is reported., Exposures: Bariatric surgery as clinical care., Main Outcomes and Measures: Primary outcomes were clinically meaningful presurgery to postsurgery improvements in pain and function using scores from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) (ie, improvement of ≥5 points on the norm-based score [range, 0-100]) and 400-meter walk time (ie, improvement of ≥24 seconds) using established thresholds. The secondary outcome was clinically meaningful improvement using the Western Ontario McMaster Osteoarthritis Index (ie, improvement of ≥9.7 pain points and ≥9.3 function points on the transformed score [range, 0-100])., Results: Of 2458 participants, 2221 completed baseline and follow-up assessments (1743 [78.5%] were women; median age was 47 years; median body mass index [BMI] was 45.9; 70.4% underwent RYGB; 25.0% underwent LAGB). At year 1, clinically meaningful improvements were shown in 57.6% (95% CI, 55.3%-59.9%) of participants for bodily pain, 76.5% (95% CI, 74.6%-78.5%) for physical function, and 59.5% (95% CI, 56.4%-62.7%) for walk time. Additionally, among participants with severe knee or disability (633), or hip pain or disability (500) at baseline, approximately three-fourths experienced joint-specific improvements in knee pain (77.1% [95% CI, 73.5%-80.7%]) and in hip function (79.2% [95% CI, 75.3%-83.1%]). Between year 1 and year 3, rates of improvement significantly decreased to 48.6% (95% CI, 46.0%-51.1%) for bodily pain and to 70.2% (95% CI, 67.8%-72.5%) for physical function, but improvement rates for walk time, knee and hip pain, and knee and hip function did not (P for all ≥.05). Younger age, male sex, higher income, lower BMI, and fewer depressive symptoms presurgery; no diabetes and no venous edema with ulcerations postsurgery (either no history or remission); and presurgery-to-postsurgery reductions in weight and depressive symptoms were associated with presurgery-to-postsurgery improvements in multiple outcomes at years 1, 2, and 3., Conclusions and Relevance: Among a cohort of participants with severe obesity undergoing bariatric surgery, a large percentage experienced improvement, compared with baseline, in pain, physical function, and walk time over 3 years, but the percentage with improvement in pain and physical function decreased between year 1 and year 3., Trial Registration: clinicaltrials.gov Identifier: NCT00465829.

While adherence to long-term follow-up after bariatric surgery is a mandate for center of excellence certification, the effect of attrition on weight loss is not well understood. The aim of this study was to assess the effect of postoperative follow-up on 12-month weight loss using the Bariatric Outcomes Longitudinal Database (BOLD) dataset. Patients with complete follow-up (3, 6, and 12 months) were compared to patients who had one or more prior missed visits. There were 51,081 patients with 12-month follow-up data available. After controlling for baseline characteristics, complete follow-up was independently associated with excess weight loss ≥50%, and total weight loss ≥30%. Adherence to postoperative follow-up is independently associated with improved 12-month weight loss after bariatric surgery. Bariatric programs should strive to achieve complete follow-up for all patients.

Background: Complications following bariatric surgery are uncommon but potentially life threatening., Objectives: The aim of this study was to assess the timing of gastrointestinal leaks (GIL) and pulmonary embolism (PE) in patients undergoing bariatric surgery., Setting: Retrospective analysis of the nationwide American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2011., Methods: Data on patient demographic characteristics, baseline co-morbidities, procedural events, and postoperative occurrences were analyzed. Thirty-day morbidity was assessed. Median (interquartile range) and frequencies are reported., Results: We identified 71,694 bariatric surgery patients; median age was 45 years (range 36-54 yr), and median body mass index was 44.8 kg/m(2) (range 40.8-50.3 kg/m(2)). Laparoscopic Roux-en-Y gastric bypass was performed in 39,480 patients, laparoscopic adjustable band in 21,104, laparoscopic sleeve gastrectomy in 3225, open Roux-en-Y gastric bypass in 4243, duodenal switch in 1064, revisional surgery in 1182, and other procedures in 1396 patients. Of these patients, 95.2% had no complications. GIL was found in 441 (.6%), deep vein thrombosis in 184 (.3%), and PE in 134 (.2%). These complications occurred 10 (5-15), 13 (7-20), and 11 (4-19) days after surgery, respectively. GIL and PE developed after discharge in 275 (62.4%) and 96 (71.6%), respectively. Only 35 (26.1%) of the patients who developed PE had deep vein thrombosis. There were no differences in patient characteristics between the groups of early PE versus postdischarge PE. Patients diagnosed with in-hospital GIL were more obese with more severe systemic disease compared with patients with postdischarge diagnosis., Conclusions: The majority of GILs and PEs after bariatric surgery occur after discharge. This finding goes against the routine use of contrast studies to rule out GIL. The risk of PE remains after discharge from bariatric surgery., (Copyright © 2016 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Laparoscopic procedures for the treatment of morbid obesity are commonly offered to patients with comorbidities previously thought to carry prohibitive operative risk. In this study, we reviewed characteristics and perioperative outcomes of patients with dialysis-dependent renal failure (DDRF) who underwent laparoscopic bariatric procedures., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2011 was reviewed. Preoperative characteristics and 30-day outcome data of patients who underwent three common laparoscopic procedures were analyzed using ANOVA and Pearson chi-squared tests., Results: One hundred thirty-eight patients (52.5 % female) with DDRF and a median body mass index (BMI) of 45.5 kg/m(2) were identified; 33.8 % (n = 47) underwent laparoscopic banding (LAGB), 48.9 % (n = 68) laparoscopic Roux-en-Y gastric bypass (RYGB), and 16.5 % (n = 23) laparoscopic sleeve gastrectomy (LSG). No differences were found among groups in age, prevalence of American Society of Anesthesiology IV classification, BMI, weight, gender, prevalence of diabetes, and vascular or neurologic comorbidities. Total operation time and length of hospital stay were significantly different between groups. Mortality was 0.7 %, and overall morbidity was 5.8 %. The case mix reflected a decrease in LAGB procedures from 45.5 to 23.3 % from 2006-2009 to 2010-2011 and an increase in LSG procedures from 9.1 to 24.7 % (p < 0.006)., Conclusions: When performed in selected DDRF patients, bariatric surgery is safe. An increase in LSG with a concurrent decline in LAGB procedures was demonstrated over the period of the study.

Background: Obesity predisposes patients to abdominal wall hernias. Patients undergoing bariatric surgery are not uncommonly found to have ventral hernias. Synchronous ventral hernia repair (S-VHR) has been reported in 2-5% of patients undergoing bariatric surgery. Studies reporting on the outcomes of S-VHR are limited by sample size. The aim of this study was to assess the effect of S-VHR on surgical site infection (SSI) rate., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2010 to 2011 was queried using Current Procedural Terminology codes for bariatric surgery. Data on patient demographics, comorbidities, procedural events, and postoperative occurrences were analyzed. Thirty-day mortality and morbidity were assessed. Comparisons between laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) were performed., Results: We identified 17,117 patients who underwent RYGB or SG. S-VHR was performed in 503 (2.94%) patients. S-VHR was independently associated with SSI (odds ratios (OR) 1.65, 95% confidence interval (CI) 1.06-2.58), but not overall morbidity (OR 1.33, 95% CI 0.96-1.86). Four hundred thirty-three patients with RYGB and 70 with SG had S-VHR. Serious morbidity (3.5 vs. 5.7%, p = 0.32) and overall morbidity (8.3 vs. 8.6%, p = 0.942) were similar. After controlling for baseline comorbidities, there was no significant effect of procedure type on SSI (OR 0.38, 95% CI 0.05-2.91)., Conclusions: S-VHR is associated with an increase in SSI but not overall morbidity. There is no significant difference in the SSI rate between RYGB and SG. Larger studies are needed to definitively assess a potential difference in the wound infection rate between RYGB and SG.

Background: Limited data guide the prediction of weight loss success or failure after bariatric surgery according to presurgery factors. There is significant variation in weight change after bariatric surgery and much interest in identifying preoperative factors that may contribute to these differences. This report evaluates the associations of a comprehensive set of baseline factors and 3-year weight change., Setting: Ten hospitals in 6 geographically diverse clinical centers in the United States., Methods: Adults undergoing a first bariatric surgical procedure as part of clinical care by participating surgeons were recruited between 2006 and 2009. Participants completed research assessments utilizing standardized and detailed data collection on over 100 preoperative and operative parameters for individuals undergoing Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB). Weight was measured 3 years after surgery. Percent weight change for RYGB or LAGB from baseline to 3 years was analyzed as both a continuous and dichotomous outcome with cut points at 25% for RYGB and 10% for LAGB. Multivariable linear and logistic regression models were used to identify independent baseline predictors of the continuous and categorical outcomes, respectively., Results: The median weight loss 3 years after surgery for RYGB (n = 1513) participants was 31.5% (IQR: 24.6%-38.4%; range, 59.2% loss to .9% gain) of baseline weight and 16.0% (IQR: 8.1%-23.1%; range, 56.1% loss to 12.5% gain) for LAGB (n = 509) participants. The median age was 46 years for RYGB and 48 years for LAGB; 80% of RYGB participants and 75% of LAGB participants were female; and the median baseline body mass index (BMI) was 46 kg/m(2) for RYGB and 44 kg/m(2) for LAGB. For RYGB, black participants lost 2.7% less weight compared with whites and participants with diabetes at baseline had 3.7% less weight loss at year 3 than those without diabetes at baseline. There were small but statistically significant differences in weight change for RYGB in those with abnormal kidney function and current or recent smoking. For LAGB participants, those with a large band circumference had 75% greater odds of experiencing less than 10% weight loss after adjusting for BMI and sex., Conclusions: Few baseline variables were associated with 3-year weight change and the effects were small. These results indicate that baseline variables have limited predictive value for an individual's chance of a successful weight loss outcome after bariatric surgery., Trial Registration: NCT00465829, ClinicalTrials.gov., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

The growth of bariatric surgery in the USA followed the adoption of gastric bypass (RYGB). The recent introduction of sleeve gastrectomy (SG) has been met with wide adoption. A single state report suggests that the popularity of SG has surpassed that of RYGB. Our study aimed to assess the nationwide changes in trend of bariatric procedures performed, using data from the National Surgical Quality Improvement Program from 2010 to 2013. In this cohort of 74,790 bariatric patients, there was a significant difference in trend between laparoscopic RYGB and SG. By 2013, SG was the most common bariatric procedure performed (49.4 %). This report underlines the exponential adoption of SG and aims to alert patients, physicians, and funding agencies of the need for longitudinal prospective long-term data.

Importance: Among women and men with severe obesity, evidence for improvement in urinary incontinence beyond the first year after bariatric surgery-induced weight loss is lacking., Objectives: To examine change in urinary incontinence before and after bariatric surgery and to identify factors associated with improvement and remission among women and men in the first 3 years after bariatric surgery., Design, Setting, and Participants: The Longitudinal Assessment of Bariatric Surgery 2 is an observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. Participants were recruited between February 21, 2005, and February 17, 2009. Adults undergoing first-time bariatric surgical procedures as part of clinical care by participating surgeons between March 14, 2006, and April 24, 2009, were followed up for 3 years (through October 24, 2012)., Intervention: Participants undergoing bariatric surgery completed research assessments before the procedure and annually thereafter., Main Outcomes and Measures: The frequency and type of urinary incontinence episodes in the past 3 months were assessed using a validated questionnaire. Prevalent urinary incontinence was defined as at least weekly urinary incontinence episodes, and remission was defined as change from prevalent urinary incontinence at baseline to less than weekly urinary incontinence episodes at follow-up., Results: Of 2458 participants, 1987 (80.8%) completed baseline and follow-up assessments. At baseline, the median age was 47 years (age range, 18-78 years), the median body mass index was 46 kg/m2 (range, 34-94 kg/m2), and 1565 of 1987 (78.8%) were women. Urinary incontinence was more prevalent among women (49.3%; 95% CI, 46.9%-51.9%) than men (21.8%; 95% CI, 18.2%-26.1%) (P < .001). After a mean 1-year weight loss of 29.5% (95% CI, 29.0%-30.1%) in women and 27.0% (95% CI, 25.9%-28.6%) in men, year 1 urinary incontinence prevalence was significantly lower among women (18.3%; 95% CI, 16.4%-20.4%) and men (9.8%; 95% CI, 7.2%-13.4%) (P < .001 for all). The 3-year prevalence was higher than the 1-year prevalence for both sexes (24.8%; 95% CI, 21.8%-26.5% among women and 12.2%; 95% CI, 9.0%-16.4% among men) but was substantially lower than baseline (P < .001 for all). Weight loss was independently related to urinary incontinence remission (relative risk, 1.08; 95% CI, 1.06-1.10 in women and 1.07; 95% CI, 1.02-1.13 in men) per 5% weight loss, as were younger age and the absence of a severe walking limitation., Conclusions and Relevance: Among women and men with severe obesity, bariatric surgery was associated with substantially reduced urinary incontinence over 3 years. Improvement in urinary incontinence may be an important benefit of bariatric surgery.

Changes in gastrointestinal peptide release may play an important role in improving glucose control and reducing body weight following Roux-en-Y gastric bypass (RYGB), but the impact of low caloric intake on gut peptide release post-surgery has not been well characterized. The purpose of this study was to assess the relationships between low caloric intake and gut peptide release and how they were altered by RYGB. Obese females including ten normoglycemic (ON) and ten with type 2 diabetes mellitus (T2DM) (OD) were studied before, 1 week, and 3 months after RYGB. Nine lean, normoglycemic women were studied for comparison. Subjects were given three separate mixed meal challenges (MMCs; 75, 150, and 300 kcal). Plasma glucagon-like peptide 1 (GLP-1) and peptide YY (PYY) were analyzed. Prior to surgery, only minimal increases in GLP-1 and PYY were observed in response to the MMCs. After surgery, the peak GLP-1 concentration was progressively elevated in response to increasing meal sizes. The meal sizes had a statistically significant impact on elevation of GLP-1 incremental areas under the curve (ΔAUC) in both ON and OD at 1 week and 3 months post-surgery visits (p < 0.05 for all comparisons). The PYY ∆AUC was also significantly increased in a meal size-dependent manner in both ON and OD at both post-surgery visits (p < 0.05 for all comparisons). Meal sizes as small as 75-300 kcal, which cause minimal stimulation in GLP-1 or PYY release in the subjects before RYGB, are sufficient to provide statistically significant, meal size-dependent increases in the peptides post-RYGB both acutely and after meaningful weight loss occurred.

Background: Even though the U.S. population is aging, outcomes of bariatric surgery in the elderly are not well defined. Current literature mostly evaluates the effects of gastric bypass (RYGB), with paucity of data on sleeve gastrectomy (SG). The objective of this study was to assess 30-day morbidity and mortality associated with laparoscopic SG in patients aged 65 years and over, in comparison to RYGB., Methods: The National Surgical Quality Improvement Program (NSQIP) database was queried for all patients aged 65 and over who underwent laparoscopic RYGB and SG between 2010 and 2011. Baseline characteristics and outcomes were compared. P value<.05 was considered significant. Odds ratios (OR) with 95% confidence interval (CI) were reported when applicable., Results: We identified 1005 patients. Mean body mass index was 44 ± 7. SG was performed in 155 patients (15.4%). The American Society of Anesthesiology physical classification of 3 or 4 was similar between the 2 groups (82.6% versus 86.7%, P = .173). Diabetes was more frequent in the RYGB group (43.2% versus 55.6%, P = .004). 30-day mortality (0.6% versus 0.6%, OR 1.1, 95% CI .11-9.49), serious morbidity (5.2% versus 5.6%, OR .91, 95% CI .42-0.96), and overall morbidity (9% versus 9.1%, OR 1.0, 95% CI .55-1.81) were similar., Conclusion: In elderly patients undergoing laparoscopic bariatric surgery, SG is not associated with significantly different 30-day outcomes compared to RYGB. Both procedures are followed by acceptably low morbidity and mortality., (Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Despite a strong correlation between obesity and insulin resistance, 25% of severely obese (BMI >40) individuals are insulin sensitive. In this review, we will examine the factors in adipose tissue that distinguish the two groups, as well as reasons for believing the insulin-sensitive group will be less disease prone., Recent Findings: Obesity has been linked to the metabolic syndrome with an increase in visceral (intra-abdominal) compared to subcutaneous fat. Recent studies in which adipose tissue of insulin-sensitive and insulin-resistant patients with severe obesity were compared indicate that the insulin-resistant group is also distinguished by increases in oxidative stress and decreases in AMP-activated protein kinase (AMPK) activity. In contrast, changes in the expression of genes for SIRT1, inflammatory cytokines, mitochondrial biogenesis and function, and the two α-isoforms of AMPK showed more depot variation. Studies of how these and other changes in adipose tissue respond to bariatric surgery are still in their infancy., Summary: Available data suggest that increases in oxidative stress, decreases in AMPK activity and SIRT1 gene expression, depot-specific changes in inflammatory, mitochondrial and other genes distinguish adipose tissue of insulin resistant from insulin-sensitive individuals with severe obesity.

Background: Anticoagulation, the use of sequential compression devices on the lower extremities perioperatively, and early ambulation are thought to reduce the incidence of venous thromboembolism (VTE) postoperatively and are recommended to reduce VTE risk. However, the evidence on which this recommendation has been based is not particularly strong. We have demonstrated that even a large, multicenter cohort with carefully collected prospective data is inadequate to provide sufficient evidence to support, or refute, this recommendation., Methods: Longitudinal Assessment of Bariatric Surgery participants from 10 centers in the United States who underwent their first bariatric surgery between March 2005 and December 2007 constituted the study group. We examined the ability to address the question of whether anticoagulation therapy, in addition to sequential compression, reduces the 30-day incidence of VTE or death sufficiently to recommend the use of prophylactic anticoagulation, a therapy that is not without risk., Results: Of 4416 patients, 396 (9.0%) received sequential compression alone, and 4020 also received anticoagulation therapy. The incidence of VTE within 30 days of surgery was low (.25% among those receiving sequential compression alone and .47% when anticoagulation therapy was added), and the 30-day incidence of death was also low (.25% versus .34%, respectively, P = .76, for sequential compression alone versus sequential compression plus anticoagulation therapy). Estimates of the number of cases required to address the question of whether a difference exists in the outcome related to VTE chemoprophylaxis or whether the outcome rates are equivalent have ranged from 13,680 to ≥ 35,760 patients, depending on whether superiority or equivalence was being analyzed., Conclusion: Sufficient evidence from a clinical trial study to determine whether prophylactic anticoagulation added to compression devices further prevents VTE is not available, and such a trial is likely to be impractical. The data presented are insufficient to make a final recommendation concerning prophylactic treatment to prevent VTE in the 30 days after bariatric surgery., (Copyright © 2012 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Severe obesity is increasing at a disproportionate rate compared with milder grade obesity. Our research group has obtained evidence indicative of an "obesity metabolic program" in skeletal muscles of severely obese individuals, which may be determined genetically or epigenetically. We believe that this represents a paradigm shift in thinking about metabolic regulation in obesity.

Background: Oral meal consumption increases glucagon-like peptide 1 (GLP-1) release which maintains euglycemia by increasing insulin secretion. This effect is exaggerated during short-term follow-up of Roux-en-y gastric bypass (RYGB). We examined the durability of this effect in patient with type 2 diabetes (T2DM) >10 years after RYGB., Methods: GLP-1 response to a mixed meal in the 10-year post-RYGB group (n = 5) was compared to lean (n = 9), obese (n = 6), and type 2 diabetic (n = 10) controls using a cross-sectional study design. Analysis of variance (ANOVA) was used to evaluate GLP-1 response to mixed meal consumption from 0 to 300 min, 0-20 min, 20-60 min, and 60-300 min, respectively. Weight, insulin resistance, and T2DM were also assessed., Results: GLP-1 response 0-300 min in the 10-year post-RYGB showed a statistically significant overall difference (p =  0.01) compared to controls. Furthermore, GLP-1 response 0-20 min in the 10-year post-RYGB group showed a very rapid statistically significant rise (p = 0.035) to a peak of 40 pM. GLP-1 response between 20 and 60 min showed a rapid statistically significant (p = 0.041) decline in GLP-1 response from ~40 pM to 10 pM. GLP-1 response in the 10-year post-RYGB group from 60 to 300 min showed no statistically significant difference from controls. BMI, HOMA, and fasting serum glucose before and >10 years after RYGB changed from 59.9 → 40.4, 8.7 → 0.88, and 155.2 → 87.6 mg/dl, respectively, and were statistically significant (p < 0.05)., Conclusions: An exaggerated GLP-1 response was noted 10 years after RYGB, strongly suggesting a durability of this effect. This phenomenon may play a key role in maintaining type 2 diabetes remission and weight loss after RYGB.

We examined the hypothesis that metabolic surgery-induced massive weight loss causes mass-driven and behavioral adaptations in the kinematics and kinetics of obese gait. Gait analyses were performed at three time points over ∼1 yr in initially morbidly obese (mass: 125.7 kg; body mass index: 43.2 kg/m(2)) but otherwise healthy adults. Ten obese adults lost 27.1% ± 5.1 (34.0 ± 9.4 kg) weight by the first follow-up at 7.0 mo (±0.7) and 6.5 ± 4.2% (8.2 ± 6.0 kg) more by the second follow-up at 12.8 mo (±0.9), with a total weight loss of 33.6 ± 8.1% (42.2 ± 14.1 kg; P = 0.001). Subjects walked at a self-selected and a standard 1.5 m/s speed at the three time points and were also compared with an age- and gender-matched comparison group at the second follow-up. Weight loss increased swing time, stride length, gait speed, hip range of motion, maximal knee flexion, and ankle plantarflexion. Weight loss of 27% led to 3.9% increase in gait speed. An additional 6.5% weight loss led to an additional 7.3% increase in gait speed. Sagittal plane normalized knee torque increased and absolute ankle and frontal plane knee torques decreased after weight loss. We conclude that large weight loss produced mechanical plasticity by modifying ankle and knee torques and gait behavior. There may be a weight loss threshold of 30 kg limiting changes in gait kinematics. Implications for exercise prescription are also discussed.

Since the discovery that gastric bypass surgery leads to the rapid reversal of type 2 diabetes mellitus in morbidly obese patients, researchers have been searching for possible mechanisms to explain the result. The significance of bariatric surgery is twofold. It offers hope and successful therapy to the severely obese; those with T2DM, sleep apnea, or polycystic ovary disease; and others plagued by the comorbidities of the metabolic syndrome. This article examines four surgical procedures and their outcomes., (Copyright © 2011. Published by Elsevier Inc.)