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The use of laparoscopic adjustable gastric banding (LAGB) is on the decline around the world despite the evidence base suggesting that it is a safe, effective and durable short-stay procedure which can be safely revised and is well tolerated by patients when they are appropriately supported. Currently, less than 1% of eligible obese persons are choosing to undergo bariatric surgery. If we are to improve uptake of bariatric surgery we need a raft of therapeutic options, including the LAGB, which sit between the relative impotence of medical therapies and the aggression of stapling procedures. This brief communication discusses what some of the drivers may be that are leading surgeons to abandon the band.

Objectives: Nonalcoholic fatty liver disease (NAFLD) affects over 80% of obese patients and is fueled by the metabolic syndrome. Weight loss is strongly advocated as a central treatment for NAFLD and has been shown to induce histological improvement. We aimed to define the patterns of improvement in NAFLD with weight loss and determine target weight goals for NAFLD resolution., Methods: A prospective study of 84 morbidly obese patients with NAFLD undergoing bariatric surgery was conducted. Intraoperative liver biopsies were taken. Monthly follow-up, including blood tests and measurements, was performed. We monitored improvements in NAFLD by monthly alanine aminotransferase (ALT) and gamma glutamyltransferase (GGT) levels over 1 year., Results: There was rapid improvement in ALT, particularly in the first 6 months following surgery, with statistically significant reduction in ALT at 2 months (35 vs 27 IU/L, p < 0.001). In multivariate analysis, there were significantly increased odds of ALT normalization after a %TBWL of 10-15% (odds ratio 2.49, p = 0.005). The odds of resolution increased with increasing weight loss. Triglyceride levels (odds ratio 0.59, p = 0.021) and baseline NAFLD activity score (odds ratio 0.28, p < 0.001) were also significantly related to ALT normalization. Improvements in ALT occurred prior to metabolic improvement and well before traditional ideal weight goals were reached., Conclusion: Improvements in NAFLD occurred rapidly after bariatric surgery and were closely related to weight loss and metabolic factors. A 10-15% reduction in body weight is an appropriate target to achieve substantial improvement in ALT levels., Trial Registration Number: Australian Clinical Trials Registry (ACTRN12610000049077).

Background: Patient-reported outcomes and perceptions are critical to the overall efficacy and acceptability of a surgical procedure. Outcomes, such as patient satisfaction and perceived success of the surgery and adverse symptoms, have not been described in detail following bariatric surgery. The associations and predictors of patient satisfaction have not been defined. This study aimed to examine long-term outcomes and perceptions after laparoscopic adjustable gastric banding (LAGB)., Methods: We conducted a prospective study of outcomes, satiety and adverse upper gastrointestinal symptoms, as well as quality of life and subjective patient satisfaction in LAGB patients. Data were collected at 3 years (T1) and 8 years post-operatively (T2)., Results: One-hundred and sixty patients completed follow-up at T1 and T2. The average age was 44.0 ± 11.2 years. At T2, the total body weight loss was 17.8 ± 11.9 %. Satisfaction decreased significantly between time points (8.6 ± 1.8 vs 7.2 ± 2.9, p < 0.01), and quality of life reduced slightly across all domains. Hunger scores remained low (3.8 ± 1.8 vs 3.9 ± 1.8, p = 0.61). The dysphagia score did not change significantly (p = 0.54). There was minimal change in frequency of regurgitation, although there was significant increase in patient assessment of how bothered they were by regurgitation. Multivariate analysis identified increased awareness of regurgitation as a principal driver of reduced satisfaction., Conclusions: Weight loss, satiety and adverse symptoms demonstrated only slight changes between 3 and 8 years post-operatively. Despite this, overall satisfaction and perception of success of the procedure reduced markedly. This appeared mediated by reduced tolerance of adverse symptoms. These data inform follow-up practises aimed at optimizing outcomes.

Background: Obesity and its related comorbidities are significant risk factors for nonalcoholic fatty liver disease (NAFLD). Liver fibrosis is the major determinant of long-term outcomes in NAFLD. A non-invasive tool that accurately identifies obese patients at elevated risk of liver fibrosis would be of significant value. Fibrosis risk scores in patients with NAFLD have been proposed but have not been validated in obese populations. We aimed to validate established simple fibrosis scores in bariatric surgical patients., Methods: We conducted a prospective study of 107 consecutive high-risk obese patients undergoing primary bariatric surgery. Proposed fibrosis scores (NAFLD fibrosis score; body mass index (BMI), aspartate aminotransferase (AST)/alanine aminotransferase ratio (ALT), and diabetes (BARD); Fibrosis-4 (FIB-4); Forn; and AST to platelet ratio index) were calculated and compared hepatic fibrosis determined by histology of intraoperative liver biopsies. Accuracy was determined, and fibrosis score thresholds were optimized. These modified thresholds were then validated in an independent bariatric surgical population., Results: Liver biopsies were available in 101 patients. Sixty-eight patients had some degree of fibrosis, with 23 patients (23 %) having significant fibrosis (F2-4). The Forn score best predicted significant fibrosis (area under the receiver operator characteristic curve (AUROC) 0.724, p = 0.001). With standard thresholds, the sensitivity for the Forn score for identification of significant fibrosis (F2-4) was 0 %. Using modified thresholds of 3.5, the sensitivity and negative predictive value increased to 85.7 and 94.7 %. This threshold was applied to an independent validation cohort with good accuracy., Conclusions: Fibrosis risk scores using simple markers have moderate success at delineating obese patients with significant NAFLD-related fibrosis. Thresholds, however, need to be lowered to maximize diagnostic accuracy in this cohort.

Objective: The objective of the study is to identify the efficacy and safety of combining laparoscopic adjustable gastric banding with repair of large para-oesophageal hernias., Background: Para-oesophageal hernias are more common in the obese with higher recurrence rates following repair. The effect and safety of combining para-oesophageal hernia repair with laparoscopic adjustable gastric banding is unknown., Methods: One-hundred fourteen consecutive patients undergoing primary laparoscopic adjustable gastric banding with concurrent repair of a large para-oesophageal hernia were prospectively identified and matched to a control group undergoing primary laparoscopic adjustable gastric banding only. Weight loss and complication data were retrieved from a prospectively maintained database, and a standardised bariatric outcome questionnaire was used to assess post-operative symptoms, satisfaction with surgery and satiety scores., Results: At a mean follow up of 4.9 ± 2.1 years, total weight loss was 16.4 ± 9.9% in the hernia repair group and 17.6 ± 12.6% in the control group (p = 0.949), with 17 vs. 11% loss to follow up rates (p = 0.246). No statistically significant difference in revisional surgery rate and symptomatic recurrence of hiatal hernia was documented in four patients in the hernia repair group (3.5%). No statistically significant difference in mean reflux (9.9 vs. 10.3, p = 0.821), dysphagia (20.7 vs. 20.1, p = 0.630) or satiety scores was identified., Conclusions: Concurrent repair of large para-oesophageal hiatal hernia and laparoscopic adjustable gastric banding placement is safe and effective both in terms of symptom control and weight loss over the intermediate term. In obese patients with large hiatal hernias, consideration should be given to combining repair of the hernia with a bariatric procedure.

Background: Regular aftercare attendance following laparoscopic adjustable gastric banding (LAGB) is associated with greater weight loss and fewer post-surgical complications. Despite high reported rates of attrition from LAGB aftercare, the reasons for non-attendance have not been thoroughly explored. The aim of the current study was to describe the scale development, explore the factor structure and evaluate the psychometric properties of the Gastric Banding Aftercare Attendance Questionnaire (GBAAQ)-a tool that measures barriers to aftercare attendance in LAGB patients., Methods: One hundred and eighty-three participants completed the GBAAQ; 107 regular attendees and 76 non-attendees., Results: A factor analysis identified four factors (Treatment Approach, Time Constraints, Stress and Pressures, Uncomfortable Participating) that demonstrated good known-groups validity and internal consistency., Conclusions: Although further validation is needed, the results of the present study provide preliminary support for the validity of the GBAAQ. Knowledge about the barriers to LAGB aftercare attendance can be used to identify those most at risk of non-attendance and can inform strategies aimed at reducing non-attendance.

Background/objectives: Diabetes and obesity are common and serious health challenges for indigenous people worldwide. The feasibility of achieving substantial weight loss, leading to remission of diabetes, was evaluated in a regional indigenous Australian community., Subjects/methods: A prospective cohort study of 30 obese indigenous adults from the Rumbalara Aboriginal Co-operative in Central Victoria was performed. Inclusion criteria included aboriginality, BMI > 30 kg/m(2) and diabetes diagnosed within the last 10 years. Weight loss was achieved using laparoscopic adjustable gastric banding (LAGB). Participants were treated in their community and followed for 2 years. Outcomes were compared with those of non-indigenous Australians from an earlier randomized controlled trial (RCT) using a similar protocol., Results: 30 participants (26 females, mean age 44.6 years; mean BMI 44.3) had LAGB at the regional hospital. Twenty-six participants completed diabetes assessment at 2 years follow-up. They showed diabetes remission (fasting blood glucose < 7.0 mmol/L and haemoglobin A1c (HbA1c) < 6.2 % while off all therapy except metformin) in 20 of the 26 and a mean weight loss (SD) of 26.0 (14) kilograms. Based on intention-to-treat, remission rate was 66 %. Quality of life improved. There was one early event and 12 late adverse events. The outcomes for weight loss and diabetes remission were not different from the LAGB group of the RCT., Conclusions: For obese indigenous people with diabetes, a regionalized model of care centred on the LAGB is an effective approach to a serious health problem. The model proved feasible and acceptable to the indigenous people., Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN 12609000319279).

Background: We aimed to determine the effects of laparoscopic adjustable gastric band (LAGB) on beta-cell function in overweight people with type 2 diabetes and to assess the relationship between baseline beta-cell function and glycemic outcomes., Methods: We studied 44 overweight but not obese people with type 2 diabetes who participated in a randomized trial whose primary outcome was the rate of diabetes remission after 2 years of multidisciplinary diabetes care (MDC group) or multidisciplinary care combined with LAGB. Dynamic beta-cell function was assessed by intravenous glucose challenge, and basal beta-cell function (HOMA-B) and insulin sensitivity (HOMA-S) were determined using the homeostatic model., Results: Twelve LAGB participants and two MDC participants were in diabetes remission at 2 years. HOMA-S and the C-peptide response to intravenous glucose increased significantly in LAGB but not in MDC participants. The insulin response to glucose did not change in LAGB participants, whereas their fasting C-peptide/insulin ratio increased. Baseline measures of beta-cell function correlated with diabetes remission but not with reduction in HbA1c following LAGB., Conclusions: In overweight people with diabetes, LAGB improves endogenous beta-cell function after 2 years. Baseline beta-cell function correlated with diabetes remission, but not with HbA1c change following LAGB.

Background: The safety and efficacy of laparoscopic adjustable gastric banding (LAGB) in the context of cirrhosis have not been established. We hypothesized that LAGB in cirrhotic patients is a safe procedure that may offer positive long-term benefits, both in terms of obesity and avoiding progression of liver disease., Methods: Data were gathered from a prospectively maintained database of 8402 patients who had undergone LAGB from November 1993 and April 2014., Results: Fourteen patients with biopsy-proven cirrhosis were identified in the database. In all cases, cirrhosis was an unexpected macroscopic finding at the time of surgery, confirmed with intraoperative biopsy. All patients were either Child-Pugh A or B. No patients had preoperative clinical evidence of decompensated liver disease. The mean initial weight was 116.6 kg and BMI 38.9. There was no operative mortality. Two patients experienced a surgical complication (Clavien-Dindo grade II and grade IIIa). At 12 months, the mean excess weight loss was 61.3% giving a mean BMI 31.7. Repeat biopsies were available in three patients. All demonstrated improvement in inflammation and two had fibrosis regression. Baseline liver biochemistry was compared in nine patients who had repeat biochemistry studies after 12 months. There was a significant improvement in alanine transaminase (ALT) (p = 0.04) and aspartate transaminase (AST) (p = 0.02). Two patients developed hepatocellular carcinoma (HCC). One has died as a result of this disease 11 years after LAGB surgery., Conclusion: LAGB may be a safe and effective bariatric intervention in patients with compensated cirrhosis. Our findings support the need for a prospective study with paired liver biopsies.

Background: Regular aftercare attendance following laparoscopic adjustable gastric banding (LAGB) is associated with greater weight loss and fewer post-surgical complications. Despite high reported rates of attrition from LAGB aftercare, the reasons for non-attendance have not been previously explored. The present study aimed to explore patient-reported barriers to LAGB aftercare attendance, and the perceived helpfulness of potential attrition-reducing strategies, in both regular attendees and non-attendees of aftercare., Methods: One hundred and seventy-nine participants (107 regular attendees and 72 non-attendees) completed a semi-structured questionnaire, assessing barriers to attrition (101 items) and usefulness of attrition prevention strategies (14 items)., Results: Findings indicate that both regular attendees and non-attendees experience multiple barriers to aftercare attendance. Non-attendees generally reported that barriers had a greater impact on their aftercare attendance. There was evidence for some level of acceptability for attrition-reducing strategies suggesting that LAGB patients may be receptive to such strategies., Conclusions: Current findings highlight the importance of assessing barriers to treatment in both attendees and non-attendees. It is proposed that addressing barriers that differentiate non-attendees from attendees may be most effective in reducing attrition from aftercare.

Background: Proximal luminal dilatation (PLD) is one of the most significant challenges following laparoscopic adjustable gastric banding (LAGB). If PLD is identified at an early stage, there is potential to avoid reoperation or irreversible change by implementing nonsurgical measures. The success of these strategies is unknown. The aim of this study was to determine the outcome of how often PLD can be successfully treated nonsurgically., Methods: The records of patients who underwent primary LAGB insertion by a single surgeon from January 2005 to December 2006 were reviewed. Study participants were all patients who had subsequently undergone a postoperative liquid contrast swallow demonstrating a PLD. The severity of PLD, subsequent management, and outcomes were recorded and assessed., Results: There were 354 patients who underwent a primary LAGB insertion during the study period. Seventy-eight patients were found to have varying degrees of PLD and had an attempt at nonsurgical management. Thirty-four of these patients (43.6 %) were successfully managed nonsurgically at a mean follow-up of 2.8 years (33.2 months, CL ± 3.2). The success with nonsurgical management was lower if the symmetrical pouch dilatation was more severe or gastric prolapse was seen at presentation, and if no improvement in liquid contrast swallow was seen., Conclusions: PLD can often be successfully managed with nonsurgical measures, maintaining good weight loss in the intermediate term. Patients with more significant dilatation are more likely to require revisional surgery. Early recognition may have a role in preventing surgery or more severe abnormalities.

Aims/hypothesis: Obesity and dysglycaemia are major risk factors for type 2 diabetes. We determined if obese people undergoing laparoscopic adjustable gastric banding (LAGB) had a reduced risk of progressing from impaired fasting glucose (IFG) to diabetes., Methods: This was a retrospective cohort study of obese people with IFG who underwent LAGB. Weight and diabetes outcomes after a minimum follow-up period of 4 years (mean ± SD 6.1 ± 1.7 years) were compared with those of Australian adults with IFG from a population-based study (AusDiab)., Results: We identified 281 LAGB patients with baseline IFG. Their mean ± SD age and BMI were 46 ± 9 years and 46 ± 9 kg/m(2), respectively. The diabetes incidence for patients in the lowest, middle and highest weight loss tertile were 19.1, 3.4 and 1.8 cases/1,000 person-years, respectively. The AusDiab cohort had a lower BMI (28 ± 5 kg/m(2)) and a diabetes incidence of 12.5 cases/1,000 person-years. This increased to 20.5 cases/1,000 person-years when analysis was restricted to the 322 obese AusDiab participants, which was higher than the overall rate of 8.2 cases/1,000 person-years seen in the LAGB group (p = 0.02). Multivariable analysis of the combined LAGB and AusDiab data suggested that LAGB was associated with ∼75% lower risk of diabetes (OR 0.24 [95% CI 0.10, 0.57], p = 0.004)., Conclusions/interpretation: In obese people with IFG, weight loss after LAGB is associated with a substantially reduced risk of progressing to diabetes over ≥4 years. Bariatric surgery may be an effective diabetes prevention strategy in this population.

Background: This study aimed to test the hypothesis that the amount of weight lost on a mandatory 2-week pre-operative very-low-calorie diet (VLCD) would predict the longer-term outcomes of laparoscopic adjustable gastric banding (LAGB)., Methods: All patients treated with a primary LAGB from 21 October 2008 until 30 June 2010, who were prescribed a 2-week pre-operative VLCD, have been included in the study. Patient age, weight, BMI and excess weight (defined as weight above a BMI of 25) were extracted on the day of first visit, day of surgery and at the post-operative visits at 3, 12 and 24 months. From these data, percent excess weight loss (EWL) was calculated and compared at all time points., Results: The weight loss achieved on a mandatory 2-week pre-operative diet did not predict weight outcomes at 2 years (r = -0.008; p = 0.931). Using multivariate analysis, the best predictor of 24-month percent EWL was percent EWL at 3 months post operation (sr(2) = 0.34; p = 0.003)., Conclusions: Results from a pre-operative diet should not be used to predict the ultimate outcome of bariatric surgery. The weight loss at 3 months following LAGB was a strong predictor of longer-term outcomes. There may be potential for improving longer-term results with LAGB by better supporting patients who are not achieving good weight loss at this early time point.

Background: Proven short-term effectiveness of obesity therapy should be re-evaluated in the long-term. The objective of this paper is to determine the long-term (10 years) outcome for patients from a randomised controlled trial (RCT)., Methods: A RCT in 2002 compared laparoscopic adjustable gastric band (LAGB) for obesity with non-surgical therapy. Follow-up has been conducted at 10 years. Eighty patients (BMI 30-35) were randomised to a non-surgical or a surgical program. Outcome data are available on 37 (92.5 %) of the surgical patients and 27 (62.5 %) of the non-surgical patients at 10 years., Results: Weight change, the metabolic syndrome, quality of life, adverse events and direct costs of the surgical cohort were the main results of the study. A durable weight loss is present in the surgical group with a mean (SD) 10-year weight loss of 14.1 (7.7) kg (63.4 % EWL), better than the non-surgical group (mean (SD) = 0.4 (10.5) kg; p < 0.001). The metabolic syndrome was reduced from 14 to 4 of the 37 patients who completed 10 years within the LAGB groups. Proximal gastric enlargements occurred in 17 (30 %) of the 57 who had LAGB and removal of the band occurred in 7 (12 %). The annual maintenance costs including additional surgery was AUD $765 per patient per year., Conclusions: Bariatric surgery with the LAGB can achieve long-term weight reduction which is better than a program of non-surgical therapy. There is also a sustained reduction of the metabolic syndrome. There is a significant maintenance requirement after LAGB.

Background: The Beck Depression Inventory (BDI) is one of the most commonly used instruments to assess depression in persons with obesity. While it has been validated in normal and psychiatric populations, in obese populations, its validity remains uncertain. This study aimed to investigate the validity and reliability of the BDI-IA and BDI-II in severely obese bariatric surgery candidates., Methods: Consecutive new candidates at a bariatric surgery clinic were invited to participate in the study by their consulting surgeon. All candidates were assessed using the Structured Clinical Interview for DSM-IV Disorders (SCID-I); 118 completed the BDI-IA and 83 completed the BDI-II. Two hundred one patients (response rate, 88 %) participated in the study. The current sample (82 % female) had an average body mass index of 42.83 ± 6.34 and an average age of 45 ± 12 years., Results: Based on the SCID-I, 54 candidates (26.9 %) met the criteria for a mood disorder, with 37 meeting the criteria for current major depressive disorder. Individuals diagnosed with a clinical mood disorder had significantly higher scores on the BDI (BDI-IA, 23.59 ± 9.69 vs. 12.76 ± 8.29; BDI-II, 22.93 ± 5.22 vs. 11.25 ± 8.44). Our results indicated that, as a screening tool for a clinical mood disorder, the BDI-II had an optimal cutoff of 13, with a sensitivity of 100 and specificity of 67.75., Conclusions: Results indicated that the BDI-IA should not be used as a tool to measure depressive symptomatology in obese bariatric surgery candidates. No cutoff was identified with adequate sensitivity and specificity, and over 20 % of patients were misclassified. As a screening tool for a clinical mood disorder, the BDI-II was adequate; however, prevalence rates were significantly overestimated.

Bariatric surgery leads to significant weight loss in the obese patient. Exercise has been shown to improve weight loss and body composition in non-surgical weight loss programmes. The role of exercise to improve weight loss following bariatric surgery is unclear. The objective of this review is to systematically appraise the evidence regarding exercise for weight loss in the treatment of obesity in bariatric surgery patients. MEDLINE, AMED, CINAHL, EBM Reviews (Cochrane Database, Cochrane Clinical Trials Register) were searched, obesity-related journals were hand-searched and reference lists checked. Studies containing post-surgical patients and exercise were included with the primary outcome of interest being weight loss. A literature search identified 17 publications exploring exercise in bariatric surgery patients. All studies were observational; there were no intervention studies found. The most commonly used instruments to measure activity level were questionnaires followed by telephone interview, surgeon reporting and clinical notes. There was a positive relationship between increased exercise and weight loss after surgery in 15 studies. Meta-analysis demonstrated in patients participating in exercise a standardised mean of 3.62 kg (CI = 1.28, 5.96) greater weight loss compared to the minimal exercise groups. Observational studies suggest that exercise is associated with greater weight loss following bariatric surgery. Randomised controlled trials are required to further examine this relationship.

Background: Over 80% of laparoscopic adjustable gastric banding (LAGB) patients are women, and approximately half of these are of reproductive age; therefore, pregnancy post-LAGB is common. It is not known if pregnancy increases the need for revisional procedures. We compare the incidence of revisions in two matched cohorts of LAGB patients, with or without subsequent pregnancy., Methods: From September 1994 to May 2009, 5,467 patients underwent LAGB at the Centre for Bariatric Surgery, Australia. Women with births post-LAGB were matched to controls, with a "matched follow-up date" calculated equivalent to pregnancy. Rates of primary and overall revisions for band-related (erosions and proximal pouch dilatations) and port/tubing complications were compared for cases and controls at 2 and 3 years post-pregnancy., Results: One hundred eighty-nine women had ≥1 pregnancies post-LAGB, including 137 with follow-up at 2 years and 104 at 3 years post-pregnancy. There was no significant difference in band or port/tubing revisions between groups at either time point: 16.8% vs 10.5% (p = 0.13) and 23.9% vs 14.6% (p = 0.09) for primary band revisions, and 5.8% vs 5.3% (p = 0.84) and 10.5% vs 6.6% (p = 0.35) for primary port/tubing revisions at 2 and 3 years, respectively. Percentage excess weight loss (%EWL) 3 years post-pregnancy was similar (47.9% vs 47.7%). Pregnancy LAGB management was not found to affect revisions; however, less time between LAGB and pregnancy was associated with a higher rate of primary band revisions (p = 0.03)., Conclusion: These data suggest that pregnancy post-LAGB does not affect revision rate or %EWL; however, a shorter time between LAGB operation and pregnancy may predispose to band revisions.

Erosion of the laparoscopic adjustable gastric band (LAGB) into the lumen of the stomach is a recognised complication of this procedure. We undertook a systematic literature review of the incidence, clinical features and management of erosions occurring after LAGB. A systematic search of relevant medical databases for full-text original articles looking for LAGB patients and reported erosions was conducted. We focussed on incidence, aetiology, clinical presentation, treatment, complications and weight loss. Twenty-five studies of LAGB reported 231 erosions in 15,775 patients (overall incidence of 1.46%). The mean number of patients per study was 631 (±486), and the mean follow-up was 3.73 (±2.4) years. In four reports involving less than 100 patients, there were 27 erosions in a total of 270 patients (10%) compared with 180 erosions in 12,978 patients (1.386%) in the remaining 21 reports. Multiple regression analysis showed that erosion rate was significantly predicted by number of patients and number of years of surgeon experience (r(2) = 0.186). Treatment was most commonly by removal of the band, repair of the stomach and later, band replacement. Other options were removal alone or conversion to another procedure. Weight loss was retained after treatment of the erosion with a mean weight loss at final follow-up of 50.34 ± 3.9 percent excess weight loss. Incidence of erosion after gastric banding is relatively low and can be related to surgeon experience. The most common treatment described in the literature is removal of the eroded band with delayed replacement. Replacement of the band is associated with maintenance of weight loss.

Background: The laparoscopic adjustable gastric band is a useful tool in the treatment of severe obesity. It is a safe and durably effective procedure, however, optimal results depend upon the patient participating in a process of lifelong care., Objective: This article discusses the procedure, follow up, and late complications for laparoscopic adjustable gastric banding. It also provides the general practitioner with 'alert' symptoms and signs of when to contact the treating surgeon., Discussion: Lifelong care involves counselling about food choices and eating patterns, as well as adjustment of the device. The delivery of this care usually involves a multidisciplinary team. Patients should not be offered surgery unless a process for continuing care is in place. Late complications of laparoscopic adjustable gastric banding are relatively common; however, they can be readily treated in most cases, with weight loss continuing. Symptoms of volume reflux, nocturnal aspiration, dysphagia, regular regurgitation and vomiting may alert the primary care GP to complications. Abdominal pain along with any of these symptoms may suggest an acute complication, but other causes of abdominal pain should also be considered, depending on the clinical scenario.

Background: Laparoscopic adjustable gastric bands (LAGB) are a safe and effective treatment for obesity. Conflicting data exist concerning their effect on the esophagus, gastroesophageal junction, and mechanism of action. These patients will increasingly require accurate assessment of their esophageal function., Methods: Twenty LAGB patients underwent high-resolution video manometry with the LAGB empty, 20% under, 20% over, and at their optimal volume. Twenty obese controls were also studied. Effects on esophageal motility, the lower esophageal sphincter (LES), and the gastroesophageal junction were measured. Transit during liquid and semisolid swallows was assessed., Results: The intraluminal pressure at the level of LAGB was a mean of 26.9 (19.8) mm Hg. This pressure varied depending on the volume within the LAGB and was separate to and distal to the lower esophageal sphincter LES. The LES was attenuated compared to controls (10 vs 18 mm Hg; p < 0.01) although relaxed normally. Esophageal motility was well preserved at optimal volume compared to 20% overfilled, with 77% normal swallows vs 51%, p = 0.008. Repetitive esophageal contractions were observed in 40% of swallows at optimal volume compared to 16% in controls, p = 0.024. In comparison to controls, the transit of liquid, 21 vs 8 s (p < 0.001), and semisolids, 50 vs 16 s (p < 0.001), was delayed., Conclusions: In LAGB patients, the LES is attenuated, although relaxes normally. Esophageal motility is preserved, although disrupted by overfilling the band. In the optimally adjusted LAGB, a delay in transit of liquids and semisolids through the esophagus and band is produced, along with an increase in repeated esophageal contractions.

Background: Laparoscopic adjustable gastric banding (LAGB) has commonly been complicated by the problem of band slippage or prolapse. Since popularization of the pars flaccida approach and improved anterior fixation, it is our impression that the problem of symmetrical dilatation of the proximal gastric pouch has become more important., Methods: We have reviewed the results of a series of 425 LAGB all performed by the pars flaccida approach from June 2003 to October 2007 to analyze the incidence and implications of this new pattern., Results: There were no posterior prolapses, 2 anterior prolapses, and 17 cases of symmetrical pouch dilatation (SPD) (revision rate 4.4%). Teenage patients had a 22% revision rate for SPD. All revisions were completed laparoscopically with no mortality, no significant complications, and a median hospital stay of 1 day. The median weight loss following revisional surgery was not significantly different from the background cohort., Conclusion: SPD is the most common reason for revision of LAGB in this series. We postulate that SPD is caused by excessive pressure in the proximal gastric pouch. This may be generated either by eating too quickly or too large a volume or excessive tightening of the band. The radial forces in the pouch may ultimately cause pressure on the phrenoesophageal ligament and a secondary hiatal hernia.

Background: Bariatric surgery facilitates substantial and durable weight loss; however, outcomes vary. In addition to physiological and technical factors, weight loss efficacy is dependent on modification of behavior to maintain a long-term change in energy balance. This study aimed to assess the extent and nature of change in energy intake and physical activity and identify factors associated with percentage weight loss (%WL) 12 months after laparoscopic adjustable gastric banding (LAGB)., Methods: 129 bariatric surgery candidates (26 men/103 women, mean age 45.2 +/- 11.5, mean body mass index [BMI] 44.3 +/- 6.8, range 31.9 to 66.7) completed the study. Data were collected at baseline and 12 months. Validated questionnaires included the Cancer Council Victoria Food Frequency Questionnaire, Three Factor Eating Questionnaire, Short Form-36, Baecke Physical Activity Questionnaire, and Beck Depression Inventory. Symptoms of "non-hungry eating," "emotional eating," and "grazing" were assessed., Results: Mean %WL was 20.8 +/- 8.5%, and excess weight loss was 50.0 +/- 20.7 (p < 0.001). Mean total energy intake reduced from 9,991 +/- 3,986 kj to 4,077 +/- 1,493 kj (p < 0.001). Average leisure time and sport-related physical activity scores increased (both p < 0.001). Regression analysis identified baseline BMI (beta = 0.241; p = 0.002), subjective hunger (beta = -0.275; p = 0.001), physical function (beta = 0.309; p < 0.001), and leisure time physical activity (beta = 0.213; p = 0.010) as independent predictors of %WL, total R (2) 0.34%. "Non-hungry eating" and symptoms of depression were also related to poorer %WL., Conclusion: LAGB affects marked behavior change and facilitates substantial weight loss in the first 12 months. However, variations in adopted behaviors can affect energy balance and weight loss success. Achievement and maintenance of favorable behaviors should be an important consideration during on-going postsurgical review and counseling. Management should include adequate band adjustment to control physical hunger, optimization of physical function and activity, and reinforcement of strategies to reduce energy intake.

Background: There is great need for simple anthropometric measures that predict risk. The authors explored the relationship between body composition measures and features of the metabolic syndrome (MtS) in women aged between 20 and 50 years with class I obesity., Methods: This is a cross-sectional study of 49 obese (BMI 30-35) women recruited into a weight management randomized trial. An analysis was conducted of the baseline weight, anthropometric measures, skin-fold thickness, bioelectrical impedance, whole body dual-energy x-ray absorptiometry (DEXA), and their relationships with the features of the MtS., Results: All women but one (n=48) had a population risk waist circumference of >88 cm. 16 of the 49 (33%) fulfilled the criteria of the metabolic syndrome. Simple anthropometric measures provided the strongest correlations with the presence of the MtS. Cut-off values were selected using receiver operator characteristics. Waist circumference of >100 cm and hip circumference <115cm was associated with odds ratios of 5.2 (95% CI, 1.4-20) and 12.3 (95% CI, 3.0-51) respectively for the MtS. Regional DEXA analysis showed that lower leg fat mass rather than fat-free mass was associated with the MtS. The dyslipidemia of the MtS was associated with a lower leg fat mass, while higher HbAlc levels and HOMA, an indirect measure of insulin resistance, were seen with increased trunk fat. Percentage fat as measured by skin-fold thickness and bioelectrical impedance were not related to any features. Women with the metabolic syndrome were found to have lower bone mineral content as measured by DEXA., Conclusion: Weight distribution is highly predictive of metabolic risk. Smaller hip and larger waist circumference provided independent effect. BMI adjusted anthropometric measures may be of value.

Background: The primary aim of weight loss intervention in obesity is the loss of fat mass (FM). Hence, determinations of changes in FM and fat free mass (FFM) during weight loss are of clinical value. The authors compared the clinical utility of SkinFold Thickness (SKF), tetrapolar bioelectrical impedance analysis (BIA) and a body mass index (BMI) based calculation, in determining changes in percentage of fat mass (delta%FM)., Methods: Using dual X-ray absorptiometry (DEXA) measurements of %FM as a standard, BIA, SKF and BMI were compared in 41 moderately obese women (BMI 30-35) before and after significant weight loss (-13.9 +/- 5.8 kg)., Results: When measuring fat mass loss, SKF was precise and accurate with a bias of +0.86 +/- 6.16 %, while the BMI-based estimation had a systematic bias of +6.36 +/- 6.04 % (r2 = 0.791, P < 0.001). BIA using the Lukaski formula had a bias of +5.22 % and limits of agreement that approached the magnitude of the measurement (+/- 20.82 %), thus providing no information. In contrast, BIA using the Segal formula had a systematic bias of +7.81% (r2 = 0.636, P < 0.001) and gave narrower limits of agreement (+/- 8.34 %)., Conclusion: For measuring changes in %FM with weight loss, BIA has no clinical value using the Lukaski formula, and using the Segal formula BIA provided no additional information to that given by BMI. We show that BIA instrument variables confound the estimates of %FM achieved by the BMI component of the Lukaski and Segal formulas.

Background: The ability for aminotransferase levels to track histological features of non-alcoholic fatty liver disease (NAFLD) with weight loss has not been examined., Methods: We examined the effect of weight loss following laparoscopic adjustable gastric banding surgery on the histological features of NAFLD and plasma aminotransferase concentrations (AST, ALT and GGT) in 60 (12M, 48F) selected severely obese patients. All 120 paired biopsies were de-identified and scored for lobular steatosis, fibrosis, inflammation, Mallory bodies and NASH., Results: 30 patients (50%) had baseline histological features of non-alcoholic steatohepatitis (NASH). Repeat biopsies were taken at 29.5+/-10 months after baseline. Mean weight loss was 31.5+/-18 kg. There were improvements in AST, ALT, GGT, lobular steatosis, inflammation and fibrosis between baseline and follow-up (P<0.001 for all). Only 6 (10%) of repeat biopsies showed NASH. No change in aminotransferase concentrations predicted the change in steatosis, but changes in AST and GGT predicted improved scores for inflammation, fibrosis, Mallory bodies and NASH. The lowering of GGT best predicted the improvements in inflammation, fibrosis and NASH., Conclusion: With weight loss, falls in GGT and, to a lesser extent, in AST, are predictive of improved lobular inflammation and fibrosis, key prognostic features of NAFLD.

Context: Leptin is thought to regulate whole-body adiposity and insulin sensitivity, at least in part, by stimulating fatty acid metabolism via activation of AMP-kinase (AMPK) in skeletal muscle. Human obesity is associated with leptin resistance, and recent studies have demonstrated that hypothalamic expression of the suppressors of cytokine signaling 3 (SOCS3) regulates leptin sensitivity in rodents., Objective: The objective of the study was to investigate the effects of leptin on fatty acid oxidation and AMPK signaling in primary myotubes derived from lean and obese skeletal muscle and evaluate the contribution of SOCS3 to leptin resistance and AMPK signaling in obese humans., Results: We demonstrate that leptin stimulates AMPK activity and increases AMPK Thr172 and acetyl-CoA carboxylase-beta Ser222 phosphorylation and fatty acid oxidation in lean myotubes but that in obese subjects leptin-dependent AMPK signaling and fatty acid oxidation are suppressed. Reduced activation of AMPK was associated with elevated expression of IL-6 ( approximately 3.5-fold) and SOCS3 mRNA ( approximately 2.5-fold) in myotubes of obese subjects. Overexpression of SOCS3 via adenovirus-mediated infection in lean myotubes to a similar degree as observed in obese myotubes prevented leptin but not AICAR (5-amino-imidazole-4-carboxamide-1-beta-d-ribofuranoside) activation of AMPK signaling., Conclusions: These data demonstrate that SOCS3 inhibits leptin activation of AMPK. These data suggest that this impairment of leptin signaling in skeletal muscle may contribute to the aberrant regulation of fatty acid metabolism observed in obesity and that pharmacological activation of AMPK may be an effective therapy to bypass SOCS3-mediated skeletal muscle leptin resistance for the treatment of obesity-related disorders.

Background: Although bariatric surgery is known to be effective in the short term, the durability of that effect has not been convincingly demonstrated over the medium term (> 3 years) and the long term (> 10 years). The authors studied the durability of weight loss after bariatric surgery based on a systematic review of the published literature., Methods: All reports published up to September, 2005 were included if they were full papers in refereed journals published in English, of outcomes after Roux-en-Y gastric bypass (RYGBP), and its hybrid procedures of banded bypass (Banded RYGBP) and longlimb bypass (LL-RYGBP), biliopancreatic diversion with or without duodenal switch (BPD+/-DS) or laparoscopic adjustable gastric banding (LAGB). All reports that had at least 100 patients at commencement, and provided > or = 3 years of follow-up data were included., Results: From a total of 1,703 reports extracted, 43 reports fulfilled the entry criteria (18 RYGBP; 18 LAGB; 7 BPD). Pooled data from all the bariatric operations showed effective and durable weight loss to 10 years. Mean %EWL for standard RYGBP was higher than for LAGB at years 1 and 2 (67 vs 42; 67 vs 53) but not different at 3, 4, 5, 6 or 7 years (62 vs 55; 58 vs 55; 58 vs 55; 53 vs 50; and 55 vs 51). There was 59 %EWL for LAGB at 8 years, and 52 %EWL for RYGBP at 10 years. Both the BPD+/-DS and the Banded RYGBP appeared to show better weight loss than standard RYGBP and LAGB, but with statistically significant differences present at year 5 alone. The LL-RYGBP was not associated with improved %EWL. Important limitations include lack of data on loss to follow-up, failure to identify numbers of patients measured at each data point and lack of data beyond 10 years., Conclusions: All current bariatric operations lead to major weight loss in the medium term. BPD and Banded RYGBP appear to be more effective than both RYGBP and LAGB which are equal in the medium term.

Background: Obesity is a chronic inflammatory condition, and elevated white blood cell counts (WBC) have widely recognized associations with inflammatory conditions. The authors explored the relationship between the WBC and degree of obesity, basic anthropometry, and clinical and biochemical markers of the metabolic syndrome at baseline, and with weight loss following Lap-Band surgery., Methods: 477 patients with complete biochemical and clinical data at baseline and at 2 years were selected for analysis. Paired analysis assessed the change in WBC at 2 years, and stepwise linear regression assessed factors independently associated with baseline counts and any change at 2 years., Results: Mean +/- SD weight loss at 2 years was 29.3 +/- 16.2 kg. There were significant decreases in total WBC (-12.2%), and major components, neutrophils (11.7%) and lymphocytes (6.9%), at 2 years (P<0.001 for all). Baseline WBC, neutrophils and lymphocyte counts increased with increasing BMI and decreased with age. Insulin levels were independently positively associated with higher neutrophil counts and triglycerides with higher lymphocyte counts. Age, gender, BMI and components of the metabolic syndrome when modeled together accounted for <10% of the variance of baseline counts. Higher BMI predicted a greater fall in the neutrophil counts at 2 years. Change in BMI at 2 years was the only independent predictor of the change in both neutrophils and lymphocytes, but accounted for <10% of the variance of change., Conclusion: BMI contributes to both baseline and weight loss WBC. However, crude WBC counts are influenced in minor ways by obesity markers and have limited value as clinical markers.

Background: Shoulder-tip pain is commonly reported following laparoscopic adjustable gastric band (LAGB) placement. The incidence, nature and factors that may increase the risk of pain have not been explored., Methods: A prospective extensive collection of patient characteristics and operative details was obtained from consecutive patients having band placement for severe obesity. Postoperatively, the presence and characteristics of shoulder pain were obtained using a structured interview at discharge from hospital, and at 1 and 5 weeks after placement., Results: 66% and 21% of patients at 1 and 5 weeks respectively following surgery reported pain predominantly in the left shoulder. At 5 weeks, only 7% found the pain of concern and 5% required analgesics. There were no factors found that predicted the presence and severity of pain at 1 week. Injury to the crus of the diaphragm (OR 4.2, 1.4-12.6, P=0.01) and a past history of any upper abdominal surgery (OR 4.2, 1.5-11.7, P=0.007) independently predicted an increased risk of pain at 5 weeks., Conclusion: Shoulder pain following LAGB surgery is common, usually affects the left shoulder, and can in some cases last 5 weeks or more. Avoiding injury to the crura during the procedure may prevent more prolonged pain.

Background: There is variety in the reporting of weight loss outcomes within the bariatric literature. Our aim is to compare methods of reporting weight loss in surgical and medical studies, and in addition look for a minimal reporting requirement that allows meaningful comparison., Method: A review of methods of reporting weight loss in studies published during 2004 was conducted. Bariatric surgical studies included all reports from MEDLINE-listed journals, and medical studies included reports of non-surgical weight loss from 9 leading journals., Results: 65 surgical and 36 non-surgical reports were retrieved. There were 3 common (>20% of reports) methods of reporting in the surgical literature; mean weight, percentage of excess weight loss (%EWL) and body mass index (BMI), and 4 in the medical literature; mean weight loss, weight, percentage weight loss and BMI. %EWL was reported in 2/3 of surgical reports and in none of the non-surgical. The origin of ideal weight for %EWL calculations was reported in 10 (23%) of these studies and included 5 differing definitions. All methods of reporting other than those using "ideal weight" can be calculated from mean weight and BMI at all time-points., Conclusion: There is complexity and confusion in the reporting of bariatric surgery weight outcomes when calculations are based on ideal weight. Providing weight (kg) and BMI (kg/m2) at all time-points allows the reader to interpret and compare the results in the context of the population of interest. These two measures should be provided as a minimum by all journals reporting on intentional weight loss.

Adiponectin is an adipocyte-derived hormone associated with antidiabetic actions. In rodent skeletal muscle, globular adiponectin (gAD) activates AMP-kinase (AMPK) and stimulates fatty acid oxidation effects mediated through the adiponectin receptors, AdipoR1 and AdipoR2. In the present study, we examined the mRNA expression of adiponectin receptors and the effects of gAD on AMPK activity and fatty acid oxidation in skeletal muscle myotubes from lean, obese, and obese type 2 diabetic subjects. Myotubes from all groups expressed approximately 4.5-fold more AdipoR1 mRNA than AdipoR2, and obese subjects tended to have higher AdipoR1 expression (P = 0.052). In lean myotubes, gAD activates AMPKalpha1 and -alpha2 by increasing Thr172 phosphorylation, an effect associated with increased acetyl-coenzyme A carboxylase (ACCbeta) Ser221 phosphorylation and enhanced rates of fatty acid oxidation, effects similar to those observed after pharmacological AMPK activation by 5-aminoimidazole-4-carboxamide riboside. In obese myotubes, the activation of AMPK signaling by gAD at low concentrations (0.1 mug/ml) was blunted, but higher concentrations (0.5 mug/ml) stimulated AMPKalpha1 and -alpha2 activities, AMPK and ACCbeta phosphorylation, and fatty acid oxidation. In obese type 2 diabetic myotubes, high concentrations of gAD stimulated AMPKalpha1 activity and AMPK phosphorylation; however, ACCbeta phosphorylation and fatty acid oxidation were unaffected. Reduced activation of AMPK signaling and fatty acid oxidation in obese and obese diabetic myotubes was not associated with reduced protein expression of AMPKalpha and ACCbeta or the expression and activity of the upstream AMPK kinase, LKB1. These data suggest that reduced activation of AMPK by gAD in obese and obese type 2 diabetic subjects is not caused by reduced adiponectin receptor expression but that aspects downstream of the receptor may inhibit AMPK signaling.

Background: Laparoscopic adjustable gastric banding (LAGB) is a safe and effective method for the treatment of obesity. The most common problem after LAGB has been the occurrence of prolapse (slippage) of the stomach through the band. It has been proposed that the pars flaccida (PF) pathway (dissection from the base of the right crus, along the left crus to the angle of His) is less likely to be associated with prolapse than the traditional perigastric (PG) pathway (dissection between the lesser curvature of stomach and lesser omentum, across the apex of the lesser sac, to the angle of His). We have tested this hypothesis using a randomized controlled trial format., Methods: We have performed a randomized controlled trial to compare the outcomes after LAGB using PF and PG pathways. 202 patients (mean age 40 years, mean weight 123 kg, mean BMI 45) were randomly allocated to the PF or PG pathway and followed for 2 years., Results: At 24 months, there have been 16 revisional procedures for prolapse, 4 in the PF group (all anterior prolapse) and 15 in the PG group (12 posterior and 3 anterior). This difference is significant (P<0.001). The mean % excess weight lost was 53% for the PF group and 46% for the PG group. There was equally significant improvements in the metabolic syndrome in both groups (59% preoperatively and 19% at 2 years). All 8 paired domain scores of the SF-36 measures of quality of life were improved significantly in both group (P<0.001)., Conclusions: The PF pathway is as effective as the PG pathway in generating substantial weight loss, improved health and improved quality of life and is significantly less likely to be associated with prolapse (slippage). It is recommended as the primary dissection pathway.

Background: The single most important attribute of the laparoscopic adjustable gastric band (LAGB) is its adjustability. Having the correct volume of fluid within the band is crucial for optimal performance. We observe a small reduction of the satiety-promoting effect with time. The characteristics and clinical relevance of volume change have not been adequately investigated., Method: One observer measured the saline volume within the 10-cm Lap-Band in 118 consecutive patients who fulfilled the entry criteria. The same observer had performed and recorded the previous adjustment. Initial volume, final volume and time between observations provide the data for analysis. In addition, a range of adjustable gastric bands currently available were bench-tested to assess broad applicability of findings., Results: The difference between observations varied from 0.0 ml to -1.0 ml, median of -0.1 interquartile range (IQR) 0.0-0.2 ml. Two factors were associated with volume change: time in days between the observations (r = -0.55, P<0.001) and the initial volume within the band system (r = -0.50, P<0.001). These two independent factors accounted for a significant proportion of the variance observed (Cox and Snell R2 = 0.45, P<0.001). Replacement of any discrepancy appears to maintain effectiveness. All six bands showed similar saline loss when bench-tested., Conclusion: Adjustable gastric bands are semipermeable, leading to a small reduction in saline volume with time. Patients should be informed of this effect, attend for regular follow-up visits and seek help if the band's effectiveness appears reduced. We recommend that the volume present should be checked and readjusted at least every 6 months.

The sustainability of surgically induced weight loss implies that energy homeostasis is favorably altered. We investigated the hypothesis that laparoscopic adjustable gastric banding (LAGB) induces prolonged satiety and that plasma ghrelin is involved. Seventeen weight-stable subjects who had achieved LAGB-induced weight loss attended blind crossover breakfast tests, one with optimal band restriction and one with reduced restriction. Standardized meals were consumed (0900 h) after 14-h fasting. Satiety visual analog scales were completed hourly (0700-1100 h) before and after feeding. Blood glucose, plasma insulin, ghrelin, and leptin levels were measured. Seventeen body mass index-matched controls were tested. Optimal restriction was associated with significantly greater fasting and postprandial satiety levels than reduced restriction (P < 0.01). Glucose, insulin, ghrelin, and leptin levels did not alter between optimal and reduced restriction. LAGB subjects displayed higher ghrelin (+12%, P = 0.13) and lower glucose (-17%, P = 0.018), insulin (-33%, P = 0.016), and leptin (-32%, P = 0.05) 4-h area under the curve levels than controls. Optimal LAGB restriction increased fasting and postprandial satiety levels. This supports the hypothesis that LAGB provides prolonged satiety, present even during fasting, favorably influencing energy homeostasis. Plasma insulin, leptin, and ghrelin appeared unrelated to the satiety effect and displayed orexigenic compensatory changes. Identifying the mechanisms underlying LAGB-induced satiety may assist the understanding of human energy homeostasis and obesity.

Background: Motivation for seeking obesity surgery has not been studied. The authors explored the patient's motivation for selecting surgery and examined for a relationship between primary motivating factors and weight outcomes., Methods: 208 (177F: 31M) unselected participants followed at least 1 year after Lap-Band placement completed a short questionnaire. 6 statements were scored 1-6 from the most important through to the least important. Statements included appearance, embarrassment, medical conditions, health concerns, physical fitness and physical limitation. Any additional factors were also sought., Results: Mean age, weight and BMI before surgery were 41+/-10 years, 129+/-16 kg and 46+/-8 kg/m(2) respectively. Responses to appearance and embarrassment correlated strongly and were grouped together. Medical conditions and health concerns account for 52%, appearance and embarrassment for 32%, and poor physical fitness and physical limitation for 16% of first choices. Those who scored 1 for appearance or embarrassment (n=67) had a lower presenting BMI (44 kg/m(2), P=0.03) and all but 1 were female (P<0.001). This group reported more depressive symptoms, poorer mental quality of life and poorer body image preoperatively. Men were more likely than women to be motivated by medical problems (P=0.007). Subjects motivated by a medical condition were more likely to have hypertension or diabetes and less likely to smoke. This group tended to be older. Weight history did not influence motivation. The first choice of motivating factor was not associated with weight outcomes at 1-3 years following surgery., Conclusion: Health issues dominate the motivation for seeking surgery. Weight outcomes do not appear to be affected by the patient's primary motivating factor.

Background: In recent years strong epidemiological evidence has arisen associating significant cardiovascular benefit with light to moderate alcohol consumption. Increased benefit in high cardiovascular risk individuals has been particularly evident. With Australian levels of obesity and type 2 diabetes now reaching epidemic proportions, lifestyle factors that can reduce cardiovascular risk are of critical importance., Objective: This article aims to inform general practitioners of the potential cardiovascular benefit of light to moderate alcohol consumption., Discussion: In offering tailored alcohol advice to patients, the GP should have two goals: to minimise harm and maximise benefit. Blanket discouragement of all levels of alcohol consumption can no longer be justified.

Background: It is common belief that sweet eaters will do poorly after gastric restrictive surgery. There is scant evidence for this and significant evidence that sweet eating behavior is not predictive of weight outcome. Preoperative and current sweet eating behavior was assessed in subjects who have had Lap-Band surgery, to find if this influenced weight outcomes., Method: 200 unselected patients who had bands inserted for > 1 year completed a questionaire regarding preoperative sweet eating behavior. The last 100 patients also reported current sweet eating behavior. Sweet eating was scored using a standard dietary questionnaire., Results: Mean +/- SD % excess weight loss at 1 year (% EWL1) for the 100 with the highest preoperative sweet eating scores (SES) was 47.1 +/- 16% compared with a loss of 48.2 +/- 16% by those with the lowest SES (P = 0.64). Analysis showed no significant linear or non-linear correlation between the SES and the % EWL. For the highest quintile of SES, the EWL1 was 47.3 +/- 14% and for the lowest was 46.1 +/- 16% (NS). Sweet eaters were younger (r = -0.21, P = 0.003) and had higher fasting insulin concentrations (r = -0.18, P = 0.03). Preoperative SES had no influence on % EWL1 after controlling for factors known to influence weight loss. % EWL at 2 years (n = 130) and 3 years (n = 88) were not different for sweet eaters and non-sweet eaters. Current sweet eating tendency (n = 100) also had no impact on % EWL., Conclusion: Sweet eaters do not have less favorable weight outcomes following Lap-Band surgery. Our study confirms the findings of two other major studies. Sweet eating behavior should not be used as a preoperative selection criterion for bariatric surgery.

The prevalence of obesity is increasing worldwide. In the United States, in 1999, 27% of adults had a body mass index >30 kg/m(2), almost double the prevalence of 20 years earlier. The estimated mortality from obesity-related diseases in the United States is approximately 300,000 annually and growing. In the future, mortality related to obesity is expected to exceed that of smoking. Numerous diseases are caused or made worse by obesity. These include type 2 diabetes; hypertension; dyslipidemia; ischemic heart disease; stroke; obstructive sleep apnea; asthma; nonalcoholic steatohepatitis; gastroesophageal reflux disease; degenerative joint disease of the back, hips, knees, and feet; infertility and polycystic ovary syndrome; various malignancies; and depression. Type 2 diabetes is perhaps the most visible obesity-related problem. Present in at least 14 million Americans, it leads to serious complications and premature death. It is largely caused by obesity, and is generally cured by weight loss. The quality of life of the obese is markedly reduced, and the costs to health care systems are great. Preventive programs have yet to affect the rising prevalence. An effective solution is needed.

Background: Obesity is now one of our major public health problems. Effective and acceptable treatment options are needed. The Lap-Band system is placed laparoscopically and allows adjustment of the level of gastric restriction., Methods: A prospective study of 709 severely obese patients was conducted over a 6-year period at a university-based multidisciplinary referral center. After extensive preoperative evaluation, patients with a body mass index > 35 were treated by Lap-Band placement. Close follow-up with progressive adjustment of gastric restriction continued permanently. Medical co-morbidities were monitored as part of comprehensive prospective data collection., Results: There have been no deaths perioperatively or during follow-up. Significant perioperative adverse events occurred in 1.2% only. Reoperation has been needed for prolapse (slippage) in 12.5%, erosion of the band into the stomach in 2.8% and for tubing breaks in 3.6%. A steady progression of weight loss has occurred through the duration of the study with 52 +/- 19% EWL at 24 months (n = 333), 53 +/- 22% EWL at 36 months (n = 264), 52 +/- 24% EWL at 48 months (n = 108), 54 +/- 24% EWL at 60 months (n = 30), and 57 +/- 15% EWL at 72 months (n = 10). Major improvements have occurred in diabetes, asthma, gastroesophageal reflux, dyslipidemia, sleep apnea and depression. Quality of life as measured by Rand SF-36 shows highly significant improvement., Conclusions: Placement of the Lap-Band system provides safe and effective control of severe obesity. The effect on weight loss is durable and is associated with major improvement in health and quality of life. It has the potential to provide a broadly acceptable option for this common and serious disease.

Background: The severely obese experience discrimination and embarrassment regarding their appearance, causing psychosocial distress. We assessed the importance of appearance, presentation and self-evaluation of appearance before and after weight loss, in severely obese subjects (BMI > 35 kg/m2)., Methods: Appearance orientation (AO) and appearance evaluation (AE) sections of the Multi-dimensional Body Self Relations Questionnaire were completed by preoperative patients and those attending an annual follow-up after Lap-Band gastric restrictive surgery over a 2-year period. AO is a measure of the importance one places in appearance. AE is a self-evaluation of one's appearance., Results: Before surgery 322 consecutive patients (48 men and 274 women) completed the survey. AO was similar to that of community norms (mean scores 3.76 +/- SD 0.6 vs 3.84 +/- 0.6), with the exception of the super obese (BMI > 50 kg/m2) who placed significantly less importance on their appearance (3.34, +/- 0.8, p = 0.001). There was no change in AO at 1-4 years after surgery, with the exception of the super obese whose mean values rose to normal by 1 year. AE was very low before surgery compared with community normal values (1.6 +/- 0.6 vs 3.4 +/- 0.8, p < 0.001). Major improvement in mean AE was seen at 1 year after surgery (n = 209, 2.6 +/- 0.8, p < 0.001) and the improvement was maintained out to 4 years. The change in AE from pre-surgery to 1 year (n = 122 paired) correlated positively with the percentage of excess weight lost (r = 0.32, p < 0.01) and positively with measures of quality of life and psychological disturbance., Conclusion: Major improvements in appearance evaluation occur with weight loss after surgery and this is associated with psychological benefit.