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Background The growing demand for bariatric surgery has been accompanied by an expensive technological evolution and the need to contain healthcare costs and to increase the quality of care. The enhanced recovery after surgery (ERAS) protocols applied to the bariatric setting can be the answer to all these different issues. Objectives Feasibility and safety of ERAS protocol in a single, high-volume bariatric center. Setting Humanitas Research Hospital, Rozzano MI, Italy. Methods Our ERAS bariatric protocol is based on the following 3 steps: (1) preoperative: optimization of all co-morbidities, counseling patients and family with information and education, and shortening fasting times (clear fluids up to 2 hr and solids up to 4 hr before induction of anesthesia); (2) intraoperative: premedication, parallel team work, awake patient positioning, standardized multimodal anesthesia and analgesia, noninvasive monitoring, video-laryngoscopy in reverse Trendelenburg position, short-acting anesthetic agents, and standardized laparoscopic surgery avoiding the nasogastric tube, catheter, and drain; and (3) postoperative: analgesia, early mobilization, early oral fluid, thromboprophylaxis, discharge planning, and follow-up telephone call. Clinical pathways were established and outcomes were retrospectively collected. Results Comparison between conventional care and ERAS protocol reveals a reduction of the length of hospital stay (from 4.7 to 2.1 d) and a low morbidity rate. From July 2015 to July 2018, a total of 2400 consecutive patients underwent primary or revisional bariatric surgery (2122 sleeve gastrectomies and 278 Roux-en-Y gastric bypasses [RYGB]). Mean body mass index was 44.9 kg/m2, mean age was 41.9 years, and the male to female ratio was 1:2.5. Total mean operative time was 85 minutes, with a surgical time of 65 minutes and an anesthesiologic/patient induction time of 4 minutes. Early complication rate was 3.5% with no perioperative mortality. Mean hospital stay was 2.1 days and the rate of readmission was .9%. Conclusions This study demonstrates that our ERAS protocol is safe, feasible, and efficient. Patient preparation and multidisciplinary/parallel team work are crucial points.

On 24th June 2020, a ‘COVID-19 Roundtable’ consensus meeting was convened comprised of a panel of BM initially it was only at 60% of pre-COVID levels to ensure that ICU capacity was maintained, Dr. Giuseppe Marinari (Humanitas Research Hospital, Milan, Italy) reported. The Humanitas Research Hospital has followed the Diabetes Surgery Summit (DSS) recommendations [14] of operating on the most complex cases, excluding patients aged > 60, BMI> 60 and challenging revision cases [17]. Surgical protocols are localised depending on the local situation, ERAS has been adopted, and patients are only sent to ICU in the event of complications. In the roundtable discussions, it was reiterated that with the right screening and pathways, bariatric surgery should be resumed immediately, and BM the theoretical risk of severe COVID-19 should be considered in the context of the need to urgently treat a life-threatening disease. B&M surgery is the most effective and durable treatment for people living with severe obesity, and the impact of obesity and diabetes on COVID19 severity demonstrates why surgery should be immediately restarted with the number of procedures increased. A greater emphasis...

Background Bariatric surgery is the most effective treatment for patients affected by morbid obesity. The Enhanced Recovery After Surgery (ERAS) protocol increases clinical outcomes, but the most recent literature shows incomplete patients’ adherence. This study aims to demonstrate the feasibility of applying a Value-Based Healthcare (VBHC) strategy associated with ERAS to increase patients’ engagement and outcomes. Method A multiprofessional team redesigned the process considering ERAS recommendations and patients’ feedbacks. Outcomes that matter to patients were defined with structured patients’ interviews and collected in the electronic clinical record. Adherence to the pathway and the cost of the cycle of care were measured to demonstrate sustainability. A model was developed to grant its replicability. Results A total of 2.122 patients were included. The lowest adherence to the protocol for a single item was 82%. 74% of excess weight loss; 90% better comorbidities control; 77.5% had no pain after surgery; 61% no postoperative nausea and vomiting. Zero mortality; 1.8% overall morbidity; 0.4% readmission and reoperation rate within 30 days. The average length of stay is 2.1 days. Patient-Reported Outcome Measures (PROMs) documented increased productivity and quality of life. Conclusion Building a caring relationship by a multidisciplinary team, adding patient wellness in a VBHC framework on top of ERAS as a patient-centered approach, increases patients’ engagement and adherence to the pathway of care, resulting in better health outcomes (clinical and PROMs). The Value-Based Model is sustainable and replicable; it represents the prototype for redesigning other pathways and may become a model for other organizations.

In Italy elective bariatric and metabolic surgery was cancelled on February 21,2020 at the beginning of the so-called phase 1 of the SARS-CoV-2 outbreak. Gradually it was restarted on May 4,2020 at the beginning of the so-called phase 2, when epidemiological data showed containment of the infection. Before the outbreak in eight high-volume bariatric centers 840 patients were surgically treated developing a Covid-19 infection, during phase 1, in only 5 cases (0.6%) without mortality. The post-operative complication rate was similar when compared to the 836 subjects submitted to bariatric surgery the year before. Since the high prevalence of infection in subjects with BMI > 30, it was argued that early intervention on obesity during phase 2 could help to minimize the effects of the disease in the event of a possible reversion to a SARS-CoV-2 outbreak phase 1. At the same time a prospective observational study from July 1 till the WHO declaration of the end of the pandemic has started in the eight high volume centers to monitor the post-operative outcome and its effect on SARS-CoV-2 infection.

Background: Sars-Cov-2 epidemic in Italy caused one of the greatest 2020 European outbreaks, with suspension of elective bariatric/metabolic surgery (BMS). From May 2020 a significant decline of the epidemic has been observed (phase 2); National Health Service protocols permitted elective BMS’ resumption. A new, more severe COVID-19 surge, the “second wave”, started on October 2020 (phase 3). Aim: The primary end point was to analyze the outcomes of any Sars-Cov-2 infection and related morbidity/mortality within 30 POD after laparoscopic BMS during phase 2–3; secondary end points were readmission and reoperation rates. Methods: Study design prospective, multicenter, observational. Setting: Eight Italian high-volume bariatric centers. All patients undergoing BMS from July 2020 through January 2021 were enrolled according to the following criteria: no Sars-Cov-2 infection; primary procedures; no concomitant procedure; age > 18 < 60 years; compensated comorbidities; informed consent including COVID-19 addendum; adherence to specific admission, in-hospital and follow-up protocols. Data were collected in a prospective database. Patients undergone BMS during July-December 2019 were considered a control group. Results: 1258 patients were enrolled and compared with 1451 operated on in 2019, with no differences for demographics, complications, readmission, and reintervention rates. Eight patients (0·6%) tested positive for Sars-Cov-2 infection after discharge, as well as and 15 healthcare professionals, with no related complications or mortality. Conclusions: Introduction of strict COVID-19 protocols concerning the protection of patients and health-care professionals guaranteed a safe resumption of elective BMS in Italy. The safety profile was, also, maintained during the second wave of outbreak, thus allowing access to a cure for the obese population.

Background: Alexithymia is the inability to express feelings with words and comprises a psychological construct frequently found in obese individuals. In eating disordered patients who show a tendency to lose control over food intake, personality traits with alexithymic characteristics have been demonstrated. The present cross-sectional study investigated the relationships between alexithymia and eating behaviour in severely obese patients. Methods: This study analysed 150 obese patients undergoing bariatric surgery and 132 subjects at more than 1 year after biliopancreatic diversion (BPD), when body weight has steadily normalised and any preoccupation with weight, food and diet has been completely abandoned. Obese and operated subjects completed the Toronto Alexithymia Scale (TAS), and eating behaviour was assessed via a semi-structured interview exploring binge eating disorder (BED), night eating and emotional eating, as well as by utilisation of the Three Factor Eating Questionnaire (TFEQ). Results: Although alexithymic patients showed deranged eating behaviour, as evaluated by the TFEQ scores, the frequency of BED, night eating and emotional eating was similar in alexithymic (TAS > 60) and non-alexithymic patients. However, the prevalence of alexithymia was similar in obese and BPD subjects, whereas, in the operated subjects, TFEQ scores were lower (P

Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD) are highly beneficial operations for type 2 diabetes mellitus (T2DM) in obese patients, leading to complete T2DM resolution in 75-90 and 97-99% of cases, respectively. In both RYGBP and BPD, the foregut is excluded from the food stream and the distal small bowel receives the food stimulation, while following BPD fat intestinal absorption is also extremely limited. This study was carried out to identify clinical features that could give insight on the different mechanisms of action on diabetes resolution.The files of 443 severely obese patients with T2DM undergoing BPD from May 1976 to May 2007 were examined, and the presence of T2DM (fasting serum glucose125 mg/ml) at 1-2 months, at 1 year, at 10 years, and ator =20 years following the operation was recorded.The percentage of patients cured (fasting serum glucose reduced toor =110 mg/dl, on free diet and with no therapy) was 74% at 1 month, 97% at 1 and 10 years, and 91% ator =20 years, the 26% of uncured patients at 1 month being those with most severe preoperative T2DM.As the early results after BPD resemble those reported after RYGBP, it can be hypothesized that the duodenal exclusion and the distal small bowel stimulation are the first mechanisms acting in BPD, immediately after the operation, that only subsequently the myocellular fat depletion, which cannot be immediate, takes over, and that the minimal fat absorption is the mechanism accounting for the long-term results of BPD.

Because of the rearrangement of the gastrointestinal tract, biliopancreatic diversion (BPD) could lead to an increased risk of colorectal cancer caused by possible carcinogenetic action of the unabsorbed food and bile acid on colonic mucosa.The incidence of colorectal cancer in 1,898 obese subjects submitted to BPD from May 76 to July 2002 with a minimum follow-up of 5 years was retrospectively evaluated.Among 28,811 person-years, seven cases of colorectal cancer were detected, for an overall incidence of 29.4 per 100,000, which is not different from that observed in the general Italian population, and lower than that reported for obese and type 2 diabetes patients. Logistic regression model suggests that occurrence of colorectal cancer is positively related to the time elapsed from BPD.This study indicates that BPD does not carry any increased risk for colorectal cancer. The complete postoperative restoration of insulin sensibility could exert a valuable protective action.

Background The benefits of bariatric surgery in adult obese patients are well known, but data are lacking regarding the outcome of the surgery in adolescents. The aim of this study was to retrospectively assess the operative morbidity and mortality, percentage of loss of initial excess weight, and the incidence of long-term complications and reoperations in a cohort of obese patients who underwent biliopancreatic diversion (BPD) before their 18th birthday. Methods A total of 76 adolescent subjects underwent BPD between 1976 and 2005. Of these 78 patients, 7 had Prader-Willi syndrome and 1 had Turner syndrome and were excluded from the study. Results The patient population comprised 52 girls and 16 boys. Their mean age was 16.8 years, mean body weight at operation was 125 kg (mean body mass index 46 kg/m 2 ). Operative mortality was nil. The mean follow-up was 11 years (range 2–23). The mean percentage of loss of initial excess weight at each patient's longest follow-up was 78%. Before surgery, 33 patients were hypertensive (49%), 11 were dyslipidemic (16%), 3 were hyperglycemic, and 2 had type 2 diabetes. At the longest follow-up period after surgery, only 6 patients were hypertensive, and none were dyslipidemic or diabetic. A total of 19 reoperations were performed in 14 patients (20%), including 7 revisions. Eleven patients developed protein malnutrition 1–10 years after BPD. The long-term mortality rate was 4%. At 4 to 23 years after BPD, 18 of the women had given birth to 28 healthy babies. Three women had had a complicated pregnancy. Conclusion Adolescents can undergo malabsorptive bariatric surgery with excellent long-term weight loss results and an incidence of long-term complications similar to that observed during the 30-year evolution of BPD in our experience.

Objectives: The objectives were to evaluate QT interval (QTc) and QT-interval dispersion (QTd) in severely obese individuals and to determine the effects of biliopancreatic diversion (BPD) and weight loss after BPD on ventricular repolarization parameters. Background: People with severe obesity (SO) have a 50% to 100% increased risk of death associated with a 1.6-fold increased risk of sudden death. BPD surgery induces rapid and considerable weight loss through severe lipid malabsorption, thus achieving long-term weight control. Research Methods and Procedures: A total of 85 subjects with SO (age, 42 ± 12 years; 66 females; mean body weight, 120 ± 29 kg; BMI, 45 ± 11 kg/m2) of 330 who had a bariatric surgical consultation between January 2001 and July 2002 were enrolled. Inclusion criteria were sinus rhythm, unremarkable 12 leads surface electrocardiogram, no atrioventricular blocks and/or bundle branch blocks, normal serum electrolyte profile, and no medical therapies exerting known effects on QTc. Exclusion criteria were previous diagnosis of coronary artery disease, known cardiovascular disease, atrial fibrillation or any other known cardiac arrhythmias, cancer, or renal dysfunction. Results: A total of 86% of patients had QTc >440 ms and/or QTd >60 ms. Subjects with SO showed a mean maximum QTc of 446 ± 28 ms and a mean QTd of 52 ± 20 ms. A close correlation was found between QTc and QTd (p < 0.0001; R2 = 0.33). One month after BPD, mean QTc was 420 ms and remained stable at follow-up; QTd was 32 ms at 1 and 6 months and became 35 ms at 1 year. Conclusions: Ventricular repolarization abnormalities are significantly increased in subjects with SO. Reduction of QT abnormalities after BPD is independent of weight loss and is caused by the 100% reduction of glucose plasma shortly after surgery. This effect may be related to surgical interruption of the entero-insular axis.

OBJECTIVE—Gastric bypass and biliopancreatic diversion (BPD) are known to have a beneficial effect on glucose metabolism superior to that of the other bariatric operations. Thanks to its excellent weight loss results and to its specific actions, BPD has proven able to guarantee permanent normalization of serum glucose, triglygeride, and cholesterol levels in the vast majority, if not the totality, of operated patients. However, clinical studies on the duration of these effects in large patient populations are still lacking. RESEARCH DESIGN AND METHODS—The files of 312 BPD obese patients with type 2 diabetes operated on from June 1984 to January 1993 were examined. Pre- and postoperative serum glucose, triglyceride, and cholesterol levels, along with arterial pressure measurements, were considered. RESULTS—After BPD, fasting serum glucose concentration fell within normal values in all but two of the operated subjects and remained in the physiological range in all but six up until 10 years. Serum triglyceride and total cholesterol steadily normalized in all subjects with abnormally high preoperative values, and arterial hypertension disappeared in the vast majority of the preoperatively hypertensive patients. CONCLUSIONS—BPD proved able to reverse all the major components of the metabolic syndrome in nearly all the operated subjects, with results being strictly maintained over a 10-year follow-up period. This outcome, which far exceeds those following similar weight loss at short or long term obtained by any other means, confirms the existence of specific actions of BPD on the major components of metabolic syndrome.

Background: The authors evaluated the predictive efficacy of preoperative resting energy expenditure (REE) on long-term weight loss maintenance following vertical banded gastroplasty (VBG). In the long-term following VBG, low energy expenditure could lead to regain of weight, and thereby REE data might be a reliable predictor of long-term weight outcomes. Methods: A prospective study was conducted, taking into account the relationship between preoperative REE values and the results at 3 and 5 years following VBG in terms of both weight loss and success of the operation. Results: Long-term weight loss and outcome following VBG appeared to be completely independent of the preoperative REE. Conclusion: Preoperative REE cannot predict long-term weight outcome following VBG.

Objective: Ghrelin is a recently discovered hormone that is produced mainly by the stomach and that increases food intake in rodents and humans. It has been postulated that the weight loss after gastric bypass surgery for obesity might be related to changes in serum ghrelin concentration. Research Methods and Procedures: Serum leptin and ghrelin concentrations were measured in a group of obese patients before biliopancreatic diversion (BPD) and 2 and 12 months postoperatively. Insulin sensitivity was determined from serum glucose and insulin levels according to the homeostatic model of assessment for insulin resistance (HOMA IR). Results: A sharp drop was observed in body weight, in BMI values, in HOMA IR data, and in serum leptin concentration at 2 and 12 months after BPD, whereas a significant increase of serum ghrelin level was observed at 12 months, when food intake had returned to preoperative levels. A negative correlation between the postoperative changes of serum ghrelin concentration and those of HOMA IR values was observed at 2 and 12 months after BPD. Discussion: No evidence upholding a relationship between serum ghrelin concentration and food intake after BPD was seen; the postoperative changes likely reflected the achievement of a new state of energy balance. The negative relationship observed between post-BPD changes in HOMA IR values and changes in serum ghrelin concentration supported the role of insulin in the modulation of ghrelin production.

Background: Liver failure after biliopancreatic diversion (BPD) has been reported. Although in our series of 2,515 BPD with a minimum follow-up of 12 months we have never observed this complication, a transitory and significant rise in serum AST and ALT has been detected in some cases, suggesting the occurrence of transient liver damage. To assess if risk factors for acute liver damage after BPD could be identified, we studied the evolution of hepatic biochemistry in a sample of our operated subjects. Methods: We studied 99 consecutive patients submitted to the same type of BPD (ad hoc stomach, ad hoc alimentary limb). Patients with a history of alcohol consumption or positive hepatic serology were excluded. Preoperative body weight (BW), body mass index (BMI), excess weight (EW), % excess weight (%EW), fasting serum glucose level (SG), hepatic histology (HI), weight loss (WL) at 2, 4 and 12 months, and excess weight % loss (IEW%L) at the same time were correlated with preoperative and 2, 4 and 12 months hepatic biochemistry. Results: Compared with preoperative values, AST levels at 2 months significantly increased (Student's t-test, P=0.0003) and significantly decreased at 12 months (P=0.0001). Spearman's Rank test showed significant correlations between 2 months AST levels and WL at 2 months (P =0.005), preoperative BW (P

Background: The authors evaluated the usefulness of routine traditional radiology in the management of patients submitted to VBG. Methods: Radiological findings in 65 subjects who had undergone VBG were evaluated. Post-surgical clinical and radiological examinations were performed 3 days, 1, 4 and 12 months after surgery. Upper GI symptoms, gastroesophageal imaging and 80% solid meal pouch emptying time were recorded. Results: The routine postoperative study, in the absence of clinical symptoms, showed no unsuspected complication in any patient, both in the early and in the late postoperative period. There was no significant correlation at 4 and 12 months between emptying time and duration of satiation, emptying time and percent excess weight loss (%EWL), and duration of satiation and %EWL. Conclusions: Traditional radiological studies can be safely omitted from both the immediate postoperative period and from the long-term follow-up in asymptomatic VBG patients. The studies were not helpful in understanding functional changes leading to weight loss after VBG.

Background: In Prader-Willi Syndrome (PWS), mental retardation and compulsive hyperphagia cause early obesity, the co-morbidities of which lead to short life-expectancy, with death usually occurring in their 20s. Long-term weight loss is mandatory to lengthen the survival; therefore, the lack of compliance in voluntary food restriction requires a surgical malabsorptive approach. Methods: 15 PWS subjects were submitted to biliopancreatic diversion (BPD) and followed (100%) for a mean period of 8.5 (4-13) years. BPD consists of a distal gastrectomy with a long Roux-en-Y reconstruction which, by delaying the meeting between food and biliopancreatic juices, causes an intestinal malabsorption. Indication for BPD was BMI >40 or >35 with metabolic complications. Preoperative mean age was 21±5 years, mean weight 127±26 kg, and mean Body Mass Index (BMI, kg/m2) 53±10. According to Holm's criteria, all of the subjects had a total score ≥8. IQ assessment was performed in each subject, with a mean score of 72±10. An arbitrary lifestyle score was given to each subject. Results: No perioperative complications were observed. Percent excess weight loss (%EWL) was 59±15 at 2 years and 56±16 at 3 years, and then progressive regain occurred; at 5 years %EWL was 46±22 and at 10 years 40±27. Spearman rank test failed to demonstrate any correlation between weight loss at 5 years and patient data, except with lifestyle score (Spearman r=0.8548, p

Background: The strict long-term weight maintenance in good nutritional conditions observed after biliopancreatic diversion (BPD) needs to be explained. Materials and Methods: 15 operated subjects were maintained at an isoenergetic and isonitrogenic diet as similar as possible to their usual diet. Apparent absorption (AA) of energy, fat, nitrogen and calcium was calculated subtracting the fecal content, measured directly, from the oral intake, derived from tables.The alimentary protein absorption was directly determined by I125 albumin oral administration. Results: Mean AA for energy and fat was 57% and 32%, respectively; AAs were unrelated as absolute value and negatively associated as percent of the intake with the energy and fat intake. I125 intestinal absorption was 73%, while nitrogen percent AA was 57%, indicating higher than normal loss of endogenous nitrogen. Calcium AA was 551 mEq/day, 26% of the intake. A positive correlation between nitrogen and calcium AA as absolute values and alimentary intake was observed, while there was no correlation when AA were considered as per cent of the intake. Conclusions: For energy and fat, an increase in intake corresponds to an increase in percent malabsorption, so that the absolute amount absorbed tends to remain constant, accounting for the excellent weight maintenance observed following BPD. This was confirmed by a long-term hypernutrition study after BPD. On the contrary, for nitrogen and calcium, the percent absorption tends to remain constant when intake varies, so that an increase in alimentary intake results in an increased absolute amount absorbed.

Macroscopic clinical evidence of tissue damaging following bariatric surgery pushed plastic surgeons to presume microscopic alterations as well.Five preliminary cases studied randomly, and compared with healthy tissues, confirmed these initial suspects. A deeper and wider study has then been structured.Preliminary results are so evident to encourage us to carry on an estimated 2-3 years multidisciplinary study.What we want to study is if histological post-bariatric alterations are confirmed, and if these can be considered responsible for higher complication rate in body contouring following bariatric surgery.

We reviewed the radiological findings in 45 morbidly obese patients (weight range 80-129 kg; mean 95.7 kg) after gastric restriction surgery with adjustable silicone gastric banding (ASBG) according to the Kuzmak technique. Radiographic studies of the stomach were performed before, and at 4 and 12 months after surgery; symptomatic patients underwent additional studies when needed. Patients were evaluated using both liquid barium and a solid opaque meal to assess post-operative gastric morphology as well as emptying time of the proximal gastric pouch. 27 patients had a normal clinical course. Variation of the calibre of the silicone band under radio- graphic guidance was required in 12 of these patients, based on dilatation of the proximal pouch, variation of the stomal calibre from operative values, or an emptying time longer than 30 min. All these problems disappeared after the adjustment manoeuvres. 18 patients had complications, of which five had stomal stenosis which could not be managed through simple deflation of the band; two had posterior bending and dilatation of the proximal pouch; four had gastritis and oesophagitis; six had infection of the inflatable reservoir; one had cranial displacement of the band, and two had migration of the band into the stomach. Removal of the gastric band was necessary in 11 cases, and removal of the reservoir alone had to be performed in three additional patients. Radiology plays an important role in evaluating complications after gastric restriction surgery. Knowing the variety of findings enables accurate treatment planning and follow-up of these patients.

Background: The continuing evolution and the mechanisms of actions of biliopancreatic diversion (BPD) as malabsorptive approach to the surgical treatment of obesity are evaluated.

Although rare, patients with biliopancreatic diversion for morbid obesity will be subject to obstruction of the biliopancreatic limb. This condition is commonly due to postoperative adhesions and intussusception and usually presents with misleading clinical and radiographic features that can delay the diagnosis and the treatment. We recently encountered a patient with obstruction of the biliopancreatic limb due to involvement from Crohn disease. We report this case to highlight the clinical and imaging findings of this rare condition.

Background. Surgical attempts to treat obsity began because of the discouraging results of conservative medical treatment, which successfully achieved initial weight loss but failed to maintain it. Gastric restrictive procedures, currently the most popular surgical methods for obesity therapy, have proved to be effective in initiating weight loss, but some concerns regarding their long-term efficacy in weight maintenance have arisen. Methods. Of a total of 1968 obese patients who underwent biliopancreatic diversion since 1976, the last consecutive 1217 underwent the “ad hoc stomach” type of diversion with a 200 cm alimentary limb, a 50 cm common limb, and a gastric volume varying between 200 and 500 ml. Mean age was 37 years old (11 to 69 years), and mean excess weight was 117%. Maximum follow-up was 115 months with nearly 100% participation. Results. In the last half of the series, operative mortality was 0.4% with no general complications and with early surgical complications of wound dehiscence and infection (total, 1.2%) and late complications of incisional hernia (8.7%) and intestinal obstruction (1.2%). Mean percent loss of initial excess weight (IEW) at 2, 4, 6, and 8 years was 78±16, 75±16, 78±18, and 77±16 in the patients with IEW up to 120% and 74±12, 73±13, 73±12, and 72±10 in those with IEW more than 120%. A group of 40 patients who underwent the original “half-half” biliopancreatic diversion maintained a mean 70% reduction of IEW during a 15-year follow-up period. Specific late complications included anemia (less than 5%), stomal ulcer (2.8%), protein malnutrition (7% with 1.7% requiring surgical revision by common limb elongation or by restoration). Clinical problems from bone demineralization were minimal in the short term and almost absent in the long term. Conclusions. Biliopancreatic diversion is a very effective procedure but is potentially dangerous if used incorrectly.

Assess insulin sensitivity and metabolic status of obese patients with stable weight loss at long term following biliopancreatic diversion (BPD).The study was carried out in 36 nondiabetic severely obese patients undergoing BPD. Serum concentration of glucose, insulin and leptin were determined prior to and at 2 y following the operation. Insulin sensitivity was calculated according to the homeostatic model assessment (HOMA IR).At 2 y following BPD, weight loss in all subjects corresponded to a marked drop in serum leptin concentration and improvement of insulin sensitivity within physiological range. Following the operation, HOMA IR values were positively correlated with serum leptin concentration independently of body mass index values.The stable weight loss following BPD at long term is accompanied by a complete reversal of the preoperative insulin resistance. Serum leptin concentration and HOMA IR data were positively related only postoperatively, suggesting that the action of factors that could influence the relation between leptin and insulin action in the obese status can be reverted.

A retrocolic submesocolic approach was used for creating the gastroenteroanastomosis in 42 consecutive patients who underwent laparoscopic biliopancreatic diversion for obesity. The surgical technique is described in detail. The laparoscopic gastroenteroanastomosis was successfully performed on all the operated patients, with no intraoperative complications requiring conversion to open surgery and no immediate or late postoperative morbidity related to the anastomosis.

Body composition was measured with bioelectric impedance analysis (BIA) in 30 patients with protein malnutrition following biliopancreatic diversion. Determinations were carried out prior to, during, and at the completion of intravenous nutritional support when the nutritional parameters had completely reverted to normal. Before treatment, body weight (BW), lean body mass (LBM), and body fat (BF) values were similar to those of controls, whereas the total body sodium/total body potassium (TBNa/TBK) and extracellular mass/body cell mass (ECM/BCM) ratios were considerably higher. During the support, no changes in BW, LBM, and BF were demonstrated, although a sharp decrease of TBNa/TBK and ECM/BCM was observed, thus demonstrating improved LBM composition. At the end of parenteral feeding, the BW, LBM, and BF values were similar to those observed before the support, while a further decrease in TBNa/TBK and ECM/BCM demonstrated a recovery towards normal of body composition. The full correspondence between clinical and BIA findings therefore suggests that this method may be valuable for monitoring body composition changes during nutritional support.

Objective: To evaluate the predictive efficacy of preoperative resting energy expenditure (REE) on weight loss after vertical banded gastroplasty (VBG). When subjected to a gastric restriction procedure of similar extent, the patients with higher energy expenditure should experience a greater negative energy balance than those with lower-energy expenditure, and thus, lose more weight, thereby making REE a reliable predictor of weight loss after VBG. Research Methods and Procedures: This was a prospective investigation after VBG, taking into account the relationship between preoperative REE values and the results at 1-year follow-up in terms of weight loss and success of the procedure. The correlations were evaluated by multiple and logistic regression analysis. Results: The weight loss and the outcome at 1 year after VBG seemed to be completely independent of preoperative energy expenditure. Discussion: These findings suggest that, despite gastric restriction, patients may voluntarily adjust their energy intake, and that the weight outcome after VBG is influenced more by behavioral and cognitive variables than by biological or surgical factors.

This study aims to evaluate the role of simple carbohydrates and alcohol intake in determining weight of stabilization at long-term following malabsorptive bariatric surgery. Sixty patients at more than 2 years following biliopancreatic diversion (BPD) were submitted to an alimentary interview for evaluating the daily consumption of simple sugar, fruits, ice-cream, sweets, and caloric and alcoholic beverages. Eating behavior was assessed by Three Factors Eating Questionnaire. The mean estimated daily energy consumption intake was 2,852 kcal, with a mean daily intake of simple carbohydrates of 89 g that represented 12% of the total energy intake. The current body weight was positively and independently related to the preoperative body weight and to simple carbohydrate and alcohol intake and negatively related to physical activity, while no association with total energy consumption and eating behavior was found. These findings confirm that following BPD the body weight is independent of energy intake and eating behavior. Furthermore, these data suggest that in post-BPD subjects the simple carbohydrates and alcohol absorption is fully preserved, and that the operated subjects could regulate their body weight by reducing simple carbohydrates and alcoholic intake and increasing physical activity.

The authors' aim in this study was to gain insight on the eating behaviors of severely obese patients seeking bariatric surgery. The authors compared anthropometric and alimentary interview data on 50 patients applying for biliopancreatic diversion with data obtained from 50 severely obese individuals enrolling in a behavior modification weight-loss program. The severely obese patients seeking bariatric surgery were metabolically more compromised than were their counterparts enrolled in the conservative treatment group, whereas the latter more often reported compromised eating behaviors. These unexpected results could reflect changes in the widespread attitudes toward bariatric surgery-that unlike in the past, it is now considered a safe and effective method to treat a serious disease.

Bariatric operations are the most powerful means of curing type 2 diabetes mellitus (T2D) and the other major components of the metabolic syndrome. Despite the very frequent occurrence of metabolic disturbances in patients with BMI from 30 to 35, there is a general reluctance to operate on these patients, as their disease is considered less severe. 7 T2D obese patients with mean BMI

Background: The authors evaluated body image attitudes in post-obese persons following bariatric surgery who require cosmetic and body contouring operations. Methods: We studied 20 morbidly obese women prior to biliopancreatic diversion (BPD) (OB group), 20 post-obese women at >2 years following BPD (POST group), 10 post-obese women following BPD who required cosmetic procedures (POST-A group), 10 post-obese women after BPD and subsequent cosmetic surgery (POST-B group), and 20 healthy lean controls. Attitudes to weight and shape were evaluated by means of the Body Uneasiness Test (BUT). Results: In comparison with the obese patients in the POST group, lower BUT scores were observed, while in the POST-A group the values were very similar to those observed in the non-operated obese individuals. In the individuals having received cosmetic surgery, the BUT findings were similar to those recorded in the POST group patients, the values approaching data found in the controls. Conclusion: Despite a fully satisfactory weight loss and maintenance, the post-BPD individuals requiring aesthetic surgery showed some disparagement of body image; in these subjects, cosmetic and body contouring procedures may actually improve body weight and shape attitudes towards normality.

Background: The authors investigated the weight loss and maintenance in type 2 diabetic obese patients undergoing biliopancreatic diversion (BPD). Methods: Two series of diabetic and non-diabetic obese patients matched for gender, age and baseline body mass index (BMI) were evaluated prior to BPD, on the occasion of the regular follow-up visit at 1, 2 and 3 years following the operation, and at the fifth postoperative year. At each follow-up point, body weight (BW), BMI, and serum glucose concentration were measured. Results: In all type 2 diabetic patients, the serum glucose level fell to within the normal range at the first postoperative year and remained within normal limits without any medication throughout all the follow-up period. In preoperatively diabetic subjects, mean values of BW and BMI were closely similar to those of non-diabetic subjects at all follow-up points, and the stabilization weight was independently related to age and to initial BW values. Conclusions: In obese patients with type 2 diabetes, the glucose level steadily normalized in every case following BPD, and values remained unchanged throughout the follow-up period. After the operation, the type 2 diabetic obese patients experienced the same stable weight reduction as their non-diabetic counterparts.

Background: Intramyocellular content of lipid (IMCL) appears to be important in the pathogenesis of insulin resistance, and the improvement of insulin activity observed following biliopancreatic diversion (BPD) for obesity has to be related to reduction of IMCL. This study evaluates the possibility of detecting changes after BPD in IMCL by means of H1 magnetic resonance spectroscopy. Methods: The investigation was carried out in obese patients undergoing BPD prior to and at 1 month following the operation. Insulin sensitivity was assessed according to the homeostatic model of assessment (HOMA), and IMCL was determined by the spectroscopy of the tibialis anterior muscle. Results: At 1 month following BPD, an improvement in insulin action was observed in all subjects, and in nearly all cases the IMCL signal decreased. Conclusion: The data from this study indicate that magnetic resonance spectroscopy can detect IMCL changes following BPD and is fully suitable for longitudinal studies on muscle metabolic status.

Background: Preoperative clinical and biochemical data and intraoperative liver biopsy of 1,000 obese patients submitted to biliopancreatic diversion (BPD) were analyzed, and correlations investigated. Methods: Of 2,645 patients submitted to BPD between May 1976 and November 2002, the last 1,000 consecutive obese patients with no history of alcohol consumption or infectious hepatitis were selected. Clinical data included: age, body weight, BMI, waist-to-hip ratio (W/H), arterial blood pressure, serum glucose, triglycerides, cholesterol, albumin/γ-globulin ratio, total, conjugated and unconjugated bilirubin, γ-GT, alkaline phosphatase, AST, ALT, and prothrombin time. The degree of steatosis, inflammation and fibrosis on intraoperative wedge liver biopsy was determined and scored. Liver steatosis >70% and presence of bridging fibrosis were analyzed separately. Results: Mean BMI was 48 kg/m2. 263 patients had steatosis of >70%, and 79 had bridging fibrosis. Regression analysis showed an association between steatosis and AST, ALT, AST/ALT ratio, body weight, W/H, serum glucose, serum tryglicerides, BMI, γ-GT, age, and unconjugated bilirubin. Inflammation was significantly greater in older patients. Patients with bridging fibrosis had significantly higher values of serum glucose, AST, γ-GT, serum cholesterol and were significantly older. Bridging fibrosis was associated with diabetes, W/H >1, hypertension, albumin/γ-globulin ratio

Background: Biliopancreatic diversion (BPD) is the most effective bariatric procedure in terms of weight loss. However, analysis of the quality of life (QoL) has never been reported. The BAROS, giving a score to each operated patient on weight loss, improvement in medical conditions, QoL, complications and reoperations, has proven to be a standard reference for evaluating bariatric surgery outcomes. Methods: In order to apply the BAROS to BPD, we sent a questionnaire to 1,800 BPD patients who had been operated between 1984 and 1998.The responserate was 51.2%. Out of 1,709 questionnaires which actually reached their destination, we had 858 fully compiled returned. There were 615 women. 596 patients had had an ad hoc stomach (AHS) BPD, and 262 had had an ad hoc stomach ad hoc alimentary limb (AHS-AHAL) BPD. Results: According to the scoring key, 3.5% were classified as a failure, 11% were fair results, 22.8% good, 39.5% very good , and 23.2% excellent results. Considering AHS BPD and AHS-AHAL BPD separately,while the mean excess weight percent loss was 70.5±23 and 64.7±17 respectively, the failure rate was 6% in the first group and 2% in the AHAL group, while 11% and 6% of cases respectively were fair results, 24% and 20% good, 36% and 47% very good, 23% and 25% excellent results. Conclusion: The BAROS evaluation of BPD highlights the importance of its flexibility: the new policy of adapting the procedure to individual characteristics caused a drop in the failure rate and an increase in good, very good and excellent results.

Background: Despite its simplicity, safety and good short-term results, progressive weight regain and a high incidence of complications have been reported after the adjustable silicone gastric banding (ASGB). The aim of this study is to evaluate the long-term results of this operation in our patient population. Methods: Between 1990 and 1996, 45 morbidly obese patients underwent insertion of an ASGB. The trend of the patients' BMI over time was studied using a linear mixed effect model adjusted for the preoperative BMI. So as to estimate the cumulative probability of band removal and the cumulative hazard function, Λ(t) Kaplan-Meier analysis was used. Results: 1 year after the operation, the average BMI was 79% of its preoperative value, which then increased linearly over time. The slope of the regression line was estimated at β =0.42, indicating an average increase of 0.42 BMI units per year. 27 bands (60%) were removed because of specific late complications. The cumulative risk of band removal increased linearly with time. The hazard rate was estimated to be λ =0.008 events/patient/month, corresponding to 0.1 events/patient/year. Conclusions: ASGB yielded good short-term results, but the progressive weight regain and constant risk of complications in the long term tend to nullify the optimism.

Objective To gain insight into the specific mechanisms by which biliopancreatic diversion (BPD) can improve insulin action. Materials and methods Nondiabetic severely obese patients ( n = 20) undergoing BPD were included. Waist-to-hip ratio and serum concentration of glucose, insulin, and leptin were determined before, at 4-day, and at 2 months after the operation. Insulin sensitivity was calculated according to the homeostatic model assessment (HOMA IR). Results A marked increase of insulin sensitivity was observed by the fourth day after the operation; at the second postoperative month, when body weight was still in the obese range and the food intake was substantially similar to the preoperative one, a further improvement of insulin action towards normality was found. Moreover, before BPD HOMA IR data were independently correlated both to BMI and waist-to-hip ratio values, whereas at 2 months after the operation data were in positive correlation only with the BMI. Discussion In obese patients, BPD seems to achieve recovery of insulin sensitivity by specific mechanisms independent of weight loss: the main causes of this sharp improvement might be both the intramyocellular fat depletion and the interruption of enteroinsular axis.

Early satiety following gastroplasty is due to the new anatomic conditions created by the operation and refers to a distressing or painful epigastric sensation after food consumption. Early satiation may act as an aversive stimulus, shaping eating habits and behaviour in such a way as to promote satisfactory weight loss and maintenance. This hypothesis was tested in patients who had undergone vertical banded gastroplasty (VBG). The duration of the sensation of early satiety was associated with the scores of questionnaires assessing eating behaviour, but seemed to be completely unrelated to the radiologically measured proximal pouch volume, energy intake and weight loss data. These findings suggest that cognitive factors play a substantial role in determining food intake and therefore in achieving weight goals following gastric restriction.

Background: The authors investigated the interrelationships between the components of the metabolic syndrome in severe obesity. Methods: In non-diabetic, severely obese women, the degree of obesity (BMI), the insulin sensitivity (from the Homeostatic Model of Assessment, HOMA), the serum leptin concentration and the presence of dyslipidemia and arterial hypertension were evaluated. Results: In insulin-resistant patients, an overall impaired metabolic status and a greater cardiovascular risk were observed, while serum leptin concentration was higher than in the insulin-sensitive ones. Leptin levels and HOMA data correlated independent of BMI findings, while the presence of dyslipidemia and hypertension was unrelated to the other metabolic syndrome factors. Conclusion: In severely obese women, although other factors independently intervene, serum leptin has a role in developing the metabolic syndrome.

Background: The authors evaluated the relationship between leptin and the clinical, anthropometric and metabolic variables connected to the metabolic syndrome in obese individuals. Methods: A large group of patients with different degrees of obesity was investigated: body mass index (BMI) values, serum leptin, fasting glucose and insulin, triglycerides and HDL-cholesterol concentrations, insulin resistance index and blood pressure were measured. Results: On multiple regression analysis, serum leptin levels appeared to be positively correlated to the BMI and to the serum HDL-cholesterol concentration. Principal component factor analysis revealed three factors, explaining 61.3% of the total variance of the sample. General features of these factors were: factor 1 - BMI values and serum leptin and fasting glucose concentration; factor 2 - systolic and diastolic blood pressure and serum triglycerides and HDL-cholesterol concentration; factor 3 - fasting serum insulin concentration and insulin resistance index. Conclusions: In obese subjects multiple factors underlie the metabolic syndrome and therefore more than one mechanism may account for the clustering characteristics. In obese patients leptin loads only one factor, and therefore leptin does not appear to be a key feature in the metabolic syndrome. On the contrary, multiple correlation and factor analysis data give rise to the hypothesis that in obese patients, leptin may play a protective role against cardiovascular risk.

OBJECTIVE: We investigated the frequency of night eating (NE) among obese patients, its biological correlates, and its relationships with binge eating disorder (BED). METHODS: The eating behaviors of 166 patients enrolled in a weight-loss program were evaluated by a clinical interview specifically designed to detect BED and NE and by the Three Factor Eating Questionnaire. In all cases body weight and resting energy expenditure were measured. RESULTS: Among all obese subjects, NE was observed in 18 cases (15.7%) and BED in 54 cases (32.5%). NE was more frequent among BED than among non-BED patients; however, in the BED patients the Three Factor Eating Questionnaire Disinhibition and Hunger scores were higher than those in non-BED and NE individuals. Further, between NE and non-NE subjects with similar body weights, fully comparable resting energy expenditure was observed, indirectly indicating the lack of difference in overall daily food intake. CONCLUSIONS: Although these behaviors may well overlap, the data of this study uphold the concept that NE and BED have different underlying behavioral constructs.

Background: A technique for standard laparoscopic BPD was developed. Methods: Standard laparoscopic BPD was performed in 26 morbidly obese patients with mean BMI 43. Details of the technique, using 6 trocars, and instrumentation are described. Intestinal limb lengths were measured fully stretched, and the gastric remnant volume was also measured. Both enteroenteral and gastrointestinal anastomoses were fashioned with a side-to-side technique using the endoGIA, the conjoined defect being closed with a manual running seromuscular suture. Results: 6 and 12 month weight loss results were similar to those obtained in open BPD. Conclusion: Laparoscopic standard BPD is a feasible alternative to the open operative procedure, the major advantage being the likely near total avoidance of wound hernia.

Background: We investigated the relationships between body mass index (BMI), serum leptin and serum HDL-cholesterol. Material and Methods: A retrospective study was carried out in 80 patients who did not have type 2 diabetes mellitus and/or high blood pressure. Results: Both serum leptin and HDL-cholesterol serum levels correlated with BMI (r = 0.616 and r = -0.269, respectively), but when the BMI values were kept constant no correlation was found between serum leptin and HDL-cholesterol both in simple and in multiple regression. Conclusion: The findings suggest that serum leptin concentration is completely independent of lipid metabolism.

The aim of this study was to analyse radiological findings in patients surgically treated for adjustable silicone gastric banding (ASGB) for morbid obesity complicated by band penetration into the gastric lumen. We reviewed the records of four patients with surgically confirmed penetration of gastric band into the gastric lumen; three had preoperative opaque meal, one only a plain abdominal film. Vomiting was the presenting symptom in two cases, whereas others had new weight gain and loss of early satiety. Two patients had normally closed bands: radiography showed that their position had changed from previous controls and the barium meal had passed out of their lumen. Two patients had an open band. One patient had the band at the duodeno-jejunal junction, and the tube connecting the band to the subcutaneous port presented a winding course suggesting the duodenum. In the other case, both plain film and barium studies failed to demonstrate with certainty the intragastric position of the band. As ASGB is becoming widely used, radiologists need to be familiar with its appearances and its complications. Band penetration into the stomach is a serious complication which needs band removal. Patients with this problem, often with non-specific symptoms and even those who are asymptomatic, are encountered during radiographic examinations requested either for gastric problems or follow-up purposes, and have to be properly diagnosed.

Background The purpose of this study was to evaluate the impairment of body image in patients with binge eating disorder (BED). Materials and methods A 3-year longitudinal study was undertaken in 25 BED obese patients and 26 non-BED obese patients who had undergone biliopancreatic diversion (BPD) for obesity. The body image was evaluated by the Eating Disorder Inventory body dissatisfaction scale. Results Within the third postoperative year, 95% of patients had stopped binge eating. After the first postoperative year, the BED patients showed body dissatisfaction scores higher than those of the non-BED group, whereas the longer-term results were closely similar. Conclusions Over the long term following BPD, binge eating disappears, which suggests that the loss of control over food intake is mainly dependent on dieting and on the preoccupation with food and body shape. The derangement of body image in obese patients with BED is only partly dependent on inner feelings. In fact, the stable weight normalization after BPD is accompanied by a sharp improvement in body image in all cases. It appears that the complete normalization requires more time in BED patients than in their non-BED counterparts.

Biliopancreatic diversion (BPD) has made reacceptable the malabsorptive approach to the surgical treatment of obesity. The procedure, in a series of 2241 patients operated on during a 21-year period, caused a mean permanent reduction of about 75% of the initial excess weight. The indefinite weight maintenance appears to be due to the existence of a threshold absorption capacity for fat and starch, and thus energy, and the weight loss is partly due to increased resting energy expenditure. Beneficial effects other than those consequent to weight loss or reduced nutrient absorption included permanent normalization of serum glucose and cholesterol without any medication and on totally free diet in 100% of cases, both phenomena being due to a specific action of the operation. Operative mortality was less than 0.5%. Specific late complications included anemia, less than 5% with adequate iron or folate supplementation (or both); stomal ulcer, reduced to 3.2% by oral H2-blocker prophylaxis; bone demineralization, increasing up to the fourth year and tending to decrease thereafter, with need of calcium and vitamin D supplementation; neurologic complications, totally avoidable by prompt vitamin B administration to patients at risk; protein malnutrition, which was reduced to a minimum of 3% with 1.3% recurrence, in exchange with a smaller weight loss, by adapting the volume of the gastric remnant and the length of the alimentary limb to the patient's individual characteristics. It is concluded that the correct use of BPD, based on the knowledge of its mechanisms of action, can make the procedure an effective, safe one in all hands.

OBJECTIVE: To investigate the effects of weight loss on sex hormone-binding globulin (SHBG) in massively obese males and whether normal SHBG concentrations could be obtained regardless or not of the achievement of normal body weight values. DESIGN AND SUBJECTS: Sera were collected for SHBG determination from 63 massively obese men, partly before they underwent biliopancreatic diversion (pre-op group=11) and partly during the post-surgical follow up (post-op group=52), and twenty normal weight healthy control men. MEASUREMENTS: Serum SHBG was measured using a noncompetitive liquid-phase immunoradiometric assay. RESULTS: Baseline general characteristics were similar in both obese groups. Obese patients in the post-op group had lost 46.4±2.9 kg since they had undergone operation, namely during a mean period of 14.9±13.8 (range 1–58) months follow up. Obese groups had significantly lower SHBG than normal weight controls (66.2±18.6 nmol/l). However, pre-op obese (19.9±5.5 nmol/l) had significantly lower values than post-op obese subjects (45.5±24.8 nmol/l; P