Search

The objectives of this study were to determine the incidence of and associated risks for falls and fractures after gastric bypass surgery for morbid obesity and to determine the clinical signs of bone loss. The sample consisted of 167 individuals at a mean age of 47 years (SD = 10). Ten participants (6%) reported a decrease in height since surgery, and 33 (20%) reported a decrease in height since they were 20 years old. Eight participants (5%) reported postoperative fractures. Twenty-three participants (13.8%) reported falling once since surgery, and 34 (20.4%) reported falling two or more times since surgery. Twelve participants reported a new diagnosis of osteoporosis postoperatively, and 1 participant reported a new diagnosis of osteopenia. Sixty-seven percent (n = 112) of the participants were never advised to undergo a bone density test postoperatively. The findings from this study suggest that bone loss is a critical issue in this patient population, with 25% (n = 42) reporting a decrease in height, 8% (n = 13) reporting a new diagnosis of osteoporosis or osteopenia, and 5% (n = 8) reporting fractures during a mean postoperative interval of 2.4 years. In addition, risk for skeletal fragility is profound in this cohort of individuals, with 34% (n = 57) indicating a history of one or more falls postoperatively. The results from this study clearly indicate a need for early recognition of bone loss in this population so that timely interventions can be initiated to prevent further loss and subsequent fractures. Copyright © 2009 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

Bariatric surgery leads to sustainable long-term weight loss and may be curative for such obesity-related comorbidities as diabetes and obstructive sleep apnea in severely obese patients. The Roux-en-Y gastric bypass has become the most common procedure for patients undergoing bariatric surgery. The procedure carries a mortality risk of up to 1 percent and a serious complication risk of up to 10 percent. Indications include body mass index of 40 kg per m2 or greater, or 35 kg per m2 or greater with serious obesity-related comorbidities (e.g., diabetes, obstructive sleep apnea, coronary artery disease, debilitating arthritis). Pulmonary emboli, anastomotic leaks, and respiratory failure account for 80 percent of all deaths 30 days after bariatric surgery; therefore, appropriate prophylaxis for venous thrombo-embolism (including, in most cases, low-molecular-weight heparin) and awareness of the symptoms of common complications are important. Some of the common short-term complications of bariatric surgery are wound infection, stomal stenosis, marginal ulceration, and constipation. Symptomatic cholelithiasis, dumping syndrome, persistent vomiting, and nutritional deficiencies may present as long-term complications. [ABSTRACT FROM AUTHOR]

Background: Symptoms of reflux after sleeve gastrectomy (SG) are common and may be refractory to medical treatment., Objectives: To assess outcomes of conversion of SG to Roux-en-Y gastric bypass (RYGB) with concomitant repair of hiatal hernias on symptoms of reflux., Setting: Tertiary community hospital., Methods: We reviewed data from all consecutive patients (2018-2021) who underwent conversion from SG to RYGB for refractory reflux symptoms. Concomitant hiatal hernias were diagnosed endoscopically or radiographically. Improvement in reflux symptoms, nausea, vomiting, dysphagia, or abdominal pain and postoperative proton pump inhibitor (PPI) use were compared with McNemar statistical test. Data are reported as mean ± standard deviation., Results: In total, 64 patients (92% female; 48 ± 10 years) underwent conversion from SG to RYGB and repair of concomitant hiatal hernias 4 ± 3 years after the index SG. A hiatal hernia was detected preoperatively in 57 of 64 patients (89%) by either upper gastrointestinal contrast studies, computed tomography scan, or esophagogastroduodenoscopy. At 29 ± 14 months postconversion to RYGB, percent total body weight loss was 14 ± 9% and percent excess weight loss was 37 ± 29%, and body mass index decreased from 37 ± 7 to 32 ± 6 kg/m 2 . Symptoms of reflux and use of PPI improved during the early follow-up period (median: 14 months; P < .001) and was sustained at late follow-up (median: 32 months; P < .01). Improvement of nausea and dysphagia reached statistical significance at late follow-up (median: 32 months; P < .01). Vomiting and abdominal pain decreased with time but did not reach statistical significance. Postoperative complications were deep surgical-site infection (n = 3), pulmonary embolism (n = 1), bleeding (n = 5), reoperation (n = 3), and 30-day readmission (n = 6)., Conclusions: Conversion of SG to RYGB and repair of concomitant hiatal hernia improves reflux symptoms, nausea, and dysphagia, reduces PPI use, and confers additional weight loss., Competing Interests: Disclosures The authors have no commercial associations that might be a conflict of interest in relation to this article., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Post-bariatric surgery hiatal hernias are associated with a cluster of symptoms, including bloating (nausea/vomiting or fullness), abdominal pain, regurgitation, and food intolerance or dysphagia (BARF)., Objectives: To report the short-term outcomes of repairing post-bariatric surgery hiatal hernias in patients with BARF., Setting: Large, multispecialty group practice with university affiliation., Methods: We reviewed the records of all consecutive patients who underwent repair of post-bariatric surgery hiatal hernias (2012-2020). Data are shown as means ± standard deviations., Results: We repaired hiatal hernias in 52 patients (age, 57 ± 10 yr), 4 ± 3 years post sleeve gastrectomy (SG; n = 27), 11 ± 6 years following Roux-en-Y gastric bypass (RYGB; n = 24), and 11 years post duodenal switch with SG (DS-SG; n = 1). Diagnoses were made by upper gastrointestinal contrast study (80%), computed tomography (70%), and/or endoscopy (56%). Hernias in patients with SG were repaired by a posterior cruroplasty after reducing the neo-stomach into the abdomen (n = 11 SG patients; n = 1 DS-SG patient) or converting the SG to RYGB (n = 16). All 24 RYGB patients underwent hernia repair similarly. At 12 ± 10 months of follow-up, dysphagia or regurgitation improved in >80% of patients; nausea, vomiting, or abdominal pain improved in 70% of patients; and heartburn persisted in 56% of patients. Subsequent recurrent hernias that required operative repair developed in 3 patients., Conclusions: Hiatal hernias containing the neo-stomach present earlier after SG than RYGB. The diagnosis can be made with a combination of imaging studies and endoscopy. Repair of post-bariatric surgery hiatal hernias markedly improves symptoms of BARF in most patients., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Many surgeons recommend weight loss in preparation for orthopedic procedures, yet the impact of surgically induced weight loss before orthopedic procedures is not clear. We undertook a literature review to assess the impact of bariatric surgery on the outcomes of total joint arthroplasty (TJA). We searched PubMed, Medline, Cochrane Library, and Google Scholar for studies (2010-2017) that evaluated the associations between obesity, bariatric surgery, and orthopedic surgery. Nine studies found that prior bariatric surgery decreased major and minor post-operative complications, operating room (OR) time, length of stay (LOS), risk of re-operation, and 90-day re-admissions after TJA. Two studies found that bariatric surgery patients had a higher reoperation rate for stiffness and infection as well as need for revision within 90 days after TJA. One meta-analysis found no statistically significant differences in wound infections, revisions, or mortality irrespective of bariatric surgery status; and another meta-analysis showed reduced medical complications, LOS, and OR time. Our review highlights many gaps in our knowledge and the need for additional studies to define the impact of the bariatric-first approach on TJA outcomes. We propose a framework from lessons learned to raise awareness of medical and surgical options of weight management before elective orthopedic operations in patients with obesity.

Nonalcoholic fatty liver disease (NAFLD) is closely linked to the metabolic syndrome and is highly prevalent in bariatric patients. The criterion standard to diagnose NAFLD is a liver biopsy specifically to detect inflammatory changes characteristic of nonalcoholic steatohepatitis. Technologic advancements will improve the accuracy of current noninvasive modalities. Modification of risk factors via food management is important to prevent the progression of NAFLD to nonalcoholic steatohepatitis and cirrhosis. Several clinical trials are underway for pharmacologic treatment of NAFLD; currently the mainstay of treatment is insulin sensitizers and vitamin E. There is strong evidence bariatric surgery improves biochemical and histologic features of NAFLD and therefore, bariatric surgery should be considered as a treatment of NAFLD in patients with obesity. Gastric bypass exhibits antilipogenic, antiinflammatory, antioxidant, and antidiabetic properties in the livers of laboratory animals; thereby, providing a unique window to study regulation of body adiposity and insulin resistance., (Copyright © 2020 American Society for Bariatric Surgery. All rights reserved.)

High-level evidence of the impact of bariatric surgery on nonalcoholic fatty liver disease (NAFLD) is lacking. We conducted a systematic review and meta-analysis according to the Cochrane guidelines to assess the resolution of NAFLD after bariatric surgery. We searched PubMed, EMBASE, Web of Science, and CENTRAL for English language publications on bariatric surgery and NAFLD. We included randomized controlled trials and observational studies of patients with NAFLD who underwent bariatric surgery and were assessed by liver biopsy or liver function tests. Duodenal switch and biliopancreatic diversion were excluded. Our primary outcome was histologic or biochemical improvement of NAFLD. Twenty-one studies (12 Roux-en-Y gastric bypass [RYGB], 3 adjustable gastric banding, 2 sleeve gastrectomy, 1 vertical banded gastroplasty, 3 multiple procedures) enrolling 2374 patients were included. The pooled proportion of patients who had improvement of steatosis was 88% (95% confidence interval [CI]: .80, .94). Steatohepatitis improved in 59% (95% CI: .38, .78) and fibrosis improved or resolved in 30% of patients (95% CI: .21, .41). Similarly, aspartate aminotransferase (AST) improved in 32% of patients (95% CI: .22, .42) and alanine aminotransferase improved in 62% of patients (95% CI: .42, .82). After RYGB, the number of patients who had improvement in NAFLD was higher than the average of all the pooled studies. Bariatric surgery improves steatosis and steatohepatitis in the majority of patients and improves or resolves liver fibrosis in 30% of patients. RYGB has a greater impact on NAFLD histology compared with other procedures. This contemporary meta-analysis strongly suggests that bariatric surgery should be considered as a treatment of NAFLD., (Copyright © 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Purpose: Pseudotumor cerebri is a debilitating condition that causes severe headaches and progressive visual field loss. In this report, we present a patient with Class III obesity, with pseudotumor cerebri who failed medical management and attempted weight loss via diet and exercise., Observations: After undergoing bariatric surgery, the patient had significant weight loss and improvement of visual field defects., Conclusion and Importance: These results suggest that bariatric surgery may be an effective option for patients with rapidly progressing visual loss due to pseudotumor cerebri.

Background: Obesity is a relative contraindication to organ transplantation. Preliminary reports suggest that bariatric surgery may be used as a bridge to transplantation in patients who are not eligible for transplantation because of morbid obesity., Setting: The Bariatric Center at Tampa General Hospital, University of South Florida, Tampa, Florida., Methods: We reviewed the outcomes of 16 consecutive patients on hemodialysis for end-stage renal disease (ESRD) who underwent bariatric surgery from 1998 to 2016. Demographics, comorbidities, weight loss, as well as transplant status were reported. Data is mean ± SD., Results: Six men and ten women aged 43-66 years (median = 54 years) underwent laparoscopic Roux-en-Y gastric bypass (LRYGB, n = 12), laparoscopic adjustable gastric banding (LAGB, n = 3), or laparoscopic sleeve gastrectomy (LSG, n = 1). Preoperative BMI was 48 ± 8 kg/m 2 . Follow-up to date was 1-10 years (median = 2.8 years); postoperative BMI was 31 ± 7 kg/m 2 ; %EBWL was 62 ± 24. Four patients underwent renal transplantation (25%) between 2.5-5 years after bariatric surgery. Five patients are currently listed for transplantation. Five patients were not listed for transplantation due to persistent comorbidities; two of these patients died as a consequence of their comorbidities (12.5%) more than 1 year after bariatric surgery. Two patients were lost to follow-up (12.5%)., Conclusion: Bariatric surgery is effective in patients with ESRD and improves access to renal transplantation. Bariatric surgery offers a safe approach to weight loss and improvement in comorbidities in the majority of patients. Referrals of transplant candidates with obesity for bariatric surgery should be considered early in the course of ESRD.

Background: Oxidative stress and inflammation are implicated in the pathogenesis of steatohepatitis. We hypothesize that Roux-en-Y gastric bypass reduces oxidative stress and inflammation in the liver of obese rats via activation of AMPK-α., Methods: Obese Sprague-Dawley male rats underwent either sham operation or Roux-en-Y gastric bypass. Hepatic TNF-α, NF-κB, IRS-2, PI3 kinase, PKC-ζ, NOX2, and AMPK-α were measured. Mechanistic studies were done in a rat Kupffer cell line (RKC1) that was treated with free fatty acids to mimic lipotoxicity and then transfected with AMPK-α siRNA. Reactive oxygen species, TNF-α, NF-κB, AMPK-α, p-AMPK-α, PPAR-γ, and NOX2 were measured. A t test was used., Results: Roux-en-Y gastric bypass lowered nonfasting serum glucose, improved the glucose tolerance test, and induced IRS2/PI3 kinase interaction. Additionally, Roux-en-Y gastric bypass decreased hepatic NOX2, PKC-ζ, TNF-α expression and activation of NF-κB. Free fatty acids increased reactive oxygen species, TNF-α protein, NOX2 protein, and activated NF-κB. Rosiglitazone attenuated the free fatty acids-induced increase in reactive oxygen species, TNF-α, NOX2, and NF-κB; blocking AMPK-α by siRNA abolished the effects of rosiglitazone., Conclusion: Roux-en-Y gastric bypass exhibits antidiabetic properties and is associated with downregulation of proinflammation genes and oxidative stress in the liver and within Kupffer cells via activation of AMPK-α., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Nonalcoholic fatty liver disease (NAFLD) is prevalent in obese patients. We sought to determine the effects of bariatric surgery on the histological features of NAFLD. Two blinded pathologists graded liver biopsies done during bariatric procedures and subsequent operations in 160 patients using the Brunt classification. Data are mean ± SD. Interval between biopsies was 31 ± 26 months. Initial biopsies demonstrated steatosis 77 %, lobular inflammation 39 %, and chronic portal inflammation 56 %. Steatohepatitis was present in 27 %. Grade 2-3 fibrosis was present in 27 %, and cirrhosis was present in one patient. On post-bariatric biopsy, steatosis resolved in 75 %, lobular inflammation resolved in 75 %, chronic portal inflammation resolved in 49 %, and steatohepatitis resolved in 90 %. Fibrosis of any grade resolved in 53 % and improved in another 3 % of patients. Grade 2 fibrosis resolved in 58 %, improved in 3 %, and did not worsen in 11 %. Bridging fibrosis resolved in 29 %, improved in 29 %, and did not worsen in 29 %. Bariatric surgery is associated with resolution of steatosis or steatohepatitis in the majority of patients. More importantly, grade 2 or 3 (bridging) fibrosis is resolved or improved in 60 % of patients. Bariatric surgery should be considered as a treatment of NAFLD in severely obese patients.

Organisms of the phylum Porifera, that is, sponges, utilize enzymatic hydrolysis to concatenate bioavailable inorganic silicon to produce lightweight, strong, and often flexible skeletal elements called spicules. In their optical transparency, these remarkable biomaterials resemble fused silica, despite having been formed under ambient marine biological conditions. Although previous studies have elucidated the chemical mechanisms of spicule formation and revealed the extensive hydration of these glasses, their precise composition and local and medium-range structures had not been determined. We have employed a combination of compositional analysis, (1) H and (29) Si solid-state nuclear magnetic resonance spectroscopy, and synchrotron X-ray total scattering to characterize spicule-derived silica produced by the demosponge Tethya aurantia. These studies indicate that the materials are highly hydrated, but in an inhomogeneous manner. The spicule-derived silica is, on average, perfectly dense for the given extent of hydration and regions of fully condensed and unstrained SiO networks persist throughout each monolithic spicule. To accommodate chemical strain and defects, the extensive hydration is concentrated in distinct regions that give rise to mesostructural features. The chemistry responsible for producing spicule silica resembles hydrolytic sol-gel processing, which offers exceptional control over the precise local atomic arrangement of materials. However, the specific processing involved in forming the sponge spicule silica further results in regions of fully condensed silica coexisting with regions of incomplete condensation. This mesostructure suggests a mechanism for atomistic defect tolerance and strain relief that may account for the unusual mechanical properties of the biogenic spicules., (© 2014 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Objective: Adipose tissue is a robust source of adipose-derived stem cells (ADSCs) that may be able to provide secreted factors that promote the ability of wounded tissue to heal. However, adipocytes also have the potential to dedifferentiate in culture to cells with stem cell-like properties that may improve their behavior and functionality for certain applications. Approach: ADSCs are adult mesenchymal stem cells that are cultured from the stromal vascular fraction of adipose tissue. However, adipocytes are capable of dedifferentiating into cells with stem cell properties. In this case study, we compare ADSC and dedifferentiated fat (DFAT) cells from the same patient and fat depot for mesenchymal cell markers, embryonic stem cell markers, ability to differentiate to adipocytes and osteoblasts, senescence and telomerase levels, and ability of conditioned media (CM) to stimulate migration of human dermal fibroblasts (HDFs). Innovation and Conclusions: ADSCs and DFAT cells displayed identical levels of CD90, CD44, CD105, and were CD34- and CD45-negative. They also expressed similar levels of Oct4, BMI1, KLF4, and SALL4. DFAT cells, however, showed higher efficiency in adipogenic and osteogenic capacity. Telomerase levels of DFAT cells were double those of ADSCs, and senescence declined in DFAT cells. CM from both cell types altered the migration of fibroblasts. Despite reports of ADSCs from a number of human depots, there have been no comparisons of the ability of dedifferentiated DFAT cells from the same donor and depot to differentiate or modulate migration of HDFs. Since ADSCs were from an obese diabetic donor, reprogramming of DFAT cells may help improve a patient's cells for regenerative medicine applications.

Purpose: Over 250,000 bariatric surgical procedures for the management of morbid obesity are performed in the United States annually. The Roux-en-Y gastric bypass (RYGB) is an effective bariatric procedure because of its efficacy in achieving significant weight loss, low complication rates, and outcomes in reducing cardiovascular and all cause mortality. Because food bypasses the portion of the small intestine whereby micronutrients are normally absorbed, micronutrient deficiencies following surgery may lead to iron deficiency anemia. Iron deficiency anemia is estimated to occur in 6%-50% of post-RYGB patients. Consequently, the procedure requires lifelong behavioral change to ensure therapeutic iron supplementation., Data Sources: A nonsystematic literature search for clinical guidelines, review articles, and research was conducted., Conclusions: Clinical recommendations include prophylactic iron supplementation with ferrous sulfate to prevent iron deficiency anemia. Ferrous sulfate is a well-established cause of constipation possibly resulting in low patient tolerability and subsequent low adherence rates., Clinical Implications: Strategies for managing the side effects of iron supplementation including constipation may require a unique approach based on the anatomical and functional changes in the post-RYGB patient and the requirement for lifelong iron supplementation., (©2013 The Author(s) ©2013 American Association of Nurse Practitioners.)

Background: Obesity-related fatty liver disease is linked to mitochondrial dysfunction and oxidative stress. Nuclear factor (erythroid-derived 2)-like 2 (Nrf2) regulates mitochondrial function and is a transcriptor of multiple genes that produce antioxidants. Because Roux-en-Y gastric bypass (RYGB) improves fatty liver and decreases the oxidative stress in the liver, we hypothesized that RYGB activates Nrf2 and increases cytochrome C oxidase subunit II (COX-II) in the liver of obese rats., Methods: Sprague-Dawley rats were fed a high-fat diet for 16 weeks. The obese rats underwent either RYGB (n = 20) or a sham operation (n = 20). The tissues were harvested 13 weeks postoperatively. The nuclear fraction and mitochondrial extracts were used for protein analysis with immunoblotting. Immunostaining was done on liver sections for COX-II, Nrf2, and the macrophage marker ED2 and F4/80. The gels were quantified using densitometry; P ≤ .05 was considered significant., Results: RYGB increased COX-II expression in the liver sections (3330 ± 56 versus 2056 ± 37 for RYGB versus sham, P < .001). The total (nuclear and cytoplasmic) Nrf2 expression was high in the obese sham-operated control (2456 ± 45 versus 4352 ± 76, RYGB versus sham, P < .001). However, the nuclear fraction of Nrf2 was significantly increased in the RYGB liver (2341 ± 46 versus 1352 ± 35, RYGB versus sham, P < .001). Furthermore, Nrf2 protein co-localized with the molecular markers of Kupffer cells., Conclusions: Diet-induced fatty liver is associated with mitochondrial dysfunction. RYGB increases COX-II, which is involved in mitochondrial respiration, and increases the nuclear translocation of the Nrf2 transcriptional factor, which is involved in mitochondrial biogenesis and function. Taken together, these data suggest that surgically induced weight loss is associated with improved mitochondrial function in obese rats., (Copyright © 2013. Published by Elsevier Inc.)

Background: We have demonstrated that activated Kupffer cells undergo accelerated apoptosis via Toll-like receptor (TLR)-4 and protein kinase C (PKC)-ζ-dependent nuclear factor (NF)-κB activation. Because PKC-ζ plays a pivotal role in cell signaling, we sought to determine the signaling pathway of PKC-ζ in Kupffer cell apoptosis., Methods: Mouse Kupffer cell line (MKCL3-2) were transfected with PKC-ζ small interfering RNA (siRNA) and then treated with elastase alone or elastase along with the extracellular signal-regulated kinase (ERK) inhibitor U0126. Cell extracts were assayed for PKC-ζ (protein and activity), TLR-4, NF-κB nuclear translocation, phosphorylated ERK-1/2, activated caspase-3, and DNA fragmentation. All n ≥3; data are expressed as mean values ± standard deviations; means were compared using the t test; P < .05 was considered significant., Results: Elastase upregulated TLR-4, PKC-ζ, NF-κB, ERK-1/2, caspase-3, and DNA fragmentation (all P < .01 versus control). Transfection with PKC-ζ siRNA attenuated the elastase-induced upregulation of PKC-ζ activity, NF-κB, ERK-1/2, caspase-3, and DNA fragmentation (all P < .01 versus control). The interaction of PKC-ζ with ERK-1/2 was increased by elastase and was attenuated by PKC-ζ siRNA as confirmed by co-immunoprecipitation and immunofluorescent staining., Conclusion: Activation of Kupffer cells upregulates PKC-ζ activity, increases apoptosis, and induces nuclear translocation of NF-κB via ERK-1/2-dependent pathways. Inhibiting the activity of PKC-ζ significantly attenuates Kupffer cell apoptosis, NF-κB, and ERK-1/2 activation. The interaction of PKC-ζ and ERK-1/2 warrants further investigation., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Background: Adiponectin has anti-inflammatory properties and is increased with weight loss. Tumor necrosis factor (TNF)-α is a pro-inflammatory cytokine that negatively regulates adiponectin. Previously, we have demonstrated that Roux-en-Y gastric bypass (RYGB) induces weight loss and improves steatosis in obese rats. We hypothesized that RYGB would alter the interplay of TNF-α and adiponectin signaling in the postoperative period., Methods: Obese Sprague-Dawley male rats that had undergone RYGB (n = 5) or sham (n = 4) were euthanatized at 9 weeks postoperatively. The adiponectin levels from serial serum samples were measured by enzyme-linked immunosorbent assay. Adiponectin, adiponectin receptor 2, and TNF-α mRNA from adipose and liver samples were quantified by reverse transcriptase-polymerase chain reaction. Data are presented as mean ± standard deviation; using a t test, P <.05 was significant., Results: RYGB did not change the serum adiponectin, adipose tissue adiponectin mRNA, or hepatic adiponectin receptor 2 levels compared with the levels in the sham-operated rats (P >.05). However, the TNF-α mRNA levels had decreased in the adipose tissue (P >.05) but remained unchanged in the liver compared with the sham controls (P >.05)., Conclusion: Surgically-induced weight loss in a rat model of RYGB did not increase adiponectin signaling in the immediate postoperative period but was associated with decreased pro-inflammatory signaling in the adipose tissue. During this period, pro-inflammatory signaling might play a more important role than adiponectin. Additional studies with longer follow-up are necessary to determine whether adiponectin plays a role in weight loss and improvement of steatosis after RYGB., (Copyright © 2010. Published by Elsevier Inc.)

Introduction: Roux-en-Y gastric bypass (RYGB) improves steatosis and reduces liver triglycerides in obese rats. Sirtuin1 (SIRT1) and AMP-activated protein kinase (AMPK) are key metabolic regulators that reduce lipogenesis and increase fatty acid oxidation. LKB1 phosphorylates AMPK and may activate SIRT1. We hypothesize that RYGB in obese rats is associated with an upregulation of the LKB1-AMPK-SIRT1 signaling pathway., Methods: Obese Sprague-Dawley male rats underwent RYGB or sham. Liver tissue was obtained at 9 weeks postoperatively. Protein levels of SIRT1, LKB1, p-LKB1, AMPKalpha, p-AMPKalpha, and p-protein kinase C-zeta (PKC-zeta ) were determined. Protein associations of LKB1 with each of SIRT1, AMPKalpha, and PKC-zeta were determined by coimmunoprecipitation.Data are mean +/- SD; for t test, p<0.05 was significant., Results: RYGB increased protein levels of hepatic AMPKalpha, p-AMPKalpha, and SIRT1 (all p<0.001 vs. sham); p-LKB1 but not LKB1 increased after RYGB (p<0.001 vs. sham). Physical interactions of LKB1-AMPK and LKB1-SIRT1 increased after RYGB (p<0.001 vs. sham). Although PKC-zeta mRNA and p-PKC-zeta did not change, interactions between LKB1 and PKC-zeta increased after RYGB (p<0.001 vs. sham)., Conclusion: RYGB increases hepatic levels of SIRT1, AMPK, and p-AMPK as well as increasing interactions of LKB1 with AMPK or SIRT1. p-PKC-zeta may play an intermediary role in the interaction between AMPK and SIRT. These findings demonstrate key signaling changes in powerful metabolic regulators that may account for the resolution of steatosis after RYGB.

Background: Recent evidence suggests that obesity is associated with hypo-adiponectinmia and chronic inflammation. Adiponectin regulates fat storage, energy expenditure, and inflammation. We propose that high fat diet induces steatohepatitis, reduces serum adiponectin, and liver adiponectin receptors., Methods: A 4-week-old C57BL male mice were fed high fat diet (n = 8) or regular chow (control; n = 6) for 7 weeks. Body weight, liver weight, and serum adiponectin were measured. Liver sections were stained with hematoxylin and eosin and oil red for fat content. Liver homogenates were used for protein (immunoblotting) and mRNA (reverse transcription PCR) of Toll-like receptor 4 (TLR4), tumor necrosis factor alpha (TNF-alpha), interleukin (IL)-6, sterol regulatory element-binding proteins (SREBP)-1c, and adiponectin receptors (AdipoR1/AdipoR2) in addition to nuclear phorsphorylated p65NF-kappaB. Gels were quantified using densitometry; t test was used, and p < 0.05 was significant., Results: High fat diet increased body (50%) and liver weight (33%), as well as hepatocyte fat content and ballooning. Mice fed high fat diet exhibited reduced serum adiponectin and liver AdipoR2. High fat diet increased hepatic levels of SREBP-1c, TLR4, TNF-alpha, and IL-6 protein and mRNA and increased activation of p65NF-kappaB., Conclusions: Diet-induced liver steatosis is associated with increased lipogensis, upregulation of pro-inflammatory cytokines, and transcription factors as well as downregulation of AdipoR2. Reduction in serum adiponectin suggests that adiponectin signaling may be the crosslink between high fat diet, hepatic inflammation, and nonalcoholic fatty liver disease.

Background: To introduce the 2-incision technique for laparoscopic adjustable gastric banding (LAGB) and report our experience with 25 consecutive patients. Newer applications of minimally invasive laparoscopic techniques have been touted as revolutionary., Methods: We have introduced a technique for LAGB that uses 2 skin incisions: 1 incision in the right upper quadrant (2.5 cm) that accommodates 2 trocars (11 and 5 mm) through which the dissection and implantation of the band were undertaken, and a 0.5-cm incision in the left upper quadrant for the 5-mm videoscope. The band reservoir was placed in a subcutaneous pocket through the upper quadrant incision. Previously, we used a standard 5-incision technique: 2 in the right upper quadrant, 2 in the left paramedian, and 1 in the subxyphoid area to retract the liver. The data from 25 consecutive 2-incision LAGB procedures (October 2007 to April 2008) were compared with the data from 19 consecutive standard 5-incision LAGB procedures (July 2007 to October 2007). The data are presented as mean +/- SD. The t test was used to compare the mean values, and P <.05 was considered significant., Results: The mean estimated blood loss in the 2-incision LAGB was 54 +/- 2 mL compared with 17 +/- 1 mL in the standard technique (P = .040). The mean operating time for the 2-incision LAGB was 119 +/- 1 minutes compared with 103 +/- 1 minutes for the standard technique (P = .047). No mortality or procedure-related complications (e.g., erosion, slippage) occurred in the 2 groups., Conclusion: Two-incision LAGB is feasible; however, it is associated with an increased operating time and blood loss. The operating time and blood loss might improve with standardization of the operative technique and introduction of newly designed flexible tip instruments. Additional prospective studies with a larger sample size are needed to assess the efficacy and benefit of the 2-incision technique versus the standard technique.

Background: The number of bariatric procedures has continued to increase worldwide. However, experience with tumors arising in the esophagus or stomach after gastric bypass is lacking. We report our technique for curative resection of esophageal adenocarcinoma in a patient who had undergone previous gastric bypass and review the reported data on esophagogastric tumors after bariatric surgery., Methods: We have described the operative details of esophagectomy after gastric bypass and reviewed the published data regarding type of bariatric surgery, gender predilection, presentation, symptom duration, cancer stage, and prognosis of patients with esophagogastric tumors occurring after bariatric surgery., Results: Only 22 esophagogastric tumors have been reported so far after bariatric surgery. The majority of them are locally advanced or metastatic at presentation., Conclusion: Esophagogastric tumors after bariatric surgery are uncommon. This operative technique pays particular attention to the altered anatomy, dissection of the gastric pouch, and preservation of the blood supply to the excluded stomach. This technique can also be applied to manage tumors arising in the gastric pouch after previous gastric bypass. Close collaboration with the bariatric surgeon during surgery is essential to achieve a successful oncologic outcome in this subset of patients.

Dysregulation of proinflammatory cytokines such as tumor necrosis factor-alpha (TNF-alpha) has been implicated in the pathogenesis of alcoholic liver injury. Sirtuin 1 (SIRT1) is an NAD(+)-dependent class III protein deacetylase that is known to be involved in regulating production of proinflammatory cytokines including TNF-alpha. In the present study, we examined the role of SIRT1 signaling in TNF-alpha generation stimulated by either lipopolysaccharide (LPS), acetaldehyde (AcH), or acetate (two major metabolites of ethanol) in two cultured macrophage cell lines. In both rat Kupffer cell line 1 (RKC1) and murine RAW 264.7 macrophages, treatment with either LPS, AcH, or acetate caused significant decreases in SIRT1 transcription, translation, and activation, which essentially demonstrated an inverse relationship with TNF-alpha levels. LPS, AcH, and acetate each provoked the release of TNF-alpha from RKC1 cells, whereas coincubation with resveratrol (a potent SIRT1 agonist) inhibited this effect. Conversely, addition of sirtinol (a known SIRT1 inhibitor) or knocking down SIRT1 by the small silencing SIRT1 plasmid (SIRT1shRNA) augmented TNF-alpha release, suggesting that impairment of SIRT1 may contribute to TNF-alpha secretion. Further mechanistic studies revealed that inhibition of SIRT1 by LPS, AcH, or acetate was associated with a marked increase in the acetylation of the RelA/p65 subunit of nuclear transcription factor (NF-kappaB) and promotion of NF-kappaB transcriptional activity. Taken together, our findings suggest that SIRT1-NF-kappaB signaling is involved in regulating LPS- and metabolites-of-ethanol-mediated TNF-alpha production in rat Kupffer cells and in murine macrophages. Our study provides new insights into understanding the molecular mechanisms underlying the development of alcoholic steatohepatitis.

Background: Toll-like receptor-4 (TLR4) and protein kinase C-zeta (PKC-zeta) play a role in macrophage activation. We hypothesized that deletion of TLR4 downregulates PKC-zeta and attenuates liver cell apoptosis in experimental pancreatitis., Methods: Acute pancreatitis was induced by choline-deficient ethionine diet in C57/BL6 (TLR4+/+ and TLR4-/-) mice., Results: During pancreatitis, staining for TLR4 and PKC-zeta, which colocalized in Kupffer cells but not in hepatocytes, increased in TLR4+/+ mice and decreased in TLR4-/- mice. In TLR4+/+ mice, pancreatitis increased TLR4 protein and mRNA and PKC-zeta protein and activity, nuclear factor (NF)-kappaB, ERK1/2, caspase-3 cleavage, and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) staining; all P < .01 versus controls. In TLR4-/- mice with pancreatitis, PKC-zeta mRNA and activity were reduced, ERK1/2 and caspase-3 did not increase, and NF-kappaB and TUNEL (mostly in hepatocytes) increased mildly (all P < .01 vs control). PKC-zeta did not interact directly with NF-kappaB; however, during pancreatitis, coimmunoprecipitation of PKC-zeta with ERK1/2 was increased in TLR4+/+ mice and was attenuated in TLR4-/- mice (all P < .01 vs control), indicating that PKC-zeta interacts with ERK1/2., Conclusion: Acute pancreatitis upregulates TLR4, PKC-zeta, NF-kappaB, and ERK1/2, and increases apoptosis in mice livers. PKC-zeta induces nuclear translocation of NF-kappaB via ERK1/2-dependent mechanisms. Deletion of TLR4 downregulates PKC-zeta, NF-kappaB, and ERK1/2, and attenuates pancreatitis-induced liver cell apoptosis.

Background: Unrealistic expectations of weight loss are prevalent in obese patients and can negatively affect their adherence to dietary and health goals. We sought to examine the expectations and perceived notions about weight loss in candidates for bariatric surgery., Methods: A total of 284 consecutive and prospective bariatric patients were surveyed using a validated Goals and Relative Weights questionnaire before an educational seminar. The participants categorized their weight loss expectations as "dream," "happy," "acceptable," and "disappointed" and rated the effect of surgically-induced weight loss on 21 indicators of health, quality of life, social functioning, and self-image on a 1-10 scale. The data are presented as the mean +/- standard deviation., Results: Of the 284 patients, 230 were women and 54 were men (age 45 +/- 10 years; body mass index 50 +/- 8 kg/m(2)). These patients stated that their "dream" weight would be 89% +/- 8% excess body weight loss and that 77% +/- 9%, 67% +/- 10%, 49% +/- 14% excess body weight loss would be their "happy," "acceptable," and "disappointed" weight, respectively. Participants ranked health, fitness, body image, work performance, and self-confidence as the most important benefits of bariatric surgery. Women had greater "happy" and "acceptable" weight loss expectations and put more emphasis on physical presence (r = .17-.33, P <.01). Younger patients put more emphasis on attractiveness and improvements in social and sex life after bariatric surgery (r = .15-.19, P <.01)., Conclusion: The results of our study have shown that although the candidates for bariatric surgery understand its benefits, they have unrealistic expectations of weight loss. In our study, the patients' most modest weight loss expectation, the "disappointed" weight, was equivalent to what providers would consider a successful weight loss outcome after bariatric surgery. Setting realistic expectations is an important aspect of the preoperative evaluation and education, especially for younger women.

Background: Adrenalectomy rates seem to be increasing in Florida, possibly due to increased availability of laparoscopic adrenalectomy, identification of incidentalomas, and access to care for minorities. We hypothesized that the rate of adrenalectomies in Florida increased from 1998-2005 while characteristics of patients, diagnoses, operations, and operating physicians changed over this period., Methods: Prospectively-collected, mandatory-reported, hospital discharge data for all inpatient adrenalectomies undertaken in Florida from 1998-2005 were obtained along with Florida census and physician certification and education data. Characteristics of adrenalectomy patients, diagnoses, operations, and physicians were analyzed., Results: 1816 adrenalectomies were available for analysis. Yearly rates of adrenalectomy nearly doubled from 1.20 to 2.26 per 100,000 Florida residents (P = .0024). Overall, patient characteristics such as demographics, indications and comorbidities did not change, whereas hospital charges increased and length-of-stay (LOS) significantly decreased (P = .0031 and P < .0001, respectively). There was a non-significant trend toward a yearly increase in physician volume and an inverse relationship between physician volume categories and mean LOS (P < .0001)., Conclusions: The rate of adrenalectomies is increasing in Florida. This increase was not associated with distinct trends in patient characteristics, although a significant decrease in LOS was identified. As these trends continue and adrenalectomy is applied more liberally, indications for adrenalectomy may need to be re-evaluated.

Background: Kupffer cells play an important role in sepsis-mediated liver injury. We tested the hypothesis that PKC-zeta plays a critical role in Kupffer cell apoptosis during sepsis., Methods: Sepsis was induced in rats by cecal ligation and puncture (CLP); 12 h later, livers were assayed for PKC-zeta, IKKalpha, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, Caspase-3, and DNA fragmentation. Kupffer cells from control rats were infected with AdPKC-zeta DN to inhibit PKC-zeta, or transfected with pCMVPKC-zeta to overexpress PKC-zeta, and then treated with lipopolysaccharide (LPS). Cellular extracts were assayed for PKC-zeta, IKKalpha, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, Caspase-3, and DNA fragmentation., Results: During sepsis, PKC-zeta localized in cells positive for the macrophage marker (F4/80). CLP upregulated PKC-zeta protein and activity, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, Caspase-3, and increased DNA fragmentation in rat livers (all p<0.001). AdPKC-zeta DN attenuated the LPS-induced upregulation of PKC-zeta activity, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, Caspase-3, and DNA fragmentation in Kupffer cells (all p<0.001), whereas overexpression of PKC-zeta augmented LPS-induced upregulation of IKKbeta, IKKgamma, NF-kappaB, Caspase-3, and DNA fragmentation (p<0.001)., Conclusion: PKC-zeta plays an important role in sepsis-induced apoptosis of Kupffer cells via activation of NF-kappaB and Fas/FasL. Manipulating the response of Kupffer cells to cellular stress may have important therapeutic implications.

Background: Urinary incontinence is common in obese individuals. We report on the prevalence of urinary incontinence in patients undergoing bariatric surgery and the effect of surgically induced weight loss on urinary incontinence., Methods: The prospectively collected data from 201 consecutive candidates for bariatric surgery were evaluated. The patients were surveyed using a questionnaire regarding the duration of incontinence, stress/urge incontinence symptoms, and incontinence severity before and after undergoing bariatric surgery. Severity was quantified using a validated index developed Data are presented as the mean +/- standard deviation., Results: Of 201 patients, 65 (32%) reported urinary incontinence. Of the 65 patients, 44 women and 1 man (age 49 +/- 11 years, body mass index 48 +/- 7 kg/m(2)) underwent Roux-en-Y gastric bypass (n = 42) or laparoscopic-assisted gastric banding (n = 3). Of the 38 patients who reported mild (2%), moderate (48%), and severe (50%) urinary incontinence preoperatively who had complete follow-up at > or = 6 months postoperatively, 19 (50%) had demonstrated resolution of urinary incontinence and 19 had reported residual slight-moderate (37%) or severe (13%) urinary incontinence. The overall severity score improved from 5.4 +/- 2.3 to 2.3 +/- 2.8 postoperatively (P <.001); the percentage of excess body weight loss was 61% +/- 19%. The patients reported subjective improvement within 4 months postoperatively or after a 50-lb weight loss., Conclusion: Urinary incontinence is prevalent in bariatric surgery patients. Surgically induced weight loss results in improvement or resolution of urinary incontinence in 82% of patients. The findings from this large cohort warrant additional investigation with urodynamic studies.

Protein kinase C-zeta (PKC-zeta) regulates cell death via NF-kappaB; therefore, we tested the hypothesis that PKC-zeta plays a critical role in pancreatitis-induced Kupffer cell apoptosis. Acute pancreatitis was induced in rats by cerulein injection 24 h later, livers were assayed for PKC-zeta, IKKalpha, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, and apoptosis was assessed with Caspase-3 and DNA fragmentation. Kupffer cells from unoperated rats were infected with a PKC-zeta domain-negative adenovirus (AdPKCzeta-DN) to inhibit PKC-zeta, or transfected with pCMVPKC-zeta to overexpress PKC-zeta, and then stimulated with pancreatic elastase; cellular extracts were assayed for PKC-zeta, IKKalpha, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, Caspase-3, and DNA fragmentation. Cerulein-induced pancreatitis upregulated PKC-zeta protein and activity, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, Caspase-3 and increased DNA fragmentation in rat livers (all p < 0.001 vs control). AdPKCzeta-DN abolished elastase-induced upregulation of PKC-zeta activity, IKKbeta, IKKgamma, NF-kappaB, Fas/FasL, Caspase-3 and DNA fragmentation (all p < 0.001 vs infection control), whereas overexpression of PKC-zeta augmented elastase-induced upregulation of IKKbeta, IKKgamma, Fas/FasL, Caspase-3 and DNA fragmentation (p < 0.001 vs control). PKC-zeta plays a critical role in pancreatitis-induced Kupffer cell apoptosis via NF-kappaB and Fas/FasL. The ability of Kupffer cells to autoregulate their stress response by upregulating their death receptor/ligand and key proapoptotic cell signaling systems warrants further investigation.

Objective: To document the effect of anastomotic leaks on morbidity and mortality after Roux-en-Y gastric bypass (RYGB) for obesity., Design: Prospectively collected data on 840 consecutive patients who underwent RYGB between 1998 and 2005. Multivariate logistic regression analysis was used to determine the effect of anastomotic leaks on postoperative morbidity independent of sex, age, preoperative body mass index, access (open vs laparoscopic), calendar year of RYGB, and comorbidities. P < .05 was considered significant., Results: A total of 36 patients (4.3%) developed leaks after RYGB. Patients who developed anastomotic leaks had a significantly higher overall complication rate (61% vs 20%, P < .001), mortality (14% vs 4%, P = .01), and duration of hospital stay (24.5 vs 4.5 days, P < .001) compared with patients who did not develop leaks. In a multivariate logistic regression model, anastomotic leaks increased the likelihood of mortality (odds ratio [OR], 15; 95% confidence interval [CI], 3-80; P = .002) and overall complications (OR, 6; 95% CI, 3-13; P < .001), specifically sepsis (OR, 27; 95% CI, 2-472; P = .02), renal failure (OR, 16; 95% CI, 3-99; P = .003), small-bowel obstruction (OR, 11; 95% CI, 2-68; P = .008), internal hernia (OR, 10; 95% CI, 2-51; P = .008), thromboembolism (OR, 9; 95% CI, 3-27; P < .001), and incisional hernia (OR, 5; 95% CI, 2-13; P = .001)., Conclusions: Anastomotic leaks significantly increase the likelihood of developing additional life-threatening complications after RYGB. Close and aggressive monitoring is recommended for early detection and management of added complications, should they occur.

Objectives: To report contemporary outcomes of gastric bypass for obesity and to assess the relationship between provider volume and outcomes., Background: Certain Florida-based insurers are denying patients access to bariatric surgery because of alleged high morbidity and mortality., Settings and Patients: The prospectively collected and mandatory-reported Florida-wide hospital discharge database was analyzed. Restrictive procedures such as adjustable gastric banding and gastroplasty were excluded., Results: The overall complication and in-hospital mortality rates in 19,174 patients who underwent gastric bypass from 1999 to 2003 were 9.3% (8.9-9.7) and 0.28% (0.21-0.36), respectively. Age and male gender were associated with increased duration of hospital stay (P < 0.001), increased in-hospital complications [age: odds ratio (OR) = 1.11, CI: 1.08-1.13; male: OR = 1.53, CI: 0.36-1.72] and increased in-hospital mortality (age: OR = 1.51, CI: 1.32-1.73; male: CI = 2.66, CI: 1.53-4.63), all P < 0.001. The odds of in-hospital complications significantly increased with diminishing surgeon or hospital procedure volume (surgeon: OR = 2.0, CI: 1.3-3.1; P < 0.001, 1-5 procedures relative to >500 procedures; hospital volume: OR = 2.1, CI: 1.2-3.5; P < 0.001, 1-9 procedures relative to >500 procedures). The percent change of in-hospital mortality in later years of the study was lowest, indicating higher mortality rates, for surgeons or hospitals with fewer (< or =100) compared with higher (> or =500) procedures., Conclusion: Increased utilization of bariatric surgery in Florida is associated with overall favorable short-term outcomes. Older age and male gender were associated with increased morbidity and mortality. Surgeon and hospital procedure volume have an inverse relationship with in-hospital complications and mortality.

The prevalence of morbid obesity in the United States and worldwide is increasing at an alarming rate. The number of bariatric surgical procedures also has steadily increased during the past decade. This article reviews the published literature and current practice trends for preoperative workup and assessment of patients undergoing bariatric surgery.

Background: Obstructive sleep apnea (OSA) is associated with obesity. Our aim in this study is to report objective improvement of obesity-related OSA and sleep quality after bariatric surgery., Methods: Prospective bariatric patients were referred for polysomnography if they scored >or=6 on the Epworth Sleepiness Scale. The severity of OSA was categorized by the respiratory disturbance index (RDI) as follows: absent, 0 to 5; mild, 6 to 20; moderate, 21 to 40; and severe, <40. Patients were referred for repeat polysomnography 6 to 12 months after bariatric surgery or when weight loss exceeded 75 lbs. Means were compared using paired t tests. Chi-square tests and linear regression models were used to assess associations between clinical parameters and RDI; P<.05 was considered statistically significant., Results: Of 349 patients referred for polysomnography, 289 patients had severe (33%), moderate (18%), and mild (32%) OSA; 17% had no OSA. At a median of 11 months (6 to 42 months) after bariatric surgery, mean body mass index (BMI) was 38 +/- 1 kg/m2 (P<.01 vs 56 +/- 1 kg/m2 preoperatively) and the mean RDI decreased to 15 +/- 2 (P<.01 vs 51 +/- 4 preoperatively) in 101 patients who underwent postoperative polysomnography. In addition, minimum oxygen saturation, sleep efficiency, and rapid eye movement latency improved, and the requirement for continuous positive airway pressure was reduced (P

Background: Kupffer cells have been implicated in the pathogenesis of various liver diseases. Primary cultures of Kupffer cells have a very limited life span, tend to de-differentiate and become senescent, and therefore are not suitable for cell signaling studies., Aim: To establish immortalized rat Kupffer cell lines that facilitate mechanistic studies of cell signaling and signal transduction., Methods: Rat Kupffer cells were sub-cultured with EGF to obtain rat Kupffer Cell line 1 (RKC1), and subsequently transfected with Simian Virus 40 Large T-antigen expression vector to obtain rat Kupffer Cell line 2 (RKC2)., Results: RKC1 and RKC2 are similar to primary Kupffer cells as they express the molecular markers ED1, ED2, ED3, and F4/80, and upregulate TNF-alpha, IL-6, IL-1beta, Fas /FasL, and NF-kappaB, as well as TLR4 in response to LPS or pancreatic elastase. Additionally, RKC1 and RKC2 maintain phagocytic properties of latex beads and exhibit increased telomerase and stabilized p53 activity., Conclusion: Immortalized RKC1 and RKC2 cells maintain properties of primary Kupffer cells and can be valuable tools in evaluating the role of Kupffer cells in immune diseases and in liver-cell based drug discovery.

Background: Anastomotic leaks are a dreaded complication of bariatric surgery. The objective of this study was to describe the clinical presentation and outcomes of treatment in patients who develop anastomotic leaks after Roux-en-Y gastric bypass for obesity., Study Design: Prospectively collected data on 3,018 consecutive patients who underwent Roux-en-Y gastric bypass in 4 tertiary referral centers were reviewed., Results: Sixty-three patients (2.1%) developed anastomotic leaks (open, 2.1%; laparoscopic, 2.1%) at a median of 3 days (range 0 to 28 days) after Roux-en-Y gastric bypass. Symptoms and signs included tachycardia (72%), fever (63%), or abdominal pain (54%). Upper gastrointestinal series and CT demonstrated leaks in only 17 of 56 (30%) and 28 of 50 (56%) patients, respectively; when done jointly, both studies were negative in 30% of patients. The 68 anastomotic leaks occurred at the gastrojejunostomy (49%), excluded stomach (25%), jejunojejunostomy (13%), gastric pouch (9%), and uncertain location (4%). Forty patients (63%) required 58 reoperations for drainage of intraabdominal collections (55%), repair of anastomotic defects (34%), or revision of the leaking anastomosis (11%), with an overall morbidity of 53% and mortality of 10%. Nonoperative treatment was successful in 23 of 26 patients, with an overall morbidity of 61% and no mortality (p=NS versus operative). Operative treatment was more common in patients with hypotension or oliguria (p < 0.01)., Conclusions: Lack of specificity in clinical presentation and imaging studies make diagnosing anastomotic leaks challenging, so operative exploration should be part of the diagnostic algorithm. Nonoperative treatment is safe and effective in a subset of patients who exhibit stable hemodynamic parameters and are known to have controlled leaks.

Background: Roux-en-Y gastric bypass (RYGB) has a long learning curve that may be reflected in operative outcomes. This study sought to assess whether training a fellow has an impact on the operative outcomes of the training program., Methods: Prospectively collected data on 150 consecutive patients were compared before (group 1) and after (group 2) establishment of a fellowship-training program., Results: A greater number of patients underwent laparoscopic RYGB (LRYGB) in group 2 than in group 1 (63% vs 46%; p = 0.01). The group 2 patients were similar to the group 1 patients in terms of age, gender, length of stay, and complication rate. However, they had a higher body mass index (BMI) (median 50 kg/m2; range, 39-64 kg/m2 vs median, 46 kg/m2; range, 38-56 kg/m2; p = 0.01) and a higher incidence of prior abdominal procedures (21% vs 7%; p = 0.006). In addition, operative time was significantly shorter for the patients who underwent open RYGB (ORYGB) (median, 150 min; range, 65-280 min vs median, 110 min; range, 50-210 min; p < 0.001) and LRYGB (median, 202 min; range, 105-450 min vs median, 134 min; range, 50-191 min; p < 0.001) in group 2 than for the patients in group 1. The patients who underwent ORYGB in groups 1 and 2 had similar characteristics and outcomes. Increasing experience with both ORYGB and LRYGB correlated with a decrease in operative times for group 2 (p < 0.001), but not for group 1., Conclusion: Establishment of a fellowship program shortens the operative times for both open and laparoscopic RYGB and expands the scope of bariatric practice by compounding the experience of the operating team without increasing complications.