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Background Evaluation of acute appendicitis (AA) in pregnancy is supported with diagnostic imaging. Typically, ultrasound (US) is performed first, and then often followed by magnetic resonance imaging (MRI) due to continued diagnostic uncertainty. The purpose of our study was to evaluate the sensitivity, specificity, and accuracy of US as compared to MRI and to evaluate the inter-radiologist agreement amongst body Radiologists with varying levels of expertise. Methods We performed a retrospective study of 364 consecutive pregnant patients with clinical suspicion of AA at a single center over a 6-year period. Sensitivity, Specificity, accuracy, positive and negative predictive values were calculated for US and MRI. Inter Radiologist agreement was determined using Cohen's Kappa analysis between original interpreting Radiologist and retrospective review by expert Radiologist. Results 31 of 364 patients (8.5%) underwent appendectomy based on preoperative diagnosis, with confirmation of acute appendicitis (AA) by pathology in 19. US was able to visualize the appendix in only 6 (1.65%), 5 of whom had appendicitis. 141 patients underwent MRI, and correctly diagnosed appendicitis in 9. No patient with a negative MRI diagnosis had AA. The sensitivity, and negative predictive value for diagnosing AA with MRI was 100%. The MRI inter-reader agreement for appendix visualization and overall accuracy were 87.9 and 98% with Cohen Kappa of 0.7 and 0.56 respectively. Conclusion Our data suggests that MRI should be considered the first line imaging modality in pregnant patients suspected of having AA. Body Radiologists with varied levels of experience in MRI readouts had substantial agreement.

Evidence supports the use of complementary techniques to reduce pain and opioid use after surgery. The NSS-2 BRIDGE device (NBD; Innovative Health Solutions, Inc., Versailles, Indiana) modulates pain via stimulation of the nucleus of the auricular branch of the cranial nerves at the level of the brainstem and the limbic system.To investigate the role of auricular nerve field stimulation for pain control following gastric bypass surgery.U.S. academic medical center.A total of 18 subjects were included. Subjects were divided in 2 groups: NBD group (n = 8) and a control group (n = 10). The NBD was placed following laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery in the recovery room. The effectiveness of NBD was assessed comparing the relative use of opioid consumption (oral morphine equivalents) and pain (0 = no pain to 10= worst possible pain) at 24 and 48 hours after surgery. In addition, the device tolerability (1-10) was assessed, with 8-10 considered excellent. Data were analyzed using unpaired t tests and presented as mean ± standard deviation. Alpha was set up at .1.Compared with the control group, the use of NBD was associated with a 60.2% reduction in oral morphine equivalents (38.15 vs 15.2 mg; P.1) and a 28% reduction in pain (5.0 vs 3.6; P = .1) at 24 hours after surgery. The tolerability of NBD was reported to be excellent.This report suggests that NBD may represent an interesting alternative to control perioperative pain and limit opioid use following bariatric surgery. This needs to be confirmed by a placebo-controlled, randomized study.

White adipose tissue (WAT), once regarded as morphologically and functionally bland, is now recognized to be dynamic, plastic, heterogenous, and involved in a wide array of biological processes including energy homeostasis, glucose and lipid handling, blood pressure control, and host defense1. High fat feeding and other metabolic stressors cause dramatic changes in adipose morphology, physiology, and cellular composition1, and alterations in adiposity are associated with insulin resistance, dyslipidemia, and type 2 diabetes (T2D)2. Here, we provide detailed cellular atlases of human and murine subcutaneous and visceral white fat at single cell resolution across a range of body weight. We identify subpopulations of adipocytes, adipose stem and progenitor cells (ASPCs), vascular, and immune cells and demonstrate commonalities and differences across species and dietary conditions. We link specific cell types to increased risk of metabolic disease, and we provide an initial blueprint for a comprehensive set of interactions between individual cell types in the adipose niche in leanness and obesity. These data comprise an extensive resource for the exploration of genes, traits, and cell types in the function of WAT across species, depots, and nutritional conditions.

Bioelectronic medical approaches to control vagus nerve-to-organ signaling have the potential to treat cardiac, respiratory, gastrointestinal (GI) and metabolic diseases, such as obesity. Unlike cervical vagus nerve stimulation (VNS), abdominal VNS could provide specific therapeutic control of the GI tract without off-target effects on thoracic organs; however, surgical approaches for abdominal VNS electrode placement are not well established. Moreover, optimal device configurations and additional placement of GI recording electrodes for closed-loop control are largely unknown. We designed VNS cuff and GI planar serosal electrodes and tested placement of these devices in laparoscopic surgery in two cadavers. We determined that electrode positioning on the ventral abdominal vagus nerve and gastric antrum was feasible but other sites, such as the duodenum and proximal stomach, were more difficult. The current investigation can guide potential placement and design of VNS cuff and GI electrodes for development of closed-loop GI therapeutic devices.

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

Background Data from a US multicenter longitudinal study of bariatric surgery were used to compare weight change (primary outcome) and comorbidities (secondary outcome) in patients who underwent sleeve gastrectomy versus Roux-en-Y gastric bypass. Methods This study includes participants who underwent sleeve gastrectomy and matched participants who underwent Roux-en-Y gastric bypass from the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study. Adults undergoing initial bariatric surgical procedures between 2006 and 2009 were enrolled. Participants who underwent sleeve gastrectomy were high-risk or superobese and intended to have a second-stage procedure. Mixed models were used to evaluate percent weight change from baseline through 7 years, and diabetes, dyslipidemia, and hypertension prevalence through 5 years. Results Fifty-seven of 59 participants who underwent sleeve gastrectomy were matched one to one. Most were female (68%) and white (81%), and had a median age of 49 (37–56) years and median body mass index of 56.4 (35.5–76.8) kg/m2 presurgery. Weight loss was significantly less 1 to 7 years after sleeve gastrectomy versus matched Roux-en-Y gastric bypass (eg, year 7 mean weight loss was 23.6% vs 30.4%, respectively; P = .001). For both surgical groups, prevalence of diabetes, low high-density lipoprotein, and hypertension were significantly (P Conclusion Higher-risk or super-obese participants after sleeve gastrectomy lost less weight than did matched Roux-en-Y gastric bypass counterparts throughout 7 years. Both groups exhibited improvements in comorbidities from presurgery through 5 years.

BACKGROUND: Initial weight loss after bariatric surgery has been associated with improvements in reproductive hormones and sexual functioning in women. Few studies have investigated the durability of these changes. OBJECTIVES: Investigate changes in sex hormones, sexual functioning, and relevant psychosocial constructs over 4 years in women who underwent bariatric surgery. SETTING: Prospective cohort of 106 women from the Longitudinal Assessment of Bariatric Surgery Consortium. METHODS: Changes in sex hormones were assessed by blood assay. Sexual functioning, quality of life (QOL), body image, depressive symptoms, and marital adjustment were assessed by psychometric measures. RESULTS: Women lost on average (95% confidence interval) 32.3% (30.4%, 34.3%) at postoperative year 3 and 30.6% (28.5%, 32.8%) at postoperative year 4. Compared to baseline, women experienced significant changes at 4 years in all hormones assessed, except estradiol. Women reported significant improvements in sexual functioning (i.e., arousal, desire, and satisfaction) through year 3, but these changes were not maintained through year 4. Changes in relationship quality followed a similar pattern. Improvements in physical aspects of QOL, body image, and depressive symptoms were maintained through 4 years. CONCLUSIONS: Improvements in reproductive hormones, and physical aspects of QOL, body image and depressive symptoms were maintained 4 years after bariatric surgery. Improvements in sexual functioning, relationship satisfaction, and mental components of QOL eroded over time.

Context Questions remain about bariatric surgery for type 2 diabetes mellitus (T2DM) treatment. Objective Compare the remission of T2DM following surgical or nonsurgical treatments. Design, setting, and participants Randomized controlled trial at the University of Pittsburgh, in the United States. Five-year follow-up from February 2015 until June 2016. Interventions 61 participants with obesity and T2DM who were initially randomized to either bariatric surgical treatments (Roux-en-Y gastric bypass [RYGB] or laparoscopic adjustable gastric banding [LAGB]) or an intensive lifestyle weight loss intervention (LWLI) program for 1 year. Lower level lifestyle weight loss interventions (LLLIs) were then delivered for 4 years. Main Outcomes and Measures Diabetes remission assessed at 5 years. Results The mean age of the patients was 47 ± 6.6 years, 82% were women, and 21% African American. Mean hemoglobin A1c level 7.8% ± 1.9%, body mass index (BMI) 35.7 ± 3.1 kg/m2, and 26 participants (43%) had BMI Conclusions Surgical treatments are more effective than lifestyle intervention alone for T2DM treatment.

Background Some studies suggest that changes in weight or metabolic outcomes are affected by the lengths of the gastrointestinal limbs in the Roux-en-Y gastric bypass. Methods Participants (N = 1,770) underwent primary Roux-en-Y gastric bypass and were followed ≤7 years in the Longitudinal Assessment of Bariatric Surgery-2, a multicenter US cohort study. Alimentary limb and biliopancreatic limb lengths were measured according to research protocol; common channel was measured in a subsample (N = 547). Aimentary limb, biliopancreatic limb, and common channel ratio to total small bowel length were calculated. Results Median presurgery body mass index was 46 (25th–75th percentile: 43–51) kg/m2. Medians (25th–75th percentiles) for alimentary limb length were 125 cm (100–150), for biliopancreatic limb length were 50 cm (50–60), and common channel length were 410 cm (322–520). Statistics for ratios to the small bowel length were 0.23 (0.18–0.27) for alimentary limb, 0.09 (0.07–0.10) for biliopancreatic limb, and 0.69 (0.63–0.73) for common length. There were no significant associations between alimentary limb, biliopancreatic limb, common channel, alimentary limb ratio, biliopancreatic limb ratio or common channel ratio, and either weight loss or improvement in cardiometabolic outcomes. Conclusion The common channel length in Roux-en-Y gastric bypass is highly variable between individuals. None of the limb lengths in this study, nor alimentary limb, biliopancreatic limb, or common channel ratios, seem to be related to weight loss or metabolic improvements >7 years.

Despite the remarkable, early remission of T2D after RYGB, the surgery’s key mechanisms have yet to be defined in a way that can be translated to less invasive therapies. Recently, we demonstrated that improved glucose homeostasis after RYGB in rodents is associated with intestinal metabolic reprogramming: the Roux Limb (RL) exhibits dramatic morphologic and metabolic remodeling, leading to augmented utilization of metabolic fuels to support the increased bioenergetic demand. To address whether this phenomenon is important for T2D remission in human patients after RYGB, RL biopsies were obtained at the time of surgery and at 1 and 6 months postoperatively. Differentially expressed genes (DEG) were determined using Affymetrix HTA 2.0 microarrays; morphology was examined via electron microscopy, revealing a significant increase in microvillus length over time (P Disclosure M.A. Stefater: None. C. Panciotti: None. H.A. Feldman: None. W.F. Gourash: Research Support; Self; Coviden, Ethicon US, LLC., National Institute of Diabetes and Digestive and Kidney Diseases. E. Shirley: None. A. Courcoulas: Research Support; Self; National Institute of Diabetes and Digestive and Kidney Diseases, Patient-Centered Outcomes Research Institute, National Institutes of Health, Coviden. N. Stylopoulos: None.

Background Bariatric surgery may prove an effective weight loss option for those struggling with severe obesity, but it is difficult to determine levels of interest in such procedures at the population level through traditional approaches. Analysis of Google Trend information may give providers and healthcare systems useful information regarding Internet users' interest in bariatric procedures. The objective of this study was to gather Google Trend information on worldwide Internet searches for "bariatric surgery", "gastric bypass", "gastric sleeve", "gastric plication", and "lap band" from 2004–2012 and to explore temporal relationships with relevant media events, economic variations, and policy modifications. Methods Data were collected using Google Trends. Trend analyses were performed using Microsoft Excel Version 14.3.5 and Minitab V.16.0. Results Trend analyses showed that total search volume for the term "bariatric surgery" has declined roughly 25% since January 2004, although interest increased approximately 5% from 2011 to 2012. Interest in lap band procedures declined 30% over the past 5 years, while "gastric sleeve" has increased 15%. Spikes in search numbers show an association with events such as changing policy and insurance guidelines and media coverage for bariatric procedures. Conclusion This report illustrates that variations in Internet search volume for terms related to bariatric surgery are multifactorial in origin. Although it is impossible to ascertain if reported Internet search volume is based on interest in potentially undergoing bariatric surgery or simply general interest, this analysis reveals that search volume appears to mirror real world events. Therefore, Google Trends could be a way to supplement understanding about interest in bariatric procedures.

Background: Bariatric surgery, especially Roux-en-Y gastric bypass (RYGB), is the best treatment for severe obesity and its complications including type 2 diabetes mellitus (T2DM). Understanding the mechanisms responsible for the beneficial metabolic effects will help to engineer ways to improve the procedure or produce these effects without surgery. Objective: The aim is to present data on recruitment and feasibility of a translational study designed to collect intestinal samples before and after bariatric surgery. The goal of biobanking is to allow future studies to test the hypothesis that the mechanism of action of RYGB involves specific changes in the postsurgical short- and long-term metabolism and morphology of the jejunum (Roux limb). Specifically, to test whether the intestine enhances its metabolism and activity after RYGB and increases its fuel utilization, we designed a prospective, longitudinal study, which involved the recruitment of candidates for RYGB with and without T2DM. We describe the tissue bank that we have generated, and our experience, hoping to further facilitate the performance of longitudinal mechanistic studies in human patients undergoing bariatric surgery and especially those involving post-RYGB intestinal biology. Methods: We conducted a trial to characterize the effects of RYGB on intestinal metabolism. Intestinal tissue samples were collected from the jejunum at surgery, 1, 6, and 12 months postoperatively for the analysis of intestinal gene expression and metabolomic and morphologic changes. The target number of patients who completed at least the 6-month follow-up was 26, and we included a 20% attrition rate, increasing the total number to 32. Results: To enroll 26 patients, we had to approach 79 potential participants. A total of 37 agreed to participate and started the study; 33, 30, and 26 active participants completed their 1-month, 6-month, and 12-month studies, respectively. Three participants withdrew, and 30 participants are still active. Altruism and interest in research were the most common reasons for participation. Important factors for feasibility and successful retention included (1) large volume case flow, (2) inclusion and exclusion criteria broad enough to capture a large segment of the patient population but narrow enough to ensure the completion of study aims and protection of safety concerns, (3) accurate assessment of willingness and motivation to participate in a study, (4) seamless integration of the recruitment process into normal clinical flow, (5) financial reimbursement and nonfinancial rewards and gestures of appreciation, and (6) nonburdensome follow-up visits and measures and reasonable time allotted. Conclusions: Human translational studies of the intestinal mechanisms of metabolic and weight changes after bariatric surgery are important and feasible. A tissue bank with unique samples has been established that could be used by investigators in many research fields, further enabling mechanistic studies on the effects of bariatric surgery. Trial Registration: ClinicalTrials.gov NCT02710370; https://clinicaltrials.gov/ct2/show/NCT02710370 (Archived by WebCite at http://www.webcitation.org/75HrQT8Dl)

Background Although it is recognized that a standardized approach to reporting weight change is essential to meaningful comparisons among cohorts and across studies, consensus is lacking. This study aimed to propose a method of reporting weight change that would allow meaningful comparisons among studies of patients who underwent bariatric surgery and to demonstrate its utility using an example from the Longitudinal Assessment of Bariatric Surgery (LABS). Methods Relationships among several measures of weight change are described. Results from an observational, longitudinal cohort study of adults undergoing bariatric surgery and from simulation studies are used to illustrate the proposed method. Results Baseline weight is a critical parameter when assessing weight change. Men undergoing a bariatric procedure other than gastric bypass or adjustable band tended to have greater weight loss 12 months after surgery than men undergoing gastric bypass when not accounting for baseline weight, but the opposite was found when results were adjusted for baseline weight. Simulation results show that with relatively modest sample sizes, the adjusted weight loss was significantly different between the 2 groups of men. Conclusion A consistent metric for reporting weight loss after bariatric surgery is essential to interpret outcomes across studies and among subgroups. The baseline weight adjusted percent of weight loss (A%WL) uses a standard population (e.g., the LABS cohort) to account for differences between cohorts with respect to baseline weight, and its use can change the interpretation of results compared with an unadjusted measure.

Background Retaining participants in observational longitudinal studies after bariatric surgery is difficult yet critical because the retention rate affects interpretation and generalizability of results. Strategies for keeping participants involved in such studies are not commonly published. The objective of this study was to review LABS retention strategies and present the 24-month retention data. Methods The LABS Consortium monitors an observational cohort study of 2458 adults enrolled before bariatric surgery at 10 centers within the United States (LABS-2). To maximize data completeness, the investigators developed retention strategies, including flexible scheduling, a call protocol, reminder letters, abbreviated visit options, honoraria, travel reimbursement, providing research progress reports, laboratory results, newsletters, study website, and retention surveys. Strategies for locating participants included frequent updates of contact information, sending registered letters, and searching medical and public records. Results At 12 and 24 months, 2426 and 2405 participants remained active, with vital status known for 98.7% and 97.3% and weight obtained for 95.2% and 92.2%, respectively. There were 148 missed visits (6.2%) at 24 months primarily because of inability to contact the participant. Only 15 (0.6%) active participants at 24 months missed all follow-up visits. Although 42 participants could not be located or contacted at 6 months, data were obtained for 23 (54.7%) of them at 12 months, and of the 52 participants who could not be located or contacted at 12 months, data were obtained for 18 (34.6%) at 24 months. Conclusion Longitudinal studies provide the ability to evaluate long-term effects of bariatric surgical procedures. The retention achieved in LABS is superior to that of many published reports but requires extensive effort and resources. This report identifies useful retention strategies. Further research is needed to identify the efficacy and cost-effectiveness of specific retention strategies.

OBJECTIVES In this study, we report long-term outcomes of high-risk, high-BMI (body mass index) patients who underwent laparoscopic sleeve gastrectomy (LSG). BACKGROUND Short- and medium-term data appear to support the effectiveness of LSG, but long-term data to support its durability are sparse. METHODS A prospective database was reviewed on all high-risk patients who underwent LSG as part of a staged approach for surgical treatment of severe obesity between January 2002 and February 2004. We included only patients who did not proceed to second-stage surgery (gastric bypass). Analyzed data included demographics, BMI, comorbidities, and surgical outcomes. All partial gastrectomies were performed using a 50F bougie. RESULTS Seventy-four patients underwent LSG, and follow-up data were available on 69 of 74 patients (93%). The mean age was 50 years (25-78) and the mean number of co-morbidities was 9.6. Perioperative mortality (

The effectiveness of Roux-en-Y gastric bypass (RYGB) against obesity and its comorbidities has generated excitement about developing new, less invasive treatments that use the same molecular mechanisms. Although controversial, RYGB-induced improvement of metabolic function may not depend entirely upon weight loss. To elucidate the differences between RYGB and dieting, we studied several individual organ molecular responses and generated an integrative, interorgan view of organismal physiology. We also compared murine and human molecular signatures. We show that, although dieting and RYGB can bring about the same degree of weight loss, post-RYGB physiology is very different. RYGB induces distinct, organ-specific adaptations in a temporal pattern that is characterized by energetically demanding processes, which may be coordinated by HIF1a activation and the systemic repression of growth hormone receptor signaling. Many of these responses are conserved in rodents and humans and may contribute to the remarkable ability of surgery to induce and sustain metabolic improvement.

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

To compare outcomes of patients with leaks after primary Roux-en-Y gastric bypass (GBP) managed operatively with those managed nonoperatively and subsequently derive indications for selective nonoperative management.There is no consensus on the management of leaks complicating GBP, which remains the commonest cause of death.We evaluated 2675 consecutive GBP procedures, determining incidence and outcomes of leaks in a program emphasizing early detection, routine drainage, and selective nonoperative management.Leaks occurred in 46 patients (41 women) with mean (+/-SD) age of 46.9 +/- 8.7 years, weight and body mass index (BMI) of 307.8 +/- 56.9 lb and 51.2 +/- 9.5 kg/m, respectively. Leaks were initially identified by upper gastrointestinal contrast swallow (UGI) on the first postoperative day (22), abnormal drain output (11), delayed UGI (3), or on clinical suspicion (10) with a respective interval to diagnosis of 1.1*, 6.5, 7, and 7.9 days (*P0.007 vs. other groups). Leaks were located in the gastrojejunal (GJ) anastomosis (37), gastric pouch (4), gastric remnant (2), jejuno-jejunostomy (1), Roux limb (1), and cervical esophagus (1), and were radiologically contained (40) or diffuse (3) or not demonstrable (3). Contained leaks were treated nonoperatively (31), by operation (7), or required no treatment (2). Patients with diffuse leaks or bilious drain output were operatively managed. They were similar in duration for nil per oral order, drain and antibiotic use and readmission rates, whereas hospital stays were longer in the operative group, P0.01. There were no deaths.Many leaks after gastric bypass are radiologically contained GJ and pouch leaks and can be safely managed nonoperatively. Radiologic features and bilious drainage were key determinants of treatment, with operative treatment used for diffuse GJ leaks, bilious drainage, or clinical suspicion with a negative UGI. Outcomes were similar in both groups.

A global childhood obesity epidemic is now affecting boys and girls of all racial and ethnic groups. Increasingly, adolescents are seeking effective weight loss options and are also increasingly undergoing bariatric procedures. Here, we briefly review various facets of the childhood obesity problem and explore the option of bariatric surgery for adolescents, highlighting specific issues related to surgery in these younger age groups. Specifically, we will discuss current information relevant to treatment options and procedures, candidacy for surgery, access and insurance coverage, and adherence during the postoperative follow-up period. We also briefly describe an ongoing NIH-funded study, which was designed to examine some of these important topics.

Since the introduction of Laparoscopic Roux-en-Y gastric bypass (LRYGBP) in the early 1990s, several investigators have demonstrated that LRYGBP is as effective as open roux-en-Y gastric bypass (RYGBP) in achieving significant long-term weight loss (60–80% percent of excess body weight loss [%EWL]) in morbidly obese patients while significantly reducing perioperative morbidity and recovery time.1–5 In 2000, our group reported (n = 275 patients) a mean excess weight loss of 77% (mean body mass index [BMI] reduced from 48 to 27 kg/m2) at 30 months and a major morbidity and mortality rate of 3.3% and 0.4%, respectively.2 Quality of life was significantly improved and all obesity comorbidities, with the exception of depression, were significantly improved or resolved. Although that study did not focus specifically on type 2 diabetes mellitus (T2DM), we did find that 82% of T2DM patients (n = 18) achieved clinical resolution (withdrawal of all antidiabetic medication) whereas the remaining 18% had significant improvement. Other investigators have also demonstrated that not only Roux-en-Y gastric bypass but other bariatric operations may result in significant clinical improvement in T2DM after weight loss.2,5–13 However, little is known concerning the effect of weight loss surgery on the degree of glycemic control that is achieved and its impact on antidiabetic medication requirement. Furthermore, factors that may be associated with postoperative resolution versus improvement in diabetes have not been fully elucidated. The goal of this study then was to evaluate the effect of LRYGBP on morbidly obese patients with T2DM and their related comorbidites and diabetes-specific complications. Our hypothesis was that LRYGBP would result in sustained weight loss that would correspond to significant improvement in glycemic control, leading to clinical resolution or improvement in T2DM and related comorbidites and complications. We specifically evaluated postoperative outcomes, including surgical complications and weight loss as well as changes in fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1C), diabetic medication requirement, and changes in comorbidity and diabetes complications.

Background: Combined gastric bypass and cholecystectomy have been advocated for open bariatric procedures. Our goal was to evaluate the safety of this technique in laparoscopic bariatric surgery patients with gallstones diagnosed preoperatively. Methods: 94 out of 556 consecutive morbidly obese patients (16.9%) underwent laparoscopic gastric bypass with simultaneous cholecystectomy (LGBP/LC) for cholelithiasis. Results: 328 patients (59%) had a concomitant secondary procedure, most commonly cholecystectomy (28.7%). Preoperative BMI was 48.6±6.9 kg/m2 for LGBP/LC patients and 48.8±7.3 kg/m2 (P=0.85) for LGBP alone. 5 patients had preoperative biliary colic; the others were asymptomatic for cholelithiasis. Postoperatively, at a mean follow-up of 7.6±6.7 months, the percent excess weight loss (%EWL) was 46.1±0.25 for the combined procedure vs 50.2±63.0 (P=0.55) for LGBP alone. There were no conversions to open procedures for the LC. Port placement for the LGBP was not altered for LC. None required intraoperative cholangiography. Operative time for the combined procedure was 293.4±79.8 minutes vs 244.8±77.2 minutes for LGBP alone (P

Background: The purpose of this study was to determine the effect of operative experience on perioperative outcomes for laparoscopic Roux-en-Y gastric bypass (LGB). Methods: Between July 1997 and September 2001, 750 patients underwent LGB for the treatment of morbid obesity at our center. We evaluated the perioperative outcomes of the first 150 consecutive patients to determine if a learning curve effect could be demonstrated. The patients were divided into three groups (1, 2, and 3) of 50 consecutive patients, and outcomes for each group were compared. Results: The patients in group 3 had a larger body mass index (BMI), were more likely to have had prior abdominal surgery, and were more likely to have secondary operations at the time of LGB. Operating time decreased from a mean of 311 min in group 11 to 237 min in group 3, and technical complications were reduced by 50% after an experience of 100 cases. Conclusions: Operative time and technically related complications decreased with operative experience even though heavier patients and higher-risk patients were more predominant in the latter part of our experience. LGB is a technically challenging operation with a long learning curve. To minimize morbidity related to the learning curve, strategies for developing training programs must address these challenges.

Background: The purpose of this study was to determine the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on symptomatic control of gas-troesophageal reflux disease (GERD). Methods: Morbidly obese patients (n = 435) who un-derwent LRYGBP for morbid obesity were assessed for changes in GERD symptoms, quality of life, and patient satisfaction after surgery. Results: A total of 238 patients (55%) had evidence of chronic GERD, and 152 patients (64%) voluntarily participated in the study. The mean body mass index (BMI) was 48 kg/m2. The mean excess weight loss was 68.8% at 12 months. There was a significant decrease in GERD-related symptoms, including heartburn (from 87% to 22%, p < 0.001); water brash (from 18% to 7%, p

Bariatric surgery has been safe and effective for treatment of severe obesity and comorbidities like type 2 diabetes mellitus (T2D). Nonetheless, weight loss and health outcomes vary considerably across individuals. Although the factors associated with outcomes are not fully understood, postoperative weight loss following any type of bariatric surgery is largely dependent on the extent to which patients can make and sustain changes in eating and activity. Therefore, lifestyle management including diet, exercise, and behavior modification is critical to helping patients achieve long-term weight loss. Pharmacotherapy and reoperation may also play a role after bariatric surgery. In this article, we highlight recent research findings in all of these areas to provide suggestions for how to enhance outcomes following bariatric surgery. Research on the mechanisms for weight loss and improvements in T2D following the different surgical procedures is needed to support the development of more personalized approaches to the multidisciplinary management of severe obesity.

The relationship between obesity and impairments in male sexual functioning is well documented. Relatively few studies have investigated changes in sexual functioning and sex hormones in men who achieve significant weight loss with bariatric surgery. The objective of this study was to assess changes in sexual functioning, sex hormones, and relevant psychosocial constructs in men who underwent bariatric surgery.A prospective cohort study of 32 men from the Longitudinal Assessment of Bariatric Surgery-2 (LABS) investigation who underwent a Roux-en-Y gastric bypass (median body mass index [25th percentile, 75th percentile] 45.1 [42.0, 52.2]) and completed assessments between 2006 and 2012. Bariatric surgery was performed by a LABS-certified surgeon. Sexual functioning was assessed by the International Index of Erectile Functioning (IIEF). Hormones were assessed by blood assay. Quality of life (QoL), body image, depressive symptoms and marital adjustment were assessed by questionnaire.Men lost, on average, (95% confidence interval) 33.3% (36.1%, 30.5%) of initial weight at postoperative year 1, 33.6% (36.8%, 30.5%) at year 2, 31.0% (34.1%, 27.9%) at year 3, and 29.4% (32.7%, 26.2%) at year 4. Participants experienced significant increases in total testosterone (P.001) and sex hormone binding globulin (SHBG) (P.001) through postoperative year 4. Although men reported improvements in sexual functioning after surgery, these changes did not significantly differ from baseline, with the exception of overall satisfaction at postoperative year 3 (P = .008). Participants reported significant improvements in physical domains of health-related quality of life (HRQoL), all domains of weight-related QOL, and body image, but not in the mental health domains of HRQoL or relationship satisfaction.Men who lost approximately one third of their weight after Roux-en-Y gastric bypass experienced significant increases in total testosterone and SHBG. They did not, however, report significant improvements in sexual functioning, relationship satisfaction, or mental health domains of HRQoL. This pattern of results differs from that of women who have undergone bariatric surgery, who reported almost uniform improvements in sexual functioning and psychosocial status.

Surgery is the only treatment for morbid obesity that has been proven to achieve a significant long-term weight loss. The Roux-en-Y gastric bypass procedure has been performed for the treatment of morbid obesity over the past two decades with excellent results. Wound complications and perioperative morbidity remain unresolved problems of the procedure. A laparoscopic approach to this procedure has great potential to minimize the complications of this highly effective technique. We describe a laparoscopically performed Roux-en-Y gastric bypass in a 28-year-old woman with morbid obesity. The technique described here preserves the anatomic construct of the operation but introduces the benefit of the laparoscopic approach.

Background Many individuals with obesity are motivated to lose weight to improve weight-related co-morbidities or psychosocial functioning, including sexual functioning. Few studies have documented rates of sexual dysfunction in persons with obesity. This study investigated sexual functioning, sex hormones, and relevant psychosocial constructs in individuals with obesity who sought surgical and nonsurgical weight loss. Methods One hundred forty-one bariatric surgery patients (median BMI [25th percentile, 75th percentile] 44.6 [41.4, 50.1]) and 109 individuals (BMI = 40.0 [38.0, 44.0]) who sought nonsurgical weight loss participated. Sexual functioning was assessed by the Female Sexual Function Index (FSFI) and the International Index of Erectile Function (IIEF). Hormones were assessed by blood assay. Quality of life, body image, depressive symptoms, and marital adjustment were assessed by validated questionnaires. Results Fifty-one percent of women presenting for bariatric surgery reported a sexual dysfunction; 36% of men presenting for bariatric surgery reported erectile dysfunction (ED). This is in contrast to 41% of women who sought nonsurgical weight loss and reported a sexual dysfunction and 20% of men who sought nonsurgical weight loss and reported ED. These differences were not statistically significant. Sexual dysfunction was strongly associated with psychosocial distress in women; these relationships were less strong and less consistent among men. Sexual dysfunction was unrelated to sex hormones, except for sex hormone binding globulin (SHGB) in women. Conclusion Women and men who present for bariatric surgery, compared with individuals who sought nonsurgical weight loss, were not significantly more likely to experience a sexual dysfunction. There were few differences in reproductive hormones and psychosocial constructs between candidates for bariatric surgery and individuals interested in nonsurgical weight loss.

Obesity has been associated with impairments in sexual function and untoward changes in reproductive hormones in women. Relatively few studies have investigated changes in these domains following bariatric surgery.To investigate changes in sexual functioning, sex hormone levels, and relevant psychosocial constructs in women who underwent bariatric surgery.A prospective cohort study of 106 women from phase 2 of the Longitudinal Assessment of Bariatric Surgery who underwent bariatric surgery (median [interquartile range] body mass index, 44.5 [41.4-49.7]). Assessments were completed between 2006 and 2012.Bariatric surgery was performed by a surgeon certified by the Longitudinal Assessment of Bariatric Surgery (85 women underwent a Roux-en-Y gastric bypass, and 21 women underwent laparoscopic adjustable gastric banding).Sexual functioning was assessed by use of the Female Sexual Function Index. Hormones were assessed by use of a blood assay. Quality of life, body image, depressive symptoms, and marital adjustment were assessed by use of validated questionnaires.Women lost a mean 32.7% (95% CI, 30.7%-34.7%) of initial body weight at postoperative year 1 and a mean 33.5% (95% CI, 31.5%-35.6%) at postoperative year 2. Two years following surgery, women reported significant improvements in overall sexual functioning and specific domains of sexual functioning: arousal, lubrication, desires, and satisfaction. They also experienced significant changes at 2 years in all hormones of interest. Women reported significant improvements in most domains of quality of life, as well as body image and depressive symptoms, within the first year after surgery, with these improvements being maintained through the second postoperative year.Women who underwent bariatric surgery had significant improvements in overall sexual functioning, in most reproductive hormones of interest, and in psychosocial status. Improvements in sexual health can be added to the list of health benefits associated with bariatric surgery.clinicaltrials.gov Identifier: NCT00670098.

Background In 2005, the American Society for Metabolic and Bariatric Surgery (ASMBS) nursing membership embarked on a journey to develop a specialty certification program for nurses caring for morbidly obese and bariatric surgical patients. In keeping with the certification industry best practices, a practice analysis study was conducted to create an empirically sound foundation for the new nursing specialty certification examination. Methods Task force meetings, subject-matter expert interviews, and an external review process were implemented to create a definition of the specialty in terms of 4 domains of practice, 45 nursing tasks, and 54 knowledge areas. The definition encompassed the work of bariatric nurse coordinators, bariatric program directors, and floor nurses caring for morbidly obese and bariatric surgical patients. A survey was administered to 1084 nurses practicing in the specialty to validate the domains, tasks, and knowledge. Results Some differences in the time spent in each of the domains and tasks were noted for the survey respondents in the different job roles. Nevertheless, the respondents for all job roles rated the domains and tasks moderately or highly important in optimizing the outcomes for morbidly obese and bariatric surgery patients. In addition, most respondents agreed that the 54 knowledge areas were acquired during the first 2 years of practice in the specialty. Conclusion The survey results validated a specialized body of nursing knowledge rooted in the tasks that define professional practice. The results are being used to guide the development of a certification program for nurses practicing in the specialty and to provide guidance for education and training initiatives.

Since 1995, the number of laparoscopic bariatric surgical procedures has dramatically increased both in the United States and in other countries. These advanced laparoscopic operations offer the advantage of more rapid recovery and dramatically reduced wound complication with established efficacy. For optimal efficiency and outcomes, laparoscopic procedures on obese patients require specialized laparoscopic equipment and instrumentation, including staplers and hand instruments, which are used with individual skill and coordinated teamwork to facilitate patient positioning, laparoscopic access, insufflation, visualization by camera, energy sources for transection and coagulation, flexible endoscopy, and voice activation and robotics, and to provide a fully integrated operating room layout.

Laparoscopic gastric bypass is one of the most technically challenging operations performed using a laparoscopic approach. It requires the completion of two intracorporeal anastomoses and advanced suturing and stapling skills. Excessive abdominal adiposity creates exposure challenges, and often instrument length may be insufficient to reach the target. To complete the operation safely and efficiently, proper patient positioning and operating setup are crucial. If these tasks are not performed optimally, the progress of the operation may be compromised and, in the worst case, patient safety jeopardized. The following recommendations regarding patient positioning and operating room setup are based on our experience of more than 1500 laparoscopic gastric bypass cases. We wish the reader to recognize that, although our approach has been proven to be safe and effective in our hands, many other approaches are suitable.

Access port dislodgement after laparoscopic adjustable gastric banding is a recurring problem that often requires operative revision. Securing the port to the abdominal wall fascia in the traditional way with standard instruments is challenging in obese patients due to a thick abdominal wall. Therefore, we have devised a novel and simple technique for access port fixation using the EndoStitch device.

Faina Linkov, Ph.D.*, Dana H. Bovbjerg, Ph.D., Kyle E. Freese, M.P.H., Ramesh Ramanathan, M.D., George Michel Eid, M.D., William Gourash, M.S.N., C.R.N.P. Department of Obstetrics, Gynecology, & Reproductive Sciences, Department of Obstetrics, Gynecology, & Reproductive Sciences, Pittsburgh, Pennsylvania University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania Division of General Surgery, University of Pittsburgh Physicians, Pittsburgh, Pennsylvania Department of Minimally Invasive Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Objective To evaluate the short-term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with a follow-up of 1 to 31 months. Background Data The Roux-en-Y gastric bypass is a highly successful approach to morbid obesity but results in significant perioperative complications. A laparoscopic approach has significant potential to reduce perioperative complications and recovery time. Methods Consecutive patients (n = 275) who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass between July 1997 and March 2000. A 15-mL gastric pouch and a 75-cm Roux limb (150 cm for superobese) was created using five or six trocar incisions. Results The conversion rate to open gastric bypass was 1%. The start of an oral diet began a mean of 1.58 days after surgery, with a median hospital stay of 2 days and return to work at 21 days. The incidence of early major and minor complications was 3.3% and 27%, respectively. One death occurred related to a pulmonary embolus (0.4%). The hernia rate was 0.7%, and wound infections requiring outpatient drainage only were uncommon (5%). Excess weight loss at 24 and 30 months was 83% and 77%, respectively. In patients with more than 1 year of follow-up, most of the comorbidities were improved or resolved, and 95% reported significant improvement in quality of life. Conclusion Laparoscopic Roux-en-Y gastric bypass is effective in achieving weight loss and in improving comorbidities and quality of life while reducing recovery time and perioperative complications.