Preoperative change in 6-minute walk distance correlates with early weight loss after sleeve gastrectomy.

INTRODUCTION: The 6-minute walk test (6MWT) is an objective preoperative measure of functional capacity and response to intervention in patients with heart or lung disease. In bariatric surgery, there has been no reliable preoperative measure predictive of postoperative success. Here we investigated the impact of bariatric surgery on changes in distance traveled in the 6MWT (the 6MWD) and whether preoperative changes in 6MWD correlated with weight change after surgery. METHODS: This is a retrospective study of consecutive patients in which the 6MWT was performed before and after laparoscopic sleeve gastrectomy for weight loss. 6MWD and total weight were measured. Pearson correlation was used to determine association between variables. RESULTS: Of 100 patients who underwent laparoscopic sleeve gastrectomy, 31 patients had a preoperative 6MWT. Thirty patients (97%) were available for follow-up after surgery. Percentage of excess weight loss was 45.7% over an average of 7 months after surgery. There was a weak correlation between the postoperative weight loss and the change in preoperative and postoperative 6MWD (r=0.28; P=.13). In a subset of patients who demonstrated a change in distance traveled in 2 separate preoperative 6MWD measurements (average 18.5% increase in distance), there was a strong correlation with postoperative weight loss (r=0.82; P=.02). CONCLUSIONS: A demonstrated increase in 6MWD before surgery correlates strongly with early postoperative weight loss after laparoscopic sleeve gastrectomy. A multidisciplinary team that includes a physical therapist is useful in preparing bariatric patients for surgery.

A prior history of substance abuse in veterans undergoing bariatric surgery.

BACKGROUND: The rates of obesity and substance abuse are high among US veterans. OBJECTIVE: To examine weight loss and substance abuse rates following bariatric surgery in veterans with a history of substance abuse (SA). METHODS: A prospective database of consecutive bariatric operations was reviewed. Data for SA patients were compared to patients without a substance abuse history (NA). Behavioral medicine staff followed patients throughout the pre- and postoperative courses. RESULTS: Of 205 bariatric surgery patients, there were 74 (36.1%) SA patients. The mean preoperative body mass index (BMI) was 46.2 ± 8.1 kg/m², and percent excess weight loss at 12 months was 71.8%, 58.0%, and 33.5% for Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic gastric banding, respectively, not significantly different than the NA group (P = 0.15, 0.75, 0.96). Postoperative substance abuse in SA and NA patients was 8.1% and 1.5%, respectively (P = 0.234). CONCLUSION: A prior history of substance abuse is common in veterans undergoing bariatric surgery; weight loss results are comparable to the general veteran bariatric cohort. Rates of substance abuse are low postoperatively, but higher in patients without a prior history of substance abuse. Close multidisciplinary followup throughout the postoperative course is likely to be integral to the patient's success.

Sleeve gastrectomy as a stand-alone bariatric operation for severe, morbid, and super obesity.

BACKGROUND: The laparoscopic sleeve gastrectomy (LSG) is emerging as an effective bariatric operation and is especially attractive in high-risk populations. In this study we examine the efficacy of LSG as a stand-alone operation in the veteran population. METHODS: This is a retrospective review of consecutive patients who underwent LSG as a stand-alone procedure at the Palo Alto Veterans Affairs medical center with a minimum 12-month follow-up. RESULTS: Of 205 patients undergoing bariatric surgery, 71 patients had a sleeve gastrectomy, 40 of whom had the operation performed at least 12 months previously. Thirty-six (90%) were available for 1-year follow-up, with a mean follow-up duration of 22 months (range: 12-42), a mean body mass index of 48.3 kg/m(2), and an 83% male population. Mean percent excess weight loss was 61% at an average of 22 months, with no significant difference between severely obese, morbidly obese, and super obese cohorts. Diabetes remission was seen in 56% of patients, hypertension remission in 51.6%, and obstructive sleep apnea remission in 46.4%, and gastroesophageal reflux disease improved or did not change in 83%. Medication use significantly decreased after surgery. CONCLUSION: LSG is safe and effective as a stand-alone bariatric operation in the high-risk veteran population. It is effective in severely obese, morbidly obese, and super obese patients. LSG induces remission or improvement in comorbidities of nearly all patients, translating to a decrease in medication use.

Short-term medication cost savings for treating hypertension and diabetes after gastric bypass.

BACKGROUND: The cost of medication for the treatment of hypertension and diabetes in the morbidly obese is a significant economic healthcare burden. In the present study, we assessed the effect of gastric bypass surgery on the average annual costs for hypertension and diabetes medication. METHODS: A prospective database of gastric bypass patients at the Palo Alto Veterans Affairs Health Care System was reviewed. The preoperative and postoperative medication requirements to treat hypertension and diabetes were identified before surgery and at 1 year postoperatively. Comparisons were made between the annual costs of the antihypertensive and diabetic medications before and after bariatric surgery using the Student paired t test. RESULTS: Of 106 patients who had undergone gastric bypass, 90 (85%) had either hypertension or diabetes. Of these 90 patients, 88 (98%) had hypertension and 60 (67%) had diabetes before surgery. Complete remission of hypertension occurred in 44% and remission of diabetes in 80% at 1 year after surgery. The annual cost of medications to treat hypertension was reduced by 65% at 1 year after surgery ($63.52 compared with $20.50, P < .0001). To treat diabetes, the annual medication cost was reduced by 88% at 1 year after gastric bypass surgery ($532.06 compared with $64.58, P < .0001). In the subset of patients with persistent hypertension or diabetes after surgery, the annual cost reduction for antihypertensive medications was 58% ($87.14 versus $36.82, P < .002). The annual cost reduction for diabetic medications was 69% ($1036.60 versus $322.90, P < .02). CONCLUSION: Gastric bypass surgery resulted in a significant reduction in the cost of medications to treat hypertension and diabetes in the morbidly obese at 1 year after surgery. These cost savings were also significant in the subset of patients who had persistent hypertension and diabetes after surgery.

Early postoperative outcomes and medication cost savings after laparoscopic sleeve gastrectomy in morbidly obese patients with type 2 diabetes.

Background. We investigated the effect of laparoscopic sleeve gastrectomy (LSG) on morbidly obese diabetics and examined the short-term impact of LSG on diabetic medication cost. Methods. A prospective database of consecutive bariatric patients was reviewed. Morbidly obese patients with type 2 diabetes who underwent LSG were included in the study. Age, gender, body mass index (BMI), diabetic medication use, glucose, insulin, and HbA1c levels were documented preoperatively, and at 2 weeks, 2 months, 6 months, and 12 months postoperatively. Insulin resistance was estimated using the homeostatic model assessment (HOMA). Use and cost of diabetic medications were followed. Results. Of 178 patients, 22 were diabetics who underwent LSG. Diabetes remission was observed in 62% of patients within 2 months and in 75% of patients within 12 months. HOMA-IR improved after only two weeks following surgery (16.5 versus 6.6, P < 0.001). Average number of diabetic medications decreased from 2.2 to <1, within 2 weeks after surgery; corresponding to a diabetes medication cost savings of 80%, 91%, 99%, and 99.7% after 2 weeks, 2 months, 6 months, and 12 months, respectively. Conclusion. Morbidly obese patients with diabetes who undergo LSG have high rates of diabetes remission early after surgery. This translates to a significant medication cost savings.

Male patients above age 60 have as good outcomes as male patients 50-59 years old at 1-year follow-up after bariatric surgery.

BACKGROUND: It is estimated that 25% of Americans older than 60 years are obese. Male gender and advanced age are indicators of increased risk for bariatric surgery. Good results have been shown in patients older than 50, but nearly all published studies include a large majority of females, and few include patients >60 years old. In this study, we examined the results of males over 60 years old. METHODS: We reviewed a prospective database of 107 consecutive patients who underwent bariatric surgery between April 2002 and June 2007 at the Palo Alto VA. Of these, 60 patients were males older than 50 and available for follow-up 12 months postoperatively. There were 47 males 50-59 years old (group I) and 13 males older than 60 years (group II). Data were analyzed using Student's t test. RESULTS: Mean preoperative body mass index was similar in both groups (49.4 vs. 47.5 kg/m(2); p = 0.468). Length of hospital stay was similar (3.2 vs. 3.5 days; p = 0.678), but early morbidity was higher in group II patients (30.8% vs. 8.5%; p = 0.037). Morbidity included urinary tract infection, cardiac arrhythmias, and early bowel obstruction. Excess weight loss after 1 year was not significantly different (63.6% vs. 60.6%; p = 0.565). Diabetes resolution or improvement was seen in 87% of group I patients and 90% of group II patients. CONCLUSION: Despite a higher early morbidity rate, obese males >/=60 years old perform as well as male patients 50-59 years old with respect to excess weight loss, mortality, length of stay, and improvement of diabetes, at 1 year postoperatively.

Introducing laparoscopic Roux-en-Y gastric bypass at a Veterans Affairs medical facility.

BACKGROUND: Previous studies have shown that advanced age, diabetes, and male gender are associated with higher morbidity and mortality after bariatric surgery. Those risk factors are characteristic of patients in the Veterans Affairs (VA) health care system. Laparoscopic Roux-en-Y gastric bypass (RYGB) has become an established treatment modality for morbid obesity. Our objective was to review the initial experience with laparoscopic (RYGB) for morbid obesity at our VA facility. METHODS: A retrospective review was used. RESULTS: Between May of 2002 and April of 2004, 40 patients underwent laparoscopic RYGB. All patients met National Institutes of Health consensus statement guidelines for bariatric surgery. There were 30 (75%) male and 10 (25%) female patients, with an average age of 49.9 +/- 8.7 years and an average body mass index (BMI) of 48.1 +/- 8.5 kg/m(2). Preoperative comorbidities included diabetes mellitus (DM) in 59%, hypertension in 79%, and obstructive sleep apnea in 74.4%. The procedure was converted to an open procedure in 3 patients (7.5%). There were no mortalities. Immediate (within 30 days) complications developed in 9 (22.5%) patients, necessitating abdominal re-operation in 3 patients (7.5%). The median length of hospital stay was 3 days. Late complications (>30 days) developed in 8 (20%) patients. Percent excess weight loss at 3, 6, and 12 months was 44% (n = 34), 59% (n = 29), and 70.0% (n = 22), respectively. In 23 patients who were followed-up for more than 3 months, DM resolved in 79% and improved in 21% at a mean follow-up evaluation of 13 months. CONCLUSIONS: Laparoscopic RYGB can be performed with acceptable morbidity and with good short-term results in a VA hospital setting. Morbid obesity is prevalent in the VA patient population and access to bariatric surgery should be an available alternative.