Sleep apnea syndrome is significantly underdiagnosed in bariatric surgical patients.

BACKGROUND: Devastating morbidity and mortality can result when patients with undiagnosed sleep apnea syndrome (SAS) undergo bariatric surgery. We evaluated the prevalence of SAS and its rate of nondiagnosis in bariatric patients at a university hospital. METHODS: The demographic, anthropomorphic, and co-morbidity data were collected from 1368 patients evaluated for bariatric surgery. All patients were screened for symptoms of SAS, and symptomatic patients were evaluated with polysomnography. RESULTS: At the time of this report, 834 patients (61%) had completed the preoperative evaluation. Of these patients, 210 (25%) presented with previously diagnosed SAS. An additional 174 patients (21%) exhibited symptoms of SAS and underwent polysomnography. Most patients tested (127, 73%) had SAS that required treatment, 11 patients (6%) had mild SAS not requiring treatment, and 36 (21%) tested negative for SAS. Thus, symptom screening for SAS had a positive predictive value of 79% for predicting the presence of SAS and 73% for identifying patients who required SAS treatment. The patients with SAS tended to be older and male and have a greater body mass index (P < .05). CONCLUSION: Overall, SAS that required treatment with an oral appliance was prevalent (40%) in patients who presented for bariatric surgery. However, many of these patients with significant SAS (38%) were previously undiagnosed, despite exhibiting clear symptoms of the disease. Symptom screening appears to be effective in identifying patients who should be evaluated by polysomnography. To avoid the potential perils of undiagnosed SAS during the perioperative period, patients who undergo bariatric surgery should be screened, tested, and treated for this co-morbidity.

Favorable internal hernia rate achieved using retrocolic, retrogastric alimentary limb in laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: The present study was performed at a tertiary care university hospital. The present study examined the incidence of internal hernia (IH) in our series of laparoscopic Roux-en-Y gastric bypass (LRYGB) with retrocolic, retrogastric routing of the alimentary limb accompanied by routine secure closure of all mesenteric defects. METHODS: During a 4-year period, 847 patients underwent LRYGB. Our operative technique included retrocolic, retrogastric placement of the alimentary limb. The enteroenterostomy mesenteric defect, mesocolic defect, and Petersen defect were routinely closed in running fashion with nonabsorbable suture. RESULTS: The study population had a mean age of 42.4 +/- 9.3 years and a mean preoperative body mass index of 45.3 +/- 5.6 kg/m(2). The mean operative time was 154 +/- 25 minutes. The mean excess body weight loss at 1 year was 70%. The incidence of IH among this large study population was 0%. A total of 11 patients (1.3%) presented with symptoms concerning for IH, most commonly nausea, vomiting, and crampy abdominal pain, from 1 month to 6 years after the initial surgery. On re-exploration, 4 patients had adhesive small bowel obstruction, 4 had adhesions without obstruction, 1 had small bowel intussusception, and 2 patients had negative findings. CONCLUSION: IH is a serious complication of LRYGB that can lead to catastrophic morbidity and mortality. We advocate vigilant screening for this complication and laparoscopic exploration for patients with worrisome symptoms. Our data have indicated that a routine and consistent technique to securely close the mesenteric defects can significantly reduce the risk of IH associated with retrocolic, retrogastric placement of the alimentary limb during LRYGB.

Depression is associated with increased severity of co-morbidities in bariatric surgical candidates.

BACKGROUND: Depression is prevalent among bariatric surgical patients, and previous studies have suggested a link between depression and quality of life. Our objective was to examine the relationship between depression and other co-morbidities of obesity at a university hospital in the United States. METHODS: Data were collected from 1368 consecutive patients evaluated for bariatric surgery. The demographic and co-morbidity profiles of these patients were compared between the depressed and nondepressed individuals. Depression was defined as an Assessment of Obesity-Related Co-morbidities score of > or = 3, signifying that the patient required medical treatment for (score of 3) or had complications of (score of 4-5) depression. RESULTS: The prevalence of depression among these patients was 36%. The mean age of the patients with depression was older (44.3 + or - 9.4 versus 42.2 + or - 9.6, P <.05), but the mean body mass index was similar. Depression was more prevalent among the female patients (37.4% versus 29.6%, P <.05). Diabetes mellitus, hypertension, polycystic ovarian syndrome, idiopathic intracranial hypertension, and obesity hypoventilation syndrome occurred with similar frequency and severity in persons with and without depression. The analysis revealed a significantly greater prevalence and severity of dyslipidemia (P <.05), gastroesophageal reflux disease (P <.05), back pain (P <.0001), joint pain (P <.05), sleep apnea (P <.01), stress incontinence (P <.01), and hernia (P <.05) among patients with depression. Overall, patients with depression had more co-morbidities per patient (5.46 versus 4.55) and a greater likelihood of severe or complicated co-morbidities (2.67 versus 1.89 per patient). CONCLUSION: This report has characterized a link between depression and other co-morbidities in bariatric surgical patients. This association was independent of the body mass index. Although a causal relationship could not yet be identified, our findings indicate that depression, in this patient population, is associated with a greater prevalence and increased severity of medical co-morbidities that express distinct physical symptoms.

Detailed description of early response of metabolic syndrome after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Previous outcome research in bariatric surgery has been unable to document quantitative changes in co-morbidities associated with obesity owing to a lack of a standardized instrument to grade the severity. We report a detailed description of the early resolution of the metabolic syndrome using our novel scheme for assessing co-morbidities. This study was performed at a tertiary care university hospital. METHODS: Co-morbidity data were prospectively collected for 827 patients who underwent laparoscopic Roux-en-Y gastric bypass during a 4-year period using the Assessment of Obesity-Related Co-morbidities (AORC) scale. This scale assigns a score of 0-5 for the major medical conditions associated with obesity. The co-morbid conditions of obesity and biochemical markers of the metabolic syndrome were examined preoperatively and at the follow-up visits. RESULTS: Of the 827 patients who underwent laparoscopic Roux-en-Y gastric bypass, 72 (8.7%) met the AORC criteria for the metabolic syndrome (AORC score >2 for diabetes mellitus [DM], hypertension [HTN], and dyslipidemia [DYS]). Overall, 75% of patients with DM, 69.4% of patients with HTN, and 76.4% of patients with DYS showed improvement in these co-morbidities (decrease from the preoperative AORC score) within 2 months after surgery. Within this period, DM, HTN, and DYS resolved in 65.3%, 51.4%, and 73.6% of patients, respectively. Concurrent decreases in hemoglobin A1c, serum lipids, and blood pressure were observed (P <.05). Patients exhibited a modest excess body weight loss of 27.7% during this period. However, the mean AORC score for the whole group decreased significantly for DM, DYS, and HTN (P <.001) before significant weight loss occurred. CONCLUSION: We have demonstrated a new and novel approach to categorize and more accurately define the magnitude of improvement in co-morbidities after laparoscopic Roux-en-Y gastric bypass. This improvement preceded the weight loss effects on the metabolic syndrome.

3-D telestration: a teaching tool for robotic surgery.

BACKGROUND: Telestration is an important teaching tool in minimally invasive surgery (MIS). While robotic surgery offers the added benefit of three-dimensional (3-D) visualization, telestration technology does not currently exist for this modality. This project aimed to develop a video algorithm to accurately translate a mentor's two-dimensional (2-D) telestration into a 3-D telestration in the da Vinci visual field. MATERIALS AND METHODS: A prototype 3-D telestration system was constructed to translate 2-D telestration from a mentor station into 3-D graphics for the trainee at the robotic console. This system uses fast image correlation algorithms to allow 2-D images to be placed over the same anatomic location in the two separate video channels of the stereoscopic robotic visualization system. Three subjects of varying surgical backgrounds, blinded to the mode of telestration (2-D vs. 3-D), were tested in the laboratory, using a simulated robotic task. RESULTS: There were few technologic errors (2), only one of which resulted in a task error, in 99 total trials. Only the experienced MIS staff surgeon had a significantly faster task time in 2-D than in 3-D (P < 0.05). The MIS fellow recorded the fastest task times in 2-D and 3-D (P < 0.05). There were nine task errors, six of which were committed by the MIS fellow. The nonsurgeon trainee had the least number of errors but also had the slowest times. CONCLUSIONS: Robotic telestration in 3-D is feasible and does not negatively impact performance in laboratory tasks. We plan to refine the prototype and investigate its use in vivo.

Weight loss before gastric bypass: feasibility and effect on postoperative weight loss and weight loss maintenance.

BACKGROUND: This study was performed at a tertiary care university hospital. We hypothesized that weight loss before laparoscopic Roux-en-Y gastric bypass (LRYGB) is feasible, does not diminish the expected postoperative weight loss, and might enhance overall weight loss and maintenance. METHODS: A population of 351 consecutive patients, who had undergone LRYGB, was divided into 4 groups depending on the percentage of body weight loss achieved before surgery (group 1, none or gain; group 2, <5%; group 3, 5-10%; and group 4, >10%). Data were collected regarding the demographics, body mass index (BMI) change, and excess weight loss and analyzed by analysis of variance and Fisher's exact test at the alpha = 0.05 level. RESULTS: All groups were demographically similar in age and were predominantly women. The maximal follow-up was 36 months. Groups 3 and 4 had significantly greater initial excess weight and BMI (P <.05) but these became similar after the preoperative weight loss. Most patients (74%) were able to lose weight before surgery, with 36% losing >5% body weight. Preoperative weight loss did not decrease the magnitude of the expected postoperative weight loss. Patients who lost weight preoperatively demonstrated more excess weight loss and BMI change (from their initial weight) that was sustained far into the postoperative period and reached statistical significance at several points (P <.05). CONCLUSION: The results of this study have demonstrated that obese patients are capable of losing weight before LRYGB and that this weight loss does not negatively affect their expected postoperative weight loss. Furthermore, preoperative weight loss combined with LRYGB might result in better long-term excess weight loss and BMI change than surgery alone.

Bariatric surgical outcomes.

This article describes the procedures that are performed for weight loss and characterizes the associated short-term success (operative safety, in-hospital morbidity/mortality) and long-term efficacy(weight loss, weight loss maintenance, postoperative complications). It discusses each category of procedure and reviews the current outcomes literature. It also addresses the technical challenges that are involved with the performance of each procedure and how these challenges may affect short and long-term outcomes. It concludes by comparatively analyzing the outcomes of the various bariatric surgical procedures and their respective roles in effectively managing the morbidly obese patient.