CONTEXT AND OBJECTIVE:Hyperinsulinemic hypoglycemia is newly recognized as a rare but important complication after Roux-en-Y gastric bypass (GB). The etiology of the syndrome and metabolic characteristics remain incompletely understood. Recent studies suggest that levels of incretin hormones are increased after GB and may promote excessive beta-cell function and/or growth.PATIENTS AND METHODS:We performed a cross-sectional analysis of metabolic variables, in both the fasting state and after a liquid mixed-meal challenge, in four subject groups: 1) with clinically significant hypoglycemia [neuroglycopenia (NG)] after GB surgery, 2) with no symptoms of hypoglycemia at similar duration after GB surgery, 3) without GB similar to preoperative body mass index of the surgical cohorts, and 4) without GB similar to current body mass index of the surgical cohorts.RESULTS:Insulin and C-peptide after the liquid mixed meal were both higher relative to the glucose level achieved in persons after GB with NG compared with asymptomatic individuals. Glucagon, glucagon-like peptide 1, and glucose-dependent insulinotropic peptide levels were higher in both post-GB surgical groups compared with both overweight and morbidly obese persons, and glucagon-like peptide 1 was markedly higher in the group with NG. Insulin resistance, assessed by homeostasis model assessment of insulin resistance, the composite insulin sensitivity index, or adiponectin, was similar in both post-GB groups. Dumping score was also higher in both GB groups but did not discriminate between asymptomatic and symptomatic patients. Notably, the frequency of asymptomatic hypoglycemia after a liquid mixed meal was high in post-GB patients.CONCLUSION:A robust insulin secretory response was associated with postprandial hypoglycemia in patients after GB presenting with NG. Increased incretin levels may contribute to the increased insulin secretory response.

BACKGROUND:Since the Food and Drug Administration (FDA) approval of laparoscopic adjustable gastric bands (LAGB) in June 2001, the number LAGB procedures performed in the United States has increased exponentially. This study aimed to benchmark the authors' initial hospital experience to FDA research trials and evidence-based literature.METHODS:Over a 2-year period, 87 consecutive patients with a mean age of 43 years (range, 21-64 years) and a body mass index of 45.6 kg/m2 (range, 35-69 kg/m2) underwent an LAGB procedure at the authors' institution. The authors conducted a retrospective review of the outcomes including conversion, reoperation, mortality, perforation, erosion, prolapse, port dysfunction, excess weight loss, and changes in comorbidities, then compared the data with published benchmarks.RESULTS:Gender, age, and body mass index were comparable with those of other series. Perioperative adverse events included acute stoma obstruction (n = 1) and respiratory complications (n = 2). Delayed complications included gastric prolapse (n = 4) and port reservoir malposition (n = 4). Five bands were explanted. The mean follow-up period was 14 months (n = 79). The mean percentage of excess weight loss was 30% (range, 4.7-69%) at 6 months, 41% (range, 9.6-82%) at 12 months, and 47% (range, 14-92%) at 24 months. Comorbidities resolved included diabetes (74%), hypertension (57%), gastroesophageal reflux disease (55%) and dyslipidemia (38%).CONCLUSIONS:The short-term outcomes for LAGB were comparable with published benchmarks. With adequate weight loss, most patients achieve significant improvement in obesity-related illnesses. With new bariatric accreditation standards and mandates required for financial reimbursement, hospitals will need to demonstrate that their clinical outcomes are consistent with best practices. The authors' early experience shows that LAGB achieves significant weight loss with low mortality and morbidity rates. Despite a more gradual weight loss, most patients achieve excellent weight loss with corresponding improvement of comorbidities within the first 2 years postoperatively.

Obesity imposes devastating health and financial tolls on society and those who suffer from it. Despite the growing awareness of the problem, the obesity epidemic, along with its associated complications, continues to expand at an alarming rate (1). The current nomenclature used to measure an individuals degree of obesity is BMI, which is calculated by dividing weight (in kilograms) by the square of height (in meters) (Table 1). Based on these criteria, the CDC (Centers for Disease Control and Prevention) reports a doubling of the obese population (BMI ≥30 kg/m2) in the period between 1976–1980 and 2001–2002 to reach an estimated number of 63 million obese people. Currently in the U.S., nearly two-thirds of adults are overweight (BMI >25 kg/m2), nearly one-third are considered obese (BMI ≥30 kg/m2), and 4.7% are extremely obese (BMI ≥40 kg/m2) (2). The financial cost of obesity in the U.S. is estimated to be in excess of $100 billion/year (3). In addition to increased risk of diabetes and other comorbid diseases, obese individuals may expect significant decreases in life expectancy (4) (Table 2). This obesity-related diminution in longetivity directly contributes to 280,000 deaths annually in the U.S. (5).Medical (nonsurgical) weight loss therapies include combinations of diet, exercise, behavioral therapies, and medications. In 1998, an NIH (National Institutes of Health) expert panel, upon critical review of the literature, concluded that these modalities, either alone or in combination, can induce modest weight loss that confers health benefits to the patients (6). However, the weight loss induced by these therapies is often short lived. Furthermore, medical management must continue indefinitely to be effective, or weight regain is common. Such medical therapies have not been shown to be effective in maintaining long-term weight loss in a morbidly obese patient population. Thus, most physicians …

BACKGROUND:Controversy exists regarding the efficacy of heated and humidified intraperitoneal gases in maintaining core body temperature. We performed a sham-controlled study to test the hypothesis that active warming and humidification of the insufflation gas reduces intraoperative heat loss and improves recovery outcomes.PATIENTS AND METHODS:Fifty morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass procedures using a standardized anesthetic technique were randomly assigned to either a control (sham) group receiving room temperature insufflation gases with an inactive Insuflow (Lexion Medical, St. Paul, MN) device, or an active (Insuflow) group receiving warmed and humidified intraperitoneal gases. Esophageal and/or tympanic membrane temperature was measured perioperatively. Postoperative pain was assessed at 15 minute intervals using an 11-point verbal rating scale, with 0 = none to 10 = maximal. In addition, postoperative opioid requirements, incidence of nausea and vomiting, as well as the quality of recovery, were recorded.RESULTS:Use of the active Insuflow device was associated with significantly higher mean +/- standard deviation (SD) intraoperative core body temperatures (35.5 +/- 0.5 vs. 35.0 +/- 0.4 degrees C). Postoperative shivering (0 vs. 19%) and the requirement for morphine in the postanesthesia care unit (5 +/- 4 vs. 10 +/- 5 mg) were both significantly lower in the Insuflow vs. control groups. Patients in the Insuflow group also reported a higher quality of recovery 48 hours after surgery (15 vs. 13, P < 0.05).CONCLUSION:The Insuflow device modestly reduced shivering and heat loss, as well as the need for opioid analgesics in the early postoperative period. However, it failed to improve laparoscopic visualization due to fogging, and provided improvement in the quality of recovery only on postoperative day 2.

Laparoscopic hernia repair is safe and effective and may result in less postoperative pain and faster recuperation compared with traditional open hernia repairs. Controversy exists as to the increased cost associated with laparoscopic repairs. The purpose of this study was to quantify and compare the cost of the totally extra-peritoneal (TEP) laparoscopic repair and the tension-free Lichtenstein repair at teaching hospitals. The records of consecutive TEP (n = 28) and Lichtenstein (n = 28) repairs performed at Parkland Memorial Hospital and Zale-Lipshy University Hospital were reviewed. A detailed cost analysis was performed. Total patient charge ($5,509 vs. $3,999) and total cost ($2,861 vs. $2,009) were higher for TEP versus Lichtenstein repairs, respectively (P < 0.05). Operative time and complications were similar for both groups. Return to full activity (15 vs. 34 days) was faster for TEP versus Lichtenstein repairs, respectively (P < 0.05). Of 9 patients in the TEP group who had previously undergone an open hernia repair, 8 (89%) preferred the laparoscopic approach. The laparoscopic TEP repair costs $852 more than the Lichtenstein repair. The TEP repair results in faster recuperation. Patient preference and faster recuperation may offset the increased cost associated with laparoscopic hernia repair.

Journal of Laparoendoscopic & Advanced Surgical TechniquesVol. 13, No. 4 Original PapersLaparoscopic Gastric Bypass Surgery: OutcomesBenjamin E. Schneider, Leonardo Villegas, George L. Blackburn, Edward C. Mun, Jonathan F. Critchlow, and Daniel B. JonesBenjamin E. Schneider, Leonardo Villegas, George L. Blackburn, Edward C. Mun, Jonathan F. Critchlow, and Daniel B. JonesPublished Online:7 Jul 2004https://doi.org/10.1089/109264203322333575AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited BySingle anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S): experience from a high-bariatric volume center29 March 2022 | Langenbeck's Archives of Surgery, Vol. 407, No. 5Laparoscopic Gastric BypassSurgical Clinics of North America, Vol. 101, No. 2High Rates of Nicotine Use Relapse and Ulcer Development Following Roux-en-Y Gastric Bypass22 September 2020 | Obesity Surgery, Vol. 31, No. 2Chronic Abdominal Pain After Previous Bariatric Surgery: Consider the Abdominal Wall27 April 2020 | Obesity Surgery, Vol. 30, No. 8Gastric Bypass Complications12 November 2019Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients18 October 2019 | Inflammatory Bowel Diseases, Vol. 384Surgery for Acute Bariatric Complications22 June 2019MagenManagement of Post-Bariatric ComplicationsLate postoperative bleeding after Roux-en-Y gastric bypass: management and review of literature9 December 2018 | BMJ Case Reports, Vol. 11, No. 1Factors Associated with Recurrent Ulcers in Patients with Gastric Surgery after More Than 15 Years: A Cross-Sectional Single-Center StudyGastroenterology Research and Practice, Vol. 2018The incidence of complications associated with loop duodeno-ileostomy after single-anastomosis duodenal switch procedures among 1328 patients: a multicenter experienceSurgery for Obesity and Related Diseases, Vol. 14, No. 5Stricture Following Gastric Bypass and Vertical Sleeve Gastrectomy27 April 2018When the Surgeon Needs the Endoscopist in Rescuing Bariatric Surgery: Intermediate and Late Post-operative Period28 November 2018Endoscopic Evaluation/Management of Bariatric Surgery Complications10 November 2017 | Current Treatment Options in Gastroenterology, Vol. 15, No. 4Gastric interventional endoscopyCurrent Opinion in Gastroenterology, Vol. 33, No. 6Complications of Bariatric Surgery: What You Can Expect to See in Your GI PracticeAmerican Journal of Gastroenterology, Vol. 112, No. 11Vertical Gastric Bypass with Fundectomy: Feasibility and 2-Year Follow-Up in a Series of Morbidly Obese Patients7 March 2017 | Obesity Surgery, Vol. 27, No. 8Review article including treatment algorithm: endoscopic treatment of luminal complications after bariatric surgery15 February 2017 | Clinical Obesity, Vol. 7, No. 2Prevention and Management of Marginal Ulcers3 February 2017Low Prevalence of Clinically Significant Endoscopic Findings in Outpatients with DyspepsiaGastroenterology Research and Practice, Vol. 2017Obesity: Presentations and Management Options1 August 2016Surgical Complications of Weight Loss Surgery2 April 2015Complications chirurgicales du by-pass gastrique dans les hôpitaux Neuchâtelois (Suisse)5 February 2014 | Obésité, Vol. 9, No. 2Development of Ulcer Disease After Roux-en-Y Gastric Bypass, Incidence, Risk Factors, and Patient Presentation: A Systematic Review14 November 2013 | Obesity Surgery, Vol. 24, No. 2Endoscopic Management of Complications After Gastrointestinal Weight Loss SurgeryClinical Gastroenterology and Hepatology, Vol. 11, No. 4Endoscopic Management of Post-Bariatric Foreign Bodies: Dysfunctional Sutures, Staples, and Bands27 December 2012Bariatric Surgery30 July 2012Surgical Treatment of Obesity23 May 20122. Laparoscopic Roux-en-Y Gastric Bypass: Techniques and Outcomes27 February 2012Clinical Outcomes of the Marginal Ulcer Bleeding after Gastrectomy: As Compared to the Peptic Ulcer Bleeding with Nonoperated StomachGastroenterology Research and Practice, Vol. 2012References4 May 2011Laparoscopic Mini-gastric Bypass for Type 2 Diabetes: The Preliminary Report17 December 2010 | World Journal of Surgery, Vol. 35, No. 3BAROS results in 700 patients after laparoscopic Roux-en-Y gastric bypass with subset analysis of age, gender, and initial body mass indexSurgery for Obesity and Related Diseases, Vol. 7, No. 1Laparoscopic revision of gastrojejunostomy revision with truncal vagotomy for persistent marginal ulcer after Roux-en-Y gastric bypassSurgery for Obesity and Related Diseases, Vol. 6, No. 5Removing foreign bodies in bariatric patientTechniques in Gastrointestinal Endoscopy, Vol. 12, No. 3Bariatric surgery: techniques, outcomes and complicationsCurrent Anaesthesia & Critical Care, Vol. 21, No. 1Benchmarking Best Practices in Weight Loss SurgeryCurrent Problems in Surgery, Vol. 47, No. 2Les complications de la chirurgie bariatriqueSituación actual de la derivación gástrica laparoscópicaDerivación gástrica laparoscópica con endograpadora circularSurgical Management of Gastroesophageal Reflux Disease in Obesity29 July 2008 | Digestive Diseases and Sciences, Vol. 53, No. 9A Perioperative Team Approach to Treating Patients Undergoing Laparoscopic Bariatric SurgeryAORN Journal, Vol. 88, No. 1DiscussionPlastic and Reconstructive Surgery, Vol. 119, No. 6Postoperative Assessment, Documentation, and Follow-Up of Bariatric Roux-en-Y Surgical PatientsLaparoscopic Roux-en-Y Gastric Bypass: OutcomesSurgical Treatment for the Overweight PatientCurrent Status of Laparoscopic Gastric BypassLaparoscopic Gastric Bypass Using the Circular StaplerUse of double-balloon enteroscopy to perform PEG in the excluded stomach after Roux-en-Y gastric bypassGastrointestinal Endoscopy, Vol. 64, No. 5Laparoscopic Surgery for ObesityAsian Journal of Surgery, Vol. 29, No. 4Length of stay and impact on readmission rates after laparoscopic gastric bypassSurgery for Obesity and Related Diseases, Vol. 2, No. 4Laparoscopic bariatric surgery16 March 2006 | Surgical Endoscopy, Vol. 20, No. S2Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypassSurgery for Obesity and Related Diseases, Vol. 2, No. 1Surgery for Obesity: Panacea or Pandora's Box?8 August 2006 | Digestive Surgery, Vol. 23, No. 1-2Techniques of Laparoscopic Gastric Bypass16 April 2013Gastric bypass for severe obesity: Approaches and outcomesSurgery for Obesity and Related Diseases, Vol. 1, No. 3Surgical Management of Morbid ObesityDiabetes Care, Vol. 28, No. 2Laparoscopic Roux-en-Y gastric bypass procedure for morbid obesity: OutcomesSurgery for Obesity and Related Diseases, Vol. 1, No. 1Effect of Bariatric Surgery on Long-term MortalityAdvances in Surgery, Vol. 39Surgical Treatment of the Overweight PatientSurgical Treatment of Obesity and Diabetes Volume 13Issue 4Aug 2003 To cite this article:Benjamin E. Schneider, Leonardo Villegas, George L. Blackburn, Edward C. Mun, Jonathan F. Critchlow, and Daniel B. Jones.Laparoscopic Gastric Bypass Surgery: Outcomes.Journal of Laparoendoscopic & Advanced Surgical Techniques.Aug 2003.247-255.http://doi.org/10.1089/109264203322333575Published in Volume: 13 Issue 4: July 7, 2004PDF download

Clinically relevant graphic approaches to the assessment of patients' blood pressure responses to antihypertensive agents are reviewed and extended to include both statistical components and the effects of treatment-related patient discontinuations. Regression line fits of change in diastolic blood pressure (DBP) versus baseline diastolic blood pressure (BDBP) are used for multicenter comparisons of placebo, guanabenz, methyldopa, clonidine, propranolol, hydrochlorothiazide, and the combination of guanabenz plus hydrochlorothiazide. Orientations of the fitted lines can be contrasted to certain "ideal" response profiles and are particularly useful for comparative purposes. An additional graphic approach was developed to show overall "therapeutic" response rate categories, two of which account for patients discontinuing treatment because of nonresponse or adverse effects. This approach assesses antihypertensive effectiveness, "adjusted" for the effects of treatment-related patient withdrawal, thus addressing criticisms often raised in the evaluation of such agents. Although these methods are generally useful for comparing agents used in chronic disease therapy, further work is needed to extend these procedures to incorporate safety assessments and overall benefit-risk considerations in the selection of treatment modalities.

Guanabenz, a centrally acting antihypertensive (alpha-agonist) that does not induce secondary sodium retention or other metabolic disturbances, was evaluated for up to two years at 19 investigational sites. In 329 patients completing six months of therapy, the mean supine diastolic blood pressure (SDBP) fell from 101 to 90 mmHg (P less than 0.01). Clinically significant individual SDBP decreases occurred in 74% of the patients by week 2, and these reductions were maintained in 72% at six months. Mean weight was reduced 1.4 lb (P less than 0.01), and mean supine pulse rate was decreased 5 beats/min (P less than 0.01). The most frequent effective doses were 8 and 16 mg BID (range, 2 to 32 mg BID). Principal side effects, usually mild, were sedation (31%), dry mouth (24%), dizziness (6%), and weakness (6%). Postural hypotension, impotence, and abrupt discontinuation symptoms were rare or absent. There were no clinically significant drug-related laboratory changes other than a 10 mg/100 ml mean serum cholesterol decrease. Two hundred twenty-two patients completed one year of therapy, and 80 completed two years, with little change in any parameters other than improvement in mean SDBP to 85 mmHg and in individual response rate to 84%. These results suggest that guanabenz is safe and effective for initial and sole therapy of hypertension.

The effects of guanabenz acetate, a centrally acting alpha-adrenergic, non-sodium-retaining antihypertensive agent, were compared with those of methyldopa in 248 hypertensive outpatients during a one-year, double-blind, multi-center study. Mean supine diastolic blood pressure (SDBP) decreased from 102 to 91 mmHg (P less than 0.01) among 78 guanabenz-treated patients and from 101 to 92 mmHg (P less than 0.01) among 89 methyldopa-treated patients who completed six months of treatment. Clinically significant individual SDBP decreases occurred in 76% of the guanabenz-treated patients and in 63% of the methyldopa-treated patients (P less thn 0.05). Blood pressure remained unchanged during the second six months, with response of 82% and 60%, respectively, for guanabenz and methyldopa (P less than 0.05). Although drowsiness and dry mouth occurred more frequently with guanabenz, evidence of fluid retention, such as weight gain, edema, and congestive heart failure, was significantly more frequent with methyldopa than with guanabenz. Because it does not induce volume expansion, guanabenz, unlike methyldopa, may be useful as sole initial antihypertensive therapy.