It was so upsetting for me to learn of John Kral’s recent passing from acute myeloid leukemia. First and foremost, John was my friend. I respected him as a scientist, physician, and, most importantly, as a fine human being. He was brilliant, loyal, and, most importantly, he was kind.

Today I invite you to join me on a somewhat complicated and circuitous trip with a few big bumps in the road. From the beginning I was a rather rambunctious and difficult child who was always getting into trouble. Perhaps because of my wild preteen years, I was sent to a preparatory school, the Mercersburg Academy, in the middle of rural Pennsylvania. They had a guard path where, when you did something bad like hang toilet paper on the trees or be late for breakfast, you would be forced to walk around a square for hours on a Saturday afternoon, when the school's football team would be in action. Much later, after I had been chosen by a national magazine as one of the top general surgeons in the country, my father's secretary called to express her amazement and incredulity because she remembered my antics as a wild kid and the problems it caused for my dad. I was admitted to Johns Hopkins. I decided it was time to shift into high gear, and I did very well there and even made Phi Beta Kappa.

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What follows are tributes from three individuals in celebration of Dr. Edward E. Mason: Dr. Pat O׳Leary and Drs. Con Doherty and Jim Maher, close friends and colleagues at the University of Iowa, as well as a cartoon by Dr. Pories and an interview with Dr. Mason by the Executive Committee of the ASMBS, including Dr. Ninh Nguyen, President, Dr. John Morton, President-Elect, Dr. Jaime Ponce, Immediate Past President, and Dr. Raul Rosenthal. There is also a video tribute to Dr. Mason, which I urge you to watch and which can be accessed online at: http://asmbs.org/mason-library. Dr. Mason׳s lecture, as the 4th Annual Edward E. Mason Lecturer, is then provided.

The recent article by Lisonkova and Joseph1Lisonkova S. Joseph K.S. Incidence of preeclampsia: risk factors and outcomes associated with early- versus late-onset disease.Am J Obstet Gynecol. 2013; 209: 544.e1-544.e12Abstract Full Text Full Text PDF PubMed Scopus (497) Google Scholar found an increased risk of preeclampsia in African Americans for early-onset and diabetes for late-onset preeclampsia, as well as an overall increased risk in Hispanics and Native Americans and a marked increase as gestation approaches term. The authors found that an increased body mass index was associated with an increased risk of early preeclampsia, but did not emphasize the issue of weight on the risk of preeclampsia. It is predictable that there would be an increased severity of preeclampsia and poor fetal outcomes in early gestation, which may be a problem secondary to the effects of obesity leading to early-onset disease. It is my hypothesis that preeclampsia is secondary to an increased intraabdominal pressure (IAP), which reduces venous flow from the uterus/placenta and throughout the body.1Lisonkova S. Joseph K.S. Incidence of preeclampsia: risk factors and outcomes associated with early- versus late-onset disease.Am J Obstet Gynecol. 2013; 209: 544.e1-544.e12Abstract Full Text Full Text PDF PubMed Scopus (497) Google Scholar A prior study has documented an increased IAP in women with central obesity.2Sugerman H.J. Hypothesis: preeclampsia is a venous disease secondary to an increased intra-abdominal pressure.Med Hypotheses. 2011; 77: 841-849Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Many of the phenomena found in this study could be related to that problem, as diabetes is often seen in obese women and obesity is a major problem in Hispanics, Native Americans, and African Americans as compared to Caucasians and, clearly, there would be an increased IAP as pregnancy approaches term. The smooth rate of increased risk of preeclampsia noted by Lisonkova and Joseph1Lisonkova S. Joseph K.S. Incidence of preeclampsia: risk factors and outcomes associated with early- versus late-onset disease.Am J Obstet Gynecol. 2013; 209: 544.e1-544.e12Abstract Full Text Full Text PDF PubMed Scopus (497) Google Scholar supports this concept and argues against >1 etiology for early vs late preeclampsia. There are several studies showing that the risk of preeclampsia decreases profoundly after surgically induced weight loss.3Sugerman H. Windsor A. Bessos M. Wolfe L. Intra-abdominal pressure, sagittal abdominal diameter and obesity comorbidity.J Intern Med. 1997; 241: 71-79Crossref PubMed Scopus (389) Google Scholar, 4Hazelgrave N.L. Oteng-Ntim E. Pregnancy after bariatric surgery: a review.J Obes. 2011; 2011: 501939PubMed Google Scholar I am currently conducting a study to determine if lowering the IAP will reverse the pathophysiology of preeclampsia. The recent article by Lisonkova and Joseph1Lisonkova S. Joseph K.S. Incidence of preeclampsia: risk factors and outcomes associated with early- versus late-onset disease.Am J Obstet Gynecol. 2013; 209: 544.e1-544.e12Abstract Full Text Full Text PDF PubMed Scopus (497) Google Scholar found an increased risk of preeclampsia in African Americans for early-onset and diabetes for late-onset preeclampsia, as well as an overall increased risk in Hispanics and Native Americans and a marked increase as gestation approaches term. The authors found that an increased body mass index was associated with an increased risk of early preeclampsia, but did not emphasize the issue of weight on the risk of preeclampsia. It is predictable that there would be an increased severity of preeclampsia and poor fetal outcomes in early gestation, which may be a problem secondary to the effects of obesity leading to early-onset disease. It is my hypothesis that preeclampsia is secondary to an increased intraabdominal pressure (IAP), which reduces venous flow from the uterus/placenta and throughout the body.1Lisonkova S. Joseph K.S. Incidence of preeclampsia: risk factors and outcomes associated with early- versus late-onset disease.Am J Obstet Gynecol. 2013; 209: 544.e1-544.e12Abstract Full Text Full Text PDF PubMed Scopus (497) Google Scholar A prior study has documented an increased IAP in women with central obesity.2Sugerman H.J. Hypothesis: preeclampsia is a venous disease secondary to an increased intra-abdominal pressure.Med Hypotheses. 2011; 77: 841-849Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Many of the phenomena found in this study could be related to that problem, as diabetes is often seen in obese women and obesity is a major problem in Hispanics, Native Americans, and African Americans as compared to Caucasians and, clearly, there would be an increased IAP as pregnancy approaches term. The smooth rate of increased risk of preeclampsia noted by Lisonkova and Joseph1Lisonkova S. Joseph K.S. Incidence of preeclampsia: risk factors and outcomes associated with early- versus late-onset disease.Am J Obstet Gynecol. 2013; 209: 544.e1-544.e12Abstract Full Text Full Text PDF PubMed Scopus (497) Google Scholar supports this concept and argues against >1 etiology for early vs late preeclampsia. There are several studies showing that the risk of preeclampsia decreases profoundly after surgically induced weight loss.3Sugerman H. Windsor A. Bessos M. Wolfe L. Intra-abdominal pressure, sagittal abdominal diameter and obesity comorbidity.J Intern Med. 1997; 241: 71-79Crossref PubMed Scopus (389) Google Scholar, 4Hazelgrave N.L. Oteng-Ntim E. Pregnancy after bariatric surgery: a review.J Obes. 2011; 2011: 501939PubMed Google Scholar I am currently conducting a study to determine if lowering the IAP will reverse the pathophysiology of preeclampsia. Incidence of preeclampsia: risk factors and outcomes associated with early- versus late-onset diseaseAmerican Journal of Obstetrics & GynecologyVol. 209Issue 6PreviewThe population-based incidence of early-onset (<34 weeks) and late-onset preeclampsia (≥34 weeks) has not been adequately studied. We examined the gestational age–specific incidence of preeclampsia onset and identified the associated risk factors and birth outcomes. 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Background: The remission rates of type 2 diabetes mellitus (T2DM) after Roux-en-Y gastric bypass (RYGB) vary according to the glycosylated hemoglobin A1c (HbA1c), fasting blood glucose (FG), and medication status. Our objectives were to describe remission using the American Diabetes Association standards for defining normoglycemia and to identify the factors related to the preoperative severity of T2DM that predict remission to normoglycemia, independent of weight loss, after RYGB. The setting was an urban not-for-profit community hospital.Methods: We performed a retrospective analysis of prospectively collected data from a cohort of 2275 patients who qualified for bariatric surgery (2001-2008). Five different models for defining remission (no diabetes medication and a FG < 100 mg/dL; no diabetes medication and HbA1c < 6.0; no diabetes medication and HbA1c < 5.7%; no diabetes medication, FG < 100 mg/dL, and HbA1c < 6.0%; and no diabetes medication, FG < 100 mg/dL, and HbAlc < 5.7%) were compared in 505 obese patients with T2DM 14 months after RYGB. The secondary aims were to determine the effects of preoperative insulin therapy and the duration of known T2DM on remission.Results: Of the 505 patients, 43.2% achieved remission using the most stringent criteria (no diabetes medication, HbA1c < 5.7%, and FG < 100 mg/dL) compared with 59.4% using the most liberal definition (no diabetes medication and FG < 100 mg/dL; P < .001). The remission rates were greater for patients not taking insulin preoperatively (53.8% versus 13.5%, P < .001) and for patients with a more recent preoperative T2DM diagnosis (8.9 versus 3.7 yr, P < .001).Conclusion: Remission, defined at a threshold less than what would be expected to result in microvascular damage, was achieved in 43.2% of diabetic patients by 14 months after RYGB. A more recent diagnosis of T2DM and the absence of preoperative insulin therapy were significant predictors, regardless of how remission was defined, independent of the percentage of excess weight loss. (Surg Obes Relat Dis 2012;8:548-555.) (c) 2012 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.

Deep vein thrombosis occurs when a blood clot forms in the deep veins of the leg and obstructs the flow of blood back to the heart. This can lead to swelling of the leg and pain in the calf muscle, although sometimes there are no symptoms. Pulmonary embolism occurs when blood clots leave the veins where they developed, travel through the right side of the heart, and lodge in the small or large branches of the blood vessels going to the lung (pulmonary arteries). This can cause symptoms such as chest pain, difficulty breathing, or coughing up blood. In severe cases, it may result in collapse and sudden death. Long airplane flights or multiple flights in a short period can cause deep vein thrombosis and pulmonary embolism. Any situation in which the leg is bent at the knee for prolonged periods without much active motion may lead to a reduction of blood flow and increase the risk of blood clots. Other factors can increase this risk, such as recent surgery, taking oral contraceptives or hormone therapy, pregnancy, cancer, heart problems, and older age. Inherited genetic factors may also play a role. PREVENTION

Severe obesity is associated with multiple comorbidities and is refractory to dietary management with or without behavioral or drug therapies. There are a number of surgical procedures for the treatment of morbid obesity, including purely gastric restrictive, a combination of malabsorption and gastric restriction or primary malabsorption. The purely gastric restrictive procedures, including vertical banded gastroplasty and laparoscopic adjustable silicone gastric banding, do not provide adequate weight loss. African-American patients do especially poorly after the banding procedure with the loss of only 11% of excess weight in one study. Gastric bypass (GBP) is associated with the loss of 66% of excess weight at 1 to 2 years after surgery, 60% at 5 years and 50% at 10 years. For unknown reasons, African-American patients lose significantly less weight than Caucasians after GBP. There is a risk of micronutrient deficiencies after GBP, including iron deficiency anemia in menstruating women, vitamin B12, and calcium deficiencies. Prophylactic supplementation of these nutrients is necessary. Recurrent vomiting after bariatric surgery may be associated with a severe polyneuropathy and must be aggressively treated with endoscopic dilatation before this complication is allowed to develop. The malabsorptive procedures include the partial biliopancreatic bypass (BPD) and BPD with duodenal switch (BPD/DS). The BPD appears to cause severe protein-calorie malnutrition in American patients; the BPD/DS may be associated with less malnutrition. Weight loss failure after GBP does not respond to tightening a dilated gastrojejunal stoma or reducing the size of the gastric pouch. These patients may require conversion to a malabsorptive distal GBP, similar to the BPD. However, because of the risk of severe protein-calorie malnutrition and calcium deficiency BPD should be reserved for patients with severe obesity comorbidity. The risk of death following bariatric surgery is between 1% and 2% in most series but is significantly higher in patients with respiratory insufficiency of obesity. In most patients, surgically induced weight loss will correct hypertension, type II diabetes mellitus, sleep apnea, obesity hypoventilation syndrome, gastroesophageal reflux, venous stasis disease, urinary incontinence, female sexual hormone dysfunction, pseudotumor cerebri, degenerative joint disease pains, as well as improved self-image and employability.

It is hypothesized that in some women an excessively high intra-abdominal pressure (IAP) compresses the inferior vena cava, uterine veins, portal vein, hepatic veins, splenic vein and renal veins which lead to a decreased flow in these vascular beds, producing lower extremity edema, fetal-placental ischemia, a glomerulopathy with proteinuria and hypertension, hepatic ischemia and thrombocytopenia, increased uric acid, and hemolysis/elevated liver enzymes/low platelet known as the HELLP syndrome. There can be variability in the expression of these components. Placental-fetal ischemia could lead to expression of soluble fms-like tyrosine kinase1 (sFLT) and endoglin which have been shown to cause additional diffuse endovascular damage. A further increase in IAP pushes the diaphragm cephalad, increasing intrathoracic pressure leading to upper extremity edema, decreased internal jugular venous flow, cerebral vascular engorgement, raised intracranial pressure, and if unresolved, seizures. Placental/fetal ischemia and hepatic ischemic necrosis may lead to diffuse inflammation and a septic inflammatory response syndrome (SIRS) which may become a vicious cycle, perpetuating the ischemia. It is further hypothesized that application of an externally applied negative abdominal pressure device will lower IAP and possibly reverse the pathophysiology of preeclampsia. As the abnormal placental proteins develop weeks before clinical preeclampsia, early application of external negative abdominal pressure may prevent development of the syndrome.

It is with great sadness I report the sudden death of Ross Brechner, MD, 71 years of age, who died from a heart attack on August 4, 2011. Ross was a great friend of bariatric surgery. After his retirement from the private practice of ophthalmology he joined the National Coverage and Analysis Group for the Centers for Medicare & Medicaid Services (CMS). In July 2004, CMS removed the following policy language, “obesity is not an illness,” and Ross, as a lead medical officer, was assigned to evaluate the efficacy of bariatric surgery for a Medicare Coverage Advisory Committee (MCAC) on November 4, 2004 [ [1] Kral J.G. Christou N.V. Flum D.R. et al. Medicare and bariatric surgery. Surg Obes Relat Dis. 2005; 1: 35-63 Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar ].

Emergency Department, Chi-Mei Medical Center, Tainan, Taiwan (Liao) Emergency Department, Chi-Mei Medical Center, Tainan, Taiwan (Chen) Department of Emergency Medicine, Taipei Medical University, Tainan, Taiwan (Chen)

BACKGROUND:The concept that advanced surgical training can reduce or eliminate the learning curve for complex procedures makes logical sense but is difficult to verify and has not been tested for laparoscopic Roux-en-Y gastric bypass (LRYGB). We sought to determine if minimally invasive/bariatric surgery fellowship graduates (FGs) would demonstrate complication-related outcomes (CRO) equivalent to the outcomes achieved during their training experience under the supervision of experienced bariatric surgeons.METHODS:We compared CRO for the first 100 consecutive LRYGBs performed in practice by five consecutive minimally invasive/bariatric fellows at new institutions (total 500 cases) to CRO for the 611 consecutive LRYGBs performed during their fellowship training experience under the supervision of three experienced bariatric surgeons at the host training institution.RESULTS:The two patient groups did not differ demographically. The 18 types of major and minor complications identified after LRYGB did not differ among the five fellowship graduates. The mentors' CRO were compatible with published benchmark data. As compared with the training institution data, the overall incidence of complications for the combined experience of fellowship graduates did not differ statistically from that of the mentors. The fellowship graduates' early experience included zero non-gastrojejunostomy leaks (0% versus 1.5%) and a low rate of anastomotic stricture (0.8% versus 3.0%), incisional hernia (1% versus 4.4%), bowel obstruction (0% versus 3%), wound infection (0.3% versus 3.1%), and gastrointestinal hemorrhage (0.2% versus 1.6%). The rate of gastrojejunostomy leak (1.8% versus 2.6%) and, most importantly, mortality (0.8% versus 0.7%) did not differ between the two groups.CONCLUSIONS:Fellowship graduates achieved high-quality surgical outcomes from the very beginning of their post-fellowship practices, which are comparable to those of their experienced mentors. These data validate the concept that advanced surgical training can eliminate the learning curve often associated with complex minimally invasive procedures, specifically LRYGB.

Data on long-term outcomes after D-GB is limited in American patients. The purpose of this study was to evaluate the long-term weight loss and metabolic outcomes of D-GB with follow-up to 24 years.

Background: The purpose of the present study was to evaluate the safety, efficacy, and nutritional outcomes of malabsorptive distal Roux-en-Y gastric bypass (D-RYGB) 20-25 years later at a university hospital.Methods: From 1985 to 1989, 49 mostly superobese (body mass index >50 kg/m(2)) patients had undergone D-RYGB. D-RYGB consisted of open laparotomy with a 50-mL proximal gastric pouch and gastroenterostomy performed 250 cm proximal to the ileocecal junction. with common channels of 50-150 cm. These 49 patients were compared with a similar group of 92 consecutive patients who had undergone long-limb RYGB. with a 75-cm biliopancreatic limb and 150-cm alimentary limb.Results: The mean +/- SD preoperative body mass index was 58.9 +/- 9.3 kg/m(2). After 1 perioperative death secondary to pulmonary embolism, limb-lengthening revisions were required in 21 (43.7%) of the 48 remaining patients for protein-calorie malnutrition. Of the 23 with a 50-cm common channel. 13 required revision compared with 8 of 25 with >= 100-cm common channel (P < .05, chi-square). Of the 48 patients who had undergone D-RYGB, 8 had died 6-19 years after D-RYGB. Of the nonrevised patients. 19 (70.4%) of 27 had >5 years of follow-up. In these, the latest body mass index was 34.2 kg/m(2) at 10 +/- 6.1 years. The percentage of excess weight loss was 66.8% +/- 14%. The lowest late serum albumin level was 3.4 +/- .5 g/dL (range 2.3-4.4). The mean 25-hydroxy vitamin D level was 14.6 +/- 11.3 ng/mL. Compared with patients who had undergone RYGB, the D-RYGB patients had a significantly greater percentage of excess weight loss after 5 years but significantly lower albumin. hemoglobin. iron. and calcium levels.Conclusion: Although D-RYGB afforded superior long-term weight loss, it caused protein-calorie malnutrition requiring frequent revision. The nonrevised patients had frequent severe metabolic derangements. Thus. D-RYGB should not be the primary operation for morbid or superobese patients. (Surg Obes Relat Dis 2011;7:189-194.) (C) 2011 American Society for Metabolic and Bariatric Surgery. All rights reserved.

Obesity is associated with comorbidities that may lead to disability and death. During the past 20 years, the number of individuals with a body mass index >30, 40, and 50 kg/m(2), respectively, has doubled, quadrupled, and quintupled in the United States. The risk of developing comorbid conditions rises with increasing body mass index. Possible cardiac symptoms such as exertional dyspnea and lower-extremity edema occur commonly and are nonspecific in obesity. The physical examination and electrocardiogram often underestimate cardiac dysfunction in obese patients. The risk of an adverse perioperative cardiac event in obese patients is related to the nature and severity of their underlying heart disease, associated comorbidities, and the type of surgery. Severe obesity has not been associated with increased mortality in patients undergoing cardiac surgery but has been associated with an increased length of hospital stay and with a greater likelihood of renal failure and prolonged assisted ventilation. Comorbidities that influence the preoperative cardiac risk assessment of severely obese patients include the presence of atherosclerotic cardiovascular disease, heart failure, systemic hypertension, pulmonary hypertension related to sleep apnea and hypoventilation, cardiac arrhythmias (primarily atrial fibrillation), and deep vein thrombosis. When preoperatively evaluating risk for surgery, the clinician should consider age, gender, cardiorespiratory fitness, electrolyte disorders, and heart failure as independent predictors for surgical morbidity and mortality. An obesity surgery mortality score for gastric bypass has also been proposed. Given the high prevalence of severely obese patients, this scientific advisory was developed to provide cardiologists, surgeons, anesthesiologists, and other healthcare professionals with recommendations for the preoperative cardiovascular evaluation, intraoperative and perioperative management, and postoperative cardiovascular care of this increasingly prevalent patient population.

Obesity ManagementVol. 5, No. 3 Original PapersBrief Overview of the Expert Recommendations for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery PatientHarvey J. Sugerman, Jeffrey I. Mechanick, and Robert F. KushnerHarvey J. SugermanSearch for more papers by this author, Jeffrey I. MechanickSearch for more papers by this author, and Robert F. KushnerSearch for more papers by this authorPublished Online:19 Jun 2009https://doi.org/10.1089/obe.2009.0303AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetails Volume 5Issue 3Jun 2009 InformationCopyright 2009, Mary Ann Liebert, Inc.To cite this article:Harvey J. Sugerman, Jeffrey I. Mechanick, and Robert F. Kushner.Brief Overview of the Expert Recommendations for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient.Obesity Management.Jun 2009.108-111.http://doi.org/10.1089/obe.2009.0303Published in Volume: 5 Issue 3: June 19, 2009PDF download