Morbid Obesity

Background: In maintenance hemodialysis (MHD) outpatients, a reverse epidemiology is described, ie, baseline obesity appears paradoxically associated with improved survival. However, the association between changes in weight over time and prospective mortality is not known. Methods: Using time-dependent Cox models and adjusting for changes in laboratory values over time, the relation of quarterly-varying 3-month averaged body mass index (BMI) to all-cause and cardiovascular mortality was examined in a 2-year cohort of 54,535 MHD patients from virtually all DaVita dialysis clinics in the United States. Results: Patients, aged 61.7 ؎ 15.5 (SD) years, included 54% men and 45% with diabetes. Time-dependent unadjusted and multivariate-adjusted models, based on quarterlyaveraged BMI controlled for case-mix and available time-varying laboratory surrogates of nutritional status, were calculated in 11 categories of BMI. Obesity, including morbid obesity, was associated with better survival and reduced cardiovascular death, even after accounting for changes in BMI and laboratory values over time. Survival advantages of obesity were maintained for dichotomized BMI cutoff values of 25, 30, and 35 kg/m 2 across almost all strata of age, race, sex, dialysis dose, protein intake, and serum albumin level. Examining the regression slope of change in weight over time, progressively worsening weight loss was associated with poor survival, whereas weight gain showed a tendency toward decreased cardiovascular death. Conclusion: Weight gain and both baseline and time-varying obesity may be associated with reduced cardiovascular mortality in MHD patients independent of laboratory surrogates of nutritional status and their changes over time. Morbidly obese patients have the lowest mortality. Clinical trials need to verify these observational findings. Am J Kidney Dis 46:489-500.

Background: Laparoscopic sleeve gastrectomy (LSG) started as the restrictive part of the more complex laparoscopic duodenal switch (LDS) operation. There is no long-term experience with the isolated LSG. The main concern about the isolated LSG is the possibility of dilatation of the gastric pouch, long-term loss of restrictive function and weight regain. Laparoscopic re-sleeve gastrectomy (LRSG) has been used sparingly, but it also may become a possibility if more patients have the isolated LSG. Methods: 2 patients with BMI 58 and 65 respectively, underwent LSG as the first stage of the LDS. Later, when the patients regained some weight and their gastric pouch was found to be too large, the LRSG/DS was done. Results: The patient with BMI 58 had an initial drop to BMI 34 and regained weight to BMI 46, but after the LRSG/DS her BMI is 36 at 4 months. The BMI patient with BMI 65 had a drop to BMI 42, and after the LRSG/DS his BMI is 33 at 3 months later. Conclusion: LRSG may become necessary after gastric tube dilatation or insufficient original gastric volume reduction. LRSG is feasible, available and easy to perform when the resulting gastric pouch is too large or dilates after the original LSG.

proportional to the severity of the surgical stress. Compared with the conventional open method, laparoscopic surgery is mini-invasive and has decreased postoperative pain and length of hospitalization. The aim of this study was to investigate the systemic inflammatory response, after laparoscopic and open stoma-adjustable silicone band application, which is thought to be mediated by cytokines. Method: 30 morbidly obese patients underwent Swedish adjustable gastric banding (SAGB). 15 patients underwent laparoscopic (group 1) and 15 open SAGB (group 2). Mean operative time for the laparoscopic group was 70-110 min and for the laparotomy group 80-120 min. Gallbladders were not removed, and there were no systemic diseases in the patients. The intensity of surgical trauma was evaluated by measurement of metabolic and hormonal responses to the surgery. Plasma levels of C-reactive (CRP), haptoglobin, ceruloplasmin, albumin, transferrin, IL-6, malonic dialdehyde (MDA) and creatinine were measured before and after the operation. Results: CRP and IL-6 levels increased during and after laparoscopic and open SAGB. However, postoperative responses were significantly greater after open SAGB (group 2) (p<0.05). MDA level, an indicator of an oxidative trauma, was elevated in group 1 at the 6th postoperative hour but was significantly higher in group 2 at the 6th and 12th postoperative hours. The results were more significant in group 2 (p<0.05). There was no statistical difference between groups 1 and 2 in terms of albumin, creatinine, and transferrin levels before and after surgery. Conclusion: The systemic inflammatory res-ponses after laparoscopic SAGB were significantly reduced compared with those after open SAGB.

Background: Vertical Banded Gastroplasty (VBG) is one of the most common bariatric operations. It can be performed by open or laparoscopic methods. The purpose of this study was to analyze and compare the 1-year results of 40 patients who underwent laparoscopic (20) and open (20).

Background Obesity is a major public health concern on a global scale. Bariatric surgery is among the treatment options, resulting in significant and sustainable weight loss as well as amelioration of comorbidities. The purpose of this study was to evaluate whether a 12-week aerobic exercise program positively impacts heart rate variability (HRV) and functional capacity after gastric bypass surgery (GBS) in a female cohort. Methods Of the 52 patients initially recruited, 21 were randomized to a training group (TG) or control group and successfully completed the study. Patients were tested on two occasions: 1 week before GBS and 4 months after GBS. Anthropometric variables, body composition, record of heart rate and R-R intervals, and 6-min walk test (6MWT) were assessed at both time points. The TG underwent an aerobic exercise training program on a treadmill (1-h session, totaling 36 sessions over 12 weeks). Results The main findings from this study were: (1) only the TG demonstrated a significant increase (p<0.05) in all indexes of heart rate variability (HRV) after 12 weeks of aerobic exercise training and only the TG demonstrated a significant increase (p<0.05) in 6MWT distance and decrease in diastolic blood pressure after aerobic exercise training. Conclusions We conclude that 12 weeks of aerobic exercise training improves cardiac autonomic modulation and functional capacity 4 months after GBS.

Few large-scale epidemiologic studies have quantified the possible link between obesity and chronic renal failure (CRF). This study analyzed anthropometric data from a nationwide, population-based, case-control study of incident, moderately severe CRF. Eligible as cases were all native Swedes who were aged 18 to 74 yr and had CRF and whose serum creatinine for the first time and permanently exceeded 3.4 mg/dl (men) or 2.8 mg/dl (women) during the study period. A total of 926 case patients and 998 control subjects, randomly drawn from the study base, were enrolled. Face-to-face interviews, supplemented with self-administered questionnaires, provided information about anthropometric measures and other lifestyle factors. Logistic regression models with adjustments for several co-factors estimated the relative risk for CRF in relation to body mass index (BMI). Overweight (BMI > 25 kg/m 2 ) at age 20 was associated with a significant three-fold excess risk for CRF, relative to BMI <25. Obesity (BMI >30) among men and morbid obesity (BMI > 35) among women anytime during lifetime was linked to three-to four-fold increases in risk. The strongest association was with diabetic nephropathy, but two-to three-fold risk elevations were observed for all major subtypes of CRF. Analyses that were confined to strata without hypertension or diabetes revealed a three-fold increased risk among patients who were overweight at age 20, whereas the two-fold observed risk elevation among those who had a highest lifetime BMI of >35 was statistically nonsignificant. Obesity seems to be an important-and potentially preventable-risk factor for CRF. Although hypertension and type 2 diabetes are important mediators, additional pathways also may exist.

Background: Bariatric surgery has the potential for serious complications. A case is presented of unilateral lower extremity compartment syndrome after a laparoscopic Roux-en-Y gastric bypass performed in the modified lithotomy position. Case report: A 38-year-old female (weight 134.5 kg, BMI 49.6) underwent a laparoscopic Roux-en-Y gastric bypass (operating time 375 min). Postoperatively, she complained of bilateral lower extremity pain that gradually subsided over the course of the day. However, on the 1st postoperative day she developed numbness on the dorsum of the foot and compartment syndrome was diagnosed (anterior compartment pressure 71 mmHg). She underwent emergency fasciotomy,which resulted in a reduction of the pain and numbness on the dorsum of the foot. The next day she ambulated without difficulty and was discharged home on the 5th postoperative day. 12 days after her operation, delayed primary closure of the fasciotomy wound was done with the assistance of a novel device (Proxiderm) that applies constant tension to the wound edges. Subsequent recovery was uneventful, and at 4- month follow-up the patient had a weight loss of 28 kg without any right leg motor or sensory deficits. Conclusion: Bariatric surgeons should be aware of compartment syndrome as a rare but serious complication. Prevention, early recognition, and prompt fasciotomy are crucial for a favorable outcome.

Background: Laparoscopic Roux-en-Y gastric bypass (RYGBP) is being performed widely as a treatment of choice for morbid obesity. We present our method and experience with the first 150 consecutive cases of laparoscopic RYGBP with a 2-m long biliopancreatic limb (BP-limb). Methods: Between November 2001 and November 2003, a prospective analysis of 150 patients was performed identifying technical success and complications. Before surgery, patients underwent a strict multidisciplinary behavioral program. At operation the stomach was transected proximally with a linear stapler (60-mm, Endo-GIA) to create a prolongation of the esophagus (gastric tube) along the lesser curvature, resulting in a 40-50 ml pouch. Two meters of the proximal jejunum were bypassed (BP-limb), creating an antecolic Roux-en-Y gastro-jejunostomy to the posterior wall of the gastric tube using a 45-mm linear Endo-GIA stapler. The entero-anastomosis was created 50 cm below the gastro-jejunostomy, also with a 45-mm linear Endo-GIA. Results: Mean BMI was 50.0, and 78% of patients were females. With 100% follow-up, we found an EWL of 50% 6 months after surgery, gradually rising to 80% after 18 months. The mean operating time was 116 min for the first 50 cases and decreased to 82 min for the last 50 cases. Intestinal leakage occurred in 5 patients (3%) and bleeding in 5 (3%). Most of these complications occurred in the first 50 cases, and all but one were treated successfully with an early laparoscopic re-operation. Marginal ulcers were found in 16.6% of patients. No internal hernias have occurred. Conclusion: The operation demands advanced laparoscopic skills, but technically it is relatively simple and has an acceptable complication rate. Short-term results regarding excess weight loss are at least comparable to the RYGBP with a long alimentary limb.

Background: In Prader-Willi Syndrome (PWS), mental retardation and compulsive hyperphagia cause early obesity, the co-morbidities of which lead to short life-expectancy, with death usually occurring in their 20s. Long-term weight loss is mandatory to lengthen the survival; therefore, the lack of compliance in voluntary food restriction requires a surgical malabsorptive approach.

Background: Binge-eating disorder (BED) may be associated with unsatisfactory weight loss in obese patients submitted to bariatric procedures. This study aims to investigate whether the presence of binge eating before Roux-en-Y gastric bypass (RYGBP) influences weight outcomes.

Morbid obesity is refractory to medical treatment. The introduction of laparoscopic linear staplers in the early 1990s contributed to the development of the laparoscopic Roux-en-Y gastric bypass technique. Many series have compared different brands of circular and linear staplers. The purpose of this study was to evaluate the 4-row versus 6-row endoscopic staplers in laparoscopic Roux-en-Y gastric bypass for creation of the anastomosis. Between July 2000 and April 2004, 1240 patients underwent laparoscopic Roux-en-Y gastric bypass. The 4-row linear stapler was used in the first 664 cases (group 1) and the 6-row stapler in the latter 576 patients (group 2) to create the anastomosis. The medical records of those patients who developed leaks, gastrogastric fistulas, strictures, or bleeding were reviewed. Strictures were diagnosed using radiologic or endoscopic techniques. Leaks were more frequent in group 2 than in group 1 (1.56% versus 1.05%, respectively, P = .46). Documented bleedin...

Introduction Roux-en-Y gastric bypass (RNYGB) surgery offers an effective and enduring treatment for morbid obesity. Gastric bypass may alter gastrointestinal (GI) flora possibly resulting in bacterial overgrowth and dysmotility. Our hypothesis was that daily use of probiotics would improve GI outcomes after RNYGB. Methods Forty-four patients undergoing RNYGB were randomized to either a probiotic or control group; 2.4 billion colonies of Lactobacillus were administered daily postoperatively to the probiotic group. The outcomes of H 2 levels indicative of bacterial overgrowth, GI-related quality of life (GIQoL), serologies, and weight loss were measured preoperatively and at 3 and 6 months postoperatively. Categorical variables were analyzed by χ 2 test and continuous variables were analyzed by t test with a p<0.05 for significance. Results At 6 months, a statistically significant reduction in bacterial overgrowth was achieved in the probiotic group with a preoperative to postoperative change of sum H 2 part per million (probiotics=−32.13, controls=0.80). Surprisingly, the probiotic group attained significantly greater percent excess weight loss than that of control group at 6 weeks (controls= 25.5%, probiotic=29.9%) and 3 months (38.55%, 47.68%). This trend also continued but was not significant at 6 months (60.78%, 67.15%). The probiotic group had significantly higher postoperative vitamin B12 levels than the control group. Both probiotic and control groups significantly improved their GIQoL. Conclusion In this novel study, probiotic administration improves bacterial overgrowth, vitamin B12 availability, and weight loss after RNYGB. These data may provide further evidence that altering the GI microbiota can influence weight loss.

Background: Although low back (LBP) pain is not a lifethreatening disease, it is a source of significant discomfort and disability and accounts for work absences. It has been shown previously that morbid obesity is associated with increased frequency of LBP and that surgical weight loss improves the symptomatology. However, there are no studies to quantitatively assess the exact degree of functional disability caused by severe obesity and the degree of improvement of LBP that follows weight loss from bariatric surgery.

Background: From 1993 to 1999, 172 patients underwent adjustable silicone gastric banding (ASGB) or laparoscopic adjustable silicone gastric banding (LASGB). In 109 patients the adjustable band was placed via laparoscopy; in the other patients it was placed via laparotomy (prelaparoscopic era, conversions from other bariatric operations, conversions for laparoscopic failure). The conversion rate from laparoscopy to laparotomy was 9.3%, occurring in the early part of our experience.

The identification of nursing diagnoses in patients with morbid obesity contributes to the planning of interventions, through a systematized and scientifically grounded care. This study aimed to identify nursing diagnoses in morbidly obese patients treated in outpatient care using the International Classification for Nursing Practice (ICNP®), version 2.0.

Morbid obesity is a rapidly escalating problem in the United States, one with serious health ramifications. Due to the lack of empirical support for the long-term efficacy of non-surgical interventions for obesity, gastric bypass surgery has been pursued with increasing frequency as a treatment for morbid obesity. Because surgery is a high-risk, invasive treatment option, medical, psychological and behavioral factors must be carefully considered in pre-surgical evaluations. Although psychological evaluations are requested by surgical teams, there is currently no commonly used, standardized protocol for this type of assessment. Further, there is little empirical data specifying which factors predict successful surgical outcomes. A general overview of a semi-structured interview for presurgical gastric bypass evaluation, developed by the Medical Psychology Service at the VA Boston Healthcare System, is provided in this paper. This standardized approach has many advantages: it ensures comprehensive assessment of relevant factors; it facilitates both research and training; and it facilitates patient education about the procedure.

Obesity Surgery,[962][963][964][965][966][967][968][969] The rising prevalence of morbid obesity and the increased incidence of super-obese patients (BMI >50 kg/m 2 ) seeking surgical treatments has led to the search for surgical techniques that provide adequate EWL with the least possible morbidity. Sleeve gastrectomy (SG) was initially added as a modification to the biliopancreatic diversion (BPD) and then combined with a duodenal switch (DS) in 1988. It was first performed laparoscopically in 1999 as part of a DS and subsequently done alone as a staged procedure in 2000. With the revelation that patients experienced weight loss after SG, interest in using this procedure as a bridge to more definitive surgical treatment has risen. Benefits of SG include the low rate of complications, the avoidance of foreign material, the maintenance of normal gastro-intestinal continuity, the absence of malabsorption and the ability to convert to multiple other operations. Reduction of the ghrelinproducing stomach mass may account for its superiority to other gastric restrictive procedures. SG should be in the armamentarium of all bariatric surgeons. Nonetheless, long-term studies are necessary to see if it is a durable procedure in the treatment of morbid obesity.

In view of the substantial, at times conflicting, literature on conversion to open surgery during laparoscopic cholecystectomy (LC), we have considered it timely to review the subject to identify the risk factors for conversion and its consequences. The review is based on a complete literature search covering the period 1990 to 2005. The search identified 109 publications on the subject: 68 retrospective series, 16 prospective nonrandomized studies, 8 prospective randomized clinical trials, 5 prospective case-controlled studies, 5 reviews and 7 others (3 observational, 2 population-based studies, 1 national survey, and 1 editorial). As the majority of reported studies are retrospective, firm conclusions cannot be reached. Single factors that appear to be important include male gender, extreme old age, morbid obesity, cirrhosis, previous upper abdominal surgery, severe/advanced acute and chronic disease, and emergency LC. The combination of patient-and disease-related risk factors increases the conversion risk. In the training of residents, the number of cases needed for reaching proficiency exceeds 200 cases. The value of predictive scoring systems is important in the selection of cases for resident training. Conversion exerts adverse effects on operating time, postoperative morbidity, and hospital costs, especially when it is enforced. There appears to be no absolute contraindication to LC that is agreed upon by all. There is consensus on certain individual risk factors and their additive effect on the likelihood of conversion. Predictive systems based on these factors appear to be useful in selection of cases for resident training.

Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) is the most commonly performed bariatric operation in the United States. Although rare, gastrogastric fistulas are an important complication of this procedure. Methods: We report a series of 1292 consecutive patients who underwent a divided RYGB procedure at our institution between January 2000 and November 2004. Of the 1292 patients, we identified 15 (1.2%) who presented with gastrogastric fistulas after surgery. Results: The mean age, weight, and body mass index of these patients was 39.5 years, 377.5 lb, and 54.9 kg/m 2 , respectively. The mean postoperative follow-up was 17.6 months. The overall follow-up success rate in this series at 1 and 2 years postoperatively was 85% and 77%, respectively. Of the 15 patients, 12 (80%) presented with symptoms of nausea, vomiting, and epigastric pain. Esophagogastroscopy revealed marginal ulcers in 8 (53%) of these symptomatic patients. The most sensitive test for the diagnosis of gastrogastric fistula was an upper gastrointestinal contrast study. The mean time to fistula diagnosis was 80 days. Four patients (27%) had had a known leak before their diagnosis of gastrogastric fistula. In all cases, the leaks were managed nonoperatively with drainage, parenteral nutrition, and bowel rest. In this subset of patients, the mean time to fistula diagnosis was 25 days. Four patients (27%) presented to the clinic unsatisfied with their weight loss. The mean excess percentage of weight loss was 60.9%. Of the 15 patients with a diagnosed gastrogastric fistula, 8 (53.3%) presented with concomitant marginal ulcers. When present, marginal ulcers were managed with chronic acid suppressive therapy consisting of proton pump inhibitors and sucralfate. Revisional surgery was performed in 5 (33.3%) of 15 patients because of the combination of constant pain and ulceration refractory to optimal medical treatment and in 1 patient (7%) because of refractory pain unresponsive to medical therapy and weight regain. All revisional procedures (100%) were performed laparoscopically. Conclusion: Gastrogastric fistulas are an uncommon, but worrisome, complication after divided RYGB. Most symptoms of gastrogastric fistula are related to epigastric pain and ulcerations around the anastomotic site, but the fistula can occur anywhere along the divided segment of the gastric wall. They can initially be managed with a conservative, nonoperative approach as long as the patient remains asymptomatic and weight regain does not occur. Refractory ulcers and pain are the main indications for revisional surgery. Weight loss failure or weight regain is an uncommon short-term finding with gastrogastric fistulas after divided RYGB that requires surgical revision as the definitive treatment option. Although we present one of the largest series to date, longer

Background: The authors assessed the quality of life (QOL) of patients after the Magenstrasse and Mill (M-M) procedure for morbid obesity (MO) and compared this with the QOL of MO patients and non-obese controls. Methods: Personal, postal and telephone questionnaire survey was completed by 82 patients after the M-M procedure, 35 MO patients and 20 normal controls. QOL was assessed by Short Form 36 (SF-36), Hospital Anxiety and Depression (HAD) scale, and obesity surgery related questionnaire. Results: Physical, social and psychological wellbeing of patients was substantially better after the M-M compared with their MO counterparts. After the M-M procedure, patients were significantly less depressed but remained anxious when compared with morbidly obese patients. The majority of patients (88%) were pleased with the result of surgery.

A ccording to the National Institutes of Health, obesity is a major health problem with clearly established health implications, including an increased risk for coronary artery disease, hypertension, dyslipidemia, diabetes mellitus, gallbladder disease, degenerative joint disease, obstructive sleep apnea, and socioeconomic and psychosocial impairment (1). The risk of developing one or more of these obesityrelated conditions is based on body mass index (BMI), with 25-30 kg/m 2 being low risk and Ͼ40 kg/m 2 being very high risk (2). The prevalence of obesity in the 18-to 29-yr-old group increased from 12% in 1991 to 18.9% in 1999 .

Background The increasing prevalence of morbid obesity together with the development of laparoscopic approaches has led to a steep rise in the number of bariatric operations. These guidelines intend to define the comparative effectivness and surrounding circumstances of the various types of obesity surgery. Methods A consensus panel representing the fields of general/endoscopic surgery, nutrition and epidemiology convened to agree on specific questions in obesity surgery. Databases were systematically searched for clinical trial results in order to produce evidence-based recommendations. Following two days of discussion by the experts and a plenary discussion, the final statements were issued. Recommendations After the patient’s multidisciplinary evaluation, obesity surgery should be considered in adults with a documented BMI greater than or equal to 35 and related comorbidity, or a BMI of at least 40. In addition to standard laboratory testing, chest radiography, electrocardiography, spirometry, and abdominal ultrasonography, the preoperative evaluation of obesity surgery patients also includes upper gastrointestinal endoscopy or radiologic evaluation with a barium meal. Psychiatric consultation and polysomnography can safely be restricted to patients with clinical symptoms on preoperative screening. Adjustable gastric banding (GB), vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) are all effective in the treatment of morbid obesity, but differ in degree of weight loss and range of complications. The choice of procedure therefore should be tailored to the individual situation. There is evidence that a laparoscopic approach is advantageous for LAGB, VBG, and GB (and probably also for BPD). Antibiotic and antithromboembolic prophylaxis should be used routinely. Patients should be seen 3 to 8 times during the first postoperative year, 1 to 4 times during the second year and once or twice a year thereafter. Outcome assessment after surgery should include weight loss and maintainance, nutritional status, comorbidities and quality-of-life.

La obesidad constituye una patología cada vez más frecuente en el mundo occidental y los esfuerzos para controlarla han sido infructuosos en su mayoría. La cirugía bariátrica aparece como una alternativa eficaz de tratamiento que logra reducción sostenida de peso en 50% de los casos, con disminución de la morbilidad y la mortalidad asociadas con la enfermedad.

Nutrition, Metabolism & Cardiovascular Diseases (2005) 15, 198e203 www.elsevier.com/locate/nmcd Conclusions: LAGB associated with a well balanced low-calorie diet achieved a satisfactory 2-year weight loss, while sparing FFM and not causing body fluid alterations. ª

Background: Quality of life (QoL) is considered to be the true measure for the effectiveness of a surgical procedure, but there are only a few validated instruments available for bariatric surgery.Therefore, a new diseasespecific 30-item instrument was created, which was called Bariatric Quality of Life (BQL) questionnaire. Methods: To validate the BQL, we studied 133 patients after 4 different types of bariatric surgery. Initially, mean body mass index (BMI) was 47.2 ±7.6 kg/m 2 and mean age was 38.8 ±11.0 years. At baseline, and 1, 6, and 12 months after surgery, patients filled in the BQL, the SF-12 (Short Form of SF-36 Health Survey), the GIQLI (Gastrointestinal Quality of Life Index), and the BAROS (Bariatric Analysis and Reporting Outcome System). Results: Internal consistency of the BQL was found to be good, with Cronbach's alpha ranging between 0.71 and 0.86. Factor analyses suggested that the BQL included a highly consistent set of QoL items and a second part on co-morbidities and gastrointestinal symptoms. At the 12 months follow-up, the BQL was closely correlated to SF 12 (Pearson's r = 0.86), GIQLI (0.68), BAROS (0.71), and excess weight loss (0.55). Standardized effect sizes over time were larger for the BQL (1.39 and 1.58) than for the other instruments. Conclusions: The BQL questionnaire is a validated instrument ready for clinical use.

The purpose of this paper is to highlight the way family dynamics and relationships affect patients who suffer from super obesity. The ideas discussed and proposed in this paper are  based on observations of the clinical cases documented in the medical documentary series My 600 lb life, which has aired on TLC since 2012. It follows the lives and treatment of individuals weighing over 600 pounds in the Houston, Texas area.
Super obese patients have weights that far surpass those of morbidly obese patients, often reaching up to 600 pounds. They face constant health complications and risk of death. As they gain weight, they lose mobility and increasingly rely on their caretakers. These caretakers are often family members, such as parents, spouses, siblings, and in cases, even  children.  As such, the patient’s entire world becomes solely their home and family life.
This has a lasting impact both on their physical health and their psychological health, which in these cases are very intricately linked. The evolution of the patient’s state often accompanies a shift in the family dynamics. 
Therefore, these family dynamics will have a huge impact on the beginning, evolution, and recovery and treatment of the super obese. They have the ability to facilitate the patient’s recovery and treatment, but often, because of the nature of the problem, they will pose an obstacle to recovery and interrupt effective treatment.

Objectifs. -É valuer l'efficacité des manoeuvres de recrutement alvéolaire (MRA) associées à une pression expiratoire positive (PEP) à 10 cmH 2 O, sur la mécanique respiratoire en période peropératoire, estimée par mesure de la compliance thoracopulmonaire (Ctp) et du delta de volume pulmonaire téléexpiratoire (D VTE) lors de la coeliochirurgie chez des patients ayant une obésité morbide. Type d'étude. -É tude prospective, randomisée. Patients et méthodes. -Deux groupes de 13 patients (IMC > 40 kg/m 2 ) opérés d'une gastroplastie par coelioscopie. Le groupe recrutement (groupe MRA) recevait une MRA suivie d'une PEP à 10 cmH 2 O contre uniquement une PEP à 10 cmH 2 O dans le groupe témoin (groupe PEP). La Ctp était mesurée au cours de l'intervention et la capacité résiduelle fonctionnelle estimée après exsufflation du pneumopéritoine en mesurant le D VTE lors d'une manoeuvre PEP to ZEP (PEP nulle). Un test de Mann et Whitney et un test t ont été utilisés (significativité p < 0,05). Résultats. -La Ctp s'améliorait de manière significative dans le Groupe MRA 52 AE 14 ml/cmH 2 O versus 36 AE 10 ml/cmH 2 O dans le groupe PEP ( p = 0,004). Cette amélioration était transitoire et il n'y avait pas de différence statistiquement significative du D VTE entre les deux groupes en fin d'intervention (360 [90-770] ml [MRA] et 310 [190-450] ml [PEP]). La variation hémodynamique lors de la MRA est restée inférieure à 20 %. Conclusion. -Chez le patient obèse en coeliochirurgie, une MRA faite avant le pneumopéritoine améliore transitoirement la mécanique ventilatoire, mais sans amélioration de la CRF en fin d'intervention comparée au groupe PEP simple. Sa tolérance hémodynamique est bonne. # 2009 Elsevier Masson SAS. Tous droits réservés.

Background: Our aim was to evolve a simpler, more physiological type of gastroplasty that would dispense with implanted foreign material such as bands and reservoirs. The Magenstrasse, or "street of the stomach", is a long narrow tube fashioned from the lesser curvature, which conveys food from the esophagus to the antral Mill. Normal antral grinding of solid food and antro-pyloro-duodenal regulation of gastric emptying and secretion are preserved.

OBJECTIVE. Laparoscopic adrenalectomy has rapidly replaced open adrenalectomy as the procedure of choice for benign adrenal tumors. The aim of this study was to evaluate the shortand long-term results of 100 consecutive laparoscopic and open adrenalectomies performed during a period of 8.5 years in our Surgical Unit. DESIGN. A retrospective analysis of patients operated on for adrenal tumors was conducted. From May 1997 to August 2005, one hundred adrenalectomies were performed on 95 patients. Five patients underwent either synchronous or metachronous bilateral adrenalectomy. There were 38 men and 57 women, aged 16 to 80 years. The size of tumors in our series ranged from 3.2 to 27 cm. The largest laparoscopically excised tumor was a ganglioneuroma with a diameter of 13 cm. RESULTS. In 73 patients laparoscopic procedure was completed successfully. In 8 cases the laparoscopic procedure was converted to open. Fourteen patients were treated with open approach. One patient with pheochromocytoma succumbed following pulmonary embolus. In one patient with morbid obesity, Cushings syndrome, and bilateral adrenal macronodular hyperplasia, the left laparoscopic adrenalectomy was complicated by a low output pancreatic fistula, conservatively treated. All other patients had an uneventful course. Operative time for laparoscopic adrenalectomies ranged from 65 to 180 minutes. The average postoperative hospital stay for laparoscopic adrenalectomy ranged from 1 to 2 days (1.5 days), versus 5 to 20 days for patients who underwent open or converted procedure. CONCLUSIONS: Laparoscopic adrenalectomy should be the treatment of choice for all benign adrenal tumors. Laparoscopic resection of large adrenal tumors necessitates experience in open and advanced laparoscopic surgery.

Objective: To determine whether the daily pattern of urine excretion of N wastes is affected by obesity and very low-calorie diets (VLCD). Design: The plasma amino acid, urea and other energy parameters, as well as the urinary excretion of total nitrogen, urea and creatinine were studied in obese and normal-weight women. The obese women's data were obtained under hospital basal controlled conditions (8.1 MJaday) and after 3 days of VLCD diet (1.9 MJaday) controls were studied only once (5.8 MJaday). The hourly excretion patterns of total N, urea and creatinine were determined from the composition of each bladder voiding. Subjects: Twenty morbidly obese and 10 age-matched normal-weight control women. Results: Plasma amino acid levels were higher in obese women, which showed a limited ability to metabolize amino acid hydrocarbon skeletons. Neither differences in the patterns between groups nor total 24 h values for urine volume were found. Total N and urea excretion diminished under VLCD diet. Hourly creatinine excretion showed a¯at pattern and was higher in obese women than in the controls, VLCD diet diminished the amount of creatinine excreted in 24 h. Conclusions: The early change in energy availability that the creatinine excretion ®gures re¯ect may result from the energy conservation mechanisms induced in response to energy restriction. The early onset of this effect (3 days, and the extent of decrease ( $ 19%) also suggest that the impact of VLCD on the muscle energy budget of the obese is more marked than usually assumed. Sponsorship: Grants FIS-94a0034, BIO98-0316 and 2FD97-0233 of the Government of Spain.

Grade III obesity (BMI >39.9 kg/m2) is considered a chronic disease where clinical and diet therapy show poor results, with high rates of relapse. The most consistent results are those obtained through surgical procedures. Several authors discuss the contraindications for the performance of anti-obesity operations. Psychiatric disorders are often considered contraindications to these operations, especially affective disorders, psychotic disorders and personality disorders. The authors report the case of a 37-year-old patient, with obesity history since the age of 12, and anorexiant abuse (amphetaminederived substances) during 20 years, binge-eating episodes, purgative compensatory behaviors and recurrent depressive symptoms. She was submitted to anti-obesity surgery in August 2000 (BMI 40.2). The outcome is reported and a discussion of the possible psychiatric contraindications for the antiobesity surgeries is proposed.

Background: Postural deviations in morbidly obese individuals may contribute to low self-esteem and to long-term adverse effects on bones and joints. In a case-control study, the axial skeleton was investigated, to disclose the main abnormalities found in obese compared to non-obese groups.

Gastrointestinal obstructive complications after laparoscopic Roux-en-Y gastric bypass (LRYGBP) are not uncommon. Their usual causes are strictures, internal hernias and adhesions. Superior mesenteric artery (SMA) syndrome is a rare disorder caused by compression of the third portion of the duodenum by the SMA that can occur after rapid weight loss. This has been reported in patients with scoliosis, burns, immobilization in body casts, and idiopathic weight loss. SMA syndrome following bariatric surgery has not been reported. We present 3 cases of SMA syndrome after LRYGBP and extensive weight loss. Two patients underwent laparoscopic duodenojejunostomy and the third patient was treated with intravenous hyperalimentation. All three are symptom free at 4-18 months follow-up. The diagnosis of SMA syndrome should be considered in bariatric surgery patients with rapid weight loss who develop atypical, recurrent obstructive symptoms not attributable to other common causes.