Background The risks of bariatric surgical procedures must be balanced against their benefits and require further characterization. Methods Longitudinal Assessment of Bariatric Surgery-1 (LABS-1) was a prospective, multi-center observational study of 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical sites in the United States (2005-2007). A composite endpoint of 30-day major adverse outcomes (death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; no discharge) was evaluated among patients undergoing first-time bariatric surgery. Results There were 4776 patients (mean age 44.5 years, 21.1% male, 10.9% non-white, median BMI of 46.5 kg/m2) who had a first-time procedure. Over half had at least two comorbid conditions. Roux-en-y gastric bypass was performed in 3412 (87.2% laparoscopic) and laparoscopic adjustable gastric banding in 1198. The 30-day mortality rate for Roux-en-y gastric bypass or laparoscopic adjustable gastric banding was 0.3%; 4.3% of participants had at least one major adverse outcome. A history of deep vein thrombosis or pulmonary embolus, obstructive sleep apnea, and functional status were each independently associated with increased risk of the composite endpoint. Extreme values of BMI were significantly associated with an increased risk of the composite endpoint, while age, sex, race, ethnicity and other co-morbid conditions were not. Conclusion The overall risk of death and adverse outcome after bariatric surgery was low, varying considerably with patient characteristics. In helping patients make appropriate choices, short-term safety should be considered in conjunction with both the longer term effects of bariatric surgery and the risk of living with extreme obesity.

No abstract

Obesity is associated with a decrement in the ability of skeletal muscle to oxidize lipid. The purpose of this investigation was to determine whether clinical interventions (weight loss, exercise training) could reverse the impairment in fatty acid oxidation (FAO) evident in extremely obese individuals. FAO was assessed by incubating skeletal muscle homogenates with [1-14 C]palmitate and measuring 14 CO2 production. Weight loss was studied using both cross-sectional and longitudinal designs. Muscle FAO in extremely obese women who had lost weight (decrease in body mass of ϳ50 kg) was compared with extremely obese and lean individuals (BMI of 22.8 Ϯ 1.2, 50.7 Ϯ 3.9, and 36.5 Ϯ 3.5 kg/m 2 for lean, obese, and obese after weight loss, respectively). There was no difference in muscle FAO between the extremely obese and weight loss groups, and FAO was depressed (Ϫ45%; P Յ 0.05) compared with the lean subjects. Muscle FAO also did not change in extremely obese women (n ϭ 8) before and 1 yr after a 55-kg weight loss. In contrast, 10 consecutive days of exercise training increased (P Յ 0.05) FAO in the skeletal muscle of lean (ϩ1.7-fold), obese (ϩ1.8-fold), and previously extremely obese subjects after weight loss (ϩ2.6-fold). mRNA content for PDK4, CPT I, and PGC-1␣ corresponded with FAO in that there were no changes with weight loss and an increase with physical activity. These data indicate that a defect in the ability to oxidize lipid in skeletal muscle is evident with obesity, which is corrected with exercise training but persists after weight loss. extreme obesity; fat oxidation; gastric bypass surgery; mitochondria; physical activity OBESITY IS ONE OF THE LEADING CAUSES of preventable death in the United States and is associated (6) with conditions such as insulin resistance, the metabolic syndrome, and type 2 diabetes. A metabolic disturbance evident with obesity is a decrement in the ability of skeletal muscle to oxidize lipid. An impairment in lipid oxidation has been observed when fatty acid oxidation (FAO) is measured in the whole body (16, 36), skeletal muscle homogenates (19), or skeletal muscle strips (13) from obese or extremely obese [body mass index (BMI) Ն40 kg/m 2 ] individuals. This decrease in FAO is also retained in primary skeletal muscle cells raised in culture from extremely obese donors (12). Such data indicate a relatively consistent impairment in the ability of human skeletal muscle to oxidize lipid with obesity, particularly in extremely obese patients. This defect may be a critical component of comorbidities seen with obesity, because a reduction in FAO can partition lipid toward ectopic storage within the muscle cell, which may in turn induce insulin resistance (9,15,22,30,31). In addition, a decrement in the ability to oxidize lipid has been linked (38) with weight gain and a propensity toward obesity. It is thus important to elucidate effective treatments that can reverse and/or compensate for the impairment in lipid oxidation seen in skeletal muscle with obesity.Exercise training and w...

ObjectiveTo detail robotic procedure development and clinical applications for mitral valve, biliary, and gastric reflux operations, and to implement a multispecialty robotic surgery training curriculum for both surgeons and surgical teams. Summary Background DataRemote, accurate telemanipulation of intracavitary instruments by general and cardiac surgeons is now possible. Complex technologic advancements in surgical robotics require well-designed training programs. Moreover, efficient robotic surgical procedures must be developed methodically and safely implemented clinically. MethodsAdvanced training on robotic systems provides surgeon confidence when operating in tiny intracavitary spaces. Three-dimensional vision and articulated instrument control are essential. The authors' two da Vinci robotic systems have been dedicated to procedure development, clinical surgery, and training of surgical specialists. Their center has been the first United States site to train surgeons formally in clinical robotics. ResultsEstablished surgeons and residents have been trained using a defined robotic surgical educational curriculum. Also, 30 multispecialty teams have been trained in robotic mechanics and electronics. Initially, robotic procedures were developed experimentally and are described. In the past year the authors have performed 52 robotic-assisted clinical operations: 18 mitral valve repairs, 20 cholecystectomies, and 14 Nissen fundoplications. These respective operations required 108, 28, and 73 minutes of robotic telemanipulation to complete. Procedure times for the last half of the abdominal operations decreased significantly, as did the knot-tying time in mitral operations. There have been no deaths and few complications. One mitral patient had postoperative bleeding. ConclusionRobotic surgery can be performed safely with excellent results. The authors have developed an effective curriculum for training teams in robotic surgery. After training, surgeons have applied these methods effectively and safely.Surgeons always have sought methods to develop new operations, but many times have been limited by technology. In many instances, initial endoscopic surgical training of senior surgeons and residents alike proceeded along variable pathways without significant prior procedure development or detailed curricula. Early clinical training frequently was at the expense of the best surgical results. Bonchek, 1 Lytle, 2 and Cooley 3 have cautioned surgeons who veer from established techniques with proven results, even if much larger incisions are required.Multispecialty procedure development is very important when any new technology is introduced in surgery. Our trek for developing surgical robotics and training surgeons has been predicated on quality expected from conventional procedures, or "base camps." Progression to each successive level has been followed by technologic "acclimatization" and experience before attempting the last challenge to surgical telemanipulation.

Early results suggest that video-assisted minimally invasive mitral operations can be done safely. These methods may benefit patients through less morbidity, earlier discharge, and lower cost.

Over the past 15 years, repair techniques, improved prostheses, retrograde cardioplegia, and enhanced exposure collectitvely have led to impressive advances in mitral valve surgery. Just as minimally invasive coronary surgery appears efficacious, cardiac valve operations using similar techniques are promising. Recently, Kaneko and associates 1 reported videoscopic examination of the mitral valve during a commissurotomy done via a sternotomyo Early this year, port-access mitral replacements were done in Malaysia by the Stanford team using new aortic balloon occlusive technology. On February 26, 1996, Carpentier successfully performed the first video-assisted mitral valve repair through a minithoracotomy during ventriculai fibrillation. 2 On May 26, 1996, our group performed a direct vision "micro-mitral" valve repair with antegrade cardioplegic arrest through a 2.4-inch incision. Two days later we replaced a rheumatic mitral valve using a video-assisted minimally invasive approach, and this case is the subject of this report.The patient was a 43-year-old man with diabetes and long-standing mitral insufficiency that had progressed to class III heart failure and recent-onset atrial fibrillation. Cardiac catheterization showed normal coronary arteries and a 0.45 ventricular ejection fraction. Transthoracic echocardiography showed an immobile posterior leaflet with type III severe mitral insufficiency. Intraoperative transesophageal echocardiography confirmed the transthoracic study. The patient was intubated with a double-lumen endotracheal tube for single lung ventilation and positioned with the right side of the chest elevated 45 degrees and the pelvis nearly flat. A 2-inch incision was made in the midaxillary line over the fifth rib and a small section was removed. A custom retractor was used to provide operative exposure (Snowden-Pencer Inc.). The pericardium was opened just anterior to the phrenic nerve with thoracoscopy scissors. Specialized instruments were used throughout the operation: however, video access was established by means of standard thoracoscopic techniques. A 10 mm thoracoscopic port was placed posterior and cephalad to the main incision, and a three-chip lighted camera (Linvatec Inc.) was inserted to visualize the limited surgical field.Peripheral cardiopulmonary support (28 ° C

After RYGB, fasting insulin decreases to levels like those of lean control subjects and diabetes is reversed (fasting blood glucose < 125 mg/dl). This leads us to propose that 1) exclusion of food from the foregut corrects hyperinsulinemia and 2) fasting insulin is dissociated from the influence of fasting glucose, insulin resistance, and BMI. The mechanisms for reversal of diabetes in the face of reduced insulin remain a paradox.

Insulin sensitivity and glucose transport are greater in the postsurgery patients than predicted from the weight-matched group, suggesting that improved insulin sensitivity after bypass is due to something other than, or in addition to, weight loss. Improved insulin sensitivity is related to reduced inhibitor of kappaB kinase beta activity and enhanced insulin signaling in muscle.