Dissertations / Theses on the topic 'Bariatric Surgery'

Obesity is a major public health problem. Bariatric surgery is currently the only available treatment that offers sufficient weight-loss and metabolic benefits over time. Although bariatric surgery is considered safe now, serious complications still occur. The aim of this thesis was to identify factors associated with an increased risk for postoperative complication after laparoscopic gastric bypass surgery. Study I included patients operated with laparoscopic gastric bypass surgery in Sweden from May 2007 until September 2012. The risk for serious complication was low (3.4%). Suffering an intraoperative adverse event or conversion of the operation to open surgery were the strongest risk factors for postoperative complication. The annual operative volume and experience of the procedure at the institution were also important risk factors. Patient-specific risk factors appeared to be less important although age was associated with an increased risk. In Study II, a raised glycated haemoglobin A1c (HbA1c) was evaluated as a risk factor for serious postoperative complications in non-diabetics. A higher incidence of serious postoperative complications was seen with elevated HbA1c values, even at levels classified as ‘‘pre-diabetic’’. Study III was a multicentre, randomised clinical trial (RCT). 2507 patients planned for laparoscopic gastric bypass surgery were randomised to either mesenteric defects closure or non-closure. Closure of the mesenteric defects reduced the rate of reoperation for small bowel obstruction from 10.2% to 5.5% at 3 years after surgery. A small increase in the rate of serious postoperative complication within the first 30 days was seen with mesenteric defects closure. This relatively small increase in risk was however outweighed by the marked reduction of later reoperations for small bowel obstruction. Study IV was a comparison between study III and an observational study on the same population under the same period of time. Although the observational study reached the same conlusion as the RCT, the efficacy of mesenteric defects closure was less pronounced. Observational studies may thus be an alternative to RCTs under situations when RCTs are not feasible. The efficacy may however be underestimated.

Background: Overweight and obesity has increased worldwide and is a leading cause of preventable death. This has led to the quantity of bariatric surgical procedures in Sweden increasing.  Research has identified significant medical benefits such as long-term weight loss, improved risk factors and significant reduction of mortality resulting from the surgery, however research focusing on the experiences of patients has not been undertaken to the same degree. The increasing incidence of overweight and obesity suggest that this patient group will continue to increase each year. Knowledge about the experience of bariatric surgery, including the challenges it represents from the patients’ perspective, is essential for nurses in order to provide the best possible care.                                                           Aim: The aim of the study was to investigate the patient’s experiences after undergoing bariatric surgery beyond the initial post-operative period of 6 months.                       Method: This study has been conducted as a literature review of nine qualitative scientific nursing articles. The data was analysed by conducting a manifest content analysis.        Result: The results found that experiences after bariatric surgery beyond the initial post-operative period were both positive and negative. How the individuals adapted to the changes the surgery entailed was found to be a strong factor in determining the nature of the experience. Two main categories emerged from the data; ‘Enforced Structure’ and ‘A Complete Transformation’.                                                                                   Conclusion: Undergoing bariatric surgery results in extensive and complex changes for this patient group to adapt to. Exploring their experiences has allowed factors for successful and challenging adaption to these changes to be identified. Nursing professionals can use this knowledge to help guide bariatric patients towards a successful adaption to the multitude of changes that surgery encompasses.

Whilst bariatric surgery is an effective intervention for life-threatening obesity, a substantial proportion of patients will continue to struggle to control their eating after surgery. Food cravings – the intense desire for a specific food or food group – are a key trigger for maladaptive eating, and are related to external cues and internal mental imagery. However, there is little known about the phenomenological experience of food cravings in people who have received bariatric surgery, or if there are any differences between types of bariatric surgery. This study recruited 43 bariatric patients between one and ten years post-surgery who reported all food cravings experienced over the course of one week using critical incident analysis methodology, resulting in a dataset of 128 cravings. The experience of people with gastric banding versus restructuring surgeries were compared, and mixed-model analyses were used to identify key predictive factors for the intensity and the resistibility of food cravings. Two to four cravings were experienced weekly: most often preceded by thinking about the food, most frequently for savoury foods, occurring in the early afternoon and within the first two hours after a meal. The majority of cravings (75%) resulted in an eating episode. Days in which a craving occurred were characterised by greater hunger, irritability and lower eating control. People with restructuring surgeries rated cravings as stronger and more difficult to resist, and more often ate after the craving than people with gastric bands, but this is likely to be due to differences between sample. Participants identified internal sensory imagery as part of their craving experience, and external sensory cues (seeing, smelling and eating the craved food) best predicted craving intensity. It is hoped that this study will help bariatric surgery candidates, those living with surgery and their clinicians to understand and anticipate food cravings, and lead to the development of effective interventions.

Obesity is an epidemic that can lead to a wide range of physical and mental problems. When traditional weight-loss methods are not effective, bariatric surgery is a viable weight-loss option. While previous researchers have investigated the role of psychological factors in relation to obesity, few have investigated psychological factors as predictors of weight loss and complications after bariatric surgery. The purpose of this study was to determine the prevalence of psychological disorders/conditions (e.g., depression and abuse) in the study population, evaluate weight and psychosocial variables before and 6 months after weight-loss surgery, and identify psychosocial factors that are predictors of weight loss and complications at 5 years post surgery. Three theoretical foundations were important to the present study: the transtheoretical model of behavior change, interpersonal processes, and protection motivation theory. Methods included a retrospective review of archival data of 93 individuals who elected to undergo bariatric surgery, were age 18+, had a BMI > 40kg/m2, and had obesity-related medical conditions Paired sample t tests were used to determine statistically significant changes before and after surgery. Multiple regression was used to predict success of bariatric surgery (measured by weight loss and no or few postsurgical complications). Results indicated that a high proportion (66.7%) of this sample had a behavioral health condition. Weight, depression, and obesity-related quality of life improved at 6 months post surgery. Poor obesity-related quality of life was significant at predicting more weight loss at 5 years postsurgery. Potential social changes may include future development of generalizable methods/tools to determine proper candidates for bariatric surgery, leading to a healthier community and lower healthcare costs.

The number of operations for morbid obesity is rising fast. We have examined aspects of postoperative physiology and results after bariatric surgery. The pH in the proximal pouch after Roux-en-Y gastric bypass (RYGBP) was investigated with catheter-based and wire-less technique. Gastric emptying, PYY-levels in the fasting state and after a standardized meal was evaluated after biliopancreatic diversion with duodenal switch (DS). A clinical trial was undertaken, comparing DS to RYGBP in patients with BMI>48. Main outcome variables were safety and long-term weight results as well as abdominal symptoms and laboratory results. Patients with stomal ulcer had significantly lower pH in their proximal gastric pouch as compared to asymptomatic control subjects. Long-time pH measurements with the wire-less BRAVO-system were feasible and demonstrated pH<4 in median 10.5% of the time in asymptomatic post-RYGBP patients. After DS, the T50 of gastric emptying was 28±16 minutes. PYY-levels were higher after DS than in age-matched control subjects. BMI-reduction was greater after DS (24 BMI-units) than after RYGBP (17 BMI-units) in median 3.5 (2.0-5.3) years after surgery (p<0.001). Fasting glucose and HbA1c levels were lower one and three years after DS as compared to RYGBP. On the other hand, DS-patients reported having more diarrhea and malodorous flatus. This thesis has resulted in deepened knowledge. Acid produced in the proximal pouch is an important pathogenetic factor in the development of stomal ulcer after RYGBP. However, symptom-free patients have an acidic environment in the proximal Roux-limb as well. After DS, gastric emptying is fast, but not instantaneous, and PYY-levels are high. DS results in superior weight reduction and better glucose control as compared to RYGBP in patients with BMI>48. We believe that DS has a place in surgical treatment of the super-obese, even though symptoms of diarrhea and malodorous flatus are more common after DS.

This portfolio has three parts. The first is a systematic literature review, in which the psychological and social factors associated with successful weight loss after bariatric surgery are reviewed. The second part is an empirical paper, which investigates the experiences of women who have successfully lost weight following bariatric surgery, specifically with reference to changes in self-concept. Seven women were interviewed and emergent themes were analysed using interpretative phenomenological analysis. Nine subthemes were identified, clustered into three superordinate themes: (1) 'obesity as socially unacceptable', (2) 'making a case for surgery', and (3) 'the slim self as socially acceptable'. Links to self-concept were made, and clinical implications were discussed. The third part of the portfolio comprises of the reflective statement and appendices.

Background: In morbidly obese individuals (MO) cardiorespiratory comorbidities and body habitus challenge the perioperative management of anesthesia. To implement safe and reproducible routines for anesthesia and fluid therapy is the cornerstone in order to minimize anesthesia-related complications and to meet individual variability in rehydration needs. Methods: Paper I: Impact of rapid-weight-loss preparation prior to bariatric surgery was investigated. Prevalence of preoperative dehydration and cardiac function were assessed with transthoracic echocardiography (TTE). Paper II: The anesthetic technique for rapid sequence induction (RSI) in MO based on a combination of volatile and i.v. anesthetics was developed. Pre- and post-induction oxygenation, blood pressure levels and feasibility of the method was evaluated. Paper III: The preoperative ideal body weight based rehydration regime was evaluated by TTE. Paper IV: Need of rehydration during bariatric surgery was evaluated by comparing conventional monitoring to a more advanced approach (i.e. preoperative TTE and arterial pulse wave analysis). Results: Rapid-weight-loss preparation prior to bariatric surgery may expose MO to dehydration. TTE was shown to be a robust modality for preoperative screening of the level of venous return, assessment of filling pressures and biventricular function of the heart in MO. The combination of sevoflurane, propofol, alfentanil and suxamethonium was demonstrated to be a safe method for RSI regardless of BMI. The preoperative rehydration regime implemented by colloids 6 ml/kg IBW was an adequate treatment to obtain euvolemia. In addition, preoperative rehydration seems to increase hemodynamic stability during intravenous induction of anesthesia and even intraoperatively. Conclusion: This thesis describes a safe and comprehensive perioperative management of morbidly obese individuals scheduled for bariatric surgery. Hemodynamic and respiratory stability can be achieved by implementation of strict and proven methods of anesthesia and fluid therapy. Much focus should be placed on feasible monitoring and preoperative optimization in morbidly obese individuals for increased perioperative safety.

An unbalanced, unhealthy diet is one of the main causes leading to obesity and the apparition of comorbidities. Bariatric surgery is currently the most effective and durable treatment against obesity. Despite being a commonly performed technique is still much investigated, as the mechanisms by which the weight is reduced and the comorbidities are improved are still largely unknown. Implementing healthier dietary habits after BS appears to be decisive to maintain the obtained benefits, besides the mechanistic restriction of the BS. On the other hand, dieting alone is also described to have beneficial effects if well implemented. Based on this information, we established the following hypothesis: A high-fat diet will induce modifications on a rodent model, such as increasing adiposity, unbalancing the gut microbiota, and modifying the fatty acid composition of several organs. The deleterious effects produced by the high-fat diet will be partly improved by either vertical sleeve gastrectomy or by a change of diet, while the combination of both actions will have a synergistic effect and a better outcome than both actions alone. To explore this hypothesis the following objectives were formulated: • Identify the major modifications caused by the HFD on adiposity, gut microbiota composition, and fatty acid composition in tissues. • Study the effects caused by VSG when the high-fat diet is continued. • Study the effects caused by a change of diet alone. • Study the effects caused by a combination of VSG and a change of diet.

Obesity has reached epidemic proportion in the United States. Results of diet, exercise regimens, and/or medications are discouraging for most individuals; therefore, bariatric surgery is on the rise. Patients undergoing bariatric surgery are overwhelmingly female. There is a plethora of research regarding improvement of co-morbidities, but little focus has been placed on the impact of bariatric surgery on positive as well as negative psychosocial outcomes. The purposes of this study were to explore experiences of women who have undergone bariatric surgery and to gain an understanding of the decision to have surgery. No qualitative research was found regarding individuals' life experiences after bariatric surgery. This study used a qualitative research design, guided by a phenomenological approach, to investigate and describe the meaning of experiences of women before and after bariatric surgery. Initially, a focus group of six members of a bariatric support group was conducted to confirm data from individual interviews. Semi-structured in-depth interviews were then conducted on a sample of ten women who had undergone bariatric surgery and were two to four years postoperative. Eight main themes emerged from the data: (a) relationship with food, (b) interpersonal relationships, (c) relationship with self, (d) living with excess skin, (e) food intolerance, (f) treatment from society, (g) concern with aging, and (h) support systems. After further analysis, three subthemes then emerged from relationship with food: food and family, emotional response to food, and coping with temptations. Interpersonal relationships developed into two subthemes: limited activity with family and relationship with others. As analysis continued, three subthemes of concern with aging emerged: fear of not growing old, fear of the unknown, and fear of gaining weight. Themes that emerged from the women's experiences all revolved around the need to be better prepared for surgery and the need for continued support after surgery. Family was interconnected to most of the themes. In order to be successful, close family members should understand the requirements of lifelong medical monitoring and the necessary changes in diet and lifestyle. Results revealed limited psychological counseling as well as long-term nutritional counseling occurred. The majority did not attend support groups, although the need for support was expressed. Support groups conducted by health professionals benefit those who are considering surgery and those who have undergone bariatric surgery. Recommendations for health education include addition of bariatric surgery into curriculums. Knowledge of bariatric surgery would assist health educators in planning programs for this population.

Obesity has emerged as one of the major global socioeconomic healthcare burdens at present. Bariatric surgery, especially Roux-en-Y gastric bypass (RYGB) has been largely utilised to treat individual suffering from morbid obesity. In the current study, a hyperinsulinemic obese Zucker rat model was employed to study two different weight loss approaches, RYGB and caloric restriction. To understand the host metabolic-microbial cross-talk, the two major analytical platforms including nuclear magnetic resonance (NMR) spectroscopy and 16S rRNA gene Illumina MiSeq sequencing were used in companion with multivariate statistical analysis to extract useful information from data with high complexity. The aim of this study was to 1) characterise the genotype-associated metabolic and microbial fingerprints; 2) investigate the dynamic changes in biofluids from RYGB-treated or caloric restriction-treated obese Zucker rats; 3) investigate genotype-related, RYGBinduced or caloric restriction-induced metabolic profiles and microbial shifts of the luminal contents; and 4) investigate the statistical correlation between metabolites and gut microbiota following either of the weight loss treatment. Metabolic observations of portal vein and peripheral blood plasma profiles in both obese and lean Zucker rats indicated the phenotype-independent absorption of short-chain fatty acids (SCFAs), choline and trimethylamine (TMA). However, phenotype-specific urinary host-microbial co-metabolites were revealed, suggesting distinct gut microbial metabolic activities in lean and obese Zucker rats. Furthermore, metabolic alterations induced by the RYGB surgery included the enhanced production of neuroactive metabolites, branchedchain amino acid (BCAA) catabolism, aromatic amino acid metabolism with lower lipogenesis and SCFA production. Even though caloric restriction demonstrated some health benefit-related biochemical and microbial markers, its effectiveness as a resolution for metabolic syndrome, especially type-2 diabetes mellitus has not been observed in this study in spite of the significant weight reduction.

Bariatric surgery is the most effective treatment for the management of severe obesity. In Chapters 3 & 4 of this thesis, in two prospective parallel-group studies we compared the effects of the ‘gold-standard’ operation Roux-en-Y gastric bypass (RYGBP) vs. the newer, increasingly performed procedure, sleeve gastrectomy (SG). We showed that in adiposity-matched patients RYGB and SG resulted in comparable reductions in circulating leptin levels at 6 and 12 weeks post-surgery. However, RYGB and SG had differential effects on circulating gut hormones levels. Plasma acyl-ghrelin levels declined post-surgery, with superior decreases observed post-SG vs. post-RYGBP. Markedly increased meal-stimulated circulating levels of peptide YY3-36 (PYY3-36), active glucagon-like peptitde-1 (GLP-1) and glucagon were observed following RYGB and SG. However, these changes were significantly greater after RYGB compared to after SG. Both operations comparably enhanced circulating glucose-dependent insulinotropic peptide (GIP) early post-meal. Whereas late postmeal, GIP levels declined post-RYGBP, but were unchanged post-SG. Glucose, insulin and homeostasis model assessment for insulin resistance (HOMA-IR) changes were comparable following RYGBP and SG. Polymorphisms within the fat mass and obesity-associated gene (FTO) associate with adiposity. We have recently shown that normal-weight subjects homozygous for the rs9939609 FTO obesity-risk variant (A) display increased post-prandial appetite and attenuated reduction in plasma acyl-ghrelin levels. In Chapter 5 we extended this work to humans with severe obesity. We found no differences in acyl-ghrelin between obese AA and TT subjects (T being the protective allele of FTO rs9939609). Furthermore, in Chapter 6 we report that AA, AT and TT subjects exhibited comparable weight-loss post-RYGBP, with comparable weight-loss outcomes across the three genotypes seen post-SG. However, comparison of RYGBP vs. SG revealed superior weight-loss outcomes post-RYGBP in TT and AT subjects vs. SG, but comparable weight-loss post-RYGBP and post-SG in AA subjects. In Chapter 6 we report that overall RYGBP resulted in superior weight-loss vs. SG. Patients with type 2 diabetes (T2DM) exhibited comparable weight-loss vs. adipositymatched normoglycaemic patients following RYGBP. However, following SG weight-loss was greater in normoglycaemic patients compared to adiposity-matched T2DM patients. In addition, we report the prevalence of 32 common obesityassociated SNPs (single nucleotide polymorphisms) in our patient cohort, and show that FTO rs9939609 had the strongest effect on BMI. Collectively, this work further adds to the rapidly expanding field of bariatric research. Future research endeavors will bring us closer to developing less invasive surgical procedures and novel pharmacotherapies for the medical management of diabetes and obesity.

Bariatric surgery is very effective at inducing weight loss and diabetes resolution in morbidly obese patients. Whether WL or increased incretin response is the crucial factor in normalising diabetes is still debatable. This thesis work prospectively investigated how bariatric surgery affected insulin action and beta-cell function in patients with morbid obesity and type 2 diabetes. Understanding these can help us to optimise diabetes treatments in patients with morbid obesity. I first discussed how obesity affects insulin sensitivity and beta-cell function, evidences that bariatric surgery is superior to conventional medical therapy at inducing weight loss and euglycaemia, and its associated mechanisms. I concluded that more robust data are needed to understand the effects of LAGB and RYGB surgery on glucose homeostasis, as this will have clinical implications for patients undergoing bariatric surgery (Chapter 1). I then described and justified the methods used for investigating insulin sensitivity and insulin secretion in the two studies (GLIPO and ISP) that make up this thesis (Chapter 2). I demonstrated that at 1 week post-op, improvements in glycaemia, insulin sensitivity and weight were the same in all patients, despite unilateral increase in incretin responses in the RYGB group. At 18 months I found that RYGB (n=32) had induced greater weight loss than LAGB (n=17). This resulted in better glycaemic control, further insulin sensitivity enhancement and marked improvements in insulin secretion and pancreatic secretory reserve in this group (Chapter 3&4). Finally, I demonstrated that marked weight loss after RYGB normalised insulin signalling (PI3K-Akt), but not glucose uptake in muscle. This suggested that major defects in the insulin signalling pathway still exist and may explain why not all patients can achieve diabetes remission after RYGB (Chapter 5). In conclusion, the degree of weight loss, not enhanced incretin response, is the major determinant of glycaemic improvement after bariatric surgery. This improvement is first brought about by improvements in insulin sensitivity followed by improvements in insulin secretion.

Childhood obesity has become a national epidemic and children are diagnosed with co-morbidities once only associated with adults. Despite current interventions, children continue to exude poor diet and physical activity outcomes. The final project is an adolescent weight management algorithm to include bariatric surgery for select adolescents who meet the criteria. The algorithm developed was in congruence with a regional healthcare facility mission and goals. A literature review was conducted by searching databases EBSCO, CINAHL, Bing, Google Scholar and Academic Search Premier. The algorithm was developed by reviewing current literature and evidence on adolescent bariatric surgery. Experts in the field of adolescent bariatric surgery were contacted to evaluate the proposed algorithm. The development of an adolescent bariatric surgery program poses many challenges as it remains a relatively new process. The screening adolescents undergo before surgery is extensive and takes several months to complete. The algorithm may be helpful in the development of an adolescent bariatric surgery program and in the primary care setting as it can guide providers in the adolescent weight management process. The algorithm and the recommendations may be used as a starting point for program development and adolescent weight management, but the ultimate decision on which adolescents have surgery should be based on expert medical and surgical personnel judgment.

Introduction: Obesity is associated with an increase in morbidity and mortality. Over the past 30 years the rate of obesity has been rising in almost all countries. The number of weight loss surgery procedures has also increased in England in recent years. Research into the psychological impact of weight loss surgery has found positive outcomes (e.g. reduced emotional distress and depression) as well as tensions (e.g. loss of identity and feeling vulnerable). Despite research into preparation for generic surgery, there is a gap in the literature on preparation for weight loss surgery patients. The present study was designed firstly to examine what preparation a UK sample of weight loss surgery patients have received, and secondly to explore the individual experiences of the weight loss surgery journey. Method: A mixed methods approach was used. An online questionnaire developed for this study was completed by 148 participants who have had weight loss surgery. A sample of seven adults were recruited from a weight loss surgery support group and participants were interviewed using a semi-structured interview schedule. Interviews were transcribed and analysed using Interpretative Phenomenological Analysis. Results: Participants reported receiving information on; the different parts of the weight loss surgery process, changes in diet, eating behaviour, and physical changes. Participants reported that information was lacking on relationship and psychological changes. Five master themes and 16 super-ordinate themes emerged following the group analysis of the interviews. Participants reflected on their lead up to surgery and their experience of preparing for surgery. Participants tried to make sense of their relationship with food and their emotional attachment to it. They reflected on their experience of changing relationships and identity post-surgery. Participants highlighted the value of support groups and the internet in preparing them for surgery, particularly communicating with individuals who have had weight loss surgery. Discussion: Preparation for weight loss surgery is an important part of the process. More preparation is needed for the psychological changes, emotional challenges, and adjustments experienced throughout the journey. A group intervention is recommended. This would be efficient and cost effective. It would provide opportunities for social inclusion and peer support.

Background: Research suggests that individuals who are obese are rated less favourably across all social groups (Wing & Jeffrey, 1999), with disgust being the strongest predictor of negative attitudes (Vartanian, 2010). Whilst some studies have explored the role of disgust in obesity, there is a distinct gap in the evidence base in relation to self-disgust and visual perspective taking, and how individual’s respond once they have transitioned out of weight-stigmatising environments. The proposed study aims to address this gap by using visual imagery to explore how individuals that have had bariatric surgery may ‘see’ themselves in relation to self-disgust. Method: The researcher interviewed eight patients (six women and two men) in an NHS Trust that had bariatric surgery and lost approximately 50% of their excess body weight. Results: Interviews were transcribed and analysed using thematic analysis. Four key themes and ten subthemes including negative childhood experiences, societal shaming and exclusion, being revolted by their body and connecting differently to self and others. Conclusion: The study concluded that people who are obese experience significant prejudice and discrimination in settings including employment, public spaces and healthcare. Recommendations were made to help individuals and communities via incorporating ideas of compassion in wider systems such as public health campaigns and the media.

Purpose: The authors' aim in this study was to gain insight on the psychological risk factors related to weight loss following bariatric surgery. Method: The authors used archival data of 137 participants who underwent both a psychological pre-assessment and bariatric surgery and attended a post-operative appointment at least six months following surgery. The factors examined at the psychological pre-assessment included alcohol abuse, smoking, exercise, binge eating, depression, stress, social support, dieting history, and history of sexual abuse. These factors were examined in relation to weight loss success defined as 50% loss of excess weight at follow-up. Main Findings: No significant relationships were found between weight loss success and the predictor variables. Conclusions: The researchers evaluated the present study results in relation to previous literature on bariatric surgery. Several limitations were evaluated, including examiner bias, participant population, and the assessment tool used. Areas of future research included examining alcohol consumption, exercise behavior, and binging and purging after surgery.

Background: Obesity is a global and growing public health problem. Bariatric surgery (BS) is indicated in patients with morbid obesity. To our knowledge, the effects of mòrbid obesity and BS on ventilation/perfusion (VA/Q) ratio distributions using the multiple inert gas elimination technique have never before been explored. Methods: We compared respiratory and inert gas (VA/Q ratio distributions) pulmonary gas exchange, breathing both ambient air and 100% oxygen, in 19 morbidly obese women (BMI, 45 ± 1 kg/m2), both before and 1 year after BS, and in eight normal-weight, never smoker, age-matched, healthy women. Results: Before BS, morbidly obese individuals had reduced arterial PO2 (76 ± 2 mm Hg) and an increased alveolar-arterial PO2 difference (27 ± 2 mm Hg) caused by small amounts of shunt (4.3 ± 1.1% of cardiac output), along with abnormally broadly unimodal blood flow dispersion (0.83 ± 0.06). During 100% oxygen breathing, shunt increased twofold in parallel with a reduction of blood flow to low VA/Q units, suggesting the development of reabsorption atelectasis without reversion of hypoxic pulmonary vasoconstriction. After BS, body weight was reduced significantly (BMI, 31 ± 1 kg/m2), and pulmonary gas exchange abnormalities were decreased. Conclusions: Morbid obesity is associated with mild to moderate shunt and VA/Q imbalance. These abnormalities are reduced after BS. Manuscript 2. Postural effects on pulmonary gas exchange abnormalities in severe obesity before and after bariatric surgery Background: We hypothesized that in morbid obesity, pulmonary gas Exchange abnormalities will worsen when supine and that bariatric surgery (BS) will mitigate this effect. Methods: Gas exchange was investigated in 19 morbidly obese and 8 non-obese, age-matched control females, spontaneously breathing ambient air, both upright and supine, before and one year after BS. Results: In control non-obese individuals, no postural changes in arterial blood gases (ABGs) were observed. While obese subjects had more altered PaO2, SaO2 and AaPO2 values than controls (p<0.05 each) when upright, the values unexpectedly remained unchanged when supine. This was also the case in the subset of 6 normoxemic obese but the remaining 13 hypoxemic individuals actually improved ABGs when supine: AaPO2 (by –3.4 ± 1.4 mmHg), SaO2 (by +1.5 ± 0.6 %), pH (by +0.01 ± 0.01); and cardiac output increased (by +0.4 ± 0.2 L·min-1) (p<0.05 each). After BS, PaO2 (from 75.5 ± 2.4 to 89.4 ± 2.4 mmHg) and AaPO2 (from 27.0 ± 2.0 to 15.4 ± 2.1 mmHg) (p<0.05 each) and pulmonary gas exchange were improved compared to before BS when upright, but ABGs worsened when supine (PaO2, by –4.6 ± 1.7 mmHg; AaPO2, by +4.2 ± 1.6 mmHg) (p<0.05 each). Conclusions: Before BS, ABGs are not altered in normoxemic obese subjects moving from upright to supine, even improving in those with hypoxemia when supine. After successful BS, pulmonary gas exchange improved when upright in all subjects but ABGs deteriorated when supine. However, the important clinical observation is the lack of gas Exchange deterioration when supine, which may have implications for critical care and anesthesia settings. Manuscript 3. Lung tissue volume is elevated in obesity and reduced by bariatric surgery Background: Bariatric surgery (BS) in severely obese subjects causes a significant reduction of body weight and improvement in lung function. We have shown previously that abnormalities in pulmonary gas exchange in morbidly obese are substantially improved with BS. These abnormalities were thought to be related to reduced lung volumes as well as to abnormal endothelial function induced by low-grade chronic inflammation linked to perivascular adipose tissue (PVAT). In this study we used computed tomography (CT) to assess whether BS also caused measurable structural changes in the lung. We focused in lung tissue volume (Vtiss) and cross-sectional vessel analysis hypothesizing that these measures could be related to the previously reported lung functional changes. Methods: Pulmonary vessels and lung volumes, including Vtiss, were quantified in thoracic CT scans. We compared findings in 12 obese women before and after BS and in 8 healthy lean women. Results: Vtiss was significantly elevated in obese subjects before BS compared to control subjects and systematically reduced after BS (by 8%); other CT lung volumes or vascular areas were not affected in a consistent manner. No relationship was observed between BS-induced individual changes in Vtiss and pulmonary vessel area. Conclusions: Vtiss is elevated in morbidly obese, compared to lean individuals of similar body height, and is systematically reduced by BS. These effects do not appear related to vascular changes but may be caused by elevated extra-vascular lung water, due to low-grade inflammation, and/or hypertrophic PVAT in severe obesity.<br>Primer artículo (First Manuscript). Anomalías de las distribuciones ventilación-perfusión en la obesidad grave, antes y después de cirugía bariátrica En la actualidad, la obesidad es un grave problema de salud pública a escala mundial. La cirugía bariátrica (CB) es un tratamiento efectivo de la obesidad grave. No existen Trabajos previos sobre los efectos de la obesidad grave y la pérdida ponderal inducida por CB sobre el intercambio gaseoso pulmonar, específicamente en la distribución de las relaciones ventilación-perfusión (VA/Q) con el empleo de la técnica de gases inertes múltiples (TEGIM). Métodos: Se investigó el intercambio gaseoso pulmonar mediante la TEGIM en 19 mujeres obesas graves (índice de masa corporal [IMC] 45 ± 1kg/m2) antes y después CB y, también en 8 mujeres con peso normal, no fumadoras, de la misma edad. Resultados: Antes de la CB, las mujeres obesas tenían una PaO2 reducida (76 ± 2 mm Hg) y un gradiente alveolo-arterial de oxígeno aumentado (27 ± 2 mm Hg) secundarios a un aumento discreto del shunt intrapulmonar (4 ± 1% del gasto cardiaco) y de la dispersión de la distribución de la perfusión pulmonar (Log SDQ, 0,83 ± 0,06 [valores normales ≤0,60]) (aire ambiente). Tras respirar oxígeno al 100%, el shunt se duplicó sin cambios acompañantes en la dispersión de la perfusión pulmonar (Log SDQ), todo ello sugestivo del desarrollo de atelectasias de reabsorción sin reversión de la vasoconstricción pulmonar hipóxica. Después de la CB, tanto el peso corporal (IMC, 31 ± 1 kg/m2) como las alteracions del intercambio gaseoso pulmonar se redujeron significativamente. Conclusiones: La obesidad mórbida se asocia con la presencia de shunt intrapulmonar discreto asociado a un desequilibro leve-moderado de las relaciones VA/Q. Estas anomalies se reducen tras CB. Segundo artículo (Second Manuscript). Efecto de los cambios posturales sobre las anomalías del intercambio gaseoso pulmonar en la obesidad grave, antes y después de cirugía bariátrica Introducción: En este trabajo se planteó la hipótesis de que las alteraciones del intercambio gaseoso pulmonar empeorarían en posición supina en la obesidad grave, hallazgo que debería mejorar tras cirugía bariátrica (CB). Métodos: Se investigó el intercambio gaseoso pulmonar (aire ambiente) en los dos grupos de mujeres, obesas graves y peso normal, en posición sentada y supina, antes y después de la CB. Resultados: No se observaron cambios gasométricos posturales en el grupo control. Mientras que todas las mujeres obesas tenían valores de PaO2, SaO2 y AaPO2 más alterados que las controles (p<0,05, respectivamente) en posición sentada, no se observaron cambios en supino. El mismo comportamiento gasométrico se observó en las mujeres obesas normoxémicas (PaO2≥80 mmHg). Por contra, la oxigenación arterial mejoró (AaPO2, –3,4 ± 1,4 mmHg; SaO2, +1,5 ± 0,6 %; pH, +0,01 ± 0,01) y el gasto cardiaco aumentó (+0,4 ± 0,2 L·min-1) (p<0,05, respectivamente) en supino en las 13 obesas hipoxémicas (PaO2<80 mmHg). Tras CB , la PaO2 (de 75,5 ± 2,4 a 89,4 ± 2,4 mmHg) y el AaPO2 (de 27,0 ± 2,0 a 15,4 ± 2,1 mmHg) (p<0,05, respectivamente) y en general el conjunto del intercambio gaseoso mejoraron en la población obesa en posición sentada, si bien la gasometría arterial (PaO2, –4,6 ± 1,7 mmHg; AaPO2, +4,2 ± 1,6 mmHg; p<0,05, respectivamente) empeoró en supino. Conclusiones: Antes de CB, la gasometría arterial no varió con los cambios posturales en las mujeres obesas normoxémicas e incluso mejoró en las hipoxémicas en supino. Tras una CB exitosa en todos los casos, el intercambio gaseoso pulmonar mejoró en posición sentada si bien la gasometría arterial empeoró en supino. El interés clínico de estos hallazgos radica en la ausencia de un deterioro del intercambio gaseoso en posición supina, lo que puede conllevar connotaciones prácticas en medicina intensiva y anestesiología. Tercer artículo (Third Manuscript). Aumento del volumen de tejido pulmonar en la obesidad grave y su reducción tras cirugía bariátrica. Introducción: En este tercer estudio, se empleó la tomografía computarizada (TC) toràcica para valorar si la cirugía bariátrica (CB) es capaz de provocar cambios estructurales a nivel pulmonar, para centrarnos en el análisis del volumen de tejido pulmonar (Vtiss) y el área de corte de los pequeños vasos pulmonares. Nuestra hipótesis fue que estos parámetros podrían correlacionarse con los cambios funcionales pulmonares descritos previamente. Métodos: Se cuantificaron mediante TC los volúmenes pulmonares, incluido el volumen de tejido pulmonar (Vtiss) y el área de los vasos pulmonares, en un subgrupo de 12 mujeres obesas mórbidas, antes y después de CB, así como en las 8 mujeres del grupo control ya referidas en los dos artículos previos. Resultados: Los valores de Vtiss estaban aumentados en las mujeres obesas antes de CB, en comparación con el grupo control, y se redujeron (en un 8%) sistemáticamente un año después. No se observaron cambios en el resto de volúmenes pulmonares o en áreas vasculares. No se observó ninguna asociación entre los cambios inducidos por la CB en las áreas vasculares pulmonares ni en el Vtiss. Conclusiones: El volumen de tejido pulmonar (Vtiss) está aumentado en las personas+ obesas graves antes de CB, en comparación con el de mujeres de peso normal y se reduce de forma sistemática tras CB. Estos efectos sobre el Vtiss no se relacionan con cambios vasculares pulmonares, pero podrían estar influidos con el aumento de agua pulmonar extravascular inducido por la inflamación sistémica y/o la hipertrofia del tejido adiposo perivascular subyacentes.

Introduction: Obesity has been suggested to be one of the risk factors for erectile dysfunction (ED) and lower urinary tract symptoms (LUTS). Bariatric surgery has been used for the treatment of obesity and has been suggested to have a significant impact on obesity-related conditions such as diabetes mellitus, ED and LUTS. Previous studies have investigated the effect of bariatric surgery on erectile and urological function in obese men; however those studies used long-term time points post-operatively (more than 1 month). Since it is now known that bariatric surgery can potentially induce glycaemic improvement within one week independent of weight loss, this study aimed to investigate the short-term effect in order to test the hypothesis as to whether improvement in urogenital function after bariatric surgery is due to weight loss or whether it is due to glycaemic improvement. Aim: To evaluate the baseline characteristics of patients with erectile dysfunction and to determine the early effects of bariatric surgery on erectile and urological function in morbidly obese men.

Obesity has grown to epidemic proportions, and in lack of efficient life-style and medical treatments, the bariatric surgeries are performed in rising numbers. The most common surgery is the Gastric Bypass (GBP) surgery, with the Biliopancreatic diversion with duodenal switch (DS) as an option for the most extreme cases with a BMI&gt;50 kg/m2. In paper I 20 GBP-patients were examined during the first post-operative year regarding the natriuretic peptide, NT-ProBNP, which is secreted from the cardiac ventricles. Levels of NT-ProBNP quickly increased during the first post-surgery week, and later established itself on a higher level than pre-surgery. In paper II we report of 5 patient-cases after GBP-surgery with severe problems with postprandial hypoglycaemia that were successfully treated with GLP-1-analogs. The effect of treatment could be observed both symptomatically and in some cases using continuous glucose measuring systems (CGMS). In paper III three groups of subjects; 15 post-GBP patients, 15 post-DS, and 15 obese controls were examined for three days using CGMS during everyday life. The post-GBP group had high glucose variability as measured by MAGE and CONGA, whereas the post-DS group had low variability. Both post-operative groups exhibited significant time in hypoglycaemia, about 40 and 80 minutes per day &lt;3.3mmol/l and 20 and 40 minutes &lt; 2.8mmol/l, respectively, longer time for DS-group. Remarkably, only about 20% of these hypoglycaemic episodes were accompanied with symptoms. In Paper IV the hypoglycaemia counter regulatory system was investigated; 12 patients were examined before and after GBP-surgery with a stepped hypoglycaemic hyperinsulinemic clamp. The results show a downregulation of symptoms, counter regulatory hormones (glucagon, cortisol, epinephrine, norepinephrine, growth hormone), incretin hormones (GLP-1 and GIP), and sympathetic nervous response. In conclusion patients post bariatric surgery exhibit a downregulated counter regulatory response to hypoglycaemia, accompanied by frequent asymptomatic hypoglycaemic episodes in everyday life. Patients suffering from severe hypoglycaemic episodes can often be treated successfully with GLP-1-analogues.

Bariatric surgery offers sustained dramatic weight loss and remission of diabetes, yet the mechanisms of these health benefits are not clear. In the present study, I profiled circulating and colorectal miRNAome in response to bariatric surgery (Roux-en-Y gastric bypass). Indeed, the response of circulating and colorectal miRNA profiles to RYGB were striking and selective. Fourteen circulating microRNA and thirteen colorectal microRNA exhibited significantly alteration post RYGB. Interestingly, circulating miR-122 decreased dramatically (56 fold) post RYGB surgery. The expression of hepatic miR-122 and its metabolic targets were examined both in in vivo RYGB surgical model and in an in vitro mechanistic model. Manipulation of miRNA-122 cold induce changes of key enzymes involved in energy metabolism, glucose transport, glycolysis, TCA cycle, pentose phosphate shunt, fatty acid oxidation and gluconeogenesis, suggesting an overall increased energy expenditure status after RYGB. Furthermore, potential mechanisms involved in the control of hepatic miR-122 were investigated, with focus on metabolites (glucose, and fatty acids), hormones (glucocorticoid) and transcription factors (PPARs). Finally, by correlating the circulating miRNAome and metabolome data, we were able to generate a comprehensive landscape of the crosstalk between miRNAs and metabolic pathways. Follow-up studies will allow a detailed understanding of miRNAs responsible for regulating specific metabolic pathways, and conversely identifying metabolites capable of regulating the expression and activity of specific miRNAs.

Thesis (M.S.)--Florida State University, 2009.<br>Advisor: Laurie Grubbs, Florida State University, College of Nursing. Title and description from dissertation home page (viewed on Oct. 27, 2009). Document formatted into pages; contains ix, 85 pages. Includes bibliographical references.

The entire dissertation/thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file (which also appears in the research.pdf); a non-technical general description, or public abstract, appears in the public.pdf file. Title from PDF of title page (University of Missouri--Columbia, viewed on January 5, 2010). Thesis advisor: Paul J. Fadel. "December 2009" Includes bibliographical references.

Background Worldwide increases in obesity present significant health and socio-economic challenges with weight loss strategies of dieting and exercise appearing to have minimal impact. Concomitantly, the choice to have bariatric surgery is becoming more prevalent, although little is known about how and why people choose this option to address their obesity issues. Aim To explore and understand the experiences involved in the decision making of the obese person choosing to have bariatric surgery so as to better inform the support required for those seeking a surgical option. Method The study design used an interpretive methodology within the qualitative paradigm to investigate the obese person’s values, attitudes and beliefs in shaping their decision to have bariatric surgery. Eight English speaking participants, having had either laparoscopic gastric band, laparoscopic sleeve gastrectomy or roux-en Y surgery, were recruited via an Australian facebook site to participate in a phone interview and provide online demographic and genogram data. Data was analysed using thematic analysis. The Health Belief Model (HBM) provided a lens through which data was collected and analysed with the supposition that individuals are understood as being able to process information, and with this cognitive understanding then decide what behaviours they wish to undertake to effect change. Findings The participants, aged between 28 and 58 years, reported struggling with their weight either since adolescence (n=5) or following childbirth (n=3). Most (n=7) had identified the internet, inclusive of social forums, as their primary information source when deciding to have surgery. Most participants (n=7) within this study autonomously decided to opt for bariatric surgery prior to consultation with a health professional, the majority of participants (n=7) also having already decided the actual bariatric procedure prior their surgical consult. Five themes were identified from the analysis of the qualitative data, ‘standing outside the circle’, ‘finding obesity all-consuming’, ‘struggling to live life’, ‘travelling the road to surgery’ and lastly ‘the good, the bad and the unsightly’. These themes identify the emotional and health roller coaster that the obese individual experienced in trying to achieve weight loss and the factors that lead to the decision to opt for a surgical procedure to ensure that their weight loss would be sustained. Conclusion Areas identified as needing further attention include: (i) the provision of information sources and patient supports that are altruistic, valid and reliable, inclusive of current data regarding bariatric surgery and efficacy (ii) design of public health promotions and support that target prevention and early treatment of obesity in high risk groups, and (iii) a comprehensive investigation into the economic costs and funding arrangements for bariatric surgery and follow up care, addressing the disparity of individuals who are uninsured.

Bariatric surgery is a major surgery that has become a frequent procedure in North America; growth in the number of bariatric surgery procedures has resulted in an increase in readmissions after the procedure. A systematic review of the literature using the shifting processes model as a guide was used to answer the practice-focused questions regarding reasons for hospital readmissions for postoperative bariatric surgery patients and strategies that reduce complications of the procedure. Providing Innovative Service Models and Assessment chart (PRISMA) was used to quantify 17 studies that met the inclusion criteria. Results demonstrated that the reasons for readmissions after bariatric surgery were related to leakage of the surgical site, infections, bowel complications, and lack of family support or other support system at home. Strategies reported in the literature that were effective in reducing complications included having a support system and preoperative and discharge education for bariatric patients. The most effective method to prevent readmission following bariatric surgery was careful preoperative assessment and screening for comorbidities, particularly gastrointestinal disorders. The results of this project may promote positive social change by providing evidence-based information for professionals and consumers to prevent readmissions following bariatric surgery.

The research program outlined in this thesis has focused on identifying the causes of weight-loss failure for primary, revisional and multiple revisional bariatric-surgery patients. Phase One comprised of two qualitative studies and informed Phase Two, a quantitative longitudinal study. The research examined the patients' psychosocial functioning and their perceptions of psychosocial factors that had contributed to these outcomes. The studies confirmed the importance of understanding primary and revisional bariatric surgery patients' needs and vulnerabilities, and identified not only their unique psychosocial factors but combinations of factors, and, the increase in intensity of factors that explained these patients' weight loss trajectories.

L'étude vise les raisons, les connaissances et les attentes des personnes subissant une chirurgie bariatrique au Moyen-Orient et en Jordanie. Une étude rétrospective a été conçue et menée au Centre de la prise en charge de l'obésité Mohammad Al-Zitawi entre 2015 et 2017. 154 patients (hommes: 45; femmes: 109) - ayant une masse corporelle supérieure à 40 kg / m2 et âgés de 20 à 60 ans- ont participé à l'étude. Ils ont été choisis au hasard. Ils représentaient 10% des patients adultes au centre de l'obésité de la période de l'étude. Âgés de 20 à 60 ans, les participants a l'étude ont été orientées vers l'unité bariatrique du Centre Al-Zitawi. Le comité d'éthique du centre a approuve le protocole de l'étude. Tous les aspects éthiques ont été respectes au cours de l'enquête. La bienfaisance (bien faire), la non-malfaisance (ne justifie pas les patients), la fidélité, la confiance, le respect, le traitement impartial, le respect culturel, le droit à la justice, le respect de la confidentialité, le droit à la prise de décision et la décision volontaire ont été prises en compte. Il s'agit d'une étude rétrospective. Deux questionnaires ont été conçus: un pour les patients et l'autre pour les professionnels impliqués de la prise en charge de l'obésité. Les entretiens et le consentement des patients ont été obtenus par téléphone (chez eux, loin du centre). Les questions de l'étude a opte l'approche des méthodes mixtes pour améliorer la qualité des données collectées.Il s'agit d'une méthodologie de recherche croissante. Elle fait progresser le mélange systématique de données qualitatives et quantitatives au sein d'une même enquête ou d'un programme de recherche constant. Elle permet une utilisation complète et synergique des données. Elle donne toutefois la parole aux participants et les résultats sont basés sur l'expérience des participants. Elle laisse une place à l'équipe multidisciplinaire par la recherche en favorisant le contact des chercheurs en méthodes quantitatives, qualitatives et mixtes (Creswell et al., 2011). Les résultats montrent que les patients du Moyen-Orient n'avaient pas de connaissances et de compréhension à propos de la chirurgie bariatrique Les études de Taube-Schiff et al. (2016) et Guler et al. (2018), indiquent que les patients obèses, même dans les pays développés, ont peu de connaissance à propos des chirurgies bariatriques, Une étude récente saoudienne d'Altaf &amp; Abbas (2019) révèle que la sensibilisation du public à l'obésité et à la chirurgie bariatrique est très limitée. Notre étude révèle une insuffisance évidente a propos de la prise de conscience et la connaissance de la chirurgie bariatrique chez les patients participants du Moyen-Orient. Différentes plates-formes sont essentielles pour mieux faire connaître la chirurgie bariatrique et ses avantages, ses facteurs de risque et ses complications associés. La revue des pratiques des chirurgiens et des éducateurs sanitaires est évidente. La plupart des patients de l'étude n'ont pas apprécié le service rendu et les bénéfices de la chirurgie. La sensibilisation du public, les services de gestion du poids, du changement de comportement et de la gestion de soi sont essentiels pour améliorer le service rendu à long terme de la chirurgie bariatrique et répondre aux attentes des patients<br>The study aimed to understand the reasons, knowledge and expectations of people undergoing bariatric surgery in Middle East and Jordan. A retrospective study is designed and was conducted in the Mohammad Al-Zitawi Obesity Management Centre between the years 2015 and 2017. A total of 154 participants (males: 45; females: 109) who had body mass greater than 40kg/m2 and aged between 20-60 years took part in the study. The study participants were randomly selected and enrolled participants were 10% of the patients who attended obesity management centre in that particular year. All study patients were above 20 years of age and had been referred to the bariatric unit at Al- Zitawi Obesity Management Centre. A total of 154 patients (males: 45; females: 109) who had body mass greater than 40kg/m2 and aged between 20-60 years took part in the study. Ethical approval for the study was taken from hospital ethical committee. At the time of filling up of questionnaire forms all ethical aspects such as beneficence (doing good), non malfeasance (not justifying patients), fidelity, trust, respect, unbiased treatment, cultural respect, right to justice, maintenance of confidentiality, right to decision making and voluntary decision were taken into consideration. The methodology involves two tier questionnaires; one for patients and the other one for the professionals involved in obesity management. Since, it is a retrospective study and participants are not in the city. Questionnaire forms and patients consent was obtained on phone from the participants. Filling up of questionnaire form was on phone. Questions were explained to participants on phone in English and Islamic language and consent was obtained. In the present study, we used mixed method approach to improve the quality of our research study. Mixed method approach refers to growing methodology of research that progress the systematic mixing of both qualitative and quantitative datum within a single investigation or constant programme of investigation. Mixed up approach allows complete and synergic use of data. Furthermore, this method gives voice to study participants and make sure that enrolled participants are part of study and results are base on participant's experience. This kind of approach provides space to multidisciplinary team by research by promoting the contact of quantitative, qualitative, and mixed methods scholars (Creswell et al., 2011). The results of our study showed that patients in the Middle East do not have much knowledge and understanding about the bariatric surgery and this finding is in consistent with the studies of Taube-Schiff et al. (2016) and Guler et al. (2018) indicating that usually obese patients have limited knowledge about bariatric surgeries even in the developed countries. Moreover, a recent research documented by Altaf &amp; Abbas (2019) in Saudi Arab documents that the public awareness about obesity and bariatric surgery is very limited. Our study shows an obvious gap in awareness and knowledge about bariatric surgery among the studied participants from the Middle East. There is a need of using different platforms for spreading accurate awareness about Bariatric surgery and its associated benefits, risk factors and associated complications. Public awareness should be created by surgeons and health educators and they should act accordingly to develop better knowledge and awareness among general public. Most of patients in our study fail to meet their expectations from surgery as benefits of treatment. Our study also throws light on the significance of weight management services, behavioural change and self management in modifying patient's expectations of having long term benefits of bariatric surgery

Obesity is the fifth leading cause of global deaths. The efficacy and safety of obesity treatment is still controversial. The objective of the thesis is to evaluate the efficacy and safety of bariatric surgery, through a systematic review of the current evidence and meta- analysis of important outcomes. Nineteen (19) randomized controlled trials (RCTs) with 1346 participants were included. Bariatric surgery resulted in greater weight loss when compared to non-surgical treatment. Weight loss was also associated with resolution and/or improvement of obesity related comorbidites such as diabetes, hypertension, hyperlipidemia, and sleep apnea. Weight loss and safety varied across the surgical procedures. Biliopancreatic diversion/duodenal switch had the greatest weight loss, followed by sleeve gastrectomy and Roux-en-Y gastric bypass, purely restrictive procedures such as vertical banded gastroplasty and adjustable gastric banding resulted in the least weight loss. Long term, high quality, and adequately powered trials are still needed to support the available evidence

Bariatric surgery is becoming a more common solution for weight loss in individuals with severe obesity. Much attention has been placed on negative surgery outcomes, specifically on psychosocial predictors of post-surgical weight regain and development of psychopathology. Literature on obesity suggests that eating in response to emotional cues is related to the obesity epidemic. The current review identifies all research in the literature that focuses on emotionality and emotional characteristics in bariatric surgery patients and the predicted negative impact on the surgery process from pre-surgical evaluation to post-surgical follow-up. The review was conducted following PRISMA guidelines for systematic reviews. Six articles were identified in the literature meeting all review criteria, specifically focusing on emotionality in bariatric surgery patients. Results suggest high rates of emotional instability, impulsivity, and difficulty in identifying emotions in bariatric surgery patients, which could have adverse effects on the bariatric surgery process. Authors suggest that these components of emotionality may lead to negative effects following surgery, specifically concerning post-surgical dietary restrictions and weight regain. These findings suggest that further research needs to be done in the area of emotionality and bariatric surgery. Authors infer that high rates of emotional instability, impulsivity, and inability to identify emotions may have significant implications for screening and intervention; however, limitations in these studies indicate a need for further research on emotionality in bariatric surgery patients, particularly the impact of emotionality on surgery outcomes.

Obesity levels are increasing worldwide, and in the United Kingdom the prevalence of overweight and obesity is amongst the highest in the developed world. Obesity is associated with reduced physical function and health-related quality of life, as well as an increased risk of co-morbidities such as type 2 diabetes and hypertension. As a result of high levels of morbid obesity and a failure of conventional methods of weight loss, more people are resorting to invasive weight loss techniques such as bariatric surgery. Bariatric surgery combined with lifestyle modification is currently the most successful weight loss intervention for the treatment of obesity and its associated co-morbidities. However, weight regain is becoming more apparent, generally occurring between 12 and 24 months after surgery. Weight regain is generally attributed to the failure of individuals to adopt or maintain the necessary lifestyle changes. The most common factors leading to weight regain after bariatric surgery are insufficient exercise and returning to pre-operative eating behaviours. Increasing physical activity after surgery positively affects weight loss and physical function outcomes; therefore, adopting an active lifestyle is fundamental. This thesis combines three research studies which collectively provide evidence for understanding the importance of physical activity for optimising physical function and facilitating the prevention of weight regain. Study one is a systematic review and meta-analysis which assessed pre to post-operative changes in physical activity behaviour and physical function outcomes among obese adults receiving bariatric surgery. This demonstrates improvements in objective and self-reported activity and function by 12 months. Study two is an analysis of body mass, co-morbidity and physical function data from pre to post bariatric surgery. This retrospective NHS dataset analysis aimed to identify if and when weight regain occurs, the proportion of co-morbidity resolution, and physical function patterns in patients after bariatric surgery. Weight loss patterns indicate weight stability from 12 to 24 months and weight regain 24 months post-surgery. Study three is a randomised controlled trial, The MOTION Study, which examined the effect of a 12 week exercise intervention on physical function and body composition in patients 12-24 months post bariatric surgery. This trial also examined maintenance of effects at six months. Findings suggest that implementing exercise at the point of weight regain is effective, notably for improving physical function and body composition in this population. This thesis therefore contributes to advancing the understanding of the role of physical activity in enhancing long-term outcomes after bariatric surgery and to informing future post-operative bariatric care.

Over 80% of patients undergoing bariatric surgery have non-alcoholic fatty liver diseas (NAFLD), including a third with steatohepatitis. Fatty livers are vulnerable to toxic insults, including ischaemia-reperfusion injury (IRI) and inflammation. The induction of pneumoperitoneum and retraction of the liver during laparoscopic surgery causes an acute inflammatory response and IRI. In this thesis, twenty patients were recruited to a randomised controlled trial of N9 acetylcysteine (NAC), an antioxidant, given before and during laparoscopic sleeve gastrectomy (LSG) to reduce liver injury and post-operative inflammatory response. The acute effects of LSG were investigated, with measurement of cytokines, markers of hepatocyte death and oxidative stress. The results showed that NAC did not significantly reduce the rise in liver enzymes or improve clinical outcomes. Further assays demonstrated that a significant inflammatory and oxidative stress insult occurs, with increases in markers such as C-reactive protein, IL-6, superoxide dismutase and cytokeratin-18 (CK-18) fragments, indicative of hepatocyte death. These markers returned to baseline within 48 hours. The patients were followed for 6 months and the result of longitudinal changes are described, showing significant reduction in BMI, along with reductions in insulin resistance, inflammatory markers and CK-18. Bile acid (BA) metabolism was also studied, showing a significant increase in fibroblast growth factor 19 levels, indicating a likely increase in bile delivery to the terminal ileum after LSG, which was associated with significant changes in four conjugated BA, although total BA was unchanged. These changes correlated with reduction in inflammatory markers and hepatocyte death. In onclusion, LSG is associated with a short-term inflammatory response and liver injury. After 6 months, the relevant markers fall below baseline, indicating improvement in inflammatory profile, glycaemic control and extent of NAFLD. Further work is needed to understand these relationships in a larger sample of patients undergoing a variety of bariatric operations.

Approximately 36% of adults in the United States population are obese. Obese patients have an increased risk of mortality and morbidity, particularly related to hypertension, dyslipidemia, Type 2 diabetes, asthma, sleep apnea, and impaired psychosocial functioning. The popularity of bariatric surgery has seen significant increases in recent years as a cost-effective way to manage weight. Determining candidates' psychological suitability for bariatric surgery is complicated by the fact that research on psychosocial predictors of success and/or poor outcomes is lacking and results are inconsistent. Psychologists often develop their own guidelines to assist in deciding whether a candidate should be cleared for surgery; thus evaluation procedures and cited contraindications to surgery vary greatly among programs. This study investigated predictors of psychological evaluation recommendation status in a sample of 100 bariatric surgery candidates. The variables that were examined included demographics, Axis I and Axis II psychopathology, and data from the Millon Behavioral Medicine Diagnostic (MBMD) (i.e., coping styles, stress moderators such as social isolation, and treatment prognostics such as interventional fragility, utilization excess, and problematic compliance). Number of Axis I diagnoses, social isolation, and educational level emerged as the strongest predictors of recommendation status. Multivariate logistic regression results suggest that for every additional Axis I diagnosis, the odds of being in the delayed group are approximately 5 times higher after controlling for the other factors in the model. Participants who reported greater social isolation on the MBMD have the odds of being delayed 6% times higher than those with higher social support. For those participants whose highest level of education is grade school, the odds of being delayed were 55 times higher than those participants who completed college or beyond. Additional research into predictors of success following bariatric surgery using large-scale, prospective, longitudinal studies is needed to better inform psychological evaluations. Efforts should also be made to review one's own bariatric psychological evaluation procedure to uncover which factors are most influential in the decision-making process.

nÃo hÃ<br>Introduction: Obesity is associated with oral diseases by promoting inflammatory processes and because of the fact that obese patients often eat cariogenic foods and use drugs capable of inducing salivary alterations. Bariatric surgery, surgical means of treating morbid obesity and obesity associated to co-morbidities, aims to change the volumetric capacity of the gastrointestinal tract and the course of the alimentary bolus. It causes changes in food consumption patterns and, often, gastro-esophageal disorders and may influence deleteriously oral health, which, however, is not determined. Objective: The aim of this study was to determine the profile of drug use, the occurrence of vomiting and tooth sensitivity, the standard of food eating and dental plaque index; to quantify Streptococcus mutans in stimulated saliva; to measure DMFT and to count erosive lesions in patients who had already been submitted to bariatric surgery and in patients who were going to be submitted to bariatric surgery, registering changes in pattern of occurrence of vomiting and tooth sensitivity and dietary patterns of patients who had already been submited to bariatric surgery. Materials and Methods: Through cross-sectional study, seeking retrospective data, there were evaluated 46 patients undergoing bariatric surgery (âNon-Operatedâ group) and 46 in the second year of postoperative follow-up of the same surgery (âOperatedâ group). After collection of personal data, we proceeded to collect saliva (to quantify S. mutans) and dental evaluation. Results: "Non-operated" group showed greater medication use and lower frequency of vomiting than "Operatedâ group, although, in this group, the occurrence of vomiting had reduced over time. "Operated" group had a higher intake of sweet foods and smaller intake of acid food than "Non-operatedâ group; the consumption of sweet foods and red meat of âOperatedâ group at the time of assessment decreased compared the preoperative period. Both groups had similar dental sensitivities and the majority of "Operated" group patients reported similarity of tooth sensitivity after surgery compared to preoperative values. Both groups showed similar and high plaque index (52.03  14.30 for "Non-operated" group and 51.59  10.38 for "Operatedâ group), the same was observed for S. mutans count (log (number of CFUs per mL of saliva +1) equal to 5.12  0.64 for "Non-operated" group and 5.05  1.06 for "Operated" group) and DMTF (13.67  5.78 for "Non-operated" group 13.33  5.78 for "Operated" group). Both groups were similar with respect to dental erosion variable. Discussion: Elevated plaque index, S. mutans count and DMFT show the condition of poor oral health of both patients with morbid obesity and submited to bariatric surgery, difficulting the eventually possible weight loss process by clinical means for obese patients and burdening the "new stomach" in patients undergoing surgery. Conclusion: Bariatric patient needs more attention to oral health, from oral hygiene orientation to the performance of operative procedures, providing oral health and contributing to the success of the surgical procedure.<br>IntroduÃÃo: A obesidade està associada a alteraÃÃes bucais, por favorecer processos inflamatÃrios e pelo fato de pacientes obesos ingerirem frequentemente alimentos cariogÃnicos e utilizarem fÃrmacos capazes de induzir alteraÃÃes salivares. A cirurgia bariÃtrica, meio cirÃrgico de tratar a obesidade mÃrbida e a obesidade associada a co-morbidades, visa alterar a capacidade volumÃtrica do trato gastrointestinal e o curso do bolo alimentar. Ocasiona alteraÃÃo do padrÃo alimentar e, nÃo raro, transtornos gastro-esofÃgicos, podendo influenciar deleteriamente a saÃde oral, o que, entretanto, nÃo està determinado. Objetivo: Determinar o perfil de uso de medicamentos, a ocorrÃncia de vÃmito e de sensibilidade dental, o padrÃo alimentar e o Ãndice de placa dental; quantificar Streptococcus mutans em saliva estimulada; medir CPOD e contar lesÃes erosivas em pacientes submetidos e a serem submetidos à cirurgia bariÃtrica; registrar alteraÃÃes em padrÃo de ocorrÃncia de vÃmito e sensibilidade dental e em padrÃo alimentar de pacientes submetidos à cirurgia bariÃtrica. Materiais e mÃtodos: Mediante estudo transversal observacional, buscando dados retrospectivos, avaliaram-se 46 pacientes a serem submetidos à cirurgia bariÃtrica (Grupo âNÃo-Operadoâ) e 46 no segundo ano de acompanhamento pÃs-operatÃrio da mesma cirurgia (Grupo âOperadoâ). ApÃs coleta de dados pessoais, procedeu-se à coleta de saliva (a fim de quantificar de S. mutans) e à avaliaÃÃo odontolÃgica. Resultados: O grupo âNÃo-operadoâ apresentou maior uso de medicamentos e menor frequÃncia de vÃmito do que o grupo âOperadoâ; apesar de, neste, ter havido reduÃÃo da ocorrÃncia de vÃmito com o passar do tempo. O grupo âOperadoâ apresentou maior ingestÃo de alimentos doces e menor ingestÃo de alimentos Ãcidos do que o grupo âNÃo-operadoâ; o grupo âOperadoâ apresentou reduÃÃo do consumo de alimentos doces, Ãcidos e carne vermelha no momento da avaliaÃÃo em comparaÃÃo ao perÃodo prÃ-operatÃrio. Os grupos apresentaram sensibilidades dentais semelhantes e a maioria dos pacientes do grupo âOperadoâ relatou similitude de sensibilidade dental no pÃs-operatÃrio em relaÃÃo ao prÃ-operatÃrio. Os grupos apresentaram Ãndices de placa elevados (52,03  14,30 para o grupo âNÃo-operadoâ e 51,59Â10,38 para o grupo âOperadoâ) e semelhantes; o mesmo tendo sido verificado para a contagem de S. mutans (log(nÃmero de UFCs por mL de saliva+1) igual a 5,12  0,64 para o grupo âNÃo-operadoâ e a 5,05  1,06 para o grupo âOperadoâ) e para CPOD (13,67  5,78 para o grupo âNÃo-operadoâ 13,33  5,78 para o grupo âOperadoâ). Os grupos mostraram-se semelhantes com relaÃÃo à variÃvel erosÃo dental. DiscussÃo: Os valores elevados de Ãndice de placa, contagem de S. mutans e CPOD demonstram a condiÃÃo inadequada de saÃde bucal tanto de pacientes obesos mÃrbidos quanto submetidos à cirurgia bariÃtrica, dificultando o processo de emagrecimento por meios clÃnicos eventualmente possÃvel do paciente obeso e sobrecarregando o ânovo estÃmagoâ no paciente operado. ConclusÃo: O paciente bariÃtrico necessita maior atenÃÃo à saÃde bucal, desde a orientaÃÃo de higiene bucal atà a realizaÃÃo de procedimentos operatÃrios, viabilizando a saÃde bucal e contribuindo para o Ãxito do procedimento cirÃrgico.

orionpizango@gmail.com<br>Case report: A 43-year-old female presented with decreased visual acuity in the right eye.“Snowball-like” retinal lesions were found in both eyes on examination. Due to a lackof improvement with intravitreal antifungal empirical treatment, vitreous culture wasperformed and Candida glabrata was isolated. The patient then received intravitreal ampho-tericin B, as well as systemic treatment with caspofungin and amphotericin B lipid complex.Discussion: Endogenous fungal endophthalmitis is a sight-threatening condition. There arefew reports of C. glabrata endogenous endophthalmitis. Treatment regimens for Candidaendophthalmitis include combinations of systemic and/or intravitreal antifungals, as wellas vitrectomy.

People who have bariatric surgery often fall short of their desired weight loss. The purpose of this study was to assess adherence to protein recommendations of the post-bariatric surgery patients. Results of 59 participants indicated that over half did not meet protein recommendations. Over half used protein supplements to help meet the recommendations. Another purpose of this study was to determine individuals whom post bariatric surgery patients identified as important in their social support network. The use of social support bariatric groups was also assessed. Results showed bariatric support groups were an important form of social support to aid in weight loss. Both studies will aid healthcare professionals deepen their understanding of the long journey of weight loss in post-bariatric surgery patients. Bariatric surgery is an effective solution for individuals with obesity because it results in long-term weight loss; therefore, learning the characteristics of successful bariatric surgery patients is priority.

Many researchers have suggested positive patient-health provider relationships can positively impact patient outcomes. A few focused explicitly on bariatric weight loss surgery (BWLS) professional-patient interactions. This study is significant because BWLS is a recommended tool to combat obesity. The purpose of this study was to analyze the perceptions of BWLS education nurses regarding their patient encounters. This mixed methods research study used an online survey combining quantitative Likert scale questions and open-ended qualitative questions, with social cognitive theory as the theoretical foundation. These explored viewpoints relate to their patient relations expressed by a health professional. Health professional beliefs incorporated into patient interactions has merit within BWLS continuum from presurgery requirements, to the procedure, and post-surgery lifestyle. Many respondents are employed in obesity services programs and received 'snowballs' from other contacted health professionals. The analyzed written response word clouds favor patient-focused care. Participation reluctance by not answering or skipping short answer perspective questions was a quantitative trend. Data revealed survey specific noticeable qualitative tendencies favorable toward patient-centered care and patient health accountability. The anticipated positive social change is a better understanding of issues surrounding the choice for and against BWLS and improved healthcare and health professional-patient communications.

Bakgrund: År 2014 utfördes 6,800 bariatriska operationer i Sverige med syfte att minska individers vikt och förbättra välbefinnandet. Studien utfördes för att beskriva patienters subjektiva erfarenheter av processen efter operation och förankrades i Dorothea Orems egenvårdsteori.   Syfte: Syftet var att beskriva patienters erfarenheter efter bariatrisk kirurgi.   Metod: En systematisk litteraturstudie som utgick från Forsberg och Wengströms (2013) metodologi.   Resultat: Resultatet presenterades som ett övergripande tema: En önskan om att återfå hälsa genom viktminskning, med sex tillhörande kategorier. Många av deltagarna beskrev att erfarenheter efter bariatrisk kirurgi överlag var positiva. De upplevde också att relationen till mat förändrades. Självkänslan samt sociala och fysiska förmågor förbättrades. Några upplevde svårigheter att anpassa sig efter operationen vilket påverkade deras erfarenheter negativt.   Slutsats: Många av dem som genomgick bariatrisk kirurgi ökade sin livskvalitet på många sätt. Utöver det kirurgiska ingreppet som förminskar magsäcken behövdes ytterligare åtgärder i form av livsstilsförändringar och egenvård. Ett ansvar som till stor del låg hos individen själv, dessutom fanns också ett ansvar hos sjukvårdspersonalen, att uppmärksamma vilken hjälp patienten kunde komma att behöva i den fortsatta hälsoprocessen och stötta dem i detta.<br>Background: In 2014, there were 6,800 bariatric surgeries performed in Sweden, in order to reduce an individual's weight and improve well-being. This study was conducted to describe the patients' subjective experiences of the process after surgery and were anchored in Dorothea Orem's self-care theory.   Aim: The aim was to describe patients' experiences after bariatric surgery.   Method: A systematic literaturereview emanated from Forsberg and Wengström’s (2013) methodology.   Result: The results are presented with an overarching theme: A desire to regain health through weight loss, and six associated categories. Experience after bariatric surgery was described by many of the participants generally positive. The most common experience was that the relationship with food changed. For many of the participants there was an improvement in both self-esteem and social and physical abilities. Some experienced difficulties adjusting after surgery which affected their experience negatively.   Conclusion: Most people who underwent bariatric surgery increased their quality of life in many ways. In addition to the surgical procedure that reduces the stomach, most of them needed additional measures in terms of lifestyle changes and self-care. A responsibility that largely lay with the individual himself, though even healthcare professionals have a responsibility in the subsequent care.

Obesity in the United States has increased to epidemic numbers over the last decade. Practitioners need to reverse the trend. To address the problem of depression in obesity, a practice guideline from a bariatric clinic for under-served populations was proposed to an expert panel. The Spell Out on First Use (PHQ-9) screening is a valid and reliable self-screening tool to assist the practitioner in determining the level of depression if any. The PHQ-9 has nine questions. No formal screening existed at the bariatric clinic, and the practice guideline (with algorithm and revised workflow) was proposed for use at the clinic. The expert panel consisted of the medical director, a surgeon, a psychiatrist, and a nurse practitioner at the clinic. The expert panel reviewed the materials and made one recommendation: to implement the PHQ-9 upon intake when the patient is being admitted to the program, and the panel recommends administering PHQ-9 prior to assessment by practitioners All panel members were in agreement about full implementation of the practice guideline, provided that an educational program on the revised workflow in the clinic was first presented. The expert panel also reviewed and approved the algorithm and the treatment pathways identified for patients to use in the practice after the results of the PHQ-9 are compiled. It is expected that use of the depression screening tool and recommended guidelines in the bariatric clinic will result in more effective treatment for the patients and thus better outcomes-a significant positive social change.

Objective: As long-term results of conservative treatment for obesity are discouraging, bariatric surgery is becoming a treatment option for extremely obese adolescents. However, mental and behavioral problems need to be respected when treating this vulnerable target group. Methods: A detailed systematic literature review on pre- and post-operative depressive, anxiety and eating disorder symptoms of adolescent patients was performed in PsychINFO, PubMed and Medline electronic databases. Results: Twelve studies met the inclusion criteria. Although strength of evidence was limited, results suggested that pre-operatively a third of adolescents suffered from moderate to severe depressive disorder symptoms and a quarter from anxiety disorder symptoms, while a substantial number showed eating disorder symptoms. Post-operatively, levels of depressive disorder symptoms significantly improved. Original articles on outcomes of eating and anxiety disorder symptoms after weight loss surgery were not found. Conclusions: Further attention is needed on consistent clinical assessment of mental health disturbances and their consecutive treatment in adolescents. Future research should also focus on psychological and psychosocial predictors of weight loss after bariatric surgery.

BACKGROUND Roux-en-Y gastric bypass (RYGB) surgery is the most effective treatment for obesity and has greater efficacy for weight loss than gastric banding (BAND) surgery. The superior weight loss seen after RYGB may result from profoundly different effects on food hedonics and reward brought about by physiological changes secondary to the distinct manipulations of gut anatomy. AIMS To compare body mass index (BMI) matched patients after RYGB or BAND surgery and unoperated controls using comprehensive phenotyping of brain structure and function, eating behaviour and metabolism. METHODS In these cross-sectional studies, un-operated controls and patients after RYGB and BAND surgery had functional and anatomical neuroimaging of food reward systems. Reward responses to food were assessed with a functional magnetic resonance imaging (fMRI) food picture evaluation task. Anatomical differences in grey and white matter were assessed using voxel-based morphometry (VBM) and diffusion tensor imaging (DTI). Eating behaviour, food appeal and palatability, potential mediators, and post-ingestive effects were compared between groups using questionnaires, test meals, food diaries and assay of plasma hormones and metabolites. Surgical patients were compared in both the fasted and fed state, and after administration of the somatostatin analogue, Octreotide, to suppress anorexigenic gut hormone responses after RYGB. RESULTS Obese patients after RYGB had healthier gut-brain-hedonic responses to food than patients after BAND surgery. RYGB patients had lower activation than BAND patients in brain reward systems, particularly to high-calorie foods, including the orbitofrontal cortex, amygdala, caudate nucleus, nucleus accumbens and hippocampus. This was associated with lower palatability and appeal of high-calorie foods, and healthier eating behaviour, including less fat intake, in RYGB compared to BAND patients and/or BMI-matched unoperated controls. These differences were not explicable by differences in hunger or psychological traits between the surgical groups, or by differences in brain structure as measured by VBM and DTI. However anorexigenic plasma gut hormones (GLP-1 and PYY), plasma bile acids and symptoms of dumping syndrome were increased in RYGB patients. Octreotide increased nucleus accumbens activation to food pictures, increased food appeal and decreased post-meal satiety in patients after RYGB, but not BAND surgery. The preliminary nature of this small study precludes extensive interpretation especially of the difference between surgical groups. Patients in the operated groups (RYGB and BAND) had lower grey matter density in areas involved in reward processing, including the amygdala, nucleus accumbens and hippocampus compared to BMI-matched controls. There was no difference between the groups in white matter tract integrity. CONCLUSIONS Identification of these differences in the gut-brain axis and hence food hedonic responses as a result of altered gut anatomy/physiology provides a novel explanation for the more favorable long-term weight loss seen after RYGB than BAND surgery. This supports targeting of gut-brain reward systems for future treatments of obesity.