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Written By: Henry Buchwald, M.D., Ph.D., F.A.C.S.
For the Consensus Conference Panel
This Consensus Statement on the state of bariatric surgery for morbid obesity has been prepared by a panel of broadly based and experienced experts based on presentations by investigators working in areas relevant to current questions in this field during a 1½-day public session; questions and statements from conference attendees during open discussion periods that were part of the public sessions; and closed deliberations by the panel. This statement is an independent report of the panel and is not a policy statement of the American Society for Bariatric Surgery or any of the sponsors or endorsers of the Consensus Conference. Though the Consensus Conference is modeled on the format used by the National Institutes of Health (NIH), the planning, execution, and development of the conference and preparation of this statement were carried out without any relationship with the NIH. In addition, although the Conference was addressed by the Honorable Tommy Thompson, Secretary of Health and Human Services, this report is not a policy statement of the federal government.
This statement reflects the panel's assessment of medical knowledge available at the time it was written. Knowledge about bariatric surgery and morbid obesity is dynamic, and this assessment is made with the realization that new knowledge, recommendations, and procedures will continue to emerge through medical research.
The Consensus Conference was convened and this Consensus Statement was prepared to update the 1991 NIH Consensus Statement on "Gastrointestinal Surgery for Severe Obesity." Findings and conclusions of the Consensus Panel include:
- Bariatric surgery is the most effective therapy available for morbid obesity and can result in improvement or complete resolution of obesity comorbidities.
- Types of operative procedures for morbid obesity have increased since 1991 and are continuously evolving; there are currently four types of procedures that can be used to achieve sustained weight loss: gastric bypass (standard, long-limb, and very long-limb Roux), alone or in combination with vertical banded gastroplasty; laparoscopic adjustable gastric banding; vertical banded gastroplasty; and biliopancreatic diversion and duodenal switch.
- Both open and laparoscopic bariatric operations are effective therapies for morbid obesity and represent complementary state-of-the-art procedures.
- Bariatric surgery candidates should have attempted to lose weight by nonoperative means, including self-directed dieting, nutritional counseling, and commercial and hospital-based weight loss programs, but should not be required to have completed formal nonoperative obesity therapy as a precondition for the operation.
- The bariatric surgery patient is best evaluated and subsequently cared for by a multidisciplinary team.
- Bariatric surgery candidates should have a comprehensive medical evaluation before the operation; evaluation by subspecialists (eg, cardiologists, psychiatrists, and psychologists) is not routinely needed but should be available if indicated.
- Bariatric surgery, performed only by experienced centers, should be considered in morbidly obese adolescents.
- Extending bariatric surgery to patients with Class I obesity (body mass index [BMI] 30 to 34.9 kg/m^2^), who have a comorbid condition that can be cured or markedly improved by substantial and sustained weight loss, may be warranted and requires additional data and longterm risk and benefit analyses.
- Bariatric surgery can be cost effective before the 4th year of followup.
- Bariatric surgery offers rich opportunities for both basic and translational patient-oriented research to provide a better understanding of the factors involved in the regulation of food intake, pathophysiology of obesity, metabolic and clinical effects of sustained weight loss, and best treatment options for obese persons.
There is a world epidemic of overweight, defined as a BMI ≥ 25 to 29.9 kg/m^2^, and obesity, defined as a BMI ≥ 30 kg/m^2^, that is estimated to encompass 1.7 billion people. According to the Worldwatch Institute, the number of overweight people is approximately equal to the number of underweight people in the world.
Approximately two-thirds of the US population is overweight, and of these, about one-half are obese; one of four adults, or over 50 million people, in the United States are obese. Prevalence of obesity is particularly high in many ethnic minority women, such as African, Mexican, Native, and Pacific Islander American women.
In children and adolescents, overweight is defined by gender- and age-specific BMI ≥ 95th percentile on growth charts determined by the National Center of Health Statistics. In the United States, overweight tripled in children between 1970 and 2000. Approximately, 15% of children and adolescents (6 to 19 years old) are overweight. An estimated 250,000 children and adolescents have a BMI ≥ 95th percentile. Overweight children and adolescents have a higher risk of becoming obese adults.
Morbid obesity, also referred to as "clinically severe obesity" or "extreme obesity," was defined as the criteria for bariatric surgery by the 1991 NIH Consensus Conference Statement on Gastrointestinal Surgery for Severe Obesity as a BMI ≥ 40 kg/m^2^ or a BMI ≥ 35 kg/m^2^ in the presence of high-risk comorbid conditions. Obesity was further classified in the 1998 NIH Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults into Class I (BMI 30.0 kg/m^2^ to 34.9 kg/m^2^), Class II (BMI 35.0 kg/m^2^ to 39.9 kg/m^2^), and Class III (BMI ≥ 40 kg/m^2^).
Morbid obesity is estimated to afflict 20% of the obese population or over 8 million of the US population. Indeed, the relative rise of morbid obesity over the already exponential rise of obesity in the past 25 years can be characterized as an epidemic within an epidemic. Between 1986 and 2000, prevalence of obesity (BMI ≥ 30 kg/m^2^) doubled, morbid obesity (BMI ≥ 40 kg/m^2^) quadrupled, and super obesity (BMI ≥ 50 kg/m^2^) increased fivefold in US adults. A similar pattern of increasing degrees of obesity has been demonstrated in the pediatric population.
Obesity should be considered a chronic disease that has serious health consequences. An expert panel convened by the National Heart, Lung and Blood Institute stated that, "obesity is a complex multifactorial chronic disease that develops from an interaction of genotype and the environment." In 1997, the World Health Organization defined obesity as "a disease in which excess fat is accumulated to an extent that health may be adversely affected." WHO has listed obesity as a disease condition in its International Classification of Disease since 1979. In the United States, the National Center for Health Statistics and the Centers for Medicare and Medicaid Services have assigned obesity a specific ICD-9, clinical modification code of #278.00, and morbid obesity, #278.01.
Morbid obesity is the harbinger of many other diseases that affect essentially every organ system: cardiovascular (hypertension, atherosclerotic heart and peripheral vascular disease with myocardial infarction and cerebral vascular accidents, peripheral venous insufficiency, thrombophlebitis, pulmonary embolism); respiratory (asthma, obstructive sleep apnea, obesity-hypoventilation syndrome); metabolic (type 2 diabetes, impaired glucose tolerance, hyperlipidemia); musculoskeletal (back strain, disc disease, weight-bearing osteoarthritis of the hips, knees, ankles, feet); gastrointestinal (cholelithiasis, gastroesophageal reflux disease, nonalcoholic fatty liver disease [steatosic steatohepatitis], hepatic cirrhosis, hepatic carcinoma, colorectal carcinoma); urologic (stress incontinence); endocrine and reproductive (polycystic ovary syndrome, increased risk of pregnancy and fetal abnormalities, male hypogonadism, cancer of the endometrium, breast, ovary, prostate, pancreas); dermatologic (intertriginous dermatitis); neurologic (pseudotumor cerebri, carpal tunnel syndrome); and psychologic (depression, eating disorders, body image disturbance). Nearly 30% of overweight adolescents in the United States meet the criteria for metabolic syndrome, which increases risk of type 2 diabetes and coronary heart disease.
The impact of obesity on longevity has been well documented. In the world, over 2.5 million deaths annually can be attributed to obesity; in the United States, over 400,000, second only to cigarette smoking. There is a direct relationship between increasing BMI and relative risk of dying prematurely as evidenced in the Nurses' Health Study with a > 100% increase in relative risk as BMI increased from < 19 kg/m^2^ to ≥ 32 kg/m^2^. Annual risk of death can be as high as 40-fold that of an age- and gender-matched nonobese cohort. The Framingham data revealed that for each pound gained between ages 30 to 42 years, there was a 1% increased mortality within 26 years, and for each pound gained thereafter, there was a 2% increased mortality. Only one in seven obese individuals will reach the US life expectancy of 76.9 years. In the morbidly obese population, average life expectancy is reduced by 9 years in women and 12 years in men.
Obesity, in particular morbid obesity, is also a social and economic problem. Obesity bias and discrimination starts in the earliest social contacts of preschool children and progresses through childhood and adolescence into adulthood. This prejudice may contribute to depression, eating disorders, body image disturbance, and other suffering. Practical social implications of morbid obesity are manifold, eg, inability to ambulate, limited selection in clothing, stress incontinence, and difficulty with personal hygiene. A direct consequence of social bias is economic disadvantage with decreased monetary and educational opportunities. In estimating the total national financial burden of obesity, the intangible socioeconomic costs must be considered in addition to the calculable health care costs, which are in excess of $117 billion annually in the United States. Bariatric surgery is the most effective therapy available for the morbidly obese population. It markedly lowers body weight, reverses or ameliorates the myriad of obesity comorbidities, and improves quality of life. The 1991 NIH Consensus Conference Panel recommended:
- Patients seeking therapy for severe obesity for the first time should be considered for treatment in a nonsurgical program with integrated components of a dietary regimen, appropriate exercise, and behavioral modification and support.
- Gastric restriction or bypass procedures should be considered for well-informed and motivated patients with acceptable operative risks.
- Patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise.
- The operation should be performed by a surgeon substantially experienced with the appropriate procedures and working in a clinical setting with adequate support for all aspects of management and assessment.
- Life-long medical surveillance after surgical therapy is a necessity.
Many of these guidelines are viable today, others have been modified, and new guidelines are needed in the dynamic field of morbid obesity management by bariatric surgery. Certain critical events have occurred over the past 13 years since the 1991 NIH Consensus Conference that mandated conducting a new Consensus Conference to develop a new Consensus Statement as a national directive in bariatric surgery. These events include:
- Marked increase in the incidence of obesity, in particular, morbid obesity.
- Expansion of available operative procedures.
- Improved safety of bariatric procedures with an acceptable operative mortality and morbidity (less than comparable operative procedures), reoperation rate, and longterm complications.
- Introduction of laparoscopic minimally invasive techniques to bariatric surgery.
- Increased experience with a team management approach.
- Increased experience with bariatric surgery in adolescent and elderly patients.
- A more complete elucidation and verification of obesity comorbidity outcomes with demonstration of reversal or improvement in diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, gastroesophageal reflux disease, cardiac function, osteoarthritic orthopaedic conditions and bone fractures, nonalcoholic fatty liver disease, intertriginous dermatitis, stress incontinence, and symptoms of depression.
- Documentation that delaying bariatric surgery diminishes the chances for full reversal of diabetes.
- Demonstration that bariatric surgery improves the life expectancy of patients.
- Data demonstrating that bariatric surgery can be costeffective less than 4 years after bariatric surgery (ie, less expensive than the care of a morbidly obese patient who has not had bariatric surgery).
2004 Consensus Conference conclusions, future directions, and recommendations
Nonsurgical treatment options
Few studies have specifically examined the effects of nonsurgical treatment in patients with morbid obesity, so conclusions about nonsurgical therapy in this population are based on inference. In studies of Class I (minimal) and Class II (moderate) obesity, medical therapy can achieve > 10% body weight loss (equivalent to > 25% excess body weight loss) in 10% to 40% of patients depending on study design, use of medications, and duration of the intervention. Duration of the weight-loss response increases with duration of treatment and with use of medications and behavior modification. Moderate weight loss of as little as 5% of body weight can have considerable health benefits. Longterm weight loss is difficult to achieve with diet, exercise, and pharmacotherapy. Most patients who present for bariatric surgery have already failed multiple attempts to achieve a sustained weight loss by using nonsurgical treatment options.
Surgical treatment options and criteria for selection
Four operative procedures (in three classes of procedures), are currently in general use in the United States and worldwide: gastric bypass with a standard, long-limb, or very long-limb Roux (restrictive and malabsorptive), alone or in combination with vertical banded gastroplasty; laparoscopic adjustable gastric banding (restrictive); vertical banded gastroplasty (restrictive); and biliopancreatic diversion and duodenal switch (primarily malabsorptive). Certain surgeons perform one operation exclusively; other surgeons offer the full range of operations. There is an everincreasing effort to match a particular patient to a particular operation. To this end, several selection approaches or algorithms have been suggested; randomized trials that test these algorithms have not been conducted.
Gastric bypass
Gastric bypass is currently the most popular procedure performed in the United States and worldwide. Gastric bypass was the first of the gastric procedures for morbid obesity and the first of the combined restrictivemalabsorptive operations. The restrictive element of the operation consists of the creation of a small gastric pouch with a small outlet that, on distention by food, causes the sensation of satiety. This restrictive element is combined with a gastrointestinal bypass as the malabsorptive element. The extent of the bypass of the intestinal tract determines the degree of macronutrient malabsorption. The minimal amount of intestinal tract bypassed consists of the distal stomach, the entire duodenum, and about 40 cm of the proximal jejunum. The standard Roux limb is about 75 cm. More extensive malabsorptive variations consist of gastric bypasses with a 150-cm Roux limb (long-limb) or with a very longlimb (distal gastric bypass).
Current techniques
Gastric bypass can be performed by both open and laparoscopic techniques. In the United States, the laparoscopic technique has become the more popular approach. The upper pouch is constructed horizontally or vertically to be 15 to 25 mL in capacity, with the distal stomach separated from this pouch by four rows of staples, or totally divided from the upper gastric pouch. The anastomotic outlet to the retrocolic or antecolic Roux limb of jejunum is fashioned to be 0.75 to 1.25 cm in diameter. A hybrid gastric bypass—vertical banded gastroplasty has also been introduced using a divided vertical gastric bypass with a gastric ring proximal to the gastrojejunostomy. In the laparoscopic approach, the gastrojejunostomy can be performed with the end-to-end stapler, the linear stapler, or it can be hand-sewn (Fig. 1).
Weight loss
Weight loss after a standard 75 cm Roux gastric bypass usually exceeds 100 lb, or about 65% to 70% of the excess body weight (EBW) and about 35% of the BMI. The longer-limb bypasses are used to obtain comparable weight reductions in super obese (BMI ≥ 50 kg/m^2^) patients. Weight loss generally levels off in 1 to 2 years, and a regain of up to 20 lb from the weight loss nadir to a longterm plateau is common.
Operative mortality and morbidity
Operative (30-day) mortality for gastric bypass when performed by skilled surgeons is about 0.5%. Operative morbidity (eg, pulmonary emboli, anastomotic leak, bleeding, wound infection) is about 5%. Compared with open procedures, laparoscopic gastric bypass has a higher rate of intraabdominal complications; whereas duration of hospitalization is shorter, wound complications are lower, and postoperative patient comfort is higher.
Long-term complications
Gastric bypass can be associated with the dumping syndrome, stomal stenosis, marginal ulcers, staple line disruption, and internal hernias. Life-long oral or IM vitamin B~12~ supplementation, and iron, vitamin B, folate, and calcium supplementation is recommended to avoid specific nutrient deficiency conditions, such as anemia. Ventral hernia formation is more prevalent after open gastric bypass than after the laparoscopic approach. A unique complication of gastric bypass is dilation of the bypassed distal stomach in the event of a small bowel obstruction, which can lead to rupture and death if not rapidly managed by distal gastric decompression. Reversal and revision Gastric bypass can be functionally totally reversed, though this is rarely required. For all bariatric procedures, pure reversal without conversion to another bariatric procedure is almost certainly followed by a return to morbid obesity. A standard Roux gastric bypass with failed weight loss can be revised to a very long-limb Roux-en-Y procedure.
Laparoscopic adjustable gastric banding
Gastric banding is the least invasive of the purely restrictive bariatric surgery procedures. It consists of a small pouch and a small stoma created by a band high on the stomach. The stomach is not cut or crushed by staples, and no anastomoses are made. Laparoscopic adjustable gastric banding was first introduced in the early 1990s. Though there was an open surgery history with gastric banding, currently this procedure is essentially a laparoscopic operation. Today, there are six adjustable bands available worldwide and one approved by the FDA (June 2001) for use in the United States. Laparoscopic adjustable gastric banding is the most common procedure performed outside of the United States, primarily in continental Europe, Australia, and South America. It is the second most commonly performed procedure worldwide. Since its introduction in the United States, it has gained greater acceptance in this country and its relative use in the United States is increasing.
Current techniques
After a period of evolution of technique, certain operative principles have been established: The upper gastric pouch is made very small (the "virtual pouch"), approximately 15 mL in volume, and placed primarily anteriorly. The dissection on the lesser curvature of the stomach includes the neurovascular bundle of the lesser omentum—the pars flaccada approach. Suture fixation of the anterior wall of the stomach, with at least four gastrogastric sutures, completely imbeds the anterior band. The system is assembled and the port for inflation and deflation of the band is secured onto the rectus fascia of the anterior abdominal wall. Adjustment of the band through the access port is an essential part of laparoscopic adjustable gastric banding therapy. Appropriate adjustments, performed up to six times annually, are critical for successful outcomes (Fig. 2).
Weight loss
Weight loss after laparoscopic adjustable gastric banding is about 50% of the EBW and about 25% of the BMI at 2 years. Because weight loss with this procedure may be progressive over time, these figures may represent an underestimation.
Operative mortality and morbidity
Operative (30-day) mortality for laparoscopic adjustable gastric banding when performed by skilled surgeons is about 0.1%. Operative morbidity is about 5%. Longterm complications There are unique longterm complications of laparoscopic adjustable gastric banding, which include gastric prolapse, stomal obstruction, esophageal and gastric pouch dilation, gastric erosion and necrosis, and access port problems. Experience has markedly reduced the incidence of these complications. Use of a prosthetic device introduces additional potential problems of malfunction and infection.
Reversal and revision
Laparoscopic adjustable gastric banding can be completely reversed with removal of the band, tubing, and port. For failed weight loss, revision procedures include removal of the device and performance of a restrictive-malabsorptive procedure (eg, gastric bypass) or a primarily malabsorptive procedure (eg, biliopancreatic diversion and duodenal switch).
Vertical banded gastroplasty
The vertical banded gastroplasty, introduced in the early 1970s, is a relatively fast and simple operation to perform. It consists of the creation of a small upper gastric pouch with a restricted orifice to the rest of the stomach. It has the advantage of not bypassing, resecting, or rearranging any part of the gastrointestinal tract. Since 1991, the percentage of patients undergoing vertical banded gastroplasty has decreased, but the operation is still performed at centers in the United States and worldwide. For the most part, vertical banded gastroplasty is performed by open procedure, but is also feasible laparoscopically.
Current techniques
There are two distinct techniques used in the construction of an open vertical banded gastroplasty. Both involve forming a linear pouch the size of a finger (15 to 25 mL) along the lesser curvature of the stomach. For the silicone elastomer ring gastroplasty, this pouch is created by a specially designed notched stapler; the outlet of the pouch is then encircled with a silicone elastomer ring. For the Marlex mesh band gastroplasty, this pouch is created by a linear stapler placed through a hole in the stomach made with an end-to-end stapler; the outlet is encircled with a mesh collar sewed to itself. Comparable with the gastric bypass, the outlet is created to be 0.75 to 1.25 cm in diameter. With some modifications of technique, gastroplasty procedures can be performed laparoscopically as well.
Weight loss
Weight loss after vertical banded gastroplasty is about 50% to 60% of EBW, and about 25% to 30% of BMI. A plateau in weight loss is generally reached at 2 years after a slight weight increase from the weight response nadir.
Operative mortality and morbidity
Operative mortality for vertical banded gastroplasty when performed by skilled surgeons is about 0.1%. Operative morbidity is about 5%.
Longterm complications
Comparable with other restrictive bariatric surgery procedures, vertical banded gastroplasty may be associated with vomiting, usually early in the postoperative period and in relation to the patient's learning curve in appreciating the tolerated size of a meal. The most notable complication of vertical banded gastroplasty is lodging of a food particle, or a large pill or capsule, within the band or ring. If this problem is not relieved spontaneously within 24 hours by antegrade or retrograde passage of the obstructing item, endoscopic removal becomes necessary. Outlet obstruction resulting from adhesion formation and twisting of the ring or band can occur and requires operative intervention because neither the ring nor the band can be endoscopically dilated.
Reversal and revision
Vertical banded gastroplasty can be functionally reversed by removal of the ring or the band, allowing the outlet to dilate. Revision of vertical banded gastroplasty for failed weight loss can be achieved by conversion to a gastric bypass or to a duodenal switch.
Biliopancreatic diversion and duodenal switch
Biliopancreatic diversion and duodenal switch are primarily malabsorptive procedures. The biliopancreatic diversion originated in Genoa, Italy and is widely used in Europe and sparingly in the United States. The duodenal switch is a US adaptation of the biliopancreatic diversion and is gaining popularity in this country. Both procedures involve a partial gastrectomy leaving a gastric pouch of 100 to 150 mL, which is considerably larger than that of gastric bypass or the restrictive procedures and, thereby, allows larger meals in comparison with those of the other bariatric operations. Both procedures avoid leaving a nonfunctioning intestinal segment by dividing the intestine into a long enteric limb joining a long biliopancreatic limb to form a common channel 50 to 150 cm from the ileocecal valve. This modification avoids the toxic problems seen with the old jejunoileal bypass procedure.
Current techniques
For the biliopancreatic diversion, a horizontal gastrectomy is performed with a retrocolic gastrojejunostomy. This long Roux limb, carrying enteric contents, is anastomosed to the biliopancreatic limb emanating from the closed postpyloric duodenum. For the duodenal switch, a pylorus-sparing vertical sleeve gastrectomy is performed with anastomosis of the proximal duodenal cuff to the retrocolic enteric limb. Comparable with biliopancreatic diversion, the enteric limb of the duodenal switch is anastomosed to the biliopancreatic limb emanating from the postpyloric duodenum. Length of the common channel formed by joining of the enteric and biliopancreatic limbs governs the malabsorptive outcomes of these procedures. Open biliopancreatic diversion and duodenal switch are long and difficult procedures requiring skilled surgeons and adequate experience. Both procedures have been performed by total or by handassisted laparoscopic techniques. A two-stage laparoscopic duodenal switch with initial subtotal gastrectomy has been used in high-risk, extremely obese (BMI ≥ 60 kg/m^2^) patients (Fig. 4).
Weight loss Weight loss after biliopancreatic diversion and duodenal switch is about 70% of the EBW and about 35% of the BMI. Weight loss with these procedures is at the upper end of the efficacy range. Weight loss may be sustained without a rise from the weight nadir. Operative mortality and morbidity Operative mortality for biliopancreatic diversion and duodenal switch when performed by skilled surgeons is about 1%. Operative morbidity is about 5%. Longterm complications On occasion, these procedures are associated with diarrhea. Some patients report malodorous stools and flatus. Long-range complications can consist of vitamin, mineral, and nutrient deficiencies, in particular, protein deficiency. These contingencies need to be anticipated and properly managed by dietary supplements with about 75 to 80 g of dietary protein and B vitamins, calcium, and iron. Biliopancreatic diversion may be associated with postoperative dumping; the duodenal switch is not.
Reversal and revision
Normal intestinal continuity can be restored, but the partial gastrectomy cannot be reversed. For failed weight loss after these procedures, shortening of the common channel has produced a desired result in some, but not all, patients.
There is no single or standard procedure for management of morbid obesity and, probably, there never will be. There never was a single procedure for peptic ulcer disease, and there is no standard inguinal hernia repair. Ingenuity and investigation will lead to changes in the procedures used, eg, the current work-in-progress testing the efficacy of gastric pacing. The next bariatric surgery consensus conference on the state-of-the-art will, undoubtedly, discuss new procedures and modifications of existing ones. This continuous evolution in operative approaches will result in continued improvement in patient management.
Introduction of laparoscopy
Laparoscopic procedures, primarily laparoscopic gastric bypass and laparoscopic adjustable gastric banding, were introduced to bariatric surgery in the early 1990s and so were not included in the 1991 NIH Consensus Conference Statement. By 2003, nearly two-thirds of bariatric procedures worldwide were performed laparoscopically. Laparoscopic bariatric surgery is not experimental or investigational.
Open bariatric operation has certain advantages over laparoscopic procedures. These include tactile control of dissection and the ability to palpate tissues, greater ease and speed for lysis of adhesions, freedom to use fine suture technique and materials, greater facility to perform ancillary procedures, possibly a lower incidence of certain perioperative complications (eg, leaks, hemorrhage), and decreased risk of specific longterm complications (eg, anastomotic strictures, internal hernias, bowel obstructions). Laparoscopic bariatric surgery has certain advantages over open procedures, such as minimal incisional scars, less postoperative pain, increased mobility, shortened hospital stay, shorter convalescent time, and fewer late ventral hernias. Operative times vary between open and laparoscopic procedures from surgeon to surgeon. Costs are similar; the cost of additional operative equipment disposables needed for laparoscopic surgery equals the cost of longer hospital stay for open procedures. Longterm weight loss and amelioration of comorbid conditions are essentially the same for open and laparoscopic bariatric operations.
When the laparoscopic approach proves to be difficult (eg, adhesions, size of liver, size of patient), the surgeon should convert to an open operation. For certain conditions, the surgeon may initially select the open approach, eg, super (BMI ≥ 50 kg/m^2^) and central obesity, hepatomegaly, inability to tolerate pneumoperitoneum, presence of congenital anomalies, anticipated severe adhesions, certain abdominal wall hernias, management of complications, and some planned revision procedures. Open and laparoscopic bariatric operations are not competitive; they are complementary.
Care of the bariatric surgery patient
Patient selection
The 1991 NIH Consensus Conference weight criteria for bariatric surgery of a BMI ≥ 40 kg/m^2^ or a BMI of 35.0 kg/m^2^ to 39.9 kg/m^2^ in the presence of severe comorbidities are still reasonable today. High-risk comorbid conditions that can justify reducing the BMI to 35 kg/m^2^ include type 2 diabetes, life-threatening cardiopulmonary problems (eg, severe sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy), obesity-induced physical problems interfering with a normal lifestyle (eg, joint disease treatable but for the obesity), and body size problems precluding or severely interfering with employment, family function, and ambulation.
Certain data demonstrate that bariatric surgery can ameliorate obesity comorbidities (eg, type 2 diabetes) in patients with a BMI < 35 kg/m^2^. Extending bariatric surgery to patients with Class I obesity (BMI 30 kg/m^2^ to 34.9 kg/m^2^) who have a comorbid condition that can be cured or markedly improved by substantial and sustained weight loss may be warranted; this BMI change requires additonal data and longterm risk-to-benefit analyses.
Successful and safe bariatric surgery has been performed in patients in their 70s and in adolescents. Patient variables of gender, race, and body habitus may influence outcomes and may dictate operative selection. Comorbidities, as a rule, are affirmative indicators for patient selection for bariatric operations.
Mental status is a difficult area in which to define standards for patient selection. Selected screening for severe depression, untreated or undertreated mental illnesses associated with psychoses, active substance abuse, bulimia nervosa, and socially disruptive personality disorders may help avoid adverse postoperative outcomes. History of compliance with nonoperative therapy may be beneficial in assessing the risk-to-benefit ratio of bariatric surgery.
Preoperative care
The bariatric surgery patient needs to be well-informed, motivated, willing to participate in longterm care, change dietary patterns, and embrace a revised lifestyle.
The bariatric patient is best evaluated and subsequently cared for by a team approach involving the surgeon, a nurse practitioner or nurse, a dedicated dietician, office personnel (scheduling and triage), and other specialists when needed. In addition to a preoperative history, physical, and laboratory evaluation, a preoperative discussion or teaching seminar that provides information on postoperative recovery, dietary changes, activity, and clinical outcomes, by the dietician, the bariatric nurse, and the bariatric surgeon, is critical. Availability of a support group is recommended, as is distribution of literature describing procedures, postoperative diets, exercise, and so forth. Availability of a full spectrum of expert consultants (eg, cardiologists, pulmonologists, psychiatrists and psychologists) is mandatory.
Perioperative care
Expert anesthesiology support, knowledgeable in the specific problems of the bariatric patient, is necessary. The anesthesiology support includes an understanding of patient positioning, blood volume and cardiac output changes, airway maintenance, and drug pharmacokinetics in the morbidly obese. It is advisable to have preoperative, intraoperative, and postoperative written protocols. The bariatric surgeon must be able to manage, and have coverage to manage, the postoperative patient and any problems and complications that may occur.
A facility that practices bariatric surgery must be equipped with appropriate operating room equipment, including operating tables that can handle large patients; bariatric instruments, including large retractors, special staplers, long laparoscopic instruments; special equipment to transfer the patient; extra-large beds, commodes, chairs, and wheelchairs; and diagnostic facilities and equipment that can accommodate the morbidly obese patient.
Postoperative care
Care of the postoperative bariatric surgery patient is recommended for the lifetime of the patient with at least three followup visits with the bariatric surgery team within the first year. Laparoscopic adjustable gastric banding will require more frequent visits for band adjustment. Postoperative dietary (including vitamin, mineral, and possibly liquid protein supplementation), exercise, and lifestyle changes should be reinforced by counseling, support groups, and working with the family physician. Favorable outcomes of bariatric surgery can lead to socioeconomic advancement, which may require patient guidance. Postoperative care may include planning for reconstructive operations after weight stabilization for certain patients.
Care of the adolescent patient
Bariatric surgery has been performed in morbidly obese adolescents for more than a decade. In these small series, surgical weight loss resulted in considerable improvement, if not complete resolution, of most obesity-related comorbidities, supporting the position that bariatric surgery in adolescents is reasonable. Longterm efficacy, potential adverse consequences related to decreased absorption of nutrients, and degree of recidivism remains unknown.
BMI guidelines for adolescents should be identical to those advocated for adults. Deferring surgery to a higher BMI standard may increase operative mortality and morbidity, and possibly prevent reversal of comorbid conditions. To be considered for bariatric surgery, the adolescent's physiologic maturity should be complete and, ideally, the adolescent should have obtained ≥ 95% of predicted adult stature. Adolescents should indicate their desire for the operation and should have sufficient cognitive and psychologic development to participate in decision-making. The adolescent needs to have a general understanding of the procedure to be performed and its lifestyle consequences.
Adolescents considered for bariatric surgery should be referred to specialized centers with a multidisciplinary bariatric team capable of providing longterm followup care. These adolescents should first undergo a trial of dietary and behavior modification for at least 6 months. The bariatric team must be expert in the technical aspects of bariatric surgery, and capable of addressing the unique cognitive, psychosocial, and emotional needs of the adolescent prospectively, as well as the longterm nutritional consequences of bariatric surgery. Centers performing adolescent bariatric surgery should be committed to clinical data collection and participation in a central database or registry.
Future directions for clinical investigation, basic research, and education
Clinic investigation
Over the past 10 years, the field of bariatric surgery has been enriched by data from numerous clinical investigations and experience. Directions for future clinical investigations are manifold and include:
- Controlled, prospective, intervention studies.
- Establishment of a major prospective database to study bariatric surgery outcomes.
- Establishment of a pediatric (adolescent) bariatric surgery registry.
- Performance of randomized clinical trials to compare the safety and efficacy of different operative procedures.
- Controlled studies of new operative modalities (eg, gastric pacing) and nonoperative modalities of treatment.
- Study by metaanalysis of outcomes of comorbid conditions of morbid obesity.
- Study of the socioeconomic outcomes of bariatric surgery.
- Study by stratified risk assessment of the risk-to-benefit ratio of treating morbid obesity with bariatric surgery and without bariatric surgery.
Basic research
Availability of thousands of bariatric patients for basic research studies, involving minimal risk (eg, blood drawing), can considerably enhance our basic knowledge of the pathogenesis and pathophysiology of obesity. Directions for future basic research are manifold and include:
- Study of the interrelationships among specific bariatric surgical procedures, marked weight loss, gastrointestinal hormones (eg, ghrelin), adipokines (eg, leptin), and inflammatory markers.
- Exploring the mechanisms by which different types of bariatric procedures work (eg, purely restrictive, restrictive and malabsorptive, primarily malabsorptive); and application of new and safe technology in these studies (eg, brain PET scanning).
- Learning the mechanisms by which various bariatric surgical procedures impinge on the comorbid conditions of morbid obesity.
- Gaining insight into the basic cause(s) and mechanisms(s) of overweight, obesity, and morbid obesity.
Bariatric surgery and bariatric surgery training is expanding. A recent survey of the 251 accredited surgery training institutions in the United States, with a 100% response rate to the survey, showed that 185 (73.7%) of the institutions perform bariatric surgery and that all of these 185 institutions teach bariatric operations in their residency training programs. Of 48 institutions that offer minimally invasive fellowships, 43 (89.5%) offer bariatric surgery training. Fellows in these programs assist in approximately 4,000 cases annually. In the future, these educational efforts will increase and bariatric surgery may well become the mainstay of general surgery.
Bariatric surgery, involving either open or laparoscopic techniques, is the most effective weight loss therapy available for patients with morbid obesity. Bariatric surgery results in marked and long-lasting weight loss and elimination or improvement of most obesity-related medical complications, including diabetes, hypertension, hyperlipidemia, obstructive sleep apnea, gastroesophageal reflux disease, cardiac dysfunction, osteoarthritis and low back pain, nonalcoholic fatty liver disease, intertriginous dermatitis, stress incontinence, symptoms of depression, and eating disorders; bariatric operations can also prevent obesity-related diseases (eg, type 2 diabetes). There is no single or standard surgical procedure for management of morbid obesity, and future studies will likely lead to modifications in current procedures and new surgical approaches.
- A multidisciplinary team including a surgeon, anesthesiologist, dietitian, nurse, and experienced office personnel should be used in the care of the bariatric surgery patient. Additional clinical expertise, such as a cardiologist, pulmonologist, or psychiatrist and psychologist, should be available if needed.
- Candidates should have attempted to lose weight by selfdirected dieting, nutrition counseling, and commercial and hospital-based weight loss programs, but should not be required to complete formal nonoperative obesity therapy as a precondition for the operation.
- Candidates should have a comprehensive medical evaluation before the operation; evaluation by subspecialists (eg, cardiologists, psychiatrists, psychologists) is not routinely needed but should be available if indicated.
- Currently recommended operative procedures include: (a) gastric bypass with standard, long-limb, or very longlimb Roux, alone or in combination with vertical banded gastroplasty; (b) laparoscopic adjustable gastric banding; (c) vertical banded gastroplasty; and (d) biliopancreatic diversion and duodenal switch.
- The surgical team should be receptive to change in selecting operative procedures and concepts and, contingent on thorough evaluation, the future introduction of new operative approaches.
- Standard of care for bariatric surgery includes use of laparoscopic and open techniques.
- Additional experience should be obtained with extending the benefits of bariatric surgery to adolescents under carefully defined conditions by a multidisciplinary team with the ability to perform longterm monitoring.
- Consideration should be given to extending the benefits of bariatric surgery to patients with Class I obesity (BMI 30 kg/m^2^ to 34.9 kg/m^2^), who have a condition that can be cured or markedly improved by substantial and sustained weight loss; this extension requires more data and longterm risk-to-benefit analysis.
- Because bariatric surgery can be cost-effective in less than 4 years, in comparison with nonoperative management, critical examination of the cost-to-benefit ratio of bariatric surgery is indicated.
- Increased clinical investigation, basic research, and education in the obesity field are strongly recommended.
Consensus conference panel
Chair: Henry Buchwald, MD, PhD, Owen H and Sarah Davidson Wangensteen Chair in Experimental Surgery, Professor of Surgery and Biomedical Engineering, University of Minnesota, Minneapolis, MN; Charles J Billington, MD, Professor of Medicine, VA Medical Center, Minneapolis, MN; Katherine M Detre, MD, PhD, Distinguished Professor of Epidemiology, Principal Investigator, Liver Transplantation Data Base, University of Pittsburgh, Pittsburgh, PA; Victor Garcia, MD, Professor of Surgery and Pediatrics, Cincinnati Children's Hospital, Cincinnati, OH; Michael D Jensen, MD, Endocrine Research Unit, Mayo Clinic, Rochester, MN; David E Kelley, MD, Professor of Medicine, Director, Obesity and Nutrition Research Center, University of Pittsburgh School of Medicine, Pittsburgh, PA; Samuel Klein, MD, William H Danforth Professor of Medicine and Nutritional Science, Washington University School of Medicine, St Louis, MO; J Patrick O'Leary, MD, Professor and Chair of Surgery, Louisiana State University Medical Center, New Orleans, LA; George F Sheldon, MD, Professor of Surgery and Social Medicine, University of North Carolina, Chapel Hill, NC; Thomas Wadden, PhD, Professor of Psychology, University of Pennsylvania School of Medicine, Philadelphia, PA; Alan Wittgrove, MD, (American Society for Bariatric Surgery President), Center for Surgical Weight Control, San Diego, CA; Bruce M Wolfe, MD, Sacramento Bariatric Medical Associates, Carmichael, CA, Emeritus Professor of Surgery, UC Davis Medical Center, Sacramento, CA.
Consensus conference speakers
Organizer and Moderator: Walter J Pories, MD, Professor of Surgery and Biochemistry, Brody School of Medicine, East Carolina University, Greenville, NC; Host and Welcome Address: Stephen RT Evans, MD, Professor and Chairman, Department of Surgery, Georgetown University Hospital, Washington, DC; Keynote Speaker: Tommy Thompson, Secretary, Health and Human Services, US Department of Health and Human Services, Washington, DC; Steven Belle, PhD, MScHyg, Principal Investigator, Longitudinal Assessment of Bariatric Surgery (LABS) Consortium Coordinating Center, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA; Robert E Brolin, MD, Director of Bariatric Surgery, University Medical Center, Princeton, NJ, Professor of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; J Kenneth Champion, MD, Clinical Professor of Surgery, Mercer University School of Medicine, Director of Bariatric Surgery, Emory-Dunwoody Medical Center, Atlanta, GA; George SM Cowan, Jr, MD, Professor Emeritus of Surgery, University of Tennessee, Memphis, TN; David E Cummings, MD, Associate Professor of Medicine, Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA; John B Dixon, MD, Senior Research Fellow, Centre for Obesity Research and Education, Monash University, Department of Surgery, Alfred Hospital, Melbourne, Australia; G Lynis Dohm, PhD, Professor of Physiology, Brody School of Medicine, East Carolina University, Greenville, NC; David R Flum, MD, MPH, Assistant Professor, Department of Surgery, Division of General Surgery, Adjunct, Assistant Professor Department of Health Services, University of Washington, Seattle, WA; Mal Fobi, MD, Center for Surgical Treatment of Obesity, Hawaiian Gardens, CA; Michel Gagner, MD, Professor of Surgery, Chief, Division of Bariatric Surgery, Weill College of Medicine, Cornell University, New York, NY; Douglas S Hess, MD, Wood County Hospital, Bowling Green, OH; Thomas Inge, MD, Assistant Professor of Surgery, University of Cincinnati, Cincinnati, OH; Kenneth B Jones, Jr, MD, Clinical Assistant Professor of Surgery, Louisiana State University Medical Center, Shreveport, LA; John G Kral, MD, PhD, Professor of Surgery and Medicine, SUNY Downstate Medical Center, Brooklyn, NY; Robert Kushner, MD, Professor of Medicine, Northwestern University, Feinberg School of Medicine, Medical Director, Wellness Institute, Northwestern Memorial Hospital, Chicago, IL; Kenneth G MacDonald, MD, Professor of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC; Edward E Mason, MD, PhD, Professor Emeritus of Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA; Ingmar Naslund, MD, PhD, Associate Professor, Department of Surgery, Örebro University Hospital, Örebro, Sweden; Jaime Ponce, MD, Medical Director for Bariatric Surgery, Hamilton Medical Center and, Dalton Surgical Group, Dalton, GA; Philip R Schauer, MD, Director of Advanced Laparoscopic and Bariatric Surgery, Cleveland Clinic Foundation, Cleveland, OH; Nicola Scopinaro, MD, Professor of Surgery, DICMI—University of Genoa, Ospedale San Martino, Genova, Italy; Scott A Shikora, MD, Associate Professor of Surgery, Tufts University School of Medicine, Tufts-New England Medical Center, Boston, MA; Harvey J Sugerman, MD, Emeritus Professor of Surgery, Virginia Commonwealth University, Richmond, VA.
Consensus conference staff
Georgeann N Mallory, RD, LD, Executive Director, American Society for Bariatric Surgery, Gainesville, FL; Pat Watson, Convention Manager, American Society for Bariatric Surgery, Gainesville, FL.


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With more than a decade of email experience, Anthony embraces educating and advising email marketers on the latest trends and insights within the email industry. In his work as Director of Product Marketing at 250ok, Anthony oversees launching new products and services through participating and influencing go-to-market strategies, supporting collateral, and brand evangelism. Before joining 250ok, Anthony served in a number of leadership roles at Salesforce, including Deliverability Practice lead and Associate Principal of Deliverability Services.
Anthony Chiulli, Director of Product Marketing, 250ok shares some valuable tips on email marketing readiness as we head into the 2018 holiday season.
Black Friday and Cyber Monday emails started as early as October 24 in 2017. We're predicting the marketing emails will start landing in inboxes even earlier this year, as the weekend after Thanksgiving has evolved into an event that looks more like a sport than shopping.
Identity Resolution is central to customer data management in the omni-channel world. Enterprise marketers would be unable to create winning CX without it. But customer data itself is both- a challenge and an opportunity.Download
We recently partnered with MailCharts to analyze 10,296 emails sent by the top 1,000 internet retail brands for Black Friday and Cyber Monday 2017 to better understand the tactics they used to get consumers shopping. The findings below fueled our tips for getting your marketing plan holiday-ready in time for the rush.
Also Read: 5 Marketing Processes that must be Automated This Year!
While the majority of Black Friday emails were sent ahead of the shopping holiday (as early as 30 days in advance), the bulk of Cyber Monday emails were sent on Cyber Monday itself. Surprisingly, 20 percent of retailers sent a post-Black Friday email, while 26 percent sent a post-Cyber Monday email up to a week after the holiday, usually to announce the extension of sale prices. To ensure your timing is on point when it's time to hit send on holiday marketing emails, you should begin preparations now. In the weeks leading up to Halloween, you should aim to finalize your holiday targeting strategy by re-engaging any lapsed or inactive subscribers that you haven't engaged with recently. Additionally, marketers should find meaningful ways to stay connected with their subscribers year-round to reduce long-term, non-engaged segments of the email list.
In 2017, "percentage off a purchase" was the incentive retailers used most often to entice shoppers, followed by "dollars off" a purchase. However, what works for some won't work for all. Allow for flexibility in your marketing campaign plan to let the metrics speak for themselves. If your unsubscribe rates or spam placement rates spike, adjust your strategy accordingly. The holidays are not the time for win-back or re-engagement campaigns. When it's time for holiday deployment, focus only on your subscriber base who have been actively engaged with your brand to avoid risk and unwanted delivery issues.
An overwhelming majority of consumers prefer email to other marketing channels, but that doesn't mean you can't leverage other channels to get back into the inbox. If you haven't "heard" from someone via email in 10 months, consider sending a push notification to their phone to make sure the email address on file is correct. This is an organic way to clean up your email lists and naturally re-introduce subscribers to your emails. On the flipside, however, don't force a non-email person into your subscriber list. Use non-engagement as a sign that those consumers are not email people and reach them another way. Engage with your audience and subscribers on the channel on which they are most comfortable.
Email volume naturally increases during the holidays. However, doubling your email volume in a single day will have your carefully crafted emails deferred queued, or potentially blocked. The holidays are not the time play games with brand reputation. Gradually build up the volume in advance of peak sending days to help establish volume expectations with mailbox providers and avoid volume spikes. Respond to engagement rates, click rates, and unsubscribe rates throughout your holiday campaign. If "unsubscribes" go through the roof, dial it back. Don't keep pushing if your metrics are advising you to do otherwise. Watch the results and be ready to make changes accordingly.
Also Read: Making Email Marketing Work
The holidays are a busy time for everyone, your customers included. By giving yourself time to solidify marketing strategy, engaging with your audience on their preferred platforms and adjusting volume gradually, your holiday marketing program will be a success!
Sign up for our weekly digest and be martech-wise!


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Stress can be a real pain. Stress is something that is inescapable and something that everyone must deal with every day of our lives. In the midst of everything that pushes our buttons, there are that many more products and theories that all claim to be stress relievers, most of which don't work all too well. Yet the most underestimated and misunderstood way to relieve stress comes in the form of doing what many people do today, playing their favorite video games.
Most stress that people experience every day comes from work, family, and friends that we interact with every day of our lives. This can take a steep mental and physical toll on us depending on the amount of stress we go through each day. In most extreme cases, an overabundance of any kind of stress can lead to dire medical issues and even death. To help relieve this, people look for distractions to help with combating the dangers of stress. In modern times, video games have become a great distraction for some who just want to get away from reality for a moment and recuperate while being entertained.
Most games that are great stress relievers are titles that draw in players with their simplistic mechanics and straight forward objectives. Life itself is already complicated as it is and taking on a task that is just as complicated, if not more so, can do more harm than good. Games like Professor Layton and Brain Age are titles that can allow anyone to play a game and relax at the same time. While such games can still provide a level of challenge and give anyone's brain a good workout, their mechanics and overall task are not complex enough to dramatically increase someone's stress level. Instead the different puzzles and problems from those games can have players focus solely on one task repetitively and shut out everything else. For some this can be relaxing as the need to multitask becomes unimportant for a brief time, making things much more simple and straightforward.
Outside of the kinds of games that help ease stress, the method in which games are played can also be a major contributing factor. In some studies conducted about the relation of gaming and stress, including some from Colorado State University, the time and place where people play their video games can be significant component to reducing stress. Having a portable gaming system on the go can be a great help to anyone, especially those who travel a lot or work most of the day. Playing games on a Nintendo 3DS or PlayStation Vita during lunch time or a break can provide a great quick distraction. However, this isn't solely limited to portable devices, as gaming at home can still be just as effective through traditional means. Games that are played on a joystick or controller on a home console can also be relaxing just as much as a handheld game device. One exception though is games played using motion controls, where more physical activity is required to participate. When playing on a controller, the rest of the body outside of one's hands and eyes is in a state of rest, allowing for one's body to relax while playing.
Stress is what every person must deal with when going about their daily routine. Stress from anything can be dealt with in a variety of different ways, with some ways being more effective than others. Through playing various video games, anyone can relax while being entertained by unique stories and fun gameplay. Regardless of the way we play or what kinds of games we may play, gaming is the modern day form of entertainment that briefly distracts us from our harsh reality that always stresses us out. While misunderstood by some who believe they cause more harm than good, video games are a really great alternative to help moderate and relieve the stress we face in our lives.


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You can order the Mammoth frame set without parts, or choose one of the complete bikes. If you are looking for the frame and some of the parts needed to build up the complete bike, please email us and we can send you a custom quote for a partial build.
Mammoth Frameset
Product Description
- Fox Float CTD
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- High Direct mount for front derailleur
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kingdom hearts
October 17, 2009
In the midst of everything I mentioned that Aiden had outgrown his carseat and that on top of everything else we were going to have to try and save up for yet another thing! Needless to say a very dear friend to Chris and I delivered to our studio this week enough cash in hand specifically so that we could go that day and buy his new carseat. You would think, oh how generous that a couple would do that? Well, this couple has trouble paying for their own bills. They share the common hardships of people who start and run their own businesses. So coming from them, it meant that much more. How easy is it for me to say..."oh well when we have a lot of money I can give freely?" Isnt that the point of the story of the widow's mite? Give even when you have nothing. Chris is huge on principles. A conversation between he and I this week spurred me to pull out my favorite book and reread a few incredible chapters that i would love to share on this topic.
"When your life is becoming beautiful to God, He says that good deeds of giving will begin to naturally flow from your character. In fact, the person who is being transformed into His likeness gives so readily and easily that she hardly reflects on what she is doing. They barely notice their own good deeds and they rarely remember them. This needs to become a part of who we are. You can belong to Jesus, be saved and set apart for all eternity, but still not have a kingdom heart. You can know and believe what the bible says, but never make the transition into actually living these truths. Relearning to stockpile in heaven will be huge for most of us. It will probably require a radical change in our thinking. When someone has a kingdom heart, he/she has an active understanding of what matters most to the heart of God. He/She lives in the balance of passion and contentment...he/she learns to love well, give without regard to self and forgive without hesitation.Understanding the value of a stockpile in heaven will shape your perspective and your actions on earth. There is a place called "good enough" and the people who store treasure in heaven know all about good enough. Their hands are open to his prompting to give things away. They stay in good enough hotels so that there is more to give. You begin to treasure the same things that God does."
The same couple that bought Aiden's carseat was struggling really bad not too long ago and I did nothing. How convicting. I feel ashamed. Why does God have to at times pry each finger open for me to give freely....I should have open hands.
My book gives an example of a household that lives rich.
"They stay up late praying with anyone who knocks on their door. They welcome everyone and judge NO ONE. Little things are big to them. Freshly bakes bread is a treat to celebrate. They give away their cars, food and money. The entire family lives with a great awareness of God and a deep appreciation for His goodness."
I want to be rich like them.
Please let me learn this lesson now on this earth. I want my stockpile in the next life. Not this one.
3 comments:
Thank you so much for sharing this post- i find myself often waiting for the next season of life to live a Kingdom Life....like, once Adam is out of school or once we live in another place or once blah blah blah. This post was so convicting and inspiring.ReplyDelete
Casey..I found your blog through Camille's. It's fun to read up on you're cute family. I just love the words from the book you quoted. What book is it? You're words and the words from the book are so convicting and I too feel like God has to pry my hands away from the things/money I feel entitled to.ReplyDelete
Casey..I found your blog through Camille's. It's fun to read up on you're cute family. I just love the words from the book you quoted. What book is it? You're words and the words from the book are so convicting and I too feel like God has to pry my hands away from the things/money I feel entitled to.ReplyDelete


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Shaquille O'Neal Asks Tech Startups to "Pitch Shaq" via Tout at SXSW Interactive 2013
Shaquille O'Neal Asks Tech Startups to "Pitch Shaq" via Tout at SXSW Interactive 2013
SXSWi 2013 Featured Speaker Shaquille O'Neal Tells All Attending Startups to Send a 15-Second "Elevator Pitch" Video Via Tout for a Chance to Have Him Invest
SAN FRANCISCO--(BUSINESS WIRE)-- SXSW Interactive 2013 Featured Speaker Shaquille O'Neal is asking tech startups attending next week's conference to "Pitch Shaq!" by downloading the free Tout mobile app (www.tout.com) and sending him a 15-second "elevator pitch" video for a chance to pitch him 1-on-1 on investing. Shaq will review all submitted Touts and select one company to pitch him in person during the conference.
NBA champ and SXSW Interactive 2013 Featured Speaker Shaquille O'Neal tells tech startups to "Pitch Shaq!" via Tout. (Photo: Business Wire)
In addition to his historic accomplishments on the court Shaq has also become a social media innovator as the first verified celebrity account on Twitter, the second-most followed athlete online in the U.S. and a catalyst in Tout's rise to success when he announced his retirement from basketball via Tout in 2011, just two months after it launched.
"SXSW Interactive is the most cutting-edge event in tech and I'm looking for something that will be bigger than Facebook, bigger than Twitter," says Shaq. "Help me help you!"
Startups attending SXSWi 2013 can "Pitch Shaq!" by downloading the free Tout mobile app for iOS or Android, using their smartphone to shoot a 15-second Tout video pitch to Shaq, and tagging their Tout #pitchshaq while sharing to Tout.com, Twitter and Facebook.
Pitches will be viewable on Tout monitors positioned in hotel lobbies throughout SXSWi, on Tout mobile, and at Tout.com. Shaq will announce the winning company from the stage during his Q&A on Monday, March 11.
About Tout
Tout is a real-time information network of up-to-the-minute video updates across news, sports, politics, entertainment, or whatever moves you. Capture and share 15-second video updates to Tout.com, Tout mobile, Facebook, Twitter, Pinterest, or your own website.
Photos/Multimedia Gallery Available:http://www.businesswire.com/multimedia/home/20130307006404/en/
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KEYWORDS: United States North America California
The article Shaquille O'Neal Asks Tech Startups to "Pitch Shaq" via Tout at SXSW Interactive 2013 originally appeared on Fool.com.Try any of our Foolish newsletter services free for 30 days. We Fools may not all hold the same opinions, but we all believe that considering a diverse range of insights makes us better investors. The Motley Fool has a disclosure policy.
Copyright © 1995 - 2013 The Motley Fool, LLC. All rights reserved. The Motley Fool has a disclosure policy.


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Ngorongoro Crater Lodge
"Expect the unexpected at this dramatic spot where Versailles meets Maasai. Don't let the eclectic architecture fool you into thinking this place isn't serious about its standards — it is the place to stay at the Crater and you won't regret the splurge."
- Trusted Friend: Martina Matthews, Menlo Park, CA
(Date Experienced: September 2009)
Great for
Seeing wildlife at any time of year. An estimated 25,000 mammals are residents of the crater.
With whom
Your spouse, kids, mom, dad... anyone who has always wanted to see Africa
Memorable moment
Arriving back to my room after a dusty safari in the crater to find my oversized bathtub filled with warm water and rose petals. Divine!
Best time to go
July, August, January, February
Be aware
The Crater floor is packed with vehicles and cameras. You won't feel like this is your private safari.
Price per night
From $685 per person, per night (all-inclusive) in low season


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The future is looking bright for gamers, thanks to Vulkan.
DirectX 12 to be unveiled at GDC 2014
Microsoft prepares to unveil its next-generation graphics API at GDC in March
Source Engine 2 in the works with OpenGL support
Valve's Source Engine 2 will support OpenGL, a boon for the push into a world of Linux gaming
AMD Mantle API poised to revolutionise PC gaming
AMD's Mantle API claimed to be much more efficient than DirectX, and can run on Nvidia and Intel graphics hardware as well
Is AMD's Mantle a game-changer?
AMD's new Mantle API could change the industry forever.
AMD shows next-gen PC GPU, audio advances
AMD will be working on improving graphics in games, audio and UltraHD 4K displays.
CryEngine coming to Linux
Crytek looking to port CryEngine to Linux
PS4 OS runs on FreeBSD with GRUB bootloader: leak
It's like Linux, but not Linux.


text:
|More by Ingenhoven Architekten
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Ingenhoven Architekten
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|contributed by
The slogan "Lebens(t)räume am Strom", meaning living dreams and spaces near the river, constitutes the basic theme for this residential project that imetas Hamburg, Büro Ingenhoven und Partner Architekten and Primus Immobilien AG developed. The oval residential tower by the future Tall Ship Harbour is an eye catcher; the building's succinct shape forms an important contrast to the adjacent buildings. Apartments that are flooded with light and which can be designed individually are located on eleven floors offering impressive views over HafenCity, Speicherstadt, the River Elbe and downtown Hamburg. The units range from 58 m2 to 300 m². 'Kontor am Kaiserkai', an office building with six floors featuring a leasing space of approximately 3,875 m², will be created next to the residential tower (text from HafenCity Hamburg).
MotorIntake Air Temperature Sensor
Camshaft position sensor
free bowling games to download
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The Hornshoppe Forum
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Topic: Shiit Audio Mani, Phono Pre Amp (Read 4418 times)
Ed Schilling
Hero Member
Posts: 1368
Shiit Audio Mani, Phono Pre Amp
December 10, 2017, 12:10:53 PM »
Well, as many of you know I have the Transcendent Sound Phono Stage. It has PLENTY of gain for The Truth and sounds excellent. I reckon the only drawback for some is that it is pricey. How great would it be to have something that nipped at it's heels for 150 bucks? I know, I know, we've all tried inexpensive stuff like the battery powered Rat Shack and maybe even a NAD with an OPA 2604 chip upgrade.
Well, I can say that IMO the Shiit Mani nips at the heels of the TS and does in fact cost 150 bucks. It has adjustable gain and should run any cart except the very lowest output types to more than enough gain for The Truth. I have mine set at the mid point about 40 db I think.
For those of you who want a killer vinyl setup for "a song", The Orbit table and a Mani will slay a LOT of "high end" setups. Is it perfect? Nope, not even close. Is it immensely satisfying? Damn right...the combo just "sounds right". Bruce at Transcendent Sound has the Orbit ( my suggestion) and he did a couple things to it and he agrees with me....it sounds too good to be that cheap. Coupled with the Mani one can have a very nice vinyl rig for peanuts.
Hero Member
Posts: 920
Re: Shiit Audio Mani, Phono Pre Amp
Reply #1 on:
December 10, 2017, 05:35:09 PM »
I have a Schiit Mani as well and Ed's right. The small box is excellent... it makes no sense.
It's quiet, dynamic and makes great bass.
With loading and gain options via little switches on the case bottom, you can match it with about any phono cartridge. I'm keeping the TS phono stage and an old Cornet that has fancy parts since I have three turntables.
You'd have to spend lots of money to beat the little Schiit. And it's fun to say "Schitt".
Steve F
Sr. Member
Posts: 432
Re: Shiit Audio Mani, Phono Pre Amp
Reply #2 on:
December 19, 2017, 07:04:11 AM »
Ed & Henry, I just listened to a custom Orbit turntable in which the owner changed out the plinth for a "concrete resin" base. He also used a cheap ART phono stage. I've got to say I was impressed. Ortofon blue cartridge.
I don't know if the tone arm was damped, or any other changes were made. I also suspect that the Orbit's bearing isn't going to beat out fancy stuff like VPI. But damn, it was good.
Steve F
Sr. Member
Posts: 432
Re: Shiit Audio Mani, Phono Pre Amp
Reply #3 on:
May 28, 2018, 04:45:46 PM »
Anyone else hear another phono pre that's "Truth" approved. I'm told Vista Audio makes a good one. Some people like one by Lounge audio, but a reviewer said Lounge sucked on YouTube. Recommendations?
Hero Member
Posts: 920
Re: Shiit Audio Mani, Phono Pre Amp
Reply #4 on:
May 29, 2018, 09:39:42 PM »
I'd like to try a Hagerman Audio Labs Cornet 3. It's a departure from the older Cornets as it's powered from a 9v wall wort that feeds a voltage booster. It still uses three tubes like the oldies, but has a smaller form. The reviews are good. And, it's assembled for $459 with free shipping.
Steve F
Sr. Member
Posts: 432
Re: Shiit Audio Mani, Phono Pre Amp
Reply #5 on:
June 18, 2018, 02:24:14 PM »
Ed & Henry,
The Mani I ordered arrived today. My system will be Schiit-y too. Since it comes so highly recommended by you guys.
Steve F
Sr. Member
Posts: 432
Re: Shiit Audio Mani, Phono Pre Amp
Reply #6 on:
June 18, 2018, 03:58:20 PM »
Henry is right. It's fun to say Schiit. I just plugged it into my system. I'm surprised at just how good that little silver box performs. Now with no break in time, just put on a record and play, it's better than several other preamps on hand. The only one better is Bruce's phono, and that's about five times the price.
I'm not a big believer in break in, or warm up time. Most equipment settles down in seconds or a few minutes at most. Anyway, anyone who feels like being frugal can't go wrong here. The unit has enough drive for Ed's Truth, and it's a damn good combo. So Ed & Henry are right on the money with this one, as usual. The Mani is very smooth throughout its range. Bass is excellent. It does lack a tiny bit of detail and space compared to the Transcendent Sound pre, but if you didn't have one to compare it to, you'd never complain. So it's really great Schiit.
Hero Member
Posts: 920
Re: Shiit Audio Mani, Phono Pre Amp
Reply #7 on:
June 19, 2018, 08:05:45 AM »
Yep Steve, it's a fine phono preamp as Ed discovered. Ironically, the similar looking Modi Uber DAC isn't that great. Shiit is known to excel in digital but flopped on the Modi IMO. Others agree. It isn't bad, just not "all that". I bought both and gave away the Modi. Go figure. Maybe climbing the DAC ladder at Shiit will be the chit.
When I get a little change, I'll give the Cornet 3 a chance. Without the transformer noise and some changes, this could be a good one.
Sr. Member
Posts: 416
Re: Shiit Audio Mani, Phono Pre Amp
Reply #8 on:
June 19, 2018, 08:39:08 AM »
Quote from: Henry on June 19, 2018, 08:05:45 AM
Maybe climbing the DAC ladder at Shiit will be the chit.
As far as DAC technology goes, the top of the ladder has been reached about 20 years ago. There is no point reaching higher into inaudible region of sound reproduction performance.
Steve F
Sr. Member
Posts: 432
Re: Shiit Audio Mani, Phono Pre Amp
Reply #9 on:
June 19, 2018, 12:10:41 PM »
Henry, Modern DAC units are all over the map. I find some cheaper ones that are excellent, and fancy ones that are lacking. If my television had a pair of RCA outputs, I wouldn't even need an external DAC.
When I had a scope, I took a gander at a couple of different units. By and large the damn things work fine. (I haven't checked any multibit DACs that Mike Moffat over at Schiit seems to prefer) I spent about 30 bucks on a cheap unit from Parts Express that does a good job. I also borrowed an expensive Benchmark Media unit that also looked good, switched a whole bunch of components, and included a world class preamp. Built like a tank by pros who designed it for studio abuse. And a $400 unit that did fine in conversion, but after that, was lacking vs any good preamp. I'm saying in a long winded way, that chances are a very basic DAC is all you probably need.
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WBAF take invest summit 2018
For the first time ever, the World Business Angels Investment Forum opens its doors to Start-ups, Scale-ups and High-growth businesses.
50 start-up or scale-up or high-growth businesses will each have a 4-square-metre area to showcase their business. They will thus have exposure to highly qualified angel investors, family office executives, co-investment fund managers, angel investment group directors, corporate venture executives, accelerator executives, techno park investment directors and venture capitalists.
The mission is to showcase the world's top start-ups and scale-ups, which, typically, are funded companies in the process of raising €500K – €3M, with the aim of globalizing.
The WBAF Take Invest Summit 2018 will essentially be a co-investment platform for angel investors, start-ups, scale-ups and high-growth businesses.
Aside from presentations by renowned thought leaders in the field of entrepreneurship and global angel investors, the event will feature keynote speeches, fireside chats, presentations and panel discussions. Each one will offer important insights into the start-up ecosystem. The summit will be also an open learning space for entrepreneurs to increase their understanding of the investment strategies of angel investors, fund-raising strategies of successful entrepreneurs, term-sheet negotiation techniques, company valuations, due-diligence check-lists of global investors, and ways to access co-investment funds.


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As much as I love city life, Manhattan gets seriously stuffy in the summer months. So over the weekend, I decided to skip the city and head straight for Coney Island with a few friends.
My first pit stop was Nathan's for the world's best (according to them!) hotdog and crinkle cut fries. And while I can't say if they are the best in the world, it was certainly the best hotdog and fries combo I've had! Hunger satisfied, it was on to the attractions.
Dress: H&M | Watch: JORD | Glasses: Wildfox | Necklace: Top Shop
I'm not the biggest fan of rollercoasters and the like, so I opted to just do the ferris wheel like the scaredy cat I am. But that was lovely, and gave me a chance to get a great view of our surroundings. Add in a fried Oreo or two and I'd say that's a day well spent at the seaside.
Coney Island isn't a must-visit place if you're popping to the city for a holiday, as it is very crowded and there are far better beaches and theme parks to visit. But if you're in NYC a little more long term and are looking for something different to do, it's worth giving it a try. I'd recommend going in the summer season (of course) and on a Friday when there are fireworks! Oh, and there's karaoke on the boardwalk too, randomly enough!
You can also catch up with me over on YouTube. Here's my most recent vlog, featuring my trip to Coney Island...
That's the latest with me. Happy 4th of July y'all. See you in the next post!


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SPF (Sender Policy Framework) is an open standard specifying a technical method to prevent sender address forgery. The domain in the HELO command is matched against a list of allowed mail relays for that domain. This states, for example, that mail from email@example.com should have come via mail.example.com and not mail.badguys.info.
In a normal mail client, the HELO command uses the internet name of the computer sending the mail, so that someone might use their computer 1-2-3-dyn.bigisp.com to send mail through bigisp.com's mail relay, which has an SPF record indicating that that's allowed.
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The domain owner wants to discourage the use of this host and thus desires limited feedback when a "SoftFail" result occurs. For example, the recipient's Mail User Agent (MUA) could highlight the "SoftFail" status, or the receiving MTA could give the sender a message using a technique called "greylisting" whereby the MTA can issue an SMTP reply code of 451 (4.3.0 DSN code) with a note the first time the message is received, but accept it the second time.
From RFC 4408
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Lewis Merthyr Winding Gear - linocut print
A hand carved, hand printed linocut of the winding gear at the Lewis Merthyr Colliery in South Wales, now the Rhondda Heritage Centre.
Printed on beautiful 100% cotton rag using red, maroon and black linseed ink.
Each of these prints is hand made and there'll be some minor variation.
55 x 42 cm (sheet size) / 40 x 30cm (actual image size)
Edition size:
Limited edition of 10
This artwork is sold unframed
This artwork will be shipped in a sturdy postal tube.


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Creche, Sunday Club & ROC
During our 11am service, we have childcare for babies and toddlers (up to age 3), and teaching for all ages up to teenagers. If you are a visitor, we aim to make your children feel very much at home and welcomed into their groups.
Children usually start the service either with their parents or teachers, then leave for their activities after a children's talk. Some seasonal services are planned to include all-age teaching in the church.
Our goal is that our children will be grounded and confident in the gospel; that Jesus died for them too so that they can have peace with God.
We want our children to grow in this faith and grace from an early age so that they are established in it throughout their adult lives.


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Hampton Galleries
7 Times Square, 39th Floor
New York, New York 10036-6569
About Us
Sales Policy
FABULOUS BRIGHT CUT TEA URN, Gale & Willis, NYC-c 1859
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Beautiful bright cut tea urn, Gale & Willis, New York City (c. 1859), 16" tall to top of finial, 13-1/4" tall to top of handle, 10-1/2" long across handles, 4-7/16" diameter of circular base, 4-1/8" long spout, urn-shaped body on round pedestal foot with beading around edge, pierced circles and diamonds on neck of pedestal, circular base sits on four cast 2 5/8" acanthus leaf-shaped legs with round shell-shaped feet, large cast handles on each side of body, removable spirit lamp with full unused wick, removable circular domed cover with beading around edge and large acorn finial on top, fabulous bright cut engraving over entire body and cover, oval bright cut leaf cartouche on front and back with Old English monogram "HFT" in front cartouche, marked underneath "GALE & WILLIS" "447 BROOME STREET" "NEW YORK" "925 STERLING" with an 1859 date stamp, all incuse.
Collectibles and Antiques ~ Est. 1996 ©
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