title: The Effectiveness of Gastric Bypass Over Gastric Partition in Morbid Obesity: Consequence of Distal Gastric and Duodenal Exclusion Clinical trial of jejunoileal and gastric bypass for the treatment of morbid obesity: four-year progress report. Laparoscopic Adjustable Gastric Banding versus Open Vertical Banded Gastroplasty: A Prospective Randomized Trial Superior Gastric Reduction Procedure for Morbid Obesity; A Prospective, Randomized Trial Weight Loss, Appetite Suppression, and Changes in Fasting and Postprandial Ghrelin and Peptide-YY Levels After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy: A Prospective, Double Blind Study Treatment of Mild to Moderate Obesity with Laparoscopic Adjustable Gastric Banding or an Intensive Medical Program A randomized prospective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets eaters. Horizontal or vertical banded gastroplasty after pretreatment with very-low-calorie formula diet: a randomized trial. Effects of bariatric surgery on mortality in Swedish obese subjects. A Prospective Comparison of Gastric and Jejunoileal Bypass Procedures for Morbid Obesity Prospective randomised comparison of adjustable gastric banding and vertical banded gastroplasty for morbid obesity. Gastric Surgery for Morbid Obesity: The Adelaide Study Annual deaths attributable to obesity in the United States. The Quality of Drug Studies Published in Symposium Proceedings Randomized clinical trial of laparoscopic Roux‐en‐Y gastric bypass versus laparoscopic vertical banded gastroplasty for obesity Laparoscopic Adjustable Silicone Gastric Banding Versus Vertical Banded Gastroplasty in Morbidly Obese Patients: A Prospective Randomized Controlled Clinical Trial Laparoscopic Roux-en-Y Versus Mini-Gastric Bypass for the Treatment of Morbid Obesity: A Prospective Randomized Controlled Clinical Trial Subtotal gastric exclusion and gastric partitioning: a randomized prospective comparison of one hundred patients. A Prospective Randomized Trial of Laparoscopic Gastric Bypass Versus Laparoscopic Adjustable Gastric Banding for the Treatment of Morbid Obesity: Outcomes, Quality of Life, and Costs Increases in morbid obesity in the USA: 2000-2005. Sex hormone-binding globulin levels and cardiovascular risk factors in morbidly obese subjects before and after weight reduction induced by diet or malabsorptive surgery. Laparoscopic Vertical Banded Gastroplasty and Laparoscopic Gastric Bypass: a Comparison Sleeve Gastrectomy and Gastric Banding: Effects on Plasma Ghrelin Levels A pilot study of long-term effects of a novel obesity treatment: omentectomy in connection with adjustable gastric banding Vertical banded gastroplasty or gastric banding for morbid obesity: effects on gastro-oesophageal reflux. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. Results of the surgical treatment of obesity. Indirect comparisons of competing interventions. Quality of reporting in randomized trials published in high-quality surgical journals. Randomized trial of diet and gastroplasty compared with diet alone in morbid obesity. A prospective study comparing vertical banded gastroplasty versus laparoscopic adjustable gastric banding in the treatment of morbid and super-obesity. A prospective randomized comparison of gastric bypass and gastroplasty. Complications and early results. Gastric Bypass and Vertical Banded Gastroplasty- a Prospective Randomized Comparison and 5-Year Follow-up Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial.
abstract: Eighty-seven morbidly obese patients were prospect ively r and omized to two operations : gastric bypass was performed on 42 and gastric partition on 45 . Gastric bypass proved to be more effective ; gastric bypass patients lost 15 % more of their original weight at 12 months and 21 % more at 18 months . There were no failures in the gastric bypass group ; 28 of the 45 operations failed in the gastric partition group . An additional 60 patients underwent gastric bypass since the completion of the study . In the total series of 147 patients who underwent gastric bypass or gastric partition  , there was no mortality , and the surgical complication rate was 12 % . Because the gastric pouches and the anastomoses were similar in the two operations , the superiority of the gastric bypass may well be due to a heretofore unexplained effect of distal gastric and duodenal exclusion The present status of 38 patients comprising a clinical trial of jejunoileal and gastric bypass for the treatment of morbid obesity , begun four years ago at North Carolina Memorial Hospital , is reported . Weight loss was greater in patients treated by jejunoileal bypass  than those treated by gastric bypass .  The poorer weight loss noted in the  gastric bypass patients is associated with an excessively large proximal gastric pouch , which had characterized the 19  gastric bypass operations done prior to May 1977 . The weight loss achieved with the current version of the gastric bypass , a smaller proximal gastric pouch , is comparable to that achieved with jejunoileal bypass . The objective and subjective sequelae and complications of jejunoileal bypass are more common and more serious than those of gastric bypass . Gastric bypass is the better operation for the treatment of morbid obesity Background : Laparoscopic adjustable gastric b and ing ( LAGB ) and open vertical b and ed gastroplasty ( VBG ) are treatment modalities for morbid obesity . However , few prospect i ve r and omized clinical trials ( RCT ) have been performed to compare both operations . Methods : 100 patients ( 50 per group ) were included in the study . Postoperative outcomes included hospital length of stay ( LOS ) , complications , percent excess weight loss ( % EWL ) , BMI and reduction in total comorbidities . Follow-up in all patients was 2 years . Results : LOS was significantly shorter in the LAGB group . 3 LAGB were converted to open ( 1 to gastric bypass ) . Directly after VBG , 3 patients needed relaparotomies due to leakage , of which one ( 2 % ) died . After 2 years , 100 % follow-up was achieved . BMI and % EWL were significantly decreased in both groups but significantly more in the VBG group compared to the LAGB group ( 31.0 kg/m2 and 70.1 % vs 34.6 and 54.9 % respectively ) . Co-morbidities significantly decreased in both groups in time . 2 years after LAGB , 20 patients needed reoperation for pouch dilation/slippage ( n=12 ) , b and leakage ( n=2 ) , b and erosion ( n=2 ) and access-port problems ( n=4 ) . In the VBG group , 18 patients needed revisional surgery due to staple-line disruption ( n=15 ) , narrow outlet ( n=2 ) or insufficient weight loss ( n=1 ) . Furthermore , 8 VBG patients developed an incisional hernia . Conclusion : This RCT demonstrates that , despite the initial better weight loss in the  VBG group , based on complication rates and clinical outcome , LAGB is preferred . It had a shorter LOS and less postoperative morbidity A prospect i ve r and omized clinical trial was undertaken to compare the effects of  gastric bypass with Roux-en-Y gastro-jejunostomy and a gastric partitioning procedure .  Operative groups were comparable , with regard to preoperative weight , age , sex , historic findings and operative complications . Postoperative weight loss was followed for one year . Patients receiving the gastric partitioning procedure  showed significantly poorer weight loss as early as three months postoperatively than did those receiving gastric bypass .  This poorer performance persisted throughout the study period Background : Bariatric surgery is currently the most effective treatment in morbidly obese patients , leading to durable weight loss . Objective : In this prospect i ve double blind study , we aim to evaluate and compare the effects of  laparoscopic Roux-en-Y gastric bypass ( LRYGBP ) with laparoscopic sleeve gastrectomy ( LSG )  on body weight , appetite , fasting , and postpr and ial ghrelin and peptide-YY ( PYY ) levels . Methods : After r and omization , 16 patients were assigned to LRYGBP and 16 patients to LSG .  Patients were reevaluated on the 1st , 3rd , 6th , and 12th postoperative month . Blood sample s were collected after an overnight fast and in 6 patients in each group after a st and ard 420 kcal mixed meal . Results : Body weight and body mass index ( BMI ) decreased markedly ( P < 0.0001 ) and comparably after either procedure . Excess weight loss was greater after LSG at 6 months ( 55.5 % ± 7.6 % vs. 50.2 % ± 6.5 % , P = 0.04 ) and 12 months ( 69.7 % ± 14.6 % vs. 60.5 % ± 10.7 % , [ P = 0.05 ] ) . After LRYGBP fasting ghrelin levels did not change significantly compared with baseline ( P = 0.19 ) and did not decrease significantly after the test meal . On the other h and , LSG was followed by a marked reduction in fasting ghrelin levels ( P < 0.0001 ) and a significant suppression after the meal . Fasting PYY levels increased after either surgical procedure ( P ≤ 0.001 ) . Appetite decreased in both groups but to a greater extend after LSG . Conclusion : PYY levels increased similarly after either procedure . The markedly reduced ghrelin levels in addition to increased PYY levels after LSG , are associated with greater appetite suppression and excess weight loss compared with LRYGBP Context Observational studies have shown sustained weight loss after surgery for extreme obesity . No r and omized trial of contemporary surgical methods has been performed . Contribution The authors r and omly assigned 80 mildly to moderately obese ( body mass index , 30 to 35 kg/m2 ) adults to laparoscopic placement of an adjustable gastric b and or to an intensive nonsurgical weight loss program . After 2 years , the surgical group had lost 21.6 % of initial weight , and the nonsurgical group had lost 5.5 % of initial weight . Four patients required laparoscopic revision of the gastric b and . Caution s The study was not design ed to detect uncommon adverse events . Implication s Laparoscopic gastric b and ing is effective treatment for mild to moderate obesity . The Editors The development of a safe and effective treatment for obesity is a leading challenge in health care today . Obesity is an increasing health problem across the world with a prevalence of more than 20 % among the adult population in Western countries and more than 30 % in the United States ( 1 , 2 ) . The increasing prevalence is associated with a parallel increase of several obesity-related diseases , in particular , the diseases of the metabolic syndrome ( 3 , 4 ) , which include type 2 diabetes , hypertension , and dyslipidemia , and are linked to nonalcoholic steatohepatitis , obstructive sleep apnea , and the polycystic ovary syndrome . For obese individuals , the options are limited . Behavioral therapies of reduced energy intake , improved eating practice s , and increased exercise and activity , supplemented by pharmacotherapy , generally achieve only modest and often transient effects ( 5 , 6 ) . Observational studies have shown that bariatric surgical therapies involving gastric restriction by various forms of stapling with or without diversion of the gut to generate malabsorption of food are effective in achieving major weight loss and clinical ly significant improvements in health and quality of life ( 7 - 11 ) . Strong direct evidence from r and omized , controlled trials of the relative benefits of nonsurgical and surgical therapies is lacking . We are aware of only a single study , performed in the 1980s , in which 60 morbidly obese patients were r and omly assigned , without informed consent , to diet plus an early form of gastric stapling or to diet alone ( 12 ) . The maximum weight losses did not differ between the groups . However , the weight regain was greater in the diet-only group . The advent of the laparoscopic adjustable gastric b and has provided a new bariatric surgical option , which has proved to be safe , minimally invasive in its application , gentle in its use through its adjustability and easy reversibility , and similarly effective to the other bariatric procedures ( 10 , 13 , 14 ) . Figure 1 shows the LAP-B AND System ( INAMED Health , Santa Barbara , California ) and demonstrates the key feature of adjustability of the area within the b and through which it induces satiety ( 15 ) . Patients require no more than an overnight hospital stay , and the procedure has been shown to be markedly safer than gastric bypass surgery ( 13 ) . Figure 1 . The laparoscopic adjustable gastric b and ( LAP-B AND System , INAMED Health , Santa Barbara , California ) with no added fluid ( top ) and with 2 mL of fluid added ( bottom ) . We hypothesized that surgical therapy would induce more weight loss , health benefit , and improvement in quality of life than nonsurgical therapy and have conducted a r and omized , controlled trial comparing the effectiveness of current nonsurgical therapy with laparoscopic adjustable gastric b and ing in a group of mildly to moderately obese adults ( body mass index , 30 kg/m2 to 35 kg/m2 ) . We did not study patients with a body mass index greater than 35 kg/m2 because current observational data suggest that outcomes after nonsurgical treatment were unlikely to be equal to those after surgical care for these patients . The principal outcome measures were weight change , health , quality of life , and complications of therapy . Methods Patient Recruitment We recruited patients for the study through a newspaper advertisement . All patient assessment s and outpatient treatments were conducted at a community clinic dedicated to obesity management or in the clinics of a university department of surgery . Surgical procedures were conducted at a private community hospital experienced in the care of bariatric surgical patients . Patients in both groups did not pay any medical costs generated by the study . The human ethics committees of The Alfred Hospital and The Avenue Hospital approved the study in accordance with the guidelines of the National Health and Medical Research Council ( www.nhmrc.gov.au/publications/synopses/e35syn.htm ) and with the Helsinki Declaration of 1975 , as revised in 2000 ( www.wma.net/e/ethicsunit/pdf/draft_historical_contemporary_perspectives.pdf ) . Inclusion Criteria We considered patients to be eligible if they were between 20 and 50 years of age ; had a body mass index of 30 kg/m2 to 35 kg/m2 ; had identifiable problems , including an obesity-related comorbid condition ( such as hypertension , dyslipidemia , diabetes , obstructive sleep apnea , or gastroesophageal reflux disease ) , severe physical limitations , or clinical ly significant psychosocial problems associated with their obesity ; had attempted to reduce weight over at least the previous 5 years ; could underst and the options offered and the r and omization process ; and were willing to comply with the requirements of each program . Exclusion Criteria We excluded c and i date s with a history of bariatric surgery or medical problems that contraindicated treatment in either study group , such as impaired mental status , drug or alcohol addiction , or portal hypertension . In addition , we excluded participants if they had undergone an intensive , physician-supervised program that used very-low-calorie diets or pharmacotherapy or if they did not attend the 2 initial patient information visits . Assessment We provided detailed information about the problems of obesity and about the 2 study groups through at least 2 discussion periods and a patient information booklet . Initial assessment included anthropometric measures ; identification of medical , physical , or psychosocial problems ( both weight-related and other ) ; and a discussion of previous weight loss efforts . The assessment included a detailed dietary history by the trial dietitian and a review by a specialist physician to determine the presence and severity of associated medical conditions . Initial investigations included measurements of fasting blood glucose level ; serum insulin level ; and a lipid profile , including HDL cholesterol and LDL cholesterol levels . After initial assessment , we instituted a program of advice on appropriate eating patterns and exercise and followed each patient on a monthly basis for 3 months . During this time , we assessed the patients ' fulfillment of tasks , such as completion of a food diary , and overall adherence to appointments . R and omization Process We r and omly allocated eligible patients to receive a conventional , intensive , nonsurgical program or laparoscopic adjustable gastric b and ing .  A computer-derived r and om allocation sequence , without blocking or stratification , performed the r and omization . This was prepared at the trial office . The trial coordinator enrolled participants and informed them of the trial allocation . After assessment had confirmed a participant 's suitability for r and omization , the coordinator contacted the trial office by telephone for allocation . The study was not blinded . Description of Nonsurgical and Surgical Interventions Common Program We instructed and encouraged all patients to follow appropriate lifestyle behavior of good eating practice s and increased exercise and activity . We also encouraged them to exercise for at least 200 minutes per week . Nonsurgical Program This program centered on the use of behavioral modification , very-low-calorie diet , and pharmacotherapy with education and professional support on appropriate eating and exercise behavior . During the 2-year period , 3 trained physicians developed a program using all the available modalities for each individual on the basis of guidelines prepared and continually review ed by a panel of experienced bariatric physicians . The program began with an intensive 6-month period of very-low-calorie diet ( 500 to 550 kcal/d ) using 1 to 3 packets of Optifast ( Novartis , Fremont , Michigan ) daily for 12 weeks , followed by a transition phase over 4 weeks combining some very-low-calorie meals with 120 mg of orlistat before nonvery-low-calorie diet meals , and then 120 mg of orlistat before all meals until the completion of the intensive phase . This intensive 6-month program was followed by further courses of very-low-calorie diets or orlistat as tolerated , as well as continual behavioral , dietary , and exercise advice to assist the participant in maintaining weight loss over a prolonged period . Sibutramine was not approved for use in Australia during the first 12 months of the study and , therefore , was not incorporated into the medical program . The management program for each individual was design ed to reflect good clinical practice . A physician saw each patient every 2 weeks during the very-low-calorie diet program and every 4 to 6 weeks during the rest of the study . All patients were seen at least every 6 weeks . Surgical Program Two experienced surgeons performed the laparoscopic adjustable gastric b and ( LAP-B AND System ) procedure , by a st and ardized method ( 14 ) , within 1 month of r and omization . The b and was placed along the perigastric pathway in all cases ( 16 ) . The treating surgeon review ed patient progress every 4 to 6 weeks during the study period and made adjustments to the volume of saline within the b and in the office by using st and ard clinical criteria ( 17 ) . Adverse Events All patients in the study were question ed about the occurrence of adverse events at each consultation , and physicians recorded the Vertical b and ed gastroplasty ( VBGP ) was compared with Roux-en-Y gastric bypass ( RYGBP ) in a r and omized prospect i ve trial that included preoperative dietary separation of " sweets eaters " versus " non-sweets eaters . " R and omization was stopped at 9 months after 20 patients had undergone each procedure because a greater weight loss ( p less than 0.05 ) was noted after RYGBP than VBGP . This difference became more significant ( p less than 0.001 ) at each 3-month interval through 3 years , when patients who had VBGPs had lost 37 + /- 20 % of excess weight compared with 64 + /- 19 % for patients who had RYGBPs . The members of the groups were comparable with regard to age , sex , eating habits , morbidity rates before surgery , ideal body weight , and weight before surgery . Although there was no significant difference between the loss of excess weight in " sweets eaters " ( 69 + /- 17 % ) or " non-sweets eaters " ( 67 + /- 17 % ) after RYGBP at 1 year , " sweets eaters " who had VBGPs lost significantly less excess weight ( 36 + /- 13 % ) than did " non-sweets eaters " who had VBGPs ( 57 + /- 18 % ) , p less than 0.02 , or " sweets eaters " who had RYGBPs , p less than 0.0001 . No significant differences were noted for electrolytes , renal or liver function tests , and most vitamins between patients who had VBGPs and RYGBPs ; however , patients who had RYGBPs had lower ( p less than 0.05 ) serum vitamin B12 levels ( 286 + /- 149 pg/dl ) than did patients who had VBGPs ( 461 + /- 226 pg/dl ) at 2 years . By 3 years , the vitamin B12 levels were equal in members of the two groups . Five patients who had RYGBPs required endoscopic stomal dilatation for stomal stenosis and one had a marginal ulcer develop , which responded to cimetidine . RYGBP was clearly superior to VBGP for " sweets eaters , " probably because of the development of dumping syndrome symptoms . However , RYGBP was associated with a larger number of correctable problems . Thus , it is important to evaluate a patient 's eating habits before surgery for morbid obesity ; " non-sweets eaters " probably should be treated with VBGP and " sweets eaters " with RYGBP Horizontal and vertical b and ed gastroplasty ( GP ) were compared as to their effectiveness and side-effects in patients pre-treated for morbid obesity with a very-low-calorie formula diet ( VLCD ) .  The pre-treatment served to select the compliant patients , to minimize the surgical hazard , and to optimize the total weight reduction . Seventy-four consecutive patients ( median age 34 years , median body weight 125.1 kg , and median overweight 93 per cent ) were included according to the criteria for entry . The median weight loss on  VLCD  was 25.7 kg ( range , 5.8 - 92.6 kg ) and the median overweight reduction reached 46 per cent of the initial overweight ( range , 9 - 83 per cent ) . Only few and mild side-effects were observed . Sixty-nine per cent of the patients fulfilled our criterion for surgery by reducing their initial overweight by at least 40 per cent . Of these , 23 and 22 patients were assigned respectively to either vertical b and ed or to horizontal GP . Patients and dietitians were not informed of the assignment . A significant weight loss occurred in both groups . Three months after surgery weight loss after vertical b and ed GP proved to be the larger ( P less than 0.001 ) . The difference became even more pronounced due to an earlier regain among patients treated with the horizontal GP . Thus , at 12 months , the net weight loss after surgery was 9.7 kg ( range , -28.2 - 28.7 kg ) in the vertical b and ed GP group and -1.0 kg ( range , -15.0 - 36.5 kg ) in patients treated with horizontal GP ( P less than 0.0005 ) . At this time , the total weight loss in the groups was 48.5 kg ( range , 6.4 - 104.0 kg ) and 32.6 ( range , 3.7 - 125.1 kg ) respectively ( P less than 0.02 ) , and the total reduction of overweight was greater in the group treated with vertical b and ed GP ( 80 per cent ( range , 10 - 96 ) versus 56 per cent ( range , 8 - 92 ) , P less than 0.005 ) . There were no deaths , and side-effects to VLCD as well as to GP were generally mild . It is concluded that vertical b and ed GP is more effective than horizontal GP and that the former operation adds a significant weight loss to that obtained by VLCD . The combined treatments offer a weight reduction comparable to that observed after jejunoileal bypass . However , some regain within 1 year makes it question able if the vertical b and ed GP is sufficient to prevent weight regain BACKGROUND Obesity is associated with increased mortality . Weight loss improves cardiovascular risk factors , but no prospect i ve interventional studies have reported whether weight loss decreases overall mortality . In fact , many observational studies suggest that weight reduction is associated with increased mortality . METHODS The prospect i ve , controlled Swedish Obese Subjects study involved 4047 obese subjects . Of these subjects , 2010 underwent bariatric surgery ( surgery group ) and 2037 received conventional treatment ( matched control group ) .  We report on overall mortality during an average of 10.9 years of follow-up . At the time of the analysis ( November 1 , 2005 ) , vital status was known for all but three subjects ( follow-up rate , 99.9 % ) . RESULTS The average weight change in control subjects was less than + /-2 % during the period of up to 15 years during which weights were recorded . Maximum weight losses in the surgical subgroups were observed after 1 to 2 years : gastric bypass , 32 % ; vertical-b and ed gastroplasty , 25 % ; and b and ing , 20 % . After 10 years , the weight losses from baseline were stabilized at 25 % , 16 % , and 14 % , respectively . There were 129 deaths in the control group and 101 deaths in the surgery group . The unadjusted overall hazard ratio was 0.76 in the surgery group ( P=0.04 ) , as compared with the control group , and the hazard ratio adjusted for sex , age , and risk factors was 0.71 ( P=0.01 ) . The most common causes of death were myocardial infa rct ion ( control group , 25 subjects ; surgery group , 13 subjects ) and cancer ( control group , 47 ; surgery group , 29 ) . CONCLUSIONS Bariatric surgery for severe obesity is associated with long-term weight loss and decreased overall mortality A r and omized prospect i ve evaluation of the gastric and jejunoileal bypass procedures for morbid obesity was performed . The gastric bypass was performed predominantly as a 90 % gastric exclusion with a Roux-en-Y reconstitution . The jejunoileal bypass was an end-to-end anastomosis between 30 cm of jejunum and 25 cm of terminal ileum , the bypassed segment of small bowel being decompressed by an end-to-side ileocolostomy . There were 32 patients in the gastric group and 27 in the jejunoileal group . The two groups were comparable in age , preoperative weight and height . There were no postoperative deaths , but the gastric bypass operation was associated with a slightly higher early complication rate indicating it is a more technically dem and ing procedure . Late sequellae were more prominent in the jejunoileal bypass group and included significant diarrhea in 56 % and need for medication in 74 % . Kidney stones and cholelithiasis also complicated the jejunoileal group and were not seen after gastric bypass . All patients showed fatty metamorphosis on the original liver biopsy . This had worsened in 75 % of the jejunoileal group at one year whereas it had improved or was stable in all of the patients in the gastric group OBJECTIVE To compare the clinical results of adjustable gastric b and ing and vertical b and ed gastroplasty for morbid obesity . DESIGN Prospect i ve r and omised trial . SETTING University hospital , Sweden . PATIENTS 59 morbidly obese patients , listed for obesity surgery . INTERVENTIONS Adjustable gastric b and ing ( n = 29 ) or vertical b and ed gastroplasty ( n = 30 ) . MAIN OUTCOME MEASURES Weight loss , complications , need for revisional surgery , reflux symptoms and the patient 's own evaluation . RESULTS Five years after surgery the mean ( SEM ) weight reduction for adjustable gastric b and ing was 43 ( 3.0 ) kg and for vertical b and ed gastroplasty 35 ( 4.8 ) kg . One patient in each group died of unrelated causes during follow-up and 3 and 2 patients , respectively , were lost to follow-up . One patient in the vertical b and ed group required reoperation for an anastomotic leak on the third postoperative day . A total of 3 patients in the adjustable group required reoperation and 11 in the vertical b and ed group . CONCLUSIONS Adjustable gastric b and ing carries a smaller risk of reoperation than vertical b and ed gastroplasty and the weight reduction is in the same order of magnitude The efficacy of three gastric restriction operations were compared in a prospect i ve r and omized study of 310 morbidly obese subjects . The median patient age was 34 years ( range , 18 to 62 years ) . They were predominantly female ( 13:1 ) and had a median pre-operative weight that was 198 % of their ideal weight ( range , 160 % to 318 % ) . There was an equitable dispersion of perceived risk factors between the groups under study and there were no deaths during the perioperative period . Compliance with follow-up at 3 years was 91 % . When success was defined as a loss of more than 50 % of excess weight or a current pregnancy , the success rates at 3 years were 17 % for gastrogastrostomy , 48 % for vertical gastroplasty , and 67 % for Roux-en-Y gastric bypass ( p less than 0.001 ) . Although the gastric bypass operation took longer to perform , there were similar outcome patterns for the three groups during the postoperative period . We conclude that the Roux-en-Y gastric bypass is the preferred procedure for the surgical treatment of morbid obesity CONTEXT Obesity is a major health problem in the United States , but the number of obesity-attributable deaths has not been rigorously estimated . OBJECTIVE To estimate the number of deaths , annually , attributable to obesity among US adults . DESIGN Data from 5 prospect i ve cohort studies ( the Alameda Community Health Study , the Framingham Heart Study , the Tecumseh Community Health Study , the American Cancer Society Cancer Prevention Study I , and the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study ) and 1 published study ( the Nurses ' Health Study ) in conjunction with 1991 national statistics on body mass index distributions , population size , and overall deaths . SUBJECTS Adults , 18 years or older in 1991 , classified by body mass index ( kg/m2 ) as overweight ( 25 - 30 ) , obese ( 30 - 35 ) , and severely obese ( > 35 ) . MAIN OUTCOME MEASURE Relative hazard ratio ( HR ) of death for obese or overweight persons . RESULTS The estimated number of annual deaths attributable to obesity varied with the cohort used to calculate the HRs , but findings were consistent overall . More than 80 % of the estimated obesity-attributable deaths occurred among individuals with a body mass index of more than 30 kg/m2 . When HRs were estimated for all eligible subjects from all 6 studies , the mean estimate of deaths attributable to obesity in the United States was 280184 ( range , 236111 - 341153 ) . Hazard ratios also were calculated from data for nonsmokers or never-smokers only . When these HRs were applied to the entire population ( assuming the HR applied to all individuals ) , the mean estimate for obesity-attributable death was 324 940 ( range , 262541 - 383410 ) . CONCLUSIONS The estimated number of annual deaths attributable to obesity among US adults is approximately 280000 based on HRs from all subjects and 325000 based on HRs from only nonsmokers and never-smokers For physicians , pharmacists , pharmacologists , and others , the medical literature is a key source of information about prescription drugs [ 1 , 2 ] . The medical literature on drugs includes articles from peer- review ed journals , non-peer- review ed ( controlled circulation or throwaway ) journals , and the published proceedings of symposia [ 3 , 4 ] . Symposia are a rapidly growing and potentially major means of disseminating information about drugs . In the clinical journals with the highest circulation rates , the number of symposia published increased from 83 during 1972 - 1977 to 307 during 1984 - 1989 . Approximately half of these symposia were on pharmaceutical topics [ 4 ] . Symposia can be valuable sources of information about drugs , but evidence suggests that they can also be used to market drugs and other interventions , especially if they are industry sponsored . Approximately 70 % of symposia on pharmaceutical topics are sponsored by drug companies [ 3 , 4 ] . Among symposia , sponsorship by a single drug company is associated with promotional characteristics that include a focus on a single drug , misleading titles , use of br and names , and lack of peer review [ 4 ] . Other studies indicate that clinical trials , including those published in symposia , are more likely to favor a new drug therapy if they are funded by the pharmaceutical industry than if they are not [ 5 , 6 ] . Although physicians often report that the peer- review ed literature is one of their main sources of drug information , industry sources of information can sometimes have a stronger influence on prescribing behavior [ 2 ] . Thus , if symposia sponsored by drug companies are a growing source of information about drugs for pharmacists and physicians , assessing the quality of the articles in these symposia is important . We compared the method ologic quality and relevance of drug studies published in symposia sponsored by single drug companies with those of studies that were published in symposia that had other sponsors or in the peer- review ed parent journals . We also assessed whether a methods section was present , because such a section is necessary for evaluating quality . Finally , we tested whether drug industry support of research was associated with study outcome . Methods A symposium is a collection of papers published as a separate issue or as a special section in a regular issue of a medical journal [ 4 ] . We defined original clinical drug articles as articles that 1 ) appeared to present original data from studies done in humans [ that is , articles that had at least one table or figure that was not acknowledged to have been reprinted from another source ] and 2 ) did not specifically state that they were review s [ 4 ] . Selection of Articles We identified original clinical drug articles that had a section describing the study methods , because such a section is needed to assess the quality of an article . Using a computer-generated list of r and om numbers from 1 to 625 , we r and omly selected symposia from 625 symposia that had been identified for a previous study [ 4 ] . We had data on the type of sponsorship of publication for each symposium . From each selected symposium , we r and omly selected one original clinical drug article that had a methods section . We continued selecting symposia until we had enough articles ( n = 127 ) according to the sample size estimates described below . We also calculated the proportion of articles in the selected symposia , overall and by type of sponsorship , that had methods sections . Quality Assessment We compared the quality of original clinical drug articles published in symposia sponsored by single drug companies with that of similar articles published in symposia that had other sponsors and in the peer- review ed parent journals . Sample Size Estimates We estimated the sample size needed to test the association between the independent variable type of sponsorship of publication and the main outcome measure , method ologic quality score . For a three-group comparison , a minimum sample of 108 symposium articles was needed to detect a minimum effect size of 0.10 ( on a scale of 0 to 1 ) , with an value of 0.05 and a value of 0.80 , and st and ard deviation of quality scores of 0.18 based on previous results [ 7 ] . To compare articles from symposia sponsored by single pharmaceutical companies with articles from the peer- review ed parent journals , we estimated that we would need 45 symposia articles and 45 journal articles ; this estimate was the result of sample size calculations done using the variables described above . Because date of publication , journal , and therapeutic class of drug could have confounded the association between source of publication and quality [ 8 - 10 ] , we matched each symposium article to an article from the parent journal by using these characteristics , as described previously [ 7 ] . Our sample of symposium articles contained 50 articles sponsored by single drug companies , but 5 articles published in Transplantation Proceedings were excluded from this analysis because no parent journal is associated with that publication . Instruments We used previously developed instruments to measure the method ologic quality of articles ( defined as the minimization of systematic bias and the consistency of conclusions with results ) and non method ologic indices of quality , such as clinical relevance and generalizability . Both instruments were valid and reliable and have been published elsewhere [ 7 ] . Four review ers independently assessed each article : Two used the method ologic quality instrument , and two used the clinical relevance instrument . We derived  method ologic quality and clinical relevance scores for each article by using a previously described scoring system [ 7 ] . Each score was between 0 ( lowest quality ) and 1 ( highest quality ) and was the average of the scores of the two review ers . Two clinical pharmacologists with extensive research experience in the health sciences did the method ologic quality assessment . For the clinical relevance instrument , three pairs of review ers with clinical experience in general internal medicine and research experience in the health sciences each assessed one third of the articles . Each pair of review ers review ed the articles in the same r and omized order . For both instruments , review ers were trained as described previously [ 7 ] . For the quality assessment s , each review er worked independently , was blinded as to whether an article had been published in a symposium , and was given photocopies of articles from which author names , institution names , journal names , date s , and all other reference information had been obliterated . Review ers were unaware of our hypotheses and the purpose of their review ing , and they were paid for their work . None of the review ers were known to us or knew of our previous work before the study . We assessed the inter-rater reliability of quality scores by using the Kendall coefficient of concordance ( W ) with adjustment for tied ranks [ 11 ] and the intraclass correlation ( R ; treating both review ers and articles as r and om effects [ 12 ] ) . Inter-rater reliability of quality scores was high ( for method ologic quality scores : W equals 0.85 , R equals 0.74 [ 95 % CI , 0.67 to 0.80 ] ; for clinical relevance scores : W equals 0.77 , R equals 0.56 [ CI , 0.44 to 0.65 ] ) . Drug Company Support and Study Outcome For each article , one of us determined whether a drug company had supported the research and whether the article 1 ) reported an outcome favorable to the drug of interest , 2 ) did not report an outcome favorable to the drug of interest , or 3 ) did not test a hypothesis . The drug of interest ( as defined from the perspective of the authors , according to Gotzsche [ 13 ] ) was the newest drug if two or more drugs were studied . We defined research as having had drug company support if the article that reported the research acknowledged either that a drug company had provided funding or drugs or that any of the authors were employed by a drug company . We determined drug company support solely on the basis of information in the paper . If an article did not test a hypothesis , it was excluded from this analysis . We classified the remaining articles as favorable or unfavorable using Gotzsche 's definitions [ 13 ] . An article was favorable if the drug that seemed to be of primary interest to the authors had the same effect as the comparison drug or drugs but with less pronounced side effects , had a better effect without more pronounced side effects , or was preferred more often by patients when the effect and side-effect evaluations were combined . All other articles were considered not favorable . The conclusions of the authors were taken at face value , even if they conflicted with the study results . To test inter-rater reliability , the other author independently assessed a subset of the articles ( n = 90 ) . Agreement in classifying articles as favorable or not favorable was 85 % . Statistical Analyses Because method ologic quality and relevance scores were distributed normally ( Shapiro-Wilk test ) , we analyzed differences between groups ( type of sponsorship of publication ) by using parametric one-way analysis of variance followed by the Tukey test for multiple comparisons or two-way analysis of variance ( total error rate , 0.05 ) . We compared matched groups ( symposium articles and peer- review ed parent journal articles ) by using the paired t-test ( two-tailed equals 0.05 ) . To analyze categorical data on the outcome of studies , we tested for differences in proportions between groups by using the chi-square statistic . For tests of significance , we used an value of 0.05 . All hypothesis tests were two-sided . Results Presence of a Method Section To obtain 127 original clinical drug articles for quality assessment , we had to select 213 symposia containing a total of 5041 articles . The proportions of articles that reported original data but contained no methods sections were 4 % overall ( 195 of 5041 ) , 10 % ( 108 of 1064 ) in the symposia sponsored by single drug companies Laparoscopic techniques have been developed for performing Roux‐en‐$\font\ss = cmss10 scaled 1000 \hbox{Y}$ gastric bypass ( LRYGBP ) and vertical b and ed gastroplasty ( LVBG ) in patients with morbid obesity . It is not certain , however , which is the better technique in non‐superobese patients ( body mass index less than 50 kg/m2 ) Objective : To compare , in a prospect i ve , r and omized , single-institution trial laparoscopic adjustable silicone gastric b and ing ( LASGB ) with laparoscopic vertical b and ed gastroplasty ( LVBG ) in morbidly obese patients . Summary Background Data : LASGB is a simple and safe procedure , but some reports have suggested disappointing long-term results . Despite the recent widespread use of LASGB , there are no prospect i ve nor r and omized trials comparing LASGB with other laparoscopic procedures . Methods : A total of 100 morbidly obese patients , with body mass index ( BMI ) 40 to 50 kg/m2 , without compulsive eating , were r and omized to either LASGB ( n = 49 ) or LVBG ( n = 51 ) . Minimum follow-up was 2 years ( mean 33.1 months ) . Results : There were no deaths or conversions in either group . Mean operative time was 94.2 minutes in LVBGs and 65.4 in LASGBs ( P < 0.05 ) . Early morbidity rate was lower in LASGBs ( 6.1 % ) versus LVBGs ( 9.8 % ) ( P = 0.754 ) . Mean hospital stay was shorter in LASGBs versus LVBGs : 3.7 days versus 6.6 ( P < 0.05 ) . Late complications rate in LVBGs was 14 % ( 7 of 50 ) and in LASGBs 32.7 % ( 16 of 49 ) ( P < 0.05 ) . The most frequent complication was the slippage of the b and ( 18 % ) . Late reoperations rate in LVBGs was 0 % ( 0 of 50 ) versus 24.5 % ( 12 of 49 ) in LASGBs ( P < 0.001 ) . Excess weight loss in LVBGs was , at 2 years , 63.5 % and , at 3 years , 58.9 % ; in LASGBs , excess weight loss , respectively , was 41.4 % and 39 % . BMI in  LVBGs  was , at 2 years , 29.7 kg/m2 and , at 3 years , 30.7 kg/m2 ; in LASGBs , BMI was 34.8 kg/m2 at 2 years and 35.7 kg/m2 at 3 years . According to Reinhold 's classification , a residual excess weight < 50 % was achieved , at 2 years , in 74 % of LVBG and 35 % of LASGB ( P < 0.001 ) . Conclusions : This study demonstrates that , in patients with BMI 40 to 50 kg/m2 , LASGB requires shorter operative time and hospital stay but LVBG is more effective in terms of late complications , reoperations , and weight loss Objectives : This prospect i ve , r and omized trial compared the safety and effectiveness of laparoscopic Roux-en-Y gastric bypass ( LRYGBP ) and laparoscopic mini-gastric bypass ( LMGBP ) in the treatment of morbid obesity . Summary Background Data : LRYGBP has been the gold st and ard for the treatment of morbid obesity . While LMGBP has been reported to be a simple and effective treatment , data from a r and omized trial are lacking . Methods : Eighty patients who met the NIH criteria were recruited and r and omized to receive either LRYGBP ( n = 40 ) or LMGBP ( n = 40 ) . The minimum postoperative follow-up was 2 years ( mean , 31.3 months ) . Perioperative data were assessed . Late complication , excess weight loss , BMI , quality of life , and comorbidities were determined . Changes in quality of life were assessed using the Gastro-Intestinal Quality of Life Index ( GIQLI ) . Results : There was one conversion ( 2.5 % ) in the LRYGBP group . Operation time was shorter in LMGBP group ( 205 versus 148 , P < 0.05 ) . There was no mortality in each group . The operative morbidity rate was higher in the LRYGBP group ( 20 % versus 7.5 % , P < 0.05 ) . The late complications rate was the same in the 2 groups ( 7.5 % ) with no reoperation . The percentage of excess weight loss was 58.7 % and 60.0 % at 1 and 2 years , respectively , in the LPYGBP group , and 64.9 % and 64.4 % in the LMGBP group . The residual excess weight < 50 % at 2 years postoperatively was achieved in 75 % of patients in the LRYGBP group and 95 % in the LMGBP group ( P < 0.05 ) . A significant improvement of obesity-related clinical parameters and complete resolution of metabolic syndrome in both groups were noted . Both gastrointestinal quality of life increased significantly without any significant difference between the groups . Conclusion : Both LRYGBP and LMGBP are effective for morbid obesity with similar results for resolution of metabolic syndrome and improvement of quality of life .  LMGBP is a simpler and safer procedure that has no disadvantage compared with LRYGBP at 2 years of follow-up A r and omized prospect i ve comparison of 50 modified Gomez gastric partitioning to 50 subtotal gastric exclusion ( bypass ) operations  is presented . Smaller pouch sizes than are generally recommended were used , along with accurate calibration of the outlet size by suturing around a 30F bougie in both operations . It is believed that these techniques improved weight loss with minimal increase in side effects , but some increase in the length of hospital stay to ensure adequate fluid intake . Significantly better weight loss and less need for reoperation was found with gastric exclusion , and the complication rates were similar . Either operation requires meticulous attention to detail and follow-up to achieve low mortality and morbidity rates and good weight loss ; but , if these are accomplished , the best end results statistically strongly favor subtotal gastric exclusion Background : Gastric bypass and adjustable gastric b and ing are the 2 most commonly performed bariatric procedures for the treatment of morbid obesity . The aim of this study was to compare the outcomes , quality of life , and costs of laparoscopic gastric bypass versus laparoscopic gastric b and ing . Study Design : Between 2002 and 2007 , 250 patients with a body mass index of 35 to 60 kg/m2 were r and omly assigned to gastric bypass or gastric b and ing . After exclusion , 111 patients underwent gastric bypass and 86 patients underwent gastric b and ing .  Outcome measures included demographic data , operative time , blood loss , length of hospital stay , morbidity , mortality , early and late reoperation rate , weight loss , changes in quality of life , and cost . Treatment failure was defined as losing less than 20 % of excess weight or conversion to another bariatric operation for failure of weight loss . Results : There were no deaths at 90 days in either group . The mean body mass index was higher in the gastric bypass group ( 47.5 vs. 45.5 kg/m2 , respectively , P < 0.01 ) while the mean age was higher in the gastric b and group ( 45 vs. 41 years , respectively , P < 0.01 ) . Compared with gastric b and ing , operative blood loss was higher and the mean operative time and length of stay were longer in the gastric bypass group . The 30-day complication rate was higher after gastric bypass ( 21.6 % vs. 7.0 % for gastric b and ) ; however , there were no life-threatening complications such as leaks or sepsis . The most frequent late complication in the gastric bypass group was stricture ( 14.3 % ) . The 1-year mortality was 0.9 % for the gastric bypass group and 0 % for the gastric b and group . The percent of excess weight loss at 4 years was higher in the gastric bypass group ( 68 ± 19 % vs. 45 ± 28 % , respectively , P < 0.05 ) . Treatment failure occurred in 16.7 % of the patients who underwent gastric b and ing and in 0 % of those who underwent gastric bypass , with male gender being a predictive factor for poor weight loss after gastric b and ing . At 1-year postsurgery , quality of life improved in both groups to that of US norms . The total cost was higher for gastric bypass as compared with gastric b and ing procedure ( $ 12,310 vs. $ 10,766 , respectively , P < 0.01 ) . Conclusions : Laparoscopic gastric bypass and gastric b and ing are both safe and effective approaches for the treatment of morbid obesity . Gastric bypass result ed in better weight loss at medium- and long-term follow-up but was associated with more perioperative and late complications and a higher 30-day readmission rate . There was a wide variation in weight loss after gastric b and ing with a small proportion of patients considered as treatment failure , and male gender was a predictive factor for poor weight loss BACKGROUND It is well known that citizens of developed countries are more likely to be overweight than they were 20 years ago . The most serious health problems are not associated with overweight or moderate obesity , however , but with clinical ly severe or morbid obesity ( e.g. more than 100 pounds ( 45 kg ) overweight ) . There is no reason to expect that morbid obesity trends parallel overweight or moderate obesity . If morbid obesity is a rare pathological condition that has biological causes , the more than 10-fold increase in bariatric surgery procedures over the past eight years in the USA could have even lowered the prevalence of morbid obesity- and may very well stem the problem in other countries . OBJECTIVE To estimate trends for extreme weight categories ( BMI > 40 and > 50 ) for the period between 1986 and 2005 in the USA , and to investigate whether trends have changed since 2000 . METHODS Data from The Behavioral Risk Factor Surveillance System ( a r and om-digit telephone survey of the household population of the USA ) , for the period from 1986 to 2005 , were analysed . The main outcome measure was body mass index ( BMI ) , calculated from self-reported weight and height . RESULTS From 2000 to 2005 , the prevalence of obesity ( self-reported BMI over 30 ) increased by 24 % . However , the prevalence of a ( self-reported ) BMI over 40 ( about 100 pounds ( 45 kg ) overweight ) increased by 50 % and the prevalence of a BMI over 50 increased by 75 % , two and three times faster , respectively . The heaviest BMI groups have been increasing at the fastest rates for 20 years . CONCLUSIONS The prevalence of clinical ly severe obesity is increasing at a much faster rate among adults in the USA than is the prevalence of moderate obesity . This is consistent with the public health idea that the population weight distribution is shifting , which disproportionately increases extreme weight categories . Because comorbidities and result ing service use are much higher among severely obese individuals , the widely published trends for overweight/obesity underestimate the consequences for population health . The aggressive and costly expansion of bariatric surgery in recent years has had no visible effect on containing morbid obesity rates in the USA One of the main goals of weight reduction in morbidly obese subjects is its benefit on coronary heart disease ( CHD ) risk . A cross-sectional study was design ed to r and omly assign 79 morbidly obese subjects ( 27 men and 52 women ; age : 30 - 45 years ) either to a diet protocol ( 20 kcal per kg fat-free mass ( FFM ) ; 55 % carbohydrates , 30 % fat , and 15 % proteins ) or to malabsorptive surgery ( biliopancreatic diversion ) .  Fatness parameters , measured by dual-energy X-ray absorptiometry , lipid profile , insulin , leptin , sex steroid hormones and sex hormone-binding globulin ( SHBG ) levels were compared at baseline and 1 year after the beginning of the study . The data showed that plasma SHBG levels , but not testosterone levels , correlated negatively to fasting insulin levels and positively to HDL-cholesterol in both men and women . Total leptin levels were significantly lower ( P<0.0001 ) in post-BPD subjects of both sexes compared to dietary treated obese subjects . The logarithm of plasma leptin correlated significantly and positively with insulin but negatively with SHBG.A step-down regression analysis showed that FFM and SHBG , but not insulin levels , were the most powerful independent variables for predicting HDL-cholesterol levels in morbidly obese patients . The negative relationship between SHBG levels and CHD risk appears to be mediated by a concomitant variation in body fatness . Finally , in obese patients , SHBG levels seem to be an indicator of total adiposity rather than an index of an altered insulin/glucose homeostasis Background : Vertical b and ed gastroplasty ( VBG ) and gastric bypass ( GBP ) are the two bariatric procedures recommended by NIH consensus conference . Recent advancement in laparoscopic ( L ) techniques has made LVBG and LGBP alternatives for the conventional open approach . Methods : From December 2000 to February 2002 , 80 patients ( 24 men and 56 women ; mean age 32 years , range 18 - 57 ) with morbid obesity ( mean BMI 43.2 kg/m2 , range 36 - 59.8 ) were enrolled in a prospect i ve trial and r and omly assigned to LVBG or LGBP .  Changes in quality of life were assessed using the Gastro-intestinal quality of life index ( GIQLI ) . Results : The conversion rate was zero for LVBG and 2.5 % ( 1/40 ) for LGBP . There has been no mortality . Surgical time was significantly longer for LGBP ( 209 minvs 126 min for LVBG , P<0.001).Mean hospital stay was 3.5 days for the LVBG vs 5.7 days for LGBP ( P<0.001 ) . Postoperative analgesic usage was also less for LVBG patients ( mean dose 1.4 vs 2.4 , P<0.05 ) . Early complication rate was higher in the LGBP group ( 17.8 % vs 2.5 % , P<0.001 ) . All 3 major complications were in the LGBP group , of which 2 were related to anastomotic leakage ( 5 % ) . Late complications consisted of upper GI bleeding , stenosis and others observed in 4 LGBP patients ( 10 % ) and 2 LVBG patients ( 5 % ) . Mean follow-up was 20 months ( range 18 to 30 ) . BMI fell significantly in both groups , with significant improvement of obesity-related co-morbidities . LGBP had significantly better excess weight loss than LVBG ( 62.9 % vs 55.4 % at 1 year and 71.4 % vs 53.1 % at 2 years ) , as well as lower BMI than LVBG ( 29.6 vs 31.1 at 1 year and 28.5 vs 31.9 at 2 years ) . There was no difference in the reduction of obesity-related laboratory abnormalities at 1 year except a lower hemoglobin in LGBP ( 11.8 vs 13.8 , P<0.05 ) . Preoperative GIQLI scores were similar between the groups ; however , at 1 year , LGBP patients had better GIOLI scores than LVBG patients ( 121 vs 106 , P<0.01 ) . LVBG had improvement in physical condition , social function and emotional conditioning but deterioration in GI symptoms which result ed in no increase in total GIQLI score . Conclusion : LGBP was a time-consuming dem and ing technique with a higher early complication rate compared with LVBG . Although both operations result ed in significant weight reduction and decrease in obesity-related co-morbidities , LGBP had a trend of greater weight loss and significantly better GIQLI than LVBG at the cost of a significant long-term trace element deficiency state . Each patient should be individualized for the operations according to the patient 's decision Background : Different changes of plasma ghrelin levels have been reported following gastric b and ing , Roux-en-Y gastric bypass , and biliopancreatic diversion . Methods : This prospect i ve study compares plasma ghrelin levels and weight loss following  laparoscopic sleeve gastrectomy ( LSG ) and laparoscopic adjustable gastric b and ing ( LAGB ) in 20 patients . Results : Patients who underwent LSG ( n=10 ) showed a significant decrease of plasma ghrelin at day 1 compared to preoperative values ( 35.8 ± 12.3 fmol/ml vs 109.6 ± 32.6 fmol/ml , P=0.005 ) . Plasma ghrelin remained low and stable at 1 and 6 months postoperatively . In contrast , no change of plasma ghrelin at day 1 ( 71.8 ± 35.3 fmol/ml vs 73.7 ± 24.8 fmol/ml , P=0.441 ) was found in patients after LAGB ( n=10 )  . Increased plasma ghrelin levels compared with the preoperative levels at 1 ( 101.9 ± 30.3 fmol/ml vs 73.7 ± 24.8 fmol/ml , P=0.028 ) and 6 months ( 104.9 ± 51.1 fmol/ml vs 73.7 ± 24.8 fmol/ml , P=0.012 ) after surgery were observed . Mean excess weight loss was higher in the LSG group at 1 ( 30 ± 13 % vs 17 ± 7 % , P=0.005 ) and 6 months ( 61 ± 16 % vs 29 ± 11 % , P=0.001 ) compared with the LAGB group . Conclusions : As a consequence of resection of the gastric fundus , the predominant area of human ghrelin production , ghrelin is significantly reduced after LSG but not after LAGB . This reduction remains stable at follow-up 6 months postoperatively , which may contribute to the superior weight loss when compared with LAGB AIM : To determine whether visceral fat reduction in connection with bariatric surgery could improve weight loss and metabolic profile of obese subjects . PATIENTS AND METHODS : In a one-center , r and omized and controlled pilot trial we assigned 50 subjects with severe obesity ( body mass index > 35 kg/m2 ) to either adjustable gastric b and ing ( AGB ) alone ( 11 men and 14 women ) , or AGB plus surgical removal of the total greater omentum ( 11 men and 14 women ) . The patients were followed at regular intervals for 2 y and examined at 0 and 24 months with respect to body composition and metabolic profile . RESULTS : No significant differences between control and omentectomized patients were observed at baseline . The removed greater omentum constituted 0.8±0.4 % ( mean±s.d . ) of total body fat . At 2 y follow-up there was an expected decrease in body weight and an improvement in metabolic profile in both groups . Although omentectomized subjects tended to lose more weight than control subjects the difference was not statistically significant and changes in waist-to-hip ratio and saggital diameter did not differ between groups . However , the improvements in oral glucose tolerance , insulin sensitivity and fasting plasma glucose and insulin were 2–3 times greater in omentectomized as compared to control subjects ( P from 0.009 to 0.04 ) , which was statistically independent of the loss in body mass index . No differences in blood lipids between the groups were recorded . No adverse effects related to omentectomy were observed . CONCLUSIONS : Omentectomy , when performed together with AGB , has significant positive and long-term effects on the glucose and insulin metabolic profiles in obese subjects OBJECTIVE To assess the effect of vertical b and ed gastroplasty and gastric b and ing on the development of  gastro-oesophageal reflux  using both subjective and objective methods . DESIGN Prospect i ve , r and omised study . SETTING Teaching hospital , Sweden . SUBJECTS 50 consecutive , morbidly obese patients ( mean ( SD ) body mass index ( BMI ) 42.5 ( 5 ) , 27 women and 23 men ; mean age 48 years , range 38 - 57 years ) . INTERVENTIONS Vertical b and ed gastroplasty ( n = 24 ) or gastric b and ing ( n = 26 ) . MAIN OUTCOME MEASURES Results of evaluation by st and ardised question naire , 24-hour ambulatory pH-metry , and endoscopy . RESULTS After six months the mean ( SD ) BMI had decreased to 34.4 ( 5.7 ) , with no differences between the groups . Mild dysphagia was somewhat more common ( 13 compared with 1 ) but the incidence of heartburn ( 8 compared with 17 ) , and acid regurgitation ( 12 compared with 14 ) were less after the operation ; 3 patients developed erosive oesophagitis , two in the vertical b and ed group and one in the b and ing group . Ambulatory pH-metry readings did not change significantly from preoperatively and there were no differences between the two operations . One patient developed pathological reflux , and in three the values returned to the normal range . CONCLUSION Gastric restriction operations including those with a narrow stoma that causes outflow obstruction do not seem to increase the incidence of reflux in patients with functioning antireflux barriers BACKGROUND Weight loss is associated with short-term amelioration and prevention of metabolic and cardiovascular risk , but whether these benefits persist over time is unknown . METHODS The prospect i ve , controlled Swedish Obese Subjects Study involved obese subjects who underwent gastric surgery and contemporaneously matched , conventionally treated obese control subjects . We now report follow-up data for subjects ( mean age , 48 years ; mean body-mass index , 41 ) who had been enrolled for at least 2 years ( 4047 subjects ) or 10 years ( 1703 subjects ) before the analysis ( January 1 , 2004 ) . The follow-up rate for laboratory examinations was 86.6 percent at 2 years and 74.5 percent at 10 years . RESULTS After two years , the weight had increased by 0.1 percent in the control group and had decreased by 23.4 percent in the surgery group ( P<0.001 ) . After 10 years , the weight had increased by 1.6 percent and decreased by 16.1 percent , respectively ( P<0.001 ) . Energy intake was lower and the proportion of physically active subjects higher in the surgery group than in the control group throughout the observation period . Two- and 10-year rates of recovery from diabetes , hypertriglyceridemia , low levels of high-density lipoprotein cholesterol , hypertension , and hyperuricemia were more favorable in the surgery group than in the control group , whereas recovery from hypercholesterolemia did not differ between the groups . The surgery group had lower 2- and 10-year incidence rates of diabetes , hypertriglyceridemia , and hyperuricemia than the control group ; differences between the groups in the incidence of hypercholesterolemia and hypertension were undetectable . CONCLUSIONS As compared with conventional therapy , bariatric surgery appears to be a viable option for the treatment of severe obesity , result ing in long-term weight loss , improved lifestyle , and , except for hypercholesterolemia , amelioration in risk factors that were elevated at baseline A prospect i ve , r and omized trial comparing vertical b and ed gastroplasty ( VBG ) and vertical gastric bypass ( GB ) for obesity was completed in 106 patients who did not differ in baseline body mass index ( BMI = kg/m2 ) or length of follow-up . The goal of this surgery was to return patients to within 50 % of their ideal weight , i.e. , a body mass index less than 35 kg/m2 , and to accomplish this while maintaining a low risk for malnutrition as well as other morbidity and mortality . Success was defined as a BMI less than 35 kg/m2 because the mortality risk increases rapidly above this degree of obesity . Surgical failures were encountered in 43 % of the 54 patients in the VBG group , all of whom had division between the vertical staple lines . The main causes of failure were stenosis and enlargement of the gastroplasty orifice . Surgery failed in 23 % of the GB-treated patients , due to perforation of the vertical staple line . An  isolated gastric bypass ( IGB )  not dependent on staples was performed as the remedial operation for the failures of both VBG and GB . IGB was significantly better than VBG or GB , with a success rate of 83 % compared with 39 % for VBG and 58 % for GB . Subsequent experience since completion of this r and omized trial in 54 consecutive patients supports IGB for primary , as well as remedial , operations for the morbidly obese ( BMI = 40 to 50 kg/m2 ) , as well as for patients who are super obese ( BMI greater than 50 kg/m2 ) OBJECTIVES To survey the frequency of use of indirect comparisons in systematic review s and evaluate the methods used in their analysis and interpretation . Also to identify alternative statistical approaches for the analysis of indirect comparisons , to assess the properties of different statistical methods used for performing indirect comparisons and to compare direct and indirect estimates of the same effects within review s. DATA SOURCES Electronic data bases . REVIEW METHODS The Data base of Abstract s of Review s of Effects ( DARE ) was search ed for systematic review s involving meta- analysis of r and omised controlled trials ( RCTs ) that reported both direct and indirect comparisons , or indirect comparisons alone . A systematic review of MEDLINE and other data bases was carried out to identify published methods for analysing indirect comparisons . Study design s were created using data from the International Stroke Trial . R and om sample s of patients receiving aspirin , heparin or placebo in 16 centres were used to create meta-analyses , with half of the trials comparing aspirin and placebo and half heparin and placebo . Methods for indirect comparisons were used to estimate the contrast between aspirin  and  heparin . The whole process was repeated 1000 times and the results were compared with direct comparisons and also theoretical results . Further detailed case studies comparing the results from both direct and indirect comparisons of the same effects were undertaken . RESULTS Of the review s identified through DARE , 31/327 ( 9.5 % ) included indirect comparisons . A further five review s including indirect comparisons were identified through electronic search ing . Few review s carried out a formal analysis and some based analysis on the naive addition of data from the treatment arms of interest . Few method ological papers were identified . Some valid approaches for aggregate data that could be applied using st and ard software were found : the adjusted indirect comparison , meta-regression and , for binary data only , multiple logistic regression ( fixed effect models only ) . Simulation studies showed that the naive method is liable to bias and also produces over-precise answers . Several methods provide correct answers if strong but unverifiable assumptions are fulfilled . Four times as many similarly sized trials are needed for the indirect approach to have the same power as directly r and omised comparisons . Detailed case studies comparing direct and indirect comparisons of the same effect show considerable statistical discrepancies , but the direction of such discrepancy is unpredictable . CONCLUSIONS Direct evidence from good- quality RCTs should be used wherever possible . Without this evidence , it may be necessary to look for indirect comparisons from RCTs . However , the results may be susceptible to bias . When making indirect comparisons within a systematic review , an adjusted indirect comparison method should ideally be used employing the r and om effects model . If both direct and indirect comparisons are possible within a review , it is recommended that these be done separately before considering whether to pool data . There is a need to evaluate methods for the analysis of indirect comparisons for continuous data and for empirical research into how different methods of indirect comparison perform in cases where there is a large treatment effect . Further study is needed into when it is appropriate to look at indirect comparisons and when to combine both direct and indirect comparisons . Research into how evidence from indirect comparisons compares to that from non-r and omised studies may also be warranted . Investigations using individual patient data from a meta- analysis of several RCTs using different protocol s and an evaluation of the impact of choosing different binary effect measures for the inverse variance method would also be useful BACKGROUND R and omized controlled trials ( RCTs ) in surgery can provide valuable evidence of the efficacy of interventions if they are well- design ed , appropriately executed , and adequately reported . Adequate reporting of methodology in surgical RCTs is known to be poor , and adverse-event reporting in surgical research is inconsistent . The Consoli date d St and ards of Reporting Trials ( CONSORT ) statement is a framework to help authors report their findings in a transparent manner . Extensions to the CONSORT statement have been published recently to address deficiencies in adverse-event reporting and in reporting of specific criteria related to nonpharmacologic treatments . The aim of this study was to assess the quality of reporting of trial methodology and adverse events in a sample of general surgical RCTs published in high- quality surgical journals using the criteria specified in the CONSORT statements . STUDY DESIGN We used impact factor to identify the top three ranked surgical journals in 2004 . We then obtained information on all RCTs published in these journals in the 2005 calendar year . We assessed quality of reporting using Jadad score , compared the quality of RCTs from CONSORT-endorsing journals with nonendorsers , and assessed the number of RCTs adequately reporting key generic method ologic , adverse-event-related , and specific nonpharmacologic criteria . RESULTS Of 42 RCTs analyzed , only 40 % ( 17 of 42 ) had a Jadad score > or = 3 . There was no significant difference in the number of high- quality RCTs published in CONSORT-endorsing journals compared with nonendorsers ( p = 0.3 ) . The median percentage of RCTs adequately reporting generic method ologic , adverse-event-related , and specific nonpharmacologic criteria was 32.5 % , 17 % , and 36.5 % , respectively . CONCLUSIONS Quality of reporting of generic method ologic , adverse-event-related , and specific nonpharmacologic criteria in surgical RCTs is poor . Increased attention to quality of reporting of surgical RCTs is required if studies are to meet published criteria We compared the weight-reducing effect of diet and gastroplasty with that of diet alone in a r and omized trial in 60 morbidly obese patients followed for two years . Initial median body weight was 120 kg in patients r and omly assigned to gastroplasty plus diet and 115 kg in those assigned to diet alone .  Maximum weight losses did not differ significantly between the groups ( 26.1 kg in the gastroplasty group and 22.0 kg in the group treated with diet alone , P greater than 0.05 ) . The risk of a Type II error with a true difference larger than 9.5 kg was less than 5 per cent . However , the group treated with diet alone  regained significantly more weight after maximum weight loss had been achieved , so that the gastroplasty group had a more favorable net outcome at two years ( P less than 0.05 ) We present our prospect i ve comparative study on 60 patients subjected to two types of gastric restrictive procedures , i.e. Vertical B and ed Gastroplasty ( VBG ) and Laparoscopic Adjustable Gastric B and ing ( LAGB ) at King Abdul Aziz University Hospital , Jeddah , Saudi Arabia . The aim of our study was to compare weight reduction after both procedures . Thirty patients had VBG and thirty had LAGB based upon informed consents . The age , sex and preoperative weight and BMI were comparable in both groups . Excess weight loss of 87 % was achieved in the VBG group while only 50 % was noticed in the LAGB group at 6 months postoperatively Fifty-seven morbidly obese patients were r and omized to gastric bypass ( 29 ) or gastroplasty ( 28 ) and observed for 24 months postoperatively . Operating time and hospital stay were longer and peroperative and postoperative complications somewhat more common in the bypass than in the gastroplasty group . But weight loss at 1 year was significantly greater and failures significantly fewer after gastric bypass . Four gastroplasties were converted to bypass after 18 - 24 months because of failure to lose weight .  Gastric bypass was judged to be much the preferable of the two operations . Dumping occurred in some patients with bypass but not after gastroplasty .  Dumping was not associated with greater weight loss . Peroperatively measured pouch volume showed significant correlation with weight loss after gastroplasty , but not after bypass . Peroperative pouch volume and postoperatively measured stoma diameter were co-acting factors , which in multiple regression analysis could explain observed variance in weight loss to about 40 % after gastroplasty , but to a negligible degree after gastric bypass Background : a prospect i ve r and omized study was undertaken to compare the outcome of vertical b and ed gastroplasty ( VBG ) and gastric bypass ( GBP ) in patients with clinical ly severe obesity . Methods : eligibility criteria included Class IV obesity , < 50 years old and a history of at least one attempt of non-operative weight loss . Patients were managed conservatively for 3 months prior to surgery . Patients were followed post-operatively and monitored for early and late complications and their weight loss outcome for up to 5 years . Results : 44 patients were recruited . Two patients withdrew within 4 weeks and were excluded . Twenty subjects had a GBP and 22 a VBG .  There were no significant differences with respect to age , gender , maximum or pre-operative weight between the groups ( p > 0.05 ) . Patients who underwent GBP demonstrated significantly greater post-operative weight loss ( p < 0.05 ) which was apparent from 6 months onwards . There were no deaths , pulmonary emboli , post-operative leaks or wound dehiscence . There were no instances of staple-line disruption . Symptomatic ulcer disease , confirmed endoscopically , developed in 25 % of GBP patients . Nine patients developed gallstones post-operatively of whom five were in the VBG and four in the GBP group . Conclusions : weight loss following GBP was maintained , while VBG patients slowly regained BACKGROUND Obesity is a risk factor for cancer . Intentional weight loss in the obese might protect against malignancy , but evidence is limited . To our knowledge , the Swedish Obese Subjects ( SOS ) study is the first intervention trial in the obese population to provide prospect i ve , controlled cancer-incidence data . METHODS The SOS study started in 1987 and involved 2010 obese patients ( body-mass index [ BMI ] > or=34 kg/m(2 ) in men , and > or=38 kg/m(2 ) in women ) who underwent bariatric surgery and 2037 contemporaneously matched obese controls , who received conventional treatment .  While the main endpoint of SOS was overall mortality , the main outcome of this exploratory report was cancer incidence until Dec 31 , 2005 . Cancer  follow-up rate was 99.9 % and the median follow-up time was 10.9 years ( range 0 - 18.1 years ) . FINDINGS Bariatric surgery result ed in a sustained mean weight reduction of 19.9 kg ( SD 15.6 kg ) over 10 years , whereas the mean weight change in controls was a gain of 1.3 kg ( SD 13.7 kg ) . The number of first-time cancers after inclusion was lower in the surgery group ( n=117 ) than in the control group ( n=169 ; HR 0.67 , 95 % CI 0.53 - 0.85 , p=0.0009 ) . The sex-treatment interaction p value was 0.054 . In women , the number of first-time cancers after inclusion was lower in the surgery group ( n=79 ) than in the control group ( n=130 ; HR 0.58 , 0.44 - 0.77 ; p=0.0001 ) , whereas there was no effect of surgery in men ( 38 in the surgery group vs 39 in the control group ; HR 0.97 , 0.62 - 1.52 ; p=0.90 ) . Similar results were obtained after exclusion of all cancer cases during the first 3 years of the intervention . INTERPRETATION Bariatric surgery was associated with reduced cancer incidence in obese women but not in obese men . FUNDING Swedish Research Council , Swedish Foundation for Strategic Research , Swedish Federal Government under the LUA/ALF agreement , Hoffmann La Roche , Cederoths , AstraZeneca , Sanofi-Aventis , Ethicon Endosurgery
target: Bariatric surgery appears efficacious compared to st and ard care in reducing BMI .
  Weight losses are greatest with diversionary procedures , intermediate with diversionary/restrictive procedures , and lowest with those that are purely restrictive .
  Compared with Roux-en-Y gastric bypass , adjustable gastric b and ing has lower weight loss efficacy , but also leads to fewer serious adverse effects
background: nan