Context:Female obesity is linked to abnormal menstrual cycles, infertility, reproductive wastage, and deficient LH, FSH, and progesterone secretion. Objective and Design:To elucidate the reproductive defects associated with obesity, we sampled 18 eumenorrheic (nonpolycystic ovary syndrome) women with a mean Ϯ SEM body mass index of 48.6 Ϯ 1.4 kg/m 2 with daily, first morning voided urine collections, seven of whom also had early follicular phase 12-h, every 10-min blood sampling to assess LH pulses. Daily hormones were compared with 11 eumenorrheic, normal-weight controls. A separate control group of 12 eumenorrheic, normal-weight women was used for the LH pulse studies. Main Outcome Measures:Assays for LH (serum and urine) and FSH, and estradiol and progesterone metabolites (estrone conjugate and pregnanediol glucuronide; urine) were performed. Daily hormones were meaned and normalized to a 28-d cycle length. LH pulsations were determined using two objective methods. Group means were compared using t tests. Results:Reduced whole-cycle mean, normalized pregnanediol glucuronide was observed in obese (38.2 Ϯ 2.1 g/mg creatine) compared with normal-weight women (181.3 Ϯ 35.1 g/mg creatine; P ϭ 0.002), without significant differences in LH, FSH, or estrone conjugate. Early follicular phase LH pulse frequency did not differ from normalweight women, but both amplitude and mean LH were dramatically reduced in obese women (0.8 Ϯ 0.1 and 2.0 Ϯ 0.3 IU/liter) compared with controls (1.6 Ϯ 0.2 and 3.4 Ϯ 0.2 IU/liter; P Ͻ 0.01). 10 -15% induces reversible deficits in reproductive function that have been well characterized (1). The effects of increased body weight on the reproductive axis are not as well understood, but the association of obesity with lower gonadotropins and reduced levels of sex steroids has been established (2, 3). One large, recent epidemiological study of 848 women used daily urinary sampling over the course of a menstrual cycle and observed longer follicular phases, lower LH and FSH, lower estradiol metabolites, and lower progesterone metabolites by 33% in overweight/obese [body mass index (BMI) of Ͼ25 kg/m 2 ] compared with normalweight women (4). Conclusions:We hypothesized that the reduced reproductive hormones in ovulatory, regularly cycling obese women are attributable to a deficient central neural reproductive drive. We studied morbidly obese (baseline BMI of Ͼ35 kg/m 2 ) women scheduled to undergo bariatric surgery before weight loss and compared menstrual cycle urinary hormone excretion and serum LH secretory patterns using frequent blood sampling to infer the characteristics of GnRH secretion. In this study, we compared our findings in the high-BMI women with normal-weight historical controls. Patients and Methods ParticipantsNineteen participants were recruited through a weight-loss surgery support group at the Montefiore Medical Center and Beth Israel Medical Center (New York, NY). Participants were aged 35-50 yr at enrollment and had to meet the following criteria: 1) BMI of at least 35 kg/m ...

Objective To determine whether obesity related reproductive endocrine abnormalities in ovulatory women are reversible with weight loss Design Observational cohort study. Setting Healthy volunteers in an academic research environment. Patients Women age 18–48 with regular menstrual cycles 21–40 days with a BMI ≥ 35 kg/m2 planning to undergo bariatric surgery were recruited. Intervention 25 eumenorrheic (non-PCOS) women with a mean BMI of 47.3 +/− 5.2 kg/m2 were sampled with daily menstrual cycle urinary hormones prior to (n=25) and 6 months after (n=9) weight loss surgery resulting in >25% reduction initial body weight. Daily hormones were compared pre- and post-operatively, and to 14 normal weight controls. Main Outcome Measures LH, FSH, estradiol and progesterone metabolites measured daily for one menstrual cycle. Group means were compared using t-tests among ovulatory cycles. Results Luteal Pdg increased from 32.8 ± 10.9 to 73.7 ± 30.5 ug/mgCr (p<0.001) and whole cycle LH increased from 168.8 ± 24.2 to 292.1 ± 79.6 mIU/mgCr (p<0.001) after surgically induced weight loss. Luteal Pdg remained lower than normal weight controls (151.7 ± 111.1 ug/mgCr). Obese women took longer to attain a postovulatory Pdg rise >2mcg/mg creatinine than controls (3.91 ± 1.51 versus 1.71 ± 1.59 days); this improved post-operatively (2.4 ± 1.82 days, p=0.046). Whole cycle E1c was similar to controls at baseline, but decreased after weight loss (from 1026.7 ± 194.2 to 605.4 ± 167.1 ng/mgCr, p<0.001). FSH did not relate to body size in this sample. Conclusions Women of very high BMI have deficient luteal LH and Pdg excretion and a delayed ovulatory Pdg rise compared to normal weight women. Although all of these parameters improved with weight loss, Pdg did not approach levels seen in normal weight women. LH may be less effective in stimulating the corpus luteum in obesity. The large postoperative decrease in E1c may reflect the loss of estrone-producing adipose tissue after weight loss.

LRYGBP can be performed safely and effectively in super-super-obese patients (BMI > or =60). Although these patients have less %EWL than lighter patients, they still end up with a good result. Therefore, LRYGBP should be considered a good surgical option even for patients with a BMI > or =60.

This model provides a straightforward, precise, and easily applicable tool for identifying bariatric patients at low, intermediate, and high risk for in-hospital mortality. Notably, baseline functional status before surgery is the single most powerful predictor of perioperative survival and should be incorporated into risk stratification models.

Background and Objectives:Laparoscopic splenectomy (LS) has been shown to offer superior outcomes when compared to open splenectomy (OS). Despite the potential advantages associated with the minimally invasive technique, laparoscopy appears to be underused. We sought to evaluate the nationwide trends in LS.Methods:The Nationwide Inpatient Sample (NIS) database was queried for both OS and LS procedures performed from 2005 through 2010. Partial splenectomies and those performed for traumatic injury, vascular anomaly, or as part of a pancreatectomy were excluded. The included cases were examined for age of the patient and comorbid conditions. We then evaluated the postoperative complications, overall morbidity, mortality, and length of hospital stay.Results:A total of 37,006 splenectomies were identified. Of those, OS accounted for 30,108 (81.4%) cases, LS for 4,938 (13.3%), and conversion to open surgery (CS) for 1,960 (5.3%). The overall rate of morbidity was significantly less in the LS group than in the OS group (7.4% vs 10.4%; P < .0001). The LS group had less mortality (1.3% vs 2.5%, P < .05) and a shorter length of stay (5.6 ± 8 days vs 7.5 ± 9 days).Conclusions:Despite the benefits conferred by LS, it appears to be underused in the United States. There has been an improvement in the rate of splenectomies completed laparoscopically when compared to NIS data from the past (8.8% vs 13%; P < .05). The conversion rate is appreciably higher for LS than for other laparoscopic procedures, suggesting that splenectomies require advanced laparoscopic skills and that consideration should be given to referring patients in need of the procedure to appropriately experienced surgeons.