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

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

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