The sociologist Erving Goffman (1963) explains how society establishes means to categorize people into ‘‘normal’’ and ‘‘abnormal,’’ defining the term stigma as a deeply discrediting attribute that involves feelings of shame. Carr and Friedman (2005) argue that obese people are stigmatized in accordance with the dimensions described by Goffman (1963): namely, the stigma is related to the obese body itself, which is defined as abnormal, and the obese person’s character, which links obesity to morality. In their study, they found that obese people felt stigmatized in situations related to work, health, and daily life in general (Carr & Friedman, 2005). Dur- ing the process ofweight loss, Nina re-discovered social norms about being severely obese. She was reluctant to identify with social norms about ‘‘normal’’ body size that say that not being severely obese also means being, morally speaking, a better person. Puhl and Brownell (2001) emphasized that several studies have argued that obese people are one ofthe very few remaining groups in society that still is deemed legitimate to stigmatize. Murray (2005, p. 155) showed how society views obese people as being out of control, weak, and unwilling to change, and stated that this view establishes the obese body as ‘‘a failed body project.’’ Gaining weightafterbariatricsurgery is described to create a double failure: being severe obese in the first place, and then failing to keep control oftheweight even afterbariatricsurgery (Groven et al., 2010). Knutsen, Terragni, and Foss (2013) interviewed morbidly obese participants who attended a course before sur- gery and self-help groups afterward, both focusing on lifestyle. The researchers found that dimensions of control and credibility framed the respondents’ identity work. They suggest that treatment pro- grams aiming at empowering these patients leave the patients trapped within theambivalence be- tween freedom and control. Again, body size, health, illness, and lifestyle are phenomena steeped in dis- courses about control and morality, which our study also points to.
The present study, based on the follow-up of 120 patients 2 years after underwent to RYGB, conirms previous results concerning eficacy and safety ofbariatricsurgery in the control of obesity and related conditions. The mortality rate was zero. Patients showed mean %EWL of 75% and total or partial control of clinical condi- tions in all 71 cases suffering from pre- surgical co-morbidities. This surgical procedure proved to be safe, with 4.2% percent of cases presenting with complications speciically related to the surgical procedure. Sixteen (13% ofthe total casuistic) subjects experienced clinical complications requiring clinical outpatients treatment (9.1% ofthe total patients) or in some cases including hospital admission (6.9% ofthe total patients). As reported by a number of studies, using the BAROS system allows us to identify good to excellent results concerning items of quality of life and overall satisfaction. We have also found that both male gender and age can be associanted with poor results as far as weight reduction. Based on our experience and medical literature, it is recommended that future studies also investigate other important variables impacting the outcome ofbariatric interventions, such as medical (e.g., fat mass), psychosocial (e.g., education, income, depression, compul- sive eating) (8,20) , ethnic, and lifestyle (e.g., inactivity, overeating), in
Longitudinal studies have shown that the highest rise in obesity prevalence occurred in the severe obesity category (8), in which lifestyle modiications and drug therapy are not effective. Bariatricsurgery provides the most long-lasting results for those individuals in whom clinical strategies fail (9). Several parameters have been proposed to assess the outcomes ofbariatricsurgery (9,10). Surgeons have used the amount ofweight loss as the main post-operative outcome, although the im- provement ofthe multiple obesity-associated medical conditions should be considered, including physical and psychological parameters (11). Considering that, from the patient perspective, QoL is the most impor- tant outcome oftheweight-reducing procedure (12), interest in measuring of health-related QoL has in- creased in recent years (13).
There is a lack of studies about the outcomes of teenage pregnancy after WLS, however, recent surveys reported a twofold increase in pregnancy in this population 61 . This suggests that there may be a higher risk of pregnancy in adolescents undergoing bariatricsurgery 61 . Therefore, it is recommended that before performing WLS all young adolescents are informed about the increased fertility following weight loss and about the risks associated with pregnancy during the first 18 months afterthe procedure (quick weight loss and potential micronutrient shortcomings may have adverse effects on the mother and the fetus) 23 . This highlights the importance of addressing contraception and pregnancy prevention in all female adolescents undergoing bariatricsurgery 61 .
The results of our study showed that there was no evi- dence that percentage body weight loss during the first 18 months afterbariatricsurgery is associated with ad- herence to nutritional follow-up and presurgical weight. This may suggest that weight loss is governed by the ef- fect ofthe surgical body alterations themselves and pa- tients should be aware of that and be encouraged to ad- here to postsurgical visits to avoid long term adverse events, such as weight regain and nutritional deficiencies. This finding may have implications for intervention strat- egies aimed at motivating patients to attend early post- surgical and life-long follow-up. Further studies are need- ed to understand weight change over a longer period of time after gastric bypass surgery, including the metabol- ic and underlying hormonal mechanisms associated with weight changes.
Type 2 diabetes mellitus is an epidemic health problem. Approximately, 90% of diabetic patients are overweight or are obese. The current increase in the prevalence of obesity has been associated with an increase in the prevalence of type 2 diabetes. Bariatricsurgery is the most effective treatment for morbid obese patients in terms of controlling weight and co-morbidities. Sustained normal plasma concentration of glucose has been reported in most diabetic morbid obese patients, which has been managed surgically. Available data show a significant alteration in the production of some gastrointestinal hormones, which might explain the improvement of glucose metabolism following these procedures. Diabetic patient improvements following some bariatric surgeries seems to be an independent factor unrelated to the amount ofweight loss. The authors reviewed data published on the effects ofbariatricsurgery in diabetic patient improvements and the possible mechanisms responsible for this control (Rev. Col. Bras. Cir. 2007; 34(5): 343-346).
can lead to depressive mood for several reasons, including physical inactivity, poorer quality of life, and social prejudice [29 – 31]. On the other hand, observations that depressed indi- viduals may gain weight because ofthe use of antidepressants, sedentarism, and poor sleep quality [32, 33] seem to support a reverse sequence of events. Finally, the co-occurrence of these two conditions must also be considered in view of common genetic and lifestyle factors [32, 34]. Significant improvement in depressive symptoms has been previously reported follow- ing bariatricsurgery , and greater weight loss has been correlated to higher rates of depression resolution in these in- dividuals . The nature ofthe postoperative improvement of depressive symptoms is probably multifactorial and may be related to psychosocial factors, including gains in self-esteem, body satisfaction, and weight-related stigmatization, as well as biological factors, such as reduction in insulin resistance, deac- tivation of pro-inflammatory states and normalization ofthe hypothalamic-pituitary-adrenal axis [37, 38]. A relevant find- ing ofthe present study is the concomitant improvement in depressive symptoms among subjects who experienced nor- malization of daytime sleepiness scores, in contrast to the ab- sence of a change in depressive symptoms among those with persistent daytime somnolence. A relationship between obesity, depression, and excessive daytime sleepiness has been previ- ously described in community cohort studies  as well as in obese subjects . Dixon and coworkers, in 1055 consecutive patients presenting for obesity surgery, observed that daytime somnolence, as measured by the ESS, was not related to the presence or severity of OSA diagnosed by overnight polysomnography in a subgroup of subjects. The largest con- tributors to variance of ESS scores in their sample were symp- toms of depression, sleep problems reported by the patient, and poor quality of life . Prospective studies evaluating the associations among depressive symptoms, sleep quality, and excessive daytime sleepiness following bariatricsurgery are scarce. However, Fernandez-Mendoza and coworkers, in a population-based study of 1395 subjects followed up after 7.5 years, reported that weight loss was associated with remis- sion of excessive daytime sleepiness. Interestingly, those inves- tigators also found that the presence of sleep disturbances could predict the incidence of daytime somnolence in individuals with depression .
A recent study on morbidly obese pa- tients submitted to bariatricsurgery reported results that were similar to ours in several aspects (12). It was observed that by about 9 months aftersurgerythe patients showed a significant fall in hip bone mass. In contrast to our results, Coates et al. (12) did not observe a significant loss of forearm BMD in their patients. The group evaluated in that study was heterogeneous, including pre- and postmenopausal women and men, whereas in our study we evaluated only premeno- pausal women. This factor may have been responsible, at least in part, for the differ- ences observed. An additional aspect of our study is that we also evaluated individuals of normal weight. Thus, it was clearly demon- strated that, while normal and obese indi- viduals maintain a normal bone mass, obese individuals submitted to bariatricsurgery show a loss of bone mass.
ment. Bariatricsurgery produces, in addition to weight loss, improvement of atherosclerosis and systemic in- lammation that can be veriied based on the decrea- se in C-reactive protein (CRP) aftersurgery. Besides the improvement in coronary circulation, there is an increase in carotid blood low due to the reduction of plaque in the carotid with consequent increase in lumen.
The majority ofthe subjects in the present study showed an improvement in excessive daytime sleepiness aftersurgery, in agreement with previous investigations [22–24]. It has been suggested that the decrease in hypersomnolence afterbariatricsurgery may be related to an improvement in nocturnal sleep, secondary to the reduction in OSA, as mentioned above, al- though other factors, such as a reduction of metabolic and inflammatory abnormalities, could also play a role [9, 25, 26]. In a previous study of 56 obese patients with high-level preoperative daytime somnolence, normalization of excessive sleepiness was achieved only 1 month afterthe surgical pro- cedure . It is worth emphasizing that about 10.0% ofthe participants ofthe present study were found to remain with excessive daytime sleepiness at the postoperative evaluation. The causes of persistent hypersomnolence after successful obesity surgery have not been adequately clarified [9, 10]. In this study, we were unable to find a correlation between per- sistence of excessive daytime sleepiness and the magnitude of sleep quality improvement or the degree ofweight loss afterthe surgical procedure.
study with 618 patients who underwent Roux-en-Y Gastric Bypass by laparoscopy and were followed-up for 52 weeks. All patients were given the same quantity (5000 UI) of unfractionated heparin every 8h for the first 24h, followed by 40 mg of enoxaparin every 12h, and remained in hospital for a mean stay of 4 days. Basal atelectasis was the most common complication while in hospital (8.4%), followed by gastrointestinal bleeding (1.6%). There were no deaths during follow-up and none ofthe patients exhibited clinical symptoms of DVT. Just one patient was diagnosed with DVT by VDU ofthe lower limbs, conducted within the first 24h aftersurgery.
i.e., when the addition of new interviews could add very little information regarding the initial aims. The interviews were recorded with patients’ consent. The irst question was: “Tell me a little about how you feel when you realize that you regained weightafterbariatric and metabolic surgery.” Based on the answer to this question, 10 previously prepared questions were asked, not necessarily in the order indicated below; whenever considered adequate, the researcher could change them, in order to make them it for the speciic situation. The 10 previously prepared questions were:
er, a dramatic improvement in glucose control frequently oc- curs immediately ater thesurgery, usually within 1 week, when signiicant weight loss has not yet taken place [1,14]. herefore, the mechanism of immediate diabetes remission or improve- ment appears to be weight loss-independent. However, adjust- able gastric banding (AGB) is typically accompanied by a grad- ual improvement in glucose control in obese type 2 diabetes pa- tients , which is in contrast to results observed from RYGB. he discrepancy in the time-course of diabetes remission be- tween RYGB and AGB suggests that there are mechanisms oth- er than weight loss per se for the rapid remission or improve- ment of diabetes ater RYGB. However, it was shown that calo- rie restriction is required for rapid improvement in insulin sen- sitivity immediately ater RYGB (within 1 week) by comparing the effects of calorie restriction and RYGB in obese subjects . Similarly, in a within-subject time series study comparing the efects of calorie restriction and RYGB, both treatments re- sulted in similar marked improvements in glucose homeostasis in obese type 2 diabetes patients . In addition, when nondi- abetic obese subjects achieved 20% weight loss from baseline ater either RYGB (average 16±2 weeks ater surgery) or AGB (average 22±7 weeks ater surgery), similar changes in β-cell function, insulin sensitivity, and gene expression in adipose tis- sue were observed , which indicates that weight loss is im- portant in improved glucose homeostasis. However, both calo- rie restriction without surgical stress [16,17] and weight loss in nondiabetic subjects  have substantial limitations in reca- pitulating the processes that occur in obese type 2 diabetes pa- tients after RYGB. Nevertheless, acute energy restriction and long-term weight loss play an important role in the improve- ment of glucose homeostasis following RYGB .
For other clinical outcomes, our findings are largely in line with the results of other studies, though we did not find the strong protective association between bariatricsurgery and mortal- ity seen by others , possibly because ofthe lack of longer term data in our study. Notably, the results of our post hoc analysis were consistent with a survival benefit a year aftersurgery— similar to the long-term protective effect seen in the SOS study —but this survival benefit did not reach statistical significance. The effect estimates we report for resolution of T2DM and hypertension are slightly weaker than those seen in some studies, but are consistent with effects seen in the SOS study, and it is clear that this effect size has varied in other studies depending on the case definition used [39–41]. Few studies have reported on vascular out- comes, with most reporting associations ofbariatricsurgery with vascular risk factors instead . Our results suggest a slightly stronger protective association between surgery and MI than reported in the SOS study , though the mix ofsurgery subtypes varies considerably between our studies and could explain these differences. Notably, we found no association between bar- iatric surgery and the risk of stroke.
The eustachian tube, an osteocartilaginous canal that commu- nicates the middle ear with the nasopharynx, is one ofthe most important structures responsible for the functional balance of middle ear structures and is involved in mechanisms of protec- tion, aeration, and draining. 1,2 Tubal malfunction can cause extremely unpleasant symptoms, such as autophony, cacophony, and the sensation of aural fullness. 1,2 These symptoms might be unveiled by several clinical conditions, including the acute loss ofweightafterbariatricsurgery. 3
RESULTS: From the total of 78 patients, 35 (44.9%) demonstrated fibrosis in the initial biopsy. The mean excess weight loss was 82.4%. Aftertheweight loss, 24 patients (30.8%) had fibrosis. Ofthe 35 who had fibrosis in the initial biopsy, 45.7% demonstrated fibrosis regression, and 54.3% remained with it. From those who did not have fibrosis in the first biopsy, 88.4% remained without it, and 11.6% showed some degree of fibrosis progression. There was no statistical significant difference between the patients who showed or not fibrosis in terms of sex, age, BMI and steatosis degree, on the first and second biopsies. Patients with fibrosis on the first biopsy presented more type 2 diabetes and dyslipidemia. Ballooning degeneration was the only variable more prevalent in patients who had fibrosis on the first (P<0.001) and second (P=0.008) biopsies. CONCLUSION: Ofthe 35 patients with fibrosis at baseline, nearly half of them (45.7%) showed fibrosis regression, many remained at the same stage, and only 11.6% had fibrosis progression afterweight loss induced by bariatricsurgery.
Second, contrary to our working hypothesis, we were not able to identify a clear effect of sex, smoking, OSAS or MS upon the systemic inflammome of morbidly obese individuals (Figures S1– S4), indicating that obesity per se is likely the main driving force of systemic inflammation in this clinical setting. By contrast, we observed a very significant effect of BS (Figure 2). Our findings confirm that BS is a safe and effective option for the treatment of very severe obesity but also showed that it has a profound effect on the systemic inflammome of these individuals (Figures 1 and 2). This may be related to the reduction of macrophage infiltration of adipose tissue, as well as to the change in the pro-inflammatory macrophage phenotype that has been reported afterweight loss . This further supports a key role of obesity in the pathobiology of systemic inflammation in these patients.
Objective: to evaluate the profile of patients submitted to post-bariatric plastic surgery at the North Wing Regional Hospital, Brasília, DF. Methods: we conducted a prospective, descriptive and analytical study of patients submitted to Roux-en-Y gastroplasty, and subsequently to plastic surgery, from January 2011 to December 2016. We assessed body mass index before gastroplasty and aftersurgery plastic surgery, postoperative complications and comorbidities. Results: we studied 139 patients (130 women and nine men), with a mean age of 41 years, who underwent 233 operations. The mean BMI at the time of plastic surgery was 27.44kg/m 2 . The mean weight loss was
Introduction: Depressive symptoms have been reported as prevalent afterbariatricsurgery. This study aims to analyze the role ofweight, eating behaviors and body image in depressive symptomatology in bariatricsurgery patients assessed post-operatively. Material and Methods: This is a cross-sectional study including 52 bariatricsurgery patients assessed post-operatively with a follow-up time ranging from 22 to 132 months. Psychological assessment included a clinical interview (Eating Disorder Examination) to assess eating disorders psychopathology, and three self-report measures: Outcome Questionnaire 45 – general distress; Beck Depression Inventory – depressive symptoms; and Body Shape Questionnaire – body image.
The experiences resulting from weight regain afterbariatricsurgery make up the knowledge back- ground acquired by obese people in the social re- ality in which they are inserted. This background reflects on the way they deal with theweight regain (“reasons why”). What these people live in the social world grounds the projects they aim to develop to reach the initial goal, theweight loss ofthe physical body (“reasons for”). The set of specificities of peo- ple who gain weightafterbariatricsurgery (“reasons why and for”) constitutes the typical characteristics of this social group (typification).