Metabolic Parameters,Weight Loss,and Comorbidities 4 Years After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

Background

Sleeve gastrectomy (LSG) is now the predominant bariatric surgery performed, yet there is limited long-term data comparing important outcomes between LSG and Roux-en-Y gastric bypass (RYGB). This study compares weight loss and impact on comorbidities of the two procedures.

Methods

We retrospectively evaluated weight, blood pressure, hemoglobin A1c, cholesterol, and medication use for hypertension, diabetes, and hyperlipidemia at 1–4 years post-operatively in 380 patients who underwent RYGB and 334 patients who underwent LSG at the University of Michigan from January 2008 to November 2013. Follow-up rates from 714 patients initially were 657 (92%), 556 (78%), 507 (71%), and 498 (70%) at 1–4 years post-operatively.

Results

Baseline characteristics were similar except for higher weight and BMI in LSG. There was greater weight loss with RYGB vs. LSG at all points. Hemoglobin A1c and total cholesterol improved more in RYGB vs. LSG at 4 years. There was greater remission of hypertension and discontinuation of all medications for hypertension and diabetes with RYGB at 4 years.

Conclusions

Weight loss, reduction in medications for hypertension and diabetes, improvements in markers of diabetes and hyperlipidemia, and remission rates of hypertension were superior with RYGB vs. LSG 4 years post-operatively. Choice of bariatric procedures should be tailored to surgical risk, comorbidities, and weight loss goals.

     

Secondary Hyperparathyroidism, Vitamin D Sufficiency, and Serum Calcium 5 Years After Gastric Bypass and Duodenal Switch

Background

The prevalence of secondary hyperparathyroidism (SHPT) is high after bariatric surgery. Vitamin D is supplied to counteract SHPT and bone disease, and we studied vitamin D associations with SHPT.

Methods

We measured serum levels of 25-OH vitamin D and parathyroid hormone (PTH) 5 years after gastric bypass and duodenal switch. One hundred twenty-five patients were included, of whom 114 (91 %) had undergone gastric bypass and 11 (9 %) had undergone duodenal switch. SHPT was defined as PTH?>?7.0 pmol/l in the absence of hypercalcemia. 25-OH vitamin D levels were divided into three categories: <50, 50–74, and ≥75 nmol/l. Serum ionized calcium, magnesium, phosphate, and creatinine were divided into tertiles.

Results

Mean age?±?SD was 44?±?9 years at 5 years follow-up. Ninety out of 125 (72 %) patients were women. SHPT was present in 45 out of 114 (40 %) gastric bypass patients and in 11 out of 11 (100 %) duodenal switch patients. The prevalence was high in all vitamin D categories studied. An inverse association between ionized calcium and PTH was found. For the gastric bypass patients, the odds ratio for SHPT in the upper two tertiles of ionized calcium was 0.35; 95 % CI, 0.15–0.79; p?=?0.011, compared with the lowest tertile. Supplements of vitamin D and calcium were not associated with a lower prevalence of SHPT at 5 years follow-up.

Conclusions

The prevalence of SHPT was high 5 years after gastric bypass and duodenal switch. SHPT was inversely associated with serum ionized calcium, but not with vitamin D. The supplementation used was insufficient to compensate for the impaired calcium absorption after surgery.     

Quality of Life Parameters,Weight Change and Improvement of Co-morbidities After Laparoscopic Roux Y Gastric Bypass and Laparoscopic Gastric Sleeve Resection—Comparative Study

The laparoscopic Roux Y gastric bypass (LRYGB) and the laparoscopic gastric sleeve resection are frequently used methods for the treatment of morbid obesity. Quality of life, weight loss and improvement of the co-morbidities were examined. Match pair analysis of the prospectively collected database of the 47 gastric bypass and 47 gastric sleeve resection patients operated on in our hospital was performed. The quality of life parameters were measured with two standard questionnaires (SF 36 and Moorehead–Ardelt II). The mean preoperative and postoperative BMI was in gastric bypass group 46.1 and 28.1 kg/m² (mean follow-up: 15.7 months) and in gastric sleeve group 50.3 and 33.5 kg/m² (mean follow-up: 38.3 months). The SF 36 questionnaire yielded a mean total score of 671 for the bypass and 611 for the sleeve resection patients (p = 0.06). The Moorehead–Ardelt II test signed a total score of 2.09 for gastric bypass versus 1.70 for gastric sleeve patients (p = 0.13). Ninety percent of the diabetes was resolved in the bypass and 55% in the sleeve resection group. Seventy-three percent of the hypertension patients needed no more antihypertensive treatment after gastric bypass and 30% after sleeve resection. Ninety-two percent of the gastro-oesophageal reflux were resolved in the bypass group and 25% in the sleeve (with 33% progression) group. Ninety-four percent of the patients were satisfied with the result after gastric bypass and 90% after sleeve resection. The patients have scored a high level of satisfaction in both study groups. The gastric bypass is associated with a trend toward a better quality of life without reaching statistical significance, pronounced loss of weight and more remarkable positive effects on the co-morbidities comparing with the gastric sleeve resection.     

Combination of Laparoscopic Adjustable Gastric Banding and Gastric Bypass: Current Situation and Future Prospects – Routine Use Not Advised

Although bariatric surgery has proven to be the most effective treatment for morbid obesity, most surgical techniques do have failures. In an effort to improve the reliability, several surgeons started to use a combination of a laparoscopic gastric bypass with an adjustable gastric band. Because of concerns regarding a possible negative outcome, an expert meeting was organized to evaluate the current situation and future application. In total, 104 operations were reported,with several technical variations. The overall complication rate was acceptable, but the percentage of the band erosions was 6.7%, which is too high. The potential advantages (adjustability, maintained access to the stomach and biliary tree, and reversibility) do not compensate for this complication rate. Based on the results and the opinion of the surgeons experienced in this technique, it is concluded that the combination of gastric bypass with an adjustable gastric band to form the pouch is not recommended.     

Insulin Resistance,Leptin and TNF-α System in Morbidly Obese Women after Gastric Bypass

Obesity is a complex disease associated with insulin resistance. Leptin and the TNF-α system could be involved in the pathogenesis of obesity and insulin resistance. Gastric bypass (GBP) is a surgical treatment for morbidly obese patients. We conducted a study after GBP to analyze the pattern of variation of anthropometric and body composition variables, leptin and sTNFR1 and 2. Methods: 29 morbidly obese women were studied, at baseline and throughout 6 months after gastric bypass. Results: At baseline, the BMI was 49 ± 6 kg/m² and patients showed a higher fasting insulin resistance index (FIRI), leptin, leptin/fat mass and sTNFR1 and 2 than did controls. 6 months after GBP, BMI was 35±4, and FIRI, leptin and leptin/fat mass decreased significantly in the first months and throughout the follow-up. sTNFR1 and 2 showed an initial increase, but at 6 months their concentrations were similar to baseline (2.6±0.8 vs 3.1±0.95 ng/ml, P < 0.05; 4.6±1.4 vs 7±2.5 ng/ml, P < 0.05). At baseline, there was no correlation between leptin and BMI and body composition variables but there was a correlation with fat mass (r=0.42, P=0.004) and sTNFR1 (r=0.58, P=0.001). At 6 months, there was a correlation between leptin and BMI (r=0.53, P=0.004) and sTNFR1 (r=0.46, P=0.013). Conclusions: Morbidly obese women after GBP became less insulin resistant with lower leptin concentrations, but showed an initial increase of sTNFR1 and 2. This pattern of variation of the leptin TNF-α axis suggests a disregulation of the system after dramatic weight loss and also that insulin and leptin up-regulate TNF-α production irrespective of insulin resistance status.     

Are Laparoscopic Gastric Bypass After Gastroplasty and Primary Laparoscopic Gastric Bypass Similar in Terms of Results?

Background  

This retrospective study compares the results of primary gastric bypass (PGB) versus secondary gastric bypass (SGB) performed after gastroplasty.     

A 5-Year Experience with Laparoscopic Adjustable Gastric Banding—Focus on Outcomes,Complications, and Their Management

Background  

Laparoscopic adjustable gastric banding (LAGB) remains the most popular surgical modality for obesity management in Europe. The aim of this publication is to present a 5-year experience in obesity treatment with LAGB operation with the assessment of outcomes, frequency of complications, and their management. Management of the band-related complications is crucial for continuous obesity treatments, despite the fact of initial failure, allowing further excess weight loss in patients with morbid obesity.     

Long-Term Follow-Up of Gastric Banding 10 Years and Beyond

Background

This investigation assessed the long-term outcome of patients with gastric banding implanted more than 10 years ago.

Methods

A total of 73 patients undergoing laparoscopic gastric banding between 1997 and 2003 were identified. Patients who had their band removed were converted to a laparoscopic gastric bypass procedure.

Results

The mean preoperative body mass index (BMI) was 44.4 (SD 5.3). The mean follow-up was 11.6 (SD 2.1) years. The reasons for reoperation were leakage (N?=?16, 21.9 %), slipping (N?=?15, 20.5 %), and insufficient weight loss (N?=?9, 12.3 %). The band was left in situ in 33 patients (45.2 %). The 5- and 10-year survival rates for the banding were 82.2 % (95 %CI 73.9–91.5 %) and 53.4 % (95 %CI 43.1–66.2 %). Best results were observed in male patients (10-year survival rate 76.5 %, 95 %CI 58.7–99.5 %, HR?=?0.44, P?=?0.043) and patients older than 50 years (10-year survival rate 63.8 %, 95 %CI 51.5–79.2 %, HR?=?0.41, P?=?0.006). Overall, the BMI was 31.0 (SD 6.3) at follow-up, excess weight loss was 68.1 % (SD 26.4), and the score for the Moorehead-Ardelt Questionnaire was 1.6 (SD 1.0). Similar results were obtained for patients with and without banding failure.

Conclusion

The present investigation provides evidence that gastric banding remains effective after more than 10 years in less than 50 % of initially operated patients. Older (>50 years) and male patients seemed to maintain the banding as long-time carriers with good results, and these patients subjectively profited from this method. Good results can be achieved if patients are followed thoroughly, and alternative surgical options for patients who fail may be offered with longstanding success.

     

Roux-en-Y Gastric Bypass in Mice—Surgical Technique and Characterisation

Background

A reproducible Roux-en-Y gastric bypass (RYGB) model in mice is needed to study the physiological alterations after surgery.

Methods

Male C57BL6 mice weighing 29.0?±?0.8?g underwent either RYGB (n?=?14) or sham operations (n?=?6). RYGB surgery consisted of a small gastric pouch (~2?% of the initial stomach size), a biliopancreatic and alimentary limb of 10?cm each and a common channel of 15?cm. Animals had free access to standard chow in the postoperative period. Body mass and food intake were recorded for 60?days. Bomb calorimetry was used for faecal analysis. Anatomical rearrangement was assessed using planar X-ray fluoroscopy and computed tomography (CT) after oral Gastrografin? injection.

Results

RYGB surgery led to a sustained reduction in body weight compared to sham-operated mice (postoperative week 1: sham 27.8?±?0.7?g vs. RYGB 26.5?±?1.0?g, p?=?0.008; postoperative week 8: sham 30.7?±?0.8?g vs. RYGB 28.4?±?1.1?g, p?=?0.003). RYGB mice ate less compared to shams (sham 4.6?±?0.2?g/day vs. RYGB 4.3?±?0.4?g/day, p?p?=?0.13) and faecal energy content (p?=?0.44) between RYGB and shams. CT scan demonstrated the expected anatomical rearrangement without leakage or stenosis. Fluoroscopy revealed rapid pouch emptying.

Conclusions

RYGB with a small gastric pouch is technically feasible in mice. With this model in place, genetically manipulated mouse models could be used to study the physiological mechanisms involved with metabolic changes after gastric bypass.     

Adjustments and Leak Detection of the Adjustable Silicone Gastric Band (ASGB) and Lap-Band™ Adjustable Gastric Band (LAGB) System

Background: The detection of a leakage in the system of the adjustable silicone gastric band (ASGB) may be difficult. Gastrografin injection into the port should be avoided because it acts like a glue and blocks the system. Methods: A syringe containing saline and a syringe containing Thallium-201 chloride is connected to the 4-way stopcock which is connected to the needle. The needle is pushed into the port. The position is confirmed by injection and aspiration of saline. 2 ml of TL-201 chloride (74 MBp) is injected to locate the leakage in the system with planar images with a gamma camera (Elscint SP 6), 30 min, 2, 3, and 24 h after injection. Results: The original ASGB was provided with an injection reservoir which, in our series, was found to be leaking in four cases (3%). Conclusions: Our technique for adjustments and leak detection appears to be simple and effective. Band-related problems such as reservoir leak should disappear with improvement of the material.     

Gastric diverticulum and halitosis—A case for surgery?

INTRODUCTION

Gastric diverticulum is a rare and frequently asymptomatic condition. Symptoms include vague pain, fullness, dyspepsia, vomiting, hemorrhage and perforation. Occasionally, the patient can present with belching and oral fetor.

PRESENTATION OF CASE

We report a 58-year-old woman with a gastric diverticulum who was suffering from a socially disabling oral fetor. After a thorough evaluation, a laparoscopic resection of the diverticulum was offered and completed successfully. At follow-up, the oral fetor had disappeared. The patient had no complaints and regarded herself as cured.

DISCUSSION

Although indications for the treatment of asymptomatic patients remain to be defined, pharmacological therapies including protein pump inhibitors and histamine receptor blockers have been employed, with limited effects in patients with miscellaneous symptoms. Surgery is required when serious complications such as hemorrhage or perforation of the diverticulum occur.

CONCLUSION

Surgery is required when serious complications such as hemorrhage or perforation of the diverticulum occur. Therapy resistent social disabling oral fetor may add to the indications for surgery.     

Do Gastric Bypass Patient Characteristics,Behavior, and Health Differ Depending upon how Successful Weight Loss is Defined?

There is no standardized definition of “weight loss success” after bariatric surgery. The current study was designed to evaluate if various patient factors differed between those with successful and unsuccessful weight loss; and if these findings varied depending upon which definition of weight loss success was used. A chart review of psychiatric and medical files was conducted for 110 patients who had Roux en-Y Gastric Bypass and at least 1 year of follow-up data. Data were analyzed for four weight loss success criteria: body mass index (BMI) < 30 kg/m² (n = 60 patients), BMI < 35 kg/m² (n = 86), ≥70% excess weight loss (EWL; n = 75), and ≥ 50% EWL (n = 103). For each success criterion, we examined the differences in demographics, physical co-morbidities, and psychological conditions before surgery and behavioral noncompliance after surgery between patients who had and had not achieved successful weight loss. Weight loss success rates with these patients ranged from 55% to 94%, depending upon which criterion was used. Having sleep apnea before surgery differentiated successful and unsuccessful patients when using BMI < 30 kg/m² and ≥70% EWL only. A success criterion of ≥50% EWL can be used for any patient, although a more stringent definition of success (BMI < 30 kg/m²) could be used for patients with BMI 40-50 kg/m². Future research should be done to examine how patient health and behavior predicts differing definitions of weight loss success.     

Gastric Bypass-Related Effects on Glucose Control, β Cell Function and Morphology in the Obese Zucker Rat

Background

Roux-en-Y gastric bypass (RYGB) may improve beta cell function by mechanisms other than caloric restriction and body weight loss. We aimed to assess the impact of anatomical and hormonal alterations specific to RYGB on glucose homeostasis, β cell function and morphology.

Methods

Male Zucker^fa/fa rats underwent either RYGB (n?=?11) or sham surgeries (n?=?10). Five of the shams were then food restricted and body weight matched (BWM) to the RYGB rats. Six male Zucker^fa/+ rats underwent sham surgery and served as additional lean controls. Twenty-seven days after surgery, an oral glucose tolerance test (OGTT) was performed and plasma levels of glucose, insulin and glucagon-like peptide-1 (GLP-1) were measured. Immunohistological analysis of pancreatic islets was performed, and GLP-1 receptor and PDX-1 mRNA content were quantified.

Results

Shams consumed more food and gained more weight compared to both RYGB and BWM (p?<?0.001). Hyperglycaemia was evident in ad libitum-fed shams, whilst postprandial glucose levels were lower in RYGB compared to the BWM sham group (p?<?0.05). During the OGTT, RYGB rats responded with >2.5-fold increase of GLP-1. Histology revealed signs of islet degeneration in ad libitum-fed shams, but not in RYGB and sham BWM controls (p?<?0.001). GLP-1 receptor and PDX-1 mRNA content was similar between the RYGB and BWM shams but higher compared to ad libitum shams (p?<?0.05).

Conclusions

Combined molecular, cellular and histological analyses of pancreatic function suggest that weight loss alone, and not the enhancement of GLP-1 responses, is predominant for the short-term β cell protective effects of RYGB.

     

Two-Day Length of Stay following Open Roux-En-Y Gastric Bypass: is it Feasible,Safe and Reasonable?

Background: As our bariatric program matured, we noted that length of stay (LOS) steadily decreased. This led us to analyze our experience to identify factors contributing to this abbreviated LOS and to evaluate the safety of discharging patients with only a 2-day LOS. Methods: All patients undergoing open Roux-en-Y gastric bypass (RYGBP) from March, 1998 to December 31, 2002 were evaluated. Contrast swallow study was performed on Day 1. Patient demographics, complications, and readmission rates were reported for all patients. Discharge criteria included adequate oral intake, pain control with oral analgesia, and an adequate understanding of the operation and its effects demonstrated by a written test before discharge. Results: 316 patients underwent open RYGBP with mean BMI 52.3. Operative time decreased from 241 minutes in 1998 to 156 minutes in 2002. No patient was discharged at 2 days during the first 2 years of the program. In 2000, 1 of 52 patients (2%) went home on the second day. In 2001, the year we fully enacted our multidisciplinary approach, 14 of 96 patients (15%) returned home on the second day. In 2002, 73 of 145 patients (50%) were discharged on the second postoperative day, with no increase in readmission rates. Three of the 73 patients (4.1%) required readmission within 30 days of discharge. No difference in co-morbid diseases or BMI was noted between groups. Conclusions: Our data support the hypothesis that patients undergoing open RYGBP can be discharged safely at Day 2, provided that aggressive preoperative education and screening are performed.