Predictors of Weight Status following Laparoscopic Gastric Bypass

Background: Weight loss after bariatric surgery varies and depends on many factors, such as time elapsed since surgery, baseline weight, and co-morbidities. Methods: We analyzed weight data from 494 patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) by one surgeon at an academic institution between June 1999 and December 2004. Linear regression was used to identify factors in predicting % excess weight loss (%EWL) at 1 year. Results: Mean patient age at time of surgery was 44 ± 9.6 (SD), and the majority were female (83.8%). The baseline prevalence of co-morbidities included 24% for diabetes, 42% for hypertension, and 15% for hypercholesterolemia. Baseline BMI was 51.5 ± 8.5 kg/m². Mean length of hospital stay was 3.8 ± 4.6 days. Mortality rate was 0.6%. Follow-up weight data were available for 90% of patients at 6 months after RYGBP, 90% at 1 year, and 51% at 2 years. Mean %EWL at 1 year was 65 ± 15.2%. The success rate (≥50 %EWL) at 1 year was 85%. Younger age and lower baseline weight predicted greater weight loss. Males lost more weight than females. Diabetes was associated with a lower %EWL. Depression did not significantly predict %EWL. Conclusion: The study demonstrated a 65 %EWL and 85% success rate at 1 year in our bariatric surgery program. Our finding that most pre-surgery co-morbidities and depression did not predict weight loss may have implications for pre-surgery screening.     

Calorie Intake and Meal Patterns up to 4 Years after Roux-en-Y Gastric Bypass Surgery

Background: Roux-en-Y gastric bypass (RYGBP) is the most popular surgical treatment for morbid obesity in the U.S.A., producing significant and durable weight loss with improvement in co-morbidities. Although a greater number of patients are undergoing surgical treatment for obesity, little data are available regarding their food intake after surgery. This study was undertaken to evaluate the caloric amount, nutrient composition and meal patterns of patients 18 months to 4 years after RYGBP. Ethnic differences in food intake were also investigated. Methods: Questionnaires were mailed to 360 patients who had undergone RYGBP at least 18 months prior to the onset of the study. Results: Data were available from 69 patients, 52% Caucasian, 25% African-American, 23% Hispanic. 30 months after surgery, the average daily calorie intake was 1733 ± 630 kcal (n=68, range 624-3486 kcal), with 44% of calories from carbohydrates, 22% from protein and 33% from fat. Sugar-sweetened beverages represented 7% of total caloric intake. Patients consumed 3 meals and 3 snacks per day on average. Food intake from dinner and an evening snack represented 40% of the daily caloric intake. Snacks accounted for 37% of the daily intake. Percent excess weight loss (%EWL) was 58 ± 17% and was not different among ethnic groups. However, Hispanics reported consuming fewer snacks and fewer calories. %EWL correlated with the total daily caloric intake (r= .446, P <0.001). Follow-up attendance was 54% at 1 year after surgery but fell to 10% at 3 years. Only 77% of patients were taking vitamin supplements. Conclusion: RYGBP resulted in significant weight loss. Caloric intake was quite variable. Long-term follow-up remained low, putting patients at risk for metabolic and vitamin deficiencies. The relationship between caloric intake and long-term weight changes remains to be studied.     

Revision of Failed Gastric Restrictive Operations to Roux-en-Y Gastric Bypass: Impact of Multiple Prior Bariatric Operations on Outcome

Background: Morbid obesity is now an epidemic with considerable associated morbidity for which bariatric surgery has been the only effective treatment. Despite its success, occasional patients require revision because of weight regain or mechanical complications. The impact of multiple prior bariatric operations on complications and weight loss after revision to Roux-en-Y gastric bypass (RYGBP) was evaluated. Methods: All patients undergoing revisional surgery to RYGBP by the senior author from 1997 through 2004 were retrospectively reviewed at a multi-center academic institution. Patients who had previously undergone multiple revisional operations (MR) were compared to patients who had undergone primary ("first-time") revision (PR). Demographics, indications for revision, complications, and weight loss were reviewed. Results: 66 patients underwent open revision to RYGBP after failed bariatric operations, with 12 in the MR group and 54 in the PR group. Mean preoperative BMI was 46.1 and 45.2 (P=0.8), respectively. Operative time (227 vs 162 min, P=0.07), blood loss (517 vs 313 ml, P=0.09) and hospital length of stay (11.5 vs 6.7 days, P=0.2) were higher in the MR group. Major perioperative complications occurred in 16.7% of MR patients compared to 9.3% of PR patients (P=0.6). Percent of excess weight loss (%EWL) has been 54.3% in the MR group and 60.6% in the PR group (P=0.6). Average follow-up is 26 and 23 months, respectively. Conclusion: Although operative times, blood loss, and LOS were greater in MR patients, RYGBP can be performed in patients with multiple previous bariatric operations with acceptable weight loss and complication rates.     

Roux-en-Y Gastric Bypass versus a Variant of Biliopancreatic Diversion in a Non-Superobese Population: Prospective Comparison of the Efficacy and the Incidence of Metabolic Deficiencies

Background: In the non-superobese population, an agreement has not been made as to the optimal bariatric operation. The present study reports the results of a prospective comparison of Roux-en-Y gastric bypass (RYGBP) and a variant of biliopancreatic diversion (BPD) in a non-superobese population. Methods: From a cohort of 130 patients with BMI 35 to 50 kg/m², 65 patients were randomly selected to undergo RYGBP and 65 to undergo BPD. All patients underwent complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. Results: Patients in both groups have completed their second postoperative year. Mean % excess weight loss (%EWL) was significantly better after BPD at all time periods (12 months, P=0.0001 and 24 months, P=0.0003), and the %EWL was >50% in all BPD patients compared to 88.7% in the RYGBP patients at 2-year follow-up. No statistically significant differences were observed between the 2 groups in early and late non-metabolic complications. Hypoalbuminemia occurred in only 1 patient (1.5%) after RYGBP and in 6 patients after BPD (9.2%). Only 1 patient from each group was hospitalized and received total parenteral nutrition. Glucose intolerance, hypercholesterolemia, hypertriglyceridemia and sleep apnea completely resolved in all patients in both groups, although mean total cholesterol level was significantly lower in BPD patients at the second year follow-up (t-test, P<0.0001). Diabetes completely resolved in all BPD patients and in 7 of the 10 diabetic RYGBP patients. Conclusion: Both RYGBP and BPD were safe and effective procedures when offered to non-superobese patients. Weight loss after BPD was consistently better than that after RYGBP, as was the resolution of diabetes and hypercholesterolemia. Because the nutritional deficiencies that occurred following this type of BPD were not severe and were not significantly different between the 2 operations, both may be offered to non-superobese patients, keeping in mind the severity and type of preoperative co-morbidities as well as the desired weight loss.     

Impact of Patient Follow-Up on Weight Loss after Bariatric Surgery

Background: Postoperative follow-up after bariatric surgery is important. Because of the need for adjustments, follow-up after gastric banding may have a greater impact on weight loss than after Roux-en-Y gastric bypass.We reviewed all patients at 1 year after these two operations. Methods: During the first year after surgery, laparoscopic adjustable gastric banding (LAGB) patients were followed every 4 weeks and Roux-en-Y gastric bypass (RYGBP) patients were followed at 3 weeks postoperatively and then every 3 months.The number of follow-up visits for each patient was calculated, and 50% compliance for follow-up and weight loss was compared. Results: Between October 2000 and September 2002, 216 LAGB and 139 RYGBP operations were performed. Of these patients, 186 LAGB patients and 115 RYGBP patients were available for 1-year follow-up. Age and BMI were similar for each group. Overall excess weight loss (EWL) after LAGB was 44.5%. 130 (70%) returned 6 or less times in the first year and achieved 42% EWL. 56 patients (30%) returned more than 6 times and had 50% EWL (P=0.005). Overall %EWL after RYGBP was 66.1%. 53 patients (46%) returned 3 or less times in the first year, achieving 66.1% EWL. 62 patients (54%) returned more than 3 times after surgery and achieved 67.6% EWL (P=NS). Conclusion: Patient follow-up plays a significant role in the amount of weight lost after LAGB, but not after RYGBP. Patient motivation and surgeon commitment for long-term follow-up is critical for successful weight loss after LAGB surgery.     

Preoperative Carbohydrate "Addiction" Does Not Predict Weight Loss after Laparoscopic Gastric Bypass

Background: Weight loss after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies. Dietary habits that exist preoperatively may continue after surgery and affect weight loss. This study investigated the hypothesis that preoperative carbohydrate addiction would predict weight loss after laparoscopic gastric bypass. Methods: 104 consecutive patients in our LRYGBP program were included in the study. A preoperative survey was used to determine level of carbohydrate craving. This survey was scored from 0 to 60. A higher score indicated a higher level of carbohydrate addiction. Percentage of excess weight loss (%EWL) was determined after at least 1 year postoperatively in all patients. Results: Data were available in 95 (91%) of the patients. There was no correlation seen between level of carbohydrate addiction and %EWL at 1 year (r=0.02; P=NS). In addition, we looked at patients with successful weight loss (>50% %EWL; n=83) versus those patients who were considered unsuccessful (<50% EWL; n=12). There was no statistical difference in the level of preoperative carbohydrate craving between these 2 groups (36±13 vs 33±15; P=NS). Conclusions: Consistently large carbohydrate intake preoperatively does not predict weight loss after LRYGBP. High level of carbohydrate addiction is not a contraindication to LRYGBP.     

Systematic Review of Medium-Term Weight Loss after Bariatric Operations

Background: Although bariatric surgery is known to be effective in the short term, the durability of that effect has not been convincingly demonstrated over the medium term (>3 years) and the long term (>10 years). The authors studied the durability of weight loss after bariatric surgery based on a systematic review of the published literature. Methods: All reports published up to September, 2005 were included if they were full papers in refereed journals published in English, of outcomes after Roux-en-Y gastric bypass (RYGBP), and its hybrid procedures of banded bypass (Banded RYGBP) and longlimb bypass (LL-RYGBP), biliopancreatic diversion with or without duodenal switch (BPD±DS) or laparoscopic adjustable gastric banding (LAGB). All reports that had at least 100 patients at commencement, and provided ≥3 years of follow-up data were included. Results: From a total of 1,703 reports extracted, 43 reports fulfilled the entry criteria (18 RYGBP; 18 LAGB; 7 BPD). Pooled data from all the bariatric operations showed effective and durable weight loss to 10 years. Mean %EWL for standard RYGBP was higher than for LAGB at years 1 and 2 (67 vs 42; 67 vs 53) but not different at 3, 4, 5, 6 or 7 years (62 vs 55; 58 vs 55; 58 vs 55; 53 vs 50; and 55 vs 51). There was 59 %EWL for LAGB at 8 years, and 52 %EWL for RYGBP at 10 years. Both the BPD±DS and the Banded RYGBP appeared to show better weight loss than standard RYGBP and LAGB, but with statistically significant differences present at year 5 alone. The LL-RYGBP was not associated with improved %EWL. Important limitations include lack of data on loss to follow-up, failure to identify numbers of patients measured at each data point and lack of data beyond 10 years. Conclusions: All current bariatric operations lead to major weight loss in the medium term. BPD and Banded RYGBP appear to be more effective than both RYGBP and LAGB which are equal in the medium term.     

The Magenstrasse and Mill Procedure can be Combined with a Roux-en-Y Gastric Bypass to Produce Greater and Sustained Weight Loss

Background: The Magenstrasse and Mill operation (M&M) is effective in producing sustained weight loss and reducing obesity-related co-morbidity. It avoids the implantation of foreign material and is a more physiological procedure by maintaining normal gastric emptying. Side-effects are minimal and operative mortality is low. Satisfactory weight loss is seen at 1 year with 60% of excess weight lost. The present study compared weight loss produced by the combination of a Roux-en-Y gastric bypass (RYGBP) with the standard M&M procedure. Methods: Between 1993 and 2001, 118 patients underwent surgery for the treatment of morbid obesity. 70 patients between 1993 and 1998 underwent only a M&M vertical gastric stapling, and 48 patients from 1998 underwent the M&M combined with a RYGBP. Results: Median follow-up for the M&M procedure was 36 months (range 1 to 72) and for the combined M & M and RYGBP was 30 months (range 1 to 48). At all time points following surgery, patients having a RYGBP performed in addition to the standard M&M procedure demonstrated a significantly greater amount of weight lost (P<0.0001, Mann-Whitney U-test) and overall percentage of excess weight lost (P<0.0001, Mann-Whitney U-test). Both groups had a significant reduction in BMI, although this was greater in the group that underwent the combined procedure at 3 years (P<0.001, sample t-test). Conclusions: A more rapid and prolonged weight loss was found when the M&M procedure was performed in combination with a RYGBP. This suggests that this combined procedure may be more beneficial when greater amounts of weight loss are needed in the super-obese.     

Sweet eating is not a predictor of outcome after Lap-Band placement. Can we finally bury the myth?

Background: It is common belief that sweet eaters will do poorly after gastric restrictive surgery.There is scant evidence for this and significant evidence that sweet eating behavior is not predictive of weight outcome. Preoperative and current sweet eating behavior was assessed in subjects who have had Lap-Band^? surgery, to find if this influenced weight outcomes. Method: 200 unselected patients who had bands inserted for >1 year completed a questionaire regarding preoperative sweet eating behavior. The last 100 patients also reported current sweet eating behavior. Sweet eating was scored using a standard dietary questionnaire. Results: Mean±SD % excess weight loss at 1 year (%EWL1) for the 100 with the highest preoperative sweet eating scores (SES) was 47.1±16% compared with a loss of 48.2±16% by those with the lowest SES (P=0.64). Analysis showed no significant linear or non-linear correlation between the SES and the %EWL. For the highest quintile of SES, the EWL1 was 47.3±14% and for the lowest was 46.1±16% (NS). Sweet eaters were younger (r=-0.21, P=0.003) and had higher fasting insulin concentrations (r=-0.18, P=0.03). Preoperative SES had no influence on %EWL1 after controlling for factors known to influence weight loss. %EWL at 2 years (n=130) and 3 years (n=88) were not different for sweet eaters and non-sweet eaters. Current sweet eating tendency (n=100) also had no impact on %EWL. Conclusion: Sweet eaters do not have less favorable weight outcomes following Lap-Band^? surgery. Our study confirms the findings of two other major studies. Sweet eating behavior should not be used as a preoperative selection criterion for bariatric surgery.     

A Prospective Randomized Study Between Laparoscopic Gastric Banding and Laparoscopic Isolated Sleeve Gastrectomy: Results after 1 and 3 Years

Background: Laparoscopic adjustable gastric banding (GB) is the most popular restrictive procedure for obesity in Europe. Isolated sleeve gastrectomy (SG), is less common, but more invasive and with a higher learning curve. The aim of this prospective randomized study was to compare the results of GB and SG after 1 and 3 years of surgery. Methods: 80 patient candidates for laparoscopic restrictive surgery were operated consecutively and randomly, between January and December 31, 2002, by GB (7M, 33F) or by SG (9M, 31F) (NS). Median age was 36 (20-61) for GB versus 40 (22-65) for SG (NS). Median BMI was 37 (30-47) for GB versus 39 (30-53) for SG (NS). After 1 and 3 years: weight loss, feeling of hunger, sweet eating, gastroesophageal reflux disease (GERD), complications and re-operations were recorded in both groups. Results: Median weight loss after 1 year was 14 kg (−5 to +38) for GB and 26 kg (0 to 46) for SG (P<0.0001); and after 3 years was 17 kg (0 to 40) for GB and 29.5 kg (1 to 48) for SG (P<0.0001). Median decrease in BMI after 1 year was 15.5 kg/m 2 (5 to 39) after GB and 25 kg/m² (0 to 45) after SG (P<0.0001); and after 3 years was 18 kg/m² (0 to 39) after GB and 27.5 kg/m 2 (0 to 48) after SG (P=0.0004). Median %EWL at 1 year was 41.4% (−11.8 to +130.5) after GB and 57.7% (0 to 125.5) after SG (P=0.0004); and at 3 years was 48% (0 to 124.8) after GB and 66% (−3.1 to +152.4) after SG (P=0.0025). Loss of feeling of hunger after 1 year was registered in 42.5% of patients with GB and in 75% of patients with SG (P=0.003); and after 3 years in 2.9% of patients with GB and 46.7% of patients with SG (P<0.0001). Loss of craving for sweets after 1 year was achieved in 35% of patients with GB and 50% of patients with SG (NS); and after 3 years in 2.9% of patients with GB and 23% of patients with SG (NS). GERD appeared de novo after 1 year in 8.8% of patients with GB and 21.8% of patients with SG (NS); and after 3 years in 20.5% of patients with GB and 3.1% of patients with SG (NS). Postoperative complications requiring re-operation were necessary for 2 patients after SG. Late complications requiring re-operation after GB included 3 pouch dilations treated by band removal in 2 and 1 laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP), 1 gastric erosion treated by conversion to RYGBP, and 3 disconnections of the system treated by reconnection. Inefficacy affected 2 patients after GB, treated by conversion into RYGBP and 2 patients after SG treated by conversion to duodenal switch. Conclusion: Weight loss and loss of feeling of hunger after 1 year and 3 years are better after SG than GB. GERD is more frequent at 1 year after SG and at 3 years after GB. The number of re-operations is important in both groups, but the severity of complications appears higher in SG.