Laparoscopic Bariatric Surgery in Super-obese Patients (BMI>50) is Safe and Effective: A Review of 332 Patients

Background: Bariatric surgery in super-obese patients (BMI >50 kg/m²) can be challenging because of difficulties in exposure of visceral fat, retracting the fatty liver, and strong torque applied to instruments, as well as existing co-morbidities. Methods: A retrospective review of super-obese patients who underwent laparoscopic adjustable gastric banding (LAGB n=192), Roux-en-Y gastric bypass (RYGBP n=97), and biliopancreatic diversion with/without duodenal switch (BPD n= 43), was performed. 30day peri-operative morbidity and mortality were evaluated to determine relative safety of the 3 operations. Results: From October 2000 through June 2004, 331 super-obese patients underwent laparoscopic bariatric surgery, with mean BMI 55.3 kg/m². Patients were aged 42 years (13-72), and 75% were female. When categorized by opertaion (LAGB, RYGBP, BPD), the mean age, BMI and gender were comparable. 6 patients were converted to open (1.8%). LAGB had a 0.5%, RYGBP 2.1% and BPD 7.0% conversion rate (P=0.02, all groups). Median operative time was 60 min for LAGB, 130 min for RYGBP and 255 min for BPD (P<0.001, all groups). Median length of stay was 24 hours for LAGB, 72 hours for RYGBP, and 96 hours for BPD (P <0.001). Mean %EWL for the LAGB was 35.3±12.6, 45.8±19.4, and 49.5±18.6 with follow-up of 87%, 76% and 72% at 1, 2 and 3 years, respectively. Mean %EWL for the RYGBP was 57.7±15.4, 54.7±21.2, and 56.8±21.1 with follow-up of 76%, 33% and 54% at 1, 2 and 3 years, respectively. Mean %EWL for the BPD was 60.6±15.9, 69.4±13.0 and 77.4±11.9 with follow-up of 79%, 43% and 47% at 1, 2 and 3 years, respectively. The difference in %EWL was significant at all time intervals between the LAGB and BPD (P<0.004). However, there was no significant difference in %EWL between LAGB and RYGBP at 2 and 3 years. Overall perioperative morbidity occurred in 27 patients (8.1%). LAGB had 4.7% morbidity rate, RYGBP 11.3%, and BPD 16.3% (P=0.02, all groups). There were no deaths. Conclusion: Laparoscopic bariatric surgery is safe in super-obese patients. LAGB, the least invasive procedure, resulted in the lowest operative times, the lowest conversion rate, the shortest hospital stay and the lowest morbidity in this high-risk cohort of patients. Rates of all parameters studied increased with increasing procedural complexity. However, the difference in %EWL between RYGBP and LAGB at 2 and 3 years was not statistically significant.     

A Prospective Comparison of Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass in a Non-Superobese Population

Background: In the non-superobese population, consensus is currently unavailable in bariatric surgery. We report the results of a prospective comparison of vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGBP) in a non-superobese population. Methods: From 1994 to 2000, 179 patients with clinically severe obesity underwent various surgical procedures in our department. During this time a prospective study was undertaken in order to compare VBG with RYGBP in morbidly obese patients with a BMI <50 kg/m². Based on specific criteria including eating behavior, 68 patients were selected to undergo RYGBP and 35 VBG. All patients have undergone complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. Results: All patients have now completed their 5th postoperative year. Mean follow-up period to date is 96.5±12.2 months for VBG and 67.6±11.3 months for RYGBP. 3 patients (8.6%) in the VBG group and 9 patients (13.2%) in the RYGBP group are lost to follow-up. Mean excess weight loss (EWL) was always better in the RYGBP group (P=0.0013). The percentage of failure, defined as EWL <25%, was not significantly different between the two procedures. No statistically significant differences were observed between the 2 groups in the total number of non-metabolic complications, and the only statistically significant difference observed in metabolic complications was vitamin B₁₂ deficiency after RYGBP. Frequency of vomiting was significantly less and quality of eating significantly better in RYGBP than in VBG patients. Conclusion: This prospective long-term study, with nearly complete follow-up, suggests that in the non-superobese population, preoperative eating habits may play a role in choosing the most appropriate bariatric operation for each patient. Although RYGBP is associated with better mean weight loss outcomes, the percentage of patients who achieved and maintained ≥50% EWL after VBG in this pre-selected patient population was not significantly different. Each type of operation has advantages and disadvantages, and, if properly chosen, a purely restrictive procedure can be successful for some patients. Therefore, it can be said that the decision regarding which bariatric procedure to perform in non-superobese patients must be based on in-depth preoperative evaluation as well as the patients' own preferences and outcome expectations.     

Depression Score Predicts Weight Loss following Roux-en-Y Gastric Bypass

Background: The prevalence of obesity is increasing in the United States. Bariatric surgery is the only intervention that can reliably induce and maintain significant weight loss in obese patients. The association between pre-surgical severity of depression and success at weight loss following Roux-en-Y gastric bypass (RYGBP) has not yet been fully elucidated. Methods: 145 charts of patients who underwent RYGBP for morbid obesity were reviewed. 47 patients who filled out the Beck Depression Inventory (BDI) before surgery and completed 1 year of follow-up were studied. The relationship between pre-surgical severity of depression and success at weight loss was examined through multivariate regression analysis using percent excess weight loss (%EWL) as a dependent variable and BDI score as one of the predictors. Results: Weight loss at 1 year was significantly related to the BDI score before surgery (P =0.014). BDI score was also found to be a significant predictor of the amount of weight lost (kg) 1 year after surgery (P =0.027). Age (P =0.03) and initial body mass index (BMI) (P =0.011) were the only other variables with significant independent relations to %EWL. Conclusions: Our data show a positive correlation between pre-surgical severity of depression as measured by BDI score and the 1-year success at weight loss after RYGBP as measured by %EWL. More depressed individuals tend to lose greater amounts of weight compared with less depressed individuals. Future prospective studies should examine possible mechanisms and effects of depression and other psychiatric disturbances on long-term weight loss after RYGBP.     

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.     

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.     

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.     

The Decrease in Plasma Ghrelin Concentrations following Bariatric Surgery Depends on the Functional Integrity of the Fundus

Background: Gastric bypass surgery, which involves the production of a reduced stomach pouch,has been shown to markedly suppress circulating ghrelin concentrations. Since bypassing the ghrelin-producing cell population may be relevant to the disruption of fundic-derived factors participating in food intake signaling, the effect of weight loss induced by either adjustable gastric banding (AGB), Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion (BPD) was studied. Methods: 16 matched obese patients [35.0 + 2.4 years; initial body weight 124.8 ± 5.7 kg; body mass index (BMI) 47.1 ± 2.2 kg/m²] in whom similar weight loss had been achieved by either AGB (n=7), RYGBP (n=6) or BPD (n=3) were studied. Blood was obtained for biochemical and hormonal analyses. Body composition was assessed by air-displacement-plethysmography. Results: Comparable weight loss (AGB: 26.1 ± 5.1 kg; RYGBP: 32.1 ± 5.0; BPD: 31.7 ± 6.1; P=NS) and decrease in percentage body fat (AGB: 10.0 ± 1.5%; RYGBP: 14.2 ± 2.8; BPD: 10.3 ± 1.0; P=NS) induced by bariatric surgery exerted significantly different (P=0.004) effects on plasma ghrelin concentrations, depending on the surgical procedure applied (AGB: 480 ± 78 pg/ml; RYGBP: 117 ± 34; BPD: 406 ± 86). Without significant differences in BMI, body fat, glucose, triglycerides, cholesterol, insulin and leptin levels, patients who had undergone the RYGBP exhibited statistically significant diminished circulating fasting plasma ghrelin concentrations compared with the other two bariatric techniques which conserve direct contact of the fundus with ingested food (P=0.003 vs AGB and P=0.020 vs BPD). Conclusion: Fasting circulating ghrelin concentrations in patients undergoing diverse bariatric operations depend on the degree of dysfunctionality of the fundus.     

Resolution of Diabetes Mellitus and Metabolic Syndrome following Roux-en-Y Gastric Bypass and a Variant of Biliopancreatic Diversion in Patients with Morbid Obesity

Background Obesity is associated with increased prevalence of type 2 diabetes mellitus (DM2) and metabolic syndrome and increased morbidity and mortality. Bariatric surgery results in significant and long-term weight loss. Two of the most effective and popular bariatric procedures are Roux-en-Y gastric bypass (RYGBP) and biliopancreatic diversion (BPD). The objective of this study was to investigate the effects of RYGBP and BPD-RYGBP, a variant of BPD with a lower rate of metabolic deficiencies than BPD, on DM2 and the major components of metabolic syndrome in patients with morbid obesity and DM2. Methods The prospective database of our unit, from June 1994 until May 2006, was analyzed and 137 patients with DM2 were found. 26 underwent RYGBP (BMI 46.1±2.9 kg/m²) and 111 BPD-RYGBP (BMI 59.7±10.6 kg/m²). 7 of the patients were on insulin (4.90%) and 37 on oral hypoglycemic agents (25.87%). Pre- and postoperative medications, and clinical and biochemical parameters were considered in the analysis. The mean follow-up was 26.39±21.17 months. Results Excess weight loss was ∼70% after either procedure. DM2 resolved in 89% and 99% of the cases following RYGBP and BPD-RYGBP, respectively. 2 years after BPD-RYGBP all the patients had blood glucose <110 mg/dl, 95% had normal cholesterol, 92% normal triglycerides and 82% normal blood pressure. The respective values following RYGBP were 66%, 33%, 78% and 44%. Uric acid decreased significantly only after BPD-RYGBP. Liver enzymes improved in both groups. Conclusions RYGBP and BPD-RYGBP are safe and lead to normalization of blood glucose, lipids, uric acid, liver enzymes and arterial pressure in the majority of patients, although this variant of BPD was more effective than RYGBP.We suggest that further studies should also investigate its usefulness in patients with milder degrees of obesity, DM2 and metabolic syndrome.     

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.     

Prospective evaluation of biliopancreatic diversion with roux-en-y gastric bypass in the super obese

The aim of this study was to determine prospectively the efficacy and safety of the biliopancreatic diversion with Roux-en-Y gastric bypass (BPD with RYGBP) procedure used as the primary bariatric procedure in super obese patients. The main characteristics of the BPD with RYGBP procedure were a gastric pouch of 15 ± 5 ml, biliopancreatic limb of 200 cm, common limb of 100 cm, and alimentary limb of the remainder of the small intestine. From June 1994 through July 2003, 132 super obese patients (body mass index [BMI]: 57 ± 7), with an incidence of comorbidities 6 ± 2 per patient, underwent BPD with RYGBP and subsequent follow-up. Mean follow-up time was 29 ± 14 months. Maximum weight loss was achieved at 18 months postoperative with average excess weight loss (EWL) 65%, average initial weight loss (IWL) 39%, and average BMI 35 kg/m². Thereafter, a decline was observed with EWL stabilizing at around 50%, IWL at around 30%, and BMI at around 40 kg/m², respectively, by the end of the study period. The majority of preexisting comorbidities were permanently resolved by the 6-month follow-up visit. Early mortality was 1% and early morbidity was 11%. Late morbidity was 27%, half of which was due to incisional hernia. Deficiencies of microelements were mild and successfully treated with additional oral supplementation. The incidence of hypoalbuminemia was 3% and there were no hepatic complications. We conclude that BPD with RYGBP is a safe and effective procedure for the super obese with few metabolic complications.     

Roux-en-Y divided gastric bypass results in the same weight loss as duodenal switch for morbid obesity

BACKGROUND: The 2 weight loss procedures most commonly performed in the United States are Roux-en-Y gastric bypass (RYGBP) and lateral gastrectomy with duodenal switch (BPD/DS). RYGB is a restrictive procedure, whereas BPD/DS relies on mild restriction of intake as well as malabsorption. Many physicians believe that weight loss is greater after BPD/DS than after RYGBP. However, these procedures have not been compared using groups of patients operated on by the same surgeons at the same institution. METHODS: We compared weight loss (expressed as percent of excess body weight [%EBW]) after 1 and 2 years in patients who underwent open RYGB or BPD/DS at our institution. RESULTS: Average length of stay was longer in BPD/DS patients than in those undergoing RYGBP (8.7 vs. 5.9 days, P <0.05). Anastomotic leaks were higher after BPD/DS (6% vs. 3%), but the difference did not achieve statistical significance. Mortality did not differ between the 2 groups (0.8% vs. 0.9%). In the group of patients followed-up for 1 to 2 years, age and distribution of men and women did not differ. Those patients undergoing BPD/DS had higher body mass index (59 vs. 55, P <0.05). Weight loss expressed as %EBW was similar between the 2 groups: 54% versus 53% at 1 year and 67% versus 64% at 2 years. CONCLUSIONS: Our data suggested that weight loss expressed as %EBW is similar between patients undergoing RYGBP and those undergoing BPD/DS. However, BPD/DS was associated with a longer hospital stay.     

Do Preoperative Eating Behaviors Influence Weight Loss After Biliopancreatic Diversion?

Background

The presence of disturbed eating patterns can affect the short- and long-term outcomes after bariatric surgery. Data about the influence of preoperative eating patterns on outcomes after biliopancreatic diversion (BPD) are lacking. The aim of the present study was to assess the role of preoperative eating behavior in patients’ selection for biliopancreatic diversion.

Methods

Sixty-one consecutive patients who underwent BPD were evaluated for the present study. For each patient, the following preoperative eating patterns were evaluated: sweet eating, snacking, hyperphagia, and gorging. The primary outcome measure was the percentage of excess weight loss (%EWL) at 3, 6, and 12 months in the groups of patients with different eating patterns at the preoperative evaluation.

Results

At the preoperative evaluation, snacking was found in 31 patients (50.8 %), sweet eating in 15 patients (24.6 %), hyperphagia in 48 patients (78.7 %), and gorging in 45 patients (73.8 %). For each eating behavior, there was no significant difference in mean preoperative BMI and weight loss at 3, 6, and 12 months between the group of patients with and the group of patients without the eating pattern considered. At the analysis of variance in the four groups of patients presenting the eating patterns considered, there was no difference in mean preoperative BMI (P?=?0.66), %EWL at 3 months (P?=?0.62), %EWL at 6 months (P?=?0.94), and %EWL at 12 months (P?=?0.95).

Conclusions

Preoperative eating behaviors do not represent reliable outcome predictors for BPD, and they should not be used as a selection criterion for patients who are candidates to this operation.     

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.     

Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Roux-en-Y gastric bypass in superobese patients

BackgroundAlthough biliopancreatic diversion with duodenal switch (BPD-DS) is not the most performed procedure, Roux-en-Y gastric bypass (RYGB) is challenged by weight regain and insufficient weight loss, especially in patients with a body mass index >50 kg/m². The aim of our retrospective study was to compare the weight loss after 2 types of primary bariatric surgery. A total of 83 BPD-DS and 97 RYGB procedures were performed from March 2002 to October 2009 for an initial mean body mass index of 55 kg/m².MethodsAll RYGB patients underwent surgery at a private practice hospital and BPD-DS patients underwent surgery at a university hospital before February 2007 and at the same private hospital thereafter. The patients were seen in follow-up every 4 months the first year, every 6 months the second, and yearly thereafter. The maximum weight loss was assessed, as well as the weight regain beyond the first postoperative year. Weight loss success was defined as a percentage of excess weight loss (%EWL) of ≥50%.ResultsThe patients did not differ by age, gender, or length of follow-up (mean 46 mo, range .5–102 for RYGB and 44.3 mo, range 9–111 for BPD-DS). Of the patients, 17 RYGB and 7 BPD-DS patients were lost to follow-up within 3 years postoperatively. At 3 years of follow-up, the mean %EWL was 63.7% ± 17.0% after RYGB and 84.0% ± 14.5% after BPD-DS (P < .0001). Weight loss success was achieved by 83.5% of the RYGB and 98.7% of the BPD-DS patients (P = .0005).ConclusionAfter 12 months postoperatively, the number of patients regaining 10% of the weight lost during the first postoperative year was significantly greater after RYGB than after BPD-DS.     

Patient Characteristics Impacting Excess Weight Loss following Laparoscopic Adjustable Gastric Banding

Background: Weight loss is more variable after laparoscopic adjustable gastric banding (LAGB) than after gastric bypass. Subgroup analysis of patients may offer insight into this variability. The aim of our study was to identify preoperative factors that predict outcome. Methods: Demographics, co-morbid conditions and follow-up weight were collected for our 1st 200 LapBand ? patients. Linear regression determined average %EWL. Logistic regression analysis identified factors that impacted %EWL. Result: 200 patients returned for 778 follow-up visits. Median age was 44 years (21-72) and median BMI 45 kg/m² (31-76). 140 (80%) were women. Average %EWL was y % = 0.007 %/day (days since surgery) + 0.12% (correlation coef. 0.4823; P<0.001). %EWL at 1 year was 37%. The best-fit logistic regression model found 7 factors that significantly changed the odds of achieving average %EWL. Older patients, diabetic patients and patients with COPD had greater odds of above average %EWL. Female patients, patients with larger BMIs, asthmatic patients and patients with hypertension had increased odds of below average %EWL. Conclusion: Specific patient characteristics and comorbid conditions significantly altered the odds of achieving satisfactory %EWL following gastric banding.     

Long-Term Results of a Prospective Comparison of Roux-en-Y Gastric Bypass versus a Variant of Biliopancreatic Diversion in a Non-Superobese Population (BMI 35–50 kg/m2)

Background

This study presents late results of a previously published 2-year prospective comparison between Roux-en-Y gastric bypass (RYGBP) versus biliopancreatic diversion with Roux-en-Y gastric bypass (BPD-RYGBP) in an exclusively non-superobese population.

Methods

From a cohort of 130 patients with a BMI of 35–50 kg/m², 65 were randomly selected to undergo RYGBP and 65 to BPD-RYGBP. All underwent follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter.

Results

Follow-up at the eighth year was achieved in 60 % of the BPD-RYGBP and in 58 % of the RYGBP group (p?=?1.00). Mean excess weight loss (EWL%), was significantly higher following BPD-RYGBP (76.89?±?1.53) as compared to RYGBP (67.17?±?1.43) (p?=?0.0004). The mean success rate (percentage of patients with EWL% ≥50 %) was significantly higher after BPD-RYGBP (95.85?±?1.01) than RYGBP (75.91?±?3.58) (p?=?0.0001). No significant differences were observed for late non-metabolic complications. The incidence of anemia, iron deficiency, B₁₂ deficiency, and low-ferritin levels was relatively high in both groups with not always significant differences. Severe protein malnutrition occurred in four patients (three BPD-RYGBP and one RYGBP) (p?=?0.37). In only one BPD-RYGBP patient (1.54 %) was revision surgery to RYGBP necessary, due to recurrent episodes of hypoproteinemia. The remaining patients were treated successfully with total parenteral nutrition and nutritional counseling.

Conclusions

Late results presented in this paper agree with the previously published 2-year results of the same patient cohort. Although both procedures are safe and effective, BPD-RYGBP seems to prevail in terms of successful weight loss without a significantly higher incidence of metabolic and non-metabolic complications.     

Hormone changes and diabetes resolution after biliopancreatic diversion and laparoscopic sleeve gastrectomy: a comparative prospective study

BackgroundBiliopancreatic diversion (BPD) is the most effective bariatric procedure in terms of weight loss and remission of diabetes type 2 (T2DM), but it is accompanied by nutrient deficiencies. Sleeve gastrectomy (SG) is a relatively new operation that has shown promising results concerning T2DM resolution and weight loss. The objective of this study was to evaluate and compare prospectively the effects of BPD long limb (BPD) and laparoscopic SG on fasting, and glucose-stimulated insulin, glucagon, ghrelin, peptide YY (PYY), and glucagon-like peptide-1 (GLP-1) secretion and also on remission of T2DM, hypertension, and dyslipidemia in morbidly obese patients with T2DM.MethodsTwelve patients (body mass index [BMI] 57.6±9.9 kg/m²) underwent BPD and 12 (BMI 43.7±2.1 kg/m²) underwent SG. All patients had T2DM and underwent an oral glucose tolerance test (OGTT) before and 1, 3, and 12 months after surgery.ResultsBMI decreased more after BPD, but percent excess weight loss (%EWL) was similar in both groups (P = .8) and T2DM resolved in all patients at 12 months. Insulin sensitivity improved more after BPD than after SG (P = .003). Blood pressure, total and LDL cholesterol decreased only after BPD (P<.001). Triglycerides decreased after either operation, but HDL increased only after SG (P<.001). Fasting ghrelin did not change after BPD (P = .2), but decreased markedly after SG (P<.001). GLP-1 and PYY responses during OGTT were dramatically enhanced after either procedure (P = .001).ConclusionsSG was comparable to BPD in T2DM resolution but inferior in improving dyslipidemia and blood pressure. SG and BPD enhanced markedly PYY and GLP-1 responses but only SG suppressed ghrelin levels.     

Predictors of remission of type 2 diabetes mellitus after laparoscopic gastric banding and bypass

Background

Type 2 diabetes mellitus (T2DM) is associated with obesity and results in considerable morbidity and mortality. Our objectives were to evaluate the effect of laparoscopic bariatric surgery on the control of T2DM in morbidly obese patients in a U.K. population and to determine the predictors of T2DM remission after bariatric surgery. The study was performed at teaching university hospitals and affiliated private hospitals.

Methods

Of 487 patients who underwent laparoscopic bariatric procedures from 2002 to 2007, 74 patients (15.2%) had established T2DM. The results are presented as the mean values. Multivariate analysis was used to identify the factors predictive of remission of T2DM after bariatric surgery.

Results

The body mass index before laparoscopic gastric bypass (LGB; n = 48) and laparoscopic adjustable gastric banding (LAGB; n = 26) were comparable (52 versus 51 kg/m², P = .508). At a mean follow-up of 16.9 months, 41% had remission and 59% had experienced improvement in T2DM. Although the duration of follow-up was significantly longer for the patients who had undergone LAGB than for those who had undergone LGB (23 versus 13.4 months, P = .001), the percentage of excess weight loss (%EWL) was significantly greater after LGB than after LAGB (59.4% versus 48.8%, P = .031), with an associated greater remission rate of T2DM (50% versus 24%, P = .034). Multivariate analysis revealed a greater %EWL and younger age to be independent predictors of postoperative remission of T2DM, and LGB, longer follow-up, and female gender were independent predictors of a greater %EWL.

Conclusion

The %EWL was the only predictor of remission of T2DM that was influenced by the choice of bariatric procedure. In our study, LGB offered greater weight loss and a chance of remission of T2DM compared with LAGB and within 2 years of surgery.