Comparison of weight loss and body composition changes with four surgical procedures

BackgroundA paucity of information is available on the comparative body composition changes after bariatric procedures. The present study reports on the body mass index (BMI) and body composition changes after 4 procedures by a single group.MethodsAt the initial consultation, the weight and body composition of the patients undergoing 4 different bariatric procedures were measured by bioimpedance (Tanita 310). Follow-up examinations were performed at 1 year and at subsequent visits after surgery. Analysis of variance was used to compare the postprocedure BMI and body composition. Analysis of covariance was used to adjust for baseline differences.ResultsA total of 101 gastric bypass (GB) patients were evaluated at 19.1 ± 10.6 months, 49 biliopancreatic diversion with the duodenal switch (BPD/DS) patients at 27.5 ± 16.3 months, 41 adjustable gastric band (AGB) patients at 21.4 ± 9.2 months, and 30 sleeve gastrectomy (SG) patients at 16.7 ± 5.6 months (P <.0001). No differences were found in patient age or gender among the 4 groups. The mean preoperative BMI was significantly different among the 4 groups (P <.0001): 61.4 kg/m², 53.2, 46.7, and 44.3 kg/m² for the SG, BPD/DS, GB, and AGB group, respectively. The postoperative BMI adjusted for baseline differences was 27.8 (difference 23.6 ± 8.3), 32.5 (difference 15.6 ± 5.0), 37.2 (difference 18.2 ± 8.2), and 39.5 kg/m² (difference 7.5 ± 4.3) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The percentage of excess weight loss was 84%, 70%, 49%, and 38% for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The postoperative percentage of body fat adjusted for baseline differences was 25.7% (23.9% ± 7.0%) 32.7% (16.1% ± 10.5%) 37.7% (16.7% ± 5.6%), and 42% (6.0% ± 6.8%) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The lean body mass changes were reciprocal.ConclusionAlthough the BPD/DS procedure reduced the BMI the most effectively and promoted fat loss, all the procedures produced weight loss. The AGB procedure resulted in less body fat loss within 21.5 months than SG within 16.7 months. Longer term observation is indicated.     

Single and dual anastomosis duodenal switch for obesity treatment: a single-center experience

BackgroundBiliopancreatic diversion with duodenal switch (BPD/DS) is the most effective bariatric surgery in super-obese patients, although technically complex and time consuming. As a primary surgery, single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) is similar to BPD/DS in terms of short-term outcomes, but long-term and comparative data are lacking.ObjectivesThe aim of this study was to compare the outcomes of patients submitted to SADI-S and BPD/DS.SettingPublic hospital.MethodsObese patients (n = 112) submitted to SADI-S (n = 83) and BPD/DS (n = 29) for obesity treatment were prospectively compared.ResultsThe mean preoperative body mass indexes (BMIs) were 53.41 ± .93 for BPD/DS and 50.61 ± .52 kg/m² for SADI-S. Follow-up of 48 months was achieved in 18% (n = 21) of patients, with a nonsignificant difference in the percentage of excess BMI loss (%EBMIL; 81.20 ± 3.71 for BPD/DS; 74.82 ± 3.45 for SADI-S). Operative time (164.30 ± 7.78 minutes for BPD/DS; 132.70 ± 7.19 minutes for SADI-S; P = .006) and hospital stay (4.90 ± 1.10 days for BPD/DS; 4.35 ± .70 days for SADI-S; P = .006) were significantly shorter for SADI-S. There was no significant difference in the 30-day postoperative complication rate. No mortality was reported. After surgery, significant improvements were observed in glucose and lipid profiles for both groups. The type 2 diabetes remission rate was 100% for BPD/DS and ranged from 60 to 80% for SADI-S across follow-up times. Dyslipidemia remission followed a similar pattern. Protein deficiency was observed in up to 50% of patients after BPD/DS and 20% after SADI-S, without statistically significances.ConclusionSADI-S and BPD/DS as primary surgery for obesity treatment result in no significant differences in %EBMIL, improvement in obesity-related diseases, nutritional deficiencies, and postoperative morbidity. Nevertheless, there was greater total weight loss after BPD/DS. SADI-S, being less time consuming and technically simpler, can represent an advantage over BPD/DS.     

Outcome of revisional bariatric surgery for insufficient weight loss after laparoscopic Roux-en-Y gastric bypass: an observational study

BackgroundInsufficient weight loss or secondary weight regain with or without recurrence of comorbidity can occur years after laparoscopic Roux en Y gastric bypass (LRYGB). In selected patients, increasing restriction or adding malabsorption may be a surgical option after conservative measures failed.ObjectivesEvaluation of short and long term results of revisional surgery for insufficient weight loss or weight regain after LRYGB.SettingTertiary hospital.MethodsRetrospective analysis of prospectively collected data from a cohort of 1150 LRYGB patients. Included were patients, who underwent revisional bariatric surgery after LRYGB for insufficient weight loss with a follow-up of minimal 1 year.ResultsFifty-four patients were included in the analysis. After an interdisciplinary evaluation, patients with insufficient weight loss, signs of dumping syndrome, and lacking restriction were offered a nonadjustable band around the pouch (banded group, n = 34) and patients with sufficient restriction, excellent compliance, and adherence were offered a revision to laparoscopic biliopancreatic diversion (BPD group, n = 20). The revisional procedure was performed 3.3 ± 2.3 years after LRYGB in the banded-group and after 6.4 ± 4.3 years in the BPD group (P = .001). Mean body mass index at the time of the primary bariatric procedure was 41.7 ± 6.2 kg/m² in the banded group and 45.2 ± 8.2 kg/m² in the BPD group (P = .08); minimal body mass index between both operations was 29.1 ± 4.7 kg/m² in the banded group and 36.5 ± 9.4 kg/m² in the BPD group, and, at the time of revisional surgery, 31.4 ± 5.5 kg/m² in the banded group and 40.8 ± 6.7 kg/m² in the BPD group (P = .0001). The mean body mass index difference 1 year after revisional surgery was 1.3 ± 3.0 kg/m² in the banded group and 6.7 ± 4.5 kg/m² in the BPD group (P = .01). In the banded group, 11 patients (32.4%) needed removal of the band, 4 patients (11.8%) needed an adjustment, and 4 patients (11.8%) were later converted to BPD. In the BPD group, 2 (10.0%) patients needed revision for severe protein malabsorption.ConclusionsInsufficient weight loss or secondary weight regain after LRYGB is a rare indication for revisional surgery. Banded bypass has modest results for additional weight loss but can help patients suffering from dumping. In very carefully selected cases, BPD can achieve additional weight loss with acceptable complication rate but higher risk for reoperation. Future “adjuvant medical treatments,” such as glucagon-like peptide 1 analogues and other pharmacologic treatment options could be an alternative for achieving additional weight loss and better metabolic response.     

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.     

Comparison of Nutritional Consequences of Conventional Therapy of Obesity, Adjustable Gastric Banding, and Gastric Bypass

Background: Roux-en-Y gastric bypass (RYGBP) is more efficient than adjustable gastric banding (AGB) in weight loss and relieving co-morbidities, but nutritional complications of each surgical procedure have been poorly evaluated. Methods: A cross-sectional study was performed to compare nutritional parameters in 201 consecutive obese patients, who had been treated either by conventional behavioral and dietary therapy (CT, n=110) or by bariatric surgery, including 51 AGB and 40 RYGBP. Results: BMI was similar after AGB (36.6 ± 5.3 kg/m²) and RYGBP (35.4 ± 6.3 kg/m²), but patients in the RYGBP group had lost more weight and had less metabolic disturbances than those in the AGB group. On the other hand, the prevalence of nutritional deficits was significantly higher in the RYGBP group than in the 2 other groups (P <0.01), whereas the AGB group did not differ from CT. Particularly, the RYGBP group presented an unexpected high frequency of deficiencies in fat-soluble vitamins. Moreover, vitamin B₁₂, hemoglobin, plasma prealbumin and creatinine concentrations were low in the RYGBP group. Conclusion: RYGBP is more efficient than AGB in correcting obesity, but this operation is associated with a higher frequency of nutritional deficits that should be carefully monitored.     

Laparoscopic Adjustable Gastric Banding with Duodenal Switch for Morbid Obesity: Technique and Preliminary Results

Background: The procedure of choice for morbid obesity remains controversial. One of the most effective treatments is the biliopancreatic diversion with duodenal switch (BPD/DS), which is, however, associated with a significant morbidity rate. Adjustable gastric banding (AGB) by the laparoscopic approach is an easier procedure with the intent to reduce complication rates. It replaced the sleeve gastrectomy in this study. The objective was to assess the feasibility and safety of this new laparoscopic treatment. Methods: AGB with duodenal switch (DS) was performed laparoscopically with 7 trocars. A gastric band was appropriately placed below the gastroesophageal junction, followed by BPD/DS with a 250-cm alimentary channel and a 100-cm common channel. Results: All 5 patients were women, with mean preoperative BMI 52.2 kg/m² (40.6 to 64.4). The operations were performed via laparoscopy in a mean of 206 ± 35 minutes. There was no postoperative complication, infection or conversion. Mean hospital stay was 8.8 days (8-11). At 12 months, mean BMI is 35.8 kg/m² (26.1-46.0), with continuing weight loss and no hypoalbuminemia. Conclusions: These data suggest that laparoscopic AGB/DS is feasible, with a low morbidity rate. This technique could combine the long-term weight loss of malabsorptive procedures, with a low-morbidity, adjustable, restrictive procedure. This technique could be used in selected patients, but requires a larger study with longer follow-up.     

Outcomes of bariatric surgery in extreme obesity: results from the United Kingdom National Bariatric Surgery Registry for patients with a body mass index >70 kg/m2

BackgroundBariatric and metabolic surgery (BMS) is an established safe, effective, and durable treatment for obesity and its complications. However, there is still a paucity of evidence on surgery outcomes in patients suffering from extreme obesity.ObjectivesThis study aimed to evaluate outcomes of BMS in weight loss and the resolution of co-morbidities in patients with a body mass index (BMI) ≥70kg/m².SettingNational Health Service and private hospitals in the United Kingdom.MethodsThis cohort study analyzed prospectively collected records from the UK National Bariatric Surgery Registry of patients with a BMI ≥70 kg/m² undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or adjustable gastric band (AGB) between January 2009 and June 2014.ResultsThere were 230 patients (64% female) eligible for inclusion in the study: 22 underwent AGB; 102 underwent SG, and 106 underwent RYGB. Preoperative weight and BMI values were comparable (76 ± 7 kg/m² for AGB; 75 ± 5 kg/m² for SG; 74 ± 5 kg/m² for RYGB). The median postoperative follow-up was 13 months for AGB (10–22 mo), 18 for SG (6–28 mo), and 15 for RYGB (6–24 mo). Patients undergoing RYGB and SG exhibited the greatest postoperative total body weight loss (35 ± 13% and 31 ± 15%, respectively; P = .14), which led to postoperative BMIs of 48 ± 10 kg/m² and 51 ± 11 kg/m², respectively (P = .14). All procedures conferred a reduction in the incidence of co-morbidities, including type 2 diabetes, and led to improved functional statuses. The overall complication rate was 7%, with 3 deaths (1%) within 30 days of surgery.ConclusionThis study found that primary BMS in patients with a BMI >70kg/m² has an acceptable safety profile and is associated with good medium-term clinical outcomes. RYGB and SG are associated with better weight loss and great improvements in co-morbidities than AGB. Given the noninferiority of SG outcomes and SG’s potential for further conversion to other BMS procedures if required, SG may be the best choice for primary BMS in patients with extreme obesity.     

Changes in fat-free mass and muscle mass at 6 and 12 months after biliopancreatic diversion with duodenal switch surgery

BackgroundBariatric surgery is associated with concomitant loss in both fat and muscle masses. Literature on muscle composition/quality after bariatric surgery is limited.ObjectivesTo measure and compare the changes in fat-free mass with the changes in muscle composition after biliopancreatic diversion with duodenal switch surgery (BPD/DS).SettingBariatric surgery is associated with concomitant loss in both fat and muscle masses. Literature on muscle composition/quality after bariatric surgery is limited.MethodsForty patients underwent BPD/DS and 22 patients are considered as controls. Bioelectrical impedance analysis (body composition) and computed tomography scan at the midthigh and abdominal levels (muscle composition) were performed at baseline, 6, and 12 months.ResultsAt 6 and 12 months, the BPD/DS group displayed significant reduction in weight (12 months: −46.6 ± 13.5 kg) and fat-free mass (12 months: −8.2 ± 4.4 kg; both P < .001). A significant reduction in abdominal (−15 ± 8%, P < .001) and midthigh muscle areas (−18 ± 7%, P < .001) was observed during the first postoperative 6 months, followed by a plateau after 6 months (abdominal: −1 ± 5%, midthigh: −1 ± 4%, both P > .05). At 6 months, both midthigh fat-infiltrated muscle (−22 ± 10%, P < .001) and normal-density muscle (−16 ± 9%, P < .001) areas decreased. Further reduction at 12 months was only observed in the fat-infiltrated muscle (−11 ± 8%, P < .001) in comparison with an increase in the normal-density muscle area (5 ± 8%, P = .001). There was no significant change for the control group.ConclusionsReduction in muscle, assessed with computed tomography scans, occurs mostly during the first 6 months postoperatively after BPD/DS. Focus on muscle quantity as well as quality, using precise imaging methods, instead of quantifying total body lean mass, is likely to provide better assessment in body content modulation after BPD/DS.     

Long-term outcome after biliopancreatic diversion with duodenal switch: a single-center experience with up to 20 years follow-up

BackgroundBiliopancreatic diversion with duodenal switch (BPD/DS) is the most effective standard bariatric procedure in terms of weight loss and remission of co-morbidities but carries the risk of severe long-term side effects.ObjectiveThe aim of this study was to analyze the long-term effects of BPD/DS in terms of morbidity, weight loss, remission of associated medical problems, deficiencies, and reoperations.SettingAcademic teaching hospital, Switzerland.MethodsThis is a retrospective, single-center study of prospectively collected data of all patients who underwent BPD/DS from 1999 to 2011 with a minimal follow-up (FU) of 10 years.ResultsA total of 116 patients (83.6% female) underwent BPD/DS with a mean initial body mass index (BMI) of 47 ± 6.5 kg/m2. Of these, 68% of the procedures were performed in open technique and 32% laparoscopically. The majority (76.7%) of patients had laparoscopic adjustable gastric banding before BPD/DS. The mean FU time was 14 ± 4.4 years and the FU rate at 5, 10, and 14 years was 95.6% (n = 108), 90% (n = 98), and 75.3% (n = 70), respectively. The mean excess BMI loss at 5, 10, and 14 years was 78% ± 24.1%, 76.5% ± 26.7%, and 77.8% ± 33.8%, respectively. Complete (n = 22) or partial remission (n = 4) of type 2 diabetes was observed in 92.8% of patients. Forty reoperations were necessary in 34 patients (29.3%) because of malnutrition or refractory diarrhea (n = 13), insufficient weight loss or weight rebound (n = 7), reflux or stenosis (n = 10), and various/combined indications (n = 10). The mean time to reoperation was 7.7 ± 5 years. There were no procedure-related deaths in the short or long term.ConclusionsBPD/DS offers sustainable long-term weight loss but is associated with important side effects that may be acceptable in selected patients with a high initial BMI (>50 kg/m²) and/or for nonresponders after primary restrictive procedures. Regular FU is necessary to detect and treat malnutrition and vitamin deficiencies.     

Laparoscopic sleeve gastrectomy followed by duodenal switch in selected patients versus single-stage duodenal switch for superobesity: case–control study

BackgroundThe prevalence of superobesity (body mass index [BMI] ≥50 kg/m²) has increased steadily during the past decade, and the most suitable surgical strategy for these patients is still controversial. Our objective was to test the hypothesis that in selected superobese patients, laparoscopic sleeve gastrectomy (SG) followed by laparoscopic duodenal switch (DS) might reduce the rate of postoperative complications and the need for the second step duodenal switch. The setting was a university hospital in France.MethodsA retrospective analysis was performed of a prospective database of 110 consecutive patients with a BMI of ≥50 kg/m² undergoing the staged approach and matched for age, gender, and BMI with 110 consecutive patients undergoing single-stage DS. The excess weight loss (EWL), co-morbidity improvement, and incidence of postoperative complications were compared between the 2 groups.ResultsOne patient died in the staged strategy group (mortality rate .9%). The postoperative complication rate was 8.2% in the staged strategy group (110 patients) and 15.5% in the single-stage DS group (110 patients; P = 1). Multivariate analysis showed that single-stage DS surgery is the only variable significantly associated with the occurrence of postoperative complications (odds ratio 2.36; 95% confidence interval 1.001–5.61). In the staged strategy group, at a mean follow-up of 36.4 ± 13 months, 39 patients (35.5%) required the second-stage procedure. The mean %EWL was 50.8% ± 17.5% for SG alone (35% failed to maintain 50% EWL after SG), 61.5% ± 19.3% for the staged strategy, 72.7% ± 14.1% for 2-step DS (3.3% failed to maintain 50% EWL after 2-step DS), and 73.3% ± 17.6% for single-stage DS (7.3% failed to maintain 50% EWL after single-stage DS).ConclusionsAt 3 years of follow-up, staged DS surgery avoided biliopancreatic diversion in 72.7% of the patients. Single-stage DS increases the risk of postoperative complications but not of anastomotic leak.     

Body weight at developmental age in siblings born to mothers before and after surgically induced weight loss

BackgroundTo gain insight into the role of epigenetic factors in determining body weight in adolescence, we studied the body weight of siblings born to the same mother before and after biliopancreatic diversion (BPD) for obesity. The study was performed in a university hospital during a 20-year period.MethodsThe siblings born before and after BPD were retrospectively rated by their mother as normal, overweight, or obese at 1, 6, and 12 years.ResultsAt 1 and 6 years, the body weight was rated as similar in the subsets. However, at 12 years of age, a greater percentage of those born before BPD were considered overweight (42% versus 33%) and obese (22% versus 3%; P <.009) than their counterparts born after BPD. Considering only the subjects aged 21–25 years at the study period, the body weight and body mass index in subjects born before BPD were greater (P <.02 and P <.012, respectively) than in those born after BPD (79.5 ± 16.5 kg versus 66.7 ± 11.8 kg, and 27.5 ± 3.9 kg/m² versus 23.4 ± 3.7 kg/m², respectively).ConclusionThe results of the present study, in which the influences of the genetic pattern and environmental and educational factors were minimized, show that adolescents born to post-BPD mothers weigh less than their siblings born to the same mother before BPD when she was still obese. An insulin-resistant milieu during pregnancy could account for the greater body weight later in adolescence.     

Is biliopancreatic diversion with duodenal switch a solution for patients after laparoscopic gastric banding failure?

BackgroundWeight loss failure after laparoscopic gastric banding (LAGB) can occur in ≤25% of patients. Conversion to a malabsorptive procedure might provide more durable weight loss. The present study evaluated biliopancreatic diversion with duodenal switch (BPD/DS) after LAGB failure with a 3-year follow-up period.MethodsA total of 35 patients underwent BPD/DS after LAGB failure and were prospectively analyzed using a multidisciplinary approach. Weight indexes, co-morbidities, complications, morbidity/mortality, and nutritional status were analyzed.ResultsExcess weight decreased from 91% (134 kg, body mass index 48 kg/m²) to 75% (124 kg, body mass index 44 kg/m²) after LAGB failure and decreased further to 40% (100 kg, body mass index 35 kg/m²) after BPD/DS. The mean percentage of excess weight loss was 55% after LAGB and BPD/DS together and 48% after BPD/DS alone. The incidence of co-morbidities, such as diabetes, sleep apnea, hypertension, hyperlipidemia, joint problems, and chronic obstructive pulmonary disease was reduced after BPD/DS. Nutritional deficiencies were already present after LAGB failure (e.g., iron, ferritin, vitamins B₁₂, B₆, A, D, and E, albumin, and calcium) and either increased (folic acid, potassium, and vitamin B₁₂), remained stable (iron, ferritin, vitamin A), or decreased after BPD/DS (albumin and vitamins B₆ and E).ConclusionBPD/DS provided substantial weight loss after LAGB failure and reduced the incidence of obesity-related co-morbidities during a 3-year period. Long-term nutritional follow-up is advocated for all patients after malabsorptive BPD/DS.     

The jejunum is the key factor in insulin resistance

BackgroundBiliopancreatic diversion (BPD) is more effective than Roux-en-Y gastric bypass (RYGB) on both insulin resistance and diabetes.ObjectivesBecause the major difference between the 2 procedures resides in the length of jejunal bypass, we investigated the role of the jejunum in insulin resistance.SettingUniversity hospital in Italy.MethodsInsulin sensitivity (IS) and secretion were measured before and 4 weeks after RYGB or BPD in 16 patients. A translational study was also conducted in 6 pigs, by isolating a jejunal loop with its vascular and nerve supply (Thiry-Vella loop [TVL]). TVL was doubly stomatized and bowel continuity restored by a side-to-side jejuno-jejunostomy. At baseline and 4 weeks postoperatively a glucose bolus was injected either in the stomach or in the TVL. Whole-body IS and jejunal heat shock proteins (HSPs) were measured. Primary porcine hepatocyte cultures were incubated with plasma or individual HSPs.ResultsWhole-body IS increased from 353.5 ± 26.7 to 442.0 ± 37.4 (P < .05) after RYGB and from 312.4 ± 14.9 to 441.2 ± 15.9 mL/m⁻²/min⁻¹ (P < .001) after BPD. Hepatic IS was unchanged after RYGB, while it increased from .3 ± .01 to .4 ± .1 (μM/pM) – 1 (P < .01) after BPD. Total insulin secretion rate remained unchanged after RYGB but decreased (from 58.3 ± 23.6 to 33.1 ± 7.8 nmol/m⁻², P < .05) after BPD. Jejunectomy in pigs enhanced IS (.3 ± .01 versus .2 ± .01 mM/pM, P < .001), while injection of glucose into TVL reduced it (.1 ± .01 versus .3 ± .01 mM/pM, P < .0001). The jejunum secreted HSPs, Hsp70, and GRP78, which impaired insulin signaling in hepatocyte cultures.ConclusionsThis study shows that jejunal bypass in both humans and pigs improves IS. Injection of glucose into the TVL in pigs determines insulin resistance. In response to glucose, the jejunum secretes HSPs that impair insulin signaling.     

Exocrine pancreatic function and dynamic of digestion after restrictive and malabsorptive bariatric surgery: a prospective,cross-sectional,and comparative study

BackgroundGastrointestinal anatomical changes after restrictive and malabsorptive bariatric surgery lead to important disturbances in the process of digestion and absorption of nutrients and could lead to exocrine pancreatic insufficiency (EPI).ObjectiveThe aim of the present study was to evaluate and to compare pancreatic function and the dynamic of digestion and absorption of nutrients after restrictive and malabsorptive bariatric surgical procedures.SettingUniversity Hospital of Santiago de Compostela, Santiago de Compostela, Spain.MethodsA prospective, observational, cross-sectional, comparative study of patients after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and biliopancreatic diversion with duodenal switch (BPD/DS) was carried out. Patients with obesity who did not undergo surgery were included as control group. Pancreatic function and the dynamic of digestion and absorption of nutrients were evaluated by the ¹³C-mixed triglyceride (¹³C-MTG) breath test. Six-hour ¹³C-cumulative recovery rate (¹³C-CRR), ¹³C exhalation peak, and 1-hour maximal ¹³C-CRR were calculated.ResultsOne-hundred five patients were included (mean age, 49.8 yr; 84 women). Six-hour ¹³C-CRR was significantly reduced after BPD/DS (P < .001) but not after SG and RYGB. EPI was present in 75% of patients after BPD/DS, 8.3% of patients after RYGB, and 4.3% of patients after SG. Compared with the control group who did not undergo surgery, digestion and absorption of nutrients tended to occur earlier after SG, whereas it was delayed after RYGB and mainly after BPD/DS (P < .001).ConclusionBariatric surgery significantly alters the dynamic of the digestive process. EPI is very common after BPD/DS, frequent after RYGB, and less frequent after SG. This information is clinically relevant since EPI is a treatable condition associated with symptoms, nutritional deficiencies, and complications.     

Early complications,long-term adverse events,and quality of life after duodenal switch and gastric bypass in a matched national cohort

BackgroundInsufficient weight loss is common in super-obese patients (body mass index >50) after Roux-en-Y gastric bypass (RYGB). Duodenal switch (DS) is more effective; however, it is considered to have an increased complication rate.ObjectivesTo compare early complications (≤30 d), long-term adverse events, and quality of life (QoL) between primary DS and RYGB.SettingSweden.MethodsNational cohort-study of super-obese patients after primary DS or RYGB in Sweden 2007 to 2017. Propensity-score matching was used to reduce confounders. Five national registers were cross-matched.ResultsThe study population consisted of 333 DS and 1332 RYGB (body mass index 55 ± 5 kg/m², 38.5 ± 11 yr, and 60.7% females). Laparoscopic approach was used in 25% of DS and 91% of RYGB. Early complications were more common after DS (15.3% versus 8.1%, P < .01), mainly because of more open surgery and related surgical site infections. During 4.6 ± 2.3 years mean follow-up, hospital admission rate was 1.4 ± 2.3 versus 1.1 ± 3.3 (P = .18), with 6.7 ± 18.3 versus 7.0 ± 43.0 in-hospital days, for DS and RYGB, respectively. An increased risk of malnutrition/malabsorption requiring inpatient care (2.8% versus .2%, odds ratio 12.3 [3.3–45.7]) and greater need for additional abdominal surgery (25.8% versus 15.3%, odds ratio 2.0 [1.5–2.7]) was observed for DS. However, QoL was more improved after DS.ConclusionDS was associated with more early complications because of more open surgery, but long-term requirement of inpatient care was similar to RYGB. The increased risk of malnutrition/malabsorption and need for additional abdominal surgeries was contrasted with a greater improvement in QoL for DS.     

Weight loss and effect on co-morbidities in the long-term after duodenal switch and gastric bypass: a population-based cohort study

BackgroundUnsatisfactory weight loss is common after bariatric surgery in patients with super obesity (body mass index [BMI] ≥50 kg/m²). Unfortunately, this group of patients is increasing worldwide.ObjectiveThe aim of this study was to compare long-term weight loss and effect on co-morbidities after duodenal switch (DS) and gastric bypass (RYGB) in super-obese patients.SettingUniversity hospital, Sweden, national cohort.MethodsThis observational population-based cohort-study of primary DS and RYGB (BMI ≥48 kg/m²) in Sweden from 2007 to 2017 used data from 4 national registers. Baseline characteristics were used for propensity score matching (1 DS:4 RYGB). Weight loss was analyzed up until 5 years after surgery. Medication for diabetes, hypertension, dyslipidemia, depression, and pain were analyzed up until 10 years after surgery.ResultsThe study population consisted of 333 DS and 1332 RYGB, with 60.7% females averaging 38.5 years old and BMI 55.0 kg/m² at baseline. DS resulted in a lower BMI at 5 years compared with RYGB, 32.2 ± 5.5 and 37.8 ± 7.3, respectively, (P < .01). DS reduced prevalence of diabetes and hypertension more than RYGB, while reduction in dyslipidemia was similar for both groups, during the 10-year follow-up. Both groups increased their use of antidepressants and a maintained a high use of opioids.ConclusionThis study indicates that super-obese patients have more favorable outcomes regarding weight loss and effect on diabetes and hypertension, after DS compared with RYGB.     

Duodenal switch improved standard biliopancreatic diversion: a retrospective study

BackgroundThis was a retrospective study, performed 10 years after surgery, to compare the results between biliopancreatic diversion (BPD) with distal gastrectomy (DG) versus BPD with duodenal switch (DS).MethodsComplete follow-up data were available for 96% of patients, allowing a comparison of weight loss, revision, side effects, and complications at 10 years.ResultsAfter BPD-DS, weight loss was 25% greater than after BPD-DG (46.8 ± 21.7 kg versus 37.5 ± 22 kg, respectively; P <.0001). The need for revision decreased from 18.5% to 2.7% (P <.0001), and the prevalence of vomiting during the previous month was 50% less (23.7–50.6%, P <.0001) after BPD-DS compared with after BPD-DG. Late complications were the same for both procedures. Blood analysis showed that, after BPD-DS, the levels of calcium, iron, and hemoglobin were significantly greater and the parathyroid hormone level was lower than after BPD-DG (71.3 ± 44.2 versus 103.0 ± 64.0 ng/L, respectively; P <.0001).ConclusionThe DS greatly improved the BPD, as it was initially proposed. The use of the DS increased weight loss, decreased the need for revision, resulted in fewer side effects, and improved the absorption of nutrients.     

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.     

Is biliopancreatic diversion with duodenal switch indicated for patients with body mass index <50 kg/m2?

BackgroundBiliopancreatic diversion with duodenal switch (DS) has been the standard surgical approach for the treatment of morbidly obese patients at our institution since the early 1990s. The published data, however, have shown the use of the DS to be limited to the treatment of super-morbidly obese patients (body mass index [BMI] ≥50 kg/m²). The aim of the present study was to present our long-term results with the DS in patients with an initial BMI of <50 kg/m².MethodsThis was a retrospective study of all patients with a BMI <50 kg/m² who had undergone DS from June 1992 to May 2005. The data are reported as the mean ± standard deviation.ResultsThe data from 810 consecutive patients, with a mean initial BMI of 44.2 ± 3.6 kg/m², were reviewed. The mean follow-up was 103 ± 49 months. Major perioperative complications occurred in 5.8% of patients, including 5 deaths (.6%). The initial excess weight loss was 76% ± 22%, and the excess weight loss was >50% in 89% of patients. Malnutrition required readmission in 4.3% and surgical revision in 1.5%. The prevalence of severe albumin deficiency (<30 g/L) was 1.1%, hemoglobin deficiency (<100 g/L), 1.6%, iron deficiency (<4 mmol/L) 2.1%, and calcium deficiency (<2 g/L) 3%. The percentage of patients “very satisfied” with the global result was 91%, and 37% would have preferred to lose more weight.ConclusionThese results showed that in non super-obese patients, DS was very efficient in terms of weight loss and patient satisfaction. This was associated with a 1.5% risk of revision for malnutrition. However, nutritional deficiencies required frequent readjustment of supplements, particularly for calcium, vitamin A, and vitamin D.