Short-term Changes in Insulin Resistance following Weight Loss Surgery for Morbid Obesity: Laparoscopic Adjustable Gastric Banding versus Laparoscopic Roux-en-Y Gastric Bypass

Background: Laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP) both effectively treat the insulin resistance associated with type 2 diabetes mellitus (T2DM). Restriction of caloric consumption, alterations in the entero-insular axis or weight loss may contribute to lowering insulin resistance after these procedures. The relative importance of these mechanisms, however, following LAGB and LRYGBP remain unclear. The aim of this study was to compare directly the short-term changes in insulin resistance following LAGB and LRYGBP in similar populations of patients. Methods: Patient preference determined operation type. The Homeostasis Model Assessment for Insulin Resistance (HOMA IR) was used to measure insulin resistance. Preoperative values were compared to postoperative levels obtained within 90 days of surgery. Significant differences between groups were tested by ANOVA. Results: There were no significant preoperative differences between groups. The 56 LAGB patients had a mean age of 42.5 years (25.7-63), BMI of 45.5 kg/m² (35-66) and preoperative HOMA IR of 4.1 (1.4-39.2). 75% of LAGB patients were female and 43% had T2DM. The 61 LRYGBP patients had a median age of 39.9 years (22.1-64.3), BMI of 45.0 kg/m² (36-62), and preoperative HOMA IR of 5.0 (0.6-56.5). 79% of LRYGBP patients were women and 44.3% had T2DM. Median follow-up for LAGB patients was 45 days (18-90) and for LRYGBP patients 46 days (8-88 days). LAGB patients had a median of 14.8% excess weight loss (6.9%-37.0%) and LRYGB patients 24.2% (9.8%-51.4%). Postoperative HOMA IR was significantly less after LRYGBP, 2.2 (0.7-12.2), than LAGB, 2.6 (0.8-29.6), although change in HOMA IR was not significantly different. Change in HOMA IR for both groups did not vary with length of follow-up or weight loss but correlated best with preoperative HOMA IR (LAGB r=0.8264; LRYGBP r=0.9711). Conclusions: Both LAGB and LRYGBP significantly improved insulin resistance during the first 3 months following surgery. Both operations generated similar changes in HOMA IR, although postoperative HOMA IR levels were significantly lower after LRYGBP. These findings suggest that caloric restriction plays a significant role in improving insulin resistance after both LAGB and LRYGBP.     

Remission of Psoriasis after Open Gastric Bypass

Psoriasis is a frequent skin disease, affecting 2% of the world's population. Stress, alcohol, smoking and obesity may be associated with psoriasis. A 56-year-old man with BMI 46.9 kg/m², hypertension and gastroesophageal reflux, had severe psoriasis for the last 39 years, without any remission on multiple treatments. Psoriatic papules and plaques were noted on his face, dorsum of hands, buttocks, knees, and elbows. He underwent open Roux-en-Y gastric bypass. At 4-month follow-up, the patient had lost 23 kg or 34.8% of excess weight, and presented complete remission of the psoriasis without medications. Bariatric surgery for positive metabolic, psychological and lifestyle consequences should be considered a treatment of psoriasis. Long-term observation is necessary.     

A biodegradeable membrane from porcine intestinal submucosa to reinforce the gastrojejunostomy in laparoscopic Roux-en-Y gastric bypass: preliminary report

Backround: A Silastic ring has been used to prevent dilation of the gastrojejunostomy in Roux-en-Y gastricbypass (RYGBP). The use of a bio-membrane may prevent dilation of the anastomosis without the risks associated with prostheses. The aim of this studywas to evaluate the feasibility and safety of applying such a bio-mem brane around the gastrojejunostomy junostomy in Laparoscopic RYGBP (LRYGBP). Methods: We used a new bio-membrane, that is dreived from porcine small intestinal submucosa (SIS)and acts as a scaffolding for the ingrowth of connective tissue. Over a 4-month period, 14 LRYGBP patients had their proximal anastom osis wrapped with 10 x 2.5 cm SIS by a single surgeon. We compared these patients to a control group of LRYGBP patients matched for BMI. Results: The average age of the patients was 35.0 years (control group: 45.1 years). The patients had a mean initial BMI of 44.7 kg/m² (±5.9) standard error, and the control subjects had a mean initial BMI of 46.7 kg/m² (±6.5). SIS application took a mean time of 11 (±3) minutes without any intraoperative complication. The median hospital stay was 3.5 days in the experimental group and 3.7 days in controls. Three patients developed a symptomatic stenosis at the gastrojejunostomy following surgery. In the control group there were two stenoses. At an average follow-up of 87 days (controls: 95 days), the mean reduction in BMI was 7.8 (± 0.8) kg/m² [controls 8.6 kg/m² (± 1.5)]. Conclusion: Application of SIS around the gastrojejunostomy in patients undergoing LRYGBP is feasible and safe. Further follow-up is required, however, to evaluate the effectiveness in preventing dilation of the anastomosis.     

Laparoscopic Roux-en-Y Gastric Bypass is Safe and Effective in Patients with a BMI ≥60

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been shown to be safe and effective. There is little data on the outcomes in massively super-obese patients, with a body mass index (BMI) &ge60 kg/m²(super-super-obese). The goal of this study was to determine the safety and effectiveness of LRYGBP in these patients, and compare these results to patients with a BMI <60. Methods: 213 consecutive patients undergoing LRYGBP by a single surgeon at a university hospital were included in the study. The patients were divided into 2 groups: BMI <60 kg/m²(n=167) and BMI ≥60 kg/m² (n=46). The 2 groups were compared with regard to perioperative complications, and postoperative weight loss. Results: Both groups had statistically similar complication rates. There were major complications in 8 patients (5%) in the lower BMI group and in 3 patients (7%) in the higher BMI group. There were minor complications in 9 patients (5%) in the lower BMI group and in 4 patients (9%) in the higher BMI group. Mean percent excess weight loss (%EWL) was 64% at 1 year in the BMI <60 group and 53% in the BMI ≥60 group. Conclusion: LRYGBP can be performed safely and effectively in super-super-obese patients (BMI ≥60). Although these patients have less %EWL than lighter patients, they still end up with a good result. Therefore, LRYGBP should be considered a good surgical option even for patients with a BMI ≥60.     

Laparoscopic Gastric Bypass after Antireflux Surgery for the Treatment of Gastroesophageal Reflux in Morbidly Obese Patients: Initial Experience

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been proven effective against gastroesophageal reflux disease (GERD) in morbidly obese patients. We present our experience with revision of antireflux procedures to LRYGBP in obese patients with recurrent GERD, weight gain or a combination of both and discuss the indications and technical considerations involved. Methods: Between June 2000 and December 2003, 7 morbidly obese patients with a mean BMI of 37.5 kg/m² underwent revision of an antireflux procedure to LRYGBP by our group. Important steps of the revision include dissection of the diaphragmatic crura and gastroesophageal fat pad, reduction and repair of hiatal hernia, and complete take-down of the wrap to avoid stapling over the fundoplication which can create an obstructed, septated pouch. Results: Mean operative time was 6 hr 12 min and length of stay was 4.8 days. There were 3 major complications postoperatively and no deaths. During follow-up, 5 patients developed anastomotic strictures and 2 patients were re-explored for gastric remnant herniation and intestinal obstruction. At a mean follow-up of 24 (3-44) months, mean excess weight loss was 70.7% and 14/20 (70%) co-morbid conditions were improved or resolved. GERD evaluation with the GERD-HRQL scale showed a significant reduction of GERD scores postoperatively (P =0.006). Conclusions: Although LRYGBP after antireflux surgery is a technically more difficult procedure with a higher morbidity, it is feasible and effective for the treatment of recurrent GERD and worsening obesity with the additional advantage of weight loss and improvement of co-morbidities.     

Intragastric Balloon for Preoperative Weight Reduction in Candidates for Laparoscopic Gastric Bypass with Massive Obesity

Background: Laparoscopic bariatric operations can be technically challenging in massively obese patients. The potential of the intragastric balloon for preoperative weight reduction was evaluated in candidates for laparoscopic Roux-en-Y gastric bypass (LRYGBP) with super obesity. Methods: From January 2004 to March 2005, 10 patients with super obesity who were potential candidates for LRYGBP were included in a prospective observational study. An intragastric balloon was placed endoscopically under general anesthesia. Patients were then followed by a multidisciplinary team until removal of the balloon after 6 months. Weight, BMI, and percent excess weight lost (%EWL) were monitored after 1, 3 and 6 months. Results: The 10 patients were all female with mean ± SD age of 33±11 years (range 17-51). Initial weight was 175±25 kg (range 135-223) and initial BMI was 64±7 kg/m² (range 59-78). After completion of 1, 3 and 6 months, weight, BMI, and %EWL reached respectively: 166±27 kg*, 165±27 kg*, and 169±26 kg*; 61.1±7.6 kg/m²*, 60.8±8.4 kg/m²*, and 61±8.2 kg/m²*; 9±5%, 10±7%, 7±6%. (*=P<0.01 vs preop). Conclusion: In potential candidates for LRYGBP with super obesity, preoperative placement of an intragastric balloon can reduce the excess weight by 10% within 3 months. Extending this period failed to improve these results further.     

Laparoscopic Roux-en-Y Gastric Bypass with Remnant Gastrectomy for Focal Intestinal Metaplasia of the Gastric Antrum

Background: Inaccessibilility of the excluded stomach after isolated gastric bypass prevents postoperative evaluation and treatment of disorders of the gastric remnant. Bleeding complications, peptic ulcer disease, and gastric malignancy in the gastric remnant have all been reported. We report a patient with morbid obesity and focal intestinal metaplasia in the antrum of the stomach that was treated with laparoscopic Roux-en-y gastric bypass (LRYGBP) with remnant gastrectomy. Case Report: A 46-year-old female with a long history of morbid obesity presented with a BMI of 47 kg/m². Preoperative upper endoscopy revealed focal intestinal metaplasia. Since intestinal metaplasia is a risk factor for gastric cancer, a LRYGBP with remnant gastrectomy was performed. Conclusions: LRYGBP with remnant gastrectomy is a safe and cost-effective treatment for morbidly obese patients with focal intestinal metaplasia of the stomach.     

Extremely High Body Mass Index is not a Contraindication to Laparoscopic Gastric Bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is an effective operation for morbidly obese patients who have failed conservative weight loss treatments. It is currently indicated for patients with BMI >40 kg/m² or >35 with significant co-morbidities. Controversy exists whether there is an upper limit to BMI beyond which this operation should not be performed. Methods: Between April 1999 and February 2001, 82 patients (19 male, 63 female) underwent LRYGBP. Average age was 43.6, and average BMI was 56 kg/m². These patients were divided into those with BMI <60 and those with BMI ≥60 kg/m². Results:There were 61 patients with BMI <60 and 21 patients with BMI ≥60. The groups were similar in age, gender, distribution or incidence of co-morbid conditions (diabetes, coronary artery disease, hypertension, sleep apnea, asthma) between the groups. The BMI ≥60 group had a significantly longer length of stay (6.6 days vs 5.3 days, P <0.05), and only 1 patient (BMI 85) developed an anastomotic leak and died. 2 patients in this group (BMI 62 and 73) developed small bowel obstruction requiring lysis of adhesions. 1 patient in the BMI <60 group developed a gastrojejunal stricture requiring balloon dilatation. Conclusion: While patients with a BMI ≥60 are at higher risk for postoperative complications, they are also at higher risk from continued extreme obesity. In our series, 85% of these patients had an uneventful postoperative course and began shedding excess weight. BMI ≥60 should not be a contraindication for LRYGBP.     

Laparoscopic Roux-En-Y Gastric Bypass is a Safe and Effective Operation for the Treatment of Morbid Obesity in Patients Older than 55 Years

Background: Bariatric surgery in patients >50 years has been controversial. We investigated the safety and efficacy of laparoscopic Roux-en-Y gastric bypass (LRYGBP) in patients >55 years of age. Methods: Prospective data on 71 patients (54 females and 17 males) undergoing LRYGBP were reviewed. The patients were followed for a mean of 17 months (range 2-35 months). Results: The mean age was 59 years (range 55-67 years), and the mean preoperative BMI was 50.2 kg/m² (range 37-65 kg/m²). There were no conversions to open technique. Mean percent of excess weight loss (%EWL) was 20%, 48%, 64% and 67% at 1, 6, 12 and 24 months respectively. 89% of patients had at least a 50% EWL at 1 year postoperatively. There was a significant decrease in the number of patients requiring medical treatment for co-morbidities associated with morbid obesity: diabetes mellitus 87%, hypertension 70% and sleep apnea 86%. There was no inpatient mortality. 1 patient died suddenly 2 weeks postoperatively of possible myocardial infarction or pulmonary embolism. 16 patients developed 22 complications. The median length of hospital stay was 3 days. Conclusion: LRYGBP is a safe and well-tolerated surgical option for the treatment of morbid obesity in patients >55 years old. These patients demonstrate a satisfactory weight loss and resolution of co-morbidities.     

Abnormal Findings on Routine Upper GI Series following Laparoscopic Roux-en-Y Gastric Bypass

Background The use of postoperative upper GI series (UGIS) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) varies among bariatric surgeons. The authors describe the findings and impact of UGIS after LRYGBP. Methods From July 2003 to January 2006, 487 patients undergoing primary LRYGBP at a single academic institution had a single-contrast Gastrografin? UGIS performed on the first postoperative day, without complication. Patient and operative demographics were: mean age 43 years, mean BMI 47 kg/m², female 84%, and laparoscopic 100%. Results Of the 487 patients, the UGIS revealed 14 (2.9%) major and 88 (15.2%) minor abnormalities. Among the majorUGIS abnormalities, 6 (1.2%) demonstrated a gastrojejunal anastomotic (GJA) leak, 8 (1.4%) confirmed complete obstruction at the GJA, and 1 (0.2%) disclosed a communication with the bypassed stomach. For the minor UGIS abnormalities, 45 (9.2%) displayed significant delay in contrast passage through the GJA, 23 (5.0%) had evidence of dilated loops of small and/or large bowel, and 6 (1.2%) verified miscellaneous abnormal findings (malrotation, lower esophageal dysmotility, jejunal clots). Patients with UGIS abnormalities necessitated additional procedures, delayed oral intake and/or longer length of stay (LOS). Conclusions UGIS on postoperative day 1 is a useful means of evaluating postoperative LRYGBP anatomy and influenced postoperative care. Presented at the 11th World Congress of the International Federation for the Surgery of Obesity, Sydney, Australia, August 31, 2006.     

Treatment of morbid obesity and hiatal paraesophageal hernia by laparoscopic Roux-en-Y gastric bypass

Obesity has been proven to be a significant independent risk factor for hiatal hernia. In morbidly obese patients, the usual techniques to improve gastroesophageal reflux after hiatal hernia repair could have poorer outcomes than in the general population. Laparoscopic Roux-en-Y gastric bypass (LRYGBP) has been demonstrated to be an effective procedure in controlling symptoms and complications of gastroesophageal reflux in these patients. Therefore, LRYGBP is one of the most frequent procedures performed in bariatric surgery. The authors report a case of a 41-year-old man with a body mass index (BMI) of 44.6 kg/m² who was diagnosed with giant type III hiatal hernia. A laparoscopic approach for both hiatal hernia repair and LRYGBP was performed. At 6 months follow-up, the patient has lost 30% of excess body weight (BMI 34.4), and there is no evidence of recurrence of the esophageal hernia.     

Histologic Studies of the Bypassed Stomach after Roux-en-Y Gastric Bypass in a Porcine Model

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is highly effective for morbid obesity. However, the long-term effects in the bypassed segments are unknown. The aim of this study is to evaluate gastrin and histologic changes in bypassed segments after LRYGBP. Methods: 10 50-kg pigs were subjected to LRYGBP. Preoperative weight and serum gastrin were compared with similar measures at 6 months postoperatively, when the pigs were euthanized. At necropsy, full-thickness gastric, duodenal, and jejunal biopsies were performed. Normal biopsies were obtained from a control group of 10 pigs. Results: 1 pig died at 3 months postoperatively because of an intestinal intussusception. In the remaining 9 pigs, weight increased after surgery from 52±2.2 kg to 55±1.9 kg. Serum gastrin was unchanged after surgery (mean 68.2 vs 68.3 pg/mL at 3 months and 61.7 pg/mL at 6 months). Histology showed no abnormalities from sections in all control pigs, and in 7 of the LRYGBP pigs as well. 1 LRYGBP pig was found to have hyperplastic duodenal glands, jejunal mucosa with mild chronic inflammation, and gastric mucosa with focal erosive gastritis. 1 LRYGBP pig had jejunal sections showing Peyer's patches. Conclusion: LRYGBP is not associated with gastrin changes and major histologic changes in the bypassed segments, at 6 months postoperatively in the porcine model.     

Routine gallbladder screening not necessary in patients undergoing laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Management of the gallbladder in patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) is controversial. We reviewed our experience in patients undergoing LRYGBP without routine gallbladder screening. METHODS: The data of 644 patients who underwent LRYGBP at our institution were analyzed. Preoperative ultrasonography was routinely obtained early in our series and selectively thereafter in patients with suspected symptomatic biliary disease. Cholecystectomy at LRYGBP was performed in symptomatic patients with positive ultrasound findings. Postoperatively, patients with intact gallbladders were prescribed ursodiol for 6 months. RESULTS: Of the 644 patients, 155 (24%) had history of cholecystectomy. A total of 104 patients underwent preoperative ultrasonography. Of the 104 patients, 20 had positive ultrasound findings and symptoms consistent with biliary disease and underwent concomitant cholecystectomy. Twelve patients had positive ultrasound findings and no biliary symptoms and did not undergo cholecystectomy. At a mean follow-up of 26.4 months, only 1 (8.3%) of the 12 patients had required cholecystectomy. Of the 104 patients, 72 had negative ultrasound findings. At a mean follow-up of 21.2 months, 5 of them (6.9%) had required cholecystectomy. The remaining 385 patients did not undergo any gallbladder screening. At a mean follow-up of 14 months, 32 (8.3%) of 385 patients had required cholecystectomy. Compliance with ursodiol for >4 months was only 39%. A time-to-event analysis did not reveal a significant difference in the cholecystectomy rate between asymptomatic patients with preoperative gallbladder screening and patients with no screening. CONCLUSION: Omission of gallbladder screening in asymptomatic patients undergoing LRYGBP is a reasonable approach that spares the patient a potentially unnecessary procedure with all its associated risks.     

Resolution of Nonalcoholic Steatohepatits after Gastric Bypass Surgery

Background Nonalcoholic fatty liver disease (NAFLD) has been increasingly recognized as a common chronic liver condition. Previous studies have been variable regarding the histological outcomes after rapid weight loss. The aim of this study was to characterize the histopathologic changes in NASH following laparoscopic Roux-en-Y Gastric Bypass surgery (LRYGBP). Methods We retrospectively analyzed paired needle liver biopsies taken during and following LRYGBP in 39 patients according to the recent NIH-based NAFLD criteria. Results The cohort included 33 females and 6 males (range 24–57 years). 23 patients (58.9%) had steatohepatitis, 12 with fatty liver (30.7%), and 4 were normal (10.2%). Follow-up needle liver biopsies were performed at a mean interval of 18 months (range 6–41 months). No significant differences in length or number of portal tracts between the paired biopsies were noted. The mean decrease in weight and BMI was 50.2 kg and 18.2 kg/m², respectively. The initial prevalence of hepatic pathology: steatosis (89.7%), hepatocellular ballooning (58.9%), and centrilobular/perisinusoidal fibrosis (50%) improved significantly after LRYGBP: steatosis (2.9%), ballooning (0%), and centrilobular fibrosis (25%). Mitigation in the lobular inflammation score (2.23 ± 0.63 vs 1.95 ± 0.56, P = 0.01) and stage of fibrosis (1.14 ± 1.05 to 0.72 ± 0.97, P = 0.002) were also noted. However, no improvements were detected in portal tract inflammation and fibrosis. Conclusions Over a mean period of 18 months, histological improvements and resolution of NASH occurs after LRYGBP. Long-term studies are warranted to assess for potential changes in the portal regions or relapse of NASH that could result with weight regain or malnutrition.     

Micronutrient Deficiencies After Laparoscopic Gastric Bypass: Recommendations

Background  The aim of this study was to evaluate the changes of micronutrients in patients with morbid obesity after laparoscopic Roux-en-Y gastric bypass surgery (LRYGBP). Methods  We retrospectively reviewed 121 patients diagnosed with morbid obesity who undertook LRYGBP and evaluated the serum iron (Fe), calcium (Ca), zinc (Zn), selenium (Se), vitamin A (VitA), 25-hydroxy vitamin D3 (VitD), vitamin B₁₂ (VitB₁₂), and parathormone (PTH) measured at 6, 12, and 24 months after LRYGBP. Results  During a follow-up period of 69 months (June 1999 to February 2005), a cohort of 121 patients, 40 men and 81 women, underwent LRYGBP, a mean age of 46 years (range 22–67). The mean body mass index (BMI) before LRYGBP was 47.00 ± 7.15 kg/m² (range 30.65–76.60 kg/m²). After 6 months of the surgery, the mean BMI was 33.79 ± 6.06 kg/m² (range 21.70–52.76 kg/m²). The mean BMI decreased (P < 0.001) 6 months after the surgery. Within the following 2 years, the serum Fe, Ca, Zn, Se, VitA, VitD, and VitB₁₂ had normalized. The serum Zn, Se, and VitA of some patients decreased but were nearly normal. In contrast, serum PTH remained continuously at a higher level than normal. Conclusions  This study confirms that LRYGBP is a reliable and safe weight loss method for the patients suffering from morbid obesity. After surgery, serum Ca, Zn, and Se metabolisms and PTH levels are altered in these patients. Therefore, multi-vitamin and mineral supplementation are strongly recommended in all patients after LRYGBP.     

Symptomatic improvement in gastroesophageal reflux disease (GERD) following laparoscopic Roux-en-Y gastric bypass

Background: The purpose of this study was to determine the effect of laparoscopic Roux-en-Y gastric bypass (LRYGBP) on symptomatic control of gastroesophageal reflux disease (GERD). Methods: Morbidly obese patients (n = 435) who underwent LRYGBP for morbid obesity were assessed for changes in GERD symptoms, quality of life, and patient satisfaction after surgery. Results: A total of 238 patients (55%) had evidence of chronic GERD, and 152 patients (64%) voluntarily participated in the study. The mean body mass index (BMI) was 48 kg/m2. The mean excess weight loss was 68.8% at 12 months. There was a significant decrease in GERD-related symptoms, including heartburn (from 87% to 22%, p<0.001); water brash (from 18% to 7%, p<0.05); wheezing (from 40% to 5%, p<0.001) laryngitis (from 17% to 7%, p<0.05); and aspiration (from 14% to 2%, p<0.01) following LRYGBP. Postoperatively, the use of medication decreased significantly both for proton pump inhibitors (from 44% to 9%, p<0.001) and for the H2 blockers (from 60% to 10%, p<0.01). SF-36 physical function scores and the mental component summary scores improved after the operation (87 vs 71; p<0.05 and 83 vs 66; p<0.05, respectively). Overall patient satisfaction was 97%. Conclusion: LRYGBP results in very good control of GERD in morbidly obese patients with follow-up as late as 3 years. Morbidly obese patients who require surgery for GERD may be better served by LRYGBP than fundoplication because of the additional benefit of significant weight loss.     

Calcium Metabolism in Pre- and Postmenopausal Morbidly Obese Women at Baseline and After Laparoscopic Roux-En-Y Gastric Bypass

Background: The authors evaluated calcium metabolism in obese women, before and after menopause, at baseline and at 6 and 12 months after laparoscopic Roux-en-Y gastric bypass (LRYGBP). LRYGBP restricts food intake and produces physiological changes that may be similar to those after high Billroth II subtotal gastrectomy. Methods: Serum calcium (Ca), phosphate, bone-specific alkaline phosphatase (BSAP) and 25-hydroxyvitamin D3 (25-OH D) were measured at baseline and 12 months after LRYGBP. Urinary N-telopeptide (u-NTX) was measured at baseline and serum C-telopeptide (s-CTX) at 6 and 12 months after LRYGBP. Parathormone (PTH) was measured at baseline and 6 and 12 months after LRYGBP. Patients were divided into 2 groups: Group I (n=30) pre-menopausal women aged 18-42 y, and Group II (n=30) post-menopausal women aged 40-71 y. Patients with renal, hepatic, metabolic and bone disease, smoking women, as well as patients with u-NTX values at baseline >67 nMBCE/mMCr were excluded. Results: At baseline, PTH was elevated in 10% of patients in each group, correlated positively with BMI, and low serum calcium values were found in 30% of Group I and 16.7% of Group II. High values of serum C-telopetide were seen in Group I at 6 months after surgery and in Group II 12 months after LRYGBP. Group II showed a greater increase in BSAP at 12 months after LRYGBP. 25-0H D decreased in both groups, and a progressive increase in PTH was observed. Serum calcium did not change in both groups. Conclusion: Calcium metabolism is altered in pre- and post-menopausal women following LRYGBP. Calcium and vitamin D supplementation is strongly advised in all patients.     

Predictors of Prolonged Hospital Stay following Open and Laparoscopic Gastric Bypass for Morbid Obesity: Body Mass Index,Length of Surgery,Sleep Apnea,Asthma and the Metabolic Syndrome

Background: The number of weight reduction operations performed for type II and type III obesity is rapidly escalating. Risk of surgery has been infrequently stratified for patient subgroups. The purpose of this study was to identify patient characteristics that increased the odds of a prolonged hospital length of stay (LOS) following open or laparoscopic Roux-en-Y gastric bypass (RYGBP). Methods: The hospital records of 311 patients who underwent RYGBP in a 6-month period were retrospectively reviewed. Patient characteristics including the presence of significant obesity-related medical conditions were recorded. Analysis was based on intent to treat. Univariate and step-wise logistic regression analysis was used to identify the odds ratio (OR) and adjusted odds ratio (AOR) for predictors of an increased hospital LOS. Results: Datasets for 311 patients were complete. 159 patients underwent open vertical banded gastroplasty-Roux-en-Y gastric bypass (VBG-RYGBP) and 152 laparoscopic RYGBP (LRYGBP). 78% of patients were female. Median age was 40 years (range 18-68). Median BMI was 49 kg/m² (range 35-82). 17% of patients had sleep apnea, 18% asthma, 19% type 2 diabetes, 13% hypercholesterolemia and 44% hypertension. Median length of surgery for open VBG-RYGBP (64 minutes) was significantly faster than for LRYGBP (105 minutes). Median length of stay was significantly shorter for LRYGBP (2 days) than open VBG-RYGBP (3 days). Univariate logistic regression analysis identified 6 predictors of increased LOS: open surgery (0.4 OR); increasing BMI (60 kg/m² 0.38 OR; BMI 70 kg/m² 0.53 OR); increasing length of surgery (120 min 0.33 OR; 180 min 0.48 OR); sleep apnea (2.25 OR); asthma (3.73 OR); and hypercholesterolemia (3.73 OR). Subset analysis identified patients with the greatest odds for a prolonged hospital stay: women with asthma (2.47 AOR) or coronary artery disease (8.65 AOR); men with sleep apnea (5.54 OR) or the metabolic syndrome (6.67 – 10.20 OR); and patients undergoing a laparoscopic operation with sleep apnea (11.53 AOR) or coronary artery disease (12.15 AOR). Conclusions: Open surgery, BMI, length of surgery, sleep apnea, asthma and hypercholesterolemia all increased the odds of a prolonged LOS. Patients with the greatest odds of long LOS were women with asthma or coronary disease, men with sleep apnea or the metabolic syndrome, and patients undergoing laparoscopic surgery with sleep apnea or coronary artery disease. Patients at high-risk for prolonged hospital stay can be identified before undergoing RYGBP. Surgeons may wish to avoid high-risk patients early in their bariatric surgery experience.     

Bowel Obstruction after Laparoscopic Roux-en-Y Gastric Bypass

Background: Bowel obstruction has been frequently reported after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The aim of this study was to review our experience with bowel obstruction following LRYGBP, specifically examining its etiology and management and to strategize maneuvers to minimize this complication. Methods: We retrospectively reviewed the charts of 9 patients who developed postoperative bowel obstruction after LRYGBP. Each chart was reviewed for demographics, timing of bowel obstruction from the primary operation, etiology of obstruction, and management. Results: 9 of our initial 225 patients (4%) who underwent LRYGBP developed postoperative bowel obstruction. The mean age was 46 ± 12 years, with mean BMI 47 ± 9 kg/m². 6 patients developed early bowel obstruction, and 3 patients developed late bowel obstruction. The mean time interval for development of early bowel obstruction was 16 ±16 days. The causes for early bowel obstruction included narrowing of the jejunojenunostomy anastomosis (n=3), angulation of the Roux limb (n=2), and obstruction of the Roux limb at the level of the transverse mesocolon (n=1). The mean time interval for development of late bowel obstruction was 7.4 ± 0.5 months. The causes for late bowel obstruction included internal herniation (n=2) and adhesions (n=1). 6 of 9 bowel obstructions (66%) were considered technically related to the learning curve of the laparoscopic approach. Eight of the 9 patients required operative intervention, and 6 of the 8 reoperations were managed laparoscopically. Management included laparoscopic bypass of the jejunojejunostomy obstruction site (n=5), open reduction of internal hernia (n=2), and laparoscopic lysis of adhesion (n=1). Conclusions: Bowel obstruction is a frequent complication after LRYGBP, particularly during the learn ing curve of the laparoscopic approach. Specific measures should be instituted to minimize bowel obstruction after LRYGBP as most of these complications are considered technically preventable.     

Gastrointestinal Quality of Life after Laparoscopic Roux-en-Y Gastric Bypass

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a commonly performed bariatric surgical procedure for the treatment of morbid obesity (MO). Obesity-related co-morbidities reduce the quality and expectancy of life. We assessed gastrointestinal quality of life in patients following LRYGBP. Methods: The Gastrointestinal Quality of Life Index (GIQLI test) was used in this study. A higher score correlates with better quality of life. The GIQLI test was administered to 3 non-selected groups: 100 morbidly obese patients (MO group), 100 patients who had undergone LRYGBP (LRYGBP group); and a control group of 100 individuals (CO group). The CO group was composed of healthy individuals with a BMI <30 kg/m², consecutively recruited among the companions of patients who came for a surgery consultation for obesity or other pathologies. Overall test and specific dimensions scores were evaluated for each group. Results: Overall test and specific dimensions scores were significantly lower in patients with MO when compared to the CO and LRYGBP groups. There were no differences between the CO and LRYGBP groups in the overall score with regard to disease-specific digestive symptoms and the psychological and social dimensions. Conclusions: The quality of life of morbidly obese patients is worsened not only because of the presence of digestive symptoms but also because of their emotional, physical and social impact. Patients operated on by LRYGBP experience an improvement in their quality of life, with good tolerance of the anatomical changes.