Results of Bariatric Surgery for Morbid Obesity in Patients Older than 50 Years

Background: Surgery is increasingly used for weight loss in morbidly obese patients. The authors evaluated the safety and efficacy of bariatric surgery in patients older than 50 years. Methods: Prospective data on 62 consecutive patients (Male = 13, Female = 49) undergoing bariatric procedures between 1985-1994 were reviewed. Mean followup was 30 ± 2 months (3-48 months). All data are mean ± sem. Results: Age was 57 ± 1 year (range 50-71 years). Patients had a mean preoperative weight of 125 ± 4 kg (275 ± 9 lb) and 119 ± 6% excess body weight. A total of 68 procedures were performed: vertical banded gastroplasty (VBG = 23), Roux-en-Y gastric bypass (RYGB = 43), and biliopancreatic diversion (BPD = 2). Six patients were converted to RYGB (5) and BPD (1) after failed VBG. Hospital mortality was nil. Complications were wound infection (5), pulmonary (4), gastric leak (2), abscess (1) and others (4). Mean weight loss at 3 years was 55 ± 7 and 33 ± 6% of percent excess body weight for RYGB and VBG, respectively. Postoperative use of medications for arthritis, diabetes mellitus and asthma was reduced by 23%, 62% and 100%, respectively. Satisfaction with the outcome of treatment and weight loss was reported by 81% of patients. Six patients that were converted from jejunoileal bypass (metabolic complications) to VBG gained weight. Conclusions: Bariatric surgery is safe and well tolerated in morbidly obese patients older than 50 years. Weight loss parallels that of younger populations and is greater in patients treated with RYGB in this subgroup. Age should not be a contraindication to bariatric surgery provided the patient has obesity-related medical morbidity. Control of obesity-related co-morbid conditions is improved by weight loss.     

A Nationwide Survey on Bariatric Surgery in France: Two Years Prospective Follow-up

Background Most studies on bariatric surgery outcomes have been performed in clinical trials (eg. the SOS) or reflect the clinical experience and practice of specific and experienced centers. Little is known about the current practice at a nationwide level. Methods This is a systematic nationwide study on the 2-year outcome of all consecutive 1,236 bariatric operations performed in France. Data on mortality, weight loss, complications, and patient satisfaction were collected independently from the medical and surgical team involved in the patients’ care. Results 87.3% of the patients underwent an adjustable gastric banding (ABG), 8.6% a vertical banded gastroplasty (VBG), 3.8% a Roux-en-Y gastric bypass (RYGBP) and 0.3% a biliopancreatic diversion (BPD). Loss of follow-up was 12% at year 1 and 18% at year 2. The rate of laparoscopic procedures was 98% for ABG and 73% for RYGBP. Mortality rate was 0.16% in the operative period and 0.27% during follow-up. Excess weight loss ranged from 43% (AGB) to 66% (RYGBP). Co-morbidities improved in more than 70% of patients. Conclusion Outcomes of bariatric surgery in routine practice (mortality, weight loss, course of co-morbidities, and quality of life) are similar to the results published in clinical trials.     

Gastric Pouch Adenocarcinoma and Tubular Adenoma of the Pylorus: A Field Effect of Dysplasia following Bariatric Surgery

There are reports of gastric carcinoma following bariatric surgery, but it is unclear if these procedures predispose to malignancy.We present a case of a 60-year-old man who, 15 years after vertical banded gastroplasty (VBG), had a massive upper GI bleed. Endoscopy revealed a large tumor of the gastric pouch. Histology confirmed an intestinal type of gastric adenocarcinoma arising in a background of H. pylori-negative gastritis with atrophy, foveolar hyperplasia and intestinal metaplasia. An incidental tubular adenoma at the pylorus was also identified. The pathogenesis of gastric pouch carcinoma is discussed. The present example of neoplastic change in both the pouch and pylorus may indicate that a field effect for dysplasia develops subsequent to VBG.     

Preoperative Weight Gain in Bariatric Surgery

A significant weight gain with a mean of 4.4 kg was found between the date of acceptance for bariatric surgery and the date of admission to hospital for the operation.     

Selected Topics in Malpractice Reduction in Bariatric and Other Surgery

On the basis of an extensive legal experience, the sound strategies that prevent or reduce malpractice litigation in bariatric or other surgery are presented.     

Rhabdomyolysis after Laparoscopic Bariatric Surgery

Background: Postoperative rhabdomyolysis is an uncommon event. The aim of this study was to determine the incidence of rhabdomyolysis following laparoscopic obesity surgery. Methods: Rhabdomyolysis was studied prospectively. Over a 6-month period, 66 consecutive patients underwent bariatric surgery (gastric banding (n=50) and gastric bypass (n=16)). All patients underwent laparoscopic procedures. A range of blood tests, including serum creatine phosphokinase (CPK) level and serum creatinine, were systematically performed before surgery, and on the first and third day postoperatively. Rhabdomyolysis was defined as a postoperative CPK level >1,050 IU/L. Results: Serum CPK was noted to increase significantly postoperatively to >1,050 units in 3 patients (6%) in the adjustable banding group and 12 patients (75%) in the gastric bypass group (P <0.01). In the bypass group, 4 patients (25%) had a serum CPK level >10,000 IU/L, but there were none in the gastric banding group. All patients with CPK level >10,000 IU/L had BMI >60 kg/m². No patients experienced acute renal failure. Conclusion: Rhabdomyolysis occurred in 22.7 % of 66 consecutive patients undergoing laparoscopic bariatric surgery. Risk factors were identified: massive obesity and long duration of the operation. Early diagnosis may have significant impact on outcome by preventing or reducing the severity of complications from rhabdomyolysis. CPK level should be performed systematically after obesity surgery.     

Mini-Gastric Bypass for Revision of Failed Primary Restrictive Procedures: A Valuable Option

Background Despite the initial success of primary gastric restrictive operations, many patients require revision for weight regain, mechanical complications or intolerance to restriction. The mini-gastric bypass (MGB) for revision of failed primary restrictive procedures was evaluated. Methods 33 patients undergoing revisional surgery to a MGB for a failed silastic ring vertical banded gastroplasty (VBG) or a gastric banding (GB) from June 2005 to September 2006, were reviewed at an academic institution. The patients had had a minilaparotomy. Revision of the VBGs was further compared with revision of the GBs. Results The MGB was completed in all except 2 patients who required Roux-en-Y gastric bypass (RYGBP) because of gastric tube damage. Mean age was 41 years (range 20–64), preoperative BMI was 39.5 kg/m² (range 28–58), and 20 (65%) were women. The revision was performed after an average of 36.3 months (range 12–84), and was more time-consuming in patients with prior VBG than GB (184 vs 155 min, P = 0.007). Postoperative complications occurred in 2 (6.4%) with prior VBG, and length of hospital stay was 4.65 days (range 3–17).Mean BMI at 6 months was 30.6 (range 24.8–50.0, P < 0.001) compared with the preoperative BMI. Reflux disease was cured, and all patients noted major improvement in the eating dimension. Conclusion Open MGB through a previous mini-incision is a safe and effective operation for revision of failed gastric restrictive operations. The revision procedure was technically more difficult in patients with prior VBG and hazardous in patients with prior redo VBG.     

Vertical Banded Gastroplasty at More than 5 Years

Background: Optimal evaluation of the results of surgery for morbid obesity requires a long-term follow-up for at least 5 years. Methods: One hundred patients were operated by vertical banded gastroplasty (VBG) and revised with a follow-up of no less than 5 years. Sixty patients were morbidly obese with a body mass index (BMI) of between 40 and 50 kg/m², and 40 were superobese with a BMI of >50 kg/m². Follow-up included 93 patients (93%). Results: Initial surgical mortality was nil. Twenty-five patients required surgery for complications related to the technique (25%) and one patient died due to pulmonary embolism after a re-stapling operation. The percentage excess weight loss was 54.3%, and the BMI was 33 kg/m² for the 84 patients followed to 5 years post VBG. Only 40 out of 92 patients (43.5%), obtained the weight loss benefit due to the operation. None of them is able to eat a regular diet, and the quality of food intake has been severely affected in some of them. Conclusions: VBG is, in our experience, a safe and technically simple operation, but the long-term results are questionable. The reoperation rate was high, and weight loss and quality of life are superior with other operations.     

Vertical Banded Gastroplasty Versus Standard or Distal Roux-en-Y Gastric Bypass Based on Specific Selection Criteria in the Morbidly Obese: Preliminary Results

Background: Predicting successful outcomes after bariatric surgical procedures has been difficult, and the establishment of specific selection criteria has been a subject of ongoing research. In an effort to choose the most appropriate surgical procedure for each patient, we have established a specific set of selection criteria for each procedure based on degree of obesity, preoperative dietary habits, eating behavior, and various metabolic features. Methods: From June 1994 to December 1998, 90 bariatric surgical procedures were performed at the authors' institution by a single surgeon (F.K.) based on specific selection criteria. Vertical banded gastroplasty (VBG) was performed in 35 patients, standard Roux-en-Y gastric bypass (RYGB) in 38 patients, and distal RYGB in 17 patients. All patients were monitored postoperatively 1, 3, 6, and 12 months and once per year thereafter, with an additional visit at 18 months in distal RYGB patients. Results: Early postoperative morbidity (<30 days) did not differ significantly between the three groups and averaged 9% of total patients. Long-term postoperative morbidity (>30 days) included 9 incisional hernias (2 in the VBG group, 5 after RYGB, and 2 in the distal RYGB group). There were 6 cases of staple-line disruption, 4 after VBG and 2 after standard RYGB, 1 of which resulted in stomal ulcer. Early postoperative mortality was 0%, and long-term mortality was 1.1%, which was due to pulmonary embolism in 1 standard RYGB patient on the 65th postoperative day. Average percentage of excess weight loss (%EWL) was 62% the first year, 61% the second year, and 50% the third year in VBG patients, and 63.6%, 65%, and 63.3%, respectively, in standard RYGB patients. In distal RYGB patients, where the patient number was significantly smaller, the %EWL at 1 and 2 years, respectively, was 51% and 53%. The most significant metabolic/nutritional complication was the appearance of hypoproteinemia (hypoalbuminemia) in 1 distal RYGB patient 20 months after surgery, which was corrected by total parenteral nutrition and subsequent increase in dietary protein intake. Significant improvement or resolution of pre-existing comorbid conditions was observed in all patient groups. The postoperative quality of eating, as evaluated by variety of food intake and frequency of vomiting, was significantly better in RYGB patients. Conclusions: These results show that selection of the bariatric surgical procedure to be performed in each patient based on specific criteria leads to acceptable weight loss, improvement in preexisting comorbid conditions, and a high degree of patient satisfaction in most patients. On the basis of our own observations as well as those of others, our selection criteria have become more strict over time and our selection of VBG as the operation of choice increasingly infrequent.     

Drug Distribution in Obesity and following Bariatric Surgery: A Literature Review

Background: The pharmacokinetic variables of drug clearance and volume of distribution are usually corrected for body weight or surface area. Only recently have the relationships which exist between body size, physiologic function and pharmacokinetic variables been evaluated in the obese population. These effects are not widely known, and data on this and the effects of bariatric surgical procedures are scantily documented in the surgical literature. Methods: Literature review. Results: Drugs with a low or moderate affinity for adipose tissue have a moderate increase in the volume of distribution (Vd), and this correlates with the increase in lean body mass (LBM). Highly lipophilic drugs, with some exceptions, show the expected increase in Vd and prolongation of elimination half-life, indicating a marked distribution into adipose tissue. Drug absorption, in general, is slowed by delayed gastric emptying and is normal when gastric emptying is normal or increased. Most drug absorption occurs in the small intestine where duration of drug/mucosal contact is the most important factor. Conclusions: Drugs whose distribution is restricted to LBM should utilize a loading dose based on ideal body weight (IBW). For those drugs which distribute freely into adipose tissue, the loading dose should be based on total body weight (TBW). Adjustment of the maintenance dose depends on clearance rates. In a few cases dosage adjustment depends on pharmacodynamic data, since drug clearance does not conform to these recommendations, for reasons which remain to be defined. Following bariatric surgery, in the absence of delayed gastric emptying or uncontrolled diarrhea, drug absorption rates are usually comparable to the non-operated patient.     

Bariatric Surgery at the 1st Surgical Department in Prague: History and Some Technical Aspects

Background: Obesity has been increasing in the Czech Republic over the last 20 years. In 1983 we were one of the first surgical departments in the country which performed bariatric surgery on a regular basis. Methods: From 1983 to 1986 we performed vertical banded gastroplasty (VBG). Because of a high rate of various complications arising both from the stomach and the wound, we switched in 1986 to ‘less aggressive’ nonadjustable gastric banding (GB). In 1993 we performed the first laparoscopic nonadjustable banding, and in 1994 we started laparoscopic placement of adjustable gastric bands. Results: In the group of 52 patients who underwent VBG and were followed-up, acceptable weight loss results (−40.5 kg) were achieved in the 24 months following surgery. The postoperative complications were high; 17.3% gastric staple-line disruption and 15.3% wound complications (incisional hernias, discharge, etc.). Since 1986, we have performed nonadjustable GB in 150 patients and achieved weight loss of -38.4 kg in the 24 months following surgery. There was no change in the wound complication rate, but the complications arising from the stomach and the band decreased to 6.3%. Since June 1993, we have performed 268 procedures laparoscopically, either with nonadjustable bands or, since 1994, with the adjustable bands. The wound complication rate decreased to 0.9%, and one complication (6.6%) was related with the adjustable band. Conclusions: Because of the high rate of post-operative complications in our experience with VBG, we started GB in 1986. Since then the number of complications arising from the stomach has decreased substantially. With the laparoscopic technique, there was a further decrease in wound healing problems. With the adjustable GB, a significant decrease in the stomach-related complications occurred. Shorter hospital stays were possible with the laparoscopic technique. Long-term weight loss results have not been significantly different among the above mentioned procedures.     

Outcome Following Bariatric Surgery in Super versus Morbidly Obese Patients: Does Weight Matter?

Background: Numerous investigators have attempted to identify prognostic indicators for successful outcome following bariatric surgery. The purpose of this study was to determine whether degree of obesity affects outcome in super obese [>225% ideal body weight (IBW)] versus morbidly obese patients (160-225% IBW) undergoing gastric restrictive/bypass procedures. Methods: Since 1984, 157 patients underwent either gastric bypass or vertical banded gastroplasty. Super obese (78) and morbidly obese (79) patients were followed prospectively, documenting outcome and complications. Results: Super obese patients reached maximum weight loss 3 years following bariatric surgery, exhibiting a decrease in body mass index (BMI) from 61 to 39 kg/m² and an average loss of 42% excess body weight (EBW). Morbidly obese patients had a decrease in BMI from 44 to 31 kg/m² and carried 39% EBW at 1 year. After their respective nadirs, each group began to regain the lost weight with the super obese exhibiting a current BMI of 45 kg/m² (61% EBW) versus 34 kg/m² (52% EBW) in the morbidly obese at 72 months cumulative follow-up. Currently, loss of 50% or more of EBW occurred in 53% of super obese patients versus 72% of morbidly obese (P < 0.01). Twenty-six percent of super obese patients returned to within 50% of ideal body weight (IBW) while 71% of morbidly obese were able to reach this goal (P < 0.01). Co-morbidities and complications related to surgery were similar in each group. Conclusions: Super obese patients have a greater absolute weight loss after bariatric surgery than do morbidly obese patients. Using commonly utilized measures of success based on weight, morbidly obese patients tend to have better outcomes following bariatric surgery.     

The Future of Bariatric Surgery

Scientific evidence is pointing more and more strongly to the fact that serious, or morbid, obesity is not a moral issue. Serious obesity is a consequence of a genetically-related, powerful biophysiological drive to consume more calories than are burned. This concept must eventually become incorporated into lay and medical paradigms of obesity. It will result in an increased understanding and sympathy for the suffering of the seriously obese and, as a consequence, stronger support for definitive treatment of serious obesity such as bariatric surgery. Reoperative bariatric surgery principles, currently limited by individual exposure and experience, will develop and evolve. Laparoscopic bariatric surgery may, in time, be developed and prove itself to be of value. Bariatric surgeons should also find it useful to enhance their teams' skills for nutritional, behavioral and psychological management, as well as broaden their operative base into other, related surgical areas such as partial ileal bypass procedures for hyperlipidemia management. As fields mature, organizational maturation is a natural and necessary accompaniment. An International Federation for Bariatric Surgery, or similar entity, will be founded to constructively unite national bariatric surgery and related organizations together. The international bariatric surgery journal, Obesity Surgery, will become more and more accepted as the truly professional and essential vehicle of communication concerning bariatric surgery that it has been since its first issue. Medical management simulating the effects of surgery will be employed successfully; it may arise out of the current genetic work. It may ultimately, in the next 25 years or so, replace the surgical treatment of serious obesity.     

Vertical Banded Gastroplasty vs Gastric Bypass: 10 Years follow-up

In 1982, a prospective study to evaluate and compare the operations for treatment of morbid obesity, vertical banded gastroplasty (VBG) and gastric bypass (GBP), was carried out at the Center for Surgical Treatment of Obesity in Los Angeles. The VBG was performed as described by Dr Mason with a 5.0 cm circumference Marlex band. The GBP was the horizontal GBP with ≤ 50 cc pouch as described by Mason and modified by Printen and Griffen. One hundred patients had the VBG and 100 had the GBP. At 10 years follow-up, only 43 of the VBG patients and 46 of the GBP patients can be found. The groups are compared as to the perioperative complications, late complications and weight loss. VBG compared favorably with GBP for control of morbid obesity. GBP yields better weight loss and maintenance at all times of follow-up. Both procedures are equal in terms of morbidity and mortality.     

A Decade of Change in Obesity Surgery

Background: The International (formerly National) Bariatric Surgery Registry began collecting data in January 1986. The aim of this study was to examine changes in the practice of surgical treatment of severe obesity that occurred during the decade of 1986 through 1995, as observed in the IBSR data. Methods: All data submitted to the IBSR during the decade were transferred to the IBM mainframe computer for analysis. Characteristics of operative type populations were compared over time using analysis of variance (ANOVA) for age, body mass index (BMI), operative weight and Chi-square (χ²) test for gender. Results: There has been a steady increase over the decade in mean patient weight. The operations used have changed from predominantly ‘simple’ operations to more frequent use of ‘complex’ operations. Within the categories of ‘simple’ and ‘complex’, an increase in the variety of operations occurred. As a group, patients with ‘simple’ operations have been heavier, more often male and public pay patients than those who have undergone ‘complex’ operations. One year weight loss was greater for Roux-en-Y gastric bypass (RGB) than vertical banded gastroplasty (VBG), but follow-up rates were too low to study the relative merits of the operations used. The reported incidence of operative mortality and serious complications (leak with peritonitis, abscess and pulmonary embolism) remained low. Conclusions: These observations and their implications can be summarized in three statements which relate to action for improved patient care in the beginning of the new century: (1) increasing weight of candidates for surgical treatment during this decade indicates the need for earlier use of operative treatment before irreversible complications of obesity can develop; (2) low risk of obesity surgery, decreasing postoperative hospital stay, and early weight control support the continued and increased use of surgical treatment; (3) continued widespread use of both ‘simple’ and ‘complex’ operations with increased modifications of standard RGB and VBG procedures emphasizes the need for standardized long-term data and analyses regarding both weight control and postoperative side-effects.     

A Psychological Profile of the Bariatric Patient with Implications for Treatment

Background: Psychological testing of the bariatric patient utilizing instruments such as the MMPI have not proven useful in predicting successful weight loss following bariatric surgery. This has led many physicians and professionals who treat bariatric patients to believe that psychological testing is of no value. This paper discusses three instruments and the psychological profile of the average bariatric patient that they provide, and how the profile may be of benefit to the bariatric patient and to professionals who treat them. Methods: The profile to be presented was obtained from the statistical analysis of the tests of 70 patients selected by random sample from a population of 695 patients. Results: Results suggest that the average bariatric patient is mentally healthy and free of any psychological disorders contraindicating surgery. Although mentally healthy, the results suggest that the average bariatric patient does have a number of attitudes, behaviors, and personality traits which may sabotage weight loss following surgery. Conclusions: The psychological profile obtained from the data provides valuable information toward the development of a comprehensive treatment program designed to improve these potentially sabotaging attitudes, behaviors, and personality traits, in order to facilitate successful weight loss following bariatric surgery.     

Analysis of the Incidence and Risk Factors for Wound Infections in Open Bariatric Surgery

Background: Our clinical impression derived from >95% follow-up of patients was that our wound infection rate was higher than the 1-10% reported in the literature. The purpose of this study was to determine the incidence and risk factors for wound infection in open bariatric surgery. Methods: We queried our prospectively acquired bariatric surgery outcomes database, and retrospectively audited the charts of patients operated from April 1 to March 31, 2003. Risk categories were obtained using the National Nosocomial Infection Surveillance (NNIS) definitions and stratification. Expected site-specific rates were adjusted for duration of operation, degree of wound contamination, and underlying disease condition. Results: 269 patients undergoing a standardized open Roux-en-Y gastric bypass were studied. The mean age (SD) was 39.5 (10.5) years and the mean BMI was 54.3 (9.9). Operating time averaged 63 (17) minutes, and length of stay was 4.1 (1.3) days. Based on NNIS categories 10.9 wound infections were expected, but 54 were observed, for a rate of 20%. Bacterial isolates included S. aureus (39%), α-hemolytic strep (26%), Enterococcus (16%), P.mirabilis (9%), and multiple other bacteria at 10%. Epidural analgesia and delayed antibiotic prophylaxis administration (after the incision was made) increased the odds of developing a wound infection, whereas gender, age, BMI, duration of surgery, and incidence of diabetes had no effect.There was a high correlation between wound infection and subsequent incisional hernia formation. Conclusion: The incidence of wound infections following open bariatric surgery is high, and the current recommendations for antibiotic prophylaxis are ineffective. As these infections carry significant morbidity, effective methods to prevent them are needed.     

Revisional Surgery After Failed Vertical Banded Gastroplasty: Restoration of Vertical Banded Gastroplasty or Conversion to Gastric Bypass

Background: An increasing number of patients with a failed primary bariatric procedure present themselves for secondary treatment. Only a few studies have investigated critically the success of revisional surgery. In the present study, the effectiveness of revisional surgery for failed vertical banded gastroplasty (VBG) is analyzed: restoration of the VBG (reVBG) is compared to conversion to a Roux-en-Y gastric bypass (RYGB). Patients and Methods: From 1980 to 1996, 136 consecutive morbidly obese patients underwent primary RYGB (n = 20) or VBG (n = 16). Weight loss, indications and complications after revisional surgery were registered. The rate of revisional surgery after primary and secondary bariatric procedures was estimated by means of a Kaplan-Meier analysis. Results: Kaplan-Meier analysis revealed that 56% of the patients will eventually require revisional surgery after initial VBG over a 12-year period compared to 12% after initial RYGB (P < 0.01). After reVBG 68% will need revisional surgery over a 5-year period, while no further revisional surgery was required after conversion to a RYGB (P < 0.05). Body mass index dropped significantly after reVBG or conversion to RYGB for insufficient weight loss (P < 0.05), however, more revisional surgery was necessary after reVBG to achieve this result. The complication rate was comparable between reVBG and conversion to RYGB (33%). Conclusion: Conversion of a failed VBG to a RYGB is more effective than a reVBG, because conversion to RYGB provides satisfactory weight loss without requiring further revisional surgery.     

Social and Economic Effects of Bariatric Surgery

One to 5 years after gastric restrictive surgery and subsequent weight loss, 79 bariatric surgery patients were compared with a similar group of 54 non-operated patients. The operated group had a significantly higher proportion of employment, more working hours, and a higher income. They were also more active in different physical and social activities and had a better sexual life. They required less medical care, had fewer days of sick leave or sick pension, and gave a much higher score in assessment of their general health. The results indicate that obesity surgery is highly cost-effective.