Outcome of Gastric Bypass Patients

Background: The authors analyzed previously studied outcomes of Roux-en-Y gastric bypass (RYGBP), examined pre-surgical factors of post-surgical outcomes, and examined some of the psychosocial benefits. Methods: A retrospective chart review was conducted of 138 patients who underwent RYGBP between 1997 and 2000. Pre-surgical BMI, cholesterol, blood pressure, creatinine, number of antidepressant/glycemic drugs, and hemoglobin were recorded. Post-surgical follow-up was reviewed to examine changes. Results: Statistically significant changes were found in BMI, hypertension, cholesterol and glycemic control. Surgery was found to reduce creatinine from a pre-surgery average of 1.14 to 1.01 (n=11, p=.0015)). Patients with early post-operative complications (defined as length of stay >6 days or re-hospitalization within 1 month following surgery) had an average BMI of 57.58 (n=23) vs a BMI of 49.9 (n=103) in those who did not experience any complications (p = 0.0004).There was a statistically significant decrease in the rate of anti-depressant use following surgery. 49 patients were on antidepressants before surgery vs 38 following surgery (p=.0016). Conclusion: RYGBP significantly improves hypertension, hyperlipidemia and type II diabetes, and may also improve kidney function. Patients with higher pre-surgical BMIs are at greater risk for postsurgical complications. Postoperative antidepressant use appears to decrease.     

Improvement in Co-Morbidities Following Weight Loss From Gastric Bypass Surgery

Background: Clinical observation reveals a close association between morbid obesity and a variety of serious medical conditions. This report describes the changes observed in some of these co-morbid conditions, following weight loss achieved by silastic ring gastric bypass (SRGBP). Methods: Between 1990 and 1998, 157 severely obese patients aged 15-62 years underwent SRGBP. Initial and follow-up data was recorded prospectively on a computerized database, with minor subsequent additions being achieved by phone call or questionnaire. Particular attention was given to associated comorbidities and improvement in these that occurred during follow-up. Median pre-operative BMI was 45 (33-97). Patients were followed for a median 2.5 years. At 2 years post-SRGBP, median BMI was 28 (20-52). Weight loss was statistically significant (p<0.0001). Results: Before surgery 42 patients were being treated for hypertension and 34 for asthma. Withdrawal of all medication for these conditions was achieved sometime after surgery in 18 and 17 patients respectively. NIDDM was present in 19 patients before surgery and subsequently resolved completely in 18. Eleven of the 12 patients with recognized obstructive sleep apnea before surgery had resolution of this after surgery. Dyslipidemia was present in the majority of patients before surgery and resolved or improved following surgery in almost all instances. Conclusions: The findings indicate that reliable and substantial weight loss can be accomplished by gastric bypass surgery with accompanying major reductions in associated co-morbidities. Such benefits suggest that greater attention should be given to this form of treatment for those with severe obesity.     

Outcome following Gastric Bypass Surgery: Impact of Past Sexual Abuse

Background: This study examined gastric bypass (GBP) outcome in 2 groups of morbidly obese females: those with a history of sexual abuse (SA) and those without a history of sexual abuse (NSA). Methods: Subjects were assessed preoperatively and at one of two time points following surgery: either 5 to 9 months or 10 to 14 months. Outcome measures included BMI, level of depression as measured through the Beck Depression Inventory (BDI), and level of self-esteem as measured through the Rosenberg Self-Esteem Scale (RSE).T-tests were conducted for pre and post scores between the 2 groups on each of the variables. Results: Of the 12 tests conducted, the only statistically significant difference was on BDI scores for the 5 to 9 month post-surgery groups, with the SA groups showing a significantly higher level of depression than the NSA group. Conclusions:The results suggest that females with a history of sexual abuse are as successful with weight loss following GBP as those without a history of abuse.While females with a history of sexual abuse show significantly more depression 5 to 9 months after surgery, they are indistinguishable from those without a history of abuse 1 year following GBP.Thus, sexual abuse does not appear to be a negative prognostic indicator for GBP.     

Pre-Surgery Binge Eating Status: Effect on Eating Behavior and Weight Outcome after Gastric Bypass

Background: The impact of pre-surgical binge eating on postoperative outcomes is poorly understood. Previous studies have found marked preoperative differences between binge eaters (BE) and non-binge eaters (NBE) in hunger and disinhibition using the Three-Factor Eating Questionnaire (TFEQ). Short-term prospective data are mixed regarding whether these differences persist after surgery and if preoperative binge eating impacts postoperative weight outcomes. The purpose of the present study was to compare self-reported eating behavior and weight outcomes between BE and NBE after the first postoperative year. Methods: Prior to surgery, 72 Roux-en-Y gastric bypass (RYGBP) patients completed the Questionnaire of Eating and Weight Patterns (QEWP) or QEWP-Revised (QEWP-R), to assess binge eating status which was defined as one objective binge episode per week over the past 6 months. Subjects also completed the TFEQ prior to surgery and again ≥12 months after surgery. Results: For BE, higher scores were found for both hunger and disinhibition prior to surgery. At a mean of 18 months after surgery, BE and NBE were indistinguishable on these subscales and there were no differences in weight lost. Conclusions: RYGBP surgery has an equally positive impact on eating behavior and weight loss for both BE and NBE. Within a multidisciplinary clinic, preoperative BE status does not appear to be a negative prognostic indicator for RYGBP surgery in the domains of weight loss and disinhibition. Further replication is needed with longer follow-up times and larger samples.     

Laparoscopic Gastric Bypass: Development of Technique,Respiratory Function,and Long-Term Outcome

Background: Roux-en-Y gastric bypass (RYGBP) is the preferred operation for the treatment of morbid obesity by many surgeons. Hereby we present the process by which laparoscopic RYGBP (LRYGBP) developed at our institution. Methods: Perioperative morbidity was recorded from 150 consecutive morbidly obese patients operated upon by RYGBP from August 1994 to March 2002. The first 76 consecutive patients have been followed up to 5 years postoperatively. A subgroup of 40 patients was recruited to evaluate the postoperative lung function in a randomized study between receiving and not receiving prophylactic chest physiotherapy. Results: In the whole series, there were 4 conversions to open surgery, 5 leaks, 12 postoperative bleedings and 1 intestinal obstruction. 1 patient succumbed after developing acute dilatation of the bypassed stomach. Respiratory function deteriorated significantly in all patients in the early postoperative period, irrespective if given physiotherapy. During the follow-up period, 3 patients developed mechanical obstruction of the Roux limb. Another patient had a perforated ulcer at the proximal pouch. Weight reduction averaged 70% of excess body weight at 2 years after surgery. Conclusions: LRYGBP is an effective treatment for morbid obesity. During the initial development, we experienced a number of serious complications. The complication rate decreased over time. Postoperative lung function was markedly impaired, but there were no beneficial effects of chest physiotherapy. Long-term weight loss after LRYGBP seems to be comparable to what has been reported after open RYGBP.     

Morbid Obesity and Gastric Bypass Surgery: Biochemical Profile

Background: Morbid obesity (MO) and the pathologies associated with it constitute an important public health problem, accounting for 7% of the health expenditure in industrialized countries. An important percentage of this expense is attributed to the different biochemical tests performed in these patients, who suffer from several metabolic derangements. We evaluated the basic biochemical abnormalities in MO patients and their reversibility by weight loss after gastric bypass, to standardize the surveillance of the different metabolic abnormalities in obese patients. Methods: By a retrospective analysis on 125 patients operated in our hospital, we evaluated anthropometric and biochemical data before and 1, 3, 6, 12 and 24 months after gastric bypass. Results: Preoperatively hyperinsulinemia, hyperglycemia, dyslipidemia and hypertensive disease were present, and began to improve 1 and 3 months after surgery (although not significantly) and significantly at 6, 12 and 24 months after it. We also observed deficient protein nutrition and a deficiency of micronutrients both before bypass and during the follow-up. Conclusion: After gastric bypass, a marked decrease in insulin occurred, with normalization of blood pressure and the biochemical parameters associated with the metabolic syndrome. We propose a biochemical follow-up protocol for MO patients.     

Psychosocial Outcome of Gastric Bypass Surgery for Patients With and Without Binge Eating

Background: There is limited data on the prevalence of eating disorder pathology in morbidly obese patients undergoing Roux-en-Y gastric bypass (RYGBP) and the degree to which this may affect surgical outcome. The present study examined surgical outcome between 2 groups of patients undergoing RYGBP: those with pre-surgical binge eating (BE) and those without pre-surgical binge eating (NBE). Methods: This study tested the hypothesis that the BE group would demonstrate greater pathology on measures of eating pathology, psychological wellbeing, and quality of life than the NBE group both pre- and post-surgery. Results: Compared with the NBE group, the BE group had significantly higher levels of disinhibited eating, and hunger, and significantly lower levels of social functioning at pre-surgery and 6 months post-surgery. The BE group had a significantly lower percentage of excess weight lost than the NBE group at 6 months post-surgery. Conclusions: These findings indicate a less successful outcome for the BE patients compared with the NBE patients. While there were more distinct differences between the BE and NBE groups before surgery, they were largely impossible to differentiate on psychosocial measures at post-surgery.     

The Effects of Roux-en-Y Gastric Bypass Surgery on Body Image

Background: Numerous studies examine the physical effects of Roux-en-Y gastric bypass (RYGBP) surgery on morbid obesity. However, the effects of this surgery on psychosocial issues such as body image have not been extensively studied. Methods: This pilot study used a cross-sectional design to examine the effects of RYGBP surgery on patients' perceived body image. Four groups (n=20) were assessed for perceived change in body image at 4 time intervals.These included pre-surgery,1 to 3 weeks post-surgery, 6-months post-surgery, and 1- year post-surgery,with two measures of body image. One-way ANOVA was applied, with body image measures as the dependent variables, and time since surgery (group) as the independent variable. Planned post-hoc t-tests were applied to assess the differences between specific groups (pre vs. 1 week, pre vs. 6 months post, 6 months post vs. 1 year post). Results: Results of the one-way ANOVAs revealed significant improvement on perceptions of body image over time following surgery. Follow-up t-tests revealed that the most significant improvement occurred between pre-surgery and 6 months postsurgery. Although smaller, the change between 6 months post-surgery and 1 year post-surgery was also significant. Conclusion: While RYGBP results in numerous medical and physical benefits, this study reveals that there are also dramatic improvements in perceived body image, demonstrating the impact of this surgery on a patient's psychosocial health.     

Revision of Failed Gastric Bypass to Distal Roux-en-Y Gastric Bypass: A Review of 65 Cases

Background: No bariatric operation has been documented to effect adequate weight loss in all patients. Patients with inadequate weight loss or significant weight regain with an anatomically intact short-limb gastric bypass, of which the Fobi pouch operation (FPO) for obesity is a modification, are usually revised to a distal Roux-en-Y gastric bypass (DRYGBP) to enhance weight loss. Method: A retrospective review of the charts of all patients who had a revision to a DRYGBP at our Center during an 8-year period was carried out and the findings analyzed. Results: 65 patients who had the FPO had a revision to the DRYGBP.Most were super obese patients who, even though they had lost significant weight, were still morbidly obese. Some were patients who had not lost adequate weight or <40% excess weight, and a small number were patients who requested more weight loss even though they had a BMI of < 35. 15 patients developed protein malnutrition requiring supplemental feeding. 6 required rerevision to short-limb gastric bypass. Conclusion: Revision of short-limb gastric bypass to DRYGBP usually enhances weight loss but at a cost of an increased incidence of protein malnutrition.     

Heparin Thromboprophylaxis in Gastric Bypass Surgery

Background: Patients undergoing gastric bypass surgery are at risk for postoperative venous thromboembolism. Thromboprophylaxis often includes fixed doses of some type of heparin. However, it is unlikely that the same dose of subcutaneous heparin will be optimal for all patients, because heparin pharmacokinetics depend on a number of patient variables, including thickness of the adipose layer. Methods: An adjusted-dose, unfractionated heparin protocol was developed using pharmacokinetic data from 245 medical and surgical patients. Heparin doses were adjusted to achieve subtherapeutic peak anti-factor Xa heparin activity levels of 0.11-0.25 units/mL. This protocol was then applied to a prospective series of 700 patients undergoing laparoscopic Roux-en-Y gastric bypass who had no history of thromboembolism. Heparin prophylaxis was begun the evening of the day of surgery. Results: No patients were diagnosed with a deep venous thrombosis, but 3 (0.4%) were diagnosed with a non-fatal pulmonary embolism. Heparin therapy was halted because of bleeding in 2.3% of patients but only half of these required blood transfusions (1% of total). No patient required reoperation. Minor wound hematomas occurred in 0.6%. There were no deaths from any cause in this series. Conclusion: Use of a monitored, adjusted-dose unfractionated heparin prophylactic protocol in a laparoscopic gastric bypass patient population resulted in doses greater than those used in traditional fixed-dose protocols. However, bleeding and thromboembolism rates were very low and no patients died.     

Gastric Bypass Surgery in a Paraplegic Morbidly Obese Patient

The complications of spinal cord injury are exaggerated with obesity, and create complex medical and socioeconomic issues. Despite the well-documented advantages of bariatric surgery in reducing the morbidity of obesity, this option has not been routinely offered to obese patients with spinal cord injuries. We describe the first case of a morbidly obese male with a spinal cord injury who underwent a successful Roux-en-Y gastric bypass.     

Revision of Failed Laparoscopic Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Background: The most common bariatric surgical operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss. Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery. Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5±2.0 years. For the RYGBP, mean operating time was 161±53 minutes, estimated blood loss was 219±329 ml, and hospital stay was 6.7±4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%) – a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2±9.3 kg/m², and decreased to 45.8±8.9 kg/m² after LAGB and was again reduced to 37.7±8.7 kg/m² after RYGBP within our follow-up period. Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.     

Rhabdomyolysis after Gastric Bypass: Severity and Outcome Patterns

Background: Rhabdomyolysis (RML) is a recently recognized complication of bariatric operations, but it is not known whether creatine kinase (CK) levels along with clinical markers are able to define the course and outcome. Methods: Bariatric patients (n=324) were reviewed retrospectively. Substantially elevated plasma CK after operation was identified in 4.9% (16/324). The affected population was divided into Group I (n=11, 68.8%) with CK 1050-8000 IU/L and no conspicuous muscle pain, weakness or swelling, and Group II (n=5, 31.2%) displaying CK >8000 IU/L and severe pain and dysfunction. The main outcome measures were CK concentration, frequency of renal failure, need for hemodialysis and mortality. Results: Group I subjects compared to Group II were younger (37.7 ± 10.9 vs 44.0 ± 5.5 years, P<0.05) and predominantly females (72.7% vs 40.0%, P<0.05). Peak CK values were definitely lower (2811 ± 952 vs 28136 ± 19000 IU/L, P<0.001), and none progressed to renal failure (0% vs 40.0%, P<0.05). No difference was detected regarding preoperative BMI (50.8 ± 8.1 vs 54.6 ± 7.0 kg/m², NS), duration of operation (5.3 ± 1.6 vs 5.6 ± 2.1 hours, NS) or types of anesthetic drugs (basically fentanyl, nitrogen oxide and halothane/isoflurane). Conclusions: 1) Demographic features, nominally gender and age, were different between the two degrees of RML; 2) Renal failure and hemodialysis were a danger only in patients with massive CK elevation and muscle pain; 3) Moderate CK increase was very well tolerated and rarely entailed major clinical symptoms; 4) Early diagnosis, fluid replenishment and general supportive therapy probably contributed to avert mortality.     

A Functional Roux-en-Y Gastric Bypass to Avoid Gastric Exclusion: 1-Year Results

Background: Roux-en-Y gastric bypass (RYGBP) is rarely performed in Italy because it involves gastric exclusion. RYGBP with the stomach partitioned by an adjustable gastric band has been previously described. We have developed a functional RYGBP (FRYGBP) where an adjustable band allows access from a stapled gastric bypass pouch into the distal stomach. Methods: From October 2001 to May 2002, 16 patients underwent FRYGBP. A 30-cc vertical gastric pouch was fashioned by a 25-mm circular and 90-mm four-row stapler as in the Mason VBG. A hand-sewn retrocolic gastroenterostomy with 150-cm Roux and 30-cm afferent limbs completed the operation. The pouch outlet was encircled distal to the gastrojejunostomy by a non-inflated adjustable gastric band. The bands were inflated at 1 month during barium swallow, to demonstrate occlusion of the gastro-gastric outlet and patency of the gastrojejunostomy. Results: There was no operative mortality. After 1 year, mean percent excess BMI loss (%EBMIL) was 71.2 ± 16.2% (SD), and gastroscopy of the bypassed stomach was possible on 81% of the patients. There were three asymptomatic late complications (19%): two band erosions, converted to RYGBP, and one stenosis of the gastro-gastric outlet. Conclusion: FRYGBP thus far has been effective and allows the study of the excluded stomach. This ongoing study will undergo long-term evaluation.     

Sensitivity and Specificity of Postoperative Upper GI Series Following Gastric Bypass

Background: Routine postoperative GI series has been common before discharging gastric bypass patients. 78,000 operations were performed in the USA in 2002. At $75 each, the total annual expenditure for the upper GI series approaches 6 million dollars. This study examines the value of performing routine upper GI series. Materials and Methods: From 1996 to 2000, 396 open gastric bypass procedures were performed by one surgeon at the University Medical Center. 242 randomly selected charts were retrospectively reviewed for signs and symptoms possibly related to leak or obstruction. Radiology reports were compared with clinical findings. Results: 82% of patients (192/242) were discharged following unremarkable postoperative courses and normal x-rays. 18% (44/242) exhibited one or more clinical signs suspicious of leak or obstruction. These included fever, tachycardia, tachypnea, inordinate pain, elevated white cell count or GI hemorrhage. Leak was reported in 5, and obstruction in 5. 4 patients with reported leaks were re-operated: 2 were positive for unconfined leak requiring surgical treatment; 2 had negative laparotomies. The 2 patients (0.82%) with free leakage had dramatic clinical deterioration, and x-rays were confirmatory rather than diagnostic. 1 patient with a minimal confined leak was treated non-operatively. 8 films were misread as showing a leak when none was present: 2 underwent negative laparotomy, the others being correctly interpreted after review. 8 of 10 initial interpretations were falsely positive. Conclusion: Routine postoperative GI series following gastric bypass is not beneficial. All true leaks are demonstrated when x-rays are indicated. We recommend GI series only when clinically indicated. GI series had low positive predictive value for leak.     

Thyrotoxicosis after Gastric Bypass

Obesity surgery is the optimal therapy for morbid obesity. A case is presented of a young woman who developed thyrotoxicosis, believed to be part of subacute thyroiditis, some days after undergoing laparoscopic Roux-en-Y gastric bypass. This clinical entity can present difficulties in differential diagnosis from potential postoperative complications. The correct diagnosis and adequate treatment made possible a favorable recovery.     

Management of Acute Bleeding after Laparoscopic Roux-en-Y Gastric Bypass

Background: The authors reviewed the incidence of hemorrhage after laparoscopic Roux-en-Y gastric bypass (LRYGBP). The purpose of this study was to determine the incidence of this complication and to evaluate various treatment options. Material and Methods: The records for 450 consecutive patients who had undergone LRYGBP over a 30-month period, were retrospectively reviewed. In all patients, the abdominal cavity had been drained with 2 19-Fr closed suction drains. The charts of patients who had developed an intraluminal or an intraabdominal bleed were chosen for further review. Results: 20 patients (4.4%) developed an acute postoperative hemorrhage. The bleeding was intraluminal in 12 cases (60%), manifested by a drop in hematocrit, tachycardia and melena. The other 8 patients (40%) developed intra-abdominal hemorrhage, confirmed by large bloody output from the drains. 3 patients (15%) with intraluminal bleeding were unstable and required a reoperation. All others were successfully treated with observation, and 15 patients (75%) required blood transfusions. Conclusions: The diagnosis and treatment of acute intraluminal bleeding after LRYGBP represents a surgical dilemma, mainly due to the inaccessibility of the bypassed stomach and the jejuno-jejunostomy, as well as the risks associated with early postoperative endoscopy. The presence of large intra-abdominal drains allows for bleeding site localization (intraluminal vs intraabdominal) and for more accurate monitoring of the bleeding rate. Most cases respond to conservative therapy. Failure of conservative management of intraluminal bleeding, however, is more problematic and may require operative intervention. A treatment algorithm is proposed.     

Endoscopy after Roux-en-Y Gastric Bypass: A Community Hospital Experience

Background: Roux-en-Y gastric bypass (RYGBP) is a common surgical intervention for morbid obesity. Postoperative GI symptoms are common. This study reports the endoscopic findings in symptomatic patients. Methods: Patients who developed GI symptoms after RYGBP at a single community hospital were referred for endoscopic evaluation. Standard endoscopic procedures using standard endoscopic equipment were used. Results: From April 2002 to April 2004, 23 out of 200 patients underwent 35 endoscopic procedures. All patients complained of some degree of epigastric pain, nausea and vomiting regardless of endoscopic findings. The most common endoscopic finding was ulcer disease (12 patients - 52%). Other findings included normal postoperative anatomy (7 patients - 30%), anastomotic stricture (1 patient - 4.3%), obstructed biliopancreatic limb (1 patient - 4.3%), acute gastric pouch bleed (1 patient - 4.3%), anastomotic rupture/dehiscence (1 patient - 4.3%). H. pylori was not detected in any patient. Conclusions: In patients who have had RYGBP, symptoms were a poor predictor of endoscopic pathology. Ulcer disease was the most common endoscopic finding. These ulcers were not associated with H. pylori. All ulcers responded well to oral proton pump inhibitors (PPI) and sucralfate therapy. The community gastroenterologist should be acquainted with the typical post-surgical anatomy and possible endoscopic intervention for RYGBP patients.     

Laparoscopic Removal of Gastric Band after Open Banded Gastric Bypass

Open banded gastric bypass has been the choice of some bariatric surgeons. This procedure includes a band (of various materials) around the gastric pouch. While there are advantages to this band, erosion and/or displacement of the band may occur. We describe a case of a symptomatic displaced band which was treated by laparoscopic removal. Laparoscopic removal of the band after open banded gastric bypass is feasible. Revision of previous bariatric surgery may be performed laparoscopically if the technical expertise is available.     

Laparoscopic Roux-en-Y Gastric Bypass in Patients with Congenital Malrotation

Bariatric surgery is the only solution for morbidly obese individuals who desire to lose weight and maintain it and have failed to do so by non-surgical means. As the incidence of morbid obesity rises, laparoscopic Roux-en-Y gastric bypass (LRYGBP) is increasingly performed. With the increase in bariatrics, the chances of discovering aberrant anatomy at the operating-table also increase. We present two cases of LRYGBP in patients with intestinal malrotation, which is a congenital anomaly caused by failure of the intestines to rotate and fixate at 270° during embryonic development. It occurs in one out of every 500 births in the United States, accounting for 5% of all intestinal obstructions. To this date, only three reports have been published describing the incidental finding of congenital malrotation during the initial laparoscopic exploration for gastric bypass. We found that the operation can still be performed laparoscopically in such patients, with some modifications to the standard technique.