Influence of pouch and stoma size on weight loss after gastric bypass

BackgroundEnlargement of the gastric pouch and/or gastrojejunostomy after Roux-en-Y gastric bypass (RYGB) is postulated to be the antecedent to suboptimal weight loss or weight regain. The present study evaluated the gastric pouch and stoma dimensions in RYGB patients and correlated them with the weight loss outcomes.MethodsPatients who underwent upper endoscopy for investigation of gastrointestinal symptoms or weight regain after RYGB were identified. The stoma was considered enlarged if >2 cm in diameter and the pouch was considered enlarged if >6 cm long or >5 cm wide. Successful weight loss was defined as excess weight loss >50% or a body mass index decrease to ≤30 kg/m².ResultsA total of 380 patients had nondiagnostic upper endoscopy findings at a mean post-RYGB interval of 5.9 ± 4.0 years. Among these were 175 patients (group A; 87% women) who had successful weight loss and 205 patients (group B; 86% women) who were referred for investigation of weight regain. The pouch and stoma size were normal in most of the patients in group A (63.4%) compared with 28.8% of the patients in group B (P <.001). The most common abnormality was an enlarged stoma. The pouch length, pouch volume, and stoma diameter correlated inversely with excess weight loss. Multivariate analysis identified that the stoma diameter was independently associated with weight regain after RYGB.ConclusionThe current definition of a “normal” size pouch/stoma is associated with optimal weight loss after RYGB, although this might need to be reviewed. Patients who regain weight are likely to have abnormal anatomy, in particular, stoma enlargement. The surgical RYGB technique and methods of evaluating the gastric anatomy in RYGB patients need to be standardized, intraoperatively and postoperatively.     

Size matters: gastric pouch size correlates with weight loss after laparoscopic Roux-en-Y gastric bypass

Background Over the past 20 years, there has been an ongoing discussion about the importance of gastric pouch size as a key factor influencing weight loss after bariatric surgery. This analysis aimed to determine the relationship between initial gastric pouch size and excess weight loss (EWL) after laparoscopic Roux-en-Y gastric bypass (LRYGB). Methods Between August 2002 and March 2005, 320 LRYGB were performed at Yale New Haven Hospital. The patients’ demographics were entered into a longitudinal, prospective database. Upper gastrointestinal series were routinely performed on postoperative day 1. Pouch size was measured as area (cm²) on an anteroposterior radiograph at maximum pouch distention. Linear regression analysis was performed to determine the association between pouch size and weight loss at 6 and 12 months postoperatively. Adjustments were made for age, gender, and preoperative body mass index (BMI). Results The mean age of the patients was 41.2 years. Of the 320 study patients, 261 were women (81.6%) and 59 were men (18.4%). The mean preoperative BMI was 51.1 kg/m²; the mean 6-month EWL was 50.5%; the mean 12-month EWL was 62.5%; and the mean pouch size was 63.9 cm². A statistically significant, negative correlation between pouch size and EWL was found at 6 months (β = –0.241; p < 0.01) and at 12 months (β = –0.302; p < 0.02). The findings show that male gender (β = 0.147; p < 0.04) and preoperative BMI (β = 0.190; p < 0.01) are positively correlated with pouch size. Conclusion The analysis demonstrates that initial gastric pouch size is not the only significant component for successful weight loss after LRYGB. Male gender and increased preoperative BMI were identified as factors predicting pouch size. Efforts to standardize small pouch size for all patients seems important to the success of surgical therapy for morbid obesity.     

Lack of correlation between variation in small-volume gastric pouch size and weight loss after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Controversy exists in published reports regarding the influence of gastric pouch size on weight loss after gastric bypass (GB). The purpose of this study was to determine whether variations in the anatomic size of small-volume (相似文献   

Endoscopic intraluminal suture plication of the gastric pouch and stoma in postoperative Roux-en-Y gastric bypass patients

BACKGROUND: Endoscopic intraluminal suturing is currently used to treat gastroesophageal reflux disease. This new field of intraluminal gastric surgery may benefit postoperative Roux-en-Y gastric bypass patients. While gastric bypass is highly successful in the majority of patients, significant weight regain can occur over time due to stretching of the gastric pouch and stoma. METHODS: Between November 2002 and January 2003, four patients who previously underwent gastric bypass (GBP) surgery presented with dilated gastrojejunostomy (GJ) anastomosis and weight regain. They gave their consent and were taken to the operating room for upper endoscopy, where they were placed under general anesthesia. Using a flexible endoscopic suturing device with a standard 11-mm endoscope, the dilated GJ anastomosis was plicated to reduce its size, and in two of the patients the gastric pouch was also plicated. RESULTS: Successful stomal plication was performed on all four patients to narrow their dilated stomas that measured > 2 cm preoperatively to < 15 mm postoperatively. Patients were told to go on a puree diet for 4 weeks. One patient had a repeat procedure due to rupture of one suture after eating solid food two weeks after the surgery. The stoma was then plicated with 3 sutures. Two patients had their gastric pouch plicated near the stoma. All patients to date report feeling full earlier with decrease caloric consumption and subsequent weight loss. CONCLUSION: Upper endoscopic intraluminal suturing represents a new field of emerging technology that will certainly find its role in the postoperative bariatric patient. Both the gastric pouch and stoma are within reach for endoscopic intraluminal therapy. How it can aid our patients is currently being studied.     

Comparison of size of proximal gastric pouch and short-term weight loss following routine upper gastrointestinal contrast study after laparoscopic Roux-en-Y gastric bypass

BACKGROUND: The authors investigated whether there is any correlation between gastric pouch size measured by routine upper gastrointestinal contrast study (UGI) after laparoscopic Roux-en-Y gastric bypass (LRYGBP) and short-term weight loss. METHODS: The study group consisted of 82 patients (66F, 16M) who underwent LRYGBP. Body mass index before surgery ranged from 35.4 to 71.7 kg/m2, with a mean of 47.4 kg/m2. UGI was performed 1 day after LRYGBP in all patients. Proximal gastric pouch size was estimated by multiplying maximal transverse and longitudinal diameters on AP spot image or film. Percent excess weight loss (%EWL) obtained at 3, 6, 12 and 24 months after surgery was used as an indicator of short-term results. According to the presence of contrast passage through the gastrojejunostomy, each patient was classified into 2 groups: Group A, negative; Group B, positive. RESULTS: There was no correlation between proximal gastric pouch size and %EWL at any point of time (P>0.05). The correlation coefficients calculated for 3, 6, 12 and 24 months after surgery were 0.038, 0.110, 0.015 and 0.042, respectively (Pearson correlation test). The gastric pouch size of Group A was larger than that of Group B (Student t-test, P<0.001). There was no difference in %EWL between Groups A and B at 3 and 6 months after surgery (P>0.05). CONCLUSION: Pouch size area, measured by routine UGI study on the first postoperative day, does not influence short-term postoperative weight loss.     

Failure of gastroplasty pouch and stoma size to correlate with postoperative weight loss

At the University of Alberta hospitals patients who underwent gastroplasty--horizontal, vertical with multistranded nylon banding of the stomas and vertical banded with Teflon reinforced stomas--have been followed up for over 2 years. Pouch volume ranged from 25 to 30 mL. Pouch volume and stoma size were measured radiologically 2 years after operation and correlated with the percentage excess weight loss. Any patient failing to lose at least 40% of the excess weight was considered a failure. There was no consistent correlation between pouch or stoma size and percentage excess weight loss for any of the three procedures studied. The failure rate for patients included in the study group was 33.3% for horizontal, 32.4% for vertical and 32.8% for vertical banded gastroplasty. The probable reason for the lack of correlation is that some patients change their diets so as to subvert the restriction imposed by the gastroplasty.     

The impact of circular stapler diameter on the incidence of gastrojejunostomy stenosis and weight loss following laparoscopic Roux-en-Y gastric bypass

Background Gastrojejunostomy stenosis after laparoscopic Roux-en-Y gastric bypass is a common occurrence. The incidence varies widely among reported series. We evaluated the impact of circular stapler size on the rate of stenosis and weight loss. Methods Our initial technique utilized a 21-mm circular stapler to construct the gastrojejunostomy. We switched to a 25-mm stapler after a large preliminary experience. Stenosis was confirmed by endoscopy in patients complaining of the inability to eat or excessive vomiting, and was defined as a gastrojejunostomy diameter less than that of a therapeutic endoscope (11-mm). Results Stenosis occurred in 23 of 145 patients (15.9%) with a 21-mm gastrojejunostomy. Five of 81 patients with a 25-mm circular stapled anastomosis have developed a stenosis (6.2%, p = 0.03). Weight loss was similar for each sized stapler at 6 and 12 months. Conclusions The use of a 25-mm circular stapler in laparoscopic gastric bypass is preferable to a 21-mm stapler. The larger stapler is associated with a significantly decreased incidence of gastrojejunostomy stenosis without compromising early weight loss.     

Conversion of gastric sleeve to Roux-en-Y gastric bypass: overall outcomes and predictors of below-average weight loss

BackgroundConversion of sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB) has been utilized to promote further weight loss, but results are variable in available literature.ObjectivesTo evaluate outcomes of SG to RYGB conversion for weight loss and to identify predictors of below-average weight loss.SettingUniversity-affiliated hospital, United States.MethodsChart review was performed of our patients who underwent SG to RYGB conversion from November 1, 2013, to November 1, 2020. Primary outcomes were below-average percent excess weight loss (%EWL) at 1 and 2 years. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for preconversion demographics to evaluate their relationship to the primary outcome.ResultsSixty-two patients underwent conversion from SG to RYGB with weight loss as a goal. One-year data was available for 47 patients. The average %EWL at 1 year was 41.5%. Twenty-six patients had below-average %EWL at 1 year. Interval to conversion <2 years (OR = 4.41, 95% CI [1.28,15.17], P = .019) and preconversion body mass index (BMI) >40 (OR = 4.00, 95% CI [1.17,13.73], P = .028) were statistically significant predictors of below-average 1-year %EWL. Two-year data was available for 36 patients. The average %EWL at 2 years was 30.8%. Seventeen patients had below-average %EWL at 2 years. Evaluated demographics were not statistically significant predictors of below-average 2-year %EWL.ConclusionsFollowing SG to RYGB conversion, %EWL outcomes are lower at 1 year (41.5%) and 2 years (30.8%) than reported values for primary RYGB. Interval to conversion <2 years and preconversion BMI >40 are predictors of below-average 1-year weight loss after conversion.     

Gastrointestinal hormones and weight loss response after Roux-en-Y gastric bypass

BackgroundMechanisms underlying variable weight loss (WL) response after Roux-en-Y gastric bypass (RYGB) are poorly understood. The objective of this study was to compare gastrointestinal hormonal responses to meal intake, and fasting plasma concentrations of surrogate markers of enterocyte mass and bile acid effect between patients with failed (F-WL) or successful WL (S-WL) after RYGB.MethodsCross-sectional study including 30 nondiabetic patients, evaluated at≥24 months after RYGB. Cases (F-WL; n = 10) and controls (S-WL; n = 20) were selected based on percent of excess WL (%EWL)<50% or≥50% from 12 months onwards after surgery. Groups were matched for gender, age, presurgical BMI, and length of follow up. Glucagon-like peptide 1 (GLP-1), peptide YY (PYY), GLP-2, and ghrelin responses to a meal challenge, and fasting plasma concentrations of citrulline and serum fibroblast growth factor 19 (FGF-19) were compared.ResultsF-WL patients presented lesser suppression of ghrelin (incremental area under the curve [iAUC]: F-WL −12490±6530 versus S-WL −31196±4536 pg×mL^-1×min; P<.01), and lesser increase in the GLP-1 (iAUC: F-WL 3354±737 versus S-WL 5629±542 pmol×L^-1×min; P = .02) but not in the PYY and GLP-2, response to meal intake. Citrulline concentrations were significantly correlated with time after surgery (rho = .537; P<.01). However, citrulline was higher in S-WL compared to F-WL patients (P<.05). Serum FGF-19 concentration was similar between groups.ConclusionAlthough limited by the cross-sectional design, our data suggest a role of some gastrointestinal hormones as mediators of successful weight loss but argues against larger enterocyte mass after BS as determinant of failed weight loss after RYGB.     

Extreme bariatric endoscopy: stenting to reconnect the pouch to the gastrojejunostomy after a Roux-en-Y gastric bypass

Background  

Among the possible complications of bariatric surgery, fistula and partial dehiscence of the gastric suture are well known. Reoperation often is required but results in significant morbidity. Endoscopic treatment of some bariatric complications is feasible and efficient.     

Effect of standard vs extended Roux limb length on weight loss outcomes after laparoscopic Roux-en-Y gastric bypass

Background: Increasing the length of the Roux limb in open Roux-en-Y gastric bypass (RYGB) effectively increases excess weight loss in superobese patients with a body mass index (BMI) >50 kg/m². Extending the RYGB limb length for obese patients with a BMI < 50 could produce similar results. The purpose of this study was to compare the outcomes of superobese patients undergoing laparoscopic RYGB with standard (100-cm) with those undergoing the procedure with an extended (150-cm) Roux limb length over 1-year period of follow-up. Methods: Retrospective data over 2.5 years were reviewed to identify patients with a BMI < 50 who underwent primary laparoscopic RYGB with 1-year follow-up (n = 58). Forty-five patients (sRYGB group) received limb lengths 100 cm, including 45 cm (n = 1), 50 cm (n = 2), 60 cm (n = 6), 65 cm (n = 1), 70 cm (n = 1), 75 cm (n = 3), and 100 cm (n = 31). Thirteen patients (eRYGB group) received 150-cm limbs. Postoperative weight loss was compared at 3 weeks, 3 months, 6 months, and 1 year. Results: Comparing the sRYGB vs the eRYGB group (average ± SD), respectively: There were no significant differences in age (41.5 ± 11.0 vs 38.0 ± 11.9 years), preoperative weight (119.2 ± 11.9 vs 127.8 ± 12.5 kg), BMI (43.7 ± 3.0 vs 45.2 ± 3.5 kg/m²), operative time (167.1 ± 72.7 vs 156.5 ± 62.4 min), estimated blood loss (129.9 ± 101.1 vs 166.8 ± 127.3 cc), or length of stay (median, 3 vs 3 days; range, 2–18 vs 3–19). Body weight decreased over time in both groups, except in the sRYGB group between 3 and 6 months and 6 and 12 months after surgery and in the eRYGB group between 6 and 12 months. BMI also decreased over time, except in the eRYGB group between 6 and 12 months. Absolute weight loss leveled out between 6 and 12 months in both groups, with no increase after 6 months. Percent of excess weight loss did not increase in the eRYGB group after 6 months. An extended Roux limb did not significantly affect body weight, BMI, absolute weight loss, or precent of excess weight loss at any time point when the two groups were compared. A trend toward an increased proportion of patients with >50% excess weight loss (p = 0.07) was observed in the extended Roux limb group. Conclusions: In this series, no difference in weight loss outcome variables were observed up to 1 year after laparoscopic RYGB. Thus, extending Roux limb length from 100 cm to 150 cm did not significantly improve weight loss outcome in patients with a BMI < 50 kg/m².     

Effects of surgically induced weight loss by Roux-en-Y gastric bypass on osteocalcin

BackgroundOsteocalcin (OC), a protein synthesized by osteoblasts, is a marker of bone turnover with undercarboxylated OC (ucOC) being involved in glucose homeostasis. Although laparoscopic Roux-en-Y gastric bypass (LRYGB)-induced weight loss likely alters bone turnover, data on markers of bone turnover remain less clear. The aim of this study was to examine the effect of surgically induced weight loss on OC and ucOC.MethodsA total of 32 individuals with a body mass index 50.2±10.2 kg/m² underwent LRYGB. Osteocalcin, ucOC, other blood analytes (e.g., vitamin D, leptin, total and high-molecular-weight adiponectin), and homeostasis model assessment for insulin resistance were measured before and after weight loss. The effect of an acute nutrient load on OC parameters after a mixed meal tolerance test also was assessed.ResultsSix months after surgery, there was an increase in OC (17.8±7.4 [mean±SD] [baseline] versus 31.5±9.8 ng/mL [follow-up]; P<.001) and ucOC (7.3±6.2 versus 18.5±8.9 ng/mL; P<.001). Although adiponectin increased, only the magnitude of change in OC and leptin was correlated (r =?.43; P = .017). After weight loss, an acute nutrient load reduced OC (31.5±9.8 [0-hour] versus 29.6±8.2 [2-hour] ng/mL; P = .024), whereas ucOC was higher (18.8±9.3 [0-hour] versus 21.1±8.6 [2-hour] ng/mL; P< .001).ConclusionSurgically induced weight loss was associated with increases in OC and ucOC. Underlying mechanisms are unclear, but change in OC may be related to change in leptin. After a nutrient load, the increase in ucOC suggests a potential role as a short-term compensatory regulator of glucose homeostasis.     

Long-term weight loss outcomes after banded Roux-en-Y gastric bypass: a prospective 10-year follow-up study

Objective

To evaluate the weight loss outcomes of banded Roux-en-Y gastric bypass (RYGB) during a 10-year follow-up.

Gut microbiota adaptation after weight loss by Roux-en-Y gastric bypass or sleeve gastrectomy bariatric surgeries

BackgroundGut microbiota could be involved in the metabolic improvement after surgery.ObjectiveThe aim of the present study was to evaluate the short-term evolution of the gut microbiome after different bariatric surgery procedures and their functionality and relate it with obesity resolution.SettingUniversity hospital, Spain.MethodsWe studied 28 patients with severe obesity; 14 underwent a Roux-en-Y gastric bypass (RYGB) and 14 underwent laparoscopic sleeve gastrectomy (SG). All patients were examined before and 3 months after the correspondent bariatric surgery. Gut microbiome profile was assessed by the sequencing of amplicons from the 16S rDNA gene by next-generation sequencing.ResultsGut microbiota profiles significantly differed between surgical procedures. RYGB suffered the largest changes in the microbiota population. SG and RYGB differed in their profiles with higher levels of Akkermansia, Eubacterium, Haemophilus, and Blautia for SG, while Veillonella, Slackia, Granucatiella, and Acidaminococcus occurred with greater levels in RYGB. RYGB microbiota changes were reflected also at the level of functionality, especially in pathways related to environmental adaptation. A biomarker discovery analysis revealed the genus Blautia as characteristic in SG, while Veillonella was of RYGB.ConclusionOur study shows a shift of the gut microbiome after a bariatric surgery in a procedure-related manner. Gut microbiome changes are related to the adaptation to the changing gut environment and could be related to the pH fluctuations.     

Effect of preoperative weight loss on laparoscopic gastric bypass outcomes

BackgroundRequiring patients to lose weight before weight reduction surgery is controversial. The goal of this study was to determine whether preoperative weight loss affects laparoscopic Roux-en-Y gastric bypass surgery outcomes.MethodsThe medical records of all laparoscopic Roux-en-Y gastric bypass patients from September 1, 2001 to March 31, 2005 were retrospectively reviewed in our prospective database. Depending on their habitus, patients were selectively required to lose >4.54 kg (10 lb) preoperatively (WL group). Their outcomes were compared with those of the patients not required to lose weight preoperatively (no-WL group). Statistical analysis was performed with the chi-square test and Student's t test for demographic data. Student's t test was used to assess the outcome data. P <.05 was considered significant.ResultsOf the 353 patients, 74 (21%) were in the WL group. The operative times in the WL group averaged 10 minutes longer than in the no-WL group (P = .022). The mean length of stay was not significantly different between the 2 groups. Of the 353 patients, 262 (74%) completed 1 year of follow-up. The mean net postoperative weight loss was not significantly different between the 2 groups. The no-WL patients had a greater percentage of excess postoperative weight loss than the WL group (74% versus 66%; P = .01). Net complications occurred less frequently in the WL group (P = .035).ConclusionPreoperative weight loss did not decrease the operative times or the length of stay. Preoperative weight loss increased neither the mean net postoperative weight loss nor the percentage of excess postoperative weight loss at 1-year follow-up. However, the WL group had fewer net complications.     

Gut hormones as mediators of appetite and weight loss after Roux-en-Y gastric bypass

OBJECTIVE: To evaluate the physiologic importance of the satiety gut hormones. BACKGROUND: Controversy surrounds the physiologic role of gut hormones in the control of appetite. Bariatric surgery remains the most effective treatment option for obesity, and gut hormones are implicated in the reduction of appetite and weight after Roux-en-Y gastric bypass. METHODS: We correlated peptide YY (PYY) and glucagon-like peptide 1 (GLP-1) changes within the first week after gastric bypass with changes in appetite. We also evaluated the gut hormone responses of patients with good or poor weight loss after gastric bypass. Finally, we inhibited the gut hormone responses in gastric bypass patients and then evaluated appetite and food intake. RESULTS: Postprandial PYY and GLP-1 profiles start rising as early as 2 days after gastric bypass (P < 0.05). Changes in appetite are evident within days after gastric bypass surgery (P < 0.05), and unlike other operations, the reduced appetite continues. However, in patients with poor weight loss after gastric bypass associated with increased appetite, the postprandial PYY and GLP-1 responses are attenuated compared with patients with good weight loss (P < 0.05). Inhibiting gut hormone responses, including PYY and GLP-1 after gastric bypass, results in return of appetite and increased food intake (P < 0.05). CONCLUSION: The attenuated appetite after gastric bypass is associated with elevated PYY and GLP-1 concentrations, and appetite returns when the release of gut hormones is inhibited. The results suggest a role for gut hormones in the mechanism of weight loss after gastric bypass and may have implications for the treatment of obesity.