Malabsorptive gastric bypass in patients with superobesity

Weight loss in superobese patients has been problematic after conventional gastric restrictive operations including conventional Roux-en-Y gastric bypass (RYGB). The goal of the present study was to compare weight loss in patients with superobesity (body mass index ≥50 kg/m²) using a distal RYGB (D-RY) in which the Roux-en-Y anastomosis was performed 75 cm proximal to the ileocecal junction (N = 47) vs. patients who had Roux limbs of 150 cm (N = 152) and 50 to 75 cm (N = 99). All operations incorporated the same gastric restrictive parameters. Minimum follow-up was 3 years and ranged to 16 years. Weight loss and reduction in body mass index were significantly greater after D-RY vs. both RYGB-150 cm and short RYGB and in RYGB-150 cm vs. short RYGB through 5 years. Mean percentage of excess weight loss peaked at 64% after DRY, at 61% after RYGB-150 cm, and at 56% after short RYGB. Weight loss maintenance through 5 years was correlated with Roux limb length with D-RY greater than RYGB-150 cm greater than short RYGB. More than 95% of obesity-related comorbid conditions improved or resolved with weight loss. There was no difference in the early postoperative morbidity rates: 9% after D-RY; 8% after RYGB-150 cm; and 2% after short RYGB with one death (0.3 %). All D-RY patients had at least one postoperative metabolic abnormality. Anemia was significantly more common after D-RY vs. the shorter RYGB with no difference in the incidence of metabolic sequelae between RYGB-150 cm and short RYGB. No operations were reversed or modified for nutritional complications. Two D-RY patients required total parenteral nutrition for protein malnutrition. These results show that Roux limb length is correlated with weight loss in superobese patients. However, the greater incidence of metabolic sequelae after D-RY vs. RYGB-150 cm calls into question its routine use in superobese patients undergoing bariatric surgery. We conclude that some degree of malabsorption should be incorporated into bariatric operations performed in superobese patients to achieve satisfactory long-term weight loss. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001.     

The dilemma of outcome assessment after operations for morbid obesity

Outcome of 56 patients who underwent horizontal gastroplasty (HGP) and 126 who underwent Roux-en-Y gastric bypass (RYGB) was assessed at 18 months postoperatively according to three definitions of successful weight loss; also, outcome was evaluated in the context of amelioration of obesity-related medical problems. Outcome definitions included the following: I, loss of 25% or more of preoperative weight; II, loss of 50% or more of excess weight; III, loss to within 50% of ideal body weight. To evaluate the impact of preoperative weight on success rate, patients were divided into two weight groups: "morbidily" obese patients, who were 100 to 199 pounds overweight (n = 146), and "super"-obese patients who were 200 pounds or more overweight (n = 36). Weight loss was significantly greater with RYGB versus HGP by each of the three definitions of success. Medical problems either improved or resolved with weight loss in 95% of cases. There were statistically significant differences in success rate depending on outcome definition in both HGP and RYGB patients. Success rate ranged from zero in super-obese HGP patients by Definition III to 97% in super-obese RYGB patients by Definition I. Although super-obese patients lost more pounds than the lighter morbidly obese patients, a significantly lower number of super-obese patients lost within 50% of ideal weight. Super-obese patients must lose more weight to reduce their actuarial risk. These results show that the definition of successful outcome may significantly influence the overall success rate in a large series of bariatric surgical patients.     

Laparoscopic Roux-en-Y gastric bypass: minimally invasive bariatric surgery for the superobese in the community hospital setting

Roux-en-Y gastric bypass (RYGB) operation has become a popular choice for weight-reduction surgery. We report an outcome analysis of our early results with laparoscopic Roux-en-Y gastric bypass for superobese (BMI >50) patients. Between January 2000 and October 2001, we operated on 71 superobese patients. The mean body mass index (BMI) of patients at time of surgery was 57 kg/m2. The prospectively collected data included patient demographics, comorbidities, operative times, postoperative weight loss, and complications. Conversion to open gastric bypass was required in one patient. The overall complication rate was 10 per cent. Preoperative comorbidities were resolved or improved in 93 per cent of patients at 1-year postoperative. Average operative time and length of hospital stay were 196 minutes and 2.3 days, respectively. Mean percentage excess weight loss at 3, 6, 9, and 12 months was 27 per cent, 39 per cent, 49 per cent, and 55 per cent, respectively. Mean BMI decreased to 36 kg/m2 over a 12-month period. Laparoscopic Roux-en-Y gastric bypass surgery for superobese patients as performed in the community hospital setting can be both safe and effective with respect to overall postoperative course, early weight loss, and reduction of comorbidity.     

Weight loss and dietary intake after vertical banded gastroplasty and Roux-en-Y gastric bypass.

OBJECTIVE. The purpose of this study was to learn whether preoperative eating habits can be used to predict outcome after vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGB). BACKGROUND SUMMARY. Several independent randomized and sequential studies have reported significantly greater weight loss after RYGB in comparison with VBG. Although the mechanism responsible for weight loss after both procedures is restriction of intake rather than malabsorption, the relationships between calorie intake, food preferences, and postoperative weight loss are not well defined. METHODS. During the past 5 years, 138 patients were prospectively selected for either VBG or RYGB, based on their preoperative eating habits. All patients were screened by a dietitian who determined total calorie intake and diet composition before recommending VBG or RYGB. Thirty patients were selected for VBG; the remaining 108 patients were classified as "sweets eaters" or "snackers" and had RYGB. Detailed recall diet histories also were performed at each postoperative visit. RESULTS. Early morbidity rate was zero after VBG versus 3% after RYGB. There were no deaths. Mean follow-up was 39 +/- 11 months after VBG and 38 +/- 14 months after RYGB. Mean weight loss peaked at 74 +/- 23 lb at 12 months after VBG and 99 +/- 24 lb at 16 months after RYGB (p < or = 0.001). Twelve of 30 VBG patients lost > or = 50% of their excess weight versus 100 of 108 RYGB patients (p < or = 0.0001). Milk/ice cream intake was significantly greater postoperatively in patients who underwent VBG versus patients who underwent RYGB after 6 months (p < or = 0.003), whereas solid sweets intake was significantly greater after VBG during the first 18 months postoperatively (p < or = 0.004). Revision of VBG was performed in 6 of 30 patients (20%) for complications or poor weight loss, whereas only 2 of 108 patients who underwent RYGB required surgical revisions (p < or = 0.001). CONCLUSIONS. These data show that VBG adversely alters postoperative eating behavior toward soft, high-calorie foods, resulting in problematic postoperative weight loss. Conversely, RYGB patients had significantly greater weight loss despite inferior preoperative eating habits. The high rate of surgical revision in conjunction with inconsistent postoperative weight loss has led us to no longer recommend VBG as treatment for morbid obesity.     

Duodenal switch provides superior weight loss in the super-obese (BMI > or =50 kg/m2) compared with gastric bypass

OBJECTIVES: Although weight loss following Roux-en-Y gastric bypass is acceptable in patients with preoperative body mass index (BMI) between 35 and 50 kg/m, results from several series demonstrate that failure rates approach 40% when BMI is > or =50 kg/m. Here we report the first large single institution series directly comparing weight-loss outcomes in super-obese patients following biliopancreatic diversion with duodenal switch (DS) and Roux-en-Y Gastric Bypass (RYGB). METHODS: All super-obese patients (BMI > or =50 kg/m) undergoing standardized laparoscopic and open DS and RYGB between August 2002 and October 2005 were identified from a prospective database. Two-sample t tests were used to compare weight loss, decrease in BMI, and percentage of excess body weight loss (% EBWL) after surgery. chi analysis was used to determine the rate of successful weight loss, defined as achieving at least 50% loss of excess body weight. RESULTS: A total of 350 super-obese patients underwent DS (n = 198) or RYGB (n = 152) with equal 30-day mortality (DS,1 of 198; RYGB, 0 of 152; P = not significant). The % EBWL at follow-up was greater for DS than RY (12 months, 64.1% vs. 55.9%; 18 months, 71. 9% vs. 62.8%; 24 months, 71.6% vs. 60.1%; 36 months, 68.9% vs. 54.9%; P < 0.05). Total weight loss and decrease in BMI were also statistically greater for the DS (data not shown). Importantly, the likelihood of successful weight loss (EBWL >50%) was significantly greater in patients following DS (12 months, 83.9% vs. 70.4%; 18 months, 90.3% vs. 75.9%; 36 months, 84.2% vs. 59.3%; P < 0.05). CONCLUSIONS: Direct comparison of DS to RYGB demonstrates superior weight loss outcomes for DS.     

Long limb Roux en Y gastric bypass revisited

Roux-en-Y gastric bypass (RYGB) that is performed with at least a 150-cm Roux limb results in significantly greater weight loss than shorter (<100-cm) Roux limb procedures in superobese patients(BMI >50 kg/m2). Conversely, longer Roux limb procedures do not provide greater weight loss in less obese (BMI <50 kg/m2)patients. Modest elongation of the Roux limb-in the range of 150 cm to 200 cm-does not result in more frequent nutritional sequelae compared with shorter Roux limb procedures. This article discusses the current status of long limb Roux-en-Y gastric bypass in the context of weight loss, metabolic sequelae and CPT coding.     

Early prediction of failure to lose weight after obesity surgery

BackgroundAfter Roux-en-Y gastric bypass (RYGB), failing to lose enough weight or regaining weight is a concern for both patients and healthcare professionals. Our objective was to report the criteria for an early prediction of the failure to lose enough weight in the setting of a private practice and an academic center of obesity surgery.Patients and MethodsA retrospective analysis of the 2-year weight loss profiles of patients after RYGB was performed using nonlinear mixed models. A total of 375 morbidly obese adult patients, with a body mass index of 49.3 ± 7.7 kg/m², were included. Weight loss success was determined 2 years after surgery using the percentage of excess weight loss criteria. The surgical treatment and the main outcome measurement was standardized RYGB and the percentage of excess weight loss time profiles.ResultsThe patients who failed, succeeded, or had intermediate results at 2 years after surgery had different percentage of excess weight loss profiles during this period. At 6 months, 71% of those who had lost <30% of their initial excess weight had not lost ≥50% at 24 months. In contrast, those who had lost >45% were unlikely to have lost <50% of their excess weight.ConclusionAn early (month 6) prediction of failure to lose significant weight after RYGB can be made, with the threshold at 30% of the initial excess weight loss. Patients who have lost <30% of their initial excess weight are unlikely to have lost ≥50% at 24 months.     

Early postoperative complications after gastric bypass revisional surgery in patients with previous sleeve gastrectomy versus primary gastric bypass

BackgroundRevisional bariatric surgery (RS) is indicated if there is weight regain or insufficient weight loss, no improvement or reappearance of co-morbidities, or previous bariatric surgery complications. It has been associated with higher postoperative morbidity.ObjectiveTo evaluate the early postoperative complications (<30 d) of Roux-en-Y gastric bypass RS (RYGB-RS) after primary sleeve gastrectomy (SG-1) compared with primary RYGB (RYGB-1) at a bariatric surgery referral center.SettingDepartment of General and Digestive Surgery of General Universitary Hospital of Alicante, Spain.MethodsRetrospective cohort study comparing RYGB-RS after SG-1 and RYGB-1 between January 2008 and March 2021. Postoperative complications, hospital stay, mortality, and readmissions were analyzed.ResultsSix hundred and twenty-eight RYGB surgeries (48 RYGB-RS, 580 RYGB-1) were studied. The mean age of patients undergoing RYGB-RS was 50 years, compared with 46 years in the RYGB-1 group (P = .017). Mean initial body mass index was 44.2 kg/m² (RYGB-RS) versus 47.6 kg/m² (RYGB-1; P = .004). Cardiovascular risk factors were higher in the RYGB-1 group (P < .05). Indications for RS were weight regain or insufficient weight loss (72.9%), weight regain or insufficient weight loss plus gastroesophageal reflux disease (14.6%), and gastroesophageal reflux disease (12.5%). There were no differences in the frequency of complications (RYGB-RS 22.9% vs RYGB-1 20.5%) or in their severity (Clavien–Dindo ≥IIIa; RYGB-RS 10.4% vs RYGB-1 6.4%; P > .05). There were no differences in emergency room visits (RYGB-RS at 12.5% vs RYGB-1 at 14.9%) or in readmissions (RYGB-RS at 12.5% vs RYGB-1 at 9.4%).ConclusionNo differences were observed between primary RYGB and revisional RYGB in early morbidity, mortality, emergencies, or readmissions. Revisional bariatric surgery is a safe procedure at referral centers and must be done by expert hands.     

Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Roux-en-Y gastric bypass in superobese patients

BackgroundAlthough biliopancreatic diversion with duodenal switch (BPD-DS) is not the most performed procedure, Roux-en-Y gastric bypass (RYGB) is challenged by weight regain and insufficient weight loss, especially in patients with a body mass index >50 kg/m². The aim of our retrospective study was to compare the weight loss after 2 types of primary bariatric surgery. A total of 83 BPD-DS and 97 RYGB procedures were performed from March 2002 to October 2009 for an initial mean body mass index of 55 kg/m².MethodsAll RYGB patients underwent surgery at a private practice hospital and BPD-DS patients underwent surgery at a university hospital before February 2007 and at the same private hospital thereafter. The patients were seen in follow-up every 4 months the first year, every 6 months the second, and yearly thereafter. The maximum weight loss was assessed, as well as the weight regain beyond the first postoperative year. Weight loss success was defined as a percentage of excess weight loss (%EWL) of ≥50%.ResultsThe patients did not differ by age, gender, or length of follow-up (mean 46 mo, range .5–102 for RYGB and 44.3 mo, range 9–111 for BPD-DS). Of the patients, 17 RYGB and 7 BPD-DS patients were lost to follow-up within 3 years postoperatively. At 3 years of follow-up, the mean %EWL was 63.7% ± 17.0% after RYGB and 84.0% ± 14.5% after BPD-DS (P < .0001). Weight loss success was achieved by 83.5% of the RYGB and 98.7% of the BPD-DS patients (P = .0005).ConclusionAfter 12 months postoperatively, the number of patients regaining 10% of the weight lost during the first postoperative year was significantly greater after RYGB than after BPD-DS.     

Biliopancreatic diversion with duodenal switch or gastric bypass for failed gastric banding: retrospective study from two institutions with preliminary results.

BACKGROUND: Of patients who have undergone gastric banding, 11-25% will require a major reoperation with band removal and conversion to another bariatric procedure after they have failed to lose sufficient weight or have developed dysphagia or reflux. The aim of this study was to evaluate the respective benefits of Roux-en-Y gastric band (RYGB) or biliopancreatic diversion with duodenal switch (BPD-DS) after failed gastric banding and whether 1 of the 2 procedures might be a better procedure for such cases. METHODS: RYGB or BPD-DS was performed according to the institutional protocols with synchronous band removal, irrespective of the reason for failure. RESULTS: Of the 53 patients, 32 underwent laparoscopic RYGB for a body mass index (BMI) of 43.1 +/- 6.4 kg/m(2) (BMI 45.8 +/- 6.4 kg/m(2) before laparoscopic adjustable gastric banding) and 21 underwent BPD-DS for a BMI of 46.0 +/- 5.5 kg/m(2) (BMI 49.6 +/- 5.2 kg/m(2) before laparoscopic adjustable gastric banding). BPD-DS required significantly longer operative times (239.7 +/- 55.8 versus 135 +/- 26.7 minutes) and resulted in more complications (62% versus 12.5%; P <.002). No patients died postoperatively. The 2 groups of patients had a similar BMI at 12 and 18 months after revision (BMI 33.4 +/- 5.6 kg/m(2) and 31.4 +/- 3.5 kg/m(2)). The weight loss was greater after BPD-DS than after RYGB compared with the prerevision weight loss (66.2% versus 58.8% excess weight loss) or initial weight (73% versus 61.8%), although this was not significant. CONCLUSION: Despite an excessive rate of complications that were, in part, related to the learning curve in this series, BPD-DS resulted in greater weight loss compared with RYGB. However, both procedures were successful after failed gastric banding. A more accurate definition of failure could help to determine the respective indications for revisional surgery.     

Laparoscopic conversion of failed gastric bypass to duodenal switch: technical considerations and preliminary outcomes

BACKGROUND: Weight loss failure after Roux-en-Y gastric bypass (RYGB) is a challenging problem facing bariatric surgeons today. Conversion from RYGB to biliopancreatic diversion with duodenal switch (BPD-DS) might provide the most durable weight loss of all revision procedures currently available. Revision to BPD-DS can be done laparoscopically in 1 or 2 stages and involves 4 anastomoses: gastrogastrostomy, duodenoileostomy, ileoileostomy, and jejunojejunostomy (to reconnect the old Roux limb). This study reports on our early outcomes after laparoscopic conversion from RYGB to BPD-DS. METHODS: The data from all patients undergoing conversion from failed RYGB to BPD-DS were retrospectively reviewed. The data analyzed included age, body mass index, excess weight loss, method of gastrogastrostomy, and morbidity/mortality. RESULTS: Twelve patients were identified for analysis. The mean age and body mass index before conversion was 41 years and 41 kg/m(2), respectively. Of these 12 patients, 4 (33%) had undergone revision surgery (lengthening of the Roux limb, resizing the gastric pouch, adjustable band on pouch, or distal gastric bypass) before conversion; 8 (66%) had obesity-related co-morbidities; 7 (58%) underwent conversion to BPD-DS in 1 stage. Most gastrogastrostomies were performed using the 25-mm circular stapler. No patient died and no leaks developed. One patient required laparotomy, and 4 developed stricture at the gastrogastrostomy. The patients lost a dramatic amount of weight after conversion to BPD-DS, with a mean body mass index and excess weight loss of 31 kg/m(2) and 63%, respectively, at 11 months postoperatively. All co-morbidities resolved completely with the weight loss. CONCLUSION: Our preliminary results indicate that laparoscopic conversion to BPD-DS from failed RYGB is highly effective with an acceptable morbidity. Using a linear stapler to construct the gastrogastrostomy might reduce the stricture rate.     

Lipid risk profile and weight stability after gastric restrictive operations for morbid obesity

There are no longitudinal data that address weight loss stability and lipid levels in bariatric surgical patients. The goal of this study was to determine whether weight regain adversely affected reduction in lipid levels after gastric bariatric operations. Of 651 consecutive patients undergoing gastric restrictive surgery for morbid obesity, 227 (35%) had increased serum levels of total cholesterol (TC), triglycerides, or both preoperatively. High-density lipoprotein cholesterol (HDL-C) levels were subnormal (≤35 mg/dl) in 45 (20%) of the hyperlipidemic patients. Fasting lipid profiles were determined at 6-month intervals postoperatively. This series included the following three operations: gastroplasty (GP; N = 13), standard Roux-en-Y gastric bypass (RYGB; N = 205), and distal Roux-en-Y gastric bypass (DRY; N = 9). By 6 months postoperatively, patients had a ≥15% mean reduction in TC and a ≥50% mean reduction in triglycerides, both of which were significant in comparison with preoperative levels (P ≤0.05). Mean HDL-C levels had increased significantly vs. preoperative levels by 12 months postoperatively (P <0.05) and continued to increase through 5 years. By 18 months both HDL-C and TC were significantly lower after DRY than after GP or RYGB. In 91 patients who were followed for 2 years or longer (mean 48 ± 25 months), mean excess weight loss was 55% with mean body mass index reduced from 48 to 33 kg/m². This group was divided into patients whose weight remained stable (N = 54) and patients who regained ≥l5% of their lost weight or lost less than 50% of excess weight (N = 3 7). Although mean excess weight loss and body mass index were significantly different between the two groups (P <0.0001) at 2 years, there was no difference in the lipid profile (TC/HDL) between the two groups at any interval through 5 years. These results show that abnormal lipid profiles can be permanently improved after gastric bariatric surgery and are not adversely affected by mediocre weight loss or regaining ≥15% of lost weight. DRY appears to be a superior operation for TC reduction in comparison with GP and RYGB.     

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.     

Gender and Racial/Ethnic Background Predict Weight Loss after Roux-en-Y Gastric Bypass Independent of Health and Lifestyle Behaviors

Our study investigated how demographic, health, and behavioral factors interacted to affect weight outcomes in bariatric patients. Roux-en-Y gastric bypass (RYGB) patients who were non-Hispanic black, Hispanic, or non-Hispanic white race/ethnicity, had no revisions to their RYGB during 2004–2009, and had at least 1 year of follow-up data for body weight after surgery (n?=?860) were surveyed by phone about their health and behaviors. The main outcomes of interest were percent excess weight loss and percent of initial weight lost. Participants were 47?±?11 years old, 54 % non-Hispanic white, 25 % Hispanic, and 21 % non-Hispanic black, 82 % female, 60 % married, 82 % had some college education, and 47 % had an annual income between $35,000 and $80,000. At the time of surgery, patients had lost 50?±?29 % of their excess weight and had achieved 24?±?15 % initial weight lost after an average of 54 months of follow-up. After accounting for weight at the time of surgery, demographics, and self-reported health and behavior, non-Hispanic black men had significantly greater weight loss compared to non-Hispanic white men (p?相似文献   

Long-long limb Roux-en-Y gastric bypass is more efficacious in treatment of type 2 diabetes and lipid disorders in super-obese patients.

BACKGROUND: Super-obese patients can achieve adequate weight loss with long limb Roux-en-Y gastric bypass (RYGB). These patients, however, might need longer intestinal limbs to control co-morbidities such as type 2 diabetes, lipid disorders, hypertension, sleep apnea, and gastroesophageal reflux disorder. METHODS: A total of 105 patients with a body mass index of > or =50 kg/m(2) were randomly divided into 2 similar groups regarding sex, age, and number of co-morbidities. All underwent laparoscopic Roux-en-Y gastric bypass. In group 1, the length of the biliary limb was 50 cm and the length of the Roux limb was 150 cm. In group 2, the length of the biliary limb was 100 cm and the length of the Roux limb was 250 cm. RESULTS: The follow-up for both group was 48 months. Diabetes was controlled in 58% of group 1 and in 93% of group 2 (P <0.05). Lipid disorders improved in 57% of group 1 and in 70% of group 2 (P <0.05). No statistical difference was found in the control or improvement of hypertension, sleep apnea, or gastroesophageal reflux disorder. The excess weight loss was faster in group 1 but was similar in both groups at 48 months (70% in group 1 and 74% in group 2), with no statistical difference. CONCLUSION: Patients with longer biliary and Roux limbs achieved greater type 2 diabetes control, greater lipid disorder improvement, and showed a trend toward faster excess weight loss.     

Interval jejunoileal bypass reduces the morbidity and mortality of Roux-en-Y gastric bypass in the super-obese

Among Roux-en-Y gastric bypass (RYGB) patients, large male patients carry the greatest risk for severe, life-threatening complications. The higher complication rate is partly related to large amounts of intra-abdominal fat that increases the technical difficulty of the RYGB. In order to minimize the risk for complications, we established a staged approach for weight loss surgery for high-risk, super-obese patients. Patients with intra-abdominal fat at exploration which precluded the performance of RYGB underwent jejunoileal bypass (JIB). Following an initial period of weight loss (6-24 months), they were converted to a RYGB during a second operation. Twenty-four patients underwent initial JIB that was associated with a major complication rate of 8.3 per cent (2/24) and no mortality. Eight patients lost 53.4 +/- 6.3 kg prior to their conversion to RYGB (mean, 14.1 months). There was one major complication (12%) and no deaths (0%). Following RYGB, an additional period of weight loss resulted in overall excess weight loss (EWL) totaling 62 per cent. A two-step procedure is a safe and effective approach for minimizing complications for high-risk patients undergoing RYGB. The initial JIB was associated with low morbidity and no mortality, and the follow-up RYGB procedure was a technically simple operation that could be performed with few complications.     

Outcomes of Roux-en-Y gastric bypass stratified by a body mass index of 70 kg/m2: A comparative analysis of 825 procedures

We compared the safety, excess weight loss (EWL), and improvement in comorbidities after Roux-en-Y gastric bypass (RYGB) in morbidly obese and superobese patients (body mass index, < 70 kg/m² or ≥70 kg/m²). Of 825 patients who underwent RYGB by our group between 1995 and 2003, 79 (9.6%) were superobese (group A) and 746 were morbidly obese (group B). There were significant differences in age (A, 40.8 years; B, 43.2 years; P = 0.01), gender (males: A, 40.5%; B, 17.6%; P < 0.0001), and type of access (laparoscopic RYGB: A, 4.1%; B, 34.2%; P < 0.0001). Sleep apnea (A, 57%; B, 31.4%; P < 0.0001) and venous insufficiency (A, 16.5%; B, 2.4%; P < 0.0001) were more common in superobese patients. Hospital stay was similar (A, 6.3 days; B, 5.3 days) with adjustment for differences in type of access. Although morbidity was comparable, mortality was higher in the superobese group (A, 2.5%; B, 0.5%; P < 0.05). At a comparable follow-up (A, 17.7 months; B, 18.25 months), percent EWL at 1 year was lower in the superobese group (A, 54.6%; B, 64.3%; P < 0.0001), but it became similar at 3 years (A, 66.5%; B, 60.7%). Postoperative improvement of comorbidities was equally dramatic in both groups with the exception of venous insufficiency. In conclusion, complications are not increased in the superobese, but they are more often fatal. Superobese patients achieve their maximum weight loss in a longer period of time and reach their nadir at year 3. Presented at the Forty-Fifth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 15–19, 2004 (oral presentation).     

Long-Term Follow-up after Gastric Surgery for Morbid Obesity: Preoperative Weight Loss Improves the Long-Term Control of Morbid Obesity after Vertical Banded Gastroplasty

Background: Gastric restrictive surgery in a large non-university teaching hospital has been combined with preoperative weight loss by diet. The aims of preoperative dieting were to test patient motivation, to reduce perioperative morbidity, to accustom patients to the restriction of food intake after surgery, and to increase total weight loss. This study was performed to investigate the long-term results of this approach. Methods: 200 morbidly obese persons were operated on between 1978 and 1986 after they had lost more than 50% of their excess weight by diet. 100 Roux-en-Y gastric bypasses (RYGB) and, after 1983, 100 vertical banded gastroplasties (VBG) were performed. Data from medical records and data concerning present weight, complaints, food intolerance, nutritional deficiencies, and medical follow-up visits were obtained by questionnaire. Results: The lowest body weight was obtained 1 year after operation with an average excess weight loss (EWL) of 78% after RYGB and 75% after VBG. Body weight gradually increased, and 7 years after surgery the average EWL was 67% after RYGB and 63% after VBG. Ten patients had died (three postoperatively after RYGB). Preoperative dieting did not decrease perioperative morbidity and mortality in comparison with other reports. Conclusions: After combined preoperative dieting and VBG, weight loss is greater than after surgery alone. No additional weight loss after preoperative dieting was observed in RYGB patients. Most patients who underwent bariatric surgery still experience nutritional, physical, and cosmetic problems 7 years after surgery.     

Adjustable gastric band placed around gastric bypass pouch as revision operation for failed gastric bypass

BackgroundThe failure rate after gastric bypass surgery for weight loss has been reported at 10–20%. To date, no reliably safe and effective salvage operation is available. This pilot study was conducted to determine whether restriction of the Roux-en-Y gastric bypass (RYGB) pouch using the adjustable gastric band (AGB) is an effective revision operation.MethodsA prospectively accrued group of patients who underwent revisional surgery using the AGB placed around the RYGB pouch by our bariatric surgical group from October 2004 to October 2006 was analyzed.ResultsOf the 10 patients accrued during this period, 2 were lost to follow-up, leaving 8 patients for analysis. Of the 8 patients, 1 was a man and 7 were women. The mean prerevision weight was 135.75 kg (range 105–165), and the body mass index was 48.42 kg/m² (range 38.92–55). The mean weight loss at 1 year of follow-up was 17.03 kg (range 0.2–42), with a mean percentage of excess weight loss of 24.29% (range 0.2–49.2%). The mean weight loss of the 5 patients with 2 years of follow-up was 36.4 kg (range 20–58), with a mean percentage of excess weight loss of 48.7% (range 21.8–98.1%). One patient with 3 years of follow-up had a weight loss of 56 kg and a percentage of excess weight loss of 66.2%. Three minor complications developed: 2 AGB port-related complications requiring port revision and 1 postoperative wound hematoma requiring evacuation. No band erosions or band slippages occurred, and no major complications developed.ConclusionIn our study, an AGB placed around the RYGB pouch was a safe and effective revision operation for a failed RYGB operation.     

A Technique for Converting the Roux-en-Y Gastric Bypass to a Modified Biliopancreatic Diversion

Our group has performed the Roux-en-Y gastric bypass (RYGB) in 1450 patients since 1983: 805 patients had primary operations, and 645 were converted from previous gastroplasty procedures, i.e. horizontal gastroplasty, vertical banded gastroplasty, and gastrogastrostomy. Within the last 2 years, 38 patients who failed the RYGB were converted to a modified biliopancreatic diversion (BPD) using a technique that did not require dismantling a major portion of the original gastric exclusion. A 24-month follow-up has demonstrated a significant and sustained weight loss in all patients. In addition, the modified BPD completely eliminated the problem of reflux bile gastritis in those patients with a short Roux-en-Y jejunal limb.