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.     

Rate of weight loss after vertical banded gastroplasty in morbid obesity: relationship to serum lipids and uric acid

The relationship between postoperative weight loss after vertical banded gastroplasty in morbidly obese patients and preoperative serum triglycerides, cholesterol, HDL-cholesterol, uric acid and fasting plasma glucose was evaluated. The rate of weight loss, calculated as a percentage of original weight, was determined at three and six months after surgery. There was a significant correlation between rate of weight loss at three months and preoperative serum uric acid (r = -0.60, p less than 0.01). and also with the total cholesterol: HDL-cholesterol ratio (r = 0.61, P less than 0.01). At six months, the rate of weight loss correlated with preoperative serum triglycerides (r = -0.54, p less than 0.02) and total cholesterol: HDL cholesterol ratio (r = 0.44, p less than 0.05). The reasons for the predictive value of these biochemical parameters is unknown and deserves further study.     

Ten and more years after vertical banded gastroplasty as primary operation for morbid obesity

Long-term follow-up (>l0 years) after vertical banded gastroplasty (VBG) is almost nonexistent. The aim of this study was to determine long-term outcome after VBG in a group of 71 patients studied prospectively. Seventy-one consecutive patients with morbid obesity (54 women and 17 men; mean age 40 years [range 22 to 71 years]) underwent VBG from 1985 to 1989 and were followed prospectively. Follow-up was obtained in 70 (99%) of the 71 patients. Weight (mean ± standard error of the mean) preoperatively was 138 ±3 kg and decreased to 108 ±2 kg 10 or more years postoperatively. Body mass index decreased from 49 ±1 to 39 ±1. Only 14 (20%) of 70 patients lost and maintained the loss of at least half of their excess body weight with the VBG anatomy. Vomiting one or more times per week continues to occur in 21% and heartburn in 16%. Fourteen patients have undergone conversion from VBG to Roux-en-Y gastric bypass (11 patients) or other procedures (3 patients) because of a combination of inadequate weight loss in 13 patients, gastroesophageal reflux in five, and frequent vomiting in four. Only 26% of patients after VBG have maintained a weight loss of at least 50% of their excess body weight; 17% underwent bariatric reoperation with good results. Thus VBG is not an effective, durable bariatric operation. Presented at the Forty-First Annual Meeting of The Society for Surgery of the Alimentary Tract, San Diego, Calif., May 21–24, 2000, and published as an absaact in Gastroenterology 118(Suppl l):A1060, 2000.     

Improvement of weight loss and metabolic effects of vertical banded gastroplasty by an added duodenal switch procedure

Background: Some patients who underwent vertical banded gastroplasty (VBG) need revisional operations because of poor weight loss and remaining comorbidities. The duodenal switch (DS) procedure with partial gastrectomy is known as an effective method for treatment of severe obesity and related dyslipoproteinemias and diabetes mellitus type 2 (DM2). Other investigations have shown that DS without gastric resection similarly corrects hypercholesterolemia and DM2 in the "less than" morbidly obese patients. Methods: Based on this knowledge, we performed a DS simultaneously with hernioplasty and panniculectomy in a 63-year-old woman with a fair EWL (36.4%), with remaining hypercholesterolemia and DM2 4 years after VBG. The pouch stoma diameter was 13 mm, and there was no pouch dilation nor staple-line disruption.The previously partitioned stomach was left in place. H2-blockers and polyvitamins were prescribed after operation. Results: 1 year after DS there were no postoperative complications and undesirable effects except slight anemia. DS allowed improvement in weight loss, improved carbohydrate handling without need for insulin or other hypoglycemic agents, and corrected severe hypercholesterolemia. Conclusion: DS per se in the case presented had a decisive effect on DM2 and hypercholesterolemia. DS should be kept in mind as a second-step malabsorptive procedure after a failed purely restrictive operation.     

Laparoscopic conversion of vertical banded gastroplasty to a Roux-en-Y gastric bypass

The vertical banded gastroplasty was the mainstay of bariatric surgery for over a decade. Though this procedure is now rarely performed many of these patients will present with failure or maladaptive eating and its sequelae. Some of these patients who demonstrate the motivation for lifestyle modification as well as many of these with complications will be candidates for revisional surgery. This article reviews the technical challenges in performing these revisions using minimally invasive techniques. In addition it reviews outcomes of laparoscopic conversion and tips for patient selection and success.     

Laparoscopic vertical banded gastroplasty for morbid obesity. Assessment of efficacy

BACKGROUND: The advantages of treating morbidly obese patients via the laparoscopic approach have been demonstrated, in particular, for adjustable silicone gastric banding, but this operation is associated with a high rate of late complications. Gastric bypass and malabsorbitive procedures are feasible via the laparoscopic approach, but they entail a prolonged operating time and a consistently high morbidity rate. Laparoscopic vertical banded gastroplasty represents an effective alternative. METHODS: We performed 250 consecutive LVBG between November 1995 and February 2000. The procedure consisted of a personal technique designed to reproduce, by laparoscopy, MacLean's modification of the standard open Mason vertical-banded gastroplasty, with a calibrated transgastric window, a complete division between the staple lines, and a 5-cm-circumference polypropylene collar. RESULTS: The operative time was 95 min and the conversion rate was 0.8%. Operative mortality was nil; early and late complications, respectively, were 4.4% and 4%; the reoperation rate was 2%. Global results at 4 years were as follows: excess weight loss (EWL) 61%, success rate (excess weight <50%) 76.9%, body mass index (BMI) 29.4 kg/m2. In morbidly obese patients, the EWL at 4 years was 62.2%, with a 77.4% success rate and a 28.4 kg/m2 BMI; in superobese patients, the EWL at 4 years was 54.9% with a 50% success rate and a 35.5 kg/m2 BMI. The overall follow-up rate was 92%. CONCLUSIONS: LVBG is an effective and safe operation in morbidly obese patients, providing good weight loss with a low morbidity rate, no mortality, and minimum discomfort. However, in superobese patients, the weight loss results are disappointing; in these patients, LVBG is questionable and more complex procedures should be considered.     

Gastrointestinal hormone responses to meals before and after gastric bypass and vertical banded gastroplasty.

The purpose of the study was to examine the gastrointestinal hormone responses to meals in morbidly obese patients before and after Roux-en-Y gastric bypass (GBP; n = 9) or vertical banded gastroplasty (VBG; n = 7). On consecutive days before and after operation, we measured changes in peripheral blood levels of glucose, insulin, enteroglucagon, serotonin, vasoactive intestinal polypeptide (VIP), and cholecystokinin (CCK) in response to a standardized glucose or protein-fat meal. The percentage of excess weight lost at 6 months after operation was 66.3% +/- 4% and 41.8% +/- 5% for GBP and VBG, respectively (p less than 0.01). The 3-hour integrated glucose response to a glucose meal decreased from 145.3 +/- 33.7 to 75.8 +/- 15.7 g min/L (p less than 0.02) after GBP. This was associated with a decrease in 3-hour integrated insulin response from 22.8 +/- 8.2 to 10.5 +/- 4.9 mU min/L. Vertical banded gastroplasty patients had lesser reductions of hyperglycemia and hyperinsulinemia. Neither the CCK, serotonin, nor VIP responses to meals were altered by either operation. The 3-hour integrated enteroglucagon response to glucose increased markedly in GBP patients after operation from 11.8 +/- 6 to 133.4 +/- 38 nmol min/mL (p less than 0.02). This increase in enteroglucagon occurred at the same time as development of dumping symptoms, which occurred exclusively in GBP patients after glucose but not protein. We conclude that (1) GBP surgery for morbid obesity results in amelioration of glucose intolerance and hyperinsulinemia, (2) CCK does not mediate an endocrine satiety effect of surgery, (3) GBP is associated with an exaggerated enteroglucagon response to glucose, and (4) enteroglucagon appears to be a marker of the dumping syndrome in GBP patients.     

Operative technique for converting a failed vertical banded gastroplasty to Roux-en-Y gastric bypass

BACKGROUND: Bariatric surgeons are increasingly encountering patients with failed weight-loss operations. Conversion from vertical banded gastroplasty (VBG) to Roux-en-Y gastric bypass (RYGB) is the most common revisional operation in our practice. We reviewed our experience in converting from VBG to RYGB using a basic five-step surgical technique. STUDY DESIGN: We reviewed data on all patients undergoing revisional surgery for failed VBG, defined as patients with body mass index >/=35 kg/m(2), weight gain, poor control of comorbidities, staple-line dehiscence, or band-specific complications. The five basic steps include identification of the band, delineation of the extent of the pouch, division of the stomach, preparation of the Roux limb, and completion of the cardiojejunostomy. RESULTS: We have undertaken 28 conversions from VBG to RYGB. Median age was 51 years (range 27 to 65 years), preoperative body mass index was 40 kg/m(2) (range 20 to 58 kg/m(2)), and 25 patients (89%) were women. Indications for revision were band-related complications (13 patients), staple-line disruption (9 patients), and inadequate weight loss (6 patients). Median operative time was 185 minutes (range 105 to 465 minutes), estimated blood loss was 450 mL (range 100 to 2,500 mL), postoperative complications occurred in 6 patients (21%), and length of hospitalization was 5 days (range 3 to 69 days). Median postoperative body mass index was 32 kg/m(2) (range 20 to 41 kg/m(2)) at a followup time of 16 months (range 1 to 32 months). CONCLUSIONS: The technique described facilitates the operative approach to patients with failed VBG, providing guidelines for safe dissection and division of the gastric pouch for conversion to RYGB. Revisional bariatric operations are technically difficult and are associated with relatively higher complication rates than those reported for primary operations.     

Previous weight loss as a predictor of weight loss outcomes after laparoscopic adjustable gastric banding

Introduction

Weight loss after laparoscopic adjustable gastric banding (LAGB) can be influenced by a variety of factors. The objective of this study is to investigate whether the maximum amount of previous weight loss with diet and exercise, prior to evaluation for bariatric surgery, is predictive of postoperative weight loss success among primary LAGB patients.

Methods

A retrospective cohort study was designed from a prospectively collected database at a single institution. Inclusion criteria consisted of age ≥18 years, initial body mass index (BMI) ≥35 kg/m², intake information on the maximum weight loss at any time prior to referral to our bariatric practice, and at least 2 years of postoperative follow-up. Patients with prior bariatric surgery were excluded. Outcomes included mean % excess weight loss (EWL), percent that achieved weight loss success (%EWL ≥ 40), and percent with suboptimal weight loss (%EWL < 20) at 2 years post-LAGB.

Results

In the study, 462 primary LAGB patients were included. Mean previous weight loss was 29.7 lb (SD 27.6, range 0–175). These patients were divided into four previous weight loss groups (0, 1–20, 21–50, >50 lb) for analysis. In adjusted multivariate analyses, patients with >50 lb of maximum previous weight loss had a significantly higher mean %EWL, (p < 0.0001) and %BMIL (p < 0.0001), were more likely to reach weight loss success (≥40 % EWL, p = 0.047), and were less likely to experience suboptimal weight loss (<20 % EWL, p = 0.027) at 2 years postoperatively.

Conclusion

Previous weight loss appears to be a significant predictor of weight loss after LAGB. With multiple options for weight loss surgery, this study helps elucidate which patients may be more likely to achieve greater weight loss with the LAGB, allowing clinicians to appropriately counsel patients preoperatively.

     

Modified vertical banded gastroplasty as revision of failed high gastric reduction for morbid obesity

Vertical banded gastroplasty is currently closest to the ideal gastric restrictive procedure for the surgical treatment of obesity. A modification of the technique of vertical banded gastroplasty can be successfully used to revise a failed high gastric reduction for morbid obesity.     

Incarceration of a calibrating band after vertical banded gastroplasty for morbid obesity: diagnostic and therapeutic implications

About a case of migration of the strip of grading placed during a gastroplasty, and revealed by a severe complication on the occasion of the transformation of a typical Mason gastroplasty in Mac Lean gastroplasty, we formulate the following propositions: 1) The staple line dehiscence of Mason's vertical gastroplasty can be bound (connected) to an excessive tightening of the strip and let us suggest lengthening (stretching out) his 2 cm length with regard to the usually recommended dimension. 2) It is necessary to look for systematically this confinement, in case of reintervention for staple line dehiscence; to ignore it is to expose itself, if we transform the Mason surgery into Mac Lean surgery, to deteriorate a fistula which the staple line dehiscence had until then contributed to hide (darken).     

Prospective randomised comparison of adjustable gastric banding and vertical banded gastroplasty for morbid obesity.

OBJECTIVE: To compare the clinical results of adjustable gastric banding and vertical banded gastroplasty for morbid obesity. DESIGN: Prospective randomised trial. SETTING: University hospital, Sweden. PATIENTS: 59 morbidly obese patients, listed for obesity surgery. INTERVENTIONS: Adjustable gastric banding (n = 29) or vertical banded gastroplasty (n = 30). MAIN OUTCOME MEASURES: Weight loss, complications, need for revisional surgery, reflux symptoms and the patient's own evaluation. RESULTS: Five years after surgery the mean (SEM) weight reduction for adjustable gastric banding was 43 (3.0) kg and for vertical banded gastroplasty 35 (4.8) kg. One patient in each group died of unrelated causes during follow-up and 3 and 2 patients, respectively, were lost to follow-up. One patient in the vertical banded group required reoperation for an anastomotic leak on the third postoperative day. A total of 3 patients in the adjustable group required reoperation and 11 in the vertical banded group. CONCLUSIONS: Adjustable gastric banding carries a smaller risk of reoperation than vertical banded gastroplasty and the weight reduction is in the same order of magnitude.     

Early weight loss as a predictor of 3-year weight loss and weight regain in patients with good compliance after sleeve gastrectomy

BackgroundSleeve gastrectomy (SG) is the most common surgery for severe obesity. Patients lose weight post SG and regain some weight in the following years. Early weight loss predicts weight loss after SG. However, etiologies of weight loss and regain after SG remain unclear.ObjectivesTo investigate the effects of early weight loss on medium-term weight regain post SG.SettingTwo university hospitals in Taiwan.MethodsPatients with records within 1 and at 3 years after SG were enrolled retrospectively. Preoperative clinical variables and percentage of total weight loss (%TWL) were analyzed. Weight regain was defined as a weight increase from 1 year postoperatively of >25% of the lost weight. Linear and multiple logistic regression were applied to examine the associations of early weight loss, weight loss, and weight regain.ResultsA total of 363 patients were included. Body mass indexes before and 1, 3, 6, 12, and 36 months postoperatively were 40.7 ± 6.8 kg/m², 36.6 ± 6.2 kg/m², 33.5 ± 5.8 kg/m², 30.9 ± 5.5 kg/m², 28.4 ± 5.2, and 29.3 ± 5.4 kg/m², respectively. At 3 years after SG, 73 patients (20.1%) had weight regain. In multivariate linear analyses, initial age, waist circumference, type 2 diabetes, and %TWL at 1 or 3 months were associated with either 1-year or 3-year %TWL. Multiple logistic regression revealed %TWL at 3 months to be a predictor for 3-year weight regain after SG (odds ratio, .927; P = .02).ConclusionEarly weight loss predicted weight loss and regain 3 years after SG. Early lifestyle and behavioral interventions are suggested in patients at high risk of poor weight loss and weight regain outcomes after SG.     

Energy expenditure during treadmill walking before and after vertical banded gastroplasty: a one-year follow-up study in 11 obese women.

OBJECTIVE: To find out whether weight reduction induced by vertical banded gastroplasty (VBG) alters the energy expenditure in severely obese women during treadmill walking. DESIGN: A prospective one year follow-up study, patients being their own controls. SETTING: University hospital, Sweden. SUBJECTS: A consecutive series of 11 women who had VBG. MAIN OUTCOME MEASURES: Indirect calorimetry, body mass index (BMI), preset and comfortable walking speeds, heart rate, perceived exertion, and quality of life. RESULTS: 11 patients were evaluated. Mean BMI (kg/ml) decreased from 41 (range 36-46) before to 32 (range 25-37) 12 months postoperatively. The energy expenditure decreased significantly both at comfortable and preset walking speeds. The comfortable walking speed increased from 2.7 km x h(-1) (range 1.3-3.4) before operation to 3.8 (range 2.0-4.2) one year postoperatively (p = 0.003). All bodily variables in the SF-36 questionnaire showed improvement from 6 months onwards. CONCLUSION: Weight reduction in women reduces the energy expenditure during walking both at comfortable and preset speeds. The comfortable walking speed is increased. The improvements are reflected in the patients' own assessment.     

De Ritis ratio as a predictor of 1-year mortality after burn surgery

BackgroundBurn is an overwhelming injury. The De Ritis ratio, defined as aspartate aminotransferase to alanine aminotransferase ratio, can be used to predict poor outcomes. We evaluated the risk factors, including the De Ritis ratio, associated with 1-year mortality after burn surgery.MethodsPatients who underwent burn surgery from 2009 to 2019 were retrospectively evaluated. Multivariate Cox regression analysis was conducted to evaluate the risk factors for 1-year mortality after burn surgery. Receiver operating characteristic (ROC) curve analysis of the De Ritis ratio was performed to predict postoperative 1-year mortality. Kaplan–Meier survival analysis was also conducted. Other postoperative outcomes, such as durations of hospital and intensive care unit stays, acute kidney injury, and major adverse cardiac events, were evaluated.ResultsOne-year mortality after burn surgery occurred in 247 (19.9%) of 1244 patients. The risk factors for 1-year mortality after burn surgery were the De Ritis ratio, age, American Society of Anesthesiologists physical status, diabetes mellitus, total body surface area burned, inhalation injury, serum creatinine level, and serum albumin level. The area under the ROC curve for the De Ritis ratio was 0.716 (optimal cutoff = 1.9). The 1-year mortality rate after burn surgery was significantly higher in patients with a De Ritis ratio >1.9 than in those with a De Ritis ratio ≤1.9 (35.8% vs. 11.8%, P < 0.001). The survival rate was significantly higher in patients with a De Ritis ratio ≤1.9 than in those with a De Ritis ratio >1.9 (log-rank test, P < 0.001). Intensive care unit stay, acute kidney injury, and major adverse cardiac events were significantly higher in patients with a De Ritis ratio >1.9 than in those with a De Ritis ratio ≤1.9 (P = 0.006, P < 0.001, and P < 0.001, respectively).ConclusionsThe preoperative De Ritis ratio was a risk factor for 1-year mortality after burn surgery. The De Ritis ratio >1.9 was significantly associated with an increased 1-year mortality after burn surgery. These findings emphasized the importance of identifying burn patients with an increased De Ritis ratio to reduce the mortality after burn surgery.