Enoxaparin thromboprophylaxis in gastric bypass patients: extended duration,dose stratification,and antifactor Xa activity

BackgroundMorbidly obese patients undergoing gastric bypass surgery are at risk for postoperative venous thromboembolism. Evidence-based recommendations regarding the dosing and duration of thromboprophylaxis are lacking for morbidly obese surgical patients. The aims of this study were to evaluate the safety and efficacy of an extended duration, body mass index (BMI)–stratified enoxaparin thromboprophylaxis regimen in patients undergoing Roux-en-Y gastric bypass and to determine the resultant antifactor Xa (AFXa) activity in morbidly obese surgical patients.MethodsIn this prospective open trial, 223 patients (75% female, mean BMI 50.4 kg/m²) undergoing Roux-en-Y gastric bypass were assigned to receive enoxaparin 40 mg (BMI ≤50 kg/m², n = 124) or 60 mg (BMI >50 kg/m², n = 99) every 12 hours during hospitalization and once daily for 10 days after discharge. The AFXa levels were monitored serially, and dose adjustments were made for results outside the target prophylactic range (.2–.4 IU/mL ± 10%) after the third dose. The safety and efficacy outcomes were major bleeding and venous thromboembolism.ResultsRoux-en-Y gastric bypass was performed laparoscopically in 208 subjects (93%). The duration of surgery averaged 99.5 ± 31 minutes, and the median length of hospitalization was 3 days. Target prophylactic AFXa concentration was achieved by 74% of patients after the third enoxaparin dose; none reached the full anticoagulation concentration. One patient developed nonfatal venous thromboembolism (.45%). Four patients required transfusion (1.79%). Bleeding was not associated with a high AFXa concentration.ConclusionThis BMI-stratified, extended enoxaparin dosing regimen provided well-tolerated, effective prophylaxis against venous thromboembolism in patients undergoing gastric bypass surgery.     

Long-term results of laparoscopic Roux-en-Y gastric bypass for morbid obesity: 105 patients with minimum follow-up of 15 years

BackgroundLaparoscopic Roux-en-Y gastric bypass (LRYGB) is the second most frequently performed bariatric procedure worldwide; however, long-term results are not frequently reported.ObjectivesTo evaluate the outcomes of LRYGB on weight loss and co-morbidities in a single center 15 years after the operation.SettingTertiary-care referral hospital.MethodsFrom February 2000 to December 2003, 105 patients (86 women; mean age 39.9 ± 17.4; mean body mass index [BMI] 47.2 ± 6.4 kg/m²; 78 with BMI < 50 kg/m² and 27 with BMI ≥ 50 kg/m²) underwent LRYGB. Retrospective analyses of a prospectively maintained database were carried out to evaluate weight loss; resolution of co-morbidities, including type 2 diabetes mellitus (T2D), hypertension (HTN), and dyslipidemia; complications; and nutritional status.ResultsThe follow-up rate at 15 years was 87.6%. Mean excess weight loss was 58.6 ± 27%, with 74.1% of patients achieving a total weight loss ≥ 20%. According to the Biron et al. criteria, an inadequate outcome was found in 11/21 (52.4%) of patients with an initial BMI ≥ 50 kg/m² versus 21/64 (32.8%) of patients with a preoperative BMI < 50 kg/m² (P = .001). Both groups experienced gradual weight regain (WR); specifically, 34.1% of patients regained more than 15% of their lowest postoperative weight. The rates of reoperations due to early and late surgical complications were 3.8% and 9.5%, respectively. T2D was resolved in 50% of patients, HTN in 61.1%, and dyslipidemia in 58.3%. Iron deficiency anemia (53%) was the most common postoperative nutritional finding.ConclusionLRYGB provides satisfactory weight loss and resolution of co-morbidities up to 15 years. WR was a common finding. A significant proportion of patients with a preoperative BMI ≥ 50 kg/m² did not achieve a favorable weight loss outcome. Indications to perform LRYGB in this group of patients should be definitively reconsidered.     

Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m2

BackgroundRoux-en-Y gastric bypass (RYGB) benefits patients with type 2 diabetes mellitus (T2DM) and a body mass index (BMI) >35 kg/m²; however, its effectiveness in patients with T2DM and a BMI <35 kg/m² is unclear. Asian Indians have a high risk of T2DM and cardiovascular disease at relatively low BMI levels. We examined the safety and efficacy of RYGB in Asian Indian patients with T2DM and a BMI of 22–35 kg/m² in a tertiary care medical center.MethodsA total of 15 consecutive patients with T2DM and a BMI of 22–35 kg/m² underwent RYGB. The data were prospectively collected before surgery and at 1, 3, 6, and 9 months postoperatively.ResultsOf the 15 patients, 8 were men and 7 were women (age 45.6 ± 12 years). Their preoperative characteristics were BMI 28.9 ± 4.0 kg/m², body weight 78.7 ± 12.5 kg, waist circumference 100.2 ± 6.8 cm, and duration of T2DM 8.7 ± 5.3 years. At baseline, 80% of subjects required insulin, and 20% controlled their T2DM with oral hypoglycemic medication. The BMI decreased postoperatively by 20%, from 28.9 ± 4.0 kg/m² to 23.0 ± 3.6 kg/m² (P <.001). All antidiabetic medications were discontinued by 1 month after surgery in 80% of the subjects. At 3 months and thereafter, 100% were euglycemic and no longer required diabetes medication. The fasting blood glucose level decreased from 233 ± 87 mg/dL to 89 ± 12 mg/dL (P <.001), and the hemoglobin A1c decreased from 10.1% ± 2.0% to 6.1% ± 0.6% (P <.001). Their waist circumference, presence of dyslipidemia, and hypertension improved significantly. The predicted 10-year cardiovascular disease risk (calculated using the United Kingdom Prospective Diabetes Study equations) decreased substantially for fatal and nonfatal coronary heart disease and stroke. No mortality, major surgical morbidity, or excessive weight loss occurred.ConclusionRYGB safely and effectively eliminated T2DM in Asian Indians with a BMI <35 kg/m². Larger, longer term studies are needed to confirm this benefit.     

Outcome of hand-assisted laparoscopic gastric bypass in super obese patients

BackgroundThe optimal surgical treatment for super obese patients (body mass index [BMI] ≥50 kg/m²) has been a challenge and debate for most bariatric surgeons. To compare the outcomes of hand-assisted laparoscopic Roux-en-Y gastric bypass (HALGB) in super obese patients (BMI ≥50 kg/m²) to morbidly obese patients (BMI <50 kg/m²).MethodsA total of 295 patients who underwent HALGB from October 2003 to December 2005 were studied. These patients included 177 with a BMI of ≤49 kg/m² (morbidly obese) and 118 with a BMI of ≥50 kg/m² (super-obese). The patient demographics, complications, and outcomes were examined. Additionally, the 12-month postoperative outcomes included the percentage of excess weight loss and improvement of co-morbidities.ResultsThe patient age and gender were similar between the 2 groups. The super-obese patients had significantly more co-morbidities and required a greater number of medications. A significant difference was found in 3 early postoperative complications, with super-obese patients experiencing more wound infections (P = .039), nausea/vomiting (P = .003), and pulmonary failure (P = .010). Logistic regression analysis found, after controlling for significant risk factors, that the difference in the incidence of nausea/vomiting was still significant (odds ratio 14.33, 95% confidence interval 1.73–118.60, P = .01). Morbidly obese patients had a significantly greater percentage of excess weight loss at 12 months postoperatively compared with the super-obese patients (80% versus 55%, respectively, P <.001).ConclusionHALGB is a safe and effective procedure in the super obese but with less favorable outcomes compared with those for morbidly obese patients regarding the percentage of excess weight loss.     

Outcomes of bariatric surgery in extreme obesity: results from the United Kingdom National Bariatric Surgery Registry for patients with a body mass index >70 kg/m2

BackgroundBariatric and metabolic surgery (BMS) is an established safe, effective, and durable treatment for obesity and its complications. However, there is still a paucity of evidence on surgery outcomes in patients suffering from extreme obesity.ObjectivesThis study aimed to evaluate outcomes of BMS in weight loss and the resolution of co-morbidities in patients with a body mass index (BMI) ≥70kg/m².SettingNational Health Service and private hospitals in the United Kingdom.MethodsThis cohort study analyzed prospectively collected records from the UK National Bariatric Surgery Registry of patients with a BMI ≥70 kg/m² undergoing Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), or adjustable gastric band (AGB) between January 2009 and June 2014.ResultsThere were 230 patients (64% female) eligible for inclusion in the study: 22 underwent AGB; 102 underwent SG, and 106 underwent RYGB. Preoperative weight and BMI values were comparable (76 ± 7 kg/m² for AGB; 75 ± 5 kg/m² for SG; 74 ± 5 kg/m² for RYGB). The median postoperative follow-up was 13 months for AGB (10–22 mo), 18 for SG (6–28 mo), and 15 for RYGB (6–24 mo). Patients undergoing RYGB and SG exhibited the greatest postoperative total body weight loss (35 ± 13% and 31 ± 15%, respectively; P = .14), which led to postoperative BMIs of 48 ± 10 kg/m² and 51 ± 11 kg/m², respectively (P = .14). All procedures conferred a reduction in the incidence of co-morbidities, including type 2 diabetes, and led to improved functional statuses. The overall complication rate was 7%, with 3 deaths (1%) within 30 days of surgery.ConclusionThis study found that primary BMS in patients with a BMI >70kg/m² has an acceptable safety profile and is associated with good medium-term clinical outcomes. RYGB and SG are associated with better weight loss and great improvements in co-morbidities than AGB. Given the noninferiority of SG outcomes and SG’s potential for further conversion to other BMS procedures if required, SG may be the best choice for primary BMS in patients with extreme obesity.     

Weight loss and effect on co-morbidities in the long-term after duodenal switch and gastric bypass: a population-based cohort study

BackgroundUnsatisfactory weight loss is common after bariatric surgery in patients with super obesity (body mass index [BMI] ≥50 kg/m²). Unfortunately, this group of patients is increasing worldwide.ObjectiveThe aim of this study was to compare long-term weight loss and effect on co-morbidities after duodenal switch (DS) and gastric bypass (RYGB) in super-obese patients.SettingUniversity hospital, Sweden, national cohort.MethodsThis observational population-based cohort-study of primary DS and RYGB (BMI ≥48 kg/m²) in Sweden from 2007 to 2017 used data from 4 national registers. Baseline characteristics were used for propensity score matching (1 DS:4 RYGB). Weight loss was analyzed up until 5 years after surgery. Medication for diabetes, hypertension, dyslipidemia, depression, and pain were analyzed up until 10 years after surgery.ResultsThe study population consisted of 333 DS and 1332 RYGB, with 60.7% females averaging 38.5 years old and BMI 55.0 kg/m² at baseline. DS resulted in a lower BMI at 5 years compared with RYGB, 32.2 ± 5.5 and 37.8 ± 7.3, respectively, (P < .01). DS reduced prevalence of diabetes and hypertension more than RYGB, while reduction in dyslipidemia was similar for both groups, during the 10-year follow-up. Both groups increased their use of antidepressants and a maintained a high use of opioids.ConclusionThis study indicates that super-obese patients have more favorable outcomes regarding weight loss and effect on diabetes and hypertension, after DS compared with RYGB.     

Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index

BackgroundThe current National Institutes of Health guidelines have recommended bariatric surgery for patients with a body mass index (BMI) >40 kg/m² or BMI >35 kg/m² with significant co-morbidities. However, some preliminary studies have shown that patients with a BMI that does not meet these criteria could also experience similar weight loss and the benefits associated with it.MethodsAn institutional review board-approved protocol was obtained to study the effectiveness of laparoscopic adjustable gastric banding in patients with a low BMI. A total of 66 patients with a BMI of 30–35 kg/m² and co-morbidities (n = 22) or a BMI of 35–40 kg/m² without co-morbidities (n = 44) underwent laparoscopic adjustable gastric banding. These patients were compared with 438 standard patients who had undergone laparoscopic adjustable gastric banding who met the National Institutes of Health criteria for bariatric surgery. The excess weight loss at 3, 6, 12, and 18 months and the status of their co-morbidities were compared between the 2 groups.ResultsThe average BMI for the study group was 36.1 ± 2.6 kg/m² compared with 46.0 ± 7.3 kg/m² for the control group. Both groups had significant co-morbidities, including hypertension, diabetes, hyperlipidemia, arthritis, gastroesophageal reflux disease, stress incontinence, and obstructive sleep apnea. The mean percentage of excess weight loss was 20.3% ± 9.0%, 28.5% ± 14.0%, 44.7% ± 19.3%, and 42.2% ± 33.7% at 3, 6, 12, and 18 months, respectively. This was not significantly different from the excess weight loss in the control group, except for at 12 months. Both groups showed similar improvement of most co-morbidities.ConclusionModerately obese patients whose BMI is less than the current guidelines for bariatric surgery will have similar weight loss and associated benefits. Laparoscopic adjustable gastric banding is a safe and effective treatment for patients with a BMI of 30–35 kg/m².     

Quality of life and predictive factors for complications in patients undergoing abdominoplasty after gastric bypass: A retrospective cohort

BackgroundObesity is a major health risk factor associated with medical complications, such as cardiovascular disease, that may compromise outcomes. Furthermore, obesity may lead to difficulties in daily life, altering the quality of life and generating psychological disorders such as devalued self-image and depression.ObjectivesThis study evaluated the quality of life and predictive factors of postoperative complications in patients who underwent abdominoplasty after Roux-en-Y gastric bypass.SettingBariatric and postbariatric center, North Wing Regional Hospital, Brasília, Brazil.MethodsData were analyzed from a prospective registry of postbariatric patients who underwent abdominoplasty from January 2011 to December 2016. Variables examined included age, sex, body mass index (BMI), complications, and comorbidities. Multivariate analyses were performed to assess outcome measures. The quality-of-life assessment was measured with the Moorehead-Ardelt quality-of-life questionnaire.ResultsOne hundred and seven postbariatric patients were included. The mean age of the patients was 41 years. BMI at the time of abdominoplasty (current BMI) was 27.6 ± 3.7 kg/m², and the average weight loss before abdominoplasty was 47.7 ± 17.3 kg. Pre-weight loss BMI (max BMI) was 45.5 ± 7.6 kg/m², and ?BMI was 18.6 ± 9.3 kg/m². The overall rate of complications was 23.4%. Among the studied factors in the multivariate analysis, amount of removed tissue in the abdomen >2000 g, ?BMI >20 kg/m², and age >40 years significantly increased the rates of postoperative complications. In our study, abdominoplasty improved the quality of life of patients (mean quality-of-life scores, 2.1 ± 0.9).ConclusionThe amount of removed tissue in the abdomen, ?BMI >20 kg/m², and age >40 years led to significantly more complications in patients undergoing abdominoplasty after gastroplasty. In addition, this study demonstrated that abdominoplasty should be proposed to patients with massive weight loss to improve quality of life.     

Use of phentermine-topiramate extended release in combination with sleeve gastrectomy in patients with BMI 50 kg/m2 or more

BackgroundSuper obesity (body mass index [BMI] ≥50 kg/m²) treatment can be complicated and high risk.ObjectivesWe studied whether the pre and postoperative use of phentermine and topiramate (phen/top) combined with laparoscopic sleeve gastrectomy (LSG) in super obesity increases the odds of achieving a BMI <40 at 2 years postoperatively.SettingAcademic medical center in Winston Salem, North Carolina.MethodsWe recruited patients between 2014 and 2016 who had a BMI ≥50 and planned to undergo LSG (n = 25) to participate in an open-label trial. Participants took phen/top (7.5/46–15/92 mg/d) for at least 3 months preoperatively and 2 years postoperatively. We compared weight loss, BMI changes, and odds for achieving BMI <40 for phen/top + LSG to historical controls. Controls had an initial BMI ≥50 and underwent LSG, without phen/top, at our center during the same timeframe (n = 40).ResultsOf the 25 participants recruited, 13 completed LSG. Phen/top participants had a baseline BMI of 61.2 ± 7.1 kg/m² compared with 57.0 ± 5.6 kg/m² for control participants. Percent initial weight loss was –39.3% (phen/top + LSG) versus –31.4% (control) at 12 months, P = .018; by 24 months, phen/top + LSG had an 11.2% greater initial weight loss, P = .007. At 24 months, the mean BMI was 33.8 kg/m² for phen/top versus 42 kg/m² for controls. The odds ratio for achieving a BMI <40 at 2 years with phen/top + LSG versus LSG alone was 4.1 (95% confidence interval, 0.8–21).ConclusionsCompared with LSG alone, phen/top combined with LSG may help patients with a BMI >50 achieve greater weight loss and reach a BMI <40. Long-term, controlled trials are needed to follow up these results.     

Laparoscopic bariatric surgery for those with body mass index of 70–125 kg/m2

BackgroundData on laparoscopic bariatric surgery in the extremely obese are limited. Technical difficulties, in addition to the patients' severe weight-related co-morbidities, can compromise the safety of bariatric surgery in these patients. Our objectives were to assess the safety and feasibility of laparoscopic bariatric surgery in extremely obese patients and to compare the outcomes of different surgical approaches at a bariatric surgery center of excellence in an academic medical center.MethodsWe reviewed our prospectively collected database and identified all patients with a body mass index (BMI) of ≥70 kg/m² who had undergone bariatric surgery. The data on patient demographics, baseline characteristics, and outcomes of bariatric surgery were retrieved.ResultsA total of 49 patients with a mean BMI of 80.7 kg/m² (range 70–125) underwent 61 bariatric procedures. Of the 49 patients, 26 underwent sleeve gastrectomy, 11 gastric bypass, and 12 underwent a 2-stage procedure (sleeve gastrectomy followed by gastric bypass). At a mean follow-up of 17.4 months, the average BMI had decreased to 60.9 kg/m² (36% excess weight loss). Overall, the patients who underwent a 2-stage procedure achieved greater percentage of excess weight loss (54.5%) than did those who underwent either single-stage sleeve gastrectomy or gastric bypass (25.4%, P = .002 and 43.8%, P = .519, respectively). Of the 61 cases, 60 (98.4%) were completed laparoscopically. The early complication rate was 16.4% overall; most were minor complications. The late complication rate was 14.8%. A single late mortality occurred in this series.ConclusionLaparoscopic bariatric surgery can be performed safely on patients with a BMI of ≥70 kg/m². A staged approach might offer better weight loss results.     

Long-Term Outcomes of Laparoscopic Adjustable Silicone Gastric Banding (LAGB) in Moderately Obese Patients With and Without Co-morbidities

Background

Overweight and obesity independently increase cardiovascular risk, while even modest weight loss can result in clinically significant improvements in cardiovascular risk and reduce long-term mortality. Lowering the body mass index (BMI) threshold for bariatric surgery to those with moderate obesity might be one way to lower the burden of this disease. The aim of this study was to evaluate the efficacy and safety of laparoscopic adjustable silicone gastric banding (LAGB) in moderately obese subjects with or without obesity-related co-morbidities.

Methods

Thirty-four patients with BMI between 30 and 35 kg/m² (5 males/29 females, mean age 36?±?10 years, mean preoperative weight 87.9?±?7.1 kg, mean BMI 32.6?±?1.6 kg/m² and mean percentage excess weight 48.7 ± 9 %) who underwent LAGB via pars flaccida between June 1, 2002 and August 31, 2010 were included. Good response was defined as BMI <30 kg/m² or percentage estimated weight loss (%EWL) >50. Poor response was defined as BMI >30 kg/m² or %EWL less than 50 after a minimum of 1 year.

Results

Mean weight, BMI and %EWL were recorded at 1, 3, 5 and 7 years and were 77.4?±?7.6, 69.9?±?10.8, 70.9?±?9.3 and 73.3?±?12.0 kg; 28.8?±?2.9, 26.4?±?3.2, 26.5?±?3.4 and 27.4?±?5.0 kg/m²; and 36?±?23, 46.1?±?33.8, 58.6?±?31.5 and 45?±?57, respectively (p?<?0.01). Co-morbidities were diagnosed in 17/34 (50 %) patients at baseline and underwent remission or improvement in all cases after 1 year.

Conclusions

LAGB in a safe and effective procedure in patients with a BMI <35 kg/m².     

Is biliopancreatic diversion with duodenal switch indicated for patients with body mass index <50 kg/m2?

BackgroundBiliopancreatic diversion with duodenal switch (DS) has been the standard surgical approach for the treatment of morbidly obese patients at our institution since the early 1990s. The published data, however, have shown the use of the DS to be limited to the treatment of super-morbidly obese patients (body mass index [BMI] ≥50 kg/m²). The aim of the present study was to present our long-term results with the DS in patients with an initial BMI of <50 kg/m².MethodsThis was a retrospective study of all patients with a BMI <50 kg/m² who had undergone DS from June 1992 to May 2005. The data are reported as the mean ± standard deviation.ResultsThe data from 810 consecutive patients, with a mean initial BMI of 44.2 ± 3.6 kg/m², were reviewed. The mean follow-up was 103 ± 49 months. Major perioperative complications occurred in 5.8% of patients, including 5 deaths (.6%). The initial excess weight loss was 76% ± 22%, and the excess weight loss was >50% in 89% of patients. Malnutrition required readmission in 4.3% and surgical revision in 1.5%. The prevalence of severe albumin deficiency (<30 g/L) was 1.1%, hemoglobin deficiency (<100 g/L), 1.6%, iron deficiency (<4 mmol/L) 2.1%, and calcium deficiency (<2 g/L) 3%. The percentage of patients “very satisfied” with the global result was 91%, and 37% would have preferred to lose more weight.ConclusionThese results showed that in non super-obese patients, DS was very efficient in terms of weight loss and patient satisfaction. This was associated with a 1.5% risk of revision for malnutrition. However, nutritional deficiencies required frequent readjustment of supplements, particularly for calcium, vitamin A, and vitamin D.     

Medium-term outcomes of converting laparoscopic adjustable gastric band to Roux-en-Y gastric bypass in patients with body mass index <35 kg/m2: a uniquely Australian perspective

BackgroundThe rates of primary laparoscopic adjustable gastric banding (LAGB) have declined in the last 5 years due to band removal secondary to complications and the subsequent weight regain that requires revisional procedures.ObjectivesThis study aimed to present medium-term weight loss results and the safety profile of converting LAGB to Roux-en-Y gastric bypass in patients with body mass index (BMI) <35.0 kg/m² who presented with LAGB intolerance or complications. Many health services do not permit such procedures on low BMI patients.SettingsSingle-surgeon series, including public and private practice, Brisbane, Australia.MethodA prospectively maintained database was reviewed and retrospectively analyzed for LAGB patients with a BMI <35.0 kg/m² who underwent conversion to Roux-en-Y gastric bypass by a single surgeon. Indications for conversion, weight loss data, and early (30 d postoperative) and late complications were recorded with follow-up out to 5 years.ResultsOne hundred thirty-two adult patients with a BMI <35.0 kg/m² underwent conversion from 2009 to 2016. The main indications for conversion were reflux and band complications. Median BMI at bypass was 32.8 kg/m² (23.1–35.0). Median percentage excess weight loss was 77%, 90%, 73%, 47%, 49%, and 44% at 1, 2, 3, 4, and 5 years, respectively among patients who were eligible and present at follow-up. Median BMI was <30.0 kg/m² (29.1–40.9) at 5 years with only 1 subject exceeding >35.0 kg/m². Mortality was 0%. Early morbidity occurred in 31.8% of patients. The most common late complication was gastrojejunostomy stricture requiring endoscopic dilation.ConclusionsIn combination with our 2014 study showing morbidity data in the short-term period being comparable to patients with BMI >35.0 kg/m², our study demonstrates that converting LABG to Roux-en-Y gastric bypass in low BMI patients is a feasible and safe option that avoids weight regain and maintains adequate weight loss at 5 years, with acceptable morbidity and no mortality.     

Patterns of surgical weight loss and resolution of metabolic abnormalities in superobese bariatric adolescents

PurposeThe aim of the study was to compare the baseline and the 18-month follow-up for weight and metabolic characteristics of superobese (SO) (body mass index [BMI] ≥50 kg/m²) and morbidly obese (MO) (BMI <50 kg/m²) adolescents who participated in a prospective longitudinal study of gastric banding delivered in an adolescent multidisciplinary treatment program.MethodsClinical information was extracted from an institutional review board–approved database of bariatric adolescents. Fasting cytokine and acute phase protein serum levels were analyzed by enzyme-linked immunosorbent assay. Liver histopathologies were assessed using the Kleiner's classification score.ResultsOther than BMI, MO (n = 11) and SO (n = 7) patients have similar degree of insulin resistance, dyslipidemia, and nonalcoholic fatty liver disease. Serum C-reactive protein (10.2 ± 5.6 SO vs 4 ± 3.9 μg/mL MO [P < .02]) and leptin (71 ± 31 SO vs 45 ± 28 MO ng/mL [P = .04]) were more elevated in SO patients. Although weight loss is similar (30 ± 19 kg MO vs 28 ± 12 kg SO, P = .8 at 18 months; mean percent change in BMI, 22.8% ± 11.6% vs 20.5% ± 10.3% SO, P = .2), SO patients has less resolution of insulin resistance and dyslipidemia but experienced significantly improved health-related quality of life.ConclusionsThe SO adolescents demonstrate equivalent short-term weight loss and improved quality of life but delayed metabolic response to a gastric banding–based weight loss treatment program compared with MO patients, illustrating the importance of early referral for timely intervention of MO patients.     

Short- to medium-term results of single-anastomosis duodeno-ileal bypass compared with one-anastomosis gastric bypass for weight recidivism after laparoscopic sleeve gastrectomy

BackgroundSingle-anastomosis duodeno-ileal bypass (SADI) and the one-anastomosis gastric bypass (OAGB) are 2 revisional procedures to address the problem of weight recidivism after laparoscopic sleeve gastrectomy (LSG).ObjectivesTo evaluate the efficacy and safety of SADI and OAGB as revisional bariatric surgery (RBS) in initially super-obese patients (body mass index [BMI] >50 kg/m²).SettingAcademic hospital, bariatric center of excellence, Germany.MethodsObservational study of outcomes in 84 initially super-obese patients who had undergone RBS after LSG (SADI n = 42, OAGB n = 42) between July 2013 and April 2018. Follow-up examinations were performed at 1, 6, 12, 24, and 36 months after RBS. The variables analyzed included time between LSG and RBS, BMI, excess weight loss, total weight loss, operation time, and complications.ResultsThe time interval between LSG and RBS was 45.5 ± 22.8 and 43.5 ± 24.2 months for SADI and OAGB, respectively. At the time of RBS, the mean BMI was 42.8 ± 7.9 kg/m² for SADI and 43.4 ± 9.2 kg/m² for OAGB. The follow-up examinations rates (%) after SADI were 97.6, 92.8, 90.5, 78.6, 57.1, and 100, 97.6, 95.2, 85.7, and 59.5 after OAGB. The BMI at the follow-up examinations were 39.1 ± 7.2, 34.2 ± 6.9, 31.2 ± 5.8, 30.2 ± 5.3, 29.3 ± 5.1 for SADI, and 39.5 ± 8.1, 36.6 ± 7.4, 34.7 ± 7.9, 32.9 ± 6.3, and 31.6 ± 5.9 for OAGB. The mean operating times for SADI and OAGB were 138 ± 40 and 123 ± 39 minutes, respectively. Three patients in the SADI group and 1 patient in the OAGB group developed a major complication within the first 30 postoperative days.ConclusionSADI and OAGB were effective second-step procedures for further weight reduction after LSG in initially super-obese patients after short to medium follow-up. There was a trend toward higher weight loss for SADI though this did not reach statistical significance. Substantial differences concerning surgery time and complications between the 2 procedures were not observed.     

Analysis of factors associated with durable remission of diabetes after Roux-en-Y gastric bypass

BackgroundData on the durability of remission of type 2 diabetes mellitus (T2DM) after gastric bypass are limited. Our purpose was to identify the rate of long-term remission of T2DM and the factors associated with durable remission.MethodsA total of 177 patients with T2DM who had undergone Roux-en-Y gastric bypass from 1993 to 2003 had 5-year follow-up data available. T2DM status was determined by interview and evaluation of the diabetic medications. Patients with complete remission or recurrence of T2DM were identified.ResultsFollow-up ranged from 5 to 16 years. Of the 177 patients, 157 (89%) had complete remission of T2DM with a decrease in their mean body mass index from baseline (50.2 ± 8.2 kg/m²) to 31.3 ± 7.2 kg/m² postoperatively (mean percentage of excess weight loss 70.0% ± 18.6%). However, 20 patients (11.3%) did not have T2DM remission despite a mean percentage of excess weight loss of 58.2% ± 12.3% (P <.0009). Of the 157 patients with initial remission of their T2DM, 68 (43%) subsequently developed T2DM recurrence. Remission of T2DM was durable in 56.9%. Durable (>5-year) resolution of T2DM was greatest in the patients who originally had either controlled their T2DM with diet (76%) or oral hypoglycemic agents (66%). The rate of T2DM remission was more likely to be durable in men (P = .00381). Weight regain was a statistically significant, but weak predictor, of T2DM recurrence.ConclusionEarly remission of T2DM occurred in 89% of patients after Roux-en-Y gastric bypass. T2DM recurred in 43.1%. Durable remission correlated most closely with an early disease stage at gastric bypass.     

Systematic review of laparoscopic adjustable gastric banding in patients with body mass index ≤35 kg/m2

BackgroundRecently, the Food and Drug Administration (FDA) panel approved laparoscopic adjustable gastric banding (LAGB) in patients with a body mass index (BMI) ≥30 kg/m² and related co-morbidities. To our knowledge there is no systematic review assessing LAGB in this group. The objective of this study was to analyze the use of LAGB in patients with BMI ≤35 kg/m².MethodsThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to systematically search MEDLINE and Embase using the medical subject headings (MeSH) terms “bariatric surgery” and “obese” with equivalent free text searches and cross-references. Studies that described LAGB in patients with BMI ≤35 kg/m² were reviewed with particular focus on weight loss after LAGB as well as morbidity/mortality, co-morbidity resolution.ResultsSix studies evaluating 515 patients were included. Mean percentage excess weight loss (%EWL) ranged from 52.5 (±13.2) to 78.6 (±9.4) at 1 year and 57.6 (±29.3) to 87.2 (±9.5) at 2 years postoperatively. Two studies reported weight loss at 3 years with mean %EWL of 53.8 (±32.8) to 64.7 (±12.2). The only study with follow-up data after 3 years reported a mean %EWL of 68.8 (±15.3) and 71.9 (±10.7) at 4 and 5 years, respectively. Thirty-four patients (6.6%) developed complications. There was 1 reported mortality (.19%), which occurred at 20 months postoperatively.ConclusionThis systematic review shows that LAGB is well tolerated and effective in patients with a BMI ≤35 kg/m². There are encouraging suggestions that co-morbidities show partial or total resolution; however, a paucity of data remains in this BMI group, particularly with regard to long-term outcomes.     

Long-or short-limb gastric bypass?

The aim of this study was to determine whether longer limb length improved results of gastric bypass in patients who were morbidly obese (body mass index <50 kg/m²) or superobese (body mass index >50 kg/m²). A total of 242 patients were followed for a mean of 5.5 years. The standard operation was a Roux-en-Y gastric bypass with a 40 cm Roux limb and a 10 cm afferent limb. The long-limb operation had a 100 cm Roux limb and a 100 cm afferent limb. Morbidly obese patients did not benefit from a long-limb bypass. The final body mass index was 28.6 ±4.7 kg/m² in the short-limb group and 28.5 ± 3.8 kg/m² in the long-limb group. The superobese patients did benefit from a long-limb bypass. Final body mass index was 35.8 ±6.7 kg/m² in the short-limb patients and 32.7 ±5.1 in the long-limb patients (P = 0.049). A subgroup of 20 patients, all of whom had a body mass index greater than 60 kg/m², benefited the most from long-limb bypass. No macronutritional side effects unique to the long-limb bypass were encountered.     

Increased Serum Amyloid A Concentrations in Morbid Obesity Decrease after Gastric Bypass

Background: Obesity is considered a state of low-grade chronic inflammation, which may favor the development of cardiovascular diseases. Serum amyloid A (SAA) is an acute phase protein synthesized in response to infection, inflammation, injury, and stress. The aim of the present study was to compare the circulating concentrations of SAA and the mRNA expression in omental adipose tissue between lean and obese individuals and to analyze the effect of weight loss after gastric bypass. Methods: 16 lean volunteers (BMI 20.5 ± 0.6 kg/m²) and 24 obese patients (BMI 47.0 ± 1.2 kg/m²) were included in the study. Serum concentrations of SAA were measured by ELISA. In addition, the concentrations of SAA in 18 morbidly obese patients (7 male/11 female; BMI 44.6 ± 1.9 kg/m²) were measured before and after weight loss following Roux-en-Y gastric bypass (RYGBP). SAA expression in omental adipose tissue was quantified by RT-PCR in biopsies from obese patients undergoing RYGBP and from age-matched lean individuals subjected to Nissen fundoplication. Results: Obese patients exhibited significantly increased circulating SAA concentrations (6.6 ± 0.5 vs 39.3 ± 9.1 μg/ml; P<0.01) compared to lean subjects. A significant positive correlation was found between logSAA and body fat (r=0.631, P<0.0001). Obese patients showed significantly increased (P<0.05) mRNA expression of SAA in omental adipose tissue compared to lean subjects. Weight loss significantly decreased SAA concentrations after RYGBP (final BMI 28.5 ± 0.9 kg/m², P<0.0001 vs initial) from 47.5 ± 14.5 to 15.7 ± 2.9 μg/ml (P<0.05). Conclusion: It can be concluded that serum SAA and mRNA expression of SAA in omental adipose tissue are increased in obese patients contributing to the obesity-associated cardiovascular disease risk. Moreover, weight loss reduces SAA concentrations, which may contribute to the beneficial effects accompanying weight reduction.     

Pretransplant BMI Should Be <25 in Japanese Kidney Transplant Recipients: A Single-Center Experience

BackgroundThe aim of this study was to determine the appropriate body mass index (BMI) in Japanese kidney transplant (KTx) recipients. We analyzed the effects of pre- and post-transplant (Tx) obesity on graft and patient survival, perioperative complications, post-transplant diabetes mellitus (PTDM), and cardiovascular disease (CVD) in Japanese KTx recipients.MethodsThis retrospective study included 269 recipients who underwent KTx from 2008 through 2020 at Niigata University Hospital. Obesity was defined as a body mass index (BMI) ≥25 kg/m². We examined the association between pre- and post-Tx obesity and graft survival, patient survival, the incidence of PTDM and CVD, and perioperative surgical complications.ResultsThe graft survival rate was lower in the pre-Tx BMI ≥25 kg/m² group, although there was no significant difference in patient survival. There was no difference in graft and patient survival between the post-Tx BMI ≥25 kg/m² group and the <25 kg/m² group. A pre-Tx BMI ≥25 kg/m² was an independent risk factor for biopsy-proven allograft rejection. New-onset DM after transplantation was significantly more common in the BMI ≥25 kg/m² group than in the BMI <25 kg/m² group (36% vs 13%; P = .002). The incidence of CVD was significantly higher in the post-Tx BMI ≥30 kg/m² group than in the BMI <30 kg/m² group (50% vs 11%; P = .023). There were no differences in surgical operating time, intraoperative blood loss, or perioperative complications between the obese and non-obese groups.ConclusionPre-Tx BMI ≥25 kg/m² may be a risk factor for allograft rejection and graft loss. Post-Tx BMI should be <25 kg/m² to reduce the risk for PTDM.