Predictive Factors for Insufficient Weight Loss After Bariatric Surgery: Does Obstructive Sleep Apnea Influence Weight Loss?

Background

Important endpoints of bariatric surgery are weight loss and improvement of comorbidities, of which obstructive sleep apnea (OSA) is the highest accompanying comorbidity (70 %). This study aimed to evaluate the influence of OSA on weight loss after bariatric surgery and to provide predictive factors for insufficient weight loss (defined as ≤50 % excess weight loss (EWL)) at 1 year follow-up.

Methods

All consecutive patients, who underwent primary laparoscopic Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy between 2006 and 2014 were retrospectively reviewed. Patients with data on preoperative apnea-hypopnea index (AHI) and pre- and postoperative body mass index (BMI) were included. After surgery, the percentage excess weight loss (%EWL) and BMI changes were compared between preoperatively diagnosed OSA-, subdivided in mild, moderate, and severe OSA, and non-OSA patients. Multivariable logistic regression analysis evaluated predictive factors for ≤50 % EWL.

Results

A total of 816 patients, 522 (64 %) with and 294 (36 %) without OSA, were included. After 1 year, OSA patients achieved less %EWL than non-OSA patients (65.5 SD 20.7 versus 70.3 SD 21.0; p?<?0.01). The lowest %EWL was seen in severe OSA patients (61.7 SD 20.2). However, when adjusted for waist circumference, BMI, and age, no effect of OSA was seen on %EWL or changes in BMI. Although AHI, gender, age, BMI, type of surgery, and type II diabetes were predictive factors for ≤50 % EWL (area under the curve 0.778), the AHI as variable was of little importance.

Conclusions

The presence of OSA does not individually impair weight loss after bariatric surgery.

     

Is Bariatric Surgery Necessary after Intragastric Balloon Treatment?

Background: The use of the Bio-Enterics intra-gastric balloon (BIB) has been shown to be a safe and effective procedure for the temporary treatment of morbid obesity. We conducted a retrospective comparative analysis of the weight loss in patients that after BIB removal underwent bariatric surgery and those who did not wish surgery. Methods: From January 2000 to March 2004, 182 BIBs were positioned in 175 patients (104 F / 71 M; mean age 37.1±11.6 years, range 16-67; mean BMI 54.4 ± 8.1 kg/m², range 39.8-79.5; mean %EW 160.8±32.9% range 89-264). Patients were excluded from this study who had emergency BIB removal for balloon rupture (n=2, 1.1%) and for psychological intolerance (n=7, 7.8%). All patients were scheduled for a bariatric operation, before BIB positioning. After BIB removal, a number of patients now declined surgery. Consequently, patients were allocated into 2 groups: Group A in whom BIB removal was followed by bariatric surgery (Lap-Band^?, laparoscopic gastric bypass, duodenal switch) (n=86); Group B patients who after BIB removal refused any surgical procedure (n=82). Both groups were followed for a minimum of 12 months. Results were reported as mean BMI and %EWL ± SD. Statistical analysis was done by Student t-test or Fisher's exact test, with P<0.05 considered significant. Results: Mean BMI and mean %EWL in the 166 patients at time of removal were 47.3 ± 8.1 kg/m² and 32.1±16.6%, respectively. At the same time, mean BMI was 47.6±6.9 and 48.1±6.5 kg/m² in group A and B (P=NS). At 12 months follow-up (100%), mean BMI was 35.1 kg/m² in Group A (BIB + surgery) and 51.7 kg/m² in Group B (BIB alone) (P<0.001). Conclusions: After BIB removal, half (49.4%) of the patients scheduled for surgery refused a bariatric operation. These patients returned to their mean initial weight at 12 months follow-up. Therefore, bariatric surgery after BIB removal is highly recommended.     

What Is My Goal? Expected Weight Loss and Comorbidity Outcomes Among Bariatric Surgery Patients

Background  

A number of reasons lead patients to choose to undergo weight loss procedures. Previous studies have demonstrated that patients have unrealistic weight loss goals. However, there is a general paucity of information on a patient’s expectations in regards to comorbidity improvement and resolution. The purpose of this study is to examine the impact a patient’s comorbid conditions have on the motivation to proceed with bariatric surgery. Furthermore, we examined the patient’s expectations regarding postoperative weight loss and comorbidity improvement.     

Adherence and Weight Loss Outcomes in Bariatric Surgery: Does Cognitive Function Play a Role?

Although bariatric surgery is the most effective intervention for severe obesity, a significant minority of participants fail to achieve or maintain optimal weight loss at extended follow-up. Accumulating evidence suggests that adherence to prescribed postoperative recommendations, including attendance at follow-up appointments and dietary and physical activity, is related to improved weight loss outcomes. However, adherence to these guidelines presents a significant challenge for many patients, potentially due in part to deficits in cognitive function. In this paper, we briefly examine current literature of adherence on postoperative weight loss outcomes, and review emerging evidence that the cognitive dysfunction present in a subset of obese individuals is related to weight loss outcomes following bariatric procedures. We then extend these findings, positing a role for cognitive function in moderating the relationship between adherence and postoperative outcomes.     

Does Exercise Improve Weight Loss after Bariatric Surgery? A Systematic Review

Bariatric surgery leads to significant weight loss in the obese patient. Exercise has been shown to improve weight loss and body composition in non-surgical weight loss programmes. The role of exercise to improve weight loss following bariatric surgery is unclear. The objective of this review is to systematically appraise the evidence regarding exercise for weight loss in the treatment of obesity in bariatric surgery patients. MEDLINE, AMED, CINAHL, EBM Reviews (Cochrane Database, Cochrane Clinical Trials Register) were searched, obesity-related journals were hand-searched and reference lists checked. Studies containing post-surgical patients and exercise were included with the primary outcome of interest being weight loss. A literature search identified 17 publications exploring exercise in bariatric surgery patients. All studies were observational; there were no intervention studies found. The most commonly used instruments to measure activity level were questionnaires followed by telephone interview, surgeon reporting and clinical notes. There was a positive relationship between increased exercise and weight loss after surgery in 15 studies. Meta-analysis demonstrated in patients participating in exercise a standardised mean of 3.62 kg (CI = 1.28, 5.96) greater weight loss compared to the minimal exercise groups. Observational studies suggest that exercise is associated with greater weight loss following bariatric surgery. Randomised controlled trials are required to further examine this relationship.     

Success in Surgical Intervention for Morbid Obesity: Is Weight Loss Enough?

Varieties of gastric surgery have increasingly been used in the management of morbid obesity. Generally, however, research and commentary in this area have related to surgical technique, with weight loss or morbidity being regarded as the most important dependent measures. In the context of the publication of several papers relating to the effects of surgery in the long-term, we believe that it is timely for surgeons to examine their criteria for success. In this paper, we argue that weight loss is inadequate as a primary criterion for success in this context, and that the value of the intervention should be measured against a multidimensional concept of success.     

Pre-operative Predictors of Weight Loss at 1-Year after Lap-Band® Surgery

Background: The authors studied a range of preoperative factors for their predictive value of effectivenes of Lap-Band? placement, using the percentage of excess weight loss at 1-year as the outcome measure (%EWL1). Methods: All factors were measured and recorded prior to surgery. Factors included: patient demographics, family, medical and weight history. Laboratory measures and the responses to the SF36 Health Survey were also assessed. Factors were assessed for correlation with %EWL1. Results: The group (N=440, F:M 383:57) had mean age 40.0 ± 9.5 years, weight of 126 ± 25 kg, and BMI 45.6 ± 7.5 kg/m2 pre-operatively. At 1-year follow-up, the group had mean weight 97.6 ± 20 kg, BMI 35.6 ± 6.3 kg/m2, and %EWL1 45.8 ± 17%. Increasing age (R=-0.13, p<0.01) and preoperative BMI (R=-0.22, p<0.001) were significantly associated with less %EWL1 and all other factors were controlled for these before assessing significance. Important factors associated with a lower %EWL1 included: hyperinsulinemia (R=-0.36, p<0.001), insulin resistance (R=-0.33, p<0.001) and disease associated with insulin resistance, poor physical ability, pain, and poor general health responses to the SF-36 Health Survey. Patients who consumed alcohol regularly had a better rate of weight loss (R= 0.23, p<0.005). Factors that had no influence included gender, a history of mental illness and measures of mental health, previous bariatric surgery, and a history of many medical conditions associated with obesity. Conclusion: Important physical factors have been found to influence the rate of weight loss.Those with increased age, pain, physical disability and insulin resistance have a great deal to gain from weight loss. Although this study has identified factors that are associated with less weight loss, we have not found any factor that predicts an unacceptably low weight loss and thus provides a contraindication to Lap-Band? placement. The findings of this study allow us to set more realistic goals for the rate of weight loss in specified sub-groups of our patients.     

DaVinci® Robotic-Assisted Laparoscopic Bariatric Surgery: Is it Justified in a Routine Setting?

Background: Laparoscopic silicone adjustable gastric banding (SAGB) has gained popularity for the surgical treatment of morbid obesity. The implantable gastric stimulator (IGS?) system represents a novel surgical alternative. We aimed to assess the feasibility of robotic-assisted laparoscopic bariatric operations and to critically elucidate the technical and financial advantages and patient outcome. Methods: Robotic-assisted laparoscopic bariatric procedures were performed on 10 consecutive patients using the daVinci? robot system (4 SAGB, 4 IGS?, 2 SAGB revisions). 10 conventional laparoscopic-operated patients (4 SAGB, 4 IGS?, 2 SAGB revisions) during the learning curve served as controls. Equipment, operative technique and procedural time were evaluated. A cost analysis was calculated. Results: The personnel equipment, numbers of trocars and operation technique were comparable in both groups. The mean operative time was 137 min (range 110-175) and 97 min (60-140) in robotic-assisted and conventional laparoscopy, respectively (P =0.04). Establishment of the pneumoperitoneum and placement of trocars and robotic arms took a mean of 30 min (15-45) in the robotic-assisted group, compared with 5 min in the control group (P <0.001). In 1 patient, intraoperative gastric injury was suspected and led to band removal in the robotic-assisted group. There was no postoperative complication. Average procedural costs were significantly higher in the robotic-assisted group. Conclusion: Primary and revisional robotic-assisted bariatric surgery is technically simple, with the benefit of precise instrument handling. However, it is still expensive, the set-up of the system is time-consuming, and a limited variety of instruments are available presently.     

Does Inadequate Weight Loss Following Bariatric Surgery Predict Staple-Line Failure? A Prospective Study

Background: This study was undertaken to determine if weight gain after gastroplasty corresponds with gastric staple-line failure. Methods: Over a 10-year period, 157 patients underwent gastric restrictive operations using 4-row staplers, and were prospectively evaluated at 1, 3, and 6 months, then yearly for 6 years thereafter. Patients who experienced weight gain or lost less than 10 lb (4.5 kg) of weight between visits while maintaining 30% or greater excess body weight, were evaluated for staple-line integrity with an upper gastrointestinal contrast study. Results: forty-three (27%) patients met the criteria for contrast study during follow-up. Fourteen (33%) of these patients experienced staple-line failure (9% of the entire population). Two-thirds of those patients with inadequate weight loss following surgery had intact staple-lines. Of those patients who had staple-line failure, male gender and reoperative gastric procedure were the most common characteristics. Of the staple-line breakdowns, 10% occurred after using 4-row TA-90 staplers and 6% following division and stapling with the GIA-80. Comorbidities and degree of failure did manifest as independent risk factors for staple-line failure. Conclusions: Inadequate weight loss following gastric restrictive procedures for morbid obesity does not accurately predict staple-line failure.     

Is Social Deprivation Associated with Weight Loss Outcomes Following Bariatric Surgery? A 10-Year Single Institutional Experience

Background

Social deprivation is associated with a greater morbidity and shorter life expectancy. This study evaluates differences in weight loss following bariatric surgery and deprivation, based on UK deprivation measures in a London bariatric centre.

Methods

All patients undergoing bariatric surgery between 2002 and 2012 were retrospectively identified. Demographic details, type of surgery and percentage excess weight loss data were collected. UK Index of Multiple Deprivation (IMD, 2010) and IMD domain of the Health Deprivation and Disability (HDD) scores were used to assess deprivation (where 1 is the most deprived in rank order and 32,482 is the least deprived). Two-way between-subjects analysis of variance (ANOVA) was performed to examine the effect of IMD score, deprivation, procedure type and gender on percentage excess weight loss.

Results

Data were included from 983 patients (178 male, 805 female) involving 3,663 patient episodes. Treatments comprised laparoscopic gastric bands (n?=?533), gastric bypass (n?=?362) and gastric balloons (n?=?88). The average percentage excess weight loss across all procedures was 38 % over a follow-up period (3 months–9 years). There was no correlation between weight loss and IMD/HDD rank scores. Gastric bypass was significantly more effective at achieving weight loss than the other two procedures at 3-, 6- and 9-month and 1-year follow-up.

Conclusions

Social deprivation does not influence weight loss after bariatric surgery, suggesting that all socioeconomic groups may equally benefit from surgical intervention. Social deprivation should not therefore negatively influence the decision for surgical intervention in these patients.     

Staging Laparoscopy for Hilar Cholangiocarcinoma: Is it Still Worthwhile?

Purpose  

This study was designed to evaluate the benefit of staging laparoscopy (SL) in patients with suspected hilar cholangiocarcinoma (HCCA) during the past 10 years. Only 50–60% of patients with HCCA who undergo laparotomy are ultimately amenable to a potentially curative resection. In a previous study, we recommended routine use of SL to prevent unnecessary laparotomies. The accuracy of imaging techniques, however, has significantly improved during the past decade, which is likely to impact the yield and accuracy of SL.     

The Intragastric Balloon – Smoothing the Path to Bariatric Surgery

Background: Intragastric balloon placement in association with diet for weight reduction is steadily gaining popularity. However, long-term follow-up studies on the effect of this method in maintaining weight loss are lacking. This study evaluated the long-term outcome following balloon removal in morbidly obese patients who had selected this method for weight loss. Methods: 140 morbidly obese patients who refused bariatric surgery because of fear of complications and mortality, underwent intragastric balloon placement and were followed over a 6- to 30-month period (mean 18.3 months) after balloon extraction. The 34 males and 106 females, with median age 38 years (range 16-62), median weight 122 kg (range 85-203), median BMI 42.3 kg/m² (range 35-61.3) and median excess weight (EW) 59 kg (range 29-132), received a Bioenterics Intragastric Balloon (BIB). Excess weight loss (EWL) ≥25% when the BIB was removed was considered a success. Weight fluctuations and any further interventional therapy requested by the patients after balloon removal were recorded. Results: 100 patients (71.4%) lost ≥25% of their EW on balloon extraction and were categorized as successes, while 40 patients (28.6%) did not achieve that weight loss and were categorized as failures of the method. During the follow-up period, 44 of the originally successful patients (31.4%) regained weight and were categorized as recurrences, while the remaining 56 patients (40%) maintained their EWL of ≥25% and were considered long-term successes. During follow-up, 45 patients (32.1%) requested and underwent bariatric surgery for their morbid obesity (21 Adjustable Gastric Band, 11 Laparoscopic Sleeve Gastrectomy, 13 Laparoscopic Gastric Bypass). Of these, 13 (32.5%) were from the group of 40 patients categorized as failures on BIB removal, 28 (63.6%) were from the group of 44 patients whose obesity recurred, and 4 (7.1%) were from the 56 patents who although they maintained successful weight loss requested further weight reduction. Conclusions: The BIB served as a first step and a smooth introduction to bariatric surgery for morbidly obese patients who initially refused surgical intervention. The incidence of surgical intervention was double in patients who initially experienced the benefits of weight loss and then had obesity recurrence, compared with patients in whom the method failed. Indeed, a significant number of patients were assisted in their efforts to lose and maintain an acceptable weight loss over a 6- to 30-month follow-up period.     

Is Ghrelin the Culprit for Weight Loss after Gastric Bypass Surgery? A Negative Answer

Background: Ghrelin is a potent appetite stimulator, mainly synthesized in the stomach. Paradoxically, obese subjects have lower plasma ghrelin than lean subjects and increase their weight in spite of low ghrelin levels. The role of ghrelin in weight regulation after bariatric surgery is still controversial. The aim of this study was to evaluate whether rapid weight loss after laparoscopic Roux-en-Y gastric bypass surgery (LRYGBP), was associated with changes in plasma ghrelin levels. In addition, we determined the acute impact of LRYGBP on insulin resistance and adiponectin levels. Methods: 49 morbidly obese subjects who underwent LRYGBP were studied. 19 subjects who underwent other laparoscopic gastrointestinal surgeries acted as the control group. Fasting plasma levels of ghrelin, insulin and adiponectin were determined preoperatively and 2 hours, 10 days and 6 months postoperatively. Results: At 2 hours after LRYGBP, there was a significant reduction in ghrelin and adiponectin levels, which coincided with elevated plasma glucose and insulin levels. Interestingly, once glucose and insulin levels normalized at 6 months after surgery, ghrelin also normalized. Adiponectin reached pre-surgical levels at 10 days after LRYGBP and continued to significantly rise until 6 months postoperatively. Conclusion: Weight loss after LRYGBP occurs in spite of the absence of significant changes in plasma ghrelin levels. Improvement of insulin resistance occurred within 10 days after surgery, and could be related to the normalization of adiponectin levels. This data questions the role of peripheral ghrelin as a cause of weight loss in obese humans after LRYGBP.     

The OTSC?-Clip in Revisional Endoscopy Against Weight Gain After Bariatric Gastric Bypass Surgery

The maintenance of the restrictive component of the Fobi pouch gastric bypass is essential for permanent weight control. Dilatation of the pouch-outlet and of the pouch itself is responsible for substantial weight gain by an increased volume per meal and binge-eating due to the rapid emptying. An endoscopic over-the-scope clip (OTSC?; Ovesco AG, Tübingen, Germany) was applied in 94 patients following gastric bypass and unintended weight gain by dilated gastro-jejunostomy to narrow the pouch-outlet. The OTSC?-clip application was safe and efficient to reduce the pouch-outlet in all cases. Best clinical results were obtained by narrowing the gastro-jejunostomy by placing two clips at opposite sites, hence reducing the outlet of more than 80%. Preferably, the clip approximated the whole thickness of the wall to avoid further dilatation of the anastomosis. Between surgery and OTSC?-clip application the mean BMI dropped from 45.8 (±3.6) to 32.8 (±1.9). At the first follow-up about 3 months (mean 118 days, ±46 days) after OTSC?-clip application the mean BMI was 29.7 (±1.8). At the second follow-up about 1 year (mean 352 days, ±66 days) after OTSC?-clip application the mean BMI was 27.4 (±3.8). The OTSC?-clip for revisional endoscopy after gastric bypass is reliable and effective in treating weight gain due to a dilated pouch-outlet with favorable short- and midterm results.