Fasting Plasma Ghrelin Concentrations 6 Months after Gastric Bypass are not Determined by Weight Loss or Changes in Insulinemia

Background: Ghrelin is a gastric peptide with potent orexigenic effects. Circulating ghrelin concentrations are increased in obese subjects, but increase after weight loss. However, in patients undergoing Roux-en-Y gastric bypass (RYGBP), a decrease in ghrelin levels has been reported. The effect of comparable weight loss induced by either adjustable gastric banding (AGB), RYGBP or conventional dietary treatment (Conv) on ghrelinemia was studied. Methods: 24 matched obese male patients in whom similar weight loss had been achieved by either AGB (n=8), RYGBP (n=8) or Conv (n=8) were studied before and 6 months after treatment start. The independence of ghrelin concentrations from body mass index (BMI) and weight loss was further analyzed in a group of patients with total gastrectomy (TtGx, n=6). Results: Comparable weight loss after 6 months exerted significantly different effects on plasma ghrelin concentrations, depending on the procedure applied (AGB: 424.6 ± 32.8 pg/ml; RYGBP: 131.4 ± 13.5; Conv: 457.3 ± 18.7; P<0.001). Without significant differences in body weight and BMI, patients who had undergone the RYGBP exhibited a statistically significant decrease in fasting ghrelin concentrations, while the other two procedures (AGB and Conv) showed a weight loss-induced increase in ghrelin levels. Despite significant differences in BMI between RYGBP and TtGx patients after 6 months (31.9 ± 2.2 vs 22.0 ± 0.7 kg/m², respectively; P<0.05), both groups showed similar ghrelin concentrations. Conclusion: The reduction in circulating ghrelin concentrations in RYGBP patients after 6 months of surgery are not determined by an active weight loss or an improved insulin-sensitivity but rather depend on the surgically-induced bypass of the ghrelin-producing cell population of the fundus.     

Comparison of Nutritional Consequences of Conventional Therapy of Obesity, Adjustable Gastric Banding, and Gastric Bypass

Background: Roux-en-Y gastric bypass (RYGBP) is more efficient than adjustable gastric banding (AGB) in weight loss and relieving co-morbidities, but nutritional complications of each surgical procedure have been poorly evaluated. Methods: A cross-sectional study was performed to compare nutritional parameters in 201 consecutive obese patients, who had been treated either by conventional behavioral and dietary therapy (CT, n=110) or by bariatric surgery, including 51 AGB and 40 RYGBP. Results: BMI was similar after AGB (36.6 ± 5.3 kg/m²) and RYGBP (35.4 ± 6.3 kg/m²), but patients in the RYGBP group had lost more weight and had less metabolic disturbances than those in the AGB group. On the other hand, the prevalence of nutritional deficits was significantly higher in the RYGBP group than in the 2 other groups (P <0.01), whereas the AGB group did not differ from CT. Particularly, the RYGBP group presented an unexpected high frequency of deficiencies in fat-soluble vitamins. Moreover, vitamin B₁₂, hemoglobin, plasma prealbumin and creatinine concentrations were low in the RYGBP group. Conclusion: RYGBP is more efficient than AGB in correcting obesity, but this operation is associated with a higher frequency of nutritional deficits that should be carefully monitored.     

Laparoscopic Bariatric Surgery in Super-obese Patients (BMI>50) is Safe and Effective: A Review of 332 Patients

Background: Bariatric surgery in super-obese patients (BMI >50 kg/m²) can be challenging because of difficulties in exposure of visceral fat, retracting the fatty liver, and strong torque applied to instruments, as well as existing co-morbidities. Methods: A retrospective review of super-obese patients who underwent laparoscopic adjustable gastric banding (LAGB n=192), Roux-en-Y gastric bypass (RYGBP n=97), and biliopancreatic diversion with/without duodenal switch (BPD n= 43), was performed. 30day peri-operative morbidity and mortality were evaluated to determine relative safety of the 3 operations. Results: From October 2000 through June 2004, 331 super-obese patients underwent laparoscopic bariatric surgery, with mean BMI 55.3 kg/m². Patients were aged 42 years (13-72), and 75% were female. When categorized by opertaion (LAGB, RYGBP, BPD), the mean age, BMI and gender were comparable. 6 patients were converted to open (1.8%). LAGB had a 0.5%, RYGBP 2.1% and BPD 7.0% conversion rate (P=0.02, all groups). Median operative time was 60 min for LAGB, 130 min for RYGBP and 255 min for BPD (P<0.001, all groups). Median length of stay was 24 hours for LAGB, 72 hours for RYGBP, and 96 hours for BPD (P <0.001). Mean %EWL for the LAGB was 35.3±12.6, 45.8±19.4, and 49.5±18.6 with follow-up of 87%, 76% and 72% at 1, 2 and 3 years, respectively. Mean %EWL for the RYGBP was 57.7±15.4, 54.7±21.2, and 56.8±21.1 with follow-up of 76%, 33% and 54% at 1, 2 and 3 years, respectively. Mean %EWL for the BPD was 60.6±15.9, 69.4±13.0 and 77.4±11.9 with follow-up of 79%, 43% and 47% at 1, 2 and 3 years, respectively. The difference in %EWL was significant at all time intervals between the LAGB and BPD (P<0.004). However, there was no significant difference in %EWL between LAGB and RYGBP at 2 and 3 years. Overall perioperative morbidity occurred in 27 patients (8.1%). LAGB had 4.7% morbidity rate, RYGBP 11.3%, and BPD 16.3% (P=0.02, all groups). There were no deaths. Conclusion: Laparoscopic bariatric surgery is safe in super-obese patients. LAGB, the least invasive procedure, resulted in the lowest operative times, the lowest conversion rate, the shortest hospital stay and the lowest morbidity in this high-risk cohort of patients. Rates of all parameters studied increased with increasing procedural complexity. However, the difference in %EWL between RYGBP and LAGB at 2 and 3 years was not statistically significant.     

The Effect of Biliopancreatic Diversion with Pylorus-Preserving Sleeve Gastrectomy and Duodenal Switch on Fasting Serum Ghrelin, Leptin and Adiponectin Levels: Is there a Hormonal Contribution to the Weight-Reducing Effect of this Procedure?

Background: Ghrelin is a peptide hormone with orexigenic properties, primarily produced by the stomach. Different changes in fasting ghrelin levels have been reported following bariatric surgery. In this study, we investigate the hypothesis that because ghrelin is mainly produced by the fundus of the stomach, biliopancreatic diversion with sleeve gastrectomy with total resection of the gastric fundus and duodenal switch (BPD-DS) will cause substantial decrease in circulating ghrelin levels. Methods: Serum fasting ghrelin, leptin and adiponectin concentrations were measured by ELISA in 13 patients with morbid obesity who achieved weight loss by BPD-DS, before the operation and 18 months after. Results: After BPD-DS, BMI decreased significantly, from 59.15±15.82 kg/m² to 32.91±6.46 kg/m² (P=0.001). Serum fasting ghrelin level decreased from 1.44±0.77 ng/ml to 0.99±0.35 ng/ml (P=0.019). Serum leptin level decreased from 1.81±0.38 ng/ml to 1.65±0.32 ng/ml, (P=0.196), and adiponectin level increased from 37.85±11.24 μg/ml to 39.84±16.27 μg/ml (P=0.422). Conclusions: BPD-DS is associated with markedly suppressed ghrelin levels, possibly contributing to the longlasting weight-reducing effect of the procedure. Leptin levels decreased and adiponectin increased, as expected, after weight loss. Sleeve gastrectomy with resection of the gastric fundus seems to be the main cause of the postoperative reduction in ghrelin levels.     

Sleeve Gastrectomy and Gastric Banding: Effects on Plasma Ghrelin Levels

Background: Different changes of plasma ghrelin levels have been reported following gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion. Methods: This prospective study compares plasma ghrelin levels and weight loss following laparoscopic sleeve gastrectomy (LSG) and laparoscopic adjustable gastric banding (LAGB) in 20 patients. Results: Patients who underwent LSG (n=10) showed a significant decrease of plasma ghrelin at day 1 compared to preoperative values (35.8 ± 12.3 fmol/ml vs 109.6 ± 32.6 fmol/ml, P=0.005). Plasma ghrelin remained low and stable at 1 and 6 months postoperatively. In contrast, no change of plasma ghrelin at day 1 (71.8 ± 35.3 fmol/ml vs 73.7 ± 24.8 fmol/ml, P=0.441) was found in patients after LAGB (n=10). Increased plasma ghrelin levels compared with the preoperative levels at 1 (101.9 ± 30.3 fmol/ml vs 73.7 ± 24.8 fmol/ml, P=0.028) and 6 months (104.9 ± 51.1 fmol/ml vs 73.7 ± 24.8 fmol/ml, P=0.012) after surgery were observed. Mean excess weight loss was higher in the LSG group at 1 (30 ± 13% vs 17 ± 7%, P=0.005) and 6 months (61 ± 16% vs 29 ± 11%, P=0.001) compared with the LAGB group. Conclusions: As a consequence of resection of the gastric fundus, the predominant area of human ghrelin production, ghrelin is significantly reduced after LSG but not after LAGB. This reduction remains stable at follow-up 6 months postoperatively, which may contribute to the superior weight loss when compared with LAGB.     

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.     

Roux-en-Y Gastric Bypass versus a Variant of Biliopancreatic Diversion in a Non-Superobese Population: Prospective Comparison of the Efficacy and the Incidence of Metabolic Deficiencies

Background: In the non-superobese population, an agreement has not been made as to the optimal bariatric operation. The present study reports the results of a prospective comparison of Roux-en-Y gastric bypass (RYGBP) and a variant of biliopancreatic diversion (BPD) in a non-superobese population. Methods: From a cohort of 130 patients with BMI 35 to 50 kg/m², 65 patients were randomly selected to undergo RYGBP and 65 to undergo BPD. All patients underwent complete follow-up evaluation at 1, 3, 6, and 12 months postoperatively and every year thereafter. Results: Patients in both groups have completed their second postoperative year. Mean % excess weight loss (%EWL) was significantly better after BPD at all time periods (12 months, P=0.0001 and 24 months, P=0.0003), and the %EWL was >50% in all BPD patients compared to 88.7% in the RYGBP patients at 2-year follow-up. No statistically significant differences were observed between the 2 groups in early and late non-metabolic complications. Hypoalbuminemia occurred in only 1 patient (1.5%) after RYGBP and in 6 patients after BPD (9.2%). Only 1 patient from each group was hospitalized and received total parenteral nutrition. Glucose intolerance, hypercholesterolemia, hypertriglyceridemia and sleep apnea completely resolved in all patients in both groups, although mean total cholesterol level was significantly lower in BPD patients at the second year follow-up (t-test, P<0.0001). Diabetes completely resolved in all BPD patients and in 7 of the 10 diabetic RYGBP patients. Conclusion: Both RYGBP and BPD were safe and effective procedures when offered to non-superobese patients. Weight loss after BPD was consistently better than that after RYGBP, as was the resolution of diabetes and hypercholesterolemia. Because the nutritional deficiencies that occurred following this type of BPD were not severe and were not significantly different between the 2 operations, both may be offered to non-superobese patients, keeping in mind the severity and type of preoperative co-morbidities as well as the desired weight loss.     

Revision of Failed Laparoscopic Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Background: The most common bariatric surgical operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss. Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery. Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5±2.0 years. For the RYGBP, mean operating time was 161±53 minutes, estimated blood loss was 219±329 ml, and hospital stay was 6.7±4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%) – a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2±9.3 kg/m², and decreased to 45.8±8.9 kg/m² after LAGB and was again reduced to 37.7±8.7 kg/m² after RYGBP within our follow-up period. Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.     

Comparison of weight loss and body composition changes with four surgical procedures

BackgroundA paucity of information is available on the comparative body composition changes after bariatric procedures. The present study reports on the body mass index (BMI) and body composition changes after 4 procedures by a single group.MethodsAt the initial consultation, the weight and body composition of the patients undergoing 4 different bariatric procedures were measured by bioimpedance (Tanita 310). Follow-up examinations were performed at 1 year and at subsequent visits after surgery. Analysis of variance was used to compare the postprocedure BMI and body composition. Analysis of covariance was used to adjust for baseline differences.ResultsA total of 101 gastric bypass (GB) patients were evaluated at 19.1 ± 10.6 months, 49 biliopancreatic diversion with the duodenal switch (BPD/DS) patients at 27.5 ± 16.3 months, 41 adjustable gastric band (AGB) patients at 21.4 ± 9.2 months, and 30 sleeve gastrectomy (SG) patients at 16.7 ± 5.6 months (P <.0001). No differences were found in patient age or gender among the 4 groups. The mean preoperative BMI was significantly different among the 4 groups (P <.0001): 61.4 kg/m², 53.2, 46.7, and 44.3 kg/m² for the SG, BPD/DS, GB, and AGB group, respectively. The postoperative BMI adjusted for baseline differences was 27.8 (difference 23.6 ± 8.3), 32.5 (difference 15.6 ± 5.0), 37.2 (difference 18.2 ± 8.2), and 39.5 kg/m² (difference 7.5 ± 4.3) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The percentage of excess weight loss was 84%, 70%, 49%, and 38% for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The postoperative percentage of body fat adjusted for baseline differences was 25.7% (23.9% ± 7.0%) 32.7% (16.1% ± 10.5%) 37.7% (16.7% ± 5.6%), and 42% (6.0% ± 6.8%) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The lean body mass changes were reciprocal.ConclusionAlthough the BPD/DS procedure reduced the BMI the most effectively and promoted fat loss, all the procedures produced weight loss. The AGB procedure resulted in less body fat loss within 21.5 months than SG within 16.7 months. Longer term observation is indicated.     

Pre- and Post-prandial Plasma Ghrelin Levels Do Not Correlate with Satiety or Failure to Achieve a Successful Outcome after Roux-en-Y Gastric Bypass

Background: We tested the hypothesis that the amount of weight lost after Roux-en-Y gastric bypass (RYGBP) correlates with plasma ghrelin levels. Methods: 36 morbidly obese patients were studied 3 years after RYGBP (6 men, 30 women) with mean initial BMI 51 kg/m² and 8 healthy controls (2 men, 6 women) with mean BMI 25 kg/m². Subjects consumed a light breakfast, and the first blood sample was drawn at 1200 hrs immediately before lunch and the second sample at 1400 hrs. Satiety was assessed using a Visual Analog Scale (VAS). Patients were stratified as success (current BMI <35) or failures (current BMI ≥35). Results: Plasma ghrelin levels were significantly lower in patients after RYGBP (269 ± 66 pcg/ml) compared with lean controls (616 ± 112 pcg/ml, P<0.001). Ghrelin levels pre or post meals were not different between patients who had a successful weight loss (preoperative BMI 47, current BMI 29, 72% EWL) or those who achieved a less then ideal weight loss (preoperative BMI 48, current BMI 41, 29% EWL). There was no correlation between any of the VAS scores and plasma ghrelin. There was a strong inverse correlation between pre-prandial ghrelin levels and the preoperative or current BMI. Conclusion: Failure to lose weight after RYGBP does not correlate with pre- or post-prandial ghrelin plasma levels. Ghrelin levels were inversely proportional to BMI and did not correlate with satiety. These data do not support a role for higher plasma ghrelin levels for inadequate weight loss after RYGBP.     

Different Effects of Vertical Banded Gastroplasty and Roux-en-Y Gastric Bypass on Meal Inhibition of Ghrelin Secretion in Morbidly Obese Patients

A decrease in ghrelin plasma levels in morbidly obese patients subjected to bariatric surgery has been considered to help increase body weight loss. Contradictory results have been described after Roux-en-Y gastric bypass (RYGBP), and no study to date has compared RYGBP and vertical banded gastroplasty (VBG), the two main operations performed in the United States. We investigated the effects of RYGBP (10 patients) and VBG (12 patients) on basal and postmeal ghrelin plasma levels in 22 morbidly obese patients (20 F and 2 M), mean age 42.1 ± 3.7 years, mean weight 115 ± 3.9 kg, mean body mass index (BMI) 43.5 ± 1.7. Before surgery and after a 20% reduction in BMI, ghrelin concentrations (pg/mL; radioimmunoassay [RIA], DRG Diagnostics, Germany) were measured in all patients 45 min before and for 3 h after a standard liquid meal (Osmolite RTH solution, 500 mL, 504 kcal). The results were expressed as mean ± SD. Differences between times and groups were evaluated by Student's t-test and one-way analysis of variance (ANOVA). We found that basal ghrelin plasma levels were reduced after RYGBP (to 73.1 ± 6 pg/mL, p <. 05) but increased after VBG (to 172 ± 26 pg/mL, p <. 0009). After a standard liquid meal, ghrelin plasma levels decreased significantly over 1 h in VBG patients, whereas they remained unchanged in RYGBP patients. Since these results were obtained under the same metabolic and anthropometric conditions, we conclude that RYGBP acts through permanent inhibition of ghrelin secretion, whereas VBG merely restores the mechanisms of ghrelin regulation by nutrients.     

Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass

Background: Patients undergoing either Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion (BPD) with RYGBP are at risk of developing metabolic sequelae secondary to malabsorption.We compared the differences in nutritional complications between these two bariatric operations. Methods: A retrospective analysis of a prospective database was done. From June 1994 to December 2001, 243 morbidly obese patients underwent various bariatric procedures at our institution. Of these patients, 79 (BMI 45.6 ± SD=4.9) who underwent RYGBP (gastric pouch 15 ± 5ml, biliopancreatic limb 60-80 cm, alimentary limb 80-100 cm and common limb the remainder of the small intestine), and 95 super obese (BMI 57.2 ± 6.1) who underwent a BPD (gastric pouch 15 ± 5ml, biliopancreatic limb 150-200 cm, common limb 100 cm and alimentary limb the remainder of the small intestine), were selected and studied for the incidence of micronutrient deficiencies and level of serum albumin at yearly intervals postoperatively. A variety of nutritional parameters including Hb, Fe, ferritin, folic acid, vitamin B₁₂ and serum albumin were measured preoperatively and compared postoperatively at 1, 3, 6, 12, 18 and 24 months, and yearly thereafter. Results: Nutritional parameters were compared preoperatively and at similar periods postoperatively. No statistically significant (P <0.05) difference in the occurrence of deficiency was observed between the groups for any of the nutritional parameters studied, except for ferritin, which showed a significant difference at the 2-year follow-up (37.7% low ferritin levels after RYGBP vs. 15.2% after BPD, P =0.0294). All of these deficiencies were mild, without clinical symptomatology and were easily corrected with additional supplementation of the deficient micronutrient, with no need for hospitalization. Regarding serum albumin, there was only one patient with a level below 3 g/dl in the RYGBP group and two in the BPD group.These three patients were hospitalized and received total parenteral nutrition for 3 weeks, without further complications. Conclusion:There was no significant difference in the incidence of deficiency of the nutritional parameters studied, except for ferritin, following RYGBP vs. BPD with RYGBP.The most common deficiencies encountered were of iron and vitamin B₁₂. The incidence of hypoalbuminemia was negligible in both groups, with mean values above 4 g/dl.     

Gastro-Esophageal Reflux and Esophageal Motility Disorders in Morbidly Obese Patients before and after Bariatric Surgery

Background Obesity is a predisposing factor to gastro- esophageal reflux disease (GERD), but esophageal function remains poorly studied in morbidly obese patients and could be modified by bariatric surgery. Methods Every morbidly obese patient (BMI ≥40 kg/m² or ≥35 in association with co-morbidity) was prospectively included with an evaluation of GERD symptoms, endoscopy, 24-hour pH monitoring and esophageal manometry before and after adjustable gastric banding (AGB) or Roux-en-Y gastric bypass (RYGBP). Results Before surgery, 100 patients were included (84 F, age 38.4 ± 10.9 years, BMI 45.1 ± 6.02 kg/m2), of whom 73% reported GERD symptoms. Endoscopy evidenced hiatus hernia in 39.4% and esophagitis in 6.4%. The DeMeester score was pathological in 53.3%; 69% of patients had lower esophageal sphincter (LES) pressure <15 mmHg and 7 had esophageal dyskinesia. BMI was significantly related to the DeMeester score (P = 0.018) but not to LES tone or esophageal dyskinesia. Postoperative data were available in 27 patients (AGB n = 12/60, RYGBP n = 15/36). The DeMeester score (normal <14.72) was significantly decreased after RYGBP (24.8 ± 13.7 before vs 5.8 ± 4.9 after; P < 0.001) but tended to increase after AGB (11.5 ± 5.1 before vs 51.7 ± 70.7 after; P = 0.09), with severe dyskinesia in 2 cases. Conclusion: GERD and LES incompetence are highly prevalent in morbidly obese patients. Preliminary postoperative data show different effects of RYGBP and AGB on esophageal function, with worsening of pH-metric data with occasional severe dyskinesia after AGB.     

Early Results after Laparoscopic Gastric Bypass: EEA vs GIA Stapled Gastrojejunal Anastomosis

Background: Various surgical techniques have been successfully applied to isolated Roux-en-Y gastric bypass (RYGBP). Many surgeons rely on stapling devices for the gastrojejunal (GJ) anastomosis. Early follow-up results were compared for two laparoscopic techniques for GJ anastomosis: circular end-to-end (EEA) and linear cutting (GIA) staplers. Methods: Medical charts were retrospectively reviewed of all patients who had undergone stapled GJ anastomosis for isolated RYGBP over a 2-year period. The jejunal limb used for GJ anastomosis was fashioned at 1 cm / unit body mass index (BMI). Patients were grouped by GJ anastomotic technique, EEA or GIA, and the results compared. Results: 61 patients underwent RYGBP (EEA=32; GIA=29), with no differences in preoperative BMI or co-morbidities. Mean (±SD) operative time was shorter for the GIA group (EEA=180±56.1 minutes; GIA=145.3±27.9 minutes, P=0.003). There were 2 early re-operations in the GIA group for anastomotic leaks. Postoperative complications were not statistically different; however, there was an increased incidence of wound infections in the EEA group vs the GIA group (21.9% vs 6.9%, P=0.08). Follow-up at 6-8 months revealed an average percent excess weight loss of 46.7%±12.2% for EEA and 51.4%±10.7% for GIA (P=0.25). Length of stay, total hospital costs and operating-room costs were similar (P=0.34, 0.53 and 0.96 respectively). Conclusion: Operative time was significantly shorter in the GIA group. Complications, length of stay, weight loss and costs were similar between the groups. Selection of anastomotic technique may be based on surgeon preference, operative time, and potential for serious complications.     

The Impact of Bariatric Surgery on the Veterans Administration Healthcare System: A Cost Analysis

Background: The economic burden of caring for veterans with clinically severe obesity and its comorbidities is straining the Veterans Administration (VA) healthcare system. The authors determined the cost of Roux-en-Y Gastric Bypass (RYGBP) in the VA's single-payor healthcare system. Methods:The records of all 25 patients who underwent RYGBP from May 1999 to October 2001 were reviewed. All obesity-related health-care costs including hospitalizations as well as outpatient visits, medications and home health devices were calculated for 12 months before and after the RYGBP. Results: Age was 52±2 yr and preoperative BMI was 52±2 kg/m²; ASA score was III (21 patients) and II (4 patients). Mean follow-up was 18 months.Total cost of care for these patients preoperatively was $10,778±2,460/patient (outpatient visits=$5,476±682, hospital admissions=$12,221±6,062, and home health devices=$1,383±349). Postoperative length of stay was 8±0.5 days. Cost of the gastric bypass was $8,976±497/pt (OR fixed cost=$1,900/patient + ICU and ward=$7,076±497/patient). For the first postoperative year, 6 patients had 12 admissions, but routine outpatient visits were significantly reduced from 55±6 to 18±2 postoperatively (P<0.001).The cost of all care excluding peri-operative charges for 1 year after gastric bypass was $2,840±622/patient (P=0.005 vs preop). Conclusions: Operative treatment of clinically severe obesity reduces obesity-related expenditures and utilization of healthcare resources. The cost of undertaking RYGBP at the VA is offset by reduction of health-care costs within the first year after surgery. These data support allocation of resources to support existing bariatric surgery programs throughout the VA system.     

Revision of Failed Gastric Restrictive Operations to Roux-en-Y Gastric Bypass: Impact of Multiple Prior Bariatric Operations on Outcome

Background: Morbid obesity is now an epidemic with considerable associated morbidity for which bariatric surgery has been the only effective treatment. Despite its success, occasional patients require revision because of weight regain or mechanical complications. The impact of multiple prior bariatric operations on complications and weight loss after revision to Roux-en-Y gastric bypass (RYGBP) was evaluated. Methods: All patients undergoing revisional surgery to RYGBP by the senior author from 1997 through 2004 were retrospectively reviewed at a multi-center academic institution. Patients who had previously undergone multiple revisional operations (MR) were compared to patients who had undergone primary ("first-time") revision (PR). Demographics, indications for revision, complications, and weight loss were reviewed. Results: 66 patients underwent open revision to RYGBP after failed bariatric operations, with 12 in the MR group and 54 in the PR group. Mean preoperative BMI was 46.1 and 45.2 (P=0.8), respectively. Operative time (227 vs 162 min, P=0.07), blood loss (517 vs 313 ml, P=0.09) and hospital length of stay (11.5 vs 6.7 days, P=0.2) were higher in the MR group. Major perioperative complications occurred in 16.7% of MR patients compared to 9.3% of PR patients (P=0.6). Percent of excess weight loss (%EWL) has been 54.3% in the MR group and 60.6% in the PR group (P=0.6). Average follow-up is 26 and 23 months, respectively. Conclusion: Although operative times, blood loss, and LOS were greater in MR patients, RYGBP can be performed in patients with multiple previous bariatric operations with acceptable weight loss and complication rates.     

Impact of Varying Levels of Protein Intake on Protein Status Indicators after Gastric Bypass in Patients with Multiple Complications Requiring Nutritional Support

Background: <6% of patients who undergo Roux-en-Y gastric bypass (RYGBP) for morbid obesity require nutritional support after surgery. Protein and caloric needs have been estimated as 14-21 kcal, 1.2 g protein/kg/current body weight/day in uncomplicated morbidly obese patients. This study assesses the effect of varying protein-calorie intake in complicated patients after RYGBP on two markers of protein status: thyroxine-binding prealbumin (TBPA) and serum albumin. Methods: This 25-month retrospective study consisted of 22 patients with postoperative complications. Serum albumin, TBPA, medical nutrition care-plans, laboratory data and history were reviewed. These post-RYGBP patients who had BMI >35 and no multi-system organ failure or fistulas, had complications after surgery requiring nutrition support services (NSS). Serum albumin and TBPA were matched to fed levels of protein using random coefficient regression analysis. Results: Mean incremental increases of 2.34 mg/dl (TBPA, P=0.0113) and 0.11 g/dl (serum albumin, P=0.0272) were found with each 0.5 g protein intake increase/kg ideal body weight/day (kg/IBW/day). Patients required NSS for 23 ± 21 (mean ± SD) days, with 15 ±19 days fed at goal rate. Initial serum albumin was 2.3 ± 0.5, with a final measure of 2.7 ± 0.5 g/dl. Goal protein and calorie intake were 2.1 g and 17 kcal/kg IBW/day versus actual intake of 1.6 g and 13 kcal/kg IBW/day. Conclusion: Morbidly obese patients requiring NSS following RYGBP risk iatrogenic protein malnutrition. There was a positive linear relationship between protein status and protein intake that warrants further study of higher protein feeding in complicated post-RYGBP patients.     

Systematic Review of Medium-Term Weight Loss after Bariatric Operations

Background: Although bariatric surgery is known to be effective in the short term, the durability of that effect has not been convincingly demonstrated over the medium term (>3 years) and the long term (>10 years). The authors studied the durability of weight loss after bariatric surgery based on a systematic review of the published literature. Methods: All reports published up to September, 2005 were included if they were full papers in refereed journals published in English, of outcomes after Roux-en-Y gastric bypass (RYGBP), and its hybrid procedures of banded bypass (Banded RYGBP) and longlimb bypass (LL-RYGBP), biliopancreatic diversion with or without duodenal switch (BPD±DS) or laparoscopic adjustable gastric banding (LAGB). All reports that had at least 100 patients at commencement, and provided ≥3 years of follow-up data were included. Results: From a total of 1,703 reports extracted, 43 reports fulfilled the entry criteria (18 RYGBP; 18 LAGB; 7 BPD). Pooled data from all the bariatric operations showed effective and durable weight loss to 10 years. Mean %EWL for standard RYGBP was higher than for LAGB at years 1 and 2 (67 vs 42; 67 vs 53) but not different at 3, 4, 5, 6 or 7 years (62 vs 55; 58 vs 55; 58 vs 55; 53 vs 50; and 55 vs 51). There was 59 %EWL for LAGB at 8 years, and 52 %EWL for RYGBP at 10 years. Both the BPD±DS and the Banded RYGBP appeared to show better weight loss than standard RYGBP and LAGB, but with statistically significant differences present at year 5 alone. The LL-RYGBP was not associated with improved %EWL. Important limitations include lack of data on loss to follow-up, failure to identify numbers of patients measured at each data point and lack of data beyond 10 years. Conclusions: All current bariatric operations lead to major weight loss in the medium term. BPD and Banded RYGBP appear to be more effective than both RYGBP and LAGB which are equal in the medium term.     

Health-related quality of life does not vary among patients seeking different surgical procedures to assist with weight loss

BackgroundImprovement in quality of life (QOL) is 1 of the goals of bariatric procedures. We hypothesized that greater impairment of QOL would encourage the choice of more invasive surgical procedures. Our study was performed at a university hospital weight loss surgical center in the United States.MethodsPatients qualifying for weight loss surgery, who at their surgical consultation had chosen their surgical option and signed an informed consent form, were asked to complete 3 QOL forms—the Medical Outcomes Study Short Form 36-item Health Survey, the Beck Depression Inventory, and the Impact of Weight on Quality of Life-Lite. Analysis of variance was used to compare the surgery types with the demographics, QOL, and depression.ResultsA total of 367 patients, 114 men (31.1%) and 253 women (68.75), completed the QOL forms at their surgical consultation. Of these 367 patients, 68.9% elected gastric bypass (GB), 15% chose biliopancreatic diversion/duodenal switch (BPD/DS), and 16.1% chose adjustable gastric banding (AGB). The mean patient age was 42.5 ± 10.7 years (P = NS), with no differences in gender distribution. The body mass index was 51.9 kg/m² for the BPD/DS group, greater than that for the GB group (45.9 kg/m²) or AGB group (44.3 kg/m²; P < .0001). No significant differences were found in the Beck Depression Inventory score among the 3 groups (GB 14.6 ± 9.6, AGB 10.8 ± 8.2, and BPD/DS 13.5 ± 7.3). For the Short Form 36-item Health Survey, only the physical component score was different for the AGB group compared with the BPD/DS group (GB 49.2 ± 25.1, BPD/DS 42.8 ± 26.4, and AGB 52.3 ± 31.7; P = .05). For the Impact of Weight on Quality of Life-Lite, all differences were nonsignificant. The total score was 44.1 ± 20.7, 44.4 ± 21.1, and 52.2 ± 19.6 for the GB, BPD/DS, and AGB groups, respectively.ConclusionPatients requesting a weight loss procedure reported moderate to severe impairments in QOL and mood dysphoria compared with the community norms. However, the patients choosing from the 3 procedures studied scored similarly on the health-related QOL assessments.