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.     

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.     

Laparoscopic gastric plication in morbidly obese adolescents: a prospective study

BackgroundThe prevalence of obesity has increased rapidly among adolescents. Bariatric surgery is associated with significant weight loss and improvement in obesity related co-morbidities, but may be associated with serious complications. Therefore, attempts on finding a safe and effective bariatric procedure for adolescents are ongoing. The objective of this study was to evaluate safety and efficacy of laparoscopic gastric plication (LGP) on adolescents.MethodA prospective study was performed on adolescents who underwent LGP from 2007–2013. Measured parameters included the percentage of excess weight (%EWL), percentage of body mass index loss (%BMIL), obesity related co-morbidities, operative time, and length of hospitalization and complications.ResultsLGP was performed in 12 adolescents (9 female and 3 male). Mean (SD) age of the patients was 13.8±1 year. Mean preoperative weight and BMI were 112.4±19.7 kg and 46.0±4 kg/m², respectively. Mean (SD) %EWL and %EBMIL were 68.2±9.9% and 79.0±9.0%, respectively after 2 years. All medical co-morbidities were improved after LGP. There were no deaths. One patient required replication 4 days postoperatively due to obstruction at the site of the last knot. No other major complications were observed. No patient required rehospitalization.ConclusionLGP has the potential of being an ideal weight loss surgery for adolescents, resulting in excellent weight loss and minimal psychological disruption. It is associated with a minimal risk of leakage, bleeding, and nutritional deficiency. However, large well-designed studies with long-term follow-up are needed.     

Obesity Surgery in the Philippines: Experience in a Private Tertiary Care Hospital for Years 2002 to 2004

Background Information on experience in bariatric surgery in the Asia-Pacific region is minimal: hence the need for more reports from this area. Methods The procedures of bariatric surgery and outcome as part of a weight management program in a tertiary care private hospital in the Philippines is reported from years 2002 to 2004. 50 patients were included, of which 60% underwent laparoscopic adjustable gastric banding (LAGB) and 40% Roux-en- Y gastric bypass (RYGBP). Results There were more females than males (64% vs 36%) with the mean age 38 ± 13.1 years. Initial mean BMI was 46.2 kg/m2, which decreased to 27.0 kg/m² in 1 year. Initial mean weight was 126.7 ± 25.4 kg, of which the 1 year weight loss was 32.3 kg for the morbidly obese and 58.0 kg for the super obese. %EWL at 1 year was 30.2%. There was greater weight loss with RYGBP compared to LAGB at 1 year (43.5 kg vs 30.2 kg). There was no mortality, and early complications were: wound infection (2/50 or 4%), and 1/50 or 2% each for pneumonia, dehydration, gastritis, and leakage. Late complications were: band slippage (2/20 or 10%), stomal stenosis (1/20 or 5%), and ventral hernia (1/5 or 20%). Conclusion Bariatric surgery is safe with a low complication rate and the outcome was similar to the reported data from Asia and the western world.     

Calorie Intake and Meal Patterns up to 4 Years after Roux-en-Y Gastric Bypass Surgery

Background: Roux-en-Y gastric bypass (RYGBP) is the most popular surgical treatment for morbid obesity in the U.S.A., producing significant and durable weight loss with improvement in co-morbidities. Although a greater number of patients are undergoing surgical treatment for obesity, little data are available regarding their food intake after surgery. This study was undertaken to evaluate the caloric amount, nutrient composition and meal patterns of patients 18 months to 4 years after RYGBP. Ethnic differences in food intake were also investigated. Methods: Questionnaires were mailed to 360 patients who had undergone RYGBP at least 18 months prior to the onset of the study. Results: Data were available from 69 patients, 52% Caucasian, 25% African-American, 23% Hispanic. 30 months after surgery, the average daily calorie intake was 1733 ± 630 kcal (n=68, range 624-3486 kcal), with 44% of calories from carbohydrates, 22% from protein and 33% from fat. Sugar-sweetened beverages represented 7% of total caloric intake. Patients consumed 3 meals and 3 snacks per day on average. Food intake from dinner and an evening snack represented 40% of the daily caloric intake. Snacks accounted for 37% of the daily intake. Percent excess weight loss (%EWL) was 58 ± 17% and was not different among ethnic groups. However, Hispanics reported consuming fewer snacks and fewer calories. %EWL correlated with the total daily caloric intake (r= .446, P <0.001). Follow-up attendance was 54% at 1 year after surgery but fell to 10% at 3 years. Only 77% of patients were taking vitamin supplements. Conclusion: RYGBP resulted in significant weight loss. Caloric intake was quite variable. Long-term follow-up remained low, putting patients at risk for metabolic and vitamin deficiencies. The relationship between caloric intake and long-term weight changes remains to be studied.     

Depression Score Predicts Weight Loss following Roux-en-Y Gastric Bypass

Background: The prevalence of obesity is increasing in the United States. Bariatric surgery is the only intervention that can reliably induce and maintain significant weight loss in obese patients. The association between pre-surgical severity of depression and success at weight loss following Roux-en-Y gastric bypass (RYGBP) has not yet been fully elucidated. Methods: 145 charts of patients who underwent RYGBP for morbid obesity were reviewed. 47 patients who filled out the Beck Depression Inventory (BDI) before surgery and completed 1 year of follow-up were studied. The relationship between pre-surgical severity of depression and success at weight loss was examined through multivariate regression analysis using percent excess weight loss (%EWL) as a dependent variable and BDI score as one of the predictors. Results: Weight loss at 1 year was significantly related to the BDI score before surgery (P =0.014). BDI score was also found to be a significant predictor of the amount of weight lost (kg) 1 year after surgery (P =0.027). Age (P =0.03) and initial body mass index (BMI) (P =0.011) were the only other variables with significant independent relations to %EWL. Conclusions: Our data show a positive correlation between pre-surgical severity of depression as measured by BDI score and the 1-year success at weight loss after RYGBP as measured by %EWL. More depressed individuals tend to lose greater amounts of weight compared with less depressed individuals. Future prospective studies should examine possible mechanisms and effects of depression and other psychiatric disturbances on long-term weight loss after RYGBP.     

Number of weight loss attempts and maximum weight loss before Roux-en-Y laparoscopic gastric bypass surgery are not predictive of postoperative weight loss

BackgroundMany insurance companies have mandated that bariatric surgery candidates already satisfying the National Institutes of Health criteria make an additional attempt at medically supervised weight loss. The objective of this study was to determine whether a correlation exists between the number of weight loss attempts (WLAs) or maximal preoperative weight loss (MWL) and the percentage of excess weight loss (%EWL) after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery.MethodsThe WLAs and MWL data were collected by bariatric medical record review. The postoperative %EWL was obtained by retrospective review of a prospectively enrolled bariatric database. Patients whose records contained 1 year of follow-up data and either the WLAs or MWL were included in the study. The data were analyzed using Pearson correlations and odds ratios.ResultsFrom September 2001 to 2006, 530 patients underwent LRYGB. Of these, 384 met the study criteria (82.6% were women). The mean WLAs was 4.3 ± 1.8. The mean MWL was 46.6 ± 31.2 lb (21.2 ± 14.2 kg). At surgery, the mean patient age was 43.3 ± 9.3 years, and the mean body mass index was 48.0 ± 5.9 kg/m². At 1 year after LRYGB, the mean body mass index was 30.2 ± 5.0 kg/m², and the mean %EWL was 72.3% ± 15.3%. Statistical analysis revealed no correlations between the %EWL at 1 year after LRYGB and the WLAs (R² = .011) or MWL (R² = .005).ConclusionNeither the WLAs nor the MWL correlated with the %EWL at 1 year after LRYGB. Our results showed no evidence that the WLAs or MWL before surgery correlates with the %EWL in patients undergoing LRYGB.     

Bariatric Re-operations: Are They Preventable?

Background: Many operations are currently used for morbid obesity, and every procedure appears to have advantages, drawbacks and failures. Re-operation is a part of bariatric surgery practice that is necessary in the event of failure. We analyzed the reasons for failure in the bariatric re-operation group. Methods: From June 1998 to April 2000, 17 morbidly obese patients had a bariatric re-operation. Of 203 bariatric operations performed in our institution, 12 patients had a re-operation (5.9%), and 5 patients had their primary procedure performed elsewhere. Mean age was 36.5 ±11 years, mean original weight 151.3 ± 44.3 kg, mean BMI 58.4±16.9 kg/m2 and mean excess body weight (EBW) 94.4±43.5 kg. Mean height was 161±7.7 cm, and 15 patients were female (88.2%).The primary bariatric operation was vertical banded gastroplasty (VBG) in 15 patients (88.2%), Roux-en-Y gastric bypass (RYGBP) in 1 patient (5.9%), and gastric banding in 1 patient (5.9%). Duration since the primary surgery was a mean of 15.6 months (range 1-72 months). Results: Reasons for re-operation were inadequate weight loss (47%) or food intolerance (53%). 11 patients had VBG converted to RYGBP,1 patient had a gastric banding converted to a BPD, 4 patients had their VBG converted to a gastro-gastrostomy, and 1 patient had a RYGBP staple dehiscence re-stapled. Conclusion: Incidence of bariatric re-operations may be decreased if super-obese patients, older patients, and sweets-consuming individuals undergo RYGBP or BPD as the primary operation rather than VBG or gastric banding. The use of staplers transecting and separating the gastric pouch from the remaining stomach can decrease staple dehiscence.     

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.     

A Nationwide Survey on Bariatric Surgery in France: Two Years Prospective Follow-up

Background Most studies on bariatric surgery outcomes have been performed in clinical trials (eg. the SOS) or reflect the clinical experience and practice of specific and experienced centers. Little is known about the current practice at a nationwide level. Methods This is a systematic nationwide study on the 2-year outcome of all consecutive 1,236 bariatric operations performed in France. Data on mortality, weight loss, complications, and patient satisfaction were collected independently from the medical and surgical team involved in the patients’ care. Results 87.3% of the patients underwent an adjustable gastric banding (ABG), 8.6% a vertical banded gastroplasty (VBG), 3.8% a Roux-en-Y gastric bypass (RYGBP) and 0.3% a biliopancreatic diversion (BPD). Loss of follow-up was 12% at year 1 and 18% at year 2. The rate of laparoscopic procedures was 98% for ABG and 73% for RYGBP. Mortality rate was 0.16% in the operative period and 0.27% during follow-up. Excess weight loss ranged from 43% (AGB) to 66% (RYGBP). Co-morbidities improved in more than 70% of patients. Conclusion Outcomes of bariatric surgery in routine practice (mortality, weight loss, course of co-morbidities, and quality of life) are similar to the results published in clinical trials.     

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 Patient Follow-Up on Weight Loss after Bariatric Surgery

Background: Postoperative follow-up after bariatric surgery is important. Because of the need for adjustments, follow-up after gastric banding may have a greater impact on weight loss than after Roux-en-Y gastric bypass.We reviewed all patients at 1 year after these two operations. Methods: During the first year after surgery, laparoscopic adjustable gastric banding (LAGB) patients were followed every 4 weeks and Roux-en-Y gastric bypass (RYGBP) patients were followed at 3 weeks postoperatively and then every 3 months.The number of follow-up visits for each patient was calculated, and 50% compliance for follow-up and weight loss was compared. Results: Between October 2000 and September 2002, 216 LAGB and 139 RYGBP operations were performed. Of these patients, 186 LAGB patients and 115 RYGBP patients were available for 1-year follow-up. Age and BMI were similar for each group. Overall excess weight loss (EWL) after LAGB was 44.5%. 130 (70%) returned 6 or less times in the first year and achieved 42% EWL. 56 patients (30%) returned more than 6 times and had 50% EWL (P=0.005). Overall %EWL after RYGBP was 66.1%. 53 patients (46%) returned 3 or less times in the first year, achieving 66.1% EWL. 62 patients (54%) returned more than 3 times after surgery and achieved 67.6% EWL (P=NS). Conclusion: Patient follow-up plays a significant role in the amount of weight lost after LAGB, but not after RYGBP. Patient motivation and surgeon commitment for long-term follow-up is critical for successful weight loss after LAGB surgery.     

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.     

Laparoscopic Placement of Non-Adjustable Silicone Ring for Weight Regain After Roux-en-Y Gastric Bypass

Background  Roux-en-Y gastric bypass (RYGBP) is presently one of the most popular surgical procedures for obesity. One of the possible long-term problems is weight regain, usually after a period of successful weight loss. Weight regain after RYGBP can be due to new eating habits, like sweet-eating or grazing, or volume eating because of impaired restriction. This paper reports our experience in patients who presented weight regain after laparoscopic RYGBP, because of new appearance of volume eating or hyperphagia, treated by the laparoscopic placement of a non-adjustable silicone ring around the gastric pouch. Methods  From July 2004 to November 2007, six patients affected by weight regain due to hyperphagic behavior, benefited from revision of RYGBP consisting of the placement of a non-adjustable silicone ring loosely encircling the stomach part. Mean weight and body mass index (BMI) at the time of RYGBP were 105.0 kg ± 12.3 and 36.3 ± 3.0 kg/m², respectively, and all patients suffered from obesity-related co-morbidities. After a mean time from RYGBP of 26.0 ± 14.2 months, patients presented a weight regain of 4.7 ± 3.4 kg compared with their minimal weight, with a final mean weight, BMI, and percentage of excess weight loss (%EWL) at the time of the silicone ring of 86.0 ± 13.1 kg, 29.5 ± 3.9 kg/m², and 47.0 ± 24.7%, respectively. Preoperative evaluation for each patient included history and physical examination, nutritional and psychiatric evaluation, laboratory tests, and barium swallow check. Outcome measures included evaluation of the Roux-en-Y construction, operative time, postoperative morbidity and mortality, and weight loss in terms of absolute weight loss, BMI, and %EWL. Results  Any modification of the digestive circuit was evidenced. Mean operative time was 82.5 ± 18.3 min. No operative mortality and no conversion to open surgery were achieved. No postoperative complications were achieved. Mean hospital stay was 2.6 ± 1.5 days. After a mean follow-up of 14.0 ± 9.2 months, the six patients presented a mean weight loss of 9.1 ± 2.4 kg, with a final mean weight, BMI, and %EWL of 76.8 ± 13.7 kg, 26.4 ± 4.2 kg/m², and 70.4 ± 30.4%, respectively. Difference in term of %EWL before and after revision (23.4 ± 5.7) is statistically significant (p < 0.05). There have been no erosions or slippage of the ring during this follow-up. Conclusion  One of the possible causes of weight regain after RYGBP is the new eating behavior of the patient, one of which is hyperphagia. Treatment of this condition can be the placement of a non-adjustable silicone ring loosely fitted around the gastric pouch which contributes to improved weight loss. This paper was presented at the XIII World Congress of International Federation for the Surgery of Obesity and metabolic disorders, Buenos Aires, Argentina, September 24–27, 2008.     

The effect of bariatric surgery on opioid consumption in patients with obesity: a registry-based cohort study

BackgroundMisuse of opioid medication has become a major health crisis in several countries. A significant number of patients with obesity use opioid medications, mostly to alleviate symptoms due to obesity-related co-morbidities.ObjectiveTo compare patterns of opioid drug usage before and after bariatric surgery in this population, hypothesizing that weight loss and improvement of obesity-related co-morbidities could reduce opioid consumption.SettingThe Ontario Bariatric Registry (Ontario, Canada).MethodsIn this retrospective cohort study, the Ontario Bariatric Registry was used to compare opioid consumption in adult patients undergoing bariatric surgery between 2010 and 2021. The primary outcome was the number of patients using opioid medication at 1 year after surgery. Multiple logistic regression analyses were performed to identify potential predictors of opioid consumption.ResultsData of 11,179 patients were analyzed. Mean age was 45.7 ± 10.2 years, mean baseline body mass index was 48.9 ± 8 kg/m², and 83.6% of patients were female. Roux-en-Y gastric bypass was performed in the majority of patients (85.6%), followed by sleeve gastrectomy (14.2%). At baseline, opioids were used by 7.7% and nonopioid pain medications by 42.3% of patients. At 1 year after surgery, these numbers significantly decreased (Δ–1.9% and Δ–18.0%, respectively). The decrease in the consumption of nonopioid pain medication needs to be interpreted in the context of the contraindication to nonsteroidal anti-inflammatory drugs after Roux-en-Y gastric bypass, which was the most commonly performed procedure. Presence of musculoskeletal pain and use of nonopioid pain medication at baseline were identified as independent predictors of opioid consumption at 1 year after surgery.ConclusionsAt 1 year after bariatric surgery, a significant decrease in opioid and nonopioid pain medication consumption was seen among patients with obesity. Aggressive management of excess weight, especially with bariatric surgery, can potentially reduce the impact of the opioid crisis in this population.     

Report on Bariatric Surgery in the Ukraine

Background: Morbid obesity (MO) is a problem internationally, including in the Ukraine.We present the surgical treatment of MO in the Ukraine over the last 15 years, during which intestinal bypasses and various gastric reduction procedures were performed. Methods: 198 patients with MO underwent: jejunoileal (JI) bypass 64, non-adjustable gastric banding (NGB) 34, Roux-en-Y gastric bypass (RYGBP) 1, horizontal gastroplasty 1, vertical banded gastroplasty (VBG) 2, and abdominal lipectomy 96.The 96 men and 102 women weighed 160-290 kg (mean 210±SD18 kg). Mean body mass index was >60 kg/m2. These patients had a high incidence of hypertension, diabetes, sleep apnea, menstrual disorders, impotency in men and infertility in women. Results: At 1 year, after JI bypass 61 patients lost a mean of 62±17 kg and after NGB 11 kg. After JI bypass, 1 patient died in the early postoperative period from acute respiratory insufficiency and 2 died in the first year from acute liver insufficiency. The JI bypass was reversed in 2 patients due to uncontrollable malabsorption syndrome; 1 year after reversal, the weight of these patients exceeded their preoperative weight. In the early postoperative period, 1 patient died after NGB and 1 after RYGBP, from acute respiratory insufficiency. Postoperative weight loss was associated with decrease in the co-morbidities of MO, but after JIB, there was a high incidence of bypass enteritis, excessive malabsorption, formation of renal stones and gallstones. After NGB, no complications have been identified. Isolated lipectomy was performed in 44 patients, lipectomy combined with a bariatric operation in 31, and lipectomy after loss of the excess body weight in 21. Conclusions: Bariatric surgery was very effective in weight loss, accompanied by reduction or disappear ance of the co-morbidities of MO, with considerable improvement in quality of life.     

Follow-up of Roux-en-Y Gastric Bypass Patients at 5 or more Years Postoperatively

Background Short-term results (24 to 36 months) after Roux-en-Y gastric bypass (RYGBP) have been extensively described. Little is reported on the patients operated ≥ 5 years ago. We analyzed the results of weight loss, resolution of co-morbidities and nutritional complications of patients submitted to the silicone ring RYGBP, at least 5 years before. Methods 75 morbidly obese patients who underwent silicone ring RYGBP between Oct 1995 and Dec 1999, 18 men and 57 women, were studied. Demographic data, nutritional status and the presence of co-morbidities (type 2 diabetes, hypertension, sleep apnea, dyslipidemia) were accessed. Pre- and postoperative BMI were registered, along with excess weight loss (EWL). Nutritional deficiencies were accessed by laboratory assays. Results Mean follow-up was 87 months. Initial BMI was 56.7 ± 10 kg/m². After 2 years, BMI had dropped to 29.3 ± 6.8, and by the last interview BMI was 35.5 ± 10. %EWL after 2 years was 80.2 ± 17.3%, and at the end was 71.8 ± 21.6%. After 2 years, only 1 of the 75 patients (1.33%) had not achieved an EWL of at least 50%. At the end, 23 patients (30.6%) could not maintain this EWL. Resolution of diabetes was 76.5%, arterial hypertension 37.3% and sleep apnea 93.5%. Iron, vitamin B12 and vitamin D were the most common nutritional deficiencies. Conclusions Long-term follow-up (5 to 9 years) after the RYGBP was associated with satisfactory mantainance of EWL, and resolution or improvement of the main co-morbidities was observed in the majority of the patients.     

Sweet eating is not a predictor of outcome after Lap-Band placement. Can we finally bury the myth?

Background: It is common belief that sweet eaters will do poorly after gastric restrictive surgery.There is scant evidence for this and significant evidence that sweet eating behavior is not predictive of weight outcome. Preoperative and current sweet eating behavior was assessed in subjects who have had Lap-Band^? surgery, to find if this influenced weight outcomes. Method: 200 unselected patients who had bands inserted for >1 year completed a questionaire regarding preoperative sweet eating behavior. The last 100 patients also reported current sweet eating behavior. Sweet eating was scored using a standard dietary questionnaire. Results: Mean±SD % excess weight loss at 1 year (%EWL1) for the 100 with the highest preoperative sweet eating scores (SES) was 47.1±16% compared with a loss of 48.2±16% by those with the lowest SES (P=0.64). Analysis showed no significant linear or non-linear correlation between the SES and the %EWL. For the highest quintile of SES, the EWL1 was 47.3±14% and for the lowest was 46.1±16% (NS). Sweet eaters were younger (r=-0.21, P=0.003) and had higher fasting insulin concentrations (r=-0.18, P=0.03). Preoperative SES had no influence on %EWL1 after controlling for factors known to influence weight loss. %EWL at 2 years (n=130) and 3 years (n=88) were not different for sweet eaters and non-sweet eaters. Current sweet eating tendency (n=100) also had no impact on %EWL. Conclusion: Sweet eaters do not have less favorable weight outcomes following Lap-Band^? surgery. Our study confirms the findings of two other major studies. Sweet eating behavior should not be used as a preoperative selection criterion for bariatric surgery.     

Does Pouch Size Matter?

Background Mechanical restriction, malabsorption, and hormonal changes appear to play a role in weight loss after Roux-en-Y gastric bypass (RYGBP). This investigation chose to investigate one aspect of the restrictive role of gastric bypass: the pouch size. Our hypothesis was that a small pouch size with no fundus after laparoscopic RYGBP (LRYGBP) would lead to greater loss of excess weight and weight loss success. Methods Upper gastrointestinal radiological (UGI) studies were retrospectively reviewed by three blinded experts (2 bariatric surgeons and 1 expert radiologist), to determine pouch size and fundus size. The following grading system was utilized: Size I - smaller than average pouch, Size II - average pouch, Size III - larger than average pouch, and Size IV - over 3 times the size of an average pouch. Fundus 0 - no fundus appreciated, Fundus I - slight amount of fundus barely noted, Fundus II - fundus noted, Fundus III - large amount of fundus noted, and Fundus IV - majority of the pouch was fundus. Percentage of excess weight loss (%EWL) and successful weight loss (A. >50% EWL, B. within 50% of ideal body weight, C. loss of >25% of preoperative weight) were calculated. Results There were 59 patients in this study with 97% follow-up of >1 year. No Size IV or Fundus IV were noted. There were no statistically significant differences between in %EWL or success for either pouch size or fundus size. Conclusions While there may be a trend for the mean %EWL to be lower with larger pouches and larger amounts of fundus, no significant differences were found. Larger pouches and the presence of fundus (within reason) still result in a high rate of success after LRYGBP.     

Revisional Bariatric Surgery - Safe and Effective

Background: Revision operations have traditionally been considered difficult and associated with a high complication and long-term failure rate. This paper demonstrates that revision and/or conversions to Roux-en-Y gastric bypass are generally safe as well as effective in long-term weight maintenance and control of co-morbidities. Methods: A retrospective study from January 1989 through August 1999 was done involving 141 patients who had had various gastroplasty (118), gastric banding (6), jejunoileal bypass (3), or loop (2) and Roux-en-Y gastric bypass (RYGBP) procedures (12), with either technical failures or poor long-term maintained weight loss. Results:The demographics were: mean pre-operative weight at original surgery 264 lbs (120 kg); postop weight at a mean elapsed time since surgery of 5 years, 4 months: 188 lbs (85 kg), or a mean excess weight loss of 59%. The mean BMI dropped from a pre-op 45 to a post-op 31.There were 7 complications which required emergency surgery (5%), which included 4 leaks, 2 subphrenic abscesses, and 1 wound dehiscence. Other complications included 4 hernias, 3 staple-line failures, 1 transient renal failure, and 3 incidences of peptic ulcer disease requiring surgery, giving a total major complication rate of 13% in 17 patients, with no deaths. An earlier experience of this author comparing conversion RYGBP vs revision gastroplasty found better morbidity rates and weight loss with those converted to RYGBP. Conclusion: Converting failed gastric limiting and other bariatric procedures to RYGBP was safe and effective. Technical approaches to each problem type encountered are presented.