Beyond Weight Loss: Evaluating the Multiple Benefits of Bariatric Surgery After Roux-en-Y Gastric Bypass and Adjustable Gastric Band

Background

Despite the evidence for benefits beyond weight loss following bariatric surgery, assessments of surgical outcomes are often limited to changes in weight and remission of type 2 diabetes mellitus. To address this shortfall in assessment, the King’s Obesity Staging System was developed. This system evaluates the individual in severity stages of physical, psychological, socio-economic and functional disease. These are categorised into disease domains arranged so as to allow an alphabetic mnemonic as Airways, Body Mass Index (BMI), Cardiovascular, Diabetes, Economic, Functional, Gonadal, Health Status (perceived) and (body) Image.

Methods

In this cohort study, patients were assessed before and 12 months after surgery using the modified King’s Obesity Staging Score. We studied 217 consecutive patients undergoing Roux-en-Y gastric bypass (RYGB; N?=?148) and laparoscopic adjustable gastric band (LAGB; N?=?69) using the modified King’s Obesity Staging System to determine health benefits after bariatric surgery.

Results

Preoperatively, the groups had similar BMI, but the RYGB group had worse Airways, Cardiovascular, and Diabetes scores (p?<?0.05). After surgery, RYGB and LAGB produced improvements in all scores. In a subgroup paired analysis matched for preoperative Airways, BMI, Cardiovascular, and Diabetes scores, both procedures showed similar improvements in all scores, except for BMI where RYGB had a greater reduction than LAGB (p?<?0.05).

Conclusions

Both RYGB and LAGB deliver multiple benefits to patients as evaluated by the modified King’s Obesity Staging System beyond BMI and glycaemic markers. A validated staging score such as the modified King’s Obesity Staging System can be used to quantify these benefits.     

Laparoscopic Conversion of Failed Gastric Banding to Roux-en-Y Gastric Bypass. Short-term Follow-up and Technical Considerations

Background

The most common bariatric procedure in Australia is laparoscopic adjustable gastric banding (LAGB). Although successful, there is a substantial long-term complication and failure rate. Band removal and conversion to Roux-en-Y gastric bypass (RYGB) can be an effective treatment for complicated or failed bands. There is increasing evidence supporting good weight loss and resolution of band-related complications after conversion.

Methods

A prospective database of all bariatric procedures is maintained. Patients having revision of LAGB to RYGB between December 2007 and April 2011 were included in this study. Indications for surgery, operative details, morbidity and mortality, weight loss data, and post-operative symptoms were recorded.

Results

Eighty-two patients were included. Indications for surgery were inadequate weight loss (n?=?42), adverse symptoms (reflux = 8, dysphagia = 2), and band complications (band erosion = 7, band sepsis = 1, band slip = 11, esophageal dilatation = 11). Seventy-eight percent of procedures were completed in a single stage and 96.3% laparoscopically. There was no 30-day mortality. Total morbidity was 46.3% (minor complications = 32.9%, major complications = 13.4%). Median BMI was 43?kg/m² pre-RYGB and 34?kg/m² after 12?months. All patients with adverse band-related symptoms had resolution.

Conclusions

LAGB has a considerable complication and failure rate. Conversion of these patients to RYGB results in further weight loss and resolution of adverse symptoms. This is a challenging procedure, but can usually be performed in a single stage with acceptable morbidity and mortality. These patients should be treated in high-volume, subspecialty bariatric units.     

Revisional versus primary Roux-en-Y gastric bypass: a case-matched analysis

Background

Laparoscopic adjustable gastric banding (LAGB) has been a widely performed bariatric procedure. Unfortunately, revisional surgery is required in 20–30 % of cases. Data comparing revisional and primary gastric bypass procedures are scarce. This study compared revisional malabsorptive laparoscopic very very long limb (VVLL) Roux-en-Y gastric bypass (RYGB) with primary VVLL RYGB and tested the hypothesis that one-stage revisional laparoscopic VVLL RYGB is an effective procedure after failed LAGB.

Methods

In this study, 48 revisional VVLL RYGBs were matched one-to-one with 48 primary VVLL RYGBs. The outcome measures were operating time, conversion to open surgery, excess weight loss (EWL), and early and late morbidity.

Results

Surgical and medical morbidities did not differ significantly. No conversions occurred. The revisional group showed an EWL of 41.8 % after 12 months of follow-up evaluation and 45.1 % after 24 months based on the pre-revisional weight. The total EWL based on the weight before the LAGB was calculated to be 54.3 % after 12 months and 57.2 % after 24 months. The EWL in the primary RYGB group was significantly higher for both types of calculation: 41.8 %/54.3 % versus 64.1 % (p < 0.001 and <0.01) after 12 months and 45.1 %/57.2 % versus 70.4 % (p < 0.001 and <0.002) after 24 months.

Conclusions

Revisional laproscopic VVLL RYGB can be performed as a one-stage procedure by experienced bariatric surgeons but shows less effective EWL than primary RYGB procedures.     

Alcohol Use Disorders After Bariatric Surgery

Background

The increased incidence of alcohol use disorders (AUD) after bariatric surgery has been proposed despite limited empirical support. We sought to determine the prevalence of current and lifetime AUD and other Axis I diagnoses in patients who have undergone bariatric surgery, and to test the hypothesis that greater weight loss is associated with a higher incidence of AUD following surgery.

Methods

Individuals who underwent bariatric surgery between 2004 and 2007 were recruited for inclusion in the study. The diagnosis of current and lifetime AUD and other Axis I disorders was assessed using the Structured Clinical Interview for DSM-IV.

Results

A total of 51 individuals were included. The prevalence of lifetime and current AUD was 35.3% and 11.8%, respectively. No associations were found between weight loss following surgery and the development of an AUD or other Axis I diagnoses. Significantly more current AUD was reported in (1) individuals with a lifetime history of AUD compared to those without a lifetime AUD (p?p?Conclusions Individuals undergoing bariatric surgery were found to have a lifetime prevalence of AUD comparable to the general population. Although weight loss was not associated with the development of an AUD following surgery, individuals with a lifetime history of AUD may be at increased risk for relapsing to alcohol use after surgery. All instances of current AUD were identified in individuals undergoing RYGB as opposed to LAGB.     

Rate of revisions or conversion after bariatric surgery over 10 years in the state of New York

Background

A primary measure of the success of a procedure is the whether or not additional surgery may be necessary. Multi-institutional studies regarding the need for reoperation after bariatric surgery are scarce.

Acute Improvement in Insulin Resistance After Laparoscopic Roux-en-Y Gastric Bypass: Is 3 Days Enough to Correct Insulin Metabolism?

Background

Although medium- to long-term improvement in insulin resistance and T2DM after Roux-en-Y gastric bypass (RYGB) is well documented, few studies have analyzed the acute effects after surgery. Understanding these effects might help explain the physiologic adjustments after surgery and help in managing insulin resistance and controlling the hypoglycemic treatment for bariatric patients.

Methods

We recruited a prospective cohort of 55 consecutive female patients that underwent primary laparoscopic RYGB between January and June/2011. Blood samples were collected preoperatively and at the first, third, and fifth post-operative days after an overnight fast.

Results

There was a significant increase in homeostasis model assessment for insulin resistance (HOMA-IR) on day 1 (2.36 vs 3.12; p?=?0.032), followed by a rapid decrease from day 3 onward (3.12 vs 1.70; <0.001). We found a statistically significant difference (p?<?0.05) at all time points compared with baseline. HOMA-IR levels at POD5 were 47 % lower than baseline values and were not significantly different from values at 6 months (1.24 vs 0.93; p?=?0.09). The blood levels of glucose and insulin closely matched those of HOMA-IR.

Conclusions

RYGB results in a rapid improvement in insulin resistance and a clinically significant decrease in fasting glucose and insulin levels. This improvement is significant at the 3rd post-operative day, and by the 5th day, patients express insulin resistance levels that are similar to those expressed at 6 months after surgery. This work highlights the acute metabolic impact of surgery. Understanding the behavior of insulin and glucose after surgery might improve our knowledge of the pathophysiology of diabetes and lead to novel therapies and tailored surgical approaches.     

Gastric Bypass and Sleeve Gastrectomy: the Same Impact on IL-6 and TNF-α. Prospective Clinical Trial

Background

Due to the association between the quantity of adipose tissue and concentrations of interleukin-6 (IL-6) and tumor necrosis factor (TNF-α), this work aimed to assess the effects of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) procedures on serum IL-6 and TNF-α concentrations.

Methods

This study evaluated serum IL-6 and TNF-α levels, as well as routine anthropometric and biochemical values, before and 1 year post-bariatric surgery. Fifty percent of patients (n?=?24) underwent RYGB, and 50 % (n?=?24) underwent SG. Prior to bariatric surgery, IL-6 and TNF-α mRNA expression levels in subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) were investigated in obese women.

Results

There was a significant reduction (p?<?0.05) in all anthropometric and routine biochemical measurements in patients in the RYGB and SG groups 1 year post-surgery. The serum concentrations of IL-6 and TNF-α were reduced following surgery in both groups (p?<?0.05). No differences in the relative expression levels of IL-6 and TNF-α were found between SAT and VAT prior to bariatric surgery.

Conclusions

RYGB and SG procedures demonstrated a similar impact on adipokine levels in women 1 year post-surgery. Both techniques may improve the course of chronic diseases and the state of inflammation associated with obesity.     

Preoperative Fasting Plasma C-Peptide Level May Help to Predict Diabetes Outcome After Gastric Bypass Surgery

Background

To evaluate whether preoperative measurement of fasting plasma C-peptide levels is useful to predict diabetes outcome after Roux-en-Y gastric bypass (RYGB) surgery.

Materials and Methods

Diabetes outcome after RYGB was evaluated in 126 obese patients: 41 non-diabetic controls (NDC), 29 with impaired glucose tolerance (IGT) and 56 had type 2 diabetes mellitus (T2DM). Body weight, fasting plasma glucose, fasting C-peptide levels, and HbA1c were measured at baseline and 3.6?±?0.16 years after GBS. Complete resolution of diabetes was defined as: fasting glucose <7.0 mmol/l, HbA1c <6.5 %, achieved without anti-diabetic medication.

Results

Patients with complete resolution of diabetes had a more recent diagnosis of T2DM, lower preoperative HbA1c levels and lower daily doses of metformin and insulin use. These parameters were related to postoperative HbA1c levels but they failed to mark the specific patients who had not reached complete resolution of T2DM. Fasting preoperative C-peptide levels had better predictive power: 90 % of T2DM patients with preoperative fasting C-peptide levels >1.0 nmol/l achieved a postoperative HbA1c <6.5 %, and 74 % achieved complete resolution of their diabetes. In contrast, none of the T2DM patients with a preoperative fasting C-peptide <1.0 nmol/l attained these goals.

Conclusions

A preoperative fasting plasma C-peptide level <1.0 nmol/l in severely obese T2DM patients indicates partial β-cell failure, and is associated with a markedly reduced chance of complete resolution of T2DM after RYGB. We therefore advocate measuring C-peptide levels in all diabetic patients up for bariatric surgery to improve the prediction of outcome.     

Impact of Roux-en-Y gastric bypass on regulation of diabetes type 2 in morbidly obese patients

Background

The idea of surgery as treatment for type 2 diabetes mellitus (T2DM) was established in the US and was based on observation of patients after bariatric surgery. Resolution of T2DM is observed within a few weeks after surgery, in some cases even during hospitalization. The aim of this study was to evaluate the impact of Roux-en-Y gastric bypass (RYGB) on diabetes in morbidly obese patients.

Methods

We present 73 patients with T2DM who underwent laparoscopic RYGB (LRYGB) to treat morbid obesity. In the group of 73 obese patients (mean BMI?=?42.3), there were 41 females and 32 males.

Results

Regression of T2DM was observed in 51 patients (69.8%) while hospitalized. In addition, 14 patients’ (19.1%) glycemia and HBA1c stabilized within 12?weeks after surgery (total regression rate of 88.9%).

Conclusion

The ultimate evaluation of this method of treating T2DM is still lacking and requires several years of meticulous clinical studies. Despite that, considering the high cost of life-long conservative therapy of T2DM and its complications and the severe impact T2DM has on quality of life, surgical metabolic intervention may become the most reasonable solution in many cases.     

Improvement of Type 2 Diabetes Mellitus (T2DM) After Bariatric Surgery—Who Fails in the Early Postoperative Course?

Backround

Diabetes surgery in nonobese or moderately obese patients is an emerging topic. The identification of preoperative factors predicting diabetes outcome following bariatric surgery, especially for metabolic nonresponders, is imperative.

Methods

Between 2005 and 2011, 235 patients underwent bariatric surgery for morbid obesity. Eighty-two of 235 patients had type 2 diabetes mellitus (T2DM). Data from this subgroup were investigated with univariate and multivariate analyses to identify predictors for metabolic nonresponse after surgery.

Results

Diabetes did not improve in 17/82 patients within 3?months after surgery. No correlation between excess body weight loss and metabolic response was detected. In univariate analysis, preoperative duration of diabetes was significantly longer in the nonresponder group (9.146 vs. 6.270?years; *p?=?0.016), preoperative HbA1c levels were significantly higher among the nonresponders than among the responders (8.341 vs. 7.781?%; *p?=?0.033), and more patients in the nonresponder group were reliant on a multi-drug approach preoperatively (*p?=?0.045). In multivariate analysis, age, preoperative doses of insulin, and preoperative oral antidiabetics showed positive correlation to metabolic nonresponse after surgery (*p?=?0.04; *p?=?0.021; *p?=?0.021). Metabolic failure rate was lower after Roux-en-Y gastric bypass compared to other bariatric procedures (**p?=?0.008).

Conclusions

A long history of preoperative T2DM, high preoperative HbA1c levels, and a preoperative therapy consisting of diverse approaches to diabetes treatment may be factors predicting failure of diabetes improvement in the early postoperative course after bariatric surgery. Age, preoperative insulin, and oral antidiabetic medication can be regarded as independent, significant predictors for metabolic outcome after bariatric surgery.     

Predictors of remission of type 2 diabetes mellitus after laparoscopic gastric banding and bypass

Background

Type 2 diabetes mellitus (T2DM) is associated with obesity and results in considerable morbidity and mortality. Our objectives were to evaluate the effect of laparoscopic bariatric surgery on the control of T2DM in morbidly obese patients in a U.K. population and to determine the predictors of T2DM remission after bariatric surgery. The study was performed at teaching university hospitals and affiliated private hospitals.

Methods

Of 487 patients who underwent laparoscopic bariatric procedures from 2002 to 2007, 74 patients (15.2%) had established T2DM. The results are presented as the mean values. Multivariate analysis was used to identify the factors predictive of remission of T2DM after bariatric surgery.

Results

The body mass index before laparoscopic gastric bypass (LGB; n = 48) and laparoscopic adjustable gastric banding (LAGB; n = 26) were comparable (52 versus 51 kg/m², P = .508). At a mean follow-up of 16.9 months, 41% had remission and 59% had experienced improvement in T2DM. Although the duration of follow-up was significantly longer for the patients who had undergone LAGB than for those who had undergone LGB (23 versus 13.4 months, P = .001), the percentage of excess weight loss (%EWL) was significantly greater after LGB than after LAGB (59.4% versus 48.8%, P = .031), with an associated greater remission rate of T2DM (50% versus 24%, P = .034). Multivariate analysis revealed a greater %EWL and younger age to be independent predictors of postoperative remission of T2DM, and LGB, longer follow-up, and female gender were independent predictors of a greater %EWL.

Conclusion

The %EWL was the only predictor of remission of T2DM that was influenced by the choice of bariatric procedure. In our study, LGB offered greater weight loss and a chance of remission of T2DM compared with LAGB and within 2 years of surgery.     

Performance of the DiaRem Score for Predicting Diabetes Remission in Two Health Systems Following Bariatric Surgery Procedures in Hispanic and non-Hispanic White Patients

Objective

The objective of this study was to determine whether the DiaRem, a score that predicts type 2 diabetes (T2D) remission following roux-en-y gastric bariatric surgery (RYGB), also predicts remission following laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) in white and Hispanic patients.

Background

While bariatric surgery is highly effective in reversing insulin resistance, there are patients for whom surgery will not lead to remission. To date, there is no score for predicting remission following LAGB or LSG surgery. Additionally, there is little known about how to predict whether Hispanic patients will experience remission.

Methods

We conducted a retrospective cohort study of white and Hispanic patients with T2D who received bariatric surgery. There were 361 white and 130 Hispanic patients among whom 328 had RYGB surgery, 107 had LSG surgery, and 56 had LAGB surgery. We used age, diabetes treatment, and hemoglobin A1c to calculate DiaRem scores. Mann-Whitney U test was used to determine the association between DiaRem scores and remission. Area under the receiver operant curve (AUC) was used to assess the ability of the DiaRem to discriminate between patients who did and did not remit.

Results

The DiaRem was associated with partial remission in all surgery types for white and Hispanic patients (Mann-Whitney, p < 0.001). The DiaRem had moderate to high discriminant ability (AUC > 0.70) for all surgical and racial/ethnic groups.

Conclusions

The DiaRem distinguishes between patients likely and unlikely to experience remission, informing expectations of patients making T2D treatment decisions.

     

Revisional Laparoscopic Roux-en-Y Gastric Bypass Following Failed Laparoscopic Adjustable Gastric Banding

Background

Obesity is a worldwide epidemic and surgery is the only proven long-term treatment. The two most commonly performed bariatric procedures are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB). There are advocates of both procedures but LAGB is associated with potentially high failure rates and may require conversion to an alternative procedure.

Methods

This study reports our unit results for failed LAGB converted to LRYGB and compares them to primary LRYGB patients. All patients undergoing revisional LRYGB from July 2006 to December 2011 were included in the study. Comparisons were made to patients undergoing primary LRYGB over the same time period for post-operative weight loss, complications and length of stay.

Results

Of the patients, 722 were analysed of which 55 underwent revisional surgery. There was no statistical difference in percentage of excess weight loss at 6 months, 1 year or 2 years following surgery between the primary and revisional surgery cohorts (54.5, 63.7, 65.2 vs 51.6, 59.5, 59.4, p?=?NS). There was no difference in morbidity, mortality or length of stay between the two groups. Revisional LRYGB was carried out as a single surgery in 43 (78 %) patients.

Conclusions

Revisional LRYGB surgery can be carried out safely and efficiently in experienced bariatric units. Good short- and medium-term weight loss can be achieved with no increase in morbidity, mortality or length of hospital stay. This study adds weight to the argument that LRYGB is the revisional procedure of choice following failed LAGB.     

Changes in GIP gene expression following bariatric surgery

Background

After bariatric surgery, there is a significant improvement in type 2 diabetes (T2D). T2D has been linked to incretins, including glucose-dependent insulinotropic polypeptide (GIP). Analysis of bariatric surgery patients may help to understand the link between GIP and T2D.

Methods

Twenty-three morbidly obese patients underwent Roux-en-Y gastric bypass (RYGB) or gastric banding. Overall, there were 12 RYGB (5 T2D; 7 nondiabetic) patients and 11 gastric band (7 T2D; 4 nondiabetic) patients. Preoperative and postoperative blood samples were collected. Total RNA was extracted, cDNA synthesized, and real-time quantitative PCR were used to quantify gene expression. Student’s t test was used for statistical analysis.

Results

Postoperatively, T2D resolved or improved in 83.3 % (10/12) of the diabetic patients. Six (4 RYGB, 2 bands) patients discontinued hypoglycemic medications and four (3 RYGB, 1 band) patients discontinued the majority of their hypoglycemic agents. The remaining two diabetic patients (bands) showed no improvement. Postoperative GIP gene expression increased 4.36-fold (p = 0.02) in diabetic RYGB patients, whereas diabetic band patients increased 1.4-fold (p = 0.25). All diabetic patients with either resolution or improvement of T2D, had a 3.4-fold increase (p = 0.01) but nonresponders decreased 0.69-fold (p = 0.41). Nondiabetic RYGB patients increased 2.21-fold (p = 0.07) versus a 0.81-fold (p = 0.37) decrease of nondiabetic band patients.

Conclusions

This is one of the initial studies that show a significant increase in GIP gene expression following a RYGB. This increase correlates with the clinical resolution of T2D. The anatomical changes after RYGB may account for these changes. Based on this data, GIP may be a key peptide in the “foregut hypothesis” for resolution of T2D.     

Morbidity Rates and Weight Loss After Roux-en-Y Gastric Bypass,Sleeve Gastrectomy,and Adjustable Gastric Banding in Patients Older Than 60 Years old: Which Procedure to Choose?

Background

As life expectancy increases, more elderly patients fit into the criteria for bariatric procedures. The aim of our study is to evaluate and compare the safety and efficacy of Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB) in patients older than 60.

Material and Methods

Between January 2005 and December 2013, 68 LAGB, 73 LSG, and 212 RYGB patients were 60 years or older at the time of primary procedure. A retrospective review was performed in these patients.

Results

Mean age and body mass index (BMI) was 62.7?±?2.2, 64.1?±?2.9, and 62.6?±?2.3 years and 42.7?±?5.6, 44.0?±?7.0, and 45.2?±?6.7 kg/m² for LAGB, LSG, and RYGB at the time of procedure, respectively.Seven (10.3 %) patients from the LAGB, 3 (4.1 %) from the LSG, and 29 (13.8 %) from the RYGB group required readmissions. Reoperation rate was 10.3, 1.4, and 9.5 % in LAGB, LSG, and RYGB, respectively. The difference in reoperation rates was statistically significant (p?<?0.03) while that in readmission rates was not (p?>?0.58). Procedure-related mortality rate was 1.4 % in the RYGB group, while no mortality was observed in LSG and LAGB groups. At 6, 12, and 18 months postoperatively, mean percentage of excess weight loss were highest in the RYGB group, followed by LSG and LAGB group (p?<?0.01). Mean number of comorbidities at the last follow-up significantly decreased in LSG and RYGB patients.

Conclusions

LSG showed the lowest readmission and reoperation rate, and RYGB patients had the highest mortality rate. Weight loss and comorbidity resolution were effectively achieved in RYGB and LSG patients.

     

Trends in adolescent bariatric surgery evaluated by UHC database collection

Background

With increasing childhood obesity, adolescent bariatric surgery has been increasingly performed. We used a national database to analyze current trends in laparoscopic bariatric surgery in the adolescent population and related short-term outcomes.

Methods

Discharge data from the University Health System Consortium (UHC) database was accessed using International Classification of Disease codes during a 36?month period. UHC is an alliance of more than 110 academic medical centers and nearly 250 affiliate hospitals. All adolescent patients between 13 and 18?years of age, with the assorted diagnoses of obesity, who underwent laparoscopic adjustable gastric banding (LAGB), sleeve gastrectomy (SG), and laparoscopic Roux-en-Y gastric bypass (LRYGB) were evaluated. The main outcome measures analyzed were morbidity, mortality, length of hospital stay (LOS), overall cost, intensive care unit (ICU) admission rate, and readmission rate. These outcomes were compared to those of adult bariatric surgery.

Results

Adolescent laparoscopic bariatric surgery was performed on 329 patients. At the same time, 49,519 adult bariatric surgeries were performed. One hundred thirty-six adolescent patients underwent LAGB, 47 had SG, and 146 patients underwent LRYGB. LAGB has shown a decreasing trend (n?=?68, 34, and 34), while SG has shown an increasing trend (n?=?8, 15, and 24) over the study years. LRYGB remained stable (n?=?44, 60, and 42) throughout the study period. The individual and summative morbidity and mortality rates for these procedures were zero. Compared to adult bariatric surgery, 30?day in-hospital morbidity (0 vs. 2.2?%, p?<?0.02), the LOS (1.99?±?1.37 vs. 2.38?±?3.19, p?<?0.03), and 30?day readmission rate (0.30 vs. 2.02?%, p?<?0.05) are significantly better for adolescent bariatric surgery, while the ICU admission rate (9.78 vs. 6.30?%, p?<?0.02) is higher and overall cost ($9,375?±?6,452 vs. $9,600?±?8,016, p?=?0.61) is comparable.

Conclusion

Trends in adolescent laparoscopic bariatric surgery reveal the increased use of sleeve gastrectomy and adjustable gastric banding falling out of favor.     

Band removal and conversion to sleeve or bypass: are they equally safe?

Introduction

Patients who require laparoscopic adjustable gastric band (LAGB) removal are often converted to sleeve gastrectomy (SG) or roux-en-Y gastric bypass (RYGB). The relative safety of these salvage bariatric procedures is unclear. We hypothesized that LAGB removal with conversion to SG (BSG) or RYGB (BRYGB) would be associated with higher morbidity and mortality compared to primary SG or RYGB.

Methods

National Surgical Quality Improvement Project data (2005–2011) were analyzed. Patients undergoing SG, RYGB, BRYGB, and BSG were identified. The incidence of major complications, as well as mortality was compared between groups. Multivariate analysis was performed to identify patient factors and operation types associated with major complications or mortality. Odds ratios (OR) were calculated with 95 % confidence intervals (CI) with p value <0.05 considered statistically significant.

Results

A total of 51,609 patients were analyzed, consisting of primary RYGB (n = 46,153), BRYGB (495), primary SG (n = 4,831), and BSG (n = 130) patients. All groups had similar mean age (45 ± 11-years old). Salvage patients were more commonly female (89 vs. 79 %) and with lower body-mass index than primary bariatric patients (BMI 42 ± 8 vs. 46 ± 8 kg/m2). Major complication rates were 5.23 % (RYGB), 4.65 % (BRYGB), 3.95 % (SG) and 6.92 % (BSG), with 30-day mortality of 0.16 % (RYGB), 0.20 % (BRYGB), 0.08 % (SG) and 0.77 % (BSG). Multivariate analysis showed that compared to SG, RYGB, and BSG were independent predictors of major complications. Multivariate analysis of mortality showed BSG was an independent predictor of mortality compared to SG (OR 8.02, 95 % CI 1.08–59.34, p = 0.04).

Conclusions

Band removal with conversion to RYGB is not associated with higher morbidity or mortality compared to primary RYGB. However, band removal with conversion to sleeve gastrectomy appears to be independently associated with a higher rate of major complications and mortality, and thus may not be the salvage procedure of choice.     

Baseline Abdominal Lipid Partitioning Is Associated with the Metabolic Response to Bariatric Surgery

Background

The purpose of this study was to compare the effects of two bariatric procedures on abdominal lipid partitioning and metabolic response.

Methods

Fifty-one patients (RYGB 31(11 M/20 F); (SG) 20(8 M/12 F)) who met the criteria of metabolic syndrome before the operation were followed following Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Visceral and subcutaneous abdominal fat depots were assessed by CT before, 6 months, and 12 months following the operation.

Results

Patients undergoing both procedures did not differ in baseline body mass index (BMI) (42.84?±?4.65 vs. 41.70?±?4.68 kg/m²) or abdominal lipid depots. BMI at 12 months post-op was similar (29.44?±?3.35 vs 30.86?±?4.31 kg/m² for RYGB and SG, respectively). Both procedures led to a significant reduction in visceral and subcutaneous fat at 6 months (p?p?p?Conclusions RYGB and SG induce a similar effect on abdominal fat mobilization. The metabolic effects in individual patients are mostly determined by their baseline abdominal lipid partitioning.     

Incidence of cholecystectomy after bariatric surgery

Background

Bariatric surgery predisposes patients to development of cholelithiasis, and therefore the need of a subsequent cholecystectomy; however, the incidence of cholecystectomy after bariatric surgery is debated.

Long-term Changes in Leptin, Chemerin and Ghrelin Levels Following Different Bariatric Surgery Procedures: Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

Background

Different studies have evaluated changes in adipo/cytokine levels after bariatric surgery and have given conflicting results. The adipo/cytokines, leptin and chemerin, and the orexigenic hormone, ghrelin, have been shown to play a role in the regulation of metabolism and appetite. The aims of our study were to test the levels of these molecules after bariatric surgery and to compare the results between Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy.

Methods

We analysed circulating levels of chemerin, ghrelin and leptin in 30 morbidly obese women (body mass index of >40 kg/m²). Subjects were studied at three time points: baseline (before the surgery started), and after 6 and 12 months.

Results

After surgery, chemerin (baseline, 95.03?±?23.79; after 12 months, 76.80?±?21.51; p?=?0.034) and leptin levels (baseline, 248.17?±?89.16; after 12 months, 63.85?±?33.48; p?<?0.001) were significantly lower than their baseline levels, whereas ghrelin was higher (baseline, 0.87?±?0.38; after 12 months, 1.08?±?0.31; p?=?0.010). Fasting glucose, insulin and homeostasis model assessment of insulin resistance levels were markedly lower postoperatively. High-density lipoprotein levels moderately increased and triglyceride levels sharply decreased. There were no differences between the types of bariatric surgery in terms of weight reduction, general metabolic state or adipo/cytokine levels after surgery.

Conclusions

Our study demonstrates a marked decrease in fasting leptin and chemerin levels, and an increase in ghrelin levels, after bariatric surgery-induced weight loss, independently of the type of surgery performed. Further studies are needed on the interrelation between the changes in the circulating levels of these molecules and the efficacy of the bariatric surgery procedures to induce the beneficial metabolic changes and to sustain body weight loss.