The Importance of the Length of the Limbs for Gastric Bypass Patients—An Evidence-based Review

The ideal length of the gastric bypass limbs is debated. Recent evidence suggests that standard limb lengths used today have a limited impact on patient weight loss. Our objective was to appraise critically the available evidence on the influence of the length of gastric bypass limbs on weight loss outcomes. We systematically reviewed MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects for articles reporting the effect of gastric bypass length on outcomes published between 1987 and 2009. Four randomized controlled trials and several retrospective studies were identified and reviewed. Longer Roux limb lengths (at least 150 cm) were associated with a very modest weight loss advantage in the short term in superobese patients. No significant impact of alimentary limb length on weight loss for patients with body mass index (BMI) <50 was seen. When the length of the common channel approaches 100 cm, a significant impact on weight loss is observed. The currently available literature supports the notion that a longer Roux limb (at least 150 cm) may be associated with a very modest weight loss advantage in the short term in superobese patients but has no significant impact on patients with BMI ≤50. To achieve weight loss benefit due to malabsorption, bariatric surgeons should focus on the length of the common channel rather than the alimentary or biliopancreatic limbs when constructing a gastric bypass especially in the superobese population where failure rates after conventional gastric bypass are higher.     

Obesity Surgery Results Depending on Technique Performed: Long-Term Outcome

Background  Many techniques have excellent results at 2 years of follow-up but some matters regarding their long-term efficacy have arisen. This is why bariatric surgery results must be analyzed in long-term follow-up. The aim of this study was to extend the analysis over 5 years, evaluating weight loss, morbidity, and mortality of the surgical procedures performed. Methods  This was a retrospective cohort study of the different procedures for morbid obesity practiced in our Department of Surgery for morbid obesity. The results have been analyzed in terms of weight loss, morbidity improvement, and postoperative morbidity (Bariatric Analysis And Reporting Outcome System). Results  One hundred twenty-five patients were operated on open vertical banded gastroplasty (VBG), 150 patients of open biliopancreatic diversion (BPD) of Scopinaro, 100 patients of open modified BPD (common limb 75 cm; alimentary limb 225 cm), and 115 patients of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Mean follow-up was: VBG 12 years, BPD 7 years, and LRYGBP 4 years. An excellent initial weight loss was observed at the end of the second year of follow-up in all techniques, but from this time an important regain of weight was observed in VBG group and a discrete weight regain in LRYGBP group. Only BPD groups kept excellent weight results so far in time. Mortality was: VBG 1.6%, BPD 1.2%, and LRYGBP 0%. Early postoperative complications were: VBG 25%, BPD 20.4%, and LRYGBP 20%. Late postoperative morbidity was: protein malnutrition 11% in Scopinaro BPD, 3% in Modified BPD group, and no cases reported either in VBG group or LRYGBP group; iron deficiency 20% VBG, 62% Scopinaro BPD, 40% modified BPD, and 30.5% LRYGBP. A 14.5% of VBG group required revision surgery to gastric bypass or to BPD due to 100% weight regain or vomiting. A 3.2% of Scopinaro BPD with severe protein malnutrition required revision surgery to lengthen common limb to 100 cm. A 0.8% of LRYGBP required revision surgery to distal LRYGBP (common limb 75 cm) due to 100% weight regain. Conclusions  The most complex bariatric procedures increase the effectiveness but unfortunately they also increase morbidity and mortality. LRYGBP is safe and effective for the treatment of morbid obesity. Modified BPD (75–225 cm) can be considered for the treatment of superobesity (body mass index > 50 kg/m²), and restrictive procedures such as VBG should only be performed in well-selected patients due to high rates of failure in long-term follow-up.     

Effects of Roux-en-Y Gastric Bypass on Resting Energy Expenditure in Women

Background  Bariatric surgery is the gold standard treatment for morbid obesity, but little is known about its effects on resting energy expenditure. Method  Twenty-one women underwent anthropometric and resting energy expenditure (REE) measurements before and 3 months after bariatric surgery using the Roux-en-Y gastric bypass (RYGBP) technique developed by Capella. Results  The patients experienced a significant reduction in body weight, body mass index, waist circumference, and waist-to-hip ratio (WHR). The cardiopulmonary variables oxygen uptake, carbon dioxide output, non-protein respiratory quotient, and heart rate all decreased, whereas oxygen pulse did not change significantly. Absolute REE showed a significant reduction 3 months postoperatively (2006.7 ± 376.4 kcal/day to 1763.3 ± 310.5 kcal/day), but no significant difference was found compared with REE relative to body weight (0.71 ± 0.15 kcal kg⁻¹h⁻¹ to 0.75 ± 0.12 kcal kg⁻¹ h⁻¹) or as percent of Harris-Benedict predicted REE (106.2 ± 21.0% to 103.3 ± 15.1%). Conclusion  In this study, bariatric surgery using the RYGBP technique (Capella) led to a significant decrease of body weight that decreased resting energy expenditure proportional to this weight loss, and to an increase in the utilization of fat as an energy substrate. It can be concluded that after 3 months, the Roux-en-Y gastric bypass surgery may provide significant metabolic benefits to morbidly obese women.     

Laparoscopic Mini-gastric Bypass: Experience with Tailored Bypass Limb According to Body Weight

Background Gastric bypass surgery is an effective and long-lasting treatment of morbidly obese patients. However, the bypass limb may need to be tailored in morbidly obese patients with a wide range of obesity. The aim of the present study was to report clinical result of tailored bypass limb in a group of patients receiving laparoscopic mini-gastric bypass surgery. Methods From Jan 2002 to Dec 2006, laparoscopic mini-gastric bypass was performed in 644 patients [469 women, 175 men: mean age 30.5 ± 8.1 years; mean body mass index (BMI) 43.1 ± 6.0] in our department. The gastric bypass limb was tailored according to the preoperative BMI. The clinical data and outcomes were analyzed. All the clinical data were prospectively collected and stored. Results Two hundred eighty-six patients belonged to lower BMI (BMI < 40; mean 36.0), 286 patients moderate BMI (BMI 40–50; mean 43.2), and 72 patients higher BMI (BMI > 50; mean 55.4). All procedures were completed laparoscopically. Mean operative time was 130 min, and mean hospital stay was 5.0 days. Twenty-three minor early complications (4.3%) and 13 major complications (2.0%) were encountered, with one death occurred (0.016%). There was no significant difference in operation time and complication rate between the groups. The mean bypass limb was 150 cm for the lower BMI group, 250 cm for moderate BMI group, and 350 cm for the higher BMI group. The mean BMI reduction 2 years after surgery was 10.7, 15.5, and 23.3 for the lower, moderate, and higher BMI group. The weight loss curves and resolution of obesity related comorbidities were compatible with the tailored bypass limbs between the groups. However, the lower BMI patients had more severe anemia than the other two groups. Conclusion Morbidly obese patients receiving gastric bypass surgery may need to tailor the bypass limb according to BMI. The application of gastric bypass in lower BMI patients should be more carefully.     

Histological Esophagitis Before and After Surgical Treatment of Morbid Obesity (Capella Technique): A Prospective Study

Background The effects of vertical banded gastroplasty/Roux-en-Y gastric bypass (Capella) on the esophageal mucosa of patients with histological esophagitis are poorly understood. To evaluate long-term effects, we investigated the persistence, aggravation or disappearance of histological esophagitis in patients with morbid obesity and reflux esophagitis (diagnosed by endoscopic biopsy) after Roux-en-Y gastric bypass. Methods Twenty-one patients with morbid obesity and esophagitis (histological diagnosis) were submitted to gastric bypass (Fobi-Capella technique) and underwent upper endoscopy and esophageal biopsy during the late postoperative period. Results The mean age of the patients was 42.57 ± 7.49 years (30 to 56). Nineteen (90.48%) patients were women, and two (9.52%) were men. Before surgery, the patients presented a mean weight of 124.26 ± 19.09 kg and a mean body mass index (BMI) of 48.46 ± 6.37 kg/m². Thirteen (61.90%) patients had endoscopic esophagitis before surgery. The mean weight and BMI were 81.65 ± 13.16 kg and 31.91 ± 4.99 kg/m², respectively, during the late postoperative period (29.80 ± 8.91 months). The mean percentage of excess weight loss was 68.7 ± 14.6%. Among the 21 patients with a preoperative histological diagnosis of reflux esophagitis, five (23.18%) had the same diagnosis after surgery, and four (19.04%) continued to present findings of endoscopic esophagitis. Conclusion Vertical banded gastroplasty/Roux-en-Y gastric bypass (Capella technique) is effective in the treatment of reflux esophagitis. No association was observed between the percentage of excess weight loss and improvement of esophagitis.     

Relationship between varying Roux limb lengths and weight loss in gastric bypass

BACKGROUND: The optimal Roux limb length for gastric bypass is unknown. Therefore, the effect of Roux limb length on weight loss and nutritional deficiency after a Roux-en-Y gastric bypass procedure was studied. METHODS: From September 2000 to February 2004, 165 Roux-en-Y gastric bypass surgeries were performed at William Beaumont Army Medical Center. One-year follow-ups were completed on 97 patients. Roux limbs varied from 100 cm to 150 cm, based on the patient's body mass index (BMI). Roux limb lengths were compared with 1-year changes in absolute weight, BMI, and nutritional levels. RESULTS: In the 97 patients, average age at the time of surgery was 44 years (range, 20-63). Average BMI was 46.7 +/- 6.6 kg/m(2) before surgery and 30.9 +/- 5.8 kg/m(2) at 1-year follow-up. Average absolute weight loss at 1 year was 43.7 +/- 12.8 kg. A statistically significant linear relationship existed between Roux limb length and reductions in BMI and absolute weight. No relationship existed between Roux limb length and changes in nutrient levels. CONCLUSION: A linear relationship exists between Roux limb length and 1-year weight loss.     

Adding malabsorption for weight loss failure after gastric bypass

Objective To present a technique of revisional RY gastric bypass in patients with unsatisfactory weight loss after primary gastric bariatric operations. Methods The Roux limb was lengthened by creating a 75–100 cm common channel below the enteroenterostomy with concomitant revision of the gastrojejunostomy. Results Fifty-four patients had this distal modification of RYGB including 47 patients who had primary gastric bypass and 7 patients who failed pure restrictive operations. Mean excess weight loss was 47.9% in patients followed for ≥1 year. Conclusions This distal modification of RYGB resulted in satisfactory weight loss for nearly half of the 54 patients in this series.     

Influence of the Actual Diameter of the Gastric Pouch Outlet in Weight Loss After Silicon Ring Roux-en-Y Gastric Bypass: An Endoscopic Study

Some sort of restriction of the pouch emptying is supported by many surgeons to allow a sustained weight loss through the use of a ring placed circumferentially around the gastric pouch. Most previous studies focused on the length of the ring, not the actual diameter of the gastric pouch outlet. This study aims to evaluate the association between the actual diameter of the gastric pouch outlet and the weight loss in obese patients submitted to silicon ring Roux-en-Y gastric bypass. We studied prospectively 257 patients that underwent silicon ring (65 mm) Roux-en-Y gastric bypass between July 2005 and August 2007. Upper digestive endoscopy was performed to measure the diameter of the gastric pouch outlet at 1 and 2 years with the aid of calibrated balloons. The diameter of the gastric pouch outlet ranged from 9 to 14 mm (mean = 11 mm). Excess weight loss ranged from 37% to 127% (mean = 69%) during the first year and 29% to 110% (mean = 69%) during the second year. A negative correlation between the diameter of the gastric pouch outlet and excess weight loss at first year (r = −0.792, p < 0.001) and at the second year of follow-up (r = −0.921, p < 0.001) was found. The actual diameter of the gastric pouch outlet was associated with weight loss after silicon ring Roux-en-Y gastric bypass during the 2-year follow-up.     

Is Weight Loss Better Sustained with Long-Limb Gastric Bypass in the Super-Obese?

Background  

While some studies have shown that long-limb gastric bypass with Roux limb length of 150 to 200 cm can attain better weight loss outcomes in super-obese patients (BMI >50 kg/m²) than the standard limb gastric bypass with Roux limb length of 100 to 150 cm, other studies have not shown similar findings. Additionally, no study has demonstrated the optimal length of the Roux limb that will result in ideal weight loss. The purpose of this study is to compare the long-term weight loss and weight regain of standard limb length (SLL) and long limb length (LLL) gastric bypass in patients with BMI >50 kg/m².     

Gastric Bypass is not Associated with Protein Malnutrition in Morbidly Obese Patients

Background  Patients undergoing bariatric surgery with a gastric bypass lose about 66% of excess weight. Although this procedure induces weight loss, it is unknown whether it leads to protein malnutrition, which is studied here. Methods  One hundred ten obese patients (body mass index, 47.9 ± 8.6 kg/m²) undergoing gastric bypass had a measurement of plasma albumin and transthyretin (formerly prealbumin) and a calculation of nutritional risk index (NRI) before and throughout the 2 years following the surgery. Results  All but five patients lost more than 15% of initial weight; the mean loss of excess weight was 65.2 ± 26.4% at 2 years. Plasma concentrations of albumin and transthyretin decreased after surgery, but while albumin returned to initial values after 12 months, transthyretin remained low. Only one patient had an albumin below 30 g/l; another one had a transthyretin lower than 110 mg/l. All NRI scores were lower than 83.5 (62 ± 5, ranging 44–70), qualifying patients for severe malnutrition. Conclusion  Malnutrition is difficult to diagnose in obese patients undergoing surgery. The large weight loss is most often not associated with protein malnutrition. Whether gastric bypass induces protein malnutrition remains to be established.     

Revision Surgery for Treatment of Weight Regain After Roux-En-Y Gastric Bypass

Background

This study aims to evaluate results on revision surgery for weight regain after gastric bypass, based on surgical technique and follow-up.

Methods

This study is a retrospective analysis of 29 patients who presented weight regain on follow-up after more than 5 years, divided into four groups according to revision surgery type: group 1 (n?=?9) includes patients who underwent an increase in the length of the alimentary limb to 200 cm; group 2 (n?=?13) are patients who underwent an increase in the length of the alimentary limb and placing of a silicon ring; group 3 (n?=?2) are patients who underwent an increase in the length of the alimentary limb and gastric plication, and group 4 (n?=?5) are patients who underwent gastric plication and placing of a silicon ring.

Results

The average preoperative weight before revision surgery was 117.8 kg, and the average postoperative follow-up for revision surgery was 13.7 months. Weight loss after revision surgery was observed in all groups but was greater in patients with longer revisional postoperative follow-up. Patients who underwent placing of a silicon ring presented greater weight loss than those who had had such a band since the original gastric bypass operation.

Conclusions

Data suggest that revision surgery may be a useful tool in achieving weight loss in patients presenting weight regain following gastric bypass, obesity, bariatric surgery, gastric bypass, weight regain, and revision surgery.     

Protein deficiency after gastric bypass: The role of common limb length in revision surgery

BackgroundBariatric surgery, especially the gastric bypass procedure, is an effective therapy for morbid obesity, but may reduce protein absorption and induce protein deficiency (PD). A recent study reported an issue about common limb length for PD.ObjectiveThis study aimed to examine the prevalence of PD after gastric bypass surgery and investigate the role of common limb length in PD-related revision surgery.SettingHospital-based bariatric center.MethodsFrom 2001 to 2016, 2397 patients with morbid obesity who underwent bariatric/metabolic surgery with 1-year follow-up were recruited. Serum albumin and total protein were measured before and 1 year after surgery. Medical records of patients who underwent revision surgery due to PD were reviewed.ResultsThe overall prevalence of PD was .5% preoperatively. The prevalence of PD increased to 2.0% at 1 year after surgery. The incidence was highest in one-anastomosis gastric bypass (2.8%) followed by Roux-en-Y gastric bypass (1.8%). Until the end of follow-up, all 19 patients who underwent revision surgery for intractable PD had a relatively short common limb length of <400 cm. After elongation of the common limb length to >400 cm in revision surgery, PD improved in all patients.ConclusionsA subset of patients can develop PD after gastric bypass surgery when the common limb length is <400 cm. In patients with intractable PD after gastric bypass surgery, revision surgery for elongation of common limb length to >400 cm is mandatory to avoid PD-related complications.     

The Impact of Race on Weight Loss After Roux-en-Y Gastric Bypass Surgery

Background Gastric bypass surgery for morbid obesity has dramatically increased in volume over the past decade. Caucasian patients have been noted previously to lose more weight after bariatric surgery than African-Americans patients. Data regarding predictors of maintaining weight loss after surgery are minimal. We sought to determine predictors of long-term weight loss after bariatric surgery. Methods Retrospective analysis using a multivariate logistic regression model of all patients undergoing Roux-en-Y gastric bypass surgery at the Medical University of South Carolina from May 1993 to December 2004 for whom 2 years of follow-up data was available. Our dependent variable was the percentage of weight lost from baseline, dichotomized at ±35%. Our primary independent variable was race, defined as Caucasian, African-American, or other. Relevant covariates were added to the model to control for their potential effects on outcome. Results One hundred eleven patients (17 male/94 female; 85% Caucasian, mean age 44 years (range 18–68 years). In our model, Caucasian subjects (adjusted odds ratio [OR] = 7.60, 95% confidence intervals [95%CI] = 1.83–31.5) and late post surgical complications (adjusted OR = 2.67, 95%CI = 1.05–6.80) significantly predicted weight loss at 2 years, after controlling for relevant confounders. Other covariates did not significantly impact the model. Conclusion Race and late post surgical complications significantly impacted the percentage of weight loss at 2 years for patients undergoing Roux-en-Y gastric bypass surgery at our institution. Future research should be directed at determining potential genetic and/or social reasons for these differences.     

Evaluation of Gastric Bypass Patients 1 Year After Surgery: Changes in Quality of Life and Obesity-Related Conditions

Background  Obesity has recently been cited as the number one killer in the USA. This problem is both a national and regional epidemic. The health care costs of obesity and obesity-related illnesses are ever increasing, and gastric bypass surgery is becoming a popular treatment strategy. Recently, reports describe not only surgical outcomes, but also quality of life outcomes. The bigger issue of obesity-related illness resolution is still evolving. Our institution has performed well over 500 gastric bypasses since 2002. We evaluated over 100 patients prior to and 1 year after gastric bypass surgery. Methods  A prospective study was designed in order to systematically examine quality of life in gastric bypass patients and couple the results with both objective and subjective assessment of bariatric surgery outcomes. One hundred nineteen patients undergoing gastric bypass at our institution from January 2005 to December of 2005 were enrolled in the study. In addition to routine preprocedural and postprocedural follow-up, completion of quality of life forms and anthropometric measurements were performed. Using these data, we then correlated the change in quality of life scores with social factors, weight loss success, and status of obesity-related conditions. We also examined the impact of alcohol intake and other demographic factors on both quality of life and obesity related conditions. Results  A total of 119 patients were enrolled in the study during the calendar year 2005. Follow-up at approximately 1 year (average 12.86 months) postsurgery was obtained in 75 patients. A significant reduction in weight (144.4 ± 34.4 vs. 91.5 ± 28.8; p < 0.0001), body mass index (52.4 ± 12.2 vs. 32.3 ± 8.6; p < 0.0001), mean systolic blood pressure (140.4 ± 14.7 vs. 130.0 ± 21.7; p < 0.001), and lipids (194.3 ± 33.8 vs. 165.7 ± 32.1; p < 0.0001) was noted. Quality of life scores 1 year after gastric bypass surgery were also significantly improved (35.9 ± 19.5 vs. 82.2 ± 23.5; p < 0.0001). There was also a significant reduction in the reported usage of medications for obesity related conditions. Various measures of success (change in BMI, change in quality of life scores, and follow up health ranking) were compared across demographic and social factors and no significant associations were identified. Conclusions  Gastric bypass is associated with a reduction in weight, BMI, mean systolic blood pressure, cholesterol, and the usage of medications for obesity-related conditions. A significant improvement in quality of life was also noted 1 year after surgery.     

Improvement of Associated Respiratory Problems in Morbidly Obese Patients after Open Roux-en-Y Gastric Bypass

Background Obstructive sleep apnea syndrome (OSAS) is present in 44% of patients scheduled for bariatric surgery. Respiratory dysfunction associated with this syndrome is attributable to chronic obstructive pulmonary disease (COPD) and/or obesity hypoventilation syndrome (OHS).We studied the long-term effect of bariatric surgery on weight loss, on the respiratory comorbidities associated with obesity, and on the need for non-invasive positive pressure ventilation. Methods We followed a sample of patients with respiratory co-morbidity scheduled for open Capella Roux-en-Y gastric bypass (RYGBP) over 5-years. Patients who were positive for polysomnographic studies and required continous positive airway pressure (CPAP) before surgery were included. All patients were subjected to the same anesthetic and surgical protocols. At 1 year after surgery, polysomnographic studies were performed and arterial blood gases and pulmonary function were tested. Results Of the 209 patients scheduled for bariatric surgery during the study period, 105 had respiratory co-morbidity. Of these, 30 required CPAP-BiPAP treatment before surgery and were included in our study. Surgery took 128 minutes (range 70 to 210 minutes). Tracheal extubation in the operating theater was possible for 26 patients (86.7%). During the early postoperative period, 7 patients (23.3%) presented respiratory complications. Length of hospitalization was 6.87 days (range 4 to 11 days). At 1 year after RYGBP, patients presented significant weight loss and improvement of hypoxemia (from 73.3 ± 10.6 to 90.5 ± 11.5, P = 0.000), hypercarbia (from 44.5 ± 5.7 to 40.6 ± 4.9, P = 0.005), and in spirometric (P = 0.004) and polysomnographic results (P = 0.001). CPAP-BiPAP treatment after weight loss was necessary in only 14% of patients (P = 0.001). Conclusions Weight loss after RYGBP improved arterial blood gases, respiratory tests and polysomnographic studies. CPAP treatment can be withdrawn in most patients.     

Distal gastric bypass: 2-m biliopancreatic limb construction with varying lengths of common channel

BackgroundLong-term durability after Roux-en-Y gastric bypass is challenging in the super-obese population. Although lengthening of biliopancreatic limb (BPL) is associated with higher rates of weight loss, shortening of common limb (CL) is related to higher risk of malabsorption.ObjectivesIn this study, we aimed at evaluating the importance of the total alimentary limb length by creating a 2-m BPL diversion with varying CL lengths.SettingHigh-volume bariatric center, Norway.MethodsThree groups of patients (N = 187) with different limb lengths were included in this retrospective cohort-analysis as follows: group 1 (n = 69; Roux limb = 150 cm, BPL = 60 cm), group 2 (n = 88; BPL = 200 cm, CL = 150 cm), and group 3 (n = 30; BPL = 200 cm, CL = 200 cm). Weight loss, regain, and failure were analyzed along with malabsorption issues.ResultsPreoperative body mass index (BMI) was higher in group 2 (58.5, P < .001) and 3 (57.4) versus group 1 (54.6, P = .011). No other clinically significant differences between the groups were noted. Follow-up rate was 95% at year 2, 74% at year 5, and 52% at year 10. At 10-year follow-up, excess weight loss and total weight loss was higher in group 2 (70.4%; 40.3%) and 3 (64.0%; 35.9%) compared with group 1 (55.9%; 29.2%). Excess weight loss failure was higher in group 1 versus 2 (30% versus 8.3%, P < .001). No difference in short- or long-term complications was seen except higher occurrence of internal hernia in distal Roux-en-Y gastric bypass groups (11.4%, 6.7%). Vitamin and mineral deficiencies occurred more frequently the shorter the CL was.ConclusionSustainable weight loss in a long-term follow-up is achieved by shortening the total alimentary limb length with a 2-m BPL diversion that should not be attached <200 cm from the ileocecal junction owing to higher rates of internal hernia and vitamin and mineral deficiencies.     

The Impact of Roux Limb Length on Weight Loss After Gastric Bypass

Background Extending the length of the Roux limb (RL) in gastric bypass (GBP) may improve weight loss in super obese patients (body mass index [BMI] > 50 kg/m²), but no consensus exists about the optimal length of the RL. We sought to determine the impact of RL length on weight loss in super obese patients 1 year after GBP. Materials and Methods One-year weight loss outcomes were analyzed in all super obese patients who underwent consecutive and primary laparoscopic or open GBP between January 2003 and June 2006. Patients were divided into two groups according to RL length (100 vs. 150 cm). The RL length was at the discretion of the attending surgeon. Baseline and follow-up data were collected prospectively. Multiple linear regression was used to adjust for potential confounders in the weight loss outcomes. Results Twelve-month follow-up data were available in 137 (85%) of 161 patients with a BMI ≥ 50 who underwent GBP during the study period. An RL of 100 or 150 cm was used in 102 (74.5%) and 35 patients (25.5%), respectively. In multivariate analysis, patients with the 150-cm RL lost more weight (68.5 vs. 55.3 kg, p < 0.01), had a greater change in BMI (25 vs. 21 kg/m², p = 0.01), and had greater excess weight loss (64 vs. 53%, p < 0.01). Conclusion A 150-cm RL provides better weight loss outcomes in super obese patients at 1-year follow-up.     

Laparoscopic Roux-en-Y Gastric Bypass in Patients with BMI <50: A Prospective Randomized Trial Comparing Short and Long Limb Lengths

Background: It has been shown that long limb gastric bypass in the super-obese (BMI >50) results in increased weight loss in comparison with conventional gastric bypass. The purpose of this study was to compare the effect of short and long limb lengths in patients with BM I<50. Methods: 48 patients with BMI <50 (46 females / 2 males, mean age 35±9.6 years) were prospectively randomized to either a short limb (biliopancreatic limb = 50 cm, alimentary limb = 100 cm) or long limb (biliopancreatic limb = 100 cm, alimentary limb = 150 cm) laparoscopic Roux-en-Y gastric bypass (LRYGBP). In all patients, a 25-mm EEA was used to fashion the gastrojejunostomy and the Roux limb was positioned in an antecolic, antegastric location. Limb lengths were precisely measured in all cases. Results: There was no difference in demographic data, preoperative BMI, presence of co-morbidities, or duration of surgery. The overall complication rate was not different between the 2 groups; however, the incidence of internal hernias was significantly higher in the long limb group (0 vs 4, P=0.029). The length of hospital stay was longer for the short limb group compared to the long limb group (3.1 vs 2.2 respectively, P=0.004). When comparing the short limb to the long limb patients, the BMI decreased equally in both groups at the following time intervals: preoperative (44.6 vs 44.9), 3 weeks (40.3 vs 40.9), 3 months (35.5 vs 35.2), 6 months (31.2 vs 31.8), and 12 months (27.7 vs 28.3). There were no significant nutritional deficiencies in either group. Conclusions: In patients with BMI <50 undergoing LRYGBP, increasing the length of the Roux limb does not improve weight loss and may lead to a higher incidence of internal hernias.     

Evaluation of Bone Disease in Morbidly Obese Women After Gastric Bypass and Risk Factors Implicated in Bone Loss

Background  In patients undergoing gastric bypass, massive weight loss and impairment of calcium intake and absorption in the duodenum and proximal jejunum may increase the risk of bone mass loss and fractures. However, few data are available regarding the impact of this surgery on the skeleton. The aim of our study was to examine the skeletal changes in a cohort of morbidly obese Caucasian women during the first year after gastric bypass and to analyse the factors implicated in the development of bone loss. Methods  Sixty-two morbidly obese white women aged 45.3 ± 8.9 years were studied. Anthropometric measurements, bone mineral density (BMD) screening using dual-energy X- ray absorptiometry and plasma determinations of calcium, phosphorus, parathyroid hormone (PTH), 25-hydroxyvitamin D [25(OH) D₃] and insulin-like growth factor-I (IGF-I) were made prior to and 12 months after surgery. Results  A year after surgery, BMD significantly decreased at the femoral neck (10.2 ± 5.7%) and at the lumbar spine (3.2 ± 4.4%). In the follow-up, 16.1% of women had osteopenia at the femoral neck and 19.3% at the lumbar spine, and 1.6% developed osteoporosis at the lumbar spine. Patients with bone disease were significantly older; the percentage of women with menopause was greater in this group and had lower initial and final values of lean mass. However, no differences in body mass index, weight loss, fat mass, calcium, PTH, 25(OH) D₃ or IGF-I values were found between groups. In the logistic regression analysis, lean mass 12 months after surgery and menopause were found to be the main determinants of osteopenia after adjusting for age with odds ratios of 0.82 and 9.13, respectively. Conclusions  There is a significant BMD loss at the femoral neck and lumbar spine a year after gastric bypass. Menopausal patients and those with greater lean mass loss are at greater risk and, consequently, should be closely followed up with periodic densitometries.     

Predictors of Weight Loss and Effectiveness of Roux-en-Y Gastric Bypass in the Morbidly Obese Hispano-American Population

Background  Co-morbidities and the metabolic response to intervention in morbid obesity have been reported to vary among different ethnic groups. We compared the rate of weight loss, effectiveness of gastric bypass surgery, and variables influencing success after gastric bypass in Hispanics compared to Caucasians. Methods  Morbidly obese adult (>18 years old) patients (body mass index [BMI] 40 or above) evaluated by our bariatric group from 2005 to 2006 who underwent Roux-en-Y gastric bypass (RYGBP) were studied. Every patient was evaluated for height, weight, BMI, percent body fat, fat mass, serum metabolic analysis (SMA) 12, lipid profile, complete blood count (CBC), iron, ferritin, Vitamins A, D, and B1, complete urinalysis and Fibrospect score II. Weight loss was evaluated at 1, 3, 6, and 12 months. Results  Seventy-five patients underwent successful open RYGBP with no mortality. Regardless of the significant difference in age and co-morbidities, the mean percentage of total weight loss after 1 year of follow-up was 32% for Hispanics and 30% for Caucasians with no significant difference (p > .5). When comparing the percentage of excess weight lost (% EWL) at 1, 3, 6, and 12 months, there was no significant difference between both groups. Using multiple regression analysis, we found that high-density lipoprotein (HDL) and systolic blood pressure (SBP) significantly predicted EWL at 12 months in Caucasians and Fibrospect predicted significantly EWL at 1 year. Conclusion  At 1 year after RYGBP, both ethnic groups lost ∼77–80% of their EWL and BMI. All Caucasians and 95.7% of Hispanics achieved successful weight loss (>50% EWL).