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.     

The Magenstrasse and Mill Procedure can be Combined with a Roux-en-Y Gastric Bypass to Produce Greater and Sustained Weight Loss

Background: The Magenstrasse and Mill operation (M&M) is effective in producing sustained weight loss and reducing obesity-related co-morbidity. It avoids the implantation of foreign material and is a more physiological procedure by maintaining normal gastric emptying. Side-effects are minimal and operative mortality is low. Satisfactory weight loss is seen at 1 year with 60% of excess weight lost. The present study compared weight loss produced by the combination of a Roux-en-Y gastric bypass (RYGBP) with the standard M&M procedure. Methods: Between 1993 and 2001, 118 patients underwent surgery for the treatment of morbid obesity. 70 patients between 1993 and 1998 underwent only a M&M vertical gastric stapling, and 48 patients from 1998 underwent the M&M combined with a RYGBP. Results: Median follow-up for the M&M procedure was 36 months (range 1 to 72) and for the combined M & M and RYGBP was 30 months (range 1 to 48). At all time points following surgery, patients having a RYGBP performed in addition to the standard M&M procedure demonstrated a significantly greater amount of weight lost (P<0.0001, Mann-Whitney U-test) and overall percentage of excess weight lost (P<0.0001, Mann-Whitney U-test). Both groups had a significant reduction in BMI, although this was greater in the group that underwent the combined procedure at 3 years (P<0.001, sample t-test). Conclusions: A more rapid and prolonged weight loss was found when the M&M procedure was performed in combination with a RYGBP. This suggests that this combined procedure may be more beneficial when greater amounts of weight loss are needed in the super-obese.     

Is Gastric Bypass Associated with More Complications in Patients Weighing >500 lb (>227 kg)?

Background: Increasing weight and BMI are believed to be independent risk factors for postoperative morbidity and mortality following Roux-en-Y gastric bypass (RYGBP). Methods: A retrospective chart review was performed. 25 patients weighing >500 lb (227 kg), mean BMI 78 kg/m² (range 69-97) underwent open RYGBP by a single surgeon over a 3-year period (Group A). Co-morbid conditions included diabetes, hypertension, obstructive sleep apnea, degenerative joint disease, and gastroesophageal reflux disease. Acute complications in this group were compared with an age and gender matched cohort of patients with similar co-morbidities who underwent the same operation by the same surgeon during the same period (Group B). The study group was also compared with the cumulative data of all patients who underwent the open RYGBP during the same period (Group C, n=253). Comparisons were made for hospital length of stay, ICU days, mortality, deep vein thrombosis (DVT), pulmonary embolism (PE), anastomotic leak, evisceration, and need for postoperative ventilation or reoperation. Results:There was no mortality,evisceration, leaks, or reoperation in the study group and no statistically significant differences between the groups. The incidence of DVT and PE was also not significantly different among the 3 groups.The days on postoperative mechanical ventilation (7 vs 0 vs 0 days), ICU days (0.68 vs 0 vs 0.03 days), and total LOS (4.56 vs 3.04 vs 3.0 days) was greater in the study group and statistically significant. Conclusions: Gastric bypass in patients weighing >500 lb (>227 kg) can be performed safely. A longer LOS, need for ICU stay and mechanical ventilation should be anticipated. Complications in this group were no greater than age-matched controls who weighed <500 lb or when compared with all patients who underwent RYGBP over the 3 years. Super-obese patients should not be discriminated against when considering a surgical option.     

Roux-en-Y divided gastric bypass results in the same weight loss as duodenal switch for morbid obesity

BACKGROUND: The 2 weight loss procedures most commonly performed in the United States are Roux-en-Y gastric bypass (RYGBP) and lateral gastrectomy with duodenal switch (BPD/DS). RYGB is a restrictive procedure, whereas BPD/DS relies on mild restriction of intake as well as malabsorption. Many physicians believe that weight loss is greater after BPD/DS than after RYGBP. However, these procedures have not been compared using groups of patients operated on by the same surgeons at the same institution. METHODS: We compared weight loss (expressed as percent of excess body weight [%EBW]) after 1 and 2 years in patients who underwent open RYGB or BPD/DS at our institution. RESULTS: Average length of stay was longer in BPD/DS patients than in those undergoing RYGBP (8.7 vs. 5.9 days, P <0.05). Anastomotic leaks were higher after BPD/DS (6% vs. 3%), but the difference did not achieve statistical significance. Mortality did not differ between the 2 groups (0.8% vs. 0.9%). In the group of patients followed-up for 1 to 2 years, age and distribution of men and women did not differ. Those patients undergoing BPD/DS had higher body mass index (59 vs. 55, P <0.05). Weight loss expressed as %EBW was similar between the 2 groups: 54% versus 53% at 1 year and 67% versus 64% at 2 years. CONCLUSIONS: Our data suggested that weight loss expressed as %EBW is similar between patients undergoing RYGBP and those undergoing BPD/DS. However, BPD/DS was associated with a longer hospital stay.     

Outcome of Gastric Bypass Patients

Background: The authors analyzed previously studied outcomes of Roux-en-Y gastric bypass (RYGBP), examined pre-surgical factors of post-surgical outcomes, and examined some of the psychosocial benefits. Methods: A retrospective chart review was conducted of 138 patients who underwent RYGBP between 1997 and 2000. Pre-surgical BMI, cholesterol, blood pressure, creatinine, number of antidepressant/glycemic drugs, and hemoglobin were recorded. Post-surgical follow-up was reviewed to examine changes. Results: Statistically significant changes were found in BMI, hypertension, cholesterol and glycemic control. Surgery was found to reduce creatinine from a pre-surgery average of 1.14 to 1.01 (n=11, p=.0015)). Patients with early post-operative complications (defined as length of stay >6 days or re-hospitalization within 1 month following surgery) had an average BMI of 57.58 (n=23) vs a BMI of 49.9 (n=103) in those who did not experience any complications (p = 0.0004).There was a statistically significant decrease in the rate of anti-depressant use following surgery. 49 patients were on antidepressants before surgery vs 38 following surgery (p=.0016). Conclusion: RYGBP significantly improves hypertension, hyperlipidemia and type II diabetes, and may also improve kidney function. Patients with higher pre-surgical BMIs are at greater risk for postsurgical complications. Postoperative antidepressant use appears to decrease.     

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

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

Experience with over 3,000 open and laparoscopic bariatric procedures: Multivariate analysis of factors related to leak and resultant mortality

Background: Intestinal leak is a potentially lethal complication of Roux en-Y gastric bypass (GBP). Identification of patients at high risk for leak may reduce complication rates of surgeons early in the procedure learning curve. Methods: A total of 3073 patients who underwent GBP were analyzed using univariate and multivariate logistic regression analyses of the following preoperative factors: hypertension (HTN), diabetes mellitus (DM), sleep apnea (SA), age, gender, weight, body mass index (BMI), and surgery type. Multivariate logistic regression analysis was performed for each procedure type. Results: There were 48 (1.5%) deaths. Independent risk factors for death included leak, weight, procedure type, and HTN. A total of 102 (3.2%) leaks were found. Independent factors for leak included age, male gender, SA, and procedure type. Conclusion: The data suggests that older, heavier male patients with multiple comorbid conditions are at increased risk for leak and mortality. Surgeons early in their learning curve should avoid these high-risk patients to reduce complications.     

Roux-Y Gastric Bypass: an effective anti-reflux procedure

Gastric limiting procedures have made an improvement in the lives of those patients in whom they have been successful. Not only have there been marked improvements in diabetes, hypertension, and arthritis, but there have been a number of other ‘spin-offs’, not the least of which is control of reflux esophagitis by totally eliminating the secretion of the parietal cell mass of the stomach from rising into the esophagus. We compared a group of 100 obese patients with reflux esophagitis who underwent Roux-Y gastric bypass (RYGBP) to a normalsized group of 23 patients on whom we had done Nissen fundoplications in the past. Visick gradings I-II of 100% vs 87%, respectively, may indicate a superiority of RYGBP over the Nissen procedure. Although the groups and time periods are too divergent to draw statistically significant conclusions, one can see that the RYGBP population was apparently better served considering their cure of ‘heartburn’ and other reflux symptoms as well as their achievement of sustained weight loss.     

Band Erosion after Laparoscopic Gastric Banding: Occurrence and Results after Conversion to Roux-en-Y Gastric Bypass

Background: Laparoscopic adjustable gastric banding is a popular bariatric operation. Unfortunately, long-term complications such as slippage, infection, and intragastric migration (erosion) may occur. With erosion, band removal is mandatory. Options to prevent weight regain are delayed implantation of a new band, or conversion to another bariatric procedure such as Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion. We present our experience with band erosion and immediate or delayed conversion to RYGBP. Methods: With a multidisciplinary team approach and prospective data collection, a comparison was made between patients with and without band erosion. The patients who were converted to RYGBP for band erosion were analyzed. Results: Gastric banding was performed on 347 patients between 1995 and 2002. Median follow-up is 52 months. Band erosion developed in 24 patients (6.8 %).The latter were heavier before gastric banding (BMI 45.9 vs 43.3, P <0,01). No band had ever been overinflated. Band erosion was diagnosed after a mean of 22.5 months (3-51). At time of diagnosis, mean BMI of 33.5 kg/m² (22.5-48) and average excess weight loss (EWL) of 52.9% (25-97) did not differ from that of the remaining patients at the respective time interval. The band was removed in all cases. Conversion to RYGBP was performed at the same time in 11, and a few months later in 2 patients. Operative morbidity included 1 leak (reoperation) and 4 wound infections. All but 1 patient lost further weight after reoperation, or at least maintained their weight. At last follow-up, mean EWL in relation to the pre-banding weight was 65.1%, and 69.2% of the patients had an EWL >50%, which compares favorably with the results obtained after primary RYGBP. Conclusions: In our series with a median follow-up >4 years, band erosion was more common than usually reported. Band removal with immediate or delayed conversion to RYGBP is feasible with an acceptable morbidity, and prevents weight regain in most cases. These results support further use of this approach for band erosion.     

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.     

Predictors of Weight Status following Laparoscopic Gastric Bypass

Background: Weight loss after bariatric surgery varies and depends on many factors, such as time elapsed since surgery, baseline weight, and co-morbidities. Methods: We analyzed weight data from 494 patients who underwent laparoscopic Roux-en-Y gastric bypass (RYGBP) by one surgeon at an academic institution between June 1999 and December 2004. Linear regression was used to identify factors in predicting % excess weight loss (%EWL) at 1 year. Results: Mean patient age at time of surgery was 44 ± 9.6 (SD), and the majority were female (83.8%). The baseline prevalence of co-morbidities included 24% for diabetes, 42% for hypertension, and 15% for hypercholesterolemia. Baseline BMI was 51.5 ± 8.5 kg/m². Mean length of hospital stay was 3.8 ± 4.6 days. Mortality rate was 0.6%. Follow-up weight data were available for 90% of patients at 6 months after RYGBP, 90% at 1 year, and 51% at 2 years. Mean %EWL at 1 year was 65 ± 15.2%. The success rate (≥50 %EWL) at 1 year was 85%. Younger age and lower baseline weight predicted greater weight loss. Males lost more weight than females. Diabetes was associated with a lower %EWL. Depression did not significantly predict %EWL. Conclusion: The study demonstrated a 65 %EWL and 85% success rate at 1 year in our bariatric surgery program. Our finding that most pre-surgery co-morbidities and depression did not predict weight loss may have implications for pre-surgery screening.     

Gastric Bypass for Morbidly Obese Patients with Established Cardiac Disease

Background: Bariatric surgery has often been avoided in patients with known cardiac disease because of the risks inherent in this patient population. This study was done to evaluate both the risks and benefits of Roux-en-Y gastric bypass (RYGBP) in morbidly obese patients with established cardiac disease. Methods: Data were analyzed to compare preoperative with postoperative co-morbid cardiac risk factors, peri-operative and postoperative complications, and change in body mass index (BMI) in 77 consecutive patients who had a preoperative diagnosis of cardiac disease and underwent RYGBP between March 1998 and January 31, 2006. Findings were compared to a concomitant control group without cardiac disease. Results: The preoperative presence of cardiac disease was manifested primarily as coronary artery disease (CAD) (45 patients) or as congestive heart failure (CHF) (32 patients). Of the patients with CAD, 60% had diabetes, 91% had hypertension and 39% had hyperlipidemia. 58% had one or more prior invasive cardiac procedures. In the CHF group, 50% had diabetes, 71% had hypertension and 44% had hyperlipidemia. The average length of stay was 3.7 days for CAD patients and 3.3 days for CHF compared to 3.0 days for controls. All co-morbid conditions were improved, and no patient died from cardiac disease. However, one patient died as a complication of GI bleeding, one patient subsequently underwent revascularization and another underwent stenting. Other complications up to 5 years postoperatively were frequent but seldom life-threatening. Conclusion: RYGBP surgery in patients with existing cardiac disease appears to have acceptable risk and is effective in reducing the co-morbid conditions of diabetes, hypertension, hyperlipidemia, sleep apnea and arthritis, but longer term data are needed.     

Suboptimal Weight Loss after Gastric Bypass Surgery: Correlation of Demographics, Comorbidities, and Insurance Status with Outcomes

Although Roux-en-Y gastric bypass surgery (RYGBP) is safe and effective at achieving weight loss in the majority of severely obese patients, a subset fails to achieve expected weight loss outcomes. Factors associated with poor weight loss are not well defined. Patients undergoing open RYGBP using a standardized surgical technique and clinical pathway by a single surgeon at a dedicated bariatric center were reviewed. Suboptimal weight loss was defined as failure to lose at least 40% excess body weight by 12 months postoperatively. Of 555 consecutive patients who underwent RYGBP from 1999 to 2004, a 12-month follow-up was available for the 495 (89%). Suboptimal weight loss occurred in 55 (11%) and was associated on unadjusted bivariate analysis with increased body mass index (BMI; p = 0.0002), diabetes mellitus (p = 0.0002), Medicaid insurance (p = 0.04), and male sex (p = 0.01). On adjusted multivariate analysis, increased BMI (p = 0.003), diabetes (p = 0.002), and male gender (p = 0.04) were associated with suboptimal weight loss, but type of insurance (p = 0.11) was not. Medicaid patients were younger (p = 0.01) and had higher BMI (p = 0.0002). Suboptimal weight loss after RYGBP appears to be associated with greater BMI, male sex, and diabetes but not type of insurance. This study may help identify patients who could benefit from increased perioperative education and counseling or selection of procedures with greater malabsorption. Presented at the 48th Annual Meeting of The Society for Surgery of the Alimentary Tract, Washington DC, May 19–24, 2007.     

Indications and Mid-Term Results of Conversion from Sleeve Gastrectomy to Roux-en-Y Gastric Bypass

Sleeve gastrectomy (SG) is currently considered as a primary bariatric surgery. This is because of its relative simplicity and satisfactory results. As observed with other bariatric procedures, surgeons are confronted with insufficient weight loss or weight regain, insufficient resolution of metabolic disorders, and intractable severe reflux. A retrospective analysis of conversion from SG to Roux-en-Y gastric bypass (RYGBP) was performed to assess weight loss, diabetes resolution, and relief of reflux symptoms. The mean interval between the two procedures was almost 24 months. Eighteen patients underwent conversion from SG to RYGBP for insufficient weight loss (n?=?9), severe reflux (n?=?6), and persistence of type 2 diabetes mellitus (T2DM) (n?=?3). The median follow-up was 15.5 months. Weight loss was significantly improved with a mean percentage of excess of body mass index loss at 64.6 % after conversion versus 47.1 % before conversion. All reflux symptoms were immediately relieved without any medication at the end of the follow-up. The three patients who had an operation for persistence of T2DM are now free of medication. Only one postoperative complication was observed as a small bowel injury, which was treated surgically. Conversion from SG to RYGBP is safe. Severe reflux is definitely treated and is an incontestable indication with this procedure. Additionally, weight loss and diabetes are clinically improved. Our results appear to be similar to those with a primary RYGBP.     

Greater Weight Loss with the Omega Loop Bypass Compared to the Roux-en-Y Gastric Bypass: a Comparative Study

Background

Despite similar initial results on weight loss and metabolic control, with a better feasibility than the Roux-en-Y gastric bypass (RYGBP), the omega loop bypass (OLB) remains controversial. The aim of this study was to compare the short-term outcomes of the laparoscopic OLB versus the RYGBP in terms of weight loss, metabolic control, and safety.

Methods

Two groups of consecutive patients who underwent laparoscopic gastric bypass surgery were selected: 20 OLB patients and 61 RYGBP patients. Patients were matched for age, gender, and initial body mass index (BMI). Data concerning weight loss, metabolic outcomes, and complications were collected prospectively.

Results

Mean duration of the surgical procedure was shorter in the OLB group (105 vs 152 min in the RYGBP group; p?<?0.001). Mean excess BMI loss percent (EBL%) at 6 months and at 1 year was greater in the OLB group (76.3 vs 60.0 %, p?=?0.001, and 89.0 vs 71.0 %, p?=?0.002, respectively). After adjustment for age, sex, initial BMI, and history of previous bariatric surgery, the OLB procedure was still associated with a significantly greater 1-year EBL%. Diabetes improvement at 6 months was similar between both groups. The early and late complication rates were not statistically different. There were three anastomotic ulcers in the OLB group, in smokers, over 60 years old, who were not taking proton pump inhibitor medication.

Conclusions

In this short-term study, we observed a greater weight loss with OLB and similar efficiency on metabolic control compared to RYGBP. Long-term evaluation is necessary to confirm these outcomes.     

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.     

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.     

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.     

Outcomes among elderly bariatric patients at a high-volume center

BACKGROUND: Bariatric surgery in elderly patients remains controversial. With a growing morbidly obese elderly population, management strategies and treatment outcomes need to be evaluated. METHODS: We reviewed all bariatric cases from 2001 to 2005 at a single institution. The preoperative factors (body mass index, smoking status, co-morbid conditions, number of medications) and surgical information (operation and length of stay) were recorded. Patients >60 years old who had undergone Roux-en-Y gastric bypass (RYGB) were followed up, and their surgical outcomes were analyzed (reduction in medications, resolution of diabetes mellitus and hypertension, percentage of excess body weight loss, complications, and mortality). RESULTS: Of 1065 patients, 76 (7.1%) were aged > or =60 years. Of these 76 patients, 61 (5.7%) underwent RYGB. The other 989 patients (92.9%) were <60 years old, and 952 of these underwent RYGB. In the older group, the mean number of co-morbid conditions was 10 +/- 3.3, 70.5% had diabetes, and 83.6% had hypertension. In the younger group, the mean number of co-morbidities was 4.7 +/- 2.3. The mean number of preoperative medications was 10 +/- 4.5 in the older group compared with 6.0 +/- 4.3 in the younger group. The mean length of stay was 2.9 days in both groups. Postoperatively, medications were reduced by nearly 50% in both groups. Diabetes and hypertension resolved or improved significantly in both groups. The mean percentage of excess body weight loss was lower in the older patients (54.9% versus 60.1%; P = .09). The 90-day operative mortality rate was 1.64% in the older group versus 0.53% for the younger group (P = NS). CONCLUSION: Our data support the use of RYGB in older patients in programs prepared to comprehensively manage the medical co-morbidities. Although the percentage of excess body weight loss was less, the mortality was acceptable despite the greater number of co-morbidities. Both diabetes and hypertension were more common in this population, with trends toward better improvement after RYGB than in younger patients.     

Is Roux-en-Y Gastric Bypass Adequate in the Super-Obese?

Background:The outcome after Roux-en-Y gastric bypass (RYGBP) in morbidly obese (MO) (body mass index [BMI] 40-50) was compared with super-obese (SO) (BMI >50) and super-super-obese (SSO) (BMI >60) patients. Methods: A prospective study was conducted in 738 consecutive patients who underwent RYGBP. 483 MO were compared with 184 SO and 70 SSO. Study endpoints included: effect on co-morbid conditions, postoperative morbidity and mortality, and long-term results. Statistical analysis utilized SPSS 11.0. Results: Percentage of males was significantly greater in the SO groups (16.5% vs 13%, P=0.01). Obesity-related conditions were significantly more frequent in the SO groups: sleep apnea (38% vs 17%, P<0.0005), gallstones (23% vs 14%, P=0.013); diabetes (29% vs 17%, P=0.002). Hospital stay was longer in the SO groups (5.7±6.1 days vs 4.6±2.6 days, P=0.024). Wound infection was more frequent in the SO groups (4.7% vs 1.4%, P=0.019). Postoperative mortality was greater in the SSO and SO groups (1.6% and 1.4%) than MO (0%) (P=0.019). Incisional hernia was more frequent in the SO groups (14.1% vs 8.6%; P=0.041). There was no significant difference in percent of excess weight loss (%EWL) between the three groups. EWL >50% at 5 years was: MO 81.5%, SO 87.5%, SSO 80%. The surgery was effective in treating the co-morbid conditions. Conclusion: RYGBP achieved significant durable weight loss and effectively treated co-morbid conditions in SO and SSO patients with acceptable postoperative morbidity and slightly greater mortality than in MO patients.