The dilemma of outcome assessment after operations for morbid obesity

Outcome of 56 patients who underwent horizontal gastroplasty (HGP) and 126 who underwent Roux-en-Y gastric bypass (RYGB) was assessed at 18 months postoperatively according to three definitions of successful weight loss; also, outcome was evaluated in the context of amelioration of obesity-related medical problems. Outcome definitions included the following: I, loss of 25% or more of preoperative weight; II, loss of 50% or more of excess weight; III, loss to within 50% of ideal body weight. To evaluate the impact of preoperative weight on success rate, patients were divided into two weight groups: "morbidily" obese patients, who were 100 to 199 pounds overweight (n = 146), and "super"-obese patients who were 200 pounds or more overweight (n = 36). Weight loss was significantly greater with RYGB versus HGP by each of the three definitions of success. Medical problems either improved or resolved with weight loss in 95% of cases. There were statistically significant differences in success rate depending on outcome definition in both HGP and RYGB patients. Success rate ranged from zero in super-obese HGP patients by Definition III to 97% in super-obese RYGB patients by Definition I. Although super-obese patients lost more pounds than the lighter morbidly obese patients, a significantly lower number of super-obese patients lost within 50% of ideal weight. Super-obese patients must lose more weight to reduce their actuarial risk. These results show that the definition of successful outcome may significantly influence the overall success rate in a large series of bariatric surgical patients.     

High secondary failure rate of rebanding after failed gastric banding

BACKGROUND: Over the last decade, more than 130,000 laparoscopic adjustable gastric bandings (LAGB) have been performed for the treatment of morbid obesity. Nowadays, longer follow-up data are available in the literature and increasing numbers of late complications and treatment failures of gastric banding have been reported. The aim of the present study was the long-term evaluation of two different rescue operations after failed LAGB: conversion to laparoscopic Roux-en-Y bypass (LRYGB) versus laparoscopic gastric rebanding. METHODS: Between January 1997 and November 2002, 74 consecutive patients underwent either laparoscopic gastric rebanding (n = 44) or LRYGB (n = 30) after failed LAGB. There were 14 men and 60 women, with a median age of 42 (23-60) years. The indication for reoperation was an increasing body mass index (BMI) and band-related complications such as pouch dilatation, band slippage, and penetration after LAGB. Rebandings were done by preference during the initial period of the study and LRYGB was the treatment of choice during the latter period. The success of the rescue operation was assessed by postoperative changes in the BMI, improvements of co-morbidities, and the need for further reoperations (secondary failure). The median follow-up was 36 months (range, 24-60 months). RESULTS: Patients who underwent LRYGB had a significantly better weight loss than patients with a rebanding operation (mean -6.1 versus +1.5 BMI points). In addition, the LRYGB patients showed a significantly better control of serum cholesterol during the long term follow-up (-0.6 versus +0.1 mmol/l). Almost half of the patients (45%) in the rebanding group needed a further operative revision, whereas only 20% underwent reoperation after rescue LRYGB. Thus, the secondary failure rate in the rebanding group was significantly higher compared to the bypass group (p = 0.028). CONCLUSIONS: The present long-term study confirms our previous finding that LRYGB is a better treatment than rebanding after failed laparoscopic gastric banding regarding weight loss and treatment of co-morbidities. During the long-term follow-up the reoperation rate due to secondary failure became significantly higher in the rebanding group. We therefore recommend that LRYGB should be preferred as rescue procedure after failed laparoscopic adjustable gastric banding.     

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.     

Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years

OBJECTIVE: To complete a long-term (>10 years) follow-up of patients undergoing isolated roux-en-Y gastric bypass for severe obesity. BACKGROUND: Long-term results of gastric bypass in patients followed for longer than 10 years is not reported in the literature. METHODS: Accurate weights were recorded on 228 of 272 (83.8%) of patients at a mean of 11.4 years (range, 4.7-14.9 years) after surgery. Results were documented on an individual basis for both long- and short-limb gastric bypass and compared with results at the nadir BMI and % excess weight loss (%EWL) at 5 years and >10 years post surgery. RESULTS: There was a significant (P < 0.0001) increase in BMI in both morbidly obese (BMI < 50 kg/m) and super obese patients (BMI > 50 kg/m) from the nadir to 5 years and from 5 to 10 years. The super obese lost more rapidly from time zero and gained more rapidly after reaching the lowest weight at approximately 2 years than the morbidly obese patients. There was no difference in results between the long- and short-limb operations. There was a significant increase in failures and decrease in excellent results at 10 years when compared with 5 years. The failure rate when all patients are followed for at least 10 years was 20.4% for morbidly obese patients and 34.9% for super obese patients. CONCLUSIONS: The gastric bypass limb length does not impact long-term weight loss. Significant weight gain occurs continuously in patients after reaching the nadir weight following gastric bypass. Despite this weight gain, the long-term mortality remains low at 3.1%.     

Laparoscopic Roux-en-Y gastric bypass, but not rebanding, should be proposed as rescue procedure for patients with failed laparoscopic gastric banding

OBJECTIVE: To define whether laparoscopic rebanding or Roux-en-Y gastric bypass represents the best approach for failed laparoscopic gastric banding in patients with morbid obesity. SUMMARY BACKGROUND DATA: Countless laparoscopic gastric bandings have been implanted during the recent years worldwide. Despite excellent short-term results, long-term failures and complications have been reported in more than 20% of patients. Which rescue procedures should be used remains controversial. Therefore, we analyzed our experience with the use of laparoscopic rebanding versus laparoscopic Roux-en-Y gastric bypass after failed gastric banding. METHODS: Using a prospectively collected database, we analyzed the feasibility, safety, and effectiveness of laparoscopic rebanding versus laparoscopic conversion to Roux-en-Y gastric bypass after failed laparoscopic gastric banding.RESULTS A total of 62 consecutive patients were treated in our institution between May 1995 and December 2002 for failed primary laparoscopic gastric banding, including 30 laparoscopic rebandings and 32 laparoscopic conversions to Roux-en-Y gastric bypass. Rebandings were preferably done during the initial period of the study and Roux-en-Y gastric bypass in the last period. Both groups were comparable before the initial banding procedures. At the time of redo surgery, patients receiving a gastric bypass had more esophageal dysmotility (47% vs. 7%, P = 0.002) and higher body mass index (BMI) than those elected for rebanding procedures (BMI 42.0 vs. 38.4 kg/m2, P = 0.015). Feasibility and safety: Each procedure was performed laparoscopically. Mean operating time was 215 minutes for gastric bypass and 173 minutes for rebanding (P = 0.03). Early complications occurred in one case in the rebanding group and in 2 cases in the bypass group; all underwent a laparoscopic reexploration without the need for open surgery. There was no mortality in this series. Effectiveness: BMI in the gastric bypass group decreased from 42.0 to 31.8 kg/m2 (P = 0.02) within 1 year of surgery, while it remained unchanged in the rebanding group. CONCLUSIONS: Laparoscopic conversion to a gastric bypass as well as laparoscopic rebanding are feasible and safe. Conversion to gastric bypass offers a significant advantage in terms of further weight loss after surgery. Therefore, this procedure should be considered as the rescue therapy of choice after a failed laparoscopic gastric banding.     

Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity

OBJECTIVE: To evaluate the short-term outcomes for laparoscopic Roux-en-Y gastric bypass in 275 patients with a follow-up of 1 to 31 months. SUMMARY BACKGROUND DATA: The Roux-en-Y gastric bypass is a highly successful approach to morbid obesity but results in significant perioperative complications. A laparoscopic approach has significant potential to reduce perioperative complications and recovery time. METHODS: Consecutive patients (n = 275) who met NIH criteria for bariatric surgery were offered laparoscopic Roux-en-Y gastric bypass between July 1997 and March 2000. A 15-mL gastric pouch and a 75-cm Roux limb (150 cm for superobese) was created using five or six trocar incisions. RESULTS: The conversion rate to open gastric bypass was 1%. The start of an oral diet began a mean of 1.58 days after surgery, with a median hospital stay of 2 days and return to work at 21 days. The incidence of early major and minor complications was 3.3% and 27%, respectively. One death occurred related to a pulmonary embolus (0.4%). The hernia rate was 0.7%, and wound infections requiring outpatient drainage only were uncommon (5%). Excess weight loss at 24 and 30 months was 83% and 77%, respectively. In patients with more than 1 year of follow-up, most of the comorbidities were improved or resolved, and 95% reported significant improvement in quality of life. CONCLUSION: Laparoscopic Roux-en-Y gastric bypass is effective in achieving weight loss and in improving comorbidities and quality of life while reducing recovery time and perioperative complications.     

Laparoscopic Roux-en-Y gastric bypass: minimally invasive bariatric surgery for the superobese in the community hospital setting

Roux-en-Y gastric bypass (RYGB) operation has become a popular choice for weight-reduction surgery. We report an outcome analysis of our early results with laparoscopic Roux-en-Y gastric bypass for superobese (BMI >50) patients. Between January 2000 and October 2001, we operated on 71 superobese patients. The mean body mass index (BMI) of patients at time of surgery was 57 kg/m2. The prospectively collected data included patient demographics, comorbidities, operative times, postoperative weight loss, and complications. Conversion to open gastric bypass was required in one patient. The overall complication rate was 10 per cent. Preoperative comorbidities were resolved or improved in 93 per cent of patients at 1-year postoperative. Average operative time and length of hospital stay were 196 minutes and 2.3 days, respectively. Mean percentage excess weight loss at 3, 6, 9, and 12 months was 27 per cent, 39 per cent, 49 per cent, and 55 per cent, respectively. Mean BMI decreased to 36 kg/m2 over a 12-month period. Laparoscopic Roux-en-Y gastric bypass surgery for superobese patients as performed in the community hospital setting can be both safe and effective with respect to overall postoperative course, early weight loss, and reduction of comorbidity.     

Roux-en-Y gastric bypass after previous unsuccessful gastric restrictive surgery

In the treatment of morbid obesity, simple gastric restrictive methods such as silicone adjustable gastric banding, vertical banded gastroplasty, and nonadjustable gastric banding often fail to control weight in the long run or give rise to intolerable side effects. Here we review our results from conversion of such failures to Roux-en-Y gastric bypass. The study comprised 44 patients (median age 42 years, range 24 to 60 years) who underwent revision surgery in 1996 and 1997. Body mass index at revision was 35 kg/m² (range 21 to 49 kg/m²). Previous bariatric procedures included silicone adjustable gastric banding (n = 26), vertical banded gastroplasty (n = 13), and gastric banding (n = 5). The most common reasons for conversion after silicone adjustable gastric banding and nonadjustable gastric banding were band erosion (n = 12) and esophagitis (n = 11). Staple line disruption (n = 12) with subsequent weight loss failure was the primary cause after vertical banded gastroplasty. There were no postoperative deaths or anastomotic leaks. One patient underwent reexploration because of an infected hematoma. Reflux symptoms and vomiting resolved promptly. At global assessment 2 years later, 70% of the patients were very satisfied. Median body mass index had decreased to 28 kg/m² (range 18 to 42 kg/m²). No patient was lost to followup. As reported previously, failure after vertical gastric banding can be treated by conversion to Roux-en-Y gastric bypass with good results. In this study we found that failure after silicone adjustable gastric banding can be treated successfully with Roux-en-Y gastric bypass as well. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, Louisiana, May 17–20, 1998 (poster presentation).     

Small Bowel Obstruction and Internal Hernias after Laparoscopic Roux-en-Y Gastric Bypass

Background: Small bowel obstruction (SBO) is a recognized complication of open bariatric surgery; however, the incidence after laparoscopic procedures is not clearly established. This paper reviews our experience with small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Methods: Between 1995 and 2001, 711 (246 antecolic, 465 retrocolic) patients underwent a laparoscopic proximal divided Roux-en-Y gastric bypass via the linear endostapler technique. 13 patients (1.8%) developed SBO requiring surgical intervention.There were 11 females and 2 males, ages 29-60 (mean 38), with mean weight 126 kg (range 105-188), and mean BMI 50 (range 41-59). 7 obstructive patients (55%) had undergone previous open abdominal surgery. Median time to obstruction was 21 days (range 5-1095). Mean follow-up of all patients is 43 months (range 3-79). Results: Etiology of obstruction was internal hernia - 6, adhesive bands - 5 (only 2 were related to prior open surgery), mesocolon window scarring - 1, and incarcerated ventral hernia - 1. The incidence of SBO was 4.5% (11/246) in the retrocolic group, and 0.43% (2/465) in the antecolic group, which was highly significant (P=.006). 1 adhesive patient required an open bowel resection for ischemia. There was 1 death. Conclusion: SBO occurred with an overall incidence of 1.8% in a large series of laparoscopic gastric bypass patients, and was associated with a high morbidity. A significant decrease in occurrence was found after adoption of antecolic placement of the Roux limb.     

Long-term results after gastric banding

BACKGROUND: Adjustable gastric banding is a popular bariatric operation in Europe. The rate of long-term complications like pouch dilatation, slippage and band migration and the long-term effect of weight loss are reported in meta-analysis and few studies for a period of more than five years. We report on experiences after gastric banding. METHODS: Over a period of 10 years 168 patients with morbid obesity were treated with gastric banding. Preoperative data, postoperative weight loss and long-term complications were prospectively obtained and retrospectively analyzed. RESULTS: Mean age of the patients was 41.7 years with a mean preoperative BMI of 49.6 kg/m2. No intraoperative or postoperative death occurred in the first 30 postoperative days. Intraoperative conversion rate was 7.1 %. 79.8 % of the patients (n = 134) were available for follow up (mean follow-up time 66.7 months). Long-term complications occurred in 22.5 % of the patients. 30 complications (17.8 %) were related to the band and 8 (4.7 %) to the access-port or to the tube. Mean excess weight loss was 39.6, 47.3, 44.2, 43.4 and 32 % after 1, 2, 4, 5 and 8 years. CONCLUSIONS: Laparoscopic gastric banding can achieve an effective weight loss. However band-related and functional complications will influence the late outcome. Pathways to choose the best surgical method for the individual patient are necessary to reduce failures after gastric banding.     

Five-year results after resleeve gastrectomy

BackgroundLaparoscopic sleeve gastrectomy (LSG) has become increasingly popular in bariatric surgery. However, in the long-term follow-up, weight loss failure and intractable severe acid reflux after primary LSG can necessitate further interventions.ObjectivesThe aim of our study was to evaluate long-term results 5 years after resleeve gastrectomy (ReSG).SettingPrivate hospital, France.MethodsThe study included all patients with failure after LSG who underwent ReSG between October 2008 and January 2014. The patients underwent radiologic evaluation, and an algorithm of treatment was proposed. We analyzed the 5-year outcomes concerning weight loss and long-term complications after ReSG.ResultsA total of 52 patients (46 women; mean age 40.2 yr) with a mean body mass index (BMI) of 39.4 kg/m² underwent ReSG. The mean interval time from the primary LSG to ReSG was of 27.8 months (11–72 mo). The indication for ReSG was inadequate weight loss (28 patients; 53.8%), weight regain (22 patients; 42.3%), and gastroesophageal reflux disease (2 patients; 3.8%). In 35 cases the contrast agent (diatrizoate meglumine/diatrizoate sodium solution [Gastrografin]) swallow results were interpreted as primary dilation and in the remaining 17 cases as secondary dilation. One patient died from gynecologic cancer. Of the remainder, 3 patients underwent single-anastomosis duodenoileal bypass, 5 patients underwent Roux-en-Y gastric bypass, and 1 patient underwent a second ReSG for reflux. A total of 39 of 42 patients with ReSG as definitive procedure had available data at 5-year follow-up. The mean percentage of excess BMI loss was 63.7%. Of the 39 patients, 28 (71.8%) had >50% excess BMI loss at 5 years. Eight of the 11 patients with weight loss failure (<50% excess BMI loss) after ReSG were diagnosed with secondary or diffuse dilation on preoperative imaging; the remaining 3 patients had been operated in our early initial experience with the resleeve procedure. All cases were completed by laparoscopy with no intraoperative incidents. In terms of complications, we recorded 1 leak, 2 stenoses, and 2 cases of bleeding with no mortality.ConclusionsAt 5 years postoperative, the ReSG as a definitive bariatric procedure remained effective for 53.8%. The results appear to be more favorable especially for the non–super-obese patients and for those with primary dilation. ReSG is a well-tolerated bariatric procedure with a low long-term complication rate. Further prospective clinical trials are required to compare the outcomes of ReSG with those of Roux-en-Y gastric bypass or single-anastomosis duodenoileal bypass for weight loss failure after LSG.     

Heterogeneity of weight loss after gastric bypass,sleeve gastrectomy,and adjustable gastric banding

Background

Laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding all lead to substantial weight loss in obese patients. Long-term weight loss can be highly variable beyond 1-year postsurgery. This study examines and compares the frequency distribution of weight loss and lack of treatment effect rates after laparoscopic Roux-en-Y gastric bypass, laparoscopic sleeve gastrectomy, and laparoscopic adjustable gastric banding.

Long-term follow-up and the role of surgery in adolescents with morbid obesity

PURPOSE: Obesity has become a health-care crisis in the United States. Adolescent obesity is now one of the most common childhood disorders, with 4.7 million American adolescents having a body mass index (BMI) greater than the 95th percentile. Most patients do not respond to diet modification or exercise programs and attention is now turning toward surgery as a source of weight loss in adolescents. Few studies have looked at the overall morbidity and mortality of weight loss surgery in this patient population. METHODS: This is a retrospective study of medical charts of 15 bariatric surgical procedures performed on 14 adolescents without known genetic syndromes associated with severe childhood obesity from 1971 to 2001 at the University of Minnesota. Procedures performed on these patients included vertical banded gastroplasty (n = 7), Roux-en-Y gastric bypass (n = 5), and jejunoileal bypass (n = 3). Jejunoileal bypass procedures were performed from 1971 to 1977, after which time this procedure was abandoned. Patient age ranged from 13 to 17 years (mean, 15.7 years). Mean follow-up time was 6 years, with 9 patients available for long-term follow-up. RESULTS: All procedures were performed using an open technique by 1 surgeon. There were no perioperative deaths; complications included 1 case of wound infection, 2 episodes of dumping syndrome that resolved without revision, 1 episode of hypoglycemia, and 1 case of short-term electrolyte imbalance in a patient who underwent jejunoileal bypass. The average BMI dropped from 58.5 +/- 13.7 to 32.1 +/- 9.7 kg/m(2) (P < .01)--a 45% reduction. CONCLUSIONS: Surgery for morbid obesity is safe and results in significant weight loss in adolescents who fail medical therapy.     

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.     

An assessment of vertical banded gastroplasty-Roux-en-Y gastric bypass for the treatment of morbid obesity

OBJECTIVE: To analyze retrospectively the mortality, morbidity, and weight loss of a specific form of gastric bypass for the treatment of morbid obesity. The technique incorporates a small pouch along the lesser curvature of the stomach, an outlet restricted by a nondistensible band and a Roux-en-Y gastric bypass. MATERIAL AND METHODS: We analyzed 652 consecutive patients with no previous bariatric surgery who underwent our present form of gastric bypass. Parameters used to evaluate the technique included mortality, weight loss at 5 years and complications. The operation is a combination of vertical banded gastroplasty and Roux-en-Y gastric bypass (VBG-RGB). The patients followed up to 5 years had an initial weight of 140 kg [range, 94 to 288] and a BMI of 50 [range, 38 to 86]. Superobese individuals (BMI of 60 [range, 48 to 86]) made up 42% of the group. RESULTS: There was an early reoperation rate of 0.5%. The incidence of late complications that required reoperation was 0.5%. There were 2 deaths in the study from pulmonary embolism for a mortality of 0.3%. At 5 years, the patients had lost an average of 58kg [range, 14 to 143] and had a percentage excess weight loss of 77 [range, 32 to 108]. Their BMI was reduced to 29 kg/m(2) [range, 20 to 43] and 93% lost more than 50% of the excess weight. CONCLUSIONS: VBG-RGB is effective in producing superior weight loss in morbid and superobese patients and has a low mortality and morbidity. We recommend this procedure without reservations.     

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.     

Initial outcomes of laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents

BACKGROUND: Adolescent obesity is an epidemic in the United States, leading to significant morbidity. Because the impact of laparoscopic bariatric surgery in this population is not as well delineated as in adults, we examined the short-term outcome of adolescents undergoing laparoscopic Roux-en-Y gastric bypass at our institution. METHODS: The medical records of patients < or =18 years of age who had undergone laparoscopic Roux-en-Y gastric bypass for morbid obesity from 1999 to June 2005 were reviewed. The outcome variables examined included preoperative body mass index, percent of excess weight lost for those with at least 3 months of follow-up, length of hospital stay, postoperative morbidity and mortality, changes in comorbid conditions, and effects of surgical weight loss on quality of life. Data are presented as the mean +/- standard error of the mean. RESULTS: Eleven patients (seven girls and four boys) had undergone laparoscopic Roux-en-Y gastric bypass. The mean follow-up was 11.5 +/- 2.8 months (range 3-32). The average patient age was 16.5 +/- 0.2 years, and the average body mass index was 50.5 +/- 2.0 kg/m(2). The average number of comorbidities was 5.3, 70% of which improved or resolved postoperatively. No mortalities resulted. Of the 11 patients, 1 had early postoperative bleeding and 2 developed a marginal ulcer. The quality-of-life surveys obtained from 9 patients reflected an overall improvement in self-esteem, social functioning, and productivity in school or the workplace. CONCLUSIONS: The initial data suggest that laparoscopic gastric bypass is an effective weight loss treatment for morbidly obese adolescents.     

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

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

Prevalence of Subclinical Hypothyroidism in a Morbidly Obese Population and Improvement after Weight Loss Induced by Roux-en-Y Gastric Bypass

Background:There are many studies concerning thyroid function in obesity, and some of them describe higher TSH levels in obese subjects. Few studies evaluated long-term changes in thyroid function caused by weight loss after bariatric surgery. Our aims were to evaluate the prevalence of subclinical hypothyroidism (SH) in a morbidly obese population and to analyze the effect of weight loss induced by Roux-en-Y gastric bypass (RYGBP) on TSH and thyroid hormone (TH) levels. Methods: TSH, free thyroxine (fT4) and total triiodothyronine (T3) levels were analyzed before and 12 months after RYGBP in patients with grade III or grade II obesity with co-morbidities. Subjects taking TH and/or with positive antithyroid antibodies and/or with overt hypothyroidism were excluded. Results: 72 subjects (62F/10M), with mean age 39.6±9.8 years and mean BMI 53.0±10.4 kg/m² were studied. The prevalence of SH before RYGBP was 25% (n=18). There was a significant post-surgical decrease in BMI in the whole population, as well as in SH patients. In the SH group and normal TSH group, there was a decrease in TSH and T3, but not in fT4. TSH was not correlated with initial BMI or percent change in BMI. TSH concentrations reached normal values in all SH patients after RYGBP. Conclusion: Our data confirm that severe obesity is associated with increased TSH. The decrease in TSH was independent of BMI, but occurred in all SH patients. A putative effect of weight reduction on the improvement of SH in all patients may be an additional benefit of bariatric surgery.     

Singapore Experience in Obesity Surgery

Background: The outcome of bariatric surgery has been well documented in large series in the West. In Asia, where obesity has been less rampant, such surgery has been correspondingly less frequent, and there is a dearth of information on bariatric surgery on Asians. Method: The outcome of a personal series of 40 patients who underwent "gastric stapling" and banding from 1987 to 2003 in Singapore is analyzed. Results: From 1987 to 1997, 26 patients underwent open bariatric surgery (Roux-en-Y gastric bypass 4, vertical banded gastroplasty 22). Initial mean BMI was 43.3 kg/m². At 0.6, 1, 2, 4 and 8 years after surgery, mean BMI was 35.2, 31.9, 31.2, 31.1 and 34.1 kg/m². Mean initial weight was 127.2 kg. %EWL was 42.2, 56.2, 56.9, 56.3 and 48.3%. From 1999 to 2003, 14 patients underwent adjustable gastric banding, 11 by laparoscopy. Initial mean BMI was 42.9 kg/m². At 0.6, 1 and 2 years, mean BMI was 38.9, 36.6, and 32.6 kg/m². Mean initial weight was 122.6 kg. %EWL was 26.6, 38.8 and 59.2%. One patient, following perigastric insertion of Lap-Band^? developed band slippage and gastric prolapse requiring removal. Since adopting the newer technique of combined pars flaccida and perigastric dissection in the last 6 patients, no band slippage has occurred. Conclusion: Our results of safety and low operative morbidity as well as the pattern and magnitude of weight loss following gastric stapling and banding for morbidly obese patients in Singapore appears to be similar to the Western experience.