Comparison of nutritional deficiencies after Roux-en-Y gastric bypass and after biliopancreatic diversion with Roux-en-Y gastric bypass

Background: Patients undergoing either Roux-en-Y gastric bypass (RYGBP) or biliopancreatic diversion (BPD) with RYGBP are at risk of developing metabolic sequelae secondary to malabsorption.We compared the differences in nutritional complications between these two bariatric operations. Methods: A retrospective analysis of a prospective database was done. From June 1994 to December 2001, 243 morbidly obese patients underwent various bariatric procedures at our institution. Of these patients, 79 (BMI 45.6 ± SD=4.9) who underwent RYGBP (gastric pouch 15 ± 5ml, biliopancreatic limb 60-80 cm, alimentary limb 80-100 cm and common limb the remainder of the small intestine), and 95 super obese (BMI 57.2 ± 6.1) who underwent a BPD (gastric pouch 15 ± 5ml, biliopancreatic limb 150-200 cm, common limb 100 cm and alimentary limb the remainder of the small intestine), were selected and studied for the incidence of micronutrient deficiencies and level of serum albumin at yearly intervals postoperatively. A variety of nutritional parameters including Hb, Fe, ferritin, folic acid, vitamin B₁₂ and serum albumin were measured preoperatively and compared postoperatively at 1, 3, 6, 12, 18 and 24 months, and yearly thereafter. Results: Nutritional parameters were compared preoperatively and at similar periods postoperatively. No statistically significant (P <0.05) difference in the occurrence of deficiency was observed between the groups for any of the nutritional parameters studied, except for ferritin, which showed a significant difference at the 2-year follow-up (37.7% low ferritin levels after RYGBP vs. 15.2% after BPD, P =0.0294). All of these deficiencies were mild, without clinical symptomatology and were easily corrected with additional supplementation of the deficient micronutrient, with no need for hospitalization. Regarding serum albumin, there was only one patient with a level below 3 g/dl in the RYGBP group and two in the BPD group.These three patients were hospitalized and received total parenteral nutrition for 3 weeks, without further complications. Conclusion:There was no significant difference in the incidence of deficiency of the nutritional parameters studied, except for ferritin, following RYGBP vs. BPD with RYGBP.The most common deficiencies encountered were of iron and vitamin B₁₂. The incidence of hypoalbuminemia was negligible in both groups, with mean values above 4 g/dl.     

Combining Laparoscopic Adjustable Gastric Banding and Biliopancreatic Diversion after Failed Bariatric Surgery

Background: A percentage of all types of bariatric surgery will fail. Our experience with failed biliopancreatic diversion (BPD) as a primary operation or revision operation for failed laparoscopic adjustable gastric banding (LAGB) convinced us that uncontrolled hunger is often the underlying cause. To control hunger after failed bariatric surgery,a novel approach combining LAGB with BPD-duodenal switch (DS) has been tried. Methods: Patients who had failed to lose weight after BPD or LAGB were considered in 2 groups. Group 1: patients who had failed LAGB underwent laparoscopic BPD-DS without sleeve gastrectomy, with the LAGB left in-situ. Group 2: patients who had failed primary (subgroup 2a) or revision (subgroup 2b) BPD had a LAGB placed with no other revision of their surgery. Results: 11 patients have undergone this form of revision surgery with little morbidity. Mean age at the original operation was 45 years, mean (range) BMI was 45.3 (38-62) kg/m². After the reoperation, at 3 months (9 patients) mean BMI was 30 kg/m² and at 6 months (4 patients) mean BMI was 27 kg/m². Conclusion: In this small study, combination surgery was safe and effective for failed BPD or LAGB. LAGB failure may be best managed with DS malabsorption without gastric resection.     

Outcome Following Bariatric Surgery in Super versus Morbidly Obese Patients: Does Weight Matter?

Background: Numerous investigators have attempted to identify prognostic indicators for successful outcome following bariatric surgery. The purpose of this study was to determine whether degree of obesity affects outcome in super obese [>225% ideal body weight (IBW)] versus morbidly obese patients (160-225% IBW) undergoing gastric restrictive/bypass procedures. Methods: Since 1984, 157 patients underwent either gastric bypass or vertical banded gastroplasty. Super obese (78) and morbidly obese (79) patients were followed prospectively, documenting outcome and complications. Results: Super obese patients reached maximum weight loss 3 years following bariatric surgery, exhibiting a decrease in body mass index (BMI) from 61 to 39 kg/m² and an average loss of 42% excess body weight (EBW). Morbidly obese patients had a decrease in BMI from 44 to 31 kg/m² and carried 39% EBW at 1 year. After their respective nadirs, each group began to regain the lost weight with the super obese exhibiting a current BMI of 45 kg/m² (61% EBW) versus 34 kg/m² (52% EBW) in the morbidly obese at 72 months cumulative follow-up. Currently, loss of 50% or more of EBW occurred in 53% of super obese patients versus 72% of morbidly obese (P < 0.01). Twenty-six percent of super obese patients returned to within 50% of ideal body weight (IBW) while 71% of morbidly obese were able to reach this goal (P < 0.01). Co-morbidities and complications related to surgery were similar in each group. Conclusions: Super obese patients have a greater absolute weight loss after bariatric surgery than do morbidly obese patients. Using commonly utilized measures of success based on weight, morbidly obese patients tend to have better outcomes following bariatric surgery.     

Analysis of Weight Loss with the Biliopancreatic Diversion of Larrad: Absolute Failures or Relative Successes?

Background: The authors studied whether morbidly obese patients who failed in stated weight loss criteria may be considered absolute failures or relative successes. Methods: 75 morbidly obese patients underwent biliopancreatic diversion (BPD) of Larrad, with a 4/5 gastrectomy (residual gastric volume 150-200 ml), a biliopancreatic limb divided 50 cm distal to Treitz' ligament, a 50-cm common limb and an alimentary limb of nearly all the bowel length (500-600 cm). Every patient had a follow-up of 5 years. A percent excess weight loss (%EWL) <50% was considered a "failure". We analyzed the post-surgical changes in the preoperative obesity-related problems in these patients and the causes of the weight loss failure. Results: At 5 years after the BPD of Larrad, 9 patients (12%) had a %EWL <50%, with a mean %EWL of 36 in these patients. Most of these failed patients were cured or improved of their preoperative illnesses. The 2 males were alcoholics, and 6 of the 7 females had an abnormal psychological examination. Comparing the"failed"patients with the successful group, there is a statistically significant influence (p<0.01) of lack of satiety, unmarried status, housewife or unemployed. Conclusion: Patients judged as a failure by weight loss criteria after bariatric surgery should not be considered absolute failures, because most of their preoperative illnesses were cured or improved, improving their quality of life. Thus, they are "relative successes".     

Patient Satisfaction and Results of Vertical Banded Gastroplasty and Gastric Bypass

Background: Morbid obesity contributes to many health risks, including physical, emotional, and social problems. Various surgical treatments for morbid obesity have developed and have so far met with good results. This study compares vertical banded gastroplasty (VBG) with gastric bypass (GBP) and the patients' satisfaction with either procedure. Methods: Between April 1993 and July 1997, 63 bariatric surgical procedures were performed at Eisenhower Army Medical Center. Of those, complete follow-up was obtained for 29 patients. The parameters evaluated included age, preoperative and postoperative weights, body mass index (BMI), type of surgery, complications, and the patient's level of satisfaction. Results: The study group consisted of 27 women and 2 men. The average preoperative weight was 135 kg, and the average preoperative BMI was 48.3 kg/m². There were 17 VBGs and 12 GBPs performed. The average total weight loss was 45.1 kg. The average postoperative BMI was 33.2 kg/m². There were no statistically significant differences in weight loss between VBG and GBP. Four of 17 patients had complications after VBG, and three of 12 patients had complications after GBP. After VBG, 94.1% of patients were satisfied, and after GBP, 100% were satisfied. Twenty-seven of 28 patients stated that they would have the surgery again. Conclusion: There were no statistically significant differences in weight loss or complications after VBG or GBP. Patient satisfaction was high after both procedures. Therefore, bariatric surgery is important in the treatment of appropriately selected, morbidly obese patients.     

Bypass of the duodenum improves insulin resistance much more rapidly than sleeve gastrectomy

BackgroundObesity is very often accompanied by other diseases, with the most common type 2 diabetes mellitus and cardiovascular complications. Bariatric surgery is the most effective strategy for treating morbidly obese patients. We evaluated the metabolic changes that occur in the early stage after 2 types of bariatric surgery, biliopancreatic diversion of Scopinaro (BPD) and sleeve gastrectomy (SG), in morbidly obese patients.MethodsThe study was undertaken in 31 nondiabetic morbidly obese patients (7 men and 24 women). Of the 31 patients, 18 underwent BPD and 13 underwent SG. All patients were examined before bariatric surgery (baseline) and at 15, 30, 45, and 90 days postoperatively.ResultsSignificant improvement occurred in the anthropometric variables after the 2 types of bariatric surgery, without significant differences between the 2 types of interventions. In patients undergoing BPD, the serum glucose, cholesterol, triglycerides, high-density lipoprotein cholesterol, and free fatty acids were significantly reduced. The changes that occurred in these biochemical variables after SG were not significant. Insulin resistance decreased significantly during the 90 days after surgery, with the greatest decrease at 15 days. However, in the patients who underwent SG, insulin resistance worsened at 15 days and later diminished.ConclusionThe results of the present study have shown that the surgical technique that excludes the duodenum (i.e., BPD) has immediate postoperative changes in the degree of insulin resistance in morbidly obese patients compared to those techniques that do not exclude the duodenum (i.e., SG).     

Impact of Age on Long-Term Complications after Biliopancreatic Diversion

Background: The aim of the study is to evaluate the importance of age on the mid- and long-term results and complications after biliopancreatic diversion (BPD). Methods: Our study comprises 132 morbidly obese patients who underwent Scopinaro BPD from February 1995 to April 2001, with follow-up from 24 to 96 months. The patients, 53 males (40%) and 79 females (60%), with mean preoperative BMI 50.2 (35.4-81.5), and mean age 42 (20-65), were divided in 4 groups. Group A age 20-35, 43 patients; Group B age 36-45, 33 patients; Group C age 46-55, 31 patients and Group D age >55, 25 patients. Incidence of long-term specific complications after BPD were analyzed, including protein malnutrition, reversals, anastomotic ulcer, and incisional hernia. Results: Mean postoperative BMI was similar in all Groups. After 60 months the following BMI values were observed. Group A 30.8, Group B 34.9, Group C 35.9, Group D 32. Incidence of long-term complications were not significantly different (χ²) in the 4 Groups, and were respectively: protein malnutrition 6.9%, 12.1%, 6.4%, 16.0%; anastomotic ulcer 11.6%, 9%, 6.4%, 16.0%; reversal 2.3%, 9.0%, 1.32%, 8.0%; ventral hernia 34.8%, 45.4%, 54.8%, 32.0%. Conclusions: From the preliminary results, it appeared that the incidence of the complications was higher in group D (>55 years old), whereas group C (46-55 years old) showed a lower complication rate. However, the prevalence of complications in all groups was not statistically different on χ² analysis. No age limit for bariatric surgery could be determined from the age ranges studied.     

Right Colon Carcinoma Infiltrating the Alimentary Limb in a Patient With Biliopancreatic Diversion

Biliopancreatic diversion (BPD) has excellent results, with the average patient losing 60% to 80% of the excess weight in the first 2 years. However, the BPD works by malabsorption and malabsorptive problems may be experienced with the operation. Therefore, monitoring is necessary for life. In the recent literature there is some debate over the possibility that this technique can increase the risk of colon cancer secondary to the action of the unabsorbed food and bile acid on colonic mucosa. We report the case of a 42-year-old patient with a previous bariatric surgery (BPD with 50 cm common channel; 300 cm alimentary limb) who developed a very aggressive right colon cancer 6 years after the operation. We also review our series of 330 patients operated on during a 14-year period to try to answer if there is any relationship between BPD and colon cancer.Key words: Morbid obesity, Bariatric surgery, Colorectal cancer, Biliopancreatic diversion     

Prospective evaluation of biliopancreatic diversion with roux-en-y gastric bypass in the super obese

The aim of this study was to determine prospectively the efficacy and safety of the biliopancreatic diversion with Roux-en-Y gastric bypass (BPD with RYGBP) procedure used as the primary bariatric procedure in super obese patients. The main characteristics of the BPD with RYGBP procedure were a gastric pouch of 15 ± 5 ml, biliopancreatic limb of 200 cm, common limb of 100 cm, and alimentary limb of the remainder of the small intestine. From June 1994 through July 2003, 132 super obese patients (body mass index [BMI]: 57 ± 7), with an incidence of comorbidities 6 ± 2 per patient, underwent BPD with RYGBP and subsequent follow-up. Mean follow-up time was 29 ± 14 months. Maximum weight loss was achieved at 18 months postoperative with average excess weight loss (EWL) 65%, average initial weight loss (IWL) 39%, and average BMI 35 kg/m². Thereafter, a decline was observed with EWL stabilizing at around 50%, IWL at around 30%, and BMI at around 40 kg/m², respectively, by the end of the study period. The majority of preexisting comorbidities were permanently resolved by the 6-month follow-up visit. Early mortality was 1% and early morbidity was 11%. Late morbidity was 27%, half of which was due to incisional hernia. Deficiencies of microelements were mild and successfully treated with additional oral supplementation. The incidence of hypoalbuminemia was 3% and there were no hepatic complications. We conclude that BPD with RYGBP is a safe and effective procedure for the super obese with few metabolic complications.     

Hormone changes and diabetes resolution after biliopancreatic diversion and laparoscopic sleeve gastrectomy: a comparative prospective study

BackgroundBiliopancreatic diversion (BPD) is the most effective bariatric procedure in terms of weight loss and remission of diabetes type 2 (T2DM), but it is accompanied by nutrient deficiencies. Sleeve gastrectomy (SG) is a relatively new operation that has shown promising results concerning T2DM resolution and weight loss. The objective of this study was to evaluate and compare prospectively the effects of BPD long limb (BPD) and laparoscopic SG on fasting, and glucose-stimulated insulin, glucagon, ghrelin, peptide YY (PYY), and glucagon-like peptide-1 (GLP-1) secretion and also on remission of T2DM, hypertension, and dyslipidemia in morbidly obese patients with T2DM.MethodsTwelve patients (body mass index [BMI] 57.6±9.9 kg/m²) underwent BPD and 12 (BMI 43.7±2.1 kg/m²) underwent SG. All patients had T2DM and underwent an oral glucose tolerance test (OGTT) before and 1, 3, and 12 months after surgery.ResultsBMI decreased more after BPD, but percent excess weight loss (%EWL) was similar in both groups (P = .8) and T2DM resolved in all patients at 12 months. Insulin sensitivity improved more after BPD than after SG (P = .003). Blood pressure, total and LDL cholesterol decreased only after BPD (P<.001). Triglycerides decreased after either operation, but HDL increased only after SG (P<.001). Fasting ghrelin did not change after BPD (P = .2), but decreased markedly after SG (P<.001). GLP-1 and PYY responses during OGTT were dramatically enhanced after either procedure (P = .001).ConclusionsSG was comparable to BPD in T2DM resolution but inferior in improving dyslipidemia and blood pressure. SG and BPD enhanced markedly PYY and GLP-1 responses but only SG suppressed ghrelin levels.     

Is Bariatric Surgery Necessary after Intragastric Balloon Treatment?

Background: The use of the Bio-Enterics intra-gastric balloon (BIB) has been shown to be a safe and effective procedure for the temporary treatment of morbid obesity. We conducted a retrospective comparative analysis of the weight loss in patients that after BIB removal underwent bariatric surgery and those who did not wish surgery. Methods: From January 2000 to March 2004, 182 BIBs were positioned in 175 patients (104 F / 71 M; mean age 37.1±11.6 years, range 16-67; mean BMI 54.4 ± 8.1 kg/m², range 39.8-79.5; mean %EW 160.8±32.9% range 89-264). Patients were excluded from this study who had emergency BIB removal for balloon rupture (n=2, 1.1%) and for psychological intolerance (n=7, 7.8%). All patients were scheduled for a bariatric operation, before BIB positioning. After BIB removal, a number of patients now declined surgery. Consequently, patients were allocated into 2 groups: Group A in whom BIB removal was followed by bariatric surgery (Lap-Band^?, laparoscopic gastric bypass, duodenal switch) (n=86); Group B patients who after BIB removal refused any surgical procedure (n=82). Both groups were followed for a minimum of 12 months. Results were reported as mean BMI and %EWL ± SD. Statistical analysis was done by Student t-test or Fisher's exact test, with P<0.05 considered significant. Results: Mean BMI and mean %EWL in the 166 patients at time of removal were 47.3 ± 8.1 kg/m² and 32.1±16.6%, respectively. At the same time, mean BMI was 47.6±6.9 and 48.1±6.5 kg/m² in group A and B (P=NS). At 12 months follow-up (100%), mean BMI was 35.1 kg/m² in Group A (BIB + surgery) and 51.7 kg/m² in Group B (BIB alone) (P<0.001). Conclusions: After BIB removal, half (49.4%) of the patients scheduled for surgery refused a bariatric operation. These patients returned to their mean initial weight at 12 months follow-up. Therefore, bariatric surgery after BIB removal is highly recommended.     

Laparoscopic Reoperative Sleeve Gastrectomy for Poor Weight Loss after Biliopancreatic Diversion with Duodenal Switch

Background: The revisional surgery for patients with inadequate weight loss after biliopancreatic diversion with duodenal switch (BPD/DS) is controversial. It has not yet been determined whether a common channel should be shortened or gastric pouch volume reduced. Since the revision of the distal anastomosis remains technically difficult and associated with possible complications, we turned our attention to the reduction of gastric sleeve volume. This operation is more feasible and potential complications are less probable. Patient and Method: We present the case of a 47-year-old women with a life-long history of morbid obesity. She was operated on in January 2000 with a laparoscopic BPD/DS with 100 ml gastric pouch, 150 cm of alimentary limb and 100 cm of common channel. Before this operation, her weight was 170 kg, with BMI 64 kg/m². She lost most of her excess weight within 17 months after surgery and was regaining weight at 77 kg and BMI 29 kg/m². Upper GI series showed a markedly dilated gastric pouch. Her second surgery consisted of a laparoscopic sleeve partial gastrectomy along the greater curvature using endo GIA staplers with bovine pericardium for reinforcement of the stapler line. Results: No postoperative complications occurred. The patient was discharged on the first postoperative day. Significant further weight reduction was noted, and at 10 months after surgery, her weight is 61 kg with BMI 22. Conclusion: A repeat laparoscopic gastric sleeve resection was performed for inadequate weight loss after BPD/DS, and resulted in further weight reduction.     

Outcome of Portal Injuries Following Bariatric Operations

Background: Portal vein thrombosis is rare following Roux-en-Y gastric bypass (RYGBP). Its natural history is dependent on the etiology of the thrombosis. Iatrogenic injuries at bariatric operations resulting in portal vein thrombosis are lethal complications typically necessitating a liver transplant, whereas postoperative portal vein thrombosis without an injury to the portal vein has a benign course. There are currently no data on management or prognostic factors of portal vein thrombosis after bariatric operations. Methods: 3 patients referred for liver transplantation secondary to portal vein injury following bariatric surgery between 2000 and 2003 are presented. Results: 2 super-obese (BMI ≥50 kg/m²) and 1 morbidly obese (BMI 44 kg/m²) patients sustained portal vein injuries during bariatric surgery (RYGBP 2, VBG 1) by experienced bariatric surgeons. In each case, the portal injury was identified and repaired. Thrombosis followed reconstruction in all 3 patients. All 3 underwent emergency liver transplantation, but died of sepsis and multi-organ failure following transplantation. Review of the literature found no cases of traumatic portal vein injuries following bariatric operations and 2 cases of postoperative portal vein thrombosis: 1 following LRYGBP (BMI 46) and one after a Lap-Band (BMI 41). Conclusion: Injury to the portal vein resulting from difficulty in discerning the anatomy of the intra-abdominal structures in the morbidly obese, is a lethal complication of bariatric surgery. Super-obese patients submitting to bariatic surgery should lose weight, undergo a two-stage bariatric procedure, or undergo laparoscopic RYGBP to minimize the risk of portal injury. Postoperative portal vein thrombosis has a benign course and can be managed conservatively.     

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.     

Ghrelin,Leptin and Insulin Levels after Restrictive Surgery: a 2-Year Follow-up Study

Background: Ghrelin is a recently discovered orexigenic gastric hormone, whose production is induced by lack of food in the stomach. In morbidly obese individuals, ghrelin levels are low compared to lean persons. During dieting, plasma ghrelin levels increase, leading to an orexigenic signal, which could explain the lack of success of dieting in morbidly obese individuals. Morbid obesity is best treated with bariatric surgery, in which gastric bypass is reported to be more effective than restrictive surgery. A possible explanation could be the difference in plasma ghrelin levels after both operations for bariatric surgery. In this study, plasma ghrelin levels were investigated during a 2-year follow-up. Methods: 17 morbidly obese patients received gastric restrictive surgery. Plasma ghrelin, leptin and insulin levels were evaluated preoperatively and 1 year and 2 years postoperatively. Results: BMI decreased from 47.5 ± 6.2 kg/m² to 33.2 ± 5.8 kg/m² (P <0.001). Plasma ghrelin levels were significantly increased 1 year (P <0.05) and 2 years (P <0.02) postoperatively. Fasting plasma leptin and insulin levels were significantly lower at 2 years after surgery (P <0.001). Conclusion: After gastric restrictive surgery, ghrelin levels increased, in contrast to the reported fall in ghrelin levels after gastric bypass. This difference in ghrelin levels between these operations may be the k ey to understanding the superiority of gastric bypass in sustaining weight loss compared with restrictive surgery.     

Laparoscopic Adjustable Gastric Banding with Duodenal Switch for Morbid Obesity: Technique and Preliminary Results

Background: The procedure of choice for morbid obesity remains controversial. One of the most effective treatments is the biliopancreatic diversion with duodenal switch (BPD/DS), which is, however, associated with a significant morbidity rate. Adjustable gastric banding (AGB) by the laparoscopic approach is an easier procedure with the intent to reduce complication rates. It replaced the sleeve gastrectomy in this study. The objective was to assess the feasibility and safety of this new laparoscopic treatment. Methods: AGB with duodenal switch (DS) was performed laparoscopically with 7 trocars. A gastric band was appropriately placed below the gastroesophageal junction, followed by BPD/DS with a 250-cm alimentary channel and a 100-cm common channel. Results: All 5 patients were women, with mean preoperative BMI 52.2 kg/m² (40.6 to 64.4). The operations were performed via laparoscopy in a mean of 206 ± 35 minutes. There was no postoperative complication, infection or conversion. Mean hospital stay was 8.8 days (8-11). At 12 months, mean BMI is 35.8 kg/m² (26.1-46.0), with continuing weight loss and no hypoalbuminemia. Conclusions: These data suggest that laparoscopic AGB/DS is feasible, with a low morbidity rate. This technique could combine the long-term weight loss of malabsorptive procedures, with a low-morbidity, adjustable, restrictive procedure. This technique could be used in selected patients, but requires a larger study with longer follow-up.     

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.     

Prevalence of Helicobacter pylori infection in bariatric patients: a histologic assessment

BackgroundStudies on rates of Helicobacter pylori (HP) infection in morbidly obese patients awaiting bariatric surgery are conflicting because of small sample size and variability in diagnostic testing. The objective of this study was to determine the rate of biopsy-proven active HP infection in morbidly obese patients undergoing bariatric surgery.MethodsRetrospective analysis was done on all morbidly obese patients who underwent bariatric surgery between 2001 and 2009. All patients underwent preoperative upper endoscopy with biopsy to evaluate HP status. All endoscopies and surgeries were performed by a single endoscopist and surgeon, respectively. Data were analyzed with Student t test, Pearson χ² test, and logistic regression for multivariate analysis.ResultsThe 611 patients included 79 males (12.9%) and 532 females (87.1%). Mean age was 39.9±10.7 years, and mean body mass index (BMI) was 47.8±6.4 kg/m². The overall HP infection rate was 23.7%. Rate of infection did not differ between gender (22.8% in males, 23.9% in females; P = .479) or BMI (48.6±6.5 kg/m² in HP-positive patients, 47.5 ± 6.4 kg/m² in HP-negative patients; P = .087). Patients with HP were older compared with those without infection (41.2 versus 38.7 years; P =.016). Hispanics had a higher prevalence of HP (OR 2.35; P = .023).ConclusionIncreasing BMI is not an independent risk factor for active HP infection within the morbidly obese patient population. Need for invasive testing to detect HP infection in these patients should be re-evaluated. Other methods of detecting active HP infection should be considered as an alternative to invasive or serologic testing.     

Anti-Xa Levels in Bariatric Surgery Patients Receiving Prophylactic Enoxaparin

Background Limited data exist regarding efficacy and dosing of low-molecular-weight heparins, including enoxaparin, for morbidly obese patients. Prophylactic doses of 30 to 60 mg every 12 h have been described in bariatric surgery patients with appropriate anti-Xa levels reported between 0.18 and 0.6 units/mL. Methods Fifty-two laparoscopic gastric bypass or banding patients were enrolled. Patients were divided into two groups by the dose of enoxaparin that was given: Group 1—enoxaparin 30 mg every 12 hours—and Group 2—enoxaparin 40 mg every 12 h. Anti-Xa levels were obtained 4 h after the first and third doses. Levels between 0.18–0.44 units/mL were considered appropriate. Results There were 19 patients (74% female, mean body mass index [BMI] 48.4 kg/m²) in Group 1 and 33 patients (82% female, mean BMI 48.5 kg/m²) in Group 2. In Group 1, anti-Xa levels were 0.06 and 0.08 units/mL after the first and third doses, respectively. In Group 2, anti-Xa levels were 0.14 and 0.15 units/mL after first and third doses, respectively (p = NS). There was a statistically significant difference in anti-Xa levels between Group 1 first dose and Group 2 first dose (p < 0.05) and between Group 1 third dose and Group 2 third dose (p < 0.05). Percentage of appropriate anti-Xa levels at first dose differed 0% vs. 30.8% (Group 1 vs. Group 2; p = 0.01) and at third dose 9.1% vs. 41.7% (Group 1 vs. Group 2; p = 0.155). Conclusion When prophylactic dose enoxaparin of 30 mg every 12 h was changed to 40 mg every 12 h in bariatric surgery patients, anti-Xa levels significantly increased with prophylactic dose enoxaparin in bariatric surgery patients. The percentage of appropriate levels also increased; however, more than half of the patients receiving 40 mg every 12 hours failed to reach therapeutic levels. No levels were supratherapeutic. Dosage of 40 mg every 12 h may not be sufficient for bariatric surgery patients. Presented at the Society of American Gastrointestinal Endoscopic Surgeons annual meeting; April 18–22, 2007; Las Vegas, NV.     

The Value of Pulmonary Function Testing Prior to Bariatric Surgery

Background: Pulmonary function tests (PFTs) are often abnormal in the morbidly obese and improve after bariatric surgery. Our aim was to determine the utility of obtaining preoperative PFTs in assessing postoperative risk. Methods: 146 consecutive patients undergoing open bariatric surgery were analyzed. Patients were divided into those who had postoperative complications (Group A, n=27) and those who did not (Group B, n=119). PFTs and BMI were compared between Groups A and B. PFT parameters are reported as the median percentage of age-matched controls. Results: Patients in Group A compared to Group B were heavier (BMI 58 vs 51 kg/m², P=.001) and older (46 vs 40 years, P=.02) than those in group B. They had reduced forced vital capacity (80% vs 97%, P<.001) and forced expiratory volume in 1 second (84% vs 99%, P=.002). They also had reduced vital capacity (VC, 85% vs 102%, P<.001) and total lung capacity (89% vs 99%, P=.01). They had decreased maximal voluntary ventilation (93% vs 106%, P=.003). They had lower arterial pO₂ (76 mmHg vs 85 mmHg, P=.001) and higher arterial-alveolar gradient (23 vs 17, P=.007). The strongest predictors of postoperative complications on multivariate analysis were reduced VC (RR 2.29 for each 10% decrease in VC, P=.0007) and age (RR 6.4 for age >40 years, P=.01). Conclusions: PFTs help to predict complications after bariatric surgery. The greatest reduction in VC may occur in patients with central obesity, reflecting increased intrabdominal pressure and diminished chest wall compliance.