Pregnancy Following Gastric Bypass for Morbid Obesity

Background: Women who suffer from morbid obesity are often infertile. If these women are able to become pregnant, they are considered high risk because of the hypertension, diabetes and other associated risk factors. Following the pregnancy is difficult due to limitations of the physical examinations. More costly ultrasound examinations are needed at a higher frequency. Bariatric surgery reduces the woman's weight and the incidence of obesity related co-morbidities. The number of pregnancies and rate of complications during those pregnancies in our post-bariatirc surgical patients were evaluated. Method: Our group has been doing bariatric surgery since the early 1980s. We have over 2000 active patients on our current newsletter mailing list. The patients also have a series of networks through support groups. The patients are informed to contact us when they become pregnant so we may assist the obstetrician with their care. Through these various means, we have been able to identify 41 women in our patient population who have become pregnant. Using personal interview, questionnaire, and review of perinatal records, pregnancy-related risks and complications were studied. Results: With over a 95% follow-up rate on the patients identified as having been pregnant following surgery, we found less risk of gestational diabetes, macrosomia, and cesarean section than associated with obesity. There were no patients with clinically significant anemia. Conclusion: Since the patients had an operation that restricts their food intake, some basic precautions should be taken when they become pregnant. With this in mind, our patients have done well with their pregnancies. The post-surgical group had fewer pregnancy-related complications than did an internally controlled group that were morbidly obese during their previous pregnancies.     

Gastric Banding for Morbid Obesity: the St Paul's experience

A group of 300 consecutive morbidly obese patients who underwent a gastric banding procedure (gastric segmentation) by a single surgeon (F.S.W.) has been analyzed as to their sex, age, hospitalization, complications and sequelae, reversal or reoperation, and weight loss. The time frame was born August 1984 to January 1991. Eighty-eight percent were females and the average age was 37 years. The operative mortality was zero, and the complications were minor (1%). Eight women have had one or more normal pregnancies after the operation. Thirty-eight cases (12.7%) have had a reversal or a reoperation. Thirty-one patients (10.3%) were lost to follow-up. 271 cases have been operated on for more than 1 year and up to 6.5 years. In those patients not lost to follow-up or who have not had a reoperation, 109 or 54% had a weight loss of 30% or more and 140 or 68% had a weight loss of 25% or more. We conclude that in our setting, the gastric banding is successful in promoting weight loss with a minimum risk and an acceptable reoperation or reversal rate.     

Technical Alternatives Laparoscopic Distal Gastric Bypass for Morbid Obesity in a Porcine Model

Background: Laparoscopic gastric bypass and vertical banded gastroplasty are two procedures used in the treatment of morbid obesity. The authors describe alternative techniques of laparoscopic distal gastric bypass as a modification of the Scopinaro procedure, which were used experimentally in a porcine model. Methods: Five pigs were used. The laparoscopic procedure was performed with the pigs under general anesthesia after pneumoperitoneum had been achieved. Five or six trocars were used. One port was converted from 12 to 33 mm, and all the other ports were 10-11 mm. The initial surgical technique was similar to that used by others for laparoscopic gastrectomy, except that atraumatic ultracision was used for all the dissection. The stomach was stapled with a linear cutter stapler (Endopath, 31 mm) to create a 50-ml pouch. The ileum was divided with a linear cutter-stapler (Endopath, 31 mm) or ultracision cautery. A long length of ileum was positioned between the stomach pouch and the jejunoileostomy. Only 50-70 cm of terminal ileum was preserved as a common channel. In three animals, the circular stapler (ILS, 21 mm) was used to produce an end-to-side anastomosis. In one animal, two purse-string sutures were handsewn in the ileum and jejunum stumps, and in another two animals, two endoloops were used for the anvil. In two animals, the linear stapler was used to form a side-to-side pouch stomach-ileum and jejunoileostomy anastomosis. In other animals, the two types of anastomosis have been combined. All animals were killed after surgery so that the anastomoses could be evaluated for size and integrity. Results: In all animals, with the circular and linear stapler, both 21 and 13-15 mm anastomoses were intact. Conclusion: Distal gastric bypass is feasible laparoscopically, with intact anastomoses.     

Eating Behavior and the Experience of Hunger Following Gastric Bypass Surgery for Morbid Obesity

Background: Numerous different factors may contribute to the varying degrees of success observed following gastric bypass surgery. It is likely that alterations in the subjective experiences of hunger and satiety, as well as behavioral factors, are important. Our aim was to investigate the association of several factors, including qualitative aspects of hunger and satiety, eating patterns, and the emotional valence of different foods, to the weight loss that occurred following obesity surgery. Methods: A questionnaire covering aspects of hunger, eating and satiety was administered to three groups: (1) a group of people who had undergone gastric bypass surgery with an acceptable weight loss; (2) a morbidly obese group of patients prior to their surgical intervention; (3) a group of people of normal weight. Results: There were significant differences amongst the three groups in scoring on standardized eating disorder scales, in the amount they could eat, and in the experience of hunger. The presurgery, waiting-list group was more receptive to food-related than interoceptive cues when deciding to stop eating. ‘Eating styles’ also differed across the groups. Conclusions: It is concluded that changes in specific food-related behaviors and other psychological variables interact with the physical restriction to eating. The relative weighting of other variables needs further exploration.     

Gastric Obesity Surgery Combined with Partial Ileal Bypass for Hypercholesterolemia

Background: It is unusual for a patient to manifest both morbid obesity and hyperlipidemia. Certain of these individuals may also have a history of hypertriglyceridemic pancreatitis. We report six morbidly obese hypercholesterolemic patients, two with recurrent hypertriglyceridemic pancreatitis, who were managed by concurrent gastric restrictive surgery and a partial ileal bypass operation. Methods: The first dual procedure was performed on January 6 1992, and the most recent on February 20 1997. Our series consists of two males and four females, with an average age of 35.5 years at the time of surgery. The mean preoperative weight of these patients was 116.8 kg, and the mean BMI was 39.7 kg/m². The preoperative mean total plasma cholesterol was 5.5 g/l and the mean plasma triglyceride was 30.61 g/l; the two patients with a history of hypertriglyceridemic pancreatitis had plasma triglyceride levels of 33.6 g/l and 65 g/l. Results: The average weight reduction, using available follow-up intervals was 40.3 kg (34.5%), with a mean postoperative BMI of 20.0 kg/m² (34.8% reduction). The markedly elevated total plasma cholesterol and plasma triglyceride levels were normalized, with a postoperative mean total plasma cholesterol of 1.47 g/l (73.3% reduction) and a concomitant mean plasma triglyceride of 1.63 g/l (94.7% reduction). The two patients with a history of pancreatitis sustained triglyceride reductions of 96.5% and 94.1%, and neither patient has had an episode of pancreatitis following the dual operative procedures. Conclusion: We conclude that the combination of a gastric restrictive operation with a partial ileal bypass procedure represents excellent management for patients with both morbid obesity and hypercholesterolemia, especially if the hypercholesterolemia is accompanied by hypertriglyceridemic pancreatitis.     

Pouch Diverticula after Vertical Banded Gastroplasty for Morbid Obesity: Report of Three Cases

Three cases of pouch diverticula following vertical banded gastroplasty for morbid obesity are presented. Symptoms, diagnosis, treatment and etiology are discussed.     

The Effect of Gastric Banding on Weight Loss in Patients with Morbid Obesity

The results following operation for morbid obesity in 41 patients (8 men and 33 women) during the period 1983-89 are reported. The median preoperative body mass index (BMI) was 43.6 (median excess weight 81%). All patients were preoperatively evaluated at the Department of Internal Medicine, and they had all tried several conservative regimens in order to lose weight. They were all operated on with gastric banding, creating a gastric stoma of 15 mm. Pneumonia developed in 10 patients, one patient got a wound infection, and one patient died postoperatively from a massive pulmonary embolism. The immediate postoperative weight loss was satisfactory, median BMI being reduced from 43.6 preoperative to 30.5 after 9 months. Median BMI after 3 and 5 years was 34 and 32 (median excess weight 42 and 41%, respectively). Six patients were reoperated, four having their band removed, two being converted to vertical gastric banding. In conclusion, gastric banding gives satisfactory results for most of the patients. The reoperation rate is, however, high and the long-term result is not favourable for all patients.     

Biochemical Evidence of Metabolic Bone Disease in Women Following Roux-Y Gastric Bypass for Morbid Obesity

Twenty-six female patients were recalled for examination 10 years after a Roux-Y gastric bypass (RGB) procedure for morbid obesity, to determine whether there was biochemical and/or bone densitometry evidence of metabolic bone disease. These patients were compared with seven control patients who had achieved weight loss by dietary restriction. The serum calcium (4.3 ± 0.03 vs 4.6 ± 0.06 mEq/l; p = 0.002) was decreased in the RGB group. Both the serum alkaline phosphatase level (121.0 ± 7.6 vs 87.3 ± 8.3 U/l; p = 0.018) and the serum osteocalcin (12.6 ± 1.2 vs 9.5 ± 1.9 mug/ml; p = 0.078) level increased in the RGB group. The 1,25(OH) vitamin D level (50.5 ± 2.5 vs 40.5 ± 4.9 pg/ml; p = 0.152) was similar for both groups; the 25(OH) vitamin D level (24.3 ± 1.6 vs 35.9 ± 3.4 ng/ml; p = 0.008) was decreased in the RGB group as compared with the control group. Bone mineral density was elevated in three of the lumbar measurement sites, and marginally decreased (0.90 ± 0.02 g/cm₂ vs 1.03 ± 0.06 g/cm₂; p = 0.067) in the femoral neck of the RGB group compared with the controls. This biochemical pattern suggests the development of metabolic bone disease following the RGB.     

Gastroesophageal Reflux Disease in Morbid Obesity: The Effect of Roux-en-Y Gastric Bypass

Background  Gastroesophageal reflux disease (GERD) is a common condition in obesity. The impact of Roux-en-Y gastric bypass (RYGBP) on GERD is poorly known. We studied the effect of the RYGBP on GERD in patients with morbid obesity (MO). Methods  Twenty consecutive patients with MO (BMI > 40 kg/m²) were studied before and 6 months after RYGBP. GERD symptoms were evaluated with Carlsson–Dent questionnaire (CDQ). All the patients underwent esophageal manometry and ambulatory 24-h pH-metry. Chi-square test was used to compare categorical variables, and Wilcoxon test was used for numerical variables. A p value under 0.05 was considered significant. Results  There were 16 women (80%) and 4 men (20%) with mean age 38.9 ± 6.9 years included in this study. BMI was 48.5 ± 6.2 kg/m² and 33.2 ± 4.5 kg/m² before and after RYGBP, respectively. Mean weight reduction was 42.5 ± 9.7 kg (p < 0.001). Reflux symptoms measured by CDQ and esophageal acid exposure improved significantly after RYGBP. The percentage of time of pH < 4 was 10.7 ± 6.7 before and 1.6 ± 1.2 after the surgical procedure (p < 0.001). LES basal pressure before and after the RYGBP was 18 ± 11 and 20.1 ± 5.6 mmHg (p = 0.372), and the esophageal body amplitude was 104.2 ± 47.2 and 75.1 ± 36.2 mmHg, respectively (p = 0.005). Conclusion  RYGBP improves GERD symptoms and reduces esophageal acid exposure in patients with MO.     

The Surgical Technique of the Fobi-Pouch Operation for Obesity (The Transected Silastic Vertical Gastric Bypass)

The Fobi-Pouch operation (FPO) for obesity is the product of clinical trials, more than 15 years of personal clinical experience and information gathered from publications, scientific meetings, and personal communications with other bariatric surgeons. The essence of the operation is the small vertical pouch (< 25 ml), an externally supported stoma, the interposed Roux-en-Y limb, the gastrostomy and the bypassed stomach marker to facilitate percutaneous transabdominal access to the bypassed segment. Patients undergoing this operation are usually given bowel prep the day before the operation, admitted the morning of the operation and started on subcutaneous heparin, prophylactic antibiotic and hydration. Antithrombotic sequential compression devices are regularly used. The hospital stay is usually 4 days. Our results and those of other surgeons who have used this modification substantiate the rationale for the modifications entailed in the FPO. Our longer-term experience and results are being compiled for publication.     

Microbial Flora of the Stomach after Gastric Bypass for Morbid Obesity

Background The normal stomach is virtually sterile but the effect of Roux-en-Y gastric bypass (RYGBP) on bacterial flora in the used (very small proximal pouch) and unused (large bypassed) gastric chambers is not known. In a prospective study, this variable was documented. Methods Bariatric subjects (n = 37) were submitted to endoscopic examination of both gastric reservoirs via FUJINON enteroscope model EN-450P5, 7.3 ± 1.4 years after RYGBP. Age was 42.4 ± 9.9 years (70.2% females), preoperative BMI was 53.5 ± 10.6, and current BMI was 32.6 ± 7.8 kg/m². Methods included quantitative culture of gastric secretion along with gastric pH and lactulose/hydrogen breath test. Results None of the subjects displayed diarrhea, malabsorption or other complaints suggestive of GI bacterial overgrowth. Elevated counts of bacteria and fungi were identified in both chambers, with predominance of aerobes and anaerobes, but not molds and yeasts, in the proximal stomach. Gram-positive cocci, bacilli and coccobacilli represented the majority of the isolates. Gastric pH was neutral (pH 7.0 ± 0.2) in the proximal pouch, whereas the distal chamber mostly but not always conserved the expected acidity (pH 3.3 ± 2.2, P < 0.001). The breath test for bacterial overgrowth was positive in 40.5% of the population. Conclusions 1) Frequent colonization of both gastric chambers was detected; 2) Aerobes, anaerobes and fungi were represented in both situations; 3) Gastric pH as well as bacterial count was higher in the functioning proximal stomach; 4) Breath test was positive in 40.5% of the subjects; 5) Clinical manifestation such as diarrhea, malabsorption or pneumonia were not demonstrated; 6) Further histologic and microbiologic studies of both the stomach and the small bowel are recommended.     

Small Bowel Obstruction Following Gastric Bypass

Intestinal obstruction is no more frequent after gastric bypass than after any other similar gastric surgical procedure. However, occurrence of any complication requiring revisional surgery in these hugely obese patients may have serious implications. Bariatric surgeons and physicians who take part in the care of such patients must be aware of the different clinical pictures which accompany the varying levels of obstruction following gastric bypass surgery. Particularly critical is an understanding of closed loop gastroduodenal obstruction, a potentially lethal complication, which can cause rapidly occurring hypovolemic shock and death within a few hours of onset.     

Helicobacter pylori Before and After Gastric Reduction for Morbid Obesity

Nine patients with morbid obesity were evaluated for the presence of Helicobacter pylori (Hp) before gastric reduction, and all were negative. Fifteen patients, including those nine, were evaluated for the presence of Hp in antral and ‘channel’ region biopsies by culture and urease test after gastric reduction. Hp-negative patients totalled 73.3% by both tests, although chronic superficial gastritis type ‘B’ was found in eight out of 13 (61.5%), and six out of seven (85.7%) gastritis patients were positive for Helicobacter-like organisms in the hematoxylin- and eosin-stained biopsies. Our data suggest that in stomachs of morbid obesity patients before as well as after gastric reduction procedures, the incidence of Hp is very low, and the reasons for this observation are yet unknown.     

The Swedish Adjustable Gastric Banding (SAGB) for Morbid Obesity: 9 Year Experience and a 4-year Follow-up of Patients Operated with a New Adjustable Band

Background: We have developed an adjustable gastric band in which the stoma diameter can be adjusted from the outside. A standardized technique was employed and the application of our band in terms of weight loss and complication rate was evaluated Methods: Between August 1990 and November 1991, 50 patients (15 men and 35 women) were operated on by laparotomy. Their mean age at surgery was 41 (19-60) years. Mean preoperative weight was 134 (106-181) kg and the mean BMI was 46 kg/m² (range 33-59 kg/m²). Results: No patient was lost to follow-up. Four were excluded from the study (brain tumor, pregnancy and two reoperations). The remaining 46 were followed for at least 4 years. At follow-up, mean weight was 80 kg and mean BMI was 27.5 kg/m². The patients had lost a mean of 54 kg. Two patients (4%) had abdominal reoperation because of technical problems. There was one incisional hernia and one minor wound infection, but no other significant complications. Conclusion: This relatively simple method appears to be at least as good as the other operations, and weight loss can be adjusted to patient comfort. Currently, the procedure is being performed laparoscopically.     

Pregnancy Following Gastric Bypass Surgery for Morbid Obesity: Maternal and Neonatal Outcomes

Background The purpose of this study was to compare obstetric and neonatal outcomes after Roux-en-Y gastric bypass (RYGB) to those in women without such surgery. Methods Women with RYGB (cases) were matched for maternal age and prior cesarean to the next two consecutive women delivering without prior bariatric surgery (controls). Pregnancy and newborn outcomes were compared by univariate analysis. Outcomes approaching or reaching statistical significance were evaluated by conditional logistic regression controlling for maternal body mass index (BMI). Results Despite gastric bypass, the 38 cases were heavier (BMI 33.4 ± 7.3 vs. 28.1 ± 6.7 kg/m², p < 0.001) and more often obese (BMI ≥ 30 kg/m², 26/38 (68.4%) vs. 20/76 (26.3%), p < 0.001) than controls. Variables evaluated by logistic regression adjusted for BMI did not differ in cases versus controls, including hypertension (odds ratio [OR] 2.62, 95% confidence interval [CI] 0.66–10.50), preterm premature rupture of membranes (OR 0.24, 95% CI 0.02–3.38), oligohydramnios (OR 2.39, 95% CI 0.66–8.61), and delivery ≥41 weeks (OR 0.57, 95% CI 0.11–2.97). Discussion Obstetric and neonatal outcomes after RYGB are similar to those of our general obstetric population. Reprints unavailable.     

Do Arthralgias Occur after Bilio-intestinal Bypass for Morbid Obesity

Background: Intestinal bypass operations are used occasionally for treating morbid obesity if other methods are unsuitable. Jejuno-ileal bypass (JIB) operations are considered to be a cause of occasional joint pain related disorders. However, biliointestinal bypass (BIB) is intended to avoid the blind loop syndrome. This study compared joint pain disorders in an operated BIB group, an obese nonoperated control group, and a lean reference group. Methods: Using a questionnaire in a cross-sectional study, pain disorders were investigated in age-, sex- and weight-matched groups of operated, obese and lean subjects. The operated group had previously had a BIB and was matched using the preoperative BMI (body mass index, kg/m²). Results: Mean time since operation was 12.4 years (SD 3.4) and the BIB group had lost 15.2 kg/m² compared with the obese control group. These two groups had a high frequency of pain disorders of similar distribution, differing significantly from the lean reference group. No evidence of major differences in the type of pain disorders could be seen in the two groups. Conclusion: Pain disorder was an integral part of an obese syndrome, and was not affected significantly by weight reduction after BIB. The study appears to support the view that approximately 4% of patients develop arthritis vasculitis syndrome after BIB.     

Predictors, Treatment, and Outcomes of Gastrojejunostomy Stricture after Gastric Bypass for Morbid Obesity

Background The aims of this study were to determine the rate of gastrojejunostomy (GJ) stricture following Roux-en-Y gastric bypass (RYGBP), the independent predictors of stricture, and clinical outcomes with and without a stricture. Methods Univariate and multivariate analysis of peri-operative and outcomes data were prospectively collected from 379 morbidly obese patients who underwent consecutive open or laparoscopic RYGBP from January 2003 to August 2006. Predictors studied were age, gender, BMI, co-morbidities, surgical technique (hand-sewn vs linear stapler vs 21-mm vs 25-mm circular stapler; open vs laparoscopic; retrocolic retrogastric vs antecolic antegastric Roux limb course, and Roux limb length), and surgeon experience. Outcomes studied consisted of occurrence of GJ strictures, technical details and outcomes after endoscopic therapy, and excess weight loss (EWL) at 12 months. Results 15 patients (4.1%) developed a GJ stricture. The use of a 21-mm circular stapler was identified as the only independent predictor of a GJ stricture (odds ratio 11.3; 95% CI 2.2-57.4, P = 0.004). Endoscopic dilation relieved stricture symptoms in all patients (60% one dilation only). There was no significant difference in %EWL at 12 months between the patients with a stricture (median EWL 54%, IQR 49 – 63) vs those without a stricture (median EWL 61%, IQR 49-73, P = 0.33). Conclusion The rate of GJ strictures is 4.1%. The use of a 21-mm circular stapler is the only independent predictor of GJ stricture. Endoscopic dilation relieved symptoms in all patients.Weight loss is independent of the anastomotic technique used and occurrence of a GJ stricture.     

Serum Magnesium Status After Gastric Bypass Surgery in Obesity

Background  Roux-en-Y gastric bypass (RYGBP) has become a common surgical procedure to treat morbid obesity. Furthermore, it strongly reduces the incidence of type 2 diabetes and mortality. However, there is scant information on how magnesium status is affected by RYGBP surgery. Previous bariatric surgery methods, like jejunoileal bypass, are associated with hypomagnesemia. Methods  Twenty-one non-diabetic morbidly obese patients who underwent RYGBP were evaluated before and 1 year after surgery and compared to a matched morbidly obese control group regarding serum magnesium. Groups were matched regarding weight, BMI, abdominal sagittal diameter and fasting glucose, blood pressure, and serum magnesium concentrations before surgery in the RYGBP group. Results  The serum magnesium concentrations increased by 6% from 0.80 to 0.85 mmol/l (p = 0.019) in the RYGBP group while a decrease by 4% (p = 0.132) was observed in the control group. The increase in magnesium concentration at the 1-year follow-up in the RYGBP group was accompanied by a decreased abdominal sagittal diameter (r ² = 0.32, p = 0.009), a lowered BMI (r ² = 0.28, p = 0.0214), a lowered glucose concentration (r ² = 0.28, p = 0.027) but not by a lowered insulin concentration (p = 0.242), a lowered systolic (p = 0.789) or a lowered diastolic (p = 0.785) blood pressure. Conclusion  RYGBP surgery in morbidly obese subjects is characterized by reduced visceral adiposity, lowered plasma glucose, and increased circulating magnesium concentrations. The inverse association between lowered central obesity, lowered plasma glucose and increased magnesium concentrations, needs further detailed studies to identify underlying mechanisms.