Weight Loss Following Transected Gastric Bypass with Proximal Roux-en-Y

Background: Cross-sectional analysis was performed to study the trend in weight loss following surgery. Methods: Among 194 patients involved in the study during the period 1990-1995, 86.6% were female and 87.1% were white. Median values for the initial cohort of 194 patients were as follows: age 32.5 years; height 163.8 cm; preoperative weight 122.81 kg. Of these patients 67%, 30%, and 3% of the patients were categorized as morbidly obese, super obese, and obese respectively. They all underwent gastric bypass surgery. Results: Follow-up rates were 67.9% at 1 year, 55.8% at 2 years, 62.8% at 3 years, and 70.0% at 4 years postoperation. Median BMI was reduced from 45.18 to 28.40, and median percentage loss of excess weight was 68.5% after 1 year. After 2, 3, and 4 years, median BMI values were 27.69, 28.63, and 29.40, and median percentages of excess weight loss were 71.18%, 69.28%, and 57.49%, respectively. Although the analysis at 4 years indicates that some patients experience slight weight gain, the increase was not significant and further analysis will be performed when more data points are available. Conclusion: Postoperative weight loss has been satisfactory.     

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

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

Depression Score Predicts Weight Loss following Roux-en-Y Gastric Bypass

Background: The prevalence of obesity is increasing in the United States. Bariatric surgery is the only intervention that can reliably induce and maintain significant weight loss in obese patients. The association between pre-surgical severity of depression and success at weight loss following Roux-en-Y gastric bypass (RYGBP) has not yet been fully elucidated. Methods: 145 charts of patients who underwent RYGBP for morbid obesity were reviewed. 47 patients who filled out the Beck Depression Inventory (BDI) before surgery and completed 1 year of follow-up were studied. The relationship between pre-surgical severity of depression and success at weight loss was examined through multivariate regression analysis using percent excess weight loss (%EWL) as a dependent variable and BDI score as one of the predictors. Results: Weight loss at 1 year was significantly related to the BDI score before surgery (P =0.014). BDI score was also found to be a significant predictor of the amount of weight lost (kg) 1 year after surgery (P =0.027). Age (P =0.03) and initial body mass index (BMI) (P =0.011) were the only other variables with significant independent relations to %EWL. Conclusions: Our data show a positive correlation between pre-surgical severity of depression as measured by BDI score and the 1-year success at weight loss after RYGBP as measured by %EWL. More depressed individuals tend to lose greater amounts of weight compared with less depressed individuals. Future prospective studies should examine possible mechanisms and effects of depression and other psychiatric disturbances on long-term weight loss after RYGBP.     

Inadequate Weight Loss vs Secondary Weight Regain: Laparoscopic Conversion from Gastric Banding to Roux-en-Y Gastric Bypass

Background  Beside complications like band migration, pouch-enlargement, esophageal dilation, or port-site infections, laparoscopic adjustable gastric banding (LAGB) has shown poor long-term outcome in a growing number of patients, due to primary inadequate weight loss or secondary weight regain. The aim of this study was to assess the safety and efficacy of laparoscopic conversion to Roux-en-Y gastric bypass (RYGBP) in these two indications. Methods  A total of 25 patients, who underwent laparoscopic conversion to RYGBP due to inadequate weight loss (n = 10) or uncontrollable weight regain (n = 15) following LAGB, were included to this prospective study analyzing weight loss and postoperative complications. Results  All procedures were completed laparoscopically within a mean duration of 219 ± 52 (135–375) min. Mean body weight was reduced from 131 ± 22 kg (range 95–194) at time of the RYGBP to 113 ± 25, 107 ± 22, and 100 ± 21 kg at 3, 6, and 12 months, respectively, which results in excess weight losses (EWL) of 28.3 ± 9.9%, 40.5 ± 12.3%, and 50.8 ± 15.2%. No statistically significant differences were found comparing weight loss within these two groups. Conclusion  RYGBP was able to achieve EWLs of 37.6 ± 16.1%, 48.5 ± 15.1%, and 56.9 ± 15.0% at 3, 6, and 12 months following conversion, respectively, based on the body weight at LAGB.     

Preoperative Weight Loss as a Predictor of Long-term Success Following Roux-en-Y Gastric Bypass

BACKGROUND: All patients undergoing gastric bypass surgery at this institution are recommended to achieve a goal of 10% total body weight (TBW) loss prior to surgery. The objective of this study was to determine whether preoperative TBW correlated with 3- and 4-year weight loss outcome. METHODS: This study was conducted prospectively at a large teaching hospital. All adult patients with 3- and 4-year follow-up data since the start of the study in 1998 to September 2007 were included. All data are expressed as mean +/- SD. Pairwise correlation and ordinary least squares regression analysis was used to determine the strength of association between preoperative TBW loss and weight loss at 3 and 4 years. RESULTS: One hundred fifty patients (120 females), age 45.3 +/- 8.9 years, were included. Their body mass indexes (BMIs), preoperatively and after 3 years, were 52.2 +/- 9.8 and 35.4 +/- 8.2 kg/m(2), respectively. There was a significant correlation between preoperative and 3-year TBW lost (9.5 +/- 6.8% vs 31.9 +/- 11.7%, r = 0.302, p = 0.0002) and between excess body weight (EBW) lost preoperatively and after 3 years (16.1 +/- 11.3% vs 55.1 +/- 20.2%, r = 0.225, p = 0.006). Ninety five patients had follow-up data available at 4 years. Their mean preoperative BMI was 52.6 +/- 9.7 kg/m(2) and decreased to 37.5 +/- 9.0 kg/m(2). The TBW loss prior to and after surgery (10.0 +/- 6.5% vs 29.4 +/- 11.5%) was significantly correlated (r = 0.247, p = 0.015). The EBW loss preoperatively and after 4 years correlated positively (17.1 +/- 11.1% vs 50.8 +/- 19.8%, r = 0.205, p = 0.046). CONCLUSION: There is a significant correlation between weight loss attained preoperatively and sustained weight loss at 3 and 4 years.     

The Effects of Acute Preoperative Weight Loss on Laparoscopic Roux-en-Y Gastric Bypass

Background: Minimal acute pre-operative weight loss significantly reduces liver size and intra-abdominal adipose tissue. We hypothesize that these changes will reduce intra-operative complications and reduce the difficulty of laparoscopic Roux-en-Y gastric bypass (LRYGBP). Methods: This is a retrospective chart review of consecutive patients who had undergone isolated LRYGBP between July 2003 and March 2005. All patients participated in our institution's medically supervised Weight Management Program before surgery. Results: 48 patients (Weight Loss Group) had an average percent loss of excess weight (%EWL) of 4.6; whereas 47 patients (No Weight Loss Group) gained an average of 4.8% of excess weight over an average period of 2.4 and 3 months (P=0.09), respectively. There were no differences between the two groups in age, gender, ASA class, co-morbidities, or BMI at operation. The Weight Loss Group had less intra-operative blood loss (102 vs 72 ml, P=.03). The surgeon was also less likely to report an enlarged liver in the Weight Loss Group (P=.02). Finally, the operation was less likely to deviate from the standard LRYGBP when patients lost weight (P=.02). No differences were seen in operative time, length of hospital stay, wound infections, or major complications. Conclusion: Acute preoperative weight loss is associated with less intra-operative blood loss and reduces the need for intraoperative deviation from the standard LRYGBP. A larger series with a greater reduction in excess weight is necessary to determine the maximal benefits of acute preoperative weight loss.     

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

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

Association of Ghrelin Receptor Promoter Polymorphisms with Weight Loss Following Roux-en-Y Gastric Bypass Surgery

Background  

Ghrelin plays a role in appetite and has been hypothesized to play a role in the mechanism of Roux-en-Y gastric bypass (RYGB) surgery. Single nucleotide polymorphisms (SNPs) in the promoter region of its receptor gene (growth hormone secretagogue receptor type 1a—GHSR) have also been associated with weight loss outcomes following long-term dietary intervention in adults with impaired glucose tolerance. Our objectives were to evaluate changes in serum ghrelin levels and determine the effect of GHSR promoter polymorphisms on post-RYGB surgery weight loss.     

Weight Loss Outcome After Silastic Ring Roux-en-Y Gastric Bypass: 8 Years of Follow-up

Background  

An underlying major aim of bariatric surgery is weight loss and its long-term maintenance. In spite of this, most studies regarding weight loss after surgical treatment of morbid obesity show 3-year follow-up results. We evaluated the effectiveness of silastic ring Roux-en-Y gastric bypass (SR-RYGBP) in promoting significant weight loss after an 8-year follow-up at the Londrina State University Hospital.     

Vagal Innervation of Intestine Contributes to Weight Loss After Roux-en-Y Gastric Bypass Surgery in Rats

Background

It is conceivable that overstimulation of chemo- and mechano-sensors in the Roux and common limbs by uncontrolled influx of undigested nutrients after Roux-en-Y gastric bypass surgery (RYGB) could lead to exaggerated satiety signaling via vagal afferents and contribute to body weight loss. Because previous clinical and preclinical studies using vagotomy came to different conclusions, the aim was to examine the effects of selective and histologically verified celiac branch vagotomy on reduced food intake and body weight loss induced by RYGB.

Methods

Male Sprague–Dawley rats underwent either RYGB + celiac branch vagotomy (RYGB/VgX, n?=?15), RYGB + sham celiac branch vagotomy (RYGB/Sham VgX; n?=?6), Sham RYGB + celiac branch vagotomy (Sham/VgX; n?=?6), or sham RYGB + sham celiac branch vagotomy (Sham/Sham; n?=?6), and body weight, body composition, and food choice were monitored for 3 months after intervention.

Results

In rats with RYGB, histologically confirmed celiac branch vagotomy significantly moderated weight loss during the first 40 days after surgery, compared to either sham or failed vagotomy (P?P?Conclusions The results suggest that signals carried by vagal afferents from the mid and lower intestines contribute to the early RYGB-induced body weight loss and reduction of food intake.     

Small-Volume,Fast-Emptying Gastric Pouch Leads to Better Long-Term Weight Loss and Food Tolerance After Roux-en-Y Gastric Bypass

Introduction

Anatomical and functional influences on gastric bypass (GBP) results are often poorly evaluated and not yet fully understood.

Purpose

The purpose of this study is to evaluate the influence of the gastric pouch volume and its emptying rate on long-term weight loss and food tolerance after GBP.

Materials and Methods

Weight loss, food tolerance, pouch volumetry (V) by three-dimensional reconstruction, and pouch emptying rate by 4 h scintigraphy were evaluated in 67 patients. Cutoffs were identified for V and retention percentage (%Ret) at 1 h (%Ret1). From these parameters, the sample was categorized, looking for associations between V, %Ret, weight loss, and food tolerance, assessed by a questionnaire for quick assessment of food tolerance (SS).

Results

PO median follow-up time was 47 months; median V was 28 mL; %Ret at 1, 2, and 4 h were 8, 2, and 1%, respectively. There were associations between V ≤ 40 mL and higher emptying rates up to 2 h (V ≤ 40 mL: %Ret1 = 6, %Ret2 = 2, p = 0.009; V > 40 mL: %Ret1 = 44, %Ret2 = 13.5, p = 0.045). An association was found between higher emptying speed in 1 h and higher late weight loss (WL), represented by lower percentage of excess weight loss (%EWL) regain (p = 0.036) and higher %EWL (p = 0.033) in the group with %Ret1 ≤ 12%, compared to the group %Ret1 ≥ 25%. Better food tolerance (SS > 24), was associated with lower %Ret1 (p = 0.003).

Conclusion

Smaller pouch size is associated with a faster gastric emptying, greater WL maintenance, and better food tolerance. These data suggest that a small pouch with rapid emptying rate is an important technical parameter for good outcomes in GBP.

     

Loss of Insulin Resistance after Roux-en-Y Gastric Bypass Surgery: a Time Course Study

Background: Gastric bypass has repeatedly been shown to improve and even cure type 2 diabetes by substantially improving insulin resistance. The mechanism by which it achieves this is not currently known, but some have hypothesized that there may be important humoral effects brought about by the bypass of the stomach, duodenum or proximal jejunum. A better understanding of the time course of the changes in insulin resistance after surgery might assist our understanding of potential mechanisms. Methods: Intravenous glucose tolerance tests (IVGTT) were performed in 26 severely obese patients on the morning of gastric bypass surgery and again 6 days later. In addition insulin resistance was assessed in 71 patients undergoing gastric bypass surgery by the homeostasis model assessment (HOMA) method before surgery, and again at 6 days, 3, 6, 9, and 12 months. Patients were divided into 3 groups for analysis: diabetics, impaired glucose tolerance and normal glucose tolerance. Results: All 3 groups of patients were noted to have insulin resistance prior to surgery. This was greatest in the diabetic patients, as indicated by HOMA. There was marked loss of/improvement in insulin resistance within 6 days of gastric bypass by both IVGTT and HOMA methods in all groups, which was maintained over the 12-month period. The study included 31 diabetic patients, of whom only 3 required medication following hospital discharge. Conclusion: The changes in insulin resistance seen after gastric bypass, which are responsible for the resolution or improvement of type 2 diabetes occur within 6 days of the surgery, before any appreciable weight loss has occurred. This finding has implications for our understanding of the mechanism of insulin resistance in severely obese patients and is consistent with a humoral mechanism emanating from the GI tract.     

Beyond Weight Loss: Evaluating the Multiple Benefits of Bariatric Surgery After Roux-en-Y Gastric Bypass and Adjustable Gastric Band

Background

Despite the evidence for benefits beyond weight loss following bariatric surgery, assessments of surgical outcomes are often limited to changes in weight and remission of type 2 diabetes mellitus. To address this shortfall in assessment, the King’s Obesity Staging System was developed. This system evaluates the individual in severity stages of physical, psychological, socio-economic and functional disease. These are categorised into disease domains arranged so as to allow an alphabetic mnemonic as Airways, Body Mass Index (BMI), Cardiovascular, Diabetes, Economic, Functional, Gonadal, Health Status (perceived) and (body) Image.

Methods

In this cohort study, patients were assessed before and 12 months after surgery using the modified King’s Obesity Staging Score. We studied 217 consecutive patients undergoing Roux-en-Y gastric bypass (RYGB; N?=?148) and laparoscopic adjustable gastric band (LAGB; N?=?69) using the modified King’s Obesity Staging System to determine health benefits after bariatric surgery.

Results

Preoperatively, the groups had similar BMI, but the RYGB group had worse Airways, Cardiovascular, and Diabetes scores (p?<?0.05). After surgery, RYGB and LAGB produced improvements in all scores. In a subgroup paired analysis matched for preoperative Airways, BMI, Cardiovascular, and Diabetes scores, both procedures showed similar improvements in all scores, except for BMI where RYGB had a greater reduction than LAGB (p?<?0.05).

Conclusions

Both RYGB and LAGB deliver multiple benefits to patients as evaluated by the modified King’s Obesity Staging System beyond BMI and glycaemic markers. A validated staging score such as the modified King’s Obesity Staging System can be used to quantify these benefits.     

Outpatient Weight Loss Surgery: Initiating a Gastric Bypass and Gastric Banding Ambulatory Weight Loss Surgery Center

Background:

Ambulatory surgery or outpatient surgery is becoming increasingly common. In 2002, 63% of all operations performed in the United States were ambulatory procedures. Bariatric procedures performed in the United States have increased from 16,200 in 1992 to approximately 205,000 in 2007. In 2002, our center began offering laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures on an outpatient basis for select candidates at an ambulatory surgery center (ASC). We subsequently added laparoscopic adjustable gastric band procedures (LAGB) in 2005.

Methods:

Between 2002 and 2008, 248 LRYGB and LAGB patients were carefully selected for ASC surgery by the bariatric surgeon and medical director. Extensive preoperative education was mandatory for all surgical candidates.

Results:

Since 2002, we have performed 248 bariatric cases at the ASC, including 38 LRYGB and 210 LAGB procedures. In this overall experience, 5 patients (2%) required readmission within 30 days of surgery, and 98.6% of LAGB patients were discharged the same day; 62% were discharged after a 4-hour to 6-hour stay in the ASC. All LRYGB patients remained in the ASC overnight and were discharge within 24 hours of their procedure. Weight loss results have been excellent.

Conclusion:

LAGB surgery can be safely performed in an ASC setting in most patients. LRYGB can be performed safely in the ASC setting with careful scrutiny and cautious selection of patient candidates.     

Maximizing Weight Loss After Roux-en-Y Gastric Bypass May Decrease Risk of Incident Organ Cancer

Background

Recent studies have suggested that metabolic surgery reduces cancer risk. This study aims to determine if incident cancer is associated with the extent of weight loss after Roux-en-Y gastric bypass (RYGB).

Methods

Patients at a large tertiary bariatric surgery center were retrospectively reviewed to identify patients with no history of cancer at the time of RYGB. Diagnoses in the electronic health record, a tumor registry, and chart review were used to identify postoperative incident solid organ cancer. The overall incidence of organ cancer was estimated using Kaplan-Meier analysis. The percent total body weight loss (%TWL) in the 48 months after surgery but prior to cancer was compared between those that developed organ cancer versus those that did not using repeated measures linear regression.

Results

The 2943 patients had a mean age of 45.6 years (SD?=?11.1), 81 % were female, and a mean baseline body mass index (BMI) of 47.2 kg/m² (SD?=?7.9). Median follow-up after surgery was 3.8 years (range?=?[<1, 12]). Incident organ cancer developed and was verified in 54 of the 2943 patients (1.8 %). Kaplan-Meier estimates for cancer at 3, 5, and 10 years postsurgery were 1.3, 2.5, and 4.2 %. After adjusting for age, BMI, sex, diabetes, hypertension, and dyslipidemia, patients that developed organ cancer achieved less weight loss (?1.5 % TWL, 95 % CI?=?[?2.9 %, ?0.1 %], p?=?0.034).

Conclusions

Greater weight loss after metabolic surgery may be associated with lower organ cancer risk.

     

Influence of Jejunoileal and Common Limb Length on Weight Loss Following Roux-en-Y Gastric Bypass

Background  Capella surgery is one of the technical variations of Roux-en-Y gastric bypass. The method includes the preparation of an alimentary (Roux) limb with a standardized length (110 cm) in order to induce deficiencies in the absorption of macronutrients and thereby contribute to weight loss. The recognized variation in jejunoileal length in humans (approximately 4 to 9 m) is not considered, although this range correlates with the wide variation in the length of the common limb. Methods  In order to assess the influence of variations in jejunoileal and common limb lengths on weight loss, intra-operative measurements were made of these segments on 100 patients undergoing Capella surgery. Patients were followed for a period of 1 year. Statistical analysis included subdivisions of the population by gender and body mass index. Results  Average jejunoileal length was 671.4 ± 115.7 cm (434–990 cm). Average common limb length was 505.3 ± 113.3 cm (268–829 cm). No correlation was detected between jejunoileal length and weight loss at 6 months or 1 year following surgery. A weak negative correlation was detected between weight loss and common limb length at 1 year following surgery in male and super-obese patients. Conclusions  Jejunoileal and common limb length vary widely in gastric bypass patients. To make modifications in the alimentary and/or biliopancreatic limb length, surgeons must consider the variability of the jejunoileal and common limb length.     

Results of The Comparative Study of 200 Cases: One Anastomosis Gastric Bypass vs Roux-en-Y Gastric Bypass

Introduction

Obesity has experienced worldwide increase and surgery has become the treatment that has achieved the best results. Several techniques have been described; the most popular are vertical gastrectomy (GV) and the Roux-en-Y gastric bypass (RYGB). However, mini-gastric bypass/one anastomosis gastric bypass (MGB/OAGB) has gained popularity due to its simplicity and good results.

Objective

To comparatively evaluate the results of MGB/OAGB with those of RYGB with 1-year follow-up.

Methods

The paper presents a comparative case and control study of 100 patients that underwent MGB/OAGB surgery and another 100 with RYGB surgery, operated between 2008 and 2016. Patients were not submitted to revision surgery and had the following pre-operative variables: age 40.46?±?12.4 vs. 39.43?±?10.33 years; sex 64 and 54 women, 36 and 46 men; BMI 44.8?±?12.06 and 45.29?±?8.82 kg/m²; 50 and 54 cases with comorbidities, respectively, these being non-significant differences.

Results

The surgical time was 69.01?±?4.62 (OAGB) vs. 88.98?±?3.44 min; the time of hospitalization was 2 days, reaching a BMI of 27.7?±?7.85 and 29?±?4.52 kg/m², with an excess weight loss 1 year after surgery of 89.4 vs. 85.9%, respectively. The morbidity rates are 9% for OAGB and 11% for the RYGB. There was a comorbidity resolution of 84.4 and 83.7% respectively, without mortality.

Conclusions

The results show the benefits of both techniques, OAGB being the easiest to perform and with less surgical time.