Fasting glycemia: A good predictor of weight loss after RYGB

BackgroundPreoperative prediction of weight loss after Roux-en-Y gastric bypass (RYGB) could help surgeons in managing surgical lists and patients’ expectations. The objective of this study was to understand if preoperative metabolic control might improve surgical results.MethodsProspective cohort of 163 consecutive patients who underwent RYGB with at least 1 year of follow-up.ResultsMost patients were female (90.2%), with a mean age of 38 (19–60) and a BMI of 46.0 (34.3–59.9) kg/m². After 12 months, the mean body mass index (BMI) was 29.7 kg/m² (21.5–39.9) with a corresponding percentage of excess weight lost (%EWL) of 78.8% and a percentage of weight loss (%WL) of 35.1%.Patients with the highest preoperative fasting blood glucose (FBG) were older (42 versus 36; P<.001); were more likely to have type 2 diabetes (T2 DM, 40% versus 6.8%; P<.001) and metabolic syndrome (89% versus 25%; P<.001), had a slightly higher BMI (30.8 versus 29.3 kg/m²; P = .03), and had achieved a significantly lower %EWL and %WL at 12 months (72.5% versus 81.2%; P = .004; 33.2 versus 35.9%; P = .03, respectively). We observed a dose-response effect with increasing FBG (<85 mg/dL, 85–100 mg/dL, and≥100 mg/dL, respectively), with 83.5%, 80.0%, and 72.5% (P = .009) of %EWL at 12 months. By multivariate logistic regression, initial BMI and FBG>100, were the only variables related (inversely) with the probability of achieving a %EWL>80 or %WL>35. This effect was not detected in patients receiving oral antidiabetic medications.ConclusionHigher preoperative FBG is independently related to a poorer weight loss 12 months after RYGB; this suggests the need to offer earlier surgical intervention for severely obese patients with impairment of glucose metabolism. The potential for less weight loss in patients with a higher FBG should not discourage RYGB, given the significant metabolic improvement after surgery.     

Clinical outcomes of the Realize Adjustable Gastric Band-C at 2 years in a United States population

BackgroundIn 2008, the Realize Band (RB) adopted a precurved design (RB-C). We present 2-year outcomes data from the first multiinstitutional study of RB-C. The objective of this study was to analyze weight loss and safety data from bariatric practices in the United States, including academic, nonacademic, public, and private.MethodsThe study included adult RB-C patients with a preoperative body mass index (BMI)≥40 kg/m² or>35 kg/m² with co-morbidity. Exclusions included RB-C’s label contraindications for use. Outcomes parameters were percent excess weight loss (%EWL), BMI change, number and volume of band adjustments, and adverse events.ResultsA total of 231 patients met inclusion/exclusion criteria. Of these, 161 had 24-month data available. Mean %EWL was 44.4%±26.9% (P<.0001). BMI decreased from 44.1±5.7 kg/m² to 35.3±6.9 kg/m² (P<.0001). Percent EWL varied by preoperative BMI (P = .0002), bariatric practice (P<.0001), aftercare frequency (P = .0004), and band fill frequency (P = .0271), but %EWL was not influenced by gender, race, or age (P>.20 each). Adverse events were dysphagia (21.2%), gastroesophageal reflux (21.6%), and vomiting (30.7%). Incidence of pouch dilation, esophageal dilation, and slippage was≤1%. Revisions (2.2%) were for unbuckled band, tube kinking, slippage, and suspected band leak (1 each). No erosions, explants, or mortality were reported.ConclusionRB-C appears to be as well tolerated and effective as the first generation RB for weight loss. The near 45% EWL at 2 years is consistent with other high-quality publications on the RB. Preoperative BMI and frequency of postoperative care, including frequency of band fills, influence %EWL. Significant weight loss is achievable with RB-C despite variable postoperative management practices. The low morbidity and the absence of mortality at 24 months reflect positively on the RB-C characteristics.     

Failure of adjustable gastric banding: starting BMI of 46 kg/m2 is a fulcrum of success and failure

BackgroundTo determine the body mass index (BMI) located at the fulcrum of success and failure in a prospective study conducted at the University of Texas Health Science Center at Houston. On average, our patients whose percentage of excess weight loss (%EWL) was >50% at 1 year had a significantly lower BMI than those with <30% EWL.MethodsWe prospectively collected the weight loss data for 430 patients who had had an adjustable gastric band placed. We stratified the %EWL within 1 year for patients with a BMI of 30–59 kg/m². A line was generated for the %EWL over time for BMI groups of 30–39, 40–49, and 50–59 kg/m² and compared with the average %EWL over time. The y-intercepts of the resulting four lines were graphed against the average BMI for each group.ResultsThe generated y-intercept line had an R² of .9237. Using the equation of this line and the known y-intercept for the average, we solved for x, resulting in a BMI of 46 kg/m². Patients with a BMI <46 kg/m² had a 50% EWL at 1 year, and those with a BMI >46 kg/m² had only a 33% EWL at 1 year. The %EWL between the groups was significantly different at all measured intervals (P <.0001).ConclusionA BMI of 46 kg/m² identifies those at high risk of failure to lose a significant percentage of excess weight after adjustable gastric banding and who require closer follow-up. Furthermore, patients who have a BMI >46 kg/m² should be advised that their weight loss might be suboptimal at 1 year.     

Algorithm for weight loss after gastric bypass surgery considering body mass index,gender, and age from the Bariatric Outcome Longitudinal Database (BOLD)

BackgroundInsight into the effects of gender and age on bariatric weight loss can be disturbed by the well-known influence of initial body mass index (BMI) on excess weight loss (%EWL). Alternative metrics can be found that eliminate this influence. Their formulas can be used to construct an algorithm in which mean weight loss becomes a constant value, describing the effectiveness of the operation independent of the initial BMI. The objective of this study was to create an algorithm describing weight loss after LRYGB in search for a better outcome metric to demonstrate unequivocally the influence of patient characteristics on bariatric results.MethodsNadir weight loss results of BOLD patients, grouped by gender and age (<40 yr and ≥40 yr), with ≥2 years follow-up after LRYGB and initial BMI ≥30 and<80 kg/m², are expressed in 26 different metrics with formula: 100%×(initial BMI – nadir BMI)/(initial BMI – a) with “reference BMI” a = 0–25 kg/m². For each subgroup, the “optimal reference BMI” (a) generating the smallest deviation and without significant difference in outcome between lighter and heavier patients is used to construct an algorithm (Mann-Whitney U test; P<.0002). Mean nadir relative weight loss results (b) are compared.ResultsA total of 8945 patients met inclusion criteria (mean initial BMI, 47.7 kg/m²; median age, 48 yr; 20.0% male). Both female subgroups had optimal reference BMI: a = 10 kg/m²; both male subgroups: a = 17 kg/m². LRYGB effectiveness (b) was significantly higher for younger patients and for female patients. The %EWL metric rendered different significances.ConclusionsBoth genders have age-independent metrics for which nadir relative weight loss after LRYGB is not influenced by initial BMI. The resulting algorithm nadir BMI = a + (100%−b) × (initial BMI−a) consists of an inert part (a = 10–17 kg/m²) on which the bariatric effectiveness (b) does not act and an alterable part (initial BMI−a) on which it does. The proposed metric percentage alterable weight loss (%AWL) reduces results to constant values for bariatric effectiveness (b), facilitating research on the precise effect of patient characteristics and surgical variables on postoperative weight loss better than %EWL, a metric able to produce false conclusions. Women and younger patients had significantly more weight loss; initial BMI had no effect.     

Early-phase insulin hypersecretion associated with weight loss outcome after LSG: a prospective cohort study in Asian patients with BMI ≥28 kg/m2

BackgroundObesity has become a global problem that poses a serious threat to human health. Laparoscopic sleeve gastrectomy (LSG) is an effective long-term treatment. However, the weight loss of some patients after LSG is still insufficient. It is necessary to investigate the factors associated with inadequate weight loss after LSG.ObjectiveThe objective of this study was to explore whether preoperative insulin secretion could be associated with weight loss after LSG in patients with obesity.SettingThis is a single-center prospective cohort study conducted in a university hospital.MethodsPatients from a prospective database who underwent LSG were analyzed. All 178 participants underwent a 75-g oral glucose tolerance test (OGTT) to assess preoperative insulin and c-peptide secretion before LSG. The areas under the curve (AUCs) for glucose, insulin, and c-peptide were determined in the OGTT. The percentage of excess weight loss (%EWL) and the percentage of total weight loss (%TWL) were used to estimate the effect of weight loss after LSG. Regression models were used to assess the correlation between preoperative insulin and c-peptide secretion with %EWL ≥75% and TWL ≥35% at 12 months after LSG.ResultsThe AUCs of insulin and c-peptide were significantly lower in the %EWL ≥75% and %TWL ≥35% groups at 0–30 minutes, 0–60 minutes, and 0–120 minutes during the OGTT. At 30, 60, and 120 minutes during the OGTT, c-peptide levels were significantly lower in the %EWL ≥75% group and %TWL ≥35% group. The preoperative c-peptide level at 30 minutes during the OGTT (C₃₀) was significantly negatively correlated with %EWL (β = ?.37, P < .001) and %TWL (β = ?.28, P = .011). Univariate logistic regression analysis showed that preoperative C₃₀ was associated with %EWL ≥75% and %TWL ≥35% after LSG. According to multiple logistic regression analysis, patients with a low preoperative C₃₀ had an 8-fold higher %TWL ≥35% after LSG than those with a high C₃₀ (odds ratio: 8.41 [95% confidence interval: 1.46–48.58], P = .017). Similarly, patients with a low preoperative C₃₀ had a 7-fold higher EWL% ≥75% after LSG than patients with a high C₃₀ (odds ratio: 7.25 [95% confidence interval: 1.11–47.50], P = .039).ConclusionsThe rate of weight loss after LSG is low among patients with preoperative hyperinsulinemia. The preoperative c-peptide level at 30 minutes during the OGTT is associated with weight loss after LSG.     

Long-term weight loss outcomes after banded Roux-en-Y gastric bypass: a prospective 10-year follow-up study

Objective

To evaluate the weight loss outcomes of banded Roux-en-Y gastric bypass (RYGB) during a 10-year follow-up.

Insurance-mandated weight management program completion before bariatric surgery provides no long-term clinical benefit

BackgroundThere is no evidence that insurance-mandated weight loss before bariatric surgery affects outcomes.ObjectiveThis retrospective study evaluated the relationship between insurance-mandated weight management program (WMP) completion before primary bariatric surgery and postoperative outcomes.SettingSuburban academic medical center.MethodsPatients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB, n = 572) or sleeve gastrectomy (SG, n = 484) from 2014 to 2019 were dichotomized to presence (LRYGB n = 431, SG n = 348) or absence (LRYGB n = 141, SG n = 136) of insurance-mandated WMP completion. Primary endpoints included follow-up rate, percent total weight loss (%TWL), and percent excess weight loss (%EWL) through 60 months after surgery. The Mann-Whitney U test compared between-group means with significance at P < .05.ResultsFollow-up rate, %TWL, and %EWL were not different (P = NS) up to 60 months postoperation between groups for either surgery. Both LRYGB and SG patients without WMP completion maintained greater %TWL (LRYGB: 34.4 ± 11.1% versus 29.8 ± 11.0%, P = .159; SG: 21.4 ± 10.0% versus 18.2 ± 10.5%, P = .456) and %EWL (LRYGB: 71.3 ± 26.3% versus 67.6 ± 26.5%, P = .618; SG: 49.2 ± 18.8% versus 47.5 ± 28.8%, P = .753) at 36 months after surgery. Secondarily, duration of time to get to surgery was significantly greater among yes-WMP patients (LRYGB: 178 days versus 121 days, P < .001; SG: 169 days versus 95 days, P < .001).ConclusionInsurance-mandated WMP completion before bariatric surgery delays patient access to surgery without improving postoperative weight loss potential and must be abandoned.     

Does the intragastric balloon have a predictive role in subsequent LAP-BAND® surgery? Italian multicenter study results at 5-year follow-up

BackgroundThe intragastric balloon has been reported to be a safe and effective tool for temporary weight loss. The aim of this study is the evaluation of the possible predictive role of intragastric balloon when used before laparoscopic adjustable gastric banding.MethodsA longitudinal multicenter study was conducted in patients with body mass index (BMI)>35 kg/m² who underwent gastric banding with the BioEnterics Intragastric Balloon (BIB). After balloon removal (6 mo), patients were allocated into 2 group according to their percentage of excess weight loss (%EWL): group>25 (%EWL>25%) and group<25 (%EWL<25%). Patients from both group underwent laparoscopic adjustable gastric banding (LAGB) 1–3 months after BIB removal. The LAP-BAND AP band was placed in all patients via pars flaccida. Weight loss parameters were considered in both groups.ResultsFrom January 2005 to December 2009, 1357 patients were enrolled in this study. Mean BMI at time of BIB positioning was 44.9±8.4 (range 29–82.5). After 6 months, at time of removal, mean BMI was 39.4±7.3. According to the cutoff, patients were allocated into group A (n = 699) and group B (n = 658). At this time the mean BMI was 36.4±6.4 and 42.7±6.9 (P = .001) in groups A and B, respectively. At 1-year follow-up from LAGB, mean BMI was 35.8±6.5 and 40.0±7.4 (P<.001) in groups A and B, respectively. This significant difference was confirmed at 3- and 5-year follow-ups. A similar pattern was observed with the %EWL.ConclusionSatisfactory results with BIB are predictive of a positive outcome of LASB at 1, 3, and 5 years after the procedure, and poor results do not inevitably indicate a negative outcome for gastric banding.     

Laparoscopic gastric greater curvature plication versus laparoscopic sleeve gastrectomy: early outcome in 140 patients

BackgroundLaparoscopic gastric greater curvature plication (LGGCP) is a novel bariatric procedure. Its outcome as a standalone procedure has been studied in the literature. We herein describe a comparative study between LGGCP versus laparoscopic sleeve gastrectomy (LSG). The objective of this study was to analyze %excess weight loss (%EWL), co-morbidity improvement and complication rate in both groups at 1, 3, 6, 12 months follow-up.MethodsRetrospective study of 140 patients undergoing LGGCP and LSG between July 2011 and March 2012 at University of Alexandria, Egypt. Data on patient demography, operative time, length of stay, body mass index (BMI) were collected.ResultsBaseline characteristics were similar for both groups, except for preoperative BMI that was higher among the LSG group. Follow up rate was 98% (n = LGCCP: 68 – LSG: 69) at 6 months and 81% (n = LGGCP: 54 – LSG: 60) at 1 year. The mean operative time and mean length of stay were longer in the LSG group (P = .03) and (P = .02), respectively. There were 4 (6.5%) readmissions and 2 (3.2%) reoperations in the LGGCP group compared to 3 (3.8%) readmission and 2 (2.6%) reoperations in the LSG group. At 6 months follow-up the mean %EWL for LGGCP and LSG was 40.4±11.9% and 47.1±13.9% (P<.001), while at 1 year it was 52.1±15.1% and 68.1±15.8% (P<.001), respectively. Both techniques showed similar results in co-morbidity improvement at 1 year.ConclusionIn the short term, both techniques were comparable as regards to co-morbidity resolution. However, LSG appears to have achieved a higher weight loss.     

Conversion of gastric sleeve to Roux-en-Y gastric bypass: overall outcomes and predictors of below-average weight loss

BackgroundConversion of sleeve gastrectomy (SG) to Roux-en-Y gastric bypass (RYGB) has been utilized to promote further weight loss, but results are variable in available literature.ObjectivesTo evaluate outcomes of SG to RYGB conversion for weight loss and to identify predictors of below-average weight loss.SettingUniversity-affiliated hospital, United States.MethodsChart review was performed of our patients who underwent SG to RYGB conversion from November 1, 2013, to November 1, 2020. Primary outcomes were below-average percent excess weight loss (%EWL) at 1 and 2 years. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for preconversion demographics to evaluate their relationship to the primary outcome.ResultsSixty-two patients underwent conversion from SG to RYGB with weight loss as a goal. One-year data was available for 47 patients. The average %EWL at 1 year was 41.5%. Twenty-six patients had below-average %EWL at 1 year. Interval to conversion <2 years (OR = 4.41, 95% CI [1.28,15.17], P = .019) and preconversion body mass index (BMI) >40 (OR = 4.00, 95% CI [1.17,13.73], P = .028) were statistically significant predictors of below-average 1-year %EWL. Two-year data was available for 36 patients. The average %EWL at 2 years was 30.8%. Seventeen patients had below-average %EWL at 2 years. Evaluated demographics were not statistically significant predictors of below-average 2-year %EWL.ConclusionsFollowing SG to RYGB conversion, %EWL outcomes are lower at 1 year (41.5%) and 2 years (30.8%) than reported values for primary RYGB. Interval to conversion <2 years and preconversion BMI >40 are predictors of below-average 1-year weight loss after conversion.     

Do patients with higher baseline BMI have improved weight loss with Roux-en-Y gastric bypass versus sleeve gastrectomy?

Background

As sleeve gastrectomy (SG) becomes the most common bariatric procedure, it remains unclear for which patients laparoscopic Roux-en-Y gastric bypass (LRYGB) may be advantageous. Some contend that patients with higher initial body mass index (BMI) achieve better weight loss with LRYGB.

10-year follow-up after laparoscopic sleeve gastrectomy: Outcomes in a monocentric series

Background

Sleeve gastrectomy (SG) has grown into the most popular bariatric operation. Nevertheless, a scarcity of long-term outcomes are available.

Clinical outcomes of the REALIZE adjustable gastric band-C at one year in a U.S. population

BackgroundIn 2008, the REALIZE Band (RB) adopted a precurved design (RB-C). The present study is the first multi-institutional report of RB-C outcomes. Our objective was to analyze the 1-year weight loss and safety data from adult RB-C patients treated at multiple U.S. centers (7 typical U.S. bariatric practices, including academic, nonacademic, public, and private practice).MethodsPatients implanted with the RB-C (preoperative body mass index ≥40 kg/m² or >35 kg/m² with co-morbidity) were recruited. The exclusion criteria included the RB-C label contraindications for use. The outcomes parameters were the percentage of excess weight loss (%EWL), change in body mass index, number and volume of band adjustments, and incidence of complications.ResultsOf the 239 patients enrolled in the 2-year study, 158 had 1-year data available for analysis in November 2010. The mean %EWL was 39.2% ± 20.5% (range ?7.7 to ?116.8, P < .0001). The body mass index decreased from 44.4 ± 5.5 kg/m² to 36.4 ± 5.8 kg/m² (P < .0001). The variability in the %EWL was significant among the study centers (P < .0001). The average band fill volume at 1 year was 8.0 ± 2.0 mL (range .0–11.1). The total fill volume was >11 mL in 1 patient. No band erosions/migrations, explants, or deaths occurred.ConclusionRB-C appears to be as safe and effective as the first-generation RB. The near 40% EWL at 1 year was consistent with other high-quality publications of the RB. Good weight loss results are achievable, despite the varying postoperative management practices. The low morbidity and the absence of mortality at 12 months reflect positively on the RB-C characteristics. Our findings suggest that the learning curve, related to the postoperative management of the RB-C, might vary by practice and that a greater frequency and smaller band fills might result in better weight loss at 12 months.     

Weight loss is more sustained after biliopancreatic diversion with duodenal switch than Roux-en-Y gastric bypass in superobese patients

BackgroundAlthough biliopancreatic diversion with duodenal switch (BPD-DS) is not the most performed procedure, Roux-en-Y gastric bypass (RYGB) is challenged by weight regain and insufficient weight loss, especially in patients with a body mass index >50 kg/m². The aim of our retrospective study was to compare the weight loss after 2 types of primary bariatric surgery. A total of 83 BPD-DS and 97 RYGB procedures were performed from March 2002 to October 2009 for an initial mean body mass index of 55 kg/m².MethodsAll RYGB patients underwent surgery at a private practice hospital and BPD-DS patients underwent surgery at a university hospital before February 2007 and at the same private hospital thereafter. The patients were seen in follow-up every 4 months the first year, every 6 months the second, and yearly thereafter. The maximum weight loss was assessed, as well as the weight regain beyond the first postoperative year. Weight loss success was defined as a percentage of excess weight loss (%EWL) of ≥50%.ResultsThe patients did not differ by age, gender, or length of follow-up (mean 46 mo, range .5–102 for RYGB and 44.3 mo, range 9–111 for BPD-DS). Of the patients, 17 RYGB and 7 BPD-DS patients were lost to follow-up within 3 years postoperatively. At 3 years of follow-up, the mean %EWL was 63.7% ± 17.0% after RYGB and 84.0% ± 14.5% after BPD-DS (P < .0001). Weight loss success was achieved by 83.5% of the RYGB and 98.7% of the BPD-DS patients (P = .0005).ConclusionAfter 12 months postoperatively, the number of patients regaining 10% of the weight lost during the first postoperative year was significantly greater after RYGB than after BPD-DS.     

Replication and extension of dietary adherence as a predictor of suboptimal weight-loss outcomes in postbariatric patients

Background

Sarwer et al. found that poor dietary adherence at 6 months postoperatively predicted lower weight loss.

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.     

Long-term outcomes of laparoscopic sleeve gastrectomy as a primary bariatric procedure

BackgroundLaparoscopic sleeve gastrectomy (LSG) has been established as a reliable bariatric procedure, but questions have emerged regarding its long-term results. Our aim is to report the long-term outcomes of LSG as a primary bariatric procedure.MethodsRetrospective analysis of patients submitted to LSG between 2005 and 2007 in our institution. Long-term outcomes at 5 years were analyzed in terms of body mass index (BMI), excess weight loss (EWL) and co-morbidities resolution. Surgical success was defined as %EWL>50%. Also, we compared long-term results according to preoperative BMI, using Mann-Whitney test.ResultsA total of 161 LSG were analyzed, and 114 patients (70.8%) were women. The median age was 36 years old (range 16–65), median preoperative BMI was 34.9 kg/m² (interquartile range [IQR], 33.3–37.5). A total of 112 patients (70%) completed 5 years of follow-up. At the fifth year, median BMI and %EWL was 28.5 kg/m² (IQR: 25.8–31.9) and 62.9% (IQR: 45.3–89.6), respectively, with a surgical success of 73.2% of followed patients. According to preoperative BMI, surgical success was achieved in 80% of patients with BMI<35 kg/m², 75% of BMI 35–40 kg/m², and 52.6% of BMI>40 kg/m², with significant lower %EWL in patients with BMI>40 kg/m² (P = .001 and .004). Dyslipidemia and insulin resistance resolution was 80.7% and 84.7%, respectively. A total of 26.7% of patients reported new-onset gastroesophageal reflux symptoms at 5 years.ConclusionLSG as a primary procedure is a reliable surgery. We observed positive long-term outcomes of %EWL and co-morbidities resolution. In our series, best results are seen in patients with preoperative BMI<40 kg/m².     

Use of phentermine-topiramate extended release in combination with sleeve gastrectomy in patients with BMI 50 kg/m2 or more

BackgroundSuper obesity (body mass index [BMI] ≥50 kg/m²) treatment can be complicated and high risk.ObjectivesWe studied whether the pre and postoperative use of phentermine and topiramate (phen/top) combined with laparoscopic sleeve gastrectomy (LSG) in super obesity increases the odds of achieving a BMI <40 at 2 years postoperatively.SettingAcademic medical center in Winston Salem, North Carolina.MethodsWe recruited patients between 2014 and 2016 who had a BMI ≥50 and planned to undergo LSG (n = 25) to participate in an open-label trial. Participants took phen/top (7.5/46–15/92 mg/d) for at least 3 months preoperatively and 2 years postoperatively. We compared weight loss, BMI changes, and odds for achieving BMI <40 for phen/top + LSG to historical controls. Controls had an initial BMI ≥50 and underwent LSG, without phen/top, at our center during the same timeframe (n = 40).ResultsOf the 25 participants recruited, 13 completed LSG. Phen/top participants had a baseline BMI of 61.2 ± 7.1 kg/m² compared with 57.0 ± 5.6 kg/m² for control participants. Percent initial weight loss was –39.3% (phen/top + LSG) versus –31.4% (control) at 12 months, P = .018; by 24 months, phen/top + LSG had an 11.2% greater initial weight loss, P = .007. At 24 months, the mean BMI was 33.8 kg/m² for phen/top versus 42 kg/m² for controls. The odds ratio for achieving a BMI <40 at 2 years with phen/top + LSG versus LSG alone was 4.1 (95% confidence interval, 0.8–21).ConclusionsCompared with LSG alone, phen/top combined with LSG may help patients with a BMI >50 achieve greater weight loss and reach a BMI <40. Long-term, controlled trials are needed to follow up these results.     

Feasibility and technique of laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy

BackgroundTo evaluate the feasibility, safety, and short-term efficacy of the conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic sleeve gastrectomy (LSG) because of inadequate weight loss.MethodsThe inclusion criteria were an inadequate percentage of excess weight loss (%EWL), defined as <30% at ≥1 year after LAGB. From August 2002 to October 2007, 27 patients (17 women and 10 men) had undergone removal of their LAGB and conversion to LSG. The average age at LSG was 43.6 ± 11.4 years (range 25–66). Before LAGB, the mean weight and body mass index was 129.8 ± 21.9 kg (range 95–178) and 45 ± 8.1 kg/m² (range 35–64), respectively. The average interval between LAGB and LSG was 51.2 ± 30.1 months (range 22–132). Before conversion, the mean weight, body mass index, and %EWL was 117.9 ± 27.3 kg (range 63–170), 39 ± 9.6 kg/m² (range 24–61), and 18.1% ± 18.3%, respectively. Of the 27 patients, 12 had 19 obesity-related co-morbidities, including arterial hypertension in 7, type 2 diabetes mellitus in 2, degenerative joint disease in 7, and sleep apnea in 3.ResultsThe mean operative time was 120.6 ± 32.4 minutes (range 65–195). No conversion to open surgery was required, and no patient died. The postoperative complications included a subphrenic hematoma that required laparoscopic drainage; no postoperative leaks developed. The mean hospital stay was 3.2 ± 1.4 days (range 2–8). After a mean follow-up of 18.6 ± 14.8 months (range 1–59) for 23 patients (4 patients were lost to follow-up), the mean weight, body mass index, and weight loss was 100.7 ± 23.5 kg (range 61–152), 34.6 ± 8.7 kg/m² (range 21–50.4), and 23 ± 12.4 kg (range 2–55), respectively. The patients had had an additional 16.7% EWL after LSG for a total average %EWL of 34.8% ± 21.8% (P <.05). Of the 12 patients with obesity-related co-morbidities, 5 had had resolution, including arterial hypertension in 1, type 2 diabetes mellitus in 1, degenerative joint disease in 2, and sleep apnea in 2.ConclusionThe results of this study support the safety of LSG in the case of an inadequate %EWL after LAGB. However, the degree of weight loss and co-morbidity resolution is of concern.     

Preoperative Weight Loss and Postoperative Weight Gain Independently Increase Risk for Revision After Primary Total Knee Arthroplasty

BackgroundThe current American Association of Hip and Knee Surgeons (AAHKS) guidelines recommend preoperative weight loss before total knee arthroplasty (TKA) in patients with body mass index (BMI) ≥40 kg/m². However, there is a paucity of evidence on TKA outcomes after preoperative weight loss. This study therefore evaluated predictors of preoperative and postoperative BMI changes and their impact on outcomes after TKA.MethodsThis is a retrospective review of 3058 primary TKAs at an academic institution from 2015 to 2019. BMI was collected on the day of surgery. Preoperative and postoperative BMI at 6 months and 1 year were also obtained. BMI change of ≥5% was considered clinically significant. Mean follow-up was 3.2 years. Patient demographics, acute postoperative outcomes, and all-cause revisions were compared between patients who gained, lost, or maintained weight using univariate and multivariable analyses.ResultsPreoperative weight loss was predictive of postoperative weight gain (P < .001), and preoperative weight gain was predictive of postoperative weight loss (P < .001). Cox regression analysis revealed that ≥5% BMI loss preoperatively increased risk for all-cause revisions (P = .030), while ≥5% BMI gain postoperatively increased risk for prosthetic joint infections (P = .016). Patients who lost significant weight both before and after surgery had the highest risk for all-cause revisions (P = .022).ConclusionWeight gain postoperatively was associated with inferior outcomes. Significant weight loss before surgery led to a “rebound” in weight gain, and independently increased risk for all-cause revision. Therefore, current recommendations for weight loss before TKA in morbidly obese patients should be re-evaluated.