Relative Outcome Measures for Bariatric Surgery. Evidence Against Excess Weight Loss and Excess Body Mass Index Loss from a Series of Laparoscopic Roux-en-Y Gastric Bypass Patients

Background  

Bariatric results expressed in the relative measure excess weight loss (%EWL) vary significantly by initial body mass index (BMI): the heavier the patient, the lower the %EWL. We examine if this variation is caused by using a wrong outcome measure and argue that no relative weight loss measure can express bariatric or metabolic goals unequivocally.     

Effectiveness and Safety of Air-Filled Balloon Heliosphere BAG® in 82 Consecutive Obese Patients

Background

Intragastric balloon is a widely used technique to treat obesity that is considered to be more efficient than conservative treatment before bariatric surgery. To describe air-filled balloon (Heliosphere BAG®) effectiveness [absolute weight loss, body mass index (BMI) loss, percentage of body weight loss (BWL), percentage of excess weight loss (EWL)] and complications 6 months after its insertion.

Methods

Eighty-four consecutive intragastric balloons were placed endoscopically. Individualized nutritional counseling was given. The follow-up was carried out in an endocrinology outpatient clinic. Due to the weight or height data missed in two cases, only 82 patients were included in this report, 63 women with a mean age 39 years (SD, 11.1); mean BMI, 39.1 kg/m² (SD, 5.8). The median follow-up was 182 days.

Results

The mean weight loss and BMI loss were 14.5 kg (SD, 8.2); and 5.3 kg/m² (SD, 2.8), respectively (for difference, p?10%. The percentage of EWL reached 33.2% (SD, 19.2). After adjusting by sex and initial BMI, absolute weight loss (p?=?0.033), BMI loss (p?=?0.034), percentage of BWL (p?=?0.034), and percentage of EWL (p?=?0.034) were inversely related to age. Absolute weight loss and BMI loss were greater in higher initial BMI, but the percentage of EWL was lower. Two spontaneous deflations occurred (3%), but only one surgical early removal (1.2%) was required. Nausea and vomiting developed in 7.4% of the patients during the first week.

Conclusions

Air-filled Heliosphere BAG® has been effective in achieving a relevant loss of body weight.

     

Single-Incision Versus Conventional Laparoscopic Adjustable Gastric Banding

Background and Objectives:

Laparoscopic adjustable gastric banding is an effective and popular bariatric surgery for weight loss in obese patients that traditionally involves up to 5 incisions. Recently, a more minimally invasive single-incision technique has been developed. In this retrospective study, we compare conventional and single-incision laparoscopic adjustable gastric banding with regard to weight loss and complication rates in a cohort of demographically similar patients.

Methods:

From February 2009 to February 2010, 59 patients underwent laparoscopic adjustable gastric banding by one surgeon at an outpatient surgery center. All patients were compared by age, sex, preoperative body mass index, 30-day complication rates, and excess weight loss. Thirty-seven operations were performed by a conventional, 5-incision technique, whereas 22 patients underwent the single-incision technique. The success of these techniques was determined by comparing complication rates and average percentage excess weight loss at 6-month follow-up intervals.

Results:

Patients who underwent conventional laparoscopic adjustable gastric banding had a mean age of 41.2 years and preoperative body mass index of 48.2 kg/m² compared with 43.9 years and 40.3 kg/m², respectively, for the single-incision patients. The mean operative time in the single-incision group was longer than that in the conventional group: 47.1 minutes versus 37.4 minutes (P = .0027). The overall percentage excess weight loss was not statistically different between the 2 groups for each follow-up period. There were no complications or deaths in either group.

Conclusion:

Although patients undergoing bariatric surgery may choose the single-incision technique for cosmetic purposes, this retrospective review comparing single-incision and conventional laparoscopic adjustable gastric banding shows longer operative times with equivalent weight loss and morbidity.     

Excess Weight Loss Variation in Late Postoperative Period of Gastric Bypass

Background  

In the late postoperative period of gastric bypass surgery, we observe that many patients weight regain. The objective of this study was to determine the excess weight loss variation at 24 and 60 months postoperative. A secondary objective was to evaluate in the period described, the association of weight regain with red meat intolerance, age, gender, and body mass index.     

Body fat mass and distribution as predictors of metabolic outcome and weight loss after Roux-en-Y gastric bypass

Background

Bariatric surgery such as Roux-en-Y gastric bypass (RYGB) remains the most effective treatment of obesity and associated co-morbidities. Body fat distribution associates with metabolic function.

Bariatric patients’ reported motivations for surgery and their relationship to weight status and health

Background

Literature on patient motivation for bariatric surgery remains limited. A few studies have examined relation to outcomes and found no established connection between motivation and weight loss.

Comparison of Weight Loss and Body Composition Changes in Morbidly Obese Taiwanese Patients with Different Bariatric Surgeries: A 1-Year Follow-up Study

Background

This study investigated the impacts of two different bariatric surgeries on the body composition of morbidly obese patients in Taiwan. Also, the differences in body composition changes between genders were compared.

Methods

In total, 198 patients who underwent bariatric surgery were included, with 130 receiving a sleeve gastrectomy (SG) and 68 receiving adjusted gastric banding (AGB). The weight and body composition were measured by bioelectrical impedance. Follow-up examinations were performed at subsequent visits after surgery and at 1 year. Only 81 SG and 40 AGB patients continued follow-up for the entire 12 months.

Results

All patients experienced significant weight loss beginning from 3 months after surgery. Compared to patients with AGB, SG patients had a greater extent of body mass index (BMI) loss, whereas a greater muscle weight percentage increase was found compared to AGB patients. Female patients had a higher body fat mass and lower muscle weight percentage and BMI than did males. There were no differences in changes in BMI, or percentages of body fat and muscle mass between male and female patients for 12 months after surgery. However, the waist/hip ratio (WHR) decrement and percentage of excess weight loss (ExWL%) were significantly greater in female than male patients with both bariatric surgeries.

Conclusions

These findings suggest that although females had greater extents of WHR decrement and ExWL% than male patients with both surgical procedures, patients who received SG had higher BMI changes and body fat losses than SGB patients regardless of differences in the gender distribution.     

Long-term results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass

Background

Studies reporting revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been underpowered and lacking long-term data. We have previously shown that short-term (12 mo) and midterm (24 mo) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. The present study represents the largest published series with longest postoperative follow-up of patients receiving salvage LAGB after RYGB failure.

Cross-sectional review of effects of laparoscopic sleeve gastrectomy at 1, 3, and 5 years

Background

Laparoscopic sleeve gastrectomy evolved as a primary bariatric procedure without data on longer term outcomes. Our objective was to measure the weight changes and quality of life after laparoscopic sleeve gastrectomy at a university hospital.

Methods

The patients scheduled follow-up visits for clinical measurements, blood sampling, and form completion, including the Medical Outcomes Study 36-item short-form questionnaire, the Impact of Weight on the Quality of Life-Lite questionnaire, and Beck depression inventory. Comparisons were performed among patients with a follow-up of 1, 3, and 5 years after laparoscopic sleeve gastrectomy.

Results

A total of 77 patients (35 at 1, 19 at 3, and 23 at 5 yr) were similar in gender (70.1% women), percentage of body fat, and body mass index by analysis of variance (P = .12; 1 versus 3 yr, P = .04). The 5-year group was older (P = .07). The 3 groups were different in the percentage of excess body mass index loss (P = .04). Differences in the Beck depression inventory were not significant by analysis of variance but were for 1 year versus 5 years (P = .04). For the Impact of Weight on the Quality of Life-Lite total scores, the difference was significant (P = .06; 1 versus 5 yr, P = .027; and public distress subscore at 1 and 5 yr, P = .04). The differences in the other domains were not significant. For the Medical Outcomes Study 36-item short-form, differences in the physical differences domain was significant (P = .001). The differences in physical function, social function, general health, vitality, body pain, and role physical were significant. The differences in mental health and role emotional were not. The differences in the Beck depression inventory scores were not significant using analysis of variance but were between the 1-year and 5-year scores (P = .04).

Conclusion

Patients undergoing laparoscopic sleeve gastrectomy had a similar body mass index at 1, 3, and 5 years. However, the percentage of excess body mass index loss was different. No differences were found in the percentage of body fat. The health-related quality of life scores resembled community norms, although the physical health differences in the 3 groups were significant, The Beck depression inventory scores were elevated at 5 years compared with at 1 year.     

Body Image After Sleeve Gastrectomy: Reduced Dissatisfaction and Increased Dynamics

Background

Individuals with severe obesity commonly report poor body image. Improvement in body image has been found after conservative weight reduction programs as well as after bariatric surgery (gastric bypass, biliopancreatic diversion, or gastric banding). However, no studies investigating body image after laparoscopic sleeve gastrectomy (LSG) are available.

Methods

Of 70 consecutive patients who planned to undergo LSG at a comprehensive obesity center, 62 patients were included in the study and evaluated before surgery. Their mean body mass index (BMI) was 51.3?kg/m² and the patients?? mean age before surgery was 43.8?years. One-year follow-up data were obtained for 51 patients (82.3?%). Body image was assessed using the body image questionnaire (BIQ-20), and depression was assessed using the Patient Health Questionnaire (PHQ-9).

Results

Patients reported poor body image before surgery. One year after LSG, negative evaluations of the body and perceptions of body dynamics and vitality had markedly improved, without reaching healthy levels. No correlations between body image and weight-related parameters (BMI, percentage of excess weight loss) or mood after 1?year were found.

Conclusions

Body image improves after LSG. This improvement might reflect changes to patients?? attitudes, beliefs, and thoughts rather than real weight lost. Further studies should investigate the factors that mediate improvement of body image after bariatric surgery.     

Prospective, Multicenter, 3-Year Trial of Laparoscopic Adjustable Gastric Banding with the MIDBAND?

Background

Although laparoscopic adjustable gastric banding (LAGB) is a popular metabolic/bariatric procedure, few prospective studies have assessed its outcomes. This study aimed to prospectively assess LAGB safety and effectiveness outcomes using the MIDBAND? (MID, Dardilly, France).

Methods

Between May 2005 and September 2006, 262 morbidly obese patients underwent primary gastric banding with pars flaccida technique in 13 French medical centers. Excess weight loss and change in body mass index (BMI, kilogram per square meter), percentage of patients with comorbidities, and obesity-related complications were recorded. Patients were followed at 6-month intervals for 3?years. A multivariable individual growth model was used to analyze weight change over time and determine potential predictors of weight loss.

Results

The majority of patients were female (n?=?233, 89%), with mean age of 36.4?±?9.7?years. At 3?years, LAGB with MIDBAND resulted in significant decrease in mean BMI from 41.8?±?4.2 to 30.7?±?5.8 (p?p?Conclusion Prospective outcomes demonstrate the safety and efficacy of gastric banding over time using the MIDBAND. Individual growth modeling demonstrated that postoperative weight loss is strongly related to the frequency and consistency of follow-up visits.     

Validating the Alterable Weight Loss (AWL) Metric with 2-Year Weight Loss Outcome of 500 Patients After Gastric Bypass

Background

Percentage alterable weight loss (AWL) is the only known weight loss metric independent of the initial body mass index (BMI), a unique feature ideal for use in weight loss research. AWL was not yet validated. The aim of the study is to validate the AWL metric and to confirm advantages over the excess weight loss (EWL) metric.

Methods

AWL is tested with 2-year weight loss results of all primary laparoscopic Roux-en-Y gastric bypass patients operated in our hospital. Nadir results of patients with higher and lower initial BMI are compared (Mann–Whitney; p?<?0.05) using outcome metrics BMI, percentage weight loss (WL), EWL, and AWL, for the whole group, for each gender, and for <40 and ≥40 years separately.

Results

Five-hundred patients (401 female) out of 508 (98.4 %) had 2-year follow-up. Of all four metrics, only AWL rendered results not significantly influenced by initial BMI. The AWL outcome is initial BMI independent for both genders and age-groups. Results also confirm that women and younger patients had significantly higher AWL outcome.

Conclusion

The recently developed AWL metric, defined as 100%?×?(initialBMI???BMI)?/?(initialBMI???13), is now validated. In contrast to the well-known outcome metrics BMI, EWL, and WL, the AWL metric is independent of the initial BMI. It should replace the misleading EWL metric for comparing weight loss results in bariatric research and for expressing the effectiveness of bariatric procedures. This effectiveness does not act on the total body mass, or on the excess part, but on the alterable part, defined as BMI minus 13 kg/m² for all adult patients, female, male, young, and old.     

Obesity Risk Factors in Patients After Kidney Transplantation

Background

Kidney transplantation is currently the best approach for renal replacement therapy. Compared with dialysis, it provides a better quality of life and improves patient prognosis. However, some evidence suggests that body composition could play a role in the complications observed in kidney transplant recipients (KTRs), and may influence survival. The purpose of this study was to assess the eating habits and body composition of KTRs.

Outcomes of a Third Bariatric Procedure for Inadequate Weight Loss

Background and Objectives:

The robust volume of bariatric surgical procedures has led to significant numbers of patients requiring reoperative surgery because of undesirable results from primary operations. The aim of this study was to assess the feasibility, safety, and outcomes of the third bariatric procedure after previous attempts resulted in inadequate results.

Methods:

We retrospectively identified patients who underwent a third bariatric procedure for inadequate weight loss or significant weight regain after the second operation. Data were analyzed to establish patient demographic characteristics, perioperative parameters, and postoperative outcomes.

Results:

A total of 12 patients were identified. Before the first, second, and third procedures, patients had a mean body mass index of 67.1 ± 29.3 kg/m², 60.9 ± 28.3 kg/m², and 49.4 ± 19.8 kg/m², respectively. The third operations (laparoscopic in 10 and open in 2) included Roux-en-Y gastric bypass (n = 5), revision of pouch and/or stoma of Roux-en-Y gastric bypass (n = 3), limb lengthening after Roux-en-Y gastric bypass (n = 3), and sleeve gastrectomy (n = 1). We encountered 5 early complications in 4 patients, and early reoperative intervention was needed in 2 patients. At 1-year follow-up, the excess weight loss of the cohort was 49.4% ± 33.8%. After a mean follow-up time of 43.0 ± 28.6 months, the body mass index of the cohort reached 39.9 ± 20.8 kg/m², which corresponded to a mean excess weight loss of 54.4% ± 44.0% from the third operation. At the latest follow-up, 64% of patients had excess weight loss >50% and 45% had excess weight loss >80%.

Conclusion:

Reoperative bariatric surgery can be carried out successfully (often laparoscopically), even after 2 previous weight loss procedures.     

Five Percent Weight Lost in the First Month of Intragastric Balloon Treatment May Be a Predictor for Long-Term Weight Maintenance

Background

Most of the weight loss with the BioEnterics intragastric balloon (BIB) has occurred during the first 3–4 months. This study aimed to evaluate the effect of initial weight loss on long-term weight maintenance.

Methods

From 2008 to 2011, 50 patients who had mean body mass index (BMI) of 44.7?±?12.4 kg/m² underwent BIB therapy for 6 months. All patients were given a diet of 1,100 kcal/day. Weight loss parameters [absolute weight loss, BMI loss, percentage of body weight loss (BWL%), and percentage of excess BMI loss] were recorded at the baseline, 1 month, 6 months (time of BIB removal), 12 months, and 18 months from the baseline. Successful weight loss was defined as ≥10 % weight loss after 6, 12, and 18 months.

Results

Twenty-seven patients (54 %) achieved a percentage of BWL?≥?10 at the time of removal. Eighteen (36 %) and 12 (24 %) patients were able to maintain weight loss of 10 % at 12 and 18 months. Percentage of BWL after 1 month was positively correlated with BWL% after 6, 12, and 18 months (r?=?0.77, 0.65, and 0.62, p?<?0.001, respectively). Twenty-four patients who lost 5 % of the BWL after 1 month of treatment succeeded in maintaining a lasting percentage of BWL ≥10 after the BIB removal: more precisely, this cutoff point was achieved in 96 % at the time of removal and in 71 %, 50 % at 12 months, and 18 months of follow-up.

Conclusions

Five percent BWL after 1 month of treatment may be a predictor for long-term weight maintenance.     

Protein intake compliance of morbidly obese patients undergoing bariatric surgery and its effect on weight loss and biochemical parameters

Background

Grade D evidence supports a daily protein intake (DPI) of >60 g/d after Roux-en-Y gastric bypass. However, the physiologic effects of this recommendation have yet to be elucidated. The primary aim of the present study was to assess the effects of DPI after laparoscopic Roux-en-Y gastric bypass on weight loss, leptin levels, and albumin levels. The setting was a 617-acute inpatient bed university-affiliated teaching hospital.

Methods

The data from 427 consecutive bariatric surgery patients were prospectively collected from December 2007 to April 2011. The data were analyzed using Pearson's correlation, the chi-square test, the paired t test, analysis of covariance, and hierarchical linear regression analysis.

Results

Of the 427 patients, 167 (39.1%) had complete data at 3, 6, and 12 months of follow-up and were used for the present analysis. Of the 427 patients, 140 (83.8%) were women with a mean age and preoperative body mass index (BMI) of 42.7 ± 11 years and 47.3 ± 8.1 kg/m², respectively. Of the 427 patients, 71.3% were compliant with a DPI of ≥1 g/kg/d at 12 months postoperatively. The patients had a mean percentage of excess weight loss of 74.9% ± 16.7% and a mean BMI of 29.4 ± 5.4 kg/m² at 12 months. When controlling for the preoperative BMI, carbohydrate violations, and exercise increase, DPI was associated with a greater percentage of excess weight loss (P = .001), BMI change (P < .0001), and percentage of lean mass (P = .003), and a lower percentage of body fat (P < .0001) at 12 months.

Conclusion

Excellent compliance with a DPI of ≥1 g/kg/d at 12 months after laparoscopic Roux-en-Y gastric bypass is feasible and might result in the benefits of increased weight loss, a decreased percentage of body fat, and improved percentage of lean mass.     

Sensitivity and Specificity of 50% Excess Weight Loss (50%EWL) and Twelve Other Bariatric Criteria for Weight Loss Success

Background

Criteria for bariatric weight loss success are numerous. Most of them are arbitrary. None of them is evidence-based. Our objective was to determine their sensitivity and specificity.

Methods

Thirteen common bariatric weight loss criteria were compared to a benchmark reflecting the gold standard in bariatric surgery. We used an elaborate baseline BMI-independent weight loss percentile chart, based on retrospective data after laparoscopic Roux-en-Y gastric bypass (LRYGB), performed between 2007 and 2017. Percentile curves p31.6 (patients’ expectation), p25 (interquartile range), p15.9 (1 standard deviation (SD) below median), and p10.9 (surgeons’ goal) were used as possible cutoff for success to determine true or false positive and negative results beyond 1 year.

Results

We operated 4497 primary LRYGB patients, with mean follow-up 22 (±?1 SD 19; range 0–109) months, 3031 patients with last result ≥?1 year, 518?≥?5 years. For all four cutoff percentile curves for success, specificities were low (2–72%) for criteria <?35 body mass index (BMI), ≥?25percentage excess BMI loss (%EBMIL), ≥?50%EBMIL, ≥?15 percentage total weight loss (%TWL), ≥?20%TWL, ≥?25 percentage excess weight loss (%EWL), and high (83–96%) for <?30 BMI. No criterion had >?80% specificity and sensitivity for a cutoff above p15.9. For p15.9, they were both >?80% for criteria ≥?10 BMI reduction and ≥?50%EWL, both >?90% for ≥?25%TWL and ≥?35 percentage alterable weight loss (%AWL). All criteria had high sensitivities for all cutoff percentile curves (87–100%), except <?30 BMI (65–78%).

Conclusions

For the first time, common bariatric criteria for weight loss success were systematically validated. Most criteria recognized success very well (high sensitivities), but ≥?15%TWL, ≥?20%TWL, <?35BMI, ≥?25%EWL, ≥?25%EBMIL, and ≥?50%EBMIL left too many poor responders unnoticed (low specificities). Bariatric weight loss success is best assessed by comparing results to percentile curve 1 SD below median (p15.9) in a bariatric baseline BMI-independent weight loss percentile chart. Criteria ≥?35%AWL and ≥?25%TWL came close to that curve, both with >?90% sensitivity and specificity. Among others, criterion ≥?50%EBMIL did not.

     

Laparoscopic Gastric Bypass for Morbid Obesity�Ca Randomized Controlled Trial Comparing Two Gastrojejunal Anastomosis Techniques

Objectives:

We present a randomized controlled trial of laparoscopic gastric bypass comparing 2 techniques of gastrojejunostomy in patients with morbid obesity.

Methods:

Eighty consecutive patients underwent laparoscopic Roux-en-Y gastric bypass between September 2005 and August 2006. Patients were randomly assigned to 2 groups by the use of sealed envelopes. In group A, the gastrojejunal anastomosis was performed with a 21-mm circular-stapler, and in group B, this anastomosis was performed with a 45-mm linear-stapler. The rest of the procedure was identical in both groups. Variables evaluated were complications involving the gastrojejunostomy, operative time, length of stay, and percentage of excess weight loss.

Results:

Both groups were similar in age and body mass index. No patients experienced leakage or gastrojejunal anastomosis fistula, but group A patients had a more frequent stricture rate (P<0.05). Operative time and hospital stay were comparable in both groups (P>0.05). Percentage excess weight loss at one year following surgery was satisfactory in both groups, without a statistically significant difference (P>0.05).

Conclusion:

Gastrojejunal anastomosis does not seem to be a critical factor in excess weight loss for morbidly obese patients who underwent laparoscopic gastric bypass. The 2 techniques used in this experience are safe and effective; however, the 45-mm liner-stapler is preferable because it has a lower stricture rate.     

Participation in 150 min/wk of moderate or higher intensity physical activity yields greater weight loss after gastric bypass surgery.

BACKGROUND: The American College of Sports Medicine's position stand on weight loss and prevention of weight regain in adults has suggested that overweight adults should participate in a minimum of 150 min/wk of moderate intensity physical activity (PA). This study compared the 3-, 6-, and 12-month postoperative weight loss between gastric bypass surgery (GBS) patients who met or exceeded the recommended 150 min/wk of moderate or higher PA and those not meeting the recommendation. METHODS: The self-administered short version of the International Physical Activity Questionnaire was used to assess moderate or higher intensity PA participation at 3 (n = 178), 6 (n = 128), and 12 months (n = 209) after GBS. The patients' height and body weight were obtained to determine the kilograms of weight lost, percentage of excess weight loss, body mass index change, and total weight loss percentage. The weight loss differences were analyzed using analysis of covariance at each point, with age and preoperative body mass index as covariates. RESULTS: Patients reporting 150 min/wk of moderate or higher PA had significantly (P <.05) greater weight lost, percentage of excess weight loss, change in body mass index, and total weight loss percentage at 6 and 12 months postoperatively. The percentage of excess weight loss was 56.0% +/- 11.5% versus 50.5% +/- 11.6% and 67.4% +/- 14.3% versus 61.7% +/- 17.0% for the group meeting and not meeting the PA requirement at 6 and 12 months after GBS, respectively. No significant difference existed at 3 months after GBS. CONCLUSION: Participation in a minimum of 150 min/wk of moderate or higher intensity PA was associated with greater postoperative weight loss at 6 and 12 months postoperatively. Patients should be encouraged to meet or exceed this recommendation until prospective, randomized studies have definitively established a link between PA and greater postoperative weight loss and maintenance.