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.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic vertical banded gastroplasty: results of a 2-year follow-up study

BACKGROUND: The world's epidemic of obesity is responsible for the development of bariatric surgery in recent decades. The number of gastrointestinal surgeries performed annually for severe obesity (BMI > 40 kg/m2) in the United States has increased from about 16,000 in the early 1990s to about 103,000 in 2003. The surgical techniques can be classified as restrictive, malabsorptive, or mixed procedures. This article presents the results for 2 years of bariatric surgery in the authors' minimally invasive center and analyzes the results of the most used surgical techniques with regard to eating habits. METHODS: Between January 2002 and January 2004, the authors attempted operations for morbid obesity in 110 consecutive patients adequately selected by a multidisciplinary obesity unit. This represented 43% of all consultations for morbidly obese patients. The patients were classified as sweet eaters or non-sweet eaters. All sweet eaters underwent gastric bypass. The procedures included 70 Roux-en-Y gastric bypasses, 39 Mason's vertical banded gastroplasties, and 1 combination of vertical gastroplasty with an antireflux procedure. Revision procedures were excluded. RESULTS: The mean age of the patients was 41.36 years (range, 23-67 years), and 72.3% were female. The mean preoperative body mass index was 44.78 kg/m2 (range, 34.75-70.16 kg/m2). The mean operating time was longer for gastric bypass than for the Mason procedure. Three patients required conversion to an open procedure (2.7%). The two operative techniques had the same efficacy in weight reduction. Early complications developed in 11 patients (10%), and late complications occurred in 9 patients (8.1%). The postoperative length of hospital stay averaged 4.4 days (range, 1-47 days; median, 4 days), and was longer in the gastric bypass group. The mortality rate was zero. Data were available 2 years after surgery for 101 of the 110 patients (91%). Most comorbid conditions resolved by 1 year after surgery regardless of the type of operation used. CONCLUSION: With zero mortality and low morbidity, bariatric surgery performed for adequately selected patients is the most effective therapeutic intervention for weight loss and subsequent amelioration or resolution of comorbidities. The patient's eating habits before surgery play an important role in the choice of the operative technique used.     

Prospective clinical cohort study: low incidence of Barrett esophagus but high rate of reflux disease at 5-year follow-up after sleeve gastrectomy versus Roux-en-Y gastric bypass

BackgroundGastroesophageal reflux disease seems more frequent after laparoscopic sleeve gastrectomy (LSG) than Roux-en-Y gastric bypass (LRYGB). Retrospective case series have raised concerns about a high incidence of Barrett esophagus (BE) after LSG.ObjectiveThis prospective clinical cohort study compared the incidence of BE ≥5 years after LSG and LRYGB.SettingSt. Clara Hospital, Basel, and University Hospital, Zürich, Switzerland.MethodsPatients were recruited from 2 bariatric centers where preoperative gastroscopy is standard practice and LRYGB is preferred for patients with preexisting gastroesophageal reflux disease. At follow-up ≥5 years after surgery, patients underwent gastroscopy with quadrantic biopsies from the squamocolumnar junction and metaplastic segment. Symptoms were assessed using validated questionnaires. Wireless pH measurement assessed esophageal acid exposure.ResultsA total of 169 patients were included, with a median 7.0 ± 1.5 years after surgery. In the LSG group (n = 83), 3 patients had endoscopically and histologically confirmed de novo BE; in the LRYGB group (n = 86), there were 2 patients with BE, 1 de novo and 1 preexisting (de novo BE, 3.6% versus 1.2%; P = .362). At follow-up, reflux symptoms were reported more frequently by the LSG group than by the LRYGB group (51.9% versus 10.5%). Similarly, moderate-to-severe reflux esophagitis (Los Angeles grade B–D) was more common (27.7% versus 5.8%) despite greater use of proton pump inhibitors (49.4% versus 19.7%), and pathologic acid exposure was more frequent in patients who underwent LSG than in patients who underwent LRYGB.ConclusionsAfter at least 5 years of follow-up, a higher incidence of reflux symptoms, reflux esophagitis, and pathologic esophageal acid exposure was found in patients who underwent LSG compared with patients who underwent LRYGB. However, the incidence of BE after LSG was low and not significantly different between the 2 groups.     

Conversion of laparoscopic Roux-en-Y gastric bypass

BACKGROUND: To determine the incidence and causes of conversion from a laparoscopic to an open gastric bypass for morbid obesity, we reviewed the experience of our bariatric center. METHODS: We performed a retrospective review of the records of consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass at our center. RESULTS: In all, 1,236 consecutive patients with body mass indes (BMI) from 35 to 82 were approached laparoscopically. In 97%, bypasses were completed laparoscopically and in 3% (40 patients), a conversion was required to complete the procedure. Older age and male sex were greater in the converted group, whereas BMI was not different nor was the proportion of super obese patients. The cause of conversion was technical in 80%, bleeding in 10%, and a massive liver in 10%. CONCLUSIONS: Our risk of conversion was generally low, but increased in older patients and males. In 33% of patients, conversions could have been avoided with technical lessons learned by experience.     

Adding malabsorption for weight loss failure after gastric bypass

Objective To present a technique of revisional RY gastric bypass in patients with unsatisfactory weight loss after primary gastric bariatric operations. Methods The Roux limb was lengthened by creating a 75–100 cm common channel below the enteroenterostomy with concomitant revision of the gastrojejunostomy. Results Fifty-four patients had this distal modification of RYGB including 47 patients who had primary gastric bypass and 7 patients who failed pure restrictive operations. Mean excess weight loss was 47.9% in patients followed for ≥1 year. Conclusions This distal modification of RYGB resulted in satisfactory weight loss for nearly half of the 54 patients in this series.     

10-year weight loss outcomes after Roux-en-Y gastric bypass and attendance at follow-up visits: a single-center study

BackgroundLong-term durability of weight loss is a prerequisite for a greater acceptance of bariatric surgery.ObjectivesTo examine long-term weight trajectory in patients undergoing Roux-en-Y gastric bypass (RYGB) and determine factors predicting long-term follow-up and weight outcomes.SettingUniversity hospital.MethodsA retrospective cohort of adults who underwent RYGB during 1997–2010 were identified and followed until 2017. Predictors for attendance at periodic follow-up visits, reduction in body mass index (BMI), and percent excess BMI lost were determined using multivariable logistic regression and linear mixed-effects models. The latter was used to predict long-term weight outcomes for a typical patient.ResultsThe study included 1104 patients with a mean age of 45.5 (standard deviation [SD] 9.9) years and a preoperative BMI of 54.7 (SD 10.9) kg/m². Follow-up data were available for 92.8% of the patients after 1 year, 50.0% after 5 years, and 35.2% after 10 years post-surgery. Black patients, compared with White patients, were less likely to attend follow-up visits. Attendance at follow-up visits at least every other year was not associated with larger weight loss, but higher preoperative BMI, being White (versus Black), and female sex were. Predicted BMI reduction for a typical patient, a 45-year-old White female with a preoperative BMI of 54.7 kg/m² and private health insurance, undergoing laparoscopic RYGB in 2004, was 18.3 (standard error [SE] .36) kg/m² at year 5 and 17.6 (SE .49) kg/m² at year 10.ConclusionRYGB results in clinically significant and durable weight loss. Attendance at periodic follow-up visits does not appear to be associated with long-term weight loss outcomes. Future work should focus on strategies to remove barriers to post-operative care.     

Predictors of change in cardiovascular disease risk and events following gastric bypass: a 7-year prospective multicenter study

BackgroundChange in short-term (i.e., 10-year) and lifetime risk of cardiovascular disease (CVD) following Roux-en-Y gastric bypass (RYGB) has significant heterogeneity.ObjectiveTo identify predictors of change in CVD risk and cardiovascular events following RYGB.MethodsBetween 2006–2009, 1625 adults without a history of CVD enrolled in a prospective cohort study and underwent RYGB at 1 of 10 U.S. hospitals. Participants were followed annually for a maximum of 7 years. Associations between presurgery characteristics (anthropometric, sociodemographic, physical and mental health, alcohol/drug use, eating behaviors) and 1) pre to postsurgery change in 10 year and lifetime atherosclerotic CVD (ASCVD) risk scores, respectively, and 2) having a CVD event (nonfatal myocardial infarction, stroke, ischemic heart disease, congestive heart failure, angina, percutaneous coronary intervention, coronary artery bypass grafting, or CVD-attributed death) as repeated measures (yr 1–7) were evaluated.SettingObservational cohort study at ten hospitals throughout the United States.ResultsPresurgery factors independently associated with decreases in both 10-year and lifetime risk scores 1–7 years post-RYGB were higher CVD risk score, female sex, higher household income, and normal kidney function. Additionally, Black race and having diabetes were independently associated with decreases in 10-year risk, while not having diabetes and a higher (better) composite mental health score were independently related to decreases in lifetime risk. A lower (worse) presurgery composite physical health score was associated with a higher CVD event risk (RR = 1.68, per 10 points).ConclusionThis study identified multiple presurgery factors that characterize patients who may have more cardiovascular benefit from RYGB, and patients who might require additional support to improve their cardiovascular health.     

Technical considerations for transabdominal loading of the circular stapler in laparoscopic Roux-en-Y gastric bypass

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass is being undertaken with increasing frequency. We describe a technique for introducing the anvil of the circular stapler using a totally transabdominal approach. METHODS: One hundred consecutive patients underwent laparoscopic Roux-en-Y gastric bypass in a university-affiliated teaching hospital. RESULTS: The cardiojejunostomy was constructed in all 100 patients using the circular stapler with no complications. No anastomotic leaks were detected postoperatively. CONCLUSIONS: The totally transabdominal approach for introducing the anvil of the circular stapler into the gastric pouch is safe and feasible.     

Comparison of one-anastomosis gastric bypass and Roux-en-Y gastric bypass for treatment of obesity: a 5-year study

BackgroundRoux-en-Y gastric bypass (RYGB) is the gold standard in bariatric surgery. One-anastomosis gastric bypass (OAGB) has been reported to have equivalent or better weight loss, with added advantages of being technically easy, amenable to reintervention/reversal, and offering better food tolerance.ObjectiveThis study was undertaken to compare weight loss, metabolic syndrome outcome, complications, and long-term nutritional outcomes between the 2 procedures.SettingsA high-volume, private-practice bariatric surgery center in India.MethodThis retrospective study is based on prospectively maintained data in a cohort of patients who had either RYGB or OAGB in 2012 at a single institution by a single surgeon. Patients were all eligible for 5-year follow-up.ResultsOn hundred twenty-two patients had RYGB and 90 had OAGB. The mean age was 44 and 46.4 years, body mass index was 45.8 and 42, percentage of total weight loss was 36.4 and 25.9, and percentage of excess weight loss was 81.6 and 66.7 for OAGB and RYGB groups, respectively. Resolution of type 2 diabetes was 79%, hypertension 57%, dyslipidemia 56%, and sleep apnea 94.54% in OAGB patients compared with type 2 diabetes of 61%, hypertension of 43%, dyslipidemia of 53%, and sleep apnea of 90.74% in RYGB patients. OAGB patients had more nutritional deficiencies than RYGB patients: anemia 44% versus 17%, hypoalbuminemia 32% versus 15%, and hypocalcemia 19% versus 8%, and other complications 7.8% versus 1.6%, respectively. There were no deaths in this study.ConclusionOAGB is associated with more weight loss and better resolution of co-morbid conditions. However, it is also associated with more nutritional deficiencies. There is a need for long-term follow-up and multicenter reports to confirm these findings.     

Outcomes in glycemic control in the intermediate follow-up of Roux-en-Y gastric bypass: a Brazilian cohort study

BackgroundIt is not widely known whether glycemic control (GC) is sustained after Roux-en-Y gastric bypass (RYGB). The objective of this study was to investigate incidence and remission of type 2 diabetes mellitus (T2DM) among 284 individuals with body mass index (BMI)≥35 kg/m² at operation (1998–2011) through 2013.MethodsBaseline GC was based on fasting glycemia (FG), hemoglobin A1c (HbA1c), and medication. Incident T2DM, complete (normal GC/HbA1c) and partial (abnormal FG/A1c) remission at the last follow-up visit, and relapse were the outcomes of interest. Kaplan-Meier curves and log-rank tests were used to compare time to improvement according to insulin use and HbA1c levels at baseline. Pre- and postoperative determinants of T2DM improvement were investigated by logistic regression.ResultsParticipants were predominantly female (220; 77.2%) with mean age of 39.6 (10.5) years and median BMI of 51.9 (46.1–57.5) kg/m² at operation. The mean follow-up time was 5.1 (3.2) years with 67.5% (55.0–78.4) of excess BMI loss (EBL) at the 5^th year. Normal GC, abnormal FG, and T2DM were observed in 169 (59.5%), 32 (11.2%), and 83 (29.3%) participants at baseline, respectively. The 7 (4.1%) patients with incident T2DM had lower BMI at baseline than those who remained with normal GC (43.6 kg/m² [42.0–50.8] versus 52.1 kg/m² [46.7–57.7]; P = .01). Complete and partial T2DM remission occurred in 61 (61.3%) and 5 (6.7%) participants, respectively. Baseline HbA1c was associated with a significant difference in the proportion of cases with remission at the 5^th year of follow-up (P = .016). Age (OR .83; 95% CI .72–.95) and % EBL at the 2^nd year of follow-up (OR 1.05; 95% CI 1.01–1.09) were independent determinants of T2DM improvement. Relapse occurred in 14 (14.3%) cases.ConclusionWe observed a low incidence and impressive improvement rates of T2DM after intermediate follow-up of RYGB.     

An assessment of vertical banded gastroplasty-Roux-en-Y gastric bypass for the treatment of morbid obesity

OBJECTIVE: To analyze retrospectively the mortality, morbidity, and weight loss of a specific form of gastric bypass for the treatment of morbid obesity. The technique incorporates a small pouch along the lesser curvature of the stomach, an outlet restricted by a nondistensible band and a Roux-en-Y gastric bypass. MATERIAL AND METHODS: We analyzed 652 consecutive patients with no previous bariatric surgery who underwent our present form of gastric bypass. Parameters used to evaluate the technique included mortality, weight loss at 5 years and complications. The operation is a combination of vertical banded gastroplasty and Roux-en-Y gastric bypass (VBG-RGB). The patients followed up to 5 years had an initial weight of 140 kg [range, 94 to 288] and a BMI of 50 [range, 38 to 86]. Superobese individuals (BMI of 60 [range, 48 to 86]) made up 42% of the group. RESULTS: There was an early reoperation rate of 0.5%. The incidence of late complications that required reoperation was 0.5%. There were 2 deaths in the study from pulmonary embolism for a mortality of 0.3%. At 5 years, the patients had lost an average of 58kg [range, 14 to 143] and had a percentage excess weight loss of 77 [range, 32 to 108]. Their BMI was reduced to 29 kg/m(2) [range, 20 to 43] and 93% lost more than 50% of the excess weight. CONCLUSIONS: VBG-RGB is effective in producing superior weight loss in morbid and superobese patients and has a low mortality and morbidity. We recommend this procedure without reservations.     

Gastric mesenchymal tumors as incidental findings during Roux-en-Y gastric bypass

Background

Occurrences of mesenchymal tumors have been more recognized in recent years, and the incidental diagnosis of these lesions during bariatric surgery has been previously reported.

Clinical resolution of severely symptomatic pseudotumor cerebri after gastric bypass in an adolescent

Pseudotumor cerebri is a disease characterized by increased intracranial pressure, often manifested by headaches, and occasionally leading to severe visual impairment or even blindness. Most cases in adolescents, as in adults, are associated with obesity. We report a 16-year-old morbidly obese adolescent girl (body mass index 42.3 kg/m(2)) with severely symptomatic pseudotumor cerebri who had progressive visual field deficits and elevated intracranial pressure (opening pressure on lumbar puncture of 50 cm H(2)O) despite intensive medical management and placement of both ventriculoperitoneal and lumboperitoneal shunts. Six months after she underwent gastric bypass surgery, she had lost 43% of her excess body weight and had had near complete regression of her visual field deficits, along with normalization of her intracranial pressures. This case demonstrates the dramatic reversal of symptoms of pseudotumor cerebri with surgically induced weight loss. Gastric bypass should be considered as a treatment option for adolescents with severe and progressive pseudotumor cerebri.     

Change in predicted 10-year and lifetime cardiovascular disease risk after Roux-en-Y gastric bypass

BackgroundLong-term changes in cardiovascular disease (CVD) risk after bariatric surgery are not well characterized.ObjectiveTo report sex-specific changes in CVD risk after Roux-en-Y gastric bypass surgery (RYGB).SettingObservational cohort study at ten hospitals throughout the United States.MethodsBetween 2006 and 2009, 1770 adults enrolled in a prospective cohort study underwent RYGB at 1 of 10 U.S. hospitals. Research assessments were conducted presurgery and annually postsurgery over 7 years. Sex specific–predicted 10-year and lifetime CVD risk were calculated using the Framingham10-year and lifetime risk scores, Framingham–body mass index, and atherosclerotic CVD scoring algorithms among participants with no history of CVD. Of 1566 eligible participants, 1234 (75.9%) with CVD risk determination pre- and postsurgery were included (1013 females, 221 males).ResultsBased on the Framingham10-year and lifetime risk scores, the percentage of females with predicted high (>20%) 10-year CVD risk declined from presurgery (6.5% [95% confidence interval: 6.7–7.5]) to 1 year postsurgery (1.0% [95% confidence interval: .8–1.2]; P < .001), then increased 1 to 7 years postsurgery (to 2.8% [95% confidence interval: 1.6–3.3]; P = .003), but was lower 7 years postsurgery versus presurgery (P < .001). Time trends for percentage of high-risk participants and mean CVD risk scores were similar for both sexes and other evaluated CVD risk scores. For example, among males mean lifetime atherosclerotic CVD score declined from presurgery to 1 year postsurgery, then increased 1 to 7 years postsurgery. However, there was a net decline from presurgery (P < .001).ConclusionAmong both females and males, predicted 10-year and lifetime CVD risk was substantially lower 7 years post RYGB than presurgery, suggesting RYGB surgery can lead to sustained improvements in short- and long-term CVD risk.     

Early intake of solid food after Roux-en-Y gastric bypass and complications. A cohort study from the Scandinavian Obesity Surgery Registry

Background

Roux-en-Y gastric bypass (RYGB) is the most common bariatric procedure worldwide. There are few studies investigating how early return to solid food affects complications.

Gastrogastric fistula: a possible complication of Roux-en-Y gastric bypass.

BACKGROUND: Gastrogastric fistula is a communication between the proximal gastric pouch and the distal gastric remnant, rarely described in the realm of bariatric procedures. The aim of this study was to review the existing literature about this topic and to demonstrate its laparoscopic treatment. METHODS: An extensive literature review found several articles reporting this complication. However, no citation was found describing the steps of the laparoscopic management of this situation. RESULTS: Gastrogastric fistula occurs in up to 6% of Roux-en-Y gastric bypasses. Two theories exist for fistula formation: (1) it is a technical complication derived from the incomplete division of the stomach during the creation of the pouch, and (2) it occurs after a staple-line failure, developing a leak with an abscess, which then drains into the distal stomach forming the fistula. Early symptoms include fever, tachycardia, and abdominal pain. Failure in weight loss is a late clinical sign observed in these patients. Diagnosis is based on radiologic study, upper endoscopy and computed tomography. When identified in the acute postoperative course, laparoscopic treatment is easy. Chronic fistulas are difficult to manage, and the laparoscopic approach is an alternative to open surgery. CONCLUSIONS: Gastrogastric fistula is a possible complication of Roux-en-Y gastric bypass and its laparoscopic treatment is feasible.     

Change in C-reactive protein after Roux-en-Y gastric bypass through 7 years of follow-up

BackgroundLong-term change in CRP is not well characterized in the context of RYGB.ObjectiveTo report C-reactive protein (CRP) after Roux-en-Y gastric bypass surgery (RYGB).SettingBetween 2006 and 2009 1770 adults enrolled in a prospective cohort study underwent Roux-en-Y gastric bypass (RYGB) at 1 of 10 U.S. hospitals.MethodsResearch assessments were conducted before surgery and annually postoperatively for up to 7 years. This study included those with high-sensitivity CRP assessed before surgery and 1 or more follow-up assessments (n = 1180).ResultsBefore surgery, participants’ median age was 46 years, and the median body mass index (BMI) was 46 kg/m²; 80% were female. Before surgery, mean (95% confidence interval [CI]) CRP was the highest of all time points (1.01 [.95–1.08] mg/L); it then decreased to a nadir of .18 (.15–.22) mg/L at 2 years postoperatively (P < .001). CRP was higher at 7 years (.26 [.22, .29] mg/L) than at 2 years postoperatively (P < .001) but remained lower at 7 years than preoperatively (P < .001). Additionally, only 3.2% (95% CI: 1.6%–4.8%) of participants had elevated CRP (>1 mg/dL) 7 years postoperatively versus 32.9% (95% CI: 30.2%–35.3%) preoperatively (P < .001). Several preoperative factors were associated with following a less favorable CRP trajectory over time, including higher preoperative CRP level, higher BMI, current smoking, and diabetes.ConclusionThe vast majority of adults who underwent RYGB experienced a sustained improvement in CRP throughout 7 years of follow-up with nonelevated values. However, those with higher preoperative CRP and BMI levels and diabetes and who smoke may benefit from additional testing and monitoring to ensure nonelevated inflammation after surgery.     

Impact of limb length on nutritional status in one-anastomosis gastric bypass: 3-year results

BackgroundBariatric metabolic surgery is a well-established treatment option associated with significant weight loss and an improvement of metabolic co-morbidities. However, the changes in gastrointestinal anatomy frequently result in nutritional deficiencies.ObjectiveTo evaluate the impact of biliopancreatic limb length in one-anastomosis gastric bypass (OAGB) on micronutrient and protein deficiencies.SettingUniversity hospital, Austria.MethodsAll patients that were (1) undergoing OAGB between 2012 and 2014, and (2) had at least 3 postoperative follow-up visits were retrospectively analyzed. Systemic levels of parathyroid hormone, vitamins (A, D, E, and B12), folic acid, magnesium, calcium, iron, albumin, and ferritin were correlated to biliopancreatic limb length as follows: short limb (150 cm), intermediate limb (200 cm), and long limb (250 cm).ResultsA total of 155 patients fulfilled inclusion criteria (female/male: n = 111/44). OAGB led to a mean percent excess weight loss of 79.9 (±24.2) and a reduction of mean body mass index from 45.4 kg/m² (±6.1 kg/m²) at baseline to 30.2 kg/m² (±9.9 kg/m²). Preoperative deficiencies were seen in 25-hydroxy-vitamin D (93.8%), folic acid (27.6%), ferritin (4.1%), vitamin A (5.5%), and vitamin B12 (2.3%). In patients with long limb, systemic folic acid levels were significantly lower after 24 months postoperatively compared with short and intermediate limb (P < .05). No difference was observed for vitamin D, A, E, B12, and iron and no patient suffered from severe protein malnutrition.ConclusionNutritional deficiencies were common after OAGB without severe deficiencies in biliopancreatic limb lengths ranging from 150 to 250 cm. A trend can be observed with more pronounced deficiencies with intermediate and long limb lengths without significant differences for most micronutrients.