Eating behavior in laparoscopic sleeve gastrectomy: Correlation between plasma ghrelin levels and hunger

Stronger control of eating 3 months after sleeve gastrectomy predicts successful weight loss outcomes at one year

Background

Weight loss response to sleeve gastrectomy (SG) is variable and predicting the effectiveness of surgery is challenging and elusive. The aim of our study was to assess and quantify the association between eating control and weight loss outcomes and identify the control of eating (CoE) attributes during the early postoperative period that might predict good vs. poor response to SG at one year.

Methods

A prospective longitudinal cohort study using the Control of Eating Questionnaire (CoEQ) was designed as a series before and at 3-, 6-, and 12-months post-SG. Primary outcomes were changes in CoE attributes and percent of total weight loss (%TWL) 12-months post-surgery. Subjects were categorized based on %TWL as good (GR, ≥25 %) or poor responders (PR, <25 %). A receiver operating characteristic and logistic regression analyses were performed.

Results

We included 41 participants (80.5% females, 51.2% Hispanic, mean age 41.7±10.6, median baseline body mass index (BMI) 43.6 kg/m2 [range 35.2-66.3]) who completed the CoEQ at all four timepoints. The "Difficulty to control eating" score at 3 months revealed the highest area under the curve (AUC) (AUC 0.711; 95%CI 0.524-0.898; p=0.032). In a trade-off between a high Youden index and high sensitivity, the "Difficulty to control eating" score of 7 at 3 months was identified as the optimal cut-off for distinguishing between GRs and PRs. Score ≤7 at 3 months was strongly independently associated with a successful weight loss target of 25%TWL at one-year post-SG (Relative Risk 4.43; 95%CI 1.06-18.54; p=0.042).

Conclusion

"Difficulty to control eating" score at 3 months post-SG is an independent early predictor of optimal response (achieving a successful TWL target of ≥25 % at one-year post-SG). Our results support the utility of this easy-to-administer validated tool for predicting the effectiveness of SG and may assist in identifying individuals with suboptimal response early and helping them with interventions to attain optimal weight loss targets.

Outcomes at 10-Year Follow-Up after Roux-en-Y Gastric Bypass, Biliopancreatic Diversion, and Sleeve Gastrectomy

INTRODUCTION

Morbid obesity is a well-defined chronic disease, the incidence of which is constantly rising. Surgical treatment of morbid obesity has produced superior outcomes compared to conventional weight loss measures. Currently, there is a gap in the literature regarding long-term outcomes. Our single-institution, retrospective cohort study aims to evaluate weight loss outcomes, comorbidity reduction, and adverse effects at 10 years following Roux-en-Y Gastric Bypass (RYGB), Biliopancreatic Diversion (BPD), and Sleeve Gastrectomy (SG).

MATERIALS AND METHODS

We included all consecutive patients with 10-year follow-up records operated on within our institution. The comparison was carried out on the average percentage of weight and BMI loss. Nausea and vomiting were evaluated through self-reporting Likert scales. Diabetes resolution and nutritional deficiencies were also evaluated.

RESULTS

A total of 490 patients from 1995 up to 2011 were included in our study. Of these, 322 underwent RYGB, 58 underwent long-limb BPD, 34 underwent laparoscopic RYGB with fundus excision, 47 underwent laparoscopic SG, and 29 underwent laparoscopic RYGB as a revision of prior SG. RYGB and BPD were significantly associated with higher percentages of weight loss (37.6% and 37.5%), but were not found to be independent predictors of weight loss. Nausea and vomiting were associated with SG and laparoscopic RYGB with fundus excision, more so than the other operations. No differences were observed regarding diabetes resolution and nutritional deficiencies.

CONCLUSIONS

Longer follow-up reports are important for the comparison of outcomes between different types of bariatric operations. BPD and RYGB resulted in superior weight loss, with no observed differences in diabetes resolution and adverse outcomes.

A comparative study of eating behaviours within and between conventional metabolic (bariatric) surgery procedures

AIMS AND OBJECTIVES

To compare eating behaviours within and between gastric bypass, sleeve gastrectomy and gastric band procedures and to investigate associations between eating behaviours and body weight.

BACKGROUND

Eating behaviours are subjective constructs representing physiological need and the hedonic need to eat. After metabolic surgery, eating behaviours have been observed to change. Little is known about whether eating behaviour change differs according to the metabolic procedure performed.

DESIGN

Adults (n = 204) with severe obesity from three countries were followed 1 year after metabolic surgical procedures (n = 121).

METHODS

We measured eating behaviours using the Three-Factor Eating Questionnaire and used linear mixed models to compare eating behaviours within and between three procedure groups. We complied with the STROBE checklist for reporting observational studies.

RESULTS

Within groups, there were statistically significant increases in restraint and decreases in disinhibition and hunger. Between groups, we observed differences in disinhibition associated with the band procedure. There were no significant differences between any group for body weight or body mass index a year post-surgery. Disinhibition was the only eating behaviour associated with body weight, body mass index and the per cent of weight loss.

CONCLUSIONS

Eating behaviours in adults with severe obesity who underwent any of the three metabolic procedures were associated with eating behaviour change 1 year post-surgery. Disinhibition was the only eating behaviour that was associated with body weight.

RELEVANCE TO CLINICAL PRACTICE

Irrespective of the procedure, we found participants had a statistically significant increase in restraint and decreases in disinhibition and hunger 1 year post-surgery. Despite the significant reduction in disinhibition within the band group, this behaviour was more pronounced post-surgery compared with other groups. Although the reduction in hunger showed the greatest change, it was not associated with weight outcomes. This is relevant clinical knowledge for nurses who support bariatric surgical patients.

Changes in self-reported eating patterns after laparoscopic sleeve gastrectomy: a pre-post analysis and comparison with conservatively treated patients with obesity

BACKGROUND

Patients with severe obesity need to adapt to surgically induced changes in their eating behaviors to maintain treatment success.

OBJECTIVES

This study examined the effects of laparoscopic sleeve gastrectomy (LSG) on weight loss and on 3 dimensions of eating behavior, namely, cognitive restraint, disinhibition, and hunger. Outcomes of the LSG group were compared with a group of conservatively treated (CT) patients, who underwent a 1-year multimodal weight-reduction group program that included dietary advice, physical exercise, psychoeducation, cognitive-behavioral therapy, training in Jacobson's progressive muscle relaxation, and social group support.

SETTING

The study setting was a multidisciplinary obesity center located in a university hospital.

METHODS

A sample of 102 patients with obesity were investigated using the Three-Factor Eating Questionnaire before and, on average, 19 (±5) months after weight loss intervention. Of the 102 patients, 62 (age 45.8±10.8 years, 71% females) underwent LSG, and 40 patients (age 50.6±11.3 years, 77.5% females) underwent the CT program. Patients were assigned to either the surgical or the nonsurgical intervention group following clinical guidelines and patient preference.

RESULTS

In the LSG group, total weight loss was 25.9±11.0%, excess weight loss was 52.8±24.1%, and body mass index decreased from 51.4±8.1 to 38.0±7.8 kg/m². In the CT group, total weight loss was 5.4±10.6%, excess weight loss was 13.9±27.1%, and body mass index decreased from 40.3±6.7 to 38.0±7.2 kg/m². Significant improvements in self-reported eating behaviors were observed in both groups, that is, an increased cognitive restraint of eating, a decreased disinhibition of eating control, and a reduced degree of perceived hunger. In contrast, whereas Three-Factor Eating Questionnaire scores before weight loss intervention did not differ between groups, LSG patients reported significantly greater reductions in disinhibition and hunger than CT patients did after weight loss intervention. In both groups, greater weight loss was associated with decreased hunger sensations.

CONCLUSION

In the second follow-up year, LSG was associated with greater weight loss and greater improvements in self-reported eating behaviors compared with conservative treatment.

Influence of additional resection of the gastric fundus on excessive weight loss in laparoscopic very very long limb Roux-en-Y gastric bypass

Roux-en-Y gastric bypass (RYGB) is the gold standard in bariatric surgery. The effect of the procedure is based on restriction, malabsorption and changes in hormonal axis. Ghrelin is an important appetite hormone which is produced mainly in the gastric fundus. By adding a resection of the gastric fundus, we hypothesized that excessive weight loss will be more prominent and the satiety feelings less pronounced compared to standard RYGB. A total of 73 patients with standard very very long limb (VVLL) RYGB (group A) were compared with 44 patients with VVLL RYGB with resection of the fundus (group B). Outcome measures were excessive weight loss (EWL), body mass index (BMI), early postoperative morbidity, change of co-morbidities, and appetite reduction as assessed by an appetite questionnaire over a postoperative period of 24 months. Groups were comparable in basic preoperative descriptions. Additional fundus resection did not influence EWL (group A 66.1 % vs. group B 70.6 %, p = 0.383) or BMI (group A 29 kg/m(2) vs. group B 27 kg/m(2), p = 0.199). No significant difference in morbidity or change of co-morbidities occurred. The appetite and satiety questionnaire showed no difference between group A and group B, respectively. Adding a resection of the gastric fundus in RYGB did not alter the clinical results, i.e., increased excessive weight loss, decrease of appetite, or increase of satiety. The value of removing a part of the ghrelin-producing cells might be overestimated.

Relationships among tonic and episodic aspects of motivation to eat, gut peptides, and weight before and after bariatric surgery

BACKGROUND

The interaction between motivation to eat, eating behavior traits, and gut peptides after Roux-en-Y gastric bypass (RYGB) surgery is not fully understood.

METHODS

Appetite and hormone responses to a fixed liquid preload were assessed in 12 obese (body mass index 45 ± 1.9 kg/m(2)) participants immediately before and 3 days, 2 months, and 1 year after RYGB surgery. Subjective appetite and plasma levels of ghrelin, leptin, insulin, and glucagon-like peptide-1 (GLP-1) were measured for a 3-hour postprandial period. Eating behavior traits were also measured using the Three Factor Eating Questionnaire 18 (TFEQR18).

RESULTS

There was a decrease in TFEQR18 emotional eating (EE) and uncontrolled eating (UE) from presurgery to 1 year postsurgery but no significant change in cognitive restraint (CR). These changes occurred independently of change in weight. In addition, there was a reduction in subjective appetite ratings and alterations in appetite peptides favoring an anorectic response. Presurgery EE was significantly related to fasting and area under the curve (AUC) ghrelin; UE was associated with AUC desire to eat, and there was a significant association between fasting desire to eat and ghrelin (fasting and AUC). One year postsurgery, UE was positively related to fasting insulin, and CR was negatively associated with GLP-1. UE and subjective hunger were positively correlated, while the relationship between desire to eat and ghrelin remained.

CONCLUSION

The relationships among subjective appetite ratings, eating behavior traits, and appetite peptides in obese patients both before and at 1 year after RYGB surgery may contribute to the reduction in a propensity to overeat (as measured by TFEQR18 factors) and weight loss.

Laparoscopic sleeve gastrectomy as a primary operation for morbid obesity: experience with 200 patients

Introduction. Laparoscopic sleeve gastrectomy (LSG) represents a valid option for morbid obesity, either as a primary or as a staged procedure. The aim of this paper is to report the experience of a single surgeon with LSG as a standalone operation for morbid obesity. Methods. From April 2006 to April 2011, 200 patients underwent LSG for morbid obesity. Each patient record was registered and prospectively collected. In July 2011, a retrospective analysis was conducted. Results. Patients were 128 females and 72 males with a median age of 40.0 years. Median pre-operative BMI was 49.4 kg/m². Median follow-up was 27.2 months. Median post-operative BMI was 30.4 kg/m². Median %excess weight loss (%EWL) was 63.6%. Median post-operative hospital stay was 4.0 days in the first 84 cases and 3.0 days in the last 116 cases. Six major post-operative complications occurred (3%): two gastric stump leaks (1%), three major bleedings (1.5%) and 1 (0.5%) bowel obstruction. One case of mortality was registered (0.5%). To date only 4 patients are still in the range of morbid obesity (BMI > 35 kg/m²). Conclusions. Laparoscopic sleeve gastrectomy is a formidable operation in the short-term period. Median %EWL in this series was 63.6% at 27.2 months follow-up.

Laparoscopic sleeve gastrectomy, 529 cases without a leak: short-term results and technical considerations

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance among bariatric surgeons as a viable option for treating morbidly obese patients. We describe results of a single surgeon's experience with LSG in a community practice revealing a low complication rate and describing the surgical technique.

METHODS

LSG was performed in 529 consecutive patients from December 2006 to March 2010. A technique is described where all operations were performed with attention to avoiding strictures at the incisura angularis and stapling close to the esophagus at the angle of His. No operations performed used buttressing material or over-sewing of the staple line. A retrospective chart review and e-mail survey was conducted to determine the occurrence of complications and weight loss.

RESULTS

Follow-up data was collected on 490 of the 529 (92.6%) patients at 6 weeks. A total complication rate of 3.2% and a 1.7% 30-day readmission rate were observed. No leaks occurred in any of the 529 patients, and one death (0.19%) was observed. The most common complications were nausea and vomiting with dehydration and venous thrombosis. The percentages of excess weight loss were 42.36, 65.92, 66.11, and 64.42 with a follow-up of 71%, 68%, 63%, and 49% at 6 months, 1 year, 2, and 3 years, respectively.

CONCLUSION

The LSG can be performed in a community practice with a low complication rate. Surgeons performing LSG should strive to minimize the risk of creating strictures at the incisura angularis and stapling near the esophagus at the angle of His.

Conversion from sleeve gastrectomy to Roux-en-Y gastric bypass--indications and outcome

BACKGROUND

Due to excellent weight loss success in the short-time follow-up, sleeve gastrectomy (SG) has gained popularity as sole and definitive bariatric procedure. In the long-term follow-up, weight loss failure and intractable severe reflux can necessitate further surgical intervention.

METHODS

A retrospective analysis of laparoscopic conversions from SG to Roux-en-Y gastric bypass (RYGB) was performed to assess the efficacy for reflux relief and weight loss success.

RESULTS

A total of eight out of 73 patients (11%) underwent conversion to RYGB for severe reflux (n=3) or weight regain (n=5) after a median interval of 33 months following laparoscopic sleeve gastrectomy. In one of the patients, a banded gastric bypass was performed. In both groups, conversion to RYGB was successful, as proton pump inhibitor medication could be discontinued in all patients presenting with severe reflux, and a significant weight loss could be achieved in the patients with weight regain within a median follow-up of 33 months. Postoperative complications were observed in only one patient as leakage at the gastrojejunostomy was successfully treated by temporary stent placement.

CONCLUSION

Conversion to RYGB is an effective treatment for weight regain or intractable reflux symptoms following SG. Thus, SG can be performed, intended as sole and definitive bariatric intervention, with conversion from SG to RYGB as an exit strategy for these complications.

Sleeve gastrectomy as sole and definitive bariatric procedure: 5-year results for weight loss and ghrelin

BACKGROUND

Due to excellent efficacy for weight loss in the short-term follow-up, sleeve gastrectomy (SG) has gained enormous popularity as bariatric procedure, not only as first step in high-risk or super-obese patients but mainly as a sole and definitive operation in morbidly obese. In contrast to a large number of short and intermediate-term results, no series of SG with a follow-up of 5 years or more has been published so far.

METHODS

We report on the weight loss results of our first consecutive 26 patients with a complete follow-up of 5 years. Furthermore in a subgroup of 12 patients, plasma ghrelin levels were measured preoperatively, and up to 5 years following SG.

RESULTS

Weight loss defined as mean percent excess weight loss (%EWL) was found as 57.5 +/- 4.5, 60.3 +/- 5.0, 60.0 +/- 5.7, 58.4 +/- 5.4, and 55.0 +/- 6.8 (not converted, n = 21) for the first 5 years. Weight regain of more than 10 kg from nadir was observed in five (19.2%) of the 26 patients. Four of the patients (15.4%) were converted to gastric bypass due to severe reflux (n = 1, 3.8%) and weight loss failure (n = 3, 11.5%). A total of eight patients (30.8%) were at chronic need for proton pump inhibitor medication due to severe reflux. Plasma ghrelin levels were reduced from 593 +/- 52 to 219 +/- 23 pg/ml 12 months postoperatively, with a slightly, non-significant increase toward the 5-years values of mean 257 +/- 23 pg/ml.

CONCLUSIONS

At 5-year follow-up, a mean EWL of 55.0 +/- 6.8% was achieved, indicating that SG leads to stable weight loss. Beside significant weight regain, severe reflux might necessitate conversion to gastric bypass or duodenal switch. After an immediate reduction postoperatively, plasma ghrelin levels remained low for the first 5 years postoperatively.