Surgical treatment of obesity

Does the Length of the Common Channel as Part of the Total Alimentary Tract Matter? One Year Results from the Multicenter Dutch Common Channel Trial (DUCATI) Comparing Standard Versus Distal Roux-en-Y Gastric Bypass with Similar Biliopancreatic Bowel Limb Lengths

PURPOSE

Although the laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is the gold-standard bariatric procedure, it remains uncertain what the optimal bowel limb lengths are to accomplish maximal weight loss while minimizing nutritional deficiencies and related gastro-intestinal complaints. The aim of this randomized controlled multicenter trial is to investigate the effect of significant lengthening of the length of the Roux limb (RL) at the cost of the length of the common channel (CC) while keeping the biliopancreatic limb (BPL) lengths the same on both study arms.

METHODS

Four hundred forty-four patients were randomized to receive either a Very Long Roux Limb LRYGB (VLRL-LRYGB) (variable RL length, BPL 60 cm, and CC 100 cm) or a Standard LRYGB (S-LRYGB) (RL 150 cm, BPL 60 cm, and a variable CC length). Results at 1-year follow-up for weight loss, effect on obesity-related comorbid conditions, complications, re-operation rate, malnutrition rate, and re-admission rate were investigated.

RESULTS

Weight loss at 1-year showed no significant differences for %EWL (84.3% versus 85.3%, p = 0.72) and %TWL (34.2% versus 33.6%, p = 0.359) comparing VLRL-LRYGB versus S-LRYGB. Malabsorption requiring surgical bowel length adjustment was observed in 1.4% in VLRL-LRYGB group versus 0.9% in S-LRYGB group (p = 0.316).

CONCLUSION

Significant lengthening of the RL at the cost of the common channel seems to have no effect on the weight loss at 1-year follow-up, which supports the theory that absorption of nutrients also occurs in the RL. Nevertheless, long-term results of the VLRL-LRYGB have to be awaited to draw final conclusions as part of the discussion towards optimal limb length in LRYGB surgery.

Small Intestinal Length Associates with Serum Triglycerides Before and After LRYGB

BACKGROUND AND AIMS

Different bariatric procedures have been associated with variable weight loss and decrease in serum levels of lipids and lipoproteins. This variation could be partly related to the length of the small intestinal bypass. We evaluated the association of the small intestinal length with the non-alcoholic fatty liver disease (NAFLD) at baseline and with lipid metabolism before and after laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS

Seventy consecutive morbidly obese patients were recruited to this prospective study. A standard 60-cm biliopancreatic limb (BPL) and 120-cm alimentary limb (AL) was performed, and thereafter, the common channel (CC) length was measured during elective LRYGB. Histological analysis of liver biopsy to diagnose NAFLD was performed. The mRNA expression of genes participating in the cholesterol and fatty acid metabolism in the liver was analyzed.

RESULTS

Female sex (p = 0.006), serum triglycerides (TG, p = 0.016), serum alanine aminotransferase (ALT, p = 0.007), and liver steatosis (p = 0.001) associated with the small intestinal length (BPL + AL + CC) at baseline. Association remained significant between levels of serum TG and CC length (p = 0.048) at 1-year follow-up. Liver mRNA expression of genes regulating cholesterol synthesis and bile metabolism did not associate with the baseline small intestinal length.

CONCLUSIONS

Our findings support the suggestions that small intestinal length regulates TG metabolism before and after LRYGB. Therefore, modification of the length of bypassed small intestine based on measured total small intestinal length could optimize the outcomes of the elective LRYGB.

Study protocol of the DUCATI-study: a randomized controlled trial investigating the optimal common channel length in laparoscopic gastric bypass for morbid obese patients

BACKGROUND

Morbid obesity has become one of the most frequent chronic medical disorders in Western countries, affecting 1.5-2 % of the Dutch population. Currently, the laparoscopic Roux-Y gastric bypass is considered to be the most effective bariatric treatment option for morbid obesity as it results in adequate weight loss and a significant decrease in comorbidity. Although this technique has been applied for years, the optimal lengths of the three bowel limbs (alimentary limb, biliopancreatic limb, and common channel) in order to achieve maximal percentage excess weight loss with minimal side effects (i.e. malabsorption symptoms), are unknown. As 'normal' sized gastric bypasses achieve an average of 60 - 80 % excess weight loss after one year, one could hypothesize that afferent limb lengths should be longer in order to reduce the common channel length, thereby improving outcome in terms of excess weight loss. The aim of the current study is to investigate the effect of the length of the common channel in gastric bypass surgery for morbid obesity. In this randomized controlled trial the very long Roux limb gastric bypass will be compared to the standard gastric bypass, in order to conclude which option is the optimal therapeutic strategy in the morbidly obese patient.

METHODS/DESIGN

In this multicentre trial patients will be randomized either to a very long Roux limb gastric bypass with a fixed common channel length of 100 cm, or to a standard gastric bypass with a variable common channel length. The primary objective is to evaluate whether the very long Roux limb gastric bypass is superior in terms of percentage excess weight loss after one year follow-up compared to the standard gastric bypass. Secondary endpoints are quality-of-life, cure /improvement of obesity related comorbidity, complications, malnutrition, re-admission rate, and re-operation rate.

DISCUSSION

We hypothesize that our proposed distal LRYGB will provide for improved results concerning % EWL with an acceptable rate of (metabolic) complications. Our main point of interest is to determine if the distal LRYGB is a superior alternative to standard LRYGB in terms of percentage excess weight loss and to put more focus on the role of the common channel. Therefore we will perform this randomized controlled trial comparing both techniques, with % EWL as a primary outcome.

TRIAL REGISTRATION

CCMO registration number: NL43951.101.13 and Netherlands Trial Registry number: NTR4466.

Laparoscopic transgastric endoscopic retrograde cholangiopancreatography after biliopancreatic diversion

Endoscopic retrograde cholangiopancreatography may be difficult in patients that have undergone Roux-en-Y gastric bypass. Due to the fact that prevalence of morbid obesity is increasing, and laparoscopic procedures for its treatment have increased, the incidence of biliary tract problems in patients of altered anatomy is also growing. We describe a laparoscopic technique to access the biliary tree by endoscope, through the excluded stomach.

Long-term results of laparoscopic Roux-en-Y Gastric bypass: evaluation after 9 years

This retrospective study aimed to evaluate the long-term results of the laparoscopic Roux-en-Y gastric bypass (LRYGB) procedure performed at our department of bariatric surgery. The 126 consecutive patients treated by LRYGB between January 1, 2001 and December 31, 2002 were analyzed in August 2011. Seventy-seven patients (61.1 %), including 18 who had had previous bariatric surgery, were available for evaluation after 9.4 ± 0.6 years (range, 8.7-10.9 years). Eight patients (10.4 %) suffered from type 2 diabetes mellitus (DMII) at the time of surgery. Initial body mass index (BMI) was 40.3 ± 7.5 kg/m(2) (range, 24.5-66.1 kg/m(2)). There was no postoperative mortality, but two patients died of causes unrelated to the surgery. Some 9 % of the patients suffered from internal herniation, despite the closure of potential hernia sites. With time, the patients had the tendency to experience weight regain: percentage of excess BMI lost was 56.2 ± 29.3 % (range, -78.8 to 117.9 %), down from a maximum of 88.0 ± 29.6 % (range, -19.7 to 197.1 %), that had been obtained after a median of 2.0 years (range, 1-8 years). LRYGB was effective for diabetes control in 85.7 % of the affected patients, but, surprisingly, 27.9 % developed new-onset diabetes. The weight regain in this latter patient group was statistically not different from the nondiabetic group. Conversely, four patients required hospitalization for hypoglycemic syndrome. Two patients underwent reversal of their bypass for problems linked to glucose metabolism (one hypoglycemia, one DMII). Patient quality of life was fair. The patient satisfaction remained good in 76 % of the cases.

Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients

BACKGROUND

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with prior Roux-en-Y gastric bypass (RYGB) surgery is challenging. Despite advancements in endoscopic technology, reaching the duodenum and entering the bile duct is still difficult. Laparoscopic assisted ERCP (LAERCP) allows the duodenum to be accessed through the excluded stomach.

OBJECTIVES

The objective of this study is to evaluate the success rates and complications in patients with prior RYGB anatomy who underwent LAERCP in a tertiary care center.

PATIENTS

Consecutive patients undergoing LAERCP between 2005 and 2010 were used for this study.

OUTCOMES

Biliary/pancreatic cannulation, endoscopic/laparoscopic interventions, postprocedure complications, postprocedure hospital stay, and procedure time were observed in this study.

RESULTS

Fifteen patients with post-RYGB surgery underwent LAERCP. Endoscopic antegrade access to the papilla was achieved through the gastric remnant in all. Cannulation and interventions in the pancreaticobiliary tree were successful in all cases. Therapeutic interventions included biliary sphincterotomy in 14 and pancreatic sphincterotomy in two patients. There were no postoperative complications related to the endoscopic portion of the procedure. The mean duration of the procedure and the median postprocedure hospital stay were 45 min and 2 days, respectively.

CONCLUSION

Laparoscopic assisted ERC is a useful approach in the diagnosis and treatment of pancreaticobiliary conditions in patients with RYGB.

Laparoscopic assisted ERCP in Roux-en-Y gastric bypass (RYGB) surgery patients

BACKGROUND

Performing endoscopic retrograde cholangiopancreatography (ERCP) in patients with prior Roux-en-Y gastric bypass (RYGB) surgery is challenging. Despite advancements in endoscopic technology, reaching the duodenum and entering the bile duct is still difficult. Laparoscopic assisted ERCP (LAERCP) allows the duodenum to be accessed through the excluded stomach.

OBJECTIVES

The objective of this study is to evaluate the success rates and complications in patients with prior RYGB anatomy who underwent LAERCP in a tertiary care center.

PATIENTS

Consecutive patients undergoing LAERCP between 2005 and 2010 were used for this study.

OUTCOMES

Biliary/pancreatic cannulation, endoscopic/laparoscopic interventions, postprocedure complications, postprocedure hospital stay, and procedure time were observed in this study.

RESULTS

Fifteen patients with post-RYGB surgery underwent LAERCP. Endoscopic antegrade access to the papilla was achieved through the gastric remnant in all. Cannulation and interventions in the pancreaticobiliary tree were successful in all cases. Therapeutic interventions included biliary sphincterotomy in 14 and pancreatic sphincterotomy in two patients. There were no postoperative complications related to the endoscopic portion of the procedure. The mean duration of the procedure and the median postprocedure hospital stay were 45 min and 2 days, respectively.

CONCLUSION

Laparoscopic assisted ERC is a useful approach in the diagnosis and treatment of pancreaticobiliary conditions in patients with RYGB.

Weight loss is coupled with improvements to affective state in obese participants engaged in behavior change therapy based on incremental, self-selected "small changes"

The aim of this study was to investigate the effects of a group behavior change intervention involving self-selected, contextualized, and mediated goal setting on anthropometric, affective, and dietary markers of health. It was hypothesized that the intervention would elicit changes consistent with accepted health recommendations for obese individuals. A rolling program of 12-week "Small Changes" interventions during 24 months recruited 71 participants; each program accommodated 10 to 13 adults (body mass index [BMI] ≥ 30 kg/m²). Fifty-eight participants completed Small Changes. Repeated measures were made at baseline, 6 and 12 weeks. Anthropometric measures included height and weight (to calculate BMI), body composition, waist circumference, and blood pressure. Affective state was monitored using relevant validated questionnaires. Dietary assessment used 3-day household measures food diaries with Schofield equations to monitor underreporting. Relevant blood measures were recorded throughout. Across the measurement period, Small Changes elicited a significant reduction in body weight (baseline, 102.95 ± 15.47 vs 12 weeks 100.09 ± 16.01 kg, P < .0005), coupled with associated significant improvements in BMI, body fat percentage, and waist circumference measures. There were additional significant positive changes in measures of affective state including general well-being (baseline, 58.92 ± 21.22 vs 12 weeks 78.04 ± 14.60, P < .0005) and total mood disturbance (baseline, 31.19 ± 34.03 vs 12 weeks 2.67 ± 24.96, P < .0005). Dietary changes that occurred were largely consistent with evidenced-based recommendations for weight management and included significant reductions in total energy intake and in fat and saturated fat as a proportion of energy. The Small Changes approach can elicit a range of health-orientated benefits for obese participants, and although further work is needed to ascertain the longevity of such effects, the outcomes from Small Changes are likely to help inform health professionals when framing the future of weight management. Long-term follow-up of Small Changes is warranted.

The importance of the length of the limbs for gastric bypass patients--an evidence-based review

The ideal length of the gastric bypass limbs is debated. Recent evidence suggests that standard limb lengths used today have a limited impact on patient weight loss. Our objective was to appraise critically the available evidence on the influence of the length of gastric bypass limbs on weight loss outcomes. We systematically reviewed MEDLINE, the Cochrane database of evidence-based reviews, and the Database of Abstracts of Reviews of Effects for articles reporting the effect of gastric bypass length on outcomes published between 1987 and 2009. Four randomized controlled trials and several retrospective studies were identified and reviewed. Longer Roux limb lengths (at least 150 cm) were associated with a very modest weight loss advantage in the short term in superobese patients. No significant impact of alimentary limb length on weight loss for patients with body mass index (BMI) <50 was seen. When the length of the common channel approaches 100 cm, a significant impact on weight loss is observed. The currently available literature supports the notion that a longer Roux limb (at least 150 cm) may be associated with a very modest weight loss advantage in the short term in superobese patients but has no significant impact on patients with BMI ≤50. To achieve weight loss benefit due to malabsorption, bariatric surgeons should focus on the length of the common channel rather than the alimentary or biliopancreatic limbs when constructing a gastric bypass especially in the superobese population where failure rates after conventional gastric bypass are higher.

Two important criteria for reducing the risk of postoperative ulcers at the gastrojejunostomy site after gastric bypass: patient compliance and type of gastric bypass

BACKGROUND

Ulcers at the gastrojejunostomy site are a common problem after gastric surgery. Their postoperative development seems to be associated with Helicobacter pylori-related gastritis or abuse of nicotine, alcohol or non-steroidal anti-inflammatory drugs (NSAIDs), but is also dependent on the choice of surgical method (Roux-en-Y or B-II gastric bypass).

PATIENTS AND METHODS

This study evaluated the follow-up of 1,908 patients over a period of 5 years (January 2006-December 2010). In 1,861 cases, we performed a Roux-en-Y gastric bypass, and in 47 cases a B-II gastric bypass.

RESULTS

All patients (n = 407) with symptoms such as dysphagia, reflux, nausea, vomiting or epigastric pain underwent gastroscopy. In 52 cases, ulcers were found at the gastrojejunostomy site. Of these patients, 39 (75%; p < 0.0001) had consumed alcohol, nicotine or NSAIDs; in 14 patients (27%; p < 0.0001) we detected H. pylorirelated gastritis. A total of 2.4% of the patients after Roux-en-Y gastric bypass (45/1,861) and 14.9% of the patients after B-II gastric bypass (7/47) developed ulcers at the gastroenteral junction. The difference is clearly significant (Fisher's exact test, p = 0.0002). Furthermore, there were significant differences regarding the recurrence rate: 86% of the B-II gastric bypass group and 13.3% of the Roux-en-Y gastric bypass group needed to be treated several times.

CONCLUSIONS

Every patient needs to be informed preoperatively that there is a markedly increased risk of ulcers at the gastroenteral junction, particularly if the patient cannot avoid potential risk factors (nicotine, alcohol, NSAIDs). Preoperative gastroscopy with H. pylori testing and subsequent eradication can also reduce the risk of ulcers. An increased incidence of peptic ulcers after B-II gastric bypass was noted. All of these patients were converted to Roux-en-Y.

Early insulin sensitivity after restrictive bariatric surgery, inconsistency between HOMA-IR and steady-state plasma glucose levels

BACKGROUND

The low-grade inflammatory condition present in morbid obesity is thought to play a causative role in the pathophysiology of insulin resistance (IR). Bariatric surgery fails to improve this inflammatory condition during the first months after surgery. Considering the close relation between inflammation and IR, we conducted a study in which insulin sensitivity was measured during the first months after bariatric surgery. Different methods to measure IR shortly after bariatric surgery have given inconsistent data. For example, the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) levels have been reported to decrease rapidly after bariatric surgery, although clamp techniques have shown sustained insulin resistance. In the present study, we evaluated the use of steady-state plasma glucose (SSPG) levels to assess insulin sensitivity 2 months after bariatric surgery.

METHODS

Insulin sensitivity was measured using HOMA-IR and SSPG levels in 11 subjects before surgery and at 26% excess weight loss (approximately 2 months after restrictive bariatric surgery).

RESULTS

The SSPG levels after 26% excess weight loss did not differ from the SSPG levels before surgery (14.3 +/- 5.4 versus 14.4 +/- 2.7 mmol/L). In contrast, the HOMA-IR values had decreased significantly (3.59 +/- 1.99 versus 2.09 +/- 1.02).

CONCLUSION

During the first months after restrictive bariatric surgery, we observed a discrepancy between the HOMA-IR and SSPG levels. In contrast to the HOMA-IR values, the SSPG levels had not improved, which could be explained by the ongoing inflammatory state after bariatric surgery. These results suggest that during the first months after restrictive bariatric surgery, HOMA-IR might not be an adequate marker of insulin sensitivity.

The decline in hip bone density after gastric bypass surgery is associated with extent of weight loss

CONTEXT

Bariatric surgery is common and may be associated with deleterious effects on the skeleton.

OBJECTIVE

Our objective was to assess bone metabolism and bone mineral density (BMD) after Roux-en-Y gastric bypass.

DESIGN AND SETTING

We conducted a 1-yr prospective longitudinal study at a university hospital bariatric surgery practice and metabolic bone disease unit.

PARTICIPANTS

Participants included 23 obese (mean body mass index 47 kg/m(2)) men and women, aged 20-64 yr.

MAIN OUTCOME MEASURES

Serum PTH, 25-hydroxyvitamin D, osteocalcin, and urinary N-telopeptide, and BMD were assessed.

RESULTS

Patients lost 45 +/- 2 kg 1 yr postoperatively (P < 0.01). PTH increased early (3 months, 43-50 pg/ml; P < 0.001) and urinary calcium dropped (161-92 mg/24 h; P < 0.01), despite doubling of calcium intake (1318-2488 mg/d; P < 0.001). Serum 25-hydroxyvitamin D concentrations were unchanged (23-26 ng/ml), although vitamin D intake increased by 260% (658 IU/d at baseline to 1698 IU/d at 12 months; P < 0.05). Markers of bone remodeling rose (P < 0.01 for both urinary N-telopeptide and osteocalcin), whereas BMD decreased at the femoral neck (9.2%, P < 0.005) and at the total hip (8.0%, P < 0.005). These declines were strongly associated with the extent of weight loss (femoral neck: r = 0.90, P < 0.0001; and total hip: r = 0.65, P = 0.02). Lumbar spine and distal radius sites did not change.

CONCLUSIONS

After Roux-en-Y gastric bypass, there was evidence of calcium and vitamin D malabsorption. Bone turnover increased, and hip bone density rapidly declined. The decline in hip BMD was strongly associated with weight loss itself. Vigilance for nutritional deficiencies and bone loss in patients both before and after bariatric surgery is crucial.

Endoscopic Retrograde Cholangiopancreatography after Laparoscopic Roux-en-Y Gastric Bypass: A Case Series and Review of the Literature

Endoscopic retrograde cholangiopancreatography (ERCP) has become an important tool in the diagnosis and treatment of pancreaticobiliary pathology. ERCP in patients that have undergone Roux-en-Y gastric bypass (RYGB) is particularly challenging because traditional transoral endoscopy may be limited. We present our experience with ERCP after RYGB and review the literature. In 2007 eight patients underwent ERCP after RYGB using open or laparoscopic transgastric access. After introduction of pneumoperitoneum, a total of four ports were placed. A purse-string was placed around a gastrotomy 4 to 6cm proximal to the pylorus. The endoscope was introduced through a 15 mm left-upper-quadrant port and the gastrotomy. Endoscopy was then performed. Laparoscopic gastrotomy was used in all patients that underwent a previous laparoscopic Roux-en-Y gastric bypass (LRYGB) (n = 6) and open gastrotomy was used for patients with a previous open RYGB (n = 2). Cannulation and interventions in the pancreaticobiliary tree were successful in all cases. There were no postoperative complications. Laparoscopic transgastric ERCP after LRYGB is feasible, highly successful, may be performed expeditiously, and does not seem to add significant morbidity to the procedure. The ability to perform ERCP in this patient population is critical due to their tendency to have preexisting biliary disease and to develop gallstones and the associated complications.

The incidence of pulmonary embolism in open versus laparoscopic gastric bypass

Obesity independently increases the risk of pulmonary embolism (PE). We compare a superobese population (body mass index [BMI] > 55 kg/m(2)) undergoing open gastric bypasses (OGBs) with a similarly matched group of laparoscopic gastric bypasses (LGB) to see if the incidence of PE differs. We included all patients undergoing OGB (n = 193, average BMI = 51 kg/m(2)) at our institution by a single surgeon between July 1999 and April 2001. Thirty-one patients were superobese (BMI > 55 kg/m(2)). LGB was started at our institution in April 2001. Since that time 213 patients (average BMI = 52 kg/m(2)) have undergone the procedure. One hundred and nine patients were superobese. Pre- and postoperative prophylaxis included sequential compression stockings and subcutaneous heparin. Postoperatively, patients who developed signs of hypoxia, tachypnea, or tachycardia underwent a chest X-ray and spiral computed tomography. In addition, all patients who expired in the 30-day postoperative period underwent postmortem examination. Data were analyzed using the chi-squared test. In the OGB group, four patients (2.1%) developed PE. All occurred in superobese patients with a BMI > 55 kg/m(2). Three were fatal PEs and one was nonfatal. None of these patients had a prior history of deep vein thrombosis, PE, venous stasis disease, or pulmonary hypertension. In the LGB group, one patient (0.9%) had a nonfatal PE. This patient had a history of deep vein thrombosis. The incidence of PE was statistically higher in the superobese OGB group (P < 0.01). Despite the theoretical hindrance to venous return and vena caval compression observed with pneumoperitoneum, fewer PEs occurred in the laparoscopic group. Our data, however, suggest that patients with a BMI > 55 kg/m(2) might be at an increased risk for PE independent of operative approach.