Assessment of patients with failed gastric operations for morbid obesity

OAGB vs BGBP: A retrospective comparative study of a cohort of patients who had bariatric surgery in 2012 at one centre by a single surgeon

Two modifications of Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB) and Roux-en-Y banded gastric bypass (BGBP), are gaining popularity in use because the OAGB is reported to be a simpler operation, and the BGBP is reported to have sustained weight loss compared to standard RYGB. A retrospective review and analysis of data comparing outcomes up to 5 years after BGBP and OAGB from a prospectively maintained database of all bariatric metabolic operations in 2012 was performed. Eighty-two patients underwent a BGBP and 90 an OAGB. The average age and body mass index were 44.12 and 43.97 and 43.57 and 45.79 in the BGBP and OAGB groups, respectively. Postoperative nutrient deficiencies were similar in both groups but were more prominent in the OAGB group. The % excess body weight loss (%EBWL) was 78% and 71.5% at 5 years in the OAGB and BGBP groups, respectively. The % total weight loss (%TWL) was also higher in OAGB compared to the BGBP group, 34.72% and 30.49%, respectively. Resolution of type 2 diabetes (T2DM) was significantly higher in the OAGB group, 79.16%, than in the BGBP group, 71.42%. The resolution of dyslipidaemia and hypertension were similar in both groups, but sleep apnoea resolution was higher in OAGB group. Both operations produced excellent weight loss in the intermediate term. The %EBWL and resolution of T2DM were significantly higher after the OAGB operation at the expense of increased incidence of nutrient deficiencies and hypoproteinemia. Quality of life improvement and patient satisfaction were high after both operations. Long-term follow up and multicentre prospective studies are needed to confirm these intermediate outcomes.

Metabolic and Bariatric Surgery for Obesity

Metabolic and bariatric surgery (MBS) leads to weight loss in obese individuals and reduces comorbidities such as type 2 diabetes. MBS is superior to medical therapy in reducing hyperglycemia in persons with type 2 diabetes, and has been associated with reduced mortality and incidences of cardiovascular events and cancer in obese individuals. New guidelines have been proposed for the use of MBS in persons with type 2 diabetes. We review the use of MBS as a treatment for obesity and obesity-related conditions and, based on recent evidence, propose that health care systems make the appropriate changes to increase accessibility for eligible patients.

Banded Roux-en-Y gastric bypass for the treatment of morbid obesity

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the most effective treatment for morbid obesity. The additional benefit of placing a nonadjustable band around the pouch remains to be determined. The objective of this study was to compare outcomes between banded and nonbanded LRYGB patients in a single bariatric center.

METHODS

A matched cohort analysis was performed between patients who had undergone banded and nonbanded (standard) LRYGB. In the banded bypass cohort, an 8 F, 6.5 cm silastic ring was placed around the proximal gastric pouch. Both cohorts were matched for age, body mass index (BMI), and anastomotic technique. Endpoints included percentage excess weight loss (%EWL), postoperative morbidity, and band-related complications.

RESULTS

Between January 2007 and July 2010, 134 banded LRYGB were performed (55% female, mean age 45 years). They were compared with a matched cohort of 134 concurrent nonbanded LRYGB patients (67% female, mean age 45.4 years). Mean preoperative BMI was 54.6 and 52.8 kg/m(2), respectively (P = .084). At 24 months postoperatively, the average %EWL was 58.6% in banded bypass patients and 51.4% in the nonbanded group (P = .015). The difference in EWL was more pronounced in super-obese patients than in those with BMI<50 (among super-obese, 57.5% versus 47.6%, P = .003; among those with BMI<50, 62.9% versus 57.9%, P = .406]. There was no difference in early (19.4% versus 19.4%) or late complications (10.4% versus 13.4%, P = .451) between banded and nonbanded LRYGB patients.

CONCLUSION

Banding the pouch during LRYGB can be performed safely and may provide better weight loss, particularly in super-obese patients. Further prospective and long-term comparative studies of this technique are warranted.

A importância do anel de silicone na derivação gástrica em Y-de-ROUX para o tratamento da obesidade

OBJETIVO: Analisaram prospectivamente pacientes obesos submetidos à derivação gástrica em y-de-roux com anel de silicone de diferentes tamanhos. MÉTODO: Os pacientes foram acompanhados durante cinco anos e através de exame endoscópico foram classificados em dois Grupos: anel com diâmetro interno até 10 mm (184 pacientes) e anel com diâmetro interno maior que 10 mm (107pacientes). Foi mensurada a porcentagem de perda do excesso de peso com um, dois e cinco anos de pós-operatório, e comparados os grupos entre si em cada ano da coleta dos dados. RESULTADOS: Houve maior emagrecimento no grupo com anel de diâmetro interno até 10 mm. A análise estatística mostrou que houve significância comparando-se os dois grupos entre si, um, dois e cinco anos após a cirurgia, sendo o emagrecimento sempre maior no grupo com anel de menor diâmetro. Não houve diferença estatisticamente significante ao se comparar outros dados da amostra como idade, sexo e IMC. CONCLUSÃO: A restrição determinada pelo anel aumenta a porcentagem de perda do excesso de peso.

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.

The weight reduction operation of choice: vertical banded gastroplasty or gastric bypass?

BACKGROUND

Despite important advances in the field of bariatric surgery over the last 40 years, no single operation has clearly emerged as the optimum procedure. Over the last decade, however, attention has focused on vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RGB).

PATIENTS AND METHODS

We compared 329 VBG procedures consecutively performed in 328 patients, and 623 VBG-RGB operations in 560 patients for mortality, early and late complications requiring reoperation, and for weight loss up to 5 years. In 272 VBG-RGB operations, the gastric segments were stapled in continuity, and in 351 cases, the gastric segments were stapled and completely separated.

RESULTS

Early complications were few for both procedures. Unsatisfactory weight loss was the most frequent late complication among VBG patients, whereas revision for staple-line disruption was the most common cause for late reoperation in the VBG-RGB group. The incidence of stapleline disruption was 22% for VBG-RGB patients when gastric segments were stapled in continuity and 2% when gastric segments were completely divided (P < 0.0001). Weight loss for the VBG patients and VBG-RGB patients at 5 years was 47% and 62%, respectively (P < 0.0001).

CONCLUSION

Our data suggest, as others have shown, that RGB is a better weight-loss operation than VBG. A lesser curvature vertical pouch stapled in continuity with the excluded stomach can be associated with a high rate of staple-line disruption in RGB. Separation of gastric segments appears to significantly diminish this complication (P < 0.0001). Late complications now are fewer, and VBG-RGB is our weight-reduction procedure of choice.

Failed gastroplasty for morbid obesity. Revised gastroplasty versus Roux-Y gastric bypass

Forty-six percent of 122 gastroplasties for morbid obesity failed. This included a failure rate of 71 percent for a single staple line without stomal reinforcement, 37 percent for a double staple line and a central stoma reinforced with 2-0 polypropylene, and 42 percent for the Gomez gastroplasty. Revisional procedures were performed in 44 patients. Ten underwent revision of a failed gastroplasty using a gastrogastrostomy and 34 had conversion to a Roux-Y gastric bypass. Patients who had revisional gastroplasty as a second procedure had a significantly higher failure and complication rate than those converted to gastric bypass. Four of these 10 patients were subsequently converted to gastric bypass as their third weight reduction procedure. Conversion of a failed gastroplasty to a Roux-Y gastric bypass is a difficult procedure that carried a significantly higher complication rate in our study than that of a group of 46 patients who underwent a primary gastric bypass procedure. Of 26 patients followed for more than 1 year after conversion to Roux-Y gastric bypass, the average weight loss was 66 +/- 18 percent of their excess body weight. This was comparable to 16 patients who had undergone a primary gastric bypass more than 1 year previously and had lost 69 +/- 17 percent of their excess body weight.