Laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding in the super-obese: peri-operative and early outcomes

Reoperations for Long-Term Complications Following Laparoscopic Adjustable Gastric Banding: Analysis of Incidence and Causality

Background: Laparoscopic adjustable gastric banding (LAGB) gained popularity in the early 2000s as a purely restrictive procedure with modest weight loss. The potential for complications requiring reoperation has since become evident. A retrospective review was performed to determine the incidence of long-term complications and predictive factors requiring surgical reintervention after LAGB.

Methods: Institutional review board approval was obtained, and a retrospective review of 200 consecutive patients undergoing LAGB over a period of six years was conducted at a single institution with American Society of Metabolic and Bariatric Surgery Center of Excellence designation. Data were collected on patient characteristics, comorbid conditions and complications requiring reintervention. Statistical analysis was performed using SPSS Statistics software (IBM Corp., Armonk, NY).

Results: Of the 200 patients, 176 (90.7%) were female with an average age of 53.6 years and preoperative body mass index (BMI) of 44.2 kg/m². The average follow-up was 46 months. Complications occurred in 55 (28.4%) patients with band slippage/prolapse as the most common need for reoperation. Younger age, lack of comorbidities and diet/exercise compliance were associated with reintervention.

Conclusions: LAGB has a high rate of reoperation secondary to complications associated with younger age. Alternative bariatric procedures may be more appropriate in these patients who have fewer comorbid conditions and are motivated to improve his or her health.

Comparative Effectiveness of Different Bariatric Procedures in Super Morbid Obesity

BACKGROUND

Super obesity (BMI ≥ 50 kg/m²) is associated with significant morbidity and mortality. The best procedure to treat super obesity is not completely established. Our aim was to compare the effectiveness of bariatric procedures (adjustable gastric band [AGB], Roux-en-Y gastric bypass [RYGB], sleeve gastrectomy [SG]) in super obesity.

METHODS

Retrospective observational study of super obese patients who underwent bariatric surgery. Data was assessed preoperatively and in the 1st and 2nd years of follow-up.

RESULTS

We evaluated 213 individuals, 77.9% female, age of 43.38 ± 11.49 years, and preoperative BMI of 54.53 ± 4.54 kg/m²; 19 submitted to AGB, 127 to RYGB, and 67 to SG. In the pre-surgical assessment, there were no significant differences in age, anthropometric parameters, blood pressure, glycemic profile, and lipid profile between the three surgical groups. The percentage of excess weight loss (%EWL) in the 1st year was 67.58% in RYGB, 58.74% in SG, and 38.71% in AGB (p < 0.001), and the percentage of total weight loss (%TWL) was 36.29%, 31.59%, and 21.07%, respectively (p < 0.001). Two years after surgery (n = 147; follow-up rate of 69%), the %EWL and %TWL were significantly higher in the RYGB group (p < 0.001). RYGB had a higher success rate (%EWL ≥ 50% and %TWL ≥ 20%) in both years of follow-up (p < 0.001). In multiple linear regression, after adjusting for other covariates, RYGB was the only strong predictive factor of %EWL and %TWL (p < 0.001).

CONCLUSION

RYGB proved to be more effective in super obesity. The beneficial effects in weight loss were evident both 1 and 2 years after the procedure, regardless of pre-surgical anthropometric characteristics.

A prospective study comparing 5-year results between superobese and non-superobese patients after laparoscopic adjustable gastric banding

Introduction

Laparoscopic adjustable gastric banding (LAGB) is considered to be the least invasive, reversible, and the safest bariatric operation regarding mortality and morbidity, and its application to high-risk superobese (SO) individuals seems rational.

Aim

There are differing viewpoints regarding the effectiveness of LAGB in superobese (BMI > 50 kg/m²) patients. The aim of this study was to compare the safety and efficacy of LAGB in SO and non-superobese (NSO) patients in the long term (> 5 years).

Material and methods

We undertook a prospective single-center study to compare the safety and efficacy of LAGB in SO and NSO patients after 5 years. One hundred and three morbidly obese patients underwent LAGB in the period from January 2009 to January 2010. Sixty-four of the patients were NSO and 39 SO. After 5 years, we evaluated their weight loss, comorbidities, complications, and quality of life.

Results

A total of 90 of 103 patients (87.3%) completed the 5-year follow-up. The percentage excess weight loss was 50.4% in the NSO and 38.8% in the SO group (p = 0.072). The proportion of patients who lost > 50% excess weight was significantly larger in the NSO group (p = 0.045). There were significantly more patients in the NSO group whose metabolic syndrome had resolved (p < 0.001). There were no differences regarding the resolution of other comorbidities and postoperative complications.

Conclusions

This study suggests that LAGB can lead to substantial and long-lasting weight loss after 5 years. Our study found that SO patients demonstrate inferior weight loss results, and lower overall BAROS scores; thus we do not support the primary use of LAGB in SO patients.

Outcomes of Bariatric Surgery in Patients with Inflammatory Bowel Disease

BACKGROUND

Obesity has become prevalent in patients with inflammatory bowel disease (IBD). Bariatric surgery can be considered to be contraindicated in IBD patients. We aimed to evaluate feasibility, safety, and efficacy of bariatric surgery in IBD patients.

METHODS

We retrospectively identified all morbidly obese patients with a known diagnosis of IBD, who underwent bariatric surgery between January 2005 and December 2012. Postoperative outcomes and status of IBD in patients on maintenance therapy for their disease were assessed.

RESULTS

We identified 20 IBD patients including 13 ulcerative colitis (UC) and 7 Crohn's disease (CD) patients with a mean age of 54.0 ± 10.5 years, BMI of 50.1 ± 9.0 kg/m(2), and duration of IBD of 11.3 ± 5.2 years. Eleven patients were on medication for IBD at baseline. Bariatric procedures included sleeve gastrectomy (N = 9), gastric bypass (N = 7), gastric banding (N = 3), and one conversion of band to gastric bypass. There were no intraoperative complications, but two conversions to laparotomy due to adhesions. Mean BMI change and excess weight loss at 1 year was 14.3 ± 5.7 kg/m(2) and 58.9 ± 21.1 %, respectively. Seven early postoperative complications occurred including dehydration (N = 5), pulmonary embolism (N = 1), and wound infection (N = 1). During a mean follow-up of 34.6 ± 21.7 months, five patients developed complications including pancreatitis (N = 2), ventral hernia (N = 2), and marginal ulcer (N = 1). Nine out of ten eligible patients experienced improvement in their IBD status.

CONCLUSIONS

Bariatric surgery is feasible and safe in morbidly obese patients suffering from IBD. In addition to being an effective weight loss procedure, bariatric surgery may help mitigate symptoms in this patient population.

Rapid Evidence Review of Bariatric Surgery in Super Obesity (BMI ≥ 50 kg/m2)

BACKGROUND

Despite accumulating evidence of the important health benefits of bariatric surgery in morbidly obese patients in general, bariatric surgery outcomes are less clear in higher-risk, high-priority populations of patients with BMI ≥ 50 kg/m². To help the Department of Veterans Affairs (VA) Health Services Research & Development Service (HSR&D) develop a research agenda, we conducted a rapid evidence review to better understand bariatric surgery outcomes in adults with BMI ≥ 50 kg/m².

METHODS

We searched MEDLINE^®, the Cochrane Database of Systematic Reviews, the Cochrane Central Registry of Controlled Trials, and ClinicalTrials.gov through June 2016. We included trials and observational studies. We used pre-specified criteria to select studies, abstract data, and rate internal validity and strength of the evidence (PROSPERO registration number CRD42015025348). All decisions were completed by one reviewer and checked by another.

RESULTS

Among 1892 citations, we included 23 studies in this rapid review. Compared with usual care, one large retrospective VA study provided limited evidence that bariatric surgery can lead to increased mortality in the first year, but decreased mortality long-term among super obese veterans. Studies that compared different bariatric surgical approaches suggested some differences in weight loss and complications. Laparoscopic gastric bypass generally resulted in greater short-term proportion of excess weight loss than did other procedures. Duodenal switch led to greater long-term weight loss than did gastric bypass, but with more complications.

CONCLUSIONS

The published literature that separates the super obese is insufficient for determining the precise balance of benefits and harms of bariatric surgery in this high-risk subgroup. Future studies should evaluate a more complete set of key outcomes with longer follow-up in larger samples of more broadly representative adults.

Surgical Endoscopy Versus Endoscopic Surgery for Obesity

BACKGROUND

Obesity treatment options are of great interest worldwide with major developments in the past 20 years. From general surgery to natural orifice transluminal endoscopic surgery intervention nowadays, obesity surgical therapies have surely developed and are now offering a variety of possibilities.

AREAS OF UNCERTAINTY

Although surgery is the only proven approach for weight loss, a joint decision between the physician and patient is required before proceeding to such a procedure. With a lot of options available, the treatment should be individualized because the benefits of surgical intervention must be weighed against the surgical risks.

DATA SOURCES

Medline search to locate full-text articles and abstracts with obvious conclusions by using the keywords: obesity, surgical endoscopy, gastric bypass, bariatric surgery, and endoscopic surgery, alone and in various combinations. Additional relevant publications were also searched using the reference lists of the identified articles as a starting point.

RESULTS

Laparoscopic Roux-en-Y gastric bypass still is the most effective, less invasive, bariatric surgical intervention, although there are various complications encountered, such as postoperative hemorrhage (1.9%-4.4%), internal hernias, anastomotic strictures (2.9%-23%), marginal ulcerations (1%-16%), fistulas (1.5%-6%), weight gain, and nutritional deficiencies. However, the absence of parietal incisions, less pain, decreased risk of infection, and short hospital stay make room for endoscopic surgery as a possible valid option for obesity for both the doctors' and the patients' perspective.

CONCLUSIONS

The current tendency is to promote surgical treatment of obesity to a status of less invasive scars therefore promoting minimally invasive surgical techniques.

How do patients' clinical phenotype and the physiological mechanisms of the operations impact the choice of bariatric procedure?

Bariatric surgery is currently the most effective option for the treatment of morbid obesity and its associated comorbidities. Recent clinical and experimental findings have challenged the role of mechanical restriction and caloric malabsorption as the main mechanisms for weight loss and health benefits. Instead, other mechanisms including increased levels of satiety gut hormones, altered gut microbiota, changes in bile acid metabolism, and/or energy expenditure have been proposed as explanations for benefits of bariatric surgery. Beside the standard proximal Roux-en-Y gastric bypass and the biliopancreatic diversion with or without duodenal switch, where parts of the small intestine are excluded from contact with nutrients, resectional techniques like the sleeve gastrectomy (SG) have recently been added to the armory of bariatric surgeons. The variation of weight loss and glycemic control is vast between but also within different bariatric operations. We surveyed members of the Swiss Society for the Study of Morbid Obesity and Metabolic Disorders to assess the extent to which the phenotype of patients influences the choice of bariatric procedure. Swiss bariatric surgeons preferred Roux-en-Y gastric bypass and SG for patients with type 2 diabetes mellitus and patients with a body mass index >50 kg/m², which is consistent with the literature. An SG was preferred in patients with a high anesthetic risk or previous laparotomy. The surgeons’ own experience was a major determinant as there is little evidence in the literature for this approach. Although trends will come and go, evidence-based medicine requires a rigorous examination of the proof to inform clinical practice.

Single-incision or conventional laparoscopic adjustable gastric banding: A systematic review

INTRODUCTION

Single-incision laparoscopic surgery (SILS) in gastric banding (SI-LAGB) has been reported to be a safe and technically feasible procedure among various operating methods. However, there is little evidence with regard to the question whether SI-LAGB has more advantages and should be recommended compared with conventional LAGB (CLAGB). Thus, this study was performed to assess the safety and efficacy of SI-LAGB.

MATERIAL AND METHODS

A computerized search of the electronic databases PubMed and EMBASE was performed. Data regarding operative parameters, postoperative recovery parameters, follow-up time, percentage of excess weight loss, and postoperative complication were pooled and analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

RESULTS

Ten comparative studies including 2,073 patients (1,038 patients who received SI-LAGB and 1,035 patients who received CLAGB) were included and analyzed. Compared with CLAGB, a similar weight loss could be obtained using SI-LAGB. The postoperative complications of SI-LAGB were within the acceptable range, but one study reported one perioperative death. SI-LAGB required a longer operative time. Other outcome variables, such as blood loss, days of hospitalization, pain score, and hospitalization costs, were not significantly different between the two groups.

CONCLUSIONS

SI-LAGB might be a safe and effective alternative to C-LAGB when performed by experienced surgeons, but available data do not allow to give a definitive answer and randomized controlled trials are needed.

Weight loss outcomes and complications from bariatric surgery in the super super obese

BACKGROUND

Bariatric surgery has been established as the most effective long-term treatment for morbid obesity.

METHODS

We performed a retrospective review of SSO patients treated at our institute between 2008 and 2013 who underwent a laparoscopic gastric bypass (LGBP) or sleeve gastrectomy (LSG). The primary end point for this study was excess weight loss (EWL) at 1, 3, 6, and 12 months. Secondary end points included procedure length (PL), length of stay (LOS), diabetes management and postoperative complications.

RESULTS

We identified 135 SSO patients who underwent bariatric surgery (93 LGBP, 42 LSG) at our institute from 2008 to 2013 with a median follow-up of 49 months. The incidence of EWL > 30 % for patients in the LGBP group was 3.9, 29.0, 72.2 and 94.6 % at 1, 3, 6 and 12 months, respectively, while the incidence of EWL > 30 % in patients in the LSG group was 4.2, 25.0, 59.1 and 100 % at 1, 3, 6 and 12 months, respectively. PL was 124 ± 49 min for the LGBP group and 98 + 51 min for the LSG group (p < 0.005). LOS was on average 3.0 days (range 1-21) for the LGBP group and 3.4 days (range 1-13) for the LSG group (p = 0.41). Patients experienced a decrease in their hemoglobin A1C level by 10 % for the LGBP group and 9 % for the LSG group at 1 year (p = 0.89). Postoperative complications were seen in 15.1 % of LGBP patients and 4.8 % of LSG patients.

CONCLUSIONS

Bariatric surgery is feasible in the SSO patients with comparable EWL outcomes and postoperative complications to historical non-SSO patients.

Bariatric and metabolic outcomes in the super-obese elderly

BACKGROUND

Numerous reports address bariatric outcomes in super-obese or elderly patients, but data addressing this high-risk combination is lacking.

OBJECTIVE

The objective of this study was to assess outcomes of bariatric surgery in the super-obese elderly.

SETTING

Academic institution, United States.

METHODS

All primary bariatric cases performed on patients aged 65 years or older with a body mass index (BMI) ≥ 50 kg/m(2) were retrospectively analyzed. Surgical approaches included laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), and laparoscopic adjustable gastric banding (LAGB).

RESULTS

Thirty patients (26 female, 4 male) with a mean age of 67.1 ± 2.7 years and BMI of 55.9 ± 3.9 kg/m(2), who had LRYGB (n = 16), LSG (n = 6), or LAGB (n = 8), were identified. There were no deaths, conversions, or intraoperative complications. Three patients were lost to follow-up after the 3-month visit. The early (<30 d) major morbidity rate was 10.0%. At a median follow-up of 37 (range, 6-95) months, the cohort had a mean BMI of 42.3 ± 6.7 kg/m(2), which corresponded to a mean percent excess weight loss of 44.5% ± 20.5% and mean percent total weight loss of 24.4% ± 12.2%. The most percent excess weight loss was achieved after LRYGB (54.1% ± 19.4%), followed by LSG (48.3% ± 10.2%) and then LAGB (26.2% ± 14.4%). Diabetic medication reduction in number and/or dosage was observed in 40% (6/15) patients, and 33% (5/15) of patients were completely off antidiabetic agents.

CONCLUSIONS

Although further research is needed, the present data suggest that successful weight loss and metabolic improvement can be achieved safely in the high-risk population of super-obese elderly.