First-year weight loss following gastric band surgery predicts long-term outcomes

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) continues to be a valid surgical treatment option to address severe obesity. However, outcomes are varied and can be difficult to predict. Early prediction of suboptimal weight loss following LAGB may enable adjustments to postoperative care and consequently improve surgical outcomes. Therefore, our aim is to investigate the prognostic utility of using early weight loss following LAGB to predict long-term weight outcomes.

METHODS

Clinical data from patients undergoing LAGB between 2001 and 2007 at a single institution were retrospectively collected and analysed. The data was used to inform a model for predicting long-term weight loss after LAGB surgery. Percent total weight loss (%TWL) greater than 20% 1 year after surgery was considered a measurement of success since it has been associated with the improvement of comorbidities and increased patient satisfaction.

RESULTS

The average %TWL 1 year after LAGB surgery was 23.73% (n = 1524, SD = 8.68%). Weight loss of less than 10% in 1 year was a negative predictor of weight loss >20% in 8-12 years (OR = 0.449; p = 0.002; 95% CI = 0.272-0.742). Moreover, weight loss >20% in 1 year was a strong predictor of weight loss >20% in 8-12 years (OR = 5.33; p < 0.001; 95% CI = 3.17-8.97).

CONCLUSION

Total body weight reduction of less than 10% 1 year after LAGB surgery suggests a lesser weight loss at 8-12 years. For these patients, targeted interventions would be appropriate to increase the chances of long-term success.

The Impact of CKD on Perioperative Risk and Mortality after Bariatric Surgery

Background

Twenty percent of patients with CKD in the United States have a body mass index (BMI) ≥35 kg/m². Bariatric surgery reduces progression of CKD to ESKD, but the risk of perioperative complications remains a concern.

Methods

The 24-month data spanning 2017-2018 were obtained from the Metabolic and Bariatric Surgery Quality Improvement Program (MBSAQIP) database and analyzed. Surgical complications were assessed on the basis of the length of hospital stay, mortality, reoperation, readmission, surgical site infection (SSI), and worsening of kidney function during the first 30 days after surgery.

Results

The 277,948 patients who had primary bariatric procedures were 44±11.9 (mean ± SD) years old, 79.6% were women, and 71.2% were White. Mean BMI was 45.7±7.6 kg/m². Compared with patients with an eGFR≥90 ml/min per BSA, those with stage 5 CKD/ESKD were 1.91 times more likely to be readmitted within 30 days of a bariatric procedure (95% CI, 1.37 to 2.67; P<0.001). Similarly, length of hospital stay beyond 2 days was 2.05-fold (95% CI, 1.64 to 2.56; P<0.001) higher and risk of deep incisional SSI was 6.92-fold (95% CI, 1.62 to 29.52; P=0.009) higher for those with stage 5 CKD/ESKD. Risk of early postoperative mortality increased with declining preoperative eGFR, such that patients with stage 3b CKD were 3.27 (95% CI, 1.82 to 5.89; P<0.001) times more likely to die compared with those with normal kidney function. However, absolute mortality rates remained relatively low at 0.53% in those with stage 3b CKD. Furthermore, absolute mortality rates were <0.5% in those with stages 4 and 5 CKD, and these advanced CKD stages were not independently associated with an increased risk of early postoperative mortality.

Conclusions

Increased severity of kidney disease was associated with increased complications after bariatric surgery. However, even for the population with advanced CKD, the absolute rates of postoperative complications were low. The mounting evidence for bariatric surgery as a renoprotective intervention in people with and without established kidney disease suggests that bariatric surgery should be considered a safe and effective option for patients with CKD.

The Effect of Laparoscopic Sleeve Gastrectomy on Gastroesophageal Reflux Disease

BACKGROUND

The laparoscopic sleeve gastrectomy (LSG) has become one of the most popular surgical weight loss options. Since its inception as a procedure intended to promote durable weight loss, the association between LSG and gastroesophageal reflux disease (GERD) has been a point of debate. First and foremost, it is known that GERD occurs more frequently in the obese population. With the sleeve gastrectomy growing to be the predominant primary bariatric operation in the United States, it is imperative that we understand the impact of LSG on GERD.

OBJECTIVE

To examine the effects of LSG on GERD symptoms.

METHODS

One hundred and ninety-one bariatric surgery candidates completed a Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) questionnaire before and after undergoing elective LSG (mean follow-up time of 20.4 ± 2.7 months). Values were stratified by the presence or absence of preoperative GERD, GERD medications, age, gender, crural repair, patient satisfaction with present condition, and percent total weight loss (%TWL).

RESULTS

For the entire group, mean weight loss, %TWL, and reduction in BMI were 79 pounds, 28.1%, and 12.7 kg/m² respectively. Within the overall cohort, there was no significant change in GERD symptoms from before to after surgery (mean GERD-HRQL scores were 6.1 before and after surgery, p = 0.981). However, in a subgroup analysis, patients without GERD preoperatively demonstrated a worsening in mean GERD-HRQL scores after surgery (from 2.4 to 4.5, p = 0.0020). The percentage of change in the usage of medications to treat GERD was not statistically significant (from 37 to 32%, p = 0.233). The percent of patients satisfied with their condition postoperatively was significantly increased in those with preoperative GERD, older age, crural repair intraoperatively, and in those with the highest %TWL.

CONCLUSION

These results suggest that while overall LSG does not significantly affect GERD symptoms, patients without GERD preoperatively may be at risk for developing new or worsening GERD symptoms after surgery. It is important to remark that this is a review of the patient's clinical symptoms of GERD, not related to any endoscopic, pathological, or manometry studies. Such studies are necessary to fully establish the effect of LSG on esophageal health.

Reducing complications with improving gastric band design

BACKGROUND

Adjustable gastric bands have undergone significant design changes since their introduction. Band diameter, balloon volume, and shape have been modified to create high balloon fill volumes but lower and more evenly distributed pressure on the upper stomach. There have been few comparative studies on complication rates with different band types.

OBJECTIVES

To compare complication rates among different types of adjustable gastric bands at a single institution.

SETTING

University-affiliated hospital, United States.

METHODS

We performed a retrospective cohort study of adult patients with a body mass index ≥ 35.0 kg/m(2) who underwent laparoscopic adjustable gastric banding from January 1, 2001 to December 31, 2007 and were followed for at least 5 years. Primary outcomes of the analysis were complications requiring operative management at our institution within the first 5 years after initial band placement. Reoperative procedures included diagnostic laparoscopy, hiatal hernia repair, band repositioning, replacing the band, removing the band, and converting to another bariatric procedure.

RESULTS

For this study, 2711 patients met the inclusion criteria-1827 (67.4%) women and 884 (32.6%) men. Bands initially implanted included first-generation bands, LAP-BAND™ 9.75 cm (24.0%), 10 cm (33.9%) and Vanguard (24.8%) and second-generation bands, AP standard (9.5%) and AP large (7.9%). Four hundred and eighty-five patients experienced complications requiring reoperation. The 5-year follow-up rate was 63.3%. In the first 5 postoperative years there were significantly fewer complications with second-generation bands (10.0% versus 19.5%, P<.0001). Smaller, older bands had the highest complication rates (LAP-BAND 9.75 cm, 28.2%) and complication rates decreased with each successive model. Rates of band removal were not different between first- and second-generation bands. The rate of multiple complications was low at 1.5%.

CONCLUSION

First-generation bands are associated with higher complication rates. Our study found that complication rates decreased with each successive model. We can expect that future design modifications will continue improve the performance with the adjustable gastric band.

Weight loss outcomes among patients referred after primary bariatric procedure

BACKGROUND

Bariatric patients may not always obtain long-term care by their primary surgeon. Our aim was to evaluate weight loss outcomes in patients who had surgery elsewhere.

METHODS

We conducted a retrospective analysis. Postreferral management included nonsurgical, revision, or conversion. Primary outcomes were percent excess weight loss (%EWL) overall, according to original operation, and based on postreferral management.

RESULTS

Between 2001 and 2013, there were 569 patients. Mean follow-up was 3.1 years. Management was 42% nonsurgical, 41% revision, and 17% conversion. Overall, mean %EWL was 45.3%. Based on original surgery type, %EWL was 41.2% for adjustable gastric banding vs 58.3% for Roux-en-Y gastric bypass (P ≤ .0001). Management affected %EWL (41.2% nonsurgical vs 45.3% revision vs 55.1% conversion, P ≤ .0001).

CONCLUSIONS

Patients referred after bariatric surgery can achieve satisfactory weight loss. This differs based on surgery type and management strategy.

Intraoperative leak testing has no correlation with leak after laparoscopic sleeve gastrectomy

BACKGROUND

Staple line leak is a serious complication of sleeve gastrectomy. Intraoperative methylene blue and air leak tests are routinely used to evaluate for leak; however, the utility of these tests is controversial. We hypothesize that the practice of routine intraoperative leak testing is unnecessary during sleeve gastrectomy.

METHODS

A retrospective cohort study was designed using a prospectively collected database of seven bariatric surgeons from two institutions. All patients who underwent sleeve gastrectomy from March 2012 to November 2014 were included. The performance of intraoperative leak testing and the type of test (air or methylene blue) were based on surgeon preference. Data obtained included BMI, demographics, comorbidity, presence of intraoperative leak test, result of test, and type of test. The primary outcome was leak rate between the leak test (LT) and no leak test (NLT) groups. SAS version 9.4 was used for univariate and multivariate analyses.

RESULTS

A total of 1550 sleeve gastrectomies were included; most were laparoscopic (99.8%), except for one converted and two open cases. Routine intraoperative leak tests were performed in 1329 (85.7%) cases, while 221 (14.3%) did not have LTs. Of the 1329 cases with LTs, there were no positive intraoperative results. Fifteen (1%) patients developed leaks, with no difference in leak rate between the LT and NLT groups (1 vs. 1%, p = 0.999). After adjusting for baseline differences between the groups with a propensity analysis, the observed lack of association between leak and intraoperative leak test remained. In this cohort, leaks presented at a mean of 17.3 days postoperatively (range 1-67 days). Two patients with staple line leaks underwent repeat intraoperative leak testing at leak presentation, and the tests remained negative.

CONCLUSION

Intraoperative leak testing has no correlation with leak due to laparoscopic sleeve gastrectomy and is not predictive of the later development of staple line leak.

Surgical management and outcomes of patients with marginal ulcer after Roux-en-Y gastric bypass

BACKGROUND

Marginal ulcers (MUs) are potentially complex complications after Roux-en-Y gastric bypass. Although most resolve with medical management, some require surgical intervention. Many surgical options exist, but there is no standardized approach, and few reports of outcomes have been documented in the literature. The objective of this study was to determine the outcomes of surgical management of marginal ulcers.

METHODS

Data from all patients who underwent surgical intervention between 2004 and 2012 for treatment of MU after previous Roux-en-Y gastric bypass were reviewed.

RESULTS

Twelve patients with MUs underwent reoperation. Nine patients had associated gastrogastric fistulae (75%). The median time to reoperation was 43 months. Ten patients underwent subtotal gastrectomy, of which 9 had a revision of the gastrojejunal anastomosis and 1 did not. One underwent total gastrectomy with esophagojejunal anastomosis for ulcer after previous revisional partial gastrectomy, and 1 patient underwent video-assisted thoracoscopic truncal vagotomy for persistent ulcer-related bleeding in the early postoperative period. Three patients (25%) experienced postoperative complications associated with revisional surgery requiring reoperation. At median follow-up time of 35 months, 7 patients (58%) had chronic abdominal pain, and 4 patients (33%) had intermittent diarrhea. Three patients (25%) were lost to recent follow-up. None had recurrence of MU.

CONCLUSION

Patients can undergo one of several available surgical interventions, including laparoscopic subtotal gastrectomy with gastrojejunostomy revision. Though this appears to offer definitive treatment of MU, its benefits must be weighed against the increased risk of significant postoperative complications and chronic symptoms related to revisional surgery.

Laparoscopic gastric banding resolves the metabolic syndrome and improves lipid profile over five years in obese patients with body mass index 30-40 kg/m(2.)

BACKGROUND

Obesity, metabolic syndrome (MS) and dyslipidemia are independent risk factors for cardiovascular disease. Bariatric surgery is increasingly recognized as an effective intervention for improving each of these risk factors. There are sparse data on the long-term durability of metabolic changes associated with bariatric surgery, in particular with laparoscopic gastric banding (LGB). Our objective was to evaluate the durability of metabolic changes associated with LGB in nonmorbid obesity.

METHODS

Fifty obese patients (BMI 30-40) with ≥1 obesity-related comorbidity were prospectively followed for five years. At follow-up, subjects underwent fasting blood measures, including lipid NMR spectroscopy and standard lipid profile.

RESULTS

Forty-seven patients (45 female, mean age 43.8 years) completed four years follow-up (46 completed five years). Baseline BMI was 35.1 ± 2.6. Subjects exhibited mean weight loss of 22.3 ± 7.9 kg (22.9 ± 7.4%) at year one and maintained this (19.8 ± 10.2%) over five years. At baseline, 43% (20/47) of subjects met criteria for MS. This was reduced to 15% (7/47) at year one and remained reduced over five years (13%, 6/46) (p < 0.001). There were reductions in triglycerides (p < 0.001) and increases in HDL cholesterol (HDL-C, p < 0.001) and HDL particle concentration (p = 0.02), with a trend toward increased HDL particle size (p = 0.06) at year five. Changes in triglycerides and HDL-C were more prominent in patients with MS at baseline, but unassociated with weight loss or waist circumference. Changes in HDL particle size and concentration were not associated with MS status, weight loss, waist circumference, or statin use.

CONCLUSIONS

LGB produces significant weight loss, resolution of MS and changes in lipid profile suggestive of beneficial HDL remodeling. These changes persist five years following LGB.

Safety of laparoscopic adjustable gastric banding with concurrent cholecystectomy for symptomatic cholelithiasis

BACKGROUND

The prevalence of cholelithiasis correlates with obesity. Patients often present for bariatric surgery with symptomatic cholelithiasis. There is a concern of cross-contamination when performing laparoscopic adjustable gastric banding (LAGB) with concurrent cholecystectomy. The primary goal of this study is to address the safety and feasibility of this practice.

METHODS

A retrospective cohort study was designed from a prospectively collected database. All LAGB patients from July 2005 to April 2013 were included. Patients undergoing LAGB with concurrent cholecystectomy comprised the study group (LAGB/chole). The control group (LAGB) consisted of patients undergoing LAGB alone, and was selected using a 3:1 (control:study) case-match based on demographic and comorbidity data. The primary outcome was overall complication rate, with secondary outcomes including operating room (OR) time, length of stay (LOS), 30-day readmission/reoperation, erosion, infection, and band/port revisional surgery.

RESULTS

There were 4,982 patients who met criteria. Of these, 28 patients had a LAGB with concurrent cholecystectomy, comprising the LAGB/chole (study) group. The remaining 4,954 patients were eligible controls, of which 84 were selected for the LAGB (control) group. Demographic and comorbidity data, along with mean follow-up time, were similar between the two groups. OR time was longer in the LAGB/chole group, but LOS was the same. The overall complication rate in the LAGB/chole group was 21 (n = 6) versus 20% (n = 17) in the LAGB group (p = 0.893). Thirty-day readmission and reoperation were similar. There was also no difference in port site, wound, and intra-abdominal infections. There were no band erosions in either group.

CONCLUSIONS

Performing a concurrent cholecystectomy at the time of LAGB does not result in increased immediate or delayed morbidity. Although longer to perform, this safe operation would avoid a second surgery for a patient already diagnosed with symptomatic cholelithiasis.

Midterm results for gastric banding as salvage procedure for patients with weight loss failure after Roux-en-Y gastric bypass

BACKGROUND

Studies reporting the revisionary options for weight loss failure after Roux-en-Y gastric bypass (RYGB) have been complex, underpowered, and lacking long-term data. We have previously shown that short-term (12-month) weight loss is achievable with laparoscopic adjustable gastric banding (LAGB) for failed RYGB. To report the midterm outcomes of LAGB after RYGB failure.

METHODS

A retrospective review of prospectively collected data before and after RYGB, when available, and before and after LAGB was performed at the New York Langone University Hospital (New York, NY). The data collected included weight, height, body mass index (BMI), gender, race, age, operative time, length of stay, postoperative complications, and the percentage of excess weight loss.

RESULTS

A total of 43 patients (9 men and 34 women) underwent LAGB after weight loss failure with RYGB. Of the 43 patients, 27 patients had undergone RYGB at other institutions, and preoperative RYGB data were available for 23 total patients. The average interval to LAGB was 6.6 years. The mean BMI before RYGB was 50.4 kg/m(2) and before LAGB was 43.3 kg/m(2) (%EWL was 17% after RYGB). At follow-up after LAGB, the average BMI was 35.2 kg/m(2), with a %EWL of 38% (calculated from LAGB only) at 26 months (range 6-66). At the 1- and 2-year follow-up visit, the BMI had decreased by 8.7 kg/m(2). The reoperation rate for complications related to LAGB was 10% and included 2 band erosions, 1 band slip, and 1 port flip.

CONCLUSION

The results of our study have shown that LAGB had good midterm data as a revisionary procedure for weight loss failure after RYGB.