The impact of roux limb length on weight loss after gastric bypass

Correlation of T2DM and Anthropometric Measures with Total Small Bowel Length and Its Effects on Diabetes Remission After Bariatric Surgery

BACKGROUND

The outcome of weight loss surgery is related to several factors, and for super-obese patients, the rate of weight loss failure and weight recovery after Roux-en-Y gastric bypass (RYGB) is high. Relevant studies have shown that the weight loss effect also correlates with total small bowel length (TSBL) and biliopancreatic (BP) and Roux limbs. However, there are few studies on the relationship between TSBL and anthropometric parameters, the BP limb, the Roux limb, and weight loss effect, and no relevant reports have been reported in China.

OBJECTIVES

The objective was to study the relationship between the total length of the small intestine and anthropometric parameters in the Chinese population. The effect of the Roux limb/biliopancreatic limb (RL/BPL) ratio on weight loss and diabetes remission in RYGB patients 1 year after surgery was evaluated to find the appropriate ratio relationship.

METHODS

In this prospective study, 148 patients between the ages of 19 and 68 years who underwent laparoscopic Roux-en-Y gastric bypass were enrolled. Height, weight, BMI, the BP limb, the Roux limb, fasting blood glucose (FBG), etc., were noted. To explore the correlation between the total length of the small intestine and these values. Subsequently, the 148 patients were followed up for 1 year after surgery. The patients diagnosed with T2DM before surgery were screened out, and 56 patients were finally identified according to the postoperative follow-up, in which BPL = 50 cm and RL = 150 cm, 175 cm, and 200 cm, respectively. RL/BPL was divided into 3, 3.5, and 4 groups according to the proportional relationship to explore the relationship between RL/BPL and diabetes remission and weight loss.

RESULTS

(1) The study included 148 patients (61 women and 87 men). The mean age was 35.68 ± 10.46 years, weight = 127.46 ± 34.51 kg, height = 167.83 ± 9.16 cm, BMI = 44.94 ± 10.58 kg/m2. The average TSBL value was 714.41 ± 101.08 cm. Linear regression analysis showed that TSBL was positively correlated with height, weight, neck circumference, chest circumference, waist circumference, and Roux limb. (2) Fifty-six patients with T2DM who were followed up 1 year after surgery were divided into three groups. Group 1: BPL = 50 cm, RL = 150 cm (n = 20); group 2: BPL = 50 cm, RL = 175 cm (n = 26); group 3: BPL = 50 cm, RL = 200 cm (n = 10); RL/BPL = 3 was associated with higher weight loss than the other groups. The remission rate of diabetes did not differ between the three groups.

CONCLUSIONS

TSBL was positively correlated with height, weight, neck circumference, chest circumference, waist circumference, and Roux limb. The TSBL of males was significantly higher than that of females. Among patients with T2DM who participated in the follow-up 1 year after surgery, RL/BPL = 3 (n = 20) had greater weight loss than the other groups.

Reappraisal of optimal reconstruction after distal gastrectomy - a study based on the KLASS-07 database

BACKGROUNDS

This study aimed to compare the incidence of bile reflux, quality of life (QoL), and nutritional status among Billroth II (BII), Billroth II with Braun anastomosis (BII-B), and Roux-en-Y (RY) reconstruction after laparoscopic distal gastrectomy (LDG).

MATERIALS AND METHODS

We reviewed the prospective data of 397 patients from a multicentre database who underwent LDG for gastric cancer between 2018 and 2020 at 20 tertiary teaching hospitals in Korea. Postoperative endoscopic findings, QoL surveys using the European Organization for Research and Treatment of Cancer questionnaire (C30 and STO22), and nutritional and surgical outcomes were compared among groups.

RESULTS

In endoscopic findings, bile reflux was the lowest in the RY group ( n =67), followed by the BII-B ( n =183) and BII groups ( n =147) at 1 year (3.0 vs. 67.8 vs. 84.4%, all P <0.05). The anti-reflux capability of BII-B was statistically better than that of BII, but not as perfect as that of RY. From the perspective of QoL, BII-B was not inferior to RY, but better than BII reconstruction in causing fewer STO22 reflux symptoms at 6 and 12 months. However, only RY caused fewer C30 nausea symptoms than BII at 6 and 12 months, but not BII-B. Nutritional status and morbidities were similar among the three groups, and the operative time did not differ between the BII-B and RY groups.

CONCLUSIONS

BII-B cannot substitute for RY in preventing bile reflux, shortening the operative time, or reducing morbidities. Regarding short-term QoL, BII-B was sufficient to reduce STO22 reflux symptoms but failed to reduce C30 nausea symptoms postoperatively.

Long Biliopancreatic Limb Roux-En-Y Gastric Bypass Versus One-Anastomosis Gastric Bypass: a Randomized Controlled Study

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is the gold standard in bariatric surgery. The one-anastomosis gastric bypass (OAGB) procedure, first introduced by Dr. Rutledge, has demonstrated a 25% greater weight loss efficiency than the traditional Roux-en-Y gastric bypass (RYGB) procedure due to the substantially longer biliopancreatic limb (BPL).

AIM OF THE STUDY

The current work aimed to compare the outcomes of OAGB and long BPL RYGB regarding weight loss and comorbidity resolution.

PATIENTS AND METHODS

This randomized controlled trial was done at our institution between September 2019 and January 2021. Patients who were candidates for bariatric surgery were randomly and equally allocated to two groups. Group A underwent OAGB, while group B underwent long BPL RYGB. Patients were followed up for 6 months postoperatively.

RESULTS

This study included 62 patients equally allocated to OAGB or long BPL RYGB, with no dropouts during follow-up. At 6 months, there was no statistically significant difference between the two groups regarding postoperative BMI (P = 0.313) and the EBWL (P = 0.238). There was comparable remission of diabetes mellitus (P = 0.708), hypertension (P = 0.999), OSA (P = 0.999), joint pain (P = 0.999), and low back pain (P = 0.999). Seven patients in the OAGB group experienced reflux symptoms (P = 0.011), which were managed by proton pump inhibitors.

CONCLUSION

Extending the BPL in RYGB provides weight loss and comorbidity remission comparable to that of OAGB. Some OAGB-related reflux cases remain a concern. However, they were sufficiently controlled with PPIs. Due to OAGB superior technical simplicity, long BPL RYGB should be preserved for cases whom are more risky for bile reflux.

American Society for Metabolic and Bariatric Surgery literature review on the effect of Roux-en-Y gastric bypass limb lengths on outcomes

This literature review is issued by the American Society for Metabolic and Bariatric Surgery regarding limb lengths in Roux-en-Y gastric bypass (RYGB) and their effect on metabolic and bariatric outcomes. Limbs in RYGB consist of the alimentary and biliopancreatic limbs and the common channel. Variation of limb lengths in primary RYGB and as a revisional option for weight recurrence after RYGB are described in this review.

Standard Biliopancreatic Limb (50 cm) Roux-en-Y Gastric Bypass Versus Long Biliopancreatic Limb (100 cm) Roux-en-Y Gastric Bypass in Patients with Body Mass Index 40-50 kg/m2: a Randomized Prospective Study

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is a widely performed procedure worldwide especially with the presence of associated medical conditions. Patients with body mass index (BMI) 40-50 kg/m² are at more risk of weight regain and relapse of comorbidities. There is a controversy on the optimum alimentary (AL) and biliopancreatic (BPL) limb lengths to be used in RYGB to achieve weight loss and remission of comorbidities without causing nutritional deficiencies in those patients.

STUDY DESIGN

hundred-and-fifty patients with BMI between 40 and 50 kg/m² were divided equally into 2 groups undergoing standard RYGB (S-RYGB) with AL:150 cm and BPL: 50 cm and long biliopancreatic RYGB (L-RYGB) with AL: 100 cm and BPL: 100 cm. BMI, % of total weight loss (%TWL), effect on diabetes (DM), hypertension (HTN), dyslipidemia, and nutritional statuses were recorded at 1, 2, and 3 years.

RESULTS

Only 64/75 patients in S-RYGB and 57/75 patients in L-RYGB completed the study. L-RYGB had faster weight loss, higher %TWL, and less BMI than S-RYGB with the maintenance of achieved weight. L-RYGB had better control of DM and dyslipidemia than S-RYGB. There were no significant differences in nutritional status between S-RYGB and L-RYGB rather than lower levels of calcium and Hb and higher levels of PTH in L-RYGB yet they remain within the normal range.

CONCLUSION

The application of L-RYGB helps in achieving faster weight loss for a longer period with better remission of associated comorbidities as DM, HTN, and dyslipidemia in patients with BMI 40-50 kg/m² but with effects on the nutritional status.

One Anastomosis Gastric Bypass Versus Long Biliopancreatic Limb Roux-en-Y Gastric Bypass

Background

Roux-en-Y gastric bypass (RYGB) is one of the most effective bariatric procedures. The study aimed to explore the value of lengthening the biliopancreatic limb (BPL) in RYGB compared to the outcome of one-anastomosis gastric bypass (OAGB).

Methods

This prospective study included morbidly obese patients divided into two groups. The RYGB group (n = 36) was subjected to long biliary limb Roux-en-Y gastric bypass (LPRYGB), and the OAGB Group (n = 36) had one anastomosis gastric bypass. During follow-up, weight, BMI, percentage of excess body weight loss (%EBWL), resolution of obesity-related comorbidities, and quality of life (QoL) were evaluated.

Results

There was no significant difference in weight and BMI after 3 and 6 months. At 12-month follow-up, weight loss was significantly higher in the OAGB group. After 12 months, the two groups showed significant improvement of comorbid conditions without significant difference between the two groups. The Qol was significantly higher in the LPRYGB group 3, 6, and 12 months after surgery compared to the OAGB group.

Conclusions

Extending the BPL length in RYGB to 150 cm is as effective as OAGB in remission of comorbidities, including diabetes. It was also equally effective in weight reduction in the short term. OAGB was more efficient in weight reduction and a significantly faster operation. LPRYGB showed a better QoL of life 1 year after surgery.

Graphical abstract

Revisional large gastric pouch with Roux-en-Y gastric bypass for patients with type 2 diabetes and a body mass index less than 35 kg/m2: a cause and effect analysis

PURPOSE

To evaluate the long-term efficacy of large gastric pouch surgery and revisional surgery in patients with a body mass index (BMI) < 35 kg/m² and type 2 diabetes mellitus (T2DM).

METHODS

We conducted a retrospective review of patients who underwent laparoscopic Roux-en-Y gastrojejunostomy with a large gastric pouch in our hospital. The clinical pre- and post-surgery data, including BMI, waist circumference, fasting plasma glucose (FPG), glycated hemoglobin (HbA1c), lipid metabolism-related indicators, homoeostatic model assessment of insulin resistance (HOMA-IR), and major complications, were recorded and analyzed.

RESULTS

Twenty-four patients were included in the analysis, 12 of whom underwent revisional surgery. At their 5-year-follow-up after the primary surgery, the BMI and waist circumference of the patients with T2DM were lower than their baseline values. The BMI, HbA1c, HOMA-IR, FPG and waist circumference also decreased after the revisional surgery. The rates of remission of diabetes after the primary vs. after the revisional surgery were 4.17% vs. 41.70%, respectively (P < 0.05).

CONCLUSION

Roux-en-Y gastrojejunostomy with a large gastric pouch is not effective in the long term and, therefore, is unsuitable for Chinese patients with T2DM and a BMI < 35 kg/m². Conversely, revisional surgery has a definite effect on these patients.

Short versus long biliopancreatic limb in Roux-en-Y gastric bypass surgery for treatment of type 2 diabetes mellitus

Introduction

Although laparoscopic Roux-en-Y gastric bypass (RYGB) is still widely accepted as a valid procedure in the treatment of obesity and type 2 diabetes mellitus (T2DM), there continues to be a significant controversy about how long the Roux and biliopancreatic limb should be bypassed for optimum results.

Aim

To assess the effect of a longer biliopancreatic limb (BPL) length on glycemic control after RYGB in T2DM patients.

Material and methods

Eighty-four patients with uncontrolled T2DM who underwent RYGB between May 2010 and April 2017 were collected from the prospectively designed database. Forty patients (S-BPL group) received BPL lengths ≤ 50 cm, including 30 cm (n = 1), 40 cm (n = 1), and 50 cm (n = 38). Forty-four patients (L-BPL group) received 100 cm BPL. Anthropometry, serum glucose and lipid metabolic parameters were measured at baseline and 1, 3, 6, 12, 24 and 36 months after surgery.

Results

Comparing the two groups, there were no significant differences in anthropometric and biochemical measures, except the weight and body mass index, which were higher in the S-BPL group (85.91 ±20.32 vs. 76.25 ±16.99, p = 0.038; 31.87 ±6.61 vs. 28.7 ±4.29, p = 0.005) compared to the L-BPL group. The body weight, glucose and lipid metabolic parameters decreased over time and then remained essentially stable from the first year in both groups. Two years after surgery, the remission (HbA_1c% ≤ 6%) of T2DM was 31.2% in the S-BPL group and 37.5% in the L-BPL group (p = 0.685).

Conclusions

With consistent total small bowel bypass (AL + BPL) lengths, lengthening of the BPL from 30 to 100 cm did not affect the post-RYGB glycemic control and weight loss.

Conventional Versus Distal Laparoscopic One-Anastomosis Gastric Bypass: a Randomized Controlled Trial with 1-Year Follow-up

BACKGROUND

There is no consensus on the ideal small bowel length that should be bypassed in laparoscopic one-anastomosis gastric bypass (OAGB). This study aimed to compare the safety and efficacy of conventional versus distal techniques of laparoscopic OAGB.

METHODS

This randomized controlled trial involved 60 adults with morbid obesity scheduled for laparoscopic OAGB randomly assigned to one of the two techniques; conventional technique (fixed anastomosis 200 cm from the ligament of Treitz) and distal technique (anastomosis 400 cm from the ileocecal valve). Total small bowel length (TSBL) was measured in all cases. Quality of life was assessed using the Gastrointestinal Quality of Life Index (GIQLI). Outcome measures were excess body weight loss percentage (EBWL%), resolution of associated comorbidities, frequency of nutritional deficiencies, and quality of life.

RESULTS

No patients were lost to follow-up. The two groups were comparable in TSBL, EBWL%, and complete resolution of comorbidities up to 12 months. The percentage of afferent loop length to TSBL was significantly higher in the distal group (p < 0.001) but was not correlated with EBWL%. The levels of hemoglobin, cholesterol, triglycerides, iron, and albumin were significantly lower and parathormone hormone was higher in the distal group. The GIQLI score was significantly higher in the conventional group during follow-up.

CONCLUSION

OAGB achieves optimum results when the afferent loop length is 200 cm; bypassing more than 200 cm does not improve weight loss or comorbidity resolution. Measuring TSBL is recommended to avoid excessive small bowel shortening that increases the risk of nutritional consequences.

Weight loss after one-anastomosis/mini-gastric bypass - The impact of biliopancreatic limb: A retrospective cohort study

Background

One-anastomosis/mini-gastric bypass (OAGB/MGB), as a popular bariatric surgery method, has many advantages; however, the biliopancreatic limb length (BPL) in this surgery is under debate. The aim of the study was to evaluate the effect of BPL on weight-loss outcome after OAGB/MGB.

Materials and Methods

A retrospective cohort study was performed on 653 patients who underwent OAGB/MGB with adjusted BPL based on preoperative body mass index (BMI) and patient's age, between 2010 and 2015 with 12-month follow-ups. Weight-loss outcomes and complications were analyzed in these patients, considering BPL.

Results

Weight, age, sex, and type 2 diabetes mellitus were the most contributory predictors as independent predictors of 12-month excess weight loss, respectively, and BPL was the least contributory predictor.

Conclusion

Tailoring BPL in OAGB/MGB based on patient's age and preoperative BMI seems to have acceptable results.

The role of alimentary and biliopancreatic limb length in outcomes of Roux-en-Y gastric bypass

Introduction

Roux-en-Y gastric bypass (RYGB) is one of the safe and easily reproducible bariatric procedures.

Aim

To evaluate the effect of biliopancreatic limb (BPL) and alimentary limb (AL) length on weight loss outcomes after RYGB.

Material and methods

This retrospective cohort study included 313 morbidly obese patients who underwent primary laparoscopic RYGB 2009–2015. Patients’ BPL and AL lengths were categorized into three groups: group 1 (BPL: 50 cm and AL: 150 cm), group 2 (BPL: 150 cm and AL: 50 cm), and group 3 (BPL: 100 cm and AL: 100 cm). Data were provided from the Iranian National Obesity Surgery Database. The generalized estimating equations method was used to assess the effect of limbs length on %excess weight loss (%EWL).

Results

Mean ± standard deviation age and body mass index (BMI) of 252 patients were 38.55 ±10.24 years and 45.8 ±4.77 kg/m², respectively. Totally, 172 (68.3%, BMI of 46 ±5 kg/m²), 48 (19%, BMI of 45.12 ±4.26 kg/m²), and 32 (12.7%, BMI of 45.43 ±4.23 kg/m²) were in group 1, 2, and 3, respectively (p = 0.44). The results showed that the choice of different limb lengths had no significant effect on %EWL over 12 months follow-up (p = 0.625) adjusted for baseline BMI (p = 0.25). Mean %EWL in the patients with longer BPL and shorter AL was 5.43% (1.91, 8.95) higher in comparison to the patients with shorter BPL and longer AL during 36 months postoperatively adjusted for baseline BMI (p = 0.002).

Conclusions

During 12 months after RYGB, %EWL was not associated with BPL or AL length. However, during 36 months postoperatively, the patients with longer BPL had a significantly higher %EWL in comparison to the patients with shorter BPL.

Factors Mediating Type 2 Diabetes Remission and Relapse after Gastric Bypass Surgery

BACKGROUND

Defining factors associated with remission and relapse of type 2 diabetes (T2D) after Roux-en-Y gastric bypass (RYGB) can allow targeting modifiable factors. We investigated factors associated with T2D remission and relapse after RYGB.

STUDY DESIGN

We conducted a retrospective review of consecutive patients with T2D who underwent RYGB between 1993 and 2017. T2D remission was defined as medication discontinuation and/or hemoglobin A1c <6.5%. Relapse was defined as recurrence medication use and/or hemoglobin A1c ≥6.5%. Independent correlates of T2D remission and relapse were identified using logistic regression.

RESULTS

Six hundred and twenty-one patients (aged 46.7 ± 10.6 years; 30% on insulin; BMI 49.8 ± 8.3 kg/m²) had at least 1-year follow-up. Median follow-up was 4.9 years (range 1 to 23.6 years). Prevalence of T2D remission was 74% at 1 year, 73% from 1 to 3 years, 63% between 3 and 10 years, and 47% beyond 10 years. Ninety-three percent of remissions occurred within 3 years of RYGB, 25% relapsed. Median time to relapse was 5.3 years (interquartile range 3 to 7.8 years) after remission. Higher 1-year percentage total body weight loss, lack of preoperative insulin use, and younger age at operation were independently associated with T2D remission. Preoperative insulin use, lower percentage total body weight loss at 1 year, and greater percentage total body weight regain after 1 year were independently associated with T2D relapse.

CONCLUSIONS

This longitudinal retrospective analysis shows that preoperative insulin use and age, 1-year weight loss, and regain after that influence T2D remission and relapse after RYGB. Referring patients at a younger age, before insulin is needed, and optimizing weight loss and preventing weight regain after RYGB can improve the rates and durability of T2D remission.

Whether a Short or Long Alimentary Limb Influences Weight Loss in Gastric Bypass: a Systematic Review and Meta-Analysis

Roux-en-Y gastric bypass, the most commonly performed procedure in bariatric surgery, still lacks a consensus on whether alimentary limb length (ALL) influences weight loss. Studies were identified by searching multiple electronic databases. Studies with enough data including body mass index (BMI) loss and percent excess weight loss (% EWL) were eligible. The statistical analysis was performed with Stata 14.0. In total, eight studies with 1714 patients were included. The meta-analysis suggested that short ALLs weakened the efficacy of Roux-en-Y gastric bypass in terms of BMI loss (standard mean deviation (SMD), - 0.33 [95% confidence intervals (CI), - 0.60, - 0.05], p = 0.021) with 3 years of follow-up and % EWL (SMD, - 0.17 [95% CI, - 0.31, - 0.04], p = 0.013) with 2 years of follow-up. The subgroup analysis demonstrated that the group with a BMI ≥ 50 kg/m² had a significant SMD between the use of short and the standard ALLs (- 0.71 [95% CI, - 1.07, - 0.35], p = 0.000), while the subgroup with a BMI < 50 kg/m² (SMD, - 0.29 [95% CI, - 0.78, 0.20], p = 0.247) did not. Compared with a standard ALL (130-150 cm), a short ALL (40-100 cm) may reduce the efficacy of the Roux-en-Y gastric bypass surgery, while a long ALL (170-250 cm) did not significantly improve the effects in terms of BMI loss and % EWL. In addition, a potential view of the meta-analysis indicated patients with a BMI < 50 kg/m² might get more benefits with a short ALL, while those patients with a BMI ≥ 50 kg/m² might benefit more from a standard ALL.

Proximal Roux-en-Y gastric bypass: Addressing the myth of limb length

BACKGROUND

Some studies suggest that changes in weight or metabolic outcomes are affected by the lengths of the gastrointestinal limbs in the Roux-en-Y gastric bypass.

METHODS

Participants (N = 1,770) underwent primary Roux-en-Y gastric bypass and were followed ≤7 years in the Longitudinal Assessment of Bariatric Surgery-2, a multicenter US cohort study. Alimentary limb and biliopancreatic limb lengths were measured according to research protocol; common channel was measured in a subsample (N = 547). Aimentary limb, biliopancreatic limb, and common channel ratio to total small bowel length were calculated.

RESULTS

Median presurgery body mass index was 46 (25th-75th percentile: 43-51) kg/m2. Medians (25th-75th percentiles) for alimentary limb length were 125 cm (100-150), for biliopancreatic limb length were 50 cm (50-60), and common channel length were 410 cm (322-520). Statistics for ratios to the small bowel length were 0.23 (0.18-0.27) for alimentary limb, 0.09 (0.07-0.10) for biliopancreatic limb, and 0.69 (0.63-0.73) for common length. There were no significant associations between alimentary limb, biliopancreatic limb, common channel, alimentary limb ratio, biliopancreatic limb ratio or common channel ratio, and either weight loss or improvement in cardiometabolic outcomes.

CONCLUSION

The common channel length in Roux-en-Y gastric bypass is highly variable between individuals. None of the limb lengths in this study, nor alimentary limb, biliopancreatic limb, or common channel ratios, seem to be related to weight loss or metabolic improvements >7 years.

Long-limb length difference had no effect on outcomes of laparoscopic Roux-en-Y gastric bypass surgery for obese Chinese patients with type 2 diabetes mellitus: A CONSORT compliant article

Bariatric surgery is effective in treating different components of metabolic syndrome including obesity, type 2 diabetes mellitus (T2DM), and hyperlipidemia. But there is no consensus on the ideal biliopancreatic and Roux limb length. This study aimed to explore the effect of biliopancreatic limb and Roux limb lengths during laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures on weight loss and T2DM control.We studied the clinical records of 58 patients with metabolic syndrome, T2DM, and body mass index (BMI) 32 to 50 kg/m who underwent LRYGB in our hospital. The short limb group (Group A) underwent LRYGB with a limb length of 160 to 200 cm (n = 31) and the long limb group (Group B) underwent LRYGB with a limb length of 210 to 240 cm (n = 27) were compared.The occurrence of acute or chronic internal hernia in Group B was higher than that in Group A (P = .026). Twelve months after surgery, patients from the 2 groups were also observed with reduction in BMI, percent excess weight loss (EWL), preoperative FPG, and HbA1c as compared with these indicators before surgery. However, the differences of these indicators between 2 groups were not significant at the time point of before and 3, 6, 12 months after surgery.LRYGB had significant effects on weight loss and diabetes control in obese T2DM patients. However, there was no significant difference in the short term on weight loss and diabetes control in the patients receiving different limb lengths.

Mechanisms of Action of Surgical Interventions on Weight-Related Diseases: the Potential Role of Bile Acids

Surgical interventions for weight-related diseases (SWRD) may have substantial and sustainable effect on weight reduction, also leading to a higher remission rate of type 2 diabetes (T2D) mellitus than any other medical treatment or lifestyle intervention. The resolution of T2D after Roux-en-Y gastric bypass (RYGB) typically occurs too quickly to be accounted for by weight loss alone, suggesting that these operations have a direct impact on glucose homeostasis. The mechanisms underlying these beneficial effects however remain unclear. Recent research suggests that changes in the concentrations of plasma bile acids might contribute to these metabolic changes after surgery. In this review, we aimed to outline the potential role of bile acids in SWRD. We systematically reviewed MEDLINE, SCOPUS, and Web of Science for articles reporting the effect of SWRD on outcomes published between 1969 and 2016. We found that changes in circulating bile acids after surgery may play a major role through activation of the farnesoid X receptor A (FXRA), the fibroblast growth factor 19 (FGF19), and the G protein-coupled bile acid receptor (TGR5). Bile acid concentration increased significantly after RYGB. Some studies suggest that a transitory decrease occurs at 1 week post-surgery, followed by a gradual increase. Most studies have shown the increase to be proportionate by all bile acid subtypes. Bile acids can regulate glucose metabolism through the expression of TGR5 receptor in L cells, resulting in a release of glucagon-like peptide 1 (GLP-1). It may also induce the synthesis and secretion of FGF19 in ileal cells, thereby improving insulin sensitivity and regulating glucose metabolism. All the present SWRD are involved with changes in food stimulation to the stomach. This implies that discovering and developing the antagonists to TGR5 and FXRA may effectively control metabolic syndrome and the elucidation of the mechanisms underlying the physiological effects related to weight loss and T2D remission after surgery may help to identify new drug targets.

Small Bowel Limb Lengths and Roux-en-Y Gastric Bypass: a Systematic Review

There is currently no consensus on the combined length of small bowel that should be bypassed as biliopancreatic or alimentary limb for optimum results with Roux-en-Y gastric bypass. A number of different limb lengths exist, and there is significant variation in practice amongst surgeons. Inevitably, this means that some patients have too much small bowel bypassed and end up with malnutrition and others end up with a less effective operation. Lack of standardisation poses further problems with interpretation and comparison of scientific literature. This systematic review concludes that a range of 100-200 cm for combined length of biliopancreatic or alimentary limb gives optimum results with Roux-en-Y gastric bypass in most patients.

A short or a long Roux limb in gastric bypass surgery: does it matter?

BACKGROUND

The Roux-en-Y gastric bypass (RYGB) still remains the gold standard in bariatric surgery. However, no consensus exists on the optimal limb lengths to induce maximum weight reduction. The aim of the present study was to assess the effect of a longer alimentary limb (AL) length on weight reduction after RYGB.

METHODS

A retrospective analysis of a prospectively collected database of patients who underwent a primary laparoscopic RYGB between January 2001 and March 2011 was performed. Patients received a short AL (SAL; 100 cm) or a long AL (LAL; 150 cm). Primary outcome was weight loss, and secondary outcomes were short- and long-term complication rates.

RESULTS

A total of 768 patients received a RYGB during the study period. Of these, 730 consecutive patients were included for long-term analysis and had a mean follow-up (FU) of 37 ± 26 [range 0-120] months; 360 (47 %) patients received a SAL RYGB. Overall %TBWL was 33 ± 9 % after 2 years (FU 74 %) and 28 ± 12 % after 5 years (FU 20 %). No significant differences in %TBWL were found between SAL RYGB and LAL RYGB during the study period. The 30-day mortality rate was 0.13, 9 % overall short-term complication rate and 19 % cumulative long-term complication rate. No differences in complications were found between SAL and LAL RYGB patients.

CONCLUSION

Lengthening of the alimentary limb from 100 to 150 cm did not affect post-RYGB weight loss. Overall complication rates were low and comparable in this series of RYGB patients.

Perioperative Outcomes of Proximal and Distal Gastric Bypass in Patients with BMI Ranged 50-60 kg/m(2)--A Double-Blind, Randomized Controlled Trial

Background

Proximal Roux-en-Y gastric bypass may not ensure adequate weight loss in superobese patients. Bypassing a longer segment of the small bowel may increase weight loss. The objective of the study was to compare the perioperative outcomes of laparoscopic proximal and distal gastric bypass in a double-blind randomized controlled trial of superobese patients. The study was conducted at two public tertiary care obesity centers in Norway.

Methods

Patients with body mass index (BMI) 50–60 kg/m² were randomly assigned to a proximal (150 cm alimentary limb) or a distal (150 cm common channel) gastric bypass. The biliopancreatic limb was 50 cm in both operations. Patients and follow-up personnel were blinded to the type of procedure. Thirty-day outcomes including complications are reported.

Results

We operated on 115 patients, of whom two were excluded at surgery, leaving 56 and 57 patients in the proximal group and distal group, respectively. The median (range) operating time was 72 (36–151) and 101 (59–227) min, respectively (p < 0.001). Two distal procedures were converted to laparotomy during the primary procedure. Median length of hospital stay was 2 (1–4) days in the proximal group and 2 (1–24) days in the distal group. The number of patients with complications and complications categorized according to the Contracted Accordion classification did not differ significantly. However, all six reoperations were performed in the distal group, of which three were completed by laparoscopy (p = 0.01 between groups). There were no deaths.

Conclusions

In superobese patients with BMI between 50 and 60 kg/m², distal gastric bypass was associated with longer operating time and more severe complications resulting in reoperation than proximal gastric bypass.

EFFECT OF SIZE OF INTESTINAL DIVERSIONS IN OBESE PATIENTS WITH METABOLIC SYNDROME SUBMITTED TO GASTRIC BYPASS

Background:

There is no consensus on the ideal size of intestinal loops in gastric bypass of bariatric surgeries.

Aim:

To evaluate the metabolic outcome of patients submitted to gastric bypass with alimentary and biliopancreatic loops of different sizes.

Methods:

Was conducted a retrospective cohort study in diabetic obese patients (BMI≥35 kg/m²⁾ with metabolic syndrome submitted to gastric bypass. The patients were divided into three groups according to the size of the intestinal loop: group 1, biliopancreatic limb 50 cm length and alimentary limb 100 cm length; group 2 , biliopancreatic limb 50 cm length and alimentary limb 150 cm length; and group 3, biliopancreatic limb 100 cm length and alimentary limb 150 cm length. The effect of gastric bypass with different sizes of intestinal loops in relation to the parameters that define metabolic syndrome was determined.

Results:

Sixty-three patients were evaluated, and they had a mean age of 44.7±9.4 years. All were diabetics, with 62 (98.4%) being hypertensive and 51 (82.2%) dyslipidemic. The three groups were homogeneous in relation to the variables. In 24 months, there was a remission of systemic arterial hypertension in 65% of patients in group 1, 62.5% in group 2 and 68.4% in group 3. Remission of diabetes occurred in 85% of patients in group 1, 83% in group 2 and 84% in group 3. There was no statistical difference in %LEW between the groups, and waist measurements decreased in a homogeneous way in all groups. The size of loops also had no influence on the improvement in dyslipidemia.

Conclusion:

Variation in size of intestinal loops does not appear to influence improvement in metabolic syndrome in this group of patients.

Gastric bypass with long alimentary limb or long pancreato-biliary limb--long-term results on weight loss, resolution of co-morbidities and metabolic parameters

Background

Several studies indicate that increasing the alimentary limb length in gastric bypass surgery produces only a minor improvement of excess BMI loss. Few studies have addressed the efficacy of increasing the length of the pancreatico-biliary limb.

Methods

Here, we present a prospective randomized study of 187 consecutive laparoscopic Roux-Y gastric bypass operations operated over 2 years (2004–2005) in Iceland. The patients were operated with a gastric bypass with either a 2-m biliopancreatic (BP)-limb and a 60-cm alimentary (A)-limb (n = 93) or with a 150-cm A-limb and a 60-cm BP-limb (n = 94).

Results

Preoperative median BMI was 44.1 (38–70), median age 35.5 (17–74) years, and 85 % of the patients were female. Follow-up rate after 5 years was 85 %. Eighteen months following surgery, the weight loss was significantly higher in the BP-limb group (p < 0.001), and this difference remained 7 years after surgery. Weight regain occurred in both groups, and 7 years after surgery, excess BMI loss (EBMIL) was 78.4 % in the BP-limb group compared to 67.1 % in the A-limb group (p < 0.001). Most patients (78 %) needed supplementation adjustment (iron, vitamin D and calcium) during the study period, significantly more often in the BP-limb group compared to the A-limb group (p < 0.001). Patients in the BP-limb group had more frequent stools than patients in the A-limb group; otherwise, gastro-intestinal symptoms rating scoring were comparable. Complication rate was similar.

Conclusions

Gastric bypass with a 2-m BP-limb gives better weight loss than gastric bypass with a 60-cm BP-limb and a 150-cm A-limb. Metabolic follow-up is of utmost importance, as most patients needed repeated adjustments of their supplementation.

Laparoscopic gastric bypass vs. sleeve gastrectomy in the super obese patient: early outcomes of an observational study

BACKGROUND

Super obesity [body mass index (BMI) > 50 kg/m2] can yield to higher morbidity/mortality in bariatric surgery, this could be related to patient's characteristics and/or surgeon's experience. In morbid obesity, both techniques proved to have a positive impact and sometimes comparable outcomes during the first 2 years. This has not been clearly analyzed in the super obese patient.

METHODS

Retrospective study comparing the records of 77 consecutive super obese patients (BMI: 50-59.9 kg/m2) submitted to either laparoscopic gastric bypass (LGBP, n = 32) or laparoscopic sleeve gastrectomy (LSG, n = 45) between 2010 and 2012 at a single institution. The primary objective was to analyze baseline demographics, comorbidities, operative outcomes, and early complications (<30 days). Secondarily, weight loss [BMI and % excess weight loss (%EWL)] was also described and compared during the first year.

RESULTS

Female sex comprised 72.7 % of all cases. Both groups had comparable BMI (52.7 ± 2.1 kg/m2 for LGBP vs. 53.87 ± 2.8 kg/m2 for LSG; p = 0.087) and homogeneous baseline characteristics. Operative time was lower for the LSG group (113.1 ± 35.3 vs. 186.9 ± 39 min for LGBP; p ≤ 0.001). Overall, early complications were observed in 16.8% of patients (LGBP 9% vs. LSG 22%; p = 0.217). There were four major complications (two in each group), with two reinterventions. Weight loss (%EWL) at 6, 9, and 12 months was significantly higher in the LGBP group (51.6 ± 12.9%, 56.5 ± 13%, 63.9 ± 13.3%, respectively) than in the LSG group (40 ± 12.8%, 45.1 ± 15.5%, 43.9 ± 10.4%, respectively).

CONCLUSIONS

Just like in morbid obesity, LGBP and LSG are effective and safe procedures in super obese patients. LGBP had better weight loss at 1 year.

Bowel length: measurement, predictors, and impact on bariatric and metabolic surgery

BACKGROUND

Small bowel length (SBL) determines the caloric absorptive capacity. The aim of this study was to evaluate SBL to identify patient-specific predictors and the interrelationships of SBL with anthropometric variables.

METHODS

Sex, age, and weight were recorded at the time of surgery when SBL and the estimated jejunal length (JLe) were measured by 3 different methods.

RESULTS

The mean SBL of 443 patients undergoing laparotomy (78% female) was 690±93.7 cm (range 350-1049 cm). Sex was correlated with SBL, as men had a longer small bowel than women (729±85 versus 678±92, P<.0001) and were significantly taller (173±8.2 versus 161±6.9, P<.001). Age did not correlate with SBL. The differences in length between fully stretched small bowel and nonstretched small bowel and between fully stretched small bowel and laparoscopic bowel were 137±19 cm and 32.4±11.4 cm, respectively. In a multivariate linear regression analysis model that included sex, age, height, and weight, only height was significantly correlated with SBL (P<.00001) and explained 12% of the variance in SBL. Sex, age, height, and JLe, but not SBL, were statistically highly significant in predicting 75% of the variance of body weight.

CONCLUSIONS

A positive association between height and SBL was found. Sex, age, height, and JLe may be strong predictors of weight. Individual JLe may be of importance in determining the weight loss and resolution of metabolic co-morbidities. Measuring the SBL can prevent the risk of nutritional consequences in malabsorptive, revisional, and metabolic procedures.

Revisional surgery after failed gastric banding: results of one-stage conversion to RYGB in 195 patients

BACKGROUND

The most performed restrictive bariatric procedure is the laparoscopic adjustable gastric band (LAGB). With many patients still receiving a LAGB in Europe and the United States, inevitably, the number of complications also increases. For many complications revisional bariatric surgery is necessary. In this study, the outcomes of one-stage LAGB conversion to a Roux-en-Y gastric bypass (RYGB) at our institution are presented. The objective of this study was to investigate the safety and efficiency of RYGB performed as a one-stage procedure after failed LAGB.

METHODS

Patients were retrospectively selected using a prospectively collected database. The gastric band had to be in situ for at least 1 year and minimum postoperative follow-up was 12 months. The revisional RYGB had to be performed as a 1-step procedure.

RESULTS

A total of 195 patients were included while 3 were lost to follow up. Overall, 178 (91%) procedures were performed without perioperative complications, and only 8 (4%) patients required reoperation within 30 days. The mean follow-up was 40 months (±24) after RYGB. Mean excess weight loss (EWL) increased from 25% (±26/-50- 120%) to 60% (±21.2/0- 130), 65% (±23.5/0- 131), 63% (±24.2/2- 132), 60% (±24.1/0- 111) and 53% (±28.7/-39- 109) in the first 5 postoperative years.

CONCLUSION

Converting a gastric band to a RYGB in a one-stage procedure is safe and feasible, with acceptable complication rates when performed in a specialized institution. The RYGB conversion results in a good EWL of 65% after 2 years. However, proper patient selection is of the utmost importance.

Fasting glycemia: a good predictor of weight loss after RYGB

BACKGROUND

Preoperative prediction of weight loss after Roux-en-Y gastric bypass (RYGB) could help surgeons in managing surgical lists and patients' expectations. The objective of this study was to understand if preoperative metabolic control might improve surgical results.

METHODS

Prospective cohort of 163 consecutive patients who underwent RYGB with at least 1 year of follow-up.

RESULTS

Most patients were female (90.2%), with a mean age of 38 (19-60) and a BMI of 46.0 (34.3-59.9) kg/m(2). After 12 months, the mean body mass index (BMI) was 29.7 kg/m(2) (21.5-39.9) with a corresponding percentage of excess weight lost (%EWL) of 78.8% and a percentage of weight loss (%WL) of 35.1%. Patients with the highest preoperative fasting blood glucose (FBG) were older (42 versus 36; P<.001); were more likely to have type 2 diabetes (T2 DM, 40% versus 6.8%; P<.001) and metabolic syndrome (89% versus 25%; P<.001), had a slightly higher BMI (30.8 versus 29.3 kg/m(2); P = .03), and had achieved a significantly lower %EWL and %WL at 12 months (72.5% versus 81.2%; P = .004; 33.2 versus 35.9%; P = .03, respectively). We observed a dose-response effect with increasing FBG (<85 mg/dL, 85-100 mg/dL, and ≥ 100 mg/dL, respectively), with 83.5%, 80.0%, and 72.5% (P = .009) of %EWL at 12 months. By multivariate logistic regression, initial BMI and FBG>100, were the only variables related (inversely) with the probability of achieving a %EWL>80 or %WL>35. This effect was not detected in patients receiving oral antidiabetic medications.

CONCLUSION

Higher preoperative FBG is independently related to a poorer weight loss 12 months after RYGB; this suggests the need to offer earlier surgical intervention for severely obese patients with impairment of glucose metabolism. The potential for less weight loss in patients with a higher FBG should not discourage RYGB, given the significant metabolic improvement after surgery.

Postoperative Body Mass Index Changes in Gastric Cancer Patients according to Reconstruction Type: Effectiveness of Long Jejunal Bypass on Weight Loss in Obese Patients after Distal Gastrectomy

The aim of this study was to investigate and compare the change of body mass index (BMI) in patients after gastrectomy for cancer according to the type of reconstruction. BMI was followed in 260 patients who had undergone curative surgery for gastric cancer from March 2003 to December 2009. The procedures were Billroth I in 63 patients, Billroth II in 52 patients, Roux-en-Y in 54 patients, long Roux-en-Y (bypassed proximal jejunum over 100 cm) in 47 patients, and total gastrectomy in 44 patients. BMI reduction was greatest in the total gastrectomy group at postoperative 6 months, 1 year, and 2 years. Postoperative 3-year BMI reduction was greatest in the long Roux-en-Y group. BMI reductions of the total gastrectomy and long Roux-en-Y groups were similar during the follow-up period. Among the subtotal gastrectomy groups, BMI reduction was greatest in the long Roux-en-Y group, and there was statistical significance in comparing with Billroth I and II groups, but no statistical difference with the Roux-en-Y group. Given the limitations of patient number and follow-up period, it can be concluded that obese patients with gastric cancer not requiring total gastrectomy may benefit from long Roux-en-Y reconstruction with adequate BMI reduction and accompanying health improvement.

Revision of failed bariatric procedures to Roux-en-Y gastric bypass (RYGB)

Bariatric surgery for morbid obesity has been established as an effective treatment method and has been shown to be associated with resolution of co-morbidities. Despite its success, some patients may require revision because of weight regain or mechanical complications. From September 2005 to December 2009, 42 patients underwent revisional Roux-en-Y gastric bypass (RYGB). All procedures were performed by one surgeon. Demographics, indications for revision, complications, and weight loss were reviewed. Thirty-seven patients were treated with laparoscopic (n = 36) or open (n = 1) RYGB after failed laparoscopic adjustable gastric banding. Four patient were treated with laparoscopic (n = 3) or open (n-1) RYGB after failed vertical banded gastroplasty, and one patient underwent open redo RYGB due to large gastric pouch. Conversion rate from laparoscopy to open surgery was 2.5% (one patient). Mean operative time was 145.83 ± 35.19 min, and hospital stay was 3.36 ± 1.20 days. There was no mortality. Early and late complications occurred in six patients (14.2%). The mean follow-up was 15.83 ± 13.43 months. Mean preoperative body mass index was 45.15 ± 7.95 that decreased to 35.23 ± 6.7, and mean percentage excess weight loss was 41.19 ± 20.22 after RYGB within our follow-up period. RYGB as a revisional bariatric procedure is effective to treat complications of restrictive procedures and to further reduce weight in morbidly obese patients.

Is weight loss better sustained with long-limb gastric bypass in the super-obese?

BACKGROUND

While some studies have shown that long-limb gastric bypass with Roux limb length of 150 to 200 cm can attain better weight loss outcomes in super-obese patients (BMI >50 kg/m(2)) than the standard limb gastric bypass with Roux limb length of 100 to 150 cm, other studies have not shown similar findings. Additionally, no study has demonstrated the optimal length of the Roux limb that will result in ideal weight loss. The purpose of this study is to compare the long-term weight loss and weight regain of standard limb length (SLL) and long limb length (LLL) gastric bypass in patients with BMI >50 kg/m(2).

METHODS

A total of 120 patients with BMI >50 kg/m(2) underwent either SLL (total bypass length = 200, biliopancreatic limb = 50-80 cm, Roux limb = 120-150 cm) or LLL (total bypass length = 250 biliopancreatic limb = 50-80 cm, Roux limb = 170-200 cm) RYGB. The excess weight loss (EWL), the weight regain, and the rate of complications were measured at 1-, 2-, and 3-year follow-up. Statistical comparisons were performed using t-test.

RESULTS

There was no difference in patient demographics, pre-operative BMI, or comorbidities between the two groups: SLL (n = 55) and LLL (n = 65). In comparing standard- to long-limb cohorts, preoperative BMI was 56.1 ±5.34 vs. 57.5 ± 6.05 kg/m(2), respectively. There was no statistical difference in percent EWL at 1, 2, and 3 years between the two groups [55.2 vs. 55 (P = 0.933), 61.5 vs. 60.8 (P = 0.831), and 61.1 vs.60 (P = 0.932)]. There was no difference in percent weight regain between the two groups, 11.2 (SLL) and 5.2 (LLL) (P = 0.13). The rates of complications were similar in the two groups.

CONCLUSION

There is no difference in weight loss or weight regain between the SLL and LLL RYGB. Longer-limb gastric bypass is not required in patients with BMI >50 kg/m(2) for them to obtain long-term, sustained weight loss.

Short versus long Roux-limb length in Roux-en-Y gastric bypass surgery for the treatment of morbid and super obesity: a systematic review of the literature

Because of an important burden of disease, obesity is a major public health challenge in the twenty-first century. Where medico-psychological management has shown its limitations, bariatric surgery is now acknowledged as the most efficient therapy potentially offered to severely obese patients. Among other options, Roux-en-Y gastric bypass (RYGBP) is the most frequently performed procedure. The objective of this review is to systematically evaluate the effect of the Roux- (alimentary) limb length on postoperative weight loss after RYGBP in severely obese patients. MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched using terms related to Roux-limb, gastric bypass and obesity. To be included, studies had to be either randomized controlled trials, quasi-randomized controlled trials or prospective cohort studies comparing a shorter to a longer Roux-limb. Studies were critically appraised with regard to methodological components. Eight studies were reviewed. Variations in methodology, operation design and outcome assessment among studies caused considerable clinical heterogeneity, preventing us from performing a meta-analysis. The overall quality was questionable, owing to lack of rigor in methodological components reporting. Results were heterogeneous, but we identified a trend supporting that the construction of a longer Roux-limb is more efficient in super obese patients. This review suggests that the tailoring of a longer Roux-limb might only be efficient in super obese patients. The overall limited quality of the included studies prompts to call for improvement in trial design in surgery.

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.

Prediction of severe complicatons and death in superobese patients undergoing open gastric bypass with the Recife Score

CONTEXT: Superobese patients who undergo gastric bypass have a greater incidence of complications. The greater incidence of comorbidity in this group leads to a higher surgical risk, and a need for special care. By analyzing the risk factors identified in the preoperative period, scoring them, constructing a score and assessing the occurrence of serious complications and death, we will have elements to identify which patients are at greater risk. OBJECTIVE: To determine the accuracy of the Recife Score for predicting serious postoperative complications and death in superobese patients who undergo Roux-en-Y gastric bypass surgery by the conventional method. METHODS: An ambidirectional study was conducted to validate the diagnostic test on 203 severely obese patients submitted to Roux-en-Y gastric bypass at the Hospital das Clínicas of the Federal University of Pernambuco, Recife, PE, Brazil, from September 1997 to May 2007. The dependent variables were major postoperative complications and death. The independent variable was the Recife Score. The data were analyzed using the Epi-Info 3.5.1 program. The accuracy of the Recife Score was analyzed considering the following parameters: sensitivity, specificity, positive predictive value, negative predictive value, positive verisimilitude ratio and negative verisimilitude ratio. RESULTS: The accuracy of the Recife Score with cut-off points higher than 3 and higher than 5 to predict serious postoperative complications was, respectively, a frequency of complications of 12.3%, with a risk ratio of 2.83, sensitivity of 57.1% and specificity of 69.8%, and 12.5%, with a risk ratio of 1.88, sensitivity of 7.1% and specificity of 96.3%. The accuracy of the Recife Score with cut-off points higher than 3 and higher than 5 to predict death was, respectively, a frequency of death of 7.7%, with a risk ratio of 10.62, sensitivity of 83.3% and specificity of 69.5%, and 12.5%, with a risk ratio of 4.88, sensitivity of 16.7% and specificity of 96.5%. CONCLUSION: A Recife Score >3 prior to conventional gastric bypass presents a high level of accuracy in the prediction of serious postoperative complications and death.

Mortality, weight loss and quality of life of patients with morbid obesity: evaluation of the surgical and medical treatment after 2 years

CONTEXT: The surgical treatment for morbid obesity is becoming common in this country. Only a few papers reported the long-term results of the surgical approach for morbid obesity, mainly in terms of quality of life. OBJECTIVE: To compare mortality rate, weight loss, improvement of both diabetes and hypertension, and quality of life of patients from the public healthcare in Cuiabá, MT, Brazil, who underwent either medical or surgical interventions after a minimum of 2 years. METHODS: The population of this study was constituted by morbidly obese patients who initiated treatment between June 2002 and December 2006. The casuistic consisted of 89 patients submitted to medical therapy and 76 patients who underwent surgical procedures. The main variables were weight loss, improvement of hypertension and diabetes, quality of life, and mortality. RESULTS: The overall results showed that weight loss was significant in the two groups (P<0.001); however surgical patients showed a greater loss than the medical group (P = 0.05). The improvement of diabetes and hypertension was significantly greater in the surgical group (P<0.001), in which no cases of diabetes persisted. There was an increase in cases of hypertension among patients receiving medical attention. Mortality occurred in six cases (6.7%) of the medical group and in five cases (6.6%) of the surgical group (P = 0.97). The median grade of the quality of life score obtained by surgical patients (2.37 [range: -2.50 to 3.00]) was significantly greater (P<0.001) when compared to the medical group (1.25 [range: -1.50 to 3.00]). CONCLUSION: The surgical group presented better results regarding the weight loss, quality of life and improvement of hypertension and diabetes. There was no significant difference in mortality rate between the two groups after a minimum of 2 years.

Randomized clinical trial of laparoscopic gastric bypass versus laparoscopic duodenal switch for superobesity

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic biliopancreatic diversion with duodenal switch (LDS) are surgical options for superobesity. A randomized trial was conducted to evaluate perioperative (30-day) safety and 1-year results.

METHODS

Sixty patients with a body mass index (BMI) of 50-60 kg/m(2) were randomized to LRYGB or LDS. BMI, percentage of excess BMI lost, complications and readmissions were compared between groups.

RESULTS

Patient characteristics were similar in the two groups. Mean operating time was 91 min for LRYGB and 206 min for LDS (P < 0.001). One LDS was converted to open surgery. Early complications occurred in four patients undergoing LRYGB and seven having LDS (P = 0.327), with no deaths. Median stay was 2 days after LRYGB and 4 days after LDS (P < 0.001). Four and nine patients respectively had late complications (P = 0.121). Mean BMI at 1 year decreased from 54.8 to 38.5 kg/m(2) after LRYGB and from 55.2 to 32.5 kg/m(2) after LDS; percentage of excess BMI lost was greater after LDS (74.8 versus 54.4 per cent; P < 0.001).

CONCLUSION

LRYGB and LDS can be performed with comparable perioperative safety in superobese patients. LDS provides greater weight loss in the first year.

Factors associated with weight loss after gastric bypass

BACKGROUND

Gastric bypass (GBP) is the most common operation performed in the United States for morbid obesity. However, weight loss is poor in 10% to 15% of patients. We sought to determine the independent factors associated with poor weight loss after GBP.

DESIGN

Prospective cohort study. We examined demographic, operative, and follow-up data by means of multivariate analysis. Variables investigated were age, sex, race, marital and insurance status, initial weight and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared), comorbidities (diabetes mellitus, hypertension, joint disease, sleep apnea, hyperlipidemia, and psychiatric disease), laparoscopic vs open surgery, gastric pouch area, gastrojejunostomy technique, and alimentary limb length.

SETTING

University tertiary referral center.

PATIENTS

All patients at our institution who underwent GBP from January 1, 2003, through July 30, 2006.

MAIN OUTCOME MEASURES

Weight loss at 12 months defined as poor (< or =40% excess weight loss) or good (>40% excess weight loss).

RESULTS

Follow-up data at 12 months were available for 310 of the 361 patients (85.9%) undergoing GBP during the study period. Mean preoperative BMI was 52 (range, 36-108). Mean BMI and excess weight loss at follow-up were 34 (range, 17-74) and 60% (range, 8%-117%), respectively. Thirty-eight patients (12.3%) had poor weight loss. Of the 4 variables associated with poor weight loss in the univariate analysis (greater initial weight, diabetes, open approach, and larger pouch size), only diabetes (odds ratio, 3.09; 95% confidence interval, 1.35-7.09 [P = .007]) and larger pouch size (odds ratio, 2.77;95% confidence interval, 1.81-4.22 [P <.001]) remained after the multivariate analysis.

CONCLUSIONS

Gastric bypass results in substantial weight loss in most patients. Diabetes and larger pouch size are independently associated with poor weight loss after GBP.