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Weight control after vertical banded gastroplasty for morbid obesity
Weight Control After Vertical Banded Gastroplasty for Morbid Obesity Charles E. Yale,
MD,
Stephen J. Weiler,
Vertical banded gastroplasty is a common method of treating morbid obesity. Several physical, behavioral, economic, and psychologic factors are believed to affect its efficacy. In this study, 100 consecutive patients received a 4.5-cm circumference band, while a second 100 consecutive patients were given a LO-cm circumference band. One year after surgery, with a follow-up of 97.5%, neither the patient’s stoma size nor their preoperative occupation, economic status, or mental health significantly affected the patient’s weight loss, which averaged 27% of their original weight. Postoperative eating behavior, however, dramatically affected weight loss. Among the patients who lost less than 20% of their original weight, 25% drank large volumes of caloried liquids, while 75% ate large amounts of soft foods. Patients with banded gastroplasties must “use” their operation to lose weight.
MD,
Madison,
Wisconsin
PATIENTS AND METHODS Patient selection: All patients
in this study were independently screened by senior staff consultants in medicine, psychiatry, and surgery at the University of Wisconsin Clinical Science Center. After agreement that the patient was morbidly obese, unlikely to achieve long-term weight control with nonsurgical treatments, and psychiatrically stable, he or she was offered the opportunity to have a VBG. None of the patients had had prior surgery for obesity. After a relatively unstructured, l-hour-long psychiatric interview, a written report was sent to the surgeon, who interpreted the report to mean that the patient either did or did not have possible psychiatric problems that might affect the operative care and poatoperative follow-up. These interpretations are summarized in thii report. Operation: A VBG using Mason’s technique [I] was done on all patients. Initially, 100 consecutive patients had a VBG with a LO-cm circumference band. Later, a second 100 consecutive patients had a VBG with a 4.5~cm circumference band. These 200 patients were not randomized, but underwent surgery at 2 different periods of time during which nearly all patients with morbid obesity had the identical procedure. There was no operative mortality. Follow-up: Routine postoperative follow-up was at 6 weeks and at 3, 6, and 12 months after surgery. Four patients were lost to follow-up during the fast year after besity as a condition and morbid obesity as a disease surgery, and one had the VBG reversed after 8 months have reached epidemic proportions in the United for stoma1 stenosis. This left 195 patients with a known States, with life-threatening consequences secondary to weight loss 1 year after surgery for a follow-up rate of serious potential disease of several organ systems. The 91.5%. The patients’ eating behavior was assessed, on a fourlong-term nonsurgical treatment of morbid obesity by any combination of modalities has usually been unsuc- part scale, at each follow-up visit by rating the patients’ cessful. A variety of surgical procedures on the stomach estimate of the size of the pouch (upper stomach) by the and intestines have been done with varying success and volume of solid food they could comfortably eat, their complication rates. At present, the vertical ring or banded tendency to be hungry between meals-perhaps indicatgastroplasty (VBG) is the most popular operation for ing an empty pouch and an overuse of soft foods or liquids morbid obesity because it is physiologic, safe, and fairly at previous meals-the amount of caloried liquid coneffective. Several physical, behavioral, socioeconomic, sumed per day, and the frequency with which they ate large amounts of soft food and/or snacked between and psychologic factors are postulated to affect the effkacy of a VBG. This report correlates weight loss 1 year meals. These habits 1 year after surgery were correlated after surgery with the size of the banded stoma, several with their weight loss. Statistical analysis: Means and standard deviations demographic variables, postoperative eating behavior, and the preoperative economic status and general mental were calculated for all appropriate parameters. Chihealth of 200 consecutive patients receiving a VBG as an square and t-teats and univariate and multivariate regression analysis were used as indicated, to determine the initial operation for morbid obesity. significance of group differences as well as the interrelationships between weight loss 1 year after surgery and From the Departments of Surgery and Psychiatry, University of Wiiconsin Me&al School, Madis&Wiiin. several different variables. Reouests for renrints should be addressed to Charles E. Yale, MD, The definition of an unsatisfactory weight loss after Depar&nt of Surgery, University of Wisconsin Medical School, 600 surgery for morbid obesity has varied widely, from a Highland Avenue, Madii, Wisconsin 53792. Manuscript submitted April 16,1990, and accepted June 25,199O. failure to lose 25% of original weight (OW) to a failure to
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TABLE I Preoperative Physlcal Characterlstlcs and Welght Loss 1 Year After Vertical Banded Gastroplasty Vertical Banded Gastroplasty @O-cm band)
Vertical Banded Gastroplasty (4.5-cm band) n Males (%) Age (yrs)* Height (inches)* Originalweight (lb)* Weight loss (lb)* Weight loss (96originalweight)* Weight loss (% excess weight)*
p Value
98 19.4 38.6 -t 9.1 65.9 2 3.7 263 2 55 75 2 30 26.6 c 8.5
97 26.6 35.6 k 9.2 66.2 -t 4.0 266 f 46 77 2 24 27.0 + 8.3
0.22 0.024 0.58 0.71 0.80 0.73
53.4 -t 17.9
54.0 f 17.8
0.82
‘Meanf SD.
0
20
40
l
Original Weight
n
Excess Weight
60
80
100
Weight Loss Percent of Original or Excess Weight
‘@we 1. Results of vertical banded gastroplasty 1 year
after
operation. lose 25% of excess weight (EW). For this article, an unsatisfactory weight loss is defined as a failure to lose at least 20% OW. EW was calculated by assuming that the ideal weight was the average weight of a medium-frame individual for height as listed in the 1983 Metropolitan Height and Weight Tables [2]. RESULTS Stoma size: There was no significant difference in the percent men (&i-square test) between the VBG 4.5 and VBG 5.0 groups or in their average preoperative height and weight or their average weight loss (two-sample ttest) 1 year after surgery (Table I). The VBG 4.5 group was, on the average, significantly older than the VBG 5.0 group, and an analysis of covariance showed that the slopes of the relationship between age and weight loss (expressed either as percent OW or EW) were significantly different (p = 0.004) for the VBG 4.5 and VBG 5.0 groups. For example, at age 30, the regression equations predicted a weight loss of 25.8% of OW for a patient with a 4.5-cm VBG versus 28.6% for a patient with a 5.0cm VBG, whereas at age 55, they predicted a weight loss of 28.2% OW for a patient with a 4.5-cm VBG and 23.0%
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OW for a patient with a 5.0~cm VBG. The biologic explanation and the clinical significance, if any, of these fmdings are unknown. Combined groups: Since it would be helpful to be able to screen out those patients who would most likely have an unsatisfactory weight loss, irrespective of stoma size, the individual weight loss 1 year after surgery of all 195 patients was analyzed to determine if weight loss correlated with any of the demographic variables, the eating behavior, the economic status, or the mental health of the patient. The percent of patients who lost less than a given percent of OW or EW is shown in Figure 1. For example, at 1 year after surgery, 20% of the patients lost less than 20% OW and 82% less than 35% OW, while 23% lost less than 40% EW and 79% less than 70% EW. The combined patients were somewhat arbitrarily divided into those losing less than 20% OW, those losing 20% to 35% OW, and those losing 35% or more OW, 1 year after surgery. Twenty percent of the patients were in the first group, 62% in the second, and 18% in the third (Table II). Even the first group lost 15.2% OW. Demographic variables: Although there was a higher percentage of men in the unsatisfactory weight loss group, and the overall average weight loss for men was 24.8% OW versus 27.4% OW for women, a t-test between these two groups was not significant (p = 0.07). Regression analysis on all patients did not find any significant correlations between weight loss (as % OW or % EW) and the age, height, or OW of the patients. Increased weight loss was negatively correlated with age in the VBG 5.0 patients (p = O.OOl),but uncorrelated with age in the VBG 4.5 patients (p = 0.32). The percentage of super-obese patients in the three weight loss groups was approximately equal and 17.9% overall. Eating behavior: Subjective ratings of the patient’s eating behavior 1 year after surgery for each of the three weight loss groups is shown in Table III. Although almost all of the patients thought that they had a small or medium-sized pouch, and were rarely or infrequently hungry between meals, those patients with an unsatisfactory weight loss reported either drinking more caloried liquid and/or using more soft foods than the patients with a greater loss of weight. Univariate chi-square tests of the eating behavior data showed that the use of caloried liquids and/or soft foods had a highly significant (p
JULY
1991
WEIGHT CONTROL AFTER VERTICAL BANDED GASTROPLASTY
TABLE II Preoperatlve Physical Characteristics and Weight Loss 1 Year After Vertical Banded Gastroplasty
n 6) Males (%) Age (YES)* Height (in)* Original weigM (Ibs)* Super obese (%)+ WeigM loss (Ibs)** Weight loss (% original weight)** Weight loss (% excess weigM)**
< 20% Original Weight
Patients Who Lost 20 to < 35% Original WeigM
2 35% Original Weight
All Patients
40 (20) 30.0 39.7 r 10.6 67.0 2 3.7 290252 20.0 442 12 15.2 f 3.0 30.7 f 7.6
120 (62) 24.2 36.5 5 8.6 66.2 -c 3.9 287 ? 51 17.1 77 z 19 27.0 + 4.0 54.0 2 10.2
35 (18) 11.4 36.2 ? 9.4 64.7 + 3.5 272 + 44 17.5 108 f 23 39.4 2 3.7 79.1 t 9.6
195 (100) 23.1 37.1 f 9.3 66.1 2 3.8 285 + 50 17.9 78 + 27 26.8 + 8.4 53.7 + 17.8
?NeigM more than225% of idealweight. *Oneyearafteroperation.
TABLE III Eating Behavlor 1 Year After Vettlcal Banded Gastroplasty
n Pouch size (%) Small or medium Large or very large Hunger between meals (%) Rarely or infrequently Frequently or usually Use of caloried liquids (%) Less than 4 glasses/day+ Over 4 glasses/day Use of soft foods (%) Rarely or infrequently Frequently or usually
<20% Original Weight
Patients Who Lost* 20to <35% Original Weight
r 35% Original Weight
All Patients
40
117
35
192
92 8
98 2
97 3
97 3
100 0
100 0
100 0
100 0
75 25
91 9
100 0
90 10
25 75
74 26
97 3
68 32
*Oneyearaftersurgery. ‘a-02.glass.
TABLE IV Preoperative Economic Status of Patients wlth Vertical Banded Gastroplasty
n (%) Mediiid recipients (%) Food workers (%) Unemployed (%) Employed (%) Professional or self-employed Office or factory worker Health care worker Homemaker
< 20% Original Weight
Patients Who Lost* 20 to < 35% Original Weight
2_35% Original WeigM
All Patients
40 (20) 20 8 25 75 30 28 12 5
120 (62) 20 8 22 78 12 41 17 8
35 (18) 14 11 17 83 28 25 8 22
195 (100) 19 7 22 78 18 36 14 IO
*oneyear eftersurgafy.
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TABLE V Preoperatlve Psychlatrlc Evaluatlon of Patients with Vertical Banded Gastroplasty Patients Who Lost*
n (%) No problem (%) Possible problem (%) Depre&on, mild Depression, prone “Diicult to manage” Mental retardation Family problem
< 20% Original Weight
20 to <35% Original Weight
z 35% Original Weight
All Patients
40 (20) 66 32 12 12 5
120 (62) 76 22 4 10 5 2
35 (16) 63 17 3 6 3 6
195 (100) 77 23 6 10 5 2
1
*oneyearaftersurgery.
that the number of homemakers was four times as great in the excellent weight loss group (22% versus 5%). This might be related to the fact that a homemaker who was looking for work outside the home was classified as unemployed. Perhaps the homemaker not looking for outside work signifies a higher economic status in the home. By contrast, the good weight loss group, sandwiched between the poor and excellent groups, had a lower percentage of professional or self-employed individuals and a higher percentage of office or factory workers than the other two groups, It is interesting to note that 14% of the morbidly obese patients were health care workers. Mental health: The surgeon’s interpretation of the psychiatrist’s preoperative report on the patient’s general mental health is recorded in Table V. Overall, 77% of the morbidly obese patients did not appear to have a serious mental health problem. Even though the psychiatrist identified a potential problem in 32% of the patients losing less than 20% OW and in only 17% of those losing 35% or greater OW, this difference was not significant (p = 0.24 by chi-square test). COMMENTS Stoma size:
Several mechanical aspects of a gastro plasty affect its efficacy. Both the size and location of the pouch and stoma are important. During the development of the gastroplasty, stomas from 3 to 12 mm diameter were tried. However, the patient with the smallest stoma could not tolerate solid food, whereas patients with large stomas could eat large amounts of any type of food. Mason et al [3] found that morbidly obese as well as super-morbidly obese patients lost more weight with a 5.0~cm circumference band than one of 5.5 cm circumference. Their super-obese, but not their morbidly obese patients, with a 4.5~cm circumference band lost more than their patients with a 5.0~cm circumference band. Our study shows, in general, that there is no increased weight loss achieved by reducing the band circumference from 5.0 cm to 4.5 cm, but this result appears to be somewhat age-dependent. Although both our 4.5~cm and 5.0-cm band circumference patients were mostly free of obstructive problems, the 5.0-cm circumference band is now our procedure of choice. For this report, a patient was defined to have an unsat16
THE AMERICAN JOURNAL OF SURGERY
isfactory weight loss if he or she did not lose at least 20% of his or her OW. This criteria will be too strict for some, and too liberal for others [4]. The “failures” in our series had an average weight loss 1 year after surgery of 15.2% OW or 30.7% EW, and many of these patients believed their VBG was helpful. Age, sex, and degree of obesity have been thought to influence weight loss. Although our group of failures on average had more men and was slightly older and a few more were super-obese than the average patient, none of these parameters related to weight loss in a statistically significant way. In our series, the ages ranged from 21 to 68 years, and both the youngest (a man) and the oldest (a woman) lost over 32% OW and 70% EW. Clearly, patients must be selected for a VBG on an individual basis, and not on age or sex alone. Eating behavior: Our data demonstrate that the eating behavior of the patient with a poor weight loss is statistically highly significantly different from that of the patient with a good or excellent loss of weight. Almost all patients were quickly satiated with relatively small amounts of solid food, and very few complained of hunger between meals-especially if one relates hunger to gastric rather than cerebral functions. It is difficult for even a full stomach to overcome some patients’ craving to eat. One quarter of the patients with a poor weight loss drank too much caloried liquid, and 75% used large amounts of soft food. Our best results were seen in patients who concluded that they could be healthy and happy with smaller amounts of food. The “soda slurpers,” “nibblers,” “cookie crunchers,” and “chip and dippers” must understand, before an operation, that they will not lose weight after a VBG with these habits. Patients must realize that the VBG is a “crutch” that will get them to their goal of weight loss only if they use the operation properly. As emphasized by Sugerman et al [5], undoubtedly a few patients will have better weight control with a gastric bypass, presumably due to the dumping syndrome, than with a VBG. Most of our excessive sweets-eaters have been included in the high calorie liquid-user group, which makes up 25% of the unsatisfactory results or 5% of all the patients with a VBG. Economic status: Other investigators [6,7] have reviewed the relationship between economic status and obesity. In developed societies, there is a strong inverse rela-
VOLUME 162 JULY 1991
WEIGHT CONTROL AFTER VERTICAL BANDED GASTROPLASTY
tionship between economic status and obesity in women interviews to the widely used Minnesota Multiphasic Per(but not in men or children), whereas in developing soci- sonality Inventory (MMPI) [12] and other less frequenteties, there is a strong direct relationship between eco- ly used psychological investigational techniques, such as the Meta-Contrast Technique (MCT) and the Rod-andnomic status and obesity in men, women, and children. Grace [8] has suggested that there might be a rela- Frame Test (RFT) [13]. Our data from unstructured tionship between unemployment and obesity since unem- psychiatric interviews suggest, but do not prove, that ployment may lead to boredom and snacking. In our there are more identifiable potential problems among the developed society, there is little information relating ei- patients with the poorest weight control than in the group ther socioeconomic or employment status to weight loss with the best weight control. Barrash et al [12] studied 138 women who completed the MMPI before undergoing after obesity surgery. In our study, the rate of employment of the group of patients with the best and the worst a VBG and attempted to correlate the MMPI type with weight loss 1 year after surgery. They identified 10 weight losses after surgery were not statistically different. Wisconsin now has a state law that precludes surgery MMPI types with some predictive utility, but the validity for morbid obesity for patients receiving medical assis- of the study is not proven. Olsson et al [13] attempted to correlate postoperative weight loss in 21 patients receivtance (Medicaid) except in an emergency, presumably because either the results of weight loss after obesity ing an unbanded gastroplasty with their findings from an extensive preoperative psychologic investigation. They surgery in patients receiving Medicaid are uniformly poor or because the results are worse than those seen in found more signs of sensitivity and denial in the poor other groups of patients. No data to support either pre- weight loss group, whereas the successful weight loss sumption are available. One might assume that patients group were more dependent and lived in an environment receiving medical assistance would be in a lower socioeco- with more social support. Although their study was handnomic class and fewer would be employed. This might icapped by the small number of patients, ail of whom affect the prevalence of obesity in this group, but again, received an unsatisfactory operation for weight control, it there is no information that relates weight loss after obe- is the type of study that must be done if our questions are sity surgery to medical assistance. Our data showed that to be answered. Until these studies are completed, we the percentage of patients receiving Medicaid was 20?6 agree with Olsson and co-workers [13] that much of the for both the group with an unsatisfactory weight loss and same type of information should be obtainable by conthe large middle group with a satisfactory weight loss. ducting a structured psychiatric interview, paying Unemployment and/or Medicaid were not predictors of particular attention to signs of immaturity and sensitivity. poor weight loss after a VBG. Society may in the short run save health care money by precluding appropriate treatment for Medicaid paThe authors have shown that the most important tients with morbid obesity, but they cannot deny the fact that a VBG is an effective means of treating morbid factor in long-term results of operations for morbid obeobesity in a patient receiving Medicaid. In the long run, sity is alteration in eating habits and have further clarisociety will bear the guilt of failing to appropriately treat fied the usefulness of psychologic evaluation of operative a whole class of patients under their care, as well as the candidates. added costs of treating the complications of morbid obesity that are certain to develop in these patients. Mental health: The obese patient’s mental status has REFERENCES been studied rather extensively, and as a result, some 1. Mason EE. Morbid obesity: use of vertical banded gastroplasty. things are now accepted as fact. Most investigators be- Surg Clm North Am 1987; 67: 521-37. lieve that: (1) the overall mental health of morbidly 2. 1983 Metropolitan height and weight tables. Statistical Bulletin obese, obese, and nonobese patients are similar 191;(2) a 1983; 64: 2-9. 3. Mason EE, Doherty C, Maher JW, Scott DH, Rodriguez EM, preoperative psychiatric examination can help to screen Blommers TJ. Super obesity and gastric reduction procedures. Gasout (e.g., alcoholic or psychotic patients) or identify pa- troenterol Clin North Am 1987; 16: 495-502. tients with potential postoperative problems (e.g., pa- 4. Brolin RE. Results of obesity surgery. Gastroenterol Clin North tients with some psychopathology, an unstable environ- Am 1987; 16: 317-338. ment, or poor social support) [10]; (3) mental health 5. Sugerman HJ, Starkey JV, Birkenhauer R. A randomized proimproves in most patients after surgery with successful spective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets weight loss [II]; and (4) some patients with serious psy- eaters. Ann Surg 1987; 205: 613-24. chiatric problems achieve good weight control after sur- 6. Sobal J, Stunkard AJ. Socioeconomic status and obesity: a gery for morbid obesity. review of the literature. Psycho1 Bull 1989; 105: 260-75. However, there are important unanswered questions: 7. Garn SM. Family-line and socioeconomic factors in fatness and What type of preoperative psychiatric evaluation would obesity. Nutr Rev 1986; 44: 381-6. 8. Grace DM. Patient selection for obesity surgery. Gastroenterol be most helpful? Are there preoperative psychiatrically Clin North Am 1987; 16: 399-413. identifiable groups among the morbidly obese, which 9. Hahni KA, Long M, Stunkard AJ, Mason EE. Psychiatric could be useful in predicting long-term weight con- diagnosis of morbidly obese gastric bypass patients. Am J Psychiatrol? try 1980; 137: 470-2. To date, preoperative psychiatric evaluations have 10. Valley V, Grace DM. Psychosocial risk factors in gastric surgery for obesity: identifying guidelines for screening. Int J Obesity varied from nonstructured and more formally structured THE AMERICAN JOURNAL OF SURGERY
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YALE AND WEILER
1987; 11: 105-13.
11. Stunkard AJ, Stinnett JL, Smaller JW. Psychological and social aspects of the surgical treatment of obesity. Am J Psychiatry 1986; 143:417-29. 12. Barrash J, Rodriguez EM, Scott DH, Mason EE, Sines JO.
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The utility of MMPI subtypes for the prediction of weight lass after bariatric surgery. Int J Obesity 1987; 11: 115-28. 13. Olsson SA, Ryden 0, Danielsson A, Nelsson-Ehle P. Weight reduction after gastroplasty: the predictive value of surgical, metabolic, and psychological variables. Int J Obesity 1984; 8: 245-58.
VOLUME 162 JULY 1991
MD,
Stephen J. Weiler,
Vertical banded gastroplasty is a common method of treating morbid obesity. Several physical, behavioral, economic, and psychologic factors are believed to affect its efficacy. In this study, 100 consecutive patients received a 4.5-cm circumference band, while a second 100 consecutive patients were given a LO-cm circumference band. One year after surgery, with a follow-up of 97.5%, neither the patient’s stoma size nor their preoperative occupation, economic status, or mental health significantly affected the patient’s weight loss, which averaged 27% of their original weight. Postoperative eating behavior, however, dramatically affected weight loss. Among the patients who lost less than 20% of their original weight, 25% drank large volumes of caloried liquids, while 75% ate large amounts of soft foods. Patients with banded gastroplasties must “use” their operation to lose weight.
MD,
Madison,
Wisconsin
PATIENTS AND METHODS Patient selection: All patients
in this study were independently screened by senior staff consultants in medicine, psychiatry, and surgery at the University of Wisconsin Clinical Science Center. After agreement that the patient was morbidly obese, unlikely to achieve long-term weight control with nonsurgical treatments, and psychiatrically stable, he or she was offered the opportunity to have a VBG. None of the patients had had prior surgery for obesity. After a relatively unstructured, l-hour-long psychiatric interview, a written report was sent to the surgeon, who interpreted the report to mean that the patient either did or did not have possible psychiatric problems that might affect the operative care and poatoperative follow-up. These interpretations are summarized in thii report. Operation: A VBG using Mason’s technique [I] was done on all patients. Initially, 100 consecutive patients had a VBG with a LO-cm circumference band. Later, a second 100 consecutive patients had a VBG with a 4.5~cm circumference band. These 200 patients were not randomized, but underwent surgery at 2 different periods of time during which nearly all patients with morbid obesity had the identical procedure. There was no operative mortality. Follow-up: Routine postoperative follow-up was at 6 weeks and at 3, 6, and 12 months after surgery. Four patients were lost to follow-up during the fast year after besity as a condition and morbid obesity as a disease surgery, and one had the VBG reversed after 8 months have reached epidemic proportions in the United for stoma1 stenosis. This left 195 patients with a known States, with life-threatening consequences secondary to weight loss 1 year after surgery for a follow-up rate of serious potential disease of several organ systems. The 91.5%. The patients’ eating behavior was assessed, on a fourlong-term nonsurgical treatment of morbid obesity by any combination of modalities has usually been unsuc- part scale, at each follow-up visit by rating the patients’ cessful. A variety of surgical procedures on the stomach estimate of the size of the pouch (upper stomach) by the and intestines have been done with varying success and volume of solid food they could comfortably eat, their complication rates. At present, the vertical ring or banded tendency to be hungry between meals-perhaps indicatgastroplasty (VBG) is the most popular operation for ing an empty pouch and an overuse of soft foods or liquids morbid obesity because it is physiologic, safe, and fairly at previous meals-the amount of caloried liquid coneffective. Several physical, behavioral, socioeconomic, sumed per day, and the frequency with which they ate large amounts of soft food and/or snacked between and psychologic factors are postulated to affect the effkacy of a VBG. This report correlates weight loss 1 year meals. These habits 1 year after surgery were correlated after surgery with the size of the banded stoma, several with their weight loss. Statistical analysis: Means and standard deviations demographic variables, postoperative eating behavior, and the preoperative economic status and general mental were calculated for all appropriate parameters. Chihealth of 200 consecutive patients receiving a VBG as an square and t-teats and univariate and multivariate regression analysis were used as indicated, to determine the initial operation for morbid obesity. significance of group differences as well as the interrelationships between weight loss 1 year after surgery and From the Departments of Surgery and Psychiatry, University of Wiiconsin Me&al School, Madis&Wiiin. several different variables. Reouests for renrints should be addressed to Charles E. Yale, MD, The definition of an unsatisfactory weight loss after Depar&nt of Surgery, University of Wisconsin Medical School, 600 surgery for morbid obesity has varied widely, from a Highland Avenue, Madii, Wisconsin 53792. Manuscript submitted April 16,1990, and accepted June 25,199O. failure to lose 25% of original weight (OW) to a failure to
0
THE AMERICAN JOURNAL OF SURGERY
VOLUME 162 JULY 1991
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TABLE I Preoperative Physlcal Characterlstlcs and Welght Loss 1 Year After Vertical Banded Gastroplasty Vertical Banded Gastroplasty @O-cm band)
Vertical Banded Gastroplasty (4.5-cm band) n Males (%) Age (yrs)* Height (inches)* Originalweight (lb)* Weight loss (lb)* Weight loss (96originalweight)* Weight loss (% excess weight)*
p Value
98 19.4 38.6 -t 9.1 65.9 2 3.7 263 2 55 75 2 30 26.6 c 8.5
97 26.6 35.6 k 9.2 66.2 -t 4.0 266 f 46 77 2 24 27.0 + 8.3
0.22 0.024 0.58 0.71 0.80 0.73
53.4 -t 17.9
54.0 f 17.8
0.82
‘Meanf SD.
0
20
40
l
Original Weight
n
Excess Weight
60
80
100
Weight Loss Percent of Original or Excess Weight
‘@we 1. Results of vertical banded gastroplasty 1 year
after
operation. lose 25% of excess weight (EW). For this article, an unsatisfactory weight loss is defined as a failure to lose at least 20% OW. EW was calculated by assuming that the ideal weight was the average weight of a medium-frame individual for height as listed in the 1983 Metropolitan Height and Weight Tables [2]. RESULTS Stoma size: There was no significant difference in the percent men (&i-square test) between the VBG 4.5 and VBG 5.0 groups or in their average preoperative height and weight or their average weight loss (two-sample ttest) 1 year after surgery (Table I). The VBG 4.5 group was, on the average, significantly older than the VBG 5.0 group, and an analysis of covariance showed that the slopes of the relationship between age and weight loss (expressed either as percent OW or EW) were significantly different (p = 0.004) for the VBG 4.5 and VBG 5.0 groups. For example, at age 30, the regression equations predicted a weight loss of 25.8% of OW for a patient with a 4.5-cm VBG versus 28.6% for a patient with a 5.0cm VBG, whereas at age 55, they predicted a weight loss of 28.2% OW for a patient with a 4.5-cm VBG and 23.0%
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OW for a patient with a 5.0~cm VBG. The biologic explanation and the clinical significance, if any, of these fmdings are unknown. Combined groups: Since it would be helpful to be able to screen out those patients who would most likely have an unsatisfactory weight loss, irrespective of stoma size, the individual weight loss 1 year after surgery of all 195 patients was analyzed to determine if weight loss correlated with any of the demographic variables, the eating behavior, the economic status, or the mental health of the patient. The percent of patients who lost less than a given percent of OW or EW is shown in Figure 1. For example, at 1 year after surgery, 20% of the patients lost less than 20% OW and 82% less than 35% OW, while 23% lost less than 40% EW and 79% less than 70% EW. The combined patients were somewhat arbitrarily divided into those losing less than 20% OW, those losing 20% to 35% OW, and those losing 35% or more OW, 1 year after surgery. Twenty percent of the patients were in the first group, 62% in the second, and 18% in the third (Table II). Even the first group lost 15.2% OW. Demographic variables: Although there was a higher percentage of men in the unsatisfactory weight loss group, and the overall average weight loss for men was 24.8% OW versus 27.4% OW for women, a t-test between these two groups was not significant (p = 0.07). Regression analysis on all patients did not find any significant correlations between weight loss (as % OW or % EW) and the age, height, or OW of the patients. Increased weight loss was negatively correlated with age in the VBG 5.0 patients (p = O.OOl),but uncorrelated with age in the VBG 4.5 patients (p = 0.32). The percentage of super-obese patients in the three weight loss groups was approximately equal and 17.9% overall. Eating behavior: Subjective ratings of the patient’s eating behavior 1 year after surgery for each of the three weight loss groups is shown in Table III. Although almost all of the patients thought that they had a small or medium-sized pouch, and were rarely or infrequently hungry between meals, those patients with an unsatisfactory weight loss reported either drinking more caloried liquid and/or using more soft foods than the patients with a greater loss of weight. Univariate chi-square tests of the eating behavior data showed that the use of caloried liquids and/or soft foods had a highly significant (p
JULY
1991
WEIGHT CONTROL AFTER VERTICAL BANDED GASTROPLASTY
TABLE II Preoperatlve Physical Characteristics and Weight Loss 1 Year After Vertical Banded Gastroplasty
n 6) Males (%) Age (YES)* Height (in)* Original weigM (Ibs)* Super obese (%)+ WeigM loss (Ibs)** Weight loss (% original weight)** Weight loss (% excess weigM)**
< 20% Original Weight
Patients Who Lost 20 to < 35% Original WeigM
2 35% Original Weight
All Patients
40 (20) 30.0 39.7 r 10.6 67.0 2 3.7 290252 20.0 442 12 15.2 f 3.0 30.7 f 7.6
120 (62) 24.2 36.5 5 8.6 66.2 -c 3.9 287 ? 51 17.1 77 z 19 27.0 + 4.0 54.0 2 10.2
35 (18) 11.4 36.2 ? 9.4 64.7 + 3.5 272 + 44 17.5 108 f 23 39.4 2 3.7 79.1 t 9.6
195 (100) 23.1 37.1 f 9.3 66.1 2 3.8 285 + 50 17.9 78 + 27 26.8 + 8.4 53.7 + 17.8
?NeigM more than225% of idealweight. *Oneyearafteroperation.
TABLE III Eating Behavlor 1 Year After Vettlcal Banded Gastroplasty
n Pouch size (%) Small or medium Large or very large Hunger between meals (%) Rarely or infrequently Frequently or usually Use of caloried liquids (%) Less than 4 glasses/day+ Over 4 glasses/day Use of soft foods (%) Rarely or infrequently Frequently or usually
<20% Original Weight
Patients Who Lost* 20to <35% Original Weight
r 35% Original Weight
All Patients
40
117
35
192
92 8
98 2
97 3
97 3
100 0
100 0
100 0
100 0
75 25
91 9
100 0
90 10
25 75
74 26
97 3
68 32
*Oneyearaftersurgery. ‘a-02.glass.
TABLE IV Preoperative Economic Status of Patients wlth Vertical Banded Gastroplasty
n (%) Mediiid recipients (%) Food workers (%) Unemployed (%) Employed (%) Professional or self-employed Office or factory worker Health care worker Homemaker
< 20% Original Weight
Patients Who Lost* 20 to < 35% Original Weight
2_35% Original WeigM
All Patients
40 (20) 20 8 25 75 30 28 12 5
120 (62) 20 8 22 78 12 41 17 8
35 (18) 14 11 17 83 28 25 8 22
195 (100) 19 7 22 78 18 36 14 IO
*oneyear eftersurgafy.
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TABLE V Preoperatlve Psychlatrlc Evaluatlon of Patients with Vertical Banded Gastroplasty Patients Who Lost*
n (%) No problem (%) Possible problem (%) Depre&on, mild Depression, prone “Diicult to manage” Mental retardation Family problem
< 20% Original Weight
20 to <35% Original Weight
z 35% Original Weight
All Patients
40 (20) 66 32 12 12 5
120 (62) 76 22 4 10 5 2
35 (16) 63 17 3 6 3 6
195 (100) 77 23 6 10 5 2
1
*oneyearaftersurgery.
that the number of homemakers was four times as great in the excellent weight loss group (22% versus 5%). This might be related to the fact that a homemaker who was looking for work outside the home was classified as unemployed. Perhaps the homemaker not looking for outside work signifies a higher economic status in the home. By contrast, the good weight loss group, sandwiched between the poor and excellent groups, had a lower percentage of professional or self-employed individuals and a higher percentage of office or factory workers than the other two groups, It is interesting to note that 14% of the morbidly obese patients were health care workers. Mental health: The surgeon’s interpretation of the psychiatrist’s preoperative report on the patient’s general mental health is recorded in Table V. Overall, 77% of the morbidly obese patients did not appear to have a serious mental health problem. Even though the psychiatrist identified a potential problem in 32% of the patients losing less than 20% OW and in only 17% of those losing 35% or greater OW, this difference was not significant (p = 0.24 by chi-square test). COMMENTS Stoma size:
Several mechanical aspects of a gastro plasty affect its efficacy. Both the size and location of the pouch and stoma are important. During the development of the gastroplasty, stomas from 3 to 12 mm diameter were tried. However, the patient with the smallest stoma could not tolerate solid food, whereas patients with large stomas could eat large amounts of any type of food. Mason et al [3] found that morbidly obese as well as super-morbidly obese patients lost more weight with a 5.0~cm circumference band than one of 5.5 cm circumference. Their super-obese, but not their morbidly obese patients, with a 4.5~cm circumference band lost more than their patients with a 5.0~cm circumference band. Our study shows, in general, that there is no increased weight loss achieved by reducing the band circumference from 5.0 cm to 4.5 cm, but this result appears to be somewhat age-dependent. Although both our 4.5~cm and 5.0-cm band circumference patients were mostly free of obstructive problems, the 5.0-cm circumference band is now our procedure of choice. For this report, a patient was defined to have an unsat16
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isfactory weight loss if he or she did not lose at least 20% of his or her OW. This criteria will be too strict for some, and too liberal for others [4]. The “failures” in our series had an average weight loss 1 year after surgery of 15.2% OW or 30.7% EW, and many of these patients believed their VBG was helpful. Age, sex, and degree of obesity have been thought to influence weight loss. Although our group of failures on average had more men and was slightly older and a few more were super-obese than the average patient, none of these parameters related to weight loss in a statistically significant way. In our series, the ages ranged from 21 to 68 years, and both the youngest (a man) and the oldest (a woman) lost over 32% OW and 70% EW. Clearly, patients must be selected for a VBG on an individual basis, and not on age or sex alone. Eating behavior: Our data demonstrate that the eating behavior of the patient with a poor weight loss is statistically highly significantly different from that of the patient with a good or excellent loss of weight. Almost all patients were quickly satiated with relatively small amounts of solid food, and very few complained of hunger between meals-especially if one relates hunger to gastric rather than cerebral functions. It is difficult for even a full stomach to overcome some patients’ craving to eat. One quarter of the patients with a poor weight loss drank too much caloried liquid, and 75% used large amounts of soft food. Our best results were seen in patients who concluded that they could be healthy and happy with smaller amounts of food. The “soda slurpers,” “nibblers,” “cookie crunchers,” and “chip and dippers” must understand, before an operation, that they will not lose weight after a VBG with these habits. Patients must realize that the VBG is a “crutch” that will get them to their goal of weight loss only if they use the operation properly. As emphasized by Sugerman et al [5], undoubtedly a few patients will have better weight control with a gastric bypass, presumably due to the dumping syndrome, than with a VBG. Most of our excessive sweets-eaters have been included in the high calorie liquid-user group, which makes up 25% of the unsatisfactory results or 5% of all the patients with a VBG. Economic status: Other investigators [6,7] have reviewed the relationship between economic status and obesity. In developed societies, there is a strong inverse rela-
VOLUME 162 JULY 1991
WEIGHT CONTROL AFTER VERTICAL BANDED GASTROPLASTY
tionship between economic status and obesity in women interviews to the widely used Minnesota Multiphasic Per(but not in men or children), whereas in developing soci- sonality Inventory (MMPI) [12] and other less frequenteties, there is a strong direct relationship between eco- ly used psychological investigational techniques, such as the Meta-Contrast Technique (MCT) and the Rod-andnomic status and obesity in men, women, and children. Grace [8] has suggested that there might be a rela- Frame Test (RFT) [13]. Our data from unstructured tionship between unemployment and obesity since unem- psychiatric interviews suggest, but do not prove, that ployment may lead to boredom and snacking. In our there are more identifiable potential problems among the developed society, there is little information relating ei- patients with the poorest weight control than in the group ther socioeconomic or employment status to weight loss with the best weight control. Barrash et al [12] studied 138 women who completed the MMPI before undergoing after obesity surgery. In our study, the rate of employment of the group of patients with the best and the worst a VBG and attempted to correlate the MMPI type with weight loss 1 year after surgery. They identified 10 weight losses after surgery were not statistically different. Wisconsin now has a state law that precludes surgery MMPI types with some predictive utility, but the validity for morbid obesity for patients receiving medical assis- of the study is not proven. Olsson et al [13] attempted to correlate postoperative weight loss in 21 patients receivtance (Medicaid) except in an emergency, presumably because either the results of weight loss after obesity ing an unbanded gastroplasty with their findings from an extensive preoperative psychologic investigation. They surgery in patients receiving Medicaid are uniformly poor or because the results are worse than those seen in found more signs of sensitivity and denial in the poor other groups of patients. No data to support either pre- weight loss group, whereas the successful weight loss sumption are available. One might assume that patients group were more dependent and lived in an environment receiving medical assistance would be in a lower socioeco- with more social support. Although their study was handnomic class and fewer would be employed. This might icapped by the small number of patients, ail of whom affect the prevalence of obesity in this group, but again, received an unsatisfactory operation for weight control, it there is no information that relates weight loss after obe- is the type of study that must be done if our questions are sity surgery to medical assistance. Our data showed that to be answered. Until these studies are completed, we the percentage of patients receiving Medicaid was 20?6 agree with Olsson and co-workers [13] that much of the for both the group with an unsatisfactory weight loss and same type of information should be obtainable by conthe large middle group with a satisfactory weight loss. ducting a structured psychiatric interview, paying Unemployment and/or Medicaid were not predictors of particular attention to signs of immaturity and sensitivity. poor weight loss after a VBG. Society may in the short run save health care money by precluding appropriate treatment for Medicaid paThe authors have shown that the most important tients with morbid obesity, but they cannot deny the fact that a VBG is an effective means of treating morbid factor in long-term results of operations for morbid obeobesity in a patient receiving Medicaid. In the long run, sity is alteration in eating habits and have further clarisociety will bear the guilt of failing to appropriately treat fied the usefulness of psychologic evaluation of operative a whole class of patients under their care, as well as the candidates. added costs of treating the complications of morbid obesity that are certain to develop in these patients. Mental health: The obese patient’s mental status has REFERENCES been studied rather extensively, and as a result, some 1. Mason EE. Morbid obesity: use of vertical banded gastroplasty. things are now accepted as fact. Most investigators be- Surg Clm North Am 1987; 67: 521-37. lieve that: (1) the overall mental health of morbidly 2. 1983 Metropolitan height and weight tables. Statistical Bulletin obese, obese, and nonobese patients are similar 191;(2) a 1983; 64: 2-9. 3. Mason EE, Doherty C, Maher JW, Scott DH, Rodriguez EM, preoperative psychiatric examination can help to screen Blommers TJ. Super obesity and gastric reduction procedures. Gasout (e.g., alcoholic or psychotic patients) or identify pa- troenterol Clin North Am 1987; 16: 495-502. tients with potential postoperative problems (e.g., pa- 4. Brolin RE. Results of obesity surgery. Gastroenterol Clin North tients with some psychopathology, an unstable environ- Am 1987; 16: 317-338. ment, or poor social support) [10]; (3) mental health 5. Sugerman HJ, Starkey JV, Birkenhauer R. A randomized proimproves in most patients after surgery with successful spective trial of gastric bypass versus vertical banded gastroplasty for morbid obesity and their effects on sweets versus non-sweets weight loss [II]; and (4) some patients with serious psy- eaters. Ann Surg 1987; 205: 613-24. chiatric problems achieve good weight control after sur- 6. Sobal J, Stunkard AJ. Socioeconomic status and obesity: a gery for morbid obesity. review of the literature. Psycho1 Bull 1989; 105: 260-75. However, there are important unanswered questions: 7. Garn SM. Family-line and socioeconomic factors in fatness and What type of preoperative psychiatric evaluation would obesity. Nutr Rev 1986; 44: 381-6. 8. Grace DM. Patient selection for obesity surgery. Gastroenterol be most helpful? Are there preoperative psychiatrically Clin North Am 1987; 16: 399-413. identifiable groups among the morbidly obese, which 9. Hahni KA, Long M, Stunkard AJ, Mason EE. Psychiatric could be useful in predicting long-term weight con- diagnosis of morbidly obese gastric bypass patients. Am J Psychiatrol? try 1980; 137: 470-2. To date, preoperative psychiatric evaluations have 10. Valley V, Grace DM. Psychosocial risk factors in gastric surgery for obesity: identifying guidelines for screening. Int J Obesity varied from nonstructured and more formally structured THE AMERICAN JOURNAL OF SURGERY
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1987; 11: 105-13.
11. Stunkard AJ, Stinnett JL, Smaller JW. Psychological and social aspects of the surgical treatment of obesity. Am J Psychiatry 1986; 143:417-29. 12. Barrash J, Rodriguez EM, Scott DH, Mason EE, Sines JO.
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The utility of MMPI subtypes for the prediction of weight lass after bariatric surgery. Int J Obesity 1987; 11: 115-28. 13. Olsson SA, Ryden 0, Danielsson A, Nelsson-Ehle P. Weight reduction after gastroplasty: the predictive value of surgical, metabolic, and psychological variables. Int J Obesity 1984; 8: 245-58.
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