- Email: [email protected]
Gastric bypass for severe obesity: Approaches and outcomes
Surgery for Obesity and Related Diseases 1 (2005) 297–300
2004 ASBS Consensus Conference
Gastric bypass for severe obesity: Approaches and outcomes Philip Schauer, M.D. Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
Keywords:
Gastric bypass; Morbid obesity; Bariatric surgery; Obesity comorbidity; Weight loss
Bariatric surgery has experienced unprecedented growth in the United States during the last 10 years [1]. Compared with the late 1980s and early 1990s, when approximately 15,000 bariatric operations were performed each year, in 2003 more than 100,000 bariatric operations were performed in the United States. This growth in bariatric surgery, the fastest-growing major operation in the United States, can be explained by 3 factors: (1) the 4-decades-old epidemic of obesity, (2) steadily improving outcomes for several bariatric operations, and (3) the introduction of laparoscopic bariatric surgery with improved perioperative outcomes. Since the introduction of bariatric surgery in the United States in the early 1950s, numerous bariatric operations have evolved and become extinct. Worldwide today, the most commonly performed procedures include gastric bypass (65%), adjustable gastric banding (24%), vertical banded gastroplasty (5%), and biliopancreatic diversion/ duodenal switch (4%) [2]. The United States accounted for 103,000 of the estimated 146,301 bariatric operations performed worldwide in 2003. Roux-en-Y gastric bypass is the most frequently performed obesity operation in the United States (85% of operations), followed by laparoscopic adjustable gastric banding (9%), duodenal switch (2.5%), and vertical banded gastroplasty (2%). The laparoscopic approach is now most common; overall, 55% of gastric bypass, 100% of adjustable gastric banding, 30% of duodenal switch, and 30% of vertical banded gastroplasty operations are performed laparoscopically.
Reprint requests: Philip Schauer, M.D., Department of General Surgery, A80, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: [email protected]
Approaches The gastric bypass for morbid obesity has evolved considerably since its inception in 1967 by Mason and Ito [3]. This procedure entailed creation of a large (50 to 100 mL) gastric pouch by stapling and dividing the upper stomach, along with a loop gastrojejunostomy to the pouch. A major modification came in 1977, when Griffin et al. [4] advocated the Roux-en-Y gastrojejunostomy to minimize bile reflux. Sugerman et al. [5] later advocated multiple staple lines during pouch creation to minimize gastrogastric fistula and demonstrated the superiority of this approach over vertical banded gastroplasty in a randomized trial. In 1986, Linner [6] suggested gastric transection to minimize staple line separation and gastrogastric fistula formation. In 1991, Fobi et al. [7] and Cappella and Capella [8] advocated reinforcing the gastric pouch outlet with either a Silastic ring or Marlex mesh. In 1994, Wittgrove et al. [9] were the first to use the laparoscopic technique for gastric bypass, dramatically reducing perioperative morbidity (see Video 1). Other variations of gastric bypass used today include long-limb gastric bypass (150-cm Roux limb length) and distal gastric bypass, a rarely used malabsorptive procedure that uses a short (75 to 150 cm) common channel measured from the ileocecal valve [10].
Outcomes Although the laparoscopic approach is slightly more popular today and has been adopted rapidly, the open approach is still commonly performed [11,12]. Most of the outcome studies on open gastric bypass were published in the 1980s and 1990s, whereas the laparoscopic gastric bypass series have been published over the last 5 to 6 years. Thus a valid comparison of these historical series is compromised, because they are not contemporary series and
1550-7289/05/$ – see front matter © 2005 American Society for Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2005.03.214
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P. Schauer / Surgery for Obesity and Related Diseases 1 (2005) 297–300
there are no controls for patient demographic and risk factors. Nevertheless, a general appreciation of complication rates and efficacy can be achieved by evaluating these series. Complications Perioperative complications. The rates of recognized shortterm (⬍ 30 days) perioperative complications for laparoscopic gastric bypass (ie, venous thrombosis, pulmonary embolus, bleeding, stenosis, symptomatic cholelithiasis, and marginal ulcer) appear very similar for both the open and laparoscopic approaches [12]. The laparoscopic approach is associated with reduced incidence of incisional hernia, wound infections, and pulmonary complications [12]. The incidence of such complications as intestinal leaks and internal hernias appears to be higher with the laparoscopic approach in the early learning experience of the surgeon [12]. In particular, the learning curve for laparoscopic Roux-en-Y gastric bypass is approximately 100 cases [13]. Major advantages of the laparoscopic approach appear to be a significant reduction in perioperative wound and pulmonary complications, as well as a reduction in hospital length of stay and overall time to recovery [14]. Collectively, major perioperative complications occur with an incidence of 5% to 10% [12]. Mortality. For the open series of gastric bypass operations (done in the 1980s and 1990s), mortality rates ranged from 0.3% to 1.5%. For laparoscopic gastric bypass series with more than 100 patients, mortality rates have varied from 0 to 0.9%. Considering that single-institution studies often represent outcomes at highly specialized centers, statewide or national studies are more reflective of mortality for all types of centers, including small rural and large city community hospitals and academic centers. Two statewide studies demonstrated in-hospital operative mortality for gastric bypass of 0.3% in California and 0.6% in Pennsylvania [15,16]. A bariatric surgery outcome study in Washington demonstrated a 1% in-hospital mortality and a 1.9% 30-day mortality [17]. In this study, a 5-fold increase in mortality was associated with surgeons who had performed fewer than 20 procedures. Another study using national inpatient hospital outcome data demonstrated an overall inpatient mortality rate of 0.6% at academic medical centers [18]. Long-term complications. Late problems (⬎ 30 days) generally fall into the category of nutritional/metabolic complications. Iron deficiency with associated anemia is the most common long-term complication, with an incidence between 25% and 50% in patients not receiving prophylactic iron supplementation [19]. The incidence of iron deficiency drops to 10% when prophylactic iron supplementation is routinely administered [20]. Vitamin B12 deficiency occurs in 33% to 37% of patients. Supplementation with intramuscular or sublingual B12 supplementation dramatically reduces the incidence of this complication. Malabsorption of
calcium and vitamin D may occur as a result of bypassing the duodenum and proximal jejunum with Roux-en-Y gastric bypass. Brolin et al. [10] demonstrated calcium and vitamin D deficiency rates of 10% and 51%, respectively, for the distal Roux-en-Y gastric bypass, but these deficiencies were not evident for the standard Roux limb length of 75 to 150 cm. Coates et al. [21] demonstrated diminished bone mineral density and content 9 months after gastric bypass surgery even though their patients were taking supplemental calcium and vitamin D. One study evaluating bone density at 3 years after gastric bypass demonstrated a decrease in bone mass only in postmenopausal women [22]. This study also found secondary hyperparathyroidism and evidence of bone resorption after gastric bypass that could not be suppressed by supplemental calcium and vitamin D for 6 months. The clinical significance of these findings suggesting impaired calcium absorption and metabolism after gastric bypass is unclear, especially because reports of secondary bone demineralization complications, such as fractures, are exceedingly rare. Thiamine (vitamin B1) deficiency rarely occurs after gastric bypass surgery (0.0002%) but can be deadly [23]. Thiamine deficiency may lead to Wernicke’s encephalopathy and a profound peripheral neuropathy that can be irreversible. This condition is characterized by mental confusion, aphonia, nystagmus, ophthalmoplegia, and, in late stages, coma and death. Treatment involves prompt administration of intravenous or intramuscular thiamine, 50 to 100 mg/day [24]. Deficiencies in fat-soluble vitamins as well as protein are known to be potential consequences of extreme malabsorption operations such as biliopancreatic diversion and distal gastric bypass, but are not generally associated with standard Rouxen-Y gastric bypass. Other deficiencies, including those of magnesium, zinc, selenium, and other micronutrients, are very rare after Roux-en-Y gastric bypass. Weight Loss Weight loss appears to be equivalent for laparoscopic and open gastric bypass procedures. The nadir of weight loss appears at 1-1/2 to 2 years after surgery and approximates 65% to 80% excess weight loss [5,7,8,12,14]. Studies with 5- to 15-year follow-up generally show some degree of weight gain over this time period. At 5 years, 60% to 70% excess weight loss is commonly reported. The longest follow-up for gastric bypass reported to date is 14 years by Pories et al. [25], demonstrating 49% excess weight loss. Ten-year follow-up in the Swedish Obese Subjects (SOS) Study demonstrated 10-year weight loss (as a percentage of initial body weight) of 25% for gastric bypass, 16% for vertical banded gastroplasty, and 13% for gastric banding [26]. A recent meta-analysis of bariatric surgery at 2 to 3 years after operation demonstrated profound excess weight loss: 62% for gastric bypass, 47% for gastric banding, 68% for gastroplasty, and 70% for biliopancreatic diversion [27].
P. Schauer / Surgery for Obesity and Related Diseases 1 (2005) 297–300
Comorbidity Changes Numerous studies have tracked improvement in comorbidity status after gastric bypass surgery [5,12,14,20,25– 27]. Although comorbidity changes after laparoscopic gastric bypass are less well studied than those after open operations, because weight loss is similar between the 2 approaches, changes in comorbidity should also be similar. The SOS Study evaluated comorbidity changes among all bariatric surgery patients compared with a matched cohort group. At 10 years after surgery, significant improvement or resolution of hypertension, diabetes, hypertriglyceridemia, and hypercholesterolemia were noted [26]. Even with the small sample size for gastric bypass patients (34 patients), they found significant improvements in diabetes and dyslipidemia but found no significant improvement in hypertension at 8 years after surgery [26]. This finding likely represents a type 2 statistical error because of the small sample size. Gastric bypass surgery appears to have a profound effect on type II diabetes mellitus, with a ⬎ 80% resolution (defined as euglycemic without the need for medication) [25–29].
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final BMI of 29 ⫾ 4 kg/m2 in a cohort of non-superobese patients (BMI ⬍ 50 kg/m2) (P ⬍ .0001). Determinants of Surgical Technique Although numerous operative technique variables, including pouch size, stoma size, and Roux limb length, have been proposed as major determinants of weight loss, only Roux limb length has been subject to randomized controlled studies. Brolin et al. [33] showed that a 150-cm Roux limb had a statistically greater weight loss than a 75-cm Roux limb in the short term, with this difference becoming less significant at 16 months after surgery. Reinforcement of the gastric outlet with a synthetic band, as promoted by Fobi et al. [7] and Capella and Capella [8], may be a modification of gastric bypass that achieves greater magnitude and longlasting weight loss. Five-year data with gastric pouch reinforcement demonstrates excess weight loss in the 77% to 80% range, which is among the highest reported for gastric bypass. Impact of Gastric Bypass on Longevity
Quality of Life Multiple studies have evaluated the effect of bariatric surgery on quality of life. A recent review by Livingston and Fink [30] identified 5 studies measuring quality of life after Roux-en-Y gastric bypass. Most of these studies used the SF 36 Quality of Life instrument and all reported significant improvements in quality of life after surgery. Determinants of Outcome Outcome studies to date have identified that patient factors, surgeon experience, and variations in surgical technique may affect complication rates and/or the magnitude and duration of weight loss. Advanced age, high body mass index (BMI), and male sex have been associated with an increased risk of perioperative complications as well as mortality [31]. It is likely that both advanced age and BMI are associated with increased operative risk, because they are associated with severe obesity comorbidity. Male sex is associated with central obesity, which has also been associated with increased perioperative risk. Surgeon experience is inversely related to operative complication rates and mortality [15–18]. Centers and surgeons that perform more than 100 gastric bypass operations per year report 2- to 3-fold lower complication rates and mortality rates. With respect to preoperative determinants of weight loss, although both sex and ethnic background have been suggested as predictors, thus far only preoperative BMI has been shown to be a negative predictor of achieving a BMI ⬍ 30 kg/m2. MacLean et al. [32], in a large series of gastric bypass patients, reported a final BMI of 35 ⫾ 7 kg/m2 in a cohort of superobese patients (BMI ⱖ 50 kg/m2) versus a
Because severe obesity is associated with significant comorbidity and premature mortality, surgically induced weight loss would be expected to enhance longevity. MacDonald et al [34] evaluated mortality rates and causes of death in 154 diabetic patients who underwent gastric bypass and in 78 diabetic patients matched for age, BMI, and sex who did not opt for surgery. They found a 9% mortality rate at 9 years of follow-up in the surgery group, compared with a 28% mortality rate at 6.2 years of follow-up in the nonsurgery control group (P ⬍ .05). The overwhelming cause of death in the control group was cardiovascular disease. Christou et al. [35], in a large Canadian study, evaluated mortality rates in 1035 patients who underwent bariatric surgery and in 5476 patients matched for age, sex, and BMI who did not undergo surgery. At 5-year follow-up, mortality was 0.68% in the surgery group and 6.17% in the nonsurgery group—a nearly 10-fold decrease in overall mortality in the surgery group. Conclusion In summary, Roux-en-Y gastric bypass is currently the most common bariatric procedure performed in North America. The laparoscopic approach offers significant benefits in terms of reduced perioperative morbidity and faster recovery. Complication and mortality rates for gastric bypass appear to be comparable to those for other major operations and appear to be dependent on patient risk factors as well as surgeon experience. Many studies have yielded excellent weight loss, 60% to 80% excess weight in the 3- to 5-year range. Surgically induced weight loss carries the benefits of comorbidity reduction, enhanced quality
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of life, and increased longevity. Gastric bypass is a safe, effective, and durable procedure for severe obesity that is well supported by evidence in the medical literature. Appendix Supplementary data Supplementary data associated with this article can be found in the online version, at 10.1016/j.soard.2005.03.214. References [1] Steinbrook R. Surgery for severe obesity. N Engl J Med 2004;350: 11:1075–9. [2] Buchwald H, Williams SE. Bariatric surgery worldwide 2003. Obes Surg 2004:14;1157– 64. [3] Mason EE, Ito C. Gastric bypass. Ann Surg 1969;170:329 –39. [4] Griffen WO, Bivins BA, Bell RM, et al. Gastric bypass for morbid obesity. World J Surg 1981;5:817–22. [5] Sugerman HJ, Londrey GL, Kellum JM, et al. Weight loss with vertical banded gastroplasty and Roux-en-Y gastric bypass for morbid obesity with selective versus random assignment. Am J Surg 1989; 157:93–102. [6] Linner JH. Comparative effectiveness of gastric bypass and gastroplasty. Arch Surg 1982;117:695–700. [7] Fobi MAL, Lee H, Holness R, et al. Gastric bypass operation for obesity. World J Surg 1998;22:925–35. [8] Capella JF, Capella RF. The weight reduction operation of choice: Vertical banded gastroplasty or gastric bypass. Am J Surg 1996;171: 74 –9. [9] Wittgrove AC, Clark GW, Schubert KR. Laparoscopic gastric bypass, Roux-en-Y: Technique and results in 75 patients with 3–30 months follow-up. Obes Surg 1996;6:500 – 4. [10] Brolin RE, LaMarca LB, Kenler HA, et al. Malabsorptive gastric bypass in patients with super obesity. J Gastrointest Surg 2002;6: 195–203. [11] Cottam DR, Mattar SG, Schauer PR. The laparoscopic era of operations for morbid obesity. Arch Surg 2003;138:367–75. [12] Schneider BE. Villegas L, Blackburn GL, et al. Laparoscopic gastric bypass surgery: Outcomes. J Laparoendosc Adv Tech Surg Tech A 2003;13:247–55. [13] Schauer P, Ikramuddin S, Hamad G, et al. The learning curve for laparoscopic Roux-en-Y gastric bypass is 100 cases. Surg Endosc 2003;17:212–5. [14] Nguyen NT, Goldman C, Rosenquist CJ, et al. Laparoscopic versus open gastric bypass: A randomized study of outcomes, quality of life, and costs. Ann Surg 2001;234:279 –91. [15] Liu JH, Zingmond D, Etzioni DA, et al. Characterizing the performance and outcomes of obesity surgery in California. Am Surg 2003;69:823– 8.
[16] Courcoulas A, Schuchert M, Gatti G, et al. The relationship of surgeon and hospital volume to outcome after gastric bypass surgery in Pennsylvania: A 3-year summary. Surgery 2003;134:613–23. [17] Flum DR, Dellinger EP. Impact of gastric bypass surgery on survival: A population-based analysis. J Am Coll Surg 2004;199:543–51. [18] Nguyen NT, Paya M, Stevens CM, et al. The relationship between hospital volume and outcomes in bariatric surgery at academic medical centers. Ann Surg 2004;240:586 –94. [19] Bloomberg RD, Fleishman A, Nalle JE, et al. Nutritional deficiencies following bariatric surgery: What have we learned? Obes Surg 2005; 15:145–54. [20] Schauer PR, Ikramuddin S, Gourash W, et al. Outcomes for laparoscopic Roux-en-Y gastric bypass. Ann Surg 2000;232:515–29. [21] Coates PS, Fernstrom JD, Fernstrom MH, et al. Gastric bypass surgery for morbid obesity leads to an increase in bone turnover and a decrease in bone mass. J Clin Endocrinol Metab 2004;89:1061–5. [22] Goode LR, Brolin RE, Chowdhury HA, et al. Bone in gastric bypass surgery: Effect of dietary calcium and vitamin D. Obes Res 2004;12: 40 –7. [23] Chang CG, Adams-Huet B, Provost DA. Acute post-gastric reduction surgery neuropathy. Obes Surg 2004;14:182–9. [24] Thaisetthawatkul P, Collazo-Clavell ML, Sarr MG, et al. A controlled study of peripheral neuropathy after bariatric surgery. Neurology 2004;63:1462–70. [25] Pories WJ, Swanson MS, MacDonald KG Jr, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset of diabetes mellitus. Ann Surg 1995;222:339 –52. [26] Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors ten years after bariatric surgery. N Engl J Med 2004;351:2683–93. [27] Buchwald H, Avidor Y, Braunwald W, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA 2004;292:1724 –37. [28] Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en-Y gastric bypass on type II diabetes mellitus. Ann Surg 2003:238;467– 85. [29] Sugerman HJ, Wolfe LG, DeMaria EJ, et al. Diabetes and hypertension in severe obesity and effects of gastric bypass induced weight loss. Ann Surg 2003;237:751– 8. [30] Livingston EH, Fink AS. Quality of life, cost and future of bariatric surgery. Arch Surg 2003;138:383– 8. [31] Livingston EH, Huerta S, Arthur D, et al. Male gender is a predictor of morbidity and age a predictor of mortality for patients undergoing gastric bypass surgery. Ann Surg 2002;236:576 – 82. [32] MacLean LD, Rhode BM, Nohr CW. Late outcome of isolated gastric bypass. Ann Surg 2000;231:524 – 8. [33] Brolin RE, LaMarca LB, Kenler HA, et al. Malabsorptive gastric bypass in patients with superobesity. J Gastrointest Surg 2002;6:195– 205. [34] MacDonald KG Jr, Long SD, Swansoin MS, et al. The gastric bypass operation reduces the progression and mortality of non–insulin-dependent diabetes mellitus. J Gastrointest Surg 1997;1:213–20. [35] Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 2004;240:416 –24.
2004 ASBS Consensus Conference
Gastric bypass for severe obesity: Approaches and outcomes Philip Schauer, M.D. Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
Keywords:
Gastric bypass; Morbid obesity; Bariatric surgery; Obesity comorbidity; Weight loss
Bariatric surgery has experienced unprecedented growth in the United States during the last 10 years [1]. Compared with the late 1980s and early 1990s, when approximately 15,000 bariatric operations were performed each year, in 2003 more than 100,000 bariatric operations were performed in the United States. This growth in bariatric surgery, the fastest-growing major operation in the United States, can be explained by 3 factors: (1) the 4-decades-old epidemic of obesity, (2) steadily improving outcomes for several bariatric operations, and (3) the introduction of laparoscopic bariatric surgery with improved perioperative outcomes. Since the introduction of bariatric surgery in the United States in the early 1950s, numerous bariatric operations have evolved and become extinct. Worldwide today, the most commonly performed procedures include gastric bypass (65%), adjustable gastric banding (24%), vertical banded gastroplasty (5%), and biliopancreatic diversion/ duodenal switch (4%) [2]. The United States accounted for 103,000 of the estimated 146,301 bariatric operations performed worldwide in 2003. Roux-en-Y gastric bypass is the most frequently performed obesity operation in the United States (85% of operations), followed by laparoscopic adjustable gastric banding (9%), duodenal switch (2.5%), and vertical banded gastroplasty (2%). The laparoscopic approach is now most common; overall, 55% of gastric bypass, 100% of adjustable gastric banding, 30% of duodenal switch, and 30% of vertical banded gastroplasty operations are performed laparoscopically.
Reprint requests: Philip Schauer, M.D., Department of General Surgery, A80, 9500 Euclid Avenue, Cleveland, OH 44195. E-mail: [email protected]
Approaches The gastric bypass for morbid obesity has evolved considerably since its inception in 1967 by Mason and Ito [3]. This procedure entailed creation of a large (50 to 100 mL) gastric pouch by stapling and dividing the upper stomach, along with a loop gastrojejunostomy to the pouch. A major modification came in 1977, when Griffin et al. [4] advocated the Roux-en-Y gastrojejunostomy to minimize bile reflux. Sugerman et al. [5] later advocated multiple staple lines during pouch creation to minimize gastrogastric fistula and demonstrated the superiority of this approach over vertical banded gastroplasty in a randomized trial. In 1986, Linner [6] suggested gastric transection to minimize staple line separation and gastrogastric fistula formation. In 1991, Fobi et al. [7] and Cappella and Capella [8] advocated reinforcing the gastric pouch outlet with either a Silastic ring or Marlex mesh. In 1994, Wittgrove et al. [9] were the first to use the laparoscopic technique for gastric bypass, dramatically reducing perioperative morbidity (see Video 1). Other variations of gastric bypass used today include long-limb gastric bypass (150-cm Roux limb length) and distal gastric bypass, a rarely used malabsorptive procedure that uses a short (75 to 150 cm) common channel measured from the ileocecal valve [10].
Outcomes Although the laparoscopic approach is slightly more popular today and has been adopted rapidly, the open approach is still commonly performed [11,12]. Most of the outcome studies on open gastric bypass were published in the 1980s and 1990s, whereas the laparoscopic gastric bypass series have been published over the last 5 to 6 years. Thus a valid comparison of these historical series is compromised, because they are not contemporary series and
1550-7289/05/$ – see front matter © 2005 American Society for Bariatric Surgery. All rights reserved. doi:10.1016/j.soard.2005.03.214
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there are no controls for patient demographic and risk factors. Nevertheless, a general appreciation of complication rates and efficacy can be achieved by evaluating these series. Complications Perioperative complications. The rates of recognized shortterm (⬍ 30 days) perioperative complications for laparoscopic gastric bypass (ie, venous thrombosis, pulmonary embolus, bleeding, stenosis, symptomatic cholelithiasis, and marginal ulcer) appear very similar for both the open and laparoscopic approaches [12]. The laparoscopic approach is associated with reduced incidence of incisional hernia, wound infections, and pulmonary complications [12]. The incidence of such complications as intestinal leaks and internal hernias appears to be higher with the laparoscopic approach in the early learning experience of the surgeon [12]. In particular, the learning curve for laparoscopic Roux-en-Y gastric bypass is approximately 100 cases [13]. Major advantages of the laparoscopic approach appear to be a significant reduction in perioperative wound and pulmonary complications, as well as a reduction in hospital length of stay and overall time to recovery [14]. Collectively, major perioperative complications occur with an incidence of 5% to 10% [12]. Mortality. For the open series of gastric bypass operations (done in the 1980s and 1990s), mortality rates ranged from 0.3% to 1.5%. For laparoscopic gastric bypass series with more than 100 patients, mortality rates have varied from 0 to 0.9%. Considering that single-institution studies often represent outcomes at highly specialized centers, statewide or national studies are more reflective of mortality for all types of centers, including small rural and large city community hospitals and academic centers. Two statewide studies demonstrated in-hospital operative mortality for gastric bypass of 0.3% in California and 0.6% in Pennsylvania [15,16]. A bariatric surgery outcome study in Washington demonstrated a 1% in-hospital mortality and a 1.9% 30-day mortality [17]. In this study, a 5-fold increase in mortality was associated with surgeons who had performed fewer than 20 procedures. Another study using national inpatient hospital outcome data demonstrated an overall inpatient mortality rate of 0.6% at academic medical centers [18]. Long-term complications. Late problems (⬎ 30 days) generally fall into the category of nutritional/metabolic complications. Iron deficiency with associated anemia is the most common long-term complication, with an incidence between 25% and 50% in patients not receiving prophylactic iron supplementation [19]. The incidence of iron deficiency drops to 10% when prophylactic iron supplementation is routinely administered [20]. Vitamin B12 deficiency occurs in 33% to 37% of patients. Supplementation with intramuscular or sublingual B12 supplementation dramatically reduces the incidence of this complication. Malabsorption of
calcium and vitamin D may occur as a result of bypassing the duodenum and proximal jejunum with Roux-en-Y gastric bypass. Brolin et al. [10] demonstrated calcium and vitamin D deficiency rates of 10% and 51%, respectively, for the distal Roux-en-Y gastric bypass, but these deficiencies were not evident for the standard Roux limb length of 75 to 150 cm. Coates et al. [21] demonstrated diminished bone mineral density and content 9 months after gastric bypass surgery even though their patients were taking supplemental calcium and vitamin D. One study evaluating bone density at 3 years after gastric bypass demonstrated a decrease in bone mass only in postmenopausal women [22]. This study also found secondary hyperparathyroidism and evidence of bone resorption after gastric bypass that could not be suppressed by supplemental calcium and vitamin D for 6 months. The clinical significance of these findings suggesting impaired calcium absorption and metabolism after gastric bypass is unclear, especially because reports of secondary bone demineralization complications, such as fractures, are exceedingly rare. Thiamine (vitamin B1) deficiency rarely occurs after gastric bypass surgery (0.0002%) but can be deadly [23]. Thiamine deficiency may lead to Wernicke’s encephalopathy and a profound peripheral neuropathy that can be irreversible. This condition is characterized by mental confusion, aphonia, nystagmus, ophthalmoplegia, and, in late stages, coma and death. Treatment involves prompt administration of intravenous or intramuscular thiamine, 50 to 100 mg/day [24]. Deficiencies in fat-soluble vitamins as well as protein are known to be potential consequences of extreme malabsorption operations such as biliopancreatic diversion and distal gastric bypass, but are not generally associated with standard Rouxen-Y gastric bypass. Other deficiencies, including those of magnesium, zinc, selenium, and other micronutrients, are very rare after Roux-en-Y gastric bypass. Weight Loss Weight loss appears to be equivalent for laparoscopic and open gastric bypass procedures. The nadir of weight loss appears at 1-1/2 to 2 years after surgery and approximates 65% to 80% excess weight loss [5,7,8,12,14]. Studies with 5- to 15-year follow-up generally show some degree of weight gain over this time period. At 5 years, 60% to 70% excess weight loss is commonly reported. The longest follow-up for gastric bypass reported to date is 14 years by Pories et al. [25], demonstrating 49% excess weight loss. Ten-year follow-up in the Swedish Obese Subjects (SOS) Study demonstrated 10-year weight loss (as a percentage of initial body weight) of 25% for gastric bypass, 16% for vertical banded gastroplasty, and 13% for gastric banding [26]. A recent meta-analysis of bariatric surgery at 2 to 3 years after operation demonstrated profound excess weight loss: 62% for gastric bypass, 47% for gastric banding, 68% for gastroplasty, and 70% for biliopancreatic diversion [27].
P. Schauer / Surgery for Obesity and Related Diseases 1 (2005) 297–300
Comorbidity Changes Numerous studies have tracked improvement in comorbidity status after gastric bypass surgery [5,12,14,20,25– 27]. Although comorbidity changes after laparoscopic gastric bypass are less well studied than those after open operations, because weight loss is similar between the 2 approaches, changes in comorbidity should also be similar. The SOS Study evaluated comorbidity changes among all bariatric surgery patients compared with a matched cohort group. At 10 years after surgery, significant improvement or resolution of hypertension, diabetes, hypertriglyceridemia, and hypercholesterolemia were noted [26]. Even with the small sample size for gastric bypass patients (34 patients), they found significant improvements in diabetes and dyslipidemia but found no significant improvement in hypertension at 8 years after surgery [26]. This finding likely represents a type 2 statistical error because of the small sample size. Gastric bypass surgery appears to have a profound effect on type II diabetes mellitus, with a ⬎ 80% resolution (defined as euglycemic without the need for medication) [25–29].
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final BMI of 29 ⫾ 4 kg/m2 in a cohort of non-superobese patients (BMI ⬍ 50 kg/m2) (P ⬍ .0001). Determinants of Surgical Technique Although numerous operative technique variables, including pouch size, stoma size, and Roux limb length, have been proposed as major determinants of weight loss, only Roux limb length has been subject to randomized controlled studies. Brolin et al. [33] showed that a 150-cm Roux limb had a statistically greater weight loss than a 75-cm Roux limb in the short term, with this difference becoming less significant at 16 months after surgery. Reinforcement of the gastric outlet with a synthetic band, as promoted by Fobi et al. [7] and Capella and Capella [8], may be a modification of gastric bypass that achieves greater magnitude and longlasting weight loss. Five-year data with gastric pouch reinforcement demonstrates excess weight loss in the 77% to 80% range, which is among the highest reported for gastric bypass. Impact of Gastric Bypass on Longevity
Quality of Life Multiple studies have evaluated the effect of bariatric surgery on quality of life. A recent review by Livingston and Fink [30] identified 5 studies measuring quality of life after Roux-en-Y gastric bypass. Most of these studies used the SF 36 Quality of Life instrument and all reported significant improvements in quality of life after surgery. Determinants of Outcome Outcome studies to date have identified that patient factors, surgeon experience, and variations in surgical technique may affect complication rates and/or the magnitude and duration of weight loss. Advanced age, high body mass index (BMI), and male sex have been associated with an increased risk of perioperative complications as well as mortality [31]. It is likely that both advanced age and BMI are associated with increased operative risk, because they are associated with severe obesity comorbidity. Male sex is associated with central obesity, which has also been associated with increased perioperative risk. Surgeon experience is inversely related to operative complication rates and mortality [15–18]. Centers and surgeons that perform more than 100 gastric bypass operations per year report 2- to 3-fold lower complication rates and mortality rates. With respect to preoperative determinants of weight loss, although both sex and ethnic background have been suggested as predictors, thus far only preoperative BMI has been shown to be a negative predictor of achieving a BMI ⬍ 30 kg/m2. MacLean et al. [32], in a large series of gastric bypass patients, reported a final BMI of 35 ⫾ 7 kg/m2 in a cohort of superobese patients (BMI ⱖ 50 kg/m2) versus a
Because severe obesity is associated with significant comorbidity and premature mortality, surgically induced weight loss would be expected to enhance longevity. MacDonald et al [34] evaluated mortality rates and causes of death in 154 diabetic patients who underwent gastric bypass and in 78 diabetic patients matched for age, BMI, and sex who did not opt for surgery. They found a 9% mortality rate at 9 years of follow-up in the surgery group, compared with a 28% mortality rate at 6.2 years of follow-up in the nonsurgery control group (P ⬍ .05). The overwhelming cause of death in the control group was cardiovascular disease. Christou et al. [35], in a large Canadian study, evaluated mortality rates in 1035 patients who underwent bariatric surgery and in 5476 patients matched for age, sex, and BMI who did not undergo surgery. At 5-year follow-up, mortality was 0.68% in the surgery group and 6.17% in the nonsurgery group—a nearly 10-fold decrease in overall mortality in the surgery group. Conclusion In summary, Roux-en-Y gastric bypass is currently the most common bariatric procedure performed in North America. The laparoscopic approach offers significant benefits in terms of reduced perioperative morbidity and faster recovery. Complication and mortality rates for gastric bypass appear to be comparable to those for other major operations and appear to be dependent on patient risk factors as well as surgeon experience. Many studies have yielded excellent weight loss, 60% to 80% excess weight in the 3- to 5-year range. Surgically induced weight loss carries the benefits of comorbidity reduction, enhanced quality
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