Medium-term metabolic outcomes of obese diabetic patients after laparoscopic adjustable gastric banding

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Abstracts / Surgery for Obesity and Related Diseases 6 (2010) 224 –234

formed as part of a planned duodenal switch procedure was excluded. The sleeves were calibrated with a 32F bougie, and 5–7 cm of antrum was retained. Results: A total of 77 patients (27% men), median age 46 years (range 19 –71), with 26% of patients aged ⱖ50 years, were included. The initial median weight was 144 kg (range 89 –283), and the median body mass index (BMI) was 53 kg/m2 (range 29 – 83); 57% of the patients had a BMI of ⱖ50 kg/m2. Sleeve gastrectomy was done as a revisional procedure in 4 patients who had previously had adjustable gastric bands. Staple line leakage, treated by laparoscopic or endoscopic intervention, occurred in 5 patients. No mortality occurred. The gastric sleeve was subsequently converted to laparoscopic Roux-en-Y gastric bypass in 7 patients or a duodenal switch procedure in 2 patients, after a median interval of 30 months (range 18 –96). For patients with no conversion to another procedure, the number of patients available for follow-up was 51, 25, 20, 15, 9, 8, 8, and 5 at 1, 2, 3, 4, 5, 6, 7, and 8 years postoperatively, respectively. The corresponding median percentage of excess weight loss was 55%, 70%, 74%, 76%, 74%, 61%, 69%, and 66%; the corresponding 25th percentile for the percentage of excess weight loss was 55%, 70%, 74%, 76%, 74%, 61%, 69%, and 66%; and the corresponding 75th percentile was 78%, 87%, 82%, 83%, 88%, 74%, 82%, and 74%. Compared with the patients with an initial BMI of ⱖ50 kg/m2, those with a BMI ⬍50 kg/m2 had a significantly greater median percentage of excess weight loss at 1 year (49% versus 77%, respectively; P ⫽ .02), but no difference was found at 3 years (74% versus 74%; P ⫽ .7). Conclusions: Sleeve gastrectomy, as a stand-alone procedure, provided a median percentage of excess weight loss of ⬎60% for ⱕ8 years; additional analysis of the follow-up data is in progress. Compared with patients with a BMI ⬍50 kg/m2, super obese patients had proportionately less weight loss at 1 year but no apparent difference at 3 years. BODY IMAGE PERCEPTION AND MISPERCEPTION IN PATIENTS UNDERGOING BARIATRIC SURGERY Conor Magee, Jonathan Barry, Jayne Brocklehurst, Robert Macadam, Shafiq Javed, David Kerrigan, Gravitas Centre for Bariatric Surgery, Wirral, United Kingdom Background: Little is known about how patients undergoing bariatric surgery perceive their body image. Do they have an overly optimistic (or as do anorexics, pessimistic) view of themselves? We investigated patients’ perceptions of their preoperative habitus and also what they considered to be “acceptable” and “ideal” body images after weight loss surgery. Methods: A questionnaire using modified Stunkard silhouettes of male and female body shapes on an ordinal scale representing body mass indexes (BMIs) from ⬍19 to 50 kg/m2 was prospectively administered to a cohort of patients undergoing bariatric surgery. Patients were asked to identify their current body image and their ideal and acceptable body image after bariatric surgery. The categorical data were analyzed using the chi-square test. Results: A total of 112 patients were studied (81% women). Overall, 46% of patients incorrectly identified the silhouette that corresponded to their actual BMI, with most underestimating their size. Super-obese patients (BMI ⬎50 kg/m2) were less likely to correctly identify their body shape than those with a BMI ⬍50 kg/m2 (71% versus 23%, P ⬍.001). Most patients considering surgery (65%) viewed a body shape corresponding to a BMI in the

range of 25–33 kg/m2 as an acceptable outcome after surgery, with only 8% choosing a silhouette with a BMI of ⬍25 kg/m2. However, rephrasing the question to enquire as to their perception of an ideal outcome after surgery showed that 33% of patients would ideally prefer a silhouette representing a BMI of ⱕ25 kg/m2 (requiring ⱖ100% excess weight loss). Worryingly, 6 patients in this study ideally wanted bariatric surgery to leave them with a silhouette corresponding to a BMI of ⬍19 kg/m2. Conclusions: Misperception of body image is very common in patients undergoing bariatric surgery, particularly in the superobese, yet expectations of what bariatric surgery can achieve remained high. Body image perception analysis is a useful tool in helping surgeons manage patient expectations and identify those with possible psychopathology manifesting itself as gross overestimation of the surgical outcome. MEDIUM-TERM METABOLIC OUTCOMES OF OBESE DIABETIC PATIENTS AFTER LAPAROSCOPIC ADJUSTABLE GASTRIC BANDING Rishi Singhal, Missba Ahmed, Avril Krempic, Mark Kitchen, Paul Super, Heart of England NHS Foundation Trust, Birmingham, United Kingdom Background: Obesity is an independent risk factor in the development of diabetes, the severity of which increases with increasing excess weight. Weight loss surgery is the most effective treatment of morbid obesity. This study examined the effect of gastric banding on the medium and long-term metabolic profile in diabetics. Methods: From April 2003 to December 2008, 195 diabetic patients underwent laparoscopic adjustable gastric banding (LAGB) by a single surgeon. Data collection included preoperative and follow-up data for body mass index, weight, hemoglobin A1c, glucose, cholesterol, triglycerides, blood pressure, and diabetic medications. Results: Associated conditions included hypercholesterolemia (37.1%), hypertriglyceridemia (42.8%), and hypertension (77.5%). The mean preoperative weight and body mass index was 148.6 ⫾ 29.8 kg and 52.3 ⫾ 9 kg/m2, respectively. The percentage of excess body mass index loss at 6 and 12 months and 2 and 3 years was 30.1% ⫾ 14.2%, 34.9% ⫾ 17.6%, 41.5% ⫾ 20.3%, and 39.4% ⫾ 21.9%, respectively. The hemoglobin A1c levels had improved in 79.6%, 89.7%, and 83.1% of patients at the end of 1, 2, and 3 years, respectively. The fasting glucose levels had improved in 90%, 81.6%, and 85.7% of patients at the end of 1, 2, and 3 years, respectively. The mean dose of metformin had decreased from 1863 mg to 1060, 924, and 957 mg at the end of 1, 2, and 3 years, respectively, for the patients who were still taking it; 69 patients had stopped taking metformin at the end of 3 years. Of the 195 patients, 65 were taking insulin preoperatively. Overall, 22, 29, and 34 patients had discontinued using insulin by the end of the first, second, and third year, respectively. All patients who continued using insulin were able to reduce the dose. The total cholesterol level had improved in 60.8%, 59.6%, and 66.7% of patients at the end of 1, 2, and 3 years, respectively. The triglyceride levels had improved in 81.1%, 80%, and 80.8% of patients at the end of 1, 2, and 3 years, respectively. The mean arterial pressure had improved in 73.7%, 73.3%, and 77.5% of patients at the end of 1, 2, and 3 years, respectively. Conclusions: The metabolic syndrome associated with morbid obesity is difficult to adequately control with medication. LAGB

Abstracts / Surgery for Obesity and Related Diseases 6 (2010) 224 –234

can be considered a potentially curative treatment option in the management of this syndrome. SLEEVE GASTRECTOMY AS A BRIDGE TO A SECOND BARIATRIC PROCEDURE IN SUPER-OBESE PATIENTS—A SINGLE-INSTITUTION EXPERIENCE Samrat Mukherjee, Mehtab Rahman, Adam Goralczyk, Kesava Mannur, Homerton University Hospital NHS Foundation Trust, London, United Kingdom Background: The surgical treatment of morbidly obese patients with a body mass index (BMI) ⬎50 kg/m2 (super obese) with significant co-morbidities remains a challenge. We evaluated the outcomes after initial laparoscopic sleeve gastrectomy (LSG) in these patients undergoing 2-stage procedures. Methods: We identified all patients (BMI ⬎50 kg/m2) who had undergone LSG as a part of a 2-stage procedure, from 2005 to 2008, from our prospectively maintained database. The patient demographics and co-morbidities were noted, and we analyzed the morbidity and length of stay. Weight loss after the initial procedure was tracked and the BMI at the decision for the second stage noted. Results: A total of 59 patients with a BMI ⬎50 kg/m2 (median 60, range 50 – 81.5) underwent sleeve gastrectomy as a part of a 2-stage procedure for obesity during this period. The median age was 41.5 years (range 21– 61.5), and 37 were women (male/female ratio 3:5). The co-morbidities of diabetes, hypertension, and obstructive sleep apnea were present in different combinations in 44 patients (74.6%). All the procedures were completed laparoscopically, barring in 1 patient who had undergone previous fundoplication. The median length of stay was 4 days (interquartile range 3– 6). Complications occurred in 8 patients (13.5%), and 4 patients required repeat laparoscopy for staple line leak or bleeding. No mortality occurred. The median weight loss at 1 year was 42.4 kg (interquartile range 30.3– 60.2). Diabetes and obstructive sleep apnea resolved, and hypertension resolved in 70% patients. Of the 59 patients, 33 went on to have a second-stage procedure. The rest, who had undergone LSG in 2008 were still losing weight and the decision to proceed to the second stage had not been made at last follow-up. Of the 33 patients who had a second-stage procedure, 2 underwent Roux-en-Y gastric bypass, 2 underwent repeat sleeve gastrectomy, and 29 underwent duodenal switch. All the procedures were performed laparoscopically. Conclusions: LSG is a safe and effective procedure for initial weight loss in the super-obese undergoing 2-stage procedures. SHOULD WE ROUTINELY TEST FOR SERUM SELENIUM LEVELS IN POST-BARIATRIC SURGERY PATIENTS? Mutaz Suyagh, Peter Sedman, Prashant Jain, El-Naseer Salim, Khaled Hamdan, Hull and East Yorkshire Bariatric Unit, Hull, United Kingdom Background: Selenium is an essential mineral that plays an important role in the function of the immune system, protection against cancer, male fertility, and cardiovascular system. Selenium deficiency has been linked to cardiomyopathy, arrhythmia, muscle wasting, impaired immunity, low thyroid function, progressive encephalopathy, and skin problems. Very few data are available on the prevalence of selenium deficiency in postbariatric surgery patients. Although the accepted lower limit of normal for serum

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selenium is .9 ␮mol/L, evidence is strong that symptoms related to selenium deficiency may only appear when serum levels decrease to ⬍.3 ␮mol/L. The aim of this study was to evaluate serum selenium levels in a large cohort of bariatric patients and to assess the clinical relevance and financial implications of routinely requesting selenium levels after bariatric surgery. Methods: Serum selenium was measured using atomic absorption spectrometry. The results after gastric bypass surgery were collected for a period of 3 years from 2006 to 2009 in Hull and East Yorkshire NHS Trust. Results: A total of 1203 selenium tests were performed on 631 patients with an average of 2 tests per patient (range 1 to 7). Of the 631 patients, 462 (73%) had low selenium levels (⬍.9 ␮mol/L), with men equally affected as women. Only 4 patients (.63%) were found to have critical selenium deficiency (⬍.3 ␮mol/L). No clinically significant symptoms or hospital admissions were directly related to selenium deficiency. The yearly cost of routinely testing for selenium levels was £11,067 (£27.60 per test). Conclusions: This study clearly shows that the prevalence of critical selenium deficiency in postbariatric surgery patients is very low. A large proportion (73%) of our patients had selenium levels ⬍.9 ␮mol/L but without clinical consequences. A proportion of these patients might have already had pre-existing selenium deficiency before their surgery. Recent research has shown that selenium deficiency is mainly related to poor intake rather than problems with absorption. In conclusion, routinely testing for selenium levels in postoperative bariatric patients might not be justified on clinical grounds and does not appear to be cost effective. ENERGY EXPENDITURE AFTER ROUX-EN-Y GASTRIC BYPASS IN RATS Marco Buetera, Christian Löwensteinb, Hutan Ashrafiana, Ahmed R. Ahmedc, Torsten Olbersc, Steve R. Blooma, Thomas Lutzb, Carel W. le Rouxa, aHammersmith Hospital, Imperial College London, London, United Kingdom, bVetsuisse Faculty University of Zurich, Zurich, Switzerland, cImperial Weight Center, Charing Cross Hospital, London, United Kingdom Background: The Mechanisms underlying weight loss maintenance after gastric bypass surgery are poorly understood. It was the aim of our study to examine the effects of gastric bypass on energy expenditure in rats. Methods: Thirty male Wistar rats underwent either gastric bypass (n ⫽ 14), sham operation, with ad libitum feeding (n ⫽ 8), or sham operation, body weight-matched (n ⫽ 8). Energy expenditure measurements were conducted using an open circuit calorimetry system. Results: The body weight after 70 days was lower after gastric bypass (414.3 ⫾ 13.8 g) compared with the sham-operated ad libitum fed rats (603.2 ⫾ 6.6 g, P ⬍.0001). The sham-operated body weight-matched controls required less food than the gastric bypass rats to reach the same body weight (sham-operated body weight-matched 16.2 ⫾ .5 g versus bypass 27.5 ⫾ .8 g, P ⬍.001). The 24-hour energy expenditure was increased after gastric bypass (4.50 ⫾ .04 kcal/kg/h) compared with the sham-operated ad libitum fed rats (4.29 ⫾ .08 kcal/kg/h) and sham-operated body weight-matched controls (3.98 ⫾ .10 kcal/kg/h, P ⬍.001). The gastric bypass rats showed greater energy expenditure during the light phase than did the sham-operated ad libitum fed controls or