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m2 with the morbidly obese
Author's Accepted Manuscript
Outcomes of Roux-En-Y Gastric Bypass in the Super Obese: Comparison of BMI 50-60kg/m2 and Z60kg/m2 to the Morbidly Obese Rena Moon MD, Lars Nelson MD, Andre Teixeira MD, Muhammad A. Jawad MD, FACS
www.journals.elsevier.com/surgery-for-obesity-and-related-diseases/
PII: DOI: Reference:
S1550-7289(15)01007-2 http://dx.doi.org/10.1016/j.soard.2015.10.072 SOARD2447
To appear in:
Surgery for Obesity and Related Diseases
Cite this article as: Rena Moon MD, Lars Nelson MD, Andre Teixeira MD, Muhammad A. Jawad MD, FACS, Outcomes of Roux-En-Y Gastric Bypass in the Super Obese: Comparison of BMI 50-60kg/m2 and Z60kg/m2 to the Morbidly Obese, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2015.10.072 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
RYGB in the Super Obese OUTCOMES OF ROUX-EN-Y GASTRIC BYPASS IN THE SUPER OBESE: COMPARISON OF BMI 50-60KG/M2 AND ≥60KG/M2 TO THE MORBIDLY OBESE
Rena Moon, MD; Lars Nelson, MD; Andre Teixeira, MD; Muhammad A. Jawad, MD, FACS
Department of Bariatric Surgery Orlando Regional Medical Center & Bariatric and Laparoscopy Center Orlando Health
Correspondence: Muhammad A. Jawad, MD Medical Director, Department of Bariatric Surgery Orlando Regional Medical Center & Bariatric and Laparoscopy Center Orlando Health 89 Copeland Dr, 1st Floor Orlando, FL, USA Phone 352-351-5770 Fax 352-629-3145 E-mail [email protected] The abstract of this manuscript was accepted for poster presentation at 2015 ASMBS annual meeting in Los Angeles, CA.
RYGB in the Super Obese
Abstract Background: Reports on the outcomes of Roux-en-Y gastric bypass (RYGB) in super obese patients are limited, especially on patients with body mass index (BMI) ≥ 60 kg/m2. Purpose: The aim of our study was to evaluate and compare the safety and efficacy of RYGB in the super obese, by comparing patients with a BMI 50-60 kg/m2 and a BMI ≥60 kg/m2 to those with a BMI 40-50 kg/m2. Setting: Academic Practice Material and Methods: Between January 2004 and November 2013, a total of 2,717 patients underwent RYGB at our institution. Of these, 661 (24.3%) had a preoperative BMI between 50-60 kg/m2 and 230 (8.5%) had a BMI ≥ 60kg/m2. A retrospective review of outcomes and complications was performed, comparing these patients to 1,555 patients with a BMI between 40-50 kg/m2. Results: Fifty-two (3.3%) patients in the BMI 40-50 kg/m2 group, fifteen (2.3%) patient in the BMI 50-60 kg/m2 group and three (1.3%) patients in the BMI ≥ 60 kg/m2 had less than 30 days of follow-up. Readmission rate was 10.7%, 9.2%, and 11.7%, and reoperation rate was 7.3%, 5.0%, and 6.1% in the BMI 40-50, 50-60 and ≥ 60 kg/m2 group, respectively. No significant difference was found in readmission rate among the three groups, and reoperation rate was significantly lower in the BMI 50-60 kg/m2 group. Mean percentage of excess BMI loss (%EBMIL) was 58.3%, 80.6%, 85.8%, 83.3%, and 80.9% in the BMI 40-50 kg/m2, 44.9%, 65.0%, 70.1%, 72.1%, and 65.9% in the BMI 50-60 kg/m2, and 38.5%, 57.4%, 62.2%, 62.8%, and
RYGB in the Super Obese 59.1% in the ≥ 60 kg/m2 group at 6, 12, 18, 24, and 36 month, respectively. The differences in %EBMIL were statistically significant among all three groups at all follow-up time points. All groups showed a significant decrease in their mean number of comorbidities after the procedure. Conclusions: Readmission and reoperation rates were similar in BMI 40-50, 50-60, and ≥ 60kg/m2 group. Super obese and super-super obese patients are not at greater risk for surgical complications when compared to those with lower BMIs. Key Words: super obese; super-super obese; gastric bypass; BMI over 60; complications; safety; efficacy
INTRODUCTION Obesity is a significant problem in the United States today. Current estimates are 69% of adults are either overweight or obese, with approximately 35% obese(1). Obesity continues to be highly prevalent, especially in some racial and ethnic minority groups, as well as in those with lower incomes and less education. Overweight and obesity are major contributors to chronic diseases and present a major public health challenge(2). Overweight is defined as a body mass index (BMI) of 25-30 kg/m2 and obesity as a BMI of ≥30 kg/m2 (1). Further classification stratification systems have sub-divided obesity into patients having a BMI of 40-50 kg/m2 as morbidly obese, a BMI of 50-60 kg/m2 as super obese, and a BMI of ≥ 60 kg/m2 as super-super obese(3). Surgical management for morbid obesity continues to be robust in the management of obesity for weight reduction and improvement in co-morbidities. There have
RYGB in the Super Obese been debates as to the ideal bariatric procedure for the super obese. Several procedures are in current practice today including: laparoscopic sleeve gastrectomy, which continues to be on the rise(4); laparoscopic biliopancreatic diversionduodenal switch, which is only offered at a few institutions; and laparoscopic Rouxen-Y gastric bypass (RYGB), which is one of the most common procedures (5). Literature on the outcomes for the super obese undergoing RYGB is limited. Several studies have been conducted showing higher morbidity and mortality in the super obese patients undergoing LRYGB (6-10). Others refute this and show comparisons to be more unequivocal (11-17). Despite the difference, bariatric surgery is considered to be safe and effective in the super obese. The goal of our study is to evaluate and compare the safety and efficacy of RYGB in the super obese, by comparing patients with a BMI 50-60 kg/m2 and BMI ≥60 kg/m2, to the morbidly obese with a BMI of 40-50 kg/m2.
METHODS AND MATERIALS After institutional review board approval and following the Health Insurance Portability and Accountability Act guidelines, the authors performed a retrospective chart review of a prospectively maintained database of 2,717 patients who underwent RYGB between January 1st, 2004 and November 30th, 2013. Majority of cases were done laparoscopic, except in 87 cases in 2004 done as open, and 48 cases in 2013 done as robot-assisted laparoscopic. A total of 1,555 patients were identified as a BMI 40-50 kg/m2, and 891 patients were identified as a BMI ≥ 50 kg/m2 at the time of LRYGB. Super obese patients were separated into two groups,
RYGB in the Super Obese BMI 50-60 kg/m2 and BMI ≥ 60 kg/m2, noting the degree of weight loss and postoperative complications. RYGB was performed by two surgeons according to the National Institutes of Health criteria for surgical management of morbid obesity. Patients were followed up at our office clinic at 1, 3, 6, 12 months postoperatively and yearly thereafter. Followup visits included weight measurement, clinical history and examination, and laboratory tests for blood glucose as well as nutrition deficiency. Comorbid conditions were recorded at each visit. Remission of hypertension was defined as blood pressure below 140/90 mmHg without medication. Remission of diabetes mellitus was defined as fasting glucose level below 126mg/dl without medication. Remission of sleep apnea was based on patient’s statement and no usage of continuous positive airway pressure (CPAP) machine. All data for age and BMI are demonstrated as mean ± standard deviation, unless otherwise noted. Statistical analysis was performed using descriptive analysis, twotailed Student’s t-test, and analysis of variance, with p<0.05 regarded as statistically significant.
RESULTS Of 1,555 morbidly obese patients with a BMI 40-50 kg/m2, 1,294 were female and 261 were male. Patients had a mean age of 42.3±11.0 years (range, 18-70), and a mean preoperative BMI of 44.6±7.7 kg/m2 (range, 40.0-49.9). Out of 891 super obese patients, 661 (74.2%) had a preoperative BMI between 5060 kg/m2 and 230 (25.8%) had a BMI ≥ 60kg/m2. The BMI 50-60 kg/m2 group
RYGB in the Super Obese consisted 522 female and 139 male patients with a mean age of 42.1±10.8 years (range, 17-66) and a mean preoperative BMI of 54.1±2.7 kg/m2 (range, 50.0-59.9). The BMI ≥ 60kg/m2 group consisted 160 female and 70 male patients with a mean age of 40.1±10.3 years (range, 19-64) and a mean preoperative BMI of 66.2±6.6 kg/m2 (range 60.0-99.7). Mean number of comorbidities showed no significant difference between the three groups. Patient demographics are shown in Table 1.
Complications Readmission rate was 10.7% (n=166), and reoperation rate was 7.3% (n=113) in the control (BMI 40-50 kg/m2) group with 2 (0.1%) procedure-related mortalities. A total of 61 patients (9.2%) in the BMI 50-60 kg/m2 group were readmitted 76 times with complaints of abdominal pain (n=42), nausea, vomiting and/or dehydration (n=9), hematemesis (n=5), pulmonary embolism (n=4), gastrostomy tube infection (n=3), gastro-gastric fistula (n=2), deep venous thrombosis (n=1), thiamin deficiency (n=1), subphrenic abscess (n=1), anemia (n=1), melena (n=1), syncope (n=1), back pain (n=1), abdominal wall abscess (n=1), candida esophagitis (n=1), dysphagia (n=1), and trocar site hernia (n=1). Initial diagnosis was made at a mean interval of 14.6±21.5 months (range, 0-100) following the RYGB. Of these patients, 33 (5.0%) underwent a total of 36 reoperations. Reoperations included lysis of adhesions (n=13), revision of the gastrojejunostomy (n=4), repair of internal herniation (n=4), repair of a perforated ulcer (n=3), choledochoduodenostomy (n=2), incision and drainage (n=2), resection of gastro-gastric fistula (n=2), inferior vena cava filter placement (n=1), resection of the dilated blind limb (n=1), incisional
RYGB in the Super Obese hernia repair (n=1), secondary wound closure (n=1), draining gastrostomy placement (n=1), and a trocar site hernia repair (n=1). One mortality (0.2%) occurred in this patient population. This patient was readmitted 37 days after an open retrocolic-retrogastric RYGB, for abdominal pain. She was sent home with conservative management. However she returned to the emergency department 8 days later with abdominal pain. When taken to the operating room (OR), her small bowel was volvulized under the Roux-limb. Her gastrojejunostomy was redone, however, the patient developed cardiac arrest and pneumothorax. Despite taking her back to the OR for exploratory laparotomy and draining gastrostomy placement, the patient expired 13 days later. A total of 27 patients (11.7%) in the BMI ≥ 60 kg/m2 group were readmitted 46 times with complaints of abdominal pain (n=19), nausea, vomiting and/or dehydration (n=13), hematemesis (n=5), chest pain (n=2), pneumonia (n=2), deep venous thrombosis (n=1), gastrostomy tube leak (n=1), gastrostomy tube infection (n=1), melena (n=1), and neuroglycopenia (n=1). Initial diagnosis was made at a mean interval of 11.7±23.1 months (range, 0-114) following the LRYGB. Of these patients, 14 (6.1%) underwent a total of 16 reoperations. The reoperations included lysis of adhesions (n=5), repair of internal herniation (n=3), revision of the gastrojejunostomy (n=3), resection of the gastrogastric fistula (n=1), repair of a perforated ulcer (n=1), reversal of the LRYGB (n=1), resection of the small bowel (n=1), and oversewing of a gastric pouch leak (n=1). One (0.4%) mortality occurred in the BMI ≥ 60 kg/m2 group. This patient had a preoperative BMI of 76.8 kg/m2, and the anesthesiologist had difficulty intubating
RYGB in the Super Obese and extubating. The patient had a respiratory and cardiac arrest 9 days following the LRYGB due to an aortic valve stenosis. He subsequently had several episodes of ventricular tachycardia and expired 15 days following the procedure. The readmission rate (p>0.07) did not show statistical difference between the three groups. The reoperation rate did not show difference between the BMI 50-60kg/m2 and ≥ 60 kg/m2 group (p<0.03), however BMI 50-60 kg/m2 group showed significantly lower rate than the BMI 40-50 kg/m2 group. The mortality rate did not show significant difference between the three groups (Table 2).
Weight Loss and Comorbidities Fifty-two (3.3%) patients in the BMI 40-50 kg/m2 group, fifteen (2.3%) in the BMI 50-60 kg/m2 group, and three (1.3%) in the BMI ≥ 60 kg/m2 group who had less than 30 days of follow-up were excluded from the data analysis. Mean follow-up period was 22.5±23.3 months (range, 1-121) in the BMI 40-50 kg/m2 group, 21.7±22.0 months (range, 1-111) in the BMI 50-60 kg/m2 group, and 21.6±22.3 months (range, 1-115) in the BMI ≥ 60 kg/m2 group. Mean percentage of excess BMI loss (%EBMIL) dating from the time of LRYGB was 58.3%, 80.6%, 85.8%, 83.3%, and 80.9% in the BMI 40-50 kg/m2 group, 44.9%, 65.0%, 70.1%, 72.1%, and 65.9% in the BMI 50-60 kg/m2 group, and 38.5%, 57.4%, 62.2%, 62.8%, and 59.1% in the ≥ 60 kg/m2 group at 6, 12, 18, 24, and 36 month, respectively. The differences in %EBMIL were statistically significant among all three groups at all follow-up time point (Fig 1, Table 3).
RYGB in the Super Obese The mean number of comorbidities at last follow-up was 1.1±1.1 (range, 0-4) in the BMI 40-50 kg/m2 group, 1.2±1.0 in the BMI 50-60 kg/m2 group, and 1.1±1.1 (range, 0-4) in the BMI ≥ 60 kg/m2 group. When these were compared to the preoperative mean number of comorbidities, all groups showed a significant decrease in their mean number of comorbidities (p<0.01).
DISCUSSION Prevalence of obesity in the United States has increased dramatically during the period of 1976 through 2000(1). Smaller changes were noted between 1999 and 2010, and overall the percentage of obese population was 35% in US adults during the 2009-2010 period. However, there is change in the distribution of the BMI. Flegal et al.(18) reported increased skewness with a greater shift in the upper part of the distribution, and so the heaviest subgroup was heavier than prior studies in 2000. According to this trend, bariatric surgeons are expected to encounter more patients with a higher BMI. Extremely obese patients may experience a higher rate of complications when compared to those of less obese patients, especially when the approach is laparoscopic (7,19,20). Stephens et al.(6) reported super-super obese (BMI ≥ 60kg/m2) patients required a longer operating room times, a longer hospital length of stay, and were more likely to be discharged to chronic care facilities than were patients with a BMI less than 60 kg/m2. On the contrary, Gould et al.(19) found no significant difference in the length of hospital stay and the 30-day readmission rate in their 28 BMI ≥ 60 kg/m2 patients when compared to those of 260 patients with a BMI < 60 kg/m2. However, they
RYGB in the Super Obese reported an overall postoperative complication rate of 46.4% in the BMI ≥ 60kg/m2 group. We found no significant difference in readmission rate and mortality among our three groups of patients. Reoperation rate was also similar, although BMI 50-60 kg/m2 group showed the lowest rate. Readmission and reoperation rates were not as high as it has been documented in the super-super obese group (21,22), at 11.7% and 61.1%, respectively. We agree with several reports concluding that super-super obese patients should not be excluded from LRYGB because of a perceived risk based upon BMI (8,11,17). Many studies have demonstrated that patients with a BMI higher than 60 kg/m2 have less weight loss than those with a lower BMI after LRYGB(11,19, 23). In our study, each subgroup showed significant difference in weight loss at 6, 12, 18, 24, and 36 months after surgery. BMI 40-50 kg/m2 group lost more than BMI 50-60 kg/m2 group, and BMI 50-60 kg/m2 group lost more than BMI ≥ 60 kg/m2 group in terms of %EBMIL. However, when we looked at the mean number of comorbid conditions, all three group showed significant decrease after the procedure. As we only took resolution of comorbidities into account, it is possible that more patients had an improvement in their comorbid conditions. We would like to note that we were not able to utilize HbA1c as an indicator for diabetes resolution, and we relied on patient’s report of CPAP usage for sleep apnea resolution. These may have factored in and weaken our comorbidity-related results. Our study is limited because it is retrospective in nature. Our patients were not randomized, the mean age of BMI ≥ 60 kg/m2 patients was younger than those of
RYGB in the Super Obese BMI 40-50 kg/m2 and 50-60 kg/m2 patients, and the number of BMI 40-50 kg/m2 patients were more than those of patients with BMI 50-60 kg/m2 and BMI ≥ 60kg/m2.
CONCLUSION The readmission and reoperation rates were similar in BMI 40-50, 50-60, and ≥ 60kg/m2 group. Super obese and super-super obese patients is not at greater risk for surgical complications when compared to those with lower BMIs.
DISCLOSURE Drs. Moon, Nelson, Teixeira, and Jawad have no commercial associations that might be a conflict of interest in relation to this article.
REFERENCES 1. Flegal KM, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA 2012;307:491– 7. 2. Jensen MD, Ryan DH, Apovian CM et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. JAMA 2014;63(25 Pt B);3029-30. 3. Standards Committee, American Society for Bariatric Surgery. Guidelines for reporting results in bariatric surgery. Obes Surg 1997;7:521-2.
RYGB in the Super Obese 4. Rosenthal RJ. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. 2012;8:819. 5. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427-36. 6. Stephens DJ, Saunders JK, Belsley S et al. Short-term outcomes for super-super obese (BMI > or =60 kg/m2) patients undergoing weight loss surgery at a highvolume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass. Surg Obes Relat Dis 2008;4:408-15. 7. Oliak D, Ballantyne GH, Davies RJ, Wasielewski A, Schmidt HJ. Short-term results of laparoscopic gastric bypass in patients with BMI > or = 60. Obes Surg 2002;12:643–7. 8. Artuso D, Wayne M, Kaul A, Bairamian M, Teixeira J, Cerabona T. Extremely high body mass index is not a contraindication to laparoscopic gastric bypass. Obes Surg 2004;14:750–4. 9. Shuhaiber J, Vitello J. Is gastric bypass associated with more complications in patients weighing >500 lb(>227 kg)? Obes Surg 2004;14: 43-6. 10. Helling TS. Operative experience and follow-up in a cohort of patients with a BMI > or =70 kg/m2. Obes Surg 2005;15:482-5. 11. Taylor JD, Leitman IM, Hon P, Horowitz M, Panagopoulos G. Outcome and complications of gastric bypass in super-super obesity versus morbid obesity. Obes Surg 2006;16:16-8. 12. Raftopoulos I, Ercole J, Udekwu AO, Luketich JD, Courcoulas AP. Outcomes
RYGB in the Super Obese of Roux-en-Y gastric bypass stratified by a body mass index of 70 kg/m2: a comparative analysis of 825 procedures. J Gastointest Surg 2005;9:44-52. 13. Kreitz K, Rovito PF. Laparoscopic Roux-en-Y gastric bypass in the “megaobese”. Arch Surg 2003;138:707-9. 14. Dresel A, Kuhn JA, McCarty TM. Laparoscopic Roux-en-Y gastric bypass in morbidly obese and super morbidly obese patients. Am J Surg 2004;187: 230-2. 15. Tichansky DS, DeMaria EJ, Fernandez AZ, Kellum JM, Wolfe LG, Meador JG, Sugerman HJ. Postoperative complications are not increased in super-super obese patients who undergo laparoscopic Roux-en-Y gastric bypass. Surg Endosc 2005;19:939–41. 16. Farkas DT, Vemulapalli P, Haider A, Lopes JM, Gibbs KE, Teixeira JA. Laparoscopic Roux-en-Y gastric bypass is safe and effective in patients with a BMI > or =60. Obes Surg 2005;15:486-93. 17. Parikh MS, Shen R, Weiner M, Siegel N, Ren CJ. Laparoscopic bariatric surgery in super-obese patients (BMI>50) is safe and effective: a review of 332 patients. Obes Surg 2005;15:858–63. 18. Flegal KM, Troiano RP. Changes in the distribution of body mass index of adults and children in the US population. Int J Obes Relat Metab Disord 2000;24:807-18. 19. Gould JC, Garren MJ, Boll V, Starling JR. Laparoscopic gastric bypass : risks vs benefits up to two years following surgery in super-super obese patients. Surgery 2006;140:524-31. 20. MacLean LD, Rhode BM, Nohr CW. Late outcomes of isolated gastric bypass. Ann Surg 2000;231:524-8.
RYGB in the Super Obese 21. Mason E, Doherty C, Maher J, et al. Super obesity and gastric reduction procedures. Gastroenterol Clin North Am 1987;16:495-502. 22. Brolin R, LaMarca L, Kenler H, et al. Malabsorptive gastric bypass in patients with superobesity. J Gastrointest Surg 2002;6:195-205. 23. Thereaux J, Czernichow S, Corigliano N, Poitou C, Oppert JM, Bouillot JL. Fiveyear outcomes of gastric bypass for super-super-obesity (BMI ≥ 60kg/m2) : A case matched study. Surg Obes Relat Dis 2014 [epub ahead of print]
Table(s)
BMI 50-60 kg/m2 522 (79.0%) 139 (21.0%) 42.1±10.8 (range, 17-66) 54.1±2.7 (range, 50.0-59.9) 1.5±1.2 (range, 0-4)
BMI 40-50 kg/m2 1,294 (83.3%) 261 (16.8%) 42.3±11.0 (range, 18-70) 44.6±7.7 (range, 40.0-49.9) 1.5±1.2 (range, 0-4)
160 (69.6%) 70 (30.4%) 40.1±10.3 (range, 19-64) 66.2±6.6 (range, 60.0-99.7) 1.4±1.2 (range, 0-4)
BMI ≥ 60 kg/m2
>0.19
<0.01
<0.01
<0.01
p-value
BMI : body mass index
Table 1. Demographics of patients with BMI 40-50 kg/m2, 50-60kg/m2 and ≥ 60kg/m2 * Comorbidities accounted for include hypertension, hypercholesterolemia, diabetes mellitus, and sleep apnea
Mean number of comorbidities*
Preoperative BMI(kg/m2)
Age(years)b
Characteristics Gender(n) Female Male
Table(s)
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Table(s)
BMI 50-60 kg/m2(n=646) n %EBMIL %WL 173 44.9±9.5 24.1±4.9 251 65.0±13.9 34.9±7.3 237 70.1±15.4 37.6±8.1 180 72.1±15.4 38.6±8.2 119 65.9±17.0 35.2±8.8
BMI ≥ 60 kg/m2 (n=227) n %EBMIL %WL 69 38.5±9.3 24.0±5.8 94 57.4±12.5 35.6±7.6 80 62.2±14.8 38.5±9.0 61 62.8±13.1 38.8±8.1 36 59.1±16.5 36.9±9.8
BMI : body mass index %EBMIL : percentage of excess body mass index loss % WL : percentage of weight loss mo : months
Table 3. Weight reduction in BMI 40-50 kg/m2, BMI 50-60 kg/m2, and BMI ≥ 60 kg/m2 patientsat 6, 12, 18, 24 and 36 months after laparoscopic Roux-en-Y gastric bypass * Fifty-two (3.3%) patients in the BMI 40-50 kg/m2 group, fifteen (2.3%) patient in the BMI 50-60 kg/m2 group and three (1.3%) patients in the BMI ≥ 60 kg/m2had less than 30 days of follow-up. ‘n’ in each column represents number of patients with available weight data.
6 mo 12 mo 18 mo 24 mo 36mo
BMI 40-50 kg/m2 (n=1,503) n %EBMIL %WL 407 58.3±13.7 25.3±5.4 536 80.6±19.4 34.9±7.9 547 85.8±19.2 37.2±8.1 459 83.3±20.8 36.3±8.8 304 80.9±21.3 35.3±9.0
Figure(s)
100 90 80
EBMIL (%)
70 60 50
BMI 40-50
40
BMI 50-60 BMI ≥60
30 20 10 0 6 mo (p<0.01)
12 mo (p<0.01)
18 mo (p<0.01)
24 mo (p<0.01)
36 mo (p<0.01)
Figure 1. Changes in the EBMILafter laparoscopic Roux-en-Y gastric bypass in the super obese * Fifty-two (3.3%) patients in the BMI 40-50 kg/m2 group, fifteen (2.3%) patient in the BMI 50-60 kg/m2 group and three (1.3%) patients in the BMI ≥ 60 kg/m2had less than 30 days of follow-up BMI : body mass index EWL :percentage of excess BMI loss
Outcomes of Roux-En-Y Gastric Bypass in the Super Obese: Comparison of BMI 50-60kg/m2 and Z60kg/m2 to the Morbidly Obese Rena Moon MD, Lars Nelson MD, Andre Teixeira MD, Muhammad A. Jawad MD, FACS
www.journals.elsevier.com/surgery-for-obesity-and-related-diseases/
PII: DOI: Reference:
S1550-7289(15)01007-2 http://dx.doi.org/10.1016/j.soard.2015.10.072 SOARD2447
To appear in:
Surgery for Obesity and Related Diseases
Cite this article as: Rena Moon MD, Lars Nelson MD, Andre Teixeira MD, Muhammad A. Jawad MD, FACS, Outcomes of Roux-En-Y Gastric Bypass in the Super Obese: Comparison of BMI 50-60kg/m2 and Z60kg/m2 to the Morbidly Obese, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j.soard.2015.10.072 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
RYGB in the Super Obese OUTCOMES OF ROUX-EN-Y GASTRIC BYPASS IN THE SUPER OBESE: COMPARISON OF BMI 50-60KG/M2 AND ≥60KG/M2 TO THE MORBIDLY OBESE
Rena Moon, MD; Lars Nelson, MD; Andre Teixeira, MD; Muhammad A. Jawad, MD, FACS
Department of Bariatric Surgery Orlando Regional Medical Center & Bariatric and Laparoscopy Center Orlando Health
Correspondence: Muhammad A. Jawad, MD Medical Director, Department of Bariatric Surgery Orlando Regional Medical Center & Bariatric and Laparoscopy Center Orlando Health 89 Copeland Dr, 1st Floor Orlando, FL, USA Phone 352-351-5770 Fax 352-629-3145 E-mail [email protected] The abstract of this manuscript was accepted for poster presentation at 2015 ASMBS annual meeting in Los Angeles, CA.
RYGB in the Super Obese
Abstract Background: Reports on the outcomes of Roux-en-Y gastric bypass (RYGB) in super obese patients are limited, especially on patients with body mass index (BMI) ≥ 60 kg/m2. Purpose: The aim of our study was to evaluate and compare the safety and efficacy of RYGB in the super obese, by comparing patients with a BMI 50-60 kg/m2 and a BMI ≥60 kg/m2 to those with a BMI 40-50 kg/m2. Setting: Academic Practice Material and Methods: Between January 2004 and November 2013, a total of 2,717 patients underwent RYGB at our institution. Of these, 661 (24.3%) had a preoperative BMI between 50-60 kg/m2 and 230 (8.5%) had a BMI ≥ 60kg/m2. A retrospective review of outcomes and complications was performed, comparing these patients to 1,555 patients with a BMI between 40-50 kg/m2. Results: Fifty-two (3.3%) patients in the BMI 40-50 kg/m2 group, fifteen (2.3%) patient in the BMI 50-60 kg/m2 group and three (1.3%) patients in the BMI ≥ 60 kg/m2 had less than 30 days of follow-up. Readmission rate was 10.7%, 9.2%, and 11.7%, and reoperation rate was 7.3%, 5.0%, and 6.1% in the BMI 40-50, 50-60 and ≥ 60 kg/m2 group, respectively. No significant difference was found in readmission rate among the three groups, and reoperation rate was significantly lower in the BMI 50-60 kg/m2 group. Mean percentage of excess BMI loss (%EBMIL) was 58.3%, 80.6%, 85.8%, 83.3%, and 80.9% in the BMI 40-50 kg/m2, 44.9%, 65.0%, 70.1%, 72.1%, and 65.9% in the BMI 50-60 kg/m2, and 38.5%, 57.4%, 62.2%, 62.8%, and
RYGB in the Super Obese 59.1% in the ≥ 60 kg/m2 group at 6, 12, 18, 24, and 36 month, respectively. The differences in %EBMIL were statistically significant among all three groups at all follow-up time points. All groups showed a significant decrease in their mean number of comorbidities after the procedure. Conclusions: Readmission and reoperation rates were similar in BMI 40-50, 50-60, and ≥ 60kg/m2 group. Super obese and super-super obese patients are not at greater risk for surgical complications when compared to those with lower BMIs. Key Words: super obese; super-super obese; gastric bypass; BMI over 60; complications; safety; efficacy
INTRODUCTION Obesity is a significant problem in the United States today. Current estimates are 69% of adults are either overweight or obese, with approximately 35% obese(1). Obesity continues to be highly prevalent, especially in some racial and ethnic minority groups, as well as in those with lower incomes and less education. Overweight and obesity are major contributors to chronic diseases and present a major public health challenge(2). Overweight is defined as a body mass index (BMI) of 25-30 kg/m2 and obesity as a BMI of ≥30 kg/m2 (1). Further classification stratification systems have sub-divided obesity into patients having a BMI of 40-50 kg/m2 as morbidly obese, a BMI of 50-60 kg/m2 as super obese, and a BMI of ≥ 60 kg/m2 as super-super obese(3). Surgical management for morbid obesity continues to be robust in the management of obesity for weight reduction and improvement in co-morbidities. There have
RYGB in the Super Obese been debates as to the ideal bariatric procedure for the super obese. Several procedures are in current practice today including: laparoscopic sleeve gastrectomy, which continues to be on the rise(4); laparoscopic biliopancreatic diversionduodenal switch, which is only offered at a few institutions; and laparoscopic Rouxen-Y gastric bypass (RYGB), which is one of the most common procedures (5). Literature on the outcomes for the super obese undergoing RYGB is limited. Several studies have been conducted showing higher morbidity and mortality in the super obese patients undergoing LRYGB (6-10). Others refute this and show comparisons to be more unequivocal (11-17). Despite the difference, bariatric surgery is considered to be safe and effective in the super obese. The goal of our study is to evaluate and compare the safety and efficacy of RYGB in the super obese, by comparing patients with a BMI 50-60 kg/m2 and BMI ≥60 kg/m2, to the morbidly obese with a BMI of 40-50 kg/m2.
METHODS AND MATERIALS After institutional review board approval and following the Health Insurance Portability and Accountability Act guidelines, the authors performed a retrospective chart review of a prospectively maintained database of 2,717 patients who underwent RYGB between January 1st, 2004 and November 30th, 2013. Majority of cases were done laparoscopic, except in 87 cases in 2004 done as open, and 48 cases in 2013 done as robot-assisted laparoscopic. A total of 1,555 patients were identified as a BMI 40-50 kg/m2, and 891 patients were identified as a BMI ≥ 50 kg/m2 at the time of LRYGB. Super obese patients were separated into two groups,
RYGB in the Super Obese BMI 50-60 kg/m2 and BMI ≥ 60 kg/m2, noting the degree of weight loss and postoperative complications. RYGB was performed by two surgeons according to the National Institutes of Health criteria for surgical management of morbid obesity. Patients were followed up at our office clinic at 1, 3, 6, 12 months postoperatively and yearly thereafter. Followup visits included weight measurement, clinical history and examination, and laboratory tests for blood glucose as well as nutrition deficiency. Comorbid conditions were recorded at each visit. Remission of hypertension was defined as blood pressure below 140/90 mmHg without medication. Remission of diabetes mellitus was defined as fasting glucose level below 126mg/dl without medication. Remission of sleep apnea was based on patient’s statement and no usage of continuous positive airway pressure (CPAP) machine. All data for age and BMI are demonstrated as mean ± standard deviation, unless otherwise noted. Statistical analysis was performed using descriptive analysis, twotailed Student’s t-test, and analysis of variance, with p<0.05 regarded as statistically significant.
RESULTS Of 1,555 morbidly obese patients with a BMI 40-50 kg/m2, 1,294 were female and 261 were male. Patients had a mean age of 42.3±11.0 years (range, 18-70), and a mean preoperative BMI of 44.6±7.7 kg/m2 (range, 40.0-49.9). Out of 891 super obese patients, 661 (74.2%) had a preoperative BMI between 5060 kg/m2 and 230 (25.8%) had a BMI ≥ 60kg/m2. The BMI 50-60 kg/m2 group
RYGB in the Super Obese consisted 522 female and 139 male patients with a mean age of 42.1±10.8 years (range, 17-66) and a mean preoperative BMI of 54.1±2.7 kg/m2 (range, 50.0-59.9). The BMI ≥ 60kg/m2 group consisted 160 female and 70 male patients with a mean age of 40.1±10.3 years (range, 19-64) and a mean preoperative BMI of 66.2±6.6 kg/m2 (range 60.0-99.7). Mean number of comorbidities showed no significant difference between the three groups. Patient demographics are shown in Table 1.
Complications Readmission rate was 10.7% (n=166), and reoperation rate was 7.3% (n=113) in the control (BMI 40-50 kg/m2) group with 2 (0.1%) procedure-related mortalities. A total of 61 patients (9.2%) in the BMI 50-60 kg/m2 group were readmitted 76 times with complaints of abdominal pain (n=42), nausea, vomiting and/or dehydration (n=9), hematemesis (n=5), pulmonary embolism (n=4), gastrostomy tube infection (n=3), gastro-gastric fistula (n=2), deep venous thrombosis (n=1), thiamin deficiency (n=1), subphrenic abscess (n=1), anemia (n=1), melena (n=1), syncope (n=1), back pain (n=1), abdominal wall abscess (n=1), candida esophagitis (n=1), dysphagia (n=1), and trocar site hernia (n=1). Initial diagnosis was made at a mean interval of 14.6±21.5 months (range, 0-100) following the RYGB. Of these patients, 33 (5.0%) underwent a total of 36 reoperations. Reoperations included lysis of adhesions (n=13), revision of the gastrojejunostomy (n=4), repair of internal herniation (n=4), repair of a perforated ulcer (n=3), choledochoduodenostomy (n=2), incision and drainage (n=2), resection of gastro-gastric fistula (n=2), inferior vena cava filter placement (n=1), resection of the dilated blind limb (n=1), incisional
RYGB in the Super Obese hernia repair (n=1), secondary wound closure (n=1), draining gastrostomy placement (n=1), and a trocar site hernia repair (n=1). One mortality (0.2%) occurred in this patient population. This patient was readmitted 37 days after an open retrocolic-retrogastric RYGB, for abdominal pain. She was sent home with conservative management. However she returned to the emergency department 8 days later with abdominal pain. When taken to the operating room (OR), her small bowel was volvulized under the Roux-limb. Her gastrojejunostomy was redone, however, the patient developed cardiac arrest and pneumothorax. Despite taking her back to the OR for exploratory laparotomy and draining gastrostomy placement, the patient expired 13 days later. A total of 27 patients (11.7%) in the BMI ≥ 60 kg/m2 group were readmitted 46 times with complaints of abdominal pain (n=19), nausea, vomiting and/or dehydration (n=13), hematemesis (n=5), chest pain (n=2), pneumonia (n=2), deep venous thrombosis (n=1), gastrostomy tube leak (n=1), gastrostomy tube infection (n=1), melena (n=1), and neuroglycopenia (n=1). Initial diagnosis was made at a mean interval of 11.7±23.1 months (range, 0-114) following the LRYGB. Of these patients, 14 (6.1%) underwent a total of 16 reoperations. The reoperations included lysis of adhesions (n=5), repair of internal herniation (n=3), revision of the gastrojejunostomy (n=3), resection of the gastrogastric fistula (n=1), repair of a perforated ulcer (n=1), reversal of the LRYGB (n=1), resection of the small bowel (n=1), and oversewing of a gastric pouch leak (n=1). One (0.4%) mortality occurred in the BMI ≥ 60 kg/m2 group. This patient had a preoperative BMI of 76.8 kg/m2, and the anesthesiologist had difficulty intubating
RYGB in the Super Obese and extubating. The patient had a respiratory and cardiac arrest 9 days following the LRYGB due to an aortic valve stenosis. He subsequently had several episodes of ventricular tachycardia and expired 15 days following the procedure. The readmission rate (p>0.07) did not show statistical difference between the three groups. The reoperation rate did not show difference between the BMI 50-60kg/m2 and ≥ 60 kg/m2 group (p<0.03), however BMI 50-60 kg/m2 group showed significantly lower rate than the BMI 40-50 kg/m2 group. The mortality rate did not show significant difference between the three groups (Table 2).
Weight Loss and Comorbidities Fifty-two (3.3%) patients in the BMI 40-50 kg/m2 group, fifteen (2.3%) in the BMI 50-60 kg/m2 group, and three (1.3%) in the BMI ≥ 60 kg/m2 group who had less than 30 days of follow-up were excluded from the data analysis. Mean follow-up period was 22.5±23.3 months (range, 1-121) in the BMI 40-50 kg/m2 group, 21.7±22.0 months (range, 1-111) in the BMI 50-60 kg/m2 group, and 21.6±22.3 months (range, 1-115) in the BMI ≥ 60 kg/m2 group. Mean percentage of excess BMI loss (%EBMIL) dating from the time of LRYGB was 58.3%, 80.6%, 85.8%, 83.3%, and 80.9% in the BMI 40-50 kg/m2 group, 44.9%, 65.0%, 70.1%, 72.1%, and 65.9% in the BMI 50-60 kg/m2 group, and 38.5%, 57.4%, 62.2%, 62.8%, and 59.1% in the ≥ 60 kg/m2 group at 6, 12, 18, 24, and 36 month, respectively. The differences in %EBMIL were statistically significant among all three groups at all follow-up time point (Fig 1, Table 3).
RYGB in the Super Obese The mean number of comorbidities at last follow-up was 1.1±1.1 (range, 0-4) in the BMI 40-50 kg/m2 group, 1.2±1.0 in the BMI 50-60 kg/m2 group, and 1.1±1.1 (range, 0-4) in the BMI ≥ 60 kg/m2 group. When these were compared to the preoperative mean number of comorbidities, all groups showed a significant decrease in their mean number of comorbidities (p<0.01).
DISCUSSION Prevalence of obesity in the United States has increased dramatically during the period of 1976 through 2000(1). Smaller changes were noted between 1999 and 2010, and overall the percentage of obese population was 35% in US adults during the 2009-2010 period. However, there is change in the distribution of the BMI. Flegal et al.(18) reported increased skewness with a greater shift in the upper part of the distribution, and so the heaviest subgroup was heavier than prior studies in 2000. According to this trend, bariatric surgeons are expected to encounter more patients with a higher BMI. Extremely obese patients may experience a higher rate of complications when compared to those of less obese patients, especially when the approach is laparoscopic (7,19,20). Stephens et al.(6) reported super-super obese (BMI ≥ 60kg/m2) patients required a longer operating room times, a longer hospital length of stay, and were more likely to be discharged to chronic care facilities than were patients with a BMI less than 60 kg/m2. On the contrary, Gould et al.(19) found no significant difference in the length of hospital stay and the 30-day readmission rate in their 28 BMI ≥ 60 kg/m2 patients when compared to those of 260 patients with a BMI < 60 kg/m2. However, they
RYGB in the Super Obese reported an overall postoperative complication rate of 46.4% in the BMI ≥ 60kg/m2 group. We found no significant difference in readmission rate and mortality among our three groups of patients. Reoperation rate was also similar, although BMI 50-60 kg/m2 group showed the lowest rate. Readmission and reoperation rates were not as high as it has been documented in the super-super obese group (21,22), at 11.7% and 61.1%, respectively. We agree with several reports concluding that super-super obese patients should not be excluded from LRYGB because of a perceived risk based upon BMI (8,11,17). Many studies have demonstrated that patients with a BMI higher than 60 kg/m2 have less weight loss than those with a lower BMI after LRYGB(11,19, 23). In our study, each subgroup showed significant difference in weight loss at 6, 12, 18, 24, and 36 months after surgery. BMI 40-50 kg/m2 group lost more than BMI 50-60 kg/m2 group, and BMI 50-60 kg/m2 group lost more than BMI ≥ 60 kg/m2 group in terms of %EBMIL. However, when we looked at the mean number of comorbid conditions, all three group showed significant decrease after the procedure. As we only took resolution of comorbidities into account, it is possible that more patients had an improvement in their comorbid conditions. We would like to note that we were not able to utilize HbA1c as an indicator for diabetes resolution, and we relied on patient’s report of CPAP usage for sleep apnea resolution. These may have factored in and weaken our comorbidity-related results. Our study is limited because it is retrospective in nature. Our patients were not randomized, the mean age of BMI ≥ 60 kg/m2 patients was younger than those of
RYGB in the Super Obese BMI 40-50 kg/m2 and 50-60 kg/m2 patients, and the number of BMI 40-50 kg/m2 patients were more than those of patients with BMI 50-60 kg/m2 and BMI ≥ 60kg/m2.
CONCLUSION The readmission and reoperation rates were similar in BMI 40-50, 50-60, and ≥ 60kg/m2 group. Super obese and super-super obese patients is not at greater risk for surgical complications when compared to those with lower BMIs.
DISCLOSURE Drs. Moon, Nelson, Teixeira, and Jawad have no commercial associations that might be a conflict of interest in relation to this article.
REFERENCES 1. Flegal KM, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999–2010. JAMA 2012;307:491– 7. 2. Jensen MD, Ryan DH, Apovian CM et al. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. JAMA 2014;63(25 Pt B);3029-30. 3. Standards Committee, American Society for Bariatric Surgery. Guidelines for reporting results in bariatric surgery. Obes Surg 1997;7:521-2.
RYGB in the Super Obese 4. Rosenthal RJ. International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines based on experience of >12,000 cases. 2012;8:819. 5. Buchwald H, Oien DM. Metabolic/bariatric surgery worldwide 2011. Obes Surg 2013;23:427-36. 6. Stephens DJ, Saunders JK, Belsley S et al. Short-term outcomes for super-super obese (BMI > or =60 kg/m2) patients undergoing weight loss surgery at a highvolume bariatric surgery center: laparoscopic adjustable gastric banding, laparoscopic gastric bypass, and open tubular gastric bypass. Surg Obes Relat Dis 2008;4:408-15. 7. Oliak D, Ballantyne GH, Davies RJ, Wasielewski A, Schmidt HJ. Short-term results of laparoscopic gastric bypass in patients with BMI > or = 60. Obes Surg 2002;12:643–7. 8. Artuso D, Wayne M, Kaul A, Bairamian M, Teixeira J, Cerabona T. Extremely high body mass index is not a contraindication to laparoscopic gastric bypass. Obes Surg 2004;14:750–4. 9. Shuhaiber J, Vitello J. Is gastric bypass associated with more complications in patients weighing >500 lb(>227 kg)? Obes Surg 2004;14: 43-6. 10. Helling TS. Operative experience and follow-up in a cohort of patients with a BMI > or =70 kg/m2. Obes Surg 2005;15:482-5. 11. Taylor JD, Leitman IM, Hon P, Horowitz M, Panagopoulos G. Outcome and complications of gastric bypass in super-super obesity versus morbid obesity. Obes Surg 2006;16:16-8. 12. Raftopoulos I, Ercole J, Udekwu AO, Luketich JD, Courcoulas AP. Outcomes
RYGB in the Super Obese of Roux-en-Y gastric bypass stratified by a body mass index of 70 kg/m2: a comparative analysis of 825 procedures. J Gastointest Surg 2005;9:44-52. 13. Kreitz K, Rovito PF. Laparoscopic Roux-en-Y gastric bypass in the “megaobese”. Arch Surg 2003;138:707-9. 14. Dresel A, Kuhn JA, McCarty TM. Laparoscopic Roux-en-Y gastric bypass in morbidly obese and super morbidly obese patients. Am J Surg 2004;187: 230-2. 15. Tichansky DS, DeMaria EJ, Fernandez AZ, Kellum JM, Wolfe LG, Meador JG, Sugerman HJ. Postoperative complications are not increased in super-super obese patients who undergo laparoscopic Roux-en-Y gastric bypass. Surg Endosc 2005;19:939–41. 16. Farkas DT, Vemulapalli P, Haider A, Lopes JM, Gibbs KE, Teixeira JA. Laparoscopic Roux-en-Y gastric bypass is safe and effective in patients with a BMI > or =60. Obes Surg 2005;15:486-93. 17. Parikh MS, Shen R, Weiner M, Siegel N, Ren CJ. Laparoscopic bariatric surgery in super-obese patients (BMI>50) is safe and effective: a review of 332 patients. Obes Surg 2005;15:858–63. 18. Flegal KM, Troiano RP. Changes in the distribution of body mass index of adults and children in the US population. Int J Obes Relat Metab Disord 2000;24:807-18. 19. Gould JC, Garren MJ, Boll V, Starling JR. Laparoscopic gastric bypass : risks vs benefits up to two years following surgery in super-super obese patients. Surgery 2006;140:524-31. 20. MacLean LD, Rhode BM, Nohr CW. Late outcomes of isolated gastric bypass. Ann Surg 2000;231:524-8.
RYGB in the Super Obese 21. Mason E, Doherty C, Maher J, et al. Super obesity and gastric reduction procedures. Gastroenterol Clin North Am 1987;16:495-502. 22. Brolin R, LaMarca L, Kenler H, et al. Malabsorptive gastric bypass in patients with superobesity. J Gastrointest Surg 2002;6:195-205. 23. Thereaux J, Czernichow S, Corigliano N, Poitou C, Oppert JM, Bouillot JL. Fiveyear outcomes of gastric bypass for super-super-obesity (BMI ≥ 60kg/m2) : A case matched study. Surg Obes Relat Dis 2014 [epub ahead of print]
Table(s)
BMI 50-60 kg/m2 522 (79.0%) 139 (21.0%) 42.1±10.8 (range, 17-66) 54.1±2.7 (range, 50.0-59.9) 1.5±1.2 (range, 0-4)
BMI 40-50 kg/m2 1,294 (83.3%) 261 (16.8%) 42.3±11.0 (range, 18-70) 44.6±7.7 (range, 40.0-49.9) 1.5±1.2 (range, 0-4)
160 (69.6%) 70 (30.4%) 40.1±10.3 (range, 19-64) 66.2±6.6 (range, 60.0-99.7) 1.4±1.2 (range, 0-4)
BMI ≥ 60 kg/m2
>0.19
<0.01
<0.01
<0.01
p-value
BMI : body mass index
Table 1. Demographics of patients with BMI 40-50 kg/m2, 50-60kg/m2 and ≥ 60kg/m2 * Comorbidities accounted for include hypertension, hypercholesterolemia, diabetes mellitus, and sleep apnea
Mean number of comorbidities*
Preoperative BMI(kg/m2)
Age(years)b
Characteristics Gender(n) Female Male
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Table(s)
BMI 50-60 kg/m2(n=646) n %EBMIL %WL 173 44.9±9.5 24.1±4.9 251 65.0±13.9 34.9±7.3 237 70.1±15.4 37.6±8.1 180 72.1±15.4 38.6±8.2 119 65.9±17.0 35.2±8.8
BMI ≥ 60 kg/m2 (n=227) n %EBMIL %WL 69 38.5±9.3 24.0±5.8 94 57.4±12.5 35.6±7.6 80 62.2±14.8 38.5±9.0 61 62.8±13.1 38.8±8.1 36 59.1±16.5 36.9±9.8
BMI : body mass index %EBMIL : percentage of excess body mass index loss % WL : percentage of weight loss mo : months
Table 3. Weight reduction in BMI 40-50 kg/m2, BMI 50-60 kg/m2, and BMI ≥ 60 kg/m2 patientsat 6, 12, 18, 24 and 36 months after laparoscopic Roux-en-Y gastric bypass * Fifty-two (3.3%) patients in the BMI 40-50 kg/m2 group, fifteen (2.3%) patient in the BMI 50-60 kg/m2 group and three (1.3%) patients in the BMI ≥ 60 kg/m2had less than 30 days of follow-up. ‘n’ in each column represents number of patients with available weight data.
6 mo 12 mo 18 mo 24 mo 36mo
BMI 40-50 kg/m2 (n=1,503) n %EBMIL %WL 407 58.3±13.7 25.3±5.4 536 80.6±19.4 34.9±7.9 547 85.8±19.2 37.2±8.1 459 83.3±20.8 36.3±8.8 304 80.9±21.3 35.3±9.0
Figure(s)
100 90 80
EBMIL (%)
70 60 50
BMI 40-50
40
BMI 50-60 BMI ≥60
30 20 10 0 6 mo (p<0.01)
12 mo (p<0.01)
18 mo (p<0.01)
24 mo (p<0.01)
36 mo (p<0.01)
Figure 1. Changes in the EBMILafter laparoscopic Roux-en-Y gastric bypass in the super obese * Fifty-two (3.3%) patients in the BMI 40-50 kg/m2 group, fifteen (2.3%) patient in the BMI 50-60 kg/m2 group and three (1.3%) patients in the BMI ≥ 60 kg/m2had less than 30 days of follow-up BMI : body mass index EWL :percentage of excess BMI loss