Weight loss eight years after gastric bypass

Abstracts

OBJETIVO: Avaliar a eficácia da derivação gástrica com bandagem em Y-de-Roux na promoção da perda de peso após oito anos de seguimento. MÉTODOS: Duzentos e onze obesos foram submetidos à derivação gástrica com bandagem em Y-de-Roux, pela mesma equipe cirúrgica. O desenho do estudo foi longitudinal, prospectivo e descritivo. A análise da diminuição do peso no pós-operatório foi baseado na perda do excesso de peso em percentual e no cálculo do IMC. Falha terapêutica foi considerada quando os pacientes perderam <50% do excesso de peso. RESULTADOS: A perda de seguimento foi de 36,5%, portanto, 134 pacientes foram incluídos neste estudo. A perda do excesso de peso em percentual média global no pós-operatório foi de: 67,6 ± 14,9% no primeiro ano, 72,6 ± 14,9% no segundo ano, 69,7 ± 15,1% no quinto ano e 66,8 ± 7,6 em oito anos. Falha no tratamento cirúrgico ocorreu em 15 pacientes (7,1%) ao longo dos oito anos. CONCLUSÃO: A derivação gástrica com bandagem em Y-de-Roux foi efetiva na promoção e manutenção da perda de peso no longo prazo, com baixa taxa de falhas.

Cirurgia bariátrica; Perda de peso; Derivação gástrica; Obesidade

ORIGINAL ARTICLE

Weight loss eight years after gastric bypass

Antonio Carlos Valezi, TCBC-PR^I; Jorge Mali Junior, TCBC-PR^II; Mariano de Almeida Menezes^III; Edivaldo Macedo de Brito, ACBC-PR^IV; José Carlos Lacerda de Souza, ACBC-PR^V

^IAssociate Professor, Department of Surgery, Hospital Universitário da Universidade Estadual de Londrina - PR-BR

^IISurgeon, University Hospital, Hospital Universitário da Universidade Estadual de Londrina - PR-BR

^IIIFormer resident, Department of Surgery, Hospital Universitário da Universidade Estadual de Londrina-PR-BR

^IVMaster's Degree in Surgery; Associate Professor, Department of Surgery, State University of Londrina-PR-BR

^VMaster's Degree in Surgery; Associate Professor, Department of Surgery, Universidade do Estado de Londrina-PR-BR

Correspondence

ABSTRACT

OBJECTIVE: To evaluate the effectiveness of banded Roux-en-Y gastric bypass in promoting weight loss after an eight-year follow-up.

METHODS: Two hundred and eleven obese patients underwent Roux-en-Y gastric bypass with banding by the same surgical team. The study design was longitudinal, prospective and descriptive. The analysis of weight decrease in the postoperative period was based on the loss of excess weight in percentage and BMI. Failure was considered when patients lost <50% of excess weight.

RESULTS: The loss of follow-up was 36.5%, therefore, 134 patients were included in this study. The loss of excess weight in global average rate in the postoperative period was: 67.6 ± 14.9% in the first year, 72.6 ± 14.9% in the second year, 69.7 ± 15.1% in fifth year and 66.8 ± 7.6 in eight years. Surgical treatment failure occurred in 15 patients (7.1%) over the period.

CONCLUSION: Banded Roux-en-Y gastric bypass was effective in promoting and sustaining weight loss in the long term, with low failure rates.

Key words: Bariatric surgery. Weight loss. Gastric bypass. Obesity.

INTRODUCTION

Obesity is a serious global public health problem, affecting developed and developing countries. People with a BMI> 30 kg/m² represent 7% of global population¹. In Brazil, the prevalence of obesity increased from 2.4% in 1970 to 6.9% in the 1990s among men and 7% to 12.5% among women. The incidence of obesity continues to increase; it is estimated that Brazil has 3.7 million people with morbid obesity, which corresponds to 3% of the population ².

People with a BMI above 40 kg/m² have higher incidence of comorbidities³ and more difficult to lose weight and maintain its loss compared with other groups. Clinical treatment based on diet, physical activity and medication is barely able to sustain weight loss, patients often regaining the lost weight over a period of one to five years⁴.

Significant weight loss and ability to keep it in the long run is the goal of bariatric surgery. Brolin et al.⁵ suggest postoperative follow-up of at least five years to establish reliable assessment of the success of surgical treatment. Few studies have longer follow-up.

The objective of this study is to evaluate the effectiveness of banded Roux-en-Y gastric bypass (BRYGB) as for weight loss and its maintenance in eight years of follow-up.

METHODS

Two hundred and eleven obese underwent BRYGB carried out by the same surgical team at the Hospital Universitário da Universidade Estadual de Londrina from May 1999 to December 2000. The sample was obtained by convenience, patients were selected prospectively and consecutively, which made the study observational, descriptive and longitudinal. The protocol was approved by the Ethics Committee in Research of the Hospital Universitário da Universidade Estadual de Londrina - number 55/99.

We analyzed demographic data (gender, age, weight, BMI) and weight loss. The analysis of this last variable during follow-up was done by comparing the percentage of excess weight loss (% EWL) with the preoperative values. Body weight was determined by reference to the table of the Metropolitan Life Insurance Company. The inability to lose more than 50% of excess weight was considered treatment failure.

To describe continuous data, we used the mean and standard deviation, and to describe smaller and discrete variables we used median and range.

Patient selection was based on the recommendation of the Brazilian Society of Metabolic and Bariatric Surgery. Patients initially underwent clinical evaluation by an interdisciplinary team. Follow-up was done through monthly outpatient visits in the first year, every six months until the fifth year and annually thereafter. The evaluation was made by the same multidisciplinary team.

RESULTS

Clinical follow-up was performed in 134 (63.5%) patients in eight years. There were 101 (75.4%) female patients and 33 (24.6%) male. Mean age was 43.4 ± 10.6 years (18-69 years). Body mass index (BMI) was 44.2 ± 5.1 kg/m² (35-67 kg/m²) preoperatively. The distribution of patients according to BMI is shown in figure 1.

The mean BMI decreased from 43.2 ± 5.3 k/m² preoperatively to 28.7 ± 4.0 kg/m² in the first year after surgery to 27.6 ± 3.7 in the second postoperative year, increased to 28.2 ± 4 in the fifth year and 29, 6 ± 3.6 in the eighth year (Figure 2). The %EWL varied inversely with the BMI. The average change in the overall %EWL was 67.6 ± 14.9 in the first postoperative year, 72.6 ± 14.9 in the second, 69.7 ± 15.1% in five years and 66.8 ± 7.6 in eight.

The %EWL in eight years, stratified by BMI, showed a reduction of 70.3 ± 17.2% after the first year, 74.3 ± 17.6% in the second, 71.4 ± 16.5% after the fifth and 69.7 ± 13.6% in the eighth year after the operation in patients with BMI <40 kg/m². In the group with BMI between 40 and 50 kg/m², weight loss was 66 ± 13.7% after the first year, 72% ± 13.6 after the second, 69.5 ± 14.4% after fifth and 66.8 ± 15.1% after the eighth postoperative year. In patients with BMI 50-60 kg/m², weight loss was 60 ± 11.8% after the first year, 66% ± 9.7 after the second, 61 ± 11.7% after the fifth and 60.3 ± 14% after the eighth year. In patients with a BMI> 60 kg/m² the %EWL was 70% ± 2% over the first year, 76 ± 4% in the second, 77% ± 6.6 in the fifth and 73.3 ± 9.8% in the eighth year (Figure 3).

Failure was found in 15 patients (7.1%) over the eight years. In super-obese patients (BMI e" 50), one of 11 (9.1%) had treatment failure.

DISCUSSION

The results of conservative treatment for morbid obesity are associated with disease recurrence. Bariatric surgery is an effective treatment for this form of obesity. Its success is defined as loss of at least 50% overweight^6,7.

Mason & Ito⁸ introduced, in 1967, the concept of reducing gastric surgery in the treatment of obesity. Printen and Mason⁹ changed the procedure in 1972, suggesting a closer anastomosis, because they understood that the limiting factor would increase weight loss. In 1977, Griffen¹⁰ recommended that the gastro-jejunal anastomosis was performed in a Roux-en-Y fashion. Torres and Oca¹¹ began using the small curvature in the construction of the gastric pouch in 1980.

The use of prostheses in the terminal portion of the gastric pouch began with Laws and Piantadosi¹² in1981, and Linner and Drew¹³ in 1985, who used a silicone ring to prevent the expansion of gastro-jejunal anastomosis. The controversy as to whether restricting gastric emptying would be necessary to obtain better surgical outcomes was started.

Fobi¹⁴, reported the placement of silicone ring above the anastomosis in RYGB in 1986. In 1990, Capella¹⁵ described a similar process, where the silicone band was placed around the distal end of the gastric pouch, which was later replaced by a polypropylene mesh. Recently, Salinas et al.¹⁶ have studied the importance of the restricting factor and concluded that a circumferential silicone band of 6.0 cm is well tolerated in most patients. These authors emphasize that if such prostheses are not used, patients may not lose weight or may be more likely to recover some of the weight lost after the operation.

Capella¹⁵ published his first results in 1991, and in 1996 showed that BRYGB promoted more significant weight loss than the Mason's vertical banded gastroplasty¹⁷. The results obtained in these years following mixed bariatric procedures have become the gold standard for surgical treatment of obesity^18-20. A systematic review focusing on long-term weight loss demonstrated that BRYGB and biliopancreatic derivation are the procedures that promote the best result in five years of follow-up²¹.

Banded Roux-en-Y gastric bypass causes satiety and reduces caloric intake by delaying gastric emptying and induces satiety even with low food intake, although there are other factors involved in weight loss after bariatric surgery, such as the gastrointestinal hormones. The silicone ring, in addition to its restrictive function, contributes to the reduction of undesirable side effects (dumping syndrome, flatulence).

The role of the ring in the prevention of weight regain in the long term remains controversial. The malabsorptive component of BRYGB is another important factor in weight loss. Despite the anatomical factor, the role of incretins is important in weight loss. BRYGB generally promotes intense and lasting weight reduction²², which is initially rapid and lessens later^23,24. After the second or third postoperative year the patient seems to adapt to the operation and suffer its side effects less intensively, which brings a certain tendency to weight regain²⁵. The small amount of weight gain is due to the patient's adaptation to the operation, lower intensity of dumping syndrome, gastric pouch dilation, increase in the diameter of the gastrojejunal anastomosis²⁶ and possibly lower restriction of gastric emptying caused by loosening of the ring^17,27.

The loss of excess weight has been used as the main factor analysis of the results of bariatric surgery. Capella²⁸ observed an average 77% EWL in five years, with 93% of patients losing over 50% of excess weight. MacLean et al.⁶ had treatment failure of 7%. Fobi et al.¹⁹ showed 72% EWL in 10 years, with 5% failure rate.Sugerman²⁹, with no use of the ring, reported average 60% EWL in five years and White et al.³⁰, 70% over the same period. Kruseman et al.³¹ showed, in an eight-years study, that 59% of patients had more than 50% excess weight loss. The present study found a 66.8% EWL in eight years, where 92.9% of patients lost more than 50% of excess weight.

Regarding follow-up, there is greater incidence of weight regain after the third year after surgery³². Scozzari et al.³³ showed 60.9% EWL three years after surgery, 57% in five years and 53% in seven years after the operation. Others showed no weight regain over the years³⁴. The data from this study show no significant recovery of weight after the fifth postoperative year.

Brolin⁵ established the time of five years as the minimum follow-up to analyze patients' weight regain. MacLean et al.⁶ conducted a follow up of 88.6% of patients between three and five years. Capella and Capella⁷ showed that only 63% of patients completed five years of follow-up. White et al.³⁰ showed mean follow-up of 48.6 months. This included 63.5% of patients in eight years postoperatively.

In conclusion, the BRYGB was effective in promoting weight loss and its long-term maintenance, with low rates of treatment failure.

REFERENCES

• 1. Seidell JC. The epidemiology of obesity. In: Bjöntorp P, editors. International textbook of obesity. New York: John Wiley and Sons; 2001. p.23-9.
• 2. Monteiro CA, D'A Benicio MH, Conde WL, Popkin BM. Shifting obesity trends in Brazil. Eur J Clin Nutr 2000; 54(4):342-6.
• 3. von Eyben FE, Mouritsen E, Holm J, Montvilas P, Dimcevski G, Suciu G, et al. Intra-abdominal obesity and metabolic risk factors: a study of young adults. Int J Obes Relat Metab Disord 2003; 27(8):941-9.
• 4. Kuczmarski RJ. Prevalence of overweight and weight gain in the United States. Am J Clin Nutr 1992; 55(2 Suppl):495S-502S.
• 5. Brolin RE, LaMarca LB, Kenler HA, Cody RP. Malabsorptive gastric bypass in patients with superbesity. J Gastrintest Surg 2002; 6(2):195-203; discussion 204-5.
• 6. MacLean LD, Rhode BM, Nohr CW. Late outcome of isolated gastric bypass. Ann Surg 2000; 231(4):524-8.
• 7. Capella JF, Capella RF. An assessment of vertical banded gastroplasty-Roux-en-Y gastric bypass for the treatment of morbid obesity. Am J Surg 2002; 183(2):117-23.
• 8. Mason EE, Ito C. Gastric bypass in obesity. Surg Clin North Am 1967; 47(6):1345-51.
• 9. Mason EE, Printen KJ, Hartford CE, Boyd WC. Optimizing results of gastric bypass. Ann Surg 1975; 182(4):405-14.
• 10. Griffen WO Jr, Bivins BA, Bell RM, Jackson KA. Gastric bypass for morbid obesity. World J Surg 1981; 5(6):817-22.
• 11. Torres JC, Oca CF, Garrison RN. Gastric bypass: Roux-en-Y gastrojejunostomy from the lesser curvature. South Med J 1983; 76(10):1217-21.
• 12. Laws HL, Piantadosi S. Superior gastric reduction procedure for morbid obesity: a prospective, randomized trial. Ann Surg 1981; 193(3):334-40.
• 13. Linner JR, Drew RL. Technique of anterior wall Roux-en-Y gastric bypass for the treatment of morbid obesity. Contemp Surg 1985; 26: 46-59.
• 14. Fobi M, Lee H, Flemming AW. The surgical technique of the banded gastric bypass. J Obes Weight Regul 1989; 8(2):99-102.
• 15. Capella RF, Capella JF, Mandec H, Nath P. Vertical banded gastroplasty-gastric bypass: preliminary report. Obes Surg 1991; 1(4):389-95.
• 16. Salinas A, Santiago E, Yegüez J, Antor M, Salinas H. Silastic ring vertical gastric bypass: evolution of an open surgical technique, and review of 1,588 cases. Obes Surg 2005; 15(10):1403-7.
• 17. Capella JF, Capella RF. The weight reduction operation of choice: vertical banded gastroplasty or gastric bypass ? Am J Surg 1996; 171(1):74-9.
• 18. Fox SR, Fox KS, Oh KH. The gastric bypass for failed bariatric surgical procedures. Obes Surg 1991; 6(2):145-50.
• 19. Fobi MA. Vertical banded gastroplasty vs gastric bypass: 10 years follow-up. Obes Surg 1993; 3(2):161-4.
• 20. Schauer PR, Ikramuddin S, Gourash W, Ramanathan R, Luketich J. Outcomes after laparoscopic roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000; 232(4):515-29.
• 21. O'Brien PE, McPhail T, Chaston TB, Dixon JB. Systematic review of medium-term weight loss after bariatric operations. Obes Surg 2006; 16(8):1032-40.
• 22. Pajecki D, Dalcanalle L, Souza de Oliveira CP, Zilberstein B, Halpern A, Garrido AB Jr, et al. Follow-up of roux-en-Y gastric bypass patients at 5 or more years postoperatively. Obes Surg. 2007; 17(5):601-7. Erratum in: Obes Surg 2007; 17(7):996.
• 23. Bessler M, Daud A, Kim T, DiGiorgi M. Prospective randomized trial of banded versus nonbanded gastric bypass for the super obese: early results. Surg Obes Relat Dis 2007; 3(4):480-4; discussion 484-5.
• 24. Arceo-Olaiz R, España-Gómez MN, Montalvo-Hernández J, Velázquez-Fernández D, Pantoja JP, Herrera MF. Maximal weight loss after banded and unbanded laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial. Surg Obes Relat Dis 2008; 4(4):507-11.
• 25. Mali JJ, Valezi AC, de Menezes MC. Weight loss outcome after silastic ring Roux-en-Y gastric bypass: five years of follow-up. Obes Surg 2007; 17(10):1287-91.
• 26. Morton JM. Weight gain after bariatric surgery as a result of a large gastric stoma: endotherapy with sodium morrhuate to induce stomal stenosis may prevent the need for surgical revision. Gastrointest Endosc 2007; 66(2):246-7.
• 27. Dapri G, Cadière GB, Himpens J. Laparoscopic placement of non-adjustable silicone ring for weight regain after Roux-en-y gastric bypass. Obes Surg 2009; 19(5):650-4.
• 28. Mason EE, Maher JW, Scott DH, Doherty C, Cullen JJ, Rodriguez EM, et al. Ten years of vertical banded gastroplasty for severe obesity. In: Mason EE, editor. Surgical treatment of morbid obesity. Philadelphia: JB Lippincott; 1992. p.280-9.
• 29. Sugerman HJ, Kelum JM, DeMaria EJ. Conversion of proximal to distal gastric bypass for failed gastric bypass for superobesity. J Gastrointest Surg 1997; 1(6):517-24; discussion 524-6.
• 30. White S, Brooks E, Jurikova L, Stubbs RS. Long-term outcomes after gastric bypass. Obes Surg 2005; 15(2):155-63.
• 31. Kruseman M, Leimgruber A, Zumbach F, Golay A. Dietary, weight, and psychological changes among patients with obesity, 8 years after gastric bypass. J Am Diet Assoc 2010; 110(4):527-34.
• 32. Bloomston M, Zervos EE, Camps MA, Goode SE, Rosemurgy AS. Outcome following bariatric surgery in super versus morbidly obese patients: does weight matter ? Obes Surg 1997; 7(5):414-9.
• 33. Scozzari G, Farinella E, Bonnet G, Toppino M, Morino M. Laparoscopic adjustable silicone gastric banding vs laparoscopic vertical banded gastroplasty in morbidly obese patients: long-term results of a prospective randomized controlled clinical trial. Obes Surg 2009; 19(8):1108-15.
• 34. Paran H, Shargian L, Shwartz I, Gutman M. Long-term follow-up on the effect of silastic ring vertical gastroplasty on weight and co-morbidities. Obes Surg 2007; 17(6):737-41. Erratum in: Obes Surg 2007; 17(7):996.

Publication Dates

• Publication in this collection
  26 Sept 2011
• Date of issue
  Aug 2011

History

• Accepted
  26 Aug 2010
• Received
  24 June 2010