Defining Weight Loss After Bariatric Surgery: a Call for Standardization.

BACKGROUND: Some weight regain is expected after bariatric surgery; however, this concept is not well defined. A favorable weight loss response has commonly been defined as 50% excess weight loss (EWL). The medical literature uses %total weight loss (%TWL), which has recently been adopted in some surgical literature. OBJECTIVE: To demonstrate variability in bariatric surgery outcomes based on the definition applied and propose a standardized definition. METHODS: A retrospective review of patients who underwent bariatric surgery from 2001 to 2016 with ≥ 1 year follow-up was completed. Several previously proposed definitions of weight regain were analyzed. RESULTS: One thousand five hundred seventy-four patients met inclusion criteria. Preoperative mean body mass index (BMI) was 47.6 ± 6.4 kg/m2. Increased preoperative BMI was associated with increased mean %TWL at 2 years postoperative (29.3 ± 9.1% for BMI < 40, vs. 37.5 ± 9.5% for BMI > 60; P < 0.001). Based on %EWL, 93% of patients experienced ≥ 50% EWL by 1-2 years, and 61.8% maintained ≥ 50% EWL through the 10-year follow-up period. Similarly, 97% experienced ≥ 20% TWL by 1-2 years and 70.3% maintained ≥ 20% TWL through the 10-year follow-up period. Over 50% of patients maintained their weight based on several proposed definitions through 5 years follow-up. CONCLUSIONS: A high percentage (> 90%) of patients achieve ≥ 20% TWL and ≥ 50% EWL. Increased preoperative BMI was associated with increased %TWL and decreased %EWL at 2 years postoperative. The incidence of weight regain varies depending on the definition. We propose a standardized definition for identifying good responders following bariatric surgery to be ≥ 20% TWL, as this measure is least influenced by preoperative BMI.

Long-term (>10-year) outcomes after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been the "gold standard" for weight loss surgery. Long-term data are limited, and reporting methods for LRYGB outcomes vary in the literature. In addition, follow-up compliance within bariatric centers is poor due to insurance and access to care issues, making long-term follow-up evaluation difficult. OBJECTIVE: Evaluate long-term LRYGB outcomes using standard outcome reporting definitions. SETTING: Integrated multispecialty health system. METHODS: A retrospective review of our institution's prospective bariatric surgery registry and integrated multispecialty electronic medical record system was completed for patients who underwent LRYGB from 2001 to 2015. Data were defined according to the 2015 Standards for Outcome Reporting. RESULTS: During the study period, 1402 patients underwent primary LRYGB; mean age and preoperative body mass index were 44.5±10.3 years and 47.5±6.2 kg/m2, respectively. Early complications included anastomotic leak (0.2%), venous thromboembolism (0.6%), surgical site infections (1.4%), and urinary tract infections (1.6%). The 30-day readmission rate was 3.5%. There were no 30-day mortalities. Follow-up weight data were available for>70% of eligible patients through 12 years postoperative. The highest mean percent excess weight loss and lowest body mass index were reached at 18 months postoperative at 79% and 30.1 kg/m2, respectively. Remission of diabetes, dyslipidemia, and hypertension were observed through 8 years postoperatively. CONCLUSION: This is the first report of long-term (>10-year) outcomes from a single integrated health system using the 2015 Standards for Outcome Reporting. LRYGB results in significant, sustained weight loss and durable improvement and remission of obesity-related co-morbidities. Integrated healthcare systems provide an optimal environment for data collection and long-term follow-up.

A prospective, blinded comparison of laparoscopic ultrasound with transabdominal ultrasound for the detection of gallbladder pathology in morbidly obese patients.

BACKGROUND: Transabdominal ultrasound (TAU) is the gold standard for detecting cholelithiasis. Morbid obesity can inhibit detection of gallbladder pathology due to increased subcutaneous and visceral fat. Laparoscopic ultrasound (LUS) has the potential to overcome these technical challenges. We hypothesized that LUS would have a sensitivity and specificity similar to TAU for detecting cholelithiasis and polyps in morbidly obese patients presenting for laparoscopic Roux-en-Y gastric bypass. STUDY DESIGN: After Institutional Review Board approval, patients underwent preoperative TAU and intraoperative LUS during laparoscopic Roux-en-Y gastric bypass. Certified ultrasonographers performed all TAUs. Surgeons, blinded to TAU results, performed the LUS. Presence of cholelithiasis or polyps and common bile duct diameter was evaluated. Statistical analysis included chi-square and McNemar's test. RESULTS: Two hundred and fifty-three patients were prospectively enrolled during a 6-year period. Seventy-six percent were female, mean age and preoperative body mass index (calculated as kg/m(2)) were 43.5 years and 48, respectively. Mean time to complete the LUS was 4 minutes. Mean common bile duct diameter measured 3.7 mm via LUS and 4.0 mm via TAU. Transabdominal ultrasound and LUS identified 61 and 60 patients with cholelithiasis, respectively (p = 0.763). The sensitivity and specificity of LUS for cholelithiasis was 90.2% and 97.4%. Laparoscopic ultrasound identified polyps in 41 patients, and TAU identified polyps in 6 patients, 5 of which had polyps identified on LUS as well (p < 0.001). Sensitivity and specificity of LUS for polyps was 83.3% and 85.4%. CONCLUSIONS: Laparoscopic ultrasound is equivalent to TAU in detecting cholelithiasis, however, LUS detected significantly more polyps. Intraoperative LUS is an appropriate alternative to TAU in patients undergoing laparoscopic Roux-en-Y gastric bypass.

The history and evolution of bariatric surgical procedures.

The search for the ideal weight loss operation began more than 50 years ago. Surgical pioneers developed innovative procedures that initially created malabsorption, then restricted volume intake, and eventually combined both techniques. Variations, alterations, and modifications of these original procedures, combined with intense efforts to follow and document outcomes, have led to the evolution of modern bariatric surgery. More recent research has focused on the hormonal and metabolic effects of these procedures. These discoveries at the cellular level will help develop possible mechanisms of weight loss and comorbidity reduction beyond the traditional explanation of reduced food consumption and malabsorption.

Excellent laparoscopic gastric bypass outcomes can be achieved at a community-based training hospital with moderate case volume.

OBJECTIVE: Our objective was to assess laparoscopic gastric bypass outcomes in a moderate case volume setting. BACKGROUND: Laparoscopic gastric bypass remains one of the most advanced laparoscopic procedures currently performed worldwide. The following represents a single institutional series from a community hospital-based training program with a minimally invasive bariatric surgical program. METHODS: Data from all patients undergoing laparoscopic gastric bypass since the inception of the program were entered into a prospective database. Measured outcomes included length of operation, length of stay, major and minor complications, and percentage excess weight loss. Results were compared with published outcomes from a review of the literature encompassing more than 3400 cases using chi and Fisher exact tests. RESULTS: Between September 2001 and October 2008, 700 consecutive patients underwent laparoscopic gastric bypass. The mean age was 43.1 +/- 9.5 years, and 83% were female. The mean initial weight was 135.5 +/- 22.4 kg. The initial body mass index was 47.9 +/- 6 kg/m. The mean length of stay was 2.2 +/- 0.9 days. The length of operation was 147.8 +/- 31.8 minutes. The mean percent excess weight loss at 1-year postoperative was 72.4%. There were no mortalities. Compared with the literature, we achieved a lower rate of anastomotic leak (0.3% vs. 2%, P = 0.001) and stomal stenosis (1% vs. 4.7%, P = 0.001). CONCLUSIONS: Excellent outcomes following laparoscopic gastric bypass can be achieved in a community hospital-based program with moderate case volume. Reimbursement decisions should take into consideration a program's actual outcomes rather than volume.

Effect of preoperative weight loss on laparoscopic gastric bypass outcomes.

BACKGROUND: Requiring patients to lose weight before weight reduction surgery is controversial. The goal of this study was to determine whether preoperative weight loss affects laparoscopic Roux-en-Y gastric bypass surgery outcomes. METHODS: The medical records of all laparoscopic Roux-en-Y gastric bypass patients from September 1, 2001 to March 31, 2005 were retrospectively reviewed in our prospective database. Depending on their habitus, patients were selectively required to lose >4.54 kg (10 lb) preoperatively (WL group). Their outcomes were compared with those of the patients not required to lose weight preoperatively (no-WL group). Statistical analysis was performed with the chi-square test and Student's t test for demographic data. Student's t test was used to assess the outcome data. P <.05 was considered significant. RESULTS: Of the 353 patients, 74 (21%) were in the WL group. The operative times in the WL group averaged 10 minutes longer than in the no-WL group (P = .022). The mean length of stay was not significantly different between the 2 groups. Of the 353 patients, 262 (74%) completed 1 year of follow-up. The mean net postoperative weight loss was not significantly different between the 2 groups. The no-WL patients had a greater percentage of excess postoperative weight loss than the WL group (74% versus 66%; P = .01). Net complications occurred less frequently in the WL group (P = .035). CONCLUSION: Preoperative weight loss did not decrease the operative times or the length of stay. Preoperative weight loss increased neither the mean net postoperative weight loss nor the percentage of excess postoperative weight loss at 1-year follow-up. However, the WL group had fewer net complications.

Length of stay and impact on readmission rates after laparoscopic gastric bypass.

BACKGROUND: A decreased length of stay (LOS) is one of the many advantages of laparoscopic over open Roux-en-Y gastric bypass for the treatment of morbid obesity. However, the mean LOS after laparoscopic gastric bypass (LGB) ranges from 1.8 to 4.5 days. In addition, the LOS has tended to improve as bariatric programs have matured. With the use of a standardized perioperative care plan, we studied the effects of LOS on readmission rates in patients undergoing LGB in a new minimally invasive bariatric surgery program. METHODS: All patients undergoing LGB between September 20, 2001 and April 5, 2004 were entered into a standardized perioperative care plan. All patient outcomes were entered into a prospective database. The discharge criteria included adequate oral intake and adequate pain control on oral medication. The reasons for patients staying >2 days were analyzed and documented. RESULTS: A total 250 patients underwent LGB. Of these, 212 patients (84.8%) were discharged on postoperative day 2. The most common reason for a LOS >2 days was bleeding (42.1%), followed by nausea (26.3%), inadequate pain control on oral medication (15.8%), and various other reasons (15.8%). The mean LOS did not change with time (P = .19). Readmission within 30 days was significantly less in patients discharged by day 2 (1.9% versus 13.1%, P = .005). CONCLUSIONS: The LOS remained constant as our program matured. The vast majority of patients undergoing LGB who have an uncomplicated postoperative course were safely discharged home on postoperative day 2. Patients staying >2 days were more likely to be readmitted within 30 days of discharge.

Travel distance, age, and sex as factors in follow-up visit compliance in the post-gastric bypass population.

BACKGROUND: There is no consensus regarding the optimal rate of follow-up in the post-bariatric surgery patient population. METHODS: The records of all patients who underwent laparoscopic Roux-en-Y gastric bypass from 2001 to 2003 were reviewed. Using patient zip codes, travel distances were calculated between the patients' places of residence and our clinic. Patients were then assigned to 1 of 3 cohorts according to the following distances: (1) < 50 miles, (2) 50 to 100 miles, and (3) > 100 miles. Patient compliance with follow-up appointments at 3 weeks, 3 months, 6 months, 9 months, and 12 months was analyzed. Linear trends were identified using the Mantel-Haenszel test. Age and sex were analyzed as possible predictors of compliance using the chi(2) test. P values < .05 were considered statistically significant. RESULTS: The study group comprised 150 patients (127 females and 23 males). The 3 cohorts contained 115, 21, and 14 patients, respectively. All patients in each cohort were compliant with the 3-week follow-up appointment. Although there were differences in compliance between cohorts at each of the remaining appointments, only the 9-month (70.3% vs 61.9% vs 35.7%) visit showed statistical significance (P = .035). The 6-month visit trended toward significance (85.2% vs 76.2% vs 64.3%; P = .088). Males were more likely to be compliant with the 12-month follow-up (P = .040). When controlling for sex, travel distance was also a predictor of compliance at this follow-up visit (P = .024). Age was not predictive of compliance (P = .827). CONCLUSION: Based on our findings, we conclude that travel distance from the clinic does not significantly affect compliance at the initial follow-up, 3-month, and 12-month appointments. However, distance does tend to affect compliance at the 6-month appointment and significantly affects compliance at the 9-month appointment. Males are more likely to be compliant at the 12 month follow-up visit. We must continue to strive for 100% follow-up in our post-bariatric surgery patients.