Roux-en-Y Gastric Bypass in Patients with Super Obesity: Primary Response Criteria and Their Relationship with Comorbidities Remission.

BACKGROUND: The prevalence of super obesity has increased considerably in recent years, representing up to the 0.5% of the population. Even though bariatric surgery induces significant weight loss in these patients, it has been reported that up to 50% of the patients with super obesity will fail according to the current primary response criteria. OBJECTIVE: To evaluate and compare different primary response criteria and their impact regarding comorbidities remission. PATIENTS AND METHODS: A total of 104 patients with super obesity who underwent Roux-en-Y gastric bypass (RYGB) were identified in our institution from March 2004 to February 2019. An evaluation of the primary response at a 2-year follow-up was made using different criteria. A multivariate analysis was made to evaluate related variables to comorbidities remission. RESULTS: Two years later, the rate of patients who achieved an EWL > 50%, %EWL > 70%, and BMI < 35 kg/m2 were 84.5%, 52.1%, and 62%, respectively. Regarding the comorbidities, 85%, 84.8%, and 81.1% of the patients improved or remitted T2D, HBP, and hyperlipidemia, respectively. An EWL > 50% 2 years later was related to complete remission of hyperlipidemia (p = 0.047), whereas weight regain above 10% is a risk factor for failure of complete remission of HBP in 3 years. CONCLUSIONS: More than 75% of patients with super obesity yield an EWL > 50% 2 years later. In terms of hyperlipidemia, it is desirable to achieve an EWL of at least 50%. Whereas for T2D and HBP, a minimum of 25% TWL yields 72% and 60.5% of complete remission.

Development of an Interactive Outcome Estimation Tool for Laparoscopic Roux-en-Y Gastric Bypass in Mexico Based on a Cohort of 1002 Patients.

BACKGROUND: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is one of the most commonly performed bariatric procedures. Considering significant differences between populations around the world, surgical outcomes may vary widely. The aim of the study was to develop an educational patient-specific interactive application that may estimate the potential outcomes of LRYGB in the Mexican population. METHODS: A database with 76 different variables from 1002 patients who underwent LRYGB at two Mexican Institutions between 1992 and 2014 and had a minimum of 6-month follow-up was analyzed. Descriptive and inferential statistics, as well as a multivariate regression analysis, were performed for the primary analysis. Results were based on four statistical models obtained from the cohort outcomes. A tool was designed to provide estimates of absolute weight loss (AWL) and resolution of four major comorbidities: type 2 diabetes (T2D), high blood pressure (HBP), hypercholesterolemia, and the obstructive syndrome of sleep apnea (OSAS). RESULTS: There were 353 males (35.2%) and 649 females (64.8%) with a mean age of 41.9 ± 12.1 years and a mean preoperative BMI of 45.3 ± 7.9 kg/m2. Mean AWL at 2 years was 39.02 ± 12.7 kg. Mean accumulative percentage of resolution for T2D, HBP, and dyslipidemias at the same time period was 78%, 66.2%, and 84.7%, respectively. Based on these results, the educational tool was developed. CONCLUSIONS: We were able to develop an interactive estimation application to provide a population-based guidance for potential outcomes of LRYGB. This might be useful not only for health professionals but also for patients interested in learning potential outcomes in specific circumstances.

Analysis of Gene Candidate SNP and Ancestral Origin Associated to Obesity and Postoperative Weight Loss in a Cohort of Obese Patients Undergoing RYGB.

INTRODUCTION: Obesity is the result of a complex interaction between multiple genetic traits and psychological, behavioral, nutritional and environmental factors. OBJECTIVES: The aims of the study were (a) to comparatively evaluate the presence of 20 candidate gene single nucleotide polymorphisms (SNPs) in morbidly obese patients, (2) their association to comorbid conditions and (3) their impact on weight loss after a Roux-en-Y gastric bypass (RYGB). PATIENTS AND METHODS: Two hundred forty-nine patients were eligible for this study. Clinical, anthropometric, biochemical and demographic variables were analyzed. Body mass index (BMI) and composition were assessed by bioelectrical impedance. Twenty SNPs were included for analysis. RESULTS: There were 168 Mexican mestizos (67.5 %) and 81 (32.5 %) patients with other ancestral origin. One hundred fifty-nine (64.1 %) were females. Mean ± SD age of the general cohort was 41.1 ± 11.3 years (17-71). Preoperative mean ± SD BMI was 42.5 ± 6.5 kg/m2. There were no significant differences between mestizo and non-mestizo for most SNPs except for IFI, LIPC, and ST8SIA2. FTO (OR = 1.71; CI95 % = 1.14-2.57; p = 0.008) and APOB (OR = 0.31; CI95 % = 0.14-0.72; p = 0.004) result is statistically associated to high blood pressure and FTO (OR = 2.0; CI95 % = 1.3-3.1; p = 0.001), GNB3 (OR = 2.69; CI95 % = 1.0-7.2; p = 0.04), IFI30 (OR = 2.0; CI95 % = 1.16-3.6; p = 0.01), and MC4R (OR = 1.81; CI95 % = 1.13-2.9; p = 0.01) to type 2 diabetes (T2D). Based on ANOVA analysis, POMC (rs1042571) was the SNP most significantly associated to a higher weight loss after RYGB. CONCLUSIONS: Obese patients have similar SNP frequencies. Several SNP results are statistically associated to high blood pressure and T2D. POMC was significantly associated to a higher surgically induced weight loss.

Assessment of two different diagnostic guidelines criteria (National Cholesterol Education Adult Treatment Panel III [ATP III] and International Diabetes Federation [IDF]) for the evaluation of metabolic syndrome remission in a longitudinal cohort of patients undergoing Roux-en-Y gastric bypass.

BACKGROUND: Bariatric surgery has proven to provide durable weight loss and control of comorbid conditions, including the metabolic syndrome (MS). Existing definitions of MS have caused substantial confusion regarding their concordance for identifying the same individuals. The aim of this study was to assess the value of 2 different diagnostic guidelines criteria (National Cholesterol Education Adult Treatment Panel III [ATP III] and International Diabetes Federation [IDF]) for the evaluation of remission of MS after Roux-en-Y gastric bypass (RYGB). PATIENTS AND METHODS: A cohort of 381 patients who underwent a primary RYGB, satisfied the criteria for MS, and had at least o1 postoperative visit were selected. Weight loss and MS remission were analyzed 6 and 12 months after surgery by ATP III and IDF criteria. RESULTS: Before surgery, 381 (48.9%) and 354 (45.4%) patients fulfilled the criteria for MS according to the ATP III and IDF, respectively. According to the ATP III definition, remission of MS after bariatric surgery occurred in 209 of 239 (87.4%) and 98/102 (96.1%) patients at 6 and 12 months, respectively. According to the IDF definition, this occurred in 180 of 232 (77.6%) and 54 of 64 (84.4%) at the same time periods. On the basis of different percentage of excess body weight loss cut-off values, the area under the curve in receiver operating characteristic analysis at 12 months was slightly better for ATP III (0.77) than IDF criteria (0.68) for remission of MS. CONCLUSIONS: With the use of the IDF definition, the remission rate of MS was 10% more rigorous than with use of the ATP-III criteria. This feature is attributable to a greater discrimination of patients with high blood pressure, glycemia, and dyslipidemia. The IDF criteria seem more accurate to evaluate MS remission.

Analysis of Causes and Risk Factors for Hospital Readmission After Roux-en-Y Gastric Bypass.

BACKGROUND: Identification of causes and preventable triggers for hospital readmission after bariatric surgery is very important to implement strategies for surgical outcome optimization. The aim of the study was to analyze our readmissions after a Roux-en-Y gastric bypass (RYGB). PATIENTS AND METHODS: From our prospectively constructed database, patients who were readmitted to the hospital within the following 30 and 90 days after discharge were analyzed. Hospital charts were reviewed to determine the cause of readmission and the outcome. Potential risk factors for readmission were statistically analyzed. RESULTS: Between June 2004 and November 2013, 657 patients underwent a primary RYGB and 100 revisions. There were 442 (58%) females and 315 (42%) males with a mean age of 40.1 ± 11.5 years and a mean BMI of 42.4 ± 6.5 Kg/m(2). Comorbidities were present in 441 (58.2%) patients. Operations were completed laparoscopically in 741 (97.8%) patients. Mean hospital stay after the RYGB was 2.5 ± 1.6 days. The 30-day and 90-day readmission rate was 2.6 and 4.58%, respectively. Most common causes for readmission at 30 days were gastrointestinal bleeding in 30%, lung disease in 15%, and food intolerance in 15%. At 90 days, they were stricture of the gastrojejunostomy in 20%, gastrointestinal bleeding in 13.3%, and nephrolithiasis in 13.3%. Open surgery and previous upper abdominal surgery were significant risk factors for 90-day readmission. CONCLUSION: Our readmission rate after RYGB was low. Most common causes for readmission were upper gastrointestinal bleeding and food intolerance. Associated risk factors were open surgery and previous upper abdominal surgery.

Evaluation of spirometric testing as a routine preoperative assessment in patients undergoing bariatric surgery.

BACKGROUND: The value of spirometry as a routine preoperative test for bariatric surgery is debatable. The aim of this study was to assess the relationship between spirometry results and the frequency of postoperative pulmonary complications in 602 obese patients. METHODS: Clinical files of patients undergoing bariatric surgery between 2004 and 2013 were reviewed. Demography, risk factors, respiratory symptoms, and spirometry results (forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC) were recorded, and their relationship with postoperative pulmonary complications was evaluated. RESULTS: There were 256 males and 346 females with a mean age of 40.2 ± 11.6 years and a mean BMI of 42.1 ± 6.4 kg/m2. History of smoking was found in 408 patients (68 %). Preoperative respiratory symptoms were present in 328 (54.5 %). Most frequent symptoms were snoring (288), dyspnea (119), bronchospasm [6], and chronic productive cough [6]. In 153 patients, history of respiratory disease was documented. The obstructive sleep apnea syndrome (OSAS) was present in 124, 20 requiring continuous positive airway pressure (CPAP). Asthma was present in 27 and chronic obstructive pulmonary disease (COPD) in 2. Variables associated to a higher risk of pulmonary complications were OSAS (OR 2.3), an abnormal spirometry (OR 2.6), male gender (OR 1.9), and preoperative respiratory symptoms (OR 1.9). Using multivariate logistic regression, an abnormal spirometry was a significant predictor of postoperative pulmonary complications in patients with respiratory symptoms and/or OSAS. However, it lost prognostic significance when both conditions were subtracted. CONCLUSIONS: In obese patients undergoing bariatric surgery, abnormal preoperative spirometry predicts postoperative respiratory complications only in patients with OSAS.

Anemia after Roux-en-Y gastric bypass. How feasible to eliminate the risk by proper supplementation?

BACKGROUND: Anemia after Roux-en-Y gastric bypass (RYGB) has been reported in 5 to 64 % of patients. Since absorption of specific elements is reduced, proper supplementation is mandatory. The aim of this study was to investigate the frequency of anemia, its causes, and the related deficiencies during the 1st postoperative year after RYGB. METHODS: A retrospective review of our prospectively collected database was performed. A total of 486 patients who underwent RYGB in a 5-year period and completed at least 1-year follow-up were included. Daily supplements as suggested by the AACE/TOS/ASMBS guidelines were routinely prescribed. Blood count, iron profile, folic acid, and B12 measurements 1 year after surgery were reviewed. RESULTS: One hundred ninety-five males and 291 females were included, with a mean age of 39.9 ± 11.6 years and a mean body mass index (BMI) of 42.4 ± 6.3 kg/m(2). Anemia 1 year after surgery was found in 19 patients (4 %), 6 males and 13 females. In seven women, it was related to iron deficiency. Two additional women had iron deficiency combined with low vitamin B12. Anemia was secondary to inflammation in two and indeterminate in two. In the six males, the cause of anemia was inflammation in three and indeterminate in three. Abnormal bleeding was found in five of these patients. CONCLUSIONS: Frequency of anemia 1 year after RYGB in our population was low (4 %). Anemia non-attributable to malabsorption was frequently present (n = 9/19). Iron deficiency was found exclusively in women. The most common non-malabsorptive types of anemia were inflammation and dysfunctional uterine bleeding.

Small bowel obstruction after antecolic and antegastric laparoscopic Roux-en-Y gastric bypass: could the incidence be reduced?

BACKGROUND: Small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass (LRYGB) may be related to the surgical technique used. The frequency and characteristics of postoperative SBO were studied in two cohorts of patients after LRYGB. METHODS: In a 4-year period, 359 patients underwent LRYGB as an initial bariatric operation at our clinic. Patients were divided into two groups. In Group 1 (n = 187), the mesentery of the jejunum was widely divided, the mesenteric defect was closed, and Petersen's space was not sutured. In Group 2 (n = 172), the mesentery was not divided, and both the mesenteric folds and Petersen's space were closed. Episodes of SBO, etiology, treatment, and outcome were analyzed and compared. RESULTS: There were 141 males and 218 females, with mean age of 41 ± 11 years. Preoperative BMI was 43.2 ± 7 kg/m(2). In Group 1, 29/187 patients (15.5%) developed SBO at a mean follow-up of 15 ± 6.4 months. In Group 2, 2/172 patients (1.1%) developed SBO at 12.3 ± 6.7 months. Internal hernia was responsible for the SBO in 29 patients (19 through the adjacent mesenteric defect and 10 through Petersen's space). Mean EWL at the time of SBO was 82.2 ± 22.7%. SBO was successfully resolved by laparoscopy in 25 patients, conversion was necessary in three, and one was treated by open surgery. One patient presented intestinal perforation after revision. CONCLUSIONS: Surgical details such as leaving the jejunal mesentery intact and closing all created defects significantly decreased the incidence of SBO due to internal hernias in antecolic antegastric LRYGB.

Laparoscopic Roux-en-Y gastric bypass as a revision procedure after restrictive bariatric surgery.

BACKGROUND: Adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG) have been extensively used to treat morbid obesity. Patients with insufficient weight loss or complications may require surgical revision. The laparoscopic Roux-en-Y gastric bypass (LRYGBP) is one of the most common procedures currently used for revision. The aim of the study was to analyze surgical outcomes of 30 consecutive patients who underwent revision to LRYGBP in a 2-year period. METHODS: The prospectively constructed database and the medical records of all patients undergoing revision to LRYGBP were reviewed. Demographics, surgical details, results, and complications were analyzed. RESULTS: There were 23 women and seven men with a mean age of 41.1+/-9.7 years (r=25-61). Mean body mass index (BMI) was 40.0+/-7.5 kg/m(2) (r=27.2-65.2). Initial operation was AGB in 24, VBG in five, and both in one patient. In ten patients, the band had been removed before revision, in 13 cases, band removal and LRYGBP were performed in one surgical intervention, and in two patients, it was performed in a two-step surgery. There were two conversions to open surgery. Five patients presented major surgical complications. Hospital stay averaged 5.1 days (r=3-25). Mean percent excess body weight loss at 6 and 12 months was 61.7+/-27.5 and 81.2+/-20.5 kg/m(2), respectively. Mean percent low body mass index at 6 and 12 months was 22.5+/-9.1 and 29.1+/-11.4 kg/m(2), respectively. CONCLUSIONS: LRYGBP as a revision procedure is feasible in most patients. Surgical complications are more frequent.

Weight loss and body composition during the first postoperative year of a laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Weight loss in patients undergoing gastric bypass should be primarily from fat mass (FM), minimizing the fat-free mass (FFM) loss. The aim of this study was to analyze changes in body weight and body composition during the first postoperative year in 50 morbidly obese patients undergoing a Laparoscopic Roux-en-Y gastric bypass (LRYGBP) at the Obesity Clinic of the ABC Medical Center. METHODS: Patient's weight and body composition were obtained before surgery and 1 year later using bioelectrical impedance analysis (BIA). Weight, FM, FMM, and total body water (TBW) were measured before and 1 year after surgery. Changes in body composition were particularly analyzed. RESULTS: There were 29 females and 21 males with mean age of 41 +/- 12 years. Mean BMI before surgery and 1 year after surgery was 44.4 +/- 7.4 kg/m(2) and 28.3+/-4.3 kg/m(2), respectively. The percentage of excess body weight loss at the 1-year period was 86% for women and 79.6% for men. The percentage of FM before surgery was 47.7 +/- 5.1, and 1 year later it was 28.8 +/- 8. The percentage of FFM was 66.5 +/- 16.5 before surgery and 58.3 +/- 13 at 1 year. CONCLUSIONS: There is a significant weight loss in patients undergoing LRYGBP. Weight loss mainly occurs as a consequence of reduction in the FM with less impact on the FFM.

Calculating surgical costs: how accurate and predictable is the cost of a laparoscopic Roux-en-Y gastric bypass?

BACKGROUND: Although bariatric surgery is highly effective for controlling obesity and its complications, it is uncovered by third-party payers in many countries. High cost and unpredictable expenses account for the lack of coverage. We developed at our obesity clinic a fixed package for the Laparoscopic Roux-en-Y Gastric Bypass (LRYGBP). The aim of this study is to evaluate the predictability and reproducibility of the estimated expenses in the first 150 consecutive patients who underwent LRYGBP as initial procedure. PATIENTS AND METHODS: A fixed package which included hospitalization, operative room expenses, medications, multidisciplinary support, and professional honorarium was established based on the experience gained with more than 500 preceding interventions. Actual direct medical costs of the initial 150 patients who underwent LRYGBP by one surgeon were analyzed and contrasted to the anticipated expenses. RESULTS: Mean age was 35.8 +/- 11.8 years (range 16-69 years). Average body mass index (BMI) was 43.1 +/- 4.8 kg/m(2) (range 35-70). Mean number of comorbidities per patient were 1.7 +/- 0.8 (range 1-5). All patients completed a LRYGBP with no conversions. Mean hospital stay was 3 +/- 0.3 days. Complications occurred in 13 patients. Mean total expenses were 98.5 +/- 10% of the estimated costs. In 143 patients (95.3%), the total expenses were within 10% of the estimated costs, whereas in five they were > or =10% and in two > or =20%. CONCLUSION: Costs of a LRYGBP can be accurately predicted and are highly reproducible when interventions are performed by an experienced team and potentially lethal complications do not occur.