Health benefits of gastric bypass surgery after 6 years.

CONTEXT: Extreme obesity is associated with health and cardiovascular disease risks. Although gastric bypass surgery induces rapid weight loss and ameliorates many of these risks in the short term, long-term outcomes are uncertain. OBJECTIVE: To examine the association of Roux-en-Y gastric bypass (RYGB) surgery with weight loss, diabetes mellitus, and other health risks 6 years after surgery. DESIGN, SETTING, AND PARTICIPANTS: A prospective Utah-based study conducted between July 2000 and June 2011 of 1156 severely obese (body mass index [BMI] ≥ 35) participants aged 18 to 72 years (82% women; mean BMI, 45.9; 95% CI, 31.2-60.6) who sought and received RYGB surgery (n = 418), sought but did not have surgery (n = 417; control group 1), or who were randomly selected from a population-based sample not seeking weight loss surgery (n = 321; control group 2). MAIN OUTCOME MEASURES: Weight loss, diabetes, hypertension, dyslipidemia, and health-related quality of life were compared between participants having RYGB surgery and control participants using propensity score adjustment. RESULTS: Six years after surgery, patients who received RYGB surgery (with 92.6% follow-up) lost 27.7% (95% CI, 26.6%-28.9%) of their initial body weight compared with 0.2% (95% CI, -1.1% to 1.4%) gain in control group 1 and 0% (95% CI, -1.2% to 1.2%) in control group 2. Weight loss maintenance was superior in patients who received RYGB surgery, with 94% (95% CI, 92%-96%) and 76% (95% CI, 72%-81%) of patients receiving RYGB surgery maintaining at least 20% weight loss 2 and 6 years after surgery, respectively. Diabetes remission rates 6 years after surgery were 62% (95% CI, 49%-75%) in the RYGB surgery group, 8% (95% CI, 0%-16%) in control group 1, and 6% (95% CI, 0%-13%) in control group 2, with remission odds ratios (ORs) of 16.5 (95% CI, 4.7-57.6; P < .001) vs control group 1 and 21.5 (95% CI, 5.4-85.6; P < .001) vs control group 2. The incidence of diabetes throughout the course of the study was reduced after RYGB surgery (2%; 95% CI, 0%-4%; vs 17%; 95% CI, 10%-24%; OR, 0.11; 95% CI, 0.04-0.34 compared with control group 1 and 15%; 95% CI, 9%-21%; OR, 0.21; 95% CI, 0.06-0.67 compared with control group 2; both P < .001). The numbers of participants with bariatric surgery-related hospitalizations were 33 (7.9%), 13 (3.9%), and 6 (2.0%) for the RYGB surgery group and 2 control groups, respectively. CONCLUSION: Among severely obese patients, compared with nonsurgical control patients, the use of RYGB surgery was associated with higher rates of diabetes remission and lower risk of cardiovascular and other health outcomes over 6 years.

Long-term mortality after gastric bypass surgery.

BACKGROUND: Although gastric bypass surgery accounts for 80% of bariatric surgery in the United States, only limited long-term data are available on mortality among patients who have undergone this procedure as compared with severely obese persons from a general population. METHODS: In this retrospective cohort study, we determined the long-term mortality (from 1984 to 2002) among 9949 patients who had undergone gastric bypass surgery and 9628 severely obese persons who applied for driver's licenses. From these subjects, 7925 surgical patients and 7925 severely obese control subjects were matched for age, sex, and body-mass index. We determined the rates of death from any cause and from specific causes with the use of the National Death Index. RESULTS: During a mean follow-up of 7.1 years, adjusted long-term mortality from any cause in the surgery group decreased by 40%, as compared with that in the control group (37.6 vs. 57.1 deaths per 10,000 person-years, P<0.001); cause-specific mortality in the surgery group decreased by 56% for coronary artery disease (2.6 vs. 5.9 per 10,000 person-years, P=0.006), by 92% for diabetes (0.4 vs. 3.4 per 10,000 person-years, P=0.005), and by 60% for cancer (5.5 vs. 13.3 per 10,000 person-years, P<0.001). However, rates of death not caused by disease, such as accidents and suicide, were 58% higher in the surgery group than in the control group (11.1 vs. 6.4 per 10,000 person-years, P=0.04). CONCLUSIONS: Long-term total mortality after gastric bypass surgery was significantly reduced, particularly deaths from diabetes, heart disease, and cancer. However, the rate of death from causes other than disease was higher in the surgery group than in the control group.

Retrograde (reverse) jejunal intussusception might not be such a rare problem: a single group's experience of 23 cases.

BACKGROUND: Retrograde (reverse) intussusception of the jejunum is thought to be a very rare occurrence, having been reported approximately 15 times (21 patients) in medical studies. A review of our own experience of >15,000 Roux-en-Y gastric bypass patients found 23 cases treated since 1996. This is the largest single-center report to date. METHODS: A chart review dating back to 1996 revealed 23 patients with retrograde intussusception involving the jejunum. Their charts were reviewed. A variety of data was reviewed to identify the risk factors for developing intussusception, as well as the presentation, findings, and treatment. RESULTS: We identified 23 patients with retrograde intussusception involving the jejunum. Of these 23 patients, 22 had undergone Roux-en-Y gastric bypass. One patient had undergone Roux-en-Y choledochojejunostomy. Of the 23 patients, 1 (4%) had a gastrojejunal intussusception and 22 (96%) jejunojejunal intussusceptions. All patients were women, with a median age of 32 years (range 20-50). The mean body mass index at gastric bypass was 45.2 kg/m2 (range 39.4-55). Of the 23 patients, 19 (83%) had undergone open and 4 (17%) laparoscopic gastric bypass. The median duration from gastric bypass to the diagnosis of intussusception was 51 months (range 6-288). Of the 23 patients, 8 (35%) presented with gangrene, perforation, or nonreducable obstruction, 9 (39%) had a spontaneous reduction, and in 6 (26%), the obstruction was successfully reduced at surgery. The treatment was surgical resection in 16 (70%) with 2 recurrences (12.5%), simple reduction in 2 (9%) with 100% recurrence, and plication in 5 patients (22%) with 2 recurrences (40%). CONCLUSION: Retrograde intussusception of the jejunum after gastric bypass is probably more common than previously believed. Although resection and revision of the area of intussusception appears to be effective, more information is needed about the treatment and possible prevention of this disorder.

Comparison of laparoscopic linear staplers in clinical practice.

BACKGROUND: Only one previous study has evaluated the clinical safety of the 2 laparoscopic linear stapling devices available. Our study compared these staplers using laparoscopic gastric bypass as the standard procedure. METHODS: A total of 400 consecutive patients were prospectively studied. Group A (200 patients) underwent gastric bypass with the Endo-GIA Universal 6-row stapler (Autosuture) used, and group B (200 patients) underwent the procedure with the Ethicon 6-row stapler used. The measured parameters included stapler misfires, staple line bleeding, staple line leaks, unexplained gastrointestinal bleeding, unexplained intra-abdominal bleeding, total bleeding events, and total adverse events. RESULTS: Both groups were similar in preoperative body mass index, age, and gender. Both groups had a single staple line leak (0.5%; P = 1.0). Three (0.25% of staple firings) misfires occurred in group B. No misfires occurred in group A (P = .25). Gastrointestinal bleeding, staple line bleeding, and unexplained intra-abdominal bleeding occurred in 6 (3%), 2 (1%), and 5 (2.5%) patients in group A and in 1 (0.5%), 0 (0%), and 2 (1%) patients in group B (P = .12, P = .5, and P = .45, respectively). Total bleeding events occurred in 13 patients (6.5%) in group A and in 3 patients (1.5%) in group B (P = 0.019). The total number of patients with an adverse event was 14 (7%) in group A and 7 (3.5%) in group B (P = .18). CONCLUSION: The results of our study have shown that the Ethicon 6-row stapler had more misfires and the Autosuture Endo-GIA 6-row stapler resulted in more bleeding complications. Only the difference in total bleeding events reached statistical significance but the difference in the total number of adverse events was not statistically significant. Therefore, in our experience both devices were equally safe and effective.

Association of Patient Age at Gastric Bypass Surgery With Long-term All-Cause and Cause-Specific Mortality.

IMPORTANCE: Bariatric surgery is effective in reducing all-cause and cause-specific long-term mortality. Whether the long-term mortality benefit of surgery applies to all ages at which surgery is performed is not known. OBJECTIVE: To examine whether gastric bypass surgery is equally effective in reducing mortality in groups undergoing surgery at different ages. DESIGN, SETTING, AND PARTICIPANTS: All-cause and cause-specific mortality rates and hazard ratios (HRs) were estimated from a retrospective cohort within 4 categories defined by age at surgery: younger than 35 years, 35 through 44 years, 45 through 54 years, and 55 through 74 years. Mean follow-up was 7.2 years. Patients undergoing gastric bypass surgery seen at a private surgical practice from January 1, 1984, through December 31, 2002, were studied. Data analysis was performed from June 12, 2013, to September 6, 2015. A cohort of 7925 patients undergoing gastric bypass surgery and 7925 group-matched, severely obese individuals who did not undergo surgery were identified through driver license records. Matching criteria included year of surgery to year of driver license application, sex, 5-year age groups, and 3 body mass index categories. INTERVENTION: Roux-en-Y gastric bypass surgery. MAIN OUTCOMES AND MEASURES: All-cause and cause-specific mortality compared between those undergoing and not undergoing gastric bypass surgery using HRs. RESULTS: Among the 7925 patients who underwent gastric bypass surgery, the mean (SD) age at surgery was 39.5 (10.5) years, and the mean (SD) presurgical body mass index was 45.3 (7.4). Compared with 7925 matched individuals not undergoing surgery, adjusted all-cause mortality after gastric bypass surgery was significantly lower for patients 35 through 44 years old (HR, 0.54; 95% CI, 0.38-0.77), 45 through 54 years old (HR, 0.43; 95% CI, 0.30-0.62), and 55 through 74 years old (HR, 0.50; 95% CI, 0.31-0.79; P < .003 for all) but was not lower for those younger than 35 years (HR, 1.22; 95% CI, 0.82-1.81; P = .34). The lack of mortality benefit in those undergoing gastric bypass surgery at ages younger than 35 years primarily derived from a significantly higher number of externally caused deaths (HR, 2.53; 95% CI, 1.27-5.07; P = .009), particularly among women (HR, 3.08; 95% CI, 1.4-6.7; P = .005). Patients undergoing gastric bypass surgery had a significantly lower age-related increase in mortality than severely obese individuals not undergoing surgery (P = .001). CONCLUSIONS AND RELEVANCE: Gastric bypass surgery was associated with improved long-term survival for all patients undergoing surgery at ages older than 35 years, with externally caused deaths only elevated in younger women. Gastric bypass surgery is protective against mortality even for older patients and also reduces the age-related increase in mortality observed in severely obese individuals not undergoing surgery.

Design and rationale of the Utah obesity study. A study to assess morbidity following gastric bypass surgery.

PURPOSE: This paper details the design and baseline characteristics of a study on the morbidity associated with Roux-en-Y gastric bypass surgery (GBP) in severely obese adults. This study is designed to assess the effectiveness of GBP in reducing morbidity and maintaining weight loss. A wide array of clinical tests and psycho-behavioral questionnaires are included as part of the study. METHODS: Three groups (n=1156 severely obese) have been recruited for this study: cases who were approved for and participated in surgery (n=415), a control group of GBP seeking individuals who were denied surgery (n=420) and a control group that was randomly chosen from a population of severely obese participants who were not seeking GBP (n=321). Clinical measures include: a physician interview and detailed medical history, resting electro- and echocardiograms, a submaximal exercise treadmill test and electrocardiogram, pulmonary function, limited polysomnography, resting metabolic rate, anthropometrics, resting and exercise blood pressure, comprehensive blood chemistry and urinalysis and dietary, quality of life and physical activity questionnaires. Most participants (76%) were tested following an overnight stay in a clinical research center. Remaining participants underwent less extensive testing in an outpatient clinic. RESULTS: Baseline characteristics of the 1156 participants are available for selected measures. Mean+/-S.D. for BMI was 46+/-7.5 kg/m(2) (range=33 to 92) and for age was 44+/-11.4 years (range=18 to 72). The prevalence of diabetes and hypertension was 19% and 35%, respectively. Of the participants who had an echocardiogram or polysomnogram, 92% had left-ventricular hypertrophy and 85% had mild to severe sleep apnea. The two control groups were similar to the surgical group. At approximately 24 months, all participants will have a second clinical examination. Statistical comparisons of changes in morbidity variables will be made between the surgical and control groups. CONCLUSIONS: This study design facilitates assessment of risks and benefits of GBP to perform recommendations on whether or not to perform surgery on the severely obese patient. Baseline and 2-year exams provide valuable data for comparison to future long-term follow-up data that can be collected at 5 and 10 years.

Open vs laparoscopic Roux-en-Y gastric bypass: comparison of operative morbidity and mortality.

BACKGROUND: Open Roux-en-Y gastric bypass (RYGBP) has proven to be an effective method for weight control for the morbidly obese patient. With technologic and surgical skill advancement in the application of laparoscopic surgery, laparoscopic RYGBP has also been found to be of value in surgical control of obesity. Risk/benefit ratios in comparison of the 2 methods are undergoing definition by experience. METHODS: 779 patients who underwent RYGBP between March 1, 2000 and June 30, 2002 were evaluated retrospectively. 328 patients underwent laparoscopic RYGBP (Group A) and 451 underwent open RYGBP (Group B). All charts and hospital records of these patients were reviewed. Questionnaires were mailed to all patients who had undergone RYGBP. Follow-up was 5-29 months. RESULTS: 89 patients in Group A and 162 patients in Group B experienced significant morbidity. There were no surgical deaths in Group A and one surgical death in Group B. Weight loss profiles were the same. Significant differences in morbidity were noted with respect to gastrojejunal stenosis (Group A = 11.6%, Group B = 4.7%, P=.0012), occurrence of ventral incisonal hernia (A=0%, B=10%, P<.00013), and wound problems (abdominal wall hematoma A=1.5%%, B=0%, P=.013; wound infection A=1.2%, B=6.2%, P=.00037). Gastrojejunal perforation was not significantly different (A=1.5%, B=0.89%, P=.50), as was true of small bowel obstruction (A=2.7%, B=3.3%, P=.68). CONCLUSIONS: Each operative approach has associated problems.Wound care problems and ventral hernias are more common in Group B (open) and anas tomotic stenoses are more common in Group A (laparoscopic). Anastomotic leaks and small bowel obstruction are troublesome but not statistically different in occurrence.

Laparoscopic reversal of gastric bypass with sleeve gastrectomy for treatment of recurrent retrograde intussusception and Roux stasis syndrome.

BACKGROUND: We reported on our experience of 23 patients with retrograde intussusception (RINT) in 2007. That series has increased to 54 patients. Surgical resection of the jejunojejunostomy appears to be the most effective treatment. We treated 8 patients with documented or suspected recurrent RINT despite resection, by reversing their gastric bypass with sleeve gastrectomy to avoid weight regain. METHODS: The medical records of 8 patients who had undergone treatment of suspected recurrent RINT with reversal of their gastric bypass followed by sleeve gastrectomy were reviewed to evaluate the outcomes, complications, weight loss, and relief of symptoms. RESULTS: All 8 patients were women, aged 29-56 years. The mean body mass index at reversal was 22.3-36.5 kg/m(2) (mean 30). The follow-up period was 1-28 months (mean 20.8). The body mass index at the last visit was 21.3-33 kg/m(2) (mean 26). Complications occurred in 5 patients. Patient 1 developed delayed splenic bleeding that required splenectomy on the second postoperative day. Patient 2 developed a gastric fistula 6 weeks after surgery after dilation. Patient 4 developed a superior mesenteric vein thrombosis at 2 weeks postoperatively. Patient 7 developed a proximal small bowel obstruction. Also, 4 patients required dilation of the gastrogastrostomy. At the last follow-up visit, the patients did not have symptoms of recurrent RINT and had not regained their weight. CONCLUSION: Laparoscopic reversal of gastric bypass with sleeve gastrectomy for recurrent RINT or RINT-like symptoms (Roux stasis symptoms) resulted in a significant risk of complications in this small group of patients but appears to be effective for relieving the symptoms of RINT with minimal risk of weight regain, at least in the medium term.

Health outcomes of gastric bypass patients compared to nonsurgical, nonintervened severely obese.

Favorable health outcomes at 2 years postbariatric surgery have been reported. With exception of the Swedish Obesity Subjects (SOS) study, these studies have been surgical case series, comparison of surgery types, or surgery patients compared to subjects enrolled in planned nonsurgical intervention. This study measured gastric bypass effectiveness when compared to two separate severely obese groups not participating in designed weight-loss intervention. Three groups of severely obese subjects (N = 1,156, BMI >or= 35 kg/m(2)) were studied: gastric bypass subjects (n = 420), subjects seeking gastric bypass but did not have surgery (n = 415), and population-based subjects not seeking surgery (n = 321). Participants were studied at baseline and 2 years. Quantitative outcome measures as well as prevalence, incidence, and resolution rates of categorical health outcome variables were determined. All quantitative variables (BMI, blood pressure, lipids, diabetes-related variables, resting metabolic rate (RMR), sleep apnea, and health-related quality of life) improved significantly in the gastric bypass group compared with each comparative group (all P < 0.0001, except for diastolic blood pressure and the short form (SF-36) health survey mental component score at P < 0.01). Diabetes, dyslipidemia, and hypertension resolved much more frequently in the gastric bypass group than in the comparative groups (all P < 0.001). In the surgical group, beneficial changes of almost all quantitative variables correlated significantly with the decrease in BMI. We conclude that Roux-en-Y gastric bypass surgery when compared to severely obese groups not enrolled in planned weight-loss intervention was highly effective for weight loss, improved health-related quality of life, and resolution of major obesity-associated complications measured at 2 years.

Cancer incidence and mortality after gastric bypass surgery.

Despite weight loss recommendations to prevent cancer, cancer outcome studies after intentional weight loss are limited. Recently, reduced cancer mortality following bariatric surgery has been reported. This study tested whether reduced cancer mortality following gastric bypass was due to decreased incidence. Cancer incidence and mortality data through 2007 from the Utah Cancer Registry (UCR) were compared between 6,596 Utah patients who had gastric bypass (1984-2002) and 9,442 severely obese persons who had applied for Utah Driver's Licenses (1984-2002). Study outcomes included incidence, case-fatality, and mortality for cancer by site and stage at diagnosis of all gastric bypass patients, compared to nonoperated severely obese controls. Follow-up was over a 24-year period (mean 12.5 years). Total cancer incidence was significantly lower in the surgical group compared to controls (hazard ratio (HR) = 0.76; confidence interval (CI) 95%, 0.65-0.89; P = 0.0006). Lower incidence in surgery patients vs. controls was primarily due to decreased incidence of cancer diagnosed at regional or distant stages. Cancer mortality was 46% lower in the surgery group compared to controls (HR = 0.54; CI 95%, 0.37-0.78; P = 0.001). Although the apparent protective effect of surgery on risk of developing cancer was limited to cancers likely known to be obesity related, the inverse association for mortality was seen for all cancers. Significant reduction in total cancer mortality in gastric bypass patients compared with severely obese controls was associated with decreased incidence, primarily among subjects with advanced cancers. These findings suggest gastric bypass results in lower cancer risk, presumably related to weight loss, supporting recommendations for reducing weight to lower cancer risk.