Better gastric bypass surgery outcomes linke to preoperative weight loss

Trenton, NJ

Preoperative weight loss is associated with fewer complications after gastric bypass surgery, according to the results of a record review reported in the December issue of Archives of Surgery.

"Despite the improved ability to accurately predict an increase in surgical risk, the optimal preoperative preparation of such high-risk bariatric surgery candidates remains controversial," write Peter N. Benotti, MD, from Saint Francis Medical Center in Trenton, New Jersey, and colleagues.

"Proposed risk-reducing strategies supported by varying degrees of evidence include staged surgical procedures, preoperative gastric balloon placement for weight loss, and preoperative medical weight reduction....Because the major determinant of postoperative length of stay is operative morbidity, we hypothesized that preoperative weight loss will reduce the frequency of surgical complications in patients who undergo bariatric surgery."

At a comprehensive, multidisciplinary obesity treatment center at a tertiary referral center serving central Pennsylvania, the investigators reviewed records of 881 patients undergoing open or laparoscopic gastric bypass surgery from May 31, 2002, through February 24, 2006. Before surgery, all patients underwent a 6-month multidisciplinary program with the goal of achieving a 10% preoperative weight loss. The primary endpoints of the study were loss of excess body weight and rates of total and major complications.

Loss of 5% or more excess body weight was achieved by 592 (67.2%) of the 881 patients and loss of more than 10% excess body weight by 423 patients (48.0%). Compared with patients undergoing laparoscopic gastric bypass surgery (n = 415), those referred for open gastric bypass (n = 466) were generally older (P < .001), had a higher body mass index (P < .001), and were more often men (P < .001). In addition, they had higher total complication rates (P < .001) and major complication rates (P = .03) vs patients undergoing laparoscopic gastric bypass surgery. Increased preoperative weight loss was associated with decreased rates of total complications (P = .004) and, most likely, decreased rates of major complications (P = .06), based on univariate analysis. In a multiple logistic regression model controlling for age, sex, baseline body mass index, and type of surgery, increased preoperative weight loss predicted reduced rates of total complications (P = .004) and major complications (P = .03). "Preoperative weight loss is associated with fewer complications after gastric bypass surgery," the study authors write. "We hope that these findings will be confirmed by prospective, controlled trials and that bariatric surgeons will consider this modality for preoperative risk reduction in selected patients who are deemed high risk for complications after surgery." Limitations of this study include retrospective design, lack of a control group, referral bias, and possible unmeasured confounding variables. In an accompanying invited critique, Patricia L. Turner, MD, from the University of Maryland Medical Center in Baltimore, recommends emphasizing an aggressive preoperative weight loss regimen. "Overall, this article presents the largest study thus far, to our knowledge, which may demonstrate a significant advantage to preoperative weight loss," Dr. Turner writes. "Moreover, the authors did not experience the attrition feared by some surgeons should they require preoperative weight loss of their patients. These findings suggest that consideration be given to incorporating either a suggestion of or the requirement for modest weight loss prior to bariatric surgery as a means of decreasing postoperative complications."

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Britain’s "most obese teen" is slim after gastric bypass surgery, says would rather be dead

Selby, North Yorks, England

At 19 years of age, Malissa Jones of Selby, North Yorks, England, sees herself as the unhappiest woman alive, whose future is extremely bleak unless she somehow comes up with £20,000 required to undergo cosmetic surgery. At 16, Malissa, Britain’s fattest teen, underwent gastric bypass after doctors told her she only had months to live, and thus became the first person in the world to undergo the surgery. She is now telling Closer magazine she’d rather be dead than live her life as she is now.

Malissa knows that the surgery saved her life, especially since she had her first suspected heart attack at the tender age of 15. Doctors told her at the time that, although risky and not usually done on under-18s, the procedure was the only hope she had to live longer than a few more months. At the time, Jones was diagnosed with angina, had her internal organs compressed, could not move and breathed at night with the help of an oxygen tank. She weighed 34 stone (215 kg) and ate 15,000 calories a day (with the daily recommended intake being of 2,000).

Now, two years later, Malissa has lost 20 stone (127 kg) and her life expectancy is increased. Still, she is depressed and is on medication because she is constantly so ill she can hardly get out of the bed. She says she’s been left with so much excess skin from her weight loss that she truly wishes she had never had the surgery at all – anything, even death, is better than looking like this. She doesn’t have the money to undergo surgery to remove the saggy skin and the NHS will not pay for it.

“I know it sounds ungrateful, but I preferred my body when I was fat. At least it was firm and curvy, not droopy and saggy. I had nice firm arms – now the skin just hangs and I have to cover them up because they look so awful. The NHS won’t remove the skin and I’ll never manage to save £20,000 to have it done privately. The surgery might have saved my life, but I wish I’d never had it done,” Jones says for Closer.

There is tinge of regret though at not having tried to lose the weight the healthy way, with diet and exercise, and especially at having let her problems become so serious. “Although my heart’s healthier and life expectancy is normal, some days I’m too ill to get out of bed. […] I hope people read this and realize gastric surgery isn’t a miracle cure. I wish I’d lost the weight through exercise and healthy eating. I know this operation was life-saving, but the complications I’m suffering now might still kill me. The truth is I feel I’m no better off than I was before,” she says for the same magazine.

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Urologist's opinion: Gastric band placement for obesity is not associated with increased urinary risk of urolithiasis compared to gastric bypass surgery

Berkley, CA

As morbid obesity is becoming increasingly prevalent in our western society, the surgical options for management of this disorder are being more widely utilized. These procedures include Roux-en-Y gastric bypass and gastric band surgery. It has been estimated that the number of bariatric surgeries performed has increased ten-fold in the past decade. It has been observed that in some patients undergoing bariatric surgery for obesity, new onset nephrolithiasis can develop.

These two studies very nicely show that patients at greatest risk are those with Roux-en-Y gastric bypass in which the normal gut flow and absorption is interrupted. These patients typically have an elevation in their urinary oxalate and a significant reduction in their urinary volume. Interestingly, patients with gastric banding appear to have a more significant reduction in their urinary volumes compared to the Roux-en-Y group of patients. However, the Roux-en-Y gastric bypass procedure results in a more significant hyperoxaluria and hypocitraturia.

Both of these studies note that due to the small numbers and the limited time of their study, they were unable to demonstrate that the increased urinary risk factors translated into an actual increased risk for renal stone development. However, it would seem prudent to counsel these patients even before they come to their surgical procedure with regards to dietary modifications to reduce their risk factors for renal stone development. These dietary modifications include maintaining an adequate fluid intake to potentiate a 2-liter urine output per day, 1,200 to 1,500 mg calcium citrate with Vitamin D and 500 mcg Vitamin B-12 and B-complex supplementation. Additional citrate supplementation may be important particularly in those patients with a prior history of stone disease.

Further clinical studies are still required to illustrate the effect of nutrition and pharmacologic therapy on the risk of stone development in patients undergoing bariatric surgery.

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