Cornelius Doherty

A Decade of Change in Obesity Surgery

Background: The International (formerly National) Bariatric Surgery Registry began collecting data in January 1986. The aim of this study was to examine changes in the practice of surgical treatment of severe obesity that occurred during the decade of 1986 through 1995, as observed in the IBSR data. Methods: All data submitted to the IBSR during the decade were transferred to the IBM mainframe computer for analysis. Characteristics of operative type populations were compared over time using analysis of variance (ANOVA) for age, body mass index (BMI), operative weight and Chi-square (χ2) test for gender. Results: There has been a steady increase over the decade in mean patient weight. The operations used have changed from predominantly ‘simple’ operations to more frequent use of ‘complex’ operations. Within the categories of ‘simple’ and ‘complex’, an increase in the variety of operations occurred. As a group, patients with ‘simple’ operations have been heavier, more often male and public pay patients than those who have undergone ‘complex’ operations. One year weight loss was greater for Roux-en-Y gastric bypass (RGB) than vertical banded gastroplasty (VBG), but follow-up rates were too low to study the relative merits of the operations used. The reported incidence of operative mortality and serious complications (leak with peritonitis, abscess and pulmonary embolism) remained low. Conclusions: These observations and their implications can be summarized in three statements which relate to action for improved patient care in the beginning of the new century: (1) increasing weight of candidates for surgical treatment during this decade indicates the need for earlier use of operative treatment before irreversible complications of obesity can develop; (2) low risk of obesity surgery, decreasing postoperative hospital stay, and early weight control support the continued and increased use of surgical treatment; (3) continued widespread use of both ‘simple’ and ‘complex’ operations with increased modifications of standard RGB and VBG procedures emphasizes the need for standardized long-term data and analyses regarding both weight control and postoperative side-effects.

Vertical gastroplasty : Evolution of vertical banded gastroplasty

Abstract. The objective of this paper is to summarize the goals, technical requirements, advantages, and potential risks of gastroplasty for treatment of severe obesity. Gastroplasty is preferred to more complex operations, as it preserves normal digestion and absorption and avoids complications that are peculiar to exclusion operations. The medical literature and a 30-year experience at the University of Iowa Hospitals and Clinics (UIHC) provides an overview of vertical banded gastroplasty (VBG) evolution. Preliminary 10-year results with the VBG technique currently used at UIHC are included. At UIHC the VBG is preferred to other gastroplasties because it provides weight control that extends for at least 10 years and the required objective, intraoperative quality control required for a low rate of reoperation. It is recommended that modifications of the operative technique not be attempted until a surgeon has had experience with the standardized operation—and then only under a carefully designed protocol. Realistic goals for surgery and criteria of success influence the choice of operation and the optimum, lifelong risk/benefit ratio. In conclusion, VBG is a safe, long-term effective operation for severe obesity with advantages over complex operations and more restrictive simple operations.

Prospective investigation of complications, reoperations, and sustained weight loss with an adjustable gastric banding device for treatment of morbid obesity☆☆☆

The purpose of this study was to determine prospectively the safety and efficacy of an adjustable silicone gastric band and reservoir system for the treatment of morbid obesity. Between 1992 and 1995, forty primary procedures were performed. Twenty-six females and 14 males entered the study. The mean age of the subjects was 34 years (range 19 to 51 years). Mean body mass index was 50 kg/m 2 (range 39 to 75 kg/m2). There were no deaths. Mean body mass index (0in kg/m 2) at follow-up visits was 38.4 at I year, 38.0 at 2 years, 40.2 at 3 years, and 40.4 at 4 years. These decreases were significant at P <0.001. Thirty-two reoperations (12 intra-abdominal procedures and 20 abdominal wall procedures) have been necessary to maintain efficacy or correct complications. At the four-year interval, the reoperation rate of 80% was unsatisfactory. The excess weight loss has been 41% for those subjects who have an intact gastric band system and continue in the study. Improvements to the implantable band and/or operative technique must be implemented and studied long term if this procedure is to become an accepted surgical treatment for severe obesity.

Vertical Banded Gastroplasty in the Severely Obese under Age Twenty-One

Background: The severely obese under 21 years of age are at high risk of missing normal development during a crucial period of life and should be considered for surgical treatment. Vertical banded gastroplasty allows patients to be treated effectively while continuing to have normal digestion and absorption without the risks of complex operations. Methods: This was a retrospective outcome review of 47 severely obese who were under age 21 when surgically treated with VBG. Results: There were no operative mortalities, leaks, or wound infections. Body mass index in 25 patients followed 5 years decreased from an average operative 48.1 to 36.2 kg m−2. Equally for 14 patients followed 10 years, BMI decreased from an average operative 49.6 to 39.2 kgm−2. Both patient groups had 74% follow-up. Conclusions: Sustained weight reduction improved general health and allowed participation in life activities that would otherwise not have been possible. Adherence to recommended operative technique and intraoperative measurement of pouch volume is necessary to avoid excessive enlargement of the pouch, with resulting weight gain, reflux, and need for revision.

Impact of Vertical Banded Gastroplasty on Respiratory Insufficiency of Severe Obesity

Background: Respiratory insufficiency associated with morbid obesity can include sleep apnea syndrome (SAS), obesity hypoventilation syndrome (OHS), or a combination of both. The aim of our study was to determine the safety and effectiveness of vertical banded gastroplasty (VBG) in the treatment of severely obese patients with respiratory insufficiency. Methods: From 1983 to 1994, 35 patients (25 males, ten females) who met the criteria for either SAS and OHS (19 patients) or SAS alone (16 patients) underwent VBG. Results: Six patients (17%) died of subsequent pulmonary-cardiac disease despite significant weight loss. Need for nasal continuous positive airway pressure (CPAP) decreased after VBG from 68% of patients preoperatively to 22% postoperatively. Of the ten patients with sleep studies, the apnea/hyponea index decreased from 45 ± 11 events per h preoperatively to 12 ± 6 events per h postoperatively, while per cent ideal body weight (%IBW) also decreased (pre-VBG: 268 ± 12, post-VBG: 204 ± 12). Of the seven patients with arterial blood gases, PaCO2 decreased from 55 ± 4 torr preoperatively to 41 ± 3 torr postoperatively, and PaO2 increased from 50 ± 4 torr preoperatively to 73 ± 6 torr postoperatively, while %IBW decreased (pre-VBG: 263 ± 16, post-VBG: 193 ± 14). Conclusion: Respiratory insufficiency is a life-threatening complication of morbid obesity. In morbidly obese patients with respiratory insufficiency, VBG offers improvement in both SAS and OHS. Respiratory insufficiency due to obesity should be considered a strong indication for VBG.

The Effect of Follow-up on Reporting Success for Obesity Surgery

Background: Much is written about the importance of follow-up in determining the effect of surgical treatment for obesity upon weight loss. When patients are lost to follow-up, it has been suggested that these patients should be considered as failures. This study was undertaken to determine the effect of incorporating patients not followed in a definition of success for weight loss at one year. Methods: Data from 34 surgical practices were used to study the effect of using two different denominators, patients followed (DF) or patients eligible (DE), to define success. The numerator used in both methods was the number of patients with ≤50% EW at 1 year. Results: One-year follow-up was 61% (5091/8356). Success was 67% (3423/5091) when calculated using the denominator patients followed (DF). No correlation was found between success and follow-up when data within each surgical practice were averaged and used in a correlation analysis. Conclusions: This study does not support the thesis that patients who fail to return for follow-up should be considered as having failed in weight control.

A Study on Predicting Weight Loss Following Surgical Treatment for Obesity

To date, longitudinal weight loss analyses (curve-fitting) have been complicated by non-linear weight patterns, incomplete follow-up, and varied follow-up times. Therefore, the cross-sectional design (one time point survey) was chosen to study predictors of weight loss at yearly postoperative time intervals (± 6 months). Mean values for the initial cohort of 7,540 patients were: age 37.4 years (± 9.4), weight 124.0 kg (± 25.5), height 165.4 cm (± 8.5). Females comprised 87.7% of the data set. Followup was 62.5% at year one, 32.0% at year 2, 20.6% at year 3, and 15.4% at year 4. The multiple regression model used included 20 explanatory variables and was performed separately for four yearly time points. Only operative weight, initial visit height, age, and operative type were consistent predictors of weight loss (p < 0.05) at all time points examined and accounted for 40-50% of weight loss variation.

Pay Status as a Predictor of Outcome in Surgical Treatment of Obesity.

Background: Higher complication rates and lower success in surgery for severe obesity have been reported for patients with government pay status. We examined the effect of pay status upon outcome in surgical treatment of obesity. Methods: This was an observational study from an aggregate data set of individual patient information. Government pay status (G) was defined as full or partial medical care payment through Medicare, Medicaid, or Veterans Administration. Payment entirely by private insurance was defined as private (P). Operations were classified as either simple (S, gastric restriction) or complex (C, gastric restriction with small bowel bypass). Two measures of outcome, perioperative complication rate and weight loss success (≤50% excess weight), were examined to determine pay status effect. Results: More G than P patients were treated with simple procedures (79% vs 51%, p < 0.05). Perioperative complication rates were more common for G than P patients (14.4% vs 9.1%, p < 0.05). One-year weight loss success was higher for P than G, regardless of operation type. Conclusion: Pay status should be included in characterization of patient groups and in the analysis of results when effectiveness of surgical treatment for severe obesity is reported.

An interval report on prospective investigation of adjustable silicone gastric banding devices for the treatment of severe obesity.

A review and updated report of an ongoing prospective investigation of two different adjustable silicone gastric banding devices is presented. One cohort of this study includes 40 subjects who have had a band placed by laparotomy. A second cohort includes 22 subjects who have had a newly designed adjustable silicone gastric band (ASGB) placed by laparoscopic or open technique. The goal of this investigation is to evaluate the achievement of sustained weight loss without the need for re-operation. Because of the frequent need for re-operation to correct life-threatening complications or ineffectiveness of ASGB devices, present clinical data indicate that improvements to the implantable system and the operative technique need to be made and verified by long-term study. At this point in development, ASGB remains an investigative procedure that has not fulfilled the scientific requirements of an accepted surgical treatment for severe obesity.

Gastric operations in obesity surgery

Gastric restriction surgery for obesity began in 1966 with the empirical use of gastric bypass, an analogue of Billroth H gastric resection (an operation that had the unwanted effect of causing patients with duodenal ulcer to remain below their desired weight). In order to simplify gastric restriction operations for severe obesity and to decrease their side effects, increase their safety, and improve lifelong weight control, the operation used today — vertical banded gastroplasty with a 5-cm circumference collar and a measured pouch averaging 13 ml — has evolved.