Hilde Risstad

Five-Year Outcomes After Laparoscopic Gastric Bypass and Laparoscopic Duodenal Switch in Patients With Body Mass Index of 50 to 60: A Randomized Clinical Trial

IMPORTANCE There is no consensus as to which bariatric procedure is preferred to reduce weight and improve health in patients with a body mass index higher than 50. OBJECTIVE To compare 5-year outcomes after Roux-en-Y gastric bypass (gastric bypass) and biliopancreatic diversion with duodenal switch (duodenal switch). DESIGN, SETTING, AND PARTICIPANTS Randomized clinical open-label trial at Oslo University Hospital, Oslo, Norway, and Sahlgrenska University Hospital, Gothenburg, Sweden. Participants were recruited between March 17, 2006, and August 20, 2007, and included 60 patients aged 20 to 50 years with a body mass index of 50 to 60. The current study provides the 5-year follow-up analyses by intent to treat, excluding one participant accepted for inclusion who declined being operated on prior to knowing to what group he was randomized. INTERVENTIONS Laparoscopic gastric bypass and laparoscopic duodenal switch. MAIN OUTCOMES AND MEASURES Body mass index and secondary outcomes including anthropometric measures, cardiometabolic risk factors, pulmonary function, vitamin status, gastrointestinal symptoms, health-related quality of life, and adverse events. RESULTS Sixty patients were randomly assigned and operated on with gastric bypass (n = 31) and duodenal switch (n = 29). Fifty-five patients (92%) completed the study. Five years after surgery, the mean reductions in body mass index were 13.6 (95% CI, 11.0-16.1) and 22.1 (95% CI, 19.5-24.7) after gastric bypass and duodenal switch, respectively. The mean between-group difference was 8.5 (95% CI, 4.9-12.2; P < .001). Remission rates of type 2 diabetes mellitus and metabolic syndrome and changes in blood pressure and lung function were similar between groups. Reductions in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and fasting glucose were significantly greater after duodenal switch compared with gastric bypass. Serum concentrations of vitamin A and 25-hydroxyvitamin D were significantly reduced after duodenal switch compared with gastric bypass. Duodenal switch was associated with more gastrointestinal adverse effects. Health-related quality of life was similar between groups. Patients with duodenal switch underwent more surgical procedures related to the initial procedure (13 [44.8%] vs 3 [9.7%] patients; P = .002) and had significantly more hospital admissions compared with patients with gastric bypass. CONCLUSIONS AND RELEVANCE In patients with a body mass index of 50 to 60, duodenal switch resulted in greater weight loss and greater improvements in low-density lipoprotein cholesterol, triglyceride, and glucose levels 5 years after surgery compared with gastric bypass while improvements in health-related quality of life were similar. However, duodenal switch was associated with more surgical, nutritional, and gastrointestinal adverse effects. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00327912.

Five-year outcome after gastric bypass for morbid obesity in a Norwegian cohort

BACKGROUND Few long-term reports with high rates of follow-up are available after gastric bypass. We report changes in weight, co-morbidity, cardiovascular risk, and health-related quality of life (HRQoL) 5 years after gastric bypass. METHODS Patients who had gastric bypass (2004-2006) were included. Prospective data were reviewed. Long-term complications, cardiovascular risk factors, and HRQoL were evaluated, and the 10-year risk for coronary heart disease was estimated (Framingham risk score). Outcomes were compared in patients with body mass index (BMI)<50 and ≥50 kg/m(2). RESULTS A total of 184 of 203 patients (91%) met to follow-up. The mean ± SD preoperative BMI was 46 ± 5 kg/m(2), and the mean ± SD age was 38 ± 9 years; 75% were women. Thirty-two percent of the patients had a BMI ≥50 kg/m(2), and 30% had type 2 diabetes. Follow-up was 63 ± 5 months. After 5 years, total weight loss was 27% ± 11%. Remission of type 2 diabetes had occurred in 67%. The prevalence of hypertension, dyslipidemia, sleep apnea, and metabolic syndrome had decreased. HRQoL was improved. The Framingham risk score was reduced (5.6% versus 4.6%; P = .021). Sixty-one patients (33%) had long-term complications, most commonly chronic abdominal pain (10%). BMI was 33 ± 5 and 37 ± 7 kg/m(2) in patients with preoperative BMI<50 and ≥50 kg/m(2), but changes in metabolic, cardiovascular risk profile and HRQoL were broadly similar. CONCLUSIONS Beneficial effects on weight loss, cardiovascular risk, and HRQoL were documented 5 years after gastric bypass in morbidly and super-obese patients.

Application of the International Diabetes Federation and American Diabetes Association criteria in the assessment of metabolic control after bariatric surgery

The International Diabetes Federation (IDF) and the American Diabetes Association (ADA) have introduced specific criteria to define the ‘optimization’ of the metabolic state and glycaemic ‘remission’ of type 2 diabetes mellitus (T2DM) after bariatric surgery, respectively. Our objective was to assess the percentage of patients achieving these criteria. Data were collected for body mass index, glycaemic markers, lipids, blood pressure, hypoglycaemia and medication usage from 396 morbidly obese T2DM patients who underwent bariatric surgery in two centres and followed up for 2 years. At year 1, 14% of patients achieved the IDF criteria and 38% the ADA criteria, whereas at 2 years 8 and 9% satisfied these criteria, respectively. A relatively low proportion of patients achieved optimization of the metabolic state and T2DM remission. These patients may potentially benefit from the combination of bariatric surgery and adjuvant medical therapy to achieve optimal metabolic outcomes.

Standard vs Distal Roux-en-Y Gastric Bypass in Patients With Body Mass Index 50 to 60: A Double-blind, Randomized Clinical Trial

Importance Up to one-third of patients undergoing bariatric surgery have a body mass index (BMI) of more than 50. Following standard gastric bypass, many of these patients still have a BMI greater than 40 after peak weight loss. Objective To assess the efficacy and safety of standard gastric bypass vs distal gastric bypass in patients with a BMI of 50 to 60. Design, Setting, and Participants Double-blind, randomized clinical parallel-group trial at 2 tertiary care centers in Norway (Oslo University Hospital and Vestfold Hospital Trust) between May 2011 and April 2013. The study included 113 patients with a BMI of 50 to 60 aged 20 to 60 years. The 2-year follow-up was completed in May 2015. Interventions Standard gastric bypass (alimentary limb, 150 cm) and distal gastric bypass (common channel, 150 cm), both with a biliopancreatic limb of 50 cm and a gastric pouch of about 25 mL. Main Outcomes and Measures Primary outcome was the change in BMI from baseline until 2 years after surgery. Secondary outcomes were cardiometabolic risk factors, nutritional outcomes, adverse events, gastrointestinal symptoms, and health-related quality of life. Results At baseline, the mean age of the patients was 40 years (95% CI, 38-41 years), 65% were women, mean BMI was 53.5 (95% CI, 52.9-54.0), and mean weight was 158.8 kg (95% CI, 155.3-162.3 kg). The mean reduction in BMI was 17.8 (95% CI, 16.9-18.6) after standard gastric bypass and 17.2 (95% CI, 16.3-18.0) after distal gastric bypass, and the mean between-group difference was 0.6 (95% CI, -0.6 to 1.8; P = .32). Reductions in mean levels of total and low-density lipoprotein cholesterol were greater after distal gastric bypass than standard gastric bypass, and between-group differences were 19 mg/dL (95% CI, 11-27 mg/dL ) and 28 mg/dL (95% CI, 21 to 34 mg/dL), respectively (P < .001 for both). Reductions in fasting glucose levels and hemoglobin A1c were greater after distal gastric bypass. Secondary hyperparathyroidism and loose stools were more frequent after distal gastric bypass. The number of adverse events and changes in health-related quality of life did not differ between the groups. Importantly, 1 patient developed liver failure and 2 patients developed protein-caloric malnutrition treated by elongation of the common channel following distal gastric bypass. Conclusions and Relevance Distal gastric bypass was not associated with a greater BMI reduction than standard gastric bypass 2 years after surgery. However, we observed different changes in cardiometabolic risk factors and nutritional markers between the groups. Trial Registration Clinicaltrials.gov Identifier: NCT00821197.

Preoperative predictors of adherence to dietary and physical activity recommendations and weight loss one year after surgery

BACKGROUND Weight loss and weight loss maintenance vary considerably between patients after bariatric surgery. Postoperative weight gain has partially been explained by lack of adherence to postoperative dietary and physical activity recommendations. However, little is known about factors related to postoperative adherence. OBJECTIVES The aim of this study was to examine psychological, behavioral, and demographic predictors of adherence to behavior recommendations and weight loss 1 year after bariatric surgery. SETTING Oslo University Hospital. METHODS In a prospective cohort study, 230 patients who underwent Roux-en-Y gastric bypass were recruited from Oslo University hospital from 2011 to 2013. They completed a comprehensive questionnaire before and 1 year after surgery. Weight was measured preoperatively, on the day of surgery, and 1-year postoperatively. RESULTS Mean body mass index was 44.9 kg/m(2) (standard deviation [SD] = 6.0) preoperatively and 30.6 kg/m(2) (SD = 5.2) 1 year after surgery. Patients lost on average 29.2 % (SD = 8.2) of their initial weight. Predictors of dietary adherence were years with dieting experience, readiness to limit food intake, and night eating tendency. Preoperative physical activity and planning predicted postoperative physical activity whereas predictors of weight loss were higher frequency of snacking preoperatively, greater past weight loss, and lower age. CONCLUSION Several preoperative psychological predictors were related to postoperative adherence to dietary and physical activity recommendations but were not associated with weight loss. Interventions targeting psychological factors facilitating behavior change during the initial postoperative phase are recommended as this might improve long-term outcomes.

A novel technique of Roux-en-Y gastric bypass reversal for postprandial hyperinsulinemic hypoglycaemia: A case report

Highlights • Postprandial hypoglycemia may be a serious adverse effect following Roux-en-Y gastric bypass surgery.• Most patient can be treated with diet and pharmacological agents, but some patients need surgical reversals.• This Roux-en-Y gastric bypass reversal alleviates severe postprandial hyperinsulinaemic hypoglycaemia.• The technique retains some component of rapid transit of food into a shorter alimentary limb in an attempt to reduce weight regain.• This new surgical procedure also attenuates s-GLP-1 and s-insulin responses along with improved p-glucose.

Anemia following Roux-en-Y gastric bypass for morbid obesity; a 5-year follow-up study

Abstract Objectives: Patients are at risk of anemia post Roux-en-Y gastric bypass (RYGB). We sought to determine the prevalence of anemia and related nutritional deficiencies 5 years after RYGB and to evaluate adherence to nutritional supplements with iron, vitamin B12, and folate. Material and methods: Patients operated with RYGB 2004–2006 were eligible for evaluation. Blood samples were collected and use of nutritional supplements was recorded preoperatively, and at outpatients’ consultations 1, 2, and 5 years postoperatively. Of 203 patients operated, 184 (91%) completed the 5 year follow-up and were included in the study. Of these, 97% had valid measurements of hemoglobin both at baseline and after 5 years. Results: During the 5 years after RYGB, the prevalence of anemia increased from 4% preoperatively to 24% in females, and from 0% to 7% in males. Ferritin levels decreased gradually in both genders. Iron deficiency increased from 6% preoperatively to 42% at 5 years in females, and from 0% to 9% in males. Vitamin B12 deficiency was not altered while folate deficiency decreased from 10% preoperatively to 1% at 5 years. Five years after surgery 25% reported the use of supplements with iron, while 83% used vitamin B12 and 65% used multivitamins with folate. Conclusions: We observed a long-term increase in anemia and iron deficiency after RYGB in both genders, but most pronounced in women. Our postoperative protocol for prevention of vitamin B12 and folate deficiencies appear acceptable. Iron status and iron supplementation seems to need stronger emphasis during follow-up after RYGB.