Nicola Corigliano

Etonorgestrel concentrations in morbidly obese women following Roux-en-Y gastric bypass surgery: three case reports☆☆☆

BACKGROUND Pregnancy should be avoided for 12 to 18 months after Roux-en-Y gastric bypass (RYGB) surgery. The etonorgestrel (ENG)-releasing implant (Implanon®) may represent a safe and effective contraceptive method in morbidly obese women who are candidates for bariatric surgery. In addition, the subcutaneous delivery of steroid is unaffected by malabsorptive surgery. METHODS Three cases of young women with ENG-releasing implant are reported. The device was inserted 1-2 months prior to RYGB. RESULTS Their initial weights were 130 to 176 kg, and the mean weight loss was 33.6 kg at 6 months. The concomitant serum ENG concentrations decreased currently with weight loss but remained above the minimum concentration required for effective contraceptive effect of the implant for at least 6 months following RYGB (average, 170 pg/mL). The concentrations observed before weight loss were lower than in normal-weight women, but decreases in ENG concentrations following implant insertion were similar. CONCLUSION These unique data in morbidly obese women highlight the need for further pharmacokinetic studies of contraceptive agents in obese women during weight loss.

Similar postoperative safety between primary and revisional gastric bypass for failed gastric banding.

IMPORTANCE Adjustable gastric bands are widely used because of low postoperative morbidity, but their long-term results are poor, often leading to revisional surgery. OBJECTIVE To assess the safety of revisional procedures by comparing the 30-day outcomes of primary gastric bypass vs revisions following failed adjustable gastric banding. DESIGN, SETTING, AND PARTICIPANTS Retrospective review using logistic regression models to compute odds ratios (95% CIs) across preoperative body mass index (calculated as weight in kilograms divided by height in meters squared) quartiles to evaluate the risk for major adverse outcomes at 30 days (death, venous thromboembolism, reinterventions, and failure to be discharged). The prospective database of a single university surgical center in Paris, France, was queried for clinical and other relevant data among all patients undergoing primary or revisional laparoscopic gastric bypass between January 1, 2004, and June 30, 2013. MAIN OUTCOMES AND MEASURES The primary outcome was a comparison between 30-day outcomes of primary gastric bypass and procedures following failed adjustable gastric banding. RESULTS In total, 831 patients had a primary procedure (group 1), and 177 patients had a secondary procedure after failed adjustable gastric banding (group 2). Overall, 78.7% of patients were female, the mean (SD) patient age was 42.6 (11.6) years, the mean (SD) body mass index was 47.6 (7.6), and mortality at 30 days was 0.5%. The rates of major adverse outcomes were similar in group 1 (7.8%) and group 2 (8.5%) (P = .77). In multivariate analyses, odds ratios for major adverse outcomes across preoperative body mass index quartiles (<42, 42-46, >46 to 52, and >52) were 1.00, 0.39 (95% CI, 0.20-0.77; P = .006), 0.55 (95% CI, 0.30-1.02; P = .06), and 0.50 (95% CI, 0.27-0.94; P = .03), respectively. CONCLUSIONS AND RELEVANCE The 30-day major adverse outcome rates were similar for primary gastric bypass and for procedures following failed adjustable gastric banding. Long-term comparative studies are required to better understand the quadratic relationship between body mass index and early postoperative outcomes.

Five-year outcomes of gastric bypass for super-super-obesity (BMI≥60 kg/m²): A case matched study

BACKGROUND Laparoscopic gastric bypass (LRYGB) is feasible for patients with body mass index (BMI)≥60 kg/m² (super-super-obesity [SSO]) but long-term data are lacking. The objective of this study was to compare the 5-year weight loss and changes in obesity-related co-morbidities after LRYGB for SSO and non-SSO patients. METHODS From January 2004 to November 2008, 32 SSO and 320 non-SSO patients underwent LRYGB. We matched 30 SSO patients undergoing LRYGB (case group) with 60 non-SSO patients (control group) for age, sex, and presence of type 2 diabetes. RESULTS Baseline data indicate that case and control groups did not differ for age (42±12.4 versus 41.8±11.5 yr; P=.92) or sex ratio (80% female, P=.99). Preoperative BMI were 64.1±4.1 and 46.3±5.6 kg/m² in SSO and non-SSO groups, respectively (P<.0001). The rates of coexisting conditions in the 2 groups were comparable except for hypertension (76.7% versus 53.3%; P=.03). At 5 years after surgery, the percentage of initial weight loss (%IWL) (27.4±11.8 versus 29.7±9.2; P=.35) for the groups were comparable whereas percentage of excess weight loss (%EWL) (44.9±19.9 versus 66.5±21.2; P<.0001) was higher for non-SSO patients. Rates of remission or improvement of coexisting conditions, including diabetes and hypertension, did not differ significantly different between groups. CONCLUSION According to %IWL and rate of partial or complete remission of diabetes and hypertension, our study shows similar outcomes for LRYGB in SSO and non-SSO patients 5 years after surgery. The %EWL does not seem to be an adequate indicator for evaluation of LRYGB outcomes in patients with extreme obesity, such as SSO.

Comparison of results after one year between sleeve gastrectomy and gastric bypass in patients with BMI≥50 kg/m²

BACKGROUND Although laparoscopic sleeve gastrectomy (LSG) was initially described as the first step of a 2-stage procedure for high-risk patients requiring laparoscopic Roux-en-Y gastric bypass (LRYGB), it is now being used as a single-stage procedure. Experience with laparoscopic bariatric surgery is growing, such that LRYGB is increasingly feasible for patients with body mass index (BMI) ≥ 50 kg/m². Nevertheless, outcomes for such category of patients following LSG and LRYGB are lacking. OBJECTIVE To compare weight loss and changes in obesity related co-morbidities at one year following LSG with LRYGB in patients with BMI ≥ 50 kg/m². SETTINGS The prospective database of a single surgery university center was queried for clinical and other relevant data. METHODS From January 2004 to January 2013, 74 and 285 patients underwent LSG or LRYGB with a BMI ≥ 50 kg/m². At one year, rate of follow-up was 92.8%. Success of surgery was defined as % of excess weight loss (%EWL)≥ 50% at one year. Logistic regression was used to compute odds ratio (OR) to evaluate the success at one year of surgery. RESULTS LSG (N = 74) and LGBP (N = 285) groups did not differ for initial BMI (57.2 ± 7.1 versus 56.7 ± 5.5 kg/m²; P = .52), % of female (64.6% versus 73.7%, P = .13) or major adverse postoperative events (5.7% versus 6.7%; P = .85). At one year, the mean percentage of weight loss (%) (22.0 ± 7.6 versus 30.3 ± 7.4; P < .0001) and percentage of excess weight loss (%) (40.2 ± 15.2 versus 55.0 ± 14.6; P < .0001) and rates of remission of diabetes (47.5% versus 70.7%; P = .01) were greater in the LGBP than LSG group. In multivariate analyses (OR), LSG was an independent factor of failure of weight loss (.12; P < .0001) CONCLUSION: After 1 year of follow-up in patients with a BMI ≥ 50 kg/m², LRYGB provides better weight loss and resolution in diabetes than LSG with similar postoperative morbidity. Further long-term studies are needed to confirm these results.

Five-year weight loss in primary gastric bypass and revisional gastric bypass for failed adjustable gastric banding: Results of a Case-Matched Study

BACKGROUND Despite their now frequent use, the long-term results for adjustable gastric bands are variable and often less than gastric bypass. Laparoscopic Roux-en-Y gastric bypass (LRYGB) provides good early results and seems to be the revisional procedure of choice. Nevertheless, the long-term outcomes following revisional LRYGB (rLRYGB) for failed adjustable gastric banding have not been compared with those for primary LRYGB (pLRYGB). METHODS The objective was to compare weight loss and changes in obesity related co-morbidities 5 years after pLRYGB and rLRYGB for failed adjustable gastric banding. The prospective database of a single surgery university center (Paris, France) was queried for clinical and other relevant data. From January 2004 to September 2008, 58 and 272 patients have undergone rLRYGB and pLRYGB, respectively. Rate of lost to follow-up was 13.3%. We matched 45 patients undergoing rLRYGB (case group) with 45 undergoing pLRYGB (control group) for age, sex, and initial body mass index (BMI). RESULTS Case and control groups did not differ for initial BMI (46.9±7.2 versus 46.9±7.5 kg/m²; P=.99), age (43.4±9.4 versus 43.6±9.8y; P=.91), or sex ratio (91.1% female, P=.99). The rates of coexisting conditions in the 2 groups were similar. At 5 years, weight loss (kg) (39.9±16.4 versus 31.4±15.8; P=.02), percentage of weight loss (%) (30.8±9.8 versus 24.8±11.5; P=.03), and percentage of excess weight loss (%) (68.4±20.6 versus 55.7±26.3; P=.007) were higher for pLRYGB than rLRYGB. Rates of remission and improvement of coexisting conditions were similar. CONCLUSION After 5 years of follow-up, pLRYGB provides greater weight loss than rLRYGB with similar rates of improvement and remission of coexisting conditions. Patients and surgeons should be aware of such results before primary and revisional bariatric surgery.