Abstract
Objective
Increased body mass index is associated with greater incidence and severity of obesity-related comorbidities and inadequate postbariatric surgery weight loss. Accordingly, comorbidity resolution is an important measure of surgical outcome in super-obese individuals. We previously reported superior weight loss in super-obese patients following duodenal switch (DS) compared to Roux-en-Y gastric bypass (RYGB) in a large single institution series. We now report follow-up comparison of comorbidity resolution and correlation with weight loss.
Methods
Data from patients undergoing DS and RYGB between August 2002 and October 2005 were prospectively collected and used to identify super-obese patients with diabetes, hypertension, dyslipidemia, and gastroesophageal reflux disease (GERD). Ali–Wolfe scoring was used to describe comorbidity severity. Chi-square analysis was used to compare resolution and two-sample t tests used to compare weight loss between patients whose comorbidities resolved and persisted.
Results
Three hundred fifty super-obese patients [DS (n = 198), RYGB (n = 152)] were identified. Incidence and severity of hypertension, dyslipidemia, and GERD was comparable in both groups while diabetes was less common but more severe in the DS group (24.2% vs. 35.5%, Ali–Wolfe 3.27 vs. 2.94, p < 0.05). Diabetes, hypertension, and dyslipidemia resolution was greater at 36 months for DS (diabetes, 100% vs. 60%; hypertension, 68.0% vs. 38.6%; dyslipidemia, 72% vs. 26.3%), while GERD resolution was greater for RYGB (76.9% vs. 48.57%; p < 0.05). There were no differences in weight loss between comorbidity “resolvers” and “persisters”.
Conclusions
In comparison to RYGB, DS provides superior resolution of diabetes, hypertension, and dyslipidemia in the super-obese independent of weight loss.
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References
Flegal KM, Carroll MD, Ogden CL et al. Prevalence and trends in obesity among US adults, 1999–2000. JAMA 2002;288:1723–1727.
Ogden CL, Carroll MD, Curtin LR et al. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006;295:1549–1555.
Sturm R. Increases in morbid obesity in the USA: 2000–2005. Public Health 2007;121(7):492–496.
Prospective Studies Collaboration. Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies. Lancet 2009;373(9669):1083–1096.
Bays HE, Chapman RH, Grandy S. The relationship of body mass index to diabetes mellitus, hypertension and dyslipidaemia: comparison of data from two national surveys. Int J Clin Pract 2007;61(5):737–747.
Nguyen NT, Magno CP, Lane KT, Hinojosa MW, Lane JS. Association of hypertension, diabetes, dyslipidemia, and metabolic syndrome with obesity: findings from the National Health and Nutrition Examination Survey, 1999 to 2004. J Am Coll Surg 2008;207:928–934.
LABS Writing Group. Relationship of body mass index with demographic and clinical characteristics in the Longitudinal Assessment of Bariatric Surgery (LABS). SOARD 2008;4(4):474–480.
Gregg EW, Cheng YJ, Cadwell BL et al. Secular trends in cardiovascular disease risk factors according to body mass index in US adults. JAMA 2005;293(15):1868–1874.
Alley DE, Chang VW. The changing relationship of obesity and disability, 1988–2004. JAMA 2007;298(17):2020–2027.
Maggard MA, Shugarman LR, Suttorp M et al. Meta-analysis: surgical treatment of obesity. Ann Intern Med 2005;142:547–559.
National Institutes of Health Consensus Development Panel. Gastrointestinal surgery for severe obesity. Ann Intern Med 1991;115:956–961.
Buchwald H, Avidor Y, Braunwald E et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004;292:1724–1737.
Clegg AJ, Colquitt J, Sidhu MK et al. The clinical effectiveness and cost-effectiveness of surgery for people with morbid obesity: a systematic review and economic evaluation. Health Technol Assess 2002;6:1–153.
Mason EE, Doherty C, Maher JW et al. Super obesity and gastric reduction procedures. Gastroenterol Clin North Am 1987;6:495–502.
Artuso D, Wayne M, Kaul A et al. Extremely high body mass index is not a contraindication to laparoscopic gastric bypass. Obes Surg 2004;6:750–754.
Bloosmston M, Zervos EE, Camps MA et al. Outcome following bariatric surgery in super versus morbidly obese patients: does weight matter? Obes Surg 1997;7:414–419.
MacLean LD, Rhode B, Nohn CW. Late outcome of isolated gastric bypass. Ann Surg 2000;231:524–528.
Melton GB, Steele KE, Schweitzer MA, Lidor AO, Magnuson TH. Suboptimal weight loss after gastric bypass surgery: correlation of demographics, comorbidities, and insurance status with outcomes. J Gastrointest Surg 2008;12(2):250–255.
Hess DS, Hess DW. Biliopancreatic diversion with a duodenal switch. Obes Surg 1998;8:267–282.
Marceau P, Biron S, Bourque RA et al. Biliopancreatic diversion with a new type of gastrectomy. Obes Surg 1993;3:29–35.
Marceau P, Hould FS, Simard S et al. Biliopancreatic diversion with duodenal switch. World J Surg 1998;22:947–954.
DeMeester TR, Fuchs KH, Ball CS et al. Experimental and clinical results with proximal end-to-end duodenojejunostomy for pathologic duodenogastric reflux. Ann Surg 1987;206:414–426.
Scopinaro N, Gianetta E, Civalleri D et al. Bilio-pancreatic bypass for obesity: II. Initial experience in man. Br J Surg 1979;66:618–620.
Fazylov RM, Savel RH, Horovitz JH et al. Association of super-superobesity and male gender with elevated mortality in patients undergoing the duodenal switch procedure. Obesity Surg 2005;15:618–623.
Dolan K, Hatzifotis M, Newbury L et al. A clinical and nutritional comparison of biliopancreatic diversion with and without duodenal switch. Ann Surg 2004;240:51–56.
Slater GH, Ren CJ, Siegel N et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg 2004;8:48–55.
Prachand VN, DaVee RT, Alverdy JC. Duodenal switch provides superior weight loss in the super-obese (BMI ≥ 50 kg/m2) compared with gastric bypass. Ann Surg 2006;244:611–619.
Crémieux P, Buchwald H, Shikora SA et al. A study on the economic impact of bariatric surgery. Am J Manag Care 2008;14(9):589–596.
Williamson DF, Serdula MK, Anada RF, Levy A, Byers T. Weight loss attempts in adults: goals, duration, and rate of weight loss. Am J Pub Health 1992;82:1251–1257.
NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. NIH Publication 1998 No. 98-4083.
Schauer P, Ikramuddin S, Gourash W et al. Outcomes after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Ann Surg 2000;232:515–529.
Hess DS, Hess DW, Oakley RS. The biliopancreatic diversion with the duodenal switch: results beyond 10 years. Obes Surg 2005;15:408–416.
Anthone GJ, Lord RV, DeMeester TR et al. The duodenal switch operation for the treatment of morbid obesity. Ann Surg 2003;238:618–628.
Marceau P, Biron S, Hould FS, Lebel S, Marceau S, Lescelleur O, Biertho L, Simard S. Duodenal switch: long-term results. Obes Surg 2007;17(11):1421–1430.
Ali MR, Maguire MB, Wolfe BM. Assessment of obesity-related comorbidities: a novel scheme for evaluating bariatric surgical patients. J Am Coll Surg 2006;202:70–77.
Kellogg TA, Andrade R, Maddaus M, Slusarek B, Buchwald H, Ikramuddin S. Anatomic findings and outcomes after antireflux procedures in morbidly obese patients undergoing laparoscopic conversion to Roux-en-Y gastric bypass. Surg Obes Relat Dis 2007;3(1):52–57. discussion 58–9.
Savage AP, Adrian TE, Carolan G et al. Effects of peptide YY (PYY) on mouth to caecum intestinal transit time and on the rate of gastric emptying in healthy volunteers. Gut 1987;28:166–170.
Gutzwiller JP, Goke B, Drewe J et al. Glucagon-like peptide-1: a potent regulator of food intake in humans. Gut 1999;44:81–86.
Kreymann B, Williams G, Ghatei MA, Bloom SR. Glucagon-like peptide-1 7–36: a physiological incretin in man. Lancet 1987;2:1300–1304.
Morinigo R, Moize V, Musri M et al. Glucagon-like peptide-1, peptide YY, hunger, and satiety after gastric bypass surgery in morbidly obese subjects. J Clin Endocrinol Metab 2006;91:1735–1740.
Borg CM, le Roux CW, Ghatei MA et al. Progressive rise in gut hormone levels after Roux-en-Y gastric bypass suggests gut adaptation and explains altered satiety. Br J Surg 2006;93:210–215.
Clements RH, Gonzalez QH, Long CI et al. Hormonal changes after Roux-en Y gastric bypass for morbid obesity and the control of type-II diabetes mellitus. Am Surg 2004;70:1–4.
Acknowledgments
We would like acknowledge Shang Lin, Ph.D. for his assistance with the statistical analysis and Roy T. DaVee for database assistance.
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Discussant
Dr. J. Chris Eagon (Washington University, St. Louis): That was a wonderful presentation. I guess one of the questions I had was, “do you think that the duodenal switch operation is worse off in terms of GERD resolution because of the anatomical configuration of the sleeve?” Or is there some other effect there that is present that is making that difference?
Second of all, I was a little surprised about the relative lack of effect of gastric bypass compared to duodenal switch in terms of diabetes resolution.
Do you have any ideas about how to detect why that is the case? Are there some hormonal differences in the fact that the nutrients are being pushed a little bit farther downstream in the GI tract as a reason for that?
Discussant
Dr. Vivek Prachand (University of Chicago): Even though the sleeve gastrectomy does result in resection of a significant amount of the gastric parietal cell mass, I suspect that the amount of acid production in the remaining pouch or sleeve is substantially greater than the small 20-cc pouch that is made during gastric bypass.
Combining this increased acid production with the relative resistance to forward flow given the long tubular structure of the sleeve—thinking about Poiseuille’s law—I think that there may be impaired esophageal clearance of acid. I think that both operations are very effective at controlling biliary reflux given the Roux limb length of greater than 100 cm.
With regards to the resolution of diabetes, I think that there are contributions both from decreased fat cell mass, as well as the neurohormonal effects of these operations that contribute to the resolution.
It may very well be that the differential stimulation and increased release of GLP 1 and peptide YY with a greater amount of distal delivery of nutrients in the duodenal switch may, in part, account for the difference that we see.
Discussant
Dr. Michael Sarr: Are there some people you would not do a duodenal switch on, such as someone who is in the weight category but has severe gastroesophageal reflux?
Closing discussant
Dr. Vivek Prachand (University of Chicago): I think that is a patient that I would have serious reservations about performing a duodenal switch on. However, if they were a very bad diabetic, hypertensive, and so forth, then I still would probably lean more toward a duodenal switch than a bypass.
One of the questions that we do ask preoperatively is, “what is their typical bowel habit pattern beforehand?” If they are already having two to four bowel movements a day regularly, which is typically the pattern that we see after DS, I am also hesitant to offer duodenal switch to those patients.
Discussant
Dr. Michael Sarr: What about a distal gastric bypass? Do you think that these patients lose the same amount of weight as a duodenal switch? That operation would get rid of the reflux problem.
Discussant
Dr. Vivek Prachand (University of Chicago): I think your group has demonstrated that the weight loss is pretty similar to the duodenal switch and that might be a good option in a patient with reflux.
Discussant
Dr. Manfred Prager (Austria): How do the comorbidities contribute to the overall effect of the duodenal switch. Is it the length of the biliopancreatic and/or the nutritional limb? Or is it also that you have the duodenal-jejunal anastomosis and that you leave the pyloric valve?
Does the pyloric valve have a positive effect on the efficacy of the duodenal switch?
Discussant
Dr. Vivek Prachand (University of Chicago): I could speculate that, again, thinking about the distal gut hormones and how they impact on gastric emptying, having an intact antropyloric mechanism may in part contribute to those sorts of effects. With regards to the biliopancreatic limb versus alimentary limb, as I mentioned, there are some groups that use fixed limb lengths as we do versus those that use proportionately tailored limbs. I think the answer is that we really do not know.
We chose to use fixed lengths because they are something that we could control, and be consistent with, and standardize. But I think that it is probably unrealistic and naive to think about the biliopancreatic limb as just being a passive conduit of biliopancreatic secretion when we know there is a lot of reabsorption and inactivation of enzymes that occurs.
Marc Ward was supported by NIDDK T35 DK062719.
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Prachand, V.N., Ward, M. & Alverdy, J.C. Duodenal Switch Provides Superior Resolution of Metabolic Comorbidities Independent of Weight Loss in the Super-obese (BMI ≥ 50 kg/m2) Compared with Gastric Bypass. J Gastrointest Surg 14, 211–220 (2010). https://doi.org/10.1007/s11605-009-1101-6
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DOI: https://doi.org/10.1007/s11605-009-1101-6