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Suboptimal Weight Loss after Gastric Bypass Surgery: Correlation of Demographics, Comorbidities, and Insurance Status with Outcomes

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Journal of Gastrointestinal Surgery

Abstract

Although Roux-en-Y gastric bypass surgery (RYGBP) is safe and effective at achieving weight loss in the majority of severely obese patients, a subset fails to achieve expected weight loss outcomes. Factors associated with poor weight loss are not well defined. Patients undergoing open RYGBP using a standardized surgical technique and clinical pathway by a single surgeon at a dedicated bariatric center were reviewed. Suboptimal weight loss was defined as failure to lose at least 40% excess body weight by 12 months postoperatively. Of 555 consecutive patients who underwent RYGBP from 1999 to 2004, a 12-month follow-up was available for the 495 (89%). Suboptimal weight loss occurred in 55 (11%) and was associated on unadjusted bivariate analysis with increased body mass index (BMI; p = 0.0002), diabetes mellitus (p = 0.0002), Medicaid insurance (p = 0.04), and male sex (p = 0.01). On adjusted multivariate analysis, increased BMI (p = 0.003), diabetes (p = 0.002), and male gender (p = 0.04) were associated with suboptimal weight loss, but type of insurance (p = 0.11) was not. Medicaid patients were younger (p = 0.01) and had higher BMI (p = 0.0002). Suboptimal weight loss after RYGBP appears to be associated with greater BMI, male sex, and diabetes but not type of insurance. This study may help identify patients who could benefit from increased perioperative education and counseling or selection of procedures with greater malabsorption.

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Acknowledgments

The authors thank the Johns Hopkins surgical house staff and the Johns Hopkins Bayview Medical Center nurses for their skill and devotion.

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Correspondence to Thomas H. Magnuson.

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Discussion

Michael G. Sarr, M.D. (Rochester, MN): This is a vexing problem for the bariatric surgeon. Do you really think that if you can identify these patients that you have an effective intervention preoperatively to offer?

Genevieve B. Melton, M.D. (Baltimore, MD): Dr. Sarr, thank you for your question. Yes, I think that there is some evidence that there are things that we can do to help these patients. First, with respect to preoperative interventions, the Stanford group, has reported that you can have improved weight loss outcomes if patients are encouraged to lose weight preoperatively. Second, with the super obese patients with BMIs over 50, there is evidence that doing a more distal gastric bypass, a Roux limb usually between 100 to 250 cm, can help patients lose more weight. Also, with the duodenal switch, similar improved weight loss outcomes have been noted in the subset of the heaviest patients.

John M. Kellum, Jr., M.D. (Richmond, VA): I too enjoyed your paper. I want to focus on the diabetic problem, because we recently looked at our database of over 4,500 patients and found that indeed they do lose less excess weight. Even though statistically it is very significant, at P < 0.0001, we are talking only about a 67% versus a 60% loss of initial excess weight. And I agree with your findings that it doesn't affect resolution of diabetes. It is known that patients with Type 2 diabetes all have insulin resistance, which slows down metabolic rate. So I am wondering if any type of preoperative counseling will affect weight loss in the diabetic? I hope this won't be used as a reason not to do gastric bypass in the diabetic patient.

Dr. Melton: Dr. Kellum, thank you for your question and comments. I think in fact that this study suggests that we get very good resolution of diabetes after Roux en Y gastric bypass. Evidence from the Rubino group with an animal model has demonstrated that if you bypass the duodenum and proximal jejunum that you often will have resolution of diabetes. In fact, this has been done with patients in India, Mexico and Brazil where they have bypassed the duodenum and have observed resolution of diabetes.

Perhaps the best study out there with respect to diabetes resolution with gastric bypass surgery is from the University of Pittsburgh from Dr. Schauer’s group, which also has shown very good resolution, about 80%, of diabetes, but they have five year data. They demonstrated that those with a shorter duration of diabetes were more likely to have resolution, as well as diet controlled diabetics. In addition, those that lose more weight following surgery tend to resolve more often, as well.

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Melton, G.B., Steele, K.E., Schweitzer, M.A. et al. Suboptimal Weight Loss after Gastric Bypass Surgery: Correlation of Demographics, Comorbidities, and Insurance Status with Outcomes. J Gastrointest Surg 12, 250–255 (2008). https://doi.org/10.1007/s11605-007-0427-1

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