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.
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.
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”.
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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We would like acknowledge Shang Lin, Ph.D. for his assistance with the statistical analysis and Roy T. DaVee for database assistance.
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?
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.
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?
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.
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.
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.
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?
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
- Morbid obesity
- Comorbidity resolution
- Duodenal switch
- Gastric bypass
- Bariatric surgery
- Gastroesophageal reflux
- Biliopancreatic diversion