Early postoperative weight loss predicts maximal weight loss after sleeve gastrectomy and Roux-en-Y gastric bypass.

BACKGROUND: Previous studies show that 'poor responders' to Roux-en-Y gastric bypass (RYGBP) may be identified on the basis of early postoperative weight loss. Early identification of poor responders could allow earlier provision of postoperative behavioural and/or intensive lifestyle interventions and enhance their maximal weight loss. Our aim was to investigate whether early postoperative weight loss predicts the maximal weight loss response after RYGBP and sleeve gastrectomy (SG). METHODS: We undertook a retrospective cross-sectional study of 1,456 adults who underwent either RYGBP (n = 918) or SG (n = 538) as a primary procedure in one of two European centres. Postoperative weight loss was expressed as weight loss velocity (WLV) and percentage weight loss. Linear regression analyses were performed to determine the association of early postoperative weight loss with maximal %WL, including adjustment for baseline variables. RESULTS: There was marked variability in maximal %WL following both RYGBP (mean 32.9 %, range 4.1-60.9 %) and SG (mean 26.2 %, range 1.1-58.3 %). WLV 3-6 months postoperatively was more strongly associated with maximal %WL (r (2) = 0.32 for RYGBP and r (2) = 0.26 for SG, P < 0.001 for both) than either WLV 0-6 weeks or 6 weeks to 3 months postoperatively (r (2) = 0.14 and 0.10 for RYGBP, respectively; r (2) = 0.18 and 0.21 for SG, respectively; P < 0.001 for all). Multiple linear regression analysis, including baseline variables of age, sex, preoperative BMI, type 2 diabetes, ethnicity, and bariatric centre, revealed that 3-6 month WLV was an independent predictor of maximal %WL in both SG and RYGBP groups (standardised ß-coefficients 0.51 and 0.52, respectively; P < 0.001 for both). CONCLUSIONS: There is a marked variability in weight loss response following RYGBP and SG. Early postoperative weight loss can be used to identify patients whose predicted weight loss trajectories are suboptimal. Early targeting of poor responders with more intensive postoperative lifestyle and behavioural support could potentially enhance their weight loss response.

Age- and sex-specific effects on weight loss outcomes in a comparison of sleeve gastrectomy and Roux-en-Y gastric bypass: a retrospective cohort study.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) and sleeve gastrectomy (SG) are the most common bariatric procedures undertaken globally but there are no evidenced-based criteria that inform the selection of one operation over the other. The purpose of this study was thus to compare weight loss outcomes between RYGBP and SG, and to define patient factors affecting weight loss. METHODS: A single-centre two-year follow-up retrospective cohort study of all adults who underwent either RYGBP (n = 422) or SG (n = 432) between 2007 and 2012, at University College London Hospitals National Health Service Foundation Trust, an academic tertiary referral centre, was undertaken. Multilevel linear regression was used to compare weight loss between groups, enabling adjustment for preoperative BMI (body mass index) and evaluation for interaction factors. RESULTS: One- and two-year results showed that unadjusted BMI loss was similar between groups; 13.7 kg/m(2) (95% CI: 12.9, 14.6 kg/m(2)) and 12.8 kg/m(2) (95% CI: 11.8, 13.9 kg/m(2)) for RYGBP patients respectively compared with 13.3 kg/m(2) (95% CI: 12.0, 14.6 kg/m(2)) and 11.5 kg/m(2) (95% CI: 10.1, 13.0 kg/m(2)) for SG patients respectively. Adjusting for preoperative BMI, there was 2.2 kg/m(2) (95% CI: 1.5, 2.8) and 2.3 kg/m(2) (95% CI: 1.3, 3.3) greater BMI loss in the RYGBP group compared to the SG group at one and two years respectively (P < 0.001 for both). The interaction analyses demonstrated that age and sex had important differential impacts on SG and RYGBP weight outcomes. Men under 40 and women over 50 years obtained on average far less benefit from SG compared to RYGBP, whereas men over 40 years and women under 50 years experienced similar weight loss with either procedure (P = 0.001 and 0.022 for interaction effects at one and two years respectively). CONCLUSIONS: Our results show that patient sex and age significantly impact on weight loss in a procedure-dependent manner and should be considered when choosing between RYGBP and SG. Optimizing procedure selection could enhance the effectiveness of bariatric surgery, thus further increasing the benefit-to-risk ratio of this highly effective intervention.

Differential effects of laparoscopic sleeve gastrectomy and laparoscopic gastric bypass on appetite, circulating acyl-ghrelin, peptide YY3-36 and active GLP-1 levels in non-diabetic humans.

Laparoscopic Roux-en-Y gastric bypass (LRYGBP) reduces appetite and induces significant and sustainable weight loss. Circulating gut hormones changes engendered by LRYGBP are implicated in mediating these beneficial effects. Laparoscopic sleeve gastrectomy (LSG) is advocated as an alternative to LRYGBP, with comparable short-term weight loss and metabolic outcomes. LRYGBP and LSG are anatomically distinct procedures causing differential entero-endocrine cell nutrient exposure and thus potentially different gut hormone changes. Studies reporting the comparative effects of LRYGBP and LSG on appetite and circulating gut hormones are controversial, with no data to date on the effects of LSG on circulating peptide YY3-36 (PYY3-36) levels, the specific PYY anorectic isoform. In this study, we prospectively investigated appetite and gut hormone changes in response to LRYGBP and LSG in adiposity-matched non-diabetic patients. Anthropometric indices, leptin, fasted and nutrient-stimulated acyl-ghrelin, active glucagon-like peptide-1 (GLP-1), PYY3-36 levels and appetite were determined pre-operatively and at 6 and 12 weeks post-operatively in obese, non-diabetic females, with ten undergoing LRYGBP and eight adiposity-matched females undergoing LSG. LRYGBP and LSG comparably reduced adiposity. LSG decreased fasting and post-prandial plasma acyl-ghrelin compared to pre-surgery and to LRYGBP. Nutrient-stimulated PYY3-36 and active GLP-1 concentrations increased post-operatively in both groups. However, LRYGBP induced greater, more sustained PYY3-36 and active GLP-1 increments compared to LSG. LRYGBP suppressed fasting hunger compared to LSG. A similar increase in post-prandial fullness was observed post-surgery following both procedures. LRYGBP and LSG produced comparable enhanced satiety and weight loss. However, LSG and LRYGBP differentially altered gut hormone profiles.

Adolescent bariatric surgery--thoughts and perspectives from the UK.

Opinions of healthcare professionals in the United Kingdom regarding bariatric surgery in adolescents are largely unknown. This study aims to explore the perspectives of medical professionals regarding adolescent bariatric surgery. Members of the British Obesity and Metabolic Surgery Society and groups of primary care practitioners based in London were contacted by electronic mail and invited to complete an anonymous online survey consisting of 21 questions. Ninety-four out of 324 questionnaires were completed. 66% of professionals felt that adolescents with a body mass index (BMI) >40 or BMI >35 with significant co-morbidities can be offered surgery. Amongst pre-requisites, parental psychological counseling was chosen most frequently. 58% stated 12 months as an appropriate period for weight management programs, with 24% regarding 6 months as sufficient. Most participants believed bariatric surgery should only be offered ≥ 16 years of age. However, 17% of bariatric surgeons marked no minimum age limit. Over 80% of the healthcare professionals surveyed consider bariatric surgery in adolescents to be acceptable practice. Most healthcare professionals surveyed feel that adolescent bariatric surgery is an acceptable therapeutic option for adolescent obesity. These views can guide towards a consensus opinion and further development of selection criteria and care pathways.

From Little Acorns, Bariatric Surgery in the United Kingdom, 2011: Personal Journey and Current Status.

Bariatric surgery in the United Kingdom dates to the early 1970s, and early pioneers made international contributions. This article gives a personal perspective on historical development from their work through the introduction of laparoscopic and revisional techniques to the present day. Bariatric surgery is becoming recognized in the United Kingdom as a cost-effective force for health improvement, but is hampered by restricted National Health Service prioritization and lack of insurance support. The British Obesity and Metabolic Surgery Society represents an active bariatric clinical community and holds its own scientific meetings. High quality is fostered by a multidisciplinary and team approach in specialized units with adequate volume. Significant advances have been made in professional recognition, science, innovation, guideline development, and health-economic validation. Challenges remain in equity of access, service capacity, reimbursement, and clinical quality assurance. The recent establishment of a National Registry will help to overcome these obstacles.

Long-term outcomes following laparoscopic adjustable gastric banding: postoperative psychological sequelae predict outcome at 5-year follow-up.

BACKGROUND: NICE guidelines state that patients with psychological contra-indications should not be considered for bariatric surgery, including Laparoscopic Adjustable Gastric Banding (LAGB) surgery as treatment of morbid obesity, although no consistent correlation between psychiatric illness and long-term outcome in LAGB has been established. This is to our knowledge the first study to evaluate long-term outcomes in LAGB for a full range of DSM-IV defined psychiatric and eating disorders, and forms part of a research portfolio developed by the authors aimed at defining psychological predictors of bariatric surgery in the short-, medium- and long-term. METHODS: Case notes of 37 subjects operated on between April 1997 and June 2000, who had undergone structured clinical interview during pre-surgical assessment to yield diagnoses of mental and eating disorders according to DSM-IV criteria were analyzed according to a set of operationally defined criteria. Statistical analysis was carried out to compare those with a poor outcome and those considered to have a good outcome in terms of psychiatric profile. RESULTS: In this group of mainly female, Caucasian subjects, ranging in age from 27 to 60 years, one-third were diagnosed with a mental disorder according to DSM-IV criteria. The development of postoperative DSM-IV defined binge eating disorder (BED) or depression strongly predicted poor surgical outcome, but pre-surgical psychiatric factors alone did not. CONCLUSION: Although pre-surgical psychiatric assessment alone cannot predict outcome, an absence of preoperative psychiatric illness should not reassure surgeons who should be mindful of postoperative psychiatric sequelae, particularly BED. The importance of providing an integrated biopsychosocial model of care in bariatric teams is highlighted.

Compliance with surgical after-care following bariatric surgery for morbid obesity: a retrospective study.

BACKGROUND: Non-compliant patients fail to match their behavior to the clinical prescription. Laparoscopic adjustable gastric banding requires strict compliance with surgical and dietary advice. Failure to attend follow-up appointments and the persistent consumption of calorie-dense liquid foods are associated with poor weight loss and postoperative complications. Prediction of "poor compliers" would enhance candidate selection and enable specific interventions to be targeted. METHODS: 9 poor compliers were identified and compared with 9 fully compliant controls. Case-notes were analyzed retrospectively. RESULTS: Cases were found to graze on foods and eat more in response to negative affects. They were reluctant to undergo psychiatric assessment, viewed the band as responsible for weight loss, and aroused caution in the psychiatric evaluator. Poor compliance was not associated with binge eating, purging, impulsivity or psychiatric illness. CONCLUSIONS: Unrealistic expectations and anxiety are known to predict non-adherence. Constant negative affects may be self-modulated by grazing. The results are explored in the context of Self-efficacy Theory, a socio-cognitive account of illness behavior.

Reported sexual abuse and cognitive content in the morbidly obese.

This study investigated whether a reported history of childhood sexual abuse (CSA) in morbidly obese adults is associated with a higher level of negative core beliefs (unconditional, schema-level representations regarding the self, the world, and others), and whether those beliefs are significantly associated with weight levels and weight fluctuation. A cross-sectional design was used, with comparative and correlational elements. The participants were 30 morbidly obese patients (age range=27-61years; body mass index [BMI] range=40.8-73.5), awaiting surgical intervention. Each completed standardized self-report measures of childhood traumatic experiences, core beliefs, and weight history. BMI was obtained from clinical interview. In terms of weight variables, the individuals with a reported history of sexual abuse (n=10) did not differ from those with no such history (n=20). However, those with a reported abuse history had higher levels of specific negative core beliefs. This group also showed more extensive associations between their BMI and their core beliefs than the nonabused group. Core beliefs, which are often associated with personality disorder pathology, were associated with the reported presence of a history of sexual abuse among the morbidly obese. The group differences (in levels of core beliefs and in their association with weight variables) suggest that there might be different mechanisms to explain weight levels in those obese patients who do or do not have a history of CSA. When psychological interventions are used in support of other treatments (e.g., surgery), they might be most productively targeted on those with such an abuse history.