Predictors of Weight Loss After Laparoscopic Gastric Plication: A Prospective Study

Abstract

Introduction:

Laparoscopic gastric plication (LGP) is a bariatric procedure for the treatment of morbid obesity that has recently increased in popularity. Herein, the predictors of weight loss following LGP are investigated.

Patients and Methods:

This prospective study was performed on cases performed by a single surgeon between 2000 and 2011. The association between nine independent variables and ideal weight loss (percentage of excess weight loss [%EWL] ≥80%) at 24 months postoperatively was assessed in 330 patients who underwent LGP. The studied variables were as follows: age at surgery, gender, preoperative body mass index, preoperative comorbidities, marital status (single versus married), employment status (employed versus unemployed), family support in helping the patient to engage in physical activities and continue on a healthy diet (never/a little versus sometimes/a lot), the experience of pain or gastroesophageal reflux during or after eating (yes or no), and participation in support groups following LGP (yes or no).

Results:

Ideal weight loss (%EWL ≥80%) was achieved in 60 patients, and %EWL <80% (suboptimal weight loss) occurred in 270 patients. Being single, female, and of younger age and participation in group meetings were significantly associated with experiencing ideal weight loss at 24 months, postoperatively. However, no significant difference was observed between the two groups in terms of preoperative body mass index, comorbidities, employment, a relative being a coworker, and the experience of pain or gastroesophageal reflux after eating.

Conclusions:

This study identified predictor factors positively associated with ideal weight loss. These results would aid surgeons in better patient selection and identification of patients requiring more careful follow-up. In addition, it provides patients with more realistic assessment of potential outcome of the procedure.

Introduction

Obesity is a growing health problem in both developed and developing countries. Exercise, diet, and medications are not usually enough to provide satisfactory and durable weight loss in morbidly obese patients.¹ Currently, bariatric surgery is the only long-term effective treatment for morbid obesity. It considerably decreases body weight, improves obesity-related comorbidities, increases quality of life, and finally results in mortality reduction.² Gastric plication is emerging as a safe and effective bariatric procedure, with increasing popularity for the treatment of morbid obesity.^3–6 According to a recent randomized clinical trial, it has been as effective as mini-gastric bypass in the 1-year follow-up period.⁷

Nonetheless, bariatric procedures are not without complications, leading to major complications and perioperative mortality.⁸ Therefore, the risk and cost of bariatric procedures should be weighed against their advantages. On the other hand, a considerable difference in the extent of weight loss after a bariatric procedure exists from patient to patient,⁹ and a significant minority of patients fails to achieve sustained a successful degree of weight loss.¹⁰ The main reasons for individual dissimilarity following bariatric surgery is not fully determined and remain to be uncovered. Finding factors associated with postoperative weight loss could lead to better patient selection and more careful follow-up of patients with lower probability of successful weight loss after weight loss surgeries.

Many reports have studied the impact of various preoperative and postoperative predictors and types of surgeries on weight loss.^11,12 However, to the best of our knowledge, no study has investigated the role of preoperative predictors of weight loss status after laparoscopic gastric plication (LGP). Herein, we aimed to investigate potential predictors of successful postoperative weight loss following LGP.

Patients and Methods

Study population

The present study was part of a large prospective study on morbidly obese patients who were referred to Laleh and Sina Hospitals (Tehran, Iran) between 2000 and 2011. Approval was obtained from the institutional board review prior to performing the study. The procedure was indicated for patients who met the National Institutes of Health criteria for the treatment of morbidly obese patients. Patients with morbid obesity (body mass index [BMI] ≥40 kg/m² or BMI ≥35 kg/m² with medical comorbidities), previous unsuccessful nonsurgical weight loss attempts, and high motivation for weight loss were included in the study. Exclusion criteria included history of bariatric surgery (restrictive or malabsorptive), previous gastric or antireflux surgeries, undergoing revisional or other bariatric procedures during the follow-up period, and pregnancy. All patients underwent multidisciplinary evaluation (with the aid of a psychiatrist, an endocrinologist, and a nutritionist) for the surgical procedure to treat morbid obesity. Metabolic, electrolyte, and hormonal laboratory tests were performed in all cases routinely.

Intervention

All patients received prophylactic heparin, lower limb bandage, and antibiotic therapy preoperatively and proton-pump inhibitors for a few days (less than 1 week) postoperatively. All operations were performed with the patient under general anesthesia.

Surgical technique

One-row and two-row LGP procedures were performed as described previously.¹⁰ All procedures were performed by a single surgeon during the 12-year period.

Study variables

Patients who attended 24 months of postoperative visits were entered into the study. The weight of patients was measured before the surgery and 24 months postoperatively. The percentage of excess weight loss (%EWL) of the included patients was calculated at 24 months postoperatively. Patients were divided into two groups. A %EWL of 80% was considered as the cutoff point for ideal weight loss after LGP. The first group included patients with %EWL of ≥80% as a group who responded to the LGP procedure ideally; the second group were patients with a %EWL of <80%, which included subjects with suboptimal weight loss.

The role of nine independent variables on obtaining an ideal weight loss (%EWL ≥80%) at 24 months postoperatively was evaluated. The factors were as follows: age at surgery, gender (male versus female), preoperative BMI (calculated as weight/height squared [in kg/m²]), preoperative comorbidities (any versus none), marital status (single versus married), employment status (employed versus unemployed), family support to help the patient engage in physical activities and continue a healthy diet (never/a little versus sometimes/a lot), the presence of pain or gastroesophageal reflux during or after eating (yes or no), and participation in support groups after the procedure (yes or no). Data for the above-mentioned variables were collected and analyzed.

Statistical analysis

Statistical Package of Social Science software (SPSS version 16; SPSS, Inc., Chicago, IL) was used for statistical analysis. Frequencies of categorical variables and means are reported for continuous variables. Categorical variables were compared using the chi-squared test. An independent t test was used to compare means between two groups. All analyses were performed by the two-sided method, and a value of P<.05 was considered statistically significant.

Results

In total, 330 patients were included in the study. Patients' characteristics are summarized in Table 1. The patients consisted of 62 males (18.8%) and 268 females (81.2%). The mean preoperative BMI was 42.9 kg/m² (range, 36.5–55 kg/m²). The mean %EWL was 70% (range, 40%–100%). The %EWL of ≥80% (ideal weight loss) occurred in 60 patients, and %EWL of <80% (suboptimal weight loss) occurred in 270 patients. Being single, female, and of younger age and participation in group meetings were statistically significant factors positively associated with ideal weight loss at 24 months postoperatively (Table 2). However, there was no significant difference between the two groups on preoperative BMI, preoperative comorbidities, employment, relative being a coworker, and the experience of pain or gastroesophageal reflux during or after eating, as shown in Table 2.

Table 1.

Characteristics of Patients

Characteristic	Value
Number of patients	330
Age (years) (range)	30.0 (12–65)
BMI (kg/m²) (range)	42.9 (36.5–55)
Gender
Male	62 (18.8%)
Female	268 (81.2%)
Preoperative comorbidity
Yes	49 (14.8%)
No	281 (85.2%)
Marital status
Single	153 (46.4%)
Married	177 (56.4%)
Participating in a support group
Yes	132 (40%)
No	198 (60%)
Experiencing pain or reflux
Yes	104 (31.5%)
No	226 (68.5%)
Family support
Yes	187 (56.7%)
No	143 (43.3%)
Employment status
Employed	232 (70.3%)
Unemployed	98 (29.7%)

Data are number (%) unless indicated otherwise.

BMI, body mass index.

Table 2.

Factors Associated with Ideal Weight Loss at 24 Months Postoperatively

	Treatment group
Factor	Ideal weight loss	Suboptimal weight loss	Odds ratio	P value
Number of patients	60 (18.2%)	270 (81.8%)
Age (years) [mean (range)]	23 (16–47)	32 (12–65)	—	<0.001^a
BMI (kg/m²) [mean (range)]	41.7±(37–53)	43.2±6 (36.5–55)	—
Gender			2.94 (1.12–7.6)	0.022^a
Male	5 (8.1%)	57 (91.9%)
Female	55 (20.5%)	213 (79.5)%
Preoperative comorbidity			0.85 (0.38–1.94)	NS
Yes	8 (13.3%)	41 (15.2%)
No	52 (86.7%)	229 (84.8%)
Marital status			3.34 (1.82–6.1)	<0.001^a
Single	42 (27.5%)	111(72.5%)
Married	18 (10.2%)	159 (89.8%)
Participating in a support group			6.31 (3.33–11.93)	<0.001^a
Yes	45 (34.1%)	87 (65.9%)
No	15 (7.6%)	183 (92.4%)
Experiencing pain or reflux			1.450 (0.81–2.59)	NS
Yes	23 (22.1%)	81 (77.9%)
No	37 (16.4%)	189 (83.6%)
Family support			1.53 (0.85–2.74)	NS
Yes	39 (20.9%)	148 (79.1%)
No	21 (14.7%)	122 (85.3%)
Employment status			1.08 (0.58–2.01)	NS
Employed	43 (18.5%)	189 (81.5%)
Unemployed	17(17.3%)	81 (82.7%)

Data are number (%) unless indicated otherwise.

Statistically significant difference (P value <.05).

BMI, body mass index; NS, difference not significant.

Discussion

LGP is emerging as a safe and effective bariatric procedure for the treatment of morbid obesity, with increasing popularity. However, successful weight loss is not achieved in some patients, in spite of standardized surgical procedures and careful follow-up. To the best of our knowledge, this is the first study evaluating preoperative predictive factors of ideal weight loss following LGP.

In line with the majority of studies investigating predictors of successful weight loss following bariatric surgery, in this study, weight loss was determined as %EWL. Here we demonstrated that younger age, being single, and being female, as well as participation in group meetings, were factors positively associated with ideal weight loss following LGP.

Some studies have investigated the role of preoperative age on the outcome of other bariatric surgeries. Scozzari et al.¹² investigated 489 patients who underwent Roux-en-Y gastric bypass (RYGBP) and reported greater BMI reduction during the long-term follow-up period (with a median follow-up period of 36 months) in younger subjects. In agreement with available data for other bariatric procedures, this study demonstrates consistent data regarding the role of younger age as a positive predictor factor for ideal weight loss after LGP, owing to its large study population, prospective nature of the study, and the 2-year follow-up period.

Furthermore, all procedures were performed by a single surgeon, thus eliminating the bias related to different surgeons.

Various behavioral and physiopathological hypotheses could explain lower weight loss in older patients. Younger patients may have a more active life and tolerate exercise better. A physically active life style is known to be associated with successful weight loss maintenance in the long term.¹³ Moreover, obesity not only poses physical health problem, but the stigmatizing properties of obesity adversely affect psychological and social wellness of obese patients.¹⁴ It has been reported that younger obese patients are more denigrated compared with older individuals,¹⁵ which may provide higher motivation to weight loss in younger patients compared with older individuals. It has been reported that higher internal motivation is associated with weight loss and maintenance.¹³ Therefore, younger subjects may have higher motivation to weight loss, leading to more ideal weight loss and maintenance.

Moreover, energy requirements decline with age.¹⁶ Toth and Tchernof ¹⁷ stated lipolytic activity was lower in older individuals with normal body weight. This may explain the finding of more adipose tissue deposition in older individuals. Moreover, weight loss with a hypocaloric diet is reported to blunt lipolytic activity in old women,¹² suggesting reduced capacity in providing energy through lipid mobilization from fat stores.¹⁸ This may provide larger intake following surgery.¹⁸ It is interesting that it has been reported that younger individuals reduced their energy intake more than older subjects following RYGBP,¹⁹ resulting in greater weight loss. However, no study has compared energy intake among different age groups following LGP. On the other hand, higher rates of complications and mortality are reported following bariatric surgery,²⁰ making surgical indication in elderly patients a controversial issue. Overall, considering lower weight loss in older patients, our data suggest that less satisfactory weight loss should be anticipated when discussing indications of LGP in older patients.

In agreement with previous reports of other bariatric procedures, female gender was a significant positive predictor of ideal weight loss in the present study. Melton et al.²¹ reported a higher rate of suboptimal weight loss in male patients in a study of 495 patients who underwent RYGBP. In addition, higher rates of postoperative complications and mortality were reported in male patients compared with female patients following RYGBP. Raftopoulos et al.,²⁰ in reviewing records of 4685 patients who had undergone RYGBP, reported greater mortality in male subjects compared with female subjects (1.2% versus 0.47%, respectively); in addition, greater adverse effects occurred in male patients than female patients (16% versus 4%, respectively). It was finally concluded that older patients, as well as male patients, should be counseled about higher preoperative risks.²⁰ Conversely, some studies found greater weight reduction in males following RYGBP.²² Regarding the higher rate of suboptimal weight loss in men in our study, we hypothesize that men may need more careful follow-up after bariatric surgery.

We found a greater incidence of ideal weight loss following LGP in patients who participated in bariatric group support groups. It has been reported that more frequent postoperative visits are associated with greater weight loss. Hildebrandt²³ reported a statistical trend for greater weight loss after RYGBP in patients who participated in group meetings regularly; it is notable that there was a significant positive association between the increased frequency of attendance in group meetings and greater weight loss. In a recent study, higher weight loss was reported in patients who participated in group meetings.⁴

Considerable numbers of obese patients suffer from psychological problems.²⁴ Waters et al.²⁵ demonstrated promising improvements in patients' mental health at 6 and 12 months, postoperatively. However, they found a return to preoperative mental status in the 24–36-month follow-up period. They suggested that improved psychological performance during the first postoperative year could be due to frequent postoperative visits during the first year. Finally, they demonstrated that frequent follow-up and psychological supports are essential components even after 3 years postoperatively.

Moreover, it has been found that patients who participated in face-to-face and Internet-based programs were more successful in maintaining their weight loss compared with control groups over the 18-month period.²⁶ Wing and Jeffery²⁷ evaluated the effect of recruiting participants either alone or with a family member or friend (a support person) in subjects who received standard behavioral treatment or standard behavioral treatment with social support strategies; greater weight loss in subjects recruited with a support person compared with those who participated alone was observed. It seems that patients should be strongly encouraged to participate continuously in bariatric support groups following LGP.

In agreement with available reports on other bariatric procedures, our data showed a higher rate of suboptimal weight loss in married patients. In a prospective study of 180 consecutive patients who underwent laparoscopic gastric bypass, Lutfi et al.²⁸ indicated marriage status as a significant predictor of weight loss, with higher %EWL in single patients compared with married individuals. This may be because single patients have more free time for regular physical activities and are more independent compared with married subjects; hence single individuals return to their job and daily activities sooner.

No significant association was found between preoperative BMI, the presence of comorbidities, employment status, having a family support, and experience of pain or gastroesophageal reflux following eating and ideal weight loss achievement.

Our study demonstrated no negative association between pretreatment comorbidities and ideal weight loss. Improvement or complete remission occurs in most comorbidities following LGP.⁷ Therefore, patients with comorbidities obtain considerable health benefits following LGP.

No significant difference was found between employed and unemployed patients in the ideal weight loss achievement. However, Sánchez-Cabezudo Diaz-Guerra and Larrad Jiménez,²⁹ in a prospective study on 75 subjects who had undergone biliopancreatic diversion, reported higher failure in weight loss (%EWL <50%) in housewives or unemployed subjects.

Social support seems to be associated with more successful weight loss. However, a close family member involvement does not obviously provide a positive effect; it may even interfere with long-term results.¹³ Our findings demonstrated no relationship between family support and ideal weight loss.

To date, no study has investigated the role of postoperative pain or gastroesophageal reflux on postoperative weight loss after LGP. In the present study, no statistical association was manifested in patients who experienced gastroesophageal reflux disease episodes or pain after eating compared with others with ideal weight loss achievement. In general practice, gastroesophageal reflux disease is usually diagnosed by history taking and gastroesophageal reflux disease–based complaints.²⁸ Although the ambulatory esophageal pH monitoring is the gold standard for gastroesophageal reflux disease diagnosis, it was not used in our study owing to reimbursement issues.

One of the key limitations of the present study includes not measuring a patient's motivation. Although we focused on weight loss in association with the potential predictive factors, the patient's expectations play an important, if difficult to measure, role. Further studies that evaluate a patient's motivation prior to surgery are recommended.

In conclusion, this study identified predictor factors positively associated with ideal weight loss. Being single, being young, being female, and participation in group meetings were positively associated with ideal weight loss. Higher BMI, preoperative comorbidities, no family support, and the experience of pain or gastroesophageal reflux after eating were not accompanied with suboptimal weight loss. These results would aid surgeons in better patient selection and identification of patients requiring more careful follow-up. It provides patients with more realistic assessment of potential outcomes of the surgery.

Footnotes

Disclosure Statement

No competing financial interests exist.

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