Long-Term Results After Bariatric Surgery in Super-Super-Obese Patients

Abstract

Introduction:

Despite addressing to high risk population, we can propose laparoscopic bariatric surgery to super-super-obese (SSO) patients (body mass index [BMI] ≥60 kg/m²). The aim of this study was to report our experience in terms of weight loss and improvement of medical comorbidities after a follow-up of 5 years in the SSO population who underwent different bariatric procedures.

Methods:

This retrospective study includes all SSO patients who underwent bariatric surgery (sleeve gastrectomy [SG] and/or gastric bypass) between 2006 and 2017. The population was divided in three groups (SG alone; Roux-en-Y gastric bypass [RYGB] alone and SG+RYGB). The rate of complication and the weight-loss results were analyzed.

Results:

Among 43 patients who underwent surgery, the mean age was 42[31–54]. There were more women (72%) with the mean preoperative BMI of 64.9 kg/m² [59.6–70.1]. There were 9 SGs, 26 RYGB, and 8 SG revised to gastric bypass (SG+RYGB) after a median delay of 23.5 months [16.5–32]. The perioperative complication rate was 25%, and there was 1 postoperative death. The median follow-up was 69 months [1–128]. The mean percentage of excess weight loss (%EWL) was 39.2% [18.2–60.3] after 5 years. For the SG group, the %EWL was inferior −27.1 [−3.6 to 57.8], but with no significant difference. An improvement of comorbidities' rate was recorded in all groups of patients.

Conclusion:

Bariatric surgery in SSO patients leads to an improvement of comorbidities even if the weight-loss results, especially in the SG group, are less favorable. The two steps approach should be re-evaluated by shortening the interval between. Other surgical strategies than RYGB are needed to be evaluated to improve long-term weight loss.

Introduction

Morbid obesity prevalence is growing in France¹ and worldwide.² Today, 16% of population is obese, with important comorbidities, leading to an important public health burden. Bariatric surgery is the most and the only effective treatment for long-term weight loss in patients with severe obesity.³ Difficulties of surgery in super-super-obese (SSO) patients are induced by, inter alia, exposition with the important intraperitoneal fat and left liver lobe, and the need for suitable material in every step of the patient care. It is known that surgery in SSO patients is associated with a more important morbidity and mortality after surgery.^4,5

Moreover, preoperative body mass index (BMI) is negatively associated with weight loss after bariatric surgery as is super-obesity (BMI >50 kg/m²) and personality disorders. Indeed, in the review published by the Livhits et al.⁶ 37 studies were found with this negative association (between BMI and weight loss), whereas 9 studies found no association and 16 studies found a positive association. All these characteristics lead to the fact that just a few of SSO patients has gone to surgery while they need it the most. Long-term outcomes of bariatric surgery for SSO are scarce and additional data will improve the knowledge about different surgical techniques.

The aim of this study was to report our experience in terms of weight loss and improvement of medical comorbidities after a follow-up of 5 years in the SSO population who underwent different bariatric procedures: sleeve gastrectomy (SG), Roux-en-Y gastric bypass, or a two-step procedure, including SG followed by Roux-en-Y gastric bypass.

Methods

All patients undergoing bariatric surgery have been included in a prospectively maintained database from January 2006 to June 2017. The database was retrospectively reviewed and 43 patients were identified with a preoperative BMI ≥60 kg/m². The patients were operated according to the French guidelines⁷ for bariatric surgery, similar to those of the U.S. National Institutes of Health.⁸ They were engaged in a program that provided guidance on diet, physical activity, and psychosocial concern before and after surgery. The preoperative workup consisted in a minimum of 1 year follow-up by a multidisciplinary team in an university nutrition department concluding the indication for a bariatric surgery.

A blood pressure >140 mmHg (systolic) and/or 90 mmHg (diastolic) or use of antihypertensive medication were the definitions for hypertension. Similarly, a fasting glycemia >1.26 g/L on at least two different occasions or use of antidiabetic medication was the definition for diabetes. Dyslipidemia was diagnosed when the blood test revealed a total cholesterol concentration >2 g/L and/or a triglyceride concentration >1.5 g/L or in case of treatment with lipid-lowering medication. The research for sleep apnea was systematically performed by a nocturnal polygraphy and it was considered positive if the apnea–hypopnea index was >5 events per hour, or if they were already being treated with nocturnal continuous positive-airway pressure.

Patients were attempted to be evaluated every year up to 5 years after surgery. The weight loss was evaluated with the percentage of excess weight loss (%EWL) because it was the most used in SSO studies and with the percentage of initial weight loss (%IWL) because it was the least influenced by preoperative BMI.⁹ %EWL was assessed as 100 × [[weight at baseline-weight at follow-up]/[weight at baseline-theorical weight]]. %IWL was calculated as: 100 × [[weight at baseline-weight at follow-up]/[weight at baseline]. Improvement in diabetes, hypertension, dyslipidemia, and obstructive sleep apnea syndrome were defined as the improvement of the corresponding baseline characteristics with the same or lower doses of therapy. Postoperative complications were analyzed using a the Dindo–Clavien classification.¹⁰

Surgical technique

During the study, the standardized surgical technique was used for both SG and Roux-en-Y gastric bypass (RYGB).

Sleeve gastrectomy

Closed pneumoperitoneum was established using a Veress needle in the left hypochondrium. Then, we inserted a supraumbilical 12-mm port used as optical port. One more 12-mm port in the right flank and two or three 5-mm ports (in the left flank, below xyphoid and sometimes on the left latero-umbilical region) were used as working ports. The greater omentum was separated from the greater curvature of the stomach. An SG was then fashioned over a 36 French frozen calibration gastric tube starting from 4 to 5 cm from the pylorus to the angle of His fat pad with the use of a linear stapler 60 mm cartridge, which was buried with a suture. The drain was placed depending on the methylene blue test which was routinely performed. Patients were allowed to drink 1 day after surgery, and to eat grinded food 2 days after surgery.

Gastric bypass

The pneumoperitoneum was established in the same manner as for SG. The 12-mm optical ports were supraumbilical and subxyphoid. We used four to five working ports, on the flanks, hypochondrium, and in the latero-umbilical region.

The stomach was first divided beneath the first vessel of the lesser curve, to create a proximal gastric pouch of nearly 30 mL with the use of a linear 60 mm cartridge. The jejunum was divided at 70 cm distal from Treitz's angle and the bowel was connected to the stomach in a transmesocolic manner. The alimentary limb (Roux limb) of 120–150 cm length was created. A manual end-side gastrojejunal anastomosis was performed; we used a 36 French tube to calibrate and verify the permeability this anastomosis. The jejunojejunostomy was a side-to-side mechanical anastomosis. All mesenteric defects (mesocolic and mesenteric) were closed with a nonabsorbable running suture. The drain depends on methylene blue test and liquid and grinded intake were the same as SG.

Second stage Roux-en-Y gastric bypass

The stage two RYGB was performed in similar manner as previously described, resulting in a 30-mL gastric pouch, a manual end-to-side gastrojejunostomy (Endo GIA, 60-mm cartridge), and a retrocolic, 120–150 cm Roux-en-Y limb.

The decision to perform first an SG or a gastric bypass procedure was made before or during the surgery, and depended on difficulty with exposure (mainly extent of hepatomegaly or adhesions).

Statistical analysis

We present the categorical data as counts and percentages. Continuous variables are reported as means ± standard deviations. The Fisher's exact tests was used for categorical variables and the Kruskal–Wallis nonparametric tests for numerical variables. The significance threshold was set at P = .05.

Results

The entire population of 43 patients was classified in three groups: SG—9 cases, RYGB—26 cases and two-step approach with SG, and RYGB—8 cases. Table 1 shows demographics and baseline health status characteristics of the patients. They were similar for preoperative BMI and physical status score of the American Society of Anesthesiologists (ASA score); the mean age was 42 ± 11 years, and the RYGB group was younger (39 ± 10 years) than the SG group (49 ± 13) years for SG group (P = .03). There was a majority of women (72%), but less in the SG+RYGB group (25%) than in the RYGB group (P = .03). There was more history of adjustable gastric banding in the SG+RYGB group (63% against 11% and 12% in SG and RYGB groups, P = .009). There were 84% of patients having at least one comorbidity. The groups were similar for associated comorbid conditions: hypertension (67%), diabetes (42%), obstructive sleep apnea syndrome (49%), and dyslipidemia (30%).

Table 1.

Demographics and Baseline Health Status Characteristics of the Patients at Time of the Bariatric Surgery

	Total (N = 43)	SG group (N = 9)	RYGBP group (N = 26)	SG+RYGBP group (N = 8)	SG (N = 9)	P
Mean age ± SD	42 ± 11	49 ± 13	39 ± 10	44 ± 10	49 ± 13	.06
Female ratio	31 (72%)	7 (78%)	22 (85%)	2 (25%)	7 (78%)	.004
Preoperative BMI	64.9 ± 6.9	66.2 ± 8.3	64.5 ± 4.2	64.5 ± 3.7	66.2 ± 8.3	.91
ASA score
ASA 1	1 (2.3%)	0	1 (3.8%)	0	0	.99
ASA 2	5 (11.6%)	0	3 (11.5%)	2 (25%)	0	.26
ASA 3	36 (83.7%)	9 (100%)	21 (80.8%)	6 (75%)	9 (100%)	.38
ASA 4	1 (2.3%)	0	1 (3.8%)	0	0	.99
Gastric banding history	9 (21%)	1 (11%)	3 (12%)	5 (63%)	1 (11%)	.009
%EWL before surgery	9.4 ± 11.1	13.9 ± 17.7	10.1 ± 9.2	1.4 ± 3.1	13.9 ± 17.7	.06
Presence of at least one comorbidity	36 (84%)	9 (100%)	19 (73%)	8 (100%)	9 (100%)	.90
Hypertension	20 (67%)	7 (78%)	16 (62%)	6 (75%)	7 (78%)	.66
Diabetes	18 (42%)	5 (56%)	8 (31%)	5 (63%)	5 (56%)	.21
Obstructive sleep apnea	21 (49%)	6 (67%)	10 (39%)	5 (63%)	6 (67%)	.27
Dyslipidemia	13 (30%)	3 (33%)	6 (23%)	4 (50%)	3 (33%)	.30

ASA score, American society of anesthesiology score; BMI, body mass index; EWL, excess weight loss; RYGBP, Roux-en-Y gastric bypass; SD, standard deviation; SG, sleeve gastrectomy.

Table 2 shows postoperative outcomes. There was no significant difference of complication rates between the three groups. Operating time was longer for the SG+RYGB group (200 ± 75 minutes versus 167 ± 60 minutes for the RYGB group, P = .01). The median hospital stay was 7 [4–20] days, with 1 [0–10] day in intensive care unit, which was systematic at the beginning of the experience. There were 2 open procedures: 1 conversion to laparotomy because of problems encountered with exposition for gastrojejunal anastomosis and 1 laparotomy at the beginning of the experience performed by another surgeon.

Table 2.

Postoperative Outcomes

	Total (N = 43)	SG group (N = 9)	RYGBP group (N = 26)	SG+RYGBP group ^a (N = 8)	P
Mean operative time (minutes)	177	130	167	200	.01
±SD	±60	±40	±58	±75
Open surgery	2 (4.7%)	0	1 (3.8%)	1 (12.5%)	.99
Early readmission	3 (7%)	0	3 (11.5%)	0	.76
Reoperation	5 (11.6%)	0	4 (15%)	1 (13%)	.66
Postoperative morbidity	12 (28%)	2 (22%)	8 (31%)	2 (25%)	.99
Dindo I–II	7 (16%)	1 (11%)	5 (19%)	1 (13%)	.99
Dindo III–IV	5 (12%)	1 (11%)	3 (12%)	1 (13%)	.99
Early mortality	1 (2.3%)	0	1 (3.8%)	0	.99
Mean length of follow-up	69	59	76	83	.09
(Months) (range)	[1–128]	[1–70]	[1–122]	[12–128]

Data concerning the second stage RY gastric bypass.

RYGBP, Roux-en-Y gastric bypass; SD, standard deviation; SG, sleeve gastrectomy.

There was 1 postoperative death due to an early obstruction of the jejuno-jejunal anastomosis migrated in a postincisional hernia, leading to an intestinal necrosis. After several surgical interventions, the patient was in septic shock and died 18 days after the initial surgery. Five patients needed a reintervention for obstruction of jejuno-jejunal anastomosis, all of them after RYGB (4 in the RYGB group and 1 in the SG+RYGB group). Three patients have been readmitted, all of them were in the RYGB group, because of occlusion (1 of the biliary loop treated medically and 2 of the jejuno-jejunal anastomosis requiring surgery). Median follow-up was 69 [1–128] months.

Thirty patients (71.4%) underwent full evaluation after 5 years. Among the rest of 13 patients: 3 died (the early postoperative death, 1 who died during the first postoperative year of unknown reason, and a last 1 of self-induced drug intoxication), 5 have been lost of view, and 5 have not reached the 5 years follow-up yet. Table 3 summarizes the weight-loss results for the three groups. At 5 years from the surgery, the %EWL was 39.2% ± 21. The SG and RYGB groups had the higher %EWL and %IWL at the second year after the surgery.

Table 3.

Postoperative Body Weight Status Characteristics

	Total	SG group	RYGBPgroup	SG+RYGBP group	P
1 year	N = 41	N = 8	N = 25	N = 8
%EWL (%) ± SD	38.4 ± 14.9	38.7 ± 9.3	40 ± 14.4	33 ± 20.9	.67
%IWL (%) ± SD	25.2 ± 9.6	25.7 ± 6	26.2 ± 9.2	21.6 ± 13.4	.69
2 years	N = 37	N = 6	N = 24	N = 7
%EWL (%) ± SD	42.3 ± 17.1	42.2 ± 12.3	44.7 ± 16.6	34 ± 21.8	.43
%IWL (%) ± SD	27.8 ± 11	27.9 ± 7.2	29.3 ± 10.7	22.3 ± 14.2	.44
5 years	N = 30	N = 6	N = 17	N = 7
% EWL (%) ± SD	39.2 ± 21	27.1 ± 30.7	43.3 ± 14.5	39.8 ± 24.5	.75
% IWL (%) ± SD	26 [12–40]	17.8 [−2 to 37.6]	28.6 [19–38.2]	26.5 [9.6–43.4]	.51

EWL, excess weight loss; IWL, initial weight loss; RYGBP, Roux-en-Y gastric bypass; SD, standard deviation; SG, sleeve gastrectomy.

After that it, respectively, decreases for the SG group and becomes stable for the RYGB group. In the fifth year, the group SG lost less weight with a less important %EWL and a %IWL (27.1% ± 30.7 and 17.8% ± 19.8, respectively), but there were no significant differences between groups (P = .75 and .51, respectively). Table 4 presents the improvement of comorbidities 5 years after surgery. The rates of improvement were 83.3% for hypertension, 81.8% for diabetes, 30.8% for obstructive sleep apnea, and 60% for dyslipidemia. There were no significant differences between the different interventions.

Table 4.

Improvement of Coexisting Conditions of the Patients 5 Years After Surgery

Comorbidities	Total (N = 30)	SG group (N = 6)	RYGBP group (N = 17)	SG+GBP group (N = 7)	P
Hypertension	83.3% (15/18)	75% (3/4)	100% (9/9)	60% (3/5)	.10
Diabetes	81.8% (9/11)	100% (2/2)	75% (3/4)	80% (4/5)	.99
Obstructive sleep apnea	30.8% (4/13)	0% (0/2)	50% (3/6)	20% (1/5)	.41
Dyslipidemia	60% (6/10)	100% (1/1)	66.6% (4/6)	33.3% (1/3)	.71

GBP, gastric bypass; RYGBP, Roux-en-Y gastric bypass; SG, sleeve gastrectomy.

Discussion

The postoperative weight-loss results are highly dependent on the initial patient's BMI and even if sometimes the results could be “spectacular,” the patients with SSO disease had less chance to get in the normal range of the BMI.⁶ Nonetheless, the surgery has a very positive result regarding its metabolic effect and the percentage of comorbid remission.

Bariatric surgeons need to debate over the balance between efficacy and risks in this high surgical risk population. As it was proved before,³ this study confirms that bariatric surgery could be considered feasible and safe in the SSO population, with an early postoperative complications rate of 38.2%, including 12% of severe complications (corresponding to Dindo III and IV), and 1 death. The morbidity and mortality rate could be considered relatively high, but this is similar to the recent literature. Using the American College of Surgeons–National Surgical Quality Improvement Project with a total of 163,413 patients who underwent nonrevisional bariatric surgery, Romero-Velez et al.¹¹ reported 2322 patients with BMI ≥70. They have noticed four times increased mortality for SSO population (0.4% versus 0.1%, P = .0001).

Medium- or long-term data are scarce about the weight-loss results for patients with SSO disease. We have only identified three studies with data at 5 years and beyond: Di Betta et al.¹² and Fielding¹³ are about gastric banding and duodenal switch with transitory vertical gastroplasty. Only Thereaux et al.¹⁴ have 44.9% of EWL for RYGB, which is similar with our 43.9% in the RYGB group; they also have a similar %IWL at 5 year.

The debate can continue for patients with SSO disease about the procedure of choice: SG or RYGB?

RYGB could represent a good option as a stand-alone procedure especially for patients with advanced age or refractory to a second surgical step. At the beginning of our experience the importance of pouch volume was underestimated as well as the length of alimentary and biliary limb. Moreover, it is known that the construction of a long alimentary limb in RYGB seems to be more efficient in super-obese patients.¹⁵ During time course, the length of the alimentary limb varied also in the literature from 150 cm alimentary limb¹⁶ to 175 cm by Wang et al.,¹⁷ 200 cm by Raftopoulos et al.,¹⁸ and up to 250 cm by Helling.¹⁹ Our initial experience with short both biliary and alimentary limbs could explain less favorable body weight loss in long term in contrast with other experiences.²⁰ Nowadays, the results could be improved by focusing both on the gastro-enteral anastomosis and especially on the length of biliary limb.

The advantages for SG are represented by the safety of the procedure and the possibility to consider it the first step of a two-stage procedure.^20,21 Up to 6 years follow-up, Arapis et al.²⁰ reported a clear benefit considering the postoperative complications: 16.1% for SG patients in contrast with 26% reported for RYGB patients. Also, the early complications are fewer for SG (6.7%) than for RYGB (11.4%). Wilkinson et al.²¹ compared a total of 5723 patients with SSO and 24,940 with SO undergoing SG and RYGB. Patients with SSO in the RYGB group were significantly more likely to experience an unplanned intubation, prolonged ventilation, and unplanned intensive care unit admission. In our experience, there were two complications after SG (22%) in contrast to 8 patients with complications after RYGB (31%).

Considering the weight-loss result, SG should probably not be considered as Arapis²⁰ a stand-alone procedure for SSO patients in the long term. Similarly, Ece et al.²² had highest %EWL and %IWL 1 year after SG; then, they decreased gradually, significantly more with SSO than the morbidly obese population. One criticism of this study is patients often do not receive the “second stage” after SG. If we compare SG with RYGB, we found more %EWL and %IWL in RYGB group compared with SG group even if it was not significant, just like Gonzales-Heredia et al.,²³ even if it was not significant.

Although there is no consensus about which technique should be performed after SG as a second-step procedure, RYGB, minigastric bypass and re-sleeve are commonly considered as “easier” alternatives for single anastomosis duodeno-ileal bypass with sleeve gastrectomy. Few reports^24–27 comparing these procedures with a clear superiority concerning the weight-loss results with a SADI-S procedure. These results are quite positive, especially considering that these series include both super-obese and SG-failed patients who could be considered as poor responders to bariatric surgery.

There were limitations to this study: even if data were sampled prospectively, it was retrospective in nature with a small number of cases especially at the 5 years follow-up (only 30 patients out of 43). There is a small number of SSO patients going to surgery, whereas the number of bariatric surgeries for morbid obesity grow every year. Because of this small number of patients, we had to use nonparametric tests. Consequently, the result is a lack of statistical power, and so we could not achieve any significant difference. There is need for more studies with larger samples to make conclusions about long-term results of bariatric surgery in SSO patients about weight loss and improvement of comorbidities.

Conclusion

Bariatric surgery is feasible in patients with SSO disease, and it allows a long-term improvement of comorbidities even with a moderate weight-loss result. The advantages for SG are represented by the safety of the procedure and the possibility to consider it a second step procedure. Considering the weight-loss result, SG should probably not be considered as a stand-alone procedure for SSO patients in the long term. A second step should be planned. RYGB could represent a good option as a stand-alone procedure especially for patients with advanced age or refractory to a second surgical step, but new procedures should be evaluated in prospective studies.

Footnotes

Authors' Contributions

Project development, data analysis, and article writing by M.N. and C.G. Project development, data analysis and collection, and article writing by M.L.-L. and B.G.-C. Project development, data analysis and collection by H.N. Data analysis and article editing by S.C., M.M., E.P., and D.C.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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