Six year outcomes with bariatric surgery

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Recently I read that suicides were increased in a group of individuals who underwent bariatric surgery.  This piqued my interest in finding the reference (JAMA 2012; 308: 1122-31 -21 authors).

This Utah study was a prospective trial between 2000-2011 involving 1156 severely obese participants between 18-72 years of age.  There were 3 groups.  The treatment group of 418 underwent Roux-en-Y gastric bypass (RYGB).  The second group (control group 1 =CG1) sought bariatric surgery but did not have surgery, and the third group (control group 2 =CG2) were a randomly selected population-based sample.

All participants had BMI ≥35.  RYGB group had average BMI of 47.3, CG1 was 46.3 and CG2 43.8.  The respective average age was 42.5, 43, and 49.4 years.  In CG1, 84 had undergone bariatric surgery by six years; in CG2 17 had undergone bariatric surgery by six years.

Results at six years:

  • Weight loss: RYGB (92.6% retained at followup): 27.7% loss of initial body weight; CG1 (92.6% followup) 0.2% weight gain, and 0% in CG2 (98% followup)
  • Diabetes remission rate: RYGB 62%, CG1 8%  and CG2 6%.  In addition, there was a 5- to 9-fold reduction in the risk of new diabetes in surgical patients compared to nonsurgical controls.
  • Mortality: No improvement in mortality was evident at six years.  RYGB 12 deaths, CG1 14 deaths  and CG2 3 deaths. None of the RYGB deaths occurred within 30 days of surgery.
  • Suicide:  all 4 patients who took their own life were in the RYGB group and 2 of 3 poisonings (undetermined intention) were in the RYGB group as well.
  • Mental health: The authors note an absence of improvement in the SF-36 mental component score in the surgical group which is in contrast to the SF-36 physical component score.
  • Glucose/insulin, Lipids & Blood pressure: Marked improvements in all of these parameters were noted at six years (Table 2).

It appears that much longer followup will be needed to show mortality benefits from bariatric surgery* and that preoperative/postoperative psychological assessment is needed.

* Mortality benefit has been evident in some studies (see references below)

Related blog entries:

References:

  • -JAMA 2011 [doi: 10.1001/jama.2011.817]). Large study failed to show that roux-en-Y gastric bypass prolonged life. n=850 VA pts to 41,244 controls. Same group showed no cost savings during initial 3 yrs: Med Care 2010; 48: 989-98.
  • -NEJM 2011; 365: 1365. Increased frequency of bariatric surgery in adolescents.

Complications from surgery:
Early: bowel obstruction, DVT, GI bleed, leaks, pul embolism, wound infection
After 30 days: anastomotic stricture, bowel obstruction, gallstones, dehiscence, fistula, Bleeding, Incisional hernia, nutrient deficiencies (iron, B12; calcium, Vit D (w RYGB), folate, B6/riboflavin)
Suggested Nutrient Monitoring–every 3 months x 3, then yearly: Vitamin A, B12, Folate, Ceruloplasmin, Vit D-25OH, Iron studies, Zinc, thiamine, Selenium, Intact PTH, Mg, PT/PTT
Suggested supplements per references: Calcium c vitamin D 1200mg, Iron, MVI with zinc/selenium
Also if duodenal switch, add Vitamin A and Vitamin D3 1200units daily or 50,000 units weeekly

Supplements:
Roux-en-Y: MVI 200%, Calcium 1500-2000mg, Fe at least 18-27mg/day, B complex (optional)
Gastric Band: MVI, Calcium, B complex (optional)
Biliopancreatic/duodenal switch: MVI, ADEK: A 10,000 IU, D 2000 IU, K 300 mcg, Calcium, Fe, B complex

  • –NASPGHAN 2011:

Bariatric surgery:
Complications from gastric band: food impaction, erosion (now banned in Finland!), band slippage, gastric volvulus, band too tight, port infection

Roux-y gastric bypass:
anastomotic leak 1.2%, anastomotic ulcers/stricture

If post-op pain: epigastric –>do EGD & if neg do ‘RUQ w/u’, RUQ –> check U/S, LFTs possibly CT
If post-op vomiting –>do EGD
If post-op nausea –>Rx PPI and EGD if not improving
Anastomotic stricture in stomach –>dilate to 10-12mm in 1 session

  • -NEJM 2009; 361: 445/520. perioperative safety.
  • -NEJM 2007; 357: 741, 753, 818. Bariatric surgery improves mortality rate.
  • -NEJM 2007; 356: 2176. Review
  • -Gastro 2006; 130: 1848, 1564, 1617. Bariatric surgery frequently improves steatosis/NAFLD. Less improvement if ongoing insulin resistance.
  • -J Pediatr 2005; 147: 10-19. Review of bariatric surgery. suggests gastric bypass/gastric banding for adolescents.
  • -Pediatrics 2004; 114: 217-23, & 252, 253, 255. Consensus panel recommendations and commentary.

Note: Medication dosages should be checked in standard references for individual patients.  The blog may have transcription errors with regard to dosages listed with references.