Long-term follow-up of proximal versus distal laparoscopic gastric bypass for morbid obesity

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1 Original article Long-term follow-up of proximal versus distal laparoscopic gastric bypass for morbid obesity M. K. Müller, S. Räder, S. Wildi, R. Hauser, P.-A. Clavien and M. Weber Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland Correspondence to: Dr M. Weber, Department of Visceral and Transplant Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland ( Background: Laparoscopic gastric bypass is the gold standard for treatment of morbidly obese patients in many centres. There is debate regarding the optimal length for small bowel limbs. This study aimed to determine whether the proximal or distal approach is better. Methods: Twenty-five patients undergoing primary distal gastric bypass in were randomly matched for age, sex and preoperative body mass index (BMI) with 25 patients having a primary proximal bypass. All distal operations were performed laparoscopically; one proximal procedure was converted to open surgery. Results: Mean operating time was 170 min for proximal and 242 min for distal bypasses (P = 0 004); median hospital stay was similar in the two groups. There were no deaths and the overall complication rate was similar, as was weight loss at 4 years: BMI decreased from 45 9 to31 7 kg/m 2 for the proximal and from 45 8 to33 1 kg/m 2 for the distal approach. Co-morbidities decreased after surgery in both groups; the prevalence of diabetes, arterial hypertension and dyslipidaemia at all time points was similar in the two groups. Conclusion: Proximal and distal laparoscopic gastric bypass operations are feasible and safe, with no differences in weight loss or reduction of co-morbidity in unselected morbidly obese patients. Presented to the Annual Meeting of the Swiss Society for Visceral Surgery, Interlaken, Switzerland, September 2006, andas a poster at the Annual Meetingof the Society of AmericanGastrointestinal and Endoscopic Surgeons, Las Vegas, Nevada, USA, April 2007 Paper accepted 15 September 2008 Published online in Wiley InterScience ( DOI: /bjs.6297 Introduction Obesity is a growing health problem with an estimated worldwide prevalence of 11 per cent in Surgical techniques have emerged as a valuable treatment option for decreasing bodyweight and co-morbidity 2. Gastric bypass has been the gold standard in the USA for many years, with increasing popularity in Europe 3. The laparoscopic gastric bypass procedure involves three main components: creation of a small gastric reservoir resulting in a reduction of oral food intake 4,5,bypassof the duodenum leading to a change in the secretion of gastrointestinal hormones 6 9 and exclusion of a length of the absorptive small bowel producing a degree of malabsorption 4. The standard gastric bypass procedure is defined by a small (25 ml) gastric pouch and bypass of the duodenal passage via a Roux-en-Y reconstruction. There is ongoing debate about the most favourable length for the small bowel limbs. Most surgeons perform proximal gastric bypass with an alimentary limb length of 150 cm 10, but it has been suggested that a longer limb may offer superior weight loss 10,11. In distal gastric bypass, the distance from the Roux-en-Y anastomosis to the ileocaecal valve, the so-called common channel, measures 150 cm or less 12. In this case, the alimentary limb length varies between 200 and 400 cm, depending on the variable total bowel length 13 (Fig. 1). Distal gastric bypass may therefore enhance the malabsorptive effect of the operation. A direct comparison between distal and proximal bypass is lacking and the present study was undertaken to compare the long-term effects of these two procedures, Copyright 2008 British Journal of Surgery Society Ltd British Journal of Surgery 2008; 95:

2 1376 M. K. Müller, S. Räder, S. Wildi, R. Hauser, P.-A. Clavien and M. Weber p 2 3 a b p 1 Operative technique All bypass procedures were performed laparoscopically as described by Wittgrove and colleagues in The stomach was transected to create a 25-ml pouch. The jejunum was transected 50 cm distal to the duodenojejunal flexure. The gastrojejunostomy was created with a 25-mm circular stapler. In the proximal gastric bypass procedure, a stapled side-to-side jejunojejunostomy was created with an alimentary limb length of 150 cm. In the distal gastric bypass, the distance from the Roux-en-Y anastomosis to the ileocaecal valve (the common channel) was fixed at cm. The mesenteric defect at the Roux-en- Y anastomosis was routinely closed with non-absorbable sutures. The small bowel length was measured in steps of 10 cm using a marked laparoscopic forceps. The bowel was held taut but not stretched. Fig. 1 a Proximal gastric bypass with 150-cm alimentary limb (1) and 50-cm biliary limb (2). b Distal gastric bypass with cm common channel (3) and 50-cm biliary limb (2). p, Pouch with emphasis on weight loss and changes in co-morbidity, in a prospectively collected cohort using a matched-pairs analysis in morbidly obese patients. Methods Twenty-five patients who had a proximal laparoscopic gastric bypass were compared with 25 undergoing a distal laparoscopic gastric bypass procedure by matched-pair analysis. The operations were performed between 2000 and 2002 by two experienced surgeons. Data were extracted from a prospectively collected database of more than 500 laparoscopic gastric bypass procedures. Inclusion criteria were body mass index (BMI) greater than 40 kg/m 2 or BMI of more than 35 kg/m 2 with comorbidities, a history of obesity for more than 5 years, failed conservative treatment for more than 2 years, and age between 18 and 60 years. The authors initial experience with the laparoscopic gastric bypass in 2000 was with the proximal approach; these patients were censored from the study to avoid bias from the learning curve. Thereafter, in the first study period, laparoscopic distal bypass procedures were performed preferentially. Later, the technique was switched back to the proximal approach. For each patient who underwent a distal gastric bypass, a paired patient who had a proximal bypass was randomly matched in terms of age, sex and BMI. Study endpoints and follow-up The endpoints of the study were operating time, length of hospital stay, complication rates, effect on co-morbidity, and postoperative BMI, as well as excess weight loss (EWL) in the 48-month follow-up. Morbidity and mortality were reported for up to 30 days after surgery as early complications and thereafter as late complications. Comorbidities were assessed before surgery and for up to 2 years after surgery. Patients were considered to have diabetes if they were receiving oral hypoglycaemic drugs or if the HbA1c level was above 7 per cent. Dyslipidaemia was diagnosed on the basis of statin use, in the presence of a total cholesterol concentration greater than 5 mmol/l or a triglyceride level above 2 mmol/l. Hypertension was diagnosed when patients were taking antihypertensive drugs or the systolic and diastolic pressures were above 130 and 95 mmhg respectively. Statistical analysis Analysis was performed using standard software SPSS version for Windows (SPSS, Chicago, Illinois, USA). The Mann Whitney U test was used to compare continuous variables between the two groups. Categorical variables were compared with the χ 2 test or, when appropriate, Fisher s exact test. Results are expressed as mean(s.d.), unless indicated otherwise. Results The two groups were comparable in terms of age, sex and BMI before surgery, reflecting adequate matching (Table 1). A metabolic syndrome with hypertension (14

3 Gastric bypass for morbid obesity 1377 Table 1 Characteristics of patients in the two groups (n = 25) (n = 25) P Sexratio(M:F) 5:20 5: Age (years)* 37 9(7 9) (22 54) 38 8(7 5) (23 52) BMI (kg/m 2 )* 45 9(4 4) (39 59) 45 8(4 4) (39 59) Bodyweight (kg)* 128 0(14 7) ( ) 124 6(15 0) (97 150) Median follow-up (months) No. with complete follow-up at 4 years *Values are mean(s.d.) (range). BMI, body mass index. Mann Whitney U test; χ 2 test. Table 2 Operative results Proximal bypass Distal bypass P* Mean(s.d.) (range) 170(55 6) 242(86 5) operating time (min) ( ) ( ) No. of deaths Median (range) hospital stay (days) 8 (4 43) 9 (6 24) *Mann Whitney U test. patients in the proximal versus 15 in the distal group), diabetes mellitus type II (ten versus nine) and dyslipidaemia (20 versus 19) occurred with the same frequency in the two groups. The median follow-up was 48 months. All operations were performed laparoscopically; one proximal gastric bypass procedure had to be converted to open surgery because of uncontrollable haemorrhage from the spleen. Mean operating time was significantly longer for distal bypass than for the proximal approach (242 versus 170 min; P = 0 004). Median hospital stay was similar in the two groups (9 versus 8 days respectively; P = 0 063) (Table 2). There were no deaths in either group. During the 4-year follow-up, 29 complications were reported in 27 patients (11 patients in the proximal versus 16 in the distal bypass group (P = 0 256)). Four reoperations for complications were necessary in the proximal group compared with eight in the distal bypass group (P = 0 289). Two patients, one in each group, had two reoperations for one early and one late complication. Early complications, within 30 days of surgery, were detected in eight patients in each group (Table 3). Endoscopic reinterventions due to anastomotic strictures were performed in two patients in the proximal bypass group compared with none in the distal group. Two reoperations were indicated for internal herniation (one in the proximal and one in the distal group), and one patient in the proximal group underwent surgical revision for staple-line bleeding into the remnant Table 3 Early complications Wound infection 3 5 Internal hernia 1 (1) 1 (1) Anastomotic stricture 2 (2) 0 Pulmonary embolism 1 1 Staple-line bleeding 1 (1) 0 Intra-abdominal abscess 0 1 Total 8 8 Reoperation 2 1 Endoscopic dilatation 2 0 Values in parentheses are numbers of reinterventions for that complication. Table 4 Late complications Internal hernia 2 (2) 5 (5) Anastomotic stricture 2 (2) 1 (1) Severe malnutrition 0 1 (1) Foreign body 0 1 (1) Anastomotic ulcer 0 1 Total 4 9 Reoperation 2 7 Endoscopic dilatation 2 1 Values in parentheses are numbers of reinterventions for that complication. distal stomach, giving an early reoperation rate of 6 per cent. Late complications occurred in four patients in the proximal bypass group and in nine who had distal bypass surgery (Table 4). In the proximal group, two patients with stenosis at the gastrojejunal anastomosis were treated by endoscopic dilatation and two needed reoperation for internal herniation. Five patients in the distal bypass group had internal hernias; all underwent reoperation. One patient had conversion to a proximal gastric bypass for severe protein deficiency. In another patient, an

4 1378 M. K. Müller, S. Räder, S. Wildi, R. Hauser, P.-A. Clavien and M. Weber BMI (kg/m 2 ) Preop Time after surgery (years) Fig. 2 Changes in body mass index (BMI) during 4 years of follow-up in patients undergoing proximal and distal laparoscopic gastric bypass asymptomatic foreign body (part of a suction drain) was removed. There were no statistically significant differences between the groups in terms of the rates of early or late complications, endoscopic reintervention or reoperation. BMI decreased from 45 9to31 7 kg/m 2 in the proximal group and from 45 8 to33 1 kg/m 2 in the distal group (Fig. 2). BMI was the same in both groups after 4 years (P = 0 413). There was no significant difference between the two groups at any time point (P > 0 225). The difference between the two groups in percentage BMI lost was 3 per cent (31 versus 28 per cent for proximal and distal bypass respectively). The prevalence of co-morbidity had decreased in both groups by 2 years, with a similar preoperative and postoperative distribution in the two groups. The prevalence of hypertension dropped from 14 to two patients in the proximal bypass group, and from 15 to five in the distal group. Diabetes declined from 10 to 2 and from 9 to 0 respectively. The frequency of dyslipidaemia decreased in the proximal group from 20 to 4, and from 19 to 5 in the distal group. Discussion Both laparoscopic proximal and distal gastric bypass operations were found to be feasible and safe, with no deaths. After 4 years of follow-up there was no difference in terms of weight loss or decrease in co-morbidity between the two groups. Most surgeons perform a standard proximal gastric bypass with an alimentary limb length of 150 cm 15,16, but others prefer a longer alimentary limb, designating it either as distal gastric bypass 12 or as very long limb gastric bypass 17. Previous studies have compared different, mostly shorter, alimentary limb lengths 11,18 in retrospective studies 19, in selected patients (for example, superobese patients) 10,17,20 or with follow-up of less than 2 years 21.A study of open gastric bypass surgery compared alimentary limb lengths of 75 and 150 cm in 69 patients with a BMI below 50 kg/m 2, and found no difference in weight loss 11. In the same study, the outcome of alimentary limb lengths of 150 and 250 cm was compared in 64 patients with a BMI above 50 kg/m 2 ; again, no significant difference was found at 24 months. In contrast, in 199 superobese patients with a BMI greater than 50 kg/m 2, significantly increased weight loss was found after distal versus proximal gastric bypass (64 versus 61 per cent respectively), although two individuals with distal bypass developed severe protein malnutrition 20. In a randomized trial of alimentary limb lengths of 100 and 150 cm in 48 patients with a BMI below 50 kg/m 2,there was no difference in weight loss at 12 months, although more internal hernias occurred in the group with a longer alimentary limb 21. The present study compared a standard proximal gastric bypass with a distal gastric bypass, using a common channel of cm. A difference in weight loss in the two groups might have been expected, because of the enhanced malabsorptive effect of the distal gastric bypass 17.Both laparoscopic gastric bypass procedures resulted in a stable weight loss, with no difference after 4 years. This finding indicates that the effect of the gastric bypass might depend more on the restrictive component and changes in the pattern of gastrointestinal hormone secretion 6 9 than on the reduction in the length of absorptive bowel. The difference between the two groups in percentage BMI lost was 3 per cent, and the BMI after 4 years was not significantly different. A relatively high rate of internal hernia was found in the present study (nine (18 per cent) of the 50 patients), compared with rates of per cent reported in other studies 22 25, perhaps as a result of the high followup rate and long period of observation. Most other studies described the development of internal hernias after 21 days 22 or 150 days 25. The majority of internal hernias in the present study occurred after significant weight loss, perhaps indicating that weight loss leads to an increase in the size of existing small mesenteric defects due to thinning of the mesentery. In addition, a slender mesentery may result in greater mobility of the small bowel, further increasing the risk of herniation. To aid comparison of the severity of complications, reoperation rates were recorded in addition to complications. The reoperation rate for early complications was 6 per cent, compared with rates of 3 6 per cent in

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