original papers - Advances in Clinical and Experimental Medicine

original papers
Adv Clin Exp Med 2011, 20, 6, 745–752
ISSN 1230-025X
© Copyright by Wroclaw Medical University
Regina Sierżantowicz1, Hady R. Hady2, Bożena Kirpsza1, Lech Trochimowicz1, 2,
Katarzyna Łagoda3, Jerzy R. Ładny2, Jacek Dadan2
Results and Post-Operative Complications
in the Surgical Treatment of Morbid Obesity
Ocena wyników leczenia chirurgicznego otyłości olbrzymiej
Department of Surgical Nursing, Medical University of Białystok, Poland
First Department of General and Endocrinological Surgery, Medical University of Białystok, Poland
3
Department of Clinical Medicine, Medical University of Białystok, Poland
1
2
Abstract
Background. Obesity is a major medical, social and economic problem. The number of people with a Body Mass
Index (BMI) ≥ 30 kg/m2 tripled from 2000 to 2005, while the number with a BMI ≥ 40 doubled. Surgical treatment
of morbid obesity has been found to be highly effective but the risk of post-operative complications is higher for
obese patients than for obese patients than for those of normal weight.
Objectives, Material and Methods. The aim of the study was to evaluate the results of surgical treatment of
morbid obesity and to analyze the complications within a six-month period following Laparoscopic Adjustable
Gastric Banding (LAGB), sleeve gastrectomy (SG) and Roux-En-Y Gastric Bypass (RYGB) among 108 patients
hospitalized at the 1st Department of General and Endocrinological Surgery.
Results. Because BMI was a guiding factor in choosing which surgical treatment to apply, there were some highly
significant differences in the pre-operative BMI of the groups scheduled for different forms of surgery: In the group
scheduled for RYGB, the patients’ BMIs were higher than in the groups scheduled for LAGB or sleeve gastrectomy.
Post-operative changes in BMI were more significant in the RYGB group than in the other two groups. The results
presented indicated the occurrence of low rate of complications, which did not exceed values presented in the
literature.
Conclusions. The study indicates that LAGB, SG and RYGB are effective methods in achieving reductions in BMI.
It was also observed that using minimally invasive methods for bariatric procedures reduces the occurrence of
complications and shortens the hospital stay (Adv Clin Exp Med 2011, 20, 6, 745–752).
Key words: obesity, surgical treatment, post-operative complications.
Streszczenie
Wprowadzenie. Otyłość jest poważnym problemem medycznym, społecznym i ekonomicznym. Liczba osób z otyłością, w której BMI ≥ 30 kg/m2 w latach 2000–2005 potroiła się, a z BMI ≥ 40 wzrosła dwukrotnie. W 2004 r. na
konferencji uzgodnień Amerykańskiego Towarzystwa Chirurgii Metabolicznej i Bariatrycznej (ASMBS) uznano,
ze chirurgiczne leczenie otyłości jest najbardziej skuteczną terapią otyłości olbrzymiej. W chirurgii bariatrycznej
wyróżnia się metody restrykcyjne, restrykcyjno-wyłączające, łączące dwie wymienione metody oraz inne. Działania
chirurgiczne stanowią ryzyko wystąpienia powikłań pooperacyjnych, które w znacznym stopniu zagrażają pacjentom otyłym, a rzadziej występują u osób szczupłych.
Cel pracy, materiał i metody. Ocena wyników leczenia chirurgicznego otyłości olbrzymiej oraz analiza występowania powikłań po LAGB, SG oraz RYGB wśród 108 chorych hospitalizowanych w I Klinice Chirurgii Ogólnej
i Endokrynologicznej po 6 miesiącach od wykonania zabiegu.
Wyniki. Stwierdzono wysoko istotną (p = 0,0008) różnicę BMI przed zabiegiem w zależności od późniejszego zabiegu operacyjnego. BMI w grupie przygotowywanej do zabiegu RYGB było większe niż w przypadku BMI u osób
przygotowywanych do LAGB lub sleeve gastrectomy, co miało wpływ na wybór takiej metody operacji. Zmiana
BMI w grupie po zabiegu RYGB była większa niż w przypadku zmiany BMI w grupach, którym wykonano zabiegi
LAGB i sleeve gastrectomy. Prezentowane wyniki własne wskazały na wystąpienie niewielkiego odsetka powikłań,
który nie wykracza poza podany w literaturze.
746
R. Sierżantowicz et al.
Wnioski. Stwierdzono, że LAGB, SG i RYGB są metodami skutecznymi w uzyskiwaniu spadku BMI. Zaobserwowano,
że prowadzenie operacji bariatrycznych metodami małoinwazyjnymi zmniejsza powstanie powikłań, skraca pobyt
w szpitalu (Adv Clin Exp Med 2011, 20, 6, 745–752).
Słowa kluczowe: otyłość olbrzymia, leczenie chirurgiczne, powikłania.
Obesity is a major medical, social and economic problem. The number of people with a Body
Mass Index (BMI) ≥ 30 kg/m2 tripled from 2000
to 2005, while the number with a BMI ≥ 40 doubled [1, 2]. The most dramatic increase in the
number of obese people has been noticed during
the last fifteen years in the United Sates, and it is
currently estimated that 15% of the US population
has a problem with obesity [3]. The World Health
Organization (WHO) describes obesity as a disease in which the accumulation of excess fat can
negatively influence the health [3]. Comorbidities
of obesity including type 2 diabetes, hypertension,
cardiovascular diseases, depression, sleep apnea
syndrome, spondyloarthrosis, osteoarthritis and
particular types of tumors, especially cancers of
the gastrointestinal tract occur more frequently
among the obese. Research has shown that among
obese patients, the average life expectancy is significantly diminished, especially in young patients
with co-existing cardiovascular disease [4]. It has
been statistically confirmed that in Europe 1 million deaths per year are caused by comorbidities
of obesity and their complications, while in the US
the rate is 300 thousand deaths per year. Studies
have shown that the risk of death for people with
a BMI > 35 is twice as high as the group with a BMI
between 20 and 25, and for people with BMI > 40
it increases tenfold [5].
Many strategies have been adopted in the
treatment and prevention of morbid obesity. The
most common are recommendations concerning
lifestyle changes, increasing physical activity, adhering to a proper diet and the use of various pharmaceuticals [6]. For slow and gradual loss of body
mass (1 kg per week), the caloric value of the daily
food ration should be 1000 calories for women and
1200 calories for men [7]. In cases where conservative treatment over a period of 2 to 5 years has
failed, surgical treatment may be recommended.
At a 2004 consensus conference of the American Society for Metabolic and Bariatric Surgery
(ASMBS) it was concluded that the most effective therapy for morbid obesity is surgical treatment [8]. Bariatric surgery distinguishes three
main categories – restrictive (based on a reduction
of food intake), malabsorbtive (reducing absorption from the gastrointestinal tract) and restrictive-malabsorbtive (combining the two aforementioned approaches) – as well as various other
approaches [6, 9].
The restrictive methods include: Vertical
Banded Gastroplasty (VBG), Laparoscopic Adjustable Gastric Banding (LAGB), Nonadjustable Gastric Banding (NAGB – not currently used), Sleeve
Gastrectomy (SG).
Restrictive-malabsorbtive methods rely on the
formation of a 20–30 ml reservoir in the upper part
of stomach, or the excision of 4/5ths of the stomach,
and next Roux-en-Y entero-enteric anastomosis
with a particular length of nutrition loop. This
group includes: Gastric Bypass (GB), Biliopancreatic Diversion with Duodenal Switch (BD-DS).
Other methods are also applied in bariatric
surgery, such as electro stimulation of the stomach, which is still undergoing clinical examination.
This method, which is regarded as entailing a low
level of risk, involves placing an implantable gastric
stimulator (IGS) in the middle part of the anterior
wall of the stomach. A stimulator is implanted in
a subcutaneous pouch in the upper left abdominal
quadrant [10, 11].
Surgical procedures involve risks of postoperative complications, which can be more dangerous for obese patients than for those of normal
weight [12, 13]. The aim of this study was to assess
the results of surgical treatment of morbid obesity
and to analyze the occurrence of complications
after LAGB, SG and Roux-En-Y Gastric Bypass
(RYGB).
Material and Methods
LAGB, SG and RYGB have been performed at
the First Department of General and Endocrinological Surgery of the Medical University of Białystok,
Poland, since 2005. The group of participants in
the study consisted of 73 women (67.6%) and 35
men (32.4%), from 20 to 60 years old (average age:
40 years old) with BMIs ranging from 41 to 52
(average value: 45.5). LAGB was performed on 18
patients (16. 6%), SG on 58 (53.3%) and RYGB on
32 (29.6%) (Table 1).
Among the comorbidities of obesity the following were recognized: type 2 diabetes in 60 patients
(55.5%), hypertension in 41 patients (37.9%), depression in 34 patients (31.5%) and the presence of
Helicobacter pylori in 15 patients (13.9%) (Table 2).
Patients qualified for the surgery were informed
of possible post-operative complications. In the
15 patients with Helicobacter pylori conservative
747
Surgical Treatment of Morbid Obesity
Table 1. The types of procedures performed
Tabela 1. Rodzaje zabiegów chirurgicznych
Type of procedure
(Rodzaj zabiegu)
Women
(Kobiety)
n (%)
Men
(Mężczyźni)
n (%)
LAGB
10 (9.2)
8 (7.4)
SG
43 (39.8)
15 (13.9)
RYGB
20 (18.5)
12 (11.1)
All (Suma)
73 (67.6)
35 (32.4)
Table 2. Comorbidities of obesity
Tabela 2. Choroby towarzyszące otyłości
Type of disease
(Choroba)
n (%)
COPD (Chronic Obstructive Pulmonary Disease)
P.o.ch.p. (Przewlekła obturacyjna
choroba płuc)
14 (12.9)
Type 2 diabetes
(Cukrzyca 2 typu)
60 (55.5)
Cholelithiasis
(Kamica żółciowa)
13 (12)
Coronary artery disease
(Choroba wieńcowa)
9 (8.3)
Hypertension
(Nadciśnienie)
41 (37.9)
Depression
(Depresja)
34 (31.5)
Varicose veins of the lower limbs
(Żylaki kończyn dolnych)
6 (5.5)
Ulcers
(Owrzodzenia)
20 (18.5)
Kidney cancer
(Rak nerki)
3 (2.8)
Colorectal cancer
(Rak jelita grubego)
1 (0.9)
No disease
(Brak chorób)
28 (25.9)
was administered to all the patients, in accordance
with accepted principles. The patients adopted
a 1000-calorie diet four weeks before the surgery;
immediately before surgery the patients were kept
on a liquid diet.
In order to gather data for the study, questionnaires were conducted among 108 patients after
bariatric surgery in the First Department of General and Endocrinological Surgery at the Medical
University Hospital in Bialystok, Poland.
The study was approved by the Bioethical
Commission of the Medical University of Bialystok, Poland. The research findings were analyzed
using Statistica for Windows 8.0.
Results
Because BMI was a guiding factor in choosing
which surgical treatment to apply, there were some
highly significant differences in the pre-operative
BMI of the groups scheduled for different forms
of surgery: The pre-operative BMI values in the
group scheduled for RYGB (anastomatosis, n = 58)
were significantly higher (p = 0.0040) than in the
group scheduled for LAGB (bypass, n = 18) and
also significantly higher than in the group scheduled for SG (resection, n = 32). The groups of paBMI before surgery
BMI przed zabiegiem
40
Median
25%-75%
Min-Max
38
36
treatment was applied and a control gastroscopy
was conducted after gastrological treatment. In the
patients with hypertension and diabetes, measurements of blood pressure and blood glucose levels
were conducted three times a day in the immediate
post-operative period. All the patients underwent
gastroscopy, abdominal USG and other tests, after any necessary consultations with an endocrinologist, dietician and (in women) gynecologist,
depending on clinical state of the patient. In the
peri-operative period, anticoagulant prophylaxis
34
32
30
28
LAGB
opaska
RYGB
zespolenie
SG
resekcja
type of procedure
rodzaj zabiegu
Fig. 1. BMI values before surgery according to the type
of procedure
Ryc. 1. BMI przed zabiegiem w zależności od rodzaju
zabiegu
748
R. Sierżantowicz et al.
BMI after surgery
BMI po zabiegu
Median
25%-75%
BMI (change)
BMI (zmiana)
Min-Max
10
40
Median
25%-75%
Min-Max
8
38
6
36
4
34
2
32
0
-2
30
-4
28
-6
26
24
-8
LAGB
opaska
RYGB
zespolenie
-10
SG
resekcja
LAGB
opaska
RYGB
zespolenie
SG
resekcja
type of procedure
rodzaj zabiegu
type of procedure
rodzaj zabiegu
Fig. 3. BMI values according to the type of procedure
Fig. 2. BMI values six months after surgery, according
to the type of procedure
Ryc. 3. BMI w zależności od rodzaju zabiegu
Ryc. 2. BMI 6 miesięcy po operacji w zależności od
rodzaju zabiegu
Table 3. BMI values recorded before and after surgery according to type of procedure
Tabela 3. Wartości BMI zmierzone przed i po operacji w zależności od rodzaju zabiegu
minimum
lower
quartile
median
upper
quartile
maximum
30.0
32.0
34.5
38.0
29.92 2.78
25.0
28.0
30.0
31.0
39.0
< 0.0001
LAGB (band)
n = 18
(16.6%)
31.44 2.71
29.0
30.0
30.0
32.0
38.0
29.94 2.64
27.0
28.0
29.5
30.0
35.0
0.0010
RYGB
(anastomosis)
n = 58
(53.8%)
34.16 2.86
29.0
32.0
34.0
36.5
38.0
29.12 2.89
25.0
27.0
29.0
30.0
39.0
< 0.0001
Sleeve
gastrectomy
(resection)
n = 32
(29.6%)
31.96 2.59
29.0
30.0
31.0
34.0
38.0
30.34 2.70
26.0
28.0
30.0
32.0
39.0
< 0.0001
Significance
0.0008
tients scheduled for LAGB and SG did not differ
significantly (p = 1.0000) in BMI values before the
surgery.
standard
deviation
maximum
29.0
average
upper
quartile
32.53 2.87
standard
deviation
All (Suma)
average
median
Significance
lower
quartile
After surgery
(Po operacji)
minimum
Type of
Before surgery
procedure
(Przed operacją)
(Rodzaj zabiegu)
0.1097
In all three groups, there were no statistically
significant differences between pre-surgery BMI
values and the BMI scores just after the proce-
749
Surgical Treatment of Morbid Obesity
Table 4. Changes in BMI for the entire group and broken down by procedure
Tabela 4. Zmiany BMI dla całej grupy oraz w podziale na zabiegi
Type of procedure
(Rodzaj zabiegu)
Change in BMI six months after surgery
(Zmiany BMI 6 miesięcy po zabiegu)
average
standard
deviation
minimum
lower
quartile
median
upper
quartile
maximum
All (Suma)
–2.61
2.40
–8.00
–4.00
–2.00
–1.00
8.00
LAGB (band)
n = 18
(16.6%)
–1.50
1.10
–3.00
–2.00
–1.50
–1.00
0.00
RYGB (anastomosis)
n = 58
(53.8%)
–5.03
2.09
–8.00
–6.00
–5.00
–4.00
4.00
Sleeve gastrectomy
(resection)
n = 32
(29.6%)
–1.62
1.85
–8.00
–2.00
–2.00
–1.00
8.00
Significance
< 0.0001
Table 5. Patients’ responses to questionnaires about early and late complications
Tabela 5. Odpowiedzi pacjentów w ankiecie na temat powikłań wczesnych i późnych
Complication (Powikłanie)
Number
(Liczba)
Percentage of response
(Odsetek odpowiedzi)
Percentage of patients
(Odsetek pacjentów)
difficulties with bowel movements
1
0.88
0.93
vomiting
1
0.88
0.93
abdominal abscess
1
0.88
0.93
abscess in the gastric band area
1
0.88
0.93
infection of the wound
9
7.95
8.34
nausea
6
5.31
5.56
heartburn
4
3.54
3.70
displacement of the gastric band
4
3.54
3.70
migration of the band to the gastrointestinal tract
1
0.88
0.93
sudden loss of consciousness
1
0.88
0.93
constipation
1
0.88
0.93
epigastric discomfort
1
0.88
0.93
anemia
1
0.88
0.93
None (Brak)
83
73.45
76.85
All (Suma)
113
100.00
104.63
Early (Wczesne)
Late (Późne)
dures (p = 0.1097). This indicates that BMI values
stabilized at a similar level regardless of the form
of surgery. But in the evaluation of changes conducted six months after the bariatric operations,
significant declines in BMI values were observed
(p < 0.01) in the entire group of patients, as well
as when the patients were divided according to the
type of treatment (Table 3).
Six months after the procedures, significant differences were noted between the various
750
groups’ BMI values depending on the type of surgical treatment (p < 0.0001). The BMI values in
the group of patients who had undergone LAGB
differed substantially (p < 0.0001) from those in
the RYGB group; and the RYGB group’s BMIs differed significantly (p < 0.0001) from those in the
SG group. The LAGB and SG groups’ BMI values
did not differ significantly (p = 1.0000). The difference between in pre-operative and follow-up BMI
was more pronounced in the RYGB group than in
the other two groups (Table 4).
Laparoscopic techniques were used on all the
patients participating in the research (n = 108).
The duration of hospitalization depended on the
type of bariatric procedure. There was no significant relationship between the occurrence of complications and the type of treatment. Migration of
the band to the gastrointestinal tract was observed
in one case. The band was eliminated endoscopically (Table 5).
Discussion
Attempts to treat morbid obesity surgically
were undertaken as early as the 1950s, in connection with the inefficiency of conservative treatment. Bariatric surgery has been found to be the
most effective treatment for obese patients [14].
Currently, surgical techniques that modify the gastrointestinal tract to limit food consumption and/
or to limited digestion and absorption are used to
achieve a reduction of body mass [14].
Among the new types of bariatric surgical procedures that have recently appeared are the Rouxen-Y gastric bypass, vertical banded gastroplasty
and vertical banded gastroplasty with the application of a silicon ring and biliopancreatic diversion [15].
The first vertical banded gastroplasty in Poland was conducted in Zabrze in 1993; the first
LAGB also took place in Zabrze, in 1998 [16]. In
2005, the First Department of General and Endocrinological Surgery of the Medical University of
Bialystok, Poland, began providing surgical treatment for obesity.
The results of treatment of morbid obesity are
assessed by the percentage of body mass loss. The
currently accepted criterion for assessing a bariatric procedure as succesful is excessive weight loss
(EWL) of 50% or more. The strictest criterion, introduced by Kral in 1985 [16].
The majority of bariatric centers provide their
own long-term post-operative monitoring (followup). During the first year after bariatric surgery,
from three to eight follow-up examinations are advised, during which changes in the patient’s body
R. Sierżantowicz et al.
mass, nutritional status, alleviation of comorbidities and quality of life are estimated. Basic blood
tests, examinations of iron, calcium, magnesium,
vitamin B12 levels, and total protein and albumin
concentrations are conducted [17–19].
In a study by Buchwald et al. assessing the effects of bariatric procedures as reported in the literature from 1990 to 2003, it was stated that the
average body mass loss after LAGB, RYGB and
biliopancreatic diversion with duodenal switch
(BPD-DS) amounted to 48%, 62% and 70% respectively. The mortality rate amounted to 0.1%, 0.5%
and 1.1% respectively [20].
The results of studies carried out in many centers
in Poland and Europe show higher rates of weight
loss among patients who have undergone RYGB
than among those who have had LAGB [15, 16]
Similar results were obtained in the current study:
The average reduction in BMI was –1.50 (±1.10 SD)
in the LAGB group, 5.03 (±2.09 SD) in the RYGB
group and 1.62 (±1.85 SD) in the SG group.
The choice of the appropriate procedure for
a particular patient should not be based only on
his/her preferences [15, 16]. At the authors’ center LAGB was performed on younger patients with
fewer comorbidities. Cholecystectomy was performed before RYGB in cases where cholelithiasis
was diagnosed.
Picot et al. [21] reviewed studies on the effectiveness of bariatric procedures, including the
vertical gastric band, laparoscopic adjustable gastric banding and sleeve gastrectomy. They also
compared those studies with research regarding
conservative treatment of obesity. The effectiveness of all the bariatric procedures mentioned was
demonstrated, with slightly higher losses of body
weight after sleeve gastrectomy in comparison to
conservative treatment. Furthermore, they noted
that surgical procedures caused remission of comorbidities. The current study confirmed that
a reduction of body mass causes serum carbohydrate levels to stabilize in patients with type 2 diabetes. However, the 6-month follow-up period was
too short for a detailed assessment of remission of
comorbidities.
Every surgical procedure, including surgical
treatment of obesity, carries the risk of post-operative complications. It has been proved that the level
of risk is higher for men and for patients with greater body weight [22, 23]. One of the contradictions
for bariatric surgery is if general anesthesia poses an
unacceptable risk (it burdens the circulatory and respiratory systems); other contraindications include
cancers, inflammatory bowel disease, severe coagulopathy, mental disorders, alcohol abuse, incapacity
to take care of oneself or a lack of long-term support from the family and society [24, 25].
Surgical Treatment of Morbid Obesity
According to Livingstone, the most frequent
post-operative complications are thromboembolic
complications, wound infections, pulmonary infections, the creation of anastomotic fistula, intraperitoneal and gastrointestinal bleeding. Common
long-term consequences are nutritional deficiency, hernia in the post-operative scar, anastomotic
stricture or ulcer, peritoneal adhesions and other
complications specific to particular procedures
(e.g., migration of the gastric band) [26].
In the current study a low percentage of complications was found, not exceeding values given
in the literature [27–29]. Among the early complications, the most frequent was wound infection, observed in nine patients (8.3%) patients.
As a consequence of the new situation in the upper part of the gastrointestinal tract, nausea was
experienced by six patients (5.5%), heartburn
by four patients (3.7%) and one patient vomited
(0.93%); these complaints disappeared after dividing the patients’ meals into smaller portions.
In four cases (3.7%), displacement of the gastric
band was observed, and in one case (0.93%) migration of the band to the gastrointestinal tract
occurred. One patient (0.93%) who had undergone RYGB suffered anemia despite vitamin
751
supplementation. The deficiency was treated using intramuscular administration of agents containing iron. It should be noted that no fatalities
occurred.
Currently, all of the patients involved in the
study are under the care of the Medical University
Hospital’s outpatient clinic. In addition to ongoing monitoring of body mass and diet, the patients’
biochemical parameters and quality of life are periodically evaluated using standardized surveys.
The authors concluded that obesity remains
a serious social, medical and economic problem,
and for this reason the use of bariatric procedures
is recommended. LAGB, SG and RYGB are efficient methods to decrease BMI and to improve
the patient’s general condition and quality of life.
Bariatric surgery entails a high risk in connection
with the large body mass and comorbidities that
can complicate the management of patients during the operation and in the post-operative period.
The use of minimally invasive methods in bariatric surgery reduces the occurrence of complications and shortens the hospital stay. The surgical
treatment of obesity requires an interdisciplinary
approach and should therefor be provided at multidisciplinary centers.
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Address for correspondence:
Regina Sierżantowicz
Department of Surgical Nursing
Medical University of Bialystok
M. Skłodowskiej-Curie 24a
15-274 Białystok
Poland
E-mail: [email protected]
Conflict of interest: None declared
Received: 10.05.2011
Revised: 10.10.2011
Accepted: 7.12.2011