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Invited Critique
Sep 2012

Gastric BypassTime for a Change?

Author Affiliations

Author Affiliations: Divisions of Trauma/Acute Care Surgery and Bariatric Surgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania.

Arch Surg. 2012;147(9):854-855. doi:10.1001/archsurg.2012.1682

The data from Nelson and colleagues1 challenge the notion that GB is the “Cadillac” of bariatric operations, noting a near 20% weight loss failure rate in superobese patients at 1 and 2 years postoperation compared with only 9% and 6% after DS. In a 2006 study specifically looking at follow-up after 10 years, Christou and colleagues2 also noted rates of weight loss failure after GB of 20.4% and 34.9% at mid- and long-term follow-up. Perhaps more importantly, Nelson and colleagues demonstrated that the rates of resolution of diabetes mellitus, hypertension, hyperlipidemia, and obstructive sleep apnea were higher after DS than GB.

In some ways, the remaining comparisons between GB and DS are a little unfair, in that (at least in the United States) DS has been performed an order of magnitude less frequently than GB, was performed with open technique about half the time, and has not been researched, presented, dissected, and discussed anywhere near as exhaustively as the GB operation has. Nelson and colleagues note that the overall complication rate for DS is still low, and if one compares the rates of leak, reoperations, and death with some of the earlier studies on GB patients, the risk profiles are comparable (and in some cases better!).3

Nelson and colleagues surmise that complication rates may fall as experience with DS grows and that the apparent benefits of DS in terms of reduced dumping syndrome, reduced anastomotic ulceration and stricture, overall weight loss, and control of weight-related health conditions (particularly in the superobese population) may outweigh the higher perioperative risks. Nelson and colleagues conclude (appropriately and conservatively) that DS for morbid obesity requires more study with regard to appropriate patient selection, operative technique, and longer-term risk vs outcomes.

This note of caution against full-throated endorsement of DS arises from the maturity of the data available to Nelson et al. Only 3% of patients in either the GB or DS cohorts had follow-up data at 2 years postoperatively, a point at which the percentage of change in the BMI curve still seems to be slowly rising for DS patients. Nutritionally deficient patients post–bariatric surgery can be extraordinarily challenging to treat. With rates of long-term nutritional deficiencies twice that of GB patients, there is no assurance that nutritional issues will not continue to arise as patients get to 5 and 10 years postprocedure. Some studies have cited higher revision and reversal rates for DS; it may be that the data that Nelson et al used is simply not mature enough to reveal higher rates (although several long-term reports of DS suggest otherwise4).

Inherent in the discussion of long-term follow-up rates and nutritional problems is the issue of patient compliance. The keys to long-term success for bariatric patients are their compliance with nutritional recommendations and follow-up. The need for compliance is even more pronounced with DS patients. Preoperative prediction of compliant patients remains challenging, particularly when those who would benefit most from a DS procedure (ie, the superobese) are quite possibly the least compliant when it comes to nutritional recommendations.

This article is nevertheless timely. Not commented on by Nelson and colleagues but perhaps beyond the scope and purpose of their study was the impact the growing use of laparoscopic sleeve gastrectomy will have on the calculus of bariatric surgery choice. Sleeve gastrectomy is now considered by many as a stand-alone procedure5 and affords comparable results in terms of early weight loss to GB while shortening operative times, maintaining endoscopic access to the gastrointestinal tract, reducing dumping syndrome, and reducing long-term vitamin and protein malnutrition.6 Staple line leak rates with sleeve gastrectomy (2.4%)7 are slightly higher than GB but certainly comparable with leak rates published in both early and contemporary GB series3,8 (and, notably, comparable with the leak rates reported by Nelson et al for DS).

A key difference between sleeve gastrectomy and GB is the ease in which sleeve gastrectomy can be operatively converted to another weight loss procedure in the event of weight loss failure. In these instances, conversion to DS for the expected weight loss failures may be the obvious procedure of choice, because it avoids the previous operative field in the mid and upper stomach and, based on the Nelson and colleagues data, provides a more durable result for long-term weight loss and treatment of weight-related health conditions.

In summary, Nelson and colleagues provide a well-researched and well-presented analysis of DS vs GB for morbid obesity, derived from an enormous and reliable database. Their findings and conclusions challenge the notion that GB is the optimal operation for the majority of patients. As more surgeons familiarize themselves with the operative techniques and follow-up requirements for DS patients, it may be used more frequently in the superobese population. Furthermore, in the era of growing use of sleeve gastrectomy, conversion to DS may gain utility and favor as the procedure of choice for weight loss failures.

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Article Information

Correspondence: Dr Beekley, Divisions of Trauma/Acute Care Surgery and Bariatric Surgery, Thomas Jefferson University Hospitals, 1100 Walnut St, 7th Floor, Medical Office Bldg, Philadelphia, PA 19107 (alec.beekley@jefferson.edu).

Financial Disclosure: None reported.

References
1.
Nelson DW, Blair KS, Martin MJ. Analysis of obesity-related outcomes and bariatric failure rates with the duodenal switch vs gastric bypass for morbid obesity.  Arch Surg. 2012;147(9):847-854
2.
Christou NV, Look D, Maclean LD. Weight gain after short- and long-limb gastric bypass in patients followed for longer than 10 years.  Ann Surg. 2006;244(5):734-740PubMedArticle
3.
Wittgrove AC, Clark GW. Laparoscopic gastric bypass, Roux-en-Y- 500 patients: technique and results, with 3-60 month follow-up.  Obes Surg. 2000;10(3):233-239PubMedArticle
4.
Marceau P, Biron S, Hould FS,  et al.  Duodenal switch: long-term results.  Obes Surg. 2007;17(11):1421-1430PubMedArticle
5.
Boza C, Salinas J, Salgado N,  et al.  Laparoscopic sleeve gastrectomy as a stand-alone procedure for morbid obesity: report of 1,000 cases and 3-year follow-up.  Obes Surg. 2012;22(6):866-871PubMedArticle
6.
Gumbs AA, Gagner M, Dakin G, Pomp A. Sleeve gastrectomy for morbid obesity.  Obes Surg. 2007;17(7):962-969PubMedArticle
7.
Aurora AR, Khaitan L, Saber AA. Sleeve gastrectomy and the risk of leak: a systematic analysis of 4,888 patients.  Surg Endosc. 2012;26(6):1509-1515PubMedArticle
8.
Boza C, Gamboa C, Salinas J, Achurra P, Vega A, Pérez G. Laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy: a case-control study and 3 years of follow-up.  Surg Obes Relat Dis. 2012;8(3):243-249PubMedArticle
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