ORIGINAL CONTRIBUTIONS

Laparoscopic Gastric Bypass vs. Sleeve Gastrectomyin the Super Obese Patient: Early Outcomes of anObservational Study

Carlos Zerrweck & Elisa M. Sepúlveda &

Hernán G. Maydón & Francisco Campos &Antonio G. Spaventa & Verónica Pratti & Itzel Fernández

# Springer Science+Business Media New York 2013

AbstractBackground Super obesity [body mass index (BMI)>50 kg/m2] can yield to higher morbidity/mortality inbariatric surgery, this could be related to patient's characteris-tics and/or surgeon's experience. In morbid obesity, bothtechniques proved to have a positive impact and sometimescomparable outcomes during the first 2 years. This has notbeen clearly analyzed in the super obese patient.Methods Retrospective study comparing the records of 77consecutive super obese patients (BMI: 50–59.9 kg/m2) sub-mitted to either laparoscopic gastric bypass (LGBP, n=32) orlaparoscopic sleeve gastrectomy (LSG, n=45) between 2010and 2012 at a single institution. The primary objective was toanalyze baseline demographics, comorbidities, operative out-comes, and early complications (<30 days). Secondarily,weight loss [BMI and % excess weight loss (%EWL)] wasalso described and compared during the first year.Results Female sex comprised 72.7 % of all cases. Bothgroups had comparable BMI (52.7±2.1 kg/m2 for LGBP vs.53.87±2.8 kg/m2 for LSG; p=0.087) and homogeneous base-line characteristics. Operative time was lower for the LSGgroup (113.1±35.3 vs. 186.9±39 min for LGBP; p≤0.001).Overall, early complications were observed in 16.8 % ofpatients (LGBP 9 % vs. LSG 22 %; p=0.217). There werefour major complications (two in each group), with tworeinterventions. Weight loss (%EWL) at 6, 9, and 12 monthswas significantly higher in the LGBP group (51.6±12.9 %,

56.5±13%, 63.9±13.3%, respectively) than in the LSG group(40±12.8 %, 45.1±15.5 %, 43.9±10.4 %, respectively).Conclusions Just like in morbid obesity, LGBP and LSG areeffective and safe procedures in super obese patients. LGBPhad better weight loss at 1 year.

Keywords Super obesity . Laparoscopic gastric bypass .

Sleeve gastrectomy

Introduction

Choosing the ideal surgical procedure for the treatment of thesuper obese patient [body mass index (BMI)>50 kg/m2] isstill subject of debate due to the unique and particularlydifficult characteristics of this group, and the technical chal-lenge they represent [1]. Mason et al. [2] first proposed theconcept of super obesity based on the observation that patientswith a higher degree of obesity often failed to achieve satis-factory weight loss after a vertical banded gastroplasty (VBG).This failure is due to multiple factors and different approacheshave been used in order to fulfill a better outcome in thisparticular group.

The usual technical difficulties found in the super obesepatient during surgery include the ones related to the size ofthe patient by itself. Males, in particular, have a higher pro-portion of central obesity and a longer distance between thexiphoid and the esophagus, and most of the patients havemassive hepatomegaly and a thicker visceral and abdominalwall fat layer. Most of the time longer instruments and lensesare needed, requiring greater force to manipulate them in-creasing operative time and fatigue. On the other hand, superobese patients have a greater incidence of coexisting morbid-ity that might increase surgical risk [1, 2].

C. Zerrweck : F. Campos :A. G. Spaventa :V. Pratti : I. FernándezThe Obesity Clinic at Hospital General “Dr. Rubén Leñero”, MexicoCity, Mexico

C. Zerrweck (*) : E. M. Sepúlveda :H. G. Maydón : F. CamposThe Obesity Clinic at Hospital General Tláhuac, Avenida La Turba#655, Col. Villa Centroamericana y del Caribe, Del. Tláhuac,13250 Mexico City, Mexicoe-mail: zerrweck@yahoo.com

OBES SURGDOI 10.1007/s11695-013-1157-y

Laparoscopic gastric bypass (LGBP) continues to be themost widely used bariatric procedure worldwide, but laparo-scopic sleeve gastrectomy (LSG) has gained popularity and arapid expansion has been observed in recent years probablyrelated to the “simplicity” when compared to LGBP, especial-ly in super obesity. Anyway, in this specific population, theefficacy as a definitive procedure is still a matter of debate,and only few studies compared it with other techniques suchas LGBP [3–5]. In this study, we compared both surgicalgroups (LSG vs. LGBP) in a super obese population in orderto determine their outcomes and 12-month weight loss.

Methods

In this retrospective study, we compared the records of 77consecutive super obese patients (BMI: 50–59.9 kg/m2) sub-mitted to either LGBP (n=32) or LSG (n=45) from March2010 to April 2012 at a single institution; data collection wasdone prospectively. Patients with BMI>60 kg/m2 were sys-tematically submitted to intragastric balloon. The primaryobjective was to analyze baseline demographics, comorbidi-ties, operative outcomes and early complications (<30 days).Secondarily, weight loss [BMI and % excess weight loss %(EWL)] was also described and compared during the first year(0, 1, 3, 6, 9, and 12 months). Gender comparison for weightloss within the LSG group was also analyzed. Patients withprevious intra-abdominal surgery, intragastric balloon, andthose associating cholecystectomy to the bariatric procedurewere not included in the study.

The LGBP was performed in an antecolic–retrogastricfashion, with a calibrated 2 cm gastro-jejunal anastomosis(linear stapler); biliary and alimentary limbs measured 70and 200 cm, respectively. Mesenteric defects were closedand the omentum divided. Methylene blue test and 7-daydrainage were done routinely.

The LSG was performed at 5–6 cm from the pylorus over a36 Fr. bougie, with oversuture of the staple line (2–0 polypro-pylene). Methylene blue test and 7-day drainage were doneroutinely.

Statistical Analysis

Data were expressed as mean±standard deviation (SD),values, and analyzed by paired and unpaired t test as appro-priate. Categorical variables were comparedwith the x2 test fordistribution assessment and the McNemar x2 test for repeated-measure comparisons. Significance was reached whenp<0.05. Analysis was performed using NCSS 2007 (NCSS,Kaysville, UT, USA).

Results

In terms of gender, female sex was predominant (72.7 % of allcases). Higher preoperative weight and height was found inthe LSG group (150±17.08 vs. 135.9±14.08 kg for LGBP;p≤0.001), but with comparable BMI (52.7±2.1 kg/m2 forLGBP vs. 53.87±2.8 kg/m2 for LSG; p=0.087). The rest ofbaseline characteristics were homogeneous between groups(Table 1). Overall comorbidities were found as follows: DM 2in 15 patients (19 %), arterial hypertension in 20 (25 %), anddyslipidemia in 11 (14 %).

Operative time was lower for the LSG group (113.1±35.3vs. 186.9±39min for LGBP; p≤0.001) with no conversions toopen surgery. Overall, early complications were observed in16.8 % of patients (LGBP 9 % vs. LSG 22 %; p=0.217).There were four major complications (5.1 %), two in eachgroup: two gastro-jejunal fistulas in the LGBP group (noreoperation); and one LSG fistula (no reoperation) and onetrocar-site bleeding that required blood transfusions (2 units)and reoperation. All fistulas were treated conservatively andclosure was observed within 2–3 weeks. Minor complicationsin the LSG group included two wound infections, three atel-ectasis, one superficial phlebitis, one urinary tract infection,and one hematoma; the LGBP group had one gastrointestinalbleeding without transfusion. (Table 1) No mortality wasreported during follow-up. Complete 1-year follow-up wasavailable in 68 % (LGBP) and 75 % (LSG) of patients.

Compared to baseline, the overall percentage of change forpatients that stop taking any medication for comorbidities at1 year were 86.6 % in DM 2, 75 % in arterial hypertension,and 81.8 % in dyslipidemia.

Table 1 Initial demographics, comorbidities and perioperative analysisbetween groups

LGBP (n 32) LSG (n 45) pValues

Female sex; n (%) 31 (96) 25 (55) <0.001

Age; mean±SD 35.4±7.6 37.5±10.4 0.354

Height (cm); mean±SD 1.60±0.08 1.66±0.009 0.004

Weight (kg); mean±SD 135.9±14.08 150±17.08 <0.001

BMI (kg/m2); mean±SD 52.7±2.1 53.87±2.8 0.087

Diabetes; n (%) 6 (18) 9 (20) 1

Arterial Hypertension; n (%) 7 (21) 13 (28) 0.601

Dyslipidemia; n (%) 4 (12) 7 (8) 0.508

Operative time (min); mean±SD 186.9±39 113.1±35.3 <0.001

Conversion; n (%) – – –

Overall complications; n (%) 3 (9) 10 (22) 0.217

Minor 1 8 0.072

Major 2 2 1

Hospital stays (days); mean±SD 4.2±0.8 4.5±1 0.145

Student's t test for independent samples and Chi-square for nonparametriccategorical data. p<0.05

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As showed in Fig. 1, BMI changes were significantlydifferent at 6 and 12 months (38.6±3.6 and 34.8±3.4 kg/m2

for the LGBP vs. 41.7±5.2 and 40.9±5.8 kg/m2 for the LSGgroup). The percentage of excess weight loss at 6, 9, and12 months was significantly higher in the LGBP group(51.6±12.9 %, 56.5±13 %, 63.9±13.3 %, respectively) thanin the LSG group (40±12.8 %, 45.1±15.5 %, 43.9±10.4 %,respectively; Fig. 2). Gender analysis for weight loss withinthe LSG group showed no differences at any time point(Fig. 3).

Discussion

In this observational study, we compared the results at 1 yearof the two most common current bariatric techniques (LGBPand LSG) in a super obese population (BMI: 50–59.9 kg/m2).We found that both methods are feasible, safe, and effective,but that LGBP had a greater impact on weight loss at 1 year.

Super obese patients are known to be more challenging forsurgeons and anesthesiologists, especially in low-volume cen-ters. The International Federation for the Surgery of Obesityand Metabolic Disorders (IFSO) recommends that surgeonsnot operate on super obese patients until they have performeda minimum of 50 bariatric surgeries [6]. LGBP in thesepatients has been reported to result in higher morbidity thanin lighter patients [7], but as experienced is gained, other serieshave reported similar outcomes in super obesity comparedwith morbid obesity [8–10]. Initially used as the first stagein duodenal switch procedures in extremely obese patients[11, 12], LSG emerged as an option with acceptable short-term results for both morbid and super obesity. The strategyfor super obese patients is to perform restriction as a firsttreatment, followed by a conversion or addition of amalabsorptive procedure. Other strategies, such as hand-assisted surgery [13–15], laparoscopic gastric banding

[16–19], mini-gastric bypass [20], and intragastric balloon[21–26], have also been proposed as treatments for thispopulation.

Both LGBP and LSG have proven to be safe and effectivein morbidly and super obese patients. In a retrospective com-parison between LGBP (n=1,345) and LSG (n=686), Weineret al. [27] recently reported a higher incidence of early majorcomplications for the LSG group (4.9 % vs. 7.14 %; p=0.039),with complications more common among male patients andthe super obese. Our complications rate was 4.4 % for the LSGgroup vs. 6.2 % for the LGBP group (p=0.724). LSG leakagerates are reported to be between 1 % and 7 % in the literature[28]; our rate was 2.2 %. Reported leakage rates in gastricbypass range from 0 % to 6.1 % [29]. In a series of 133 superobese patients, Suter et al. observed five leaks and two “intra-abdominal infections” (5.2 %). Other similar series reportedleaks in 1.4 % and 4.1% of patients [30, 31]. We had two leaksin this group (6.2 %) without reoperation: one in a patient with

Fig. 1 Weight loss (BMI) follow-up between groups. *p<0.05, signifi-cant difference between groups at 6 and 12 months

Fig. 2 Weight loss (%EWL) follow-up between groups. *p<0.05, sig-nificant difference between groups at 6, 9, and 12 months

Fig. 3 Gender-related weight loss (%EWL) follow-up within the LSGGroup. No significant difference at any time point

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a BMI of 52.4 kg/m2 and previous abdominoplasty, and an-other in a patient with a BMI of 59.2 kg/m2 [32].

The efficacy of LSG in super obese patients is less than inlighter patients [33–35]. Available studies comparing LSGwith LGBP report conflicting results: some report better re-sults with LGBP [36], some report equal results [3, 4], andsome report better results with LSG (in morbid obesity) [37].A systematic review by Fischer et al. showed that the %EWLat 12 months was significantly higher after LGBP than afterLSG (68.3 % vs. 56.1 %; p<0.01) but the mean preoperativeBMI for the 123 papers analyzed was 48 kg/m2. In the samereview, the author found 54 papers reporting 12-month weightloss after LSG ranging from 30% to 83.3 % of EWL [36]; our12-month %EWL was 43.9 %.

The few complete studies of weight loss after LSG in superand super super obese patients report variable results.Comparable to our observations, Silecchia et al. [38] reportedan average BMI at 12 months of 40.8 kg/m2 (initial BMI57.3 kg/m2) in 41 patients. Another study with 20 patientsreported 35 % of EWL at 6 months [39]; we had 40 % at6 months. Tagaya et al. [34] compared LSG results betweenmorbidly and super morbidly obese patients, reporting thatpatients with BMI>50 kg/m2 dropped from a mean BMI of62.2 kg/m2 to 52.2 kg/m2 at 12 months after surgery (n=10);they also observed a weight loss plateau after the ninth month,a phenomenon also found in our study. Another study of 39patients with BMIs>50 kg/m2 who underwent LSG reported55.5±16.8 % (27 %–83 %) of EWL at 1 year [35]. Cottamet al. [40] reported 46 % of EWL at 1 year in patients having amean initial BMI of 65.3 kg/m2, different from Mukherjee,who reported 39 % of EWL at 1 year among patients with aninitial BMI of 60 kg/m2 [41].

Technical details under debate related to LSG includesleeve calibration. Originally, it was believed that tightersleeve gastrectomies (32–36 Fr bougie calibration) might leadto greater and sustained weight loss. A recent systematicreview and meta-analysis of 9,991 patients who underwentLSG showed otherwise: using >40 Fr calibration may de-crease leakage without impacting %EWL up to 36 monthspostoperatively compared with smaller bougies (<40 Fr) [42].We used a 36 Fr bougie in all of our cases. A technical detail inLGBP surgery is construction of the Roux-limb, where a longlimb (~200 cm) is performed systematically in our super obesepatients. Evidence suggests that a long limb might be moreimportant for effective weight loss in patients>50mg/kg2 thanin those <50 mg/kg2 [43–46]. Ciovica reported 64 % of EWLat 12 months in patients with a long Roux limb, resultscomparable to our observations (63.9 %) [45].

Definition of surgical failure should be different betweenmorbid and super obesity, because it is well known that weightloss (%EWL) is less in extremely obese patients. Alexandroureported a “failure” rate of 44% for LSG, with success definedas achieving a BMI below 40 kg/m2. When the definition of

failure changes to losing less than 50 % of initial excessweight, the failure rate goes down to 22 %. Our 1-year BMIanalysis revealed that 41 % of LSG patients still had a BMI>40 kg/m2, compared with only 10 % in the LGBP group.According to Interdisciplinary European Guidelines [47], the-se patients remain surgical candidates. The highest observed%EWL in the literature for LSG is after 24 months.

Among the success predictors for bariatric surgery, initialweight plays an important role in 1-year weight loss, accord-ing to some authors [48–50], but not others [51, 52]. Inge et al.[48] reported a predictable BMI decrease of 36.8–37.7 % at1 year in adolescents undergoing LGBP, irrespective of initialBMI. The percentage of BMI change in our series for LGBPwas 33.9 % vs. only 23.9 % for LSG (both groups hadcomparable initial BMI). Another form of reporting weightloss is the percentage of total weight loss (%TWL). In a recentstudy, three methods of reporting weight loss (%EWL, % ofEBMI loss, and %TWL) were used in two groups (BMI<50vs. ≥50 kg/m2). The authors concluded that %TWL washigher in the super obese, whereas %EWL was similar be-tween groups, and % of EBMI loss was higher in less obesepatients [53].

After analyzing the literature, Campos and colleagues [51]summarized other factors associated with poor weight loss:older age, black race, being married, presence of DM, malesex, physical activity, poor follow-up, pouch area, and insur-ance status. A recent systematic review found 37 out of 62studies reporting a negative association between preoperativeBMI and weight loss, and 24 out of 33 studies reporting thesame association for super obesity [54].

We analyzed the effect of sex within the LSG group, tryingto identify a possible sex-related failure, based on the knownhigher likelihood of sugar cravings among women than men[55]; no statistical differences were found. In the same group,no correlation between age and 1-year %EWL was found(data not shown).

Surgical revision rates in the literature vary from 5 %to 56 %. Further options for patients requiring a secondprocedure after LSG include placement of an adjustableband, LGBP, duodenal switch, or even banded LGBP.According to Shimizu et al. [56], conversion to LGBPcan result in a mean additional 36.7 % of EWL at1 year.

In summary, we found that both LGBP and LSG are safe insuper obese patients, but that LGBP resulted in greater weightloss at 1 year. Limitations of our study included its samplesize, retrospective nature, short follow-up, and a considerableloss of patients at 1 year. Another limitation could be uninten-tional selection bias resulting from patient selection of thesurgical method, because 96 % of patients undergoingLGBP were women vs. 55 % in the LSG group (p<0.01).Chronicity and severity of DM could also play a role in theselection of surgical method, but complete data (% Hb A1c,

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C-peptide, and time of diagnosis) for all of our patients couldnot be obtained.

Conclusion

LGBP and LSG are safe and efficient procedures to treatpatients with super obesity, but LGBP showed better weightloss at 6, 9, and 12 months. Randomized controlled trials inthis specific population are required to choose the ultimate andmost adequate procedure, trying to avoid furtherinterventions.

Conflict of Interest The author (Carlos Zerrweck) and coauthors (ElisaSepulveda, Hernan Maydon, Antonio Spaventa, Francisco Campos,Veronica Pratti, and Itzel Fernandez) have no conflict of interest.

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