HOLLYWOOD, FLA. — A two-stage procedure may be more appropriate for superobese patients undergoing weight loss surgery, Philip Schauer, M.D., advised at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.
“These patients [those with a body mass index over 60] can be enormously difficult to operate on,” he said, explaining that challenges such as a thick abdominal wall, enlarged liver, and extensive comorbidities can extend operating time and greatly increase the risk of perioperative complications.
A two-stage procedure using a less technically difficult and less risky operation for the first stage can lead to sufficient short-term weight loss that reduces risk for the higher-risk second-stage procedure such as gastric bypass, said Dr. Schauer, director of advanced laparoscopic and bariatric surgery at the Cleveland Clinic. For the first stage, he recommended vertical sleeve gastrectomy, which is an effective short-term weight loss procedure, or laparoscopic gastric banding. For the second stage, he recommended a Roux-en-Y gastric bypass procedure.
Weight loss after the initial procedure can reduce comorbidities and effectively downstage risk category.
Dr. Schauer reported on a series of 102 patients undergoing a two-stage weight loss procedure at the University of Pittsburgh. The patients' average age at the time of the first procedure was 50, and their BMI ranged up to 91. Each patient had an average of 10 comorbidities, and nearly half had a severe life-threatening disability. All had severe fatty liver disease.
Overall, 23 of the patients had completed the second stage as of February. Most underwent a sleeve gastrectomy followed by Roux-en-Y gastric bypass, Dr. Schauer reported.
After the first stage, average BMI dropped from 65 to the high 30s, and about 45% of excess weight was lost over 12 months. The weight loss had beneficial effects on patients and comorbidities, Dr. Schauer noted.
The rate of major complications in the first stage was 13%, which is “fairly minimal” for this very high-risk population, and the minor complication rate was 16%, he said.
All complications resolved without long-term disability. No deaths occurred.
More than half of the patients in the highest-risk category were downgraded by 1 or 2 categories, which represents a major difference in terms of operative risk at the time of the second procedure. The average number of comorbidities dropped from 10 to 6, and the vast majority of patients experienced major improvements in sleep apnea and diabetes.
Following the second-stage procedure, there were two major complications and three minor complications. None of these resulted in long-term morbidity.
The overall excess weight lost after the second stage was 60%.
The two-stage approach can transform a nonoperative candidate, who would otherwise be denied the most effective weight loss surgery, into a good candidate who has the potential to experience significant weight loss, Dr. Schauer said.
Other surgeons speaking on the topic of weight loss surgery for the superobese argued in favor of other procedures.
Emma Patterson, M.D., for example, said there are very few data on the use of sleeve gastrectomy in the two-stage procedure for the superobese, but several studies support laparoscopic gastric banding in this population.
Patients prefer gastric banding, she said, adding that it is more cost effective, and—according to some studies—it is associated with a lower mortality (0.02% vs. 1%) and complication rate (3% vs. 10%) than gastric bypass.
At least one other study suggested that bypass surgery is less effective than gastric banding in the superobese, said Dr. Patterson, director of bariatric surgery at Oregon Health and Science University, Portland.
And Ninh T. Nguyen, M.D., argued that not all superobese patients are technically difficult to operate on, and a two-stage procedure might subject patients to an unnecessary second surgery. A Roux-en-Y bypass can be performed from the outset in carefully selected lower-risk patients, he said, noting that at least one study shows that this operation is feasible in the superobese.
Furthermore, data suggest that if you can't safely perform a laparoscopic Roux-en-Y bypass operation, then you probably can't safely perform a laparoscopic sleeve gastrectomy either, said Dr. Nguyen, chief of the division of gastrointestinal surgery, University of California Irvine Medical Center. In these patients, he recommends a staged Roux-en-Y procedure.