LOUISVILLE, KY. — “Super-super obese” patients obtain nearly the same benefits from laparoscopic Roux-en-Y gastric bypass as do less obese patients without incurring unwarranted risks, Dr. Jon C. Gould reported at the annual meeting of the Central Surgical Association.
Surgeons have taken several different approaches in treating super-super obesity (a body mass index greater than 60 kg/m
Still others consider super-super obese patients to be nonoperative, said Dr. Gould of the bariatric program at the University of Wisconsin, Madison.
To study the results of laparoscopic surgery in these patients, he and his colleagues reviewed prospectively collected data on procedures performed on 28 patients with a BMI greater than 60 kg/m
The super-super obese patients were required to lose a specific amount of weight on a high-protein, low-calorie diet before the operation. The required amount of weight loss, determined at the discretion of the surgeon, was “somewhat subjectively” based on where a patient carried his or her weight, but the amount typically was 30–40 pounds, he said.
The surgery involved a circular stapled gastrojejunostomy with an antecolic, antegastric placement of a 150-cm Roux limb. A 50-cm biliopancreatic limb was used.
Few early complications developed in patients in either group. The group of less obese patients incurred one death, two staple-line leaks, four bleeding episodes, and six wound infections. One staple-line leak and one wound infection occurred among the 28 super-super obese patients.
Stenosis developed among significantly more of the super-super obese patients (29%) than among those with a lower BMI (9%). This difference persisted even after the investigators had switched from using a 21-mm stapler in the first 142 patients to a 25-mm stapler in the following 142 patients. Dr. Gould was unsure whether stenosis resulted from surgeons routinely oversewing the gastrojejunostomy in the super-super obese patients, from increased tension on the anastomosis, or from intraabdominal pressure. But all of the patients with stenosis responded well to endoscopic dilatation without any long-term comorbidity, he said.
Patients with lower BMI lost a significantly higher percentage of their excess weight at 1 and 2 years (69% and 75%, respectively) than did higher BMI patients (57% and 61%). But the super-super obese patients lost significantly more weight overall (about 150 vs. 120 pounds). Most of the super-super obese patients (92%) failed to achieve a BMI less than 35, compared with 17% of the less obese patients.
Resolution of preoperative medical conditions post surgery was similar among super-super obese and less obese patients: type 2 diabetes (100% vs. 80%, respectively), gastroesophageal reflux disease (80% vs. 96%), and hyperlipidemia (80% vs. 91%).
But hypertension resolved in significantly more of the less obese than in the super-super obese patients (89% vs. 63%). The super-super obese patients also reported a quality of life similar to that reported by the less obese patients after the operation.
“It's not clear to me why [super-super obese] patients respond somewhat differently to some of these procedures than our less obese patients do, and I think we do need to take a step back to assess and think about how we're going to define success in these patients,” Dr. Gould said. “To what lengths should we go to achieve a specific postoperative BMI, what morbidity should we accept to achieve that BMI, or should our end point—our definition of success—be more related to quality of life and health?”