Users Online : 621 About us |  Subscribe |  e-Alerts  | Feedback | Login   
Journal of Minimal Access Surgery Current Issue | Archives | Ahead Of Print Journal of Minimal Access Surgery
           Print this page Email this page   Small font sizeDefault font sizeIncrease font size 
  Search
 
  
 ¤   Similar in PUBMED
 ¤Related articles
 ¤   Article in PDF (931 KB)
 ¤   Citation Manager
 ¤   Access Statistics
 ¤   Reader Comments
 ¤   Email Alert *
 ¤   Add to My List *
* Registration required (free)  


 ¤  Abstract
 ¤ Introduction
 ¤  Materials and Me...
 ¤ Results
 ¤ Discussion
 ¤ Conclusions
 ¤  References
 ¤  Article Figures
 ¤  Article Tables

 Article Access Statistics
    Viewed637    
    Printed59    
    Emailed0    
    PDF Downloaded65    
    Comments [Add]    

Recommend this journal

 


 
 Table of Contents     
ORIGINAL ARTICLE
Year : 2021  |  Volume : 17  |  Issue : 2  |  Page : 159-164
 

Is weight regaining significant post laparoscopic Roux-en-Y gastric bypass surgery? – A 5-year follow-up study on Indian patients


1 Department of General, Laparoscopic and Bariatric Surgery, Moulana Hospital, Perinthalmanna, Kerala, India
2 Yenepoya Research Centre, Yenepoya University, Mangalore, Karnataka, India

Date of Submission29-Apr-2019
Date of Decision25-Nov-2019
Date of Acceptance27-Jan-2020
Date of Web Publication28-Mar-2020

Correspondence Address:
Dr. Mohamed Ismail
Department of General, Laparoscopic and Bariatric Surgery, Moulana Hospital, Perinthalmanna, Kerala
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_108_19

Rights and Permissions

 ¤ Abstract 

Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) has been proven to induce significant weight loss and remission of related co-morbidities in patients with morbid obesity. The long-term follow-up data show weight regain or failure to achieve complete remission of type 2 diabetes mellitus (T2DM) in some patients. In this study, we report weight loss patterns and remission of T2DM in patients with morbid obesity during a 5-year follow-up after RYGB.
Objective: The objective was to evaluate outcomes during the follow-up on excess weight loss (EWL) and remission of T2DM after laparoscopic RYGB among Indian patients.
Setting: The study was conducted in a tertiary care hospital, Kerala, India.
Materials and Methods: This is a retrospective study in patients who underwent surgery between 2007 and 2010. The patient demographics, pre- and post-operative body mass index (BMI), co-morbidities and EWL were recorded from the medical records. These data were compared between pre-operative and follow-up intervals till 5 years using statistical approaches.
Results: The study included 157 patients (91 males and 66 females) having a mean pre-operative BMI of 47.91 ± 7.01 kg/m2. A significant reduction in the BMI was observed at each follow-up point (P < 0.01) till 5 years after the surgery. The mean percentage of EWL increased from 34.57% ± 12.62% to 71.50% ± 15.41% from 3 months to 5 years after the surgery. Twelve per cent (n = 19) of patients achieved normal BMI (<25 mg/kg2) by 3rd year after the surgery. However, the remission of T2DM was achieved in >50% of patients within a year of surgery. During the 5th year, weight regain (1–22 kg) was observed in 36.70% (n = 58) patients, and recurrence of T2DM was observed in two patients.
Conclusions: The long-term durability of RYGB in the study population was satisfactory with significant weight loss and remission of T2DM.


Keywords: Bariatric surgery, body mass index, diabetes, obesity, Roux-en-Y gastric bypass


How to cite this article:
Ismail M, Nagaraj D, Rajagopal M, Ansari H, Iyyankutty K, Nair M, Hegde A, Rekha P D. Is weight regaining significant post laparoscopic Roux-en-Y gastric bypass surgery? – A 5-year follow-up study on Indian patients. J Min Access Surg 2021;17:159-64

How to cite this URL:
Ismail M, Nagaraj D, Rajagopal M, Ansari H, Iyyankutty K, Nair M, Hegde A, Rekha P D. Is weight regaining significant post laparoscopic Roux-en-Y gastric bypass surgery? – A 5-year follow-up study on Indian patients. J Min Access Surg [serial online] 2021 [cited 2021 Apr 17];17:159-64. Available from: https://www.journalofmas.com/text.asp?2021/17/2/159/281497



 ¤ Introduction Top


Roux-en-Y gastric bypass (RYGB) is the 'gold standard' bariatric surgical procedure due to both restrictive and malabsorptive properties and offers superior results in resolution of obesity-related co-morbidities such as type 2 diabetes mellitus (T2DM) and hypertension.[1],[2] The RYGB procedure increases the delivery rate of nutrients into the small intestine, with a fast glycaemic rise and increased secretion of glucagon-like peptide-1 (GLP-1), restoring the first-phase insulin response.[3] This leads to an improved insulin secretion after a meal, suggesting enhanced beta-cell function which makes RYGB as an effective treatment for patients with T2DM and morbid obesity.[4] RYGB offers advantage for the obese patients with T2DM through improvement in cardiovascular function, reduced inflammation and an improvement in the abnormal metabolic panel.[5]

Peak body mass index (BMI) reduction is generally achieved within 1–2 years after the surgery, and on long term, most patients maintain >50% weight loss and remission of co-morbidities.[4] In a recent 12-year follow-up study, long-term durability of weight loss and effective remission and prevention of T2DM after RYGB was found to be superior compared to medical management.[6] However, long-term durability of weight loss and remission of co-morbidities varied among individuals. Long-term outcome from the follow-up data after RYGB surgery is important to assess the performance of the patients, durability and sustainability of weight loss and/or T2DM remission pattern. Although bariatric or metabolic surgery is practiced by many centres, follow-up data on the outcome are relatively lesser. It has been shown in earlier reports that RYGB, although is an attractive procedure, often fails in maintaining or achieving satisfactory weight loss with weight regain in some patients.[7],[8] Weight regain after RYGB often has a large negative impact on the bariatric quality of life index.[9]

Here, we report the long-term outcome from RYGB among morbidly obese Indian patients from a single centre using the post-surgery regular follow-up data.


 ¤ Materials and Methods Top


Patients and study design

This is a retrospective, single-centre, observational study using the data from the patients who had undergone RYGB for obesity/obesity-related metabolic disorders between 2007 and 2010. The data were reviewed from hospital medical records for pre- and post-operative details. The inclusion criteria were patients with morbid obesity (BMI >30 kg/m2) with or without co-morbidities and undergone RYGB with the follow-up data at 3 months, 6 months, 1 year, 3 years and 5 years.

Ethical clearance

This study was approved by the Institutional Ethical Committee - Moulana Hospital Ethical Committee, Mallapuram, Kerala (MH/EC/04/2017, dated 11th September, 2017). As this was a retrospective study, informed consent was not applicable.

Surgical technique and post-operative care

The RYGB was performed using the 6-port technique with standard pre-operative care and precautions. After gastroesophageal junction identification, the stomach was transected with a linear stapler entering the lesser sac 3–5 cm below the junction, creating a small gastric pouch with a volume of approximately 15 ml. A 50-cm biliopancreatic limb was measured, and an antecolic end-to-side gastroenterostomy was formed using a 45-mm vertical stapler. A stapled side-to-side jejunojejunostomy was formed 150 cm distally. Intermesenteric and Petersen spaces were closed with non-absorbable sutures. The standard post-operative care was given to all patients. Fluid and food intakes were monitored and discharged with dietary instructions by a bariatric dietician along with daily multivitamin and calcium supplements.

Data and study outcomes

Patient demographics, pre-operative weight, BMI, fasting blood sugar (FBS), HbA1c, co-morbidities and post-operative complications were recorded from the medical records. The end points such as percentage of excess weight loss (%EWL), changes in BMI and remission of T2DM were calculated with reference to the pre-operative data at every follow-up and between follow-ups. Standard conventions were followed for the assessment of prevalence, remission and incidence of coexisting conditions. Complete remission of T2DM was considered if the FBS level was <100 mg/dL (<5.6 mmol/L) and HbA1c was <6.0%. Interpretation of weight loss: the bariatric procedure was considered inadequate if the %EWL was between 30% and 50%, and failure if %EWL was <30%. Underweight was defined as BMI <20 kg/m2.

Statistical analysis

Continuous data were expressed in mean ± standard deviation, and categorical data were presented as frequency and percentages. Normality was tested using Shapiro–Wilk test, and paired t-test was used to compare quantitative variables across the time points. All statistical analyses were performed using IBM SPSS Statistics for Windows software (version 22.0, IBM Corp, Armonk, New York, USA).


 ¤ Results Top


Patient demographics

The pre-operative patient demographics and baseline data are given in [Table 1]. The study group included 157 patients (58% male and 42% females) with complete follow-up data. The mean age of the group was 35.64 ± 10.11 years (range: 17–63 years). At baseline, 2.5% (n = 4) of the patients were in the teenage age group (range: 17–19 years), 68.80% (n = 108) were in the age group of 20–40 years and 28.70% (n = 45) were above the age of 40 years.
Table 1: Patient demographics (n=157)

Click here to view


Follow-up data

The patients were followed up at regular intervals for a period of 5 years (3 months, 6 months, 1 year, 3 years and 5 years).

Anthropometric changes

The mean weight of patients was 132.93 ± 22.46 kg at the baseline, and significant reduction in the mean weight was observed in the post-surgery follow-up period. The mean weight loss at the follow-up periods is given in [Table 2]. At 3 months after surgery, the mean weight reduction of the cohort was 22.71 ± 8.51 kg (range: 7–52 kg).
Table 2: Changes in the weight loss, BMI, %TWL and %EWL after RYGB in the study cohort (n=157)

Click here to view


Within 3 and 6 months after surgery, 12.10% (n = 19) and 50.30% (n = 79) of patients achieved >50% EWL, and at the same time points, the mean %EWL of the study group was 34.13% and 51.36%, respectively. Within 1 year – 75.80% (n = 119), at 3 years – 91.10% (n = 143) and at 5 years – 93.06% (n = 147) patients achieved more than 50% EWL. Even at 5 years after surgery, one (0.63%) patient could not achieve satisfactory results (%EWL: 20.58%).

At 1 year, 3 years and 5 years of surgery, the mean %EWL of the study group was 61.98%, 70.41% and 71.50%, respectively [Table 2].

The mean pre-operative BMI was 47.91 ± 7.05 kg/m2 (range: 29.70–67.2 kg/m2). Significant reduction in mean BMI was observed throughout the follow-up period. Within a year after surgery, the mean BMI of the study group was 32.71 ± 5.40 kg/m2, and at the last follow-up (5 years), it was 30.04 ± 4.52 kg/m2, which was significantly lower than the pre-operative and previous follow-ups (P < 0.001) [Table 2]. About 1.90% (n = 3) of patients (initial BMI between 30 and 38 kg/m2) had achieved normal BMI (<25 kg/m2) as early as 6 months after the surgery. At 1-year follow-up, 5.7% (n = 9) of patients had attained normal BMI, in 29.30% (n = 46) of patients, the BMI was reduced to <30 kg/m2 (25 <BMI <30 kg/m2) and 65% (n = 102) were still obese. However, at 3 years, 12.10% (n = 19) of patients had attained the normal BMI, in 38.2% (n = 60) of patients, the BMI was <30 kg/m2 (25 <BMI <30 kg/m2) and 49.7% (n = 79) of patients were still obese. At 5 years, 55.40% (n = 87) of patients had BMI <30 kg/m2, and 44.60% (n = 70) of patients were still obese with BMI >30 kg/m2 (range: 30.0–43.56 kg/m2). The distribution of BMI, weight and %EWL of the study cohort at different time points is given in [Figure 1].
Figure 1: Distribution of BMI (body mass index), weight loss, % TWL (total weight loss) and % EWL (Excess weight loss) in the study cohort at different time points

Click here to view


Weight regain

Weight regain was observed in some patients post surgery. 12.73% (n = 20) of patients had regained a mean weight of 4.1 ± 1.97 kg (range: 1–9 kg) between 6 months and 1 year. However, 17 of these patients had achieved >50% EWL at 6 months, except three patients, others maintained >50% EWL [Table 3]. Between 1 and 3 years, 19.74% (n = 31) of patients showed weight regain (4.74 ± 2.80 kg; range: 1–11 kg); among them, 24 patients continued to maintain >50% EWL. Between 3 and 5 years, weight regain (2.57 ± 1.20 kg; range: 1–22 kg) was observed in 36.94% (n = 58) patients; 55 of these patients had achieved >50% EWL previously and they still maintained the weight loss at >50% EWL.
Table 3: Weight regain among the patients who had >50% EWL

Click here to view


Remission of co-morbidities

In the cohort at the baseline, T2DM was present in 27.38% (n = 43) of patients, having a mean FBS of 125.88 ± 16.99 mg/dL and the mean HbA1c of 6.24 ± 0.58%. The mean BMI of the diabetic patients was 47.71 ± 7.46 kg/m2 (range: 30–63 kg/m2), and at 5-year follow-up, it was 30.39 ± 4.36 kg/m2 (range: 23.15–43.56 kg/m2) [Table 4].
Table 4: Number of patients showing success after bariatric surgery (RYGB) in remission of diabetes (n=43)

Click here to view


After surgery, a significant reduction in FBS was observed at 3 months, 6 months and 1 year compared to the baseline and also between the follow-ups (P < 0.001). Similarly, mean HbA1c levels decreased significantly after the surgery at 3 months (P < 0.001) without further increase in the levels in subsequent follow-ups. 60.46% (n = 26) of patients achieved remission at 3 months, 62.79% (n = 27) at 6 months and 83.72% (n = 36) at 5 years had complete remission of T2DM, and improvement in HbA1c levels (>6.0%–6.5%) was seen in 11.62% (n = 5) patients. However, two patients still had HbA1c levels above 6.5%.


 ¤ Discussion Top


Results from the follow-up data show satisfactory outcome from RYGB in terms of both weight loss and remission of T2DM among patients. Here, 50% of patients achieved satisfactory outcomes at 6 months after surgery and increased to 91.9% within 3 years after surgery. A small percentage of patients could attain normal BMI within a year (6.97%); however, absolute failure (<0% reduction in BMI) was not observed in this cohort. 9.30% of patients could not achieve satisfactory weight loss; still, these patients had complete remission of T2DM. Several studies have demonstrated improved glycaemic control in obese patients with T2DM after surgery independent of weight loss in procedures like RYGB.[10],[11] The diabetic remission is attributed to the calorie restriction and nutrient exclusion to the proximal gut. RYGB has been known to increase the delivery rate of nutrients to the small intestine, resulting in fast glycaemic rise and increased secretion of GLP-1 leading to insulin response. The metabolic surgery procedure has shown better disease management in patients with inadequate glycaemic control despite using the best available medical treatments.[12],[13],[14],[15],[16]

Previous reports have shown weight reduction peak at 1–2 years after the surgery.[4],[17] The long-term durability of weight loss depends on the patients' compliance with the post-surgery guidelines with respect to diet and physical activities. Long-term follow-up studies has shown favourable results in terms of the durability of weight loss after RYGB.[18]

The outcome from surgery in super-obese patients with respect to %EWL was appreciable, however, most of them could achieve ≥50% EWL within a year or 2 years after the surgery. Interestingly, in this study, 12.03% of super obese patients could attain normal BMI. Ideally, >50% EWL is a favourable outcome from any bariatric/metabolic surgery. The initial weight loss following the surgery will not be durable in a few patients, and they tend to regain weight after the initial weight loss. Here, 7.60% (n = 6) of patients who had initially lost >50% excess weight regained weight within a year after the surgery. One case of underweight (BMI 19.38 kg/m2) was seen in the cohort at 5-year follow-up.

Remission of diabetes in a subset of patients as early as 3 to 6 months after the surgery was observed. Remission of obesity-related co-morbidities is strongly associated with weight loss.[19]

The finding of this study is corroborated by many published works that although RYGB is a preferred, most commonly performed, highly efficient surgery in patients with morbid obesity, some patients regain a part of the weight loss, and to address this, alternative endoscopic therapies have been introduced.[20]


 ¤ Conclusions Top


Long-term follow-up is necessary to explicate the effectiveness of RYGB surgery in terms of weight loss and remission of T2DM in morbidly obese patients. This long-term study indicates that although weight loss was observed post RYGB, some of the patients did not attain appreciable %EWL, and weight regain was also observed in a few cases. Hence, for morbidly obese patients, alternative procedures like minigastric bypass surgery can be considered. Physical exercise, diet and other lifestyle-associated factors also play an important role in the durability of weight loss.

Statement of Human and Animal Rights: This study was performed in accordance with the principles of the Declaration of Helsinki and was approved by the Institutional Ethical Committee.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 ¤ References Top

1.
Salinari S, Bertuzzi A, Guidone C, Previti E, Rubino F, Mingrone G. Insulin sensitivity and secretion changes after gastric bypass in normotolerant and diabetic obese subjects. Ann Surg 2013;257:462-8.  Back to cited text no. 1
    
2.
Owen JG, Yazdi F, Reisin E. Bariatric Surgery and Hypertension. Am J Hypertens 2017;31:11-7.  Back to cited text no. 2
    
3.
Di J, Zhang H, Yu H, Zhang P, Wang Z, Jia W. Effect of Roux-en-Y gastric bypass on the remission of type 2 diabetes: A 3-year study in Chinese patients with a BMI <30 kg/m2. Surg Obes Relat Dis 2016;12:1357-63.  Back to cited text no. 3
    
4.
Mehaffey JH, LaPar DJ, Clement KC, Turrentine FE, Miller MS, Hallowell PT, et al. 10-Year outcomes after roux-en-Y gastric bypass. Ann Surg 2016;264:121-6.  Back to cited text no. 4
    
5.
Liang Z, Wu Q, Chen B, Yu P, Zhao H, Ouyang X. Effect of laparoscopic Roux-en-Y gastric bypass surgery on type 2 diabetes mellitus with hypertension: A randomized controlled trial. Diabetes Res Clin Pract 2013;101:50-6.  Back to cited text no. 5
    
6.
Adams TD, Davidson LE, Litwin SE, Kim J, Kolotkin RL, Nanjee MN, et al. Weight and metabolic outcomes 12 years after gastric bypass. N Engl J Med 2017;377:1143-55.  Back to cited text no. 6
    
7.
Maleckas A, Gudaitytė R, Petereit R, Venclauskas L, Veličkienė D. Weight regain after gastric bypass: Etiology and treatment options. Gland Surg 2016;5:617-24.  Back to cited text no. 7
    
8.
Shantavasinkul PC, Omotosho P, Corsino L, Portenier D, Torquati A. Predictors of weight regain in patients who underwent Roux-en-Y gastric bypass surgery. Surg Obes Relat Dis 2016;12:1640-5.  Back to cited text no. 8
    
9.
Jirapinyo P, Abu Dayyeh BK, Thompson CC. Weight regain after Roux-en-Y gastric bypass has a large negative impact on the Bariatric Quality of Life Index. BMJ Open Gastroenterol 2017;4:e000153.  Back to cited text no. 9
    
10.
UK Prospective Diabetes Study (UKPDS) Group. Intensive blood glucose control with sulfonylureas or insulin compared with conventional treatment and risk for complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53.  Back to cited text no. 10
    
11.
ADVANCE Collaborative Group, Patel A, MacMahon S, Chalmers J, Neal B, Billot L, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560-72.  Back to cited text no. 11
    
12.
Ikramuddin S, Korner J, Lee WJ, Bantle JP, Thomas AJ, Connett JE, et al. Durability of Addition of Roux-en-Y gastric bypass to lifestyle intervention and medical management in achieving primary treatment goals for uncontrolled type 2 diabetes in mild to moderate obesity: A randomized control trial. Diabetes Care 2016;39:1510-8.  Back to cited text no. 12
    
13.
Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Leccesi L, et al. Bariatric surgery versus conventional medical therapy for type 2 diabetes. N Engl J Med 2012;366:1577-85.  Back to cited text no. 13
    
14.
Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012;366:1567-76.  Back to cited text no. 14
    
15.
Ikramuddin S, Korner J, Lee WJ, Connett JE, Inabnet WB, Billington CJ, et al. Roux-en-Y gastric bypass vs. intensive medical management for the control of type 2 diabetes, hypertension, and hyperlipidemia: The Diabetes Surgery Study randomized clinical trial. JAMA 2013;309:2240-9.  Back to cited text no. 15
    
16.
Laferrère B, Teixeira J, McGinty J, Tran H, Egger JR, Colarusso A, et al. Effect of weight loss by gastric bypass surgery versus hypocaloric diet on glucose and incretin levels in patients with type 2 diabetes. J Clin Endocrinol Metab 2008;93:2479-85.  Back to cited text no. 16
    
17.
Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009;360:129-39.  Back to cited text no. 17
    
18.
Maciejewski ML, Arterburn DE, Van Scoyoc L, Smith VA, Yancy WS Jr., Weidenbacher HJ, et al. Bariatric surgery and long-term durability of weight loss. JAMA Surg 2016;151:1046-55.  Back to cited text no. 18
    
19.
Sjöström L, Peltonen M, Jacobson P, Ahlin S, Andersson-Assarsson J, Anveden Å, et al. Association of bariatric surgery with long-term remission of type 2 diabetes and with microvascular and macrovascular complications. JAMA 2014;311:2297-304.  Back to cited text no. 19
    
20.
Brunaldi VO, Jirapinyo P, de Moura DT, Okazaki O, Bernardo WM, Galvão Neto M, et al. Endoscopic treatment of weight regain following roux-en-Y gastric bypass: A systematic review and meta-analysis. Obes Surg 2018;28:266-76.  Back to cited text no. 20
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
Print this article  Email this article
 

    

© 2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04