Tag Archive for: Obesity

Bariatric surgery substantially reduces the risk of diabetes (AlphaGalileo, 18 September 2012)

19 Sep 2012

Bariatric surgery substantially reduces the risk of diabetes (AlphaGalileo, 18 September 2012)

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Further results from the Swedish Obese Subjects study published in The New England Journal of Medicine demonstrate rates of diabetes in a 15-year follow-up of obese people undergoing bariatric surgery vs. those undergoing traditional care and lifestyle changes.

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By Nancy Walsh, Staff Writer, MedPage Today

Published: September 18, 2012

Reviewed by Dori F. Zaleznik, MD; Associate Clinical Professor of Medicine, Harvard Medical School, Boston and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Action Points

  • Explain that a long-running Swedish study found that overall hospitalizations did not decrease in patients undergoing bariatric surgery compared with controls, primarily because of increased hospital use during the first 6 years after the procedure.
  • Note, however, that drug use, especially for diabetes and cardiovascular disease, decreased for those who had the surgery compared with controls, and weight loss was sustained over the 20-year follow-up period.

Obese patients who underwent bariatric surgery had greater healthcare utilization during the first years after the procedure, but this leveled off over time and medication costs eventually were significantly lower than for patients who had not had the surgery, a Swedish study found.

During the first 6 years postsurgery, patients spent an annual mean of 1.7 days in the hospital compared with 1.2 days among controls, for an adjusted difference of 0.5 (95% CI 0.2 to 0.7, P<0.001) days, according to Martin Neovius, PhD, of the Karolinska Institute in Stockholm, and colleagues.

However, between years 7 and 20, surgery patients and controls both had an annual 1.8 in-hospital days (P=0.95), the researchers reported in the Sept. 19 Journal of the American Medical Association.

Drug costs were lower among the surgery group during this same period, however. Between years 7 and 20, the mean annual drug price tag for the surgery patients was $930, compared with $1,123 for controls (adjusted difference ?$228, 95% CI ?335 to ?121, P<0.001).

In particular, drug costs were lower for cardiovascular and diabetes treatments, “reflecting the effects of bariatric surgery on diabetes remission, diabetes prevention, and cardiovascular disease events,” the researchers noted.

Many benefits have been established for bariatric surgery among obese individuals, including reductions in rates of cardiovascular disease and diabetes, as well as decreased mortality.

Nonetheless, the long-term effects on healthcare utilization have not been established, so Neovius and colleagues examined data from the Swedish Obese Subjects study, which included 2,010 patients who had bariatric surgery and 2,037 matched controls who were given interventions such as behavior modification and lifestyle guidance.

Available data included hospitalizations beginning 4 years before the surgery through 20 years postsurgery, outpatient visits (other than primary care) between postsurgery years 2 through 20, and drug expenditures between years 7 and 20.

At baseline, patients who had the surgery were heavier and younger and more likely to smoke and have diabetes.

In almost 70% of the surgical patients, the procedure used was vertical-banded gastroplasty.

After 10 years, those who had surgery had lost 17% of their body weight. At years 15 and 20, their weight loss was maintained at 16% and 18%, respectively.

In contrast, controls gained 1% of their body weight by year 10, and lost 1% at years 15 and 20.

During the overall 20-year follow-up, the surgery group accrued 54 total hospital days compared with 40 days among controls, for an adjusted difference of 15 days (95% CI 2 to 27, P=0.03).

A year-by-year analysis determined that the greatest difference in days spent in the hospital among surgery patients was during the first year, at 9.4 versus 0.9 for controls, giving an adjusted difference of 8.4 (95% CI 7.8 to 9.1, P<0.001) days, the researchers reported.

However, the differences declined in the subsequent years, though remaining significant, to 1 (95% CI 0.6 to 1.4, P<0.001) during the second year, 0.4 (95% CI 0.1 to 0.7, P=0.02) during the third year, and 0.5 (95% CI 0.1 to 0.9, P=0.02) in the fourth year.

By the fifth year, differences in in-hospital days no longer were seen.

These increased hospitalizations in the surgery group most likely related to the need for surgical revisions and management of complications, as well as for gallstones and anemia, according to the researchers.

For nonprimary care outpatient visits, the surgery group again had more usage between years 2 and 6, with an adjusted mean difference of 0.3 (95% CI 0.1 to 0.4, P=0.003) visits.

Beginning in year 7, however, no differences were seen (adjusted mean difference ?0.2, 95% CI ?0.4 to 0.1, P=0.12).

The researchers conceded that an overall reduction in healthcare usage was not seen in the study.

Despite the benefits of surgery on chronic disease, “translating these benefits into reduced healthcare resource use may not be evident for many years because these diseases take many years before they become problematic,” they explained.

Limitations of the study included a lack of randomization, no information on primary care outpatient visits, and changes in surgical procedures since the early years of enrollment in the cohort.

Support for this study and for the Swedish Obese Subjects study was provided by the Swedish Medical Research Council, the Swedish Research Council, the Swedish Foundation for Strategic Research, the Swedish government, and from Hoffmann-La Roche, AstraZeneca, Cederroth, sanofi-aventis, and Johnson & Johnson.

Several of the authors reported receiving support from companies including sanofi-aventis, Johnson & Johnson, Merck, Novo Nordisk, Hoffmann-LaRoche, Abbott, and Allergan.

From the American Heart Association:

Primary source: Journal of the American Medical Association
Source reference:
Neovius M, et al “Health care use during 20 years following bariatric surgery” JAMA 2012; 308: 1132-1141.

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Outcomes of Revisional Procedures for Insufficient Weight Loss or Weight Regain After Roux-En-Y Gastric Bypass

Background  

The Roux-en-Y gastric bypass (RYGB) performed laparoscopically (LRYGB) is the most frequently performed bariatric procedure in Belgium. However, late results in terms of weight loss or weight regain are inconsistent and may warrant a second procedure. This retrospective study analyzes the laparoscopic options for revisional surgery after LRYGB.

Methods  

Between January 1, 2001 and December 31, 2009, 70 patients underwent a new laparoscopic procedure for poor weight loss or weight regain after LRYGB. The revisional procedure was performed a median of 2.6 years after the initial bypass operation. Fifty-eight patients were available for follow-up (82.9 %); 19 underwent distalization; and 39 a new restrictive procedure.

Results  

The mean mass index (BMI) before the revisional procedure was 39.1?+?11.3 kg/m2 (30.8–51.8), down from 42.7?+?19.7 kg/m2 (33.0–56.6) initially, which corresponded to a percentage of excess weight loss (EWL) of 12.4?+?9.3 % (?1.0–29.1). After the corrective procedure, with a follow-up of approximately 4 years, mean BMI was 29.6?+?12.4 kg/m2 (18.0–45.5), for a significant additional percentage of EWL of 53.7?+?9.8 % (2.0–65.8). The overall complication rate was 20.7 %, and the reoperation rate was 7.3 %. The overall leak rate was 12.1 %. Patients suffering from leaks could consistently be treated conservatively or by stent placement. Two patients needed reconversion after distal bypass. The satisfaction index was good in just over 50 % of the patients.

Conclusion  

Revisional laparoscopic surgery after RYGB performed for weight issues provides good additional weight loss but carries significant morbidity. Leaks can usually be handled non-surgically. Patient satisfaction is only fair.

Keywords  Laparoscopic Roux-en-Y gastric bypass – Revisional surgery – Weight regain – Insufficient weight loss – Complications

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