Revision Rates Dim Enthusiasm for Roux-en-Y : The high rates suggest that the distal procedure is a poor first-line treatment for morbid obesity.

LAS VEGAS — Distal Roux-en-Y gastric bypass surgery led to excellent long-term weight loss in superobese and morbidly obese individuals, but researchers found a high incidence of protein-calorie malnutrition requiring revision, in a study of 49 patients.

Calling the revision rate “unacceptable,” Dr. John M. Kellum said the distal procedure “should not be the primary operation for morbid or superobesity.”

Data on long-term outcomes in American patients who have undergone distal gastric bypass are limited. Dr. Kellum and his colleagues at Virginia Commonwealth University in Richmond evaluated the long-term weight loss and metabolic outcomes of 49 individuals who underwent the procedure from 1985 to 1989 with follow-up of up to 24 years.

Of the 49 patients, 43 were classified as superobese (a body mass index greater than 50 kg/m

All procedures were performed using celiotomy and included a Roux-en-Y gastric bypass with a 30- to 50-mL proximal gastric pouch (stapled in continuity), a biliopancreatic limb extending from the ligament of Treitz to 250 cm from the ileocecal junction, and a common channel of 50-150 cm, Dr. Kellum explained. “It should be noted that, by 1988, surgeons were no longer doing 50-cm common channels because of the unacceptably high incidence of protein-calorie malnutrition,” he said.

One patient died perioperatively of a massive pulmonary embolus. Of the remaining 48 patients, 21 underwent limb-lengthening revisions for protein-calorie malnutrition that was not improved by intermittent total parenteral nutrition (TPN), including 13 of the 23 patients with 50-cm common channels and 8 of the 25 patients with common channels greater than 100 cm, Dr. Kellum said, noting that revision rate difference between the two groups was statistically significant.

Of the 27 patients who did not undergo limb-lengthening revisions, 2 required hospitalization (including 1 who received TPN for 30 days) and 6 received intestinal tube feedings at home. Eight late deaths, from 6 to 19 years after surgery, occurred in this group, Dr. Kellum noted.

For 19 of the 27 patients who did not need revision surgery, more than 5 years of follow-up data showed “excellent long-term weight loss,” with a median BMI of 34.2 at 10 years, said Dr. Kellum. However, the mean levels of serum albumin (3.6 g/dL), iron (24.4 U/dL), and 25-OH vitamin D (14.6 ng/mL) were “unacceptably low.” Because of the small number of patients, the resolution of comorbidities over the long term couldn't be determined, he noted.

Compared in a nonrandomized fashion with the long-term outcomes of a similar group of patients who underwent long-limb gastric bypass starting in 1992, “there was superior weight loss but also a statistically higher incidence of iron deficiency anemia in the distal bypass group, and the rates of [decreased] albumin approached significance by the Student's t-test and reached significance using the Wright subtest,” Dr. Kellum said (Ann. Surg. 1992;215:387-95). “Because of the albumin levels, serum calcium was also significantly lower in the distal bypass group.”

Based on the findings, Dr. Kellum said, “this particular form of distal gastric bypass should not be used as a primary bariatric surgery for morbid or superobesity because of the high revision rate and the high incidence of late metabolic morbidity. Distal Roux-en-Y gastric bypass should be reserved for those patients who have failed conventional proximal gastric bypass [and] who continue to have life-threatening medical conditions.”

Dr. Robert E. Brolin of New Jersey Bariatrics in Plainsboro, who served as the discussant, complimented Dr. Kellum “for reporting what can be perceived as negative results, so similar experiences are not repeated by other surgeons.”

Dr. Brolin also asked Dr. Kellum if malabsorption—achieved either through a shorter biliopancreatic limb or the duodenal switch, which has a larger stomach capacity but similar malabsorptive characteristics to the procedure described—has any role in terms of long-term weight-loss maintenance in severe clinical obesity.

“I still don't think malabsorption should ever be the initial operation,” Dr. Kellum replied. “I believe patients should be followed carefully by dietitians and should maintain regular exercise programs. Doing so leaves some responsibility on the patients rather than depending on the length of the common channel.”

Dr. Kellum reported having no relevant financial conflicts. He noted that one of the study coauthors, Dr. Harvey Sugerman, is editor in chief of Surgery for Obesity and Related Diseases, the journal of the American Society for Metabolic annual meeting of theand Bariatric Surgery.

LAS VEGAS — Distal Roux-en-Y gastric bypass surgery led to excellent long-term weight loss in superobese and morbidly obese individuals, but researchers found a high incidence of protein-calorie malnutrition requiring revision, in a study of 49 patients.

Calling the revision rate “unacceptable,” Dr. John M. Kellum said the distal procedure “should not be the primary operation for morbid or superobesity.”

Data on long-term outcomes in American patients who have undergone distal gastric bypass are limited. Dr. Kellum and his colleagues at Virginia Commonwealth University in Richmond evaluated the long-term weight loss and metabolic outcomes of 49 individuals who underwent the procedure from 1985 to 1989 with follow-up of up to 24 years.

Of the 49 patients, 43 were classified as superobese (a body mass index greater than 50 kg/m

All procedures were performed using celiotomy and included a Roux-en-Y gastric bypass with a 30- to 50-mL proximal gastric pouch (stapled in continuity), a biliopancreatic limb extending from the ligament of Treitz to 250 cm from the ileocecal junction, and a common channel of 50-150 cm, Dr. Kellum explained. “It should be noted that, by 1988, surgeons were no longer doing 50-cm common channels because of the unacceptably high incidence of protein-calorie malnutrition,” he said.

One patient died perioperatively of a massive pulmonary embolus. Of the remaining 48 patients, 21 underwent limb-lengthening revisions for protein-calorie malnutrition that was not improved by intermittent total parenteral nutrition (TPN), including 13 of the 23 patients with 50-cm common channels and 8 of the 25 patients with common channels greater than 100 cm, Dr. Kellum said, noting that revision rate difference between the two groups was statistically significant.

Of the 27 patients who did not undergo limb-lengthening revisions, 2 required hospitalization (including 1 who received TPN for 30 days) and 6 received intestinal tube feedings at home. Eight late deaths, from 6 to 19 years after surgery, occurred in this group, Dr. Kellum noted.

For 19 of the 27 patients who did not need revision surgery, more than 5 years of follow-up data showed “excellent long-term weight loss,” with a median BMI of 34.2 at 10 years, said Dr. Kellum. However, the mean levels of serum albumin (3.6 g/dL), iron (24.4 U/dL), and 25-OH vitamin D (14.6 ng/mL) were “unacceptably low.” Because of the small number of patients, the resolution of comorbidities over the long term couldn't be determined, he noted.

Compared in a nonrandomized fashion with the long-term outcomes of a similar group of patients who underwent long-limb gastric bypass starting in 1992, “there was superior weight loss but also a statistically higher incidence of iron deficiency anemia in the distal bypass group, and the rates of [decreased] albumin approached significance by the Student's t-test and reached significance using the Wright subtest,” Dr. Kellum said (Ann. Surg. 1992;215:387-95). “Because of the albumin levels, serum calcium was also significantly lower in the distal bypass group.”

Based on the findings, Dr. Kellum said, “this particular form of distal gastric bypass should not be used as a primary bariatric surgery for morbid or superobesity because of the high revision rate and the high incidence of late metabolic morbidity. Distal Roux-en-Y gastric bypass should be reserved for those patients who have failed conventional proximal gastric bypass [and] who continue to have life-threatening medical conditions.”

Dr. Robert E. Brolin of New Jersey Bariatrics in Plainsboro, who served as the discussant, complimented Dr. Kellum “for reporting what can be perceived as negative results, so similar experiences are not repeated by other surgeons.”

Dr. Brolin also asked Dr. Kellum if malabsorption—achieved either through a shorter biliopancreatic limb or the duodenal switch, which has a larger stomach capacity but similar malabsorptive characteristics to the procedure described—has any role in terms of long-term weight-loss maintenance in severe clinical obesity.

“I still don't think malabsorption should ever be the initial operation,” Dr. Kellum replied. “I believe patients should be followed carefully by dietitians and should maintain regular exercise programs. Doing so leaves some responsibility on the patients rather than depending on the length of the common channel.”

Dr. Kellum reported having no relevant financial conflicts. He noted that one of the study coauthors, Dr. Harvey Sugerman, is editor in chief of Surgery for Obesity and Related Diseases, the journal of the American Society for Metabolic annual meeting of theand Bariatric Surgery.

LAS VEGAS — Distal Roux-en-Y gastric bypass surgery led to excellent long-term weight loss in superobese and morbidly obese individuals, but researchers found a high incidence of protein-calorie malnutrition requiring revision, in a study of 49 patients.

Calling the revision rate “unacceptable,” Dr. John M. Kellum said the distal procedure “should not be the primary operation for morbid or superobesity.”

Data on long-term outcomes in American patients who have undergone distal gastric bypass are limited. Dr. Kellum and his colleagues at Virginia Commonwealth University in Richmond evaluated the long-term weight loss and metabolic outcomes of 49 individuals who underwent the procedure from 1985 to 1989 with follow-up of up to 24 years.

Of the 49 patients, 43 were classified as superobese (a body mass index greater than 50 kg/m

All procedures were performed using celiotomy and included a Roux-en-Y gastric bypass with a 30- to 50-mL proximal gastric pouch (stapled in continuity), a biliopancreatic limb extending from the ligament of Treitz to 250 cm from the ileocecal junction, and a common channel of 50-150 cm, Dr. Kellum explained. “It should be noted that, by 1988, surgeons were no longer doing 50-cm common channels because of the unacceptably high incidence of protein-calorie malnutrition,” he said.

One patient died perioperatively of a massive pulmonary embolus. Of the remaining 48 patients, 21 underwent limb-lengthening revisions for protein-calorie malnutrition that was not improved by intermittent total parenteral nutrition (TPN), including 13 of the 23 patients with 50-cm common channels and 8 of the 25 patients with common channels greater than 100 cm, Dr. Kellum said, noting that revision rate difference between the two groups was statistically significant.

Of the 27 patients who did not undergo limb-lengthening revisions, 2 required hospitalization (including 1 who received TPN for 30 days) and 6 received intestinal tube feedings at home. Eight late deaths, from 6 to 19 years after surgery, occurred in this group, Dr. Kellum noted.

For 19 of the 27 patients who did not need revision surgery, more than 5 years of follow-up data showed “excellent long-term weight loss,” with a median BMI of 34.2 at 10 years, said Dr. Kellum. However, the mean levels of serum albumin (3.6 g/dL), iron (24.4 U/dL), and 25-OH vitamin D (14.6 ng/mL) were “unacceptably low.” Because of the small number of patients, the resolution of comorbidities over the long term couldn't be determined, he noted.

Compared in a nonrandomized fashion with the long-term outcomes of a similar group of patients who underwent long-limb gastric bypass starting in 1992, “there was superior weight loss but also a statistically higher incidence of iron deficiency anemia in the distal bypass group, and the rates of [decreased] albumin approached significance by the Student's t-test and reached significance using the Wright subtest,” Dr. Kellum said (Ann. Surg. 1992;215:387-95). “Because of the albumin levels, serum calcium was also significantly lower in the distal bypass group.”

Based on the findings, Dr. Kellum said, “this particular form of distal gastric bypass should not be used as a primary bariatric surgery for morbid or superobesity because of the high revision rate and the high incidence of late metabolic morbidity. Distal Roux-en-Y gastric bypass should be reserved for those patients who have failed conventional proximal gastric bypass [and] who continue to have life-threatening medical conditions.”

Dr. Robert E. Brolin of New Jersey Bariatrics in Plainsboro, who served as the discussant, complimented Dr. Kellum “for reporting what can be perceived as negative results, so similar experiences are not repeated by other surgeons.”

Dr. Brolin also asked Dr. Kellum if malabsorption—achieved either through a shorter biliopancreatic limb or the duodenal switch, which has a larger stomach capacity but similar malabsorptive characteristics to the procedure described—has any role in terms of long-term weight-loss maintenance in severe clinical obesity.

“I still don't think malabsorption should ever be the initial operation,” Dr. Kellum replied. “I believe patients should be followed carefully by dietitians and should maintain regular exercise programs. Doing so leaves some responsibility on the patients rather than depending on the length of the common channel.”

Dr. Kellum reported having no relevant financial conflicts. He noted that one of the study coauthors, Dr. Harvey Sugerman, is editor in chief of Surgery for Obesity and Related Diseases, the journal of the American Society for Metabolic annual meeting of theand Bariatric Surgery.