J J Lara, L Murray, R Carter, R Stuart, M E J Lean
Departments of Human Nutrition and Surgery, University of Glasgow
Correspondence to: Professor Michael E.J. Lean, Department of Human Nutrition, University of Glasgow, Glasgow Royal Infirmary, Glasgow G31 2ER Tel 0141 2114686 / Fax 0141 2114844 E mail: Lean@clinmed.ac.uk
SMJ 2005 50(2): 58-60
Abstract
Aims: This study assessed the patterns of weight change in response to surgical treatment for obesity. Methods: Vertical Banded Gastroplication (VBG) was performed during the period 1994-2000. Patients were required to follow a liquid diet (800 kcals) for 12 weeks before surgery. The same diet plus a multivitamin capsule (Forceval) was followed for 12 weeks postoperatively, after which normal foods were introduced. Data from 23 patients, 16 women and 7 men, aged 33-63 years (mean, SD; 42±8yrs), with BMI from 38 to 69 kg/m2 (52.5±8.1 kg/m2) at the time of the surgery were available for analysis. Follow up was 3 to 7 years (mean 4 years). Results: An initial weight loss of 44.4 ± 24.3 kg (min 11.5, max 110.5 kg) was reached during the first two years (mean BMI decrease 15.8 kg/m2). However a regain in weight (36% of the initial weight loss = 5.6 kg/m2) up to 3 to 7 years after surgery was usual. Average annual regain was 13.6 kg (n=17), 9.45 kg (n=11) and 0.8 kg (n=8) during the 3rd, 4th and 5th year after surgery). Five participants reached a BMI below 30 but only one, BMI<25, has maintained all the weight loss after 5 years. Conclusions: Weight loss following VBG ceased after two years with a subsequent substantial weight regain. Auxiliary therapies to counteract weight regain are necessary after VBG.
Introduction
The development of both effective therapeutic and preventive measures is critical to counteract the expansion of obesity worldwide.1 Within the diverse treatment approaches, surgery is often recommended as the treatment of choice for people with a BMI >40 or for those with lower BMI (e.g. 35) whose life is threatened by obesity-related complications. In the short and medium term surgery results in a rapid and important weight loss; however in the long-term results vary between specific surgical procedures.
Since its introduction2 Vertical Banded Gastroplication (gastroplasty) (VBG), a restrictive procedure, has been widely recommended3 although gastric bypass is now becoming more favoured.4 Long term results on weight loss, and weight maintenance, after VBG are sparse and variable.5,6 The aim of the present study was to document the success rate in weight loss and weight maintenance, and its effects on blood pressure and lipids, in unselected subjects after VBG in Glasgow, Scotland within the past 10 years.
Methodology
An audit of patients undergoing surgical treatment in Glasgow, Scotland was undertaken to assess changes in body weight and weight maintenance afterwards. Changes in lipids and blood pressure were also investigated. The Glasgow Royal Infirmary Research Ethics Committee granted ethical approval for this study.
Surgery
A Vertical Banded Gastroplication (VBG) was performed during the period 1994-2000. The surgical procedure originally described by Mason2 was employed. Briefly, a ~2.5cm in diameter circular window is created using a 25mm circular stapler through both walls of the anterior surface of the upper stomach; approximately eight to nine centimetres from the angle of His and just above the crow’s foot of Latarjet’s nerve and 3cm from the lesser curvature. Staples are applied up to the angle of His using a GIA80 linear stapler to create a small 20-50ml verticaloriented pouch with a narrow outlet which is reinforced by a 7 x 1.5cm strip of polypropylene mesh placed around the lesser curvature channel and sutured to itself resulting in a 5 to 5.5cm length collar. Patients were required to follow a liquid diet (800 kcals) for 12 weeks before surgery. The same diet plus a multivitamin capsule (Forceval) was followed for 12 weeks postoperatively, after which normal foods were introduced. Forceval treatment was continued as long as weight loss continued. It was planned that all patients would receive indefinite follow-up in a specialised human nutrition outpatient clinic.
Subjects
A total of 28 patients were identified with VBG over seven years previously. Not all continued to attend formal review. After exhaustive approaches to patients and their GPs to secure follow-up information, data were available for twentythree patients, 16 women and 7 men, aged 33-63 years and with a BMI from 38-69 kg/m2 at the time of the surgery (Table I). Weight loss data since time of surgery was gathered for every patient for a follow up duration 3- 7 years (mean 4 years).
Statistical analysis
Descriptive statistics, means ± SD, and proportions (%), were used to describe the patterns of weight change. All statistical comparisons were carried out with SPSS 9.0 for windows (SPSS Inc., Chicago, Ill, USA).
Results
Every patient lost weight within two years after surgery, but patterns of weight loss varied considerably. Figure 1 shows a plot of the individual cases. On average, initial weight loss two years after surgery was 44.4±24.3 kg (min 11.5, max 110.5kg) representing 30% of initial body weight (Figure 2); this weight loss represented a mean fall in BMI of 15.8kg/m2. Most of that weight loss occurred during the first year after surgery; mean ± SD 39.8±19.7kg representing 26.3% of initial body weight.
At the minimum post-operative weight, 74 % of the patients achieved a BMI < 40; 43.5% a BMI <35 and 21% a BMI <30. One patient achieved a normal BMI (18.5 to 24.9 kg/m2). Based on the last observation carried forward, only 26% of the patients remained with a BMI <40; only half of them (13%) remained with a BMI <35 and only one patient, who initially reached a BMI<25, has maintained all the weight loss so far (Figure 3).
After the second year weight loss ceased and substantial regain in weight up to three to seven years after surgery was observed. On average 36% of the initial weight loss, representing 5.6 kg/m2, was regained. Average annual regain was 13.6kg (n=17), 9.45kg (n=11) and 0.8kg (n=8) during the 3rd, 4th and 5th year after surgery (Figure 4). Incomplete information on clinical outcomes was obtained because of variable compliance with follow-up plans. There were no deaths, but complications of surgery, which required re-admission included vomiting (17.4%) and hernia (8.7%).
Table II shows the values for blood pressure (measured with a large cuff), glucose and lipids before the operation and at the within the last six months of performing this audit. A significant decrease in systolic blood pressure after weight loss was observed, however no significant differences were observed in the rest of the variables.
Discussion
This report presents the outcomes of an audit in obese patients undergoing surgical treatment for weight loss. Weight loss ceased after two years and substantial weight regain was common. Maximum weight loss, reached within two years after surgery, in the present study represented 29.3% of the initial body weight. However according to the last observation carried forward, five years after operation, that figure had dropped to 16.1% of the initial body weight.
These figures are very similar to those obtained after VBG in the Swedish Obese Study (SOS) of 25±8% loss at one year and 17% below preoperative level at five years after surgery.7 A weight loss of 21% at³10 years was reported by Balsiger et al.5 All these studies suggest that an ultimate plateau weight is reached about five years after VBG 16- 20% below the preoperative levels.
Improvements in metabolic and clinical factors are commonly reported after quite modest weight loss.3, 8-9 In the present study only blood pressure, showed a significant decrease after weight loss. It is important to notice that these comparisons involved pre-operative values with the most recent values. Therefore these comparisons might be influenced by the substantial weight loss many patients achieved prior to surgery by dietary means and the regain observed after the maximum weight loss was achieved. Insufficient data were available to establish any possible improvement on the metabolic and clinical variables at the time of maximum weight loss. Improvement in symptoms such as tiredness, breathlessness, musculo-skeletal pains, depression and profuse sweating are documented as common benefits from weight loss, but these were infrequently recorded. A lack of clinical information is common in retrospective audits and can only be improved by more systematic clinical practice.
In conclusion, surgical treatment of obesity seems a successful way to ensure substantial and rapid weight loss in very obese subjects; however significant weight regain is a common problem that requires from auxiliary counteracting therapies after VBG. The “plateau” weight following VBG seems to be 16-20% below pre-operative levels, which is similar to that achieved in responders to non-surgical treatments such as orlistat10 or sibutramine.11 More effective surgical interventions are now being assessed, but a randomised controlled trial against optimal nonsurgical approaches is clearly needed.
Quite modest weight loss (5-10%) is now considered the most appropriate target for most obesity treatments 3, 12 as this has been shown to bring about remarkably large clinical benefits.3, 8, 10-15 A relatively large amount of intra-abdominal fat is lost in the early phase.16 For patients with a BMI >40 or >50 for whom surgery is most often considered, the dominant clinical problem is often immobility for which much greater weight loss is needed. The present data give some insight into the power of appetite over motivation to lose and maintain body weight. The average preoperative weights of 177.2±30.4kg in men and 134.8±17.9kg in women indicate energy intakes of 4365±524 kcals/day in men and 2943±221 kcals/day in women.
The minimum weight after surgery would be maintained by a mean energy intake 3362±489 kcals/day in men, 2456±234 kcals/day in women. The final “plateau” weight loss of 16-20kg indicates that VBG leads to a reduction in food intake of only 376±433 kcals/day below the preoperative level. Additional treatment is clearly needed to combat appetite.
Note: Figs 2 and 3 are available from the authors.
ACKNOWLEDGEMENTS : Jose Lara was supported by CONACyT in Mexico
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