Bariatric surgery in 1119 patients with preoperative body mass index<35 (kg/m2): results at 1 year

doi:10.1016/j.soard.2015.03.012

Surgery for Obesity and Related Diseases

Volume 11, Issue 5, September–October 2015, Pages 1127-1132

https://doi.org/10.1016/j.soard.2015.03.012 Get rights and content

Abstract

Background

The use of body mass index (BMI) as the only criterion to indicate bariatric surgery is currently under discussion. There is growing evidence that supports bariatric surgery in carefully selected patients with lower BMI.

Objectives

To report our experience in bariatric surgery in>1000 patients with BMI<35 kg/m² and their results at 1 year.

Setting

University hospital (censored).

Methods

A retrospective analysis was performed in patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (SG) with preoperative BMI<35 kg/m² from January 2008 to December 2011. Demographic and anthropometric data, preoperative co-morbidities, and perioperative variables were retrieved. Weight loss and co-morbidities progression were analyzed 1 year after surgery and compared among procedures. A P value<.05 was considered significant.

Results

We identified 1119 patients: mean age 38.8±11.4, 951 (85%) women, preoperative weight 87.5±9.3 kg and BMI 33.1 (31.9–34.1) kg/m². Preoperatively, 11.7% had type 2 diabetes mellitus, 25.9% arterial hypertension, 55.6% insulin resistance, and 53.2% dyslipidemia. In total, 283 patients (25.2%) underwent LRYGB and 836 (74.8%) SG. One year after surgery (follow-up: 66.67%) patients reached 24.5 (22.8–26.4) BMI and the percentage of excess of weight loss (%EWL) was 107.9±36.6%. Diabetes, hypertension, insulin resistance, and dyslipidemia remission/improvement rates were 54/39%, 58/29%, 72/17%, and 54/30%, respectively.

Conclusions

Bariatric surgery in selected class I obesity patients can safely be performed. We have observed good results in terms of weight loss and co-morbidity improvement/remission. Long-term follow-up is required.

Section snippets

Study design

We conducted a retrospective analysis of our electronic bariatric surgery database, including all patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or sleeve gastrectomy (SG) as primary procedures in our institution, between January 2008 and December 2011 with preoperative BMI<35 kg/m². All these patients were assessed by a multidisciplinary team, including nutriologists, psychologists, nutritionists, physiotherapists, and surgeons, to determine if there were candidates. All

Results

We identified 1119 patients who underwent LRYGB or SG with BMI<35 kg/m². Mean age was 38.8±11.4 years, and 951 (85.0%) were women. Preoperative weight and BMI were 87.5±9.3 kg and 33.1 (31.9–34.1) kg/m², respectively (Table 1). Table 2 shows preoperative co-morbidities, the most common being insulin resistance (55.6%), dyslipidemia (53.2%), arterial hypertension (aHT, 25.9%), hypothyroidism (21.7%), osteoarticular disease (19.3%), and T2DM (11.7%).

Among these patients, 283 (25.1%) underwent

Discussion

It is widely accepted that bariatric surgery is the most effective treatment against obesity. As stated before, NIH consensus criteria [12] are currently under revision [18] in the light of promising results of bariatric surgery in nonseverely-obese patients with metabolic disturbances. Body adiposity, rather than BMI, is the main determinant of metabolic disturbances and mortality [19]. The World Health Organization defines obesity as an “excessive fat accumulation that may impair health” [20]

Conclusion

Bariatric surgery has been found to be beneficial in patients with BMI<35 kg/m² in terms of weight loss and control of co-morbidities, achieving improvement/remission rates of 92.5% in T2DM, 87.7% in hypertension, 84% in dyslipidemia, and 89.3% in insulin resistance, with a low rate of complications. It should be considered as a therapeutic alternative in this group of patients whenever they have failed an appropriate nonsurgical treatment and are followed by a multidisciplinary team.

Disclosures

None of the authors have any conflict of interest disclosures to make.

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Cited by (26)

National usage of bariatric surgery for class I obesity: an analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program
2023, Surgery for Obesity and Related Diseases
National and international consensus statements, as well as the National Institutes of Health (NIH), support the use of bariatric surgery for the treatment of class I obesity. Despite this, most payors within the United States limit reimbursement to the outdated 1991 NIH guidelines or a similar adaptation.
This study aimed to determine the safety of bariatric surgery in patients with lower BMI compared with standard patients, as well as determine U.S. utilization of bariatric surgery in class I obesity in 2015–2019.
A retrospective analysis was performed of the 2015–2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database.
Laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass patients were divided into body mass index cohorts: class I obesity (<35 kg/m²) and severe obesity (≥35 kg/m²). Differences in preoperative patient selection and postoperative outcomes were established, and frequency trends were delineated.
Analysis included 760,192 surgeries with 8129 (1%) for patients with class I obesity. The patients with class I obesity were older, more commonly female, and with lower American Society of Anesthesiologists (ASA) class, but with higher rates of type 2 diabetes, hyperlipidemia, and gastroesophageal reflux disease (P < .05). Variation was found for operative time, length of stay, 30-day readmission, and composite morbidity. Minimal annual variation was found for bariatric surgeries performed for patients with class I obesity.
The short-term safety of bariatric surgery in patients with class I obesity was corroborated by this study. Despite consensus statements and robust support, rates of bariatric surgery in patients with class I obesity have failed to increase and remain limited to 1%. This demonstrates the impact of the outdated 1991 NIH guidelines regarding access to care for these potentially life-saving surgeries.
Does Abrupt Weight Loss Caused by Bariatric Surgery Compromise the Voice in Women?
2023, Journal of Voice
Citation Excerpt :
All other exams showed normal mucosal wave. Our results confirmed the effectiveness of bariatric surgery in abrupt weight loss and, consequently, a considerable reduction in BMI, with an average 35% loss after 12 months as compared to the initial value, as also pointed by other authors.1,7,10 Weight loss also reduced abdominal and neck circumference.
To evaluate vocal symptoms, voice characteristics and videolaryngoscopy in obese women before and after bariatric surgery.
Obese patients (18 to 59 years old), candidates for bariatric surgery were recruited. Evaluation times: T1 (preoperative), T2 (after six months), T3 (after 12 months). Evaluated parameters: weight, height, body mass index, abdominal and neck circumference, vocal self-assessment, perceptual and acoustic vocal assessment, and videolaryngoscopy.
A total of 37 obese women were included, average age 40.8 years. There was a decrease in anthropometric measurements between the preoperative assessment and after 12 months: weight (121.18 ± 15.4 kg; 77.1 ± 11.6 kg), BMI (46.6 ± 6.95 kg/m²; 30 ± kg/m²), abdominal circumference (128 ± 16.1; 99.1 ± 12.1), and neck circumference (41.1 ± 5.85; 36.6 ± 3.02). Gastroesophageal (21.6%) and vocal symptoms (27%) prevailed. No difference was identified in vocal self-assessment between the evaluations. In the acoustic analysis, f0 increased and the soft phonation index decreased. The perceptual analysis registered lower scores for the degree of dysphonia (G) and voice instability (I). The maximum phonation time values increased without changing the s/z ratio. Videolaryngoscopies showed a posterior middle cleft and improvement in the signs of reflux.
Bariatric surgery led to an important and gradual decrease in anthropometric parameters. The voice became less hoarse, with higher pitch and more stable, with an improvement in maximum phonation time, however with slight breathiness. Such changes were not noticed by the patients.
Real-world retrospective analysis of outcomes in patients undergoing bariatric surgery with class 1 obesity
2022, Surgery for Obesity and Related Diseases
Citation Excerpt :
From the patients with follow-up (66.7%), patients reached mean BMI of 24.5 kg/m2 (22.8–26.4 kg/m2). In addition, rates of diabetes, hypertension, insulin resistance, and dyslipidemia improvements were 39%, 29%, 17%, and 30%, respectively [21]. Murad et al. [22] prospectively examined 102 RYGB patients with 2 years’ follow-up.
NIH-established indications for bariatric surgery were set close to 3 decades ago.
The purpose of this study was to evaluate outcomes in patients undergoing bariatric surgery with class I obesity, a class that does not fall into current indications.
University Hospital.
De-identified records from a clinic system’s Electronic Health Record database were accessed to identify adult patients undergoing Roux-en-Y gastric bypass (RYGB) (n = 566) and sleeve gastrectomy (SG) (n = 730). Patients were compared in terms of resolution of co-morbidities and weight loss outcomes at 3 years following surgery. A mixed effects model was used, adjusting for the type of surgery, the number of quarters after the surgery when the averaged measurements were taken, and the interaction between these two variables.
Patients lost up to 20% of their initial body mass index (BMI). Being of younger age, female, and having an obesity-related co-morbidity were associated with greater weight loss. At around 2 years after the surgery, the likelihood of being in remission from type 2 diabetes reached 45%. Remission probabilities for hypertension are 60% for RYGB and 50% for SG, 3 years after the surgery. On the other hand, the probabilities of remission from hyperlipidemia are close to 50% and 25% for RYGB and SG at 2 years. There was no difference between the BMI trajectories and remission from type 2 diabetes (T2D) when comparing the 2 groups.
Bariatric surgery is effective in weight loss and resolution of comorbidities in patients with class I obesity. This data further supports the need to revisit the current indication criteria.
Sleeve gastrectomy in class 1 obesity: Assessment of operative outcomes
2021, Surgery for Obesity and Related Diseases
Citation Excerpt :
The gallstone-related morbidity reported here is therefore surely an underestimate; some may have been missed and some may yet occur. Our experience was similar to the experience of Maiz et al. [10], who diagnosed new onset of cholelithiasis in 6.4% of 836 consecutive SGs at short term, or Noun et al. [11], who reported a 3.1% rate of post-SG cholecystectomy for de novo symptomatic cholelithiasis within the first postoperative year in 541 consecutive SGs. No previous data on UDCA usage after SG in patients with class 1 obesity are available.
The risk/benefit ratio of sleeve gastrectomy (SG), especially in patients without type 2 diabetes (T2D), is unknown for patients with class 1 obesity.
Assessment of operative outcomes of SG in class 1 obesity.
Private practice.
Candidates for a primary SG with body mass index 30–35 kg/m² after 5 years of unsuccessful dieting were included after informed consent was obtained. Participants who did not complete 3-month follow-up and those who underwent modified SGs were excluded. Data and complications were recorded prospectively. Patients were followed up at 3, 6, and 12 months and yearly thereafter. Definition of presence and remission of T2D and insulin resistance were set according to guidelines. Effects on weight loss parameters were evaluated with Wilcoxon signed-rank test.
Between 2012 and 2020, 143 consecutive SGs were performed in patients with class 1 obesity without conversion, leak, mortality, or a venous event. Two were lost to follow-up. In 141 participants, 2 bleedings and 1 colon perforation occurred (2.1% rate for acute life-threatening events). During a mean follow-up of 25.9 months; 1 case of functional stenosis and 4 cases of de novo symptomatic cholelithiasis clinically became evident in different patients, all requiring reoperation. Therefore a 5.6% rate of major complications were identified at 2 years. The benefit on weight loss was immediate and permanent (P < .001). T2D and insulin resistance were in remission in 100% and 98.1% of participants at 1 year, respectively.
The 5.6% major complication rate reflects a minimum because more de novo symptomatic gallstones and stenosis are yet to occur or overlooked. Additionally, this excludes patients with de novo reflux and malnutrition, dissatisfaction issues, or recidivism. Caution is required to freely operate on patients with class 1 obesity with no co-morbidity. Evidence-based outcome data are lacking to balance the reported risks.
Evaluating the safety of bariatric surgery for weight loss in class I obesity: A propensity-matched analysis of North American data
2019, Surgery for Obesity and Related Diseases
Bariatric surgery is an effective treatment for severe obesity. However, there has been an evolving role for bariatric surgery as a primary treatment in the management of class I obesity.
We aimed to assess the safety of surgery by directly comparing surgical outcomes of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in class I obesity (body mass index [BMI] 30–35 kg/m²) with those with class II obesity (BMI 35–40 kg/m²) and higher (BMI >40 kg/m²) using an analysis of a large-scale matched-patient cohort analysis.
Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, United States and Canada.
We performed a retrospective analysis using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database, which collects patient information from >790 bariatric surgery centers in North America. Patients included in our analysis underwent surgery in the years 2015 and 2016 and had either LRYGB or LSG for weight loss.
Initial analysis included 274,091 patients. Propensity-matching resulted in 9104 patients for analysis in each of the class I and class II and higher groups. The overall major complication rate between the 2 matched groups was 3.9% for class I and 3.5% for class II and higher (P = .11). We did not find that class I obesity was associated with an increased risk of 30-day complication or death.
In our analysis of propensity-matched patients undergoing LSG and LRYGB for weight loss, class I obesity did not have statistically higher risk of postoperative complication rates compared with class II and higher.
ASMBS updated position statement on bariatric surgery in class I obesity (BMI 30–35 kg/m <sup>2</sup> )
2018, Surgery for Obesity and Related Diseases

View all citing articles on Scopus

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Original articleBariatric surgery in 1119 patients with preoperative body mass index<35 (kg/m2): results at 1 year

Abstract

Background

Objectives

Setting

Methods

Results

Conclusions

Section snippets

Study design

Results

Discussion

Conclusion

Disclosures

Lancet

Prevalence of childhood and adult obesity in the United States, 2011-2012

JAMA

Obesity as a medical problem

Nature

The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis

BMC Public Health

Obesity and health-related quality of life: a cross-sectional analysis of the US population

Int J Obes Relat Metab Disord J Int Assoc Study Obes

Overweight, obesity, and mortality in a large prospective cohort of persons 50 to 71 years old

N Engl J Med

Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis

JAMA

Bariatric surgery: a systematic review and meta-analysis

JAMA

The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003-2012

JAMA Surg

Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel

Ann Intern Med

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

Original article
Bariatric surgery in 1119 patients with preoperative body mass index<35 (kg/m²): results at 1 year