Guest guest Posted February 3, 2003 Report Share Posted February 3, 2003 This was posted on the Protein and Vitamin lists. Thought it might be of interest to some of those not on those lists. ********************************* LONG-TERM FOLLOW-UP OF PATIENTS STATUS POST-GASTRIC BYPASS FOR OBESITY E. 1,2, M.D., L. Lancaster, B.A.1, A. Burgard, B.A.1, L. Howell, M.D.3, Dean D. Krahn, M.D.4, Ross D. Crosby, Ph.D. 1,2, A. Wonderlich, Ph.D. 1,2, Blake A. Gosnell, Ph.D. 1,2 1Neuropsychiatric Research Institute, Fargo, North Dakota 2Department of Neuroscience, University of North Dakota School of Medicine and Health Sciences, Fargo, North Dakota 3Department of Surgery, MeritCare Health Systems, Fargo, North Dakota 4Department of Psychiatry, University of Wisconsin School of Medicine Madison, Wisconsin Corresponding Author: E. , M.D. Neuropsychiatric Research Institute 700 1st Avenue South, P.O. Box 1415, Fargo, ND 58107 RUNNING HEAD: FOLLOW-UP OF GASTRIC BYPASS PATIENTS ABSTRACT Objective: This article reports a long-term (13-15 year) follow-up of a cohort of 100 patients who underwent gastric bypass for obesity. Method: Sources of information include baseline data collected prior to surgery and information obtained at follow-up interview including data on weight history, psychosocial functioning, and medical complications. Results: Mean age at follow-up was 56.8 years. The mean weight loss at long-term follow-up was 65 pounds with a range of –30 to 206 pounds. Three subjects weighed more at long-term follow-up than prior to surgery. Overall, 74% of those interviewed indicated that the gastric bypass procedure had benefited them in terms of their physical health. However, 68.8% reported continued problems with vomiting and 42.7% with " plugging " . Eight had died. Discussion: The findings in this study suggest that at long-term follow-up the majority of individuals who have undergone gastric bypass for the treatment of obesity feel the procedure benefited them, although some complications including difficulties with " plugging " and vomiting were present at long-term follow-up. Over the last few decades gastric bypass procedures have become a commonly accepted surgical treatment for the morbidly obese1. Gastric bypass has shown to be reasonably well tolerated, to significantly modify risk factors associated with the medical complications of obesity, and to result in ongoing improvement in psychosocial functioning despite some tendency toward regain of weight2. A number of follow-up studies on samples of patients undergoing such procedures have been published. Relatively short term (e.g., > 18 months)3, 2 as well as longer term (e.g., 5 years4; 7 years5, 6; 10 years7) studies suggest evidence of lasting improvement in health status, although some studies suggest problems in this regard7, and complications, including late complications8, are possible9, 10, 11, 12. Given the growing prevalence of obesity worldwide, and the increasing evidence linking obesity to a variety of adverse medical complications, we were interested in examining the long-term outcome of a cohort of individuals all of whom had undergone gastric bypass for obesity. To our knowledge, this represents the longest term study (13-15 years) of its type, and was done to gather data in preparation for a prospective study of a cohort of such individuals. In particular, we were interested in examining further the observation by Hsu, Sullivan & Benotti13 and Hsu et al14 that symptoms of binge-eating disorder pre- and post-surgery may be associated with greater weight regain. Methods Procedures All subjects had undergone a standard gastric bypass roux-en-y with a 100-125 cm. roux limb. Two applications of the TA 90 B stapler were used to create a small 20-30 cc. stomach pouch. The upper anastamoses were hand sewn to be 12-14 mm. in diameter. A single circumfrential O-Deklene suture was used to try to prevent long-term enlargement of the upper anastamoses. Subjects were initially sent a letter describing the study and what participation would entail along with a consent form. Informed consent was obtained verbally over the telephone by the research coordinator, and those subjects who were interested were scheduled for an interview time. All interviews were conducted by the research coordinator by phone. Because of the fact that we were quite concerned that those who had initially declined interview (n = 16) might have the worst outcome and that this might bias our results, we asked the Institutional Review Boards involved for permission to recontact the initial refusers and offer them a larger financial incentive. Subjects had initially been offered $15, and those who initially declined interview but recontacted were offered $100. Eight then agreed to interview, but of interest did not seem to have a worse outcome than those initially interviewed. Instruments The interviews, which took approximately one hour, consisted of four interviews/questionnaires regarding weight and eating history, general health status and medical history, and psychopathology. The instruments used included the following: a) The M-FED15 is an interview designed to collect longitudinal data during follow-up assessments on eating behaviors and psychopathology. The SF-3616 is a questionnaire designed to assess current health status and quality of life. c) The AUDIT17 is a questionnaire used to assess current alcohol use. d) MeritCare Long Term Post-operative Questionnaire for Gastric Bypass Patients: This interview/questionnaire was developed by one of the authors (MH) to assess health status and medical history in gastric bypass patients. Results Subjects Seventy (70) subjects initially agreed to be interviewed, 16 refused, 8 were deceased, and 6 were not located. Among those 16 initially refusing to participate, 8 agreed to participate when recontacted, bringing the total number of subjects interviewed to 78. Of those interviewed, 36 (46.2%) were 13 years post-surgery, 33 (42.3%) were 14 years post-surgery, and 9 (11.5%) were 15 post- surgery. The mean age at the time of follow-up were 56.8 years with a range of 31-77. Thirteen (17%) were male and 65 (83%) were female. Weight Loss Based on medical records, the mean BMI pre-surgery was 43.8 (range 32.1 – 57.2). Based on patient self-report, mean BMI at maximum weight loss post-surgery was 25.9 (range 18.4 – 38.0), and at time of follow-up 32.8 (range 22.7 – 49.5). The range for maximum weight loss was 43 – 206 lbs., with a mean of 109.5 lbs. Relative to baseline pre-surgery weight, the weight loss range at long-term follow-up was a mean of 66.3 lbs. with a range of –30 lbs. to 206 lbs. Three subjects weighed more at follow-up than prior to surgery (one by 30 lbs., one by 10 lbs., and one by 2 lbs.). Health Status Relative to gastrointestinal related problems, a number of patients reported the following symptoms: involuntary vomiting (n=52; 68.8%), " plugging " (n=32; 42.7%), " heartburn " (n=33; 42.9%), and diarrhea (n=24; 31.6%). We define " plugging " as the patient's subjective experience of ingested food becoming lodged in the small pouch created by the surgery, with back pressure into the esophagus. Patients generally describe pressure, spasm and/or pain in the mid- chest. This usually results from the ingestion of certain foods, such as dry meat, fibrous vegetables, pasta or bread. We find that the stomach will frequently " unplug " on its own, or if the patient regurgitates the food. Rarely, upper-GI endoscopy is necessary. Usually patients learn to chew their food at length to avoid this complication. Despite the high prevalence of vomiting, few subjects were concerned about it or cited it as a significant adverse outcome. Overall, 54 (69.2%) have been hospitalized for any reason since the surgery, 24 (30.8%) were hypertensive and 11 (14.1%) indicated they had been diagnosed with heart problems. Also, 5 (6.4%) had diabetes mellitus, but none were using insulin. Overall, relative to global health status, 54 (74%) responded positively to the question " Has the gastric bypass operation helped you with your physical health? " , and 59 (75.6%) responded positively to the question " Has the operation helped you with your mental outlook? " . Our contacts revealed that 8 subjects had died. Two died of what could be considered psychiatric related conditions (one suicide by carbon monoxide poisoning, and one death from a gastrointestinal bleed associated with severe cirrhosis and alcoholism), and 4 died of medical illnesses (amyotrophic lateral sclerosis, chronic obstructive pulmonary disease, gram negative sepsis, and coronary artery disease). We were unable to obtain death certificates on 2 subjects. Binge Eating Status Binge eating status was determined by the M-FED15, a semi- structured interview that includes questions operationalizing DSM- IV18 criteria for binge-eating and binge-eating disorder. By retrospective report, nearly half of the subjects 38 (49%) have met criteria for binge eating disorder prior to the surgery. In Table 1, criteria for BED prior to and subsequent to surgery, as well as use of various types of other behaviors before and post-surgery (at any time point), are summarized. As can be seen, the criterion for " a large amount of food " is included. Only 5 (6.4%) subjects met the complete BED criteria, but if this criterion is eliminated (in an attempt to address the mechanical inability of some patients to consume large amounts of food after the procedure), 9 (12%) met BED criteria. As can be seen in Table 2, fear of gaining weight, dissatisfaction with shape and weight, and influence of weight and shape on self-perception seemed to be decreased at follow-up relative to baseline. Data on the subjects who were non-BED pre-surgery (n = 40), BED pre- surgery but not post-surgery surgery (n = 29), and BED both pre- and post-surgery surgery (n = 9) (excluding the " large amount of food " criterion, given the mechanical constraints against it) are shown in Figure 1. Groups did not differ significantly on pre-surgical BMI (F = 1.40, df = 2.75, p = .252). An ANCOVA was conducted, comparing lowest BMI among the 3 BED groups, controlling for pre-surgery BMI. No significant differences were obtained among the 3 groups (F = 3.01, df = 2.73, p = .055), although the difference approached significance. However, ANCOVAs comparing follow-up BMI among the 3 groups revealed significant differences when controlled for either baseline BMI (F = 6.96, df = 2.74, p = .002) or lowest BMI (F = 4.08, df = 2.73, p = .04). Post hoc comparisons recorded greater weight regain for those in the third group (p < .05). This indicates that those who resumed binge-eating post-surgery were likely to regain more weight. Psychopathology All subjects were also interviewed using the M-FED which attempts to establish DSM-IV18 based psychopathology using sections of the SCID and the EDE. These data are summarized in Table 3. At follow-up 23, (29%) reported an episode of major depression post- surgery. Of some interest, 19 (24.4%) reported having specific phobias, but the rate for phobia was also quite high prior to surgery. Most of these cases were claustrophobia. Discussion These patients were not re-examined 13-15 years post-op for possible stable line failure or enlargement of the upper anastamoses, which, if present, could account for excessive weight regain in some of these patients. This study suggests that at long term follow-up, the majority of individuals who have undergone gastric bypass for treatment for obesity feel that the procedure benefited them in terms of their physical health and their " mental outlook " . Despite this, many still reported a number of GI related problems, including episodic vomiting in approximately two-thirds, and diarrhea, heartburn, and " plugging " in a third or more. Most denied that the GI sequellae were a major concern. Therefore, most of the subjects clearly have learned to live with these problems. Of note, Powers et al19 have previously reported a high prevalence of vomiting (33%) at follow-up (mean of 5 years) post-bariatric surgery. Of interest, the majority of individuals who met criteria for binge eating disorder did not meet such criteria at long term follow-up, even if the criterion for eating a large amount of food is excluded. It is of note that hunger perception changes with gastric bypass, which may be involved in this finding20. Those who did redevelop problems with BED symptoms after the procedure tended to regain more weight. This has been reported previously by Hsu et al14, which suggests that counseling to avoid the reestablishment of binge eating behavior post-surgery in those with a history of BED may be useful. Although the rates of psychopathology were significant, the prevalences do not seem to be grossly elevated compared to rates in the general population, including the rate of depression, given the rates of other problems in this population. The results of this study can be interpreted to indicate that although careful education about possible complications, particularly gastrointestinal complications, appear indicated for individuals who are candidates for gastric bypass, approximately three quarters of such patients will do well overall in terms of physical and psychiatric outcome. The strengths of the current study include the sample size, the fact that we were able to obtain data on 78% of the initial sample, and that the surgery for all the subjects was performed by the same surgeon (MH) in the same facility. Limitations include the fact that information available at baseline was very limited. This was a retrospective study and the validity of data obtained when subjects attempt to remember detailed information about what transpired 13-15 years or more before the interview must be assumed to have significant inaccuracies. Also, although three quarters of those who were contacted and interviewed appeared to be doing well, 8 had died, 8 refused interview, and 6 were unfindable. It is reasonable to assume that in addition to those that were deceased, the outcome among these 14 may have been less positive. REFERENCES 1. Balsiger BM, Murr MM, Poggio JL, et al. Bariatric Surgery: Surgery for weight control in patients with morbid obesity. Med Clin North Am 2000; 84: 477-489. 2. Delin CR, Watts JM, & Bassett DL. An exploration of the outcomes of gastric bypass surgery for morbid obesity: Patient characteristics and indeces of success. Obes Surg 1995; 5: 159-170. 2. Kolanowski J. Surgical treatment for morbid obesity. Br Med Bull 1997; 53: 433-444. 3. Choban PS, Onyejekwe J, Burge JC, & Flancbaum L. A health status assessment of the impact of weight loss following Roux-en-Y gastric bypass for clinically severe obesity. J Am Coll Surg 1999; 188: 491-497. 4. L, Malone M, Michalek A, et al. Gastric bypass and vertical banded gastroplasty: A prospective randomized comparison and 5-year follow-up. Obes Surg 1995; 5: 55-60. 5. Avinoah E, Ovnat A, & Charuzi I. Nutritional status seven years after Roux-en-Y gastric bypass surgery. Surgery 1992; 111: 137- 149. 6. SC, Goodman GN, & CB. Roux-en-Y gastric bypass: A 7-year retrospective review of 3,855 patients. Obes Surg 1995; 5: 314-318. 7. Wolfel R, Gunther K, Rumenapf G, et al. Weight reduction after gastric bypass and horizontal gastroplasty for morbid obesity. Results after 10 years. Eur J Surg 1994; 160: 219-225. 8. Sapala JA, Wood MH, Sapala MA, et al. Marginal ulcer after gastric bypass: A prospective 3-year study of 173 patients. Obes Surg 1998; 8: 505-516. 9. Alvarez-Cordero R & Aragon-Viruette E. Post-operative complications in a series of gastric bypass patients. Obes Surg 1992; 2: 87-89. 10. MacLean LD, Rhode Bm, Nohr C, et al. Stomal ulcer after gastric bypass. J Am Coll Surg 1997; 185: 1-7. 11. Grace DM, Alfieri MA, Leung FY. Alcohol and poor compliance as factors in Wernicke's encephalopathy diagnosed 13 years after gastric bypass. Can J Surg 1998; 41: 389-392. 12. Mason EE. Starvation injury after gastric reduction for obesity. World J Surg 1998; 22: 1002-1007. 13. Hsu LK, Sullivan SP, & Benotti PN. Eating disturbances and outcome of gastric bypass surgery: A pilot study. Int J Eat Dis 1997; 21: 385-390. 14. Hsu LK, Benotti PN, Dwyer J, et al. Non-surgical factors that influence the outcome of bariatric surgery: A review. Psychosom Med 1998; 60: 338-346. 15. Agras WS, Crow SJ, Halmi KA, et al. Outcome predictors for the cognitive behavior treatment of bulimia nervosa: Data from a multisite study. Am J Psychiatry 2000; 157: 1302-1308. 16. Ware JE, Gandek B, & the IQOLA Project Group. The SF-36 Health Survey: Development and use in mental health research and the IQOLA Project. Int J Ment Health 1994; 23: 49-73. 17. Babor TF, De La Fuente JR, Saunders J, et al. The Alcohol Use Disorders Identification Test: Guidelines for use in primary health care. WHO Publication No. 89.4, Geneva 1989: World Health Organization. 18. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association, 1994. 19. Powers PS, A, Boyd F, et al. Eating pathology before and after bariatric surgery: A prospective study. Int J Eat Dis 1999; 25: 293-300. 20. Delin CR, Watts JM, Saebel J, et al. Eating behavior and the experience of hunger following gastric bypass surgery for morbid obesity. Obes Surg 1997; 7: 405-413. Table 1. Criteria for BED Variable Before After Eat large amounts of food 74.4% (n = 58) 6.4% (n = 5) Feeling out of control 61.5% (n = 48) 15.4% (n = 12) Eating more rapidly 65.4% (n = 51) 26.9% (n = 21) Eating until uncomfortable 73.1% (n = 57) 25.6% (n = 20) Eating large amount/not hungry 74.4% (n = 58) 23.1% (n = 18) Eat alone/embarrassment 33.3% (n = 26) 2.6% (n = 2) Felt disgusted, depressed, guilty 55.1% (n = 43) 17.9% (n = 14) BED Criteria 49% (n = 38) 12% (n = 9) Table 2. Weight and Shape Issues Variable Before After Fear of gaining weight 89.7% (n = 70) 57.7% (n = 45) Dissatisfied with weight or shape 98.7% (n = 76) 70.5% (n = 55) Weight/shape influence self-perception 92.3% (n = 72) 51.3% (n = 48) Table 3. Major Areas of Psychopathology Variable Before After Major Depression 16.7% (n = 13) 29.5% (n = 23) General Anxiety Disorder 2.6% (n = 2) 6.5% (n = 5) Panic Disorder 1.3% (n = 1) 10.3% (n = 8) Manic Depression 0% 1.3% (n = 1) Specific Phobia 21.8% (n = 17) 24.4% (n = 19) Social Phobia 9.0% (n = 7) 6.4% (n = 5) Agoraphobia 5.1% (n = 4) 22.6% (n = 2) OCD 1.3% (n = 1) 3.8% (n = 3) Schizophrenia 0% 0% Somatization 0% 0% Anti-Social Personality 0% 0% Alcohol Abuse 2.6% (n = 2) 5.1% (n = 4) Alcohol Dependence 10.3% (n = 8) 2.6% (n = 2) Drug Abuse 3.8% (n = 3) 1.3% (n = 1) Figure 1 Body mass index (BMI) in subjects categorized as having never binged (n = 40 (39 in the " lowest " condition)), binged pre-surgery only (n = 29), or binged pre- and post-surgery (n = 9). The BMI of the latter group was significantly different from the " never binged " and the " binged pre-surgery " groups when the data were controlled for either baseline BMI or lowest BMI (* p < 0.05). 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