The nonsurgical treatment of severe obesity is a lifelong struggle with high recidivism and suffering.⁷ Whereas no one disputes the ability of morbidly obese patients to lose weight,⁸ the challenge is to maintain weight loss in the long term.^9–11 Such weight-loss maintenance is critical to achieving the beneficial effects of a reduced weight. Bariatric surgery is the only treatment modality that produces significant, sustained, long-term weight loss in patients with severe obesity.^12,13 In addition, permanent weight loss through bariatric surgery reduces the relative risk of death by 35% to 89%, depending on the study,^14–18 and produces significant pharmacoeconomic benefits.¹⁹

Since the first laparoscopic Roux-en-Y gastric bypass²⁰ (LRYGBP), the technique has rapidly evolved and currently represents the preferred surgical procedure for weight loss in North America. Since the Food and Drug Adinistration approval of the laparoscopic adjustable gastric banding device (LAGBD) in 2001 in the United States, the LAGBD method has been gaining popularity as an alternative bariatric procedure.²¹ The McGill University bariatric surgery program has performed all bariatric procedures with open laparotomy since 1963. Our minimally invasive bariatric surgery experience began on the Feb. 8, 2002, when we successfully completed our first laparoscopic gastric bypass. We added the LAGBD method shortly thereafter. To date, our unit has performed more than 1000 laparoscopic bariatric procedures. In this study, we aimed to assess our 5-year outcomes with LRYGBP and the LAGBD method.

We used a detailed patient questionnaire to obtain patient demographics and information about patients’ past attempts at weight loss, obesity-associated conditions, previous surgery and current medications, and we verified this information at the initial consultation. Initial body weight and height were measured in the office, and a BMI was calculated. Data on subsequent weight loss were obtained by direct measurement at our bariatric clinic or from the reports submitted by the patient’s physician. All subsequent complications and reoperations were recorded in our electronic registry. The percent excess-weight loss (%EWL) was calculated as 100% × ([W₀–W_i]/EW₀), where W₀ is the weight (kg) at the time of surgery, W_i is the weight (kg) at the last follow-up, and EW₀ is the excess weight at the time of surgery. We estimated excess weight according to the formula described by Deitel and Green-stein²³ and defined excess weight based on the Metropolitan tables for middle frame individuals.²⁴ We defined complications occurring within 30 days from the date of surgery as short-term complications, and those occurring after 30 days as long-term complications. We also determined the 90-day and long-term mortalities that could be related to the original bariatric surgery.

Our LRYGBP technique has been described elsewhere²⁵ and involves a 30–50 cm biliopancreatic limb and a 100-cm retrocolic, antegastric, alimentary limb. The surgeon constructs the jejunojejunal anastomosis side-to-side with a single firing of a linear endostapler, and hand sews the defect. The gastric pouch is small (1.5 × 5.0 cm) and vertically oriented, and the gastrojejunal anastomosis is hand sewn. The Petersen space and the transverse mesocolic defect are routinely closed with polypropelene sutures. We insert all the LAGBDs via the pars flaccida technique, and perform band adjustments in the office by direct puncture of the port. The first adjustment is performed 6 weeks after surgery and the subsequent adjustments according to the patient’s weight loss, satiety and gastrointestinal symptoms. Patients with insufficient weight loss are referred for dietician review. Upper gastrointestinal contrast studies are requested if a problem with the band is suspected clinically.

We provided all patients in our study with an operation-specific information kit outlining detailed postoperative diet plans and activity regimens. We encouraged all patients to wear an accelerometer (pedometer) and to maintain an activity level of at least 10 000 steps per day or the equivalent. They were given follow-up appointments at 14, 30, 90 and 180 days, and at 6–12 months thereafter. All attempts were made to achieve 100% follow-up.

Table 2 shows the follow-up rate at each time point, and the mean weight loss in kg, the mean BMI and the %EWL of the 2 groups. We have made every effort possible, given the limited bariatric clinic staff, to follow-up all our patients for life. This included follow-up phone calls and emails by our single bariatric nurse clinician and receptionist, communication with patients’ physicians, or, in desperate circumstances, asking the local police department for help in tracing the patients. Despite these efforts, we were unable to follow up one-third of our patients after 2–3 years. The main reasons were lack of patient adherence, patient relocation and loss of contact information. There was no statistical difference in the follow-up rates of the 2 cohorts. Patients in the LRYGBP group had more weight loss, lower BMI and %EWL at each time point. The nadir of weight loss occurred at 2 years with the LRYGBP group, with weight regain and stabilization subsequently. The LAGBD group showed continual weight loss up to 5 years, where partial data are available because some patients were lost to follow-up. The rate of loss to follow-up is similar between band and bypass patients. Figure 1 shows the %EWL of patients followed up at each time point up to 5 years. Patients in the LAGBD group who had their band removed were not included in the analysis from the time of band removal onward. The LRYGBP group shows significantly increased %EWL at each time point, averaging 15% greater than the LAGBD group. Figure 2 shows the %EWL within 25% cut-off points. The LRYGBP group demonstrated a significantly higher proportion of patients in the upper quartiles of excess-weight loss.

Table 3 lists the complications observed in this study. These are separated into short-term complications (within 30 d postsurgery) or long-term complications (occurring after 31 d postsurgery). The complications that led to re-operation are listed as well. Complications occurred in 35 (23.5%) of LAGBD cases and in 135 (15.2%) of the LRYGBP cohort (significantly fewer than in the LAGBD cohort, χ² = 4.17, p = 0.041). In the LAGBD cohort, ¹¹ (7.3%) short-term complications were observed, with none requiring reoperation. The 74 (8.4%) short-term complications in the LYRGBP cohort (χ² = 0.06, p = 0.86) required 22 reoperations and 10 percutaneous drainage interventions to treat them. There were 24 (16.1%) long-term complications in the LAGBD cohort. All but 1 required reoperation. These reoperations were all carried out laparoscopically, except for the port revisions that required change of the port under short-duration general anesthesia. In one band leak, the patient elected not to have this corrected and has retained his leaking band. There were 6 band erosions (4.0%), 3 band leaks (2.0%) and 4 band slippages (2.7%). The 7 patients who did not tolerate their bands and/or did not lose weight were included as patients with long-term complications because reoperation was performed to deal with the problem as identified by the patient. The 61 (6.8%) cases involving long-term complications in the LRYGBP cohort (significantly fewer than in the LAGBD cohort, χ² = 9.8, p = 0.002) required 27 (3.0%) reoperations to treat them. This included 3 perforations after endoscopic dilatation of strictures of the gastrojejunostomy. The remaining 30 endoscopic/radiologic dilatations of gastrojejunostomy strictures were successful without perforation. All but 1 reoperations in the LRYGBP cohort were carried out laparoscopically, with 1 conversion to laparotomy in the patient with jejunojejunal intrasusception.

There were no deaths in the LAGBD group. There were 3 deaths in the LRYGBP group, and these are listed in Table 4, along with the complications presumed to be the causes of death. The sequence number indicates the position of the particular patient in the order of performance of his or her operation, with 1 being the first case. The first female patient who died (sequence no. 45) developed a large liver laceration from aggressive manipulation of the liver retractor, which was controlled by packing. Deep vein thrombosis prophylaxis was withheld in the postoperative period, and the patient collapsed and died from a massive pulmonary embolus on the way out of the hospital on her day of discharge, 4 days after surgery. The male patient (sequence no. 507) with anastomotic leak developed shortness of breath on the first postoperative day; a myocardial infarction was suspected and he was transferred to the intensive care unit and treated for an infarct. He died 2 days later. At autopsy, a contained anastomotic leak was found, which we attributed as contributing to his death. Though the cause of death was listed as a myocardial infarction, we believe this patient succumbed from multiple organ failure secondary to his leak. The young female patient (sequence no. 662) who developed an anastomotic leak received prompt laparoscopic repair and drainage (within 36 h) but succumbed to unrelenting progressive organ failure within 76 hours of the original surgery despite aggressive critical care support (including activated protein C). This patient’s case is detailed elsewhere.²⁶ Fisher exact test analysis of the deaths within each surgery group shows p = 1.0, indicating that the type of surgery did not significantly influence mortality risk.

Our rate of band explantations is not different from those reported in the literature.^30,31 Some of the band complications such as the erosions, slips and leaks had to be treated with reoperation. The inclusion of band intolerance and/or inability to lose weight as a long-term complication is debatable. We feel that the availability of laparoscopic conversion of failed LAGBD to LRYGBP, unique to our program, accounts for the number of such conversions in our study. The bariatric team is less likely to diagnose or declare “band intolerance” if they have no capability to correct the problem with a back-up bariatric surgical procedure that can be performed by minimal invasive approaches. Our findings suggest that converting actual or perceived band failures to LRYGBP produces much better short-term results than revisions performed for perceived/actual failures (inability to lose the targeted weight) after gastric bypass. The revision of failed standard gastric bypass to distal gastric bypass did not produce the desired results. This is not surprising given our long-term follow-up of short versus long limb gastric bypass results.¹²

Weight loss greater than 50% of the excess weight³² or reduction of the BMI³³ to less than 35 kg/m² have been proposed as potential definitions of success of a bariatric surgical procedure. Our results suggest superiority in weight loss for LRYGBP versus the LAGBD method at all time intervals both as a mean of %EWL and by looking at individual groups of weight loss. At medium term (3 yr), 91% of the LRYGBP patients studied had achieved greater than 50% EWL compared with 62% in the LAGBD group. For the same period, mean %EWL for the LRYGBP group was 80% versus 59% for the LAGBD group. At every time point, the LRYGBP showed about 15% more %EWL than the LAGBD group. In assessing these results, it is important to take into consideration reoperation and reintervention rate. This was higher in the LAGBD group compared with the LRYGBP group, but the success rate of the revisional procedure from LAGBD to LRYGBP was much higher compared with the distal gastric bypass conversion of the RYGBP patients with insufficient weight loss. These results compare well to those reported by others.^34–36 Another consideration is the rate of patient follow-up in our study. Despite our best efforts with the limited resources available, we were not able to follow up about one-third of our patients after 3 years. At least 40% of our patients come from a distance (> 4-h commute from Montréal). Our efforts to reach all our patients are ongoing, and we have gone to extremes of having the provincial health authority (all patients must be registered in order to have access to health care) or the local police authorities (using their internal databases) send letters to our patients on our behalf encouraging them to contact us. Since the follow-up rate is comparable in the 2 cohorts, we feel that the results reflect a real difference in weight loss outcomes as reported here.

It is important for future studies to identify robust predictors of successful weight loss for the procedure that will be offered to patients, thus avoiding disappointment, financial expenses, impairment in quality of life, and potential morbidity. Other series have reported on limited weight loss success with the LAGBD procedure and low quality of life.^27,37–39 Our results are in keeping with pooled LAGBD series reporting 55% EWL at 5 years.^21,40–42 Our LRYGBP weight loss data are in agreement with published large series of LRYGBP manifesting an identical 5-year 83% EWL.^43,44 Our outcomes are similar to previous comparisons of the LAGBD procedure and LRYGBP in Europe⁴¹ and North America.^45,46 They are also similar to the only prospective randomized trial of LAGBD versus LRYGBP reporting outcomes at 5 years postsurgery.⁴⁷ This study comprised 51 patients, and all but 1 was followed up to 5 years. They found that, as in our study, the LRYGBP group had significantly better weight loss and a lower failure rate. Our 0.3% mortality is also within the reported 0.5% mortality rate as it has been verified from a large meta-analysis.⁴⁸ We had no deaths in the LAGBD group. Though this procedure is promoted as “less complex” and “safer” than gastric bypass, mortality of LAGBD varies from 0.04%, as recently reported by Watkins and colleagues,⁴⁹ up to 0.51%, as recently reported in a review by Gagner and colleagues.⁵⁰ Some may argue that the LRYGBP is a more “radical” procedure, fraught with increased mortality. Indeed, one website in Canada quotes a mortality range of 3%–40% after gastric bypass,⁵¹ which is unsubstantiated. Mortalities after gastric bypass can be reduced by eliminating technical factors such as gastrointestinal leaks. After the last patient death from a leak (sequence no. 662), we instituted a new protocol of pneumatic testing of the pouch after formation under water, and methylene blue distention of the pouch and the gastrojejunostomy upon completion, followed by a final pneumatic test of both and the jejunojejunostomy under water, and we have not seen a postoperative leak in the remaining patients (> 400 overall to date).

Inability to achieve the weight loss goal after bariatric surgery is difficult to correct. The options are conversion to biliopancreatic diversion with duodenal switch,⁵² adjustable gastric band over bypass⁵³ or distal gastric bypass (75–100 cm common channel). We have no experience with the first 2 revisions, as we converted all our LRYGBP patients who did not achieve adequate weight loss to laparoscopic distal gastric bypass with 100-cm common channel. Our results are not very encouraging and are in line with those reported by Brolin and Cody.⁵⁴ We do not feel that our poor results are likely to improve with more follow-up. We feel there is something unique to the small numbers of gastric bypass patients who do not achieve at least 50% EWL that we as yet do not understand. Converting patients who did not lose weight after LAGBD surgery to LRYGBP produced acceptable reductions in weight and is in keeping with the findings reported by others.^55–57 We have no experience with converting patients who were unsuccessfully treated with the LAGBD procedure to duodenal switch operations.⁵²