Gastric Bypass with Long Alimentary Limb or Long Pancreato-Biliary Limb—Long-Term Results on Weight Loss, Resolution of Co-morbidities and Metabolic Parameters

Abstract

BackgroundSeveral studies indicate that increasing the alimentary limb length in gastric bypass surgery produces only a minor improvement of excess BMI loss. Few studies have addressed the efficacy of increasing the length of the pancreatico-biliary limb.MethodsHere, we present a prospective randomized study of 187 consecutive laparoscopic Roux-Y gastric bypass operations operated over 2 years (2004–2005) in Iceland. The patients were operated with a gastric bypass with either a 2-m biliopancreatic (BP)-limb and a 60-cm alimentary (A)-limb (n = 93) or with a 150-cm A-limb and a 60-cm BP-limb (n = 94).ResultsPreoperative median BMI was 44.1 (38–70), median age 35.5 (17–74) years, and 85 % of the patients were female. Follow-up rate after 5 years was 85 %. Eighteen months following surgery, the weight loss was significantly higher in the BP-limb group (p < 0.001), and this difference remained 7 years after surgery. Weight regain occurred in both groups, and 7 years after surgery, excess BMI loss (EBMIL) was 78.4 % in the BP-limb group compared to 67.1 % in the A-limb group (p < 0.001). Most patients (78 %) needed supplementation adjustment (iron, vitamin D and calcium) during the study period, significantly more often in the BP-limb group compared to the A-limb group (p < 0.001). Patients in the BP-limb group had more frequent stools than patients in the A-limb group; otherwise, gastro-intestinal symptoms rating scoring were comparable. Complication rate was similar.ConclusionsGastric bypass with a 2-m BP-limb gives better weight loss than gastric bypass with a 60-cm BP-limb and a 150-cm A-limb. Metabolic follow-up is of utmost importance, as most patients needed repeated adjustments of their supplementation.

Intestinal Calcium Absorption Decreases Dramatically After Gastric Bypass Surgery Despite Optimization of Vitamin D Status

“…If the most proximal aspect of the jejunum (just distal to the ligament of Treitz) is critical for Ca absorption, and if biliopancreatic limb length is longer at our institution, a potential result could be lower postoperative FCA in our cohort. In fact, a very long biliopancreatic limb (200 cm, much longer than that performed at our institution) has been associated with more secondary hyperparathyroidism than a 60‐cm limb …”

Detailed characterization of incretin cell distribution along the human small intestine

“…Diabetes remission rate varies with the type of surgical procedure, ranging from 48% after purely restrictive procedures to 95% after malabsorptive procedures, and 84% after mixed procedures, such as RYGB [19]. In addition, diabetes remission rates observed in patients undergoing RYGB variations using long biliopancreatic limbs, compared with the classic procedure, have been reported to be greater than those previously described [18][19][20]37,38].…”

Mucosal glucagon-like peptide-1 and glucose-dependent insulinotropic polypeptide cell numbers in the super-obese human foregut after gastric bypass

“…Beneficial effects on overall mortality [1], cancer incidence [2], and quality of life [3] have been established. More advanced obesity, super-obesity (body mass index 450), is difficult to treat successfully, because a standard RYGB normally causes loss of only about 14-16 body mass index units [4,5]. Therefore, attention has been given to the effect of lengthening the alimentary limb [6] or the biliopancreatic limb (BP-limb) [5].…”

“…More advanced obesity, super-obesity (body mass index 450), is difficult to treat successfully, because a standard RYGB normally causes loss of only about 14-16 body mass index units [4,5]. Therefore, attention has been given to the effect of lengthening the alimentary limb [6] or the biliopancreatic limb (BP-limb) [5]. However, the mechanisms at play for weight loss remain to be elucidated.…”