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Obesity Surgery, 15, 155-163

Background: While a great deal has been publishedregarding the short- and medium-term outcomes ofgastric bypass surgery, much less information isavailable regarding long-term follow-up. Such infor-mation would be valuable in changing attitudestowards this surgery.

Methods: 342 severely obese patients underwentgastric bypass between June 1990 and April 2003 bya single surgeon. Careful preoperative documenta-tion and follow-up have been maintained on a com-puterized database. Where necessary, recent follow-up information has been gained by mailed question-naire and blood tests.

Results: Follow-up data from within the last 12months is available for 88% of patients. Follow-uptime ranges from 0-14 years, with a median of 48.6months. Of those lost to follow-up, only 24 (7%) have<12 months follow-up. The series includes 261females and 81 males. Preoperative BMI ranged from28-99 (median 44). Before surgery, hypertension waspresent in 138, type 2 diabetes in 62, and dyslipidemiain 265. There was no 30-day peri-operative mortality.Three life-threatening complications occurred. BMIand % excess weight loss after 1, 2, 5 and 10 yearswere 28.7 and 89%, 28.3 and 87%, 31.2 and 70% and31 and 75%, respectively. At most recent follow-up,62% of those with hypertension before surgery werecured and 25% had improved. 85% of those with type2 diabetes were cured and 10% had improved. Nopatients with impaired glucose tolerance had pro-gressed to diabetes. 34% of those with dyslipidemiawere cured and 38% had improved.

Conclusion: The excellent outcomes, in terms ofweight loss and improvement in co-morbidities, seenin both the short- and medium-term after gastricbypass, are well maintained into the longer-term.

Key words: Gastric bypass, morbid obesity, long-term fol-low-up, weight loss, co-morbidities, hypertension, dia-betes, dyslipidemia, bariatric surgery

Introduction

Obesity is becoming a worldwide epidemic. It isparticularly visible in developed countries and isshowing no signs of abating. Populations appearhelpless to avoid or improve the problem. At a timewhen obesity is worsening in countries where it hasbeen an issue for many years, it is emerging as aproblem in other countries, where it was hithertoseldom seen. The increase in childhood obesity sug-gests the burden will pass to the coming generationswho are likely to be even heavier than their parents.The implications of a worsening worldwide epi-demic are immense.

Severe obesity is a biological, psychological andsocial disaster. The co-morbid conditions associatedwith obesity are chronic and ultimately life-threat-ening. Diabetes, hypertension, dyslipidemia, heartdisease, respiratory failure, joint degeneration andcancer have all been implicated with excessiveweight.1,2 Life expectancy and quality of life arereduced in the obese. For the community, the loss ofproductivity and the costs of health-care are signifi-cant and could become crippling.

Politicians, the creators of public health policyand medical professionals alike seem unable todetermine where efforts might best be focused.Primary prevention is a worthy goal, but the meansof achieving it remain elusive. Successful manage-ment of established obesity seems equally elusive,because the conventional approaches of dietaryrestriction and exercise programs are almost always

Research Articles

Long-Term Outcomes after Gastric Bypass

Sarah White, MBChB; Emma Brooks, RCpN, BN; Lydia Jurikova; RichardS. Stubbs, MD, FRACS

Wakefield Gastroenterology Centre, Wellington, New Zealand

Presented at the 9th World Congress of the InternationalFederation for the Surgery of Obesity, Tokyo, Japan, September8-11, 2004.

Reprint requests to: Mr. Richard Stubbs, WakefieldGastroenterology Centre, Private Bag 7909, Wellington, NewZealand. Fax: 0064 4 381 8111;e-mail: [email protected]

ineffective in achieving substantial long-termweight loss.3 Even the modern pharmacologicalapproaches, although encouraging, are unable toachieve a major impact on severe obesity.4 We areleft treating the numerous and difficult co-morbidi-ties of obesity, or end-stage disease.

Meanwhile, bariatric surgery has been evolvingover the past 50 years, and is becoming increasinglyaccepted in some countries by both the public andthe medical establishment as a legitimate solution tosevere obesity. Surgery can help individuals achievewhat is otherwise unattainable. Gastric bypassremains the operation of choice for both weight lossand reduction in co-morbidities. While there is nowabundant published literature supporting the short-and medium-term efficacy of gastric bypass sur-gery,5-8 long-term follow-up data remains relativelyscant.9

This report presents a single surgeon’s experiencewith gastric bypass over a 14-year period, with cur-rent follow-up in 88% of patients. It focuses on theoutcomes of weight loss and the improvement in themetabolic co-morbidities of hypertension, type 2diabetes and dyslipidemia.

Methods

A total of 342 consecutive patients underwent theirfirst bariatric operation at Wakefield Hospitalbetween June 1990 and April 2003. All surgery wasperformed by a single surgeon (RS). During thistime, two similar forms of gastric bypass, both ini-tially described by Fobi,10,11 were performed. Thefirst, which we have termed silastic ring Roux-en-Ygastric bypass (SRGBP), is shown in Figure 1A andhas been previously described in detail by ourgroup.12 The subsequent modification of this tech-nique, known as a Fobi pouch, is shown in Figure1B, and differs principally from SRGBP in that gas-tric transection is performed to overcome subse-quent staple-line disruption.

Fobi pouch was performed under general anesthe-sia with epidural analgesia, as follows. Through anupper midline incision, a window was producedadjacent to the lesser curvature of the stomach 9 cmfrom the angle of His, and a passage was createdfrom this point, behind the stomach, to the angle of

His. A TCT-10® linear stapler-cutter (Johnson &Johnson) was positioned between these two points,and its position was adjusted before firing, so as toproduce a blind lesser curvature gastric pouch 7-8cm in length and 1.5-2 cm in diameter. Firing of thestapler achieves gastric transection, with 2 rows ofstaples on either side. The staple-line on thebypassed stomach was oversewn with a continuous2/0 Ethibond suture. A 70-cm Roux-loop of jejunumwas fashioned, with the entero-entero anastomosisperformed with two layers of 2/0 chromic catgut ata convenient point 40-60 cm from the ligament ofTreitz. The Roux-loop was passed in a retrocolic,retrogastric fashion to lie alongside the newly cre-ated lesser curvature pouch, separating this from theoversewn distal stomach. The Roux-loop is suturedto the lesser curvature pouch, in two layers with 2/0polypropylene (Prolene®) in such a way as to createa serosal patch over a buried staple-line. A 6.0 cm(for age <50 years) or 6.5 cm (for age >50 years)length of 8F silastic rubber tubing was passed cir-cumferentially around the lesser curve pouch 5 cmfrom the angle of His, and defined the size of thepouch above the ring (approximately 10-15 ml).This was fixed in place with an internal 2/0 Prolenesuture. The Prolene sutures creating the serosalpatch above the ring were continued to a point 1-2cm beyond the silastic ring, at which point a 2-layerend-to-side gastro-jejunal anastomosis 1-1.5 cmlong was created, after removal of a portion of thestaple-line. The inner layer was fashioned with all-coats 2/0 chromic catgut, and the outer seromuscu-

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156 Obesity Surgery, 15, 2005

Figure 1. Diagramatic representation of (A) silastic ringgastric bypass (SRGBP) and (B) Fobi pouch operation.

A B

lar layer completed with 2/0 Prolene.Mesenteric defects were closed, and cholecystec-

tomy was performed if gallstones were present. Theupper abdominal cavity was lavaged with warmsaline and the abdomen was closed with a mass No.1 nylon suture. The subcutaneous fat layer was vig-orously lavaged with saline so as to dislodge allloose fat, and skin was closed with subcuticularVicryl® suture (Johnson and Johnson) and steri-strips. All patients received a single intra-operativedose of a prophylactic antibiotic (usually Cefotetan®

2 g), and were commenced on preoperativeClexane® (Aventis) 20 mg subcutaneously forDVT/PE prophylaxis. The latter was continueddaily after surgery, until discharge. Epidural analge-sia was continued postoperatively for 4 days.Urinary catheters were not employed and patientswere initially mobilized off the side of the bed 4hours postoperatively.

A prospective, computerized database has beenmaintained on all patients, including relevant preop-erative details of weight, height, BMI, % excessweight, existence of co-morbidities, operativedetails, complications and follow-up data. Patientswere seen or assessed postoperatively at 3-monthlyintervals for the first year, at 6-monthly intervals forthe second year, and annually thereafter. Detailedpreoperative blood tests included fasting lipid pro-files, HbA1c, fasting glucose in known diabeticsand glucose tolerance test in all other patients. Earlypostoperative complications were assessed clini-cally and entered into the database immediately fol-lowing discharge. Medium- and long-term compli-cations seen during follow-up included anastomoticstenosis, ulceration, staple-line disruption and inci-sional hernia.

Data collected during follow-up included weightand changes in co-morbidities. Blood tests takenbefore each follow-up visit included fasting lipids,fasting glucose, HbA1c, iron indices, serum and redcell folate, and vitamin B12 levels. All patients werecommenced on a multivitamin tablet at the firstpostoperative visit and recommended to remain onthis for life. Supplementation of Vitamin B12, folicacid and iron was given as indicated by blood tests.In the case of vitamin B12 and folic acid, supple-ments were maintained life-long once a deficiencyappeared. Where regular follow-up had been lost orinformation was lacking, this was gathered by a

phone call or mailed questionnaire, coupled withblood tests.

In patients who were stable at 2 years, follow-upevolved to a point where it was accomplished byannual questionnaire and a set of blood tests.Questionnaires covered such issues as currentweight, medications, new medical problems andalteration in eating habits. A laboratory request formfor a fasting blood test was sent out with each ques-tionnaire. Patients were reviewed in the Clinic, asand when problems arose.

Our primary focus in analyzing the data was tolook at weight loss and changes in metabolic co-morbidities. We were interested to determine howquickly the co-morbidities resolved and whetherthey remained so over time. Medium- and long-termcomplications following surgery were also impor-tant. These included the need for re-operation, suchas removal of the silastic ring, revision for staple-line disruption or other reason, adhesiolysis forbowel obstruction, cholecystectomy and repair ofincisional hernia. The need for nutritional supple-mentation following the gastric bypass was alsoassessed.

The co-morbidities of particular interest werehypertension, diabetes, and dyslipidemia.Hypertension was deemed to be present if patientswere taking antihypertensive medication or had adiastolic pressure in >90 mmHg. Diabetes wasdetermined by history or preoperative oral glucosetolerance test. Dyslipidemia was judged present ifone or more of the following abnormalities existedon fasting lipid profile: total cholesterol >5.0mmol/l (>195 mg/dl), triglycerides >2.0 mmol/l(>180 mg/dl), or total cholesterol/HDL cholesterol>4.5. Changes in co-morbidities were classified asfollows:Resolution: normalization of the co-morbidity with-out requirement for medication;Improvement: better control of the co-morbiditywith the same or reduced medication;No change: no evidence of resolution or improve-ment.

Staple-line disruption was suspected when therewas either substantial weight regain or a markedchange in eating capability. It was frequently asso-ciated with pain related to the presence of stomalulceration. Confirmation of the diagnosis was madeby either barium meal or gastroscopy.


Obesity Surgery, 15, 2005 157

All numerical data was expressed as median ±standard deviation with a range. Changes in lipidprofiles were analyzed using a paired Student t-test.A P-value <0.05 was considered as statistical sig-nificance. Weight loss is demonstrated by reductionin weight, BMI and the percentage of excess weightlost (%EWL). Excess weight was calculated bydetermining ideal body weight from the New YorkMetropolitan Life Insurance Tables (1983) and sub-tracting this from the preoperative weight.

Results

There were 81 males and 261 females, agedbetween 15 and 68 years at the time of surgery(median 43 years). Of these, 175 (51%) had anSRGBP and 167 (49%) had a Fobi pouch procedure.The latter were all performed after August 1997.Mean operating time (excluding anesthetic time)was 120 minutes (60-420 min) and blood loss was200 ml (100-4000 ml). Fifty-six patients (16%) hadcoincidental cholecystectomy for gallstones, and 2(0.6%) required splenectomy during the surgery forcontrol of bleeding.

Perioperative complications are outlined in Table1. There were no anastomotic leaks, but one patienthad peritonitis from a leak at the esophagogastricjunction presumed to be related to a “tear-through”of a suture placed at that point for the creation of theserosal patch over the staple-line. This patientrequired re-operation and drainage of an upperabdominal collection. Twenty-four patients sufferedrespiratory complications postoperatively, princi-pally atelectasis or infection. There was a single

case of pulmonary embolism, which presented 1month postoperatively. One patient with severeobstructive sleep apnea and obesity hypoventilationsyndrome presented a major management problemin the postoperative first 24 hours because of respi-ratory failure. Cardiac complications were seen in 5patients (congestive heart failure 2, atrial fibrillation3). There was no 30-day mortality, although 3 life-threatening complications (referred to above) didoccur. The median hospital stay was 7 days (3-43).

Of the total 342 patients, 260 (76%) have beenfollowed for >2 years and 133 (39%) for at least 5years. Follow-up data from within the last 12months is available for 88% of the patients. Themedian follow-up period is 48.6 months (0-164).Only one patient had no follow-up at all. At the timeof analysis, 5 patients were deceased, none for rea-sons related to gastric bypass surgery. Of those lostto follow-up, 22 (6.4%) were able to be located butdid not respond to either questionnaire or telephonecall, and the remaining 21 patients (6.4%) could notbe located.

Ninety-one patients (27%) underwent re-opera-tion, on 113 occasions, during which a total of 125different procedures were performed (Table 2). All25 revisions, and 16 of the 23 ring removals (70%)were performed on patients who underwent SRGBP.Only 26 patients (7%) who had a Fobi pouch proce-dure required further surgery. A total of 33 patientswho had SRGBP (19%) are known to have had par-tial staple-line disruption, of whom 25 have hadrevision surgery with gastric transection (i.e. con-version to Fobi pouch).

The following late complications were observed.Stomal ulceration developed in 22 patients (6%),usually in association with staple-line disruption orNSAID use. Anastomotic stenosis was seen in 12

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Table 1. Perioperative complications occurring in 342patients after gastric bypass

Complication Number

wound infection 38 (11%)peritonitis 1 (0.3%)respiratory complication 24 (7%)cardiac complication 5 (1%)urinary tract infection 4 (1%)deep venous thrombosis 2 (0.6%)intra-abdominal abscess 1 (0.3%)other 11 (3%)

Table 2. Nature of re-operations required in 91 patientsafter gastric bypass

Re-operation Number

ring removal 23 (7%)revision 25 (7%)bowel obstruction 2 (0.6%)incisional hernia 15 (4%)abdominoplasty 31 (9%)cholecystectomy 23 (7%)

patients (4%) and was resolved in all instances by aseries of balloon dilatations. An incisional herniadeveloped in 23 patients (7%), of whom 15 have hadthis repaired. Two episodes of ring erosion occurred,both in association with staple-line disruption andulceration. Removal of the silastic ring was under-taken in 23 patients (6.7%) because of major restric-tion to solid food. This was most often required forthose with the smaller diameter ring as shown in theTable 3. Cholecystectomy was necessary in 23patients (7%) during the follow-up period for symp-tomatic gallstones. This was undertaken and accom-plished laparoscopically in almost all instances.

Mean ± sd preoperative weight, BMI and %excess weight were 131.9 ± 33.5 kg (72-360), 46.2± 9.2 kg/m2 (28-99) and 92% (22-335) respectively.The operation produced excellent weight loss, withmaximum loss achieved after 18 months as shownin the Figure 2. There was good maintenance ofweight loss thereafter with mean ± sd %EWL at 1,2, 5, 10 and 14 years of 88.5 ± 40.5%, 87.1 ± 35.7%,69.9 ± 26.5%, 74.6 ± 55.2% and 58.5 ± 3.5% andmean ± sd BMI at 1, 2, 5, 10 and 14 years of 28.7 ±5.76, 28.3 ± 5.69, 31.2 ± 5.96, 31.0 ± 6.21 and 32.5± 0.7 kg/m2 (Figures 3 and 4). Not surprisingly, bet-ter weight loss was achieved and maintained inthose who did not experience staple-line disruptionor need silastic ring removal.

The outcomes of patients’ co-morbidities areshown in Table 4. Hypertension was present in 138patients before surgery, of whom follow-up is avail-able in 134. Following surgery, hypertensionresolved in 85 (62%), improved in 34 (25%),remained unchanged in 11 (8%) and became worsein 4 (3%). During the period of follow-up, hyper-tension recurred in 9 patients, none of whom hadhad significant weight regain.

Before surgery, 62 patients had type 2 diabetes: 27

were taking oral hypoglycemic agents, 18 were tak-ing insulin, 5 were “diet controlled” and 12 werediagnosed at the time of preoperative testing.Following surgery, 53 (85%) were completely curedof diabetes, determined by fasting blood glucose



Table 3. Requirement for ring removal related to ringsize

Size of ring Number Rings removed

no ring 2 -5.5 cm 66 10 (15%)6.0 cm 181 11 (6%)6.5 cm 92 2 (2%)7.0 cm 1 0 (0%)

0

20

40

60

80

100

120

140

0 2 4 6 8 10 12 14

Time post-op (years)

Bo

dy

wei

gh

t (k

g)

Figure 2. Graph showing median weight of 342 patientsbefore and after gastric bypass.

20

25

30

35

40

45

0 2 4 6 8 10 12 14


Bo

dy

Mas

s In

dex

Figure 3. Graph of median Body Mass Index (BMI) in 342patients before and after gastric bypass.

0

10

20

30

40

50

60

70

80

90

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14


% E

xces

s w

eig

ht

loss

Figure 4. Graph showing median % excess weight lossafter gastric bypass in 342 patients.

(mmol/l) and HbA1c (%) levels of 7.0 or lower. Twopatients had no follow-up blood results, 6 patientsshowed improved glycemic control, and a singlepatient had worse fasting blood glucose and HbA1clevels, despite satisfactory maintenance of weightloss. Of the 7 who remained diabetic, two requiredinsulin and two required oral medication, but in allinstances, at much reduced doses. Abnormal glu-cose tolerance was found in 66 patients before sur-gery; of these, none progressed to diabetes duringfollow-up, although 6 have been lost to long-termfollow-up.

Deranged lipids were present in 81% (265/327)before surgery. Of those identified as dyslipidemicpreoperatively, 73% had elevated cholesterol, 31%had elevated triglycerides and 54% had an elevatedcholesterol/HDL ratio. At last follow-up, hypercho-lesterolemia had resolved in 33% and improved inanother 34%. Hypertriglyceridemia had resolved in73% and improved in another 10%. Elevated cho-lesterol/HDL ratios reverted to normal in 74% andimproved in another 12%. Overall dyslipidemia wascompletely resolved postoperatively in 89 patients(34%), improved in 101 (38%), remainedunchanged in 19 (7%) and had deteriorated in 27(10%). Follow-up fasting lipid data was not able tobe obtained in 29 patients (11%), most of whom hadsurgery >10 years ago, at which time follow-up fast-ing lipid tests were not routinely being performed.

Vitamin B12 deficiency developed in 217 patients(63%) mostly within 2 years of surgery and requiredinstitution of regular vitamin B12 injections. Folatedeficiency developed in 159 (46%), requiring dailysupplementation, and iron supplementation wasrequired from time to time in 215 (63%).

At the time of each follow-up consultation orquestionnaire, patients were asked to indicate the

range of food that they were able to eat. This wascategorized as either “almost normal”, “minorrestriction” or “major restriction”. This informationwas not available for 6 patients, but in the remaining336, 221 (66%) described the range of food eaten as“almost normal” at the time of their most recent fol-low-up, 94 (28%) indicated they had “minor restric-tion”, and 21 (6%) declared a “major restriction”.

Patients were also asked for their overall satisfac-tion regarding the outcome of their surgery. Thiswas categorized as “pleased”, “neutral” or“unhappy”. Again, there was no data for 6 patients(the same 6 as above), but at the most recent follow-up, 282 (84%) were pleased, 32 (9.5%) felt neutral,and 22 (6.5%) were unhappy. Of the 22 patientswho were unhappy, 16 had undergone significantweight regain, and in 8 of these, staple-line disrup-tion had been confirmed. A further 3 patients wereunhappy because of complications related to sur-gery (2 incisional hernias and 1 who suffered ananastomotic leak at the time of revision surgery),and 2 had unacceptable eating difficulties despitering removal.

Discussion

Although there has been a wealth of documentationto show the occurrence and benefits of short- andmedium-term weight loss following gastric bypass,the long-term benefits are less well-documented. Theuse of a prospective database at our clinic since 1990,coupled with a very high rate of follow-up, allows usto analyze a moderately large group of patients out to14 years. The results support the use of gastric bypassin the severely obese, both for the achievement of

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Table 4. Changes in co-morbidities after gastric bypass

resolved improved unchanged worse unknown

Hypertension 62% 25% 8% 3% nilIGT 91% nil nil nil 9%Diabetes 85% 10% nil 2% 3%Dyslipidemia 34% 38% 7% 10% 11%

IGT = impaired glucose tolerance

long-term weight loss and resolution or improvementof important metabolic co-morbidities.

The goal for most patients who undergo bariatricsurgery is the achievement of substantial weightloss, with the objective being to improve quality oflife and the prospects of good health. The two mostcommonly employed operations today are laparo-scopic banding and gastric bypass. Both these oper-ations undoubtedly accomplish significant weightloss and improvement in co-morbidities.5-9,13-15

Gastric bypass is generally regarded as the gold stan-dard operation and is reported to achieve a greaterweight loss and with greater reliability. Most reportsof gastric bypass document mean %EWL of 65-75% after 2-5 years.5-9 This compares with mean%EWL of 50-60% at 5 years for laparoscopic band-ing.13-16 The present study indicates that weight lossafter gastric bypass, with the inclusion of a silasticring, is well maintained out to 14 years, and that theprincipal reason for weight regain in this group ofpatients is either staple-line disruption or ringremoval. While there is general accord amongstthose performing bariatric surgery that gastric tran-section is an important component of gastric bypass,there is less agreement that the placement of a ringaround the gastric pouch is important. Before theadoption of gastric transection at the WakefieldGastroenterology Centre, the staple-line was createdwith the TA90B stapler, which was probably themost reliable of the stapling devices used in this typeof surgery. Our finding of 19% staple-line disruptionto the present time is in line with other publishedaccounts17,18 and clearly indicates the advisability ofgastric transection. Although gastro-gastric fistulaehave been reported after gastric transection,19 wehave never seen this after a Fobi pouch procedure,which interposes the Roux-loop between the gastricstaple-lines, and indeed creates a serosal patch overthe staple-line of the gastric pouch. This would seemto provide an additional measure of security.

The purpose of the silastic ring is to slow the rateof emptying from the gastric pouch and to preventthe outlet from enlarging with the passage of time,which is one of the recognized reasons for weightregain after gastric bypass. The prediction of manythat ring erosion would be a problem has not beenborne out. We have only seen this on two occasions,both in the context of staple-line disruption andulceration. It was clear, however, from our early

experience that a 5.5-cm circumference ring was alittle small and needed to be removed in about 15%of patients,20 to permit a reasonable quality of eat-ing. Thus, we moved to placing 6.0-cm and 6.5-cmcircumference rings, depending on the patient's age.This was predicated on the belief that the motility ofthe esophagus and gastric pouch above the ring maybe less vigorous with aging, and therefore make abigger ring desirable. This policy led to a dramaticreduction in the number of rings requiring removal,as reported in this study. Ring removal is almostalways associated with a degree of weight regain,generally of between 5 and 15 kg. We now believethat a 6.5-cm ring is the optimal size for mostpatients and expect to remove this in only around2% or patients. This can usually be accomplishedlaparoscopically. With gastric transection and theuse of larger rings comes an expectation that ourlong-term weight loss figures will improve, becausethere should no longer be problems with staple-linedisruption and ring removal.

That improvement in co-morbidities is accom-plished by bariatric surgery is now well-docu-mented.5,9,21,22 The improvements and even resolu-tion seen in the metabolic co-morbidities of hyper-tension, diabetes and dyslipidemia are particularlyimportant and are likely to be associated withimproved life expectancy. These diseases arebecoming a particular scourge on Western societiesand are consuming huge sums of money in the pur-suit of what is so often only poor control. That gas-tric bypass can provide long-term cure in about 85%of severely obese type 2 diabetics23 and prevent oth-ers from becoming diabetic5 is of immense value tothe individual and society. Similarly to find long-term resolution or improved control of hypertensionin this difficult group of patients,5,24,25 who oftenrequire multiple medications in an attempt to con-trol the problem, is of real importance.Dyslipidemia, particularly hypertriglyceridemia andelevated cholesterol/HDL cholesterol are alsoresolved or improved, much more reliably andimpressively than with any medication, which ben-efit is also maintained over time.5,26 The combina-tion of these changes must have an important bearingon life expectancy in the severely obese and shouldlead to a new paradigm for the management of thesemetabolically-based diseases when seen in associa-tion with severe obesity.



There is growing evidence to indicate that insulinresistance may be central to both hypertension anddyslipidemia as well as type 2 diabetes.27-31 Gastricbypass has been found to lead to a rapid and sub-stantial improvement, or even loss of, insulin resist-ance, and it is very likely that this provides theexplanation for the rapid improvement or loss ofthese conditions seen after surgery. That this occurswell ahead of weight loss is an important observa-tion which may ultimately lead to unlocking themystery surrounding the mechanism of insulinresistance itself.32

It is interesting to note that satisfaction with theoutcome of surgery was most commonly linked tothe degree of weight loss or weight regain.However, as important that the improvement in co-morbidities is, in the end the majority of patientswho seek this surgery, do so with weight loss astheir primary objective. Although at times thisobjective may not be stated as the most important, itnevertheless usually underpins the decision to pro-ceed with surgery. For this reason, it is importantthat surgeons who undertake this form of surgeryseek to perform the most effective operation thatthey can, as safely as they can. Gastric bypass con-sistently performs better than gastric banding orgastroplasty in terms of reliability and extent ofweight loss and deservedly remains the choicebariatric operation. While definitive description ofthe most effective form of gastric bypass is not yetpossible, it is likely to entail creation of a small ver-tical pouch with gastric transaction, and possibly theplacement of a 6.5-cm silastic ring.

Long-term follow-up of bariatric surgery patientsrequires collection of accurate clinical and bio-chemical information that can only be achieved withappropriate resources and a commitment from bothclinical teams and their patients. Regrettably, this isseldom achieved, and as a result the data supportingthe use of surgery in the severely obese whichshould be so compelling is so easily ignored or crit-icized by funders of health-care and policy-makers.It is hoped that the information provided by thisstudy and others like it will provide greater impetusfor the development and the expansion of bariatricsurgery for the benefit of those who suffer this dis-abling and ultimately devastating condition.

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(Received September 5, 2004; accepted October 28, 2004)



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