To the Editor:
I read the article by Christou et al1 with considerable interest. Their finding that Roux limb length does not significantly affect weight loss at 10 years following Roux-en-Y gastric bypass (RYGB) conflicts with shorter-term weight loss results in previously published prospective randomized comparisons (including their own) of Roux limb length in bariatric surgical patients.2,3 I was most surprised that the authors chose not to cite or discuss the results of those shorter-term studies in their recent publication. However, in many ways, their findings at 10 years postoperatively are not surprising. It is common knowledge that most bariatric surgical patients regain some portion of their lost weight 2 to 3 years after the nadir of weight loss. The weight regain phenomenon supports the concept that obesity is a chronic, even progressive disease (much like atherosclerosis) that is highly resistant to current methods of medical and surgical treatment. Regain is likely due to the adaptive anatomic and physiologic changes that occur after all bariatric operations. Because the stomach is designed to stretch, stomal dilatation is a universal occurrence following procedures that do not incorporate prosthetic stomal reinforcement. Hence, some portion of the so-called “satiety response” is lost following unbanded RYGB. Absorptive capacity of the functional small bowel also increases over time.4,5 They also found that superobese patients both lose and regain their weight more rapidly than less severely obese patients, attesting to the “incorrigibility” of this subset of severely obese patients.
In my view, the authors’ use of the Reinhold scale for classification of postoperative weight loss results is both simplistic and short-sighted. Although this system likely bears some relationship with improved health status and possibly longevity, it does not in any way account for improvement or resolution of obesity-related comorbidities, which tends to occur in many patients with relatively modest weight loss. For example, a 5 foot 5 inch woman with weight/BMI of 400 pounds/67 kg/m2 losing to 220 pounds/37 kg/m2 would be classified as a “failure,” according to Reinhold's classification. I am also curious as to why 70% of the superobese patients in their study had short-limb operations. Moreover, the authors do not specifically mention how many of the 30 superobese patients who had long-limb operations were followed at 5 and 10 years postoperatively.
The authors also make an interesting “apples versus oranges” comparison in Table 5, which shows a similar failure rate between their series of RYGB gastric bypass and the Quebec group's results with biliopancreatic diversion/duodenal switch (BPD/DS). These results are contradicted by the recent prospective comparison of RYGB versus BPD/DS from the University of Chicago, which showed significantly greater weight loss favoring the duodenal switch 6 months postoperatively.6
The preponderance of available clinical data shows that adding malabsorption to gastric restriction improves short-term weight loss in bariatric surgical patients. These data include all of the prospective randomized comparisons of purely restrictive operations versus RYGB and the recent comparison of RYGB versus BPD/DS.6 It seems reasonable and appropriate to give superobese patients a “jump start” in their weight loss provided that the operation performed provides this benefit at no additional risk.
Finally, let me take this opportunity to compliment the authors on the fastidious long-term follow-up of bariatric patients achieved at McGill University Health Centre. Their long-term follow-up is superior to that of all but 1 medical center in North America (East Carolina University) and attests to their diligence in pursuit of long-term outcomes. The McGill group has made tremendous contributions to the field of bariatric surgery during the past 3 decades, and I congratulate them for that.
Robert E. Brolin, MD
University of Pittsburgh Medical School
University Medical Center at Princeton
Princeton, NJ
rbrolin@njbariatricspc.com
REFERENCES
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