Obesity Surgery

Published by Springer Nature

Online ISSN: 1708-0428

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Print ISSN: 0960-8923

Articles


Reply to letter regarding “Does Pregnancy Increase the Need for Revisional Surgery after Laparoscopic Adjustable Gastric Banding?” (MS#OBSU-D-10-00107R1)
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August 2011

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18 Reads

Paul E O'Brien

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Response from Dilip Dan to Commentary from Inge on Case Report OBSU-D-09-00159
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  • Full-text available

October 2009

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85 Reads

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We would like to thank Professor Inge for his commentary and agree with most of the comments. It has been said that the first step of a journey is usually the most important and often the most difficult. This case was the first in our collective experience and provided an extraordinarily difficult therapeutic challenge. The risk/benefit ratio of bariatric surgery is well established in the morbidly obese adult and is under current investigation in teenagers. The decision to undertake a sleeve gastrectomy in one so young and with such debility as in the current case was the Aristotelian mean of cost, benefit, availability, feasibility, and accessibility of therapeutic options. We agree that our work with this child has just begun! It is clear even from the commentary that little is known about the management of such a case and the long-term sequelae of medical or surgical options. The only real option provided was the use of octreotide. The long-term effects of this may also be harmful and cost prohibitive in our setting. There is tremendous investigational work with ghrelin and other hormones in the understanding of the physiology of weight gain and loss, and much work is also being done on the whole issue of the true mechanism of bariatric surgery. However, this is investigational and would be of little help to this patient in our setting today. Suffice it to say that we exercised what appeared to be the best option in our circumstances fully cognizant of our responsibility to carefully follow-up the patient and manage the metabolic consequences of this intervention. It has been over 2 years since her surgery and she continues to do very well. We will continue our follow-up of the patient and would be pleased to inform you through this journal of her progress in 5 years.
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Liver Damage in Severely Obese Patients: a Clinical-Biochemical-Morphologic Study on 1,000 Liver Biopsies

August 2004

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29 Reads

Preoperative clinical and biochemical data and intraoperative liver biopsy of 1,000 obese patients submitted to biliopancreatic diversion (BPD) were analyzed, and correlations investigated. Of 2,645 patients submitted to BPD between May 1976 and November 2002, the last 1,000 consecutive obese patients with no history of alcohol consumption or infectious hepatitis were selected. Clinical data included: age, body weight, BMI, waist-to-hip ratio (W/H), arterial blood pressure, serum glucose, triglycerides, cholesterol, albumin/gamma-globulin ratio, total, conjugated and unconjugated bilirubin, gamma-GT, alkaline phosphatase, AST, ALT, and prothrombin time. The degree of steatosis, inflammation and fibrosis on intraoperative wedge liver biopsy was determined and scored. Liver steatosis >70% and presence of bridging fibrosis were analyzed separately. Mean BMI was 48 kg/m(2). 263 patients had steatosis of >70%, and 79 had bridging fibrosis. Regression analysis showed an association between steatosis and AST, ALT, AST/ALT ratio, body weight, W/H, serum glucose, serum tryglicerides, BMI, gamma-GT, age, and unconjugated bilirubin. Inflammation was significantly greater in older patients. Patients with bridging fibrosis had significantly higher values of serum glucose, AST, gamma-GT, serum cholesterol and were significantly older. Bridging fibrosis was associated with diabetes, W/H >1, hypertension, albumin/gamma-globulin ratio <1. Severe steatosis and bridging fibrosis seem to be associated with the metabolic syndrome. No reliable biochemical data could identify patients with severe chronic liver damage with sufficient sensitivity to avoid liver biopsy for diagnosis and staging of the disease.

Laparoscopic Sleeve Gastrectomy as a Stand-Alone Procedure for Morbid Obesity: Report of 1,000 Cases and 3-Year Follow-Up

March 2012

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157 Reads

Laparoscopic sleeve gastrectomy (LSG) is an emerging surgical technique with encouraging results. The objective of this study is to report surgical results after 1,000 consecutive LSG cases as a stand-alone procedure for morbid obesity during a 3-year follow-up. Data were obtained by review of our prospectively maintained database, patients' clinical charts, and phone interview of all patients who underwent LSG in our institution from December 2005 to February 2010. There were 773 (77.3%) women whose preoperative age and BMI was 36.9 ± 11.5 years and 37.4 ± 4.0 kg/m(2), respectively. The most common co-morbid conditions were insulin resistance 55.1%, dyslipidemia 45.5%, arterial hypertension 23.1%, hypothyroidism 15.4% and non-alcoholic fatty liver disease 12%. Excess weight loss was as follows: 1 year 86.6%, 2 years 84.1%, and 3 years 84.5%. Early and late complications occurred in 34 (3.4%) and 20 (2.0%) patients, respectively. Reoperation was required in seven (0.7%) patients. There was no mortality during follow-up. LSG seems to be a safe and effective surgical technique for morbid obesity as a stand-alone procedure.

Figure 3. Esophageal perforation on Gastrografin ® swallow on Day 1.
Figure 4. Esophageal dilatation.
Figure 5. Tube disconnection.
Figure 6. Tube leakage.
Figure 7. Saggital diagram showing the correct site for the band around the stomach.

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Complications after Laparoscopic Adjustable Gastric Banding for Morbid Obesity: Experience with 1,000 Patients over 7 Years

April 2004

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177 Reads

Laparoscopic adjustable gastric banding (LAGB) is considered the least invasive surgical option for morbid obesity. It is less efficient than gastric bypass in weight loss, but has the advantage of being potentially reversible and can improve the quality of life if mortality and morbidity are low. Between 1996 and 2003, 1,000 patients underwent LAGB. There were 896 women and 104 men with mean age 40.4 years (16.3-66.3). Preoperative mean BMI was 44.3 kg/m(2). There were no deaths. Cumulative rate of complications was 192 (19.2%). 12 were life-threatening (1.2%): gastric perforation (n=4), acute respiratory distress (n=2), pulmonary embolism (n=2), migration (n=3), and gastric necrosis (n=1). 111 patients required an abdominal reoperation (11.1%) for perforation (n=2), slippage (n=78), migration (n=3), necrosis (n=1), esophageal dilatation (n=2), incisional hernias (n=4) and port problems (n=21). Before October 2000, we used the perigastric technique, and the slippage rate was 24% (91 / 378 ).Then, we changed to the pars flaccida approach and the slippage rate fell to 2% (13 / 622). The pars flaccida approach demonstrated safety in relation to both risks of perforation and slippage. The cumulative complication rate increased to 3-4 years, and then decreased with experience and technical improvement. Concerns of long-term follow-up should be migration and esophageal dilatation, which seem to be rare at 3 years.

Total Stapled, Total Intra-Abdominal (TSTI) Laparoscopic Roux-en-Y Gastric Bypass: One Leak in 1,000 Cases

June 2004

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31 Reads

Variations in technique of laparoscopic Roux-en-Y gastric bypass (LRYGBP) have been reported. These changes, mainly in the construction of the gastro-jejunostomy, are intended to decrease complications. 1000 consecutive LRYGBPs were performed using the Total Stapled Total Intra-abdominal (TSTI) technique antecolic and antegastric approach. Technical details and results, including perioperative morbidity and mortality, are reported. Although the correction or improvement of the most serious co-morbidities with the use of the TSTI technique were similar to results reported by other gastric bypass surgeons, we noted a considerable difference in the development of leaks using this surgical approach. Current literature on gastric bypass reports a 2-5% incidence of leaks. Using the TSTI approach, the incidence of leaks at our facility was 0.1% (one in 1000 cases). After analysis of the factors involved, it was concluded that the use of the antecolic and antegastric approach in gastric bypass, as described in the TSTI,should be an important consideration by the surgeon. This technique, which uses a circular stapler, was found to be easy to perform while maintaining a reproducible, controlled opening of the anastomosis. Although this was a non-randomized study, the results found a considerable improvement in the incidence of morbidity and mortality, and a remarkable decrease in the frequency of leaks.

Laparoscopic Surgery for Morbid Obesity: 1,001 Consecutive Bariatric Operations Performed at the Bariatric Institute, Cleveland Clinic Florida

March 2006

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138 Reads

Morbid obesity is an epidemic in America. This series evaluates the safety and efficacy in the first 1,001 laparoscopic bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida. A retrospective review was conducted examining all patients undergoing a primary bariatric procedure (either laparoscopic gastric bypass or laparoscopic gastric banding) from July 2000 to December 2003. 2 surgeons performed 1,001 laparoscopic bariatric operations. Average age was 47 (19-75) years, average BMI was 55.6 (35-97) kg/m2, and average ASA class was III. Excess weight loss was 51% at 6 months, 73.4% at 1 year for the gastric bypass group and 54% at 1 year for the laparoscopic banding group. The overall complication rate was 31.8% (12.4% major and 19.4% minor) in the gastric bypass group and 13% in the laparoscopic banding group. There was no postoperative mortality. Laparoscopic bariatric surgery is feasible and safe for weight loss. Results obtained have been comparable to those reported for the open approach for weight loss, with a similar major morbidity rate and an improved mortality rate.

Complications of the Laparoscopic Roux-en-Y Gastric Bypass: 1,040 Patients - What Have We Learned?

January 2001

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88 Reads

The Roux-en-Y gastric bypass (RYGBP) is one of the most common operations for morbid obesity. Laparoscopic techniques have been reported, but suffer from small numbers of patients, longer operative times and seemingly higher initial complication rates as compared to the traditional "open" procedure. The minimally invasive approach continues to be a challenge even to the most experienced laparoscopic surgeons. The purpose of this study is to describe our experience and complications of the laparoscopic Roux-en-Y gastric bypass with a totally hand-sewn gastrojejunostomy. 1,040 consecutive laparoscopic procedures were evaluated prospectively. Only patients who had a previous open gastric procedure were excluded initially. Eventually, even patients with failed "open" bariatric procedures and other gastric procedures were revised laparoscopically to the RYGBP. All patients met NIH criteria for consideration for weight reductive surgery. There were no anastomotic leaks from the hand-sewn gastrojejunostomy. Early complications and open conversions were related to sub-optimal exposure and bowel fixation techniques. Several staple failures were attributed to a manufacturer redesign of an instrument. Average hospital stay was 1.9 days for all patients and 1.5 days for patients without complications. Operative times consistently approach 60 minutes. Average excess weight loss was 70% at 12 months. There were 5 deaths: perioperative pulmonary embolism (1), late pulmonary embolism (2), asthma (1), and suicide (1). The laparoscopic Roux-en-Y gastric bypass for morbid obesity with a totally hand-sewn gastrojejunostomy can be safely performed by the bariatric surgeon with advanced laparoscopic skills in the community setting. Fixation and closure of all potential hernia sites with non-absorbable sutures is essential. Stenosis of the hand-sewn gastrojejunal anastomosis is amenable to endoscopic balloon dilation. Meticulous attention must be paid to the operative and perioperative care of the patient.

A 6-Year Experience with 1,054 Mini-Gastric Bypasses-First Study from Indian Subcontinent

March 2014

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240 Reads

We started laparoscopic mini-gastric bypass (MGB) for the first time in India in February 2007 for its reported safety, efficacy, and easy reversibility. A retrospective review of prospectively maintained data of all 1,054 consecutive patients (342 men and 712 women) who underwent MGB at our institute from February 2007 to January 2013 was done. Mean age was 38.4 years, preoperative mean weight was 128.5 kg, mean BMI was 43.2 kg/m(2), mean operating time was 52 ± 18.5 min, and mean hospital stay was 2.5 ± 1.3 days. There were 49 (4.6 %) early minor complications, 14 (1.3 %) major complications, and 2 leaks (0.2 %). In late complications, one patient had low albumin and one had excess weight loss; MGB was easily reversed in both (0.2 %). Marginal ulcers were noted in five patients (0.6 %) during follow-up for symptomatic dyspepsia, and anemia was the most frequent late complication occurring in 68 patients (7.6 %). Patient satisfaction was high, and mean excess weight loss was 84, 91, 88, 86, 87, and 85 % at years 1 to 6, respectively. This study confirms previous publications showing that MGB is quite safe, with a short hospital stay and low risk of complications. It results in effective and sustained weight loss with high resolution of comorbidities and complications that are easily managed.

Fig. 1 Trocar layout. A , 10-mm trocar (camera). B , C , D , 12-mm trocar. E , 5-mm trocar 
Fig. 2 Fully stapled laparoscopic Roux-en-Y gastric bypass 
Table 2 Thirty-day complication rate
Smaller Staple Height for Circular Stapled Gastrojejunostomy in Laparoscopic Gastric Bypass: Early Results in 1,074 Morbidly Obese Patients

November 2010

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214 Reads

Anastomotic leaks, stenosis, and bleeding from the gastrojejunal anastomosis (GJA) after gastric bypass may carry high morbidity and mortality. To date, the standard operation with the circular stapler (CS) used the 25 mm with a staple height of 4.8 mm. We present herein our experience with the 3.5-mm staple height. A total of 1,074 morbidly obese patients who underwent fully stapled laparoscopic Roux-en-Y Gastric Bypass over a period of 18 months were included in the study. Mean body mass index was 41.9 (range 28.6-70.7). Mean age was 40.9 years (range 15-74 years). Mean operating time was 73 min (range 43-210 min) and the mean length of stay was 4.2 days (range 1-25 days). The 30-day complication rate associated with GJA was prospectively analyzed. Twenty patients (1.86%) developed postoperative bleeding. Four developed GJA bleeding (0.37%). One leak was recorded from the vertical staple line of the gastric pouch, but no leaks from the GJA were seen. Conversion to open approach was required in two patients (0.18%). Reoperation and readmission rates were 1.7% and 1.8%, respectively. Perioperative complications were observed in 34 patients (3.1%). One case of clinical GJA stenosis was detected in a mean follow-up of 10.5 months (range 5-20 months). There was no mortality in our series. Compared to our previous experience with 4.8 mm CS, creating the GJA using a smaller staple height significantly reduced the bleeding rate and seems to be a safe technique that potentially reduces other complications related to the GJA as reported in the literature.

The Mini-Gastric Bypass: Experience with the First 1,274 Cases

July 2001

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522 Reads

Results of the laparoscopic Mini-Gastric Bypass (MGB) are reported. 1,274 MGB patients are continuously monitored as part of an online computer tracking data-base system. Mean preoperative weight (+/- Standard Deviation) was 132 +/- 21 kg, BMI 47 +/- 7. Mean excess weight loss was 51% at 6 months, 68% at 12 months and 77% at 2 years. The mean operating-time was 36.9 +/- 33.5 minutes. The shortest time was 19 minutes. Hospital stay was 1.5 +/- 1.6 days. The overall complication rate has been 5.2%. The overall rate of deep vein thrombosis and pulmonary embolism was 0.08% and 0.16% respectively. The leak rate was 1.6%. There was one hospital death, 0.08%. Associated medical illnesses were either completely reversed or markedly improved. The MGB is safe, results in major weight loss, has a short operating-time, and has a short hospital stay. The MGB appears to meet many of the criteria of an "ideal" weight loss operation.

Laparoscopic vs Open Gastric Bypass in the Management of Morbid Obesity: A 7-year Retrospective Study of 1,364 Patients from a Single Center

May 2008

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35 Reads

We performed a retrospective analysis of 1,364 consecutive morbidly obese patients who underwent restrictive-malabsorptive Roux-en-Y gastric bypass (RYGBP) between January 1998 and December 2004. A selective use of open and laparoscopic approaches was employed since 2001. Patients were seen in the office at 1 week; 2, 3, 6, 9, 12, and 24 months; and yearly thereafter. During visits, each patient was weighed and dietary intake and exercise regimen were recorded. We report a sustained weight reduction in over 90% of patients. The anastomotic leak rate was 0.15%, the 30-day readmission rate was 1.17%, and the overall mortality rate was 0.15%. Minor surgical site infection rate was 0.5%, and revision to long limb RYGBP rate was 0.07%. Morbid obesity represents a significant health issue. None of the medical methods of weight reduction provide a lasting weight reduction. Surgery offers the only achievable long-term solution. Although not yet universally employed, laparoscopic RYGBP is rapidly becoming the standard operation for the surgical treatment of clinically severe obesity.

Silastic Ring Vertical Gastric Bypass: Evolution of an Open Surgical Technique, and Review of 1,588 Cases

November 2005

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28 Reads

Silastic ring vertical gastric bypass (SRVGBP) has evolved from a stapled (SSRVGBP) to a transected (TSRVGBP), and finally to a transected pouch with jejunal interposition (TSRVGBP with J-I). The creation of the gastroenterostomy evolved from a hand-sewn to a stapled and finally to a combined stapled and hand-sewn anastomosis. The circumference of the ring was increased from 5.5 to 6.0 cm. We address the effect of these modifications on surgical outcome. The records of 1,588 consecutive patients (mean BMI of 44.5) since 1990 who had a SRVGBP were indentified from a prospective data-base of all patients undergoing bariatric operations. 205 patients with a prior bariatric operation were excluded from the review, leaving 1,383 patients who had a primary SRVGBP. In the 193 SRVGBP patients, there was 1 gastric leak (0.5%) and 64 gastrogastric fistulas (33.2%). In the 165 TSRVGBP patients, there were 4 gastric leaks (2.4%) and 14 gastrogastric fistulas (8.5%). In the 1,025 patients with TSRVGBP with JI, there were 8 gastric leaks (0.8%) and no gastro-gastric fistulas. In the TSRVGBP with J-I, 367 patients had a hand-sewn, 16 a stapled, and 642 a combined stapled and hand-sewn anastomosis. Stricture rate was 3.8%, 31%, and 2.6% respectively. There were 7 ring migrations (0.7%), all in the totally hand-sewn group. Ring removal was necessary in 20 (5%) with a 5.5-cm and 4 (0.74%) with a 6.0-cm ring. TSRVGBP with J-I with a combined stapled and hand-sewn gastrojejunal anastomosis using a 6.0-cm ring decreased the incidence of complications, and is our current technique.

Table 2 . Major complications requiring reoperation (106/1791 patients; Sept. 1993-Dec. 2005) 
Table 4 . Weight loss (kg, BMI) in morbidly obese and super-obese patients 
Table 5 . Weight loss (%EWL) in morbidly obese and super-obese patients 
Laparoscopic Adjustable Gastric Banding in 1,791 Consecutive Obese Patients: 12-Year Results

March 2007

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1,859 Reads

This study examines 1,791 consecutive laparoscopic adjustable gastric banding (LAGB) procedures with up to 12 years follow-up. Long-term results of LAGB with a high follow-up rate are not common. Between September 1993 and December 2005, 1,791 consecutive patients (75.1% women, mean age 38.7 years, mean weight 127.7 +/- 24 kg, mean BMI 46.2 +/- 7.7) underwent LAGB by the same surgical team. Perigastric dissection was used in 77.8% of the patients, while subsequently pars flaccida was used in 21.5% and a mixed approach in 0.8%. Data were analyzed according to co-morbidities, conversion, short- and long-term complications and weight loss. Fluoroscopy-guided band adjustments were performed and patients received intensive follow-up. The effects of LAGB on life expectancy were measured in a case/control study involving 821 surgically-treated patients versus 821 treated by medical therapy. Most common baseline co-morbidities (%) were hypertension (35.6), osteoarthritis (57.8), diabetes (22), dyslipidemia (27.1), sleep apnea syndrome (31.4), depression (21.2), sweet eating (22.5) and binge eating (18.5). Conversion to open was 1.7%: due to technical difficulties (1.2) and due to intraoperative complications (0.5). Together with the re-positioning of the band, additional surgery was performed in 11.9% of the patients: hiatal hernia repair (2.4), cholecystectomy (7.8) and other procedures (1.7). There was no mortality. Reoperation was required in 106 patients (5.9%): band removal 55 (3.7%), band repositioning 50 (2.7 %), and other 1 (0.05 %). Port-related complications occurred in 200 patients (11.2%). 41 patients (2.3%) underwent further surgery due to unsatisfactory results: removal of the band in 12 (0.7%), biliopancreatic diversion in 5 (0.27%) and a biliopancreatic diversion with gastric preservation ("bandinaro") in 24 (1.3%). Weight in kg was 103.7 +/- 21.6, 102.5 +/- 22.5, 105.0 +/- 23.6, 106.8 +/- 24.3, 103.3 +/- 26.2 and 101.4 +/- 27.1 at 1, 3, 5, 7, 9, 11 years after LAGB. BMI at the same intervals was 37.7 +/- 7.1, 37.2 +/- 7.2, 38.1 +/- 7.6, 38.5 +/- 7.9, 37.5 +/- 8.5 and 37.7 +/- 9.1. The case/control study found a statistically significant difference in survival in favor of the surgically-treated group. LAGB can achieve effective, safe and stable long-term weight loss. In experienced hands, the complication rate is low. Follow-up is paramount.


Influences of Gender on Complication Rate and Outcome after Roux-en-Y Gastric Bypass: Data Analysis of More Than 10,000 Operations from the German Bariatric Surgery Registry

April 2014

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30 Reads

Since 1 January 2005, bariatric surgery has been monitored in Germany. All related data are registered prospectively in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University Magdeburg. Data collection regarding obesity and metabolic surgery was started in an online database in 2005. Follow-up data are collected once a year. Participation in the quality assurance study is voluntary. Since 2005, 10,330 Roux-en-Y gastric bypass (RYGB) procedures have been performed in Germany. In total, 8,013 patients were female and 2,317 were male. Male patients suffered significantly more comorbidities than female patients. The men also had higher body mass indexes (BMIs) and ages than the women at the time of operation. Data on the gender-specific aspects of RYGB from the Nationwide Survey of Bariatric Surgery in Germany (GBSR) showed a significant difference in anastomotic insufficiency at the gastro-entero-anastomosis. The leakage rate was 2.37 % (55/2,317) in men and 1.68 % (135/8,013) in women. Additionally, specific complication and mortality rates were significantly higher in male than in female patients. Metabolic and obesity surgery is becoming increasingly popular in Germany. Data from the GBSR show significant differences in preoperative comorbidities and postoperative complication and mortality rates between male and female patients. There is a need for further evaluation of gender-specific aspects to optimize patient selection and reduce specific postoperative complications.

Table 2 . Indication for conversion from VBG to RYGBP
Table 3 -A. Causes of VBG failure
Table 5 . Complications after RYGBP
Conversion of Vertical Banded Gastroplasty to Roux-en-Y Gastric Bypass Results in Restoration of the Positive Effect on Weight Loss and Co-morbidities: Evaluation of 101 Patients

June 2007

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118 Reads

Vertical banded gastroplasty (VBG) is a widely used restrictive procedure in bariatric surgery. However, the re-operation rate after this operation is high. In the case of VBG failure, a conversion to Roux-en-Y gastric bypass (RYGBP) is an option. A study was undertaken to evaluate the results of the conversion from VBG to RYGBP. 101 patients had conversion from VBG to RYGBP. Patients were separated into 3 groups, based on the indication for conversion: weight regain (group 1), excessive weight loss (group 2) and severe eating difficulties (group 3). Data for the study were collected by retrospective analysis of prospectively recorded data. Weight regain (group 1) was the reason for conversion in 73.3% of patients. Staple-line disruption was the most important cause for the weight regain (74.3%). Excessive weight loss (group 2) affected 14% of patients and was caused by outlet stenosis in 78.6% of patients. The remaining 13% had severe eating difficulties as a result of outlet stenosis (46.1%), pouch dilatation (30.8%) and pouch diverticula (23.1%). Mean BMI before conversion to RYGBP was 40.5, 22.3 and 29.8 kg/m2 in group 1, 2 and 3, respectively. Minor or major direct postoperative complications were observed in 2.0% to 7.0%. Long-term complications were more frequent, and consisted mainly of anastomotic stenosis (22.7%) and incisional hernia (16.8%). Follow-up after conversion was achieved in all patients (100%), with a mean period of 38 +/- 29 months. BMI decreased from 40.5 to 30.1 kg/m2, increased from 22.3 to 25.3 kg/m2. and decreased slightly from 29.8 to 29.0 kg/m2 in group 1, 2 and 3, respectively. All patients in group 3 noticed an improvement in eating difficulties. Complications after conversion from failed VBG to RYGBP are substantial and need to be considered. However, the conversion itself is a successful operation in terms of effect on body weight and treating eating difficulties after VBG.

11-Year Experience with Laparoscopic Adjustable Gastric Banding for Morbid Obesity—What Happened to the First 123 Patients?

April 2008

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19 Reads

Few long-term studies regarding the outcome of laparoscopic adjustable gastric banding for morbid obesity have so far been published. We report our 11-year experience with the technique by looking closely at the first 123 patients that have at least 5 years (mean 86 months) of follow-up. Data have been collected prospectively among 280 patients operated since March 1996. Until March 2002 (minimum 5-year follow-up), 123 patients have been operated laparoscopically with the Swedish band. We report major late complications, reoperations, excess weight losses (EWL) and failure rates among these patients, with a mean (range) follow-up time of 86 months (60-132). EWL < 25% or major reoperation was considered as a failure. EWL > 50% was considered a success. Mean (range) age of the patients (male/female ratio 31:92) was 43 years (21-44). Mean (range) preoperative weight was 130 kg (92-191). Mean (range) preoperative body mass index was 49.28 kg/m2 (35.01-66.60). Patients lost to follow-up was nearly 20% at 5 years and 30% at 8 years. Major late complications (including band erosions 3.3%, slippage 6.5%, leakage 9.8%) leading to major reoperation occurred in 30 patients (24.4%). Nearly 40% of the reoperations was performed during the third year after the operation. The mean EWL at 7 years was 56% in patients with the band in place, but 46% in all patients. The failure rates increased from about 15% during years 1 to 3 to nearly 40% during years 8 and 9. The success rate declined from nearly 60% at 3 years to 35% at 8 and 9 years. Complications requiring reoperations are common during the third year after the operation, and almost 25% of the patients will need at least one reoperation. Mean EWL in all patients does not exceed 50% in 7 years or 40% in 9 years and failure rates increase with time, up to 40% at 9 years.

Kalfarentzos F, Kechagias I, Soulikia K, Loukidi A, Mead N. Weight loss following vertical banded gastroplasty: intermediate results of a prospective study. Obes Surg 11, 265-270

July 2001

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32 Reads

Morbidly obese patients who undergo purely restrictive bariatric operations may fail to maintain satisfactory long-term results. In an attempt to achieve the best possible outcome after restrictive procedures, we have employed preoperative selection criteria and are following this selected patient group over time in order to evaluate long-term success. From June 1994 through August 2000, 166 morbidly obese patients underwent various bariatric procedures at our institution. Of these patients, 35 underwent vertical banded gastroplasty (VBG) based on selection criteria, including degree of obesity and dietary habits and eating behavior. All patients were seen at 1, 3, 6, 9, and 12 months postoperatively and yearly thereafter. Average follow-up time now is 4.1 years (29-75 mos.), and follow-up is 100%. A multivitamin and mineral supplement is administered to all patients for at least 6 months. Radiology examination is performed in all patients on the 4th postoperative day and at each yearly visit, in order to check for staple-line disruption and stomal stenosis. Early postoperative morbidity was 5.7%. Late postoperative morbidity was 22.8%. A significant number of patients had some degree of stomal stenosis as shown by radiology examination, but to date there has been no need for surgical revision. There has been no early or late mortality. Weight loss results expressed as average percent excess weight loss (% EWL) were as follows: 61% (28-90) at 1 year, 61% (20-90) at 2 years, 57% (13-91) at 3 years, 56% (25-87) at 4 years and 37% (24-59) at 5 years following surgery. A significant number of patients with excellent weight loss had a high frequency of vomiting. Evaluation by BAROS showed that 25% of patients had an overall unsatisfactory outcome. Anemia and iron deficiency were found in 46% and 32% of VBG patients respectively. Recurrence of preexisting comorbidities was significant if lost weight was regained. In spite of preoperative selection of patients for VBG, a significant percentage of patients had poor overall results in terms of weight loss, quality of life, and resolution of preexisting comorbidities. For these reasons and based on the long-term results published by others, VBG is no longer our preferred surgical option in morbidly obese patients.

Reduction in Slippage with 11-cm Lap-Band<SUP>®</SUP> and Change of Gastric Banding Technique

September 2005

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33 Reads

Slippage occurs after 2-18% of gastric bandings performed by the perigastric technique (PGT). We investigated the slippage-rate before and after the introduction of the pars flaccida technique (PFT) and the 11-cm Lap-Band, and the long-term results of the re-operated patients. Between Dec 1996 and Feb 2004, 360 patients with a mean BMI of 44 kg/m2 were operated. The PGT (n=168) and PFT9.75 (n=15) groups received the 9.75-cm Lap-Band, and the PFT11 group (n=177) received the new 11-cm Lap-Band. Follow-up rate was 99%. Slippage occurred in a total of 31 patients from all groups (PGT, n=28, or 17%; PFT9.75, n=1, or 7%; PFT11, n=2, or 1%). Average yearly re-operation rate for slippage in the first 3 years postoperatively was 3.8%, 2.2% and 0.9%, respectively. Laparoscopic re-banding was necessary for posterior (n=19) or lateral (n=12) slippage. The late postoperative course after re-banding was: uneventful 58%, weight regain 35% and/or esophageal motility disorder 23%, secondary band intolerance 20%, and one persistent posterior slippage. 8 patients (26%) needed biliopancreatic diversion. Since the introduction of the PFT and the 11-cm Lap-Band, we observed a significant reduction in slippage rate and no posterior slippage. Re-banding had a less favorable long-term result than did first-procedure banding.

11-cm Lap-Band<SUP>®</SUP> System Placement after History of Intragastric Migration

July 2003

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24 Reads

Intragastric migration (erosion) of the band after laparoscopic adjustable silicone gastric banding (LAGB) is a serious late complication. It requires removal of the entire system. Subsequent recurrence of obesity can be treated by laparoscopic placement of a larger band: the 11-cm Lap-Band System. In 727 laparoscopic gastric bandings using the 9.75 Lap-Band, 10 cases presented with intragastric migration of the band. The same complication was encountered in an additional 4 patients who had previously been implanted with an Obtech band in another hospital. Laparoscopic removal of the band was performed in all cases. In 9 cases, after a delay of 6 months, a new gastric band was placed using the 11-cm Lap-Band, because of uncontrollable recurrence of obesity. No complication was observed during the laparoscopic removal of the system. The placement of a new band required conversion to laparotomy in 1 patient who had previously received an Obtech band which had been placed using the pars flaccida technique. After a mean follow-up of 21 months, no intragastric migration of the new bands was noted. Laparoscopic placement of an 11-cm Lap-Band in patients with a history of intragastric migration is a safe procedure. It allows effective control of recurrent obesity. The laparoscopic procedure was easier in patients initially operated using the perigastric technique.

Stoma Adjustable Silicone Gastric Banding: Results in 111 Consecutive Patients.

September 1994

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6 Reads

From April 1990 through December 1992, 111 patients (80 females, 31 males, mean age 38 years, range 16-60) underwent stoma adjustable silicone gastric banding (SASGB) at the Department of Surgery, University Hospital, Padua, Italy. Patients' characteristics were: mean height 166 +/- 8 cm; mean body weight (BW) 129.1 +/- 21.6 kg; mean body mass index (BMI) 46.4 +/- 6.3 kg/m(2); mean percentage of ideal body weight (%IBW) 206.2 +/- 27. Eighty-eight patients were morbidly obese and 23 superobese. All patients were available for follow-up. Median follow-up was 18.8 months (range 12-44). At I year (I 03 patients), mean postoperative BW, BMI, %IBW and excess weight lost (%EWL) were 101.5 +/- 20 kg, 36.5 +/- 6 kg/m(2), 164 +/- 30 and 40.8 +/- 19 respectively; at 2 years (58 patients) 92.3 +/- 19 kg, 33.1 +/- 6 kg/m(2), 148.8 +/- 28, 52 +/- 23, respectively, and at 3 years (26 patients) 86.9 +/- 14 kg, 31.4 +/- 5 kg/m(2), 141.5 +/- 25 and 63.6 +/- 20 respectively. The overall postoperative mortality rate was zero and the early morbidity rate 9%. Late complications were band slippage (two patients), stoma stenosis with pouch dilatation (seven patients), band erosion (one patient), reservoir leakage (three patients) and reservoir infection (two patients). Surgical revision was performed in ten (9%) patients, two of whom required band removal. Most complications occurred in patients who underwent SASGB during our initial experience. Our findings confirm that SASGB is a safe and effective surgical means of achieving weight reduction.

Fig. 1 Absolute weight in patients following laparoscopic sleeve gastrectomy (* P <0.05 vs. baseline) 
Table 1 Baseline characteristics of patients undergoing laparoscopic sleeve gastrectomy
Fig. 2 Body mass index (BMI) in patients following laparoscopic sleeve gastrectomy (* P <0.05 vs. baseline) 
Laparoscopic Sleeve Gastrectomy with Staple Line Buttress Reinforcement in 116 Consecutive Morbidly Obese Patients

April 2012

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435 Reads

Obesity rates have reached epidemic levels with over 300 million obese individuals worldwide. Laparoscopic sleeve gastrectomy (LSG) as a primarily restrictive bariatric surgical procedure has been shown to be effective in producing marked weight loss. However, LSG-associated gastric leakage and hemorrhages remain the most important challenges postoperatively. Staple line buttress reinforcement has been suggested to reduce these postoperative complications. Our objective was to assess staple line buttress reinforcement via the Duet™ tissue reinforcement stapler system in morbidly obese patients undergoing LSG as part of a comprehensive weight management strategy, focusing on postoperative complications. Between January 2008 and April 2011, we retrospectively reviewed the medical records of 116 consecutive patients that underwent LSG with staple line buttress reinforcement at an academic teaching hospital with advanced bariatric fellowship. The mean age of patients was 44.3 ± 9.5 years, with mean preoperative BMI of 44 ± 7 kg/m2. The mean operative time to perform LSG was 96 ± 25 min. Postoperative weight was significantly lower following LSG at 1-year follow-up compared to baseline (104 ± 25 vs. 125 ± 27 kg, P < 0.05). There were no postoperative gastric leaks observed. Postoperative bleeding from the gastric staple line occurred in one patient (0.9%) and was treated with conservative management. In LSG, staple line buttress reinforcement limits postoperative gastric leakage and bleeding in morbidly obese patients.

Laparoscopic Roux-En-Y Gastric Bypass Versus Laparoscopic Sleeve Gastrectomy for the Treatment of Morbid Obesity. A Prospective Study of 117 Patients with 2 Years of Follow Up

February 2011

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62 Reads

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most widely used bariatric procedures today, and laparoscopic sleeve gastrectomy (LSG) is becoming increasingly popular. The aim of this study was to compare mid-term results of both procedures. Methods: From January 2008 to December 2008, 117 obese patients were assigned by patient choice after informed consent to either a LRYGB procedure (n=75) or a LSG procedure (n=42). We determined operative time, length of stay, morbidity, comorbidity outcomes, failures, and excess weight loss at 5 years. Results: Both groups were comparable in demographic characteristics and comorbidities at baseline. No significant statistical differences were found in length of stay and early major morbidity, but mean operative time was shorter in LSG group, p<0.05. Follow-up was achieved in 74 patients (63.2 %) at 5 years, and major complications (early and late) were 10 (21.2 %) for the LRYGB group and 3 (11.1 %) for the LSG group, p>0.05. Five years after surgery, the percentage of excess weight loss was similar in both groups (69.8 % for LRYGB and 67.3 % for LSG, p>0.05). Failures were more common for LSG group, 22.2 versus 12.7 % for LRYGB group, but this difference was not significant, p>0.05. Conclusions: Both techniques are comparable regarding safety and effectiveness after 5 years of follow-up, so not one procedure is clearly superior to the other.

Fig. 1 11β-HSD1 gene expression in VAT and SAT from morbidly obese patients. A box-plot represents the differences observed in VAT and SAT tissue of 11bHSD1 mRNA normalized with 18S mRNA. A Mann Whitney U-test was performed to evaluate significant differences between groups (asterisk, p<0.05)  
Table 2 11β-HSD1 mRNA levels according to biochemical variables
Fig. 3 mRNA expression levels of 11β-HSD1 gene and its association with BMI level. The box-and-whisker plot represents median (minimum and maximum) mRNA levels, expressed as AU after normalization by 18S gene expression. Asterisks, p<0.05, denote a statistically significant difference in SAT mRNA levels according to BMI level using Kruskall–Wallis test. SAT subcutaneous adipose tissue, VAT visceral adipose tissue, AU arbitrary units, BMI body mass index (kg/m 2 )  
Fig. 4 mRNA expression levels of 11β-HSD1 gene according to MS. Bars plot represent mean±95% IC mRNA expression levels and expressed as AU after normalization by 18S gene expression. Not statistically significant differences in mRNA levels using Mann– Whitney test. MS metabolic syndrome, AU arbitrary units, SAT subcutaneous adipose tissue, VAT visceral adipose tissue  
Fig. 2 Correlation between SAT and VAT 11β-HSD1 gene expression . Spearman linear regression (with scatter plot) represents the correlation between paired SAT and VAT samples expressed as AU after normalization with 18S expression. Spearman correlation R=−0.60, p=0.018  
11β-Hydroxysteroid Dehydrogenase Type 1 is Overexpressed in Subcutaneous Adipose Tissue of Morbidly Obese Patients

August 2008

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163 Reads

11beta-Hydroxysteroid dehydrogenase type 1 (11beta-HSD1) enzyme catalyzes interconversion of inactive cortisone to active cortisol. Its expression in adipose tissue has been associated with obesity and some of its metabolic disorders. Controversies regarding which fat depots [subcutaneous adipose tissue (SAT) or visceral adipose tissue (VAT)] have higher expression still remain. The aim of this work was to evaluate 11beta-HSD1 expression in SAT and VAT of obese patients and evaluate its association to metabolic features of metabolic syndrome. In 32 morbidly obese patients, paired samples of SAT and VAT were collected. All patients, 40.2+/-12.3 years and 36.7+/-3.8 body mass index (BMI), underwent sleeve gastrectomy or laparoscopic gastric bypass. Gene expression of 11beta-HSD1 in adipose tissue samples were determined by real-time reverse transcriptase polymerase chain reaction. Spearman correlation test was used to evaluate relationships between 11beta-HSD1 levels and clinical and biochemical parameters. 11beta-HSD1 mRNA levels were higher in SAT than in VAT, with median expression levels of 11.4 arbitrary units (AU) and 7.8 AU, respectively (p=0.03). SAT 11beta-HSD1 mRNA were correlated with VAT mRNA levels (r=-0.6, p=0.018) and hip circumference (r=0.66, p=0.018). SAT 11beta-HSD1 levels increase parallel according to BMI category. We did not find a correlation between SAT or VAT with fasting glucose (r=0.15, p=NS), total cholesterol (r=0.13, p=NS), triglycerides (r=0.04, p=NS), and high-density lipoprotein (r=-0.16, p=NS). However, SAT expression in patients with features of MS was higher than those without features of MS. Our results demonstrate that SATs express higher 11beta-HSD1 mRNA levels than VAT. This finding highlights the importance of SAT in obesity and its possible role on metabolic disorders associated with obesity.

Fig. 1 11β-HSD1 expression in analyzed tissues. To compare tissue gene expression in liver, VAT, and SAT, we used a generalized linear model observing that hepatic mRNA levels of 11β-HSD1 in morbidly obese patients were significantly higher [31.03±16.4 AU, range (2.690.4)] than those seen in VAT [1.36±1.09 AU, range (0.2-4.6)] and SAT [5.24±4.89 AU, range (0.8-23.9)] with no gender-related differences 
Fig. 2 Correlation between hepatic 11β-HSD1 and BMI. Hepatic expression of 11β-HSD1 was inversely associated with the obesity status according to BMI (r=− 0.30, p=0.05, Spearman correlation test). We hypothesize that a down regulation of liver enzyme occurs as a result of long-term overstimulation secondary to increased visceral adiposity and probably portal hypercortisolism 
Overexpression of 11β-Hydroxysteroid Dehydrogenase Type 1 in Hepatic and Visceral Adipose Tissue is Associated with Metabolic Disorders in Morbidly Obese Patients

August 2009

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126 Reads

The enzyme 11-beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) catalyzes intracellular glucocorticoid reactivation by conversion of cortisone to cortisol in different tissues and have been implicated in several metabolic disorders associated with obesity. The aim of this study was to evaluate the 11beta-HSD1 expression in liver, visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT) in morbidly obese patients undergoing bariatric surgery and its correlations with clinical, anthropometric, and biochemical variables. A prospective study was conducted over a 27-month period. Hepatic, VAT, and SAT samples were obtained at the time of surgery. 11beta-HSD1 and 18S gene expression was measured using real-time quantitative reverse transcriptase-polymerase chain reaction. Forty nine patients met the inclusion criteria [mean age: 42.2 +/- 10 years, body mass index (BMI): 42 +/- 6 kg/m(2), 71% women and 63% with metabolic syndrome (MS)]. 11beta-HSD1 mRNA levels were higher in liver than fat tissue (p < 0.001), being higher in SAT than in VAT (p < 0.001) without gender-specific differences. Hepatic expression of 11beta-HSD1 correlated positively with SAT and VAT, alanine aminotransferase (ALT), and serum glucose and was inversely associated with BMI. 11beta-HSD1 mRNA in VAT correlated positively with insulinemia, ALT, and LDL cholesterol. There were no associations between 11beta-HSD1 mRNA in SAT and the variables analyzed. 11beta-HSD1 expression is higher in liver in comparison to adipose tissue in obese patients. The observed correlations between hepatic and VAT 11beta-HSD1 expression with dyslipidemia and insulin resistance suggest that this enzyme might have a pathogenic role in obesity and related metabolic disorders.

Table 1 Patients' demographic characteristics, postoperative weight, and BMI alterations (values expressed as mean±SD) 
Laparoscopic Sleeve Gastrectomy with Minimal Morbidity Early Results in 120 Morbidly Obese Patients

September 2008

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82 Reads

In recent years, laparoscopic sleeve gastrectomy (LSG) as a single-stage procedure for the treatment of morbid obesity is becoming increasingly popular. Of continuing concern are the rate of postoperative complications and the lack of consensus as to surgical technique. A prospective study assessment was made of 120 consecutive morbidly obese patients with body mass index (BMI) of 43+/-5 (30 to 63), who underwent LSG using the following technique: (1) division of the vascular supply of the greater gastric curvature and application of the linear stapler-cutter device beginning at 6-7 cm from the pylorus so that part of the antrum remains; (2) inversion of the staple line by placement of a seroserosal continuous suture close to the staple line; (3) use of a 48 Fr bougie so as to avoid possible stricture; (4) firing of the stapler parallel to the bougie to make the sleeve as narrow as possible and prevent segmental dilatation. Intraoperative difficulties were encountered in four patients. There were no postoperative complications-no hemorrhage from the staple line, no anastomotic leakage or stricture, and no mortality. In 20 patients prior to the sleeve procedure, a gastric band was removed. During a median follow-up of 11.7 months (range 2-31 months), percent of excess BMI lost reached 53+/-24% and the BMI decreased from 43+/-5 to 34+/-5 kg/m(2). Patient satisfaction scoring (1-4) at least 1 year after surgery was 3.6+/-0.8. The good early results obtained with the above-outlined surgical technique in 120 consecutive patients undergoing LSG indicate that it is a safe and effective procedure for morbid obesity. However, long-term results are still pending.

Table 1 Demographic data 
Fig. 2 Percentage of excess weight loss (%EWL) 
Table 4 Pre-and postoperative BMI 
Surgical Treatment of Morbid Obesity: Mid-term Outcomes of the Laparoscopic Ileal Interposition Associated to a Sleeve Gastrectomy in 120 Patients

May 2011

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117 Reads

The aim of this study was to evaluate the mid-term outcomes of the laparoscopic ileal interposition associated to a sleeve gastrectomy (LII-SG) for the treatment of morbid obesity. The procedure was performed in 120 patients: 71 women and 49 men with mean age of 41.4 years. Mean body mass index (BMI) was 43.4 ± 4.2 kg/m². Patients had to meet requirements of the 1991 NIH conference criteria for bariatric operations. Associated comorbidities were observed in all patients, including dyslipidemia in 51.7%, hypertension in 35.8%, type 2 diabetes in 15.8%, degenerative joint disease in 55%, gastroesophageal reflux disease in 36.7%, sleep apnea in 10%, and cardiovascular problems in 5.8%. Mean follow-up was 38.4 ± 10.2 months, range 25.2-61.1. There was no conversion to open surgery nor operative mortality. Early major complications were diagnosed in five patients (4.2%). Postoperatively, 118 patients were evaluated. Late major complications were observed in seven patients (5.9%). Reoperations were performed in six (5.1%). Mean postoperative BMI was 25.7 ± 3.17 kg/m², and 86.4% were no longer obese. Mean %EWL was 84.5 ± 19.5%. Hypertension was resolved in 88.4% of the patients, dyslipidemia in 82.3%, and T2DM in 84.2%. The LII-SG provided an adequate weight loss and resolution of associated diseases during mid-term outcomes evaluation. There was an acceptable morbidity with no operative mortality. It seems that chronic ileal brake activation determined sustained reduced food intake and increased satiety over time. LII-SG could be regularly used as a surgical alternative for the treatment of morbid obesity.



Multi-Centre European Experience with Intragastric Balloon in Overweight Populations: 13 Years of Experience

December 2012

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77 Reads

Background: The request to lose weight is expanding not only in obese and morbidly obese patients but also in overweight patients affected by co-morbidities as diabetes and hypertension and who do not tolerate diet regimen or lifestyle changes. The aim of this study is a multicenter evaluation of outcomes of intragastric balloon in overweight patients. Methods: Patients (BMI 27-30 kg/m2) treated with a BioEnterics Intragastric Balloon (BIB) between 1996 and 2010 were extracted from the database of the participating centres in Rome (Italy), Liège (Belgium) and Madrid (Spain). Primary endpoints were the efficacy and safety at 6 and 42 months from balloon positioning. Secondary endpoints included resolution of co-morbidities. Results: A total of 261 patients were included in this study. The most common indication for balloon placement was a psychological disorder (54%). Mean body mass index (BMI) fell from 28.6 ± 0.4 at baseline to 25.4 ± 2.6 kg/m2 at 6 months and to 27.0 ± 3.1 kg/m2 at 3 years from BIB removal. The mean %EWL was 55.6% at 6 months and 29.1% at 3 years. Forty-seven patients (18%) had complications associated with placement of the intragastric balloon (leak = 28, intolerance = 14, duodenal ulcer = 2, gastritis = 1, oesophagitis = 1, duodenal polyps = 1). The rate of patients with hypertension decreased from 29% at baseline to 16% at 3 years. Diabetes decreased from 15 to 10%, dyslipidaemia decreased from 20 to 18%, hypercholesterolaemia decreased from 32 to 21% and osteoarthropathy decreased from 25 to 13%. Conclusions: The intragastric balloon is safe and effective in overweight patients, helping to reduce progression to obesity and decreasing the prevalence of a number of important co-morbidities.

Linitis Plastica Presenting as Pouch Outlet Stenosis 13 Years after Vertical Banded Gastroplasty

March 1996

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8 Reads

A 53-year-old woman, 13 years after vertical banded gastroplasty (VBG), presented with recently increased vomiting and high-grade pouch outlet stenosis, and was confirmed at laparotomy to have linitis plastics, for which she underwent total gastrectomy. Her pathology is unfavorable. Question is raised as to the incidence of gastric carcinoma subsequent to VBG and other gastric reductive and/or bypass procedures. Comparison is made of the increased incidence of gastric carcinoma over time, after gastric resective procedures for benign disease, versus the 'normal' incidence of gastric carcinoma, and the worse prognosis of gastric stump carcinoma. Noted is the recent observation, in a small series, of worrisome mucosal changes by endoscopic biopsies in patients after VBG, in the area of the pouch outlet. Long-term follow-up, with interval endoscopic biopsies and careful case reporting, will be important if we are to know the risk of eventual gastric carcinoma in these patients.

Robotic Sleeve Gastrectomy: Experience of 134 Cases and Comparison with a Systematic Review of the Laparoscopic Approach

August 2013

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67 Reads

Robotic technology has recently emerged in different surgical specialties, but the experience with robotic sleeve gastrectomy (RSG) is scarce in the literature. The purpose of this study is to compare our preliminary experience with RSG versus the descriptive results of a systematic review of the laparoscopic approach. Data from our RSG experience were retrospectively collected. Two surgeons performed all the cases in one single surgery center. Such information was compared with a systematic review of 22 selected studies that included 3,148 laparoscopic sleeve gastrectomy (LSG) cases. RSG were performed using the daVinci® Surgical System. This study included 134 RSG vs 3,148 LSG. Mean age and mean BMI was 43 ± 12.6 vs 40.7 ± 11.6 (p = 0.022), and 45 ± 7.1 vs 43.6 ± 8.1 (p = 0.043), respectively. Leaks were found in 0 RSG vs 1.97 % LSG (p = 0.101); strictures in 0 vs 0.43 % (p = 0.447); bleeding in 0.7 vs 1.21 % (p = 0.594); and mortality in 0 vs 0.1 % (p = 0.714), respectively. Mean surgical time was calculated in 106.6 ± 48.8 vs 94.5 ± 39.9 min (p = 0.006); and mean hospital length of stay was 2.2 ± 0.6 vs 3.3 ± 1.7 days (p = <0.005), respectively. Four (2.9 %) complications were found in our robotic series. Our series shows that RSG is a safe alternative when used in bariatric surgery, showing similar results as the laparoscopic approach. Surgical time is longer in the robotic approach, while hospital length of stay is lower. No leaks or strictures were found in the robotic cases. However, further studies with larger sample size and randomization are warranted.

Laparoscopic Gastric Greater Curvature Plication: Results and Complications in a Series of 135 Patients

September 2011

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62 Reads

Laparoscopic gastric greater curvature plication (LGGCP) is an emerging restrictive bariatric procedure that successfully reduces the gastric volume by plication of the gastric greater curvature. Its main advantages are the reversibility of the technique as well as the lack of foreign materials or gastrectomy. We present our results, focusing on the effectiveness and complications, and on a new modification of the original technique. One hundred and thirty-five patients underwent LGGCP between April 2008 and December 2009. A five-trocar port technique was used, and following dissection of the greater gastric curvature, single plication of the latter was performed under the guidance of a 36-Fr bougie. Modification of the technique included multiple gastric plications. One hundred and four obese women and 31 obese men (mean age of 36 years) underwent LGGCP for weight reduction. Operative time was 40-50 min, and mean hospital stay was 1.9 days (range 1-6 days). After a follow-up of 8-31 months (mean 22.59), the mean percentage of excess weight loss (%EWL) was 65.29. Subgroup analyses based on BMI values showed that %EWL was significantly higher for patients with BMI < 45 kg/m² (group I) compared with patients with BMI > 45 kg/m² (group II) (69.86 vs 55.49, respectively, p = 0.006). Similarly, inadequate weight loss was significantly higher for group II, while the failure of the technique and postoperative complications were comparable. On the other hand, subgroup analysis based on the technique showed that the modification of the technique did not affect the effectiveness or the operative time; however, it reduced early complications dramatically, including prolonged postoperative vomiting and late gastric obstruction, thus affecting the length of hospitalization. Overall complication rate in our series was 8.8% (12/135). Cases of prolonged postoperative vomiting, GI bleeding, and leak were treated conservatively, while one case of portomesenteric thrombosis and three cases of acute gastric obstruction were treated surgically. LGGCP is an emerging technique sparing gastric resection, the use of foreign materials and intestinal bypass. Its effectiveness is satisfactory for patients with BMI < 45 kg/m², and the complication rate is acceptable.


Gastric Emptying of Solids and Semi-solids in Morbidly Obese and Non-obese Subjects: An Assessment Using the 13C-Octanoic Acid and 13C-Acetic Acid Breath Tests

March 2007

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46 Reads

It has been suggested that obesity is associated with an altered rate of gastric emptying. The objective of the present study was to determine whether the rates of solid and semi-solid gastric emptying differ between morbidly obese patients and lean subjects. The Gastric-emptying time (GET) of solid and semi-solid meals were compared between lean healthy subjects and morbidly obese patients enrolled in two previously published studies. GET of solid and semi-solid meals was measured using the 13C-octanoic acid breath test and 13C-acetic acid breath test, respectively, in 24 lean and 14 morbidly obese individuals of both sexes. Student t-test was used to compare the mean data between the lean and morbidly obese groups. The influence of sex, gender, BMI and morbid obesity on the GET of solid meals was verified by linear regression analysis. Mean t(1/2) values of solid GET (+/- standard deviation) were 203.6 +/- 76.0 min and 143.5 +/- 19.1 min for lean and obese subjects, respectively (P = 0.0010). Mean t(lag) values of solid GET were 127.3 +/- 42.7 min and 98.4 +/- 13.0 min for lean and obese subjects, respectively (P = -0.0044). No significant difference in semi-solid GET was observed between the lean and morbidly obese groups. The present study demonstrated a significantly enhanced gastric emptying of the solid meal test in morbidly obese patients when compared to lean subjects. This finding is compatible with the hypothesis that rapid gastric emptying in morbidly obese subjects increases caloric intake due to a more rapid loss of satiety.

Does Somatostatin-14 Have an Impact on Gastric Fistula After Laparoscopic Sleeve Gastrectomy?

November 2014

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119 Reads

The main complications following laparoscopic sleeve gastrectomy (LSG) is gastric fistula (GF). Gastric fistula is a rare but serious complication (affecting 2 % of LSGs). Somatostatin-14 and its analogs are mainly used in the prevention and curative treatment of digestive fistulas. These compounds inhibit secretions in the pancreas, stomach, and small intestine. Treatment with somatostatin-14 increases the spontaneous closure rate and reduces the closure time of postoperative digestive fistulas. However, the impact of somatostatin-14 on GF after LSG has not been studied. We report on a prospective, non-randomized, single-center, case-matched study of patients receiving somatostatin-14 after a post-LSG GF was discovered. Our results suggest that use of somatostatin-14 is associated with a shorter length of hospital stay and (perhaps) a shorter treatment period.

Table 2 . Scores on eating measures 
Table 3 . Mean IWQoL-Lite scores pre-and post-gastric bypass surgery (n=40) 
Table 4 . Mean BQA physical activity scores on selected items 
Boan J, Kolotkin RL, Westman EC, McMahon RL, Grant JP. Binge eating, quality of life and physical activity improve after Roux-en-Y gastric bypass for morbid obesity. Obes Surg 14, 341-348

April 2004

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449 Reads

Severe obesity has been associated with disordered eating, impaired quality of life (QoL), and decreased physical activity. This study examines changes in these variables 6 months after Roux-en-Y gastric bypass (RYGBP). 40 morbidly obese patients were evaluated at baseline and at 6 months after RYGBP on the following measures: Binge Eating Scale, Three Factor Eating Questionnaire, Impact of Weight on Quality of Life-Lite (IWQoL-Lite), and the Baseline Questionnaire of Activity. 6 months after RYGBP, weight loss averaged 26.7%, and scores on measures of disordered eating, weight-related QoL, and physical activity showed statistically significant improvement from baseline. At the time of follow-up, 100% of participants achieved a score on the Binge Eating Scale that indicated no binge eating problems, and weight-related QoL scores approached those obtained by a reference sample of community volunteers. There were also improvements in the level of self-reported physical activity and television watching behavior. RYGBP resulted in significant improvements in disordered eating, weight-related QoL, and physical activity in addition to weight loss.

Remission of Metabolic Syndrome: A Study of 140 Patients Six Months after Roux-en-Y Gastric Bypass

March 2008

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120 Reads

Metabolic Syndrome (MS) is a complex disorder characterized by a number of cardiovascular risk factors usually associated with central fat deposition and insulin resistance. Nowadays, there are many different medical treatments to MS, including bariatric surgery, which improves all risk factors. The present study aims to evaluate the influence of gastric bypass in the improvement of risk factors associated with MS, during the postoperative (6 months). This was a retrospective study of 140 patients submitted to gastric bypass. The sample was comprised of a female majority (79.3 %). The mean body mass index (BMI) was 44.17 kg/m2. We evaluated the weight of the subjects, the presence of diabetes mellitus and hypertension as comorbidities, as well as plasma levels of triglycerides (TG), total cholesterol and its fractions, and glycemia, in both preoperative and postoperative. The percentage of excess weight loss (%EWL) was similar in men and women, with an average of 67.82 +/- 13.21%. Concerning impaired fasting glucose (> or =100 mg/dl), 41 patients (95.3%) presented normal postoperative glycemia. There has been an improvement of every appraised parameter. The mean decrease in TG level was 66.33 mg/dl (p<0.0001). Before the surgery, 47.1% were hypertensive; after it, only 15% continued in antihypertensive drug therapy (p<0.0001). Otherwise, the only dissimilar variable between sexes was the high-density lipoprotein (HDL) level. Gastric bypass is an effective method to improve the risk factors of metabolic syndrome in the morbidly obese.

Hand-Assisted Laparoscopic Vertical Banded Gastroplasty: Technique and Analysis of the First 140 Cases

October 2002

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9 Reads

The use of laparoscopic surgery to perform bariatric operations offers advantages to morbidly obese patients. Between January 1999 and June 2001, 140 patients underwent hand-assisted laparoscopic VBG using the Handport System. In the 110 females (78.6%) and 30 males (21.4%), mean age was 38 years (range 19-65), mean body weight 115.8 kg (range 89-200), and mean BMI 41.8. Severe obesity was present in 41%, morbid obesity in 41% and super obesity in 9% of the patients. Comorbid conditions included hyperlipidemia in 70% of patients, arthritis in 44%, hypertension in 38%, COPD in 18%, GERD in 12%, impaired glucose tolerance and diabetes in 10%, sleep-apnea in 5% and coronary heart disease in 1%. There was no operative mortality. Mean excess weight loss was 60.7% at 12 months and 63% at 18 months. Mean BMI was 30.8 at 12 months and 30.4 at 18 months. A decrease in BMI of 11 kg/m2 was reached at 12 months. According to the Reinhold Classification (residual excess weight < 50%), good to excellent results were achieved in 75.7% at 1 year and in 77.7% at 18 months. Early postoperative complications were 4 wound infections, 3 atelectasis or pneumonia, 1 deep vein thrombosis, 1 subphrenic abscess and 1 wound hematoma. Late postoperative complications were 2 incisional hernias, 2 esophagitis, 1 symptomatic gallstones, 1 staple-line fistula, 9 protracted vomiting and 6 band-related problems. The short-term results compare favorably with the literature on open VBG. Because of the reduction of perioperative risks with the laparoscopic approach, bariatric surgery should be performed laparoscopically if the expertise is available.

Laparoscopic Roux-en-Y Gastric Bypass with 2-metre Long Biliopancreatic Limb for Morbid Obesity: Technique and Experience with the First 150 Patients

February 2005

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111 Reads

Laparoscopic Roux-en-Y gastric bypass (RYGBP) is being performed widely as a treatment of choice for morbid obesity. We present our method and experience with the first 150 consecutive cases of laparoscopic RYGBP with a 2-m long biliopancreatic limb (BP-limb). Between November 2001 and November 2003, a prospective analysis of 150 patients was performed identifying technical success and complications. Before surgery, patients underwent a strict multidisciplinary behavioral program. At operation the stomach was transected proximally with a linear stapler (60-mm, Endo-GIA) to create a prolongation of the esophagus (gastric tube) along the lesser curvature, resulting in a 40-50 ml pouch. Two meters of the proximal jejunum were bypassed (BP-limb), creating an antecolic Roux-en-Y gastro-jejunostomy to the posterior wall of the gastric tube using a 45-mm linear Endo-GIA stapler. The entero-anastomosis was created 50 cm below the gastro-jejunostomy, also with a 45-mm linear Endo-GIA. Mean BMI was 50.0, and 78% of patients were females. With 100% follow-up, we found an EWL of 50% 6 months after surgery, gradually rising to 80% after 18 months. The mean operating time was 116 min for the first 50 cases and decreased to 82 min for the last 50 cases. Intestinal leakage occurred in 5 patients (3%) and bleeding in 5 (3%). Most of these complications occurred in the first 50 cases, and all but one were treated successfully with an early laparoscopic re-operation. Marginal ulcers were found in 16.6% of patients. No internal hernias have occurred. The operation demands advanced laparoscopic skills, but technically it is relatively simple and has an acceptable complication rate. Short-term results regarding excess weight loss are at least comparable to the RYGBP with a long alimentary limb.

The Incidence of Clinical Postoperative Thrombosis After Gastric Surgery for Obesity During 16 Years

September 1997

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9 Reads

Suggested risk factors for postoperative thrombosis such as high fatty acid levels, hypercholesterolemia and diabetes are common in obese patients. In a retrospective study, the case records of 328 patients operated for obesity by gastric procedure from September 1977 until December 1993 were analyzed: 253 women and 75 men with a mean age of 38 years and a mean body mass index (BMI) of 44 kg/m2. The operation time, use of epidural anesthesia, and the occurrence of risk factors; fatty acid levels, hypercholesterolemia and diabetes were recorded. Symptomatic thromboses were verified by phlebography or phlethysmography and pulmonary embolism with ventilation/perfusion scintigraphy or autopsy. The mean operating time was 128 minutes, 77% had epidural anesthesia and the mean hospital stay was 12.3 days. The long hospital stay was due to the fact that most patients took part in different scientific studies perioperatively. The incidence of thromboembolism was 2.4%. Four patients had pulmonary embolism, in one of them this was fatal. Three patients had deep leg vein thrombosis and one patient had arm thrombosis secondary to a central venous catheter. None of these patients had high fatty acids, diabetes or high cholesterol. Of the patients, 298 were given dextran-70 (Macrodex, Pharmacia) as prophylaxis, seven were given heparin and 23 were given no prophylaxis. In the patient group without diagnosed thrombosis, 31% had high fatty acid levels, 2% had high cholesterol levels and 9% had diabetes. Obese patients seem to have a moderate risk of developing postoperative thrombosis when an effective prophylaxis is used. High free fatty acids, hypercholesterolemia and diabetes are not obvious extra risk factors in obese patients. Thromboprophylaxis should be given to all operated obesity patients regardless of age. The surgeons must be aware and investigate promptly any symptoms suggestive of thromboembolism.

Greenstein RJ, Rabner G, Taler Y. Bariatric surgery vs. conventional dieting in the morbidly obese. Obes Surg 4: 16-23

February 1994

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13 Reads

Weight loss and psychosocial events have been compared between low calorie conventional diet (n = 11) or following obesity surgery (n = 17). Interviews were >/= 9 months following initiation of treatment. After surgery significantly less hunger was experienced (surgery 76% [13/17] vs diet 18% [2/11] p < 0.01) and less will-power was required to stop eating (surgery 88% [15/17] vs diet 27% [3/11] p < 0.001). More dieters stopped eating because of 'figure and health' (surgery 12 % [2/17] vs diet 64 % [7/11 ] p < 0.01) whereas postoperative patients stopped due to vomit avoidance (surgery 53% [9/17] vs diet 0% [0/11] p </= 0.05). More of the postoperative group were employed (surgery 76% [13/17] vs diet 18% [2/11) p < 0.005). Following surgery there were subjective appearance improvements (surgery 94% [15/16] vs diet 50% [5/10] p < 0.01) and fewer social limitations (surgery 69% [11/16] vs diet 27% [3/11] p </= 0.05). Physical activity improved (surgery 73% [11/15] vs diet 18% [2/11] p < 0.01). Although both groups continue to feel 'fat' at times, more dieters think other people view them as obese (surgery 35% [6/17] vs diet 91% [10/11] p </= 0.05). Satisfaction with weight control method was greater following surgery (surgery 100% [16/16] vs diet 33% [3/9] p < 0.005). Enforced behavior modification (vomit avoidance) is the mechanism of action of gastric restrictive surgery. Physical activity increases, and satisfaction with weight loss method is greater, after surgery. Employment is greater (probably self selection) in the post-surgical group. We found that comparing >/= 9 months following surgery or beginning a conventional diet, the morbidly obese have a more positive response to surgery.

Table 1 Data for individual patients 
Fig. 4 Algorithm for evaluation of patients suspected of having Cushing's syndrome. UFC urine free cortisol, DST dexamethasone suppression test. Abnormal values are UFC greater than the upper limit of normal for the assay, DST cortisol level >1.8 μg/dL (50 nmol/L), and late-night salivary cortisol >4 nmol/L (145 ng/dL). *Unusual features for  
Discovery of Cushing’s Syndrome After Bariatric Surgery: Multicenter Series of 16 Patients

April 2015

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508 Reads

The aim of this study is to demonstrate the importance of considering Cushing's syndrome (CS) as a potential etiology for weight gain and metabolic complications in patients undergoing bariatric surgery (BS). This is a retrospective chart review case series of patients (n = 16) with CS from five tertiary care centers in the USA who had BS. Median age at BS surgery was 35.5 years (median 2.5 years between BS and CS surgery). CS was not identified in 12 patients prior to BS. Four patients had CS surgery prior to BS, without recognition of recurrent or persistent CS until after BS. Median body mass index (BMI) values before BS, nadir after BS, prior to surgery for CS, and after surgery for CS were 47, 31, 38, and 35 kg/m(2), respectively. Prior to BS, 55 % of patients had hypertension and 55 % had diabetes mellitus. Only 17 % had resolution of hypertension or diabetes mellitus after BS. CS may be under-recognized in patients undergoing BS. Testing for CS should be performed prior to BS in patients with features of CS and in post-operative BS patients with persistent hypertension, diabetes mellitus, or excessive weight regain. Studies should be conducted to determine the role of prospective testing for CS in subjects considering BS.

Laparoscopic Mini-Gastric Bypass (LMGB) in the Super-Super Obese: Outcomes in 16 Patients

July 2008

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36 Reads

The ideal management of the super-super obese patient (SSO) is unclear and controversy exists as to the choice of procedure as well as the risk for increased morbidity and mortality. I present my experience of laparoscopic mini-gastric bypass (LMGB) in 16 SSO patients with early follow-up results. Review of a prospectively maintained database was performed. All the patients underwent LMGB by a single surgeon (CP). Data collected included demographics, operative time, length of stay, complications, and weight loss. Follow-up data was obtained at office visits in addition to periodic telephone interviews and e-mails. All office follow-up and review of correspondence from Primary Care Physicians (PCP) was managed by the operating surgeon. Sixteen patients were identified as being SSO and comprise the study group. There were 14 women and two men. Average age was 40 years (27-61). Average weight and BMI were 166 (150-193) and 62.4 (60-73), respectively. All procedures were performed laparoscopically by a single surgeon with no conversion to open. Average operative time was 78 min (41-147 min) and hospital stay was 1.2 days. Intraoperative complications included a liver laceration in one patient and an enterotomy in another. Both were managed laparoscopically. No patients required readmission to the hospital, and there were no major complications or deaths. Weight loss showed a consistent increase over the follow-up period with 2 year results of 72 KG lost or 65% EWL. Laparoscopic mini-gastric bypass (MGB) is a technically simple and safe procedure in SSO patients. LMGB has the advantages of being a single stage procedure, being easily reversible and revisable in a laparoscopic procedure and does not sacrifice portions of the stomach or implant foreign materials. Weight loss appears favorable in the short term; however, information regarding long-term weight loss, durability, and safety profile in this population will require a greater number of patients and longer follow up.

Table 1 Sample characteristics (mean (SD) or %) of bariatric surgery patients 2-16 years postsurgery 
Table 3 Differences in means (SD) for weight status, weight loss, and weight maintenance in bariatric surgery patients 2-16 years postsurgery, according to MVPA and sitting time 
Table 4 Results of multivariate logistic and linear regression analyses, evaluating the independent associations of MVPA and sitting time with weight loss outcomes in bariatric surgery patients 2-16 years postsurgery 
Keeping the Weight Off: Physical Activity, Sitting Time, and Weight Loss Maintenance in Bariatric Surgery Patients 2 to 16 Years Postsurgery

February 2014

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332 Reads

Bariatric surgery patients often exhibit low levels of physical activity (PA), despite the presumed importance of PA as an adjunct to surgery for successful weight loss. Little is known regarding the associations of PA and sedentary behaviors to weight loss outcomes in the long term following surgery. The objective of the study was to assess the associations of PA and sitting time with weight status, weight loss, and weight maintenance outcomes in bariatric patients 2-16 years postsurgery. A total of 303 Roux-en-Y Gastric Bypass patients (73 % female; mean age 47 ± 10 years, mean 7 ± 4 years since surgery) completed a telephone questionnaire. Patients reported moderate-to-vigorous PA (MVPA: # sessions/week ≥30 min) and average daily sitting time (h/day). Associations with various weight outcomes were assessed. Only 48 % of patients reported ≥1 session/week MVPA, and mean reported sitting time was 7 ± 4 h/day. Neither MVPA nor sitting time was associated with weight loss outcomes at patients' lowest weight postsurgery. However, both MVPA and sitting time were independently positively and inversely, respectively, associated with total (kg) weight loss, % weight loss, and % excess weight loss at current weight, as well as weight loss maintained vs. regained, controlling for age, sex, surgery type, presurgery BMI, total initial weight loss, and time since surgery. Results demonstrate associations between MVPA and high sitting time and weight loss outcomes among bariatric patients in the long term. The implications for long-term weight management and concomitant health outcomes highlight the need for appropriate follow-up and interventions in this unique high-risk patient population.

A Prospective Multicenter Study of 163 Sleeve Gastrectomies: Results at 1 and 2 Years

April 2008

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54 Reads

Good results obtained after laparoscopic sleeve gastrectomy (LSG), in terms of weight loss and morbidity, have been reported in few recent studies. Our team has designed a multicenter prospective study for the evaluation of the effectiveness and feasibility of this operation as a restrictive procedure. From January 2003 to September 2006, 163 patients (68% women) with an average age of 41.57 years, were operated on with a LSG. Indications for this procedure were morbid obese [body mass index (BMI)>40 kg/m2] or severe obese patients (BMI>35 kg/m2) with severe comorbidities (diabetes, sleep apnea, hypertension...) with high-volume eating disorders and superobese patients (BMI>50 kg/m2). The average BMI was 45.9 kg/m2. Forty-four patients (26.99%) were superobese, 84 (51.53%) presented with morbid obesity, and 35 (21.47%) were severe obese patients. Prospective evaluations of excess weight loss, mortality, and morbidity have been analyzed. Laparoscopy was performed in 162 cases (99.39%). No conversion to laparotomy had to be performed. There was no operative mortality. Perioperative complications occurred in 12 cases (7.36%). The reoperation rate was 4.90% and the postoperative morbidity was 6.74% due to six gastric fistulas (3.66%), in which four patients (2.44%) had a previous laparoscopic adjustable gastric banding. Long-term morbidity was caused by esophageal reflux symptoms (11.80%). The percentage of loss in excessive body weight was 48.97% at 6 months, 59.45% at 1 year (120 patients), 62.02% at 18 months, and 61.52% at 2 years (98 patients). No statistical difference was noticed in weight loss between obese and extreme obese patients. The sleeve gastrectomy seems to be a safe and effective restrictive bariatric procedure to treat morbid obesity in selected patients. LSG may be proposed for volume-eater patients or to prepare superobese patients for laparoscopic gastric bypass or laparoscopic duodenal switch. However, weight regained, quality of life, and evolution ofmorbidities due to obesity need to be evaluated in a long-term follow up.