Surgery for Obesity and Related Diseases - Articles in Press

Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) Versus Laparoscopic Adjustable Gastric Banding (LAGB): 5 Year Follow-Up - Accepted Manuscript

2010-03-08

Abstract: Background:: Bariatric surgery is an effective alternative of treatment for morbid obesity. Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic adjustable gastric banding (LAGB) are commonly performed procedures. The aim of this study was to evaluate and compare long-term outcomes after LRYGB and LAGB.Methods:: Prospective database of all patients that underwent LRYGB or LAGB with 5 years follow up.Results:: From July 2001 to September 2003, 91 and 62 patients underwent LRYGB and LAGB respectively. 73.6% of LRYGB and 91.9% of LAGB had 5 years follow up. 89% and 82% were women respectively. Mean age and BMI was 34.5±11.0 years and 39.6±4.9 kg/m2 for LRYGB and 38.4±13.1 years and 35.8±4.0 kg/m2 for LAGB. Mean operative time was LRYGB 150±58 minutes and 73±23 minutes for LAGB (p<0.05). Conversion and reoperation rate was 8% and 4.3 % in LRYGB versus 0 % in LAGB. Early postoperative complications were observed in 12 and 1 patients (p=0.014) after LRYGB and LAGB. Late complications were present in 33 and 17 patients respectively (p=NS). %EWL at 5 years was 92.9±25.6% and 59.1±46.8% (p<0.001) for LRYGB and LAGB respectively. Surgical failure (%EWL<50%) at 5 years was 6% for LRYGB and 45.6% for LAGB. A late reoperation was needed in 24.1% of LAGB.Conclusion:: A higher %EWL at 1 and 5 years was observed in LRYGB compared to LAGB. LAGB had >40% of surgical failure and a 24.1% reoperation rate at 5 years follow up.

The Incidence of Low Vitamin A Levels and Ocular Symptoms after Roux-en Y Gastric Bypass - Accepted Manuscript

2010-03-03

Abstract: Background:: Previous reports have demonstrated a significant incidence of fat soluble vitamin deficiency after bariatric surgery. The purpose of this study was to determine the incidence of Vitamin A deficiency after Roux-en Y gastric bypass (RYGB) and to correlate laboratory findings with ocular symptoms potentially related to Vitamin A deficiency.Methods:: All patients who underwent RYGB were invited to participate in a nutritional screening. Patients completed a detailed survey concerning ocular symptoms and had their Vitamin A level evaluated.Results:: Low Vitamin A levels were identified in 7 of 64 RYBG patients (11%).. Ocular xerosis was present in 18 patients (27%) with night vision changes reported in 45 (68%). Visual disturbances occurred in 7 patients (11%) found to have low Vitamin A , with hypovitaminosis A present in 22% of patients with xerosis (p < 0.05).Conclusions:: Low Vitamin A levels and frequent ocular complaints that may be associated with decreased Vitamin A, are common findings in the post-RYBG patient population. Further study is needed to assess the role of routine vitamin A screening and replacement in the post-bariatric surgery patient.

Assessing Cost-Effectiveness in Obesity: Laparoscopic adjustable gastric banding for severely obese adolescents - Accepted Manuscript

Jaithri Ananthapavan, Marjory Moodie, Michelle Haby, Robert Carter — 2010-03-02

Abstract: Objective:: To assess from a societal perspective the incremental cost-effectiveness of laparoscopic adjustable gastric banding for severely obese adolescents in Australia.Methods:: The intervention, modelled as part of the Assessing Cost-Effectiveness in Obesity (ACE-Obesity) project, used evidence of effectiveness and costs from a case series of 28 adolescents who had gastric banding in Melbourne, and extrapolated to the eligible Australian adolescent population. Cost offsets and DALY benefits (based on the change in Body Mass Index (BMI) 3 years post surgery) were tracked until the cohort reached the age of 100 years or death and were discounted at 3% per annum. Simulation-modelling techniques were used to present a 95% uncertainty interval (UI) around the cost-effectiveness ratio. The intervention was also assessed against second stage filter criteria (‘equity’, ‘strength of evidence’, ‘acceptability’, feasibility’, sustainability’ and ‘side-effects’).Results:: The intervention reached 4,120 severely obese, privately insured adolescents. It cost AUD130M (95%UI AUD52M; AUD265M), and resulted in an incremental saving of 55,400 (95%UI 12,600; 140,000) BMI units at 3 years post surgery, which translated to 12,300 (95%UI 5,000; 24,670) DALYs saved over their lifetime. The cost-offsets totalled AUD75M (95%UI AUD30.5M; AUD150M), resulting in a net cost per DALY saved of AUD4,400 (95%UI AUD2,900; AUD6,120).Conclusion:: Whilst the intervention was cost-effective under current modelling assumptions, it is unlikely to be acceptable to all stakeholders, including some severely obese adolescents. Nevertheless, gastric banding has an important role in the management of morbid obesity in adolescents.

The role of endoscopy in the evaluation and management of persistent gastrojejunostomy leaks after RYGB - Accepted Manuscript

Tannous K. Fakhry, Michel M. Murr — 2010-03-02

Computed Tomography Guided Percutaneous Gastrostomy for Management of a Gastric Remnant Leak Following Roux-en-Y Gastric Bypass - Accepted Manuscript

Shahzeer Karmali, Nader Azer, Vadim Sherman, Daniel W. Birch — 2010-03-02

5-Year Outcomes of Patients with Type 2 Diabetes who Underwent Laparoscopic Adjustable Gastric Banding - Accepted Manuscript

2010-03-02

Abstract: Background:: Evidence of the positive effects of gastric banding on patients with diabetes continues to mount. Long-term follow-up of such patients, however, is limited. The purpose of this study is to provide long-term outcomes in diabetics undergoing laparoscopic adjustable gastric banding (LAGB) at our institution.Methods:: From January 2002 through June 2004, 102 patients with type-2 diabetes underwent LAGB. Study parameters included: preoperative age, gender, race, BMI, duration of diabetes prior to surgery, fasting glucose level, HbA1c and medications. Preoperative data on all patients were collected prospectively and entered into an IRB-approved database. Then beginning in 2008, efforts were made to collect 5-year follow-up data.Results:: 7 patients were excluded because they did not reach the 5-year time-point (2 patients had the band removed early and 5 patients died - 2 from cancer, 3 unknown causes), leaving 95 patients included in the study. Mean preop age was 49.3 years (21.3 – 68.4). Mean preop BMI was 46.3 kg/m2 (range: 35.1 –71.9), which decreased to 35.0 kg/m2 (range: 21.1 – 53.7) by the 5-yr follow-up time-point, yielding a mean of 48.3% excess-weight-loss. The mean time of diabetes diagnosis was 6.5 years before surgery. 88.3% of patients (83/94) were taking medications preop, with 14.9% overall taking insulin. At 5 years postoperatively, 46.5% (33/71) of patients were on medications, with 8.5% on insulin. Mean fasting preoperative glucose level was 146.0 mg/dL which decreased to 118.5 at 5-years (P=0.004). Mean preoperative HbA1c was 7.53 (n=72), versus 6.58 (n=64) at 5-years (P<0.001). Overall, diabetes resolved (off meds, with HbA1c < 6 and/or glucose < 100 mg/dL) in 39.7% (23/58) of patients and improved (use of fewer medications and/or fasting glucose levels between 100-125 mg/dL) in 71.9% (41/57). The combined improvement/remission rate was 80% (64/80).Conclusion:: Our data demonstrates that LAGB delivers substantial sustained positive impact on diabetes in morbidly obese patients, with a significant reduction in HbA1c and 80% overall rate of improvement/remission.

Internal consistency and validity assessment of the SCL-90-R for bariatric surgery candidates - Accepted Manuscript

Dana Ransom, Kathleen Ashton, Amy Windover, Leslie Heinberg — 2010-02-24

Abstract: Background:: Presurgical bariatric psychological evaluations often utilize both a clinical interview and psychometric testing. Among the most commonly used measures to date are the MMPI-2, BDI-II, MBMD, and SCL-90-R [1,2].Objective:: Given concerns regarding psychometric properties of some measures [3], this study explored the internal consistency reliability and validity of the SCL-90-R [4] and provides a preliminary set of norms for the instrument within a bariatric population. While the American Society for Metabolic and Bariatric Surgery includes the SCL-90-R as a suggested measure for the assessment of personality and psychopathology [2], no known studies have been published on the reliability or validity of the SCL-90-R within bariatric samples.Setting:: The study was completed at a large Midwestern medical center in the United States.Methods:: SCL-90-R inventories were completed by 322 pre-surgical bariatric patients as part of their psychological evaluation. The majority of patients were female (75.5%), with a Mean age of 46.7 ± 10.8 years and a Mean body mass index of 50.4 kg/m2 ± 10.9 kg/m2.Results:: Internal consistency coefficients for the 9 subscales ranged from .76 to .90. Convergent validity was demonstrated by scale correlations with data gathered in the clinical interview.Conclusion:: In comparison with other recently studied measures, including the MBMD, the SCL-90-R demonstrates good internal consistency and preliminary validity data for bariatric patients. Providers may want to consider the SCL-90-R as a screening measure for bariatric surgery patients.

Psychological Classification as a Communication and Management Tool in Obese Patients Undergoing Bariatric Surgery - Accepted Manuscript

Robin P. Blackstone, Melisa Celaya Cortes, L. Buddy Messer, David Engstrom — 2010-02-22

Abstract: Background: Psychological evaluation is used to ascertain the patient’s suitability for bariatric surgery and challenge their ability to comply with therapy. The modern paradigm of obesity includes a neurobiological component working in parallel with the limbic system of appetite and reward. To achieve the goals of surgery evaluation of the psychological fitness of the patient is often included in the clinical pathway. A psychological classification system is presented with the goal of integrating psychological factors into patient management.Methods: All patients (RYGB, N=1814; LAGB, N=589) were evaluated with psychological testing/interview and assigned to Groups 1-4 prior to surgery. Group 1 patients (N=788; 32.8%) did not necessitate intervention, Group 2 (N=1110; 46.2%) were requested to attend support group, group 3A (N=394; 16.4%) and 3B (N=111; 4.6%) required intervention in order to continue to surgery, Group 4 patients were not recommended for surgery. Main outcome measures such as complication rates, readmissions and reoperations were analyzed for differences between psychological groups.Results: After comparing outcome measures between each classification, there were no significant differences in major complication rates, readmissions, reoperations, and length of stay between each group. Group 3A and 3B were able to achieve similar rates of success despite their psychosocial impairment at the time of the initial evaluation.Conclusion: Assignment of psychological classification facilitates bariatric team recognition of unique psychological factors that impact the success of surgery. Assessing the patient’s psychological composition and addressing potential psychosocial barriers prior to surgery can increase positive long-term outcomes and reduce complications after bariatric surgery.

Endoscopic Foreign Body Removal (EFBR) for Treatment of Chronic Abdominal Pain in Post-Roux-en-Y Gastric Bypass Patients - Accepted Manuscript

Marvin Ryou, Owen Mogabgab, David B. Lautz, Christopher C. Thompson — 2010-02-22

Abstract: Background:: Common endoscopic findings in patients who have undergone Roux-en-Y gastric bypass (RYGB) with chronic abdominal pain include marginal ulceration, gastro-gastric fistulae, and jejunal erosions. However, suture or staples eroding into the gastric pouch may also contribute to abdominal pain. Redundant suture is typically regarded as a normal part of post-operative anatomy.Objective:: To assess the effects of endoscopic foreign body removal (EFBR) of partially exposed sutures and staples in post-RYGB patients with chronic abdominal pain.Setting:: University hospital, United StatesMethods:: Retrospective study of consecutive patients between January 2006 to July 2007.. Post-RYGB patients with chronic abdominal pain underwent EFBR of exposed sutures/staples. Pain scores were obtained pre-procedure, immediately post-procedure, and at the time of telephone follow-up (median 7.2 months)Results:: Of a total 21 patients, 15 (71%) reported immediate symptomatic improvement. Specific endoscopic accessories were found to be more useful than others in dealing with various foreign materials. 15 of 21 patients (71%) were available for telephone follow-up. 13 of 15 (87%) reported continued symptomatic improvement, with 9 (60%) reporting complete pain resolution and 4 (27%) reporting partial improvement. Eroded foreign material was seen in association with marginal ulcers in 3 patients (14%), with gastritis in 7 patients (33%), and with an inflammatory polyp in 1 patient (5%).Conclusions:: Eroded suture and staples may cause chronic abdominal pain in post-RYGB patients. In symptomatic patients, visible suture or staples should be considered potential etiologies of chronic pain, instead of being regarded as normal post-operative findings. EFBR may be of therapeutic benefit in these patients.

Endoscopic Repair of Gastro-Gastric Fistula After Roux-En-Y Gastric Bypass: A Less Invasive Approach - Accepted Manuscript

Gloria Fernandez-Esparrach, David B. Lautz, Christopher C. Thompson — 2010-02-22

Abstract: Introduction:: Gastro-gastric fistulae (GGF) are a well known complication of Roux-en-Y gastric bypass (RYGB). Surgical repair of such fistulae is technically difficult with significant associated morbidity.Aim:: Evaluate the efficacy of endoscopic GGF closure.Setting:: University Hospital, United StatesPatients and methods:: Patients with RYGB and confirmed GGF on EGD or barium study. Endoscopic repair was performed with the EndoCinch suturing system (Group 1) or clips (Group 2). All patients were followed in the outpatient clinic or contacted by phone 1, 6 and 18 months after the procedure, then as indicated by symptoms.Results:: Ninety five patients were included in this series (Group 1, n=71, 75%; Group 2, n=24, 25%). Mean fistula size was significantly larger in Group 1 than Group 2 (14.5±8.7 vs 7.7±6, p=0.01). An average of 2.2 sutures or 3 clips (range, 2-7) was used. Complete initial fistula closure was achieved in 90 patients (95%) and reopening was seen in fifty-nine (65%) at an average of 177±202 days. Average follow-up was 395 days (±49), with 22 patients lost to follow-up. Two significant complications were reported (bleeding and esophageal tear). None of the GGF with an initial size >20 mm remained closed during the follow-up period, whereas 10/31 (32%) of the fistulae 10 mm in diameter or smaller remained closed.Conclusion:: Per-oral endoscopic repair of post bariatric GGF is technically feasible and safe, but with limited durability. Fistula size predicts long term outcomes with best results seen in fistulae 10 mm in diameter or smaller.

Successful management of chyloperitoneum after laparoscopic adjustable gastric banding in two patients - Accepted Manuscript

Peter Nau, Vimal Narula, Bradley Needleman — 2010-02-22

Association of Obesity With Risk for Coronary Heart Disease: Findings From the National Health and Nutrition Examination Survey, 1999-2006 - Accepted Manuscript

2010-02-22

Abstract: Background:: Obesity is a well known risk factor for development of coronary heart disease (CHD). The aim of this study was to examine the differences in the 10-year CHD risk with increasing severity of obesity from men and women participating in the latest National Health and Nutrition Examination Survey (NHANES).Study Population:: Data from a representative sample of 12,500 U.S. participants in the NHANES between 1999 and 2006 were reviewed. The Framingham Risk Scores (FRS) were calculated for men and women according to body mass index (BMI) of <25.0, 25.0-29.9, 30.0-34.9, and ≥35.0.Results:: The prevalence of individuals with hypertension increased with increasing BMI, from 24% for BMI <25.0 to 54% for BMI ≥35.0, and abnormal total cholesterol level (>200 mg/dl) increased from 40% for BMI <25.0 to 48% for BMI ≥35.0. The 10-year CHD risk for men increased from 3.1% for BMI <25.0 to a peak of 5.6% for the BMI 30.0-34.9 group, and the 10-year CHD risk for women increased from 0.8% for BMI <25.0 to a peak of 1.5% for BMI ≥35.0. Both diabetes and hypertension are independent risk factor for increasing CHD risk.Conclusions:: The 10-year coronary heart disease risk, as calculated from the Framingham risk scores, substantially increases with increasing BMI. An important implication from this study is the need for implementing surgical and medical approaches to weight reduction in an effort to reduce the impact of morbidity and mortality from coronary heart disease on the U.S. healthcare system.

A Technique for Non-Fascial Fixation of the Laparoscopic Adjustable Gastric Band Access Port - Accepted Manuscript

James Clay Wellborn, Suzan Hayden Wellborn, Trey Wellborn — 2010-02-16

Abstract: Background:: Access port complications occur in 10-20% of patients undergoing Laparoscopic Adjustable Gastric Banding (LAGB). These include infection, leakage, difficult access, erosion, pain and poor cosmetic results requiring revision. Additionally, traditional fascial fixation techniques require longer operative times and fluoroscopic or sonographic localization increasing the time, expense, and discomfort associated with LAGB. A technique of non fascial fixation of the LAGB access port with minimal complication is described.Methods:: From August 2001 to August 2007 1,027 consecutive patients underwent LAGB. 1008 (97%) patients were available for follow up for greater than 1 year. The access port was placed in a subcutaneous pocket created 2 cm deep to the skin anterior to the sutures. The group was analyzed for complications requiring revision,operative placement time,ease of access, and need for radiographic localization of the port.Results:: There were 0 (0%) early post-operatively infections and 6 (0.6%) late postoperative infections. Other complications requiring revision were distributed as follows: Skin erosions; 2 (0.2%), poor cosmetic results; 2 (0.2%), malposition; 2 (0.2%), and leakage due to access trauma; 3 (0.3%). Overall, there were 15 (1.5%) access port complications. Additionally, port placement time averaged 5 minutes and no patient required sonographic or fluoroscopic guidance for access.Conclusions:: Non-fascial fixation of LAGB access port, utilizing a technique familiar to most general surgeons, is associated with fewer complications than traditional fascial fixation. Additionally, operative times, ease of access, and patient comfort and expense are positively impacted by this technique.

Laparoscopic gastric band slippage diagnosed with esophagogastroduodenoscopy in a 12-week gestation nulliparous patient - Uncorrected Proof

W.F. DeNino, R.S. Zubarik, P.M. Forgione — 2010-02-15

As the prevalence of obesity has increased, the number of bariatric operations performed has also increased annually. From 1999 to 2002, approximately one third of American women of child-bearing age (20–39 years) were considered obese. Laparoscopic adjustable gastric banding (LAGB) is the most commonly performed bariatric procedure in Europe and Australia and is growing in popularity in the United States . LAGB has been shown to be safe during pregnancy and, moreover, has decreased the occurrence of obesity-related gestational complications . LAGB is not without complications, however. The complications are typically related to the port (e.g., port site infection, tube disconnection, dislocation) or to the band itself (e.g., slippage, erosion, pouch dilation) . Such complications are usually diagnosed from the clinical history and routine radiologic imaging findings. During pregnancy, additional attention must be paid, not only to proper nourishment and fetal weight gain, but also to distinguishing the physiologic responses to gestation from complications due to gastric banding.

Laparoscopic Single-Port Sleeve Gastrectomy for Morbid Obesity: Preliminary Series - Accepted Manuscript

2010-02-15

Abstract: Background:: Laparoscopic sleeve gastrectomy (LSG) has been recently proposed as a sole bariatric procedure because of its considerable weight loss in morbidly obese patients. Traditionally, LSG requires five to six skin incisions to allow for placement of multiple trocars. With the introduction of single-incision laparoscopic surgery (SILS), multiple abdominal procedures have been performed with a sole umbilical incision with good cosmetic outcomes. The purpose of our study is to evaluate the feasibility and safety of laparoscopic single incision sleeve gastrectomy for morbid obesity.Methods:: Eight consecutive patients underwent laparoscopic single-incision sleeve gastrectomy at the Operative Unit of Bariatric Surgery of the University of Rome Tor Vergata between March 2009 and June 2009.Results:: There were five women and three men, with a mean age of 44.4 years . Mean pre-operative BMI (body mass index) was 56.2 Kg/m2. Mean operative time was 128 min. Mean post-operative stay was 2.4 days. Mean post-operative BMI was 49.3 Kg/m2 with a mean follow-up period of 3.6 months. Mean %EWL was 33% for the same period.Conclusion:: laparoscopic single incision sleeve gastrectomy seems to be safe, technically feasible and reproducible. A randomized trial comparing single incision sleeve gastrectomy vs conventional sleeve gastrectomy may be needed to evaluate post-operative results related to abdominal wall complications.

Editorial comment - Uncorrected Proof

Stacy A. Brethauer — 2010-02-15

Escalona et al. have presented their initial experience with an innovative modification of the duodenal-jejunal bypass liner (DJBL). In this report, the authors present their results with 10 patients who had a flow restrictor placed at the proximal end of the DJBL. Importantly, they also evaluated the physiologic effects of this modification using gastric emptying studies. This small pilot study was well planned and executed and builds on the previous investigations of this type of device.

Incisionless Revision of Post Roux-en-Y Bypass Stomal and Pouch Dilitation: Multi-center Registry Results - Accepted Manuscript

2010-02-15

Abstract: Background:: Surgical revision for weight regain after Roux-en-Y gastric bypass (RYGB) has been tempered by the high complication rates associated with standard approaches. Endolumenal revision of stoma and pouch dilatation should intuitively confer a better risk profile. However, questions of clinical safety, durability, and weight loss need to be answered. We report our multi-center intra-operative experience and post-operative follow-up to date utilizing the Incisionless Operating Platform™ (IOP) for this patient subset.Methods:: Patients who had regained significant weight 2+ years after RYGB after losing = 50% of EBW post-RYGB were endoscopically screened for stomal and/or pouch dilatation. Qualified patients underwent incisionless revision using the IOP to reduce stoma and pouch size by placing anchors to create tissue plications. Data on safety, intra-operative performance, post-op weight loss, and anchor durability were recorded to date as part of 2 year post-op follow-up.Results:: 116 consecutive patients were prospectively studied. Anchors were successfully placed in 112/116 (97%), with average intraoperative stoma diameter and pouch length reduction of 50% and 44%, respectively. O.R. time averaged 87 minutes. There were no significant complications. At 6 months post procedure (N=96), an average of 32% of weight regain post-RYGB was lost. %EWL averaged 18%. 12 month EGD results confirmed presence of anchors and durable tissue folds.Conclusion:: Incisionless revision of stoma and pouch dilatation with the IOP can be performed safely. Data to date demonstrates mild-moderate weight loss and early 12 month endoscopic images confirm anchor durability. Patients remain actively followed to document long term durability of this intervention in the entire patient subset.

Acute postgastric reduction surgery neuropathy and severe malnutrition after sleeve gastrectomy for morbid obesity - Uncorrected Proof

2010-02-08

Sleeve gastrectomy (SG) is a bariatric operation that has rapidly gained popularity as a first-stage procedure and even as a stand-alone operation. The purported advantages of SG are that it is a relatively simple operation, results in considerable weight loss, does not involve any digestive anastomosis, creates no mesenteric defects, does not require placement of foreign materials or adjustments, preserves the pylorus and digestive continuity, is not associated with the dumping syndrome, decreases ghrelin production, can be performed in less time than bypass procedures, and the absorption of nutrients, vitamins, minerals, and drugs is not altered. The possible disadvantages of SG include the irreversibility of the operation, the increased risk compared with other restrictive procedures, the unproved durability, and the lack of studies with long-term results and complications. We present 1 patient who developed severe malnutrition and peripheral neuropathy 5 months after SG.

Bariatric surgery literature in nonbariatric surgery journals: January 2009–June 2009 - Uncorrected Proof

John J. Gleysteen — 2010-02-08

The following articles on bariatric surgery and/or morbid obesity topics have been published during the first 6 months of 2009 in journals other than Surgery for Obesity and Related Diseases or Obesity Surgery. They have been allocated to a series of headings (and subheadings) or descriptors of their content, although some articles might cross several headings. I have selected the descriptor that seemed most pertinent clinically. The article titles I thought particularly important for bariatric surgeons have been printed in bold, to which I have usually added some overall assessment from the abstract or full article review.

Effects of C358A missense polymorphism of the endocannabinoid degrading enzyme fatty acid amide hydrolase on weight loss and cardiovascular risk factors 1 year after biliopancreatic diversion surgery - Uncorrected Proof

2010-02-08

Abstract: Background: Bariatric surgery is the most effective long-term treatment of morbid obesity and also results in a reduction of obesity-associated co-morbidities. We investigated the role of the polymorphism (C358A) of the fatty acid amide hydrolase gene on the clinical outcomes 1 year after biliopancreatic diversion in morbidly obese patients.Methods: A total of 67 morbidly obese patients (body mass index >40 kg/m2) underwent biliopancreatic diversion. Their weight, blood pressure, basal glucose, triglycerides, total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol were measured at the baseline visit and at each follow-up visit. The frequency of the metabolic co-morbidities was recorded at each visit.Results: Of the 67 patients, 46 (68.7%) had genotype C358C (wild-type group) and 21 (10.3%) had genotype C358A (mutant-type group). In the wild- and mutant-type groups, the body mass index, weight, waist circumference, systolic blood pressure, and glucose, total cholesterol, low-density lipoprotein cholesterol, and triglyceride concentrations decreased, without statistical significance between the 2 groups. The initial percentage of weight loss at 9 months and 1 year of follow-up was greater in the mutant-type group (9 months, 22.1% versus 28.8%, P <.05; and 1 year, 28.3% versus 36.4%, P <.05).Conclusion: The allele A358 of fatty acid amide hydrolase was associated with a better initial percentage of excess weight loss 9 and 12 months after biliopancreatic diversion.

Aerobic endurance training improves weight loss, body composition, and co-morbidities in patients after laparoscopic Roux-en-Y gastric bypass - Uncorrected Proof

Edward Shang, Till Hasenberg — 2010-02-08

Abstract: Background: One of the most effective treatments of patients with morbid obesity is laparoscopic Roux-en-Y gastric bypass (RYGB). Sudden weight loss after RYGB for morbid obesity can result in a concurrent decrease in the lean body mass. However, the long-term results (weight reduction and reduced co-morbidities) depend on the postoperative long-term therapy. Aerobic physical exercise (APE) has been considered conservative treatment of obesity and type 2 diabetes mellitus. The aim of the present study was to assess the efficacy of APE on weight loss, body composition, and co-morbidities in patients after laparoscopic RYGB. The study was performed at a university hospital in Germany.Methods: A total of 60 consecutive morbidly obese patients underwent laparoscopic RYGB. The patients were prospectively randomized into a low-exercise group (APE 1 time for 1 hr/wk) or a multiple-exercise group (APE 2 times for 1 hr/wk). The following prospective data were collected: age, gender, length of hospital stay, operative details, co-morbidities, postoperative complications, initial body weight and height, postoperative weight, and body composition. The patients' body composition was assessed every 8 weeks during the 24-month follow-up period.Results: The average body mass index (52 kg/m2) and other baseline characteristics were distributed equally in the 2 groups. No major complications and no significant differences in the minor complications were found postoperatively between the 2 groups. The multiple exercise group had a significantly more rapid reduction of body mass index, excess weight loss, and fat mass compared with the low-exercise group. The initial loss of body cell mass and lean body mass was significantly lower in the multiple exercise group and was regained more rapidly in the low-exercise group. In addition, the multiple exercise group showed significantly earlier resolution or improvement of co-morbidities.Conclusion: APE positively influenced weight loss, body composition, and co-morbidity resolution after RYGB for obesity. Additional controlled studies and longer follow-up are needed to confirm these positive findings.

Congruence between clinical and research-based psychiatric assessment in bariatric surgical candidates - Uncorrected Proof

J.E. Mitchell, K.J. Steffen, M. de Zwaan, T.W. Ertelt, J.M. Marino, A. Mueller — 2010-02-08

Abstract: Background: Mental health professionals have become increasingly involved in working with bariatric surgical candidates, particularly in performing preoperative psychological evaluations to clear candidates for surgery. The objective of the present study was to examine the concordance of the psychiatric diagnoses obtained during routine clinical evaluation before bariatric surgery and the diagnoses obtained separately at a research facility using the Structured Clinical Interview for DSM (Diagnostic and Statistical Manual of Mental Disorders)-IV axis I disorders.Methods: The study included 68 consecutively enrolled bariatric surgical candidates who had participated in the Longitudinal Assessment of Bariatric Surgery-3 study. The Structured Clinical Interview for DSM disorders data obtained from the research assessments were compared with the diagnostic data from the routine preoperative psychiatric evaluations. The congruence of the current and lifetime diagnoses was assessed using Cohen's coefficient kappa.Results: Considerable variability was found among the major diagnostic categories, with generally poor agreement found for the current diagnoses. The kappa coefficients tended to be larger for the lifetime diagnoses. The agreement was moderate for any lifetime mood disorder, with a kappa value of 0.45. Regarding any lifetime anxiety, substance use, and eating disorder, the clinical diagnoses rarely concurred with the results from the Structured Clinical Interview for DSM disorders, with a kappa statistic of 0.30, 0.36, and 0.32, respectively.Conclusion: The congruence between the diagnoses assigned during the routine clinical psychiatric evaluations and research assessment using the Structured Clinical Interview for DSM disorders was surprisingly low. These conclusions should be considered tentative, given the interval and the possibility of treatment having occurred between the 2 evaluations. Overall, these data raise interesting questions concerning the use of unstructured psychiatric evaluations before bariatric surgery.

Gastric band erosion and intraluminal migration leading to biliary and small bowel obstruction: case report and discussion - Uncorrected Proof

Kavin G. Shah, Ernesto P. Molmenti, Jeffrey Nicastro — 2010-02-08

Adjustable gastric banding is a safe and effective treatment of morbid obesity that has gained widespread popularity. One of the complications associated with adjustable gastric bands is erosion into the stomach. Larger series have reported an incidence of 1–2% for the adjustable silicone gastric band , the Swedish gastric band (Ethicon Endo-Surgery, Johnson & Johnson, Cincinnati, OH), and the Lap-Band (Inamed, Irvine, CA) . Previously described complications have included intraluminal duodenal obstruction after erosion of a Kuzmak adjustable band (BioEnterics, Carpinteria, CA) , gastric outlet obstruction after laparoscopic adjustable gastric band Lap-Band placement, and early small bowel obstruction after laparoscopic adjustable gastric band placement. We present the case of a patient with gastric erosion and migration into the jejunum with resultant biliary and small bowel obstruction occurring 15 years after open vertical banded gastroplasty and Kuzmak adjustable band application.

Laparoscopic left adrenalectomy after laparoscopic gastric bypass - Uncorrected Proof

Tejwant S. Datta, Kimberley Steele, Michael Schweitzer — 2010-02-08

Abstract: Laparoscopic adrenalectomy is the preferred approach for resecting functional adrenal tumors. The most common contraindications to a laparoscopic approach include extensive adhesions from previous surgery, an inability to tolerate the pneumoperitoneum, and bleeding diathesis. A paucity of data is available describing adrenalectomy in the bariatric surgery patient. A PubMed search revealed only 1 reported case of adrenalectomy at laparoscopic Roux-en-Y gastric bypass (LRYGB) []. No description of adrenalectomy performed after previous bariatric surgery has been reported. To our knowledge, this is the first report of left adrenalectomy performed >1 year after LRYGB.

Editorial comment - Uncorrected Proof

Samer G. Mattar — 2010-02-03

One of the distinguishing features of bariatric surgery is that the discipline continues to evolve, and at a rapid pace. As a result, our lives, as bariatric surgeons, continue to be exciting. Not only is the list of benefits in the clinical, psychological, social, and economic domains constantly growing, but also, the relentless advancement of current technology provides glimpses of a future rich in surgical and technical options for bariatric surgeons and their patients. The reports of such progress, in this and other publications, occur with increasing frequency, to the extent that we must expend almost constant surveillance of the literature lest an important development pass us by.

Longitudinal cost experience for gastric bypass patients - Uncorrected Proof

Deborah M. Mullen, Thomas J. Marr — 2010-02-01

Abstract: Background: To assess the effect of gastric bypass surgery on the total cost of medical care for morbidly obese members compared with obese members and a general population.Methods: We used an observational pre–post test design to analyze the administrative claim records of 224 gastric bypass patients during 3 periods (preoperative, surgical, and postoperative years) for a total of 7.5 years. The estimated future care costs for gastric bypass patients were determined from their preoperative cost trends, adjusting for the annualized actuarial trends. The general membership population actuarial trends and overweight/obese member medical expenditure data were used as comparison groups.Results: The inflation adjusted mean per member per year total paid decreased by $1895 in the fifth year after surgery. The mean costs for gastric bypass patients were lower within the first year after surgery than their preoperative costs. At 3.5 years after surgery, the surgical costs had been recouped for patients undergoing gastric bypass surgery, and by year 2, they had incurred fewer costs than the obese health plan population.Conclusion: Although gastric bypass is a costly surgical procedure, the longitudinal costs savings and overall health improvement for patients undergoing gastric bypass surgery are cost-effective within a closed, experienced network. Weight loss surgery decreased the annual costs per patient in the years after surgery. The costs were slightly elevated in the fifth year after surgery because of maternity cases and orthopedic surgeries.

Reasons and outcomes of laparoscopic revisional surgery after laparoscopic adjustable gastric banding for morbid obesity - Uncorrected Proof

2010-01-27

Abstract: Background: Laparoscopic adjustable gastric banding (LAGB) is a purely restrictive procedure that has been proved to be an effective tool in achieving weight loss. The low operative morbidity and reversibility are often seen as advantages of this procedure compared with other bariatric approaches. We have attempted to define the reasons for revisional surgery after LAGB and the outcomes.Methods: A retrospective review of a prospectively maintained database was performed from February 2001 to October 2008 at a center of excellence after institutional review board approval. The patients who had undergone revisional surgery after primary LAGB were evaluated.Results: Of 343 patients who had undergone primary LAGB, 60 subsequently underwent a revisional procedure. In addition, 28 revisional procedures were performed on patients who had undergone primary LAGB at an outside institution. These procedures included 39 (44.3%) band removals alone, 12 (13.6%) band removals with conversion to sleeve gastrectomy, 13 (14.8%) band removals with conversion to Roux-en-Y gastric bypass, 9 (10.2%) band repositioning, and 2 (2.3%) band replacements. In addition, 13 (14.8%) port-related procedures (3 relocations, 6 reconnections, and 4 replacements/removals) were performed.Conclusion: Although reversible and efficacious, LAGB appears to have a high incidence of complications requiring revisional surgery and/or band removal. The results of our study have shown that laparoscopic revisional surgery after primary LAGB is safe and can be performed with minimal morbidity.

Bariatric surgery history among substance abuse treatment patients: prevalence and associated features - Corrected Proof

2010-01-20

Abstract: Background: In 2006, Brighton Hospital (Brighton, Michigan), a comprehensive substance abuse treatment facility, began observing increasing admissions who reported a history of bariatric surgery. Data on the magnitude of this postoperative outcome is lacking. The hospital instituted procedures to better track this variable in the electronic medical records at admission to estimate the prevalence of bariatric surgery history among substance abuse treatment admissions.Methods: The data analyzed for the present report included the electronic medical record data obtained from 7199 patients admitted from 2006 to 2009 and the chart review data from 54 bariatric patients and 54 controls.Results: The findings suggested that 2-6% of recent admissions were positive for a bariatric surgery history. The substance abuse treatment patients with a bariatric surgery history were significantly more likely to be women and nonsmokers. The bariatric and nonbariatric patients were equally likely to have been diagnosed with alcohol dependence; however, bariatric patients were significantly more likely to also have a diagnosis of alcohol withdrawal. Relative to the matched control cases, the alcohol-dependent bariatric patients reported consuming a significantly greater maximum quantity of drinks per drinking day.Conclusion: A bariatric surgery history might be overrepresented in substance use programs and such patients' recovery efforts might pose unique challenges.

Initial human experience with restrictive duodenal-jejunal bypass liner for treatment of morbid obesity - Uncorrected Proof

2010-01-20

Abstract: Background: The duodenal-jejunal bypass liner is an endoscopically placed and removable intestinal liner that creates a duodenal-jejunal bypass, leading to diabetes improvement and weight loss. The aim of the present study was to evaluate the clinical effects and safety of the duodenal-jejunal bypass liner combined with a restrictor orifice (flow restrictor).Methods: The device was endoscopically implanted in 10 patients (body mass index 40.8 ± 4.0 kg/m2) and removed after 12 weeks. Dilation of the restrictor orifice was performed as clinically indicated with a 6-, 8-, or 10-mm diameter through-the-scope balloon. The measured outcomes included the percentage of excess weight loss, total weight loss, adverse events, and gastric emptying (GE) at baseline, weeks 4 and 12 of implantation, and 3–5 months after device removal. GE was measured by scintigraphy at 1, 2, and 4 hours after implantation.Results: The percentage of excess weight loss and total weight loss at explantation was 40% ± 3% (range 21–64%) and 16.7 ± 1.4 kg (range 12.0–26.0), respectively. The 4-hour GE was 98% ± 1% at baseline, 72% ± 6% at 4 weeks (P = 0.001 versus baseline), and 84% ± 5% at 12 weeks (P <.05 versus baseline). After explantation, the rate of GE returned to normal in 7 of 8 subjects, but remained slightly delayed in 1 subject (84% at 4 hours). Episodes of nausea, vomiting, and abdominal pain required endoscopic dilation of the restrictor orifice with a 6-mm through-the-scope balloon in 7 patients and a 10-mm balloon in 1, with no clinically significant adverse events.Conclusion: Endoscopic implantation of a combination flow restrictor and duodenal-jejunal bypass liner induced substantial weight loss. The implanted patients exhibited delayed GE that was reversed after device removal.

Favorable internal hernia rate achieved using retrocolic, retrogastric alimentary limb in laparoscopic Roux-en-Y gastric bypass - Uncorrected Proof

Linda A. Miyashiro, William D. Fuller, Mohamed R. Ali — 2010-01-14

Abstract: Background: The present study was performed at a tertiary care university hospital. The present study examined the incidence of internal hernia (IH) in our series of laparoscopic Roux-en-Y gastric bypass (LRYGB) with retrocolic, retrogastric routing of the alimentary limb accompanied by routine secure closure of all mesenteric defects.Methods: During a 4-year period, 847 patients underwent LRYGB. Our operative technique included retrocolic, retrogastric placement of the alimentary limb. The enteroenterostomy mesenteric defect, mesocolic defect, and Petersen defect were routinely closed in running fashion with nonabsorbable suture.Results: The study population had a mean age of 42.4 ± 9.3 years and a mean preoperative body mass index of 45.3 ± 5.6 kg/m2. The mean operative time was 154 ± 25 minutes. The mean excess body weight loss at 1 year was 70%. The incidence of IH among this large study population was 0%. A total of 11 patients (1.3%) presented with symptoms concerning for IH, most commonly nausea, vomiting, and crampy abdominal pain, from 1 month to 6 years after the initial surgery. On re-exploration, 4 patients had adhesive small bowel obstruction, 4 had adhesions without obstruction, 1 had small bowel intussusception, and 2 patients had negative findings.Conclusion: IH is a serious complication of LRYGB that can lead to catastrophic morbidity and mortality. We advocate vigilant screening for this complication and laparoscopic exploration for patients with worrisome symptoms. Our data have indicated that a routine and consistent technique to securely close the mesenteric defects can significantly reduce the risk of IH associated with retrocolic, retrogastric placement of the alimentary limb during LRYGB.

Intensive care unit stay not required for patients with obstructive sleep apnea after laparoscopic Roux-en-Y gastric bypass - Uncorrected Proof

2010-01-14

Abstract: Background: Many programs admit morbidly obese patients with obstructive sleep apnea (OSA) to the intensive care unit after laparoscopic gastric bypass (LGB), fearingpulmonary complications. Our practice has been to admit these patients to the surgical floor. Our objective was to compare the perioperative course and outcomes in morbidly obese patients with OSA to those of patients without OSA undergoing LGB in a physician-led health system with a 325-bed community teaching hospital serving 19 counties.Methods: We retrospectively reviewed the medical records of 650 patients who had undergone LGB from 2001 to 2008 and divided them into 2 groups: patients with OSA as confirmed by polysomnography (OSA group) and those without OSA (non-OSA group). The patients who reported a diagnosis of OSA without documentation confirming the diagnosis were excluded. The statistical analysis included t tests and chi-square tests.Results: A total of 217 patients met the inclusion criteria for the OSA cohort and 368 for the non-OSA cohort. Of the 650 patients, 65 reported a history of OSA without confirmation and were excluded from the present study, leaving 585 patients. The demographic data were similar between the 2 groups, and no difference was found between the OSA and non-OSA groups for the length of postanesthesia care unit stay (105.4 versus 106.3 minutes), length of hospital stay (2.2 days for both groups), and 30-day major complication rate (3.7% versus 5.2%). No deaths and no intensive care unit admissions for pulmonary complications occurred in either group.Conclusion: The results of our study have shown that morbidly obese patients with OSA undergoing LGB have a perioperative course and postoperative pulmonary complication rate similar to that of patients without OSA. Thus, routine admission to the intensive care unit after LGB in patients with OSA is not indicated.

Editorial comment - Corrected Proof

Robert E. Brolin — 2010-01-14

This laboratory study showed that the application of BioGlue resulted in a rather remarkable improvement in the acute bursting pressure in fresh stapled porcine gastrojejunostomies. The investigators' method documented the anastomotic integrity by demonstrating no leak in the submerged specimens at the lowest measured air pressure. Anastomotic healing did not occur, because the specimens were explanted within minutes of performing the anastomosis. In the leak model, BioGlue again provided a significant increase in bursting strength that appeared to be substantially, if not significantly, greater than that of the intact control anastomoses in experiment 1. It is not entirely clear whether the 10 anastomoses in experiment 2 served as their own controls, which would seem legitimate, as well as economical.

Duodenal obstruction due to erosion and migration of an adjustable gastric band: a novel endoscopic approach to management - Uncorrected Proof

2010-01-04

Laparoscopic adjustable gastric banding (LAGB), since its introduction in 1992, has proved to be an effective and safe treatment modality for morbid obesity. Accordingly, it is the most popular restrictive bariatric procedure performed in the United States. The years since its inception have brought an evolution in the techniques of band placement, as more surgeons have acquired the advanced laparoscopic experience necessary. The perioperative morbidity and mortality rates have been estimated to be .1–.33% .

Fatal perforations in laparoscopic bowel lengthening operations for malnutrition - Corrected Proof

Aniceto Baltasar, Rafael Bou, Marcelo Bengochea — 2010-01-04

Protein-calorie malnutrition (PCM) is probably the most feared complication after bariatric malabsorptive surgery in the morbidly obese patient. PCM almost always occurs after complex restrictive plus malabsorptive operations and can usually be corrected medically if diagnosed early. However, some patients require small bowel lengthening or conversion by laparotomy or laparoscopy.

Pre–Lap-Band group education in Medicaid population: does it really make a difference? - Corrected Proof

2009-12-23

Abstract: Background: The effect of group education classes before a Lap-Band procedure has not been well defined. We hypothesized that in a Medicaid population, the completion of a standardized 12-week multidisciplinary preoperative program (SMPP) would significantly improve the preoperative and early postoperative weight loss. All procedures were performed at a University-affiliated community hospital from 2006 to 2007.Methods: A prospectively collected database of 292 patients who underwent Lap-Band placement was retrospectively reviewed. All patients in the study cohort were encouraged to participate in the SMPP, which included medical, psychological, and nutritional interventions. The patients were divided into 2 groups according to their participation in the SMPP program: SMPP compliant and non-SMPP compliant. The postoperative weight loss of these 2 groups was then compared using the general linear models for repeated measures statistical analysis.Results: No significant difference was found in the mean baseline excess body weight between the 2 groups (74 ± 20 kg in the SMPP-compliant and 76 ± 20 kg in the non–SMPP-compliant participants). The mean baseline body mass index (47 ± 7 versus 48 ± 72 kg/m2 for the SMPP-compliant and non–SMPP-compliant participants) was also similar in the 2 groups. The postoperative follow-up rate was 94.5% at 1 month, 72.3% at 6 months, and 52.7% at 12 months. The excess weight loss was significantly greater in the SMPP compliant group than in the noncompliant group during the observed 12-month follow-up period (P = .04, by general linear models for repeated measures).Conclusion: In a Medicaid population, implementation of an intensive preoperative SMPP resulted in a significant improvement in the short-term weight loss after Lap-Band placement.

Prospective controlled study of effect of laparoscopic sleeve gastrectomy on small bowel transit time and gastric emptying half-time in morbidly obese patients with type 2 diabetes mellitus - Corrected Proof

Shashank Shah, Poonam Shah, Jayashree Todkar, Michel Gagner, S. Sonar, S. Solav — 2009-12-21

Abstract: Background: Published data on sleeve gastrectomy (SG) have indicated better remission of type 2 diabetes mellitus (T2DM) and improvement in satiety compared with other restrictive procedures. Mechanisms in addition to rapid, extensive weight loss are responsible for the restoration of the euglycemic state. To prospectively evaluate the role of laparoscopic SG on gastric emptying half-time and small bowel transit time (SBTT) and effect of these on weight loss, satiety, and improvement in T2DM.Methods: A total of 67 subjects were studied. Of these 67 subjects, 24 were lean controls (body mass index 22.2 ± 2.84 kg/m2), 20 were severely and morbidly obese patients with T2DM who had not undergone SG (body mass index 37.73 ± 5.35 kg/m2), and 23 were severely and morbidly obese patients with T2DM after SG (body mass index 40.71 ± 6.59 kg/m2). All 67 patients were evaluated for gastric emptying half-time and SBTT using scintigraphic imaging. Imaging was performed every 15 minutes up to the ileocecal region. The Three-Factor Eating Questionnaire was administered simultaneously. Fasting blood sugar, postprandial blood sugar, and glycated hemoglobin were assessed. Nonparametric analysis of variance and the Mann-Whitney U test were applied.Results: The mean SBTT was significantly lower (P <.05) in the post-SG group (199 ± 65.7 minutes) than in the non-SG group (281.5 ± 46.2 minutes) or control group (298.1 ± 9.2 minutes). The gastric emptying half-time values were also significantly shorter (P <.05) in the post-SG (52.8 ± 13.5 minutes) than in the non-SG (73.7 ± 29.0 minutes) and control (72.8 ± 29.6 minutes) groups. The glycated hemoglobin, fasting blood sugar, and postprandial sugar were all significantly lower after SG. The Three-Factor Eating Questionnaire findings revealed significantly earlier satiety (29.0 ± 7.2) for the post-SG patients (P <.05) compared with the non-SG (45.8 ± 9.0) and control (37.9 ± 6.2) subjects.Conclusion: A decreased gastric emptying half-time and SBTT after SG can possibly contribute to better glucose homeostasis in patients with T2DM.

Evaluating gastric erosion in band management: an algorithm for stratification of risk - Corrected Proof

2009-12-21

Abstract: Background: Laparoscopic gastric banding has several known complications, including gastric erosion. No clear factors have been determined for the development of band erosion, but technical factors such as covering the buckle of the band have been implicated. The objective of the present study was to determine whether band management after surgery, band size, or filling beyond the manufacturer-determined maximal volume has an effect on the incidence of erosion at a university hospital in the United States.Methods: We performed a retrospective review of a prospective institutional review board–approved database. All patients who had been followed from 2002 to 2008 were identified. The maximal band volume was 4 cm3 for the 9.75-cm/10-cm band and 10 cm3 for the Vanguard band. The bands were considered overfilled if they had been filled to greater than the maximal volume for ≥3 months.Results: A total of 2437 patients had undergone Lap-Band surgery. Of these 2437 patients, 14 developed erosion (.57%). The primary erosion rate was .39% (9 of 2359). These patients were divided into 3 groups according to the type of band placed: group 1, Vanguard (n = 735); group 2, 9.75-cm/10-cm band (n = 1624); and group 3, revisions to Vanguard, including a band placed around a bypass (n = 78). The incidence of gastric erosion by group was .95% (7 of 735) in group 1, .12% (2 of 1624) in group 2, and 6.41% (5 of 78) in group 3. The difference in the erosion rate among the groups was significant (group 1 versus 2, P = .005; group 3 versus 1, P = .003; and group 3 versus 2, P = .001). Erosions developed in each group without overfilling. Also, comparing the erosion rate in the overfilled versus underfilled bands, statistical significance was found only for group 1 at 3.18% versus .35% (P = .006). The erosion rate in the overfilled versus underfilled was 1.01% versus .07% in group 2 and 11.11% versus 3.92% in group 3.Conclusion: A band that needs to be overfilled might be a sign of erosion, and patients should undergo endoscopy. Band revision has a greater rate of erosion than primary banding. The Vanguard band has a greater risk of erosion than the 4-cm3 bands.

Venous thromboembolism prophylaxis for patients undergoing bariatric surgery: a systematic review - Corrected Proof

Rajender Agarwal, Todd E.H. Hecht, Myra C. Lazo, Craig A. Umscheid — 2009-12-17

Obesity has acquired epidemic proportions in the United States, with nearly 65% of the adult population overweight and obese. This has led to an exponential increase in the rate of bariatric procedures, with about 103,000 procedures performed in the United States in 2003 . The most common bariatric procedures in the United States are the Roux-en-Y gastric bypass and gastric banding . Minimally invasive techniques have become popular in the past decade, and a large number of laparoscopic gastric bypass procedures are now performed as outpatient procedures .

Baseline data from American Society for Metabolic and Bariatric Surgery-designated Bariatric Surgery Centers of Excellence using the Bariatric Outcomes Longitudinal Database - Corrected Proof

Eric J. DeMaria, Virginia Pate, Michael Warthen, Deborah A. Winegar — 2009-12-14

Abstract: Background: The Bariatric Outcomes Longitudinal Database (BOLD) is a registry of self-reported bariatric surgery patient information from the American Society for Metabolic and Bariatric Surgery Bariatric Surgery Center of Excellence participants. The present study was undertaken to define the baseline characteristics of the patients with data entered into BOLD.Methods: The data submitted by >800 surgeons and >450 facilities using BOLD before May 20, 2009, were analyzed.Results: A total of 57,918 research-consented patients with surgical procedure data were included. Of the 57,918 patients, 41,243 were adults aged 26–55 years, with few patients aged ≤18 years (.14%) or ≥66 years (5.67%). Females constituted a significant majority of the study population (45,619 [78.76%]). Of the 57,918 patients, 78.12% registered were described as Caucasian, 10.52% as African-American, 6.02% as Hispanic, .20% as Asian, and .46% as Native American. The most common bariatric surgical procedure was some form of gastric bypass (31,668 [54.68%]), followed by some form of gastric banding (22,947 [39.62%]), sleeve gastrectomy (1,328 [2.29%]), and biliopancreatic diversion (517 [.89%]). The vast majority of index procedures were completed using laparoscopic surgery techniques, except for biliopancreatic diversion, which was primarily done with an open approach. Through May 2009, 78 deaths were reported at any point after the index procedure, for a mortality rate of .13%. The 90-day mortality rate was .11%, and the 30-day mortality rate was .09%.Conclusion: This is the first report of data from BOLD. The data have revealed important characteristics of patients undergoing bariatric surgery across the United States in centers participating in the Bariatric Surgery Center of Excellence program. Future analyses of BOLD data are likely to have a major effect on the specialty of bariatric surgery.

Laparoscopic revisional surgery after Roux-en-Y gastric bypass and sleeve gastrectomy - Uncorrected Proof

2009-12-14

Abstract: Background: Failure of primary bariatric surgery is frequently due to weight recidivism, intractable gastric reflux, gastrojejunal strictures, fistulas, and malnutrition. Of these patients, 10–60% will undergo reoperative bariatric surgery, depending on the primary procedure performed. Open reoperative approaches for revision to Roux-en-Y gastric bypass (RYGB) have traditionally been advocated secondary to the perceived difficulty and safety with laparoscopic techniques. Few studies have addressed revisions after RYGB. The aim of the present study was to provide our experience regarding the safety, efficacy, and weight loss results of laparoscopic revisional surgery after previous RYGB and sleeve gastrectomy procedures.Methods: A retrospective analysis of patients who underwent laparoscopic revisional bariatric surgery for complications after previous RYGB and sleeve gastrectomy from November 2005 to May 2007 was performed. Technical revisions included isolation and transection of gastrogastric fistulas with partial gastrectomy, sleeve gastrectomy conversion to RYGB, and revision of RYGB. The data collected included the pre- and postoperative body mass index, operative time, blood loss, length of hospital stay, and intraoperative and postoperative complications.Results: A total of 26 patients underwent laparoscopic revisional surgery. The primary operations had consisted of RYGB and sleeve gastrectomy. The complications from primary operations included gastrogastric fistulas, refractory gastroesophageal reflux disease, weight recidivism, and gastric outlet obstruction. The mean prerevision body mass index was 42 ± 10 kg/m2. The average follow-up was 240 days (range 11–476). The average body mass index during follow-up was 37 ± 8 kg/m2. Laparoscopic revision was successful in all but 1 patient, who required conversion to laparotomy for staple line leak. The average operating room time and estimated blood loss was 131 ± 66 minutes and 70 mL, respectively. The average hospital stay was 6 days. Three patients required surgical exploration for hemorrhage, staple line leak, and an incarcerated hernia. The overall complication rate was 23%, with a major complication rate of 11.5%. No patients died.Conclusion: Laparoscopic revisional bariatric surgery after previous RYGB and sleeve gastrectomy is technically challenging but compared well in safety and efficacy with the results from open revisional procedures. Intraoperative endoscopy is a key component in performing these procedures.

Surgical adhesive increases burst pressure and seals leaks in stapled gastrojejunostomy - Corrected Proof

Govind Nandakumar, Bryson G. Richards, Koiana Trencheva, Gregory Dakin — 2009-12-14

Abstract: Background: Leakage from a gastrointestinal anastomosis in bariatric surgery is a catastrophic complication and is the second-most preventable cause of death after Roux-en-Y gastric bypass. Several adjuncts for staple line reinforcement have been investigated to reduce the incidence of this complication. The purpose of our study was to determine whether a commercially available tissue sealant (BioGlue) could reinforce a stapled gastrojejunal anastomosis and whether it could seal an artificially created anastomotic leak.Methods: Circular-stapled gastrojejunostomies were performed on freshly explanted porcine stomach and intestine. Experiment 1 consisted of 10 control nonreinforced gastrojejunostomies and 10 gastrojejunostomies reinforced with BioGlue. The staple lines were submerged in saline and exposed to increased pressure using constant-rate infusion of air. The burst pressures were recorded at the point of visible leakage from the anastomosis. In experiment 2, a small defect was created in 10 gastrojejunostomies. The burst pressures were recorded before and after application of BioGlue to the anastomosis. The data were analyzed using the 2-tailed paired t test.Results: In experiment 1, the burst pressure was significantly increased in the reinforced gastrojejunostomies, from 27.4 ± 8.4 mm Hg to 59.1 ± 19.2 mm Hg (P <.001). In experiment 2, the defective gastrojejunostomies had an average burst pressure of 1.2 ± 0.8 mm Hg. After application of BioGlue, the burst pressure increased to 42.8 ± 15.9 mm Hg (P <.001).Conclusion: These ex vivo findings suggest that the surgical adhesive BioGlue can reinforce both intact and defective stapled gastrojejunal anastomoses. Additional in vivo study is warranted to determine whether BioGlue can prevent or help seal gastrojejunal leaks.

Mood disorders in laparoscopic sleeve gastrectomy patients: does it affect early weight loss? - Corrected Proof

Debra A. Semanscin-Doerr, Amy Windover, Kathleen Ashton, Leslie J. Heinberg — 2009-12-14

Abstract: Background: Research has demonstrated that laparoscopic Roux-en-Y gastric bypass patients with a lifetime history of a mood disorder have a lower percentage of excess weight loss (%EWL) compared with patients without this lifetime history. No studies have examined the effect of psychiatric history on postoperative outcomes among laparoscopic sleeve gastrectomy (LSG) patients. The objectives of the present study were to determine whether mood disorders relate to the first year of weight loss for patients undergoing LSG at an academic medical center.Methods: A total of 104 patients (78.6% white and 71.2% women), with a median body mass index of 60.35 kg/m2 (range 31.37–129.14) underwent LSG. The patients were prospectively followed up at 1, 3, 6, 9, and 12 months. The semistructured preoperative psychiatric evaluations demonstrated that 43.1% had a current, and 62.5% a lifetime, diagnosis of a mood disorder.Results: LSG patients with current mood disorders had a significantly lower %EWL than patients without a psychiatric diagnosis at the 1-, 3-, 6-, and 9-month follow-up visits. LSG patients with a lifetime history of a mood disorder had a significantly lower %EWL than patients without psychiatric diagnosis at the 1-, 9-, and 12-month follow-up examinations. However, after removing patients with bipolar disorder from the analyses, no significant differences were found in the %EWL between patients with and without a lifetime history of depressive disorders.Conclusion: Consistent with the laparoscopic Roux-en-Y gastric bypass findings, a lifetime history of mood disorders appears to be associated with significantly less weight loss in LSG patients. These findings highlight the importance of the psychiatric assessment in bariatric patients. Additionally, patients with a current or lifetime history of mood disorders might need additional pre- and postoperative care to improve their outcomes.

Recurrent paraesophageal hernia presenting as obstruction of Roux limb after Roux-en-Y gastric bypass - Corrected Proof

Manuel Caceres, George M. Eid, Carol A. McCloskey — 2009-12-14

As the number of patients with morbid obesity has increased, the incidence of obesity-related diseases has also increased dramatically. An increased body mass index is a risk factor for the development of hiatal hernias and gastroesophageal reflux disease (GERD) . Conventional antireflux procedures have not proved to be a successful solution to GERD in morbidly obese patients. Roux-en-Y gastric bypass (RYGB) offers an effective solution to GERD, in addition to the resolution of other obesity-related co-morbidities . The surgical management of hiatal hernias, when performed in association with RYGB, is still controversial.

Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index - Corrected Proof

2009-12-11

Abstract: Background: The current National Institutes of Health guidelines have recommended bariatric surgery for patients with a body mass index (BMI) >40 kg/m2 or BMI >35 kg/m2 with significant co-morbidities. However, some preliminary studies have shown that patients with a BMI that does not meet these criteria could also experience similar weight loss and the benefits associated with it.Methods: An institutional review board-approved protocol was obtained to study the effectiveness of laparoscopic adjustable gastric banding in patients with a low BMI. A total of 66 patients with a BMI of 30–35 kg/m2 and co-morbidities (n = 22) or a BMI of 35–40 kg/m2 without co-morbidities (n = 44) underwent laparoscopic adjustable gastric banding. These patients were compared with 438 standard patients who had undergone laparoscopic adjustable gastric banding who met the National Institutes of Health criteria for bariatric surgery. The excess weight loss at 3, 6, 12, and 18 months and the status of their co-morbidities were compared between the 2 groups.Results: The average BMI for the study group was 36.1 ± 2.6 kg/m2 compared with 46.0 ± 7.3 kg/m2 for the control group. Both groups had significant co-morbidities, including hypertension, diabetes, hyperlipidemia, arthritis, gastroesophageal reflux disease, stress incontinence, and obstructive sleep apnea. The mean percentage of excess weight loss was 20.3% ± 9.0%, 28.5% ± 14.0%, 44.7% ± 19.3%, and 42.2% ± 33.7% at 3, 6, 12, and 18 months, respectively. This was not significantly different from the excess weight loss in the control group, except for at 12 months. Both groups showed similar improvement of most co-morbidities.Conclusion: Moderately obese patients whose BMI is less than the current guidelines for bariatric surgery will have similar weight loss and associated benefits. Laparoscopic adjustable gastric banding is a safe and effective treatment for patients with a BMI of 30–35 kg/m2.

Small bowel obstruction from small bowel volvulus and gram-positive peritonitis in laparoscopic adjustable gastric banding - Corrected Proof

Walter F. DeNino, Patrick M. Forgione — 2009-12-11

As the prevalence of obesity increases, the number of bariatric operations performed increases as well. Laparoscopic adjustable gastric banding (LAGB) presents an attractive option for patients who prefer minimally invasive, adjustable, reversible surgical approach with lower morbidity and mortality than other forms of bariatric surgery. Thus, LAGB is the most commonly performed bariatric procedure in Europe and Australia and growing in popularity in the U.S. However, LAGB is not without complications. Complications are typically related to the port (infection, tube disconnection, dislocation) or band itself (slippage, erosion, pouch dilatation) .

Editorial comment - Uncorrected Proof

Nicolas Christou — 2009-12-10

The Longitudinal Assessment of Bariatric Surgery (LABS-1, safety cohort) study group report in a previous issue of the Journal their findings on the outcomes of revisional bariatric surgery. Revisional bariatric surgery was defined as surgery after a previous bariatric surgical procedure, except for primary gastric banding. The exclusion of the latter group of patients could be questioned, but their argument provided “the morbidity and mortality of LapBand surgery is so low, it would result in an unbalanced comparison in this report.” The comparison of 3577 primary and 225 revisional procedures showed that the complications of revisional bariatric surgery were low such that a “composite endpoint” (a combination of death, deep vein thrombosis or venothromboembolism, reintervention (any form), reintubation, or failure to discharge within 30 days of surgery) was used in the statistical analysis.

Insulin sensitivity during first months after restrictive bariatric surgery, inconsistency between HOMA-IR and steady-state plasma glucose levels - Corrected Proof

2009-12-10

Abstract: Background: The low-grade inflammatory condition present in morbid obesity is thought to play a causative role in the pathophysiology of insulin resistance (IR). Bariatric surgery fails to improve this inflammatory condition during the first months after surgery. Considering the close relation between inflammation and IR, we conducted a study in which insulin sensitivity was measured during the first months after bariatric surgery. Different methods to measure IR shortly after bariatric surgery have given inconsistent data. For example, the Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) levels have been reported to decrease rapidly after bariatric surgery, although clamp techniques have shown sustained insulin resistance. In the present study, we evaluated the use of steady-state plasma glucose (SSPG) levels to assess insulin sensitivity 2 months after bariatric surgery.Methods: Insulin sensitivity was measured using HOMA-IR and SSPG levels in 11 subjects before surgery and at 26% excess weight loss (approximately 2 months after restrictive bariatric surgery).Results: The SSPG levels after 26% excess weight loss did not differ from the SSPG levels before surgery (14.3 ± 5.4 versus 14.4 ± 2.7 mmol/L). In contrast, the HOMA-IR values had decreased significantly (3.59 ± 1.99 versus 2.09 ± 1.02).Conclusion: During the first months after restrictive bariatric surgery, we observed a discrepancy between the HOMA-IR and SSPG levels. In contrast to the HOMA-IR values, the SSPG levels had not improved, which could be explained by the ongoing inflammatory state after bariatric surgery. These results suggest that during the first months after restrictive bariatric surgery, HOMA-IR might not be an adequate marker of insulin sensitivity.

American Society for Metabolic and Bariatric Surgery Position Statement on Emergency Care of Patients with Complications Related to Bariatric Surgery - Corrected Proof

2009-12-10

The following position statement has been issued by the American Society for Metabolic and Bariatric Surgery (ASMBS) in response to numerous inquiries made to the Society by patients, physicians, society members, hospitals, health insurance payors, the media, and others regarding the role of bariatric surgeons in the care of patients with complications related to bariatric surgery. The intent of issuing such a statement is to provide a guideline derived from ethical standards and expert opinion on the topic of emergency care of bariatric surgery patients for bariatric surgeons, for general surgeons who do not perform bariatric surgery, and for hospitals (both those with bariatric surgery programs and those without such programs). The statement is not intended as, and should not be construed as, stating or establishing a local, regional, or national standard of care. The statement will be revised in the future should modifications be deemed necessary by the Society.

Editorial comment - Corrected Proof

Jaime Ponce — 2009-12-10

Erosions are a rare complication of the laparoscopic adjustable gastric banding procedure. Technique and band device improvements have decreased the occurrence of this problem significantly. We still do not know the exact cause of how and why erosions develop. The questions posted in the report “Evaluating gastric erosion in band management: an algorithm for stratification of risk” are very valid: does postoperative management, band type, or overinflation have an effect?

Small intestinal obstruction due to self-deflated free intragastric balloon - Uncorrected Proof

Alaattin Öztürk, Ömer Faruk Akinci, Mehmet Kurt — 2009-12-10

Morbid obesity has become a severe health problem, especially in Western countries. The prevalence of morbid obesity has been gradually increasing in recent years. Morbidly obese people develop concomitant diseases, in addition to the severity of the obesity itself. Obesity can be treated using several methods—employed individually or combined—such as diet, a change in eating habits, exercise, medical therapy, intragastric balloon implantation, or surgery. Depending on the medical condition and socioeconomic status of the patient, 1 of these methods, or a combination of them, can be used. Each method has its pros and cons. Implanting a balloon device in the stomach is a method that can accelerate weight loss by giving the patient the sensation of satiety. In the present report, we describe patients with an obstructed intestine related to the spontaneous deflation of a free intragastric balloon.