Gastroplasty for morbid obesity: technique, complications and results in 60 cases

Endoscopic Management of Drain Inclusion in the Gastric Pouch after Gastrojejunal Leakage after Laparoscopic Roux-en-Y Gastric Bypass for the Treatment of Morbid Obesity (LRYGBP)

Background. Drain inclusion inside the gastric pouch is rare and can represent an important source of morbidity and mortality associated with laparocopic Roux-en-Y gastric bypass (LRYGBP). These leaks can become chronic and challenging. Surgical options are often unsuccessful. We present the endoscopic management of four patients with drain inclusion. Patients. All four obese morbidly patients underwent LRYGBP and presented a gastro-jejunal fistula after acute anastomotic leakage. During follow-up endoscopy the drain was found inside the gastric pouch. It was moved into the abdominal cavity. Fistula debit reduced significantly and closed. Results. Gastric leak closure in less than 24 hours was achieved in all, with complete resolution of symptoms. These patients benefited exclusively from endoscopic treatment. Conclusions. Endoscopy is useful and technically feasible in chronic fistulas. This procedure is a less invasive alternative to traditional surgical revision. Other therapeutic strategies can be used such as clips and fibrin glue. Drains should not be placed in contact with the anastomosis or stapled lines. Drain inclusion must be suspected when fistula debit suddenly arises. If so, endoscopy is indicated for diagnostic accuracy. Under endoscopy vision, the drain is gently removed from the gastric reservoir leading to sudden and complete resolution of the fistula.

Endoscopic fibrin sealing of gastrocutaneous fistulas after sleeve gastrectomy and biliopancreatic diversion with duodenal switch

BACKGROUND AND AIM

Gastrocutaneous fistulas (GCF) are uncommon complications accounting for 0.5-3.9% of gastric operations. When their management is not effective, the mortality rate is high. This study reports the conservative treatment of GCF in morbidly obese patients who underwent biliopancreatic diversion with duodenal switch.

METHODS

Ninety-six morbidly obese patients were treated in our department with biliopancreatic diversion with duodenal switch (Marceau technique) and, in six of them, a high-output GCF developed. A general protocol was applied to all patients presenting a GCF. Everyone was treated by total parenteral nutrition (TPN) and somatostatin for at least 7 days after the appearance of the leak. If the leak continued, then fibrin glue was used as a tissue adhesive. Endoscopic application of the sealant was accomplished under direct vision via a double-lumen catheter passed through a forward-viewing gastroscope.

RESULTS

All patients were treated successfully with conservative treatment (either solely with TPN and somatostatin, or with endoscopic fibrin sealing sessions). No evidence of fistula was observed at gastroscopy 3 and 24 months after therapy.

CONCLUSION

The conservative treatment of GCF following biliopancreatic diversion with duodenal switch is highly effective. All patients should enter a protocol that includes TPN and somatostatin. When the GCF persist, endoscopic sealing glue should be considered before operation because it is simple, safe, effective and, in some cases, life-saving. Therefore, conservative treatment should be employed as a therapeutic option in GCF developing after bariatric surgery.

Endoscopic argon plasma coagulation of Marlex mesh erosion after vertical-banded gastroplasty

BACKGROUND

Marlex mesh erosions may occur as late complications after vertical-banded gastroplasty. Experience with the endoscopic treatment is limited.

OBJECTIVE

To describe the use of argon plasma coagulation in the endoscopic treatment of eroded Marlex mesh.

DESIGN

Case report.

SETTINGS

Endoscopy Unit, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.

PATIENTS

We describe the endoscopic treatment of eroded Marlex mesh in 2 patients who presented with symptoms of gastric-outlet obstruction.

INTERVENTIONS

In both cases, argon plasma coagulation was used to break down the eroded Marlex mesh. Fragments were subsequently removed with forceps and electrocautery snares. We did not encounter any complications with this method.

RESULTS

The endoscopic treatment resulted in lasting symptomatic improvement in both patients.

LIMITATIONS

Our experience is limited to 2 cases.

CONCLUSIONS

Argon plasma coagulation appears to be a promising option for the endoscopic treatment of eroded Marlex mesh. It allows the fragmentation of large mesh portions and enables subsequent removal with a snare and a forceps. This method can result in symptomatic improvement and may obviate the need for surgery. Further data are necessary to evaluate the safety and the efficacy of this approach.

[Incarceration of a calibrating band after vertical banded gastroplasty for morbid obesity: diagnostic and therapeutic implications]

About a case of migration of the strip of grading placed during a gastroplasty, and revealed by a severe complication on the occasion of the transformation of a typical Mason gastroplasty in Mac Lean gastroplasty, we formulate the following propositions: 1) The staple line dehiscence of Mason's vertical gastroplasty can be bound (connected) to an excessive tightening of the strip and let us suggest lengthening (stretching out) his 2 cm length with regard to the usually recommended dimension. 2) It is necessary to look for systematically this confinement, in case of reintervention for staple line dehiscence; to ignore it is to expose itself, if we transform the Mason surgery into Mac Lean surgery, to deteriorate a fistula which the staple line dehiscence had until then contributed to hide (darken).

Endoscopic management of gastrocutaneous fistula after bariatric surgery by using a fibrin sealant

BACKGROUND

Gastrocutaneous fistula is an uncommon and difficult to treat complication that occurs in 0.5% to 3.9% of patients who undergo gastric surgery. Sepsis usually follows, and, when it is not managed effectively, the associated mortality rate can be as high as 85%. A fibrin sealant was used to endoscopically manage gastrocutaneous fistulas that developed in 3 morbidly obese patients after bariatric surgery.

METHODS

Two of 14 (14.29%) patients who underwent vertical gastroplasty (MacLean procedure) developed a non-healing gastrocutaneous fistula. In addition, one of 24 (4.17%) patients who had a biliopancreatic diversion with preservation of pylorus developed a gastrocutaneous fistula. Endoscopic application of a fibrin sealant was performed under direct vision via a double-lumen catheter passed through a forward-viewing endoscope.

OBSERVATIONS

Treatment was successful in all patients after one or more endoscopic sessions in which the fibrin sealant was applied; no evidence of fistula was found at follow-up endoscopy.

CONCLUSIONS

Endoscopic closure of gastrocutaneous fistula with human fibrin tissue sealant is simple, safe, and effective, and, in some cases, can be life-saving. Endoscopic application of fibrin sealant should be considered a therapeutic option for treatment of gastrocutaneous fistula that develops after bariatric surgery.

Laparoscopic adjustable gastric banding for the treatment of morbid obesity

BACKGROUND

This prospective study evaluated the effectiveness and safety of laparoscopic adjustable gastric banding (LAGB) for morbid obesity.

METHODS

Ninety-five consecutive patients (89 female; median age 38 years, range 19 to 69) underwent LAGB for morbid obesity. Median weight and body mass index were 123.2 (88.9 to 228.6) kg and 45 (32.7-76.4) kg/m(2) respectively. Significant coexistent disease was present in 52 (55%) patients.

RESULTS

Median excess weight loss was 53% (range 96.9% to 12.1%) and 62% (range 107.5% to 32.3%) at 1 and 2 years respectively (P <0.001). Median operative time was 90 (range 35 to 285) minutes and inpatient stay 2 (range 1 to 10) days. Early complications were seen in 17 (18%) patients most commonly nausea/vomiting or dysphagia. Late complications were seen in 25 (26.3%) patients, most frequently vomiting or reflux due to band slippage or pouch dilatation. There was 1 (1%) operative death.

CONCLUSIONS

LAGB is an effective operation for morbid obesity that results in equivalent weight loss to open surgical procedures.

Intragastric balloon in the treatment of patients with morbid obesity

BACKGROUND

Morbid obesity is a major health problem. This study evaluated the effectiveness and safety of an intragastric balloon (IGB) for the treatment of morbid obesity.

METHODS

Sixty-nine IGBs were inserted endoscopically over a 3-year period in 63 consecutive patients (59 women; median age 41 (range 24-67) years). Median weight and body mass index were 124.5 (range 89.0-177.8) kg and 46.3 (range 36.2-72.4) kg/m(2) respectively. Significant coexistent disease was present in 34 patients. Median American Society of Anesthesiologists score was 3 (range 1-4). Data were recorded following retrospective review of patient case notes.

RESULTS

Mean operating time was 22 (range 15-30) min and median inpatient stay was 1 (range 1-6) day. Vomiting was the commonest early complication following 31 procedures and necessitated early removal of four IGBs. Of 58 patients with long-term follow-up, 18 suffered displacement of the IGB after at least 6 months in situ and three required a laparotomy for intestinal obstruction. Fifty patients (86 per cent) lost weight; median weight loss was 15.0 kg (P < 0.001). Median excess weight loss was 16.4 (range - 49.0 to + 4.8) and 18.7 (range - 51.5 to 12.6) per cent by 4 and 7 months after IGB insertion respectively.

CONCLUSION

The IGB represents a useful device for the treatment of morbid obesity, particularly in preparation for definitive antiobesity procedures. Early IGB replacement is essential to minimize complications.

Hand-assisted laparoscopic vertical banded gastroplasty: early results

BACKGROUND

Minimally invasive hand-port-assisted laparoscopic vertical banded gastroplasty has the potential to reduce postoperative complications after bariatric surgery.

METHODS

We analyzed the postoperative course of 46 hand-port-assisted laparoscopic vertical banded gastroplasties (LVBG) completed between January 1998 and April 1999.

RESULTS

The operating time for the LVBG was shorter (140.8 +/- 6.0 vs 180.2 +/- 6.3 min; p < 0.05). Individuals were able to ambulate sooner (1.36 +/- 0.09 vs 2.44 +/- 0.16 days; p < 0.05), and start oral intake earlier (2.7 +/- 0.27 vs 3.7 +/- 0.17 days; p < 0.05) than the open vertical banded gastroplasty (VBG) controls. Three staple line leaks were detected in this group. Two leaks resolved without clinical sequelae, but one patient developed intraabdominal sepsis. This complication extended the average hospital stay to 6.8 +/- 2.00 days, as compared to 7.71 +/- 0.18 days for historical controls. By discounting this patient from the analysis, we arrive at a more representative length of hospitalization of 4.82 +/- 0.34 days (p < 0.05).

CONCLUSIONS

LVBG offers a good alternative to the standard open VBG. Although this procedure has a relatively short learning curve, it should be done at centers with an interest in bariatric surgery.

Abdominoplasty following vertical banded gastroplasty for morbid obesity

We describe 15 patients who underwent abdominoplasty following vertical banded gastroplasty for morbid obesity between 1991 and 1994. Vertical banded gastroplasty was performed (by CMSR) on patients with a Body Mass Index greater than 39. Following this, the patients lost weight rapidly, leading to excess folds of skin and fat on the abdomen, arms and thighs, and were referred for plastic surgery when their weight had stabilised. After abdominoplasty, the Body Mass Indices of all the patients decreased to an acceptable range. Because vertical banded gastroplasty causes little long-term metabolic or nutritional disturbance, the abdominal skin could be undermined up to the costal margin and the umbilicus re-sited without major necrosis of the abdominal wall or umbilicus. All patients received prophylactic low dose heparin perioperatively until early ambulation. Prophylactic antibiotics were not used but there were no major wound infections. Patients were reviewed up to 12 months after abdominoplasty and were satisfied with the results. Abdominoplasty following vertical banded gastroplasty for morbid obesity safely provides acceptable cosmetic results.

Surgical treatment of morbid obesity

Morbid obesity significantly reduces life span and is associated with much co-morbid pathology. Diet, behavioural therapy and drug therapy are largely unsuccessful. Surgical treatment offers the best hope. This review summarizes the rationale for treatment and the available surgical options.

Vertical banded gastroplasty for morbid obesity: weight loss at short and long-term follow up

A standardized vertical banded gastroplasty (VBG) was carried out by the one surgeon on 60 consecutive morbidly obese patients. All patients were followed at 4 week intervals for 1.5 years. Long-term follow up was carried out at medians 5.7 and 9.6 years. All patients had significant weight loss at 1.5 years. However, at long-term follow up, despite an apparently intact gastric restrictive procedure, only 40% of patients had maintained their weight loss. Sixty per cent had regained significant weight and 31% had returned to or were above their pre-operative weight level.

Vertical banded gastroplasty for the treatment of morbid obesity

Prospective evaluation of 114 obese patients (96 women, 18 men) undergoing vertical banded gastroplasty over a 5-year period was undertaken. The age range was 17-58 (median 37) years, median weight 119.3 (range 79-216) kg, mean(s.d.) proportion of excess body-weight 104.1 (34.9) per cent and median body mass index (BMI) 44.8 (range 33.2-77.7) kg/m2. Three gastric outlet stoma circumferences were used: 5.5 cm (31 patients), 5.0 cm (28) and 4.75 cm (55). A total of 109 patients (95.6 per cent) were available for follow-up. At 1 year after operation, 54 patients (59 per cent) had lost greater than 50 per cent of excess body-weight. No patient lost less than 25 per cent of excess body-weight, and the median BMI was 32.5 (range 21.3-47.8) kg/m2. The operative mortality rate was zero, but three patients (2.6 per cent) with gastric leakage required surgical revision. Vertical banded gastroplasty is a relatively safe and simple procedure that produces significant and sustained weight reduction in the majority of morbidly obese patients.

Severe reflux esophagitis after vertical banded gastroplasty for treatment of morbid obesity

Herein we describe two patients with medically refractory, severe reflux esophagitis after vertical banded gastroplasty for morbid obesity. Neither patient had symptoms of reflux preoperatively. Both patients underwent conversion to a vertical Roux-en-Y gastric bypass, an operation that prevents acid and peptic reflux and maintains a weight-reducing anatomy. Symptoms of gastroesophageal reflux are common (they occur in approximately 38% of patients) after vertical banded gastroplasty has been performed. Patients with unusually severe reflux may require operative management.