Vertical gastroplasty: evolution of vertical banded gastroplasty

Rates and Risk Factors for 30-Day Morbidity After One-Stage Vertical Banded Gastroplasty Conversions: A Retrospective Analysis

Background: The vertical banded gastroplasty (VBG) is a historic restrictive bariatric operation often requiring further surgery. In this investigation utilizing the 2021 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) national dataset, we aim to better define the outcomes of VBG conversions.Methods: We queried the 2021 MBSAQIP dataset for patients who underwent a conversion from a VBG to Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Demographics, comorbidities, laboratory values, and additional patient factors were examined. Rates of key consequential outcome measures 30-day readmission, reoperation, reintervention, mortality, and a composite endpoint (at least 1 of the 4) were further calculated.Results: We identified 231 patients who underwent conversion from VBG to SG (n = 23), RYGB (n = 208), or other anatomy (n = 6), of which 93% of patients were female, and 22% of non-white race. The median age was 56 years and body-mass index (BMI) was 43 kg/m2. The most common surgical indications included weight considerations (48%), reflux (25%), anatomic causes (eg, stricture, fistula, and ulcer; 10%), and dysphagia (6.5%). Thirty-day morbidity rates included reoperation (7.8%), readmission (9.1%), reintervention (4.3%), mortality (.4%), and the composite endpoint (15%). Upon bivariate analysis, we did not identify any specific risk factor for the 30-day composite endpoint.Discussion: One-stage VBG conversions to traditional bariatric anatomy are beset with higher 30-day morbidity relative to primary procedures. Additional MBSAQIP data will be required for aggregation, to better characterize the risk factors inherent in these operations.

Closed loop small bowel obstruction due to herniation through silastic ring after bariatric surgery

Bariatric surgery is an effective treatment for obesity and obesity-related complications. Weight regain after surgery plagues all methods of bariatric procedures including the minigastric bypass. The use of a 'silastic ring' around the gastric pouch has been shown to reduce weight regain. We present here a very rare complication of silastic ring use, in which a loop of small bowel had herniated through the ring and produced a closed loop small bowel obstruction. The patient was successfully treated with an emergency laparotomy to resect the silastic ring and release the herniated bowel. This case highlights the hernia risk that silastic rings pose and cautions careful consideration before their use.

Seventy years of bariatric surgery: A systematic mapping review of randomized controlled trials

While research publications on bariatric surgery (BS) have grown significantly over the past decade, there is no mapping of the existing body of evidence on this field of research. We performed a systematic review followed by a mapping of randomized controlled trials (RCTs) in BS for people with obesity. From January 2020 to December 2020, we performed a systematic review of RCTs evaluating BS, versus another surgical procedure, or versus a medical control group, through a search of Embase and PubMed. There was no restriction on outcomes for study selection. A total of 114 RCTs were included, most (73.7%) of which were based on a comparison with Roux-en-Y gastric bypass (RYGB) and conducted between 2010 and 2020. Only 15% of the trials were multicenter and few (3.5%) were international. The median number of patients enrolled was 61 (interquartile range [IQR]: 47.3-100). Follow-up time was 1 to 2 years in 36% and 22.8% of the trials, respectively. Weight loss was the most studied criterion (87% of RCTs), followed by obesity-related diseases, and medical and surgical complications (73%, 54%, and 47% of RCTs, respectively). Nutritional deficiency frequency, body composition, and mental health were little studied (20%, 18% and 5% of RCTs, respectively). Our literature review revealed that much research in BS is wasted because of replication of RCTs on subjects for which there is already body of evidence, with small populations and follow-up times mostly below 2 years. Yet several research questions remain unaddressed, and there are few long-term trials. Future studies should take into account the experience of the past 70 years of research in this field.

From the Knife to the Endoscope-a History of Bariatric Surgery

PURPOSE OF REVIEW

Current bariatric surgical practice has developed from early procedures, some of which are no longer routinely performed. This review highlights how surgical practice in this area has developed over time.

RECENT FINDINGS

This review outlines early procedures including jejuno-colic and jejuno-ileal bypass, initial experience with gastric bypass, vertical banded gastroplasty and biliopancreatic diversion with or without duodenal switch. The role laparoscopy has played in the widespread utilization of surgery for treatment of obesity will be described, as will the development of procedures which form the mainstay of current bariatric surgical practice including gastric bypass, sleeve gastrectomy and adjustable gastric banding. Endoscopic therapies for the treatment of obesity will be described. By outlining how bariatric surgical practice has developed over time, this review will help practicing surgeons understand how individual procedures have evolved and also provide insight into potential future developments in this field.

Banded Sleeve Gastrectomy: Better Long-Term Results? A Long-Term Cohort Study Until 5 Years Follow-Up in Obese and Superobese Patients

INTRODUCTION

The failure rate of the laparoscopic sleeve gastrectomy (LSG) is increasing. Gastric pouch dilation is frequently suggested to be one of the causes for the failure. The banded laparoscopic sleeve gastrectomy (BLSG) has been proposed to overcome this complication. This is the first study that reports the long-term outcome (> 5 years) of BLSG in obese and superobese patient population.

MATERIALS AND METHODS

One hundred and forty-seven patients (n = 51, non-banded LSG (NLSG)/n = 96, BLSG) were followed up for 5 years. Patients were evaluated for % excess weight loss (%EWL), % excess body mass index loss (%EBMIL), weight regain, BMI, and complications. Weight loss analysis was also done between banded and non-banded superobese patient populations.

RESULT

There was statistical significant difference between two groups at each given time point in terms of %EWL and %EBMIL. NLSG group had higher weight loss failure rate (35.2%) and weight regain (19.6%) at the 5-year follow-up compared to BLSG group (P < 0.001). There was no statistical significant difference in weight loss between obese and superobese BLSG group. The complication rates were more with BLSG group (14.5%) compared to NLSG group (9.8%); no signs of band slippage, erosion, or migration were seen. There was no mortality seen.

CONCLUSION

BLSG surgery was found to be safe and effective in maintaining weight loss on the long term compared to the NLSG group with low incidence of band-related problems. Additionally, the NLSG group had a higher rate of weight loss failure and weight regain at 5 years compared to the BLSG group.

Long-Term Follow-Up of Autonomic and Enteric Measures in Patients Undergoing Vertical Banded Gastroplasty for Morbid Obesity

Background

A multi-component model of autonomic and enteric factors may correlate with ultimate weight loss or gain after restrictive obesity surgery. This study aimed to determine relevant parameters to predict successful long-term weight loss.

Methods

Thirty-nine patients (four males and 35 females) with a mean age of 37.2 years were followed for over 15 years after vertical banded gastroplasty. Baseline adrenergic: postural adjustment ratio (PAR) and vasoconstriction (VC); cholinergic: electrocardiogram R-to-R interval (RRI) and enteric measure: electrogastrogram (EGG) were utilized by a discriminant function analysis to classify patients as a long-term loser or gainer. Using latest weight compared to baseline, patients were divided as 10 gainers and 29 losers.

Results

A discriminate model successfully predicted ultimate weight gain in 8/10 (80%) of patients who subsequently gained weight and weight loss in 24/29 (83%) of patients who lost weight for a total correct classification of 32/39 (82%). The same model with data at 3 months postoperatively predicted weight gain in 9/10 (90%) of patients and weight loss in 24/29 (83%) of patients, for a total correct classification of 34/39 (87%).

Conclusions

A multi-component model at baseline and 3 months postoperative can predict long-term weight outcome from restrictive obesity surgery.

Long-term results after revisions of failed primary vertical banded gastroplasty

AIM: To compare the results after revision of primary vertical banded gastroplasty (Re-VBG) and conversion to sleeve gastrectomy (cSG) or gastric bypass (cRYGB).

METHODS: In this retrospective single-center study, all patients with a failed VBG who underwent revisional surgery were included. Medical charts were reviewed and additional postal questionnaires were sent to update follow-up. Weight loss, postoperative complications and long-term outcome were assessed.

RESULTS: A total 152 patients were included in this study, of which 21 underwent Re-VBG, 16 underwent cSG and 115 patients underwent cRYGB. Sixteen patients necessitated a second revisional procedure. No patients were lost-to-follow-up. Two patients deceased during the follow-up period, 23 patients did not return the questionnaire. Main reasons for revision were dysphagia/vomiting, weight regain and insufficient weight loss. Excess weight loss (%EWL) after Re-VBG, cSG and cRYGB was, respectively, 45%, 57% and 72%. Eighteen patients (11.8%) reported postoperative complications and 27% reported long-term complaints.

CONCLUSION: In terms of additional weight loss, postoperative complaints and reintervention rate, Roux-en-Y gastric bypass seems feasible as a revision for a failed VBG.

Long-Term Results of Primary Vertical Banded Gastroplasty

BACKGROUND

The vertical banded gastroplasty (VBG) used to be a common restrictive bariatric procedure but has been abandoned by many due to a high failure rate, a high incidence of long-term complications, and the newer adjustable gastric band (AGB) and sleeve. However, potential favorable long-term results and the upcoming banded gastric bypass, with a similar mechanical outlet restriction and control of the pouch size, renewed our interest in the VBG. Therefore, we investigated the long-term outcome of primary VBG at the Catharina Hospital in the Netherlands.

METHODS

Patients that underwent a primary VBG between 1998 and 2008 were included. Patients' characteristics, operative details, evolution on weight and comorbidities, complications, and outcome of revisions were reviewed.

RESULTS

A total of 392 patients (80 % female) were reviewed with a mean age of 40 ± 9 years and body mass index of 44 ± 5 kg/m(2). Mean follow-up after VBG was 66 ± 50 months and showed a mean excess weight loss (EWL) of 53 ± 27 % and comorbidity reduction of 54 %. One hundred fifty-two patients (39 %) out of 227 patients (58 %) with long-term complaints underwent revisional surgery. Main reasons for revision were weight regain and vomiting/food intolerance. Analysis before revision showed an outlet dilatation (17 %), pouch dilatation (16 %), and outlet stenosis (10 %). After revision, an additional EWL of 23 % and 33 % further reduction in comorbidities was seen.

CONCLUSIONS

Primary VBG has an acceptable EWL of 53 % and 55 % of comorbidities were improved. However, the high complication rate, often necessitating revision, underlines the limits of this procedure.

Decrease in microvesicle-associated tissue factor activity in morbidly obese patients after bariatric surgery

BACKGROUND

Tissue factor (TF) is the main in vivo initiator of the blood coagulation cascade. Active circulating TF was detected on small, negatively charged membrane vesicles, the so-called microvesicles (MVs), which are released upon cell activation and apoptosis from a variety of cells. Increased coagulation activation was found in morbidly obese patients, and elevated levels of TF-bearing MVs may contribute to the prothrombotic state in these patients.

AIM

To determine MV-associated TF activity levels in morbidly obese patients before and after weight loss due to bariatric surgery.

METHODS

MV-TF activity was measured with a factor Xa generation assay in morbidly obese patients before and 2 years after bariatric surgery. In addition, clinical parameters were determined.

RESULTS

Seventy-four morbidly obese patients (mean age: 42 (±11) years; 61 females) were included in this study. After bariatric surgery, the body mass index decreased from (median, 25-75th percentile) 45.5 (42.3-50.2) to 30.5 (28.0-34.4 kg m(-2); P<0.001), and a significant improvement in metabolic parameters was observed. Preoperative MV-TF activity correlated with C-reactive protein levels (r=0.3; P=0.02). Postoperatively, the mean MV-TF activity decreased significantly from 0.20 pg ml(-1) (0.18-0.47) to 0.02 (0.00-0.28; P<0.01).

CONCLUSION

We could demonstrate a significant decrease in MV-TF activity after weight loss in morbidly obese patients. Decreased MV-TF activity might contribute to an improved coagulation profile in these patients after weight loss.

To band or not to band--early results of banded sleeve gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is the procedure with the fastest growing numbers worldwide. Although excellent weight loss can be achieved, one major obstacle of LSG is weight regain due to sleeve dilatation. Banded sleeve gastrectomy (BLSG) has been described as an option to counteract sleeve dilatation and ameliorate weight loss over time. In a retrospective study, we analysed 25 patients who underwent BLSG using a MiniMizer® ring. Twenty five patients who had previously undergone a conventional LSG were selected for matched-pair analysis. Patient follow-up was 12 months in both groups. Mean preoperative BMI was 56.1 ± 7.2 kg/m(2) for BLSG and 57.0 ± 6.3 kg/m(2) for LSG, P = 0.522. Operative time was significantly shorter for BLSG (53 ± 27 min vs. 68 ± 20 min, P = 0.0025). Excess weight loss (%EWL) was equal in both groups with %EWL at 12 months of 58.0 ± 14.6 % for BSLG patients vs. 58.4 ± 19.2 % for LSG patients. There was no procedure-related mortality in either group. At 12 months postoperative, vomiting was significantly increased in BSLG patients (OR 6.75, P = 0.035). New onset reflux was equal in both groups (OR 0.67, P = 0.469). Ring implantation does not increase the duration of surgery or early surgical complications. Weight loss in the first follow-up year is not influenced, but the incidence of vomiting is raised after 12 months when patients start to increase eating volume.

Laparoscopic revolution in bariatric surgery

The history of bariatric surgery is investigational. Dedicated surgeons have continuously sought for an ideal procedure to relieve morbidly obese patients from their burden of comorbid conditions, reduced life expectancy and low quality of life. The ideal procedure must have low complication risk, both in short- and long term, as well as minimal impact on daily life. The revolution of laparoscopic techniques in bariatric surgery is described in this summary. Advances in minimal invasive techniques have contributed to reduced operative time, length of stay, and complications. The development in bariatric surgery has been exceptional, resulting in a dramatic increase of the number of procedures performed world wide during the last decades. Although, a complex bariatric procedure can be performed with operative mortality no greater than cholecystectomy, specific procedure-related complications and other drawbacks must be taken into account. The evolution of laparoscopy will be the legacy of the 21^st century and at present, day-care surgery and further reduction of the operative trauma is in focus. The impressive effects on comorbid conditions have prompted the adoption of minimal invasive bariatric procedures into the field of metabolic surgery.

What makes a gastric bypass a good gastric bypass? Opinion and hypothesis

Gastric bypass is widely accepted as the gold standard bariatric operation. It was first reported 1967 and has been the subject of many technical alterations and variations since that time. Each of these variations has the potential to confer different outcomes, in terms of such things as weight loss, ease of surgery, risk, complications and durability of weight loss. All variations being performed these days should be accomplished with high levels of safety, in which case the primary interest of those undergoing surgery is the degree of weight loss that can be expected and the durability of that weight loss. Broadly speaking these two features will also determine the degree to which all co-morbidities are improved, which is also a goal of those undergoing surgery. In this article the authors describe the features of the Fobi Pouch gastric bypass which make it the most predictable and reliable variant of gastric bypass and report such evidence in the literature as exists for their contentions.

A brief history of the surgery for obesity to the present, with an overview of nutritional implications

Massive obesity results in serious diseases, which are a major public health problem. Surgery is frequently the only means to achieve and sustain significant weight loss. This historical overview is aimed at providing knowledge and appreciation of this surgery to scientists in other complex areas of nutrition. The development of these operations is provided, including their potential nutritional sequelae. Because type 2 diabetes frequently improves or resolves postoperatively, related operations are being investigated in patients with lower weights.

Ten years experience of banded gastric bypass: does it make a difference?

Many surgeons support some sort of restriction of the gastric pouch outlet by placing a ring around the gastric reservoir. Previous studies have shown positive results of banded gastric bypass (BGBP); however, there are not many comparative long-term studies to assess the real advantage of placing a ring during gastric bypass (GBP) surgery. This study aims to evaluate the long-term outcome of patients subjected to BGBP and nonbanded GBP procedures. We studied 260 retrospective, nonrandomized obese patients who underwent BGBP and 218 patients without the ring (i.e., GBP). They were followed up for 10 years, and the following parameters were evaluated: excess weight loss (EWL), quality of life (QOL), food tolerance, and correction of comorbidities. The study was approved by the Committee on Ethics, and all the patients gave their informed consent. There is a significant difference in %EWL from the third year until the tenth year of observation, with the proportion being 82% in BGBP versus 63% in nonbanded GBP patients at the end of the study. Although there was some increased intolerance to food intake in the BGBP patients, this was not felt to reduce the QOL. The outcome in terms of comorbidities was not conclusive. There is a clear advantage in terms of %EWL in the BGBP patients. No differences in QOL were found in both groups. Further, selecting the right type of material and the right size of the ring is important to improve results and avoid complications.

Type 2 diabetes mellitus: a possible surgically reversible intestinal dysfunction

Type 2 diabetes mellitus (T2DM) is a global public health problem often associated with obesity. Bariatric surgery is effective for treating serious obesity, and techniques involving intestinal bypass have metabolic benefits, such as complete and early remission of T2DM. We present a literature review of the possible mechanisms of early normalization of glycemic homeostasis after bariatric surgery, including intestinal gluconeogenesis, increased antidiabetogenic signals from L cells located in the distal small intestine, and impaired secretion of diabetogenic signals in the upper part of the small intestine. Adding to these potential mechanisms, unknown factors that regulate insulin sensitivity may be involved and altered by bariatric surgery. This review discusses the various hypotheses about the mechanisms of glycemic control after bariatric surgery involving intestinal bypass. Further research is essential to better understand these mechanisms and to identify potential new mechanisms that might help in developing less invasive and safer alternatives for the treatment of T2DM and reveal novel pharmaceutical targets for glycemic control.

Long-term results of bariatric restrictive procedures: a prospective study

Laparoscopic adjustable gastric banding (LAGB) and vertical-banded gastroplasty (VBG) are surgical treatment modalities for morbid obesity. This prospective study describes the long-term results of LAGB and VBG. One hundred patients were included in the study. Fifty patients underwent LAGB and 50 patients, open VBG. Study parameters were weight loss, changes in obesity-related comorbidities, long-term complications, re-operations including conversions to other bariatric procedures and laboratory parameters including vitamin status. From 91 patients (91%), data were obtained with a mean follow-up duration of 84 months (7 years). Weight loss [percent excess weight loss (EWL)] was significantly more after VBG compared with LAGB, 66% versus 54%, respectively. All comorbidities significantly decreased in both groups. Long-term complications after VBG were mainly staple line disruption (54%) and incisional hernia (27%). After LAGB, the most frequent complications were pouch dilatation (21%) and anterior slippage (17%). Major re-operations after VBG were performed in 60% of patients. All re-operations following were conversions to Roux-en-Y gastric bypass (RYGB). In the LAGB group, 33% of patients had a refixation or replacement of the band, and 11% underwent conversion to another bariatric procedure. There were no significant differences in weight loss between patients with or without re-interventions. No vitamin deficiencies were present after 7 years, although supplement usage was inconsistent. This long-term follow-up study confirms the high occurrence of late complications after restrictive bariatric surgery. The failure rate of 65% after VBG is too high, and this procedure is not performed anymore in our institution. The re-operation rate after LAGB is decreasing as a result of new techniques and materials. Results of the re-operations are good with sustained weight loss and reduction in comorbidities. However, in order to achieve these results, a durable and complete follow-up after restrictive procedures is imperative.

Metabolic surgery to treat type 2 diabetes: clinical outcomes and mechanisms of action

Several gastrointestinal (GI) operations that were designed to promote weight loss can powerfully ameliorate type 2 diabetes mellitus (T2DM). Although T2DM is traditionally viewed as a chronic, relentless disease in which delay of end-organ complications is the major treatment goal, GI surgery offers a novel endpoint: complete disease remission. Ample data confirm the excellent safety and efficacy of conventional bariatric operations-especially Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding-to treat T2DM in severely obese patients. Use of experimental procedures as well as conventional bariatric operations is increasingly being explored in less obese diabetic patients, with generally favorable results, although further assessment of risk:benefit profiles is needed. Mounting evidence indicates that certain operations involving intestinal diversions improve glucose homeostasis through varied mechanisms beyond reduced food intake and body weight, for example by modulating gut hormones. Research to elucidate such mechanisms should facilitate the design of novel pharmacotherapeutics and dedicated antidiabetes GI manipulations. Here we review evidence regarding the use and study of GI surgery to treat T2DM, focusing on available published reports as well as results from the Diabetes Surgery Summit (DSS) in Rome and the World Congress on Interventional Therapies for T2DM in New York City.

A review of weight loss following Roux-en-Y gastric bypass vs restrictive bariatric surgery: impact on adiponectin and insulin

BACKGROUND

Bariatric surgery is a common procedure often used to ameliorate comorbidities associated with obesity, including type 2 diabetes. Substantial weight loss leads to alterations in inflammation and insulin sensitivity as well as numerous metabolic and physiologic pathways. Several inflammatory markers have been evaluated, yet adiponectin, an anti-inflammatory adipokine, has not been fully investigated. Adiponectin may play a key role as a mediator between obesity and inflammation, as lower blood levels are more commonly associated with obesity and type 2 diabetes and because adiponectin lessens insulin resistance. This review evaluates outcome variables from patients who underwent Roux-en-Y gastric bypass (RYGB) or restrictive bariatric surgery to compare and contrast any differential surgical impacts on weight loss, adiponectin, and insulin.

METHODS

A systematic literature review was conducted using a PubMed search. Published studies from 1999 to 2009 that measured blood levels of adiponectin and insulin in bariatric surgery patients prior to and at least 6 months after surgery were included.

RESULTS

Eighteen studies met inclusion criteria for evaluation. RYGB surgery compared to restrictive surgery led to significantly greater weight loss and improvements in adiponectin and insulin sensitivity. Despite significant weight loss, many patients did not achieve "healthy" body mass index or normalization of inflammatory markers.

CONCLUSIONS

While RYGB surgery appears to more favorably influence body weight and inflammatory markers, data are insufficient to fully understand the impact of bariatric surgery on changes in adiponectin and insulin and related health implications. Long-term research is needed to more thoroughly evaluate inflammatory outcomes following these two bariatric surgery procedures.

Laparoscopic gastric banding as revisional procedure to failed vertical gastroplasty

BACKGROUND

Vertical gastroplasty (VG) was worldwide and until recently a very popular restrictive bariatric procedure. Unfortunately, many patients required revisional surgery for failure of this technique. The present study aimed to evaluate retrospectively the feasibility, safety, and efficiency of conversion of failed VGs to laparoscopic adjustable gastric banding (LAGB).

METHODS

Forty patients underwent LAGB as revisional surgery between August 2001 and June 2008. Preceding VGs were performed either by open procedure {silastic ring vertical gastroplasty (SRVG, n = 21) and vertical-banded gastroplasty (VBG, n = 10)} or by laparoscopy {laparoscopic silastic ring vertical gastroplasty (L-SRVG, n = 9)}. The delay between initial and revisional surgery was significantly shorter for SRVG (5.5 +/- 1.7 years; p < 0.001) as compared to VBG and L-SRVG (9.2 +/- 2.3 and 9.4 +/- 1.8 years, respectively). The reasons for failure of the VG were: disruption of the staple line (n = 23), excessive enlargement of the gastric pouch (n = 15) and inefficient stoma (n = 2). Patients were qualified for revisional surgery in case of uncontrolled weight regain with or without frequent vomiting.

RESULTS

There were three conversions from laparoscopy to laparotomy (7.5%). There was no mortality. Minor morbidity was 12.5%. There were two major complications (5%); one incarcerated port-site hernia requiring small bowel resection, and one band erosion necessitating band removal. The mean BMI dropped from 38.9 kg/m(2) before revision to 30.7 kg/m(2) after conversion to LAGB (follow-up 6-88 months).

CONCLUSIONS

Conversion of failed VGs to gastric banding is safe and efficient. The morbidity rate is acceptable. Gastric banding to correct failing VG is a reasonable option when performed in selected patients.

A case of epigastric pain in the ED: late mechanical complication after vertical banded gastroplasty

A 50-year-old woman presented to our emergency department complaining of recurrent epigastric stabbing pain on eating of 1 month duration. She had a history of morbid obesity treated 13 years before with laparoscopic vertical banded gastroplasty (VBG). Diagnosis was made by radiology, after upper gastrointestinal series and abdominal unenhanced computed tomography. These demonstrated intragastric band migration, with outlet stenosis of narrowed stomach. Vertical banded gastroplasty is a miniinvasive approach that gives the benefits of shorter hospital stay, less postoperative pain, and quicker functional recovery. However, many complications are known and require recognition to be appropriately treated. In our case, the history and clinical presentation led to a high suspicion of intraabdominal pathology due to postoperative complication. Radiologic upper gastrointestinal investigation and computed tomography findings were then decisive to detect the intragastric band migration.

Perspective on biomaterials used in the surgical treatment of morbid obesity

Morbid obesity is defined as having a body mass index greater than or equal to 40.0 kg m(-2), or 37.0 kg m(-2) with comorbidities. Bariatric surgery remains the most effective treatment for morbid obesity. Bariatric procedures such as sleeve gastrectomy, vertical banded gastroplasty and adjustable gastric banding all generate excess body-weight loss typically over 3-5 years. The biomaterials used during these procedures, namely silicone, polypropylene, expanded polytetrafluoroethylene and titanium, are all non-degradable biomaterials. Hence, their presence in vivo exceeds the functional requirement of an implant to treat morbid obesity. Accordingly, research into non-invasive and reversible surgical procedures has increased, particularly in light of the dramatic increase in paediatric obesity. Tissue engineering is an alternative approach to treat morbid obesity, as it incorporates both engineering and biological principles into the design and development of an implant to surgically treat morbid obesity. It is hypothesized that a biodegradable polymer to treat morbid obesity could be developed to effectively promote excess weight loss. The aim of this review is to discuss morbid obesity with regards to its aetiology, prevalence and current modalities of treatment. Specifically, the shortcomings of the biomaterials currently used to surgically treat morbid obesity shall be reviewed, and alternative biomaterials shall be proposed.

High revision rates after laparoscopic vertical banded gastroplasty

BACKGROUND

To evaluate, in a surgical department at a university hospital in Stockholm, Sweden, the long-term results after laparoscopic vertical banded gastroplasty (VBG), with special emphasis on revisional surgery. Few studies are available with long-term results after laparoscopic VBG. Some short-term studies have shown results similar to gastric banding.

METHODS

All consecutive patients who underwent attempted laparoscopic VBG between 1995 and 2005 were followed up regarding weight loss and the need for revisional surgery. Follow-up was from the date of surgery to the end of the observational period (December 2006).

RESULTS

In 486 patients, laparoscopic VBG was attempted. Of the 486 cases, 64 were converted to open surgery. Conversions were common in the first patients, with a conversion rate of 4% during the last 100 patients. The mean body mass index at surgery was 42.4 kg/m2. The median follow-up was 3 years (range 0-11). All patients lost weight. A total of 104 patients (21%) required revisional surgery 114 times during the follow-up period, with food intolerance/vomiting and insufficient weight loss the most common reasons. Of the 104 patients, 31 underwent repeat VBG, of whom 10 needed a secondary revisional procedure, and 49 required conversion to gastric bypass, of whom none have required additional revisional surgery.

CONCLUSION

Laparoscopic VBG is associated with high revisional rates. In the case of failed VBG, repeat VBG seems to be a poor option and conversion to gastric bypass yields better results. We have abandoned VBG as a surgical option in the treatment of obesity.

Postoperative morbidity of biliopancreatic diversion depending on common limb length

BACKGROUND

Laparoscopic gastric bypass, currently the most popular surgical method for bariatric therapy, have proved to be effective in weight loss, but some matters regarding its long-term efficacy for super-obese patients (BMI >50 kg/m2) have arisen. Biliopancreatic diversion (BPD) is a complex technique that has shown good results in the treatment of the super-obese patient. We analyze our >5 years results, evaluating weight loss, morbidity and mortality of this operation, depending on the length of the common and alimentary limbs.

METHODS

We studied two series of patients: 150 patients with BPD of Scopinaro (50-200 cm) and 70 patients with modified BPD (75-225 cm). The results have been analyzed in terms of weight loss, co-morbidity improvement, and postoperative morbidity using BAROS.

RESULTS

Range of follow-up is 1-12 years. Weight loss was slightly higher for the Scopinaro group than for the Modified group but with no significant difference. There was more prevalence of malnutrition and of iron deficiency in the Scopinaro group (16% and 60%) than in the modified group (2% and 40%), with similar postoperative morbidities.

CONCLUSION

The modified BPD method (75-225 cm) shows long-term effectiveness in weight loss and comorbidity improvement for super-obesity. Proteins, vitamins and oligoelement deficits appear distant in time, and thus it is necessary to maintain strict followup of these patients and supplement against deficiencies for the rest of their lives.

Surgical management of gastro-gastric fistula after divided laparoscopic Roux-en-Y gastric bypass for morbid obesity

BACKGROUND

Gastro-gastric fistula (GGF) formation is uncommon after divided laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity. Optimal surgical management remains controversial.

METHODS

A retrospective review was performed of a prospectively maintained database of patients undergoing LRYGB from January 2001 to October 2006.

RESULTS

Of 1,763 primary procedures, 27 patients (1.5%) developed a GGF and 10 (37%) resolved with medical management, whereas 17 (63%) required surgical intervention. An additional seven patients requiring surgical intervention for GGF after RYGB were referred from another institution. Indications for surgery included weight regain, recurrent, or non-healing gastrojejunal anastomotic (GJA) ulceration with persistent abdominal pain and/or hemorrhage, and/or recurrent GJA stricture. Remnant gastrectomy with GGF excision or exclusion was performed in 23 patients (96%) with an average in-hospital stay of 7.5 days (range, 3-27). Morbidity in six patients (25%) was caused by pneumonia, n=2; wound infection, n=2; staple-line bleed, n=1; and subcapsular splenic hematoma, n=1. There were no mortalities. Complete resolution of symptoms and associated ulceration was seen in the majority of patients.

CONCLUSION

Although uncommon, GGF formation can complicate divided LRYGB. Laparoscopic remnant gastrectomy with fistula excision or exclusion can be used to effectively manage symptomatic patients who fail to respond to conservative measures.

Disappointing results with a 5 cm calibrating device for laparoscopic vertical banded gastroplasty

BACKGROUND

The gastric outlet represents a critical point of laparoscopic vertical banded gastroplasty (LVBG): the diameter and the material used to calibrate the gastric outlet are essential for long-term success. We present the results of our initial clinical experience with the Proring band, a new calibrating device specifically designed to calibrate LVBG outlet.

METHODS

Between February and April 2004, 13 LVBG were performed using the Proring band. There were 12 women and one man; their mean age was 44 years; mean preoperative weight was 118.8 kg; mean body mass index (BMI) was 44.4 kg/m(2).

RESULTS

The immediate postoperative course was uneventful in all cases. In the follow-up 10 patients out of 13 (76.9%) presented a sudden or progressive food intolerance. Five patients were immediately reoperated by laparoscopic approach and five underwent endoscopic dilatation with initial clinical improvement; early recurrence of symptoms despite further dilatations occurred in four out of five cases. These four patients were then reoperated. Therefore a total of nine (69.2%) patients underwent a laparoscopic reoperation with Proring band removal and its replacement with a polypropylene band. In seven cases an intraoperative endoscopic dilatation was associated with the laparoscopic procedure. Outcome was successful in all cases, with discharge after two days.

CONCLUSION

The results of our experience using the Proring band are unsatisfactory, showing 76.9% with outlet stenosis and 69.2% with reoperations. These data compare negatively with our previous experience on more than 900 VBG procedures using polypropylene mesh.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Nutritional consequences of weight-loss surgery

Nutritional deficiencies are already present in many morbidly obese patients before weight-loss surgery. Appropriate preoperative detection and correction is essential. The severity and pattern of deficiencies is dependent on the presence of preoperative uncorrected deficiency, the type of procedure performed varying with the degree of restriction or the length of bypassed small intestine, the modification of eating behavior, the development of complications, compliance with oral multivitamin and mineral supplementation, and compliance with follow-up. Rigorous control of fluids and electrolytes with establishment of adequate oral nutrition is important in the immediate postoperative period. Regular follow-up of the metabolic and nutritional status of the patient is essential, with life-long multivitamin and mineral supplementation.

Intragastric balloon for obesity

BACKGROUND

Obesity is one of the major public health problems of modern society. Intragastric balloon (IGB) treatment for obesity has been developed as a temporary aid. Its primary objective is the treatment of obese people, who have had unsatisfactory results in their clinical treatment for obesity, despite of being cared for by a multidisciplinary team, and super obese patients with a higher surgical risk. However, the effects of different IGB procedures compared with conventional treatments and with each other are uncertain.

OBJECTIVES

To assess the effects of intragastric balloon in people with obesity.

SEARCH STRATEGY

Studies were obtained from computerised searches of MEDLINE, EMBASE, LILACS, The Cochrane Library and other electronic databases. Furthermore, reference lists of relevant articles and hand searches of selected journals were performed. Experts in the field were contacted.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials fulfilling the inclusion criteria were used. Short term weight loss is common, so studies were included if they reported measurements after a minimum of four weeks follow-up.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and checked independently by two reviewers. Two reviewers independently assessed the quality of trials.

MAIN RESULTS

Nine randomised controlled trials involving 395 patients were included. Six out of nine studies had a follow-up of less than one year, the longest study duration was 24 months. Only a third of the analysed studies revealed a low risk of bias. No information was available on quality of life, all-cause mortality and morbidity. Compared with conventional management, IGB did not show convincing evidence of a greater weight loss. On the other hand, complications of intragastric balloon placement occurred, however few of a serious nature. The relative risks for minor complications like gastric ulcers and erosions were significantly raised.

AUTHORS' CONCLUSIONS

Evidence from this review is limited for decision making, since there was large heterogeneity in IGB trials, regarding both methodological and clinical aspects. However, a co-adjuvant factor described by some authors in the loss and maintenance of weight has been the motivation and the encouragement to changing eating habits following a well-organized diet and a program of behavioural modification. The IGB alone and the technique of positioning appear to be safe. Despite the evidence for little additional benefit of the intragastric balloon in the loss of weight, its cost should be considered against a program of eating and behavioural modification.

Fifty consecutive patients with the GaBP ring system used in the banded gastric bypass operation for obesity with follow up of at least 1 year

BACKGROUND

The premanufactured GaBP ring system can be used in the banded gastric bypass operation instead of a surgeon-fashioned ring or band in current use.

METHODS

The GaBP ring system was used in 50 consecutive patients, and the outcomes were reviewed after 1 year of follow-up. Data were kept prospectively.

RESULTS

The GaBP ring system was used in 50 patients undergoing gastric bypass surgery, 9 with an open procedure and 41 with a laparoscopic approach. Placement took an average of < 5 minutes, and there were no GaBP ring system-related complications at the 1-year follow-up. The outcomes in terms of weight loss and resolution of comorbidities are similar to those previously reported for banded gastric bypass.

CONCLUSION

The GaBP ring system provides a premanufactured standardized ring for use in the banded gastric bypass operation.

Implantable gastric stimulation to achieve weight loss in patients with a low body mass index

This report describes the authors' early outcomes with implantable gastric stimulation (IGS) used to achieve weight loss in patients with a low body mass index (BMI). After prescreening of potential candidates with a selection algorithm, 24 patients (21 women and 3 men) with a low BMI (30-34.9) underwent IGS implantation at two centers. The patients had a mean age of 43 years (range, 32-60 years), a mean BMI of 33 (range, 30-36), and a mean weight of 92 kg (range, 80-117 kg). At this writing, 6 months postoperatively, there have been no serious adverse events related to the device. The mean percentage of excess weight loss (EWL) was 5.9%, with three patients explanted because of noncompliance. The mean waist circumference decreased 5.8%, which was significant (p = 0.009). A subset of nine patients (37.5%) had an EWL exceeding 10% (mean, 20.1%). A subset of low BMI patients lost a clinically significant amount of weight with IGS within 6 months. Further study is required for better identification of potential candidates for this novel approach.

Medical management of obesity

BACKGROUND

Obesity is associated with elevated morbidity and death rates. The World Health Organization defines obesity as a chronic disease. The percentage of obese persons is increasing worldwide. Many different treatment modalities are available. Long-term success rates are not convincing.

RESEARCH FOCUS

Overweight and obesity should be treated in an interdisciplinary and multimodal approach. The best results in loosing body weight, especially body fat use very low calorie diets followed by a fat-reduced, carbohydrate-rich diets. Weight-loss drugs should be used only in a weight-loss program including diet and physical activity. Surgical intervention is necessary in a small group of persons refractory to conservative obesity treatment.

CONCLUSIONS

New structured guidelines oriented and quality controlled programs for treatment of obese patients are necessary.

Weight loss reduces tissue factor in morbidly obese patients

OBJECTIVE

To investigate the tissue factor (TF) pathway in clinical obesity and associated metabolic syndrome.

RESEARCH METHODS AND PROCEDURES

Thirty-seven morbidly obese patients (4 men; BMI, 48 +/- 7 kg/m(2); range, 42 to 53 kg/m(2)), undergoing elective gastroplasty for the induction of weight loss, were examined for hemostatic, metabolic, and inflammatory parameters at baseline and 14 +/- 5 months postoperatively.

RESULTS

Weight loss significantly reduced circulating plasma TF (314 +/- 181 vs. 235 +/- 113 pg/mL, p = 0.04), coagulation factor VII (130 +/- 22% vs. 113 +/- 19%, p = 0.023), and prothrombin fragment F1.2 (2.4 +/- 3.4 vs. 1.14 +/- 1.1 nM, p = 0.04) and normalized glucose metabolism in 50% of obese patients preoperatively classified as diabetic or of impaired glucose tolerance. The postoperative decrease in plasma TF correlated with the decrease of F1.2 (r = 0.56; p = 0.005), a marker of in vivo thrombin formation. In subgroup analysis stratified by preoperative glucose tolerance, baseline circulating TF (402.6 +/- 141.6 vs. 176.2 +/- 58.2, p < 0.001) and TF decrease after gastroplasty (DeltaTF: 164.7 +/- 51.4 vs. -81 +/- 31 pg/mL, p = 0.02) were significantly higher in obese patients with impaired glucose tolerance than in patients with normal glucose tolerance.

DISCUSSION

Procoagulant TF is significantly reduced with weight loss and may contribute to a reduction in cardiovascular risk associated with obesity.

Treatment of gastroesophageal reflux with a gastric tube cardioplasty

PURPOSE

Surgical control of gastroesophageal reflux (GER) is a challenging problem especially in neurologically impaired children and in acquired GER patients after caustic insult to the esophagus because of high failure rates of the classical antireflux procedures. A surgical technique has been designed to overcome this high relapse incidence.

METHODS

During the past 75 months, 39 children between 4 months and 14 years of age underwent a gastric tube cardioplasty fashioned from the lesser curvature as the antireflux barrier.

RESULTS

In all patients, the preoperative RI values of 72 to 10 (average, 32) fell to 0 to 5 (average, 2) after the described procedure, and, in the follow-up period of 2 to 75 months, the RI values did not deteriorate in any one of the cases.

CONCLUSIONS

It is possible that a 6-cm antireflux barrier (HPZ) created from the lesser curvature of the stomach is enough to control GER at any age.

The development of the surgical treatment of morbid obesity

Morbid obesity is defined as obesity with a body mass index >/=40, or >/=35 with secondary serious diseases. Conservative medical therapies in these individuals generally fail to sustain weight loss. Thus, surgical operations have evolved which are based on gastric restriction and/or malabsorption. Historically, the intestinal bypass operation was followed by the gastric bypass operation (in some instances combined with intestinal bypass) or by the gastric restriction operations (gastroplasty or gastric banding). Laparoscopic techniques are now being used for these operations, but require surgical expertise in both the bariatric operations and advanced laparoscopic skills. All operations may have complications, but these occur in a very small percent. Postoperative follow-up and nutritional surveillance are mandatory. The operations result in significant weight loss, and the current operations have a mean lasting weight loss of about 50 percent of excess body weight, with improvement or resolution of most obesity-associated conditions. There is evidence that even modest to moderate weight loss in these individuals has significant medical benefit.

Cirurgia da obesidade mórbida por videolaparoscopia

OBJETIVO: Demonstrar nossa experiência com a gastroplastia em Y de Roux por videolaparoscopia (GYRL), usando pequena bolsa gástrica e anastomose jejunal com grampeador circular. A gastroplastia com desvio em Y de Roux é uma das operações mais comuns para o tratamento da obesidade mórbida. Técnicas por laparoscopia têm sido relatadas, mas descrevem maior tempo operatório e maiores complicações quando comparadas com a cirurgia aberta. A abordagem por videocirurgia continua a ser um desafio mesmo para os cirurgiões mais experientes. MÉTODO: De setembro de 1999 a maio de 2001, 102 pacientes foram submetidos à gastroplastia em Y de Roux. A anastomose jejuno-jejunal foi feita a uma distância de 100cm a 150cm de acordo com o índice de massa corporal (IMC). Uma análise prospectiva identificou o índice de fístula e de estenose pós-operatória e a conduta em uma série consecutiva de pacientes, submetidos a GYRL com anastomose gastrojejunal realizada com grampeador circular 25mm ou 28mm. Nos últimos dez casos esta anastomose foi executada com sutura manual. RESULTADOS:. A média etária foi de 37,5 anos (17-62) e a média de IMC foi de 50,3kg/m² (35-78). O tempo operatório variou de 55min a 210min com média de 119min. O tempo médio de internação foi 4,3 dias (2-10). Dois pacientes superobesos tiveram a cirurgia convertida para o procedimento aberto por dificuldades técnicas. Houve dois óbitos (1,9%), ambos por embolia pulmonar. Houve uma fístula (0,9%) da anastomose gastrojejunal tratada conservadoramente. Quinze pacientes (14,7%), desenvolveram estenose na anastomose e necessitaram de dilatação endoscópica. Nove pacientes sofreram uma única dilatação e seis receberam duas a quatro dilatações e permaneceram sem disfagia. Vinte pacientes foram avaliados após um ano e mostraram uma média de IMC 33,4kg/m² (24-44). CONCLUSÃO: A GYRL com anastomose gastrojejunal com grampeador é segura e efetiva. Ocorreram estenoses que foram tratadas com dilatação endoscópica, mas, com o uso do grampeador circular de 28mm ou sutura manual, não mais aconteceram. Os dois óbitos ocorreram em superobesos, em que a intervenção foi convertida para procedimento aberto e evoluíram com embolia pulmonar irreversível.

Vertical banded gastroplasty: a treatment for morbid obesity

Stomach stapling to aid the morbidly obese patient with weight loss has been available for years. Unfortunately, some methods of bariatric surgery (e.g., gastric bypass surgery) can lead to serious complications. This article discusses vertical banded gastroplasty (VBG) and presents on overview of morbid obesity and its inherent medical problems, the screening process and the physical and psychological needs of patients undergoing bariatric procedures, the anatomy and physiology of normal digestion, and the perioperative nursing considerations in caring for a patient undergoing VBG.

A comparison study of laparoscopic versus open gastric bypass for morbid obesity

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (GBP) has been previously described, but a comparative study between laparoscopic and open GBP has not been reported. The purpose of this study was to compare surgical outcomes oflaparoscopic GBP with those of open GBP for treatment of morbid obesity.

STUDY DESIGN

From August 1998 to September 1999, we prospectively collected outcome data on 35 patients with body-mass indices between 40 kg/m2 and 60 kg/m2 who underwent laparoscopic GBP. Demographics, operative data, perioperative complications, and weight losses were collected and compared with those obtained from a retrospective chart review of 35 patients with body-mass indices between 40 kg/m2 and 60 kg/m2 who underwent open GBP before August 1998.

RESULTS

Age, gender, preoperative body-mass index, preoperative comorbidity, and earlier abdominal surgery were similar in both groups. All laparoscopic operations were completed without conversion to laparotomy. Mean operative time, operative blood loss, length of intensive care stay, and length of hospital stay were significantly less after laparoscopic GBP than after open GBP (p<0.05). There was no 30-day mortality in either group. At 1-year followup, analysis of the percentage of excess body weight loss showed no significant difference between the two groups (p<0.05).

CONCLUSIONS

Laparoscopic Roux-en-Y gastric bypass is technically feasible and safe. Laparoscopic GBP confers the clinical benefits of laparoscopy and an initial weight loss similar to that of open GBP.