The Optimal Surgical Management of the Super Obese Patient: The Debate

Long-term results of conversion of Roux-en-Y to biliopancreatic diversion with duodenal switch

BACKGROUND

Despite the fact Roux-en-Y gastric bypass (RYGB) is one of the most efficient bariatric procedures, postoperative weight regain still can be seen.

OBJECTIVES

To retrospectively assess the early outcomes and up to 10-year weight results of the conversion of RYGB to biliopancreatic diversion with duodenal switch (BPD-DS).

SETTING

French private hospital, 2-surgeon practice in a bariatric surgery center with an experience of >20 RYGB procedures.

METHODS

Analysis was conducted on patients who had a conversion of RYGB to BPD-DS performed since 2010 for a percentage of excess weight loss (%EWL) <50% with a small gastric pouch.

RESULTS

A total of 65 females and 9 males aged 46.8 ± 8.8 years had an RYGB procedure done 110.6 ± 38.8 months earlier for a body mass index of 47.4 ± 7.8 kg/m2. Conversion was always performed in 1 stage and laparoscopically for 93% of the patients. The 30-day complication rate was 25.7%, with 14.8% of patients undergoing reoperation. Maximum results were seen 2 years after conversion, outranging RYGB: %EWL of 78.3% ± 24% with percent total weight loss (%TWL) of 35.9% ± 11.9% and %EWL of 72% ± 24.1% with %TWL of 32.6% ± 11%, respectively. The 5-year weight of all the patients (85.7% follow-up) remained lower than the pre-conversion weight. Over time, 1 reversal and 4 revisions were required, and frequent stools and gastroesophageal reflux were the most frequent complaints.

CONCLUSION

Despite its complexity, conversion of RYGB to BPD-DS can be performed in 1 stage, although the use of an unconventional technique could not reduce the high complication rate. BPD-DS remains an efficient procedure after RYGB in selected patients, comparable to distalization of RYGB, which can be less risky.

Impacts of sleeve gastrectomy on gastroesophageal reflux disease in severely obese Korean patients

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has established popularity as a bariatric and metabolic surgery. However, the incidence of gastroesophageal reflux disease (GERD) following LSG is controversial. This study aims to describe the prevalence of de novo GERD after LSG.

METHODS

A retrospective chart review was performed for 130 patients who underwent a routine endoscopic surveillance before and after LSG between January 2013 and October 2018. The diagnosis of GERD was determined by presence of symptoms, history of PPI treatment, and endoscopic findings. The esophagogastroduodenoscopy (EGD) was performed annually after LSG and/or when the patients complained of severe reflux symptoms.

RESULTS

The prevalence of GERD before surgery was 18.5%. At 1 year after LSG, GERD was present in 70 (53.8%) of the 130 patients. GERD consisted of 55 patients with newly developed GERD, and 15 with preexisting GERD. 9 (37.5%) out of pre-existing GERD patients were free of symptoms and abnormal finding at EGD following LSG. During the LSG, 66 (50.8%) patients with hiatal hernia underwent re-approximation of the diaphragmatic crura. There was no significant relationship between hiatal hernia repair and postoperative GERD (p = 0.39). Number of patients taking PPI medication before and after LSG were 34 (26.2%) and 49 (37.7%). Out of 56 (43.1%) patients with endoscopic lesions, LA grade A was 31 (23.9%), B = 15 (11.5%), C = 4 (3.1%), and D = 6 (4.6%).

CONCLUSION

In this study, 42.3% (n = 55) of total patients developed newly developed GERD, and 7.7% (n = 10) had LA grade C or D esophagitis.

Outcomes and Effects of 250-cm Biliopancreatic Limb One Anastomosis Gastric Bypass in Patients with BMI > 50 kg/m2 with Total Bowel Length > 6 m: a 2-Year Follow-up

Background

There is a controversy on the suitable bariatric procedure for patients with BMI > 50 kg/m². Many surgeons prefer the Roux en-Y gastric bypass (RYGB) while others resort to long biliopancreatic limb (BPL) one anastomosis gastric bypass (OAGB).

Methods

This study included patients with BMI > 50 kg/m² who underwent 250-cm BPL OAGB with total bowel length (TBL) > 6 m and completed 24-month follow-up from July 2015 to November 2021. Demographic data with preoperative weight, BMI, hypertension (HTN), DM (HbA1C), Hb, iron, calcium, albumin, vitamin D, and parathormone levels (PTH) were recorded. Operative time, total bowel length (TBL), residual length (RBL), complications and postoperative weight, BMI, % of total weight loss (%TWL), HTN, DM, and alkaline reflux as well as Hb, iron, calcium, albumin, vitamin D, and PTH levels were recorded at 6, 12, 18, and 24 months.

Results

OAGB had a significant decrease in weight, BMI (25.6 ± 3.4 kg/m² at 24 months) with %TWL of 48 ± 5% at 24 months. TBL and RBL were 6.7 ± 0.65 and 4.2 ± 0.65 m respectively. %BL (RBL/TBL*100) was 62.4 ± 3.3%. The HbA1C, HTN, and alkaline reflux incidence were 5.5 ± 0.29 gm%, 1.4%, and 3.7% respectively at 24 months. Hb, iron, calcium, albumin, and vitamin D showed a significant decrease but still within normal range, and PTH showed a significant increase at 24 months.

Conclusion

Long BP (250 cm) OAGB in patients with BMI > 50 kg/m² with TWL > 6 m had good results in the achievement of weight loss and weight maintenance goals with remission of associated comorbidities as HTN and DM.

Graphical abstract

Patient Selection and 30-Day Outcomes of SADI-S Compared to RYGB: a Retrospective Cohort Study of 47,375 Patients

PURPOSE

Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) offers a novel bariatric procedure with few comparative studies evaluating patient selection or perioperative outcomes. We aim to compare SADI-S to Roux-en-Y gastric bypass (RYGB).

MATERIALS AND METHODS

The 2020 Metabolic and Bariatric Accreditation and Quality Improvement Program (MBSAQIP) registry was analyzed, comparing SADI-S to RYGB. Bivariate analysis was performed to determine intergroup differences. Multivariable logistic regression determined factors associated with serious complications and mortality.

RESULTS

We evaluated 47,375 patients, with 501 (1.1%) receiving SADI-S. Patients undergoing SADI-S had higher body mass index (51.4 ± 9.7 kg/m² SADI-S vs. 44.6 ± 7.9 kg/m² RYGB; p < 0.001), and more metabolic comorbidities including non-insulin dependent diabetes (21.7% SADI-S vs 19.0% RYGB; p = 0.011), insulin dependent diabetes (12.0% SADI-S vs. 8.6% RYGB; p = 0.011), and hypertension (54.9% SADI-S vs 47.6% RYGB; p < 0.001). Patients undergoing SADI-S experienced more anastomotic leaks (2.2% vs. 0.5%; p < 0.001), reoperations (5.0% vs 2.6%; p < 0.001), pneumonias (1.6% vs 0.5%; p < 0.001), had sepsis more frequently (1.4% vs 0.3%; p < 0.001), and required more unplanned reintubations (1.2% vs 0.3%; p = 0.004). SADI-S was independently associated with serious complications (OR 1.45, CI 1.09-1.95, p < 0.001) but was not a predictor of mortality (OR 3.29, p = 0.060).

CONCLUSIONS

In comparison to RYGB, patients undergoing SADI-S were found to have more metabolic comorbidities. Compared to RYGB, SADI-S has worse perioperative outcomes and is independently associated with serious complications. It remains unclear whether this represents a learning curve or true findings and prospective studies analyzing the risk-benefit ratio following SADI-S are needed.

Five Years of MBSAQIP Data: Characteristics, Outcomes, and Trends for Patients with Super-obesity

PURPOSE

Incidence of super obesity (SO; BMI ≥ 50 kg/m²) is growing rapidly and confers worse metabolic complications than non-SO (BMI 30-50 kg/m²). We aim to characterize bariatric surgery patients with SO, their postoperative complications, and treatment trends over the last 5 years in hopes of informing SO-specific treatment protocols.

MATERIALS AND METHODS

The MBSAQIP database was analyzed, and two cohorts were compared, those with SO and non-SO. Univariate analysis was performed to determine between-group differences. Multivariable logistic regression analysis was performed to determine if SO was independently associated with serious complications or mortality.

RESULTS

We evaluated 751,952 patients with 173,110 (23.0%) having SO. Patients with SO were younger (42.2 ± 11.8 SO vs 45.1 ± 12.0 years non-SO, p < 0.001) and less likely to be female (74.8% vs 81.1%, p < 0.001). While comorbidities seem to be decreasing overall in bariatric surgery patients, those with SO have worse functional capacity and more endocrine, pulmonary, and vascular comorbidities. Patients with SO also have worse 30-day postoperative complications, and SO was independently associated with severe complications (OR 1.08; CI 1.05-1.11, p < 0.001) and mortality (OR 2.49; CI 2.12-2.92, p < 0.001) CONCLUSIONS: Patients with SO have significantly increased preoperative comorbidities resulting in worse postoperative outcomes. SO remains an independent risk factor for serious complications and the greatest independent risk factor for 30-day postoperative mortality. Considering the expected increase in patients with SO, substantial work is required to optimize bariatric surgery strategies specific to these patients.

Identifying Patients at High Risk of Having Pulmonary Dysfunction Before Laparoscopic Bariatric Surgery and Its Impact on Postoperative Pulmonary Complications

Background: Morbid obesity is associated with variable degrees of pulmonary dysfunction that may predispose to postoperative complications. This study aimed to identify high risk patients to have pulmonary dysfunction before bariatric surgery in terms of age, sex, and body mass index (BMI) and the impact of pulmonary dysfunction on postoperative pulmonary complications. Methods: Prospective database of patients with morbid obesity who underwent bariatric surgery was reviewed. Data on patients' demographics, parameters of pulmonary function tests, and postoperative pulmonary complications were collected. The correlation between patients' age, sex and BMI, and pulmonary function was investigated using Pearson's correlation coefficient test. Results: Ninety-seven patients (82 female) with morbid obesity were included in the study. Twenty-eight (28.9%) patients had pulmonary dysfunction. Patients >40 years had higher odds of pulmonary dysfunction than patients ≤40 years (odds ratio [OR]: 2.54, P = .05). Male patients had significantly higher odds of pulmonary dysfunction than female patients (OR: 2.5, P = .03). Patients with BMI >50 had significantly higher odds of pulmonary dysfunction than patients with BMI <50 (OR: 4.9, P = .002). Patients with pulmonary dysfunction had significantly higher odds of developing pulmonary complications than patients with normal spirometry (OR: 9.13, P = .009). Conclusion: Around 30% of patients undergoing bariatric surgery had pulmonary dysfunction. Pulmonary dysfunction in preoperative spirometry was able to predict postoperative pulmonary complications. Men, patients older than 40 years, and superobese individuals had higher odds of having pulmonary dysfunction and are at higher risk to develop pulmonary complications after bariatric surgery.

Gastroesophageal reflux-related physiologic changes after sleeve gastrectomy and Roux-en-Y gastric bypass: a prospective comparative study

BACKGROUND

The development of gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG) is a major concern as it affects the quality of life of the patients and potentially exposes them to the complications of GERD. The reported incidence of GERD after LSG is up to 35%. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the procedure of choice for patients with morbid obesity with GERD but objective evidence based on physiologic studies for the same are limited.

OBJECTIVE

The objectives of the study were to determine the physiologic changes related to gastroesophageal reflux based on symptoms index, 24-hour pH study, impedance, and manometry after LSG and LRYGB.

SETTINGS

Tertiary care teaching hospital, India.

METHODS

This registered study (CTRI/2017/06/008834) is a prospective, nonrandomized, open-label clinical trial comparing the incidence of GERD after LSG and LRYGB. In this study, non-GERD patients were evaluated for GERD based on clinical questionnaires, 24-hour pH study, and impedance manometry preoperatively and 6 months postoperatively.

RESULTS

Thirty patients underwent LSG, and 16 patients underwent LRYGB. The mean DeMeester score increased from 10.9 ± 11.8 to 40.2 ± 38.6 (P = .006) after LSG. The incidence of GERD after LSG was 66.6%. The increase in DeMeester score from 9.5 ± 4.6 to 12.2 ± 17.2 after LRYGB was not significant (P = .7). There was a significant increase in the nonacid reflux both after LSG and LRYGB.

CONCLUSION

The incidence of GERD after LSG is high, making it a contraindication for LSG. LRYGB remains the preferred procedure for patients with GERD. However, more studies are needed to understand the physiologic changes in patients with preexisting GERD.

Outcomes of Roux-en-Y gastric bypass versus sleeve gastrectomy in super-super-obese patients (BMI ≥60 kg/m2): 6-year follow-up at a single university

BACKGROUND

Among the population of morbidly obese people, super-super-obese (SSO) individuals (body mass index >60 kg/m²) present a treatment challenge for bariatric surgeons.

OBJECTIVES

To compare the long-term outcomes between laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB) and to evaluate the efficacy of SG as a stand-alone bariatric procedure for SSO patients.

SETTING

University hospital, Paris, France.

METHODS

We retrospectively reviewed the data outcomes of 210 SSO patients who underwent SG or RYGB between January 2000 and December 2011. The 6-year follow-up data were analyzed and compared.

RESULTS

Follow-up data at 6 years were collected for 57.1% and 52.1% of patients in the SG group and RYGB groups, respectively. Both procedures were effective at promoting weight loss. Most weight loss was achieved at 24 months with both procedures. The average percent excess weight loss and change in body mass index of SG versus RYGB showed no significant differences at the 4-year follow-up. Except for sleep apnea, RYGB showed slightly better resolution of the evaluated co-morbidities. The composite endpoint of major short-term adverse events (<30 d) occurred in 11.7% of patients with RYGB and 6.4% of those with SG (P = .02). Postoperative complications were seen in 26% of RYGB patients and 16.1% of SG patients.

CONCLUSIONS

SG as a primary procedure for SSO patients remains effective even though RYGB achieves better midterm outcomes. SG can be proposed as the primary-option p+rocedure. Further investigations are needed to identify the ideal procedure for patients with symptoms of gastroesophageal reflux disease.

Impact of sleeve gastrectomy on gastroesophageal reflux disease in a morbidly obese population undergoing bariatric surgery

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has established popularity as a weight loss procedure based on its success. However, LSG's effect on gastroesophageal reflux disease (GERD) is unknown.

OBJECTIVES

To analyze the incidence of GERD after LSG and to compare the results in patients with preexisting and de novo GERD.

SETTING

Tertiary Medical center.

METHODS

The authors performed a retrospective review of primary LSG from 2005 to 2013 and compared patients with pre-existing and de novo GERD who underwent LSG.

RESULTS

A total of 919 patients underwent LSG. GERD was present in 38 (4%) of the LSG cohort. We identified 2 groups: Group A consisted of 25 (3%) patients with de novo GERD, and Group B consisted of 13 (1%) patients with pre-existing GERD. Diagnosis of GERD in both groups was determined by symptoms and history of proton pump inhibitor (PPI) treatment, upper gastrointestinal endoscopy, esophagogastroduodenoscopy, and pH manometry. In Group A, 1 (4%) patient was managed with over-the-counter drugs, 17 (68%) patients were treated with low-dose PPI, 6 (24%) patients were treated with high-dose PPI, and 1 (4%) patient was lost to follow-up. Group B consisted of 9 (69%) patients treated with low-dose PPI and 4 (31%) patients treated with high-dose PPI. Medical treatment failed in 4 patients (10.5%) who subsequently required conversion to laparoscopic Roux-en-Y gastric bypass (LRYGB). In Group A, 1 patient (4%) required LRYGB, and in Group B, 3 patients (23%) required LRYGB. The outcome of conversion for Group A was incomplete resolution of symptoms in the 1 patient, whereas in Group B, all 3 patients (100%) had complete resolution of GERD symptoms after LRYGB.

CONCLUSIONS

In this study, 3% of patients developed de novo GERD, but most responded to either low- or high-dose PPI, with 4% requiring conversion to LRYGB.

Laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding in the super-obese: peri-operative and early outcomes

INTRODUCTION

Controversy exists between laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding in super-obese patients.

METHODS

This is a retrospective review of prospectively collected data. A total of 102 consecutive super-obese (body mass index >50) patients underwent laparoscopic Roux-en-Y gastric bypass (Group 1), and 79 consecutive ones underwent laparoscopic adjustable gastric banding (Group 2). Early complications and weight loss outcomes were evaluated.

RESULTS

No significant difference was found in operative mean (± standard deviation) time (93.5 ± 33 vs 87.7 ± 39 min, p = 0.29), hospital stay (2.68 ± 2.27 vs 2.75 ± 1.84 days, p = 0.80), or overall early postoperative morbidity (17.65% and 10.12%, p = 0.20). Intra-operative complications occurred in six patients (5.9%) in Group 1 and none in Group 2 (0.0%, p = 0.04). Mean excess weight loss percent at 6 and 12 months in Group 1 was 44.75% ± 11.84% and 54.71% ± 18.18% versus 26.20% ± 12.42% and 31.55% ± 19.79% in Group 2 (p < 0.001).

CONCLUSION

There seems to be no significant differences in early complications between laparoscopic Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding operations in the short term. Weight loss and excess weight loss percent at 6 and 12 months are significantly better after laparoscopic Roux-en-Y gastric bypass.

Vertical gastrectomy and gastric bypass in Roux-en-Y induce postoperative gastroesophageal reflux disease?

Background

The association between obesity and gastroesophageal reflux disease has a high incidence and may be present in half of obese patients with surgical indication. Bariatric operations can also induce reflux alone - differently from BMI factors - and its mechanisms are dependent on the type of procedure performed.

Objective

To perform a literature review comparing the two procedures currently most used for surgical treatment of obesity and analyze their relationship with the advent of pre-existing reflux disease or its appearance only in postoperative period.

Method

The literature was reviewed in virtual database Medline/PubMed, SciELO, Lilacs, Embase and Cochrane crossing the following MeSH descriptors: gastric bypass AND / OR anastomosis, Roux-en-Y AND / OR gastroesophageal reflux AND / OR gastroenterostomy AND / OR gastrectomy AND / OR obesity AND / OR bariatric surgery AND / OR postoperative period. A total of 135 relevant references were considered but only 30 were used in this article. Also was added the experience of the authors of this article in handling these techniques on this field.

Conclusion

The structural changes caused by surgical technique in vertical gastrectomy shows greater commitment of antireflux mechanisms predisposing the induction of GERD postoperatively compared to the surgical technique performed in the gastrointestinal Bypass Roux-en-Y.

Robot-assisted Roux-en-Y gastric bypass for super obese patients: a comparative study

Superobese patients (SO) (body mass index (BMI) ≥ 50 kg/m(2)) represent a real surgical challenge and the best management remains debatable. While the safety of a laparoscopic approach has been questioned for this population, robotics has been introduced in the armamentarium of the bariatric surgeon, yet its role remains poorly assessed, especially for a very high BMI. The study aim is thus to report our experience with robot-assisted Roux-en-Y gastric bypass (RYGB) for SO. From July 2006 to May 2012, 288 consecutive robot-assisted RYGB procedures have been performed at a single institution. All data were collected prospectively in a dedicated database. Among those patients, 41 were SO (14.2 %). All the peri- and postoperative parameters were compared to the morbidly obese (MO) group (BMI < 50). Data have been reviewed retrospectively. The SO group presented a higher ASA score and more male patients. The operative time was similar between both groups, yet there were more conversions in the SO group (two versus one for MO; p = 0.05). The morbidity and mortality rates were similar between both groups. The length of stay was longer for the SO population (7 vs. 6 days; p = 0.03). The percent BMI loss was similar at 1 year (34 vs. 34 %; p = 1), but the percent excess BMI loss was higher for the MO group (83 vs. 65 % for the SO group; p = 0.0007). Robot-assisted RYGB can be performed safely for SO, with complication rates and functional results at 1 year comparable to MO, yet this approach for SO has been associated with a slightly increased conversion rate and length of stay.

What is the actual fate of super-morbid-obese patients who undergo laparoscopic sleeve gastrectomy as the first step of a two-stage weight-reduction operative strategy?

The overall success-rate of the two-stage treatment plan for the treatment of super-morbid obesity has not yet been assessed. We reviewed the long-term results of 41 treated super-morbid-obese patients. Mean initial BMI was 59.5 ± 3.5 kg/m(2). Twelve patients (29.3 %) achieved after only LSG a BMI <35 kg/m(2) (mean 31.9 ± 2). They have lost 78.7 ± 11.8 % of excess body weight (EBW). The remaining 28 patients lost 48.1 ± 11.9 % of EBW and achieved a mean BMI of 44.2 ± 4.3 kg/m(2), thus requiring the second stage. Ten of them (24.4 % of the total or 35.7 % of those in need), were submitted to laparoscopic Roux-en-Y gastric bypass (LRYGBP). They lost 71.9 ± 4.3 % of EBW and have a mean BMI of 33.6 ± 2.7 kg/m(2). The 18 remaining patients have a BMI of 42 ± 3.6 kg/m(2) and they still suffer from morbid obesity. They have lost 48.5 ± 8.7 % of EBW. The mean rate of EBW loss for all the available 39 patients after either LSG or both LSG and LRYGBP has been 63.2 ± 16.5 % after a mean follow-up of 42.8 ± 19.5 months. Out of 41 patients, 1 died, 1 was lost to follow-up, 21 (51.2 %) achieved "healthy" BMIs and 18 (44 %) still require LRYGBP. The rate of cure of morbid obesity was 51.2 %. A remaining 44 % of super-morbid obese patients still need the completion LRYGBP but have not undergone it. Half of these patients have lost >50 % of their EBW. The two-stage strategy is an effective treatment plan for super-morbid obesity. A less patient-dependent strategy may be needed for a subset of patients.

Laparoscopic adjustable banded roux-en-y gastric bypass as a primary procedure for the super-super-obese (body mass index > 60 kg/m²)

BACKGROUND

Currently, there is no consensus opinion regarding the optimal procedure of choice in super-super-morbid obesity (Body mass index, BMI > 60 kg/m²). Roux-en-Y gastric bypass (RYGB) is associated with failure to achieve or maintain 50% excess weight loss (EWL) or BMI < 35 in approximately 15% of patients. Also, percent EWL is significantly less after 1-year in the super-super-obese group as compared with the less obese group and many patients are still technically considered to be obese (lowest post-surgical BMI > 35) following RYGB surgery in this group. The addition of adjustable gastric band (AGB) to RYGB has been reported as a revisional procedure but this combined bariatric procedure has not been explored as a primary operation.

METHODS

In a primary laparoscopic RYGB, an AGB is drawn around the gastric pouch through a small opening between the blood vessels on the lesser curve and the gastric pouch. The band is then fixed by suturing the gastric remnant to the gastric pouch both above and below the band to prevent slippage.

RESULTS

Between November 2009 and March 2010, 6 consecutive super-super-obese patients underwent a primary laparoscopic adjustable banded Roux-en-Y gastric bypass procedure at our institution. One male patient (21 years, BMI 70 kg/m²) developed a pneumonia postoperatively. No other postoperative complications were observed.

CONCLUSION

To the best of our knowledge, this is the first series of patients that underwent a laparoscopic adjustable banded RYGB as a primary operation for the super-super obese in the indexed literature. With the combined procedure, a sequential action mechanism for weight loss is to be expected. The restrictive, malabsorptive and hormonal working mechanism of the RYGB will induce weight loss from the start reaching a stabilised plateau of weight after 12 - 18 months. At that time, filling of the band can be started resulting in further gastric pouch restriction and increased weight loss. Moreover, besides improving the results of total weight loss, a gradual filling of the band can as well prevent the RYGB patient from weight regain if restriction would fade away with time.

[Early imaging features after sleeve gastrectomy]

PURPOSE

Sleeve gastrectomy is a new bariatric surgical procedure with promising early results and low morbidity and mortality. We have evaluated the early imaging findings and value of upper GI study (UGI) and CT.

PATIENTS AND METHODS

Twenty five patients (mean age=38.9 years, mean BMI=51.5 kg/m2) following sleeve gastrectomy for morbid obesity underwent UGI at day 1. CT was immediately performed in patients with suspected leak or as a follow-up examinations in patients with suspected complication. The different imaging features observed were recorded.

RESULTS

UGI demonstrated 13 normal examinations (52%), an abnormal appearance in 11 cases (44%) with opacification of a lateral pouch, and one complication (leak confirmed on CT). Two patients underweent CT (day 3 and day 15) for suspected complication, with demonstration of leak in both cases.

CONCLUSION

An abnormal appearance after sleeve gastrectomy is frequently observed on UGI. Routine UGI at day 1 is useful to detect large leaks. CT with oral contrast should be performed in all patients with imaging or clinical suspicion of leak.

Mid-term follow-up after sleeve gastrectomy as a final approach for morbid obesity

BACKGROUND

In previous publications, we demonstrated the safety and short-term efficacy of laparoscopic sleeve gastrectomy (LSG) as a final step in the treatment of morbid obesity (MO). This study aimed to assess the mid-term efficacy of LSG.

METHODS

We performed a retrospective review of a prospectively collected database. Between November 2004 and January 2007, 130 consecutive patients underwent LSG as a final procedure to MO. Data including patient demographics, operative time, length of hospital stay, complications, preoperative body mass index (BMI), complications, and weight loss at 3, 6, 12, 18, and 24 months were recorded and analyzed.

RESULTS

The mean age was 45.6 (range: 12-79) years while the mean BMI was 43.2 (range: 30.2-75.4) kg/m(2). The mean operative time was 97 (range, 58-180) min and all operations were completed laparoscopically. The mean hospital stay was 3.2 (range, 1-19) days with zero mortality in this series. One patient (0.7%) had leakage at the stapler line, while four patients (2.8%) developed trocar site infection. Three patients (2.1%) complained of symptoms of gastroesophageal reflux disease (GERD), three patients (2.1 %) developed symptomatic gallstones, and trocar site hernia was present in one (0.7%) patient. The mean weight loss was 21, 31.2, 37.4, 39.5, and 41.7 kg at 3, 6, 12, 18, and 24 months, respectively, while the mean BMI decreased to 36.9, 32.8, 29.5, 28, and 27.1 at 3, 6, 12 18, and 24 months, respectively. Percent of excess weight loss (%EWL) was 33.1, 50.8, 62.2, 64.4, and 67.9 at 3, 6, 12, 18, and 24 months, respectively.

CONCLUSIONS

LSG is a safe and effective surgical procedure for the morbidly obese up to 2 years. Excess body weight loss seems to be acceptable at 2 years postoperatively.

Laparoscopic placement of non-adjustable silicone ring for weight regain after Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGBP) is presently one of the most popular surgical procedures for obesity. One of the possible long-term problems is weight regain, usually after a period of successful weight loss. Weight regain after RYGBP can be due to new eating habits, like sweet-eating or grazing, or volume eating because of impaired restriction. This paper reports our experience in patients who presented weight regain after laparoscopic RYGBP, because of new appearance of volume eating or hyperphagia, treated by the laparoscopic placement of a non-adjustable silicone ring around the gastric pouch.

METHODS

From July 2004 to November 2007, six patients affected by weight regain due to hyperphagic behavior, benefited from revision of RYGBP consisting of the placement of a non-adjustable silicone ring loosely encircling the stomach part. Mean weight and body mass index (BMI) at the time of RYGBP were 105.0 kg +/- 12.3 and 36.3 +/- 3.0 kg/m(2), respectively, and all patients suffered from obesity-related co-morbidities. After a mean time from RYGBP of 26.0 +/- 14.2 months, patients presented a weight regain of 4.7 +/- 3.4 kg compared with their minimal weight, with a final mean weight, BMI, and percentage of excess weight loss (%EWL) at the time of the silicone ring of 86.0 +/- 13.1 kg, 29.5 +/- 3.9 kg/m(2), and 47.0 +/- 24.7%, respectively. Preoperative evaluation for each patient included history and physical examination, nutritional and psychiatric evaluation, laboratory tests, and barium swallow check. Outcome measures included evaluation of the Roux-en-Y construction, operative time, postoperative morbidity and mortality, and weight loss in terms of absolute weight loss, BMI, and %EWL.

RESULTS

Any modification of the digestive circuit was evidenced. Mean operative time was 82.5 +/- 18.3 min. No operative mortality and no conversion to open surgery were achieved. No postoperative complications were achieved. Mean hospital stay was 2.6 +/- 1.5 days. After a mean follow-up of 14.0 +/- 9.2 months, the six patients presented a mean weight loss of 9.1 +/- 2.4 kg, with a final mean weight, BMI, and %EWL of 76.8 +/- 13.7 kg, 26.4 +/- 4.2 kg/m(2), and 70.4 +/- 30.4%, respectively. Difference in term of %EWL before and after revision (23.4 +/- 5.7) is statistically significant (p < 0.05). There have been no erosions or slippage of the ring during this follow-up.

CONCLUSION

One of the possible causes of weight regain after RYGBP is the new eating behavior of the patient, one of which is hyperphagia. Treatment of this condition can be the placement of a non-adjustable silicone ring loosely fitted around the gastric pouch which contributes to improved weight loss.

Primary laparoscopic gastric bypass can be performed safely in patients with BMI >or= 60

BACKGROUND

Several studies suggest patients with a body mass index (BMI; calculated as kg/m(2)) >or= 60 have a greater operative risk and so advocate a staged approach to bariatric procedures. This requires two separate operations and all associated risks. At our institution, we do not perform staged bariatric operations for these patients; we execute a single-stage laparoscopic Roux-en-Y gastric bypass (LGBP). Here, we analyze our experience in this population with a single-stage LGBP.

STUDY DESIGN

Ninety-five patients with a BMI >or= 60 were compared with 1,311 patients with BMI < 60 undergoing LGBP from December 2001 to May 2007. Data recorded included age, BMI, estimated blood loss, operating time, length of stay, and complications within the first 30 days after operation. Analyses of the data were performed using unpaired Student's t-test, with p < 0.05 as significant.

RESULTS

There were no statistically significant differences in age (42.6 versus 42.8 years), estimated blood loss (68.5 versus 69.5 mL), length of stay (3.1 versus 3.1 days), overall complications (12.7% versus 13.7%), or 30-day mortality (0.2% versus 0%) for patients with BMI < 60 as compared with patients with BMI >or= 60. The difference in operating time between the 2 groups was statistically significant (111 versus 118.7 minutes; p = 0.02) but likely reflected the learning curve.

CONCLUSIONS

In our experience, there were no differences in the incidence of complications or mortality for patients with a BMI >or= 60 undergoing LGBP as compared with those with a BMI < 60. These high-risk patients can safely undergo a single-stage LGBP.

Laparoscopic mini-gastric bypass (LMGB) in the super-super obese: outcomes in 16 patients

BACKGROUND

The ideal management of the super-super obese patient (SSO) is unclear and controversy exists as to the choice of procedure as well as the risk for increased morbidity and mortality. I present my experience of laparoscopic mini-gastric bypass (LMGB) in 16 SSO patients with early follow-up results.

METHODS

Review of a prospectively maintained database was performed. All the patients underwent LMGB by a single surgeon (CP). Data collected included demographics, operative time, length of stay, complications, and weight loss. Follow-up data was obtained at office visits in addition to periodic telephone interviews and e-mails. All office follow-up and review of correspondence from Primary Care Physicians (PCP) was managed by the operating surgeon.

RESULTS

Sixteen patients were identified as being SSO and comprise the study group. There were 14 women and two men. Average age was 40 years (27-61). Average weight and BMI were 166 (150-193) and 62.4 (60-73), respectively. All procedures were performed laparoscopically by a single surgeon with no conversion to open. Average operative time was 78 min (41-147 min) and hospital stay was 1.2 days. Intraoperative complications included a liver laceration in one patient and an enterotomy in another. Both were managed laparoscopically. No patients required readmission to the hospital, and there were no major complications or deaths. Weight loss showed a consistent increase over the follow-up period with 2 year results of 72 KG lost or 65% EWL.

CONCLUSION

Laparoscopic mini-gastric bypass (MGB) is a technically simple and safe procedure in SSO patients. LMGB has the advantages of being a single stage procedure, being easily reversible and revisable in a laparoscopic procedure and does not sacrifice portions of the stomach or implant foreign materials. Weight loss appears favorable in the short term; however, information regarding long-term weight loss, durability, and safety profile in this population will require a greater number of patients and longer follow up.

Indications for sleeve gastrectomy as a primary procedure for weight loss in the morbidly obese

BACKGROUND

Single-stage laparoscopic sleeve gastrectomy (LSG) may represent an additional surgical option for morbid obesity.

METHODS

We performed a retrospective review of a prospectively maintained database of LSG performed from November 2004 to April 2007 as a one-stage primary restrictive procedure.

RESULTS

One hundred forty-eight LSGs were performed as primary procedures for weight loss. The mean patient age was 42 years (range, 13-79), mean body mass index of 43.4 kg/m(2) (range, 35-75), mean operative time of 60 min (range, 58-190), and mean blood loss of 60 ml (range, 0-300). One hundred forty-seven procedures (99.3%) were completed laparoscopically, with a mean hospital stay of 2.7 days (range, 2-25). A 2.7% major complication rate was observed with four events in three patients and no deaths. Four patients required readmission; mild dehydration in two, choledocholithiasis in one, and a gastric sleeve stricture in one.

CONCLUSION

Laparoscopic SG is a safe one-stage restrictive technique as a primary procedure for weight loss in the morbidly obese with an acceptable operative time, intraoperative blood loss, and perioperative complication rate.

Laparoscopic sleeve gastrectomy: surgical technique, indications and clinical results

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been introduced as a multipurpose restrictive procedure for obese patients. Variations of the surgical technique may be important for the late results.

METHODS

50 patients submitted to LSG from January 2005 to December 2006 were studied. Mean age was 38.2 years, preoperative weight was 103.4 +/- 14.1 kg (78 to 146 kg), and preoperative BMI was 37.9 +/- 3.4 (32.9 to 46.8). Important co-morbidities were present in 39 patients (78%).

RESULTS

Operative time was 110 +/- 15 min. Intraoperative difficulties were observed in 7 patients. Volume of the resected specimen was 760 +/- 55 ml and capacity of the gastric remnant was 108.5 +/- 25 ml. There was no conversion to open surgery. Histology of the resected stomach was normal in 8 patients, while chronic gastritis was found in 42 patients. At 6 and 12 months postoperatively, weight loss was 28.0 +/- 6.4 kg and 32.6 +/- 6.8 kg respectively. In the 18 patients who have reached 1 year follow-up, % excess BMI loss reached 85 +/- 0.7%. Most of the medical diseases associated with the obesity resolved after 6 to 12 months.

CONCLUSION

LSG may be an acceptable operation. It is easy to perform, safe, and has a lower complication rate than other bariatric operations. Further studies are necessary for the clinical results at long-term follow-up.

Outcome of hand-assisted laparoscopic gastric bypass in super obese patients

BACKGROUND

The optimal surgical treatment for super obese patients (body mass index [BMI] >or=50 kg/m2) has been a challenge and debate for most bariatric surgeons. To compare the outcomes of hand-assisted laparoscopic Roux-en-Y gastric bypass (HALGB) in super obese patients (BMI >or=50 kg/m2) to morbidly obese patients (BMI <50 kg/m2).

METHODS

A total of 295 patients who underwent HALGB from October 2003 to December 2005 were studied. These patients included 177 with a BMI of <or=49 kg/m2 (morbidly obese) and 118 with a BMI of >or=50 kg/m2 (super-obese). The patient demographics, complications, and outcomes were examined. Additionally, the 12-month postoperative outcomes included the percentage of excess weight loss and improvement of co-morbidities.

RESULTS

The patient age and gender were similar between the 2 groups. The super-obese patients had significantly more co-morbidities and required a greater number of medications. A significant difference was found in 3 early postoperative complications, with super-obese patients experiencing more wound infections (P = .039), nausea/vomiting (P = .003), and pulmonary failure (P = .010). Logistic regression analysis found, after controlling for significant risk factors, that the difference in the incidence of nausea/vomiting was still significant (odds ratio 14.33, 95% confidence interval 1.73-118.60, P = .01). Morbidly obese patients had a significantly greater percentage of excess weight loss at 12 months postoperatively compared with the super-obese patients (80% versus 55%, respectively, P <.001).

CONCLUSION

HALGB is a safe and effective procedure in the super obese but with less favorable outcomes compared with those for morbidly obese patients regarding the percentage of excess weight loss.

Surgical treatment of obesity

Obesity is very prevalent. Most treatments fail owing to hard-wired survival mechanisms, linking stress and appetite, which have become grossly maladaptive in the industrial era. Antiobesity (bariatric) surgery is a seemingly drastic, efficacious therapy for this serious disease of energy surfeit. Technical progress during the last two decades has greatly improved its safety. The surgical principles of gastric restriction and/or gastrointestinal diversion have remained largely unchanged over 40 years, although mechanisms of action have been elucidated concomitant with advances in knowledge of the molecular biology of energy balance and appetite regulation. Results of bariatric surgery in large case-series followed for at least 10 years consistently demonstrate amelioration of components of the insulin-resistance metabolic syndrome and other comorbidities, significantly improving quality of life. Furthermore, bariatric surgery has convincingly been demonstrated to reduce mortality compared with nonoperative methods. This surgery requires substantial preoperative and postoperative evaluation, teaching, and monitoring to optimize outcomes. In the absence of effective societal changes to restore a healthy energy balance, bariatric surgery is an important tool for treating a very serious disease.

Laparoscopic gastric bypass: Risks vs. benefits up to two years following surgery in super-super obese patients

BACKGROUND

Super-super obesity (body mass index [BMI] >/= 60 kg/m(2)) is thought to be a risk factor for complications and mortality in laparoscopic Roux-en-Y gastric bypass. Excess weight loss has been demonstrated to be diminished compared with less obese patients following surgery. However, we hypothesize that super-super obese patients who undergo laparoscopic gastric bypass can realize major improvements in their health and a good quality of life without a significantly increased risk of complications when compared with less obese patients.

METHODS

From July 2002 to July 2005, University of Wisconsin Health bariatric surgeons performed 288 consecutive laparoscopic Roux-en-Y gastric bypass procedures. Patients were divided into 2 groups: BMI >/= 60 kg/m(2) (n = 28) and BMI < 60 kg/m(2) (n = 260). The groups were compared at defined time intervals during a 2-year period following surgery. Comparison criteria included complications, weight loss, comorbidities, and quality of life.

RESULTS

Both groups had similar morbidity and mortality rates. Excess weight loss was shown to be less, but total pounds lost were greater, for the super-super obese patients at all postoperative time intervals specified for postoperative analysis. Despite this fact, overall health improved to a similar degree in each group of patients following surgery; both groups also had similar Moorehead-Ardelt quality of life scores. Using the Bariatric Analysis and Reporting Outcome System (BAROS) to categorize outcomes, the average result for a patient in either group of patients would be considered "very good" at 1 year following surgery.

CONCLUSIONS

Laparoscopic Roux-en-Y gastric bypass can be accomplished safely even in extremely obese patients. Although excess weight loss in the super-super obese is diminished postoperatively when compared with less obese patients, health is improved and quality of life is good regardless of a patient's preoperative BMI. Therefore, laparoscopic gastric bypass is a good option even in the extremely obese.

Randomized clinical trial of postoperative hernia prophylaxis in open bariatric surgery

Background

Postoperative hernia following bariatric procedures is more common than in other groups of surgical patients, and remains a serious problem. Gastric bypass is the most often performed bariatric procedure and, despite the increasing popularity of a laparoscopic approach, many morbidly obese patients are still offered open procedures. The aim of this study was to assess the effects of prophylactic polypropylene mesh in morbidly obese patients undergoing gastric by-pass surgery.

Methods

The study randomized 74 patients undergoing open Roux-en-Y gastric bypass into two groups: wound closure with (n = 36) or without (n = 38) a polypropylene mesh. Mean(s.d.) body mass and body mass index in the mesh group were 137·3(24·5) kg and 46·2(7·1) kg/m2 and in the non-mesh group were 139·0(24·9) kg and 46·8(7·6) kg/m2 respectively. In the non-mesh group, the wound was closed with a polypropylene suture. Patients in the mesh group had in addition a polypropylene mesh inserted in a sublay manner.

Results

Patients were followed up for at least 6 (range 6–38) months. Hernia developed in eight patients in the non-mesh group but in none in the mesh group. The duration of hospital stay was similar in both groups: mean(s.d.) 8·4(3·2) and 10·3(5·9) days (P = 0·092). There were no serious complications in either group.

Conclusion

The use of a mesh prevented hernia development and did not lengthen hospital stay.

The malabsorptive very, very long limb Roux-en-Y gastric bypass for super obesity: results in 257 patients

BACKGROUND

For the past 11 years, we have used a malabsorptive form of Roux-en-Y gastric bypass (RYGB), the "very, very long limb" RYGB, for selected patients with BMIs >50 kg/m(2) and in highly selected patients with BMI <50 kg/m(2). This modified distal gastric bypass establishes a 100-cm common channel (for digestion and absorption) and a "very, very" long Roux limb of 400 to 500 cm.

METHODS

To determine long-term efficacy and complications, we followed prospectively 257 consecutive patients; 188 (73%) participated in a postoperative survey.

RESULTS

Of the patients, 60% were female; overall age (x +/- SD) was 45 +/- 11 years, and BMI was 61 +/- 11 kg/m(2). Operative mortality was 1% with substantive postoperative morbidity occurring in 13%. Eighty-two percent of patients returning the survey an average of 48 months postoperatively (range, 12 to 148 months) lost >50% of excess body weight; BMI at follow-up was 37 +/- 9 kg/m(2). Resolution of comorbidities included diabetes mellitus (94%), hypertension (65%), sleep apnea (48%), and asthma (30%). Side effects included mild food intolerance (82%), occasional loose or watery stools (71%), nephrolithiasis (16%), and symptomatic steatorrhea (5%). Nine patients (4%) who developed or were developing impending protein/calorie malnutrition required proximal relocation of the enteroenterostomy with symptom resolution.

CONCLUSIONS

Overall, 90% were satisfied with the operation, and 93% would recommend it to a friend. The very, very long limb RYGB is relatively safe and effective and has acceptable side effects in the treatment of selected patients with super obesity (BMI >50). Because of the possibility of malabsorptive sequelae, patients should be selected based on degree of medical sophistication, insight, and compliance.