Biliopancreatic Diversion with Transitory Gastric Restriction and Duodenal Bulb Preservation: 88 Patients since 1992

Five-year follow-up after biliopancreatic diversion with duodenal switch

BACKGROUND

Only limited data are available for assessing the medium and long-term outcomes after bariatric surgery. We report our own long-term results after biliopancreatic diversion with duodenal switch (BPD-DS).

METHODS

The data from 51 patients with a theoretical ≥5-year follow-up were reviewed after BPD-DS performed from February 2002 to October 2004. The patients were assessed every 3 months during their first postoperative year, every 6 months during the second year, and annually thereafter.

RESULTS

The preoperative body mass index (BMI) was 47 ± 6.1 kg/m(2). The first 23 patients had undergone open BPD-DS. The same procedure was used (150-mL sleeve, 150-cm alimentary limb, and 100-cm common channel) for the 28 laparoscopic BPD-DS procedures, although 15 patients underwent conversion to laparotomy at the beginning of our experience. No patients died postoperatively. Of the 51 patients, 7 were not available for follow-up: 2 patients had died 9 months after BPD-DS (1 of myocardial infarction and 1 after ventral hernia repair), 1 underwent reversal, 1 refused follow-up after a complicated postoperative course, and contact was lost with 3 patients (7.8% lost to follow-up). The 5-year BMI was 31 ± 4.5 kg/m(2), with a mean excess weight loss of 71.9% ± 20.6%. Of the 44 patients, 7 (15.9%) had an excess weight loss of <50%; 4 of these unsatisfactory results occurred after revision BPD-DS. After primary BPD-DS, excess weight loss of 75.8% ± 18.0% was observed. Biologic data were obtained for 85% of the patients at 5 years. The main vitamin and micronutrients parameters remained stable over time. However, a trend was seen toward an increase in the parathormone levels and difficulties in maintaining a normal vitamin D level despite updated vitamin supplementation.

CONCLUSION

The results of our study have shown that BPD-DS achieves sustainable significant weight loss with >5 years of follow-up, with unsatisfactory results in <20% of cases. Although not statistically significant, revision surgery more often resulted in lesser weight loss, although this difference had almost vanished when the initial BMI was taken as a reference compared with the BMI before BPD-DS.

Laparoscopic adjustable banded sleeve gastrectomy as a primary procedure for the super-super obese (body mass index > 60 kg/m2)

Isolated laparoscopic sleeve gastrectomy is increasingly being used for the treatment of morbid obesity. However, doubts still persist regarding long-term weight loss, and the 5-year results are awaited. Whether the aetiology of failed excess weight loss is the result of an inadequate sleeve or attributable to dilatation of the sleeve is not clear. In an effort to prevent gastric dilatation and increase gastric restriction to promote further weight loss in the long term, we performed a combined procedure of laparoscopic adjustable gastric banding with sleeve gastrectomy. The patient was a 39-year-old woman with a life-long history of obesity and a body mass index of 79.8 kg/m(2). The surgical technique of the laparoscopic adjustable gastric banded sleeve gastrectomy is described. There were no immediate complications, and the patient was discharged home on the third postoperative day. She is doing extremely well on clinic follow-up at 6 weeks. To the best of our knowledge, laparoscopic adjustable gastric banded sleeve gastrectomy, as a primary operation, has not been described in the literature. It is hoped that this combined procedure will be most useful in the super-super obese (body mass index > 60) patients. More patients with a long-term follow-up are necessary to provide definitive conclusions regarding long-term benefits and complications of this combined bariatric procedure.

Feasibility and technique of laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy

BACKGROUND

To evaluate the feasibility, safety, and short-term efficacy of the conversion of laparoscopic adjustable gastric banding (LAGB) to laparoscopic sleeve gastrectomy (LSG) because of inadequate weight loss.

METHODS

The inclusion criteria were an inadequate percentage of excess weight loss (%EWL), defined as <30% at > or =1 year after LAGB. From August 2002 to October 2007, 27 patients (17 women and 10 men) had undergone removal of their LAGB and conversion to LSG. The average age at LSG was 43.6 +/- 11.4 years (range 25-66). Before LAGB, the mean weight and body mass index was 129.8 +/- 21.9 kg (range 95-178) and 45 +/- 8.1 kg/m(2) (range 35-64), respectively. The average interval between LAGB and LSG was 51.2 +/- 30.1 months (range 22-132). Before conversion, the mean weight, body mass index, and %EWL was 117.9 +/- 27.3 kg (range 63-170), 39 +/- 9.6 kg/m2 (range 24-61), and 18.1% +/- 18.3%, respectively. Of the 27 patients, 12 had 19 obesity-related co-morbidities, including arterial hypertension in 7, type 2 diabetes mellitus in 2, degenerative joint disease in 7, and sleep apnea in 3.

RESULTS

The mean operative time was 120.6 +/- 32.4 minutes (range 65-195). No conversion to open surgery was required, and no patient died. The postoperative complications included a subphrenic hematoma that required laparoscopic drainage; no postoperative leaks developed. The mean hospital stay was 3.2 +/- 1.4 days (range 2-8). After a mean follow-up of 18.6 +/- 14.8 months (range 1-59) for 23 patients (4 patients were lost to follow-up), the mean weight, body mass index, and weight loss was 100.7 +/- 23.5 kg (range 61-152), 34.6 +/- 8.7 kg/m2 (range 21-50.4), and 23 +/- 12.4 kg (range 2-55), respectively. The patients had had an additional 16.7% EWL after LSG for a total average %EWL of 34.8% +/- 21.8% (P <.05). Of the 12 patients with obesity-related co-morbidities, 5 had had resolution, including arterial hypertension in 1, type 2 diabetes mellitus in 1, degenerative joint disease in 2, and sleep apnea in 2.

CONCLUSION

The results of this study support the safety of LSG in the case of an inadequate %EWL after LAGB. However, the degree of weight loss and co-morbidity resolution is of concern.

Laparoscopic adjustable pyloric band with fundoplication in bariatric surgery: technique and preliminary results

BACKGROUND

Laparoscopic biliopancreatic diversion according to Scopinaro is an extremely effective operation for weight loss, but carries significant morbidity in terms of metabolic deficiencies.

METHODS

A study was conducted as to the feasibility, safety and efficiency of a novel procedure, accomplishing a 'reversible Scopinaro BPD', performed in two stages: first the placement of an adjustable band in a juxtapyloric position, aiming at maintaining postprandial satiety, and second, the construction of a transmesocolic Roux-en-Y gastro-enterostomy with a 2.5-m long distal jejunal limb, reanastomosed 50 cm proximal to the ileocecal valve.

RESULTS

15 patients, mean BMI 38.9, 8 males and 7 females, underwent the first stage of pyloric adjustable banding. All benefited at the same time from a Nissen fundoplication, to avoid gastroesophageal reflux. 1 patient was withdrawn from the study at this stage because of peritonitis of unknown cause and removal of the band. 3 patients benefited from the second stage of the operation because of insufficient weight loss, and/or symptoms of gastric stasis. 1 patient developed diarrhea and was treated by peroral cholestyramine. Weight loss was similar to the regular BPD figures.

CONCLUSION

The placement of an adjustable gastric band in a juxtapyloric position, combined with a Nissen fundoplication, appears to be a safe and efficient satiety-inducing operation. In case of insufficient weight loss, and/or exaggerated gastric stasis, a Scopinaro BPD construction can be added to the otherwise unharmed stomach, hereby constituting an instantly reversible malabsorptive component.