Bariatric Surgery: Early Results with a Multidisciplinary Team

Background: Bariatric surgery depends on complete preoperative study of morbid obesity, in order to obtain the treatment of choice. A multidisciplinary group was founded in 1998 at the University of Siena. Methods: During 1998, 16 patients, with median weight 121.8 ± 31 kg and median body mass index (BMI) 43 ± 6, underwent bariatric surgery. A multidisciplinary assessment was used in order to evaluate psychological status, food intake problems and patient compliance, and hemodynamic, respiratory, metabolic and arthritic functions. 13 patients were submitted to laparoscopic surgery: in 11 adjustable gastric banding was performed and 2 were submitted to a vertical gastroplasty plus adjustable gastric banding.Three patients were operated via traditional laparotomy, due to previous abdominal surgery in 2 cases (submitted to an adjustable gastric banding) and one woman was submitted to a bilio-intestinal bypass according to the Hallberg technique, for her psychiatric troubles and coexisting systolic hypertension and uncontrolled diabetes. Monthly follow-up for each patient continues after 6 months. Results: No morbidity or mortality has occurred. The median weight loss at three months, was 19.5 kg. Two cases required injection of 1 ml more of fluid into the port, respectively at 4 and 9 months. Fifteen days after surgery, seven patients (46%) had vomiting episodes, due to rapid food intake. All patients have shown an improvement of their comorbidities after surgery. Conclusion: Early results via the multidisciplinary team and laparoscopic banding have been satisfactory thus far.     

Laparoscopic Surgery for Morbid Obesity: 1,001 Consecutive Bariatric Operations Performed at the Bariatric Institute, Cleveland Clinic Florida

Background: Morbid obesity is an epidemic in America. This series evaluates the safety and efficacy in the first 1,001 laparoscopic bariatric operations performed at The Bariatric Institute, Cleveland Clinic Florida. Methods: A retrospective review was conducted examining all patients undergoing a primary bariatric procedure (either laparoscopic gastric bypass or laparoscopic gastric banding) from July 2000 to December 2003. Results: 2 surgeons performed 1,001 laparoscopic bariatric operatons. Average age was 47 (19-75) years, average BMI was 55.6 (35-97) kg/m², and average ASA class was III. Excess weight loss was 51% at 6 months, 73.4% at 1 year for the gastric bypass group and 54% at 1 year for the laparoscopic banding group. The overall complication rate was 31.8% (12.4% major and 19.4% minor) in the gastric bypass group and 13% in the laparoscopic banding group. There was no postoperative mortality. Conclusion: Laparoscopic bariatric surgery is feasible and safe for weight loss. Results obtained have been comparable to those reported for the open approach for weight loss, with a similar major morbidity rate and an improved mortality rate.     

Does patient compliance with preoperative bariatric office visits affect postoperative excess weight loss?

BackgroundThe amount of excess weight loss (EWL) achieved after bariatric surgery has varied considerably. Reliable preoperative predictors of the postoperative %EWL do not exist. Patient compliance with the physician recommendations has generally been believed to be important for long-term success after bariatric surgery, especially after gastric banding. We hypothesized that poor preoperative patient compliance with office visits, a likely indicator of overall compliance, would be associated with lower %EWL after bariatric surgery at a teaching hospital in the United States.MethodsWe performed an institutional review board-approved review of prospectively collected data from all patients undergoing bariatric surgery from 2007 to 2009. The patients were categorized into 2 groups: those who had missed <25% of all preoperative appointments at our bariatric center and those who had missed >25%. The average %EWL at 12 months between the 2 groups was compared using the unpaired t test separately for the gastric bypass and gastric banding patients.ResultsThe gastric band patients with >25% missed appointments had lost 23% EWL at 12 months compared with 32% EWL for the gastric band patients who had missed <25% of their appointments (P = .01). No difference was found in the %EWL for the gastric bypass patients according to the missed preoperative appointments. The postoperative compliance was significantly poorer than preoperatively.ConclusionThe patients with a greater percentage of missed preoperative appointments had a lower postoperative %EWL at 1 year after gastric banding but not after gastric bypass. This information could prove useful during patient selection or when counseling patients about the type of bariatric surgery to pursue.     

Bariatric Surgery Worldwide 2003

Background: There is a world epidemic of overweight, obesity, and morbid obesity, encompassing 1.7 billion people. Bariatric surgery today is the only effective therapy for morbid obesity. Methods: E-mail requests for information were sent to the presidents of the national societies of the 31 International Federation for the Surgery of Obesity (IFSO) nations, or national groupings, plus Sweden. Responses were tabulated; calculation of relative prevalence of specific procedures was done by weighted averages. Results: Responders were 26 of 32 (81%) for the general questions and 24 of 32 (75%) for the question on specific operative percentages. In the year 2002-2003, 146,301 bariatric surgery operations were performed by 2,839 bariatric surgeons; 103,000 of these operations were performed in USA/Canada by 850 surgeons. The earliest start date for bariatric surgery was 1953 in the USA; IFSO was founded in 1995. In the year 2002-2003, 37.15% of operations were open; 62.85% laparoscopic. The 6 most popular procedures by weighted averages were: laparoscopic gastric bypass, 25.67%; laparoscopic adjustable gastric banding, 24.14%; open gastric bypass, 23.07%; laparoscopic long-limb gastric bypass, 8.9%; open long-limb gastric bypass, 7.45%; and open vertical banded gastroplasty, 4.25%. Pooling open and laparoscopic procedures, relative percentages were: gastric bypass, 65.11%; gastric banding, 24.41%; vertical banded gastroplasty, 5.43%; and biliopancreatic diversion/duodenal switch, 4.85%. Categorizing into restrictive/malabsorptive, purely restrictive, and primarily malabsorptive, the relative distribution of procedures was 65.11%, 29.84%, and 4.85%, respectively. The number of countries performing gastric banding was 23 (95%), gastric bypass 21 (88%), vertical banded gastroplasty 19 (79%), and biliopancreatic diversion/duodenal switch 16 (67%). Purely restrictive procedures were performed in 24 (100%) of the countries, restrictive/malabsorptive in 21 (88%), and primarily malabsorptive in 18 (75%). Conclusions: Bariatric surgery is expanding exponentially to meet the global epidemic of morbid obesity. Operative procedures in bariatric surgery are in flux and specific geographic trends and shifts are evident. Yet, of the patients qualifying for surgery, only about 1% are receiving this therapy – the only effective treatment currently available.     

The Influence of Helicobacter pylori Infection on the Development of Gastric Ulcer in Symptomatic Patients after Bariatric Surgery

Background: There are few data relating to the role of H. pylori infection and surgical procedures on the occurrence of gastric ulcer following bariatric surgery. Methods: Subjects with upper gastrointestinal symptoms after bariatric surgery and receiving gastroscopic examinations were prospectively enrolled. All clinical data including age, sex, BMI before surgery, and surgical method were recorded. IgG antibodies against H. pylori were measured in preoperative serum by enzyme-linked immunosorbent assay (ELISA). Results: A cohort of 636 patients undergoing laparoscopic vertical banded gastroplasty (LVBG) or Roux-en-Y gastric bypass (LRYGBP) was recruited. The seropositivity of H. pylori in symptomatic and asymptomatic patients after surgery was 39% (32/82) and 39.7% (220/554) respectively. Endoscopic examinations revealed that 22 (26.8%) of 82 symptomatic patients had a gastric ulcer. Comparison of demographic characteristics between patients with ulcer (n=22) and patients without ulcer (n=60) showed no difference in distribution of gender, age, BMI, and seroprevalence of H. pylori (27.3%, 6/22 vs 43.3%, 26/60, P=0.212). Patients undergoing LRYGBP showed a higher rate of gastric ulcer (45.5%, 10/22) when compared to patients undergoing LVBG (20%, 12/60; P=0.027). Conclusion: Gastric ulcers in symptomatic patients following laparoscopic bariatric surgery are related to surgical procedures rather than exposure to H. pylori infection.     

Preoperative thiamine deficiency in obese population undergoing laparoscopic bariatric surgery

BACKGROUND: Nutritional deficiencies are a recognized complication of bariatric surgery. Thiamine deficiency has been reported as a possible consequence of both restrictive and malabsorptive bariatric procedures. Most of the reported cases occurred after Roux-en-Y gastric bypass (RYGB) surgery; fewer were described after biliopancreatic diversion, vertical banded gastroplasty, or duodenal switch. Adults who have a high carbohydrate intake derived mainly from refined sugars and milled rice are at greater risk of developing thiamine deficiency, because thiamine is absent from fats, oils, and refined sugars. Currently, no reports have evaluated the preoperative thiamine status of bariatric patients. The aim of this study was to evaluate the degree of thiamine deficiency in obese patients before bariatric surgery at our institution. METHODS: The medical records of consecutive patients who underwent laparoscopic RYGB or laparoscopic adjustable gastric banding at our institution between March 2003 and February 2004 were retrospectively reviewed. Patients were selected for this study on the basis of predetermined criteria. Preoperative thiamine levels were retrospectively recorded. Excluded from this study were patients who had been taking multivitamins or other nutritional supplements before surgical intervention, had a history of frequent alcohol consumption, any malabsorptive diseases, or previous restrictive-malabsorptive surgical interventions, such as RYGB, biliopancreatic diversion, or adjustable gastric banding, according to the initial evaluation and questionnaire. RESULTS: Of 437 consecutive patients who underwent laparoscopic RYGB or laparoscopic adjustable gastric banding, 303 were included in the study. Forty-seven patients (15.5%) presented with low preoperative thiamine levels. The mean age and body mass index of these patients was 46 years and 60 kg/m(2), respectively. Male patients presented with greater mean preoperative thiamine levels (3.2 microg /dL) than female patients (2.4 microg/dL). CONCLUSION: Obese patients undergoing bariatric surgery may have significant thiamine deficiency before surgery.     

Gastric Bypass But Not Sleeve Gastrectomy Increases Risk of Major Osteoporotic Fracture: French Population-Based Cohort Study

The objective of this work was to investigate the risk of major osteoporotic fracture (MOF; hip, proximal humerus, wrist and distal forearm, and clinical spine) in bariatric surgery patients versus matched controls. Bariatric surgery is associated with an increase in fracture risk. However, it remains unclear whether the same degree of fracture risk is associated with sleeve gastrectomy, which has recently surpassed gastric bypass. Records from the French National Inpatient database were used from 2008 to 2018. Bariatric surgery patients, aged 40 to 65 years, with BMI ≥40 kg/m², hospitalized between January 1, 2010 and December 31, 2014, were matched to one control (1:1) by age, sex, Charlson comorbidity index, year of inclusion, and class of obesity (40 to 49.9 kg/m² versus ≥50 kg/m²). We performed a Cox regression analysis to assess the association between the risk of any MOF and, respectively, (i) bariatric surgery (yes/no) and (ii) type of surgical procedure (gastric bypass, gastric banding, vertical banded gastroplasty, and sleeve gastrectomy) versus no surgery. A total of 81,984 patients were included in the study (40,992 in the bariatric surgery group, and 40,992 matched controls). There were 585 MOFs in the surgical group (2.30 cases per 1000 patient-year [PY]) and 416 MOFs in the matched controls (1.93 cases per 1000 PY). The risk of MOF was significantly higher in the surgical group (hazard ratio [HR] 1.22; 95% CI, 1.08–1.39). We observed an increase in risk of MOF for gastric bypass only (HR 1.70; 95% CI, 1.46–1.98) compared with the matched controls. In patients aged 40 to 65 years, gastric bypass but not sleeve gastrectomy or the other procedures increased risk of major osteoporotic fractures. © 2020 American Society for Bone and Mineral Research.     

Revision of Failed Laparoscopic Adjustable Gastric Banding to Roux-en-Y Gastric Bypass

Background: The most common bariatric surgical operation in Europe, laparoscopic adjustable gastric banding (LAGB), is reported to have a high incidence of long-term complications. Also, insufficient weight loss is reported. We investigated whether revision to Roux-en-Y gastric bypass (RYGBP) is a safe and effective therapy for failed LAGB and for further weight loss. Methods: From Jan 1999 to May 2004, 613 patients underwent LAGB. Of these, 47 underwent later revisional Roux-en-Y gastric bypass (RYGBP). Using a prospectively collected database, we analyzed these revisions. All procedures were done by two surgeons with extensive experience in bariatric surgery. Results: All patients were treated with laparoscopic (n=26) or open (n=21) RYGBP after failed LAGB. Total follow-up after LAGB was 5.5±2.0 years. For the RYGBP, mean operating time was 161±53 minutes, estimated blood loss was 219±329 ml, and hospital stay was 6.7±4.5 days. There has been no mortality. Early complications occurred in 17%. There was only one late complication (2%) – a ventral hernia. The mean BMI prior to any form of bariatric surgery was 49.2±9.3 kg/m², and decreased to 45.8±8.9 kg/m² after LAGB and was again reduced to 37.7±8.7 kg/m² after RYGBP within our follow-up period. Conclusion: Conversion of LAGB to RYGBP is effective to treat complications of LAGB and to further reduce the weight to healthier levels in morbidly obese patients.     

Factors Influencing Patient Choice for Bariatric Operation

Background: No study has surveyed the factors that influence morbidly obese patients' preference for a particular bariatric operation. Method: 469 consecutive patients in 2 major bariatric surgery centers in the United States (US, 124) and Australia (AU, 345) were prospectively studied to determine referral pattern and reason for their choice of operation. Results: The predominant operation was laparoscopic adjustable gastric banding (LAGB) in both US (75%) and AU (83%) centers. Gender (70% female), BMI (45 kg/m² ) and age (42.5 years) were similar in both cohorts. In Australia, 53% had referral initiated by primary doctors and 25% by another patient, while in the US, 43% by another patient and 27% by the Internet. Safety of the operation (43%) was the highest-rated factor in choosing LAGB. LAGB being "least invasive" was most significant in the US (46%), and "surgical safety" in Australia (45%). In the US, Rouxen-Y gastric bypass was preferred due to "lack of a foreign body" (31%) and "inability to cheat" (28%), while in Australia, "dumping" was the most significant reason (50%). Duodenal switch (BPD/DS) was selected in 11% of patients, primarily because of "durability of the weight loss" (51%). Surprisingly, only 1 patient in the US group selected BPD/DS because the pylorus remains intact. Conclusion: Safety and invasiveness had the greatest impact on patient choice for bariatric operation in two different countries. This information may help clinicians better understand their patients' concerns, and their treatment choices.     

Laparoscopic Gastric Bypass versus Laparoscopic Adjustable Gastric Banding in the Super-obese: A Comparative Study of 290 Patients

Background: Controversy exists regarding the best surgical treatment for super-obesity (BMI >50 kg/m 2 ). The two most common bariatric procedures performed worldwide are laparoscopic adjustable gastric banding (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGBP). We undertook a retrospective single-center study to compare the safety and efficacy of these two operations in super-obese patients. Methods: 290 super-obese patients underwent laparoscopic bariatric surgery: 179 LAGB and 111 LRYGBP. Results: There were one death in both groups. The early complication rate was higher in the LAGB group (10% vs 2.8%, P<0.01). Late complication rate was higher in the LAGB group (26% vs 15.3%, P<0.05). Operating time and hospital stay were significantly higher in the LRYGBP group. LRYGBP had significantly better excess weight loss than LAGB (63% vs 41% at 1 year, and 73% vs 46% at 2 years), as well as lower BMI than LAGB (35 vs 41 at 18 months). Conclusion: LRYGBP results in significantly greater weight loss than LAGB in super-obese patients, but is associated with a higher early complication rate.     

Singapore Experience in Obesity Surgery

Background: The outcome of bariatric surgery has been well documented in large series in the West. In Asia, where obesity has been less rampant, such surgery has been correspondingly less frequent, and there is a dearth of information on bariatric surgery on Asians. Method: The outcome of a personal series of 40 patients who underwent "gastric stapling" and banding from 1987 to 2003 in Singapore is analyzed. Results: From 1987 to 1997, 26 patients underwent open bariatric surgery (Roux-en-Y gastric bypass 4, vertical banded gastroplasty 22). Initial mean BMI was 43.3 kg/m². At 0.6, 1, 2, 4 and 8 years after surgery, mean BMI was 35.2, 31.9, 31.2, 31.1 and 34.1 kg/m². Mean initial weight was 127.2 kg. %EWL was 42.2, 56.2, 56.9, 56.3 and 48.3%. From 1999 to 2003, 14 patients underwent adjustable gastric banding, 11 by laparoscopy. Initial mean BMI was 42.9 kg/m². At 0.6, 1 and 2 years, mean BMI was 38.9, 36.6, and 32.6 kg/m². Mean initial weight was 122.6 kg. %EWL was 26.6, 38.8 and 59.2%. One patient, following perigastric insertion of Lap-Band^? developed band slippage and gastric prolapse requiring removal. Since adopting the newer technique of combined pars flaccida and perigastric dissection in the last 6 patients, no band slippage has occurred. Conclusion: Our results of safety and low operative morbidity as well as the pattern and magnitude of weight loss following gastric stapling and banding for morbidly obese patients in Singapore appears to be similar to the Western experience.     

Impact of Patient Follow-Up on Weight Loss after Bariatric Surgery

Background: Postoperative follow-up after bariatric surgery is important. Because of the need for adjustments, follow-up after gastric banding may have a greater impact on weight loss than after Roux-en-Y gastric bypass.We reviewed all patients at 1 year after these two operations. Methods: During the first year after surgery, laparoscopic adjustable gastric banding (LAGB) patients were followed every 4 weeks and Roux-en-Y gastric bypass (RYGBP) patients were followed at 3 weeks postoperatively and then every 3 months.The number of follow-up visits for each patient was calculated, and 50% compliance for follow-up and weight loss was compared. Results: Between October 2000 and September 2002, 216 LAGB and 139 RYGBP operations were performed. Of these patients, 186 LAGB patients and 115 RYGBP patients were available for 1-year follow-up. Age and BMI were similar for each group. Overall excess weight loss (EWL) after LAGB was 44.5%. 130 (70%) returned 6 or less times in the first year and achieved 42% EWL. 56 patients (30%) returned more than 6 times and had 50% EWL (P=0.005). Overall %EWL after RYGBP was 66.1%. 53 patients (46%) returned 3 or less times in the first year, achieving 66.1% EWL. 62 patients (54%) returned more than 3 times after surgery and achieved 67.6% EWL (P=NS). Conclusion: Patient follow-up plays a significant role in the amount of weight lost after LAGB, but not after RYGBP. Patient motivation and surgeon commitment for long-term follow-up is critical for successful weight loss after LAGB surgery.     

Incidence of GERD,esophagitis, Barrett’s esophagus,and esophageal adenocarcinoma after bariatric surgery

BackgroundSome bariatric procedures have been associated with increased gastroesophageal reflux disease (GERD) symptoms; however, there are limited data on the long-term changes to the esophagus across bariatric procedures, and how preoperative esophageal disease is impacted by bariatric surgery.ObjectivesTo estimate incidence of GERD, esophagitis, Barrett’s esophagus, and esophageal adenocarcinoma before and after bariatric surgery and to identify potential risk factors for these conditions.SettingRetrospective analysis of New York State Database (SPARCS).MethodsAdult patients undergoing bariatric surgery (Roux-en-Y gastric bypass, adjustable gastric banding, laparoscopic sleeve gastrectomy, and biliopancreatic diversion) from 1995 to 2010. Multivariable Cox proportional hazard models were used to examine the association between preoperative diagnosis, surgery type, and postoperative diagnosis.ResultsA total of 48,967 records were analyzed; 30.3% had a diagnosis of GERD at the time of surgery and .4% had a diagnosis of esophagitis and Barrett’s. Preoperative GERD/esophagitis/Barrett’s was associated with higher risk of GERD, esophagitis, and Barrett’s, but not esophageal adenocarcinoma, postoperatively. Roux-en-Y gastric bypass patients had lowest risk of being diagnosed with GERD postoperatively. Overall, esophageal adenocarcinoma incidence in the sample was .04%; the rate among patients with preoperative GERD and Barrett’s was .1% and .9%, respectively. Incidence of esophageal adenocarcinoma did not differ by bariatric surgery type.ConclusionsPreoperative diagnosis is a risk factor for postoperative esophageal disease after bariatric surgery. Adjustable gastric banding and laparoscopic sleeve gastrectomy are associated with higher risk of postoperative GERD and esophagitis compared with Roux-en-Y gastric bypass. Incidence of esophageal adenocarcinoma did not differ by surgery type.     

Resolution of Diabetes After Bariatric Surgery Among Predominantly African-American Patients

Background

The aim of this study was to assess the relative efficacy in diabetes remission among predominantly African-American patients who have undergone one of the three different types of bariatric surgical procedures.

Methods

A total of 597 morbidly obese patients underwent one of the three bariatric surgical procedures at Harper University Hospital, Detroit, Michigan from 2008 to 2011. Of the three procedures, 203 (34 %) patients had laparoscopic sleeve gastrectomy, 264 (44.2 %) patients had laparoscopic gastric bypass, and 130 (21.8 %) had laparoscopic adjustable gastric banding. The prevalence of diabetes prior to surgery was 20.7, 17.4, and 24 %, respectively. There was no statistical difference in the prevalence of diabetes among the three surgical groups.

Results

Of the 119 patients with diabetes, 46 (38.7 %) were males and 73 (61.3 %) were females. The majority of patients were African-Americans (65 %). The average age of patients was 42.2?±?8.3 years for sleeve gastrectomy, 44.8?±?7.9 years for gastric banding, and 41.5?±?7.7 years for gastric bypass surgery. Of all the study patients with a preoperative diagnosis of type 2 diabetes, 86 patients (72.3 %) had resolution of diabetes 1 year after surgery. The resolution of diabetes was reported in 89.1, 66.7, and 54.8 % of patients who underwent laparoscopic gastric bypass, sleeve gastrectomy, and gastric banding, respectively.

Conclusions

This study, which was conducted among predominantly African-Americans, showed consistent results with other studies. Patients who underwent laparoscopic gastric bypass appeared to benefit the most in terms of achieving better remission of diabetes.     

Weight Changes in Spouses of Gastric Bypass Patients

Background: The effectiveness of gastric bypass for weight loss has been demonstrated. No study has documented the effect of this surgery on patient spouses' weight. Excess leftover food may be consumed by the spouses of gastric bypass patients, which may increase the total caloric intake compared to the preoperative intake. This investigation tested the hypothesis that there would be a significant change in patient spouse's weight. Methods: Patients who underwent Roux-en-Y gastric bypass (RYGBP) ≥ 12 months before were included. Preoperative weights of their spouses were requested before RYGBP surgery. Current weights of spouses were collected ≥ 12 months postoperatively. Chi-squared tests were used for statistical analysis. Results: 63 patients were included in this study. 1 patient was divorced and current data was not available. 3 patients' spouses themselves had RYGBP during the study period, and their average weight loss was 49 kg. Of the spouses who had a significant change in weight (but did not have a RYGBP), 13 lost weight and 20 gained weight. In this subgroup of spouses, 75% (15/20) of obese spouses gained weight compared to only 38% (5/13) non-obese spouses (P <0.04). Conclusions: Patients' spouses who are obese are more likely to have weight gain while the patients lose weight after RYGBP. Preoperative counseling should be offered to spouses of potential bariatric surgery patients, especially to spouses who are obese. This phenomenon suggests that obese spouses of bariatric patients should be counselled regarding weight gain or even be considered for candidates for bariatric surgery.     

Laparoscopic Swedish Adjustable Gastric Banding: 6-year Follow-up and Comparison to other Laparoscopic Bariatric Procedures

Background: The advantages of laparoscopy over open surgery are well known. The aim of this study was to compare our results with Swedish adjustable gastric banding (SAGB) with other laparoscopically performed bariatric procedures (gastric bypass, LapBand^?, vertical banded gastroplasty). Methods: Between January 1996 and December 2001, 454 patients (381 women, 73 men) underwent laparoscopic SAGB. All data (demographic and morphologic, co-morbidities, operative, and follow-up) were prospectively collected in a computerized databank. Results: Mean follow-up was 30 months (range 1-66). Average total weight loss was 35.5 kg after 1 year, reaching an average total of 54 kg after 3 years. Mean excess weight loss was 72% after 3 years, and the BMI decreased from 46.7 to 28.1 kg/m². Patients with co-morbidities reported marked improvement of their accompanying diseases. Complications requiring reoperation occurred in 7.9%. There was no mortality. The clinical outcome compared with the other laparoscopic bariatric procedures showed no significant difference. Conclusion: All laparoscopically performed bariatric procedures are very promising. The great advantage of laparoscopic adjustable gastric banding is that this operation is minimally invasive to the stomach, totally reversible and adjustable to the patients' needs.     

Hand-Assisted Laparoscopic Revision of Previous Restrictive Operations to Vertical Banded Gastroplasty

Background: Revision of failed gastric restrictive procedures to proximal Roux-en-Y gastric bypass (RYGBP) is the standard for many bariatric surgeons. Where the patient is not a suitable candidate or simply refuses gastric bypass, an alternative is herewith proposed. Methods: 3 patients had undergone a gastric banding as the original operation and 1 patient had had a vertical banded gastroplasty (VBG). 1 patient presented with insufficient weight loss, 1 with regain of weight and 2 with complaints of food intolerance and vomiting. The gastric bands were removed by hand-assisted laparoscopy (HALS), with conversion to a VBG. In the patient with stomal stenosis after a VBG, HALS interposition of PTFE was performed to enlarge the collar. Results: In 2 patients, further weight reduction was achieved. In the other 2 patients, relief of symptoms was achieved.There were no complications during or after the revisional surgery. Conclusion: HALS conversion of a gastric banding to a VBG, or PTFE interposition in the case of stomal stenosis after a VBG, can be a valuable alternative for patients unsuitable for or refusing proximal RYGBP.     

Laparoscopic band repositioning for pouch dilatation/slippage after gastric banding: disappointing results

Background: Pouch dilatation with or without slippage of the band is a serious complication of gastric banding, often attributed to initial malpositioning of the band. Food intake is increased, and weight regain occurs. Progressive rotation of the band follows, leading to functional stenosis and dysphagia. Reoperation is necessary in most cases, and may consist of band removal, band change, band repositioning, or conversion to another bariatric procedure. Material and Methods: The study consisted of chart review of all patients who underwent laparoscopic repositioning of the band for pouch dilatation/slippage, and long-term follow-up through regular office visits and phone calls. Results: Among 272 patients who had laparoscopic gastric banding, 20 (7.3 %) developed pouch dilatation and/or slippage, of whom 19 underwent reoperation. Laparoscopic band repositioning was performed in 9 patients. One of them developed an intraabdominal collection postoperatively and required percutaneous CT-guided drainage. Recovery was uneventful in the other 8. Follow-up since reoperation varies from 13 to 42 months (mean 20 months). The result was good in 2 patients who lost further weight, satisfactory in 1 whose weight remained stable, and unsatisfactory in 6 patients. Weight loss was insufficient in 2, dilatation recurred in 2, and band infection or erosion developed each in 1 patient. 5 patients required further surgery: band removal in 3 and conversion to gastric bypass in 2. Conclusions: Laparoscopic band repositioning is feasible and safe if pouch dilatation and/or slippage develops after gastric banding.The mid-term results are disappointing in two-thirds of the patients. In some patients, pouch dilatation could result from poor adjustment to diet restriction rather than merely from original malplacement. Conversion to gastric bypass may be a better option in these cases.     

Screening endoscopy before bariatric surgery: a series of 448 patients

BackgroundThe role of upper esophagogastroduodenoscopy (EGD) in morbidly obese patients before bariatric surgery is controversial. The purpose of this study was to determine the diagnostic yield of routine EGD before bariatric surgery.MethodsA consecutive series of 448 morbidly obese patients, who were otherwise cleared for bariatric surgery, underwent routine EGD. The endoscopic findings were classified by the clinical significance. The findings were tabulated and analyzed.ResultsA total of 447 patients (389 women and 58 men) underwent EGD successfully. Of the 447 patients, 85% had a body mass index of 40–59.9 kg/m², and 93% had significant co-morbidities. Abnormal findings that did not change the surgical approach or postpone surgery were found in 60 patients (13%), including hiatal hernia and benign polyps. Abnormal findings that changed the medical management before surgery were found in 81 patients (18%), including inflammation and/or ulcers. This group included 9 of 61 patients with gastritis who were treated for Helicobacter pylori found within the biopsy specimen. Findings that changed the surgical approach were found in 1 patient, and findings of severe ulcerations that postponed surgery were found in another patient. Of the 447 patients, 389 actually underwent bariatric surgery, including Roux-en-Y gastric bypass in 57% and adjustable gastric banding in 43%. During follow-up, 37 gastric bypass patients (13%) developed ulceration. Both gastritis and duodenitis, but not the presence of H. pylori, was statistically related to ulcer formation (Fisher's exact test).ConclusionIn this consecutive series of 451 successful screening EGDs, positive findings led to a change in medical treatment in a significant number of patients (18%), but a change in the timing of surgery or the surgical technique in relatively few (<1%). In addition, a significant correlation between gastritis and postoperative anastamotic ulceration suggests a causative link, with implications arguing for stronger medical therapy. A randomized trial should be performed to validate the usefulness of preoperative EGD in bariatric patients.     

Preoperative upper endoscopy is useful before revisional bariatric surgery.

BACKGROUND AND OBJECTIVES: We hypothesized that patients who have previously had bariatric surgery and are undergoing revision to laparoscopic Roux-en-Y gastric bypass would have abnormal findings detected by upper endoscopy that could potentially influence patient management. The procedures that are being revised include vertical banded gastroplasty, laparoscopic adjustable gastric bands, nonadjustable gastric bands and previous Roux-en-Y gastric bypass (open and laparoscopic). METHODS: We conducted a retrospective chart review of patients who previously had undergone vertical banded gastroplasty or nonadjustable gastric banding. We preoperatively performed an upper endoscopy on all patients. The endoscopy reports were reviewed and the findings entered into a database. RESULTS: Eighty-five percent of 46 patients undergoing revisional bariatric surgery had an abnormal upper endoscopy. Eleven percent had a gastrogastric fistula. Gastritis and esophagitis were noted in 65% and 37%, respectively. Eleven percent of patients had band erosion, 2 from a nonadjustable band, and 5 from vertical banded gastroplasties. Based on our findings, 65% of our patients required medical treatment. CONCLUSIONS: Preoperative upper endoscopy provides valuable information before revisional laparoscopic bariatric surgery. In addition to identifying patients who need preoperative medications, the preoperative upper endoscopy also provided valuable information regarding pouch size and anatomy. Preoperative upper endoscopy should be performed by the operating surgeon on every patient undergoing revisional bariatric surgery.