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.     

Revision of Failed Vertical Banded Gastroplasty to Non-resectional Scopinaro Biliopancreatic Diversion: Early Experience

Background: The most commonly performed revision operation following failed vertical banded gastroplasty (VBG) is Roux-en-Y gastric bypass, although revision to biliopancreatic diversion (BPD) with duodenal switch is now another common option. We describe the surgical technique for revision of a failed VBG to a non-resectional Scopinaro BPD in a series of patients, as well as the outcome in terms of complications and mean % excess weight loss (%EWL). Methods: A retrospective review was conducted on all patients who underwent revision to BPD at Mercy Bariatrics, Western Australia, between June 2001 and April 2005. This yielded 20 patients who had revision to BPD, 9 of whom had VBG as their initial operation. The mean %EWL was measured at regular intervals postoperatively (3, 6, 12, and 24 months). Results: Mean %EWL at 12 and 24 months was 69.5 and 76.7, respectively. These results are comparable to %EWL after a primary BPD. Nutritional manifestations were found to be the most common of the minor complications. Conclusion: Our technique for revision of a failed restrictive operation to a non-resectional Scopinaro BPD is described. The preliminary results in terms of %EWL and complications are comparable to other revisional malabsorptive operations. Prospective randomized controlled trials are needed to further evaluate effects of revision to a non-resectional Scopinaro BPD and to ensure that the results (in terms of %EWL) are reproducible.     

Laparoscopic Roux-en-Y Gastric Bypass as a Revision Procedure after Restrictive Bariatric Surgery

Background  Adjustable gastric banding (AGB) and vertical banded gastroplasty (VBG) have been extensively used to treat morbid obesity. Patients with insufficient weight loss or complications may require surgical revision. The laparoscopic Roux-en-Y gastric bypass (LRYGBP) is one of the most common procedures currently used for revision. The aim of the study was to analyze surgical outcomes of 30 consecutive patients who underwent revision to LRYGBP in a 2-year period. Methods  The prospectively constructed database and the medical records of all patients undergoing revision to LRYGBP were reviewed. Demographics, surgical details, results, and complications were analyzed. Results  There were 23 women and seven men with a mean age of 41.1 ± 9.7 years (r = 25–61). Mean body mass index (BMI) was 40.0 ± 7.5 kg/m² (r = 27.2–65.2). Initial operation was AGB in 24, VBG in five, and both in one patient. In ten patients, the band had been removed before revision, in 13 cases, band removal and LRYGBP were performed in one surgical intervention, and in two patients, it was performed in a two-step surgery. There were two conversions to open surgery. Five patients presented major surgical complications. Hospital stay averaged 5.1 days (r = 3–25). Mean percent excess body weight loss at 6 and 12 months was 61.7 ± 27.5 and 81.2 ± 20.5 kg/m², respectively. Mean percent low body mass index at 6 and 12 months was 22.5 ± 9.1 and 29.1 ± 11.4 kg/m², respectively. Conclusions  LRYGBP as a revision procedure is feasible in most patients. Surgical complications are more frequent.     

Has Laparoscopic Bariatric Surgery been Accepted in Japan? The Experience of a Single Surgeon

Background  Obesity is steadily increasing in Asia due to factors such as a lack of exercise, adoption of a more Western diet, changing lifestyles, environments, or stresses. Even in Japan, this tendency is notable, and metabolic syndrome has become widely recognized. However, bariatric surgery is still uncommon in Japan. There are no adequate data regarding the experience and outcome of bariatric surgery in Asia. Here, we report on the current status of morbid obesity and the outcomes of bariatric surgery by a single surgeon in Japan. Methods  Between February 2002 and January 2008, we have performed laparoscopic bariatric surgery for morbid obesity in 178 cases. They consisted of laparoscopic Roux-en-Y gastric bypass (LRYGBP) in 105 cases, laparoscopic sleeve gastrectomy (LSG) in 26 cases, laparoscopic sleeve gastrectomy with duodenal jejunal bypass (LSG/DJB) in 14 cases, laparoscopic adjustable gastric banding (LAGB) in 13 cases, and laparoscopic biliopancreatic diversion with duodenal switch in one case under the same protocol of follow up. The first author of this paper performed all procedures. Results  One hundred and thirty-eight patients with a follow-up of over 3 months after surgery were enrolled. LRYGBP accounted for 72% of all bariatric procedures. The reduction of weight and body mass index (BMI) in LRYGBP and LSG showed similar results. These outcomes were superior to those of LAGB. Percentage of excess BMI loss (%EBMIL) of LRYGBP showed greater reductions at follow-ups 6, 9, 12, and 18 months after surgery compared to that of LRYGBP and LAGB. All procedures resulted in over 50% of %EBMIL after 18 months of follow-up. There was no postoperative mortality within 30 days after surgery. Preoperative comorbidity including diabetes mellitus, hypertension, and hyperlipidemia were resolved or improved after surgery in most patients. Conclusion  In bariatric surgery, LRYGBP is the most effective treatment for morbid obesity, while LAGB has a low risk of postoperative complications. LSG is also a safe procedure for supermorbidly obese patients. We expect that bariatric surgery will be a common procedure for patients with morbid obesity in Japan.     

Vertical Banded Gastroplasty vs Gastric Bypass: 10 Years follow-up

In 1982, a prospective study to evaluate and compare the operations for treatment of morbid obesity, vertical banded gastroplasty (VBG) and gastric bypass (GBP), was carried out at the Center for Surgical Treatment of Obesity in Los Angeles. The VBG was performed as described by Dr Mason with a 5.0 cm circumference Marlex band. The GBP was the horizontal GBP with ≤ 50 cc pouch as described by Mason and modified by Printen and Griffen. One hundred patients had the VBG and 100 had the GBP. At 10 years follow-up, only 43 of the VBG patients and 46 of the GBP patients can be found. The groups are compared as to the perioperative complications, late complications and weight loss. VBG compared favorably with GBP for control of morbid obesity. GBP yields better weight loss and maintenance at all times of follow-up. Both procedures are equal in terms of morbidity and mortality.     

Laparoscopic Mini-Gastric Bypass for Failed Vertical Banded Gastroplasty

Background: Bariatric surgery is the only method for sustained weight loss in morbid obesity. However, 10-25% of patients will require re-operation for unsatisfactory weight loss or weight regain after restrictive surgery. Re-operation is associated with higher morbidity and mortality. This study is to evaluate the s a fety and efficacy of laparoscopic mini-gastric bypass (LMGB) for failed vertical banded gastroplasty (VBG). Methods: From May 2001 to March 2003, 29 consecutive patients underwent LMGB for failed VBG. Average age was 39.7 years (range 22 to 56), and average BMI before re-operation was 41.7 kg/m² (range 35.0-70.8). 8 patients had previous open VBG, and 21 had laparoscopic VBG. The re-operation was for regain of weight in 16 patients, inadequate weight loss in 10 patients, and severe reflux esophagitis in 3 patients. Re-operation was performed after an average of 58.5 months (range 14 to 180). Results: All the re-operations were completed laparoscopically. Average operative time was 171.4 minutes (range 130 to 290). There was 1 mortality, due to leakage (3.4%). 1 re-operation was necessary, for incarceration of small bowel in a trocar wound 10 days after the LMGB (3.4%). 1 anastomotic site bleeding and 1 wound infection occurred. Average BMI 12 months after the LMGB was 32.1 kg/m² (range 26.4 to 42.7). The quality of life study was significantly improved. The revision operation had much more technical difficulty for those with previous open VBG than laparoscopic VBG. Conclusion: LMGB is an effective and safe revision operation for patients with failed VBG. A large series and long-term follow up is needed for confirmation.     

Laparoscopic Sleeve Gastrectomy as Revisional Procedure for Failed Gastric Banding and Vertical Banded Gastroplasty

Background  The problem of revision of failed gastric banding (GB) and vertical banded gastroplasty (VBG) procedures has become a common situation in bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) has been recently used to revise failed restrictive procedures. The objective of this study is to evaluate the results of LSG as revisional procedure for failed GB and VBG. Methods  A prospective held database was questioned regarding patients' demographic, indication for revision, conversion to open surgery, morbidity, percentage of excess weight loss (%EWL), evolution of comorbidities, and need for a second procedure after LSG. Results  Forty-one patients, 34 women and seven men with a mean age of 42 years (range 19 to 63 years) and a mean body mass index at 49.9 kg/m² (range 35.9–63 kg/m²), underwent laparoscopic conversion of GB (36 patients) and VBG (five patients) into LSG. Indication for revisional surgery was insufficient weight loss in all the cases. All procedures were completed laparoscopically. There was no mortality and five patients (12.2%) developed complications (high leak, one patient; intra-abdominal abscess, three patients; and complicated incisional hernia, one patient). At a mean follow-up of 13.4 months, %EWL is on average 42.7% (range 4–76.1%). Six patients had a second procedure (four had laparoscopic duodenal switch, one had laparoscopic Roux-en-Y gastric bypass, and one had laparoscopic biliopancreatic diversion). Conclusion  Conversion of GB and VBG into LSG is feasible and safe. LSG is effective in the short term with a mean %EWL of 42.7% at 13.4 months. Long-term results of LSG as revisional procedure are awaited to establish its efficacy in the long term.     

Revisional Surgery for Failed Vertical-Banded Gastroplasty

Vertical-banded gastroplasty (VBG) was once a common bariatric procedure. It has fallen out of favor due to the emergence of the adjustable gastric band and late complications including band erosion and stenosis. Options for revision include conversion to a Roux-en-Y gastric bypass (RYGB) or VBG reversal via gastrogastrostomy. Patients undergoing revision of a previous VBG were identified. VBG reversal was performed laparoscopically. Conversion to RYGB was performed by both laparotomy and laparoscopy. Perioperative outcomes and long-term weight loss were evaluated. A total of 34 patients with a previous open VBG underwent revision over a nearly 8-year period (January 2003 to September 2010). Conversion to RYGB was performed in 25 (four laparoscopically) and VBG reversal in nine patients. Mean age for all patients was 56.3 years (range 36–70), and VBG had been performed 23 years previously (range 16–30). Patients to undergo VBG reversal were more likely to be male and less likely to be morbidly obese at the time of revision. Operative time and length of stay were shorter for laparoscopic procedures. Complication rates did not differ based on technique or procedure. Patients with a previous VBG may present with complications and obesity decades after the primary procedure. Revisional surgery can be accomplished laparoscopically. Following VBG reversal, most patients gain weight and many become morbidly obese again. Conversion to RYGB is associated with weight loss and resolution of morbid obesity in most patients. When feasible, laparoscopic conversion to RYGB may offer the best outcomes.     

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.     

Laparoscopic Conversion of Vertical Banded Gastroplasty with an Antireflux Wrap into Roux-en-Y Gastric Bypass

Background Vertical banded gastroplasty (VBG) is associated with a significant rate of revision because of regain of weight due to staple-line disruption, gastric pouch and stoma dilation, change to sweet eating, outlet stenosis with vomiting and reflux. To avoid reflux, some surgeons added an antireflux wrap. Methods We report laparoscopic revision of VBG with antireflux wrap to Roux-en-Y gastric bypass (RYGBP) in 4 patients. The indication for revision was insufficient weight loss in all 4 patients, with stenosis of the stoma resistant to endoscopic balloon dilation in one and reflux esophagitis in one, who shifted to high-calorie liquids. Revision was performed 73.5 months (range 57–84) after the primary procedure, at mean BMI 39.5 (range 37–41). Results Mean operative time was 193.7 min (165–220). There was no conversion to open surgery. There was no mortality. One patient developed a stenosis at the gastrojejunostomy that was managed successfully with endoscopic balloon dilation. Mean length of stay was 6.8 days (range 4–9). At mean follow-up of 11.2 months (range 11–18), mean BMI is 28.5 (range 27–30), and all patients were free of co-morbidities. Conclusions Laparoscopic revision of VBG with an antireflux wrap into an LRYGBP is feasible and effective in achieving weight loss, but the safety requires assessment by a larger series.     

Revision Surgery for Treatment of Weight Regain After Roux-En-Y Gastric Bypass

Background

This study aims to evaluate results on revision surgery for weight regain after gastric bypass, based on surgical technique and follow-up.

Methods

This study is a retrospective analysis of 29 patients who presented weight regain on follow-up after more than 5 years, divided into four groups according to revision surgery type: group 1 (n?=?9) includes patients who underwent an increase in the length of the alimentary limb to 200 cm; group 2 (n?=?13) are patients who underwent an increase in the length of the alimentary limb and placing of a silicon ring; group 3 (n?=?2) are patients who underwent an increase in the length of the alimentary limb and gastric plication, and group 4 (n?=?5) are patients who underwent gastric plication and placing of a silicon ring.

Results

The average preoperative weight before revision surgery was 117.8 kg, and the average postoperative follow-up for revision surgery was 13.7 months. Weight loss after revision surgery was observed in all groups but was greater in patients with longer revisional postoperative follow-up. Patients who underwent placing of a silicon ring presented greater weight loss than those who had had such a band since the original gastric bypass operation.

Conclusions

Data suggest that revision surgery may be a useful tool in achieving weight loss in patients presenting weight regain following gastric bypass, obesity, bariatric surgery, gastric bypass, weight regain, and revision surgery.     

Revisional bariatric surgery is more effective for improving obesity-related co-morbidities than it is for reinducing major weight loss

BackgroundPatients having previous bariatric surgery are at risk for weight regain and return of co-morbidities. If an anatomic basis for the failure is identified, many surgeons advocate revision or conversion to a Roux-en-Y gastric bypass. The aim of this study was to determine whether revisional bariatric surgery leads to sufficient weight loss and co-morbidity remission.Patients and MethodsFrom 2005-2012, patients undergoing revision were entered into a prospectively maintained database. Perioperative outcomes, including complications, weight loss, and co-morbidity remission, were examined for all patients with a history of a previous vertical banded gastroplasty (VBG) or Roux-en-Y gastric bypass (RYGB).ResultsTwenty-two patients with a history of RYGB and 56 with a history of VBG were identified. Following the revisional procedure, the RYGB group experienced 35.8% excess weight loss (%EWL) and a 31.8% morbidity rate. For the VBG group, patients experienced a 46.2% %EWL from their weight before the revisional operation with a 51.8% morbidity rate. Co-morbidity remission rate was excellent. Diabetes (VBG:100%, RYGB: 85.7%), gastroesophageal reflux disease (VBG: 94.4%, RYGB: 80%), and hypertension (VBG: 74.2%, RYGB:60%) demonstrated significant improvement.ConclusionRevision of a failed RYGB or conversion of a VBG to a RYGB provides less weight loss and a higher complication rate than primary RYGB but provides an excellent opportunity for co-morbidity remission.     

Five-year outcomes of laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass in a comprehensive bariatric surgery program in Canada

Background

Bariatric surgery remains the most effective modality to induce sustainable weight loss in the morbidly obese. Our aim was to compare outcomes between the laparoscopic Roux-en-Y gastric bypass (LRYGBP) and the laparoscopic adjustable gastric banding device (LAGBD) method with 5-year follow-up in a Canadian bariatric surgery centre.

Methods

This is a retrospective outcomes analysis of 1035 laparoscopic bariatric procedures performed over 7 years. We extracted data from our prospectively collected bariatric surgery registry from Feb. 1, 2002, to Jun. 30, 2008. We evaluated patient demographics, weight loss, complications, mortality and need for revision surgery by procedure type.

Results

We examined outcomes in 149 (14.4%) LAGBD and 886 (85.6%) LRYGBP procedures. The mean body mass index (BMI) was significantly higher in the LRYGBP group (50.9, standard deviation [SD] 8.9, v. 45.0, SD 6.7) whereas age and sex ratio were the same. There were 3 deaths (0.3%) in the LRYGBP group and no deaths in the LAGBD group. Sixteen patients (10.8%) in the LAGBD group needed conversion to LRYGBP because of poor weight loss, band intolerance, band erosion or slippage, and 6 patients (0.7%) in the LRYGBP group required revision because of inability to achieve the desired weight loss. The percent excess-weight loss was 41, 49, 59, 60 and 61 at 1, 2, 3, 4 and 5 years postsurgery for the LAGBD patients who kept their band, and 70, 79, 79, 79 and 75 for the LRYGBP patients.

Conclusion

Laparoscopic weight loss surgery can be performed safely with acceptable mortality. Our study suggests superior weight loss and low revision requirement for the LRYGBP, making this a more durable procedure in a publicly funded health care system.     

Biliopancreatic Diversion,with Distal Gastrectomy, 250 cm and 50 cm Limbs: Long-term Results

Background: Since 1984, biliopancreatic diversion (BPD) has been our procedure of choice in the treatment of morbid obesity. Better understanding of long-term outcome following BPD is needed. Methods: We report the results of our first consecutive 92 patients who underwent BPD more than 5 years ago. Of these 92, only 82 were available for a recent formal evaluation after a mean of 79 months. Results: Weight loss was maintained over the years at 62% of initial excess weight; the success rate for losing more than 50% of initial excess weight was 72%. The gastrointestinal side-effects decreased with time, but diarrhea was still present in 13%. The average number of daily stools was 3 ± 1.0. Of the patients, 76% were free from any gastrointestinal side-effects, taking normal diet and having normal stools. Malabsorption, however, was still present. A third of patients had laboratory values slightly below normal levels for haemoglobin, albumin and calcium. These values were mostly without clinical manifestation and were well tolerated by the patients. Regarding associated diseases, 75% were cured or improved following BPD. In 14 patients, reoperation was required to improve diarrhea or serum albumin. In these patients, the common channel was lengthened from 50 to 100 cm. The revision was successful in 11 and did not cause significant weight gain. Conclusion: BPD, as proposed by Scopinaro, was an efficient surgical treatment of morbid obesity that allowed normal eating habits and despite malabsorption was well tolerated by the great majority of patients.     

Protein deficiency after gastric bypass: The role of common limb length in revision surgery

BackgroundBariatric surgery, especially the gastric bypass procedure, is an effective therapy for morbid obesity, but may reduce protein absorption and induce protein deficiency (PD). A recent study reported an issue about common limb length for PD.ObjectiveThis study aimed to examine the prevalence of PD after gastric bypass surgery and investigate the role of common limb length in PD-related revision surgery.SettingHospital-based bariatric center.MethodsFrom 2001 to 2016, 2397 patients with morbid obesity who underwent bariatric/metabolic surgery with 1-year follow-up were recruited. Serum albumin and total protein were measured before and 1 year after surgery. Medical records of patients who underwent revision surgery due to PD were reviewed.ResultsThe overall prevalence of PD was .5% preoperatively. The prevalence of PD increased to 2.0% at 1 year after surgery. The incidence was highest in one-anastomosis gastric bypass (2.8%) followed by Roux-en-Y gastric bypass (1.8%). Until the end of follow-up, all 19 patients who underwent revision surgery for intractable PD had a relatively short common limb length of <400 cm. After elongation of the common limb length to >400 cm in revision surgery, PD improved in all patients.ConclusionsA subset of patients can develop PD after gastric bypass surgery when the common limb length is <400 cm. In patients with intractable PD after gastric bypass surgery, revision surgery for elongation of common limb length to >400 cm is mandatory to avoid PD-related complications.     

Laparoscopic Roux-en-Y versus mini-gastric bypass for the treatment of morbid obesity: a prospective randomized controlled clinical trial

OBJECTIVES: This prospective, randomized trial compared the safety and effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic mini-gastric bypass (LMGBP) in the treatment of morbid obesity. SUMMARY BACKGROUND DATA: LRYGBP has been the gold standard for the treatment of morbid obesity. While LMGBP has been reported to be a simple and effective treatment, data from a randomized trial are lacking. METHODS: Eighty patients who met the NIH criteria were recruited and randomized to receive either LRYGBP (n = 40) or LMGBP (n = 40). The minimum postoperative follow-up was 2 years (mean, 31.3 months). Perioperative data were assessed. Late complication, excess weight loss, BMI, quality of life, and comorbidities were determined. Changes in quality of life were assessed using the Gastro-Intestinal Quality of Life Index (GIQLI). RESULTS: There was one conversion (2.5%) in the LRYGBP group. Operation time was shorter in LMGBP group (205 versus 148, P < 0.05). There was no mortality in each group. The operative morbidity rate was higher in the LRYGBP group (20% versus 7.5%, P < 0.05). The late complications rate was the same in the 2 groups (7.5%) with no reoperation. The percentage of excess weight loss was 58.7% and 60.0% at 1 and 2 years, respectively, in the LPYGBP group, and 64.9% and 64.4% in the LMGBP group. The residual excess weight <50% at 2 years postoperatively was achieved in 75% of patients in the LRYGBP group and 95% in the LMGBP group (P < 0.05). A significant improvement of obesity-related clinical parameters and complete resolution of metabolic syndrome in both groups were noted. Both gastrointestinal quality of life increased significantly without any significant difference between the groups. CONCLUSION: Both LRYGBP and LMGBP are effective for morbid obesity with similar results for resolution of metabolic syndrome and improvement of quality of life. LMGBP is a simpler and safer procedure that has no disadvantage compared with LRYGBP at 2 years of follow-up.     

Vertical Banded Gastroplasty: Stable Trends in Weight Control at 10 or More Years

Whether long-term weight loss outcomes will succumb to adaptations in patients after gastric restrictive procedures has yet to be determined. The relationship, if any, of post-operative weight loss and maintenance to follow-up by support group and/or by surgeon, at least long-term, is uncertain. These questions have prompted review of my patients at 10-12 and at 5-10 years after vertical banded gastroplasty (VBG). Of the 118 patients (43 at 10-12 years), 65 were able to be contacted (55%). Successes were defined as patients who at the time of study interview, without operative revision, had lost at least 25% of their pre-operative excess weight. All known revisions (7) are reported as failures; only one of the seven was discovered in the study interviews. The mean body mass index of the entire study group (65) pre-operatively was 49.7, with 32% (21/65) super obese. Patient pre-operative profiles of successes and failures of both interval groups are remarkably similar. Successes were 65% in the ≥10 year group and 68% in the 5-10 year group. Respectively, mean percent excess weight loss was 46% and 54%. Six (of seven) failures, and ten (of 13) successes, in the ≥ 10 year group had 5.5 cm circumference outlets; all patients in the 5-10 year group were at 5.0 cm. Marked reduction in the follow-up pattern in the 5-10 year group failures was not significant but appears predictive. This experience suggests little deterioration in success rate, weight loss among successes, or revision requirement in VBG patients between 5 and > 10 years.     

Short-, Mid- and Long-Term Results of Larrad Biliopancreatic Diversion

Background In an effort to reduce the complications of Scopinaro’s biliopancreatic diversion (BPD), in 1989 we introduced the modification of lengthening the alimentary channel preserving most of the jejunum-ileum, by creating a short biliopancreatic limb (50 cm) and maintaining 50 cm of common limb (Larrad 50–50 BPD). Methods Of 343 patients who consecutively underwent Larrad 50–50 BPD surgery, 325, 194 and 65 patients were evaluated at 2, 5 and 10years after surgery, respectively, in terms of surgical morbidity, mortality, metabolic sequelae and weight. Mean age was 41.2years (range 17–62), mean initial weight 151.2 kg (range 97–260), and BMI was 52.2 kg/m2. Maximum follow- up was 120months. Results Mortality was 0.87% and surgical morbidity 7.6%. There were no cases of suture dehiscence, peritonitis or stomal stenosis. Percent excess weight loss (%EWL) stabilized 2years after surgery and at 10years was 77.8±11.2% for morbidly obese patients and 63.2±11.8% for super-obese patients. The main complications were 43.8% clinical incisional hernia, 2.5% severe diarrhea, 10.8% mild diarrhea and 9.2% constipation. 30% experienced anemia and/or iron deficiency, and 3% required iron parenterally or lifelong zinc supplements. 28% showed preoperative PTH elevation and 30% vitamin D deficiency; these values postoperatively increased to 45% and 43% respectively. Both these alterations were resolved using supplements, although 12% needed increased doses of vitamin D. The incidence of severe hypoproteinemia was 0.29%. No patient required surgical reversal. When independently evaluated, failure rates in terms of insufficient weight loss were 9% at 5years and 11.3% at 10 years for morbidly obese, and 12.2% and 14% for super-obese patients respectively. According to the BAROS questionnaire, 75% of surgery outcomes were excellent or very good, 18% good, 5% fair and 2% failures. Conclusions After 2, 5 and 10years, Larrad’s BPD has offered excellent results in terms of weight loss and quality of life, a low rate of metabolic sequelae, including a hypoproteinemia rate <0.5%, and a revision surgery rate 0%.     

Current Attitudes to the Laparoscopic Bariatric Operations among European Surgeons

Background: The current attitudes among European bariatric surgeons toward the laparoscopic bariatric operations were examined. Methods: 150 questionnaires were sent to recognized bariatric surgeons in Europe, and 60% responded. Results: 47% of respondents perform laparoscopic Roux-en-Y gastric bypass (LRYGBP), 81% laparoscopic adjustable gastric banding (LAGB), and 29% laparoscopic biliopancreatic diversion with or without duodenal switch (L-BPD/BPDDS). For BMI <40, 57% of respondents would only perform LAGB, 7% LRYGBP, 2% vertical banded gastroplasty (VBG), 3% L-BPD/BPDDS, and 2% intra-gastric balloon. For BMI 40-50, 43% of respondents prefer LAGB, 11% LRYGBP, 8% VBG, 5% L-BPD/BPDDS, and 33% contemplate several operations. For BMI 50-60, 30% prefer LAGB, 23% LRYGBP, 5% VBG, 16% L-BPD/BPDDS, and 26% tailor each patient's treatment. For BMI >60, 20% prefer LAGB, 24% LRYGBP, 37% L-BPD/BPDDS, 2% VBG, and 17% consider more than one operation. Although important, BMI and patient eating habits are not significant in choosing an operation for 25% of respondents. Interestingly, 39% of the surgeons offer laparoscopic bariatric surgery to so-called pediatric patients (<18). Of these, 76% favor LAGB, 8% LRYGBP, 8% L-BPD and 4% other procedures. Conclusions: The overall body of respondents prefers laparoscopic procedures. The responses suggest that at lower BMI there is a higher trend for restrictive operations. However, as BMI increases, combined and malabsorptive operations are preferred. At least one-third of surgeons offer bariatric surgery to patients with age <18 years, and here LAGB is greatly preferred.     

High-rate of long-term revision surgery due to weight regain after Laparoscopic Gastric Greater Curvature Plication (LGGCP)

PurposeTo present the long-term clinical outcomes of laparoscopic gastric greater curvature plication (LGGCP) in terms of weight loss and revision surgery rate.Material and methodsThis single-center study involved a retrospective analysis of patients that underwent revision surgery after LGGCP due to weight regain. Demographic and anthropometric data, comorbidities, operation time, hospital stays, mortalities, and immediate and long-term postoperative complications were analyzed. Postoperative Body Mass Index (BMI), %total weight loss (TWL), and complications were collected during follow-up.ResultsOf the 75 patients that underwent LGGCP at our hospital from March 2013 to February 2016, 13 (13/75, 17.3%) underwent revision surgery. All patients except one opted for sleeve gastrectomy. The mean interval between LGGCP and revision surgery was 71.0 ± 12.0 months (range, 54.8–93.6), and mean body weight, BMI, and TWL at revision were 89.2 ± 11.3 kg, 33.9 ± 4.2 kg/m², and 4.7 ± 9.3%, respectively. The main reason for revision was weight regain. Additional problems were chronic intermittent GERD (4/13, 30.8%), dyspepsia (4/13,30.8%), and chronic relapsing melena (1/13, 7.7%). Two patients experienced immediate postoperative complications (Clavien-Dindo II and III). At one year after revision surgery, the mean body weight, BMI, and additional %TWL from revision surgery were 63.0 ± 5.3 kg, 24.0 ± 2.9 kg/m², and 28.7 ± 8.0%, respectively. One of four patients (1/4, 25%) that complained of GERD before revision surgery, was still on PPI medication at 1 year after revision surgery.ConclusionAlthough LGGCP showed initial acceptable weight loss outcomes, long term (>5 years) follow-up showed that LGGCP is associated with a high rate of revision surgery (17.3%) due to weight regain.