Obesity surgery in patients suffering from monogenetic adipositas

Surgical treatment of patients suffering from monogenetic forms of morbid obesity is considered to be the poorest investigated theme in bariatric surgery. This review article presents aspects of genetic disorders in morbid obesity as well as some aspects of surgical treatment in patients with monogenetic forms of morbid obesity (Prader-Willi-Syndrome). Gastric restrictive procedures such as vertical banded gastroplasty or adjustable gastric banding as well as malabsorptive and mix procedures such as biliopancreatic diversion or Roux-en-Y gastric bypass are used for treatment, similar to polygenetic forms of morbid obesity. Until to now there is no evidence-based data because of the small number of published cases. Decisions about the indication to operation and about the choice of surgical procedures are based on the empiric fundament. It is to suggest that the use of growth hormones in patients with monogenetic forms of morbid obesity could positively influence the results of bariatric surgery in these patients.     

Primary care and subspecialty management of morbid obesity: referral patterns for bariatric surgery.

BACKGROUND: The global rise in morbid obesity and associated comorbid diseases concerns a wide range of specialists. Although bariatric surgery has been proven to be an effective, enduring treatment available for morbid obesity, the rates of referral for surgery are not consistent with the number of individuals affected. METHODS: A survey of 478 experienced physicians from 6 specialty areas was conducted to ascertain the attitudes and practices regarding the treatment of morbidly obese patients. RESULTS: Approximately 21% (12% family practitioners and 34% internists) of patients seen by respondents were morbidly obese. Bariatric surgery was perceived as, by far, the most effective morbid obesity treatment available (judged to be effective for 49% of patients). Medical treatments were perceived as effective for <20% of patients (15% drugs and 23% exercise). Despite the respondents' perception that most surgery recipients achieve good to excellent long-term results, only 15.4% of patients were referred for consultation with a surgeon (8.0% for cardiologists and 26.1% for bariatricians). Most physicians were not knowledgeable regarding the National Institutes of Health morbid obesity management guidelines. Few could identify a local bariatric surgeon. The volume of referrals across all 6 specialty groups was low, at an average of 6 patients annually (3 patients for cardiologists and 19 patients for bariatricians). CONCLUSIONS: The results of our study have demonstrated that primary care physicians and subspecialists see a high proportion of morbidly obese patients; however, many are unfamiliar with morbid obesity management and surgical referral guidelines. Even though the perception of surgical effectiveness was quite high, the referrals for surgery were relatively low.     

Laparoscopic gastroplasty (adjustable silicone gastric banding)

Until now, for treatment of morbid obesity in the long term, surgery remained as the final option. For 40 years, surgeons looked at the best procedure. Among the restrictive procedures (gastroplasty), the laparoscopic adjustable silicone banding is the least invasive surgical treatment of morbid obesity. Between October 1992 and January 1998, we performed this procedure on 652 patients. Median body mass index was 45 (range, 35-65). Median hospital stay was 3 days (range, 2-10 days). The mean operative time was 80 minutes (range, 40-240 minutes). Four patients (0.6%) presented early complications: bleeding (1 patient), gastric perforation (2 patients), and pneumonia (1 patient). Forty-seven (7.2%) patients presented late complications and needed to be reoperated. There is one case of mortality. Loss of mass body weight was 62% in 2 years. According to these results, laparoscopic adjustable silicone gastric banding seems to be a safe and efficient technique.     

Achalasia in the Context of Morbid Obesity: a Rare but Important Association

Background: The simultaneous occurrence of achalasia and morbid obesity is rare. Nevertheless, the surgical therapy of morbid obesity may be harmful, if undiagnosed achalasia were left untreated. We report the clinical presentation and response to treatment of achalasia in the context of morbid obesity. Methods: From 1998 to 2002, 638 patients underwent surgery for morbid obesity. Preoperative upper gastrointestinal radiography was performed in all patients. Three patients had manometric confirmation of achalasia. The characteristic symptoms were recurrent episodes of regurgitation, chronic cough and aspiration. No patient reported dysphagia or recent weight loss. Results: All patients had a duodenal switch procedure and in two a concurrent Heller myotomy was added. The other patient required a Heller myotomy after a duodenal switch had been performed, because the motility study was initially misinterpreted. All patients reported gradual resolution of presenting symptoms after myotomy. Conclusions: A careful symptomatic history focusing on aspiration, regurgitation and cough may identify the unusual combination of achalasia and morbid obesity. Treatment of morbid obesity alone may lead to progression of pulmonary symptoms.     

The duodenal switch operation for morbid obesity

The duodenal switch provides excellent weight loss with preservation of good alimentation, even in the superobese. This is accomplished with acceptable operative mortality and minimal dietary limitations and metabolic sequelae. The results of the duodenal switch that are reported in the literature should remove any inhibitions that exist about the use of this procedure as treatment for patients who have morbid obesity. This article discusses the duodenal switch operation for morbid obesity.     

Bariatric Surgery and Multiple Personality Disorder: Complexities and Nuances of Care

Background: Multiple personality disorder (MPD) can occur in patients with morbid obesity in need of bariatric surgery, though few reports noting this association exist in the literature. Herein we address MPD in morbid obesity, in the context of a patient presenting to us seeking surgical treatment of her morbid obesity. Methods: A 31-year-old morbidly obese (BMI 49 kg/m²) Hispanic female presented in early 1994 requesting bariatric surgery. She had been a victim of violent sexual abuse as a young girl. Subsequently, she developed at least three personalities, including one male personality. Results: Although she has lost nearly 45 kg after gastroplasty, her care has been complicated by her named multiple personalities. While MPD are infrequent and unfamiliar to most care providers, successful outcomes can be promoted with a proper approach. Conclusions: This patient's care illustrates that: (1) all personalities must agree to proposed operative intervention; (2) consent must be obtained from the ‘true’ patient; and (3) postoperative care and follow-up must address all personalities for an optimal outcome.     

Gastric restrictive operations for morbid obesity

Gastric restrictive surgery has evolved over the past decade as the treatment of choice for morbid obesity. We reviewed our experience with 289 patients who underwent gastric surgery for morbid obesity. Comorbid diseases included respiratory insufficiency in 19 percent of the patients, hypertension in 36 percent, diabetes in 15 percent, arthritis in 30 percent, and heart disease in 6 percent. Operative mortality was 0. The follow-up rate was 93 percent. Overall mortality was 1 percent, with no death directly attributed to the operative procedure. Weight loss was studied over the 6-year study period. Four to 6 years postoperatively, overall weight loss was 50 to 64 percent of excess weight. The treatment failure rate 12 to 18 months postoperatively was 5 percent. The experience with gastric restrictive surgery in 12 centers involving 5,178 patients was reviewed and compared with our results. Overall operative and late mortality rates were quite similar to observed death rates for nonobese men and women between 25 and 64 years of age. These data suggest that gastric surgery for morbid obesity results in a significant reduction in health risk.     

Laparoscopic adjustable gastric banding for the treatment of morbid obesity

BACKGROUND: This prospective study evaluated the effectiveness and safety of laparoscopic adjustable gastric banding (LAGB) for morbid obesity. METHODS: Ninety-five consecutive patients (89 female; median age 38 years, range 19 to 69) underwent LAGB for morbid obesity. Median weight and body mass index were 123.2 (88.9 to 228.6) kg and 45 (32.7-76.4) kg/m(2) respectively. Significant coexistent disease was present in 52 (55%) patients. RESULTS: Median excess weight loss was 53% (range 96.9% to 12.1%) and 62% (range 107.5% to 32.3%) at 1 and 2 years respectively (P <0.001). Median operative time was 90 (range 35 to 285) minutes and inpatient stay 2 (range 1 to 10) days. Early complications were seen in 17 (18%) patients most commonly nausea/vomiting or dysphagia. Late complications were seen in 25 (26.3%) patients, most frequently vomiting or reflux due to band slippage or pouch dilatation. There was 1 (1%) operative death. CONCLUSIONS: LAGB is an effective operation for morbid obesity that results in equivalent weight loss to open surgical procedures.     

Prophylaxis of thromboembolic complications in bariatric surgery

The efficacy of prophylaxis of tromboembolic complications in surgical treatment of 331 patients with morbid obesity, who underwent different bariatric operations, is estimated. The comparative analysis and results of application of non-fractionized heparin and low molecular weight heparins (Fraxiparin) in patients, suffering morbid obesity, are presented.     

Maxillofacial surgery and obstructive sleep apnea: a review of 80 patients

To determine the effectiveness of the surgical treatment of obstructive sleep apnea, we retrospectively evaluated 80 patients. One group consisted of 55 patients who had undergone a limited osteotomy of the anterior mandible: inferior sagittal osteotomy with hyoid myotomy and suspension. Important criteria for the selection of these patients were normal pulmonary function, normal mandibular skeletal development, and the absence of morbid obesity. Polysomnography revealed that 37 patients (67%) had responded to the surgical treatment and 18 patients (33%) had not. The second group of 25 patients, selected for morbid obesity, severe mandibular deficiency, and failure of other surgical procedures, had undergone maxillomandibular osteotomy with hyoid advancement. All patients in the second group showed good results, as determined by polysomnography.     

Surgical treatment of severe forms of metabolic syndrome

The authors analyze the components of the metabolic syndrome in patients with morbid obesity treated at the surgical department. The effects of a modified operation of jejunal-ileal shunt on the components of the metabolic syndrome were shown in 220 patients operated upon at the clinic of Faculty surgery of the Pavlov Medical Academy in St. Petersburg. The indications to the operative treatment of the metabolic syndrome were substantiated on the basis of etiopathogenesis. The estimation of long-term results of the operation of jejunal-ileal shunt in patients with the metabolic syndrome is given.     

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目的 评估腹腔镜垂直捆绑胃成形术（LVBG）的减肥效果并探讨肥胖手术治疗的适应证。方法 利用该手术治疗25例病态肥胖病人，平均年龄27．56岁（12－47岁），体重指数（BMI）为41（26－56）。结果 平均手术时间120min(50-240min)，未出现手术死亡和并发症。术后随访23例病人，第1个月减重均在12kg以上，6个月后平均减重24.3kg，平均BMI降至35。一年平均减重约42kg，平均BMI降至31。无营养不良。结论 LVBG是一种治疗病态肥胖症的安全、有效手术方法。     

Late Pouch Dilation after Laparoscopic Adjustable Gastric and Esophagogastric Banding: Incidence, Treatment, and Outcome

Background: Pathologic late pouch dilation is the most frequent complication following gastric banding procedures for morbid obesity. In this study, possible predictive factors were sought. The treatment of these complications and the final outcome are discussed. Methods: Between December 1994 and December 1997, 171 patients underwent laparoscopic adjustable banding for morbid obesity. 40 patients underwent classic gastric banding (Group 1), and 131 patients underwent esophagogastric banding (Group 2). Results: Pouch dilation developed in 6 patients (15%) in Group 1 and 12 patients (9.2%) in Group 2. There were no significant predictive factors, although the complication occurred more frequently in patients with presurgical hiatus hernia. The type of dilation was different for each group, as was the surgical treatment. Laparoscopic repositioning of the band was always possible and was uncomplicated. The long-term outcome has been good, and weight loss has been maintained. Conclusions: A frequent complication following banding procedures for morbid obesity is pathologic late pouch dilation. In experienced hands, when appropriate surgical treatment is carried out, this is not a major problem. Nevertheless, efforts should be made to decrease the number of late dilations.     

Learning curve for laparoscopic Roux-en-Y gastric bypass with totally hand-sewn anastomosis

Background Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a challenging operation for the treatment of morbid obesity with well-demonstrated effectiveness in weight lost. There are several variations to the technique.Methods From September 2000 to July 2004, 600 consecutive patients underwent surgery for morbid obesity at our institution. The surgical technique employed was LRYGB with totally hand-sewn gastrojejunal anastomosis (GJA). All patients were considered candidates for laparoscopic approach regardless of age, gender, body mass index (BMI), or previous bariatric or digestive surgery.Results Mean BMI was 44.4 ± 7.6 kg/m². Thirty-two patients had undergone previous failed bariatric procedures. Conversion to an open procedure was necessary in three patients. Seventy-two patients (12%) developed early complications, including 23 (3.8%) leaks at the GJA (eight in the first 18 patients). Mortality rate was 1.1% (one death was related to GJA leakage). Early and late reoperation rates were 5.3 and 1.8%, respectively. Rate plateau of morbidity and mortality was reached after the first 18 patients when the surgical technique was fully standardized.Conclusions LRYGB is a technically demanding procedure for the surgical treatment of morbid obesity with significant morbidity during the learning curve. The learning curve can be soon overcome, reaching a rate plateau of complications after adequate training. Morbidly obese patients should be operated on in expert bariatric surgical laparoscopic units to obtain the best results.     

Laparoscopic Adjustable Silicone Gastric Banding: Preliminary Results of the University of Naples Experience

Background: Laparoscopic adjustable silicone gastric banding (LASGB) is a minimally invasive surgical procedure indicated for the treatment of patients with morbid obesity. Methods: From January 1996, eight patients successfully underwent the video-laparoscopic procedure. Results: Preoperative body mass index was 44.4 ± 4.7 (range 37.9-53.3). Mean operative time was 255 ± 73 minutes (range 150-360). Mean hospital stay was 3 ± 1 days. Intraoperative complications were absent. Conclusion: Preliminary results have been satisfactory, and encourage us to continue with LASGB.     

Follow-up of patients who have undergone ileogastrostomy

Patients who have had ileogastrostomy for the treatment of morbid obesity require close, long-term follow-up. From a prospective study of a large number of variables in 12 consecutive patients, and from experience with more than 200 patients who have undergone this procedure since 1982, a protocol has evolved. The authors outline the associated morbid conditions, operative complications and biochemical alterations that are important in the management of these patients.     

Implantable Gastric Stimulation - the surgical procedure: combining safety with simplicity

Implantable Gastric Stimulation is a safe and minimally invasive surgical therapy currently under investigation for the treatment for severe obesity. Over 500 patients have been implanted internationally, and thus far, there have been no major complications or mortalities. While this technology is proving to be the least morbid of the bariatric surgical procedures, it still has the potential to result in devastating complications because of the high-risk nature of operating on severely obese patients. Keeping the risk of a complication to a minimum requires careful attention to preoperative patient preparation, good operative technique, and comprehensive perioperative patient care. In addition, like for all bariatric procedures, the program must have the appropriate equipment and resources to serve this unique patient population. This review will highlight the most significant aspects of each issue.     

Gastric bypass for obesity: Results of a community hospital series

Seven hundred patients at a community hospital underwent gastric bypass for morbid obesity. Postoperative complications developed in 14.9 percent. The incidence of major complications was particularly low. Both weight loss and the percentage of excess weight lost in the postoperative period were very satisfactory. The criteria for selecting patients for gastric bypass are presented and preoperative evaluation is reviewed. Major technical points in the operation are stressed. Roux-Y reconstruction of gastrointestinal continuity is the preferred technique in our hands. This report reemphasizes the safety and efficacy of gastric bypass as a treatment for morbid obesity. When careful patient selection, preoperative evaluation and operative techniques are combined, excellent results can be expected in the community hospital.     

Implantable Gastric Stimulation — The Surgical Procedure: Combining Safety with Simplicity

Implantable Gastric Stimulation is a safe and minimally invasive surgical therapy currently under investigation for the treatment for severe obesity. Over 500 patients have been implanted internationally, and thus far, there have been no major complications or mortalities. While this technology is proving to be the least morbid of the bariatric surgical procedures, it still has the potential to result in devastating complications because of the high-risk nature of operating on severely obese patients. Keeping the risk of a complication to a minimum requires careful attention to preoperative patient preparation, good operative technique, and comprehensive perioperative patient care. In addition, like for all bariatric procedures, the program must have the appropriate equipment and resources to serve this unique patient population. This review will highlight the most significant aspects of each issue.     

A new method of surgical treatment of morbid obesity

The article presents results of surgical treatment of 48 patients with morbid obesity and concomitant metabolic disorders in the clinic of Faculty Surgery of the Bashkir state medical university. A new means of vertical gastroplasty is described allowing to prevent the early development of reflux-esophagatis and to reduce the number of postoperative complications. Stable reduction of the body mass was obtained in 7 patients with morbid obesity by using the method in the clinical practice.